Overview of Anatomy and Physiology of the Respiratory System

Respiration – process of gaseous exchange between the • Macrophages

individual and environment. • Lymphatics
3 process of Respiration 2. Immunologic Responses – cell mediated immunity in
1. Ventilation alveoli.
• Inhalation 3. Pulmonary protection in the injury
• Exhalation • Respiratory epithelium
2. Diffusion/Gas exchange
• Mucociliary system
3. Perfusion
The pleura
Structures in the Respiratory System
ꙋ Serous membrane encloses the lungs
1. The airways
ꙋ Covers the lungs-VP
1. Nasal Cavity or nares
ꙋ Lines the cavity of hemi thorax-PP
2. Pharynx
The Lungs
3. Larynx or Voice box
ꙋ Right-3 Lobes/L-2 lobes
2. Lower Airways
ꙋ Separated by a space called
1. Trachea
Mediastinum.
2. R and L mainstem bronchi
ꙋ Alveoli – tiny air sacs that take up oxygen. They’re the
3. Segmental bronchi
workhorses of your respiratory system.
4. Sub-segmental bronchi
5. Terminal bronchi

Lung Capacities and Volumes

1. Residual volume: amount of air remains in lungs after
forceful expiration: prevents lung collapse (1,250ml).
2. Tidal Volume: TV: amount of air that moves out, in, and
out of the lungs with each normal breath(500ml)
3. Inspiratory reserve volume: amount of extra air that can
be inhaled beyond tidal volume (2,000ml)
4. Expiratory reserve volume: amount of extra air that can
be exhaled after a normal breath (1,250ml)
5. Total lung capacity: total of all volume. RV+TV+IRV+ERV
6. Functional Residual Capacity: amount of air that
remains in lungs after normal exhalation (2,500ml).

Thorax and Diaphragm

• Provides protection to lungs, heart, great vessels.
• Thorax – 12 pairs of ribs, bounded anteriorly by the
sternum and posteriorly by the thoracic vertebrae.
• Diaphragm – main respiratory muscle for inspiration. It
is supplied by the phrenic nerve.
Respiratory Centers
A. Medulla Oblongata: Primary Center
B. Pons contains the following:
• Pneumotach center: Rhythm and quality of
Function of Upper Airways breathing
1. Transport gas to the lower airways • Apneustic center. Deep and prolonged inspiration.
2. Protection of the lower airway from foreign matters C. Carotid and Aortic
3. Warming, filtration and humidification of inspired air • Peripheral Chemoreceptors
Functions of the Lower Airways D. Muscle and Joints:
1. Clearance mechanism • Proprioceptors: Exercise
• Cough
• Mucociliary system
Physiologic Changes in the Respiratory System with Aging
• Reduce chest wall compliance that results from: o Increase calcification of costal cartilage
 o decrease strength of intercostal accessory muscle ✓ Prolonged, gasping inspiration followed by a short
and diaphragm. inefficient expiration.
• Reduced breathing capacity Normal Findings
• Reduced Vital Capacity 1. General appearance:
• Increase Residual Volume 2. Breathing Pattern
• Decrease Cough reflex 3. Respiratory rate
4. Skin
• Decrease ciliary activity
5. Nails
Assessment of Clients with Respiratory Disorder
6. Chest wall configuration
A. History 7. Tracheal position
✓ Biographic data 8. Vocal/Tactile fremitus
✓ Chief Complaint 9. Abnormal Responses
▪ Dyspnea 10. Increase fremitus
▪ Cough 11. Decrease fremitus
▪ Sputum production 12. Percussion tones
▪ Hemoptysis a. Resonant: Normal
▪ Wheezing b. Flat-Hear over airless tissue
▪ Stridor c. Dull: occur over dense lung tissue such as tumor or
▪ Chest Pain consolidation
B. Past Medical History d. Tympanic: pneumothorax
e. Hyperresonant
✓ Childhood/ infectious diseases
f. Air tapping
✓ Respiratory immunization Diagnostic Studies and Therapies
✓ Major/ Illnesses/ Hospitalization 1. Skin test: Mantoux Test
✓ Medications ✓ Route: ID
✓ Allergies ✓ Read 48 to 72 hours after administration
C. Family History ✓ (+) if more than 10 mm
D. Psychosocial history and lifestyle ✓ HIV px: 5mm is considered positive
✓ Occupation or environmental exposure ✓ (+) Mantoux Test (exposure to MTB)
E. Geographic location ✓ (+) Clients who received BCG
F. Personal habits: years of smoking x 2packs/day = 2. X-ray
pack years ✓ Chest x Ray:
Physical Examination ✓ Hold breath and to do deep breathing
1. Inspection: ✓ No metals from the chest
✓ S and Sx of respiratory distress ✓ interfere with the images
✓ I:E ratio 1:2 3. Fluoroscopy
✓ Speech pattern 4. Bronchogram – radiopaque medium is instilled directly
✓ Chest wall configuration into the trachea and bronchi and the entire bronchial
tree or selected areas may be visualized through X-ray
✓ Chest movement
Before:
✓ Fingers and toes
▪ Consent
2. Palpation ▪ Allergies
✓ Trachea ▪ NPO 6t0 8 hours
✓ Chest wall ▪ Pre-op meds: Atropine SO4; Topical
✓ Thoracic excursion anesthesia; then LA
✓ Tactile fremetous ▪ O2 ready and anti-spasmodic drugs
3. Percussion After
✓ Resonnance ▪ Side lying: Aspiration
✓ Hyperresonance ▪ NPO until gag reflex and cough
✓ Dullness ▪ Low grade fever is common
4. Auscultation 5. Bronchoscopy – detect the cause of breathing
Adventitious sounds difficulties and lung problems, such as tumors,
Normal Breath Sounds
infection, and bleeding.
