1. NUR 213 Ventral Septal Defect
Unfolding Case Study
Developed by Benita Beard, MSN, RN
Brenda Stepp, MSN, RN

2. Outcomes for Case Study
Determine current best practice for nursing and collaborative care strategies in the treatment of individuals with ventral septal defect.
Determine pharmacological considerations related to the management of individuals with a ventral septal defect.
Incorporate principles of growth and development, prioritize the plan of care for the family of and the individual with a ventral septal defect.
Determine other physiological and psychosocial concepts and/or exemplars related to ventral septal defect.

3. Outcomes for Case Study
Determine the incidence, etiology, populations at risk, and epidemiology of ventral septal defect.
Determine assessment findings and diagnostic testing related to ventral septal defect.
Review fetal circulation and newborn assessment.
Recognizing cultural diversity, incorporate the nursing process in providing primary, secondary, and tertiary care for, and prevention of, ventral septal defect.

4. What if ? Baby Girl H was admitted to the Well-Baby Nursery at 0742.
Admission Data: Temp: 97.2 ®; Heart Rate:144; Respiratory Rate: 42
Are these normal assessment finding?
What else do you need to know?
Prenatal History
Labor & Delivery History
Weight
CONCEPTS:
Perfusion-
Oxygenation-
Assessment and Critical Thinking/Clinical Decision Making
Thermoregulation-
Communication- do you have what you need to care for this child? (SBAR could be emphasized in practicing giving and/or receiving report.

5. What else do you want to know?
Maternal History: 24 y/o Hispanic female, g2p1, 37 weeks by ultrasound, 2 months prenatal care through local health department, O+, Rubella equivalent, HIV Negative, Negative history for drugs, alcohol, smoking; Group B Strep Negative; Questionable Rubella 8 weeks gestation
Labor History: Delivered vaginally, membranes ruptured X 4hours with clear fluid, 1st stage 12 hours, 45 minutes 2nd stage; no episiotomy or lacerations; Stadol 1 mg administered 2 hours prior to delivery
Other significant information: plans to breast feed; baby bonded for 15 minutes post delivery before transfer to nursery; Father present; speaks limited English but father speaks fluent English
Maternal History:
What, if any thing, in a maternal history might make the newborn/child at risk for problems with perfusion?
Were there any concerns noted with this maternal history? (potential rubella exposure and the effects of rubella on the unborn fetus)
Labor history:
What things in the labor history could be significant findings when looking at perfusion for the newborn?
What other things in the labor history could be significant in stabilization of the newborn?
Other concepts you have addressed here other than perfusion may include but are not limited to:
Assessment
Oxygenation
Thermoregulation and Temperature stabilization?
Effects of maternal medications on the unborn child
Communication
Culture and effects on care of the newborn/family
Infection and Immunity

6. What else do you want to know?
Weight was 6 lb 2 oz: 18 inches
Apgar scores: 7;9
Other assessment findings: Questionable benign murmur noted upon initial assessment; weak cry; color pink with acrocyanosis; Dubowitz 37 weeks; void and stool noted upon admission
Routine meds administered
What other things occur during the admission assessment?
Are there things that you would be concerned about that were determined in this assessment?
How do these things relate to the assessment of perfusion?
Discuss the implications if there are indications of genetic abnormalities.
Compare and contrast assessment findings of a child with a problem with hypoxemia.
Concepts:
Assessment of and admission of the newborn review
Stabilization of the newborn
Health Promotion for initial medications at birth

7. Discharge Data
Discharged at 36 hours of age with both parents and 3 year old brother.
Weight 5 lbs, 11oz
No jaundice noted
To return to pediatrician’s office in AM for weight and color check
What do you want to know before discharging infant?
Review newborn discharge instructions
Could review regression of the three year old?
Concepts of teaching and learning
Family
Growth and development

8. 2 Month Check-Up
Baby Girl H (Maria) was brought to the Pediatrician’s office for her “baby shots”
Weight is 7 lbs 8 oz; T: 97.2 Ax, HR 156, RR 48; Color pale; appears somewhat listless during exam
Immunizations administered
If provided this information, what else do you want to know?
Was the murmur still noted?
What assessment findings might you be concerned with?
Nutritional assessment needs to be completed
What immunizations should be administered?
What developmental milestones should be met at this age?
Concepts possibly related to these findings:
Perfusion
Growth and Development
Health Promotion/immunizations

