Acknowledgement

We humbly recognize the limitedness of our young minds thus, we had to consult different people concerning this case presentation, people who are more knowledgeable than us. Now we see this case study printed, we would like to express our utmost gratitude to our significant others whom have inspired and helped us dedicate ourselves in the success of our case study. First, to the Almighty God, for giving and showering us blessings, further, strengthening our spirit to face the inherent demands of the task assigned, thereby, molding us to become useful citizens of this land. To the family of our patient, for their willingness to be the subject for our case study, for being responsive and open to inquiries during the interview process and for being cooperative in everything that we did. To our wonderful Clinical Instructors, Mrs. Mary Hazel Facundo, RN MN, Ms. Grace Guitguiten, RN, MN, Mrs. Dinna Rose Bayog, RN MN, and Mrs. Yvonne Kuan, RN, MN, who imparted their best knowledge for us to be able to work our best as student nurses, may they all find it in their hearts to keep going and keep teaching the eager young minds of tomorrow. To the residents-on-duty, staff, and nurses-on-duty at Southern Philippines Medical Center Pediatrics Ward, for accommodating us and for being understanding and patient with us during the whole time of our duty.

Lastly, to our parents and family who never left us and remained with us during our hard times, may they remain in our hearts all through the years as we finish and reach our goals.

INTRODUCTION

We, the group 3 of Section 2A of the Ateneo de Davao University, conducted an interview and physical assessment last February 9 and 10, 2012 at the Pediatrics Ward of the Southern Philippines Medical Center as part of our case study in relation to Pediatrics Abnormalities concept. Our case is about Errshen, who was admitted to the Pediatrics-Sick Neonate ward, with a medical diagnosis of neonatal sepsis and suspected patent ductus arteriosus.

The circulatory system is a vital system in the human body. Without it, there will be no transporter of nutrients, water, and oxygen to our billions of body cells and carrier away of wastes such as carbon dioxide that body cells produce. It is an amazing highway that travels through your entire body connecting all sour body cells. (hes.ucfsd.org). But what if the system itself has defect, will we still survive?

The first condition of our patient is septicemia or more commonly known as sepsis. Septicemia is a serious systemic illness caused by bacteria and bacterial toxins circulating in the bloodstream. During the past 30 years, it has become an increasingly common condition among hospitalized patients. Of newborns with early-onset infection, 85% present within 24 hours, 5% present at 24-48 hours, and a smaller percentage present within 48-72 hours

(www.emedicine.medscape.com). According to the World Health Organization, neonatal sepsis accounts for 33% of over 40,000 newborns death in the Philippines each year.

Onset is most rapid in premature neonates. Early-onset sepsis syndrome is associated with acquisition of microorganisms from the mother. Transplacental infection or an ascending infection from the cervix may be caused by organisms that colonize in the mother's genitourinary tract, with acquisition of the microbe by passage through a colonized birth canal at delivery. The second condition of our patient is Patent ductus arteriosus (PDA) which is one of the most common congenital heart defects. The ductus arteriosus is a remnant of the distal sixth aortic arch and connects the pulmonary artery at the junction of the main pulmonary artery and the origin of the left pulmonary artery to the proximal descending aorta just after the origin of the left subclavian artery. Most typically, it is a left aortic remnant. In PDA, abnormal blood flow occurs between two of the major arteries connected to the heart. These arteries are the aorta and the pulmonary artery. A right-sided patent ductus arteriosus can occur, or the ductus arteriosus can be present on both the right and the left. Although a left ductus arteriosus is a normal structure during normal fetal development, the presence of a right ductus arteriosus is usually associated with other congenital abnormalities of the cardiovascular system, most typically involving the aortic arch or conotruncal development. The presentation widely varies. Depending on the size of the patent ductus arteriosus, the gestational age of the neonate, and the pulmonary vascular resistance, a premature neonate may develop life-threatening pulmonary overcirculation in the first few days of life. Conversely, an adult with asmall patent ductus arteriosus may present with a newly discovered murmur well after adolescence.

The incidence of this anomaly is twice in females than males. After Ventricular septal defect the Patent Ductus Arteriosus is the commonest congenital heart defect in children. Around the world, it accounts for approximately 10% in newborns (www.clevelandclinic.org). In the Philippines, the case rises at an unacceptable increasing level. The patent ductus arteriosus incidence best estimates for the Philippines suggest that approximately 0.25% children are affected by this. Those cases that were left untreated have led to death by 78% (The Mindanao Daily Mirror, 2009). The group chose the case of Errshen which are neonatal sepsis and patent ductus arteriosus primarily because we already have the prior knowledge on thess type of pediatric illnesses, thus requiring us to apply this knowledge in the actual setting. This would serve as a good avenue for us to develop our skills in relation to the facts and information that we have already learned in the university.

OBJECTIVES

General: Within our 2 days of duty at the Pediatrics Ward of the Southern Philippines Medical Center, the goal of the group is to be able to provide holistic nursing care to our client and to be able to apply the knowledge we have gained in the university to the actual clinical situation. Specific: Cognitive Formulate objectives to be followed on the course of making this case study; Gather pertinent data of the past and present health history of the patient through interview and assessment; Collect necessary information about our clients personal data regarding patients profile, family background, social status and nutritional status; Draw the family genogram of the patient to trace disease inheritance; Ascertain the patients developmental status using the theories of Robert Havighurst, Erik Erikson and Jean Piaget; Provide a precise cephalocaudal assessment obtained from the client; Define the complete diagnosis of the patient by directly citing it from three different sources; Discuss the anatomy and physiology of the affected body systems related to the case of our patient; Identify and rationalize the signs and symptoms associated with the disease Trace and explain the pathophysiology of the disease
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 Present the doctors orders and make rationales for each order; Obtain, analyze and interpret laboratory and diagnostic procedures done on the patient and include the normal and abnormal values and findings for comparison, and the specific nursing responsibilities associated with each diagnostic procedure; Make a drug study on the medications given to our patient that includes the generic and brand names, classification, indication, contraindication, action, adverse effects, side effects, and nursing responsibilities. Relate the clients condition to three nursing theories Correlate the different nursing theories with the nursing care plans that are presented in this case study; Make a specific, measurable, attainable, realistic, and time-bounded nursing care plans for the patient; Validate patients prognosis according to onset of illness, duration of illness, precipitating factors, willingness to take medications and treatment, age, environmental factors and family support; Make a discharge plan for the patient with the use of M.E.T.H.O.D.S.; Evaluate the enhancement of the clients condition from the interventions rendered. Psychomotor Find a patient who will be the subject of our case presentation; Perform a thorough physical assessment which will serve as our baseline data; Identify clients health problems and provide care based on the various nursing care plans formulated by the researchers; Give the family health teachings to provide wellness for the betterment of the patient;
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 Share information about Patent Ductus Arteriosus and the related factors that may be of concern to the patient. Affective Establish a trusting relationship with the patients family to gain necessary information regarding the patients status. Approach the patient and the significant others in a non-judgmental demeanor. Respect the patients familys right for confidentiality and their religious, cultural, and personal beliefs.

HEALTH ASSESSMENT

PATIENTS DATA BIOGRAPHICAL: Patients Name: Errshen Address: Purok 5, Buda, Marilog District, Davao City Date of birth: January 15, 2012 Parents Religion: Christianity (Roman Catholic) Parents Occupation: Mother: Housewife Father: Security Guard Occupation: None Health Insurance: PhilHealth (under fathers name) Source and Reliability of Information: Mother Profile: Age: 14 days old Gender: Female Parents Race/Ethnic Background: Bagobo Chief Complaint: Referral from a local hospital (German Doctors Hospital); episode of respiratory arrest, cyanosis Date of Admission January 29, 2012 Healthcare institution Southern Philippines Medical Center
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Admitting Diagnosis: Neonatal Sepsis R/O CHD probably PDA Admitting Physician: Dr. Mardigrace B. Puracan Admitting Clerk: Daisy Mae Maniquit Vital Signs upon admission: Pulse Rate: 133 bpm Respiratory Rate: 54 cpm Temperature: 36.7C

B.PRESENT HEALTH HISTORY Last January 20, 2012, according to the mother, the patient experienced convulsions around 10:30 in the evening and was rushed to German Doctors Hospital. The patient was admitted at that hospital for continuous care. By January 29, 2012 at around 9:00 AM, the mother noticed that her child was pale and had difficulty in breathing. Later on, the child had cyanosis and they immediately rushed to the doctor. The patient was diagnosed to have congenital heart defect, which is probably patent ductus arteriosus. Since the institution cannot provide the childs needs for care, the patient was referred to SPMC for continuous recovery. At around 1:00 PM, they have arrived at the institution.

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C. PAST HEALTH HISTORY According to the mother, the child didnt have any communicable disease or any illness except for the childs convulsions and heart defect. Her first hospitalization was at German Doctors Hospital due to convulsions. The child has not encountered any injuries or accidents. For the childs immunizations, only Hepatitis B vaccine was given to her when she was delivered. She didnt undergo any surgery or blood transfusions yet. Medication Reconciliation Medication Indication as known Dosage by the parents Both the parents 300g IVTT doesnt know about the medications are 45g IVTT OD for. 15g IVTTq 12 Prescribing Health Care Provider

Cefotaxime Amikacin Ceftriaxone

Dr. Mardigrace Puracan

B.

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D. Family Health History

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E. Social History The mother verbalized that upon their stay inside the hospital, mother-child bonding was implemented. The mother usually breastfeeds the child, changes the diapers and clothes, and provides comfort to the patient. The mother verbalized ginapunasan nako ni siya adlaw-adlaw gamit ang labakara. The mother usually watches over the patient. She never left the hospital since their child was admitted. The father works as a security guard in a hardware located at Uyanguren and earns 4,500 pesos in a month. He works daily except for Sundays from 8 in the morning to 5 in the afternoon. He visits their child every after work. He provides the needs of the mother like clothes and food. To support the childs needs aside from using his own money, he asked for a cash advance in order to pay for the hospital expenses and the childs medications, except for the childs lumbar puncture since they cant afford it. The mother verbalized ginasuportahan man namo sya sa mga gastuhunon pareho anang magpalaboratory ug kanang makaya lang namo bayaran. They both ensure the wellbeing of their child. Inside the ward, the patient shares a bed with another patient. The room was crowded with things which make it look untidy. Regarding the childs condition, the mother verbalized ang nahibal-an lang namo kay naa siyay buslot sa dughan, wala gyud mi kabalo kung unsa to siya.

F. Health Maintenance Activities According to the mother, her child wakes up to breastfeed. The doctor ordered breastfeeding with strict aspiration precaution and is advised to have nothing per orem if respiratory rate is greater than 60. After breastfeeding, the child will immediately go to sleep. The mother tries to let the child burp, but she couldnt do it. The child is also lethargic; sometimes the child suddenly goes to sleep while shes breastfeeding. Whenever the child is

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experiencing difficulty or fast breathing, the mother would administer oxygen to the child via face mask, 4 liters per minute as ordered.

G. Nutritional Assessment Height: 54 cm Weight: 3.5 Kg BMI: 12.00 Head circumference: 35 cm Chest circumference: 36 cm Abdominal Circumference: 37 cm Diet History The mother verbalized that the baby was purely breastfed; she complies with the doctors order that she should limit the childs intake both orally and intravenously due to the possible cardiac overload that may happen.

