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ANGELES UNIVERSITY FOUNDATION

ANGELES CITY

COLLEGE OF NURSING

Ventricular Septal Defect in Failure with

Pneumonia

Case Study:Pediatric Ward

In partial fulfillment of the requirements in

Related Learning Experiences ± Pediatric Area

Submitted to:

Abigail A. Buan, RN

Clinical Instructor

Submitted by:

Galang, Miguel Paolo A.

Dimla, Shayne M.

Magtoto, Jessica E.

Mallari, Giselle M.

Policarpio, Frances Joye P.

Group 7

BSN III-2



I. INTRODUCTION

³What we have most to fear is failure of the heart.´

-Sonia Johnson

The heart is a muscular four-chambered organ whose primary purpose is to

pump blood throughout the body. It is composed of four chambers namely: left atrium,

left ventricle, right atrium and right ventricle. It is a special organ that mainly supports our

body to function well. Without the heart, human being will die. But even though the heart

is a special organ, as a part of the body, it is not exempted to have damage. Many

defects and diseases are being associated with the heart. One of these defects is called

Ventricular Septal Defect.

Ventricular septal defect is a congenital defect, an abnormal opening between

the right and left ventricles. A ventricular septal defect can allow newly oxygenated blood

to flow from the left ventricle, where the pressures are higher, to the right ventricle,

where the pressures are lower, and mix with unoxygenated blood. The mixed blood in

the right ventricle flows back or recirculates into the lungs. This means that the right and

left ventricles are working harder, pumping a greater volume of blood than they normally

would.

VSDs rank first in frequency on all lists of cardiac defects. Ventricular septal

defects are rare congenital malformations of the heart that occur more frequently in

males than females. They account for 25-40% of all cardiac malformations at birth. U.S.

and international frequencies are identical²approximately 1-2 cases per 1000 live

births. Of the babies born with VSDs, 80 to 90 percent present with a small hole and mild

symptoms. Studies have shown that the prevalence of VSDs has increased in the United

States during the past 30 years. A twofold increase in the prevalence of VSD was

reported by the Centers for Disease Control and Prevention from 1968-1980. The

Baltimore-Washington Infant Study (BWIS) reported a twofold increase in the prevalence

of VSD from 1981-1989. The BWIS study reported that the increase is primarily

attributed to more sensitive detection through echocardiography.

In 2002, a total of 4178 Americans died from cardiovascular defects. Thousands

of babies are born each year with cardiovascular defects. Of these, Ventricular septal



defects have the highest prevalence among congenital heart defects accounting 14-16%

(American Heart Association, Congenital cardiovascular defects: statistics, 2005)

A. Current trends about the disease condition

In February 21, 2010, the science daily reported that there is a worsening of

heart failure when the right ventricle is non-compliant. The research is from the

University of Alabama at Birmingham. In VSD, there is shunting of blood from left to right

ventricles (sometimes,from right to left) that causes decrease low left ventricular ejection

fraction (if blood shunts from left to right) or low right ejection fraction-the blood pump by

the ventricles (if blood shunts from right to left). It was discovered that low RVEFincreased the risk of death in patients with heart failure which may occur in patients with

VSD. Identifying at risk patients and providing appropriate therapy for them is the best

suggestion of this article.

Another article was released by the science daily on September 15, 2010 that a

talk about repairing restrictive (small) defects in VSD is more helpful this time. The study

found out that even though patients with rVSD have normal blood circulation, there were

molecular changes, evidence of right ventricular diastolic dysfunction and impairment of

muscle contraction and relaxation at the cellular level. These changes may have a great

effect in the heart¶s effectiveness in providing circulation in the whole body. The study

suggests that early detection and comprehensive management of rVSD is essential to

prevent further complications of this condition.

B. Reasons for choosing such presentation

The group has three main reasons why they got aby Hearty¶s case as their case

study in the pediatric ward. The first reason is because, when the group had taken their

first duty at a public hospital in San Fernando specifically in pediatric ward, their

attention was caught by this patient who seems to be the youngest patient in the ward.

In the first exposure, the group didn¶t approach the patient¶s SO but instead, they



approached the SO of the other patient (who has the same condition) who is an Aeta.

They tried to establish rapport with the aeta but unfortunately, they didn¶t succeed. So,

they have made their decision that if they can establish rapport with the first patient they

had seen, they will get the case as their case study. After a few minutes of therapeutic

communication, they had established rapport causing them to get the case. Second

reason is that the case of the patient is related to the group¶s topic in the lecture. And the

last reason is that, the group wants to study uncommon cases to acquire knowledge

about the case, its causes, manifestations, preventions, treatment and other information

regarding the disease condition.

OBJECTIVES

1. STUDENT±CENTERED

Short Term

After a day of nursing intervention, the students will be able to:

y gain the trust of the patient and the patient¶s significant other

y gain enough information about the patient¶s past and present medical history

y have a background of the condition, which is Ventricular Septal Defect

y know the incidence, prevalence, and mortality rates of the disease in foreign and

local statistics

y know the current trends about the condition, and

y identify factors present to the patient that predisposed her to the said condition

Long Term

After 1 week of completing this study, the students will be able to:

y accomplish the case study requirement

y explain briefly the anatomy and physiology of the heart

y gain proper knowledge and understanding about the existing disease condition,

its pathophysiology and etiology involved in its acquisition and progression

y identify the different predisposing and precipitating factors associated in the

development of the condition

y identify the different early clinical manifestations of the condition



y analyze the different laboratory and diagnostic procedures, their indications to

the condition and identify the different nursing interventions before, during and

after the performance of the said procedures

y explain the different treatments or medical modalities and their importance, and

different nursing interventions during the performance of the said procedures,

y identify common medications used as treatment for the condition, their

mechanism of action, adverse effects and nursing interventions before, during

and after the administration of the medications, appropriate nursing diagnoses

and their corresponding effects for the disease conditions, and finally,

y render appropriate nursing interventions to prevent complications of the condition

2. PATIENT±CENTERED

Short Term

After a day of performing nursing interventions, the patient and/or patient¶s

significant others will be able to:

y have a background of Ventricular Septal defect

y know the reasons why such diagnostic procedures and treatment modalities are

performed

y know the progression of the condition

y cooperate in the necessary medical and nursing interventions

Long Term

After a week of accomplishing this case study, the patient and/or patient¶s

significant others will be able to:

y know the reasons why the patient experiences the signs and symptoms of the

condition

y know preventive measures in response to the condition so as to prevent

deterioration of the patient¶s condition

y participate willingly in the care of the patient¶s conditions such as adhering to

health teachings provided by the student nurses

y know how to provide care for health promotion

y know the possible surgery that the patient will undergo, if ordered by the

attending physician



II. NURSING ASSESSMENT

1. PERSONAL DATA

Baby hearty, a 5 month old boy, was born on March 19, 2010. He is a Filipino

citizen and not yet baptized. He was born via Cesarean section, bikini cut at a tertiary

hospital in San. Fernando Pampanga. He should have been the second child of his

mother but unfortunately, intrauterine fetal death occurred to the f irst baby.. Baby Hearty,

was diagnosed of Ventricular Septal Defect when he was 2 months old. Baby hearty

together with his family resides in Guagua, Pampanga.

He was admitted last August 27, 2010; 10:30pm at a tertiary hospital at San

Fernando, Pampanga with a chief complaint of difficulty of breathing with cough for four

days along with fever. Baby hearty was diagnosed of Congenital Heart Disease,

Acyanotic Type probably Ventricular Septal Defect in heart Failure with Pneumonia. With

vital signs T-37.6 C, PR-120 bpm, RR-46 cpm with positive rales and positive

tachycardia. Complete blood count and chest x-ray was done that day.

2. PERTINENT FAMILY HISTORY

The Heart family is classified as nuclear type of family where in the members live

together in one house consisting of the father, mother, and children. Baby hearty was

delivered via Cesarean section. Mother hearty had her prenatal checkups every month

and had a complete dose of Ferrous sulfate supplementation during the entire

pregnancy period.

Heart family¶s house is made up of concrete materials, having two rooms and

kitchen and a bathroom. There are total of two doors and four windows in their house

that makes their house well ventilated. The house is lighted with fluorescent light, which

is the only appliance that uses electricity. They own appliances such as two television

and three electric fans. The house has a total floor area of 18 m . The floor area, as

calculated and compared with the standard floor are per family member of NEDA 2004,

was considered to be adequate with all of the family members.



Daddy Hearty, 42 years old, is a guitar maker in Guagua, Betis Pampanga where

he earns approximately 20,000 pesos monthly. Mommy Hearty, 20 years old is a plain

housewife with grandmother Hearty and baby Hearty. Their estimated total family

income is 20,000. The family is categorized as not poor. According to NEDA(2004), a

family must have P2, 768.60 pesos per individual, in relation with the total family income,

every individual was allotted P6666.67/month that makes them categorized as to be not

poor. They spend 300 pesos for food daily. Every week Mommy Hearty and

grandmother Hearty buys their grocery at the market, they spend 1,000 pesos. Family

Hearty are fond of eating pork, fish, vegetable and fruits, they also love to drink

softdrinks everyday. Mother hearty spends 500php for her load every month. They also

pay for water 1,000 and electric bill 2,500 per month. There is also allotted money for

health care emergency purposes 2,450 php.

The sum total of the family¶s monthly income is approximately P 20,000php,

which is divided in to the following expenses:

*The data were only estimated by Mother Hearty upon interaction.

They belive in ³usog´ which is very evident especially by Grandmother hearty

who lets her grandchild wear a bracelet adorned with red and black beads.. When it

comes to self-medication, they made use of paracetamol that are bought on the nearby

sari-sari store. They also avail health services in their baranggay and had their checkups

when illness occurs. They also availed free immunizations.

Monthly Expenses

Food (meals)

Electricity

Water

Other grocery items

Transportation

Cellphone Load

Emergency money

9,300

2,500

1,000

4,000

250

500

2,450

Total 20,000



The figure below shows the schematic diagram of the pertinent family history. On

the maternal side , both grandparents, Grandfather M and Grand mother M are healthy.

While On the paternal side, both grandparents are deceased wherein Grandmother F

died of stroke and Grandfather F died of heart attack.

The mother of Baby Hearty, Mother Hearty, is the eldest among her siblings. She

has two siblings who are twins. The child next to Mother Hearty is Uncle M who only

suffered Hepatitis A when he was young and the youngest of the three is the other twin,

Auntie M who suffered Pneumonia in the past.

The father of Baby Hearty, Father Hearty, is the eldest among his siblings too.

He has three other siblings namely Uncle F, Auntie F and Aunt F. All of the children of

Grandmother F and Grandfather F were health except Uncle F who is currently

experiencing Hypertension.



Genogram

Maternal Side

Grandmother M

Healthy

Grandfather M

Healthy

Grandmot

Deceased

Stroke

Mother

Hearty

Healthy

Eldest

Uncle M

Twin of

Auntie M

Hepa A

Auntie M

Twin of

Uncle M

Pneumonia

Uncle F

Hyperten

Father

Hearty

Healthy

Eldest

Baby Hearty (Patient)

VSD w/ Pneumonia



3. PERSONAL HISTORY

A. Pre-natal (mother¶s practice/ habits during pregnancy)

Mother hearty has a maternal-obstetrical record of G2P2T1P0 A1L1M0 where in G

or Gravida is the number of times a woman was pregnant whether it was delivered or

not, P or Parity indicates number of pregnancies that was delivered whether the baby is

alive or not, T or Term is the number or times a woman came to term (37 weeks), P or

Preterm is the number of premature babies the woman had or pregnancy that did not

reach term (20-36 weeks and 6 days), A or Abortion is the number of miscarriage,

abortion and L or number of live births or the number of living children the woman has

now. And M or multiparty which signifies multiple births. As her part of the conception,

Mother hearty often walks around within their house every morning so that when the due

date comes, she can deliver fast and to have a healthy baby. On the first pregnancy of

mother hearty she was so conscious about her childbearing she has her prenatal

checkups every month and takes her vitamins as well. . During her pregnancy she loves

to eat chicken legs and white chocolate. She did not experience morning sickness during

pregnancy. Mother hearty experienced having stretch marks on the abdominal area,

edema on the lower extremities, enlargement of the nose and back ache. On the 6 th

month of her pregnancy she had a prenatal checkup with her doctor because she

experienced bleeding. After the consultation Mother Hearty was diagnosed with

intrauterine fetal death and after that her doctor did Dilatation and Curettage. She was

so upset and sad because her baby was gone. After 1 year, she got pregnant to baby

Hearty and in this time she was so depressed and emotionally sick because of private

matters. On the first trimester of her pregnancy specifically on the 3 rd month she took

Cytotec and tried to abort her baby, but the baby was not aborted.