9. What education/follow-up is indicated based on these assessment findings?
Nutritional Assessment: Maria is breast fed but continually falls asleep during feedings. Maria feeds every four hours for a total of 10 to 15 minutes each feeding. Awakes at least twice during the night to feed.
Bonding: Mother is very attentive, smiles at Maria and talks to her during assessment.
What findings from this assessment should be of concern?
Some the possible related concepts:
Assessment
Mood and Affect
Metabolism and Elimination
Perfusion
Growth and Development
Health Promotion/immunizations

10. Follow-up Weight check in 2 weeks Feedings every two to three hours
Other diagnostics that might be indicated?
What nutritional teaching is indicated?
Pump and put in bottle to determine intake
Assess output
H&Hgb and electrolytes for baseline
Some the possible related concepts:
Assessment
Teaching and Learning
Metabolism and Elimination
Perfusion
Growth and Development
Health Promotion/immunizations

11. 2 week follow-up visit
Weight is 7 lbs 10 oz; T: 97.2 Ax, HR 164 while sleeping, RR 52; Color pale, skin cool and dry except on forehead which is sweaty; sleeps during exam but weak cry noted during lab draws; Murmur present; PaSO2 94%
What do you think is going on?
What assessment finding are of concern?
What might be going on with this infant?
Review the abnormal findings.
Review the assessment findings of CHF for children and compare it with those for an adult?
What diagnostic studies do you think would be indicated?
Some the possible related concepts:
Assessment
Teaching and Learning
Metabolism and Elimination
Perfusion and oxygenation
Growth and Development
Health Promotion/immunizations

12. Diagnostics Ultrasound of heart reveals large Ventral Septal Defect
Labs: Hct 42, HGB 17
Plan is to send to pediatric referral center for Cardiac Catheterization
What do you know about an ultrasound?
What is the prep if any? To whom do you give the prep?
Are the labs normal?
How might they differ, or would they possibly differ, if the child was experiencing a heart condition related to hypoxemia?
What teaching is indicated and to whom is the teaching directed for the cardiac cath?
How would this differ if the child was three? Ten?
Related concepts:
Teaching and Learning
Growth and Development
Perfusion and oxygenation
Legal considerations for minor

13. Care of the Child Undergoing a Cardiac Catheterization
Pre-Procedural management
Post-Procedural management
Discuss the pre-procedural care incorporating teaching to the parents? Consent for treatment.
The actual procedure itself.
You could also look at the stressors of hospitalization here or ask how they might differ for different aged children.
Related concepts:
Teaching and Learning
Growth and Development
Perfusion and oxygenation
Legal considerations for minor

14. Follow-Up Visit with Cardiologist
Assessment Findings: Weight 7 lbs 6 oz; T: Ax, HR 176 while sleeping, RR 58; Color remains pale, skin cool and dry at time of exam; Hard to arouse during exam; Murmur present; PaSO2 93% at rest
What do you think about these assessment findings?
What are the nursing considerations?
Related concepts:
Assessment
Clinical Decision Making
Evidence Based Practice
Teaching and Learning
Growth and Development
Perfusion and oxygenation
Legal considerations for minor

15. Plan of Care for the Child with Heart Failure
Nutritional Management
Medical Management
Other Medical and Nursing Strategies that should be considered in the management of a child with heart failure related to a congenital heart defect
Teaching Needs
This slide is where you pull it all together.
What do we teach a parent/family member/care giver and or the individual related to the nutritional management of heart failure?
How does the compare to the nutritional management of heart failure in an adult?
How would you anticipate the medical management of a child with heart failure might include?
Compare this to that of an adult with heart failure.
You can add more slide if you choose to break these teaching moments up
Spend a lot of time on the medications that will be administered for heart failure.
What are the teaching needs of this and/or other families of children with heart failure?
What are the general teaching needs of this and/or other families of children with a congenital heart defect?
Related concepts:
Caring Interventions
Assessment
Clinical Decision Making
Evidence Based Practice
Teaching and Learning
Growth and Development
Perfusion and oxygenation
Legal considerations for minor