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DEVELOPMENTAL DATA

Developmental task theory of Robert Havighurst Is a task which arises at or about a certain period in the life of an individual, successful achievement of which leads to his happiness and to success with later tasks, while failure leads to unhappiness in the individual, disapproval by society, and difficulty with later tasks (Havighurst, 1972, p.2).

Havighurst also identified Six Major Stages in human life covering birth to old age which are the following: Infancy & early childhood (Birth till 6 years old) Middle childhood (6-12 years old) Adolescence (13-18 years old) Early Adulthood (19-30 years old) Middle Adulthood (30-60years old) Later Maturity (60 years old and over) Our patient is in Infancy and early childhood because at this age he learns to walk, crawl, eat solid food, talk, eliminate body waste, and differentiate sexuality. learning language to describe social and physical reality. Forming concepts and

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DEVELOPMENTAL TASK Learning to Walk

Learning to take solid food

Learning to Talk

Learning to control the elimination of body wastes Achieving psychological stability Forming simple concepts of social and physical reality

Learning to relate emotionally to parents, siblings, and other people Learning to distinguish Not achieved right from wrong and developing conscience

ACHIEVED OR NOT JUSTIFICATION ACHIEVED Not achieved The patient is only 14 days old and hasnt learned to walk. The child is only being carried. Not achieved The patient is purely breastfed by the mother. Also, she is not yet on the weaning phase (not less than 4 months, not more than 6 months.) Not achieved The child cannot talk. Because the infants brain is not yet at the age of learning or expressing. The child only cries whenever she needs something. Not achieved The child was unable to defecate and urinate. She depends on diaper usage for her to eliminate body wastes. Not achieved The child is only 14 days old. At that age, infants still depend on crying to express of what they feel and need. Not achieved The child at the age of 14 days old does not have the awareness of the environment around her; may it be her family or the physical environment around her. Not achieved At her age of 14 days old, ways of expression is dependent on crying. 14 day old infants cannot distinguish between right and wrong because at that age, infants do what they want and they something were to hinder, they would express by crying. The child is only 14 days old. Awareness of sex and sexual differences is beyond her understanding.

Learning Sex differences Not achieved and sexual modesty

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Psychosocial theory of Erik Erickson Eriksons theory proposes that life is a sequence of developmental stages or levels of achievement. Each stage signals a task that must be accomplished. The resolution of the task can be complete, partial, or unsuccessful. Erikson believed that the more success an individual has at each developmental stage, the healthier the personality of the individual. Stages of Eriksons Psychosocial Theory are as follows: Infancy Early childhood Late childhood School age Adolescence Young adulthood Adulthood Maturity Being an infant at the age mistrust stage of Erikson. Stage Infancy (Birth-18 months) TRUST VERSUS MISTRUS T Description Result Erikson also referred to infancy as Achieved the Oral Sensory Stage (as anyone might who watches a baby put everything in her mouth) where the major emphasis is on the mother's positive and loving care for the child, with a big emphasis on visual contact and touch. If we pass successfully through this period of life, we will learn to trust that life is basically okay and have basic confidence in the future. If we fail to experience trust and are constantly frustrated because our needs are not met, we may end up with a deepseated feeling of worthlessness and a mistrust of the world in general. Justification The infant is only 14 days old and is fully dependent to her parents. Whenever the child is hungry, her mother would breastfeed her. Her mother also does the changing of her diapers from time to time whenever it is wet and full. The mother also provides comfort to her child whenever she is crying and whenever she goes to sleep. The mother always gives what her child needs from her. Birth-18 months Trust vs. mistrust 1-3 years Autonomy vs. Shame 3-6 years Initiative vs. Guilt 6-12 years Industry vs. Inferiority 12-18 years Identity vs. Role Confusion 18-30 years Intimacy vs. Isolation 30-65 years Generativity vs. Stagnation 65 years to death Integrity vs. Despair of 3 days old, he is considered as a part of the Trust versus

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Cognitive Theory of Piaget Cognitive Theory refers to the manner in which people learn to think, reason, and use language. It involves a persons intelligence, perceptual ability, and ability to process information. Cognitive development represents a progression of mental abilities form illogical to logical thinking, from simple to complex problem solving, and from understanding concrete ideas to understanding abstract concepts Piagets Phases of Cognitive Development Phases and Stages Age Sensorimotor Phase Birth to 2 years

Stage 1 Use of reflexes Stage 2 Primary Circular reaction Stage 3 Secondary Circular reaction Stage 4 Coordination of secondary schemata Stage 5 Tertiary Circular reaction Stage 6 Inventions of new means

Birth to 1 month 1 to 4 months 4 to 8 months 8 to 12 months 12 to 18 months 18 to 24 months

Significant Behavior The first is centered on the infant trying to make sense of the world. During the sensorimotor stage, an infants knowledge of the world is limited to their sensory perceptions and motor activities. Behaviors are limited to simple motor responses caused by sensory stimuli. Children utilize skills and abilities they were born with, such as looking, sucking, grasping, and listening, to learn more about the environment. Most action is reflexive Perception of events is centered on the body Acknowledges the external environment Can distinguish a goal from means of attaining it Tries to discover new goals and ways to attain goals. Interprets the environment by mental image. Uses makebelieve and pretend to play
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Preconceptual Phase

2 to 4 years

Intuitive Though Phase

4 to 7 years

Concrete Operations Phase

7 to 11 years

Formal operations phase

11 to 15 years

Uses an egocentric approach to accommodate the demands of an environment Egocentric thinking diminishes. Thinks of one idea at a time. Includes others in the environment. Words express thoughts Solves concrete problems. Begins to understand relationships such as size. Understands right and left. Cognizant of viewpoints Uses rational thinking. Reasoning is deductive and futuristic

Phase and Stage Stage 1 Use Reflexes

Description Justification of Achieved. The child was able to achieve: rooting reflex with weak response. The child turned her head toward the side of the face stroked; sucking reflex because the child was able to suck her thumb and was able to breastfeed frequently; palmar grasp reflex with strong, immediate response; flexion of the hands and feet were present; tonic neck reflex with weak response; the childs head turned to one side and the arm and leg on the same side extended; babinski reflex with weak response; the big toe rose and the remaining toes fanned out upon stroking the sole of the foot from heel to toe; moro reflex with quick response, where sudden extension and abduction of extremities were noted.

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ETIOLOGY

As a baby develops in the womb, a vascular connection (ductus arteriosus) between two major blood vessels leading from the heart the aorta and pulmonary artery is a normal and necessary part of your baby's blood circulation while in the womb. The ductus arteriosus diverts blood from the lungs of the fetus while they aren't being used. The fetus receives oxygen from the mother's circulation. But, the ductus arteriosus is supposed to close within two or three days after birth once the newborn's heart adapts to life outside the womb. In premature infants, the connection often takes longer to close on its own. If the connection remains open, it's referred to as a patent ductus arteriosus. The abnormal opening causes too much blood to circulate to the lungs and heart. If not treated, the blood pressure in the lungs may increase (pulmonary hypertension) and the heart may enlarge and weaken. Congenital heart defects arise from problems early in the heart's development but there's often no clear cause. Genetics and environmental factors may play a role. Predisposing Present/ Rationale Factors Absent Patent ductus arteriosus Being born too soon Absent (PDA) occurs more (prematurity) commonly in babies who are born too early than in babies who born full term because the infants heart was not fully developed before delivery. Justification The mothers LMP was on April 16, 2011 and the baby was born on Jan 15, 2012. Therefore the baby was exactly born 9months and 1 day. Proving that she is not in a preterm state.

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Having other heart Absent defects

Babies who have other Other than Patent Ductus heart problems when Arteriosus, no other heart defect they're born (congenital has been noted/diagnosed. heart defects) are also more likely to have a patent ductus arteriosus. Because other defects such If you have a family history of heart defects, it's more likely your child may have a patent ductus arteriosus. Other genetic conditions, such as heart problems or chromosomal abnormalities, also have been linked to an increased chance of having a PDA. PDAs are much more common in girls than in boys. Tracing back to the family history, the grandmother of the baby has myocardial infarction in which may be a factor for her to have PDA.

Family history and Present other genetic conditions.

Having a female baby Present

The baby was born as a female as evidenced by the presence of only female genitalia.

Precipitating Factors

Present/ Absent

Rationale

Justification

Use of Teratogens Absent during pregnancy

Teratogens are any Only FeSO4 was taken by the chemical, substance, or mother during her pregnancy exposure that could possibly with patient Errshen. cause birth defects in a developing fetus. Exposure to teratogens seems to result in malformations especially when it occurs during the fourth and tenth week of pregnancy.
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Smoking

Present

Chromosomal abnormalities

Absent

Maternal Absent infections (esp. Rubella/German measles)

A shortage of oxygen can have devastating effects on your baby's growth and development. On average, smoking during pregnancy doubles the chances that a baby will be born too early or weigh less than 5 1/2 pounds at birth. Smoking also more than doubles the risk of heart diseases on infants Trisomy 21, the chromosomal abnormality associated with Down syndrome, is associated with cardiac abnormalities in 50 percent of babies. Chromosomal abnormalities If you have rubella in the first trimester, you have about a 25% risk of having a birth defect, known as congenital rubella syndrome. The defects can include: heart deformities hearing loss mental retardation eye deformities others

The mother told us that she smoked during the first trimester of her pregnancy; however, she stopped smoking when she knew that she was pregnant.

The infant may have PDA, but no signs of Chromosomal abnormalities, like simians crease, lethargic eyes, short neck, Brushfield spots, and others was seen. The mother told us that she had no diagnosis of infections before and during her pregnancy.

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PHYSICAL ASSESSMENT

General Survey The patient is 14 days old. She looked appropriate to her age. The patient has no obvious physical deformities; her body is symmetrical and normal for her age. No body odor or breath odor was noted. Skin integrity is interrupted due to IVTT insertion of D5IMB 500 cc infusing @ 13cc/hr at the left metacarpal vein.

The patient was awake and was carried by the mother upon assessment. The patient was in respiratory distress manifested by fast breathing with a respiratory rate of 100 cycles per minute. Oxygen was administered to her via face mask at 4 liters per minute. Vital signs Vital Signs Upon Admission: Blood Pressure Cardiac Rate Respiratory Rate Temperature ---133 bpm 54 cpm 36.7C ---171 bpm 100 cpm 38.3C ---120 bpm 58 cpm 37.2C 4PM 8PM

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Skin, Hair, Nails Assessment Skin

The skin is smooth, thin, and pale; no edema and tenderness noted. The patient has a brown complexion in all areas. No bleeding or lesions was noted. The skin is warm to touch and has good skin turgor. The child has a birthmark on her left leg at about 5 cm in length and 3 cm in width. Milia was not present. Hair The hair is black in color, thin, and is evenly distributed. Her scalp is light brown, with no signs of lesions. There is presence of lanugo at the back of the patient. Nails The nails were round, hard. Nails were intact and pale in color with a capillary refill of 3-4 seconds. The nails are clean and smooth with clubbing noted. No lesions were observed.

Head, Neck, and Regional Lymphatic Assessment Head The head of the patient is normocephalic and symmetrical. The head circumference of the

patient is 35 cm. The mother verbalized pag mag-utong ni siya, mamula jud ni iyang agtang which was observed upon assessment. Upon palpation, the skull is smooth, soft, and fused except for the fontanels. Her facial features and expressions are symmetrical and the shape of the head is round. There are no obvious deformities. She could open and close her mouth without any discomfort.

