Far Eastern University

Institute of Health Sciences and Nursing

Department of Nursing

NUR1101 - Anatomy and Physiology

Module 11 – The Cardiovascular System

The major function of the cardiovascular system is transportation. Using blood as the transport vehicle,
the system carries oxygen, nutrients, cell wastes, hormones, and many other substances vital for body
homeostasis to and from the cells. The force to move the blood around the body is provided by the
beating heart and by blood pressure.

The Heart
Approximately the size of a person’s fist, the hollow, cone-shaped heart weighs less than a pound.
Snugly enclosed within the inferior mediastinum, the medial section of the thoracic cavity, the heart is
flanked on each side by the lungs. Its pointed apex is directed toward the left hip and rests on the
diaphragm, approximately at the level of the fifth intercostal space. Its broad posterosuperior aspect, or
base, from which the great vessels of the body emerge, points toward the right shoulder and lies
beneath the second rib.

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 Far Eastern University
Institute of Health Sciences and Nursing
Department of Nursing

Coverings and Walls of the Heart

The heart is enclosed by a sac called the pericardium (per″i-kar′de-um) that is made up of three layers:
an outer fibrous layer and an inner serous membrane pair. This fibrous layer helps protect the heart and
anchors it to surrounding structures, such as the diaphragm and sternum.

The visceral layer of the serous pericardium, or visceral pericardium, also called the epicardium, is part
of the heart wall. In other words, the epicardium is the innermost layer of the pericardium and the
outermost layer of the heart wall.

The heart walls are composed of three layers: the outer epicardium, the myocardium, and the innermost
endocardium.

Chambers and Associated Great Vessels

The heart has four hollow cavities, or chambers—two atria (a′tre-ah; singular atrium) and two ventricles
(ven′tr˘ı-kulz). Each of these chambers is lined with endocardium, which helps blood flow smoothly
through the heart.

Although it is a single organ, the heart functions as a double pump, with arteries carrying blood away
from and veins carrying blood toward the heart. The right side works as the pulmonary circuit pump.

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Institute of Health Sciences and Nursing
Department of Nursing

Oxygen-rich blood returned to the left atrium flows into the left ventricle and is pumped out into the
aorta (a-or′tah), from which the systemic arteries branch to supply essentially all body tissues.

The systemic and Pulmonary Circulation

This circuit, from the right ventricle (the pump) to

the lungs and back to the left atrium (receiving
chamber), is called the pulmonary circulation. Its
only function is to carry blood to the lungs for gas
exchange.
The second circuit, from the left ventricle through
the body tissues and back to the right atrium, is
called the systemic circulation. It supplies oxygen-
and nutrient-rich blood to all body organs.

Heart Valves
The heart is equipped with four valves, which allow
blood to flow in only one direction through the heart
chambers—from the atria through the ventricles and
out the great arteries leaving the heart.

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Institute of Health Sciences and Nursing
Department of Nursing

The atrioventricular (AV) valves (a″tre-o-ven-trik′u-lar) are located between the atria and ventricles on
each side. These valves prevent backflow into the atria when the ventricles contract. The left AV
valve—the bicuspid valve, also called the mitral (mi′tral) valve—consists of two flaps, or cusps, of
endocardium. The right AV valve, the tricuspid valve, has three cusps. Tiny white cords, the chordae
tendineae (kor′de ten-din′e)—literally, “tendinous cords” (think of them as “heart strings”)—anchor the
cusps to the walls of the ventricles.

The second set of valves, the semilunar (sem″˘ı-lu′nar) valves, guards the bases of the two large arteries
leaving the ventricular chambers. Thus, they are known as the pulmonary semilunar valve and aortic
semilunar valve.

Each set of valves operates at a different time. The AV valves are open during heart relaxation and
closed when the ventricles are contracting. The semilunar valves are closed during heart relaxation
and are forced open when the ventricles contract. The valves force blood to continually move forward
through the heart by opening and closing in response to pressure changes in the heart.

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Institute of Health Sciences and Nursing
Department of Nursing

Operation of the AV valves

Operation of the semilunar valves

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Institute of Health Sciences and Nursing
Department of Nursing

Cardiac Circulation

The functional blood supply that oxygenates and nourishes the myocardium is provided by the right and
left coronary arteries. The coronary arteries branch from the base of the aorta and encircle the heart in
the coronary sulcus (atrioventricular groove) at the junction of the atria and ventricles.

