OXYGENATION: CARDIAC FUNCTIONS Review of Cardiac Anatomy and Physiology

Throughout a person’s life, the heart and blood vessels work together as the main component of the cardiovascular system. The primary function of this system is to transport oxygen and nutrients to the tissues and to deliver the end-products of tissue metabolism to appropriate organ for their excretion The proper functioning of every organ and tissue depends on the efficiency and the effectiveness of the cardiovascular system. A healthy vessel distributes the blood at precisely the amount of blood available to every tissue of the body.

 Cardiac Structures

 The cardiovascular system consists of the heart, the major blood vessels that empty

into or exit directly from the heart, and a vast network of smaller peripheral blood vessels.  The hearts ability to pump blood is the result of the five qualities unique to cardiac tissue: o Automaticity – the ability to initiate electrical stimulus independently o Excitability – the ability to respond to electrical stimulation o Conductivity – the ability to transmit electrical stimulus from the cell in the heart o Contractility – the ability to stretch as a single unit and recoil o Rhythmicity – the ability to repeat the cycle with regularity  The heart is a four chambered muscular pump about the size of a fist o Upper Chambers – receiving chambers for blood  Right Atrium  Left Atrium o Lower Chambers – the heart’s pumping chambers  Right Ventricle  Left Ventricle  The interventricular septum divides the heart into two: the right side and left side o Right side: conducts pulmonary circulation o Left-side: responsible for systemic circulation

 It is surrounded by the pericardium, which is a saclike structure that surrounds and
supports the heart. It has two membranes: o Parietal (outer) pericardium – the tough, outer layer. Its density safeguards the heart from invasion by infectious microorganisms o Visceral (inner) pericardium – inner, serous layer. Serous fluid fills the pericardial space between the two layers lubricating the heart and reducing friction with each heart beat.  The heart has three layers o Epicardium (visceral pericardium) – the outer layer, composed of fibrous and connective tissue o Myocardium – the middle layer, consists of muscle tissue and is the force behind the heart’s pumping action. o Endocardium – the inner, thin, smooth layer of endothelial cells. The endocardium is in direct contact with the blood that passes through the heart.  The valves of the heart are membranous structures that ensure that blood passes through the heart in a one-way forward direction. The heart has four valves. o Atrioventricular valves – separate the atria from the ventricles. They prevent blood from returning to the atria when the ventricles contract.  Tricuspid valve – between the right atrium and the right ventricle  Bicuspid / Mitral valve – valve between the left atrium and the left ventricle

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o Semilunar valves – resemble portion of the moon, prevent blood from flowing

back into the ventricles after the heart contracts.  Pulmonic valve – valve between the right ventricle and pulmonary artery  Aortic valve – between the left ventricle and aorta

 Myocardial Blood Supply

 The left coronary artery branches out into the left anterior descending (LAD) artery
and the circumflex artery. o The LAD artery supplies blood to the anterior wall of the ventricle, the anterior ventricular septum, and the bundle branches. o The circumflex artery provides blood to the lateral and posterior portions of the left ventricle. The right coronary artery (RCA) fills the groove between the atria and ventricles and gives rise to the right marginal artery, ending as the posterior descending artery. o The RCA sends blood to the sinus and atrioventricular nodes to the right atrium. o The posterior descending artery supplies the posterior and inferior wall of the left ventricle and the posterior portion of the right ventricle.

 Coronary arteries receive blood primarily during ventricular relaxation (diastole)  Blood is pumped out to the systemic circulation during contraction of the ventricles
(systole)

 Circulation
 Inferior and superior vena cava to right atrium  Through tricuspid valve to right ventricle  Through pulmonic valve to pulmonary artery  To lungs  Through pulmonary veins to left atrium  Through mitral valve to left ventricle  Through aortic valve to aorta  To systemic circulation

