CORONARY ARTERY DISEASE

Also known as Coronary Heart Disease or Ischemic Heart Disease Caused by hardening and narrowing of the blood vessels of the heart (atherosclerosis) resulting in an impaired blood supply to the myocardium Most common cause of death in persons over 65 years Risk Factors in Elderly Population 1. Smoking 2. Hypertension 3. Increase in pulse pressure 4. Concurrent diagnosis of DM 5. Obesity 6. Sedentary lifestyle/inactivity 7. Advancing age 8. Hyperhomocysteinemia 9. Hypertriglyceridemia 10. Increases in total and LDL cholesterol and decreases in HDL ANGINA PECTORIS Classification: a) Stable angina usually indicates a pattern of symptoms that recur in a regular fashion - can be managed with medication and lifestyle modification b) Unstable angina characterized by a change in frequency, type or severity of symptom; also called Acute Coronary Syndrome - requires immediate medical attention - ACS are admitted & sent to the heart catheterization (direct angioplasty or stent placement)

squeezing pain or pressure on sternal area chest pain is shorter than MI (<5mins)and may or may not radiate to right arm,neck,jaw or throat pain occurs related to exercise or stress and relieve by rest or nitroglycerin for older adult symptoms may include breathlessness,diz ziness, confusion, extreme fatigue Diagnostics 1. ECG 2. Nuclear Imaging 3. PET 4. Exercise Stress Test 5. Cardiac Catheterization 6. Labs- lipid profiles, cardiac enzymes, troponin complex

chest pain appearing as tightness,fullness or pressure in female,no substernal pain but more often experience sharp pain,fatigue,weakn ess pain radiating to arms, unexplained numbness in arms,neck & back SOB with or without activity sweating,nausea,p allor, dizziness indigestion or epigastric discomfort esp.when not relieved by antacid Diagnostics 1. ECG 2. Angiogram or cardiac catheterization Nsg.Responsibility after the procedure: - keeping the leg straight with pressure on the femoral artery entry site - importance of monitoring the entry site for bleeding - lifting or driving should be avoided Treatment 1. Angioplasty a common procedure that uses a balloon or other device to open the blocked vessels 2. Coronary Artery Bypass Graft (CABG) or commonly known as open heart surgery

*monitor for S/E like CNS depression, excessive fatigue & hypoglycemia 4. Calcium antagonist act as a direct vasodilators *not recommended for older pt.with reduced left ventricular ischemia 5. ACE inhibitors 6. Lifestyle changes -avoid smoking -avoid heavy meals, caffaine -avoid emotional and physical strain

3. Implantable Cardiac Defibrillator (ICD) for pt. who sustain a large AMI w/ reduced ventricular fxn 4. Beta blockers, ACE inhibitors, antihypertensive Steps in Acute Care Treatment Of M.I. M morphine O oxygen N nitroglycerine ( SL every 5 mins x 3 & monitor v/s) A aspirin if not contraindicated

Nursing Diagnosis Decreased Cardiac Output Ineffective Tissue Perfusion: Cardiopulmonary, Cerebral, Rena, Gastrointestinal, Peripheral Acute Pain Anxiety Activity Intolerance Ineffective Sexuality Patterns Deficient Knowledge CONGESTIVE HEART FAILURE

ANGINA

MI

Treatment 1. Nitroglycerin SL, nasal or epidermal 2. Long acting nitroglycerin topical ointment or transdermal patches 3. Beta blockers

defined as an inadequate contraction of the heart muscle, which results in insufficient cardiac output to meet body needs and in circulatory congestion there maybe failure involving one or both sides of the heart,which,over time, may cause the development of pulmonary and systemic congestion and complications in elderly, the most common cause of heart failure is coronary artery

disease;other causeas are HPN, valvular heart disease, cardiomyopathy, ventricular aneurysm

For HF caused by diastolic dysfunction; - beta-adrenergic antagonists - ACE inhibitors - restrict salt intake to 2gm/day or less - eat foods and fruits rich in potassium to prevent hypokalemia * Monitor fluid status, electrolytes and renal function * In extreme cases,surgery maybe a treatment option, vulvular repair/replacement or heart transplant

Signs and symptoms wheezing, cough, dyspnea, orthopnea,fatigue, increased heart rate,confusion,weight gain,paroxysmal nocturnal dyspnea often leading to insomia in some patients,the predominating symptoms maybe anorexia, early satiety and nausea weight gain may also be noted as fluid accumulates in the lungs in leftsided heart failure and in the extremeties in right-sided Diagnosis and etiology of HF in older adult maybe difficult because symptoms such as ankle edema and dyspnea maybe due to some disease. A fourth heart sound is often heard normally in the elderly. Crackles or rales are often heard with chronic lung disease. Non-specific signs such as somnolence,confusion, disprientation,weakness and fatigue maybe the initial sign without dyspnea. Treatment For HF caused by systolic dysfunction; - rest - minimizing Na and fluid intake - reduction of afterload and preload - chair rest with legs elevated is preferred (it enhances diuresis and oxygenation) - preload is reduced with diuretics - afterload maybe reduced with vasodilator particularly nitrates and ACE inhibitors - digitalis in chronic HF - digoxin

Nursing Diagnosis Decreased Cardiac Output Impaired Gas Exchange Excess Fluid Volume Constipation Disturbed Sleep Pattern Fatigue Ineffective Coping Deficient Knowledge

Nursing Interventions To improve cardiac activity tolerance - encourage some activities but to space them well exercise to tolerance level - during and after activity, monitor the patients heart rate and watch for shortness of breath and fatigue Collaborative management is important physician,nurse,dieticians,social workers and PT Daily weighing at the same time of the day with same clothes on the same scale are essential O2 saturation of less than 90% in older person is cause concern and further investigation To improve cardiac activity tolerance - encourage some activities but to space them well exercise to tolerance level - during and after activity, monitor the patients heart rate and watch for shortness of breath and fatigue Collaborative management is important physician,nurse,dieticians,social workers and PT Daily weighing at the same time of the day with same clothes on the same scale are essential O2 saturation of less than 90% in older person is cause concern and further investigation

CEREBROVASCULAR DISEASE 1. Transient Ischemic Attack (TIA) - also called ministroke is characterized by transient focal neurological signs and symptoms that occur suddenly and last a short time, usually less than hour and never longer than 24 hours. Cause In elderly, it is caused by microembolism to the brain from atherosclerotic plaques in the aortocranial arteries. Signs and symptoms If the anterior (carotid) system is involved: - ipsilateral blindness - monocular blurring - gradual obscuration of vision - flashes of light - headaches that may simulate a migraine If the posterior (vertebrobasilar) system is involved: - tinnitus and vertigo - simultaneous bilateral sensory & motor symptom - signs of brainstem pathology including diplopia, facial weakness, ataxia & droop attacks

Treatment 1. Carotid Endarterectomy (CEA) a standard treatment for symptomatic and asymptomatic carotid artery disease; it is benificial than aspirin and safe and effective stroke prevention intervention 2. Catheter-based Percutaneous Transluminal Angioplasty (PTA) alternative for treating arterial stenosis throughout the circulation 3. Carotid Artery Angioplasty and Stenting (CAS) maybe done for older adult who would not meet the criteria for surgery Nursing Intervention Early identification and referral of people who have these transient symptoms Auscultation of carotid bruits in the routine assessment of the aged Support and teaching older adult through the diagnostic process, treatment and possible surgery 2. Stroke - also known as cerebrovascular accident (CVA) or brain attack - an interruption of the blood supply to the brain that may result in devastating neurological damage, disability or death - the fourth leading cause of death affecting 50,000 people each year Classification of Stroke a. Thrombotic the most common type of stroke in older adult which is associated with atherosclerosis. b.Embolic c. Hemorrhagic 3 Early Signs of Stroke - facial droop - motor weakness - language difficulties Warning Signs of Stroke - sudden numbness or weakness of face,arm,or leg especially on one side of the body

- sudden confusion;trouble speaking or understanding - sudden trouble seeing in one or both eyes - sudden trouble walking, dizziness, loss of balance or coordination - sudden severe headache with no known cause Signs and Symptoms Motor deficit (hemiplegia,dysarthria,dysphagia) Sensory deficit (perceptual deficit) Language deficit (aphasia) Visual deficit (defects in the visual fields, diplopia, decreased acuity) Intellectual or emotional deficit Bowel and bladder dysfunction Treatment For hemorrhagic treatment often requires surgery to evacuate blood and stop bleeding For ischemic the treatment is t-Pa (tissue plasminogen activator). It must be given 3 hours after the onset of stroke symptoms Medications such as aspirin, ticlopidine, clopidogrel, dipyridamole, heparin, warfarin, enoxapirine Other musch less common procedures such asangioplasty, laser emulsification, mechanical clot retrieval Nursing Interventions Caring for right hemiplegic patients 1.Do not underestimate the patients ability to learn and communicate even if he or she cannot use speech 2. If he or she cannot use speech,try other forms of communication. Pantomime and demonstration are often useful 3. Do not overestimate the patients understanding of speech and overload the patient with static

4. Do not shout. Keep messages simple 5. Divide tasks into simple steps 6. Give much feedback and many
indications of progress and brief

Caring for left hemiplegic patients 1. Do not overestimate their

abilities.Spatial-perceptual deficits are easy to miss

2. Use verbal cues if the patients have

difficulty with demonstration

3. Break tasks into small steps and

give much feedback

4. Watch to see what they can do

safely rather than taking their word for it 5.Minimize clutter around them

6. Avoid rapid movement around them 7. Highlight visual reference point

PERIPHERAL VASCULAR DISEASE

Involves occlusion of the blood supply to arteries, veins and lymphatics in the extremeties by a atherosclerotic plaques Risk factors are the same as those for CHD with diabetes and smoking being the greatest risk factors

Signs and Symptoms intermittent claudication involving pain, tightness or weakness in an exercising muscle complains of cold feet on warm days

burning pain in the feet when they are warmed leg pain and cramps when walking and completely relieved by rest diminished or absent peripheral pulses presence of bruit over the obstructed artery trophic changes maybe seen in the leg w/c imcludes thinning of the skin, loss of hair, thick nails and decreased muscle mass Treatment Lifestyle modification it is vital to control risk factors. Stop smoking,weight reduction and regular exercise program Antiplatelet and lipid-lowering therapy Percutaneous transluminal angioplasty Surgical reconstruction with aortobifemoral grafts or femoral-femoral grafts is also an option Some local treatments are important to preserve tissue - feet must be kept clean and protected from trauma - thickened nails and skin calluses should be treated by a podiatrist - infection should be treated with an appropriate antibiotic - if ulcers develop regular, gentle cleansing and application of firmly bandage