1. Cardiovascular Disorders
Assessment and Management of Clients with Cardiovascular Disorders

2. Age-Related Changes of the Cardiovascular System
Heart disease is the leading cause of hospitalization and death
in the elderly.

3. Key Terms
Atherosclerosis — An arterial disease in which plaques form on the inner surfaces of the arteries, obstructing blood flow
Atrophy — A wasting away; a reduction in the size of a cell, tissue, organ, or part
Congestive Heart Failure (CHF) — A condition in which the heart cannot pump enough blood to the body’s other organs, characterized by shortness of breath, abnormal peripheral circulation, or both, depending on whether the heart failure is right-sided or general
Hypertrophy — The enlargement or overgrowth of an organ
Myocardium — The thick muscular wall of the heart
Pulmonary Embolism — A sudden blockage in a pulmonary artery due to a blood clot or embolism, preventing the exchange of oxygen and carbon dioxide and decreasing blood supply to the lung tissue itself
Sinus Node — A small mass of specialized cardiac muscle fibers in the wall of the right atrium of the heart that originate the regular electrical impulses that stimulate the heartbeat

4. Introduction
Although the size of the heart does not change with normal aging, several age-related changes in the cardiovascular system reduce the efficiency of the heart
Treatment of existing heart disease can causes significant changes in the structure of the heart muscle.
The myocardium may atrophy (shrink) or hypertrophy (enlarge).
Both changes are worsened by inactivity or disease processes, such as hypertension.
These conditions will progressively worsen with time.
Changes to the myocardium’s thickness and shape affect the function of the heart valves as well.

5. Normal Changes
Heart muscle slowly loses its efficiency and contractile strength decreased cardiac output
There is also a reduction in the number of pacemaker cells in the sinus node changes the electrical timing or rhythm of the heart.
These changes affect the time needed for the chambers of the heart to fill during diastole, the resting phase, and to eject blood during systole, the contracting phase.

6. Normal Changes
Prolonged cardiac cycle reduced exercise capacity. (many adults compensate by using the elevator instead of stairs)
Reduced heart rate ineffective response to stress and fever,
In general, the heart rate of an old person does not increase in response to stress and fever as in a young person.
Instead the older client’s heart is unable to meet the demands when there is a sudden physical exertion or emotional stress.
How does the heart compensate for the decreased cardiac output and contractility?

7. The heart increases blood pressure and heart rate.
The downside of this response is tachycardia which can lead to heart failure
The layers of the arteries age differently.
Tunica intima (innermost layer) undergoes most changes – Ca and Lipid build ups cause Atherosclerosis
The elastic fibers of the tunica media become thin and calcified making it stiffen.
Increased systolic pressure
Tunica adventitia is unaffected by the aging process

8. Loss of subcutaneous fat and vessel elasticity
Veins lose elasticity
Reduced activity leads to lessened pumping action of calf muscles
Veins dilate and blood pools in dependant areas.
This causes edema in legs and feet
Why do superficial vessels of the head, neck and extremities become more prominent?
Loss of subcutaneous fat and vessel elasticity
Blood flow to all organs decreases.

9. Assessing the Cardiovascular System

10. Key Terms
Carotid Pulse — Arterial pulse palpated over the carotid artery on the patient’s neck
Coronary arteries — Blood vessels that supply blood directly o the heart muscle
Cyanosis — Blue ,gray ,slate, or dark purple skin or mucous membrane discoloration caused by deoxygenated or reduced blood hemoglobin
Dorsalis pedis pulse - arterial pulse palpated n the dorsal aspect of the foot
Femoral Pulse — Arterial pulse palpated in the groin/ femoral artery
Mediastinum — A septum or cavity between two principal portions of an organ; the cavity between the two pleural sacs (and lungs)containing the heart, great vessels, trachea, bronchi, oesophagus, thymus gland, lymphnodes, nerves,and other tissues.
Murmur - an unusual heart sound, which may or may not be innocent or reflect disease

11. Pallor - lack of color or paleness
Popliteal Pulse — Arterial pulse palpated behind the knee over the popliteal artery
Posterior Tibial Pulse — Arterial pulse palpated behind the medial malleolus
Radial pulse- arterial pulse palpated in the thumb side of the wrist over the radial artery
Temporal Pulse — Arterial pulse palpated on either of the temporal areas of the head
Thrombophlebitis- inflammation of a vein in conjunction with the formation of thrombus (clot),, usually occuring in the extremity, most frequently the leg.

