KATHMANDU UNIVERSITY

SCHOOL OF MEDICAL SCIENCES

DHULIKHEL, KAVRE

A CASE STUDY ON
“VENTRICULAR SEPTAL DEFECT WITH
SEVERE PULMONARY HYPERTENSION”

Submitted by:
Submitted to: Sudipta Ghimire
Mrs. Bhawana Regmi Roll no: 07
Nursing Lecturer B.Sc. Nursing 4th year
KUSMS 13th Batch
KUSMS

Date of submission:
ACKNOWLEDGEMENT
I would like to express my special thanks of gratitude to everyone who contributed to make this
case study success.
First of all, I would like to thank the KATHMANDU UNIVERSITY SCHOOL OF MEDICAL
SCIENCES, Dhulikhel for providing this marvelous opportunity to perform the case study as a
part of our curriculum of Critical Care Nursing B. Sc Nursing 4th Year Nursing
I am highly indebted to Manmohan Cardiothoracic Vascular and Transplant Center for
providing me Adult Critical Care Unit as a platform to do case study and to our respected
teacher, Mrs. Bhawana Regmi (Nursing Lecturer, KUSMS) for her constant guidance and
supervision as well as for providing necessary information regarding case study and also for
support in completing this case study. I am thankful to all the nursing staffs of AICU for their
immense support.
Moreover, I am very grateful to the patient, his family and relatives for co-operating with me and
providing information throughout the study period.
Last but not the least, my sincere thanks goes to all of my friends and seniors for their never
ending co-operation, encouragement and support. My thanks and appreciations also go to all the
people who directly or indirectly helped me out in completing this case study.
INTRODUCTION
I am SUDIPTA GHIMIRE, Bachelor of Sciences in Nursing 4 th year (13th Batch) student,
studying in Kathmandu University School of Medical Sciences. According to the curriculum of
B.Sc. Nursing 4th year, we have a total of 4 weeks posting in the Adult Critical Care
Unit/Pediatric Critical Care. During this period, we are supposed to do case study on any one
gynecology problems available in the ward. Likewise, I also performed case study on topic
“Ventricular Septal Defect with severe pulmonary artery Hypertension” in 6 months old
male patient. I chose this topic because it is one of the common problems that we encountered
during our posting in the PICU and it is an important disease that I believe we can learn more
about, if we observe and care for the patient in clinical settings.

I got an opportunity to provide holistic care to my patient for total 3 days and got clear concept
about the disease condition and its management in details.
OBJECTIVES OF DOING CASE STUDY
General Objective:
 To learn about the “Ventricular Septal defect with severe Pulmonary artery
hypertension” in details.

Specific Objectives:
 To strengthen my capacity to build inter-personal relationship with the patient.
 To develop skill on history taking and physical examination.
 To identify high risk condition related to “Ventricular Septal defect with severe
Pulmonary artery hypertension”.
 To obtain deep knowledge about ‘Ventricular Septal defect with severe Pulmonary
artery hypertension’.
 To compare the patient’s condition with the theoretical knowledge and try to find
similarities and differences.
 To provide therapeutic management of the patient with “Ventricular Septal defect
with severe Pulmonary artery hypertension’.
 To apply appropriate nursing theory for the management of the respective disease.
 To provide disease specific comprehensive nursing management of the patient with
“Ventricular Septal defect with severe Pulmonary artery hypertension’.
 TABLE OF CONTENT:

Contents Page no

1. Demographic Data…………………………………………………… 5
2. History Taking…………………………………………………………. 6-9
3. Physical Examination………………………………………………… 9-12
4. Disease portion………………………………………………………… 12-24
 Introduction

 Etiology

 Clinical Features

 Types

 Diagnostic Evaluation

 Management
5. Drug Profile…………………………………………………………… 25-33
6. Developmental Task…………………………………………………. 33-35
7. Application of Nursing Theory……………………………………….. 35
8. Nursing Care Plan……………………………………………………. 36-47
9. Summary of clients progress……… …………………………………. 47-70
10. Holistic health and diversional therapy……………………………… 70
11. Discharge teaching……………………………………………………. 71-72
12. Learning from the case study…………………………………………. 73
13. Conclusion………………………………………………………….. 74
14. References…………………………………………………………… 75

DEMOGRAPHIC DATA
Name Yubi Shrestha

Age 6 months

Sex Male

Ethnicity Newar

Religion Hindu

Hospital No. 24283

Bed No. 403

Address Hetauda, Makwanpur/ Satungal, Kathmandu

Ward Pediatric Intensive Care Unit

Admission date 13th Mangsir 2076

Diagnosis Ventricular Septal Defect with severe pulmonary hypertension

Duration of care 3 days

Discharge Date

Informant His mother

Education of parents Mother: Literate

Father: Grade 7
Surgeon Prof. Dr. Bhagwan Koirala
Dr. Prabhat Khakhural
Date of Trans in 17th Mangsir 2076

Date of interview 18th Mangsir 2076

Final diagnosis Ventricular Septal Defect with severe pulmonary hypertension

S/P Main Pulmonary artery Banding

COMPLETE HISTORY OF PATIENT:

CHIEF COMPAINTS:
Cough and cold for 5 days - Difficulty in feeding

Low grade Fever for 2 days - Fast breathing

Unable to gain weight since 3 months -excessive sweating

PRESENT COMPLAINTS:
According to patient’s mother, he was apparently well 2 months back then he had cough
and cold for 5 days associated with low grade fever for 2 days on 20th Asoj (no any
documentation). He was taken to traditional healer but he could not be fine. He was taken to
hospital the next day to Kanti Children Hospital but due to some reasons he was not admitted.
Then, he was taken to Ishan Hospital, Tokha. He was admitted there for 5 days with diagnosis of
Acute Respiratory infection. He was treated with Montaz 375 mg IV 12 hourly, Inj. Fluclox 175
mg IV 6 hourly, Neculize with salbutamol stat and every 20 min for 3 doses then every 6 hours,
Niko Drop 0.5 ml PO SOS,ORS. After that he had again the same problems after 15 days again
taken to Ishan Hospital. Due to recurrent respiratory problems, Echo was done to screen for
congenital heart disease. On Echo; Perimenbranous inlet VSD 5.0mm and ASD secundum 3.0
mm, Both left to right shunt Mild MR, Mild PR with PRPG 47.0 mmhg, Severe PAH, Mildly
Dilated all cardiac chambers. Therefore parents were referred to Sahid Gangalal Cardia center
for any cardiac problems. To show the report, patient mother was referred to MCTVT center to
Dr. Bhagwan Koirala. Then, he was given medicine for months, advised to followup after a
month in OPD. He was again advised to have surgery after 2 weeks.

PAST HISTORY:
He had no history of hospitalization before the present illness. No history of blood
transfusion.

PRENATAL, POSTNATAL HISTORY:

- Gravida: G2
- Status of TT vaccine: All given
- No of ANC checkups and place: >4 visit in Thapathali hospital
- History of drugs taken during pregnancy: Iron, calcium and folic acid.
(According to mother, no maternal medical disorder had urinary tract infection
during 4 months of pregnancy and was hospitalized)
- Type of delivery: Cesarean Section
- Term

NEONATAL HISTORY:
 -According to mother, he cried immediately after birth and had no any complications.

-His weight was 3.300 kg at birth.

NUTRITIONAL HISTORY:
According to mother, he was breastfed for 5 months and weaning was done by sarbottam
pitho.

IMMUNIZATION:
According to His mother, child was immunized according to the Expanded Program of
Immunization.

Age Immunization
Birth BCG
6 weeks DPT, Hepatitis B, OPV
10 weeks DPT, Hepatitis B, OPV
14 weeks DPT, Hepatitis B, OPV
FAMILY HISTORY:
According to his mother, his grandmother, uncle, father had history of hypertension. No
any history of chronic disorder like asthma, COPD, diabetes, tuberculosis, cardiac disease

INDEX

Alive
Female
Alive
male
Patient

PERSONAL HISTORY:
 Patient was active and alert when he was healthy. He used to cry a lot, decreased feeding and
failure to gain weight.

ENVIRONMENTAL HISTORY:
The patient lives in concrete house. His parents have different room for kitchen and
bedroom. They use boiling water as drinking water.

