Ventral Septal Defect UNFOLDING Reasoning

Ventral Septal Defect UNFOLDING Reasoning Mandy Gray, 2 months old Primary Concept Perfusion Interrelated Concepts (In order of emphasis) • Gas Exchange • Clinical Judgment • Patient Education • Communication 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%  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) RELEVANT Data from Present Problem: Clinical Significance: 2 mos infant w/large VSD Tachypnea/Increased WOB Increased Wt by 8oz within 24h Extra fluid volume (blood) being pumped into lungs. FVO. Heart and lungs working harder to circulate the extra fluid. Heart & lungs working harder (congested) to compensate for the extra fluid. Extra fluid (RAAS system) RELEVANT Data from Social History: Clinical Significance: Mother (Jessica) is an RN Mother cares for Mandy at home Both parents are anxious/hopeful for surgery No grandparents on Father's (Jim) side, and both grandparents on Jessica's side (they don't live close by) Mother is able to understand Mandy's condition Mother knows daughter's needs. Imperative to reassure and support needs & concerns of parents. W/no grandparents or family close, a lack of support for the parents. 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) RELEVANT VS Data: Clinical Significance: HR: 210 RR: 74 BP: 70/45 MAP:50 SpO2: 90 Unsustainable heart function. Lungs are attempting to compensate, but is not compensating Blood pressure is not compensating. Hypoxia due to lack of perfusion. Current Assessment: 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) RELEVANT Assessment Data: Clinical Significance: Pale, quiet, WOB, tired Fine crackles bilaterally at bases/grunting/flaring/retractions Cap refill >2s, systolic murmur, Tachy @ apical, LE +1 Pitting edema Appears tired. Hepatosplenomegaly One wet diaper today Poor perfusion. Fluid buildup=increased weight. (inadequate perfusion) Poor perfusion to extremities. Increased HR to pump extra fluid. Edema from extra fluid. Tired due to poor perfusion. Hepatosplenomegaly due to? One wet diaper due to vasoconstriction to GI/GU/extremities. Body is compnesating only to the vital organs (vasodilating) and body is vasoconstricting the rest of the body. Cardiac Telemetry Strip: Regular/Irregular: P wave present? PR: QRS: QT: Interpretation: Regular-P wave present, QRS present, T wave present-Sinus Tachycardic