12. Subjective
Demographic data
Personal and Family History
Diet history
Socioeconomic status
Modifiable risk factors
Current health problems
Objective
General Appearance
Integumentary System
Blood Pressure
Venous & Arterial Pulsations

13. Assessment A complete set of vitals must be taken along with the exam.
Ensure client is relaxed
An uncomfortable and anxious client will have an elevated pulse rate which can lead to misinterpretations of findings
Use inspection and palpation simultaneously

14. Inspection
Begin the inspection with the resident in a supine position with his head slightly elevated.
The room should be well lit.
Visualize the anterior chest. There is a normal impulse discrete and localized over the apex of the heart that is easily visualized in older persons who are thin.
This is the Apical Pulse.
It is usually located in the left fifth inter-costal space in the mid-clavicular line.
On inspection of the periphery, look for cyanosis this implies diminished blood flow.
Pallor (pale skin)can be evidence of anemia.

15. The resident’s hands should be warm and dry.
Under stress, they may be cool and moist, and with cardiogenic shock cold and clammy.
Edema makes the skin tight whereas dehydration and aging create a loose feeling to the skin also called reduced skin turgor.
Inspect the lips and earlobes for cyanosis.
Many residents with heart disease have peripheral artery disease. Therefore, peripheral artery circulation and venous return should be assessed.
Those residents on bed rest or suffering from immobility are at high risk for thrombophlebitis,
So careful monitoring through inspection of skin color, skin temperature, and hair growth is essential.

16. Palpation Fluid Retention Dehydration
Palpate the apical pulse by using the palm of one hand.
Use two or three fingers to palpate the temporal, carotid radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses.
Note the quality of pulse feeling for a bounding, faint, or irregular pulse.
Palpate the resident’s skin temperature. Cool or cold extremities may be a sign of decreased circulation or absence of blood flow.
Palpate the skin for turgor and moisture.
Very tight skin
Very loose skin
Fluid Retention
Dehydration

17. Edema is common in the nursing home population as many are wheelchair bound causing dependent edema.
To assess edema, press index finger over the bony prominence of the tibia (lower leg) or the medial malleolus (ankle) for a few seconds.
Pitting edema is a depression that does not rapidly refill or resume its original contour.
Severity of edema is measured using a grading system (1+ through 4+) as follows:
1+ pitting edema is 2mm or slight pitting with rapid recovery.
2+ is 4mm pitting with recovery in 10 to 15 seconds.
3+ is 6mm of pitting lasting greater than one minute.
4+ is 8mm pitting lasting two to five minutes.

18. Always measure the severity of edema of both extremities.
If edema is unilateral, you must suspect occlusion of a major vein such as with deep vein thrombosis (DVT).
Different problems with circulation can have different causes.
With arterial (supply) disease, the feet may be cool or even bluish at the toes.
Any swelling indicates either local infection or possibly a venous (return) blockage, or dependent edema from gravity.

19. Auscultation
Closure of the heart valves creates heart sounds heard by auscultation.
Abnormalities of the heart valves causing them to be open when they should be closed gives rise to heart murmurs.
During auscultation, the room should be quiet and the resident in a sitting or supine position.
Using the diaphragm of the stethoscope, the examiner should listen at the left anterior chest for heart sounds.
Auscultate for rate and rhythm.

