WISCONSIN

INTERNATIONAL

UNIVERSITY COLLEGE

PEADIATRIC NURSING

PRACTICALS

GROUP (6) SIX

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 SICKLE CELL DISEASE

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1.1 The Patient’s Particulars

Madam S.S is a 2 year old girl born on the 2nd of March, 2021 Takoradi Municipal Hospital

in the Western Region of Ghana. According to Madam S.S’s mom – Madam C.G, madam S.S

is the first born. She is 83cm tall and weighs 10kg. She is a fante and hails from Salt Pond in

the Central Region of Ghana. She stays with her family at Kpone, a suburb of Tema. The

family are Christians and members of the True Believers Church at Tema. Madam S.S is yet

to start her formal education.

1.4 The Patient’s Developmental History

Information gathered from Madam C.G, patient’s mother, indicated that patient was delivered

via spontaneous vaginal delivery with a weight of 2.3kg after nine months of normal

pregnancy at Takoradi Municipal Hospital in the Western Region of Ghana by a midwife

without any complications and with no congenital abnormalities or malformations. She is

said to have sat at the age of seven months, crawled at nine months and walked at about

twelve months in Takoradi. She also started making sounds of talking at about one year. She

was exclusively breast fed for the first three months and not six months, because her mother’s

breast milk was not enough for her and was supplemented with porridge. Her growth

monitoring card showed that she had had all her immunizations including BCG, Pentavalent,

Polio, Rotarix, Measles first and second doses, Yellow fever and Vitamin A as scheduled.

1.10 Literature Review on Sickle Cell Disease

Sickle-cell disease is an autosomal recessive genetic blood disorder with incomplete

dominance, characterized by red blood cells that assume an abnormal, rigid, sickle shape.

(Clopton, 2020)

INCIDENCE

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Sickle cell disease, usually presenting in childhood, occurs more commonly in people (or

their descendants) from parts of tropical and sub-tropical regions where malaria is or was

common but it also occurs in people of other ethnicities. Most commonly found in Africa, the

Mediterranean, the middle Basin and other Sub Saharan African country. (Pace et al., 2021)

AETIOLOGY (Clopton, 2020)

The disease is caused by a mutation of haemoglobin structure of the red blood cell. This

mutation enables the red blood cells to sickle when there is a low presence of oxygen in the

cell. Sickle cell disease is a genetic condition that is present at birth. It is inherited when a

child receives two genes—one from each parent—that code for abnormal hemoglobin.

PATHOPHYSIOLOGY (Clopton, 2020)

Sickle cell anaemia is caused by a point mutation in the beta-globin chain of haemoglobin,

causing the hydrophilic amino acid glutaminc acid valine at the sixth position. The red blood

cell less elasticity is central to the pathophysiology of sickle cell disease. Normally red blood

cells are quite elastics which allows the cell deform to pass through the capillaries. In sickle-

cell disease, low oxygen promotes red blood cell to change its shape from the spherical to

sickle shape to form cluster. These cells fail to return to normal shape when normal oxygen

tension is restored, thus making it difficult for the blood cells to pass through narrow

capillaries leading to vessel occlusion. Oxygen supply is impeded leading to the ischaemia.

Also, when haemoglobin C combines with haemoglobin S the result is haemoglobin SC

disease. This occurs when glutamic acid is place with a less polar amino acid lycine at the

sixth position. On average haemoglobin SC is milder than sickle cell anaemia.

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CLASSIFICATION OR TYPES OF SICKLE CELL DISEASE (Pace et al., 2021)

There are several types of sickle cell disease. The most common are: Sickle Cell Anemia

(SS), Sickle Hemoglobin-C Disease (SC), Sickle Beta-Plus Thalassemia and Sickle Beta-

Zero Thalassemia.

Sickle Cell Anemia (SS): When a child inherits one substitution beta globin genes (the sickle

cell gene) from each parents, the child has Sickle Cell Anemia (SS). Populations that have a

high frequency of sickle cell anemia are those of African and Indian descents.

Sickle Hemoglobin- C Disease (SC): Individuals with Sickle Hemoglobin-C Disease (SC)

have a slightly different substitution in their beta globin genes that produces both hemoglobin

C and hemoglobin S. Sickle Hemoglobin-C disease may cause similar symptoms as sickle

cell anemia but less anemia due to a higher blood count level. Populations that have a high

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frequency of Sickle Hemoglobin-C disease are those of West African, Mediterranean and

Middle Eastern descents.

Sickle Beta-Plus Thalassemia: Individuals with Sickle Beta Thalassemia (SB) disease also

contain substitutions in both beta globin genes. The severity of the disease varies according to

the amount of normal beta globin produced. When no beta globin is produced, the symptoms

are almost identical to sickle cell anemia, with severe cases needing chronic blood

transfusions. Populations that have a high frequency of Sickle Beta Thalassemia are those of

Mediterranean and Caribbean descents.

Sickle Hemoglobin-D Disease: Through research, hemoglobin D, which is a different

substitution of the beta globin gene, has been found to interact with the sickle hemoglobin

gene. Individuals with Sickle Hemoglobin-D disease (SD) have moderately severe anemia

and occasional pain episodes. Populations that have a high frequency of Sickle Hemoglobin-

D disease are those of Asian and Latin American descents.

Sickle Hemoglobin-O Disease: Hemoglobin O, another type of substitution in the beta

globin gene, also interacts with sickle hemoglobin. Individuals with Sickle Hemoglobin- O

disease (SO) can have symptoms of sickle cell anemia. Populations that have a high

frequency of Sickle Hemoglobin-O disease are those of Arabian, North African and Eastern

Mediterranean descents.

There are three types of sickle- cell crisis:

 The most common is vaso-occlusive. It is a painful sickle crisis, which result from

tissue hypoxia and necrosis due to inadequate blood flow to a specific region of tissue

or organ.

