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Physiological basis of the care of the elderly client. Cardiovascular System. Patient scenario. RB, 73 year old Caucasian male Medical diagnosis hypertension Prescribed Norvasc, 5 mg qd and Accupril 10 mg BID Often forgets his evening dose Wants “one pill once-a-day”

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patient scenario
Patient scenario
  • RB, 73 year old Caucasian male
  • Medical diagnosis hypertension
  • Prescribed Norvasc, 5 mg qd and Accupril 10 mg BID
  • Often forgets his evening dose
  • Wants “one pill once-a-day”
  • Complains of frequent headache on waking
  • …pill makes him urinate too much
  • …he has a cough that won’t go away
  • …feels fine, maybe he doesn’t need it after all
informal evaluation
Informal evaluation

What additional information do you need?

  • Subjective information
  • Objective information
  • Psychosocial information
the cardiovascular system
The cardiovascular system
  • Supplies oxygen to all parts of the body
  • A failure in this system creates a cascade of failure in other systems
  • Regardless of nursing focus, you are likely to encounter cardiovascular concerns in the elderly client due to normal age related changes
review of cardiac structure and function
Review of cardiac structure and function
  • Circulation is established by electrical system of the heart
  • Left side of heart produced enough force to overcome systemic resistance
  • Effective circulation due in part to one way valves between the chambers of the heart
  • Effective circulation is also dependent upon sequential contraction and

relaxation of the heart

preload and afterload
Preload and afterload
  • Preload is a representation of the

pressure stretching the left ventricle

after passive filling and atrial

contraction (diastole) by the blood

returning to the heart

  • Afterload is the amount of pressure

produced by the left ventricle in

order to contract (systole)

left ventricle efficiency
Left ventricle efficiency
  • Determined by amount of blood pumped from the left ventricle at end of diastole
  • Affected by
    • Strength of contraction
    • Amount of blood in the ventricle
    • Competency of the valves
    • Peripheral vascular resistance
  • Ejection fraction = stroke volume /

left ventricle end diastolic volume

the electrocardiogram
The electrocardiogram
  • Normal PR = .12-.20 (3-5 □s)
  • Normal QRS = < .12 (3 □s)
  • Normal sinus rhythm
    • Each P wave followed by QRS
    • Rate 60-90 with <10% variation
  • P wave: atrial depolarization
  • QRS complex: ventricular depolarization
  • T wave: ventricular repolarization
  • Little boxes = .04 sec; Big boxes = 5x.04 = .2 sec
normal age related changes
Normal age related changes
  • Heart valves become stiff
  • Decreased renin, angiotensin and aldosterone production
  • Arterial stiffening and loss of elasticity
  • Veins thicken and valvular reflux occurs
  • Decreased baroreceptor sensitivity
  • Decrease in number of normal pacemaker cells in

sinus node

  • Myocardial hypertrophy
    • Increased size of myocardial

cells

    • Thickening of left ventricular

wall

resulting systemic effects
Resulting systemic effects
  • Increased resistance of peripheral vessels
  • Decreased coronary blood flow
  • Reduced cardiac output
  • Less efficient cardiac oxygen usage
  • Slower response to cardiac

challenge if not in good

physical condition

to prevent debilitation from cardiovascular changes through lifestyle modification
To prevent debilitation from cardiovascular changes through lifestyle modification…
  • Remain physically active—30 minutes aerobic activity per day most days of the week
  • Avoid obesity—maintain normal BMI between 22-25
  • Avoid smoking
  • Control blood pressure
  • Control cholesterol levels
  • Restrict sodium intake to

2.4 g/day

  • Limit alcohol to ≤2/day for

men, ≤1/day for women

atypical presentation of cardiac disease
Atypical presentation of cardiac disease
  • Presenting complaint may be heartburn, nausea, fatigue
  • Mental status changes
  • Dizziness and falls
  • Agitation
  • Sudden change in cognitive

abilities

  • New onset atrial fibrillation
  • Particularly in women:
    • Fatigue
    • Sleep disturbances
    • Epigastric pain
heart disease in elderly women
Heart disease in elderly women

