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College of Nursing
CASE STUDY
OF
ISCHEMIC CARDIOMYOPATHY
WITH ACUTE RENAL FAILURE
SUBMITTED BY:
GROUP 4
Viaña, Mark Anthony Y.
Aniceto, Roneo I.
Araña, Annabel L.
Arcasitas. Cherrelyn F.
Bentinganan, Mark Edwin A.
Sengco, Suzane S.
Serrano, Armando I.
Sucayre, Analyn P.
Tesoro, Joan Mariel B.
Verzosa, Shealtiel Ruth P.
Vertudez, Jeanlyn L.
Viray, Regina Joy P.
SUBMITTED TO:
Mr. Romeo Rivera, R.N., M.S.N.
1
TABLE OF CONTENTS
PAGE
I. INTRODUCTION ……………………………………………………………
………………………1
2
G. Neck …………………………………………………………..….………
…… 10
H. Thorax and Lungs ………………………………………………………
…………………. 11
I. Heart
……………………………………………….……......…………………… 11
J. Abdomen
………………………………………………..…..……………….… ……. 11
K. Lower Extremities ………………………………………………………
…………………..11
L. Neurologic …………………………………………………...………..…
……… …11
XII.PROGNOSIS
………….………………………………………………………………………31
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I. INTRODUCTION
Epidemiology
This case is curable. But some patient suffering from this case, can’t afford
to undergo surgery or too buy medicines. It may lead to severe heart failure,
dysrrhytmias and often death.
The name ischemic refers to episodes of cardiac ischemia that occur when
the heart is not getting enough oxygen-rich blood and cardiomyopathy is any
disease of the heart muscle. It is most often used to refer to a heart that is
abnormally enlarge, thickened or stiffened.
Risk Factors
Family history
Atherosclerosis / Arteriosclerosis
High blood pressure
Smoking
Diabetes
High fat diet
High cholesterol diet
Age
II. OBJECTIVES
A. General Objectives
To gain knowledge and to further understand the nature and extent of the
disease so as to prepare and arm ourselves with knowledge whenever we
encounter the same case in the future. And also to have a clear and better
understanding about Ischemic Cardiomyopathy particularly on its diseases
process, treatment, diagnostic exam, preventive measures and nursing
management.
B. Specific Objectives
To know the latest facts and keep our self updated with the newest
information about Ischemic Cardiomyopathy.
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To be familiar with the disease and medical used that may help us in doing
health teaching with our client.
To let the public be aware with the manifestation and complications brought
by the diseases.
A. BIOGRAPHIC DATA
Name: Patient X
Address: XYZ Valenzuela City
Height: 5’8”
Weight: 232 lb
Age: 63 years old
Sex: Male
Civil Status: Married
Nationality: Filipino
Religion: Roman Catholic
Date of Admission: January 7, 2009
Time of Admission: 1:40 pm
Admitting Diagnosis: Ischemic Cardiomyopathy with Acute Renal Failure
Four to Six months prior to admission, the client experiences on and off
increase in abdominal girth and edema with no consultation and medications
taken.
At the same day laboratory and diagnostic tests were done to the patient.
Culture/sensitivity and gram’s stain of foot results (-) microorganisms, there was
an increase in BUN and Creatine of the patient that affects the function of the
kidney specifically the Glumerular Filtration Rate that results to Oliguria. He was
given Godex, Moriamin and Aldactone as his medications that helps to lessen his
edema and improve the functions of the kidney and his liver.
5
Hyperlipidemia or increase in cholesterol from his sedentary lifestyle and
hypertension and given a diet of low salt, low fat and low cholesterol that helps to
decrease his cholesterol level. On his urine test and laboratory results it reveals
normal and no medications given. Hematology of the patient result an increase on
his WBC, segmenters, and eosinophiles and decrease in lymphocytes revealed a
presence of infection.
E. SOCIO-ECONOMIC HISTORY
Patient X is a hardworking person that’s why he was able to give what his
family needs. In their community hazard, patient X was living near the main road,
air and noise pollution affects them but the patient interpreted that their place is
safe.
F. ENVIRONMENTAL HISTORY
Patient X admitted that before going to Manila for work, he already knew
that he has hypertension, diabetes and heart problem. He believes that heredity
caused them, it is common to their family to have hypertension and heart disease,
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his father also has heart disease. His main reason of deciding to be admitted in the
hospital is the edema on his legs and feet, now, being admitted he notices changes
are already tolerable.