• Bronchial (Tracheal) • Crackles
6. Lung Scan
• Bronchovesicular • Crackles
o Injection of radio isotope
• Vesicular • Pleural friction rub
o Scans are taken with scintillation camera
Voice Sounds • Wheeze
o Measures the blood perfusion through the lungs.
A. Egophony: o Confirms Pulmonary-embolism or other blood flow
✓ Say prolonged ‘e”; If “a”? Consilidation abnormalities
B. Whispered Pectoriloquy o Instruct client to remain still during the procedure.
✓ Whisper 1,2,3 7. Sputum Examination:
✓ Auscultated as muffled 1,2,3 o A sputum culture requires minimal effort on your
✓ Bonchophony part. You simply need to provide the sample for
C. Bronchophony the lab to test. You'll be asked to cough deeply to
✓ Say 99 bring up the sputum from your lungs. Saliva that
✓ Increase resonance and word are head clearly can come up when someone is asked to cough is
Altered Breathing Pattern typically from the mouth and upper airways and
• Cheyne Stokes breathing isn't useful for this test.
✓ Marked rhythmic waxing and waning respiration 8. Lung Biopsy
from very deep or very shallow breathing and o Transbroncoschopic Biopsy: During bronchoscopy
temporary apnea. o Percutaneous Needle Biopsy: Aspiration
• Kausmulls breathing – hyperventilation increases rate o Open biopsy: surgery
and depth o Lymph node biopsy
• Hypoventilation – slow and shallow respiration 9. Pulmonary Function Studies
• Biot’s – shallow breaths interrupted by apnea. o Vital Capacity
• Apneustic breathing o Tidal Volume
o Inspiratory reserve volume
 o Functional Residual Capacity
o Residual volume Common Respiratory Interventions
10. Pulse oximetry 1. Oxygen Therapy
11. Thoracentesis ✓ Assess signs and symptoms of hypoxia
o Aspiration of fluid or air from pleural space: ✓ Check doctors order.
Before: ✓ Position: semi fowlers
✓ Secure written consent. (invasive) ✓ Open source of oxygen before insertion of O2
✓ Take VS (Hypovolemia) device, to check for malfunctioning device.
✓ Position: upright leaning over bed table. ✓ Regulate oxygen flow accurately. Excessive
✓ Remain still; avoid coughing during needle administration of oxygen can cause oxygen
insertion. (trauma to lungs) narcosis (respiratory alkalosis).
✓ Pressure sensation is felt on insertion of needle. ✓ Place a “No Smoking” sign at the bedside.
✓ Topical anesthetic is used at the site of ✓ Avoid use of oil, greases, alcohol and ether near
insertion the client receiving oxygen. These may further
After: support combustion.
✓ Turn client on the unaffected side to prevent ✓ Check electrical appliances. Small spark may
leakage of fluid in the thoracic capacity. cause a fire if there is leakage of oxygen.
✓ Bed rest (prevent postural hypotension) ✓ Avoid materials that generate static electricity:
✓ Check the expectoration of blood (trauma) synthetic fabrics. Use cotton blankets.
notify the physician ✓ Humidify oxygen. Place sterile water into the
✓ Monitor VS to Assess for signs and symptoms of oxygen humidifier. To prevent dryness and irritation
internal hemorrhage. of mucus membrane in the airways.
✓ Provide good oronasal hygiene. To prevent dryness
Arterial Blood Gas and irritation of mucus membrane.
PaCO2 (carbonic acid) – respiratory indicator ✓ Lubricate nares with water-soluble lubricant to
ꙋ CO2 – acts as an acid. When CO2 combines with sooth the mucous membrane. Do not use oil. Oil
plasma, carbonic acid is formed. ignites when exposed to compressed oxygen.
ꙋ H2CO3 = CO2 + H2O ✓ Assess effectiveness of oxygen therapy.
Normal Values: 2. Tracheobronchial Suctioning: to remove secretions
< Acidosis ✓ Client should be in semi- or high-Fowler’s position.
Blood pH 7.35-7.45
> Alkalosis ✓ Practice sterile technique. To prevent infection.
< Alkalosis ✓ Hyperventilate client with 100% oxygen before and
paCO2 35- 45 mm/Hg after suctioning. To prevent hypoxia.
> Acidosis
< Acidosis ✓ Insert catheter (3-5 inches length of catheter
HCO3 22-26 mEq/L insertion). The trachea is 4-5 inches in length.
