CARDIOMYOPATHY
OBJECTIVES OF CASE STUDY PR ESENTATION
To share experience and knowledge to friends and supervisors.
To get feedback from the friends and supervisors for further improvement.
To develop confidence in facing the mass and presenting skills.
RATIONAL FOR THE SELECTION OF CASE
Cardiomyopathy causes more than 27,000 deaths each year in the United States (American
Heart Association, 2001).
•
The mortality rate is highest for African Americans and the elderly I selected this case as
to learn in depth about the disease condition.
•
Providing nursing care by applying nursing process.
•
To provide holistic nursing care to the patient using the nursing process.
•
To gain knowledge about the specific disease, it’s etiology, sign and symptoms and
management process.
METHODOLOGY
The methodology adopted to produce this report was based on:

History taking and interviewing to the patient and her visitors .

The observation and ,physical examination to the patient

Discussion with teachers, senior staffs and doctors

Using various text books and references of Medicine and related net search technology.
BIO-DATA OF MY PATIENT
1
Patient’s Name
: - Surya Maya Rai
Age/ sex
: - 67yrs/female
Marital status
: - Married
Education
: - Illiterate
Occupation
: - Housewife
Religion
: - Hindu
Address
: - Kathmandu, Basbari
Diagnosis
: - Cardiomyopathy
Ward
: - Medical intensive care unit
Bed No.
: - 16
IP No.
: - 45795
Date of admission
: - 2068/11/15
Interview date
: - 2068/11/18
Date of discharge
:- 2068/12/21
Attending physician
: - Dr. Rabi Mall
Informants
: - Patient (self) & her Husband
CHIEF COMPLAIN
Shortness of Breath for 2 days
Pedal Edema for 1 month
HISTORY OF PRESENT ILLNESS
As stated by the patient party, patient was apparently well 2 days back when she started
having shortness of breath on exertion. she also had pedal edema for one month and made
her difficult to mobilize. so she was taken to the emergency department of Sahid Gangalal
National Heart Center
2
she was diagnosed as known case of DCM 2 year back. She was having her medicine
regularly. She was admitted to the general ward of SGNHC on 2068/11/15. then she was
transfer to Medical Intensive Care Unit for Increased Shortness of breath and admitted there
No any skin change ,bowel and bladder are normal, she had no history of any abnormality of
the menstrual cycles.
Symptom
Shortness
Onset
of 2 days
charecter
Duration
Aggrevating
allevating
factor
factor
Sharp pain
Continues
Not known
Not known
Mild
Continuous
Not known
Not known
breath
Padal edema
2 month
INVESTIGATION OF SYMPTOM
Past illness
Disease condition Childhood illness
Disease condition
Adulthood
illness
Yes
Measeals
Mumps
Whooping cough
Polio
Rheumatic fever
Tuberculosis
Malnutrition
Operation
Others
No
Yes
 


 

 


 

Hypertension
Heart disease
Tuberculosis
Diabetes II
Filariasis
Malaria
Cancer
Asthma
Accidents
Others(hypothyrodism,
renal impairment)
No

2) Injuries and Accidents: My patient had no any history of external injuries and accidents.
3
3) Hospitalization, Operations or Special Treatment: She had history of previous
hospitalization before 2 years back
5) Medication Taken at Home :- She uses to takes some home remedy like ginger, salt
besar for some common health problem.
6) Traditional Healer’s Prescription: she did not used to take the Traditional Healer’s
prescriptions.
7) Medical Practioner’s prescription:- According to patient’s husband, she takes medical
practioner’s prescription.
8)Self prescription: My patient use to take some common medicines like paracetamol,
brufen aciloc etc
9.FAMILY TREE
67 year, patient
75 year, husband
39 year,
son
37 year,
daughter in -law
35 year.
daughter in-law
8 year.
grand daughter
37 year,son
6year.
grandson
Patient
Male
Female
4
10 Psychological:Client’s Reaction to illness:
My patient’s has normal reaction to her illness .
b) Client’s Coping Pattern:
She has good coping pattern by gossiping with relatives.
C) Client’s Value of Health:
She thinks that health is very essential for life. she thinks that health is wealth.
d) Client’s Perception of the Care Giver:
She
thinks that all health care provider are good but everybody do not detailed explain
about the disease prognosis
11.Sociological:
A) Family Relationship:
Client’s Position in the Family: she is the house wife of the family.
Person Living With Client (Support System) : Her Family Members (husband and her son).
Recent Family Crisis or Changes: According to my patient,
she has no any recent family
crisis
B) Occupational History: she is housewife., she is illiterate
12.Health belief and practice
Client’s Beliefs about Health and Illness: Her beliefs that the illness is caused by careless
of the diet
Client’s Health Practice: she has good health practice
Sources of Care(Modern /traditional):
sometimes they goes to traditional healer, but usually they goes to modern practice
12.Personal history
e) Leisure Time Activities: she spends her time with her friends, watching TV, chat with
friends, son and grand son
f) Chemical Use (type, frequency, problems related to use)
She is non smoker and non substance abuser but alcohol user . she had left 3 years back
5
13. Gyne/obs history
•
Menarche- 12 year
•
Menstruation regular
•
Menstrual bleeding normal
•
Duration 4-5 days.
•
No history of dysmenorrhoea.
•
No history of the gynecological problem
Environmental history
•
•
•
•
•
•
•
•
•
Type of family
No. of family
Type of house
NO. of rooms
Kitchen
Fuel used
Drinking Water
Toilet
Drainage System
:- Joint Family
:- 9 members
:- Cemented house
:- 8
:- Separated
:- Gas
:- Tap water
:- Water seal
:- Closed drainage
PHYSICAL EXAMINATION
General Inspection:
Gait
: Normal
Body Build
: Thin
Consciousness
: conscious and alert
Facial expression
: ill looking
Vital signs
Temperature
: 99.40 f
Pulse
: 78b/minute and regular, normal volume and character
Respiration
: 24 b /minute, regular
Blood Pressure
: 100/80 mm Hg in both arms (supine)
Height
: 5'
Weight
: 52 kg
GENERAL EXAMINATION
6
Pallor absent
Icterus absent
Lymph node not palpable
Clubbing, cyanosis absent
Edema present
Dehydration absent
Skin dry and rough.
Examination of head ,face and neck
1. Inspection of head
Hair colour and texture normal. Normal hair distribution graying of hair related to aging.
Rounded face wrinkle of skin related to age.Scar of injury present
2. Inspection of eyes
No discharge and
redness of the eye lid, but swelling of the eyelid , slightly vision
problem
3. Inspection of ears
No discharge and pain, no hearing problem
4. Nose
No discharge , bleeding and smelling problem.
5. Mouth
Good oral hygiene, missing teeth present and dental carries, no cyanosis present.
6. Neck
No enlarged lymph node and thyroid gland, normal neck mobility is present
Respiratory examination
Inspection
7
Shape of the chest- normal, equal movement of the chest both side, no venous
prominences or scar marks, trachea center. Spine normal. Shortness of breathe
Palpation
Non tender. Vocal fremitus present. Trachea in center. Chest expansion 3 cm, apex beat
5th intercostals space in mid, clavicular line
Percussion
Resonant in left side and dullness in organ area
Auscultation
Normal vesicular breath sound.
Cardiovascular system
Inspection:
Cardiac impulse in 5th intercostal space in MCl. No abnormal impluse seen.
Palpation
Non tender. Apex beat in 5th intercostals space in MCl, no thrill
Auscultation
S1 and S2 normal
murmur heart sound
Abdominal problem
InspectionNormal shape and size.Distended ,no dilated superficial veins, no scar marks
PalpationSoft organomegaly present. No organomegaly
Percussion- Normal tympanic sound present
AuscultationBowel sounds present (normal)
CNS examination
Higher mental function normal. Motor examination eg position of limbs normal ,no
atrophy, no ulcer. No abnormal movement. Normal
muscle tone. Normal power in all
limbs. Deep tendon jerk (bicep,tricep,supinator ,knee and ankle) normal. Sensory normal.
Comfort sleep , rest
8
Patient feeling of discomfort first
day of admission. No properly sleep at night during
first day of admission.
Impression: No any systemic disorders present except slight dyspnea and peripheral
edema(pedal).
DEVELOPMENTAL TASK OF OLDER ADULT
My patient belongs to older adult, development task of my patient are
ACCORDING TO BOOK
ACCORDING TO MY PATIENT
1. Seven developmental tasks for older 1. Adjusting to decrease health and physical strength.
adult are listed.
2. Adjusting to decreasing health and 2. the most common losses one of the health
physical strength.
,significant other a sense of being useful
,socialization ,income and independent living.
3. Adjusting to retirement and reduced
or fixed income
3. Adjusting to retirement by engaging in housewife
4. Adjusting to death of a spouse.
4. My patient was not faced death of spouse.
5. Accepting self as ageing person.
5. My patient accepted self as ageing person.
Structural and functional change associated with
ageing eg loss of hearing ,vision problem, dental
missing etc
6. Maintaining
arrangement.
7. Redefining
children.
satisfactory
living
6. My
patient
maintained
satisfactory
living
arrangement eg comfortable living arrange all
physical facilities.
relationship
with
adult
7. Redefining relationship with adult children by give
permission to their children whatever they like.
8. Finding way to maintaining quality
of life.
8. My patient maintained quality of life through use
leisure time in social work, spiritual activities
CHAPTER II
9
CARDIOMYOPATHY
Definition
Is a heart muscle disease associated with cardiac dysfunction. The cardiomyopathies are a
group of diseases that primarily affect the heart muscle and are not the result of congenital,
acquired valvular, hypertensive, coronary arterial, or pericardial abnormalities.It is classified
according to the structural and functional abnormalities of the heart musclesas:

