PCAP D, CHF 2 CHD

NURSING
ASSESSMENT I

Chief Complaint:

Cough and colds, Dyspnea

Admitting Diagnosis:

PCAP D, CHF 2 CHD

History of Present Illness:

A day prior to admission, patient experience DOB and
dyspnea associated with cough and fever. The
mother applied liniment but no alleviation of
patients condition. Aggravation of condition
prompted admission to hospital.

History of Past Illness

Its the second admission of the patient in the hospital
specifically in GTLMH. The first hospitalization of
the patient was on December 26, 2012 to January 1,
2013 due to DOB with cyanotic extremities and was
diagnosed with Down syndrome, severe MR, severe
pneumonia, and congestion of the heart. The patient
has no previous injuries, procedures, infectious
disease. The patient is not yet fully immunized.
According to his mother, the baby had received
vaccines but unable to recall what kind of vaccines it
was. Patient was restricted from being exposed to
soap and pillows content. Patient is breastfed.

Physical and Developmental History

0 month

1 month

2 months

3 months

1.

Fine motor adaptive

skills

N/A

close fist

Open fist

Close-open fist

1.

Gross motor skills

N/A

Head lug

Head lug

Slight head lug

1.

language

crying

crying

crying

crying

1.

social language

Not noted

Not noted

Not noted

Not noted

Heredo-familial History
Cardiac Disease (+)
Asthma (+)
Liver Diseases (+)

Genogram

NURSING
ASSESSMENT II

Activity-Rest
Before Hospitalization:
Feed and sleep. Patient has disturbed sleep pattern
Initial:
Feed and sleep. Patient has disturbed sleep pattern as evidenced by
tired facial expression.
Day 1:
Feed and sleep. Patient has disturbed sleep pattern as evidenced by
tired facial expression.
Day 2:
Feed and sleep. Patient has disturbed sleep pattern as evidenced by
tired facial expression.
Day 3:
Feed and sleep. Patient has disturbed sleep pattern as evidenced by
tired facial express

Nutrition
Before Hospitalization:
Milk and water. Weight not taken.
Initial:
Milk and water. Weight = 3.5 kg
Day 1:
NPO. Weight not taken.
Day 2:
Milk and water. No dark colored foods. Weight not taken.
Day 3:
Milk and water. No dark colored foods. Weight not taken.

Elimination
Before Hospitalization:
Patients mother usually change patients underwear (lampin) 1-3 times a
day soiled with yellowish urine. Patient defecates 2-3 times a day with
brownish stool.
Initial:
Patient able to consume 1 diaper soiled with yellowish urine and greenish
semi-formed stool.
Day 1:
Patient able to consume 1 diaper soiled with yellowish urine. No stool.
Day 2:
Patient able to consume 1 diaper soiled with yellowish urine and greenish
semi-formed stool.
Day 3:
Patient able to consume 2 diapers soiled with yellowish urine and greenish
semi-formed stool.

Ego Integrity
Before Hospitalization:
Not assessed.
Initial:
Patients mother has always been by his side.
Day 1:
Patients mother has always been by his side.
Day 2:
Patients mother has always been by his side.
Day 3:
Patients mother has always been by his side.

Neuro - Sensory
Before Hospitalization:
GCS = 12. Patient able to see and can follow a moving object, respond to
sound made such as clapping, and able to respond to touch.
Initial:
GCS = 12. Patient able to see and can follow a moving object, respond to
sound made such as clapping, and able to respond to touch.
Day 1:
GCS = 12. Patient able to see and can follow a moving object, respond to
sound made such as clapping, and able to respond to touch.
Day 2:
GCS = 12. Patient able to see and can follow a moving object, respond to
sound made such as clapping, and able to respond to touch.
Day 3:
GCS = 12. Patient able to see and can follow a moving object, respond to
sound made such as clapping, and able to respond to touch.

Oxygenation
Before Hospitalization:
Not taken
Initial:
RR- 36 cpm; PR- 140 bpm; HR- 140 bpm. Crackles heard all over lung
field.
Day 1:
RR- 55 cpm; PR- 137 bpm; HR- 137 bpm. Crackles heard all over lung
field.
Day 2:
RR- 42 cpm; PR- 86 bpm; HR- 86 bpm. Crackles heard all over lung
field.
Day 3:
RR- 44 cpm; PR- 85 bpm; HR- 85 bpm.Crackles heard all over lung
field.