> Alkalosis
pO2 80-100 ꙋ Suction during withdrawal of catheter. To prevent
a. Uncompensated: paCO2 or HCO3 trauma to mucous membrane of airways. Applying
b. Partially Compensated: nothing is normal suction during insertion of the catheter causes
c. Compensated: pH is normal trauma and bleeding.
R – respiratory pH ; paCO2 = Alkalosis ꙋ When withdrawing the catheter, rotate the
O – opposite pH ; paCO2 = Acidosis catheter while applying intermittent suction. To
ensure adequate removal of mucous secretions.
M – metabolic pH ;  HCO3 = Alkalosis ꙋ Suctioning: 5 to 10 seconds (maximum of 15
E – equal pH ;  HCO3 = Acidosis seconds). To prevent hypoxia, vagal stimulation
and bleeding. Vagal stimulation causes
Nursing Diagnosis hypotension and bradycardia.
1. Altered respiratory function rt chronic lung disease ꙋ Evaluate: clear breath sounds on auscultation.
requiring tracheostomy and ventilator support. 3. Bronchial Hygiene Measures
2. Risk for ineffective respiratory function and impaired • Therapy (BHT) is a broad term used to describe
gas exchange rt: chronic lung disease; and various airway clearance techniques: chest
tracheostomy (altered secretions - plugging, physiotherapy (which consists of postural drainage,
ineffective airway clearance) percussion, vibration, coughing, and suctioning),
3. Risk of impaired spontaneous ventilation and breathing exercises (such as huffing and
hypoxemia related to respiratory insufficiency diaphragmatic breathing used in spontaneously
4. Risk of dysfunctional ventilatory weaning response breathing patients),
related to: fatigue; ineffective airway clearance; other 4. Suctioning: oropharyngeal; nasopharyngeal
physical/ emotional factor(s) ꙋ Steam inhalation
5. Risk for equipment malfunction ꙋ Aerosol inhalation
6. Alteration in oral motor function related to medical ꙋ Medimist inhalation
condition and lack of use. 5. Chest Physiotherapy
7. Alteration in mobility related to disuse of legs (long • Postural drainage
hospitalizations, medical condition) • Percussion
8. Alteration in nutrition related to medical condition with • Vibration
delayed oral-motor development, feeding via Nursing Interventions in CPT
gastrostomy tube, decreased oral stimulation, and ꙋ Do CPT with upper before lower lobes of lungs.
oral aversion. ꙋ Place client in each position for 10 to 15 minutes; a
9. Alteration in elimination total of 30 minutes for each treatment
10. Fatigue related to medical condition and related ꙋ Percussion and vibration are done to loosen mucus
compromised endurance. secretions
Nursing Process: The Care of Patients with Upper Respiratory ꙋ Change position gradually to prevent postural
Tract Infections: Diagnosis hypotension
• Ineffective airway clearance ꙋ 60 to 90 minutes before meals to prevent vomiting,
• Acute pain in morning upon awakening (mucus secretions
• Impaired verbal communication accumulate during night) & bedtime.
• Deficient fluid volume ꙋ Provide good oral care after the procedure. To
• Deficit of knowledge rt prevention, treatment, remove the unpalatable taste of sputum from the
surgical procedure, or post-op care. mouth.
6. Incentive Spirometry
ꙋ This is done to enhance deep inhalation
ꙋ As the patient inhales, the balls in the spirometer
goes up. This signifies good lung expansion.
7. Closed Chest Drainage (Thoracostomy Tube)
Purposes:
- Remove air and/or fluids from the pleural space.
- Reestablish negative pressure & re expand lungs.

OXYGENATION
I. Anatomy and Physiology of Cardiovascular system C. Systematic Circulation
A. Anatomy of the Heart ➢ Oxygenated blood in the left atrium then passes
➢ A normal, healthy heart is separated into two through the bicuspid valve into the left ventricle,
halves, the left side and the right side, with no direct where it is powerfully pumped out to the rest of the
connection between them. Each side is divided in body through the major artery, the aorta. The aorta
turn into two chambers: an upper chamber, the arches over and behind the heart, with arteries
atrium, which receives blood into that half, and a quickly branching off at the top to supply the upper
lower chamber, the ventricle, which pumps blood body (aorta ascending) and the rest of the blood
out from it. This is shown in the image below. flow moving down the aorta (descending) to
supply the lower half of the body. This is illustrated in
the diagram of the anatomy of the heart above. As
the aorta sits behind the heart, the diagram shows
the aorta (ascending) with the arteries branching
off at the top of the diagram, and the aorta
(descending) at the bottom of the diagram.
➢ In the tissues and organs of the body, this blood
goes through another gas-exchange, this time the
reverse of the pulmonary circulation: oxygen is
passed out of the blood (to play its central role in
cell metabolism) and carbon
dioxide (and other waste
materials) is absorbed into
the blood.
➢ To complete the systemic
circulation, this
deoxygenated and carbon
dioxide-rich blood then flows
back to the heart through a
system of veins, to enter the
➢ Heart is the “pump” – receives blood at low right atrium (either via the
pressure and pumps out by imparting energy superior vena cava,
through high-pressure system ice arterial system. gathering blood from the
➢ Blood vessels – constricts & dilate to regulate arterial upper part of the body, or the
blood flow and pressure. inferior vena cava, gathering it from the lower).