PHYSICAL EXAMINATION
I had done the head to toe physical examination on 18th Mangsir, the findings are as follows:

S.N Physical Yes No Physical examination finding

examination (objective data)

1. General -General condition is ill looking.

appearance -Temperature: 100.2ºC
Fever Yes -Pulse rate: 142 beats/ min
Consciousness Yes -Respiration: 42 breaths /min
-SpO2: 99% at 2 liter oxygen.
-length: 71 cm
-Weight: 7.160 Kg
-BMI:
2. Head -Normal hair distribution
Syncope No - Not closure of Fontanel
Head injury No -No bulging or sunken of fontanel

3. Eyes -Eyebrows symmetrical.

Discharge No -Eyes alignment normal.
Swelling Yes - Normal hair distribution in eyebrows and eyelids
- Periorbital swelling
-No signs of nystagmus

4. Ears - Patent external meatus

Discharge No -Slight cerumen
-Auricle aligned with outer canthus of eye, about
10°, from vertical

5. Nose - Polyps absent

Injury No - Pink mucosa
Discharge Yes -Nasal flaring present
Bleeding No -secretions present
Blockage No -Nasogastric tube insitu.
S.N Physical Yes No Physical examination finding
examination (objective data)

6. Mouth, Throat -Buccal mucosa is pink, no lesion, bleeding

and neck - Starting of eruption of lower incision tooth.
Dry mouth No -Normal pink palate, lips pink
Stomatitis No -Uvula centrally located
-lymph nodes lightly palpable
-thyroid not palpable.
-Central line present.

7. Thorax -Median sternal sutures scars of length about 6 cm

Scars Yes -Symmetrical chest expansion.
Symmetrical -Palpation and percussion cannot be done.
Respiratory -On auscultation, crepitus was heard over right upper
expansion Yes and middle lobes of lungs.
symmetrical rhythm Yes
Pain Yes
Crepitus Yes
8. Cardiovascular -No prominent veins
system - Periorbital swelling, no pitting edema on other
Bleeding No body parts.
Bruises No -Hives and thrills not significant
Cyanosis No -Murmur present.
9. Gastrointestinal -Oval shaped abdomen.
system -Bowel sound present 6 per minute
loss of appetite Yes -palpation not significant.
Dysphagia No -centrally located umbilicus.
Nausea, vomiting Yes
Diarrhoea No
Constipation No
Melena No
Abdominal distension No
10. Genitourinary -Foley’s catheter insitu.
system -Output:
Hematuria No - presence of femoral sheath.
Urethral discharge. - Presence of testes on both scrotum
Proteinuria Yes No
11. Musculoskeletal -No any abnormalities found
system -Normal and symmetrical extriemities.
Muscle weakness No -Centrally located straight spine
Fractures No
 S.N Physical Yes No Physical examination finding
Examination (objective data)

12. Skin and -Capillary refill within 2 seconds

Appendages -No evidence of pressure sore
Rashes No -No cyanosis or clubbing of nails.
Changes in texture of No -No any extra digit.
skin and hair -smooth skin.
Pressure ulcer No

13. Nervous system -Range of motion exercise present.

Convulsion No

14. Reflexes -Presence of all the reflexes during 6 months

Moro reflex Yes -Babinski reflex positive i.e. dorsiflexion of toe with
Gag reflex Yes fanning of toes.
Cough reflex Yes
Rooting reflex Yes
Sucking reflex Yes
Tonic neck reflex Yes
Grasp relfex Yes

CONCLUSION:
On head to toe examination, condition of patient was ill- looking, febrile, Central Line,
Foleys catheter, Femoral sheath insitu. Presence of sutures on median sternum area of about 7
cm with mediasternal drain.
 VENTRICULAR SEPTAL DEFECT (DISEASE PORTION)
INTRODUCTION:

Congenital heart disease is a

defect in the structure of the heart or great vessels that is present at birth.

A ventricular septal defect (VSD) is communication in the interventricular septum, causing

a shunt between the ventricles.This is the most common congenital cardiac lesion identified at
birth accounting for one-quarter of all congenital heart disease. After bicuspid aortic valves,
VSDs are the most commonly encountered congenital heart defects. VSD are located in the
membranous part of the ventricular septum with variable extension into the muscular septum and
can be multiple.
 Classification of
CHD

Acyanotic Cyanotic

Increased Obstruction to Decreased

Mixed blood
pulmonary blood blood flow from pulmonary blood
flow
flow ventricles flow

Atrial septal
Coarctation of Tetralogy of Transposition of
defect,
aorta, fallot, great vessels,
Ventricular
Aortic stenosis, Tricuspid Hypoplastic left
septal defect,
Pulmonic atresia heart syndrome
Patent ductus
stenosis
arteiosus

EPIDEMIOLOGY:

VSD affect 2-7% of live births. An echocardiographic study revealed a high incidence of 5-
50 VSDs per 1000 newborns. VSDs are slightly more common in female (56%) patients than in
male patients (44%). The incidence of isolated VSD is about 0.3% of newborns.

ETIOLOGY:

In Book In patient
1. Maternal Factors
-Maternal diabetes Absent
-Alcohol consumption Absent
-Maternal infection(rubella, influenza Present ( History of Urinary tract infection
and febrile illness) during pregnancy)
-Use of metronidazole, ibuprofen Not significant
2. Family history Absent
3. Congenital Present
4. Twins (same malformation is about 3 Absent
times that of general population)
5. Chromosomal abnormality Absent
Most common lesion in many chromosomal syndromes, including

-Trisomy 13

-Trisomy 18

-Trisomy 21

PATHOPHYSIOLOGY:

The interventricular septum is an asymmetric curved structure due to the pressure

difference in ventricular chambers. It is composed of five parts: the membranous, muscular
(frequently referred to as trabecular), infundibular, atrioventricular and the inlet.

Failure of development or fusion of one of the above components during morphogenesis (4-8 th
weeks of gestation) of the embryonic heart results in a VSD in the corresponding component.

A defect in the interventricular septum allows communication between the systemic and
pulmonary circulations. As a result, flow moves from a region of high pressure to a region of low
pressure that is from the left ventricles to right ventricles.

Because of the higher pressure within the left ventricle and because the systemic arterial
circulation offers more resistance than the pulmonary circulation

Blood flows through the defect into the pulmonary artery.

The increased blood volume is pumped into the lungs

Result in increased pulmonary vascular resistance

Increased pressure in the right ventricle as a result of left to right shunting

Pulmonary resistance causes the muscle to hypertrophy

If the right ventricle is unable to accommodate the increased workload, the right atrium may also
enlarge as it attempts to overcome the resistance offered by incomplete right ventricular
emptying.The pulmonary vascular endothelium undergoes irreversible changes resulting in
persistent PAH. When the pressure in the pulmonary circulation exceeds the pressure in the
systemic circulation, the shunt direction reverses and becomes a right-to-left shunt. This is
known as Eisenmenger syndrome, and it occurs in 10% to 15% of patients with VSD.

NATURAL HISTORY:

The natural history of VSD has a wide spectrum and is directly proportional to the size of
the defect, ranging from spontaneous closure to congestive heart failure (CHF) or the
development of pulmonary vascular disease without heart failure symptoms. Spontaneous
closure frequently occurs in children, usually by age 2 years. Closure is uncommon after age 4
years. Those with large defects develop CHF early in childhood due to the severe LV overload
and severe PAH.

CLINICAL FEATURES:

Symptoms vary with size of the defects, age and amount of resistance.

In book In patient
Recurrent chest infections, Present

feeding difficulties Present

tachypnea, exertional dyspnea, Present

Tachycardia Not significant

Excessive sweating associated Not significant

with feeding

Poor weight gain, failure to Present

thrive

Hepatomegaly Absent

Fatigue, features of CCF. Absent

Eisenmenger syndrome Absent

TYPES OF VENTRICULAR SEPTAL DEFECT:

1. Membranous VSDs are the most common type and originate inferior to the crista
supraventricularis, yet still towards the left ventricular outflow tract.
2. Perimembranous VSDs are also inferior to the crista supraventricularis; however extend
into the muscular septum.
3. Supracristal VSDs occur just beneath the aortic valve at the left ventricular outflow tract.
A Venturi effect can occur from the left to right shunt causing the aortic valve leaflet to
prolapse into the VSD resulting in significant aortic valve regurgitation.

