CASE STUDY 1

CEYAN PEACHES S. GARANCHON BSN2E

Objectives:
This presentation aims to:
1.Present the patient’s profile, including the patient’s history, to
determine the nature of underlying problems.
2.Discuss the normal findings of physical assessment.
4.Understand the disease pathophysiology and etiology of the
case being presented.
5.Understand the role of drug therapy in managing the client in
relation to the diagnosis.
6.Present data in relation to the case.
7.Effectively provide appropriate nursing diagnosis with regards to
client’s condition and develop a nursing care plan for the identified
problem.
8.Apply effective nursing interventions which are necessary for
the client’s condition.

ACTUAL NURSING DIAGNOSIS:

-severe central cyanosis caused by several congenital heart problems after birth and suffered
from respiratory distressas evidenced by the report where his initial SaO2 was only about 70%.
And on appearance, he was dusky-looking and his peripheries were cold and cyanosed.

Patient’s Profile:
Patient's name: Baby J Age: 3 week old Sex: Male Birthday: Not indicated

Address: Lopez Jaena St. Jaro, Iloilo City

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Room No: ER 110 Diet:feeding via TPN and was given 6ml of EBM

Religion:Not Indicated Physician: Dr. Cortez

Chief Complaint: initial SaO2 was only about 70%. dusky-looking and his peripheries were
cold and cyanosed.

Admitting diagnosis:severe central cyanosis caused by several congenital heart

problems

Nursing History: Present Medical

History
Baby J, a 3-week-old infant, was admitted to Ward 5A since birth due to severe central cyanosis
caused by several congenital heart problems. Soon after birth, he suffered from respiratory
distress, where his initial SaO2 was only about 70%. He was resuscitated and given 5
nanograms/kg/min of Prostin (Prostaglandin E2). On appearance, he was dusky-looking and his
peripheries were cold and cyanosed. Antenatal scans found pulmonary atresia, overriding aorta
and ventricular septal defect (VSD). Postnatally, cardiac catheterisation confirmed the antenatal
findings with extra major aortopulmonary collateral arteries (MAPCAs).

Nursing History: Past Medical History

Not indicated
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Physical Assessment
General Appearance:
Client’s admission assessment reveals:

-Not distressed or in pain.

-Alert and non-lethargic.

-Apyrexial (Temperature – 37.1 0C)

-Mild bluish discolouration of lips and tongue

HEENT(HEAD, EYES, EARS, NOSE, THROAT):

Deep-set eyes, prominent forehead (features of Alagille’s syndrome)

Non-pallor conjunctiva

Mild central cyanosis (bluish tinge to tongue)

Parameter

Temperature 37.1 0C

Heart Rate 156 bpm

Respiratory Rate 48/min

Sa02 83% on room air.

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Pathophysiology

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DRUG: furosemide

Mechanism of Drug Indication Drug Contraindications Adverse Effects

action

Furosemide inhibits The Food and Drug Furosemide is contraindicated in ● Urinary

patients with known
tubular Administration hypersensitivity to this drug. Frequency
reabsorption of (FDA) has Frusemide is contraindicated in
sodium and chloride approved anuria. Although, it can be used ● Dryness
in the proximal and furosemide to treat in renal insufficiency, any ● Muscle
marked increase in blood urea
distal tubules and conditions with Pain/Cramps
nitrogen or creatinine, or the
the thick ascending volume overload development of oliguria during ● Dizziness
loop of Henle by and edema therapy of patients with
inhibiting the secondary to progressive renal disease, is an ● Fatigue
sodium-chloride congestive heart indication for discontinuation of ● Electrolyte
cotransport system failure treatment.
Problems.
resulting in exacerbation, liver
excessive excretion failure, or renal
of water along with failure, including
sodium, chloride, nephrotic
magnesium, and syndrome.
calcium
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DRUG:Digoxin

Mechanism Of action Drug Indication Drug Contraindication

Adverse effects

it can be harmful for the next

. Digoxin helps by Digoxin also has
depending on other health mild and include nausea,
interfering with the the ability to affect vomiting, and anorexia.
conditions and drugs taken.
action of the the amount of Visual side effects might
sodium-potassium fluids in the body If you are taking any of a include color changes,
pump. This leads and so it is very wide variety of drugs for also known as
to an increase of useful in treating heart problems, antibiotics,
xanthopsia. But yellow
sodium inside the heart failure, which or green-tinted vision is
HIV drugs, or NSAIDS, then
usually associated with
cell. When sodium is when the heart these can prevent you from digoxin toxicity. Patients
within the cell doesn't function getting the full benefit of may also highlight
increases, another well enough to taking digoxin. These blurry vision or
electrolyte mover meet the demands categories of drugs cause an photopsia. At toxic
pushes the excess of the body. When increase in the amount of levels, digoxin is
sodium out of the this happens, fluid digoxin in your system and proarrhythmic. An
cell. This then builds up in the that can have harmful,
impaired ventricle is
more prone to
pushes calcium body and can begin adverse effects on your heart
ventricular
into of the cell, to surround the and body. tachyarrhythmias and
leading to heart heart which further ectopy. Abnormally high
Being on atorvastatin,
muscle prevents it from digoxin levels stimulate
cyclosporine, nilotinib,
contractions. functioning well. atrial activation, thus
itraconazole, nefazodone, atrial tachycardias,
Digoxin helps from
both angles of
tolvaptan, quinine, and which, in a patient on
ranolazine will also increase digoxin, is highly
heart function and suggestive of toxicity.
the amount of digoxin in the
reducing fluid. These atrial
bloodstream and may cause
your heart rate to become too
tachycardias are
persistent and resolve
slow or blood pressure to
with a decrease in serum
drop too low.
digoxin levels.
Digoxin is also Other common side
contraindicated if you are effects include:
taking stimulant drugs, such
as epinephrine or
● Rash
norepinephrine, or
● Headache
succinylcholine. Combining
● Gynecomastia
these drugs in your body can ● Weakness
cause you to have an
irregular heartbeat. That, of
course, would defeat the
whole reason why you are
taking digoxin to begin with.
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