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Case Study on Congenital Heart Defect...

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Case Study - Congenital Heart Defect

Johnny Patterson, 5 months old Primary Concept Perfusion Interrelated Concepts (in order of emphasis) Gas exchange Nutrition Elimination Patient/family education

NCLEX Client Need Categories Safe and Effective Care Environment Management of Care Safety and Infection Control Health Promotion and Maintenance Psychosocial Integrity Physiological Integrity Basic Care and Comfort Pharmacological and Parenteral Therapies Reduction of Risk Potential Physiological Adaptation

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NCSBN Clinical Judgment Model Step 1: Recognize Cues Step 2: Analyze Cues

Covered in Case Study

Step 3: Prioritize Hypotheses Step 4: Generate Solutions Step 5: Take Action Step 6: Evaluate Outcomes

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Part 1: History of Present Illness Johnny Patterson was born at 38 weeks gestation and diagnosed with Trisomy 21 (Down Syndrome). At his one-week 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 o 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 4kg. At his last visit three weeks ago, he weighed 4.4kg. The cardiologist prescribed 12 mcg digoxin every 12 hours (0.05mg/mL solution is received from the pharmacy) and 8mg 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?

RELEVANT Data:  Trisomy 21 (Down Syndrome).  Gestational age: 38 weeks.  Prominent heart murmur was auscultated at one-week checkup at the pediatrician’s office.  Echocardiogram: Large ventricular septal defect immediately below the aorta.  Cardiologist suggested no immediate interventions, due to no distress upon evaluation. Weight is 4.4kg  2nd Cardiologist appt, 3 weeks later, Parents report sleeping more, times when he breathes faster than usual, and becomes sweaty when he breastfeeds. Weight is 4kg. Prescribed 12mcg digoxin Q12H and 8mg furosemide QD. RELEVANT Data Social History:  Parents Married (8 years)  Mom 37, works from home part time as engineer, 2 miscarriages, 1 live birth.  Dad engineer.  No daycare.

Clinical Significance:  Physical and cognitive developmental delays are common in trisomy 21 patients.  Not born premature.  Lost weight (0.4kg) in 3 weeks.  Change in normal behavior, due to heart failure.

Clinical Significance:  May influence how you approach infant and child.  Mom works part time from home as is probably primary care giver.  Geriatric pregnancy.  Not exposed to other children in daycare.

Dosage Calculation Current weight: 4kg Digoxin 12mcg BID PO (0.05mg/mL solution) Dose in mL? 0.24ml Safe dose? Yes Furosemide 8mg PO daily (10mg/mL oral solution) Dose in mL? 0.8ml Safe dose? Yes Johnny’s 5-Month Visit Johnny has been seen monthly by the cardiologist. Appointments at three and four months were unremarkable. At his five-month visit, his dosage of digoxin was increased o 22mcg two times a day and furosemide increased also to 14.4mg because his weight increased to 7.2kg. Is this a safe dose for both medications? What data is RELEVANT and must be NOTICED as clinically significant by the nurse? RELEVANT Data: Clinical Significance:  Monitored monthly for change in status.  Seen monthly by cardiology.  Due to weight gain medication doses increased.  Month 3 & 4 unremarkable.  5 month visit: Weight 7.2kg Digoxin dose increased to 22mcg BID, Furosemide increased to 14.4mg Dosage Calculation Current weight 7.2kg Digoxin 22mcg BID PO (0.05mg/mL solution) Dose in mL? 0.44 ml Safe dose? Yes Furosemide 14.4mg PO daily (10mg/mL oral solution) Dose in mL? 1.44 ml 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 the 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 mange 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 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? RELEVANT Data: Clinical Significance:  Possible hypovolemia due to vomiting and diarrhea.  5 ½ Months: ER visit, Repeated vomiting the past 24 hours, several loose stools. More fatigued than normal.  Possible Digoxin toxicity. Mother has not been checking HR before giving digoxin the past week. Johnny weight 6.5kg and is promptly brought back to a room in the ED. You are the nurse assigned to care for him and you collect the following clinical data: Patient Assessment Current VS: T: 37.0 rectal (C) P: 85 (regular) R: 36 (regular) BP: 74/50 left leg

