case study on cardiomyopathy

CARDIOMYOPATHY

OBJECTIVES OF CASE STUDY PRESENTATIONOBJECTIVES OF CASE STUDY PRESENTATION

To share experience and knowledge to friends and supervisors.

To get feedback from the friends and supervisors for further improvement.

To develop confidence in facing the mass and presenting skills.

RATIONAL FOR THE SELECTION OF CASE

Cardiomyopathy causes more than 27,000 deaths each year in the United States (American

Heart Association, 2001).

• The mortality rate is highest for African Americans and the elderly I selected this case as

to learn in depth about the disease condition.

• Providing nursing care by applying nursing process.

• To provide holistic nursing care to the patient using the nursing process.

• To gain knowledge about the specific disease, it’s etiology, sign and symptoms and

management process.

METHODOLOGY

The methodology adopted to produce this report was based on:

History taking and interviewing to the patient and her visitors .

The observation and ,physical examination to the patient

Discussion with teachers, senior staffs and doctors

Using various text books and references of Medicine and related net search technology.

BIO-DATA OF MY PATIENT

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Patient’s Name : - Surya Maya Rai

Age/ sex : - 67yrs/female

Marital status : - Married

Education : - Illiterate

Occupation : - Housewife

Religion : - Hindu

Address : - Kathmandu, Basbari

Diagnosis : - Cardiomyopathy

Ward : - Medical intensive care unit

Bed No. : - 16

IP No. : - 45795

Date of admission : - 2068/11/15

Interview date : - 2068/11/18

Date of discharge :- 2068/12/21

Attending physician : - Dr. Rabi Mall

Informants : - Patient (self) & her Husband

CHIEF COMPLAIN

Shortness of Breath for 2 days

Pedal Edema for 1 month

HISTORY OF PRESENT ILLNESS

As stated by the patient party, patient was apparently well 2 days back when she started

having shortness of breath on exertion. she also had pedal edema for one month and made

her difficult to mobilize. so she was taken to the emergency department of Sahid Gangalal

National Heart Center

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she was diagnosed as known case of DCM 2 year back. She was having her medicine

regularly. She was admitted to the general ward of SGNHC on 2068/11/15. then she was

transfer to Medical Intensive Care Unit for Increased Shortness of breath and admitted there

No any skin change ,bowel and bladder are normal, she had no history of any abnormality of

the menstrual cycles.

Symptom Onset charecter Duration Aggrevating

factor

allevating

factor

Shortness of

breath

2 days Sharp pain Continues Not known Not known

Padal edema 2 month Mild Continuous Not known Not known

INVESTIGATION OF SYMPTOM

Past illness

Disease condition Childhood illness Disease condition Adulthood

illness

MeasealsMumpsWhooping coughPolioRheumatic feverTuberculosisMalnutritionOperationOthers

Yes No Yes No

P P P P P P P P

Hypertension Heart diseaseTuberculosisDiabetes IIFilariasisMalariaCancer Asthma Accidents Others(hypothyrodism,renal impairment)

P

2) Injuries and Accidents: My patient had no any history of external injuries and accidents.

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3) Hospitalization, Operations or Special Treatment: She had history of previous

hospitalization before 2 years back

5) Medication Taken at Home :- She uses to takes some home remedy like ginger, salt

besar for some common health problem.

6) Traditional Healer’s Prescription: she did not used to take the Traditional Healer’s

prescriptions.

7) Medical Practioner’s prescription:- According to patient’s husband, she takes medical

practioner’s prescription.

8)Self prescription: My patient use to take some common medicines like paracetamol,

brufen aciloc etc

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10 Psychological:Client’s Reaction to illness:

My patient’s has normal reaction to her illness .

b) Client’s Coping Pattern:

She has good coping pattern by gossiping with relatives.

C) Client’s Value of Health:

She thinks that health is very essential for life. she thinks that health is wealth.

d) Client’s Perception of the Care Giver:

She thinks that all health care provider are good but everybody do not detailed explain

about the disease prognosis

11.Sociological:

A) Family Relationship:

Client’s Position in the Family: she is the house wife of the family.

Person Living With Client (Support System) : Her Family Members (husband and her son).

Recent Family Crisis or Changes: According to my patient, she has no any recent family

crisis

B) Occupational History: she is housewife., she is illiterate

12.Health belief and practice

Client’s Beliefs about Health and Illness: Her beliefs that the illness is caused by careless

of the diet

Client’s Health Practice: she has good health practice

Sources of Care(Modern /traditional):

sometimes they goes to traditional healer, but usually they goes to modern practice

12.Personal history

e) Leisure Time Activities: she spends her time with her friends, watching TV, chat with

friends, son and grand son

f) Chemical Use (type, frequency, problems related to use)

She is non smoker and non substance abuser but alcohol user . she had left 3 years back

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13. Gyne/obs history

• Menarche- 12 year

• Menstruation regular

• Menstrual bleeding normal

• Duration 4-5 days.

• No history of dysmenorrhoea.

• No history of the gynecological problem

Environmental history

• Type of family :- Joint Family• No. of family :- 9 members• Type of house :- Cemented house• NO. of rooms :- 8• Kitchen :- Separated• Fuel used :- Gas• Drinking Water :- Tap water• Toilet :- Water seal• Drainage System :- Closed drainage

PHYSICAL EXAMINATION

General Inspection:

Gait : Normal

Body Build : Thin

Consciousness : conscious and alert

Facial expression : ill looking

Vital signs

Temperature : 99.40 f

Pulse : 78b/minute and regular, normal volume and character

Respiration : 24 b /minute, regular

Blood Pressure : 100/80 mm Hg in both arms (supine)

Height : 5'

Weight : 52 kg

GENERAL EXAMINATION

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Pallor absent

Icterus absent

Lymph node not palpable

Clubbing, cyanosis absent

Edema present

Dehydration absent

Skin dry and rough.

Examination of head ,face and neck

1. Inspection of head

Hair colour and texture normal. Normal hair distribution graying of hair related to aging.

Rounded face wrinkle of skin related to age.Scar of injury present

2. Inspection of eyes

No discharge and redness of the eye lid, but swelling of the eyelid , slightly vision

problem

3. Inspection of ears

No discharge and pain, no hearing problem

4. Nose

No discharge , bleeding and smelling problem.

5. Mouth

Good oral hygiene, missing teeth present and dental carries, no cyanosis present.

6. Neck

No enlarged lymph node and thyroid gland, normal neck mobility is present

Respiratory examination

Inspection

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Shape of the chest- normal, equal movement of the chest both side, no venous

prominences or scar marks, trachea center. Spine normal. Shortness of breathe

Palpation

Non tender. Vocal fremitus present. Trachea in center. Chest expansion 3 cm, apex beat

5th intercostals space in mid, clavicular line

Percussion

Resonant in left side and dullness in organ area

Auscultation

Normal vesicular breath sound.

Cardiovascular system

Inspection:

Cardiac impulse in 5th intercostal space in MCl. No abnormal impluse seen.

Palpation

Non tender. Apex beat in 5th intercostals space in MCl, no thrill

Auscultation

S1 and S2 normal murmur heart sound

Abdominal problem

Inspection-

Normal shape and size.Distended ,no dilated superficial veins, no scar marks

Palpation-

Soft organomegaly present. No organomegaly

Percussion- Normal tympanic sound present

Auscultation-

Bowel sounds present (normal)

CNS examination

Higher mental function normal. Motor examination eg position of limbs normal ,no

atrophy, no ulcer. No abnormal movement. Normal muscle tone. Normal power in all

limbs. Deep tendon jerk (bicep,tricep,supinator ,knee and ankle) normal. Sensory normal.

Comfort sleep , rest

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Patient feeling of discomfort first day of admission. No properly sleep at night during

first day of admission.

