Chapter 13: Management of Common Illnesses, Disease, and Health Conditions: CV and Resp.

1. Chapter 13: Management of Common Illnesses, Disease, and Health Conditions:CV and Resp. Bonnie M. Wivell, MS, RN, CNS

2. Statistics 27 million Americans age 65 or older have some form of CVD 32% of all deaths in 2008 were attributed to CVD (AHA, 2008) Major diseases (AHA, 2005): Hypertension CHD MI Angina CHF Stroke

3. Hypertension: Background 65 million Americans have HTN In 2004, 63.6% of men and 73.9 % of women ages 65–74 were diagnosed with HTN Of those age 75 or older, 69.5% of men and 83.8% of women had HTN African American males have highest incidence Have a 1.8 times greater risk than whites of having a fatal stroke, and a 4.2 times greater chance of developing end stage renal disease (AHA, 2008) Number one risk factor for stroke Significant cause of ESRD Goal: 120/80 or less consistently – ideal BP determined with physician

4. Hypertension: Risk Factors Heredity Race (African American) Increased age Sedentary lifestyle Obesity Male gender High sodium intake Excessive alcohol intake Diabetes or renal disease Pregnancy Oral contraceptives or other meds

5. Hypertension: Control Limit alcohol intake to one drink per day Limit sodium intake Stop smoking Maintain a low fat diet that still contains adequate vitamins and minerals through adding leafy green vegetables and fruits Exercise Weight management Regular BP checks Take meds as directed

6. Coronary Heart Disease (CHD): Background Also called CAD or ischemic heart disease Atherosclerosis resulting in an impaired blood supply to the myocardium Older females after menopause are more than twice as likely to have CHD than those before menopause Over 82% of people who die with CHD are age 65 years and over (AHA, 2008) Myocardial infarction and angina are two results of CHD

7. Angina: Background Chest pain caused by lack of oxygen to heart muscle Higher incidence in females, Mexican American males and females, and African American females Stable – managed with meds and lifestyle changes Unstable – usually requires hospitalization Related to exercise or stress and is relieved with rest and NTG Symptoms in elderly: Dizziness Dyspnea Confusion Chest pain

8. Angina: Control Teaching patients and families: Weight management Stress management Limiting caffeine Smoking cessation Regular exercise Control of hypertension Medical management of any co-existing endocrine disorder (such as hyperthyroidism)

9. Angina: Medications Beta blockers and calcium channel blockers are often prescribed to decrease the oxygen demand on the heart Side effects Fatigue Drowsiness Dizziness Slow heart rate

10. MI: Background 365,000 new and 300,000 recurrent heart attacks each year In the USA Risk increases with age Men more at risk until age 70 then risk equalizes Average age for a person’s first MI of 65.8 for men and 70.4 for women (AHA, 2005)

11. MI: Risk factors Hypertension Race (especially African American males with HTN) High fat diet Sedentary lifestyle Diabetes Obesity High cholesterol Family history Cigarette smoking Excessive alcohol intake Stress

12. MI: Warning signs Chest pain appearing as tightness, fullness, or pressure Pain radiating to arms Unexplained numbness in arms, neck, or back Shortness of breath with or without activity Sweating Nausea Pallor Dizziness Unexplained jaw pain* Indigestion or epigastric discomfort, especially when not relieved with antacids* *(of particular significance in the elderly)

13. MI: Treatment Antithrombolytics if given early decreases morbidity and mortality Rest MONA (Morphine, Oxygen, NTG q 5 mins x 3, ASA chew, if not contraindicated) ECG Angiogram and/or Cardiac Cath Angioplasty CABG Medications Beta blockers, ACE inhibitors, Antihypertensives

14. MI: Patient Education Exercise regularly Do not smoke Eat a balanced diet with plenty of fruits and vegetables; avoid foods high in saturated fats Maintain a healthy weight Manage stress appropriately Control existing diabetes by maintaining healthy blood sugars and taking medications as prescribed

15. MI: Patient Education (cont’d) Limit alcohol intake to 1 drink per day for women and 2 drinks per day (or less) for men Visit the doctor regularly After a heart attack, participate fully in a cardiac rehabilitation program Involve the entire family in heart-healthy lifestyle modifications Report any signs of chest pain immediately Be involved in and buy into the prescribed medication regimen

