The

CARDIOVASCULAR
System

1.Heart
2.Blood Vessels
3.Blood
… pumps blood
…transport blood
…carry oxygen & other substances
Heart

…..a hollow cone-shaped

muscular organ
 Location
Mediastinal Cavity

Rest on the diaphragm

Coverings

Parietal Pericardium Visceral

With 20-30 ml of serous fluid which protects

the heart from trauma & friction
Layers
EPICARDIUM

MYOCARDIUM

ENDOCARDIUM
 1. Atria
Chambers 2. Ventricles

Septum

Largest, high pressured &

most muscular
 1. Atrioventricular
Valves 2. Semilunar
 mitral valve

tricuspid
valve

aortic valve pulmonic valve

Structures that prevent backflow of blood

Flaps/cusps

Chordae tendinae

Papillary muscles
Structures of the Heart
 Blood Flow
From CS, SVC & IVC
to RA to LA via Tv
to PA to the LUNGS via Pv
to PV to LV to RV via Bv
to Aorta via Av
Circulatory Pathway
Pulmonary Circulation

Systemic Circulation
 Blood Supply LMCA
-L side of the heart

Circumflex
- lateral wall &
posterior wall of LV
- Occasionally:
interventricular
septum & SA/AV
nodes

RCA LAD
-R side of the heart - anterior wall
-Inferior wall of the LV - apex
-Posterior septal wall - anterior VS of LV
-SA & AV nodes
 Left Main Coronary Artery

Circumflex
Right Coronary Artery

LAD
 Properties:
1. Automaticity
2. Excitability
3. Conductivity
Pacemaker
of the heart 4. Refractoriness

Terminal Point in
the conduction
system

Conduction System
• Depolarization
• Repolarization

(2) Phases:
1. Systole
2. Diastole
Depolarization….

Ventricular pressure
Blood flow into the PA
1 & Aorta

S1
(lub)
Atrial pressure
Blood flow from atria
to ventricles

Ventricular pressure
Arterial pressure
(Pulmonary artery & Aorta)
 S2
(dub)
Blood flow from SVC
& IVC into the Atria
& Ventricles

3
….Repolarization
• Arteries
• Veins
• Capillaries
 Types

capillaries

venule

arteriole

artery vein
Layers

1. Tunica adventitia
2. Tunica media
3. Tunica intima
Lymphatic System
Control & Regulation

Regulatory Mechanisms

1. ANS
2. Receptors
3. Hormones
4. Others
 SNS
Norepinephrine
PSNS
Contractility
Acetylcholine HR/BP
CO
Contractility Vasoconstriction
HR
 Peripheral Baroreceptors,
Stretch/Mechanoreceptors and
Chemoreceptors

Baroreceptors
• Decreased HR
Mechanoreceptors
• Increased HR
• Vasoconstriction
Chemoreceptors
• Increased HR
Hormonal Influences

Posterior Pituitary Gland

Inhibition of ADH

Increased UO/Diuresis

Decreased Blood Volume

Increased BP
 Kidney

Conversion of Renin

Angiotensinogen

Angiotensin I & II

Vasoconstriction

Increased BP

Release of aldosterone

Increased Water & Na retention / Decreased UO

Increased BV
Histamine – vasodilation of small blood vessels
Bradykinin – vasodilation of superficial blood vessels
Serotonin – vasoconstriction of superficial arterioles
& vasodilation of capillaries
Lactic acid – vasodilation
• Chest pain
• Shortness of Breath
• Fatigue
• Palpitations
• Dizziness or Syncope
• Diaphoresis
• Edema / Weight Gain
• Intermittent claudication
• Skin changes: pallor,
rubor & cyanosis
• Reduce, obliterate or
absence of peripheral
pulse
• Alopecia, brittle nails,
dry skin, atrophy,
ulcerations & gangrene
 stabbing

constricting

burning heavy pressure

 and their underlying causes

Due to decreased coronary tissue perfusion or

compression & irritation of nerve endings
•Sharp, severe substernal
pain or pain to the left of the
sternum

•Maybe felt in epigastrium or

referred to neck, arms & back

•Intermittent, with sudden

onset; increases with
inspiration, swallowing,
coughing & rotation of trunk

•Relieved by sitting upright &

medications (analgesic/anti-
inflammatory)
• Pericarditis
•Substernal or retrosternal
pain spreading across chest