 Aplastic crisis results from infection with human parvovirus. The haemoglobin levels

falls rapidly and the marrow cannoy compensate as evidenced by absence of

reticulocyte.

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  Splenic Sequestration crisis are acute painful enlargement of the spleen. The abdomen

becomes bloated and very hard. Haemolytic crisis is an acute acceleration drop in

haemoglobin level. The red blood cells are destroyed at a faster rate.

CLINICAL MANIFESTATION OF SICKLE CELL DISEASE (Clopton, 2020)

1. Acute and chronic pain: The most common clinical manifestation of SCD is vaso-

occlusive crisis; pain crises are the most distinguishing clinical feature of SCD

2. Bone pain: Often seen in long bones of extremities, primarily due to bone marrow

infarction

3. Anemia: Universally present, chronic, and hemolytic in nature

4. Aplastic crisis: Serious complication due to infection with parvovirus B19 (B19V)

5. Splenic sequestration: Characterized by the onset of life-threatening anemia with

rapid enlargement of the spleen and high reticulocyte count

6. Infection: Organisms that pose the greatest danger include encapsulated respiratory

bacteria, particularly Streptococcus pneumoniae; adult infections are predominantly

with gram-negative organisms, especially Salmonella

7. Growth retardation, delayed sexual maturation, being underweight

8. Hand-foot syndrome: This is a dactylitis presenting as bilateral painful and swollen

hands and/or feet in children

9. Acute chest syndrome: Young children present with chest pain, fever, cough,

tachypnea, leukocytosis, and pulmonary infiltrates in the upper lobes; adults are

usually afebrile, dyspneic with severe chest pain, with multilobar/lower lobe disease

10. Pulmonary hypertension: Increasingly recognized as a serious complication of SCD

11. Avascular necrosis of the femoral or humeral head: Due to vascular occlusion

12. Central nervous system (CNS) involvement: Most severe manifestation is stroke

13. Ophthalmologic involvement: Ptosis, retinal vascular changes, proliferative retinitis

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 14. Cardiac involvement: Dilation of both ventricles and the left atrium

15. Gastrointestinal involvement: Cholelithiasis is common in children; liver may become

involved

16. Genitourinary involvement: Kidneys lose concentrating capacity; priapism is a well-

recognized complication of SCD

17. Dermatologic involvement: Leg ulcers are a chronic painful problem

DIAGNOSTIC MEASURES (Pace et al., 2021)

A. ASSESSMENT

1. A previous history of frequent admission, blood transfusion.

2. Family history of sickle cell may also be an indication that the patient is Sickling

positive

3. Patient may complain pain in the joints whenever it rains or the weather becomes cold

4. Physical assessment may review discoloration of skin and sclera (jaundice) and

swelling of the affected joint

B. LABORATORY INVESTIGATIONS

1. Sickling test: to indicate whether patient is sickling positive or negative

2. Haemoglobin electrophoresis: used to identify the type of abnormal haemoglobin

inherited

3. Grouping and cross matching: to identify the blood group of the client for possible

transfusion

4. Blood film: to indicate whether there is malaria parasite in the blood

MEDICAL MANAGEMENTS

1. The goal of management is to ensure oxygenation to relieve pain and promote red

blood cell production

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 2. Painful crisis is treated symptomatically with analgesics like paracetamol

administrations at regular intervals until the crisis are settled

3. Intravenous infusion to maintain fluids and electrolytes balance

4. Anti-malaria drugs are prescribed when malaria parasite can be found in the blood

5. Haematemics to increase haemoglobin for example Multivitamins

6. Good nutrition is also recommended to promote blood cell productions

NURSING MANAGEMENT

IMMEDIATE;

1. When there is low oxygen tension, administer oxygen if prescribed

2. Provide warmth when the environment is cold by closing windows or doors and also

adding other cover clothes because cold is a precipitating factor

3. Reduce child fever through Tepid Sponging because fever may aggravate dehydration

4. Affected joints should be immobilized to relieve pain

5. Ensure bed rest to decrease energy expenditure

ANXIETY

 Maintain a calm and reassuring environment; minimize noise

 Explain every procedure carried on patient to patient and caregiver

 Educate parent on condition, its management and complications

 Encourage parent’s presence and participation to enhance ability to support the child.

 Support expression and identification of feelings and worries of parent

 Compassionately acknowledge and validate concerns.

 Utilize existing coping strategies and assist in developing new strategies

 Identify thoughts and feelings that led to current anxiety onset to enhance

understanding of triggers.

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  Reframe anxiety-provoking situations; provide a new perspective and engage in

problem-solving.

ASSESSMENT

 Assess for any signs and symptoms of less tissue perfusion including cold and

clammy skin, facial pallor, and poor capillary refill of nailbeds.

 Assess fluid balance, including intake and output, with a goal of optimizing fluid

volume

 Examine skin turgor and mucous membranes for signs of dehydration

 Assess patient’s level of pain

 Assess for signs of anaemia including fatigue, difficulty in breathing

 Assess patient’s oxygen saturation levels

ORAL HYGIENE

 Assist mother to brush patient’s teeth twice daily

 Educate mother to use a tooth brush with soft bristles to brush patient’s teeth

 Encourage mother to change patient’s tooth brush at least every 3 months

 Educate mother to use a fluoride toothpaste in brushing patient’s mouth

 Observe patient’s teeth for cavities and debris

 Observe patient’s tongue for its pinkish colour and moist with papillae

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  Ensure patient’s lips are moist and devoid of cracks

