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The Cardiovascular SystemThe Cardiovascular System

Rachel S. Natividad, RN, MSN, NPN212 Medical Surgical Nursing 1

Case Study Intro…

Mrs. E is a 70 year-old female admitted for left total hip replacement. Hx of DJD, Hypertension, CHF, asthma, and allergies. She also has a history of an MI 12 years ago.

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Circulation through the HeartCirculation through the Heart

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Diagnostic StudiesDiagnostic Studies

CBC CBC WBC WBC RBCRBC

• HGBHGB• HCT HCT

COAGULATIONCOAGULATION Platelet countPlatelet count PT/INRPT/INR PTT/APTTPTT/APTT

CXRCXR

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Diagnostic Studies:Diagnostic Studies:Blood ComponentsBlood Components

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Diagnostic Studies: Blood Components:Diagnostic Studies: Blood Components:White Blood Cell DifferentialWhite Blood Cell Differential

WBC CountWBC Count: Measurement of total number of leukocytes: Measurement of total number of leukocytes

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WBC with DifferentialWBC with Differential

30-40% 55-70%5-6% 1-2% <1%

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Diagnostic Studies:Diagnostic Studies:WBC Differential–NeutrophilsWBC Differential–Neutrophils

Segmented Neutrophils (Mature)Band Neutrophils (Immature)

NEUTROPHIL MATURATION BandsSegs:Mature

Bands (immature neutrophils-released into circulation In response to severe infection (Left Shift or “Left Shift or “BandemiaBandemia”)”)

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Diagnostic Studies:Diagnostic Studies:RBC – Erythrocyte countRBC – Erythrocyte count

Number of Number of circulating RBCscirculating RBCs

Altered in the same Altered in the same conditions that alter conditions that alter Hgb and Hct valuesHgb and Hct values

Erythrocytes

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Diagnostic Studies:Diagnostic Studies:HemoglobinHemoglobin

HGB LEVEL: Measurement of the HGB LEVEL: Measurement of the oxygen -carrying capacity of RBCoxygen -carrying capacity of RBC

Increased in: Increased in: Hemoconcentration (severe Hemoconcentration (severe dehydration, burns, shock, dehydration, burns, shock, vomiting), polycythemia veravomiting), polycythemia vera

Decreased in:Decreased in: Anemias due to blood Anemias due to blood loss or poor nutrition loss or poor nutrition Hemodilution (fluid volume excess); Hemodilution (fluid volume excess); other anemiasother anemias

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Diagnostic Studies:Diagnostic Studies:HematocritHematocrit

The percentage of whole The percentage of whole blood volume composed blood volume composed of erythrocytesof erythrocytes

Women: 38-47 %Women: 38-47 % Men: 40-54 % Men: 40-54 %

Altered in same conditions Altered in same conditions that alter Hgbthat alter Hgb

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Diagnostic Studies:Diagnostic Studies:Case StudyCase Study

#1#1

#2 POD #2 POD

PE: Incision site appears pink and slightly edematous with moderate amt. PE: Incision site appears pink and slightly edematous with moderate amt. serosanguinous drainage, JP drain intact draining reddish colored serosanguinous drainage, JP drain intact draining reddish colored drainage. drainage. VS: Temp 99.8 F, Resp 20/min, P 98 BPM, BP 138/88.VS: Temp 99.8 F, Resp 20/min, P 98 BPM, BP 138/88.

CBC results 2 day post-op reveal →→→→CBC results 2 day post-op reveal →→→→

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Diagnostic Studies:Diagnostic Studies:CoagulationCoagulation

Monitoring hemostasisMonitoring hemostasis

Bleeding Clotting

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Diagnostic Studies:Diagnostic Studies:CoagulationCoagulation

Platelets – critical to Platelets – critical to hemostasis and clot hemostasis and clot formationformation

Platelet count – measures Platelet count – measures the the number of circulating number of circulating platelets platelets

Normal range: Normal range: 150,000-400,000 mm3150,000-400,000 mm3

Monitor in patients Monitor in patients receiving receiving LovenoxLovenox

--

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Diagnostic Studies:Diagnostic Studies:How would you proceed?How would you proceed?

You are to administer Lovenox 40 mg SQ You are to administer Lovenox 40 mg SQ once daily.once daily.

Pt.’s Plt. Count = 250,000 mm3Pt.’s Plt. Count = 250,000 mm3

Pt’s Plt. Count = 80,000 mm3Pt’s Plt. Count = 80,000 mm3

Pt’s Plt. Count = 450,000 mm3Pt’s Plt. Count = 450,000 mm3

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Diagnostic Studies:Diagnostic Studies:Case Study #2Case Study #2

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Diagnostic Studies:Diagnostic Studies:Coagulation Cont.Coagulation Cont.

How long does it take for blood to clot?How long does it take for blood to clot?