Pain - Comfort
Before Hospitalization:
Not assessed.
Initial:
Patient felt pain as evidenced by crying, oxygen requirement, increased vital signs
(T,RR), tired facial expression, disturbed sleep pattern. One example of situation that
patient will demonstrate some of these behaviors is during administration of medication.
Day 1:
Patient felt pain as evidenced by crying, oxygen requirement, increased vital signs
(T,RR), tired facial expression, disturbed sleep pattern. One example of situation that
patient will demonstrate some of these behaviors is during administration of medication.
Day 2:
Patient felt pain as evidenced by crying, oxygen requirement, increased vital signs
(T,RR), tired facial expression, disturbed sleep pattern. One example of situation that
patient will demonstrate some of these behaviors is during administration of medication.
Day 3:
Patient felt pain as evidenced by crying, oxygen requirement, increased vital signs
(T,RR), tired facial expression, disturbed sleep pattern. One example of situation that
patient will demonstrate some of these behaviors is during administration of medication.

Hygiene
Before Hospitalization:
Patient received baby bath every other day, depending on
the climate.
Initial:
Patient received tepid sponge bath.
Day 1:
Patient received tepid sponge bath.
Day 2:
Patient received tepid sponge bath.
Day 3:
Patient received tepid sponge bath.

Sexuality
Patient is an infant and not yet circumcised.

REVIEW OF
SYSYTEMS

General
Received patient without IVF, carried by her mother,

crying and irritable.

Patient looks pale and small as to age.
Patient has delayed growth and development
patient was lethargic and has decreased level of
consciousness.
Patient has low set of ears.
Patient has small nose with flat nasal bridge.
Patient has upward slant eyes.

HEENT
Normocephalic, with head circumference of 14.8 inches;
hair is straight, thin, dry and evenly distributed; scalp is

moist;
ears equal bilaterally and skin color is even; Patient has
low set of ears.
eyebrow present bilaterally; eyelashes present; sclerae
whitish in color; conjunctiva pinkish in color; Patient has
upward slant eyes.
nostrils present at the midline; Patient has small nose
with flat
lower central incisors not yet present, soft palate is moist
and pinkish in color; uvula at the midline;
thyroid is not palpable. nasal bridge.

Integumentary
Hair is thin, fine and straight; Hair is properly

distributed;
Nail beds are pale; nails are translucent; nails are
uncut;
Skin is warm; has good skin turgor; skin is pale and
uniform in color

Respiratory
Chest skin color is consistent and even, chest surface

dont have lesions,

adventitious sounds noted: located on both lungs (+)
crackles ,
patients facial expression has difficulty in breathing,
patients breathing is with effort, irregular and
uneven and produces noise,
patient uses accessory muscles when breathing, (+)
cyanosis, (+nasal flaring),
RR:36 cpm, CRT of 4 seconds.

Cardiovascular
Carotid artery is smooth, and is in normal strength

(normal strength is 2+ or moderate),

Symmetrical strength of both carotid artery,
PMI is at the 5th ICS MCL
Tachycardic at 145 bpm, dysrhythmia noted,
(+) S1 and clear, (+) S2 and clear,
Presence of bilaterally equal and palpable peripheral
pulses, CRT is increased at 4 seconds

Digestive
Lips is pale pink, symmetrical but dry. Cracking of lips

was noted.
Patient doesnt have teeth yet. Gums is pink, moist, tight
and well-defined. Tongue is pink and moist. Patient's
tongue is big and protruding.
Buccal mucosa is pink, moist and smooth.
Gag reflex is present.
Abdomen is warm to touch, symmetric and has even
color. Umbilicus is in midline, and inverted.
Patients stool is greenish in color and semiformed.
Abdominal girth is 13.5 inches.

Excretory
Pt was using diaper and changed it 3x a day.

Pts urine was clear and yellowish.

Pts defecates with greenish loose stool.

Musculoskeletal
Skin over the joints is even in color. No masses,

swelling, deformities noted in the joints upon

palpation. Joints are intact and warm to touch.
Barrel chest noted and patient uses accessory
muscles when breathing, such as
sternocleidomastoid and pectoralis major.
Babinskis reflex is elicited, can grasp in both hands
but weak.

