NURSING PROCESS: THE PATIENT WITH CARDIOMYOPATHY
Nursing assessment for the patient with cardiomyopathy begins with a detailed history of the presenting signs and symptoms. The nurse identifies possible etiologic factors, such as heavy alcohol intake, recent illness or pregnancy, or history of the disease in im-mediate 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 dys-pnea with exertion. The number of pillows that are needed to sleep, usual weight, any weight change, and limitation to activi-ties of daily living also are assessed. The New York Heart Associ-ation Classification for heart failure is determined. The patient’s usual diet is evaluated to determine if alterations are needed to re-duce sodium intake.
Because of the chronicity of cardiomyopathy, the nurse com-piles a careful psychosocial history exploring the impact of the disease on the patient’s role within the family and community. Identification of all perceived stressors helps the patient and the health care team to implement activities to relieve anxiety related to changes in health status. Very early on, the patient’s support systems are identified, and members are involved in the patient’s care and therapeutic regimen. The assessment addresses the effect the diagnosis has had on the patient and members of his or her support system and the patient’s emotional status. Depression is not uncommon in patients with cardiomyopathy who have developed heart failure.
The physical assessment focuses on signs and symptoms of congestive heart failure. The baseline assessment includes such key components as:
· 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
Based on the assessment data, major nursing diagnoses for the pa-tient may include:
· Decreased cardiac output related to structural disorders caused by cardiomyopathy or to dysrhythmia from the dis-ease process and medical treatments
· Ineffective cardiopulmonary, cerebral, peripheral, and renal tissue perfusion related to decreased peripheral blood flow (resulting from decreased cardiac output)
· Impaired gas exchange related to pulmonary congestion caused by myocardial failure (decreased cardiac output)
· Activity intolerance related to decreased cardiac output or excessive fluid volume, or both
· Anxiety related to the change in health status and in role functioning
· Powerlessness related to disease process
· Noncompliance with medication and diet therapies
Based on the assessment data, potential complications include:
· Congestive heart failure
· Ventricular dysrhythmias
· Atrial dysrhythmias
· Cardiac conduction defects
· Pulmonary or cerebral embolism
1. Valvular dysfunction
These complications are discussed earlier.
The major goals for the patient include 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.
During a symptomatic episode, rest is indicated. Many patients with DCM find that sitting up with their legs down is more com-fortable than lying down in a bed. This position is helpful in pooling venous blood in the periphery and reducing preload. Assessing the patient’s oxygen saturation at rest and during activity may assist with determining a need for supplemental oxygen. Oxygen is usually given through nasal cannula when indicated.
Ensuring that medications are taken as prescribed is important to preserving adequate cardiac output. It is important to ensure that patients with HCM avoid diuretics and that patients with DCM avoid verapamil (Calan, Isoptin) to maintain contractility. The nurse may assist the patient with planning a schedule for taking medications and identifying methods to remember to fol-low it, such as associating the time to take a medication with an activity (eg, eating a meal, brushing teeth). Ensuring that the patient receives or chooses food selections that are appropriate for the low-sodium diet is also important. Determining the patient’s weight every day and identifying any significant change is one way to monitor the patient’s response to treatment. Assessing if the patient experiences shortness of breath after more or less activity than before treatment is another indication of the effect of treat-ment. Patients with low cardiac output may need assistance keep-ing warm and frequently changing position to stimulate circulation and reduce the possibility of skin breakdown.
The nurse plans the patient’s activities so that they occur in cycles, alternating rest with activity periods. This benefits the patient’s physiologic status, and it helps to 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 or pay bills. Suggesting that patients sit while chopping vegeta-bles, drying their hair, or shaving helps them to identify methods to balance rest with activity. The nurse can also make sure that 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.
Spiritual, psychological, and emotional support may be indicated for the patient, family, and significant others. Interventions are directed toward eradicating or alleviating perceived stressors. The patient is provided with appropriate information about cardiomy-opathy and self-management activities. An atmosphere in which the patient feels free to verbalize concerns is provided, as is assur-ance that these concerns are legitimate. If the patient is facing death or awaiting transplantation, time must be provided to dis-cuss these issues. Providing the patient with realistic hope helps to reduce anxiety while the patient awaits a donor heart. Nurses help the patient, family, and significant others with anticipatory grieving. Accomplishing a goal, no matter how small, also pro-motes the patient’s sense of well-being.
Patients need to recognize that they go through a grieving process when given a diagnosis of cardiomyopathy. They are assisted in identifying the things in their life that they have lost (eg, foods that they have enjoyed eating but are high in sodium, ability to engage in constant active lifestyle, ability to play sports, ability to lift grandchildren). They also are assisted in identifying their emotional responses to the loss (eg, anger, depression). The nurse then assists patients in identifying the amount of control that they have in their lives, such as making food choices, managing their medications, and working with their provider to achieve the best possible outcomes. The use of patient tools that track behaviors with the resulting symptoms may be helpful. For example, a diary in which the patient records his or her food selections andweight may assist the patient with understanding the relationship between sodium intake and weight gain. Some patients are able to manage a self-titrating diuretic regimen, in which the patient is able to adjust the dose of diuretic to his or her symptoms.
Teaching patients about the med-ication regimen, symptom monitoring, and symptom manage-ment is a key part of the plan of nursing care. The nurse is integral to the learning process as patients learn to balance their lifestyle and work while accomplishing their therapeutic activities. Helping patients cope with their disease status assists them in adjusting their lifestyles and implementing a self-care program at home.
The nurse reinforces previous teaching andperforms ongoing assessment of the patient’s symptoms and progress. The nurse also assists the patient and family to adjust to lifestyle changes. Teaching patients to read nutritional labels, to maintain a record of daily weights and symptoms, and to orga-nize daily activities to increase activity tolerance can be helpful. The patient’s responses to diet and fluid restrictions and to the medication regimen are assessed, and explanations about symp-toms that should be reported to the physician are emphasized. Because of the risk of dysrhythmia, the patient’s family may be taught cardiopulmonary resuscitation. Women are often advised to avoid pregnancy; each case is assessed individually. The nurse assesses the psychosocial needs of the patient and family on an on-going basis. There may be concerns and fears about the progno-sis, changes in lifestyle, effects of medications, and the possibility of others in the family having the same condition that increase the patient’s anxiety and interfere with effective coping strategies. Establishing trust is vital to the relationship with these chronically ill patients and their families. This is particularly significant when the nurse is involved with the patient and family in discussions about end-of-life decisions. Patients who have significant symp-toms of heart failure or other complications of cardiomyopathy may need a home care referral.
Expected patient outcomes may include:
1) Maintains or improves cardiac function
a) Exhibits heart and respiratory rates within normal limits
b) Reports decreased dyspnea and increased comfort; main-tains or improves gas exchange
c) Reports no weight gain
d) Maintains or improves peripheral blood flow
2) Maintains or increases activity tolerance
a) Carries out activities of daily living (eg, brushes teeth, feeds self)
b) Reports increased tolerance to activity
3) Is less anxious
a) Discusses prognosis freely
b) Verbalizes fears and concerns
c) Participates in support groups if appropriate
4) Decreases sense of powerlessness
a) Identifies emotional response to diagnosis
b) Discusses the control he or she has in life
5) Adheres to the self-care program
a) Takes medications according to prescribed schedule
b) Modifies diet to accommodate sodium and fluid re-strictions
c) Modifies lifestyle to accommodate recommended activ-ity and rest behaviours
d) Identifies signs and symptoms to be reported to the health care professional