ANGELES UNIVERSITY FOUNDATION ANGELES CITY COLLEGE OF NURSING

Ventricular Septal Defect in Failure with Pneumonia

Case Study:Pediatric Ward

In partial fulfillment of the requirements in Related Learning Experiences Pediatric Area

Submitted to: Abigail A. Buan, RN Clinical Instructor

Submitted by: Galang, Miguel Paolo A. Dimla, Shayne M. Magtoto, Jessica E. Mallari, Giselle M. Policarpio, Frances Joye P.

Group 7 BSN III-2

I. INTRODUCTION What we have most to fear is failure of the heart. -Sonia Johnson The heart is a muscular four-chambered organ whose primary purpose is to pump blood throughout the body. It is composed of four chambers namely: left atrium, left ventricle, right atrium and right ventricle. It is a special organ that mainly supports our body to function well. Without the heart, human being will die. But even though the heart is a special organ, as a part of the body, it is not exempted to have damage. Many defects and diseases are being associated with the heart. One of these defects is called Ventricular Septal Defect. Ventricular septal defect is a congenital defect, an abnormal opening between the right and left ventricles. A ventricular septal defect can allow newly oxygenated blood to flow from the left ventricle, where the pressures are higher, to the right ventricle, where the pressures are lower, and mix with unoxygenated blood. The mixed blood in the right ventricle flows back or recirculates into the lungs. This means that the right and left ventricles are working harder, pumping a greater volume of blood than they normally would. VSDs rank first in frequency on all lists of cardiac defects. Ventricular septal defects are rare congenital malformations of the heart that occur more frequently in males than females. They account for 25-40% of all cardiac malformations at birth. U.S. and international frequencies are identicalapproximately 1-2 cases per 1000 live births. Of the babies born with VSDs, 80 to 90 percent present with a small hole and mild symptoms. Studies have shown that the prevalence of VSDs has increased in the United States during the past 30 years. A twofold increase in the prevalence of VSD was reported by the Centers for Disease Control and Prevention from 1968-1980. The Baltimore-Washington Infant Study (BWIS) reported a twofold increase in the prevalence of VSD from 1981-1989. The BWIS study reported that the increase is primarily attributed to more sensitive detection through echocardiography. In 2002, a total of 4178 Americans died from cardiovascular defects. Thousands of babies are born each year with cardiovascular defects. Of these, Ventricular septal

defects have the highest prevalence among congenital heart defects accounting 14-16% (American Heart Association, Congenital cardiovascular defects: statistics, 2005)

A. Current trends about the disease condition

In February 21, 2010, the science daily reported that there is a worsening of heart failure when the right ventricle is non-compliant. The research is from the University of Alabama at Birmingham. In VSD, there is shunting of blood from left to right ventricles (sometimes,from right to left) that causes decrease low left ventricular ejection fraction (if blood shunts from left to right) or low right ejection fraction-the blood pump by the ventricles (if blood shunts from right to left). It was discovered that low RVEF increased the risk of death in patients with heart failure which may occur in patients with VSD. Identifying at risk patients and providing appropriate therapy for them is the best suggestion of this article. Another article was released by the science daily on September 15, 2010 that a talk about repairing restrictive (small) defects in VSD is more helpful this time. The study found out that even though patients with rVSD have normal blood circulation, there were molecular changes, evidence of right ventricular diastolic dysfunction and impairment of muscle contraction and relaxation at the cellular level. These changes may have a great effect in the hearts effectiveness in providing circulation in the whole body. The study suggests that early detection and comprehensive management of rVSD is essential to prevent further complications of this condition.

B. Reasons for choosing such presentation

The group has three main reasons why they got aby Heartys case as their case study in the pediatric ward. The first reason is because, when the group had taken their first duty at a public hospital in San Fernando specifically in pediatric ward, their attention was caught by this patient who seems to be the youngest patient in the ward. In the first exposure, the group didnt approach the patients SO but instead, they

approached the SO of the other patient (who has the same condition) who is an Aeta. They tried to establish rapport with the aeta but unfortunately, they didnt succeed. So, they have made their decision that if they can establish rapport with the first patient they had seen, they will get the case as their case study. After a few minutes of therapeutic communication, they had established rapport causing them to get the case. Second reason is that the case of the patient is related to the groups topic in the lecture. And the last reason is that, the group wants to study uncommon cases to acquire knowledge about the case, its causes, manifestations, preventions, treatment and other information regarding the disease condition. OBJECTIVES 1. STUDENTCENTERED Short Term After a day of nursing intervention, the students will be able to:

y
y y y

gain the trust of the patient and the patients significant other
gain enough information about the patients past and present medical history have a background of the condition, which is Ventricular Septal Defect know the incidence, prevalence, and mortality rates of the disease in foreign and local statistics

y y

know the current trends about the condition, and identify factors present to the patient that predisposed her to the said condition

Long Term After 1 week of completing this study, the students will be able to: y y y accomplish the case study requirement explain briefly the anatomy and physiology of the heart gain proper knowledge and understanding about the existing disease condition, its pathophysiology and etiology involved in its acquisition and progression y identify the different predisposing and precipitating factors associated in the development of the condition y identify the different early clinical manifestations of the condition

analyze the different laboratory and diagnostic procedures, their indications to the condition and identify the different nursing interventions before, during and after the performance of the said procedures

explain the different treatments or medical modalities and their importance, and different nursing interventions during the performance of the said procedures,

identify common medications used as treatment for the condition, their mechanism of action, adverse effects and nursing interventions before, during and after the administration of the medications, appropriate nursing diagnoses and their corresponding effects for the disease conditions, and finally,

render appropriate nursing interventions to prevent complications of the condition

2. PATIENTCENTERED Short Term After a day of performing nursing interventions, the patient and/or patients significant others will be able to: y y have a background of Ventricular Septal defect know the reasons why such diagnostic procedures and treatment modalities are performed y know the progression of the condition

cooperate in the necessary medical and nursing interventions

Long Term After a week of accomplishing this case study, the patient and/or patients significant others will be able to: y know the reasons why the patient experiences the signs and symptoms of the condition y know preventive measures in response to the condition so as to prevent deterioration of the patients condition y participate willingly in the care of the patients conditions such as adhering to health teachings provided by the student nurses y y know how to provide care for health promotion know the possible surgery that the patient will undergo, if ordered by the attending physician

II. NURSING ASSESSMENT 1. PERSONAL DATA Baby hearty, a 5 month old boy, was born on March 19, 2010. He is a Filipino citizen and not yet baptized. He was born via Cesarean section, bikini cut at a tertiary hospital in San. Fernando Pampanga. He should have been the second child of his mother but unfortunately, intrauterine fetal death occurred to the first baby.. Baby Hearty, was diagnosed of Ventricular Septal Defect when he was 2 months old. Baby hearty together with his family resides in Guagua, Pampanga.

He was admitted last August 27, 2010; 10:30pm at a tertiary hospital at San Fernando, Pampanga with a chief complaint of difficulty of breathing with cough for four days along with fever. Baby hearty was diagnosed of Congenital Heart Disease, Acyanotic Type probably Ventricular Septal Defect in heart Failure with Pneumonia. With vital signs T-37.6 C, PR-120 bpm, RR-46 cpm with positive rales and positive tachycardia. Complete blood count and chest x-ray was done that day.

2. PERTINENT FAMILY HISTORY The Heart family is classified as nuclear type of family where in the members live together in one house consisting of the father, mother, and children. Baby hearty was delivered via Cesarean section. Mother hearty had her prenatal checkups every month and had a complete dose of Ferrous sulfate supplementation during the entire pregnancy period. Heart familys house is made up of concrete materials, having two rooms and kitchen and a bathroom. There are total of two doors and four windows in their house that makes their house well ventilated. The house is lighted with fluorescent light, which is the only appliance that uses electricity. They own appliances such as two television and three electric fans. The house has a total floor area of 18 m . The floor area, as calculated and compared with the standard floor are per family member of NEDA 2004, was considered to be adequate with all of the family members.

Daddy Hearty, 42 years old, is a guitar maker in Guagua, Betis Pampanga where he earns approximately 20,000 pesos monthly. Mommy Hearty, 20 years old is a plain housewife with grandmother Hearty and baby Hearty. Their estimated total family income is 20,000. The family is categorized as not poor. According to NEDA(2004), a family must have P2, 768.60 pesos per individual, in relation with the total family income, every individual was allotted P6666.67/month that makes them categorized as to be not poor. They spend 300 pesos for food daily. Every week Mommy Hearty and grandmother Hearty buys their grocery at the market, they spend 1,000 pesos. Family Hearty are fond of eating pork, fish, vegetable and fruits, they also love to drink softdrinks everyday. Mother hearty spends 500php for her load every month. They also pay for water 1,000 and electric bill 2,500 per month. There is also allotted money for health care emergency purposes 2,450 php. The sum total of the familys monthly income is approximately P 20,000php, which is divided in to the following expenses: Monthly Expenses Food (meals) Electricity Water Other grocery items Transportation Cellphone Load Emergency money 9,300 2,500 1,000 4,000 250 500 2,450

Total

20,000

*The data were only estimated by Mother Hearty upon interaction. They belive in usog which is very evident especially by Grandmother hearty who lets her grandchild wear a bracelet adorned with red and black beads.. When it comes to self-medication, they made use of paracetamol that are bought on the nearby sari-sari store. They also avail health services in their baranggay and had their checkups when illness occurs. They also availed free immunizations.

The figure below shows the schematic diagram of the pertinent family history. On the maternal side , both grandparents, Grandfather M and Grand mother M are healthy. While On the paternal side, both grandparents are deceased wherein Grandmother F died of stroke and Grandfather F died of heart attack. The mother of Baby Hearty, Mother Hearty, is the eldest among her siblings. She has two siblings who are twins. The child next to Mother Hearty is Uncle M who only suffered Hepatitis A when he was young and the youngest of the three is the other twin, Auntie M who suffered Pneumonia in the past. The father of Baby Hearty, Father Hearty, is the eldest among his siblings too. He has three other siblings namely Uncle F, Auntie F and Aunt F. All of the children of Grandmother F and Grandfather F were health except Uncle F who is currently experiencing Hypertension.

Genogram Maternal Side

Grandmother M Healthy Grandfather M Healthy

Paternal Side
Grandmother F Deceased Stroke Grandfather F Deceased Heart Attack

Mother Hearty Healthy Eldest

Uncle M Twin of Auntie M Hepa A

Auntie M Twin of Uncle M Pneumonia

Father Hearty Healthy Eldest

Uncle F Hypertension

Auntie F Healthy

Aunt F Healthy

Baby Hearty (Patient) VSD w/ Pneumonia

3. PERSONAL HISTORY A. Pre-natal (mothers practice/ habits during pregnancy) Mother hearty has a maternal-obstetrical record of G2P2T1P0A1L1M0 where in G or Gravida is the number of times a woman was pregnant whether it was delivered or not, P or Parity indicates number of pregnancies that was delivered whether the baby is alive or not, T or Term is the number or times a woman came to term (37 weeks), P or Preterm is the number of premature babies the woman had or pregnancy that did not reach term (20-36 weeks and 6 days), A or Abortion is the number of miscarriage, abortion and L or number of live births or the number of living children the woman has now. And M or multiparty which signifies multiple births. As her part of the conception, Mother hearty often walks around within their house every morning so that when the due date comes, she can deliver fast and to have a healthy baby. On the first pregnancy of mother hearty she was so conscious about her childbearing she has her prenatal checkups every month and takes her vitamins as well. . During her pregnancy she loves to eat chicken legs and white chocolate. She did not experience morning sickness during pregnancy. Mother hearty experienced having stretch marks on the abdominal area, edema on the lower extremities, enlargement of the nose and back ache. On the 6 th month of her pregnancy she had a prenatal checkup with her doctor because she experienced bleeding. After the consultation Mother Hearty was diagnosed with intrauterine fetal death and after that her doctor did Dilatation and Curettage. She was so upset and sad because her baby was gone. After 1 year, she got pregnant to baby Hearty and in this time she was so depressed and emotionally sick because of private matters. On the first trimester of her pregnancy specifically on the 3rd month she took Cytotec and tried to abort her baby, but the baby was not aborted.