Symptoms may be unrecognized:

  • Sleep disturbances
  • Intermittent chest tightness,

squeezing, pressure

  • Back, neck, stomach, jaw

discomfort

  • Shortness of breath, nausea,

lightheadedness

  • Break out in cold sweat
hypertension
Hypertension
  • A major risk factor for developing other cardiovascular conditions because:
    • It does not always produce its

own symptoms

    • Many are unaware they have

hypertension

    • It is easily ignored
jnc 7 2003 guidelines jnc 8 in development
JNC 7 (2003) Guidelines(JNC 8 in development)
  • After age 50, SBP >140 is a more important risk factor than DBP
  • A 90% risk of developing HTN exists even in those age 55 who are normotensive
  • 120-139/80-89 is prehypertensive; patients should begin lifestyle modifications
  • Most patients with HTN need 2+ medications
  • Thiazide diuretics should be used to treat uncomplicated HTN
  • Effective therapy requires patient motivation
  • Empathy builds trust and promotes motivation
instant teaching points regarding htn
“Instant” teaching points regarding HTN
  • It is not the same as anxiety
  • Once you are diagnosed, you

are on medication for life*

  • It is defined as systolic

blood pressure > 140 mmHg

  • Most cases of HTN are classified

as primary HTN—the underlying

cause is not known

*some exceptions!

results of untreated hypertension
Results of untreated hypertension
  • Atherosclerosis of the aorta

and large vessels accelerates

  • Left ventricular hypertrophy

develops

  • Proteinuria due to increased

renal arteriole pressure

  • Vascular changes in the retina

(A-V “nicking”)

  • Increased stroke risk
nursing management patients with htn
Nursing management—patients with HTN
  • Evaluate BP bilaterally and in lying,

sitting and standing positions

  • Blood pressure varies with time

of day and with activity

  • Respond to “white coat

hypertension”

  • Home blood pressure monitoring

must be confirmed

  • Assess for target organ damage

with each encounter

nursing management patients with htn1
Nursing management—patients with HTN
  • High blood pressure screening
  • Promote healthy lifestyles
    • Low fat diet
    • Low sodium diets
    • Weight control
    • Exercise
    • Smoking cessation
    • Controlled alcohol consumption
  • Monitor effects of medication
medication management of hypertension
Medication management of hypertension
  • Initial treatment usually involves diuretics
  • Second medication selected pertaining to patient’s health status
  • β-blockers can cause bradycardia, fatigue, exercise intolerance
  • Postural hypotension can occur with adrenergic inhibitors and α-blockers
  • Dry cough, hyperkalemia can occur with ACE inhibitors and angiotensin receptor blockers
  • Benzothiazepines may cause decreased cardiac output and slow conduction
hypotension
Hypotension
  • Frequently associated with medication

side effects

  • Decreased responsiveness of

sympathetic nervous system with age

affects autoregulation of cardiac output

  • Lying/sitting (postural) blood pressure:
    • Supine for at least 5 minutes,

then check blood pressure

    • Check again after 1 and 3

minutes of sitting or standing

hyperlipidemia
Hyperlipidemia
  • Elevated cholesterol is a risk factor for cardiovascular disorders
  • Remember…Keep HDLs high, keep LDLs low!
    • LDL < 100 mg/dl*
    • HDL > 60 mg/dl*

*Optimal per JNC7!