FEEDING

 Spoon feed patient with high calorie foods and snacks

 Schedule regular meals and snacks, usually 3 meals and several health snacks

 Encourage parent to feed child diets high in folate such as green leafy vegetable, corn,

etcetera

 Serve patient with a well-nourished diet that is high in protein and calories to help in

building up the body and also help the patient to regain his or her energy

 Encourage patient to take in orange juice to help in the absorption of iron

 Encourage the frequent intake of liberal fluid

 Administer intravenous fluids as prescribed and monitor it by keeping accurate record

on fluid intake and output

PREVENTING DIARRHOEA

 Wash hands thoroughly under running water with soap before feeding or attending to

patient

 Educate patient and parents to wash hands under running water with soap

 Assist patient in washing the hands before and after eating, after playing and after

visiting the toilet

 Educate parents to wash the hands before feeding patient, after visiting the washroom

and after nappy change

 Follow and teach parent good food safety practices

 Maintain environmental cleanliness

 Provide clean potty to patient

 Ensure patient’s toilets are clean

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Use and educate parent to use clean water

OTHER NURSING MANAGEMENT

1. Apply warm compresses at the affected site of the joint to relieve pain

2. Ensure patient maintain personal hygiene to prevent infection

3. Prescribed medications should be served on time and well documented

4. Administered blood if prescribed in cases of severe anaemia and monitor for any

transfusion reaction

HEALTH EDUCATION

1. Patient is educated about the disease condition. He is also given explanation about the

crisis and why they occur

2. Information is also provided about the prescribed treatment, plan of care and the

parent understanding is evaluated by having him or her carry out procedures such as

administration of medications

3. Parents should receive an explanation of the disease and factors that predispose to

crisis.

4. Children and can be advised on the importance of prophylactic care. This involves

living as normal as possible but avoiding chilling, contact with people with infections

avoiding over fatigue and stressful situations.

5. Individual with hereditary form of anaemia are advised on genetic counseling. It is

important that they are able to make choices about their chances of having affected

children.

COMPLICATIONS (Pace et al., 2021)

Sickle cell disease may lead to various acute and chronic complications. They are;

1. Bone damage due to chronic osteomyelitis

2. Eye damage

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 3. Stroke

4. Anaemia (chronic)

5. Splenomegaly

6. Hepatic disorders

7. Encephalopathy

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 Nursing Care Plan
DATE NURSING OBJECTIVES/OUT NURSING NURSING DATE EVALUATION SIGNA
AND DIAGNOSIS COME CRITERIA ORDERS INTERVENTION AND TURE/
TIME TIME INITIA
L

10/02/23 Acute pain Patient will be relieved 1. Assess patient’s 1. Patient’s level of 10/02/23 Goals fully met AA
(joint pain) of joint pain within 1 – level of pain using pain assessed using a as:
at related to vaso- 2 hours as evidenced a visual analog visual analog scale at • Nurse observed
occlusion by: scale and reassure and patient and patient relaxed in
10:00 • Patient verbalizing patient tand mother reassured 12:00pm bed
am absence of pains mother that she is that they are in
• Nurse observing in competent competent hands
patient relaxed in bed hands 2. Patient’s vital
2. Monitor signs checked and
patient’s vital recorded as
signs including temperature 37.5,
temperature, pulse, pulse 100cpm,
respiration 4hourly respiration 24cpm
3. Assist patient to ent assisted to
assume a assume a
comfortable

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 position as can be comfortable position
tolerated administered
4. Administer 5. Warm compress
prescribed applied on patient’s
analgesic joints
5. Apply warm 6. Divertional
compress on therapy provided
patient’s joints 7. Prescribed
6. Provide intravenous
divertional therapy infusions (0.9%
e.g. Watching Sodium Chloride,
television Ringers Lactate)
7. Administer administered
prescribed 8. Patient and
intravenous mother educated on
infusions (0.9% reporting if pain
Sodium Chloride, worsens
Ringers Lactate)
8. Educate patient
and mother to
report if pain is

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 worsening

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 LOBAR PNEUMONIA

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1.1 The Patient’s Particulars

Madam S.S is a 2 year old girl born on the 2nd of March, 2021 Takoradi Municipal Hospital

in the Western Region of Ghana. According to Madam S.S’s mom – Madam C.G, madam S.S

is the first born. She is 83cm tall and weighs 10kg. She is a fante and hails from Salt Pond in

the Central Region of Ghana. She stays with her family at Kpone, a suburb of Tema. The

family are Christians and members of the True Believers Church at Tema. Madam S.S is yet

to start her formal education.

1.4 The Patient’s Developmental History

Information gathered from Madam C.G, patient’s mother, indicated that patient was delivered

via spontaneous vaginal delivery with a weight of 2.3kg after nine months of normal

pregnancy at Takoradi Municipal Hospital in the Western Region of Ghana by a midwife

without any complications and with no congenital abnormalities or malformations. She is

said to have sat at the age of seven months, crawled at nine months and walked at about

twelve months in Takoradi. She also started making sounds of talking at about one year. She

was exclusively breast fed for the first three months and not six months, because her mother’s

breast milk was not enough for her and was supplemented with porridge. Her growth

monitoring card showed that she had had all her immunizations including BCG, Pentavalent,

Polio, Rotarix, Measles first and second doses, Yellow fever and Vitamin A as scheduled..

1.10 Literature Review on Lobar Pneumonia

DEFINITION OF LOBAR PNEUMONIA

Pneumonia is an inflammatory process of the lung parenchyma caused by infectious agent

and usually characterized by accumulation of fluid in the alveoli. (Shankar, 2020)

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Lobar Pneumonia is an acute inflammation which occurs in one or more of the lobes of the

lungs. It involves a whole lobe or large portions of the lobe of the lungs. (Morrow et al.,

2021)

INCIDENCE

It occurs in all age groups. Pneumonia is more common among infants and the elderly. It

also occurs in adults and precipitated in people living in areas of high exposure to cold air. It

affects both sexes and common in people with compromised immunity, example people

living with AIDS. (Shankar, 2020)

CAUSES/ETIOLOGY

Pneumonia is caused by an infectious agent. Example: Bacteria, Virus and Fungi.

