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 Viaa, Aniceto, Araa, Arcasitas. Sengco, Serrano, Sucayre, Tesoro, Verzosa, Vertudez, Viray, Mark Anthony Y. Roneo I. Annabel L. Cherrelyn F. Suzane S. Armando I. Analyn P. Joan Mariel B. Shealtiel Ruth P. Jeanlyn L. Regina Joy P.

Bentinganan, Mark Edwin A.

SUBMITTED TO:

Mr. Romeo Rivera, R.N., M.S.N.

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. Gordons 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

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

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, cant 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. 4

 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: 58 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 grams 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.

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 B. Injuries/ Accident 2006-appendectomy Minor burn(first degree) No other major injuries

E. SOCIO-ECONOMIC HISTORY Patient X is a hardworking person thats 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. GORDONS 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, thats 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 doesnt 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: 58 TIME FRAME Before the illness During the illness WEIGHT 100 kgs. 105kgs. BMI 33.55 35.23 INTERPRETATION Above the normal 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) ht= 68 inches x 2.54 = 1.73 = 2.98 100 105 2.98 = 33.55 2.98 = 35.23 BEFORE Breakfast-coffee, bread, Snacks Lunch-rice, vegetables, meat, water Snacks Dinner-rice, meat, vegetable, soup, water DURING HOSPITALIZATION 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 doesnt have time to monitor his blood glucose level and blood pressure because he spends most of his time on work.

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 DAILY LIVING Feeding Dressing Grooming Toileting LEVEL 1 1 1 1 MOBILITY STATUS Bed Mobility Chair/toilet Transfer Ambulation LEVEL 1 1 1 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 hes been working for. He doesnt 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:

Patient X sees himself as ever determined thats why hes 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 hes 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 cant 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 doesnt 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 doesnt stop him from being a husband and a father. Pattern of Elimination: BEFORE ILLNESS BOWEL ELIMINATION Frequency Character of stool Problems encountered such as constipation, diarrhea, etc. URINARY ELIMINATION Frequency Quantity Character of urine Problems encountered such as 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, 4-6 times a day 900ml Yellow to reddish in color None 6-7 times a day 6,500ml Amber yellow None Every other day Yellowish brown, solid Constipation BEFORE ILLNESS Every other day Yellowish brown, solid Constipation PRESENT PRESENT

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 4:00am 5:00 am 6:00am-2:00pm9:00pm 10:00pm Activity ( Before ) Wakes up Eats breakfast Goes to work depending on shift, sometimes overtime Sleeps for bed Activity ( During) Wakes up Eats breakfast Stays on room read news papers, talks with friends or relatives 12:00pm Eats lunch 2:00pm-4:00pm Takes a nap 7:00pm Eats dinner 10:00pm Sleeps for bed Time 4:00am 6:00am 7:00am11:00am

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 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 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 11 Proportion to the size of the head No presence of discharge Poor hearing No pain and itching White in color Dry and the texture is smooth Cold to touch It has a bad skin turgor

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

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Hgb

162.0

120-160 g/L

Total Red Cell Total WBC 10.2

4.5-5.0 x 10-12 g/L 5-10 x 10-19 g/L

Increased, in the presence of smokers and CHF Increased in failure of oxygenation because of Congestive heart Failure

Hct Clotting time Bleeding time Segmenters

0.49

0.38-0.50 2-5 min 1-3 min 0.40-0.60

Increase in the presence of infection, cigarette smoking, exercise, renal failure, tissue necrosis Infected cellulitis in lower left leg Normal

0.80

Lymphocytes 0.12 0.20-0.40

Discharge cause of inflammation of connective tissue known as cellulitis

Monocytes Eosinophiles 0.08

0.02-0.08 0.01-0.03

Decreased in lymphocytes which is the one who combats foreign bodies may decrease immune system that leads to infection Decreased with immuno-deficiency, AIDS

Basophiles

0-0.01

Increased indicates metastatic or tumors in thyroid Increased in subacute infections, collagen disease

Test

BLOOD CHEMISTRY REPORT Result Normal Values Interpretation

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Glucose FBS Uric acid

98.0 mg/dL 5.44 mg/dL 8.4 mg/dL

75-115 mg/dL 4.2-6.4 mg/dL 2.4-7.0 mg/dL

Normal Normal Increased alcoholism, high-protein weight reduction diet, renal failure, heart failure Increased, indicate a slowing of the glumerular filtration rate Increase, impaired renal function Increase creatinine secondary to Ascites congestion

Creatinine

2.7 mg/dL

0.5-1.7 mg/dL

BUN SGOT 55.7 u/L

10.1-50.0 mg/dL up to 37 u/L 37C

SGPT 52.7 u/L up to 42 u/L 37C Cholesterol 159.2 mg/dL suspect >220mg/dL

Increase, liver disease, alcoholism, Ischemic Cardiomyopathy Increase, heart failure, Liver cirrhosis, Ascites

Triglycerides

80.0 mg/dL

Elevation is a cardiovascular risk factor Increase hypertension suspect >150mg/dL uncontrolled diabetes mellitus Fatty acids, elevation is a cardiovascular risk factors Increase blood viscosity due to Diabetes Mellitus result to heart disease High cholesterol level leads to hypertension Greater incidence of CAD

HDL-P LDL VLDL Na K

35.2 mg/dL 168.0 mg/dL

> 35 mg/dL < 150 mg/dL 0-357 mg/dL 135-155 mmol/L

4.0 mmol/L

3.6-5.5 mmol/L

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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 .