Impression: No any systemic disorders present except slight dyspnea and peripheral

edema(pedal).

DEVELOPMENTAL TASK OF OLDER ADULT

My patient belongs to older adult, development task of my patient are

ACCORDING TO BOOK ACCORDING TO MY PATIENT

1. Seven developmental tasks for older adult are listed.

2. Adjusting to decreasing health and physical strength.

3. Adjusting to retirement and reduced or fixed income

4. Adjusting to death of a spouse.

5. Accepting self as ageing person.

6. Maintaining satisfactory living arrangement.

7. Redefining relationship with adult children.

8. Finding way to maintaining quality of life.

1. Adjusting to decrease health and physical strength.

2. the most common losses one of the health ,significant other a sense of being useful ,socialization ,income and independent living.

3. Adjusting to retirement by engaging in housewife

4. My patient was not faced death of spouse.

5. My patient accepted self as ageing person. Structural and functional change associated with ageing eg loss of hearing ,vision problem, dental missing etc

6. My patient maintained satisfactory living arrangement eg comfortable living arrange all physical facilities.

7. Redefining relationship with adult children by give permission to their children whatever they like.

8. My patient maintained quality of life through use leisure time in social work, spiritual activities

CHAPTER II

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CARDIOMYOPATHY

Definition

Is a heart muscle disease associated with cardiac dysfunction. The cardiomyopathies are a

group of diseases that primarily affect the heart muscle and are not the result of congenital,

acquired valvular, hypertensive, coronary arterial, or pericardial abnormalities.It is classified

according to the structural and functional abnormalities of the heart musclesas:

Dillated cardiomyopathy

Hypertrophic cardiomyopathy

Restrictive or Constrictive cardiomyopathy

Arrythmogenic right ventricular cardiomyopathy

Unclassified cardiomyopathy

Etiology of cardiomyopathy

Pregnancy

Heavy alcohol intake

Viral infection

Chemotherapeutic medication

Iidiopathic

Genetics

DILATED CARDIOMYOPATHY (DCM)

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This condition is characterized by dilatation and impaired contraction of the left (and

sometimes the right) ventricle.

Distinguished by significant dilatation of the ventricles without simultaneous

hypertrophy.

The ventricles of elevated systolic and diastolic volume but a decreased ejection

fraction

Left ventricular mass is increased but wall thickness is normal or reduced.

The histological changes are variable but include myofibrillary loss, interstitial

fibrosis and T-cell infiltrates.

When the causative factor cannot be identified, the term used is idiopathic DCM.

Idiopathic

Most patient present with heart failure or are found to have the condition during

routine investigation.

Arrhythmias ,thromboembolism and sudden death are common and may occur at any

stage.

Chest pain is a surprisingly the diagnosis.

Although some patient remain well for many year, the prognosis is variable and

cardiac transplantation may be indicated

Risk is subsiquently reduced by regerious medical therapy with beta blocker and

angiotensin receptor antagonist

Some patient may be considered for implantation of a cardiac defrillator

HYPERTROPHIC CARDIOMYOPATHY( HCM)

In HCM, the heart muscle increases in size and mass, especially along the septum

The increased thickness of the heart muscle reduces the size of the ventricular cavities

The ventricles to take a longer time to relax.

Making it more difficult for the ventricles to fill with blood during the first part of

diastole and making them more dependent on atrial contraction for filling

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Structural changes may also result in a smaller than normal ventricular cavity and a

higher velocity flow of blood out of the left ventricle into the aorta,which may be

detected by echocardiography .

HCM may cause significant diastolic dysfunction, but systolic function can be normal

or high, resulting in a higher than normal ejection fraction

It may also be idiopathic

RESTRICTIVE CARDIOMYOPATHY

Restrictive cardiomyopathy (RCM) is characterized by diastolic.

Dysfunction caused by rigid ventricular walls that impair ventricular stretch and

diastolic filling .

Systolic function is usually normal.Because RCM is the least common

cardiomyopathy.

Its pathogenesis is the least understood

Restrictive cardiomyopathy can be associated with amyloidosis (in which amyloid, a

protein substance, is deposited within the cell) and other such infiltrative diseases.

However, the cause is unknown in most cases (ie, idiopathic).

ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY

ARVC occurs when the myocardium of the right ventricle is progressively infiltrated

and replaced by fibrous scar and adipose tissue.

Initially, only localized areas of the right ventricle are affected, but as the disease

progresses, the entire heart is affected.

Eventually, the right ventricle dilates and develops poor contractility right ventricular

wall abnormalities, and dysrhythmias

The prevalence of ARVC is unknown because many cases are not recognized.

ARVC should be suspected in patients with ventricular tachycardia originating in the

right ventricle (ie, a left bundle branch block configuration on ECG) or sudden

death, especially among previously symptom-free athlete.

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The disease may be genetic (ie, autosomal dominant) . Family members should be

screened for the disease with a 12-lead ECG, Holter monitor, and echocardiography.

UNCLASSIFIED CARDIOMYOPATHIES

Unclassified cardiomyopathies are different from or have characteristics of more than one

of the previously described cardiomyopathies.

Unclassified cardiomyopathies include fibroelastosis, noncompacted myocardium,

systolic dysfunction with minimal dilation, and mitochondrial involvement

Primary Myocardial Involvement

Idiopathic

Familial

Eosinophilic endomyocardial disease

Endomyocardial fibrosis

Secondary Myocardial Involvement

Infective

Viral myocarditis, Bacterial myocarditis ,Fungal myocarditis , Protozoal myocarditis

Metazoal myocarditis

Spirochetal

Rickettsial

Metabolic

Familial storage disease

Glycogen storage disease

Mucopolysaccharidoses( thickness secreation)

Hemochromatosis (Iron deposit in body)

Connective tissue disorders

Systemic lupus erythematosus

Polyarteritis nodosa

Rheumatoid arthritis

Progressive systemic sclerosis

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Dermatomyositis

Infiltrations and granulomas

Amyloidosis

Sarcoidosis

Malignance

Neuromuscular

Muscular dystrophy

Myotonic dystrophy

Friedreich's ataxia

Sensitivity and toxic reactions

Alcohol

Radiation

Drugs (doxorubicine)

Peripartum heart disease

Pathophysiology

It is a series of progressive events that culminate in impaired cardiac output.

Decreased stroke volume stimulates the sympathetic nervous system and the renin-

angiotensin-aldosterone response

Resulting in increased systemic vascular resistance and increased sodium and fluid

retention

Increased workload on the heart.

These alterations can lead to heart failure

CLINICAL FEATURE

According to book In patient

1. Signs and symptoms of heart failure (eg, dysponea on exertion,

fatigue).

