older adults 2

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kbryant86
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older adults 2
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2013-09-24 12:03:38
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older adults
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  1. Left HF results from and can lead to
    from CAD, HPT. Left sided failure can lead to right sided failure
  2. manifestations of L HF
    • result from: 
    • Decreased cardiac output: dizziness and syncope

    Pulmonary congestion: dyspnea, shortness of breath, cough, orthopnea
  3. L HF assessment
    cyanosis, breath sounds include crackles and wheezes, S3.
  4. L ventricle HF
    shortness of breath, tachypnea, audible crackles
  5. Right HF results from
    restricted blood flow to lungs, as with acute or chronic pulmonary disease
  6. manifestation  of R HF
    • result from:
    • Right sided heart distension: distended neck veins
    • peripheral tissue edema seen in dependent tissues: feet and legs or sacrum, if bedridden
    • GI congestion: nausea and anorexia
    • Liver engorgement: RUQ pain 
  7. R ventricle HF
    neck vein distension, liver enlargement, anorexia, nausea
  8. Recognize why combinations of medications may be used to treat older adults with cardiovascular problems
    With using combination medication you are able to use lower doses of medications
  9. Modifiable cardiovascular risk factors
    • l Cigarette smoking: independent risk factor
    • l  Obesity (body weight > 30% of ideal body weight)
    • l  Physical inactivity: regular activity less prone to CHD than sedentary
    • l  Diet: protective effect from diets high in fruits, vegetables, whole grains, unsaturated fatty acids
  10. non-modifiable cardiovascular risk factors
    • Age: > 50% are 65 or older; 80% of deaths
    • l  Gender: male
    • l  Race: African Americans have higher rates of Hypertension
    • l  Genetic factors: occurs in families
  11. The root cause of valvular heart disease
    • 1.      Rheumatic heart disease: most common cause
    • Damage from acute MI, which involves papillary muscles that affect valve leaf function Congenital heart disease: often manifests in adulthood
    • Effects of aging: changes in heart structure and function
  12. Circulatory changes evident during assessment of heart patient with Type 2 DM
    • 1.      Postural symptoms of lightheadedness or dizziness with standing
    • Blood pressure drops with changes in position (orthostatic hypotension)
    • Symptoms of lightheadedness may be delayed or absent altogether, giving no signal or warning of an impending fall -
  13. 1.      Assessment of patient with heart failure-
    • a.       Systolic versus Diastolic Failure
    • b.      Systolic failure: ventricle fails to contract adequately to eject sufficient blood Activity intolerance
    • c.       Due to loss of myocardial cells as with ischemia, infarction, cardiomyopathy, inflammation
    • d.      Results in decreased cardiac output: fatigue, decreased exercise tolerance
    • e.       Diastolic failure: heart cannot completely relax resulting in less than normal filling
    • f.       Due to decreased ventricular compliance
    • g.      Manifestations from increased pressure and congestion behind ventricle
    • h.      Left ventricle: shortness of breath, tachypnea, audible crackles
    • i.        Right ventricle: neck vein distension, liver enlargement, anorexia, nausea
    • j.        Often components of systolic and diastolic failure are present
  14. Categories of drugs to treat HTN and heart failure 
    • Beta Blockers
    • ACE Inhibitors
    • Calcium Channel Blockers
    • Nitrates
  15. Beta Blockers
    • Treatment of:HTN &CHF=Concurrent drug use ACE inhibitors & diuretics…
    • Nonselective=Block both β1 (cardiac) and β2 (smooth muscle in the bronchi and blood vessels) receptors
    • Selective= More effect on β1 receptors than on β2 Preferred when β blockers are needed by patients with asthma or other bronchospastic pulmonary disorders, diabetes, or peripheral vascular disorders. Reduces heart rate, cardiac work and myocardial oxygen demand thus Reduces pain Limits infarct size Decrease serious ventricular dysrhythmias Oral therapy continued to reduce risk of re-infarction and death from cardiovascular causes
  16. Ace Inhibitors
    Angiotensin converting enzyme (ACE also called kininase) is located in the endothelial lining of blood vessels which is the site of production of most angiotensin II. Block ACE (the angiotensin converting enzyme) Decrease vasoconstriction Have a vasodilating effect Decrease aldosterone production Reduce retention of sodium and water Inhibit the breakdown of bradykinin Which prolongs bradykinin’s vasodilating effects. Widely used to treat heart failure and HTN May decrease morbidity and mortality in other cardiovascular disorders Improve post-Myocardial Infarction survival when added to standard therapy of aspirin and a beta blocker Reduce ventricular remodeling post MI: Reduce risk for development of heart failure Reduce risk of re-infarction
  17. Nitrates-
    • Reduces myocardial work by reducing afterload by vasodilation which also increases coronary blood flow
    • Observe for excessive reflex tachycardia or excessive hypotension
  18. Calcium Channel Blockers- 
    • Reduces myocardial oxygen demand
    • Increases myocardial blood and oxygen supply
    • Acts by lowering blood pressure and heart rate
    • Reduces myocardial contractility
    • Potent coronary vasodilatorsLong term prophylaxis of angina
    • Used cautiously in clients with dysrhythmias, heart failure, hypotension
  19. 1.      Sympathetic nervous system response: alpha versus beta receptors

