Hemodynamics Apparatus Capillary Refill Test

• Hemodynamic Monitor - Pressing nail beds, 2 seconds.

• Blood pressure – 80/120 mmHg - Used to monitor dehydration & amount of
• Sphygmomanometer – Cuff Manometer blood flow to tissue.
• Digital manometer - Best site is index finger.
- display PR
- blood pressure 60-100 BPM
- use 3x, get average - is a healthy resting heart rate for most healthy
• Cubital area, 2 finger breath. adults.
- The more fit you are, the lower your resting
Proper Fit of a Blood Pressure Cuff heart rate will be.
• Too small – false high reading.
Factors can influence heart rate including:
• Too large – false low reading.
• Age
- Width of bladder = 2/3 of upper arm • Fitness & activity levels
- Length of bladder encircles 80% or arm. • Being a smoker
- Lower edge of cuff approximately 2.5 cm above • Having cardiovascular disease, high
the antecubital space. cholesterol, or diabetes.
• Air temperature
Arterial Pressure Measurement • Body position (standing up/lying down)
• Systolic pressure, measured at peak of • Emotions
waveform. • Body size
• Pressure reflects function of the left ventricle. • Medications
• Normal Value = 100-30 mmHg
• Lowest point on waveform – end diastolic Respiratory Rate:
pressure. - A person’s respiratory rate is the number of
• Pressure reflects systemic resistance. breaths you take per minute.
• Normal diastolic pressure = 60-90 mmHg - Adult normal respiration rate at rest is 12 to 20
breaths per minute.
Dicrotic Notch - Respiration under 12 or over 25 breaths per
- Small notch on downstroke of the waveform. minute while resting is abnormal.
- Represents closure of aortic valve.
- Reference point b/w systolic & diastolic Conditions that can change normal RR:
phases of cardiac cycle. • Asthma
• Anxiety
Mean Arterial Pressure/MAP • Pneumonia
- A calculated pressure closely estimates the • Congestive heart failure
perfusion pressure in aorta and its branches. • Lung disease
- Represents average systemic arterial • Use of narcotics
pressure during the entire cardiac cycle. • Drug overdose
- Normal MAP = 70-100 mmHg
- MAP MUST be maintained above 60 for major Shock
organs to perfuse. - Failure to deliver or utilize adequate amounts
of oxygen.
Hypotension (low blood pressure)
- A reading of 90/60 mmHg or lower, w/c can Types of Shock:
be normal for some people. • Hypovolemic Shock
- If your low BP causes symptoms such as - Result from significant fluid loss.
dizziness, fainting, nausea, cold sweats & - Two hypovolemic shock secondary to
blurred vison, talk to your doctor to discover if fluid loss: refractory gastroenteritis &
other condition is behind the problem. extensive burns.
• Cardiogenic Shock
- Heart is unable to pump enough oxygen-
rich blood to body organs.