Dillated cardiomyopathy

Hypertrophic cardiomyopathy

Restrictive or Constrictive cardiomyopathy

Arrythmogenic right ventricular cardiomyopathy

Unclassified cardiomyopathy
Etiology of cardiomyopathy

Pregnancy

Heavy alcohol intake

Viral infection

Chemotherapeutic medication
Iidiopathic

Genetics
DILATED CARDIOMYOPATHY (DCM)

This condition is characterized by dilatation and impaired contraction of the left (and
sometimes the right) ventricle.
10

Distinguished
by
significant
dilatation
of the
ventricles
without
simultaneous
hypertrophy.

The ventricles of elevated systolic and diastolic volume but a decreased ejection
fraction

Left ventricular mass is increased but wall thickness is normal or reduced.

The histological changes are variable but include myofibrillary loss, interstitial
fibrosis and T-cell infiltrates.

When the causative factor cannot be identified, the term used is idiopathic DCM.
Idiopathic

Most patient present with heart failure or are found to have the condition during
routine investigation.

Arrhythmias ,thromboembolism and sudden death are common and may occur at any
stage.

Chest pain is a surprisingly the diagnosis.

Although some patient remain well for many year, the prognosis is variable and
cardiac transplantation may be indicated

Risk is subsiquently reduced by regerious medical therapy with beta blocker
and
angiotensin receptor antagonist

Some patient may be considered for implantation of a cardiac defrillator
HYPERTROPHIC CARDIOMYOPATHY( HCM)

In HCM, the heart muscle increases in size and mass, especially along the septum

The increased thickness of the heart muscle reduces the size of the ventricular cavities

The ventricles to take a longer time to relax.

Making
it more difficult for the ventricles to fill with blood during the first part of
diastole and making them more dependent on atrial contraction for filling

Structural changes may also result in a smaller than normal ventricular cavity and a
higher velocity flow of blood out of the left ventricle into the aorta,which may be
detected by echocardiography .
11

HCM may cause significant diastolic dysfunction, but systolic function can be normal
or high, resulting in a higher than normal ejection fraction

It may also be idiopathic
RESTRICTIVE CARDIOMYOPATHY

Restrictive cardiomyopathy (RCM) is characterized by diastolic.

Dysfunction caused by rigid ventricular walls that impair ventricular
stretch and
diastolic filling .

Systolic
function
is
usually
normal.Because
RCM
is
the
least
common
cardiomyopathy.

Its pathogenesis is the least understood

Restrictive cardiomyopathy can be associated with amyloidosis (in which amyloid, a
protein substance, is deposited within the cell) and other such infiltrative diseases.

However, the cause is unknown in most cases (ie, idiopathic).
ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY

ARVC occurs when the myocardium of the right ventricle is progressively infiltrated
and replaced by fibrous scar and adipose tissue.

Initially, only localized areas of the right ventricle are affected, but as the disease
progresses, the entire heart is affected.

Eventually, the right ventricle dilates and develops poor contractility right ventricular
wall abnormalities, and dysrhythmias

The prevalence of ARVC is unknown because many cases are not recognized.

ARVC should be suspected in patients with ventricular tachycardia originating in the
right ventricle (ie, a left bundle branch
block configuration on ECG) or sudden
death, especially among previously symptom-free athlete.

The disease may be genetic (ie, autosomal dominant) . Family members should be
screened for the disease with a 12-lead ECG, Holter monitor, and echocardiography.
UNCLASSIFIED CARDIOMYOPATHIES
12

Unclassified cardiomyopathies are different from or have characteristics of more than one
of the previously described cardiomyopathies.

Unclassified
cardiomyopathies
include
fibroelastosis,
noncompacted
myocardium,
systolic dysfunction with minimal dilation, and mitochondrial involvement
Primary Myocardial Involvement

Idiopathic

Familial

Eosinophilic endomyocardial disease

Endomyocardial fibrosis
Secondary Myocardial Involvement

Infective

Viral myocarditis, Bacterial myocarditis ,Fungal myocarditis , Protozoal myocarditis
Metazoal myocarditis

Spirochetal

Rickettsial

Metabolic

Familial storage disease

Glycogen storage disease

Mucopolysaccharidoses( thickness secreation)

Hemochromatosis (Iron deposit in body)

Connective tissue disorders

Systemic lupus erythematosus

Polyarteritis nodosa

Rheumatoid arthritis

Progressive systemic sclerosis

Dermatomyositis

Infiltrations and granulomas

Amyloidosis
13

Sarcoidosis

Malignance

Neuromuscular

Muscular dystrophy

Myotonic dystrophy

Friedreich's ataxia

Sensitivity and toxic reactions

Alcohol

Radiation

Drugs (doxorubicine)

Peripartum heart disease
Pathophysiology

It is a series of progressive events that culminate in impaired cardiac output.

Decreased stroke volume stimulates the sympathetic nervous system and the reninangiotensin-aldosterone response

Resulting in increased systemic vascular resistance and increased sodium and fluid
retention

Increased workload on the heart.

These alterations can lead to heart failure
CLINICAL FEATURE
According to book
1. Signs
In patient
and symptoms of heart failure (eg, dysponea on exertion, Present
fatigue).
2. Patient
report paroxysmal nocturnal dyspnea, cough (especially Present
with exertion)
3. Orthopnea
Present
4. Fluid retention,
Present
5. Peripheral edema
present
14
6. Nausea The patient may experience chest pain
Present
7. Palpitations
Absent
8. Dizziness
Present
9. Syncope with exertion
Absent
DIAGNOSIS OF THE CARDIOMYOPATHY
According to book
In patient
1. Chest X-ray
1. Moderate to marked cardiac silhouette
enlargement, Pulmonary venous hypertension
2. Electrocardiogram
2. ST-segment and T-wave abnormalities
3. Echocardiogram
3. Left ventricular dilatation and dysfunction
4. Radionuclide study
4. Left ventricular dilatation and dysfunction
5. Cardio catheterization
5. Elevated left- and often right-sided filling
pressures. Diminished cardiac output
INVESTIGATION
Component
Inpatient
Reference
Hemoglobin
WBC count
Neutrophil
Lymphocyte
Monocyte
Esinophil
Basinophil
Platlet
12.1%
9000/cumm3
68%
26%
00
06
00
31600
14-16gm%
4000-11000/cumm
40-75%
20-50%
2-10%
1-6%
<1%
150000-450000
Component
In patient
Reference range
ALT
38.0IU/L
5.0-35.0IU/L
15
AST/GOT
34.0
5.0-40.0IU/L
Sugar
96 mg/dl
65 – 140 mg/dl
Urea
33mg/dl
10-45mg/dl
Creatinine
184umol/l
40-110umol/l
Sodium
137mEq/l
135-145mEq/l
Potassium
3.8mEq/l
3.6-5.5mEq/l
MEDICATIONS USED IN THE PATIENT
1. Tab Isoniazid
225mg+Tab Rifampicine 450mg+Tab Pyrezenamide 1200mg+Tab
Ethambutaol 825mg 3 tabs PO OD
2. Tab Pyridoxine 30mg PO OD
3. Enalpril 5mg OD continue
4. Asprin 75mg OD continue
5. Cloplet 75 OD continue
6. Tab Carvedilol 3.125 mg BD for 7 days
MEDICAL MANAGEMENT

