Chapter 14

The Cardiovascular System

Chapter 14

The Cardiovascular System

Anatomy and Physiology

Location of the Heart and Great Vessels

Anatomy and Physiology(cont’d)

Location of the Heart and Great Vessels

Anatomy and Physiology (cont’d)

Cardiac Chambers, Valves, and Circulation

Anatomy and Physiology(cont’d)

• The cardiac cycle– Ventricular pressures• Systole: period of

ventricular contraction

• Diastole: period of ventricular relaxation

Anatomy and Physiology(cont’d)

• The cardiac cycle (cont’d)– Valve openings and closings

Anatomy and Physiology(cont’d)

• The cardiac cycle (cont’d)– Valve openings and closings (cont’d)

Anatomy and Physiology(cont’d)

• The splitting of heart sounds– Split S2

Anatomy and Physiology(cont’d)

• The splitting of heart sounds– Split S1

• Earlier mitral and later tricuspid

• Heard throughout precordium

• Loudest at cardiac apex

• Softer tricuspid best at lower left sternal border

• Does not vary with respiration

Anatomy and Physiology(cont’d)

Heart Murmurs

Anatomy and Physiology(cont’d)

Relation of Auscultatory Findings to the Chest Wall

Anatomy and Physiology(cont’d)

• Conduction system– SA node– AV node– Bundle of His– Bundle branches– Purkinje fibers

Anatomy and Physiology (cont’d)

• Conduction system (cont’d)

Anatomy and Physiology(cont’d)

• Conduction system (cont’d)

Anatomy and Physiology(cont’d)

• The heart as a pump– Cardiac output: volume of blood ejected from each ventricle in

one minute

– Stroke volume: volume of blood ejected with each heartbeat

– Preload: the load that stretches the cardiac muscle before contraction

– Myocardial contractility: ability of cardiac muscle when given a load, to contract or shorten

– Afterload: degree of vascular resistance to ventricular contraction

Anatomy and Physiology(cont’d)

• Arterial pressure– Factors influencing arterial pressure• Left ventricular stroke volume

• Distensibility of the aorta and the large arteries

• Peripheral vascular resistance, particularly at the arteriolar level

• Volume of blood in the arterial system

Anatomy and Physiology(cont’d)

• Jugular venous pressure– Reflects right atrial

pressure

– Best estimated from right internal jugular vein

– Right external jugular vein useful for estimating CVP

Anatomy and Physiology(cont’d)

Jugular Venous Pressure (cont’d)

The Health History• Common or concerning symptoms

– Chest pain

– Pain or discomfort radiating to the neck, left shoulder or arm, and back

– Nausea

– Diaphoresis

– Arrhythmias: skipped beats, palpitations

– Dyspnea

– Orthopnea

The Health History(cont’d)

• Common or concerning symptoms (cont’d)– Paroxysmal nocturnal dyspnea

– Cough

– Edema

– Nocturia

– Fatigue

– Cyanosis

– Pallor

The Health History(cont’d)

• Assessing cardiac symptoms– Chest pain

• Angina pectoris, coronary artery disease, myocardial infarction, acute coronary syndrome

– Palpitations• Heart skipping, racing, fluttering, pounding

– Shortness of Breath• Dyspnea, orthopnea, paroxysmal nocturnal

dyspnea

The Health History(cont’d)

• Assessing cardiac symptoms (cont’d)– Cough

• Heart failure, fine crackles and rales

– Edema• Dependent edema, congestive heart disease,

hypoalbuminemia

– Nocturia• Dependent edema, clears at night when patient

supine

The Health History(cont’d)

• Assessing cardiac symptoms (cont’d)– Fatigue• Signals heart is not adequately supplying

oxygen

– Cyanosis or pallor• Poor oxygenation of body

Past History• Heart problems?

• Heart disease?

• Murmurs?

• Congenital heart disease/defect?

• Rheumatic fever?

• Hypertension?

• Elevated cholesterol or triglycerides?

• Diabetes?

Family History

• Coronary artery disease?• Hypertension?• Sudden death younger than 60?• Stroke?• Diabetes?• Obesity?

Lifestyle Habits

• Nutrition• Smoking• Alcohol• Exercise• Medications, over-the-counter drugs,

herbs, nutritional supplements

Physical Examination

• Preparation of the patient– Comfortable and calm

– Explain procedure

– Examination gown (opened in the front)

– Assist to examining table

– Cover with drape

– Perform examination from patient’s right side

Physical Examination(cont’d)

• Equipment– Stethoscope with a bell and diaphragm

– Sphygmomanometer

– Two 15-cm rulers

– Watch with second hand

– Examination light for tangential lighting

Physical Examination(cont’d)

• Blood pressure and heart rate– Review measurements recorded from General Survey and Vital

Signs.

– Repeat if needed.

– Refer to Table 14-1.

• Face– Color: cyanosis, pallor

– Orbital edema

– Anxiety: occurs during myocardial infarctions

Physical Examination(cont’d)

• Great vessels of the neck– Carotid artery pulse• Amplitude and contour

Physical Examination(cont’d)

• Great vessels of the neck– Carotid artery pulse• Thrills and bruits

– Brachial artery

Physical Examination(cont’d)

• Great vessels of the neck– Jugular venous pressure• Head of bed: elevated 30 degrees

• Hypovolemic: may need to be flat

• Hypervolemic: may need to be higher

• Note height of head of bed in record

Physical Examination(cont’d)

• Jugular venous pressure (cont’d)– Refer to page 359.

