University of the Philippines Manila

The Health Sciences Center

COLLEGE OF NURSING
WHO Collaborating Center for Leadership and Nursing Development
CHED Center of Excellence
Julita V. Sotejo Hall, Pedro Gil St., Ermita, Manila

A Case Analysis on a
Critically-ill Pediatric Patient
In partial fulfillment of the requirements for
N124: Critical Care Nursing

Submitted by:

AGUSTIN, Anne Julia H.

BIDAURE, Rensha Mari T.
DELOS SANTOS, Jose Raphael M.
LEE, Kim Gabrielle Exene C.
LEUENBERGER, Alyssa Simone L.
MACATANGAY, Nathaniel Bernard B.
MAHILUM, Ella Mae Lolith P.
MEJIA, Robert L.
ORILLA, Kharissa Anne P.
RAMIREZ, Ma. Elena A.
UY, Kathleen Nicole T.

Submitted to:
Asst. Prof. Aldin D. Gaspar, MSc, MHC, MN, RN
Course Coordinator, N-124
INTRODUCTION
 The organ systems are very important in maintaining the stability of internal environment

for optimal cell metabolism. One of the most important organ system is the cardiovascular

system. It plays an important role in maintaining the constancy of the extracellular fluid. The

cardiovascular system delivers oxygen and nutrients needed for metabolic processes to the

tissues, carries wastes from cells to kidneys and other organs for elimination, and circulates

electrolytes and hormones needed to regulate body function (Porth, 2014).

However, once the function of this system is altered, a disturbance of homeostasis can

occur. Congenital Heart Disease (CHD) is one of the most common alterations in the

cardiovascular function in pediatric patients. This disease suggests one or more structural

abnormalities that develop before birth (James & Ashwill, 2007). CHD includes primarily

anatomic abnormalities present at birth that result in abnormal cardiac function (Hockenberry &

Wilson, 2013). There are three broad categories of the clinical consequences of CHDs namely,

heart failure (HF), pulmonary hypertension, and hypoxemia.

CHD is said to be the most common form of structural birth defect as approximately 1 of

every 115 to 125 infants born has this disease. Moreover, about 2 or 3 in 1000 infants will be

symptomatic during the first year of life with significant heart disease that requires treatment

(Porth, 2014: Hoffman and Kaplan, 2002). Considering that CHD has a mortality of 30% to

50%, it is the major cause of death, aside from prematurity, in the first year of life (Gilboa et al.,

2010).

A patient-centered nursing approach that promotes holistic care in caring for pediatric

patients with cardiac abnormality in the critical care unit will be emphasized in this case analysis.

The pediatric patient was assessed, problems were identified, interventions were provided, and

the outcome evaluation of care was provided. In addition to that, a database containing
significant information about the patient’s case such as the health history, physical assessment

findings, and laboratory and diagnostic results was also encompassed. This analysis also covered

the discussion of the plan of care, the nursing interventions done to address the problems and the

medical management including pharmacologic treatment given to the patient. Lastly, the

outcome and process evaluation will be tackled as well.

ASSESSMENT FINDINGS

A. Nursing Health History

Client Profile

RM is a 2-year-old toddler from a far-flung community in Antique. He is the first-born child.

The community of the patient is a barrier of health optimization and it predisposes him to a

health status decline.

Chief Complaint

RM was admitted for the first time at PGH due to cyanosis and “hindi mawala-walang ubo at

sipon”.

History of Present Illness

1 week PTA, Mrs. Magsino noticed that RM was “matamlay at ayaw kumain”. Within that same

week, she noticed that her child was not as playful as he used to, and a few more days after, he

was occasionally cyanotic especially when crying. Such presentations prompted consult to the

Barangay Health Station. They were subsequently referred to the District Hospital and then to

PGH for further management.

Health History and Functional Patterns

The child’s mother reported that the toddler is usually playful but he gets fatigued at times

especially “pag maghapon naglalaro at nagtatakbo sa paghahagad ng mga manok”. He is prone

to have cough and colds. RM’s mother would often just shrug it off saying that it is common

among children in their neighbourhood

Course in the Hospital/ICU

Upon admission to PGH, RM’s echocardiogram result revealed Ventricular Septal

Defect, perimembranous, 4 to 5mm with increased pulmonary vascular resistance and mild right

ventricular enlargement. On his second day of hospitalization, he is still on standby intubation,

but is on oxygen support at 10 LPM via face mask. He is on NPO with a nasogastric tube open to

bedside bottle. RM also has a right femoral vein catheter to 3-way lumen with D10IMB at 50

cc/hr on blue port, Dopamine 8 mcg/kg/min at 1 cc/hr and Dobutamine 10 mcg/kg/min at 1.5

cc/hr on white port, and brown port for blood extraction use and medications but is clamped. The

patient also has a foley catheter to urine bag draining amber-colored urine at 3 cc/kg/hr.

B. Physical Examination

Vital Signs

Upon receiving the patient, he had a heart rate of 132 beats per minute which is high. The patient

is tachycardic which may be due to the ventricular septal defect that causes his heart to work or

pump harder. His respiratory rate is 42 respirations per minute which is also high. Increased

respiratory rate may indicate impaired oxygenation and can be correlated to his heart problem.
His blood pressure is 72/43 mmHg which is hypotensive and may mean reduction in any of the

following: cardiac output, venous pressure, or systemic vascular resistance. His MAP is 53

mmHg

Anthropometric Measurements

The patient’s weight upon admission is 10 kg and the z-score for weight-for-age is -2.

Neurologic

The patient was drowsy and withdraws to pain upon assessment. His GCS score is E4V3M4 =

11. His pupils were both round at 3 mm in diameter. Both pupils also had an equal and brisk

reaction to light.

Chest and Lungs

The patient’s chest is flat with equal expansion. It was observed that he had an adynamic

precordium which is a normal finding. However, crackles were heard on both lower lung fields

and subcostal retractions were also seen. Manifestation of crackles suggests fluid in the small

airways or alveoli. Subcostal retractions indicate increased respiratory effort.

Heart

Findings show that the patient’s PMI is located at the fourth intercostal space, left midclavicular

line. There were no heaves and thrills noted. However, holosystolic murmur is at 3/6 is present at

the apex. Presence of holosystolic murmurs is indicative of mitral regurgitation that is a

complication from ventricular septal defect.

Abdomen

The patient’s abdomen is flat. There were no bruits and his bowel sounds are normoactive. The

spleen was not palpable and the liver was noted to be 3 cm below the right costal margin.

According to Wolf and Lavine (2000), “a liver edge greater than 2 cm in children below the right

costal margin suggests liver enlargement."

Perfusion

The patient has symmetrical and full pulses. There were no pulse deficits. His skin was warm

and his capillary refill time is prolonged at three seconds. Occasional cyanosis can also be noted

when the patient is crying. Findings suggest systemic tissue hypoperfusion.

Contraptions

RM has a nasogastric tube open to bedside bottle. He is also on oxygen support at 10 liters per

minute via face mask. A right femoral vein catheter to 3-way lumen is also present with D10IMB

at 50 cc/hr on blue port, Dopamine 8 mcg/kg/min at 1 cc/hr and Dobutamine 10 mcg/kg/min at

1.5 cc/hr on white port, and brown port for blood extraction use and medications but is clamped.

The patient has a foley catheter attached to a urine bag as well and it is draining amber-colored

urine at 3 cc/kg/hr. His urine output is increased.

