PART I

HISTORY TAKING

Bio-demographic Data

Name of the patient - Mr. Krishna lama

Age/Sex - 28yrs/ Male

Hospital number - 6708

Ward - Joanne Ward

Bed no. - 11

Marital Status - Married

Religion - Hindu

Occupation - Driver

Education - literate (10class)

Socioeconomic status - Middle class

Address -Baglung, Dhading

Date of admission - 2067/11/02 at 2:00 pm

Final diagnosis - Epidural hemorrhage

Date of care started - 2067/11/5

Date of care ended - 2067/11/10

Chief complains:-

Pain over the left knee joint and left hip

History of present illness:-

Mr. Krishna Lama 28 year’s old gentleman, a referred case from western
regional hospital with allergic history of fall from a height of 10-12 feet
yesterday at around 4 pm. He was under the influence of alcohol at that time
of incident. Following the incident there is history of loss of conscious for
around one and half hour. At that time there is no history of bleeding,

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vomiting or seizure like activity. There is history of irrelevant talks at that
time.

Family History

• Health status of the parents and his siblings: No any abnormality

found(including history of tuberculosis , diabetes serious illness or
complication, cardiac disease hyper tension and neurological disorder)
etc.

Medical History

• Cardiac disease -Not present

• Epilepsy - Not present
• Respiratory insufficiency - Not present
• Diabetes -Not present
• Anemia -Not present
• Injury or other infection.- Not present
• Childhood illness –No any

Nutritional history:

-He is a non- vegetarian. Takes every kind of food.

Occupational history:-

He is a head of family and he is driver.

Socio-Economic history:-

Middle class family.

Personal History

• Smoking and alcohol habit : Present

• Bowl & bladder habit : Regular
• Diet : simple & non vegetarian
• Any allergic history of drugs, foods etc: No

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 PHYSICAL EXAMINATION

Date:- 2067/11/7

o Observe general condition /appearance

 Nutritional status - average
 Personal hygiene – Normal
 Build – average
 Neurological Status
 Behavior – co-operative
 Mental State – patient was oriented
Clinical examination
Weight –50 kg , Height – 5ft. 5"

Vital signs

 T- 99 degree F
 P – 80 beat/min
 R – 20times/min
 BP – 100/70 mm of Hg
o Systematic examination
 Head
 Inspect color of hair texture – Normal
 Cleanliness of head and hair – not well
 Eyes
 Sclera – Normal
 Cornea – Normal
 Swelling – not found
 Pupil reaction – normal
 Eye movement – normal

 Ears

 Inspect and palpate outside of ears-normal

 Check deformity of mastoid-no any
 Discharge - no
 Examine hearing capacity- normal
 Nose

 Inspect nose for flaming – Normal

 Discharge – No
 Nasal septum – centrally located
 Polyp or tumor – not present
 Blockage problem- not present
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 Oral Cavity

Inspect teeth gum for swelling or bleeding - No

Tongue for color and dehydration – mild type
Enlargement of tonsils – No
Any gingivitis or dental carries – No
Hygiene of oral cavity – Not well
 Color of Lips - pinkish
 Neck

 Inspect necks position vein - Normal

 Palpate enlargement of thyroid glands- Normal
 Lymph nodes-Normal
 Ability to move neck- Normal
 Respiratory System

 Breathing pattern –Irregular

 Size and shape of chest – Normal, bilateral equal movement
 Cough – present
 Chest movement – Irregular
 Respirator rate – 24/m
 Auscultate for detection of breathing sound – Abnormal breath
sound. ( slightly crackles)
 Cadio - Vascular System

 Auscultation the heart sound:- S1+ S2+ M+ Present, palpitation

 Pedal edema – Slightly edema on leg
 Rhythm – Slightly irregular
 Pulse – 80/min
 BP – 100/70 mm of Hg
 Musculo Skeletal System

 Inspect Joint movement- Normal, moveable

 Joint deformity-not any
 Redness-no
 Swelling at foot area – edema on foot area
 Genitor-Urinary

 Observe or Inspect for swelling – not

 Pain in micturation – no
 Hygiene – normal

 Endocrine system( thyroid, supra-renal: pituitary, genitalia,

breasts, fat and hair distribution)- Normal

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  Skin and glands ( rashes, naevi, scars, pigmentation, petechiae,
nails, mucous membranes, teeth lymph glands, salivary glands)-
Normal

 Bones and joints (deformity, mobility, arthritis)-Not significant

Abnormal findings during examination

 Irregular breathing pattern

 Irregular chest movement.