VACCINE SCHEDULE

% OF

PROTECTION RECEIVED BY MOTHER

TT1 As early as possible

during pregnancy

--TT1 was received by Mother

hearty on her first pregnancy

TT2 At least 4 weeks later 80%TT2 was received by Mother

Hearty on her first pregnancy

TT3 At least 6 mos. later 95%TT3 was received by Mother

hearty on her first pregnancy

TT4 At least 1 yr later 99%

TT4 was received by Mother

Hearty on her second

pregnancy

TT5 At least 1 yr after TT4 99%TT5 was not yet received by

Mother hearty

a. Birth duration and circumstances of labor, home or hospital delivery, type,

complication, birth weight and age of gestation.

Baby Hearty was delivered by Cesarean Section, maturely at 9months of

gestation, with no complications.

Baby hearty is a 5 month old boy that is active whenever you play with him. He

smiles whenever he is being playedwith and will cry whenever he is hungry. He was

born on March 19, 2010 by Cesarean Section, bikini cut, at a tertiary hospital at San.

Fernando Pampanga. He is the only child and cared by his grandmother. He weighs 6.8

grams when he was delivered.



Feeding

When Baby Hearty was born, he was breastfed by his mother but because he

was diagnosed of having Ventricular Septal Defect he was stopped being breastfed and

he started being bottle fed (Bona). The type of his feeding was milk feeding that

comprises of formula feeding.

Growth and development

Psychosexual Theory of Sigmund Freud

The psychosexual stages of Sigmund Freud are five different developmental

periods during which the individual seeks pleasure from different areas of the body

associated with sexual feelings. These stages are as follows:

Oral Birth to 1 year

Anal 2 to 3 years

Phallic 4 to 5 years

Latency 6 to 12 years

Genital 13 and up

Basing on this theory, baby Hearty belongs to the oral phase. It is very evident

that baby Hearty is on the oral stage because everything that touches on the mouth his

tendency is to suck it. And everything that he holds he grab it and put it in his mouth. His

security blanket is his pacifier that whenever he cries grandmother hearty will put the

pacifier on the mouth of baby Hearty.



Cognitive Theory of Jean Piaget

Cognitive development refers to how a person perceives, thinks, and gains

understanding of his or her world through the interaction and influence of genetic and

learning factors. This is divided into five major phases:

Sensorimotor Phase Birth to 2 years

Pre-conceptual Phase 2 ± 3 years

Intuitive Thought Phase 4 ± 6 years

Concrete Operations Phase 7 ± 11 years

Formal Operational Phase 12 ± adulthood

Basing on this theory, Baby hearty belongs to the sensorimotor phase.

Recognizes self as agent of action and begins to act intentionally. In this phase baby

hearty is very sensitive to noise and to the things that he sees. Whenever he is hungry,

he cries and that in order to be pacified, his grandmother talks to him, making different

sounds just to keep him quiet. Also, Baby Hearty likes to imitate the faces that he sees.

When a nursing student smiles at him, he smiles back.

Psychosocial Theory of Erik Erickson

Erik Erickson envisioned life as a sequence of levels of achievement. Each

stage signals a task that must be achieved. He believed that the greater that task

achievement, the healthier the personality of the person. Failure to achieve a task

influences the person¶s ability to achieve the next task. Stages of Erickson¶s

Psychosocial Theory are as follows:



Infancy Birth ± 18 months Trust vs. Mistrust

Early Childhood 18 months ± 3 years Autonomy vs. Shame

Late Childhood 3 ± 5 years Initiative vs. Guilt

School Age 6 ± 12 years Industry vs. Inferiority

Adolescence 12 ± 20 years Identity vs. Role Confusion

Young Adulthood 18 ± 25 years Intimacy vs. Isolation

Adulthood 25 ± 65 years Generativity vs. Stagnation

Maturity 65 years to death Integrity vs. Despair

Basing on this theory, baby hearty belongs to infancy ³Trust vs. Mistrust´. It is

evident because whenever the student nurse will get him he will cry and look for his

grandmother because Baby Hearty is being cared by his Grandmother hearty.

Anna Freud¶s Psychoanalysis

The first stage of psychosexual development is the oral stage, which lasts from

the beginning of one¶s life up to 2 years. According to Anna Freud, The ego, however, is

under formation during this first stage. Body image is developed, which implies that the

infant recognizes that the body is distinct from the outer world.

One of the signs that Baby hearty showed that he really has his own body image

is through crying. Crying means that he feels pain, pain on his own body and that he

uses crying in order to satisfy his need (Ego).

Milestones of Baby Hearty

On the first month of Baby hearty can lifts his head when lying on tummy and he

responds to sound whenever grandmother Hearty calls him. He also stares at faces. On

the second month of baby hearty he can vocalizes gurgles and coos, he can also follow

objects across field of vision. He can hold his head up for short periods. On the third



month of baby hearty he can recognizes the face of his grandmother to the face of his

mother. In this month he can already holds head steady and visually tracks moving

objects. On the fourth month of baby hearty he can now smiles and laughs and can bear

weight on legs. He coos when grandmother Hearty talks to him. On the fifth month of

baby hearty he now distinguishes between bold colors and plays with his hands and

feet.

Immunization Status

Baby Hearty had his immunization 1 dose of BCG and 1 dose of Hepa only

because he is 5 months old.

Vaccine # of doses

Bacillus Calmette Guerin (BCG) 1 dose

Oral Polio Vaccine (OPV) 0 doses

Diphteria Pertussis Tetanus (DPT) 0 doses

HEPA 1 doses

Measles 0 dose

4. HISTORY OF PAST ILLNESS

According to Grandmother Hearty, her grandson has never been hospitalized, no

history of asthma attracts and no history of allergy, until they found out that baby Hearty

has a congenital Disease specifically Ventricular Septal Defect. He only experienced

cough and colds, and fever. They managed it by consulting their pediatrician.

5. HISTORY OF PRESENT ILLNESS

Prior to admission (August 27, 2010) had cough and colds with accompanying

fever. No medicine was taken and no consultation was done.



Few hours before admission persistence of cough and colds with fever are

present so family Hearty decided to confine baby hearty to the nearest hospital. When

they got to the hospital and they told about baby hearty¶s condition the secondary

hospital near to their house refer them to the tertiary hospital in San. Fernando

Pampanga.

On the admission, August 27, 2010, the vital signs of the client were T- 37.6 C,

PR-120 bpm, RR-46 cpm negative cyanosis, negative jaundice, pink palpebral

conjunctiva, anicteric sclera, presence of tachypnia, rules on the left lung field upon

auscultation, positive murmur, with retraction.

6. PHYSICAL EXAMINATION

I. Integumentary:

Skin: He is white in complexion, with presence of skin rashes on left arm, with

good skin turgor.

Nails: Fingernails and toenails are both unclean and long. Smooth in textureand the shape is convex. The capillary refill easily goes back to its color for less

than 3 second.

Hair: black in color, short, thin hair with patches of hair loss.

II. Head

Scalp: with presence of lesions and scar .

Skull: The shape of the skull is round and normocephalic.

Face: Smooth with no edema

III. Eyes



Eyebrows: Hair is evenly distributed and symmetrically aligned.

Eyelashes: Equally distributed and the curled slightly outward.

Eyelids: No discharge and discoloration.

Bulbar conjunctiva: Transparent in color, capillaries are sometimes evident and

the sclera appears white

Palpebral conjunctiva: Shiny, smooth and pink.

Pupils: Black in color, equal in size and its iris is flat and round.

IV. Ears

Auricle: The auricle is aligned with the outer canthus of the eyes. Symmetrical

and has the same color with the facial skin.

External ear: Symmetrical in shape and size and no presence of lesions.

Internal ear: There is no presence of excessive cerumen.

V. Mouth and throat

Lips: dark and smooth with no presence of sores.

Teeth: no teeth yet

Tongue: Pinkish in color with no presence of lesions.

Throat: Uvula is aligned at the center and no inflammation noted.

Speech: Able to stutter

Gag reflex: Able to swallow without difficulty and pain.

Gums: no gingivitis and no presence of sores.



VI. Nose

Symmetric and straight, uniform in color, not tender and no presence of lesions.

VII. Neck

Has smooth, coordinated movements.

VIII. Thorax and Lungs

Symmetrical when chest is expanded normal rise and fall of chest when

breathing and presence of rales on the left upper quadrant upon auscultation, use

of accessory muscle.

IX. Heart

Increase heart rate and murmurs noted.

X. Abdomen

Skin in the abdomen is uniform in color, globular in shape.

XI. Extremities

No presence of edema on his lower extremities

XIII. Mental state

Awake and conscious, responds to stimuli.



7. DIAGNOSTIC AND LABORATORY PROCEDURES

CHEST X-RAY

Diagnostic

Procedure

Date

Ordered

/Date

results in

Indications or

purpose

Results Normal values

Chest X-Ray Date

Ordered:

8-27-10

Date results

In:

9-2-10

A chest x ray

is a procedure

used to

evaluate

organs and

structures

within the

chest for

symptoms of

disease. Chest

x rays include

views of the

lungs, heart,

small portions

Theres is an increased

pulmonary vascularity. A

wedge-shaped opacity is seen

in the right apex. Hazy

infiltrates are noted in the left

upper lung zone. The heart is

enlarged with prominent left

ventricle. The diaphragm,its

sulcus and visualized bones

are intact.

A chest x ray is a

procedure used to

evaluate organs and

structures within the

chest for symptoms of

disease. Chest x rays

include views of the

lungs, heart, small

portions of the

gastrointestinal tract,

thyroid gland, and the

bones of the chest

area. X rays are a

form of radiation that



of the

gastrointestinal

tract, thyroid

gland, and the

bones of the

chest area. X

rays are a form

of radiation

that can

penetrate the

body and

produce an

image on an x-

ray film.

Another name

for the film

produced by x

rays is

radiograph.

can penetrate the

body and produce an

image on an x-ray

film. Another name for

the film produced by x

rays is radiograph.



Nursing Responsibilities for Chest X-ray:

Prior:

y

Check the doctor¶s order.y Determine the prescribed test and other restrictions prior to the test.

y Get the laboratory requisition slip.

y Explain to the patient¶s SO what the procedure to be done is.

y Inform the patient¶s SO how the procedure is performed, the equipment to be used and what

during the procedure.

y The client may need analgesics and other pain relieving interventions.

During:

y Explain to the patient¶s SO what test should be done.

y Prepare all the equipments to be used.

y Assist the patient if necessary.

y Instruct the patient to be still or instruct the SO to keep the client calm.

After:

y Proper documentation.

y Tell the client¶s SO to wait until the technologist checks the images for motion and makes sure



CBC

Diagnostic

Procedure

Date Ordered /Date

results in

Indications or purpose Results Normal value

Hemoglobin August 27,2010

September 1 ,2010

Hemoglobinmolecule fills up the red bloodcells. It carries oxygen andgives the blood cell its redcolor. Hgb level indicates theamount of hemoglobin inblood and is a good measureof the blood's capacity tocarry oxygen throughout thebody. Abnormalities in Hgb

indicate defects in the redblood cell homeostasis.

