Question

Please prioriitize 3 nursing diangosds for the following:

The patient is a 4month old African American female admitted to the general unit from the pediatric ICU s/p cardiothoracic surgery for placement of a shunt due to congenital pulmonary atresia with ventricular septal defect. Only the first stage of cardiac repair has been completed, and the infant is stable with a consistent O2 saturation of 78%. Additionally, she has experienced pulmonary edema post surgery. The scene takes place in the early morning on the infant toddler unit, with the infant’s primary nurse and other professionals present to begin immediate interventions. The grandmother, who will be the primary care taker at home for the baby is also present. This exercise should include achieving a smooth transition between all health care providers and coordinating care for the infant in a timely fashion. Educating the grandmother should also be a consideration.

Be prepared to:

Introduce yourself to the RT, OT and grandmother.

Explain what your plan is for the baby and outline how you plan to include all the essential doctor's orders with both the health care team and the family. Perform a head-to-toe assessment and obtain vital signs on the infant.React to infant’s crying or discomfort.

Document I & O

Coordinate feeding schedule and respiratory treatments.

Practice active conversation with RT and OT to coordinate a complete plan of care as you perform usual daily morning care for the infant. Teach the grandmother as you provide appropriate care.

Answer 1

Ventricular septal defect (VSD) with pulmonary atresia (PA) is considered as a severest form of Tetralogy of Fallot (a congenital heart disease- cyanotic heart disease), where patient presents with combination of two conditions pulmonary artery atresia and ventricular septal defect. In pulmonary atresia pulmonary valve (valve that controls blood flow from the right ventricle to the main pulmonary artery which carries blood from the heart to the lungs) didn’t form at all, and no blood can flow from the right ventricle to the lungs. When associated with Ventricular septal defect there is only one chamber formed by both ventricles.

In patients with pulmonary atresia with a ventricular septal defect, presence of ventricular septal defect (VSD) allows blood to flow into and out of the right ventricle (RV). Therefore, blood flowing into the RV can help the ventricle develop during pregnancy, so it is typically not as small as in pulmonary atresia with an intact ventricular septum.

Diagnosis-

During pregnancy

· Prenatal screening tests

· fetal echocardiogram to confirm the diagnosis.

After the Baby is Born

Babies born with pulmonary atresia will show symptoms at birth or very soon afterwards. They may have a, called

Cyanosis bluish discoloration of skin, because their blood doesn’t carry enough oxygen. Infants with pulmonary atresia can have additional symptoms such as:

· Problems breathing

· Ashen or bluish skin color

· Poor feeding

· Extreme sleepiness

Management:

Surgery is done in stages-

Temporary Operation

A shunt operation may be done first to provide adequate blood flow to the lungs. This is not open-heart surgery and doesn't fix the defect inside of the heart. The shunt is a small tube of synthetic material placed between aorta and pulmonary artery. The shunt is closed when a complete repair is done later.

Complete Repair

Complete repair tends to be done early in life. The surgeon closes the ventricular septal defect with a patch and opens the right ventricular outflow tract by removing some thickened muscle below the pulmonary valve, or by repairing or removing the obstructed pulmonary valve and if needed, enlarging the branch of pulmonary arteries that go to each lung.

3 priority nursing diagnoses and nursing interventions are:

Nursing diagnosis: Activity Intolerance related to imbalance between oxygen supply and demand

Nursing Interventions	Rationale
Assess dyspnoea on exertion, skin colour changes during rest and when active.	Indicates hypoxia and increased oxygen demand.
Allow for rest periods between care. Disturb child only when necessary for care and procedures.	Promotes rest and conserves energy.
Do not allow infant to cry for long periods of time, use soft nipple for feeding; cross-cut nipple; if unable for infant to take orally in sufficient quantity then gavage-feed infant.	Conserves energy. Cross-cut nipple requires less energy for the infant to feed.
Provide neutral environmental temperature; when bathing infant, expose only the area being bathed and keep the infant covered to prevent heat loss.	Avoids hot or cold extremes which increase oxygen and energy needs.
Provide toys and games for quiet play and diversion appropriate for age of child (specify), allow to limit own activities as much as possible.	Promotes growth, diversion, and physical and mental development.
Inform about activity or exercise restrictions for infant.	Prevents fatigue while engaging in activities as nearly normal as possible.
Assist parents to plan for care and rest schedule.	Provides for rest and prevents overexertion, minimizes energy expenditure.
Inform to request assistance when needed for daily activities.	Prevents overtiring and fatigue of caregivers.