Normal Range: 5-month Awake 100-180, sleeping 90-160 bpm 30-53 bpm Systolic 72-1-4mm/Hg Diastolic 37-56mm/Hg

O2 sat: 98% on RA

FLACC Score: Faces Legs Activity Crying

0 0 0 0

Consolability

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What VS data are RELEVANT and must be NOTICED as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance:  Pulse not being checked before giving Digoxin dose, hold Digoxin  Pulse: 85 laboratory value is back.  Weight loss: Was 7.2kg now is 6.5kg.  Due to vomiting and diarrhea.  FLACC  Not in pain as referenced by FLACC scale Current Head-to-Toe Nursing Assessment General Survey Arouses easily but falls back to sleep. Neurological HEENT Respiratory Cardiac Abdomen GU Integumentary

Patient opens eyes when mom talks to him but closes eyes quickly. Eyes PERRLA. Head without obvious deformities. Lips dry. Breath sounds equal and clear posteriorly and anteriorly Circulation: Pink, warm, & dry, no edema, heart sounds regular, pulses strong, equal. Capillary refill on toes 3-4 seconds. Abdomen round, soft, and non-tender. BS active in all 4 quadrants. No wet diaper in 6 hours per parent. 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? RELEVANT Assessment Data: Clinical Significance:  Fatigue, LOC  Hypovolemia  Lips dry  Digoxin toxicity  Capillary refill on toes 3-4 seconds  No wet diapers in past 6 hours  Skin turgor decreased  Vomiting  Diarrhea  Decreased appetite

3.

Interpreting relevant clinical data, identify potential problems. What additional data is needed to identify the priority problem and nursing priorities? Likely Problems: Additional Clinical Data Needed:  Digoxin toxicity  BMP  CBC  Hypovolemia  Blood culture  Urine culture  Digoxin level  EKG, heart monitoring While awaiting lab results, the primary care provider orders the following: Care Provider Orders: Rationale:  To rehydrate and in case of emergency for Establish peripheral IV giving medications.  To rehydrate 0.9% NS 10mL/kg over 15 minutes  Monitor for signs of decline, Hx of VSD and heart failure, and effects of Digoxin Place on cardiac monitor toxicity

Expected Outcome:  IV access for rehydration to balance electrolytes and medication administration.  Patient will have normal sinus rhythm.

4. What are the nursing considerations with the effect on hospitalization for a child of this age? Fear. Separation anxiety. Use treatment room for invasive procedures, not patient room. Family centered care. Maintain home routine as much as possible. Extensive patient education, specifically importance of checking HR before giving Digoxin. Safe environment for developmental age. Activities and stimulation appropriate for developmental age. Interpreting Diagnostic Data The primary care provider orders the following diagnostic tests and the results just posted in the electronic health record. Lab Results

Normal Range: Current: 2 months ago:

WBC 6.1-7.5g/hL (1-23 months) 8.5 7.5

Complete Blood Count (CBC) HGB PLTs 9.3-13.3mmol/L (3275-565 x 10 to the 11 months) 3rd/micro/L (3-6 months) 12.5 290 11.9 280

% Neuts 1.9-5.4 absolute value (1-23 months)

Bands 0.2-0.5 absolute value (1-23 months)

65 62

0 0

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s) Clinical Significance TREND: Improve/Worsening/Stable  WBC 8.5 High  Indication of inflammation or possible infection  Worsening  Neuts 65 High  Indication of inflammation or possible infection

Normal Range: Current: 2 months ago:

Na 134-142mEq/L (25 months) 134 136

Basic Metabolic Panal (BMP) K Glucose 3.5-5.6mmol/L (1-5 30-100mg/dL (2 days months) to 2 years) 2.9 90 3.7 88

