Medical-Surgical Nursing

Cardiopulmonary System

Anatomy of the Heart

- Muscular, pumping organ of the body
- Left mediastinum
- Weigh 300 400 grams
- Resembles a closed fist
- Covered by serous membrane pericardium

Coverings

Pericardium
a. fibrous pericardium
b. serous
Layers

1. Epicardium (visceral pericardium)

-protects heart
2. Myocardium cardiac muscle
3. Endocardium epithelial/ connective/ fibers

Four chambers
A. Upper chambers -Collects blood
1. right atria
2. left atria
B. Lower chambers -pumps blood from heart
1. right ventricle
2. left ventricle
Arteries
carry blood away from heart
Veins
blood toward heart
Valves

A. AV valves
1. Tricuspid right atrium
2. Bicuspid or mitral - left atrium
B. Semilunar valves
1. Pulmonary semilunar (pulmonary trunk)
2. Aortic semilunar (aortic arch)

Passage of Blood Through the Heart

Blood follows this sequence through the heart: superior and inferior vena
cava right atrium tricuspid valve right ventricle pulmonary
semilunar valve pulmonary trunk and arteries to the lungs
pulmonary veins leaving the lungs left atrium bicuspid valve left
ventricle aortic semilunar valve aorta to the body.

Blood supply to the heart

Arterial supply
The heart is supplied with arterial blood by the right and left
coronary arteries, which branch from the aorta immediately
distal to the aortic valve
The coronary arteries receive about 5% of the blood pumped
from the heart, although the heart comprises a small proportion
of body weight
This large blood supply, especially to the left ventricle,
highlights the importance of the heart to body function
The coronary arteries traverse the heart, eventually forming a vast network of capillaries

Venous drainage
 Most of venous blood is collected into several small veins that join to form coronary sinus, which opens into
right atrium
The remainder passes directly into the heart chambers through little venous channels

CARDIAC CYCLE

1. sequence of events that occur when the heart beats There are two phases of this cycle:
Diastole - Ventricles are relaxed
Systole - Ventricles contract
2. Heart at rest
Blood flows from large veins into atria
Passive flow from atria into ventricles
3. Atria (R & L) contract simultaneously
Blood forced into ventricles
4. Ventricles (R & L) contract simultaneously
Atrioventricular valves close lubb sound
Blood forced into large arteries
5. Ventricles relax
Semilunar valves close dub sound
6. Heart at rest

Heart valves
Valves are flap-like structures that allow blood to flow
in one direction
The heart has two kinds of valves,
atrioventricular and semilunar valves

Conducting system of Heart

SA node
Acting as the heart's natural pacemaker,
the SA node "fires" at regular intervals to
cause the heart of beat with a rhythm of about
60 to 70 beats per minute for a healthy, resting
heart
The electrical impulse from the SA node triggers a sequence
of electrical events in the heart to control the orderly
sequence of muscle contractions that pump the blood out of the heart
AV node
The AV node (AV stands for atrioventricular) is an electrical relay station
between the atria (the upper) and the ventricles (the lower chambers of the heart)
Electrical signals from the atria must pass through the AV node to reach the ventricles

AV node (bundle of his)

The bundle of His is located in the proximal interventicular septum
It emerges from the AV node to begin the conduction of the impulse from the AV node to the
ventricles

Purkinje fibers
Purkinje fibers are heart muscle tissues that are specialized to conduct electrical impulses to ventricular
cells, which induce the lower chambers of the heart to contract
Impulses from the upper chambers of the heart are relayed by this node to large bundles of Purkinje fibers
referred to as the Bundle of His
These bundles branch into smaller elements and eventually form terminal ends that burrow into left and
right ventricular chamber muscles
As the impulse is passed to the ventricles, the muscles contract and pump blood
The contraction caused by the specialized fibers begins from the bottom of the ventricles and move
upwards so that the blood leaves the lower chambers through the pulmonary arteries and the aorta
Electrocardiography

Cardiac Output

CO is the amount of blood pumped by each

ventricle in one minute
CO is the product of heart rate (HR) and stroke
volume (SV)
HR is the number of heart beats per minute
SV is the amount of blood pumped out by a
ventricle with each beat

Regulation of Stroke Volume

SV = end diastolic volume (EDV) minus end
systolic volume (ESV)
EDV = amount of blood collected in a ventricle
during diastole
ESV = amount of blood remaining in a ventricle after contraction

Blood Vessels
Functions:
Distribution of blood
Exchange of materials with tissues
Return of blood to the heart

Structure:
Most have the same basic
structure:
3 layers surrounding a
hollow lumen

