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					The Cardiovascular System




      Rachel S. Natividad, RN, MSN, NP   1
Review A & P




               2
Circulation through the Heart




                                3
              Diagnostic Studies
CBC                    COAGULATION
     WBC                   Platelet count
     RBC                   PT/INR
      • HGB                 PTT/APTT
      • HCT            CXR




                                              4
    Blood Components






                       5
                     Blood Components:
                  White Blood Cell Differential
   WBC Count                              2 Segs, 1 Band
       Measurement of total number
        of leukocytes (4,000-11,000/uL)
    Granulocytes
       Neutrophils (55-70%)
         • Segmented neutrophils
           (Segs)
         • Immature band neutrophils
           (Bands/Stabs) (0-3%)
       Eosinophils (1-2%)
       Basophils (<1%)
    Agranulocytes
       Lymphocytes (30-40%)
       Monocytes (5-6%)
                                                            6
        WBC Differential– Cont.
                  NEUTROPHIL MATURATION




                                          Left Shift or “Bandemia”




Segmented Neutrophils (Mature)   Band Neutrophils (Immature)




                                                              7
                     WBC Differential– Cont.




      Eosinophils (parasitic infections,   Basophils (inflammation from allergies)
                 allergies)




Monocytes (phagocytic bacterial action)    Lymphocytes ( immune response)       8
           RBC – Erythrocyte count
   Count of the number
    of circulating RBCs

   Altered in the same
    conditions that alter
    Hgb and Hct values
                            Erythrocytes




                                           9
                              Hemoglobin
   HGB LEVEL: Measurement of the
    oxygen -carrying capacity of RBC

Increased in:
   Hemoconcentration (severe
    dehydration, burns, shock,
    vomiting), polycythemia vera

Decreased in:
   Anemias due to blood
    loss or poor nutrition
   Hemodilution (fluid volume excess);
    other anemias




                                           10
                          Hematocrit
   The percentage of whole
    blood volume composed
    of erythrocytes

   Women: 38-47 %
   Men: 40-54 %

   Altered in same conditions
    that alter Hgb

   Also reflects pt’s state of
    hydration

   Hgb high or WNL with low
    Hct= dehydration

                                       11
Case Study



             12
                 Patient Presents…
   69 year-old female admitted for left total hip
    replacement. Hx of DJD and DM type 2, asthma,
    and allergies.

   #2 POD
    PE: Incision site appears red and edematous
    with moderate amt. purulent drainage, JP drain
    intact draining reddish tan colored drainage.
    VS: Temp 100.9, Resp 22/min, P 98 BPM, BP
    138/88.

   CBC results 1 day post-op reveal →→→→
                                                     13
              CBC with Differential
Lab Value        Result           Reference   Range
RBC             3.14        4.2- 5.4 m/uL
Hgb             9.3         12-16 g/dL
Hct             25.3        37-47 %
WBC             18,000/uL   5,000-10,000/uL
Neutrophils     90          55-70
Bands           9           0-3
Eosinophils     6           1-2
Basophils       4           <1

                                                      14
       Coagulation Studies
 Monitoring hemostasis




       Bleeding           Clotting
                                     15
                    Coagulation Studies
   Platelets – critical to         -
    hemostasis and clot
    formation

       Platelet count – measures
        the number of circulating
        platelets
       Normal range:
        150,000-400,000 mm3

       Monitor in patients
        receiving Lovenox


                                          16
     How would you proceed?
 You are to administer Lovenox 40 mg SQ
  once daily.

 Pt.’s Plt. Count   = 250,000 mm3

 Pt’s Plt. Count   = 80,000 mm3

 Pt’s Plt. Count   = 450,000 mm3

                                           17
          Coagulation Studies: Cont.

   How long does it take for blood to clot?

   PT & INR
       Assessment of extrinsic coagulation

       To monitor patients taking certain medications as well
        as to help diagnose clotting disorders

       Used primarily to evaluate oral anticoagulant
        therapy: warfarin (Coumadin)

                                                             18
      Coagulation Studies: Cont.
 PTT &    aPTT

     Assessment of intrinsic coagulation

     Used to monitor therapeutic Heparin




                                            19
       CXR
•Examine lung
fields and heart
size

•Check for normal
heart size and
contour, change in
heart chambers,
displaced heart,
presence of extra
fluid around the
heart



               20
Cardinal Signs and Symptoms (pp 687-688)

 Chest  Pain        Pallor
 Palpitations       Syncope
 Dyspnea
 Edema
 Fatigue



                                       21
                     Angina

   Chest pain
    due to
    reversible
    ischemia to
    myocardium

 reduced
    blood flow     Coronary Artery Disease
    to the heart
                                             22
        Chest Pain: Myocardial Infarction (MI)
                                   CAD with Thrombosis
   Ischemia to the heart
    muscle is irreversible
    and results in tissue
    damage and necrosis