Nervous
Level of consciousness of the patient is lethargic. Patient always

cries whenever he is touched.

Patients expression is tired. The babys posture is not relaxed.
Patient breathes heavily and uses accessory muscles.
Patient has developed chest with 14.5 inches. Head
circumference is 14 inches. Patient has low-muscle tone.
Patient is able to follow large objects.
Patient can feel pain and touch. Patient responds to sound.
Glasgow Coma Scale is 12, which is normal.
Patient is able to close and open his fists.
Slight head lag was noted. Babinski reflex is present, there was
slight fanning of toes. Reflexes such as sucking reflex, blinking
reflex, rooting reflex, and palmar grasp reflex are present.

Endocrine
Pt. has heat/cold intolerance; skin is able to perspire

in hot environment.
Pt. has generalized weakness, tachycardia and is
lethargic.
Pt. has hypoactive bowel sounds;
Scalp and hair is evenly distributed with a shiny hair;
Pt. is restless , experiences dehydration and malaise
and is experiencing difficulty in breathing.

Reproductive
Pt is male, infant- 3months old.

SUMMARY OF
MEDICATIONS & IVF

Summary of Medications
Date

Medication

January 13 & 16, 2013

Gentamycin (Gentrobex) 21 mg IVTT q 24H

January 11 - 15, 2013

Furosemide 40 mg 1 tab; 2 mg per tab

2x/day

Remarks

Cloxacillin 60 mg IVTT q 6H
January 10, 2013 January 16, 2013
January 11 16, 2013

Nebulized with salbutamol + ipratropium

(combivent) 1 neb q 20H x 3 doses then q
8H
Ceftazidine 100 mg IVTT q 8H ANST (-)

January 11- 13, 2013 & January 15, 2013

January 10 16, 2013

Paracetamol 40 mg IVTT q 4H

January 11 14, 2013 & January 16, 2013

Ceftriaxone 350mg q 24H IVTT ANST(-)

January 11 -14, 2013

Shift to Terbutaline 2.5 mg/mL 1.0 mL + 1
cc NSS q 28 min then q 2H
Hydrocortisone q 6H x 6 doses

Given and tolerated

Date

Medication

December 26 28, 2012

Ampicillin Na (Polypen) 150 mg q 12H no

test

December 26 30, 2012

Gentamycin SO4 (Genmycin) 15 mg OD no

test

December 26 27, 2012

Nebulized with salbutamol + ipratropium

(Pulmodual) 2.5 mL q 4H

December 27, 2012

Paracetamol (Temogen) drops 0.4 mL q 4H

x fever 40 mg IVTT q 4H

December 26 28, 2012

Zinc (Pedzinc) drops 1 mL OD

December 29, 2012 & January 2, 2012

Salbutamol (Amoltex) 2/5 1 mL TID q 8H

January 2, 2013

Ceftriaxone 300 mg IVTT OD no test

Remarks

Given and tolerated

Summary of IVF
Date/Time
Started

Intravenous Fluids
& Volume

J
anuary 10, 2013 #1 D5 0.3 NaCl 500
8:34
cc
January 11, 2013 #1 D5 0.3 NaCl 500
9:30
cc

January 12, 2013

7:30

#2 D5IMB 500 cc

Drop Rate

KVO
20 cc/H

No. of Hours

Date/Time
Consumed

January 11, 2013

9:30
January 12, 2013
7:30

KVO

Indications

D5 0.3 NaCl- is a hypertonic saline solutions

that are used in critical care settings to help in
haemorrhagic shock (but no other type of
shock), acutely increased intracranial
pressure, or severe hyponatremia. Inhalation
of hypertonic saline has also been shown to
help in other respiratory problems, specifically
bronchiolitis.
D5imb is an IV solution that consists of
5% dextrose and water level. It is usually
given to patients in hospitals that could
potentially become ill through high sodium
levels or low blood sugar levels. The
D5imb solution can be used for both adult
and child patients. The indications for usage
would be when the patient needs an increase
in calories, hydration and electrolytes in the
body

