Chapter 20
Circulation
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TERMS TO KNOW
• Arrhythmia: abnormal heart rate or rhythm
• Atherosclerosis: hardening and narrowing of arteries due to
plaque buildup in vessel walls
• Physical deconditioning: decline in cardiovascular function due to
physical inactivity
• Homans’ sign: pain when the affected leg is dorsiflexed, usually
associated with deep phlebitis of the leg
• Hypertension: consistent blood pressure reading >140 mm Hg
systolic and >90 mm Hg diastolic
• Postural hypotension: decline in systolic blood pressure of 20
mm Hg or more after rising and standing for 1 minute
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Introduction
• Improved technology and increased public
awareness resulted in decline in heart
disease
• Cardiovascular disease has become the
major cause of disability and death in older
population
• Nursing interventions for prevention address
potential problems related to circulation
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Effects of Aging on
Cardiovascular Health
• Heart valves become thicker and rigid
• Aorta becomes dilated
– Slight ventricular hypertrophy
– Thickening of left ventricular wall
• Myocardial muscle less efficient
– Decreased contractile strength
– Decreased cardiac output when demands increased
• Calcification, reduced elasticity of vessels
• Less sensitive to baroreceptor regulation of blood pressure
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Effects of Aging on
Cardiovascular Health
• Conditions altering tissue perfusion
– Cardiovascular diseases
– Diabetes, cancer, renal failure
– Blood dyscrasias
– Hypotension
– Medication side effects
– Other issues of concern
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Question
Is the following statement True or False?
Symptoms of age-related changes in the
cardiovascular system become most apparent
when the older adult is faced with unusual
physiological stress.
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Answer
True
Age-related changes in the cardiovascular system
are typically gradual and become most apparent
when the older adult is faced with unusual
physiological stress, such as heightened activity or
infection.
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Cardiovascular Health Promotion
• Alterations modified by lifestyle and diet
• Identify and lower risks through education
• Important practices: proper diet, exercise,
no cigarette smoking, manage stress, and
proactive interventions
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Proper Nutrition
• Proper diet and weight
• Control of cholesterol
– Reduced cardiovascular and cerebrovascular
incidents
• Nutritional supplements
• Various diets
• Lifestyle modifications
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Adequate Exercise
• Exercise important for optimal health
• Regular exercise versus spurts of activity
• Physical deconditioning related to functional
decline
• Enhance circulation with aerobic exercise,
yoga, strengthening exercises, balance
exercises, t’ai chi
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Question
Is the following statement True or False?
Regular exercise can decrease or limit the agerelated functional declines that aging people can
experience.
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Answer
True
Regular exercise has a positive impact on
functional status of the older adult. Lack of
physical exercise, known as physical
deconditioning, can heighten many of the agerelated functional declines that aging people can
experience.
