Cardiomyopathy is used to describe a disorder that affects the heart muscle. It is characterized by the thickening, stretching, and stiffening of the heart, affecting the ability of the heart to pump blood.
In this article:
- Types of Cardiomyopathy
- Nursing Process
- Nursing Care Plans
- Decreased Cardiac Output
- Impaired Gas Exchange
- Ineffective Tissue Perfusion
- Risk for Unstable Blood Pressure
Types of Cardiomyopathy
Cardiomyopathy can affect anyone at any age and may have no known cause. These are the three major types of cardiomyopathy:
Dilated – This is the most common type of cardiomyopathy and is characterized by rapid degeneration and diffused inflammation of heart fibers, causing ventricular dilation, atrial enlargement, and impaired systolic function. Clinical manifestations include fatigue, decreased exercise capacity, dyspnea at rest, orthopnea, and paroxysmal nocturnal dyspnea. Its causes include:
- Cardiotoxic agents: alcohol, cocaine, doxorubicin
- Genetics
- Coronary artery disease
- Diabetes
- Hypertension
- Myocardial infarction
- Myocarditis
- HIV
- Congenital heart disease
- Complications in pregnancy
Hypertrophic – This type of cardiomyopathy involves left ventricular thickening, reducing the ability to pump blood into the heart and the rest of the body. This can lead to atrial fibrillation or other arrhythmias, heart failure, and stroke. This is a major cause of sudden cardiac death in young adults. Clinical manifestations include syncope, exertional dyspnea, angina, and fatigue. This type of cardiomyopathy is rare and is often inherited.
Restrictive – This is the least common type of cardiomyopathy and involves impaired diastolic filling and stretching due to scarring or stiffening. Clinical manifestations include edema, exercise intolerance, fatigue, and dyspnea. The cause may be idiopathic or result from the following:
- Endomyocardial fibrosis
- Amyloidosis
- Cancer
- Post-radiation therapy
- Ventricular thrombus
- Sarcoidosis
Nursing Process
Cardiomyopathy can be asymptomatic and shortness of breath, fainting spells, or chest pain may only develop in the later stages of the disease. Diagnosis is confirmed through ECG, echocardiogram, stress tests, and more which the nurse may assist with.
In some cases, cardiomyopathy can develop quickly and exhibit severe symptoms and complications. Prompt treatment is essential to control the progression of the disease, reduce the risk of complications, and prevent sudden death.
Nurses plan an essential role in caring for patients with cardiomyopathy from assessment and identification of at-risk individuals to providing treatment such as drug therapy and surgical interventions.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for cardiomyopathy, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section you will find nursing care plan examples for cardiomyopathy.
Activity Intolerance
Activity intolerance is a classic sign of patients with cardiomyopathy along with other symptoms like dyspnea at rest or on exertion, fatigue, and orthopnea. This is a direct result of decreased cardiac function.
Nursing Diagnosis: Activity Intolerance
Related to:
- The imbalance between oxygen supply/demand
- Generalized weakness
As evidenced by:
- Abnormal blood pressure response to activity
- Abnormal heart rate response to activity
- Anxiety when activity is required
- Exertional discomfort
- Exertional dyspnea
- Expresses fatigue
Expected outcomes:
- Patient will be able to increase their activity level to perform desired activities.
- Patient will demonstrate the ability to climb one flight of stairs without dyspnea.
Assessment:
1. Assess the patient’s response to activities.
Parameters like tachycardia, dyspnea, chest pain, excessive fatigue, diaphoresis, weakness, and syncope can determine the patient’s physiological response to the stress of activity and evaluate ongoing progress or deconditioning.
2. Assess factors that affect the patient’s desired tolerated activity level.
Cardiomyopathies can affect patients of any age. Consider the activity level of patients, especially children and younger adults who enjoy playing and participating in sports.
Interventions:
1. Assist in self-care while promoting independence when tolerated.
Providing care to the patient ensures that the patient’s needs are met while reducing efforts that compromise cardiac workload. Encouraging participation in self-care activities if tolerated allows the patient to maintain a sense of control and independence.
2. Schedule interventions with rest periods in between.
Scheduling interventions and procedures with rest periods ensures that the patient’s needs are met without increasing oxygen demand and cardiac workload.
3. Monitor for an increasing incidence of activity intolerance.
Increasing activity intolerance may indicate increasing cardiac decompensation.
4. Encourage the patient to adhere to a graded cardiac rehabilitation program.
Patients with cardiomyopathy have irreversible cardiac dysfunction. Adhering to a graded cardiac rehabilitation program can help strengthen cardiac function without overexertion.