20. Irregular rhythms may be caused simply by breathing or may indicate a condition such as atrial fibrillation.
Each combination of S1 and S2 (“lub-dub”) counts for one heart beat.
You should follow a pattern when auscultating the left anterior chest starting just above the medial breast on a female and above and medial to the nipple on a male.
Move the stethoscope systemically in a counterclockwise motion listening at 11, 9, 7, and 4 o’clock.
The nurse must note extra heart sounds such as murmurs.

21. Murmurs are sustained swishing sounds heard between the two heart sounds.
Murmurs can be a sign of a chronic valvular heart disease or a newly found valve disorder.
If the murmur is a new finding, it should be reported to the health care provider for further evaluation.
Cardiovascular disease is the number one cause of death in the elderly patient.
Abnormal findings can be a sign of progression of chronic disease or lead to the diagnosis of a newly diagnosed cardiac disease.
Carefully document cardiac findings in the resident’s chart and report any new findings to the healthcare provider.

22. Cardiovascular Disorders
The nurse must know the signs and general treatment strategies for common vascular diseases, and be quickly able to assess and identify a need for urgent intervention.

23. Key Terms
Angiotension Converting Enzyme (ACE) Inhibitors — Drugs that inhibit angiotension I to angiotension II conversion, which results in falling bloodpressure; used to treat hypertension, heart failure, and other diseases
Acidosis — An actual or relative increase in the acidity of blood due to an accumulation of acids or an excessive loss of bicarbonate
Angina Pectoris — A feeling of tightness, squeezing, or pain in the chest occurring when the heart does not get enough oxygen-rich blood
Anti-platelets — A drug that destroys or inactivates platelets, preventing them from forming clots
Arrhythmias — A disturbance in or loss of regular heart rhythm; any variation from the normal rhythm of the heartbeat; an abnormality of the rate, regularity, or site of impulse origin or the sequence of activation
Atrial Fibrillation (AF) — A particular type of heartbeat (arrhythmia) characterized by an extremely fast irregular rhythm in which the heart quivers or fibrillates (beats faster and irregularly), with the atria contracting up to 500 times a minute, and the ventricles contracting up to 180 times

24. A1C (Hemoglobin A1C) — The main fraction of glycosylated hemoglobin (glycohemoglobin), which is hemoglobin to which glucose is bound; used to monitor the long-term control of diabetes mellitus
Beta Blockers — Any drug that inhibits the activity of the sympathetic nervous system and of adrenergic hormones; used to treat hypertension, angina, heart attack, glaucoma, and arrhythmias
B-type Natriuretic Peptide (BNP) — A specific chemical marker of heart failure; secreted by the heart at high levels when the heart is injured or overworked
Calcium Channel Blockers — Any of a group of drugs that slow the influx of calcium ions into smooth muscle cells, resulting in decreased arterial resistance and oxygen demand; used to treat angina, hypertension, vascular spasm, intracranial bleed, congestive heart failure, and tachycardia
Cardiomyopathy — A general diagnostic term designating a noninflammatory disease of the heart muscle, often of obscure or unknown etiology or the result of ischemic, hypertensive, congenital, valvular, or pericardial disease

25. Claudication — An aching, crampy, tired, and sometimes burning pain in the legs that comes and goes; typically occurs with walking and goes away with rest due to poor circulation of blood in the arteries of the legs
Congestive Heart Failure (CHF) — A clinical syndrome due to heart disease, characterized by shortness of breath, abnormal peripheral circulation, or both, depending on whether the heart failure is right-sided or general
Coronary Artery Disease (CAD) — Atherosclerosis of the coronary arteries, which may cause angina pectoris, myocardial infarction, and sudden death
Deep Vein Thrombosis (DVT) — Thrombosis or blood clot of one or more deep vein, usually of the lower limb, characterized by swelling, warmth, and redness; frequently a precursor of pulmonary embolism
Ejection Fraction — The percentage of the blood emptied from the ventricle during systole

