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PN 131

PN 131. Health History Identifying Risk Factors Modifying Risk Factors. OBJECTIVES. Describe the nurses’ role in obtaining a health history on a client. Health History. Social History Medication List Medical History Surgical History

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PN 131

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  1. PN 131 Health History Identifying Risk Factors Modifying Risk Factors

  2. OBJECTIVES Describe the nurses’ role in obtaining a health history on a client

  3. Health History • Social History • Medication List • Medical History • Surgical History Listen to the client, and try not to interrupt. If the client becomes frustrated, it will actually take longer.

  4. Identifying Risk Factors

  5. Non-Modifiable Risk Factors • Age • >45 for men >55 for women • 4 of 5 deaths from CAD are >65 years old • Gender • Males develop heart disease sooner and more often • Even after menopause, women still have a slightly lower risk of CAD, however women are more likely to die from their MI • Race • African American (because of the greater incidence of HTN) • Family History • Immediate family members (Parents)

  6. Modifiable Risk Factors • HTN • Get the blood pressure down • Diabetes • Just having the diagnosis of DM, increases the risk of Arterial disease • Abnormally high blood sugars further increases the risk • Obesity • BMI >30 (weight in Kg/height in m squared) • Waist circumference • Men >40 inches • Women >35 inches

  7. Modifiable Risk Factors • Diet • High in sodium, cholesterol, saturated fat • Low in B (6 and 12) vitamins, folic acid • Diets low in these vitamins are linked to elevated homocysteine levels • Elevated homocysteine levels have been linked to heart disease

  8. Modifiable Risk Factors • Sedentary Lifestyle • The heart muscle needs exercise too! • Benefits of exercise • Increased HDL • Weight loss • Increased energy • Release of Endorphines • As effective as anti-depressants • Reduces stress and anger

  9. Modifiable Risk Factors • Stress and Anger • Sympathetic Nervous System activation • Elevated hormones and steroid hormones • Epinephrine and Cortisol • Increased fluid retention and blood pressure • Oral Contraceptives • Synthetic estrogen has been linked to heart disease, especially if the woman smokes • Alcohol • More than one drink per day is associated with heart disease

  10. Modifiable Risk Factors • Smoking (including second hand smoke) • Increases incidence of heart disease by 2-4 times • 70% higher death rate from Coronary Artery Disease than non-smokers • Increases HR and BP • Decreases the effect of anti-hypertensives

  11. Modifiable Risk Factors • Smoking (cont.) • Increases LDL and lowers HDL cholesterol • Damages arteries, promoting atherosclerosis • Cigarettes contain carbon monoxide which decreases the bloods ability to carry oxygen • Associated with early onset menopause

  12. Modifiable Risk Factors • Fats in the blood • Triglycerides-chemical name for fat • Cholesterol is a fat compound and it is necessary for cell function although excess stays in the arteries • Lipoproteins- fat wrapped in protein and carry fat and cholesterol to the tissues for metabolism and back to the liver for breakdown and excretion • VLDL = very low-density lipoproteins • LDL = low-density lipoproteins • HDL = high-density lipoproteins- carry less fat and more proteins

  13. Modifiable Risk Factors • Risky cholesterol numbers • Total cholesterol (mg/dl) • 200-239 Borderline high risk • >239 High risk • LDL cholesterol (mg/dl) • 130-159 Borderline high risk • 160-189 High risk • >189 Very high risk • HDL cholesterol (mg/dl) • <40 High risk • Triglycerides (mg/dl) • 150-199 Borderline high risk • >199 High risk *Reducing cholesterol levels by 10%, reduces your risk of CAD by 20%*

  14. Cholesterol Goals • Total Cholesterol <200 • Triglycerides <150 • LDL • High Risk (CAD, PAD, CVA, DM) • <100 • Moderate Risk (Have risk factors) • <130 • Low Risk (Very few or no risk factors) • <160 • HDL >40

  15. Reaching Cholesterol Goals • Exercise (raises HDL levels) • Diet • Risk Factor Reduction

  16. Modifying Risk Factors Non-pharmacologic interventions • Education of disease processes • Weight reduction • Dietary Instruction: sodium restriction to 2g per day • Moderation in intake of caffeine and alcohol • Exercise program • Smoking cessation • Stress reduction (relaxation techniques)

  17. Smoking Cessation • Medications • Wellbutrin, Chantix, Nicotine Patch • Behavioral Therapy • Pick a date to stop smoking • Record when and why you smoke • Wean down the number of cigarettes you have each day • Smoke at different times and different places to help break the connection between smoking and certain activities • List your reasons to quit smoking • Find activities to replace smoking