Physiology of the Heart

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Institute of Health Sciences and Nursing
Department of Nursing

What makes the heart beats? Unlike skeletal muscle cells, which must be stimulated by nerve impulses
before they will contract, cardiac muscle cells can and do contract spontaneously and independently,
even if all nervous connections are severed. Moreover, these spontaneous contractions occur in a
regular and continuous way. Although cardiac muscle can beat independently, the muscle cells in
different areas of the heart have different rhythms. Atrial cells beat about 60 times per minute, but
ventricular cells contract more slowly (20–40 times per minute). Therefore, without some type of
unifying control system, the heart would be an uncoordinated and inefficient pump.

Two systems act to regulate heart activity. One of these involves the nerves of the autonomic nervous
system, which act like brakes and gas pedals to decrease or increase the heart rate, depending on which
division is activated. The second system is the intrinsic conduction system, or nodal system, that is built
into the heart tissue and sets its basic rhythm.

One of the most important parts of the intrinsic conduction system is a crescent-shaped node of tissue
called the sinoatrial (si″no-a′tre-al) (SA) node, located in the right atrium. Other components include
the atrioventricular (AV) node at the junction of the atria and ventricles, the atrioventricular (AV)
bundle (bundle of His) and the right and left bundle branches located in the interventricular septum,
and finally the Purkinje (pur-kin′je) fibers, which spread within the myocardium of the ventricle walls.
The SA node is a tiny cell mass with a mammoth job. Because it has the highest rate of depolarization in
the whole system, it starts each heartbeat and sets the pace for the whole heart. Consequently, the SA
node is often called the pacemaker.

Cardiac Cycle
The term cardiac cycle refers to the events of one complete heartbeat, during which both atria and
ventricles contract and then relax. The average heart beats approximately 75 times per minute, so the
length of the cardiac cycle is normally about 0.8 second. We will consider the cardiac cycle in terms of
events occurring during five periods.

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Institute of Health Sciences and Nursing
Department of Nursing

Cardiac Output
Cardiac output (CO) is the amount of blood pumped out by each side of the heart (actually each
ventricle) in 1 minute. It is the product of the heart rate (HR) and the stroke volume (SV). Stroke volume
is the volume of blood pumped out by a ventricle with each heartbeat. In general, stroke volume
increases as the force of ventricular contraction increases. If we use the normal resting values for heart
rate (75 beats per minute) and stroke volume (70 ml per beat), the average adult cardiac output can be
easily calculated:
CO = HR (75 beats/min) × SV (70 ml/beat)
CO = 5250 ml/min = 5.25 L/min

Regulation of Stroke Volume A healthy heart pumps out about 60 percent of the blood present in its
ventricles. As noted previously, this is approximately 70 ml (about 2 ounces) with each heartbeat.
According to Starling’s law of the heart, the critical factor controlling stroke volume is how much the
cardiac muscle cells are stretched by the filling of the chambers just before they contract. The more they
are stretched, the stronger the contraction will be. The important factor stretching the heart muscle is
venous return, the amount of blood entering the heart and distending its ventricles. If one side of the
heart suddenly begins to pump more blood than the other, the increased venous return to the opposite
ventricle will force it to pump out an equal amount, thus preventing backup of blood in the circulation.

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Institute of Health Sciences and Nursing
Department of Nursing

Influence of selected factors on cardiac output

Factors Modifying Basic Heart Rate

1. Neural (ANS) controls.
2. Hormones and ions.
3. Physical factors.

Electrocardiography
The heart’s electrical activity produces currents that radiate through the surrounding tissue to the skin.
When electrodes are attached to the skin, they sense those electrical currents and transmit them to an
ECG monitor. The currents are then transformed into waveforms that represent the heart’s
depolarization repolarization cycle.