A WBC count is the number of white blood cells per volumeof blood, and is reported ineither thousands in amicroliter or millions in a liter of blood. A high WBC count

can be an indicator of aninfection, inflammation, or allergy.

112 g/L

108 g/dl

125-175 g/L



WBC August 27,2010

September 1, 2010

12.2 x 10 9/L

12.2 x 10 9/L

5-10 x 10 9/L



Hematocrit August 27, 2010 Measures the amount of space (volume) red bloodcells take up in the blood. This

indicates the proportion of cells and fluids in the blood. Itis useful in evaluatingdehydration and hypovolemia.

.33 M: .40-.52

Neutrophils August 27, 2010

September 1, 2010

Neutrophils are the mostabundant type of white blood

cells in humans and some of the domestic mammals andform an essential part of theinnate immune system. It istested to detect infection or inflammation. During thebeginning (acute) phase of inflammation, particularly as aresult of bacterial infectionand some cancers,neutrophils are one of thefirst-responders of

inflammatory cells to migratetoward the site of inflammation.

.55

.46

M:.45-.46



Lymphocytes

Platelet

August 27, 2010

September 1, 2010

August 27,2010

September 1, 2010

Lymphocytes are the secondmost abundant WBCs.Lymphocytes originate in thelymphoid tissues and are notphagocytic. They are

responsible for initiating andregulating the immuneresponse by the production of antibodies and cytokines.

Bleeding disordersrequire the determination of the number of plateletspresent and/or their ability tofunction correctly.

.50

.49

363 x 10 9/L

365 x 10 9/L

.22-.35

150-400 x 10 9



Nursing responsibilities for Complete Blood Count:

Prior:

y Verify if the order and verify the patient¶s identity

y Gather the equipment to be used

y Wear gloves and other personal protective gear

y Choose the site for venipuncture

During

y Prepare the site to be used

y Perform the blood draw

After

y Apply pressure on the site after the blood draw to promote blod clotting

y Label the sample

y Properly dispose the used equipment



III. ANATOMY and PHYSIOLOGY

Circulatory System

The human heart is a muscular pump. While most of the hollow organs of the

body do have muscular layers, the heart is almost entirely muscle. Unlike most of the

other hollow organs, whose muscle layers are composed of smooth muscle, the heart is

composed of cardiac muscle. All muscle types function by contraction, which causes the

muscle cells to shorten. Skeletal muscle cells, which make up most of the mass of the

body, are voluntary and contract when the brain sends signals telling them to react. The

smooth muscle surrounding the other hollow organs is involuntary, meaning it does not

need to be told to contract. Cardiac muscle is also involuntary. So functionally, cardiac

muscle and smooth muscle are similar. Anatomically though, cardiac muscle more

closely resembles skeletal muscle. Both skeletal muscle and cardiac muscle are striated.

Under medium to high power magnification through the microscope, you can see small

stripes running crosswise in both types. Smooth muscle is nonstriated. Cardiac muscle

could almost be said to be a hybrid between skeletal and smooth muscle. Cardiac

muscle does have several unique features. Present in cardiac muscle are intercalated

discs, which are connections between two adjacent cardiac cells. Intercalated discs help

multiple cardiac muscle cells contract rapidly as a unit. This is important for the heart to

function properly. Cardiac muscle also can contract more powerfully when it is stretched

slightly. When the ventricles are filled, they are stretched beyond their normal resting

capacity. The result is a more powerful contraction, ensuring that the maximum amount

of blood can be forced from the ventricles and into the arteries with each stroke. This is

most noticeable during exercise, when the heart beats rapidly.

There are four chambers in the heart - two atria and two ventricles. The atria

(one is called an atrium) are responsible for receiving blood from the veins leading to the

heart. When they contract, they pump blood into the ventricles. However, the atria do not

really have to work that hard. Most of the blood in the atria will flow into the ventricles

even if the atria fail to contract. It is the ventricles that are the real workhorses, for they

must force the blood away from the heart with sufficient power to push the blood all the

way back to the heart (this is where the property of contracting with more force when

stretched comes into play). The muscle in the walls of the ventricles is much thicker than

the atria. The walls of the heart are really several spirally wrapped muscle layers. This



spiral arrangement results in the blood being wrung from the ventricles during

contraction. Between the atria and the ventricles are valves, overlapping layers of tissue

that allow blood to flow only in one direction. Valves are also present between the

ventricles and the vessels leading from it.

Though the brain can cause the heart to speed up or slow drain, it does not

control the regular beating of the heart. As noted earlier, the heart is composed of

involuntary muscle. The muscle fibers of the heart are also self-excitatory. This means

they can initiate contraction themselves without receiving signals from the brain. This

has been demonstrated many times in high school classes of the past by removing the

heart of a frog or turtle, and then stimulating it to contract. The heart continues to beat

with no further outside stimulus, sometimes for hours if bathed in the proper solution. In

addition, cardiac muscle fibers also contract for a longer period of time than do skeletalmuscles. This longer period of contraction gives the blood time to flow out of the heart

chambers.

The heart has two areas that initiate impulses, the SA or

sinoatrial node, and the AV or atrioventricular node. The heart

also has special muscle fibers called Purkinje fibers that

conduct impulses five times more rapidly than surrounding cells.

The Purkinje fibers form a pathway for conduction of the

impulse that ensures that the heart muscle cells contract in the

most efficient pattern. The SA node is located in the wall of the

right atrium, near the junction of the atrium and the superior

vena cava. This special region of cardiac muscle contracts on

its own about 72 times per minute. In contrast, the muscle in the rest of the atrium

contracts on its own only 40 or so times per minute. The muscle in the ventricles

contracts on its own only 20 or so times per minute. Since the cells in the SA node

contract the most times per minute, and because cardiac muscle cells are connected to

each other by intercalated discs, the SA node is the pacemaker of the heart. When the

SA node initiates a contraction, Purkinje fibers rapidly conduct the impulse to another

site near the bottom of the right atrium and near the center of the heart. This region is

the AV node, and slows the impulse briefly. The impulse then travels to a large bundle of

Purkinje fibers called the Bundle of His, where they move quickly to the septum that

divides the two ventricles. Here, the Purkinje fibers run in two pathways toward the

Opened heart



posterior apex of the heart. At the apex, the paths turn in opposite directions, one

running to the right ventricle, and one running to the left. The result is that while the atria

are contracting, the impulse is carried quickly to the ventricles. With the AV node holding

up the impulse just enough to let the atria finish their contraction before the ventricles

begin to contract, blood can fill the ventricles. And, since the Purkinje fibers have carried

the impulse to the apex of the ventricles first, the contraction proceeds from the bottom

of the ventricles to the top where the blood leaves the ventricles through the pulmonary

arteries and the aorta.

The contraction of the heart and its anatomy cause the

distinctive sounds heard when listening to the heart with

a stethoscope. The "lub-dub" sound is the sound of the

valves in the heart closing. When the atria end their contraction and the ventricles begin to contract, the

blood is forced back against the valves between the

atria and the ventricles, causing the valves to close. This

is the "lub" sound, and signals the beginning of ventricular contraction , known as

systole. The "dub" is the sound of the valves closing between the ventricles and their

arteries, and signals the beginning of ventricular

relaxation, known as diastole.

A physician listening carefully to the heart can

detect if the valves are closing completely or

not. Instead of a distinctive valve sound, the

physician may hear a swishing sound if they are

letting blood flow backward. When the swishing

is heard tells the physician where the leaky

valve is located.

The Pulmonary and Systemic Circuits and the Blood Supply to the Heart.

The heart is responsible for pumping the blood to every cell in the body. It is also

responsible for pumping blood to the lungs, where the blood gives up carbon dioxide and

takes on oxygen. The heart is able to pump blood to both regions efficiently because

The cardiac cycle

Stethoscope placements (shade areas)

for hearing heart sounds



there are really two separate circulatory circuits with the heart as the common link. Some

authors even refer to the heart as two separate hearts--a right heart in the pulmonary

circuit and left heart in the systemic circuit. In the pulmonary circuit, blood leaves the

heart through the pulmonary arteries, goes to the lungs, and returns to the heart through

the pulmonary veins.

In the systemic circuit, blood leaves the heart through the

aorta, goes to all the organs of the body through the

systemic arteries, and then returns to the heart through

the systemic veins. Thus there are two circuits. Arteries

always carry blood away from the heart and veins always

carry blood toward the heart. Most of the time, arteries

carry oxygenated blood and veins carry deoxygenatedblood. There are exceptions. The pulmonary arteries

leaving the right ventricle for the lungs carry deoxygenated blood and the pulmonary

veins carry oxygenated blood. If you are confused as to which way the blood flows

through the heart, try this saying "When it leaves the right, it comes right back, but when

it leaves the left, it's left." The blood does not have to travel as far when going from the

heart to the lungs as it does from the heart to the toes. It makes sense that the heart

would be larger on one side than on the other. When you look at a heart, you see that

the right side of the heart is distinctly smaller than the left side, and the left ventricle isthe largest of the four chambers.

While you might think the heart would have no problem getting enough oxygen-rich

blood, the heart is no different from any other organ. It must have its own source of

oxygenated blood. The heart is supplied by its own set of blood vessels. These are the

coronary arteries. There are two main ones with two major branches each. They arise

from the aorta right after it leaves the heart. The coronary arteries eventually branch into

capillary beds that course throughout the heart walls and supply the heart muscle with

oxygenated blood. The coronary veins return blood from the heart muscle, but instead of

emptying into another larger vein, they empty directly into the right atrium.

The Blood Vessels

Arterial and Venous Systems



We need to briefly discuss the anatomy of the vessels. There

are three types of vessels - arteries, veins, and capillaries.

Arteries, veins, and capillaries are not anatomically the same.

They are not just tubes through which the blood flows. Both

arteries and veins have layers of smooth muscle surrounding

them. Arteries have a much thicker layer, and many more

elastic fibers as well. The largest artery, the aorta leaving the

heart, also has cardiac muscle fibers in its walls for the first few

inches of its length immediately leaving the heart. Arteries have to expand to accept the

blood being forced into them from the heart, and then squeeze this blood on to the veins

when the heart relaxes. Arteries have the property of elasticity, meaning that they can

expand to accept a volume of blood, then contract and squeeze back to their original

size after the pressure is released. A good way to think of them is like a balloon. When

you blow into the balloon, it inflates to hold the air. When you release the opening, the

balloon squeezes the air back out. It is the elasticity of the arteries that maintains the

pressure on the blood when the heart relaxes, and keeps it flowing forward. if the

arteries did not have this property, your blood pressure would be more like 120/0,

instead of the 120/80 that is more normal. Arteries branch into arterioles as they get

smaller. Arterioles eventually become capillaries, which

are very thin and branching.

Capillaries are really more like a web than a branched

tube. It is in the capillaries that the exchange between

the blood and the cells of the body takes place. Here the

blood releases its oxygen and takes on carbon dioxide,

except in the lungs, where the blood picks up oxygen

and releases carbon dioxide. In the special capillaries of

the kidneys, the blood gives up many waste products in

the formation of urine. Capillary beds are also the sites where white blood cells are able

to leave the blood and defend the body against harmful invaders. Capillaries are so

small that when you look at blood flowing through them under a microscope, the cells

have to pass through in single file. As the capillaries begin to thicken and merge, they

become venules. Venules eventually become veins and head back to the heart. Veins

do not have as many elastic fibers as arteries. Veins do have valves, which keep the

Blood vessel anatomy

Capillary Bed



blood from pooling and flowing back to the legs under the influence of gravity. When

these valves break down, as often happens in older or inactive people, the blood does

flow back and pool in the legs. The result is varicose veins, which often appear as large

purplish tubes in the lower legs.