 Abnormal lung sound

 Abnormal heart sound

 Edema on foot area

 Enable to walk due to restricted movement of TPI leg.

 Palpitation

 Anxiety

 Not good hygiene

 Back pain.

 Hypertension etc.

PART II

Definitions:-

Epidural hemorrhage occurs in the potential space between the dura and the cranium. Epi is
Greek for over or upon. An Epidural hemorrhage can also be referred to as extradural (outside of
the dura).

It is a type of traumatic brain injury (TBI) in which a buildup of blood occurs between the dura
mater (the tough outer membrane of the central nervous system) and the skull. The dura mater
also covers the spine, so epidural bleeds may also occur in the spinal column. Often due to

5
trauma, the condition is potentially deadly because the buildup of blood may increase pressure in
the intracranial space and compress delicate brain tissue.

Epidemiology

. Frequency
United States

Epidural hematoma occurs in 1-2% of all head trauma cases and in about 10% of patients who
present with traumatic coma.

Mortality/Morbidity

Reported mortality rates range from 5-43%.

Higher rates are associated with the following:

• Advanced age
• Intradural lesions
• Temporal location
• Increased hematoma volume
• Rapid clinical progression
• Pupillary abnormalities
• Increased intracranial pressure (ICP)
• Lower Glasgow coma scale (GCS)

Mortality rates are essentially nil for patients not in coma preoperatively and approximately 10%
for obtunded patients and 20% for patients in deep coma.

Age

Patients younger than 5 years and older than 55 years have an increased mortality rate.

Patients younger than 20 years account for 60% of EDHs.

EDH is uncommon in elderly patients because the dura is strongly adhered to the inner table of
the skull. In case series of EDH, fewer than 10% of patients are older than 50 years.

Causes of Heart Block:-

• Skull fracture during childhood or adolescence.

• Rupture of a blood vessel, usually an artery,.

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 • Venous (from a vein) bleeding in young children.
• Severe head injury, caused by motorcycle or automobile accidents.

Patho-physiology

Approximately 70-80% of epidural hematomas (EDHs) are located in the temporoparietal region
where skull fractures cross the path of the middle meningeal artery or its dural branches. Frontal
and occipital epidural hematomas each constitute about 10%, with the latter occasionally
extending above and below the tentorium. Association of hematoma and skull fracture is less
common in young children because of calvarial plasticity.

Right temporal epidural hematoma with midline shift.

Patient should be taken immediately to the operating room for neurosurgery. This
may require emergent transport to a trauma center or other facility with a
neurosurgeon available.

Epidural hematomas are usually arterial in origin but result from venous bleeding in one third of
patients. Occasionally, torn venous sinuses cause an epidural hematoma, particularly in the
parietal-occipital region or posterior fossa. These injuries tend to be smaller and associated with
a more benign course. Usually, venous epidural hematomas only form with a depressed skull
fracture, which strips the dura from the bone and, thus, creates a space for blood to accumulate.
In certain patients, especially those with delayed presentations, venous epidural hematomas are
treated nonsurgically.

Expanding high-volume epidural hematomas can produce a midline shift and subfalcine
herniation of the brain. Compressed cerebral tissue can impinge on the third cranial nerve,
resulting in ipsilateral pupillary dilation and contralateral hemiparesis or extensor motor
response.

Epidural hematomas are usually stable, attaining maximum size within minutes of injury;
however, Borovich et al demonstrated progression of epidural hematoma in 9% of patients
during the first 24 hours. Rebleeding or continuous oozing presumably causes this progression.
An epidural hematoma can occasionally run a more chronic course and is detected only days
after injury.