➢ Heart contraction – induced by the generation and Once back in the right atrium, blood flows into the
conduction of an electrical impulse, which passes right ventricle (via the tricuspid valve), to begin the
through a network of conducting cells to all parts. pulmonary circulation once again and be pumped
- This conduction stimulates the muscle cells of the to the lungs. This is shown in the image below.
upper and lower chambers of the heart to D. Risk factors for Cardiovascular Disease
contract. The start of the electrical impulse is at the ➢ This step looks at the major risk factors to the health
sinoatrial node (SA node), which is also called the of the heart, and how these can affect the body
‘pacemaker’ of the heart. in a number of ways.
➢ With contraction, blood is pumped from the atrium ➢ Major risk factors for the development of
into the ventricle (when the ventricle has been atherosclerosis and ischemic heart diseases can
emptied and is ready to be refilled) through a one- be either modifiable or non-modifiable.
way valve (on the left side this is the bicuspid valve, Non-modifiable factors
and on the right the tricuspid valve). Blood flows ✓ Age – although the start of atherosclerosis has
into the heart (into each atrium) through blood been identified at a very young
vessels called veins, and flows out from the heart age, the plaques involved require decades to
(from each ventricle) through blood vessels called develop and actually cause
arteries. Each side of the heart relates differently to disease. This is why as people age, their chances
two separate circulatory systems: the pulmonary of atherosclerosis
circulation (flowing to and from the lungs), and the increase likewise.
systemic circulation (flowing to and from the rest of ✓ Sex; Ethnic background; Family Hx – South Asian
the body). male over the age of 60, with a family history of
B. Pulmonary Circulation cardiovascular problems, has a significantly higher
➢ Deoxygenated (and carbon-dioxide rich) blood risk of cardiovascular disease. This is in comparison
from the right ventricle is pumped out to the lungs to a French female in her thirties, with no family
via the pulmonary artery (which quickly branches history of cardiovascular complaints. This is
into either the left or the right lung).In the lungs, this because South Asian ethnicity (genetic factors),
blood goes through a gas exchange, passing male sex (hormonal factors), age, and family
carbon dioxide out and absorbing oxygen in. The history each present a non- modifiable risk factor.
now-oxygenated blood passes back from the left This results in the combined risk for the South Asian
or right lung through pulmonary veins to the heart, male being much higher.
gathering in a single vein that takes the blood into Modifiable factors: lifestyles
the left atrium. ✓ Smoking – cause vasoconstriction and raised
blood pressure. It can also:
 • increase heart rate and the force of heart Sport England Active Lives survey for 2015/16 asked
contraction, leading to increased blood participants how much physical activity they are
pressure engaged in. Of those surveyed:
• cause spasms in coronary vessels • 25.6% said they were inactive, as they were
• induce aggregation (stick together) of blood engaged in less than 30 minutes of physical
platelets, leading to clotting inside blood activity per week
vessels, thus blocking blood flow. • 13.7% were classed as fairly inactive, as they were
• Trigger irregular heartbeats (arrhythmias) doing between 30 and 149 minutes of physical
• Adversely affect blood cholesterol level, activity per week
leading to build-up of atheroma in coronary • 60.7% were active, meaning that they were
vessels. engaged in 150 minutes or more of physical
II. Physical inactivity and obesity activity per week.
➢ leads to an increased level of ‘bad cholesterol’ (low Differences in physical activity levels between different
density lipoproteins, LDL) and a reduction in ‘good socioeconomic groups. People who were long-term
cholesterol’ (high density lipoproteins, HDL). LDL unemployed or had never worked were the most likely
increases the chances of atherosclerosis by to be inactive. People in managerial, professional and
depositing cholesterol in peripheral tissues including administrative occupations were the least likely to be
arteries. HDL reduces the chances by increasing the inactive. The reasons for this are complex, and may
transport of cholesterol away from tissues, towards include cultural or community norms and
the liver and bile. expectations, health literacy and educational
Type II Diabetes background.
➢ The insulin resistance found in people with type 2 Smoking
diabetes leads to dysfunction of endothelial cells ➢ The British Heart Foundation (BHF) reports that more
(the inner lining cells of blood vessels). This in turn than one in six adults in the UK smokes cigarettes. The
leads to vasoconstriction, high blood pressure, and BHF estimates that around 20,000 cardiovascular
enhanced atherosclerosis and blood clotting. disease deaths in the UK are linked to smoking. The
High Blood Pressure World Health Organisation provides information on
➢ leads to excessive stretching of arteries throughout the health benefits of smoking cessation. Smokers
body, which can cause injury to inner lining cells of who have a heart attack will halve the chance of
arteries (endothelial cells). Endothelial cells maintain having a second heart attack, if they give up
the patency of artery, increasing vasorelaxation and smoking.
preventing stiffening and atheromatous plaque Obesity
formation. When those cells are injured, arterial ➢ The BHF reports that 27% of adults and 30% of
stiffness and build-up of bad cholesterol increases, children in the UK are obese. The Health Survey for
resulting in atherosclerosis. England (HSE), 2015 found differences in obesity
Stress – not a direct risk factor, the coping mechanisms rates based on sex, age, household income and
and behaviors associated with it usually are. Stress- where people live. For example, the HSE report
related factors that increase CVD risk include: found a difference in obesity levels for women
✓ high blood pressure and cholesterol levels based on household income, but this did not show a
✓ anger similar difference for men.