    Beta-Nonselective 

    Beta Selective
    B-NS= Block both β1 (cardiac) and β2 (smooth muscle in the bronchi and blood vessels) receptors-

    • B-S= More effect on β1 receptors than on β2 Preferred when β blockers are needed by patients with asthma or other bronchospastic pulmonary disorders, diabetes, or peripheral vascular disorders
  20. 1.      Sympathetic nervous system response: alpha versus beta receptors

    Alpha
    A1 cause vasodilation
  21. .      Cardiovascular Symptoms of heart failure 
    • Activity intolerance,
    • Tachycardia, Palpitations S3, S4 Heart Sounds, Elevated central venous pressure,
    • Neck Vein distention, Hepatojugular reflex, Splenomegaly Potential
    • Complications, Angina, Dysrhythmias ,Sudden cardiac death,Cardiogenic
  22. Neurogenic Symptoms of heart failure-
    Confusion ,Impaired Memory, Anxiety, Restlessness, Insomnia
  23. Resp Symptoms of heart failure-
    Dyspnea on exertion, Shortness of breath, Tachypnea , Orthopnea , Dry cough, Crackles (rales) in lung bases, shock
  24. Genit-Urinary Symptoms of heart failure-
    Decreased urine output, Nocturia
  25. GI Symptoms of heart failure-
    Anorexia, nausea, Abdominal distention, Liver enlargement. Right upper quadrant pain
  26. Ms. Skele Symptoms of heart failure-
        1. Fatigue, Weakness
  27. Skin Symptoms of heart failure-
    Pallor or cyanosis, Cool, clammy skin, Diaphoresis
  28. Other potenial complications- Symptoms of heart failure-
    Malnutrition, Ascites, Liver dysfunction

    Increased risk for tissue breakdown, Metabolic processes, Peripheral edema, Weight gain, Potential Complications, Metabolic Acidosis
  29. Assessment cardiovascular function
    a.       Use of alcohol and caffeine, Use of tobacco products, type, duration, amount, efforts to quit, Use of street drugs, type, efforts to quit, Activity level and tolerance, recreation and relaxation habits, Sleep patterns; interruptions due to dyspnea, cough, discomfort, urination, stress, Pillows used to sleep, Psychosocial factors, Personality type
  30. Objective of cardio assessment
    Perception of health or illness, compliance with treatment, Thrill (palpable vibration over precordium or artery): severe valve stenosis; Palpable thrill: suggests arterial narrowing as with atherosclerosis, Bruit- Murmuring or blowing sound heart over blood vessel suggests atherosclerosis, Aortic Aneurysm- increased pulsation at aortic area, Palpable second heart sound (S2): systemic HTN, Pulse deficit (Radial pulse < than apical when checked simultaneously): weak ineffective contractions of left ventricle, Irregular rhythm: frequent ectopic beats such as premature ventricular beats, atrial fibrillation
  31. Early s/s cardiac problems older adult
    • a.       Mental status changes
    • b.      Agitation
    • c.       Frequent falls
  32. 1.      Normal heart rate and hrt rate for older adult
    a.       Heart Rate (HR): number of cardiac cycles in a minute (normal 70 –80)(for the older adult, normal may be 70-100, depending on their activity level)
  33. Chambers of heart and their jobs:
    RA
    RV
    LA
    LV
    • RA= receives deoxygenated blood from the veins of the body
    • RV=  receives deoxygenated blood from the Right Atrium and pumps it through the pulmonary artery to the lungs for oxygenation