2. Patient report paroxysmal nocturnal dyspnea, cough (especially

with exertion)

3. Orthopnea

Present

Present

Present

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4. Fluid retention,

5. Peripheral edema

6. Nausea The patient may experience chest pain

7. Palpitations

8. Dizziness

9. Syncope with exertion

Present

present

Present

Absent

Present

Absent

DIAGNOSIS OF THE CARDIOMYOPATHY

According to book In patient

1. Chest X-ray

2. Electrocardiogram

3. Echocardiogram

4. Radionuclide study

5. Cardio catheterization

1. Moderate to marked cardiac silhouette enlargement, Pulmonary venous hypertension

2. ST-segment and T-wave abnormalities

3. Left ventricular dilatation and dysfunction

4. Left ventricular dilatation and dysfunction

5. Elevated left- and often right-sided filling pressures. Diminished cardiac output

INVESTIGATION

Component Inpatient Reference

Hemoglobin WBC countNeutrophilLymphocyteMonocyteEsinophilBasinophilPlatlet

12.1%9000/cumm368%26%00060031600

14-16gm% 4000-11000/cumm 40-75% 20-50% 2-10% 1-6% <1% 150000-450000

Component In patient Reference range

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ALT

AST/GOT

Sugar

Urea

Creatinine

Sodium

Potassium

38.0IU/L

34.0

96 mg/dl

33mg/dl

184umol/l

137mEq/l

3.8mEq/l

5.0-35.0IU/L

5.0-40.0IU/L

65 – 140 mg/dl

10-45mg/dl

40-110umol/l

135-145mEq/l

3.6-5.5mEq/l

MEDICATIONS USED IN THE PATIENT

1. Tab Isoniazid 225mg+Tab Rifampicine 450mg+Tab Pyrezenamide 1200mg+Tab

Ethambutaol 825mg 3 tabs PO OD

2. Tab Pyridoxine 30mg PO OD

3. Enalpril 5mg OD continue

4. Asprin 75mg OD continue

5. Cloplet 75 OD continue

6. Tab Carvedilol 3.125 mg BD for 7 days

MEDICAL MANAGEMENT

Correcting heart failure with medication

Low sodium diet

Exercise and rest regimen

Controlling Dysrhythmia

Systemic anticoagulant

Restriction in fluid intake

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Implantation of electronic devices(implantable cardioverter defibrillator)

If patients exhibit signs and symptoms of congestion, their fluid intake may be limited

to 2 liters each day.

The person with HCM may also have to limit physical activity to avoid a life-

threatening dysrhythmia.

A pacemaker may be implanted to alter the electrical stimulation of the muscle and

prevent the forceful hyper dynamic contractions that occur with HCM.

SURGICAL MANAGEMENT

Left Ventricular Outflow Tract Surgery.

The most common procedure is a myectomy (sometimes referred to as a

myotomymyectomy),in which some of the heart tissue is excised.

Septal tissue approximately 1 cm wide and deep is cut from the enlarged septum

below the aortic valve.

The length of septum removed depends on the degree of obstruction caused by the

hypertrophied muscle.

Instead of a septal myectomy, the surgeon may open the left ventricular outflow tract

to the aortic valve by removing the mitral valve, chordae, and papillary muscles.

The mitral valve then is replaced with a low-profile disk valve.

The space taken up by the mitral valve is substantially reduced by the prosthetic valve

compared with the patient’s own valve, chordae, and papillary muscles, allowing

blood to move around the enlarged septum to the aortic valve in the area that the

mitral valve once occupied.

The primary complication of both procedures is dysrhythmia; additional

complications are postoperative surgical complications such as pain, ineffective

airway clearance, deep vein thrombosis, risk for infection, and delayed surgical

recovery.

HEART TRANSPLANTATION.

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a. The first human-to-human heart transplant

It was performed in 1967. Since then, transplant procedures, equipment, and medications

have continued to improve. Since 1983, when cyclosporine became available, heart

transplantation has become a therapeutic option for patients with end-stage heart disease

Cyclosporine is an immunosuppressant that greatly decreases the body’s rejection of

foreign proteins, such as transplanted organs.

Unfortunately, cyclosporine also decreases the body’s ability to resist infections, and a

satisfactory balance must be achieved between suppressing rejection and avoiding

infection

Common indication

o Cardiomyopathy

o Ischemic heart disease

o Valvular disease

o Rejection of previously transplanted hearts

o Congenital heart disease has severe symptoms uncontrolled by medical therapy,

no other surgical options

• A multidisciplinary team screens the candidate before recommending the transplantation

procedure.

The person’s age

Pulmonary status

other chronic health conditions

psychosocial status

family support

Infections

history of other transplantations,

compliance,

current health status

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• When a donor heart becomes available, a computer generates a list of potential recipients

on the basis of

o ABO blood group compatibility

o The sizes of the donor and the potential recipient,

o The geographic locations of the donor and potential recipient;

o Distance is a variable because postoperative function depends on the heart being

implanted within 6 hours of harvest from the donor.

Orthotropic transplantation

• Most common surgical procedure for cardiac transplantation.

• The recipient’s heart is removed, and the donor heart

• is implanted at the vena cava and pulmonary veins

• Some surgeons still prefer to remove the recipient’s heart leaving a portion of the

recipient’s atria (with the vena cava and pulmonary veins) in place.

• The donor heart, which usually has been preserved in ice.

• The donor heart is implanted by suturing the donor atria to the residual atrial tissue of

the recipient’s heart.

HETEROTOPIC TRANSPLANTATION

• The donor heart is placed to the right and slightly anterior to the recipient’s heart

the recipient’s heart is not removed.

• Initially, it was thought that the original heart might provide some protection for the

patient in the event that the transplanted heart was rejected.

• Although the protective effect has not been proved, other reasons for retaining the

original heart have been identified a small donor heart or pulmonary hypertension

• The transplanted heart has no nerve connections with the recipient’s body (ie,

denervated heart), and the sympathetic and vagus nerves do not affect the transplanted

heart.

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• The resting rate of the transplanted heart is approximately 70 to 90 beats per minute,

but it increases gradually if catecholamines are in the circulation.

• Patients must gradually increase and decrease their exercise (ie, extended warm-up

and cool-down periods), because 20 to 30 minutes may be required to achieve the

desired heart rate.

• Atropine does not increase the heart rate of these patients

Postoperative Care

• Heart transplant patients are constantly balancing the risk of rejection with the risk of

infection.

• They must comply with a complex regimen of diet, medications, activity, follow-up

laboratory studies, biopsies (to diagnose rejection), and clinic visits.

• Most commonly, patients receive cyclosporine or tacrolimus (FK506, Prograf),

azathioprine (Imuran) or mycophenolate mofetil (CellCept), and corticosteroids (ie,

prednisone) to minimize rejection.

• Rejection and infection, complications may include accelerated atherosclerosis of the

coronary arteries

• Hypertension may be experienced by patients taking cyclosporine or tacrolimus; the

cause has not been identified.

• Osteoporosis frequently occurs as a side effect of the anti-rejection medications and

pre transplantation dietary insufficiency and medications.

• Post transplantation lymphoproliferative disease and cancer

• Weight gain, obesity, diabetes, dyslipidemias (eg hypercholesterolemia) hypotension,

renal failure, and central nervous system

• Respiratory, and gastrointestinal disturbances may be caused by the corticosteroids or

other immunosuppressants.

• Other complications are immunosuppressant medication toxicities and responses to

the psychosocial stresses imposed by organ transplantation.

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• Patients may experience guilt that someone died for them to live, have anxiety about

the new heart, experience depression or fear when rejection is identified, or have

difficulty with family role changes before and after transplantation

Survival rate

• The 1-year survival rate for patients with transplanted hearts is approximately 80% to

90%

• The 5-year survival rate is approximately 60% to 70%

Mechanical Assist Devices and Total Artificial Hearts

• Cardiopulmonary bypass for cardiovascular surgery and the possibility of performing

heart transplantation for end-stage cardiac disease have increased the need for

mechanical assist devices.

• Patients who cannot be weaned from cardiopulmonary bypass or patients in

cardiogenic shock may benefit from a period of mechanical heart assistance.

• The most commonly used device is the intra-aortic balloon pump.

• This pump decreases the work of the heart during contraction but does not perform

the actual work of the heart

Ventricular Assist Devices.

• More complex devices that actually perform some or all of the pumping function for

the heart also are being used.

• These more sophisticated ventricular assist devices can circulate as much blood per

minute as the patient’s heart, if not more.

• Each ventricular assist device is used to support one ventricle.

• Some ventricular assist devices can be combined with an oxygenator; the

combination is called extracorporeal membrane oxygenation (ECMO).

• The oxygenator– ventricular assist device combination is used for the patient whose

heart cannot pump adequate blood through the lungs or the body

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• There are three basic types of devices: centrifugal, pneumatic, and electric or

electromagnetic.

