Disturbances in Gas Transport

DISTURBANCES IN GAS TRANSPORT The Heart

Propels oxygenated blood into arterial system located in the center of the thorax , in the middle of mediastinum occupies the space between the lungs and rest on diaphragm

weighs 300g (10.6

0z)
weight and size influenced by age, gender body wt., extent of physical exercise and conditioning, disease

normal HR 60-80 ejects 70 ml of blood/beat by each ventricle 5L/min output per day (2000 gal/day) Layers

The heart is enclosed by pericardium

Layers of Pericardium a. Visceral Pericardium(Inner) b. Parietal Pericardium (Outer) c. Pericardial Sac (20ml but can hold 30-50ml of fluid) Layers of the Heart A. Epicardium (outer) B. Myocardium, the thick muscular middle layer C. Endocardium, the inner layer

Chambers of the Heart

Upper chamber (left and right atrium), are receiver chamber of the blood Lower chamber ( left and right ventricle), are the hearts pumping chamber

Valves of the heart

CARDIOPULMONARY CIRCULATION

CONDUCTION SYSTEM

ELECTRICAL CONDUCTION
Consist of:
SA node (Sinoatrial), initiate the electrical impulses that cause the atria and ventricles to contract thats why its called as pacemaker of the heart

Normally it produces between 60-100 impulses/min, the average is 72impulses/min Initiate impulses faster in response to sympathetic nervous system stimulation and slow impulses in response to parasympathetic stimulation

AV node, coordinates the incoming electrical impulses from atria and delayes the impulse about hundredths of a seconds allowing time for atria to contract. Bundle of His, to the right and left bundle branch. Purkinje Fibers, the terminal point in the conduction system. The point at which the myocardial cells are stimulated causing ventricular contraction.

Cardiac Cycle One cardiac cycle=to one complete heartbeat Cardiac Output The amount of blood ejected from a ventricle per minute 4.0 8.0 L/min normal CO Stroke Volume the total amount of blood ejected from a ventricle with each beat 70ml normal SV Has major influence on CO

Control of Stroke Volume 1. PRELOAD

Degree of stretch of cardiac muscle fibers at the end of diastole SV is directly R/T preload Frank Starling LAW states that the greater the stretch the stronger the degree of contraction

Greater the stretch Strong Contraction Produce Large SV Increase CO

2. AFTERLOAD the amount of pressure required by the left ventricle to open the aortic valve during systole to eject blood

SV is inversely R/T afterload 3. CONTRACTILITY force generated by contracting myocardium under any given condition

Cardiac Output is computed by: CO = SV x HR

ASSESSMENT
A. Nursing History
I. HISTORY A)Biographic age, gender,status,occupation B)Demographic data ethnic background & cultural consideration C)Current health organize the history and reveals the sequence of events that lead to client seek help D)CHIEF COMPLAINT

B. Clinical Manifestation 1. CHEST PAIN (OLDCARR) O onset ( gradual) L location (Retrosternal that radiates bilaterally across the chest into the arms, left greater than right to the neck and jaw D duration (<1' or longer than 15' but lasts less than 20')

C characteristic

Strange feeling Dull, heavy pressure Burning, crushing, constricting, squeezing Crescendo( gradually increasing) pattern at onset Dyspnea Nausea and vomiting Palpitations Diaphoresis Syncope Fatigue for several week (common in women)

A - associated symptoms

A aggravating factor Exertion Eating a heavy meal Excitement Extreme temperature Exercise
R relieving factor

Rest Vasodilator Oxygen

2. Palpitation (means to throb) Sensation of rapid, skipping hear beat Ask about the use of the ff: Over the counter drug Decongestant Caffeine intake Hx of thyroid disease 3. Cyanosis Bluish discoloration of mucous membrane or skin caused by hgb level or blood perfusion

2 Forms

A. Peripheral Cyanosis

Result of blood flow to the areas of the body caused by cutaneous vasoconstriction or CO Lips, earlobes, nailbeds

B. Central Cyanosis

Result of arterial oxygen saturation caused by impaired pulmonary function (reduced Oxygen inspiration &/or inability to oxygenate blood in the lungs) Causes: Advance pulmonary edema R-L shunting within the heart

4. Syncope Fainting caused reduce CO resulting to inadequate circulation Most are of cardiac origin Dysrhythmias Vasovagal Neurocardiogenic (postural hypotension)

Other causes: Medications Valvular disorder (aortic stenosis)

5. Dyspnea

Defined as shortness of breath or labored breathing Sudden onset of dyspnea may occur with: Fever Pneumonia pneumothorax,emboli,obstruction Chronic dyspnea may occur in: Anxiety Depression Left ventricular failure

Pulmonary disease (Asthma) Obesity L ventricular failure Bronchial constriction

Dyspnea with wheezing:

Forms

Exertional cardiac related occur during mild-mod exercise activity

Orthopnea

Result from increase pressure in the lungs when the person is

lying flat

Paroxysmal nocturnal dyspnea

Caused by L-ventricular heart failure 2-4 after the person goes to bed Complaints of fatigue should be considered as warning sign of impending cardiac event Manifestation low cardiac output

