A Closer Look OnCardiomyopathy

Presented by: Josephine Mick – Surgery Ward Dept.

Demographic Data

DEMOGRAPHIC DATACASE NUMBER: 206***

Name: Mr. G

Age: 55 y/o

Gender: Male

Admitted on: June 20, 2013

Discharged on: June 25, 2013

Nationality: Sri Lankan

Admitting Physician: Dr. U

Chief Complaint: Shortness of breath

Diagnosis: Cardiomyopathy

Physical Assessment

PHYSICAL ASSESSMENTGeneral Appearance:

Patient is conscious and oriented, ambulatory and distressed

Vital Signs:Blood Pressure: 110/70 mmHgPulse Rate: 130 bpmRespiratory Rate: 26 cpmTemperature: 36.5 °C

Integumentary System:

Has a dark complexion Skin is intact Rashes Blisters Edema

> Scalp has no lesions, tenderness or masses on palpation.

> Hair is short and black in color. Evenly distributed, covers the whole scalp.

> Nails are thick. Capillary refill: 4 seconds.

Head and Neck: Symmetrical in shape Normocephalic Can move facial muscles Neck veins are not distended

Involuntary muscle movements No tenderness 

Eyes:Evenly placed and in line with each other.Eyes are not protruding.Both conjunctivae are pinkish in color.Sclerae is white in color.Pupils equally round, reactive to light, and

accommodate. (PERRLA)

Ears:The ear lobes are bean shaped, parallel,

and symmetrical.Skin is same in color as in the complexion.No lesions noted on inspection.Able to hear sounds well.

Nose and Sinuses:Nose is in the midline.No discharges.No tenderness upon palpation.Nasal flaring noted.

Mouth and throat:Lips are not dry and no swelling noted.No gum bleeding noted.No loose tooth noted.Gag reflex is present.Able to move the tongue freely and with

strength.Surface of the tongue is rough.

Thorax and Lungs: Bilateral wheezing along with decreased air

entry at bases noted.RR: 26 cpmSPO2 on room air is 78%.Breasts has no lumps and lesions

Abdomen:Soft, no distention noted.Bowel sounds present.

Musculoskeletal System:No involuntary movements.No edema.Can perform complete range of motion.No crepitus noted on joints.

Cardiovascular System:S1 and S2 are heard.No abnormal heart sounds is heard.BP: 110/70 mmHgPR: 130 bpmNo edema noted on all extremities.

Genitourinary System:No difficulty and pain in urinating.No tenderness or mass noted.

Gastrointestinal System:No diarrhea or vomiting noted.

 Neurologic System:

Oriented to time, place and person.Responsive and coherent.

Patient’s History

PATIENT'S HISTORY

HISTORY OF PAST ILLNESSNo any known significant medical historyNo past surgeriesNot allergic to any food or medicinesNo family history mentioned

HISTORY OF PRESENT ILLNESS Smoker x 20 years (3-4 sticks/day) No food restrictions No form of exercise

(+) DOB & Fever

Discharged

4 days PTA

(other medical center)

(Meds: Augmentin, Amboroxol and

Ranitidine )

3-4 hrsPTA

(+) SOB

I.C.U.

 

DIAGNOSTIC TESTS/INVESTIGATIONS UPON ADMISSION

(yellow – abnormal results)

Diagnostic test Result Reference ranges

WBC 12.61 x109/L 4.23-9.07 x109/L

RBC 5.45 x 1012/L 4.63-6.08 x 1012/L

HGB 14.1 gm/dl 13.7-17.5 gm/dl

HCT 41.1% 40.1-51.0%

PLT 403 x 109/L 163-337 x 109/L

Glucose (Random) 15.9 mmol/L 3.9-7.8 mmol/L

Urea 3.4 mmol/L 1.8-8.3 mmol/L

Creatinine 85.14 μmol/L 58-110 μmol/L

Sodium 137 mmol/L 135-150 mmol/L

Potassium 3.5 mmol/L 3.5-5.0 mmol/L

Magnesium 0.73 mmol/L 0.65-1 mmol/L

ALT (SGPT) 22.25 U/L 10-41 U/L

Cholesterol 5.94 mmol/L 3.1-5.2 mmol/L

Triglycerides 1.57 mmol/L 0.34-2.30 mmol/L

HDLc 0.88 mmol/L 0.9-1.87 mmol/L

LDLc 5.9 mmol/L 3.9-4.7 mmol/L

CPK (CK) 336.46 U/L 26-308 U/L

CK-MB 16.07 U/L 7.0-25.0 U/L

HBA1C 8.9 % of Hb 4.1-6.2 % of Hb

Pro-BNP 6,290 pg/mL <125 pg/mL

Trop-I 0.37 ng/mL 0-0.1 ng/mL

(yellow – abnormal results)