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 Comparing patient’s signs and symptoms with books:-

The typical pattern of symptoms that indicate an extradural hemorrhage is loss of consciousness,
followed by alertness, then loss of consciousness again. But this pattern may NOT appear in all
people. The symptoms usually occur within minutes to hours after a head injury and indicate an
emergenc

According to book In my patient

Confusion
Drowsiness or altered level of alertness
Enlarged pupil in one eye
Headache (severe)
loss of consciousness
Nausea and/or vomiting
Weakness

Comparing Diagnosis with books:-

According to books According to patient

CT Scan

x-ray
MRI

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Investigations

Date Type of Patient value Normal value

investigation

2067-11-4 Biochemistry
test
26 10-50 mg%
Urea

Creatinine 0.6 0.4-1.4mg%

Sodium 137 135-146mEq/L

Potassium 3.8 3-5mEq/L

Glucose 106 Upto 140mg%

random

Haematologic
al test

Hb 14.8 M:-13-17mg/dl,
F:- 12-15gm%

WBC 8600 4000-

11000/ccm

Differential
count

Neutrophil 65

40-80%

Lymphocytes 30 20-40%

Monocytes 05 2-10%

Eosinophil 00 1-6%

ESR 04

Platelets 220000

Bleeding time 2minutes 2-7 minutes

Prothrombine
test

Prothrombine 14seconds
time test

Prothrombine 13seconds
time control

INR

Blood group B9+VE

and RH

Serological
test
Medical management

Comparing management of patient with book.

Initial resuscitation efforts include assessment and stabilization of airway patency, breathing, and
circulation. A thorough trauma evaluation is mandatory, including inspection for skull fractures
and appreciation of the force and location of impact. Immobilization of the spine should be
followed by emergent transfer of the patient to the nearest level I trauma center supported with
neurosurgical consultation.

• Triage and initial management of a patient with epidural hematoma may be tailored to the
degree of neurological impairment at presentation. Alert patients may be evaluated with a
CT scan following a brief neurologic examination.
• A patient with a small epidural hematoma may be treated conservatively, though close
observation is advised, as delayed, yet sudden, neurological deterioration may occur.
• Trauma patients may require diagnostic peritoneal lavage and radiographs of the chest,
pelvis, and cervical spine.
• While neurosurgical consultation is requested, administer intravenous fluids to maintain
euvolemia and to provide adequate cerebral perfusion pressure.
• Patients with elevated intracranial pressure may be treated with osmotic diuretics and
hyperventilation, with elevation of the head of the bed at an angle of 30 degrees. Patients
who are intubated may be hyperventilated with intermittent mandatory ventilation at a
rate of 16-20 breaths per minute and tidal volume of 10-12 mL/kg. A carbon dioxide
partial pressure of 28-32 mm Hg is ideal, as severe hypocapnia (< 25 mm Hg) may
induce cerebral vasoconstriction and ischemia.
• Coagulopathy or persistent bleeding may require administration of vitamin K, protamine
sulfate, fresh frozen plasma, platelet transfusions, or clotting factor concentrates.

Although several recent reports have described successful conservative management of epidural
hematoma, surgical evacuation constitutes definitive treatment of this condition. Craniotomy or
laminectomy is followed by evacuation of the hematoma, coagulation of bleeding sites, and
inspection of the dura. The dura is then tented to the bone and, occasionally, epidural drains are
employed for as long as 24 hours.

Minimally invasive surgical procedures, including the use of burr holes and negative pressure
drainage, may be used in selected cases.

