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15. Lecture Note PowerPoint Presentation. The Cardiovascular System. LEARNING OUTCOME 1. Describe changes in the cardiovascular system that occur with aging. . Structure and Function of Cardiovascular System. Heart structure Right atrium Tricuspid valve Right ventricle Pulmonic valve.

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the cardiovascular system

15

Lecture Note PowerPoint Presentation

The Cardiovascular System

learning outcome 1
LEARNING OUTCOME 1

Describe changes in the cardiovascular system that occur with aging.

structure and function of cardiovascular system
Structure and Function of Cardiovascular System
  • Heart structure
    • Right atrium
    • Tricuspid valve
    • Right ventricle
    • Pulmonic valve
structure and function of cardiovascular system1
Structure and Function of Cardiovascular System
  • Heart structure
    • Mitral valve
    • Left ventricle
    • Aortic valve
    • Pericardium
structure and function of cardiovascular system2
Structure and Function of Cardiovascular System
  • Heart function
    • Diastole
    • Systole
      • Cardiac output
      • Ejection fraction
      • Autonomic nervous system
        • Sympathetic: alpha and beta receptors (adrenergic)
        • Parasympathetic: vagus nerve
structure and function of cardiovascular system3
Structure and Function of Cardiovascular System
  • Heart function
    • Systole
      • Conduction system
        • Action potential noting the refractory period
        • Sinoatrial (SA) node
        • Atrioventricular (AV) node
        • Bundle branches
structure and function of cardiovascular system4
Structure and Function of Cardiovascular System
  • Heart function
    • Electrocardiogram (EKG)
      • P wave
      • P-R interval
      • QRS wave
      • T wave
structure and function of cardiovascular system5
Structure and Function of Cardiovascular System
  • Heart function
    • Circulatory system structure
      • Arteries
        • Tunica intima
        • Tunica media
        • Tunica adventitia
      • Capillaries
        • Endothelial layer
        • Basal lamina
      • Veins
        • Inferior and superior vena cava
structure and function of cardiovascular system6
Structure and Function of Cardiovascular System
  • Heart function
    • Circulatory system function
      • Regulation of blood flow
        • Local conditions
        • Release of nitric oxide → vasodilation
        • Metabolic activity
      • Cardiac circulation
        • Left coronary artery (LCA)
        • Left anterior descending (LAD)
        • Circumflex
        • Right coronary artery (RCA)
wide range of cardiovascular function among older adults
Wide Range of Cardiovascular Function Among Older Adults
  • Genetics
  • Conditioning
  • Effect of other aging organ systems
    • Different body systems age at different rates
    • Compensation ability
    • Comorbidities
  • Social and physical environments
aging changes with the heart
Aging Changes with the Heart
  • Myocardium
    • Hypertrophy
      • Left ventricle wall 25% thicker in an 80-year-old person vs. a 30-year-old person
    • Increased collagen and connective tissue
    • Cardiac cells
      • Accumulation of lipofuscin, amyloid
aging changes with the heart1
Aging Changes with the Heart
  • Valves
    • Fibrosis and calcification → stiffening of valves
    • Changes in valve rings → contribute to stenosis or incompetence
  • Resting heart rate unchanged with age
    • Difficulty responding to stress
  • Small decline in cardiac output from age 20
aging changes with the heart2
Aging Changes with the Heart
  • Electrical activity
    • Decrease in number of normal pacemaker cells in SA node
      • After age 75 < 10% still functional
        • Supports normal cardiac function
    • Decrease in number of normal pacemaker cells in AV node and both bundle branches
    • Refractory period of the AV node increases
      • EKG without specific changes with normal aging
      • Refractory period: the amount of time it takes for an excitable membrane to be ready for a second stimulus once it returns to its resting state following excitation
aging changes with the heart3
Aging Changes with the Heart
  • Electrical activity
    • Layers
      • Arterial
        • Thickening of the intimal and medial layers
        • Lipid deposits
        • Calcification → medial layer→ collagen deposits→ decreased elasticity + “hardening”
aging changes with the heart4
Aging Changes with the Heart
  • Autonomic nervous system (is a part of prepheral NS, and affects heart rate, digestion, respiration rate, salivation, perspiration, diameter of the pupils, micturition (urination), and sexual arousal.
    • Decreased responsiveness to beta-adrenergic stimulation
  • Baroreceptors less efficient
  • Other aging systems that affect cardiovascular function
    • Pulmonary
    • Renal
    • Baroreceptors (or baroceptors) are sensors located in the blood vessels of several mammals.` They are a type of mechanoreceptor that detects the pressure of blood flowing through them, and can send messages to the central nervous system to increase or decrease total peripheral resistance and cardiac output.
learning outcome 2
LEARNING OUTCOME 2

List focus areas of assessment for cardiovascular patients.