26. Electrocardiogram (ECG/EKG) — A recording of the heart’s electrical activity taken by placing electrodes placed on the skin of the chest and connecting them in a specific order to a machine that measures electrical activity all over the heart
Electrical Cardioversion — The conversion of one cardiac rhythm or electrical pattern to another, almost always from an abnormal to a normal one by electrical cardioversion using a defibrillator
Hypertension — High arterial blood pressure, generally defined a 140 mm Hg diastolic or greater
Hypotension — Abnormally low blood pressure
Myocardial Infarction — Loss of living heart muscle as a result of coronary artery occlusion
Nitrates — A class of drugs that are arteriovenous dilators used to treat angina, hypertension, and congestive heart failure

27. Occlusion — Closure, obstruction, or prevention of passage
Orthostatic Hypotension (postural hypotension) — A fall in blood pressure associated with dizziness, blurred vision, and sometimes syncope, occurring upon standing or when standing motionless in a fixed position
Peripheral Artery Disease (PAD) — A form of peripheral vascular disease in which there is partial or total blockage of an artery, usually one leading to a leg or arm
Peripheral Vascular Disease (PVD) — Refers to diseases of the blood vessels (arteries and veins) located outside the heart and brain
Premature Ventricular Contractions (PVC)/(VPC) — An ectopic beat arising in the ventricles and stimulating the myocardium prematurely; may occur in normal hearts, but often is indicative of organic heart disease
Sinus Bradycardia (SB) — A slow sinus rhythm, with a heart rate of less than 60 beats per minute in an adult

28. Sinus Tachycardia (ST) — Increased sinus rhythm, with a heart rate of greater than 100 beats per minute in an adult
Syncope — Partial or complete loss of consciousness with interruption of awareness of oneself and ones surroundings
Venous Insufficiency — A condition in which the veins fail to return blood efficiently to the heart; symptoms include swelling of the legs and pain in the extremities, such as a dull aching, heaviness, or cramping
Ventricular Tachycardia (VT or V tach) — A condition in which the heart beats too fast and its contractions start in the wrong part of the heart

29. Coronary Artery Disease
Coronary artery disease (CAD) is a disorder in which one or more coronary arteries are narrowed by plaques.
Unavoidable risk factors include age, sex, and family history.
In men, the incidence of CAD steadily increases with age. In women, the incidence increases sharply after menopause.
Risk factors that can be controlled include:
Elevated Cholesterol
Elevated Blood Pressure
Diabetes
Cigarette Smoking
Physical Inactivity
Obesity.

30. Blood pressure should be less than 140/90 except for diabetics who should have a blood pressure 130/80 or less.
Diabetes must be kept under tight control with goal hemoglobin A1C (HgbA1C) of 7.0.
Cigarette smoking should be strongly discouraged. Even the elderly will improve their cardiac risk from smoking cessation.
The elderly person will also benefit from physical activity, which in turn will improve body weight.
The elderly with CAD often display different kinds of symptoms than the younger adult.
You, as a nurse, should report any symptoms you discover.
Remember, the incidence of sudden cardiac death increases with age.

31. Symptoms Chest discomfort Arm pain Jaw pain
Abdominal pain with or without nausea.
Pale gray or blue skin color (cyanosis)
Swelling in the legs, abdomen or areas around the eyes
Swelling in the hands, ankles or feet
Confusion
Shortness of breath
Palpitations /fluttering in the chest
Worsening fatigue
Lightheadedness/Dizziness
Tachycardia
Bradycardia
Coldness in legs or arms

32. Coronary Artery Disease
Coronary arteries become narrow or even blocked secondary to plaque deposits.
These are the arteries that deliver oxygen enriched blood to the heart muscle (myocardium)
If there is a complete block (occlusion) then a heart attack (myocardial infarction) occurs.

