NCM 103: OXYGENATIO N (CVS, PVS & HEMATOLOGIC System Overview) Reubien Quicho Ignacio, MAN

Wesleyan University-Philippines

ANATOMY & PHYSIOLOGY OF THE CVS (review)

STRUCTURES: q Heart q Blood q Blood vessels functions: q effects the circulation of blood around the body q transports nutrients and oxygen to the cells/tissues q removes waste products

THE HEART

Hollow, cone-shaped, with size of the fist Within the mediastinal cavity 3 Layers: q Pericardium outermost covering; anchors the heart to its surrounding tissues; 2 sub-layers: Fibrous outermost; anchor; attached to the large vessels Serous 2 sub-layers: inner (visceral) attached to the myocardium (forming the EPICARDIUM); & outer (parietal) attached to the fibrous layer q Myocardium contractile layer q Endocardium lines the inside of the heart

THE HEART

2 atria and 2 ventricles separated by septum (interatrial and interventricular) Atrioventricular valves separates atrium and ventricle (cusps = leaflets)
q

Tricuspid (right) and bicuspid or mitral (left)

Semilunar valves facilitate movement from ventricles to the great vessels

q

Pulmonic (right) and aortic (left)

THE HEART

BLOOD / systemic circulation

Deoxygenated blood SVC/IVC RA TV RV PSLV PA lungs for gas exchange (pulmonary circulation) oxygenated blood PV LA MV/BV LV ASLV A cardiac and systemic circulation

THE HEART

Coronary circulation

Coronary arteries from base of the aorta, penetrates all layers of the heart Coronary arteries fill during ventricular relaxation Cardiac veins drain blood from myocardium to the right atrium through coronary sinuses

THE HEART

Cardiac cycle & heart sounds

1. S1 first sound; systole; closure of AV valves; pumps/ejects blood 2. S2 second sound; diastole; closure of SL valves; refilling of blood 3. Depolarization : Repolarization length ratio (1:2)

The heart

Measures tissue perfusion and delivery of O2 and nutrients to the cells

v

Stroke volume amount of ejected blood from the ventricles

v

Cardiac output amount of blood ejected with each contraction (in one minute)
v

CO = SV x HR = LPM ??? v CO = (60 mL to 80 mL) x (60 to 100 bpm)

v

The heart
CHARACTERISTICS of the heart (C.C.A.R.E.E.R.)
q

Contractility shortening of muscle fibers Conductivity transmits electrical stimuli Automaticity beats spontaneously and repetitively Rhythmicity regularity Excitability action potential (K+, Na+, Ca+) Extensibility stretch ability
v

Frank-Starlings Law = increase ability to stretch (increase area / accommodation)

Refractoriness non-responsive to new stimulus while in the state of contraction (0-60 mV)

BLOOD VESSELS
q

Arteries distribute blood away from the heart Carry oxygenated blood (except from pulmonary arteries) Blood moves from higher pressure area to lower pressure area Layers: v Tunica intima (mesothelium); v media (thicker than veins); and v adventitia (externa, for anchoring)

BLOOD VESSELS
q

Veins carry blood towards the heart

Distribute deoxygenated blood (except from pulmonary veins) Pressure is too low, passive Layers: v Tunica intima (valves to prevent backflow); v media (thinner than artery); and v adventitia (same with artery)

Capillaries single layer only (intima, mesothelium) to allow diffusion of gas and other molecules

BLOOD & BLOOD CELLS

STRUCTURES:

Blood cells Plasma (serum; plasma CHON-Ig, Albumin; sugar; clotting factors, etc)

BLOOD & BLOOD CELLS

FUNCTIONS: Transports oxygen, nutrients, hormones, and metabolic wastes for elimination

Regulates body pH and fluid volume Prevent infection and blood loss Blood clot control (video: 1)

PHYSICAL ASSESSMENT (Focused Assessment of CVS, PVS, & Hematologic System)

