NRSG 232

Applications and
Interventions II
Plan:
• Course overview
• Introduction to the cardiac system
Cardiac System
Learning Objectives

1. Describe the location of the heart

2. Name the three layers and covering of the heart
3. Explain the function of the heart as two separate pumps
4. Identify the four chambers and great vessels of the heart
5. Explain the functions of the four heart valves
6. Describe blood flow through the heart
7. List the vessels that supply blood to the heart
8. Identify the major components of the heart’s conduction system
Learning Objectives (cont’d)

9. Describe aging of the CV system, nursing care r/t conditions such as CAD,
MI, angina, CHF, and arrhythmias
10. Discuss hearth health related to the above conditions and identify common
drug classifications and related interventions consistent with best practices
11. Apply concepts related to the CV system, terminology, principles, attitudes
and knowledge required to function ethically, safely and competently in the
workplace
12. Recognize normal and abnormal body functions r/t to the CV system and
their associated interventions in order to report and record observations in a
safe and timely manner
Cardiac System
Anatomy and Function
Cardiovascular System Statistics

• In Canada, someone dies from heart disease, stroke or vascular impairment

every 5 minutes
• Related to the COVID-19 pandemic, people living with CV conditions were not
always able to access care in a timely manner
• COVID-19 is also causing damage to previously healthy hearts
• 9 in 10 people in Canada have at least one risk factor for stroke
• 1.6 million Canadians and their families are living with the effects of heart
disease or stroke
• Heart and Stroke Foundation Canada (2021) [link will open in separate
window]
Anatomy of the Heart

• Cone-shaped
• Hollw
• Muscular organ
• Located in the mediastinum between
the lungs
• Approximately the size of closed fist
• Weighs less than 0.5 kg
 R L
Anatomy of the
Heart (cont’d)

• Base (flat portion) is superior

• Apex (the point) inferior
• 2/3 of the heart is located to the
left of the midline of the
sternum
• 1/3 to right
Anatomy - Layers
• Pericardium
• Protective covering that encapsulates
the heart
• 3 layers
• Fibrous pericardium
• Parietal pericardium
• Pericardial space (cavity) in
between these two layers)
• Visceral pericardium
• Images c/o Herlihy (2022)
Anatomy – Layers
(cont’d)
• Epicardium
• “epi” = over
• Outer surface
• Thin, transparent
• Myocardium
• “myo” = muscle
• Thickest layer
• Composed of cardiac muscle fibers responsible for contraction
• Endocardium
• “endo” = innermost
• Endothelial tissue
• Lines the champers of the heart and valves
• Smooth and shiny – allows blood to flow without friction
• Image c/o Herlihy (2022)
Anatomy -
Chambers
• 2 atria on top
• Right and left atrium
• 2 ventricles on the bottom
• Right and left
ventricles
• Septum
• Separates right and
left side
• Muscular wall
Function - Chambers
• Right atrium • Left atrium
• Receives deoxygenated blood • Receives oxygenated blood
(a reduced level of O2) from the from the lungs
body
• Left ventricle
• Right ventricle • Receives oxygenated blood
• Receives deoxygenated blood from the left atrium
from the right atrium • Primary function: Pumps
• Primary function: Pumps oxygenated blood into the body
deoxygenated blood to the
lungs to pick up oxygen
• The left ventricle is thicker
than the right ventricle – why?
Anatomy -
Valves
• Atrioventricular valves
• Located between the atria and
ventricles
• Tricuspid valve
• Between the RA and RV
• Mitral (Bicuspid) valve
• Between the LA and LV
• Semilunar valve
• Half moon shape
• Pulmonic valve
• Separates RV from
pulmonary artery
• Aortic valve
• Separates LV from the
aorta
Function – Heart
Valves

• Allow blood to flow in one direction:

forward
• Prevent blood from flowing backwards
• Open and close passively in response to
pressure and volume changes
• Right atrium contracts – opens
tricuspid valve
• Right atrium relaxes – closes
tricuspid valve
• The “lub-dup” you hear when
ausculating the heart is the
sounds of the valves closing
Great Vessels of the Heart
– Anatomy and Function