Correcting heart failure with medication

Low sodium diet

Exercise and rest regimen

Controlling Dysrhythmia

Systemic anticoagulant

Restriction in fluid intake

Implantation of electronic devices(implantable cardioverter defibrillator)
16

If patients exhibit signs and symptoms of congestion, their fluid intake may be limited
to 2 liters each day.

The person with HCM may also have to limit physical activity to avoid a lifethreatening dysrhythmia.

A pacemaker may be implanted to alter the electrical stimulation of the muscle and
prevent the forceful hyper dynamic contractions that occur with HCM.
SURGICAL MANAGEMENT
Left Ventricular Outflow Tract Surgery.

The most common procedure is a myectomy (sometimes referred to as a
myotomymyectomy),in which some of the heart tissue is excised.

Septal tissue approximately 1 cm wide and deep is cut from the enlarged septum
below the aortic valve.

The length of septum removed depends on the degree of obstruction caused by the
hypertrophied muscle.

Instead of a septal myectomy, the surgeon may open the left ventricular outflow tract
to the aortic valve by removing the mitral valve, chordae, and papillary muscles.

The mitral valve then is replaced with a low-profile disk valve.

The space taken up by the mitral valve is substantially reduced by the prosthetic valve
compared with the patient’s own valve, chordae, and papillary muscles, allowing
blood to move around the enlarged septum to the aortic valve in the area that the
mitral valve once occupied.

The
primary
complication
of
both
procedures
is
dysrhythmia;
additional
complications are postoperative surgical complications such as pain, ineffective
airway clearance, deep vein thrombosis, risk for infection, and delayed surgical
recovery.
HEART TRANSPLANTATION.
17
a.
The first human-to-human heart transplant
It was performed in 1967. Since then, transplant procedures, equipment, and medications
have continued to improve. Since 1983, when cyclosporine became available, heart
transplantation has become a therapeutic option for patients with end-stage heart disease

Cyclosporine is an immunosuppressant that greatly decreases the body’s rejection of
foreign proteins, such as transplanted organs.

