MARTINEZ MEMORIAL COLLEGES

198 A. Mabini St., Caloocan City

College of Nursing

CASE STUDY
OF
ISCHEMIC CARDIOMYOPATHY
WITH ACUTE RENAL FAILURE

A case study Presented to the Faculty of College of Nursing in

Martinez Memorial Colleges

In Partial Fulfillment of the Requirements in

Nursing Care Management 102

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.

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 TABLE OF CONTENTS

PAGE
I. INTRODUCTION ……………………………………………………………
………………………1

II. OBJECTIVES ………………………………………………………

…....................................... 2

III. NURSING HEALTH HISTORY

A. Biographic Data ……………………………………………
…....................................................... 3
B. Chief Compliant and Clinical Diagnosis ..…………………………….....
………………………………………………….3
C. History of Present Illness …………………………………………….…
….................................................. 4
D. Past Medical History ……………………………………………….…...
….......................................... 4
E. Socio- Economic History …………………………………….………..…
……………………………….... 4
F. Environment History ……………………………………….……………
…............................................5
G. Gordon’s Eleven Functional Patterns ……………………………………
……..………………….…………..……….. .5

IV. PHYSICAL ASSESSMENT

A. Skin ……………………………………………………………….…..……
… 10
B. Head …………………………………………………………………....…
….. 10
C. Eyes ……………………………………………………………….………
….. 10
D. Ears ……………………………………………………………….………
….. 10
E. Nose ……………………………………………………………..…………
…. 10
F. Oral cavity ……………………………………………………..….………
…. ……...10

2
 G. Neck …………………………………………………………..….………
…… 10
H. Thorax and Lungs ………………………………………………………
…………………. 11
I. Heart
……………………………………………….……......…………………… 11
J. Abdomen
………………………………………………..…..……………….… ……. 11
K. Lower Extremities ………………………………………………………
…………………..11
L. Neurologic …………………………………………………...………..…
……… …11

V. LABORATORY EXAMINATION ANALYSIS ……….………….…………

……………………………………………..……. 12

VI. ANATOMY AND PHYSIOLOGY ……………….…………………………

……………………….....………….. 14

VII. REVIEW OF RELATED LITERATURE …………………..……………

…………………………………………...…….18

VIII. PATHOPHYSIOLOGY ……………………………………………………

…………….……………… 21

IX. DRUG STUDY

…………… ………………………………………………..…………….. …...22

X. NURSING CARE PLAN ……………………………………………………

………..………………….. 27

XI. DISCHARGE PLAN …………………………………………………………

…..…….…………......30

XII.PROGNOSIS
………….………………………………………………………………………31

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 I. INTRODUCTION

Epidemiology

Ischemic Cardiomyopathy is a term that doctors use to describe patients

who have congestive heart failure due to coronary artery disease. The condition
may occurred at any age and affects both men and women. About 1 out 100 adult
over the age of 60 has Ischemic Cardiomyopathy.

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 best to prevent ischemic cardiomyopathy is to avoid getting heart

disease, stop smoking, eating healthy diet, maintain a healthy weight, exercise as
much as possible, and avoid excessive drinking of alcohol and consult your doctor
to control blood pressure.

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.

III. NURSING HEALTH HISTORY

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

B. CHIEF COMPLAINT AND CLINICAL IMPRESSION

Chief Complaint: Edema of both legs and feet

Clinical Impression: Ischemic Cardiomyopathy with Acute Renal Failure

C. HISTORY OF PRESENT ILLNESS

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.

Patient X a client with type II diabetes (non- insulin- dependent) for 13

years and hypertension presented to the hospital with edema on his both leg and
feet and a feeling of a fullness on his peritoneal cavity. On January 7 during
physical assessment and history taking of Dr. Ferdinand Calalang revealed
accumulation of fluid on his peritoneal cavity and edematous feet with discharge
on his left foot and was initially diagnose with BPH, Ascites secondary to liver
cirrhosis.

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.

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 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.

Sonogram of the patient revealed Ascites, bilateral pleural effusion, diffuse

hepatic parenchymal disease consider cirrhosis, non dilated biliary tree and gassy
abdomen.

Continue monitoring to the patient especially BP for the sign of

hypertension. Furosemide and Lasix diuretic medications were given to decrease
the edema of the patient from his both leg and foot, dopamine to increase the
myocardial contractility to increase the heart rate of the pt. and also to increase
the peripheral resistance.

