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Cardiovascular System

Chapter 8

10/13/2010 1Ra'eda Almashagba

Cardiovascular System

Functions:

pump saturated oxygenated blood into

arterial system cells

pump desaturated deoxygenated blood to

lungs via veins for reoxygenation

Heart size depends on persons size

size of fist


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Anatomy of the Heart

Four Chambers: Right atrium

Left atrium

Right ventricle

Left ventricle

Four Valves:

Two atrioventricular (AV)

1. tricuspid

2. mitral

Two semilunar (SL)

1. pulmonic

2. aortic

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Heart

Chambers

Right

Atrium

Left

Atrium

Right

Ventricle

Left

Ventricle

Apex


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2 Types of Valves

AV valves - mitral between LA & LV

- tricuspid between RA & RV

Prevents backflow during contraction -systole

Semilunar valves - prevent backflow during relaxation of ventricles - diastole


Heart Valves

Apex

Left

Right

Tricuspid

Mitral

Pulmonary Veins


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The right ventricle occupies most of the anterior surface of the cardiac surface.

Inferior border lies below the junction of the sternum and the xiphoid process.

RV narrowed superiorly and meets at 3ed costal cartilage.

LV : apical Impulse 5th ICS MCL.

RA and LA not identified in the physical examination.


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Coronary Circulation


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Four Chambers

Right atrium (deoxygenated bld)

Right ventricle (to lungs)

Left atrium (receives oxygenated blood)

Left ventricle (to systemic circulation)


Pulmonary and Systemic Circuits

Systemic Circuit

Left side of heart

Pumps oxygenated

blood to body via

arteries

Returns deoxygenated

blood to right heart via

veins

Pulmonary Circuit

Right side of heart

Pumps deoxygenated

blood to lungs via

pulmonary arteries

Returns oxygenated

blood to left heart via

pulmonary veins


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Cardiac Cycle

It has two phases:

(A) Diastole – ventricles relax & fill with

blood (This is 2/3 of the

cardiac cycle.)

(B) Systolic – heart contracts & pushes

blood out of the ventricles to:(i) the lungs

(ii) systemic arteries

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Cardiac Cycle

Systole & Diastole = 1 heartbeat

Systole - period when ventricles

contract & eject blood

- mitral & tricuspid close

- S1 produced


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Cardiac Cycle

Diastole - ventricles in relaxed state

- atria contract blood to

ventricles

- aortic & pulmonary valve close

- S2 produced


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Heart Sounds

S1 – when closure of the AV valves

(tricuspid & mitral) & ventricles

contract

S2 – when closure of the semilunar

valves ( pulmonic & aortic) &

the ventricles relax

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Extra Heart SoundsS3 – This occurs immediately after S2

Why? Resistance to filling of ventricles

Note: also called a ventricular gallop

*It is caused by overload.

* use diaphragm (it is a high sound)

S4 - This occurs at the end of diastole, just before the next S1.

Why? The atrium contract & push blood into a non-compliant ventricles.

Note: also called an atrial gallop

*caused by HTN, CAD, Aortic stenosis, cardiomyopathy

* Use bell to listen as it is a low sound.

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Heart murmur Distinguished from heart sound by

their longer duration.

Indicate serious heart disease.

Cause by a stenotic valver orifice (abnormal narrowed).

A systolic murmur may occure with normal heart or with heart disease.

Diastole murmur always indicate heart disease.


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Murmurs

Caused by ―turbulence‖

Therefore we hear a gentle blowing, swooshing sound.

Why?

1. Velocity of blood increases

(eg. exercise, thyrotoxicosis)

2. Velocity of blood decreases (eg. anemia)

3. Structural defect in the valves or an unusual

opening occurs in the chambers

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Grading of MurmursUse VI point grading scale & record as a fraction

(ie. I/VI or II/VI)

Grades:

Grade I – barely audible, heard only in a quiet room & then with

difficulty

Grade II – clearly audible, but faint

Grade III – moderately loud, easy to hear

Grade IV – loud, associated with a thrill palpable on the chest wall

Grade V – very loud, heard with one corner of the stethoscope lifted

off the chest wall

Grade VI – loudest, still heard with the entire stethoscope lifted off

the chest

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1-SA Node (Pacemaker)

2-AV Node

3-Bundle of His

4-Perkinje fibers

Conduction System


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Conduction System of the Heart


Electrocardiogram

Records electrical activity of the heart

P wave

Atrial depolarization

QRS complex

Ventricular depolarization

T wave

Ventricular repolarization


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EKG

Electrical activity recorded as specific waves.

Records 2 Electrical Events:

1. Depolarization - spread of impulse through

heart

2. Repolarization - return of heart muscle to

resting state.