Unfortunately, cyclosporine also decreases the body’s ability to resist infections, and a
satisfactory balance must be achieved between suppressing rejection and avoiding
infection
Common indication
o Cardiomyopathy
o Ischemic heart disease
o Valvular disease
o Rejection of previously transplanted hearts
o Congenital heart disease has severe symptoms uncontrolled by medical therapy,
no other surgical options
•
A multidisciplinary team screens the candidate before recommending the transplantation
procedure.
 The person’s age
 Pulmonary status
 other chronic health conditions
 psychosocial status
 family support
 Infections
 history of other transplantations,
 compliance,
 current health status
18
•
When a donor heart becomes available, a computer generates a list of potential recipients
on the basis of
o ABO blood group compatibility
o The sizes of the donor and the potential recipient,
o The geographic locations of the donor and potential recipient;
o Distance is a variable because postoperative function depends on the heart being
implanted within 6 hours of harvest from the donor.
Orthotropic transplantation
•
Most common surgical procedure for cardiac transplantation.
•
The recipient’s heart is removed, and the donor heart
•
is implanted at the vena cava and pulmonary veins
•
Some surgeons still prefer to remove the recipient’s heart leaving a portion of the
recipient’s atria (with the vena cava and pulmonary veins) in place.
•
The donor heart, which usually has been preserved in ice.
•
The donor heart is implanted by suturing the donor atria to the residual atrial tissue of
the recipient’s heart.
HETEROTOPIC TRANSPLANTATION
•
The donor heart is placed to the right and slightly anterior to the recipient’s heart
the recipient’s heart is not removed.
•
Initially, it was thought that the original heart might provide some protection for the
patient in the event that the transplanted heart was rejected.
•
Although the protective effect has not been proved, other reasons for retaining the
original heart have been identified a small donor heart or pulmonary hypertension
•
The transplanted heart has no nerve connections with the recipient’s body (ie,
denervated heart), and the sympathetic and vagus nerves do not affect the transplanted
heart.
•
The resting rate of the transplanted heart is approximately 70 to 90 beats per minute,
but it increases gradually if catecholamines are in the circulation.
19
•
Patients must gradually increase and decrease their exercise (ie, extended warm-up
and cool-down periods), because 20 to 30 minutes may be required to achieve the
desired heart rate.
•
Atropine does not increase the heart rate of these patients
Postoperative Care
•
Heart transplant patients are constantly balancing the risk of rejection with the risk of
infection.
•
They must comply with a complex regimen of diet, medications, activity, follow-up
laboratory studies, biopsies (to diagnose rejection), and clinic visits.
•
Most commonly, patients receive cyclosporine or tacrolimus (FK506, Prograf),
azathioprine (Imuran) or mycophenolate
mofetil (CellCept), and corticosteroids (ie,
prednisone) to minimize rejection.
•
Rejection and infection, complications may include accelerated atherosclerosis of the
coronary arteries
•
Hypertension may be experienced by patients taking cyclosporine or tacrolimus; the
cause has not been identified.
•
Osteoporosis frequently occurs as a side effect of the anti-rejection medications and
pre transplantation dietary insufficiency and medications.
•
Post transplantation lymphoproliferative disease and cancer
•
Weight gain, obesity, diabetes, dyslipidemias (eg hypercholesterolemia) hypotension,
renal failure, and central nervous system
•
Respiratory, and gastrointestinal disturbances may be caused by the corticosteroids or
other immunosuppressants.
•
Other complications are immunosuppressant medication toxicities and responses to
the psychosocial stresses imposed by organ transplantation.
•
Patients may experience guilt that someone died for them to live, have anxiety about
the new heart, experience depression or fear when rejection is identified, or have
difficulty with family role changes before and after transplantation
20
Survival rate
•
The 1-year survival rate for patients with transplanted hearts is approximately 80% to
90%
•
The 5-year survival rate is approximately 60% to 70%
Mechanical Assist Devices and Total Artificial Hearts
•
Cardiopulmonary
bypass for cardiovascular surgery and the possibility of performing
heart transplantation for end-stage cardiac disease have increased the need for
mechanical assist devices.
•
Patients who cannot be weaned from cardiopulmonary bypass or patients in
cardiogenic shock may benefit from a period of mechanical heart assistance.
•
The most commonly used device is the intra-aortic balloon pump.
•
This pump decreases the work of the heart during contraction but does not perform
the actual work of the heart
Ventricular Assist Devices.
•
More complex devices that actually perform some or all of the pumping function for
the heart also are being used.
•
These more sophisticated ventricular assist devices can circulate as much blood per
minute as the patient’s heart, if not more.
•
Each ventricular assist device is used to support one ventricle.
•
Some ventricular assist devices can be combined with an oxygenator; the
combination is called extracorporeal membrane oxygenation (ECMO).
•
The oxygenator– ventricular assist device combination is used for the patient whose
heart cannot pump adequate blood through the lungs or the body
•
There are three basic types of devices: centrifugal, pneumatic, and electric or
electromagnetic.
21
•
Centrifugal VADs are external, nonpulsatile, cone-shaped devices with internal
mechanisms that spin rapidly creating a vortex (tornado-like action) that pulls blood
from a large vein into the pump and then pushes it back into a large artery.
•
Pneumatic VADs are external or implanted pulsatile devices with a flexible reservoir
housed in a rigid exterior
•
The reservoir usually fills with blood drained from the patient’s atrium or ventricle.
•
The VAD then forces pressurized air into the rigid housing, compressing the reservoir
and returning the blood to the patient’s circulation, usually into the aorta.
•
Electric or electromagnetic VADs are similar to the pneumatic VADs, but instead of
pressurized air.
•
One or more flat metal plates are pushed against the reservoir to return the blood to
the patient’s circulation.
Total Artificial Hearts.
•
Total artificial hearts are designed to replace both ventricles. Some require the
removal of the patient’s heart to implant the total artificial heart; others do not.
•
All of these devices are experimental.
•
Although there has been some short-term success, the long-term results have been
disappointing.
•
Researchers hope to develop a device that can be permanently implanted and that will
eliminate the need for donated human heart transplantation for the treatment of endstage cardiac disease
•
Most VADs and total artificial hearts are temporary treatments.
•
While the patient’s own heart recovers or until a donor heart becomes available for
transplantation. Some devices are being investigated for permanent use.
•
Bleeding disorders, hemorrhage, thrombus, emboli, hemolysis,
infection, renal
failure, right heart failure, multisystem failure, and mechanical failure are some of the
complications of VADs and total artificial hearts
22
DRUG PROFILE
1. Pyridoxine
Category: Vitamin
Brands available: a) ABDEC FORTE
b)B-LONG
C)BEPLEX ELIXIR
Dosage regimen:
Dietary Deficiency
ADULTS: PO/IM/IV 10 to 20 mg/day for 3 wk.
Drug-Induced Deficiency Anemia or Neuritis
ADULTS: PO/IM/IV 100 to 200 mg/day for 3 wk; follow with 25 to 100 mg/day.
23
d)B-VITAL
Neuropathy
ADULTS: PO/IM/IV 50 to 200 mg/day.
Vitamin B6 Dependency Syndrome
ADULTS: PO/IM/IV 600 mg, followed by 30 mg/day for life. Dependency has been noted in adults
administered 200 mg/day. PYRIDOXINE-DEPENDENT INFANTS: IM/IV 10 to 100 mg, followed by 2
to 100 mg/day.
Metabolic Disorders
ADULTS: PO/IM/IV 100 to 500 mg/day
Indication: Pyridoxine deficiency, including inadequate diet, drug-induced causes (eg, isoniazid,
hydralazine, oral contraceptives) or inborn errors of metabolism
Adverse effect: CNS: Neuropathy; unstable gait; drowsiness; somnolence. EENT: Perioral numbness.
OTHER: Numbness of feet; decreased sensation to touch, temperature or vibration; paresthesia; low
serum folic acid levels; burning/stinging at IM injection site; photoallergic reaction; ataxia.
Contraindications: Standard considerations.
Caution: Pregnancy: Category A. (Category C in doses that exceed the RDA.) Lactation: Excreted in
breast milk; may inhibit lactation. Children: Safety and efficacy not established in doses exceeding
nutritional requirements.
Nursing Implementation:
Instruct patient to swallow sustained-release preparation whole and not to break, crush or chew.
When giving via IM route, rotate sites.
IV preparation may be given undiluted or added to standard compatible IV solutions.
Store all forms of drug at room temperature in tightly-closed, light-resistant containers. Avoid freezing
injection
1. Isoniazide
Category: Antituberculosis drug ( first line drug) bacteriacidal
Brands available: a)Isokin
b)Solonex
c)Isonex d)Tubernex forte
Dosage regimen: 300mg /day Adult
5-10mg/kg/day children
Indication: Tuberculosis, Prophylaxis of tuberculosis.
Adverse effect: convulsion, joint pain, agranulocytosis, skin rash, buring sensation of feet, drowsiness,
hallucinations, abdominal pain, nausea, vomiting, epigastric distress, fever;
Contraindications: Hypersensitivity
24
Caution: Severe renal impairment,hepatic failure pregnancy and lactation
Nursing implementation
Careful monitoring is necessary for black and Hispanic women, notice and inform side effect full course
of treatment should be given
.
2. Rifampicine
 Therapeutic category: Antituberculosis drug ( first line drug), Antileprotis drug
 Indications:
Tuberculosis, Leprosy, Prophylaxis of meningococcal infections, prophylaxis of
meningitis due to H.influeza type B, treatment of asymptomatic carriers of Neisseria meningitis..
 Dose regimen: TB: 450-600mg/day for first 2 month, 10-15mg/kg 3 times a week.
 Adverse effect: Anorexia, nausea, vomotting, abdominal pain, hepatitis, acute renal failure,
drowsiness. Headache, atoxia, visual disturbance, skin rash, shock, eosinophila, transcient
leucopenia.GI disturbance, peptic ulceration, abnormalities of kidney function.
 Contraindications: Hypersensitivity, jaundice, biliary destruction, severe hepatic disease impaired
hepatic renal functions.
 Nursing implementation: Take in empty stomach informs patient that orange red urine is harmless,
take full course of the drug.
 Storage condition: Store in cool and dry place.
3. Ethambutol
 Therapeutic category: Antituberculosis drug ( first line drug)
 Indications: Pulmonary and extra pulmonary tuberculosis
 Dosage regimen:Adult: 15-25mg/kg/day continuous upto 50mg/kg
 Children 10-15mg/kg/day continuous
 Adverse effects: headache, stomach upset. Anorexia, nausea, vomiting, skin rash. Hepatitis, neuritis,
dizziness, neuropathy, reduced renal clearanceof ureters.
 Contraindication: drug allergy, optic neuritis, renal/ hepatic failure, history of epilepsy, neonates,
impaires pretreatment visual acquity.
 Nursing consideration: visual function test is recommended before and during therapy liver function
test should be done.
 Storage: store in a cool and dry place
25
4. Pyrazinamide
 Therapeutic category: Antituberculosis drug ( first line drug)
 Indications: Tuberculosis
 Dosage regimen: 20-35mg/kg/day (adult), 15-30mg/kg/day (children)
 Adverse effects: joint pain hepatitis hepatomegaly, spleenomegaly. Arthrolgai, malaise, fever,
hyperuricaemia, rashes, photosensitivity, anemia
 Contraindication: hypersensitivity, diabetes, hepatic, impairment condition ,gout renal failure.
 Nursing consideration: liver function test should be done, full course of drugs should be done,
vitamin B6 should be supplement.
 Storage: store in a cool and dry place
5. Carvedilol
Drug classes
Alpha- and beta-adrenergic blocker, Antihypertensive
Therapeutic actions
Competitively
blocks
alpha-,
beta-,
and
beta2 -adrenergic
receptors
and
has
some
sympathomimetic activity at beta2 -receptors. Both alpha and beta blocking actions contribute to
the BP-lowering effect; beta blockade prevents the reflex tachycardia seen with most alphablocking drugs and decreases plasma renin activity. Significantly reduces plasma renin activity.
Indications

Hypertension, alone or with other oral drugs, especially diuretics

Treatment of mild to severe CHF of ischemic or cardiomyopathic origin with digitalis,
diuretics, ACE inhibitors

Left ventricular dysfunction (LVD) after MI

Unlabeled uses: Angina (25–50 mg bid)
Contraindications and cautions
26

Contraindicated with decompensated CHF, bronchial asthma, heart block, cardiogenic
shock, hypersensitivity to carvedilol, pregnancy, lactation.

Use cautiously with hepatic impairment, peripheral vascular disease, thyrotoxicosis,
diabetes, anesthesia, major surgery.
Available forms
Tablets—3.125, 6.25, 12.5, 25 mg

Hypertension: 6.25 mg PO bid; maintain for 7–14 days, then increase to 12.5 mg PO bid
if needed to control BP. Do not exceed 50 mg/day.

