1. Chapter 20 Circulation

2. TERMS TO KNOW Arrhythmia: abnormal heart rate or rhythm
Atherosclerosis: hardening and narrowing of arteries due to plaque buildup in vessel walls
Physical deconditioning: decline in cardiovascular function due to physical inactivity
Homans’ sign: pain when the affected leg is dorsiflexed, usually associated with deep phlebitis of the leg
Hypertension: consistent blood pressure reading >140 mm Hg systolic and >90 mm Hg diastolic
Postural hypotension: decline in systolic blood pressure of 20 mm Hg or more after rising and standing for 1 minute

3. Introduction
Improved technology and increased public awareness resulted in decline in heart disease
Cardiovascular disease has become the major cause of disability and death in older population
Nursing interventions for prevention address potential problems related to circulation

4. Effects of Aging on Cardiovascular Health
Heart valves become thicker and rigid
Aorta becomes dilated
Slight ventricular hypertrophy
Thickening of left ventricular wall
Myocardial muscle less efficient
Decreased contractile strength
Decreased cardiac output when demands increased
Calcification, reduced elasticity of vessels
Less sensitive to baroreceptor regulation of blood pressure

5. Effects of Aging on Cardiovascular Health
Conditions altering tissue perfusion
Cardiovascular diseases
Diabetes, cancer, renal failure
Blood dyscrasias
Hypotension
Medication side effects
Other issues of concern

6. Question Is the following statement True or False?
Symptoms of age-related changes in the cardiovascular system become most apparent when the older adult is faced with unusual physiological stress.

7. Answer
True
Age-related changes in the cardiovascular system are typically gradual and become most apparent when the older adult is faced with unusual physiological stress, such as heightened activity or infection.

8. Cardiovascular Health Promotion
Alterations modified by lifestyle and diet
Identify and lower risks through education
Important practices: proper diet, exercise, no cigarette smoking, manage stress, and proactive interventions

9. Proper Nutrition Proper diet and weight Control of cholesterol
Reduced cardiovascular and cerebrovascular incidents
Nutritional supplements
Various diets
Lifestyle modifications

10. Adequate Exercise Exercise important for optimal health
Regular exercise versus spurts of activity
Physical deconditioning related to functional decline
Enhance circulation with aerobic exercise, yoga, strengthening exercises, balance exercises, t’ai chi

11. Question Is the following statement True or False?
Regular exercise can decrease or limit the age- related functional declines that aging people can experience.

12. Answer
True
Regular exercise has a positive impact on functional status of the older adult. Lack of physical exercise, known as physical deconditioning, can heighten many of the age- related functional declines that aging people can experience.

13. Cigarette Smoke Avoidance
Smokers aware of risks
Breaking habit difficult
Support and assistance needed for cessation
Keep trying after failure
Educate about limiting exposure to cigarette smoke

14. Stress Management Stress normal part of life
Educate regarding identification of stressors, reactions to stress, and effective management
Interventions for handling stress: relaxation exercises, yoga, meditation, and other stress-reducing activities

15. Proactive Interventions
Low-dose aspirin daily: preventive measure
Alcohol: light drinking may be beneficial
Nutritional supplements
Comprehensive assessment of the cardiovascular system includes C-reactive protein screening

16. Cardiovascular Disease and Women
Prevalence increases with age
Signs differ with women
Education regarding cardiovascular disease and promotion of cardiovascular health
Guide women about not ignoring symptoms

17. Selected Cardiovascular Conditions
Hypertension
Hypotension
Congestive heart failure
Pulmonary emboli
Coronary artery disease
Hyperlipidemia
Arrhythmias
Peripheral vascular disease

18. Hypertension Incidence and prevalence increases with age
Evaluation of blood pressure
Systolic blood pressure ≥ 140 mm Hg
Diastolic blood pressure ≥ 90 mm Hg
Factors to consider when monitoring blood pressure: anxiety, stress, and activity before assessment
Symptoms: dull headache, impaired memory, disorientation, confusion, epistaxis, and slow tremor
Wide range of treatment

19. Hypotension
Decline in systolic blood pressure of 20 mm Hg or more after changing positions
Postural and postprandial hypotension due to increased intake of vasoactive medications and baroreceptor sensitivity
Consequences: falls, stroke, syncope, other coronary complications

20. Question
Postural and postprandial hypotension is most often related to
Vasoactive medications and decreased baroreceptor activity
Antibiotics and increased cardiac output
Antispasmodic drugs and increased levels of potassium
Antibiotics and decreased renal function

21. Answer Vasoactive medications and decreased baroreceptor activity
Studies have shown that many older adults experience problems related to postural and postprandial hypotension due to the increased intake of vasoactive medications and concomitant decrease in physiologic function, such as baroreceptor activity.

22. Congestive Heart Failure
Incidence increases with age
Leading cause of hospitalization
Complication of arteriosclerotic heart disease
Coronary artery disease responsible for most cases
Symptoms: shortness of breath, dyspnea on exertion, confusion, insomnia, wandering at night, agitation, depression, orthopnea, wheezing, weight gain, and edema

23. Question
Which of the following breath sounds heard on auscultation would indicate an exacerbation of congestive heart failure?
a. Crackles
b. Vesicular
c. Bronchovesicular
d. Rhonchi

24. Answer
Crackles
Some of the symptoms of congestive heart failure in older patients include dyspnea on exertion, confusion, insomnia, weakness, shortness of breath, bilateral ankle edema, and moist crackles on auscultation.