16. Congestive Heart Failure (CHF): Background Incidence varies by age, gender, and races Lifetime risk for persons is 1 in 5 The risk in older adults doubles for those with blood pressures over 160/90 75% of those with CHF also have HTN The major risk factors are diabetes and MI Often occurs within 6 years after an MI

17. CHF: Signs and Symptoms Shortness of breath Edema Coughing or wheezing Fatigue Lack of appetite or nausea Confusion Increased heart rate Older adults: decreased appetite, weight gain, insomnia

18. CHF: Treatment Check O2 saturation - less than 90% requires intervention Daily weight at same time, clothes, scale Threshold wt. gain between 1 and 3 pounds Potential medications: ACE inhibitors, diuretics, vasodilators, beta blockers, blood thinners, angiotensin II blockers, calcium channel blockers, potassium Digoxin rarely used any more

19. CHF: Patient Education Teach lifestyle modifications as discussed for promoting a healthy heart Limit or eliminate alcohol use Maintain a healthy weight Stop smoking (no tobacco use in any form) Limit sodium intake to 2 – 3 g per day Take medications as ordered – do not skip doses Exercise to tolerance level Alternate rest and activity – learn energy conservation techniques

20. Stroke and TIAs: Background Cerebrovascular accident (CVA) Interruption of blood supply to the brain that may result in devastating neurological damage, disability, or death Transient ischemic attack (TIA) Symptoms similar to stroke but go away with in minutes to 24 hours and leave no residual effects 780,000 new or recurrent strokes per year Third leading cause of death in US 10% of all strokes are preceded by a TIA CVA is the #1 diagnosis for hospital discharge to LTCF 2/3 happen to those over 65 years of age

21. Types of Stroke • Ischemic (86%) • Thrombotic: occurs when a blood clot forms in an artery that supplies the brain, causing tissue death (carotid artery stenosis); develops over time • Embolotic: occurs suddenly when a blood clot (embolism) forms in one part of the body, travels through the bloodstream, and lodges in and obstructs a blood vessel in the brain • Hemorrhagic

24. Stroke and TIAs: Risk Factors • Controllable • HTN #1 • High Cholesterol • Heart Disease • Smoking (quit and risk equalizes after 5 years) • Obesity • Stress • DM • Depression • A Fib • Uncontrollable • Age • Gender (males > females until menopause) • Race (AA > White) • Heredity

25. Stroke and TIAs: Warning Signs • Sudden numbness or weakness of face, arm, or leg, especially on one side of the body • Sudden confusion; trouble speaking or understanding • Sudden blurred or decreased vision in one or both eyes • Sudden trouble walking, dizziness, loss of balance or coordination • Sudden severe, unexplainable headache -- often described as “the worst headache of my life” (more common with hemorrhagic)

26. 3 Easy Assessment Signs Facial droop Motor weakness Language difficulties

27. Stroke: Treatment H & P, esp. neuro exam Vital signs ECG, CXR, CBC, PT, PTT, Lytes, Glucose Diagnostic testing: CT scan and/or MRI Arteriography US of carotids

28. Stroke: Acute Management Determine cause/type of stroke Hemorrhagic → surgery to evacuate blood Ischemic → t-PA (tissue plasminogen activator): Gold standard Must be given within 3 hours after the onset of stroke symptoms Some patients will not be candidates May reduce or eliminate symptoms in over 40% of pts who receive it within time frame

29. Stroke: Acute treatment Manage hypertension, hyperthermia, and hyperglycemia To prevent recurrence: Medications ASA Ticlid Plavix Persantine Heparin Coumadin Lovenox

30. Effects of Stroke Effects and degree of recovery vary Hemiplegia Hemiparesis Visual /perceptual deficits Language deficits Emotional changes Swallowing dysfunction Bowel/bladder problems

31. Stroke: Rehabilitation Maximize function Prevent complications Promote QOL Encourage adaptation Enhance independence Emphasize abilities NOT disabilities