• Superior vena cava

• Brings blood to the RA from the upper body
• Inferior vena cava
• Brings blood to the RA from the lower body
• 2 Pulmonary arteries
• Sends blood from the RV to the R and L
lungs
• 4 Pulmonary veins
• Bring blood back to the LA from the R and L
lung
• Aorta
• Sends blood from the LV to the body
Anatomy –
Great Vessels
• Identify the great vessels
3D Anatomy of the Heart
• Visible Body 3D Anatomy of the Heart and Great Vessels
• https://www.visiblebody.com/learn/circulatory/circulatory-the-hea
rt
Function – The heart as a double pump

Pulmonary Circulation Systemic Circulation

• The right side of the heart • The left side of the heart
• Receives deoxygenated • Receives oxygenated blood
blood from the body from the lungs
• Pumps deoxygenated blood • Pumps oxygenated blood to
to lungs for oxygenation the body
• Deoxygenated blood appears • Oxygenated blood appears
blue therefore diagrams often red therefore diagrams often
coloured blue coloured red
Pulmonary
Circulation
• Deoxygenated blood enters the RA through the IVC
and SVC
• Deoxygenated blood flows from RA to the RV
through the tricuspid valve
• Deoxygenated blood is pumped from the RV
through the pulmonic valve to the pulmonic artery
• The R and L PA carry deoxygenated blood to the
lungs
Systemic Circulation
• Oxygenated blood enters the LA through the L and
R PVs
• Oxygenated blood flows from LA to the LV through
the bicuspid (mitral) valve
• Oxygenated blood is pumped from the LV through
the aortic valve to the aorta
• The aorta branches into smaller arteries which
carry oxygenated blood to the body
Flow of blood through the body
Vena Cavae
Right Atrium
Tricuspid Valve
Right Ventricle
Pulmonic Valve
Pulmonary Arteries (right and left)
Lungs
Pulmonary Veins (2 right and 2 left)
Left Atrium
Bicuspid (mitral) Valve
Left Ventricle
Aortic Valve
Aorta
Body
Blood flow
• Trace the flow of blood
through the heart
• Identify whether blood is
oxygenated or
deoxygenated
Animation – Blood flow through
the Heart
• Watch the Herlihy (2022) animation included with your text book’s student
resources
• Chapter 16: External Anatomy of the Heart [link to Elsevier resources will
open in a new tab]
Blood Vessels

• Blood flows to body tissues and cells

through blood vessels
• “Transportation network”
• Transports nutrients, oxygen
and water to all tissues
• Arteries
• Capillaries
• Veins
• We’ll discuss in more detail in Week
10
• However. . .
Anatomy -
Coronary
Arteries
• The heart needs its own
blood supply
• Main arteries branch off
the aorta
• Left coronary artery
(nourishes left side)
• Right coronary artery
(nourishes right side)
Function -
Coronary
Arteries
• The heart must have a
constant blood (oxygen)
supply
• Under resting conditions,
heart uses almost all
oxygen from the blood
• How does our body
compensate if the heart
needs more oxygen?
Conduction
System
• Electrophysiologic
properties of the heart
regulate HR and rhythm
• Cardiac conduction system
is composed of specialized
tissue capable of rhythmic
electrical impulse formation
• This is the stimulus for
muscle contraction and
coordinates pumping of the
atria and ventricles
Anatomy – Conduction System
• In a healthy heart, electrical
conduction starts in the SA
node
 • The heart functions as an adaptable pump
Function – • The heart adjusts pumping activity to meet day to day needs (eating,
Conduction exercise, etc.)

System • Heart initiates its own cardiac impulse but the autonomic nervous
system (ANS) can effect the HR
Autonomic Nervous System
• Part of the nervous system
• 2 branches
• Sympathetic branch
• In times of stress – increases the speed and force of heart
• Parasympathetic branch
• In times of rest – slows and decreases the speed of the heart
• To be continued in Week 12
Cardiac Output
• Cardiac output is the amount of blood pumped by each ventricle in 1 minute
• In adults the CO ranges from 4-7 L/min

Cardiac output (CO)= Heart rate (HR) x stroke volume (SV)

Heart Rate
• Heart rate (HR) refers to the number
of times the ventricles contract each
minute
• Measure by auscultating or checking
pulse
• Caused by the firing of the SA node
(in a healthy heart)
• Normal resting HR for an adult is 60-
100 BPM (average = 72)
• Impacts on resting HR
• Size, gender, age, medications,
hormones (TSH, epinephrine),
beverages (coffee), smoking
Cardiac System
Cardiovascular Changes with
Aging
Aging