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Heart Valves The four valves in the heart permit blood to flow only one direction. the valves, which are composed of thin leaflets of fibrous tissues , open and close in response to the movement of blood and pressure changes within the chambers . There are two types of valve: atrioventricular and semilunar. Atrioventricular Valve The valves that separate the atria from the ventricles are termed atrioventricular valves. The tricuspid valve, so named because it composed of three cusps or leaftlets separates the right ventricles. The mitral or bicuspid valve (two cups) lies between the left atrium and the left ventricles. 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 impulses The cardiac conduction system generates and transmits electrical that stimulate contraction of the myocardium.Under normal 18

circumstances; the 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 weights 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

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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 2025% of the total cardiac output, which means that all of the bodys 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 diseaseis 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: SYMPTOMS: Family history Atherosclerosis / Arteriosclerosis High blood pressure Smoking Diabetes High fat diet High cholesterol diet Age

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 21

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. 3. LIFESTYLE CHANGES Diet low fat , low cholesterol and low sodium Exercise non competitive anerobic exercises 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

23

Crea a BUN

Plueral Effusion

24

Crea a BUN

25

NURSING CARE PLAN

Assessment Subjective: Nahihirapan akong kumilos as verbalized by the patient. Objective: Edema and Ascites Weeping wound on left lower extremity with yellowish watery discharge Black patches on skin. Diagnosis Activity Intolerance related to decreased cardiac output & excessive fluid volume as evidenced by verbal report Scientific Rationale Decreased Cardiac output Excertional discomfort Activity Tolerance Planning Patient will be able to have an improved / increased activity intolerance at the end of shift Intervention Monitor daily weight Keep patient warm and change position frequently stimulate circulation and reduce skin breakdown

Rationale To promote wellness Improving cardiac output and relieving respiratory difficulties

Evaluation Patient was able to have an improved / increased activity intolerance at the end of shift

Limit fluid intake to 500 cc/ day Position modified trendelenburg Avoid salty and fatty foods DEPENDENT: Dopamine

Not to increase the edema and ascites To drain fluids accumulating in feet Avoid fluid retention To increase myocardial contractility and peripheral resistance to maintain BP while receiving Lasix and Aldactone Fluid excretion Potassium sparring diuretic

Lasix Aldactone 22

Assessment Subjective: Parang lumalaki ang manas ko as verbalized by the patient Objective: Swelling edema both legs Yellowish watery discharge Enlargement of legs and Abdomen Changes in respiratory pattern Finger clubbing Weeping wound on left lower extremity with yellowish watery discharge Black patches

Diagnosis Excess fluid volume related to excess fluid or sodium intake and retention of fluid.

Scientific Rationale Decrease cardiac output Increased ADH Increased water re-absorption Increased sodium retention Decreased osmotic pressure Fluid overload edema & ascites

Planning

Intervention

Rationale To promote wellness

Evaluation The patient was able to stabilize fluid volume as evidenced by balanced I/O, vital signs within normal limits, stable weight, and free of signs of edema.

The patient will be Review dietary able to stabilize restriction & safe fluid volume as substitutes for salt evidences by balanced I/O, vital Note circumference of signs within normal bipedal edema & limits, stable abdominal ascites weight, and free of signs of edema. Monitor intake/ output

To evaluate degree of excess To maintain adequate nutrition and fluid balance To promote mobilization / elimination of excess fluid.

Weight patient daily

Not to increase the Elevate feet or edema and ascites and position patient in to drain fluids modified accumulating in feet trendelenburg dependent limit oral fluid intake at 500/day. Give lasix & aldactone To promote mobilization / as diuretics elimination of excess fluid

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on skin.

Assessment

Diagnosis

Scientific Rationale

Planning 24

Intervention

Rationale

Evaluation

Subj: Ang tagal gumaling ng sugat ko as verbalized by the patient. Obj: Edema & Ascites Weeping wound on left lower extremity with yellowish watery discharge Black patches on skin.

Impaired skin integrity related to impaired circulation.

Imbalanced nutritional state Impaired circulation Edema & Ascites Impaired skin integrity

Patient will be able to include ideal fluid balance & body weight & electrolyte levels, participation in activities as tolerated at the end of shift.

