Managing Acute Decompensated Heart Failure and Infected Wound

This article discusses the management of acute decompensated heart failure and an infected wound in a patient. It explores the collaborative and independent nursing interventions, including patient monitoring, medication administration, wound dressing, and psychological support. The article emphasizes the importance of nurses in providing comprehensive care and improving patient outcomes.

Introduction:
Reggie Simpson is a 42-year-old male, with a history of rheumatic heart disease since
childhood resulting in compensated heart failure presented for management of an acute
decompensation of heart failure. He complains of pain on inspiration and a persistent wound
on his hand. He also has a history of weight gain of 10- 15 Kg, in the past couple of months.
On examination, the patient appeared fatigued and had a slightly elevated respiratory rate of
28 breaths per minute, had ascites, bilateral pitting oedema up to knees and coarse
crepitations on auscultation. His systolic blood pressure is high with a value of 184 mm Hg.
The wound on his hand appears infected on examination. He is under treatment with
frusemide and metoprolol. He was admitted in CCU for management.
Reggie has to be managed for acute decompensated heart failure. He also has an
infected wound on his hand which is quite bothersome and needs to be managed. The two
priority problems in this patient are management of the pulmonary oedema and the infected
wound on this hand. The collaborative nursing care in the first priority problem is patient
monitoring, and dispensing the medicines. The independent nursing intervention includes
physical and psychological care. For the second priority problem, collaborative nursing role
is dispensing the antibiotics as per the doctor’s orders and independent nursing role is
dressing of the wound following wound debridement by the doctor.
Priority problem 1:
Reggie is a known case of rheumatic heart disease, which has progressed to acute
decompensated heart failure. He has a history of tonsillectomy in the childhood which
suggests that he probably was infected with streptococcal bacteria in the throat which resulted
in development of rheumatic fever. Chronic inflammation of the heart can progress to heart
failure which can cause inadequate ventricular filling and ejection of blood (Harris, Croce &
Cao, 2015; Inamdar & Inamdar, 2016). His respiratory rate is slightly increased and he also
has pain on inspiration. There is an increase in body weight and bilateral pitting peripheral
oedema which suggests that he has developed pulmonary oedema which is a complication of
heart failure (Harjola et al., 2017).
The first priority problem for this patient is managing the pulmonary oedema which
could be fatal if not treated immediately. The collaborative nursing care in such cases
includes patient monitoring, and dispensing the medicines. The role of a nurse is regular
checking of oxygen level (SPO2) of the patient (Wang, 2015). Nurses play a vital role in
oxygen administration to patients with heart failure. Supplemental oxygen is recommended in
patients with heart failure to prevent hypoxemia (Sepehrvand, 2016). The position of the
patient is also vital in pulmonary oedema and a nurse is responsible for positioning of the
patient (Stacy, 2017). The nurse also has an important role in dispensing the medications as
per the doctor’s orders. The infusion speed of the medications needs to be controlled by the
nurse to avoid cardiac overload. The infusion speed should not be too fast or with too much
fluid. Nurses also assist the doctor in further management of a patient with pulmonary
oedema by providing statistics of the patient regularly during the course of treatment (Wang,