C. Reason for Admission in the ICU

A critical care article from California Pacific Medical Center states that an intensive care

unit is “a unit in the hospital where seriously ill patients are cared for by specially trained staff.”
 Furthermore, according to Urden et. Al. (2010), a critically ill patient is one who is at

imminent risk of death and one whose condition warrants immediate recognition and prompt

action to assess, identify, and manage their usually multi-systematic and unstable disease

condition.

The patient has been admitted due to unresolved cough and colds and cyanosis. He needs

to be managed due to the complications of his illness and its effect on his general well-being as a

two-year-old child. Respiratory and cardiac impairment must be addressed immediately.

In light of the instances cited, the patient fits the description of a critically ill patient as a

complex, unstable, and vulnerable case. He is in need of intensive management and close and

continuous monitoring and assessment, which could be provided in an ICU by specially trained

critical care health care team.

D. Laboratory and Diagnostic Findings

Arterial Blood Gas

Arterial Blood Gas provides information in assessing and managing a patient's respiratory

(ventilation) and metabolic (renal) acid-base and electrolyte homeostasis (Pagana, 2013). In the

case of the client, it will facilitate monitoring of the ability of the lungs to facilitate gas exchange

which can affect certain pressures in the physiology of the heart especially in the case of

Ventricular Septal Defect. Ventricular Septal Defect tends to increase pulmonary blood flow

which increases pulmonary vascular resistance d/t pulmonary vasoconstriction. Due to the

acuity of client’s cardiopulmonary condition, it will also help monitor client’s oxygenation needs

and his response to the current oxygenation device.

 Upon analysis of the results, it revealed that the client has Respiratory acidosis with

metabolic compensation. Due to the pulmonary hypertension caused by the congenital heart

defect, it led to pulmonary congestion which impairs gas exchange at the alveolar level. Due to

the inability to excrete enough carbon dioxide to maintain normal blood pH, the kidneys tend to

retain bicarbonate to compensate which is reflected by the elevated bicarbonate levels (pHCO3 =

28).

With the result of the client’s blood gases, it warrants resolution of the current heart and

lung pathology such as left to right shunting and fluid retention in the lungs as evidenced by

presence of the septal defect in echocardiogram and presence of bilateral basal crackles

respectively. The client is currently on standby intubation and the nurse should monitor the client

for signs warranting emergency intubation. Administer diuretics as ordered to relieve fluid

congestion from the lungs. Elevate head of bed as tolerated to facilitate proper lung expansion

and prevent dyspnea.

Serum Electrolytes

Serum Electrolytes, as a laboratory test, determines if there are electrolyte imbalances

that are caused by the disease state and gives the healthcare providers an idea on the excretion

and absorptive state of the client (Pagana, 2013). In the case of a client with VSD, it is

particularly important to monitor electrolyte levels such as Potassium and Calcium which may

affect conduction of the heart. It also monitors response of the client to certain medications and

current fluid status of the client.

The client’s electrolyte panel reflects hyponatremia and hypocalcemia. Hyponatremia, in

the case of the client,can be due to hemodilution as the client is starting to retain fluid as
evidenced by presence of crackles or can also be due to increased urinary output of the client ( 3

cc/kg/hr). The client is currently receiving inotropes which indicates decreasing ability of the

heart to pump effectively due to the anatomical defect. This predisposes the client to heart failure

which will eventually lead to fluid overload that will further dilute the client’s electrolytes.

Hypocalcemia can be attributed to nutritional deficiency caused by poor feeding, increased

urinary output and administration of heparin to keep femoral catheter patent (Heparin comes

with citrate which chelates calcium causing hypocalcemia).

With the knowledge of current electrolyte levels, the client should be continuously

monitored for signs of hyponatremia and hypocalcemia and ensure adequate sodium and

calcium replacement replacement. Signs of hyponatremia include nausea and vomiting,

headache, confusion, loss of energy and fatigue, restlessness and irritability, muscle weakness,

spasms or cramps, seizures and coma. Signs of hypocalcemia include muscle cramps, tingling

sensation, cardiac dysrhythmias, Trousseau’s sign, Chvostek sign. Monitor client’s cardiac

rhythm for possible effects of hypocalcemia. Refer client to physician as needed.

Electrolytes Normal Range Results

Sodium 135-145 mg/dL 130 ↓

Potassium 3.5-4.5 mEq/L 3.5 N

Calcium 4.5-5.8 mEq/L 2.8↓

Figure 1. Serum Electrolytes of RM

Complete Blood Count

 Complete Blood Count facilitates monitoring of client’s hematologic status and immune

status. It also reflects oxygenation, nutritional and fluid status of the critically ill pediatric client.

Client’s response to medications can also be monitored through a complete blood count.

The client has an elevated red blood cell, hemoglobin and hematocrit count due to

episodes of cyanosis which can be attributed to the septal defect. Usually, VSD is acyanotic as

the shunt is left to right. However, as it enlarges, the increase in pulmonary blood flow increases

preload and thus increase workload for the right ventricle. As evidenced in the echocardiogram,

the right ventricle hypertrophies and possibly offshoots pressure from left ventricle. Thus, the

reversal of the direction of the shunting. With the mixing of deoxygenated and oxygenated

blood, it decreases oxygen saturation in the blood. This decreased saturation is sensed by the

kidneys, resulting in a compensatory increase in erythropoietin production and an increased

production of red blood cells in an attempt to increase oxygen delivery, thus the elevated red

blood cell counts. The increase in platelet count is an effect of increased stimulation of the bone

marrow which also produces platelets when stimulated.

The client should be monitored for signs of ineffective systemic perfusion especially that

his capillary refill time is already increased. Hyperviscosity of the blood may lead to higher

blood pressure which may not be helpful for a client with increased pulmonary blood flow. Thus,

strict monitoring of the client’s vital signs especially HR and BP should be monitored as well as

cardiac rhythm. Ensure adequate fluid replacement in order to prevent dehydration which may

lead to further blood viscosity. Monitor client’s oxygenation status and watch out for signs of

respiratory distress.

Blood Count Normal Range Result

 White Blood Cell 6200-17,000/mm3 15 x 103/ mm3

Red Blood Cell 4.0 -5.5 x 103/ mm3 5.8 x 103/ mm3

Hemoglobin 9.5-14 g/dL 16 mg/dL

Hematocrit 30%-40% 59%

Platelet Count 150,000-400,000/mm3 450 x 103/ mm3

Figure 2. Complete Blood Count of R.M.

Echocardiography

Echocardiography is a noninvasive ultrasound procedure used to evaluate the structure

and function of the heart (Pagana, 2013). It utilize high frequency sound waves to create a

tracing. It is essential in the diagnosis of Ventricular Septal Defect as it visualizes the structures,

namely, a lack of continuity in the interventricular septum which allows the direct circulation of

blood between the two ventricles in VSDs. It also helps in the visualization of the size of

shunting as it predicts pressure differences between the right and left side of the heart. It also

helps in the classification of the VSD on whether it is perimembranous, subarterial or muscular

(Soto et al., 1980). Vais (1992) classified the size of VSDs as follows: small (diameter less than

or equal to 3 mm), medium (3 to 6 mm) and large (greater than 6 mm).

The echocardiogram confirmed the presence of Ventricular Septal Defect which is

perimembranous in nature. Perimembranous ventricular septal defects (VSDs) are located in the

left ventricle outflow tract beneath the aortic valve. Upon usage of Vais’ (1992) classification by

size; the client, having 4-5 mm in diameter, has a medium sized VSD. It also showed increased

pulmonary vascular resistance and mild right ventricular enlargement which is expected in

patients with increased pulmonary blood flow.