• Novel therapeutic approaches

o Endovascular embolization to minimize bleeding during the acute stage
o Thrombolytic evacuation using closed suction drain

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Prognosis
• An extradural hemorrhage has a high risk of death without prompt surgical
intervention. Even with prompt medical attention, a significant risk of death
and disability remains

Complication

• There is a risk of permanent brain injury whether the disorder is treated or untreated.
Symptoms (such as seizures) may persist for several months, even after treatment, but in
time they usually become less frequent or disappear completely. Seizures may begin as
many as 2 years after the injury.
• In adults, most recovery occurs in the first 6 months, with some improvement over
approximately 2 years. Children usually recover more quickly and completely than
adults.
• Incomplete recovery is the result of brain damage. Other complications include
permanent symptoms (such as paralysis or loss of sensation, which began at the time of
the injury), herniation of the brain (which may result in permanent coma), and normal
pressure hydrocephalus (excess fluid in the cavities of the brain).

Drugs used in my patients

-Injection NS with 20 meg KCL in alternate drip IV pint over 24 hours.

-Injection Aciloc 50 mg IV 8 hourly.

-Injection Pentazocin 30 mg 8 hourly.

PART III

Nursing process (Nursing management)

Pre-operative management

Assessed his health factors that affect his pre-operatively i.e nutritional and
fluid status, respiratory, cardiovascular, hepatic, renal endocrine,
immune function.

11
Preanesthetic checkup was done.
Assessed his psychological factors as well as cultural and spiritual beliefs.
Explained him and his family members about the operative procedure,
complication etc. and take voluntary and written consent.
Checked all the necessary materials required prior surgery like investigation
reports, x-ray, allergic test, blood grouping etc and sent them
immediately if they are missing.
Keep him NPO for about 8 hours.
Prepare the bowel for surgery by using prescribed laxatives.
Rechecked all the necessary required materials including informed consent.
Prepared him for operation i.e change gown, remove jeweler, artificial
dentures, plates or any other artificial materials.
Asked him to void before entering OT.
Assessed his vital signs before entering OT.

Pre-operative management

Prevented respiratory complication

Assessed his breathing pattern, rate regularity and ausculted his chest for
crackles, wheezing sounds.
Taught him deep- breathing and coughing exercise.
Encoruraged him to take deep breaths every 2 hours.

Relieved pain

Assessed the pain intensity.

Provide pain medication as prescribed.
Provide mind diversional therapy like talked to the patient, asked him to
think something about positive.

Maintain nutrition

Provide oral intake from small sips to clear liquid and to soft diet if tolerated.
Encourage him for oral hygiene.
Explain the importance of diet for healing.

Provided emotional support to the patient and family

Provided them reassurance and information and spent time listening to and
addressing their concerns.
Informed them when to initiate oral food with what when to get out of the
bed, when IV lines are removed.
Manipulated the environment to enhance rest and relaxation of my patient.

Psychological management

12
Beside pre-operative anxiety, fear and post-operative anxiety, I also provided
psychological care to my patient. During his hospital stay, following
psychological cares were received by my patient.

Assessed his psychological state and identified previously used coping

mechanism.
Assessed his feeling about his disease, hospital stay, treatment etc.
Acknowledge family members concerns and accepted and encouraged their
participation in his care.

Application of Nursing Theory in Nursing Management

To this patient, I applied the Henderson’s Basic Need (independent theory)

which suggest for the fulfillment of 14 needs. His focus on individual care is
evident in that he stressed assisting individual with essential activities to
maintain health, to recover or to achieve which the optimum level of
functioning of health which the person is unable to do independently.

Henderson’s 14 basic needs are:-

The patient independence is an important criterion for health.

Henderson identifies 14 basic needs that form the component of nursing
care. The nurse help the patient meet these needs.

1 Breath normally Mr. K.B subba was 54 years old,

and he had dyspnea and
shortness of breath related to
disease condition. So O2
administered and position
changed on no TPI implanted
side.

2 Eat and drink adequately he had lost appetite. So, I

encouraged his for taking small
amount of food without fat and
salt.

3 Eliminate body waste His bowel habit was normal but

he had incontinence of urine
related to disease condition. So,
catheterization done.

4 Move and maintain desirable he couldn’t move and maintain

position desirable position related to
disease condition. So, positions
changed according to patient’s

13
 need for comfort and to prevent
pressure sore as well on non
implanted side.

