CARDIOVASCULAR

SYSTEM
By: Lendell Kelly B. Ytac, RN
Nurse Educator, FNAHS-BSN
Learning Objectives

■ Review the structures and functions of the cardiovascular

system
■ Discuss assessment of the cardiovascular system
■ Identify diagnostic tests and procedures for the
cardiovascular system
■ Explain cardiovascular disorders and treatments.
Understanding the cardiovascular
system
■ Heart
■ Blood Vessels
complex system functions to:
■ carry life-sustaining oxygen and nutrients in the blood to all cells of the
body
■ remove metabolic waste products from the cells
■ move hormones from one part of the body to another.
The Heart

■ About the size of a closed fist

■ lies beneath the sternum in the mediastinum (the cavity between the
lungs), between the second and sixth ribs.
■ right border of the heart aligns with the right border of the sternum.
■ The left border aligns with the midclavicular line.
■ The exact position of the heart varies slightly in each patient.
Pericardium

■ sac that surrounds the heart

■ Composed of an outer (fibrous) layer and an inner (serous) layer.
■ The serous layer of the pericardium is composed of a visceral (inner) layer and a
parietal (outer) layer.
■ pericardial space separates the visceral and parietal layers of the serous
pericardium.
■ contains 10 to 30 mL of thin, clear pericardial fluid, which lubricates the two
surfaces of the serous pericardium and cushions the heart.
Heart wall

■ Epicardium includes the outer layer of the heart wall and the visceral layer of the
serous pericardium. It’s made up of squamous epithelial cells overlying connective
tissue.
■ Myocardium is the middle and largest portion of the heart wall. This layer of muscle
tissue contracts with each heartbeat.
■ Endocardium is the innermost layer of the heart wall. It contains endothelial tissue
made up of small blood vessels and bundles of smooth muscle.
The Four chambers of heart

■ right atrium
■ left atrium
■ right ventricle
■ left ventricle.
Powerful pumps
Heart valves

■ keep blood flowing in one direction.

■ Healthy valves open and close passively as a result of pressure changes in the four
heart chambers. The valves prevent blood from traveling the wrong way.
Where the valves are located?

■ Valves between the atria and ventricles are called atrioventricular (AV) valves and
include the tricuspid valve on the right side of the heart and the mitral valve on the
left side.
■ Valves between the ventricles and the pulmonary artery and the aorta are called
semilunar valves.
■ Include the pulmonic valve on the right (between the right ventricle and the
pulmonary artery) and the aortic valve on the left (between the left ventricle and the
aorta).
What is a cusp?
■ leaflets, or cusps, of each valve keep the valves tightly closed. The tricuspid valve
has three cusps. The mitral valve has two.
■ The cusps are anchored to the heart wall by cords of fibrous tissue called chordae
tendineae, which are controlled by papillary muscles.
Great vessels

■ The aorta, which carries blood away from the left ventricle, is the main trunk of the
systemic artery system.
■ The inferior and superior vena cavae carry deoxygenated blood from the body into
the right atrium.
■ The pulmonary artery is a large artery that carries blood away from the right
ventricle. Above the heart, it splits to form the right and left pulmonary arteries,
which carry blood to the right and left lungs.
■ The four pulmonary veins—two on the left and two on the right—carry oxygenated
blood from the left and right lungs to the left atrium.
Coronary arteries

■ Like all other organs, the heart needs an adequate blood supply to survive. The
coronary arteries, which lie on the surface of the heart, supply the heart muscle with
blood and oxygen.
What is a coronary ostium?
■ The coronary ostium is an opening in the aorta above the aortic valve. It feeds blood
to the coronary arteries.
■ When the left ventricle is pumping blood through the aorta, the aortic valve is open
and the coronary ostium is partly covered. When the left ventricle is filling with
blood, the aortic valve is closed and the coronary ostium is open, enabling blood to
fill the coronary arteries.
Right coronary artery

■ supplies blood to the right atrium, the right ventricle, and part of the left ventricle.
■ It also supplies blood to the bundle of His (muscles that connect the atria with the
ventricles) and the AV node (fibers at the base of the interatrial septum that transmit
the cardiac impulses from the sinoatrial [SA] node).
left coronary artery

■ The left coronary artery runs along the surface of the left atrium, where it splits into
two major branches: the left anterior descending artery and the left circumflex
artery.
■ anterior wall of the left ventricle
■ interventricular septum
■ right bundle branch (a branch of the bundle of His)
■ left anterior fasciculus (small cluster) of the left bundle branch.
■ left anterior descending artery (LADA)—the septal perforators and the diagonal
arteries—supply blood to the walls of both ventricles.
Circumflex-ability

