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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?