ASSESSMENT EXPLANATION OF THE OBJECTIVE NURSING RATIONALES EVALUATION

PROBLEM INTERVENTION

Subjective: NA Tricuspid atresia (TA) STO: Dx: STO:

Objective: my is a heart defect within  Assess  Most patients
baby can’t breath present at birth 50minutes to heart rate have (Goal partially
properly as (congenital). It occurs 1hour of and blood compensatory met)
when the tricuspid effective pressure. tachycardia After 50 minutes
verbalized by the
valve doesn’t form. nursing and to 1 hour of an
mother. Normally, the tricuspid
Shortness of interventions, significantly effective nursing
valve is located the patient will low blood intervention the
breath. between the right be able to: pressure in patient was able
Bluish upper chamber
response to to maintain an
discoloration of (atrium) and the right
a, maintain an reduced adequate
the skin. lower chamber
adequate cardiac cardiac output,
Fatigue (ventricle) of the heart.
Instead of a valve, a cardiac output. with a normal
Swelling in the output. skin color.
piece of tissue forms
lower  Note skin  Cold,
which restricts blood
extremities. flow between the right b. Have a color, clammy, and
atrium and right normal skin temperat pale skin is LTO:
A. Decreased ventricle. The defect color. ure, and secondary to (Goal met)
cardiac output keeps low oxygenated moisture a After 24-48 hours
related to blood from flowing LTO: compensatory of effective
decreased normally into the right Within 24-48 increase in nursing
peripheral pulse atrium to the right hours of sympathetic n interventions, the
secondary to ventricle and to the effective ervous patient’s was
tricuspid atresia lungs where the blood nursing system stimul able to tolerate
as evidenced becomes oxygenated. interventions, ation and low minimal activity
by skin color With tricuspid atresia, the patient cardiac output without
change. there is mixing of low will: and oxygen symptoms of
oxygenated blood with desaturation. dyspnea.
oxygenated blood.
This means not  ability to
enough oxygen in the tolerate  Check for  Weak pulses
blood is carried to the activity periphera are present in
body. This causes a without l pulses, reduced strok
bluish coloring of the symptoms of including e volume and
skin. dyspnea. capillary cardiac
refill. output.
Tx;
Reference;
Stanfordchildrens.org  Position
child in  Help with
semi- breathing, for
Fowler’s easier
position. breathing.

 Minimize
their  Rest
energy decreases
expenditu metabolic
 re. rate,
decreasing
myocardial
and oxygen
demand.

 Administe  The failing

r oxygen heart may not
therapy be able to
as respond to
prescribe increased
d oxygen
demands.
Oxygen
saturation
needs to be
greater than
90%.
Administer
medication as  Increases
prescribed. contractility of
 Digoxin. the heart and
 Furosemi force of
de. contraction

 Decreases
edema
formation and
diminish
afterload.

Edx:

 Teach  When the

the patient is at
subordina rest more
te other oxygen is
the need reserved.
for
patient’s
frequent
rest.
 Frequent
 Encourag meal will help
e the child to
frequent increase the
meal to nutrient
the child intake.

 Encourag  For easier

 e the passage.
need for
feeding
with a
large
opening

ASSESSMENT EXPLANATION OF OBJECTIVE NURSING RATIONALES Evaluation

THE PROBLEM INTERVENTION

Subjective: Tricuspid atresia STO: DX: STO:

Objective: (TA) is a heart within  Assess for  Early identification
My baby looks defect present at 50minutes to risk of drug of signs (Goal
weak as birth (congenital). It 1hour of toxicity, and symptoms of partially met)
verbalized by occurs when the effective a cardiac complications After 50
the mother. tricuspid valve nursing complication allows preventive minutes to
Fatigue doesn’t form. interventions measures and 1 hour of an
of
Lethargic Normally, the , the patient adjustments to be effective
heart failure.
tricuspid valve is will be able nursing
made.
located between the
B. Risks for to:  Monitor intervention
right upper chamber
injury related orders for  Allows for s the
(atrium) and the
to cardiac tolerate diagnostic preparation and patient was
right lower chamber
function (ventricle) of the minimal tests support of parents able to
compromised heart. Instead of a activity and and infant/child. tolerate
by tricuspid valve, a piece of without procedures. minimal
atresia and tissue forms which symptoms of activity
medication restricts blood flow dyspnea.  Assist and  Provides needed without
administration between the right support to symptoms
support
. atrium and right LTO: allay anxiety and of dyspnea
family’s
ventricle. The defect Within 24-48 promote caring
feelings
keeps low hours of
and decision attitude.
oxygenated blood effective LTO:
regarding
from flowing nursing (Goal met)
normally into the interventions surgery. After 24-48
right atrium to the , the patient hours of
right ventricle and to will:  Ensures safe and effective
 Ensure that
the lungs where the accurate administr nursing
patient is on
blood becomes Child will not ation and because interventions
NPO to 46hrs
oxygenated. With experience digoxin is going to , the
tricuspid atresia, prior to the
there is mixing of injury. surgery slow down the patient’s was
procedures. heart rate. able to
low oxygenated
remain safe
blood with
Tx: from injury.
oxygenated blood.
This means not  Ensure that in
enough oxygen in the  To help prevent
the blood is carried administration over dose
to the body. This of digoxin,
causes a bluish taking the
coloring of the skin. apical
pulse, when
to withhold
Reference; (less than 70-
stanfordchildrens.or 80 in child
g and 90-100 in
an infant), to
notify the
physician of
low pulse or
irregular
pulse, signs
of toxicity.

 Ensure to use  To avoid

a calibrated administering
device that overdose to the
comes with patient.
the
medication

 Monitor for  Digoxin toxicity

signs and can lead to brady
symptoms of cardia, GI upset,
digoxin vomiting ,
toxicity. dysthymia.

Edx:
 Teach actions  Encourages
to take if the calmness during
child an attack and
becomes teaches actions
cyanotic that will relieve
(knee-chest episode and
or associated fear.
squatting posi
tion, elevating
head and
chest), when
to call the
physician.