Question

Case Study - Infant with a Congenital Heart Defect

Setting – Hospital

Index words – ventricular septal defect (VSD), assess, cardiac catherization, preprocedural and postprocedural car, parent teaching, dosage calculation

Scenario –

Three-week-old J.T. and her parents arrive at the cardiac cath lab for her cardiac catherization. She was born at term with Down syndrome and her pediatrician is concerned because of lack of weight gain and poor feeding. You are getting her parents prepared for the procedure.

1 – As you obtain her history and vital signs, which statements or findings would be concerning and suggestive of heart failure? Select all that apply.

A – J takes 30- 40 min to take 2 to 3 ounces of formula

B – Rectal temperature 36.6 C

C – J gets damp and sweaty when she feeds

D – Heart rate 195 at rest

E – Peripheral pulses +3

F – J seems to have fewer wet diapers than when we brought her home from the hospital.

2 – You are preparing J.T.’s parents for the procedure. Describe the points you would address in your teaching.

Case Study Progress

After the catheterization, J.T. returns to the unit in a crib. The orders shown in the chart are below.

Chart-

Daily Weights: Current weight 4kg

Strict intake and output

O2 per nasal cannula as needed to maintain O2 saturations greater than 93%

VS every 15 minutes x 4, then every 1-hour X 4, then every 4 hours

Digoxin (Lanoxin) 60 mcg PO now, then 20 mcg PO every 12 hours

Furosemide (Lasix) 4 mg PO now, then 4 mg PO every 12 hours

3 – What will you document in your postprocedural assessment? Include rationale.

4 – You are reviewing J.T.’s medications and her mother states the following rationale for starting J.T. on digoxin. “I need to give this to J to decrease her blood pressure so her heart does not have to work so hard. Is this true or false, explain your answer

5 – You have a student nurse working with you, and the student asks why the first ordered dose is high. What would be a possible explanation for this?

6 – The student nurse asks whether there are any precautions to observe when giving digoxin to an infant. Describe medication safety precautions that should be observed.

Case Study Progress

You administer the ordered medication and proceed with your assessment.

7 – Which of these are possible complications to monitor for after a cardiac catheterization?

A – hemorrhage

B – hematoma

C – hyperglycemia

D – dysrhythmia

E – decreased pulse in unaffected leg

F – vasospasm

8 – You are preparing to administer J.T.’s furosemide. Your drug reference gives the following therapeutic range 0.5 to 1 mg/kg/dose every 8 to 24 hours. Is the ordered dose of 4 mg safe?

Case Study Progress

Lab Results –

Glucose                85 mg/dL

Calcium                9.1 mg/dL

Sodium                 142 mEq/L

Potassium           3.3 mEq/L

Chloride               101 mEq/L

9 – Which lab finding would concern you and why?

10 – True or False - This defect would create decreased pulmonary flow. Explain your answer.

Case Study Progress

J.T. will be discharged home tomorrow with medication and close monitor but will return in a few months for surgical intervention of the VSD.

11 – You being discharge teaching. Describe what information you will include.

Answer 1

CASE SCENARIO

1)A - J takes 30-40 minutes to take 2-3 ounces of formula.(Poor feeding)

C - J gets damp and sweaty when she feeds(As it causes extra pressure on heart to pump the blood out to the body so the body compensates by increasing the metabolic rate - hence the sweating).

F - J seems to have fewer wet diapers than we brought her home from the hospital (This is due to reduced blood flow to kidneys to make adequate amount of urine, secondary to decreased cardiac output).

2)The teaching points includes

briefly describing the procedure

The need for the procedure - usually it is a diagnostic procedure which helps the cardiologist to look closely into the heart and blood vessels supplying to it.

Educating them the risks and complications associated during and after the procedure.

Advising them not to feed the baby atleast 6 hours prior to the procedure.

CASE STUDY PROGRESS:

3)The following are the points to be documented in postprocedural assessment:

Vitals - needs to check BP, heart rate ,heart rhythm and respiratory rate. This is to rule out bradycardia, hypotension, internal bleeding which are common postprocedural complications.

The punctured site needs to be checked for swelling, redness.This is to rule out hematomas.

The conscious level needs to be checked to find out the action of sedative given during the procedure.

4)False, as digoxin is used to increase the force of contractions of the heart so that it pumps out blood more efficiently.

5)The initial dose or loading doses are usually higher than the maintainence dose.

This is done to buildup the drug levels in the body to achieve therapeutic effect at earliest.

6)Before giving digoxin to an infant, pulse rate needs to be checked. During IV administration, continous monitoring of heart rate and rhythm should be done. Should inform the cardiologist if the pulse rate falls below 90 or any changes in heart rhythm.

7)B - Hematoma, D - Dysarythmias, E - decreased pulse in unaffected leg.

8)YES as the ordered dose is 4mg initial dose followed by 4mg two times a day which is within the recommended dose for J (2-4 mg can be given every 8-24 hours).