Cardiovascular System

Kristine A. Velasco, RN, UAE-RN, US-RN,

-is a hollow, muscular organ located at the center of the thorax.
-it occupies the space between the lungs (mediastinum) and
rests on the diaphragm.
-weighs approximately 300grams (10.6 oz.)
-the weight and the size of the heart are influenced by age, gende
body weight, extent of physical exercise and conditioning and hear
-supplies oxygen and other nutrients to the tissues by pumping blo
3 layers

1.Inner layer (endocardium)

2.Middle layer (myocardium)
3.Exterior Layer (epicardium)
Diastole
- All four chambers relax simultaneously, which allows the
ventricles to fill in preparation for contraction.
- Commonly referred to as “period of ventricular filling”

Systole
-contraction of the atria and ventricles.
- Atrial systole occurs first, just at the end of diastole
followed by ventricular systole.
Pulmonary Artery
-the only artery that carries deoxygenated blood.

Superior Vena Cava

- (Head, neck, and upper extremities)

Inferior Vena Cava

-(Trunk and lower extremities)

Aorta
-distributes oxygenated blood throughout the system
Apical Pulse
- Point of maximal pulse
- Located at the intersection of the midclavicular line of the left chest wal
and the fifth intercostal space
Heart Valves
- The 4 valves in the heart permit blood to flow in only one direction.
- The valves are composed of thin leaflets of fibrous tissue, open and close
in response to the movement of blood and pressure changes within the cha

2 types of valves
1. Atrioventricular Valve
2. Semilunar Valve
Atrioventricular Valves
1. Tricuspid Valve
-composed of three cusps or leaflets, separated the right atrium from the right ventricle.

2. Mitral Valve (Bicuspid)

- Lies between the left atrium and the left ventricle.

*during diastole, tricuspid and mitral valves are open allowing the blood in the atria to flow freely int
Ventricles. As the ventricles contracts and blood flows upward into the cusps of the tricuspid and mitr
Causing them to close.

Semilunar Valves
1. Pulmonic Valve
- Valve between the right ventricle and the pulmonary artery

2. Aortic valve
- Valve between the left ventricle and the aorta
*semilunar valves are forced open during ventricular systole as blood is ejected from the right and left
The pulmonary artery and aorta respectively.
Coronary Arteries

-the left and right coronary arteries and their

branches supply arterial blood flow to the heart.
-normal heart rate of 60 to 80 bpm, there is an
ample time during diastole for myocardial perfusion.
-as heart rate increases, diastolic time is shortened,
which may not allow adequate time for
myocardial perfusion
-patients are at risk for myocardial ischemia during
tachycardia especially with patients with CAD.
-the left coronary artery has 3 branches:
1. Left main coronary artery –artery from the point of
origin to the first major branch
2. Left anterior descending artery –courses down
the anterior wall of the heart
3. Circumflex artery – circles around to the lateral left
wall of the heart.

- The right side of the heart is supplied by the Right

Coronary Artery
- The posterior wall of the heart supplied by the Posterior
Descending Artery
Myocardium
-isthe middle, muscular layer of the atrial
and ventricular walls.
- composed of specialized cells called Myocytes
– this fibers encircles the
heart in a figure of eight from base (top) to the
apex (bottom)
Function of the Heart
Cardiac Conduction System
-generates and transmits electrical impulse that stimulate contraction of the
myocardium.
-stimulates atria first before ventricles.

2 types of SPECIALIZED ELECTRICAL CELLS

1. Nodal Cells
2. Purkinje Cells

3 Physiologic Characteristics
1. Automaticity – ability to initiate an electrical impulse
2. Excitability – ability to respond to an electrical impulse
3. Conductivity – ability to transmit an electrical impulse from one cell to ano
Sinoatrial Node (SA Node)
–primary pacemaker of the heart

Atrioventricular Node (AV Node)

-the secondary pacemaker of the heart

*both are composed of Nodal Cells

SA Node – in a normal adult heart has an inherent firing
rate at 60 to 100 impulses per minute;
AV Node – inherent firing rate 40 to 60 per minute
However the rate changes according to metabolic
demand of the body.