Assess skin routinely,

noting moisture, color and elasticity Observe for reddened blanched areas or skin rashes, and institute treatment immediately.
To reduce pressure

To assess causative / contributing factors To maintain skin integrity of optimal level

Patient was able to conclude ideal fluid balance, body weight & electrolyte levels, participation in activities as tolerated at the end of shift.

on / enhance circulation to compromised tissue Note skin color texture and turgor assess areas of least pigmentation for color changes.

To assists client w/ correcting / minimizing condition to promote optimal healing To assess extent of involvement injury.

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DRUG GENERIC NAME: -Furosemide BRAND NAME: -Lasix

CLASSIFICATION -Loop diuretic DOSAGE: -40 mg tab Q8hrs.

INDICATIONS Edema associated with CHF, hepatic cirrhosis, and ascites and renal disease

ACTION Inhibits the reabsorption of the NA and chloride in the proximal and distal tubules as well as the ascending loop of henle, this results in the excretion of NA and chloride.

CONTRAINDICATION 90/60 PR 60 -anuria, hypovolemic

SIDE EFFECTS Tinnitus, hearing Impairment hypotension, water and electrolyte depletion

DRUG INTERACTION ALDACTONE: may cause hyponatremia

NSG. CONSIDERATIONS monitor vital signs BP PR monitor I and O

monitor the weight observe for s/sx of hypokalemia

DRUG STUDY
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DRUG GENERIC NAME: -Dopamine HCL BRAND NAME: -Dopamine CLASSIFICATION -sympathomimetic, Indirect and direct acting DOSAGE: -500cc/ml OD

INDICATION For cardiogenic shock, renal failure due to cardiac decompensation (as in CHF)

ACTION to increase the myocardial contractility of the heart to increase the heart rate to increase the peripheral resistance to increase or elevate the blood pressure of the patient.

CONTRAINDICATION Uncorrected tachycardia, ventricular fibrillation, or arrhythmias.

SIDE EFFECTS Tachycardia, angina pain, palpitations, dyspnea,nausea, and vomiting, headache, anxiety, hypotension and hypertension

DRUG INTERACTION LASIX and ALDACTONE : diuretics/addict ive/potentiating the effects no known interaction with unasyn

NSG. CONSIDERATIONS monitor vital signs monitor I & O

if extravasation is present the way to prevent sloughing and necrosis is infiltrate 10-15ml of PNSS containing 510mg of phentolamine in a syringe with fine needle

DRUG

INDICATION

ACTION

CONTRAINDICATION 27

SIDE EFFECTS

DRUG INTERACTION

NSG. CONSIDERATIONS

GENERIC NAME: -Ampicillin NA and Sulbactam NA BRAND NAME: -Unasyn CLASSIFICATION -Antibiotic DOSAGE -750mg/tab Q12hrs.

For the cellulitis of the left leg of the patient and skin and soft tissue infection

Irreversibly inhibits betalactamase thus ensuring the activity of ampicillin against beta-lactamase producing microorganisms

History of any allergic reaction to the drug

Hypersensitivity, nausea and vomiting, gastritis and stomatitis

No known interaction with dopamine, lasix and aldactone

document type, onset, characteristics of s/sx note sensitivity reaction to this drug or related drug monitor CBC, cultures, with impaired renal function, reduce dose during first 30 mins. of IV therapy, monitor closely for s/sx of hypersensitivity.

DRUG

INDICATION

ACTION

CONTRAINDICATION 28

SIDE EFFECTS

DRUG INTERACTION

NSG. CONSIDERATIONS

GENERIC NAME: -Spinolactone BRAND NAME: -Aldactone CLASSIFICATION -K-sparing diuretics DOSAGE -50 mg/tab BID

Edema 2hrs to CHF and acute renal failure

Mild diuretics that acts on the distal tubule to inhibit NA exchange for potassium, resulting in increased secretion of NA and water and conservation of potassium

acute renal insufficiency, progressive renal failure, hyperkalemia and anuria low BP

decreasing LASIX: may cause severe the BP hyponatremia (hypotension) -decrease HR/PR -dizziness,

monitor BP monitor I & O

hold if the BP is 100/60 10 rights of the patient

blurred vision nausea and vomiting, fatigue, anorexia, nasal congestion

DRUG

INDICATION

ACTION 29

SIDE EFFECTS

DRUG INTERACTION

NSG. CONSIDERATIONS

GENERIC NAME: -Moriamin Forte BRAND NAME: -Moriamin CLASSIFICATION: -Vit. B complex DOSAGE -1 cap OD

maintenance of body resistance Vit. deficiencies nutritional imbalance

to supply Vitamins for the body to balance the nutritions that the body needed

The urine may become yellow

No known drug interaction with aldactone, lasix, dopamine and unasyn

Monitor the dose given to the patient to avoid hypervitaminosis Monitor weight with the same time, clothing, weighing scale and same person Evaluate daily total food intake Consult the nutritional team

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XI. DISCHARGE PLAN Medications: Lasix 400mg 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

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 drinking alcoholic beverages can worsen heart failure 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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