Objectives of case study 1. To collect data related to the etiology and predisposing factors causing diseases. 2. To identify the manifestations of medical/surgical conditions from the underlying patho physiological changes. 3. To correlate the principles of physical, biological and behavioral sciences in application of nursing process in care of the patients with specific conditions regarding Medical/Surgical treatment. 4. To conduct health educations for individuals and groups. 5. To provide comprehensive nursing care according to the need of the patient. 6. To assist individual in different diagnostic investigations. . Controls the infection by applying recommended Infective prevention measures. HISTORY TAKING Demographic Data Name: Nutan Govinda Joshi Age: 82 years. Sex: Male Marital Status: Married. Religion: Hindu. Education: Literate (Bachelor in Pharmacology) Occupation: Retired Address: Jhamsikhel Ward:CCU Bed no: 10 Hospital No. :51974 Diagnosis: Complete heart block with hypertension with type 2 DM Date of admission: 2069/09/02 Date of discharge: 2069/09/11 Unit:1 ‘A’ Dr. Murari Dungana and Dr. Pranita Dhakal. Chief complaints At the time of admission: * Generalized weakness since 3pm * Altered sensorium since 5pm
At the time of assessment: * Pain at pacemaker implanted site History of Present illness: According to the patient, he was in his usual state of health then he suddenly developed generalized body weakness since today 3pm associated with two episodes of vomiting. Patient also gave history of altered sensorium for few minutes. ECG done at Kathmandu Hospital show Complete Heart Block at rate of 42 bpm for which he received 4ml of atropine and isoprenaline was started. Patient referred here for TPI. No history of loss of consciousness, SOB, palpitation, chest pain, burning micturation, constipation and passage of loose stool.
History of past illness: * Known case of Hypertension and type 2 DM and under medication. Personal History: No history of any drugs or food allergy. He is non-vegetarian and he used smoke in past about 2-3 sticks/day since 16 years and he left smoking 35 years back. He is non-alcoholic. Bowel : Has not passed stool since 2 days Appetite: Normal Sleep : Decreased Urine : Normal Socio-economic status: * Income source: Pharmacy and Son * Road and electricity facilities : Present * Drinking water : boiled water * Excreta disposal: Toilet * Health facilities : Nearby hospital: Kathmandu Hospital * Waste disposal : Manure 9yrs Family tree67 yrs 83 yrs 78 yrs 80 yrs 76 yrs 80 years 82 yrs 5 Male: Female: Patient: Marriage 49 yrs 42 yrs 55 yrs 62 yrs 37 yrs 61 yrs 58yrs 56 yrs 60yrs His father had history hypertension. Died at 67 yrs age due to some cardiac problems. Mother had suffered from hemiparalysis for about 6 years and later died at 79 yrs. PHYSICAL EXAMINATION: On date:2069/09/03 His general condition is weak. He is well oriented to time, place and person. General appearance: Looks ill. Level of consciousness: Conscious. Cleanliness: Maintained. Gait : Balanced Weight : 50 kg. VITALS: * Temperature: 98 F Pulse: 88 beats per min * Respiration: 20/min * Blood Pressure: 90/70 mmHg * PILCCOD: nil HEAD TO TOE EXAMINATION: * Head and face Hair: whitish and short with no dandruff present No any scars and injuries. Face : wrinkled face and looks tiered. * Eyes Pupil: React to light Vision: Decreased. Opacity of lens: Transparent. Blurred vision: Not present Anemia: Not present Jaundice: Not present * Ears Normal shape and size, and No any discharge. Condition of mastoid area: No any sign of Inflammation External ear canal: Normal * Nose Normal shape and size, and no any bleeding.