 Electrical Conduction

 The heart contains specialized muscle fibers that generate and conduct their own electrical
impulses spontaneously  The following make up the system that conducts electrical impulses and coordinates chamber contractions: o SA Node (Sinoatrial) – is an area of nerve tissue located in the posterior wall of the right atrium. It is also called the pacemaker of the heart. It produces 62 -100 impulses per minute, the average of which is around 72 impulses. o AV Node (AV Junction) – located in the lower aspect of the atrial septum. It can be a secondary cardiac pacemaker, but normally receives electrical impulses from the SA Node and it is the only pathway for conducting impulses from the atria to the ventricles. The slow rate of action potential conduction in the AV node allows the atria to complete their contraction before action potentials are delivered to the ventricles. o Bundle of His – it is the intraventricular septum, which is relatively short, branching into right and left segments. o Purkinje Fibers – are diffuse network of conducing strands beneath the ventricular endocardium; they rapidly spread the wave of depolarization through the ventricles.  Impulses follow a right-to-left, top-to-bottom path  A normal electrical impulse is initiated at the SA node, the heart’s intrinsic pacemaker.

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 Once generated, the normal impulse must move forward through the conduction system to the ventricles.  Numerous events occur almost simultaneously in the following order after the initiation of the impulse at the SA node. o Atrial depolarization o Atrial contraction o Impulse transmission to the AV node o Impulse transmission to the bundle of His, bundle branches, and Purkinje fibers o Ventricular depolarization o Ventricular contraction o Ventricular repolarization.

 Cardiac Function

 Cardiac Output (CO) – total amount of blood ejected per minute (4-8 L / min; ave: 5L)  Stroke Volume (SV) – amount of blood ejected with each beat (ave: 65 – 70 mL)  Cardiac output equals stroke volume times heart rate (HR)

Cardiac Output = Stoke Volume x Heart Rate
 Alterations in cardiac output affect every body system  Ejection fraction is the percent of left ventricular end-diastolic volume ejected during systole (60 to 70%)

 Cardiac Cycle

 It refers to the contraction (systole) and relaxation (diastole) of both atria and both
ventricles.

 The contraction of the left ventricle can be felt as a wave-like impulse (pulse) in the
peripheral arteries.

 Starling’s Law – the greater the stretch of the myocardium as the ventricles fill with
blood, the stronger is the ventricular contraction.

 Heart Rate
 The normal heart rate is 60 – 100 beats per minute.  Sinus tachycardia is a rate of more than 100 BPM  Sinus bradycardia is a rate of lower than 60 BPM  Intrinsic heart rate is 90 BPM.  At rest, the heart rate of 70 BPM reflects the dominant control by the parasympathetic nervous system.

 Arterial Pressure
 It is the pressure of blood against the arterial walls.  Systolic pressure is the maximum pressure of the blood exerted against the artery walls when the heart contracts (normally 100 – 140 mm Hg)  Diastolic pressure is the force of blood exerted against the artery walls during the heart’s relaxation (or filling) phase (normally 60 -90 mm Hg).  Blood pressure is expressed as systolic / diastolic pressure (e.g. 120 /80)

 Blood Vessels

 Arteries are three-layered vessels that carry oxygenated blood from the heart to the
tissues. Arteries have thicker walls but are smaller in diameter. o Tunica Adventitia – the outer layer, consists of the connective tissue o Tunica Media – middle layer, consists of smooth muscle o Tunica Intima – the inner layer, composed of endothelial cells

 Arterioles are small resistance vessels that feed into capillaries 3

 Capillaries join arterioles to venules (larger, lower-pressured vessels that arterioles),  

where nutrients and wastes are exchanged. Venules join capillaries to veins Veins are large-capacity, low-pressure vessels that return unoxygenated blood to the heart. Veins have thinner walls than arteries because venous pressure is lower than arterial pressure. Despite being having thinner walls, veins, in turn, have larger diameters than those of arteries.

The Factors Affecting Normal Cardiovascular Function:

 Age – the rapid metabolic rate of newborns demands tremendous blood flow to the     

developing tissues. Their heart rate is considerably faster. In old age, the vascular system has naturally narrowed and stiffened, thus the BP somewhat increases. Activity and Exercise – increased metabolic demands from the exercising muscles will force the heart to beat faster. The increased temperature causes vasodilation, increasing local blood flow. Gender – heart rate and BP vary slightly among men and women. Men have usually lower heart rates but higher BPs. Menopausal women however, have comparably higher BP. Body Position – blood tends to pool to the lower gravity-dependent extremities. The heart usually must work harder to force blood through the system. Temperature – when the body temperature begins to rise, the autonomic system signals the arerioles to open wide (dilate) to allow heat loss. The opposite occurs when the body is exposed to cold. Lifestlyle and Habits – smoking increases heart rate and BP.

