Activity # 3: ISBAR

KRISTIAN KARL B. KIW-IS

BSN IV-A
I Name: Kristian Karl B. Kiw-is
Role: Student Nurse
Ward: BGHMC Medical ward
I am calling because of the case of my patient who is suffering from TOF.
S Baby Mu, an 8 week (2month) OLD-old infant, was admitted to Pediatrics (MEdical)
Ward. Regarding the systemic inquiry of Baby Mu, there was cyanosis, Passed urine
normally, No fevers or rigors (Temperature – 37 C), Not in pain, Alert and non-lethargic,
Mild bluish discoloration of lips and tongue, SaO2 83%, Heart rate: 156 bpm RR:
48/min, anterior fontanelle normal. During the onset of Respiratory distress at birth he
was rendered resuscitation, given CPAP and PEEP to maintain oxygenation to lungs.
His breathing was monitored, routine blood exam was done including ABG. Continuous
monitoring oxygen saturation was also done.
.
He was given feeding via TPN (6ml/kg/2 hourly). Cardiac catheterization was also done
to assess for cardiac anomaly.
He was monitored for temperature elevation post-operatively – If pyrexial, he was
given vancomycin and gentamicin. Additional medications were aspirin, frusemide,
spironolactone and paracetamol PRN. His feeding was increased to 150ml/kg/day via
bottle
B Baby Mu, an 8 week (2month) OLD-old infant, was admitted to Pediatrics (MEdical)
Ward with an ongoing IVF of 0.9 NACL x KVO since birth due to severe systemic cyanosis
caused by several congenital heart problems. Soon after birth, he suffered from (z)
(A)cute (R)espiratory (D)istress, where his initial SaO2 was only about 72%. On
appearance, he was dark complexion looking and his peripheries were cold and
cyanotic. He was started on biphasic continuous positive airway pressure (CPAP) via an
apnea mask and was also given positive end-expiratory pressure (PEEP) as additional
help. His CPAP was delivered using nasal cannula the following day after his SaO2
increased to 80% and he remained on CPAP for the first 5 days after birth, which
subsequently was weaned off. Antenatal scans found pulmonary atresia, overriding
aorta, and ventricular septal defect (VSD). Bay Mu underwent Echocardiogram and CXR
and the findings was consistent with Tetralogy of Fallot in his CXR it was found that he
has cardiomegaly.
Cardiology experts advised surgery to establish a connection between aorta and
pulmonary artery to increase pulmonary blood flow.
A shunt was inserted via median sternotomy. Echo post-op showed good flow in small
pulmonary arteries and patent central shunt.
Continue monitoring oxygen saturation – aim to keep above 75%
An ECG was performed.
A Monitor vital signs, peripheral pulses, and capillary refill by comparing measurements.
Assess and record the cardiac rate.
Observation of cyanotic attacks.
Give a knee-chest position.
Observe for signs of decreased sensory: lethargy, confusion, and disorientation.
Monitor intake and output adequately.
Provide adequate rest time.
Collaboration in the examination serial ECGs, chest radiographs, administration of anti-
dysrhythmias.
Collaboration of oxygen.
Collaboration IV fluid administration.
R Surgery for tetralogy of Fallot involves open-heart surgery to correct the defects
(intracardiac repair) or a temporary procedure that uses a shunt.
Continue monitoring oxygen saturation – aim to keep above 75%
Continue administering medical and nursing management.
Refer accordingly
Close monitoring after operation.