■ supplies oxygenated blood to the lateral walls of the left ventricle, the left atrium
and, in about 50% of the population, the SA node.
■ supplies blood to the left posterior fasciculus of the left bundle branch. This artery
circles around the left ventricle and provides blood to the ventricle’s posterior
portion.
veins

■ Like other parts of the body, the heart has veins, called cardiac veins, that collect
deoxygenated blood from the capillaries of the myocardium.
■ These cardiac veins join together to form an enlarged vessel called the coronary
sinus. The right atrium receives deoxygenated blood from the heart through the
coronary sinus.
Pulmonary circulation

■ During pulmonary circulation, blood travels to the lungs to pick up oxygen in

exchange for carbon dioxide.
■ Here’s what happens during pulmonary circulation:
1. Deoxygenated blood travels from the right ventricle through the pulmonary semilunar
valve into the pulmonary arteries.
2. Blood passes through smaller arteries and arterioles into the capillaries of the lungs.
3. Blood reaches the alveoli and exchanges carbon dioxide for oxygen.
4. Oxygenated blood returns through the venules and veins to the pulmonary veins.
5. The pulmonary veins carry the oxygenated blood back to the left atrium of the heart.
Cardiac rhythm
■ Contractions of the heart occur in a rhythm that’s regulated by impulses initiated at
the SA node.
■ SA node is the heart’s pacemaker. Impulses initiated at the SA node are conducted
from there throughout the heart. Impulses from the autonomic nervous system
affect the SA node and alter its firing rate to meet the body’s needs.
The cardiac cycle

■ consists of two phases: systole and diastole

■ Out with systole, in with diastole
■ Diastole consists of ventricular filling and atrial contraction.
■ During ventricular filling, 70% of the blood in the atria drains into the ventricles
passively, by gravity.
■ The active period of diastole, atrial contraction (also called atrial kick), accounts for
the remaining 30% of blood that passes into the ventricles.
The pressure’s on

■ When the pressure in the ventricles is greater than the pressure in the aorta and
pulmonary artery, the aortic and pulmonic valves open.
■ Blood then flows from the ventricles into the pulmonary artery, then to the lungs and
into the aorta, and then to the rest of the body.
The pressure’s off

■ At the end of ventricular contraction, pressure in the ventricles drops below the
pressure in the aorta and pulmonary artery.
■ The difference in pressure forces blood back up toward the ventricles and causes
the aortic and pulmonic valves to snap shut.
■ As the valves shut, the atria fill with blood in preparation for the next period of
diastolic filling, and the cycle begins again.
Out in a minute

■ Cardiac output is the amount of blood the heart

pumps in 1 minute. It’s equal to the heart rate
multiplied by the stroke volume (the amount of
blood ejected with each heartbeat).
Stroke volume depends on three major factors:
■ preload
■ afterload
■ contractility.
Preload
■ Blowing up the balloon
■ Preload is the stretching of muscle fibers in the
ventricles. This stretching results from blood volume in
the ventricles at end-diastole.
■ According to Starling’s law, the more the heart muscles
stretch during diastole, the more forcefully they contract
during systole. Think of preload as the balloon stretching
as air is blown into it. The more air, the greater the
stretch.
Contractility

■ The balloon’s stretch

■ refers to the inherent ability of the
myocardium to contract normally.
■ Contractility is influenced by preload.
The greater the stretch, the more
forceful the contraction— or, the more
air in the balloon, the greater the
stretch, and the farther the balloon will
fly when air is allowed to expel.
Afterload

■ refers to the pressure that the ventricular

muscles must generate to overcome the
higher pressure in the aorta to get the blood
out of the heart.
■ Resistance is the knot on the end of the
balloon, which the balloon has to work against
to get the air out.
Blood vessels