34. Pathophysiology Plaque may rupture
Fatty streaks-earliest lesion lipid filled smooth muscle cells. Yellow tinge appears.
Raised fibrous plaque resulting from smooth muscle cell proliferation
Complicated lesion-is most dangerous plaque consists of core of lipid materials (mainly cholesterol) with an area of dead tissue. Partially or totally occlude an artery.
Plaque may rupture

35. Family history of cardiovascular disease
Risk Factors
Family history of cardiovascular disease
High levels of LDL (bad) cholesterol and triglycerides
Low levels of HDL (good) cholesterol
Uncontrolled high blood pressure (even in the teenage years)
Smoking
Lack of regular exercise
High-fat diet
Overweight or obesity
Uncontrolled diabetes
Chronic stress or depression
Age->65
Gender –middle aged Caucasian male
Race-Caucasian
Genetic inheritance-mechanism of inheritance not fully understood defects in coronary walls predispose to plaque formation.

36. Clinical Manifestations
Symptoms typically associated with CAD include chest pain (angina) and shortness of breath, especially after stress or exercise. Women with CAD may experience breast pain or a feeling of indigestion in the upper abdomen.
However, about 25 to 30 percent of patients have no symptoms, despite the presence of CAD. They may have silent ischemia, or be unaware of potentially dangerous abnormal heart rhythms (arrhythmias).
The absence of chest pain or other common symptoms can also set the stage for a heart attack that occurs without warning.

37. Therapeutic Management
Angioplasty

38. Therapeutic Management
                                                   

39. Drugs ASA-inhibits platelet aggregation
Nitrates-decrease SVR,venous pooling and decrease venous return to the heart and dilate coronary arteries.
Beta adrenergic blockers-decrease myocardial contractility, HR, BP which decrease myocardial O2 demand.
Antiplatelet aggregation
-ASA, Persantine(dipyridamole)
Nitrates(vasodilate) first line therapy
-nitroglycerin
Beta-Adrenergic blocking agents
-lopressor, inderal (Generics ending in olol)
Calcium Channel blocking agents
-nifedipine, Cardizem, verapamil

40. Angina pectoris
Angina pectoris is a pressure sensation in the anterior chest, upper back, neck or left arm.
The discomfort can be intense or dull, may radiate as high as the jaw or down the left side or right arm.
It usually comes on after strenuous physical activity or eating and frequently during intense cold.
Relief may occur in minutes if the activity is stopped. Angina that occurs at rest is called unstable angina.

41. Take med and wait 30min to 1 hr before engaging in activity.
Stable Angina
Exercise induced.
Take med and wait 30min to 1 hr before engaging in activity.
Unstable Angina
Unpredictable, can occur at rest
ASA, anticoagulants, nitrates and beta blockers first line of treatment.

42. Myocardial infarction (MI)
Myocardial infarction (MI) is death of cardiac tissue.
MI usually results from sudden reduction in blood flow to the heart muscle (myocardium).
The resident may complain of any or all of the following:
chest pain
shortness of breath
confusion
gastrointestinal symptoms (nausea, vomiting, heartburn, indigestion).
The elderly resident tends to withhold complaints until symptoms become severe and are more likely to die with a MI.

43. The older person requires ongoing management and monitoring.
All individuals, young and old, benefit from intensive treatment initiated immediately following symptom onset.
The older person requires ongoing management and monitoring.
Prevention and treatment focuses on modifying risk factors.
Blood pressure and blood sugars should be monitored and controlled.
The treatment of elevated cholesterol in the elderly is controversial due to the uncertainty of true benefit.
The treatment of cholesterol in most adults has proven to significantly lower risk of MI.

44. The patient must be encouraged to participate in regular physical activity when possible and try to maintain an ideal body weight.
Treatment of CAD in the elderly resident is generally more complex than treatment of the younger adult.
Decisions involve considering many factors in addition to age.
Individual treatment plans must consider overall health, lifestyle, and expectations.
Often cardiac surgeries cannot prolong life but may improve quality.
No invasive procedure is without risk.

45. The elderly are more prone to complications and longer hospital stays.
In most cases, long-term care residents elect to be treated more conservatively with medications.
Medications often used to treat heart disease include beta-blockers, aspirin, ACE inhibitors, nitrates, anti-platelets, cholesterol-lowering agents, and calcium channel blockers.
The elderly are more likely to experience side effects from many drugs. Dosing of these drugs requires adjustments that are more delicate.