CLASSIFICATION OF PNEUMONIA (Morrow et al., 2021)

Pneumonia can be classified according to:

1. Type of infectious agent

2. Source of infection

3. Site of pathological process

TYPE OF INFECTIOUS AGENT

1. Bacterial pneumonia: This is the most common among the type of infectious agent

and organisms include

• Streptococcus pneumonia

• Staphylococcus aureus

• Haemophilus influenza

• Klebsiella pneumonia

2. Viral pneumonia: This is the common cause of pneumonia in children.

Organisms include

• Influenza virus

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 • Adenovirus

• Corona virus

• Varicella zoster virus

• Rhinovirus

3. Fungal pneumonia: This type of pneumonia occurs commonly in

an immunocompromised patient. Organism includes Pneumocystis carina pneumonia

SOURCES OF INFECTION

(Includes where and how the infection is acquired)

1. Community Acquired Pneumonia (CAP): This occurs either in the community

setting or within the first 48 hours after hospitalization or institutionalization. Causative

agents include streptococcus pneumonia, haemophilus influenza.

2. Hospital Acquired Pneumonia (HAP): This is also known as nosocomial

pneumonia and a symptom of such pneumonia occurs at least 48 hours after admission.

HAP is common in post-operative patients, old age and patients who have been

intubated.

3. Aspiration Pneumonia (AP): This is a type of pneumonia that occurs due to

the inhalation or entry of foreign materials usually oropharyngeal or gastric contents

(food, saliva, and vomitus) into the lungs. It usually results from entry of endogenous

or exogenous substances into the lower airway.

4. Opportunistic Pneumonia (OP): This type of pneumonia only affects people who

have weakened immunity. It is usually caused by fungal and viral infection.

SITE OF PATHOLOGICAL PROCESS/ MORPHOLOGY

• Bronchopneumonia: This is the consolidation occurring on patches around the

terminal bronchioles. It may be confined to a small segment of the lung or with

widespread bronchial involvement.

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  Lobar pneumonia

RISK FACTORS (Shankar, 2020)

• People with depressed cough reflex

• Cigarette smokers since the smoke destroys both mucocilliary and macrophage

activities.

• Any condition that produces mucous or bronchial obstruction of the lungs

example asthma

• Extreme exposure to cold

• Age (infants and the elderly)

• Alcoholics in whom there is increased risk of aspiration.

• People sleeping under fans

• Patients who are permitted to lie passively on bed for long periods, relatively

immobile

• People receiving treatment from equipment that are not well cleaned.

PATHOPHYSIOLOGY (Shankar, 2020)

It occurs when the organism example Haemophilus Influenza, Staphylococcus

Aureus, streptococcus pneumonia enters the pulmonary circulation and inflammation reaction

occurs in the alveoli of the lungs. This leads to the development of oedema and exudate

which fills the alveoli and reduces the surface area available for exchange of carbon dioxide

and oxygen. Oedema from the inflammation process stiffens the lungs thereby decreasing

lung capacity and also causes partial occlusion of the bronchi or alveoli with a resultant

decrease in alveoli oxygen tension. This results in hypoventilation and venous blood coming

into the lungs then passes through the under ventilated area and get to the left side of the heart

poorly oxygenated. This eventually results in arterial hypoxemia, which will make the patient

feel weak, restlessness, cough etcetera.

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CLINICAL FEATURES (Shankar, 2020)

• Fever

• Chills

• Cough which is initially dry but becomes productive later

• Diaphoresis

• Tachypnoea

• Use of accessory muscles in respiration

• Pleuritic chest pain

• Anorexia

• Fatigue

• Tachycardia

• Dyspnoea

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 • Cyanosis of the tongue and nail beds

• Headache

• Nausea and vomiting

DIAGNOSTIC INVESTIGATION (Morrow et al., 2021)

• Clinical history and physical examination

• Chest x-ray showing consolidation or pacification in the lung tissue

• Sputum examination for culture, sensitivity and to rule out tuberculosis

• Full blood count to note number of elevated white blood cells which is an

Indication of infection

• Blood for culture and sensitivity

• Liver function test

MEDICAL TREATMENT (Shankar, 2020)

1. Antibiotics; the main objective is to treat infection and prevent complications.

• Penicillin 250mg -1g 6hourly intravenously

• Erythromycin 500mg 8hourly for 7 days intravenously

• Ceftriaxone 2g daily for 7 days

• Azithromycin 500mg daily for 3 days

• Clindamycin 150-450mg 6 hourly intravenously or intramuscularly

• Amoxiclav 1.2g 8hourly intravenously or 625mg – 1g 12hourly for 7days

• 2. Antipyretic or analgesic;

E.g.; Tablet Paracetamol 1g to relieve pain and minimize pyrexia

3. Expectorant to expectorate sputum and minimize cough. Example Syrup benylin

15mls

8hourly x 7days

4. Oxygen therapy to help in breathing and prevent hypoxia

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 5. Normal saline nebulization to moisten secretions

SURGICAL MANAGEMENT

The following surgical treatment are given

• Lobectomy: This refers to the removal of the affected lobe of the lung.

• Pneumonectomy: This also refers to total or partial removal of the lung

NURSING MANAGEMENT

ANXIETY

 Maintain a calm and reassuring environment; minimize noise

 Establish rapport to enhance communication.

 Reassure patient’s family to allay anxiety.

 Educate family members on the disease condition to clear all misconception.

 Orientate them to the ward environment and to equipment at the ward.

 Explain into details all treatments and diagnostic investigation perform

 Encourage parent’s presence and participation to enhance ability to support the child.

 Support expression and identification of feelings and worries of parent

 Compassionately acknowledge and validate concerns.

ASSESSMENT

 Assess temperature, pulse, respiration and SPO2 every 4 hourly and record.

 Ensure Intake and output are checked and recorded and balanced over 24hours

 Assess for signs of cyanosis.

 Assess for signs of dehydration such as poor skin turgor, cracked lips, and sunken

eyes.