Initially, the impulse is conducted through a bundle of

specialized conducting tissue, referred to as bundle of His.

Impulses travel through the bundle branches to reach

terminal point in the conduction system Purkinje Fibers.
-this fibers are composed of Purkinje cells that rapidly
conducts impulses throughout the thick walls of the
ventricles
Cardiac Output
- refers to the total amount of blood ejected by one of the ventricles in liters per minute.
-the cardiac output in a resting adult is 4 to 6 l/min

Stroke Volume
- is the amount ejected from one ventricles per heartbeat.
- average resting stroke volume is about 60 to 130 mL
Preload
- refers to the degree of stretch of the ventricular cardiac muscle fiber
at the end of diastole.

Afterload
- resistance to ejection of blood from the ventricle.

Contractility
- refers to the force generated by the contracting myocardium
Gerontologic Considerations
-Changes in cardiac structure and function occur with age.
-size of the heart increases due to hypertrophy (thickening of heart walls) which reduces the volume of bloo
The chambers can hold.
-the valves due to stiffening, no longer close properly.
-results backflow of blood creates heart murmurs, a common finding in older adults.
Gender Considerations
- heart of woman tends to be smaller than that of a man.
-arteries are narrower in diameter in woman
-women develop CAD 10 years later than men as women have the
benefit of the cardioprotective effects of a female
Hormone estrogen.

3 major effects of estrogen

1. An increase in HDL high density lipoprotein that transports cholesterol
out of the arteries.
2. A reduction in low-density lipoprotein that deposits cholesterol in the
artery.
3. Dilatation of the blood vessels, which enhance blood flow to the heart.
Assessment of the Cardiovascular System
Cardiovascular Structural Changes
Structure
Atria Increase size of left atrium
Thickening of Endocardium
Left Ventricle Endocardial Fibrosis
Myocardial thickening(hypertrophy)
Infiltration of fat into myocardium
Valves Thickening and rigidity of AV valves
Calcification of aortic valve
Conduction System Connective tissue collects in SA node, AV
node and bundle branches – decrease # SA
node cells, decrease #of AV, bundle of His
and right and left bundle branch cells
Sympathetic Decrease response to beta-
Nervous System adrenergic stimulation
(regulation of heart function under
conditions)
Aorta and Stiffening of vasculature
arteries Decrease elasticity and widening of
aorta
Elongation of aorta, displacing the
brachiocephalic artery upward
Baroreceptor Decrease sensitivity of
Response baroreceptors in the carotid artery
and aorta to transient episodes of
HTN and hypotension
Functional Changes History and Physical Findings

Increase atrial irritability Irregular heart rhythm from

atrial dysrhythmias
Left ventricle stiff and less Fatigue; low exercise tolerance;
compliant; progressive decline s&sx of HF or ventricular
in the CO; increase risk for dysrhythmias.
ventricular dysrhythmias; PMI palpated lateral to the MCL
prolonged systole Decrease intensity S1, S2; split
s2
S4 may be present
Abn. Blood flow across valves Murmurs may be present
during cardiac cycle Thrill may be palpated if
significant murmur is present
Slower SA node rate of impulse Bradycardia; Heart Block; ECG
discharge; slowed conduction across Changes consistent with slowed
AV node and Ventricular conduction (Increase PR interval,
Conduction system widened QRS complex)
Low adaptive repose to exercise; Fatigue
contractility and HR slower to Diminished exercise tolerance
respond to exercise demands; HR Decrease ability to respond to stress
takes more time to return to
baseline
Left ventricular hypertrophy Progressive increase in systolic BP;
slight increase in Diastolic BP; widening
pulse pressure, pulsation visible above
right clavicle
Baroreceptor unable to regulate HR Postural BP changes and reports of
and vascular tone, causing slow feeling dizzy, fainting when moving
response to postural changes in from lying to sitting and standing
body position position
Health History
- patient’s ability to recognize cardiac symptoms and to
know what to do when they occur is
essential for effective self-care management.