CHF: Monitor patient very closely, individualize dose based on patient response. Initial
dose, 3.125 mg PO bid for 2 wk, may then be increased to 6.25 mg PO bid. Maximum
dose, 25 mg PO bid in patients < 85 kg or 50 mg PO bid in patients > 85 kg.

LVD following MI: 6.25 mg PO bid, increase after 3–10 days to target dose of 25 mg bid.
Metabolism: Hepatic; T1/2 : 7–10 hr
Distribution: Crosses placenta; may enter breast milk
Excretion: Bile, feces
Adverse effects

CNS: Dizziness, vertigo, tinnitus, fatigue, emotional depression, paresthesias, sleep
disturbances

CV: Bradycardia, orthostatic hypertension, CHF, cardiac arrhythmias, pulmonary edema,
hypotension

GI: Gastric pain, flatulence, constipation, diarrhea, hepatic failure

Respiratory: Rhinitis, pharyngitis, dyspnea

Other: Fatigue, back pain, infections
27
Interactions

Increased effectiveness of antidiabetics; monitor blood glucose and adjust dosages
appropriately

Increased effectiveness of clonidine; monitor patient for potential severe bradycardia and
hypotension

Increased serum levels of digoxin; monitor serum levels and adjust dose accordingly

Increased plasma levels of carvedilol with rifampin

Potential for dangerous conduction system disturbances with verapamil or diltiazem; if
this combination is used, closely monitor ECG and BP

Slowed rate of absorption but not decreased effectiveness with food
Nursing management
Assessment

History: CHF, bronchial asthma, heart block, cardiogenic shock, hypersensitivity to
carvedilol,
pregnancy,
lactation,
hepatic
impairment,
peripheral vascular
disease,
thyrotoxicosis, diabetes, anesthesia or major surgery

Physical: Baseline weight, skin condition, neurologic status, P, BP, ECG, respiratory
status, LFTs, renal and thyroid function tests, blood and urine glucose
Warning :

Do
not
discontinue
drug
abruptly
after
chronic
therapy
(hypersensitivity
to
catecholamines may have developed, causing exacerbation of angina, MI, and ventricular
arrhythmias); taper drug gradually over 2 wk with monitoring.

Consult with physician about withdrawing drug if patient is to undergo surgery
(withdrawal is controversial).

Give with food to decrease orthostatic hypotension and adverse effects.

Monitor for orthostatic hypotension and provide safety precautions.

Monitor patients with diabetes closely; drug may mask hypoglycemia or worsen
hyperglycemia.
28

Monitor patient for any sign of liver dysfunction (pruritus, dark urine or stools, anorexia,
jaundice, pain); arrange for LFTs and discontinue drug if tests indicate liver injury. Do
not restart carvedilol.
Teaching points

Take drug with meals.

Do not stop taking drug unless instructed to do so by a health care provider.

Avoid use of over-the-counter medications.

You may experience these side effects: Depression, dizziness, light- headedness (avoid
driving or performing dangerous activities; getting up and changing positions slowly may
help ease dizziness).

Report difficulty breathing, swelling of extremities, changes in color of stool or urine,
very slow heart rate, continued dizziness.
6. Enalapril maleate
Drug classes
Antihypertensive, ACE inhibitor
Therapeutic actions
Renin, synthesized by the kidneys, is released into the circulation where it acts on a plasma
precursor to produce angiotensin I, which is converted by ACE to angiotensin II, a potent
vasoconstrictor that also causes release of aldosterone from the adrenals; both of these actions
increase BP. Enalapril blocks the conversion of angiotensin I to angiotensin II, decreasing BP,
decreasing aldosterone secretion, slightly increasing serum K + levels, and causing Na+ and fluid
29
loss; increased prostaglandin synthesis also may be involved in the antihypertensive action. In
patients with heart failure, peripheral resistance, afterload, preload, and heart size are decreased.
Indications

Treatment of hypertension alone or in combination with other antihypertensives,
especially thiazide-type diuretics

Treatment of acute and chronic CHF

Treatment of asymptomatic left ventricular dysfunction (LVD)

Unlabeled use: Diabetic nephropathy
Contraindications and cautions

Contraindicated with allergy to enalapril.

Use cautiously with impaired renal function; salt or volume depletion (hypotension may
occur); lactation, pregnancy.
Available forms
Tablets—2.5, 5, 10, 20 mg; injection—1.25 mg/mL

Hypertension:
Patients not taking diuretics: Initial dose is 5 mg/day PO. Adjust dosage based on patient
response. Usual range is 10–40 mg/day as a single dose or in two divided doses
.
Patients taking diuretics: Discontinue diuretic for 2–3 days if possible. If it is not possible
to
discontinue diuretic, give initial dose of 2.5 mg, and monitor for excessive
hypotension.
Converting to oral therapy from IV therapy: 5 mg daily with subsequent doses based on
patient response.

Heart failure: 2.5 mg PO daily or bid in conjunction with diuretics and digitalis.
Maintenance dose is 5–20 mg/day given in two divided doses. Maximum daily dose is
40 mg.
30

Asymptomatic LVD: 2.5 mg PO bid; target maintenance dose 20 mg/day in two divided
doses.
Give IV only. 1.25 mg q 6 hr given IV over 5 min. A response is usually seen within 15
min, but peak effects may not occur for 4 hr.

Hypertension:
Converting to IV therapy from oral therapy: 1.25 mg q 6 hr; monitor patient response.

Patients taking diuretics: 0.625 mg IV over 5 min. If adequate response is not seen after 1
hr, repeat the 0.625-mg dose. Give additional doses of 1.25 mg q 6 hr.

Excretion is reduced in renal failure; use smaller initial dose, and adjust upward to a
maximum of 40 mg/day PO. For patients on dialysis, use 2.5 mg on dialysis days.

If creatinine clearance 30 mL/min, the initial dose is 0.625 mg, which may be repeated.
Additional doses of 1.25 mg q 6 hr may be given with careful patient monitoring.
Pharmacokinetics
Metabolism: T1/2 : 11 hr
Distribution: Crosses placenta; enters breast milk
Excretion: Urine
Preparation: Enalaprilat can be given as supplied or mixed with up to 50 mL of 5% dextrose
injection, 0.9% sodium chloride injection, 0.9% sodium chloride injection in 5% dextrose, 5%
dextrose in lactated Ringer's, Isolyte E. Stable at room temperature for 24 hr.
Infusion: Give by slow IV infusion over at least 5 min.
Adverse effects

CNS: Headache, dizziness, fatigue, insomnia, paresthesias

CV: Syncope, chest pain, palpitations, hypotension in salt- or volumedepleted patients

GI: Gastric irritation, nausea, vomiting, diarrhea, abdominal pain, dyspepsia,
elevated liver enzymes

GU: Proteinuria, renal insufficiency, renal failure, polyuria, oliguria, urinary
frequency, impotence
31

Hematologic: Decreased Hct and Hgb

Other: Cough, muscle cramps, hyperhidrosis
Interactions

Decreased hypotensive effect if taken concurrently with indomethacin, rifampin
Nursing considerations
Assessment

History: Allergy to enalapril, impaired renal function, salt or volume depletion, lactation,
pregnancy

Physical: Skin color, lesions, turgor; T; orientation, reflexes, affect, peripheral sensation;
P, BP, peripheral perfusion; mucous membranes, bowel sounds, liver evaluation;
urinalysis, LFTs, renal function tests, CBC, and differential
Interventions

Warning : Alert surgeon, and mark patient's chart with notice that enalapril is being
taken; the angiotensin II formation subsequent to compensatory renin release during
surgery will be blocked; hypotension may be reversed with volume expansion.

Monitor patients on diuretic therapy for excessive hypotension after the first few doses of
enalapril.

Monitor patient closely in any situation that may lead to a drop in BP secondary to
reduced
fluid volume (excessive perspiration and dehydration, vomiting, diarrhea)
because excessive hypotension may occur.

