NURS 243 Keith RN Congenital Heart Disease Case StudyVentral Septal Defect
UNFOLDING Reasoning
Mandy Gray, 2 months old
Primary
... [Show More] Concept
Perfusion
Interrelated Concepts (In order of emphasis)
• Gas Exchange
• Clinical Judgment
• Patient Education
• Communication
NCLEX Client Need Categories
Safe and Effective Care Environment
✓ Management of Care
✓ Safety and Infection Control
Health Promotion and Maintenance
Psychosocial Integrity
Percentage of Items from
Each Category/Subcategory
17-23%
9-15%
6-12%
6-12%
✓
✓
Covered in
Case Study
✓Physiological Integrity
✓ Basic Care and Comfort
6-12%
✓ Pharmacological and Parenteral Therapies
✓ Reduction of Risk Potential
✓ Physiological Adaptation
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 25 th 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: 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:
12-18%
9-15%
11-17%
✓
✓
✓
✓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
Patient Care Begins:
Current VS:
Increased anxiety on the parents can affect the baby if they are
stressed out then baby can sense that and become stressed as well
FLACC Behavioral Pain Assessment Scale:
T: 99.4 F/37.5 C (temporal) Face:
P: 210/min ( regular)
1
Legs:
R: 74/min
BP: 70/45 MAP: 50
O2 sat: 90% on RA
Activity:
Cry:
Consolability
:
0
0
1
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: 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
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
Current Assessment:
GENERAL
APPEARANCE:
RESP:
CARDIAC:
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
Fine crackles at bases bilaterally. Grunting noted with expirations and mild to
moderate sub-costal retractions and slight nasal flaring
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 edemaNEURO:
Awake but appears tired. Responds to mother and father appropriately with an
occasional smile.
GI:
GU:
SKIN:
Abdomen rounded, soft and non-tender, hepatosplenomegaly present, bowel sounds audible
Per Mom, has only had one wet diaper today
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:
Cardiomegaly and
increased pulmonary
blood flow
Clinical Significance:
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
Results:
Large perimembranous
ventricular septal wall
defect (VSD)
Lab Results:
Complete Blood Count (CBC)
WBC
Current:
Most Recent:
8.0
8.5
HGB
10.2
10.5
PLTs
205
250
% Neuts
60
55
WNL
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:
All labs WNL
Labs indicate no signs of infection or hemorrhage
TREND:
Improve/Worsening/Stable:
Stable
Radiology: Cardiac Echocardiogram
Clinical Significance:
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 prefusedNa
Basic Metabolic Panel (BMP)
Gluc.
K
Current:
Most Recent:
130
133
5.5
4.5
70
80
Creat.
0.2
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:
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
TREND:
Improve/Worsening/Stable:
Worsening
MISC. Misc.
Current:
Most Recent:
Mag
1.6
2.0
Total Calcium
9.0
8.9
Lactic Acid
17.1
10.0
GFR
55
57
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:
PT/INR
0.95
1.0Low magnesium
Low GFR
The magnesium can be the cause for her fatigue
The pt’s GFR indicates kidney disease
Worsening
Liver Panel
Albumin
Current:
Most Recent:
2.3
2.5
Total Bili
0.5
0.35
Alk. Phos.
400
320
ALT
42
35
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:
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
TREND:
Improve/Worsening/Stable:
Worsening
AST
74
65
Cardiac
Current:
Most Recent:
Trop.
<0.05
<0.05
BNP
120
<100
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:
BNP elevated
Elevated BNP is indicative of heart failure WorseningLab Planning: Creating a Plan of Care with a PRIORITY Lab: (Reduction of Risk Potential/Physiologic Adaptation)
Lab: BNP
Value: 120
Normal Value:
Critical Value:
Clinical Significance:
Indicative of heart failure it is elevated since last lab which means heart failure is worsening
Nursing Assessments/Interventions Required:
Freq cardiac assessments Consistent tele monitoring Notify provider ASAP
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)
Problem:
Heart failure secondary to VSD
Pathophysiology of Problem in OWN Words:
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 [Show Less]