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wvc Ch.35-Cardiac

The cardiovascular system (CV) comprises... the heart and blood vessels (both arteries and veins)
Myocardium aka... heart muscle
Each beat of the heart pumps... 60 mL or 5 L of blood per minute
The heart is protected by a covering called the... pericardium broken up into 3 membranes: *Fibrous *Parietal *Visceral
The muscular wall (septum) seperates the heart into... two halves: Rt and Lt--->each half has an upper chamber (atrium) and a lower chamber (ventricle).
The right atrium recieves... DEOXYGENATED venous blood PASSIVELY from the body through the superior and inferior vena cava.---> Rt atrium also receives blood from acutal heart muscle through coronary sinus.
The right Ventricle... muscular pump located behind sternum---> generates enough pressure during depolarization that it closes the tricuspid valve and opens pulmonic valve to propel blood into pulmonic artery to the lungs.
The workload of the right ventricle is _________ compared to that of the left ventricle... light
Route of blood through the heart.. from sup/inf vena cava--->Rt Atrium---> tricuspid valve-->Rt Ventricle-->pulmonic Valve --> Pulmonary Artery --> Lungs --> 4 pulmonary Veins --> Lt Atrium --> Mitral Valve -->Lt Ventricle --> Aortic Valve --> Aorta --> Systemic Arterial Circulation
The pressure of blood in the aorta of a yound adult is about 100-120 mm Hg while the pressure in the Rt Atrium is... 0-5 mm Hg
There are _________ cardiac valves responsible for maintaining forward flow of blood through the chambers of the heart: 4...these cardiac valves are classified into two types: *Atrioventricular (AV) valves *Semilunar Valves
Atrioventricular Valves *Tricuspid *Mitral(bicuspid) ---> they seperate the atria from the ventricles
The tricuspid valve seperates... the Rt Atrium from the Rt Ventricle
The Mitral valve seperates... the Lt Atrium from the Lt Ventricle
During Ventricular Distole, the tricuspid and mitralvalves act as funnels to... help move flow of blood from Atrium to Ventricles.
During Ventricular Systole, the tricuspid and mitral valves... close to prevent backflow (regurgitation) into the Atrium.
The semilunar Valves *Pulmonic Valve *Aortic Valve --> prevents backflow of blood back into ventricles during Systole.
the pulmonic valve seperates... the right ventricle from the pulmonary artery
The aortic valve seperates... the left ventricle from the aorta.
The heart muscle recieves blood to meet its own metabolic needs through... the coronary arterial system---> the coronary arteries originate from an area on the aorta just beyond the aortic valve.
Coronary Artery blood flow to the myocardium occurs primarily during... diastole.
There are two main Coronary Arteries that wrap the heart... *Left Main Artery *Right Coronary Artery
Left Main Artery *Divides into 2 branches---> *Lt Anterior Descending(LAD) *Left Circumflex Coronary Artery (LCX)
The Left Anterior Descending (LAD) Branch descends toward... the anterior wall and apex of Lt. Ventricle--> supplies blood to *portions of Lt. Ventricle *Ventricular Septum *Chordae Tendineae *Papillary Muscle *a little bit to Rt. Ventricle
The Left Circumflex Coronary Artery descends... toward lateral wall of Lt. Ventricle and apex ---> supplies blood to: *Lt. Atrium *Lateral and Posterior surfaces of Lt. Ventricle *In half of people, it also supplies the SA node and a small amount of people the AV node
The Right Coronary Artery (RCA) originates from... right sinus of Valsalva, encircles the heart, and descends toward apex to Rt. Ventricle.---> supplies blood to: *RA *RV *inferior portion of LV *In half of people, supplies SA node, and in almost everyone, it supplies the AV node
Cardiac muscle cells possess the charactoristics of... *automaticity *excitability *conductivity *contractility *refractoriness
The phases of the cardiac cycle are generally described in relation to... changes in pressure and volume in the left ventricle during filling (diastole) and ventricular contraction (systole)
Diastole normally about 2/3 of the cardiac cycle----> consists of: *relaxation and filling of the atria and ventricles
Systole the contraction and emptying of the atria and ventricles
Myocardial contraction results from... the release of large numbers of calcium ions from the sarcoplasmic reticulum and from the blood.
