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CONGENITAL HEART DEFECT
dextro-TRANSPOSITION OF GREAT ARTERIES
Submitted to: Maria Lilibeth Q. Icasiano R.N. Coordinator Submitted by: Albarico Cindy E. Algoso Virgilio D.C. Allen, Meltimar O. Alvero, Emily Rose B. Araos, Hyacinth L. Arellano, Michael Bernard F. Bagarinao, Ma. Adel E. Balverde, Marianne Bañagale, Dianne Marie B. Basco, Daniel Paul B. Batoon, Mar Clement Maninang, Yasmin Ann D.
Transposition of the great arteries is a relatively common congenital heart condition presenting in the neonate. It is the most common heart condition causing cyanosis at birth. The overall annual incidence is 20-30 per 100,000 live births. It is more common in males than females with a ratio of about 3:1. Maternal factors associated with an increased risk include rubella or other viral illness during pregnancy, alcoholism, maternal age over 40 and diabetes. Transposition is rarely associated with syndromes or extra-cardiac malformations. Moore (1995) found that TGA accounts for 27% of infant die from congenital heart disease within the first month of life. By 6 months almost all TGA who are not treated are dead, most of them dying before 3 months (Keith et al, 1967: Boesen, 1863A). Rashkind (1966, 1968) has completely changed the outlook for TGA with his concept of balloon atrial septostomy (BAS). BAS involves the introduction of a septostomy catheter from the right atrium to the left atrium via a patent foramen ovale. The septostomy catheter has a balloon at the tip which can be inflated when it is in the left atrium. When the balloon is inflated the catheter is jerked back into the right atrium with considerable force, thereby tearing the atrial septum and creating atrial septal defect (ASD). This ASD allows bidirectional shunting at the level and with a good septostomy mostly uncomplicated TGA will survive for 1-3 years when radical surgery (Mustard operation) is technically easy. In the past surgical palliation most often used has been the creation of an inter-atrial communication with Blalock-Hanton (1950) technique. II. STATEMENT OF OBJECTIVES
III. PATIENT’S PROFILE A. GENERAL DATA NAME AGE GENDER CITIZENSHIP RELIGION BIRTHDATE PLACE OF BIRTH CHIEF COMPLAINT ADMITTING DIAGNOSIS ATTENDING PHYSICIAN DATE OF ADMISSION B. HISTORY 1. PERINATAL a. Antenatal The patient’s mother is a 30-year old prima gravida (G1P1) mother who had regular prenatal consultation during her pregnancy. On the first trimester, the mother contracted Urinary Tract Infection. An unrecalled antibiotic was prescribed to her by her OB-GYNE for 7 days then recovered. As to her recollection, she contracted no other disease. b. Intrapartal The patient was delivered full term via NSD at Nazareno Hospital in Marilao, Bulacan. : : : : : : : : : : : Baby Boy Blue 3 months Male Filipino Roman Catholic June 21, 2009 Marilao, Bulacan Dyspnea, Cyanosis CHD, d-TGA, VSD, PDA, PFO Dr. Gamponia, Dr. Carlos August 13, 2009
c. Postpartal Upon delivery via NSD, the baby was fairly active with good cry and suck, and pinkish in appearance. A normal APGAR score was claimed by the pediatrician as to the mother’s recollection. 2. FAMILY HISTORY His parents have a known history of DM and HPN. Cardiac problems were also evident in the family. His cousins, on both parents’ side, were diagnosed with VSD. His uncle on his mother’s side was diagnosed with Down’s Syndrome. 3. SOCIO-ECONOMIC Both of the patient’s parents are college graduates, working as sales supervisor and store design officer in SM Department Store respectively. 4. HISTORY OF PRESENT ILLNESS On his first week of life, the patient was apparently well until the mother noticed weak cry. Patient had no history of interrupted feeding or cyanosis. No fever, colds or cough noted at that time. Patient was then brought to a pediatrician who referred them to an EENT doctor due to hoarseness of voice. Two days after, patient was noted to be irritable with poor suck, poor activity and with episodes of coughing of previously ingested milk, No consult was done at that time. On his second week of life, there was persistence of symptoms and patient was seen gasping by his mother thereby prompting consult with a pediatrician. Upon auscultation, a murmur was heard and his CXR revealed pneumonia and cardiomegaly. Patient was then advised for further consultation at any tertiary hospital around Metro Manila. He was then admitted at UST hospital where emergency intubation which hooked to a mechanical ventilator and was inserted with OGT. He was initially treated for pneumonia and E-coli in the urine. His 2DECHO revealed CHD, TGA with VSD, PFO, and PDA. Because the hospital is not capable of such procedure, the pediatric cardiologist advised them to seek
consultation with the Philippine Heart Center. The patient was discharged but with OGT in place. Two days after discharge, the parents went to PHC for an emergency admission but were refused due to problem in operation schedule which may occur in the next two months. They were sent home advising them to continue infant’s medication. On their way home, incessant crying and nailbed and circumoral cyanosis were noted. They went back to PHC, hence they were admitted. Admission was made on August 13, 2009 at 4:05 am. C. INITIAL ASSESSMENT 1. Physical Assessment Norms Physical Appearance Head Hair Skin Neat and clean Actual Findings Neat and clean Interpretation and Analysis Well-groomed. Normal. Normal. Increase amount of deoxygenated hemoglobin; associated with hypoxia. Can be due to heart / lung disease, cold environment. Normal
Rounded and smooth Rounded and smooth Open anterior and posterior fontanelles (HC 35cm) Evenly distributed Evenly distributed Color varies from Cyanotic, noted poor ruddy pink to light capillary refill. pink Shiny smooth pink conjunctiva Shiny smooth pink conjunctiva No edema
Ears Nose Mouth
No edema/tenderness over lacrimal gland No tearing No edema or tearing Sound is heard in Sound is heard in both ears both ears Nasal septum intact Nasal septum intact and in and in midline midline Lips are pink, moist, Circumoral cyanosis noted. symmetrical, and smooth. With presence of OGT
Normal Normal Normal Increase amount of deoxygenated hemoglobin; associated with hypoxia. For feeding purposes
Symmetrical chest expansions No retractions
Symmetrical chest expansions Normal Intercostal and Subcostal retractions Hypoxemia Presence of secretions
Clear breath sounds Crackles on bilateral lung fields
Presence of CHD Dynamic precordium AB at 5th LICS LMCL, S1 normal, S2 split, grade 3/6 PSM LMSB Limbs can be moved Noted spasticity on both To rule out cerebral palsy freely upper extremity and lower extremity
2. Vital Signs Actual Findings Temperature Pulse rate Respiratory rate Blood pressure Weight Height/Length 36.4°C 126 bpm 30 cpm 90/P 3.2 kg 57 cm Interpretation and Analysis 36-37.5°C is still within the normal range therefore 37.6°C is normal Normal Normal Normal Normal Normal
3. Neurological Assessment
Reflexes Babinski reflex Blinking reflex Grasping reflex Moro reflex Rooting reflex Sucking reflex
How Elicited Sole of foot is stroked Flash of light or puff of air striked to the eyes Palms are touched Sudden movement / loud noise is induced Cheek is stroked or side of mouth is touched Mouth is touched by an object
Norms Fans out toes and twists foot in Closes eyes Palms grasps tightly Startles Mouth turns toward source, opens mouth and sucks Sucks on the object
Findings Fanning of toes Eyes closed, blinks rapidly Forms a fist Throws out arms and legs and then pulls them toward body Mouth turns towards the source Sucks the source
Interpretation Normal Normal Normal Normal Normal
In transposition of the great arteries, the aorta arises from the right ventricle instead of the left, and the pulmonary artery arises from the left ventricle instead of the right. In a normal heart, oxygen-depleted blood is pumped from the right side of the heart, through the pulmonary artery, to the lungs where it is oxygenated. The oxygen-rich blood then returns to the left heart, via the pulmonary veins, and is pumped through the aorta to the rest of the body, including the heart muscle itself. With d-TGA, deoxygenated blood from the right heart is pumped immediately through the aorta and circulated to the body and the heart itself completely deoxygenated,
bypassing the lungs altogether, while the left heart pumps oxygenated blood continuously back into the lungs through the pulmonary artery. In effect, two separate "circular" (parallel) circulatory systems are created, rather than the "figure 8" (in series) circulation of a normal cardio-pulmonary system. This severe defect is incompatible with life. In most instances, atrial and ventricular septal defect occur in connection with this transposition, making the entire heart one mixed circulatory system. Often, d-TGA accompanied by other heart defects. The most common type of these defects being intracardiac shunts are atrial septal defect (ASD) including patent foramen ovale (PFO), ventricular septal defect (VSD), and patent ductus arteriosus (PDA). Stenosis of valves or vessels may also be present. When no other heart defects are present it is called 'simple' d-TGA; when other defects are present it is called 'complex' d-TGA. Although it may seem counterintuitive, complex d-TGA presents better chance of survival and less developmental risks than simple d-TGA. This is because the left-to-right and bidirectional shunting caused by the defects common to complex d-TGA allow a higher amount of oxygen-rich blood to enter the systemic circulation.
Heart Development The primordium of the heart forms in the cardiogenic plate located at the cranial end of the embryo. Angiogenic cell clusters which lie in a horse-shoe shape configuration in the plate coalesce to form two endocardial tubes. These tubes are then forced into the thoracic region due to cephalic and lateral foldings where they fuse together forming a single endocardial tube. The tube can be subdivided into primordial heart chambers starting caudally at the inflow end: the sinus venosus, primitive atria, ventricle, and bulbus cordis. The heart tube begins to grow rapidly forcing it to bend upon itself. The result is the bulboventricular loop. Septa begin to grow in the atria, ventricle and bulbus cordis to form right and left atria, right and left ventricles and two great vessels- the pulmonary artery and the aorta. By the end of the eighth week partitioning is completed and the fetal heart has formed.
Week 5 6
Atrial Partitioning Figure 1 By the time the heart tube has formed the bulboventricular loop , the two primitive right and left atria have fused to form a common atrium. Note that it now lies cranial to the primitive ventricle and dorsal to the bulbus cordis. The truncus arteriosus lies on the roof of the common atium causing a depression and indicates where septation of the atrium will occur.
• • • •
AS = Aortic sac BC = Bulbus cordis CC = Conus cordis LA = Left atrium
• • • •
LV = Left ventricle RA = Right atrium SV = Sinus venosus TA = Truncus arteriosus
Figure 2 The partitioning of the atrium begins with the appearance of septum primum at about the 28th day. This is a crest of tissue that grows from the dorsal wall of the atrium towards the endocardial cushions - - the ostium (opening) formed by the free edge of septum primum is the ostium primum. Figure 3 Before the septum primum fuses with the endocardial cushions, perforations appear in the upper portion of the septum primum. These perforations will coelasce to form the ostium secundum.
• • •
SAO = Sinoatrial oriface SS = Septum spurium S1 = Septum primum
• • •
Perf = Perforations O1 = Ostium secundum EC = Endocardial cushions
Figure 4 Unlike the septum primum, septum secundum does not fuse with the endocardial cushions. Its free edge forms the foramen ovale. The left venous valve and the septum spurium, located on the dorsal wall of the right atrium, fuse with the septum secundum as it grows.
• • •
EC = Endocardial cushions LVV = Left venous valve O1 = Ostium secundum
• • •
SS = Septum spurium S1 = Septum primum S2 = Septum secundum
Figure 5 At the end of the seventh week the human heart has reached its final stage of development. Because the fetus does not use its lungs, most of the blood is diverted to the systemic circulation. This is accomplished by a right to left shunting of blood that occurs between the two atria. The foramen ovale and the septum primum control this right and left communication. The septum primum acts as a valve over the foramen ovale. At birth the child will use its lungs for the first time and consequently more blood will flow into the pulmonary circulation. The pressure increase in the left atrium (where the pulmonary veins empty) will force septum primum to be pushed up against septum secundum. Shortly thereafter the two septa fuse to form a common atrial septum.
• • • •
O1 = Ostium primum S1 = Septum primum FO = Foramen ovale S2 = Septum secfundum
V. COURSE IN THE WARD
Day 1 August 13, 2009 Day of Admission The patient was drowsy and in respiratory distress with and tight air entry and decreased breath sounds on both lung fields. Thus, he was intubated and hooked to mechanical ventilator. Midazolam dirip 3.5 mg+diluents to make 12cc at 0.5 cc/hr was also started. Nebulization with Salbutamol Q6 then CPPT were done. Arterial line was started; ABG‘s were frequently obtained and MV settings were gradually adjusted accordingly WBC was elevated and blood and ETA GS/CS were done. The following antibiotics were started. Piperacillin Tazobactam 150 mg IV Q6 Amikacin 50 mg IV OD
Chest X-ray revealed congestion, hence, Furosemide 3 mg TIV Q12 was given He had faint pulses and cyanotic nail beds, thus Dopamine drip (5:800) at 1.5 cc/hr was initiated He was hypoglycemic thus D10W 7cc was given as IV bolus for Hgt 44mg/dl His weight was below his IBW, so feeding via OGT was eventually started as glucose water 10cc Q3 then later progressed to milk formula 10cc/hr q3 x 2 doses and increased by 10 cc Q feeding until 60 cc Q3 is reached.
Day 4 August 16, 2009
The patient was referred to PIDS and pulmonologist for Arterial Switch Operation (ASO) clearance. HR 131, RR60, BP 80P. Dopamine drip was decreased to (3:500). 0.8cc/hr then D/C. The following meds were started: Lanoxin elixir 0.25 ml Q12 Captopril 200mg/pp tab, 1 pp tab Q12
Day 6 August 18, 2009 Blood and Urine C/S result showed no growth Patient was cleared for ASO and was referred to TCVS. The following supplements were started: Multivitamins drops 0.3 cc/day Ascorbic acid 0.3 cc/ day Heraclene 1 cap 10 Grains BID.
Day 11 August 23, 2009 Patient was scheduled for ASO on August 24, 2009 at 6:00 a.m. The following were secured in preparation for the operation: 25% Human Albumin 1 vial Ilopress 1 ampoule PRBC 1 unit Cryoprecipitate 1 unit Platelet Concentrate 2 units Milrinone 10 cc.
Day 12 August 24, 2009 Pre-operative: Methyl prednisolone was given at 3:00 a.m. Patient was put on NPO
ABG and CBG were taken
Intra-operative (Surgery: VSD Patch Closure and Arterial Switch Operation) Duration of anesthesia 6:50 a.m. to 4:30 p.m. Duration of operation 8:16 a.m. to 4:30 p.m. Continuous bleeding was noted at the end of surgery probably at right coronary site Hct went down from 0.30 to 0.15. PRBC, Plasma, and Platelet were transfused The following lines were maintained: ML 1 R CVP SD1 Levophed (o.4: 80) 0.8cc/hr SD2 NTG OFF SD3 Dopamine (20:1600) 2cc/hr SD4 Dobutamine (20:5000) 0.7cc/hr SD5 Epinephrine (0.5:40) 0.2 cc/hr SD6 Milrinone (0.54: 200) 0.6 cc/hr
ML2 R femoral Blood line PRBC 15cc/hr ML3 L hand A-line L Femoral 1.5cc/hr LA-line 1.5cc/hr The following medication were given: Meropenem 70mg IV Q8 Amikacin 50 mg IV OD Ranitidine 4mg IV Q12 Ca Gluconate 250mg IV Q6
Patients pupils were fixed dilated, hypotensive with BP 15/2, CR 0; CPR was done and Epinephrine 1 amp and Atropine 2 doses given was given. Patient was revived after 5 minutes. Patient was BP= 76/42 and CR= 126. Post CPR Pacer Setup revised: Rate 130, Atrial output 10, and Ventricular output 10 The following medications were given: Na HCO3 13 mEqs+ EAD SIVP Stat Vit K 3 mg IV Stat Cryoprecipitate 20 ml
Volume per volume replacement was done initially using D5 0.3 NaCl
then PRBC at 80cc/hr based on patient’s CT drain. Day 13 August 25, 2009 (-) UO for 12 hours, thus: Referred to nephrologist for PD Tenckhoff catheter was inserted by TCVS PD started 1.5 L dialysate; infusion time 5-10 minutes. Dwelling time 20 mins; draining 20 mins. JP drain of 49 cc was noted thus: Bleeding parameters were checked Vitamin K 3 mg IV Q6 was started PRBC and Platelet transfusion of 50ml/hr were done Patient was referred to hematologist
The following were started: Mannitol 15cc IV for 2 hours then 10 ml Q6 Dexamethasone 3.5 mg IV Q6 FFP 10 to 15 ml/ kg/day OD
Day 14 August 26, 2009
Lip smacking for 6 seconds, nystagmus, stiffening of extremities, hence: Phenobarbital 35 mg was given stat Patient was referred to neurologist
V-tach at 167bpm, BP 57/37 was noted, thus the following done: Defibrillation 7 joules to 14 joules; Rhythm was converted to sinus tachycardia Epinephrine was placed on hold Dobutamine and Levophed was decreased Calcium 1.8. Calcium gluconate 50 mg IV stat
15 minutes after, twitching of extremities was noted thus the following were ordered: Phenobarbital 25 mg IV loading dose then 10 mg IV Q12 Citicholine Cranial UTZ
Patient had another episode of seizure. Midazolam 5mg +D5 0.3 8ml was increased from 0.2ml/hr to 0.4 ml/hr. BP 100/60, CR 182 thus, NTG (0.3:200) was started at 0.3 ml/hr Blood GS/CS was done. Amikacin was discontinued once Vancomycin was started.