 Its implications to care include strict monitoring of hemodynamic parameters such as

heart rate, blood pressure, respiratory rate and cardiac rhythm. Dysrhythmias can occur due to

increased heart workload which leads to deterioration of heart’s conduction system as the muscle

hypertrophies.Signs of ineffective perfusion should also be monitored such as slow capillary

refill time, pallor, cold extremities, weak pulses and decreased level of consciousness.

Administer inotropic agents as ordered such as Dopamine and Dobutamine to further augment

cardiac contractility. Ensure adequate oxygenation of client by continuously monitoring blood

gases, respirations and signs of respiratory distress.

E. Drugs and Other Treatment Modalities

Dopamine

Dopamine is an adrenergic inotrope used to improve blood pressure, cardiac output, urine

output and increase renal perfusion in low doses (FA Davis Company, 2013). It acts by

stimulating dopaminergic and beta1-adrenergic receptors, which produces therapeutic effects of

increased cardiac contractility and renal vasodilation. Its effect varies with its dosage: it is a

renal vasodilator at 1-2 mcg/kg/min . In moderate dosages (3-10 mcg/kg/min), it results in

stimulation of beta1 receptors to increase myocardial contractility and improve cardiac output.

Doses greater than 10 mcg/kg/min stimulate alpha-adrenergic receptors and may cause renal

vasoconstriction. It is administered only intravenously with an onset of 1–2 min , peak of up to

10 min and duration of less than 10 min.

In the case of the client, dopamine is indicated to increase heart contractility (as reflected

by current dosage) as the preload increases due to the shunting. Increased workload warrants
increased contractility in order to ensure adequate cardiac output of the patient despite increased

pulmonary vascular resistance.

Side effects include hypotension and arrhythmias. Monitor BP, heart rate, pulse pressure,

ECG, cardiac output, CVP, and urinary output continuously during administration. Monitor for

signs of ineffective perfusion due to vasoconstrictive effects of dopamine.Administer only into a

large vein and assess administration site frequently. There is a risk of extravasation during

dopamine infusion.

Dobutamine

Dobutamine is an adrenergic inotrope that stimulates beta1(myocardial)-adrenergic

receptors with relatively minor effect on heart rate or peripheral blood vessels (FA Davis

Company, 2013). It is an inotrope, compared to others, which does not cause increased systemic

vascular resistance which can be attributed to lack of alpha receptor activation. It is indicated to

a client with Ventricular Septal Defect to help in augmenting cardiac contractility without

causing further systemic vasoconstriction from Dopamine.

It has an onset of 1–2 min, peak of 10 min and a brief duration. Side effects include

hypertension, increased heart rate, premature ventricular contractions and shortness of breath.

Strict monitoring of BP, heart rate, ECG, pulmonary capillary wedge pressure (PCWP), cardiac

output, CVP, and urinary output is needed. Consult physician for parameters for pulse, BP, or

ECG changes for adjusting dose or discontinuing medication. Palpate peripheral pulses and

assess appearance of extremities routinely throughout dobutamine administration.

D10 IMB (Euro-Ion® in D10 Water (Balanced Multiple Maintenance Solution with 10%

Dextrose)
 As D10 IMB is not available in the market, it is said that this IVF is being produced from

a mixture of D5 IMB and D5050. D10 IMB serves the same purpose as D5 IMB only with a

higher dextrosity. The general formula for mixing any two solutions having different dextrosities

is: Volume of solution with high dextrosity = [(Total Volume Required)(Desired Dextrosity -

Dextrosity of the IVF with Lower Dextrosity)] / (Dextrosity of the IVF with Higher Dextrosity -

Dextrosity of the IVF with Lower Dextrosity). This formula may be utilized to concoct the

required D10 IMB solution.

D5050 or 50% Dextrose Injection is typically indicated for the treatment of

hypoglycemia to restore blood glucose levels. After dilution, the solution is also indicated for

intravenous infusion as a source of carbohydrate calories in patients whose oral intake is

restricted or inadequate to maintain nutritional requirements. As it provides a source of

carbohydrate calories, carbohydrate in the form of dextrose may aid in minimizing liver

glycogen depletion and exerts a protein-sparing action. Generally speaking, this sterile,

nonpyrogenic, hypertonic solution is for fluid and nutrient replenishment. The solution contains

no bacteriostat, antimicrobial agent or added buffer (except for pH adjustment) and is intended

only for use as a single-dose injection. Each mL of fluid contains 0.5 g dextrose, hydrous which

delivers 3.4 kcal/gram. To avoid production of hyperglycemia and to ensure proper utilization of

dextrose, slow infusion of hypertonic solution is essential.

D5 IMB (Euro-Ion® in D5 Water (Balanced Multiple Maintenance Solution with 5%

Dextrose) is a sterile, nonpyrogenic solution designed for intravenous administration (NIH,

2006). The solution is formulated to provide fluid and electrolytes for treatment of dehydration

and acidosis. Compared with the original Butler’s solution, the modified solution contains 5

mEq less sodium, 5 mEq more potassium, and 3 mEq added magnesium. Solutions containing
dextrose such as D5IMB restore blood glucose levels and provide calories especially for

pediatric clients with possible nutritional deficiencies (NIH, 2006). Being hypotonic in terms of

electrolytes it is best suited for parenteral maintenance of water requirements when only small

quantities of electrolytes are desired (NIH, 2006). Clinical evaluation and periodic laboratory

determinations are necessary to monitor changes in fluid balance, electrolyte concentrations and

acid-base balance during prolonged parenteral therapy or whenever the condition of the patient

warrants such evaluation.

PROBLEM IDENTIFICATION AND PRIORITIZATION

I. Risk For Cardiogenic Shock as evidenced by decreased coronary perfusion, impaired

breathing, and increased workload of the heart

A. RC: Pulmonary Edema as evidenced by fluid accumulation in pulmonary interstitium

and alveoli and increased pulmonary blood flow secondary to VSD

● Risk for Impaired Respiratory Function:

○ Ineffective Breathing Pattern r/t respiratory compensation and decreased

oxygenated blood circulating in the system

○ Impaired Gas exchange r/t VQ mismatch aeb crackles, tachypnea, occasional

cyanosis when crying, subcostal retractions, and uncompensated respiratory

acidosis

● Impaired comfort r/t illness related symptoms such as difficulty of breathing

B. RC: Ineffective Cardiovascular Function:

● Decreased Cardiac Output r/t altered stroke volume secondary to VSD

 ● Ineffective cardiac, peripheral, cerebral, hepatic, and renal perfusion r/t decreased

blood flow to organ systems

● Activity Intolerance r/t imbalance between oxygen consumption and supply to

cells

II. Ineffective protection r/t impaired bodily defenses aeb increased WBC count and

inability to meet caloric requirements secondary to progression of the disease process

- Risk for Imbalanced Nutrition: Less than Body Requirements as evidenced by increased

metabolic and nutritional requirements

- Risk for injury as evidenced by decreased LOC

III. Risk for Delayed Growth and Development as evidenced by limited opportunity to meet

developmental goals (motor, social, play, or educational) and compromised physical ability

and dependence secondary to congenital heart defect

Risk for Cardiogenic Shock was identified as the primary nursing problem since

complications concerning his current cardiac condition, in addition with fluid accumulation in

his lungs, would eventually lead to an increased myocardial demand and decreased myocardial

tissue perfusion. Following the ABC principle, the respiratory concerns, which are under the

nursing problem of Risk for Complications of Pulmonary Edema, were first identified and given

priority since it it was seen as the immediate problem of the patient which the nurse can

immediately intervene with. After this, the cardiac concerns, which fall under the nursing

diagnosis of Risk of Complication of Ineffective Cardiovascular Function, were given the next
priority since it is the root cause of why the patient suffers from both cardiac and pulmonary

disturbances. After these two problems under the primary nursing diagnosis, Ineffective

Protection was also identified because of the patient’s impaired bodily defenses in addition to

being in a compromised situation. Lastly, the psychosocial problem of Risk for Delayed Growth

and Development was identified because the need of the patient does not only concern his

physiologic condition. In order to ensure holistic care, the normal growth and development of the

patient during his stay in the hospital, as well as after his hospitalization, will be taken into

consideration (motor, social, play, or educational needs) in coming up with appropriate

interventions under this nursing diagnosis.