The electrical and mechanical properties of cardiac muscle determine... the function of the cardiovascular system.
Blood flow from the heart into the systemic arterial circulation is measured clinically as.. cardiac output (CO)
Cardiac output can also be described as... the amount of blood pumped from the left ventricle each minute
CO depends on the relationship between two variables and can be written in an equation Cardiac Output= Heart Rate x Stroke Volume
In adults, CO ranges from... 4-7 L/min
Heart Rate refers to... the # of times the ventricles contract each minute. ---> normal resting HR is between 6-100 bpm
The heart rate is extrinsically controlled by... autonomic nervous system (ANS)----> parasympathetic slows HR, sympathetic stimulates to increase HR.
Stroke Volume amount of blood ejected by left ventricle during each contraction.
Several variables that influence Stroke Volume... HR, preload, afterload and contractility.
Preload the degree of myocaridal fiber stretch at the end of diastole and just before contraction.
Preload is determined by... the amount of blood returning to the heart from both the venous system(right side) and pulmonary system (left side).
Starlings Law the more the heart is filled during diastole, the more forcefully it contracts.
Afterload the pressure of resistance that the ventricles must overcome to eject blood through the semilunar valves and into peripheral blood vessels.
Impedance the peripheral component of afterload, the pressure the heart must overcome to open the aortic valve.
Myocardial Contractility affects... stroke volume and CO and is the force of cardiac contraction independent of preload.
Contractility is increased by factors such as.. *sympathetic stimulation *calcium release *posative inotropic drugs.---> it is decreased by hypoxia and acidemia.
The vascular system serves several purposes: *provides route for blood to travel from heart to nourish tissues *carries cellular wastes to the excretory organs *allows lymphatic flow to drain tissues *returns blood to heart for reciculation
The vascular system is divided into... *arterial system *venous system
In the arterial system, blood flows from arteries to arterioles,then to the capillaries. and in the venous system blood flows from... the capillaries to the venules and then to the larger veins.
Exchange of nutrients across this capillary membrane occurs primarily by three processes: *osmosis *filtration *diffusion
The arterial system not only delivers blood to tissues for oxygenation, but it also... transports cellular wastes to the excretory organs----> ie..kidney and lungs
BP the force of blood excreted against the vessel walls.
What is neccessary to maintain BP? *volume *adequate contracting ventricles *vascular tone
How is BP determined? BP= Cardiac Output x peripheral vascular resistance
Three mechanisms mediate and regulate BP: *Autonomic Nervous System (ANS) *Kidneys *Endocrine System
ANS and regulation of BP ANS excites or inhibits sympathetic NS activity in response to impulses from chemoreceptors and baroreceptors
Kidneys and regulation of BP they sense a change in blood flow and activate the renin-angiotensin-aldosterone mechanism.
The endocrine system and regulation of BP the release of various hormones to stimulate the sympathetic NS at the tissue level.
Systolic BP the amount of pressure or force generated by the left ventricle to distribute blood into the aorta with each contraction of the heart.
Diastolic BP the amount of pressure against the arterial walls during the relaxation phase of heart.
Changes in ANS activity (sympathetic/parasymp)are responses to messages sent by.. sensory receptors in various tissues of the body---> *baroreceptors *chemoreceptors *stretch receptors ----> these all respond differently to biochemical and physiologic changes in the body.
Baroreceptors *In arch of aorta and origin of interal carotid ateries *stimulated when arterial walls stretched by increased BP *Impulses from these inhibit vasomotor center located in pons and medulla which then creates DROP in BP.
Peripheral Chemoreceptors *In carotid arteries and aortic arch *primarily sensitive to hypoxemia (decrease in arterial O2) *when stimulated, sends impulses along vagus nerve to activate vasoconstrictor response and RAISE BP
Central Chemoreceptors *In respiratory center of brain *stimulated by hypercapnia (increase in arterial CO2) and acidosis
Stretch Receptors *In Vena Cava and Rt. Atrium *sensitive to pressure or volume changes *ex: pt is hypovolemic->stretch receptors sense decrease in volume->fewer impulses sent to CNS->stimulation occurs of Sympathetic NS-> increase in HR and constriction of peripheral bl v
How Kidneys help regulate cardiovascular activity *renal bl flow or pressure decreases--> kidneys retain sodium and water-->BP rises d/t retention of fluids and activation of renin-angiotensin-aldosterone mechanism--->this results in vasoconstriction and sodium retention
Vascular volume is also regulated by the release of... an antidiuretic hormone (vasopressin) from posterior pituitary gland.
