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Cardiovascular System Layers of the Heart Wall (From superficial to deep)
o Epicardium
o Myocardium
o Endocardium
● Pericardium: Protective layer of the heart, on top of epicardium
Chambers and Valves of the heart
● Atrium: low pressure area
o Right atrium: receives deoxygenated blood from the rest of the body
▪ Blood from lower body (legs and abdomen) enters through inferior vena
cava
▪ Blood from upper body (head and neck) enters through superior vena
cava
● Ventricles: low pressure area
o Left ventricle has the thickest wall because it pumps oxygenated blood to the
rest of the body
● Valves (REMEMBER APT M)
o Tricuspid: 5th^ intercostal space, left sternal border (5 th^ ICS LSB)
▪ Between right atrium and right ventricle
▪ 3 “leaves”
o Mitral: 5th^ intercostal space midclavicular line (5 th^ ICS MCL)
▪ Between left atrium and left ventricle
o Aortic: 2nd^ intercostal space right sternal border (2 nd^ ICS RSB)
▪ Between left ventricle and aorta
o Pulmonic: 2nd^ intercostal space left sternal border (2 nd^ ICS LSB)
● Pulmonary artery: receives deoxygenated blood from right ventricle and brings it to
lungs
● Pulmonary Veins: carries oxygenated blood from the lungs to the left atrium
Cardiac Cycle
● Rhythmic movement of blood through the heart
● Diastole
o Ventricles relaxed
o AV valves are open
o Pressure in atria is higher than in ventricles
o Blood pours rapidly intro ventricles
● Systole
o Ventricle pressure is higher than atria
o Mitral and tricuspid valves swing shut
● Diastole again
Heart sounds
● S1: When tricuspid and mitral valves close (“lub”)
o REMEMBER: “TeaM 1”
● S2: When aortic and pulmonic valves close (“dub”)
● Murmur: “whooshing sound” in between lub and dub
o Valve isn’t closing fully, and blood can regurgitate back into the atrium from the
ventricle
o Grades
▪ 1= minimal
▪ 2 = slightly louder
▪ 3= can hear immediately with stethoscope
▪ 4= very loud
▪ 5= can hear without stethoscope (needs valve transplant to fix)
● Normal heart sounds: S1 and S
● Extra heart sounds: S3 and S
o S3: 3 looks like 2 ‘C’s’ so remember 3HF= CONGESTIVE HEART FAILURE
o Auscultate carotid artery
o Inspect jugular venous pulse
● Precordium
o Inspect anterior chest for:
▪ Heave or lift (at point of maximal impulse)
▪ Palpate apical pulse
▪ Palpate across precordium
o Thrill: vibrating when they aren’t doing anything
o Auscultation of precordium
▪ Rate and rhythm
▪ Identify S1 and S
▪ Timing: regular or irregular
▪ Listen for extra heart sounds
▪ Loudness
▪ Pitch
▪ Pattern: can have irregularly irregular (ex. Afib)
▪ Quality: strong, weak, or thready
▪ Location
▪ Radiation
▪ Posture
● Altered cardiovascular function
o Changes in vital signs (BP, HR, respiration)
o Changes in skin (ex. Blue= cyanosis)
o Ischemia: decreased blood flow to a specific area
o Thrombus: clot
o Embolism: clot that breaks off and travels to another part of the body
o Angina: chest pain, occurs due to ischemia of heart
▪ Give 3 nitroglycerin’s, if no improvement call 911
o Altered blood flow: shock
● Physical assessment
o Inspection
▪ Cognition: peripheral blood flow (capillary refill, looks at tips of fingers,
toes, and legs) LOC (level of consciousness): carotid artery blockage can cause this from lack of oxygen to brain
▪ Skin color: lips (blue/purple), paleness
▪ Edema: pooling of fluid caused by poor blood flow
▪ Shiny skin= swollen
▪ Ulcerations
▪ Varicose veins
o Palpation
▪ Skin temp, pulses
▪ Capillary refill: normal= <3 seconds
▪ Edema
▪ Homan’s sign: “point toes to nose”
● Pt should feel a stretch while doing this, if they feel pain, it is a (+)
Homan’s sign
● Checks for DVT
o Auscultate
▪ BP
▪ Apical Pulse
▪ Abnormal heart sounds
● Clicks: metal valve closing (lub, click, dub)
o In patients with valve transplants
From Lecture
● Left side of the heart pumps oxygenated blood to the body
● Right side of the heart received oxygenated blood
● Right atrium: collects deoxygenated blood from the rest of the body
● Blood components
o Plasma: 50% of blood
o Buffy coat (platelets and leukocytes): 1% of blood
o Red Blood Cells (erythrocytes)
▪ Biconcave shape
▪ Flexible
▪ Able to fit through small spaces
● Platelets: promote clotting
● If a vessel is damaged/injured: platelets go to stop and fibrinogen travels there and
forms a clot
o Can possibly break off and cause damage
o Can cause DVT in leg (ischemia to area will cause pain)
o Can go through heart and lead to MI (heart attack)
o Can go to veins and travel to lungs and cause pulmonary embolism
o Can go to brain and cause stroke
● Static blood and cause clots
o If you’re in bed for more than 2 days, a clot can start to form
Respiratory System
● Right lung: has 3 lobes
o RML: right middle lobe
o RUL: right upper lobe
o RLL: right lower lobe
o Horizontal fissure: separates RUL from RML
o Oblique fissure: separates RML from RLL
● Left lung: has 2 lobes
o LUL: left uppjjer lobe
o LLL: left lower lobe
o Oblique fissure separates LUL from LLL
● Apex of the lung is at the top
● Base is the bottom of the lung
● Esophagus is posterior to trachea
● Mediastinum: where the heart is located
● Pleurae
o Parietal: lies against ribs (outside layer)
o Visceral: encapsulates lungs
● We breathe 21% oxygen
● Trachea: bifurcates into right main bronchus and left main bronchus
Bronchi->segmental bronchus-> tertiary bronchus->bronchiole->terminal bronchiole-->alveoli
● Posterior landmarks
o Vertebra Prominens
o Spinous Processes
o Inferior Border of the Scapula
o Twelfth Rib
Reference lines (TEST QUESTION!)
