NCM 109

CASE STUDY WEEK 4

DIRECTIONS: Read the following cases and answer the questions provided below.

CASE STUDY #1 Congenital Heart Defects

James is a four week old diagnosed at birth with Tetralogy of Fallot. He was scheduled for surgery
in 2 weeks, but because of hypercyanotic spells he is admitted to the intensive care unit from the
emergency room. As James’ nurse, you know that Tetralogy of Fallot is a combination of ventricular septal
defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy. The hypercyanotic spells
that James is experiencing are primarily related to pulmonary stenosis. The greater the amount of
obstruction in the pulmonary outflow tract or the greater the degree of pulmonary stenosis the more
cyanotic the patient will be. Because blood is unable to flow from the right side of the heart to the lungs to
receive oxygenation the blood will shunt right to left across the Ventricular Septal Defect and return to body
without being oxygenated. The hypercyanotic spells is caused by an increased oxygen requirement
together with increased resistance to pulmonary flow.

SOURCE: https://www.youtube.com/watch?v=21Ta4c61TZs

Questions:

1. Create 2 nursing diagnoses in 1 NCP.

Assessment Nursing Planning Nursing Rationale Evaluation

Diagnosis Intervention

OBJECTIVE: 3rd Dx STG: Independent: STG:

Risk for infection ● Monitor for signs ● Prevent further
 Admission related to impaired After 2 hrs of of worsening complications After 2 hrs of
due to peripheral nursing intervention, symptoms. in the infant’s nursing intervention,
circulation and the patient’s condition. the patient’s
hypercyan
inadequate significant others ● Instruct parents ● Prevents significant others
otic spells. will be notified and and child in reduced are able to
oxygenation as
educated about the personal defenses or understand the
evidenced by
condition of their hygiene and exposure to condition of their
hypercyanotic baby and the practices. possible infant as evidenced
spells. necessary contaminants. by verbalization of
procedures to be ● Position the ● Improves confirmation to
2nd Dx done once baby child in a knee- oxygenation notify healthcare
Risk for manifests symptoms to-chest by reducing providers if
decreased cardiac of TOF. position. the volume of manifestations of
output related to blood that is TOF arise.
structural LTG: shunted
abnormalities of through the Goal Met.
the heart After 16 hrs of overriding
secondary to nursing intervention, aorta and the LTG:
the patient will not interventricular
Tetralogy of Fallot
experience any septal defect. After 16 hrs of
as evidenced by
infection. The ● Provide ● Protects nursing intervention,
hypercyanotic against the patient will not
patient will also adequate rest
 spells. demonstrate and nutritional potential experience any
adequate cardiac needs for age. infection by infection. The
Reference:  output. increasing patient will also
body demonstrate
Doenges, M. E., resistance and adequate cardiac
Moorhouse, M. F., Dependent: defenses. output as evidenced
Murr, A.C. Nurse’s ● Administer ● To achieve by within normal
Pocket Guide: oxygen therapy stabilization. parameters of infant
Diagnosis, as per MD vital signs.
Prioritized order. ● Provides
● Monitor vital information Goal Met.
Interventions and
signs especially indicating
Rationales. (14th
the oxygen, potential
ed.). pp. 113-121, temperature and infection.
499-505 cardiac output.

Interdependent: ● For further

 Refer to assessment
pediatric and
cardiologist. evaluation.

2. Identify your Health Teaching for the mother and in relation to newborns diagnosis.

a. Educate the patient’s significant others about the condition and the status of their child to
relieve them from anxiety and prevent misunderstanding of information present.
b. Inform the parents to ensure that if medications are prescribed, that they may monitor the
intake as this will help the child’s heart beat strongly and regularly.
c. Instruct the parents to contact healthcare provider immediately if manifestations of Tetralogy of
Fallot arise.
d. Tell the parents to teach the infant, as he grows, to execute the knee-chest position to help
increase blood flow in the lungs.
e. Prevent smoking as this will harm the child’s heart and lungs.
f. Monitor the vaccination schedule of the child to help protect him against infections.
 CASE STUDY #2 Lung Case Study

