To identify and understand basic anatomy and physiology of the cardiovascular system To discuss surgical pathophysiology in relation to cardiac

c status: What puts our surgical patients at risk? To discuss and demonstrate elements of cardiac assessment To understand how findings of physical assessment facilitate clinical care of surgical patients

Evaluation of the functioning of the pump of the heart ( the muscle), the power of the heart ( the electrical) and the systemic circulation.

A large muscle made up of 3 layers and surrounded by the pericardial sack. Divided into 4 chambers Atrium are the receiving chambers and responsible for 30% of cardiac output The ventricles that are the workhorses and responsible to push blood to the lungs and the extremities

Cardiac Output Cardiac output (CO) refers to the amount of blood pumped by each ventricle during a given period. The cardiac output in a resting adult is approximately 5litres per minute. This however is greatly dependant upon the metabolic needs of the body. Cardiac output equals the volume of blood ejected per heart beat (called stroke volume) times the number of hearts beats per minute (heart rate) CO=SV x HR Eg:The volume at the end of diastole is 130mls. The volume at the end of systole is 60mls. Therefore the stroke volume is 70mls. If a person has a resting HR of 80 bpm the cardiac output would be 80 x 70 =5600mls or 5.6L This is the output needed to perfuse the brain

Comes immediately of the pulmonary vessel Already compromised coronary circulation will be most affected by hypotension or low hemoglobin Chest pressure, diaphoresis, nausea first signs of impaired circulation to the coronary arteries

The SA node is the primary pacemaker of the heart and is located at the junction of the superior vena cava and the right atrium. The AV node is located in the right atrial wall near the tricuspid valve. The AV node coordinates the incoming electrical impulses from the atria and after a delay (allowing the atria time to contract and complete ventricular filling) relays the impulse to the ventricles. Impulses travel through the bundle branches to reach the terminal point in the conduction system, called the Purkinje fibers. These fibers then directly innervate the myocytes which in turn cause ventricular contraction.

Heart rate: Apical and Radial Apical should always be done for irregular rates and compared to apical Quality and regularity is as important as rate Tachycardia is the earliest sign of hypotension and happens long before a fall in BP

Ask the patient to breath normally and to hold their breath periodically to enhance sounds that may be difficult to hear Initially auscultate for heart sounds with the patient in a supine position with the head of the bed raised 30-45degrees Note heart rate and rhythm, identify 1st and 2nd heart sounds (S1 and S2) and listen for abnormal sounds such as 3rd and 4th heart sounds (S3 and S4), and murmurs.

Blood pressure refers to the force exerted by circulating blood on the walls of blood vessels. The pressure of circulating blood decreases as blood moves through arteries, arterioles, capillaries and veins. Systolic pressure is the peak pressure in the arteries, which occurs during ejection. Diastolic pressure is the lowest pressure, when the ventricles relax, and the blood remaining in the arteries exerts a minimum pressure.

Use both arms when there is a major change from baseline Dont rely on a mechanical cuff if the result doesnt make sense clinically All the rules from the VS competency

 Class

I- 15% or 750mls (compensatory mechanisms) Class II- 30% or up to 1500mls ( HR goes to over 100,, RR up to 20-30, UO down to 20-30mls/hr), pale, cool. Class III- 40% or up to 2000 ml loss systolic BP down, HR and dysrhythmias, acidosis Class IV- greater than 2000 ml loss, compensatory mechanisms fail

Carotid gently place you fingers just medial to the trachea and below the angle of the jaw. Note the rate and rhythm. Palpate both sides, but not at the same time. Apical- located at the 5th intercostals space, at or just medial to the left clavicular line. Locate the pulse using one finger pad. Asking the patient to exhale and hold their breath, will aid in locating. Note heaves or thrills. Note the apical pulse is palpable in about half of adults. It is not palpable in obese patients in patients with thick chests. Femoral position fingers inferior to the inguinal ligament and press firmly

Brachial position fingers medial to the biceps tendon Radial apply gentle pressure to the medial and ventral side of the wrist, just below the thumb Popliteal press firmly in the popliteal fossa, at the back of the knee Dorsalis pedis- .place fingers on the medial dorsum of the foot while the patient points their toes down

Edema is not normally present. To assess for edema/swelling 1. Firmly press fingers against the skin (A) 2. Hold fingers in place for 5 seconds then release (B) 3. If there is edema the indentation will remain

Grading of edema: Trace: +1: 2mm indentation Mild: +2: 4mm indentation Moderate: +3: 6mm indentation Severe: +4: 8mm indentation

Jugular vein pulse position the patient supine at 3045degrees. Remove the pillow to avoid flexing the neck. Ask the patient to turn their neck slightly away from you. Locate the angle of Louis (sternal notch) by palpating where the clavicles that join the sternum and then sliding your fingers down the sternum until you feel a bony protuberance. Find the internal jugular vein. Shine your pen torch across the patients neck to create shadows that highlight their venous pulse. Locate the highest point along the vein where you can see pulsations

Inspect and palpate the nails Consistency the surface is smooth and regular, not brittle or splitting. The nail thickness is uniform and the nail is firmly adherent to the nail bed and the nail base is firm to palpation Colour the translucent nail plate is a window to the even, pink nail bed underneath. Note splinter hemorrhages and clubbing. Capillary refill depress the nail edge to blanch and then release, noting the return of colour. Normally colour return is instant or within a few seconds in a cold environment. This indicates the status of peripheral circulation. A sluggish colour return takes longer than 1 or 2 seconds. Cyanotic nail beds or sluggish return consider cardiovascular or respiratory dysfunction.

S1 The first heart sound occurs with the closure of the AV valves and thus signals the beginning of ventricular systole S2 The second heart sound occurs with the closure of the semiluminar valves and thus signals the onset of ventricular diastole

S3 Normally diastole is a silent event, however in some conditions ventricular filling creates vibrations that can be heard over the chest. These vibrations are S3. The S2 occurs when the ventricles are resistant to filling during early rapid filling phase (protodiastole). This occurs immediately after S2, when the AV valves open and atrial blood pours in to the ventricles. S4 The fourth heart sound occurs at the end of diastole, at pre systole, when the ventricle is resistant to filling. The atria contract and push blood into a noncompliant ventricle. This creates vibrations that are heard as S4. This occurs just before S1.

Fluid balance is critical Cardiac history of angina, arrthymias, risk factors HBG and HCT