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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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Physiological basis of the care of the elderly client

Physiological basis of the care of the elderly client

Cardiovascular System

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


    • Thickening of left ventricular


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 lifestyle modification…

  • Presenting complaint may be heartburn, nausea, fatigue

  • Mental status changes

  • Dizziness and falls

  • Agitation

  • Sudden change in cognitive


  • New onset atrial fibrillation

  • Particularly in women:

    • Fatigue

    • Sleep disturbances

    • Epigastric pain

Heart disease in elderly women
Heart disease in elderly women lifestyle modification…

Symptoms may be unrecognized:

  • Sleep disturbances

  • Intermittent chest tightness,

    squeezing, pressure

  • Back, neck, stomach, jaw


  • Shortness of breath, nausea,


  • Break out in cold sweat

Hypertension lifestyle modification…

  • A major risk factor for developing other cardiovascular conditions because:

    • It does not always produce its

      own symptoms

    • Many are unaware they have


    • It is easily ignored

Classifications of blood pressure
Classifications of blood pressure lifestyle modification…

Jnc 7 2003 guidelines jnc 8 in development
JNC 7 (2003) Guidelines lifestyle modification…(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 lifestyle modification…

  • 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 lifestyle modification…

  • Atherosclerosis of the aorta

    and large vessels accelerates

  • Left ventricular hypertrophy


  • 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 lifestyle modification…

  • Evaluate BP bilaterally and in lying,

    sitting and standing positions

  • Blood pressure varies with time

    of day and with activity

  • Respond to “white coat


  • 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 lifestyle modification…

  • 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 lifestyle modification…

  • 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 lifestyle modification…

  • 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 lifestyle modification…

  • 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 “ lifestyle modification…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)

Metabolic syndrome syndrome x
Metabolic syndrome (“syndrome X”) lifestyle modification…

Characteristics of metabolic syndrome
Characteristics of metabolic syndrome lifestyle modification…

  • 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 lifestyle modification…

  • 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 lifestyle modification…

  • Chest pain is not always present

  • Fatigue

  • Weakness

  • Shortness of breath

  • GI disturbances

Chest pain
Chest pain lifestyle modification…

  • 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 lifestyle modification…

  • Pericarditis

  • Heartburn, ulcers

  • Chondritis

  • Pulmonary embolus, pneumonia

  • Herpes zoster

Treatment of angina
Treatment of angina lifestyle modification…

  • 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


  • 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 lifestyle modification…

  • 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


  • Hemodynamic monitoring necessary

    if heart failure suspected

Complications of mi
Complications of MI lifestyle modification…

  • Arrhythmia (dysrhythmia)

  • Conduction blockages

  • Heart failure

  • Pulmonary edema

  • Ventricular aneurysm

  • Pericarditis

Anticoagulation treatment of mi
Anticoagulation treatment of MI lifestyle modification…

  • 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 lifestyle modification…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 lifestyle modification…

  • 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

Right sided versus left sided failure
Right sided versus lifestyle modification…left sided failure

Neck vein distention
Neck vein distention lifestyle modification…

Dysrhythmias not arrhythmias
Dysrhythmias (not “arrhythmias!”) lifestyle modification…

  • 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 lifestyle modification…

  • 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 lifestyle modification…

  • What is your nursing

    diagnosis for RB?

  • What is your desired


  • What are appropriate

    interventions pertinent

    to your desired outcome?