chapter 12 heart and peripheral vascular system kevin dobi, msn, aprn kevin dobi, msn, aprn revised...

Chapter 12Heart and Peripheral

Vascular SystemKevin Dobi, MSN, APRN

Kevin Dobi, MSN, APRN revised 7/2013

Concept Overview

• Perfusion:• Mechanisms that facilitate and impair

perfusion of oxygenated blood• All tissues require perfusion of oxygenated

blood.• All of these physiologic concepts are

interrelated.

Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

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Anatomy and Physiology

• Cardiovascular system: • Transports oxygen• Transports nutrients• Transports other substances to body’s tissues• Carries metabolic waste products to kidneys

and lungs• This dynamic system is able to adjust to

changing demands for blood by:• Constricting or dilating blood vessels• Altering cardiac output


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Anatomy and Physiology:The Heart and Great Vessels• Heart is a pump:

• Beats 60 to 100 times a minute without rest.• Responds to both external and internal demands.• Each side has two chambers:

• Atrium• Ventricle

• Right side:• Receives blood from superior and inferior venae cavae.• Pumps blood through pulmonary arteries to pulmonary

circulation.

• Left side:• Receives blood from pulmonary veins.• Pumps blood through aorta into systemic circulation.


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Anatomy and Physiology:The Heart and Great Vessels (contd.)

• Upper part of heart is base.• Lower left ventricle is apex.• Heart lies behind sternum and above

diaphragm in mediastinum.• Lies at an angle so right ventricle makes

up most of anterior surface and left ventricle lies left and posteriorly.


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Anatomy and Physiology:The Heart and Great Vessels (contd.)

• Pulmonary arteries and aorta are termed the great vessels.• Aorta curves upward out of left ventricle

and bends posteriorly and downward just above the sternal angle.• Pulmonary arteries emerge from superior

aspect of right ventricle near third intercostal space.


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Anatomy and Physiology:Pericardium and Cardiac Muscle

• Heart wall has three layers: Pericardium, myocardium, and endocardium.• Heart encased in pericardium, which has a

fibrous layer and two serous layers.• Fibrous layer, fibrous pericardium, is fibrous

sac of elastic connective tissue shielding heart from trauma and infection.

• One of serous layers lies next to fibrous pericardium and other serous layer lies next to myocardium.


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Anatomy and Physiology:Pericardium and Cardiac Muscle (contd.)

• Pericardial space lies between fibrous pericardium and serous pericardium and contains pericardial fluid to reduce friction as myocardium contracts and relaxes. • Serous pericardium, or epicardium, covers heart

surface and extends to great vessels.• Middle layer, or myocardium, is thick muscular

tissue that contracts to eject blood from ventricles.• Endocardium lines inner chambers and valves.


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Anatomy and Physiology: Blood Flow through the Heart – The Cardiac Cycle

• Four valves govern blood flow through four chambers of heart:• Tricuspid valve on right.• Mitral valve on left termed atrioventricular (AV)

valves because they separate atria from ventricles.• Aortic valve opens from left ventricle into aorta.• Pulmonic valve opens from right ventricle into

pulmonary artery; aortic and pulmonic valves are termed semilunar valves because of their half-moon shape.Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

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Anatomy and Physiology: Blood Flow Through the Heart – The Cardiac Cycle Diastole

• Diastole: Ventricles relax and fill with blood from left and right atria.• Movement of blood from atria to ventricles is

accomplished when pressure of blood in atria becomes higher than pressure in ventricles.

• Higher atrial pressures passively open AV valves, allowing blood to fill ventricles.

• About 80% of blood from atria flows into relaxed ventricles.


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Anatomy and Physiology: Blood Flow Through the Heart – The Cardiac Cycle Diastole (contd.)

• Diastole:• Contraction of atria forces remaining 20% of blood into

ventricles.• This added atrial thrust is termed the atrial kick.• At end of diastole, ventricles are filled with blood.