2015) (Roger, 2015) (Fihn, Blankenship, Alexander et al. 2014). The pharmacological agents
used for the treatment of heart failure include diuretics, Angiotensin-converting enzyme
inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), Beta-adrenergic blockers,
Aldosterone antagonists, Digoxin and Inotropic agents (Inamdar & Inamdar, 2016). Thus, the
collaborative nursing care for the heart failure will help to resolve Reggie’s hypoxia and
breathlessness.
The rationale behind the collaborative nursing management in such cases is that
regular monitoring of the patient provides the required data for the doctor to prescribe the
correct dose of the medicines and to decide additional investigations if required. It is
recommended that oxygen administration should be done by a well- trained registered nurse
for efficient patient management (O’Driscoll, 2008). The vital signs of the patient are closely
monitored by a nurse. Signs of hypoxia on the central nervous system such as coma, pupil
dilatation needs to be checked by the nurse and alarming signs should be brought to the
doctor’s notice for further management. (Wang, 2015). The aim of patient positioning is to
facilitate ventilation (Stacy, 2017). Beta blockers help in slowing the progression of the
disease. They are used particularly in patients with decompensation of heart failure and are
known to reduce the mortality risk (Krum & Driscoll, 2013; Yancy CW, Jessup M, Bozkurt
B, et al., 2017). Diuretics are used as background therapy for patients with heart failure.
Therefore, the patient was treated with frusemide 20mg twice daily. Nurses play a very
important role in patient care and efficient nursing care has a positive impact on patient
outcome (Kieft, Brouwer, Francke & Delnoij, 2014). Thus, this nursing intervention on the
basis of the medical knowledge and clinical judgement aims to improve patient outcome in
this patient with decompensated heart failure (Jung, Yoo, Lee & Chung, 2015; Pfrimmer et
al., 2017).
The independent nursing intervention includes physical and psychological care.
Psychological support helps to fasten the recovery patients with pulmonary oedema (Wang,
2015) (Araújo, Nobrega & Garcia, 2013). In this case, Reggie was anxious about his family.
This added to the mental stress on his already stressed physical condition. Therefore,
providing psychological support constitutes independent nursing intervention in this patient.
It will help in rapid amelioration of the symptoms (Wang, 2015) (Araújo, Nobrega & Garcia,
2013). Nurses also play an important role in patient education. The patient should be
educated about the amount of sodium consumption in diet. Sodium should be restricted to 2-3
gm per day (Inamdar & Inamdar, 2016). Fluid restriction of less than 2 litres per day is
required for Reggie. He should be advised about compliance with medical treatment and
interventions. Also, alarming signs such as shortness of breath, excessive fatigue and oedema
should be explained to him (Inamdar & Inamdar, 2016). The second independent nursing
intervention includes physical care such as keeping the patient warm, meal feeding and
cleaning. This intervention will help to relieve the mental stress which in turn will lead to
faster recovery of the patient Wang, 2015; Araújo, Nobrega & Garcia, 2013).
In this patient with heart failure, the nurse is the primary healthcare provider to
educate the patient about the pathophysiology, diagnosis and management strategies of heart
failure. Such physical care by nurses helps in psychological support to the patient (Wang,
2015; Araújo, Nobrega & Garcia, 2013). This intervention plays a vital role in the
management of this patient to hasten the recovery with amelioration of his symptoms.

The evaluation of outcome of collaborative and direct nursing intervention for this
management would be improvement in oxygen saturation, relief from dyspnoea and
resolution of pedal oedema and ascites (Wang, 2015; Stacy, 2017; O’Driscoll, 2008). The
blood pressure and respiratory rate will return back to normal. All the biochemical parameters
will show normal results. The direct nursing intervention in this case will result in reduction
of stress in the patient due to psychological support and care (Vann et al., 2015). This will in
turn help in early resolution of the physical symptoms. The direct nursing intervention in the
form of patient education will have an impact even after the patient is discharged from the
hospital and will have long term positive effect (Wang, 2015; Araújo, Nobrega & Garcia,
2013).
Priority problem 2:
The second priority issue in Reggie is the wound on the hand. Pain is a very common
manifestation in the presence of chronic wounds. Such chronic and unrelenting pain can be
very uncomfortable for the patient, as it can have a significant negative impact on the
patient’s day to day life including physical activity, social life. Therefore, comprehensive
wound management plays crucial role in patient management to relieve the pain associated
with the wound and thereby improve the psychological status and quality of life of the patient
(Woo, Abbott, Librach, 2013).
The wound should be carefully inspected to notice the signs of infection which
include erythema, colour, oedema, malodour, and purulent drainage with enlargement of the
draining lymph nodes. The nursing role in this condition is collaborative for dispensing the
antibiotics as per the doctor’s orders (Nicolosi & Botek, 2015). Augmentin DUO was
prescribed the doctor, and dispensing this medicine was the collaborative nursing
intervention. Augmentin DUO is composed of amoxicillin and clavulanic acid. Amoxicillin is
an antibiotic and clavulanic acid contains beta lactamase which enhances the antimicrobial
spectrum of the tablets. The dose prescribed was amoxicillin 875 mg and calvulanic acid 125
mg given twice a day orally for 5 days (MIMS, 2019). The outcome of this intervention will
be resolution of the wound and thereby pain relief.
The adverse reactions with this antibiotic can be nausea, vomiting, diarrhoea, and skin
rashes. It is contraindicated in patients with hypersensitivity to penicillin (MIMS,
2019).Therefore, the role of a nurse in this patient is to rule out contraindications before
dispensing the medicine and also to watch for the presence of side effects (Zarchi, Haugaard,
Hjalager & Jemec, 2014). Nurses are the main healthcare providers to deal with management
of wound. Therefore, it vital for nurses to have sound knowledge regarding diagnosis and
treatment of wound for effective wound management (Gillespie, Chaboyer, Allen, Morely &
Nieuwenhoven, 2013). Nurses are expected to inspect, diagnose and treat wounds. A multi-
disciplinary approach for wound management is recommended with collaboration of doctor
and nurses. Nurses not only carry out doctor’s orders for wound management but also
provide critical observations which help in deciding further course of treatment (Zarchi,
Haugaard, Hjalager & Jemec, 2014). Thus, appropriate antibiotic treatment will heal the
wound of the patient.