PHYSICAL ASSESSMENT FINDINGS  History
 Dyspnea  Paroxysmal nocturnal dyspnea  Orthopnea  Fatigue and weakness  Cough  Chest pain  Syncope  Palpitations  Leg Pain

 Physical Examination
 Blood pressure changes  Pulse changes including rate, rhythm, and quality  Skin color and temperature  Abnormal heart sounds  Edema  Arrythmias  Jugular vein distention  Respiratory distress  Vascular bruits  Point of maximal impulse alterations  Pruritus

DIAGNOSTIC TESTS AND PROCEDURES

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 Electrocardiography (ECG)
 Non-invasive test  Graphical representation of the heart’s electrical activity  Nursing Interventions: o Determine the patient’s ability to lie still o Reassure the patient that electrical shock won’t occur o Interpret ECG for changes

 Ambulatory Electrocardiography (Holter monitoring)
 Non-invasive test  Records the heart’s electrical activity and cardiac events for 24 hours  Nursing Interventions: o Advise the patient on activity limitations while wearing monitor:  Instruct the patient not to bathe, shower, operate machinery, or use a microwave oven or an electric shaver while wearing the monitor. o Instruct the patient to keep an activity diary.

 Cardiac Catheterization
 Invasive, fluoroscopic procedure  Examines intracardiac structures, pressures, oxygenation, and cardiac output  Nursing Intervention: o Before the procedure:  Withhold the patient’s food and fluids after midnight.  Take baseline vital signs and palpate peripheral pulses.  Place obtained written informed consent in the patient’s chart.  Inform the patient about possible nausea, chest pain, flushing of the face, or throat irritation form the injection of radiopaque dyes.  Note the patient’s allergies to seafood, iodine or radiopaque dyes before testing  Shave and scrub the insertion site as ordered  Mark peripheral pulses with an “X”  Administer sedation as prescribed  Remove all jewelry, and prosthetic devises.  Ensure patent I.V. access o After the procedure:  Monitor vital signs, peripheral pulses, and insertion site for bleeding  Maintain a pressure dressing and bed rest for 4 to 8 hours, or as ordered.  Increase fluid intake unless contraindicated.  Allay the patient’s anxiety.  Monitor for complaints of chest pain, a possible sign of myocardial infarction (MI) – a serious complication of cardiac catheterization – and report immediately!  Keep affected leg extended  Assess peripheral pulses in both legs and compare to baseline  Monitor urinary output  Monitor for delayed reaction for radiopaque dye

 Coronary Arteriography
 Invasive, fluoroscopic procedure  Examination of coronary arteries  Nursing Interventions: o Before the procedure:  Note the patient’s allergies to iodine, seafood, or radiopaque dyes  Monitor the patient’s vital signs

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  o After   

Allay the patient’s anxiety. Inform the patient about possible flushing of the face or throat irritation from the injection. the procedure: Check the insertion site for bleeding Assess peripheral pulses Maintain a pressure dressing at bed rest

 Digital subtraction angiography
 Invasive procedure using a computer system and fluoroscopy with an image intensifier  Allows for complete visualization of the arterial blood supply to a specific area especially the carotid and cerebral arteries  Nursing Interventions: o Before the procedure:  Place obtained written informed consent in the patient’s chart  Monitor the patient’s vital signs  Remove all jewelry in the are to be imaged  Perform a baseline neurologic examination before cerebral angiography  Administer sedation, as ordered o After the procedure:  Check the insertion site for bleeding  Instruct the patient to drink at least 1 L of fluid  Monitor delayed reaction to radiopaque dye

 Echocardiography
 Non-invasive examination of the heart  Uses echoes from sound waves to visualize intracellular cardiac structures and direction of blood flow.  Nursing Interventions: o Determine the patient’s ability to lie still o Explain the procedure