Respiratory System

The respiratory system's function is to absorb oxygen into the lungs and output carbon

dioxide and a small amount of oxygen. The space between the alveoli and the

capillaries, the anatomy or structure of the exchange system, and the precise

physiological uses of the exchanged gases vary depending on organism. In humans and

other mammals, for example, the anatomical features of the respiratory system include

airways, lungs, and the respiratory muscles. Molecules of oxygen and carbon dioxide

are passively exchanged, by diffusion, between the gaseous external environment and

the blood. This exchange process occurs in the alveolar region of the lungs.



UPPER RESPIRATORY TRACT

Respiration is defined in two ways. In common usage, respiration refers to the

act of breathing, or inhaling and exhaling. Biologically speaking, respiration strictly

means the uptake of oxygen by an organism, its use in the tissues, and the release of

carbon dioxide. By either definition, respiration has two main functions: to supply the

cells of the body with the oxygen needed for metabolism and to remove carbon dioxide

formed as a waste product from metabolism. This lesson describes the components of

the upper respiratory tract.

The upper respiratory tract conducts air from outside the body to the lower

respiratory tract and helps protect the body from irritating substances. The upper

respiratory tract consists of the following structures: The nasal cavity, the mouth, the

pharynx, the epiglottis, the larynx, and the upper trachea. The esophagus leads to the

digestive tract.

One of the features of both the upper and lower respiratory tracts is the

mucociliary apparatus that protects the airways from irritating substances, and is

composed of the ciliated cells and mucus-producing glands in the nasal epithelium. The

glands produce a layer of mucus that traps unwanted particles as they are inhaled.

These are swept toward the posterior pharynx, from where they are swallowed, spat out,

sneezed, or blown out.

Air passes through each of the structures of the upper respiratory tract on its way

to the lower respiratory tract. When a person at rest inhales, air enters via the nose and

mouth. The nasal cavity filters, warms, and humidifies air.

The pharynx or throat is a tube like structure that connects the back of the

nasal cavity and mouth to the larynx, a passageway for air, and the esophagus, a

passageway for food. The pharynx serves as a common hallway for the respiratory and

digestive tracts, allowing both air and food to pass through before entering the



appropriate passageways. The pharynx contains a specialized flap-like structure called

the epiglottis that lowers over the larynx to prevent the inhalation of food and liquid into

the lower respiratory tract.

The larynx, or voice box, is a unique structure that contains the vocal cords,

which are essential for human speech. Small and triangular in shape, the larynx extends

from the epiglottis to the trachea. The larynx helps control movement of the epiglottis. In

addition, the larynx has specialized muscular folds that close it off and also prevent food,

foreign objects, and secretions such as saliva from entering the lower respiratory tract.

LOWER RESPIRATORY TRACT

The lower respiratory tract begins with the trachea, which is just below the

larynx. The trachea, or windpipe, is a hollow, flexible, but sturdy air tube that contains

C-shaped cartilage in its walls. The inner portion of the trachea is called the lumen.



The first branching point of the respiratory tree occurs at the lower end of the

trachea, which divides into two larger airways of the lower respiratory tract called the

right bronchus and left bronchus. The wall of each bronchus contains substantial

amounts of cartilage that help keep the airway open. Each bronchus enters a lung at a

site called the hilum. The bronchi branch sequentially into secondary bronchi and

tertiary bronchi.

The tertiary bronchi branch into the bronchioles. The bronchioles branch

several times until they arrive at the terminal bronchioles, each of which subsequently

branches into two or more respiratory bronchioles.

The respiratory bronchiole leads into alveolar ducts and alveoli. The alveoli

are bubble-like, elastic, thin-walled structures that are responsible for the lungs¶ most

vital function: the exchange of oxygen and carbon dioxide.

Each structure of the lower respiratory tract, beginning with the trachea, divides

into smaller branches. This branching pattern occurs multiple times, creating multiple

branches. In this way, the lower respiratory tract resembles an ³upside-down´ tree that

begins with one trachea ³trunk´ and ends with more than 250 million alveoli ³leaves´.

Because of this resemblance, the lower respiratory tract is often referred to as the

respiratory tree.

In descending order, these generations of branches include:

trachea

right bronchus and left bronchus

secondary bronchi

tertiary bronchi

bronchioles

terminal bronchioles

respiratory bronchioles

alveoli



THE LUNGS

The thoracic cage, or ribs, and the diaphragm bound the thoracic cavity.

There are two lungs that occupy a significant portion of this cavity.

The diaphragm is a broad, dome-shaped muscle that separates the thoracic and

abdominal cavities and generates most of the work of breathing. The inter-costal

muscles, located between the ribs, also aid in respiration. The internal intercostal

muscles lie close to the lungs and are covered by the external intercostal muscles.

The lungs are cone-shaped organs that are soft, spongy and normally pink. The

lungs cannot expand or contract on their own, but their softness allows them to change

shape in response to breathing. The lungs rely on expansion and contraction of the

thoracic cavity to actually generate inhalation and exhalation. This process requires

contraction of the diaphragm.

To facilitate the movements associated with respiration, each lung is enclosed by

the pleura, a membrane consisting of two layers, the parietal pleura and the visceral

pleura.

The parietal pleura comprise the outer layer and are attached to the chest

wall. The visceral pleura are directly attached to the outer surface of each lung. The

two pleural layers are separated by a normally tiny space called the pleural cavity. A

thin film of serous or watery fluid called pleural fluid lines and lubricates the pleural

cavity. This fluid prevents friction and holds the pleural surfaces together during

inhalation and exhalation.

Ventilation

Ventilation of the lungs is carried out by the muscles of respiration.



Control

Ventilation occurs under the control of the autonomic nervous system from parts

of the brain stem, the medulla oblongata and the pons. This area of the brain forms the

respiration regulatory center, a series of interconnected brain cells within the lower and

middle brain stem which coordinate respiratory movements. The sections are the

pneumotaxic center, the apneaustic center, and the dorsal and ventral respiratorygroups. This section is especially sensitive during infancy, and the neurons can be

destroyed if the infant is dropped and/or shaken violently. The result can be death due to

"shaken baby syndrome.

Inhalation

Inhalation is initiated by the diaphragm and supported by the external intercostal

muscles. Normal resting respirations are 10 to 18 breaths per minute, with a time period

of 2 seconds. During vigorous inhalation (at rates exceeding 35 breaths per minute), or

in approaching respiratory failure, accessory muscles of respiration are recruited for

support. These consist of sternocleidomastoid, platysma, and the scalene muscles of the

neck. Pectoral muscles and latisimus dorsi are also accessory muscles.



Under normal conditions, the diaphragm is the primary driver of inhalation. When

the diaphragm contracts, the ribcage expands and the contents of the abdomen are

moved downward. This results in a larger thoracic volume and negative (suction)

pressure (with respect to atmospheric pressure) inside the thorax. As the pressure in the

chest falls, air moves into the conducting zone. Here, the air is filtered, warmed, and

humidified as it flows to the lungs.

During forced inhalation, as when taking a deep breath, the external intercostal

muscles and accessory muscles aid in further expanding the thoracic cavity.

Exhalation

Exhalation is generally a passive process; however, active or forced exhalation is

achieved by the abdominal and the internal intercostal muscles. During this process air

is forced or exhaled out.

The lungs have a natural elasticity: as they recoil from the stretch of inhalation,

air flows back out until the pressures in the chest and the atmosphere reach equilibrium.

During forced exhalation, as when blowing out a candle, expiratory muscles

including the abdominal muscles and internal intercostal muscles, generate abdominal

and thoracic pressure, which forces air out of the lungs.

Gas exchange

The major function of the respiratory system is gas exchange between the

external environment and an organism's circulatory system. In humans and mammals,

this exchange facilitates oxygenation of the blood with a concomitant removal of carbon

dioxide and other gaseous metabolic wastes from the circulation. As gas exchange

occurs, the acid-base balance of the body is maintained as part of homeostasis. If

proper ventilation is not maintained, two opposing conditions could occur: respiratory

acidosis, a life threatening condition, and respiratory alkalosis.

Upon inhalation, gas exchange occurs at the alveoli, the tiny sacs which are the

basic functional component of the lungs. The alveolar walls are extremely thin (approx.



0.2 micrometers). These walls are composed of a single layer of epithelial cells (type I

and type II epithelial cells) in close proximity to the pulmonary capillaries which are

composed of a single layer of endothelial cells. The close proximity of these two cell

types allows permeability to gases and, hence, gas exchange. This whole mechanism of

gas exchange is carried by the simple phenomenon of pressure difference. When the

atmospheric pressure is low outside, the air from lungs flow out. When the air pressure

is low inside, then the vice versa.



IV.THE PATIENT¶S ILLNESS

A.Synthesis of the Disease

1.Definition of the Disease( Book-based)

Ventricular septal defect

Ventricular septal defect describes one or more holes in the wall that separates

the right and left ventricles of the heart. Ventricular septal defect is one of the most

common congenital (present from birth) heart defects. It may occur by itself or with

other congenital diseases. These defects are more common in premature infants.

The ventricles are the 2 lower chambers of the heart. The wall between them is

called the septum. A hole in the septum is called a septal defect. If the hole is located

between the upper chambers or atria, it is called an atrial septal defect. Infants may be

born with either or both types of defects. These conditions are commonly known as

"holes in the heart."

Before a baby is born, the right and left ventricles of its heart are not separate. As

the fetus grows, a wall forms to separate these two ventricles. If the wall does not

completely form, a hole remains. This hole is known as a ventricular septal defect, or a

VSD.

Ventricular septal defect is one of the most common congenital heart defects. The baby

may have no symptoms, and the hole can eventually close as the wall continues to grow

after birth. If the hole is large, too much blood will be pumped to the lungs, leading to

heart failure.

Ventricular septal defects are the most common congenital heart defects in

infants (that is, defects that a person is born with) but the cause of VSD is not yet known.

This defect often occurs along with other congenital heart defects.

Normally, unoxygenated blood from the body returns to the right half of the

heart, that is the right atrium, then the right ventricle, which pumps the blood to

the lungs to absorb oxygen. After leaving the lungs, the oxygenated blood returns to the

left half of the heart, that is the left atrium, then the left ventricle, where it is pumped out

to provide oxygen to all the tissues of the body.



A ventricular septal defect can allow newly oxygenated blood to flow from the

left ventricle, where the pressures are higher, to the right ventricle, where the pressures

are lower, and mix with unoxygenated blood. The mixed blood in the right ventricle

flows back or recirculates into the lungs. This means that the right and left ventricles are

working harder, pumping a greater volume of blood than they normally would.

Eventually, the left ventricle can work so hard that it starts to fail. It can no longer

pump blood as well as it did. Blood returning to the heart from the blood vessels backs

up into the lungs, causing pulmonary congestion, and further backup into the body,

causing weight gain and fluid retention. Overall, this is called congestive heart failure.

If the VSD is large and surgically uncorrected, pressure can build excessively in

the lungs, called pulmonary hypertension. The higher the lung or pulmonary pressure,

the greater the chance of blood flowing from the right ventricle to the left

ventricle, backwards, causing unoxygenated blood to be pumped to the body and

cyanosis (blue skin).

The risk for these problems depends on the size of the hole in the septum and how well

the infant¶s lungs function.

The ventricular septal defect may not be heard with a stethoscope until several

days after birth. This is because a newborn's circulatory system changes during the first

week with drop in the lung or pulmonary pressure, creating the greater pressure

differential between the 2 ventricles, thus greater left-to-right shunt and audible murmur.

The condition occurs in about 25% of all infants born with a heart defect.

Eisenmenger's complex is a ventricular septal defect coupled with pulmonary

high blood pressure, the passage of blood from the right side of the heart to the left (right

to left shunt), an enlarged right ventricle and a latent or clearly visible bluish discoloration

of the skin called cyanosis (si"ah-NO'sis). It may also include a malpositioned aorta that

receives ejected blood from both the right and left ventricles (an overriding aorta).

People with Eisenmenger's complex, before and after treatment, are at risk for

getting an infection within the aorta or the heart valves (endocarditis). Please see the



section on ³Endocarditis´ below to determine whether your child will need to take

antibiotics before certain dental procedures.