TTN (Transient Tachypnea of the Newborn)

You're called to assess a newborn who's breathing rapidly and grunting. Mother is a 32-year old woman
who has had an uncomplicated pregnancy, this is her second child. Since her first was delivered by cesarean
section, she and her doctors have decided to deliver this baby by cesarean section as well. Baby is a 39 weeks
gestational age, so its term. The operation was scheduled and the mother did not go into labor in advance. The rapid
noisy breathing began when the baby was 15 minutes old. Transient tachypnea of the newborn or TTN, this is a
common problem in babies who are full term and delivered by cesarean section without labor or in babies who are
born vaginally but very rapidly or precipitously.

SOURCE:
Part 1 - https://www.coursera.org/lecture/newborn-capstone/lungs-case-studies-part-1-FqdeX

Questions:

1. Create 1 nursing diagnosis in 1 NCP.

Assessment Nursing Planning Nursing Rationale Evaluation

Diagnosis Intervention

OBJECTIVE: Ineffective STG: Independent: STG:

breathing pattern ● Maintain a clear ● To clear
 Rapid related to transient After 2 hrs of airway by obstruction in After 2 hrs of
breathing tachypnea of the nursing intervention, suctioning the airway. nursing intervention,
newborn as the patient will secretions. the patient
and
evidenced by establish a normal, demonstrates a
grunting of effective respiratory normal, effective
the rapid breathing
pattern as Dependent: respiratory pattern
newborn and grunting.
evidenced by within ● Administer ● For as evidenced by
 39 weeks normal limits of vital oxygen therapy management within normal limits
Reference:  signs. as per MD of underlying of vital signs.
AOG infant
order. pulmonary
(Term) Doenges, M. E.,
LTG: ● Monitor vital condition, Goal Met.
Moorhouse, M. F., signs especially respiratory
Murr, A.C. Nurse’s After 20 hrs of the oxygen and distress, or LTG:
Pocket Guide: nursing intervention, RR. cyanosis.
Diagnosis, the patient ● Provides After 20 hrs of
Prioritized maintains an information nursing intervention,
Interventions and effective breathing indicating the patient
Rationales. (14th pattern, as potential maintains an
ed.). pp. 107-113 evidenced by infection. effective breathing
relaxed breathing at pattern, as
normal rate and evidenced by
depth and absence relaxed breathing at
of tachypnea. normal rate and
depth and absence
of tachypnea.

Goal Met.
 Respiratory Infections
You are asked to assess a newborn whose mother has had risk factors for infection. Let's say this mother
had prolonged rupture of her membranes that means that her water broke more than 18 hours prior to delivery. In
addition, she had fever during labor, had a positive Group B streptococcus and has refused all antibiotics.

A chest X-ray would be the best way to diagnose pneumonia in this case. In addition, they will have blood tests done
to look for infection and be given antibiotics to treat.

SOURCE:
Part 2 - https://www.coursera.org/lecture/newborn-capstone/lung-case-studies-part-2-b73IP

Questions:

1. Create 1 nursing diagnosis in 1 NCP.

Assessment Nursing Planning Nursing Rationale Evaluation

Diagnosis Intervention

OBJECTIVE: Risk of infection STG: Independent: STG:

