ch15 The Cardiovascular System f.ppt

Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
CHAPTER
Gerontological Nursing, Second Edition
Patricia A. Tabloski
The Cardiovascular
System
15
Lecture Note PowerPoint Presentation

LEARNING OUTCOME 1
Describe changes in the cardiovascular
system that occur with aging.

Structure and Function of
Cardiovascular System
• Heart structure
– Right atrium
– Tricuspid valve
– Right ventricle
– Pulmonic valve

Figure 15-3
The capillary network between arterial and venous blood.

• Heart structure
– Mitral valve
– Left ventricle
– Aortic valve
– Pericardium

• Heart function
– Diastole
– Systole
 Cardiac output
 Ejection fraction
 Autonomic nervous system
• Sympathetic: alpha and beta receptors (adrenergic)
• Parasympathetic: vagus nerve

• Heart function
– Systole
 Conduction system
• Action potential noting the refractory period
• Sinoatrial (SA) node
• Atrioventricular (AV) node
• Bundle branches

• Heart function
– Electrocardiogram (EKG)
 P wave
 P-R interval
 QRS wave
 T wave

• Heart function
– Circulatory system structure
 Arteries
• Tunica intima
• Tunica media
• Tunica adventitia
 Capillaries
• Endothelial layer
• Basal lamina
 Veins
• Inferior and superior vena cava

• Heart function
– Circulatory system function
 Regulation of blood flow
• Local conditions
• Release of nitric oxide → vasodilation
• Metabolic activity
 Cardiac circulation
• Left coronary artery (LCA)
• Left anterior descending (LAD)
• Circumflex
• Right coronary artery (RCA)

Wide Range of Cardiovascular
Function Among Older Adults
• Genetics
• Conditioning
• Effect of other aging organ systems
– Different body systems age at different rates
– Compensation ability
– Comorbidities
• Social and physical environments

Aging Changes with the Heart
• Myocardium
– Hypertrophy
 Left ventricle wall 25% thicker in an 80-year-old
person vs. a 30-year-old person
– Increased collagen and connective tissue
– Cardiac cells
 Accumulation of lipofuscin, amyloid

Figure 15-4
Normal changes of aging in the cardiovascular system.

• Valves
– Fibrosis and calcification → stiffening of
valves
– Changes in valve rings → contribute to
stenosis or incompetence
• Resting heart rate unchanged with age
– Difficulty responding to stress
• Small decline in cardiac output from age
20

• Electrical activity
– Decrease in number of normal pacemaker
cells in SA node
 After age 75 < 10% still functional
• Supports normal cardiac function
– Decrease in number of normal pacemaker
cells in AV node and both bundle branches
– Refractory period of the AV node increases
 EKG without specific changes with normal aging
 Refractory period: the amount of time it takes for an excitable
membrane to be ready for a second stimulus once it returns to its
resting state following excitation

• Electrical activity
– Layers
 Arterial
• Thickening of the intimal and medial layers
• Lipid deposits
• Calcification → medial layer→ collagen deposits→
decreased elasticity + “hardening”

• Autonomic nervous system (is a part of prepheral NS, and affects
heart rate, digestion, respiration rate, salivation, perspiration, diameter of the pupils, micturition
(urination), and sexual arousal.
– Decreased responsiveness to beta-adrenergic
stimulation
• Baroreceptors less efficient
• Other aging systems that affect cardiovascular function
– Pulmonary
– Renal
– Baroreceptors (or baroceptors) are sensors located in the blood vessels of several
mammals.` They are a type of mechanoreceptor that detects the pressure of blood flowing
through them, and can send messages to the central nervous system to increase or
decrease total peripheral resistance and cardiac output.

LEARNING OUTCOME 2
List focus areas of assessment for
cardiovascular patients.