Decreased Cardiac Output
When the heart muscles become stiff, thick, or dilated in cardiomyopathy, cardiac function decreases causing poor cardiac output.
Nursing Diagnosis: Decreased Cardiac Output
Related to:
- Altered heart rate and contractility
- Disease process
- Inflammation of cardiac muscles
As evidenced by:
- Fatigue
- Heart palpitations
- ECG changes
- Tachycardia
- Bradycardia
- Dyspnea upon exertion
- Decreased ejection fraction
- Hypotension
Expected outcomes:
- Patient will demonstrate adequate cardiac output with blood pressure and heart rate within normal limits.
- Patient will report reduced feelings of dyspnea and angina.
Assessment:
1. Assess heart rate, rhythm, and pulses.
To compensate for decreased cardiac muscle contractility, the patient with cardiomyopathy will experience tachycardia. Decreased peripheral pulses are also an indication of decreased cardiac output. Pulses may be irregular or strong beats alternating with weak beats (pulsus alternans).
2. Monitor blood pressure.
Hypotension can occur in advanced cardiac failure when the body is unable to compensate for the loss of cardiac function.
3. Assess and monitor urine output.
With decreased cardiac output, the kidneys will respond by retaining sodium and water, decreasing urine output as fluid shifts onto the tissues.
4. Assess diagnostic studies.
A chest x-ray may show an enlarged heart and pulmonary congestion. ECG can show ST segment depression and T wave flattening due to myocardial oxygen demand.
Interventions:
1. Encourage the patient to rest.
Rest is essential to improve the efficiency of cardiac contractility and decrease myocardial workload by decreasing oxygen consumption.
2. Provide supplemental oxygen.
Supplemental oxygenation increases oxygen availability for myocardial uptake to prevent hypoxia in patients with cardiomyopathy.
3. Administer medications as indicated.
Medications such as antidysrhythmics, vasopressors, and diuretics can help control the progression of reduced cardiac output.
4. Prepare for pacemaker insertion.
A pacemaker may be required to keep the heart beating in a regular rhythm. The nurse can instruct the patient on precautions following the procedure.
Impaired Gas Exchange
Impaired gas exchange associated with cardiomyopathy can be caused by the interrupted blood supply to the heart muscles altering pulmonary function and compromising gas exchange.
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Inadequate gas exchange
- Lack of oxygenated blood
- Ineffective heart muscle contraction
- Compromised blood supply
- Disease process
As evidenced by:
- Dyspnea
- Tachypnea
- Fatigue
- Use of accessory muscles
- Nasal flaring
- Headache
- Change in level of consciousness
- Change in skin color (pale and cyanotic)
- Reduced ejection fraction
- Anxiety
- Restlessness
- Hypoxia
- Ejection fraction < 40%
- Altered ABGs
Expected outcomes:
- Patient will display oxygen saturation > 95% and breathing pattern within normal limits.
- Patient will perform ADLs without dyspnea or excessive fatigue.
- Patient will maintain an ejection fraction > 40%.
Assessment:
1. Determine respiratory status.
Decreased oxygenation (hypoxia) and quick, shallow breaths are effects of ineffective gas exchange in cardiomyopathy. It can be accompanied by the following:
- Increased respiratory rate
- Use of accessory muscles
- Nasal flaring
- Abdominal breathing
- Anxiety and restlessness
2. Auscultate lung sounds.
Inadequate gas exchange is linked to diminished breath sounds due to lung hypoinflation. CHF or stiff and stretched heart tissue can cause fluid to build in the lungs, leading to crackles on auscultation.
3. Regularly monitor pulses and breathing.
Vital signs are a significant indication of impairment in gas exchange. The blood may not complete the gas exchange adequately due to the restrictive heart contraction and ineffective cardiac oxygen consumption. It can manifest as bounding pulses, rapid breathing, and decreased oxygen saturation.
4. Observe for any change in mentation.
Changes in mentation and behavior are early signs of inadequate gas exchange. Cognitive alteration and restlessness can result from poor oxygenation to the brain.
5. Monitor ABGs.
Hypercapnia, or the buildup of CO2 in the blood, can cause dizziness, disorientation, and headaches. Severe CO2 retention can lead to dysrhythmias and respiratory failure.
Interventions:
1. Track the vital signs.
Monitor the heart rate, blood pressure, SpO2, and cardiac rhythm. Hypoxemia can result in fluctuations in blood pressure, heart rate, decreasing oxygen saturation, and fatal dysrhythmias.