Possible Complication may include heart failure ,infective endocarditis (bacterial

infection of the heart),aortic insufficiency (leaking of the valve that separates the leftventricle from the aorta),damage to the electrical conduction system of the heart during

surgery (causing arrhythmias), delayed growth and development (failure to thrive in

infancy), pulmonary hypertension (high blood pressure in the lungs) leading to failure of

the right side of the heart.

Pneumonia

Pneumonia is an infection of one or both lungs which is usually caused by

bacteria, viruses, or fungi. Prior to the discovery of antibiotics, one-third of all people

who developed pneumonia subsequently died from the infection. Currently, over 3

million people develop pneumonia each year in the United States. Over a half a million

of these people are admitted to a hospital for treatment. Although most of these people

recover, approximately 5% will die from pneumonia. Pneumonia is the sixth leading

cause of death in the United States.

Some cases of pneumonia are contracted by breathing in small droplets that contain the

organisms that can cause pneumonia. These droplets get into the air when a person

infected with these germs coughs or sneezes. In other cases, pneumonia is caused

when bacteria or viruses that are normally present in the mouth, throat, or nose

inadvertently enter the lung. During sleep, it is quite common for people to aspirate

secretions from the mouth, throat, or nose. Normally, the body's reflex response

(coughing back up the secretions) and their immune system will prevent the aspirated

organisms from causing pneumonia. However, if a person is in a weakened condition

from another illness, a severe pneumonia can develop. People with recent viral

infections, lung disease, heart disease, and swallowing problems, as well as alcoholics,

drug users, and those who have suffered a stroke or seizure are at higher risk for

developing pneumonia than the general population. As we age, our swallowing

mechanism can become impaired as does our immune system. These factors, along

with some of the negative side effects of medications, increase the risk for pneumonia in

the elderly.



Once organisms enter the lungs, they usually settle in the air sacs and passages

of the lung where they rapidly grow in number. This area of the lung then becomes filled

with fluid and pus (the body's inflammatory cells) as the body attempts to fight off the

infection.

Most people who develop pneumonia initially have symptoms of a cold (upper

respiratory infection, for example, sneezing, sore throat, cough), which are then followed

by a high fever (sometimes as high as 104 F), shaking chills, and a cough with sputum

production. The sputum is usually discolored and sometimes bloody. Depending on the

location of the infection, certain symptoms are more likely to develop. When the infection

settles in the air passages, cough and sputum tend to predominate the symptoms. In

some, the spongy tissue of the lungs that contain the air sacs is more involved. In this

case, oxygenation can be impaired, along with stiffening of the lung, which results inshortness of breath. At times, the individual's skin color may change and become dusky

or purplish (a condition known as "cyanosis") due to their blood being poorly

oxygenated.

The only pain fibers in the lung are on the surface of the lung, in the area known

as the pleura. Chest pain may develop if the outer aspects of the lung close to the pleura

are involved. This pain is usually sharp and worsens when taking a deep breath and is

known as pleuritic pain or pleurisy. In other cases of pneumonia, depending on the

causative organism, there can be a slow onset of symptoms. A worsening cough,

headaches, and muscle aches may be the only symptoms.

Children and babies who develop pneumonia often do not have any specific

signs of a chest infection but develop a fever, appear quite ill, and can become lethargic.

Elderly people may also have few symptoms with pneumonia



.Ventricular Septal defect:

Modifiable factors:

Having the following conditions during pregnancy can increase your risk of having a

baby with a heart defect.

Rubella infection- Becoming infected with rubella (German measles) while

pregnant can increase the risk of fetal heart defects. The rubella virus crosses the

placenta and spreads through the fetus' circulatory system damaging blood vessels and

organs, including the heart.

Poorly controlled diabetes- Uncontrolled diabetes in the mother in turn affects

the fetus' blood sugar, causing various damaging effects to the developing fetus.

Drug or alcohol use or exposure to certain substances- Use of certain

medications, alcohol or drugs or exposure to chemicals or radiation during pregnancy

can harm the developing fetus.

Non- modifiable Factors:

Genetics-

chromosomal disorders- absent or duplicated chromosomes

single-gene disorders- deletions, missense mutations and duplications within a

gene

polygenic disorders- result from environmental and genetic factors



Signs and Symptoms

Small holes in the ventricular septum usually produce no symptoms but

are often recognized by the child's health care provider when a loud heart murmur along

the left side of the lower breast bone or sternum is heard. Large holes typically

produce symptoms 1-6 months after an infant¶s birth. The baby often has symptoms

related to heart failure.

The most common symptoms include:

y Shortness of breath-it results when there is a respiratory infection. Pulmonary

hypertension also causes pulmonary vascular resistance that causes shortness of

breath.

y Fast breathing-As a compensation in shortness of breath, the patient may

manifest fast breathing to get enough oxygen.

y Hard breathing-Because of decreased oxygen and feeling of dyspnea, hard

breathing may manifest by the patient.

y Paleness- In VSD, there is a decrease in cardiac output of the heart leading to

decrease blood circulation and decrease blood in the blood leading to paleness.

y Failure to gain weight- there is a failure to gain weight because of the discomfort

during feeding and the accompanying manifestation like dyspnea.

y Fast heart rate- As a compensation to the decrease cardiac output, the heart will

increase its force of pumping and its heart rate to increase cardiac output.

y Sweating while feeding- The patient has easy fatigability because of decrease

oxygen in the body.

y Frequent respiratory infections- Because of pulmonary congestion brought about

by an increase blood congestion, there will be frequent respiratory infections.

y Listening with a stethoscope usually reveals a heart murmur (the sound of the

blood crossing the hole)-The loudness of the murmur is related to the size of the defect

and amount of blood crossing the defect

y Cyanosis-there will be a cyanosis because the oxygenated blood is being mix

with the unoxygenated blood. Cyanosis may also manifest because of decrease

perfusion of blood in the body. The skin turns faintly bluish when the tissues are not

receiving quite enough oxygen.



Pneumonia

Modifiable factors:

Smoke-Cigarette smoking is the strongest risk factor for developing pneumonia

in healthy young people.2

Have another medical condition-especially lung diseases such as chronic

obstructive pulmonary disease (COPD) or asthma.

Have an impaired immune system- fighting bacteria is difficult if you have

impaired immune system

Have a change in mental status (such as confusion or loss of consciousness) -

increases the risk of breathing mucus or saliva from the nose or mouth, liquids,

or food from the stomach into the lungs (aspiration).

Take medicine called a proton pump inhibitor (such as pantoprazole or

omeprazole) that reduces the amount of stomach acid.

Don't get enough to eat to stay healthy (malnutrition)- may impaired immune

system

Non-modifiable factors:

Are younger than 1 year of age or older than 65- Immune system is not yet

develop (younger than 1 year of age) and degenerative changes (older than 65).

Signs and symptoms:

In children, symptoms may depend on age: In infants younger than 1 month of age,

symptoms may include:

Having little or no energy (lethargy) - may due to the feeling of dyspnea

causing small amount of oxygen in the body producing little amount of

energy.

Feeding poorly- due to the feeling of dyspnea.

grunting

Having a fever- as a compensation of the body, fever may occur.



Fast, often shallow, breathing and the feeling of being short of breath- may be due

to mucus production that obstructs the air.

Fast heartbeat- because of the decrease oxygen and blood receive by the body,

the heart compensate.

In adult patients, symptoms may include:

Cough- often producing mucus (sputum) from the lungs. Mucus may be rusty or

green or tinged with blood.

Shaking, "teeth-chattering" chills (one time only or many times)- when fever

reach a much higher value.

Chest wall pain that is often made worse by coughing or breathing in- it is due to

the bacteria in the lungs that cause inflammation.

Definition of the disease ( Patient-centered )

The normal heart has two sides, the left and the right, which are separated by a

muscular wall called the septum. Each side of the heart also has two parts - an upper

chamber called an atrium and a lower chamber called a ventricle.

Ventricular septal defect (VSD), a congenital (present at birth) defect, is an opening in

the ventricular septum, or dividing wall between the two lower chambers of the heart

known as the right and left ventricles. It is cause by taking teratogenic drug specifically,

cytotec during the mother¶s 2nd month of pregnancy. This drug is toxic to the fetus during

the growth and the development of it in the womb of the mother specially, in the first

semester where in organogenesis occurs.

Normally, oxygen-poor blood returns to the right atrium from the body, travels to the right

ventricle, then is pumped into the lungs where it receives oxygen. Oxygen-rich blood

returns to the left atrium from the lungs, passes into the left ventricle, then is pumped outto the body through the aorta. A ventricular septal defect allows oxygen-rich blood to

pass from the left ventricle through the opening in the septum, and then mix with

oxygen-poor blood in the right ventricle.



Pneumonia

Pneumonia is an infection of one or both lungs which is usually caused by bacteria,

viruses, or fungi. A person is in a weakened condition from another illness, a severe

pneumonia can develop. People with recent viral infections, lung disease, heartproblems, and swallowing problems, as well as alcoholics, drug users, and those who

have suffered a stroke or seizure are at higher risk for developing pneumonia than the

general population. Pulmonary congestion in a patient with heart defect/disease is at

higher risk of having pneumonia. Congestion of blood is a good medium in the

development of bacteria and viruses that will cause pneumonia.

Ventricular Septal Defect:

Modifiable Factor:

Drug or alcohol use or exposure to certain substances-During pregnancy of the

patient¶s mother, she had take a medicine called cytotec which is proven dangerous to

the growth and development of the fetus inside the mother¶s womb during

organogenesis.

Signs and Symptoms

y Shortness of breath-it results when there is a respiratory infection. Pulmonary

hypertension also causes pulmonary vascular resistance that causes shortness of

breath.

y Fast breathing-As a compensation in shortness of breath, the patient may

manifest fast breathing to get enough oxygen.

y Hard breathing-Because of decreased oxygen and feeling of dyspnea, hard

breathing may manifest by the patient.

y Paleness- In VSD, there is a decrease in cardiac output of the heart leading to

decrease blood circulation and decrease blood in the blood leading to paleness.

y Failure to gain weight- there is a failure to gain weight because of the discomfort

during feeding and the accompanying manifestation like dyspnea.

y Fast heart rate- As a compensation to the decrease cardiac output, the heart will

increase its force of pumping and its heart rate to increase cardiac output.

y Sweating while feeding- The patient has easy fatigability because of decrease

oxygen in the body.



y Frequent respiratory infections- Because of pulmonary congestion brought about

by an increase blood congestion, there will be frequent respiratory infections.

y Listening with a stethoscope usually reveals a heart murmur (the sound of the

blood crossing the hole)-The loudness of the murmur is related to the size of the defect

and amount of blood crossing the defect

y Cyanosis-there will be a cyanosis because the oxygenated blood is being mix

with the unoxygenated blood. Cyanosis may also manifest because of decrease

perfusion of blood in the body. The skin turns faintly bluish when the tissues are not

receiving quite enough oxygen.

Pneumonia

Modifiable factor:

Having other medical condition- the patient is having heart defect, VSD.

Non-modifiable factor:

Are younger than 1 year of age- the patient is a 6-month old baby.

Signs and symptoms:

Having little or no energy (lethargy) - may due to the feeling of dyspnea

causing small amount of oxygen in the body producing little amount of

energy.

Feeding poorly- due to the feeling of dyspnea and discomfort.

Having a fever- as a compensation of the body, fever may occur.

Fast, often shallow, breathing and the feeling of being short of breath- may be due

to mucus production that obstructs the air.

Fast heartbeat- because of the decrease oxygen and blood receive by the body,

the heart compensate.



Nursing Duties and Responsibilities:

Health teaching is a very vital role of the nurse in providing health care services.

In line with the condition, we, health care providers must provide health teachings and

emotional support to our patient.

