RESPIRATORY

SYSTEM
CARDIOVASCULAR

SYSTEM
CARDIOVASCULAR SYSTEM

ELECTROCARDIOGRAM
Hearth Sound

S1 – “lub” – closure of the valves

S2- “ dub” – clussure of the ventricular valves

S3- ventricular gallop- normal < 35, abn > 35

S4 –Atril gallop – heart failure, valve defect, RHD, MI

Conduction System
PARTS OF THE ECG
1. SA Node – 60-100/min @SVC and RA
P wave – atrial depolarization < 0.11 sec
2. AV Node – 40-60/min
QRS – ventricular depolarization <0.12
3. Bundle of His - right and left branch bundle of his
T wave – ventricular repolarization
4. Purkenji Fibers – 15- 40/min
U wave – PF Repolarization ---- abn

hypokalemia PR interval – 0.12-0.20

Normal Cardiac Output – 4-6lpm
QT interval – 0.32-0.40
Cardiac Volume – 5LPM

CV=SV x HR

SV =60-80ml
DYSTRRYTHMIAS-

ABNORMAL CARDIAC RHYTHYMM

1. Sinus Tachycardia

Heart rate <100bpm originating from SA nodes

Causes :Exercise, antiety, fever, drugs, anemia, HF, hypovolemia, shock

Manifestation: asymptomatic, palpitation, hypotension, angina

Management : Beta-blockers, CCB, digitalis

2. Sinus Bradycardia

HR with <60bpm originating from SA nodes

Etiology: vagal stimulation, anorexi, hypothermia conditioned athletes

Manifestation : asymptomatic , fatigue, lightheadedness, syncope

Management : Atropine s04

3. Supraventricular Tachycardia or Paroxysmal Atrial Tachycardia

- an onset/ abrupt rapid heart rate originating from the atria

HR is 150-250bpm

Etiology : extreme emotion, alcohol, smoking, caffeine

Manifestation : palpitation , lightheadedness, dyspnea, angina

Management: Valsalva maneuver, Carotid sinus pressure, Digitalis, DOC – Adenosine

4. Atrial Fibrillation

Disorganized and uncoordinated twitching of atrial musculature caused by over rapid

production of atrial impulses

Characteristic : atrial rate 350-600

Ventricular rate : 120-200

Etiology : atherosclerosis, RHD,HF CHD, COPD, Thyrotoxicosis

Manifestation : Palpitation, dyspnea , pulmonary edema, signs of cerebral and vascular hypoxia

Management : Digitalis, CCB, anticoagulant, Cardioversion

5. V-Fib

Management: defib

6. Premature Ventricular Contractions – PVC

Wide and bizzare QRS

Management – Lidocaine
7. Asystole/ cardiac Standstill

CPR, EPI,

8. Torsades de Pointes

DOC- MGSULFATE

9. Atrial flutter - >150/min

Saw tooth p wave

Coronary Artery Disease/ CAD/Coronary Artherosclerosis

Narrowing of the coronary artery branch (LADA) d/t fatty plaque

Risk factor:

Non Modifiable : Age,Gender, Race, Family History, Genetic predisposition

Modifiable: HPN, Hyperlipidemia, DM, Obesity, OCP ( Estrogen), Cigarette Smoking, Sedendary lifestyle,
improper diet

Smoking contains nicotine --- vasoconstriction

Obesity - Normal BMI --- 18.5-24.5

OW- 25-29.9

Obese 30-39.9

Morbid 40-up

Pathophysiology:
Sx: 1 Asyptomatic

2. Chest Pain

Diagnostic:

1. Blood Lipid Profile NC – fasting x 12 hours

Total cholesterol - < 200mg/dl

LDL - <160 MG/ DL

Trigylceride <200mg/dl

HDL - > 40mg/dl

2. Stress test/ ECG

3. CBC- inc. ESR—inflammation

4. Coronary Angiography – cardiac lab – angioplasty

Site – Femoral artery, Fluroscopy

Brachial Artery

Managements

1. Antilipidemic drugs

➢ Statins- simvastatin

MOA: inhibits Hmg- Coa reductase -→ decrease LDL synthesis

SE – myalgfia due to rhabdomlyosis

AE- hepatoxic- possible increase ALT,SLT

 2. Bile Acid Sequestrants

- Cholestyramine

3. Fibric Acid derivatives

- Chlofibrates

4. Niacin/ B3

- Multiple SE

Nursing management

Knowledge Deficit

1.Provide Health teachings

Proper diet and nutrition – high unsaturated fat

Low sat , High complex cartbohydrates, , increase K +, smoking cessation, mod Alchoholism