The independent nursing role is dressing of the wound following wound debridement
by the doctor and to inspect the wound bed, size, degree of infection. Appropriate wound
management includes, cleansing, surgical debridement, and antimicrobial dressings (Nicolosi
& Botek, 2015). The independent role of a nurse is to perform wound dressing in an aseptic
manner which includes a no- touch technique to promote healing with minimal risk of
infection. This aseptic procedure prevents micro- organisms present on hands, surfaces and
equipments to spread and contaminate the wound. Therefore, following aseptic precautions
are the mainstay of wound management. Another technique for wound care is wound field
concept. This is also known as the ‘clean’ technique. The principle behind this technique is
that exogenous source of infection can cause further contamination of the wound and
therefore it is important to practice evidence based clinical wound care for effective
management of wound (Vowden & Vowden, 2017). Antimicrobial dressings are used for
eradication of the infective micro-organisms. The antimicrobial dressing currently available
include agents containing iodine such as cadexomer iodine and povidone iodine or agents
containing silver such as silver sulfadiazine and ionic silver-impregnated dressings.
Antiseptic agents such as polyhexamine are also used as antimicrobial dressings for infected
wounds. Honey is also recommended to be used since it has antimicrobial properties, and is a
debriding agent with odour controlling effect (Vowden & Vowden, 2017). Topical agents
such as slow- release ibuprofen foam dressings are very useful to alleviate pain associated
with chronic and persistent wounds. Several other topical agents such as morphine, non
steroidal anti- inflammatory drugs, ketamine, lidocaine, prilocaine, capsaicin, tricyclic anti-
depressants such as amitriptyline have been demonstrated to exert pain relieving effect in
chronic wounds (Woo et al., 2013). This intervention will help in faster recovery of Reggie’s
wound.
The advantage of topical agents is that the drug is directly inserted into the wound and
have a crucial role for temporary pain suppression on dressing removal during change of
dressings. (Woo et al., 2013). Wound cleansing with 0.9% saline solution is done by nurses
(Oliveira, Oliveira, Santana, Silva et al, 2016). Debridement of the non-viable tissue to
remove the infected tissue and reduce the bacterial growth can be achieved by surgical,
mechanical, chemical, or ultrasonic methods (Nicolosi & Botek, 2015; Aalaa, Malazy,
Sanjari, Peimani & Tehrani, 2012). The dressings should be able to achieve maximum
exposure of the tissue infected with bacteria to the antimicrobial agent. The aim of wound
dressing is absorption of exudates, reduction of pain and protection of the newly formed
healing tissue (Nicolosi & Botek, 2015; Aalaa, Malazy, Sanjari, Peimani & Tehrani, 2012).
Infected wounds with bacterial load can be a barrier to wound healing and such cases require
antimicrobial dressing for short periods of time up to 2 weeks (Vowden & Vowden, 2017). It
is vital for a nurse to have adequate knowledge about wound dressing and management
(Gillespie et al., 2013). Thus, the direct nursing intervention in this case is to perform wound
dressing using adequate aseptic precautions to hasten the wound recovery.
The nurse is the primary caregiver to educate the patient regarding the degree of
wound infection and the outcome of the management. The evaluation criteria to measure the
outcome of the nursing intervention would be the wound healing with secondary intention
(when the wound margins are not approximated and clear). The infection of the wound
should subside which will be measured by the absence of exudation. The wound bed and