D. PAST MEDICAL HISTORY

A. Previous hospitalization 2006-appendectomy

Minor burn(first degree)
B. Injuries/ Accident
No other major injuries

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

Mr. X is unaware of problems he may encounter as a cook. He

also does overtime work. In their home and community hazard, patient X said that
their stairs in house have several flights. He was always having difficulty in going
up and down stairs. He said that he have to move slowly for him to be safe.

G. GORDON’S FUNCTIONAL HEALTH PATTERNS

Pattern of Health Perception and Health Management:

Patient X describes his current health as deteriorating, manifested by

feeling of numbness and easy fatigability particularly on his lower extremities.
Patient X is aware that his present condition is something that is really serious and
needs an immediate medication, he is also aware that the symptoms that he is
experiencing, is not normal. He admitted that he is afraid about it, that’s why he
decided to seek help and medication by hospitalization and he is always willing to
undergo treatment and rehabilitations to have a healthy and normal life again.

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,

6
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.

Before having a work in manila he smoked but he stops when he knew

that he has a heart disease however, he is still an occasional alcohol drinker he
drinks 4 bottles of beer in a week he said that he just drinks if there is an occasion.

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

TIME FRAME WEIGHT BMI INTERPRETATION

Before the illness 100 kgs. 33.55 Above the normal
During the illness 105kgs. 35.23 Above the normal

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

ht= 68 inches x 2.54 = 1.73²

= 2.98
100 105
2.98 = 33.55 2.98 = 35.23

BEFORE DURING HOSPITALIZATION

Breakfast-coffee, bread,
Snacks
Lunch-rice, vegetables, meat, water
Snacks
Dinner-rice, meat, vegetable, soup, water
Breakfast-bread, water,
Snacks-fruits, water
Lunch-rice, water, vegetables
Snacks-bread
Dinner-rice, water, vegetable, soup

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.

Even though he knew that he has diabetes and hypertension he doesn’t

have time to monitor his blood glucose level and blood pressure because he
spends most of his time on work.

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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.

Activities of Daily Living and Mobilization Status during Hospitalization:

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

Functional Level Classification

0- Completely Independent
1-Requires use of equipment or device
2- Requires help from another person for assistance, supervision or teaching
3- Requires help from another person and equipment device
4- Dependent does not participate in activity

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 is well oriented and mentally fit evidenced by his cooperative

attitude during the interview. He was able to comprehend the questions and
answer them logically.

Patient X has an intact short term memory, he also admitted that now,
knowing his situation made him feel anxious.

Pattern of Sleep and Rest:

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.

Pattern of Self perception and Self Concept:

8
 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:

BEFORE ILLNESS PRESENT

BOWEL ELIMINATION

Frequency Every other day Every other day

Character of stool Yellowish brown, Yellowish brown, solid

solid

Problems encountered such as Constipation Constipation

constipation, diarrhea, etc.
BEFORE ILLNESS PRESENT
URINARY ELIMINATION

Frequency 4-6 times a day 6-7 times a day

Quantity 900ml 6,500ml

Character of urine Yellow to reddish in Amber yellow

color
None
Problems encountered such as None
pain, burning

Pattern of Activity and Exercise:

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,

9
he occasionally feel dizzy, light headed and headaches it happened mostly at night
and in the morning when he wakes up.

He believes that his pattern of urination is normal.

Time Activity ( Before ) Time Activity ( During)

4:00am Wakes up 4:00am Wakes up
5:00 am Eats breakfast 6:00am Eats breakfast
6:00am-2:00pm- Goes to work 7:00am- Stays on room read
9:00pm depending on shift, 11:00am news papers, talks
sometimes with friends or
overtime relatives
10:00pm Sleeps for bed 12:00pm Eats lunch
2:00pm-4:00pm Takes a nap
7:00pm Eats dinner
10:00pm Sleeps for bed

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.

Pattern of Coping and Stress Tolerance:

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.

Pattern of Values and Belief:

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

 The hair is distributed well

 The color of the hair is brown and some white hair
 Dry hair
 No head lice, dandruff or any infection
 Round head
 Scalp is smooth
 No nodules or masses

3. EYES

 Proportion the size

 Eyebrows are black in color and symmetrical
 Conjunctiva is pale in color – due to decrease in RBC, Hgb and
Hct.count
 Sclera are white in color and cornea are shiny
 No abnormal involuntary movements
 PERRLA
 Can able to move in all direction

4. EARS

 Proportion to the size of the head

 No presence of discharge
 Poor hearing
 No pain and itching

5. NOSE

 No tenderness, masses and displacement of the bone

 Maxillary and Frontal sinus is normal and not inflamed

6. MOUTH

 Absent of any swelling, lesions and ulcerations

 Lips are pale in color
 No teeth in upper and lower incisors the pt. used dentures
 The tongue is negative in lesions and tenderness

