Congenital Heart Defect Case Study PDF

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Congenital Heart Defect Case Study...

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Congenital Heart Defect Unfolding Reasoning

Johnny Patterson, 5 months old

Primary Concept Perfusion

Interrelated Concepts (In order of emphasis)    

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

Gas exchange Nutrition Elimination Patient/family education

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NCSBN Clinical Judgment Model Step 1: Recognize Cues Step 2: Analyze Cues Step 3: Prioritize Hypotheses Step 4: Generate Solutions Step 5: Take Action Step 6: Evaluate Outcomes

Covered in Case Study      

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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: 1. Weight loss, 0.4kg 2. Ventricular septal defect 3. Prescribed digoxin and furosemide 4. Baby has trisomy 21 (down syndrome)

RELEVANT Data Social History: 1. Mom works from home part time 2. Mom was advanced maternal age, 37 years old 3. Born at 38 weeks

Clinical Significance: 1. Difficulty breastfeeding, fast breathing, diaphoresis (sweats) s/s of VSD 2. VSD is a congenital heart defect, hole in septum that separates ventricles 3. Helps heart work more efficiently, doses are therapeutic and safe. 4. Genetic disorder caused by extra chromosome, at risk for heart disease, GI abnormalities, musculoskeletal problems, endocrine disorders, feeding and sleep problems, developmental disabilities, and more

Clinical Significance: 1. Mom can take care of baby/involved in patient’s care, does not have to attend daycare 2. Advanced maternal age is at risk for babies with abnormal chromosomes down syndrome 3. Full term

Dosage Calculation Current weight: 4.0 kg Digoxin 12 mcg BID PO. 0.05mg/ml solution. Dose in mL: 0.24ml Safe dose? Yes Furosemide 8 mg 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 to 22 mcg two times a day and furosemide increased also to 14.4 mg because his weight increased to 7.2 kg. Is this a safe dose for both medications? 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:

1. Digoxin dose increased to 22mcg BID 2. Furosemide dose increased to 14.4mg 3. Birth weight increased to 7.2kg

1. Digoxin maintenance dose for children 0-24 months is 1015mcg/kg/day divided into two doses  dose is low (not therapeutic), should be at least 35mcg BID 2. Furosemide is is the correct dose 3. Medication dosage should be increased accordingly

Dosage Calculation Current weight: 7.2 kg Digoxin 22 mcg BID PO. 0.05mg/ml solution. Dose in mL: 0.44ml Safe dose? Yes Furosemide 14.4 mg PO daily. 10mg/ml oral solution. Dose in mL: 1.44ml 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: 1. Vomiting, loose stools, more sleepy 2. Mom did not check heart rate before giving digoxin

Clinical Significance: 1. s/s of digoxin toxicity 2. digoxin should not be given if heart rate is lower than 90bpm

Johnny weighs 6.5 kg 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 old Awake 100-180, sleeping 90-160 BPM 30-53 BPM Systolic 72-104 mm/Hg Diastolic 37-56 mm/Hg

O2 sat: 98% on RA

FLACC Score: Faces: Legs: Activity: Crying:

0 0 0 0

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:

1. Weighs 6.5kg 2. Pulse is 85

1. Baby lost weight 2. HR is low, possible digoxin toxicity

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: 1. Baby is lethargic; possible digoxin toxicity 1. Arouses easily but falls back 2. Sign of dehydration asleep; patient opens eyes when 3. Sign of dehydration, poor perfusion moms talks to him, but closes eyes 4. Possible digoxin toxicity quickly 2. Dry lips, skin turgor decreased, no wet diaper the past 6 hours 3. Cap refill 3-4 seconds 4. Decreased appetite

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: 1. Digoxin toxicity 2. Signs of dehydration

Additional Clinical Data Needed: 1. Check digoxin serum levels, Electrolytes 2. CBC, BUN, Creatinine, Electrolytes, Urinalysis

While awaiting lab results, the primary care provider orders the following: Care Provider Orders: 1. Establish peripheral IV

Rationale: 1. Have access to fluids and other medications 2. Rehydrate 3. Monitor HR and rhythm

2. 0.9% NS 10 mL/kg over 15 minutes

3. Place on cardiac monitor

4.