 Assess for signs of respiratory distress

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ORAL HYGIENE

 Clean patient’s gums after feeding gently with a moistened clean cloth or gauze pad

 Use a child’s soft bristled tooth brush to clean patient’s teeth if present with no

toothpaste

 Gently massage patient’s gums

 Observe patient’s teeth for brown or white patches which may denote tooth decay

 Ensure patient’s lips are moist and devoid of cracks

 Encourage patient to start weaning patient from bottle gradually

 Encourage parent to limit the frequency and amount of sweetened beverages and

foods patient consumes

FEEDING

 Encourage mother to continue breastfeeding patient

 Encourage mother to gradually wean patient off bottle to drinking from cups

 Serve patient with foods that are soft and semi liquid

 Begin spoon feeding by placing food at the back of the tongue because of tendency to

thrust tongue forward

 Use small spoons with straight handles

 Encourage mother to introduce fruits and vegetables in patient’s diets

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PREVENTING DIARRHOEA

 Wash hands thoroughly under running water with soap before feeding or attending to

patient

 Educate parents to wash hands under running water with soap

 Educate parents to wash the hands before feeding patient, after visiting the washroom

and after nappy change

 Wash patient’s feeding items thoroughly

 Follow and teach parent good food safety practices

 Maintain environmental cleanliness

 Educate parent on proper handling and disposal of used diapers

 Use and educate parent to use clean water

REST AND COMFORT

1. Patient should be given a complete bed rest in a comfortable bed to avoid over

secretion and possible exacerbation of symptoms.

2. Ensure calm and a noise free environment to enhance comfort.

3. Prop up patient in bed or nurse patient in a cardiac bed to aid breathing.

4. Restriction of visitors to promote enough rest and sleep.

5. Change clothing’s and bed linens when necessary.

6. Ensure proper ventilation by opening windows.

7. Nurse patient away from drought

PERSONAL HYGIENE

1. Clean nasal cavity especially in children to aid breathing.

2. Give mouth care if necessary.

3. Patient should be given bed bath with tepid water or warm water depending on

the weather.

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 4. If endotracheal tube is institute, give daily care.

5. Care for the hands and feet and treat pressure areas.

6. Feeding items should well cleaned

7. Soiled and wet linens should be changed regularly with clean, dry ones to

prevent infections

HEALTH EDUCATION

 Educate parent to wear patient protective clothing especially during chilling

conditions.

 Advice parent to avoid indiscriminate use of antibiotic

 Advice parent to ensure an environment free from dust.

 Encourage annual influenza vaccination and prevalent pneumococcal vaccine.

 Advice parent to report, respiratory tract infections such as catarrh, sinusitis,

tonsillitis early for prompt medical treatment.

 Teach patient’s family about the disease condition, treatment available and

possible complications

 Teach patient’s family signs and symptoms that necessitate medical attention such as

difficulty in breathing, cyanosis and fever with high temperature 39C and above

COMPLICATIONS (Morrow et al., 2021)

• Pleural effusion

• Meningitis

• Lungs abscess

• Pericarditis

• Cardiac failure

• Otitis media

• Atelectasis

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 • Respiratory failure

• Septicemia

• Hypoxia

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 Nursing Care Plan
DATE NURSING OBJECTIVES/OUT NURSING NURSING DATE EVALUATION SIGNA
AND DIAGNOSIS COME CRITERIA ORDERS INTERVENTION AND TURE/
TIME TIME INITIA
L

10/02/23 Ineffective Patient’s breathing 1. Assess patient’s 1. Patient’s 10/02/23 Goals fully met SS
breathing pattern will improve breathing pattern breathing pattern as:
at pattern related (18 – 30 cycles per and reassure her assessed and patient At • Patient’s
to congestion minute) within 30 and aunty of and aunty reassured respiration
09:00 within the minutes as evidenced competent nursing 2. Patient’s vital 09:30 am assessed to be
am lungs by: care signs checked and within normal
secondary to • Nurse assessing 2. Monitor vital recorded as range (18 – 30
pneumonia patient’s respiration to signs including temperature- 37.5, cycles per
be within normal temperature, pulse, pulse- 100cpm, minute)
range (18 – 30 cycles respiration and respiration 30cpm, •Patient
per minute) by vital SPO2 and SPO2- 97% verbalized ease in
signs monitoring 3. Prop patient up 3. Patient propped breathing.
• Patient verbalizing in bed to aid up in bed
ease in breathing. breathing 4. All tight clothes

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 4. Loosen all tight around patient’s
clothes around neck and chest
patients’ neck and loosened
chest 5. Prescribed
5. Administer Salbutamol
Salbutamol as administered
prescribed 6. Patient taught
6. Teach patient about performing
about performing relaxation
relaxation techniques
technique.

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 HEART FAILURE

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1.1 The Patient’s Particulars

Madam S.S is a 2 year old girl born on the 2nd of March, 2021 Takoradi Municipal Hospital

in the Western Region of Ghana. According to Madam S.S’s mom – Madam C.G, madam S.S

is the first born. She is 83cm tall and weighs 10kg. She is a fante and hails from Salt Pond in

the Central Region of Ghana. She stays with her family at Kpone, a suburb of Tema. The

family are Christians and members of the True Believers Church at Tema. Madam S.S is yet

to start her formal education.

1.4 The Patient’s Developmental History

Information gathered from Madam C.G, patient’s mother, indicated that patient was delivered

via spontaneous vaginal delivery with a weight of 2.3kg after nine months of normal

pregnancy at Takoradi Municipal Hospital in the Western Region of Ghana by a midwife

without any complications and with no congenital abnormalities or malformations. She is

said to have sat at the age of seven months, crawled at nine months and walked at about

twelve months in Takoradi. She also started making sounds of talking at about one year. She

was exclusively breast fed for the first three months and not six months, because her mother’s

breast milk was not enough for her and was supplemented with porridge. Her growth

monitoring card showed that she had had all her immunizations including BCG, Pentavalent,

Polio, Rotarix, Measles first and second doses, Yellow fever and Vitamin A as scheduled.