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7. NECK

 Symmetrical and freely movable without difficulty

 presence of jugular vein distension

8. THORAX

 ( + ) crackles
 Tachypnea- inadequate blood supply/decrease blood flow resulting
to decrease oxygen,the lungs need to compensate
 Cheyne-stokes breathing

9. HEART

 (+) murmur – abnormal heart sound

 Tachycardia – 105bpm

10. ABDOMEN

 Flat
 NABS
 (+) ascites

11. LOWER EXTREMITIES

 (+) edema at the right foot

 (+) yellowish discharge

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 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

Total WBC 10.2 5-10 x 10-19 g/L

 Increase in the presence
of infection, cigarette
smoking, exercise, renal
failure, tissue necrosis
 Infected cellulitis in
lower left leg
Hct 0.49 0.38-0.50
Clotting time 2-5 min  Normal
Bleeding time 1-3 min

Segmenters 0.80 0.40-0.60

 Discharge cause of
inflammation of
connective tissue known
as cellulitis
Lymphocytes 0.12 0.20-0.40
 Decreased in
lymphocytes which is
the one who combats
foreign bodies may
decrease immune system
that leads to infection
 Decreased with
Monocytes 0.02-0.08 immuno-deficiency,
AIDS
Eosinophiles 0.08 0.01-0.03

 Increased indicates
metastatic or tumors in
thyroid
Basophiles 0-0.01  Increased in subacute
infections, collagen
disease

BLOOD CHEMISTRY REPORT

Test Result Normal Values Interpretation

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Glucose 98.0 mg/dL 75-115 mg/dL  Normal

FBS 5.44 mg/dL 4.2-6.4 mg/dL  Normal

Uric acid 8.4 mg/dL 2.4-7.0 mg/dL  Increased alcoholism,

high-protein weight
reduction diet, renal
failure, heart failure

Creatinine 2.7 mg/dL 0.5-1.7 mg/dL  Increased, indicate a

slowing of the
glumerular filtration
rate
 Increase, impaired
renal function
 Increase creatinine
secondary to Ascites
congestion
BUN 10.1-50.0 mg/dL

SGOT 55.7 u/L up to 37 u/L 37C

 Increase, liver disease,
alcoholism, Ischemic
SGPT 52.7 u/L up to 42 u/L 37C Cardiomyopathy

 Increase, heart failure,

Liver cirrhosis, Ascites
Cholesterol 159.2 mg/dL suspect >220mg/dL
 Elevation is a
cardiovascular risk
factor
 Increase hypertension
uncontrolled diabetes
mellitus
Triglycerides 80.0 mg/dL suspect >150mg/dL
 Fatty acids, elevation
is a cardiovascular risk
factors
 Increase blood
viscosity due to
Diabetes Mellitus
result to heart disease
HDL-P 35.2 mg/dL > 35 mg/dL
 High cholesterol level
leads to hypertension
LDL 168.0 mg/dL < 150 mg/dL
 Greater incidence of
VLDL 0-357 mg/dL CAD

Na 135-155 mmol/L

K 4.0 mmol/L 3.6-5.5 mmol/L

 Normal
VI. ANATOMY AND PHYSIOLOGY

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ANATOMY OF THE HEART

The Heart is composed 3 layers. The Inner layer or the endocardium

consist of endothelial tissues and lines the inside of the heart and valves. The
Middle layer or myocardium, is made up of muscle fibers and is responsible for
the pumping action and the exterior layer of the heart is called the epicardium.

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 .

16
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.

Normally, when the ventricles contract, ventricular pressure increases

closing the atrioventricular valve leaflets. Two additional structures, the pappilary
muscles and the chordae tendineae, maintain the valve closure. The papillary
muscles located on the sides of the ventricular walls are connected to the valve
leaflets by thin fibrous bands called chordate tendinae. During systole, contraction
of the papillary muscles causes the chordate tendinae to become tact, keeping the
valve leaflets approximately and closed.

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.

PHYSIOLOGY OF THE HEART

The cardiac conduction system generates and transmits electrical impulses

that stimulate contraction of the myocardium.Under normal circumstances; the

17
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.

 AUTOMATICITY-ability to initiate an electrical impulse.

 EXITABILITY-ability to respond to an electrical impulse.
 CONDUCTIVITY-ability to transmit an electrical impulse from one cell
to another

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.

