Case Study E3

Question 1

Like many infants with VSD the defect was not picked up at birth but noticed at 2 month well child check, how would you explain that to his father?

Question 3

Pertinent assessment and H/P findings of VSD infant at 6 months

Question 4

Mom of VSD pt is happy with weight upon admission, upon further questioning you find it is 8 oz heavier than morning weight at the office what is your response?

Question 5

6MO Infant with VSD admitted and treated with Dig, Lasix and Aldactone. On Oxygen and lethargic with poor suck r/t feedings. What methods (feeding, positioning, temperature) can be used to minimize cardiac workload?

Question 6

Infant with VSD what lab findings would be concerning [Normal K+ = 3.5-5.0 mEq/L & Therapeutic Dig = 0.8-1.5 mcg/L]
a. K+ = 6.0 & Dig 0.4 mcg/L
b. K+ = 3.0 & Dig = 2.6 mcg/L

Question 7

Infant admitted with VSD uninterested in eating and vomiting
Vitals: 98.6, HR 84 Irregular Resp 32 what are your concerns?

Question 8

Pre-Cath VSD: NPO with IV and teaching is done. What history is significant when preparing him for cath?

Question 9

6 MO Infant VSD: Physical assessments important to preparing for cath?

Question 10

Infant 6 MO: Morning of cath pt is NPO and IV started no specific order r/t usual AM medications (dig, lasix, aldactone) What are the priority actions?

Question 11

6 MO Infant VSD: Complications monitoring for post cath

Question 12

Temp 100.5°Fax, pulse 150, resp 36 with no distress, BP 91/53. Oximeter 94% with oxygen. He has a pressure dressing in his right groin with a small amount of old blood. Left leg: pale pink, warm with +1-2 pulses and 2 second capillary refill. Right leg: pale, cool with +1 pulses and 3 second capillary refill. Lungs clear. Cardiac murmur unchanged. Blood sugar is 80. IV intact and infusing. What are your concerns and what do you do?

Question 13

6MO infant VSD: Nursing care needed following cardiac cath

Question 14

6 MO VSD: What immunizations recommended to prevent bronchiolitis

Question 15

Priority treatments for a TET spell?

Question 16

What should be done to prevent TET spell?

Question 17

Possible causes of TET spell?

Question 18

What assessments are associated with Tetralogy of Fallot (without a TET spell)

Question 19

Once a “TET” spell has resolved, further assessment reveals dry mucus membranes, sunken eyeballs, depressed anterior fontanel, poor skin turgor with tenting and lethargy. What are your concerns? What is the treatment?

Cont 2: Temp 101.5, concerns and treatment

Cont 3: Labs Drawn Hct 65% (35-45%) WBC 22,000 (5-19.5 x 1000) ESR 45 (0-15 mm/hr) Concerns

Question 20

TET spell then diagnosed with bacterial endocarditis
* Change in his murmur
* Thin black lines under his nails (splinter hemorrhages)
* Small red-purple, slightly raised lumps with a pale center on the tips of his fingers and toes that appear painful (Osler nodes)
* Nontender, irregular shaped bluish areas on palms and soles of feet (Janeway lesions)
* Petechiae on his oral mucosa
a. Significance of following findings
b. Likely treatment
c. Future episodes be prevented

Question 21

Significant H/P findings for diagnosis of coarctation of the aorta in teen vs infant

Question 22

Why did it take so long for the teens coarctation of the aorta to be diagnosed? What assessments could have picked it up earlier?

Question 23

Treatment plans for coarctation in teen and infant

Question 24

What symptoms would alert an OB nurse to a possible cardiac anomaly?

Answer 24

Dusky, sweating, feedings difficult or continues to get worse

Question 25

15 MO admitted in acute stage of Kawasaki Disease what is the significant history?

Answer 25

Fever, rash, cervical lymph node enlargement, conjunctiva (no drainage), strawberry tongue, antibiotics not working and tylenol not working for fever

Question 26

15 mo admitted with Kawasaki Disease, significant physical assessment findings

Answer 26

Temp: 102 (38.8)
Erythematous rash, hands/feet edematous, mucous membranes erythematous, tonsils red/enlarged
Conjunctivae infected without discharge
!Strawberry Tongue!

Question 27

Significant lab findings with Kawasaki disease

Answer 27

Acute: WBC >20,000, increased CRP+ESR, increased platelets (around day 7)
Subacute: Plts 600,000 - 2 million, EKG and echo changes
Convalescent: plts normal and echo normal

Question 28

15 mo admitted with Kawasaki - During your 8am morning assessment includes the following: Temp 100.8F ax, P 180, R 36 with cry, unable to obtain BP. Dry diaper; last void of 60ml at 2000. Has periorbital and scrotal edema. Daily weight shows 1 kg increase; respirations appear labored with cry

What are your concerns? Likely treatment?