Nursing diagnosis: Compromised family coping related to situational and developmental crises in the life child and family

Nursing Interventions	Rationale
Observe for erratic behaviours (anger, tension, disorganization), perception of crisis situation	Information affecting the ability of the family to cope with infant/child’s cardiac condition.
Encourage expression of feelings and provide factual information about infant/child.	Reduces anxiety and enhances family’s understanding of the condition.
Assess coping methods used by family and their effectiveness.	Identifies need to develop new coping skills if existing methods are ineffective.
Assess need for information and support.	Provides information about need for interventions to relieve anxiety and concern.
Clarify any misinformation and answer questions regarding disease process.	Prevents unnecessary anxiety resulting from inaccurate knowledge or beliefs.
Encourage to maintain the health of family members and social contacts.	Chronic anxiety, fatigue, and isolation as a result of infant care will affect health and care capabilities of family.
Teach that overprotective behaviour may hinder growth and development during infancy/ childhood.	Knowledge will enhance family understanding of the condition and of adverse effects of behaviours.
Encourage parents to include ill infant/ child in family activities rather than family revolving around needs of infant/child.	Promotes normal growth and development of family and infant/child.
Instruct parents in nutritional and activity needs and/or limitations and approaches that will assist in establishing an effective pattern.	Assists in coping with effects and special needs of infant/child with a cardiac defect.
Refer family for additional support and counselling if indicated.	Referral supplies more assistance with coping than is available from nursing personnel.

Nursing diagnosis: Risk for Infection

Nursing Interventions	Rationale
Assess temperature, IV site if present, increased WBC, increased pulse and respirations.	May be signs of indicating potential infection.
Avoid contact of those having infection with infant/ child.	Prevents transmission of infectious agents to infant/child with compromised defense.
Provide adequate rest and nutritional needs for age.	Protects against potential infection by increasing body resistance and defense.
Wash hands before giving care.	Prevents transmission of microorganisms to infant/ child.
Administer prophylactic antibiotics as ordered	Safe guards against infection.
Instruct parents about maintaining personal hygiene and hygiene of baby (preparing for and feeding the baby, elimination, bathing, handling the baby).	Reduces exposure to child to possible contaminants.

Home care considerations:

Regular lifelong follow up

· Child will need regular follow-up and monitoring initially with a paediatric cardiologist, and later in life also even after corrective surgery. As child will grow older, his or her care will be transitioned to an adult congenital cardiologist, who can monitor his or her condition over time

· Child need definitive surgery later. After surgical repair of defect if there's no obstruction or leak in the pulmonary valve, child can participate in normal activities without much increased risk. But he will need to limit activities if there is leftover obstruction or a pulmonary valve leak, which is common after repair. This limitation may be especially necessary for competitive sports.

· Generally, the long-term outlook is good, but there is high risk for cardiac arrhythmias after repair of defects. Sometimes these may cause dizziness or fainting

Preventing infection

Children with tetralogy of Fallot are at increased risk for endocarditis. Children who had valve replacement, shunt or have leaks around surgical patches are at more risk of endocarditis.

In the past, patients with nearly every type of congenital heart defect needed to receive antibiotics one hour before dental procedures or operations on the mouth, throat, gastrointestinal genital, or urinary tract. However, in 2007 the American Heart Association simplified its recommendations.

Preventive antibiotics are now recommended only for:

· Cyanotic congenital heart disease (birth defects with oxygen levels lower than normal), that has not been fully repaired, including children who have had a surgical shunts and conduits.

· A congenital heart defect that's been completely repaired with prosthetic material or a device for the first six months after the repair procedure.

· Repaired congenital heart disease with residual defects, such as persisting leaks or abnormal flow at or adjacent to a prosthetic patch or prosthetic device.