Brief Pathophysiology

A ventricular septal defect is an abnormal opening between the right and left ventricle of the

heart. The higher pressure on the left ventricle causes shunting of blood into the right ventricle

hence oxygenated blood enters the pulmonary artery. This increases the pulmonary blood flow

and the pulmonary capillary pressure. Pulmonary interstitial fluid increases which causes

pulmonary edema. This could explain the patient’s cough and the crackles heard on both lower

lung fields of the patient. The pulmonary edema could cause alterations in alveolar-capillary

membrane function and hence cause a ventilation and perfusion mismatch. This causes the

patient to have impaired gas exchange. Since the patient is a pediatric client, her intercostal

muscles are immature and has a compliant rib cage when breathing. This causes a decreased

ability to increase tidal volume and an increase in respiratory effort. The patient would

experience compensatory hyperventilation. This could be why the patient is experiencing

tachypnea as well as subcostal retractions.

Also, because of the increase in pulmonary blood flow due to the left to right shunting, an
increase in pulmonary venous return to the left atrium causes an increase in blood volume in the

left ventricle. This causes dilation of the left ventricle and its eventual hypertrophy. Due to this,

the end-diastolic volume pressure increases hence increasing left arterial pressure; pulmonary

pressure increases and hence there is pulmonary artery hypertension.

Due to the increase in the pulmonary blood flow, heart muscles get circumferentially stretched

because of the shear stress caused. Smooth muscle cell proliferates and increases in extracellular

matrix. This increases pulmonary vascular resistance causing the pressure in the right ventricles

to increase. This increases the cardiac workload of the right ventricle and explains why the

patient is experiencing tachycardia. Due to the increased workload, the right ventricle

hypertrophies which further increases the workload. Eventually, the right ventricle

decompensates which results in a decrease in cardiac output. There is hypoperfusion to the organ

systems; this includes renal, peripheral, cerebral tissue perfusion. For a more detailed discussion

on the organ systems with the nursing diagnoses, please see the pathophysiology diagram in the

appendices.

The increased pressure in the right ventricle due to the shunting also increases the filling pressure

of the heart. The right ventricle hypertrophies and there is passive congestion of the liver

resulting in hepatomegaly. This could explain why the patient’s liver was 3cm below RCM.

PLAN OF CARE

Priorities of Care

To help his oxygenation, interventions are focused on his ventilatory condition which

involves maintaining the patient at an oxygen support at 10 Lpm via face mask. Monitoring is

again vital as an onset of signs and symptoms that indicate airway difficulties due to possible
increase in pulmonary vascular system could lead to intubation in order to secure an access and

support him with a mechanical ventilator. Since acid-base problem originating in respiratory

function is present; hydration, humidification, positioning, breathing and coughing exercises,

suctioning, physiotherapy and turning must be done as deemed needed. These are involved in

assisting the patient with pulmonary rehabilitation that is ideally started at admission as it

provides restorative and preventative care to reverse respiratory acidosis secondary to underlying

conditions.Therapy modalities and length of intervention may vary depending on the progress in

the patient’s status. The activities will also be individualized and modified to match his age such

that it will be more exciting and will invite active participation of the child.

However, decreased cardiac output still leads to insufficient oxygenated blood that may

not meet the metabolic needs of tissues. Decreased circulating volume can result in

hypoperfusion of the kidneys and decreased tissue perfusion with a compensatory response of

decreased circulation to extremities and increased pulse and respiratory rates. Changes in

mentation may result from cerebral hypoperfusion. Vasoconstriction and venous congestion in

dependent areas (e.g., limbs) produce changes in skin and pulses. Therefore, the plan of care

would first prioritize addressing the risk for experiencing inadequate blood supply for tissue and

organ needs because of insufficient blood pumping by the heart. Interventions must be done

towards the goal of having the patient display hemodynamic stability as evidenced by parameters

being within normal range. Set objectives must include:

● Patient will maintain adequate blood flow to body’s tissues to prevent life

threatening cellular dysfunction.

● Patient and SO will participate in activities that reduce the workload of the heart

and minimize required oxygenation of the child.

 ● Patient will demonstrate increased activity tolerance.

● Patient will improve lung reexpansion for adequate oxygenation and ventilation.

● Patient will display normal and effective respiratory pattern with ABGs within

client’s normal range.

● SO will verbalize knowledge of disease process, individual risk factors and

treatment plan.

● SO will identify signs of cardiac decompensation, activity restrictions and will

know when to seek help appropriately.

● Patient will maintain fluid volume and electrolyte balance.

● Patient will maintain patent airway.

Close monitoring of the response of the organs to the cardiac output is vital and the

parameters would include the vital signs, sensorium, urine output, skin color, and pulses.

Physical rest should be maintained to improve efficiency of cardiac contraction and to decrease

myocardial oxygen consumption and workload. Physical and psychological rest helps reduce

stress, which can produce vasoconstriction, elevating BP and increasing heart rate and work.

Allowing the patient to be held and comforted by the parents may also help as long as they know

what restriction in activities their child needs. Bulk of the interventions will be collaborative as

the nurse needs to work well with the physician and the parents of the child. In a client with

impaired ventricular function, IV fluids must be cautiously administered together with inotropic

and vasoactive agents as prescribed to improve contractility. In part, management towards the

patient’s cardiac problems could also assist in improving his oxygenation status.

Surgical performed may be performed as a definitive management for this case as

absence of repair may lead to further complications. However, it entails a lot of teaching and
encouraging for parental input in care as the nurse should also assist them in coping with the

perceived developmental difficulties of the patient as he adapts to the condition. Abstract

aspects of an illness often prove more difficult to grasp. Congenital cardiac anomalies are often

complex in nature, which requires an individualized teaching with appropriate aids using

consistent and layman’s terms. Parental input assists in meeting the parent and child’s emotional

needs and supports the care given by healthcare personnel. This action also allows for learning

essential skills in a supportive environment. In suggesting this kind of management, the nurse

must ensure that both the benefits and risks must be explained to the parent and a significant

other of the child will be available to take care of him as long as he needs after the surgery.

In regard to the second cluster of problems, the goal of the care must be for the patient to

be free from infection by displaying no signs of local or systemic invasion of bacteria or viruses.

The objectives to be met will include:

● Patient will be free from injury.

● Patient will maintain an ideal weight for his age.

● Patient will not display signs of malnutrition or dehydration.