•May radiate to inside of

arm, neck or jaws

•5-15 mins, usually related

to exertion, emotions,
eating, cold weather

•Relieved by rest, NTG &

oxygen

• Angina Pectoris
•Substernal or pain over
precordium

•May spread widely

throughout chest
• With painful disability of
shoulders & hands

•> 15 mins, Occurs

spontaneously but may be
sequela to unstable angina

•Relieved by MoSO4

• AMI
•Substernal pain
•May be projected around
chest or shoulders

•5-60 mins, spontaneous

•Occurs when in recumbent
position, cold liquids,
exercise

• Relieved by food, antacids,

NTG

• Esophageal pain
• Hiatal hernia, reflux
esophagitis
• Pain arises from inferior
portion of pleura
• Maybe referred to costal
margins or upper abdomen
• Can be located by patient

• 30+ mins; often occurs

spontaneously; increases
with inspiration

• Relieved by rest, time and

bronchodilators

• Pleuritic pain
• Pain over chest
• Maybe variable
• Does not radiate

•Patient may complain of

numbness or tingling of
hands & mouth

• 2-3 mins.; occurs with

stress, emotional tachypnea

• Removal of stimulus,
relaxation techniques

• Anxiety
Exertional Dyspnea
• Most common
• Occurs with physical exertion & relieved
by rest
• Occurs when the body uses more
oxygen and makes more carbon dioxide -
during exercise or physical activity
• May indicate DECREASED CARDIAC
RESERVE
PND
• SOB with sudden onset
• Occurs during sleep or at night
• Awakens patient with feeling of suffocation
• Relieved by sitting up
• Heart failure
Orthopnea
• SOB when in reclining/ lying position
• Relieved by sitting up
• Heart disease or COPD
• as a consequence of INADEQUATE CARDIAC
OUTPUT

• unpleasant awareness of the heartbeat

• described as POUNDING, RACING or
SKIPPING
• Occur during mild exertion
• May indicate heart failure, anemia or
thyrotoxicosis
• Characterized generalized body weakness
with an inability to stand upright, followed by
loss of consciousness
• Due to decreased cerebral tissue perfusion

• Due to increased hydrostatic pressure in the

venous system resulting to fluid shift from IVF to
ISF
1. Childhood and Infectious
Diseases
2. Previous Illnesses &
Hospitalizations
3. Medications
1.Non-modifiable
2. Modifiable
1. Age Higher incidence in African
Americans than in whites
2. Gender Above
Males With
40
One of family
- before
theage
years old
TOPhxofleading
of65CVD
years old of
causes
Age death worldwide
3. Heredity Females – after age of 65 years
Heredity
Gender
Race
4. Race
 Stimulation of SNS during stressful situation
causes increased secretion of norepinephrine

Stress
 Increased dietary intake of Na, fats & cholesterol
Increased body weight

Diet/ Obesity
 Lack of exercise
Sedentary lifestyle

Exercise/Activity
 Nicotine causes vasoconstriction
& arterial spasm, increased
myocardial O2 demands,platelets
adhesion and decreased LDL
Smoking/ Alcohol
 Type A: competitiveness,
impatience, aggressiveness, and
time urgency
Behavioral Factors/
Personality Type
 Precipitate thromboembolism &
high blood pressure

Oral Contraceptives
1. Stress
2. Dietary Intake
3. Exercise & Activity
4. Habits
5. Type of Personality
6. Contraceptive pills
1. General Appearance - LOC
2. Skin - color
3. Vital Signs – BP, RR, PR
4. Jugular Veins – distention, CVP
5. Carotid Arteries – pulsations, bruits
6. Chest – heart sounds/ PMI
7. Extremities – peripheral edema, capillary
refill time, clubbing
8. Lungs – breath sounds, cough
9. Abdomen – liver, bladder problems
Assessing for Jugular Vein distention
A.Blood Tests

1. CBC
2. Lipid Profile
3. Cardiac Enzymes
4. Blood Coagulation
 Can you still
remember them?
RBC: Male: 4.5 M to
Significance 5.5M
· RBC- Decreases in RF, infective carditis, anemia Female: 4.5M
to 5.0M
Increases in heart diseases characterized by inadequate
WBC: 5,000 to 10,000/ mm3
oxygenation such as CHD, Polycythemia
Platelets:
· WBC - Increases in infectious & inflammatory 200T
diseases of the to 400T/ mm3
heart as well as MI Hgb: Male: 12 to 16 g/dl
· Hct - Increases in Hypovolemia & excessive diuresis Decreases in anemia
Female: 14 to18 g/dl
· Hgb- Decreases in various anemias Increases in Polycythemia, CHF
Hct: Male: 40% to 54%
Female: 31% to 47%
• Measurement of the RATE at which RBC’s
“settle out”
• N: Males: 15-20 mm/hr
Females: 20-30 mm/hr
• Significance:
• Increased in infectious heart disorders & MI
• Total Cholesterol
(150 to 250 mg/dl)
• LDL (<130mg/dl)
• HDL (35 –85 mg/dl)
• Triglycerides
(140 t0 200 mg/dl)
• Significance:
Increased in CADs

NPO for 10 to 12 hrs.