VACCINE

SCHEDULE

% OF PROTECTION

RECEIVED BY MOTHER

TT1

As early as possible during pregnancy

--

TT1 was received by Mother hearty on her first pregnancy TT2 was received by Mother Hearty on her first pregnancy TT3 was received by Mother hearty on her first pregnancy TT4 was received by Mother

TT2

At least 4 weeks later

80%

TT3

At least 6 mos. later

95%

TT4

At least 1 yr later

99%

Hearty on her second pregnancy TT5 was not yet received by Mother hearty

TT5

At least 1 yr after TT4

99%

a. Birth duration and circumstances of labor, home or hospital delivery, type, complication, birth weight and age of gestation.

Baby Hearty was delivered by Cesarean Section, maturely at 9months of gestation, with no complications. Baby hearty is a 5 month old boy that is active whenever you play with him. He smiles whenever he is being playedwith and will cry whenever he is hungry. He was born on March 19, 2010 by Cesarean Section, bikini cut, at a tertiary hospital at San. Fernando Pampanga. He is the only child and cared by his grandmother. He weighs 6.8 grams when he was delivered.

Feeding When Baby Hearty was born, he was breastfed by his mother but because he was diagnosed of having Ventricular Septal Defect he was stopped being breastfed and he started being bottle fed (Bona). The type of his feeding was milk feeding that comprises of formula feeding. Growth and development

Psychosexual Theory of Sigmund Freud

The psychosexual stages of Sigmund Freud are five different developmental periods during which the individual seeks pleasure from different areas of the body associated with sexual feelings. These stages are as follows:

Oral Anal Phallic Latency Genital

Birth to 1 year 2 to 3 years 4 to 5 years 6 to 12 years 13 and up

Basing on this theory, baby Hearty belongs to the oral phase. It is very evident that baby Hearty is on the oral stage because everything that touches on the mouth his tendency is to suck it. And everything that he holds he grab it and put it in his mouth. His security blanket is his pacifier that whenever he cries grandmother hearty will put the pacifier on the mouth of baby Hearty.

Cognitive Theory of Jean Piaget

Cognitive development refers to how a person perceives, thinks, and gains understanding of his or her world through the interaction and influence of genetic and learning factors. This is divided into five major phases:

Sensorimotor Phase Pre-conceptual Phase Intuitive Thought Phase Concrete Operations Phase Formal Operational Phase

Birth to 2 years 2 3 years 4 6 years 7 11 years 12 adulthood

Basing on this theory, Baby hearty belongs to the sensorimotor phase. Recognizes self as agent of action and begins to act intentionally. In this phase baby hearty is very sensitive to noise and to the things that he sees. Whenever he is hungry, he cries and that in order to be pacified, his grandmother talks to him, making different sounds just to keep him quiet. Also, Baby Hearty likes to imitate the faces that he sees. When a nursing student smiles at him, he smiles back.

Psychosocial Theory of Erik Erickson Erik Erickson envisioned life as a sequence of levels of achievement. achievement, the healthier the personality of the person. Psychosocial Theory are as follows: Each

stage signals a task that must be achieved. He believed that the greater that task Failure to achieve a task influences the persons ability to achieve the next task. Stages of Ericksons

Infancy Early Childhood Late Childhood School Age Adolescence Young Adulthood Adulthood Maturity

Birth 18 months 18 months 3 years 3 5 years 6 12 years 12 20 years 18 25 years 25 65 years 65 years to death

Trust vs. Mistrust Autonomy vs. Shame Initiative vs. Guilt Industry vs. Inferiority Identity vs. Role Confusion Intimacy vs. Isolation Generativity vs. Stagnation Integrity vs. Despair

Basing on this theory, baby hearty belongs to infancy Trust vs. Mistrust. It is evident because whenever the student nurse will get him he will cry and look for his grandmother because Baby Hearty is being cared by his Grandmother hearty. Anna Freuds Psychoanalysis The first stage of psychosexual development is the oral stage, which lasts from the beginning of ones life up to 2 years. According to Anna Freud, The ego, however, is under formation during this first stage. Body image is developed, which implies that the infant recognizes that the body is distinct from the outer world. One of the signs that Baby hearty showed that he really has his own body image is through crying. Crying means that he feels pain, pain on his own body and that he uses crying in order to satisfy his need (Ego).

Milestones of Baby Hearty On the first month of Baby hearty can lifts his head when lying on tummy and he responds to sound whenever grandmother Hearty calls him. He also stares at faces. On the second month of baby hearty he can vocalizes gurgles and coos, he can also follow objects across field of vision. He can hold his head up for short periods. On the third

month of baby hearty he can recognizes the face of his grandmother to the face of his mother. In this month he can already holds head steady and visually tracks moving objects. On the fourth month of baby hearty he can now smiles and laughs and can bear weight on legs. He coos when grandmother Hearty talks to him. On the fifth month of baby hearty he now distinguishes between bold colors and plays with his hands and feet. Immunization Status Baby Hearty had his immunization 1 dose of BCG and 1 dose of Hepa only because he is 5 months old.

Vaccine Bacillus Calmette Guerin (BCG) Oral Polio Vaccine (OPV) Diphteria Pertussis Tetanus (DPT) HEPA Measles

# of doses 1 dose 0 doses 0 doses 1 doses 0 dose

4. HISTORY OF PAST ILLNESS According to Grandmother Hearty, her grandson has never been hospitalized, no history of asthma attracts and no history of allergy, until they found out that baby Hearty has a congenital Disease specifically Ventricular Septal Defect. He only experienced cough and colds, and fever. They managed it by consulting their pediatrician.

5. HISTORY OF PRESENT ILLNESS Prior to admission (August 27, 2010) had cough and colds with accompanying fever. No medicine was taken and no consultation was done.

Few hours before admission persistence of cough and colds with fever are present so family Hearty decided to confine baby hearty to the nearest hospital. When they got to the hospital and they told about baby heartys condition the secondary hospital near to their house refer them to the tertiary hospital in San. Fernando Pampanga.

On the admission, August 27, 2010, the vital signs of the client were T- 37.6 C, PR-120 bpm, RR-46 cpm negative cyanosis, negative jaundice, pink palpebral conjunctiva, anicteric sclera, presence of tachypnia, rules on the left lung field upon auscultation, positive murmur, with retraction. 6. PHYSICAL EXAMINATION

I. Integumentary: Skin: He is white in complexion, with presence of skin rashes on left arm, with good skin turgor. Nails: Fingernails and toenails are both unclean and long. Smooth in texture and the shape is convex. The capillary refill easily goes back to its color for less than 3 second. Hair: black in color, short, thin hair with patches of hair loss.

II. Head Scalp: with presence of lesions and scar. Skull: The shape of the skull is round and normocephalic. Face: Smooth with no edema III. Eyes

Eyebrows: Hair is evenly distributed and symmetrically aligned. Eyelashes: Equally distributed and the curled slightly outward. Eyelids: No discharge and discoloration. Bulbar conjunctiva: Transparent in color, capillaries are sometimes evident the sclera appears white Palpebral conjunctiva: Shiny, smooth and pink. Pupils: Black in color, equal in size and its iris is flat and round. and

IV. Ears Auricle: The auricle is aligned with the outer canthus of the eyes. Symmetrical and has the same color with the facial skin. External ear: Symmetrical in shape and size and no presence of lesions. Internal ear: There is no presence of excessive cerumen.

V. Mouth and throat Lips: dark and smooth with no presence of sores. Teeth: no teeth yet Tongue: Pinkish in color with no presence of lesions. Throat: Uvula is aligned at the center and no inflammation noted. Speech: Able to stutter Gag reflex: Able to swallow without difficulty and pain. Gums: no gingivitis and no presence of sores.

VI. Nose Symmetric and straight, uniform in color, not tender and no presence of lesions. VII. Neck Has smooth, coordinated movements. VIII. Thorax and Lungs Symmetrical when chest is expanded normal rise and fall of chest when breathing and presence of rales on the left upper quadrant upon auscultation, use of accessory muscle. IX. Heart Increase heart rate and murmurs noted. X. Abdomen Skin in the abdomen is uniform in color, globular in shape. XI. Extremities No presence of edema on his lower extremities XIII. Mental state Awake and conscious, responds to stimuli.

7. DIAGNOSTIC AND LABORATORY PROCEDURES CHEST X-RAY Diagnostic Procedure Date Ordered /Date results in Chest X-Ray Date 8-27-10 In: 9-2-10 A chest x ray used to organs and structures within the chest for symptoms of x rays include views of the lungs, heart, small portions Theres is an increased A chest x ray is a procedure used to structures within the disease. Chest x rays include views of the lungs, heart, small portions of the gastrointestinal tract, thyroid gland, and the bones of the chest area. X rays are a form of radiation that Findings suggestive of congestive heart disease , probably, Ventricular septal defect, atelectasis, right apex zone. Indications or purpose Results Normal values
Analysis and Interpretation

Ordered: is a procedure pulmonary vascularity. A Date results evaluate in the right apex. Hazy infiltrates are noted in the left upper lung zone. The heart is enlarged with prominent left ventricle. The diaphragm,its sulcus and visualized bones

wedge-shaped opacity is seen evaluate organs and

chest for symptoms of and Pneumonia, left upper lung

disease. Chest are intact.

of the gastrointestinal tract, thyroid gland, and the bones of the chest area. X rays are a form of radiation that can penetrate the body and produce an image on an xray film. Another name for the film produced by x rays is radiograph.

can penetrate the body and produce an image on an x-ray film. Another name for the film produced by x rays is radiograph.

Nursing Responsibilities for Chest X-ray: Prior: y y y y y Check the doctors order. Determine the prescribed test and other restrictions prior to the test. Get the laboratory requisition slip. Explain to the patients SO what the procedure to be done is. Inform the patients SO how the procedure is performed, the equipment to be used and what the patient would expect to feel during the procedure. y The client may need analgesics and other pain relieving interventions.

During: y y y y Explain to the patients SO what test should be done. Prepare all the equipments to be used. Assist the patient if necessary. Instruct the patient to be still or instruct the SO to keep the client calm.

After:

y y

Proper documentation. Tell the clients SO to wait until the technologist checks the images for motion and makes sure that the entire chest is included.

CBC Diagnostic Procedure Date Ordered /Date results in Indications or purpose Results Normal values Analysis and Interpretation

Hemoglobin

August 27,2010

Hemoglobin molecule fills up the red blood cells. It carries oxygen and gives the blood cell its red color. Hgb level indicates the amount of hemoglobin in blood and is a good measure of the blood's capacity to carry oxygen throughout the body. Abnormalities in Hgb indicate defects in the red blood cell homeostasis.

112 g/L

125-175 g/L

Lower than normal. This indicates of bronchi inadequate secretion of the

distribution of oxygen due to accumulation within the

patient which obstructs normal distribution of oxygen.

September 1 ,2010 A WBC count is the number of white blood cells per volume of blood, and is reported in either thousands in a microliter or millions in a liter of blood. A high WBC count can be an indicator of an infection, inflammation, or allergy.

108 g/dl

This may also indicate that there is a dyspnea occurring to the patient. Lower than normal.

WBC

August 27,2010

12.2 x 10 9/L

5-10 x 10 9/L

September 1, 2010

12.2 x 10 9/L

Elevated than normal. This indicates an ongoing infection. It may be due to pneumonia.

Elevated than normal.

Hematocrit

August 27, 2010 Measures the amount of space (volume) red blood cells take up in the blood. This indicates the proportion of cells and fluids in the blood. It is useful in evaluating dehydration and hypovolemia.

.33

M: .40-.52

Decreased Hematocrit level. This can be related to

insensible water loses that happens because of rapid respirations.

Neutrophils

August 27, 2010 Neutrophils are the most abundant type of white blood cells in humans and some of the domestic mammals and form an essential part of the innate immune system. It is tested to detect infection or inflammation. During the beginning (acute) phase of inflammation, particularly as a result of bacterial infection September 1, 2010 and some cancers, neutrophils are one of the first-responders of inflammatory cells to migrate toward the site of inflammation.