To attain these, appropriate supervision of the infant at all times must be maintained. Allow

respite time for the parents. Infants and small children are prone to putting small pieces in mouth,

nose, or ears so safety of all attachments for crib or bassinet must be monitored. All personnel

and visitors that needs contact with the child must be ensured to have performed hand hygiene

before and after interaction to prevent cross-contamination and nosocomial infections. If WBC

count is increased, it may be necessary to collaborate with the physician on further laboratory

test to specify area of possible infection for timely medical management. Supplements and/or

food must also be given as indicated and according to the patient’s tolerance.
 Lastly, children with congenital heart disease like this patient may grow or develop more

slowly than other children. Children with CHD are at risk for developmental delays. A

characteristic pattern of a high prevalence of low-severity or combined disabilities in the areas of

visual motor integration, language, motor skills, attention, executive function, and behavior has

been described in multiple research studies. There may be a number of underlying reasons. In

this case, an inadequate nutrition doesn't meet the body's energy requirements, or allow for

proper growth and development of muscles, bones, and brain and nerve cells. Also, an

anticipated prolonged hospitalization may prevent the child from getting enough stimuli that help

with development. This includes being played with, talked to, held, or touched. To reduce the

risk of delayed growth and development, efforts must be made for the patient to display age-

appropriate development and expectations as time goes by. A lot of work will come from the

parents so interventions that will be done will be meant to achieve the following: The caregiver

will

● Verbalize understanding of age-appropriate expectations and activities.

● Actively participate in formulating a plan with health care providers for prevention of

developmental deviation.

● Initiate interventions and lifestyle changes promoting appropriate development.

The nurse, on the other hand, has a vital role in explaining and demonstrating to the parents on

how to handle the child as he grows, even from current hospitalization. Parents of children with

congenital heart disease can play help promote their child's development. Doctors, nurses,

physical therapists, and other healthcare team members will provide guidelines that are tailored

for each child. Parents must be encouraged to touch and talk to the child as this can soothe him

and provide reassurance, especially in the intensive care unit or right after surgery, even if he has
been sedated. Toys and other objects from home that stimulate his or her senses of hearing,

vision, touch, and smell, even while in the hospital may also be provided as long as they are

clean. A collaboration among the nurse, therapist and parents is essential to provide exercises

that are safe for the child at his age and identify activities that must be restricted for a certain

period of time. A pediatric patient must be allowed to participate in everyday family activities as

much as he can tolerate and as long as it is in accordance to unit regulations as children also

learn new skills from interaction with brothers, sisters, and friends.

NURSING INTERVENTIONS

To address the first cluster of nursing problems, the following interventions were first

identified to address the problem related to respiratory function and gas exchange. First and

foremost prior to doing other interventions the nurse must always obtain baseline vital signs at

the start of the shift. This will help the nurse to identify any untoward changes in the client's

status during the entire shift. aside from untoward changes it would also help in the evaluation of

the other interventions to be made. Take note for any alterations in the patient's vital signs. Initial

onset of hypoxia and hypercapnia is manifested through increased BP, HR and RR. If not

addressed, decrease in HR and BP takes place and possible dysrhythmia may also occur. Aside

from the vital signs, also observe for other assessment parameters indicative of hypoxia, these

includes cyanosis in the nail beds, oral mucosa and in the skin. Cyanosis is already considered as

a medical emergency for it signifies serious hypoxia. Reposition the client to a high fowlers

position. Increase in head of bed elevation promotes lung expansion, increasing the patient’s

thoracic capacity. It was also noted that the client is currently presenting with uncompensated

respiratory acidosis, given this the nurse must always take note of new laboratory results and
take note of trends present. Since there is maintained supplemental oxygen needed by the client,

the nurse must ensure that it is properly maintained and maintain O2 sats within acceptable limits

and watch out for desaturation especially during episodes of crying. The presence of crackles

indicates presence of secretions, performance of chest physiotherapy and postural drainage may

aid in the easier expectoration of secretions. Since problems regarding gas exchange is already

present proper planning and structuring of activities is a must to decrease the oxygen demands of

the client during performance of tasks.

The nurse must be watchful of the different assessment findings that would warrant the

patient for possible intubation. indications for intubation include inability to maintain patency of

airway, inability to protect the airway against aspiration, failure to ventilate, failure to oxygenate

and anticipation of deteriorating course that eventually lead to respiratory failure. Since the client

already had an order for stand-by intubation, the nurse must be prepared for possible bedside

intubation anytime. Orient the primary caregiver, in this case RMs mother, regarding his current

condition and explain possible anticipated intubation once the condition of her son deteriorates.

Ensure that mother had consented with the procedure and explain why the procedure is needed

and its possible consequences. Preparation would include ensuring equipment for intubation is

complete and properly working. Instruments that must be secured include: 2 endotracheal tubes

(for cuffed ET tube: sizes 3.0 and 4.0, for uncuffed ET tube: sizes 3.5 and 4.5), Miller

laryngoscope with battery (considering the anatomy of the pediatric client, having a larger

epiglottis and a slanted glottis anteriorly makes the use of the Miller laryngoscope to be the ideal

option), stylet, cardiorespiratory monitor, suction catheters with appropriate sizes, ET tie and

tape to secure ET tube.

 If the need for intubation is perceived and is confirmed by the attending physician,

secure the ready the intubation set. Intubation set must contain materials previously discussed

above. And prepare the client for intubation. Position the client in a supine position. To maintain

an open airway, provide headrest and shoulder roll to bring the patient in a good sniffing

position. Avoid applying pressure on the cricoid cartilage. Prepare self, monitor patient and be

alert for any untoward event and additional orders of physician during intubation.

Observe after care once the intubation has finished, ensure the patency of the system and

review physicians orders and adjust mechanical ventilator settings accordingly. Watch out for

any acute complication such as displacement, obstruction, pneumothorax and equipment failure.

Ensure performance of the recommended VAP bundles of care appropriate to the clients age to

prevent the onset of VAP which may further compromise the condition of the client. According

to Cooper and Haut (2013), the following are the recommended guidelines to prevent VAP in

children below 6 years old. Changing of ventilator circuits and in-line suction catheters should

only be done when they are visibly soiled or already malfunctioning, draining of condensates

from ventilator circuit should be done every 2-4 hours, oral suction devices must be stored in a

non sealed plastic bag at the bedside when not in use, devices must be rinsed after use, perform

hand hygiene before and after contact with ventilator circuit, wearing of gown is recommended

before providing care to patient when soiling from respiratory secretions is expected, follow

unit’s mouth care policy every 2-4 hours, elevate the head of the bed 30°-45°, always drain the

ventilator circuit before repositioning patient.

An oral hygiene protocol was also suggested. Considering the age group of the client the

following were to be perceived to be an essential part in promoting oral hygiene. These include

brushing the teeth with a small soft toothbrush and fluoride toothpaste and suctioning out excess
toothpaste but not rinsing the mouth every 12 hours, moisten the mouth with swabs soaked in

clean water or physiological saline every 2 hours and coating lips with petroleum jelly every two

hours as needed. Oral suctioning must be performed with strict asepsis and must be performed if

the assessments shows a need for suctioning such as visible secretions in the ET tube, coarse

breath sounds, coughing, increased work in breathing, desaturation and must be performed after

chest physiotherapy (Cooper and Haut, 2013). Daily assessment of readiness for weaning is also

a must.

Since this is a pediatric client, one must ensure that the child is able to received utmost

comfort and care during the period of hospitalization with consideration for his developmental

needs. Presence of external stimuli might acts as a stressor and increases the client's demand for

oxygen. Reducing stimuli also contributes to the promotion of comfort by reducing the amount

of stress possibly brought about by presence of external stimuli.This can be achieved through

provision of adequate rest periods and modification of the environment. Interventions addressing

the problem risk for delayed growth and development will be discussed in the succeeding

paragraphs.

