Congenital Heart Defect Unfolding Reasoning, Johnny Patterson, 5 months old (heart) | GRADED A.

Congenital Heart Defect Unfolding Reasoning Johnny Patterson, 5 months old Primary Concept Perfusion Interrelated Concepts (In order of emphasis) • Gas exchange • Nutrition • Elimi nation • Patient/family education NCLEX Client Need Categories Covered in Case Study NCSBN Clinical Judgment Model Covered in Case Study Safe and Effective Care Environment Step 1: Recognize Cues  • Management of Care  Step 2: Analyze Cues  • Safety and Infection Control Step 3: Prioritize Hypotheses  Health Promotion and Maintenance  Step 4: Generate Solutions  Psychosocial Integrity  Step 5: Take Action  Physiological Integrity Step 6: Evaluate Outcomes  • Basic Care and Comfort  • Pharmacological and Parenteral Therapies  • Reduction of Risk Potential  • Physiological Adaptation  Part I: History of Present Illness Johnny Patterson was born at 38 weeks gestation and diagnosed with Trisomy 21 (Down Syndrome). At his one-week well checkup at the pediatrician’s office, a prominent heart murmur was auscultated. An echocardiogram revealed a large ventricular septal defect immediately below the aorta. A referral was made to a cardiologist who suggested no immediate interventions because Johnny did not appear to be in any distress. Three weeks later at his second cardiologist appointment, his parents report that Johnny seems to be sleeping more. He seems to have times when he breathes faster than usual, and becomes sweaty when he breastfeeds. His weight is 4 kg. At his last visit three weeks ago he weighed 4.4 kg. The cardiologist prescribed 12 mcg digoxin every 12 hours (0.05mg/ml solution is received from the pharmacy) and 8 mg furosemide every day (10mg/ml oral solution is received from pharmacy). Personal/Social History: Johnny lives with his mom and dad who were married eight years ago. His mom is 37 years old and Johnny is their first child. Mom has had two miscarriages before being able to carry this baby to term. Both parents are engineers. Mom has recently begun working part-time from home so day care is not needed. 1. What data from the histories are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential) RELEVANT Data: Clinical Significance: Ventricular septal defect below aorta Lost weight in last 3 weeks Breathing difficulty, diaphoresis Prescribed digoxin and furosemide there is a hole in the heart between the left and right ventricles creating the murmur decreased weight, difficulty feeding diaphoresis are signs of a ventricular septald defect aid in help of circulation and work more efficiently (possible surgery) RELEVANT Data Social History: Clinical Significance: Born at 38 weeks, mother at advancedmaternal age Mother is able to work and stay hom a term birth and advanced maternal age is a risk factor of down syndrome The baby does not have to attend daycare/babysitter, mother will be able to care Dosage Calculation Current weight: 4.0 kg Digoxin 12 mcg BID PO. 0.05mg/ml solution. Dose in mL: 0.24 Safe dose? yes Furosemide 8 mg PO daily. 10mg/ml oral solution. Dose in mL:0.8 Safe dose? yes Johnny’s 5-month visit: What data is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential) RELEVANT Data: Clinical Significance: Increase meds as baby gains weight Digoxin dose is high, therapeutic effect range is 10-15 Furosemide increase Dosage Calculation Current weight: 7.2 kg Digoxin 22 mcg BID PO. 0.05mg/ml solution. Dose in mL: 0.44 Safe dose? yes Furosemide 14.4 mg PO daily. 10mg/ml oral solution. Dose in mL:1.44 Safe dose? yes Present Problem: Two Weeks Later… His mother brings Johnny, now 5 ½ months old, to the emergency department (ED). She is extremely anxious and states, “Something is wrong with my son. I can’t get him to keep any of his feedings down. Please help him!” The triage nurse obtains a history from the mother and finds out that he has vomited repeatedly the past 24 hours and had several loose stools. She reports that Johnny has been sleepier the last couple of hours. He was started on digoxin and furosemide four months ago to manage his heart failure secondary to a VSD that was diagnosed when he was one month old. When asked if she checks Johnny’s heart rate before giving digoxin, his mom admits that she forgot and has not checked his HR the past week. Education given about the need to check Johnny’s heart rate before each dose of digoxin and not to give the medicine if the heart rate is below 90 beats per minute. 2. What data from the histories are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential) RELEVANT Data Present Problem: Clinical Significance: Keeps vomiting and not able to keep feedings down Increased sleeping Unchecked HR prior to medication administration Possible digoxin toxicity Decreased HR= holding dose Patient Assessment Current VS: Normal Range: 5-month old FLACC Score: T: 37.0 rectal (C) Faces: 0 P: 85 (regular) Awake 100-180, sleeping 90-160 BPM Legs: 0 R: 36 (regular) 30-53 BPM Activity: 0 BP: 74/50 left leg Systolic 72-104 mm/Hg Diastolic 37-56 mm/Hg Crying: 0 O2 sat: 98% on RA Consolability: 0 What VS data are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: Pulse 85 Weight 6.5 kg Low heart weight The baby has lost weight, possibly due to not able to keep feedings down? Current Head to Toe Nursing Assessment: GENERAL SURVEY: Arouses easily but falls back to sleep NEUROLOGICAL: Patient opens eyes when Mom talks to him, but closes eyes quickly HEENT: Eyes PERRLA, Head without obvious deformities, Lips dry RESPIRATORY: Breath sounds equal and clear posteriorly and anteriorly CARDIAC: Circulation: Pink, warm & dry, no edema, heart sounds regular, pulses strong, equal. Capillary refill on toes 3 to 4 seconds ABDOMEN: Abdomen round, soft, and nontender. BS active in all 4 quadrants GU: No wet diaper in 6 hours per parent INTEGUMENTARY: Skin cool, dry, intact, normal color for ethnicity. Skin turgor decreased GI: Vomiting, diarrhea, decreased appetite What assessment data is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: Lethargic Arouses easily and falls back asleep Skin turgor decreased Medication is possibly making the baby more tired and lethargic. Could be possible toxicity/side effects and lead to fluid/electrolyte imbalnce Baby is showing no signs of dehydration 3. Interpreting relevant clinical data, identify potential problems. What additional data is needed to identify the priority problem and nursing priorities? (NCSBN: Step 2 Analyze cues/NCLEX: Management of Care/Physiologic Adaptation) Likely Problems: Additional Clinical Data Needed: Drug toxicity Possible side effects Digoxin serum level test urinalysis. serum electrolyte test, BUN, CBC, and creatinine While awaiting lab results, the primary care provider orders the following: Care Provider Orders: Rationale: Expected Outcome: Establish peripheral IV 0.9% NS 10 mL/kg over 15 minutes Place on cardiac monitor access to administer possible fluids and medications rehydrate infant and help with symptoms monitor babys HR and rhythm (digoxin) the baby will have patent IV that is clean, dry, and intact, no edema or redness. baby will have no signs of dehydration/diarrhea any heart abnomalities will recorded to read data and help determine possible problem 4. What are the nursing considerations with the effect on hospitalization for a child of this age? Interpreting Diagnostic Data Lab Results: Complete Blood Count (CBC) WBC HGB PLTs % Neuts Bands Normal Range: 6.1-17.5 g/dL(1 to 23 months) 9.3-13.3 mmol/L (3 to 11 months) 275-565 x10 to the 3