Once parents learn of the heart defect, they are initially in a period of shock,

followed by high anxiety, especially fear of the child¶s death. The family needs a period

of grief before assimilating the meaning of the defect. The parents must be informed of

the condition to give informed consent for diagnostics and therapeutic procedures. The

nurse can be instrumental in supporting parents in their loss, assessing their level of

understanding, supplying information as needed and helping other members of the

health team to understand the parent¶s reaction.

Once parents are ready to hear about their child¶s heart condition, it is essential

that they be given a clear explanation based on the level of their understanding.

Parents are the child¶s principal caregivers and need to develop a positive,

supportive working relationship with the health care team. Good communication between

the family and the healthcare practitioner is essential. Parents of children with cyanosis

should be informed about fluid management and hyper cyanotic spells. The family also

needs to be knowledgeable regarding the therapeutic management of the disorder and

role that surgery, other procedures, medications, and a healthy lifestyle play in

maintaining good health. Instructing parents in feeding methods that decrease the work

of the infant and giving high-calorie formula are important interventions.

When the child needs to undergo procedure, the expected outcomes before the

procedure includes reducing anxiety, improving patient cooperation with procedures,

enhancing recovery, developing trust with the caregiver, and improving long-term

emotional and behavioral adjustments following procedures.

After the procedure, the health care provider must observe vital signs and arterial

and venous pressures, maintain respiratory status, provide maximum rest, provide



comfort monitor for fluids intake and output and observe for complications of heart

surgery.

Health promotion and Disease prevention:

In most cases, you can't do anything to prevent having a baby with a ventricular

septal defect. However, it's important to do everything possible to have a healthy

pregnancy. Here are the basics: Get early prenatal care, even before you're

pregnant. Quitting smoking, reducing stress, stopping birth control ² these are all

things to talk to your doctor about before you get pregnant. Also, be sure you talk to

your doctor about any medications you're taking. Eat a balanced diet. Include a

vitamin supplement that contains folic acid. Also, limit caffeine. Exercise regularly.

Work with your doctor to develop an exercise plan that's right for you. Avoid risks.

These include harmful substances such as cigarettes and illicit drugs. Also, avoid X-

rays, hot tubs and saunas. Avoid infections. Be sure you're up to date on all of your

vaccinations before becoming pregnant. Certain types of infections can be harmful to

a developing fetus. Keep diabetes under control. If you have diabetes, work with

your doctor to be sure it's well controlled before getting pregnant. If you have a family

history of heart defects or other genetic disorders, consider talking with a genetic

counselor before getting pregnant. Drinking alcohol and using the antiseizure

medicines depakote and dilantin during pregnancy have been associated with

increased incidence of VSDs. Other than avoiding these things during pregnancy,

there is no known way to prevent a VSD.

If the defect is small, no treatment is usually needed. However, the baby should

be closely monitored by a health care provider to make sure that the hole eventually

closes properly and signs of heart failure do not occur.

Babies with a large VSD who have symptoms related to heart failure may need

medicine to control the symptoms and surgery to close the hole. Medications may

include digitalis (digoxin) and diuretics.

If symptoms continue despite medication, surgery to close the defect with a

Gore-tex patch is needed. Some VSDs can be closed with a special device during a

cardiac catheterization, although this is infrequently done.



V.THE PATIENT AND HIS CARE

A .MEDICAL MANAGEMENT

a. IVF

MedicalManagement/Treatment

DateorderedDatechanged

GeneralDescription

Indication/ Purpose C

D5 0.3 NaCl DateOrdered:8-27-10

DateChanged:

9-13-10

A hypotonicsolution that hasgreater concentration of free water molecules that

are found insidethe cell.

To provide a balanced solution of fluid andelectrolytes for the patient

Thin

Nw

ThtreIVsk



Nursing Responsibilities for D5 0.3 NaCl

Before

y Check for the doctor¶s order

y Explain the procedure to the SO with it¶s importance and purposey Wash hands and observe other appropriate infection control procedures

y Always observe and check for the correct type of IVF as well as the clarity of the fluid

During

y Be sure to clean the site of entry with cotton and alcohol in a circular motiony Ensure appropriate infusion flow

y Adhere to standard precautions, then regulate flow rate as per doctor¶s order

After

y Check and observe the puncture site for bleeding, edema, or thrombophlebitis

y Make sure that the IVF is patent and properly regulated. Check regularly

y Document relevant data



Nursing Responsibilities for Heplock

Before

y Check for the doctor¶s order y Explain the procedure to the SO with it¶s importance and purpose

y Wash hands and observe other appropriate infection control procedures

y

MedicalManagement/Treatment

Date orderedDate changed

GeneralDescription

Indication/ Purpose Client Response

Heplock Date ordered:

9-13-10

Heparin lock flushis used to clear (flush) IV lines or catheters to keepthem open andflowing freely. Thisform of heparinmust not be usedas a blood thinner.

To clear (flush) IV linesor catheters to keepthem open and flowingfreely.

The patient tolefluid.

No allergies or oexperienced



During

y Be sure to clean the site of entry with cotton and alcohol in a circular motion

y Adhere to standard precautions

After

y Check and observe the puncture site for bleeding, edema, or thrombophlebitis

y Make sure that the heplock is patent. Check regularly

y Document relevant data

Medical

Management/Treatment

Date ordered

Date changed

General

Description

Indication/

Purpose

Client Response

OxygenInhalation vianasal canullaat 2-3 LPM

Date Ordered:8-27-10

In the hospital, oxygen issupplied to each patientroom via an outlet in thewall. Oxygen is deliveredfrom a central sourcethrough a pipeline in thefacility. A flow meter attached to the wall outletaccesses the oxygen. Avalve regulates the

oxygen flow, andattachments may beconnected to providemoisture. In the home, theoxygen source is usuallya canister or air compressor. Whether inhome or hospital, plastictubing connects the

The body isconstantly takingin oxygen andreleasing carbondioxide. If thisprocess isinadequate,oxygen levels inthe blooddecrease, and the

patient may needsupplementaloxygen. Oxygentherapy is a keytreatment inrespiratory care.The purpose is toincrease oxygensaturation in

The patient hadoxygen to compthe needed oxygdifficulty of breaoxygen.



Nursing Responsibilities:

Before:

y Check for the doctor¶s order.

y Explain the procedure to the patient/SO with its purpose and importance.

y Wash hands and observe other appropriate infection control procedures.

y Provide client privacy.

oxygen source to thepatient.Oxygen is mostcommonly delivered to thepatient via a nasal

cannula or mask attachedto the tubing. The nasalcannula is usually thedelivery device of choicesince it is well toleratedand doesn't interfere withthe patient's ability tocommunicate, eat, or drink. The concentrationof oxygen inhaleddepends upon theprescribed flow rate and

the ventilatory minutevolume (MV).

tissues where thesaturation levelsare too low due toillness or injury.Breathing

prescribedoxygen increasesthe amount of oxygen in theblood, reducesthe extra work of the heart, anddecreasesshortness of breath.



During:

y Adhere to standard precautions, then regulate flow rate as per doctor¶s order.

y Humidify the oxygen first before you administer

y Check for bubbles in the humidifier to promote adequate flow of oxygen

y Check for kinks in the tubing

y Position: semi-fowler's/high fowler's position

y Place cautionary reading: "NO SMOKING: OXYGEN IS IN USE"

y Instruct the client not to use woolen blankets as this may create static electricity

After:

y Check regularly.

y Document relevant data.

b. Drugs

Name of DrugGeneric and BrandName

Date Ordered/DateChanged

Route of AdministrationDosage and Frequencyof administration

Indication/ Purpose

Generic name: AmpicillinBrand name:

Principen


Date Discontinued:09-01-10

To reduce developof resistant to bacteand to treat infectio

that is proven to becaused by bacteria



NURSING RESPONSIBILITIES:

Prior

y Assess for allergies to Ampicillin, Penicillins, Cephalosporins, or other allergensy Assess for renal disorders

y Culture infected area

During

y Check IV site carefully for signs of thrombosis or drug reactiony Administer in slow IV push

After

y Monitor IV site carefully




Prior

y Assess for allergies to Cefotaxime

y Assess for hepatic and renal impairment

y Culture infected area and arrange for sensitivity test


Date Ordered/DateChanged


Indication/ Purpose

Generic name:Cefotaxime SodiumBrand name:Claforan


Intravenously 200mgq8 hours

To reduce thedevelopment of druresistant bacteria amaintain theeffectiveness of CLAFORAN (cefotasodium) and other antibacterial drugs,CLAFORAN shouldused only to treat oprevent infections tare proven or stron

suspected to be caby bacteria.



During

y Check IV site carefully for signs of thrombosis or drug reaction

y Administer in slow IV push

After

y Monitor IV site carefully


Prior

y Assess for allergies to Furosemide


Date Ordered Route of AdministrationDosage and Frequencyof administration

Indication/ Purpose

Generic name:

FurosemideBrand name:Lasix

08-28-10 Intravenously 6 mg

q 12 hours

To treat fluid retent

people with congesheart failure byabsorbing too muchallowing the salt toinstead be passed your urine.



y Administer with food or milk to prevent GI upset

y Give early in the day so that increased urination will not disturb sleep

y Do not expose to light

During


y Measure and record weight to monitor fluid changes

After

y Arrange for potassium rich diet

y Monitor urine output


Date Ordered/ DateDiscontinued


Indication/ Purpose

Generic name: AcetaminophenBrand name:Tempra

Date ordered:

08-31-10

Date Discontinued:

08-31-10

Intravenously 60 mgq 4 hours

To reduce fever,headache, and othminor aches and pa




Prior

y Assess for allergies to Acetaminophen

y Administer with food or milk to prevent GI upset

During


y Do not exceed the recommended dosage

After

y Report rash, unusual bleeding or bruising, yellowing of skin or eyes




Prior

y Assess for allergies to aminoglycosides

y Assess for decreased renal function, dehydration

y Culture infected area and arrange for sensitivity test

During





Indication/ Purpose

Generic name: Amikacin Sulfate

Brand name: Amikin

Date Ordered:

09-01-10

Date Discontinued:

09-09-10

Intravenously 45mgq 12 hours

To reduce thedevelopment of dru

resistant bacteria amaintain theeffectiveness of the

Amikacin and otherantibacterial drugs,

Amikacin should beused only to treat oprevent infections tare proven or stronsuspected to be caby bacteria.



y Ensure that patient is well hydrated

After

y Report pain at injection site, severe H/A, difficulty of breathing




Indication/ Purpose

Generic name:Oxacillin Sulfate

Date Ordered:

09-03-10

Date Discontinued:

09-09-10

Intravenously 200mgq 8 hours

To reduce thedevelopment of druresistant bacteria amaintain the

effectiveness of Oxacillin Injection, and other antibactedrugs, OxacillinInjection, USP shouused only to treat oprevent infections tare proven or stronsuspected to be caby bacteria.




Prior

y Assess for allergies to penicillins, cephalosporins, or other allergens

y Assess for renal disordersy Culture infected area and arrange for sensitivity test

During


y Keep epinephrine, IV fluids, vasopressors, bronchodilator, oxygen, in case of serious hyperse

After

y Report difficulty of breathing, severe pain at injection site

y Finish entire course of therapy as prescribed



Indication/ Purpose

Generic name:DigoxinBrand name:

Lanoxin

09-07-10 1.2 ml/elixir 500gm/ml X40dose then .5ml q12hours

To Increase force avelocity of myocardcontraction and pro

refractory period ofatrioventricular (AVnode by increasingcalcium entry intomyocardial cells. S




Prior

y Monitor apical pulse for 1 min before administering

y Check dosage and preparation carefully

y Follow diluting instructions carefully, and use diluted solution promptly

During

y Have emergency equipment ready; have K salts, lidocaine, phenytoin, atropine, and cardiac mtoxicity develops

y Monitor for therapeutic drug levels: 0.5-2ng/ml

After

y Have a regular medical checkupsy Report slow or irregular pulse

conduction throughsinoatrial and AV nand producesantiarrhythmic effec




Prior

y Assess for allergies to amminoglycosides

y Assess for renal or hepatic disordersy Culture infected area and arrange for sensitivity test

During




Indication/ Purpose

Generic name:Gentamicin sulfateBrand name:

Maitec

09-09-10 30mg IV OD To reduce thedevelopment of druresistant bacteria a

maintain theeffectiveness of gentamicin and othantibacterial drugs,gentamicin should used only to treat oprevent infections tare proven or stronsuspected to be caby bacteria



y Ensure adequate hydration of patient

After

y Report difficulty of breathing, severe pain at injection sitey Finish entire course of therapy as prescribed

c. Diet

Type of Diet Date ordered;performed; changed

General DescriptionIndication/s

or Purposes

NPO Date ordered :

08-28-10

Date changed:

08-29-10

NPO is no food or drink

is allowed .

