Exam (elaborations) NURS 243 Keith RN Congenital Heart Disease Case St

Exam (elaborations) NURS 243 Keith RN Congenital Heart Disease Case St 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) Physiological Integrity Basic Care and Comfort 6-12% Pharmacological and Parenteral Therapies 12-18% Reduction of Risk Potential 9-15% Physiological Adaptation 11-17% RELEVANT Data from Present Problem: Clinical Significance: ● PMH/x of VSD ● Increased WOB and elevated RR ● Difficulty feedings d/t pt tiring easily ● Pt is below 25th percentile in weight and has gained 8 oz in the last 24 hrs Pt’s heart failure seems to be worsening, with the rapid gain of weight it suggests that she is retaining fluid most likely in her extremities (edema) we need to get rid of that extra fluid (diuretic) We need to monitor nutritional intake so that she does not drop below 5th percentile We also must definitely address her increased WOB and RR by checking her sats and if they are below 95% implementing supplemental O2 if appropriate She is at risk for acid base imbalance (elevated RR and increased WOB) and F&E imbalance (fluid retention and inadequate nutritional intake) RELEVANT Data from Social History: Clinical Significance: Patient Care Begins: What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved. The parents are overwhelmed they have no support system (the parents parents are deceased or out of state) Mom is a nurse and can not work d/t having to take care of pt Increased anxiety on the parents can affect the baby if they are stressed out then baby can sense that and become stressed as well 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 RELEVANT VS Data: Clinical Significance: ● Elevated HR ● Elevated RR ● Decreased o2 ● 2 on the FLACC ● Tachy and elated RR decreased o2 d/t heart failure, your body is trying to compensate ● We need to use supplemental o2 ● Pt is in pain 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 3 rd , 4 th , 5 th 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 What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance) 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 RELEVANT Assessment Data: Clinical Significance: ● Pallor of face and trunk with prolonged cap refill ● 3/6 holosystolic murmur at 3rd, 4th, and 5thintercostal space, pulses weak and palpable, LE +1 pitting edema ● Increased WOB ● Fine crackles at bases with grunting, substernal retractions, and nasal flaring ● Presenting with mild lethargy ● Enlarged liver blood is pulling into liver and spleen d/t congestion ● Respiratory distress is evident and needs treated decreased perfusion is also noted, supplemental O2 needed wich will also improve decreased LOC ● Turbulent blood flow in the heart AED holosystolic murmur ● Edema is present d/t CHF and a possible diuretic is needed if appropriate Cardiac Telemetry Strip: Regular/Irregular: P wave present? PR: QRS: QT: Interpretation: Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved. Radiology Reports: What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) Lab Results: What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) Clinical Significance: Radiology: Chest X-Ray Results: Clinical Significance: Cardiomegaly and increased pulmonary blood flow Could indicate an enlarged VSD Cardiomegaly indicates that the heart is working extremely hard to keep up with basic functions and therefore has enlarged in size just like someone working out their biceps and they get bigger over time Radiology: Cardiac Echocardiogram Results: Clinical Significance: Large perimembranous ventricular septal wall defect (VSD) There is significant back flow into the heart right ventricle causing too much blood to go to the lungs and pull into other organs causing the extremities to not be adequate prefused Complete Blood Count (CBC) WBC HGB PLTs % Neuts Current: 8.0 10.2 205 60 WNL Most Recent: 8.5 10.5 250 55 WNL RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: All labs WNL Labs indicate no signs of infection or hemorrhage Stable What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved. What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) Basic Metabolic Panel (BMP) Na K Gluc. Creat. Current: 130 5.5 70 0.2 Most Recent: 133 4.5 80 0.3 RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Hyponatremia Hyperkalemia Low creatinine The pt is holding on to a significant amount of extra water AEB +1 edema therefore is makes sense that she is hyponatremic she also has heart failure which this imbalance goes hand in hand with The increased potassium can cause life threatening arrhythmias which she already has heart failure and a VSD so we need to fix this soon The low creatinine indicates decreased kidney function, she is retaining a lot of water and that the kidneys are not functioning properly Worsening 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 RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) Low