PT & INRPT & INR Assessment of extrinsic coagulationAssessment of extrinsic coagulation

To monitor patients taking certain medications as well To monitor patients taking certain medications as well as to help diagnose clotting disordersas to help diagnose clotting disorders

Used primarily to evaluate oral anticoagulant Used primarily to evaluate oral anticoagulant therapy: warfarin (Coumadin) therapy: warfarin (Coumadin)

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Diagnostic Studies:Diagnostic Studies:Coagulation Cont.Coagulation Cont.

PTT & aPTTPTT & aPTT

Assessment of intrinsic coagulationAssessment of intrinsic coagulation

Used to monitor therapeutic HeparinUsed to monitor therapeutic Heparin

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Diagnostic Studies:Diagnostic Studies:

CXRCXR•Examine lung Examine lung fields and heart fields and heart sizesize

•Check for normal Check for normal heart size and heart size and contour, change in contour, change in heart chambers, heart chambers, displaced heart, displaced heart, presence of extra presence of extra fluid around the fluid around the heartheart

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Cardinal Signs and Symptoms (pp 687-688)Cardinal Signs and Symptoms (pp 687-688)

Chest PainChest PainPalpitationsPalpitationsDyspneaDyspneaEdemaEdemaFatigueFatigue

PallorPallorSyncopeSyncope

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Chest Pain: AnginaChest Pain: Angina

Chest pain Chest pain due to due to reversible reversible ischemia to ischemia to myocardiummyocardium

reduced reduced

blood flow blood flow to the heartto the heart

Coronary Artery DiseaseCoronary Artery Disease

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Chest Pain: Myocardial Infarction (MI)Chest Pain: Myocardial Infarction (MI)

Ischemia to the heart muscle is Ischemia to the heart muscle is irreversibleirreversible and and results in tissue damage (infarction) and necrosisresults in tissue damage (infarction) and necrosis

Obstruction of blood flowObstruction of blood flow Atheroma (plaque)Atheroma (plaque) ThrombosisThrombosis Embolism Embolism

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Chest Pain: Myocardial Infarction- Chest Pain: Myocardial Infarction- Cont.Cont.

CAD with Thrombosis

Diminished coronary Diminished coronary perfusionperfusion

►► Ischemia – AnginaIschemia – Angina

►► Infarction – NecrosisInfarction – Necrosis• Fibrous scarringFibrous scarring

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Chest Pain: PericarditisChest Pain: Pericarditis Inflammation of pericardiumInflammation of pericardium Pleuritic type chest painPleuritic type chest pain pericardial scarring and fibrosispericardial scarring and fibrosis

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Chest Pain: What’s the difference?Chest Pain: What’s the difference?

ANGINAANGINA MIMI PERICARDITISPERICARDITIS

CauseCause IschemiaIschemia

Onset;Onset;

Precipitating Precipitating factorsfactors

SuddenSudden

No precip. FactorsNo precip. Factors

Often early amOften early am

QualityQuality

SeveritySeverity

squeezingsqueezing stabbing pain or stabbing pain or pressurepressure

SevereSevere

Sharp stabbingSharp stabbing

Moderate to severeModerate to severe

LocationLocation

RegionRegion

SubsternalSubsternal

May spread to May spread to chest, arms, back, chest, arms, back,

SubsternalSubsternal

May spread to ant. May spread to ant. Chest, arms, back, jaw, Chest, arms, back, jaw, neckneck

SubsternalSubsternal

Usually spreads to Usually spreads to left side or backleft side or back

Duration,Duration,

Relieving Relieving FactorsFactors

< 15 min< 15 min

Rest, Nitro, O2Rest, Nitro, O2

30 min or longer30 min or longer

Not relived by restNot relived by rest

Relieved with opioidsRelieved with opioids

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Locations of Chest PainLocations of Chest Pain

Other Symptoms- Other Symptoms- Ask about:Ask about:

SOBSOB DiaphoresisDiaphoresis N/VN/V Cold/clammy skinCold/clammy skin PalpitationsPalpitations FaintingFainting Loss of Loss of

consciousnessconsciousness

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Heart Failure (Pump Failure)Heart Failure (Pump Failure) A disorder in which the heart A disorder in which the heart

loses its ability to pump blood loses its ability to pump blood efficientlyefficiently throughout the body throughout the body

Affects Cardiac OutputAffects Cardiac Output SV X HRSV X HR

End result:End result:↓↓Cardiac OutputCardiac Output

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CausesCauses of Heart Failure of Heart Failure

Acute/Chronic Acute/Chronic ♥ Problems♥ Problems HTN -#1HTN -#1 CADCAD MIMI Valvular Valvular ♥ Disease♥ Disease

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Heart FailureHeart Failure Pathophysiology:Pathophysiology: Impaired Cardiac Function Impaired Cardiac Function