Shifted to heplock

Drugs
Gentamycin
Furosemide
Cloxacillin
salbutamol + ipratropium
Ceftazidine
Paracetamol
Ceftriaxone
Terbutaline
Hydrocortisone
Ampicillin Na
Zinc (Pedzinc)

LABORATORY AND
DIAGNOSTIC
PROCEDURE

Ideal
Electrocardiogram

ECG is performed to check for the electrical activity of the patients

heart.
Findings:
One of the helpful diagnostic findings that we see in patients
with AVSDs is an ECG with left axis deviation. Left axis deviation
means that the overall electrical forces of the heart are shifted
leftward.
What happens is that the atrioventricular node (A-V node), the
single electrical connection between the atria and the ventricles,
travels exactly in the location that involves the AVSD. Therefore, if
theres a hole, the A-V node has to go somewhere when the heart is
formed. It is thus displaced away from where it should be, and
falsely causes the left axis deviation seen in these ECGs.

 Echocardiogram:

It is performed to see the hole and how the blood moves through the
heart.
Findings:
The bottom images reveal large defects in the atrial and ventricular
septae with a single large Atrio-ventricular valve replacing the mitral and
tricuspid valves. In fact the the ASD is so large, that it appears like a
single large atrium.
There is a ventricular septal defect
involving the upper part of the
septum.>>
A large atrial septal defect (ASD) is
also seen in these ultrasound images.

<<Note the single large AV

valve replacing the Mitral and
Tricuspid valves

Color flow ultrasound image shows

>> flow across the ventricular
septal defect (VSD).

 Chest X-Ray:

It is performed to see the size and the position of the heart.

Findings:
CXR will vary depending on the extent of the AVSD. In those with
a partial AVSD defect, CXR may resemble a secundum atrial defect.
There will be cardiomegaly and increased pulmonary vascularity, both
of which become more prominent with increasing mitral regurgitation.
In patients with a complete AVSD, the CXR will reveal cardiomegaly, in
most cases and there will be pulmonary vasculature congestion. This
may include prominent shunt vascularity markings toward the lung
apices. On lateral film,the posterior aspect of the heart may be
enlarged, projecting into the airways and esophagus.

Actual Laboratory and Diagnostic Examination

PROCEDURE

INDICATION

Hematology
Used to evaluate
(Taken 1/10/13) anemia, leukemia,
reaction to
inflammation and
infections, peripheral
blood cellular
characters, State of
hydration and
dehydration,
Polycythemia,
Hemolytic disease of
the newborn, to
manage chemotherapy
decisions.

NORMAL VALUE
Complete Blood Count
WBC 5 10 x 10/L
HB M=135 160 g/L
F=120-150 g/L
HCT M=0.40 0.48
F=0.37 - 0.45
Differential Count
Neutrophils 0.55-0.65

Lymphocytes 0.25
0.40

Eosinophil 0.01 - 0.05

Platelet Count 140-440 x
1012/L

RESULT

IMPLICATION

7.8
100

Normal
Decreased, may
indicate
hemodilution and
anemia
Decreased, may
indicate
hemodilution and
anemia
Increased, may
indicate
inflammation and
infection
Decreased, may
indicate congestive
heart failure
Normal
Normal

0.30

0.80

0.19

0.01
200

Actual Laboratory and Diagnostic Examination

PROCEDURE
Hematology
(Taken
12/26/12)

INDICATION
Used to evaluate
anemia, leukemia,
reaction to
inflammation and
infections, peripheral
blood cellular
characters, State of
hydration and
dehydration,
Polycythemia,
Hemolytic disease of the
newborn, to manage
chemotherapy
decisions.

NORMAL VALUE
Complete Blood Count
WBC 5 10 x 10/L

RESULT

IMPLICATION

13.0

Increased, may
indicate presence of
infection
Decreased, may
indicate hemodilution
and anemia
Decreased, may
indicate hemodilution
and anemia

HB M=135 160 g/L

F=120-150 g/L

100

HCT M=0.40 0.48

F=0.37 - 0.45

0.30

Differential Count
Neutrophils 0.55-0.65

0.79

Lymphocytes 0.25 0.40

0.21

Platelet Count 140-440 x

1012/L

308

Increased, may
indicate inflammation
and infection
Decreased, may
indicate congestive
heart failure
Normal

