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Estudo de caso: Assistência de Enfermagem ao portador de Transposição de Grandes Vasos

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Estudo de caso: Assistência de Enfermagem ao portador de Transposição de Grandes Vasos

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Estudo de caso: Assistência de Enfermagem ao portador de Transposição de Grandes Vasos

  1. 1. Enfermeira Residente Renata Melo UNIVERSIDADE DE PERNAMBUCO PRONTO SOCORRO CARDIOLÓGICO DE PERNAMBUCO PROFº LUIZ TAVARES PROGRAMA DE ESPECIALIZAÇÃO EM CARDIOLOGIA MODALIDADE RESIDÊNCIA Assistência de enfermagem ao paciente com transposição de grandes artérias - Estudo de caso
  2. 2. Objetivos • Compreender a fisiopatologia da TGA(Transposição de Grandes Artérias),manifestações, diagnóstico e tratamento. • Relatar o caso de um paciente com TGA e associá-lo aos achados na literatura. • Elaborar a SAE(Sistematização da Assistência em Enfermagem), para o paciente em questão, de acordo com suas peculiaridades.
  3. 3. Histórico da TGA • 1797 : Descrito pela primeira vez por Mathew Baillie. • 1875 : Estudo anatômico detalhado e classificação por Rokitansky. • 1976 : Inovação cirúrgica por Jatene.
  4. 4. Epidemiologia: TGA • 1981 – 1989 : estudo epidemiológico Baltimore – Washington, TGA representou 4,2% das malformações cardíacas congênitas. Com prevalência de 2/10.000 nascidos vivos. (Brenner, 1993) • Mais frequente em meninos do que em meninas. (Porto, 2005)
  5. 5. Fisiopatologia: TGA • Principal característica: concordância atrioventricular e discordância ventriculoarterial. • O sangue venoso é bombeado pelo VD para a circulação sistêmica através da aorta, enquanto o sangue venoso pulmonar é ejetado pelo VE na circulação pulmonar. (Fonte: http://www.sbccv.org.br/dccvped/04caso_junho.asp)
  6. 6. Fisiopatologia: TGA • A fisiopatologia varia de acordo com o local e a magnitude entre os dois sistemas circulatórios e o grau de obstrução no circuito pulmonar. Divide-se em três: - TGA com peq comunicações(FO ou PCA). - TGA com grand comunicações (CIA e CIV). - TGA associada a CIV e estenose pulmonar.
  7. 7. Manifestações clínicas: TGA • Duas manifestações clínicas principais: cianose e insuficiência cardíaca. • Ausculta cardíaca: hiperfonese na 1º bulha no FT, e hiperfonese da 2º bulha no FP. • Quando há CIV o sopro é mais audível e intenso na região mesocárdica.
  8. 8. Diagnóstico • Exames laboratoriais: a gasometria demonstra acentuada hipoxemia com evolução para acidemia, nos casos com septo interventricular íntegro. • Eletrocardiograma: vai depender dos defeitos cardíacos associados, porém constantemente observa-se sobrecarga VD. • Rx de tórax: vão depender dos defeitos cardíacos associados e da faixa etária.
  9. 9. Diagnóstico • Ecocardiograma: permite fazer o diagnóstico desta cardiopatia intra-útero. (Fonte: http://www.scielo.br/pdf/abc/v91n4/15.pdf)
  10. 10. Diagnóstico • Cateterismo cardíaco: tem finalidade diagnóstica e terapêutica. • Como medida terapêutica pode-se realizar a septostomia atrial com balão. • Instituída por Blalock em 1950 e aperfeiçoada por Rashkind em 1966.
  11. 11. Tratamento • Não existe tratamento clínico. • Cirurgia de Jatene (F0nte:http://ecgepm.files.wordpress.com/2011/11/jatene.jpg)
  12. 12. ESTUDO DE CASO
  13. 13.  Coleta de dados: Enfermaria de Cardiopatias Congênitas do Pronto-Socorro Cardiológico de Pernambuco - PROCAPE .  Período da coleta: maio/junho, 2013.  Identificação: J.K.P.V.S, 10 meses de vida, sexo masculino, branco, nascido e procedente da cidade de Parnamirim – PE, admitido no dia 13/05/2013.
  14. 14. • História Clínica: Histórico de dispnéia, cianose e irritabilidade, notada com 3 semanas de vida. Na ocasião foi internado com ITR, quando foi evidenciado cardiopatia e encaminhado a um cardiologista. Em janeiro de 2013 foi internado no IMIP, realizado o ecocardiograma, evidenciou DVSVD com CIV restritiva subpulmonar + HAP. • Diagnóstico secundário: desnutrição
  15. 15. Exame físico(antes da cirurgia) • Evolução(dia 20/05/2013) EGR, consciente, irritado, sono prejudicado, cianótico(+++/4+), desidratado(+/4+), afebril(35,5ºC), taquipnéico(Fc~140bpm), tórax abaulado, precórdio dinâmico, emagrecido, baixa acietação da dieta por via oral, abdômen, fíg palpável 3cm do RCD, depressível, indolor a palpação, eliminações presente, evacuação diarréica( 3 episódios durante a noite e um de manhã), diurese presente sem alterações segundo genitora. ACV: RCR em 2T, B2 , SS BEEM. AR: MV presentes com creptos basais em AHT.