In addressing the problem of decreased cardiac output, it is important to monitor the

patient’s blood pressure and watch out for hypertension. It is important to watch out for this as

the patient’s heart has a decreased ability to pump out blood and an increase blood pressure may

worse his condition. It is also significant to monitor the patient’s urine output, noting the color

and amount. This will indicate the response of the patient’s kidneys to the decreased cardiac

output. It is important to take this into consideration as the kidneys usually retain water and

sodium resulting from decreased cardiac output. Another intervention would be to observe for

changes in sensorium to assess for cerebral perfusion as this may be affected by the decreased
cardiac output. Continue administration of the patient’s supplemental oxygen as this will

increase the available oxygen for the myocardium to utilize in compensating for the effects of

hypoxia and ischemia. The nurse should also assess the patient’s oxygenation status to see if the

patient is responding well to the oxygen therapy. Administer Dopamine and Dobutamine as

ordered. It is also important to monitor and replace electrolytes as indicated. The nurse must also

monitor ECG results as ST-segment depression and T-wave flattening may develop resulting

from increased myocardial demand. Monitoring of serum electrolytes, especially Potassium and

Calcium, should be done as altered levels may affect the conduction of the heart and is also an

adequate means of monitoring the patient’s response to medications as well as his current fluid

status. As previously mentioned, it is also important to continuously monitor the patient for signs

of hyponatremia and hypocalcemia, and ensure adequate sodium and calcium replacement.

To address ineffective peripheral tissue perfusion, extremities should be elevated above

the level of the heart (although it is important to assess if this is contraindicated especially in

severe cardiac or respiratory disease). For ineffective cerebral tissue perfusion, it is important to

monitor the patient’s neurological status frequently and compare the baseline using the following

parameters: GCS during the first 48 hours, evaluating eye opening, verbal response, and motor

response. The patient should also monitor vital signs such as blood pressure taking watching out

for systolic hypertension, and widening pulse pressure. Evaluate the patient’s pupils, noting size,

shape, equality and light reactivity. Assess the position and movement of the eyes as well

observing for loss of doll’s eye reflex and oculocephalic reflex. In addition to the presence or

absence of other reflexes such as blink, cough, gag, and Babinski. It is also important to promote

cerebral perfusion by monitoring temperature and regulating environmental temperature as

indicated, also monitor the patient’s intake and output, weigh the patient as indicated noting the
status of the patient’s skin turgor and mucous membranes. The nurse should also maintain the

patient’s neck in a midline or neutral position supporting this with small towel rolls and pillows.

It is also important to elevate the head of bed gradually to 20 to 30, as tolerated or indicated. To

address ineffective renal tissue perfusion, monitoring of changes in the urine output as well as

appearance is essential to keep track of possible impairment of the kidneys function. Along with

this, accurate measurement of the intake and hourly output should be practiced. Laboratory tests

of serum electrolyte levels, serum creatinine and BUN is also needed to evaluate kidney

function.

To address the patient’s activity intolerance, it is important to immediately assess the

patient’s vital signs, especially his blood pressure, before and after activity. This is significant as

orthostatic hypotension may occur because of the compromised cardiac pumping function.

Document the patient’s cardiopulmonary response to activity noting tachycardia, dysrhythmias,

dyspnea, diaphoresis, and/or pallor. In addressing the risk for injury, ensure that the patient’s

side-rails are always raised and as he is a toddler, it is important that he always has his mother or

S.O. watching over him.

Considering that the client has VSD, one of the medical interventions for this condition is

surgical closure of the defect. The nurse has many responsibilities when it comes to clients

undergoing surgical procedures. The nurse must secure the consent of the primary caregiver.

Sine the patient is a minor the mother is the most appropriate person to decide for the child while

he is in the hospital. The attending surgeon would be the one to explain the surgical procedure to

be done and its possible outcomes. Conducting a preoperative teaching would be helpful to

reduce the anxiety of the patient as well as his mother. Use of simple terms is a must to avoid

confusion from the mother's part. Preoperative teaching would include informing both that the
patient would remain in NPO status at least 8 hours prior to the surgery. Prior to the surgery, all

belongings must be left at the bedside only the hospital gown the child is currently wearing is

allowed to be brought in the operating room. The mother may accompany the child to the OR but

will be advised to leave once the operation about to start. The exact duration of the operation is

unknown but they will be advised once the operation is finished and they could check for updates

by inquiring in the nurses station. The patient’s caregivers should also be informed that the child

will be admitted to the ICU after surgery and should be weaned off post-operative inotopic

support, and/or pressor support within 24 hours after surgery. The nurse should also anticipate

the use of diuretic therapy resulting from the lack of intravascular volume. Caregivers should

also be reassured that most children are discharged 4 to 7 days post-surgery, especially if no

complications occur. Complications of VSD closure are the following: growth failure, congestive

heart failure, pulmonary vascular disease (irreversible muscular hypertrophy, followed by

degradation of pulmonary vasculature, and pulmonary resistance greater than systemic

resistance), severe viral or bacterial pneumonia, infective endocarditis, aortic regurgitation, right

ventricular stenosis, ventricular septum aneurysm, paradoxical emboli, sudden death, heart

block, impaired left ventricular function, and an increase in weight. The significance of follow

ups should also be reinforced when educating caregivers highlighting that this important for

relief of residual CHF as well as the promotion of normal growth and development of the child.

For ineffective protection, it is important to maintain aseptic techniques throughout all

procedures to be done on the patient to prevent further infection. In accordance with this, it is

important the practice proper handwashing techniques as well as teach this to the S.O. so they

may practice this as well. Ensure that the patient’s foley catheter is regularly changed if possible

and IV insertion sites cleaned if possible.

 The presence of an illness to a pediatric client imposes a threat of delayed growth and

development for many aspects essential for normal growth is compromised. Initial assessment is

essential so as to provide the nurse with baseline data regarding the current level of development

of the child, these would also be checked in a timely manner. Parameters such as the weight and

different anthropometric measurements should be obtained to check his physical growth.

Provision of age appropriate communication and activities will enable the child to still achieve

developmental needs despite presence of illness. Considering Erik Erikson's psychosocial

development theory, the patient is currently in stage of the developmental task of autonomy vs

shame and doubt. In this stage the child develops his sense of independence and self- control.

However current hospitalization and simply the presence of illness hinders the child into

successfully performing the said task. Failure to accomplish the task might result in significant

developmental delays. Considering if the child is to be intubated, the nurse must consider

referring the patient to a speech pathologist to assist the client to improve his swallowing ability

also his speech. Developmental milestones such as being able to follow simple instructions and

say sentences with 2 to 4 words should already be present. Also, educate the parents regarding

the expected developmental tasks as well as set realistic goals with the parent in relation with the

current condition of the child. The nurse should encourage the presence and support of the

parents especially during this period of hospitalization while keeping in mind the policies of the

institution and without compromising asepsis. Use age appropriate communication whenever

talking to child or explaining procedures. Also, encourage primary caregiver to do the same and

communicate with the child frequently. If the child is capable for play, the nurse may provide

age appropriate toys such as blocks, trucks, cars and books with illustration.
 The nurse must also take into consideration the condition of the child once he returns to

the community setting. Reviewing the client's case, it can be noted the mother has some

misconceptions regarding the nature of cough and colds. The nurse shall conduct health teaching

to correct these misconceptions. The mother previously attributed her child’s continuous play to

be the cause of his colds. Common misconception includes: one may acquire colds because of

the cold weather and sweating too much and letting it dry makes someone catch a cold. The cold

is an upper respiratory tract infection that is caused by different virus. Taking into consideration

the socio-economic status of the family the following may be recommended to address possible

onset of colds. Eating food high in vitamin C or drinking extractracted fruit juice such as

calamansi may aid in reducing the days of the duration of colds. Appropriate referrals to the

local health center shall also be made to ensure adequate monitoring of the child's condition after

discharge. Also, referral to a pulmonary rehabilitation facility may help in improving the child’s

breathing problem. Prior to referral, first educate the mother regarding the importance of