Nasal deviation absent. * Mouth, Throat and Neck Lips: Pink, no cracks Gums: Normal Tonsils: Not enlarged. Palate: Normal Uvula: Normal. Thyroid: Not enlarged and palpable. * Chest and Lung Inspection Shape : Normal Movement of chest: Moving equal during respiration Palpation : Non tender Percussion : Resonant sound felt on Percussion. Auscultation Breath sound: Normal Vesicular Breathing Sound Bilateral Equal Air Entry No wheezing or crept. Respiration: Normal 20/minute. * Cardiovascular System Chest pain: complains of pain at incision site on movement Pulse : 88/minute
Blood pressure: 110/70 mm of Hg Incision on left side of the chest made for Permanent Pacemaker implantation. Auscultation Heart sound: Normal (lub and dup) Murmur: absent. * Gastro-intestinal system Bowel habit: has not passed stool since 3 days Vomiting: Absent Loss of appetite: Absent Palpation Liver: Not palpable. Spleen: Not palpable. Kidney: Not palpable. Any abnormal masses: No. Auscultation for bowel sound: 3-4 times per minute. Tenderness : Absent * Genito Urinary System No any abdominal pain present Pain on micturation: No Blood in urine: No Color of urine: Light yellow. (Straw) Patient was on indwelling catheter
No any signs of UTI seen (fever, lower abdomen pain, foul smelling urine, frequency in urination etc) * Musculoskeletal system Normal body posture. No any deformity * Nervous System Convulsion: No. Level of conscious: Conscious. Gait balance: Well balanced. Orientation : Oriented to time, place and person. Speech problem : No. Problem of rest and sleep : not present. Findings of physical examination * Looks ill. * Has not passed stool since 3-4 days * On the left side of his chest there was a surgical incision done for the permanent pacemaker implantation.
Patient complains of pain on movement. * Patient on indwelling urinary catheter. ANATOMY AND PHYSIOLOGY OF CONDUCTIVITY OF HEART: The SA node is situated at the junction of the superior venacava and RA. It comprises specialized atrial cells that depolarize at rate influenced by the automatic nervous system and by circulating catecholamine. During normal (sinus) rhythm, this depolarization wave propagates through both atria via sheets of atrial myocytes. The annulus fibrosus forms a conduction barrier between atria and ventricles, and the only pathway through it is AV node.
This is midline structure extending from right side of inter atrial septum, penetrating the annulus fibrosus anteriorly. The AV node conducts relatively slowly, producing a necessary time delay between atrial and ventricular contraction. The His-Purkinje system is comprised of the bundle of His extending from AV node into interventricular septum, the right and left bundle branches passing along the ventricular septum and into the respective ventricles, the anterior and posterior fascicles of left bundle branch, and the smaller Purkinje fibers that ramify through ventricular myocardium.
The tissues of His-Purkinje system conduct very rapidly and allow near simultaneous depolarization of entire ventricular myocardium. The heart rate is determined by the myocardial cells with the fastest inherent firing rate, under normal circumstances, the SA node has highest inherent rate (60-100impulses per minute), the AV node has second highest inherent rate (40-60 impulses per minute, and the ventricular pacemaker sites have the lowest inherent rate (30-40 impulses per minute). If SA node malfunctions, AV node generally takes over the pacemaker function of the heart at its inherently lower rate.
If both the SA node and AV node fail in their pacemaker function, the pacemaker site in ventricle will fire its inherent rate at 30-40 impulses per minute. DESCRIPTION OF DISEASE – COMPLETE HEART BLOCK * It is the medical condition in which the impulse generated in the SA node in the atrium does not propagate to the ventricles. * When AV conduction fails completely, the atria and ventricles beat independently. Ventricular activity is maintained by an escape rhythm arising in the AV node or bundle of His (narrow QRS complexes) or distal purkinje tissues (broad QRS complexes). Distal escape rhythms tend to be slower and less reliable. Complete heart block produces a slow (25-50/min), regular pulse that, except in the case of congenital complete heart block, does not vary with exercise. There is usually compensatory increase in stroke volume with a large volume pulse and systolic flow murmurs. * Rate: atrial rate is measured independently of the ventricular rate, usually normal but the ventricular rate is usually very slow. * Rhythm: each independent rhythm will be regular, but they will bear no relationship to each other * P wave: present but no consistent relationship with the QRS * PR interval: not really measurable QRS complex: depends on the escape mechanism (ie, AV nodal will have normal QRS, ventricular will be wide and the rate will be slower) * T wave: normally conducted Aetiology of complete heart block * Congenital * Acquired * Idiopathic fibrosis * Myocardial infarction/ischemia * Inflammation * Acute (e. g. aortic root abscess in infective endocarditis) * Chronic (e. g. sarcoidosis, chagas disease) * Trauma (e. g. cardiac surgery) * Drugs (e. g. digoxin, Beta blockers) Clinical features In book | In my patient | Bradycardia | Present (43 beats per minute) | Hypotension | Present (90/70 mm of Hg)|