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Anatomy and Physiology: Blood Flow Through the Heart – The Cardiac Cycle Systole

• Systole: Ventricles contract creating pressure that closes AV valves, preventing backflow of blood into atria.• Ventricular pressure also forces semilunar valves to open,

resulting in ejection of blood into aorta from left ventricle and pulmonary arteries from right ventricle.

• As blood is ejected ventricular pressure decreases, causing semilunar valves to close.

• Ventricles relax to begin diastole.


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Anatomy and Physiology:Electric Conduction

• Heart stimulated by electric impulse originating in sinoatrial (SA) node in superior aspect of right atrium and travels in internodal tracts to AV node.• SA node, termed cardiac pacemaker, normally

discharges 60 to 100 impulses per minute.• Electric impulses stimulate contractions of

both atria and then the flow to AV node in inferior aspect of right atrium.

• Impulses are then transmitted through series of branches and Purkinje fibers in myocardium, which results in ventricular contraction.


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Anatomy and Physiology:Electric Conduction (contd.)

• AV node prevents excessive atrial impulses from reaching ventricles.

• If SA node fails to discharge, AV node can generate ventricular contraction at slower rate of 40 to 60 impulses per minute.

• If both SA and AV nodes are ineffective, bundle branches may contract, but at very slow rate of 20 to 40 impulses per minute.


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Anatomy and Physiology:Peripheral Vascular System

• Arteries, capillaries, and veins provide blood flow to and from tissues.

• Tough and tensile arteries; their smaller branches, arterioles, are subjected to remarkable pressure generated from myocardial contraction.

• They maintain blood pressure by constricting or dilating in response to stimuli.

• PVR- Peripheral Vascular Resistance.Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

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Anatomy and Physiology:Peripheral Vascular System (contd.)

• The more passive veins and smaller branches, venules, are less sturdy, but more expansible, enabling them to act as reservoir for extra blood, if needed, to decrease workload on heart.

• Pressure within veins is low, compared with arterial circulation.

• Valves in each vein keep blood flowing in a forward direction toward heart. (IV Issues)


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Anatomy and Physiology:Lymph System

• Lymph system works in collaboration with peripheral vascular system in removing fluid from interstitial spaces.

• As blood flows from arterioles into venules, oxygen and nutrient-rich fluid is forced out at arterial end of capillary into interstitial space, and then into cells.

• Waste products from cells flow through interstitial spaces to venous end of capillary.


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Lymphatics


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Anatomy and Physiology:Lymph System (contd.)

• Excess fluid left in interstitial spaces is absorbed by lymph system and carried to lymph nodes throughout body.• Lymphatic fluid is clear, composed mainly

of water and a small amount of protein, mostly albumin.• Lymph nodes are tiny oval clumps of

lymphatic tissue, usually located in groups along blood vessels.


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• In peripheral vascular system, lymph node locations of interest are arm, groin, and leg.• Epitrochlear nodes on medial surface of

arm above elbow are palpable.• These nodes receive fluid via radial,

ulnar, and median lymph vessels.• In upper thigh, inguinal lymph nodes are

superficial; they receive most of lymph drainage from great and small saphenous lymphatic vessels in legs.


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• In men, lymph from penile and scrotal surfaces drains to inguinal nodes, but nodes of the testes drain into abdomen.• In posterior surface of leg, behind knee,

are popliteal nodes, which receive lymph from medial portion of lower leg.• Ducts from lymph nodes empty into

subclavian veins.


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Assessment


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General Health History:Present Health Status

• Do you have any chronic illnesses such as diabetes mellitus, renal failure, chronic hypoxia, or hypertension? • Are you taking medications?

• What are you taking, and when did you start? • Have you experienced any side effects? • Do you take medications as prescribed?

• What over-the-counter drugs do you take? • Do you take an aspirin on a regular basis

to help thin your blood? • Do you take herbal medications? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

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General Health History:Family Health Status

• Is there anyone in your family with a history of diabetes mellitus, renal failure, chronic hypoxia, or hypertension? • If so, who?


