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PDA CASE STUDY

PDA CASE STUDY

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Published by kreny10

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Published by: kreny10 on Dec 12, 2009
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01/16/2013

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I.OBJECTIVESGeneral Objective:General Objective:
At the end of the case study, the level 3 nursing students will be able to expound andAt the end of the case study, the level 3 nursing students will be able to expound and connect all ideas and knowledge gained to the nursing approach in doing valid and outmost careconnect all ideas and knowledge gained to the nursing approach in doing valid and outmost care with the patient diagnosed of CHD D-TGA, PDA,with the patient diagnosed of CHD D-TGA, PDA,PFOPFO..
Specific Objectives:Specific Objectives:
As supported by our main objective, the level 3 student nurses will be able to:As supported by our main objective, the level 3 student nurses will be able to:
1.
Familiarize with the background of what Congenital Heart Disease and PatentFamiliarize with the background of what Congenital Heart Disease and PatentDuctusDuctus ArteriosusArteriosusis all about;is all about;
2.
Recognize the predisposing and precipitating factors that may increase the development of Recognize the predisposing and precipitating factors that may increase the development of  PatentPatentDuctusDuctusArteriosusArteriosus;;3.3.Review and understand the Anatomy and Physiology of the Cardiovascular System and eachReview and understand the Anatomy and Physiology of the Cardiovascular System and each functions;functions;
4.
Explain and Illustrate theExplain and Illustrate thePathophysiologyPathophysiologyof Patentof PatentDuctusDuctusArteriosusArteriosus;;
5.
Determine what specific laboratory results that may lead to PatentDetermine what specific laboratory results that may lead to PatentDuctusDuctusArteriosusArteriosus;;
6.
Describe the potential complications related to PatentDescribe the potential complications related to PatentDuctusDuctusArteriosusArteriosus..
7.
Develop a comprehensive nursing care plan, with a principle of SMART, that is applicable toDevelop a comprehensive nursing care plan, with a principle of SMART, that is applicable to the client diagnosed with Patentthe client diagnosed with PatentDuctusDuctusArteriosusArteriosus;;8.8.Provide a well-develop Health Teaching using the METHODS formula to promote positiveProvide a well-develop Health Teaching using the METHODS formula to promote positive continuity of care to the patient after discharge which would be in great help for hiscontinuity of care to the patient after discharge which would be in great help for his condition; andcondition; and9.9.Elaborate and appreciate the importance of the Cardiovascular System.Elaborate and appreciate the importance of the Cardiovascular System.
I.I.PERSONAL DATAPERSONAL DATA
 
NAME:NAME:
C.T.EC.T.E
GENDER:GENDER:
FemaleFemale
AGE:AGE:
1 6/121 6/12y.oy.o
ADDRESS:ADDRESS:
129129AnonasAnonasExt.Ext.SikatunaSikatunaVillage Quezon CityVillage Quezon City
BIRTHDATE:BIRTHDATE:
January 04, 2008January 04, 2008
BIRTHPLACE:BIRTHPLACE:
TagbilaranTagbilaranBoholBohol
RELIGION:RELIGION:
Roman CatholicRoman Catholic
CIVIL STATUS:CIVIL STATUS:
SingleSingle
NATIONALITY:NATIONALITY:
FilipinoFilipino
ATTENDING PHYSICIAN:ATTENDING PHYSICIAN:
Dr. J.D.Dr. J.D.
DATE AND TIME OF ADMISSION:DATE AND TIME OF ADMISSION:
July 16, 2009; 8:10 PMJuly 16, 2009; 8:10 PM
CHIEF COMPLAINT:CHIEF COMPLAINT:
CCyanosisyanosis
ADMITTING DIGNOSIS:ADMITTING DIGNOSIS:
CHD D-TGA, PDA, PFOCHD D-TGA, PDA, PFO
INITIAL V/SINITIAL V/S(9:00AM)(9:00AM)
T 37.3 C
        ̊
T 37.3 C
        ̊
HR 165HR 165RR 65RR 65
II.II.NURSING ASSESSMENTNURSING ASSESSMENT
 
A.
NURSING HISTORY (Gordon’sNURSING HISTORY (Gordon’s 11 FUNCTIONAL HEALTH PATTERNS))
1.Health PerceptionAccording to the mother, being in the hospital makes C.J.E. cry a lot especiallywhen inserted with IV needle/catheter. Also, during phlebotomy, she sees her daughter in so much suffering. However, when visited by nurses, C.J.E. doesn’tcry a lot and seems to understand that they are there just to take care of her. Shedoesn’t manifest any avoidance behavior 2.Nutritional-Metabolic PatternC.J.E. is on DAT diet. Her mother reveals that she likes to brestfeed very often but can’t eat nor drink water that much. Because of her illness, she has minimalappetite for food. She can’t tolerate large amount of them because it will causeher dyspnea (shortness of breath). C.J.E. eats in very small, frequent feedings andher favorites are biscuits and fried chicken. On the other hand, C.J.E. drinks water with the use of a dropper containing just 2ml water.3.Elimination PatternC.J.E’s bowel movement is regular. She defecates semi-solid to solid, brownish toyellowish stool. She is not constipated at all. However, her voiding pattern isimpaired. C.J.E. experiences extreme oliguria in the absence of Furosemide. Sheeven cries so much if she can’t pass urine thus, making her diuretic-dependent.4.Activity and ExerciseC.J.E. learns to crawl at her 1
st
year of age, as well as grasping of objects, sayingher first word, waving goodbye and rolling over the bed. She is fond of graspingany object within her reach and loves to play with them. Her mother shares,
“Pag latag ko sa kanya sa kama, nagpapaikot-ikot na siya. Parang gumigiling siyatuwing naririnig yung kantang Igiling-giling”.
However, upon admission toPCMC, C.J.E. becomes generally lethargic.5.Sleep-Rest PatternC.J.E.manifests sleep disturbances. She wakes up at night every now and then.Her sleeping pattern is interrupted and not comfortable. Her mother tells,
“Hinditalaga tuloy-tuloy ang pagtulog niya. `Ni hindi nga siya nakakatulog ng matagal at mahimbing e. Kapag dumedede lang siya nakakatulog ng matiwasay”.
6.Cognitive-Perceptual PatternAt 1 year of age, C.J.E. utters the words “Ma” and “Pa”. She is very attracted toanything that’s color red and easily turns her head upon hearing her name.According to her mother, C.J.E. speaks words on her own, without having toteach them to her.7.Self-Perception PatternC.J.E.’s overall response to hospitalization is somewhat negative. Though sheseems okay at times, her cries and grimaces show that she feels very ill and trulysuffering.8.Role-Relationship Pattern

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