Physical Examination(cont’d)

• Hepatojugular reflux

• If heart failure is present, jugular venous pressure will remain elevated.

Physical Examination(cont’d)

• The heart– Positioning patient• Supine

• Turning to left side

• Sitting and leaning forward

– Correlate findings with jugular venous pressure and carotid pulse.

The Physical Examination(cont’d)

Sequence of the Cardiac Examination

Physical Examination(cont’d)

• The heart (cont’d)– Inspection

• Apical pulse• See Table 14-3.

– Palpation

Physical Examination(cont’d)

Apical Pulse

Physical Examination(cont’d)

• Apical pulse (cont’d)– Location

– Diameter

Physical Examination(cont’d)

Apical Pulse (cont’d)

Physical Examination(cont’d)

• The heart (cont’d)– Percussion• Rarely used to estimate cardiac size

• X-rays, ECG, and echocardiography provide more accurate measurements

Physical Examination(cont’d)• The heart (cont’d)

– Auscultation• Overview• Know your stethoscope

Physical Examination(cont’d)

• The heart (cont’d)– “Inching” your stethoscope

– Importance of timing S1 and S2

Physical Examination(cont’d)

Physical Examination(cont’d)

• The heart (cont’d)– Listening for heart sounds

• S1 (see Table 14-4)

• S2 (see Table 14-5)

• Split S2

• Extra sounds in systole (see Table 14-6)

• Extra sounds in diastole (see Table 14-7)

• Systolic and diastolic murmurs (see Tables 14-8 thorugh 14-11)

Physical Examination(cont’d)

• The heart (cont’d)– Correctly identifying heart murmurs

• Tips for identifying heart murmurs– Time the murmur.

– Locate where it is the loudest

– Conduct any necessary maneuvers

– Shape

– Grade intensity

– Associated features

Physical Examination(cont’d)

• Peripheral edema– Inspect feet, ankles, and legs.

– May indicate heart failure

– To be covered in detail in Chapter 15

• Integrating cardiovascular assessment– Correlate complaints with findings.

– Put together information to form hypothesis of patient complaint’s.

Recording Your Findings

• Structures

• Colors

• Auscultations

• Pulsations

• Palpations

• Heart sounds

Health Promotion

• Topics– Coronary heart disease

– Stroke prevention

– Hypertension prevention and management

– Hyperlipidemia prevention and management

Health Promotion(cont’d)

• Key roles for nurse– Screening patients for disease and risk factors

– Teaching patients relationship of risk factors to disease

– Educating patients on lifestyle changes to reduce risk factors

– Encouraging patients to adhere to healthy lifestyles and medical regimens to reduce the incidence of disease morbidity

Health Promotion(cont’d)

Blood Pressure Classification

Health Promotion(cont’d)

• Risk reduction– Coronary heart disease risk factors• Modifiable risk factors

– Diabetes

– Systolic and/or diastolic hypertension

– Smoking

– Obesity

– Physical inactivity

Health Promotion(cont’d)

• Risk reduction (cont’d)– Coronary heart disease risk factors

(cont’d)• Nonmodifiable factors

– Increasing age

– History of cardiovascular disease

– Family history of early heart disease

Health Promotion(cont’d)

• Hypertension risk factors– Modifiable risk factors

• Obesity

• Physical inactivity

• Smoking

• Microalbuminuria

• Excess dietary sodium

• Insufficient intake of potassium

• Excess alcohol consumption

Health Promotion(cont’d)

• Hypertension risk factors (cont’d)– Nonmodifiable factors• Age

• Family history of hypertension or CVD

Health Promotion(cont’d)

• Risk factors used to assess the 10-year coronary heart disease risk score– Age

– Gender

– Height, weight, waist circumference (of BMI)

– Smoking

– History of cardiovascular disease or diabetes

Health Promotion(cont’d)

• Risk factors used to assess the 10-year coronary heart disease risk score (cont’d)– Systolic and diastolic blood pressure

– Total cholesterol, LDL, and HDL cholesterol

– Triglycerides

– Family history of early heart disease

Health Promotion(cont’d)

Health Promotion(cont’d)

Healthy Lifestyles

Health Promotion(cont’d)Healthy Lifestyles (cont’d)

Health Promotion(cont’d)

• Healthy eating– Healthy fats• Foods high in monounsaturated fat

• Foods high in polyunsaturated fat

• Foods high in omega-3

Health Promotion(cont’d)

• Healthy eating (cont’d)– Unhealthy Fats• Foods high in trans fat

• Foods high in cholesterol

• Foods high in saturated fat

Health Promotion(cont’d)

• Counseling about weight and exercise– Dietary factors are associated with 4 of the 10

leading causes of death.

– Discuss principles of healthy eating.

– Encourage exercising, at least 30 minutes on most days of the week.

– Evaluate any cardiovascular, pulmonary, or musculoskeletal conditions before selecting an exercise regimen.