Gerontological nursing department
Assiut university
Cardiovascular System Prepared by :Soher Ahmmed Awad Under
supervision:-
Dr/ Rabaa Hamed Assistant professor- Community health nursing department
Dr/Safaa Kotb Assistant professor- Community health nursing department
Dr/ Neama El-Magrabi Assistant professor- Community health nursing department
Dr/Soad Sharkawy Assistant professor- Community health nursing department
Dr/Safaa Rashad Lecturer - Communityhealthnursingdepartment
Dr/ Nermmen Mahmmoud Lecturergerontologicalnursing department 2015 Outlines •
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Anatomy of cardiovascular system
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function of cardiovascular system
Age-related changes of cardiovascular system •
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Introduction
Effect of changes
Common disorders related to CVS in the elderly: 1
Heart Failure 2. Coronary Artery Disease Angina 1.
Myocardial Infarction Hypertension
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Nursing care plan
Patient and Family Teaching •
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References
Introduction: The cardiovascular system is a complex network of the heart, blood vessels and blood. It's job is to deliver nutrients to the body and remove byproducts from the tissues. At the center of the cardiovascular system is the heart--a four chambered pump that dispenses blood to the arteries. The arteries carry nutrients and oxygenated blood to the body's tissues. The veins return de-oxygenated blood to the heart, where the cycle repeats itself thousands of times a day. Anatomy and function of cardiovascular system:
• 1.
Function of cardiovascular system
Transporting Oxygen and Removing Carbon Dioxide
One of the most important functions of the circulatory system is to supply oxygen to all the cells in the body. Every cell in the body requires a constant supply of oxygen to stay alive. Because most of the cells are not in contact with air, the circulatory system must supply them with oxygen. 3
2. Transporting Nutrients and Removing Wastes A second critical function of the circulatory system is to supply all the cells in the body with nutrients and energy. After food is digested in the stomach, it migrates through the intestines, where nutrients from food are absorbed into the bloodstream.
3. Fighting Disease In addition to nutrients and oxygen, the blood also carries around important disease-fighting cells. The organs of the immune system, such as the spleen, create many types of specialized cells that can kill foreign cells trying to invade the body. The circulatory system is responsible for transporting these cells from the immune system to all other parts of the body.
4. Transporting Hormones Hormones are crucial chemical signals that the body uses to communicate with itself. Hormones control many things such as growth, the reproductive cycle and glucose metabolism. Hormones are created in one part of the body, such as the brain or the liver, and then must be transported to another part of the body by the cardiovascular system in order to deliver their message.
5. Regulating Body Temperature The cardiovascular system also plays a role in regulating body temperature. If body temperature rises too high, blood vessels close to the skin dilate, increasing in size. The larger surface area of blood vessels close to the skin means more heat is conducted across the skin into the air. Conversely, if body temperature drops, the blood vessels constrict, decreasing in size. The smaller surface area of blood vessels next to the 4
skin causes less heat to be lost across the skin and retains more heat in the body. AGING CHANGES: Heart: •
The heart has a natural pacemaker system that controls the heartbeat. Some of the pathways of this system may develop fibrous tissue and fat deposits. The natural pacemaker (the SA node) loses some of its cells. These changes may result in a slightly slower heart rate.
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A slight increase in the size of the heart, especially the left ventricle, is not uncommon. The heart wall thickens, so the amount of blood that the chamber can hold may actually decrease despite the increased overall heart size. The heart may fill more slowly.
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Heart changes cause the ECG of a normal, healthy older person to be slightly different than the ECG of a healthy younger adult. Abnormal rhythms (arrhythmias), such as atrial fibrillation, are more common in older people. They may be caused by heart disease.
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Normal changes in the heart include deposits of the "aging pigment," lipofuscin. The heart muscle cells degenerate slightly. The valves inside the heart, which control the direction of blood flow, thicken and become stiffer. A heart murmur caused by valve stiffness is fairly common in the elderly.
Blood vessels:
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Receptors called baroreceptors monitor the blood pressure and make changes to help maintain a fairly constant blood pressure when a person changes positions or is doing other activities. The baroreceptors become less sensitive with aging. This may explain why many older people have orthostatic hypotension, a condition in which the blood pressure falls when a person goes from lying or sitting to standing. This causes dizziness because there is less blood flow to the brain.
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The capillary walls thicken slightly. This may cause a slightly slower rate of exchange of nutrients and wastes.
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The main artery from the heart (aorta) becomes thicker, stiffer, and less flexible. This is probably related to changes in the connective tissue of the blood vessel wall. This makes the blood pressure higher and makes the heart work harder, which may lead to thickening of the heart muscle (hypertrophy). The other arteries also thicken and stiffen. In general, most elderly people have a moderate increase in blood pressure.