DIAGNOSTIC INVESTIGATION:

In book In patient Findings

History taking Done Mentioned above
Physical examination Done Mentioned above
Chest X-ray Done ----
Echocardiography Done Perimenbranous inlet VSD
5.0mm and ASD secundum 3.0
mm, Both left to right shunt
Mild MR, Mild PR with PRPG
47.0 mmhg, Severe PAH,
Mildly Dilated all cardiac
chambers
CBC, LFT,RFT, Done
MANAGEMENT:

1.Medical Management:
It consists of control of congestive cardiac failure, treatment of chest infections and
prevention and treatment of anemia and infective endocarditis. The patient should be
followed carefully to assess the development of pulmonic stenosis, pulmonary arterial
hypertension or aortic regurgitation.
In this case, a patient was treated to chest infection and then plans Operation for
VSD and severe pulmonary hypertension.

2.Surgical Management:

It is indicated if:

a. Congestive cardiac failure occurs in infancy

b. The left-to- right shunt is large (pulmonary flow more than twice the systemic flow)
c. If there is associated pulmonic stenosis, pulmonary arterial hypertension or aortic
regurgitation.

It is not indicated in patient with:

a. A small VSD (exception subpulmonic VSD with aortic valve prolapse and in those who
have severe pulmonary arterial hypertension and significant right-to-left shunt).

3.Operative treatment:
It is performed as early as few months after birth, if congestive failure cannot be
controlled with medical management.
With evidence of pulmonary hypertension, the operation should be performed as early as
possible. For VSD, it consists of closure of VSD with the use of patch.

PULMONARY HYPERTENSION:
INTRODUCTION:

Pulmonary hypertension is defined as a mean of pulmonary artery pressure (PAP) of at

least 25 mm of Hg at rest, as measured by right heart catheterization. It can be redefined by
consideration of the pulmonary wedge pressure (PWP) < 15 mm of Hg the cardiac output and the
transpulmonary pressure gradient (mean PAP- mean PWP).
 In this patient, the pulmonary arterial pressure before surgery was 43 mm of Hg and
post operative values was 30 mm of Hg.

TYPES:

1.Pulmonary arterial hypertension:

Primary pulmonary hypertension: sporadic and familiar.

Secondary to connective tissue disease (limited cutaneous systemic sclerosis)

-Congenital systemic to pulmonary shunts,

- Portal hypertension,

-HIV infection, exposure to various drugs or toxins and persistent pulmonary

hypertension of the newborn.

2. Pulmonary venous hypertension.

-Left sided atrial or ventricular heart disease
-left sided valvular heart disease.
-Pulmonary veno-occlusive disease.
-Pulmonary capillary haemangiomas.

3.Pulmonary hypertension associated with disorders of the respiratory system and/or

hypoxemia.
4.Pulmonary hypertension caused by chronic thromboembolic disease.

In this case, the cause of pulmonary arterial hypertension is congenital systemic to

pulmonary shunts. No any chromosomal abnormality found.

CLINICAL FEATURES:

In book In patient
Progressive shortness of breathe Not significant
Hyperventilation Present
Fatigue Not significant
Fainting spells Absent
Lightheadedness Absent
Coughing up blood Absent
TREATMENT:

1. Medical Management:

a. Oxygen − can be used at home and often helps with breathing issues. It is also known to
relax the muscles in the arteries of the lungs, which will lower the pressures in the
pulmonary arteries.
b. Diuretics – drugs used to get rid of excess fluid in the body and reduce the amount of
work on the heart.
c. Calcium channel blockers (CCB) – drugs that relax the muscles in the blood vessel
walls and help the right side of the heart work better. Although CCBs have been proven
to be effective, only a small number of patients respond to them.
d. Phosphodiesterase-5 (PDE5) inhibitors - drugs that relax the blood vessels in the lungs
to allow blood to flow through more easily. This class of drugs is often used in
combination with other drugs to lower pulmonary artery pressures.

2. Surgical Management:

  In general, pressure overload and conditions with high flow such as occurs with large
VSDs are more likely to cause PAH. Patients with a VSD or PDA do not develop irreversible
pulmonary vascular changes before 9 months to 2 years of age, but surgery is generally
recommended sooner. Without appropriate surgery, an estimated 50% of patients with a large,
nonrestrictive VSD will develop ES.

Children, who underwent surgical repair before 9 months of age, had normal PAP 1 year
after surgery.

MAIN PULMONARY ARTERY BANDING:

INTRODUCTION:

Pulmonary artery banding (PAB) is a technique of palliative surgical therapy used by

congenital heart surgeons as a staged approach for operative correction of congenital heart
defects. This technique was widely used in the past as an initial surgical intervention for infants
born with cardiac defects characterized by left-to-right shunting and pulmonary over circulation.

The primary objective of performing PAB is to reduce excessive pulmonary blood flow
and protect the pulmonary vasculature from hypertrophy and irreversible (fixed) pulmonary
hypertension.
PATHOPHYSIOLOGY:

Congenital heart defects with left-to-right shunting and unrestricted pulmonary blood flow
(PBF) due to a drop in pulmonary vascular resistance result in pulmonary over circulation. In the
acute setting, this leads to pulmonary edema and congestive heart failure (CHF) in the neonate.
Within the first year of life, this unrestricted flow and pressure can lead to medial hypertrophy of
the pulmonary arterioles and fixed pulmonary hypertension. Pulmonary artery banding (PAB)
creates a narrowing, or stenosing, of the main pulmonary artery (MPA) that decreases blood flow
to the branch pulmonary arteries and reduces PBF and pulmonary artery pressure. In patients
with cardiac defects that produce left-to-right shunting, this restriction of PBF reduces the shunt
volume and consequently improves both systemic pressure and cardiac output. A reduction of
PBF also decreases the total blood volume returning to the LV (or the systemic ventricle) and
often improves ventricular function.

INDICATIONS:

(1) Those with pulmonary over circulation and left-to-right shunting who require reduction
of pulmonary blood flow (PBF) as a staged approach to more definitive repair.

(2) Those with transposition of the great arteries (TGA) who require training of the left
ventricle (LV) as a staged approach to the arterial switch procedure.

3) In patients with elevated, but reactive, pulmonary hypertension from long-standing left-
to-right shunting. An immediate surgical repair may carry significant morbidity and even
mortality. With the use of a PAB and pulmonary vasodilator, some of these patients may drop
their pulmonary vascular resistance and subsequently respond more favorably to surgery.

In this case, patient, had pulmonary over circulation and left to right shunting who require
reduction of pulmonary blood flow as staged approach to more definitive repair and
pulmonary hypertension.
CONTRAINDICATED:

1) Patient with single ventricular defect

2) Aortic pressure gradient more than 15-20 mm of Hg.
3) Sub aortic obstruction.

COMPLICATIONS:

1) Impingement or stenosis of one or both of the arches (common- right pulmonary artery)
2) If the band is placed too proximal on the MPA, it may distort the pulmonary valve and
ultimately create dysplastic changes in the pulmonary valve leaflets, can lead to
obstruction of coronary blood flow by direct impingement, usually of the circumflex
coronary artery.

DRUG PROFILE
DURING ADMISSION:
1) Tab Frusix/ Frusemide 5 mg PO OD
2) Inj Xone 50 mg IV stat
3) Syp Fluclonazole 60 mg PO stat
4) Syp Albendazole 20 mg PO stat
5) Mupirocin ointment apply on IV site

DURING HOSPITALIZATION:
1) Inj. Xone/ ceftriaxone 150 mg IV BD
2) Inj. Fluclox 150 mg QID
3) Inj. Amikacin 90 mg IV OD (if RFT normal)
4) Inj. Paracetamol 90 mg QID
5) Inj Fentanyl 10 mcg IV hourly, tapper
6) Inj. Omeprazole 5 mg IV OD
7) Inj Lasix 6 mg IV BD
8) Tab. Sildenafil 6.25 mg PO BD via NG.

DURING DISCHARGE:
1) Inj. Xone/ Ceftriaxone:
Classification: anti-infective, antibiotic and 3rd generation cephalosporin.

Actions : Semi synthetic third-generation cephalosporin antibiotic. Preferentially

binds to one or more of the penicillin-binding proteins (PBP) located on cell walls of
susceptible organisms. This inhibits third and final stage of bacterial cell wall
synthesis, thus killing the bacterium.

Uses: bone and joint infections, gonorrhea and intra-abdominal infections, meningitis
and lower respiratory tract infections, otitis media, pelvic inflammatory
disease, Proteus infections, septicemia, skin and soft tissue infections, urinary tract
infections, and is used for surgical prophylaxis, reducing or eliminating infection,
surgical prophylaxis.