46. Common side effects of drug therapy include :-
Lightheadedness,
Fatigue,
Low blood pressure,
Headache,
Flushing,
Muscle pain,
Abnormal liver function
Abnormal kidney function.

47. Nursing interventions include assisting the resident with risk factor modification such as smoking cessation, and monitoring for the obvious or subtle signs of heart disease.
Checking vital signs is critical in identifying slowed or elevated heart rate, weak pulse or elevated blood pressure.
Communication with the provider is imperative if any of these abnormalities are noted to speed the necessary medical treatment for the residents.

48. Interventions for CVD Education/teaching life-style changes/diet
Monitor s/sx of CHF
Monitor fluid intake/output/diet
Monitor weight daily/biweekly/weekly
Ausculate heart & lung sounds
Monitor lab values
Cardiac rehab programs
Provide comfort measures- in end-of life care if palliative/hospice care is indicated
Monitor risk for exercise related orthostatic hypotension r/t ↓in baroreceptor responsiveness
Exercise in climate controlled environment
Alter lifestyle – smoking, diet, emotions

49. Laboratory Tests * Serum markers of myocardial damage:
Creatinine kinase
Troponin
Lactate dehydrogenase
* Serum lipids
* Homocysteine
C-reactive protein
BNP
*Blood Coagulation Tests
- Prothrombin and international normalized ratio (PT and INR)
- Partial Thromboplastin Time (PTT)
*Arterial Blood Gases
*Serum electrolytes
*Complete Blood Count

50. Radiographic Exams
*Chest X-ray
*Cardiac Fluoroscopy
*Angiography
*Cardiac Catheterization
Electrophysiologic Studies
*Exercise Electrocardiography (Stress test)
*Echocardiography

51. Congestive heart failure (CHF)
Congestive heart failure (CHF) is a disorder of fluid overload

52. Risk Factors
Conditions that could lead to heart failure include the following:
Coronary artery disease
High blood pressure (hypertension)
Heart attack
Diabetes mellitus
Cardiomyopathy
Heart valve disease (e.g., valvular stenosis or valvular regurgitation)
Infection in the heart valves (valvular endocarditis) or of the heart muscle (myocarditis)
Congenital heart disease (cardiac conditions present since birth)
Severe lung disease (e.g., pulmonary hypertension) or obstructive sleep apnea
Pericardial disease (pericarditis)
CHF is a condition in which the heart can’t pump enough blood to the body’s other organs.

53. Types of Heart Failure
Right-sided heart failure (cor pulmonale) takes place when the right ventricle is not pumping adequately, which tends to cause fluid build-up in the veins and swelling (edema) in the legs and ankles. Right-sided heart failure usually occurs as a direct result of left-sided heart failure. It can also be caused by severe lung disease (e.g., chronic obstructive pulmonary disease, pulmonary hypertension) in which the right side of the heart cannot generate enough force to pump blood through a diseased pair of lungs.
Left-sided heart failure occurs when the left ventricle cannot adequately pump oxygen-rich blood from the heart to the rest of the body.
The main symptoms for this condition include shortness of breath, fatigue and coughing, especially at night or while lying down. There may also be lung congestion (with both blood and fluid).

54. Congestive heart failure can affect many organs of the body.
For example
The weakened of heart muscle may not be able to supply enough blood to the kidneys, which then can cause the body to hold more fluid.
The lungs may be solid with fluid (pulmonary edema) and someone’s ability to exercise is reduced.
Fluid may also accumulate in the liver, thus disturbing its ability to eliminate toxins from the body and produce essential proteins.
The intestines may become less efficient in absorbing nutrients and drugs.
In the long time period and if it’s untreated, worsening congestive heart failure will affect nearly every organ in the body.