Actual Laboratory and Diagnostic Examination

PROCEDURE
Urinalysis
(Taken
12/27/12)

INDICATION

NORMAL VALUE

Screen for early signs of Physical:

medical problems.
Color: light yellow to
Abnormal waste
amber
products or abnormal
Reaction: 4.6 - 8
levels of cells may
Specific Gravity: 1.002indicate disease.
1.030
Chemical:
Albumin: Few
Sugar: Negative
Microscopic:
Pus cells: 1 to 10/HPF
RBC: 0-2/HPF
Epithelial Cells: 0 to Few

RESULT
Physical:
Color: Yellow
Reaction: 5.0
Specific Gravity:
1.025
Chemical:
Albumin: TRACE
Sugar: Negative
Microscopic:
Pus cells: 0-2/HPF
RBC: 0-1/ HPF
Epithelial Cells:
Moderate

Granular cast (fine): 0-1

hpf
Granular cast (fine):
Others:
0-1 HPF
Uric crystals: none
Others:
Uric crystals: many

IMPLICATION

Normal
Normal
Normal

Normal
Normal
Normal
Normal
Increased, may
indicate inflammation
or infection
Normal

Increased, may
indicate heart failure,
malnutrition and
anemia

Actual Laboratory and Diagnostic Examination

PROCEDURE

Fecalysis
(Taken
12/26/12)

INDICATION

Determines the
various properties of
the stool. Evaluates
stool color,
consistency, parasite
identification and
early detection of
gastro -intestinal
problems.

NORMAL VALUE

Macroscopic:
Color: Brown
Consistency: soft
and bulky
Microscopic:
Viruses: None
Parasites: None
Miscellanous:
Fat globules: Few

RESULT

IMPLICATION

Macroscopic:
Greenish stool may
Color: Greenish
indicate that the
Consistency: soft baby is not feeding
Microscopic:
well or is reactive
No intestinal
to some
parasites found
medications.
Miscellanous:
Fat globules:
Moderate

Actual Laboratory and Diagnostic Examination

PROCEDURE
Chest X-ray
( APL)
(12/26/12)

INDICATION

NORMAL VALUE

RESULT

IMPLICATION

Used to visualise the

lung fields, the heart
and the rest of chest. It
is used also to rule out
pathology. Clinicians
can also request a chest
x-ray before booking a
patient for a theatre
procedure. Chest x-rays
are also used to
visualise air and fluid
levels within the lung
fields.

Normal chest X-ray

shows normal size and
shape of the chest wall
and the main structures
in the chest. White
shadows on the chest Xray signify solid
structures and fluids
such as, bone of the rib
cage,vertebrae, heart,
aorta, and bones of the
shoulders. The dark
background on the chest
X-rays represents air
filled lungs. These lung
fields are seen on either
side of the heart and the
vertebrae located in the
center of the film.

Lung fields appear

hyperaerated with
flattened diaphragm.
Hazy infiltrates are
seen in both lungs
with hilar fullness.
Heart and great
vessels are not
unusual.
Costophrenic sulci are
intact.
Impression:
Compatible with
bilateral pneumonia.
Bilateral pulmonary
hyperaeration.

Hyperaeration
indicates that lung
volume is abnormally
increased, with
increased filling of the
alveoli. Hazy
infiltrates indicates
interstitial
pneumonia.

ANATOMY

PATHOPHYSIOLOGY

NURSING CARE
PLAN

Ineffective Airway Clearance related to excessive,

thick mucus secretions
Independent:
Monitor IVF.
Monitor vital signs especially respiratory rate.
Monitor for signs and symptoms of congestive heart failure such as
edema, crackles, and weight gain
Position head at midline with flexion appropriate for condition.
Encourage hydration: fluid intake (2-3 L/day)
Suction orally prn
Elevate head of bed and change position every 2 hours and prn

Dependent:
Assist in administering bronchodilators.

Impaired gas exchange related to ventilation

perfusion imbalance
Independent:
Monitor IVF.
Monitor vital signs especially respiratory rate.
Elevate head of bed appropriately
Encourage frequent position changes
Provide calm/restful environment
Maintain adequate I/O

Dependent:
Assist in administering bronchodilators.