Hemodynamic instability | Present (semi-conscious, dizziness, altered body sensorium)| Fatigue | Present | Shortness of breath | Present | Exercising may be difficult | Present | Test and diagnosis In book | In my patient | Remarks | ECG | Done | Heart rate= 43bpm, Complete heart block| Complete blood count | Done | WBC elevated | Echo | Done | Mild MR and mild TR| Electrolytes | Done | Electrolyte imbalances present. Sodium level decreased. And others; urea, creatinine, RBS elevated. | Cardiac enzymes| Not done| —| Chest x ray | Done | Normal |
Types: 1) Temporary pacemaker 2) Permanent pacemaker Temporary pacemaker This is an artificial device used to stimulate or pace the heart for short term treatment. The pulse generator containing the circuit and batteries is located outside the body and the pacemaker lead is fixed in right ventricle Purpose: * To initiate and maintain the heart rate when the natural pacemaker of heart is unable to do so. * To prevent circulatory failure * To slow rapid arrythmia not responding to drugs or cardioversion Indication: * Complete heart block * Symptomatic sick sinus syndrome Anterior or inferior wall infarction with second or high AV block * Tri fascicular block * Post cardiac surgery * Prior to permanent pacemaker generator change Complications: * Infection and phlebitis * Cardiac temponade * Pulmonary embolism/pneumothorax * Battery failure * Lead dislodgement * Diaphragmatic stimulation * Venous thrombosis Medical and nursing management (TPI) Before: patient preparation * Explain the procedure and type of pacemaker to the patient. * Obtain written consent from the patient and patient party * Clean and shave the area (both groin) Check the vital signs * Mental support * Maintain the room temperature at 24 to 26 deg centigrade * Check serology: HIV, HbsAg, HCV and others * Start an IV line with 5% dextrose solution or normal saline solution * Prepare isoprenaline drip * Check battery in pulse generator * Prepare the emergency cart, the defibrilator and ECG monitor * Set up all the equipment for insertion of pacemaker * The nurse should know about the pacemaker generator including the power switch, indicator light for pacing and sensing, stimulus output dial, sensitivity dial, and their proper setting.
During the procedure * Assist the doctor and scrub nurse during procedure step by step * Scrub hands thoroughly and put on sterile gloves aseptically * Assist during the insertion of temporary pacemaker lead * Observe vital signs and observe ECG monitor carefully for arrythmias and other complications * The pacemaker lead can be inserted through the femoral, sub clavian or internal jugular vein and fixed into the right ventricular apex. The lead and generator should be connected and fixed properly to avoid pacing failure. * Record the pacing parameters
After the procedure * Observe the patient and check vital signs. Continue ECG monitor for arrythmias, pacing function for at least 24 hours * Watch for the symptoms of nausea, palpitation, rigor and pain for next 3-4 hours. Asses the pacing parameters, battery, wire connection and take a 12 lead ECG. * Confirm inserted position of wire, rate and output. * Use elastoplast to immobilize hands and legs of the pacemaker implant site. Then allow gradual mobilization after 48 hours with sterile dressings. * Assist the technician to take chest X ray Cover the dial of pacemaker to prevent accidental disconnection * Record and report about the patient’s condition. Permanent pacemaker * An artificial device used to stimulate the heart for long term treatment. The pulse generator is permanently implanted in the body. It is most commonly used in patient with complete heart block. Purpose: * To initiate and maintain the heart rate when natural pacemaker of the heart is unable to do so * To prevent circulatory failure Indication: * Complete heart block * Symptomatic sick sinus syndrome * Tri fascicular block * Symptomatic Mobitz II AV block
Complications: As in temporary pacemaker In addition: Pneumothorax/ hemothorax Pacemaker pocket infection Pacemaker syndrome APPLICATION OF NURSING THEORY VIRGINIA HENDERSON’S INDEPENDENT THEORY OF NURSING According to Henderson, “The unique function of nurse is to assist the individual sick or well in the performance of those activities contributing to health or its recovery (or to peaceful death) that he/she would perform unaided if he/she had the necessary strength, will or knowledge and to do so in such a way as to help him/her gain independence as rapidly as possible. ”-1996.