The patient doesn’t have cardiologist or primary health care providers. His
last check up was when he is still on the province; he already forgot when it was.
Patient X said that he rarely eat meat he normally eats vegetable and
healthy foods, he also takes DXN (Anti oxidant) an herbal supplement, he said
that it is his way of taking care his heart.
Nutritional-Metabolic Pattern:
HEIGHT: 5’8
Basic of Interpretation
BMI of < 18.5 is classified as underweight
BMI of 18.5-24.9 is classified as normal
BMI of 25-29.9 is classified as overweight
BMI of 30-39.9 is classified as obese/ above normal
BMI Computation
wt (kg)
ht (m)²
Patient X was never obese he just gained weight due to edema on his legs
and feet which he is complaining for 4-6 months.
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His wife prepares for their meal, his wife normally prepares him
vegetables, which he likes and use to eat. Patient X said that he prefer to eat
healthy foods. Because of feeling full all the time, he also experiences loss of
appetite.
ACTIVITY MOBILITY
LEVEL LEVEL
DAILY LIVING STATUS
Feeding 1 Bed Mobility 1
Dressing 1 Chair/toilet 1
Grooming 1 Transfer 1
Toileting 1 Ambulation 1
His current situation made a big change in his daily activities. His is now
admitted on Calalang General Hospital for care and monitoring.
Cognitive-Perceptual Pattern:
Patient X has an intact short term memory, he also admitted that now,
knowing his situation made him feel anxious.
Prior to illness patient X admitted that he just had 5-6 hours of sleep a day
because he sometimes work overtime on being a work. However, he makes a
point to exercise and use the gym of establishment he’s been working for. He
doesn’t even have time to take a nap in a day. But during hospitalization he
believed that he already have time to have enough sleep, he also finds time to take
a nap in a day, in spite of the illness patient X has time to rest by reading, or
talking with family and friends.
Patient X usually sleep and have rest on their house only after his work, he
sometimes fell asleep sitting on a chair, chest pain sometimes awakes him at
night.
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Patient X sees himself as ever determined that’s why he’s really working
hard for his family, he has a positive outlook about life and he always believes
that he can still do things that he normally do before having the illness. He
believes that he can still do he’s plans for him and family after his medications.
Mr. X hopes that his present condition will not affect his lifestyle before that he
can still continue to be a provider for his family.
Role-Relationship Pattern:
Patient X admitted that his family is not that ideal, being the only one
working for the family he consider himself as the breadwinner, in spite the fact
that he has two children that can work to help their family, sad to say they can’t
work because the eldest has a body image problem and the next, already had his
own family. This is the reasons why patient X is always been hard working.
Patient X lives with his wife and 4 children, he considers his place as safe
home environment. He doesn’t have health insurance but believes that his
finances is just enough for the needs of his family.
Now that patient X is having an illness his family serves as his inspiration,
he is also glad that his children together with his wife are always been supportive
in spite the fact that he is not on work already for the preparation of his treatment.
His family always made him feel that he is still their provider, which is really
helping him and inspiring him to be better, he once told that being in the hospital
doesn’t stop him from being a husband and a father.
Pattern of Elimination:
Prior to admission patient X had a series of chest pain his been feeling this
for the past 1 month but he thought that it was just because of being tired on work,
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he occasionally feel dizzy, light headed and headaches it happened mostly at night
and in the morning when he wakes up.
Before the illness Mr. X enjoys working, he also finds time to exercise
(weights) once week as his leisure time. He occasionally hang out with friends
and drink beer.
Sexuality-Reproductive Pattern:
Mr. X admitted that he and his wife rarely have sexual activity anymore
because his job takes most of his time, and that he believes that they are already
old to have sexual activity.
Mr. X views problems as something normal that should be faced; this has
been his perception on problems even before when he knew that he has a heart
problem. Now having an illness, he said that the support of his family is the main
reason that he is coping with his hospitalization, he believes that having an illness
will not end his being the family provider but instead, made him feel that he is
well love and appreciated by his family. Mr. X admitted that having an illness is
considered to be his main stressor now.
Being a Catholic Mr. X has a strong faith in God. He believes that he will
not give you problems that you cannot solve. His present condition made his faith
stronger and made him closer to God. He believes that God has a purpose behind
everything and he is willing to accept Gods will.