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Neck Her neck is short and warm to touch. Her neck movement is coordinated; the patient can move her head from side to side without signs of discomfort. Regional Lymphatics There were no visible lymph nodes upon inspection. No palpable lymph nodes were present. There were also no abnormalities in her thyroid gland both anteriorly and posteriorly.

Eye Assessment Upon assessment, eyebrows are thin, smooth, and symmetrically aligned. The eyelashes

are evenly distributed and curled slightly outward. No noted discharges were present in the lacrimal apparatus. The color of her iris is dark brown. The iris and pupils were round and equal on both sides. Pupillary reflex is not yet developed. The sclera is clear. Whenever the child cries, tears are not present since the childs tearing ability is not yet fully developed.

Ears, Nose, Mouth, and Throat assessment Ears Both of her ears are symmetrical in size and are located. There is no presence of foreign

bodies, redness, deformities, or lesions. Inflammation and nodules were not visible. The external auditory canal curves upward and is short and straight. Minimal amount of cerumen in the ear canal was observed. The ears were physically symmetrical in size; pinna is in line with the outer canthus of his eyes. Upon palpation, ears are smooth and no tenderness is noted. No bleeding or masses were noted. No pain or tenderness was noted.

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Nose Nose was located symmetrically in the midline of the face with no evidence of swelling, bleeding, lesions, and masses. Nasal flaring was noted. No tenderness noted upon palpation. Both left and right nares were patent, with no discharges; air could freely move in and out when the patient breathes. The nasal septum was at the midline without perforation, lesions, or bleeding. Mouth Her lips are pale and smooth. Upon inspection of the mouth, oral mucosa was pinkish and moist. The tongue is located at the midline without lesions present. The gums were pinkish and bleeding is absent. Her tonsils were free from inflammation. The patients teeth are not yet developed; teeth were absent upon inspection.

Breast and Regional Nodes The patients breasts were flat and symmetrical. Areolar areas and nipples were pale in

color. No thickening or edema was found. No fixed, firm, immobile, irregular lymph nodes were present.

Thorax and lungs Her respiration is irregular. Rapid, shallow breathing was noted. The patients respiratory

rate is 100 breaths in one full minute. Upon auscultation, breath sounds were low in pitch with snoring quality, indicating rhonchi. No tenderness and masses noted upon palpation. No sputum was present.

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Heart and Peripheral Vasculature The patients cardiac rate was 171 beats per minute. Presence of abnormal heart sounds

was noted. Upon auscultation, machine-like murmurs were heard, which indicates heart disease. The apical pulse is easily palpable. Her skin was warm upon palpation and capillary refill time is 3-4 seconds.

Upper Extremities The patients upper extremities are symmetrical. Body fats are evenly distributed. Upper

extremities were pale and warm to touch. 5 fingers were present on both hands. The palm is lighter in color than the hands.

Abdomen Upon inspection, the abdomen is cylindrical, round, and soft. The patients

abdomen has same color with his ches. The umbilicus is medially located and shows no signs of inflammation or abnormal discharges. Bowel sounds were heard upon auscultation. The abdomen rises with inspirations and falls with expiration.

Genitalia The genitals are warm, dry, smooth, and soft, with good skin turgor. Labia majora covers

labia minora. There were no discharges present.

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Lower Extremities The patients lower extremities are symmetrical. No lesions were noted. Legs have equal

length. 5 toes were present on both legs. Cyanosis was noted; lower extremity is cold to touch and was pale. The soles are lighter in color than the legs.

Anus Anal patency is present; the child was able to defecate once during the shift.

Musculoskeletal System The extremities resist when extended and return to flexed state when released. Sutures of

the head are palpable. The neck moves freely and holds the head in midline position. Clavicles are symmetrical and intact. The spine is flexible and rounded. Palm was able to stay in both prone and supine in a good manner without difficulty. She was able to exhibit strong hand grip on both arms. No tenderness was visible upon moving the patient. Reflex on the upper extremity was good. No hand tremors noted. Neurological System

Rooting Reflex: Achieved; weak response. The child turns head toward side of face stroked. Sucking Reflex: Achieved; the child was able to suck her thumb and was able to breastfeed frequently. Palmar Grasp Reflex: Achieved; flexion of hands and feet were present; the grasp was strong; the child was able to grasp immediately. Tonic Neck Reflex: Achieved; weak response; the childs head turned to one side, the arm and leg on the same side extended.

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Stepping Reflex: Not achieved; the child wasnt able to execute this reflex since the child was asleep and carried by the mother. Babinski Reflex: Achieved; with weak response; upon stroking the outer sole of foot from heel to toe, the big toe rise and the remaining toes fan out. Moro Reflex: Achieved with quick response; sudden extension and abduction of extremities noted.

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PATIENTS DIAGNOSIS

Definition of the complete diagnosis Neonatal Sepsis:

A life threatening illness defined as a suspected or known plus the systemic inflammatory response syndrome F. J. Domino; The 5-minute Clinical Consult 2011

Neonatal sepsis is defined as a clinical syndrome of bacteremia with systemic signs and symptoms of infection and a positive culture from central body fluid. D.K. Guha; Guhas NEONATOLOGY Principles and Practice

Sepsis means putrefaction, i.e., the decomposition of organic matter (by bacteria or fungi) resulting from an interaction between germs and host J.L. Vincent; Intensive Care Medicine

Patent Ductus Arteriosus:

Patent Ductus Arteriosus (PDA) is the persistence in postural life of the normal fetal vascular conduit between the central pulmonary and systemic arterial systems.
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M. William Schwart; Five-minute pediatric consult

Patent Ductus Arteriosus (PDA) is the failure of the ductus arteriosus to close after birth. F. J. Domino; The 5-minute Clinical Consult 2011

A patent ductus arteriosus is a permanent defect in the muscle wall of the duct and is unlikely to close spontaneously A.A. Fanaroff, T. Lissauer; Neonatology at a Glance

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ANATOMY AND PHYSIOLOGY

Patent Ductus Arteriosus is a heart problem that occurs soon after birth in some babies. In PDA, abnormal blood flow occurs between two of the major arteries connected to the heart.

Superior vena cava

Brings de-oxygenated blood from the head, neck, arm and chest regions of the body to the right atrium. Inferior vena cava

Brings de-oxygenated blood from the lower body regions (legs, back, abdomen and pelvis) to the right atrium.

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Right Atrium: The right upper chamber of the heart. The right atrium receives deoxygenated blood from the body through the vena cava and pumps it into the right ventricle which then sends it to the lungs to be oxygenated.

Tricuspid valve: Valves are flap-like structures that allow blood to flow in one direction. The tricuspid valve is located between the right atrium and the right ventricle. Prevents the back flow of blood as it is pumped from the right atrium to the right ventricle

Right ventricle

the relatively thin-walled chamber of the heart that pumps blood received from the right atrium into the pulmonary arteries to the lungs for oxygenation. The right ventricle is shorter and rounder than the long conical left ventricle. The chordae tendineae of the tricuspid valve of the right ventricle are finer than the coarse strands of the chordae tendineae of the left ventricle. Pulmonary semilunar valve:

a semilunar valve between the right ventricle and the pulmonary artery; prevents blood from flowing from the artery back into the heart Pulmonary artery

The pulmonary artery is the vessel transporting de-oxygenated blood from the right ventricle to the lungs. A common misconception is that all arteries carry oxygen-rich blood. It is more appropriate to classify arteries as vessels carrying blood away from the heart.

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Pulmonary vein

The pulmonary vein is the vessel transporting oxygen-rich blood from the lungs to the left atrium. A common misconception is that all veins carry de-oxygenated blood. It is more appropriate to classify veins as vessels carrying blood to the heart. Left Atrium

The left atrium receives oxygenated blood from the lungs through the pulmonary vein. As the contraction triggered by the sinoatrial node progresses through the atria, the blood passes through the mitral valve into the left ventricle. Mitral Valve

The mitral valve separates the left atrium from the left ventricle. It opens to allow the oxygenated blood collected in the left atrium to flow into the left ventricle. It closes as the left ventricle contracts, preventing blood from returning to the left atrium; thereby, forcing it to exit through the aortic valve into the aorta. Left Ventricle

The left ventricle receives oxygenated blood as the left atrium contracts. The blood passes through the mitral valve into the left ventricle. The aortic valve leading into the aorta is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they contract. As the left ventricle contracts, the mitral valve closes and the aortic valve opens. The closure of the mitral valve prevents blood from backing into the left atrium and the opening of the aortic valve allows the blood to flow into the aorta and flow throughout the body.

34

Aortic Valve:

The aortic valve separates the left ventricle from the aorta. As the ventricles contract, it opens to allow the oxygenated blood collected in the left ventricle to flow throughout the body. It closes as the ventricles relax, preventing blood from returning to the heart. Aorta

The aorta is the largest single blood vessel in the body. It is approximately the diameter of your thumb. This vessel carries oxygen-rich blood from the left ventricle to the various parts of the body. Chondrae Tendinae

The chordae tendineae are tendons linking the papillary muscles to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. As the papillary muscles contract and relax, the chordae tendineae transmit the resulting increase and decrease in tension to the respective valves, causing them to open and close. The chordae tendineae are string-like in appearance and are sometimes referred to as "heart strings."

35

Ductus arteriosus:

The ductus arteriosus is part of the normal fetal circulatory system. This vessel connects the aorta and the pulmonary artery. Prior to birth the ductus arteriosus allows for antegrade flow from the right ventricle to the aorta. Following birth the ductus arteriosus normally closes Ductus venosus:

in the fetus, the ductus venosus shunts approximately half of the blood flow of the umbilical vein directly to the inferior vena cava. Thus, it allows oxygenated blood from the placenta to bypass the liver. In conjunction with the other fetal shunts, the foramen ovale and ductus arteriosus, it plays a critical role in preferentially shunting oxygenated blood to the fetal brain. It is a part of fetal circulation.
36

Foramen ovale: Blood from the mother enters the placenta and comes in close proximity to the fetal blood that has returned from the fetus to the placenta through the umbilical arteries . once the two circulations are in close proximity in the placenta , the oxygen and nutrients, like sugar , protein and fat molecules can move from maternal to fetal blood, carbon dioxide and waste products can move from fetal to maternal blood. The maternal blood returns from the placenta to the mothers veins for her systems to take care of the waste. The new nourished fetal blood returns to the baby through the umbilical vein. Fetal circulation: Oxygenated blood from the placenta enters the fetus through the umbilical vein Most of the newly oxygenated blood bypasses the liver via the DUCTUS VENOSUS and combines with deoxygenated blood in the inferior vena cava Blood then joins deoxygenated blood from the superior vena cava and empties into the right atrium Since pressure in the right atrium is larger than pressure left atrium, most blood will be shunted through the foramen ovale Some blood does travel from the right atrium to the right ventricle through the pulmonary trunk but most blood bypasses the pulmonary arteries and moves directly to the aorta via the ductus arteriosus Deoxygenated blood returns to the placenta via the umbilical arteries originating from the internal iliacs near the bladder

37

Oxygenated blood from the placenta is transported through the umbilical vein into the body of the fetus. Blood bypasses the liver by traveling through the ductus venosus. The ductus venosus provides a direct communication between the umbilical vein and inferior vena cava. Oxygenated blood from the ductus venosus combines with deoxygenated blood in the inferior vena cava and continues to the heart. Blood travels to the heart through the inferior vena cava and mixes with deoxygenated blood returning from the superior vena cava. Blood enters the right atrium of the heart. Because the fetal lungs are not functional, most blood will bypass the right ventricle and be shunted to the left atrium via the foramen ovale. Blood will then travel into the left ventricle and be distributed throughout the body via the aorta. Some blood will enter the right ventricle from the right atrium and proceed into the pulmonary trunk. However, most of this blood will be shunted away from the pulmonary arteries and into the aorta via the ductus arteriosus. Blood then circulates through the body and returns to the placenta via the umbilical arteries. These arteries are carrying deoxygenated blood back to the placenta . The placenta reoxygenates blood returning from the umbilical arteries and repeats the fetal cardiovascular cycle by recycling newly oxygenated blood to the fetus through the umbilical vein. Postnatal Circulatory Changes: With the first breath, increased alveolar oxygen pressure causes vasodilation in the pulmonary vessels Obstetrical clamping induces spontaneous constriction and changes of the umbilical vein to ligamentum teres and umbilical arteries to medial umbilical ligaments

38

Within 10 -15 hours after birth, the ductus arteriosus constricts and will become the ligamentum arteriosum

Increased left atrial pressure and decreased right atrial pressure causes the foramen ovale to close and become fossa ovalis.