DEFINITION OF HEART FAILURE (Belleza, 2021)

Heart failure, also known as congestive heart failure, is recognized as a clinical syndrome

characterized by signs and symptoms of fluid overload or of inadequate tissue perfusion. It is

the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen

and nutrients. The term heart failure indicates myocardial disease in which there is a

32
problem with contraction of the heart (systolic dysfunction) or filling of the heart (diastolic

dysfunction) that may or may not cause pulmonary or systemic congestion.

TYPES (Belleza, 2021)

Heart failure is classified into two types: left-sided heart failure and right-sided heart failure.

Left-Sided Heart Failure

 Left-sided heart failure or left ventricular failure have different manifestations with

right-sided heart failure.

 Pulmonary congestion occurs when the left ventricle cannot effectively pump blood

out of the ventricle into the aorta and the systemic circulation.

 Pulmonary venous blood volume and pressure increase, forcing fluid from the

pulmonary capillaries into the pulmonary tissues and alveoli, causing pulmonary

interstitial edema and impaired gas exchange.

Right-Sided Heart Failure

 When the right ventricle fails, congestion in the peripheral tissues and the viscera

predominates.

 The right side of the heart cannot eject blood and cannot accommodate all the blood

that normally returns to it from the venous circulation.

 Increased venous pressure leads to JVD and increased capillary hydrostatic pressure

throughout the venous system.

The American College of Cardiology and American Heart Association have

classifications of heart failure.

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  Stage A. Patients at high risk for developing left ventricular dysfunction but without

structural heart disease or symptoms of heart failure.

 Stage B. Patients with left ventricular dysfunction or structural heart disease that has

not developed symptoms of heart failure.

 Stage C. Patients with left ventricular dysfunction or structural heart disease with

current or prior symptoms of heart failure.

 Stage D. Patients with refractory end-stage heart failure requiring specialized

interventions. (Schwinger, 2021)

INCIDENCE (Schwinger, 2021)

Heart failure can affect both women and men, although the mortality is higher among

women.

 There are also racial differences; at all ages death rates are higher in African

American than in non-Hispanic whites.

 Heart failure is primarily a disease of older adults, affecting 6% to 10% of those older

than 65.

 It is also the leading cause of hospitalization in older people.

AETIOLOGY (Sadasivuni et al., 2022)

From a clinical standpoint, classifying the causes of heart failure into the following four

broad categories is useful:

 Underlying causes: Underlying causes of heart failure include structural abnormalities

(congenital or acquired example tetralogy of fallot) that affect the peripheral and

coronary arterial circulation, pericardium, myocardium, or cardiac valves, thus leading

to increased hemodynamic burden or myocardial or coronary insufficiency

34
  Fundamental causes: Fundamental causes include biochemical and physiologic

mechanisms, through which either an increased hemodynamic burden or a reduction in

oxygen delivery to the myocardium results in impairment of myocardial contraction

 Precipitating causes: Overt heart failure may be precipitated by progression of the

underlying heart disease (example further narrowing of a stenotic aortic valve or mitral

valve) or various conditions (fever, anemia, infection) or medications (chemotherapy,

nonsteroidal anti-inflammatory drugs [NSAIDs]) that alter the homeostasis of heart

failure patients

 Genetics of cardiomyopathy: Dilated, arrhythmic right ventricular and restrictive

cardiomyopathies are known genetic causes of heart failure

PATHOPHYSIOLOGY (Schwinger, 2021)

In heart failure, the heart may not provide tissues with adequate blood for metabolic needs,

and cardiac-related elevation of pulmonary or systemic venous pressures may result in

organ congestion. This condition can result from abnormalities of systolic or diastolic

function or, commonly, both. Although a primary abnormality can be a change in

cardiomyocyte function, there are also changes in collagen turnover of the extracellular

matrix. Cardiac structural defects (eg, congenital defects, valvular disorders), rhythm

abnormalities (including persistently high heart rate), and high metabolic demands

(example, due to thyrotoxicosis) also can cause Heart Failure.

CLINICAL FEATURES (Belleza, 2021)

The clinical manifestations produced by the different types of Heart Failure are similar and

therefore do not assist in differentiating the types of heart failure. The signs and symptoms

can be related to the ventricle affected.

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Left-sided Heart Failure

 Dyspnea or shortness of breath may be precipitated by minimal to moderate activity.

 Cough - The cough associated with left ventricular failure is

initially dry and nonproductive.

 Pulmonary crackles. Bibasilar crackles are detected earlier and as it worsens, crackles

can be auscultated across all lung fields.

 Low oxygen saturation levels. Oxygen saturation may decrease because of increased

pulmonary pressures.

Right-sided Heart Failure

 Enlargement of the liver result from venous engorgement of the liver.

 Accumulation of fluid in the peritoneal cavity may increase pressure on

the stomach and intestines and cause gastrointestinal distress.

 Loss of appetite results from venous engorgement and venous stasis within the

abdominal organs.

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DIAGNOSTICS INVESTIGATIONS (Schwinger, 2021)

 ECG: Ventricular or atrial hypertrophy, axis deviation, ischemia, and damage

patterns may be present. Dysrhythmias, example, tachycardia, atrial fibrillation,

conduction delays, especially left bundle branch block, frequent premature ventricular

contractions (PVCs) may be present. Persistent ST-T segment abnormalities and

decreased QRS amplitude may be present.

 Chest x-ray: May show enlarged cardiac shadow, reflecting chamber

dilation/hypertrophy, or changes in blood vessels, reflecting increased pulmonary

pressure. Abnormal contour, e.g., bulging of left cardiac border, may suggest

ventricular aneurysm.

 Sonograms (echocardiography, Doppler and

transesophageal echocardiography): May reveal enlarged chamber dimensions,

alterations in valvular function/structure, the degrees of ventricular dilation and

dysfunction.