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IV. PHYSICAL ASSESSMENT
1. SKIN
White in color
Dry and the texture is smooth
Cold to touch
It has a bad skin turgor
2. HEAD
3. EYES
4. EARS
5. NOSE
6. MOUTH
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7. NECK
8. THORAX
( + ) crackles
Tachypnea- inadequate blood supply/decrease blood flow resulting
to decrease oxygen,the lungs need to compensate
Cheyne-stokes breathing
9. HEART
10. ABDOMEN
Flat
NABS
(+) ascites
12
V. LABORATORY AND DIAGNOSTIC TEST
HEMATOLOGY
Examination Result Reference Value Interpretation
13
Hgb 162.0 120-160 g/L Increased, in the
presence of smokers and
CHF
Increased in failure of
oxygenation because of
Congestive heart Failure
Total Red Cell 4.5-5.0 x 10-12 g/L
Increased indicates
metastatic or tumors in
thyroid
Basophiles 0-0.01 Increased in subacute
infections, collagen
disease
14
Glucose 98.0 mg/dL 75-115 mg/dL Normal
Na 135-155 mmol/L
15
ANATOMY OF THE HEART
The Heart is encased in a thin , fibrous sac called the pericardium which is
composed of two layers adhering to the epicardium is the visceral pericardium
enveloping the visceral pericardium , a tough fibrous tissue that attaches to the
great vessels , diaphragm ,sternum and vertebral column and supports the
mediastenum .. The space between these two layers (pericardial space) is
filled with about 30 ml of fluid. Which lubricates the surfaces of the heart and
reduces friction during systole
Heart Chamber
The four chambers of the heart constitute the right and left sided pumping
system the right side of the heart made up of the right atrium and right ventricles ,
distributes venous blood ( deoxygenated blood ) to the lungs via the pulmonary
artery ( pulmonary circulation ) for oxygenation the right atrium receives blood
returning from the superior vena cava ( head , neck , and upper extremities )
inferior vena cava ( trunk , and lower extremities ) and coronary sinus ( coronary
circulation ) the left side of the heart composed of the left atrium and left
ventricles distributes oxygenated blood to the remainder of the body via the aorta
( systemic circulation ) .
The left atrium receives oxygenated blood from the pulmonary circulation
via the pulmonary veins. The varying thickness of the atrial and ventricular walls
relate to the work loads required by each chamber. The atria are thin walled
because blood returning to these chambers generates low pressures. In contrast,
the ventricular walls are thicker because they generate greater pressures during
systole. The right ventricle contrast against low pulmonary vascular pressure and
has thinner walls than the left ventricles. The left ventricle, with walls two and
half times more muscular than those of the right ventricles, contrast against high
systemic pressure. Because the heart lies in a rotated position with in the chest
cavity. The right ventricle lies anteriorly ( just beneath the sternum ) and the left
ventricles lies anteriorly ( just beneath the sternum ) and the left ventricle is
situated posteriorly the left ventricle is responsible for the apical beat for the point
of maximum impulse ( PMI ) which is normally palpable in the left midclavicular
line of the chest wall at the fifth intercostal space .
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Heart Valves
The four valves in the heart permit blood to flow only one direction. the
valves, which are composed of thin leaflets of fibrous tissues , open and close in
response to the movement of blood and pressure changes within the chambers .
There are two types of valve: atrioventricular and semilunar.
Atrioventricular Valve
The valves that separate the atria from the ventricles are termed
atrioventricular valves. The tricuspid valve, so named because it composed of
three cusps or leaftlets separates the right ventricles. The mitral or bicuspid valve
(two cups) lies between the left atrium and the left ventricles.
Semilunar Valves
The two semilunar valves are composedof three half moons like leaflets.
The valve between the right ventrivles and the pulmonary artery is called
pulmonic valve. The valve between the left ventricle and the aorta is called the
aortic valve.
Coronary Arteries
The left and right coronary arteries and their branches supply
arterial blood to the heart. These arteries originate from the aorta just above the
aortic valve leaflets. The Heart has large metabolic requirements, extracting
approximately 70% to 80% of the oxygen delivered (other organs exract 25%)
unlike other arteries, the coronary arteries are perfused during diastole; the
increase in heart rate shortens diastole and can decreased myocardial perfusion.
Patients particularly those with CAD, can develop myocardial ischemia
(inadequate oxygen supply) when the heart rate accelerates.
The left coronary artery has three branches. The artery from the point of
origin to the first major branch called the left main coronary artery. Two branches
arise off the left main coronary artery. The left anterior descending artery which
courses down the anterior wall of the heart, and the circumflex artery, which
encircles around to the lateral left wall of the heart.