The ductus venosus also constricts and will become the ligamentum venosum. Obstetrical clamping leads to spontaneous constriction of the umbilical vessels and

eventually leads to the conversion of the ductus venosus to the ligamentum venosum. Changes due to increased alveolar pressure in the lungs lead to anatomical and physiological alterations in the circulatory system. Usually within 10 -15 hours after birth, the ductus arteriosus will constrict and change to the ligamentum arteriosum. The umbilical vein and umbilical arteries become the ligamentum teres and medial umbilical ligaments, respectively. Normal Heart and Heart With Patent Ductus Arteriosus

39

ETIOLOGY:

As a baby develops in the womb, a vascular connection (ductus arteriosus) between two major blood vessels leading from the heart the aorta and pulmonary artery is a normal and necessary part of your baby's blood circulation while in the womb. The ductus arteriosus diverts blood from the lungs of the fetus while they aren't being used. The fetus receives oxygen from the mother's circulation. But, the ductus arteriosus is supposed to close within two or three days after birth once the newborn's heart adapts to life outside the womb. In premature infants, the connection often takes longer to close on its own. If the connection remains open, it's referred to as a patent ductus arteriosus. The abnormal opening causes too much blood to circulate to the lungs and heart. If not treated, the blood pressure in the lungs may increase (pulmonary hypertension) and the heart may enlarge and weaken. Congenital heart defects arise from problems early in the heart's development but there's often no clear cause. Genetics and environmental factors may play a role. Etiology for PDA: Predisposing Present/ Absent Factors Being born too soon Absent (prematurity) Rationale Patent ductus arteriosus (PDA) occurs more commonly in babies who are born too early than in babies who born full term because the infants heart was not fully developed before delivery. Justification The mothers LMP was on April 16, 2011 and the baby was born on Jan 15, 2012. Therefore the baby was exactly born 9months and 1 day. Proving that she is not in a preterm
40

state.

Having other heart Absent defects

Babies who have other heart problems when they're born (congenital heart defects) are also more likely to have a patent ductus arteriosus. Because other defects such If you have a family history of heart defects, it's more likely your child may have a patent ductus arteriosus. Other genetic conditions, such as heart problems or chromosomal abnormalities, also have been linked to an increased chance of having a PDA. PDAs are much more common in girls than in boys.

Other than Patent Ductus Arteriosus, no other heart defect has been noted/diagnosed.

Family history and Present other genetic conditions.

Tracing back to the family history, the grandmother of the baby has myocardial infarction in which may be a factor for her to have PDA.

Having a female baby Present

The baby was born as a female as evidenced by the presence of only female genitalia.

Precipitating Factors

Present/ Absent

Rationale Teratogens are any chemical, substance, or exposure that could possibly cause birth defects in a developing fetus. Exposure to teratogens seems to result in malformations especially

Justification Only FeSO4 was taken by the mother during her pregnancy with patient Errshen.

Use of Teratogens Absent during pregnancy

41

Smoking

Present

Chromosomal abnormalities

Absent

when it occurs during the fourth and tenth week of pregnancy. A shortage of oxygen can have devastating effects on your baby's growth and development. On average, smoking during pregnancy doubles the chances that a baby will be born too early or weigh less than 5 1/2 pounds at birth. Smoking also more than doubles the risk of heart diseases on infants Trisomy 21, the chromosomal abnormality associated with Down syndrome, is associated with cardiac abnormalities in 50 percent of babies. Chromosomal abnormalities If you have rubella in the first trimester, you have about a 25% risk of having a birth defect, known as congenital rubella syndrome. The defects can include: heart deformities hearing loss mental retardation eye deformities others

The mother told us that she smoked during the first trimester of her pregnancy; however, she stopped smoking when she knew that she was pregnant.

Maternal infections Absent (esp. Rubella/German measles)

The infant may have PDA, but no signs of Chromosomal abnormalities, like simians crease, lethargic eyes, short neck, Brushfield spots, and others was seen. The mother told us that she had no diagnosis of infections before and during her pregnancy.

42

Etiology for Neonatal Sepsis: Etiology Sepsis Predisposing Factors Preterm baby Absent Experimental well epidemiological as The mothers LMP as was on April 16, 2011 and the baby delivered 17, on Present or absent Rationale Justification

studies have shown was that low birthweight Jan. is also

2012.

a Hence the baby was

predisposing factor born 9 months and for such atherosclerosis, cardiovascular diseases, sepsis, abnormalities a day. Proving that as she was not a

preterm baby.

renal disease, noninsulin diabetes,

hypertension, obesity metabolic syndrome. the human Indeed, fetus or the

43

adapts undernutrition redistribution infection flow infants months, immune haven't under 3 Present Infants months immune below

to by and

of blood

3 At the age of 14 old, the

whose systems developed

have days systems infants

immune is still thus

that are still in the system process maturation. being certain infections prone of maturing

enough to fight off overwhelming infections

Thus making her prone to to certain infections. blood

Bloodstream infection of the

Absent

Mothers with blood There stream also baby infection share infection diagnosis causes to for the

is of

no the

mother(bacteremia)

the mother about blood have stream infection. they same

blood during fetal development Precipitating Present or absent Rationale Justification

44

Factors Infection Absent Newborn baby can Mother was not of during

get infected in many diagnosed ways. Infection in infection mother can

be pregnancy or after

transmitted to the delivery. baby. After birth the umbilical cord can be source of

infection.

Infection

of the skin can also invade and cause sepsis. Baby can

catch infection from other Because people. the

immune system of the newborn is not mature any infection can potentially

cause sepsis. Alcoholism Present A woman who Tracing to the social

drinks alcohol while mothers

45

she is pregnant may history, harm developing

she

her verbalized that she baby has taken alcohol the first After of being

(fetus). Alcohol can during pass from the trimester.

mothers blood into knowing

the babys blood. It pregnant, she has can damage and stopped the alcholol

affect the growth of intake. the babys cells. immunosuppressive medications by the mother taken Absent Taking of Mother taken has not any aside FeSO4. she

immunosuppressive

drugs weakens the medications immune system of from the mother which However

makes her prone to suspects that it was infections. So if the the reason for her mother has hematemesis during

infections, the baby her first 7 months of will also share the pregnancy. same fate. Frequent checkups vaginal Absent during Frequent check-ups vaginal Due to financial the

can pressures,

46

pregnancy.

cause infection to family only goes to the womens genital the area because times check-up of in

severe such

clinical instruments symptoms

are foreign to the vaginal bleeding, or body abdominal pain

47

SYMPTOMATOLOGY

Symptoms

Rationale The normal respiratory rate for infants is 40-60 breaths per minute. Lower than normal indicates bradypnea; higher than normal indicates tachypnea. Poor feeding occurs when infants lack interest in nursing or cannot obtain the nutrition necessary for appropriate weight gain and other development. Infants lacking appropriate nutrition due to poor feeding can suffer significant and permanent delays in mental and physical development. The normal pulse rate for infants is 120-160 beats per minute. Lower than normal indicates bradycardia; higher than normal indicates tachycardia. baby likely sweats because he's warm while breastfeeding. Being skin to skin with your baby raises body temperature, which initiates his natural cooling system.

Present/Absent Present

Justification The respiratory rate of the patient is 100 cycles per minute.

Rapid breathing

Poor feeding habits

Absent

The patient was able to breastfeed every four hours.

Rapid Pulse

Present

The cardiac rate of the patient is 171 breaths per minute, which indicates tachycardia.

Sweating while feeding

Present

Sweat was visible upon breastfeeding.

48

PATHOPHYSIOLOGY

Superior vena cava and inferior vena cava with unoxygenated blood Right atrium (deoxygenated blood flow in right heart)

Right ventricle

Pulmonary arteries

Lungs ( oxygenated blood)

Pulmonary veins

Left atrium

Left ventricle

Aortic valve

Aorta (mixing of blood from aorta (oxygenated) and pulmonary artery (deoxygenated blood))

- Machine like murmur - Fast breathing - Poor feeding

distributes to the circulatory system

Superior vena cava and Inferior vena cava

49

Pregnancy

Maternal age Smoking Increased parity congenital

Fetal Development( begins at the 10th week of gestation)

1st trimester: Embryo increases in size to about 1 inches. Bones and muscles begin to round Out contours of body Sex organs begins to form Beginning of fetal period

2nd trimester: Hands and feet are well formed. Skin appears dark red Finger closure is possible Reflexes become more active

3rd trimester: Generally the fetus is about 15 inches long and weighs about three pounds Fat is formed all over the body Fetal heart rate becomes quite rapid Birth
50

Failure of ductus arteriosus to close within 10-15 hours

Machine like murmur Fast breathing Rapid pulse Poor feeding

Blood enters systemic circulation Through ductus bypassing The pulmonary system

Systemic pressure greater than Pulmonary pressure

Left to right shunting from aorta To pulmonary artery

Right ventricular hypertrophy If treated: Medical management -fluid restriction -indomethacin -cardiac catheterization -surgical repair Nursing management -assessment of vital signs such as tachycardia, tachypnea -avoid cold stress to infant - position semi-fowlers if necessary -reduce environmental stimuli -promote uninterrupted sleep if not treated Bad prognosis Poor growth Poor feeding Increased heart size Prolonged capillary refill time

51

Doctors Orders

DATE ORDERED February 3, 2012

DOCTORS ORDER Please admit to SN ward

RATIONALE To monitor closely the neonate for any eventualities that may occur. Vitals signs should be checked so that we would have a baseline record for comparison. Also, to be able to check if there are any abnormalities in the persons vital statistics. Breastfeeding is always recommended for all neonates, however since the patient has cardiac problems, he may develop difficulty of breathing anytime which may lead to aspiration. If the patient has tachypnea, the patient is predisposed to aspiration especially when feeding. Therefore the patient is advised to have nothing per orem if the RR >60.