.55

M:.45-.46

Elevated than normal level. Neutrophils are elevated bacterial infection. This is may be due to the infection acquired by the patient,pneumonia.

.46

Normal level.

Lymphocytes

August 27, 2010 Lymphocytes are the second most abundant WBCs. Lymphocytes originate in the lymphoid tissues and are not phagocytic. They are responsible for initiating and regulating the immune response by the production of antibodies and cytokines. September 1, 2010

.50

.22-.35

Elevated than normal. An increase in the lymphocyte count is indicative of infection in the body like pneumonia.

.49

Elevated than normal.

Platelet

August 27,2010

September 1, 2010

Bleeding disorders require the determination of the number of platelets present and/or their ability to function correctly.

363 x 10 9/L

150-400 x 10 9/L

Normal level. There is no bleeding occurring.

365 x 10 9/L

Nursing responsibilities for Complete Blood Count: Prior:

y y y y

Verify if the order and verify the patients identity Gather the equipment to be used Wear gloves and other personal protective gear Choose the site for venipuncture
During

y y

Prepare the site to be used Perform the blood draw After

y y y

Apply pressure on the site after the blood draw to promote blod clotting Label the sample Properly dispose the used equipment

III. ANATOMY and PHYSIOLOGY Circulatory System The human heart is a muscular pump. While most of the hollow organs of the body do have muscular layers, the heart is almost entirely muscle. Unlike most of the other hollow organs, whose muscle layers are composed of smooth muscle, the heart is composed of cardiac muscle. All muscle types function by contraction, which causes the muscle cells to shorten. Skeletal muscle cells, which make up most of the mass of the body, are voluntary and contract when the brain sends signals telling them to react. The smooth muscle surrounding the other hollow organs is involuntary, meaning it does not need to be told to contract. Cardiac muscle is also involuntary. So functionally, cardiac muscle and smooth muscle are similar. Anatomically though, cardiac muscle more closely resembles skeletal muscle. Both skeletal muscle and cardiac muscle are striated. Under medium to high power magnification through the microscope, you can see small stripes running crosswise in both types. Smooth muscle is nonstriated. Cardiac muscle could almost be said to be a hybrid between skeletal and smooth muscle. Cardiac muscle does have several unique features. Present in cardiac muscle are intercalated discs, which are connections between two adjacent cardiac cells. Intercalated discs help multiple cardiac muscle cells contract rapidly as a unit. This is important for the heart to function properly. Cardiac muscle also can contract more powerfully when it is stretched slightly. When the ventricles are filled, they are stretched beyond their normal resting capacity. The result is a more powerful contraction, ensuring that the maximum amount of blood can be forced from the ventricles and into the arteries with each stroke. This is most noticeable during exercise, when the heart beats rapidly. There are four chambers in the heart - two atria and two ventricles. The atria (one is called an atrium) are responsible for receiving blood from the veins leading to the heart. When they contract, they pump blood into the ventricles. However, the atria do not really have to work that hard. Most of the blood in the atria will flow into the ventricles even if the atria fail to contract. It is the ventricles that are the real workhorses, for they must force the blood away from the heart with sufficient power to push the blood all the way back to the heart (this is where the property of contracting with more force when stretched comes into play). The muscle in the walls of the ventricles is much thicker than the atria. The walls of the heart are really several spirally wrapped muscle layers. This

spiral arrangement results in the blood being wrung from the ventricles during contraction. Between the atria and the ventricles are valves, overlapping layers of tissue that allow blood to flow only in one direction. Valves are also present between the ventricles and the vessels leading from it. Though the brain can cause the heart to speed up or slow drain, it does not control the regular beating of the heart. As noted earlier, the heart is composed of involuntary muscle. The muscle fibers of the heart are also self-excitatory. This means they can initiate contraction themselves without receiving signals from the brain. This has been demonstrated many times in high school classes of the past by removing the heart of a frog or turtle, and then stimulating it to contract. The heart continues to beat with no further outside stimulus, sometimes for hours if bathed in the proper solution. In addition, cardiac muscle fibers also contract for a longer period of time than do skeletal muscles. This longer period of contraction gives the blood time to flow out of the heart chambers. The heart has two areas that initiate impulses, the SA or sinoatrial node, and the AV or atrioventricular node. The heart also has special muscle fibers called Purkinje fibers that conduct impulses five times more rapidly than surrounding cells. The Purkinje fibers form a pathway for conduction of the impulse that ensures that the heart muscle cells contract in the most efficient pattern. The SA node is located in the wall of the Opened heart right atrium, near the junction of the atrium and the superior vena cava. This special region of cardiac muscle contracts on its own about 72 times per minute. In contrast, the muscle in the rest of the atrium contracts on its own only 40 or so times per minute. The muscle in the ventricles contracts on its own only 20 or so times per minute. Since the cells in the SA node contract the most times per minute, and because cardiac muscle cells are connected to each other by intercalated discs, the SA node is the pacemaker of the heart. When the SA node initiates a contraction, Purkinje fibers rapidly conduct the impulse to another site near the bottom of the right atrium and near the center of the heart. This region is the AV node, and slows the impulse briefly. The impulse then travels to a large bundle of Purkinje fibers called the Bundle of His, where they move quickly to the septum that divides the two ventricles. Here, the Purkinje fibers run in two pathways toward the

posterior apex of the heart. At the apex, the paths turn in opposite directions, one running to the right ventricle, and one running to the left. The result is that while the atria are contracting, the impulse is carried quickly to the ventricles. With the AV node holding up the impulse just enough to let the atria finish their contraction before the ventricles begin to contract, blood can fill the ventricles. And, since the Purkinje fibers have carried the impulse to the apex of the ventricles first, the contraction proceeds from the bottom of the ventricles to the top where the blood leaves the ventricles through the pulmonary arteries and the aorta. The contraction of the heart and its anatomy cause the distinctive sounds heard when listening to the heart with a stethoscope. The "lub-dub" sound is the sound of the valves in the heart closing. When the atria end their contraction and the ventricles begin to contract, the The cardiac cycle blood is forced back against the valves between the atria and the ventricles, causing the valves to close. This is the "lub" sound, and signals the beginning of ventricular contraction , known as systole. The "dub" is the sound of the valves closing between the ventricles and their arteries, and signals the beginning of ventricular relaxation, known as diastole. A physician listening carefully to the heart can detect if the valves are closing completely or not. Instead of a distinctive valve sound, the physician may hear a swishing sound if they are letting blood flow backward. When the swishing is heard tells the physician where the leaky Stethoscope placements (shade areas) valve is located. for hearing heart sounds

The Pulmonary and Systemic Circuits and the Blood Supply to the Heart. The heart is responsible for pumping the blood to every cell in the body. It is also responsible for pumping blood to the lungs, where the blood gives up carbon dioxide and takes on oxygen. The heart is able to pump blood to both regions efficiently because

there are really two separate circulatory circuits with the heart as the common link. Some authors even refer to the heart as two separate hearts--a right heart in the pulmonary circuit and left heart in the systemic circuit. In the pulmonary circuit, blood leaves the heart through the pulmonary arteries, goes to the lungs, and returns to the heart through the pulmonary veins. In the systemic circuit, blood leaves the heart through the aorta, goes to all the organs of the body through the systemic arteries, and then returns to the heart through the systemic veins. Thus there are two circuits. Arteries always carry blood away from the heart and veins always carry blood toward the heart. Most of the time, arteries Arterial and Venous Systems carry oxygenated blood and veins carry deoxygenated blood. There are exceptions. The pulmonary arteries leaving the right ventricle for the lungs carry deoxygenated blood and the pulmonary veins carry oxygenated blood. If you are confused as to which way the blood flows through the heart, try this saying "When it leaves the right, it comes right back, but when it leaves the left, it's left." The blood does not have to travel as far when going from the heart to the lungs as it does from the heart to the toes. It makes sense that the heart would be larger on one side than on the other. When you look at a heart, you see that the right side of the heart is distinctly smaller than the left side, and the left ventricle is the largest of the four chambers. While you might think the heart would have no problem getting enough oxygen-rich blood, the heart is no different from any other organ. It must have its own source of oxygenated blood. The heart is supplied by its own set of blood vessels. These are the coronary arteries. There are two main ones with two major branches each. They arise from the aorta right after it leaves the heart. The coronary arteries eventually branch into capillary beds that course throughout the heart walls and supply the heart muscle with oxygenated blood. The coronary veins return blood from the heart muscle, but instead of emptying into another larger vein, they empty directly into the right atrium. The Blood Vessels

We need to briefly discuss the anatomy of the vessels. There are three types of vessels - arteries, veins, and capillaries. Arteries, veins, and capillaries are not anatomically the same. They are not just tubes through which the blood flows. Both arteries and veins have layers of smooth muscle surrounding them. Arteries have a much thicker layer, and many more Blood vessel anatomy elastic fibers as well. The largest artery, the aorta leaving the heart, also has cardiac muscle fibers in its walls for the first few inches of its length immediately leaving the heart. Arteries have to expand to accept the blood being forced into them from the heart, and then squeeze this blood on to the veins when the heart relaxes. Arteries have the property of elasticity, meaning that they can expand to accept a volume of blood, then contract and squeeze back to their original size after the pressure is released. A good way to think of them is like a balloon. When you blow into the balloon, it inflates to hold the air. When you release the opening, the balloon squeezes the air back out. It is the elasticity of the arteries that maintains the pressure on the blood when the heart relaxes, and keeps it flowing forward. if the arteries did not have this property, your blood pressure would be more like 120/0, instead of the 120/80 that is more normal. Arteries branch into arterioles as they get smaller. Arterioles eventually become capillaries, which are very thin and branching. Capillaries are really more like a web than a branched tube. It is in the capillaries that the exchange between the blood and the cells of the body takes place. Here the blood releases its oxygen and takes on carbon dioxide, except in the lungs, where the blood picks up oxygen and releases carbon dioxide. In the special capillaries of the kidneys, the blood gives up many waste products in the formation of urine. Capillary beds are also the sites where white blood cells are able to leave the blood and defend the body against harmful invaders. Capillaries are so small that when you look at blood flowing through them under a microscope, the cells have to pass through in single file. As the capillaries begin to thicken and merge, they become venules. Venules eventually become veins and head back to the heart. Veins do not have as many elastic fibers as arteries. Veins do have valves, which keep the Capillary Bed

blood from pooling and flowing back to the legs under the influence of gravity. When these valves break down, as often happens in older or inactive people, the blood does flow back and pool in the legs. The result is varicose veins, which often appear as large purplish tubes in the lower legs. Respiratory System The respiratory system's function is to absorb oxygen into the lungs and output carbon dioxide and a small amount of oxygen. The space between the alveoli and the capillaries, the anatomy or structure of the exchange system, and the precise physiological uses of the exchanged gases vary depending on organism. In humans and other mammals, for example, the anatomical features of the respiratory system include airways, lungs, and the respiratory muscles. Molecules of oxygen and carbon dioxide are passively exchanged, by diffusion, between the gaseous external environment and the blood. This exchange process occurs in the alveolar region of the lungs.