The posterior wall of the heart receives its blood supply by an additional
branch from the right coronary artery called the posterior descending artery.
Superficial to the coronary arteries are the coronary arteries are the
coronary veins. Venous blood from these veins to the heart primarily through the
coronary sinus. This is located posteriorly at the right atrium.
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conduction system first stimulates contraction of the atria and then the ventricles.
The synchronization of the atrial and ventricular events allows the ventricles to
fill completely before ventricular ejection, thereby maximizing cardiac output.
Three physiological characteristics of two specialized electrical cells, the nodal
cells and the purkinje cells, provide this synchronization.
Both the sinoatrial (SA) node and the atrioventricular (AV) node are
composed of nodal cells. The SA node, the primary pacemaker of the heart, is
located at the junction of the superior vena cava and the right atrium. The SA
node in a normal resting adult heart has an inherent firing rate of 60 to 100
impulses per minute, but the rate can change in response to the metabolic
demands of the body.
The electrical impulses initiated by the SA node are conducted along the
myocardial cells of the atria via specialized tracts called intermodal pathways.
The impulses cause electrical stimulation and subsequent contraction of his atria.
The impulses are then conducted to the AV node, which is located in the right
atrial wall near the tricuspid valve.
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tissue, the fibrous connective tissue, blood vessel, and lymphatic surrounding
each kidney are known as the renal capsule.
The renal parenchyma is divided into two parts: the cortex and medulla.
The medulla which approximately 5cm wide is the inner portion of the kidney. It
contains the loop of henle, the vasa recta, and the collecting ducts of the
juxtamedullary cortical nephrones connect to the renal pyramids, which are
triangular and are situated with the base facing the concave surface of the kidney
point (papilla) facing the hilum, or pelvis. Each kidney contains approximately
8-18 pyramids, the pyramids drains into 4-13 million calices which drain 2-3
major calices that open directly into the renal pelvis is the beginning of the
collecting system and composed of structures that are design to collect and
transport urine. Once the urine leave the renal pelvis, the composition on amount
of urine does not change.
The cortex which is approximately 1cm wide is located farthest from the
center of the kidney and around the outer most edges. It contains the nephron
(functional unit of the kidney).
The hilum or the pelvis is the concave portion of the kidney through which
the renal artery enters and the ureters and renal vein exit. The kidney receives 20-
25% of the total cardiac output, which means that all of the body’s blood
circulates through the kidneys approximately 12 times per hour. The renal artery
(arising from the abdominal aorta) divides into smaller and smaller vessels,
eventually forming the efferent arterioles. Each arteriole branch to perform a
glumerolus which is the capillary bed responsible for the glumerular filtration.
Blood leaves the glumerolus through efferent arteriole through a network of
capillary and veins.
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Ischemia – it is a lack of blood supply to an organ such as heart.
Ishemic Cardiomyopathy
CAUSES:
RISK FACTORS:
Family history
Atherosclerosis / Arteriosclerosis
High blood pressure
Smoking
Diabetes
High fat diet
High cholesterol diet
Age
SYMPTOMS:
Shortness of breath
Palpitations or fluttering in the chest due to abnormal heart rhythms
(arrhythmia)
Fatigue ( feeling overly tired ), inability to exercise, or carry out activities as
usual
Swelling of the legs and feet ( edema )
Angina ( chest pain or pressure that occurs with exercise or physical activity
and can also occur with rest or after meals ) is a less common symptom
Weight gain, cough and congestion related to fluid retention.
Dizziness or lightheadedness
20
Fainting ( caused by irregular heart rhythms , abnormal responses of the blood
vessels during exercises, without appears cause )
DIAGNOSIS:
Blood test
Electrocardiogram ( ECG )
Chest X-Ray – to see the possible cardiomegaly
Echocardiogram – to see the size and shape of the heart and how will it
pumping.
Exercise Stress Test – to determine how long the patient can walk and to
measure the ankle systolic blood pressure in response to walking.
Cardiac Catheterization – to check the heart and blood vessels
CT – Scan – to check for possible damage
MRI Scan
Myocardial biopsy – to determine the cause of cardiomyopathy
TREATMENT:
1. MEDICATIONS
2. LIFESTYLE CHANGES
3. IMPLANTABLE DEVICES
21
VIII. PATHOPHYSIOLOGY
22
↑Crea a
BUN
Plueral
Effusion
23
NURSING CARE PLAN
Scientific
Assessment Diagnosis Planning Interventio
Rationale
Black patches
on skin.