REMARKS DONE

DONE

VSq4

BF with SAP, NPO if RR > 60

DONE

Rx: CBC, UA, LP, 2DECHO, Crea, Na+, k+, MCHC MCV, Blood GSCS

CBC is used as a broad screening test to check for such disorders as anemia, infection and many other diseases. It is actually a panel of tests that examines different parts of the blood and it includes: WBC count, RBC count, Hemoglobin, Hematocrit. - The hematocrit is used to screen for anemia, or is measured on a person to determine the extent of anemia. An anemic person has fewer or smaller than normal red blood

DONE

52

cells. A low hematocrit, combined with other abnormal blood tests, confirms the diagnosis. - Lumbar puncture is done to determine infection in the meninges. To rule out the presence of meningitis or any cerebral infection. - 2Dimensional Echocardiography is used to examine the heart. It is capable of displaying a cross-sectional "slice" of the beating heart, including the chambers, valves and the major blood vessels that exit from the left and right ventricle. For us to be able to see presence of blockage and any abnormalities in the chamber. - Urinalysis is a test to check for the presence of bacteria, blood and pus which cause urinary tract infection. - Serum sodium examination is done to assess the levels of the sodium in the blood which is especially critical in Cardiac Patients. - Serum potassium examination is done to assess the concentration of potassium in the blood which is critical in the functioning of muscular organs like the heart. - mean corpuscular volume, or "mean cell volume" (MCV), is a measure of the average red blood cell size that is reported as part of a standard complete blood count to detect anemia and polycythemia. - The mean corpuscular hemoglobin concentration, or MCHC, is a measure of the
53

concentration of hemoglobin in a given volume of packed red blood cells. It is reported as part of a standard complete blood count to detect if the patient is anemic or not. - Blood Gram stain, Culture and Sensitivity is to detect what type of bacteria grows in the infected blood of the patient and for the Doctors to know what type of antibiotics is responsive to the bacteria present in the patients blood. IVF D5IMB 500 cc to run @ 13cc/hr - Balanced Multiple Maintenance Solution with 5% Dextrose was given to the patient as a maintenance fluid to increase calories, hydration and electrolytes in the body. This specific infusion rate is advised depending on the weight of the patient and the condition. Since this patient is a cardiac patient, we cant give too much IV fluid because this might lead to cardiac overload. Ceftriaxone is a thirdgeneration cephalosporin antibiotic a choice drug for treatment of bacterial meningitis. In pediatrics, it is commonly used in febrile infants between 4 and 8 weeks of age who are admitted to the hospital to exclude sepsis and since the patient is being considered to be septic, therefore this drug was prescribed.Amikacin is an aminoglycoside antibiotic used to treat different types of bacterial infections. Amikacin is most often used for treating DONE

Meds: Ceftriaxone 15g IVTTq 12 Amikacin 45g IVTT OD Diazepam 0.6g IVTT PRN for active seizure

DONE

54

I &O q shift

severe, hospital-acquired infections with multidrug resistant Gram negative DONE bacteria. Amikacin was prescribed to the patient to prevent hospital ward infection. Diazepam is an anti-convulsant or anti-seizure drug given to patient as a stand-by medication in case the Patient will have seizure. - Intake and Output is DONE monitored because too much fluid intake for our patient can cause cardiac overload both orally and intravenously. While Urine output is also monitored to make sure the kidneys are functioning normally meaning whatever is being taken inside the body should be excreted. - Patients with cardiac problems DONE may develop dyspnea anytime thats why oxygen inhalation is considered as a standby amenity for emergency purposes. The patient is for close watch thus referral is necessary if any abnormalities occur.

O2 inhalation @ 4LPM via face mask PRN for tachypnea

Refer unusualities

DONE

February 4, 2012

Rx: FU CBC, FU Na+, K+ ,

The laboratory tests that are still DONE for follow-up are really necessary to establish the diagnosis and treatment of the patient. This procedure is requested to rule out any other congenital abnormalities present in the Nervous System of the neonate because some PDA patients can DONE

S/F cranial CT scan

55

have concomitant neurological defects. DONE S/F 2DECHO This examination is still for follow-up because it is necessary to establish the diagnosis and treatment of the patient. DONE S/F LP undecided This examination is still for follow-up because this procedure can detect whether the patient has bacterial meningitis or sepsis. DONE To continue to give the nutritional and electrolyte needs of the patient and for IV medications as well. DONE Shift cefriaxme to cefortaxime tt. 300g IVTT Ceftriaxone was shifted to Cefotaxime because this drug has a broader spectrum activity against Gram positive and Gram negative bacteria compared to that first drug. For close monitoring of the patient and to check if there are changes in the Vital signs and sensorium of the patient. Intake and Output is monitored because too much fluid intake for our patient can cause cardiac overload both orally and intravenously. While Urine output is also monitored to make sure the kidneys are functioning normally meaning whatever is being taken inside the body should be excreted. DONE

IVF same @ 1L

VSq4

DONE I &O q

DONE
56

Refer any unusualities Rx: FU CBC, Na+, K+

The patient is for close watch thus referral is necessary if any abnormalities occur. DONE The laboratory tests that are still for follow-up are really necessary to establish the diagnosis and treatment of the patient. DONE This procedure is requested to rule out any other congenital abnormalities present in the Nervous System of the neonate because some PDA patients can have concomitant neurological defects DONE

February 5, 2012

S/F cranial CT scan

S/F 2DECHO

This examination is still for follow-up because it is necessary to establish the diagnosis and treatment of the patient. DONE This examination is still for follow-up because this procedure can detect whether the patient has bacterial meningitis or sepsis. DONE For close monitoring of the patient and to check if there are changes in the Vital signs and sensorium of the patient. DONE To continue to give the nutritional and electrolyte needs of the patient and for IV medications as well. DONE These meds are still to be continued to complete the dosage to treat the severity of the disease. DONE
57

S/F LP

\ Continue monitoring of VS Continue IVF at SR

Continue meds: Cefotaxime D1 Amikacin- D2

I &O q shift

Intake and Output is monitored because too much fluid intake for our patient can cause cardiac overload both orally and intravenously. While Urine output is also monitored to make sure the kidneys are functioning normally meaning whatever is being taken inside the body should be excreted. DONE The patient is for close watch thus referral is necessary if any abnormalities occur. This procedure is requested to rule out any other congenital abnormalities present in the Nervous System of the neonate because some PDA patients can have concomitant neurological defects This examination is still for follow-up because it is necessary to establish the diagnosis and treatment of the patient. DONE This examination is still for follow-up because this procedure can detect whether the patient has bacterial meningitis or sepsis. DONE To continue to give the nutritional and electrolyte needs of the patient and for IV medications as well. DONE These meds are still to be continued to complete the dosage to treat the severity of the disease. DONE
58

Refer any unusualities S/F cranial CT scan

February 6, 2012

DONE

DONE S/F 2DECHO

S/F LP

IVF @ SR

Cont meds: Cefotaxime D1 Amikacin- D2

I &O q shift

Intake and Output is monitored because too much fluid intake for our patient can cause cardiac overload both orally and intravenously. While Urine output is also monitored to make sure the kidneys are functioning normally meaning whatever is being taken inside the body should be excreted DONE The mother refused to undergo this procedure because they dont have the money to pay for this procedure. Also, the Mother didnt think this procedure was necessary to be undergone DONE This procedure is requested to rule out any other congenital abnormalities present in the Nervous System of the neonate because some PDA patients can have concomitant neurological defects DONE This examination is still for follow-up because it is necessary to establish the diagnosis and treatment of the patient. DONE The condition of the patient has improved and the IV line was removed therefore heplock was inserted for the medications of the patient. DONE These meds are still to be continued to complete the dosage to treat the severity of the disease.

Refuse LP

February 7, 2012

Rx S/F Cranial CT scan

S/F 2DECHO

shift to Heplock

Cont meds:

Cefotaxime D1 Amikacin- D2

DONE
59

VSq4

For close monitoring of the patient and to check if there are changes in the Vital signs and sensorium of the patient. DONE Intake and Output is monitored because too much fluid intake for our patient can cause cardiac overload both orally and intravenously. While Urine output is also monitored to make sure the kidneys are functioning normally meaning whatever is being taken inside the body should be excreted. DONE The patient is for close watch thus referral is necessary if any abnormalities occur. DONE This procedure is requested to rule out any other congenital abnormalities present in the Nervous System of the neonate because some PDA patients can have concomitant neurological defects DONE This examination is still for follow-up because it is necessary to establish the diagnosis and treatment of the patient. DONE These meds are still to be continued to complete the dosage to treat the severity of the disease DONE For close monitoring of the patient and to check if there are changes in the Vital signs and sensorium of the patient.

I &O q shift

Refer any unusualities

February 8, 2012

Rx: S/F Cranial CT scan

S/F 2DECHO

Med: cefotaxime- D2 Amikacin D3

VSq4

DONE
60

I &O q shift

Intake and Output is monitored because too much fluid intake for our patient can cause cardiac overload both orally and intravenously. While Urine output is also monitored to make sure the kidneys are functioning normally meaning whatever is being taken inside the body should be excreted. DONE The patient is for close watch thus referral is necessary if any abnormalities occur. DONE This procedure is requested to rule out any other congenital abnormalities present in the Nervous System of the neonate because some PDA patients can have concomitant neurological defects DONE This examination is still for follow-up because it is necessary to establish the diagnosis and treatment of the patient. DONE These meds are still to be continued to complete the dosage to treat the severity of the disease DONE For close monitoring of the patient and to check if there are changes in the Vital signs and sensorium of the patient. DONE Intake and Output is monitored because too much fluid intake for our patient can cause cardiac overload both orally and intravenously. While Urine output is also monitored to make sure the kidneys are
61

February 9, 2012

Refer unusualities

S/F cranial CT scan

S/F 2DECHO

Meds: Cefotaxime D3 Amikacin D4

VSq4

I &O q shift

functioning normally meaning whatever is being taken inside the body should be excreted. DONE Refer unusualities The patient is for close watch thus referral is necessary if any abnormalities occur DONE February 10, 2012 Rx: S/F 2DECHO on Thursday Meds: Cefotaxime D6 Amikacin D5 This examination is still for follow-up because it is necessary to establish the diagnosis and treatment of the patient. DONE These meds are still to be continued to complete the dosage to treat the severity of the disease DONE VSq4 For close monitoring of the patient and to check if there are changes in the Vital signs and sensorium of the patient. Intake and Output is monitored because too much fluid intake for our patient can cause cardiac overload both orally and intravenously. While Urine output is also monitored to make sure the kidneys are functioning normally meaning whatever is being taken inside the body should be excreted. The patient is for close watch thus referral is necessary if any abnormalities occur DONE

I &O q shift

Refer any unusualities

DONE

62

Date/ Time Ordered

Diagnostic Test and Normal Range of Values

Result

Clinical Significance/Rationale

Nursing Responsibilities

February Urinalysis 3, 2012 Findings:

Color:

Straw( Pale Yellow)

An unusual urine color is among the most common signs of a urinary tract infection.

-provide the patients mother or significant other with urine container with lead

N: pale yellow to deep amber

Appearance

Clear

Cloudy or foamy urine may occur occasionally due to mild dehydration, polyuria or phosphate in urine. -instruct the watcher or significant other to collect sample of urine

63

preferably arising Increased in: dehydration, Specific Gravity N:1.010-1.020 1.005 fever, profuse sweating, (Normal) vomiting, diarrhea, -Collect specimen glycosuria, proteinuria from infants or Decreased in: overhydration, hypotension, severe renal damage, diabetes insipidus young children into a disposable apparatus consisting of a plastic bag with an adhesive Albumin Negative Positive in: renal disorders, backing around associated with hypertension, diabetes mellitus the opening that can be fastened to the perineal area or the penis to Positive in: Sugar Negative Hyperglycemia, diabetes directly to the mellitus bag. Depending Pus cells 0-2 High level of pus in urine is an indication of Urinary tract infection on the hospital policy, the collected urine can be transferred permit voiding

64

Bacteria

Few

Numerous amount of bacteria in urine will lead to Urinary tract infection

to an appropriate specimen container.