 Exercise (Stress) Testing
 Non-invasive test of the heart  Study of the heart’s electrical activity and ischemic events during prescribed levels of exercise  Nursing Interventions: o Withhold food and fluids, especially those that contain caffeine, for 1 hour before the test o Instruct the patient to wear loose-fitting clothing and supportive shoes o Explain the procedure

 Nurclear Cardiology
 Visual examination of the heart using radioisotopes  Imaging of myocardial perfusion and contractility after I.V. injection of isotopes  Nursing Interventions: o Explain the procedure o Allay the patient’s anxiety o Determine the patient’s ability to lie still during the procedure

 Hemodynamic Monitoring (Single procedure or continuous monitoring)
 Invasive procedure involving balloon-tipped, flow-directed catheter placed in pulmonary artery (pulmonary artery catheter)  Allows for examination of intracardiac pressures and cardiac output  Nursing Interventions:

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o

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Before the procedure:  Place the obtained written informed consent in the patient’s chart  Explain the procedure and its purpose to the patient After the procedure:  Check the insertion site for infection  Monitor the pressure tracings and record readings

 Putting hemodynamic monitoring to use: o To understand intracardiac pressures, picture the cardiovascular system as a

continuous loop with constantly changing pressure gradients that keep the blood moving.  Right Atrial Pressure (RAP) or Central Venous Pressure (CVP) The RAP reflects right atrial, or right heart function and end-diastolic pressure • Normal: 1 to 6 mm Hg / 1.34 to 8 cm H20


Elevated value suggests: right sided heart failure, fluid volume overload, tricuspid valve stenosis or insufficiency, constrictive pericarditis, pulmonary hypertension, cardiac tamponade, or right ventricular infarction Low value suggests: reduced circulating blood volume

Right Ventricular Pressure (RVP) Right ventricular (RV) systolic pressure normally equals pulmonary artery pressure; RV end-diastolic pressure, which equals right atrial pressure, reflects RV function • Normal: systolic: 15 to 25 mm Hg; diastolic: 0-8 mm Hg

Elevated value suggests: mitral valve stenosis or insufficiency, pulmonary disease, hypoxemia, constrictive pericarditis, chronic heart failure, atrial and ventricular septal defects, and patent ductus arteriosus

Pulmonary Artery Pressure (PAP) Pulmonary artery systolic pressure reflects right ventricular function and pulmonary circulation pressures. Pulmonary artery diastolic pressure reflects left ventricular pressures, specifically left-ventricular enddiastolic pressure. • Normal: Systolic, 15 to 25 mm Hg; Diastolic: 8 to 15 mm Hg; mean: 10 to 20 mm Hg • Elevated value suggests: Left-sided heart failure, increased pulmonary blood flow (left or right shunting as in artial or ventricular septal defects), or any condition causing increased pulmonary arteriolar resistance. Pulmonary Artery Wedge Pressure (PAWP) PAWP reflects left atrial and left ventricular pressures unless the patient has mitral stenosis. Changes in PAWP reflect changes in left ventricular filling pressure. The heart momentarily relaxes during diastole as it fills with blood from the pulmonary veinsl this permits the pulmonary vasculature, left atrium, and left ventricle to act as a single chamber. • Normal: mean pressure: 6 to 12 mm Hg

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Elevated value suggests: left-sided heart failure, mitral stenosis or insufficiency, and pericardial tamponade Low value suggests: hypovolemia

Left Atrial Pressure

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This value reflects left ventricular end-diastolic pressure in patients without mitral valve disease. • Normal: 6 – 12 mm Hg  Cardiac Output Cardiac output is the amount of blood ejected by the heart each minute • Normal: 4 to 8 L; varies with the patient’s weight, height, and body surface area. Adjusting the cardiac output to the patient’s size yields a measurement called the cardiac index

 Chest X-ray (CXR)
 Non-invasive test  Provides radiographic picture of the heart and lungs  Nursing Interventions: o Determine the patient’s ability to hold his breath o Ensure that the patient removes jewelry before the test

 Blood Tests

 Laboratory test of a blood sample
 Blood Chemistries: Sodium Glucose Potassium Cholesterol Magnesium Triglicerides Calcium Phosphorus Uric Acid Bicarbonate
BUN (Blood Urea Nitrogen)