Ineffective cardiac tissue perfusion related to

decreased hemoglobin concentration in blood.
Independent:
Monitor IVF regularly.
Monitor vital signs especially respiratory rate.
Monitor cardiac rhythm
Encourage quiet, restful, atmosphere.
Encourage intake of multivitamins and nutrients
Dependent:
Assist in administering medications.
Assist in administering supplemental oxygen, 1-2LPM via
nasal cannula, as prescribed by physician.

Decreased cardiac output related to altered

myocardial contraction
Independent:
Monitor IVF.
Determine baseline vital signs
Monitor cardiac rhythm continuously
Assess hourly or periodic urine output
Provide for adequate rest and positioning client for
maximum comfort

Dependent:
Assist in administering diuretics.
Assist in administering supplemental oxygen as needed

disturbed sleeping pattern related to difficulty

breathing
Monitor IVF

Monitor vital signs

Determine SOs expectations of adequate sleep.
Provide a quiet environment

Provide back rubbing

Provide cleaning and straightening of sheets
Implement bed time rituals such as rocking and

cuddling

MEDICAL
MANAGEMENT

Ideal
Labs and Diagnostic Procedure for Pneumonia
Sputum Tests. The color of the mucus (sputum) sample coughed up from

the lungs can reveal the severity of the disease. Only a sputum sample will
reveal the organism causing the infection.
Blood Tests
White blood cell count (WBC). High levels indicate infection.
Blood cultures. Cultures are done to determine the specific organism
causing the pneumonia, but they usually cannot distinguish between
harmless and dangerous organisms.
Polymerase Chain Reaction (PCR). In some difficult cases, PCR may be
performed. The test makes multiple copies of the genetic material (RNA) of
a virus or bacteria to make it detectable. PCR is useful for identifying
certain atypical bacteria strains, including mycoplasma and Chlamydia
pneumoniae, and possibly, Haemophilus influenzae type b, but it is
expensive.
X-Rays

Treatment for Pneumonia

Antibiotics for hospital-acquired pneumonia include
third- and fourth-generation cephalosporins,
carbapenems, fluoroquinolones, aminoglycosides,
and vancomycin.

Labs and Diagnostic Procedures for Down Syndrome

Ultrasound. The doctor uses ultrasound to measure a specific region on the back of a

baby's neck. This is known as a nuchal translucency screening test. When

abnormalities are present, more fluid than usual tends to collect in this tissue.
Blood tests. Results of the ultrasound are paired with blood tests that measure levels
of pregnancy-associated plasma protein-A (PAPP-A) and a hormone known as
human chorionic gonadotropin (HCG). Abnormal levels of PAPP-A and HCG may
indicate a problem with the baby.
Amniocentesis. A sample of the amniotic fluid surrounding the fetus is withdrawn
through a needle inserted into the mother's uterus. This sample is then used to
analyze the chromosomes of the fetus. Doctors usually perform this test after 15
weeks of gestation. The test carries a 1 in 200 risk of miscarriage.
Chorionic villus sampling (CVS). Cells taken from the mother's placenta can be used
to analyze the fetal chromosomes.
Percutaneous umbilical blood sampling (PUBS). Blood is taken from a vein in the
umbilical cord and examined for chromosomal defects. This test carries a greater
risk of miscarriage than does amniocentesis or chorionic villus sampling.

Treatment for Down Syndrome

There is no specific treatment for Down syndrome.
Thus treatment is focused on the other health
manifestations Down syndrome bring.

Labs and Diagnostic Procedure for Mental Retardation

An assessment of age-appropriate adaptive behaviors can be made using

developmental screening tests. The failure to achieve developmental milestones

suggests mental retardation.
The following may be signs of mental retardation:
Abnormal Denver developmental screening test
Adaptive behavior score below average
Development way below that of peers
Intelligence quotient (IQ) score below 70 on a standardized IQ test

The primary goal of treatment is to develop the person's potential to the fullest.

Special education and training may begin as early as infancy. This includes social
skills to help the person function as normally as possible.
It is important for a specialist to evaluate the person for other affective disorders
and treat those disorders. Behavioral approaches are important for people with
mental retardation.

