Primary Nursing Diagnosis

Decreased cardiac output related to reduced myocardial contractility

OUTCOMES. Circulation status; Cardiac pump effectiveness; Tissue perfusion: Cardiopul-monary, Cerebral, Renal, Peripheral; Vital sign status

INTERVENTIONS. Circulatory care; Emergency care; Vital signs monitoring; Cardiac care; Cardiac precautions; Oxygen therapy; Fluid/electrolyte management; Fluid monitoring; Shock management: Volume, Medication administration, Resuscitation, Surveillance

192 Cardiomyopathy

^ PLANNING AND IMPLEMENTATION Collaborative

The treatment for cardiomyopathy is palliative rather than curative. Control of the symptoms of CHF is the primary goal in treatment. Medical management may vary, depending on the type of cardiomyopathy present. Surgical treatment most commonly consists of excision of part of the hypertrophied septum to reduce the outflow obstruction (septal myotomy-myectomy). The patient with restrictive cardiomyopathy usually undergoes surgery to implant a permanent cardiac pacemaker.

Pharmacologic Highlights

Medication or Drug Class

Dosage

Description

Rationale

Angiotensin-converting enzyme (ACE) inhibitors

Digoxin

Vasodilators

Varies by drug

0.25 mg qd

Varies by drug

Inactivates renin-angiotensin system, thereby decreasing vascular resistance and ventricular afterload.

Direct action on cardiac muscle to increase contractility

Drugs such as nitrates and hydralazine dilate arteries

ACE inhibitors decrease mortality rates in patients with left ventricular dysfunction; reduces readmissions caused by heart failure

Idiopathic dilated cardiomyopathy: improves contractility and slows the renin-angiotensin response.

Reduce both preload and afterload by causing venous and arterial vasodilation

Other Medications: Beta-adrenergic antagonists have also been known to be beneficial In the treatment of dilated cardiomyopathy because of the resultant decrease in myocardial oxygen demand, improved ventricular filling, and inhibition of sympathetic vasoconstriction. Medical interventions for hypertrophic cardiomyopathy are aimed at decreasing the force of ventricular contraction and decreasing the outflow obstruction. Agents commonly used to achieve this goal include beta-adrenergic antagonists or calcium-channel blockers. Diuretic treatment is not indicated for hypertrophic cardiomyopathy because the outflow obstruction requires an adequate preload to maintain sufficient cardiac output. The longer filling time, optimal preload, and decrease in contractility diminish the outflow obstruction by the septum and mitral valve during systole. Calcium-channel blockers, most commonly verapamil, are used to promote relaxation of the ventricle, which also results in improved diastolic filling time.

Independent

Elevate the head of the patient's bed 30 to 45 degrees to help alleviate dyspnea. The elevation lowers pressure on the diaphragm, which is caused by the contents of the abdomen, and decreases venous return, thereby decreasing preload. If necessary, assist the patient with the activities of daily living. Although the patient requires frequent rest periods, maintain some level of activity. Prolonged periods of little or no activity can be very difficult to reverse.

Education of the patient and family is most important to prevent exacerbations and frequent hospital visits. CHF as a response to cardiomyopathy is a condition that is managed on an outpatient basis. Teach the patient and family how to prevent exacerbation and worsening of the condition. Explain the disease process clearly, using audiovisual aids whenever possible to help the patient understand the necessity of the prescribed medications, activity restrictions, diet, fluid restrictions, and lifestyle changes. Provide written material for the patient to take home and use as a reference; however, before giving the patient this material, be sure to assess his or her literacy level.

Teach the patient and family measures to prevent the condition from worsening. Patients and their families may be fearful and anxious, whether this is a new diagnosis or a progression of a chronic condition. The patient and family are required to make many lifestyle changes. Fear, anxiety, and grief can all stimulate the sympathetic nervous system, leading to catecholamine release and additional stress on an already compromised heart. Helping the patient to work through these feelings may improve psychological well-being and cardiac output.

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