Contraindications:
Hypersensitivity to cephalosporin’s and related antibiotics ; pregnancy (category B).

Route and dosage:

-Surgical prophylaxis:
Adult: 1 gm IV 30-120 min before surgery.
Child: IV 50-75 mg/kg/day in equal dose every 12-24 hour.

Side effects:
1) CNS: headache, dizziness, weakness, seizures
2) CV: heart failure
3) EENT: oral candidacies
4) GI: nausea, vomiting, diarrhea, anorexia, pain, glossitis, bleeding, increased
AST/ALT.
5) GU: proteinuria, nephrotoxicity, increased BUN.
6) Hematology: leucopenia, thrombocytopenia, agranulocytosis, hemolytic anemia.
7) Resp: Dyspnea.

Nursing consideration:

Assess:

1) Sensitivity to penicillin, other cephalosporin

2) Nephrotoxicity: increased BUN, creatinine; urine output; if decreasing notify
prescriber.
3) Blood studies
4) Anaphylaxis: rash, urticaria, purities, chills, fever.
 Evaluate for therapeutic response; decreased symptoms of infection.

2) Inj.Flucloxacillin:
Therapeutic category: Antibacterial, penicillin

MOA: Binds to specific penicillin binding protein(PBPs) located inside the bacterial
cell wall, it inhibits 3rd and last stage of bacterial cell wall synthesis
Indications: Infection caused by gram positive bacteria including penicilinase
including staphylococcus aureus

Dosage: Adult: 250-500 mg 6 hourly

Child:50-100 mg/kg/day in 4 divided doses before meals

Adverse effects: Hypersensitivity, skin rashes, urticaria to severe anaphylactic

reaction, GI upsets,etc

Contraindications: Hypersensitivity

Caution: Renal and hepatic dysfunction, increased risk of adverse effects in elderly

Nursing Management:
-Observe IV site carefully before and during drug administration as it may cause
extravasations
-observe signs of adverse effects
-observe signs of infection.

3) Amikacin:

Functional class: Antiinfective

Chemical class: Aminoglycoside

Action: Interferes with protein synthesis in bacterial cells by binding to ribosomeal

subunits, which causes misreading of genetic code; inaccurate peptide sequence forms in protein
chain, thereby causing bacterial death.

Uses: Severe systemic infections of CNS, respiratory tract, GI tract, urinary tract, bone,
skin, soft tissues caused by staphylococcus aureus, Klebseilla.

Contraindications: Pregnancy, hypersensitivity to aminoglycosides, sulfites.

Dosage and Routes:

Severe systemic infections:

 Adult/ Child: IV infusion: 15mg/kh/day in 2-3 divided doses every 8-12 hour in 100-200
ml D5 over 30-60 min, max 1.5 gm/day.

Neonate: IV/IM 10mg/ kh initially, then 7.5 mh/kg every 8-12 hour.

Side effects:

1) CNS: confusion, depression, numbness, tremors, seizures,neurotoxicity, dizziness,

vertigo, tinnitus

2) CV: Hypo/hypertension

3) EENT: Ototoxicity, deafness,

4) GI: Nausea, vomiting, anorexia, bilirubin

5) Hematology: Eosinophilia, anemia

6) Integ: Eosinophilia, anemia

Nursing interventions:

Assess:

1) Weight before treatment; calculation of dosage is usually based on ideal body weight
but may calculated on actual body weight, in those underweight and not obese, use
total body weight, instead of ideal body weight.
2) Input and output.
3) IV site for thrombophlebitis including pain, redness, swelling every 30 min
4) Nephrotoxicity: Renal impairment, obtain urine for Ccr, BUN, serum creatinine,
lower dosage should be given renal impairment, Nephrotoxicity may be reversible if
the product stopped at 1st sign.
5) Dehydration
6) Overgrowth

Teach patient/ family:

1) Report headache, dizziness, symptoms of overgrowth of infection, renal impairement,

symptoms of neurotoxicity, hepatoxicity
2) To report loss of hearing, ringing, roaring in ears; feeling of fullness in head.
3) To report hypersensitivity.
4) Fentanyl:

Therapeutic category: opioids analgesics

MOA: binds with stereo specific receptors at many sites within CNS in order to increase
pain threshold
Indications: Management of pain, post cardiac surgery, cancer

Dosage: not exceeding 500 mcg/ day

Adverse effects: Depression, Bradycardia, hypotension, constipation, apnea, urinary

retention

Contraindications: Hypersensitivity, respiratory depression, myasthenia gravis

Nursing Management:
-Administration is necessary by trained professional
-Caution should be taken in case of pulmonary disease, liver and kidney dysfunction

5) Inj. Paracetamol:
Therapeutic category: Para-aminophenol derivative, Analgesic

MOA: inhibit cyclo oxygenase (COX ) enzyme, hence inhibiting prostaglandin

pathway

Indications: Mild- moderate pain, post operative pain, fever, pain associated with
musculo skeletol and joint disorder

Dosage: Adult: 500-1000 mg TDS/QID as needed

Child: less than 3 month: 10 mg/kg, more than 3 month: 10-15 mg/dose( 3- 4
doses/24 hours)

Adverse effects: Nausea, allergic reaction, skin rashes, acute renal tubular necrosis,
hypoglycemia, liver damage

Contraindications: Hypersensitivity, hepatic diseases like jaundice

Nursing Management:
-Assess for allergies and impaired hepatic function
 -Avoid excessive dosage and explain adverse effects to patients

6) Omeprazole
Functional class: Antiulcer, proton pump inhibitor
Chemical class: Benzimidazole

Action: Supressess gastric secretion by inhibiting hydrogen/ potassium ATPase

enzyme system in gastric parietal cells; characterized as gastric acid pump
inhibitor because it blocks the final step of aci production.

Uses: GERD, severe erosive esophagitis, poorly response systemic GERD,

duodenal ulcers with/without anti-infective for helicobacter pylori.

Contraindications: hypersensitivity.

Dosage/ Routes:  The effective dosage range of omeprazole in their study was 0.7
to 3.3 mg/kg per day (mean, 1.9 mg/kg).

Side effects:
1) CNS: headache,, dizziness, asthenia
2) GI: diarrhea, abdominal pain, vomiting, nausea, constipation, flatulence, acid
regurgitation, hepatic failure
3) Inte: Rash, dry skin, urticaria, purities.
4) Muscular: Back pain, fever, fatigue, malaise
5) Respiratory: Upper respiratory infections, cough, epistaxis, pneumonia

Nursing considerations:

Assess:

-GI system: bowel sounds every 8 hour abdominal pain, swelling,

anorexia, blood in stools.

-Electrolyte imbalances: Hyponatremia; hypomagnesaemia

-hepatic enzymes.

Teach patient/family:

-To report severe diarrhea; black, tarry stools; abdominal cramps/pain; or

continuing headaches; product may have to be discontinued.
 -if diabetic, hypoglycemia may occur

-To avoid hazardous activities because dizziness may occur

-To avoid alcohol, salicylates, NSAIDS

7) Lasix
Therapeutic category: Loop diuretics

MOA: It acts primarily by inhibiting the reabsorption of electrolytes in Loop

of Henle. It decreases the reabsorption of sodium and chloride and increase
potassium excretion in the distal renal tubule

Indications: congestive heart failure, Hyperkalemia, cirrhosis of liver,

nephritic syndrome, hypertensive crisis, pulmonary edema, raised ICP, acute
renal failure
Dosage: Adult: PO 20-80 mg/day; IV/IM: 2mg/kg, increased by 20 mg 2
hourly until desired response
Child: PO/IV/IM: 2mg/kg, may increase by 1-2 mg/kg 6-8 hourly up to
6mg /kg

Adverse effects: Headache, Hyponatremia, hyperurecemia, hypomagnesia,

anorexia, dizziness, vertigo, muscle cramps

Contraindications: hypersensitivity, hypovolemia

Nursing Management:
-strictly monitor input and output and observe for electrolyte imbalance
-Administer drug in morning and early afternoon to reduce nocturnal
-weigh patient daily
-Be alert for sign and symptoms of Hyperkalemia
-Watch for swelling
- Encourage patient to take potassium rich foods

8) Sildenafil:
Functional class: Erectile agent, antihypertensive, peripheral vasodilator

Chemical class: Phosphodiesterase type-5 inhibitor

Action: Enhances the effect of nitric oxide by inhibiting phosphodiesterase
type 5, which is necessary for degrading cGMP in the corpus caversnosum

Uses: Treatment of erectile dysfunction, improvement in exercise ability,

pulmonary hypertension.