2. Administer oxygen as ordered.
Increased oxygen delivery to the cardiac muscle helps the heart contract effectively. This aids in the gas exchange process.
3. Ask the patient to demonstrate pursed-lip breathing.
Pursed-lip breathing helps the patient slow their respirations and release trapped air and CO2.
4. Remove fluid from the lungs.
Cardiomyopathies such as congestive heart failure cause fluid to back up in the lungs from inadequate heart contraction, causing dyspnea and ineffective gas exchange. Diuretics can be administered IV or orally to rid the body of fluid.
5. Teach the patient when to seek medical help.
Encourage the patient to seek emergency medical assistance if they experience signs of heart failure and complications of poor gas exchange. Note the following:
- Chest pain or discomfort
- Shortness of breath
- Worsening activity intolerance
- Lightheadedness
- Dizziness
- Syncope
Ineffective Tissue Perfusion
Patients with cardiomyopathy may display ineffective tissue perfusion as the cardiac function worsens, making it difficult to perfuse other organs.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Ineffective heart muscle contraction
- Compromised blood supply
- Thickening of the heart muscle
- Stretching of the cardiac muscle
- Enlarged heart
- Structural heart damage
- Difficulty of the heart muscle to contract
- Increased workload of the heart
- Insufficient blood flow to the heart
- Hypoxemia
- Hypoxia
As evidenced by:
(symptoms are dependent on the organ system and may include:)
- Angina
- Dyspnea
- Change in the level of consciousness
- Restlessness
- Fatigue
- Exertional dyspnea or chest pain during activities
- Cold and clammy skin
- Prolonged capillary refill time
- Change in color of the membranes
- Edema
- Syncope
- Pallor or cyanosis
Expected outcomes:
- Patient will manifest peripheral pulses and capillary refill time within normal limits.
- Patient will demonstrate intact skin and mucosa with no edema.
- Patient will present an alert, conscious, and coherent level of consciousness.
Assessment:
1. Obtain ECG.
An ECG can detect cardiomyopathy and other problems, including heart attacks, arrhythmias (abnormal heartbeats), and heart failure.
2. Review echocardiogram results.
Educate the patient on the echocardiogram procedure. Echocardiography creates a moving image of the heart using sound waves. The “stress echo,” as part of a stress test, is one of the varieties of echocardiography. Transesophageal echo (TEE) is a more invasive type of echocardiogram.
3. Prepare the patient for cardiac catheterization.
The pressure and blood flow in the heart’s chambers is examined during cardiac catheterization. A catheter is inserted and guided to the heart through an artery. X-ray imaging will be used to visualize for blockages in the arteries leading to the heart.
4. Obtain BNP levels.
The heart produces the protein B-type natriuretic peptide (BNP). When a patient has cardiac damage or heart failure, their blood level of BNP may increase.
Interventions:
1. Improve blood flow.
Devices used in cardiac resynchronization treatment (CRT) regulate heart contractions and rhythm to improve blood flow. A left ventricular assist device (LVAD) is a surgically implanted pump to assist the left ventricle in pumping blood. This can be a treatment option for patients with end-stage cardiomyopathy.
2. Correct the arrhythmias.
Irregular cardiac rhythms are treated using pacemakers or implanted cardioverter defibrillators (ICDs). If an arrhythmia is caused by infection, hyperthyroidism, or an electrolyte imbalance, these can easily be corrected with medications.
3. Consider surgical procedures.
Primary percutaneous coronary intervention (PCI) can be completed within 120 minutes after an ECG diagnosis to widen coronary arteries and restore blood flow.
4. Manage chronic conditions.
Diabetes, HIV, hyperlipidemia, sleep apnea, hypertension, cancer, and more can contribute to ineffective tissue perfusion and cardiomyopathy. Maintaining strict control of comorbidities is necessary for positive outcomes.
5. Prevent blood clot formation.
Blood thinners or anticoagulants prevent blood clot formation. Blood thinners are commonly used to keep patients with dilated cardiomyopathy from developing blood clots.
6. Discuss other surgical options.
Consider heart surgery if the patient has severe symptoms or underlying heart problems. Open heart surgery or a heart transplant are discussed after all other options to enhance the blood flow have failed.
7. Refer the patient to cardiac rehab.
An essential component of treating a patient with cardiomyopathy following surgery or procedures is cardiac rehabilitation. Cardiac rehabilitation programs offer patient education, cardiovascular risk factor management, exercise and physical activity counseling, and psychological support.
Risk for Unstable Blood Pressure
Risk for unstable blood pressure (BP) associated with cardiomyopathy can be caused by thickening, stretching, and hardening of the heart, affecting the heart contraction and resulting in unstable blood pressure, insufficient blood flow, and poorly oxygenated blood to the heart.