Arteries and veins are composed of three

tunics:
1. tunica interna
2. tunica media
3. tunica externa

Tunica Intima
innermost smooth layer
simple squamous epithelium
continuous with the endocardium
present in all vessels

Tunica Media
layer of smooth muscle - circular arrangement contains elastin
supplied by sympathetic division of the ANS
depending on bodys needs lumen is narrowed (vasoconstriction) or widened (vasodilation)

Tunica Externa (Adventitia)

thin layer of CT
elastic & collagen fibres

Vessels

Types
1. Arteries carry blood away from the heart
2. Veins carry blood towards the heart
3. Capillaries the most important part of the vascular system; site of exchange of materials
Disorders of the Cardiopulmonary System

ATHEROSCLEROSIS
- condition in which an artery wall thickens as a result of the accumulation of fatty materials such as cholesterol
-commonly referred to as a hardening or furring of the arteries. It is caused by the formation of multiple plaques within the arteries

Predisposing Factor
1. Sex male
2. Black race
3. Hyperlipidemia
4. Smoking
5. HPN
6. DM
7. Oral contraceptive- prolonged use
8. Sedentary lifestyle
9. Obesity
10. Hypothyroidism

Signs & Symptoms

1 Chest pain
2 Dyspnea
3 Tachycardia
4 Palpitations
5 Diaphoresis

Treatment
P percutaneous
T tansluminar
C coronary
A angioplasty

Objective:
1 To revascularize the myocardium
2 To prevent angina
3. Increase survival rate

PTCA done to pt. with single occluded vessel

CABAG-for Multiple occluded vessels is CABAG
C coronary
A arterial
B bypass
A and
G graft surgery

Nsg Mgt Before CABAG

1 Deep breathing cough exercises
2 Use of incentive spirometer
3 Leg exercises

ANGINA PECTORIS
- A clinical syndrome characterized by paroxysmal chest pain usually relieved by REST or NGT nitroglycerin,
resulting from myocardial ischemia

Predisposing Factor
1 sex male
2 black raise
3 hyperlipidemia
4 smoking
5 HPN
6 DM
7 oral contraceptive prolonged
8 sedentary lifestyle
9 obesity
 10.hypothyroidism

Precipitating factors
4 Es
1. Excessive physical exertion
2. Exposure to cold environment - Vasoconstriction
3. Extreme emotional response
4. Excessive intake of food saturated fats.

Signs & Symptoms

1 Initial symptoms Levines sign hand clutching of chest
Chest pain sharp, stabbing excruciating pain. Location
substernal
-radiates back, shoulders, axilla, arms &
jaw muscles
-relieve by rest or NGT
2 Dyspnea
3 Tachycardia
4 Palpitation
6.diaphoresis

Diagnosis
1.History taking & PE
2. ECG ST segment depression
3. Stress test treadmill = abnormal ECG
4. Serum cholesterol & uric acid - increase

Nursing Management
1.) Enforce Complete Bed Rest
2.) Administer medications as ordered
NTG small doses venodilator
Large dose vasodilator
st
1 dose NTG give 3 5 min
2nd dose NTG 3 5 min
3rd & last dose 3 5 min
Still painful after 3rd dose notify the phycisian, It may be a sign of Myocardial Infaction
Medications:
A. NTG- Nsg Mgt:
1. Keep in a dry place. Avoid moisture & heat, may inactivate the drug
2. Monitor S/E:
a. orthostatic hypotension decrease BP
b. transient headache
c. dizziness
3. Rise slowly from sitting position
4. Assist in ambulation.
5. If giving NTG via patch:
a. avoid placing it near hairy areas because it will decrease drug absorption
b. avoid rotating transdermal patches it will decrease drug absorption
c. avoid placing near microwave oven or during defibrillation it will burn pt. due aluminum
foil in patch
B. Beta blockers propanolol
C. ACE inhibitors captopril
D. Ca antagonist - nefedipine
3.) Administer O2 inhalation
4.) Semi-fowler
5.) Diet- Decrease Na and saturated fats
6.) Monitor VS, I&O, ECG
7.) Health Teaching
a. Avoid precipitating factors 4 Es
b. Prevent complications MI
c. Take meds before physical exertion-to achieve maximum therapeutic effect of drug
d. Importance of follow-up care
MYOCARDIAL INFARCTION(MI)
-hear attack terminal stage of CAD
-Characterized by necrosis & scarring due to permanent mal-occlusion

Types
1 Trasmural MI most dangerous MI Mal-occlusion of both R&L coronary artery
2 Sub-endocardial MI mal-occlusion of either R & L coronary artery