pulmonary rehabilitation which is to optimize her son's physical and social performance as well

as autonomy. Awareness and participation of the primary caregiver is important for she will

serve as guidance since the patient is still a child. Orient that the child will again be assessed for

the caregivers to have a more individualized plan or program. Components of the pulmonary

rehab program will include energy conservation, bronchial hygiene techniques (postural

drainage, percussion, vibration, and coughing), breathing exercises, sleep disturbance, activity

conditioning and techniques as well as nutrition. For the nutritional aspect, it is advised for the

patient to have food that is high in caloric value. With the presence of difficulty in breathing, the

body needs more calories. High protein is essential to support the muscles and prevent its

wasting. For protein source they may include the following: lean poultry, fish, eggs, beans and
nuts. For carbohydrate fresh fruits and vegetables may be their best option. Possible

complications of VSD are the following: aortic insufficiency, damage to the electrical

conduction system of the heart during surgery, delayed growth and development, heart failure,

infective endocarditis, and pulmonary hypertension. Educating the mother regarding different

signs and symptoms to observe that would entail immediate attention of the physician is also

essential. The mother should take mote of the following, difficulty in breathing, fever, swollen

lymph nodes, increasing pain or tenderness around site, oozing of pus or blood from the incision,

swelling and increasing area of redness around the surgical site. Should she observe these signs

they must immediately consult his physician.

One of the referrals that may be made, could possibly be for cardiac rehabilitation as this

is sometimes indicated in individuals with a high risk of possible heart failure. Prior to referral, it

is important to assess the following to ensure that the patient is a good candidate for cardiac

rehabilitation: demographic information and social determinants of health (includes financial

constraints and other possible barriers to participation and adherence), medical history and

symptoms, cardiovascular risk factors (ventriculo-septal defect in the case of the patient),

medication history emphasizing use and tolerance of any evidence-based cardioprotective

therapies and adherence, focused physical assessment (vital signs, anthropometric measurements,

respiratory and neuromusculoskeletal systems, and lastly reviewing of ECG results and cardiac

imaging (LVEF), if available, as well as testing of testing of cardiac capacity and ischemic

thresholds. Although the cardiac rehabilitation will mainly be facilitated by the physical

therapist, the nurse still plays an important role in ensuring that the plan of care to be

implemented is individualized and is in line with the preferences of the patient’s caregivers since

he is still a child. Once goals for cardiac rehabilitation are set, it is important to ensure that these
are realistic and within the capabilities of the patient. One of the core components of cardiac

rehabilitation is cardiovascular risk factor management, usually achieved through physical

exercise. This is very important in a pediatric case as it will promote the development and

maintenance of cardiorespiratory and muscular fitness. This is usually done two to three times a

week for up to around 12 sessions and consists of a combination of walking, stretching, ROM,

and aerobic exercises. This may also be supervised and progressive depending on the patient’s

capability. It is important for the nurse to ensure that the agreed upon exercise plan for the

patient is specific to his age and physical capabilities and limitations. It is also important to

make sure the caregivers understand the exercise plan as the child is an infant and will definitely

need to be aided in achieving successful exercise therapy. In addition, nutrition is an important

component of cardiac rehabilitation. In this case, a referral to a dietitian will need to be made.

The nurse should make sure that the diet plan for the child is appropriate and specific to his case.

Other nursing interventions in accordance with discharge of the patient would be to reinforce the

importance of making sure the patient takes his maintenance medications with the caregivers

since they play a big part in the patient’s medication adherence. After all necessary referrals and

planning have been made and the patient is ready for discharge, it is important to reinforce main

points such as exercise therapy, types of exercise to be done, and how frequent, also meal

planning specific to the patient’s case, and medication adherence.

EVALUATION

For the first cluster of problems, the goal for the patient is to exhibit optimal respiratory

function and the patient is expected to maintain adequate ventilation, effectively supported by O2

support (NOC: Vital Signs, Acid-Base Balance, Ventilation, Gas Exchange) as manifested by
normal vital signs (RR: 20-30 /min, HR: 70-110 bpm, SBP: 90-105 mmHg, DBP: 55-70 mmHg,

and SaO2: >90%), absence of cyanosis, capillary refill time of <2 seconds, minimal use of

accessory muscles for breathing, and negative intercostal retractions. The patient is also expected

to maintain a patent airway (NOC: Vital Signs, Acid-Base Balance, Respiratory Status: Airway

Patency, Ventilation) as manifested by decreased respiratory secretions, decreased adventitious

breath sounds (rhonchi, wheezes, and rales), and decreased effort of breathing. Another goal for

the patient is to be hemodynamically stable, as appropriate specifically for his age and condition.

The patient is expected to maintain adequate blood flow to body’s tissues to prevent life

threatening cellular dysfunction (NOC: Vital sign Status, Cardiopulmonary Status) as manifested

by normal vital signs (T: 36-38*C, HR:70-110 bpm, RR: 20-30/min, SBP: 90-105 mmHg, DBP:

55-75 mmHg, and O2 Sat: >90%). He is also expected to maintain adequate blood pumped by

the heart to meet metabolic demands of the body and maintain fluid volume and electrolyte

balance (NOC: Circulation Status, Tissue Perfusion [peripheral, cardiac, renal, hepatic, cerebral])

as manifested by pupils equally brisk and reactive to light, capillary refill time less than 2

seconds, no episodes of pallor and cyanosis, full and symmetric peripheral pulses, distinct heart

sounds, good skin moisture, good skin turgor, skin ward to touch, non-distention of abdomen,

normal bilirubin and liver enzyme levels, and urine output of not less than 0.5 cc/kg/hr.

For the second cluster of problems which has the goal for the patient to be free from

infection, the patient is expected to be free from injury, to maintain an ideal weight for his age,

and to not display signs of malnutrition or dehydration as manifested by capillary blood glucose

of 60 mg/dL, weight of 11-13 kgs (z-score of 0), stable vital signs, normal WBCs, good skin

moisture and turgor, normal electrolyte values, and non-distention of abdomen.

 Lastly, for the goal for the patient to display age-appropriate development and

expectations as time goes by due to his risk of having delayed growth or development, the

caregivers are expected to verbalize understanding of age-appropriate expectations and activities

for the patient, to actively participate in formulating a plan with health care providers for

prevention of developmental deviation, and for the caregivers to initiate interventions and

lifestyle changes promoting appropriate development of the patient.

Nurse-centered Objectives

During the shift, the nurse will be able to:

1. Provide comprehensive and timely assessment

2. Integrate assessment findings to understanding the patient’s case and prioritizing

interventions

3. Deliver bedside interventions and nursing skills needed by the patient with caution,

precision and mastery

4. Ensure privacy and security of the patient

Patient-centered Objectives

During the shift, the patient will be able to:

1. Exhibit optimal respiratory function as manifested by normal vital signs (RR: 20-30 /min,

HR: 70-110 bpm, SBP: 90-105 mmHg, DBP: 55-70 mmHg, and SaO2: >90%), absence

of cyanosis, capillary refill time of <2 seconds, minimal use of accessory muscles for

breathing, and negative intercostal retractions.

 2. Remain hemodynamically stable, as appropriate specifically for his age and condition

with adequate blood flow to body’s tissues to prevent life threatening cellular

dysfunction.

3. Maintain adequate blood pumped by the heart to meet metabolic demands of the body

and maintain fluid volume and electrolyte balance

Time and Activity Plan in an 8-hr Shift

TIME ACTIVITY

6:00-6:30 ● Receive Patient Endorsements from Previous Shift

● Attend Nursing Rounds
● Verify patient endorsements at bedside

6:30 ● Obtain baseline vital signs including neurologic parameters such as

GCS and reflexes at the start of the shift the hourly thereafter.
● Watch out for: increased BP, HR and RR. If not addressed, decrease in
HR and BP takes place and possible dysrhythmia may also occur.
● Reduce stimuli to the promote comfort.