history of cardiovascular problems
History of Cardiovascular Problems
  • Careful interview is important
    • Allow patient to share concerns
    • Gather pertinent information
history of cardiovascular problems1
History of Cardiovascular Problems
  • Comprehensive
    • Demographic information
      • Patient’s date of birth
      • Source of history, if other than the patient
      • Chief complaint
      • History of the present illness
      • Past history
      • Review of systems
      • Family history
      • Social history
      • Functional health pattern assessment, for nursing planning
complete review of systems
Complete Review of Systems
  • Focus for an older patient with cardiovascular problems
    • Presence or absence of chest pain
    • Shortness of breath
    • Syncope
    • Palpitations
    • Edema
complete review of systems1
Complete Review of Systems
  • Focus for an older patient with cardiovascular problems
    • Nocturnal dyspnea
    • Nocturia
    • Pain in the extremities
    • Cough
    • Fatigue
women s symptoms are often vague and often not reported
Women’s Symptoms are Often Vague and Often Not Reported
  • Symptoms include
    • Sleep disturbance
    • Chest discomfort such as tightness, squeezing, fullness, or pressure that can come and go
    • Discomfort in the back, neck, jaw, or stomach
    • Shortness of breath
    • Feelings of nausea, light-headedness, or breaking out in a cold sweat
learning outcome 3
LEARNING OUTCOME 3

Relate physiological concepts to the diagnosis and management of common cardiovascular conditions, including hypertension, angina, heart failure, and peripheral vascular disease.