Contraindications: hypersensitivity

Dosage and Routes:

Pulmonary Hypertension: Sildenafil is available as tablets (20 mg), oral
suspension (20 mg/mL, after reconstitution with 90 mL of water) and injection
for intravenous (IV) use (10 mg/12.5 mL). The oral preparation of sildenafil is
widely used in the management of PAH.

Side effects:
1) CNS: headache, flushing, dizziness, transient global amnesia,, seizures
2) CV: MI, sudden death, CV collapses, TIAs, ventricular dysrhthymias, CV
hemorrahage.
3) MISC: dyspepsia, nasal congestion, rash, priapism.

Nursing consideration:

Assess:

-use of organic nitrates, that should not be use with this.

-Cardiac status, hemodynamic parameters, exercise tolerance in pulmonary

hypertension: B/P, pulse

-Evaluate therapeutic response

Teach patient/ family:

-That product should not be used with nitrates in any form.

-To notify prescriber immediately and to stop taking if vision/ hearing loss
occurs or erection lasts >4 hour

-do not use more than 100 mg in 24 hour.

DEVELOPMENTAL TASK
-Age: 6 months

- Trust Vs, Mistrust

-Oral stage

Developmental task In Patient

1. Develop consonant sound such s, n, k , g,. They Present

coo, babble and laugh aloud
2. Produce monosyllable sound such as ma, ba. Absent

3. Enjoys social interaction Present

4. Recognize strangers, shows strong preference to Present

mother and other familiar family members.
5. Reach out with both or one hand and pull objects Present
towards mouth, play with own hands and feet.
6. Roll over from abdomen to back Present

7. Sit with support, rolls from back to abdomen Absent

APPLICATION OF NURSING THEORY

Nursing problems:
1) Acute pain related to surgical incision as evidenced by tachycardia, increased body
temperature, increased respiration rate 44 breaths/minute.
2) Ineffective airway clearance related to accumulation of secretions as evidenced by
crepitus on lung auscultation, thick mucus secretion on suctioning, high respiration rate.
3) Fluid volume excess related to low protein in plasma evidenced by periorbital swelling,
increased central venous pressure.
4) Hyperthermia related to infection as evidenced as body temperature 100°F, flushed skin,
sweating.
5) Imbalanced nutrition less than body requirement related to anorexia secondary to
congenital heart defect as evidenced by low body weight than age, decreased serum
albumin, dry skin.
6) Risk for decreased cardiac output related to structural factors of congenital heart defect as
evidenced by tachycardia, dyspnea.
Assessment Nursing Expected Planning Interventions Rationale Evaluation
diagnosis outcome

Subjective Acute pain After 30 -Vital signs will -Vital signs i.e. -to know the My goal was
data: related to minutes of be assessed. temperature: baseline fully met as
Language surgical interventions, 98F. heart information. patient facial
was not incision as patient’s pain rate:138 beats expression
developed. evidenced control at a per min, shows
by level less respiration:30 decrease of
tachycardia, than 3 to 4 on breaths/min. pain 2/10,
Objective increased a rating scale decrease in
data: body of 0 to -Pain rating was -According to - Assessment of heart rate, not
tachycardia: temperature, 10.Patient assessed. visual analogue pain experience is frequent
48 increased displays scale, 8/10 the first step in crying and
breaths/min respiration improved scale. planning pain quiet sleep.
-respiration rate 44 well-being management
rate: 38 breaths/min such as strategies.
breaths/minu ute. baseline
te. levels for -Rest periods -Rest periods -Pain may result
pulse, BP, will be were provided in fatigue which
respirations, provided to to promote may result in
and relaxed promote relief, relief, sleep and exaggerated pain
muscle tone sleep and relaxation. may facilitate
or body. relaxation. rest.
 -Analgesics as -Analgesics -It helps to
prescribed will Fentanyl 5 mcg decrease the pain.
be provided. was provided.

-Reassessment -Reassessment -To provide other

will be done. was done on pharmacological
relief of pain. interventions for
pain relief if these
does not relief
pain.

Assessment Nursing Expected Planning Interventions Rationale Evaluation

diagnosis outcome
Subjective Ineffectiv Patient will -Vital signs will -Vital signs -To assess the My goal was
data: e airway have clear be taken. especially baseline partially met
-Intubated clearance airway, no respiration(16), information. as patient
-Language related to clogged ventilation had
was not accumulat secretions. alarms, oxygen improved
developed. ion of saturation(100%) chest x-ray
secretions was assessed. -It permits adequate i.e.
Objective as -Patient will be -Patient was kept lungs expansion and decreased
data: evidenced kept in proper in position with decrease chances for consolidatio
-abnormal by body alignment. head elevation at secretion stasis. n, decreased
breath crepitus 45 degree. abnormal
sounds; on lung -Position will -Position was -To decrease the breathe
crackles. auscultati be changed changed 2 hourly. chances of stasis. sound.
on, thick frequently.
-excessive mucus -Sterile ET -To keep the airway
secretions secretion -Sterile suctioning was clear for good
on Endotracheal done as per need. ventilation and
suctioning suctioning will sterile to prevent
, high be done as ventilator associated
respiration needed. -Nasal and oral pneumonia.
rate. -Suctioning will suctioning was -It helps in removal
be done after done. of secretion when
 extubation. the infant cannot
cough out
-Chest -Chest secretions.
physiotherapy physiotherapy;
will be done. cupping was -It helps in thinning
done. of mucous and
secretion.
-Nebulization -Nebulization
will be done. with half N- -It works as thinning
Acetylcholine or of mucus and helps
ipratromium in suctioning.
bromide was
done.
-Reassessment -Reassessment
will be done. was done by -To know if the goal
monitoring chest is met or not.
x-ray,
auscultation of
lungs
improving.
Assessment Nursing Expected Planning Interventions Rationale Evaluation
diagnosis outcome

Objective Fluid After -Vital signs -Vital signs are -To know the My goal is
data: volume nursing will be assessed. baseline partially
- excess intervention, assessed. information. met as
tachycardia: related to patient will -Dehydration ma patient
132 low protein have -Intake and -Intake and y be the result of have
beats/min in plasma balanced output will be output was fluid shifting decreased
evidenced intake and monitored. monitored even if overall edema.
-periorbital by output, through limited fluid intake is
swelling. periorbital decreased input and proper adequate.
swelling edema. documentation
-negative increased -Edema was - Edema occurs
balance central -edema will be assessed by when fluid
venous assessed. inspection on accumulates in
-decrease pressure. periorbital area, the extra
urine palpating over vascular spaces.
output. the tibia, ankles
and feet.
-increased
central -Sodium intake -restriction of
venous -sodium intake was limited. sodium aids in
pressure will be limited. decreasing fluid
retention.
-diuretics i.e.
 -diuretics will lasix 5 mg was -Diuretics aids in
be provided. excretion of
administered. excess body
fluids.
-Positioning was
-Positioning done every -Edematous skin
will be provide is more
susceptible to
injury.
Repositioning
prevents fluid
accumulation in
gravity depended
areas.

Assessment Nursing Expected Planning Interventions Rationale Evaluation

diagnosis outcome

Subjective Hypertherm Within 30 -Vital signs will -Vital signs i.e. -To get the My goal is
data: ia related to minutes, be assessed. heart rate:154 baseline fully met as
-Language infection as patient will beats/min, information. patient’
not evidenced have normal temperature: temperature
developed. as body body 100°F. was within
temperature temperature -Excess -Excess -Exposing skin to normal
100°F, after nursing clothing was clothing like room air range.
flushed interventions. removed. blankets was decreases warmth 97.6°F.
Objective skin, removed. and increases
data: sweating. evaporative
cooling.
- -Tepid -Tepid -it helps in
Temperature sponging was sponging was decreasing the
:100.0ºF done. done on whole body
body. temperature.
-increased -oxygen level -Oxygen was -Hyperthermia
heart was increased. provided as 6 causes increase
rate:154 liters/min. metabolic rate so
beats/min need more
oxygen.
-Antipyretics -Antipyretics - Antipyretic
will be Inj PCM 90 mg medications
provided. was lower body
administered. temperature by
blocking the
synthesis of
prostaglandins
 that act in
the hypothalamus
-Expressed -Expressed -it helps to
breast milk will breast milk was decreased the
be fed through provided internal body
Nasogastric without temperature.
tube. warming to
decrease the
temperature
-To know if the
-Reassessment -Reassessment nursing
will be done. of temperature interventions
was done. should be
changed.
Assessment Nursing Expected Planning Interventions Rationale Evaluation
diagnosis outcome

Risk for Patient will -Vital signs will -Vital signs i.e. Mechanical My goal is
decreased maintain the be assessed. blood pressure ( ventilation can partially
cardiac adequate with MAP 87 produce a met
output cardiac mm og Hg), decreased patient’s
related to output as heart rate:126 venous return to heart rate
mechanical evidenced by beats/min, the heart, was
ventilation. systolic B.P Central venous resulting in maintained
within 20 pressure. decreased BP, but the
mm of Hg, compensatory blood
Heart rate increased heart pressure
60-100 beats rate, and was not
per minute. decreased maintained.
-Capillary refill, cardiac output.
-Capillary refill, skin temperature -Capillary refill
skin and peripheral is slow with
temperature, pulses was reduced cardiac
and peripheral assessed and output. Cold
pulses will be found to be clammy skin is
assessed. within 2 secondary to
seconds, mostly compensatory
cool extremities sympathetic
respectively, nervous system
slightly strong stimulation.
pulses.

