Serrano, Alyssa Marie C.

19-1527
BSN-II
Case study on children with cardiac disorders.
An 11-year-old previously healthy boy is hit in the chest while playing tag with friends and develops acute chest pain and dyspnea, followed by a brief syncopal episode. He is
brought to a rural emergency department by his parents with no intervention on scene and subsequently transferred to a pediatric trauma center for suspected cardiac contusion.
Review of systems indicates that he has been in good health and is physically active. The only finding of note on his past medical history is seasonal allergies and an episode of
pharyngitis 1.5 years ago that was sufficiently severe to require administration of intramuscular antibiotics. There is no family history of cardiac diseases or sudden death.
Physical examination shows a well-developed boy in respiratory distress with mild petechiae isolated to his chest. His temperature is 37.4°C (99.3°F), heart rate is 140 beats per
minute, respiratory rate is 40 breaths per minute, blood pressure is 117/55 mm Hg, and oxygen saturation is 85% on nonrebreather mask. He is intubated for work of breathing and
hypoxia. Cardiac examination reveals normal heart sounds and no murmur. He has normal radial pulses but faint pedal pulses with delayed capillary refill. There is no
hepatomegaly. Breath sounds are coarse bilaterally. The remainder of the physical examination findings are normal.

Diagnosis:
Chest pain and dyspnea may feel when the boy was hit in his chest, due to this complaint and the past medical history of the boy 1.5 years ago, which is pharyngitis that was
sufficiently severe, that it requires administration of IM antibiotics, I concluded that this is a Rheumatic heart fever/ rheumatic heart disease.
For the nursing intervention, since administration of oxygen supply was already given on nonrebreather mask, I prioritize the circulation of the boy, since there was a faint pedal
pulses with delayed capillary refill. So my nursing care plan focused on tissue perfusion of the perepherals.
NURSING CARE PLAN

ASSESSMENT NURSING PLANNING/EXPECTED NURSING RATIONALE EVALUATION

DIAGNOSIS OUTCOME INTERVENTION
Chief complaint: Ineffective tissue After 6-8 hours of nursing Inspect for pallor, cyanosis, Systemic vasoconstriction After 6 hours of nursing
-Acute chest pain and perfusion related to intervention, patient will mottling, cool and clammy resulting from diminished intervention, patient
Dyspnea, followed by reduction/interruption of demonstrate adequate skin. Note strength of cardiac output may be demonstrated an adequate
brief syncopal episode. blood flow as evidenced perfusion as evidenced by peripheral pulses. evidenced by decreased skin perfusion as evidenced by
by faint pedal pulses with present/strong peripheral perfusion and diminished strong pedal pulses with
Past medical hx: delay capillary refill. pulses. pulses. normal capillary refill, 2
-Seasonal allergies seconds capillary time.
-Episode of pharyngitis Monitor respirations, note Cardiac pump failure and/or
(sufficiently severe), 1.5 work of breathing. ischemic pain may precipitate Goal met.
years ago with respiratory distress; however,
administration of IM sudden or continued dyspnea
antibiotics may indicate thromboembolic
pulmonary complications.
Family hx:
-No hx of cardiac Monitor intake, note changes Decreased intake or persistent
disease or sudden death in urine output. Record urine nausea may result in reduced
specific gravity as indicated. circulating volume, which
Observation: negatively affects perfusion
T: 37.4°C and organ function. Specific
HR: 140 bpm gravity measurements reflect
R: 40 hydration status and renal
BP: 117/55 function.
SpO2: 85%
Encourage active or passive Enhances venous return,
-respiratory distress leg exercises, avoidance of reduces venous stasis, and
with mild petechiae isometric exercises. decreases risk of
isolated to his chest. thrombophlebitis; however,
isometric exercises can
-faint pedal pulses with adversely affect cardiac
delay capillary refill. output by increasing
-course breath sounds, myocardial work and oxygen
bilaterally. consumption.

Monitor laboratory data: Indicators of organ perfusion

ABGs, BUN, creatinine, and function. Abnormalities
electrolytes, coagulation in coagulation may occur as a
studies (PT, aPTT, clotting result of therapeutic measures.
times).