magnesium Low GFR The magnesium can be the cause for her fatigue The pt’s GFR indicates kidney disease Worsening Liver Panel Albumin Total Bili Alk. Phos. ALT AST Current: 2.3 0. Most Recent: 2.5 0. RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: AST elevated Low albumin High AST can indicate heart problems which the pt has, or it indicate liver issue which there is pooling blood in liver at this time Low albumin is evidence of malnutrition, the pt is on the lower side of weight for her age however she is not below the 5th percent Worsening Cardiac Trop. BNP Current: <0.05 120 Most Recent: <0.05 <100 RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: BNP elevated Elevated BNP is indicative of heart failure Worsening Lab Planning: Creating a Plan of Care with a PRIORITY Lab: (Reduction of Risk Potential/Physiologic Adaptation) Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved. Clinical Reasoning Begins… 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) Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: BNP Value: 120 Critical Value: Indicative of heart failure it is elevated since last lab which means heart failure is worsening Freq cardiac assessments Consistent tele monitoring Notify provider ASAP Problem: Pathophysiology of Problem in OWN Words: Primary Concept: Heart failure secondary to VSD The heart is not able to adequately provide enough oxygenated blood to the bodies tissues even though it is working very hard to do so, the hole in the left ventricle caused by the VSD is creating backflow into the right ventricle having an excess of blood go to the lungs which pools in other organs and the lack of blood in the left ventricle is trying to compensate by working really hard to push that blood out to the extremities which it is unable to do The heart begins to fail because it cannot meet the the demands to adequate oxygenate the body d/t a hole in the heart Care Provider Orders: Rationale: Expected Outcome: Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved. PRIORITY Setting: Which Orders Do You Implement First and Why? (Management of Care) Admit to pediatric Special Care Unit. Saline lock IV Diet as per breastfeeding schedule. May need to do gavage feedings with pumped breast milk or cardiac formula if oral/breastfeeding not tolerated Place in an infant seat or may hold with head and upper chest upright > 30 degrees Place on cardiac monitor and continuous pulse oximetry with vital signs and oxygen saturation recorded every 2 hours Furosemide 2mg/kg/dose now and then 1mg/kg twice daily Captopril 0.5 mg/kg/day PO divided every 8 hours 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. ECG 6 hours after each dose of Digoxin to monitor for toxicity Daily Weight Strict I & O ● Pt needs higher level of care and continuous monitoring ● We need access for medication and fluid replacement ● Need to make sure that baby is getting adequate nutrition ● Will help decreased WOB ● Must monitor heart and o2 level at all times since pt was trending towards hypoxia and pt has cardiovascular problems ● Furosemide to get rid of excess fluid from fluid retention and fix hyperkalemia ● Captopril helps treat heart failure ● Digoxin will fix the tachycardia and lower the workload for the heart so that it may rest ● ECG to see the effectiveness of the meds specifically digoxin ● Daily weight and I &Os to see effectiveness of furosemide By giving these meds and monitoring the heart and lungs, we can decrease the amount of work that the heart has to do makes sure our pt is adequate oxygenated, and our pt is not retaining fluid Care Provider Orders: Order of Priority: Rationale: Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (Management of Care) 4. What body system(s) will you assess most thoroughly based on the primary/priority concern? (Reduction of Risk Potential/Physiologic Adaptation) Admit to pediatric Special Care Unit. Position upright in infant seat or parents to hold. Mattresses on beds can be adapted to prop infant up as well. Start IV saline lock for medications Furosemide 2mg/kg/dose now then begin 1 mg/kg/dose twice per day Digitalizing dose of Digoxin 30 mcg/kg IV: give one half now then one quarter for each subsequent doses every 12 hours Daily dose of Digoxin 10 mcg/kg/day divided every 12 hours. Captopril 0.5 mg/kg/day PO divided every 8 hours 1. Pt needs to be admitted 2. Sit upright 3. Start IV 4. IV digoxin 5. Captopril 6. Furosemide 7. Daily digoxin 1. Pt needs to be admitted to receive this care first 2. Sit upright to reduce venous return and thus reduce workload of heart 3. Start IV for meds 4. We must decrease HR and decrease workload of heart ASAP (IV quick) 5. Decreased workload of heart 6. We need to get rid of excess fluid which will also fix potassium imbalance 7. PO digoxin is not as fast but we need to lower workload of heart as much as possible Nursing PRIORITY: PRIORITY Nursing Interventions: Rationale