■ The vascular system is the complex network of blood vessels throughout the body
that conducts systemic circulation. Blood carries oxygen and other nutrients to body
cells and transports waste products for excretion.
■ Upper blood suppliers
■ Three arteries arise from the arch of the aorta and supply blood to the brain, arms,
and upper chest.
– left common carotid artery
– left subclavian artery
– brachiocephalic artery (also called the innominate artery).
Descending distribution
■ As the aorta descends through the thorax and abdomen, its branches supply blood to the GI and
genitourinary organs, spinal column, and lower chest and abdominal muscles.
■ Then the aorta divides into the iliac arteries, which further divide into the femoral arteries.
■ Arterioles
– As the arteries divide into smaller units, the number of vessels increases, thereby
increasing the area of perfusion.
– These smaller units known as arterioles, can dilate to decrease blood pressure or constrict
to increase blood pressure.
■ Capillaries
– Where the arterioles end, the capillaries begin. Strong sphincters control blood flow from
the capillaries into the tissues. The sphincters open to permit more flow when needed and
close to shunt blood to other areas.
– Although the capillary bed contains the smallest vessels, it supplies blood to the largest
area.
– Capillary pressure is extremely low to allow for exchange of nutrients, oxygen, and carbon
dioxide with body cells.
Branching back to the right atrium

■ venules and veins

– From the capillaries, returning blood flows into venules and, eventually, into
veins. Valves in the veins prevent blood backflow, and the pumping action of
skeletal muscles assists venous return.
■ The veins merge until they form branches that return blood to the right atrium. The
two main branches include the superior vena cava and the inferior vena cava.
Cardiovascular assessment

■ Assessment of a patient’s
cardiovascular system includes a health
history and physical examination.
Health history
■ To obtain a health history of a patient’s cardiovascular
system, begin by introducing yourself and explaining
what happened during the health history and physical
examination. Then obtain the following information.
– Chief complaint
– Personal and family health
– Rating pain
Chief complaint
■ Patients with cardiovascular problems typically cite specific complaints, including:
– chest pain
– irregular heartbeat or palpitations
– shortness of breath on exertion, when lying down, or at night
– cough
– weakness or fatigue
– unexplained weight change
– swelling of the extremities
– dizziness
– headache
– peripheral skin changes, such as decreased hair distribution, skin color
changes, a thin shiny appearance to the skin, or an ulcer on the lower leg that
fails to heal
– pain in the extremities, such as leg pain or cramps.
Personal and family health
■ Also ask about:
– stressors in the patient’s life and coping strategies he uses to
deal with them
– current health habits, such as smoking, alcohol intake, caffeine
intake, exercise, and dietary intake of fat and sodium
– drugs the patient is taking, including prescription drugs, over-the-
counter drugs, and herbal preparations
– previous surgeries
– environmental or occupational considerations
– activities of daily living (ADLs)
– menopause (if applicable).
Rating pain
■ Many patients with cardiovascular problems complain of chest pain.
■ If the patient is experiencing chest pain, ask him to rate the pain on a scale of
0 to 10, in which 0 indicates no pain and 10 indicates the worst chest pain
imaginable. It’s vital to assess pain thoroughly.
■ Where, what, and why
– If the patient isn’t in distress, ask questions that require more than a yes-
or-no response. Use familiar expressions rather than medical terms
whenever possible.
■ In his own words
– Let the patient describe his condition in his own words. Ask him to
describe the location, radiation, intensity, and duration of pain and any
precipitating, exacerbating, or relieving factors to obtain an accurate
description of chest pain
Physical examination
■ Cardiovascular disease affects people of all ages and can take many forms.
To best identify abnormalities, use a consistent, methodical approach to the
physical examination.
■ First things first
– Before you begin the physical examination, wash your hands
thoroughly.
– Obtain a stethoscope with a bell and a diaphragm, an appropriate-
sized blood pressure cuff, and a penlight.
– Also, make sure the room is quiet.
– Ask the patient to remove all clothing except his underwear and to put
on an examination gown.
– Have the patient lie on his back, with the head of the bed at a 30- to
45-degree angle
The heart of it

■ When performing an assessment of a patient’s heart health,

■ proceed in this order:
– inspection
– palpation
– percussion
– auscultation.
Inspection
■ First, take a moment to assess the patient’s general appearance.
■ First impressions
– Is the patient too thin or obese? Is he alert? Does he appear
– anxious? Note the patient’s skin color.
– Are his fingers clubbed? (Clubbing is a sign of chronic hypoxia caused by a lengthy
cardiovascular or respiratory disorder.)
– If the patient is dark-skinned, inspect his mucous membranes for pallor.
■ Check the chest
– Look for pulsations, symmetry of movement, retractions, or heaves (strong outward
thrusts of the chest wall that occur during systole).
■ Inspecting the impulse
– Note the location of the apical impulse.
– This is also usually the point of maximal impulse (PMI) and should be located in the fifth
intercostal space medial to the left midclavicular line.
Abnormal findings on inspection

