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The Cardiovascular System
- Aorta
- left main Coronary Artery
- left circumflex
- left anterior descending
- right coronary artey
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The Cardiovascular System
- right atrium
- tricuspid valve
- right ventricle
- pulmonic valve
- pulmonary arteries
- pulmonic veins
- left arteries
- mitral valve
- left ventricle
- aortic valve
- aorta
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Diagnostic Studies
- CBC
- > WBC
- > RBC
- •HGB
- •HCT
- Coagulation
- >PLATELET COUNT
- >PT/INR
- >PTT/APTT
- CXR
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BLOOD COMPONENTS
- PLASMA 55%
- WHITE BLOOD CELLS AND PLATELETS <1%
- RED BLOOD CELLS 45%
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DIAGNOSTIC STUDIES BLOOD COMPONENTS WHITE BLOOD CELL DIFFERENTIAL
- WBC COUNT MEASUREMENT OF TOTAL NUMBER OF LEUKOCYTES
- WHITE BLOOD CELL BACTERIA
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WBC WITH DIFFERENTIAL
- NEUTROPHIL 55-70%
- BASOPHIL <1%
- EOSINOPHIL 1-2%
- MONOCYTE 5-6%
- LYMPHOCYTE 30-40%
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Diagnostic Studies:
WBC Differential–Neutrophils
- BAND IMMATURE NEUTROPHILS- RELEASED INTO CIRCULATION IN RESPONSE TO SEVERE INFECTION.(LEFT SHIFT OR BANDEMIA)
- shift to the left” – represents an increase in immature band neutrophils and
- occurs in severe bacterial infection but can also occur in acute stress
- situations
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WBCs
- >Increased with:
- .Infection, inflammation,
- autoimmune disorders, and leukemia
- >Decreased with:
- .Prolonged infection, or bone
- marrow suppression
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Diagnostic Studies:
RBC – Erythrocyte count
- >Number of circulating RBCs
- >RBCs produced from bonemarrow and erythropoiesis by kidneys
- >Altered in the sameconditions that alter Hgb and Hct values
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Diagnostic Studies:
Hemoglobin
- HEMOGLOBIN
- >HGB LEVEL: Measurement of the oxygen -carrying capacity of RBC
- >Essential substances: iron,Vit B12, folic acid, copper, pyroxidine, cobalt and nickel
- .Increased in:
- >Chronic hypoxia, polycythemia veraHemoconcentration (severe dehydration, burns, shock, vomiting),
- Decreased in:
- >Anemias; hemorrhage; or poor nutrition, chronic disease
- >Hemodilution (fluid volume excess);
- other anemias
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Diagnostic Studies:
Hematocrit
- HEMATOCRIT
- >The percentage of whole blood volume composed of erythrocytes
- >Women: 38-47 %
- >Men: 40-54 %
- >Altered in same conditions that alter Hgb and RBCs
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DIAGNOSTIC STUDIES COAGULATION
- MONITORING HEMOSTASIS
- BLEEDING=CLOTTING
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DiagnosticStudies:Coagulation
- Platelets – critical to hemostasis and clot formation
- Normal range: 150,000-400,000 mm3
- Monitor in patients receiving Lovenox
- ↑ in PV, malignancy
- ↓in bone marrow depression, autoimmune disease,
- hypersplenism
- •PV-Polycythemia Vera
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Diagnostic StudiesHow would you proceed?
- You are to administer Lovenox 40 mg SQ
- once daily.
- qPt.’sPlt.Count = 250,000 mm3
- qPt’sPlt.Count = 80,000 mm3
- qPt’sPlt.Count = 450,000 mm3
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DiagnosticStudies:
Coagulation Cont.
How long does it take forblood to clot? PT/INR
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>PT (Prothrombin Time)
- Assessment of extrinsic coagulation
- •Extrinsicfactors (II, V, VII, X) deal with problems or substances outside of the celland form a platelet plug.lInflamed or damaged blood vessels
- Normal range: 11-13 secl Increased in anticoagulant therapy
- •Decreased in vitamin K excess•
- >To monitor patients taking certain medicationsas well as to help diagnose clotting disorders
- >Used primarily to evaluate oral anticoagulant therapy: warfarin (Coumadin)
- >Therapeutic range: PT 1.5-2 X the patient’s normal PTl Ø
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DiagnosticStudies:
Coagulation Cont.
>International normalized ratio (INR)
- >Used to assess clotting time
- >Now used more often than PT to reduce errors
- >Normal range: 0.7-1.8
- >Warfarin therapy: maintain INR between2.0 to 3.0
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DiagnosticStudies:
Coagulation Cont.