• Assist in diagnosis of INFECTIOUS
DISEASES of the heart
• Pericarditis

Prevent contamination of the SPECIMEN.

 Cardiac Enzymes

When myocardial tissues

are damaged, the • Following MI, the rise,
following enzymes are peak and normal
values should be
released: noted.
• The greater the
1. AST PEAK in enzyme
2. CK-MB activity and the
LENGTH of time it
3. LDH remains at peak
level, the more
serious the damage.
 Cardiac Enzymes

• AST(10-30 IU or 7-40 mu/ml)

– Increases when there is tissue necrosis
• CK-MB (35-232 IU or 50-325 mu/ml)
– MOST cardiac specific enzyme
– An accurate indicator of myocardial damage
• LDH(100-193 IU or 100-225 mu/ml)
– LDH1 is the most sensitive indicator of
myocardial damage
 Blood Coagulation
• PT
• PTT
• APTT
• Used to evaluate person
with high risk of thrombus
formation
• Also done to assess
patients receiving
HEPARIN and WARFARIN
(Coumadin).
 APTT : MOST specific test to evaluate effectiveness of HEPARIN
N: 30-45 secs.
PT : Measures the time required for clotting to occur after
thromboplastin & calcium is added to decalcified plasma
N: 11-6 secs
To evaluate effectiveness of COUMADIN (1.5-2x the
normal range)

PTT: Measures the required for clotting to occur after PT reagent is

added to plasma
N: 60-70 secs.
BEST single screening test for coagulation disorders
To evaluate effectiveness of HEPARIN (2-3x the normal range)
BUN: Indicator for RENAL function – tissue perfusion &
glomerular filtration
N: 10-20 mg/dl
Elevated when CO is decreased
low renal tissue
perfusion & reduction in GFR
B. Non-Invasive Procedures

1. CXR
2. ECG
3. Echocardiogram
4. Radio nuclide Testing
5. Doppler UTZ
 (Holter monitoring, Stress test/Treadmill)

•Measures the electrical activities of the heart

•Indicates changes in myocardial oxygenation
•FIRST diagnostic test done when CVD is suspected.

•Significance:
MI: Elevated ST segment
Inverted T wave
Pathologic Q wave
 (MYOCARDIAL SCINTIGRAPHY)

• Use of radioisotopes • Common

• To evaluate CA radioisotopes used:
perfusion, detect 1. Thallium 201
myocardial ischemia 2. Technetium 99m
& infarction and
assess left ventricular
function
Doppler UTZ

• To evaluate
patency and
valvular
competence of
blood vessels
C. Invasive Procedures

1. Cardiac
Catheterization
2. Angiography
3. CVP
4. PAP
 Cardiac Catheterization
• Radio opaque catheter is
inserted from the blood
vessels into the heart to:
1. Measure O2 concentration
• Sites for R-heart
2. Detect shunts
catheterization:
3. Obtain blood samples
– Femoral
4. Determine CO & blood flow
– Antecubital
5. Assess patency of CA
• Usually done with
Angiography
• Measure pressure in the
RA or large central vein
• Site: Subclavian, jugular,
antecubital/median basilic,
femoral
• N: 5-10 cm H20 or 2-6
mmHg
• Zero point: level of RA @
4th ICS MAL
 PAP/ PCWP
• A Swan-Ganz pulmonary
artery catheter is inserted then
passed into the VC and RA
until it finally reached the PA
• 110 cm long; flow-directed,
balloon-tipped and with 4-5
lumens
• N: 4-12mmHg (15 mmHg) or
25/9 mmHg
Swan-Ganz catheter
Significance:

If above 25 mmHg
suggests impending

PULMONARY EDEMA

1. Inflate balloon only for PCWP readings, deflate

between readings
2. Observe insertion site
3. Culture site every 48 hrs.
4. Assess extremities for color, temperature, sensation
& capillary time
1. Antiarrhythmics
2. Anticoagulants
3. Antilipemics
4. Beta-adrenergic blockers
5. Calcium channel blockers
6. Cardiac glycosides
7. Nitrates
8. Thrombolytic agents
9. Vasodilators
 i.e. LIDOCAINE

Action: Decreases cardiac excitability

Indications: PVCs, V-Tac, V-fibrillation

S/E: Bradycardia, tachycardia, hypotension, dizziness

confusion, drowsiness (1st sign of toxicity)
seizures (severe toxicity)