Regular physical exercise (Aerobic Exercise ), brisk walking, jogging, swimming

For Females – STOP OCP – Combined estrogen and progesterone

SAFER – POP- Minipill

ANGINA PECTORIS
Angina Pectoris

--- chest pain d/t myocardiac schemia secondary to partial occlusion

Causes –

CAD (Atherosclerosis )

Anemia

Hyperthyroidism

Chronic Hypertension

Sx: 1. Precordial pain/ sternal pain

2. Pallor

3. Cold clammy skin

 4. Anxiety and fear

5. Tachycardia and tachypnea

Decrease myocardial tissue perfusion

Myocardial schemia

Anaerobic metabolism

Increase elactic acid

Chest pain

Types of Angina

1. Stable Angina -- < 15 mins

Emotional Stress

Eating Heavy Meals

Exertion

Expo to cold

2.Unstable -- @ rest

15-30 mins, unrelieved by NTG.

3. Prinzmetal/ Variant

- night d/t coronary vasospasm

Increase SNS d/t deep rapid eye movement

4. Intractable/ refractory

Diagnostic

1. ECG –most common

ST depression

T wave inversion

Flat T waves d/t myocardiac schemia

2. Angiography --- do determine obstruction ---confirmatory---cathlab

3. ESR (Erythrocytes Sedimentary Rate ) Normal – 20

4. Stress ECG- treadmill—no chestpain

NC 1. Avoid cola, coffee, tea—increase SNS

2.Avoid bronchodilators

Management

NTG- Nitrates

MOA- pheripheral vasodilation – vein ---dec retrun, dec preload

NC

1. Admin NTG SL 3x doses q 15 mins

2. Storage – 6 mons – dark amber

3. SE- Orthostatic hypotension, Headache

4. Prob- Tolerance- Due to frequent using

5. If patch avoid NTG at bedtime

6. NTG oral- Prohylaxis

 Aspirin – Anticoagulants

Aspilet – diphendamole

Clopidogrel

Ticlopidine

MOA—inhibits platelet aggregation

NC 1. Admin after meals

2. SE=-GI upset

3. Toxicity ( ASA) – Tinittus, Gi bleeding

Beta- Blockers- Metoprolol

MOA- inhibits B1 receptors, -- to decrease HR---- Increase myocardial tissue perfusion

NC- Bradycardia , Check apical pulse

PMI- 5th ICM mid clavicular line

CCB-Veraparil, Diltiazem

MOA- inhibits Ca across myocardial cell --- dec Hr-

Nursing management

Ineffective Tissue Perfusion: Coronary

Assess Vs, Positioning Semi Fowler 30-45 degress to decrease vascular resistant

Home – NTG, ER o2 @ 3-4 LPM

CBR, with bedside commode

Surgical management

1. Closed

Basilic Vein – Cepalic vein, greater sapheneous vein,

2. Open – CABG via thoracothomy

MYOCARDIAL INFARCTION

ACUTE MYOCARDIAC INFARCTION

-sudden chest pain d/t myocardial schemia/ necrosis sec total occlusion ( LADA)

Causes: Coronary atherosclerosis ( CAD)

Thromboembolism

Atrial Fibrillation

Direct Trauma --- GSW, stab wounds

Hemorrhage

M.I.

1. shock 4. cardiac tamponade

a. neurogenic (severe pain) 5. dysrhythmias
- the phrenic nerve is triggered

b. cardiogenic shock (pump failure)

- sympathonimetic (shock; s/sx

hypo-tachy-tachy)

nx mx: dopamine increases bp

PNS (rest)

SNS (fight/flight)

2. heart failure

3.Dreller ’s Syndrome

s/sx: chest pain – pleuritic, pericardial

f r i c t i o n r u b , a n d f e v e r.
Pathophysiology

Decrease myocardiac tissue perfusion > 30 mins

Myocardial necrosis

Increase SNS

Ventricular constriction

Increase preload and afterload

Decrease myocardial 02 supply

Bradycardia

- Unrelive- Decrease cardiac output

Sx.