Day 15 August 27, 2009 Hypokalemia was noted (Serum K 2.9 mmol/L) thus, KCL drip was started (2.3 mEqs +12 ml)at 2 ml/hr Pre-operative: Placed on NPO An uneventful Sternal Closure was accomplished Duration of anesthesia 1:32 p.m. to 3:10 p.m. Duration of operation 1:57 p.m. to 3:10 p.m.
Post-operative: Good chest rise was noted (+) copious ET secretions; NAC 40mg was started BP 87/57 mmHg; Levophed and Milrinone were discontinued
Day 17 August 29, 2009 CXR revealed decreasing of congestion, negative pleural effusion, negative pneumothorax and re-expansion of atelectasis. Thus, CTT was pulled out per doctor’s order Abdominal X-ray revealed abdominal bloating, thus the following were ordered: Abdominal girth measurement Q8 Stool exam Metronidazole 30mg TIV Q6 OGT draining by gravity (+) wakefulness was noted; thus, the following medications were tapered Mannitol Phenobarbital Dexamethasone
Day 18 August 30, 2009 gradually:
UO > 1cc/hr for 24 hours thus PD was placed on hold BP 70 systolic, hence, the following were ordered: Dopamine was increased (3:1600) at 0.4cc/hr NTG was decreased to (0.5:200) at 0.5cc/hr
Day 20 September 1, 2009 Urine output more than 1 cc/hr for 48 hours. Tenckhoff catheter was removed and PD was discontinued. Milk feeding was resumed at 15 cc Q3. Ranitidine was discontinued. Weaning from MV was started: SIMV mode for 2 hours alternated with AC mode for 1 hour tolerated SaO2 99% and RR 30’s
Day 22 September 3, 2009 Electrolyte imbalances (Mg 0.30, K 3.3) were noted, thus the following were given:
MgSo4 80mg + EAD x 30 mins Q6 hrs for KCL 4 MEqs + D5IMB to make 10 cc x 4 hrs
Dopamine and NTG were discontinued NAC was shifted to oral form 100 mg sachet + 5ml, 2.5 ml BID MV was shifted to Spontaneous mode with Pressure Support of 10cm H2O PEEP 3cm H2O, Fio2 30. Retractions were noted. MV was shifted back to SIMV: Aminophylline drip 3mg + EAD x 3 hrs was started.
Isolated PVC’s and occasional bigeminy were noted Lidocaine 3.5 IV was given then Lidocaine drip (20:16000) was started
Day 23 September 4, 2009 Lanoxin elixir was started. K 3.3 UO 10cc/kg/hr hence, Furosemide decreased to 1.5 mg IV Q12
Day 25 September 6, 2009 Wheezes and retraction were noted after 1 hour on Pressure Support Ventilator at 14cm H2O thus the following were done: Nebulization and suctioning MV was shifted to SIMV Repeat CXR revealed pulmonary edema and positive air bronchogram TPAG was ordered.
Day 26 September 7, 2009 TP 43, Albumin 23, Globulin 20, A/G 1.15. 25% thus, Albumin 15 cc was transfused to run for 4 hrs. Occasional PVC’S were noted. Repeat serum electrolytes showed hypomagnesemia Mg 0.60 hence, MgSo4 80 mg Q8 x 3 doses was given. Day 27 September 8, 2009
Blank stare was noted and diazepam 1mg stat dose was given.
Day 29 September 10, 2009 SaO2 98.7%. Negative alar flaring, negative DOB on continuous alternate ventilator settings. PSV was tolerated for 4 hours. Patient was for possible extubation. Dexamethasone 0.5 IV Q6 was ordered.
Day 30 September 11, 2009 Patient was placed on NPO then extubated and hooked to O2 inhalation at 6 LPM via FM then was later decreased to 2LPM via NC. Feeding was resumed 5 hours post extubation. Muscle spasm of extremities was noted thus, Baclofen 0.7mg/pptab 1 pptab Q8 was started. Day 33 September 14, 2009 Negative episode of desaturation was noted thus, O2 was decreased to 0.5 LPM via NC Referred to rehabilitation for physical therapy
Day 35 September 16, 2009 Repeat CXR revealed atelectasis with consolidation, thus right lung up positioning and CPT of RUL area after each nebulization were done CVP line was removed after shifting aminophylline to doxyphylline (ansimar) 100 mg/ 5 ml syrup 0.5 ml BID Day 36 September 17, 2009 Domperidone 0.3 ml TID was started. NGT was shifted to OGT. Mother was allowed to feed the patient. Day 37 September 18, 2009
Patient have febrile episodes, thus, Ciprofloxacin 30 mg pptab BID was started. Inguinal line was removed then patient was transferred to ward per physicians order.
Day 43 September 24, 2009 (-) wheezes, (-) harsh breath sounds, (-) retraction Milk feeding was tolerated Patient is for possible discharge this week
DIAGNOSTIC AND THERAPEUTIC MANAGEMENT
A. Arterial Switch Operation The Jatene procedure, or arterial switch, is an open heart surgical procedure used to correct dextro-transposition of the great arteries (d-TGA); its development was pioneered by Canadian cardiac surgeon William Mustard and it was named for Brazilian cardiac surgeon Adib Jatene, who was the first to use it successfully. It was the first method of dTGA repair to be attempted, but the last to be put into regular use because of technological limitations at the time of its conception. Use of the arterial switch is historically preceded by two atrial switch methods: the Senning and Mustard procedures. This surgery may be used in combination with other procedures for treatment of certain cases of double outlet right ventricle (DORV) in which the great arteries are dextrotransposed. Timing
The Jatene procedure is ideally performed during the second week of life, before the left ventricle adjusts to the lower pulmonary pressure and is therefore unable to support the systemic circulation. In the event of sepsis or delayed diagnosis, a combination of pulmonary artery banding (PAB) and shunt construction may be used to increase the left ventricular mass sufficiently to make an arterial switch possible later in infancy. Prognosis The success of this procedure is largely dependent on the facilities available, the skill and experience of the surgeon, and the general health of the patient. Under preferable conditions, the intra-operative and post-operative success rate is 96% or more, with a comparable survival rate after 5 years. Approximately 10% of arterial switch recipients develop residual pulmonary stenosis post-operatively, which can lead to right heart failure if left untreated; treatment usually involves endovascular stenting and/or xenograft patching. Method Overview General anaesthesia and cardiopulmonary bypass are used. The aorta and pulmonary artery are detached from their native roots and reattached to the opposite root; thus, the pulmonary root becomes the neo-aorta, and the aortic root becomes the neo-pulmonary artery. The coronary arteries are transplanted from the aorta/neo-pulmonary artery to the pulmonary artery/neo-aorta. Length of procedure, from initiation of anaesthesia to postoperative cease thereof, is approximately 6-8 hours. Preparatory If the procedure is anticipated far enough in advance (with prenatal diagnosis, for example), and the individual's blood type is known, a family member with a compatible blood type may donate some or all of the blood needed for transfusion during the use of a heart-lung machine (HLM). The patient's mother is normally unable to donate blood for the transfusion, as she will not be able to donate blood during pregnancy (due to the needs of the fetus) or for a few weeks after giving birth (due to blood loss), and the
process of collecting a sufficient amount of blood may take several weeks to a few months. However, in cases where the individual has been diagnosed but surgery must be delayed, maternal (or even autologous, in certain cases) blood donation may be possible, as long as the mother has a compatible blood type. In most cases, though, the patient receives a donation from a blood bank. A blood transfusion is necessary for the arterial switch because the HLM needs its "circulation" filled with blood and an infant does not have enough blood on their own to do this (in most cases, an adult would not require blood transfusion). The patient will require a number of imaging procedures in order to determine the individual anatomy of the great arteries and, most importantly, the coronary arteries. These may include angiography, magnetic resonance imaging (MRI), and/or computed tomography (CT scan). The coronary arteries are carefully mapped out in order to avoid unexpected intra-operative complications in transferring them from the native aorta to the neo-aorta. Pre-operative As with any procedure requiring general anaesthesia, arterial switch recipients will need to fast for several hours prior to the surgery to avoid the risk of choking on vomit while unconscious. After the patient is anesthetized, they receive the following drugs via intravenous drip, which continue as necessary throughout the procedure: 1. Aprotinin, to prevent excessive bleeding 2. Solumedrol, to reduce swelling and inflammation 3. Regitine, to prevent hypertension 4. Prophylactic antibiotics, to prevent infection
Intra-operative The heart is accessed via median sternotomy, and the patient is given heparin to prevent the blood from clotting. A generous section of pericardium is harvested, then disinfected
and sterilized with a weak solution of glutaraldehyde; and the coronary and great artery anatomy are examined. The ductus arteriosus and right pulmonary branch, up to and including the first branches in the hilum of the right lung, are separated from the surrounding supportive tissue to allow mobility of the vessels. Silk marking sutures may be placed in the pulmonary trunk at this time, to indicate the commissure of the aorta to the neo-aorta; alternatively, this may be done later in the procedure. The cardiopulmonary bypass is then initiated by inserting a cannula into the ascending aorta as distally from the aortic root as possible while still supplying all arterial branches, another cannula is inserted into the right atrium, and a vent is created for the left ventricle via catheterization of the right superior pulmonary vein. The HLM is started at a lowflow and the patient's body is cooled to a rectal temperature of 20 °C (68 °F), which prevents the brain damage otherwise associated with the temporary circulatory arrest necessary during the procedure; the patient must be cooled for a minimum of 20 minutes prior to beginning the repair. While the patient is cooling, the ductus arteriosus is ligated at both the aortic and pulmonary ostia, then transected at its center; the left pulmonary branch, including the first branches in the hilum of the left lung, is separated from the supportive tissue; and the aorta is marked at the site it will be transected, which is just below the pulmonary bifurcation, proximal to where the pulmonary artery will be transected. When the patient is fully cooled, the ascending aorta is clamped as close as possible below the HLM cannula, and cryocardioplegia is achieved by delivering cold blood to the heart via the ascending aorta (below the cross clamp). The aorta is then transected at the marked spot, and the pulmonary artery is transected a few millimetres below the bifurcation. The vessels are again examined, and the pulmonary root is inspected for left ventricular outflow tract obstruction (LVOTO). If a ventricular septal defect (VSD) is present, it may be repaired, at this point via either the aortic or pulmonary valve; it may alternatively be repaired later in the procedure. The great arteries are usually arranged using the Lecompte maneuver, with the aortic cross clamp positioned to hold the pulmonary artery anterior to the ascending aorta;
though with some congenital arrangements of the great arteries, such as side-by-side, this is not possible and the arteries will be transplanted in the non-anatomic 'anterior aorta' arrangement. If the aortic commissure has not yet been marked, it may be done at this point, using the same method as would be used prior to bypass; however, there is a third opportunity for this still later in the procedure. Coronary arteries are examined closely, and the ostia and proximal arterial course are identified, as are any infundibular branches, if they exist. The coronary ostia and a large "button" of surrounding aortic wall are then excised from the aorta, well into the sinus of Valsalva; and the proximal sections of the coronary arteries are separated from the surface of the heart, which prevents tension or distortion after anastomosis to the neoaorta. Infundibular branches are sometimes unable to be spared, but this is a very rare occurrence. If the aortic commissure has not previously been marked, the excised coronary arteries will be used to determine the implantation position of the aorta. The aorta is then transplanted onto the pulmonary root, using either absorbable or permanent continuous suture. The aortic clamp is temporarily removed while small sections of the neo-aorta are cut away to accommodate the coronary ostia, and a continuous absorbable suture is then used to anastomose each coronary "button" into the prepared space. In most cases, the coronary implantation sites will be at left and right anterior positions at the base of the neo-aorta; however, if the circumflex coronary artery branches from the right coronary artery, the circumflex coronary artery will be distorted if the pair are not implanted higher than normal on the neo-aorta, and in some cases they may need to be implanted above the aortic commissure, on the native aorta itself. The circumflex coronary artery may originate from the same coronary sinus as, rather than directly from, the right coronary artery, in which case they may still be excised on the same "button" and transplanted similarly to if they had a shared ostium, unless one or both have intramural communication with another coronary vessel. Sometimes, one or more coronary ostia are located very close to the valvular opening and a small portion of the native aortic valve must be removed when the coronary artery is excised, which causes a generally mild, and usually well-tolerated, neo-pulmonary valve regurgitation.
The HLM is turned off and the aortic and atrial cannula are removed, then an incision is made in the right atrium, through which the congenital or palliative atrial septal defect (ASD) is repaired; where a Rashkind balloon atrial septostomy was used, the ASD should be able to be closed with sutures, but cases involving large congenital ASDs or BlalockHanlon atrial septectomy, a pericardial, xenograft, or Dacron patch may be necessary. If there is a VSD which has not yet been repaired, this is performed via the atrial incision and tricuspid valve, using sutures for a small defect or a patch for a large defect. When the septal defects have been repaired and the atrial incision is closed, the previously removed cannula are replaced and the HLM is restarted. The left ventricle is then vented and the cross clamp removed from the aorta, enabling full-flow to be reestablished and rewarming to begin; at this point the patient will receive an additional dose of Regatine to keep blood pressure under control. The previously harvested pericardium is then used to patch the coronary explantation sites, and to extend - and widen, if necessary - the neo-pulmonary root, which allows the pulmonary artery to be anastamosed without residual tension; the pulmonary artery is then transplanted to the neo-pulmonary root. Final stages The patient is fitted with chest tubes, temporary pacemaker leads, and ventilated before weaning from the HLM is begun; and administration of post-operative drugs is initiated, these include: 1. 2. 3. muscle relaxant, to induce temporary paralysis opioid analgesic, to manage pain, cause sedation and induce serenity inotrope, to assist the heart in contracting adequately
The rib cage is relaxed and the external surgical wound is bandaged, but the sternum and chest incision are left open to provide extra room in the pleural cavity, allowing the heart room to swell and preventing pressure caused by pleural effusion. Post-operative
The sternum and chest can usually be closed within a few days; however, the chest tubes, pacemaker, ventilator, and drugs may still be required after this time. The patient will continue to fast for up to a few days, and breastmilk or infant formula can then be gradually introduced via nasogastric tube (NG tube); the primary goal after a successful arterial switch, and before hospital discharge, is for the infant to gain back the weight they have lost and continue to gain weight at a normal or near-normal rate. NURSING RESPONSIBILITIES A. Pre-op Nursing Care 1. Pre-op Assessment Purposes: Obtain patient information, Give information, and Get consent. Also allows assessment of emotional state and expectations. Careful assessment is necessary in order to prevent operative complications and alert nurse to postoperative care needs.
History and physical exam (must be completed by the physician, reviewed by the nurse, and a separate nursing assessment must be completed. Nursing assessment is holistic baseline data - identify potential problems. Use lay terms in your questioning. Finally, an anesthesia preop assessment is usually written in the chart as well.
a. Vital Signs
Preoperative and baseline. Reveal abnormalities and establish norms.
b. Past surgical history
Generally, also previous bad outcomes or distressing experiences Also ask what type anesthesia they have had.
Need to be questioned about any allergies to medications, foods, substances. Clearly identify any allergies on the front of the chart. In OR, must be alert to any allergic responses since patient will not be able to advocate for self.
In OR, particularly concerned with allergies to tape, latex, iodine. Distinguish between allergies and adverse reactions.
d. Nutritional State
Patients who are healthy will recover better than individual not in homeostasis. Need to assess nutritional state (ideal body weight, loss of SQ fat, edema, lymphocyte count, serum albumin).
Protein is essential for tissue repair. CHO provides the necessary energy for tissue repair. Vitamins necessary (Vit B maintains GI function, Vit C promotes wound healing and collagen formation, Vit K promotes clotting)
e. Body Weight
Most are weighed before surgery (basis for anesthetic drug dose)
Obesity: more complicated. Increased potential for dehiscence and evisceration, wound infection. Takes more anesthesia and stored in adipose tissue delaying excretion.
More post-op complications - respiratory, ambulation Underweight: lack of protein stores. Diet high in PRO, CHO, VIT.
f. Fluid / Electrolyte Balance
Correction of any imbalance is essential. Patients prone to hypovolemia: diarrhea, vomiting, bleeding, insufficient fluid intake, GI bleed. Need to assess for dehydration (skin turgor, mucous membranes, I/O)
Hypervolemia: renal failure, CHF, malnutrition. electroytes: NA, K, Cl, Ca, Mg. (BUN, Creat for kidney function)
"Routine bloodwork" concept is giving way to minimal labs based on complexity of procedure and findings in H&P.
Unless the reason for surgery is an infection (I and D), then surgery will always be rescheduled if evidence of infection. Assessment, temperature, WBC.
h. Chronic Illness
• • • •
Chronic illness can complicate the postoperative phase Respiratory (COPD): increase pneumonia, decrease ability to exchange CO2 and O2 Asthma - intraop bronchospasm Cardiac disease: prosthetic valves increases post op inflammatory process and potential for infection. PVD impairs tissue and wound healing. Increase risk for thrombophlebitis
Hematologic disorders: risk of hemorrhage with clotting disorders. Anemia can compound the surgical loss of blood leading to hypovolemia/shock. Endocrine disorders: DM may experience hypo/hyperglycemia during the surgical period. Increase risk of infection, silent MI, peripheral nerve injury, difficult intubation. Other endocrine disorders can alter the stress response (thyroid, pheochromocytoma).
