Transcript Physiological basis of the care of the care of the elderly

Physiological basis of the care
of the elderly client
Cardiovascular System
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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
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Informal evaluation
What additional information do you need?
Subjective information
Objective information
Psychosocial information
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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 will encounter
cardiovascular concerns in the elderly client due to
normal age related changes
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Review of cardiac structure and function
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
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Potential challenges for the elderly client
Electrical
Coordination
Force
Valves
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Preload and afterload
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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
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Afterload is the amount of pressure
produced by the left ventricle in
order to contract (systole)
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Regulation of cardiac function
Preload
Afterload
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Contractility
Left ventricle efficiency
Determined by amount of blood pumped from the left
ventricle at end of diastole
Affected by
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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
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The electrocardiogram
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Normal PR = .12-.20 (3-5 □s)
Normal QRS = < .12 (3 □s)
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Normal sinus rhythm
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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
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Normal age related changes
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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
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Increased size of myocardial
cells
Thickening of left ventricular
wall
Resulting systemic effects
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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
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To prevent debilitation from cardiovascular
changes through lifestyle modification…
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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
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Atypical presentation of cardiac disease
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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:
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Fatigue
Sleep disturbances
Epigastric pain
Heart disease in elderly women
Symptoms may be unrecognized:
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Sleep disturbances
Intermittent chest tightness,
squeezing, pressure
Back, neck, stomach, jaw
discomfort
Shortness of breath, nausea,
lightheadedness
Break out in cold sweat
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Hypertension
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A major risk factor for developing other cardiovascular
conditions because:
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It does not always produce its
own symptoms
Many are unaware they have
hypertension
It is easily ignored
Classifications of blood pressure
Optimal: <120/<80
Screen every 2 years
Prehypertension: 120-139/80-89
Assess annually
Stage 1 HTN: 140-159/90-99
Assess more frequently
Stage 2 HTN: ≥160 OR ≥100
Assess more frequently
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JNC 8 (2014) Guidelines
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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
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JNC 8 Hypertension Management
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Lifestyle interventions apply throughout all treatment
recommendations
Blood pressure goals and medication treatment based on
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Age
Diabetes
Chronic kidney disease
JNC 8 HTN Management Algorithm:
Age ≥60 years No diabetes No CKD
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Goal
SBP
• <150 mm Hg
Goal
DBP
• <90 mm Hg
JNC 8 HTN Management Algorithm:
Age <60 years No diabetes No CKD
Goal
SBP
•< 140 mm Hg
Goal
DBP
•< 90 mm Hg
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JNC 8 HTN Management Algorithm:
All ages With diabetes No CKD
Goal
SBP
•< 140 mm Hg
Goal
DBP
•< 90 mm Hg
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JNC 8 HTN Management Algorithm:
All ages with CKD
Goal
SBP
•< 140 mm Hg
Goal
DBP
•< 90 mm Hg
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JNC 8 HTN Treatment Guidelines
Black
No CKD
• Thiazide-type
diuretic, or,
• CCB, or,
• Combination
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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
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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!
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Results of untreated hypertension
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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
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Nursing management—patients with HTN
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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
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Nursing management—patients with HTN
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High blood pressure screening
Promote healthy lifestyle
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Low fat diet
Low sodium diets
Weight control
Exercise
Smoking cessation
Controlled alcohol consumption
Monitor effects of medication
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Medication management of hypertension
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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
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Hypotension
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Frequently associated with medication
side effects
Decreased responsiveness of
sympathetic nervous system with age
affects autoregulation of cardiac output
Lying/sitting (postural) blood pressure:
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Supine for at least 5 minutes,
then check blood pressure
Check again after 1 and 3
minutes of sitting or standing
Hyperlipidemia
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Elevated cholesterol is a risk factor for cardiovascular
disorders
Remember…Keep HDLs high, keep LDLs low!
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LDL < 100 mg/dl*
HDL > 60 mg/dl*
LDL
*Optimal per JNC7!
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HDL
Benefits of the “statins”
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Lower LDL cholesterol
Anti-inflammatory
Antithrombotic
Protect plaque stability
Generally well tolerated
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Atorvastatin (Lipitor)
Fluvastatin (Lescol XL)
Lovastatin (Mevacor)
Pravastatin (Pravachol)
Rosuvastatin (Crestor)
Simvastatin (Zocor)
Metabolic syndrome (“syndrome X”)
• > 135/80
• Men > 40”
• Women >
35”
• >150
mg/dl
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Waist
Circ.
BP
TG
BG
• >100mg/dl
(fasting)
Characteristics of metabolic syndrome
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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)
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Treatment plan for metabolic syndrome
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Cholesterol lowering drugs
Antihypertensives
Diet high in omega-3 fatty acids
Avoid processed foods
Exercise 30-45 minutes
moderate intensity
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Ischemic heart disease in the elderly
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Chest pain is not always present
Fatigue
Weakness
Shortness of breath
GI disturbances
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Chest pain
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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
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Other causes of chest pain
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Pericarditis
Heartburn, ulcers
Chondritis
Pulmonary embolus, pneumonia
Herpes zoster
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Treatment of angina
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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
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Myocardial infarction findings
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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
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Complications of MI
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Arrhythmia (dysrhythmia)
Conduction blockages
Heart failure
Pulmonary edema
Ventricular aneurysm
Pericarditis
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Anticoagulation treatment of MI
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Useful within first few hours of event
Chew an aspirin while waiting for ambulance!
Not all patients are candidates for thrombolytic therapy
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Aortic stenosis
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Most common valvular disorder in the elderly
Usually due to calcification
Risk factors:
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Hyperlipidemia
Diabetes
Hypertension
Left ventricular hypertrophy
Heart failure
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Heart failure
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Heart no longer able to provide sufficient cardiac output
Men develop after an MI; women after long-standing HTN
Compensatory events
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Increased heart rate
Renin → angiotensin I → angiotensin II → increased BP and
sodium and water retention
Risk factors:
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Coronary artery disease
Hypertension
Right sided versus left sided failure
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Neck vein distention
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Dysrhythmias (not “arrhythmias!”)
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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])
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Venous disease
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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
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Formal evaluation
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What is your nursing
diagnosis for RB?
What is your desired
outcome?
What are appropriate
interventions pertinent
to your desired outcome?
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