Creatinine 0.31-0.71mg/dl (infant) 0.5 0.45

BUN 4-15mg/dL (less than 2 years) 16 6

Misc. Normal Range: Current: 2 months ago: RELEVANT Lab(s)

Digoxin 0.5-2ng/mL 2.5 1.7 Clinical Significance

TREND: Improve/Worsening/Stable

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Na: 134 K: 2.9 BUN: 16 Digoxin

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Hypovolemia Hypovolemia Hypovolemia Toxicity

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Worsening, Low Worsening, Low Worsening, High Worsening, High

Put it All Together to Think Like a Nurse 1. Interpreting clinical data collected, rank the most likely problems by priority. Which problem is priority? Why Problem(s) Priority Problem Rationale Digoxin toxicity Digoxin toxicity Immune Fab antidote for digoxin toxicity, digoxin toxicity can Hypokalemia lead to cardiac arrest. Acute and can lead to other issues if left untreated. Hypovolemia Hold medication until fluid volume is restored. VSD, Heart failure Vomiting Diarrhea Prominent heart murmur Trisomy 21 2. What is the pathophysiology of the priority problem? Priority Problem Pathophysiology of Problem in OWN Words Digoxin toxicity 3.

What body system(s) will you assess most thoroughly based on the primary/priority problem? Identify correlating specific nursing interventions. Priority Body System Priority Nursing Assessments Monitor laboratory values. Laboratory values Try to rouse child. LOC Give ordered fluids, and antiemetics. Gastrointestinal Heart disease and low heart rate at intake. Vital signs 4. What nursing priority(ies) and goal will guide how the nurse RESPONDS to formulate a plan of care? Restore fluid imbalance, and bradycardia Nursing PRIORITY GOAL of Care Get patient back to his baseline by restoring fluid, and heart rate, caregiver education. Nursing Intervention Rationale Expected Outcome Continue cardiac monitoring Restoring fluid imbalances to baseline Improved laboratory values. Monitoring vital signs Digoxin toxicity causes arrhythmias and slow heart rate. Stable heart rate. IV fluids Caregiver will demonstrate and adhere Holding Digoxin to proper medication administration Reassess laboratory values after regime. interventions. 5. What is the worst possible/most likely complication(s) to anticipate based on the primary problem? Worst Possible/Most Likely Cardiac arrest due to the digoxin toxicity Complication to Anticipate Nursing Interventions to PREVENT this Complication Assessment to Identify Problem EARLY Nursing Interventions to Rescue Holding Digoxin dose Assessment of pulse, heart and lung sounds and repeat Correct fluid volume imbalances, Restoring fluid volume laboratory values. administer ordered medications, notify provider of decline in status.

Collaborative Care: Medical Management 6. State the rationale and expected outcomes for the medical plan of care. Care Provider Orders Rationale

Expected Outcome

Admit to PICU Cardiac Monitor Maintenance IV fluids Strict I&O Evaluate need for digoxin immune Fab (Digibind) Hold digoxin CMP in AM Digoxin level in AM

Potential life threatening condition needs to be monitored, and treated, as well as VSD, and Heart failure. Acute vomiting and diarrhea need to replace fluids. To ensure baby is having adequate intake and output. Monitoring laboratory values as fluids are restored will determine need for immune Fab. Until you know how body is responding to restoration of fluids and blood levels of digoxin medication needs to be held and have laboratory values reassessed.

7. Which orders do you implement first? Why? Care Provider Orders Order of Priority 1 Cardiac Monitor 4 Maintenance IV fluids 5 Strict I&O 3 Evaluate need for digoxin immune Fab (Digibind) 2 Hold digoxin 6 CMP in AM

Fluid volume deficits will be restored. Heart rate and other vitals will become and remain stable and within normal limits. Digoxin levels will be within therapeutic range. All laboratory values will be within normal limits.