    • LA= receives freshly oxygenated blood from the lungs through the pulmonary
    • veins
    • LV= receives the freshly oxygenated blood from the Left Atrium and pumps it
    • out the Aorta to the arterial circulation 
  34. Anticoagulant therapy- 
    • 1.      Maintain coronary artery patency post thrombolysis or revascularization procedure- Abciximab (ReoPro)
    • suppresses platelet aggregation- Heparin, standard or low-molecular-weight
  35. Etioligy of Hrt failure
    • Atherosclerotic CHD is the most common etiology of HF in the US,
    • followed closely by HTN alone and valvular disease

    ***Consider the possibility of asymptomatic or silent ischemia or infarction as a cause of HF
  36. Aminophylline safe administration- 
    bronchodilator use for long-term control of reversible airway obstruction caused by COPD, asthma, or pneumonia. Increases diameter of bronchi and alveoli. Can be administered PO or IV. -can be used IV or orally, has narrow therapeutic range so can be very dangerous (10-20)-initial dose reduction may be necessary in older adults (IV)-signs of toxicity: increased confusion, nausea, complaints of anorexia, sees different colors, dehydration
  37. Patient teaching about anticoagulant therapy
    Avoid dangerous sports, shave with electric razor, use soft tooth brush, use waxed dental floss, wear gloves for yard work, wear no slip foot wear, trim nails carefully, monitor fo s/s of bleeding brusing ex.
  38. Peripheral vascular resistance
    a resistance to the flow of blood determined by the tone of the vascular musculature and the diameter of the blood vessels. It is responsible for blood pressure when coupled with stroke volume
  39. Effects of the SNS on cardiac vasculature
    Action of kidneys to excrete or conserve sodium and water=Kidneys initiate renin-angiotensin mechanism in response to decrease in blood pressure, Release of aldosterone from adrenal cortex, Sodium ion reabsorption and water retention, Kidneys reabsorb water in response to pituitary release of antidiuretic hormone, Increase in blood volume and therefore increase in cardiac output and blood pressure
  40. Atherosclerosis question from the PVD tutorial done in LRC
    • a.       Peripheral Artery disease- intermediate claudification, Diminished absent pulse, Skin shiny rubber thick hair and nails, Mild peripheral edema, Deep round punched out appearance, found on toes and feet,  Complication gangreen
    • b.      DVT- Localized pain in safé, Pulse present, Skin red sore warm, sudden unilateral edema, complication pulm emboli
    • c.       Chronic venous in sufficiency- Dull pain, Pulse present but hard to find with edema, Brawny brown pigmentation with tough skin, ankle edema that increases through out day, superficial uneven edges found over inner or outer ankle, complication chronic non healing ulcer
    • d.      Acute arterial occlusion- acute sudden onset, Pulse absent but distal to obbclusion, Pale cyanotic skin feels cool, no edema, comp necrosis and gangrene w/I hours
  41. Acute care rehab
    Physical, occupation and speech therapy
  42. Ace Unit-  
    It is an acute care inpatient unit designed to allow us to care for older adults while focused on improving clinical outcomes paying particular attention to:Medications, Safety from falls ,Skin care ,Pain control and pain management ,Promotion of appropriate physical activity,Quality of life    
  43. Nursing intervention and goals for management of chronic pain
    The management of chronic musculoskeletal pain in the elderly requires a knowledge of: pain mechanisms; diagnoses; and disease progression. Pain control in the elderly involves extensive use ofanalgesics, among them the non-steroidal anti-infl amatory drugs (NSAIDs), paracetamol (acetaminophen), and various, narcotics.
  44. Assessment of patient with osteoarthritis
    18    Pain, swelling, and bony overgrowth are common, as well as stiffness that follows awakening or inactivity and disappears within 30 minutes, particularly if the joint is moved.
  45. risk factors of OA
    • obesity
    • overuse of joint
    • trauma
    • cold climate
    • 'wear and tear arth"
  46. 18    Rheumatoid arthritis education and treatment.
    • a.       Treatment can include:Assistive devices and splints ,Rest and exercise,Drugs,Nonsteroidal anti-inflammatory drugs [NSAIDs],Disease-modifying antirheumatic drugs, Immunosuppressive drugs, Heat and cold,Surgery.  Pain relief prevent complications of immobility, exercise and rest, antirheumatic drugs
    • b.      Education for RA-  can still remain physically active but back off when you have a flare up, Rest when inflamed, gentle ROM/ stretching
  47. 18    Nursing diagnosis for patient with RA- 
    • a.       Acute Pain
    • b.      Impaired physical mobility
  48. 18    Osteomalacia causes, assessment, treatment
    • a.       Cause- Vitamin D Deficiency, Phosphate Depletion, Systemic Acidosis, Bone Mineralization Inhibitors,Chronic Renal Failure,Calcium Malabsorption
    • b.      Assessment- Blood test to check vitamin d, creatinine calcium and phosphate, Check bone softening loss with bone xray, biopsy and density test, Other tests may be done to determine if there is another underlying disorder. These tests include:
    • c.       ALP (alkaline phosphatase) isoenzyme ,PTH
    • Treatment- Treated with vitamin D, calcium, and phosphorus supplements, taken by mouth. Larger doses of vitamin D and calcium may be needed for people who cannot properly absorb nutrients into the intestines.
  49. care plan for osteoporosis
    • treating chronic pain
    • ditrubed body image
    • mal-nutrition
    • imparied physical mobility
  50. 18    Relationship of musculoskeletal disorders to frequency of fractures
    Bones become stiffer, weaker, and more brittle

