Post on 22-Feb-2016
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Physiological basis of the care of the elderly client
Cardiovascular System
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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
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Informal evaluationWhat additional information do you need?
Subjective information Objective information Psychosocial information
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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 will
encounter cardiovascular concerns in the elderly client due to normal age related changes
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Review of cardiac structure and function Circulation is established by electrical system
of the heart Left side of heart produces 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
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Potential challenges for the elderly client
Electrical
Force
Valves
Coordi-nation
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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)
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Regulation of cardiac function
Preload
Contractility Afterload
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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
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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
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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
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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
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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
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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
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Heart disease in elderly womenSymptoms 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
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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
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Classifications of blood pressureOptimal: <120/<80Screen every 2 years
Prehypertension: 120-139/80-89Assess annually
Stage 1 HTN: 140-159/90-99Assess more frequently
Stage 2 HTN: ≥160 OR ≥100Assess more frequently
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JNC 8 (2014) Guidelines 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
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JNC 8 Hypertension Management Lifestyle interventions apply throughout all
treatment recommendations Blood pressure goals and medication
treatment based on Age Diabetes Chronic kidney disease
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JNC 8 HTN Management Algorithm:Age ≥60 years No diabetes No CKD
Goal
SBP•<150 mm Hg
Goal
DBP•<90 mm Hg
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JNC 8 HTN Management Algorithm:Age <60 years No diabetes No CKD
Goal
SBP•< 140 mm Hg
Goal
DBP•< 90 mm Hg
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JNC 8 HTN Management Algorithm:All ages With diabetes No CKD
Goal
SBP•< 140 mm Hg
Goal
DBP•< 90 mm Hg
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JNC 8 HTN Management Algorithm:All ages with CKD
Goal
SBP•< 140 mm Hg
Goal
DBP•< 90 mm Hg
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JNC 8 HTN Treatment Guidelines
BlackNo CKD
• Thiazide-type diuretic, or,
• CCB, or,• Combinatio
n
Non-BlackNo CKD
• Thiazide-type diuretic, or,
• ACEI, or,• ARB, or,• CCB, or,• Combinatio
n
All RacesCKD
• ACEI, or,• ARB, or,• Combinatio
n with other class
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“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 underlyingcause is not known
*some exceptions!
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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
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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
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Nursing management—patients with HTN High blood pressure screening Promote healthy lifestyle
Low fat diet Low sodium diets Weight control Exercise Smoking cessation Controlled alcohol consumption
Monitor effects of medication
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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 Calcium channel blockers (esp. Benzothiazepines) may
cause decreased cardiac output and slow conduction
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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
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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!
LDL
HDL
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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)
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Metabolic syndrome (“syndrome X”)
• >100mg/dl (fasting)
• >150 mg/dl
• > 135/80
• Men > 40”• Women > 35”
Waist
Circ.BP
BGTG
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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)
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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
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Ischemic heart disease in the elderly Chest pain is not always present Fatigue Weakness Shortness of breath GI disturbances
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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
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Other causes of chest pain Pericarditis Heartburn, ulcers Chondritis Pulmonary embolus, pneumonia Herpes zoster
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Treatment of angina Nitroglycerine—vasodilator NTG is 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
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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
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Complications of MI Arrhythmia (dysrhythmia) Conduction blockages Heart failure Pulmonary edema Ventricular aneurysm Pericarditis
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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
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Aortic stenosis Most common valvular disorder in the elderly Usually due to calcification Risk factors:
Hyperlipidemia Diabetes Hypertension
Left ventricular hypertrophy Heart failure
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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
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Right sided versus left sided failure
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Neck vein distention
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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])
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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
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Formal evaluation What is your nursing
diagnosis for RB? What is your desired
outcome? What are appropriate
interventions pertinent to your desired outcome?