History of Cardiovascular Problems
• Careful interview is important
– Allow patient to share concerns
– Gather pertinent information

History of Cardiovascular Problems
• Comprehensive
– Demographic information
 Patient’s date of birth
 Source of history, if other than the patient
 Chief complaint
 History of the present illness
 Past history
 Review of systems
 Family history
 Social history
 Functional health pattern assessment, for nursing
planning

Complete Review of Systems
• Focus for an older patient with
cardiovascular problems
– Presence or absence of chest pain
– Shortness of breath
– Syncope
– Palpitations
– Edema

Complete Review of Systems
• Focus for an older patient with
cardiovascular problems
– Nocturnal dyspnea
– Nocturia
– Pain in the extremities
– Cough
– Fatigue

Women’s Symptoms are Often
Vague and Often Not Reported
• Symptoms include
– Sleep disturbance
– Chest discomfort such as tightness,
squeezing, fullness, or pressure that can
come and go
– Discomfort in the back, neck, jaw, or stomach
– Shortness of breath
– Feelings of nausea, light-headedness, or
breaking out in a cold sweat

LEARNING OUTCOME 3
Relate physiological concepts to the
diagnosis and management of common
cardiovascular conditions, including
hypertension, angina, heart failure, and
peripheral vascular disease.

Heart Disease is the Number-One
Cause of Death for Older People
• Develops slowly
• Takes years to develop

Hypertension
• Major risk factor for other cardiovascular
conditions
• No symptoms of its own

Statistics
• 43 million Americans (24%) have
hypertension
• Only 69% of people with elevated BP are
aware of it

Physiological Mechanisms of
Hypertension
• Increased systemic vascular resistance →
decrease cardiac output
• Decrease stroke volume
• Stroke volume: The amount of blood pumped by the left ventricle of
the heart in one contraction.

Causes
• Primary hypertension
– No known cause
• Secondary hypertension
– 5% to 10% of cases
– Specific causes
 Renal artery stenosis
 Adrenal dysfunction

Untreated Hypertension
• Left ventricular hypertrophy and increased
risk of CAD
• Proteinuria: High blood pressure can cause damage to the
kidneys, which may be reflected as an increase in the amount of
protein present in the urine.
• Eye
• Stroke

Hypotension
• Orthostatic hypotension
– BP check while lying, sitting, standing
• Medications with hypotensive effect
– Alpha-adrenergic blockers
– Centrally acting antihypertensive agents
– Psychotropic drugs and tranquilizers
– High-dose antibiotics
– Nonsteroidal anti-inflammatory drugs
(NSAIDs)

Hyperlipidemia
• Lipid classifications
– High-density lipoproteins (HDLs)
– Low-density lipoproteins (LDLs)
– Triglycerides
• Risk factors
– Elevated cholesterol
– Atherosclerosis
 Peripheral artery disease
 Abdominal aortic aneurysm
 Diabetes mellitus

Hyperlipidemia
• Medication management
– HMG CoA reductase inhibitors (statins) lower
LDL cholesterol
 Anti-inflammatory
 Antithrombotic
 Protect intravascular plaque stability
– Bile acid sequestrants
 Attach to bile in the gut and prevent returns to liver
 HMG CoA reductase is a liver enzyme that is responsible for
producing cholesterol

Hyperlipidemia
– Fibrates
 Reduce triglycerides
– Nicotinic acid
 Lowers LDL and triglycerides
 Raises HDL

Chest Pain
• Myocardium deprived of blood supply →
ischemia→ pain + loss of function
• Chronic pain = angina
• Other causes
– Aortic stenosis
– Pericarditis
– GI problems
 Heartburn, acid reflux, or ulcers

Chest Pain
• Other causes
– Pulmonary problems
 Pulmonary embolus, pneumonia, or pleural
effusions
– Musculoskeletal
– Herpes zoster (shingles): is a nerve infection
caused by the chicken-pox virus

Angina
• Ischemic heart disease
– Inadequate oxygen supply
• Stressed cardiac cells → arrhythmias →
ineffective contractions
• Categories
– Supply: decreased blood flow to the
myocardium
– Demand: increased demand for oxygen to
myocardium

