COURSE UNIT: MEDICAL SURGICAL NURSINGNAME: AKANKWATSA DICKSONREG. NO: 13/BSU/BNS/002LECTURER: MR. ASIIMWE JOHNBAPTISTDATE: 10/12/2015

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BISHOP STUART UNIVERSITY

FACULTY: APPLIED SCIENCESDEPARTMENT: NURSING SCIENCE

2A REFLECTIVE JOURNAL ON CONGESTIVE CARDIAC FAILURE.In this reflective journal, I want to elucidate what heart failure is, how it comes about, and its relationship with other vital organs especially the lungs to bring about total human morbidity. In Uganda and even the entire globe in general, heart failure has become rampant, cutting across people of all ages thus making it one of the leading cause of current morbidities and mortalities.

As the name suggests, heart failure means failure of the heart to execute its cardinal role in the humans general system, that is to say pumping of blood out of itself to the rest of the body parts. This blood may be oxygenated or not; depending on where it is going. Heart failure can either be compensated or decompensate and or right sided or left sided and the manifestations thus different depending on the affected side. But the common symptoms and signs start from where the blood is coming from to the heart. For example, a patient with R.H.F will present with generalized edema commonly the peripherals, easy fatigability, dyspnea, tender smooth hepatomegally, ascites, pleural transudates, increased jugular venous pressure and restlessness. And a patient with L.H.F will present with easy fatigability, exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, pulmonary edema and basilar lung crackles.3

4Heart failure comes about by a number of factors; some of which are predisposing for example age, diet, impending HTN, liver disease, kidney disease, smoking, sex, pregnancy and even the genetic component.

The hearts anatomical location in relation to the lungs endangers the heart secondary to lung infection. A case in point, this reflective journal is about a 21year old NYU Mukiga male; AE from Kambuga-Kanungu, who on 19th/ 4/2015 reported to Kisiizi Mission Hospital following horrific situations of chest tightness, exertional dyspnea, easy fatigability, tachypnea and intercostal tenderness for then 3/7 days. The plan was admission to high dependency unit (H.D.U) and on examination; he was febrile, not pale, not jaundiced, had signs of dehydration, no edema but was in distress, GCS-15/15. Significantly, chest percussion revealed generalized dullness. Vitals were (BP-160/100mmHg, PR-35r/m, PR-92b/m and T-38.10C).

5He was immediately started on oxygen therapy, morphine, IV X-PEN 2MU QDS *5/7, IV gentamicin 80mg OD* 5/7 and IV fluids [N/S], fluid balance chart started and was positioned in fowlers to allow total lung expansion and clearly open the air way. Mean while blood sample was collected for CBC; HB, LFTs and RFTs. Emergency chest x-ray was ordered for and results revealed infiltrations, and constrictive barrier above the parietal pleura of the right lung extending to the left lung and slight cardiomegally. Lab results showed (elevated WBC, slight neutrophilia, Hb 12.1g/dl, high creatinine and urea levels, normal ALT/ASP.

The impression of constrictive pleuritis secondary to infection, pleural effusion and hypertension secondary to renal damage was made. The plan was to start on losartan H, captopril and cardiac aspirin, and to continue with the antibiotics plus pleural taping.

6The nursing care given included; monitoring vitals timely, emptying the drainage bottle, collecting and taking samples to the lab, reassuring the patient about the condition and administering prescribed drugs.

On 23rd/4/15, Pleural taping was done; minimal volume of blood and pus drained and sample taken to lab for C & S. Patient kept on under water seal drainage for three more days.

On 27/4/15, patient reported some relief and drainage seemed to be complete, another chest x-ray was ordered for that revealed visible coating around the around the lungs. Vitals were BP-140/100mmHg, PR-85b/m, RR-30r/m, T-37.60C. Patient was reviewed by a team of Mos and surgeons and the new plan was to discuss the case with the caretaker and patient and arrange for elective surgery which was to be due to take place two days later. The mainstay aim of the surgery was decoartication of the lungs so as to free them of the constrictive pressure and allow maximum activity. The patient and caretaker agreed to undergo the planned care.