Sequence of R & D = ACTION POTENTIAL


EKG other terms:

Conductivity - cells ability to conduct & transmit

electrical impulse

Contractility - ability of fibers to contract

- contractility = C.O.

EKG

P waves

QRS complex

ST segment


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The heart as a pump

Cardiac Output: The amount of blood pumped

from the left ventricle each minute

Cardiac Output = Heart Rate X Stroke Volume

Heart Rate

Number of times ventricles contract each minute

Normal adult 60-100

Stroke Volume

Amount of blood ejected by the ventricles during

each systole


Stroke Volume (SV) determined by

Preload

Contractility

Afterload


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Preload

Degree of myocardial fiber stretch at the end of diastole and

just before contraction

Determined by LVED pressure and blood return from the

venous system

Starlings Law: the more the heart fills during diastole, the

more forcefully it contracts

Afterload

Pressure or resistance that the ventricles must overcome to eject blood through the semilunar valves and into the peripheral blood vessels.

Contractility

The force of cardiac contraction independent of preload

Increased by:Sympathetic stimulation,Calcium release

Decreased by: Hypoxia and acidemia


Preload and Afterload


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Blood Pressure

Measure of pressure exerted by blood

against walls of arteries.

Systolic - pressure when heart contracts

Diastolic - pressure with relaxation


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Postural BP Changes

Compare and contrast normal

and abnormal blood pressure

responses to postural position

changes.

What do orthostatic changes

indicate?


Jugular venous pressure & pulses Systematic venous pressure is much

lower than arterial pressure.

Wall of veins contain less smooth muscle than arterial wall.

Venous pressure fall when left venticular out put or blood volume is significantly reduced.

Pressure in the jugular vein reflect right atrial pressure.


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The Neck Vessels

The Carotid Artery

The Jugular Venous Pulse & Pressures

2 components: (a) internal jugular

(b) external jugular

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Neck Vessels


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The Health Hx

Common or Concerning Symptoms

Chest pain.

Palpitation.

Shortness of breath: dyspnea, orthopnea, or paroxysmal nocturnal dyspnea.

Swelling or edema.

Assessment. History - major symptom, chest pain.

P - exercise, straining, activity, emotional

- rest, O2

Q - crushing, heavy, dull, burning, pressure

(own words)

R - (L) Anterior chest

- (R) arm, jaw, neck, shoulders

S - anorexia, N & V

- SOB, anxious, sweaty, dizzy

T - constant, intermittent, sudden, insidious


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Palpitation Palpitations are an unpleasent

awareness of the heart beat.

Patients use various terms such as: Skipping, Racing, Pounding, Fluttering, or Stopping the heart.

Are you ever aware of your heart beat?.

Ask Pt about the rhythem( was it fast or slow, regular, irregular).

Shortness Of Breath Dyspnea is uncomfortable awarness of breathing that

is inappropriate to a given level if exertion.

Orthopnea is duspnea that occurs when the Pt lying

down and improves when the Pt sits up.

Paroxysmal Nocturnal Dyspnea PND, describes

epispdes of sudden dyspnea & orthopnea that awaken

the Pt from sleep, usually 1or 2 hrs after going to bed,

prompting the Pt to sit up, stand up, or go to window

for air. There may be associated with wheezing &

coughing.


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Assessment continuo……

Cough

Fatique

Cyanosis or pallor

Edema

Past cardiac history

Family cardiac history

Personal habits

Environment

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Additional Assessment Areas Health perception and management

Nutrition and metabolism

Elimination

Activity and exercise

Sleep rest patterns

Cognition and perception

Self-perception and self-concept

Roles and relationships

Sexuality and reproduction

Coping and stress tolerance 10/13/2010 46Ra'eda Almashagba

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Physical Exam

Cyanosis

clubbing

edema

capillary refill

pulse - rate, rhythm, strength

pulse pressure - 120/80 pp - 40

General appearance - distress, color, LOC

Urinary output - kidney perfusion


Assessing for Clubbing


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Recommended Sequencefor assessing cardiovascular system

1. Pulses & BP

2. Extremities

3. Neck Vessels

4. Precordium

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Heart Rate or Pulse - Evaluate for

Rate 60 - 100 Adults

90 - 120 Children

70 - 170 Newborns

< normal = bradycardia

> normal = tachycardia

Rhythm Regular or irregular

Irregular beat may indicate arrhythmias

Strength Bounding? Arteriosclerosis

Weak and thready? shock


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Blood Pressure Classification Category Systolic (mmHg) Diastolic

(mmHg)

HypertensionStage 3 (sever)Stage 2

(moderate)Stage 1 ( mild)

≥ 180160-179140-159

≥ 110100-10990-99

High Normal 130-139 85-89

Normal < 130 < 85

Optimal < 120 < 80


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The Neck Vessels

A. Carotid Arteries Palpate low in neck to avoid the sinus

Be gentle

Palpate only one side at a time to avoid compromising blood flow to the head

Auscultate using the bell

Listen in 3 places: angle of jaw

midcervical area

base of neck

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Assessment of the Jugular Vein

Purpose: To measure the ―central venous

pressure‖

Method: Position patient @ 45 degree angle at

the hip, Turn head slightly away, Use a strong

light tangentially, Observe the external jugular

over the sternomastoid muscle

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Specific Process for CVP Measurement

Locate the internal jugular pulsation

Mark the highest point of pulsation

Locate the ―angle of Louis‖

Make a ―T square‖ with 2 index cards

Read the level of intersection

Note: The normal jugular venous pressure is

2 cm or less above the sternal angle.