heart disease is the number one cause of death for older people
Heart Disease is the Number-One Cause of Death for Older People
  • Develops slowly
  • Takes years to develop
hypertension
Hypertension
  • Major risk factor for other cardiovascular conditions
  • No symptoms of its own
statistics
Statistics
  • 43 million Americans (24%) have hypertension
  • Only 69% of people with elevated BP are aware of it
physiological mechanisms of hypertension
Physiological Mechanisms of Hypertension
  • Increased systemic vascular resistance → decrease cardiac output
  • Decrease stroke volume
  • Stroke volume: The amount of blood pumped by the left ventricle of the heart in one contraction.
causes
Causes
  • Primary hypertension
    • No known cause
  • Secondary hypertension
    • 5% to 10% of cases
    • Specific causes
      • Renal artery stenosis
      • Adrenal dysfunction
untreated hypertension
Untreated Hypertension
  • Left ventricular hypertrophy and increased risk of CAD
  • Proteinuria: High blood pressure can cause damage to the kidneys, which may be reflected as an increase in the amount of protein present in the urine.
  • Eye
  • Stroke
hypotension
Hypotension
  • Orthostatic hypotension
    • BP check while lying, sitting, standing
  • Medications with hypotensive effect
    • Alpha-adrenergic blockers
    • Centrally acting antihypertensive agents
    • Psychotropic drugs and tranquilizers
    • High-dose antibiotics
    • Nonsteroidal anti-inflammatory drugs (NSAIDs)
hyperlipidemia
Hyperlipidemia
  • Lipid classifications
    • High-density lipoproteins (HDLs)
    • Low-density lipoproteins (LDLs)
    • Triglycerides
  • Risk factors
    • Elevated cholesterol
    • Atherosclerosis
      • Peripheral artery disease
      • Abdominal aortic aneurysm
      • Diabetes mellitus
hyperlipidemia1
Hyperlipidemia
  • Medication management
    • HMG CoA reductase inhibitors (statins) lower LDL cholesterol
      • Anti-inflammatory
      • Antithrombotic
      • Protect intravascular plaque stability
    • Bile acid sequestrants
      • Attach to bile in the gut and prevent returns to liver
      • HMG CoA reductase is a liver enzyme that is responsible for producing cholesterol
hyperlipidemia2
Hyperlipidemia
  • Medication management
    • Fibrates
      • Reduce triglycerides
    • Nicotinic acid
      • Lowers LDL and triglycerides
      • Raises HDL
chest pain
Chest Pain
  • Myocardium deprived of blood supply → ischemia→ pain + loss of function
  • Chronic pain = angina
  • Other causes
    • Aortic stenosis
    • Pericarditis
    • GI problems
      • Heartburn, acid reflux, or ulcers
chest pain1
Chest Pain
  • Other causes
    • Pulmonary problems
      • Pulmonary embolus, pneumonia, or pleural effusions
    • Musculoskeletal
    • Herpes zoster (shingles): is a nerve infection caused by the chicken-pox virus
angina
Angina
  • Ischemic heart disease
    • Inadequate oxygen supply
  • Stressed cardiac cells → arrhythmias → ineffective contractions
  • Categories
    • Supply: decreased blood flow to the myocardium
    • Demand: increased demand for oxygen to myocardium
angina1
Angina
  • Stable angina: relieved by rest
    • Management: sublingual nitroglycerin
  • Unstable angina: not relieved with rest of medication
    • Progression to MI
  • Prinzmetal’s angina: chest pain at rest
    • Transient coronary artery contractions, unrelieved by nitroglycerin
myocardial infarction
Myocardial Infarction
  • Cell death → loss of cell contraction → decreased heart function
  • Damage determined by size and location
    • LAD: The left anterior descending coronary artery
    • RCA
    • Circumflex
diagnosis of an mi
Diagnosis of an MI
  • History
    • Atypical symptoms in older adults
      • Complaints of MI symptoms different in older women
      • May include nausea or vomiting
      • Weakness
      • Shortness of breath
      • Diaphoresis
      • Confusion
      • Syncope
diagnosis of an mi1
Diagnosis of an MI
  • Physical assessment: may be unremarkable
  • Laboratory
    • CK (creatine kinase) and CK-MB (CK-m band)
    • Tropinin
    • LDH (lactic dehydrogen)
diagnosis of an mi2
Diagnosis of an MI
  • EKG analysis
    • ST segment elevation
    • Widened QRS complexes
    • Q wave presence
  • Other examinations
    • Hemodynamic monitoring
    • Echocardiography
diagnosis of an mi3
Diagnosis of an MI
  • Complications of MI
    • Arrhythmias
    • Blockages of electrical conduction
    • Heart failure
    • Ventricle aneurysms
    • Pericarditis
diagnosis of an mi4
Diagnosis of an MI
  • Medication management
    • Anti clot agents
    • Pain control
    • Beta-blockers
    • Calcium channel blockers
    • Angiotension-converting enzyme inhibitors
diagnosis of an mi5
Diagnosis of an MI
  • Medication management
    • ASA (aspirin)
    • Antiarrhythmic drugs
    • Other management
      • Coronary angioplasty
      • Oxygen
valvular heart disease
Valvular Heart Disease
  • Two categories
    • Stenosis
    • Incompetence, regurgitation, or insufficiency
valvular heart disease1
Valvular Heart Disease
  • Aortic stenosis
    • Most common valve disorder in the older adult
    • Major cause is calcified degenerative stenosis
    • Can lead to CHF, angina, alterations in BP, and arrhythmias
    • Risk factors
      • Hyperlipidemia
      • Diabetes
      • Hypertension
valvular heart disease2
Valvular Heart Disease
  • Aortic stenosis
    • Diagnosis
      • History: progressive shortness of breath
      • Physical examination for murmur
    • Treatment
      • Mechanical intervention
      • Surgical intervention
congestive heart failure
Congestive Heart Failure
  • Statistics
    • 33% of hospitalizations are for CHF
    • Men and women develop equally
    • Incidence for women has increased
    • Men develop after an MI or longstanding hypertension
    • Incidence of mortality is declining
      • Long-term prognosis is not good
congestive heart failure1
Congestive Heart Failure
  • Pathophysiology
    • Loss of contractility of the myocardium → inadequate cardiac output → activity intolerance
    • Frank-Starling Law
      • Overstretching → decreased force of contraction
      • Starling's law states that the greater the volume of blood entering the heart during diastole (end-diastolic volume), the greater the volume of blood ejected during systolic contraction (stroke volume) and vice-versa.
congestive heart failure2
Congestive Heart Failure
  • Risk factors
    • Coronary artery disease
    • Hypertension
    • Family history
    • Cardiotoxic drugs eg chemotherapy

cardiotoxicity is a condition when there is damage to the heart muscle

    • Smoking
    • Obesity
    • Alcohol abuse
    • Diabetes mellitus
    • Sleep disorders
congestive heart failure3
Congestive Heart Failure
  • Clinical manifestations
    • Left-sided heart failure
      • Pulmonary symptoms
    • Right-sided heart failure
      • System symptoms
congestive heart failure4
Congestive Heart Failure
  • Tests
    • Laboratory
      • CBC
      • Elevated creatinine
      • Thyroid function
    • Diagnostics
      • EKG
      • Echocardiogram
congestive heart failure5
Congestive Heart Failure
  • Treatment
    • ACE inhibitors
    • Beta-blockers
    • Diuretics
    • Digoxin
arrhythmias and conduction disorders
Arrhythmias and Conduction Disorders
  • Atrial fibrillation
    • Most common sustained arrhythmia
    • EKG shows no P wave
    • Incidence increases with age
    • Causes
      • Hypertension
      • Valvular stenosis
      • Ischemic heart disease
      • Irregularly irregular heart rate
      • Rapid pulse
arrhythmias and conduction disorders1
Arrhythmias and Conduction Disorders
  • Atrial fibrillation
    • Not life threatening but has complications
      • Embolic CVA
    • Treatment
      • Correct hemodynamic instability with heparin or Coumadin
      • Monitor Coumadin effects in INR
      • Control ventricular rate with calcium channel blocker
      • Restore sinus rhythm, if possible, with antiarrhythmic drugs
heart block
Heart Block
  • If results in decreased cardiac output, treat with internal pacemaker
arterial disease
Arterial Disease
  • Atherosclerosis: occlusion of specified vessels→ loss of function and symptoms of pain in areas perfused by the artery
  • Symptoms
  • Intermittent claudication
    • Burning pain in legs or buttocks during exercise, which is relieved by rest
    • Pain at rest with progressive disease
arterial disease1
Arterial Disease
  • History
  • Physical examination
  • Treatment
    • Medication
      • Antithrombotic agents
      • Prostaglandins
      • Calcium channel blockers
    • Surgery
    • Vascular rehabilitation programs
venous disease
Venous Disease
  • Pathophysiology
  • Venous insufficiency → stasis → ulcers, wide with irregular borders
  • Risk factors
    • Obesity
    • Occupations
      • Long periods of standing or sitting
venous disease1
Venous Disease
  • Treatment
    • Wearing external compression hose
    • Treat ulcers with multilayer compression bandages
learning outcome 4
LEARNING OUTCOME 4