caused by ● Maintain strict  Aseptic
 Respiratory increased After 2 hrs of asepsis technique After 2 hrs of
distress of vulnerability of nursing intervention, technique while decreases the nursing intervention,
infant related to the patient will taking care of chances of the patient maintain
an infant
pneumonia as maintain normal the infant. transmitting or normal vital signs as
 Fever and vital signs as spreading evidenced by within
Group B evidenced by
evidenced by within pathogens to normal parameters
newborn’s mother
strep- normal parameters or between of infant vital signs.
having fever and of infant vital signs.
positive patients.
positive for Group ● Ensure that any  This reduces Goal Met.
mother B strep during LTG: articles used are acquiring of
during labor and delivery. properly infection. LTG:
labor and After 20 hrs of disinfected or
delivery Reference:  nursing intervention, sterilized before After 20 hrs of
the patient will use. nursing intervention,
Doenges, M. E., remain free from ● Educate mother  To prevent the patient remains
Moorhouse, M. F., infection as about the further health free of infection as
Murr, A.C. Nurse’s evidenced by importance of complications. evidenced by
Pocket Guide: normal vital signs medications. normal vital signs
Diagnosis, and absence of and absence of
Prioritized signs and symptoms Dependent: ● For signs and symptoms
Interventions and of infection. ● Administer management of infection.
Rationales. (14th medications as and treatment
per MD order. of infections. Goal Met.
ed.). pp. 499-505
● Monitor vital ● Provides
signs. information
indicating
potential
infection.
 Respiratory Distress
What if you're called to the delivery of a newborn who's 41 weeks gestational age and has had meconium in
the amniotic fluid before birth. Meconium is the name for newborns stool and sometimes the baby will have a bowel
movement before birth, usually either because they are overdue, or as a result of some sort of stress factor. A
newborn who is born with meconium in the amniotic fluid may develop meconium aspiration syndrome. This means
that the meconium and fluid were aspirated or inhaled into the lungs. Meconium in the lungs causes the infant to
have respiratory distress for several reasons. First, the meconium itself is made up of many different substances that
are toxic to a newborn lung. Second, the meconium can block the small airways of the lungs. Third, meconium
inactivates a chemical called surfactant, that is necessary to keep the smallest parts of the airways open during
breathing. Finally, babies with meconium aspiration are at risk for a collapse of the lung, which is also known as a
pneumothorax. Babies who have symptoms of meconium aspiration may need supplemental oxygen or additional
pressure for their lungs to support their breathing.

In severe cases, they may need to have a tube inserted into their airway to have a machine breathe for
them. This last group of babies will need intensive care. When are called about a newborn in respiratory distress,
remember to go evaluate the baby right away. Make sure that the baby is being supported or stabilize as needed with
oxygen and pressure, perform your exam and take a quick history in order to narrow down the potential cause of
respiratory distress. 

SOURCE:
Part 3 - https://www.coursera.org/lecture/newborn-capstone/lungs-case-studies-part-3-FBMeT

Questions:

1. Create 1 nursing diagnosis in 1 NCP.

Assessment Nursing Planning Nursing Rationale Evaluation

Diagnosis Intervention

OBJECTIVE: Risk for Ineffective STG: Independent: STG:

airway clearance ● Maintain a clear ● To clear
 41 weeks related to After 2 hrs of airway by obstruction in After 2 hrs of
AOG infant excessive mucus nursing intervention, suctioning the airway nursing intervention,
in the newborn’s the patient will secretions. when the patient
(Term)
respiratory establish a normal, excessive or demonstrates a
 Infant effective respiratory viscous normal, effective
having passages as
pattern as secretions are respiratory pattern
evidenced by
meconium evidenced by within blocking as evidenced by
meconium normal limits of vital airway. within normal limits
in the
aspiration signs. ● Monitor infant ● This may of vital signs.
amniotic
for feeding compromise
fluid before Reference:  LTG: intolerance, the airway. Goal Met.
birth abdominal
Doenges, M. E., After 10 hrs of distention, and LTG:
Moorhouse, M. F., nursing intervention, emotional
Murr, A.C. Nurse’s the patient stressors. After 10 hrs of
Pocket Guide: maintains an airway ● Auscultate ● To ascertain nursing intervention,
Diagnosis, patency as breath sounds current status the patient
Prioritized evidenced by a and assess air and note maintains an airway
Interventions and respiratory rate movement. effects of patency as
Rationales. (14th within normal range treatment in evidenced by a
ed.). pp. 27-33 of 30-60 bpm, clearing respiratory rate
showing no signs of airways. within normal range
respiratory distress. Dependent: of 30-60 bpm,
● Monitor vital ● To prevent showing no signs of
signs. further respiratory distress.
complications.
Goal Met.