7:00 ● Obtain hourly vital signs including neurologic parameters such as GCS
and reflexes.
● Provide morning care through partial/full bed bath, changing of linen
7:30 and diaper.
● Keep thermoregulated.
● Monitor hourly input and output. Compute fluid balance.
● Perform chest physiotherapy to aid in the easier expectoration of
secretions. Suction secretions aseptically.
● Reposition the client to a high fowlers position

8:00 ● Obtain CBG readings q shift to monitor blood glucose levels for patient
on NPO.
● Maintain on NPO.
● Obtain hourly vital signs including neurologic parameters such as GCS
and reflexes.
● Assess for need for suctioning airway of secretions. Suction secretions
aseptically as needed.
● Monitor hourly input and output. Compute fluid balance.
 ● Observe for changes in sensorium to assess for cerebral perfusion as
this may be affected by the decreased cardiac output.
● Administer Dopamine and Dobutamine as ordered.
● Monitor and replace electrolytes as indicated.
● Monitor ECG results as ST-segment depression and T-wave flattening
may develop resulting from increased myocardial demand.

9:00 ● Obtain hourly vital signs including neurologic parameters such as GCS
and reflexes.
● Assess for need for suctioning airway of secretions. Suction secretions
aseptically as needed.
● Monitor hourly input and output. Compute fluid balance.
● Observe for changes in sensorium to assess for cerebral perfusion as
this may be affected by the decreased cardiac output.

10:00 ● Obtain hourly vital signs including neurologic parameters such as GCS
and reflexes.
● Assess for need for suctioning airway of secretions. Suction secretions
aseptically as needed.
● Monitor hourly input and output. Compute fluid balance.
● Observe for changes in sensorium to assess for cerebral perfusion as
this may be affected by the decreased cardiac output.

11:00 ● Obtain hourly vital signs including neurologic parameters such as GCS
and reflexes.
● Assess for need for suctioning airway of secretions. Suction secretions
aseptically as needed.
● Monitor hourly input and output. Compute fluid balance.
● Observe for changes in sensorium to assess for cerebral perfusion as
this may be affected by the decreased cardiac output.

12:00 ● Obtain hourly vital signs including neurologic parameters such as GCS
and reflexes.
● Assess for need for suctioning airway of secretions. Suction secretions
aseptically as needed.
● Monitor hourly input and output. Compute fluid balance.
● Observe for changes in sensorium to assess for cerebral perfusion as
this may be affected by the decreased cardiac output.

1:00 ● Obtain hourly vital signs including neurologic parameters such as GCS
and reflexes.
● Assess for need for suctioning airway of secretions. Suction secretions
aseptically as needed.
● Monitor hourly input and output. Compute fluid balance.
● Observe for changes in sensorium to assess for cerebral perfusion as
this may be affected by the decreased cardiac output.
2:00 ● Obtain hourly vital signs including neurologic parameters such as GCS
and reflexes.
● Assess for need for suctioning airway of secretions. Suction secretions
aseptically as needed.
● Monitor hourly input and output. Compute fluid balance.
● Observe for changes in sensorium to assess for cerebral perfusion as
this may be affected by the decreased cardiac output.
● Endorse patient status to incoming shift
 References

Ball, Jane, Bindler, Ruth McGillis.Cowen, Kay J. (2008) Child health nursing :partnering with

children & families New York : Pearson,

Brissaud, O., Botte, A., Cambonie, G., Dauger, S., Blanquat, L. D. Saint, Durand, P., … Mauriat,

P. (2016). Experts ’ recommendations for the management of cardiogenic shock in

children. Annals of Intensive Care. https://doi.org/10.1186/s13613-016-0111-2

Bates, B., Bickley, L. S., & Lippincott Williams & Wilkins. (2005). Bates' visual guide to

physical examination. Philadelphia, PA: Lippincott Williams & Wilkins.

Brunner, L. S., Suddarth, D. S., & Boyer, M. J. (2010). Study guide for Brunner and

Suddarth's textbook of medical-surgical nursing. Philadelphia: Wolters Kluwer.

Bulechek, G. M., Butcher, H. K., Dochterman, J. M., & Iowa Intervention Project. (2008).

Nursing interventions classification (NIC). St. Louis, MO: Mosby Elsevier.

Burns, S. (2014). AACN Essentials of Critical Care Nursing. united States: McGraw-Hill

Education.

Carpenito, L. J. (2017). Nursing diagnosis: Application to clinical practice (15th ed.).

Philadelphia, PA: Wolters Kluwer Lippincott Williams and Wilkins.

Cooper, V., Haut, C. (2013). Preventing ventilator associated pneumonia in children: an

evidence based protocol. American Association of Critical Care- Nursess. Doi:http://

dx.doi.org. 10.4037//ccn2013204

Doenges, M. E., & Moorhouse, M. F. (2008). Application of nursing process and nursing

diagnosis: An interactive text for diagnostic reasoning. Philadelphia, PA: F.A. Davis.

Doi, K. (2016). Role of kidney injury in sepsis. Journal of Intensive Care, 1–6.

https://doi.org/10.1186/s40560-016-0146-3
Hockenberry, M. J., & Wilson, D. (2013). Wong's essentials of pediatric nursing (8th ed.). St.

Louis, MO: Mosby/Elsevier.

Hoeper, M. M., & Granton, J. (n.d.). Concise Clinical Review Intensive Care Unit Management

of Patients with Severe Pulmonary Hypertension and Right Heart Failure, (15).

https://doi.org/10.1164/rccm.201104-0662CI

Huether, S. E., & McCance, K. L. (2008). Understanding pathophysiology. St. Louis, MO:

Mosby/Elsevier.

Ignatavicius, D. D., & Workman, M. L. (2010). Medical-surgical nursing: Patient-centered

collaborative care. St. Louis, MO: Saunders/Elsevier.

Kizior, R. J., Hodgson, B. B., Hodgson, K. J., & Witmer, J. B. (2016). Saunders nursing

drug

handbook 2016.

Leeuwen, A. M. (2006). Davis's Comprehensive Lab/Diagnostic Test Handbook.

Philadelphia: F.A. Davis Co.

Moorhead, S., Johnson, M., Maas, M., & Iowa Outcomes Project. (2008). Nursing outcomes

classification (NOC). St. Louis, MO: Mosby.

Naghavi-behzad, M., Alizadeh, M., Azami, S., & Foroughifar, S. (2013). Risk Factors of

Congenital Heart Diseases : A Case-Control Study in Northwest Iran, 5(1), 5–9.

https://doi.org/10.5681/jcvtr.2013.002

Porth, C. (2014). Essentials of Pathophysiology:4th International edition: Concepts of

Altered States. Philadelphia: LIPPINCOTT WILLIAMS AND WILKINS.

Wolf, A. D., & Lavine, J. E. (2000). Hepatomegaly in Neonates and Children. Pediatrics in
 Review, 21(9), 303 LP-310. Retrieved from

http://pedsinreview.aappublications.org/content/21/9/303.abstract

Pediatric Cardiac Rehabilitation from the Nursing Service Policy Manual of the Philippine

Heart Center (2014) retrieved from

https://www.phc.gov.ph/about-

phc/policy_manual/manuals/Division%20of%20Pediatrics//FUNCTIONAL%20DUTIES%2

0AND%20RESPONSIBILITIES/PediaCare.pdf