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 • Distributive Shock
- Cause of inadequate tissue perfusion.
• Obstructive Shock
- Physical obstruction of great vessels or
the heart itself.
Case 1:
23-year-old, female, 3months amenorrhea, had
profuse vaginal bleeding with hypogastric tenderness.
She claimed she passed some meaty materials. She
looks pale, dizzy & confused, with decrease urine
output. On physical examination, the patient is lying
quietly in bed and somewhat difficult to arouse with
sternal rub. Her pulse is 120 beats/min, BP is 80/40,
RR is 18, & temperature is 101 degrees Fahrenheit.
Her cardiac & pulmonary exam are within normal
limits. Her abdominal exam reveals some mild top
moderate suprapubic tenderness but is otherwise
normal. The rest of her physical examination is
normal. A Foley catheter is in place and contains dark
colored urine w/ small amounts of pus.
Pulse: 120 beats/min
BP is 80/40
RR is 18
Mental Status: Confused & dizzy.
Temp. is 101 degrees Fahrenheit.
Cardiac: no murmur; pulmonary exam are w/in normal
limits
HR: 120 fast, steady, regular.
Pulse Ox: 93%
Glucometer: 10 mg%
Capillary refill > 3
Urine: dark colored urine w/ small amounts of pus.
Diagnosis: Hypovolemic Shock
Intervention:
Oxygen by nasal prong 6L per minute
Normal Saline (NSS or LRS) to give bolus of 500 to
1L NSS, reassess and bolus again. If no response to
insert a CVP and give vasopressors.
Request for blood 2 units, patient’s type and
crossmatch and transfuse.
Reassess RR, BP, HR, mental status.
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Heart Anatomy & Physiology
Cardiovascular System
- To pump blood through the body, the
heart is connect to vascular system of the
body.
- Closed system.
- Designed to transport oxygen & nutrients
to cells of body & remove carbon dioxide
& metabolic waste products from the
body.
Components of CVS
• Heart
- A pump composed of 4 chambers (2 atria
& 2 ventricles).
- Driving force for CVS.
• Blood Vessels “System of tubes” including:
o Arteries & arterioles – w/c carries blood
from heart to all parts of the body.
- Arteries serves as distribution
channels to the organs.
Systole – contraction, valve opens. *Korotkoff sound*
Diastole – relaxation, close valve.
Human Heart
4 chambers:
o 2 atria (thin walled)
o 2 ventricles (thick walled)
• Veins - deoxygenated blood except pulmonary
vein.
• Arteries – oxygenated blood except pulmonary
artery.
• Valves – stop blood flowing backwards.
• Coronary Arteries – supply the heart muscle
with food and oxygen.
o Venules & veins – carry blood back from
tissues to heart.
- Veins serves as blood reservoirs
& collect the blood to return it to
heart.
o Blood capillaries – form a network of fine
vessels connecting arterioles w/ venules.
- Sites of exchange of gases (O2 &
CO2), nutrients & waste products
b/w blood & tissues.
Valves of the Heart
- regulates the pumping actions of the heart.
• Mitral Valve – b/w R atrium & R ventricle,
prevents blood to go back to R atrium.
• Pulmonary Valve – opens goes to pulmonary
circulation.
• Tricuspid Valve – carries the blood away.
• Aortic Valve – towards aorta to circulation.
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 Systemic & Pulmonary Circulations
Construction of CVS
- Made up of 2 major circulatory system, acting
together.
- Right side of heart pumps blood to lungs
through pulmonary artery (PA), pulmonary
capillaries, & returns blood to left atrium
through the pulmonary veins (PV).
- Left side of heart pumps blood to rest of the
body through the aorta, arteries, arterioles,
systemic capillaries, & returns blood to right
atrium through venules & great veins.

•
In CVS, blood passes through 2 circulations in
series.
• 1 full circul. consist of these 2 circul. together.
• Both circul. start & end in the heart.
Two Circulations:
• Systemic (greater/high-pressure) circulation:
✓ Starts left ventricle – aorta – systemic
arteries – systemic capillaries – systemic
veins – superior & inferior vena cava – ends
in right atrium. *conti. basic function*
• Pulmonary (lesser/low-pressure) circulation: o Ventricular contraction (systole), distend
by blood ejected into them, & energy is at
✓ Starts in right ventricle – pulmonary trunk –
load in their walls.
pulmonary arteries – pulmonary capillaries –
o Ventricular relaxation (diastole), energy
pulmonary veins – ends in left atrium.
released causing elastic recoil of their
walls, w/c acts as additional pump to
• Two circulations are in series. Blood finishes one blood during diastole.
circulation to start the other. o Efficient pressure – maintained during
• Allow whole blood volume to carry out its systole & diastole, resulting in continuos
respiratory function more efficiently as blood goes blood flow through tissues.
once through systemic capillaries and once
through pulmonary capillaries. 2. Arterioles
• Both ventricles must pump the same volume of - resistance vessels that act as
blood during any significant time interval because variable resistors because
of the series arrangement of systemic & their diameters continuosly
pulmonary circulations. undergo changes in order to
regulate amount of blood flow
Basic Function of various CVS parts: into capillaries.
• Heart - “taps” regulating blood flow to
1. Left side of heart (high pressure side) tissues.
– acts as pressure pump that pumps
blood into systemic arteries at a
sufficient pressure that drives blood to
tissues.
2. Right side of heart (low pressure
sside) – pumps blood into pulmonary
arteries at a lower pressure that drives
blood into the lungs.
• Blood Vessels
1. Arteries – aorta & pulmonary artery o Ventricles occupy the bulk of heart.
are elastic arteries, have properties of o Arteries & veins all attach to base of heart.
stretch (=distention or compliance) o One-way flow through the heart to ensured by
and reccoil. two sets of valve.