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Institute of Health Sciences and Nursing
Department of Nursing

The typical ECG has three recognizable waves. The first wave, which follows the firing of the SA node, is
the P wave. The P wave is small and signals the depolarization of the atria immediately before they
contract. The large QRS complex, which results from the depolarization of the ventricles, has a
complicated shape. It precedes the contraction of the ventricles. The T wave results from currents
flowing during the repolarization of the ventricles. (Atrial repolarization is generally hidden by the large
QRS complex, which is being recorded at the same time).

2 Types of ECG
• 12-lead ECG
• Rhythm strip

Different leads provide different information.

The six limb leads—I, II, III, augmented vector
right (aVR), augmented vector left (aVL), and
augmented vector foot (aVF)—provide
information about the heart’s frontal (vertical)
plane. Leads I, II, and III require a negative and
positive electrode for monitoring, which makes

those leads bipolar. The augmented leads record information from one lead and are called unipolar.

lead I
Lead I provide a view of the heart that shows current moving from right to left. Because current flows
from negative to positive, the positive electrode for this lead is placed on the left arm or on the left side
of the chest; the negative electrode is placed on the right arm.

lead II
Lead II produces a positive deflection. Place the positive electrode on the patient’s left leg and the
negative electrode on the right arm. The current travels down and to the left in this lead. Lead II tends to
produce a positive, high voltage deflection, resulting in tall P, R, and T waves.

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Institute of Health Sciences and Nursing
Department of Nursing

lead III
Lead III produces a positive deflection. The positive electrode is placed on the left leg; the negative
electrode, on the left arm.

Leads aVR, aVL, and aVF are called augmented leads because the small waveforms that normally would
appear from these unipolar leads are enhanced by the ECG. The “a” stands for “augmented,” and “R, L,
and F” stand for the positive electrode position of the lead. In lead aVR, the positive electrode is placed
on the right arm (hence, the R) and produces a negative deflection because the heart’s electrical activity
moves away from the lead. In lead aVL, the positive electrode is on the left arm and produces a positive
deflection on the ECG. In lead aVF, the positive electrode is on the left leg (despite the name aVF) and
produces a positive deflection. These three limbs lead also provide a view of the heart’s frontal plane.

The six precordial or V leads—V1, V2, V3, V4, V5, and V6—provide information about the heart’s
horizontal plane. Like the augmented leads, the precordial leads are also unipolar, requiring only a single
electrode. The opposing pole of those leads is the center of the heart as calculated by the ECG.

Lead V1—The precordial lead V1 electrode is placed on the right side of the sternum at the fourth
intercostal rib space. This lead corresponds to the modified chest lead MCL1 and shows the P wave, QRS
complex, and ST segment particularly well.

Lead V2—Lead V2 is placed at the left of the sternum at the fourth intercostal rib space.

Lead V3—Lead V3 goes between V2 and V4. Leads V1, V2, and V3 are biphasic, with both positive and
negative deflections. Leads V2 and V3 can be used to detect ST-segment elevation.

Lead V4—Lead V4 is placed at the fifth intercostal space at the midclavicular line and produces a
biphasic waveform.

Lead V5—Lead V5 is placed at the fifth intercostal space at the anterior axillary line. It produces a
positive deflection on the ECG and, along with V4, can show changes in the ST segment or T wave.

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Institute of Health Sciences and Nursing
Department of Nursing

Lead V6—Lead V6, the last of the precordial leads, is placed level with V4 at the midaxillary line. This
lead produces a positive deflection on the ECG.

12 Lead ECG Electrode Placement

The principle behind Einthoven's triangle describes how electrodes RA, LA and LL do not only record the
electrical activity of the heart in relation to themselves through the aVR, aVL and aVF leads. They also
correspond with each other to form leads I (RA to LA), II (RA to LL) and III (LL to LA).

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Institute of Health Sciences and Nursing
Department of Nursing

Pre-procedure Routines
• Ensure that electronic devices (e.g., smartphone) are removed from the patient. These devices
can produce artifact (interference) and cause problems with the readings.
• Place patient in supine or Semi-Fowler's position. If both positions are impossible, you can
perform ECG with the patient in a more elevated position.
• With arms lying flat on the side, ask the patient to relax the shoulders and keep the legs
uncrossed.
• Unless you're performing a stress ECG test, ask the patient to lie still and quietly until the test is
done.
• For patients that do not fit comfortably on the bed or exam table due to size, ask them to cross
their arms on their stomach to reduce muscle tension and movement.
• Skin should be dry, hairless, and oil-free. Shave hair that can possibly impede electrode
placement. Electrodes should have full contact with the patient's skin.
• For better electrode adhesion and oil-free skin, rub the area with an alcohol prep pad or gauze
paid with benzoin tincture.
• Reduce electrical resistance minus the skin redness with 5 to 10 gentle strokes. This will help
ensure that the heart's electrical signals are transmitted to the electrodes.
• Promote an environment that prevents the patient from sweating profusely.