Blood: •
The blood itself changes slightly with age. Normal aging causes a reduction in total body water. As part of this, there is less fluid in the bloodstream, so blood volume decreases.
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The speed with which red blood cells are produced in response to stress or illness is reduced. This creates a slower response to blood loss and anemia.
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Most of the white blood cells stay at the same levels, although certain white blood cells important to immunity (neutrophils) decrease in their number and ability to fight off bacteria. This reduces the ability to resist infection. 6
EFFECT OF CHANGES Normally, the heart continues to pump enough blood to supply all parts of the body. However, an older heart may not be able to pump blood as well when you make it work harder. Some of the things that make your heart work harder are: Certain medicines
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Emotional stress Physical exertion Illness
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Infections
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Injuries
Common disorders related to CVS in the elderly: 1-
Heart
Failure
Introduction: Heart failure can significantly decrease quality of life and functional ability In addition to causing death for elderly. Definition of Heart failure is a condition that occurs when the heart is unable to pump enough blood to meet the body's metabolic demands. Symptoms of heart failure 1. Edema (general or dependent) 2. Fatigue 3. Poor exercise tolerance 4. Dyspnea on exertion 5. Paroxysmal nocturnal dyspnea 6. Orthopnea 7. Altered mental status (e.g., confusion, especially in the
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elderly) Notes:
For many patients, dyspnea on exertion is the earliest
symptom. Dyspnea on exertion may result in a change in functional status of the older adults.
Older adults may also experience a change in mental status,
especially confusion. Disorders that increase the risk of developing heart failure include:
Angina
MI (myocardial infarction)
Diabetes (uncontrolled)
Hypertension
Coronary artery disease
Diagnostic
Tests:
Test that help identify heart failure include:
Electro-cardiography (ECG) Chest X-ray
Cardiac catheterization
Echocardiography and
Laboratory blood test
Medical *
Treatment:
Treatment involves decreasing volume overload with the use of diuretics. Diuretics decrease total blood volume and circulatory congestion.
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Potassium loss (i.e., hypokalemia) must be monitored closely in elderly patients receiving diuretics. Symptoms of hypokalemia include weakness, muscle cramps, and numbness or tingling in the extremities.
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The adverse reactions include postural hypotension, 8
dizziness, headache, nausea, vomiting, diarrhea, constipation, polyuria and impotence. *
Digoxin is used in the management of heart failure to
strengthen myocardial contractility. While on digoxin therapy, serum digoxin levels must be monitored. Therapeutic digoxin levels range between 0.5 - 2 ng/mL. *
Symptoms of toxicity include anorexia, nausea, visual
disturber’s, abdominal pain, and bradycardia or other arrhythmias. If these symptoms are observed, the drug is with held and the physician notified. Older adults are at greater risk for toxicity because of the kidney's decreased ability to excrete the drug. Using the Nursing Process to Care for a Patient With Heart Failure: Assessment: The physical assessment provides important information about the patient's symptoms. Patients suspected of having heart failure must have pulse rate and rhythm, blood pressure, and respirations monitored. Assessment may reveal dyspnea, especially on exertion,
episodes of nighttime breathing difficulties, and difficulty breathing when lying down. The elderly patient may be confused or exhibit a change in
mental or functional status. Nursing Diagnoses: The following nursing diagnoses may be appropriate for the patient with heart failure: Decreased Cardiac Output related to altered myocardial
contractility 9
Fluid Volume Excess related to sodium or water retention Activity Intolerance related to dyspnea, muscle weakness,
fatigue Ineffective Breathing Pattern related to dyspnea, decreased lung
expansion Risk for Ineffective Management of Therapeutic Regimen related
to lack of knowledge of disease process, treatment regimen, drug therapy, other (specify) Other diagnoses may be appropriate to meet individual needs. Planning and Implementation: Care of the patient with cardiovascular disease is aimed at reducing the workload of the heart, increasing myocardial contractibility, and eliminating edema. Decreased Cardiac Output. In heart failure the heart is unable to pump forcefully enough for adequate amounts of blood to reach the systemic circulation causing a decreased cardiac output. Nursing Interventions for Deceased Cardiac Output: Assess vital signs(for increased respiratory and heart rates for
narrowing pulse pressure) and mental status Assess heart rate and rhythm. Report any irregularities or a heart rate less than 60 or greater than
100 beats/minute. Auscultate lung sounds for rales, crackles or ronchi. Note the extent of dyspnea. Note any decrease in mental alertness or thought processes. The head
of the bed is kept elevated and the patient in a semi- or high Fowler's 10
position and give him supplemental oxygen to help him breathe more easily. Weigh the patient daily at the same time and in the same type of
clothing. Encourage the patient to avoid straining during defecation. Straining
increases venous return and Increases the workload of the hear .A stool softener may be needed to prevent straining. Administer medications, and monitor closely for adverse drug
reactions. Fluid Volume Excess. 1. Fluid volume excess must be reduced if heart failure is to
be managed. The physician usually orders a diuretic to promote diuresis and loss of excess fluid. The patient is monitored for adverse reactions to the medications such as hypokalemia, nausea, vomiting, tingling or numbness in the extremities, headache, diarrhea, constipation. 2. Dietary sodium is restricted to approximately 2 to 3 g/day.
Foods high in sodium are avoided, and no salt is added to foods. Activity Intolerance. Patients with acute or worsening heart failure may become short of breath with minimal exertion. Ineffective Breathing Pattern. Respiratory rate, depth, and pattern are monitored every 2 to 4 hours. The nurse checks the lung sounds for crackles, wheezes, or diminished breath sounds. Evaluation and Expected Outcomes Successful care can provide the following outcomes: 11
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No evidence of symptoms of circulatory insufficiency
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Maintenance of stable weight with no 'evidence of
edema •
Decreased episodes of dyspnea
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Respiratory rate, rhythm, and depth and breath sounds
within baseline parameters Participation in self-care and social activities Expression of increased knowledge about the disease process, medication regimen, or other (specify) V- Coronary Artery Disease Introduction: Coronary artery disease (CAD) is the most common disorder affecting the heart. More than 50% of deaths of individuals older than 65 years of age are caused by coronary artery disease. The coronary arteries supply blood and oxygen to the heart muscles. With age, the arteries, including the coronary arteries, accumulate yellowish plaques of cholesterol, lipids, and other debris on the inner surfaces of the vessels. This condition is called atherosclerosis. The walls of the mediumsize and large arteries become thickened, causing the lumen (ie, opening) of the vessel to narrow.
Angina Angina is caused by atherosclerotic heart disease. The most
prominent symptom of angina is chest pain. The chest pain with angina typically is severe and causes a feeling of tightness, pressure, or suffocation. The pain may radiate down the left side of the body to the neck, jaw, shoulders, or arms. 12
The pain of angina may result from:
Exercise or physical exertion (eg, climbing stairs)
Exposure to cold
Eating a large meal (ie, pain occurs as the blood is diverted to the digestive system and away from the heart)
Stress
Risk factors for coronary heart disease:
Aging
High blood pressure ·.Elevated blood pressure
Smoking :cigarettes
Diabetes mellitus (hyperglycemia )
Obesity
Stress
Lack of exercise
Family history of a myocardial infarction
Treatment: Treatment for angina is aimed at increasing the oxygen supply to the heart muscle and decreasing the heart's oxygen demands. This is accomplished through the use of medication and patient education. Surgical treatment may be necessary if the' medication regimen fails to control the angina. Drug Therapy: 1. The nitrates are the most significant drugs used to manage
angina pectoris. These anti angina drugs relax the smooth muscle layer of arterial blood vessels causing vasodilatation (ie, increase in the size of the blood vessels). Vasodilatation increases the blood flow to the affected area, resulting in complete or partial relief of pain and other symptoms associated with angina. The nitrates may be administered sublingually, transdermally, or orally. 13
2. Calcium channel blockers (eg, diltiazem, verapamil, nifedipine)
are also used to treat chronic stable angina or hypertension. Side effects of calcium channel blockers include peripheral edema, dizziness, lightheadedness, nausea, skin rash, fever, and chills.
Myocardial Infarction
MI (Myocardial Infarction) occurs when areas of the heart are deprived of blood, causing tissue death and destruction. Symptoms indicating an MI include chest pain (not relieved by rest or by nitroglycerin). The pain occurs suddenly over the (lower) substernal area and is the most common symptom. The pain is often severe and unrelenting. The diagnosis after an MI is made through laboratory studies such as:
Serum enzyme and isoenzyme determinations.
Electrocardiogram and echocardiogram.
Treatment: Treatment is aimed at reducing the pain, stabilizing the heart rhythm, and reducing the work load of the heart. Analgesics are given to relieve the pain. Oxygen, cardiotonic drugs, Antiarrhythmic drugs and anticoagulants are usually
'administered in the acute stage. The patient is 'admitted to the cardiac care unit and placed on a cardiac monitor. Using the Nursing Process to Care for a Patient with Coronary Artery Disease Assessment: When assessing the patient for problems of the coronary arteries pain is the most prominent symptom. Have the patient describe the pain-its onset, location, severity, and duration. 14
The nurse checks:
The vital signs (ie, blood pressure, pulse, respirations, and
temperature). Vital signs are used to establish a baseline for future comparison. Nursing Diagnoses The following nursing diagnoses may be appropriate for patients with coronary artery disease: Pain related to ischemia of the coronary vessels
Decreased Cardiac Output related to changes in heart rate, rhythm, and conduction
Risk for Decreased Tissue Perfusion related to decreased
Cardiac Output
Altered Sexuality Patterns related to pain, anxiety, other
(specify)
Risk for Ineffective Management of Therapeutic Regimen
related to lack of knowledge of disease process, medication regimen, other (specify) Planning and Implementation For an older patient with an MI, 1. Immediate hospitalization in a coronary intensive care unit is necessary
during the acute phase. 2. Cardiac monitoring and administration of medications 3. A cardiac rehabilitation program may be helpful for those elderly
recovering from an MI. Older adults are taught to administer medications, monitor diet, and maintain a balance between activity and rest. 4. Vital signs (ie, pulse, respirations, and blood pressure) are taken before
administering of any drug to help monitor the effects of the drug and any adverse reactions. Vital signs are checked every 4 hours or more often if necessary. 15
5. patients with known CAD take supernal nitroglycerin before an ECG
Patient and Family Teaching. 1. the patient needs explanation of the disease process, ways to modify
risk factors, the prescribed medication regimen, dietary recommendations, symptoms that should be reported, type and amount of activity allowed, and any special precautions necessary. 2. The nurse may teach relaxation techniques to assist in managing
stress. 3. It is helpful for the patient to enroll in a cardiac rehabilitation
program, particularly after an MI. 4. teach life style modification to reduce cardiac risk
VI- Hypertension Definition: Hypertension is a sustained elevation in blood pressure. "Systolic pressure is greater than 140 mmHg or the diastolic pressure is above 90 mmHg. Causes: The exact cause of essential hypertension is un known. In addition to age-related changes, contributing factors in elderly patients include family history, diabetes mellitus, race, physical inactivity, obesity, high fat diet. Secondary hypertension may result from, renal diseases , diabetes mellitus , neurological disorder, and dysfunction of the thyroid pituitary, or parathyroid gland. Assessment of the Patient with Hypertension: Hypertension is often called the silent killer because few or no symptoms are apparent until complications develop as the result of vascular changes. With prolonged hypertension, The individual may complain of headache, dizziness, or tinnitus (ie, ringing in the ears). 16
Other symptoms include nosebleeds, visual disturbances, and nocturia. Frequent assessment of the blood pressure is important. Treatment Treatment is aimed at maintaining a blood pressure below 140/90 mmHg, modifying risk factors, and preventing complications. 1- Some risk factors can be modified by a more healthful lifestyle. Other risk factors such as age and sex are unable to be changed. 2-Weight reduction, sodium restriction, limiting alcohol consumption, eliminating tobacco, learning stress reduction techniques, and exercising moderately can help in managing hypertension. Caring for the Patient with Hypertension: 1. There are many drugs available; the physician may prescribe a
different antihypertensive drug as diuretics and beta blockers. 2. The patient is monitored for any adverse reactions related to the
medications. Common side effects of the antihypertensives include orthostatic hypotension, hypotension, dizziness, fatigue, nausea, vomiting, depression, and impotence. 3. Obtain the blood pressure and pulse rate immediately before each
dose of an antihypertensive.
Patient and Family Teaching: The nurse must be certain the caregiver and the patient understand the following points: 
Do not discontinue the medication except on the advice of
the physician. 
To minimize postural Hypotension and dizziness, rise
slowly from a sitting or lying position. 17
Follow dietary restrictions concerning sodium or fat. Do not use a salt substitute unless approved by the physician. (These substitutes sometimes contain potassium, and their use can cause an electrolyte disturbance.)
Take the diuretics early in the morning unless directed otherwise.
Avoid the use of alcohol.
Lose weight if overweight and weigh weekly to monitor weight loss or gain.
Stop smoking, and reduce the intake of dietary saturated fat
and cholesterol for overall cardiovascular health.
If taking an antihypertensive that causes hypokalemia,
include foods high in potassium in the diet (e.g., bananas, orange juice).
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Refrences 1. James PA et al. Evidence-Based Guideline for the Management of
High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. 2. Minaker KL. Common clinical sequelae of aging. In Goldman L,
Schafer AI, eds. Goldman's Cecil Medicine. 24th ed. Philadelphia, PA: Elsevier Saunders;2011:chap 24. 3. Schwartz JB, Zipes DP. Cardiovascular disease in the elderly. In:
Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook
of
Cardiovascular
Medicine.
9th
ed.
Philadelphia, PA: Elsevier Saunders; 2011:chap 80. 4. Stone MJ et al. American College of Cardiology/American Heart
Association Guidelines on the Treatment of Blood Cholesterol to Reduce Athersclerotic Cardiovascular Risk in Adults. Circulation. 2014;129:S1-45. 5. U.S. Preventive Services Task Force Recommendation Statement.
Screening for Abdominal Aortic Aneurysm, June 24, 2014.
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