Neurological disorders: neuro assessment provides a baseline for post operative. Incorporate care of chronic neurological disorder into care. GI disorders: adequate liver function is necessary for the detoxification of drugs. (Hx of PUD, constipation) Renal disorders: kidneys responsible for excretion of waste and maintenance of fluid and electrolyte balance. If CRF then need careful assessment of preop: I & O, specific gravity of urine, and adequate fluid intake.
Musculoskeletal disorders: ROM
i. Integumentary Status: pressure ulcers from immobility j. Drug History: Prescription as well as OTC usage
antibiotics: combine with curare to prolong apnea.
Valvular disease or prosthesis may need antibiotics prophylaxis anticoagulants: increase bleeding time diuretics: hypokalemia steroids: decrease adrenal function aspirin: decreased platelet aggregation tranquilizers: hypotension and shock Note: anti-HTN medications usually continued through the am of surgery (this used to be avoided fearing hypotension, now done to promote control without as many oscillations)
• • • • •
Instruction is essential. Research demonstrates that those who are informed will have better recovery. Best time to teach is the afternoon or evening before surgery. Challenging when most are same day admits - even carotids or heart surgery. Important because it decreases anxiety, influences recovery, promotes patient satisfaction.
A. General Principles of Preop teaching 1. Reinforce what the patient parent has been told about surgery. Find out patient’s parents understanding of procedure first. Know enough basic information about common procedures to anticipate and answer the common questions. 2. Balance telling too little vs too much 3. Avoid anxiety producing words -- "pain" (discomfort) 4. Include family members, if possible 5. Prepare for situations (cold, bright light, never left alone) B. Patient Teaching About Postoperative Care 1. Therapeutic devices: indwelling catheter, nasogastric tube, chest tube 2. Medications for Pain: assured that medication will be available, PCA devices.
3. Postoperative self-care procedures: Cough and Deep Breathing, splinting, leg exercises, turning Preop legal preparation—the Operative Permit It is the surgeon’s responsibility to explain the surgical procedure, alternatives, risks, and benefits. Purpose is to ensure the patient is not undergoing a procedure without informed consent. Helps protect from liability. Adults must be oriented and not under sedation in order to sign. May take a telephone consent. Consent is witnessed - that is a witness to the signature. 3. Day of surgery preparation A. Physical Preparation
Nursing responsibilities: orders carried out, final preparations done, records complete and accompany patient to OR. Diet: NPO after midnight (allow time for the stomach to empty, decrease aspiration) or at least 4-8 hours. Skin Preparation: decrease bacteria to a minimum. Mild antiseptic soap and water the night or day before. Shaving can increase skin bacteria. Bowel Preparation: type of surgery determines the need for a bowel prep. Enema or laxative may be administered to permit visualization of the colon and decrease chance of infection when bowel is resected.
B. Medications Table Sedative to ensure adequate rest and to decrease anxiety (midazolam, diazepam, lorazepam). Preanesthetic agent may be given 30 minutes to 1 hour before surgery to promote sleep and relaxation. No consent if sedated-- get it signed before giving. Also, void before giving. 1. Sedatives: decrease the anxiety ie benzodiazepines, barbiturates 2. Narcotic analgesic: reduce the amount of anesthetic needed. Given 30 minutes to 1 hour before sx, often IM
3. Anticholinergic: reduce secretions. Also cause dry mouth and dilatation of the pupils. (Atropine or Robinul). 4. Tranquilizer: may be given instead of a narcotic, especially to the elderly. (Valium or Phenergan).
VS before the pre-op injection (consent signed, etc.)
C. Information for the family
What time the procedure will be done, how long it will take, that the physician will communicate progression and recovery until out of anesthetic agent.
D. Preoperative Checklist / Transportation to the OR Nursing responsibility to see that the checklist is completed--important, shows that the patient is ready for transfer to the OR. Unusual observations and abnormal labs are reported to the physician. "If you want to take care of the patient, take care of the paperwork"
NPO 6 hours adults, less for the very tiny. NPO before ALL types of anesthesia. Explain reasons for restriction and importance, mark cardex, inform other caretakers, don’t leave pitcher at bedside. Signed OR Consent
Current history and physical (the surgeon’s, as opposed to your nursing assessment and anesthesia assessment) Completion of physical preparation Vital signs Void on call Recording of preop medication ID band in proper order
• • • • •
2. THE INTRAOPERATIVE PHASE A. Introduction
Transfer to surgery (preop hold or direct to OR room). Floor RN checks chart and makes certain the patient is correctly identified ("What is your name?"). Will be transferred to the OR on a gurney. Family is given instructions.
In holding area, final surgical preparations are made. Preop, RN repeats checks, abdominal prep. prn, IV.
B. Wound Closure
• • • •
Contaminated wounds are left open to heal. Otherwise closed in layers. Sutures: absorbable or nonabsorbable - require removal Sterile adhesive strips Retention sutures (provides a secondary suture which relieves undue strain on the suture line. Suture is passed through a small tube or over a plastic bridge that is placed on the skin.
Staples: reduces edema and inflammation because manipulation and handling has been reduced.
3. NURSING MANAGEMENT OF THE POSTOPERATIVE PATIENT A. Transfer to Recovery Room (PACU) Two stressors the patient is recovering from: surgery and anesthesia.
• • • • •
Transferred to recovery room by circulating nurse and CRNA. Close observation. 1:1 or 1:2. Standard and emergency equipment are present (like ICU). Almost all receive oxygen Monitoring is individualized to patient need and type of surgery. Continuous, then up to q15m: EKG, NIBP, pulse oximetry, Intake & output All preop orders are discontinued postop, rewritten in PACU (vitals, position, medications, IV, type of PO intake, activity, diagnostic tests, dressing changes).
B. Immediate postoperative complications "ABC" Airway obstruction
Causes: effects of anesthestics, effects of narcotics given intraop or postop, secretions, swelling from a surgical site in the neck S/S: snoring respirations, "rocking boat", apnea Treatment: stimulation, chin lift, jaw thrust, nasal or oral airways, reintubation, mechanical ventilation
Breathing: Respiratory insufficiency
S/S: shallow respirations, restlessness or other signs of hypoxemia, ABGs, pulse oximetry < 90%
Causes: Internal hemorrhage: may occur from insecure sutures, erosion of a vessel. S/S: rapid, deep respirations, rapid thready pulse, hypotension with narrow pulse pressure, cool, moist, pale skin, restlessness, faintness, dizziness, thirst. Treatment: flat, pressure, IV, blood. Shock
Cause: decreased perfusion of tissues. Hemorrhage, trauma, anesthesia, pooling, or anaphylactic shock. Treatment: Change position slowly, avoid Fowler’s, raise legs
o • • • •
Other problems Pain Nausea and vomiting Neurological problems (delayed emergence, delirium, problems related to the surgery type i.e. carotid endarterectomy vs lumbar laminectomy) Hypothermia
C. Transfer to floor Ready to be discharged to the floor once
patent airway with sufficient ventilation
stable vital signs normal movement
responds to questions
D. Postop care includes:
• • •
Immediate rapid assessment, then review all systems VS and assessments every 15 minutes x4, q30m x 4, q1hrx4, q4h until 24 hrs has elapsed. Temperature/Infection. Don’t change first dressing, that’s the surgeon’s prerogative. Reinforce only. Fluid intake/output (usually until oral intake reestablished) Safety: ready equipment, raise side rails, call bell, assist OOB, etc. Comfort and rest Pulmonary Chest Physiotherapy and Range of motion exercises
• • • •
E. Drains are soft rubber tubular structures placed in wounds to
• • • •
remove fluid (blood, pus) prevent deep wound infections in areas that may contain purulent material obliterate dead spaces Types
Penrose: open gravity drain. Safety pin placed on the external end of these drains to prevent them from sliding back into the wound. Usually inserted into a nearby stab wound rather than the surgical wound to allow the surgical wound to heal properly. Perforated catheter and the proximal end is placed into a closed portable suction device which creates gentle constant suction. Jackson Pratt: small reservoir bulb where fluid collects. After emptied it is compressed and the spout closed to create negative pressure.
F. Complications Related To Surgery
Stress can cause serious complications and nursing care is aimed at preventing complications. Vigilant assessment can determine presence of complications, and good nursing care can help prevent some complications. 1. Pulmonary Problems "Temperature elevations after surgery are due to wind, water, then wound."
Report fever > 101.5 . Treat fever < this with chest physiotherapy, oral intake. F Risk factors: general anesthesia, obese, smokers, lung disease, surgery on upper abdomen, airway, or chest Atelectasis: collapse of alveoli in a portion of the lung. See more in persons with upper abdominal surgeries because of the reluctance to chest physiotherapy S/S: decreased breath sounds, diminished chest expansion (affected side), fever, tachycardia, decreased cough. TX: antibiotics, decrease viscosity of secretions, chest physiotherapy, Turn q 2h. Don’t forget to get them moving even if you feel sorry for them.
Pneumonia: inflammation of the lungs usually due to bacteria. Lower lobes. S/S: similar to atelectasis. Tx: antibiotics, fluids, C & DB, turn. Pulmonary embolism: dislodgement of a thrombus from a vein which lodges in the branch of the lung. S/S: severe, sudden SOB, chest pain, tachypnea, tachycardia, anxiety. Prevention/Tx: early ambulation (if SBR, leg exercises or SCD or TEDs), anticoagulants, antibiotics.
Other problems: airway obstruction, hypoxemia, pulmonary edema, aspiration of gastric contents, bronchospasm, hypoventilation
2. Cardiovascular Problems
Orthostatic hypotension: a change in BP when changing from supine to upright. Causes: cardiac, hemorrhage, medications. SS. Hypotension when standing, tachycardia, faintness. Tx: change positions slowly. Thrombophlebitis may develop from stasis and hypovolemia.
Other problems: Hypertension, arrhythmias.
3. Neurologic problems
• • •
Emergence delirium Delayed awakening CVA or decreased LOC related to cerebral blood supply interruptions related to surgery
Risk factors: extremes of age, debilitated, intoxicated, long surgery time
• • •
They’re not just being babies. Don’t resent their demands or be fearful of addiction Don’t just think of IM drugs-- many other techniques available including PCA, epidural catheters, NSAIDS
6. Nausea and vomiting
PONV a huge problem 30-70% based on population sampled. Worsened with narcotics, movement, female gender. Tx: pharmacologic ie droperidol Inapsine®, diphenhydramine Benadryl®, dimenhydrinate Dramamine®, ondansetron Zofran®, etc.
7. Fluid and electrolyte problems
Hypovolemia: decreased fluid intake: dry mouth, thirst, decreased skin turgor, decreasing urine output, tachycardia, dry skin. Tx: fluid replacement. Hypervolemia: IV fluids more than cardiovascular system can handle. Fluids are retained the first 24 to 48 hours because of stimulation for ADH. s/s: crackles,
increased respiration, pulse, BP, edema, increased urine output. Tx: decreased fluid intake.
Urinary retention because of trauma from surgery. Other causes include anesthetics, anticholinergics, positioning. S/S: inability to void, bladder distension. Tx: catheterization, give privacy, allow to stand, warm water over perineum, or just the sound of running water.
Renal failure: from inadequate kidney perfusion related to hypotension. S/S: decreasing urine output in spite of adequate intake. Oliguria, increasing BUN, creat. Tx: 250-500 ml in 30 minutes, U.O increases then due to hypovolemia.
• • •
Hypokalemia: loss of blood, GI fluid Hyperkalemia: IV fluids Hyponatremia: loss of body fluids, vomiting, diarrhea
8. Incisional Problems
Wound infection may develop due to 1) surface bacteria, 2) contamination during sx, 3) tissue infected prior to sx. S/S: wound pain, temperature. Tx: open the wound and allow to drain.
Dehiscence: partial to total separation of all layers of the incision. Evisceration: rupture of all layers of the incision with extrusion of abdominal organs. Usually occur in infected wounds and related to coughing, vomiting, and distension.
Treatment: dehiscence - taping or suturing the incision. Evisceration - sudden profuse, pink drainage, exposed loops of the intestine. Tx: immediate covering of the loops with sterile towels and saline, notify the MD, low fowler’s and knees flexed to support organs, withhold food and fluids, IV to prevent shock.
B. Peritoneal Dialysis (PD) In this procedure, dialysate—the solution instilled into the peritoneal cavity by a catheter —draws waste products, excess fluid and electrolytes from the blood across the semipermeable peritoneal membrane. After a prescribed period, the dialysate is drained from the peritoneal cavity, removing impurities with it. The dialysis procedure is then repeated, using a new dialysate each time, until waste removal is complete, and fluid,
electrolyte, and acid base balance has been restored. The catheter is inserted in the operating room or in an acute situation or at the patient’s bedside with a nurse assisting. With special preparation, the nurse may perform dialysis, either manually or using an automatic or semiautomatic cycle machine. Indication: For patients with renal failure who have cardiovascular instability, vascular access problems that prevent hemodialysis, fluid overload, or electrolyte imbalances. Nursing Responsibilities: 1. During and after dialysis, monitor the patient and his response to treatment. PD is usually contraindicated in patients who have had extensive abdominal or bowel surgery or extensive abdominal trauma. 2. Monitor the patient’s vital signs every 10-15 minutes for the first 1 to 2 hours of exchanges, then every 2 to 4 hours, or more frequently if necessary. Notify the practitioner of any abrupt changes in the patient’s condition. 3. To reduce the risk of peritonitis, use strict sterile technique during catheter insertion, dialysis, and dressing changes. Masks should be worn by all personnel in the room whenever the dialysis system is opened or entered. Change the dressing at least every 24 hours or whenever it becomes wet or soiled. Frequent dressing changes will also help prevent skin excoriation from any leakage. 4. To prevent respiratory distress, position the patient for maximum lung expansion. Promote lung expansion through turning and deep- breathing exercises. In some patients, decreasing volumes may be necessary. 5. If the patient suffers severe respiratory distress during the dwell phase of dialysis, drain the peritoneal cavity and notify the practitioner. Monitor any patient on PD who is being weaned from a ventilator. 6. To prevent protein depletion, the practitioner may order a high-protein diet or protein supplement. He will also monitor serum albumin.
7. Patients with low serum potassium levels may require the addition of potassium to the dialysate solution to prevent further losses. 8. Monitor fluid volume balance, blood pressure, and pulse to prevent fluid imbalance. Assess fluid balance at the end of each infusion-dwell-drain cycle. Fluid balance is positive if less than the amount infused was recovered; it is negative if more than the amount infused was recovered. 9. Weigh the patient daily to help determine how much fluid is being removed during dialysis treatment. Note the time and the variations in the weighing technique next to his weight on his chart. 10. If inflow and outflow are slow or absent, check the tubing for kinks. Also try raising the IV pole or repositioning the patient to increase the inflow rate. Repositioning the patient or applying manual pressure to the lateral aspect of the patient’s abdomen may also help increase drainage. If these maneuvers fail, notify the practitioner. Improper positioning of the catheter or an accumulation of fibrin may obstruct the catheter. 11. Always examine outflow fluid (effluent) for color and clarity. Normally it is clear or pale yellow, but pink-tinged effluent may appear during the first 3 or 4 cycles. If the effluent remains pink-tinged, or if it is grossly bloody, suspect bleeding into the peritoneal cavity and notify the practitioner. Also notify the practitioner if the outflow contains feces, which suggests bowel perforation, or if it is cloudy, which suggests peritonitis. Obtain a sample for culture and gram stain. Send the sample in a labeled specimen container to the laboratory with a laboratory request form. 12. Patient discomfort at the start of the procedure is normal. If the patient experiences pain during the procedure, determine when it occurs, its quality and duration, and whether it radiates to other body parts. Then notify the practitioner. Pain during infusion usually results from a dialysate that is too cool or acidic. Pain may also resolve from rapid inflow; Slowing the inflow rate may reduce the pain. Severe, diffuse pain with rebound tenderness and cloudy effluent may indicate peritoneal infection.
13. The patient undergoing PD will require a great deal of assistance in his daily care. To minimize his discomfort, perform daily care during a drain phase in the cycle, when the patient’s abdomen is less distended. C. Mechanical Ventilation A mechanical ventilator moves air in and out of a patient’s lungs. Although the equipment serves to ventilate a patient, it does not ensure adequate gas exchange. Mechanical ventilators may use either a positive or negative pressure to ventilate patients. Other indications for ventilator use include central nervous system disorders such as cerebral hemorrhage and spinal cord transaction, adult respiratory distress syndrome, pulmonary edema, chronic obstructive pulmonary disease, flail chest, and acute hypoventilation. Nursing Responsibilities: 1. Provide emotional support during all phases of mechanical ventilation to reduce his anxiety and promote successful treatment. 2. Make sure the ventilator alarms are on at all times. These alarms alert the nursing staff to potentially hazardous conditions and changes in the patient’s status. IF alarm sounds and if the problem cannot be identified easily, disconnect the patient from the ventilator and use a handheld resuscitation bag to ventilate him. 3. Unless contraindicated, turn the patient from side to side every 1 to 2 hours to facilitate lung expansion and removal of secretions. Perform active or passive ROM exercises for all extremities to reduce the hazards of immobility. If the patient’s condition permits, position him upright at regular intervals to increase lung expansion. When moving the patient or the ventilator tubing, be careful to prevent condensation in the tubing from flowing into the lungs, because aspiration of this contaminated moisture can cause infection. Provide care for the patient’s artificial airway as needed.