   Obstruction of blood
    flow
      Atheroma (plaque)

      Thrombosis

      Embolism




                                                    23
             Myocardial Infarction




   Diminished coronary perfusion
       Ischemia – Angina
       Infarction – Necrosis
         • Fibrous scarring          24
Chest Pain: Pericarditis




                           25
Pericarditis
            Inflammation of
             pericardium

            Pleuritic type
             chest pain

            pericardial
             scarring and
             fibrosis

                              26
                           CHEST PAINS
                   ANGINA                  MI              PERICARDITIS
Onset;        Sudden               Sudden                Sudden
Precipitating Response to          No precip. Factors    Upright position
factors       exertion, emotion,   Often early am        Inspiration
              extremes
Quality       squeezing            stabbing pain or      Sharp stabbing
                                   pressure
                                   Severe                Moderate to severe
Severity
Location      Substernal           Substernal            Substernal


Region        May spread to        May spread to ant.    Usually spreads to left
              chest, arms, back,   Chest, arms, back,    side or back
                                   jaw, neck
Duration,     < 15 min             30 min or longer      Intermittent
Relieving     Rest, Nitro, O2      Not relived by rest   Relieved by sitting
Factors                            Relieved with         upright, analgesia,
                                   opiods                Anti-inflammatory
                                                         agents

                                                                                   27
Locations of Chest Pain

                   Other
                    Symptoms:
                       SOB
                       Diaphoresis
                       N/V
                       Cold/clammy
                        skin
                       Palpitations
                       Fainting
                       Loss of
                        consciousness

                                    28
    Heart Failure (Pump Failure)
   A disorder in which
    the heart loses its
    ability to pump blood
    efficiently throughout
    the body

   ↓Cardiac Output




                                   29
                                           Pathophysiology:
                                  Impaired Cardiac Function

   Failure to empty ventricles
    & reduced delivery of blood
    into circulation (↓ CO)

   Increased ventricular
    pressures

   Elevated pulmonary and
    systemic pressures

   further ↓ CO

   Series of compensatory
    mechanisms
                                                         30
                      Cardiac Function

Recall that Cardiac Output
  (CO) is: HR X SV

  Which consists of:
 Contractility

   Preload: filling of the
    heart during diastole

   Afterload: the resistance
    against which the heart
    must pump


                                         31
           Causes
Acute/Chronic ♥ Problems
 CAD
 HTN (#1)
 MI
 Valvular ♥ Disease

                           32
    Compensatory mechanisms of low CO…
…Starling’s Law/…Ventricular    …Ventricular hypertrophy
  dilation: ↑ CO                … cardiac contractility… ↑ CO




…SNS stimulation… ↑ HR and
  cardiac contractility… ↑ CO

…Decreased renal blood
  flow…increasing Na & H20
  retention…increases blood
  volume, ↑ HR & CO.




                                                                33
                  Clinical manifestations :
                 Pulmonary Congestion (L)
                and Systemic Congestion (R)

Right Heart Failure                      Left Heart Failure




                                                       34
              Left Heart Failure-Cont.

Pulmonary edema
 The most severe
    manifestation of Left
    Heart Failure

   Fluid leak into the
    pulmonary interstitial
    spaces (Pulmonary
    congestion)

   Hypoxia and poor 02
    exchange
                                         35
Clinical picture…Left Heart Failure
   Dyspnea
   Tachypnea
   Cough orthopnea
   Paroxysmal nocturnal
    dyspnea
   Pale, possible cyanotic
   Clammy and cold skin
   Extra heart sounds – S3,
    S4
   Crackles/Wheezes


                                  36
CXR: Pulmonary edema




                       37
              Right Heart Failure
   Unresolved Left failure:
    eventually leads to right
    sided failure by venous
    congestion in the
    systemic circulation


   Clinical picture…
       JVD, hepatomegaly
        and dependent edema
        (LEs, thighs,
        abdomen-ascites)

                                    38
        Review: Subjective Data
Pt. may c/o
 anxiety
 dyspnea at rest/on
   exertion (DOE) -most
   sensitive
 paroxysmal
   nocturnal dyspnea
   (PND)
 orthopnea
 productive cough with
   pink frothy sputum


                                  39
         Review: Objective Data
PA may reveal:
 Tachypnea/SOB
 Use of accessory
  muscles
 Wheezes/Crackles
 skin
    Clammy/cold

    gray/cyanotic

 peripheral edema
 JVD
 Ascites, enlarged
  spleen/liver

                                  40
         Review: Heart Failure
 Left Heart Failure –
  pulmonary congestion
 Right Heart Failure –
  systemic congestion
 Left Heart failure
  often leads to Right
  sided heart failure
  causing biventricular
  failure
  → Cor Pulmonale

                                 41

				
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