What are the nursing considerations with the effect on hospitalization for a child of this age? - Separation anxiety keep baby with mom - Have mom assist in assessments and procedures - Encourage mom to bring belongings from home to help comfort baby o Bright colored objects, favorite toys, things to help stimulate senses - If the baby has enough energy, encourage play time - Assess vitals accordingly - Infection control - Aspiration precautions - Parent education/teaching - Encourage parent to be active in overall care

Expected Outcome: 1. Patient will have clean and dry IV site, no edema or redness, no s/s of infection 2. Patient will have no signs of dehydration, moist lips, increased skin turgor, increased output 3. Abnormalities will be recorded and will help with treatment

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:

WBC 6.1-17.5 g/dL(1 to 23 months)

Current: 2 months ago:

8.5 7.5

Complete Blood Count (CBC) HGB PLTs % Neuts 9.3-13.3 mmol/L 275-565 x10 to 1.9-5.4 absolute the 3/microL (3 to 11 months) value (1 to 23 (3 to 6 months months)

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

male) 290 280

0 0

12.5 11.9

2.5 2.4

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s): Bands

Clinical Significance:

TREND:

Patient has increased risk of infection

Normal Range: Current: 2 Months ago:

Na 134-142 (2 to 5 months) 134 mEq/L 136 mEq/L

Improve/Worsening/Stable: Stable

Basic Metabolic Panel (BMP) K Gluc. Creat. 3.5-5.6 (1 to 5 30-100 (2 days 0.31-0.71 (infant) months) to 2 years) 2.9 mmol/L 90 mg/dL 0.5 mg/dl 3.7 mmol/L 88 mg/dL 0.45 mg/dl

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

What lab results 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/Physiologic Adaptation)

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

1. 2.

Potassium BUN

1. 2.

Both are worsening Potassium level is low, possibly due to vomiting and diarrhea, sign of digoxin toxicity High due to dehydration, kidneys may not be functioning properly to excrete meds

Misc. Normal Range: Current: 2 months ago:

Digoxin 0.5-2 ng/ml 2.5 ng/mL 1.7 ng/mL

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

Digoxin level is high

Digoxin toxicity, medication needs to be held; future dosage needs Worsening to be adjusted or discontinued

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? (NCSBN: Step 2: Analyze cues/Step 3: Prioritize hypotheses/NCLEX: Management of Care)

Problems: 1. 2. 3. 4.

Priority Problem:

Digoxin toxicity Digoxin toxicity Dehydration Low potassium level Parent education

Rationale: Baby is digoxin toxicity; he is dehydrated (poor skin turgor, dry lips, no urine output for 6 hours, strong pulses), hypokalemic, and has vomiting and diarrhea. Discontinue drug or recommend alternative.

2. What is the pathophysiology of the priority problem? (NCLEX: Management of Care/Physiologic Adaptation)

Priority Problem: Digoxin toxicity

Pathophysiology of Problem in OWN Words: Common side effects of digoxin are bradycardia, anorexia, nausea, vomiting, and diarrhea, causing hypokalemia and dehydration. The baby was having reduced/no urine output from the side effects listed above, this increased the risks for digoxin toxicity because the drug was not properly excreted by the kidneys

3. What body system(s) will you assess most thoroughly based on the primary/priority problem? Identify correlating specific nursing assessments. (NCLEX: Reduction of Risk Potential/Physiologic Adaptation)

PRIORITY Body System: 1. 2.

PRIORITY Nursing Assessments:

Cardiovascular GI/GU

1. 2.

Monitor HR for full minute, monitor ECG, vital signs Monitor I/O, daily weight

4. What nursing priority (ies) and goal will guide how the nurse RESPONDS to formulate a plan of care? (NCSBN: Step 4 Generate solutions/Step 5: Take action/NCLEX: Management of Care) Restore fluids and electrolytes, restore HR Nursing PRIORITY: Increase patient hydration status and have no adverse side effects of medication present

GOAL of Care: Nursing Interventions: 1. 2. 3.

Rationale:

Hold digoxin Give IV fluids/electrolytes Monitor I/O, vitals, labs, cardiac

1. 2. 3.

Expected Outcome:

Patient has digoxin toxicity Patient is dehydrated with low K levels Continuous monitoring is needed to ensure no other complications will occur

1. 2. 3.