-Fluid intake
including
-Fluid intake medication and -Optimal
and output will urine output was hydration status
 be monitored. monitored and is needed to
recorded. maintain
effective
circulating
blood volume
and counteract
the ventilatory
-Optimal fluid effects on
balance cardiac output.
-Optimal fluid according to the -Volume
balance will be output was therapy may be
done. done. required to
maintain
adequate filling
pressures and
Assessment Nursing Expected Planning Interventions Rationale Evaluation
diagnosis outcome

optimize
-Ionotropes will -Nor-adrenaline cardiac output.
be 0.2 ml/hr was -Ionotropes
administered. provided and helps in
monitored. contractility of
heart and
increase cardiac
-Diuretics will -Frusemide/ output.
be provided. Lasix 6 mg was - Diuretics may
provided. be useful to
maintain fluid
balance if fluid
retention is a
problem.

Assessment Nursing Expected Planning Interventions Rationale Evaluation

diagnosis outcome

Subjective Imbalanced Patient’s 1)I will monitor 1)Laboratory 1)It play a My goal was
data: nutrition estimated the laboratory values like significant part partially met as
Mother said” less than required value. albumin, in determining patient weigh
He had body weight will transferrin, and the patient’s was gained up
decreased requiremen be electrolytes nutritional to 7 kg but not
feeding milk t related to maintained values were status. up to the
and have not anorexia throughout monitored. required weight
got weight of secondary the 2)Weight was 2)Weight was 2)to know if the of that age.
his age. to hospitalizati monitored. monitored weight is gained
congenital on. regularly and or lose.
heart defect recorded.
Objective as
data: evidenced 3)Physical signs 3) Physical 3) The patient
by low for poor signs for poor encountering
-low body body nutritional intake nutritional nutritional
weight than weight than will be assessed. intake was deficiencies
age. age, assessed by may resemble
decreased assessing pale to be sluggish
-dry skin serum and dry skin, and fatigued.
-decreased albumin, tachycardia,ede
body serum. dry skin. ma.

3) I will provide 3) Good oral

good oral hygiene was 3)To maintain
hygiene. provided by good digestive
chlorhexidine system and
in every shift. prevent
4) Mothers infection.
4)I will provide expressed milk 4) To provide
expressed breast was provided nutrition to
milk. through NG and body, mother’s
lactogen when milk is the best
beast milk is not for nutrition.
adequate.

Assessment Nursing Expected Planning Interventions Rationale Evaluation

diagnosis outcome

Risk for Patient will -Vital signs will -Vital signs i.e. Congenital defect My goal is
decreased have be assessed. blood pressure causes left to right partially met
cardiac adequate (88/50) heart shunt decreasing as patient
output cardiac rate: 154 volume in ventricle had
related to output as beats/min, and increasing lung maintained
structural evidenced Central venous congestion and blood
 factors of by blood pressure:16 cm mechanical pressure
congenital pressure H2O. ventilation can 100/70 mm
heart and pulse produce a decreased Hg, heart
defect. rate; venous return to the rate:80beats
and rhythm heart, resulting in Per minute
within decreased BP, and strong
normal compensatory pulse.
parameters increased heart rate,
for patient and decreased
within -Capillary refill, cardiac output.
hospitalizat skin - Capillary -Capillary refill is
ion. temperature, refill, skin slow with reduced
and peripheral temperature cardiac output. Cold
pulses will be and peripheral clammy skin is
assessed. pulses was secondary to
assessed and compensatory
found to be sympathetic nervous
within 3 system stimulation.
seconds,
mostly cool
extremities
-Fluid intake respectively,
and output will and weak -Optimal hydration
be monitored. pulse. status is needed to
- Fluid intake maintain effective
including circulating blood
medication and volume and
-Optimal fluid urine output counteract the
balance will be was monitored ventilatory effects
done. and recorded. on cardiac output.
-Volume therapy
-Optimal fluid may be required to
balance maintain adequate
according to filling pressures and
the output was optimize cardiac
done
Assessment Nursing Expected Planning Interventions Rationale Evaluation
diagnosis outcome

output.
-Ionotropes will -Nor- - Ionotropes helps in
be adrenaline 0.05 contractility of heart
administered. mcg/kg/min. and increase cardiac
was output.
administered.
 -Diuretics will -Diuretics i.e. - Diuretics may be
be provided. lasix 5 mg was useful to maintain
administered. fluid balance if fluid
retention is a
problem and
reduces lung
congestion.
-Reassessment -Reassessment
will be done. was done
regarding input -To assess if the
and output,, care plan should
nursing be changed.
interventions
and its
outcomes.

CLIENT PROGRESS NOTE:

1) 2076/8/13 ( Day of admission):

Chief complaints:

- Cough and cold for 5 days - Difficulty in feeding

-Low grade Fever for 2 days - Fast breathing

-Unable to gain weight since 3 months -excessive sweating

 Patient was admitted to general ward A bed. No 324. At 6 pm, patient was admitted to
Manmohan Cardiothoracic vascular and transplant center with the diagnosis of
Ventricular Septal defect and severe Pulmonary artery hypertension. The vital signs were
within normal range i.e.
Heart rate: 142 beats/min
Respiration: 48 breaths/min
Temperature: 97.2 F
O2 saturation: 95 % in Room air
Chest X-ray ad ECG was done. ECG shows biventricular hypertrophy.
1) Medications as follows: Tab Frusix/ Frusemide 5 mg PO OD
2) Inj Xone 50 mg IV stat
3) Syp Fluclonazole 60 mg PO stat
4) Syp Albendazole 20 mg PO stat
5) Mupirocin ointment apply on IV site

2) 2076/08/13 (1st day of admission):

Time Pulse(beats/min) Blood Temperature Respiratory Rate Oxygen

pressure (F) (breaths/minute) saturation
(mm of hg) (%) at room
air

6 am 130 -- 97.0 30 89
6 pm 132 -- 96.8 32 --
10 pm 130 -- 97.4 30 --

Patient general condition was fine and no any investigations done.

3)2076/08/14 (2nd day of admission):

Time Pulse(beats/min) Blood Temperature Respiratory Rate Oxygen

pressure (F) (breaths/minute) saturation
(mm of hg) (%) at room
air

6 am 130 -- Afebrile 30 --
10 pm 130 -- Afebrile 30 --
Patient condition was fair. Vital signs were within normal range. No any fresh complaints.
Medications given as per cardex. No any investigation done.

4)2076/08/15 (3rd day of admission):

Time Pulse(beats/min) Blood Temperature Respiratory Rate Oxygen

pressure (F) (breaths/minute) saturation
(mm of hg) (%) at room
air
6am 124 -- 98 30 --

10 am 122 -- afebrile 36 --

2pm 124 -- 98 30 94%

6 pm 128 -- 97.4 30 95

10 pm 124 -- 98 30 95%

General condition of patient was fair. Vital signs are within normal range. Blood
investigations send. Medications provided as per cardex.