Angina
• Stable angina: relieved by rest
– Management: sublingual nitroglycerin
• Unstable angina: not relieved with rest of
medication
– Progression to MI
• Prinzmetal’s angina: chest pain at rest
– Transient coronary artery contractions,
unrelieved by nitroglycerin

Myocardial Infarction
• Cell death → loss of cell contraction →
decreased heart function
• Damage determined by size and location
– LAD: The left anterior descending coronary
artery
– RCA
– Circumflex

Diagnosis of an MI
• History
– Atypical symptoms in older adults
 Complaints of MI symptoms different in older
women
 May include nausea or vomiting
 Weakness
 Shortness of breath
 Diaphoresis
 Confusion
 Syncope

Diagnosis of an MI
• Physical assessment: may be
unremarkable
• Laboratory
– CK (creatine kinase) and CK-MB (CK-m
band)
– Tropinin
– LDH (lactic dehydrogen)

Diagnosis of an MI
• EKG analysis
– ST segment elevation
– Widened QRS complexes
– Q wave presence
• Other examinations
– Hemodynamic monitoring
– Echocardiography

Diagnosis of an MI
• Complications of MI
– Arrhythmias
– Blockages of electrical conduction
– Heart failure
– Ventricle aneurysms
– Pericarditis

Diagnosis of an MI
– Anti clot agents
– Pain control
– Beta-blockers
– Calcium channel blockers
– Angiotension-converting enzyme inhibitors

Diagnosis of an MI
– ASA (aspirin)
– Antiarrhythmic drugs
– Other management
 Coronary angioplasty
 Oxygen

Valvular Heart Disease
• Two categories
– Stenosis
– Incompetence, regurgitation, or insufficiency

• Aortic stenosis
– Most common valve disorder in the older adult
– Major cause is calcified degenerative stenosis
– Can lead to CHF, angina, alterations in BP,
and arrhythmias
– Risk factors
 Hyperlipidemia
 Diabetes
 Hypertension

• Aortic stenosis
– Diagnosis
 History: progressive shortness of breath
 Physical examination for murmur
– Treatment
 Mechanical intervention
 Surgical intervention

Congestive Heart Failure
• Statistics
– 33% of hospitalizations are for CHF
– Men and women develop equally
– Incidence for women has increased
– Men develop after an MI or longstanding
hypertension
– Incidence of mortality is declining
 Long-term prognosis is not good

• Pathophysiology
– Loss of contractility of the myocardium →
inadequate cardiac output → activity
intolerance
– Frank-Starling Law
 Overstretching → decreased force of contraction
 Starling's law states that the greater the volume of blood entering
the heart during diastole (end-diastolic volume), the greater the
volume of blood ejected during systolic contraction (stroke volume)
and vice-versa.

• Risk factors
– Coronary artery disease
– Hypertension
– Family history
– Cardiotoxic drugs eg chemotherapy
cardiotoxicity is a condition when there is damage to the heart muscle
– Smoking
– Obesity
– Alcohol abuse
– Diabetes mellitus
– Sleep disorders

• Clinical manifestations
– Left-sided heart failure
 Pulmonary symptoms
– Right-sided heart failure
 System symptoms

• Tests
– Laboratory
 CBC
 Elevated creatinine
 Thyroid function
– Diagnostics
 EKG
 Echocardiogram

• Treatment
– ACE inhibitors
– Beta-blockers
– Diuretics
– Digoxin

Arrhythmias and Conduction
Disorders
• Atrial fibrillation
– Most common sustained arrhythmia
– EKG shows no P wave
– Incidence increases with age
– Causes
 Hypertension
 Valvular stenosis
 Ischemic heart disease
 Irregularly irregular heart rate
 Rapid pulse

Arrhythmias and Conduction
Disorders
• Atrial fibrillation
– Not life threatening but has complications
 Embolic CVA
– Treatment
 Correct hemodynamic instability with heparin or
Coumadin
 Monitor Coumadin effects in INR
 Control ventricular rate with calcium channel
blocker
 Restore sinus rhythm, if possible, with
antiarrhythmic drugs

Heart Block
• If results in decreased cardiac output, treat
with internal pacemaker