4. Assess the patient’s peripheral circulation, and monitor his urine output for signs of decreased cardiac output. Watch for signs and symptoms of fluid volume excess or dehydration. 5. Administer a sedative or neuromuscular blocking agent as ordered to relax the patient. Remember that the patient receiving a neuromuscular blocking drug requires close infection because of his inability to breathe or communicate. 6. Make sure that the patient gets adequate rest and sleep because fatigue can delay weaning from the ventilator. Provide subdued lightning, safely muffle equipment noises, and restrict staff access to the area to promote silence during rest periods. 7. When weaning the patient, continue to observe for signs of hypoxia. Schedule weaning to fit comfortably and realistically with the patient’s regimen. Avoid scheduling sessions after meals, bath, or lengthy therapeutic or diagnostic procedures.
Complete Blood Count Pre Operative August 13 August 22 August 24 August 25 Post Operative August 27 August 29 September 9 September 17
Hgb 141 Hct 0.47
Hgb 78 Hct 0.24 WBC 9.80 Platelet: 87
Hgb 69 Hct 0.20 WBC 9.00 Platelet: 58
Hgb 107 Hct 0.31 WBC 7.90 Platelet: 47
Hgb 120 Hct 0.36 WBC 13.50 Platelet: 60
Hgb 108 Hct 0.32 WBC 13.60 Platelet: 499
Hgb 105 Hct 0.32 WBC 22.50 Platelet: 188
Hct 0.44 WBC WBC 12.60 Platelet: Platelet: 180 HEMOGLOBIN (Hgb) Hemoglobin is the protein molecule in red blood cells that carries oxygen from the lungs to the body's tissues and returns carbon dioxide from the tissues to the lungs. Hemoglobin is made up of four protein molecules (globulin chains) that are connected together. The normal adult hemoglobin (Hbg) molecule contains 2 alpha-globulin chains and 2 betaglobulin chains. In fetuses and infants, there are only a few beta chains and the hemoglobin molecule is made up of 2 alpha chains and 2 gamma chains. As the infant grows, the gamma chains are gradually replaced by beta chains. Each globulin chain contains an important central structure called the heme molecule. Embedded within the heme molecule is iron that transports the oxygen and carbon dioxide in our blood. The iron contained in hemoglobin is also responsible for the red color of blood. Hemoglobin also plays an important role in maintaining the shape of the red blood cells. Abnormal hemoglobin structure can, therefore, disrupt the shape of red blood cells and impede its function and its flow through blood vessels. The hemoglobin level is expressed as the amount of hemoglobin in grams (gm) per deciliter (dl) of whole blood, a deciliter being 100 milliliters. The normal ranges for hemoglobin depend on the age and, beginning in adolescence, the gender of the person. The normal ranges are: • Newborns: 17-22 gm/dl • One (1) week of age: 15-20 gm/dl 329 10.00
• One (1) month of age: 11-15gm/dl
• Children: 11-13 gm/dl
Low hemoglobin is referred to as anemia. There are many reasons for anemia. 1. loss of blood (traumatic injury, surgery, bleeding colon cancer or stomach ulcer), 2. nutritional deficiency (iron, vitamin B12, folate), 3. bone marrow problems (replacement of bone marrow by cancer, 4. suppression by chemotherapy drugs, 5. kidney failure), and 6. Abnormal hemoglobin (sickle cell anemia). Higher than normal hemoglobin levels can be seen in people living at high altitudes and in people who smoker. Dehydration produces falsely high hemoglobin which disappears when proper fluid balance is restored. Some other infrequent causes are: 1. advanced lung disease (for example, emphysema), 2. certain tumors, 3. a disorder of the bone marrow known as polycythemia rubra vera, and 4. Abuse of the drug erythropoietin (Epogen) by athletes for blood doping purposes.
HEMATOCRIT (Hct) The hematocrit is the proportion, by volume, of the blood that consists of red blood cells. The hematocrit (hct) is expressed as a percentage. For example, a hematocrit of 25% means that there are 25 milliliters of red blood cells in 100 milliliters of blood. The normal ranges for hematocrit are dependent on age and, after adolescence, the sex of the individual. The normal ranges are: • • • Newborns: 55%-68% One (1) week of age: 47%-65% One (1) month of age: 37%-49% • • Three (3) months of age: 30%36% One (1) year of age: 29%-41%
A low hematocrit is referred to as being anemic. There are many reasons for anemia. Some of the more common reasons are loss of blood (traumatic injury, surgery, bleeding colon cancer), nutritional deficiency (iron, vitamin B12, folate), bone marrow problems (replacement of bone marrow by cancer, suppression by chemotherapy drugs, kidney failure), and abnormal hematocrit (sickle cell anemia). Higher than normal hematocrit levels can be seen in people living at high altitudes and in chronic smokers. Dehydration produces a falsely high hematocrit that disappears when proper fluid balance is restored. Some other infrequent causes of elevated hematocrit are lung disease, certain tumors, a disorder of the bone marrow known as polycythemia rubra vera, and abuse of the drug erythropoietin (Epogen) by athletes for blood doping purposes.
WHITE BLOOD CELL One of the cells the body makes to help fight infections. There are several types of white blood cells (leukocytes). The two most common types are the lymphocytes and neutrophils (also called polymorphonuclear leukocytes, PMNs, or "polys"). Lymphocytes are made in lymphoid tissue in the spleen, lymph nodes, and thymus gland. There are different kinds of lymphocytes. Lymphocytes identify foreign substances from germs (bacteria or viruses) in the body and produce antibodies and cells that specifically target them. It takes from several days to weeks for lymphocytes to recognize and attack a new foreign substance. Neutrophils are also major players in the body's defense against bacterial infections. Neutrophils are made in the bone marrow and circulate in the bloodstream. Neutrophils move out of the blood vessels into the infected tissue to attack the bacteria. The pus in a boil (an abscess) is made up largely of neutrophils. Normally a serious bacterial infection causes the body to produce an increased number of neutrophils, resulting in a higher than
normal white blood cell count (WBC). When the WBC is low, there may not be enough neutrophils to defend against bacterial infections. The white blood cell count is done by counting the number of white blood cells in a sample of blood. A normal WBC is in the range of 4,000 to 11,000 cells per microliter. A low WBC is called leukopenia. A high WBC is termed leukocytosis. THROMBOCYTE (Platelet) Platelets are the smallest formed elements in blood. They promote coagulation and the formation of a hemostatic plug in vascular injury. Platelet count is one of the most important screening tests of platelet function. Accurate counts are vital.Normal Values are the following: • • Adults: 140000-400000/ul (SI 140-400 x 10 9/L) Children: 150000-450000/ul (SI 150-450 x 10 9/L)
BLOOD C/S August 20, 2009 – No growth after 7 days incubation • Persistent, continuous, or recurrent bacteremia reliably confirms the presence of serious infection. URINALYSIS Specific Gravity: August 15 1.005 Protein: negative Sugar: negative RBC: 1/hph WBC: 10/hpf Bacteria: rare
Urinalysis can disclose evidence of diseases, even some that have not caused significant signs or symptoms. Therefore, a urinalysis is commonly a part of routine health screening.
Urinalysis is also a very useful test that may be ordered by your physician for particular reasons. Urinalysis is commonly used to diagnose a urinary tract or kidney infection, to evaluate causes of kidney failure, to screen for progression of some chronic conditions such as diabetes mellitus and high blood pressure (hypertension).
• • •
Interpretation of urinalysis is generally based on reviewing all the components of the test as well as the clinical symptoms and signs of the patient. Epithelial (flat cells) and red and white blood cells may be seen in the urine. Sometimes cells, cellular debris, and casts are seen in the microscopic urinalysis. Epithelial cells (cells in the lining of the bladder or urethra) may suggest inflammation within the bladder, but they also may originate form the skin and could be contamination.
Casts and cellular debris originate from higher up in the urinary tract, such as in the kidneys. These are material shed from kidney cell lining and travel down through the urinary tubes. These usually suggest an injury to the kidney from an inflammation or lack of blood flow to the kidneys. Rarely, tumor cells can be in the urine suggesting a urinary tract cancer.
Red blood cells can enter the urine from the vagina in menstruation or from the trauma of bladder catherization. A high count of red blood cells in the urine can indicate infection, trauma, tumors, and kidney stones. If red blood cells seen under microscopy look distorted, they suggest kidney as the possible source and may arise due to kidney inflammation (glomerulonephritis). Small amounts of red blood cells in the urine are sometimes seen young healthy people and not indicative of any disease.
Urine is a generally thought of as a sterile body fluid, therefore, evidence of white blood cells or bacteria in the urine is considered abnormal and may suggest a urinary tract infection such as, bladder infection (cystitis), infection of kidney (pyelonephritis). White blood cells may be detected in the urine through a microscopic examination (pyuria or leukocytes in the blood). They can be seen under high power field and the numbers of cells are recorded (quantitative).
White cells from the vagina or the opening of the urethra (in males, too) can contaminate a urine sample. Such contamination aside, the presence of abnormal numbers of white blood cells in the urine is significant.
URINE GS/CS August 19, 2009 – No growth after 48 hours incubation POTASSIUM Pre Operative August 13 4.7 August 22 4.4 August 23 4.7 August 24 5.4 August 25 5.7 6.1 Post Operative August 26 4.5 August 27 2.9 September 4 3.8 September 9 4.9
The potassium test measures serum level of potassium, the major intracellular cation. Potassium helps to maintain cellular osmotic equilibrium; regulates muscle activity, enzyme activity, and acid-base balance; and influences renal function. The body cannot conserve potassium, as it does sodium. The kidneys excrete nearly all ingested potassium, even when the body’s supply is depleted, so potassium deficiency can arise quickly. Potassium levels are affected by variations in the secretions of adrenal steroid hormones and by fluctuations in pH, glucose levels, and sodium levels. A reciprocal relationship exists between potassium and sodium; a substantial intake of one causes a decrease in the other. Because the kidneys excrete nearly all ingested potassium daily, a dietary intake of at least 40 mEq/day is essential. A normal diet usually includes 60 to 100 mEq of daily potassium.
Normal Values: Serum Potassium 3.5-5 mEq/L (SI 3.5-5 mmol/L) High potassium levels (hyperkalemia) occur when excess cellular potassium enters the blood, as in burn injuries, crush injuries, diabetic ketoacidosis, transfusions of large amounts of blood, and myocardial infarction. Hyperkalemia may also indicate reduced sodium excretion, possibly due to renal failure (preventing normal exchange of sodium and potassium) or Addison’s disease (due to potassium buildup and sodium depletion). Low potassium levels (hypokalemia) commonly result from alosteronism or cushing’s syndrome, loss of body fluids (as with long term diuretic therapy, vomiting, or diarrhea), and excessive licorice ingestion. SODIUM (130-144) mmol/L Pre Operative August 22 138 August 24 127 Post Operative August 26 132 September 9 135
The sodium test measures serum sodium levels in relation to the amount of water in the body. Sodium, the major extracellular cation, affects body water distribution, maintains osmotic pressure of extracellular fluid, helps promote neuromuscular function, helps maintain acid-base balance, and influences chloride and potassium levels. Because the extracellular sodium level helps the kidneys to regulate body water (decreased levels promote water excretion and increased levels promote retention), sodium levels are evaluated in relation to the amount of water in the body. For example, a sodium deficit (hyponatremia) refers to a decreased level of sodium in relation to the body’s water level. The body normally regulates the sodium-water balance through aldosterone, which inhibits sodium excretion and promotes its resorption (with water) by the renal tubules to maintain balance. Low sodium levels stimulate aldosterone secretion; high sodium levels suppress it.
Sodium imbalance can result from a loss or gain of sodium or from a change in the patient’s state of hydration. High serum sodium levels (hypernatremia) may be due to inadequate water intake, excessive sodium intake, water loss in excess of sodium (as with diabetes insipidus, impaired renal function, prolonged hyperventilation, and occasionally, severe vomiting or diarrhea), and sodium retention (as with aldosteronism). Low serum sodium levels (hyponatremia) may result from inadequate sodium intake or excessive sodium loss due to profuse sweating, GI suctioning, diuretic therapy, diarrhea, vomiting, adrenal insufficiency, burns, or chronic renal insufficiency with acidosis. Urine sodium determinations are usually more sensitive to early changes in sodium balance and should be evaluated simultaneously with serum sodium findings. CALCIUM Pre Operative August 22 2.48 August 24 3.14 Post Operative August 26 1.80 September 27 2.46
About 99% of body’s calcium is found in the teeth. About 1% of total calcium in the body circulates in the blood. About 50% of these serum calcium is bound to plasma proteins and 40% is ionized, or free. Evaluation of serum calcium levels measures the total amount of calcium in the blood, and evaluation of ionized calcium measures the fraction of serum calcium occurring in the ionized form. Normal Values: Children: Total serum calcium 8.6-11.2 mg/dl (SI 2.15-2.79 mmol/L) High serum calcium levels (hypercalcemia) may occur in hyperparathyroidism and parathyroid tumors, Paget’s disease of the bone, sarcoidosis, vitamin D intoxication, multiple myeloma, matastatic carcinoma, multiple fractures, and prolonged immobilization.
High levels may also result from inadequate excretion of calcium, as with adrenal insufficiency and renal disease; from excessive calcium ingestion; and from overuse of antacids such as calcium carbonate. Low serum calcium levels (hypocalcemia) may result from hypoparathyrodism, total parathyroidectomy, or malabsorption. Decreased serum calcium levels may also occur with cushing’s syndrome, renal failure, osteomalacia, vitamin D deficiency, acute pancreatitis, peritonitis, malnutrition with hypoalbuminemia, and blood transfusions (due to citrate). MAGNESIUM Pre Operative August 22 1.00 August 24 1.00 Post Operative September 9 0.30 September 7 0.80
The magnesium test measures serum levels of magnesium, an electrolyte that is vital to neuromuscular function. It also helps in intracellular metabolism, activates many essential enzymes, and affects the metabolism of nucleic acids and proteins. Magnesium also helps transport sodium and potassium across cell membranes and influences intracellular calcium levels. Most magnesium is found in extracellular fluid. Magnesium is absorbed by the small intestine and excreted in urine and stool. Normal values: Serum magnesium 1.3-2.1 mg/dl (SI 0.65-1.05 mmol/L) High magnesium levels (hypermagnesemia) most commonly occur in renal failure, when the kidneys excrete inadequate amounts of magnesium, and also occur with magnesium administration or ingestion. Adrenal insufficiency (Addison’s disease), dehydration, and diabetic acidosis can also increase serum magnesium levels. Low magnesium levels (hypomagnesemia) most commonly result from chronic alcoholism. Other causes include malabsorption syndrome, diarrhea, delirium tremens, excessive insulin administration, cirrhosis, toxemia of pregnancy, ulcerative colitis, faulty absorption after bowel resection,
prolonged bowel and gastric aspiration, acute ancreatitis, primary aldosteronism, severe burn, ypercalcemic conditions (including hyperparathyroidism), malnutrition, and certain diuretic therapy. BLOOD UREA NITROGEN (3.20-7.10) mmol/L Pre Operative August 19 3.80 August 24 5.80 Post Operative August 25 10.30 August 26 13.90 August 28 10.70
The Blood Urea Nitrogen (BUN) test measures the nitrogen fraction of urea, the chief end product of protein metabolism. Formed in the liver from ammonia and excreted by the kidneys, urea constitutes 40% to 50% of the blood’s non protein nitrogen. The BUN level reflects protein intake and renal excretory capacity, but is a less reliable indicator of uremia than the serum creatinine level. (BUN levels are slightly higher in elderly patients). High BUN levels occur in the renal disease, reduced renal blood flow (from dehydration, for example), urinary tract obstruction, GI bleed, congestive heart failure, and increased protein catabolism (possibly from burns). Low BUN levels indicate severe hepatic damage, malnutrition, low protein diets, and overhydration. ACTIVATED PARTIAL THROMBOPLASTIN TIME (30.0-45.0) Pre Operative August 22 49.9 secs August 24 118 secs Post Operative August 25 55.5 secs August 27 42.1 secs
Evaluates all the clotting factors of the intrinsic pathway (except platelets) by measuring how long it takes for the fibrin clot to form after calcium and phospholipids emulsion are added to a plasma sample. An activator such as kaolin is used t shorten clotting time.
PROTHROMBIN TIME (Control: 10.70sec) Pre Operative August 22 PT: 10.0 PTPA: 126% INR: 0.934 August 24 PT: 19.9 PTPA: 39% INR: 1.871 Post Operative August 25 PT: 15.0 PTPA: 59% INR: 1.407 August 27 PT: 12.1 PTPA: 86% INR: 1.132
Prothrombin Time (PT) measures the time required for a fibrin clot to form in a citrated plasma sample after addition of calcium ions and tissue thromboplastin (factor III). Normal values: 10-14 seconds (SI 10-14 seconds), depending on the source of tissue thromboplastin and the type of sensing devices used to measure clot formation. In a patient receiving oral anticoagulants, PT is usually maintained between 1 and 2.5 times the normal control value. Prolonged PT may indicate deficiency in fibrinogen; prothrombin; factors V, VII, or X (specific assays can pinpoint such deficiencies); or vitamin K. It may also result from ongoing oral anticoagulant therapy. A prolonged PT that exceeds 2.5 times the normal control value is commonly associated with abnormal bleeding. C-REACTIVE PROTEIN (0.0-10.0) mg/L Pre Operative August 14 1.1 Post Operative September 9 14.9
C-reactive protein (CRP) is an abnormal protein that appears in the blood during an inflammatory process. It’s absent from the blood of healthy people. This non specific protein is synthesized mainly in the liver and is found in many body fluids (pleural, peritoneal, pericardial, and synovial). It appears in the blood 18-24 hours after the onset of tissue damage, with levels that increase up to 1000-fold and then decline rapidly when the when the inflammatory process regresses. Normal values: CRP is not present in the blood. During the third trimester of pregnancy, the CRP level may increase. In adults, normal results may be reported as less than 0.8 mg/dl (SI less than 8 mg/L). An elevated CRP level may be present in rheumatoid arthritis, rheumatic fever, myocardial infarction (MI), cancer (active, widespread), acute bacterial and viral infections, inflammatory bowel disease, hodgkin’s disease, systemic lupus erythematosus, and postoperatively (declines after the fourth day). ETA G/S and C/S Pre Operative Post Operative August 15 August 24 September 19 Adequate catch with no Adequate catch with no Adequate catch with occasional significant pathogens significant pathogens isolated gram positive cocci in pairs and occasional gram negative bacilli Bacteriologic examination of sputum (material raised from the lungs and bronchi) is an important aid to the management of lung disease. The usual method of specimen collection (which may require ultrasonic nebulization, hydration, physiotherapy, or postural drainage); others methods include tracheal suctioning and bronchoscopy. A gram stain of expectorated sputum must be examined to make sure that it is a representative specimen of secretions from the lower respiratory tract (many white blood cells, few epithelial cells) rather than one contaminated by oral flora (few WBC’s, may epithelial cells). Careful examination of an acid-fast smear of sputum may provide presumptive evidence of a mycobacterial infection such as tuberculosis.