Investigations: (2076/08/15):

Biochemistry report

Test Result Reference Range Interpretation

Random Blood sugar 108 mg/dl 74-106 Normal
Blood urea Nitrogen 13 7-18 Normal
Creatinine 0.29 mg/dl 0.8-1.3 Low
Na 136 135-146 Normal
K 4.5 3.5-5.2 Normal
Total Protein 6.2 g/dl 6.4/8.2 Low
Bilirubin total 0.3 mg/dl 0-1.1 Normal
Bilirubin Direct 0.1 mg/dl 0-0.4 Normal
SGPT 32U/L 30-65 Normal
SGOT 36 U/L 0-45 Normal
Alkaline Phosphatase 151U/L 4-140 High
Albumin 3.2 g/dl 3.2-4.9 Low
Hematology:

Test Result Reference Range Interpretation

Blood group B positive - -
Haemogloin 9.1 gm% 13.0-18.0 Low
TC 8820 cells/cum 4000-11000 Normal
DC
Neutrophils 44 % 45-75 Low
Lymphocyte 44% 25-45 Normal
Monocytes 10 % 2-8 High
Eosinophil 02% 1-4 Normal
Platelets 412000 cells/cum 150000-400000 Normal
PT 10.9 sec -- Normal
Control 10.0 sec -- Normal
INR 1.1

Endocrinology:

Test Result Reference Range Interpretation

HBsAg <0.90 0-1.0 Non reactive

Anti-HCV ab < 0.90 0-1.0 Non reactive

HIV 1 and 2 Ab < 0.90 0-1.0 Non reactive

5)2076/08/16 (4th day of admission):

Time Pulse(beats/min) Blood Temperature Respiratory Rate Oxygen

pressure (F) (breaths/minute) saturation
(mm of hg) (%) at room
air
6 am 116 -- 96.5 26 92

2 pm 125 -- 96 28 92
 6 pm 130 -- 96 26 92

10 pm 126 -- 98 28 92

General condition of patient seems satisfactory. Vital signs are within normal range and
recorded. Medications given as per cardex. OT preparation going on. No any investigations
done.

6)2076/08/17 (5th day of admission/ OT day/ 1st ICU day/1st day of care):

Time Pulse(beats/min) Blood Temperature Respiratory Rate Oxygen

pressure (F) (breaths/minute) saturation
(mm of hg) (%) at room
air
6 am 128 -- 97.7 32 92

Patient’s general condition seems satisfactory. Vital signs are within normal range. Patient was
kept NPO from midnight. Preoperative Anesthetic checkup to be done, other OT preparations
done.

After Operation:

Heart rate: 108 beats/ min SpO2: 100%

Respiration rate: 20 breaths/min Mode: VAC(volume Assist Control)

Blood pressure: 84/56 mm Hg Tidal volume: 50

Temperature: 96 ºF PEEP: 5

GCS: under sedation Pressure support: 14

CVP/MAP: 10/5 FiO2: 100%

ECG: sinus Tachycardia ET tube ID/L: 3.5 /12 mm

Pupil : bilateral reactive

Patient was received in lower ICU from OT at 12:00 pm in the evening after surgical
procedure i.e. Main Pulmonary Artery Banding. General Condition of patient is ill-looking.
Patient is under ventilation in VAC mode. Patient was under sedation and inj adrenaline 0.12
mcg/hour, inj. Plasmalyte at 20 ml/ hour. Patient had central line, one mediastinal drain and
Foleys catheter insitu. Arterial Blood Gas (ABG) was taken for analysis , investigations were
sent and post-operative chest X-ray was done. On ABG, 2mEq KCl replaced, GRBS was done
and random blood sugar was 163 mg/dl. At around 1 pm, nasogastric tube was inserted.
Sildenafil 6.25 mg, Inj. Fentanyl 5 mcg was provided. Ionotropes decreased to 0.1 mcg. At 2 pm
Adrenaline 0.05 mcg/hour. Mechanical Ventilator was changed to SIMV ( Synchronized
intermittent Mandatory ventilator) mode for 1 hour and then spontaneously. At 3:15 pm
extubation was done and kept in 60% venturi mask. GCS was 4/5/6, ABG done and MgSO4 180
mg was replaced. N-acetlycysteine nebu was provided. At around 4 PM Ionotropes was hold.
Random blood sugar measured and found to be 245 mg /dl. Patient was provided Fentanyl 5 mcg
hourly. At around 10:00 pm, temperature was 100.2°F, inj.PCM 90 mg was provided. At around
11:00pm grunting respiration therefore NAC Nebu was provided. Lasix 6 mg was provided due
to continuous positive balance and puffiness of face. GRBS done and found to be 108 mg/dl.
ABG done and MgSO4 180 mg, potassium 1.5 mEq provided. At 3 am, ABG was done and KCl
3 mEq provided. IVF 1/2NS and D5 administered at 20 ml/hour. At 6 am, temperature was
100.4ºF, paracetamol 90 mg was provided. Expressed breast milk of mother was provided
through nasogastric tube. Total urine output 24 hour=300 ml, mediastinal drain= 45 ml.

Arterial Blood Gases:

Component 8/17 with Fio2 100% 8/17 with FiO2 60%at 2 8/17 with FiO2 60% at 4
at 12:30 pm pm
pH 7.415 7.367 7.339
PCO2 27.6mm Hg 31.4 mm Hg 32.5 mmHg
pO2 326 mm Hg 162.8mmHg 174.8mm Hg
HCO3 17.8 mm Hg 18.2 mmol/L 17.7 mmol/L
Na+ 132.1mmol/L 132.7mmol/L 133.7mmol/L
K+ 3.90mmol/L 3.75 mmol/L 3.34 mmol/L
Ca++ 1.08 mmol/L 1.13 mmol/L 1.17 mmol/L
Mg++ 0.60 mmol/L 0.57 mmol/L 0.54 mmol/L
Intrepretation/ Compensated MgSO4 180 mg replaced
Maintainance respiratory
alkalosis/2mEqKCl
replaced, FiO2 -60%

Component 8/17 with FiO2 40% 8/18 with FiO2 28% at 2 8/18 with FiO2 28% at
at 9:30 pm am 5 am

pH 7.365 7.387 7.383

PCO2 33.0 mm Hg 29.9 mmHg 28.0mmHg
pO2 116.9 mmHg 80.8 mmHg 69.8mmHg
HCO3 19.1 mmol/L 18.1 mmHg 16.8mmHg
Na+ 135.3 mmol/L 135.7mmol/L 135.7mmol/L
K+ 3.57 mmol/L 3.27 mmol/L 3.75 mmol/L
Ca++ 1.15 mmol/L 1.11 mmol/L 1.14 mmol/L
 Mg++ 0.55 mmol/L 0.55 mmol/L 0.56 mmol/L
Intrepretation/ MgSO4 180 mg, Compensated respiratory
Maintainance potassium 1.5 mEq alkalosis,
replaced.

Investigation:

Hematology:

Test Result Reference Range Interpretation

PT 13 seconds -- Normal
Control 10.0 seconds -- Normal
INR 1.3 Normal

Biochemistry:

Test Result Reference Range Interpretation

Random blood sugar 95 mg/dl 74-106 mg/dl Normal
Blood Urea Nitrogen 10 7-18 Normal
Creatinine 0.26 mg/dl 0.8-1.3 Low
Sodium 137 135-146 Normal
Potassium 4.3 3.5-5.2 Normal
Total protein 4.0g/dl 6.4-8.2 Normal
Bilirubin total 0.3 mg/dl 0-1.1 Normal
Bilirubin Direct 0.1mg/dl 0-0.4 Normal
SGPT 21 U/L 30-65 Normal
SGOT 30U/L 0-45 Normal
Alkaline phosphatase 98 U/L 40-140 Normal
Albumin 2.0g/dl 3.8-4.9 Low
Gamma GT 18 U/L 5-40 Normal

Hematology:

Test Result Reference Range Interpretation

Hemoglobin 7.6 gm% 13.0-18.0 Low
 TC 8,580cells/cum 4000-11000 Normal
DC
Neutrophils 69 45-75 Normal
Lymphocyte 25 25-45 Normal
Monocytes 05 2-8
Eosinophil 01 1-4
RBC 3.77milliom/cu 4.5-6.5 Low
Platelets 339,000cells/cum 150000-400000 Normal

Problems:

-Pain

-Tachycardia, hypotension

Nursing Diagnosis:

1. Acute pain related to surgical incision as evidenced by tachycardia, increased body

temperature, increased respiration rate 44 breaths/minute.
2. Risk for decreased cardiac output related to structural factors of congenital heart defect as
evidenced by tachycardia, dyspnea.