>PTT (Partial Thromboplastin Time)& PTT (activated PTT)
- >Assessment of intrinsic coagulation
- >•Deal withproblems directly in the blood itself (abnormal blood/circulating debris,prolonged venous stasis)
- >Assesses clotting factors (II,V,VIII,IX,XI,XII)
- >Prolonged inhemophilia, DIC, liver disease•
- >Used to monitor therapeutic Heparin
- >Therapeutidc range: 1-2 X the normal values
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Diagnostic Studies:
CXR
- •Examine lung fields and heart size•
- •Check for normal heart size andcontour, change in heart chambers, displaced heart, presence of extra fluidaround the heart
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>Chest Pain: Angina
- Chest pain due to reversible ischemia to myocardium
- >reduced blood flow to the heart
- angina a type of temporary chest pain pressure discomfort
- due to narrowed artery
- heart muscle is not receiving enough oxygen due to a narrowed coronary artery
- pt take nitro pill under repeat x3 in 5 min
- DUE TO CAD
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Assessment of CV System
- Cardinal Signs and Symptoms(pp 712-715)
- >Chest Pain
- >Dyspnea
- >Fatigue
- >Palpitations
- >Edema
- >Syncope
- CAUSES of Chest Pain
- Angina
- MI
- Pericarditis
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Chest Pain: Myocardial Infarction (MI)
- >Ischemia to the heart muscle is irreversible and results in tissuedamage (infarction) and necrosis
- >Obstruction of blood flow
- Atheroma (plaque) fatty degeneration of inner coat of the arteries
- Thrombosis the formation or presence of a blood clot within a blood
- Embolism the sudden obstruction of blood vessel by an embolus
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chest pain: myocardial infarction cont.
- Diminished coronary perfusion
- Ischemia– Angina
- Infarction– Necrosis
- •Fibrous scarring
- CAD WITH THROMBOSIS
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Chest Pain: Pericarditis
- Inflammationof pericardium
- Pleuritic type chest pain
- pericardial scarring and fibrosis
- Sandy rough surface it is
- painful with breath In.
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ASSESSMENT OF CHEST PAIN T -35
Angina
Precipitating
factors
Onset
Quality
Severity
Region
Radiation
Duration (Timing)
Relieving Factors
Angina
Sudden, in response to emotion,
extremes in temp
Squeezing viselike pain
Substernal, may spread across the chest and
back or down arms
< 15 min;
Rest, Nitro, O2
MI
Sudden
No precip. Factors
Often early am
stabbing pain or viselike pain / pressure
Severe
Substernal
May spread to ant. Chest, arms, back, jaw, neck
30 min or longer
Not relived by rest
Relieved with opioids
Pericarditis
Sudden
Sharp stabbing
Moderate to severe
Substernal
Usually spreads to left side or back
Intermittent, relieved with
sitting upright, analgesia or anti-inflammatory agents
- Angina
- PRECIPTATION FACTOR ONSET
- Sudden, in response to emotion,extremes in temp
- QUALITY SEVERITY
- Squeezing viselike pain
- REGION/RADIATION
- Substernal, may spread across the chest and
- back or down arms
- DURATION/TIMING RELIEVING FACTOR
- < 15 min;
- Rest, Nitro, O2
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MI
- MI
- P FACTOR ONSET
- Sudden
- No precip. Factors
- Often early am IN MORING
- QUALITY/SEVERITY
- stabbing pain or viselike pain / pressure
- Severe
- REGION/RADIATION
Substernal
May spread to ant. Chest, arms, back, jaw, neck
- DURATION
- 30 min or longer
- Not relived by rest
- Relieved with opioids
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PERICARDITIS
Pericarditis
- QUALITY/SEVERITY
- Sharp stabbing
- Moderate to severe
- REGION/R
- Substernal
- Usually spreads to left side or back
- DURATION
- Intermittent, relieved with
- sitting upright, analgesia or anti-inflammatory agents
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LOCATION OF CHEST PAIN
- SOB
- Diaphoresis
- N/V
- Cold/clammy skin
- Palpitations
- Fainting
- Loss of consciousness
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LOCATION OF CHEST PAIN DUSING ANGINA OR HEART ATTACK
- UPPER CHEST
- SUBSTERNAL RADIATION TO NECK AND JAW
- SUBSTERNAL RADIATING DOWN LEFT ARM
- SUSTERNAL RADIATING DOWN LEFT ARM
- EPIGASTRIC RADAIATING TO NECK, JAW, AND ARMS
- NECK AND JAW
- LEFT SHOULDER AND DOWN BOTH ARMS
- INTRA SCAPULAR