6. Fatigue

7. Edema

Excess accumulation of fluid in the tissues Anasarca generalized edema associated with nephrotic syndrome, HF, cirrhosis

Peripheral Edema particular areas for examination are the dependents parts of the (feet , ankles legs and sacrum) Non pitting peripheral edema is caused by gravity flow or interruption of venous return to the heart as a result of constricting clothing or pressure on the veins of LE

Pitting Edema

Degree of pit

+1 slight indention (30% accumulation of interstitial fluid) +2 deeper pit after pressing (4mm) +3 deep pit (6mm) +4 deep pit (8mm), frank swelling

Brawny edema Fluid could no longer be displaced 2excessive accumulation of ISF No pitting Tissue is firmed and hard Skin surface is shiny, warm and moist

Physical examination A. General appearance

Consider the ff: Does the client lies quietly, restless Can lie flat or upright Facial expression Manifestations LOC BP Assess for postural hypotension (lying , sitting & standing)

B. Vital signs

Orthostatic changes:
a) decrease of 10-15 mmHg systolic and 10 mmHg diastolic b) Increase in HR 10-20%

Pulse

Assess for pulse deficit Quality

Refers to the its palpated volume (bounding, thready, absent)

Rhythm

Pattern of pulsation There should be similar pauses between them

Respiratory Rate

Character

Easy, labored, dyspneic, deep shallow Use of accessory muscle

C. Skin

Warm dry skin Cold clammy Cyanosis and pallor

D. Edema

E. Weight

Can indicate edema 2 lb weight gain means of additional liter of fluid in the body Should weigh at same time, same clothing, scale each day

F. Jugular veins

A general estimate of venous return can be obtained by observation of the neck vein Normal distended neck vein in supine position Collapsed in a 45 degrees angle If jugular vein distention is present, assess the pressure by measuring from the highest point of visible distention to the sternal angle 3 cm is elevated indicates venous pressure cause by RHF, Regurgitation

Jugular vein distention

Physical Examination
S1

first heart sound heard due to closure of AV valves loudest at the apex second heart sound due to closure of semilunar valves loudest at the base

S2

S3 or Ventricular Gallop rd 3 heart sound. Normal in children S4 or Atrial Gallop th 4 heart sound normal in children but is associated w/ systemic or pulmonary HPN, MI, and other cardiac disease

AUSCULTATORY AREAS

APE TO MAN

AUSCULTATORY AREAS

DIAGNOSTIC TEST A. Laboratory Test

SERUM ENZYMES 1.Troponin,

an enzyme in myocardial contractile & is present only in myocardial tissue more specific to cardiac injury for diagnosis of MI w/an uncertain time frame returns to normal after 2 weeks

2.Creatine kinase (CK) formerly creatine phospokinase (CK-MB) cardiac muscle (CK-MM) muscles (CK-BB) Brain

Elevation indicates injury Returns to normal after 2-3 days

3.Lactate Dehydrogenase (LDH)

Is found in many body tissues

Useful in delayed diagnosis of MI Elevated w/in 24-72 hours after MI Returns to normal after 2 weeks

SERUM LIPID

Plasma lipids are composed mainly of cholesterol, triglycerides, phospholipids and free fatty acids All are insoluble in water and require a carrier for transport PROTEIN are carrier of plasma lipid thats why they are known as LIPOPROTEIN

4 MAJOR CLASSES : Chylomicrons Very low density lipoproteins (VLDL) Low density lipoproteins( LDL) High Density Lipoproteins (HDL) A. High Density Lipoprotein

Transport cholesterol away from tissues to liver excretion Total cholesterol ratio should be at least 5:1 with an optimal ratio range from 3.5:1 NV = >60 mg/dl

B. Low Density Lipoprotein

They transport cholesterol into peripheral tissues NV = <100 mg/dl Preparation:

Fasting for 12-14 hours Avoid alcoholic beverages or lipid influencing drugs (estrogen, oral contraceptives, steroids and salicylates)

Echocardiography (2D Echo)

Uses ultrasound waves to assess cardiac structure and mobility noninvasively Conditions detected by echocardiography Abnormal pericardial fluid Valvular disorders including prosthetics valves Ventricular aneurysm Congenital heart defects Cardiac tumors Cardiac chamber size SV & CO

ECHOCARDIOGRAPHY

You will be asked to remove clothing above the waist EKG patches will be placed on your chest. You will be lying on your back or left side. A doctor or technician will apply gel, which feels cold, to your chest and a transducer will be placed over the heart area. Heart structures will be examined by changing the direction of the transducer. The sound waves cause no discomfort. You may hear a "whooshing" sound, timed with your heart beat. This is the blood movement near the transducer. An EKG will be recording the electrical activity of your heart which will help the doctor interpret your test. When the test is completed the gel can be wiped off easily. Considerations An echo takes about 45 minutes.