To prevent patient t

vomit




Before:

y Check for doctor's order.

y Instruct the patient about the prescribed diet ordered by the physician.y Explain the purpose and importance of the diet and no foods are allowed for the patient.

During:

y Remind patient¶s SO that the patient is not allowed to take anything orally.

After:

y Monitor the reaction of the patient.

y Assess improvement on the pt. condition

Type of Diet Date ordered General description Indication/Purpose Specific fo

Full diet with SAP 08-29-10 This kind of diet isordered when theclient¶s appetite

A full, well-balanceddiet containing all of the essential

nutrients needed for optimal growth,tissue repair, andnormal functioningof the organs. Such

Formula M



a diet containsfoods rich inproteins,carbohydrates,high-quality fats,

minerals, andvitamins inproportions thatmeet the specificcaloricrequirements of theindividual. Alsocalled normal dietwith strict aspirationprecaution.


Before:

y Check for doctor's order.

y Instruct the patient about the prescribed diet ordered by the physician.y Explain the purpose and importance of the diet and what specific foods are allowed for the pa

y Explain also the appropriate foods that should and should not to be taken.

During:

y Assist the patient when eating.y As much as possible, promote independence.



After:

y Monitor the reaction of the patient.

y Assess improvement on the pt. condition

d. Activity and Exercise

Type of Activity Date ordered General description Indication/Purpose Specific ataken

Bed Rest Date Ordered:

8-27-10

Patient is restrictedfrom any stressfulactivities

To decreasepatient¶s metabolicdemand and to

decrease oxygenand energy supply

Anything tpatient ca


Prior

Explain properly the activity/exercise that the patient has to go through Educate the SO by enumerating all the activities that patient may perform

During



>Monitor and document patient¶s reaction to the activity

After

Assist patient in performing activities Encourage adequate rest period



B. NURSING MANAGEMENT

PROBLEM#1: Impaired Gas exchange r/t pulmonary congestion secondary to VSD

ASSESSMENT

NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION OBJECTIVES

NURSING

INTERVENTIONS

S> Ø

O> the patient

manifested:

-restlessness

-lethargy

-hypoxemia

-tachynypnea

-nasal flaring

-tachycardia

>may manifest:

-daiphoresis

Impaired gas exchange

r/t pulmonary

congestion secondary

to VSD

Increase in

ventricular

pressure are

transmitted back

to the pulmonary

capillary

hydrostatic

pressure and

exceeding

osmotic

pressure, fluid

moves within the

alveolar septum

causing

decrease in the

lung¶s air volume

as the air is

displaced by theblood or

interstitial fluid

which causes

Short term:

After 4 hours of

NI, the patient

will

demonstrate

adequate

ventilation andoxygenation of

tissues by ABG

or oximetry

within the

patient¶s

normal ranges

and free of

signs of

respiratory

distress.

> assess and

monitor for the

changes in

respiratory

function.

> auscultate

breath sounds,

noting crakles,

wheezes.

> maintain bedrest with HOB

elevated 30-60



pulmonary

congestion and

result in an

impaired gas

exchange in thealveoli.

Long term:

After 24 hours

of NI, thepatient will

participate in

treatment

regimen such

as breathing

exercises and

use of oxygen,

within client¶s

limit.

degree.

> monitor serial

ABG.

>

provide brief explanation of all

treatments and

procedures.

> Administer

supplemental

oxygen as

indicated.



> prepare for

intubation and

assisted

mechanical

ventilation if required.

> administer

anticoagulant



PROBLEM#2: Altered tissue perfusion r/t impaired transport of O2 across alveolar and capillary mem

ASSESSMENTNURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATIONOBJECTIVES

NURSING

INTERVENTIONS

S> Ø

O> the patient

manifested:

-use of

accessorymuscles

-nasal flaring

Altered tissue

perfusion r/t

impaired

transport of O2

across alveolar

and capillary

membrane.

Disruption in the

structure of the

heart can

decrease cardiac

output. This will

decrease or alter

the delivery of

oxygen andnutrients to tissue

of different parts

of the body

organs.

Short term:

After 4 hours of

NI, the patient

will demonstrate

Increased

perfusion AEB

vital signs within

client¶s normal

limits, alert

oriented and

decreased pain

and discomfort.

Long term:

After 24 hours of

NI, the patient

>note color and

temperature of skin

q 4 hours.

>note strength of

peripheral

>

s

o

p

t

p

>

v

r

d

m

e

d

p

>

f

p



will demonstrate

increase in

tissue perfusion

as individually

appropriate AEBwarm skin an

adequate urine

output.

>monitor

respiration, note

work of breathing

>monitor intake,

note changes inurine output.

r

d

>

i

p

n

r

r

c

v

n

a

p

o

>

m

r

h

r

>

f

m



>record specific

gravity as indicated

after urinalysis.

>assess GI

function, noting

anorexia,

decreased or

absent vowel

sounds, N/V,

abdominal

distension and

constipation.

>monitor

laboratory data

(ABG, BUN,

Creatinine,

coagulation

r

d

>

o

f

a

c

m

r

t

m

>

c

f

a

o

b



studies)

>administer

diuretics and

anticoagulants.

b



PROBLEM#3: Decreased Cardiac Output r/t altered Contractility

ASSESSMENTNURSING

DIAGNOSIS

SCIENTIFIC


NURSING

INTERVENTIONS

S> Ø

O> the patient

manifested:

-tachycardia

-altered

contractility

-dyspnea

-tachypnea

-restlessness

Decreased

Cardiac Output

r/t altered

Contractility

Inadequate blood

pumped by the

heart to meet the

metabolic

demands of the

body in a hyper

metabolic state,

although C.O

may be at normalrange. It may still

be inadequate to

meet the needs

of the body¶s

tissues.

Short term:

After 2Û of NI pt.

will verbalize

knowledge of

the disease

process,

individual risk

factors and

treatment plan.

Long term:

After 3 days of

NI pt. will

demonstrate an

increase inactivity

tolerance.

>Monitor VS

> Asses pt¶s

condition

>Monitor

decreased heart

rate

>Note presence of

edema

>To

bas

>To

pre

>To

in h

>To

as

>To

in w



>Monitor

decreased weight

daily

>Perform

exercises within

the pt¶s pones

>Give due

medications

>To

incrstre

>To

pha



PROBLEM#4: Ineffective breathing pattern r/t hypertension AEB tachypnea and use of accessory mu

ASSESSMENTNURSING

DIAGNOSIS

SCIENTIFIC


NURSING

INTERVENTIONS

S> Ø

O> the patient

manifested:

-dyspnea

-tachypnea

-alteration in

depth of

breathing

-use of

accessory

muscles to

breathe

-nasal flaring

Ineffective

breathing

pattern r/t

hypertension

AEB tachypnea

and use of

accessory

musle to breath.

The defense

mechanism of the

lungs loose

effectiveness and

allow organisms

to penetrate the

sterile lower

respiratory tract,

whereinflammation

develops.

Disruption of themechanicaldefenses of cough and ciliarymotility leads tocolonization of thelungs andsubsequent

inflexion inflamedand fluid filledalveolar sacscannot exchangeoxygen and

Short term:

After 7 hours of

NI, the patient

will establish on

reflective

respiratory

pattern AEBabsence of sign

and symptoms

of hypoxia.

Long Term:

After 3 days of nursinginterventions the

patient will befree fromcongestion andrespiratory

>Establish rapport

to the patient and

with significant

others.

> Assess patient¶s

condition.

>Monitor vital

signs especially

respiratory rateevery 2 hours

> Auscultate breath

sounds.

>Provide

opportunities for

rests.

>

t

>

b

>

m

sr

d

>

s

p

a

r

t

f

r



carbon dioxideeffectively.alveolar exudatestends toconsolidate so it

is difficult toexpectorate.

distress asevidenced byabsence of productivecough and

difficulty of breathing.

>Provide hydration

>Give health

teaching such as

performing deep

breathing exercise

>Repositionpatient periodically

>Provide

supplemental

humidification

>Instruct SO to

place the client on

a semi fowlers

p

>

s

ee

>

h

u

o

p

>

s

b

>

a



position

> Give

expectorants or

bronchodilators asordered

>

s



PROBLEM#5: Pain r/t decreased oxygen supply to the heart.

Assessment Nursing diagnosis ScientificExplanation

Planning Intervention

S> Ø

O> thepatientmanifested:

-sleepdisturbance

-change inrespirationand andheart rate

Pain r/t decreasedOxygen supply toThe heart

Due to left to rightshunting of theblood, there is aninadequateoxygenated bloodpumped towardsthe systemiccirculation. Adecrease thesupply of oxygenated bloodvia the coronaryarteries towardsthe heart. Thisresults to ischemiacausing anaerobicmetabolismleading to lacticacid formationthereby causingpain

Short Term: After 3 hours of nursinginterventions andhealth teachings,patient¶s pain willbe relieved andwill demonstratebehaviors toprevent recurrence

Long Term: After 24 hours of NI,The patient willverbalize techniqueson avoidance inacquiring pain suchas increase in bedrest.

>Monitor andrecorded VS

>Encouragedverbalization of feelings

>elevate patient¶shead of bed to semifowlers position

>plan care betweenrest periods

>provide therapeuticcommunication andtouch therapy

>administer painreliever as orderedby the physician

>administer Nitroglycerin asordered>provide O2 therapyvia nasal cannula



PROBLEM#6:Hyperthermia

Assessment Nursingdiagnosis

ScientificExplanation

Planning Intervention

S: O

O: patientmanifested :

- with bodyTemp of morethan 380C/ax

- flushed skinand warm totouch

- tachypnea

-tachycardia

Patient maymanifest:

-seizure /convulsion

Hyperthermia Formation of plaque in theartery resultingfrom traumacausesobstruction of blood flow willdiminished bloodflow tothe myocardialcellshamperingaerobicmetabolismand leading toanaerobicmetabolismcausingproduction of lactic acid,which irritatesmyocardialtissue causinginflammatory

Short term:

After 4 hours of NI, the patient¶sBodyTemperatureWill decreaseFrom 38.2 C to37 C

Long term:

After 24 hoursof NI, patientwill be free of fever.

>monitor patientTemperature>note presenceor absence of searing as bodyattempts toincrease heat lossby evaporation,conduction, anddiffusion

>promote surfacecooling by meansof tepid spongebath

>providesupplementaO2

>maintain bedRest

>administer replacement

>to evaHyperth

>evapodecreasenvironof high

>to assmeasurbody te

>to offsdemandconsum

>to redudemandconsum

>to supvolumeperfusio



processleading tohyperthermia

fluids

>administer antipyreticmedication

>to dectempera



2. Actual Soapiers(7-13-10 & 7-14-10)

(7-13-10)

S>

O> received patient lying on bed, asleep; with intact heplock on the left hand; with O2

inhalation at 2 Lpm via nasal cannula; skin is warm to touch; with murmur; with

tachypnea and tachycardia; afebrile; VS taken and recorded as follows T=36 ÛC, RR= 59

cpm PR=146 bpm

A>Ineffective breathing pattern r/t hypertension AEB tachypnea and use of accessory

musle to breath.