Patient will have increased HR Patient’s F/E balance will be restored Patient will have stable HR/rhythm, vitals, labs. And I/O

4. What is the worst possible/most likely complication(s) to anticipate based on the primary problem? (NCLEX: Reduction of Risk Potential/Physiologic Adaptation) Cardiac arrythmia

Worst Possible/Most Likely Complication to Anticipate:

Nursing Interventions to PREVENT this Complication:

Assessments to Identify Problem EARLY:

Cardiac monitoring, F/E balance and monitor labs

Monitor HR and labs

Nursing Interventions to Rescue: Correct F/E imbalance, correct medication dosage

Collaborative Care: Medical Management 5. State the rationale and expected outcomes for the medical plan of care. (NCLEX: Pharm. and Parenteral Therapies) Care Provider Orders: Rationale: Expected Outcome: 1.

Admit to PICU 2. Cardiac Monitor

1. 2. 3. 4.

Patient needs to be closely monitored Patient’s heart needs to be monitored for fatal side effect of cardiac arrythmia Patient has F/E imbalance, dehydrated, and low potassium. Restoration of fluids will help with excretion of digoxin Necessary to assess hydration status

1. 2.

Patient will be closely monitored Patient’s HR will be in normal limits

5. 6. 7. 8.

Patient has digoxin toxicity, Digibind is indicated for treatment of digoxin toxicity if stopping medication is not enough Patient has digoxin toxicity To check electrolytes, kidney function, and to see if treatment is effective and if other treatments are necessary To treatment is effective

3. 4. 5.

6.

7. 8.

Patient will have balanced F/E Patient will have no signs of dehydration Digoxin level will in therapeutic range Digoxin level will in therapeutic range Patient will have values within normal limits Digoxin will be in therapeutic range

3. Maintenance IV fluids Strict 4. I & O 5. Evaluate need for digoxin immune Fab (Digibind) 6. Hold digoxin 7. Complete metabolic panel (CMP) in AM 8. Digoxin level in AM

6. Which orders do you implement first? Why? (NCLEX: Management of Care) Care Provider Orders: Order of Priority: Rationale: 1. To assess before treating 1. Cardiac monitor  Cardiac Monitor 2. Medication should be held until baby is stable  Maintenance IV fluids 2. Hold digoxin 3. Digibind may be needed if holding digoxin is ineffective 3. Evaluate need for Digibind  Strict I & O 4. To restore F/E balance 4. Maintenance of IV fluids  Evaluate need for 5. To assess and maintain adequate hydration 5. Strict I/O 6. Treatment needs time to be effective 6. CMP in AM digoxin immune Fab (Digibind)  Hold digoxin  CMP in AM (Pediatric digitalis toxicity, n.d.)

7. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (NCLEX: Psychosocial Integrity/Basic Care and Comfort)

Psychosocial PRIORITIES:

PRIORITY Nursing Interventions: CARE/COMFORT: 1. Encourage mom to participate in care of patient 2. Provide support for mom 3. Provide activities to stimulate patient

Use your lens of practice as an educator to determine how you would establish a plan of care for each of the psychosocial priorities identified above. I have some general recommendations below that can be used to initiate dialogue and discussion. Rationale: Expected Outcome: 1. 2.

Patient will be more comfortable This is a very stressful time for mom, she may have a lot of questions. Providing support and educating may help alleviate some stress 3. Baby’s need stimulation

1.

2.

3.

Patient will feel secure, comfortable and be less anxious Mom will be less anxious, more informed, and more confident in how to properly care for her baby Patient will not regress during hospital stay

Evaluation: Two Hours Later in PICU… All orders have been implemented. Johnny has had one wet diaper measuring 30 mL. 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. (NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care)

RELEVANT Assessment Data: 1. One wet diaper (30ml) 2. More alert and interacting 3. HR 130, no PVCs or arrythmias

Clinical Significance: 1. Hydration status is replenishing 2. No longer lethargic 3. Increased HR, no signs of bradycardia

2. Has the overall status of your patient improved, declined, or remain unchanged? What is the current nursing PRIORITY? If your patient has not improved, what nursing interventions need to be implemented? (NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care)

Overall Status: Improved

Current Nursing Nursing Interventions: Priority: Continue with Continue to monitor and assess cardiac, I/O, vitals, labs, to ensure treatment is treatments as effective and patient remains stable prescribed

Johnny continues to improve and was transferred to the general pediatric floo...