• Physiological changes occur naturally in the cardiovascular system

• This may result in decrease in cardiac function/reserve
• May not be evident at rest
• Cardiac valves
• Calcification of cardiac valves
• Cardiac conduction system
• Pacemaker cells decrease in number
• Conduction time increases
• Left ventricle
• Size of left ventricle increases (hypertrophy) and stiffens
Aging (cont’d)

• Vessels
• Decreased elasticity of
vessels
• Increased thickening of
vessels
• Aorta and other large
arteries thicken and
become stiff
Cardiac System
Cardiovascular Disorders
Cardiovascular Disorders
• Involve problems with the heart or blood vessels
• Leading cause of death in Canada

1. Coronary Artery Disease (CAD)

a) Angina
b) Myocardial Infarction

2. Arrythmias
3. Heart Failure (HF or CHF)
4. Valvular Heart Disease
1. Coronary Artery Disease (CAD)

• Changes to the coronary arteries

that supply the heart with oxygen
• The arteries become narrowed
and/or blocked
• Arteriosclerosis = a thickening or
hardening of the arterial wall
Coronary Artery Disease (cont’d)
• Atherosclerosis is a type of
arteriosclerosis
• Build up of cholesterol and fatty
substances along the inside of
the walls
• When coronary arteries are
narrow or blocked, blood flow to
the heart is decreased or stops
• Heart muscle does not get
enough oxygen or nutrients
• Heart does not function well
Coronary
Artery
Disease -
Progression
CAD may lead to chest
pain and heart attack
(myocardial infarction –
MI)
CAD - Risk Factors
• Hypertension
• High blood cholesterol
• Lifestyle factors (exercise, smoking, diet, alcohol use)
• Uncontrolled diabetes
• Age
• Sex (M>F)
• Family history of CAD
• Metabolic syndrome
• A name for a group of risk factors that raises your risk of CAD and DM2
• >5 risk factors, you have metabolic syndrome
• Risk factors = larger waistline, high triglyceride, low HDL cholesterol, HTN, high fasting
blood sugar
• These risk factors are consistent for angina and MI
Treatment
• Health teaching to reduce risk factors
• Weight loss
• Exercise
• Smoking cessation
• Healthy diet
• Control HTN and diabetes
• Cardiac catheterization
• Invasive procedure to view coronary
arteries
• Possible stent insertion
• Coronary artery bypass graft (CABG)
• Video Mayo Clinic (2019)
Angina

• Results from CAD

• Chest pain results from heart not getting enough oxygen
• At risk for myocardial infarction
• Triggers
• Physical exertion
• Stress
• Extreme temperatures
• Heavy meals
• Alcohol
• Smoking
Angina (cont’d)

• Symptoms often the same as a myocardial infarction but temporary

• 3-5 minutes, up to 30 minutes
• Pain (“heaviness”, “ache”) in the chest, left arm, jaw, back, neck
• Shortness of breath
• Dizziness
• Nausea
• Diaphoresis
• Often associated with a trigger
• Often relieved with rest and medication (if previously diagnosed)
• Decreased oxygen to the heart muscle
• It’s a warning that, without treatment, there is risk for a myocardial infarction
 Medication Name Nitroglycerin
Angina - Treatment Classification of Anti-anginal
medication Vasodilates blood
(description of action) vessels
• Health teaching
• Risk factors Indication Treatment of angina
• Avoid common triggers
• Rest Route Oral, transdermal,
• Medication sublingual, injection
• Anti-anginal: Nitroglycerin
• Routine nitroglycerin Common side effects Headache,
patch hypotension, rash
• Rescue: spray/tablet
• Always keep near client Important Client may rpt dose
• May require CABG or considerations q5min x 3, then go to
stent ER
Myocardial
Infarction (MI)
• Heart attack
• Death of heart tissue
(myocardium)
• Caused by lack of oxygen to the
heart
• Blood flow is occluded suddenly
• Could be a large or small
vessel
• Causes
• Atherosclerosis (CAD)
• Thrombus (blood clot)
• Sudden cardiac arrest can occur
Myocardial Infarction
– Signs & Symptoms
• Chest pain (left sided, sudden,
severe)
• “heavy”, “crushing”, “stabbing”
• Radiating pain
• Neck, left arm, jaw
• Pain not relieved by rest or
nitroglycerin
• Shortness of breath
• Nausea
• Cool, clammy skin
• Alterations to pulse (weak, irregular)

Heart and Stroke Foundation of Canada (2022)