2D ECHO (2 Dimension Echocardiography)

Transesophageal Echocardiography

Involves passing of a tube with a small transducer internally from the mouth to the esophagus Images of the posterior heart and its internal structures are obtained ( this provides superior views that are not possible using the conventional technique

Transesophageal echocardiography ultrasound transducer mounted on the tip of a directable gastroscopelike tube about 12mm in diameter. Using topical mouth anesthesia and a little sedative most individuals can swallow the probe without difficulty. Because

Nsg intervention:

Can be performed at the bedside w/o contrast dye with the patient under conscious sedation NPO 4-6 hours Cardiac rhythm, V/S and O2 sat are monitred Caution the client to avoid eating or drinking until sensation and gag reflex return which may take one hour or longer after removal of the tube containing the transducer( bec the throat is anesthesized locally) Remain client in upright or side-lying position position to support ventilation

ELECTROCARDIOGRAPHY

Is the graphic recording of the electrical current generated by the heart muscle Helpful in identifying cardiac dysrhythmias and detecting myocardial damage

Forms: Standard 12 Lead ECG

Ambulatory ECG/Holter Monitoring,

is the recording of an ambulatory clients cardiac rate and rhythm over 28-48 hours as the client performs daily activities
to evaluate how the heart functions during exercise

Exercise-Induced Stress Testing

The activity of the heart is assessed with an ECG monitor while the patient walks on a treadmill ,pedals a stationary bicycle, or climbs up and down stairs Preparation

Consent Light meal 1-2 hours before the test No caffeine, alcohol, smoking Wear comfortable clothing

During the Procedure

Nursing Responsibility:

Obtain baseline BP and ECG tracing Instruct client to report onset of chest pain, dizziness, leg cramps or weakness The stress test is aborted if the client develop severe dyspnea, elevated BP, confusion or dysrhythmias

After the procedure:

Nursing Responsibility

Continue to monitor ECG and BP until client to baseline and is symptom free

Drug-Induced Stress Testing Drugs maybe used to stress the heart for client w/sedentary lifestyles or those w/physical disability such as severe arthritis, that interferes w/exercise testing

Cardiac Catheterization

Valuable diagnostic tool for obtaining detailed information about the structure of the cardiac chambers, valves and coronary arteries Indication

Confirmation of suspected heart disease Determination of the location and severity of heart disease Preoperative assessment whether cardiac surgery is indicated Evaluate ventricular function

Evaluation of the effect of medical treatment modalities performance of specialized cardiac interventions such as internal pacemaker

Nursing Responsibility b4 test: 1.Foods and fluids are withheld, if the test is late in the day, clear liquid meal maybe permitted 2.Allergies must be identified (iodine, shellfish, radiographic dye) 3.IV fluids to maintain hydration 4.a sedative is administered before the test 5.assess peripheral pulses before the test

During the procedure:

instruct the client that a warm sensation is felt when dye is injected (Left-sided catheterization) Instruct client to report if any chest discomfort, nausea or difficulty in breathing after removing the catheter apply pressure dressing to prevent bleeding

After the procedure

1.Keeping the extremities straight for several hours and avoiding movement are important. Monitor for bleeding and infection 2.Monitor BP and pulse frequently 15 minutes x 1 hour then every 30 min x 3 hours 3.Check the dressing at the insertion site to detect for bleeding
4.Palpate pulse in various location and checked the color and temp of the extremeties to confirm that blood is circulating well.

5. Monitor I & O . Drink large volume of fluid to relieve thirst.

Hemodynamic MonitoringA

Is used to assess the volume and pressure of blood in the heart and vascular system by means of surgically inserted catheter Such monitoring is used to: 1.Assess cardiac function and circulatory status 2.Adjust fluid infusion rates

Methods: 1.Central Venous Pressure

CVP measurements reflects the pressure in the R atrium and provide information regarding changes in right ventricular pressure Used to monitor blood volume and the adequacy of venous return to the right side of the heart

NV vary w/different equipment ; however a range of 5-15 cmH20 is acceptable Low (Falling) indicate inadequate blood volume High (rising) usually secondary to LNV vary w/different equipment ; however a range of 5-15 cmH20 is acceptable.sided heart failure

2.Pulmonary Artery Pressure 3.Pulmonary Capillary Wedge Pressures

A balloon- tipped catheter (Swan-Ganz) maybe introduced into the pulmonary artery to obtain essential information regarding L ventricular function Normal reading of PAEDP 4-12 mmHg. Elevation results fr increased peripheral vascular resistance Normal reading of PCWP- 4-12mmHg. (>25mmHg indicate pulmonary edema

Intra-arterial Pressure Monitoring

Method in obtaining BP in critically ill patients Method in obtaining BP in critically ill patients Beneficial for clients whose BP measurement are unreliable such as those w/ low COBeneficial for clients whose BP measurement are unreliable such as those w/ low CO

If Radial artery is chosen as site blood flow to the hand should be evaluated w/ Allens Test