✓ smoking The National Child Measurement Programme (NCMP) –
✓ physical inactivity England, 2015-16 measures obesity rates. Nearly all
✓ overeating such as comfort eating. children in their first year at school (aged 4-5 years) and
Dyslipidaemia in their last year at primary school (aged 10-11years) are
➢ atheroma formation (atheromatous plaque build- measured. The report found that 9% of children aged 4-
up) is the pathological basis of CVD. At the core of 5 years were obese, compared with 20% of 10-11-year
atheroma are lipids. ‘Bad’ cholesterol in the blood old. The report also found marked differences in
moves into the arterial wall and starts to build up, childhood obesity based on levels of deprivation. For 10-
eventually leading to atheromatous plaque 11-year olds, 26% of children living in the most deprived
formation. Hence dyslipidaemia (abnormal blood areas in England were obese, compared with 12% of
lipid levels) is one of the major risk factors for CVD. children living in the least deprived areas.
However, it can be controlled by proper diet and Diet and food choices
physical activity. ➢ The British Heart Foundation reports that only 25% of
Preventing cardiovascular disease adults and 20% of children in the UK are consuming
➢ In this step, you look at modifiable risk factors for the recommended minimum of five portions of fruit
cardiovascular disease. These include the following: and vegetables per day. The report also states that
a. Medical risk factors – medical conditions include a quarter of adults in the UK exceed the
hypertension and diabetes that can increase recommended weekly intake of alcohol.
the risk of cardiovascular diseases. These can be III. Coronary Problems
managed through medication and health Coronary heart disease and atherosclerosis
checks. a. CHD – group of diseases which cause the arteries
b. Lifestyle risk factors – these are risk factors that supplying blood to the heart itself to become
can be reduced by an individual making blocked with a build-up of fatty material (plaque).
changes to their lifestyle. Examples include b. Atherosclerosis – process of fatty plaque build-up is
smoking, diet and exercise. called atherosclerosis, leading to the gradual
Modifying lifestyle risk factors is a significant way of narrowing or blocking of the inner lining of arteries.
reducing the risk of cardiovascular disease, and is a key This is most common in large or medium sized
aspect of prevention. Lifestyle risk factors include: muscular arteries. Blockage (or occlusion) can occur
• physical inactivity in any artery. The most common areas are:
• smoking • coronary artery – leading to a heart attack
• obesity • cerebral artery – leading to ischaemic stroke
• diet, food choices and alcohol intake. • leg arteries – leading to peripheral vascular
There are other risk factors that are more difficult for diseases.
individuals to modify, such as air pollution levels. When the blockages completely cut off blood supply
Physical inactivity (usually due to blood clotting on top of the plaque) this can
➢ significant factor in the prevention of cardiovascular lead to the death of an area of heart tissue. This is
disease is physical exercise or physical activity. The
commonly known as a heart attack, and is also called a chosen method for diagnosis is a stress
myocardial infarction. electrocardiogram (ECG).
Atherosclerosis begins when initial lesions develop in Cardiovascular disease and strain on the heart
the arteries. This can start before the age of 10. These lesions ➢ Like any other organ, the heart receives its supply of
develop when the build-up of plaque forms scar tissue, oxygen and nutrients through the blood. The
causing thickening to the inside of the arteries. This reduces chambers of the heart are filled with blood.
the space available in the arteries for blood to pass However, most of the cells of the heart (those
through. The core of this scar tissue is mainly filled with making up the thickness of its muscle walls) cannot
cholesterol. receive sufficient oxygen and nutrients directly from
Early lesions develop and are called fatty streaks. As the blood in the chambers. Instead, the heart has its
these lesions develop, they increase in size and take up own network of blood vessels, called coronary
more space in the arteries. These larger build-ups are called vessels.
fibrous plaque. Advanced lesions also cause thrombosis in ➢ If the coronary arteries become narrowed or
the blood vessels, when blood clots form and block the flow blocked, the region of heart supplied by that
of blood. Although these lesions cause many problems in particular artery will become functionally impaired,
the body, they can be ‘clinically silent’ and undiagnosed and will eventually die. This is especially the case
until someone begins to develop symptoms. when the body’s demand for oxygen is specifically
for the heart itself, such as during exercise. For
example, one natural course of CVD would start
from exercise-induced angina (which limits
exercising ability), proceeding to angina at rest, and
eventually to myocardial infarction (heart attack).
Diagnosing cardiovascular disease (CVD)
➢ In this step, you explore the common laboratory
investigations and imaging techniques currently
used for diagnosing cardiovascular disease. You are
then introduced to three broad approaches to
treatment.