  16. 16. Exame físico(após cirurgia) • Evolução(dia 31/05/2013) EG um pouco comprometido, consciente, ativo, reativo, sono preservado, cianótico(+/4+), hidratado, AVC/SCD sem sinais flogísticos, afebril(35,5ºC), taquipnéico(Fc~150bpm), em uso de cateter de O2 contínuo, emagrecido, dieta por SNG em BI, abdômen, fíg palpável 3cm do RCD, depressível, indolor a palpação, eliminações, evacuação ausente há 2 dias, diurese presente sem alterações. ACV: RCR em 2T, BNF, s/s. AR: MV presentes com creptos em BHE.
  17. 17. Exames complementares • Rx de tórax 25/05/2013 (antes da cirurgia)
  18. 18. Exames complementares • Rx de tórax 03/06/2013 (depois da cirurgia)
  19. 19. Exames complementares • Exames laboratoriais(13/05/2013)(antes da cirurgia) Resultados Referências Eritrócito 8,79 x 10^6/uL [4,5 – 6,10]10^6/uL Hemoglobina 19,2g/dl [12,8 - 17,8] g/dl Hematócrito 65,5% [40 – 54] % Leucócitos 9,22 10^3/uL [4 – 11] 10^3/uL Plaquetas 150,00 10^3/uL [150 – 450] 10^3/uL Uréia 38,8mg/dl [10 – 50]mg/dl Creatinina 0,23mg/dl [0,17 - 0,42]mg/dl
  20. 20. Exames complementares • Ecocardiografia TT(14/05/2013)(antes da cirurgia) VE: aumento de grau leve. AE: aumentado de grau moderado. AD: aumento de grau moderado(septo abauladopara o AE). VD: dimensões normais. Aorta: ascendente com calibre normal. Valva aórtica e mitral: textura e mobilidades normais. Artéria pulmonar: dilatação moderada com refluxo pulmonar de grau leve. Conclusão: TGA com pequena CIV muscular de via de saída + HAP.
  21. 21. Exames complementares • Ecocardiografia TT(04/06/2013)(depois da cirurgia) VE: sem alterações. AE: dimensões normais. AD e VD: levemente diminuído?? Aorta: anterior à AP, com calibre normal. Valva aórtica e mitral: sem alterações. Artéria pulmonar: posterior Conclusão: TGA com pequena CIV muscular com shunt VD/VE. Cerclagem de AP com gradiente sistólico máximoVE/AP= 40 mmHg.
  22. 22. Exames complementares • ECG
  23. 23. Medicamentos em uso(31/05/2013) • Cefazolina 1g+AD > 1,5ml IV de 8/8h • Mupirocina pomada em vestíbulo nasal 3x dia • Furosemida >0,2ml IV de 12/12h • Vit K (10mg/ml) > 0,5ml+9,5ml AD IV 24/24h • NBZ c/ berotec 5 gts + SF à 0,9% > 3ml +O2- 6l/min
  24. 24. SAE • Diagnóstico de Enfermagem 1. Atraso no crescimento e desenvolvimento relacionado a capacidade física comprometida e dependência a defeitos cardíaco congênito, evidenciado emagrecimento acentuado para a idade. • Intervenções de Enfermagem Proporcionar períodos de repouso antes da alimentação. Observar interação mãe-filho durante a alimentação. Observar aceitação da dieta por VO ou por SNG.
  25. 25. SAE • Diagnóstico de Enfermagem 2. Risco de infecção relacionado a procedimentos invasivos, evidenciado por AVC, AVP e cirurgia. • Intervenções de Enfermagem Verificar temperatura a cada 6h. Avaliar a FO a cada 24h e registrar alterações. Usar técnica asséptica ao realizar curativos. Administrar antibiótico dentro de 15min do horário estabelecido.
  26. 26. SAE • Diagnóstico de Enfermagem 3. Padrão respiratório ineficaz relacionado a cardiopatia, evidenciado por taquipinéia. • Intervenções de Enfermagem Verificar e registrar SSVV a cada 6h. Observar nível de reatividade do bebê. Monitorar Sat de O2 regularmente. Observar mudança de padrão respiratório.
  27. 27. SAE • Diagnóstico de Enfermagem 4. Perfusão tissular ineficaz relacionado a distúrbios vasculares, evidenciado por cianose central e periférica. • Intervenções de Enfermagem Investigar os fatores causadores. Manter paciente aquecido. Monitorizar Sat de O2 regularmente. Oferecer O2 quando necessário.
  28. 28. Referências • Porto, C.C. Doenças do coração - prevenção e tratamento. 2 ed. Rio de Janeiro: Guanabara Koogan, 2005. • Estudo de caso, retirado do endereço eletrônicohttp://www.sbccv.org.br/dccvped/04caso_junho.asp . Data 10/06/2013. • Artigo retirado do endereço eletrônicohttp://www.scielo.br/pdf/abc/v91n4/15.pdf , no dia 10/06/2013. • Thaler, M.S. ECG essencial: Eletrocardiograma na prática clínica. São Paulo: Atheneu, 2009.
  29. 29. OBRIGADA!

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