2D ECHO: Dilated LV with EF 25-30%Moderate to severe mitral regurgitationSevere generalized LV dysfunctionNo LV or LA clotNo pericardial effusionPartial collapse of inferior vena cava with

inspiration

Initial ECG:Sinus tachycardia with poor progressive R at

V1-V5 with elevation 1-1.5 mm at precordial lead.

Chest X-ray: Apparent Cardiomegaly. Hilar shadows and

vascular markings are prominent. Haziness with interstitial and patchy opacities are seen in both lungs. Both costophrenic angles are hazy.

Medications uponAdmission

Enoxaparin 80mg/SC/OD

an anticoagulant used to prevent and treat deep vein thrombosis or pulmonary embolism

Lasix infusion 5mg/hr treats fluid retention

(edema) in people with congestive heart failure, liver disease, or a kidney disorder such as nephrotic syndrome. This medication is also used to treat high blood pressure (hypertension).

Ceftriaxone 1gm/IV/BIDtreatment of infections

of lower respiratory tract, skin and skin structures, bone and joint, and urinary tract; treatment of pelvic inflammatory disease, intra-abdominal infections, gonorrhea (uncomplicated), meningitis, and septicemia caused by susceptible microorganisms.

Aspirin 81mg/PO/ODhas an antiplatelet

effect by inhibiting the production of thromboxane, which under normal circumstances binds platelet molecules together to create a patch over damaged walls of blood vessels.

Clopidogrel 75mg/PO/OD

antiplatelet agent used to inhibit blood clots in coronary artery disease, peripheral vascular disease, and cerebrovascular disease.

Omeprazole 40mg/IV/OD

belongs to group of drugs called proton pump inhibitors. It decreases the amount of acid produced in the stomach.

Atorvastatin 40mg/PO/OD

used for lowering blood cholesterol. It also stabilizes plaque and prevents strokes through anti-inflammatory and other mechanisms.

Ventolin nebulization

Treatment & prevention of bronchial asthma, bronchitis, emphysema w/ associated reversible airways obstruction.

TOPIC PRESENTATION

CARDIOMYOPATHY

CARDIOMYOPATHYLiterally means "heart muscle disease".

Makes it harder for the heart to pump blood and deliver it to the rest of the body.

Anatomy and Physiology

The HeartThe heart is the muscular organ of the

circulatory system that constantly pumps blood throughout the body.

Approximately the size of a clenched fist.

Composed of cardiac muscle tissue that is very strong and able to contract and relax rhythmically.

ANATOMY AND PHYSIOLOGY

Click to see each functions.

Right Atrium

Function:returns

deoxygenated blood from the body to the right ventricle

Left Atrium

Function:Drains/pumps

oxygenated blood from the lungs into the left ventricle

Left Ventricle

Function:Pumps

oxygenated blood from lungs to body.

Right Ventricle

Function: pumps

deoxygenated blood from the body to the lungs

Pulmonary Artery

Function:carry de-

oxygenated blood to the lungs.

Aorta

Function:Distributes the

blood to the different parts of the body

Inferior Vena Cava

Function:is the large vein

that carries de-oxygenated blood from the lower half of the body into the right atrium of the heart.

Superior Vena Cava

Function:large diameter, yet

short, vein that carries deoxygenated blood from the upper half of the body to the heart's right atrium.

Tricuspid Valve

Function:opens to allow

blood to flow from the right atrium into the right ventricle.

Mitral Valve

Function:opens to allow

blood to flow from the left atrium into the left ventricle.

Pulmonary Valve

Function:allowing blood to

exit the right ventricle into the pulmonary artery.