IPD Hematology -Cover all CBC WBC count N: 5-10 8.35 x10/ uL Increased in: Infection, inflammation, hematologic malignancy, leukemia. specimens tightly, label properly and send immediately to the laboratory

Decreased in: Aplastic anemia, B12 or folate, - identify patient sepsis (decreased survival) and check for the requisition form with the patients Increased in: Hemoglobin N: 115-155 acute thermal injury 133.0 g/L polycythemia, dehydration, bracelet identification

Decreased in: hemorrhage, bleeding, anemia, hemolytic anemia, fluid -inform the watcher or

65

overload, fluid retention

significant other of the patient that

Low levels of hematocrit is Hematocrit N: 0.36-0.48 acute or chronic bleeding designated site. from the digestive tract, Nutritional deficiencies such as iron, folate or B12 - ask assistance deficiency from the mother or the significant other in handling High level of RBC in the 0.38 an indication of anemia, drawn from the blood needs to be

Red Blood Cells N: 4.20-6.10

3.81x10^6/uL urine Indicates bleeding at

the baby in order for him/her to be some point in the urinary secured. tract

Neutrophils N: 55-75 30%

Increased neutrophils: suggests infection, acute stress, acute and chronic inflammations Decreased neutrophils: suggests aplastic anemia, drug-induced neutropenia,

- the patient may be seated or in supine position. The patients arm Is in extension.

66

folate or B12 deficiency

Post test -instruct the

Increased lymphocytes: Lymphocytes N: 20-35 insufficiency disease, patient to continue chronic infection, drug and compression of allergic reactions, the puncture site autoimmune disease. for 2 5 mins or Decreased lymphocytes: until the bleeding immune deficiency stops syndrome. 54% viral infection, adrenal watcher of the mother or the

Monocytes N: 2- 10 14%

Increased monocytes: inflammation, infection, malignancy, TB, myeloproliferative disorders. Decreased monocytes: depleted in overwhelming bacterial infection. -assess the patients arm to ensure that the bleeding has ceased. -Apply adhesive bandage if necessary. Increased eosinophils: 2% allergic states, drug sensitivity reaction, skin -if hematoma disorders, tissue invasion
67

Eosinophils N: 1-8

by parasites, hypersensitivity response to malignancy, pulmonary infiltrative disease, Decreased eosinophils: acute and chronic inflammation, stress

occurs or if there is still bleeding, ask the watcher or the mother of the patient to continue compression of puncture site or elevate the arm

A highly acidic urine pH PH N: 150-400 Uncontrolled diabetes, Diarrhea, Starvation and dehydration, Respiratory diseases in which carbon dioxide retention occurs and acidosis develops 464x10/uL occurs in: Acidosis,

A highly alkaline urine occurs in: Urinary tract obstruction, Pyloric obstruction, Salicylate intoxication, Renal tubular acidosis, Chronic renal failure

68

Increased in: Liver MCV N:79.4-94.8 99.7 disease, megaloblastic anemia (folate, B12 deficiencies), high WBC.

Decreased in: Iron deficiency, thalassemia; decreased or normal in anemia of chronic disease.

MCH N: 25.6- 32.2

34.9 pg

increased in: Macrocytosis , Megaloblastosis (Vitamin B12 or folate deficiency), reticulocytosis, liver disease. Decreased in: Microcytosis (iron deficiency, thalassemia).

MCHC N:32.2-35.5

35.0 g/dL

Increased in: hyperchromia, hemolysis (with spuriusly high Hb or low MCV or RBC), Decreased in:

69

Hypochromic anemia (iron deficiency, thalassemia)

BLOOD CHEM

Glucose RBC N: 4.10-6.6

4.5

increased in: Diabetes mellitus, Cushing's syndrome, chronic pancreatitis

Decreased in: Pancreatic islet B cell disease with increased insulin, diffuse liver disease, infant of diabetic mother, enzyme deficiency diseases.

Creatinine N: 53.00-115.00

15.40 umol/L Increased in: Acute or chronic renal failure; urinary tract obstruction

Decreased in: Reduced muscle mass

70

Sodium N:136.00-155.00

137.70 mmol/L

increased in: Dehydration, polyuria , inadequate water intake

Decreased in: Congestive heart failure, cirrhosis, vomiting, diarrhea, excessive sweating, adrenal insufficiency, nephrotic syndrome.

Potassium Increased in: N: 3.5- 5.5 4.63 mmol/L Hyperkalemia, acute tubular necrosis, Cushing syndrome (rare), Diabetic =989898988 acidosis and other forms of 2.54 mmol/L metabolic acidosis, Kidney Disorders Decreased in: Hypokalemia, adrenal gland insufficiency, Gastrointestinal disorders associated with diarrhea Prior to taking the
71

and vomiting

blood sample, the nurse should inform the patient

Calcium N: 1.75-2.39

Increased in: Hyperparathyroidism, Vitamin D excess, Vitamin A intoxication

or the watcher or significant other of the patient about the test(s) to be performed and

Decreased in: the preparation for Hypoparathyroidism, the test. You vitamin D deficiency, renal should: insufficiency, pseudohypoparathyroidism, -Suprasternal magnesium deficiency, view: the hyperphosphatemia, image massive transfusion, showed a hypoalbuminemia. large patent purpose of 2/D echo results ductus the test arteriosus 2Dimensional that runs Echocardiography is used above the left to examine the heart. It is atrium capable of displaying a between the cross-sectional "slice" of preparatio
72

1. define and explain the test 2. state the specific

3. explain the procedure 4. discuss test

aorta and the pulmonary artery.

the beating heart, including the chambers, valves and the major blood vessels that exit from the left and right ventricle. For us to be able to see presence of blockage and any abnormalities in the chamber

n, procedure, and posttest care

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Nursing Theories CORE, CARE, CURE MODEL Lydia Hall

Lydia Halls Model is a philosophy of nursing that proposed that nursing functions differ insofar aspects of patient care is concerned. She postulated that individuals could be conceptualized in three separate domains: care (hands on bodily care), core (using the self in relationship to the patient) and cure (applying medical knowledge). She said Nursing is a distinct body of knowledge that provides nursing care to patients who are in need of nursing care in support of medical interventions, in collaboration with other members of the health team, or exclusively and independently by the nurse herself. Furthermore, she maintained that nurses functioned in all three domains but in different degrees. Care domain was exclusive to nursing, core was shared with social workers, psychologists, clergy, and other professions. She believed that professional nursing hastened the recovery of patients and that more professional nursing care and health teaching was needed in the light of decreasing medical care rendered to the patient. In relation to our patient, we student nurses must carry out nursing intervention independently, dependently, or interdependently. The core aspect means that it is our responsibility to make sure that the patient receives the highest level of care possible from all concerned health professionals. Our role must be in collaboration, coordination, and cooperation with other members of the health care team on matters pertaining to our patients welfare. The cure aspect clearly delineates nursing functions that are dependent on the members of the medical profession and examples of these include medication administration, performance of

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diagnostic procedures and some other interventions. The care refers to our knowledge and skills about our patients condition to carry our responsibilities as student nurses.

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Transcultural Theory of Nursing Madelleine Leininger

Leiningers Theory forwards the principle that caring is the true essence of nursing. However, it varies from one culture to another in terms of how it is expressed, the processes and patterns unique to the culture. She said Nursing is the art of improving and providing culturally congruent care to people that is beneficial, will fit with, and will be useful to the client, family, or culture group healthy life ways. Worldview of caring is composed of many social and cultural factors like religion, economics, education, history, language, cultural values, generic and professional care, and environmental context. She said that these are critical factors that can influence patterns of cultural care to predict health, wellbeing, illness or even death. She carefully considers: Worldview of caring, language of caring, philosophical and religious factors, kinship and social factors, cultural values, beliefs and life ways, political and legal factors, educational factors and technological factors. These factor are taken within the cultures environmental context, language and ethno-history to understand and appreciate a cultures expression patterns, and practices of caring. In relation to our patient, their culture was not a barrier for us not to care for the patient since they are Bagobo. All patients must be treated according to their beliefs. We respect their opinions and culture since people from other cultures may not actually behave in the same way as we would behave if given the same situation. It is important to also learn their beliefs and practices so that student nurses like us won't exhibit culture shock. Culture shocks only happen if any people would fail to know about someone who dont practice the same way as the said individual would behave.

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Caseys Model of Nursing

Casey's Model of Nursing focuses on the nurse working in partnership with the child and his or her family. It was one of the earliest attempts to develop a nursing model designed specifically for child health nursing.

The five aspects of this nursing theory are child, family, health, environment, and the nurse. The philosophy of Casey's model is that the best people to care for the child are the members of the family, with health care professionals assisting. This necessitates a relationship between the parents and nurse.

It is important that the nurse should provide the outmost care to the child especially because the child has a heart defect but the most significant action that we must do is to communicate with the patients family. As student nurses, we should provide support to the family and we should inform them about the condition of the patient. We should emphasize that the person who are suitable to take care of the child is the family and our role is to assist them in the process.

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Drug Study Generic Name Cefotaxime

Brand Name

Claforan [vial] Cefatax [vial] Cefotax [vial] Ceftax [vial] Antax [vial] Third-generation cephalosorins Cefotaxime exerts its action against most gram negative aerobic bacteria as well as some gram positive bacteria like Enterobacter, Klebsiella and Proteus and also against Beta lactamase producing bacteria. It is strongly indicated in gram negative bacillary meningitis, hospital acquired infections, and infections in immuno-compromised patients.
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Classification Indication

Contraindication

Hypersensitivity to Cephalosporins Serious hypersensitivity to penicilins

Use cautiously in: - History of GI disease, especially colitis Geriatric patients Pregnancy and lactation Renal Impairment

Dosage IM, IV (Adults):

Most infections: 1g q 12 hr. Moderate or severe infections: 1-2g q 6-8 hr Life-threatening infections: 2g q 4hr

IM, IV (Children > 1 mo):

8.3-30mg/kg q 4 hr or 12.5-45 mg/kg q 6 hr

IV (Neonates 1-4 wk)

50 mg/kg q 8 hr

IV (Neonates < 1 wk)

50 mg/kg q 12 hr.

Renal Impairment (Adults):

CCr< 20ml/min decrease dose by 50%

Mode of Action

Interferes with bacterial cell wall synthesis by inhibiting the cross-linking of peptidoglycan strands. Peptidoglycan makes cell membranes rigid and

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protective. Without it, bacterial cells rupture and die. Adverse Reaction Pain at injection site; hypersensitivity reactions, rash, pruritus; diarrhoea, nausea, vomiting; candidiasis; eosinophilia, neutropenia, leucopenia, thrombocytopenia. Potentially Fatal: Anaphylactic reaction; nephrotoxicity. Nursing Responsibilities Use cefotaxime cautiously in patients with impaired renal function, a history of GI disease (especially colitis), or hypersensitivity to penicillin because cross-sensitivity has occurred in about 10% of patients. If possible, obtain culture and sensitivity test results, as ordered, before giving drug. For I.V. use, reconstitute each 0.5-1-, or 2-g vial with 10ml of sterile water for injection. Shake

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to dissolve. For intermittent I.V. infusion, further dilute in 50 to 100 ml of D5W or normal saline solution. Give cefotaxime by I.V. injection over 3 to 5 minutes through tubing of a flowing compatible I.V. solution. Temporarily stop other solutions being given through same I.V. site. Discard unused drug after 24 hours if stored at room temperature, 5 days if refrigerated Monitor I.V. sites for signs of phlebitis or extravasation. Rotate I.V. sites every 72 hours. Monitor BUN and serum creatinine levels and fluid intake and output for signs of nephrotoxicity Assess bowel pattern daily; severe diarrhea may indicate pseudomembranous colitis

81

Monitor patient closely for superinfection. If signs appear, notify prescriber and expect to stop drug and give appropriate care.