Answer 28

Cardiac complications: Coronary artery aneurysm (damage and weakness) coronary artery stenosis (scarring) coronary thrombosis (platelets) As well as rhythm problems, CHF and MI
Treatment: IVIG over 10-12 hours, ASA (high dose until fever break then low until symptoms resolve)
Echos: at Baseline, 1 week and 4-6 wks plus every 8 weeks until resolved
If cardiac complications continue then patient is put on anticoagulation therapy (asa, plavix, lovenox, warfarin)

Question 29

While administering the IVIG, you note a developing rash: red irregularly shaped wheals that are elevated, some with a blanched center over his body. The rash seems to be itchy.

What are your concerns? What will you do first? What will you be monitoring?

Answer 29

Allergic reaction to IVIG, STOP infusion
Keep site open with NS
Pt going on Benadryl, Tylenol and steroids - will still have to get IVIG but slower, continue to monitor for other signs of reaction

Question 30

Infant 15 mo with Kawasakis discharged. You find out shortly before getting sick he visited a cousin who has chicken pox, what are your concerns?

Answer 30

No immunized against chicken pox - so at risk
Risk for developing Reye syndrome r/t ASA and current viral infection

Question 31

Two weeks after Kawasakis onset: afebrile and irritable, rash on trunk, hands and feet beginning to peel, Plts over 1,000,000
Echo showed mild left ventricular enlargement w/ no coronary artery dilation
Is this what you would expect?

Answer 31

Yes, he is in the subacute stage of the disease
- Resolving fever, still irritable, feeling fingers/toes, arthritis, highest risk for cardiac complications

Question 32

Kawasakis 2 mo after onset: Asymptomatic plts 505000, echo normal
1 yr after onset asymptomatic + no sequelae. Is this what you would expect?

Answer 32

Yes, convalescent stage then resolved
Concalescent: resolving symptoms > 21 days
Resolved: When labs and echo are normal

Question 33

17 mo w/ hx of kawasaki’s follow up with pediatrician, what would the possible immunization schedule be? Why?

Answer 33

He missed MMR and Varicella at 6 mo because they are live and he had IVIG
Do not give live viruses for 11 months

Question 34

Besides antibiotics what is the treatment for Scarlet Fever on the first visit

Answer 34

Acetaminophen (pain/fever) salt water gargling or throat lozenges, bland diet, encourage fluids and rest

Question 35

School nurse is concerned when a student comes back to visit again. She has a previous strep infection. What are you monitoring for and what are your next steps?

Answer 35

Rheumatic fever: Evidence of previous strep infection + FEVER and 4 of the 5
1. Carditis
2. Polyarthritis
3. Chorea
4. Erythema marginatum
5. Subcutaneous nodules
Next: Cant send her back to class, call parents to pick her up

Question 36

Patient is hospitalized for RH with CHF complications, what is the purpose of the following orders, and what concerns do you have?
Orders: Bedrest, IV at KO, Lasix PO, Digoxin PO, Penicillin G IV po x 10 days, ASA po, Prednisone IV, Chest XR, EKG, Echo

Answer 36

Bedrest: pt in CHF - rest and get carditis under control
IV at KO: potential for fluid overload
Lasix PO: treat CHF (get rid of excess fluid)
Digoxin PO: CHF treatment
Penicillin G IV po x 10 days: pt was not treated for strep, want to irradiate any possible infections
ASA PO: for the polyarthritis
Prednisone IV: treats carditis (decreases inflammation)
Chest XR, EKG, Echo

Question 37

Pt with rheumatic fever is on prophylactic antibiotics, for how long and what pt education is important regarding treatment

Answer 37

Pt will be on ABX 5-10 years or until 21. If pt gets strep infection it could affect the heart and that damage does not go away

Question 38

What interventions are put into place for a child after they are hospitalized with rheumatic fever and going back to school? What other concerns do you have for her?

Answer 38

Since she had CHF so she should have gym restrictions, lifting restrictions and may need to use an elevator.
If strep goes around she needs to be monitored for a sore throat and get a screen for strep.

Question 39

What are the common H/P findings related to chronic anemia. What are his risks for infection?

Question 40

What are the symptoms of a vaso-occlusive crisis? What circumstances can cause these?

Question 41

What are the purpose of these orders listed for a patient admitted with a vaso-occlusive crisis
Activity as tolerated, IV bolus of 250 mL