Community Prep Guide: Blood Pressure Clinic

Age-related Changes:

Cardiovascular:

• Myocardial degenerative changes

• Amyloid deposits (amyloid = a waxy translucent substance consisting
primarily of protein that is deposited in organs & tissues)
• Lipofuscin accumulation (lipofuscin = a dark brown lipochrome. Lipochrome
= naturally occurring pigments soluble in fats)
• Basophilic degeneration (degeneration of white blood cells)
• Myocardial atrophy or hypertrophy
• Valvular thickening and stiffening
• Increased amounts of connective tissue
• Arterial stiffening: Can lead to: atherosclerosis (thickening & hardening of
artery walls), hypertension
• Increased peripheral resistance due to decreased elasticity
• Altered baroreflex mechanisms (mechanisms which regulate blood pressure)
• Veins become thicker, more dilated, and less elastic with increasing age.
• Tiny capillaries lose their effectiveness/function

Age-Related Changes:
Source: http://www.innvista.com/health/anatomy/cardage.htm

The cardiovascular system is sometimes called the circulatory system because it is

comprised of the heart, blood, and blood vessels (arteries, veins, and capillaries).
Because it is responsible for circulating oxygen and nutrients to all parts of the
body, it is, understandably, one of the body systems most affected by age.

The walls of the arteries thicken, lose their elasticity, and become stiffer. This
causes a decrease in blood flow to vital organs and causes blood pressure to rise.
Major age-related changes include the following:

Blood

• A decreased hematocrit (the number of erythrocytes in the whole blood) can

lead to anemia, as well as certain dietary deficiencies. Erythrocytes also help
in the transport of oxygen and carbon dioxide and in maintaining a normal
acid/base balance.
• Peripheral veins become constricted or blocked by the formation of
stationary blood clots (thrombus). These can dislodge, causing an embolism
in the lungs or an extremity, thus shutting down circulation. When this
happens, it most often means an amputation.
 • Because the valves in leg veins are often not able to work to capacity, blood
often pools causing swelling of the lower extremeties.
• One thing that does remain constant with age is the volume and composition
of blood. This means that most lab values remain normal. Abnormal lab
values for blood tests usually indicate alterations in other organ systems. For
instance, fasting blood glucose level increases with aging but not as a result
of changes in the blood. Rather, it is the result of age-related changes
associated with insulin. The same holds true for serum lipids. While serum
lipids increase 25-50% after the age of 55, the increase results from an
altered metabolism and not to changes in the blood or blood-forming organs.
• The amount of red bone marrow decreases with age, causing a decline in the
formation of new blood cells. Therefore, recovery from bleeding episodes will
be slowed.
• Age-related decline also occurs in WBC (white blood cell) activity. Although
WBC activity increases in response to infection, it does so more slowly.
Cardiac muscle fibers and neurons cannot be replaced, and cumulative
lapses result from even relatively minor damage.

Blood Vessels

• Blood vessel walls become thicker and tougher. Since the walls no longer
have the elasticity to adjust to sudden changes in blood pressure, there is an
increased risk of aneurysms.
• As the inner surface of blood vessels become roughened, age-related
changes cause an increased risk in the development of fatty plaques and of
thrombus formation.
• Weakened vascular walls also collect calcium salts, which increase the risk of
heart attack or stroke.
• As the walls of veins weaken and stretch, their valves become incompetent.
This is more likely to occur in the legs where the walls are subject to greater
pressure as the blood struggles to return to the heart against the force of
gravity. As a result, distended superficial veins develop (varicose veins). An
inflammation, called phlebitis, also occurs more often in the elderly.
• Baroreceptors become less sensitive; therefore, adjustments to changes in
position are slowed, causing an increase in dizziness and falling.