Other factors that influence activity of cardiovascular system: *emtional behaviors *Body Temp affects metabolic needs of tissues, therby influencing delivery of blood *hypo/hyperthermia
Venous System: the primary function of the venous system,.. to complete the circulation of blood by returning blood from the capillaries to the right side of heart.
Veins have the ability to... accomdate large shifts in volume with minimal changes in venous pressur
The force that pushes blood forward in the veins is... skeletal muscles in extremities.
Assessment methods used in cardiac assessments: The assessment of: *pt hx *nutrtion hx *family hx *current health problems *functional hx *physical assessment *diagnostic assessment
Patient History *obtain info about risk factors and symptoms of CVD---> age, gender, ethnic origin, chronic disease,illness, personal habits, physical activity, obesity, psychological variables.
Smoking is a major risk factor for... CVD---> three compounds in the smoke have been implemented in cause: *tar *nicotine *carbon monoxide
Smoking history should include... *# of cigarettes smoked daily *duration of smoking habit *age of pt when first started smoking
A person who smokes fewer than four cigarettes a day has... twice the risk of CVD
Anyone who smokes more than 20 per day has... four times the risk.
Record the smoking history in... pack-years, which is the number of packs per day x # years patient has smoked.
pyschiological factors to assess for in pts at risk for CVD: *stress *anger *depression *hostility are all closely related with risk of developing heart disease
What to look for in review of someone's medical hx when assessing cardiovascular system: *major illnesses such as: *diabetes mellitus *renal disease *anemia *high BP *Stroke *bleeding disorders *heart disease *thrombophlebitis ---> these all influence cardiovascular status
Other things to inquire about when assessing... *any kind of recurrent tonsilitis, strep infections, rheumatic fever because they may lead to valvular abnormalities *drug history *social history
What to assess when assessing Nutritional History... *pts food/fluid intake for past 24 hrs *self-imposed or medically prescribed dietary restrictions *amount/type of alochol consumption *amount of sodium, sugar, cholesterol, fiber, fat consumption.
When assessing current health problems in a pt, it is important to note major symptoms usually identified in pts with CVD: *chest px or discomfort *dyspnea *fatigue *palpations *weight gain *syncope *extremity pain
thoroughly evaluate nature and charectoristics of pain by... knowing that pain associated with CVD should be d/t ischemic (reduced or obstructed blood flow to myocardium) until proven otherwise.
When assessing pain, ask... *Onset: did s/s come on suddenly or develop gradually? *how long? *How often is pain? *any precipitating factors? *location of pain *quality of px (sharp,dull,crushing) *severity of px (0-10) *associated s/s *aggrivating/relieving factors *
what are some other signs of CVD? *dyspnea *fatigue *palpations *sudden wt increase of 2.2 lbs *syncope *extremity pain
palpations a feeling of fluttering or unpleasant feeling in the chest by an irregular heartbeat ---> causes include paroxysmal supraventricular tachycardia, premature contractions, sinus tachycardia.
weight gain is the best indicator of... fluid retention aka edema
syncope brief loss of conciousness---> most commonly caused by decreased perfusion to brain
What to look for in a phyical head to toe assessment when assessing for CVD... *skin *extremities *BP *Venous and Arterial Pulses *Precordium
When assessing skin, look at... *color and temperature *nailbeds, mucous membranes, conjunctival mucosa cuz small vessels here located close to surface *
Decreased profusion in the body manifests as.. cool, pale, and moist skin.