1 Precordial pain – unrelieved by rest and NTG

P- rovoke

Q- uality tight, squezzing, heavy pressure

R-adiate right arms, shoulder

S-everity

T- ime < 30 mins- 45mins

Atypical – epigastric pain

2. Increase PR, RR
3. DOB

4. Cool Clammy Skin

5. Palor – cyanosis

Diagnostic

1. ECG

ST elevation

Prolonged Q wave

T inversion

Zone of Infarction –pathologic Q wave Palatandaan : It’z a Sin To Fa-Q

Zone of Injury – ST elevation

Zone of Ischemia – T wave inversion

2. Coronary Angiography

3. Serum Cardiac Enzymes

Troponin I –confirm

LDH (Lactse Dehydronase )

Myoglobin – 1st

CKMB

AST

Management

1. Narcotocs/ Opiod Analgesic

Morphine S04—MOA To decrease myocardsia; 02 demand

To decrease preload + afterload

NURSING CONSIDERATIONS

➢ IV infusion pump – for accuracy

o SE includes Nausea, vomiting, addiction, resp. depression, constipation, pupil;
constriction, tolerance, itchiness, hypotension
➢ Assess RR and BP
➢ Narcotrics antagonist – Naloxone

2. Thrombolytics- streptokinase, Tpa, alteplase

o MOA – activate plasmin, - dissolve thrombin/ fibrin

NURSING CONSIDERATIONS

➢ Admin within 3 hours

➢ SE – Hge
➢ WOF – Sx of bleeding
➢ Antagonist Aminocaproic acid

3.Anticoagulants – prevents venous blood clots

Heparin- parenteral IV and SQ

Enoxaparin – LMW- SQ

NURSING CONSIDERATIONS

➢ Check PTT x 1.5 -2

➢ SE Hge
 ➢ Antagonist – Protamine SO4
➢ IV infusion pump

4. Antiplatelet

- prevent arterial clot formation

5. Anti dysrhythmia

➢ Bradycardia – antropine sulfate (antichol – SNS )

➢ PVC – Wide and bizarre QRS – lidocaine
➢ V. tach – Amiodarone
➢ V. Fib – dfib
➢ Asystole / cardiac standstill – CPR EPI IV, ET, defib

Nursing Management

1. Acute Pain

➢ Assess VS, PS , severity, 7/10 neurogenic shock

➢ Monitor 02sat
➢ Position – semi fowlers
➢ Admin 02 – 2-3 lpm
➢ CBR

2. Ineffective tissue perfusion : cardiac

➢ Avoid valsalva maneuver – laxative, lactulose at HS

➢ Bedside commode
➢ WOF decrease tissue perfusion
Oliguria,
decrease peripheral pulses
skin—pallor/ cyanosis
CRT – normal 2-3 sec
➢ Holter Monitor , Lead 2,4
Complication of M.I

1. Shock

Neurogenic – severe pain

Cardiogenic shock – pump failure

Management – Sympathomimetic drugs – dopamine and dobutamine

2.Heart failure

3. Dreller’s Syndrome – Pericarditis

➢ Sx- Chest pain – pleuritic

➢ Pericardial frictyion rub
➢ Fever
NC – tripod position

4. Cardiac tamponade

➢ Sx: Paradoxical Pulse/ Pulsus paradxus

Decrease SBP . 10mmgHg on deep inspiration

➢ Narrowing of pulse pressure

Management : Pericardiocentesis

5. Dysrhythmias – abnormal cardiac rhythm

Sx . decrease CO=- restlessness

Chest pain, pallor, syncope, palpitation, hypotension , lightheadedness

➢ Sinus Bradycardia
SA > 100, ECG – regular , management : BB, CCB, Digoxin

➢ Sinus Bradycardia
SA < 60, Management : Atropine Sulfate

➢ Supraventricular Tachycardia or Paroxysmal Atrial Tachycardia

ECG- ectopic P wave, short PR interval,
DOC – Adenosine
Management :BB, CCB, Vagal maneuver

Cough, gag,cold H20, Bear down, Swat (Head to knees)

➢ Atril Flutter >150beats/ min
o Saw toothed p wave

Management : BB, CCB

➢ Atril Fibrilation -Atrial rate >300bpm, No P wave , irregular QRS

Management : Heparin Na, Cardioversion

➢ Av Block/ Heart Block

1st degree AV Block – Prolonged PR interval
2nd degree AV Block
Mobitz Type 1- Wenchkeback phen
-Progressively prolonge PR
- Dropped QRS
3rd degree Av Block - <40bpm, wide QRS

nx consideration: do not
Management: Pacemaker
Generator; Battery 5-10 years go to places w high

voltage (to prevent

NC- 1. Check the apical pulse
2. Complic- Infection dysrhythmias)
3. Avoid high voltage
 ➢ Premature Ventricular Contraction

ECG – Wide and bizarre QRS

Management : Lidocaine

➢ Ventricular Tachycardia
➢ > 150-250bpm
No P wave
1 form QRS

Management : If conscious- Cardioversion, if not / pulseless- defib

➢ Ventricular Fibrilation
ECG- disorganized and chaotic
Mangement : Defib, CPR, Epi