Creatinine CK (creatinine kinase) CK isoenzymes Troponin I

Troponin T Bilirubin AST (aspartate aminotransferase)
Alanine amino-transferase

 Nursing Interventions: o Note any drugs that may alter test results o Restrict the patient’s exercise before the blood sample is drawn o Withold I.M. injections or note the time of the injection on the laboratory slip (alter CK levels) o Withhold any food and fluids as ordered o Assess the venipuncture site for bleeding  Hematologic Studies: RBCs ESR (Erythrocyte PTT (Partial Hemoglobin Sedimentation Rate) Thromboplastin Time) WBCs PT (Prothrombin time) Platelets HCT (Hematocrit)  Nursing Interventions: o Note any drugs that may alter test results before the procedure o Assess the venipuncture site for bleeding after the procedure

 Arterial Blood Gas (ABG) Analysis
 Assessment of tissue oxygenation, ventilation, and acid-base status  Test of arterial blood  Nursing Interventions: o Before the procedure:  Note whether the patient needs supplemental oxygen or mechanical ventilation  Perform Allen’s test prior to obtaining sample  Avoid using a limb with an arteriovenous shunt o After the procedure:  Check the site for bleeding  Maintain a pressure dressing  Check peripheral pulses in the affected limb

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 Doppler Ultrasound

 Non-invasive test that transforms echoes from soundwaves into audible sounds
 Examination of blood flow in peripheral circulation  Nursing Interventions: o Determine the patient’s ability to lie still o Explain the procedure

 Venogram

 Visualization of the veins after I.V. injection of a dye
 Diagnosis of deep vein thrombosis or incompetent valves  Nursing Interventions: o Before the procedure:  Withhold food and fluids after midnight  Record the patient’s baseline vital signs and peripheral pulses  Place obtained written consent in the patient’s chart  Note the patient’s allergy to seafood, iodine, or radiopaque dye before the test  Inform the patient about possible flushing of the face or throat irritation form the injection  Ensure the patient is adequately hydrated o After the procedure:


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Check the injection site for bleeding and hematoma Force fluids unless contraindicated Evaluate for signs of delayed reaction to radiopaque dye Assess vital signs and compare to baseline

 Pulse Oximetry

 Non-invasive procedure using infrared light to measure arterial oxygen saturation in the

blood  Continuous assessment of oxygen saturation assists in pulmonary assessment of patient and weaning patient from a ventilator.  Nursing Interventions: o Avoid placing the pulse oximetry sensor on an extremity that has impeded blood flow. o Protect sensor from bright light o Attach the monitoring sensor to a fingertip, earlobe, or toe. o Consider using the earlobe if the patient has artificial nails, nail tips, or nail polish, as these may interfere with light transmission. Some sensors can accurately read through these as long as polish is removed, but this isn’t recommended.

PSYCOSOCIAL IMPACT OF A CARDIOVASCULAR DISORDER
 Developmental Impact o Fear of rejection o Lowered self-esteem o Fear of dying o Role conflict  Economic Impact o Disruption or loss of employment o Cost of hospitalization, medications, and special diets  Occupational and Recreational Impact o Restrictions in work activity o Changes in leisure activity o Restrictions in physical activity (walking, climbing stairs)

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Restrictions in activity related to environmental temperature; for example, hot or cold weather may interfere with patient’s ability to take walks or go outside  Social Impact o Changes in dietary habits such as dining out o Changes in sexual function o Changes in role performance including work, family roles o Social isolation o

MODIFIABLE RISK FACTORS
      Smoking Hypertension Hypercholesterolemia Obesity Physical inactivity Emotional stress

NON-MODIFIABLE RISK FACTORS
 Gender and Age  Family history of cardiovascular disease  Childhood history of cardiovascular illness  Ethnicity  Race

ALTERED CARDIAC FUNCTIONS

 Decreased pumping ability of the heart – can be a result of conduction problems
termed as cardiac arrhythmias, making the heart unable to pump coordinately. Another cause of pump failure is valvular dysfunction wherein the valves which guard the chambers may be damaged such as in myocardial infarction, which can weaken the pump action of the heart. Altered blood flow – d/t obstruction & narrowing which can affect tissue oxygenation. Altered blood composition – alteration in RBC, plasma, or circulating volume

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