ANATOMY OF THE KIDNEY

The kidneys are pair of bean-shaped, brownish red structures located

retroperitoneal on the posterior wall of the abdomen from the twelfth thoracic
vertebra to the third lumbar vertebra in the adult. The average adult kidney
weight’s approximately 113-170 g. (about 4.5 oz) and is 10-12 cm long and 2.5
cm thick. The right kidney is slightly lower than the left due to the location of the
liver.
Externally, the kidneys are well protected by the ribs and by the muscles
of the abdomen and back. Internally, fat deposit surround each kidney, providing
fat are suspended from the abdominal wall by renal fascia made of connective

18
tissue, the fibrous connective tissue, blood vessel, and lymphatic surrounding
each kidney are known as the renal capsule.

An adrenal glands lies on top of each kidney, each organ is independent in

terms of its function, blood supply and innervations.

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).

BLOOD SUPPLY TO THE KIDNEYS

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.

VII. REVIEW OF LITERATURE

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Ischemia – it is a lack of blood supply to an organ such as heart.

Cardiomyopathy – literally means “heart muscle disease”is the deterioration of

the function of the myocardium (i.e, the actual heart muscle).

3 LAYERS OF THE HEART

1. ENDOCARDIUM – inner layer

2. MYOCARDIUM – middle layer
3. EPICARDIUM – outer layers

Ishemic Cardiomyopathy

It is a weakness in the muscle of the heart due to inadequate oxygen

delivery to the myocardium with coronary artery disease being most common
cause. Anemia and sleep apnea are relatively common conditions that can
contribute to ischemic myocardium and hyperthyroidism can cause a relative
ischemia secondary to high output heart failure. In typical presentation , the area
of the heart affected by a myocardial infarction will initially become necrotic as it
dies, and will then be replaced by scar tissue (fibrosis). This fibrotic tissue is
akinetic; it is no longer muscle and cannot contribute to the hearts function as a
pump. If the akinetic region of the heart is substantial enough, the affected side of
the heart (i.e the left or right side) will go into failure, and this failure is a
functional result of an ischemic cardiomyopathy.

CAUSES:

2. Coronary Artery Disease (CAD )

3. Heart Attack ( MI )

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

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 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

 Beta blockers – reduce myocardial oxygen consumption by blocking beta

adrenergic symphathetic stimulation to the heart.
ex: Atenolol , Metoprolol, and Propanolol
 ACE inhibitor – inhibits conversion of angiotensin 1 to angiotensin 2 thus
prevent vasoconstriction.
ex : Captopril , Enalapril and Ramipril
 Digoxin ( Lanoxin ) – increase the force of myocardial contraction and slows
conduction through the atrioventricular node
 Diuretics – decreases blood volume by promoting water excretion.
ex : Furosemide , Mannitol and Spironolactone

2. LIFESTYLE CHANGES

 Diet – low fat , low cholesterol and low sodium

 Exercise – non competitive anerobic exercises

3. IMPLANTABLE DEVICES

 Cardiac Resynchronization Theraphy ( CRT )

ex: Biventricular pacing – a pacemaker that senses and initiates heart beats in
the right and left ventricle. It reduces symptoms and increases exercise
capacity or tolerance. For people with heart block or some bradycardias ( slow
heart rates ), this pacemaker will also serve to maintain an adequate heart rate.
 Implantable Cardioverter Defibrillators ( ICD ) –constantly monitor the heart
rhythm. When it detects a very fast , abnormal heart rhythm, it delivers energy
( shock ) to the heart muscle to cause the heart to beat in a normal rhythm
again.

4. INTERVENTIONAL PROCEDURES AND SURGERY

 Interventional procedures ( angioplasty, stents ) or bypass surgery may be

advice to treat coronary artery desease.
 Heart transplant or other heart failure surgical options.

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VIII. PATHOPHYSIOLOGY

22
 ↑Crea a
BUN

Plueral
Effusion

23
 NURSING CARE PLAN
Scientific
Assessment Diagnosis Planning Interventio
Rationale

Subjective: Activity Decreased Cardiac Patient will be able  Monitor daily

Intolerance related output to have an
“Nahihirapan to decreased ↓ improved /  Keep patient w
akong kumilos “as cardiac output & Excertional increased activity change positio
verbalized by the excessive fluid discomfort intolerance at the frequently stim
patient. volume as ↓ end of shift circulation and
evidenced by Activity Tolerance skin breakdow
verbal report
Objective:  Limit fluid inta
 Edema and 500 cc/ day
Ascites
 Position modif
 Weeping trendelenburg
wound on left
lower  Avoid salty an
extremity with foods
yellowish DEPENDENT:
watery  Dopamine
discharge

 Black patches
on skin.