Most critical period upon diagnosis of MI 48 to 72h

Because majority of pt suffers from PVC premature ventricular contraction

Predisposing factors Signs & symptoms Diagnostic Exam

sex male 1. chest pain excruciating, vice like, visceral 1. cardiac enzymes
black raise pain located substernal or precodial area (rare) a.) CPK MB Creatinine
hyperlipidemia - radiates back, arm, shoulders, axilla, jaw & Phosphokinase
smoking abd muscles. b.) LDH lactic acid dehydrogenase
HPN - not usually relived by rest r NTG c.) SGPT (ALT) Serum Glutanic
DM 2. dyspnea Pyruvate Transaminase- increased
oral contraceptive 3. erthermia d.) SGOT (AST) Serum Glutamic
prolonged 4. initial increase in BP Oxalo-acetic - increased
sedentary lifestyle 5. mild restlessness & apprehensions 2. Troponin test increase
obesity 6. occasional findings 3. ECG tracing ST segment
hypothyroidism a.) split S1 & S2 increase,
b.) pericardial friction rub widening or QRS complexes means
c.) rales /crackles arrhythmia in MI indicating PVC
d.) S4 (atrial gallop) 4. serum cholesterol & uric acid -
increase
5. CBC increase WBC

Nursing Management
1. Narcotic analgesics Morphine SO4 to induce vasodilation &
decrease levels of anxiety
2. Administer O2 inhalation low inflow (CHF-increase inflow)
3. Enforce Complete Bed Rest without BP
a.) Prepare commode at bedside
4. Avoid valsalva maneuver
5. Semi fowler
6. General liquid to soft diet decrease Na, saturated fat,
caffeine
7. Monitor VS, I&O & ECG tracings
8. Take 20 30 ml/week wine, brandy/whisky to induce vasodilation
9. Assist in surgical; CABAG
10. Provide pt. Health Teaching
a.) Avoid modifiable risk factors
b.) Prevent complications:
1. Arrhythmias PVC
2. Shock cardiogenic shock. Late signs of cardiogenic shock
in MI oliguria
3. Thrombophlebitis - deep vein
4. CHF left sided
5. Dresslers syndrome post MI syndrome
-Resistant to medications
-Administer 150,000 450,000 units of streptokinase
c.) Strict compliance to medications
1. Vasodilators
a. NTG
b. Isordil
2. Antiarrythmic
a. Lydocaine
b. Brithylium
3. Beta-blockers lol
a. Propanolol (inderal)
4. ACE inhibitors - pril
a. Captopril (enalapril)
5. Ca antagonist
a. Nifedipine
6. Thrombolitics or fibrinolytics to dissolve clots/ thrombus
 d.) Resume ADL sex/ activity after 4 to 6 weeks
1.)Sex as an appetizer rather then dessert
Before meals not after, due after meals increase metabolism heart is pumping hard
after meals.
2.) Position non-weight bearing position

When to resume sex/ act: When pt can already use staircase, then he can resume sex.
e.) Diet decrease Na, Saturated fats, and caffeine
f.) Follow up care

CONGESTIVE HEART FAILURE(CHF)

- Inability of heart to pump blood towards systemic circulation
- Backflow
-CHF can be Left-sided or Right-sided
-Left-sided CHF can lead to Right-sided CHF, but Right cannot lead to Left
-Lasix is given to both types of CHF
-CHF is the inability of the heart to pump blood towards systemic
circulation
RIGHT-SIDED CHF the #1 cause is TRICUSPID VALVE STENOSIS
LEFT-SIDED CHF the #1 cause is MITRAL VALVE STENOSIS

Left sided heart failure

Predisposing factors
-Can be caused by Rheumatic Heart Disease:
Tonsillitis strep bacteria migrate to mitral valve
RHEUMATIC HEART DISEASE mitral stenosis LSHF

Complication
1. Right Sided-CHF
2. Aging degeneration / calcification of mitral valve
3. Ischemic heart disease
4. HPN, MI, Aortic stenosis

Signs and Symptoms

Pulmonary congestion/ Edema
1 Dyspnea
2 Orthopnea
3 Paroxysmal nocturnal dysnea
4 Productive cough with blood tinged sputum
5 Frothy salivation (from lungs)
6 Cyanosis
7 Rales/ crackles due to fluid
8 Bronchial wheezing
9 PMI(Point of Maximal Implant) is displaced laterally due to cardiomegaly
10 Pulsus alternons weak-strong pulse
11 Anorexia & general body malaise
12 S3 extra heart sound (Ventricular gallop)

Diagnostic
1 Chest Xray cardiomegaly
2 PAP Pulmonary Arterial Pressure
PCWP Pulmonary CapillaryWedge Pressure
3. Echocardiography reveals enlarged heart chamber or cardiomayopathy
4. ABG PCO2 increase, PO2 decrease = = hypoxemia = resp acidosis