Nursing Alert: 1. Take apical pulse before admnistration

2. Administer LIDOCAINE IV
3. Stand by: Dopamine for circulatory depression
 i.e. Warfarin (Coumadin); Heparin

Action: Disrupt coagulation pathways

Indications: Thrombosis, Embolism

S/E: Anorexia, nausea, diarrhea, rash, bleeding,

Hematuria, thrombocytopenia & hemorrhage

Nursing Alert: C – heck V/S, platelet count, PT

O – bserve for bleeding
R – eview bleeding protocol
A – void ASA, may use acetaminophen
 i.e. drugs that end in “LOL”

Action: Decreases contractility, renin release &

sympathetic output
Indications: HPN in CAD, Angina, MI , arrhytmias

S/E: B – radycardia
L – ipedemia, Libido
brO – nchospasm
C – HF/ conduction abnormalities
K – onstriction peripheral vascular
E – xhaustion/ emotional depression
R – educes recognition of hypoglycemia
1. Monitor blood sugar in DM patients
2. Monitor Triglycerides/cholesterol
3. Monitor BP & PR prior to administration
4. DO NOT give if HR/PR is below 60 bpm
or if SBP less than 90 mmHg
 i.e.Amlodipine, Diltiazem, Felodipine
Nifedipine, Verapamil

Action: Inhibit CA ions, produced vasodilation,

decreased contractility
Indications: HPN in CAD, Angina

S/E: Headache (most common), hypotension, syncope,

Peripheral edema & bradycardia; constipation

Nursing Alert: Do not give if SBP < 90 mmHg & PR < 60 bpm
Do not chew or crush
Take with meals
Monitor I & O
 i.e. Digoxin, Digitoxin

Action: Increases the force of contraction, slow HR & nerve

conduction
Indications: CHF, Atrial fibrillation/ flutter

S/E: Nausea (1st sign of adult toxicity),

GI upset (older child), confusion (elderly),
Anorexia dizziness, photophobia, halos and flashes
of light, bradycardia, muscle weakness, depression
1. Monitor apical pulse for one full minute
2. DO NOT give if SBP , 90 mmHg
3. and HR <60 bpm
4. Weigh daily, monitor I & O
5. WOF signs of CHF
 i.e. NTG, ISDN

Action: Relaxes vascular smooth muscle

Decreased myocardial demand for oxygen, venous
return, arterial BP, left ventricular workload

Indications: Angina Pectoris

S/E: Headache, syncope, weakness, nausea,

hypotension
1. Monitor BP & HR before administration
2. Have client sit or lie down if taking drug for the
1st time
3. Oral: Instruct to take ON EMPTY STOMACH
with a full glass of water
4. DO NOT chew tablet
5. Protect from light, moisture & heat
6. Apply NTG patch OD usually in AM
7. Rotate site of application
 i.e. t-PA, StreptokinASE, urokinASE

Action: Dissolves blood clots

Indications: Deep vein thrombosis, Pulmonary embolism

S/E: Headache, Nausea, rash, fever, bleeding, allergic

reaction, hypotension
C– BC, Hgb, Hct monitoring
L– ook for dysrhytmias
O– bserve for bleeding
T– he V/S must be monitored during & after infusion
 i.e. Hydralazine, Minoxidil

Action: Direct relaxation of vascular smooth muscle

Decreases afterload
Decreases PVR

Indications: HPN

S/E: Headache, dizziness, anorexia, N/V, diarrhea,

palpitations, tachycardia, hypotension, edema,
weight gain, flushing, nasal congestion, LUPUS-like
reaction (fever, facial rash, muscle/joint pains,
splenomegaly)
D– irectly acts on vascular smooth muscle causing
VASODILATION
I– ncreases renal & cerebral blood flow
L– upus-like reaction is common
A– ssess for peripheral edema of hands and feet
T- ake with food
O- ther S/E: headache, dizziness, anorexia,
tachycardia, and hypotension
R- eview BP
 i.e. Drugs that end in “PRIL”

Action: S – VR, PVR decreased

T – reatment of MI
R – elease of aldosterone, decreased
O – ccult diabetic retinopathy, decreased
L – VD after MI, decreased
Indications: HPN, CHF

S/E: C – ough; C/I in renal artery stenosis

H – ypotension. Hyperkalemia
F – irst dose: WOF hypotension
ood has loss of taste
C– BC, Hgb, Hct monitoring
L– ook for dysrhytmias
O– bserve for bleeding
T– he V/S must be monitored during & after infusion