Myocardial Infarction - Treatment
• Be aware of signs and symptoms
• Call 911
• Be prepared to administer CPR
• Surgical Interventions: CABG, stent, angioplasty
• Aftercare:
• Health teaching
• Signs and symptoms
• Healthy lifestyle
• Medications to reduce cholesterol, control HTN and diabetes
2. Arrythmias

• Abnormal heart rhythms

• Malfunction of the electrical
system
• Can be benign
• Skipped beats
• Extra beats
• Can be severe
• May cause SOB, dizziness,
SOB, fainting, death
Treatment for Arrythmias
• Varies based on arrythmia (follow care plan)
• Avoid caffeine and alcohol
• Medications may be necessary for severe arrhythmias
• Anti-arrythmics
• Anti-coagulants to prevent clots
• Pacemaker may be used to treat some arrythmias
• Medical device implanted in the body
• May work with natural pacemaker (on demand) or may override natural
pacemaker
• Avoid magnets
Arrythmia -
Atrial Fibrillation • Most common arrythmia
• Affects over 200 000 Canadians
• High risk of stroke or heart
failure
• May experience it intermittently
or constantly
• Often on anti-coagulants or rate
control medications
3. Heart Failure (HF
or CHF)

• The heart cannon pump blood normally

• Blood backs up and causes an
abnormal amount of fluid in the tissues
• May affect right side, left side, or both
sides of the heart
• Common causes: HTN, MI, anemia,
valvular disease, lung diseases
Right vs Left sided Heart Failure
Right sided HF Left sided HF
Blood backs up in to Blood backs up in the
systemic circulation pulmonary circulatory
system
Fluid collects in the body Fluid collects in the lung
tissues tissue

Swelling in feet and ankles Dyspnea

Enlarged neck veins Increased sputum
Engorged liver and Cough
impaired function

GI problems Fatigue and weakness

HF – Risk Factors

• Smoking
• Physical inactivity
• Obesity
• Psychological variables
• Chronic diseases
CHF - Treatment

• Diet
• Heart healthy diet
• Low/restricted sodium
• Possible fluid restriction
• Medications
• Digoxin slows and strengths the heart’s contraction
• Diuretics help to eliminate excess fluid
• Potassium helps strengthen muscle contraction, helps heart beat effectively
• Oxygen as needed
• Monitor fluid intake and output
• Semi or high fowler’s position for dyspnea
• Elevate feet for peripheral edema
 Mary Lou Poppins was discharged from the hospital to long-
Case Study term care with a diagnosis of left-sided CHF. Although her
symptoms are improving, she remains on 1L of oxygen via NP
and is participating in rehabilitation to regain her strength.
What activities do you anticipate you will need to complete
related to her diagnosis of CHF?

Personal Support Anticipated activities

Assist with activities of daily living

Assist with meals

Assist with elimination

Assist with positioning and transferring

4. Valvular Heart Disease

• Dysfunctions of the valves

• Stenosis (stiffening)
• Regurgitation (leaking)
• Prolapse (valve flops
backwards)
• Causes: CAD, MI,
cardiomyopathy, syphilis,
HTN, aortic aneurysms,
connective tissues disease,
tumors, some chemotherapy
drugs and radiation
 Fatigue
Valvular
Heart Palpitations
Disease –
Dyspnea
Signs &
Symptom Chest pain
s
Arrhythmia
Valvular
Heart • Drug therapy to treat signs and symptoms
• Surgical repair
Disease - • Rest

Treatment
References
• Crash Course. (2015, July 6). The Heart - Part 1 - Under Pressure: Crash Course A&P
#25. [Video]. YouTube. https://youtu.be/X9ZZ6tcxArI
• Heart and Stroke Foundation of Canada. (2022).
https://www.heartandstroke.ca/heart-disease/emergency-signs
• Herlihy, B. (2022). The Human Body in Health and Illness. 7th Edition. St. Louis,
Missouri, USA.

Herlihy, B. (2022). Study Guide The Human Body in Health and Illness. 7th Edition.
St. Louis, Missouri, USA.
• Science Music Videos. (2012, July 22). Circulatory System Rap - Pump it Up!. [Video].
YouTube. https://youtu.be/KSbbDnbSEyM
• Wilk, M. (2022). Sorrentino's Canadian Textbook for the Support Worker. 5th
Canadian Edition. Toronto.

Wilk, M and Sekhon, N. (2022). Workbook to Accompany Sorrentino's Canadian

Textbook for the Support Worker. 5th Canadian Edition. Toronto.