Since my client was admitted in the CCU with the diagnosis “Complete Heart Block with known case of hypertension and type2 DM’, there were various changes and problems which were diagnosed on the basis of Henderson’s Unique Function of Nurses. Henderson conceptualized the nurse role as assisting sick or well and gain independence in meeting 14 fundamental needs. Essential Components| Findings in my patient| Breathe normally. | Shortness of breathing and wheezing present (pneumothorax) present. Oxygen at 4lt/min through facemask. | Eat and drink adequately| Appetite was normal. |
Move and maintain desirable posture. | Assisted to move and maintain desire posture with support. | Eliminate body wastes| On indwelling urinary catheter later removed and self voiding. No bowel since 3-4 days, passed stool on enema. | Sleep and rest. | Rest and sleep normal, but some difficulty and discomfort due to pain on left chest tube site. | Select suitable clothes-dress and undress. | Able to select suitable clothes-dress and undress. | Maintain body temperature within normal range by adjusting clothing and modifying the environment| Able to maintain body temperature within normal range. Keep the body clean and well groomed and protect the integument. | Patient’s body was clean and well groomed. | Avoid dangers in the environment and avoid injuring others. | Able to avoid dangers. | Communicate with others in expressing emotions, needs, fears or opinions. | Was expressive and cheerful. | Worship according to one’s faith. | Patient worships according to her belief. | Work in such a way that there is a sense of accomplishment. | he works with a sense of accomplishment. | Play or participate in various forms of recreation. he participates in various forms of recreational activities. | Learning, discovering or satisfying the curiosity that leads to normal development of health using available health facilities. | Try to use available health facilities. | ASSESSMENT Patient was assessed from the 2nd day of admission until day of discharge and continuous nursing care was provided as per the need identified according to Henderson’s Independent theory. FINDINGS Patient problems were: * Restricted left hand movement S/P PPI. * Patient on indwelling urinary catheter. Patient has not passed stool since 3-4 days. * Ineffective breathing pattern; Pneumothorax (left side) PRIORIOTIZED NURSING DIAGNOSIS * Acute pain and discomfort related to chest tube insertion and pleural effusion. * Ineffective breathing pattern related to pain at left sided pleural effusion. * Activity intolerance related to status post Permanent pacemaker implantation with restriction of left hand movement * Constipation related to impaired physical mobility and change in daily routines. * Risk for infection (UTI) related to indwelling urinary catheter. Risk for infection related to surgical incision for pacemaker implantation. Date| Day| C/O| Vital signs| O/E| S/E| I/O| Plan| 09/02| DOA with diagnosis of Complete heart block with known case of type 2 diabetes mellitus & hypertension. S/P Temporary pacemaker implantation at 9:00 pm. | Generalized weakness since 5-6 hoursAltered sensorium since 3-4 hours. | T| P| R| BP| GC| PILCyCOD| RS: B/L NVBS and no added sound| Urine nil. Informed to Dr. so Inj. lasix 20 mg stat at 7am . | Monitor vital signs 2 hourly. Watch for arrythmias. Patient to be kept in NPO from 6am tomorrow.
