Physiological basis of the care of the elderly client

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

2. Patient scenario • 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

3. Informal evaluation What additional information do you need? • Subjective information • Objective information • Psychosocial information

4. The cardiovascular system • 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 are likely to encounter cardiovascular concerns in the elderly client due to normal age related changes

5. Review of cardiac structure and function • Circulation is established by electrical system of the heart • Left side of heart produced 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

6. Potential challenges for the elderly client

7. Preload and afterload • 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)

8. Regulation of cardiac function

9. Left ventricle efficiency • 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

10. The electrocardiogram • Normal PR = .12-.20 (3-5 □s) • Normal QRS = < .12 (3 □s) • Normal sinus rhythm • Each P wave followed by QRS • Rate 60-90 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

11. Normal age related changes • 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

12. Resulting systemic effects • 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

13. To prevent debilitation from cardiovascular changes through lifestyle modification… • Remain physically active—30 minutes aerobic activity per day most days of the week • Avoid obesity—maintain normal BMI between 22-25 • 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

14. Atypical presentation of cardiac disease • 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

15. Heart disease in elderly women 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

16. Hypertension • 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

17. Classifications of blood pressure

18. JNC 7 (2003) Guidelines(JNC 8 in development) • 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 • 120-139/80-89 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

19. “Instant” teaching points regarding HTN • 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!

20. Results of untreated hypertension • 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

21. Nursing management—patients with HTN • 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

22. Nursing management—patients with HTN • High blood pressure screening • Promote healthy lifestyles • Low fat diet • Low sodium diets • Weight control • Exercise • Smoking cessation • Controlled alcohol consumption • Monitor effects of medication

23. Medication management of hypertension • 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 • Benzothiazepines may cause decreased cardiac output and slow conduction

24. Hypotension • 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

25. Hyperlipidemia • 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!

26. Benefits of the “statins” • 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)

27. Metabolic syndrome (“syndrome X”)

28. Characteristics of metabolic syndrome • 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)

29. Treatment plan for metabolic syndrome • Cholesterol lowering drugs • Antihypertensives • Diet high in omega-3 fatty acids • Avoid processed foods • Exercise 30-45 minutes moderate intensity

30. Ischemic heart disease in the elderly • Chest pain is not always present • Fatigue • Weakness • Shortness of breath • GI disturbances

31. Chest pain • 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

32. Other causes of chest pain • Pericarditis • Heartburn, ulcers • Chondritis • Pulmonary embolus, pneumonia • Herpes zoster

33. Treatment of angina • Nitroglycerine—vasodilator • 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

34. Myocardial infarction findings • 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

35. Complications of MI • Arrhythmia (dysrhythmia) • Conduction blockages • Heart failure • Pulmonary edema • Ventricular aneurysm • Pericarditis

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

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

38. Heart failure • 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

39. Right sided versus left sided failure

40. Neck vein distention

41. Dysrhythmias (not “arrhythmias!”) • 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])

42. Venous disease • 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

43. Formal evaluation • What is your nursing diagnosis for RB? • What is your desired outcome? • What are appropriate interventions pertinent to your desired outcome?