• Centrifugal VADs are external, nonpulsatile, cone-shaped devices with internal

mechanisms that spin rapidly creating a vortex (tornado-like action) that pulls blood

from a large vein into the pump and then pushes it back into a large artery.

• Pneumatic VADs are external or implanted pulsatile devices with a flexible reservoir

housed in a rigid exterior

• The reservoir usually fills with blood drained from the patient’s atrium or ventricle.

• The VAD then forces pressurized air into the rigid housing, compressing the reservoir

and returning the blood to the patient’s circulation, usually into the aorta.

• Electric or electromagnetic VADs are similar to the pneumatic VADs, but instead of

pressurized air.

• One or more flat metal plates are pushed against the reservoir to return the blood to

the patient’s circulation.

Total Artificial Hearts.

• Total artificial hearts are designed to replace both ventricles. Some require the

removal of the patient’s heart to implant the total artificial heart; others do not.

• All of these devices are experimental.

• Although there has been some short-term success, the long-term results have been

disappointing.

• Researchers hope to develop a device that can be permanently implanted and that will

eliminate the need for donated human heart transplantation for the treatment of end-

stage cardiac disease

• Most VADs and total artificial hearts are temporary treatments.

• While the patient’s own heart recovers or until a donor heart becomes available for

transplantation. Some devices are being investigated for permanent use.

• Bleeding disorders, hemorrhage, thrombus, emboli, hemolysis, infection, renal

failure, right heart failure, multisystem failure, and mechanical failure are some of the

complications of VADs and total artificial hearts

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DRUG PROFILE

1. Pyridoxine

Category: Vitamin

Brands available: a) ABDEC FORTE b)B-LONG C)BEPLEX ELIXIR d)B-VITAL

Dosage regimen:

Dietary Deficiency

ADULTS: PO/IM/IV 10 to 20 mg/day for 3 wk.

Drug-Induced Deficiency Anemia or Neuritis

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ADULTS: PO/IM/IV 100 to 200 mg/day for 3 wk; follow with 25 to 100 mg/day.

Neuropathy

ADULTS: PO/IM/IV 50 to 200 mg/day.

Vitamin B6 Dependency Syndrome

ADULTS: PO/IM/IV 600 mg, followed by 30 mg/day for life. Dependency has been noted in adults

administered 200 mg/day. PYRIDOXINE-DEPENDENT INFANTS: IM/IV 10 to 100 mg, followed by 2

to 100 mg/day.

Metabolic Disorders

ADULTS: PO/IM/IV 100 to 500 mg/day

Indication: Pyridoxine deficiency, including inadequate diet, drug-induced causes (eg, isoniazid,

hydralazine, oral contraceptives) or inborn errors of metabolism

Adverse effect: CNS: Neuropathy; unstable gait; drowsiness; somnolence. EENT: Perioral numbness.

OTHER: Numbness of feet; decreased sensation to touch, temperature or vibration; paresthesia; low

serum folic acid levels; burning/stinging at IM injection site; photoallergic reaction; ataxia.

Contraindications: Standard considerations.

Caution: Pregnancy: Category A. (Category C in doses that exceed the RDA.) Lactation: Excreted in

breast milk; may inhibit lactation. Children: Safety and efficacy not established in doses exceeding

nutritional requirements.

Nursing Implementation:

Instruct patient to swallow sustained-release preparation whole and not to break, crush or chew.

When giving via IM route, rotate sites.

IV preparation may be given undiluted or added to standard compatible IV solutions.

Store all forms of drug at room temperature in tightly-closed, light-resistant containers. Avoid freezing

injection

1. Isoniazide

Category: Antituberculosis drug ( first line drug) bacteriacidal

Brands available: a)Isokin b)Solonex c)Isonex d)Tubernex forte

Dosage regimen: 300mg /day Adult

5-10mg/kg/day children

Indication: Tuberculosis, Prophylaxis of tuberculosis.

Adverse effect: convulsion, joint pain, agranulocytosis, skin rash, buring sensation of feet, drowsiness,

hallucinations, abdominal pain, nausea, vomiting, epigastric distress, fever;

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Contraindications: Hypersensitivity

Caution: Severe renal impairment,hepatic failure pregnancy and lactation

Nursing implementation

Careful monitoring is necessary for black and Hispanic women, notice and inform side effect full course

of treatment should be given

.

2. Rifampicine

Therapeutic category: Antituberculosis drug ( first line drug), Antileprotis drug

Indications: Tuberculosis, Leprosy, Prophylaxis of meningococcal infections, prophylaxis of

meningitis due to H.influeza type B, treatment of asymptomatic carriers of Neisseria meningitis..

Dose regimen: TB: 450-600mg/day for first 2 month, 10-15mg/kg 3 times a week.

Adverse effect: Anorexia, nausea, vomotting, abdominal pain, hepatitis, acute renal failure,

drowsiness. Headache, atoxia, visual disturbance, skin rash, shock, eosinophila, transcient

leucopenia.GI disturbance, peptic ulceration, abnormalities of kidney function.

Contraindications: Hypersensitivity, jaundice, biliary destruction, severe hepatic disease impaired

hepatic renal functions.

Nursing implementation: Take in empty stomach informs patient that orange red urine is harmless,

take full course of the drug.

Storage condition: Store in cool and dry place.

3. Ethambutol

Therapeutic category: Antituberculosis drug ( first line drug)

Indications: Pulmonary and extra pulmonary tuberculosis

Dosage regimen:Adult: 15-25mg/kg/day continuous upto 50mg/kg

Children 10-15mg/kg/day continuous

Adverse effects: headache, stomach upset. Anorexia, nausea, vomiting, skin rash. Hepatitis, neuritis,

dizziness, neuropathy, reduced renal clearanceof ureters.

Contraindication: drug allergy, optic neuritis, renal/ hepatic failure, history of epilepsy, neonates,

impaires pretreatment visual acquity.

Nursing consideration: visual function test is recommended before and during therapy liver function

test should be done.

Storage: store in a cool and dry place

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4. Pyrazinamide

Therapeutic category: Antituberculosis drug ( first line drug)

Indications: Tuberculosis

Dosage regimen: 20-35mg/kg/day (adult), 15-30mg/kg/day (children)

Adverse effects: joint pain hepatitis hepatomegaly, spleenomegaly. Arthrolgai, malaise, fever,

hyperuricaemia, rashes, photosensitivity, anemia

Contraindication: hypersensitivity, diabetes, hepatic, impairment condition ,gout renal failure.

Nursing consideration: liver function test should be done, full course of drugs should be done,

vitamin B6 should be supplement.

Storage: store in a cool and dry place

5. Carvedilol

Drug classes

Alpha- and beta-adrenergic blocker, Antihypertensive

Therapeutic actions

Competitively blocks alpha-, beta-, and beta2-adrenergic receptors and has some

sympathomimetic activity at beta2-receptors. Both alpha and beta blocking actions contribute to

the BP-lowering effect; beta blockade prevents the reflex tachycardia seen with most alpha-

blocking drugs and decreases plasma renin activity. Significantly reduces plasma renin activity.

Indications

Hypertension, alone or with other oral drugs, especially diuretics

Treatment of mild to severe CHF of ischemic or cardiomyopathic origin with digitalis,

diuretics, ACE inhibitors

Left ventricular dysfunction (LVD) after MI

Unlabeled uses: Angina (25–50 mg bid)

Contraindications and cautions

26

Contraindicated with decompensated CHF, bronchial asthma, heart block, cardiogenic

shock, hypersensitivity to carvedilol, pregnancy, lactation.

Use cautiously with hepatic impairment, peripheral vascular disease, thyrotoxicosis,

diabetes, anesthesia, major surgery.

