Medical management

DATE
ORDERED
CLIENT’S
MEDICAL DATE
GENERAL INDICATIONS RESPONSE
MANAGEMENT PERFORMED
DESCRIPTION OR PURPOSES TO THE
OR TREATMENT
DATE TREATMENT
CHANGED or
D/C

D5 0.3 NaCl 30-31 Date Ordered An hypotonic Replenish cells in Patient was
gtts/min and Performed: solution the body and able to maintain
significant amount a good
of fluids and hydration in
July 19, 2010 electrolytes. replace to the
fluid loss in his
body.

D5 NM 30-31 Date Ordered An hypertonic It is indicated for Patient was

gtts/min and Performed: solution parental able to maintain
maintenance of a good
routine daily fluid hydration in
July 20, 2010 and electrolyte replace to the
requirements with fluid loss in his
minimal body.
carbohydrate
calories from
dextrose

Oxygen Inhalation Date Ordered Tasteless,

via Nasal Cannula and Performed: odorless, It is given to the Patient’s
at colorless gas patient via nasal breathing was
essential for cannula and is improved.
2-3 LPM
September 19, human respiration used most
2006 in oxygen function commonly when
as a carrier gas the patient has
for proper difficulty of
oxygenation of breathing.
tissues in the
body especially in
the gas exchange
in the lungs.

NURSING RESPONSIBILITIES

Prior:

1. Check doctor’s order

2. Compute for the drops/min
3. Prepare the materials needed
4. Explain the procedure to the patient

During:

1. Check/locate for the insertion site of IV

2. Observe aseptic technique
3. Check for the patency of the tubings
4. Regulate the IVF
5. Mark the IV bottle with date, time and # of the IVF
After:

1. check for any signs of abnormalities in the insertion site

2. Document to the patient chart

OXYGEN THERAPY

□ Check for doctor’s order for the concentration needed by the patient.

□ Thoroughly and carefully observe patient’s need for oxygen and response to therapy.

□ Check for oxygen toxicity

Ineffective tissue perfusion

Cues Nursing Scientific Objectives Interventions Rationale Expected

Diagnosis explanation outcome

S>ø Ineffective Reduced arterial Short term:  Establis  to gain Patient is

tissue blood flow h rapport patient’s expected to
O> patient manifested: After 4 hrs. of
perfusion causes trust and demonstrate
nursing
 Pale palpebral decreased cooperation participation on
interventions,
conjunctiva nutrition and therapeutic
patient will  To
 Pale nail beds oxygenation at  Assess measures
demonstrate monitor for
with capillary the cellular lower given to
participation on impairment
refill of 1 sec. level. extremities; prevent
therapeutic of blood flow
 Restlessness Management is noting skin complications
measures given in the lower
directed at texture, as well as
 Weakness to prevent extremities
removing presence of
occurrence of Demonstrate
vasoconstricting ulcerations
complications. tissue
patient may manifest: factor(s),  Monitor  For
Perfusion as
improving and record baseline
 Dysrhythmias evidenced by
peripheral blood v/s measureme
 Edema Long term: decreased
flow, and  Monitor nt
 Temperature HGT results
reducing After 3 days of blood  To
changes (90 mg/dl by
metabolic nursing glucose monitor for Nov 25) normal
 Skin
demands on the interventions, level as the increase vital
discolorations signs,
body. patient will ordered or decrease absence of
Decreased demonstrate
tissue perfusion tse. Perfusion in the pallor
can be transient as evidenced amount of
with few or by decreased blood
minimal HGT results, circulating in
consequences normal v/s, the body
to the health of absence of
the patient. If pallor, absence  Explain
 To
the decreased of paresthesia, the client’s
inform the
perfusion is numbness and condition
pt.
acute and tingling  Emphas
protracted, it sensation ize strict
can have compliance
devastating to
 To gain
effects on the therapeutic
patient’s
patient. regimen
compliance
Diminished such as
tissue perfusion, taking the
which is chronic medications
in nature, as ordered
invariably and
results in tissue complying
or organ with the
damage or diet.
death. This care  Ask the
plan focuses on patient to  To
problems in have conserve
hospitalized enough rest energy and
patients. to increase
O2 supply to
the body
 Assist  to
patient in facilitate
doing proper blood
Passive flow
range of
motion
(PROM)
exercises
 Turn
 To
patient from
prevent
side to side
complication
every 2
s such as
hours
formation of
ulcers
IV. The Patient’s Illness

A. Synthesis of the disease ( book based)

Definition

Ebstein's anomaly is a rare heart defect that's present at birth (congenital). In

Ebstein's anomaly, your tricuspid valve — the valve between the chambers on the right
side of your heart — doesn't work properly. Blood leaks back through the valve, making
your heart work less efficiently. Ebstein's anomaly may also lead to enlargement of the
heart or heart failure.

