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Nursing Assessment
Obtain a thorough nursing history.
Discuss the care plan with the health care team (cardiologist, cardiac surgeon,
nursing case manager, social worker, nutritionist). Discuss the care plan with the
patient, parents, and other caregivers.
Measure and record height and weight. Plot on a growth chart.
Record vital signs and oygen saturations.
o Measure vital signs at a time when the in!ant"child is #uiet.
o $hoose appropriate%si&e blood pressure ('P) cu!!.
o $heck !our etremity 'P () *.
+ssess and record,
o -kin color, pink, cyanotic, mottled.
o Mucous membranes, moist, dry, cyanotic.
o .tremities, check peripheral pulses !or #uality and symmetry/ dependent
edema/ capillary re!ill/ color and temperature.
+ssess !or clubbing (cyanotic heart disease).
+ssess chest wall !or de!ormities/ prominent precordial activity.
+ssess respiratory pattern.
o 'e!ore disturbing the child, stand back and count the respiratory rate.
o 0oosen or remove clothing to directly observe chest movement.
o +ssess !or signs o! respiratory distress, increased respiratory rate,
grunting, retractions, nasal !laring.
o +uscultate !or crackles, whee&ing, congestion, stridor.
+ssess heart sounds.
o Determine rate (bradycardia, tachycardia, or normal !or age) and rhythm
(regular or irregular).
o 1denti!y murmur (type, location, and grade).
+ssess !luid status.
o Daily weights.
o -trict intake and output (number o! wet diapers/ urine output).
+ssess and record the child2s level o! activity.
o Observe the in!ant while !eeding. Does the in!ant need !re#uent breaks or
does he or she !all asleep during !eeding3 +ssess !or sweating, color
change, or respiratory distress while !eeding.
o Observe the child at play. 1s play interrupted to rest3 +sk the parent i! the
child keeps up with peers while at play.
o +ssess and record !indings relevant to the child2s developmental level,
age%appropriate behavior, cognitive skills, gross and !ine motor skills.
Nursing Diagnoses
1mpaired 4as .change related to altered pulmonary blood !low or pulmonary
Decreased $ardiac Output related to decreased myocardial !unction
+ctivity 1ntolerance related to hypoia or decreased myocardial !unction
1mbalanced 5utrition, 0ess 6han 'ody Re#uirements related to ecessive energy
demands re#uired by increased cardiac workload
Risk !or 1n!ection related to chronic illness
7ear and +niety related to li!e%threatening illness
Nursing Interventions
Relieving Respirator Distress
Position the child in a reclining, semi%upright position.
-uction oral and nasal secretions as needed.
1denti!y target oygen saturations and administer oygen as prescribed.
+dminister prescribed medications and document response to medications
(improved, no change, or worsening respiratory status).
o Diuretics.
o 'ronchodilators.
May need to change oral !eedings to nasogastric !eedings because o! increased
risk o! aspiration with respiratory distress.
Improving Car!ia" Output
Organi&e nursing care and medication schedule to provide periods o!
uninterrupted rest.
Provide play or educational activities that can be done in bed with minimal
Maintain normothermia.
+dminister medications as prescribed.
o Diuretics (!urosemide, spironolactone),
4ive the medication at the same time each day. 7or older children,
do not give a dose right be!ore bedtime.
Monitor the e!!ectiveness o! the dose, measure and record urine
o Digoin,
$heck heart rate !or * minute. 8ithhold the dose and noti!y the
physician !or bradycardia (heart rate less than 9: beats"minute
0ead 11 rhythm strip may be ordered !or PR interval monitoring.
Prolonged PR interval indicates !irst%degree heart block (dose o!
digoin may be withheld).
4ive medication at the same time each day. 7or in!ants and
children, digoin is usually divided and given twice per day.
Monitor serum electrolytes. 1ncreased incidence o! digoin toicity
associated with hypokalemia.
o +!terload%reducing medications (captopril, enalapril),
8hen initiating medication !or the !irst time, check 'P
immediately be!ore and * hour a!ter dose.
Monitor !or signs o! hypotension, syncope, light%headedness, !aint
8ithhold medication and noti!y the physician according to ordered
Improving O#genation an! A"tivit Toleran"e
Place pulse oimeter probe (continuous monitoring or measure with vital signs)
on !inger, earlobe, or toe.
+dminister oygen as needed.
6itrate amount o! oygen to reach target oygen saturations.
+ssess response to oygen therapy, increase in baseline oygen saturations,
improved work o! breathing, and change in patient com!ort.
.plain to the child how oygen will help. 1! possible, give the child the choice
!or !ace mask oygen or nasal cannula oygen.
$rovi!ing A!e%uate Nutrition
7or the in!ant,
o -mall, !re#uent !eedings.
o 7orti!ied !ormula or breast milk (up to =: cal"o&).
o 0imit oral !eeding time to *> to ?: minutes.
o -upplement oral !eeds with nasogastric !eedings as needed to provide
weight gain (ie, continuous nasogastric !eedings at night with ad%lib by%
mouth !eeds during the day).
7or the child,
o -mall, !re#uent meals.
o @igh%calorie, nutritional supplements.
o Determine child2s likes and dislikes and plan meals accordingly.
o +llow the parents to bring the child2s !avorite !oods to the hospital.
Report !eeding intolerance, nausea, vomiting, diarrhea.
Document daily weight (same time o! day, same scale, same clothing).
Record accurate inputs and outputs/ assess !or !luid retention.
7luid restriction not usually needed !or children/ manage ecess !luid with
$reventing In&e"tion
Maintain routine childhood immuni&ation schedule. 8ith the eception o! R-A
(-ynagis) and in!luen&a, immuni&ations should not be given !or B weeks a!ter
cardiovascular surgery.
+dminister yearly in!luen&a vaccine.
+dminister R-A immuni&ation !or children younger than age ? with comple
$@D and those at risk !or $@7 or pulmonary hypertension.
Prevent eposure to communicable diseases.
4ood hand washing.
Report !evers.
Report signs o! CR1, runny nose, cough, increase in nasal secretions.
Report signs o! 41 illness, diarrhea, abdominal pain, irritability.
Re!u"ing Fear an! An#iet
.ducate the patient and !amily.
Provide the !amily with contact phone numbers, how to schedule a !ollow%up
visit/ how to reach a cardiologist during the work week, evenings, weekends, and
Famil E!u"ation an! Healt' (aintenan"e
1nstruct the !amily in necessary measures to maintain the child2s health,
o $omplete immuni&ation.
o +de#uate diet and rest.
o Prevention and control o! in!ections.
o Regular medical and dental checkups. 6he child should be protected
against in!ective endocarditis when undergoing certain dental procedures.
o Regular cardiac checkups.
6each the !amily about the de!ect and its treatment.
o Provide patients and !amilies with written and verbal in!ormation
regarding the $@D. O!!er appropriate 1nternet resources !or in!ormation
about $@D and medical and surgical treatment options.
o -igns and symptoms o! $@7 (see page *DEE).
o -igns o! hypercyanotic spells associated with cyanotic de!ects and need to
place child in knee%chest position.
o 5eed to prevent dehydration, which increases risk o! thrombotic
o .mergency precautions related to hypercyanotic spells, pulmonary edema,
cardiac arrest (i! appropriate).
o -pecial home care e#uipment, monitors, oygen.
.ncourage the parents and other people (teachers, peers) to treat the child in as
normal a manner as possible.
o +void overprotection and overindulgence.
o +void reFection.
o Promote growth and development with modi!ications. 7acilitate
per!ormance o! the usual developmental tasks within the limits o! the
child2s physiologic state.
o Prevent adults !rom proFecting their !ears and anieties onto the child.
o @elp !amily deal with its anger, guilt, and concerns related to the disabled
1nitiate a community health nursing re!erral i! indicated.
-tress the need !or !ollow%up care.
.ncourage attendance in support groups !or patients and !amilies.
Evaluation) E#pe"te! Out"omes
1mproved oygenation evidenced by easy, com!ortable respirations
1mproved cardiac output demonstrated by stable vital signs, ade#uate peripheral
per!usion, and ade#uate urine output
1ncreased activity level
Maimal nutritional status demonstrated by weight gain and increase in growth
curve percentile
5o signs or symptoms o! in!ection
Parents discuss diagnosis and treatment together and with child