PHYSICAL ASSESSMENT (I.P.P.A.): CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM

GENERAL SURVEY/APPEARANCE: Stature and body build q slender, q medium-build, q stocky or muscular)

Posture, gait, & movement q erect & upright q no diff. with position changes q coordinated, balanced movement

PHYSICAL ASSESSMENT (I.P.P.A.): CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM

GENERAL SURVEY/APPEARANCE: General skin color

q

abN pale, jaundice, cyanotic, redness, cold, clammy, dry)

LOC (calm, awake, oriented to time place & persons) Speech (abN hoarse, stuttering, slurring) Grimaces

PHYSICAL ASSESSMENT (I.P.P.A.): CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM VITAL SIGNS Ht. & Wt. Males 5 = 106 lbs (6 lbs for every 1 inch) Females 5 = 100 lbs (5 lbs for every 1 inch)

TPR Temp. = 36.8-37.5 oC Pulse = 60-100 bpm; regular; +2 RR 12-20 cpm; eupnic/regular; tidal volume / not too deep nor shallow BP 90/60 to 140/90

PHYSICAL ASSESSMENT (I.P.P.A.): CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM

Thorax / chest Inspection of Chest shape and size Normal (elliptical) AP diameter twice smaller than Lat./Transverse diameter Palpation of posterior chest N = evenly spaced spinous process, no pain nor tenderness

PHYSICAL ASSESSMENT (I.P.P.A.): CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM

ABNORMAL FINDINGS: Barrel chest AP:Lat (1:1) diameter; e.g. COPD

Pigeon chest (Pectum carinatum) anterior projection; protruding sternum; narrow transverse diameter; no abnormal physiological effect (just altered body image) Funnel chest (Pectum excavatum) decreased AP diameter; congenital; danger is compression of the great vessels (Vena cavae, pulmonary, aorta) Flail (wave) chest multiple rib fracture

PHYSICAL ASSESSMENT (I.P.P.A.): CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM

Chest landmarks Helps the nurse to identify position of

underlying organs & record abnormal assessment findings

Midsternal line line running thru the center of the sternum Midclavicular line vertical; from the clavicle midpoint Axillary line Anterior A.L. ant. axillary fold Midaxillary A.L. apex of the axilla Posterior A.L. - post axillary fold

PHYSICAL ASSESSMENT (I.P.P.A.): CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM

Chest landmarks

Vertebral line along the spinous processes Scapular line inferior angle of scapula Supra-sternal notch hallow curve at the base of neck Sternum Manubrium (joins clavicle & 1st pair of ribs) Body joins 2nd to 7th pair of ribs Angle of Louis junction bet. sternum & manubrium; main guide in locating ribs (2nd) & ICS; position of carina; used to measure JVD Xyphoid process

PHYSICAL ASSESSMENT (I.P.P.A.): CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM

Chest Inspection PMI at 5th ICS L midclavicular line Inspect = thrust (normal) ***Heave = excessive thrust (abnormal) When Palpated = thrill When Auscultate = murmur (aka heart murmur) blowing or whooshing, graded *** Note: bruit (aka vascular murmur) = orbital, peripheral

PHYSICAL ASSESSMENT (I.P.P.A.): CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM

chest Palpation and auscultation PRECORDIUM: Pulmonic area 2nd ICS L para-sternal line; S2 Aortic area 2nd ICS R para-sternal line; S2 Mitral/bicuspid/apical area - 5th ICS L midclavicular line; S1 Tricuspid area 5th ICS L para-sternal line; S1

Normal = no thrill on aortic and Pulmonic; with thrill on PMI or mitral abN = thrills on aortic/Pulmonic areas valvular stenosis

PHYSICAL ASSESSMENT (I.P.P.A.): CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM

chest auscultation (S1, S2, S3 & S4) HEART SOUNDS: S1 lubb; systole S2 dubb; diastole