 Heart scan (multigated acquisition [MUGA]): Measures cardiac volume during

both systole and diastole, measures ejection fraction, and estimates wall motion.

 Exercise or pharmacological stress myocardial perfusion (example, Persantine or

Thallium scan):Determines presence of myocardial ischemia and wall motion

abnormalities.

 Positron emission tomography (PET) scan: Sensitive test for evaluation of

myocardial ischemia/detecting viable myocardium.

 Cardiac catheterization: Abnormal pressures are indicative and help differentiate

right- versus left-sided heart failure, as well as valve stenosis or insufficiency. Also

assesses patency of coronary arteries. Contrast injected into the ventricles reveals

abnormal size and ejection fraction/altered contractility. Transvenous

37
 endomyocardial biopsy may be useful in some patients to determine the underlying

disorder, such as myocarditis or amyloidosis.

MEDICAL MANAGEMENT (Belleza, 2021)

 ACE Inhibitors. ACE inhibitors slow the progression of heart failure, improve

exercise tolerance, decrease the number of hospitalizations for heart failure, and

promote vasodilation and diuresis by decreasing afterload and preload.

 Angiotensin II Receptor Blockers. ARBs block the conversion of angiotensin I at

the angiotensin II receptor and cause decreased blood pressure, decreased systemic

vascular resistance, and improved cardiac output.

 Beta Blockers. Beta blockers reduce the adverse effects from the constant

stimulation of the sympathetic nervous system.

 Diuretics. Diuretics are prescribed to remove excess extracellular fluid by

increasing the rate of urine produced in patients with signs and symptoms of fluid

overload.

 Calcium Channel Blockers. CCBs cause vasodilation, reducing systemic vascular

resistance but contraindicated in patients with systolic heart failure.

SURGICAL MANAGEMANT (Sadasivuni et al., 2022)

Catheter Ablation - Catheter ablation uses radiofrequency energy to heat and destroy a

small area of heart tissue causing problems such as arrhythmia (irregular heartbeat).

Implanted Devices - Many patients with heart failure need a device implanted in the heart to

control and/or monitor heart rate and rhythm. Examples of these devices include:

• Implantable cardioverter defibrillators (ICDs), which detect life-threatening heart

rhythms and deliver an electrical shock or a series of paced beats to restore the heart to

normal rhythm.

• Pacemakers, which control heart rate and rhythm.

38
 • Remote monitoring devices that detect abnormal heart rhythms and send real-time

signals to alert your healthcare team to potential problems

Coronary Artery Bypass Graft (CABG) - If blocked arteries are damaging the heart,

coronary artery bypass surgery can improve blood flow and prevent future damage. CABG

takes a healthy blood vessel from another part of the body and places it near the heart. This

redirects blood around the blocked artery in the heart to improve heart function and lessen

symptoms

Valve Repair or Replacement - If heart failure is caused by a defective or diseased heart

valve, your doctor may recommend repairing or replacing the valve to ease stress on your

heart.

Ventricular Assist Device (VAD) - A ventricular assist device (VAD) helps the heart pump

when it can't pump on its own. VADs are surgically implanted in the lower chambers of the

heart (the ventricles). VADs are sometimes called mechanical circulatory support devices.

Heart Transplant - If the heart can no longer meet your body's needs, you may need a heart

transplant.

NURSING MANAGEMENT (Belleza, 2021)

ANXIETY

 Maintain a calm and reassuring environment; minimize noise

 Provide familiar items; offer choices and follow home routine.

 Encourage parent’s presence and participation to enhance ability to support the child.

 Support expression and identification of feelings and worries of parent

 Compassionately acknowledge and validate concerns.

 Utilize existing coping strategies and assist in developing new strategies (e.g., music,

deep breathing, relaxation techniques, massage, diversional activity, play, pet

therapy).
39
  Identify thoughts and feelings that led to current anxiety onset to enhance

understanding of triggers.

 Reframe anxiety-provoking situations; provide a new perspective and engage in

problem-solving.

ASSESSMENT

 Assess for lowering of systolic pressure, low pulse pressure, and alternate strong and

weak pulsation.

 Assess for any signs and symptoms of less tissue perfusion including cold and

clammy skin, facial pallor, and poor capillary refill of nailbeds.

 Check for symptoms of hypovolemia like thirst, decrease in urine output, orthostastic

hypotension, weak thready pulse.

 Assess fluid balance, including intake and output, with a goal of optimizing fluid

volume

 Examine skin turgor and mucous membranes for signs of dehydration

 Assess for symptoms of fluid overload including shortness of breath, rapid weight

gain, oedema in arms, legs and face

ORAL HYGIENE

 Assist mother to brush patient’s teeth twice daily

 Educate mother to use a tooth brush with soft bristles to brush patient’s teeth

 Encourage mother to change patient’s tooth brush at least every 3 months

40
  Educate mother to use a fluoride toothpaste in brushing patient’s mouth

 Observe patient’s teeth for cavities and debris

 Observe patient’s tongue for its pinkish colour and moist with papillae

 Ensure patient’s lips are moist and devoid of cracks

FEEDING

 Patient’s meals should be spoon-fed

 Schedule regular meals and snacks, usually 3 meals and 2 snacks

 Offer more solids meals than liquids, consider fortifying calories with extra oils and

carbs, increase protein, and consider vitamin and/or mineral supplements especially

zinc and iron.

 Limit the patient salt intake and avoid high sodium diet and processed food.

 Feed the child slowly and carefully in a quiet environment

 Encourage parent to become involved in the child’s feedings.

 Carefully document food intake with caloric intake and strict intake and

output records.