UPPER RESPIRATORY TRACT Respiration is defined in two ways. In common usage, respiration refers to the act of breathing, or inhaling and exhaling. Biologically speaking, respiration strictly means the uptake of oxygen by an organism, its use in the tissues, and the release of carbon dioxide. By either definition, respiration has two main functions: to supply the cells of the body with the oxygen needed for metabolism and to remove carbon dioxide formed as a waste product from metabolism. This lesson describes the components of the upper respiratory tract. The upper respiratory tract conducts air from outside the body to the lower respiratory tract and helps protect the body from irritating substances. The upper respiratory tract consists of the following structures: The nasal cavity, the mouth, the pharynx, the epiglottis, the larynx, and the upper trachea. The esophagus leads to the digestive tract. One of the features of both the upper and lower respiratory tracts is the mucociliary apparatus that protects the airways from irritating substances, and is composed of the ciliated cells and mucus-producing glands in the nasal epithelium. The glands produce a layer of mucus that traps unwanted particles as they are inhaled. These are swept toward the posterior pharynx, from where they are swallowed, spat out, sneezed, or blown out. Air passes through each of the structures of the upper respiratory tract on its way to the lower respiratory tract. When a person at rest inhales, air enters via the nose and mouth. The nasal cavity filters, warms, and humidifies air. The pharynx or throat is a tube like structure that connects the back of the nasal cavity and mouth to the larynx, a passageway for air, and the esophagus, a passageway for food. The pharynx serves as a common hallway for the respiratory and digestive tracts, allowing both air and food to pass through before entering the

appropriate passageways. The pharynx contains a specialized flap-like structure called the epiglottis that lowers over the larynx to prevent the inhalation of food and liquid into the lower respiratory tract. The larynx, or voice box, is a unique structure that contains the vocal cords, which are essential for human speech. Small and triangular in shape, the larynx extends from the epiglottis to the trachea. The larynx helps control movement of the epiglottis. In addition, the larynx has specialized muscular folds that close it off and also prevent food, foreign objects, and secretions such as saliva from entering the lower respiratory tract.

LOWER RESPIRATORY TRACT The lower respiratory tract begins with the trachea, which is just below the larynx. The trachea, or windpipe, is a hollow, flexible, but sturdy air tube that contains C-shaped cartilage in its walls. The inner portion of the trachea is called the lumen.

The first branching point of the respiratory tree occurs at the lower end of the trachea, which divides into two larger airways of the lower respiratory tract called the right bronchus and left bronchus. The wall of each bronchus contains substantial amounts of cartilage that help keep the airway open. Each bronchus enters a lung at a site called the hilum. The bronchi branch sequentially into secondary bronchi and tertiary bronchi. The tertiary bronchi branch into the bronchioles. The bronchioles branch several times until they arrive at the terminal bronchioles, each of which subsequently branches into two or more respiratory bronchioles. The respiratory bronchiole leads into alveolar ducts and alveoli. The alveoli are bubble-like, elastic, thin-walled structures that are responsible for the lungs most vital function: the exchange of oxygen and carbon dioxide. Each structure of the lower respiratory tract, beginning with the trachea, divides into smaller branches. This branching pattern occurs multiple times, creating multiple branches. In this way, the lower respiratory tract resembles an upside-down tree that begins with one trachea trunk and ends with more than 250 million alveoli leaves. Because of this resemblance, the lower respiratory tract is often referred to as the respiratory tree. In descending order, these generations of branches include: trachea right bronchus and left bronchus secondary bronchi tertiary bronchi bronchioles terminal bronchioles respiratory bronchioles alveoli

       

THE LUNGS The thoracic cage, or ribs, and the diaphragm bound the thoracic cavity. There are two lungs that occupy a significant portion of this cavity. The diaphragm is a broad, dome-shaped muscle that separates the thoracic and abdominal cavities and generates most of the work of breathing. The inter-costal muscles, located between the ribs, also aid in respiration. The internal intercostal muscles lie close to the lungs and are covered by the external intercostal muscles. The lungs are cone-shaped organs that are soft, spongy and normally pink. The lungs cannot expand or contract on their own, but their softness allows them to change shape in response to breathing. The lungs rely on expansion and contraction of the thoracic cavity to actually generate inhalation and exhalation. This process requires contraction of the diaphragm. To facilitate the movements associated with respiration, each lung is enclosed by the pleura, a membrane consisting of two layers, the parietal pleura and the visceral pleura. The parietal pleura comprise the outer layer and are attached to the chest wall. The visceral pleura are directly attached to the outer surface of each lung. The two pleural layers are separated by a normally tiny space called the pleural cavity. A thin film of serous or watery fluid called pleural fluid lines and lubricates the pleural cavity. This fluid prevents friction and holds the pleural surfaces together during inhalation and exhalation.

Ventilation
Ventilation of the lungs is carried out by the muscles of respiration.

Control
Ventilation occurs under the control of the autonomic nervous system from parts of the brain stem, the medulla oblongata and the pons. This area of the brain forms the respiration regulatory center, a series of interconnected brain cells within the lower and middle brain stem which coordinate respiratory movements. The sections are the pneumotaxic center, the apneaustic center, and the dorsal and ventral respiratory groups. This section is especially sensitive during infancy, and the neurons can be destroyed if the infant is dropped and/or shaken violently. The result can be death due to "shaken baby syndrome.

Inhalation
Inhalation is initiated by the diaphragm and supported by the external intercostal muscles. Normal resting respirations are 10 to 18 breaths per minute, with a time period of 2 seconds. During vigorous inhalation (at rates exceeding 35 breaths per minute), or in approaching respiratory failure, accessory muscles of respiration are recruited for support. These consist of sternocleidomastoid, platysma, and the scalene muscles of the neck. Pectoral muscles and latisimus dorsi are also accessory muscles.

Under normal conditions, the diaphragm is the primary driver of inhalation. When the diaphragm contracts, the ribcage expands and the contents of the abdomen are moved downward. This results in a larger thoracic volume and negative (suction) pressure (with respect to atmospheric pressure) inside the thorax. As the pressure in the chest falls, air moves into the conducting zone. Here, the air is filtered, warmed, and humidified as it flows to the lungs. During forced inhalation, as when taking a deep breath, the external intercostal muscles and accessory muscles aid in further expanding the thoracic cavity.

Exhalation
Exhalation is generally a passive process; however, active or forced exhalation is achieved by the abdominal and the internal intercostal muscles. During this process air is forced or exhaled out. The lungs have a natural elasticity: as they recoil from the stretch of inhalation, air flows back out until the pressures in the chest and the atmosphere reach equilibrium. During forced exhalation, as when blowing out a candle, expiratory muscles including the abdominal muscles and internal intercostal muscles, generate abdominal and thoracic pressure, which forces air out of the lungs.

Gas exchange
The major function of the respiratory system is gas exchange between the external environment and an organism's circulatory system. In humans and mammals, this exchange facilitates oxygenation of the blood with a concomitant removal of carbon dioxide and other gaseous metabolic wastes from the circulation. As gas exchange occurs, the acid-base balance of the body is maintained as part of homeostasis. If proper ventilation is not maintained, two opposing conditions could occur: respiratory acidosis, a life threatening condition, and respiratory alkalosis. Upon inhalation, gas exchange occurs at the alveoli, the tiny sacs which are the basic functional component of the lungs. The alveolar walls are extremely thin (approx.

0.2 micrometers). These walls are composed of a single layer of epithelial cells (type I and type II epithelial cells) in close proximity to the pulmonary capillaries which are composed of a single layer of endothelial cells. The close proximity of these two cell types allows permeability to gases and, hence, gas exchange. This whole mechanism of gas exchange is carried by the simple phenomenon of pressure difference. When the atmospheric pressure is low outside, the air from lungs flow out. When the air pressure is low inside, then the vice versa.

IV.THE PATIENTS ILLNESS A.Synthesis of the Disease

1.Definition of the Disease( Book-based) Ventricular septal defect Ventricular septal defect describes one or more holes in the wall that separates the right and left ventricles of the heart. Ventricular septal defect is one of the most common congenital (present from birth) heart defects. It may occur by itself or with other congenital diseases. These defects are more common in premature infants. The ventricles are the 2 lower chambers of the heart. The wall between them is called the septum. A hole in the septum is called a septal defect. If the hole is located between the upper chambers or atria, it is called an atrial septal defect. Infants may be born with either or both types of defects. These conditions are commonly known as "holes in the heart." Before a baby is born, the right and left ventricles of its heart are not separate. As the fetus grows, a wall forms to separate these two ventricles. If the wall does not completely form, a hole remains. This hole is known as a ventricular septal defect, or a VSD. Ventricular septal defect is one of the most common congenital heart defects. The baby may have no symptoms, and the hole can eventually close as the wall continues to grow after birth. If the hole is large, too much blood will be pumped to the lungs, leading to heart failure. Ventricular septal defects are the most common congenital heart defects in infants (that is, defects that a person is born with) but the cause of VSD is not yet known. This defect often occurs along with other congenital heart defects. Normally, unoxygenated blood from the body returns to the right half of the heart, that is the right atrium, then the right ventricle, which pumps the blood to the lungs to absorb oxygen. After leaving the lungs, the oxygenated blood returns to the left half of the heart, that is the left atrium, then the left ventricle, where it is pumped out to provide oxygen to all the tissues of the body.

A ventricular septal defect can allow newly oxygenated blood to flow from the left ventricle, where the pressures are higher, to the right ventricle, where the pressures are lower, and mix with unoxygenated blood. The mixed blood in the right ventricle flows back or recirculates into the lungs. This means that the right and left ventricles are working harder, pumping a greater volume of blood than they normally would. Eventually, the left ventricle can work so hard that it starts to fail. It can no longer pump blood as well as it did. Blood returning to the heart from the blood vessels backs up into the lungs, causing pulmonary congestion, and further backup into the body, causing weight gain and fluid retention. Overall, this is called congestive heart failure. If the VSD is large and surgically uncorrected, pressure can build excessively in the lungs, called pulmonary hypertension. The higher the lung or pulmonary pressure, the greater the chance of blood flowing from the right ventricle to the left ventricle, backwards, causing cyanosis (blue skin). The risk for these problems depends on the size of the hole in the septum and how well the infants lungs function. The ventricular septal defect may not be heard with a stethoscope until several days after birth. This is because a newborn's circulatory system changes during the first week with drop in the lung or pulmonary pressure, creating the greater pressure differential between the 2 ventricles, thus greater left-to-right shunt and audible murmur. The condition occurs in about 25% of all infants born with a heart defect. Eisenmenger's complex is a ventricular septal defect coupled with pulmonary high blood pressure, the passage of blood from the right side of the heart to the left (right to left shunt), an enlarged right ventricle and a latent or clearly visible bluish discoloration of the skin called cyanosis (si"ah-NO'sis). It may also include a malpositioned aorta that receives ejected blood from both the right and left ventricles (an overriding aorta). People with Eisenmenger's complex, before and after treatment, are at risk for getting an infection within the aorta or the heart valves (endocarditis). Please see the unoxygenated blood to be pumped to the body and

section on Endocarditis below to determine whether your child will need to take antibiotics before certain dental procedures. Possible Complication may include heart failure ,infective endocarditis (bacterial infection of the heart),aortic insufficiency (leaking of the valve that separates the left ventricle from the aorta),damage to the electrical conduction system of the heart during surgery (causing arrhythmias), delayed growth and development (failure to thrive in infancy), pulmonary hypertension (high blood pressure in the lungs) leading to failure of the right side of the heart. Pneumonia Pneumonia is an infection of one or both lungs which is usually caused by bacteria, viruses, or fungi. Prior to the discovery of antibiotics, one-third of all people who developed pneumonia subsequently died from the infection. Currently, over 3 million people develop pneumonia each year in the United States. Over a half a million of these people are admitted to a hospital for treatment. Although most of these people recover, approximately 5% will die from pneumonia. Pneumonia is the sixth leading cause of death in the United States. Some cases of pneumonia are contracted by breathing in small droplets that contain the organisms that can cause pneumonia. These droplets get into the air when a person infected with these germs coughs or sneezes. In other cases, pneumonia is caused when bacteria or viruses that are normally present in the mouth, throat, or nose inadvertently enter the lung. During sleep, it is quite common for people to aspirate secretions from the mouth, throat, or nose. Normally, the body's reflex response (coughing back up the secretions) and their immune system will prevent the aspirated organisms from causing pneumonia. However, if a person is in a weakened condition from another illness, a severe pneumonia can develop. People with recent viral infections, lung disease, heart disease, and swallowing problems, as well as alcoholics, drug users, and those who have suffered a stroke or seizure are at higher risk for developing pneumonia than the general population. As we age, our swallowing mechanism can become impaired as does our immune system. These factors, along with some of the negative side effects of medications, increase the risk for pneumonia in the elderly.