55. Signs & Symptoms
Signs of heart failure include shortness of breath, pulmonary edema (back up of fluid in the lungs), fatigue, edema, and tachycardia.
In the elderly, other symptoms may be present, such as sleepiness, confusion, weakness, or loss of appetite. Lower extremity edema is a common symptom of CHF, but is not caused solely by heart failure.
Shortness of breath one to two hours after lying down is suggestive of heart failure.
Any or all of the symptoms above must be reported as further diagnostic testing will likely be performed.

57. Over 75 percent of heart failure in the elderly is related to Cardiomyopathy caused by hypertension or coronary artery disease
Cardiomyopathy refers to the dysfunction of the lower chambers of the heart (ventricles).
This dysfunction causes an inability of the heart to effectively pump blood, oxygen, and nutrients to the organs of the body.
Valvular heart disorders, coronary artery disease, hypertension, viral infection, alcoholism, drugs, toxic agents, and other causes may all produce cardiomyopathy.

58. Left-sided Cardiac Failure
Left ventricle unable pump blood that enters it from the lungs
Characteristics
Dyspnea
Moist sounding cough
Fatigue
Tachycardia
Restlessness
Anxiety

59. Right-sided Cardiac Failure
Right side of heart cannot empty all of blood received from venous circulation
Characteristics
Edema of lower extremities (pitting edema)
Weight gain
Enlargement of liver (hepatomegaly)
Distended neck veins
Ascites
Anorexia
Nocturia
Weakness

60. Prevention
Prevention of cardiomyopathy is aimed at avoidance of toxins that can lead to cardiomyopathy, including alcohol and tobacco.
In addition, cardiomyopathy can be prevented by aggressive, early treatment of hypertension
Prevention of coronary artery disease with aggressive treatment of hyperlipidaemia, diabetes, obesity, and tobacco avoidance.

61. Be Aware
Normal and pathological aging changes may often make the early assessment and treatment of CHF difficult. For example, pedal edema or weight gain of CHF may be confused with normal pedal edema that occurs with aging or the side effects of steroid treatment for COPD. Other symptoms such as chest pain or tightness, fatigue, general weakness, a nonproductive cough, insomnia, and other may be commonly attributable to other conditions of aging and orthopnea.

62. Treatment & Nursing Management
Before treatment, the presence of CHF will be confirmed through testing.
Such tests include blood tests, chest x-ray and 12-leadechocardiogram. Transthoracic Echocardiogram, Doppler flow studies, MRI
Laboratory evaluation may include B-type natriuretic peptide (BNP).
BNP is a specific marker of heart failure.
Treatment of heart failure is aimed at reducing symptoms as well as trying to prevent progression of disease.
Treat high blood pressure,
Identify and treat coronary artery disease
Encourage cessation of alcohol and tobacco
Treatment can improve CHF and potentially improve the pumping power of the heart.

63. Therapeutic Management: Chronic CHF
O l/min
Rest
Digitalis preparations
Diuretics
Vasodilators-Ace inhibitors, Nitrates,nesiritide(natrecor)
Inotropic drugs- dopamine, dobutrex, inocor
Daily weights
Sodium restricted diets
Intraaortic balloon pump
Ventricular assist device
Cardiac transplant

64. Therapeutic Management
ACUTE WITH PULMONARY EDEMA
High Fowler’s position
O2 with mask or nasal cannula
Morphine IV
Diuretics IV(Lasix, Bumex)
Nitroglycerin,nitroprusside
Dopamine, dobutrex
V/S hrly
Daily weights
Endotracheal intubation/mechanical ventilation

66. Nursing Diagnosis
Impaired gas exchange r/t inadequate cardiac pump function
Decreased cardiac output r/t a reduction in stroke volume
Activity tolerance r/t an imbalance between oxygen demand and supply

67. Commonly Drugs Used To Treat Heart Failure
Beta-blockers
Diuretics
ACE-inhibitors
Digitalis
Nitrates
The drugs used to treat cardiomyopathy and heart failure are the same as those used to treat coronary heart disease.
There are significant side effects to all of the cardiac medications.