Aortic Valve

Function:allowing blood to

exit the left ventricle into the aorta.

Pulmonary Vein

Function:large blood vessels

that carry oxygenated blood from the lungs to the left atrium of the heart.

Cardiac Muscleis a type of involuntary

striated muscle found in the walls and histological foundation of the heart, specifically the myocardium.

It contracts, which allows heart to pump, allowing movement of the blood into the heart and the circulatory system that goes throughout the body.

Coronary Artery

Supply oxygenated and nutrient filled blood to the heart muscle.

Right Coronary Artery - Supplies oxygenated blood to the walls of the ventricles and the right atrium.

Left Main Coronary Artery - Directs oxygenated blood to the left anterior descending artery and the left circumflex.

Blood vesselsBlood vessels are intricate networks of hollow

tubes that transport blood throughout the entire body. Blood delivers nutrients to and removes wastes from our cells.

Arteries transport blood from the heart to the body

tissues. (oxygenated blood)

Veins carry blood back to the heart. (deoxygenated

blood)

Capillariesare extremely small vessels located within

the tissues of the body that transport blood from the arteries to the veins.

Video: Heart and circulatory system — How they work

Click inside the box to watch the video

Etiology

ETIOLOGY

Most of the time, the cause of the Cardiomyopathy is unknown.

Possible causes of Cardiomyopathy include: Long-term high blood pressureHeart valve problemsHeart tissue damage from a previous heart attackChronic rapid heart rateMetabolic disordersNutritional deficiencies of essential vitamins or

minerals

Pregnancy

Excessive use of alcohol over many years

Abuse of cocaine or antidepressant medications

Use of some chemotherapy drugs to treat cancer

Certain viral infections, which may injure the

heart and trigger cardiomyopathy

Iron buildup in your heart muscle

(hemochromatosis)

Genetic conditions

Three Types of Cardiomyopathy:Dilated cardiomyopathy enlargement of the heart cavity and systolic

dysfunction of one or both ventricles Hypertrophic cardiomyopathy

left ventricular hypertrophy without an identifiable cause that results in impaired diastolic filling.

Restrictive cardiomyopathy restricted filling and reduced diastolic volume

of either or both ventricles, with normal or nearly normal wall thickness and systolic function

Signs and Symptoms

SIGNS AND SYMPTOMS:

Early stage:No signs and symptoms

But as the condition advances, signs and symptoms usually appear.

Cardiomyopathy symptoms may include:

breathlessness

Swelling of the legs,Ankles and feet

Bloating of the abdomen

Fatigue

Irregular heartbeats

that feel rapid, pounding or fluttering

Diziness, lightheadednessAnd fainting

Complications

CARDIOMYOPATHY

Heart failure

Blood clots

Valve problems

Cardiac arrest and

sudden death

Diagnostic Tests/Procedures

Chest X-ray. An image of the heart

will show whether it's enlarged.

Echocardiogram. uses sound waves

to produce images of the heart.

Cardiac catheterization and biopsy.a thin tube

(catheter) is inserted in the groin and threaded through blood vessels to the heart, where a small sample (biopsy) of the heart can be extracted for analysis in the laboratory.

Cardiac magnetic resonance imaging (MRI).uses magnetic

fields and radio waves to create images of the heart.

Blood tests.One blood test can

measure B-type natriuretic peptide (BNP), a protein produced in your heart. The blood level of BNP rises when the heart is subjected to the stress of heart failure, a common complication of cardiomyopathy.

Pathophysiology

PREDISPOSING FACTORS:

>Age: 60 and above

>Gender: Male

>Race

>Genetic: a pattern of familial

inheritance is evident in up to 20%

>Endocrine disorders

>Long-term high blood pressure

PRECIPITATING FACTORS:

>Alcoholism

>Smoking

>Abuse of cocaine or

antidepressant medications, such

as tricyclic antidepressants

>Sedentary lifestyle

>Stress

Heart muscle begins to dilate (stretch and

thinner)

Walls of ventricles thicken

Ventricles becomes stiff and rigid (scar tissue)

Left ventricle becomes enlarged

Heart muscle begins to enlarge

)