Labs and Diagnostic Procedure for Congestive Heart Failure

Useful diagnostic tests include the electrocardiogram (ECG) and chest X-ray to detect
previous heart attacks, arrhythmia, heart enlargement, and fluid in and around the lungs.
Perhaps the single most useful diagnostic test is the echocardiogram, in which ultrasound is
used to image the heart muscle, valve structures, and blood flow patterns. The echocardiogram
is very helpful in diagnosing heart muscle weakness. In addition, the test can suggest possible
causes for the heart muscle weakness (for example, prior heart attack, and severe valve
abnormalities).

Once heart failure is suspected, evaluation should include the following tests:
Laboratory tests:
CBC
serum creatinine
serum albumin
serum electrolytes
liver function studies
BUN
Urinalysis

Treatment for Congestive Heart Failure

ACE inhibitors improve both the quality of life and survival of heart failure patients and should
be considered the cornerstone of heart failure medical treatment whenever possible. Use of
these agents is contraindicated for patients with a history of hypersensitivity and should be
used with great caution when hyperkalemia or renal insufficiency is present.

Examples of ACE inhibitors: captopril, enalapril, lisinopril, fosinopril and quinapril.

Diuretics are of benefit when signs of volume overload are present. The dosage should be
carefully adjusted to a level that effectively removes excess fluid without causing volume
depletion. Examples of diuretics used in treatment of heart failure: hydrochlorothiazide
(HCTZ), chlorthalidone, furosimide, spironolactone and metolazone.

Digoxin may be added to the regimen of patients in whom symptoms are not adequately
controlled with ACE inhibitors and diuretics.

Vasodilators such as isosorbide dinitrate or hydralazine may also be useful in these patients.

Labs and Diagnostic Procedures of CHD

These test will help determine the presence of CHD in the patient:
Echocardiogram or transesophageal echocardiogram (TEE)
Cardiac catheterization
In this test, a thin, flexible tube (catheter) is inserted into a blood vessel at your

baby's groin or arm and guided through it into the heart.

Chest X-ray
Electrocardiogram (ECG or EKG)
MRI

Treatment of CHD
Treatment for the defect can include medicines, surgery and other medical
procedures and heart transplants. The treatment depends on the type and severity
of the defect and a child's age, size and general health. Today, many children born
with complex heart defects grow to adulthood and lead productive lives.

Actual

1/10/13
2:10 PM

Please admit to CCU

Secure Consent to care
TPR q 1
NPO
IVF D5 0.3 NaCl 500 cc @ KVO rate
Labs: CBC, platelet count
Meds:
Cloxacillin 60 mg IVTT q 6 ANST
Ceftazidine 100 mg IVTT q 8
Ipra + Salbu nebulization 1 neb q 2x 3
doses
Salbu nebulizing soln 2 ml + neb
Bodesamide q 8 (10am-6pm-2am)
O2 inhalation @ 1-2 L/min
Refer

1/10/13

Furosemide 3 mg 5/ml IVTT q 12

Retrieve old chart and attach

1/11/13
8:34 AM
Mottled skin
d/t low
perfusion of
O2

Revise Cloxacillin to 125 mg q 6

If Ceftazidine not available, give
Ceftriaxone 350 mg q 4 OD ANST
Nebulize w/ Salbu, 1 neb + 1 cc NSS
now then 20 mins x 2 doses then q 2
May use Salbu neb soln 2.5 mg/cc +
1 cc NSS
Run 2.5 cc of present IVF fluid drip then
After 1 hour if still dehydrated give 2nd
IV bolus after 2 then refer for
Reassessment of hydration
Otherwise regulate to 20 cc/hr
TSB if T=38.1C
Give paracetamol drops 0.5 mg 4 PRN
If T=38.5
AP of P.O meds
Increase O2 inhalation to 5L/min
Suction oronasal junction Patient
For close watch
Hydrocortisone 15 mg q 6 x 4 doses

10:35 am
11:20 am
1/11/13
12:15 am
5:10 pm
1/12/13
8:50 am
Tachypneic
(+) crackles
12:30 pm

01/12/13
1:10 pm

May use Ferbutaline instead of

Salbutamol nebulizing soln if Salbu not
Available
Shift Para IV to P.O with strict AP
D/C Salbu + Ipra nebulization if not
not available, use only Salbu with
Tarbutaline 2.5 mg/cc in liew of above
Neb soln
IV: D5 IMB 500 cc @ SR
Continue meds
IVFTF D5 IMB 500 cc @ SR