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Institute of Health Sciences and Nursing
Department of Nursing

Blood Vessels
As the heart beats, it propels blood into the large arteries leaving the heart. As the large arteries branch,
blood moves into successively smaller and smaller arteries and then into the arterioles (ar-ter′e-ˉolz),
which feed the capillary (kap′˘ı-lar″e) beds in the tissues. Capillary beds are drained by venules
(ven′ulz), which in turn empty into veins that merge and finally empty into the great veins (venae cavae)
entering the heart.

Except for the microscopic capillaries (which have only one layer), the walls of blood vessels have three
layers, or tunics. The tunica intima, tunica media, and tunica externa.

Structural Differences in Arteries, Veins, and Capillaries

1. The walls of arteries are usually much thicker than those of veins.
2. Skeletal muscle activity, known as the muscular pump, also enhances venous return.
3. The transparent walls of the capillaries are only one cell layer thick—just the tunica intima.
4. The true capillaries number 10 to 100 per capillary bed, depending on the organ or tissues
served.

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Department of Nursing

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Department of Nursing

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Anatomy of a capillary bed

The transparent walls of the capillaries are only one cell layer thick—just the tunica intima. Because of
this exceptional thinness, substances are exchanged easily between the blood and the tissue cells. The
tiny capillaries tend to form interweaving capillary beds. The flow of blood from an arteriole to a
venule—that is, through a capillary bed—is called microcirculation. In most body regions, a capillary
bed consists of two types of vessels: (1) a vascular shunt, a vessel that directly connects the arteriole
and venule at opposite ends of the bed, and (2) true capillaries, the actual exchange vessels.

Capillary Exchange of Gases and Nutrients

1. Direct diffusion through membrane.

2. Diffusion through intercellular clefts.
3. Diffusion through pores.
4. Transport via vesicles

Fluid Movements at Capillary Beds

Because of their intercellular clefts and
fenestrations, some capillaries are leaky,
and bulk fluid flow (fluid moving all at once)
occurs across their plasma membranes.

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Institute of Health Sciences and Nursing
Department of Nursing

Blood pressure tends to force fluid (and solutes) out of the capillaries, and osmotic pressure tends to
draw fluid into them because blood has a higher solute concentration (due to its plasma proteins) than
does interstitial fluid. Whether fluid moves out of or into a capillary depends on the difference between
the two pressures. As a rule, blood pressure is higher than osmotic pressure at the arterial end of the
capillary bed, and lower than osmotic pressure at the venous end. Consequently, fluid moves out of the
capillaries at the beginning of the bed and is reclaimed at the opposite (venule) end. However, not quite
all of the fluid forced out of the blood is reclaimed at the venule end. Returning fluid left in tissues to the
blood is the chore of the lymphatic system.

Arterial Supply of the Brain and the Circle of Willis

Because a lack of blood for even a few minutes causes the delicate brain cells to die, a continuous blood
supply to the brain is crucial. The brain is supplied by two pairs of arteries, the internal carotid arteries
and the vertebral arteries.

The internal carotid arteries, branches of the common carotid arteries, run through the neck and enter
the skull through the temporal bone. Once inside the cranium, each divides into the anterior cerebral
artery and middle cerebral artery, which supply most of the cerebrum.

The paired vertebral arteries pass upward from the subclavian arteries at the base of the neck. Within

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Department of Nursing

the skull, the vertebral arteries join to form the single basilar artery. This artery serves the brain stem
and cerebellum as it travels upward. At the base of the cerebrum, the basilar artery divides to form the
posterior cerebral arteries, which supply the posterior part of the cerebrum.