Once organisms enter the lungs, they usually settle in the air sacs and passages of the lung where they rapidly grow in number. This area of the lung then becomes filled with fluid and pus (the body's inflammatory cells) as the body attempts to fight off the infection. Most people who develop pneumonia initially have symptoms of a cold (upper respiratory infection, for example, sneezing, sore throat, cough), which are then followed by a high fever (sometimes as high as 104 F), shaking chills, and a cough with sputum production. The sputum is usually discolored and sometimes bloody. Depending on the location of the infection, certain symptoms are more likely to develop. When the infection settles in the air passages, cough and sputum tend to predominate the symptoms. In some, the spongy tissue of the lungs that contain the air sacs is more involved. In this case, oxygenation can be impaired, along with stiffening of the lung, which results in shortness of breath. At times, the individual's skin color may change and become dusky or purplish (a condition known as "cyanosis") due to their blood being poorly oxygenated. The only pain fibers in the lung are on the surface of the lung, in the area known as the pleura. Chest pain may develop if the outer aspects of the lung close to the pleura are involved. This pain is usually sharp and worsens when taking a deep breath and is known as pleuritic pain or pleurisy. In other cases of pneumonia, depending on the causative organism, there can be a slow onset of symptoms. A worsening cough, headaches, and muscle aches may be the only symptoms. Children and babies who develop pneumonia often do not have any specific signs of a chest infection but develop a fever, appear quite ill, and can become lethargic. Elderly people may also have few symptoms with pneumonia

.Ventricular Septal defect: Modifiable factors: Having the following conditions during pregnancy can increase your risk of having a baby with a heart defect.


Rubella infection- Becoming infected with rubella (German measles) while

pregnant can increase the risk of fetal heart defects. The rubella virus crosses the placenta and spreads through the fetus' circulatory system damaging blood vessels and organs, including the heart.


Poorly controlled diabetes- Uncontrolled diabetes in the mother in turn affects

the fetus' blood sugar, causing various damaging effects to the developing fetus.


Drug or alcohol use or exposure to certain substances- Use of certain

medications, alcohol or drugs or exposure to chemicals or radiation during pregnancy can harm the developing fetus. Non- modifiable Factors:    gene  polygenic disorders- result from environmental and genetic factors Geneticschromosomal disorders- absent or duplicated chromosomes single-gene disorders- deletions, missense mutations and duplications within a

Signs and Symptoms Small holes in the ventricular septum usually produce no symptoms but

are often recognized by the child's health care provider when a loud heart murmur along the left side of the lower breast bone or sternum is heard. Large holes typically produce symptoms 1-6 months after an infants birth. The baby often has symptoms related to heart failure. The most common symptoms include:
y

Shortness of breath-it results when there is a respiratory infection. Pulmonary

hypertension also causes pulmonary vascular resistance that causes shortness of breath.
y

Fast breathing-As a compensation in shortness of breath, the patient may Hard breathing-Because of decreased oxygen and feeling of dyspnea, hard Paleness- In VSD, there is a decrease in cardiac output of the heart leading to Failure to gain weight- there is a failure to gain weight because of the discomfort Fast heart rate- As a compensation to the decrease cardiac output, the heart will Sweating while feeding- The patient has easy fatigability because of decrease

manifest fast breathing to get enough oxygen.

y

breathing may manifest by the patient.

y

decrease blood circulation and decrease blood in the blood leading to paleness.
y

during feeding and the accompanying manifestation like dyspnea.

y

increase its force of pumping and its heart rate to increase cardiac output.
y

oxygen in the body.

y

Frequent respiratory infections- Because of pulmonary congestion brought about Listening with a stethoscope usually reveals a heart murmur (the sound of the

by an increase blood congestion, there will be frequent respiratory infections.

y

blood crossing the hole)-The loudness of the murmur is related to the size of the defect and amount of blood crossing the defect
y

Cyanosis-there will be a cyanosis because the oxygenated blood is being mix

with the unoxygenated blood. Cyanosis may also manifest because of decrease perfusion of blood in the body. The skin turns faintly bluish when the tissues are not receiving quite enough oxygen.

Pneumonia Modifiable factors:

 Smoke-Cigarette smoking is the strongest risk factor for developing pneumonia

in healthy young people.2

 Have another medical condition-especially lung diseases such as chronic

obstructive pulmonary disease (COPD) or asthma.

 Have an impaired immune system- fighting bacteria is difficult if you have

impaired immune system

 Have a change in mental status (such as confusion or loss of consciousness) -

increases the risk of breathing mucus or saliva from the nose or mouth, liquids, or food from the stomach into the lungs (aspiration).
 Take medicine called a proton pump inhibitor (such as pantoprazole or

omeprazole) that reduces the amount of stomach acid.

 Don't get enough to eat to stay healthy (malnutrition)- may impaired immune

system Non-modifiable factors:

 Are younger than 1 year of age or older than 65- Immune system is not yet

develop (younger than 1 year of age) and degenerative changes (older than 65). Signs and symptoms: In children, symptoms may depend on age: In infants younger than 1 month of age, symptoms may include:

 Having little or no energy (lethargy) - may due to the feeling of dyspnea causing small amount of oxygen in the body producing little amount of energy.  Feeding poorly- due to the feeling of dyspnea.  grunting  Having a fever- as a compensation of the body, fever may occur.

 Fast, often shallow, breathing and the feeling of being short of breath- may be due to mucus production that obstructs the air.  Fast heartbeat- because of the decrease oxygen and blood receive by the body, the heart compensate. In adult patients, symptoms may include:


Cough- often producing mucus (sputum) from the lungs. Mucus may be rusty or green or tinged with blood.

 Shaking, "teeth-chattering" chills (one time only or many times)- when fever

reach a much higher value.

 Chest wall pain that is often made worse by coughing or breathing in- it is due to

the bacteria in the lungs that cause inflammation. Definition of the disease ( Patient-centered )

The normal heart has two sides, the left and the right, which are separated by a muscular wall called the septum. Each side of the heart also has two parts - an upper chamber called an atrium and a lower chamber called a ventricle. Ventricular septal defect (VSD), a congenital (present at birth) defect, is an opening in the ventricular septum, or dividing wall between the two lower chambers of the heart known as the right and left ventricles. It is cause by taking teratogenic drug specifically, cytotec during the mothers 2nd month of pregnancy. This drug is toxic to the fetus during the growth and the development of it in the womb of the mother specially, in the first semester where in organogenesis occurs. Normally, oxygen-poor blood returns to the right atrium from the body, travels to the right ventricle, then is pumped into the lungs where it receives oxygen. Oxygen-rich blood returns to the left atrium from the lungs, passes into the left ventricle, then is pumped out to the body through the aorta. A ventricular septal defect allows oxygen-rich blood to pass from the left ventricle through the opening in the septum, and then mix with oxygen-poor blood in the right ventricle.

Pneumonia Pneumonia is an infection of one or both lungs which is usually caused by bacteria, viruses, or fungi. A person is in a weakened condition from another illness, a severe pneumonia can develop. People with recent viral infections, lung disease, heart problems, and swallowing problems, as well as alcoholics, drug users, and those who have suffered a stroke or seizure are at higher risk for developing pneumonia than the general population. Pulmonary congestion in a patient with heart defect/disease is at higher risk of having pneumonia. Congestion of blood is a good medium in the development of bacteria and viruses that will cause pneumonia. Ventricular Septal Defect: Modifiable Factor: Drug or alcohol use or exposure to certain substances-During pregnancy of the patients mother, she had take a medicine called cytotec which is proven dangerous to the growth and development of the fetus inside the mothers womb during organogenesis.

Signs and Symptoms

y

Shortness of breath-it results when there is a respiratory infection. Pulmonary

hypertension also causes pulmonary vascular resistance that causes shortness of breath.
y

Fast breathing-As a compensation in shortness of breath, the patient may

manifest fast breathing to get enough oxygen.

y

Hard breathing-Because of decreased oxygen and feeling of dyspnea, hard Paleness- In VSD, there is a decrease in cardiac output of the heart leading to Failure to gain weight- there is a failure to gain weight because of the discomfort Fast heart rate- As a compensation to the decrease cardiac output, the heart will Sweating while feeding- The patient has easy fatigability because of decrease

breathing may manifest by the patient.

y

decrease blood circulation and decrease blood in the blood leading to paleness.
y

during feeding and the accompanying manifestation like dyspnea.

y

increase its force of pumping and its heart rate to increase cardiac output.
y

oxygen in the body.

Frequent respiratory infections- Because of pulmonary congestion brought about Listening with a stethoscope usually reveals a heart murmur (the sound of the

by an increase blood congestion, there will be frequent respiratory infections.

y

blood crossing the hole)-The loudness of the murmur is related to the size of the defect and amount of blood crossing the defect
y

Cyanosis-there will be a cyanosis because the oxygenated blood is being mix

with the unoxygenated blood. Cyanosis may also manifest because of decrease perfusion of blood in the body. The skin turns faintly bluish when the tissues are not receiving quite enough oxygen. Pneumonia Modifiable factor:
 Having other medical condition- the patient is having heart defect, VSD.

Non-modifiable factor:

 Are younger than 1 year of age- the patient is a 6-month old baby.
Signs and symptoms:

 Having little or no energy (lethargy) - may due to the feeling of dyspnea causing small amount of oxygen in the body producing little amount of energy.  Feeding poorly- due to the feeling of dyspnea and discomfort.  Having a fever- as a compensation of the body, fever may occur.
 Fast, often shallow, breathing and the feeling of being short of breath- may be due to mucus production that obstructs the air.  Fast heartbeat- because of the decrease oxygen and blood receive by the body, the heart compensate.

Nursing Duties and Responsibilities: Health teaching is a very vital role of the nurse in providing health care services. In line with the condition, we, health care providers must provide health teachings and emotional support to our patient. Once parents learn of the heart defect, they are initially in a period of shock, followed by high anxiety, especially fear of the childs death. The family needs a period of grief before assimilating the meaning of the defect. The parents must be informed of the condition to give informed consent for diagnostics and therapeutic procedures. The nurse can be instrumental in supporting parents in their loss, assessing their level of understanding, supplying information as needed and helping other members of the health team to understand the parents reaction. Once parents are ready to hear about their childs heart condition, it is essential that they be given a clear explanation based on the level of their understanding. Parents are the childs principal caregivers and need to develop a positive, supportive working relationship with the health care team. Good communication between the family and the healthcare practitioner is essential. Parents of children with cyanosis should be informed about fluid management and hyper cyanotic spells. The family also needs to be knowledgeable regarding the therapeutic management of the disorder and role that surgery, other procedures, medications, and a healthy lifestyle play in maintaining good health. Instructing parents in feeding methods that decrease the work of the infant and giving high-calorie formula are important interventions. When the child needs to undergo procedure, the expected outcomes before the procedure includes reducing anxiety, improving patient cooperation with procedures, enhancing recovery, developing trust with the caregiver, and improving long-term emotional and behavioral adjustments following procedures. After the procedure, the health care provider must observe vital signs and arterial and venous pressures, maintain respiratory status, provide maximum rest, provide

comfort monitor for fluids intake and output and observe for complications of heart surgery. Health promotion and Disease prevention: In most cases, you can't do anything to prevent having a baby with a ventricular septal defect. However, it's important to do everything possible to have a healthy pregnancy. Here are the basics: Get early prenatal care, even before you're pregnant. Quitting smoking, reducing stress, stopping birth control these are all things to talk to your doctor about before you get pregnant. Also, be sure you talk to your doctor about any medications you're taking. Eat a balanced diet. Include a vitamin supplement that contains folic acid. Also, limit caffeine. Exercise regularly. Work with your doctor to develop an exercise plan that's right for you. Avoid risks. These include harmful substances such as cigarettes and illicit drugs. Also, avoid Xrays, hot tubs and saunas. Avoid infections. Be sure you're up to date on all of your vaccinations before becoming pregnant. Certain types of infections can be harmful to a developing fetus. Keep diabetes under control. If you have diabetes, work with your doctor to be sure it's well controlled before getting pregnant. If you have a family history of heart defects or other genetic disorders, consider talking with a genetic counselor before getting pregnant. Drinking alcohol and using the antiseizure medicines depakote and dilantin during pregnancy have been associated with increased incidence of VSDs. Other than avoiding these things during pregnancy, there is no known way to prevent a VSD. If the defect is small, no treatment is usually needed. However, the baby should be closely monitored by a health care provider to make sure that the hole eventually closes properly and signs of heart failure do not occur.