Available forms

Tablets—3.125, 6.25, 12.5, 25 mg

Hypertension: 6.25 mg PO bid; maintain for 7–14 days, then increase to 12.5 mg PO bid

if needed to control BP. Do not exceed 50 mg/day.

CHF: Monitor patient very closely, individualize dose based on patient response. Initial

dose, 3.125 mg PO bid for 2 wk, may then be increased to 6.25 mg PO bid. Maximum

dose, 25 mg PO bid in patients < 85 kg or 50 mg PO bid in patients > 85 kg.

LVD following MI: 6.25 mg PO bid, increase after 3–10 days to target dose of 25 mg bid.

Metabolism: Hepatic; T1/2: 7–10 hr

Distribution: Crosses placenta; may enter breast milk

Excretion: Bile, feces

Adverse effects

CNS: Dizziness, vertigo, tinnitus, fatigue, emotional depression, paresthesias, sleep

disturbances

CV: Bradycardia, orthostatic hypertension, CHF, cardiac arrhythmias, pulmonary edema,

hypotension

GI: Gastric pain, flatulence, constipation, diarrhea, hepatic failure

Respiratory: Rhinitis, pharyngitis, dyspnea

Other: Fatigue, back pain, infections

Interactions

27

Increased effectiveness of antidiabetics; monitor blood glucose and adjust dosages

appropriately

Increased effectiveness of clonidine; monitor patient for potential severe bradycardia and

hypotension

Increased serum levels of digoxin; monitor serum levels and adjust dose accordingly

Increased plasma levels of carvedilol with rifampin

Potential for dangerous conduction system disturbances with verapamil or diltiazem; if

this combination is used, closely monitor ECG and BP

Slowed rate of absorption but not decreased effectiveness with food

Nursing managementAssessment

History: CHF, bronchial asthma, heart block, cardiogenic shock, hypersensitivity to

carvedilol, pregnancy, lactation, hepatic impairment, peripheral vascular disease,

thyrotoxicosis, diabetes, anesthesia or major surgery

Physical: Baseline weight, skin condition, neurologic status, P, BP, ECG, respiratory

status, LFTs, renal and thyroid function tests, blood and urine glucose

Warning :

Do not discontinue drug abruptly after chronic therapy (hypersensitivity to

catecholamines may have developed, causing exacerbation of angina, MI, and ventricular

arrhythmias); taper drug gradually over 2 wk with monitoring.

Consult with physician about withdrawing drug if patient is to undergo surgery

(withdrawal is controversial).

Give with food to decrease orthostatic hypotension and adverse effects.

Monitor for orthostatic hypotension and provide safety precautions.

Monitor patients with diabetes closely; drug may mask hypoglycemia or worsen

hyperglycemia.

28

Monitor patient for any sign of liver dysfunction (pruritus, dark urine or stools, anorexia,

jaundice, pain); arrange for LFTs and discontinue drug if tests indicate liver injury. Do

not restart carvedilol.

Teaching points

Take drug with meals.

Do not stop taking drug unless instructed to do so by a health care provider.

Avoid use of over-the-counter medications.

You may experience these side effects: Depression, dizziness, light-headedness (avoid

driving or performing dangerous activities; getting up and changing positions slowly may

help ease dizziness).

Report difficulty breathing, swelling of extremities, changes in color of stool or urine,

very slow heart rate, continued dizziness.

6. Enalapril maleate

Drug classes

Antihypertensive, ACE inhibitor

Therapeutic actions

Renin, synthesized by the kidneys, is released into the circulation where it acts on a plasma

precursor to produce angiotensin I, which is converted by ACE to angiotensin II, a potent

vasoconstrictor that also causes release of aldosterone from the adrenals; both of these actions

increase BP. Enalapril blocks the conversion of angiotensin I to angiotensin II, decreasing BP,

decreasing aldosterone secretion, slightly increasing serum K+ levels, and causing Na+ and fluid

loss; increased prostaglandin synthesis also may be involved in the antihypertensive action. In

patients with heart failure, peripheral resistance, afterload, preload, and heart size are decreased.

29

Indications

Treatment of hypertension alone or in combination with other antihypertensives,

especially thiazide-type diuretics

Treatment of acute and chronic CHF

Treatment of asymptomatic left ventricular dysfunction (LVD)

Unlabeled use: Diabetic nephropathy


Contraindicated with allergy to enalapril.

Use cautiously with impaired renal function; salt or volume depletion (hypotension may

occur); lactation, pregnancy.

Available forms

Tablets—2.5, 5, 10, 20 mg; injection—1.25 mg/mL

Hypertension:

Patients not taking diuretics: Initial dose is 5 mg/day PO. Adjust dosage based on patient

response. Usual range is 10–40 mg/day as a single dose or in two divided doses

.

Patients taking diuretics: Discontinue diuretic for 2–3 days if possible. If it is not possible

to discontinue diuretic, give initial dose of 2.5 mg, and monitor for excessive

hypotension.

Converting to oral therapy from IV therapy: 5 mg daily with subsequent doses based on

patient response.

Heart failure: 2.5 mg PO daily or bid in conjunction with diuretics and digitalis.

Maintenance dose is 5–20 mg/day given in two divided doses. Maximum daily dose is

40 mg.

Asymptomatic LVD: 2.5 mg PO bid; target maintenance dose 20 mg/day in two divided

doses.

30

Give IV only. 1.25 mg q 6 hr given IV over 5 min. A response is usually seen within 15

min, but peak effects may not occur for 4 hr.

Hypertension:

Converting to IV therapy from oral therapy: 1.25 mg q 6 hr; monitor patient response.

Patients taking diuretics: 0.625 mg IV over 5 min. If adequate response is not seen after 1

hr, repeat the 0.625-mg dose. Give additional doses of 1.25 mg q 6 hr.

Excretion is reduced in renal failure; use smaller initial dose, and adjust upward to a

maximum of 40 mg/day PO. For patients on dialysis, use 2.5 mg on dialysis days.

If creatinine clearance 30 mL/min, the initial dose is 0.625 mg, which may be repeated.

Additional doses of 1.25 mg q 6 hr may be given with careful patient monitoring.

Pharmacokinetics

Metabolism: T1/2: 11 hr

Distribution: Crosses placenta; enters breast milk

Excretion: Urine

Preparation: Enalaprilat can be given as supplied or mixed with up to 50 mL of 5% dextrose

injection, 0.9% sodium chloride injection, 0.9% sodium chloride injection in 5% dextrose, 5%

dextrose in lactated Ringer's, Isolyte E. Stable at room temperature for 24 hr.

Infusion: Give by slow IV infusion over at least 5 min.

Adverse effects

CNS: Headache, dizziness, fatigue, insomnia, paresthesias

CV: Syncope, chest pain, palpitations, hypotension in salt- or volume-

depleted patients

GI: Gastric irritation, nausea, vomiting, diarrhea, abdominal pain, dyspepsia,

elevated liver enzymes

GU: Proteinuria, renal insufficiency, renal failure, polyuria, oliguria, urinary

frequency, impotence

Hematologic: Decreased Hct and Hgb

Other: Cough, muscle cramps, hyperhidrosis

31

Interactions

Decreased hypotensive effect if taken concurrently with indomethacin, rifampin

Nursing considerationsAssessment

History: Allergy to enalapril, impaired renal function, salt or volume depletion, lactation,

pregnancy

Physical: Skin color, lesions, turgor; T; orientation, reflexes, affect, peripheral sensation;

P, BP, peripheral perfusion; mucous membranes, bowel sounds, liver evaluation;

urinalysis, LFTs, renal function tests, CBC, and differential

Interventions

Warning : Alert surgeon, and mark patient's chart with notice that enalapril is being

taken; the angiotensin II formation subsequent to compensatory renin release during

surgery will be blocked; hypotension may be reversed with volume expansion.

Monitor patients on diuretic therapy for excessive hypotension after the first few doses of

enalapril.