7)2076/8/18(1st POD/2nd day of care):

Heart rate: 166 beats/ min SpO2: 100%

Respiration rate: 48 breaths/min CVP/MAP: 10/5

Temperature: 99°F

GCS:15/15 ECG: sinus Tachycardia

Pupil : bilateral reactive

Blood pressure: 84/56 mm Hg

General condition of patient was satisfactory. GCS was 15/15, sinus tachycardia. Patient had
normal temperature in the morning but had maximum of 100.4ºF., respiration rate was
high.SpO2 was maintained at 40% venturi mask. CVP was raised of maximum 17 cm H20. IVF
½ NS+ D5 running at 10 ml/hour. In the morning meidastinal drain out was done with nil drain
but central line and Foleys insitu. Nebulization was done with ipratromium bromide and
suctioning done and found to be mucus secretion. Expressed breast milk given through
nasogastric tube. Fentanyl 2.5 mcg was provided hourly. Random blood sugar done 6 hourly and
low under normal range. Patient was change fromVenturi mask to face mask at 11:00am.
Total urine: 380ml

Test Result Reference Range Interpretation

Random blood sugar 104 mg/dl 74-106 mg/dl Normal
Blood Urea Nitrogen 8 7-18 Normal
Creatinine 0.39 mg/dl 0.8-1.3 Low
Sodium 138 135-146 Normal
Potassium 4.5 3.5-5.2 Normal
Total protein 4.9 g/dl 6.4-8.2 Normal
Bilirubin total 0.4 mg/dl 0-1.1 Normal
Bilirubin Direct 0.1mg/dl 0-0.4 Normal
SGPT 25 U/L 30-65 Normal
SGOT 39 U/L 0-45 Normal
Alkaline phosphatase 103 U/L 40-140 Normal
Albumin 2.5 g/dl 3.8-4.9 Low
Gamma GT 18 U/L 5-40 Normal
CKMB 28U/L 0-25 High
Hematology:

Test Result Reference Range Interpretation

Hemoglobin 8.5 gm% 13.0-18.0 Low
TC 2,6660 cells/cum 4000-11000 High
DC
Neutrophils 75 45-75 Normal
Lymphocyte 18 25-45 Normal
Monocytes 07 2-8
Eosinophil 00 1-4
Basophil 00 0-1
Test Result Reference Range Interpretation
Platelets 532000 cells/cum 150000-400000 Normal
PT 13.6 --
Control 10.0 seconds -- Normal
INR 1.4 -- Normal

Problems:
-Fever

-Crepitus on lung auscultation

-Pain

Nursing diagnosis:

1) Acute pain related to surgical incision as evidenced by tachycardia, increased body

temperature, increased respiration rate 44 breaths/minute, excessive crying.
2) Fluid volume excess related to low protein in plasma evidenced by periorbital swelling,
increased central venous pressure.
3) Hyperthermia related to infection as evidenced as body temperature 100°F, flushed skin,
sweating.
4) Ineffective airway clearance related to accumulation of secretions as evidenced by
crepitus on lung auscultation, thick mucus secretion on suctioning, high respiration rate.

8)2076/08/19 (2nd POD/3rd ICU day/ 3rd day of care):

Heart rate: 160 beats/ min SpO2: 98%

Respiration rate: 58 breaths/min CVP/MAP: 76 mm Hg

Temperature: 99°F

GCS:15/15 ECG: sinus Tachycardia

Blood pressure: 116/64 mm Hg Pupil : bilateral reactive

General condition of patient seems satisfactory. ECG shows sinus tachycardia. O2 via Face mask
provided with maintained saturation but was Tachypnea persist. Feeding done via mouth as
tolerated. Nebulatization, chest physiotherapy and suctioning done. Peripheral I/V cannulation
done, central lines out. Normal bladder habit and had passed stool. Planned for trans out.

Investigations:

Biochemistry:

Test Result Reference Range Interpretation

Random blood sugar 95 mg/dl 74-106 mg/dl Normal
Blood Urea Nitrogen 5 7-18 Normal
 Creatinine 0.29 mg/dl 0.8-1.3 Low
Sodium 136 135-146 Normal
Potassium 2.9 3.5-5.2 Normal

Hematology:

Test Result Reference Range Interpretation

Hemoglobin 7.3 gm% 13.0-18.0 Low
TC 18420cells/cum 4000-11000 High
DC
Neutrophils 68 45-75 Normal
Lymphocyte 24 25-45 Normal
Monocytes 08 2-8
Eosinophil 10.0 1-4

Platelets 360000cells/cum 150000-400000 Normal

PT 12.8 --
Control 10.0 seconds -- Normal
INR 1.3 -- Normal
General condition of patient was satisfactory after shifted toward. Vital signs are within normal
range. Normal bowel and bladder habit. Saturation was maintained with 5-6L face mask. Patient
was under breast feeding. Vancomycin continued

Medications:

1) Inj. Meropenem 20 mg IV BD
2) Inj vancomycin 60 mg IV QID
3) Syp. PCM 5 ml PO QID
4) Inj Lasix6 mg IV QID

Problems:

1) Imbalanced nutrition less than body requirement related to anorexia secondary to

congenital heart defect as evidenced by low body weight than age, decreased serum
albumin, dry skin.
2) Hyperthermia related to infection as evidenced as body temperature 100°F, flushed skin,
sweating.
 3) Ineffective airway clearance related to accumulation of secretions as evidenced by
crepitus on lung auscultation, thick mucus secretion on suctioning, high respiration rate.

9)2076/08/20 (3rd post-op day):

Time Pulse(beats/min) Blood Temperature Respiratory Rate Oxygen

pressure (F) (breaths/minute) saturation
(mm of hg) (%)

2 pm 135 -- 96.6 28 93 6L O2 via

Face mask
6 pm 124 -- 98 28 100 in 5 L O2
via face mask
10 pm 100 -- 97.5 30 99 in 5L O2
via face mask
General condition of patient was satisfactory. Vital signs were within normal range. Patient
was under breast feeding. Normal bowel and bladder habit. Meropenem and vancomycin
stopped. NG tube and pacing wire removed in the evening. Fentanyl 5 mcg was
administered at night due to continuously crying (may be due to pain).

Medications:

1) Tab sildanafil 6.25 mcg PO BD

2) Inj. Fentanyl 5 mcg IV stat

9)2076/08/21 (4th post-op day):

Time Pulse(beats/min) Blood Temperature Respiratory Rate Oxygen

pressure (F) (breaths/minute) saturation
(mm of hg) (%)

6 am 100 -- 96.5 26 92

10 am 138 -- 97 28 92 in Room
air
6 pm 139 -- 98 38 86 in RA

10 pm 144 -- 96.8 28 75 in RA

General condition of patient was satisfactory. Vital signs were within normal range. Patient
was under breast feeding. Normal bladder habit but had thick mucus mixed loose stool
passed therefore stool was send for parasitological finding.NG tube and pacing wire
removed. Fentanyl 5 mcg was administered at night due to continuously crying (may be due
to pain).
 Investigations: Parasitology

Stool RE/ME Findings

Physical examination
Color Brown
Consistency Semi-solid
Mucus Present
Microscopic examination
Pus cell 0-1
RBC Nil
Undigested food particles Fat droplets plenty
Parasites Not seen

Added Medications:

1) Syp. Bifilac 5 ml PO BD
2) Syp. Cefixime 5 ml 15 ml PO BD

10)2076/08/22 (5th post-op day):

Time Pulse(beats/min) Blood Temperature Respiratory Rate Oxygen

pressure (F) (breaths/minute) saturation
(mm of hg) (%)

10 am 138 -- 96 28 92 in Room
air
6 pm 139 -- 98 38 86 in RA

10 pm 138 -- 96.8 28 75 in RA

General condition of patient seems satisfactory. Vital signs were within normal range. Normal
bladder habit. Patient was under breast feeding. Patient’s parents were encouraged to have oral
rehydration. Fentanyl 25 mcg was provided at night. Plan for discharge tomorrow.

10)2076/08/23 (6th post-op day):

Time Pulse(beats/min) Blood Temperature Respiratory Rate Oxygen

pressure (F) (breaths/minute) saturation
(mm of hg) (%)

10 am 122 -- 96.8 30 92 in Room

air
2 pm 139 -- 97.6 28 93in RA
General condition was satisfactory. Vital signs were within normal range. Normal bowel and
ladder habit. Patient was discharge. Discharge teaching was provided.