Normal Results :Flora commonly found in the respiratory tract include alpha-hemolytic streptococci, neisseria species, and diphtheroids. The presence of normal flora does not rule out infection. Abnormal Results: Because sputum is invariably contaminated with normal oropharyngeal flora, a culture isolate must be interpreted in light of the patient’s overall clinical condition. Isolation of M. tuberculosis is always significant finding. Isolation of pathogenic organisms most often includes streptococcus pneumoniae, M. tuberculosis, klebsiella pneumoniae (and other enterobacteriaceae), haemophilus influenzae, staphylococcus aureus, and pseudomonas aeruginosa. Urine KOH September 17 – Adequate catch with no significant pathogens isolated CREATININE (0.06-0.14) mmol/L Post Operative August 27 0.12
August 24 0.09
August 26 0.11
August 28 0.10
Analysis of serum creatinine levels provides a more sensitive measure or renal damage than blood urea nitrogen levels. Creatinine is a non protein and product of creatinine metabolism that appears in serum in amounts proportional to the body’s muscle mass. Normal values: • • Male: 0.8-1.2 mg/dl (SI 62-115 umol/L) Female: 0.6-0.9 mg/dl (SI 53-97 umol/L)
High creatinine levels usually indicate renal disease that has seriously damaged 50% or more of the nephrons; high creatinine levels may also suggest gigantism, acromegaly, and rhabdomyolosis. ERTHROCYTE SEDIMENTATION RATE September 9 – Result: 66
Erythrocyte sedimentation rate (ESR) measures the degree of erythrocyte settling in a blood sample during a specified period. The ESR is a sensitive but non specific test that is commonly the earliest indicator of disease when other chemical or physical signs are normal. The ESR usually increases significantly in widespread inflammatory disorders; elevations may be prolonged in localized inflammation and malignant disease. Normal value: • • • Male: 0-15 mm/hour Female: 20 mm/hour ESR gradually increases with age
The ESR rise in pregnancy, anemia, acute or chronic inflammation, tuberculosis, paraproteinemias (especially multiple myeloma and waldenstrom’s macroglobulinemia), rheumatic fever, rheumatoid arthritis, and some cancers. Polycythemia, sickle cell anemia, hyperviscosity, and low plasma fibrinogen or globulin levels tend to depress the ESR.
TOTAL PROTEIN ALBUMIN GLOBULIN (TPAG) A total serum protein test measures the total amount of protein in the blood. It also measures the amounts of two major groups of proteins in the blood: albumin and globulin. A test for total serum protein reports separate values for total protein, albumin, and globulin. The amounts of albumin and globulin also are compared (albumin/globulin ratio). Normally, there is a little more albumin than globulin and the ratio is greater than 1. A ratio less than 1 or much greater than 1 can give clues about problems in the body. Albumin is tested to: Check how well the liver and kidney are working. Find out if the diet contains enough protein. Help determine the cause of swelling of the ankles (edema) or abdomen (ascites) or of fluid collection in the lungs that may cause shortness of breath (pulmonary edema). Globulin is tested to determine the chances of developing an
infection. Test if there have a rare blood disease, such as multiple myeloma or macroglobulinemia. Post Operative August 28 TP: 47.0 Albumin: 25.0 Globulin: 22.0
August 25 TP: 38.0 Albumin: 22.0 Globulin: 16.0 X-RAY REPORT DATE 08/13, 17, 20/2009
September 7 TP: 43.0 Albumin 23.0 Globulin: 20.0
Four (4) serial follow-up chest films dated Aug. 13/15/17/20/2009 were reviewed. • • • • • • Overall pulmonary vascularity remains increased until the last film. Heart remains enlarged until the last study. Aorta and main pulmonary artery segment are difficult to assess. Low-lying endotracheal tube is noted in the last study (8/20/2009). Diaphragm is unremarkable. No other significant interval chest findings.
ECG September 3, 2009 INTERPRETATION Rate: A V Axis: Description: • • rR pattern in V1, V3R, V4R Tall R in V5 V6 V7 136 bpm 136 bpm +105 PR: P: 0.12 QRS: QRS: 0.08 QT: T: 0.28 Ranges: 0.40
Right bundle branch block Isolated premature ventricular contraction
INTERPRETATION: • • • Right bundle branch block Isolated premature ventricular contractions Biventricular hypertrophy in quadrigeminy
DISCHARGE CARE PLANNING Upon admission of the patient, discharge planning has been started and patient’s family should participate in planning to his care. A. MEDICATIONS: Instruction of home medications including the name of medication, dosage/ route, timing, actions and precautions/ considerations. The medications are as follows: 1. Lanoxin Elixir 0.3 ml q12 hours po 2. KCL syrup 2 ml TID po 3. Heraclene 1 capsule OD po 4. Baclofen 0.7mg/pptab q8 hours po 5. Doxophylline 0.5 ml q12 hours po 6. Ciprofloxacin 30mg/pptab 1 pptab BID po B. HOME MEDS INSTRUCTIONS 1. Teach parents the precautions and consideration of each medication. For example: 2. For Lanoxin, it should not be give if the cardiac rate is less than120 beats/min 3. Explain for how long these medications should be taken. For example, the Ciprofloxacin- to complete for 14 days (it is variable and individualized) 7. Multivitamins 0.3 ml OD po 8. Ascorbic Acid 0.3 ml OD po 9. Phenobarbital gr1/4 (15mg) OD po 10. Domperidone 0.3 ml TID po 11. Furosemide 3mg/ pptab q12 hours po 12. Procaterol 5mcg/ml BID po
4. Reiterate the actions of each drug. 5. Emphasize the importance of compliance, timing, right dosage, and not stopping the medication abruptly. 6. Teach parents to know signs and symptoms of adverse reactions or toxicity to each drug (make a list) and to report immediately if any of these are encountered. 7. Inform the parents that blood tests may be necessary for the effectiveness of the medication given and check for blood drug level and its effects on other electrolytes and blood components of the body. C. EXERCISE/ REHABILITATION: 1. Reiterate the exercises that the physical therapist had been doing starting the rehabilitation such as: a. b. Passive range of motion of both upper and lower extremities, shoulder motion Gradual back rest elevation 2. Instruct the family to turn the child from side to side on sleeping hours to prevent skin irritation and respiratory depression. 3. Instruct the family to perform gentle chest tapping and back rubbing for the child. 4. Instruct the family to give time for play therapy and provide toys appropriate for the child’s age group. 5. Instruct the family also to provide enough rest for the child after every play time therapy. D. TREATMENT I. Wound Care 1. Instruct the proper way of cleaning the wound site such as: a. Do hand washing b. Prepare the materials c. Applying betadine or cysteal solution d. Applications of ointment like bactroban or cimeosol if ordered
2. Instruct to clean the wound site daily 3. Teach the parents to note if there’s any redness, discharges or foul smell on the wound site then report immediately to physician. II. Safety Measures 1. Instruct parents to ask assistance in performing activities like bathing and feeding 2. Stress the importance of not leaving the child unattended. III. Others 1. Instruct on compliance of nebulizations and Immunizations
E. HYGIENE 1. Instruct to maintain hygienic measures in terms of: a. Patient care: Give patient bath daily. Do mouth care. Properly trim finger/ toe nails. Clean perineal area daily and change diaper as needed. Provide clean and comfortable clothing and footwear. b. Food handling: Do hand washing. Sterilize the feeding bottles, pacifier and food utensils. Prepare the food in a clean area and cook foods well. F. OUT PATIENT FOLLOW UP 1. Stress to parents to see the doctor on scheduled date either on
2. 1st visit- usually after a week 3. 2nd visit- depending on the patient’s condition
4. Provide information regarding the physician’s clinic schedule, room & contact numbers for better compliance of the patient and family.
5. Instructions for ordered laboratory exams (CBC or PTT) and diagnostic procedures (CXR) should be done as OPD basis and should bring the recent results to the physician. G. DIET AND NUTRITION 1. Providing adequate nutrition by: a. Giving the frequency and amount of milk feeding that the patient should take. b. Giving supplemental such as Heraclene, cell life, karo syrup or VCO oil if the physician permits. 2. Health Teaching on Feeding a. Place the child in upright or moderate high back rest during and after feeding. b. Burp the child every after milk feeding. c. Stress to parents not to give milk feeding after nebulization. Instruct them to wait for 30 mins before giving the milk formula. H. SUPPORT SYSTEM/FAMILY READINESS/SEXUALITY 1. An assessment of the family’s ability to care for their infant should be made. 2. A primary care giving adult should be identified and be capable to meet the needs of the infant. 3. If concerns about the adequacy of the home environment exist, discuss options prior to discharge. 4. The home caregiver(s) should demonstrate basic skills in infant care (e.g. feeding, bathing, dressing, etc). 5. Infant’s safety should be discussed including use of a car seat, and safe sleeping position. 6. The home caregiver(s) should demonstrate knowledge and skills appropriate to the needs of their infant such as administration of medications, oxygen, suction, tube feeding, cardiorespiratory monitoring if the patient is going home with contraptions.
The rationale for incorporating this theoretical framework is to serve as a guide in forming nursing assessment, planning, intervention and evaluation for the optimum care of the patient. Nursing Theory: Anne Casey Casey's Model of Nursing was developed in 1988 by Casey whilst working on the Paediatric Oncology Unit at the Great Ormond Street Hospital London. The focus of the model is on working in partnership with children and their families, and was one of the earliest attempts to develop a model of practice specifically for child health nursing. The model has been developed in other areas of England to focus upon local aspects of practice concerning child health and development. It comprises the five concepts of child, family, health, environment and the nurse. The philosophy behind the model is that the best people to care for the child is the family with help from various professional staff. Casey (1988) describes a continuum starting at conception through maturity. At the start of this the child is dependent in the careers for all its needs. But at the end is independent and self-caring. The process of functioning, growing and developing is based on the following concepts: Physical Emotional Intellectual Social Spiritual
When undertaking an assessment, the nurse will need to explore the structure of the family and establish who normally undertakes the caring role. It is essential for the nurse to have an understanding of the family structure to enable effective communication.
The process of assessment and care for the child will be between the child, the nurse and the family career. The group chose this nursing theoretical framework because it is the most preferred in child care. This model of nursing helps the nurse understand how the roles and actions of nurses and family interconnect in order to provide the optimum care for the child.
DRUG STUDY Drug Name Ranitidine hydrochloride (ra nye' te deen) Drug class Histamine2 (H2) antagonist Indication/Dosages Indications: Short-term treatment of active duodenal ulcer Maintenance therapy for duodenal ulcer at reduced dosage Short-term treatment of active, benign gastric ulcer Short-term treatment of gastroesophageal reflux disease (GERD) Available forms Tablets—75, 150, 300 mg; effervescent tablets and granules —150 mg; capsules —150, 300 mg; syrup —15 mg/mL; injection—1, 25 mg/mL Contraindication Contraindicated with allergy to ranitidine, lactation. Use cautiously with impaired renal or hepatic function, pregnancy. Adverse Effect Nursing Consideration CNS: Headache, Administer oral malaise, drug with meals dizziness, and at bedtime. somnolence, Decrease doses in insomnia, vertigo renal and liver CV: Tachycardia, failure. bradycardia, Provide PVCs (rapid IV concurrent administration) antacid therapy to Dermatologic: relieve pain. Rash, alopecia Administer IM GI: dose undiluted, Constipation, deep into large diarrhea, nausea, muscle group. vomiting, Arrange for abdominal pain, regular followhepatitis, up, including increased ALT blood tests, to levels evaluate effects. GU: Take drug with Gynecomastia, meals and at impotence or bedtime. Therapy decreased libido may continue for Hematologic: 4–6 wk or longer. Leukopenia, granulocytopenia, thrombocytopeni a, pancytopenia Local: Pain at IM site, local burning or itching at IV site
Midazolam hydrochloride (mid ay' zoh lam) Versed Drug classes Benzodiazepine (shortacting) CNS depressant Therapeutic actions Exact mechanisms of action not understood; acts mainly at the limbic system and reticular formation; potentiates the effects of gamma-aminobutyrate (GABA), an inhibitory neurotransmitter; anxiolytic and amnesia effects occur at doses below those needed to cause sedation, ataxia; has little effect on cortical function.
IV or IM; oral syrup for children: Sedation, anxiolysis, and amnesia prior to diagnostic, therapeutic, or endoscopic procedures or surgery Induction of general anesthesia Continuous sedation of intubated and mechanically ventilated patients as a component of anesthesia or during treatment in the critical care setting Available forms Syrup—2 mg/mL; injection—5 mg/mL, 1 mg/mL
Contraindicated with hypersensitivity to benzodiazepines; psychoses, acute narrow-angle glaucoma, shock, coma, acute alcoholic intoxication; pregnancy (cleft lip or palate, inguinal hernia, cardiac defects, microcephaly, pyloric stenosis have been reported when used in first trimester; neonatal withdrawal syndrome reported in infants); neonates.
CNS: Transient, Do not mild drowsiness administer intra(initially); arterially, which sedation, may produce depression, arteriospasm or lethargy, apathy, gangrene. fatigue, light Do not use small headedness, veins (dorsum of disorientation, hand or wrist) for restlessness, IV injection. confusion, crying, Monitor IV delirium, injection site for headache, slurred extravasation. speech, Carefully monitor dysarthria, stupor, P, BP, and rigidity, tremor, respirations dystonia, vertigo, carefully during euphoria, administration. nervousness, Keep resuscitative difficulty in facilities readily concentration, available; have vivid dreams, flumazenil psychomotor available as retardation antidote if CV: Bradycardia, overdose should tachycardia, CV occur. collapse, Keep patients in hypertension, bed for 3 hr; do hypotension, not permit palpitations, ambulatory edema patients to operate Dermatologic: a vehicle Urticaria, pruritus, following an skin rash, dermatitis injection. GI: Constipation, Arrange to monitor liver diarrhea, dry and kidney mouth, Adverse Effect Nursing Consideration salivation, nausea, function and CBC at anorexia, vomiting, intervals during longdifficulty in term therapy. swallowing, gastric Establish safety disorders, elevations precautions if
Drug Name Aminophylline (theophylline ethylenediamine) (am in off' i lin) Truphylline Drug classes Bronchodilator Xanthine Therapeutic actions Relaxes bronchial smooth muscle, causing bronchodilation and increasing vital capacity, which has been impaired by bronchospasm and air trapping; in higher concentrations, it also inhibits the release of slowreacting substance of anaphylaxis (SRS-A) and histamine.
Indication/Dosages Symptomatic relief or prevention of bronchial asthma and reversible bronchospasm associated with chronic bronchitis and emphysema Unlabeled uses: Respiratory stimulant in Cheyne-Stokes respiration; treatment of apnea and bradycardia in premature babies Available forms Tablets—100, 200 mg; CR tablets— 225 mg; liquid— 105 mg/5 mL; injection—250 mg/10 mL; suppositories— 250, 500 mg Dosages Individualize dosage: Base adjustments on clinical responses; monitor serum theophylline levels;
Contraindication Contraindicated with hypersensitivity to any xanthine or to ethylenediamine, peptic ulcer, active gastritis; rectal or colonic irritation or infection (use rectal preparations). Use cautiously with cardiac arrhythmias, acute myocardial injury, CHF, cor pulmonale, severe hypertension, severe hypoxemia, renal or hepatic disease, hyperthyroidism, alcoholism, labor, lactation.
Adverse Effect CNS: Irritability (especially children); restlessness, dizziness, muscle twitching, seizures, severe depression, stammering speech; abnormal behavior characterized by withdrawal, mutism, and unresponsiveness alternating with hyperactive periods CV: Palpitations, sinus tachycardia, ventricular tachycardia, lifethreatening ventricular arrhythmias, circulatory failure GI: Loss of appetite, hematemesis, epigastric pain, gastroesophageal reflux during sleep, increased AST GU: Proteinuria, increased excretion of renal tubular cells and
Nursing Consideration Administer to pregnant patients only when clearly needed —neonatal tachycardia, jitteriness, and withdrawal apnea observed when mothers received xanthines up until delivery. Caution patient not to chew or crush entericcoated timed-release forms. Give immediaterelease, liquid dosage forms with food if GI effects occur. Do not give timedrelease forms with food; these should be given on an empty stomach 1 hr before or 2 hr after meals. Maintain adequate hydration. Monitor results of serum theophylline levels carefully, and arrange for reduced
Indication/Dosages maintain therapeutic range of 10–20 mcg/mL; base dosage on lean body mass; 127 mg aminophylline dihydrate = 100 mg theophylline anhydrous.