7On 29/4/15 at 1100hrs, nurses prepared patient, consented, gave prophylactic antibiotics (benzyl penicillin 2MG, IV metronidazole 400mg, and IV Ceftriaxone 2g), fluids N/S 1L and took him to theatre for an operation to do decoatication of the lungs. Aseptic measures taken and procedure was successfully done under general anesthesia and patient recovered well from anesthesia. During the procedure, the surgeon found out that the heart felt hard on touch and was slightly enlarged. Nurses monitored patient closely post operatively and stabilized well. Patient treated and later was discharged and was given an appointment of 12/5/15 to be reviewed by the surgeon and medical team. .When he reported on the due time, he was unwell and had developed grade 1 edema, palpitations and easy fatigability, reduced urine output. O/E was Afebrile, sick looking, pitting edema up to ankles, chest with mild basilar crepitations, dull towards left side, HS1+2 normal, and regular fast heart beat, tender abdomen laterally. {JACCOLD}0 O+, Vitals taken BP- 160/100mmHg, PR -102b/m, RR- 30r/m and T-36.50C.

8An impression of hypertension secondary to renal damage was made and the plan was to re-admit and to give antihypertensives; propranolol, Losartan H, thiazide diuretic as fluid input and output are monitored. Patient improved and on the 4th day discharged.The nursing care given included timely monitoring of the vitals, administering prescribed medication, monitored fluid I & O, gave d/c education on drug adherence.On 19/10/015, patient reported back with complaints of generalized body swelling and DIB *2/12. Swelling started mildly with the limbs, became persistent for 2/12 and worsened with tenderness to involve the whole body for a month. Reported that when swelling worsened, it became associated with hemoptysis and DIB that aggravates when sleeping in supine position. Reports myalgia, chest pain, palpitations, headache, tachycardia, reduced urine output and no paralysis or visual issues.O/E, sick looking, in distress, {JACOLD}0 O+++ C+, PEARL, Vitals BP-190/116mmHg, PR-99b/m, RR-29r/m, T-35.40C, SPO2-85%. Neck exam revealed mild lymphadenopathy, soft, weak and thread carotid pulse,

9normal JV pressure. Chest revealed tenderness and dullness all over, wide spread crepitations, HS 1+2+0, fast and irregular heartbeat, increased tactile fremitus. P/A revealed generalized swelling and tender abdomen with hepatomegally.The plan was to do CBC, LFTs, RFTs, Electrolytes and CXR. Meanwhile, an Impression of Decompensated cardiac failure was made. Patient was started on cardiac aspirin 75mg od, IV Frusemide 60mg stat, Bendrofruazide 12.5mg , Digoxin 0.5mg, Losartan H, Nifedipine retard 20mg bd.Laboratory results revealed lymphocytosis, neutropenia, thrombocytopenia, elevated creatinine and urea; slightly raised ALT. CXR showed coating around the whole heart and of normal size. An impression of constrictive pericarditis was made. Plan made; continue treatment and close monitoring of vitals, weight and start FBC.

10On 24/10/15 reported increased DIB, coughing, tachycardia and increased limb swelling. O/E, basal crackles, HS1+2+0, weak apical beat, tender right upper quadrant, tender pitting grade 4 edema of limbs. Vitals BP-130/110mmHg, PR-I56b/m, RR-31r/m, T-35.70C, SPO2-94%, weight increasing and UO still low despite the diuretics given. The plan was Bendrofruazide 25mg bd, captopril 12.5mg, Bisoprolol 5mg and continue other treatment.On 1/11/15, patient reported some improvement in the chest, reduction in weight but still tachycardic and with clearly visible generalized edema. A team of medical officers and surgeons was called to review the patient and to discuss about further management. Their conclusion was to talk matters with the

11N.O.K and the patient himself, whether to go for surgery and the surgeons do pericardectomy. Good enough, patient and N.O.K had thought of that and therefore Nurses did all it took to educate and reassure them about the condition and its prognosis and together came to consent. The nurses informed the surgeons about the decision and the plan was to arrange for the surgery on 3/11/15.On 3/11/015 at 900hrs, pre-operative arrangements done, patient consented for the procedure, Reverend called to pray for the patient and at 1103hrs, patient taken to theatre.Unfortunately, no sooner had the Surgeon opened the chest, than the patient packed.