S3 heard in apex (bell) a.k.a. ventricular gallop; diastolic gallop; or abnormal S2

lubb-dubb-dubb or lubb-dubb-ly (kentuc-ky)

normal in child or young adult abN=30 yrs & above (L sided heart failure, pulmonary congestion, intracardiac shunting of blood, MI, anemia, or

PHYSICAL ASSESSMENT (I.P.P.A.): CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM

chest auscultation (S1, S2, S3 & S4)

S4 a.k.a atrial or pre-systolic gallop heard louder in inspiration (bell) La-lubb-dubb (ten-nes-see) Heard prior to S1 abN = MI, HPN, CAD, cardiomyopathy, anemia, elevated L ventricular pressure or aortic stenosis

PHYSICAL ASSESSMENT (I.P.P.A.): CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM

Inspect, Palpate, Auscultate Carotid Artery

Normal = symmetrical; 2+ thrust; No sound/bruit (elastic arterial wall)

abN = asymmetrical (r/t stenosis, thrombosis, arteriosclerosis); decreased pulse dec. CO; increased pulse cardiomegaly

PHYSICAL ASSESSMENT (I.P.P.A.): CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM

Inspect, Palpate Jugular Vein

Done in Semi-Fowlwers position Normal = not visible (normal R side heart); For distended jugular vein assess external JVD/JVPressure Steps:

1. 2. 3.

4.

Semi-Fowlers position measure vertical height lowest point at Angle of Louis; highest point at visible distension, measure vertically Interpret: Normal = 3-4 cm; abN = <3 DHN, bleeding; >5 R sided heart failure

JUGULAR VEIN VS CAROTID ARTERY

Jugular Vein No pulsations palpable. Carotid Artery Palpable pulsations.

Pulsations obliterated by pressure Pulsations not obliterated by above the clavicle. pressure above the clavicle. Level of pulse wave decreased on inspiration; increased on expiration. No effects of respiration on pulse.

Usually two pulsations per systole One pulsation per systole. (x and y descents). Prominent descents. Pulsations sometimes more prominent with abdominal pressure. Descents not prominent. No effect of abdominal pressure on pulsations.

PHYSICAL ASSESSMENT (I.P.P.A.): CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM Peripheral vascular system Peripheral pulses (arteries):

Normal = symmetrical; 2+; no thrill / bruit abN = asymmetrical (impaired circulation); 0 or 1+ (impaired CO); 3+ (HPN, inc. CO, circulatory overload) Normal = symmetrical; non tender; - dependent position distended; - limbs elevated veins collapse; except elderly abN = (+) Homans sign upon dorsiflexion (thrombophlebitis); painful, warm, swollen and tender (varicosities)

Peripheral veins (extremities):

PHYSICAL ASSESSMENT (I.P.P.A.): CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM

Peripheral vascular system Peripheral Perfusion: assess color, temperature, edema, and lesions on skin of hands and feet capillary refill (immediate return test) Normal = pinkish/fair; not warm/cold; no edema; not too dry/not too moist

PHYSICAL ASSESSMENT (I.P.P.A.): CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM

Peripheral vascular system Perform Buergers test Steps: 1. Supine 2. Raise a limb 30 cm or 1 foot above heart move it up & down 3. Sit up and dangle feet observe color return Normal = returns within 10-15 sec. abN = delayed venous filling (arterial insufficiency)

PHYSICAL ASSESSMENT (I.P.P.A.): CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM

Peripheral vascular system Capillary refill test (blanch test): Normal = 2-3 seconds abN = >4sec. arterial insufficiency abN = cyanotic (venous insufficiency); - dusky red color & cool skin (arterial insufficiency); - brown pigmentation around ankles, skin shiny, thin, fragile (chronic arterial or venous insufficiency)

Arterial VS Venous Ulcer

PHYSICAL ASSESSMENT (I.P.P.A.): CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM

***All data collected should be documented (esp. abnormal findings) in the clients record sheet (chart).

The End