benefits of the statins
Benefits of the “statins”
  • Lower LDL cholesterol
  • Anti-inflammatory
  • Antithrombotic
  • Protect plaque stability
  • Generally well tolerated
    • Atorvastatin (Lipitor)
    • Fluvastatin (Lescol XL)
    • Lovastatin (Mevacor)
    • Pravastatin (Pravachol)
    • Rosuvastatin (Crestor)
    • Simvastatin (Zocor)
characteristics of metabolic syndrome
Characteristics of metabolic syndrome
  • Abdominal fat cells secrete hormones promoting heart disease and diabetes
  • Patients have below-normal HDL
  • Decreased insulin sensitivity (level of insulin required to process glucose)
treatment plan for metabolic syndrome
Treatment plan for metabolic syndrome
  • Cholesterol lowering drugs
  • Antihypertensives
  • Diet high in omega-3 fatty acids
  • Avoid processed foods
  • Exercise 30-45 minutes

moderate intensity

ischemic heart disease in the elderly
Ischemic heart disease in the elderly
  • Chest pain is not always present
  • Fatigue
  • Weakness
  • Shortness of breath
  • GI disturbances
chest pain
Chest pain
  • Caused by a mismatch between what the body is able to deliver and what the body requires
  • Supply ischemia—due to decreased blood flow to the heart
  • Demand ischemia—due to

increased demand for oxygen

  • In stable angina, chest pain

is relieved with rest

  • If not relieved by rest, can

progress to myocardial infarction

other causes of chest pain
Other causes of chest pain
  • Pericarditis
  • Heartburn, ulcers
  • Chondritis
  • Pulmonary embolus, pneumonia
  • Herpes zoster
treatment of angina
Treatment of angina
  • Nitroglycerine—vasodilator
  • Treatment of choice
  • Comes in tablets, sprays,

patches, ointment, IV, sublingual

  • Tablets for acute attacks
  • Transdermal, capsules, ointments do not work rapidly enough during acute

attacks

  • Repeat tablet every 5 minutes for acute attack
  • If no resolution after 3 tablets, patient must be transported to hospital
myocardial infarction findings
Myocardial infarction findings
  • Occurs in stages, treatment directed to the stage
  • EKG changes—ST elevation
  • Q wave represents infarcted tissue
  • CK-MB elevation 4 to 6 hours after infarction
  • Troponin elevation 6 to 8 hours after

infarction

  • Hemodynamic monitoring necessary

if heart failure suspected

complications of mi
Complications of MI
  • Arrhythmia (dysrhythmia)
  • Conduction blockages
  • Heart failure
  • Pulmonary edema
  • Ventricular aneurysm
  • Pericarditis
anticoagulation treatment of mi
Anticoagulation treatment of MI
  • Useful within first few hours of event
  • Chew an aspirin while waiting for ambulance!
  • Not all patients are candidates for thrombolytic therapy
aortic stenosis
Aortic stenosis
  • Most common valvular disorder in the elderly
  • Usually due to calcification
  • Risk factors:
    • Hyperlipidemia
    • Diabetes
    • Hypertension
  • Left ventricular hypertrophy
  • Heart failure
heart failure
Heart failure
  • Heart no longer able to provide sufficient cardiac output
  • Men develop after an MI; women after long-standing HTN
  • Compensatory events
    • Increased heart rate
    • Renin → angiotensin I → angiotensin II → increased BP and sodium and water retention
  • Risk factors:
    • Coronary artery disease
    • Hypertension
dysrhythmias not arrhythmias
Dysrhythmias (not “arrhythmias!”)
  • Atrial fibrillation most common dysrhythmia
  • Incidence increases with age
  • Not life-threatening by itself; can increase mortality
  • No P-wave
  • Disorganized electrical impulses overwhelm SA node
  • Results in an irregular heart rhythm
  • Treated with anticoagulation (Heparin, Warfarin [Coumadin])
venous disease
Venous disease
  • Valvular incompetence
  • Pressure transferred to capillaries

of lower extremities

  • Cells break down
  • Debris collects
  • Can cause nonhealing ulcers
  • Often misinterpreted as

“spider bite”

  • Treatment is compression
formal evaluation
Formal evaluation
  • What is your nursing

diagnosis for RB?

  • What is your desired

outcome?

  • What are appropriate

interventions pertinent

to your desired outcome?

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