12Lessons learnt as a future BSN NurseAs a future BSN nurse, I learnt several lessons that will enrich my carrier as a future nurse some of which include;Learnt pharmacologic and conservative management of stroke depending on what the cause and predisposing factors are.Learnt holistic patient care; spiritually, physically, and psychologically, because had it not been holistic management, patient would have died long time ago.Fully learnt and appreciated the role of a nurse in patient care and management and care taker involvement in patient care.Learnt the impact of delayed seeking of medical care on the prognosis of any disease, because had the patient sought care when signs and symptoms developed, prognosis was going to be good.Appreciated the impact of exercise on health as far as stroke and hypertension management are concerned.

13 Recommended Medical and Nursing management: The management of CCF consists of a multidisciplinary team of physicians, pharmacists, nurses, lab technicians and social workers. It starts with the critical assessment of hemodynamic parameters HB levels, electrolytes CBC. The treatment goals in this case areImproving symptoms of congestion and low cardiac outputRestore normal oxygenation To identify and address precipitating factors( like poor drug adherence excessive salt intake)Correcting anemia which is an exacerbating factorOptimizing volume status

14 From the history and examination the patient most probably confirmed by x-ray has chronic congestive cardiac failure following infection, in view of signs of hypo-perfusion like capillary refill ++, temperature above 37.50C, and signs of hypervolemia evidenced by edema. Therefore the management targets treatment of chronic CCF and the secondary infection. Pharmacological mgt - IV diuretics (high ceiling) like IV Frusemide 80mg bdIv inotrope like dobutamine ( owing to impaired renal function),Blood transfusion 3units q12h to correct anemiaHematenics fefo 200mg od 1/12 (to further stabilize Hb)Tabs captopril 12.5mg bd 1/52 (renal protective ACEI)IV Ceftriaxone 2g od 5/7 (due to risk for infection like pneumonia due to pulmonary edema)

15 Nursing care - indwelling catheter with a urine bag to monitor input and outputPsychotherapy (counseling to patient and attendants)Education on drug adherence, precipitating factors, and dietary adviceMonitor RFTs and blood transfusion reactionDaily weighing to monitor weight lossAssist in activities of daily livingAvoid use of NSAIDS, non dihydropyridine Ca2+ channel brokers and B-blockers

16 Impact of this scenario on me as a future BSN nurseThis impacted my life in a way that; I should always be confident enough to utter out my findings and suggestions regarding patient care to the rest of the medical team despite their professional status. Perhaps the patient would have had chance to see the next morning because of me. This was because according to my finding about patients vital signs and physical state, he was not legible for the operation.

17 As a ChristianMany people who know John 3:16 do not know 1John 3:16{ For God so loved the world, that he gave to us his only begotten son that whoever believes him will not perish but have an everlasting life; vs we should lay down our lives for our brothers as Jesus laid down his own life for us all.}. This emphasizes the spirit to love and serve.Matthew 11:28(come to me, all you who are weary and heavily burdened, and I will give you rest), my patient has no any option in life, but only to believe that God gives rest to his own people who have faith in him. This is because God knows those who are his (2Timothy 2:19).

18 Nursing theory used:Finally, relative to this case scenario I used Dorothea Orems self care deficit to manage this patient, because the patient could barely perform activities of daily living since he had worsening symptoms of dyspnea chest tightness and easy fatigability. Therefore with assistance of attendants and the health care team would collaboratively help the patient until he is able to perform these activities unaided. I also employed Betty Newmans theory of stress management because AE underwent several strange procedures for example, pleural taping, and decoatication despite his age that elicit psychosocial and physical stress. Therefore, AE needed clear ways of stress management to achieve better health.

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