Heart

• There is a reduction in exercise cardiac output. Because the heart is not able
to pump the blood as efficiently, circulation is slowed. In addition, the heart
cannot respond as quickly, or as forcefully, to the increased workload of the
exercised heart. Exertion, sudden movements, and changes in position may
cause a decrease in cardiac output, resulting in dizziness and loss of balance.
However, opinions vary as to whether or not there are changes in the resting
cardiac output. In general, heart resting output is decreased to 80% by age
50 and to 70% of capacity by age 70. When output does decline, it is often
 associated with such other age-related processes as atherosclerosis. A
reduction in cardiac output leads to pooling of blood in the legs, cold
extremeties, and edema.
• The health of the myocardium (the heart’s muscular wall) depends on blood
supply, and with age, the likelihood of athersclerosis increases, causing the
coronary arteries to narrow, restricting the vital blood supply.
• High blood pressure (hypertension) causes the left ventricle to work harder.
It may enlarge and outgrow its blood supply and thus becomes weaker.
• Several structural changes in the heart contribute to the impaired response
to exercise:
o heart muscle loses elasticity and becomes more rigid;
o heart valves become thickened by fibrosis and more rigid (leading to
murmurs);
o the number of pacemaker cells decreases;
o aging heart cells have a decreased ability to use oxygen;
o arrythmias are more common with age as the cells of the conduction
pathway become less efficient.
• An age-related increase occurs in blood pressure. As a result, the heart
needs to work harder to pump blood into the systemic circulation.

Normal Limits:

Canadian Statistical Data:

Source:
http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3484023/k.2174/Heart_diseas
e__High_blood_pressure.htm?gclid=COf8rZSHjp4CFSUMDQodAwvxoA
http://www.heartandstroke.on.ca/site/c.pvI3IeNWJwE/b.3581729/k.359A/Statistics.h
tm

• High blood pressure – also known as hypertension – affects one in five

Canadians.
• It is the number one risk factor for stroke and a major risk factor for heart
disease, so it is very important that it is properly controlled.
 • Yet 42 per cent of Canadians with high blood pressure don't even know they
have it because there are no symptoms. You can't see it. You can't feel it.
But the good news is that you can control it.
• With proper diagnosis and treatment of high blood pressure, you can cut
your risk of stroke by up to 40 per cent and heart attack by up to 25 per
cent.
• Every 7 minutes in Canada, someone dies from heart disease or stroke.
• Stroke is the third leading cause of death in Canada. Six percent of all deaths
in Canada are due to stroke.
• Each year, more than 14,000 Canadians die from stroke.
• Each year, more women than men die from stroke.
• More than 50,000 strokes occur in Canada each year. That’s one stroke
every 10 minutes.
• For every 100,000 Canadian children under the age of 19, there are 6.7
strokes.
• About 300,000 Canadians are living with the effects of stroke.
• After age 55, the risk of stroke doubles every 10 years.
• A stroke survivor has a 20% chance of having another stroke within 2 years.
• Five million Canadian adults have high blood pressure, representing 22% of
the adult population.
• Of Canadians with high blood pressure:

 42% are unaware of their condition

 Only 16% have it treated and under control.

Women and blood pressure: Women with high blood pressure have a 3.5-times
greater risk of developing heart disease than women with normal blood pressure.

In 2005

 15.7% of Canadian females (12 years and older) had high blood pressure.
 21.3% of Canadian women (45-64 years of age) had high blood pressure.
 47.9% of Canadian women (65 years and older) had high blood pressure.

Risk Factors: (Differentiate between modifiable and non-modifiable)

Source: http://highbloodpressure.about.com/od/understandyourrisk/tp/risk_tp.htm

1. Age (non-modifiable)
Being older than age 55 is an important risk factor.

2. Ethnicity (non-modifiable)

Being black is associated with a higher risk of developing high blood pressure. New
studies are inconclusive on whether the risk is equivalent between African
Americans and people of African heritage who have never left the African
continent.

3. Gender (non-modifiable)

At younger ages, women are less likely to develop high blood pressure than men.
This risk equalizes later in life, but statistically, women are still less likely to
develop high blood pressure, overall.

4. Family History (non-modifiable)

Having a family history of high blood pressure places you in a higher risk category
than someone with no family history of high blood pressure. However, what this
actually means is still a topic of research. It is clear that family history plays an
important role in determining risk, but there are probably more important factors,
and they are under your control.

5. Smoking (modifiable)

Smoking is the number 1 risk factor over which you have control. Smoking is such
a powerful risk factor for so many different human diseases that doctors are
encouraged to ask every patient who smokes if they would like to quit - every time
they visit the office! Quitting smoking is the best thing you can do for your health.

6. Activity Level / Exercise (modifiable)

A low exercise lifestyle leads to a weak heart, poor exercise tolerance, and obesity.
All of which have been implicated in the development of high blood pressure.