Adverse Effect RBCs; diuresis (dehydration), urinary retention in men with prostate enlargement Respiratory: Tachypnea, respiratory arrest Other: Fever, flushing, hyperglycemia, SIADH, rash
Nursing Consideration dosage if serum levels exceed therapeutic range of 10–20 mcg/mL. Take serum samples to determine peak theophylline concentration drawn 15–30 min after an IV loading dose. Monitor for clinical signs of adverse effects, particularly if serum theophylline levels are not available. Ensure that diazepam is readily available to treat seizures.
Drug Name captopril (kap' toe pril) Apo-Capto (CAN), Capoten, GenDrug classes Angiotensin-converting enzyme (ACE) inhibitor Antihypertensive Therapeutic actions Blocks ACE from converting angiotensin I to angiotensin II, a powerful vasoconstrictor, leading to decreased blood pressure, decreased aldosterone secretion, a small increase in serum potassium levels, and sodium and fluid loss; increased prostaglandin synthesis also may be involved in the antihypertensive action.
Indication/Dosages • Treatment of hypertension alone or in combination with thiazide-type diuretics • Treatment of CHF in patients unresponsive to conventional therapy; used with diuretics and digitalis • Treatment of diabetic nephropathy • Treatment of left ventricular dysfunction after MI • Unlabeled uses: Management of hypertensive crises; treatment of rheumatoid arthritis; diagnosis of anatomic renal artery stenosis, hypertension related to scleroderma renal crisis; diagnosis of primary aldosteronism, idiopathic edema; Bartter's syndrome; Raynaud's syndrome
Contraindication • Contraindicated with allergy to captopril, history of angiodema. • Use cautiously with impaired renal function; CHF; salt or volume depletion, lactation, pregnancy.
Adverse Effect • CV: Tachycardia, angina pectoris, MI, Raynaud's syndrome, CHF, hypotension in salt- or volumedepleted patients • Dermatologic: Rash, pruritus, pemphigoid-like reaction, scalded mouth sensation, exfoliative dermatitis, photosensitivity, alopecia • GI: Gastric irritation, aphthous ulcers, peptic ulcers, dysgeusia, cholestatic jaundice, hepatocellular injury, anorexia, constipation • GU: Proteinuria, renal insufficiency, renal failure, polyuria, oliguria, urinary frequency
Nursing Consideration • Administer 1 hr before or 2 hr after meals. • Alert surgeon and mark patient's chart with notice that captopril is being taken; the angiotensin II formation subsequent to compensatory renin release during surgery will be blocked; hypotension may be reversed with volume expansion. • Monitor patient closely for fall in BP secondary to reduction in fluid volume (excessive perspiration and dehydration, vomiting, diarrhea); excessive hypotension may occur.
Indication/Dosages Available forms Tablets—12.5, 25, 50, 100 mg PEDIATRIC PATIENTS Safety and efficacy not established.
Adverse Effect Nursing Consideration • Hematologic: • Reduce dosage Neutropenia, in patients with agranulocytosis, impaired renal thrombocytopeni function. a, hemolytic anemia, pancytopenia • Other: Cough, malaise, dry mouth, lymphadenopath y
Drug Name Digoxin (di jox' in) Digitek, Lanoxicaps Drug classes Cardiac glycoside Cardiotonic Therapeutic actions Increases intracellular calcium and allows more calcium to enter the myocardial cell during depolarization via a sodium–potassium pump mechanism; this increases force of contraction (positive inotropic effect), increases renal perfusion (seen as diuretic effect in patients with CHF), decreases heart rate (negative chronotropic effect), and decreases AV node conduction velocity.
Indication/Dosages • CHF • Atrial fibrillation Available forms Lanoxicaps capsules— 0.05, 0.1, 0.2 mg; tablets —0.125, 0.25, mg, elixir —0.05 mg/mL; injection —0.25 mg/mL; pediatric injection—0.1 mg/mL Dosages Patient response is quite variable. Evaluate patient carefully to determine the appropriate dose.
Contraindication • Contraindicated with allergy to digitalis preparations, ventricular tachycardia, ventricular fibrillation, heart block, sick sinus syndrome, IHSS, acute MI, renal insufficiency and electrolyte abnormalities (decreased K+, decreased Mg++, increased Ca++). • Use cautiously with pregnancy and lactation.
Adverse Effect CNS: Headache, weakness, drowsiness, visual disturbances, mental status change CV: Arrhythmias GI: GI upset, anorexia
Nursing Consideration • Monitor apical pulse for 1 min before administering; hold dose if pulse < 60 in adult or < 90 in infant; retake pulse in 1 hr. If adult pulse remains < 60 or infant < 90, hold drug and notify prescriber. Note any change from baseline rhythm or rate. • Take care to differentiate Lanoxicaps from Lanoxin; dosage is very different • Check dosage and preparation carefully. • Avoid IM injections, which may be very painful. • Follow diluting instructions carefully, and use diluted solution promptly. • Avoid giving with meals; this will delay absorption.
Indication/Dosages PEDIATRIC PATIENTS • Loading dose: Oral (mcg/kg) Prematu 20–30 re Neonate 25–35 1–24 mo 35–60 2–5 yr 30–40 5–10 yr 20–35 > 10 yr 10–15 Maintenance dose, 25%– 35% of loading dose in divided daily doses. Usually 0.125– 0.5 mg/day PO.
Nursing Consideration • Have emergency equipment ready; have K+ salts, lidocaine, phenytoin, atropine, cardiac monitor on standby in case toxicity develops. • Monitor for therapeutic drug levels: 0.5–2 ng/mL.
Drug Name furosemide (fur oh' se mide) Apo-Furosemide (CAN), Furoside (CAN), Lasix, Myrosemide (CAN) Drug class Loop diuretic Therapeutic actions Inhibits the reabsorption of sodium and chloride from the ascending limb of the loop of Henle, leading to a sodium-rich diuresis.
Indication/Dosages • Oral, IV: Edema associated with CHF, cirrhosis, renal disease • IV: Acute pulmonary edema • Oral: Hypertension Available forms Tablets—20, 40, 80 mg; oral solution— 10 mg/mL, 40 mg/5 mL; injection— 10 mg/mL PEDIATRIC PATIENTS Avoid use in premature infants: stimulates PGE2 synthesis and may increase incidence of patent ductus arteriosus and complicate respiratory distress syndrome. • Edema: Initially, 2 mg/kg/day PO. If needed, increase by 1– 2 mg/kg in 6–8 hr. Do not exceed 6 mg/kg. Adjust
Contraindication • Contraindicated with allergy to furosemide, sulfonamides; allergy to tartrazine (in oral solution); anuria, severe renal failure; hepatic coma; pregnancy; lactation. • Use cautiously with SLE, gout, diabetes mellitus.
Adverse Effect • CNS: Dizziness, vertigo, paresthesias, xanthopsia, weakness, headache, drowsiness, fatigue, blurred vision, tinnitus, irreversible hearing loss • CV: Orthostatic hypotension, volume depletion, cardiac arrhythmias, thrombophlebiti s • Dermatologic: Photosensitivity, rash, pruritus, urticaria, purpura, exfoliative dermatitis, erythema multiforme • GI: Nausea, anorexia, vomiting, oral and gastric irritation, constipation, diarrhea, acute pancreatitis, jaundice • GU: Polyuria, nocturia, glycosuria,
Nursing Consideration CLINICAL ALERT! Name confusion has occurred between furosemide and torsemide; use extreme caution. • Administer with food or milk to prevent GI upset. • Reduce dosage if given with other antihypertensive s; readjust dosage gradually as BP responds. • Give early in the day so that increased urination will not disturb sleep. • Avoid IV use if oral use is at all possible. • Do not mix parenteral solution with highly acidic solutions with pH below 3.5. Do not expose to light, may discolor tablets or solution;
Indication/Dosages • maintenance dose to lowest effective level. • Pulmonary edema: 1 mg/kg IV or IM. May increase by 1 mg/kg in 2 hr until the desired effect is seen. Do not exceed 6 mg/kg.
Adverse Effect • urinary bladder spasm • Hematologic: Leukopenia, anemia, thrombocytopen ia, fluid and electrolyte imbalances • Other: Muscle cramps and muscle spasms
Nursing Consideration • do not use discolored drug or solutions. • Discard diluted solution after 24 hr. • Refrigerate oral solution. • Measure and record weight to monitor fluid changes. • Arrange to monitor serum electrolytes, hydration, liver function. • Arrange for potassium-rich diet or supplemental potassium as needed.
Drug Name spironolactone (speer on oh lak' tone) Aldactone, Novospiroton (CAN) Drug classes Potassium-sparing diuretic Aldosterone antagonist Therapeutic actions Competitively blocks the effects of aldosterone in the renal tubule, causing loss of sodium and water and retention of potassium.
Indication/Dosages • Diagnosis and maintenance of primary hyperaldosteroni sm • Adjunctive therapy in edema associated with CHF, nephrotic syndrome, hepatic cirrhosis when other therapies are inadequate or inappropriate • Treatment of hypokalemia or prevention of hypokalemia in patients who would be at high risk if hypokalemia occurred: Digitalized patients, patients with cardiac arrhythmias • Essential hypertension, usually in combination with other drugs • Unlabeled uses: Treatment of hirsutism due to its antiandrogenic properties, palliation
Contraindication • Contraindicated with allergy to spironolactone, hyperkalemia, renal disease, anuria, amiloride or triamterene use. • Use cautiously with pregnancy, lactation.
Adverse Effect • CNS: Dizziness, headache, drowsiness, fatigue, ataxia, confusion • Dermatologic: Rash, urticaria • GI: Cramping, diarrhea, dry mouth, thirst, vomiting. • GU: Impotence, irregular menses, amenorrhea, postmenopausal bleeding • Hematologic: Hyperkalemia, hyponatremia, agranulocytosis • Other: Carcinogenic in animals, deepening of the voice, hirsutism, gynecomastia
Nursing Consideration • Mark calendars of edema outpatients as reminders of alternate day or 3- to 5-day/wk therapy. • Give daily doses early so that increased urination does not interfere with sleep. • Make suspension as follows: Tablets may be pulverized and given in cherry syrup for young children. This suspension is stable for 1 mo if refrigerated. • Measure and record regular weight to monitor mobilization of edema fluid. • Avoid giving food rich in potassium. • Arrange for regular evaluation of serum electrolytes, BUN.
Indication/Dosages • of symptoms of PMS, treatment of familial male precocious puberty, shortterm treatment of acne vulgaris Available forms Tablets—25, 50, 100 mg PEDIATRIC PATIENTS • Edema: 1– 3.3 mg/kg/da y PO adjusted to patient's response, administered as single or divided dose.
Drug Name albuterol sulfate (al byoo' ter ole) AccuNeb, Novo-Salmol (CAN), Proventil, Proventil HFA, Proventil Repetabs, Salbutamol (CAN), Ventodisk (CAN), Ventolin, Ventolin HFA, Volmax
Indication/Dosages • Relief and prevention of bronchospasm in patients with reversible obstructive airway disease • Inhalation: Treatment of acute attacks of bronchospasm • Prevention of exercise-induced Pregnancy Category C bronchospasm • Unlabeled use: Drug classes Adjunct in treating Sympathomimetic drug serious hyperkalemia Beta2-selective adrenergic in dialysis patients; agonist seems to lower Bronchodilator potassium Antiasthmatic concentrations when inhaled by patients on Therapeutic actions hemodialysis In low doses, acts relatively Available forms selectively at beta2Tablets-2, 4 mg; ER adrenergic receptors to tablets-4, 8 mg; syrupcause bronchodilation and 2 mg/5 mL; aerosolvasodilation; at higher 90 mcg/actuation; doses, beta2 selectivity is solution for inhalationlost, and the drug acts at 0.083%, 0.5%, beta2 receptors to cause 1.25 mg/3 mL, typical sympathomimetic 0.63 mg/3 mL; capsules cardiac effects. for inhalation-200 mcg Drug Name Indication/Dosages PEDIATRIC PATIENTS Oral, tablets • 6–12 yr: 2 mg tid– qid. Do not exceed 24 mg/day. • > 12 yr: Use adult dosage. ER tablets
Contraindication • Contraindicated with hypersensitivity to albuterol; tachyarrhythmias, tachycardia caused by digitalis intoxication; general anesthesia with halogenated hydrocarbons or cyclopropane (these sensitize the myocardium to catecholamines); unstable vasomotor system disorders; hypertension; coronary insufficiency, CAD; history of stroke; COPD patients with degenerative heart disease. • Use cautiously with diabetes mellitus (large IV doses can aggravate diabetes and ketoacidosis); hyperthyroidism; history of seizure
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Adverse Effect CNS: Restlessness, apprehension, anxiety, fear, CNS stimulation, hyperkinesia, insomnia, tremor, drowsiness, irritability, weakness, vertigo, headache CV: Cardiac arrhythmias, tachycardia, palpitations, PVCs (rare), anginal pain Dermatologic: Sweating, pallor, flushing GI: Nausea, vomiting, heartburn, unusual or bad taste GU: Increased incidence of leiomyomas of uterus when given in higher than human doses in preclinical studies Respiratory: Respiratory difficulties, Adverse Effect pulmonary edema, coughing, bronchospasm, paradoxical airway resistance with repeated, excessive use of inhalation preparations
Nursing Consideration • Use minimal doses for minimal periods; drug tolerance can occur with prolonged use. • Maintain a betaadrenergic blocker (cardioselective beta-blocker, such as atenolol, should be used with respiratory distress) on standby in case cardiac arrhythmias occur. • Prepare solution for inhalation by diluting 0.5 mL 0.5% solution with 2.5 mL normal saline; deliver over 5–15 min by nebulization. • Do not exceed recommended dosage; administer pressurized inhalation drug forms during second half of inspiration, because the airways Nursing Consideration • are open wider and the aerosol distribution is more extensive.
Contraindication • disorders; • psychoneurotic individuals; labor and delivery (oral use has delayed second stage of labor; parenteral use of beta2-adrenergic agonists can accelerate fetal heart
Indication/Dosages exceed 24 mg/day in divided doses. • > 14 yr: Use adult dosage. Inhalation • 2–12 yr: For child 10–15 kg, use 1.25 mg; for child > 15 kg, use 2.5 mg. • > 12 yr: Use adult dosage. Solution for inhalation • 10–15 kg: 1.25 mg bid–tid by nebulization. • > 15 kg: 2.5 mg bid–tid by nebulization. Inhalation capsules • > 4 yr: One 200 mcg capsule inhaled q 4–6 hr. Prevention of exerciseinduced asthma: One 200 mcg capsule inhaled 15 min before exercise.
Drug Name Paracetamol acetaminophen (Nacetyl-paminophenol) Drug classes Antipyretic Analgesic (nonopioid) Therapeutic actions Antipyretic: Reduces fever by acting directly on the hypothalamic heat-regulating center to cause vasodilation and sweating, which helps dissipate heat. Analgesic: Site and mechanism of action unclear. •
Indication/Dosages Analgesic• antipyretic in patients with aspirin allergy, • hemostatic disturbances, bleeding diatheses, upper GI disease, gouty arthritis • Arthritis and rheumatic disorders involving musculoskeletal pain (but lacks clinically significant antirheumatic and anti-inflammatory effects) • Common cold, flu, other viral and bacterial infections with pain and fever Unlabeled use: prophylactic for children receiving DPT vaccination
Contraindication Contraindicated with allergy to acetaminophen. Use cautiously with impaired hepatic function, chronic alcoholism, pregnancy, lactation. • •
Adverse Effect CNS: Headache CV: Chest pain, dyspnea, myocardial damage when doses of 5–8 g/day are ingested daily for several weeks or when doses of 4 g/day are ingested for 1 yr GI: Hepatic toxicity and failure, jaundice GU: Acute kidney failure, renal tubular necrosis Hematologic: Methemoglobinemia —cyanosis; hemolytic anemia—hematuria, anuria; neutropenia, leukopenia, pancytopenia, thrombocytopenia, hypoglycemia Hypersensitivity: Rash, fever
Nursing Consideration • • Do not exceed the recommended dosage. Consult physician if needed for children < 3 yr; if needed for longer than 10 days; if continued fever, severe or recurrent pain occurs (possible serious illness). Avoid using multiple preparations containing acetaminophen. Carefully check all OTC products. Give drug with food if GI upset is noted. Discontinue drug if hypersensitivity reactions occur. Treatment of overdose: Monitor serum levels regularly, Nacetylcysteine should be available as a specific antidote; basic life support measures may be necessary.
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Indication/Dosages • to reduce incidence of fever and pain PEDIATRIC PATIENTS PO or PR Doses may be repeated 4–5 times/day; do not exceed five doses in 24 hr; give PO or by suppository. Age 0–3 mo 4–11 mo 1–2 yr 2–3 yr 4–5 yr 6–8 yr 9–10 yr 11 yr Dosage (mg) 40 80 120 160 240 320 400 480
Drug Name Suprax Generic name: Cefixime
Indication/Dosages Suprax, a cephalosporin antibiotic, is prescribed for bacterial infections of the lungs, ears, urinary tract, and throat. It is also used to treat uncomplicated gonorrhea.
