Ventral Septal Defect SKINNY Reasoning

Ventral Septal Defect SKINNY Reasoning Mandy Gray, 2 months old NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment • Management of Care 17-23% • Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% Psychosocial Integrity 6-12% Physiological Integrity • Basic Care and Comfort 6-12% • Pharmacological and Parenteral Therapies 12-18% • Reduction of Risk Potential 9-15% • Physiological Adaptation 11-17% Part I: Recognizing RELEVANT Clinical Data History of Present Problem: Mandy Gray is a two-month-old infant born with a large ventricular septal defect (VSD) that was diagnosed by her pediatrician during her two-week infant check-up. The parents called her pediatric cardiology clinic because Mandy was breathing faster and showed signs of increased work of breathing. Her mother states that she is having difficulty nursing because she tires easily and then becomes fussy and cries because she is hungry. Her height and weight are below the 25th percentile (wt: 4.5 kg. ht: 54 cm). Her Mom reports that Mandy’s weight has increased by 8 ounces (240 g) in the last 24 hours. Her pediatric cardiologist is concerned about worsening heart failure and Mancy will be admitted with a diagnosis of acute heart failure. Personal/Social History: Mandy is the first child of Jim and Jessica who were married two years ago. They were both raised in the Catholic faith but are not active in the church. Both parents seem anxious about their infant daughter but express hopefulness about the surgery to correct the problem. The surgery is scheduled in four months. Her mother is an RN who works in a dermatology clinic. Since Mandy’s birth, her mother has stayed home to care for Mandy because she is too medically fragile to be cared for in a daycare setting. Both of Jim’s parents are deceased, and Jessica’s parents live in another state. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) Patient Care Begins: Current VS: FLACC Behavioral Pain Assessment Scale: T: 99.4 F/37.5 C (temporal) Face: 1 P: 210/min (regular) Legs: 0 R: 74/min Activity: 0 BP: 70/45 MAP: 50 Cry: 1 O2 sat: 90% on RA Consolability: 0 What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) GENERAL APPEARANCE: Pale in color, quiet while in mother’s arms. Working moderately hard to breathe and appears tired with eyes closing but startles awake with loud sounds or voice RESP: Fine crackles at bases bilaterally. Grunting noted with expirations and mild to moderate sub-costal retractions and slight nasal flaring CARDIAC: Pallor noted at face and trunk; capillary refill is greater than 2 seconds. Grade 3/6 holosystolic murmur heard at 3rd, 4th, 5th intercostal space at the left sternal border. Apical heart rate is rapid and peripheral pulses are equal, weak but palpable, lower extremities 1+ pitting edema NEURO: Awake but appears tired. Responds to mother and father appropriately with an occasional smile. GI: Abdomen rounded, soft and non-tender, hepatosplenomegaly present, bowel sounds audible GU: Per Mom, has only had one wet diaper today SKIN: Skin integrity intact, skin turgor elastic What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance) Radiology Reports: What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) Radiology: Chest X-Ray Results: Clinical Significance: Cardiomegaly and increased pulmonary blood flow Heart has to work harder to pump blood Radiology: Cardiac Echocardiogram Results: Clinical Significance: Large perimembranous ventricular septal wall defect (VSD) Inadequate cardiac output Lab Results: WBC HGB PLTs % Neuts Current: 8.0 10.2 205 60 Most Recent: 8.5 10.5 250 55 Basic Metabolic Panel (BMP) Na K Gluc. Creat. Current: 130 5.5 70 0.2 Most Recent: 133 4.5 80 0.3 MISC.Misc. Mag Total Calcium Lactic Acid GFR PT/INR Current: 1.6 9.0 17.1 55 0.95 Most Recent: 2.0 8.9 10.0 57 1.0 Liver Panel Albumin Total Bili Alk. Phos. ALT AST Current: 2.3 0.5 400 42 74 Most Recent: 2.5 0.35 320 35 65 Cardiac Trop. BNP Current: <0.05 120 Most Recent: <0.05 <100 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) Part II: Put it All Together to THINK Like a Nurse! 1. Interpreting relevant clinical data, what is the primary problem? What primary health related concepts does this primary problem represent? (Management of Care/Physiologic Adaptation) Collaborative Care: Medical Management 2. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies) Care Provider Orders: Rationale: Expected Outcome: Admit to pediatric Special Care Unit. Saline lock IV -advanced care for patient -IV that’s available for continued use -patient will receive appropriate care -Saline lock will remain patent p y Diet as per breastfeeding schedule. May need to do gavage feedings with pumped breast milk or cardiac formula if oral/breastfeeding not tolerated -need nutrition to maintain energy, decreased risk for aspiration due to rapid breathing -patient will receive adequate nutrition & free from aspiration Place in an infant seat or may hold with head and upper chest upright > 30 degrees -allows expansion of lungs -patient will breathe easier Place on cardiac monitor and continuous pulse oximetry with vital signs and oxygen saturation recorded every 2 hours -monitor HR and oxygenation -frequent vitals will determine if condition is improving or worsening Furosemide 2mg/kg/dose now and then 1mg/kg twice daily -diuretic to decrease pressure on the heart -pressure will be reduced on heart Captopril 0.5 mg/kg/day PO divided every 8 hours -decreased work on the heart, improves heart’s ability to pump blood -hearts ability to pum will increase Start Digitalizing Dose: Digoxin 30 mcg/kg IV: give one-half of the total digitalizing dose (TDD) now then give one quarter in each of the two sequent doses at 12 hours intervals then begin daily dose of Digoxin 10 mcg/kg/day IV divided every 12 hours. -slows down HR -accurate amount of Digoxin will be given safely and will increase contractibilit of heart ECG 6 hours after each dose of Digoxin to monitor for toxicity Daily Weight Strict I & O -monitor for dysrhythmias -monitor for fluid retention -monitor for adequate hydration and urination -patient will remain free from dysrhythmias -patient will remain free from fluid retention