NURSING CARE PLAN

Baseline data of client: Name: A. J. Mondejar Age: 8y.o. Sex: Male Cues Nursing Diagnosis A. Actual or Abnormal Cues Subjective: Patient verbalizes complaints of frontal splitting headache: Sakit akun ulo; dw mabuka. Patient verbalizes complaints of cramplike pain of lower extremitie s (intermitte nt claudicatio n): Daw ga binhod akun tiil; felt either together Ineffective Cerebral, Cardiopulmonary & Peripheral Tissue Perfusion R/T impaired transport of oxygen secondary to Congenital Heart Defect: Tetralogy of Fallot AEB dyspnea upon exertion, frontal splitting headache, intermittent claudication, restlessness, generalized weakness of extremities, clubbing of fingers and toes, mild cyanosis of fingernails and toenails, delayed physical growth and development, and mild bradycardia. Chief Complaint: headaches & chills Medical Diagnosis: CHD (Congenital Heart Defect: ToF) in Failure Attending Physician: Dr. Castronuevo Pathophysiology of Tetralogy of Fallot Desired Nursing Outcome Intervention Predisposing factors: After 8 hours of A. Independent Advanced maternal age nursing Genetic predisposition intervention, the client will be able Congenital Heart Defect: Tetralogy of Fallot to: Structural malformation of the heart Large Sub-aortic ventricular septal defect Pulmonic Stenosis 1. Folks will be 1. a. Educate able to verbalize parents as needed understanding of regarding condition, congenital heart therapy regimen, disease. purpose of medications, and when to contact healthcare provider. 1.b. Provide information on normal tissue perfusion and possible causes for impairment. c. Instruct folks to inform the nurse immediately if symptoms of decreased perfusion persist, increase, or

Justification

Evaluation After 8 hours of nursing intervention:

Overriding of Aorta

Decreased Pulmonary blood flow

Increased effort to force blood through the pulmonary artery

Decreased amount of oxygenated blood returning to the heart

Right ventricular hypertrophy

Parents need an understanding of patients condition to respect and comply with the need for rest and medications. Knowledge of causative factors provides understanding for treatments. Early assessment facilitates prompt treatment.

1.Goal met Folks were able to recognize the severity of the disease including the Importance of therapy regimen to improve patients condition AEB active participation during discussions, compliance to medications and verbalizations of the need to contact health provider when patient complains of difficulty of breathing and presence of cyanosis.

Increased pressure at the right side of the heart

20

with splitting headache or independe ntly. Patient verbalizes feeling of dyspnea upon exertion: Kabudlay magginhawa kng daw makapuya n or mamwersa ko. Objective: Clubbing of fingers and toes Mild cyanosis of fingernails and toenails noted Generalized weakness of extremities noted Restlessness noted Delayed physical growth and development:

Definition: Decrease in oxygen resulting in the failure to nourish the tissues at the capillary level. [Tissue perfusion problems can exist without decreased cardiac output; however there may be a relationship between cardiac output and tissue perfusion.] Source: NANDA 11th Edition

Venous blood from right ventricle shunted to left ventricle via ventricular septal defect Mixing of oxygenaed and unoxygenated blood Preferential flow of the mixed blood from both ventricles through the dextropositioned aorta

return (e.g. cyanosis and difficulty of breathing). c. 2.a. Discuss the These importance of positions exert prevention of pressure on 2. Demonstrate venous stasis (e.g. vessels in the behaviors/ not crossing legs, lower lifestyle changes and elevating feet extremities, to improve without bending which circulation such knees.) compromises as the blood flow. performance of 2.b. Provide for a Rest is a major ROM exercises quiet atmosphere aspect of care and prevention of and limit since it venous stasis. procedures to reduces the those that are metabolic rate necessary to and tissue provide for rest oxygen periods. demand. 2.c If the client is To enhance on bed rest, instruct venous return. and assist with range of motion exercises at least 3 times/day and active foot and leg exercises every 1-2 hours. 2.d.Implement measures to prevent vasoconstriction: Vasoconstricti on narrows vessel lumens, which results 2. Goal met Patient and SO were able to implement behavioral changes to improve blood flow AEB able to rest with minimal disruption, performance of assistive exercises under the supervision of the nurse and avoidance of activities that may cause venous stasis.

Low blood oxygen saturation in systemic circulation Ineffective Cerebral, Cardiopulmonary & Peripheral Tissue Perfusion

Sources: Textbook of Pediatrics; 15th Edition by Behrman, Klegman & Arvin Pediatrics; January 1991 Edition Maternal & Child Health Nursing; 5th Edition by Pillitteri Understanding Pathophysiology 3rd Edition by Sue E. Huether and Kathryn L. McCane

21

Wt.: 19.3kg; Ht.: 123 cm (Normal: Wt: 39kg; Ht: 142cm) Weak but palpable pulse of 66bpm as of 8pm of 10-08-08 Presence of systolic murmur upon auscultation of left sternal border 2-D Echo findings 10-0608: ToF with severe infundibular pulmonic stenosis; Mild aortic insufficiency; Right atrial enlargement; Right ventricular enlargement; Right ventricular hypertrophy; Good cardiac contractility; McGoons index: 1.4-1.5 CT Scan findings as of

2.

e.perform actions to reduce stress

in diminished blood flow through the affected vessels. Stress stimulates the sympathetic nervous system, which results in vasoconstricti on. When the body is cold, peripheral constriction occurs in an attempt to contain body heat.

2.f. Perform actions to keep client from getting cold (e.g. maintain a comfortable room temperature, provide adequate clothing and blankets)

3. Demonstrate increased perfusion as individually

3.a. Elevate head of bed by 10 and maintain head/neck in midline or neutral position.

To promote circulation/ven ous drainage and increase gravitational blood flow.

3.Goal met patient was able to exhibit signs of increased tissue perfusion AEB degree of cyanosis at the fingernails and toenails lessened, able to transfer form

22

10-07-08 show presence of multiple brain abscess (Left tempoparietal; Left parietosagittal) B. Risk Related Factors Condition may call for multiple hospitalizations Monetary constraints C. Strengths Strong belief in God Good emotional support from family Positive outlook regarding condition

appropriate as characterized by decreased cyanosis & episodes or extent of pain and observable increase in activity tolerance.

3.b.If hypoxic Squatting spells occur, gives relief to instruct patient to an assume a squatting overstressed position if dyspneic heart by or knee-chest trapping blood position. in lower extremities; knee-chest position increases intraabdomina l pressure; decreases systemic venous return; decreases right-to-left shunting. B. Collaborative Assist with To improve tissue treatment of underlying perfusion/orga n function. conditions such as administration of medications for infections, as indicated. Monitor laboratory Polycythemia findings (CBC) for causes blood polycythemia, to become thick, so clots decreased blood glucose levels and in blood vessels may reduced oxygen

bed to chair, reduced frequency of complains of pain and splitting headache, and able to perform ADLs with minimal support such as feeding oneself.

23

saturation; refer.

occur; children with cyanotic heart disease are likely to develop hypoglycemia; thus proper intervention will be undertaken. Dyspneic attacks may be precipitated by iron deficiency; iron therapy improves exercise tolerance & general well being.

Monitor for relative iron deficiency; refer.

Review medical To maintain regimen and physical safety appropriate safety of patient. measures in assisting with administration of Diazepam prn for frank seizures.

24