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 o Atria has 2 main functions:
1. Act as blood reservoir for blood
returning to heart.
2. Act as pumps (primer pumps). Atrial
contraction pushes 25% of blood filling
the ventricles during ventricular
diastole about 75% of blood that
ventricles during diastole pass
passively by its own weight.
o Ventricles – powerful cardiac pumps filling
arteries w/ blood.
- Right ventricle (pulmonary
pumps) pushes blood into
pulmonary arteries
- Left ventricle (systemic pump)
pushes blood into aorta during
ventricular systole.
Cardiac Valves & Functions
Human heart contains 4 valves:
• 2 Atrioventricular Valves (AV) - b/w atria and
ventricles.
- Tricuspid valve b/w R atrium & R
ventricle.
- Mitral or tricuspid valve b/w L
atrium & L ventricle.
• 2 Semi Lunar Valves:
- Aortic valve b/w left ventricle &
aorta.
- Pulmonary valve b/w R ventricle &
pulmonary trunk.
Functions of CV:
• AV Valves – allow blood to pass from atria
into ventricles during ventricular diastole.
- Ventricular systole, AV valves
close to prevent back flow of blood
from ventricles into atria.
• Semi Lunar Valves – allow blood to pass from
the ventricles into arteries during ventricular
diastole, valves prevent back flow of blood
from arteries into ventricles (as valves closes
during ventricular diastole).
Note:
Valves open or close depending upon the
pressure gradient of blood on both sides of valves
e.g↓
o AV Valves:
- Open when atrial pressure
becomes higher than ventricular
pressure,
- Close when the ventricular
pressure becomes higher that the
atrial pressure.
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1. Semi Lunar Valves:
- Open when ventricular pressure becomes
higher than atrial pressure,
- Close when atrial pressure becomes
higher than ventricular pressure.
Right Ventricle (RV)
- Pumps large volumes of blood at low pressure
through pulmonary circulation
(RV is essentially flow generator).
- Normal cross-section of RV is crescent
shaped.
- Must eject blood against high pressure for
prolonged periods (seen in certain pulmonary
diseases)
- Assumes a cylindrical appearance & there is a
thickening of RV free wall (right ventricular
hypertrophy).
Left Ventricle (LV)
- Pumps blood through systemic circulations.
- Cylindrical in shape & normally has a thicker
wall than RV.
- Works much harder than RV because of
higher pressure in systemic circulation (LV is
essentially pressure generator).
- LV is commonly affected by disease process
than RV.
Blood Flow From Heart
o During ventricular systole – blood is pumped
into circulation.
o Diastole – pumping of blood stops & ventricles
get filled w/ blood.
o With this, flow of blood from ventricles into
systemic & pulmonary circulations is
intermittent pulsatile flow.
o Heart rate – under neural control
- Cardiac sympathetic efferent activity
increases heart rate.
- Parasympathetic (vagal) efferent impulses
decrease heart rate.
o Normal adult male heart beats regularly at 75
beats/minute during rest.
- Normal range of heart rate is b/w 60-100.
o Stroke volume for each ventricle averages
70ml of blood,
- Normal HR is approx. 70-75 beats/min
- Cardiac output at rest is approx.. 5 L/min
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 Areas of Ausculation

Assesing Peripheral Vascular System

1. Blood pressure.
2. Palpate peripeheral pulses & compare both
sides of the body.
o Rate & Rhythm.
o Volume & Character.
3. Inspect for presence of edema.