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Jugular Vein Pressure


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Elevated JVP: Right-sided CHF, constrictive pericarditis, tricuspid stenosis, or superior vena cava obstruction.

Low JVP: Hypovolemia.

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Hepatojugular Reflux

This is measured if the CVP (central venous pressure) is elevated or CHF is suspected.

Patient is supine

Instruct patient to breathe quietly with mouth open

With rt. hand on the patient’s RUQ of abdomen, just below the rib cage, exert firm consistent pressure for 30 seconds

Watch the level of the jugular pressure

Note: Normally the jugular rises but recedes back.

Abnormally, the pressure elevates & stays.

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Hepatojugular Reflex


Congestive Heart Failure( CHF)


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The Heart ( Precordium)

Inspection: Check pulsations, heaves, lifts

(You may see the apical pulse.)

Note: The apical is located in the 4th or 5th

ICS @ the left MCL .

Palpate: Feel the apical impulse (also called the PMI). * Use 1 finger pad.

Use palmar side of 4 fingers to feel for other pulsations on the chest.(eg. ―thrills‖

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Palpation

Note any thrills

Palpate the PMI


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Palpation

PercussionPercussion: To check for heart enlargement

(Note:often done by chest Xray)


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Auscultation

1. Position the patient supine with the head of the table slightly elevated.

2. Always examine from the patient's right side. A quiet room is essential.

3. Listen with the diaphragm at the right 2nd intercostal near the sternum (aortic area).

4. Listen with the diaphragm at the left 2nd intercostal near the sternum (pulmonic area).

5. Listen with the diaphragm at the left 3rd, 4th, and 5th interspaces near the sternum (tricuspid area).


Auscultation 6. Listen with the diaphragm at the apex (mitral area). 7. Listen with the bell at the apex. 8. Listen with the bell at the left 4th and 5th intercostal near

the sternum. 9. Have the patient roll on their left side.

Listen with the bell at the apex. This position brings out S3 and mitral murmurs.

10. Have the patient sit up, lean forward, and hold their breath in exhalation. Listen with the diaphragm at the left 3rd and 4th

intercostal near the sternum. This position brings out aortic murmurs.

11. Record S1, S2.12. Auscultate the carotid arteries.


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Heart Assessment (continued)

Auscultation: Start at the base of the heart.

―APE to Man‖

Aortic - 2nd Rt. ICS

Pulmonic – 2nd left ICS

Erb’s Point

Tricuspid – left sternal border

Mitral – 5th ICS @ left MCL

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Sequence for Auscultating

A. Begin with the diaphragm.

Note at each area:

1. rate & rhythm

2. identify S1 and S2

3. assess S1 and S2 separately

4. listen for extra heart sounds (ie. S3,S4)

5. listen for murmurs

B. Repeat above using the bell.

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10/13/2010 69

What do you hear?

S1 and S2 sound like ―lub-dup‖

S1 is louder than S2 at the apex

S2 is louder than S1 at the base

S1 coincides with the carotid pulsation

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Auscultatory Areas


Relationship of auscultatory finding to the chest wall

Sounds & murmurs arising from the mitral valve are usually heared best at & around the cardiac apex.

The sound originated in the tricuspid valve are heard best at or near the lower left sternal border.

Murmur arising from pulmonic valve heard best in the 2nd left ICS close to the sternum.

The sound originated in the aortic valve may heard any where from Rt 2nd ICS to the apex.

The base of the heart refers to the Rt & Lt 2nd

ICS close to the sternum.


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First and Second Heart sound


Sounds – S1(Lub)…& S2(Dub)


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Extra Heart Sounds

S3…

Due to Rapid ventricularfilling: ventricular gallop

S1 -- S2-S3 (Ken--tuc-ky)

S4…

Due to slow ventricular

contraction: atrial gallop

S4-S1 — S2 (Ten-nes—

see)


Murmurs

turbulent blood flow

within the heart

Listen for murmurs in

the same auscultatory

sites APETM

Grading of murmurs

(I/VI -VI/VI)


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THE END

Thank You

Ra'eda Almashagba

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