Plan for PPI tomorrow. Insulin on sliding scale. | | | | 970F| 62 bpm| 18/min| 90| Ill | Nil | CVS: S1 S2 and no murmur| | | | | | | | | 70| | | PA: soft, non- tender and no organomegaly, BS +| | | 9/03| Ist DOA ;CHB with TPI, K/C/O T2DM & HTN. Day of PPI. Received from cath S/P PPI at 12:15pm | Cough | T| P| R| BP| GC| PILCyCOD| RS: B/L NVBS and no added sound| 1600/ 3600ml -ve balance 2000ml| Administer Nebulization 8 hourly. Syp. Grillinctus, Inj. levoflox, Inj. Monocef added. Tab Glycomet SR stopped. Oxygen through face maskFoleys continue. | | | 97. 80F| 64 bpm| 20/min| 110| Ill | Nil | CVS: S1 S2 and no murmur| | | | | | | | | 70| | | PA: soft, non- tender and no organomegaly, BS +| | | 09/04| 2nd DOA:CHB with PPI, K/C/O T2DM & HTN. | Shortness of Breathing Pleural effusion done : C/O pain at chest tube site | 97. 80F| 72 bpm| 24/min| 90| Ill | Nil | RS: wheezing present | 1770/ 1360 ml + ve balance | Chest X-Ray. Pneumothorax present so left pleural drainage done. Post chest X-ray. Continue O2 at 4 lt/min. Blood for WBC,DC, RFT tomorrow. Tab codomol SOS added. Inj, Lantus added today. | | | | | | 60| | | CVS: S1 S2 and no murmur| | | | | | | | | | | | PA: soft, non-tender and no organomegaly, BS 3 to 5 times per 10 mins. | | | 09/05| 3rd DOA:CHB with PPI, K/C/O T2DM & HTN| Not passed stool since 4 days. Severe pain at left pleural drainage site. | T| P| R| BP| GC| PILCyCOD| RS: wheezing present | 1400/1500ml-ve balance100ml| Nasal cannula at 3lt/min. Dressing at PPI site. Chest X-Ray done and Seen by Dr, left pleural drain to be clamped on from tomorrow 6am. Perform chest X-Ray while clamping. Sliding scale insulin stopped and regular started,blood sugar testing tomorrow. | | | 960F 0F 0F 0F. 80F| 80 bpm| 20/min| 100| Ill| Nil | CVS: S1 S2 and no murmur| | | | | | | | | 70| | | PA: soft, non tender and no organomagaly, BS=3-5/10m| | | 09/06| 4th DOA:CHB with PPI, K/C/O T2DM & HTN| None | T| P| R| BP| GC| PILCyCOD| RS: B/L NVBS and no added sound| 1600/ 1400 ml | Drain tube clamped. Chest X-ray at 9 am FBS, pre dinner, post dinner to be done daily by glucometer. Inj, mixtard dose increased. Plan to transfer out to Single cabin,Drain tube out at 3:15 pm and no any chief complain. O2 at 3lt/min continue.
Chest X-ray after tube out. Foleys out. | | | | 980F| 74 bpm| 20/min| 110| Satisfactory | Nil | CVS: S1 S2 and no murmur| | | | | | | | | 80| | | PA: soft, non-tender and no organomeagaly, BS+| | | MEDICATION USED IN MY PATIENT: 2069/09/02 * Inj. Cefazolin 1gm IV 8 hourly TDS * Tab. Glymet SR 500mg PO BD * Inj. humolog 50 S/C 10U morning: HOLD * Inj, levomor 14U S/C evening: HOLD * Tab. Omnitan 50mg PO BD * Inj. insulin sliding scale * 150-200 : 2U, 200-250: 4U, 250-300: 6U, 300-350: 10U, 350-400: 12U, 400 or more then 400: 2069/09/03 * Tab. Augmentin 625mg PO BD Inj Monocef 2gm IV OD * Inj. levoflox 500mg IV OD * Syp Ascril 2tsf PO TDS 2069/09/04 * Syp. Cremaffin 2069/09/05 * Inj. Mixtard 30:70 (12U S/C in morning and 6U S/C in evening : both ? hour before meal) * Tab. Tramadol 50mg PO BD * Inj. Pethidine 25mg IV stat and SOS * Inj Phenargan 25mg IV stat and SOS. * Herbolax 3 cap with warm water HS * Note: NO NSAID: allergy history HEALTH TEACHING TO PATIENT AND FAMILY DURING STAY Patient education about disease condition: The patient and the family were given all the information regarding the disease condition.
