Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
Gas exchange
Nutrition
Elimination
•
•
✓
✓
•
•
Basic Care
... [Show More] and Comfort
Pharmacological and
Parenteral Therapies
Reduction of Risk Potential
Physiological Adaptation
✓
✓
Congenital Heart Defect
NextGen SKINNY Reasoning
Johnny Patterson, 5 months old
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
Step 4: Generate Solutions
✓
Health Promotion and Maintenance ✓ ✓
Psychosocial Integrity ✓ Step 5: Take Action ✓
Physiological Integrity Step 6: Evaluate Outcomes ✓
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case stduy
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).
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:
1. Trisomy 21 diagnosed 1. At great risk of Tetralogy of Fallot
2. Prominent heart murmur 2. At great risk of Tetralogy of Fallot
3. large ventricular septal defect 3. Congenital heart defect
4. sleep more and breath faster than normal 4. Signs of heart failure
5. lost weight 0.4kg in 3 weeks 5. Failure to thrive, not getting enough nutrients
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:
1. johnny now weights 7.2 kg. no tissue noted by provider and Mom expressed no concerns.
2. Digoxin dose increased to 22 mcg BID and furosemide dose increased to 11.4 mg q 24 hours.
1. Normal weight
2. Digoxin dose: 43.2 mcg to 72 mcg daily
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?
2
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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.
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 from Present Problem: Clinical Significance:
1. vomit repeats in past 24 hours 1. Lack of blood flow to the abdominal make GI upset
2. Loose stools 2. HF cause abdominal upset
3. Become sleepier 3. Not enough energy
4. Mum did not check HR before give digoxin 4. May cause digoxin toxicity
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
Patient
As
the following clinical data:
sessment
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:
1. Pulse is a little bit low 1. Weaker heartbeat indicate digoxin toxicity [Show Less]