Major Barriers
-lack of knowledge
-attributing symptoms to benign source
-denying symptom significance
-feeling embarrassed about having symptoms

Nurses should include family members or caregivers in assessing

and taking history of the patient.
Assessment Findings Associated Causes and Conditions

Clubbing of the fingers and toes Chronic hemoglobin desaturation most often to
(thickening of skin under the fingers or Congenital HD, advanced pulmonary diseases.
toes)
Cool/cold skin and diaphoresis Low cardiac output (e.g. Cardiogenic Shock, Acute MI)
causing Sympathetic Nervous system stimulation with
resultant vasoconstriction
Cold, pain, pallor of the fingertips or Intermittent arteriolar vasoconstriction (Raynaud
toes disease), skin may change in color from white, blue,
and red accompanied by numbness, tingling and
burning pain.
Cyanosis, central (a bluish tinged in the Serious cardiac disorders (pulmonary edema,
tongue and buccal mucosa) cardiogenic shock, congenital heart disease) result in
venous blood passing through the pulmonary circulation
without being oxygenated
Cyanosis, peripheral (a bluish tinge, Peripheral vasoconstriction, allowing more time for the
most often of the nails and skin of the hemoglobin molecules to become desaturated. It can be
nose, lips, earlobes, and extremities) caused by exposure to cold environment, anxiety, or &
cardiac output
Ecchymosis or bruising (a purplish-blue Blood leaking outside of the blood vessels
color fading to green, yellow, or brown) Excessive bruising is a risk for patients on
anticoagulants or platelet-inhibiting medications
Edema, lower extremities (collection of fluid in the Heart failure and vascular problems (PAD, chronic venous insufficiency,
interstitial spaces of the tissues) deep vein thrombosis, thrombophlebitis)
Hematoma (localized collection of clotted blood Bleeding after catheter removal/tissue injury in patients on
in the tissue) anticoagulant/antichrombotic agents
Pallor (4 skin color in fingernails, lips, oral mucosa, Anemia or arterial perfusion. Suspect PAD if feet develop pallor after
and lower extremities) elevating legs 60° from a supine position
Rubor (a reddish-blue discoloration of the legs, Filling of dilated capillaries with deoxygenated blood, indicative of
seen within 20 s to 2 min after placing in a PAD
dependent position)
Ulcers, feet and ankles: Superficial, irregular ulcers Rupture of small skin capillaries from chronic venous insufficiency
at medial malleolus. Red to yellow granulation
tissue
Ulcers, feet and ankles: Painful, deep, round ulcers Prolonged ischemia to tissues due to PAD. Can lead to gangrene
on feet or from exposure to pressure. Pale to
black wound base
Thinning of skin around a pacemaker or an Erosion of the device through the skin
implantable cardioverter defibrillator
Xanthelasma (yellowish, raised plaques observed Elevated cholesterol levels (hypercholesterolemia)
along nasal portion of eyelids) PAD, peripheral
arterial disease.
Blood Pressure
-It is affected by factors such as cardiac output; distention of the arteries; and
the volume, velocity,
and viscosity of the blood.

-Pulse pressure, which normally is 30 to 40 mm Hg, indicates how well the

patient maintains cardiac output.
-increases in conditions that elevate the stroke volume (anxiety, exercise,
bradycardia),
-reduce systemic vascular resistance (fever), or reduce distensibility of the arteries
(atherosclerosis, aging, HTN).
-decreased pulse pressure reflects reduced stroke volume and ejection velocity
(shock, HF, hypovolemia, mitral regurgitation) or obstruction to blood flow
during systole (mitral or aortic stenosis.
-pulse pressure of less than 30 mm Hg signifies a serious reduction in cardiac
output and requires
further cardiovascular assessment
Postural (Orthostatic) Blood Pressure
Changes
There is a gravitational redistribution of
approximately 300 to 800 mL of blood into the lower
extremities and the gastrointestinal system immediately
upon standing. These changes reduce venous return to
the heart, compromising preload that ultimately reduces
stroke volume and cardiac output.
Assessing Patients for Postural Hypotension
• Position the patient supine for 10 minutes before taking the
initial blood pressure (BP) and heart rate measurements.
• Reposition the patient to a sitting position with legs in the
dependent position, wait 2 minutes, then reassess both BP and
heart rate measurements.
• If the patient is symptom free or has no significant decreases in
systolic or diastolic BP, assist the patient into a standing position,
obtain measurements immediately, and recheck in 2 minutes;
continue measurements every 2 min for a total of 10 minutes to
rule out postural hypotension.
• Return the patient to a supine position if postural hypotension is
detected or if the patient becomes symptomatic.
• Document heart rate and BP measured in each position (e.g.,
supine, sitting, and standing) and any signs or symptoms that
accompany the postural changes.
Normal Heart Sounds