He and his family members were taught about the possible causes and contributing factors according to book and in comparison with his life to make them know about it. So that they will all be aware of it and follow the necessary consideration. Nutrition: Patient was encouraged to take adequate amount of fluid and fiber diet to prevent from constipation. Patient was encouraged to take low salt diet, decrease intake of fatty diet, decrease cholesterol intake for healthy heart as per antihypertensive medicines suggest.
She was advised to avoid red meat and replaced it by chicken or fish that has low fat with high protein. Paient was advised for diabetic diet and regular use of insulin as advised by Doctor. Personal hygiene: Personal hygiene is an important factor for the health recovery of the patient. It brings the sense of self well being and promotes self-esteem. Besides this maintaining oral hygiene promotes appetite and prevents weight loss, vomiting. Daily dressing once a day basis was given to promote wound healing and prevent infection. Medication: Medication is important for restoration of client’s health.
So, it should be continued as doctor advised. I explained him about the importance of complete dose of antibiotic to be taken to eradicate infection that degrades her disease condition. I also encouraged him to continue the use of antihypertensive medication and antidiabetic medication as per doctor’s advice. I also said about the possible adverse effects of the drug. Daily habit changes: I explained her disease condition and important daily activities to be changed like taking proper rest until she recovers and avoidance of sexual activities for 6 to 8 weeks.
She was advised to change her dietary habit into low salt diet, low fatty diet as per hypertensive patient should take. Possible complication: Patient was made aware of possible complication like hemorrhage, retention of urine, bladder injury, rectal injury, vault cellulitis, pelvic abscess, thrombophlebitis, pulmonary embolism, vault prolapse etc were explained resulting from complication of vaginal hysterectomy and Pelvic floor repair. And patient was encouraged to come for F/U immediately with any of the symptoms of underlying complications.
Discharge Teaching At the time of discharge, teaching was basically given to the patient and patient’s party. Following things were included in the teaching at the time of discharge. Treatment at Discharge: CONCLUSION Nutan Govinda Joshi, 60 years old female from Kavre was admitted in bed no. 222 in Gynae Ward of Kathmandu Medical College at 11:30 pm on 2068/12/12 and discharged at 3:00 pm on 2068/12/16 with the diagnosis of “2nd degree Utero-Vaginal Prolapse with cystocele” and “Vaginal hysterectomy with pelvic floor repair” was done on 2068/12/13.
The patient was under my close observation from the 2nd day of admission till the day she was discharged. During her hospital stay, I tried my level best to provide her a quality nursing care based on her needs with the application of Virginia Henderson’s independent theory and I also tried to give suggestion to her and her family members on the management of her disease condition. Though I had very short duration to provide her care, I kept my maximum efforts and help her in any ways that I could.
I provided teaching to her, her husband and her mother in laws her present disease condition and treatment she has undergone through. It was very exciting case and I felt very happy to have company with the patient along with her family members so that I could teach and convince them about the care needed. She and her family members were very co-operative and supportive. Even then, it was very educational to study this case.
It helped to learn in better way and even helps to practice as well as enhanced my skills to some extent. Bibliography * Burner and Suddharth’s, “Text book of Medical Surgical Nursing” Volume:2; 12th edition Wolters Kluwer(India) Pvt. Ltd, New Delhi,. * Chaurasia, B. D. (2009). Human Anatomy volume 2 (4th edition). CBS Publishers & Distributors Pvt. Ltd. New Delhi, India. * Kozier and Erb’s “fundamental of Nursing”; 8th edition; Pearson Education, published by Dorling Kindersley (India) Pvt. Ltd. ; 528-43. Lippincot,Manual of Nursing Practice , 9th edition, churchill livinstone * Mosby’s “Comprehensive Review of Nursing for NCLEX- RN examination” ;19th edition; Elsevier publication; 535-36 * Mosby’s “Nursing drug reference”; 22nd edition 2009 Elsevier publication;22-23,129-30,1143-44,685-89. * Smeltzer, S. C & Bare; 2008. Textbook of Medical-Surgical Nursing, 11thedition. Lippincott Williams & Wilkins. Philadelphia. * Retrieved on 2069/09/10 http://en. wikipedia. org/wiki/Artificial_cardiac_pacemaker#Considerations http://www. nhlbi. nih. gov/health/health-topics/topics/hb/