Babies with a large VSD who have symptoms related to heart failure may need medicine to control the symptoms and surgery to close the hole. Medications may include digitalis (digoxin) and diuretics. If symptoms continue despite medication, surgery to close the defect with a Gore-tex patch is needed. Some VSDs can be closed with a special device during a cardiac catheterization, although this is infrequently done.

V.THE PATIENT AND HIS CARE A .MEDICAL MANAGEMENT a. IVF Medical Management/ Treatment D5 0.3 NaCl Date ordered Date changed Date Ordered: 8-27-10 General Description Indication/ Purpose Client Response to Treatment

A hypotonic solution that has greater concentration of Date free water Changed: molecules that 9-13-10 are found inside the cell.

To provide a balanced solution of fluid and electrolytes for the patient

The patient tolerated the intravenous fluid. No allergies or other reactions were experienced The client responded well to treatment because of continuous IVF therapy as evidenced by good skin turgor.

Nursing Responsibilities for D5 0.3 NaCl

Before y y y y During y y y After y y y Check and observe the puncture site for bleeding, edema, or thrombophlebitis Make sure that the IVF is patent and properly regulated. Check regularly Document relevant data Be sure to clean the site of entry with cotton and alcohol in a circular motion Ensure appropriate infusion flow Adhere to standard precautions, then regulate flow rate as per doctors order Check for the doctors order Explain the procedure to the SO with its importance and purpose Wash hands and observe other appropriate infection control procedures Always observe and check for the correct type of IVF as well as the clarity of the fluid

Medical Management/ Treatment

Date ordered Date changed

General Description

Indication/ Purpose

Client Response to Treatment

Heplock

Date ordered: 9-13-10

Heparin lock flush is used to clear (flush) IV lines or catheters to keep them open and flowing freely. This form of heparin must not be used as a blood thinner.

To clear (flush) IV lines or catheters to keep them open and flowing freely.

The patient tolerated the intravenous fluid. No allergies or other reactions were experienced

Nursing Responsibilities for Heplock

Before y y y y Check for the doctors order Explain the procedure to the SO with its importance and purpose Wash hands and observe other appropriate infection control procedures

During y y After y y y Check and observe the puncture site for bleeding, edema, or thrombophlebitis Make sure that the heplock is patent. Check regularly Document relevant data Be sure to clean the site of entry with cotton and alcohol in a circular motion Adhere to standard precautions

Medical Management/ Treatment Oxygen Inhalation via nasal canulla at 2-3 LPM

Date ordered Date changed Date Ordered: 8-27-10

General Description In the hospital, oxygen is supplied to each patient room via an outlet in the wall. Oxygen is delivered from a central source through a pipeline in the facility. A flow meter attached to the wall outlet accesses the oxygen. A valve regulates the oxygen flow, and attachments may be connected to provide moisture. In the home, the oxygen source is usually a canister or air compressor. Whether in home or hospital, plastic tubing connects the

Indication/ Purpose The body is constantly taking in oxygen and releasing carbon dioxide. If this process is inadequate, oxygen levels in the blood decrease, and the patient may need supplemental oxygen. Oxygen therapy is a key treatment in respiratory care. The purpose is to increase oxygen saturation in

Client Response to Treatment

The patient had received enough oxygen to compensate his body with the needed oxygen to prevent difficulty of breathing and absence of oxygen.

oxygen source to the patient. Oxygen is most commonly delivered to the patient via a nasal cannula or mask attached to the tubing. The nasal cannula is usually the delivery device of choice since it is well tolerated and doesn't interfere with the patient's ability to communicate, eat, or drink. The concentration of oxygen inhaled depends upon the prescribed flow rate and the ventilatory minute volume (MV).

tissues where the saturation levels are too low due to illness or injury. Breathing prescribed oxygen increases the amount of oxygen in the blood, reduces the extra work of the heart, and decreases shortness of breath.

Nursing Responsibilities:

Before: y y y y Check for the doctors order. Explain the procedure to the patient/SO with its purpose and importance. Wash hands and observe other appropriate infection control procedures. Provide client privacy.

During:

y
y y y y y y After: y

Adhere to standard precautions, then regulate flow rate as per doctors order.
Humidify the oxygen first before you administer Check for bubbles in the humidifier to promote adequate flow of oxygen Check for kinks in the tubing Position: semi-fowler's/high fowler's position Place cautionary reading: "NO SMOKING: OXYGEN IS IN USE" Instruct the client not to use woolen blankets as this may create static electricity

Check regularly.

y
b. Drugs

Document relevant data.

Name of Drug Generic and Brand Name Generic name: Ampicillin Brand name: Principen

Date Ordered/Date Changed Date Ordered: 08-28-10 Date Discontinued: 09-01-10

Route of Administration Dosage and Frequency of administration

Indication/ Purpose

Client respond to treatment The clients actual responds to medication is that he was able to reduce development of resistant to bacteria and the

To reduce development of resistant to bacteria and to treat infections that is proven to be caused by bacteria.

effectiveness of the drug was maintained.

NURSING RESPONSIBILITIES:

Prior y y y During y y After y Monitor IV site carefully Check IV site carefully for signs of thrombosis or drug reaction Administer in slow IV push Assess for allergies to Ampicillin, Penicillins, Cephalosporins, or other allergens Assess for renal disorders Culture infected area

Name of Drug Generic and Brand Name Generic name: Cefotaxime Sodium Brand name: Claforan

Date Ordered/Date Changed Date Ordered: 08-28-10

Route of Administration Dosage and Frequency of administration Intravenously 200mg q8 hours

Indication/ Purpose

Client respond to treatment The clients actual responds to medication is that he was able to reduce development of resistant to bacteria and the effectiveness of the drug was maintained.

To reduce the development of drugresistant bacteria and maintain the effectiveness of CLAFORAN (cefotaxime sodium) and other antibacterial drugs, CLAFORAN should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria.

NURSING RESPONSIBILITIES:

Prior y y y Assess for allergies to Cefotaxime Assess for hepatic and renal impairment Culture infected area and arrange for sensitivity test

During y y After y Monitor IV site carefully Date Ordered Route of Administration Dosage and Frequency of administration Intravenously 6 mg q 12 hours Indication/ Purpose Client respond to treatment The patient tolerated the medication. Check IV site carefully for signs of thrombosis or drug reaction Administer in slow IV push

Name of Drug Generic and Brand Name Generic name: Furosemide Brand name: Lasix

08-28-10

To treat fluid retention in people with congestive heart failure by absorbing too much salt, allowing the salt to instead be passed in your urine.

NURSING RESPONSIBILITIES:

Prior y Assess for allergies to Furosemide

y y y During y y

Administer with food or milk to prevent GI upset Give early in the day so that increased urination will not disturb sleep Do not expose to light

Check IV site carefully for signs of thrombosis or drug reaction Measure and record weight to monitor fluid changes

After y y Arrange for potassium rich diet Monitor urine output

Name of Drug Generic and Brand Name Generic name: Acetaminophen Brand name: Tempra

Date Ordered/ Date Discontinued Date ordered: 08-31-10 Date Discontinued: 08-31-10

Route of Administration Dosage and Frequency of administration Intravenously 60 mg q 4 hours

Indication/ Purpose

Client respond to treatment The clients actual responds to medication is that he was able to reduce fever.

To reduce fever, headache, and other minor aches and pain

NURSING RESPONSIBILITIES:

Prior y y Assess for allergies to Acetaminophen Administer with food or milk to prevent GI upset

During y y Check IV site carefully for signs of thrombosis or drug reaction Do not exceed the recommended dosage

After y Report rash, unusual bleeding or bruising, yellowing of skin or eyes

Name of Drug Generic and Brand Name Generic name: Amikacin Sulfate Brand name: Amikin

Date Ordered/ Date Discontinued Date Ordered: 09-01-10 Date Discontinued: 09-09-10

Route of Administration Dosage and Frequency of administration Intravenously 45mg q 12 hours

Indication/ Purpose

Client respond to treatment The clients actual responds to medication is that he was able to reduce development of resistant to bacteria and the effectiveness of the drug was maintained.

To reduce the development of drugresistant bacteria and maintain the effectiveness of the Amikacin and other antibacterial drugs, Amikacin should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria.

NURSING RESPONSIBILITIES:

Prior y y y During y Check IV site carefully for signs of thrombosis or drug reaction Assess for allergies to aminoglycosides Assess for decreased renal function, dehydration Culture infected area and arrange for sensitivity test

y After

Ensure that patient is well hydrated

Report pain at injection site, severe H/A, difficulty of breathing

Name of Drug Generic and Brand Name Generic name: Oxacillin Sulfate

Date Ordered/ Date Discontinued Date Ordered: 09-03-10 Date Discontinued: 09-09-10

Route of Administration Dosage and Frequency of administration Intravenously 200mg q 8 hours

Indication/ Purpose

Client respond to treatment The clients actual responds to medication is that he was able to reduce development of resistant to bacteria and the effectiveness of the drug was maintained.

To reduce the development of drugresistant bacteria and maintain the effectiveness of Oxacillin Injection, USP and other antibacterial drugs, Oxacillin Injection, USP should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria.

NURSING RESPONSIBILITIES:

Prior y y y During y y After y y Report difficulty of breathing, severe pain at injection site Finish entire course of therapy as prescribed Date Ordered Route of Administration Dosage and Frequency of administration 1.2 ml/elixir 500gm/ml X 40dose then .5ml q12 hours Indication/ Purpose Client respond to treatment The clients actual responds to medication is that he was able to reduce difficulty breathing, and extreme tiredness or weakness AEB Check IV site carefully for signs of thrombosis or drug reaction Keep epinephrine, IV fluids, vasopressors, bronchodilator, oxygen, in case of serious hypersensitivity reaction Assess for allergies to penicillins, cephalosporins, or other allergens Assess for renal disorders Culture infected area and arrange for sensitivity test

Name of Drug Generic and Brand Name Generic name: Digoxin Brand name: Lanoxin

09-07-10

To Increase force and velocity of myocardial contraction and prolongs refractory period of atrioventricular (AV) node by increasing calcium entry into myocardial cells. Slows

conduction through sinoatrial and AV nodes and produces antiarrhythmic effect.

increase activity tolerance.

NURSING RESPONSIBILITIES:

Prior y y y During y y After y y Have a regular medical checkups Report slow or irregular pulse Have emergency equipment ready; have K salts, lidocaine, phenytoin, atropine, and cardiac monitor readily available in case toxicity develops Monitor for therapeutic drug levels: 0.5-2ng/ml Monitor apical pulse for 1 min before administering Check dosage and preparation carefully Follow diluting instructions carefully, and use diluted solution promptly

Name of Drug Generic and Brand Name Generic name: Gentamicin sulfate Brand name: Maitec

Date Ordered

09-09-10

Route of Administration Dosage and Frequency of administration 30mg IV OD

Indication/ Purpose

Client respond to treatment The clients actual responds to medication is that he was able to reduce development of resistant to bacteria and the effectiveness of the drug was maintained.

To reduce the development of drugresistant bacteria and maintain the effectiveness of gentamicin and other antibacterial drugs, gentamicin should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria

NURSING RESPONSIBILITIES:

Prior y y y During y Check IV site carefully for signs of thrombosis or drug reaction Assess for allergies to amminoglycosides Assess for renal or hepatic disorders Culture infected area and arrange for sensitivity test

y After

Ensure adequate hydration of patient

y y c. Diet

Report difficulty of breathing, severe pain at injection site Finish entire course of therapy as prescribed

Type of Diet NPO

Date ordered; performed; changed Date ordered : 08-28-10 Date changed: 08-29-10

Indication/s General Description or Purposes NPO is no food or drink is allowed . To prevent patient to vomit

Clients Response to the Diet The patient fully understood and complied with the prescribed diet and the patient was able to tolerate the diet as well.

NURSING RESPONSIBILITIES: Before: y y y Check for doctor's order. Instruct the patient about the prescribed diet ordered by the physician. Explain the purpose and importance of the diet and no foods are allowed for the patient.