5 Sleep and rest Normal pattern of sleeping.

6 Select suitable clothing Suggest for loose dress but

changed dress according patient’
s hygiene.

7 Maintain body temperature His body temperature was up and

down for sometime so that
paracetamol 500mg OD given
and cold sponge also provided.

8 Maintain bodily cleanliness he could not clean and maintain

and grooming his hygiene due to weakness. So,
helped his for maintaining his
hygienic status and body
cleanliness by changing dress
and morning care.

9 Avoid danger in environment Provided psychological support

and avoid injuries due to not allowed visitor in CCU
so that ward staffs was closed
supervision.

10 Communicate with others to To express his anxiety, fear and

express emotion, needs, fear opinion with others, I suggested
or opinion his to communicate with his
Doctors, ward sisters, sons,
daughters, grand children. So
that he could feel relax after
expressing anxiety.

11 Worship according to one’s he was let to do whatever she

faith want to according to his own
faith.

12 Work in a way that provides a he had good sense of

sense of accomplishment accomplishment.

13 Play or participate in various he used to participate in various

forms of reaction forms of reaction as he could
whether in society or at home as
well.

14 Learn, discover or satisfy the he was becoming interested in

14
 curiosity that leads to normal doing something that he can do.
development and health

Assessme Diagnosis Goals planning Rational Evaluation

nt e

Subjective Altered Nutritional To assess Helps to

data;- nutrition pattern will the get
pattern be nutrition baseline Goal was
Patient related to maintained pattern. data. partially
said that “ met as the

15
I don't like disease during To Helps to patient’s
meals." condition. hospitalizati encourage maintain nutritional
on. for time body condition
interval & function was
small as well as improving.
Objective
amount of prompt
data:-
food coronary
-Patient except circulatio
seems highly salt n by
exhausted. and fat maintaini
containing ng
-Patient diet. pressure.
seems
weak.

To monitor Helps to
& record identify
the bowl the
movement improve
s, body ment
weight of
patients.

To Helps to
encourage feel fresh
the &
nutritional increase
hygiene. the
appetite.

To explain Helps to
the eat a
importance food at
of diet. time.

16
 Anxiety related to fear of fetal death

Assessme Nsg.diagnos Nsg.goal Plan of Rationale Evaluatio

nt is action n

Subjective Anxiety Anxiety To assess - It helps to

data:- related to will be the patient’s know the
fear of death. reduced 2 condition by level of Goal was
he days. maintaining anxiety of fully met as
verbalized interpersona patient. he
that, “I feel l relationship verbalized
so sad”. his feeling

17
 To provide - It helps to as well as
complete reduce she looks
Objective information anxiety by happy &
data:- about heart knowing active after
block and its the disease knowing
he looks
treatment . condition. the
anxious,
information
sad &
of disease
fatigue.
condition.
To -It helps to
encourage reduce
to take tension by
nutritious maintainin
diet by g body
maintain function.
salt and fat
amount.

To - It helps to
encourage minimize
to express anxiety by
his problems sharing his
with visitors problems.
or nurse.

Ineffective cardiac tissue perfusion related to reduced coronary blood

flow

Assessme Nsg.diagnos Nsg.goa Plan of Rationale Evaluatio

nt is l action n

18
Subjective Ineffective Cardiac To assess - It helps to
data:- cardiac tissue tissue the patient’s determine
perfusion perfusio condition by the Goal was
cause
he related to n will be collecting fully
and effect of met
verbalized reduced effected sign and chest as he
that, “I feel coronary for symptoms discomfort verbalized
so sad”. blood flow. 3days. and providehis feeling
a as well as
baseline
which she looks
post
therapy. happy &
Objective
active due
data:-
To monitor - It helps to to TPI.
he looks ECG diagnose of
anxious, regularly . and
sad & extension of
fatigue. MI.

To provide -It helps to

02 therapy increases
continuously the 02
. supply to the
myocardium
if actual 02
saturation is
less than
normal.