    osteoporosis
  51. Prevention and Tx of Osteoporosis
    • adequate Ca++ and Vit. D.
    • stretching and weight bearing activity
    • taking bisphosphonates
  52. Musculoskeletal system altered function
    Disproportionate size of long bones of arm and legs, Seen in eighth and ninth decades, Kyphosis ,Backward tilt of the head for eye contact, Erosion of joint linings, Thinning knee cartilage, Ligaments, tendons, and joint capsules Lose elasticity Reduced range of motion Stiffening of collagen 
  53. Nursing diagnosis for musculoskeletal problem
    Impaired physical mobility
  54. 18    Musculoskeletal change that can impact respiratory status
  55. Osteomalacia cause and Tx 
    • a.       Cause- Vitamin D Deficiency, Phosphate Depletion,Systemic Acidosis, Bone Mineralization Inhibitors, Chronic Renal Failure,Calcium Malabsorption
    • b.      Treatment- Treated with vitamin D, calcium, and phosphorus supplements, taken by mouth. Larger doses of vitamin D and calcium may be needed for people who cannot properly absorb nutrients into the intestines
  56. Assessment of patient with Paget’s disease
    • 18    bigger bone but bone is not stronger breaks easy!!!
    • Clinical manifestations, Deep, aching pain, Muscle spasms, Bowing of legs, Gait changes, Mobility impairments, Stress fractures, Hypnosis ,Cord compression, Paralysis
  57. Rhabdomyolysis symptoms- 
    Muscle weakness malaria dark urine
  58. Viral Upper Resp INfection (URI)
      • URI and common cold
      • Most common respiratory tract infections
      • Highly contagious
      • Prevalent in school and work environments
      • Most adults experience 2 – 4 colds per year
  59. URI pathophysiology
      • More than 200 strains of virus cause URI; spread by aerosolized droplet nuclei during sneezing, coughing or direct contact.
      • Infected individuals are highly contagious and shed virus few days before manifestations appear
  60. manifestations of URI
      • Nasal mucous membranes red and boggy; nasal congestion
      • Coryza, rhinnorrhea: profuse nasal discharge
      • Sore throat
      • Systemic: low-grade fever, headache, malaise, muscle ache
      • Manifestations last from few days to 2 weeks, usually mild, self-limiting
  61. complications of URI
      • More serious bacterial infections: sinusitis, otitis media
      • Usually self care unless complications require medical care
      • Symptomatic treatment
      • Rest
      • Maintain fluid intake
      • Avoid chilling
      • Covering mouth and nose
      • Avoid crowds
  62. Tx of URI
      • Mild decongestants
      • Over the counter antihistamines
      • Warm gargles
  63. Manifestations of PE
      • Asymptomatic, if very small
      • Usually develops abruptly: dyspnea, pleuritic chest pain
      • Anxiety, impending doom
      • Diaphoresis, low grade fever
      • Hemoptysis
      • Massive embolus results in syncope and cyanosis
  64. Tx of PE
    prevention
  65. risk factors for PE
      • Prolonged immobility
      • Trauma
      • Myocardial infarction
      • Obesity
      • Advanced age
  66. Emphysema
    Pink Puffer