Ventricles cannot relax and normally fill with

blood

Blood flow is blocked in the ventricles

Blood flow of heart is reduced

Ventricles works hard to pump blood

Heart cannot pump blood well

Heart becomes weaker

Chest pain, dizziness, SOB and

fainting fatigue, swelling on extremities

Cardiac arrest, arrythmia

CARDIOMYOPATHY

Course In the Hospital

Day 1: Patient was kept in ICU for further

management and workup.He received:

o Enoxaparin 80mg SCo Lasix infusion 5mg/hro Ceftriaxone IV, T. Aspirin 81mg/ODo T. Clopidogrel 75mg/ODo T. Atorvastatin 40mg/ODo Omperazole 40mg/OD

He was started on Low Salt, Low Fat Diabetic Soft Diet

With fluid restriction of 1.5 L/dayIntake and Output was strictly monitoredHooked to O2 support @ 5 LPM via face maskNebulizations given

After initiation of treatment his condition improved.

Day 2Added with low dose of Captopril, Digoxin,

Spinorolactone and continued with other treatment, his urine output became adequate and remained in negative balance of 2 liters.

Started with oral K replacement

Day 3Added with low dose of betablockers, he

tolerated well the betablockers and ACEI.

His saturations improved and he remained afebrile and with improved HR of 90 bpm and BP of 110/70 mmHg.

Remained in negative balance of 0.8 liters.

Day 4Switched to long acting ACEI Enalapril

2.5mg/OD and Lasix IV 40mg/BID.

Room air saturations improved to 91% and continued with intermittent oxygen through nasal cannula.

He denied any chest pain or heaviness, he is being continuously monitored for heart rate and rhythm along with saturations and other parameters. During the stay he was monitored for blood sugar and received Regular Insulin SC.

Later on he was shifted to ward and remained asymptomatic, afebrile and hemodynamically stable.

He ambulated as well and oxygen saturations improved.

Started with T. Glimipiride 2mg.

Day 5Patient is asymptomatic.

Ambulating well.

CXR improved and SPO2 on room air is 98%.

CBG is 122 mg//dl.

The doctor discussed in detail regarding the disease and treatment plan upon discharge.

Prioritization ofNursing Problems

BREATHINGIneffective Breathing Pattern

 ACTIVITY AND REST

Disturbed Sleep PatternRisk for Activity intolerance

FATIGUEDecreased Cardiac Output

NUTRITIONRisk for Electrolyte Imbalance

ELIMINATIONRisk for Impaired Urinary Elimination/Urinary

Retention

SAFETYRisk for Infection

THERAPEUTICEffective Therapeutic Regimen Management

Nursing Care Plans

Cues/ Evidences Nursing DiagnosisGoals and Desired

OutcomesNursing Order/Action Rationale for Action Evaluation

Subjective: “I easily get tired when I’m doing something,” as verbalized by the patient.

appears weak

easy fatigability

BP: 110/70 mmHg

HR: 130 bpm

(+) weak bounding pulse

SPO2:78% on room air

capillary refill: 4 seconds

tachypneic: RR: 26 cpm

> 2D echo findings: Severe generalized LV

dysfunction

Decreased cardiac output related to left ventricular dysfunction.

After the 12 hour shift, patient will maintain adequate cardiac output as evidenced by BP and pulse rate and rhythm within normal range.

> Auscultate apical pulse; assess heart rate, rhythm and note heart sounds.

Monitor blood pressure.

Monitor urine output, noting decreasing output and dark/concentrated urine.

 Tachycardia is usually present (even at rest) to compensate for decreased ventricular contractility. S1 and S2 may be weak because of diminished pumping action. Gallop rhythms are common (S3 and S4), produced as blood flows into noncompliant/distended chambers. Murmurs may reflect valvular incompetence/stenosis.

The body may no longer be able to compensate, and profound/irreversible hypotension may occur.

Kidneys respond to reduced cardiac output by retaining water and sodium. Urine output is usually decreased during the day because of fluid shifts into tissues but may be increased at night because fluid returns to circulation when patient is recumbent.

Goal met. After rendering nursing interventions for 12 hours, patient’s heart rate decreases from 130 bpm to 90 bpm. No reports of dyspnea or fatigue noted.