Arterial Disease
• Atherosclerosis: occlusion of specified
vessels→ loss of function and symptoms
of pain in areas perfused by the artery
• Symptoms
• Intermittent claudication
– Burning pain in legs or buttocks during
exercise, which is relieved by rest
– Pain at rest with progressive disease

Arterial Disease
• History
• Physical examination
• Treatment
– Medication
 Antithrombotic agents
 Prostaglandins
 Calcium channel blockers
– Surgery
– Vascular rehabilitation programs

Venous Disease
• Pathophysiology
• Venous insufficiency → stasis → ulcers,
wide with irregular borders
• Risk factors
– Obesity
– Occupations
 Long periods of standing or sitting

Venous Disease
• Treatment
– Wearing external compression hose
– Treat ulcers with multilayer compression
bandages

LEARNING OUTCOME 4
List common nursing diagnoses for the
cardiovascular patient.

Nursing Diagnoses for Common
Cardiovascular Problems
• Fatigue
• Activity Intolerance

Nursing Diagnosis for Patients Experiencing, or at
Risk for, Heart Failure or Angina
• Ineffective Management of Therapeutic
Regimen

Nursing Diagnoses for Patients with
Heart Failure
• Decreased Cardiac Output
• Fluid Volume Overload

Nursing Diagnosis for Patients with Orthopnea or
Paroxysmal Nocturnal Dyspnea
• Sleep Pattern Disturbance

LEARNING OUTCOME 5
Describe specific nursing interventions used
with cardiovascular patients.

Nursing Interventions for Promoting
Cardiac Health
• Lifestyle modification
• Judicious (careful) use of medications
• Ongoing assessment of the older person’s
cardiac status

Use High Blood Pressure Instead of
Hypertension
• May be mistakenly associated with anxiety
or tension

Management of Hypertension and
Risk Reduction
• Establish blood pressure goals
• Teach lifestyle modifications
• Suggest nutritional adjustments
• Encourage exercise programs
• Encourage smoking cessation
• Encourage reduced alcohol intake
• Manage medications

Role of Nursing
• Community blood pressure screening
• Promote healthy lifestyles
• Teach importance of consistently taking
medications

Patients Taking Statins
• Teach importance of reporting muscle
aches and symptoms to their healthcare
providers
• Statins are a class of drug used to lower cholesterol levels by inhibiting the
enzyme HMG-CoA reductase.

Patients Taking Coumadin
(warfarin)
• Limit dietary intake of green leafy
vegetables rich in vit k bcz Vitamin K can
make Coumadin less effective
• Safety precautions

Interventions for Older Patients with
Angina
• Support lifestyle changes
• Teach proper medication use
– Many patients are reluctant to use prescribed
medications, particularly when prescribed “as
needed”
– Present scenarios and ask patients what they
would do if they have sudden weakness, or if
they take the medication and it does not help

Risk Factor Reduction
• Done across a variety of settings from
home to hospital to long-term-care facility
• Creativity with approach (what matters to
each patient; i.e., sports, grandchildren,
etc.)

Activity and Exercise Support
• Supervise increases in activity
• Plan rest periods

Diet Therapy
• Teaching
• Consultation with dietitians

Smoking Cessation
• Ask patient to record cigarettes smoked on
a daily basis for a week
• Review smoking diary and ask patient to
select a time they could avoid smoking

Medication Management
• Teach how to open medication bottles
• Create a system to remember to take
them
• Teach when they should report side
effects

Caregiver Support
• Teach about medications
• Identify respite programs

Advance Directives
• Discuss with family and patient
• Assist in preparing an individualized
document

LEARNING OUTCOME 6
Outline an education plan for cardiovascular
patients.

Importance of Knowledge of
Cardiovascular Disorders
• Signs and symptoms in older adults
• Assists the nurse in assuming the role of
teacher and coach

Patient-Family Education
• Critical for interpreting and clarifying
scientific data to individualize a nursing
care plan

ch15 The Cardiovascular System f.ppt

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