List common nursing diagnoses for the cardiovascular patient.

nursing diagnosis for patients experiencing or at risk for heart failure or angina
Nursing Diagnosis for Patients Experiencing, or at Risk for, Heart Failure or Angina
  • Ineffective Management of Therapeutic Regimen
nursing diagnoses for patients with heart failure
Nursing Diagnoses for Patients with Heart Failure
  • Decreased Cardiac Output
  • Fluid Volume Overload
nursing diagnosis for patients with orthopnea or paroxysmal nocturnal dyspnea
Nursing Diagnosis for Patients with Orthopnea or Paroxysmal Nocturnal Dyspnea
  • Sleep Pattern Disturbance
learning outcome 5
LEARNING OUTCOME 5

Describe specific nursing interventions used with cardiovascular patients.

nursing interventions for promoting cardiac health
Nursing Interventions for Promoting Cardiac Health
  • Lifestyle modification
  • Judicious (careful) use of medications
  • Ongoing assessment of the older person’s cardiac status
use high blood pressure instead of hypertension
Use High Blood Pressure Instead of Hypertension
  • May be mistakenly associated with anxiety or tension
management of hypertension and risk reduction
Management of Hypertension and Risk Reduction
  • Establish blood pressure goals
  • Teach lifestyle modifications
  • Suggest nutritional adjustments
  • Encourage exercise programs
  • Encourage smoking cessation
  • Encourage reduced alcohol intake
  • Manage medications
role of nursing
Role of Nursing
  • Community blood pressure screening
  • Promote healthy lifestyles
  • Teach importance of consistently taking medications
patients taking statins
Patients Taking Statins
  • Teach importance of reporting muscle aches and symptoms to their healthcare providers
  • Statinsare a class of drug used to lower cholesterol levels by inhibiting the enzyme HMG-CoA reductase.
patients taking coumadin warfarin
Patients Taking Coumadin (warfarin)
  • Limit dietary intake of green leafy vegetables rich in vit k bcz Vitamin K can make Coumadin less effective
  • Safety precautions
interventions for older patients with angina
Interventions for Older Patients with Angina
  • Support lifestyle changes
  • Teach proper medication use
    • Many patients are reluctant to use prescribed medications, particularly when prescribed “as needed”
    • Present scenarios and ask patients what they would do if they have sudden weakness, or if they take the medication and it does not help
risk factor reduction
Risk Factor Reduction
  • Done across a variety of settings from home to hospital to long-term-care facility
  • Creativity with approach (what matters to each patient; i.e., sports, grandchildren, etc.)
activity and exercise support
Activity and Exercise Support
  • Supervise increases in activity
  • Plan rest periods
diet therapy
Diet Therapy
  • Teaching
  • Consultation with dietitians
smoking cessation
Smoking Cessation
  • Ask patient to record cigarettes smoked on a daily basis for a week
  • Review smoking diary and ask patient to select a time they could avoid smoking
medication management
Medication Management
  • Teach how to open medication bottles
  • Create a system to remember to take them
  • Teach when they should report side effects
caregiver support
Caregiver Support
  • Teach about medications
  • Identify respite programs
advance directives
Advance Directives
  • Discuss with family and patient
  • Assist in preparing an individualized document
learning outcome 6
LEARNING OUTCOME 6

Outline an education plan for cardiovascular patients.

importance of knowledge of cardiovascular disorders
Importance of Knowledge of Cardiovascular Disorders
  • Signs and symptoms in older adults
  • Assists the nurse in assuming the role of teacher and coach
patient family education
Patient-Family Education
  • Critical for interpreting and clarifying scientific data to individualize a nursing care plan