7. Diet (modifiable)

While there is evidence that specific items, such as salt, can worsen high blood
pressure in certain individuals, the main impact that diet plays in high blood
pressure risk is that it is a big factor in how much you weigh.

8. Medications and Street Drugs (modifiable/non-modifiable)

Certain medications can cause or worsen high blood pressure, as can a wide
variety of street, or "recreational" drugs, like cocaine, crack, and amphetamines
("speed").

9. Kidney Problems (non-modifiable)

The kidneys are very important regulators of long term blood pressure, and
damage to the kidneys - such as can occur from diabetes - almost invariably leads
to high blood pressure.

10. Other Medical Problems (non-modifiable/modifiable)

Hormone imbalances, certain anatomic abnormalities, tumors, and other medical

problems can cause a type of high blood pressure known as secondary
hypertension.

Nutrition:

An individualized eating guide for this group of elderly Americans recognizes their
special nutrient needs. As a result of common health problems and bodily changes
that occur with aging, people over the age of 70 years have:

1. Decreased energy needs

2. A need for increased nutrient density in daily food selections
3. An increased need for fiber (20 g/d)
4. Increased needs for calcium (1200-1400 mg/d), vitamin D (600 IU), and
vitamin B-12 (with nutritional supplements sometimes necessary to achieve
these levels)
5. Special concerns for adequate hydration. Drinking 8 cups of fluid/day is
recommended, in addition to any alcohol or caffeine-containing beverages
consumed, and regardless of a lack of sensation of thirst.

Hallmarks of previous food selection guides that remain important for older
healthy, active adults include:

1. Choosing a variety of foods

2. Eating a diet high in grain products, fruits and vegetables
3. Eating a diet low in saturated fatty acids and cholesterol
4. Using low to moderate amounts of sugar, salt, and alcohol
5. Balancing energy intake with physical activity

Specialized recommendations for the "70 and over" senior crowd are:
 1. Choose the lower number of recommended servings from each food group.
2. For grain products, choose whole grain, enriched/fortified products; brown
rice rather than white; and a high fiber breakfast cereal fortified with vitamin
B-12 and folic acid.
3. From the vegetables and fruits, choices should include deeply-colored
produce and the whole food rather than just the juice. Dark green, orange,
red and yellow ones should be chosen often.
4. Dairy choices should emphasize low fat selections, with at least 3 calcium-
rich product servings/d, or the equivalent in calcium-fortified orange juice or
in nutritional supplements.
5. From the meat/poultry/fish/dry beans/egg/nuts food group, choose a variety
of lean cuts of meats and poultry. Eat fish at least once a week and legume
dishes at least twice a week instead of a meat main dish.
6. Most fat choices should be limited. Those chosen should consist primarily of
a variety of liquid oils, or foods prepared with oils, rather than hydrogenated
or saturated fats.
7. Food selections with refined carbohydrates (sugar) should be kept to a
minimum.

Nutrient Recommendations for Adults 50+ Years:

Calcium 700 mg
Phosphorus 550 mg
Magnesium 270 mg
Sodium 1600 mg
Potassium 3500 mg
Chloride 2500 mg
Iron 14.8 mg
Zinc 9 mg
Copper 1.2 mg
Selenium 60 μg
Iodine 140 μg
Vitamin A 600 μg
Thiamine 0.8 mg
Riboflavin 1.1 mg
Niacin 12 mg
Vitamin B6 1.2 μg
Vitamin B12 1.5 μg
Folate 200 μg
Vitamin C 40 mg
Vitamin D 10 μg
Explain the negative functional consequences for a client whose
assessment falls outside the normal limits.
Source: http://www.holisticonline.com/Remedies/Heart/hypert_consequences.htm

Consequences of Untreated High Blood Pressure:

High blood pressure is dangerous because it makes the heart work too hard.
It also makes the walls of the arteries hard. High blood pressure increases the risk
for heart disease and stroke. High blood pressure can also cause other problems,
such as heart failure, kidney disease, and blindness. The ultimate consequence of
long term high blood pressure could be death.

Stroke

High blood pressure is the most important risk factor for stroke. Very high pressure
can cause a break in a weakened blood vessel, which then bleeds in the brain. This
can cause a stroke. If a blood clot blocks one of the narrowed arteries, it can also
cause a stroke.