● Anterior Chest
● Posterior chest
● Factors that affect breathing
o Body position: elderly people with kyphosis cannot breathe fully
o Environment
▪ Air pollution
▪ Pollens and allergies
o Lifestyle
▪ Smoking
▪ Drugs and alcohol
▪ Nutrition
o Increased work of breathing
▪ Restricted lung movement (ex. Braces for scoliosis)
▪ Airway obstruction
● Levels of dyspnea
o Level 1: client can walk 1 mile at own pace before experiencing SOB
o Level 2: client becomes short of breath after walking 100 yards on level ground
of climbing a flight of stairs
o Level 3: client becomes short of breath while talking or performing ADLs
o Level 4: client is short of breath during periods of no activity
o Orthopnea: client is short of breath lying down
▪ Needs 2 or more pillows
Physical Assessment
● Inspection
o AP diameter vs transverse diameter: should be 2:1 ratio
▪ 2:2 indicates barrel chest (COPD)
o Chest all should be symmetrical
● Palpation
o Tactile fremitus: “99” or “blue moon”
▪ Want equal vibration on anterior and posterior chest
o Crepitus: air leaking from lungs (subcutaneous air)
▪ Can feel popping while palpating
● Percussion
o Resonance: want to hear hollow sounds on lungs
RESPIRATORY=RESONANCE
● Auscultation
o Egophony: “E” to “A” change
▪ Indicates area of consolidation (ex. Pneumonia, tumor, or growth)
▪ E sound is normal
▪ A is abnormal
o Whispered pectoriloquy: Pt will whisper 1,2,3,
▪ Sound will be louder if there is an obstruction in lungs
o Bronchophony: Have patient say “99” or “blue moon”
▪ (+) bronchophony: sounds will be louder in certain spots; indicates
consolidation of lung tissue in certain spots
▪ Cheyne-stokes: cyclical breathing (stop and go)
● Indicates brain damage, impending death and increased
intracranial pressure
▪ Biot: sequence of several breaths that alternate with apnea
● Indicates brain damage
o Pleural friction rub: caused by inflammation of pleural structures
▪ Grating sound
▪ Heard during inspiration or expiration
Respiratory Diseases/Illnesses/ Treatments
● Aspiration pneumonia is common in the elderly
o Head of the bead should be 30-45° when feeding patients
● Hypoxia symptoms
o Early signs
▪ Agitation, anxiety, irritability
▪ Changes in level of consciousness
▪ Disorientation
▪ Tachypnea
o Late stage
▪ Bradycardia
▪ Cardiac arrythmias
▪ Cyanosis
▪ Bradypnea
▪ Substernal retractions
● Atelectasis: collapse of part of all of a lung
● Venturi mask: PRECISE way of providing oxygen
o Order is given in percentage NOT liters
o For COPD patients
Gastrointestinal System Nursing responsibilities
● Assess bowel function
● Promote normal bowel health
o Fiber from fruits and vegetables are necessary for healthy bowel movements
● Manage alterations in bowel function
o Coffee: if you drink it already, don’t stop. If you don’t drink it don’t start
o Caffeine can affect the heart
o Coffee can reduce colon cancer
▪ The number one way to prevent colon cancer is to have at least one
bowel movement a day
▪ Constipation causes constant friction, breaks down the cells, which can
become abnormal, and cancer can form
▪ Cells will thicken first (lichen patterns)
Structure of the GI tract
● Esophagus-> Small Intestine-> Large intestine (ESL)
● Esophagus-> stomach->DJI (duodenum, Jejunum, ileum: parts of small intestine)
● Ileum->ileocecal valve
● Ascending color (on right side next to appendix)-> transverse colon (poop becomes
thicker here)
o Appendix collects poop
o Appendicitis can occur if something gets caught inside the appendix and the
bacteria reproduces, infection can occur