Right sided HF

Predisposing factor
1 90% - tricuspid stenosis
2 COPD
3 Pulmonary embolism
4 Pulmonic stenosis
5 Left sided heart failure

Signs and Symptoms

 1. Venous congestion
2. Neck or jugular vein distension
3. Pitting edema
4. Ascites
5. Wt gain
6. Hepatomegalo/ splenomegaly
7. Jaundice
8. Pruritus
9. Esophageal varies
10. Anorexia, gen body malaise

Diagnosis
1. CXR cardiomegaly
2. CVP measures the pressure at R atrium
Normal: 4 to 10 cm of water
Increase CVP > 10 hypervolemia
Decrease CVP < 4 hypovolemia
Flat on bed position of pt. when giving CVP
Position during CVP insertion Trendelenburg to prevent pulmonary embolism & promote
ventricular filling
3. Echocardiography enlarged heart chamber / cardiomyopathy
4.Liver enzyme
- Increase SGPT ( ALT)
- Increase SGOT AST

Nursing Management
1.Administer medications as ordered
Treatment for LSHF:
M morphine SO4 to induce vasodilatation
A aminophylline & decrease anxiety
D digitalis (digoxin)
D - diuretics
O - oxygen
G - gases

a.) Cardiac glycosides

Increase myocardial = increase CO
Digoxin (Lanoxin). Antidote: digivine
Digitoxin: metabolizes in liver not in kidneys not given if with kidney failure.
b.) Loop diuretics: Lasix takes effect within 10-15 min. Max = 6 hrs
c.) Bronchodilators: Aminophillin (Theophyllin). Avoid giving caffeine
d.) Narcotic analgesic: Morphine SO4 - induce vasodilaton & decrease anxiety
e.) Vasodilators NTG
f.) Anti-arrythmics Lidocaine

2. Administer O2 inhalation @ 3 -4L/min via nasal cannula

3. High fowlers
4. Restrict Na
5. Provide meticulous skin care
6. Weigh pt. daily. Assess for pitting edema.
Measure abdominal girth daily & notify MD
7. Monitor V/S, I&O, breath sounds
8. Institute bloodless phlebotomy. Rotating tourniquet or BP cuff rotated clockwise q 15 mins to promote
decrease venous return
9. Diet decrease salt, fats & caffeine
10. Health Teachings
Complications :
1. shock
2. Arrhythmia
3. Thrombophlebitis
4. MI
5. Cor Pulmonale RT ventricular hypertrophy
b.) Dietary modifications
c.) Adherence to meds
PERIPHERAL MUSCULAR DISEASE

Thromboangiitis obliterates/
BUERGER DISEASE
- Acute inflammatory disorder affecting small to medium
sized arteries & veins of lower extremities

Predisposing factors:
- Male
- Smokers

Signs and Symptoms

1. Intermittent claudication leg pain upon walking
relieved by rest
2. Cold sensitivity & skin color changes
3. Decrease or diminished peripheral pulses - Post tibial,
Dorsalis pedis
4. Tropic changes
5. Ulcerations
6. Gangrene formation

Dianostic
1 Oscillometry decrease peripheral pulse volume
2 Doppler UTZ decrease blood flow to affected extremities
3 Angiography reveals site & extent of mal-occlusion

Nursing Management
1 Encourage a slow progression of physical activity
a Walk 3 -4 x / day
b Out of bed 2 3 x a / day
2 Administer medications as ordered
a Analgesic
b Vasodilator
c Anticoagulant
3 Foot care mgt. like DM
a Avoid walking barefoot
b Cut toe nails straight
c Apply lanolin lotion prevent skin breakdown
d Avoid wearing constrictive garments
4 Avoid smoking & exposure to cold environment
5 Surgery: BKA (Below the knee amputation)

REYNAUDS PHENOMENON
acute episodes of arterial spasm affecting digits of hands & fingers

Predisposing factors
1. Female, 40 yrs
2. Smoking
3. Collagen disease
a. SLE pathognomonic sign butterfly rash on face
1. Chipmunk face bulimia nervosa
2. Cherry red skin carbon monoxide poisoning
3. Spider angioma liver cirrhosis
4. Caput medusae leg & trunk umbilicus- Liver cirrhosis
5. Lion face leprosy
b. Rheumatoid arthritis
4. Direct hand trauma piano playing, excessive typing, operating chainsaw
Signs and Symptoms
1 Intermittent claudication - leg pain upon walking - Relieved
by rest
2 Cold sensitivity

Nursing Management
a Analgesics
b Vasodilators
c Encourage to wear gloves especially when opening a
refrigerator
d Avoid smoking & exposure to cold environment