Monitor patient closely in any situation that may lead to a drop in BP secondary to

reduced fluid volume (excessive perspiration and dehydration, vomiting, diarrhea)

because excessive hypotension may occur.

Arrange for reduced dosage in patients with impaired renal function.

Monitor patient carefully because peak effect may not be seen for 4 hr. Do not administer

second dose until BP has been checked.

Teaching points

Do not stop taking the medication without consulting your health care provider.

Be careful in any situation that may lead to a drop in blood pressure (diarrhea, sweating,

vomiting, dehydration).

Avoid over-the-counter medications, especially cough, cold, and allergy medications that

may interact with this drug.

32

You may experience these side effects: GI upset, loss of appetite, change in taste

perception (will pass with time); mouth sores (frequent mouth care may help); rash; fast

heart rate; dizziness, light-headedness (usually passes in a few days; change position

slowly, limit activities to those not requiring alertness and precision).

Report mouth sores; sore throat, fever, chills; swelling of the hands, feet; irregular

heartbeat, chest pains; swelling of the face, eyes, lips, tongue, difficulty breathing.

7. Aspirin Apo-ASA (CAN), Aspergum, Bayer, Easprin, Ecotrin, Empirin, Entrophen (CAN), Genprin,

Halfprin 81, 1/2 Halfprin, Heartline, Norwich, Novasen (CAN), Ascriptin, Asprimox, Bufferin,

Buffex, Magnaprin

Drug classes

Antipyretic, Analgesic (nonopioid), Anti-inflammatory, Antirheumatic, Antiplatelet, Salicylate,

NSAID

Therapeutic actions

Analgesic and antirheumatic effects are attributable to aspirin's ability to inhibit the synthesis of

prostaglandins, important mediators of inflammation. Antipyretic effects are not fully

understood, but aspirin probably acts in the thermoregulatory center of the hypothalamus to

block effects of endogenous pyrogen by inhibiting synthesis of the prostaglandin intermediary.

Inhibition of platelet aggregation is attributable to the inhibition of platelet synthesis of

thromboxane A2, a potent vasoconstrictor and inducer of platelet aggregation. This effect occurs

at low doses and lasts for the life of the platelet (8 days). Higher doses inhibit the synthesis of

prostacyclin, a potent vasodilator and inhibitor of platelet aggregation.

Indications

Mild to moderate pain

Fever

Inflammatory conditions—rheumatic fever, rheumatoid arthritis, osteoarthritis

Reduction of risk of recurrent TIAs or stroke in males with history of TIA due to fibrin

platelet emboli

33

Reduction of risk of death or nonfatal MI in patients with history of infarction or unstable

angina pectoris

MI prophylaxis

Unlabeled use: Prophylaxis against cataract formation with long-term use


Contraindicated with allergy to salicylates or NSAIDs (more common with nasal polyps,

asthma, chronic urticaria); allergy to tartrazine (cross-sensitivity to aspirin is common);

hemophilia, bleeding ulcers, hemorrhagic states, blood coagulation defects,

hypoprothrombinemia, vitamin K deficiency (increased risk of bleeding)

Use cautiously with impaired renal function; chickenpox, influenza (risk of Reye's

syndrome in children and teenagers); children with fever accompanied by dehydration;

surgery scheduled within 1 wk; pregnancy (maternal anemia, antepartal and postpartal

hemorrhage, prolonged gestation, and prolonged labor have been reported; readily

crosses the placenta; possibly teratogenic; maternal ingestion of aspirin during late

pregnancy has been associated with the following adverse fetal effects: low birth weight,

increased intracranial hemorrhage, stillbirths, neonatal death); lactation.

Available forms

Tablets—81, 165, 325, 500, 650, 975 mg; SR tablets—650, 800 mg; suppositories—120, 200,

300, 600 mg

Dosages

Available in oral and suppository forms. Also available as chewable tablets, gum; enteric

coated, SR, and buffered preparations (SR aspirin is not recommended for antipyresis, short-

term analgesia, or children < 12 yr.)

Minor aches and pains: 325–650 mg q 4 hr.

Arthritis and rheumatic conditions: 3.2–6 g/day in divided doses.

Acute rheumatic fever: 5–8 g/day; modify to maintain serum salicylate level of 15–

30 mg/dL.

TIAs in men:1,300 mg/day in divided doses (650 mg bid or 325 mg qid).

34

MI prophylaxis: 75–325 mg/day.

Analgesic and antipyretic: 65 mg/kg per 24 hr in four to six divided doses, not to exceed

3.6 g/day. Dosage recommendations by age

Juvenile rheumatoid arthritis: 60–110 mg/kg per 24 hr in divided doses at 6- to 8-hr

intervals. Maintain a serum level of 150–300 mcg/mL.

Acute rheumatic fever: Initially, 100 mg/kg/day, then decrease to 75 mg/kg/day for 4–6

wk. Therapeutic serum salicylate level is 150 300 mg/dL.

Kawasaki disease: 80–180 mg/kg/day; very high doses may be needed during acute

febrile period; after fever resolves, dosage may be adjusted to 10 mg/kg/day.

Metabolism: Hepatic (salicylate); T1/2: 15 min–12 hr

Distribution: Crosses placenta; enters breast milk

Excretion: Urine

Adverse effects

Acute aspirin toxicity: Respiratory alkalosis, hyperpnea, tachypnea, hemorrhage,

excitement, confusion, asterixis, pulmonary edema, seizures, tetany, metabolic acidosis,

fever, coma, CV collapse, renal and respiratory failure (dose related, 20–25 g in adults, 4

g in children)

Aspirin intolerance: Exacerbation of bronchospasm, rhinitis (with nasal polyps, asthma,

rhinitis)

GI: Nausea, dyspepsia, heartburn, epigastric discomfort, anorexia, hepatotoxicity

Hematologic: Occult blood loss, hemostatic defects

Hypersensitivity: Anaphylactoid reactions to anaphylactic shock

Salicylism: Dizziness, tinnitus, difficulty hearing, nausea, vomiting, diarrhea, mental

confusion, lassitude (dose related)

Interaction

Increased risk of bleeding with oral anticoagulants, heparin

Increased risk of GI ulceration with steroids, phenylbutazone, alcohol, NSAIDs

35

Increased serum salicylate levels due to decreased salicylate excretion with urine

acidifiers (ammonium chloride, ascorbic acid, methionine)

Increased risk of salicylate toxicity with carbonic anhydrase inhibitors, furosemide

Decreased serum salicylate levels with corticosteroids

Decreased serum salicylate levels due to increased renal excretion of salicylates with

acetazolamide, methazolamide, certain antacids, alkalinizers

Decreased absorption of aspirin with nonabsorbable antacids

Increased methotrexate levels and toxicity with aspirin

Increased effects of valproic acid secondary to displacement from plasma protein sites

Greater glucose lowering effect of sulfonylureas, insulin with large doses (> 2 g/day) of

aspirin

Decreased antihypertensive effect of captopril, beta-adrenergic blockers with salicylates;

consider discontinuation of aspirin

Decreased uricosuric effect of probenecid, sulfinpyrazone

Possible decreased diuretic effects of spironolactone, furosemide (in patients with

compromised renal function)

Unexpected hypotension may occur with nitroglycerin

Decreased serum protein bound iodine (PBI) due to competition for binding sites

False-negative readings for urine glucose by glucose oxidase method and copper

reduction method with moderate to large doses of aspirin

Interference with urine 5-HIAA determinations by fluorescent methods but not by

nitrosonaphthol colorimetric method

Interference with urinary ketone determination by the ferric chloride method

Falsely elevated urine VMA levels with most tests; a false decrease in VMA using the

Pisano method

Nursing considerationsAssessment

History: Allergy to salicylates or NSAIDs; allergy to tartrazine; hemophilia, bleeding

ulcers, hemorrhagic states, blood coagulation defects, hypoprothrombinemia, vitamin K

deficiency; impaired hepatic function; impaired renal function; chickenpox, influenza;

36

children with fever accompanied by dehydration; surgery scheduled within 1 wk;

pregnancy; lactation

Physical: Skin color, lesions; T; eighth cranial nerve function, orientation, reflexes,

affect; P, BP, perfusion; R, adventitious sounds; liver evaluation, bowel sounds; CBC,

clotting times, urinalysis, stool guaiac, LFTs, renal function tests

Interventions

Give drug with food or after meals if GI upset occurs.

