Keith RN Congenital Heart Disease Case Study PDF

Preview

Summary

Download Keith RN Congenital Heart Disease Case Study PDF

Description

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

✓ Management of Care

17-23%

✓

✓ Safety and Infection Control

9-15%

Health Promotion and Maintenance

6-12%

✓

Psychosocial Integrity

6-12%

✓

Safe and Effective Care Environment

Physiological Integrity ✓ Basic Care and Comfort

6-12%

✓

✓ Pharmacological and Parenteral Therapies

12-18%

✓

✓ Reduction of Risk Potential

9-15%

✓

✓ Physiological Adaptation

11-17%

✓

Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

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: ● ● ● ●

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

RELEVANT Data from Social History:

Clinical Significance: 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)

Clinical Significance:

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

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: ● ● ● ●

Elevated HR Elevated RR Decreased o2 2 on the FLACC

Clinical Significance: ● ● ●

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

Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

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:

GI:

Awake but appears tired. Responds to mother and father appropriately with an occasional smile. 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: ● ●

● ●

●

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

Clinical Significance: ● ●

● ●

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:

Clinical Significance:

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)

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

Lab Results: 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

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

All labs WNL

Labs indicate no signs of infection or hemorrhage

Stable

Basic Metabolic Panel (BMP)

Current: Most Recent:

Na

K

Gluc.

Creat.

130

5.5

70

0.2

133

4.5

80

0.3

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

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.

Current: Most Recent:

Mag

Total Calcium

Lactic Acid

GFR

PT/INR

1.6

9.0

17.1

55

0.95

2.0

8.9

10.0

57

1.0

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)

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

Low magnesium Low GFR

The magnesium can be the cause for her fatigue The pt’s GFR indicates kidney disease

Worsening

Liver Panel

Current: Most Recent:

Albumin

Total Bili

Alk. Phos.

ALT

AST

2.3

0.5

400

42

74

2.5

0.35

320

35

65

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

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

Current: Most Recent:

Trop.

BNP...