margins should show signs of healing and there should be absence of pain. The healing of the
wound would indicate successful nursing intervention both collaborative and direct
management (Oliveira, Oliveira, Santana, Silva et al, 2016).
Conclusion:
Reggie had a history of rheumatic fever following streptococcal throat infection in
childhood which had developed a complication of heart failure with pulmonary oedema and
he presented for management of acute decompensation of heart failure. He was very anxious
about his health condition and his family which was away and was bothered by a wound on
his hand which was diagnosed to be infected. The priority for his management was treatment
of his acute decompensation of heart failure in which the collaborative nursing intervention
was regular monitoring of the vitals, oxygen saturation and overall monitoring of the patient’s
condition and dispensing the medication dosage as prescribed by the doctor. The direct
intervention of the nurse for this problem was providing patient education and physical as
well as psychological support to the patient. The second priority problem was management of
the infected wound. The collaborative nursing intervention for this problem was to assist the
doctor for performing wound debridement and to dispense medications as per the doctor’s
advice. The direct nursing intervention was wound dressing and regular monitoring of the
wound to diagnose whether the infected wound was healing or if the infection was
progressing further. Thus, in this patient the nurse has a critical role by direct and
collaborative nursing intervention for appropriate management with a positive outcome of the
treatment protocol.

References:
Aalaa, M., Malazy, O.T., Sanjari, M., Peimani, M. & Tehrani, M.R. (2012) Nurses’ role in
diabetic foot prevention and care; a review. Journal of Diabetes & Metabolic Disorders,
11,pp.24. doi: 10.1186/2251-6581-11-24
De Araújo, A., Da Nóbrega, M., & Garcia, T. (2013). Nursing diagnoses and interventions
for patients with congestive heart failure using the ICNP. Revista Da Escola de
Enfermagem, 47(2), pp.380–387. https://doi.org/10.1590/S0080-62342013000200015
Araújo, A.A., Nobrega, M.M., Garcia, T.R. (2013) Diagnoses and nursing interventions for
patients with congestive heart failure using CIPE. Revista Da Escola de Enfermagem USP,
São Paulo, 47(2), pp.385-392.
Fihn, S.D., Blankenship, J.C., Alexander, K.P. et al. (2014)
ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and
Management of Patients with Stable Ischemic Heart Disease. A Report of the American
College of Cardiology/American Heart Association Task Force on Practice Guidelines, and
the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses
Association, Society for Cardiovascular Angiography and Interventions, and Society of
Thoracic Surgeons. Journal of the American College of Cardiology, 64(18) 1929-
1949; doi: 10.1016/j.jacc.2014.07.017
Gillespie, B. M., Chaboyer, W., Allen, P., Morely, N., & Nieuwenhoven, P. (2013). Wound
care practices: a survey of acute care nurses. Journal of Clinical Nursing, 23(17-18), pp.
2618–2627. Doi: 10.1111/jocn.12479
Kieft, R. A. M. M., de Brouwer, B.B.J.M., Francke, A. L., & Delnoij, D. M. J. (2014). How
nurses and their work environment affect patient experiences of the quality of care: A
qualitative study. BMC Health Services Research, 14, 249.
doi: http://dx.doi.org.ezp01.library.qut.edu.au/10.1186/1472-6963-14-249
Harjola. et al. (2017) Organ dysfunction, injury and failure in acute heart failure: from
pathophysiology to diagnosis and management. A review on behalf of the Acute Heart
Failure Committee of the Heart Failure Association (HFA) of the European Society of
Cardiology (ESC). European Journal of Heart Failure, 19(7), pp.821–836.
https://doi.org/10.1002/ejhf.872
Harris, C., Croce, B., & Cao, C. (2015) Rheumatic heart disease. Annals of Cardiothoracic
Surgery, 4(5), pp.492. https://doi.org/ 10.3978/j.issn.2225-319X.2015.09.05.

