NUR 112/NUR112Congenital Heart Disease Case Study - Ventral Septal Defect UNFOLDING Reasoning

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Ventral Septal Defect UNFOLDING Reasoning Mandy Gray, 2 months old Primary Concept Perfusion Interrelated Concepts (In order of emphasis) • Gas Exchange • Clinical Judgment • Patient Edu... cation • Communication NCLEX Client Need Categories Percentage of Items from Each Covered in Category/Subcategory Case Study Safe and Effective Care Environment ✓ Management of Care 17-23% ✓ ✓ Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% ✓ Psychosocial Integrity 6-12% ✓ 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: Clinical Significance: RELEVANT Data from Social History: Clinical Significance: 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: Clinical Significance: Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved. -Pts past diagnosis could contribute to the presenting problem -Increased WOB could be due to heart failure, must be a priority intervention, check O2 stats and admin supp O2 if necessary -could be r/t heart failure and exhaustion -could be d/t fluid retention r/t heart failure -Hx of VSD -Increased WOB -difficulty w/ feedings d/t tiring easily -pt is below 25th percentile in weight, gained 8 oz in last 24 hrs -Increased parental anxiety can cause the baby to become anxious as well -parents need support and may have financial strain d/t mom not working -both parents are anxious/overwhelmed and have no support system -Mom is a nurse but has been unable to work d/t taking care of pt -elevated HR and RR and decreased O2 are all related to heart failure, body is overcompensating -pt should be placed on 2lt of supp O2 Pt is in pain, should get pain meds or use non pharmalogical pain methods [Show More]

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