32. Stroke: Mauk Model

34. Stroke: Patient Education PREVENTION is KEY Know the warning signs of stroke Call 911 if experiencing warning signs TIA is a warning sign Manage high blood pressure Take medication as scheduled Visit the doctor regularly

35. Peripheral Vascular Disease: Background Peripheral artery disease (PAD) is most common type of PVD Affects 8 – 12 million Americans, 12 – 20% of those over the age of 65

36. PVD: Risk Factors/Symptoms Same as those for CHD Diabetes and smoking are the greatest risk factors (AHA, 2005) More at risk of MI or CVA Symptoms: Leg cramps with activity but alleviated at rest (intermittent claudication) None

37. PVD: Treatment Heart healthy lifestyle and modifications as those discussed previously with CAD Left untreated can lead to decreased quality of life Sometimes results in gangrene and amputation

38. Respiratory Pneumonia COPDs Chronic bronchitis Emphysema TB Lung cancer

39. Pneumonia: Background Leading cause of death among the elderly Those over age 65 have 5 – 10 times the risk of death from pneumonia than young adults Causes: bacterial, viral, aspiration More at risk if COPD, CHF, or immune-suppressing disease

40. Pneumonia: Signs/Symptoms Viral (less severe) Fever, non-productive hacking cough, muscle pain (chest), weakness, shortness of breath, anxiety, crackles in lungs Bacterial (sudden or gradual onset) Chills, chest pain, sweating, productive cough, or dyspnea Older adults may not present with these typical symptoms Confusion, disorientation, or delirium in the elderly

41. Pneumonia: Treatment CXR CBC Sputum culture to determine type and causal agent H&P Viral – no tx; self-limiting Bacterial – antibiotics

42. Pneumonia: Treatment (cont’d) • Hydration, rest • Tylenol/ASA if not contraindicated • Monitor for worsening of symptoms • Hospitalization often required in frail elderly • Vaccines recommended • Pneumonia once in life time • Flu annually

43. COPDs: Background Obstructed airflow Emphysema and chronic bronchitis Fourth leading cause of death in the US 118,000 deaths in 2004 Nearly 24 million American adults have some type of impaired lung function Slightly more females than males are affected Female smokers have a 13 times greater chance of death from COPD than nonsmoking females

44. COPDs: Risk Factors Smoking – 80-90% of COPD deaths Air pollution Second-hand smoke Heredity History of respiratory infections Industrial pollutants Environmental pollutants Excessive alcohol consumption Genetic component (alpha1-antitrypsin deficiency)

45. Chronic Bronchitis 8.5 million Americans diagnosed as of 2005 Females 2x more likely than males Recurrent inflammation and mucus production produces blockage and eventual scarring that restricts airflow S/S: Increased mucus production, shortness of breath, wheezing, decreased breath sounds, and chronic productive cough Can lead to emphysema

46. Emphysema Alveoli are irreversibly destroyed; lungs lose elasticity, air comes trapped in alveolar sacs resulting in CO2 retention and impaired gas exchange Nearly 4 millions Americans have it Males more than females S/S: Shortness of breath, decreased exercise tolerance, and cough Diagnosed: PFTs and H&P

47. COPDs: Treatment Control symptoms and minimize complications Lifestyle modifications Stop smoking Respiratory therapy Medications Pulmonary rehabilitation Oxygen therapy required as disease progresses

48. COPDs: Patient Education Involve the family and plan for long term Lifestyle modifications – reduce factors that contribute to symptoms Appropriate use of meds Alternating rest and activity (energy conservation) Stress management Relaxation Supplemental oxygen Work with respiratory therapist and physician on home maintenance program

49. Tuberculosis: Background • Infection that can attack any part of body but targets lungs and is spread through air droplets • Number of cases in US steadily decreasing over last 10 years • Asian Americans, Pacific Islanders, African Americans, American Indians, Hispanics, Whites • 8 times greater incidence in non-US born • Spread common in less developed countries related to immune suppression associated with AIDS • Nursing home residents at risk – TB testing prior to admission

50. Tuberculosis: Signs and Symptoms • Severe cough lasting more than 2 weeks • Chest pain • Bloody sputum • Weakness • Fatigue • Weight loss • Chills, fever, night sweats (May not be present in elderly)