Contraindication If you are allergic to either penicillin or cephalosporin antibiotics in any form, consult your doctor before taking Suprax. An allergy to either type of medication may signal an allergy to Suprax, and if a reaction occurs, it could be extremely severe. If you take the drug and feel signs of a reaction, seek medical attention immediately. Do not take Suprax if you are sensitive to or have ever had an allergic reaction to the drug or to other cephalosporin antibiotics.
Adverse Effect Side effects cannot be anticipated. If any develop or change in intensity, tell your doctor as soon as possible. Only your doctor can determine if it is safe for you to continue taking this drug. Side effects may include: abdominal pain, gas, indigestion, loose stools, mild diarrhea, nausea, vomiting
Nursing Consideration If you are taking Suprax once a day and you forget to take a dose, take it as soon as you remember. Wait at least 10 to 12 hours before taking your next dose, then return to your regular schedule. If you are taking Suprax 2 times a day and you forget to take a dose, take it as soon as you remember and take your next dose 5 to 6 hours later. Then go back to your regular schedule. If you are taking Suprax 3 times a day and you forget to take a dose, take it as soon as you remember and take your next dose 2 to 4 hours later. Then return to your
Nursing Consideration regular schedule. The nurse should always remember the following: Suprax liquid may be kept for 14 days, either at room temperature or in the refrigerator. Keep the bottle tightly closed and do not store in damp places. Keep away from direct light and heat. Discard any unused Suprax after 14 days.
Drug Name Baclofen Muscle Relaxants
Indication/Dosages Severe chronic spasticity. PO 5 mg 3 times/day for 3 days, increased to 10 mg 3 times/day for 3 days. May further increase if needed. Max: 100 mg/day. Intrathecal Test dose: 25 or 50 mcg. Increase dose by 25 mcg not more often than 24 hrly until 100 mcg/dose to determine appropriate dose. Responders w/ response lasting >8-12 hr, the test dose that was used to produce the response can be given as a 24-hr infusion; if the response lasted ≤8-12 hr, then a dose equivalent to twice the test dose is given.
Contraindication Hypersensitivity. Active peptic ulcer disease.
Adverse Effect Nursing Consideration The most common • Abrupt Drug adverse reaction during Withdrawal treatment with baclofen Hallucinations and is transient drowsiness seizures have (10-63%). In one occurred on abrupt controlled study of 175 withdrawal of patients, transient baclofen. Therefore, drowsiness was observed except for serious in 63% of those receiving adverse reactions, the baclofen tablets dose should be compared to 36% of reduced slowly when those in the placebo the drug is group. Other common discontinued. adverse reactions are • Impaired Renal dizziness (5-15%), Function weakness (5-15%) and Because baclofen is fatigue (2-4%). Others primarily excreted reported: unchanged by the Neuropsychiatric: kidneys, it should be Confusion (1-11%), given with caution headache (4-8%), and it may be insomnia (2-7%); and, necessary to reduce rarely, euphoria, the dosage in patients excitement, depression, with impaired renal hallucinations, function. paresthesia, muscle pain, tinnitus, slurred speech, coordination disorder, tremor,
rigidity, dystonia, ataxia, • Stroke blurred vision, nystagmus, Baclofen has not strabismus, miosis, mydriasis, significantly diplopia, dysarthria, epileptic benefited patients seizure. with stroke. These Cardiovascular: Hypotension patients have also (0-9%). Rare instances of shown poor dyspnea, palpitation, chest tolerability to the pain, syncope. drug. Gastrointestinal: Nausea (412%), constipation (2-6%); and, rarely, dry mouth, anorexia, taste disorder, abdominal pain, vomiting, diarrhea, and positive test for occult blood in stool. Genitourinary: Urinary frequency (2-6%); and, rarely, enuresis, urinary retention, dysuria, impotence, inability to ejaculate, nocturia, hematuria. Adverse Effect Nursing Consideration Other: Instances of rash, pruritus,drug therapy. The than to ankle edema, excessive perspiration, weight following laboratory tests gain, nasal congestion. Some have been found to be of the CNS andfew abnormal in a genitourinary symptoms may be related to patients receiving the underlying disease rather baclofen: increased SGOT, elevated alkaline phosphatase, and elevation of blood sugar. The adverse experience profile seen with KEMSTRO™ was similar to that seen with baclofen tablets.
Drug Name Zosyn (piperacillin tazobactam) Injection To reduce the development of drugresistant bacteria and maintain the effectiveness of Zosyn (piperacillin and tazobactam) injection and other antibacterial drugs, Zosyn (piperacillin and tazobactam) should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria.
Indication/Dosages Contraindication Zosyn (piperacillin contraindicated in and tazobactam for patients with a injection) is history of allergic indicated for the reactions to any of treatment of patients the penicillins, with moderate to cephalosporins, or severe infections β-lactamase caused by inhibitors piperacillinresistant, piperacillin/tazobact am-susceptible, βlactamase producing strains of the designated microorganisms in the specified conditions listed below:
Adverse Effect Autonomic nervous system hypotension, ileus, syncope Body as a whole rigors, back pain, malaise In the Cardiovascular tachycardia, including supraventricular and ventricular; bradycardia; arrhythmia, including atrial fibrillation, ventricular fibrillation, cardiac arrest, cardiac failure, circulatory failure, myocardial infarction Central nervous system - tremor, convulsions, vertigo
Nursing Consideration Careful inquiry should be made concerning previous hypersensitivity reaction, as serious and occasionally fatal anaphylactic/anaphylac toid reactions (including shock) have been reported in patients receiving therapy with penicillins including ZOSYN The nurse should know that periodic assessment of organ system functions, including renal, hepatic, and hematopoietic, during prolonged therapy is advisable because ZOSYN possesses the characteristic low toxicity of the penicillin group of antibiotics
Adverse Effect The The whole MFN Gastrointestinal melena, flatulence, hemorrhage, gastritis, hiccough, ulcerative stomatitis Hypersensitivity anaphylaxis Metabolic and Nutritional symptomatic hypoglycemia, thirst Musculoskeletal myalgia, arthralgia Platelets, Bleeding, Clotting mesenteric embolism.
Drug Name Meropenem I.V.
Indication/Dosages To reduce the development of drug-resistant bacteria and maintain the effectiveness of MERREM I.V. and other antibacterial drugs, MERREM I.V. should only be used to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria. When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility
Contraindication Patients with known hypersensitivity to any component of this product or to other drugs in the same class or in patients who have demonstrated anaphylactic reactions to βlactams.
Adverse Effect Nursing Consideration MERREM I.V. was The safety and studied in 515 pediatric effectiveness of patients ( ≥ 3 months to MERREM I.V. have < 13 years of age) with been established for serious bacterial pediatric patients ≥ 3 infections (excluding months of age. meningitis. See next Use of MERREM I.V. section.) at dosages of in pediatric patients 10 to 20 mg/kg every 8 with bacterial hours. The types of meningitis is supported clinical adverse events by evidence from seen in these patients adequate and wellare similar to the controlled studies in the adults, with the most pediatric population. common adverse Use of MERREM I.V. events reported as in pediatric patients possibly, probably or with intra-abdominal definitely related to infections is supported MERREM I.V. and by evidence from their rates of adequate and welloccurrence as follows: controlled studies with Diarrhea 3.5%, Rash1.6%, Nausea and Vomiting 0.8% MERREM I.V. was studied in 321 pediatric patients ( ≥ 3 months to < 17 years of age) with meningitis at a dosage of 40 mg/kg every 8 hours. The types of
Indication/Dosages patterns may contribute to the empiric selection of therapy. MERREM I.V. is indicated as single agent therapy for the treatment of the following infections when caused by susceptible isolates of the designated microorganisms F.
Adverse Effect clinical adverse events seen in these patients are similar to the adults, with the most common adverse events reported as possibly, probably, or definitely related to MERREM I.V. and their rates of occurrence as follows: Diarrhea 4.7%, Rash (mostly diaper area moniliasis), Glossitis 1.0%
Drug Name Heraclene Dibencozide Classification: A15 - Appetite Enhancers
Indications/Dosages For Premature babies. Low birth weight. Retarded growth. Poor appetite in infants, children and adults. Adjuvant to treatment of tuberculosis and other chronic ailments. Convalescence from acute infection or surgery. Faulty nutrition in older people. Premature Babies, Infants: 1 cap daily (the capsule may be opened and the odorless, tasteless powder mixed with milk or juice).
Contraindications No known effect noted
Adverse Effects No known effect noted
Nursing Considerations Treatment must be continuous for 2-6 weeks. The initial sign of its effectiveness is manifested by a marked increase in appetite.
Milrinone Classification: Cardiac Drugs/ phosphodiesterase inhibitors
Short-term management of severe heart failure, Acutely decompensated heart failure Child: Initial loading dose of 75 mcg/kg by IV injection over 10-60 min followed by continuous infusion of 0.50.75 mcg/kg/min.
Heart valve stenosis, acute myocardial infarction
Angina-like chest pain, headache, hypokalaemia, tremor, thrombocytopenia, bronchospasm. Potentially Fatal: Supraventricular and ventricular arrhythmias; hypotension.
Improved cardiac output may increase urine output, reduced diuretic dosage when heart failure improves. Potassium lost may cause digitalis toxicity. Monitor fluid & electrolyte status & vital signs. Excessive decrease in BP. Requires stopping the infusion.
Drug Name Methylprednisolone Classification: Corticosteroid Hormones/ glucocorticoids
Indication/Dosages Suppression of inflammatory & allergic disorders, cerebral edema, rheumatic disease; immunosuppressant in spinal cord injury. Children: give 0.117 to 1.66 mg/kg or 3.3 to mg/m2 PO. Daily in 3 doses.
Contraindications Systemic mycoses. Septic shock.
Adverse Effects Fluid & electrolyte balance disturbance; musculoskeletal system effects; GI effects; skin reactions; -ve nitrogen balance due to protein catabolism; nervous system effects, seizures, psychic disorders; endocrine system disorders; immune system suppression
Nursing Considerations Determine whether pt. is sensitive to other corticosteroids, for better result and less toxicity, give once daily dose in the morning. Measure growth & dev. Periodically in children during high dose or prolonged treatment. Monitor pt. wt, BP. Electrolyte level and sleep patterns, Euphoria may initially interfere with sleep, but pt. adjust typical in 1-3 weeks. Always adjust to lowest effective dose.
Drug Name MANNITOL Classification: Diuretics/ Solutions producing osmotic diuresis
Indication/Dosages Contraindication IV Renal function Pulmonary test 0.2 g/kg over 3congestion or 5 mins. Oliguric oedema; phase of renal intracranial failure 50-100 g in a bleeding; CHF; 24-hr period via metabolic infusion; adjust rate oedema with to maintain a urine abnormal flow of ≥30-50 capillary mL/hr. Raised fragility; anuria intracranial due to severe pressure; Raised renal disease; intraocular pressure; severe Cerebral oedema dehydration. 0.25-2 g/kg over 3060 mins. Transurethral prostatic resection Use 2.5-5% soln for bladder irrigation
Adverse Effect Fluid and electrolyte imbalance; acidosis (with high doses). Nausea, vomiting, thirst; headache, dizziness, convulsions, chills, fever; tachycardia, chest pain; blurred vision; urticaria and hypotension or hypertension; acute renal failure; skin necrosis; thrombophloebitis.
Nursing Consideration Hypervolaemia; urinary tract obstruction; check for signs of fluid and electrolyte imbalance. Should not be administered with whole blood. Pregnancy, lactation. Monitor I/O, BP.& wt.
Drug Name Dexamethasone Classification: Corticosteroid Hormones/ Glucocorticoids Used in systemic corticosteroid preparations.
Indication/Dosages Contraindication Asthma & Neonate & related infant. bronchospastic disorder unresponsive to other therapy, allergic rhinitis, inflammatory nasal condition. Also used in cerebral edema due to malignancy.
Adverse Effect Risk of osteoporosis & spontaneous fracture, muscle wasting, nitrogen depletion, hyperglycemia. Increased insulin requirement in diabetics, increased appetite. hyperhidrosis, skin thinning, ocular changes including development of glaucoma & cataract, neurological disturbances, benign intracranial HTN, acute pancreatitis, avascular necrosis of the bone. Increased blood coagulation that may lead to thromboembolic complication. Peptic ulcer. Adrenal atrophy, secondary adrenocortical insufficiency. Paresthesia & irritation, epidural lipomatosis.
Nursing Consideration Caution use in heart failure, recent MI, HTN, DM, epilepsy, glaucoma, hypothyroidism, hepatic failure, osteoporosis, peptic ulcer, psychoses, severe affective disorders, renal impairment. Reduce CA & K intake. Monitor fluid intake & output, & wt daily. Rapid IV inj of massive dose may cause CV collapse. Childn. Elderly.
Drug Name Midazolam Classification: Hypnotics and sedatives
Indication/Dosages Disturbances of sleep rhythm, insomnia esp difficulty in falling asleep either initially or after premature awakening. Tab/Inj Sedation in premed before surgical or diagnostic procedures, induction & maintenance of anesth. Neonates less than 32 weeks gestational age; initially 0.03 mg/kg/hr
Contraindication Premature infants. Myasthenia gravis.
Adverse Effect Rarely cardioresp adverse events, nausea, vomiting, headache, hiccoughs, laryngospasm, dyspnoea, hallucination, oversedation, drowsiness, ataxia, rash, paradoxical reactions, amnesic episodes.
Nursing Consideration Have O2 and resuscitation equipment available in case of severe respiratory depression. Continiously monitor BP. HR. RR. Airway integrity and arterial O2saturation during procedure. When inj. Give IM. Deeply into a large muscle
Drug Name Epinephrine HCl Classification: Cardiac Drugs
Indication/Dosages Cardiac stimulant in case of collapse, shock & anesthetic accidents. Hemostatic in hemorrhages. Prolongs action of infiltration anesthetic agent. Urticaria. Childn 10 mcg/kg body wt or 300 mcg/m2 body surface up to 500 mcg/dose, repeated as necessary up to 6 times a day.
Contraindication Cardiac arrhythmia, tachycardia >140 bpm, severe HTN, narrow angle glaucoma, anesth w/ halogenated hydrocarbon of cyclopropane, w/ local anesth of finger or toe, woman in labor, cardiac dilation & coronary insufficiency.
Adverse Effect CNS: drowsiness, headache, nervousness, tremor, cerebral hemorrhage, stroke, vertigo, pain disorientation, agitation, fear, dizziness, weakness. Palpitations, ventricular fibrillation, shock, widened pulse pressure, hypertension, tachycardia, angina, altered ECG, decrease T-wave GI: nausea, vomiting RESP:Dyspnea Skin: urticaria, hemorrhage at inj. site, pallor.
Nursing Consideration Drug interferes with tests for urinary catecholamines. Drug of choice in emergency treatment of acute anaphylactic reactions. Observe pt. closely for adverse reaction, adjust dosage or stop drug if necessary. One mg. equals 1ml of 1:1000 solution or 10 ml of 1:10,000 solution. When treating pt. with reactions caused by other drugs given IM. Or subcutaneously, inject this drug into the site where the other drug was given to minimize further absorption.
Drug Name Phenobarbital Classification: anticonvulsant
Indication/Dosages Partial seizures/ anti convulsants
Contraindication Severe renal and hepatic disorders. Severe respiratory depression, dyspnoea or airway obstruction; porphyria. Pregnancy.
Adverse Effect Bradycardia, hypotension, syncope; drowsiness, lethargy CNS excitation or depression, impaired judgment, hangover effect, confusion, somnolence, agitation, hyperkinesia, ataxia, nervousness, headache, insomnia, nightmares, hallucinations, anxiety, dizziness; Skin:rash, exfoliative dermatitis; GI: nausea, vomiting, constipation; agranulocytosis, thrombocytopenia, megaloblastic anaemia; pain at inj site, thrombophlebitis (IV); oliguria: laryngospasm, respiratory depression, apnoea (especially with rapid IV admin),
Nursing Consideration Therapeutic level is 15-40 mcg/ml. Watch signs for barbiturate toxicity; coma, cyanosis, asthmatic breathing, clammy skin, and hypotension. Don’t stop drug abruptly because this may worsen seizure. Drg. May decrease bilirubin level in neonates, pt. with epilepsy, and those with congenital nonhemolytic, unconjigated bilirubinia. Elderly or debilitated patients, children. Withdraw gradually. Impaired renal, hepatic and respiratory function. Patients with acute pain and depressive disorders. May impair ability to drive or operate machinery. Lactation. Symptoms: Unsteady
Adverse Effect hypoventilation. Potentially Fatal: Stevens-Johnson syndrome.
Nursing Consideration gait, slurred speech, confusion, jaundice, hypothermia, hypotension, respiratory depression, coma. Management: Charcoal haemoperfusion (in severe cases). Treatment is symptomatic and supportive. Special Precautions Extravasation. Patient w/ profound hypoxia or hypercarbia. Concomitant MAOI or tricyclic antidepressant. Hypersensitivity to sulfites. Monitor BP.
Levophed Classification: Vasoconstrictors/ adrenergic and dopaminergic cardiac stimulants
Used in the treatment of heart failure
Patients who are hypotensive from blood vol deficits except as emergency measure. Concomitant cyclopropane & halothane anesth. Patient w/ mesenteric or peripheral vascular thrombosis unless it is lifesaving.
Bradycardia, arrhythmias; anxiety, transient headache. Plasma vol depletion (prolonged administration). Resp difficulty, ischemic injury.