Impaired Vision

High blood pressure can eventually cause blood vessels in the eye to burst or
bleed. Vision may become blurred or otherwise impaired and can result in
blindness.

Arteries and Coronary-artery disease

As people get older, arteries throughout the body "harden," especially those in the
heart, brain, and kidneys. High blood pressure is associated with these "stiffer"
arteries. This, in turn, causes the heart and kidneys to work harder.

Kidney Damage

The kidneys act as filters to rid the body of wastes. Over time, high blood pressure
can narrow and thicken the blood vessels of the kidneys. The kidneys filter less
fluid, and waste builds up in the blood. The kidneys may fail altogether. When this
happens, medical treatment (dialysis) or a kidney transplant may be needed.

Heart Attack

High blood pressure is a major risk factor for heart attack. The arteries bring
oxygen-carrying blood to the heart muscle. If the heart cannot get enough oxygen,
chest pain, also known as "angina," can occur. If the flow of blood is blocked, a
heart attack results.

Congestive Heart Failure

High blood pressure is the number one risk factor for congestive heart failure
(CHF). CHF is a serious condition in which the heart is unable to pump enough
blood to supply the body's needs.

Consequences of low blood pressure:

Even moderate forms of low blood pressure can cause not only dizziness and
weakness but also fainting and a risk of injury from falls. And severely low blood
pressure from any cause can deprive your body of enough oxygen to carry out its
normal functions, leading to damage to your heart and brain.

Summarize the priority areas of health teaching you would provide to a client
attending this screening clinic. Identify what teaching strategies you would use.
State the rationale for each area of content. NB: identify teaching content that
addresses prevention and management for this screening topic
Source: http://www.hypertensionfoundation.org/patients.cfm

Explain the desired limits of BP and explain hypertension and its effect on the
heart, blood, vessels, kidneys and brain (see prep guide)
• Rational:
Provides a basis for understanding elevations of BP and clarifies
misconceptions and also understanding that high blood pressure can exist
without symptoms or even when feeling well.

Assist the patient in identifying modifiable risk factors (i.e. diet high in sodium,
saturated fats and cholesterol) that contribute to hypertension.
• Rational: These risk factors have been known to contribute to hypertension

Encourage client to decrease or eliminate caffeine (tea, coffee, cola, chocolate)

 • Rational: Caffeine is a cardiac stimulant and may adversely affect cardiac
function

Teach client warning signs of stroke and heart attack.

• Rational: The client can get the help they need if they are able to identify
warning signs.

Provide information regarding community resources and support client in making

lifestyle changes.
• Rational: Community resources like health care centers and check ups are
helpful in controlling hypertension.

If you are overweight – lose weight – 1–2 lbs a week: avoid fad or rigid diets.
• Rational: Weight loss is the single most effective non-drug method for
lowering blood pressure and helping to correct other risk factors for heart
disease like diabetes and abnormal amounts of cholesterol in the blood.

Reduce Salt Intake: Avoid processed foods, canned soups,

tomato juice, and obviously salty foods such as pretzels, pickles,
etc. – avoid foods with more than 150 mg of sodium in each
portion.
• Rational: Reducing sodium intake may be sufficient to
control mild HTN

Exercise Regularly: You do not have to jog or run – walking for 30–45 minutes 3–4
times a week, climbing extra stairs, participating in sports that you enjoy will help
to reduce your heart attack risk and may lower blood pressure
• Rational: Individuals who are less active and less physically fit have a 30%-50% greater
frequency (incidence) of hypertension. Clinical trials have shown that physical activity may
reduce blood pressure in hypertensive and normotensive (having normal blood pressure)
individuals, independent of changes in weight.
Stop Smoking: If you are one of the decreasing numbers of people who still smoke.
• Rational: This may not lower your blood pressure but it will eliminate one of
the most important heart attack risk factors.

If your blood pressure remains above 140/90 mm Hg despite weight reduction if

appropriate, a lower salt diet, and an exercise program, discuss the use of
medication with your doctor.
• Rational: Numerous studies have demonstrated that lowering even a
slightly elevated blood pressure will reduce the risk of stroke, heart attack,
or kidney failure. Most people with hypertension will need some medication
to lower blood pressure to normal levels. There are many safe and effective
medications available.

Note: If you are put on medication, take it. It won’t do you any good in the
medicine cabinet.