Nursing Diagnosis: Risk for Unstable Blood Pressure
Related to:
- Ineffective heart muscle contraction
- Compromised blood supply
- Thickening of the heart muscle
- Stretching of the cardiac muscle
- Enlarged heart
- Structural heart damage
- Difficulty of the heart muscle to contract
- Increased workload of the heart
- Insufficient blood flow to the heart
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will maintain blood pressure within an acceptable range.
- Patient will participate in activities that lower blood pressure.
- Patient will adhere to medications to control blood pressure.
Assessment:
1. Track the patient’s blood pressure.
The most common complication of high blood pressure in patients with cardiomyopathy is hypertensive cardiomyopathy. Hypertensive cardiomyopathy is a structural heart disorder characterized by left ventricular hypertrophy and diastolic and systolic dysfunction. It is caused by persistent high blood pressure.
2. Assess the ejection fraction (EF).
The heart may deteriorate over time, and cardiomyopathy may result in heart failure. Ejection fraction is a measurement used to assess the amount of blood the heart pumps with each beat. An EF below 55% is abnormal, and below 40% signals heart failure.
3. Check for arrhythmias.
High blood pressure can result in the stiffening and thickening of the left ventricle walls, which might alter the way electrical signals go through the heart resulting in arrhythmias.
Interventions:
1. Control blood pressure.
The following medications are for patients with cardiomyopathy that help regulate blood pressure:
- Angiotensin-converting enzyme inhibitors (ACE inhibitors) relax veins and arteries to control high blood pressure
- Beta-blockers control blood pressure, angina, and irregular heartbeats
- Entresto (a combination of valsartan and sacubitril) enhances blood flow, dilates blood vessels, and lowers blood pressure by decreasing the sodium levels (sacubitril) and preventing constriction of the blood vessels (valsartan)
2. Maintain sinus heart rhythm.
Stabilize a regular heart rhythm with the following medications:
- Amiodarone treats irregular heartbeats and assists regulation of the heart rhythm and rate
- Digoxin strengthens contractions and decreases heart rate. Adjust the dose when amiodarone is initiated
- Medications that lengthen the QT interval must be adjusted to regulate heart rhythms
3. Teach the recommended diet.
A well-balanced diet will prevent worsening hypertension and promote heart health. Emphasize fresh produce, whole grains, lean proteins, nuts, seeds, and low-fat dairy.
4. Assist the patient in meal planning.
Teach the patient about the DASH (Dietary Approaches to Stop Hypertension) eating plan to control blood pressure. Assist the patient in creating their meal plan. The following food sources should be avoided:
- Red meat
- Sodium
- Processed foods and packaged snacks
- Beverages with added sugar
- Alcohol
- Fried foods
References
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- Cardiomyopathy. Centers for Disease Control and Prevention. Page last reviewed: December 9, 2019. From: https://www.cdc.gov/heartdisease/cardiomyopathy.htm
- Cardiomyopathy. Cleveland Clinic. Updated: April 28, 2021. From: https://my.clevelandclinic.org/health/diseases/16841-cardiomyopathy
- CARDIOMYOPATHY. What Is Cardiomyopathy? NIH. National Heart, Lung, and Blood Institute. Last updated on April 19, 2022. From: https://www.nhlbi.nih.gov/health/cardiomyopathy
- Cleveland Clinic. (2021, April 28). Cardiomyopathy: What is it, types, causes, symptoms & treatment. Retrieved February 2023, from https://my.clevelandclinic.org/health/diseases/16841-cardiomyopathy
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Mayo Clinic. (2022, April 2). Cardiomyopathy – Symptoms and causes. Retrieved February 2023, from https://www.mayoclinic.org/diseases-conditions/cardiomyopathy/symptoms-causes/syc-20370709
- Mayo Clinic. (2022, April 2). Cardiomyopathy – Diagnosis and treatment – Mayo Clinic. Retrieved March 2023, from https://www.mayoclinic.org/diseases-conditions/cardiomyopathy/diagnosis-treatment/drc-20370714
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
- Story, C. M. (2022, March 22). Cardiomyopathy: Symptoms, types, treatment, and causes. Healthline. Retrieved February 2023, from https://www.healthline.com/health/heart-disease/cardiomyopathy
- What Is Cardiomyopathy in Adults? American Heart Association. Last Reviewed: May 3, 2022. From: https://www.heart.org/en/health-topics/cardiomyopathy/what-is-cardiomyopathy-in-adults