  18. Modifying Risk Factors • PharmacologicSupport: (Antihypertensives, Antihyperlipidemics, and consider smoking cessation aides) • Start one medication at a time and add more medications one step at a time until goals are reached • Evaluate patient/client compliance, emphasize importance of lifelong medications, and to notify doctor before stopping the medication (i.e. undesirable side effects)

  19. Modifying Risk Factors • TLC Diet (Therapeutic Lifestyle Changes) • Calories taken in should equal calories used in a day • Reduce total fat intake to less than 30% of calorie intake • Reduce saturated fats to 7%, polyunsaturated fat to 10%, and monounsaturated fat to 20% of total fat intake • Reduce cholesterol to 200 mg/day • Complex carbohydrates should make up about 50% of calorie intake • Increase soluble fiber to 10-25g • Protein should account for 15% of calorie intake • Diet rich in vegetables, fruits, whole grains, low in trans fats and saturated fats

  20. Modifying Risk Factors • Sodium-Restricted Diet • Mild • 2-3 g sodium per day • Moderate • 1 g sodium per day • Strict • 500 mg sodium per day

  21. Modifying Risk Factors • DASH Diet • Dietary Approaches to Stop Hypertension • 4-6 servings of fruits per day • 4-6 servings of vegetables per day • 2-3 servings of low fat dairy foods per day • Lean meats and high fiber grains • Mediterranean Diet

  22. Medications Treat Hyperlipidemia

  23. Medications Used to Treat Hyperlipidemia • Colesevelam Hydrochloride (WelChol) • HMG-CoA Reductase Inhibitors (HMG’s or Statins) • Fibrates or Fibric Acid Derivatives • Niacin or Nicotinic Acids • Bile Acid Sequestrants

  24. Fibratesaka Fibric Acid Derivatives • Examples • Gemfibrozil (Lopid) • Fenofibrate (TriCor) • Action • Lowers triglycerides and raises HDL • Reduces synthesis of triglycerides in the liver • Increases elimination of triglycerides • Side effects • Abdominal pain, GI disturbance, Myositis • Client Teaching • Take with meals • Report any muscle pain to physician

  25. HMG-CoAReductase Inhibitors[aka “HMG’s” or “Statins] • Action • Inhibit HMG-CoAreductase, an enzyme used by the liver to produce cholesterol • The liver still needs cholesterol, so it pulls cholesterol from the blood • Lowers triglycerides, LDL, and VLDL. Raises HDL • Examples • Atorvastatin (Lipitor) • Ezetimibe (Zetia) • Lovastatin (Mevacor) • Pravastatin (Pravachol) • Rosuvastatin (Crestor) • Simvastatin (Zocor) • Side Effects • Liver changes (elevated liver enzymes) • GI upset, constipation, or diarrhea • Photosensitivity • Headaches • Client Teaching • Take at night (most cholesterol is synthesized at night) • Wear sunscreen and protective clothing when outside • Take lovastatin with meals • Report muscle pain, weakness, or malaise to physician • Tell physician of alcohol use

  26. Vitamin B3 Niacinaka Nicotinic Acid • Requires higher doses than when used as a vitamin • Action • Decreases triglycerides • Increases HDL • Effective and inexpensive • Often used in combination with other lipid-lowering agents • Side Effects • Hypotension from vasodilation • GI irritation • Pruritus • Client Teaching • May cause flushing, but this can be avoided by taking aspirin 30 minutes beforehand • Notify physician if dizziness (could be hypotension)

  27. Bile Acid Sequestrants(aka Bile Acid Binder Resins) • Examples • Cholestyramine (Questran, Cholybar) • Colestipol HCL (Colestid) • Action • Cholesterol is a precursor to bile acids, which are made in the liver. The bile acids are secreted into the intestines and then absorb ingested lipids. Then the bile acids are absorbed into the bloodstream and return to the liver. • The medication binds to bile acids in the intestines and prevent them from being absorbed into the bloodstream. The liver, needing the bile acids, draws cholesterol from the bloodstream to make more bile acids. • Side Effects • Constipation, abdominal discomfort, N/V, diarrhea • Client Teaching • Do not take 1 hour before or 4 hours after other medications • If in powder form, mix with liquid

  28. Colesevelam Hydrochloride (aka WelChol) • Very similar to Bile Acid Sequestrants • Increases HMG-CoA enzyme • Increases the number of LDL receptors in the liver

  29. Changing Behavior A major part of Cardiovascular Nursing is changing behavior Smoking Controlling Diabetes How can food that tastes so good be so bad! Lifelong Medication Exercise

  30. Changing Behavior Remember Therapeutic Communication! and Education, Education, Education! Try Being a Role Model Instead of Telling People What To Do.

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