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Cigarette Smoke Avoidance
• Smokers aware of risks
• Breaking habit difficult
• Support and assistance needed for cessation
• Keep trying after failure
• Educate about limiting exposure to cigarette
smoke
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Stress Management
• Stress normal part of life
• Educate regarding identification of stressors,
reactions to stress, and effective
management
• Interventions for handling stress: relaxation
exercises, yoga, meditation, and other
stress-reducing activities
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Proactive Interventions
• Low-dose aspirin daily: preventive measure
• Alcohol: light drinking may be beneficial
• Nutritional supplements
• Comprehensive assessment of the
cardiovascular system includes C-reactive
protein screening
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Cardiovascular Disease and Women
• Prevalence increases with age
• Signs differ with women
• Education regarding cardiovascular disease
and promotion of cardiovascular health
• Guide women about not ignoring symptoms
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Selected Cardiovascular Conditions
• Hypertension
• Hypotension
• Congestive heart failure
• Pulmonary emboli
• Coronary artery disease
• Hyperlipidemia
• Arrhythmias
• Peripheral vascular disease
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Hypertension
• Incidence and prevalence increases with age
• Evaluation of blood pressure
– Systolic blood pressure ≥ 140 mm Hg
– Diastolic blood pressure ≥ 90 mm Hg
– Factors to consider when monitoring blood pressure:
anxiety, stress, and activity before assessment
• Symptoms: dull headache, impaired memory,
disorientation, confusion, epistaxis, and slow tremor
• Wide range of treatment
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Hypotension
• Decline in systolic blood pressure of
20 mm Hg or more after changing positions
• Postural and postprandial hypotension due to
increased intake of vasoactive medications
and baroreceptor sensitivity
• Consequences: falls, stroke, syncope, other
coronary complications
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Question
Postural and postprandial hypotension is most
often related to
a. Vasoactive medications and decreased
baroreceptor activity
b. Antibiotics and increased cardiac output
c. Antispasmodic drugs and increased levels of
potassium
d. Antibiotics and decreased renal function
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Answer
a. Vasoactive medications and decreased
baroreceptor activity
Studies have shown that many older adults
experience problems related to postural and
postprandial hypotension due to the increased
intake of vasoactive medications and concomitant
decrease in physiologic function, such as
baroreceptor activity.
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Congestive Heart Failure
• Incidence increases with age
• Leading cause of hospitalization
• Complication of arteriosclerotic heart disease
• Coronary artery disease responsible for most cases
• Symptoms: shortness of breath, dyspnea on
exertion, confusion, insomnia, wandering at night,
agitation, depression, orthopnea, wheezing, weight
gain, and edema
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Question
Which of the following breath sounds heard on
auscultation would indicate an exacerbation
of congestive heart failure?
a. Crackles
b. Vesicular
c. Bronchovesicular
d. Rhonchi
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Answer
a. Crackles
Some of the symptoms of congestive heart
failure in older patients include dyspnea on
exertion, confusion, insomnia, weakness,
shortness of breath, bilateral ankle edema,
and moist crackles on auscultation.
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Pulmonary Emboli
• Incidence high
• Detection and diagnosis challenging
• Risk factors: fractures, congestive heart failure,
arrhythmias, history of thrombosis, and
immobilization
• Signs/symptoms: confusion, apprehension,
shortness of breath, temperature elevation,
pneumonitis, and elevated sedimentation rate
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Coronary Artery Disease
• Ischemic heart disease
• Prevalence increase with age
• Angina
– Atypical presentation: coughing, syncope, sweating, and
confusion
– Nitroglycerin effective
– Education
• Myocardial infarction
– Atypical presentation: confusion, decreased blood pressure,
shortness of breath, elevated temperature, and
sedimentation rate
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Hyperlipidemia
• Risk of coronary artery disease with elevated
total cholesterol
• Evaluate full lipid profile, triglycerides, highdensity lipoprotein, low-density lipoprotein
• Familial tendency
• Treatment: dietary changes, medications, and
alternative and complementary therapies
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Arrhythmias
• Causes: digitalis toxicity, hypokalemia, acute
infections, hemorrhage, anginal syndrome, and
coronary insufficiency
• Symptoms: weakness, fatigue, palpitations,
confusion, dizziness, hypotension, bradycardia, and
syncope
• Treatment: antiarrhythmic drugs, digitalis,
potassium supplements, and cardioversion
• Education: modify diet, smoking cessation, decrease
alcohol, and activity
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Question
Is the following statement True or False?
Hypokalemia, acute infections, hemorrhage, and
coronary insufficiency are potential causes of
arrhythmias in the older adult population.
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Answer
True
In addition to digitalis toxicity as the most common
cause or arrhythmia, hypokalemia, acute
infections, hemorrhage, anginal syndrome, and
coronary insufficiency are potential causes of
arrhythmias in the older adult population.