During: y After: y y Monitor the reaction of the patient. Assess improvement on the pt. condition Date ordered 08-29-10 General description This kind of diet is ordered when the clients appetite Indication/Purpose A full, well-balanced diet containing all of the essential nutrients needed for optimal growth, tissue repair, and normal functioning of the organs. Such Specific food taken Formula Milk Client response to treatment The patients SO fully understood and complied with the prescribed diet and the patient was able to tolerate the diet as well. Remind patients SO that the patient is not allowed to take anything orally.

Type of Diet Full diet with SAP

a diet contains foods rich in proteins, carbohydrates, high-quality fats, minerals, and vitamins in proportions that meet the specific caloric requirements of the individual. Also called normal diet with strict aspiration precaution.

NURSING RESPONSIBILITIES: Before: y y y y Check for doctor's order. Instruct the patient about the prescribed diet ordered by the physician. Explain the purpose and importance of the diet and what specific foods are allowed for the patient. Explain also the appropriate foods that should and should not to be taken.

During: y y Assist the patient when eating. As much as possible, promote independence.

After: y Monitor the reaction of the patient.

Assess improvement on the pt. condition

d. Activity and Exercise

Type of Activity Bed Rest

Date ordered Date Ordered: 8-27-10

General description Patient is restricted from any stressful activities

Indication/Purpose To decrease patients metabolic demand and to decrease oxygen and energy supply

Specific activity taken Anything that patient can tolerate

Client response to treatment The client So complied very well by providing a adequate rest time for the patient.

NURSING RESPONSIBILITIES:

Prior  Explain properly the activity/exercise that the patient has to go through  Educate the SO by enumerating all the activities that patient may perform During

>Monitor and document patients reaction to the activity

After  Assist patient in performing activities  Encourage adequate rest period

B. NURSING MANAGEMENT PROBLEM#1: Impaired Gas exchange r/t pulmonary congestion secondary to VSD ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC EXPLANATION OBJECTIVES NURSING INTERVENTIONS RATIONALE EXPECTED OUTCOME

S>

O> the patient manifested: -restlessness -lethargy -hypoxemia -tachynypnea -nasal flaring -tachycardia >may manifest: -daiphoresis

Impaired gas exchange r/t pulmonary congestion secondary to VSD

Increase in ventricular pressure are transmitted back to the pulmonary capillary hydrostatic pressure and exceeding osmotic pressure, fluid moves within the alveolar septum causing decrease in the lungs air volume as the air is displaced by the blood or interstitial fluid which causes

Short term:

> assess and monitor for the After 4 hours of changes in NI, the patient respiratory will function. demonstrate adequate ventilation and oxygenation of > auscultate tissues by ABG breath sounds, noting crakles, or oximetry wheezes. within the patients normal ranges and free of signs of respiratory distress. > maintain bed rest with HOB elevated 30-60

>to detect signs of impaired ventilation and perfusion.

>to note presence of pulmonary congestion/ collection of secretions.

>to reduce oxygen consumption/ demands and promotes maximal lung

Short term: The patient should demonstrate adequate ventilation and oxygenation of tissues by ABG or oximetry within the patients normal ranges and free of signs of respiratory distress.

pulmonary congestion and result in an impaired gas exchange in the alveoli.

degree. Long term: After 24 hours of NI, the patient will participate in treatment regimen such as breathing exercises and use of oxygen, within clients limit.

inflation. Long term: >to identify hypoxemia, hypercapnia. the patient should participate in treatment regimen such as breathing exercises and use of oxygen, within clients limit.

> monitor serial ABG.

>to prevent hyperventilation resulting from fear and anxiety.

> provide brief explanation of all treatments and procedures.

>to maintain arterial oxygen saturation by SpO2>90%

> Administer supplemental oxygen as indicated.

>to increase surface area for appropriate gas exchange.

> prepare for intubation and assisted mechanical ventilation if required.

>to treat underlying condition such as Myocardial Infarction.

> administer anticoagulant

PROBLEM#2: Altered tissue perfusion r/t impaired transport of O2 across alveolar and capillary membrane ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC EXPLANATION OBJECTIVES NURSING INTERVENTIONS RATIONALE EXPECTED OUTCOME

S>

O> the patient manifested: -use of accessory muscles -nasal flaring

Altered tissue perfusion r/t impaired transport of O2 across alveolar and capillary membrane.

Disruption in the structure of the heart can decrease cardiac output. This will decrease or alter the delivery of oxygen and nutrients to tissue of different parts of the body organs.

Short term: After 4 hours of NI, the patient will demonstrate Increased perfusion AEB vital signs within clients normal limits, alert oriented and decreased pain and discomfort.

>note color and >cool and pale Short term: temperature of skin skin is indicative The patient q 4 hours. of decreased should be able peripheral demonstrate tissue perfusion. Increased perfusion AEB vital signs within clients normal limits, alert oriented and decreased pain and discomfort.

>note strength of peripheral

>systemic vasoconstriction resulting from diminished CO may be evidence by diminished pulses.

Long term: After 24 hours of NI, the patient >cardiac pump failure may precipitate

Long term: The patient should be able to demonstrate

will demonstrate increase in tissue perfusion as individually appropriate AEB warm skin an adequate urine output.

respiratory distress.

>monitor respiration, note work of breathing

>monitor intake, note changes in urine output.

>decreases intake/ persistent nausea may result in reduced circulating volume which negatively affects perfusion and organ function.

increase in tissue perfusion as individually appropriate AEB warm skin an adequate urine output.

>specific gravity measurements reflects hydration and renal function.

>reduced blood flow to mesentery can

reduce GI dysfunction.

>record specific gravity as indicated after urinalysis.

>assess GI function, noting anorexia, decreased or absent vowel sounds, N/V, abdominal distension and constipation.

>indicators of organ perfusion/ function abnormalities in coagulation may occur as a result of therapeutic measures.

>monitor laboratory data (ABG, BUN, Creatinine, coagulation

>to treat congestion of fluid in the body and prevention of further blockage in the

studies)

blood flow.

>administer diuretics and anticoagulants.

PROBLEM#3: Decreased Cardiac Output r/t altered Contractility ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC EXPLANATION OBJECTIVES NURSING INTERVENTIONS RATIONALE EXPECTED OUTCOME

S>

O> the patient manifested: -tachycardia -altered contractility -dyspnea -tachypnea -restlessness

Decreased Cardiac Output r/t altered Contractility

Inadequate blood pumped by the heart to meet the metabolic demands of the body in a hyper metabolic state, although C.O may be at normal range. It may still be inadequate to meet the needs of the bodys tissues.

Short term: After 2 of NI pt. will verbalize knowledge of the disease process, individual risk factors and treatment plan.

>Monitor VS

>To obtain baseline date

Short term: pt. will verbalize knowledge of the disease process, individual risk factors and treatment plan.

>Asses pts condition

>To know pts present condition

>To note changes in heart rate >Monitor decreased heart rate >To treat it as soon as possible >Note presence of edema

Long term: After 3 days of NI pt. will demonstrate an increase in activity tolerance.

Long term: pt. will demonstrate an increase in activity tolerance

>To note changes in weight

>Monitor decreased weight daily

>To slowly increase pts strength

>Perform exercises within the pts pones

>To help the pt. pharmacologically

>Give due medications

PROBLEM#4: Ineffective breathing pattern r/t hypertension AEB tachypnea and use of accessory musle to breath. ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC EXPLANATION OBJECTIVES NURSING INTERVENTIONS RATIONALE EXPECTED OUTCOME

S>

O> the patient manifested: -dyspnea -tachypnea -alteration in depth of breathing -use of accessory muscles to breathe -nasal flaring

Ineffective breathing pattern r/t hypertension AEB tachypnea and use of accessory musle to breath.

The defense mechanism of the lungs loose effectiveness and allow organisms to penetrate the sterile lower respiratory tract, where inflammation develops.

Short term:

>Establish rapport >To gain their to the patient and trust. Short term: with significant others. obtain the patient shall >Assess patients >To baseline data. condition. be able to establish on in reflective >Monitor vital >Helpful signs especially monitoring respiratory of pattern AEB respiratory rate signs respiratory every 2 hours absence of sign distress. and symptoms of hypoxia. >To ascertain >Auscultate breath states and note sounds. progress Long Term: >Provide opportunities rests. >This is to limit for activities of respiratory tolerance and for faster recovery of the the patient shall be free from congestion and respiratory distress as evidenced by absence of

After 7 hours of NI, the patient will establish on reflective respiratory pattern AEB absence of sign and symptoms Disruption of the of hypoxia. mechanical defenses of cough and ciliary Long Term: motility leads to colonization of the After 3 days of lungs and nursing subsequent interventions the inflexion inflamed patient will be and fluid filled free from alveolar sacs congestion and cannot exchange respiratory oxygen and

carbon dioxide effectively .alveolar exudates tends to consolidate so it is difficult to expectorate.

distress evidenced absence productive cough difficulty breathing.

as by of >Provide hydration and of

patent

productive cough and difficulty of >To liquefy secretions for breathing. easy expectoration

>For the SO >Give health have an teaching such as understanding performing deep of the disease breathing exercise process.

>Reposition patient periodically

>to mobilize secretions

>Provide supplemental humidification

>To dilate bronchioles

>To prevent >Instruct SO to aspiration. place the client on a semi fowlers

position > Give expectorants or bronchodilators as ordered > To loosen secretions

PROBLEM#5: Pain r/t decreased oxygen supply to the heart. Assessment Nursing diagnosis Pain r/t decreased Oxygen supply to The heart Scientific Explanation Due to left to right shunting of the blood, there is an inadequate oxygenated blood pumped towards the systemic circulation. A decrease the supply of oxygenated blood via the coronary arteries towards the heart. This results to ischemia causing anaerobic metabolism leading to lactic acid formation thereby causing pain Planning Short Term: After 3 hours of nursing interventions and health teachings, patients pain will be relieved and will demonstrate behaviors to prevent recurrence Long Term: After 24 hours of NI, The patient will verbalize techniques on avoidance in acquiring pain such as increase in bed rest. Intervention >Monitor and recorded VS Rationale >serve as a baseline data for future evaluation >to determine the degree of the problem >to decrease cardiac workload >to decrease O2 demand >to promote comfort and wellness >to relieve pain >to promote wellness >to promote ventilation. Expected outcome Short Term: The patients pain will be relieved and will demonstrate behaviors to prevent recurrence Long Term: After 24 hours of NI, The patient shall be able to verbalize techniques on avoidance in acquiring pain such as increase in bed rest.

S> O> the patient manifested: -sleep disturbance -change in respiration and and heart rate

>Encouraged verbalization of feelings >elevate patients head of bed to semi fowlers position >plan care between rest periods >provide therapeutic communication and touch therapy >administer pain reliever as ordered by the physician >administer Nitroglycerin as ordered >provide O2 therapy via nasal cannula

PROBLEM#6:Hyperthermia Assessment S: O O: patient manifested : - - with body - Temp of more than 380C/ax - flushed skin and warm to touch - - tachypnea -tachycardia Patient may manifest: -seizure / convulsion Nursing diagnosis Hyperthermia Scientific Explanation Formation of plaque in the artery resulting from trauma causes obstruction of blood flow will diminished blood flow to the myocardial cells hampering aerobic metabolism and leading to anaerobic metabolism causing production of lactic acid, which irritates myocardial tissue causing inflammatory Planning Short term: After 4 hours of NI, the patients Body Temperature Will decrease From 38.2 C to 37 C Long term: After 24 hours of NI, patient will be free of fever. >promote surface cooling by means of tepid sponge bath >provide supplementaO2 >maintain bed Rest >administer replacement Intervention >monitor patient Temperature >note presence or absence of searing as body attempts to increase heat loss by evaporation, conduction, and diffusion Rationale >to evaluated degree of Hyperthermia >evaporation is decreased by environmental factors of high humidity >to assist with measures to reduce body temperature >to offset increase O2 demands and consumptions >to reduce metabolic demands / oxygen consumption >to support circulating volume and tissue perfusion Expected outcome Short term: Patients body temperature shall be decreased from 38.2 to 36.4 C Long term: Patient shall have been free from fever.

process leading to hyperthermia

fluids >administer antipyretic medication

>to decreased temperature

2. Actual Soapiers(7-13-10 & 7-14-10) (7-13-10) S> O> received patient lying on bed, asleep; with intact heplock on the left hand; with O2 inhalation at 2 Lpm via nasal cannula; skin is warm to touch; with murmur; with tachypnea and tachycardia; afebrile; VS taken and recorded as follows T=36 C, RR= 59 cpm PR=146 bpm A>Ineffective breathing pattern r/t hypertension AEB tachypnea and use of accessory musle to breath. P>After 7 hours of NI, the patient will establish on reflective respiratory pattern AEB absence of sign and symptoms of hypoxia. I>monitored and recorded VS q 1hr >noted RR and areas of pallor >auscultated breath sounds >elevated the head of the bed >referred need for adequate rest >provided comfort and safety measures such as staying with the patients and not living him unattended. >maintained O2 as ordered >kept back dry >stretched linens >encouraged proper hygiene >needs attended >reinforced SAP and give other health teaching such as importance of 2D echo.

