A client seeks medical attention for dyspnea, chest pain, syncope, fatigue, and palpitations. A thorough physical examination reveals an apical systolic thrill and heave, along with a fourth heart sound (S4) and a systolic murmur. Diagnostic tests reveal that the client has a new onset of hypertrophic cardiomyopathy (HCM). What will be included on the plan of care?

1. Risk for injury

2. Risk for deficient fluid

volume

3. Ineffective

thermoregulation

4. Risk for peripheral

neurovascular dysfunction

RATIONALES: Risk for injury is an appropriate nursing diagnosis for a client with HCM because physical exertion may cause syncope or sudden death. Heart failure may complicate HCM, causing fluid volume excess; therefore, the nursing diagnosis of Risk for deficient fluid volume isn't applicable. Ineffective thermoregulation and Risk for peripheral neurovascular dysfunction are inappropriate because HCM doesn't cause these problems.

NURSING PROCESS STEP: Planning

CLIENT NEEDS CATEGORY: Physiological integrity

CLIENT NEEDS SUBCATEGORY: Reduction of risk potential

COGNITIVE LEVEL: Application

Explanation:

Tests

Echocardiogram. Your doctor is likely to recommend an imaging test called an echocardiogram to diagnose hypertrophic cardiomyopathy. This test allows your doctor to see whether your heart muscle is abnormally thick, your blood flow is obstructed and your heart valves are moving normally.

Additional tests might be ordered to look for other effects of hypertrophic cardiomyopathy and help your doctor determine the most appropriate treatment for your condition. These tests include:

Electrocardiogram (ECG). Wires (electrodes) attached to adhesive pads on your skin measure electrical impulses from your heart. An ECG can detect enlarged chambers of your heart and abnormal heart rhythms.

Treadmill stress test. Your heart rhythm, blood pressure and breathing are monitored while you walk on a treadmill. Your doctor may recommend a treadmill stress test to evaluate symptoms, determine your exercise capacity and determine if exercise provokes abnormal heart rhythms.

Treadmill stress tests are sometimes performed with echocardiography if you have symptoms of HCM, but a resting echocardiogram doesn't show obstructed blood flow. Treadmill stress tests are commonly used in people with hypertrophic cardiomyopathy.

Holter monitor. You may wear a portable ECG that records your heart's activity continuously over one to two days. This test is often done in people with hypertrophic cardiomyopathy.

Cardiac MRI. A cardiac MRI uses magnetic fields and radio waves to create images of your heart. Cardiac MRI is often used in addition to echocardiograms to evaluate people with hypertrophic cardiomyopathy.

Cardiac catheterization. In this procedure, a catheter is inserted into a blood vessel, usually in your neck or groin area. The catheter is then carefully threaded to your heart chambers under guidance of an X-ray machine.

In addition to measuring pressures in your heart, cardiac catheterization is used to obtain X-ray images (angiograms) of your heart and blood vessels. A dye is injected through the catheter to help visualize your heart and blood vessels. This test is rarely used to diagnose hypertrophic cardiomyopathy.

The options  of treatment include:

Medications. You may be given medications to relax the heart muscle and to slow the heart rate so that the heart can pump more efficiently. Your doctor may recommend beta blockers such as metoprolol (Lopressor, Toprol), propranolol (Inderal, Innopran) or atenolol (Tenormin), calcium channel blockers such as verapamil (Verelan, Calan, Covera) or diltiazem (Cardizem, Tiazac, Dilacor), or medications to control your heart rhythm such as amiodarone (Pacerone) or disopyramide (Norpace).

If you have atrial fibrillation, your doctor may prescribe blood thinners such as warfarin (Coumadin, Jantoven), dabigatran (Pradaxa), rivaroxaban (Xarelto) or apixaban (Eliquis) to reduce your risk of blood clots.

Septal myectomy. A septal myectomy is an open-heart procedure in which the surgeon removes part of the thickened, overgrown septum between the ventricles. Removing part of this overgrown muscle improves blood flow and reduces mitral regurgitation.

Surgeons may conduct this procedure using different approaches, depending on the location of the thickened heart muscle. In one type of septal myectomy called apical myectomy, surgeons remove thickened heart muscle from near the tip of the heart. Surgeons may sometimes perform mitral valve repair at the same time as a myectomy.

A septal myectomy may be recommended if medications don't relieve your symptoms. Most people who have a myectomy have no further symptoms. Septal myectomy is available only in medical centers that specialize in the treatment of hypertrophic cardiomyopathy.

Septal ablation. In septal ablation, a small portion of the thickened heart muscle is destroyed by injecting alcohol through a long, thin tube (catheter) into the artery supplying blood to that area. This procedure may improve your symptoms. Possible complications with this procedure include heart block — a disruption of the heart's electrical system — which requires implantation of a pacemaker.

Implantable cardioverter-defibrillator (ICD). Doctors may recommend an ICD if you have life-threatening heart rhythm disorders (arrhythmias) such as ventricular tachycardia or ventricular fibrillation. An ICD is a small device that continuously monitors your heartbeat. It's implanted in your chest like a pacemaker.

If a life-threatening arrhythmia occurs, the ICD delivers precisely calibrated electrical shocks to restore a normal heart rhythm. Your doctor may recommend an ICD if you have hypertrophic cardiomyopathy and you're at high risk of sudden cardiac death because of abnormal heart rhythms.

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