P>

After 7 hours of NI, the patient will establish on reflective respiratory pattern AEBabsence of sign and symptoms of hypoxia.

I>monitored and recorded VS q 1hr

>noted RR and areas of pallor

>auscultated breath sounds

>elevated the head of the bed

>referred need for adequate rest

>provided comfort and safety measures such as staying with the patients and not living

him unattended.

>maintained O2 as ordered

>kept back dry

>stretched linens

>encouraged proper hygiene

>needs attended

>reinforced SAP and give other health teaching such as importance of 2D echo.



E>GOAL MET aeb patient establishing effective respiratory pattern AEB absence of sign

and symptoms of hypoxia.

(7-14-10)

S>

O>> received patient lying on bed, asleep; with intact heplock on the left hand; with O2

inhalation at 2 Lpm via nasal cannula; skin is warm to touch; with murmur; with

tachypnea and tachycardia; afebrile; VS taken and recorded as follows T=36.7 ÛC, RR=

69 cpm PR=130 bpm

A>impaired gas exchanged r/t ventilation perfusion imbalance AEB tachypnea and

tachycardia.

P> After 4 hours of NI, the patient will demonstrate improved ventilation and adequate

oxygenation of tissues by absence of symptoms of respiratory distress.

I>monitored and recorded VS

>noted RR and pallor/cyanosis

>auscultated breath sounds

>

elevated the head of the bed

>referred need for adequate rest

>provided comfort and safety measures such as staying with the patients and not living

him unattended.

>maintained O2 as ordered

>kept back dry

>stretched linens

>encouraged proper hygiene

E>GOAL MET aeb by patient demonstrating improved ventilation and adequate

oxygenation of tissues by absence of symptoms of respiratory distress.



VI. CLIENT¶S DAILY PROGRESS IN THE HOSPITAL

Aug27

Aug28

Aug29

Aug30

Aug31

Sep1

Sep2

Sep3

Sep4

Sep5

Sep6

Sep7

Se8

NURSING

PROBLEMS

1) Impaired GasExchange

~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

2) AlteredTissuePerfusion

~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

3) DecreasedCardiacOutput

~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

4) Ineffective

BreathingPattern

~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

5) Pain ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

6) Hyperthermia ~ ~ ~ ~

VITAL SIGNS

Temp 37.1 36.2 36.5 38 38.5 38.3 38.5 36.8 37 37.3 36.8 37 37

PR 160 142 125 132 150 160 130 126 125 133 136 132 14

RR 40 32 40 45 53 53 78 60 62 72 60 60 65

DIAGNOSTIC /LAB

PROCEDURESHemoglobin( g/L) 112 108

Hematocrit .33

WBC(x109/L) 12.2 12.2Lymphocytes .50 .49



Aug27

Aug28

Aug29

Aug30

Aug31

Sep1

Sep2

Sep3

Sep4

Sep5

Sep6

Sep7

Se8

Neutrophils .55 .46Platelets(x109/L) 363 365

Chest X-Ray ~

RSLT

INMEDICAL

MANAGEMENT

D5.03 NaCl~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

Heplock

Oxygen Tx~ ~ ~ ~ ~ ~ ~ D/C ~ ~ ~ ~ ~

DRUGS Ampicillin ~ ~ ~ ~ ~ D/C

Cefotaxime ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ D/C

Dopamine ~ ~ ~ ~ ~ ~~ ~ ~ ~ ~ D/C

Furosemide ~ ~ ~~ ~ ~ ~ ~ ~ ~ ~ ~ ~

Paracetamol~ ~ ~ D/C

Oxacillin~ ~ ~ ~ ~ ~ D/C

Amikacin~ ~ ~ ~ ~ ~ D/C

Lanoxin~ ~

Gentamicin~ ~

DIET



NPO ~ D/C

Full Feeding w/SAP

~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

ACTIVITY

Bed rest ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~



VII. CONCLUSION

A baby's heart begins to develop shortly after conception. During development,

structural defects can occur. These defects can involve the walls of the heart, the valves

of the heart and the arteries and veins near the heart. Congenital heart defects can

disrupt the normal flow of blood through the heart

Embryonic organogenesis occurs in the first trimester of pregnancy.Having said

that, it is very crucial that a mother is very careful in taking care of herself, her diet, her

activities and her way of treating the baby inside her womb.

One of the most common child illnesses is the Congenital heart Diseases, this

kind of anomalies are so fatal if left unrecognized and untreated. Ventricular Septal

Defect is the most common form of congenital anomalies and it may occur during the

cardiogenesis or during the formation of the heart. It is so unique that this kind of defect

can occur unnoticed even during the first few months of life.

The student nurses also realized that a minute amount of drug can have a very

big impact on a baby¶s life. In our case, it created a hole in the ventricular septum of the

patient. We have realized that such small hole can lead to fatal circumstances if not

managed.



VIII.RECOMMENDATIONS

y To the future researchers, that this case study may serve as a background

and basis of future studies if with the same disease conditions and with

additional disease would be pursued.

y To the Community Health Nursing,since there might be a possibility that

mothers from depressed,deprived and underserved areas of the

community might do the same thing as the mother of Abby Hearty did, in

order to prevent this, Community Health Nurses should provide and widen

community awareness by conducting seminars, discussion groups,

distributing brochures and posting of visual aids that will focus on

promoting health and preventing the disease to be acquired from the

community people.

y To the nursing service, since having a better grasp of a disease condition

will lead to a better delivery of quality care. This will also help in adding

more knowledge to them and also updating them with current trends.

y To student nurses that would be exposed in clinical area with similar

diagnoses that they would individualized prioritized plan of care based on

patients identified problems of higher risk involved and requiring

immediate interventions.

y To the Department of Health, so that they can conduct further research

and seminars regarding VSD and othe congenital heart diseases.. In this

way, the people can become more aware on the disease condition and it

will be easier for them to prevent it.



IX. LEARNING DERIVED

There is always a learning experience in our everyday encounter with other

people. Whether small or big things, people grow and continue to learn. I learned a lot

while doing this case study. I was able to increase my knowledge about a congenital

heart disease, enhance my skills, and improve my attitude; furthermore I also had the

chance to develop teamwork with my group mates. The Lord Almighty, my supportive

family, my clinical instructor, group mates, and my commitment have been of great help

to accomplish my objectives and goals throughout this rotation.

From having Baby Hearty as our patient for the case study, I have learned that

no matter what happens, a person should be strong enough and go forward fighting for

survival. Though he is only six months old, I perceive him as a very brave and strong

person.

This was the first time I had my duty at a pediatric ward at a tertiary hospital, it

was tiring and there were adjustments to be done since it was also my first time to be in

JBL. Though it was tiring, nothing compares to the feeling of fulfillment whenever a

patient that I handled thanks me and shows a smile. In my patient¶s case,his smile is

enough to make my day. It makes me feel that I have done a good job and that I have

made something for the betterment of humanity. No matter how small my help was, I

know that our dear Creator was very proud of me. It also made me realize that there are

so many disease conditions that a person can acquire and that urged me to be more

healthy and be and to take one step forward in taking care of myself.

-Miguel Paolo A. Galang

BSN III-2, Group 7, Leader



First times are always overwhelming and bring mix emotions, as much as this

case study does. Yeah, this is not our first case study in relation with nursing, but this is

our first case study in the relation with Ventricular septal defect. I have to admit it. This

case study is not that easy for us to do, but yet as a group, we finished it. Though we

had sleepless nights just to finish this case study, still, I am so happy that we did this

case study to learn more and to help the public by providing information about the

condition. I learn so much things in doing this case study not only by means of

knowledge but also, by means of attitude. In terms of knowledge, this case study

broadened my wisdom about the condition. It gives me additional experience and

information like what is VSD, its signs and symptoms, who are at risk, what are the

preventive measures and the manifestations that will help me to function as an effective

nurse in the future. Finishing this case study requires time, effort, patience, cooperation

and unity among the group. Our objective in this study is not only to finish, pass and

have a grade but also, I want to emphasize that we did this case study to help those

patients who suffer from this condition and those people at risk in acquiring the

condition.

As a nursing student, activities like this helps in developing our knowledge, skills

and attitude as we go along our journey in the course until we are already registered

nurses.

I also thank God for helping us in doing this case study. He is the reason why we

had finished this case study. To Him be all the glory and praises.

-Shayne M. Dimla

As a student nurse I¶ve learned how to deal with children in different ages. At first

it is challenging on my part, because children are scared of nurses or the people who

wears white uniform. Because all they know is that they will be prick by a needle. But as

time goes by I learned to socialize with them like playing before doing the responsibilities

as a student nurse.



It¶s sad for me to have a patient who has a congenital heart disease just because

of a single tablet.i can¶t judge the mother of the baby because I don¶t know the reason

behind that, but for me I really pity the baby because it¶s a life and death condition.

As a student nurse I did my job to help so, I thought the mother and the

grandmother of the baby on the proper management, like treat the baby as normal, give

all his needs, proper hand washing and proper food sanitation and daily check up if they

will be discharge. I also thought the mother to have her child proper hygiene to protect

her baby from microorganisms or pathogens.

-Magtoto Ma. Jessica E.

After accomplishing this case study, the researchers met their reasons in

choosing the problem, ventricular septal defect. As nurses, it is our duty to provide our

patients as well as their significant others with adequate knowledge about the condition

of the patient and possible complications of this disease. Because in here, the most

appropriate goal of care is the proper treatment/support for the patient in order to

understand and cope with the situation. That is why, as much as possible, nurse¶s mustguide their patients and their family in identifying ways on how to manage the disease in

order to avoid its progress to a more complicated one. Also, as nurses, they must have

the competent skills, adequate knowledge and a compassionate heart. The nurse is not

the sole determinant of the failure or effectiveness of any treatment. The patients

themselves, with support of loved ones are the prime factors for achieving the best

possible results of the interventions made, yet the nurse who spends greater time with

the patient functions not only to perform health assessment, administer medications or

provide health teachings, but the nurse is also important in helping the patient processboth the physiological and psychological impact of the treatment.

-Mallari, Giselle M.



Being at the pediatric ward was not easy for me, because it so sad for me to see

little children suffering from an illness. I¶ve learned the right care that the nurse must do

for the patients. I was able to see procedures and the different scenario in the hospital. I

as given a chance to share my knowledge and care for the patient I have handled.

In this case study I¶ve realized that the disease that we¶re just discussing in our

NCM lecture can really happened. And it¶s so sad to thing that the one who¶s suffering is

just a child. I¶ve learned to give importance to the things and concept that was discussed

in our lecture especially the right managements. Because of this knowledge I¶ve learned

I was able to know what are the right things I can do for the patient.

-Policarpio, Frances joye P.



BIBLIOGRAPHY

Books

Black, Joyce M. and Jane Hokanson Hawks. Medical-Surgical Nursing Clinical

Management for Positive Outcomes. Singapore: Elsevier, 2009

Blakiston. Blakiston¶s Pocket Medical Dictionary. United States of America: McGraw-

Hill,1979

Doenges,Moorhouse & Murr, Nurse¶s Pocket Guide.

Weber,Janet R.Nurses¶ Handbook of Health Assessment (Sixth Edition). United States

of America: Lippincott Williams & Wilkins

Karch,Amy M.2010 Lippincott¶s Nursing Drug Guide. United States of America:

Lippincott Williams & Wilkins

Internet

http://www.cincinnatichildrens.org/health/heart-encyclopedia/anomalies/vsd.htm

http://www.nlm.nih.gov/medlineplus/news/fullstory_99249.html

http://www.nlm.nih.gov/medlineplus/ency/article/001099.htm

http://www.emedicinehealth.com/ventricular_septal_defect/page3_em.htm

http://www.mayoclinic.com/health/ventricular-septal-

defect/DS00614/DSECTION=coping-and-support

http://www.medicinenet.com/pneumonia/article.htm

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