Lasix
Aldactone
22
Scientific
Assessment Diagnosis Planning Interve
Rationale
Scientific
Assessment Diagnosis Planning Interve
Rationale
23
Black patches color chan
on skin.
DRUG NSG.
INDICATIO CONTRAINDIC SIDE
DRUG ACTION INTERAC CONSIDERAT
NS ATION EFFECTS
TION IONS
DRUG STUDY
DRUG INDICATION ACTION CONTRAINDICATION SI
24
GENERIC NAME: For cardiogenic to increase the Uncorrected tachycardia, Tac
-Dopamine HCL shock, renal failure myocardial ventricular fibrillation, or ang
due to cardiac contractility of arrhythmias. pal
BRAND NAME: decompensation (as the heart to dys
-Dopamine in CHF) increase the and
heart rate hea
CLASSIFICATION hyp
-sympathomimetic, to increase the hyp
Indirect and direct peripheral
acting resistance
DOSAGE: to increase or
-500cc/ml OD elevate the
blood pressure
of the patient.
25
GENERIC NAME: For the cellulitis of Irreversibly History of any allergic Hy
-Ampicillin NA and the left leg of the inhibits beta- reaction to the drug nau
Sulbactam NA patient and skin and lactamase thus vom
soft tissue infection ensuring the and
BRAND NAME: activity of
-Unasyn ampicillin against
beta-lactamase
CLASSIFICATION producing
-Antibiotic microorganisms
DOSAGE
-750mg/tab Q12hrs.
26
GENERIC NAME: Edema 2hrs to CHF Mild diuretics acute renal insufficiency, d
-Spinolactone and acute renal that acts on the progressive renal failure, B
failure distal tubule to hyperkalemia and anuria (
BRAND NAME: inhibit NA
-Aldactone exchange for low BP -
potassium, H
CLASSIFICATION resulting in
-K-sparing diuretics increased -
secretion of NA
DOSAGE and water and b
-50 mg/tab BID conservation of n
potassium v
f
a
c
27
GENERIC NAME:
-Moriamin Forte maintenance of body to supply Vitamins for The urine may bec
resistance the body yellow
BRAND NAME:
-Moriamin Vit. deficiencies to balance the
nutrition’s that the
CLASSIFICATION: nutritional imbalance body needed
-Vit. B complex
DOSAGE
-1 cap OD
28
XI. DISCHARGE PLAN
Medications:
Lasix 400mg ½ tab Q8
Aldactone 50mg tab BID
Unasyn 750 mg 1 tab Q12
Goddex OD
Dopamine 500ml tiv
Lasix: Indicated for edema associated with CHF, hepatic cirrhosis, ascites and renal
failure diseases. Contraindicated if BP is < 90/60 PR of < 60 and anuria. v/s, I&O and
weight should be monitor.
Aldactone: Indicated for edema secondary to CHF and acute renal failure contraindicated
if patient is experiencing acute renal insufficiency, progressive renal failure,
hyperkalemia and anuria BP, I&O should be monitor hold if the BP is 100/60.
Unasyn: Indicated for Left leg cellutitis, skin, and soft tissue infection contraindicated
for patients with history of allegic reaction to pencillins.adequate hydration should be
ensured.
Goddex: Indicated for acute or chronic liver cirrhosis, intoxication and fatty liver.
Dopamine: Indicated for cardiogenic shock due to renal failure and cardiac
decompensation (as in congestive heart failure) contraindicated to patient with
tachycardia and arrhythmia, v/s,I&O should be monitor.
Exercise:
Encourage non competitive aerobic exercises are
Heavy weight lifting is not recommended
Prefer a light daily exercise such as walking
30
Out Patient Care includes:
Diet:
XII. PROGNOSIS
Medications and its effect have been discussed to client. Effect of medication such
as Lasix and Aldactone can only treat the underlying signs and symptoms of ascites and
edema. But it is not given to treat the main problem.
Cellulitis in left leg of the patient will subside as long as infection will resolve.
Weeping wound and excretion of yellowish watery drainage will stop once wound heal.
The client, who has Ischemic Cardiomyopathy if to follow the standard treatment,
may have a longer uncomplicated life. But if the client is unable to meet the necessary
adjustment in lifestyle, diet and to comply with medications and treatment, his illness
may have a very severe complication that would risk his life.
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