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General Health History:Personal and Psychosocial History

• Do you use cocaine? • Other street drugs? • How often do you use drugs?

• Do you exercise? • What kind of exercise? • How often?

• How would you describe your personality type? • How do you deal with stress?

• How often do you take time to relax? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

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General Health History:Personal and Psychosocial History (contd.)

• Describe your usual eating habits: • How often do you eat red meat? • Do you monitor your fat and salt intakes? • Do you eat whole grains each day?

• Do you drink alcoholic beverages? • What type of alcohol do you drink? • How much? How often?

• Do you consume caffeine?

• Do you smoke, or have you been a smoker in past? • Are you interested in quitting smoking?


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General Health History:Past Medical History

• During childhood did you have “growing pains,” unexplained joint pains? • Rheumatic fever? • Heart murmur?

• Have you been told you have high levels of cholesterol or elevated triglycerides?• Have you ever had surgery on heart?

• On blood vessels?


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Problem-Based History:Chest Pain

• Where are you feeling the chest pain? • What does it feel like? Sharp, dull, ache?• Does pain radiate to any location? • When did pain start?

• Is pain intermittent or constant? • What symptoms have you noticed with

pain? • Sweating? • Turning pale or gray? • Heart skipping beats or racing? • Shortness of breath? • Vomiting? • Anxiety?


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Problem-Based History:Chest Pain (contd.)

• What factors preceded pain? • Exercise? • Rest? • Highly emotional situations? • Sexual intercourse?

• What makes pain worse? • What relieves pain?

• Rest? • Nitroglycerin? • How many nitroglycerin tablets does it take to

relieve chest pain?


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Problem-Based History:Shortness of Breath

• How long have you had shortness of breath? • Do you feel short of breath now?

• When does shortness of breath happen? • How often? • How long does it last?

• Does shortness of breath interfere with your daily activities? • Do you have other symptoms with

shortness of breath (e.g., do your feet swell during day)?


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Problem-Based History:Shortness of Breath (contd.)

• What makes shortness of breath worse? • Walking upstairs? • Lying down? • How many pillows do you require when you lie

down to sleep? • Do you sleep in recliner?

• When episodes of shortness of breath occur, what do you do to breathe more easily?


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Problem-Based History:Cough

• When did your cough start? • How often do you cough?• Do you cough up anything? (productive or non-

productive?)• What does it look like?

• Is cough associated with position?• More coughing when lying down?• With anxiety?• Talking or activity?

• What makes it worse? • What actions do you take to relieve cough?


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Problem-Based History: Urinating During the Night

• For how long have you been getting up during night to urinate? • How many times a night do you get up to

urinate?• What have you done to prevent this from

happening? • How successful have your efforts been?


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Problem-Based History: Fatigue

• When do you notice fatigue? • Was onset sudden or gradual? • Is it worse in morning or evening? • Are you too tired to take part in normal

activities? • Do you take iron pills?

• Do you eat foods with iron, such as green leafy vegetables and liver?

• For women: Do you have heavy menstrual flow?


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Problem-Based History: Fatigue (contd.)

• Have you had any other symptoms associated with fatigue?• Rapid heart rate?• Headache?• Pale skin?

• Have you noticed any unusual feelings in your feet and hands, muscle weakness, or trouble thinking?


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Problem-Based History: Fainting

• What were you doing just before you fainted? • Did you feel dizzy?• Did you lose consciousness?

• Has this happened to you before? • Was fainting preceded by any other

symptoms? • Nausea? • Chest pain?• Headache? • Rapid heart rate? • Confusion?


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Problem-Based History: Swelling of Extremities

• Where is swelling located? • Arms or legs? • Unilateral or bilateral?

• What makes swelling go away? • Does elevating your arms or feet reduce

swelling? • Does swelling disappear after night’s sleep?

• Are there any symptoms associated with swelling? • Shortness of breath? • Weight gain?

