Physiological basis of the care of the elderly client Cardiovascular System 1

Patient scenario 2  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 3 What additional information do you need?  Subjective information  Objective information  Psychosocial information

The cardiovascular system 4  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

Review of cardiac structure and function 5  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

Potential challenges for the elderly client 6 ElectricalForceValves Coordi- nation

Preload and afterload 7  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)

Regulation of cardiac function 8 Preload Contractility Afterload

Left ventricle efficiency 9  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 10  Normal PR = (3-5 □ s )  Normal QRS = <.12 (3 □ s)  Normal sinus rhythm  Each P wave followed by QRS  Rate 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 11  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

Resulting systemic effects 12  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… 13  Remain physically active—30 minutes aerobic activity per day most days of the week  Avoid obesity—maintain normal BMI between  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 14  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

Heart disease in elderly women 15 Symptoms 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

Hypertension 16  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

Classifications of blood pressure 17 Optimal: <120/<80 Screen every 2 years Prehypertension: /80-89 Assess annually Stage 1 HTN: /90-99 Assess more frequently Stage 2 HTN: ≥160 OR ≥100 Assess more frequently

JNC 8 (2014) Guidelines 18  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  /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

JNC 8 Hypertension Management 19  Lifestyle interventions apply throughout all treatment recommendations  Blood pressure goals and medication treatment based on  Age  Diabetes  Chronic kidney disease

JNC 8 HTN Management Algorithm: Age ≥60 yearsNo diabetes No CKD 20 Goal SBP <150 mm Hg Goal DBP <90 mm Hg

JNC 8 HTN Management Algorithm: Age <60 yearsNo diabetes No CKD 21 Goal SBP < 140 mm Hg Goal DBP < 90 mm Hg

JNC 8 HTN Management Algorithm: All agesWith diabetes No CKD 22 Goal SBP < 140 mm Hg Goal DBP < 90 mm Hg

JNC 8 HTN Management Algorithm: All ages with CKD 23 Goal SBP < 140 mm Hg Goal DBP < 90 mm Hg

JNC 8 HTN Treatment Guidelines 24 Black No CKD Thiazide-type diuretic, or, CCB, or, Combination Non-Black No CKD Thiazide-type diuretic, or, ACEI, or, ARB, or, CCB, or, Combination All Races CKD ACEI, or, ARB, or, Combination with other class

“Instant” teaching points regarding HTN 25  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 26  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

Nursing management—patients with HTN 27  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

Nursing management—patients with HTN 28  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

Medication management of hypertension 29  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

Hypotension 30  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 31  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

Benefits of the “statins” 32  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”) 33 >100mg/dl (fasting) >150 mg/dl > 135/80Men > 40” Women > 35” Waist Circ. BP BGTG

Characteristics of metabolic syndrome 34  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 35  Cholesterol lowering drugs  Antihypertensives  Diet high in omega-3 fatty acids  Avoid processed foods  Exercise minutes moderate intensity

Ischemic heart disease in the elderly 36  Chest pain is not always present  Fatigue  Weakness  Shortness of breath  GI disturbances

Chest pain 37  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 38  Pericarditis  Heartburn, ulcers  Chondritis  Pulmonary embolus, pneumonia  Herpes zoster

Treatment of angina 39  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

Myocardial infarction findings 40  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

Complications of MI 41  Arrhythmia (dysrhythmia)  Conduction blockages  Heart failure  Pulmonary edema  Ventricular aneurysm  Pericarditis

Anticoagulation treatment of MI 42  Useful within first few hours of event  Chew an aspirin while waiting for ambulance!  Not all patients are candidates for thrombolytic therapy

Aortic stenosis 43  Most common valvular disorder in the elderly  Usually due to calcification  Risk factors:  Hyperlipidemia  Diabetes  Hypertension  Left ventricular hypertrophy  Heart failure

Heart failure 44  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 45

Neck vein distention 46

Dysrhythmias (not “arrhythmias!”) 47  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 48  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 49  What is your nursing diagnosis for RB?  What is your desired outcome?  What are appropriate interventions pertinent to your desired outcome?