25. Pulmonary Emboli Incidence high Detection and diagnosis challenging
Risk factors: fractures, congestive heart failure, arrhythmias, history of thrombosis, and immobilization
Signs/symptoms: confusion, apprehension, shortness of breath, temperature elevation, pneumonitis, and elevated sedimentation rate

26. Coronary Artery Disease
Ischemic heart disease
Prevalence increase with age
Angina
Atypical presentation: coughing, syncope, sweating, and confusion
Nitroglycerin effective
Education
Myocardial infarction
Atypical presentation: confusion, decreased blood pressure, shortness of breath, elevated temperature, and sedimentation rate

27. Hyperlipidemia
Risk of coronary artery disease with elevated total cholesterol
Evaluate full lipid profile, triglycerides, high- density lipoprotein, low-density lipoprotein
Familial tendency
Treatment: dietary changes, medications, and alternative and complementary therapies

28. Arrhythmias
Causes: digitalis toxicity, hypokalemia, acute infections, hemorrhage, anginal syndrome, and coronary insufficiency
Symptoms: weakness, fatigue, palpitations, confusion, dizziness, hypotension, bradycardia, and syncope
Treatment: antiarrhythmic drugs, digitalis, potassium supplements, and cardioversion
Education: modify diet, smoking cessation, decrease alcohol, and activity

29. Question Is the following statement True or False?
Hypokalemia, acute infections, hemorrhage, and coronary insufficiency are potential causes of arrhythmias in the older adult population.

30. Answer
True
In addition to digitalis toxicity as the most common cause or arrhythmia, hypokalemia, acute infections, hemorrhage, anginal syndrome, and coronary insufficiency are potential causes of arrhythmias in the older adult population.

31. Peripheral Vascular Disease
Arteriosclerosis: common especially among those with diabetes
Affects smaller vessels furthest from heart
Diagnosis: arteriography, radiography, and oscillometric testing
Treatment: warmth, exercises, and vasodilators

32. Special Problems Associated with Diabetes
High risk for peripheral vascular problems
Arterial insufficiency
Resting pain: intermittent claudication
Arterial pulses: absent or difficult to palpate
Skin discoloration, ulcerations, and gangrene
Diagnostic measures
Treatment selected per extent of disease

33. Aneurysms Advanced arteriosclerosis aids in development of aneurysms
Some seen, some palatable, and others detected by radiography
Thrombosis can develop
Various treatments

34. Varicose Veins Common problem Dilated, tortuous nature of vein
Dull pain, cramping, can interfere with sleep
Dizziness may occur
Susceptible to trauma and infection
Treatment aimed at reducing venous stasis

35. Venous Thromboembolism
Increased incidence
High risk: restricted to bed rest, recent surgery, and fractures
Edema, warmth over affected area, pain in foot, cyanosis, aching, and engorgement of superficial veins
Anticoagulants, surgery, elastic stockings, bandages, and elevation of extremities

36. General Nursing Considerations for Cardiovascular Conditions
Prevention
Keep the patient informed
Prevent complications
Promote circulation
Provide foot care
Manage problems associated with peripheral vascular disease
Promote normality
Integrate complementary therapies

37. Prevention
Incorporation of preventive measures of planning and caregiving
Education, counseling, coaching, rehabilitative/restorative activities enables prevention on three levels:
Primary
Secondary
Tertiary

38. Keeping the Patient Informed
Full explanations with reinforcement necessary for educating about diagnostic and treatment
Sensory deficits, anxiety, poor memory, and illness can affect comprehension
Opportunities to ask questions and discuss concerns

39. Preventing Complications
Edema can promote skin breakdown
Change position frequently
Proper alignment of body
Monitor conditions that increase chances of edema
Protect from skin breakdown
Monitor, observe, and document
Fluid balance
Assessment of vital signs
Careful administration of oxygen
Potential for anorexia
Potential for vagal stimulation

40. Promoting Circulation
Increased risk of altered tissue perfusion
Interventions that improve tissue circulation
Prevention of peripheral vascular problems
Education about appropriate health practices
Enhancement of circulation

41. Providing Foot Care
People with peripheral vascular disease must pay special attention to their feet
Bathe and inspect daily
Avoid injury
Prompt attention for any lesions
Potential for fungal infections
Interventions to prevent injury to feet

42. Question
Which of the following foot care interventions is essential to older adults who have peripheral vascular disease?
a. Daily inspection of the feet
b. Wearing tight-fitting shoes for comfort
c. Application of heat to areas of infection
d. Vaccination to prevent varicella zoster

43. Answer Daily inspection of the feet
Persons with peripheral vascular disease must pay special attention to the care of their feet, which should be bathed and inspected daily. To avoid injury, patients should not walk in bare feet and shoes should be large enough to avoid pressure and injury to the feet.

44. Managing Problems Associated with Peripheral Vascular Disease
Care of ischemic foot lesions
Medical and nursing management
Loss of a limb
Loss of independence
Altered body image

45. Promoting Normality
Consideration of impact of cardiovascular function on sexuality
Often subject of interest in sex not discussed with health care providers
Nursing interventions that include teaching
Relaxation and rest vital to treatment
Considerations of stressors

46. Integrating Complementary Therapies
Various herbs and spices considered for preventing and treating cardiovascular disorders
Some nonconventional measures
Meditation
Biofeedback
Guided imagery
T’ai chi
Yoga
Full benefit of complementary therapies is in process of discovery: less intrusive, less expensive, and minimal risks