68. The use of diuretics can result in worsening kidney function.
The use of ACE inhibitors can result in elevation of serum potassium levels.
Residents with heart failure are often on both diuretics and ACE inhibitors.
Therefore not requiring potassium supplementation at times.
Blood monitoring will determine the need for electrolyte replacement.
Routine monitoring of kidney function and potassium levels is recommended.

69. Nursing interventions include dietary modifications and fluid restrictions.
No added salt (NAS) diets and restriction of fluids can help to reduce fluid retention and heart failure.
Daily weights are key in early identification and treatment of fluid accumulation.
Encouragement of light to moderate physical activity is beneficial for the resident with CHF.
Residents with CHF will benefit from yearly influenza vaccines and should receive the Pneumovax® vaccine.

70. Hypertension is defined as a systolic blood pressure greater than 140mmHg or diastolic blood pressure greater than 90mmHg in the young or elderly.
Hypertension

71. Over 50 percent of Americans over the age of 65 have hypertension.
The higher the systolic or diastolic blood pressures, the higher the risk for disease and death.
Also known as the “silent killer,” hypertension is often asymptomatic and therefore easily ignored.
Headache, bloody nose, and ringing in the ears may be caused by hypertension.

72. Risk Factors Age-65 and older Sex- men young adulthood and middle age
Race - African Americans
Obesity
Cigarette Smoking
Excess Sodium Intake
Elevated Serum Lipids
Sedentary Lifestyle
Diabetes Mellitus
Socioeconomic Status
Stress

74. Sudden onset of severe headache with hypertension could be a symptom of bleeding in the brain and warrants immediate communication with the provider.
Hypertension results in increased oxygen demand on the heart and may in turn cause chest pain and an enlarged heart or cardiomyopathy.

75. Clinical Manifestations
“Silent Killer” –asymptomatic
Secondary symptoms-fatigue, reduced activity tolerance, dizziness, palpitations, angina, and dyspnea.
Nosebleeds,Headache and dizziness= in hypertension and general population.

76. Prevention & Treatment
Prevention is aimed at
Weight control
Daily physical activity
Limiting sodium intake
Limiting caffeine intake
The treatment is with drugs
Beta-blockers,
Ace-inhibitors,
Angiotensin converting agents,
Calcium channel blockers,
Diuretics,
Nitrates,
Alpha-blockers, and
Central acting agents.

77. Side effects of Drug Therapy
Side effects include
Lightheadedness
Dizziness,
Fainting
Dehydration
Slowed heart rate

78. Nursing Interventions include regularly monitoring vital signs and assisting with life-style changes even within the LTC setting.
Limiting alcohol
Limiting sodium intake
Regular exercise
Smoking cessation
Dietary intake or supplementation with calcium and magnesium helps
All hypertensive residents should continue treatment after blood pressure is controlled because blood pressure is likely to increase if treatment is discontinued.

79. Nursing Management Nursing Diagnosis:
Risk for ineffective therapeutic management r/t non compliance with treatment
Knowledge Deficit r/t information misinterpretation

80. Therapeutic Management
The ultimate goal of antihypertensive therapy is to reduce cardiovascular and renal morbidity and mortality.
Lifestyle modifications
Weight reduction
Healthy diets

81. Lifestyle modifications

85. Reduce Stress !!!

86. Untreated Hypertension

87. Benefits of Smoke Cessation
20 minutes- after quitting the BP and pulse decrease and body temp of feet and hands increase.
At 6 hours- the Carbon Monoxide and Oxygen levels return to normal.
At 24 hours- the chances of heart attack decreases.
Within 3 months- circulation improves, walking is easier and lung function improves.
At 1 year- the ex-smokers risk of CHD is decreased to ½ that of a smoker.
By 15 years- the risk of CAD is then similar to that of a person who has never smoked.

88. Do it Yourself! Study the definition, Causes Risk factors
Clinical manifestations
Treatment and management
Prevention
Investigations
Peripheral Vascular Disease
Varicose Veins
Deep Vein Thrombosis
Arrhythmias

90. Watch this video 2!!!