Managing Acute Decompensated Heart Failure and Infected Wound

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.