E>GOAL MET aeb patient establishing effective respiratory pattern AEB absence of sign and symptoms of hypoxia. (7-14-10) S> O>> received patient lying on bed, asleep; with intact heplock on the left hand; with O2 inhalation at 2 Lpm via nasal cannula; skin is warm to touch; with murmur; with tachypnea and tachycardia; afebrile; VS taken and recorded as follows T=36.7 C, RR= 69 cpm PR=130 bpm A>impaired gas exchanged r/t ventilation perfusion imbalance AEB tachypnea and tachycardia. P>After 4 hours of NI, the patient will demonstrate improved ventilation and adequate oxygenation of tissues by absence of symptoms of respiratory distress. I>monitored and recorded VS >noted RR and pallor/cyanosis >auscultated breath sounds >elevated the head of the bed >referred need for adequate rest >provided comfort and safety measures such as staying with the patients and not living him unattended. >maintained O2 as ordered >kept back dry >stretched linens >encouraged proper hygiene E>GOAL MET aeb by patient demonstrating improved ventilation and adequate oxygenation of tissues by absence of symptoms of respiratory distress.

VI. CLIENTS DAILY PROGRESS IN THE HOSPITAL Aug 27 NURSING PROBLEMS 1) Impaired Gas Exchange 2) Altered Tissue Perfusion 3) Decreased Cardiac Output 4) Ineffective Breathing Pattern 5) Pain 6) Hyperthermia VITAL SIGNS  Temp  PR  RR DIAGNOSTIC/LAB PROCEDURES
Hemoglobin( g/L)

Aug 28

Aug 29

Aug 30

Aug 31

Sep 1

Sep 2

Sep 3

Sep 4

Sep 5

Sep 6

Sep 7

Sep 8

Sep 9

Sep Sep 10 11

Sep Sep 12 13

Sep 14

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~ ~

~ ~ ~

~ ~ ~

~ ~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

~ ~

37.1 160 40

36.2 142 32

36.5 125 40

38 132 45

38.5 150 53

38.3 160 53

38.5 130 78

36.8 126 60

37 125 62

37.3 133 72

36.8 136 60

37 132 60

37.2 145 65

37 138 67

36 135 60

36 135 55

37 125 58

36 146 59

36.7 130 69

Hematocrit WBC(x109/L) Lymphocytes

112 .33 12.2 .50

108 12.2 .49

Neutrophils Platelets(x109/L) Chest X-Ray MEDICAL MANAGEMENT D5.03 NaCl Heplock Oxygen Tx DRUGS Ampicillin Cefotaxime Dopamine Furosemide Paracetamol Oxacillin Amikacin Lanoxin Gentamicin DIET

Aug 27 .55 363 ~

Aug 28

Aug 29

Aug 30

Aug 31

Sep 1 .46 365

Sep 2

Sep 3

Sep 4

Sep 5

Sep 6

Sep 7

Sep 8

Sep 9

Sep Sep 10 11

Sep Sep 12 13

Sep 14

RSLT IN

IV OUT

~ ~ ~ ~ ~ ~ ~ ~ D/C ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

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D/C ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ D/C ~ ~ ~ ~ ~ ~ ~ ~ D/C D/C ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ D/C D/C ~ ~ ~ ~ ~ ~ ~ ~

NPO Full Feeding w/ SAP ACTIVITY Bed rest

D/C ~

VII. CONCLUSION

A baby's heart begins to develop shortly after conception. During development, structural defects can occur. These defects can involve the walls of the heart, the valves of the heart and the arteries and veins near the heart. Congenital heart defects can disrupt the normal flow of blood through the heart Embryonic organogenesis occurs in the first trimester of pregnancy.Having said that, it is very crucial that a mother is very careful in taking care of herself, her diet, her activities and her way of treating the baby inside her womb. One of the most common child illnesses is the Congenital heart Diseases, this kind of anomalies are so fatal if left unrecognized and untreated. Ventricular Septal Defect is the most common form of congenital anomalies and it may occur during the cardiogenesis or during the formation of the heart. It is so unique that this kind of defect can occur unnoticed even during the first few months of life. The student nurses also realized that a minute amount of drug can have a very big impact on a babys life. In our case, it created a hole in the ventricular septum of the patient. We have realized that such small hole can lead to fatal circumstances if not managed.

VIII.RECOMMENDATIONS

To the future researchers, that this case study may serve as a background and basis of future studies if with the same disease conditions and with additional disease would be pursued.

To the Community Health Nursing,since there might be a possibility that mothers from depressed,deprived and underserved areas of the community might do the same thing as the mother of Abby Hearty did, in order to prevent this, Community Health Nurses should provide and widen community awareness by conducting seminars, discussion groups, distributing brochures and posting of visual aids that will focus on promoting health and preventing the disease to be acquired from the community people.

To the nursing service, since having a better grasp of a disease condition will lead to a better delivery of quality care. This will also help in adding more knowledge to them and also updating them with current trends.

To student nurses that would be exposed in clinical area with similar diagnoses that they would individualized prioritized plan of care based on patients identified problems of higher risk involved and requiring immediate interventions.

To the Department of Health, so that they can conduct further research and seminars regarding VSD and othe congenital heart diseases.. In this way, the people can become more aware on the disease condition and it will be easier for them to prevent it.

IX. LEARNING DERIVED

There is always a learning experience in our everyday encounter with other people. Whether small or big things, people grow and continue to learn. I learned a lot while doing this case study. I was able to increase my knowledge about a congenital heart disease, enhance my skills, and improve my attitude; furthermore I also had the chance to develop teamwork with my group mates. The Lord Almighty, my supportive family, my clinical instructor, group mates, and my commitment have been of great help to accomplish my objectives and goals throughout this rotation. From having Baby Hearty as our patient for the case study, I have learned that no matter what happens, a person should be strong enough and go forward fighting for survival. Though he is only six months old, I perceive him as a very brave and strong person. This was the first time I had my duty at a pediatric ward at a tertiary hospital, it was tiring and there were adjustments to be done since it was also my first time to be in JBL. Though it was tiring, nothing compares to the feeling of fulfillment whenever a patient that I handled thanks me and shows a smile. In my patients case,his smile is enough to make my day. It makes me feel that I have done a good job and that I have made something for the betterment of humanity. No matter how small my help was, I know that our dear Creator was very proud of me. It also made me realize that there are so many disease conditions that a person can acquire and that urged me to be more healthy and be and to take one step forward in taking care of myself. -Miguel Paolo A. Galang BSN III-2, Group 7, Leader

First times are always overwhelming and bring mix emotions, as much as this case study does. Yeah, this is not our first case study in relation with nursing, but this is our first case study in the relation with Ventricular septal defect. I have to admit it. This case study is not that easy for us to do, but yet as a group, we finished it. Though we had sleepless nights just to finish this case study, still, I am so happy that we did this case study to learn more and to help the public by providing information about the condition. I learn so much things in doing this case study not only by means of knowledge but also, by means of attitude. In terms of knowledge, this case study broadened my wisdom about the condition. It gives me additional experience and information like what is VSD, its signs and symptoms, who are at risk, what are the preventive measures and the manifestations that will help me to function as an effective nurse in the future. Finishing this case study requires time, effort, patience, cooperation and unity among the group. Our objective in this study is not only to finish, pass and have a grade but also, I want to emphasize that we did this case study to help those patients who suffer from this condition and those people at risk in acquiring the condition. As a nursing student, activities like this helps in developing our knowledge, skills and attitude as we go along our journey in the course until we are already registered nurses. I also thank God for helping us in doing this case study. He is the reason why we had finished this case study. To Him be all the glory and praises. -Shayne M. Dimla

As a student nurse Ive learned how to deal with children in different ages. At first it is challenging on my part, because children are scared of nurses or the people who wears white uniform. Because all they know is that they will be prick by a needle. But as time goes by I learned to socialize with them like playing before doing the responsibilities as a student nurse.

Its sad for me to have a patient who has a congenital heart disease just because of a single tablet.i cant judge the mother of the baby because I dont know the reason behind that, but for me I really pity the baby because its a life and death condition.

As a student nurse I did my job to help so, I thought the mother and the grandmother of the baby on the proper management, like treat the baby as normal, give all his needs, proper hand washing and proper food sanitation and daily check up if they will be discharge. I also thought the mother to have her child proper hygiene to protect her baby from microorganisms or pathogens.

-Magtoto Ma. Jessica E.

After accomplishing this case study, the researchers met their reasons in choosing the problem, ventricular septal defect. As nurses, it is our duty to provide our patients as well as their significant others with adequate knowledge about the condition of the patient and possible complications of this disease. Because in here, the most appropriate goal of care is the proper treatment/support for the patient in order to understand and cope with the situation. That is why, as much as possible, nurses must guide their patients and their family in identifying ways on how to manage the disease in order to avoid its progress to a more complicated one. Also, as nurses, they must have the competent skills, adequate knowledge and a compassionate heart. The nurse is not the sole determinant of the failure or effectiveness of any treatment. The patients themselves, with support of loved ones are the prime factors for achieving the best possible results of the interventions made, yet the nurse who spends greater time with the patient functions not only to perform health assessment, administer medications or provide health teachings, but the nurse is also important in helping the patient process both the physiological and psychological impact of the treatment. -Mallari, Giselle M.

Being at the pediatric ward was not easy for me, because it so sad for me to see little children suffering from an illness. Ive learned the right care that the nurse must do for the patients. I was able to see procedures and the different scenario in the hospital. I as given a chance to share my knowledge and care for the patient I have handled. In this case study Ive realized that the disease that were just discussing in our NCM lecture can really happened. And its so sad to thing that the one whos suffering is just a child. Ive learned to give importance to the things and concept that was discussed in our lecture especially the right managements. Because of this knowledge Ive learned I was able to know what are the right things I can do for the patient. -Policarpio, Frances joye P.

BIBLIOGRAPHY Books Black, Joyce M. and Jane Hokanson Hawks. Medical-Surgical Nursing Clinical Management for Positive Outcomes. Singapore: Elsevier, 2009 Blakiston. Blakistons Pocket Medical Dictionary. United States of America: McGrawHill,1979 Doenges,Moorhouse & Murr, Nurses Pocket Guide. Weber,Janet R.Nurses Handbook of Health Assessment (Sixth Edition). United States of America: Lippincott Williams & Wilkins Karch,Amy M.2010 Lippincotts Nursing Drug Guide. United States of America: Lippincott Williams & Wilkins

Internet http://www.cincinnatichildrens.org/health/heart-encyclopedia/anomalies/vsd.htm http://www.nlm.nih.gov/medlineplus/news/fullstory_99249.html

http://www.nlm.nih.gov/medlineplus/ency/article/001099.htm http://www.emedicinehealth.com/ventricular_septal_defect/page3_em.htm http://www.mayoclinic.com/health/ventricular-septaldefect/DS00614/DSECTION=coping-and-support http://www.medicinenet.com/pneumonia/article.htm