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Heart Failure (Pump Failure)
>A disorder in which the heart loses its ability to pump blood efficiently throughout the body
- >Affects Cardiac Output
- SV X HR
- >End result:
- ↓Cardiac Output
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Causes of Heart Failure
- Acute/Chronic ♥ Problems
- HTN
- CAD
- MI
- Valvular ♥ Disease
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Heart Failure Pathophysiology: ImpairedCardiac Function
- >Failure to pump
- >Increased ventricular pressures
- >Elevated pulmonary and systemic pressures
- >further ↓ CO
- >Series of compensatory mechanisms
- Failure to empty ventricles & reduced delivery of blood into circulation (↓ CO)
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Heart Failure Compensatory mechanisms of low CO…
- 1. SNS stimulation… ↑ HR and
- cardiac contractility… ↑ CO
- 2. Starling’s Law/…
- Ventricular dilation.. ↑
- SV…↑ CO
- ENLARGED CHAMBERS
- STRECTCHED HEART MUSCLE
- 3 VENTICULAR HYPERTROPHY CARDIAC CONTRATILITY
- ENLARGED CHAMBERS
- THICKER MUSCLE WALL
- 4 DECREASE RENAL BLOOD FLOW INCREASE NA AND WATER RETENTION INCREASE BLOOD VOLUME INCREASE HEART RATE AND CO
- RENUN ANGIOTENSION SYSTEM ACTIVATION
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PULMONARY EDEMA
- Pulmonary Edema
- >The most severe
- manifestation of Left Heart Failure
- >Fluid leak into the
- pulmonary interstitial spaces (Pulmonary congestion/edema)
- >Hypoxia and poor 02 exchange
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Left Heart Failure
- >Dyspnea/Dyspnea on
- exertion (most sensitive: absence indicates Tx
- effective)
- >Cough orthopnea
- >Paroxysmal nocturnal dyspnea
- (PND)
- >Productive cough with pink frothy sputum
- >Tachypnea
- >Pale, possible cyanotic
- >Clammy and cold skin \
- >Crackles/Wheezes
- >Extra heart sounds – S3, S4
- >Heart murmur
- productive cough with pink frothy sputum
- Fatigue and w
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SYSTEMIC EDEMA
- 1 LEFT VENTRICULAR OUTPUT EXCEEDS RIGHT VENTRICULAR OUTPUT
- 2 PRESSURE BACKS UP
- 3 FLUID ACCUMULATES IN SYSTEMIC TISSUE
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RIGHT HEART FAILURE
- Right Heart Failure
- >Unresolved Left failure: eventually leads to right
- sided failure by venous congestion in the
- systemic circulation
- >Also other causes…
- Clinical picture…(Congestion)
- >JVD, hepatomegaly and dependent edema (LEs, thighs, abdomen-ascites)
- JVD JUGULAR VEIN DISTENSION
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BNP TEST
- Brain Natriuretic Peptide (BNP):
- Normal values:< 100
- >300 represents HF
- >a substance secreted from the ventricles of
- the heart in response to changes in pressure that occur when heart failure develops and worsens.
- >BNP level in the blood increases when heart
- failure symptoms worsen
- >BNP level in the blood decreases when the
- heart failure condition is stable.
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REVIEW
- REVIEW
- Heart Failure Clinical manifestations :
- Pulmonary Congestion (L)
- and Systemic Congestion (R)
- Biventricular failure will eventually happen
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LEFT SIDE
- ANXIET
- FALLING OXYGEN SATURATION
- CONFUSION
- JVD
- INFARCT
- FATIGUE
- S3 GALLOP,
- TRACHYCARDIA
- ENLARGED SPLEEN AND LIVER
- DECREASED URINE OUTPUT
- WEEK, PULSE, COOL, MOIST, SKIN
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RIGHT SIDE
DILATED PUPILS SKIN PALE, GRAY OR CYANOTICDYSPNEA ORTHOPNEA CRACKLES, WHEEZECOUGHDECREASED BLOOD PRESSUREN/VASCITESDEPENDENT, PITTING EDEMA
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RIGHT SIDE
- Right
- Heart Failure
- peripheral edema
- JVD
- Ascites, enlarged spleen/liver
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LEFT SIDE
- PA may reveal:
- Left heart Failure
- Tachypnea/SOB
- Use of accessory muscles
- Wheezes/Crackles
- skin
- Clammy/cold
- Pale/cyanotic
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Left Heart Failure – _________ congestion
Right Heart Failure – _________ congestion
Left Heart failure often leads to _______ causing biventricular failure:
→ Cor Pumonale
Note:There are other causes of R Heart Failure
- 1 PULMONARY
- 2 SYSTEMIC
- 3 RIGHT SIDE
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