➢ Asystole/ Cardiac standstill

No PQRS
Management : CPR, EPI, Defib

CARDIOVERSION DEFIBRILATION
Synchronized QRS (R wave ) Asynchronized
Sedated Unconscious
500-1000 J 200-360J
AFIB, V.Tach. SVT V.Fib, P VTach, Asystole

automated external defibrillator (agsao

nu ubraem)

- if heart rate decreases give atropine

- if asystole give cpr/epinephrine

- if bp decreases give dopamine

- if v-fib give defibrillation

2+ hours of tachycardia bradycardia

remember: if the px is having arrhythmia it means there’s no enough blood coming/pumping

from the heart (heart compensate hence tachycardia)

HEART FAILURE
Heart Failure

- Inability of the heart to get adequate CO to meet the body’s metabolic demand

Causes : CAD/ Ischemic Heart Dse

Chronic Hypertension

Pulmonary Embolism

M.I

Cogenital Heart Defects (VSD)

RHD

Pathophysiology

RSHF LSHF
INCREASE VENOUS CONGESTION PULMONARY CONGESTION- LUNG EDEMA

JVD CRACKLES- COURSE RALES

HEPATOMEGALY ORTHEOPNEA
ASCITES EXERTIONAL DYSPNEA
HEMMORHOIDS Frothy blood tinged sputum
ANOREXIA Paroxysmal Noctornal Dyspnea
BIPEDAL EDEMA –LATE SX

Sx:

➢ HPN
➢ Increase PR- palpitation
➢ Cyanosis
➢ Oligoria
➢ Restlessness
➢ Edema – late sign due to increase hydrostatic pressure
Diagnostic :

1. Echocardiogram – ejection fraction --- N 60%

2. CXR – cardiomegaly ( Hypertrophy of the ventricles )

3. ECG- proloned PR interval , prolonge QRS

4. Hemodynamic Monitoring

CVP (Central venous Pressure ) Pulmonary Capillary Wedge Pressure / PAP

N- 2-3 mmHg Swanzganz catheter

Increase RHF
Decrease Hypovolemia and DHN

Inserted at SVC, RA Pulmonary artery

5. Serum Beta Natriunetic Peptide – BNP—

To increase na, - H2O excreation

6. ABG

Management :

➢ Digitalis – Digoxin (Lanoxin )

MOA: increase Ca ++ influx across myocardial cells --- (+) innotripc effect , (-) chronotropic effect

NC . 1. SE- Bradycardia – check for apical pulse

2.Digitalis Toxicity – GI manifestation ( Digibind )

Anorexia, Abdominal Pain, NV, Diarhhea, Blurry of vision, Halos

 4. Diet – Increase K

➢ Sympathomimethics – dopamine , dobutamine

MOA: stimulate SNS , (+) inotropic, (+)chronotropic

NC. 1. IV, SE – tachycardia, palpitation , Tremors

➢ Diuretics
K wasting –
Loop diuretics – furosemide (Lasix)
MOA- inhibits reabsorption of NA+ + K ++ in the acending loop of Henle
Thiazide – hydrochlorothiazide
MOA- Distal tubule
NC.
1. Admin in AM
2. SE- DHN, DEC. K
K+ sparing
Spironolactone (Aldactone )
MOA- inhibits aldosterone
Increase NA ++ - H20 excreation
SE- DHN, inc. K

➢ Monitoring of ECG
hypoK hyperK

short and flat t wave peaked wave/ tall T wave

ST depression / downslopping ST elevation
U wave Proloned QRS complex
➢ ACE inhibitors

Betrablockers – MOA inhits SNS

N. Management

✓ Decrease Cradiac Outout

Assess VS
Monitor 02, ABG,CPV, PCVP
POs- High Fowler’s
Admin Digoxin
IV dotutamine
CBR w/ BRP
Diet – low sodium, low fat, low CHO, High Protein

✓ Fluid Volume Excess

Monitor weight- I and O , abdominal Girth
Admin diuretics – at morning
OFI- decrease
Diet Na
Paracenthesis – 5 liters
 HYPERTENSION
Define as Vasodilation of the arteries greater than or equal to 140/90

Classification
Classification SP DP
Pre HPN 120-139 80-89
Stage 1 140-149 90-99
Stage 2 160-179 100-109
HPN Crisis 180-110 180-120

Sx:
1. Asymptomatic
2. Nuchal Headache
3. Blurring of vision
4. N/V
5. Dizziness
6. Epistaxis

Diagnostics
Bp Monitoring
ECG
CXR
Urine Analysis to detect the cause
Management
A. ACE INHIBITORS
MOA - inhibits conversion of A1 to A2
Example. Captopril

B. ANGIOTENSIN RECEPTOR BLOCKER

MOA- inhibits ACE receptors in the lungs
NC- SE Cough ( non productive )
AE- increase K +

C. BETA BLOCKERS
- Blocks A1, A2, B1,B2
Examples :
Metoprolol (Selective or Cardioselective beta blockers)

Blockers of both Alpha and Beta- Receptors

Carvedilol selectively antagonizes alpha-1 adrenergic receptors; antagonizes beta-1 and beta-2
adrenergic receptors nonselectively. That is, Carvedilol is a selective alpha and non-selective beta
blocker.