PREVENTING DIARRHOEA

 Wash hands thoroughly under running water with soap before feeding or attending to

patient

 Educate patient and parents to wash hands under running water with soap

 Assist patient in washing the hands before and after eating, after playing and after

visiting the toilet

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  Educate parents to wash the hands before feeding patient, after visiting the washroom

and after nappy change

 Follow and teach parent good food safety practices

 Maintain environmental cleanliness

 Provide clean potty to patient

 Ensure patient’s toilets are clean

 Use and educate parent to use clean water

OTHER NURSING MANAGEMENT

 Give patient complete bed to reduces the workload of the heart.

 Nurse patient in a semi-recumbent position to promotes diuresis by improving renal

perfusion.

 Administer prescribed medications and monitor for any side effects.

 Administer prescribed diuretics in the morning to avoid sleep disturbances to the

patient.

 Keep a record of input and output. Fluid restriction should be there.

 Alert for any signs of hypokalemia including anorexia, nausea, vomiting, paralytic

ileus, muscle weakness, confusion, and dysrhythmias. Hypokalemia reduces force of

the contraction.

 Provide potassium supplement as prescribed.

 Administer I.V. fluid with the intermittent access device, it prevents fluid overload.

 Weigh the patient daily at the same time on the same scale, usually in the morning

after the patient urinates (a 0.9- to 1.4-kg gain in a day or a 2.3 kg gain in a week

indicates trouble)

 Auscultate lung sounds to detect an increase or decrease in pulmonary crackles

42
  Determine the degree of jugular vein distension

 Monitor the patient's pulse rate and BP and check for postural hypotension due to

dehydration

COMPLICATIONS (Sadasivuni et al., 2022)

 Kidney damage or failure. Heart failure can reduce the blood flow to your kidneys,

which can eventually cause kidney failure if left untreated. Kidney damage from heart

failure can require dialysis for treatment.

 Heart valve problems. The valves of the heart, which keep blood flowing in the right

direction, may not work properly if your heart is enlarged or if the pressure in your

heart is very high due to heart failure.

 Liver damage. Heart failure can cause fluid buildup that puts too much pressure on the

liver. This fluid backup can lead to scarring, which makes it more difficult for your liver

to work properly.

Many potential complications associated with heart failure therapy relate to the use

of diuretics.

 Hypokalemia. Excessive and repeated dieresis can lead to hypokalemia.

 Hyperkalemia. Hyperkalemia may occur with the use of ACE inhibitors, ARBs, or

spironolactone.

 Prolonged diuretic therapy might lead to hyponatremia and result in

disorientation, fatigue, apprehension, weakness, and muscle cramps.

 Dehydration and hypotension. Volume depletion from excessive fluid loss may lead

to dehydration and hypotension.

43
 Nursing Care Plan

DATE NURSING OBJECTIVES/OUT NURSING NURSING DATE EVALUATION SIGNA

AND DIAGNOSIS COME CRITERIA ORDERS INTERVENTION AND TURE/
TIME TIME INITIA
L

10/02/23 Anxiety related Patient will be relieved 1. Assess patient 1. Patient and 11/02/23 Goal fully met as: SS
to from anxiety within 24 and mother level mother’s level of 1. Patient seen
at breathlessness hours as evidenced by: of anxiety and anxiety assessed and at relaxed in bed
from 1. Patient seen relaxed reassure them of reassured. 2. • Nurse
02:30 inadequate in bed competent nursing 2. patient propped 03:00pm assessing
pm oxygenation 2. Nurse assessing care. up in bed patient’s oxygen
patient’s oxygen 2. Prop patient up 3. Oxygen therapy saturation to be
saturation to be within in bed to aid administered within normal
normal range (92%- breathing 4. All tight clothing range (92%-
100%) 3. Administer around patient’s 100%)
oxygen therapy neck, chest and
4. Loosen all tight abdomen loosened
clothing around 5. Patient’s mother
patient’s neck, educated on heart
chest and abdomen failure and its

44
 5. Educate mother management
on heart failure 6. All procedures
and its carried on patient
management explained to mother
6. Explain all Patient’s mother
procedure carried involved in patient’s
on patient to care
patient and mother 7. patient mother
7. Involve involved in patient’s
patient’s mother in care
patient’s care 8. Vital signs
8. Monitor vital including
signs including temperature, blood
temperature, blood pressure, pulse,
pressure, pulse, respiration and
respiration and oxygen saturation
oxygen saturation monitored.
4 hourly

45
REFERENCE

Belleza, M. (2021). Heart Failure; Nursing Management. 1–18. https://nurseslabs.com/heart-

failure/

Clopton, J. (2020). What Is a Sickle Cell Crisis?

https://www.webmd.com/a-to-z-guides/sickle-cell-crisis#1

Morrow, G., Roberts, A., Newton, J., Rees, J., Walkley, M., & Flavell, L. (2021). Impact of a

community-acquired pneumonia care bundle in North East England from 2014 to 2017

—A quality improvement project. Clinical Respiratory Journal, 15(1), 74–83.

https://doi.org/10.1111/crj.13271

Pace, B. S., Starlard-Davenport, A., & Kutlar, A. (2021). Sickle cell disease: progress

towards combination drug therapy. British Journal of Haematology, 194(2), 240–251.

https://doi.org/10.1111/bjh.17312

Sadasivuni, Kishor Kumar. Oadkad, Hassen M. Al-Maadeed, Somaya. Yalcin, Huseyin C.

Bahadur, A. B. (2022). Predicting Heart Failure. Wiley.

https://doi.org/10.1002/9781119813040

Schwinger, R. H. G. (2021). Pathophysiology of heart failure. Cardiovascular Diagnosis and

Therapy, 11(1), 263–276. https://doi.org/10.21037/CDT-20-302

Shankar, V. S. (2020). Respiratory Systems: Pathology on Pneumonias.

https://www.slideshare.net/VijayShankar4/respiratory-system-pathology-of-pneumonias

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 GROUP MEMBERS

NAMES INDEX NUMBERS

ANGELA ABLORH. 11420969

SALOMEY STANLEY GAMPSON. 11421189

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48