Procedure:
• Px lies in supine or sitting position w/
sphygmomanometer at level of heart.
• Arm cuff is tied around upper arm above
cubital fossa.
• Size of cuff, appropriate for arm.
Inspection • Cuff attached to mercury manometer:
1. Position client. 3 Methods:
2. Inspect client’s face, lps ears and scalps. 1. Palpatory Method:
3. Insp. jugular veins. - Radial artery is palpated.
4. Insp. carotid arteries. - Cuff is inflated until radial pulse
5. Ins. clienth and sand fingers, legs. disappears.
6. Inspect chest, abdomin. - Pressure is increased further by
20mmHg.
7. Listen with the diaphragm at apex (mitral
area). Purpose/Indications:
8. Listen w/ bell at apex. To Measure:
9. Listen w/ bell at 4th and 5th intercostal near • Any damage to heart.
sternum. • Heart disease
10. Have patient roll on their side: • Effects of drugs (digitalis) or devices
o Listen w/ bell at apex. (pacemaker) used to control heart.
o Position brings out S3 and mitral • Size & position of heart chambers.
murmurs. • Heart rate
11. Have px sit up, lean forward, & hold breath in • Heart rhythm
exhalation.
o Listen w/ the diaphragm at 3rd and 4th Symptoms Like:
intercostal neat sternum.
• Cardiac murmurs
o Position brings out aortic murmurs.
• Syncope or collapse
o Record S1, S2.
• Seizures
o Ausculatate carotid arteries.
• Perceived cardiac dysrhythmias
• Angina, palpitations, breathlesness
• S1 “lab” – closing of mitral & tricuspid valves.
• S2 “dub” – closing aortic & pulmonic valves.