Note changes in sensorium like lethargy, confusion, disorientation, anxiety, and depression.

Encourage rest, semirecumbent in bed or chair.

Provide quiet environment; explain medical/nursing management; help patient avoid stressful situations; listen/respond to expressions of feelings/fears.

May indicate inadequate cerebral perfusion secondary to decreased cardiac output.

Physical rest should be maintained to improve efficiency of cardiac contraction and to decrease myocardial oxygen demand/consumption and workload.

Psychological rest helps reduce emotional stress, which can produce vasoconstriction, elevating BP and increasing heart rate/work.

Elevate legs, avoiding pressure under knee. Encourage active/passive exercises. Increase ambulation/activity as tolerated.

Administer supplemental oxygen as indicated, 2 LPM via nasal cannula

> Administer medications as indicated: > Furosemide (Lasix) 5mg/ hour via infusion

Decreases venous stasis, and may reduce incidence of thrombus/embolus formation.

Increases available oxygen for myocardial uptake to combat effects of hypoxia/ischemia.

Diuretics, in conjunction with restriction of dietary sodium and fluids, often lead to clinical improvement in patients. Loop diuretics block chloride reabsorption, thus interfering with the reabsorption of sodium and water.

Anticoagulants – Enoxaparin 80mg/SC/OD and Clopidogrel 75mg/PO/OD

Monitor/replace electrolytes such as Sodium and Potassium.

Monitor serial ECG and CXR changes.

May be used prophylactically to prevent thrombusembolus formation in presence of risk factors such as venous stasis, enforced bedrest, cardiac dysrhythmias, and history of previous thrombolic episodes.

Because of existing elevated left ventricular pressure, patient may not tolerate increased fluid volume (preload). Patients o excrete less sodium, which causes fluid retention and increases myocardial workload.

Chest x-ray may show enlarged heart and changes of pulmonary congestion

Cues/ Evidences Nursing DiagnosisGoals and Desired

OutcomesNursing

Order/ActionRationale for Action Evaluation

Subjective:“I have difficulty of breathing,” as verbalized by the patient.

RR: 26 cpm

SPO2:78% on room air

(+) rapid breathing

(+) nasal flaring

Ineffective breathing pattern related to shortness of breath secondary to dyspnea.

After the 12 hour shift, patient will demonstrate adequate ventilation and oxygenation as evidenced by respiratory rate and oxygen saturation within normal limits.

> Monitor Vital signs

>Administered bronchodilator, such as Ventolin nebulization as ordered,

Administer oxygen therapy at 2 LPM by cannula.

Provide small meals six times per day.

Provide bed rest with head of bed elevated 30 to 60 degrees.

Perform deep breathing exercises, incentive spirometry ever two hours.

To obtain baseline data.

Dilates airways to facilitate breathing if dyspneic.

Provides oxygen if hypoxic from decreased cardiac output or with ventilation perfusion imbalance from fluid in alveoli.

>Reduces pressure on diaphragm and enhances chest expansion.

Promotes lung expansion and decreases venous return.

Improves breathing and oxygen intake.

Goal fully met. After rendering nursing interventions for 12 hours, patient’s respiratory rate decreased from 26 cpm to 22 cpm. Patient had verbal reports that he can breathe without difficulty.

Nursing Health Teachings

Avoid smoking.

Eat meals with low salt, fats at sugar.

Limit fluid intake to 1.5 liters per day.

Get regular walk as tolerated with empty

stomach.

Keep blood sugar under control.

Take prescribed medicines regularly and on

time.

See physician regularly.

Conclusion

Cardiomyopathy is a disease that weakens and enlarges the heart muscle. Some people who develop cardiomyopathy have no signs and symptoms during the early stages of the disease. But as the condition advances, signs and symptoms usually appear.

In many cases, people can't prevent cardiomyopathy. Let the doctor know if you have a family history of the condition. If cardiomyopathy is diagnosed early, treatments may prevent the disease from worsening.

People can help reduce the chance of heart failure by avoiding some of the conditions that can contribute to a weak heart, including the abuse of alcohol or cocaine or not getting enough vitamins and minerals. Controlling high blood pressure with diet and exercise also prevents many people from developing heart failure later in life.