Cyanosis bluish, or darkened discoloration of skin and mcous membranes in light-skinned---> results from increased amount of deoxygenated hemoglobin--> occurs in later stages of poor perfusion
Central cyanosis decreased oxygentaion of arterial blood in lungs and appears as bluish tinge of conjunctivae and mucous membranes of mouth and tongue---> may indicate impaired lung fxn
Peripheral Cyanosis occurs when blood flow to peripheral vessels is decreased d/t vasoconstriction---> results from low Cardiac Output or increased extraction of O2 from peripheral tissues
Peripheral Cyanosis localized in an extremity often means... usually a result of arterial or venous insufficiency.
Rubor dusky redness that replaces pallor in a dependent foot--> suggests arterial insufficiency.
What to assess for when assessing pts extremities... *any skin changes *vascular changes *clubbing *edema *skin mobility and turgor
edema decreases.. skin elasticity
vascular changes include... *paresthesia *muscle fatigue/discomfort *numbness *pain *coolness *loss of hair distribution
Clubbing caused by chronic oxygen deprivation in body tissues---> common in pts with chronci pulmonary disease, congenital heart defects, or right sided heart failure
The angle of the normal nail bed is 160 degrees, but in clubbing.. the nail straigtens out to an angle of 180 degrees and base of nail becomes spongy.
Peripheral edema is a common finding in patients with cardiovascular problems and the location of it helps determine... its potential cause.
Looking at BP: define hypertension a systolic pressure of 140 mm Hg or higher OR a diastolic pressure of 90 mm Hg or more OR taking drugs to control BP.
A blood pressure that exceeds ___________ increases the workload of the left ventricle and oxygen consumption of the myocardium.. 135/85
Prehypertension BP of 120-139 over 80-89
Noram BP systolic < 120 /diastolic <80
However, BP less than ____________ may be inadequate for providing proper and sufficient nutrition to body cells 90/60
Postural (orthostatic) Hypotension occurs when BP is not adequately maintained while moving from a lying to a sitting or standing position. decrease of more than 20 mm Hg of systolic pressure or more than 10 mm hg of diastolic pressure as well as 10-20% increase in HR.
Causes of Postural (orthostatic) hypotension *caridovascular drugs *blood volume decrease *prolonged bedrest * age-related changes * disorders of ANS
Jugular Vein Distention *used to assess filling volume and pressure on right side of heart *caused by an increase in jugular vein pressure d/t rt sided heart failure, tricuspid regurgitation or stenosis, pulmonary hypertension, hypervolemia constrictive pericarditis, ect.
Pericordium area over the heart---> assessment includes inspection, palpation, percussion, auscultation
inspection of pericordium *note any prominent pulses---> movement over aortic, pulmonic, and tricuspid areas is abnormal, but pulses in mitral area are normal.
Apical impulse or aka point of maximal impulse (PMI) are the pulse movements normally seen in the mitral area of the chest upon inspection---> located left 5th ICS in midclavicular line.
Auscultation evaluates... *HR and rhythm *cardiac cycle (systole and diastole) *valvular function
The diaphragm of stethoscope is used to listen to... high frequency sounds---> useful for S1 and S2 sounds and high frequency murmurs
The bell is used to listen to... listening for low frequency sounds (gallops-diastolic filling sounds/ or murmors)---> it screens out the high frequency sounds
The first heart sound *S1 *created by closure of mitral/tricuspid valves *softer and longer *best heard in apex of heart
S1 marks the beginning of.. ventricular systole *occurs right after QRS complex *can be assentuated through excercise, hyperthyroidism, mitral stenosis
Second Heart Sound *S2 *caused by closing of aortic and pulmonic valves *shorter *higher pitched *best heard at base of heart
Abnormal Heart Sounds *paradoxical splitting *ventricular gallop *atrial gallop *murmurs *pericardial friction rub
Paradoxical Splitting *Abnormal splittng of S2 *heard in pts with severe myocardial depression *causes early closure of pulmonic valve or delay in aoric valve closure *such conditions include MI, left bundle branch block, aortic stenosis...ect.
Gallops and Murmurs are common abnormal heart sounds that may occur with heart disease, or... they can also occur in healthy people as well.
Diastolic Filling sounds are aka.... S3 and S4---> produced when blood enters noncompliant chamber during rapid ventricular filling
S3 is produced during... the rapid passive filling phase of ventricular diastole when blood flows from atrium to a noncompliant ventricle.
