HESI Case Study Congenital Heart Disease
Which clinical manifestations would the nurse expect to assess in an infant diagnosed with a ventricular septal defect?
Tachypnea and grunting with intercostal retractions
What statement by Teresa supports billy’s diagnosis of CHF?
Billy never sems to get full even when I breastfeed him for a long time
Teachings about post procedure care for cardiac catheterization:
Explain they will need to hold them in the prone position after the procedure
What actions should the nurse implement?
Notify the cardiologistand do not allow AAron to sign
What nursing diagnosis is important to include in the plan (parents worried heis not eating enough, losing wt)
imbalanced nutrition:less than body requirements
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which member of the perinatal team will best be able to assist the nurse? (Mother worried about whetherbreast milk is best)
cert lactation specialist CLC
Which measure will be most valuable to assess the infants response to each feeding?
SaO2 changes during feeding
What intervention would you implement prior to administering first dose of Lanoxin?
Obtain apical pulse to determine within the guidelines of written order (Don’t give if > 90)
When should you give a dose of Digoxin how many hours before a routine lab test?
give a regular dose of medication at least 6 hours prior to the test
If patient starts to choke, turn blue, and goes limp what is the first intervention you would do?
Attempt to stimulate patients breathing by rubbing the sole of his foot
Billy is lethargic and irritable, with a SpO2of 90% – what should the nurse do next?
administer O2 and stay with him
what data supports the nurse’s response that he is growing on targert for 4 month old?
plays with feet and puts them in mouth
what activity should the nurse include as appropriate for a 4 month old?
read brightly colored books to him
what stage of erikson’s is he at?
trust vs mistrust
what action is most theraputic when she finds the mother crying?
stand by her, says “I can seeyou are upset, would you liketo talk?”
mother expresses guilt and concern over baby’s condition
it is unknown why VSD hapens, but being a working mother is not a risk factor
What to say when asked to respond about alternative therapy?
should consult doctor before allowing him to take any herbal treatments
A man arriveds claiming to be the family priest and asks about billy
Billy’s room number is 410. I think mr adams is in there. I would be happy to walk you there.
Nursing plan of care for patient diagnosed with “Decreased Cardiac Output”:
Assess infants’s peripheral pulses and capillary refill time
what nursing task can be delegated to UAP?
sit with billy while teresa takes a shower
whichprescription for care should be questioned?
digoxin 12.5 mg IVP twice daily
Which intervention should you include when teaching parents about administration of Digoxin?
Advise parents to administer meds about 20 – 30 minutes before the infant is fed
which statements by aaron indicate CPR teaching is effective
will perform chest compressions before breaths, and will do 30 complressions then 2 breaths
billy is to be discharged. teresa and aaron work outside the home, teresa plans to quit. how do you respond?
discuss them attending a support group
What type of feedings does a infant with CHF need to have?
Small concentrated feedings
which preoperative intervention has a priority (parents are frightened)
offer verbal and written info about the surgery
what does the cardiopulmonary machine bypass do?
takes over for the heart and lungs during surgery
additional assessment data warranting immediate intervention?
apicalpulse88, serum potassium 2.6mEq/L
lab results requiring attention
plan ofcare info addressing fluid/electrolyte imbalance?
intervention to address regarding his pain
explain continuous IV of pain meds with prn bolus willcontrol pain
what info should be included as part of his discharge?
pat incision dry, do not rub until healed
what statement indicates teaching has been effective?
we will resume his regular meal, sleep and playtimes as soon as we get home
Why do you need to use a soft nipple with a large hole to feed?
Will be able to suck more easily and not get tired from eating
What should you expect to see as manifestations of Heart Failure in an child?
Ventricular Septal Defect (VSD) Clinical manifestations:
Left to right shunting
Systolic murmur at left lower sternal border
Which manifestations would you expect to find in a child with Rheumatic Fever?
Elevated C-reactive protein
Uncoordinated movements of extremities
Two or more major Jones criteria
What does digoxin do for the heart?
Improves myocardial contractility
What is the hallmark sign of digitoxicity?
Why is glucose important to the heart?
It is important for cardiac contractability
Rids body of excess fluid and sodium:
Increases tissue oxygenation:
Improves myocardial contractility: