Page 82 nursing.elitecme.com Complete Your CE Test Online - Click Here is still higher than normal, even though he takes his medication as prescribed. Mr. Lewis explains, “I eat bacon and eggs every morning. I’m not supposed to, but I’ve eaten bacon and eggs every morning for 60 years and I’m not changing now. Those egg substitutes are terrible!” Should the nurse re-emphasize the importance of eliminating his morning breakfast eggs and bacon as recommended by the dietician? Or is there a compromise that can be reached with this patient? This scenario illustrates one of the challenges of caring for older adults. Nurses know the clinical importance of adhering to diet, but sometimes a compromise must be reached. As part of cardiovascular assessment (and patient education), the nurse must be able to work with, not in opposition to, her patient’s pursuit of health and wellness. Mr. Lewis may not be willing to eliminate eggs from his diet, but would he be willing to reduce the number of times per week he eats eggs, bacon, and other foods high in fat and cholesterol? How much input has he had in his plan of care? What options has he been offered? Remember that the patient is the most important partner in the establishment of, and adherence to, an effective treatment plan. Insisting that patients adhere to a treatment plan that they have not helped to develop (nor agree with) is doomed to fail. Nursing consideration: Nurses must be realists as well as advocates for a healthy lifestyle. In Mr. Lewis’s case, the nurse must work with him to help design a treatment plan that he agrees with. Age-related changes in the cardiovascular system Cardiovascular (CV) disease is the number one cause of death in the U.S. When assessing the older adult patient’s cardiovascular system, nurses should not only be alert to normal aging changes and pathology, but to opportunities to teach patients ways to enhance their cardiovascular health. Cardiovascular changes are often a culmination of genetics, environmental effects, lifestyle choices and co-morbid disease processes [15]. It can also be challenging to distinguish between disease pathology and normal aging changes in the cardiovascular system. A decrease in cardiac tolerance may be due to disease or simply an effect of the aging process. Here are some normal cardiovascular changes that are associated with aging [9,14,15,46]: ● ● Heart valves lose elasticity and stiffen due to calcification, thus decreasing cardiac conductivity. ● ● Left ventricular wall thickens. ● ● Increased potential for postural hypotension due to decreased baroreceptor mechanisms. ● ● Increased risk for arrhythmias due to a decrease in pacemaker cells in the SA and AV nodes. ● ● Arterial elasticity decreases, which increases the risk for systolic hypertension and left ventricular hypertrophy. ● ● Decrease in maximal heart rate, cardiac output and muscle extraction of oxygen from the blood, resulting in less maximal oxygen consumption. ● ● Decreased blood perfusion to vital organs and the periphery of the body. This is due to arterial “stiffening.” This may make it difficult to palpate some peripheral pulses. ● ● Veins thicken, allowing for increased valvular reflux (backflow of blood), and increasing the risk for varicosities and dependency edema after sitting or standing for long periods of time. ● ● Decreased cardiac ability to handle stressful activities such as shoveling snow due to changes in the sympathetic and parasympathetic systems. There is an increased risk for “silent MI”. Nursing consideration: You may hear bruits (swishing or blowing sounds) over arteries such as the carotid arteries or abdomen in older adults due to atherosclerosis. Pay special attention to this finding since there is a high incidence of stroke associated with carotid bruits [14,47]. Although the preceding normal aging changes must be acknowledged, nurses should not expect older adults to experience a debilitated cardiac system as a result of aging alone. By remaining physically active, not smoking, maintaining a normal weight, eating a healthy diet, and controlling blood pressure and cholesterol, older adults can lead healthy lives and maintain a healthy cardiac status. However, chest pain, abnormal fatigue, and significant sleep disturbances are not normal and may indicate cardiac pathology. Let’s review some of the more common cardiac problems seen in older adults such as hypertension, atrial fibrillation, myocardial infarction (heart attack) and congestive heart failure (CHF). Hypertension According to the CDC, about 70 million American adults (29%) have high blood pressure (BP, and only half of those individuals have their blood BP controlled [48,49]. Untreated, high blood pressure can lead to stroke, heart attack, blindness, and renal dysfunction. It increases the workload of the heart, which can lead to heart failure and pulmonary edema [13,49]. Table 1. The National Institutes of Health classify blood pressure as follows [13,14]. Systolic Diastolic Stage 100 mm Hg Hypertension Stage 2 Nursing consideration: The definitions of hypertension have changed over the past several decades. “Normal” blood pressure is now considered to be significantly lower than many people may believe. It is important that nurses teach patients and families the limits of normal and hypertensive categories and how important it is to maintain a blood pressure within normal limits. When assessing BP, be sure that the cuff size is appropriate for the patient’s arm circumference and that the cuff is properly applied. The bladder length should be 80% of the arm circumference, with a width at least 40% of the arm circumference, with a length-to-width ratio of 2:1. Check BP in standing, sitting, and supine positions. Ask the patient if s/ he has had any beverages containing caffeine and/or if s/he is stressed or emotionally upset, which can cause an elevated reading [13,14]. Do not initiate treatment based on only one reading, especially if dietary or emotional factors influence readings [13,14]. Nursing consideration: Many healthcare professionals take blood pressure readings from only one patient position. It is important to assess blood pressure standing, sitting, and supine and to take the time to ask about recent dietary and/or any stress-related issues that may influence blood pressure. Remember that even “positive” events such as an upcoming wedding or the purchase of a “dream” home is accompanied by stress. Patient education for older adults should include these items [9,13]: ● ● Maintain a healthy weight. ● ● Reduce salt intake. ● ● Stop or do not start smoking. ● ● Initiate a medically approved exercise program. ● ● Increase potassium, especially if taking potassium-depleting diuretics. Fruits and vegetables are good sources of potassium. ● ● Reduce stress. A consult concerning methods of relieving stress (e.g., counseling, relaxation techniques, etc.) may be necessary. Nursing consideration: Remember that the patients must be active partners in developing treatment regimens! Their cooperation is essential if treatment and patient education are to be effective. Atrial fibrillation Atrial fibrillation (AFib) is the most frequently encountered arrhythmia. Currently, approximately 70% of patients with AFib are between 65 and 85 years old, and it is projected that by 2050 half of all adults will have AFib [50]. “AFib occurs when structural and/or electrophysiological