• For women: Is swelling associated with your menstrual period?Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

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Problem-Based History: Leg Cramps or Pain

• Describe pain and its location. • What makes pain worse? • What relieves the pain?

• Have you noticed any changes in skin of your legs?• Coldness• Pallor• Hair loss• Sores• Redness or warmth over the veins• Visible veins


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PE: Physical Examination


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Examination:Procedures with Normal Findings

• Assess general appearance.• Inspect patient for general appearance,

skin color, and breathing effort.• Palpate temporal and carotid pulses for

amplitude.• Inspect jugular vein for pulsations. JVD• Measure blood pressure. Auscultate• Inspect and palpate upper extremities for

skin turgor and symmetry.


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Examination:Procedures with Normal Findings (contd.)

• Inspect and palpate upper extremities for:• Symmetry• Skin integrity• Color and temperature• Capillary refill

• Palpate brachial and radial pulses for:• Rate• Rhythm• Amplitude• Contour

• Inspect and palpate lower extremities for skin turgor and symmetry.


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Apical ImpulsePalpate over the Apex: 5th-6th ICS at

MCL (left side)


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Examination:Procedures with Normal Findings (contd.)

• Inspect and palpate lower extremities for symmetry, skin integrity, color and temperature, hair distribution, capillary refill, color and angle of nail beds, tenderness, and superficial veins.• Palpate lower extremities for femoral, popliteal,

posterior tibial pulses, and dorsalis pedis pulses for amplitude.


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Examination:Cardiac Assessment

• Inspect anterior chest wall for:• Contour• Pulsations• Lifts• Heaves• Retractions

• Auscultate S1 and S2 heart sounds for:• Rate• Rhythm• Pitch• Splitting


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Heart Sounds: S1 S2


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Landmarks


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Landmarks

•Aortic: 2nd-3rd ICS at left sternal border

•Pulmonic: 2nd-3rd ICS at right sternal border

•Tricuspid: 5th ICS at left sternal border

•Mitral: 5th ICS and left MCL (apex)

•All •Patients•Take•MedsCopyright © 2013 by Mosby, an imprint of Elsevier Inc.

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Examination: Special Circumstances or Advanced Practice

• Peripheral vascular system:• Auscultate carotid artery for bruits.• Estimate jugular venous pressure for

pulsations.• Palpate epitrochlear lymph nodes for

size, consistency, mobility, borders, tenderness, and warmth.• Palpate inguinal lymph nodes for size,

consistency, mobility, borders, tenderness, and warmth.


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Examination: Special Circumstances or Advanced Practice (contd.)

• Peripheral vascular system:• Calculate the ankle brachial index to estimate arterial

occlusion.• Perform Trendelenburg’s test to evaluate competence of

venous valves in patients who have varicose veins.

• APRNs----Don’t worry about this technique


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Examination: Special Circumstances or Advanced Practice (contd.)

• Cardiac assessment:

•Palpate precordium for pulsations, thrills, lifts, and heaves.

• Percuss heart borders for heart size……NO!


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Age-Related Variations:Infants, Children, and Adolescents

• There are several differences in assessment of cardiovascular system for infants and young children:• Equipment used to measure blood pressure is

smaller, sequence of exam may be different, and findings may differ based on anatomic differences.

• Assessment of older child and adolescent follows same procedures and reveals similar expected findings.

• One exception in exam is electrocardiography, which is not typically performed.Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

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Age-Related Variations:Older Adults

• Assessing cardiovascular status of older adults usually follows same procedures as for all adults.• Expected variations may be found in

heart rate and blood pressure.


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Common Problems and Conditions: Cardiac Disorders –Valvular Heart Disease

• Valvular heart disease (VHD) is an acquired or congenital disorder of heart valve characterized by:• Stenotic valve, which does not open completely.• Incompetent valve, which does not close completely.• Rheumatic fever and endocarditis account for most cases

of acquired VHD.Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

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Common Problems and Conditions: Cardiac Disorders –Angina Pectoris

• Angina pectoris is chest pain due to ischemia of myocardium.• Usually caused by atherosclerosis within coronary

arteries.• Can occur during activity, stress, or exposure to intense

cold because of an increased demand on heart.• Can also occur during rest as result of spasms of

coronary arteries.Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

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Common Problems and Conditions: Cardiac Disorders –Angina Pectoris (contd.)