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Note: o Small amount of coronary blood flows back
• Whether or not a px suffers from coronary into heart through Thebesian vein.
heart disease & needs further evaluation.
• If there is adequate blood flow to heart. Non-invasive Hemodynamic Monitoring
• If a person’s heart medication is properly
controlling angina and ischemia. • Noninvasive BP
• If a person has abnormal heart rhythms. • Heart rate, pulses
• Whether or not a procedure to improve blood • Mental status
flow w/in heart vessels has been effective. • Mottling (absent)
• Skin temperature
EVOLUTION • Capillary refill
Teleonomy: Toolbox: • Urine output
• Economy of • Heart flow
metabolic support. resistance. Normal Ranges
• Specificity & • Vasomotor tone, Cardiac index C.I. 3.0 - 5.0
selectivity of Frictional forces, Stroke volume index SVI 40 – 60
vascular coupling. Arterial pressure. Global end-diastolic GEDVI 680 - 800
• Territorially & • Arborescent volume index
temporality of circulation. Intrathoracic blood ITBVI 850 – 1000
metabolic demand. • Local inhibition of volume index
Extravascular lung EVLWI 3.0 – 7.0 ml/kg
• Diversification & vasomotor tone.
water index
complementarity of • Ontogeny. Stroke volume SVV ≤10 %
organ function. variation
IMPRINTING Cardiac function CFI 4.5 – 6.5
Pathology: Physiology: index
• Aging & • Mechanotransduction Mean arterial MAP 70 – 90 mmHg
pressure
hypertension. • Energy transfer & Systemic vascular SVRI 1700 - 2400
• Heart failure dissipation. resistance-index
• Valve diseases, • Outward convection.
Aneurysm. • Inward cellular Parameter Abbreviation Normal range
• Adventitial conductance. Central Venous CVP 0 – 5 mmHg
response. • Blood cell collision. Pressure
• Atheroma • Epigenetic plasticity Pulmonary Artery PAWP 6 – 12 mmHg
Wedge Pressure
• Fetal exaptation
Cardiac Index CI 2.4 – 4.0 L/min/𝑚2
Stroke Index SI 20 – 40 ml/𝑚2
HEMODYANIC VARIABLE Systemic Vascular SVRI 25 - 30 wood units
CONTRACTILITY (force) Resistance Index
Pulmonary Vascular PVRI 1 – 2 wood units
Resistance Index
Volume: Oxygen Delivery DO2 520 – 570 ml/min/𝑚2
o Preload: Oxygen Uptake VO2 110 – 160 ml/min/𝑚2
CVP – central venous pressure Oxygen Extraction O2ER 0.2 – 0.3
Ratio
PAWP – pulmonary arterial wedge pressure
Resistance:
Coronary Blood Flow (CBF)
o Afterload:
• Resting CBF in human, average is approx.
SVR – sustained virologic response
225ml/min, W/c is 0.7 to 0.8ml per gram of
PVR – post void residual
heart muscle.
• During diastole cardiac muscle relaxes
VESSELS,
completely & no longer obstruct blood flow
TISSUES,
through left ventricular capillaries.
VASCULAR BED
• This is phasic changes in coronary blood flow
during cardiac muscle compression.
o Venous blood flow from left ventricle leaves • During cardiac contraction – intra myocardial
by way of coronary sinus. pressure in inner layer of heart muscle is
o Most venous blood from right ventricle flow much greater than outer layer.
through small anterior cardiac vein directly • It compresses sub endocardial blood vessels
into right atrium & not connected w/ coronary far more than it compresses outer vessel.
sinus.
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 • Local metabolism as primary control of 2. Auscultatory Method:
coronary flow. - Steth. placed over brachial artery in
• Blood flow through coronary system is cubital fossa.
regulated almost entirely by vascular - Pressure is raised by 20mmHg after pulse
response to needs. disappears to occlude brachial artery.
- Pressure is releases from cuff through
Control of Coronary Blood Flow opening of valve.
1. Oxygen demand major factor in local blood A series of sounds – Korotkoff’s sounds are heard
flow regulation. 1st phase:
2. Determinants of oxygen consumption. o Sudden clear tapping sound
3. Importance of increase in coronary blood flow o Louder on releasing pressure
in response to myocardial oxygen usage. o Appearance – systolic pressure
nd
2 phase:
4. Reactive hyperemia in coronary system.
o Murmuring sound
rd
3 phase:
Electrocardiography (ECG/EKG)
- Transthoracic interpretation of electrical o Clear louder GONG type of sound
th
4 phase:
activity of heart over a period of time,
- detected by electrodes attached to outer o Mild muffled sound
th
5 phase:
surface of skin & recorded by a device
external to body (electrocardiograph). o Disappearance of sound
- Recording produced by this procedure is o Diastolic blood pressure
electrocardiogram (ECG/EKG- German
Elektrokardiogramm). 3. Oscillatory Method:
- Pressure is increased above systolic
Sphygmomanometry pressure – mercury column remains still.
• Use to measure blood pressure. Used in - When pressure decreased – oscillators
conjunction w/ stethoscope. occur.
• Manual sphyg. consists of: - Pressure is reduced further,
o inflatable cuff – to restrict blood flow, o Amplitude & duration of
o a measuring unit – the mercury oscillations suddenly increase –
manometer or aneroid gauge, & Systolic BP
inflation bulb & valve. - When further deflated – amplitude &
duration of oscillations is reduced –
Diastolic BP.
- Inaccurate
Uses:
Diagnosing
• Hypotension
• Hypertension
- Indicative of:
o Congestive Heart Failure
o Stroke
o Myocardial Infraction

• pressure is then releases slowly through

opening of valve.
• Mercury column is noted, pulse reappears &
felt.
• Systolic pressure is obtained.

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