Increase O2 inhalation to 6L/min via face

Mask
Prepare intubation set, ET tube size 3.0
Please inform ROD once ready
Salbu + Ipra, 1 neb q 20 mins/ 3 doses
Shift Para P.O to Para 40 mg IVTT q 4

01/13/13
(+) crackles

Decrease O2 inhalation to 2-4 L/mins

Continue meds
FF AP CXR

01/13/13
5:15 pm

Nebulize with Salbu + Ipra 1.0 ml q 20

mins x 3 doses
Gentamycin (Gesilubex) 21mg IVTT q 24

01/14/13
9:50 am

IVF change to heplock

Please FF up IV meds- refer if no stools
Facilitate Philhealth paper then PUICI
Continue nebulization decrease to q 4
X 4 doses then 6
Revise breastfeeding with strict AP
Suction oronasal junction Patient
Still for close watch
D/C Trace IV- shift to P.O with
Paracetamol as maintenance

1/14/13
11:30

Revise Furosemide 40 mg/tab for 2x/day

1/15/13
Continue nebulization
Still tachypneic Continue other meds
(+) crackles
1/16/13
8:40 am

Continue meds

NURSING
MANAGEMENT

Ideal
Impaired gas exchange r/t altered pulmonary

blood flow or oxygen deprivation

Altered cardiac output r/t specific anatomic
defect
Activity intolerance r/t decreased oxygenation in
blood and tissues
Altered Nutrition: less than body requirements
r/t the excessive energy demands required by
increased cardiac workload
Increased potential for infection r/t poor
nutritional status
Alteration in parenting related to parental
perception of the child as vulnerable

Nursing Interventions
A. Provide adequate nutritional and fluid intake to maintain
the growth and developmental needs of the child
B. Prevent infection
C. Reduce the workload of the heart since decreased activity
and expenditure of energy will decrease oxygen requirements
D. Observe infant for symptoms of Congestive Heart Failure
that occur frequently as a complication of Congenital Heart
Disease
E. Observe for the development of thrombosis that may occur
as a complication of congenital heart disease
F. Explain cardiac problems to parents

Health Education
A. Instruct the family in necessary measures to
maintain the infants health
B. Teach the family about the defect and its
treatment
C. Encourage the parents and other persons to treat
child in a normal manner as possible

Actual
Ineffective Airway Clearance related to excessive, thick mucus

secretions

Decreased cardiac output related to altered myocardial contraction

Impaired gas exchange related to ventilation perfusion imbalance
Ineffective cardiac tissue perfusion related to decreased hemoglobin

concentration in blood.

Ineffective cardiac tissue perfusion related to decreased hemoglobin

concentration in blood.

DISCHARGE
PLAN

Medication
Instruct and explain to the patients mother that the
medication is very important to continue depending
on the duration that the doctor ordered for the total
recovery of the patient. Instruct to take the following
take home medications at the right dose, time,
frequency and route.

Exercise
Instruct the mother or any family member to perform
passive ROM to the patient and give the baby enough
sleep.

Diet
Teach the mother the proper way of breastfeeding and
by eating nutritious foods for the nourishment of the
baby. Instruct the mother that when breastfeeding,
aspiration precaution should be considered (e.g. do
not feed the baby while laying down and let the baby
burp after feeding).

Health Teaching
Encourage and explain to the patients mother that it
is important to maintain proper hygiene to prevent
further infection. Instruct the patients mother to
bath the baby every day.

Schedule for Next Visit

Emphasized the importance of regular follow-up
check-ups and as instructed by physician. Advise
family members to seek medical advice if any
unusuality arises.

Spiritual
Instruct the family to strengthen and continue to
seek Gods guidance and enlightenment. Suggest in
attending a healing prayer or mass to strengthen
their bond with the father almighty. Encourage them
to continue to have a positive outlook in life and also
encourage him to keep faith in God and not to give
up easily when hard time comes

Lifestyle
Encourage the care giver to change the patients
diapers when needed to prevent rashes. Encourage
her also to perform passive ROM.

Referral
Encourage the patient to refer the patient to a
cardiologist if needed and if he can meet the expense.