■ Inspection may reveal cyanosis, pallor, or cool or cold skin, which may indicate poor
cardiac output and tissue perfusion.
■ Skin may be flushed if the patient has a fever.
■ Absence of body hair on the arms or legs may indicate diminished arterial blood flow
to those areas.
■ Swelling, or edema, may indicate heart failure or venous insufficiency. It may also be
caused by varicosities or thrombophlebitis.
■ Chronic right-sided heart failure may cause ascites and generalized edema.
A chest of clues
■ Inspection may reveal barrel chest (rounded thoracic cage
caused by chronic obstructive pulmonary disease), scoliosis
(lateral curvature of the spine), or kyphosis (convex
curvature of the thoracic spine). If severe enough, these
conditions can impair cardiac output by preventing chest
expansion and inhibiting heart muscle movement.
■ Retractions (visible indentations of the soft tissue covering
the chest wall) and the use of accessory muscles to breathe
typically result from a respiratory disorder but may also
occur with a congenital heart defect or heart failure.
Palpation
■ Note skin temperature, turgor, and texture. Using the ball of your hand and then your
fingertips, gently palpate over the precordium to find the apical impulse.
■ Note heaves or thrills (fine vibrations that feel like the purring of a cat).
■ Elusive impulse
– apical impulse may be difficult to palpate in patients who are obese or
pregnant and in patients with thick chest walls. If it’s difficult to palpate with
the patient lying on his back, have him lie on his left side or sit upright.
■ Plus, palpate
– Also palpate the sternoclavicular, aortic, pulmonic, tricuspid, and epigastric
areas for abnormal pulsations. Pulsations aren’t usually felt in those areas.
However, an aortic arch pulsation in the sternoclavicular area or an abdominal
aorta pulsation in the epigastric area may be a normal finding in a thin patient.
Percussion

■ Percussion is less useful than other assessment methods, but it may

help you locate the cardiac borders.
■ Border patrol
– Begin percussing at the anterior axillary line and continue toward
the sternum along the fifth intercostal space.
– The sound changes from resonance to dullness over the left
border of the heart, normally at the midclavicular line.
– The right border of the heart is usually aligned with the sternum
and can’t be percussed.
Auscultation
■ You can learn a great deal about the heart by auscultating for heart sounds. Cardiac
auscultation requires a methodical approach and lots of practice.
■ Here’s the plan
– First, identify the auscultation sites, which include the sites over the four cardiac valves,
at Erb’s point, and at the third intercostal space at the left sternal border. Use the bell
to hear low-pitched sounds and the diaphragm to hear high-pitched sounds.
– Begin by warming the stethoscope in your hands. Auscultate for heart sounds with the
patient in three positions:
■ lying on his back with the head of the bed raised 30 to 45 degrees
■ sitting up
■ lying on his left side.
Upward, downward, zigward, zagward

■ Use a zigzag pattern over the precordium.

■ Start at the apex and work upward or at the base and work downward.
Whichever approach you use, be consistent.
■ Use the diaphragm to listen as you go in one direction; use the
■ bell as you come back in the other direction. Be sure to listen over the
entire precordium, not just over the valves. Note the patient’s heart rate
and rhythm.
Abnormal findings on heart
auscultation
■ On auscultation, you may detect S1 and S2 heart sounds that are accentuated, diminished, or inaudible.
■ Other abnormal heart sounds—such as S3, S4, and murmurs—may result from pressure changes, valvular
dysfunctions, and conduction defects.
■ Third heart sound
– The third heart sound—known as S3 or ventricular gallop—is a low-pitched noise best heard by placing
the bell of the stethoscope at the apex of the heart.
■ Kentucky galloper
– Its rhythm resembles a horse galloping, and its cadence resembles the word “Ken-tuc-ky” (lub-dub-by).
Listen for S3 with the patient in a supine or left-lateral decubitus position.
– An S3 usually occurs during early diastole to middiastole, at the end of the passive-filling phase of
either ventricle. Listen for this sound immediately after S2. It may signify that the ventricle isn’t
compliant enough to accept the filling volume without additional force.
Age-related adversity
■ An S3 may occur normally in a child or young adult. In a patient older than age 30,
however, it usually indicates a disorder, such as:
■ right-sided heart failure
■ left-sided heart failure
■ pulmonary congestion
■ intracardiac shunting of blood
■ myocardial infarction (MI)
■ anemia
■ thyrotoxicosis
■ mitral insufficiency
■ tricuspid insufficiency.
Tennessee walker

■ An S4 shares the same cadence as the word “Ten-nes-see” (le-

lubdub). It’s heard best on expiration with the bell of the stethoscope
and with the patient in the supine position.