      • Characterized by destruction of alveolar walls with enlargement of abnormal air spaces; major factor: cigarette smoking
      • Enlarged air spaces causes loss of portions of pulmonary capillary bed decreasing gas exchange; loss of support tissue causes airways to collapse during expiration leading to trapped air
  67. Pink Puffer Tx
      • Remain inside during times of significant air pollution; air filters and air conditioning
      • Pulmonary hygiene measures
      • Hydration
      • Effective cough: “huffing” between relaxed breathing
      • Percussion and postural drainage
      • Avoiding cough suppressants and sedation
      • Regular exercise program
      • Improve tolerance
      • Improve ability for ADLs
      • Prevent physical deterioration
      • Breathing exercises to slow respiratory rate and relieve accessory muscle fatigue
      • Pursed-lip breathing
      • Abdominal breathing
      • Oxygen
      • Long term therapy used for severe, progressive hypoxemia
      • Intermittent or continuous, only at night
      • If oxygen administered without intubation and mechanical ventilation, use with caution
      • Chronic elevated carbon dioxide levels and do not respond to that as stimulus to breathe
      • Responds to low levels of oxygen as stimulus to breathe; giving high flow rates of oxygen will reduce all stimulus to breathe
      • Surgery: Lung transplantation may be only option if medical therapy not effective
      • STOP SMOKING
  68. Resp health assessment
      • Subjective data (What is the patient telling you about these things?)
      • Difficulty in breathing: pausing to breathe in mid sentence
      • Hoarseness, change in voice quality, and cough
      • Pain in nose, throat, or chest
      • Cough
      • Type and when it occurs
      • Productive and type of sputum,
      • What brings relief
      • Dyspnea: association with activity, time of day
      • Chest pain
      • Problems with swallowing, smelling, taste
      • Nosebleed, nasal or sinus stuffiness or pain
      • Current medication use, aerosols or inhalants, oxygen use
  69. pneumonia
      • Inflammation of lung parenchyma (respiratory bronchioles and alveoli)
  70. care of pt w/ pneumonia
        • Older and debilitated clients may be atypical: little respiratory distress; more likely: NO fever, but: tachypnea, altered mentation or agitation


        • Immunizations: 


        • Pneumococcal vaccine: antigens from 23 types of pneumococcus, imparts life long immunity


        • Influenza vaccine: recommended for high-risk populations


        • Medications: antibiotics and bronchodilators


        • Resp Tx: spirometer, O2, chest physiotherapy (vibrations etc.)


        • Inc. fluid intake
  71. exacerbation of emphysemz
      • Insidious onset: initially dyspnea on exertion; progresses to severe dyspnea occurring at rest
      • Anterior-posterior chest diameter increases due to air trapping, hyperinflation: barrel chest
      • Client is often thin, tachypneic, uses accessory muscles to breath and leans forward while sitting to ease breathing
      • Prolonged expiration; diminished breath sounds and percussion tone is hyperresonant
  72. Chronic Bronchitis
    Blue Bloater

      • Excessive bronchial mucus secretion; major factor: cigarette smoking
      • Characterized by productive cough lasting 3 or more months in 2 consecutive years
      • Client develops narrowed airways, impaired ciliary function, recurrent infection, pulmonary hypertension, right-sided heart failure
  73. discharge planning for blue bloater
  74. sleep patterns associate with resp health
    • sleep apnea
      • Intermittent absence of airflow through mouth and nose during sleep
      • Leading cause of excessive daytime sleepiness
      • Loud snoring during sleep
      • Excessive daytime sleepiness
      • Headache, irritability and restless sleep
  75. Central sleep apnea
    neurological disorder involving transient impairment of neurology drive to respiratory muscles

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