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Generic Name Amikacin Sulfate

Brand Name

Amikacide [vial] Abcin [vial] Abiox [vial] Acean [vial] Acil [vial]

Classification Aminoglycoside Indication To treat serious gram-negative beacterial infections (including septicema; neonatal sepsis; respiratory tract, bone, joint, CNS, skin, soft-tissue, intra-abdominal, burn, and post-operative infections; and serious complicated, and recurrent UTI) Contraindication Hypersensitivity to amikacin or other aminoglycosides Most parenteral products contains bisulfites and should be avoided in patients with known intolerance

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Products containing benzyl alcohol should be avoided in neonates

Use cautiously in: - Hearing impairment Dosages

-

Geriatric patients and premature infants Neuromuscular diseases such as myasthenia gravis Obese patients Pregnancy Neonates Lactating mothers I.V. Infusion, I.M. Infusion

Adults and Children:

15 mg/kg daily in equal doses at equally spaced intervals (7.5 mg/kg every 12 hr or 5 mg/kg every 8 hr) for 7 to 10 days. Maximum: 1500 mg daily.

Infants:
10 mg/kg initially, then 7.5mg/kg q 12 hr

Neonates: Loading dose: 10 mg/kg. Maintenance: 7.5 mg/kg every 12 hr for 7 to 10 days

Mode of Action

Bind to negatively charged sites on bacterias outer cell membrane, disrupting cell integrity. Also binds to bacterial ribosomal subunits and inhibits protein synthesis. Both actions lead to

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cell death. Adverse Reactions CNS: Drowsiness, headache, loss of balance, neuromuscular blockade, tremor, vertigo EENT: Hearing loss, ototoxicity, tinnitus GI: Nausea, vomiting GU: Aztomeia, dysuria, nephrotoxicity, oliguria or polyuria, proteinuria MS: Acute muscle paralysis; arthralgial; muscle fatigue, spasms, and weakness RESP: Apnea Other: Hyperkalemia Nursing Responsibilities Expect to obtain results of culture and sensitivity testing before therapy begins Prepare amikacin I.V. solution by adding contents of 500-mg vial to 100 to 200 ml of sterile diluents. Then infuse drug over 30 to 60 minutes. Monitor for signs of ototoxicity, such as tinnitus and vertigo, especially during high dosage or prolonged amikacin therapy.

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Generic Name Ceftriaxone

Brand Name

Cefalin [vial] Malocef [vial] Winceft [vial] Garamycin Gentaswift Third-generation cephalosporin T-aminocephalosporanic acid To treat infections of the lower respiratory tract, skin, soft tissue, urinary tract, bones, and joints; sinusitis; intrabdominal infections; and septicaemia caused by anaerobes, gramnegative organisms and gram-positive organisms.

Classification

Indication

Contraindication

Hypersensitivity to Cephalosporins Serious hypersensitivity to penicilins

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Use Cautiously in: - History of GI disease, especially colitis Pregnancy and lactation Geriatric patients Diabetes Renal impairment

Dosages I.V. Infusion, I.M. Infusion Adults: - Most infections: 0.5 1g q 12 hr or 1-2g q 24 hr. - Gonorrhea: 250 mg IM - Meningitis: 2 g q 12 hr Children: Most infections: 25 37.5 mg/kg q 12 hr

Meningitis: 100mg/kg q24 hr or 50 mg/kg q 12 hr

Skin/soft-tissue infections: 50-75 mg/kg q 24hr.

Acute otitis media: 50mg/kg IM single dose

Mode of Action

Interferes with bacterial cell wall synthesis by inhibiting cross-linking of peptidoglycans strands. Peptidoglycan makes the cell membrane rigid and protective. Without it, bacterial cells rupture and die.

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Adverse Reaction

CNS: Chills, fever, headache, seizures CV: Edema EENT: Hearing loss GI: Abdominal cramps, diarrhea, elevated liver function test results, hepatic failure, hepatomegaly, nausea, oral candidiasis, pseudolithasis, pseudomembranous colitis, vomiting GU: Elevated BUN level, nephrotoxicity, renal failure, vaginal candidiasis HEME: Eosinophilia, haemolytic anemia, hypoprothrombinemia, neutropenia, thrombocytopenia, unusual bleeding MS: Arthraglia RESP: Allergic pneumonitis, dyspnea SKIN: Ecchymosis, erythema, erythema multiforme, pruritus, rash, Steven-Jhonson syndrome Other: Anaphylaxis; injection site pain, redness, and swelling; superinfection

Nursing Responsibilities

Use ceftriaxone cautiously in patients who are hypersensitive to penicilins because cross-sensitivity has

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occurred in about 10% of patients. If possible, obtain culture and sensitivity results, as ordered, before giving drug. Protect powder from light. For I.V. use, reconstitute with an appropriate dilutent, such as sterile water for injection or sodium chloride, as follows: for 250-mg vial, add 2.4 ml; for 500-mg vial, add 4.8 ml; for 1-g vial, add 9.6 ml; and for 2-g vial, add 19.2 ml to yield 100 mg/ml. Monitor BUN and serum creatinine levels to detect early signs of nephrotoxicity. Also monitor fluid intake and output; decreasing urine output may indicate nephrotoxicity. Monitor patients for allergic reactions a few days after therapy starts. Assess bowel pattern daily; severe diarrhea may indicate pseudomembranous colitis

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Assess for perineal itching, fever malaise, redness, swelling, rash, and change in cough or sputum; they may indicate a superinfection.

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Nursing Care Plan Name: Errshan Age: 14 days old Date and Time February 10, 2012 4:00pm Subjective: Luya kaayo akong bata kay ingon sa doctor dili normal iyahang kasingkasing as verbalized by her mother A C T I V I T Y E Objectives: -machine-like X E Decreased cardiac output related to altered heart rate/rythm secondary to patent ductus arteriosus Rationale: In a patent ductus arteriosus (PDA) the vessel does not close and remains "patent" resulting in irregular -display hemodynamic - a normal cardiac rate Cues Need Nursing Diagnosis Objectives of care Within our 8 hours span of care, the patient will achieve: 1. Assess patients baseline vital signs. R: to know if there are any deviations 2. Regulate D5IMB 500 to 13cc/hr using infusion pump as ordered R: to prevent cardiac Goal partially met! February 10,2012 11:00 pm The CR of the baby is 164 which is not in a normal range while pulmonary congestion not Date: February 9-10, 2012 Diagnosis: Intervention and Rationale Evaluation

within 120-160 overload 3. Hook to oxygen supply @ 2 L/M via nasal cannula as ordered

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heart murmur -Heart rate = 175bpm - 3 seconds capillary refill --tachypnea noted -decreased urine output (2cc/hr)

R C I S E

transmission of blood between two of the most important arteries close to the heart, the aorta and the pulmonary artery

stability

R: For the patient not to exert further effort to

noted as evidenced by clear lung sounds noted upon

-exhibit improved cardiac output

breathe enough air 4. Placed a pillow in her right side as well as at

her feet to maintain left auscultation of semi-fowlers position R: This reduces preload and ventricular filling thus increasing cardiac output. 5. Instruct the watcher to limit handling of patient and to address patients need immediately when heard crying to avoid The patient was able to exhibit improved cardiac output as evidenced by warm skin; strong bilateral, equal both lung fields.

P A T T E R N

resulting to inadequate blood to meet the metabolic demands of the body.

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stress and fatigue R: Stress and fatigue increase cardiac demands. 6. Watch out for any sign of impending cardiogenic failure/ shock (hypotension, tachycardia, tachypnea) R: early recognition of such symptoms will prompt early treatment. 7. Monitor patients sleeping pattern R: Patients with decreased cardiac

peripheral pulses and adequate urine output of 4cc/hr.

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output are prone to developing restlessness. 8. Interpreted 2D/Echo result R: to monitor cardiac rhythm. 9. Promote scheduled activities and assessments R: to maximize sleep periods 10. Monitor fluid intake and output R: to know the balance of fluids

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Date & Time February 9, 2012 6:00pm

Cues

Need

Diagnosis

Objectives of Care

Intervention

Evaluation

Subjective: Lisod sya magginhawa as verbalized by the mother Objective: 1. Dyspnea shortness of breath noted 2. RR=82 cycles/m with irregular breathing pattern 3. (+) Nasal

A C T I V I T Y

Ineffective breathing pattern related to increased work of breathing secondary to Patent ductus arteriosus Rationale: A patent

Within our 1 hour of nursing the goals be

1. Check and record vital especially respiratory rate. To acquire baseline signs,

February 9, 2012 6:45pm Goal Met! After 1 hour of nursing intervention,

intervention, following would achieved: 1. Optimal breathing pattern of

data for assessing any Patient established an changes condition. of pt.s effective respiratory

pattern and is able to well by as a

2. Assess the rate & breathe depth respiration, of evidenced

patient will be achieved 2. Patients anxiety and discomfort will be relieved

E X E R

ductusarteriosus allows a portion of the oxygenated blood from the left

respiratory rate of 40

breathing pattern, cycles per minute. muscles used for The patient can sleep breathing; then and relax well without

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flaring 4. Respiratory depth changes 5. Irritability and restlessness noted 6. Frequent crying and yawning 7. cyanosis of the lower extremities but not of the upper body

C I S E

heart to flow back to the lungs by flowing from the aorta (which has higher pressure) to the pulmonary artery. If

monitor changes.

for disruption; episodes of crying have decreased.

RR & rhythm changes are early signs of

impending respiratory difficulties. 3. Anticipate need intubation possible mechanical ventilation if the child is unable to maintain adequate gas exchange with the present the for &

P A T T E R N

this shunt is substantial, the neonate becomes short of breath: the additional fluid returning to the lungs increases lung pressure to the point that the neonate has greater difficulty

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inflating the lungs resulting to dyspnea.

breathing pattern. Air hunger can

extremely

produce

anxious state to the infant. 4. Ensure oxygen system appropriately applied child to the before that the

delivery is

administering oxygen if

condition worsens To ensure adequate cellular oxygenation,

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support metabolism,

aerobic and

prevent desaturation. 5. Maintain body

temp. at 36.5C to 37C Temp. < 36.5 may cause pulmonary

vasoconstriction while temp. > 37.5 lead to increased rate & metabolic oxygen

consumption 6. Maintain pt. in

semi-fowlers position

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 to allow diaphragmatic excursion expansion 7. Provide

maximal

and

lung

comfort

to pt. & minimize handling to limit frequency crying. Handling increases of

pulmonary pressure & oxygen demands. 8. Closely during breastfeeding. still If monitor

tachypnic,

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delay

feeding

temporarily. To prevent chocking/ regurgitation. 9. Provide the patient adequate rest and sleep R: to decrease energy expenditure

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Date and Time Feb. 9, 2012

Cues

Needs

Nursing Diagnosis

Objectives

Interventions

Evaluation

Subjective:

N U

Hyperthermia related to inflammatory process/

After 30 minutes of nursing intervention, the patient will

1. Monitor neonates condition. R: To determine the need for intervention and the effectiveness of therapy

Goal met. Feb. 9, 2012 4:30 PM The temperature decreased to 37.2 and skin not warm

Objective: Temp- 38.3 RR-

T R I T I O N A L M

hypermetabolic state -maintain normal core as evidenced by an increase in body temperature, warm skin and tachycardia. temperature as evidenced by vital signs within normal limits -skin not warm to touch Presence of an infectious -able to rest and sleep

4:10 PM

CR-irritability -weakness -skin warm to touch

2. Monitor Vital signs, especially temperature.

to touch. The patient was also

R: To provide comparison with able to rest and current findings. sleep comfortably.