Failure to pump: Failure to pump: Failure to empty ventricles Failure to empty ventricles

& reduced delivery of blood & reduced delivery of blood into circulation (into circulation (↓↓ CO) CO)

Increased ventricular Increased ventricular pressurespressures

Elevated Elevated pulmonarypulmonary and and systemicsystemic pressures pressures

further further ↓↓ CO CO

Series of Series of compensatory compensatory mechanismsmechanisms

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Heart Failure Heart Failure Compensatory mechanisms of low CO…Compensatory mechanisms of low CO…

1. 1. SNS stimulation… SNS stimulation… ↑↑ HR HR and and

cardiac contractility… cardiac contractility… ↑ ↑ COCO

3. Ventricular hypertrophy … 3. Ventricular hypertrophy … cardiac contractility… ↑ COcardiac contractility… ↑ CO

2. Starling’s Law/…2. Starling’s Law/…

Ventricular dilationVentricular dilation: : ↑ ↑ CO CO

44. Decreased renal blood flow…increasing . Decreased renal blood flow…increasing Na & H20 retention…increases blood Na & H20 retention…increases blood volume, ↑ HR & CO.volume, ↑ HR & CO.

Pulmonary EdemaThe most severe manifestation of Left The most severe manifestation of Left Heart Failure Heart Failure

Fluid leak into the pulmonary interstitial Fluid leak into the pulmonary interstitial spaces (Pulmonary congestion/edema)spaces (Pulmonary congestion/edema)

Hypoxia and poor 02 exchangeHypoxia and poor 02 exchange

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Clinical picture…Clinical picture…Left Left Heart FailureHeart Failure Dyspnea/Dyspnea on exertion Dyspnea/Dyspnea on exertion (most (most

sensitive: absence indicates Tx sensitive: absence indicates Tx effective)effective)

Cough orthopneaCough orthopnea

Paroxysmal nocturnal dyspnea Paroxysmal nocturnal dyspnea (PND)(PND)

Productive cough with pink frothy Productive cough with pink frothy sputumsputum

Tachypnea Tachypnea

Pale, possible cyanoticPale, possible cyanotic

Clammy and cold skinClammy and cold skin

Crackles/WheezesCrackles/Wheezes

Extra heart sounds – S3, S4Extra heart sounds – S3, S4

Heart murmurHeart murmur

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CXR: Left Heart FailureCXR: Left Heart FailurePulmonary edemaPulmonary edema

Systemic Edema

Unresolved Left failureUnresolved Left failure: : eventually leads to right sided eventually leads to right sided failure failure by by venous congestion in the venous congestion in the systemic circulationsystemic circulation

Also Also other causesother causes……

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RightRight Heart Failure Heart Failure

Clinical picture…Clinical picture…((CongestionCongestion)) JVD, hepatomegaly JVD, hepatomegaly

and dependent edema and dependent edema (LEs, thighs, (LEs, thighs, abdomen-ascites)abdomen-ascites)

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Heart Failure Heart Failure Clinical manifestations : Clinical manifestations : Pulmonary Congestion (L) Pulmonary Congestion (L)

and Systemic Congestion (R)and Systemic Congestion (R)

Right Heart Failure Left Heart Failure

Pulmonary fluid overloadPeripheral fluid overload

BNP - Test Brain Natriuretic Peptide (BNP)

BNP is a substance secreted from the ventricles or lower chambers of the heart in response to changes in pressure that occur when heart failure develops and worsens.

BNP level in the blood increases when heart failure symptoms worsen

BNP level in the blood decreases when the heart failure condition is stable.

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Review: Subjective DataReview: Subjective Data

Pt. may c/oPt. may c/o anxietyanxiety DOEDOE PNDPND orthopneaorthopnea productive cough productive cough

with with pinkpink frothy frothy sputumsputum

Fatigue and Fatigue and weaknessweakness

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Review: Objective DataReview: Objective DataPA may reveal:PA may reveal:

Left heart FailureLeft heart Failure Tachypnea/SOBTachypnea/SOB Use of accessory Use of accessory

musclesmuscles Wheezes/CracklesWheezes/Crackles skinskin

Clammy/coldClammy/cold pale/cyanoticpale/cyanotic

Right Heart FailureRight Heart Failure peripheral edemaperipheral edema JVDJVD Ascites, enlarged Ascites, enlarged

spleen/liverspleen/liver

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Review: Review: Heart FailureHeart Failure

Left Heart Failure – Left Heart Failure – pulmonary congestionpulmonary congestion

Right Heart Failure – Right Heart Failure – systemic congestionsystemic congestion

Left Heart failure often Left Heart failure often leads to Right sided heart leads to Right sided heart failure causing failure causing biventricular failure biventricular failure

→ → Cor PulmonaleCor Pulmonale Note: There are other Note: There are other

causes of R Heart Failurecauses of R Heart Failure

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