Give drug with full glass of water to reduce risk of tablet or capsule lodging in the

esophagus.

Do not crush, and ensure that patient does not chew SR preparations.

Do not use aspirin that has a strong vinegar-like odor.

Institute emergency procedures if overdose occurs: Gastric lavage, induction of emesis,

activated charcoal, supportive therapy.

Teaching points

Take extra precautions to keep this drug out of the reach of children; this drug can be

very dangerous for children.

Use the drug only as suggested; avoid overdose. Avoid the use of other over-the-counter

drugs while taking this drug. Many of these drugs contain aspirin, and serious overdose

can occur.

Take the drug with food or after meals if GI upset occurs.

Do not cut, crush, or chew sustained-release products.

Over-the-counter aspirins are equivalent. Price does not reflect effectiveness.

You may experience these side effects: Nausea, GI upset, heartburn (take drug with

food); easy bruising, gum bleeding (related to aspirin's effects on blood clotting).

Report ringing in the ears; dizziness, confusion; abdominal pain; rapid or difficult

breathing; nausea, vomiting, bloody stools.

NURSING MANAGEMENT

37

Assessment

• Detailed history of the presenting signs and symptoms.

• Identifies possible etiologic factors, such as heavy alcohol intake, recent illness or

pregnancy, or history of the disease in immediate family members.

• If the patient complains of chest pain, a thorough review of the pain, including its

precipitating factors, should be performed.

• The review of systems includes the presence of orthopnea, paroxysmal nocturnal

dyspnea, and syncope or dyspnea with exertion.

• usual weight, any weight change, and limitation to activities

• patient’s support systems are identified, and members are involved in the patient’s

care and therapeutic regimen.

• Vital signs

• Calculation of pulse pressure and identification of pulsus paradoxus

• Current weight; determination of weight gain or loss

• Detection by palpation of the point of maximal impulse, often shifted to the left

• Cardiac auscultation for a systolic murmur and third and fourth heart sounds

• Pulmonary auscultation for crackles

• Measurement of jugular vein distention

• Identification of presence and severity of edema

Nursing diagnoses

1. Decreased cardiac output related to structural disorders

2. caused by cardiomyopathy or to dysrhythmia from the disease process and medical

treatments

3. Ineffective cardiopulmonary, cerebral, peripheral, and renal tissue perfusion related to

decreased peripheral blood flo(resulting from decreased cardiac

4. Impaired gas exchange related to pulmonary congestion

5. Activity intolerance related to decreased cardiac output or excessive fluid volume, or

both

6. Anxiety related to the change in health status and in role functioning

38

7. Powerlessness related to disease process

8. Noncompliance with medication and diet therapies

Potential complications

• Congestive heart failure

• Ventricular dysrhythmias

• Atrial dysrhythmias

• Cardiac conduction defects

• Pulmonary or cerebral embolism

• Valvular dysfunction

Planning and Goals

• Improved or maintained cardiac output

• increased activity tolerance

• Reduction of anxiety

• Adherence to the self-care program, increased sense of power with decision making,

and absence of complications.

39

APPLICATION OF THE HENDERSON INDEPENDENCE THEORY IN THIS CASE

NURSING

Henderson concept of nursing is interesting from the prospective of time. Nursining help the

patient to meet the basic need through the formation of nurse pt relationship.

She was one of the earlier leader who believed nurse need a liberal education including

knowledge of science and humanities. Aside from the definition of nursing and the fourteen

component of basic nursing care, the nurse is expected to carryout the physician therapeutic.

40

Person view as individual requiring assistance to achieve health and independence or peaceful

death. person and family are view as a unit. Person consist of biological,

psychological ,sociological and spiritual component. Person is either sick or well and strive

towards a state of independence. person needs strength, will or knowledge to perform activities

necessary for healthy living. The individual has 14 basic need for survival.

Nursing process

Her definition and explanation of nursing do not directly fit the step of nursing process.

Assessment

She does not refer directly to assessment ,she implies in description of the 14 component of

basic nursing care. To complete the assessment phase the nurse need to analyze data. according

to her the nurse must have knowledge about what is normal in health and disease. Using this

knowledge the nurse would data compare the assessment data

Nursing diagnosis:

She does not specifically discussed nursing diagnosis. She believes that physician makes the

diagnosis and nurse acts upon that diagnosis. Base on the assessment and analysis of the data, the

nurse can identify the actual problem .

Planning:

Regarding the planning of care, she states plans need continue modification based on individual

needs. She emphasize that nursing care is always arranged around or fitted into the physician

therapeutic plan. Implement:

41

Handerson nursing implementation is based on helping the patient meet the 14 component

Nursing assessment

The 14 components are:

1. Breathe normally.

2. Eat and drink adequately.

3. Eliminate body wastes.

4. Move and maintain desirable postures.

5. Sleep and rest.

6. Select suitable clothes-dress and undress.

7. Maintain body temperature within normal range by adjusting clothing and modifying

environment

8. Keep the body clean and well groomed and protect the integument

9. Avoid dangers in the environment and avoid injuring others.

10. Communicate with others in expressing emotions, needs, fears, or opinio

11. Worship according to one’s faith.

12. Work in such a way that there is a sense of accomplishment.

13. Play or participate in various forms of recreation.

14. Learn, discover, or satisfy the curiosity that leads to normal development and health and

use the available health facilities.

Nursing process

1. Analysis

Compare data to knowledge base of health and disease the patient eat and drink is

inadequate

Nursing diagnosis

• Identify the patient ‘s ability to meet own need with or without assistance .

• The patient unable to meet eat and drinks need without assistance.

42

• ( Altered nutrition: less than body requirements related to decrease appetite secondary

to disease condition)

Nursing plan

• Patient encourage to take balanced diet and frequent small meal.

• Suitable environment will provide while taking food

• Treat the disease with medications or any other measures.

• Advise to increase the activity and ask to mobilize

Nursing implementation

• Patient encouraged to take balanced diet and frequent small meal..

• Suitable environment was provided while taking food.

• Treat the disease with medications or any other measures.

• Advised to increase the activity and asked to mobilize

Evaluation

My patient able to eat and drink adequately with out assistance.

2. Analysis

Patient was unable to Communicate with others in expressing emotions, needs, fears, or

opinion

Nursing diagnosis

• Identify the patient ‘s ability to meet own need with or with out assistance .

• Patient unable to communicate with other expressing emotion, needs, fears or

opinion with out assistance .

• ( Anxiety related to the change in health status and in role functioning)

Nursing plan

• The patient will provide with appropriate information about cardiomyopathy and

self-management activities.

• Patient will provide atmosphere in which the patient feels free to verbalize

43

• Patient will provide discuss about treatment modalities .

• Providing the patient with realistic hope helps to reduce anxiety while the patient

awaits a donor heart.

Implementation

• The patient is provided with appropriate information about cardiomyopathy and self-

management activities.

• Patient was provided atmosphere in which the patient feels free to verbalize.

• Patient provided the time about discuss the treatment modalities.

• Providing the patient with realistic hope helps to reduce anxiety .

Evaluation

Patient was Communicate with others in expressing emotions, needs, fears, or opinion

3. Analysis

Patient was unable to move and maintain desirable postures.