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Peripheral Vascular Disease
• Arteriosclerosis: common especially among
those with diabetes
• Affects smaller vessels furthest from heart
• Diagnosis: arteriography, radiography, and
oscillometric testing
• Treatment: warmth, exercises, and
vasodilators
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Special Problems Associated with
Diabetes
• High risk for peripheral vascular problems
• Arterial insufficiency
– Resting pain: intermittent claudication
– Arterial pulses: absent or difficult to palpate
– Skin discoloration, ulcerations, and gangrene
• Diagnostic measures
• Treatment selected per extent of disease
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Aneurysms
• Advanced arteriosclerosis aids in
development of aneurysms
• Some seen, some palatable, and others
detected by radiography
• Thrombosis can develop
• Various treatments
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Varicose Veins
• Common problem
• Dilated, tortuous nature of vein
• Dull pain, cramping, can interfere with sleep
• Dizziness may occur
• Susceptible to trauma and infection
• Treatment aimed at reducing venous stasis
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Venous Thromboembolism
• Increased incidence
• High risk: restricted to bed rest, recent
surgery, and fractures
• Edema, warmth over affected area, pain in
foot, cyanosis, aching, and engorgement of
superficial veins
• Anticoagulants, surgery, elastic stockings,
bandages, and elevation of extremities
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General Nursing Considerations for
Cardiovascular Conditions
• Prevention
• Keep the patient informed
• Prevent complications
• Promote circulation
• Provide foot care
• Manage problems associated with peripheral vascular
disease
• Promote normality
• Integrate complementary therapies
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Prevention
• Incorporation of preventive measures of
planning and caregiving
• Education, counseling, coaching,
rehabilitative/restorative activities enables
prevention on three levels:
– Primary
– Secondary
– Tertiary
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Keeping the Patient Informed
• Full explanations with reinforcement
necessary for educating about diagnostic and
treatment
– Sensory deficits, anxiety, poor memory, and
illness can affect comprehension
• Opportunities to ask questions and discuss
concerns
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Preventing Complications
• Edema can promote skin breakdown
–
Change position frequently
–
Proper alignment of body
–
Monitor conditions that increase chances of edema
–
Protect from skin breakdown
–
Monitor, observe, and document
• Fluid balance
• Assessment of vital signs
• Careful administration of oxygen
• Potential for anorexia
• Potential for vagal stimulation
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Promoting Circulation
• Increased risk of altered tissue perfusion
• Interventions that improve tissue circulation
• Prevention of peripheral vascular problems
• Education about appropriate health practices
• Enhancement of circulation
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Providing Foot Care
• People with peripheral vascular disease must
pay special attention to their feet
– Bathe and inspect daily
– Avoid injury
– Prompt attention for any lesions
– Potential for fungal infections
• Interventions to prevent injury to feet
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Question
Which of the following foot care interventions
is essential to older adults who have
peripheral vascular disease?
a. Daily inspection of the feet
b. Wearing tight-fitting shoes for comfort
c. Application of heat to areas of infection
d. Vaccination to prevent varicella zoster
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Answer
a. Daily inspection of the feet
Persons with peripheral vascular disease must
pay special attention to the care of their feet,
which should be bathed and inspected daily. To
avoid injury, patients should not walk in bare feet
and shoes should be large enough to avoid
pressure and injury to the feet.
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Managing Problems Associated with
Peripheral Vascular Disease
• Care of ischemic foot lesions
– Medical and nursing management
• Loss of a limb
– Loss of independence
– Altered body image
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Promoting Normality
• Consideration of impact of cardiovascular
function on sexuality
– Often subject of interest in sex not discussed
with health care providers
• Nursing interventions that include teaching
• Relaxation and rest vital to treatment
• Considerations of stressors
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Integrating Complementary
Therapies
• Various herbs and spices considered for preventing and
treating cardiovascular disorders
• Some nonconventional measures
– Meditation
– Biofeedback
– Guided imagery
– T’ai chi
– Yoga
• Full benefit of complementary therapies is in process of
discovery: less intrusive, less expensive, and minimal
risks
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