Predisposing and Precipitating factors

• Race – it is common in children of white females

• Sex – no specific sex predominance exists
• Age

• Fetus
o Abnormal fetal scan - 86%
o Arrhythmia - 5%

• Neonate (aged 0-1 mo)

o Cyanosis - 74%
o Heart failure with poor feeding and failure to thrive - 10%
o Incidental heart murmur - 9%

• Infant (aged 2 mo to 2 y)
o Cyanosis - 35%
o Heart failure with poor feeding and failure to thrive - 43%
o Incidental heart murmur - 13%

• Child (aged 3-10 y)

o Cyanosis - 14%
o Heart failure with poor growth and decreased exercise tolerance - 8%
o Arrhythmia with complaints of palpitations - 12%
o Incidental heart murmur - 66%
 • Adolescent (aged 11-18 y)
o Cyanosis - 13%
o Heart failure with dyspnea on exertion and decreased exercise tolerance

- 13%
o Arrhythmia with complaints of palpitations - 40%
o Incidental heart murmur, 33%

• Adult (aged >18 y)

o Cyanosis - 4%
o Heart failure with dyspnea on exertion and decreased exercise

tolerance - 26%
o Arrhythmia with complaints of palpitations - 43%
o Incidental heart murmur - 13%
o Chest pain - 20%
o Syncope - 6%

Signs and Symptoms

Mild forms of Ebstein's anomaly may not cause symptoms until later in
adulthood. Even some people with very abnormal valves may have minimal, if any,
problems. Ebstein's anomaly symptoms may develop slowly over many years and
include:

Shortness of breath

Fatigue, especially with exertion

Leg swelling

Heart palpitations or abnormal heart rhythms (arrhythmias)

A bluish discoloration of the lips and skin caused by low oxygen (cyanosis)
 Newborns and infants who are diagnosed with Ebstein's anomaly usually show
signs of cyanosis early, in addition to signs and symptoms of heart failure. When signs
and symptoms appear at such a young age, this usually indicates a severe defect that
requires treatment.

Older children may show signs of heart failure, such as tiring easily or becoming
short of breath during play. Their other symptoms may include heart pounding or racing
or cyanosis, especially around the lips and fingertips.

Health promotion and Preventive aspects of the disease

Asymptomatic patients with Ebstein anomaly who have mild tricuspid

regurgitation need only outpatient clinic evaluation, which may include periodic ECG,
chest radiography, and oxygen saturation measurement. All patients with this diagnosis
require lifetime prophylaxis for bacterial endocarditis. In neonates who have a severe
form of this disease, an adequate atrial communication is crucial. If the patient is born
with only a patent foramen ovale (PFO) or a restrictive atrial septal defect (ASD), a
balloon atrial septostomy or urgent surgical intervention may be required. Atrial
septostomy can be accomplished at the bedside with echocardiographic guidance or in
the cardiac catheterization laboratory, under echocardiographic and/or fluoroscopic
guidance.

Electrophysiological studies are performed both as a diagnostic tool to determine

the cause of an arrhythmia and as a curative procedure using radiofrequency catheter
ablation. Catheter ablation for paroxysmal supraventricular tachycardia (SVT) is highly
successful in children, with a low complication and recurrence rate; however, the subset
of patients with Ebstein anomaly and SVT has been shown to be more challenging to
cure, likely because of the derangement in tricuspid valve alignment with the tricuspid
annulus and the increased likelihood of multiple accessory pathways.

The reported acute success rate in the Pediatric Radiofrequency Ablation Registry and
other sources ranges from 75-90%, and the recurrence rate is reported to be as high as
32%.4 As expected, success rates, complications, and recurrence rates vary with
complex pediatric radiofrequency catheter ablation procedures, depending on operator
and institutional experience. Radiofrequency ablation appears to be most successful in
patients with a mild degree of tricuspid regurgitation.

Surgical Care

The surgical care of these patients depends on the severity of the leaflet
displacement and on the degree of associated right ventricular outflow tract obstruction.

In neonates with the most severe form of Ebstein anomaly, the functional right
ventricle is hypoplastic, and the patient is usually best treated by closing the tricuspid
valve and, in effect, creating a tricuspid atresia physiology (Starnes procedure). In
addition, these infants require a systemic artery–to–pulmonary artery shunt. When the
patient is aged approximately 6 months, a bidirectional Glenn procedure (superior vena
cava–to–pulmonary artery anastomosis) and shunt takedown is performed. Fontan
completion (inferior vena cava–to–pulmonary artery anastomosis) is usually performed
when the patient is aged 2-4 years.

In infants with mild-to-moderate tricuspid regurgitation and severe right

ventricular outflow tract obstruction, a systemic artery–to–pulmonary artery shunt is
performed in addition to an unrestrictive atrial communication being created. In patients
with moderate-to-severe tricuspid regurgitation, the abnormal valve can be replaced with
a mechanical or prosthetic valve, a surgical reconstruction, or a combination of the two.

In a study by Brown et al from the Mayo clinic the results of 539 patients who had
604 cardiac operations is described.5 The mean age of this group was 24 years. The
first repair consisted of tricuspid valve repair in 182 patients and tricuspid valve
replacement in 337 patients. Late survival was 84.7% at 10 years and 71.2% at 20
years. Preoperative characteristics associated with mortality included increased
hematocrit levels, associated mitral valve repair, prior cardiac operation, and moderate-
to-severe reduction in right ventricular systolic function.

Diet
 Special dietary restrictions are not usually required. An infant with severe
tricuspid regurgitation may require a high caloric density formula.

Activity

The activity restrictions of these patients depend on the severity of the leaflet
displacement. If the displacement is mild and patients do not have an associated
paroxysmal SVT, they should be allowed to determine their own level of activity. For
patients with cyanosis, sports participation is usually somewhat restricted. An exercise
stress test and other noninvasive assessments might be helpful in making this
determination.
Pathophysiology

Ebstein’s Anomaly

Modifiable: Non- modifiable:

• Maternal • Age
Lithium
intake • Sex

• Hereditary

Normal blood flow of the

blood

Blood from the pulmonic Increased pressure

circulation enters the right shunts though the
atrium

Downward displacement of an Left

Regurgitati abnormal tricuspid valve atrium
on

Right ventricle Cyanosis

Failure to thrive
activity intolerance Decreased cardiac Polycythemia