Drug Name Ca. Gluconate Classification: Electrolytes
Indication/Dosages Drugs for fluid and electrolyte balance /electrolyte replacement solutions.
Contraindication Patients with calcium renal calculi or history of renal calculi. Conditions associated with hypercalcaemia and hypercalciuria. Special Precautions: Impaired renal function; cardiac disease; hypercalcaemiaassociated diseases, e.g. sarcoidosis; other malignancies. Pregnancy.
Adverse Effect GI irritation; softtissue calcification, skin sloughing or necrosis after IM/SC inj. Hypercalcaemia characterised by anorexia, nausea, vomiting, constipation, abdominal pain, muscle weakness, mental disturbances, polydipsia, polyuria, nephrocalcinosis, renal calculi; chalky taste, hot flushes and peripheral vasodilation. Potentially Fatal: Cardiac arrhythmias and coma.
Nursing Consideration Double-check that you are giving the correct form of calcium; resuscitation cart may contain both calcium gluconate and ca. chl. Monitor Ca. levels frequently; maintain Ca. level of 9 to 10.4 mg/dl. Hypercalcemia may result after large doses in chronic renal failure. Report abnormalities Sx/s. of severe hypercalcemia may include stupor, confusion, delirium and coma.
Drug Name Dobutamine Classification: Cardiac Drugs/ adrenergic and dopaminergic cardiac stimulants
Indication/Dosages Contraindication Used in the Idiopathic treatment of heart hypertrophic failure subaortic stenosis & Inotropic support in patients w/ the short-term known allergy to treatment of cardiac corn or corn decompensation due products. to depressed contractility resulting either from organic heart disease or cardiac surgical procedures. Long-term treatment of CHF. Start at a low rate of 0.5-1 mcg/kg/min & titrate at intervals of a few min. Usual optimal infusion rate 2-20 mcg/kg/min. Max: 40 mcg/kg/min.
Adverse Effect Increased heart rate, BP & ventricular ectopic activity; hypotension.Phlebitis at IV inj sites.
Nursing Consideration Special Precautions May cause marked increase in heart rate or BP. Patients w/ atrial fibrillation are at risk of developing rapid ventricular response; w/ preexisting HTN are at increased risk of exaggerated pressor response. Continuously monitor BP & ECG as well as pulmonary wedge pressure & cardiac output. Hypovolemia should be corrected. Patients w/ subclinical or overt DM. Pregnancy & lactation, childn & elderly.
Drug Name Citicoline Classification: Nootropics & Neurotonics
Indication/Dosages IV/IM Parkinson's disease; Cerebrovascular disorders and head injury
Contraindication Contraindicated in conditions like unconsciousness and brain surgery
Adverse Effect Stop taking your medicine right away and talk to your doctor if you have any of the following side effects. Allergic reaction: Itching or hives, swelling in your face or hands, swelling or tingling in your mouth or throat, chest tightness, trouble breathing, or rash. Other Side Effects: You may have the following side effects, but this medicine may also cause other side effects. Tell your doctor if you have side effects that you think are caused by this medicine. Low blood pressure (faintness, dizziness) Slow or fast heart beat Headache Nausea, vomiting, or diarrhea (loose BMs)
Nursing Consideration Before taking citicoline, tell your doctor if you are pregnant or breast feeding
Drug Name Vancomycin HCl Classification: Antibiotics glycopeptide antibacterials
Indication/Dosages Used in the treatment of systemic infections Treatment of methicillin-resistant staphylococcal infections; in conditions eg brain abscess, staphylococcal meningitis, peritonitis associated w/ continuous peritoneal dialysis & septicemia. Children Single dose of 20 mg/kg Intestinal & hepatic amoebiasis Childn 40-50 mg/kg body wt in 3 divided doses for 5-7 consecutive days. Treatment may be continued up to 10 days if deemed necessary in severe cases. Giardiasis Childn >10 yr 2 tsp qid for 5 consecutive days. 4-9 yr 1-1½tsp, 1-3 yr 1 tsp.
Contraindication Hypersensitivity to vancomycin
Adverse Effect Erythema, flushing or rash over the face & upper torso, hypotension & shocklike symptoms. Hypersensitivity reactions eg rashes, fever & chills.
Nursing Consideration Do not inject IM & care should be taken when given IV to avoid extravasation due to risk of tissue necrosis.
Metronidazole Classification: Imidazole derivative antibacterials/Antia moebics
History of blood dyscrasia
GI:Nausea, headache, anorexia. Occasionally, vomiting, diarrhea, epigastric cramping, constipation, mild leukopenia.
Observe pt. for edema, especially if he’s receiving corticosteroids; Flagyl IV RTU may cause sodium retention Record number of character of stools when drug is used to treat amebiasis.
Drug Name Amikacin sulfate Classification: Aminoglycosides
Indication/Dosages Contraindication Indicated for; Hypersensitivity Bacterial septicemia to including neonatal aminoglycosides sepsis. Serious infections . of the resp tract. Infections of the bone & joints. Intra-abdominal infections including peritonitis. Burns & post-op infections. Serious & complicated UTI due to susceptible organisms. As initial therapy in suspected gm-ve infections before the results of susceptibility testing are obtained. In mixed, gm-ve, staph infections & other gm+ve organism eg Strep & pneumococci. Adult, childn & older infant 7.5 mg/kg 12 hrly or 5 mg/kg 8 hrly.
Adverse Effect Dehydration, renal dysfunction, neuromuscular disorders, premature & neonatal infants. Auditory, vestibular, renal toxicity & neuromuscular blockade. Rash, drug fever, headache, paresthesia, tremor, nausea & vomiting, eosinophilia, arthralgia, anemia & hypotension.
Nursing Consideration Obtain specimen for culture and sensitivity tests before giving first dose. Therapy may begin while awaiting results. Weigh Pt. and review renal function studies before therapy begins Correct dehydration before therapy begins, because of increase risk of toxicity Monitor renal function, urine output, specific gravity, BUN & creatinine clearance. Watch for S/sx of super infection, URT, such as continued fever, chills & increase pulse rate. Peak drug levels more than 10 mcg/ml may be linked to higher risk of toxicity.
Drug Name Mupirocin Classification: Topical Antibiotics
Indication/Dosages Treatment of primary (impetigo, folliculitis, furunculosis, ecthyma) & secondary skin infections (infected abrasions & insect bites, minor wounds & burns) due to susceptible organisms. Prevention of contamination of small cuts, wounds, abrasions, incisions & other lesions. Apply a small amount on affected area tid for up to 10 days.
Contraindication Hypersensitivity to drug
Adverse Effect Burning, stinging or pain. Itching. Rash, erythema, dry skin, tenderness, swelling, contact dermatitis, increased exudate.
Nursing Consideration Avoid contact w/ eyes. Prolonged use. Discontinue if sensitivity occurs
NURSING CARE PLAN
Date/Cues Objective Data: -Thick tenacious secretions (+) rhonchi (+) crackles -Restlessness -Irritability RR: 80s breathes/min Subjective Data: “Sobrang mahalak pa din siya, kapag humihinga siya rinig na rinig ko” as verbalized by the mother
Analysis of the Problem Nursing Diagnosis: Ineffective airway clearance related to excessive secretions as evidenced by rhonchi and crackles upon auscultation Scientific Implication: Ineffective airway clearance will lead to imbalanced ventilation-perfusion ratio leading to inadequate systemic oxygen circulation
Goal & Objectives After one hour of nursing intervention: The client’s secretions will be decreased enabling the client to have improved breath sounds and patent airway.
Nursing Interventions Encourage warm versus cold liquids as appropriate Keep environment pollutant free Elevate head of the bed/change positions every 2 hours and PRN
Rationale Warm liquids relaxes airway and loosens secretions To reduce irritant effect on airways To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage & ventilation of different lung segments To clear away secretions Promotes drainage of secretions
Evaluation After one hour the nurse was able to clear the client’s secretions manifested by decreased crackles on auscultation. The client’s parents verbalized understanding of the nurse’s health teaching regarding use of warm versus cold liquids and maintaining a pollutant-free environment. Interdisciplinary collaboration in accordance with medication coverage and nebulization were facilitated.
The client’s parents will verbalize understanding with the health teachings to maintain a patent airway and Suction naso/oral become involved secretions PRN in patient care. Use Chest The client will Physiotherapy as have a patent indicated airway
The client’s retained secretions will be removed. The client will demonstrate reduction/ absence of congestion with breathe sounds clear and respirations noiseless. Facilitate coordination with other members of the health care team for interdisciplinary approach.
Maintain adequate I/O and avoid fluid overload
To monitor fluid balance
Accurately regulate IV To prevent fluid fluid as ordered using overload a syringe pump Administer To treat underlying medications as ordered condition Facilitate referral to respiratory therapist for nebulization For interdisciplinary collaboration. For tenacious secretions to be liquefied for easier suctioning.
Analysis of the problem Ineffective cardiopulmonary tissue perfusion related to impaired cardiac function and increased cardiac workload
Goal and objectives After one hour of nursing intervention, the patient’s arterial blood gas, oxygen saturation and blood pressure will gradually improve.
Objective data: -Arterial BP: 50/46 mmHg -ABG result: Respiratory Acidosis pH-7.24 pCo2-64 pO2-24 HCo3-27 -Oxygen Saturation: 31.8Very severe hypoxemia -Pale -Dyspneic -Lungs with harsh rhonchi and crackles on auscultation
Assessed patient’s vital signs including heart rate, pulse, and respirations. Auscultated heart and lung sounds
Vital signs and heart and lung sounds are important indicators for overall heart function Supplemental oxygen enhances tissue perfusion without increasing the child’s metabolic oxygen demand Arterial blood gases and pulse oximetry provide information about the status of tissue oxygenation Continuous cardiac monitoring provides objective
Administered supplemental oxygen as ordered
Monitored arterial blood gas values and oxygen saturation levels via pulse oximetry Institute continuous cardiac monitoring as ordered
After one hour of nursing intervention, the patient’s arterial blood gas, oxygen saturation and blood pressure gradually improveded as evidenced by: -ABG result of: pH-7.30 Co2-54 pO2-42 HCo3-29 -Blood pressure: 80/55 -Oxygen saturation: 35
evidence of cardiac function, including changes indicative of ischemia. Removed any constricting clothing from the chest Constricting clothing interferes with chest expansion
Limit procedures to those that are necessary and Activity increases provide adequate rest metabolic and periods myocardial oxygen demands, further impairing cardiopulmonary tissue perfusion Administer medications, such as digoxin and Digoxin improves diuretics as ordered. myocardial Assess apical pulse prior contractility. to digoxin Diuretics reduce administration. Obtain fluid overload. Too serum digoxin levels as rapid or too slow a ordered. heart rate may indicate digoxin toxicity. Measuring serum digoxin level aids in evaluating the effectiveness of therapy and preventing digoxin toxicity.
Analysis of the problem Hyperthermia related to infection as evidence by temperature of 37.9°C
Goal and objectives After 4 hours of nursing care, the patient will maintain a normal body temperature.
Objective data: • Flushed skin; warm to touch • Restlessness • Vital signs as follows: T: 37.9°C HR: 152 RR: 33 BP: 85 / 63
Assess temperature hourly and other signs and symptoms.
To provide baseline data
Record every fluid intake To assess for signs and urine output. of dehydration. Promote surface cooling by rendering tepid sponge bath. Provide air conditioning or fan. Remove excess clothing and blankets. Maintain on comfortable position and provide rest periods. Administer prescribed antipyretics To decrease metabolic demand and oxygen consumption. To facilitate fast recovery. To reduce temperature by means of evaporation and conduction.
After 4 hours of nursing care, patient was able to maintain a normal body temperature.
Date/Cues Objective Data: - height: 57 cm -weight: 3.2 kg (ideal body weight: 4.2 kg) -Poor skin turgor -Pale conjunctiva and mucous membrane -with OGT tube
Analysis of the Problem Imbalanced nutrition less than body requirements related to feeding intolerance as evidenced by decrease in body weight appropriate for his age. Scientific Implication: Prolong NPO status may lead to low immunity, unmet nutritional needs and delay in growth
Goal & Objectives Demonstrate stable weight gain/progressive weight gain using age- appropriate measurements, including weight and body fluid, strength, activity level, sleep/rest cycles. To promote adequate infant intake
Nursing Interventions Determine appropriate method for feeding
Rationale Providing usual and typical feedings is important to infant well-being and early growth. Provides information about digestion/bowel function and may affect choice/timing of feeding. To determine the patient’s progressive weight gain To avoid aspiration and to assist in conserving energy demanded for sucking To increase his weight.
Evaluation After 4 days of nursing intervention the patient was able to tolerate a gradual increase of feeding of 60 ml every 3 hours After 4 days of nursing intervention, the patient’s weight progressed to 3.4 kg.
Auscultate bowel sounds. Note characteristics of stool (color, amount, frequency, and so on).
Weigh patient daily
Maintained the patency of the OGT
Feed the patient via OGT as orderd and tolerated
Review drug regimen, side effects, and potential interactions with other medications/over-thecounter drugs.
Timing of medication doses, interaction with certain foods can alter effect of medication or digestion/absorptio n of nutrients
Analysis of the Problem Nursing Diagnosis: Impaired skin integrity related to surgical intervention Scientific Implication: The skin layer is the largest multifunctional organ of the body. The alteration that resulted from iatrogenic interventions may compromise its ability to protect the body from infectious organisms and/or thermoregulation.
Goal & Objectives After 7 days of nursing intervention, the client will display timely healing of skin lesions without complication. The client will maintain physical well-being The client’s family will verbalize understanding of purpose and enumerate interventions in wound care The client’s wounds will be free of
Objective Data: Poststernotomy surgical incision site
Inspect skin on a daily basis, describing lesions and changes observed. Keep affected area clean and dry Cool, moist compresses to skin. Avoid use of soap because it tends to dry skin and make it more likely to breakdown. Assist the family in following medical regimen for the client and develop program of preventive care and daily maintenance. Daily wound care using sterile equipment and practicing aseptic technique in dressing.
To obtain baseline data To assist body’s natural process of repair Moisture potentiates skin breakdown.
The client displayed timely wound healing without any complication after the consistent and continuous interventions. The client’s parents’ verbalized understanding of the nurse’s varied health teaching regarding wound care. Interdisciplinary collaboration in accordance with medication therapy was facilitated.
Enhances commitment to plan, optimizing outcomes
To maintain skin integrity, promote timely wound healing, and
complication like purulent discharge from infection. The client’s family will participate in prevention measures and treatment program. Facilitate coordination with other members of the health care team for interdisciplinary approach.
Teach the parents the above interventions and rationale
prevent infection. To involve the client’s significant others in wound care and promote readiness and independence in care prior to discharge. To promote optimum recovery of the incision site.
Carry-out dependent interventions such as application of topical antibiotic ointment and timely, well regulated administration of intravenous antibiotic coverage. Endorse plan of care to receiving bedside nurse.
For interdisciplinary management and to make possible the continuity of care
Analysis of the problem Impaired parenting due to illness as evidenced by prolonged separation from sick child.
Goal and objectives At the end of the interaction, approximately 30 minutes, the mother will identify own strengths, parenting needs and methods to meet them.
Objective data: -Statements of the mother of her inability to meet child’s needs. -Verbalization of frustration on inadequacy of role as a parent. Subjective Data: “Hindi ko na maalagaan ang anak ko” as verbalized by the mother.
Note absence from home setting and the lack of infant supervision by the parent. Make time for listening to concerns of the parents and to acknowledge difficulty of the situation. Provide adequate visiting time for the parents.
To assess causative/ contributing factors.
After 30 minutes of nurse-parent reaction, the mother was able to identify methods on how to meet her parenting needs.
Enhances feeling of acceptance and expression of feelings. Create an environment for relationship to be developed and foster development of parenting skills. Facilitate satisfactory implementation of the plan.
Let parents participate in caring for their child and provide information appropriate to the situation, including limit
IX. BIBLIOGRAPHY WEBSITES: • • • • • • • • • • • • •
www.americanheart.org/presenter.jhtml?identifier=11074 en.wikipedia.org/wiki/Dextro-Transposition_of_the_great_arteries www.health.uab.edu/14585 cincinnatichildrens.org/health/.../anomalies/transposition.htm www.mayoclinic.org/corrected-transposition-great-arteries/about.html www.childrenshospital.org/az/Site511/mainpageS511P0.html rarediseases.info.nih.gov/GARD/Disease.aspx? PageID=4&diseaseID=7795 cnn.com/.../library/transposition-of-the-great-arteries/DS00733.html www.ojrd.com/content/3/1/27 circ.ahajournals.org/cgi/content/full/114/24/2699 yourtotalhealth.ivillage.com/transposition-great-arteries.html www.wikidoc.org/index.php/Transposition_of_the_great_vessels emedicine.medscape.com/article/900574-overview
• • • Maternal and Child Health : Programs, Problems, and Policy in Public Health, Second Edition (Hardcover)by Jonathan Kotch (Author) Nanda Nursing Diagnoses: Definitions and Classification 2005-2006 (Nanda Nursing Diagnosis) (Paperback) by Nanda (Editor) Lippincott's Nursing Procedures by Lippincott Williams & Wilkins Textbook (Hardcover-Fifth Edition) Pub. Date: May 2008
Lippincott’s Nursing: Deciphering Diagnostic Tests
Author(s): Springhou Pub Date: March 2007 Nurse's Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr Textbook (Paperback - New Edition) Pub. Date: January 2008