Arrange for reduced dosage in patients with impaired renal function.

Monitor patient carefully because peak effect may not be seen for 4 hr. Do not administer
second dose until BP has been checked.
Teaching points

Do not stop taking the medication without consulting your health care provider.

Be careful in any situation that may lead to a drop in blood pressure (diarrhea, sweating,
vomiting, dehydration).
32

Avoid over-the-counter medications, especially cough, cold, and allergy medications that
may interact with this drug.

You may experience these side effects: GI upset, loss of appetite, change in taste
perception (will pass with time); mouth sores (frequent mouth care may help); rash; fast
heart rate; dizziness, light- headedness (usually passes in a few days; change position
slowly, limit activities to those not requiring alertness and precision).

Report mouth sores; sore throat, fever, chills; swelling of the hands, feet; irregular
heartbeat, chest pains; swelling of the face, eyes, lips, tongue, difficulty breathing.
7. Aspirin
Apo-ASA (CAN), Aspergum, Bayer, Easprin, Ecotrin, Empirin, Entrophen (CAN), Genprin,
Halfprin 81, 1/2 Halfprin, Heartline, Norwich, Novasen (CAN), Ascriptin, Asprimox, Bufferin,
Buffex, Magnaprin
Drug classes
Antipyretic, Analgesic (nonopioid), Anti-inflammatory, Antirheumatic, Antiplatelet, Salicylate,
NSAID
Therapeutic actions
Analgesic and antirheumatic effects are attributable to aspirin's ability to inhibit the synthesis of
prostaglandins,
important
mediators
of
inflammation.
Antipyretic
effects
are
not
fully
understood, but aspirin probably acts in the thermoregulatory center of the hypothalamus to
block effects of endogenous pyrogen by inhibiting synthesis of the prostaglandin intermediary.
Inhibition of platelet aggregation is attributable to the inhibition of platelet synthesis of
thromboxane A2 , a potent vasoconstrictor and inducer of platelet aggregation. This effect occurs
at low doses and lasts for the life of the platelet (8 days). Higher doses inhibit the synthesis of
prostacyclin, a potent vasodilator and inhibitor of platelet aggregation.
Indications

Mild to moderate pain

Fever

Inflammatory conditions—rheumatic fever, rheumatoid arthritis, osteoarthritis
33

Reduction of risk of recurrent TIAs or stroke in males with history of TIA due to fibrin
platelet emboli

Reduction of risk of death or nonfatal MI in patients with history of infarction or unstable
angina pectoris

MI prophylaxis

Unlabeled use: Prophylaxis against cataract formation with long-term use
Contraindications and cautions

Contraindicated with allergy to salicylates or NSAIDs (more common with nasal polyps,
asthma, chronic urticaria); allergy to tartrazine (cross-sensitivity to aspirin is common);
hemophilia,
bleeding
ulcers,
hemorrhagic
states,
blood
coagulation
defects,
hypoprothrombinemia, vitamin K deficiency (increased risk of bleeding)

Use cautiously with impaired renal function; chickenpox, influenza (risk of Reye's
syndrome in children and teenagers); children with fever accompanied by dehydration;
surgery scheduled within 1 wk; pregnancy (maternal anemia, antepartal and postpartal
hemorrhage, prolonged gestation, and prolonged labor have been reported; readily
crosses the placenta; possibly teratogenic; maternal ingestion of aspirin during late
pregnancy has been associated with the following adverse fetal effects: low birth weight,
increased intracranial hemorrhage, stillbirths, neonatal death); lactation.
Available forms
Tablets—81, 165, 325, 500, 650, 975 mg; SR tablets—650, 800 mg; suppositories—120, 200,
300, 600 mg
Dosages
Available in oral and suppository forms. Also available as chewable tablets, gum; enteric
coated, SR, and buffered preparations (SR aspirin is not recommended for antipyresis, shortterm analgesia, or children < 12 yr.)

Minor aches and pains: 325–650 mg q 4 hr.

Arthritis and rheumatic conditions: 3.2–6 g/day in divided doses.
34

Acute rheumatic fever: 5–8 g/day; modify to maintain serum salicylate level of 15–
30 mg/dL.

TIAs in men:1,300 mg/day in divided doses (650 mg bid or 325 mg qid).

MI prophylaxis: 75–325 mg/day.

Analgesic and antipyretic: 65 mg/kg per 24 hr in four to six divided doses, not to exceed
3.6 g/day. Dosage recommendations by age

Juvenile rheumatoid arthritis: 60–110 mg/kg per 24 hr in divided doses at 6- to 8-hr
intervals. Maintain a serum level of 150–300 mcg/mL.

Acute rheumatic fever: Initially, 100 mg/kg/day, then decrease to 75 mg/kg/day for 4–6
wk. Therapeutic serum salicylate level is 150 300 mg/dL.

Kawasaki disease: 80–180 mg/kg/day; very high doses may be needed during acute
febrile period; after fever resolves, dosage may be adjusted to 10 mg/kg/day.
Metabolism: Hepatic (salicylate); T1/2 : 15 min–12 hr
Distribution: Crosses placenta; enters breast milk
Excretion: Urine
Adverse effects

Acute
aspirin toxicity: Respiratory alkalosis, hyperpnea, tachypnea, hemorrhage,
excitement, confusion, asterixis, pulmonary edema, seizures, tetany, metabolic acidosis,
fever, coma, CV collapse, renal and respiratory failure (dose related, 20–25 g in adults, 4
g in children)

Aspirin intolerance: Exacerbation of bronchospasm, rhinitis (with nasal polyps, asthma,
rhinitis)

GI: Nausea, dyspepsia, heartburn, epigastric discomfort, anorexia, hepatotoxicity

Hematologic: Occult blood loss, hemostatic defects

Hypersensitivity: Anaphylactoid reactions to anaphylactic shock

Salicylism: Dizziness, tinnitus, difficulty hearing, nausea, vomiting, diarrhea, mental
confusion, lassitude (dose related)
35
Interaction

Increased risk of bleeding with oral anticoagulants, heparin

Increased risk of GI ulceration with steroids, phenylbutazone, alcohol, NSAIDs

Increased serum salicylate levels due to decreased salicylate excretion with urine
acidifiers (ammonium chloride, ascorbic acid, methionine)

Increased risk of salicylate toxicity with carbonic anhydrase inhibitors, furosemide

Decreased serum salicylate levels with corticosteroids

Decreased serum salicylate levels due to increased renal excretion of salicylates with
acetazolamide, methazolamide, certain antacids, alkalinizers

Decreased absorption of aspirin with nonabsorbable antacids

Increased methotrexate levels and toxicity with aspirin

Increased effects of valproic acid secondary to displacement from plasma protein sites

Greater glucose lowering effect of sulfonylureas, insulin with large doses (> 2 g/day) of
aspirin

Decreased antihypertensive effect of captopril, beta-adrenergic blockers with salicylates;
consider discontinuation of aspirin

Decreased uricosuric effect of probenecid, sulfinpyrazone

Possible decreased diuretic effects of spironolactone, furosemide (in patients with
compromised renal function)

Unexpected hypotension may occur with nitroglycerin

Decreased serum protein bound iodine (PBI) due to competition for binding sites

False-negative readings for urine glucose by glucose oxidase method and copper
reduction method with moderate to large doses of aspirin

Interference with urine 5-HIAA determinations by fluorescent methods but not by
nitrosonaphthol colorimetric method

Interference with urinary ketone determination by the ferric chloride method

Falsely elevated urine VMA levels with most tests; a false decrease in VMA using the
Pisano method
Nursing considerations
Assessment
36

History: Allergy to salicylates or NSAIDs; allergy to tartrazine; hemophilia, bleeding
ulcers, hemorrhagic states, blood coagulation defects, hypoprothrombinemia, vitamin K
deficiency; impaired hepatic function; impaired renal function; chickenpox, influenza;
children with fever accompanied by dehydration; surgery scheduled within 1 wk;
pregnancy; lactation

Physical: Skin color, lesions; T; eighth cranial nerve function, orientation, reflexes,
affect; P, BP, perfusion; R, adventitious sounds; liver evaluation, bowel sounds; CBC,
clotting times, urinalysis, stool guaiac, LFTs, renal function tests
Interventions

Give drug with food or after meals if GI upset occurs.