Rationale With VSD and heart failure as known problems it is important to evaluate status of heart, hold digoxin until the laboratory data is back as this is the likely cause of his problem, Immune Fab is the antidote for digoxin toxicity and should be considered if symptoms are severe enough or laboratory data supports its use. Restoring fluids is important to help regulate laboratory values, I&O monitoring to assess improvement in hypovolemia, CMP will help determine how well interventions worked needs to be drawn later.

8. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? Psychosocial PRIORITIES Trust vs. Mistrust PRIORITY Nursing Rationale Interventions CARE/COMFORT Baby will be able to rest and receive necessary treatment if he feels safe, keeping caregivers close will help facilitate this. Help baby to feel safe and secure. Caregiver will comfort child if able to stay at bedside. Allow caregiver to stay with baby Baby will start to feel better and will need stimulation, as much as possible. providing toys and activities for mom and baby will help with Provide age appropriate activities overall care. and stimulation for baby while Supporting caregiver and patient will help ease worry and admitted. concern and answer all questions that may arise. Provide support to caregiver.

Expected Outcome Baby will be calm and able to rest. Caregivers will feel apart of the care and feel well informed of what is being done and the why behind it. Regression due to hospitalization will not take place.

Evaluation: Two Hours Later in PICU. . . All orders have been implemented. Johnny has had one wet diaper measuring 30mL. He is more alert and interacting with both parents. His heart rate is 130 and rhythm is sinus tachycardia with no PVCs or other arrythmias present. 1. After implementing the plan of care, EVALUATE your patient by INTERPRETING relevant clinical data. RELEVANT Assessment Data Clinical Significance Fluid volume deficit is improved. One 30ml wet diaper in last 2 hours. LOC is improved. Alert and interacting with caregivers. Heart rate has increased and no PVC or arrythmias are present. Heart rate increase to 130, no PVC or arrythmias Status overall improved from initial assessment. present. 2.

Has the overall status of your patient improved, declined, or remained unchanged? What is the current nursing PRIORITY? If your patient has not improved, what nursing interventions need to be implemented? Overall Status Current Nursing Priority Nursing Interventions Improved Continue current treatment plan Continue to monitor status for continued improvement, restart Monitor Digoxin laboratory values digoxin when indicated.

Johnny continues to improve and was transferred to the general pediatric floor and will be discharged to home tomorrow. What are the educational priorities to successfully mange his current problem and maintain optimal state of health? 3.

What educational/discharge priorities are needed to develop a teaching plan for this patient and/or family?

PRIORITY Topics to Teach Importance of adhering to proper medication administration. Side effects to watch for. When to seek medical help, or call provider. Signs of dehydration and when to seek medical help. If any support or further education is needed.

Rationale Adhering to proper medication administration will decrease adverse effects from occurring in future. Education on signs and symptoms to watch for while on the medication will get baby the help he needs faster. Making sure caregivers have all information they need and there questions answered will result in better care of baby’s medical needs.

Reflect on Your Thinking to Develop Clinical Judgment 4. To develop clinical judgment, reflect on your thinking that was used to complete this case study by answering the following questions: What did you do well in this case study? What knowledge gaps did you identify? Unsure of all the side effects digoxin could produce. Worked well as a team! Unaware of need to take pulse before administering digoxin. Everyone gave input that made others think in different ways. Gaps in knowledge were filled by others or we worked together to look Did not understand the significate effect not taking the pulse before administration could lead to. up the information needed to move forward. What did you learn? Started out thinking it was possibly a viral illness causing symptoms and discovered the medication he is prescribed causes the same symptoms at toxic levels. Learned the antidote or treatment for digoxin toxicity.

How will you apply what you learned to caring for future patients? To be open minded on what the diagnosis and treatment may be until you have all the information needed to make the correct plan. Educating the patients on the severity of side effects medications can cause will help decrease likelihood of patient experiencing problems....