Nursing diagnosis


• The patient unable to move and maintain desirable postures with out assistance

• (Activity intolerance related to decreased cardiac output or excessive fluid volume, or

both)

Nursing plan

• Teach the patient about the need for planned cycles of rest and activity.

• Helps them to identify methods to balance rest with activity.

• Help the patient recognizes the symptoms that indicate the need for rest and the

actions to take when the symptoms occur.

• Patients with HCM need to avoid strenuous activity and sports.

Implementation

• Teach the patient about the need for planned cycles of rest and activity. For example, after

taking a bath or shower, the patient should plan to sit and read the paper.

• Suggesting that patients sit while chopping vegetables, drying their hair, or shaving helps

them to identify methods to balance rest with activity.

44

• Help the patient recognizes the symptoms that indicate the need for rest .

• Help to the patient the actions to take when the symptoms occur.

Evaluation

Patient was move and maintain desirable posture.

4. Analysis

Learn, discover, or satisfy the curiosity that leads to normal development and health and

use the available health facilities.

Nursing diagnosis


• The patient unable learn, discover, or satisfy the curiosity that leads to normal

development and health and use the available health facilities with out assistance

(Noncompliance with medication and diet therapies)

Nursing Planning

• Patient will be teaching about the medication regimen, symptom monitoring, and

symptom management

• Helping patients cope with their disease status

• Assists them in adjusting their lifestyles and implementing a self-care program at

home.

Implementation

• Assists the patient and family to adjust to lifestyle changes.

• Teaching patients to read nutritional labels, to maintain a record of daily weights and

symptoms

• and to organize daily activities to increase activity tolerance

• Assessed diet and fluid restrictions and to the medication regimen

• Explanation about symptoms that should be reported to the physician are emphasized.

45

Evaluation

The patient was able to learn, discover, or satisfy the curiosity that leads to normal

development and health and use the available health facilities with out assistance.

DIVERSIONAL THERAPY

Diversional Therapy is a client centered practice recognizes that leisure and recreational

experiences are the right of all individuals.

• These are often quite diverse and can range from: Games, outings, computers, gentle

exercise, music, arts and crafts.

• Individual emotional and social support

• Sensory enrichment, activities like massage and aromatherapy, pet therapy

• Discussion groups, education sessions like grooming, beauty care, cooking.

• The diversional therapy programme has definitely had a positive influence on

patient’s life and will continue to do so for as long as he is living at the hospital

• The divertional therapy suggested for my patient is Gardening and gentle exercise

• Social, cultural and spiritual activities

In my patient

In order to reduce anxiety and query about disease, I used following diversional therapy:

• I provided him suitable environment that help to express his feelings.

• I talked and interacted with him and his relatives about their family, occupation,

study.

• Provide gentle exercise

• Provide opportunity talking with other patient.

• Listening music by mobile phone.

46

DAILY PROGRESS REPORT

Admission day (2068/11/18)

Vital signs

Respiration: 22/min Temperature: 37.2 °C

Pulse: 86/min BP: 100/70 mm of Hg

• Patient diagnosis of Cardiomyopathy with Rt sided pleural effusion was admitted in

medical from medical OPD.

• Patient came by walking. Vitals within normal range.

• Patient is conscious and well oriented to time place and person.

• Plan for diagnostic tapping today.

• Report CBC ,Hb, ESR is to be collected.

2068/11/19

1st day of admission

Vital signs

Respiration: 20/min Temperature: 36.8° C


• Patient’s general condition is fair. Vitals within normal range.

• Tolerating normal diet. Normal bowel and bladder habit.

• Patient is started ATT drugs. No any specific complain from patient side..

• Patient’s general condition is improving.

• Saturation maintained at room air tolerating normal diet.

• Normal bowel and bladder habit. No soakage from tapping site.

• Patients complains of slight chest pain.

2068/11/20

47

Vital signs

Respiration: 20/min Temperature: 36.8° C


• Patient’s general condition is improve.

• Vitals within normal range.

• Tolerating normal diet.

• Normal bowel and bladder habit.

• Patient give instruction about ATT drug

• No any specific complain from patient side.

2068/11/20

2nd of admission

Vital signs

Respiration: 18/min Temperature: 98.8° f


• Patient improve the condition today.

• Assist patient for morning care.

• Attend morning round.

• Ambulate the patient.

2068/11/21

3rd day of admission

Vital signs

Respiration: 18/min Temperature: 98.8° f


• Patient improve the condition and plan of discharge.

48

• Discharge patient today

• Provide health education

• At the time of hospitalization, the following teaching was given to client and his

visitor about health promotion including

Personal hygiene:

• The following informal teaching related to personal hygiene was provided:

• Trimming nail and keeping it clean.

• Washing hand before and after having food and after defecation.

• Also frequent hand washing is necessary for infection prevention.

• Oral hygiene and hair care is also necessary.

• wearing neat and clean dress.

2) Nutritious food:

• Encouraged for balanced diet and provided informal teaching on its importance and

sources.

3) Rest and sleep:

• Provided informal teaching regarding importance of enough rest and sleep for

patient’s recovery.

4) Infection prevention:

• Encouraged the client’s family to adopt infection control measures such as:

• Keeping environment clean

• Hand washing

• Washing raw vegetables and fruits properly before consuming it.

• Drinking safe water after purifying it, taught them about SODIS method of water

purification.

• Care of the operative wound and its infection prevention

DISCHARGE TEACHING

Discharge medicine:

49

Tab Aspirin 75mg OD continue

Tab Enalpril 5mg OD continue Carvedilol 3.125mg BD continue

At the time of discharge I was present there.

• Patient was informed about the follow up on 2068/12/15

• Patient was advised to have the prescribed medication on proper time and dose after

discharge. Patient was informed about the side effect of the drugs and importance of

continuation of ATT drug.

• Patient advice to be far from smoke, dust. Close the mouth while coughing, sneezing etc

SPECIAL GAGETS USED IN MY PATIENT

Sphygmomanometer

Stethoscope

ECG monitoring

X-ray machine

Pulse oxymeter.

U.S G mechine.

LEARNED FROM THE EXPERIENCE

This case study gives following opportunity and knowledge such as

• Identified the complete health need of older adult and give nursing care

• Provide comprehensive nursing care to the adult patient.

• Assist in different type of diagnosis procedure of the patient

• Analyze the concept and approach to nursing practice according to trend and

technology

• Identified the factors influencing nursing practice.

• Develop competency in handling various gadgets.

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• Identified the plan, implement and evaluate the educational need of the patient and

patient family.

REFERENCES

1. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing Lippincott 12 th edition

vol-1 p-776

2. Black J.M &Hawks J.H. “Medical Surgical Nursing Clinical Management For Positive

Outcome”, division of Reed Elsevier India pvt ltd 8th edition ,vol -2 pg no 1392

3. Lippincott , “manual of nursing practice of the adult “ 8th Edition ,Jaypee brother pgno.

4. Devidson’s “principle and practice of mrdicine” 20th edition.pg.no .641

5. Smeltzer. C. Suzanne, Bare. G. Brenda, “Brunner and Suddarth’s Textbook of Medical

Surgical Nursing”, 12th edition (2010), Wolters Kluwer India Pvt. Ltd, Page no: 574-575

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6. Kumar. Parveen, Clark. Michael, “Clinical Medicine”, 6th edition (2005), Elsevier

Limited,

7. Boon. A. Nicholas, Colledge. R. Nicki, “Davidson’s Principles and Practice of

Medicine”, 20th edition (20), Elsevier Limited

8. Mosby’s “Nursing Drug Reference” , 23rd Edition, 2010

9. Cardiomyopathy www.medlineplus.com

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case study on cardiomyopathy

Health & Medicine