Inamdar, A.A. & Inamdar, A.C. (2016) Heart Failure: Diagnosis, Management and
Utilization. Journal of Clinical Medicine, 5(7), pp.62. doi: 10.3390/jcm5070062
Jung, H., Yoo, H., Lee, Y., & Chung, K.Y. (2015). Interactive pain nursing intervention
system for smart health service. Multimedia Tools and Applications, 74(7), pp.2449-2466.
doi: 10.1007/s11042-014-1923-4
Krum, H., Driscoll, A. (2013) Management of heart failure. Medical Journal of Australia,
199 (5), pp. 334-339. doi: 10.5694/mja12.10993
MIMS website. (2019). Amoxicillin + clavulanic acid. Retrieved from
https://www.mims.com/india/drug/info/amoxicillin%20%2b%20clavulanic%20acid/
Nicolosi, N., Botek, G. (2015) The Basics of Wound Care. American college of cardiology, 1,
pp.11. Retrieved from https://www.acc.org/latest-in-cardiology/articles/2015/11/24/15/14/
the-basics-of-wound-care
O’Driscoll, B.R., Howard, L.S., Davison, A.G. (2008). BTS guideline for emergency oxygen
use in adult patients. Thorax, 63 (S6): 1-68. doi:10.1136/thx.2008.102947.
Oliveira, F., Oliveira, B., Santana, R., Silva, B., & Candido, J. (2016) Nursing interventions
and outcomes classifications in patients with wounds: cross-mapping. Revista Gaucha de
Enfermagem, 37(2), pp. e55033.Doi: 10.1590/1983-1447.2016.02.55033
Pfrimmer, D.M., Johnson, M.R., Guthmiller, M.L., Lehman, J.L., Emste, V.K., & Rhudy,
L.M. (2017). Surveillance: A nursing intervention for improving patient safety in critical care
environment. Dimensions of Critical Care Nursing, 36(1), pp.45-52. doi:
10.1097/DCC.0000000000000217
Rogers, C., & Bush, N., (2015) Heart failure: Pathophysiology, Diagnosis, Medical
Treatment Guidelines, and Nursing Management. Nursing clinics of North America, 50(4),
pp.787-799. doi: 10.1016/j.cnur.2015.07.012.
Sepehrvand, N., Ezekowitz, J.A. (2016). Oxygen Therapy in patients with acute heart failure:
Friend or Foe. JACC Heart Fail., 4(10), 783-790. doi:10.1016/jchf.2016.03.026.
Stacy, K.M. (2017) Pulmonary disorders. In: Urden, L.D., Stacy, K.M., Lough, M.E.
(Eds.), Critical Care Nursing - E-Book: Diagnosis and Management (8th ed.). Elsevier. USA.
Vann, J., Hawley, J., Wegner, S., Falk, R. J., Harward, D. H., & Kshirsagar, A. V. (2015).
Nursing intervention aimed at improving self-management for persons with chronic kidney
disease in north carolina medicaid: A pilot project. Nephrology Nursing Journal, 42(3),
pp.239-256.
Retrieved from https://gateway.library.qut.edu.au/login?url=https://search-proquest-
com.ezp01.library.qut.edu.au/docview/1703856134?accountid=13380
Vowden, K., & Vowden, P. (2017). Wound dressings: principles and practice. Surgery
(Oxford), 35(9), pp.489–494. doi: 10.1016/j.mpsur.2017.06.005

Wang, X. (2015). Analysis of Systematic Nursing Intervention on High-altitude Pulmonary
Edema. Journal of Nursing, 4(3), pp.7-9. doi:10.18686/jn. v4i3.3
Woo, K.Y., Abbott, L.K., & Librach, L. (2013). Evidence based approach to manage
persistent wound- related pain. Current Opinion in Supportive and Palliative Care, 7(1),
pp.86-94.doi:10.1097/SPC.0b013e32835d7ed2.
Yancy, C.W., Jessup, M., Bozkurt, B., et al. (2017) ACC/AHA/HFSA Focused Update of the
2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American
College of Cardiology/American Heart Association Task Force on Clinical Practice
Guidelines and the Heart Failure Society of America. Circulation, 136(6), pp. e137- e161.
https://doi.org/10.1161/CIR.0000000000000509
Zarchi, K., Latif, S., Haugaard, V., Hjalager, I., & Jemec, G. (2014). Significant Differences
in Nurses’ Knowledge of Basic Wound Management – Implications for Treatment. Acta
Dermato Venereologica, 94(4), pp.403–407. doi: 10.2340/00015555-1770.