Labetalol selectively antagonizes alpha-1 adrenergic receptors; antagonizes beta-1 and beta-2
adrenergic receptors nonselectively. That is, labetalol is a selective alpha and non-selective beta blocker.
D. CALCIUM CHANNEL BLOCKER

Examples- Amlodipine, Felodipine, Nifedipine

E. DIURETICS
Thiazide -decrease sodium reabsorption and therefore decreased fluid reabsorption
Example: Hydrochlorothiazide

F. SYMPATHOLYTICS
- inhibits SNS
Example- Clonidine , Methyldopa

G. Vasodilators
Example- Hydralazine

SE- Orthostatic Hypotension

Gradual change of position/ dangling of legs
Nursing management : Knowledge Deficit
1. Heat Teachings
Low sodium, low fat
Regular physical exercise: brisk walking 30 mins x 3 days / week
Smoking cessation
Moderate alcohol- red wine

ANEURISM
➢ Permanent dilatation of a part of the artery

Causes : coronary artherosclerosis

Chronic hypertension

Congenital malformation

Types:

1. SACCULAR – one side

2. FUSIFORM-both side

3. DISSECTING- bleeding between the layers of the aorta

Location
1. Cerebral Aneurism – increase ICP
2. Thoracic Aortic Aneurism- chest pain
3. AAA- pulsatile abdominal mass

Diagnostics
CT scan
UTZ
CXR
Management
I. Anti HPN
II. Antilipidemics
Surgery – Endovascular stent
Surgical resection with anastomosis

Nursing Management
I. Ineffective Tissue Perfusion- peripheral
➢ Supine, flat on bed
➢ Assess VS
➢ Avoid abdominal palpation
➢ Avoid Valsalva maneuver – lactoluse , enema

II. Risk for injury/ Fluid volume deficit

➢ VS
➢ WOF sign and symptoms of shock
 Buerger’s Disease
• Auto immune disorder
Cases : Chronic smoking Males

Increase blood viscosity

Blood clots

Occlusion
Skin color changes / decrease peripheral 02

Sx

• Intermittent claudification calf pain d/t exercion

• Thick nails/ thin nails
• Decrease peripheral pulse
• Gangrene
 Raynaulds Disease
Intermittent vasospasm of the arterioles
RF – Females , genetic predisposition, prolonged cold exposure, collagen dse

Sx. Pallor , Cyanosis, erythema

Dx. PE + HX
Angiography

Nursing management
1. NSAIDS
2. VD- Nifedipine , hydralzine
3. Amputation – Symes Surgery – ankle

Nursing managements
I . Ineffcetive Tissue Perfusion – peripheral
➢ Assess VS, skin color, temp (cold ) , peripheral pulses
➢ POS – reversed Trendelenburg – extended
➢ Pentoxifylline – to decrease blood viscosity
➢ Foot Care
➢ Stop smoking
➢ Warm temp
➢ Gloves
 Deep Vein Thrombosis

Blood clpots in the deep vein – either popliteal or femoral

RF- Pregnancy
OCP
Smoking
Hip/Abdominal/Pelvic surgery
Immobility

Sx.
➢ Homan’s Sign- cvalf pain upon dorsiflesion
➢ Edema
➢ Erythema/ Redness ®
➢ Warm to touch- C
➢ Pain/ tenderness- d
➢ Swelling- t
➢ Loss of function – FL
Compli- P.E

Dx. Duplex Utz

Venography – Obs

Management
➢ Thrombolytics
➢ Anticoagulants

Parenteral Oral
Heparin-IV, SQ Warfarin – Comadin
SQ – LMW ( dalteparin, enoxaparin) PO
Check PTT Check PT/INR

➢ Eat green leafy vegetable - inhibits Vit K dependent ( X, IX, VII, II )

Nursing Management
I. Acute Pain
II. NSAIDS except aspirin e.g naproxen
Warm compress
Pos- Elecate the affected legh

III. Ineffective Tissue perfusion

Wear compression stocking , anti embolic
Avoid massage, prolonge travel, leg crossing or sitting