 Lasix
 Aldactone

22
 Scientific
Assessment Diagnosis Planning Interve
Rationale

Subjective: Excess fluid Decrease cardiac The patient will be  Review di

volume related to output able to stabilize restriction
“Parang lumalaki excess fluid or ↓ fluid volume as substitutes
ang manas ko as sodium intake and Increased ADH evidences by
verbalized by the retention of fluid. ↓ balanced I/O, vital  Note circu
patient” Increased water signs within normal bipedal ed
re-absorption limits, stable abdominal
↓ weight, and free of
Objective: Increased sodium signs of edema.  Monitor in
 Swelling edema retention
both legs ↓
 Yellowish Decreased
watery osmotic pressure  Weight pat
discharge ↓
 Enlargement of Fluid overload
legs and edema & ascites
Abdomen
 Changes in  Elevate fee
respiratory position pa
pattern modified
 Finger clubbing trendelenb
 Weeping wound dependent
on left lower fluid intak
extremity with  Give lasix
yellowish as diuretic
watery
discharge
 Black patches
on skin.

Scientific
Assessment Diagnosis Planning Interve
Rationale

Subj: Impaired skin Imbalanced Patient will be able  Assess ski

integrity related to nutritional state to include ideal noting mo
“Ang tagal impaired ↓ fluid balance & color and e
gumaling ng sugat circulation. Impaired body weight &
ko” as verbalized circulation electrolyte levels,  Observe fo
by the patient. ↓ participation in blanched a
Edema & Ascites activities as skin rashes
↓ tolerated at the end institute tr
Obj: Impaired skin of shift. immediate
 Edema & integrity
Ascites  To reduce
/ enhance c
 Weeping wound to compro
on left lower tissue
extremity with
yellowish  Note skin
watery texture and
discharge assess area
pigmentati

23
  Black patches color chan
on skin.
DRUG NSG.
INDICATIO CONTRAINDIC SIDE
DRUG ACTION INTERAC CONSIDERAT
NS ATION EFFECTS
TION IONS

GENERIC Edema Inhibits the  ≤ 90/60 Tinnitus, ALDACTO  monitor vital

NAME: associated reabsorption hearing NE: signs
-Furosemide with CHF, of the NA  PR ≤60 Impairment may cause
hepatic and chloride hypotension hyponatrem  BP
BRAND cirrhosis, and in the  -anuria, , water and ia
NAME: ascites and proximal hypovolemic electrolyte  PR
-Lasix renal disease and distal depletion
tubules as  monitor I
CLASSIFICAT well as the and O
ION ascending
-Loop diuretic loop of  monitor the
henle, this weight
DOSAGE: results in the
-40 mg ½ tab
excretion of
Q8hrs.  observe for
NA and
s/sx of
chloride.
hypokalemia

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.

DRUG INDICATION ACTION CONTRAINDICATION SI

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.

DRUG INDICATION ACTION CONTRAINDICATION SI

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

DRUG INDICATION ACTION SIDE EFFEC

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

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 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

Possible treatment for heart failure includes:

 Surgery- will help the heart work better
 Bypass- to open clogged arteries
 Angioplasty- to repair or to replace heart valve

Lifestyle change (smoking, drinking alcohol should stop) is an important part of

treatment too.

Important health teaching includes:

 pay attention on medications regimen, dietary and fluid restriction

 self care activities such as exercise and how to perform them at none are necessary
 patient and family should report symptoms immediately
 monitor blood glucose, blood pressure and weight regularly
 have a regular medical check ups
 working hard can worsen heart failure
 drinking alcoholic beverages can worsen heart failure

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Out Patient Care includes:

 support and cooperation of family members

 Incorporate therapeutic activities to balance lifestyle and work
 Have a regular check ups as preferred by the doctor
 Monitor blood glucose level, blood pressure and weight regularly

Diet:

 Maintain low salt, low fat diet

 Remove salt from preparing foods
 Avoid fatty foods or foods high in cholesterol
 Promote proper hydration
 Limit drinking alcoholic beverages

Signs and symptom to watch out and report immediately

 Edema
 Weight gain Indicates fluid retention
 Fatigue ( indicates poor circulation )
 Angina ( due to reduce circulation on coronary arteries)
 Ascites ( due to pulling of blood to the peritoneal cavity , poor circulation )
 Shortness of breath

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.

Prognosis is good if to follow standardized treatment.

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