Give drug with full glass of water to reduce risk of tablet or capsule lodging in the
esophagus.

Do not crush, and ensure that patient does not chew SR preparations.

Do not use aspirin that has a strong vinegar- like odor.

Institute emergency procedures if overdose occurs: Gastric lavage, induction of emesis,
activated charcoal, supportive therapy.
Teaching points

Take extra precautions to keep this drug out of the reach of children; this drug can be
very dangerous for children.

Use the drug only as suggested; avoid overdose. Avoid the use of other over-the-counter
drugs while taking this drug. Many of these drugs contain aspirin, and serious overdose
can occur.

Take the drug with food or after meals if GI upset occurs.

Do not cut, crush, or chew sustained-release products.

Over-the-counter aspirins are equivalent. Price does not reflect effectiveness.

You may experience these side effects: Nausea, GI upset, heartburn (take drug with
food); easy bruising, gum bleeding (related to aspirin's effects on blood clotting).
37

Report ringing in the ears; dizziness, confusion; abdominal pain; rapid or difficult
breathing; nausea, vomiting, bloody stools.
NURSING MANAGEMENT
Assessment
•
Detailed history of the presenting signs and symptoms.
•
Identifies possible etiologic factors, such as heavy alcohol intake, recent illness or
pregnancy, or history of the disease in immediate family members.
•
If the patient complains of chest pain, a thorough review of the pain, including its
precipitating factors, should be performed.
•
The review of systems includes the presence of orthopnea, paroxysmal nocturnal
dyspnea, and syncope or dyspnea with exertion.
•
usual weight, any weight change, and limitation to activities
•
patient’s support systems are identified, and members are involved in the patient’s
care and therapeutic regimen.
•
Vital signs
•
Calculation of pulse pressure and identification of pulsus paradoxus
•
Current weight; determination of weight gain or loss
•
Detection by palpation of the point of maximal impulse, often shifted to the left
•
Cardiac auscultation for a systolic murmur and third and fourth heart sounds
•
Pulmonary auscultation for crackles
•
Measurement of jugular vein distention
•
Identification of presence and severity of edema
Nursing diagnoses
1. Decreased cardiac output related to structural disorders
2. caused by cardiomyopathy or to dysrhythmia from the disease process and medical
treatments
38
3. Ineffective cardiopulmonary, cerebral, peripheral, and renal tissue perfusion related to
decreased peripheral blood flo(resulting from decreased cardiac
4. Impaired gas exchange related to pulmonary congestion
5. Activity intolerance related to decreased cardiac output or excessive fluid volume, or
both
6. Anxiety related to the change in health status and in role functioning
7. Powerlessness related to disease process
8. Noncompliance with medication and diet therapies
Potential complications
•
Congestive heart failure
•
Ventricular dysrhythmias
•
Atrial dysrhythmias
•
Cardiac conduction defects
•
Pulmonary or cerebral embolism
•
Valvular dysfunction
Planning and Goals
•
Improved or maintained cardiac output
•
increased activity tolerance
•
Reduction of anxiety
•
Adherence to the self-care program, increased sense of power with decision making,
and absence of complications.
39
APPLICATION OF THE HENDERSON INDEPENDENCE THEORY IN THIS CASE
NURSING
40
Henderson concept of nursing is interesting from the prospective of time. Nursining help the
patient to meet the basic need through the formation of nurse pt relationship.
She was one of the earlier leader who believed nurse need a liberal education including
knowledge of science and
humanities. Aside from the definition of nursing and the fourteen
component of basic nursing care, the nurse is expected to carryout the physician therapeutic.
Person view as individual requiring assistance to achieve health and independence or peaceful
death. person and family are view as a unit. Person consist of biological, psychological
,sociological and spiritual component. Person is either sick or well and strive towards a state of
independence. person needs strength, will or knowledge to perform activities necessary for
healthy living. The individual has 14 basic need for survival.
Nursing process
Her definition and explanation of nursing do not directly fit the step of nursing process.
Assessment
She does not refer directly to assessment ,she implies in description of the 14 component of
basic nursing care. To complete the assessment phase the nurse need to analyze data. according
to her the nurse must have knowledge about what is normal in health and disease. Using this
knowledge the nurse would data compare the assessment data
Nursing diagnosis:
She does not specifically discussed nursing diagnosis. She believes that physician makes the
diagnosis and nurse acts upon that diagnosis. Base on the assessment and analysis of the data, the
nurse can identify the actual problem .
Planning:
Regarding the planning of care, she states plans need continue modification based on individual
needs. She emphasize that nursing care is always arranged around or fitted into the physician
therapeutic plan.
41
Implement:
Handerson nursing implementation is based on helping the patient meet the 14 component
Nursing assessment
The 14 components are:
1. Breathe normally.
2. Eat and drink adequately.
3. Eliminate body wastes.
4. Move and maintain desirable postures.
5. Sleep and rest.
6. Select suitable clothes-dress and undress.
7. Maintain body temperature within normal range by adjusting clothing and modifying
environment
8. Keep the body clean and well groomed and protect the integument
9. Avoid dangers in the environment and avoid injuring others.
10. Communicate with others in expressing emotions, needs, fears, or opinio
11. Worship according to one’s faith.
12. Work in such a way that there is a sense of accomplishment.
13. Play or participate in various forms of recreation.
14. Learn, discover, or satisfy the curiosity that leads to normal development and health and
use the available health facilities.
Nursing process
1. Analysis
Compare data to knowledge
base of health and disease the patient eat and drink is
inadequate
Nursing diagnosis
42
•
Identify the patient ‘s ability to meet own need with or without assistance .
•
The patient unable to meet eat and drinks need without assistance.
•
( Altered nutrition: less than body requirements related to decrease appetite secondary
to disease condition)
Nursing plan
•
Patient encourage to take balanced diet and frequent small meal.
•
Suitable environment will provide while taking food
•
Treat the disease with medications or any other measures.
•
Advise to increase the activity and ask to mobilize
Nursing implementation
•
Patient encouraged to take balanced diet and frequent small meal..
•
Suitable environment was provided while taking food.
•
Treat the disease with medications or any other measures.
•
Advised to increase the activity and asked to mobilize
Evaluation
My patient able to eat and drink adequately with out assistance.
2. Analysis
Patient was unable to Communicate with others in expressing emotions, needs, fears, or
opinion
Nursing diagnosis
•
Identify the patient ‘s ability to meet own need with or with out assistance .
•
Patient unable to communicate with other
expressing emotion, needs, fears or
opinion with out assistance .
•
( Anxiety related to the change in health status and in role functioning)
Nursing plan
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•
The patient
will
provide with appropriate information about cardiomyopathy and
self-management activities.
•
Patient will provide atmosphere in which the patient feels free to verbalize
•
Patient will provide discuss about treatment modalities .
•
Providing the patient with realistic hope helps
to reduce anxiety while the patient
awaits a donor heart.
Implementation
•
The patient is provided with appropriate information about cardiomyopathy and selfmanagement activities.
•
Patient was provided atmosphere in which the patient feels free to verbalize.
•
Patient provided the time about discuss the treatment modalities.
•
Providing the patient with realistic hope helps to reduce anxiety .
Evaluation
Patient was Communicate with others in expressing emotions, needs, fears, or opinion
3. Analysis
Patient was unable to move and maintain desirable postures.
Nursing diagnosis
•
Identify the patient ‘s ability to meet own need with or with out assistance .
•
The patient unable to move and maintain desirable postures with out assistance