Congestive heart failure (CHF) is a chronic progressive
condition that affects the pumping power of your heart
muscles. While often referred to simply as “heart failure,”
Stroke CHF specifically refers to the stage in which
➢ When part of the brain stops working properly due to fluid builds up around the heart and causes it to pump
disease affecting the blood vessels that supply it, this inefficiently.
is called a stroke. Approximately 84% of strokes are Cardiomyopathy is a disease of the heart muscle that
caused by atheromatous plaque and/or related makes it harder for your heart to pump blood to the rest
blood of your body. This can lead to heart failure. The main
clots (ischaemic strokes). Strokes can also be caused type includes dilated, hypertrophic and restrictive
by the bleeding of vessels ruptured due to high cardiomyopathy.
blood pressure (these are called haemorrhagic Pulmonary embolism (PE) usually happens when a blood
strokes). clot called a deep vein thrombosis (DVT), often in your
Arrhythmia leg, travels to your lungs and blocks a blood vessel. That
➢ Any disorder of the rate, rhythm and conduction of leads to low oxygen levels in your blood. It can damage
heart contraction can be called arrhythmia. There the lung and other organs and cause heart failure, too.
are different kinds of arrythymia, including: A heart attack occurs when the flow of blood to the heart
• tachycardia, when the heart rate is abnormally is blocked. The blockage is most often a buildup of fat,
fast cholesterol and other substances, which form a plaque in
• bradycardia, when the heart rate is abnormally the arteries that feed the heart (coronary arteries).
slow Sometimes, a plaque can rupture and form a clot that
• ectopic rhythm, when the origin of the blocks blood flow. The interrupted blood flow can damage
heartbeat is abnormal. or destroy part of the heart muscle. A heart attack, also
Cardiomyopathies called a myocardial infarction, can be fatal, but treatment
➢ These are groups of disorders which affect the has improved dramatically over the years. It's crucial to call
muscle cells of the heart leading to abnormal heart 911 or emergency medical help if you think you might be
function. Common types include: having a heart attack.
• dilated cardiomyopathy
• hypertrophic cardiomyopathy 4 signs of an impending heart attack?
• restrictive cardiomyopathy. • Pressure, tightness, pain, or a squeezing or aching
Genetic factors, alcoholism and viral infections can sensation in your chest or arms that may spread to
lead to cardiomyopathies, but many cases have no your neck, jaw or back.
particular cause. • Nausea, indigestion, heartburn or abdominal pain.
Cardiac failure (heart failure) • Shortness of breath.
➢ when heart fails to pump out enough blood to meet • Cold sweat.
the requirements of the body; most cardiac diseases • Fatigue.
can lead to cardiac failure. Non-cardiac diseases • Lightheadedness or sudden dizziness.
such as blood loss, shock and some poisonings can
also lead to heart failure. IV. Diagnosis
Angina Noninvasive Procedures:
➢ If blood supply is reduced to the myocardium (heart 1. Electrocardiograms – measure the heart’s rhythm and
muscle) itself, this can give rise to pain. This is usually electrical activity by recording the electrical activity
felt as a dull, heavy and squeezing/crushing pain in generated by cells in the heart. Using this
the center of chest, but it may also radiate out to the measurement, doctors are able to identify
neck, arms and jaw. Angina occurs in stable and abnormalities very quickly.
unstable varieties. The stable variety of angina is 2. Cardiovascular imaging – used to give doctors a
generally induced by physical exertion and/or clearer understanding of what is happening in the
emotional outburst, and is relieved by rest. However, blood vessels. There are two main types:
the unstable version may occur even at rest. The
 a. Angiography – uses a special dye and x-rays, to pressure" (CVP) describes the pressure in the thoracic
show how the blood flows through the arteries in vena cava near the right atrium (therefore CVP and
the heart. right atrial pressure are essentially the same). CVP is an
b. Cardiac ultrasound (echocardiography) – uses important concept in clinical cardiology because it is
sound waves to create a moving image of the a major determinant of the filling pressure and
heart. This is much more detailed than an x-ray, therefore the preload of the right ventricle, which
and has the added benefit of not requiring regulates stroke volume through the Frank-Starling
radiation exposure. mechanism.
Invasive Procedures: ΔCVP = ΔV / Cv
1. Blood investigation – foundation for diagnosis of many
diseases. There are a number of assessments which
doctors can make for suspected cardiovascular
disease, including a complete blood count (CBC), a
lipid profile, and tests of blood clotting and enzyme
function.
2. A coronary artery bypass graft (CABG) – surgical
procedure that is used to treat coronary artery disease.