Normal heart sounds, referred to as S1 and S2,

- are produced by closure of the AV valves and the
semilunar valves, respectively.
-When the heart rate is within the normal range, systole
is much shorter than the period between S2 and S1
(diastole).
- However, as the heart rate increases, diastole shortens.
S1-First Heart Sound
-Tricuspid and mitral valve closure creates the first heart
sound (S.). The word "lub" is used to replicate its sound. S, is
usually heard the loudest at the apical area. S, is easily
identifiable and serves as the point of reference for the
remainder of the cardiac cycle.

S2-Second Heart Sound

-Closure of the pulmonic and aortic valves produces the
second heart sound (S2), commonly referred to as the "dub" .
sound. The aortic component of S, is heard the loudest over the
aortic and pulmonic areas. However, the pulmonic component
of S, is a softer sound and is heard best over the pulmonic area.
S3-Third Heart Sound
-An S, ("DUB") is heard early in diastole during the
period of rapid ventricular filling as blood flows from the
atrium into a noncompliant ventricle.
- It is heard immediately after S,. "Lub-dub-DUB" is
used to imitate the abnormal sound of a beating heart
when an S is present. It represents a normal finding in
children and adults up to 35 or 40 years of age.
- In older adults, an S, is a significant finding,
suggesting HF. It is best heard with the bell of the
stethoscope. If the right ventricle is involved, a right-sided
S, is heard over the tricuspid area with the patient in a
supine position. A left-sided S, is best heard over the apical
area with the patient in the left lateral position.
S4-Fourth Heart Sound S4 ("LUB")
-S4 heard just before S1 is generated during atrial
contraction as blood forcefully enters a noncompliant ventricle.
-This resistance to blood flow is due to ventricular
hypertrophy caused by hypertension, CAD, cardiomyopathies,
aortic stenosis, and numerous other conditions. "LUB lub-dub" is
the mnemonic used to imitate this gallop sound.
-S4, produced in the left ven-tricle, is auscultated using the
bell of the stethoscope over the apical area with the patient in
the left lateral position.
-A right-sided S4, although less common, is heard best over
the tricuspid area with the patient in supine position.
-There are times when both S, and S, are present, creating
a quadruple rhythm, which sounds like "LUB lub-dub DUB."
-During tachycardia, all four sounds combine into a loud
sound, referred to as a summation gallop.
Murmurs
-Murmurs are created by turbulent flow of blood in the
heart.
-The causes of the turbulence may be a critically narrowed
valve, a malfunctioning valve that allows regurgitant blood flow,
a congenital defect of the ventricular wall, a defect between the
aorta and the pulmonary artery, or an increased flow of blood
through a normal structure (e.g., with fever, pregnancy, and
hyperthyroidism).
-Murmurs are characterized and consequently described by
several characteristics, including their timing in the cardiac
cycle, location on the chest wall, intensity, pitch, quality, and
pattern of radiation.
Friction Rub
-A harsh, grating sound that can be heard in both
systole and diastole is called a friction rub.
-It is caused by abrasion of the inflamed pericardial
surfaces from pericarditis.
-Because a friction rub may be confused with a
murmur, care should be taken to identify the sound and
to distinguish it from murmurs that may be heard in both
systole and diastole.
-A pericardial friction rub can be heard best using the
diaphragm of the stethoscope, with the patient sitting up
and leaning forward.