S4 is produced as... blood enters the ventricles during the active filling phase at the end of ventricular diastole
S3 is also called.. a ventricular gallop
S4 is refered to as.. atrial gallop
S3 sounds are often times however considered a normal finding in pts who are... children or younger than 30---> if found in pts older than 35, it is considered abnormal and represents decrease in left ventricular compliance.
The S4 (atrial gallop) may be heard in pts with.. *hypertension *anemia *ventricular hypertrophy *MI *aortic or pulmonic stenosis *pulmonary emoboli
S4 may also be heard with... advancing age d/t a stiffened ventricle.
The prescence of both S3 and S4 is called... summation or quadruple gallop----> it is an indication of severe heart failure.
Murmurs... reflect blood flow through normal or abnormal valves.---> classified according to timing in cardiac cycle: *systolic murmor(between S1 and S2) *diastolic murmurs (between S2 and S1)
Murmurs are also graded according to... *intensity, depending on level of loudness
Quality of murmurs can further be described as... harsh, blowing, whistling, rumbling, or squeaking...and also described by pitch, usually high or low.
Pericardial Friction Rub *originates from pericardial sac and occurs with movement of the heart during cardiac cycle.
Rubs are usually transient and are a sign of.. *inflammation *infection *infiltration
Rubs may be heard in pts with pericarditis resulting from.. *MI *cardiac tamponade *post-thoracotomy
Performing a Psychosocial assessment on a pt with CVD, what to ask... *assess meaning of illness to pt and family by asking "what do you understand about what happened to you?" and "what does that mean to you?" or "How did you manage the situation?"
Coping behaviors of pts with CVD vary, but a common and normal response to CVD is... Denial, which is a defense mechanism that enables the pt to cope with threatening circumstances.
Some other behaviors associated with pts coping with CVD... *anxiety *fear *disorganization
Diagnostic Assessment: Different tools used to assess for CVD... *Laboratory Assessment *Aniography *Cardiac Catheterization *other diagnostic imaging
Different Laboratory Assessments used to assess cardiovascular dysfunction.. *Serum Markers of Myocardial Damage *Serum Lipids *Other Serum Tests
Acute Myocardial infarction can be confirmed by abnormally high levels of certain ____________ or ___________ in serum proteins or isoenzymes---> these serum studies are commonly called cardiac markers..
Cardiac markers include... *troponin *creatine kinase-MB *myoglobin
Troponin a myocardial muscle protein released into bloodstream with injury to myocardial muscle.
Creatine Kinase enzyme specific to cells of the brain, myocardium and skeletal muscle. appearance of these indicates tissue necrosis or injury. 3 types: MM, MB, BB----> CK-MB is the one found in myocardial muscle.
Myoglobin low molecular-weight heme protein found in cardiac and skeletal muscle and is the earliest marker detected (as early as 2 hrs after MI with rapid decline
Because myoglobin is not cardiac specific and is found in skeletal muscle as well, its clinical usefulness is more limited than... troponin
Serum Lipids: Elevated serum lipids are considered a risk factor for... coronary artery disease (CAD)
Lipids evaluated to assess for risk of CAD: *Cholesterol *triglycerides *protein components of high-density lipoproteins(HDL) and low-density (LDL)
The desired ranges for lipids... *Total cholesterol <200 mg/dL *Triglyceride < 150 mg/dL *HDL > 40 mg/dL *LDL < 70 mg/dL in hi risk pts and <100 mg/dL in pts with moderate risk factors.
arteriography an invasive diagnostic procedure that involves fluroscopy and the use of contrast media. *performed when there is an arterial obstruction, narrowing, and aneurysm is suspected.
Cardiac Catheterization most definitive use but most invasive test in dx of heart disease *includes studies of the right and left side of heart and coronary arteries
Complications of Cardiac Catheterization... *MI *Stroke *Aterial Bleeding *Thromboembolism *lethal dysrrythmias *arterial dissection *death
Electrocardiogram (ECG) *various forms available: resting ECG, continuous ambulatory ECG, exercise ECG *one of the most valuable diagnostic tests
Created by: wvc