To ensure - It helps to
physical to reduces
rest; use of myocardial
the bedside 02
commode consumption
with .
assistance

High risk for infection related to surgical incision.

Assessme Nsg.diagno Nsg. goal Plan of Rational Evaluatio

nt sis action e n

19
 High risk for Infection will To assess - It helps Goal was
infection be prevented the patient to know fully met,
related to during by taking the this
surgical hospitalizatio vitals sign. general condition
incision n. condition hadn’t
(pacemaker of developed
insertion) patient. to my
patient.
To use - It helps
aseptic to
technique prevent
during cross
providing infection.
care.

To teach - It helps
about to
maintain maintain
hygiene and personal
care of hygiene
incision site. &
prevent
infection.

-To suggest - It helps

the patient to
maintain prevent
personal from
hygiene by cross
doing his infection.
morning
care and
changing his
clothes and
bed sheet
and
maintain his
home
environment
..

STRESS MANAGEMENT:

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 Stress is a change in environment or unpleasant experience of, life that is
prescribed as a threat, challenge or harm to the personal dynamic
equilibrium. When stress is more severe or more prolonged than usual,
however a person may need a nurses help in coping she was on stress
due to strange environment and feeling of tension because baby
condition and also due to painful medical procedure. I tried to minimize
her stress by-

 Building good rapport with patient, his parents and other family
members.
 Giving a complete orientation of ward, routine of ward, its rules and
regulation e.g. visiting time, diet, doctor’s round, available facilities
etc.
 Giving clear information of disease.
 Parents are allowed and encouraged to express their feelings and
concerns and cleared them whenever possible.
 Developing a trustful relationship with patient and his family.
 Giving clear information about treatment procedure.
 Respecting them, their culture, belief and practice.
 By applying different diversion therapy to the patient to divert their
mind from the stress of pain.

DIVERSIONAL THERAPY

To, the patient since patient was diagnosed as Complete Heart Bock I
applied the diversional therapy of mind which helped his to flip out his
mind to another topic so that his problems don’t bother his performance.

Initiating Non-pharmacologic relief measures:- Although sedatives

& analgesics are usually the primary treatment of sleep disturbance and
pain, there is a growing trend involving integration of complementary,
non pharmacologic measures with conventional medical treatment.

Distraction:- distraction requires the patient to focus attention on

something other than the tension. It has also proved effective when
used with sedative/analgesics for treatment of a brief episode of severe
pain. Techniques that distract attention include the following:-

• Visual distraction- reading on books and watching T.V

• Auditory distraction- listening of music

• Tactile kinesthetic distractions- slow rhythmic breathing

Relaxation:- relaxation technique reduce skeletal muscle tension and

lessen anxiety, by assisting the patient with relaxation technique, the
nurse acknowledges the patient’s pain & expresses a willingness to help
the patient relieve the distraction caused by his or her pain includes:

21
  Improved problem solving ability

 Distraction from pain.

Cutaneous stimulation:- it relieves acute or chronic pain. Technique

such as pressure, massage, heat, cold.

It also works in principle of distraction & relaxation & also help to

establish or extend nurse-patient relationship.

I applied to my patient all above diversional therapy .

DISCHARGE TEACHING:- Health teaching is an important part while

providing care to patient as well as family members. It is an integral part of
the nursing process too. It begins from the time of admission till the
discharge time including follow up visit/care. So, it is our responsibility to
plan and suggest the patient and family members for continuity of care at
home and motivate them to implement the suggested plan at home. Patient
was not discharged during my duty period but I planned health teaching on
different topics. These are following:-

1. Nutrition
2. Personal hygiene
3. Exercise and rehabilitation
4. Sexual intercourse
5. Medication
6. Follow up visit

1. Nutrition. I will provide importance and function of nutritious diet to

maintain health and encourage to take small amount frequently. I will inform
about which type of food prefer( vegetables, fruits and fiber rich foods) or
which isnot prefer(cholesterol containing food, alcohol, and junk food )

2. exercise and rehabilitation:- I will provide importance and how much

time do and what types of exercise will needed.