•
(Activity intolerance related to decreased cardiac output or excessive fluid volume, or
both)
Nursing plan
•
Teach the patient about the need for planned cycles of rest and activity.
•
Helps them to identify methods to balance rest with activity.
•
Help the patient recognizes the symptoms that indicate the need for rest and the
actions to take when the symptoms occur.
•
Patients with HCM need to avoid strenuous activity and sports.
Implementation
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•
Teach the patient about the need for planned cycles of rest and activity. For example, after
taking a bath or shower, the patient should plan to sit and read the paper.
•
Suggesting that patients sit while chopping vegetables, drying their hair, or shaving helps
them to identify methods to balance rest with activity.
•
Help the patient recognizes the symptoms that indicate the need for rest .
•
Help to the patient the actions to take when the symptoms occur.
Evaluation
Patient was move and maintain desirable posture.
4. Analysis
Learn, discover, or satisfy the curiosity that leads to normal development and health and
use the available health facilities.
Nursing diagnosis
•
Identify the patient ‘s ability to meet own need with or with out assistance .
•
The patient unable
learn, discover, or satisfy the curiosity that leads to normal
development and health and use the available health facilities with out assistance
(Noncompliance with medication and diet therapies)
Nursing Planning
•
Patient will be teaching
about the medication regimen, symptom monitoring, and
symptom management
•
Helping patients cope with their disease status
•
Assists them in adjusting their lifestyles and implementing a self-care program at
home.
Implementation
•
Assists the patient and family to adjust to lifestyle changes.
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•
Teaching patients to read nutritional labels, to maintain a record of daily weights and
symptoms
•
and to organize daily activities to increase activity tolerance
•
Assessed diet and fluid restrictions and to the medication regimen
•
Explanation about symptoms that should be reported to the physician are emphasized.
Evaluation
The patient was able to
learn, discover, or satisfy the curiosity that leads to normal
development and health and use the available health facilities with out assistance.
DIVERSIONAL THERAPY
Diversional Therapy
is a client centered practice
recognizes that leisure and recreational
experiences are the right of all individuals.
•
These are often quite diverse and can range from: Games, outings, computers, gentle
exercise, music, arts and crafts.
•
Individual emotional and social support
•
Sensory enrichment, activities like massage and aromatherapy, pet therapy
•
Discussion groups, education sessions like grooming, beauty care, cooking.
•
The diversional therapy programme has definitely had a positive influence on
patient’s life and will continue to do so for as long as he is living at the hospital
•
The divertional therapy suggested for my patient is Gardening and gentle exercise
•
Social, cultural and spiritual activities
In my patient
In order to reduce anxiety and query about disease, I used following diversional therapy:
•
I provided him suitable environment that help to express his feelings.
•
I talked and interacted with him and his relatives about their family, occupation,
study.
46
•
Provide gentle exercise
•
Provide opportunity talking with other patient.
•
Listening music by mobile phone.
DAILY PROGRESS REPORT
Admission day (2068/11/18)
Vital signs
Respiration: 22/min
Temperature: 37.2 °C
Pulse: 86/min
BP: 100/70 mm of Hg
•
Patient diagnosis of Cardiomyopathy
with
Rt sided pleural effusion was admitted in
medical from medical OPD.
•
Patient came by walking. Vitals within normal range.
•
Patient is conscious and well oriented to time place and person.
•
Plan for diagnostic tapping today.
•
Report CBC ,Hb, ESR is to be collected.
2068/11/19
1st day of admission
Vital signs
Respiration: 20/min
Pulse: 64/min
Temperature: 36.8° C
BP: 100/60 mm of Hg
•
Patient’s general condition is fair. Vitals within normal range.
•
Tolerating normal diet. Normal bowel and bladder habit.
•
Patient is started ATT drugs. No any specific complain from patient side..
•
Patient’s general condition is improving.
•
Saturation maintained at room air tolerating normal diet.
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•
Normal bowel and bladder habit. No soakage from tapping site.
•
Patients complains of slight chest pain.
2068/11/20
Vital signs
Respiration: 20/min
Temperature: 36.8° C
Pulse: 64/min
BP: 100/60 mm of Hg
•
Patient’s general condition is improve.
•
Vitals within normal range.
•
Tolerating normal diet.
•
Normal bowel and bladder habit.
•
Patient give instruction about ATT drug
•
No any specific complain from patient side.
2068/11/20
2nd of admission
Vital signs
Respiration: 18/min
Temperature: 98.8° f
Pulse: 68/min
BP: 100/60 mm of Hg
•
Patient improve the condition today.
•
Assist patient for morning care.
•
Attend morning round.
•
Ambulate the patient.
2068/11/21
3rd day of admission
48
Vital signs
Respiration: 18/min
Temperature: 98.8° f
Pulse: 68/min
BP: 100/60 mm of Hg
•
Patient improve the condition and plan of discharge.
•
Discharge patient today
•
Provide health education
•
At the time of hospitalization, the following teaching was given to client and his
visitor about health promotion including
Personal hygiene:
•
The following informal teaching related to personal hygiene was provided:
•
Trimming nail and keeping it clean.
•
Washing hand before and after having food and after defecation.
•
Also frequent hand washing is necessary for infection prevention.
•
Oral hygiene and hair care is also necessary.
•
wearing neat and clean dress.
2) Nutritious food:
•
Encouraged for balanced diet and provided informal teaching on its importance and
sources.
3) Rest and sleep:
•
Provided informal teaching regarding importance of enough rest and sleep for
patient’s recovery.
4) Infection prevention:
•
Encouraged the client’s family to adopt infection control measures such as:
•
Keeping environment clean
•
Hand washing
•
Washing raw vegetables and fruits properly before consuming it.
•
Drinking safe water after purifying it, taught them about SODIS method of water
purification.
49
•
Care of the operative wound and its infection prevention
DISCHARGE TEACHING
Discharge medicine:
Tab Aspirin 75mg OD continue
Tab Enalpril 5mg OD continue
Carvedilol 3.125mg BD continue
At the time of discharge I was present there.
•
Patient was informed about the follow up on 2068/12/15
•
Patient was advised to have the prescribed medication on proper time and dose after
discharge. Patient was informed about the side effect of the drugs and importance of
continuation of ATT drug.
•
Patient advice to be far from smoke, dust. Close the mouth while coughing, sneezing etc
SPECIAL GAGETS USED IN MY PATIENT
Sphygmomanometer
Stethoscope
ECG monitoring
X-ray machine
Pulse oxymeter.
U.S G mechine.
LEARNED FROM THE EXPERIENCE
This case study gives following opportunity and knowledge such as
•
Identified the complete health need of older adult and give nursing care
•
Provide comprehensive nursing care to the adult patient.
50
•
Assist in different type of diagnosis procedure of the patient
•
Analyze the concept and approach to nursing practice according to
trend and
technology
•
Identified the factors influencing nursing practice.
•
Develop competency in handling various gadgets.
•
Identified the plan, implement and evaluate the educational need of
the patient
and
patient family.
REFERENCES
1. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing
vol-1 p-776
51
Lippincott 12th
edition
2. Black J.M &Hawks J.H. “Medical Surgical Nursing Clinical Management For Positive
Outcome”, division of Reed Elsevier India pvt ltd 8 th edition ,vol -2 pg no 1392
3. Lippincott , “manual of nursing practice of the adult “ 8 th Edition ,Jaypee brother pgno.
4. Devidson’s “principle and practice of mrdicine” 20 th edition.pg.no .641
5. Smeltzer. C. Suzanne, Bare. G. Brenda, “Brunner and Suddarth’s Textbook of Medical
Surgical Nursing”, 12th edition (2010), Wolters Kluwer India Pvt. Ltd, Page no: 574-575
6. Kumar. Parveen, Clark. Michael, “Clinical Medicine”, 6th edition (2005), Elsevier
Limited,
7. Boon. A. Nicholas, Colledge. R. Nicki, “Davidson’s Principles and Practice of
Medicine”, 20th edition (20), Elsevier Limited
8. Mosby’s “Nursing Drug Reference” , 23rd Edition, 2010
9. Cardiomyopathy www.medlineplus.com
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