• Clinical findings: Patients describe pain as squeezing, suffocating, or constricting.• May be significant hypertension, but hypotension may

also occur.• The duration of angina is important to

determine:• If precipitated by exertion and patient rests

promptly, may last less than 3 minutes.• If it follows heavy meal or caused by anger,

may last 15 to 20 minutes.• Angina lasting more than 30 minutes is

unusual, may indicate developing myocardial infarction.


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Common Problems and Conditions: Cardiac Disorders – Myocardial Infarction

• Myocardial infarction occurs when myocardial ischemia is sustained, resulting in death of myocardial cells (necrosis).• Left ventricle more commonly affected, but right

ventricle may also be affected.


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Common Problems and Conditions:

Cardiac Disorders – Myocardial Infarction (contd.)• Clinical findings: Patients describe pain as worst

chest pain ever experienced, pain lasts longer than 5 minutes. • May radiate to left shoulder, jaw, arm, or other

areas of chest; it is not relieved by rest or nitroglycerin.• Dysrhythmias are common; heart sounds may

be distant with a thready pulse.• Women report different symptoms; they report

pain or discomfort in center of chest and shortness of breath, cold sweat, nausea, vomiting, or lightheadedness.


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Common Problems and Conditions: Cardiac Disorders – Heart Failure

• Heart failure occurs when either ventricle fails to pump blood efficiently into aorta or pulmonary arteries.• Heart failure may occur in left or right

ventricle or both.


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Common Problems and Conditions: Cardiac Disorders – Heart FailureLeft Ventricular Failure

• Left ventricular failure is caused by :• Increased resistance that occurs with aortic stenosis or

hypertension, when ventricle can no longer compensate for increased workload, or

• Weakening of left ventricular contraction occurring after myocardial infarction when death of myocardial cells may result in an ineffective contraction.

• Because left ventricle cannot pump sufficient blood forward, some blood backs up into left atrium and eventually into pulmonary capillaries, causing pulmonary edema.Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

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Common Problems and Conditions: Cardiac Disorders – Left Ventricular Failure (contd.)

• Clinical findings: Patient complains of fatigue and shortness of breath, including orthopnea, dyspnea on exertion, and paroxysmal nocturnal dyspnea. • Findings may reveal precordial movement, displaced

apical pulse, palpable thrill, S3, and systolic murmur at apex.

• In acute phase, patient usually has crackles bilaterally from pulmonary edema.Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

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Common Problems and Conditions: Cardiac Disorders –Right Ventricular Failure

• Right ventricular failure caused by hypertrophy from pulmonary hypertension or from necrosis from myocardial infarction.• Failure of right ventricle to pump blood into pulmonary

arteries causes a backflow of blood into inferior and superior venae cavae.

• Right ventricular failure caused by pulmonary disease is termed cor pulmonale.


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Common Problems and Conditions:

Cardiac Disorders – Right Ventricular Failure (contd.)

• Clinical findings: • Findings may include precordial movement at xiphoid or

left sternal border, elevated jugular venous pressure, dependent peripheral edema, S3 at lower left sternal border, systolic murmur, and weight gain.


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Common Problems and Conditions: Cardiac Disorders –Ineffective Endocarditis

• Infective endocarditis is infection of endothelial layer of heart, including cardiac valves:• Develops when endocardial surface is damaged by

turbulent blood flow as result of valvular heart disease, congenital lesions, or direct injury from intravenous lines or injections, cardiac catheterization, or artificial valves.

• Clinical findings:• Heart sounds normal during early infection; in late

infection, murmur is heard if valve damage occurs.