3. Personal hygiene:- I will encourage of maintaining personal hygiene

after returning your home and teach your family about hygiene importance
and keep patient in good hygiene.

4. Sexual intercourse:- I will teach about limitation of sex during

pacemaker implant time and which time suit for sex after implant.

5.Safety and security:-

• Should manage well toilet.

22
 • Not leave patient alone.

• Patient should take ID card if go anywhere.

• Patient should take some precaution if pacemaker insertion.

6. Medicine:- I will give teaching about regular medication time, duration

and certain side effects of medicine. Take medicine regularly according to
discharge order.

7. Follow – up visit:- Should have follow up according to discharge order.

Advised his any time follow up visit if any complication raised .I explained
about importance of follow up visit and come this hospital if possible
otherwise visit other facilities near to his village.
Health teaching:-Health teaching plays an important role to prevent
disease, promote health as well as to cure disease more rapidly
without any complications. One of the most important roles of the
nurse is to provide health education. So I, being a nurse, I had also
given health education to patient and family.

• To promote the health

• To motivate for early diagnosis and treatment
• To help limit the disability
• To keep in relationship
Keeping above objectives in mind I had given health education to the patient
about following topics.
Nutrition:-. Cardiac patient needs adequate amount of balance diet
including low salt and restricted fat diet and should take soft and digestible
food with small amount frequently.

• Choose fresh vegetables grown locally whenever possible

• Eat whole-grain products

• adequate amounts of B-complex.

• Low salt and fat diet

Exercise and Rehabilitation:-

• May return to doing normal activity within 6 wks after surgery.

• Any exercise is fine after 4-5 wks

• May still go to work unless the physician was instructed you what not
to do so.

• May almost do all household activities.

23
 • May still participate in sport and other recreational activity except
contact sports that may increased the chance of receiving a blow on
the chest and pacemaker device.

Treatment:-

• Wound care:-

- Proper hand washing should be carried out and observe

cleanliness at all times.

- Observe wound daily, instruct patient to report any sign of

inflammation to your doctor.

- Clean the wound daily by prescribed antiseptic solution.

- Wear loose clothes

- After 1 wk stitches remove if shower cover the incision site.

• Pacemaker management:- Regular ensure that pacemaker is

properly placed by; taking pulse daily either radial or carotid. The
pulse is found on the site of lower neck, on the side of elbow. If
the rate is slower than normal inform to doctor.

Rest and sleep:-

Rest and sleep is very important cardiac patient. So he has to rest in a day
also. Sleep pattern should be good. Light exercise can be done. Lifting heavy
things should be avoided.

Personal hygiene-

• Maintain cleanness at all time by doing the following; take a bath

daily to cover the wound, practice good oral hygiene by bruising
your teeth, keep finger/toes nails properly trimmed, make sure
perineal area should cleaned daily.

• Wear clean and loose clothes.

• Wear supporting bra and to cover generator by gauze.

Sexual intercourse / Social/Spiritual:-

• May continue sexual contact after 6 wks of surgery.

• May joint support group concerning patient also with

pacemaker.
24
 • You may practice healthy habits; Take enough sleep and rest( at
least 7 hours), drinking plenty of water (8 glasses), Avoid alcohol
intake)

• May not restrict at any area or he may participate in any area

but with ID card.

Follow Up-

• Before leaving the hospital the patient will have full evaluation
including chest x ray,ECG, ECHO, and pacemaker check. 1wk to 10
days after discharge , incision site will be checked.

• 6 to 8 wks after placement of pacemaker, a full evaluation including

chest x ray, eco, ECG and pacemaker will be checked.

• 3 to 6 moth. after placement of pacemaker, patient should visit doctor

to check pacemaker through phone, or direct.

• Once or twice per year , patient will be asked to visit his doctor to full
evaluation of pacemaker.

Others-

Immediate check up if any signs of infection, fever, chest pain, swelling, or

any complication.

At last I am satisfied with this case presentation because the goals

(Objectives) were met.

25
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