3. Provide tepid sponge bath. R: Helps in lowering down the

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E T A B O L I C

agents stimulates the monocytes that triggers the release of the pyrogenic cytokine. It stimulates the anterior hypothalamus to elevate thermoregulatory set point. Increase in heat conservation also increases the heat production.

temperature.

4. Ensure that all equipment used for infant is sterile, scrupulously clean. Do not share equipment with other infants R: this would prevent the spread of pathogens to the infant from equipment

5. Continue IV fluids while child is drowsy, and when fully awake, encourage PO intake R: Increase fluids intake

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promotes more rapid excretion of the dye.

6. Encourage mother to do small breastfeeding. R: Small breastfeeding will reduce energy expenditure and breastfeeding has IgA.

7. Promote rest and sleep. R: To reduce metabolic demand and oxygen consumption. 8. Remove unnecessary clothing or blanket. R: To promote heat loss.

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104

Date Cues and Time Feb. 10, Objective: 2012 Congenital disorder 3-11 6 PM

Needs

Nursing Diagnosis Risk for delayed development related to congenital disorder.

Objectives

Interventions

Evaluation

A C T I V I T Y E X E R C I S E

After 2 hours of nursing intervention, the patients family will be able to verbalize understanding of Presence condition, therapy of congenital regimen and when to disorder may cause contact health care the person risk for provider. delayed development because it needs further screening, studies and surgical treatment that may affect /delay the normal activity of a person

1.Assess the condition of the patient R:To obtain baseline data 2.Collaborate in multidisciplinary evaluation to assess clients development in ff areas: gross motor, fine motor, cognitive, social /emotional, adaptive and communicative development R:To determine area(s) of need /possible interventions 3.Ascertain nature of caregiver-required activities and abilities to perform needed activities R:To be able to not develop too much dependencies and promote independence 4.Note chronological age and review expectations for normal development at this stage R:To help determine developmental expectations 5:Provide information to the

Goal met Feb 10, 2012 7:30 PM The family was able to verbalize understanding about the infants condition and need of the family to consult other sectors for support.

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family regarding normal development, as appropriate, including pertinent reference materials. R:To help determine developmental expectations 6. Inform family about the possible surgical procedures to be done to correct the disorder. R:Promotes understanding and relief from anxiety 7. Initiate referral to child development expert R: Provides source of assistance to ensure proper age-related development.

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Date and Time

Cues

Needs

Nursing Diagnosis

Objectives

Interventions

Evaluation

Feb. 10, Subjective: 2012 Wala na lagi mi 3-11 6:30 PM kabalo unsay buhaton. . .mahadlok mi basig operahan siya o maunsa ba, as verbalized by the mother.

C O P I N G / S T R E S S

Risk for compromised family coping related to lack of knowledge and situational and developmental crises of family and child.

After 4 hours of nursing intervention, the family will cope more effectively and will understand more about the patients condition. The family should be able to verbalize understanding about

1. Observe erratic behaviors (anger, tension, disorganization), perception of crisis situation. R:Information affecting ability of family to cope with infants cardiac condition.

Goal met Feb. 10, 2012 9 PM The mother was able to verbalize understanding of the infants condition. The

2. Assess usual family coping methods and effectiveness. R: Identifies needs to develop new coping skills if existing methods are ineffective in

mother was also able to recognize the need for further medical treatment. Mao diay

The presence of a congenital heart disease can

the condition.

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T O L E R A N C E

cause compromised coping since the family came from a far-flung area. They lack knowledge about the disease and they might probably develop financial problem because of the procedure to be done to correct the defect.

changing behaviors exhibited.

manglisod siya ug ginhawa. Kinanglan

3. Assess needs for information and support. R: Provides information about need for interventions to relives anxiety and concern.

jud siya operahan dayon, as verbalized by the mother.

4. Encourage expression of feelings and provide factual information about infant. R: Reduces anxiety and enhances family understanding of condition.

5. Provide anticipatory

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guidance for crisis resolution and allow for grieving process. R: Assist family in adapting to situation and developing new coping mechanisms.

6. Suggest and reinforce appropriate coping behaviors, support family decisions. R: Promotes behavior change and adaptation to care of infant.

7. Inform the family about the disease process and behaviors, physical effects, and symptoms

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of condition. R: Relives tension when they know what to expect.

8. Clarify any misinformation and answer questions regarding disease process. R:Prevents unnecessary anxiety resulting from inaccurate knowledge or beliefs

9. Instruct parents in nutritional and activity needs/limitations and approaches what will assist in

110

establishing an effective pattern. R: Assist in coping with effects and special needs of infant with cardiac defect.

10. Refer family for additional support and counseling. R: Referral supplies more assistance with coping than is available from nursing personnel.

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PROGNOSIS Criteria Onset of Illness Poor Fair Good Justification Patient Errshen has a patent ductus arteriosus and sepsis. It was diagnosed 1 week after her birth. Since it was detected in an earlier stage, she received immediate medical care and further complications were prevented. Duration of Illness Since she was diagnosed of having sepsis earlier, chance of healing is greater because of earlier medication treatment. Early diagnosis of patent ductus arteriosus prepared the family for the patients further treatments. Environmental Factors The environment in SPMC is not advisable for our patient since she might get another disease or it may worsen her condition because she has a compromised immune system. Health team provider can also be her stressors because of their frequent visits. Age When we our assessment, she was 14 days old. Her immune system is still weak and
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she is susceptible to other diseases. Also, the surgical procedure that can correct PDA is done between ages 1-3. Since she is just 14 days old, her body is not yet ready for surgery. Family Support The family showed complete concern to the patient. The parents are always there taking care of her and they always make sure to give her their absolute care, love and concern. They are also trying their best to look for financial support for the future treatment. Precipitating Factors Sepsis can be cured because the patient is already undergoing antibiotic regimen but PDA can only be treated only if the patient will reach 1-3 years of age.

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Discharge Plan

Medications

The mother was instructed to continue the prescribed medications by the medical doctor. Since the patient is a neonate, other possible medications, except drops, may be administered through an intravenous fluid in the hospital.

The possible medications ordered by the physician to the patient:

Folic Acid (drops) 0.1 mg/day

Exercise

Regular exercise improves the immune function. Regular exercise causes the kind of development that may be critical for health in later life. Infancy and the toddler years are the time that the brain is developing pathways and connections to the muscles.

Here are some of the suggestions for infants: Infants should be placed in settings that encourage physical activity and do not restrict movement for prolonged periods of time.

114

Parents and caretakers should be aware of the importance of physical activity and encourage the child's movement skills.

Due to the physical limitation of the baby, the parent or caretaker should try to play with childs feet so that he may be able to fully exercise his range of motion.

Treatment

Educate the mother about the importance of drug compliance Instruct the mother to follow the physician and other health care providers advice

Inform the parent to provide a comfortable and safe environment, for the baby, that help in providing comfort and relaxation

Hygiene & Health Teachings

The mother and other care taker of the baby should wash their hands before handling the baby to prevent the child from infections.

Encourage the mother to bond with her baby by cuddling her all the time and meeting the physiological needs of the baby

Instruct the mother to always keep the baby warm and dry Inform the mother of the importance of strictly adhering to the immunization program
115

Instruct the parent to give the medications on time to avoid missing a single dose. Missing a dose will make the medication ineffective. The medication will not be able to achieve its desired effects.

Instruct the parent to continue the medications as prescribed by the physician. The medication will not be able to achieve its desired effects.

Instruct the parent to give the exact amount of medicine that the physician prescribed. Overdosing on a medication may lead to harmful side effects.

Educate the parent about the basic information and the effects of the medication needed. The parents understanding about their childs medicine will induce a stronger medical compliance.

Advise the parent to chart and record doses taken or to have a medicine organizer to avoid confusion.

Teach the parent to keep the medication in proper storage. Keeping medication in proper storage ensures that the medication is still viable to treat illnesses.

Out patient

Instructed the parent to come back at JHCA (OPD) as

116

prescribed by the medical doctor. Inform mother to come immediately to the nearest hospital for any unusualities such as poor feeding, lethargy, persistent vomiting and etc.

Diet

Encourage the mother to breastfeed the baby frequently as needed by the child

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Recommendations

To the family:

We recommend that the family aid and support the patient through everything. They are able to do this by giving emotional and physical support by helping in taking care of the baby. We would like to recommend that they should promote a clean environment in order for the patient to prevent the reoccurrence of an infection. We have also discovered that the parent doesnt know anything about condition of the disease of their baby. They should know more about the disease, so that they will be aware of what has happened to their baby. The family should also comply to the health teachings given by the health care providers.

To the student nurse:

We recommend to the student nurses, who are conducting this case study, to maintain the confidentiality of the patient and his family, so as to respect their privacy. They should also improve their skills on basic nursing procedures to avoid errors. The student nurses should always be aware that when they are regularly conducting case studies, they should learn to improve and develop their analysis, research, knowledge and skills in the field of nursing. They should also learn to appreciate that nursing is not wholly based on skills, but knowledge and information should always be adjacent to it for the accomplishment of the desired aim. We would also like to recommend the group to continue the spirit of teamwork.

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To the Ateneo de Davao University College of Nursing:

We would like to recommend that they would expand their coverage of our duties in the pediatric ward (ex. Gastrointestinal) of Southern Philippines Medical Center, so our knowledge will not be limited and our relevant nursing procedures can be practiced and our skills be enhanced. The school should continue their support for the development of student nurses.

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Bibliography Internet: http://nurseslabs.com/neonatal-sepsis-nursing-care-plans/all/1/ Luxner, K. (2005) Delmars pediatric nursing care plans http://biolab.com hes.ucfsd.org www.emedicine.medscape.com www.clevelandclinic.org http://hes.ucfsd.org/gclaypo/circulatorysys.html http://emedicine.medscape.com/article/978352-overview

Books: M.E. Doenges, M.F. Moorhouse, A.C. Geissler-Murr; Nurses Pocket Guide Diagnoses, Interventions, and Rationales; Ninth Edition, F.A. Davis Company J.H. Deglin, A.H. Vallerand; Davids Drug Guide For Nurses; Ninth Edition, F.A. Davis Company MIMS 2002 F. J. Domino; The 5-minute Clinical Consult 2011 D.K. Guha; Guhas NEONATOLOGY Principles and Practice J.L. Vincent; Intensive Care Medicine The Mindanao Daily Mirror M. William Schwart; Five-minute pediatric consult A.A. Fanaroff, T. Lissauer; Neonatology at a Glance
J. Bautista; Theoretical Foundations in Nursing 120