In a CABG procedure, grafts are used to divert the
Factors Increasing CVP Change in
blood around the narrowed or blocked parts of arteries
compliance or volume
and to maintain sufficient blood flow and oxygen
Decreased cardiac output V
supply to the affected part of the heart. CABG
Increased blood volume V
procedures are commonly referred to as “bypass
surgery”. In the image here, a “double bypass” is Venous constriction C
shown, with two grafts needed to divert the blood in Changing from standing V
different arteries or parts of the heart. The number of to supine body posture
grafts will depend on the extent of the narrowing of the Arterial dilation V
blood vessels. Single, double, triple or quadruple CABG Forced expiration (e.g. C
procedures may be needed. Valsalva)
3. Co-determination (cardiac output) - volume of blood Muscle contraction V, C
ejected by each ventricle per minute and is the (abdominal and limb)
product of stroke volume and heart rate. CO can thus • A decrease in cardiac output either due to decreased
be manipulated by alteration in heart rate or rhythm, heart rate or stroke volume (e.g., in ventricular failure)
preload, contractility and afterload. Moreover, it gives results in blood backing up into the venous circulation
important information about tissue perfusion and (increased venous volume) as less blood is pumped into
oxygen delivery. CO can be measured by various the arterial circulation. The resultant increase in
methods and thermodilution method using pulmonary thoracic blood volume increases CVP.
artery catheter (PAC) is till date considered as gold • An increase in total blood volume as occurs in renal
standard method. Complications associated with PAC failure or fluid retention through activation of the renin-
led to development of newer methods which are angiotensin-aldosterone system increases venous
minimally or non-invasive. pressure.
The pulmonary artery catheter (PAC) is a balloon • Venous constriction caused by sympathetic activation
tipped thermo dilution catheter 110cms long, that is of veins, or by circulating vasoconstrictor substances
inserted via a large vein and floated into the pulmonary (e.g., catecholamines, angiotensin II) decreases
artery. It is used to obtain haemodynamic venous compliance, which increases CVP.
measurements which together with clinical • A shift in blood volume into the thoracic venous
observations indicate how efficiently the heart is compartment that occurs when a person changes
functioning. from standing to supine position increases CVP. Arterial
4. Cardiac catheterization – long thin tube called a dilation as occurs during withdrawal of sympathetic
catheter is inserted in an artery or vein in your groin, tone or with arterial vasodilator drugs causes increased
neck or arm and threaded through your blood vessels blood flow from the arterial into the venous
to your heart, with the aid of a special X-ray machine. compartments. This increases venous blood volume
Doctors use contrast dye that they inject into your and CVP. This is what occurs when the heart is
blood vessel through the catheter to create X-ray functioning normally. It is important to note, however,
videos of your valves, coronary arteries, and heart that arterial dilation in ventricular failure leads to a
chambers. Your doctor uses cardiac catheter to: decrease in CVP instead of an increase. This occurs
• Check for heart disease (such as coronary artery because the arterial dilation decreases afterload on
disease, heart valve disease, or disease of the the ventricle leading to an increase in stroke volume.
aorta) Ventricular stroke volume is more strongly influenced by
• Check how your heart muscle is working afterload when the ventricular is in failure than when it
• Decide whether you need further treatment (such has normal function.
as an interventional procedure or bypass surgery) • CVP is also increased during force expiration,
Procedures that might be done during your cardiac particularly against a high resistance (as occurs with a
catheterization include: Valsalva maneuver) due to external compression of the
• Angioplasty. Your doctor inserts a catheter with a thoracic vena cava as intrapleural pressure rises. This
tiny balloon at the tip. When this balloon is inflated, mechanical compression of the vena cava functionally
it pushes plaque out and widens your artery. reduces the compliance of the vena cava.
• Biopsy. Your doctor takes a small sample of tissue • Muscle contraction, particularly of the limbs and
from your heart. abdomen, compresses the veins (i.e., decreases
• Repair of heart defects. Your doctor closes a hole compliance) and forces blood into the thoracic
in your heart or stops a leak in a valve. compartment, thereby increasing thoracic blood
• Stent placement. Your doctor places a tiny mesh volume and CVP.
tube called a stent into your artery to help keep it 6. Bone marrow biopsy involves removing a small sample
open. of the bone marrow inside your bones for testing. Bone
5. CVP (central venous pressure) or RAP (right atrial marrow is a soft tissue in the center of most large
pressure) is the venous pressure is a term that bones. It makes most of the body's blood cells. The
represents the average blood pressure within the biopsy is done using a small needle inserted into the
venous compartment. The term "central venous bone.
7. Hemodynamic monitoring measures the blood While LDL cholesterol tends to build up and block
pressure inside the veins, heart, and arteries. It also arteries, HDL cholesterol helps to mop up other
measures blood flow and how much oxygen is in the cholesterol in the blood and unstick it from artery walls.
blood. It is a way to see how well the heart is working. This is why HDL cholesterol is considered good.
It can detect these changes early by testing samples Triglycerides, which are a type of fat bundled with
of blood from deep inside the body. cholesterol.
Normal Ranges
Age; Total serum HDL LDL Triiglyce-
sex chol. Level level rides
45 < 100 < 150
≤ 19 170 mg/dl
mg/dl mg/dl mg/dl
Females; 125-200 50 < 100 < 150
> 20 mg/dl mg/dl mg/dl mg/dl
Males; 125-200 40 < 100 < 150
≥ 20 mg/dl mg/dl mg/dl mg/dl

Noninvasive procedure
1. Pulse oximetry – method of indirectly evaluating arterial
oxygenation through measurement of peripheral
8. Enzyme levels is cardiac enzyme test is a blood test saturation of hemoglobin. It provides an estimate of
that measures the cardiac enzymes in the blood. A arterial oxyhemoglobin saturation by using selected
technician will insert a needle into a person’s arm and wavelengths of light. It measures the amount of oxygen
draw a sample of blood. They will send the sample to being carried in your blood, as a percentage. The
a lab where it will be analyzed for cardiac enzymes. measurement is taken at the finger using a Pulse
People undergoing a cardiac enzyme test do not Oximeter. This measurement is known as the Sp02 – the
need to fast or undergo any special preparations. saturation of peripheral oxygen – and it is an estimate
Doctors often order this test in an emergency situation of the Sa02 – the saturations of arterial oxygen.
when they suspect a person may be having a heart
attack.
Levels of troponin are normally so low that this enzyme
is undetectable in the blood. If someone’s cardiac
enzyme test comes back positive for troponin, they
have likely had a heart attack or injury to the heart. 2. Heart ultrasound (transthoracic echocardiogram; TTE;
The results of a cardiac enzyme test can also help a echocardiogram; echo) provides your doctor with
doctor to assess the level of damage caused by the moving images of your heart and takes excellent
heart attack. The more troponin found in the blood, pictures that will help your doctor evaluate your heart
the more damaged the heart generally is. health. The most common type of heart ultrasound is
9. Serum are blood tests detect substances that normally noninvasive and very easy on the patient. A specially
are not present or measure substances that, when trained technician, called a cardiac sonographer, uses
elevated above normal levels, indicate disease. a gel to slide a microphone like device called a
Available Blood-Based Tests for Heart Disease transducer over the chest area. This allows reflected
Substance Patient Indications of sound waves to provide a live picture of your heart and
Detected by symptoms elevations valves. Heart Ultrasound uses the same technology that
Blood Test allows doctors to see an unborn baby inside a pregnant
Cardiac Chest pain or Injury to the heart mother. No radiation is involved in heart ultrasound,
troponins (1 & T) potential heart and the technology can be used on people of all ages.
attack 3. Transesophageal echo is a form of echo where a
Ischemia Chest pain or Possible miniature ultrasound camera is passed down the throat
modified potential heart diminished blood to look at the back of the heart. This allows the
albumin attack flow to the heart physician to obtain very high-quality moving images.
Natriuretic Shortness of Probable You can be sedated during the procedure if you wish.
peptides breath; possible congestive heart Transesophageal echocardiograms are typically
(BNP and pro- heart failure failure performed to evaluate serious heart conditions. A
BNP) useful tool used to evaluate the function and small
Lipids Current or future Increased risk of detailed structures of the heart and associated vessels.
(cholesterol, HDL, risk of atherosclerosis 4. ECG – graphical recording of the electrical conduction
LDL) atherosclerosis of the heart usually 10 secs using electrodes place over
C-reactive Current or future Increased risk of the skin. The overall magnitude of electrical activity of
protein risk of cardiac events heart is from the leads. The graph of voltage versus time
atherosclerosis produced is called Electrocardiogram.
Lipoprotein Current or future Increased risk of ➢ 2-D echo is a safe and painless procedure that uses
phospholipase risk of cardiac events a transducer (a small, microphone-type device) to
A2 atherosclerosis send high frequency sound waves to the heart. The
BNP indicates B-type natriuretic peptide; pro-BNP, N- technologist can view the heart valves and
terminal pro–B-type natriuretic peptide; HDL, high- pumping strength, look for structural defects, heart
density lipoprotein; and LDL, low-density lipoprotein. enlargement and/or fluid buildup. A Doppler exam
and Color Flow exam are also performed. This allows
10. Cholesterol is a type of body fat, or lipid. A serum doctors to evaluate blood flow through the heart.
cholesterol level is a measurement of certain elements The technologist will videotape parts of the study for
in the blood, including the amount of high- and low- later diagnosis by the cardiologist.
density lipoprotein cholesterol (HDL and LDL) in a 5. Stress test or stress echo combines the echo exam with
person’s blood. Serum cholesterol levels also show the a treadmill to walk on or bike to pedal, or medication
amount of triglycerides present. Triglycerides are that shows the effect of exercise on the heart. Stress
another lipid that can be measured in the blood. tests are used to diagnose the narrowing of the
coronary arteries.
 6. Doppler ultrasonography evaluates blood flow in the
heart and blood vessels. This procedure measures the
speed and direction of the blood flow within the heart.
It screens the four valves for leaks. With Doppler
echocardiograms, as the wand moves over your heart
you will hear a “whooshing” sound much like that of a
washing machine. This is the sound of blood moving
within your heart.
Treatment options:
1. Medication is now available to treat many of the
symptoms of cardiovascular disease, such as anti-
anginal drugs for chest pain, and ACE inhibitors to
treat hypertension.
2. Lifestyle modification is an effective way to
prevent cardiovascular disease, and can also be
used to manage the progression of the disease
once it is established.
3. Surgery is also a possible treatment, with options
ranging from angioplasty (to widen blocked
arteries), pacemaker implantation, a heart bypass
(as shown here), or even a full heart transplant.
V. Nursing Interventions for altered cardiac function:
1.