The anterior and posterior blood supplies of the brain are united by small communicating arterial
branches. The result is a complete circle of connecting blood vessels called the cerebral arterial circle or
the circle of Willis, which surrounds the base of the brain. The cerebral arterial circle protects the brain
by providing more than one route for blood to reach brain tissue in case of a clot or impaired blood flow
anywhere in the system.

Hepatic Portal Circulation

The veins of the hepatic portal circulation drain the digestive organs, spleen, and pancreas and deliver
this blood to the liver through the hepatic portal vein.

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Institute of Health Sciences and Nursing
Department of Nursing

Hepatic Portal Circulation

The major vessels composing the hepatic portal circulation include the inferior and superior mesenteric
veins, the splenic vein, and the left gastric vein. The inferior mesenteric vein, draining the terminal part
of the large intestine, drains into the splenic vein, which itself drains the spleen, pancreas, and the left
side of the stomach. The splenic vein and superior mesenteric vein (which drains the small intestine and
the first part of the colon) join to form the hepatic portal vein. The L. gastric vein, which drains the right
side of the stomach, drains directly into the hepatic portal vein.

Physiology of Circulation
The alternating expansion and recoil of an artery that occurs with each beat of the left ventricle creates a
pressure wave—a pulse—that travels through the entire arterial system. Normally the pulse rate
(pressure surges per minute) equals the heart rate (beats per minute). The pulse averages 70 to 76 beats
per minute in a healthy resting person. It is influenced by activity, postural changes, and emotions. You
can feel a pulse in any artery lying close to the body surface by compressing the artery against firm
tissue; this provides an easy way of counting heart rate. Because it is so accessible, the point where the
radial artery surfaces at the wrist (the radial pulse) is routinely used to take a pulse measurement, but
there are several other clinically important arterial pulse points. Because these same points are

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Department of Nursing

compressed to stop blood flow into distal tissues during significant blood loss or hemorrhage, they are
also called pressure points.

Blood Pressure

Blood pressure is the pressure the blood exerts

against the inner walls of the blood vessels, and
it is the force that keeps blood circulating
continuously even between heartbeats.
Blood Pressure Gradient When the ventricles
contract, they force blood into large, thick-
walled elastic arteries close to the heart that
expand as the blood is pushed into them. The
high pressure in these elastic arteries forces the

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blood to continuously move into areas where the pressure is lower. The pressure is highest in the large
arteries closest to the heart and continues to drop throughout the systemic pathway, reaching zero at
the right atrium.

Measuring Blood Pressure

Two arterial blood pressures are usually measured: systolic (sis-t˘o′lik) pressure, the pressure in the
arteries at the peak of ventricular contraction, and diastolic (di″us-t˘o′lik) pressure, the pressure when
the ventricles are relaxing. Blood pressures are reported in millimeters of mercury (mm Hg), with the
higher systolic pressure written first—120/80 (read “120 over 80”) translates to a systolic pressure of
120 mm Hg and a diastolic pressure of 80 mm Hg. Most often, systemic arterial blood pressure is
measured indirectly by the auscultatory (os-kul′tuh-tor-e) method. This procedure is used to measure
blood pressure in the brachial artery of the arm.

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Institute of Health Sciences and Nursing
Department of Nursing

Arterial blood pressure (BP) is directly related to cardiac output (CO; the amount of blood pumped out
of the left ventricle per minute) and peripheral resistance (PR). This relationship is expressed by the
equation BP = CO × PR. We have already considered regulation of cardiac output, so we will concentrate
on peripheral resistance here.

Peripheral resistance is the amount of friction the blood encounters as it flows through the blood
vessels.
1. Neural factors: the autonomic nervous system.
2. Renal factors: the kidneys.
3. Temperature.
4. Chemicals.
5. Diet

Neural factors: the autonomic nervous system.

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 Far Eastern University
Institute of Health Sciences and Nursing
Department of Nursing

REFERENCES:

Berman, A., & Snyder, S. (2012). Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and
Practice. Prentice Hall.
Marieb, E. N., & Keller, S. M. (2017). Essentials of human anatomy and physiology. Pearson.
VanPutte, C., Russo, A., Regan, J., & Russo, A. F. (2018). Seeleys Essentials of Anatomy and Physiology.

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