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Common Problems and Conditions: Cardiac Disorders –Pericarditis

• Pericarditis is inflammation of parietal and visceral layers of pericardium and outer myocardium.• May be idiopathic or the result of myocardial infarction,

uremia, cancer, trauma, infections, cardiac surgery, or autoimmune reaction.


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Common Problems and Conditions: Cardiac Disorders –Pericarditis (contd.)

• Clinical findings: Two classic findings are pericardial friction rub and chest pain.• Pericardial friction rub develops as inflamed layers

of pericardium move against each other.• Friction rub is best heard with patient leaning

forward so that heart is closer to chest wall.• Listen in second, third, or fourth intercostal spaces

at left sternal border or at apex; louder during inspiration.

• Pain described as sharp pleuritic pain aggravated by deep breathing, lying supine, or coughing.


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Common Problems and Conditions: Peripheral Vascular DiseaseHypertension

• Hypertension is diagnosed on the basis of mean of two or more properly measured seated blood pressure readings on each of two or more occasions above 120/80 mm Hg in an adult over 18 years of age.• Pressure in arteries can become elevated due to

constriction of blood vessels or fluid volume overload or both.


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Common Problems and Conditions: Peripheral Vascular Disease –Hypertension (contd.)

• Clinical findings: Hypertension • Normal blood pressure values are less

than 120 mm Hg systolic and less than 80 mm Hg diastolic.• Because there are no specific symptoms

of hypertension, periodic screening is important.


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Common Problems and Conditions: Peripheral Vascular Disease –Venous Thrombosis and Thrombophlebitis

• Venous thrombosis occurs when a thrombus (clot) develops within a vein.• Thrombophlebitis is inflammation of vein that may

or may not be accompanied by clot.• Triad of venous stasis, damage to inner layer of veins,

and hypercoagulability are usually responsible for both. • Either may occur in lower extremity, usually in deep

veins.Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

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Common Problems and Conditions: Peripheral Vascular Disease –Thrombosis and Thrombophlebitis (contd.)

• Clinical findings: Thrombosis• Sometimes recognized by dilated superficial

veins, edema and redness of involved extremity, and increased circumference of involved leg.

• In upper extremity, venous thrombosis and thrombophlebitis may occur in superficial veins and are recognized by redness, warmth, and tenderness over affected area. (can happen from IV therapy)

• Veins may be visible and palpable.


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Common Problems and Conditions: Peripheral Vascular Disease – Aneurysm

• Aneurysm is localized dilation of artery caused by weakness in arterial wall. • Can occur anywhere along aorta and iliac vessels.


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Common Problems and Conditions: Peripheral Vascular Disease – Aneurysm (contd.)

• Clinical findings: • Depend on location of aneurysm.• Abdominal aortic aneurysms are most common.• Thoracic, usually asymptomatic with deep, diffuse chest

pain reported by some patients.• Aorta and aortic arch aneurysms can produce hoarseness

from pressure on laryngeal nerve or dysphagia from pressure on esophagus.

• A pulsatile mass may be palpated in periumbilical area.• A thrill or bruit may be noted over aneurysm.


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Question 1

A patient has been admitted to the medical-surgical unit for exacerbation of congestive heart failure. The nurse notes bilateral +2 pitting edema and dry scaling skin. As the nurse assesses the dorsalis pedis pulse, the nurse is unable to detect it and notes that both feet are warm. What is the best action for the nurse to take?

•Call the physician immediately.•Assess skin turgor over the clavicle.•Use a Doppler and assess capillary refill.•Use a Doppler and assess for renal artery stenosis.Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

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Question 2

In the cardiac unit, a patient awaits surgery for mitral valve repair. As the nurse auscultates the patient’s heart, the nurse will expect to hear a murmur that is:

A.Most pronounced at the base of the heart.B.Most pronounced over the carotid arteries.C.Heard best at the left sternal border.D.Heard best over the left midclavicular line.Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

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The End


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chapter 12 heart and peripheral vascular system kevin dobi, msn, aprn kevin dobi, msn, aprn revised...

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