This document discusses congenital heart disease, specifically focusing on a 9-year-old female patient diagnosed with tetralogy of Fallot, a cyanotic congenital heart defect. It details the patient's medical history, current condition, and ongoing diagnostic work-ups, including nursing care and treatment plan considerations. The document aims to educate healthcare professionals on managing such cases and emphasizes the importance of family support and self-reliance in patient health management.

1. INTRODUCTION
“You can never be wrong when you think of your patient”
-Rabj
Our heart plays an important role in our body. It has four chambers, muscular organ that
functions as a powerful pump. It continuously pumps blood through the body’s extensive network of
arteries and veins. This circulation of blood delivers oxygen and nutrients to the body while removing
waste products.
Congenital heart disease is a type of defect or malformation in one or more structures of the
heart or blood vessels that occurs before birth. Many heart defects and common health condition such
as heart disease occur as a result of interactions of multiple gene mutations and environmental
influences.
These defects occur while the fetus is developing in the uterus and affect 8-10 out of every
1,000 children. Congenital heart defects may produce symptoms at birth, during childhood, and
sometimes not until adulthood. About 500,000 adults in the U.S. have congenital heart disease
(http://www.webmd.com/heart-disease/guide/congenital-heart-disease?page=2).
According to the Mortality Country Fact Sheet of the year 2006, the top 4 causes of death in
children are congenital anomalies. It covers about 8% out of 100% total percentage of deaths among
children in both national and local areas. (www.who.international.mortality.philippines.com)
Patient X is a 9 year old, female, who was diagnosed with congenital heart defect, cyanotic to
consider tetralogy of fallot. It defined as defects with decrease pulmonary blood flow. It is a form of
congenital heart defect which includes four abnormalities – narrowing of the pulmonary artery, a septal
defect between the ventricles, hypertrophy of the right ventricles and displacement of the aorta to the
right. The condition results in deficient oxygenation of the blood with cyanosis, dyspnea, polycythemia,
clubbing of the fingers.
We choose this as the prime proponent of this case presentation primarily because the content
of this presentation tackles about the condition of the patient whose the course of the disease, its
management of both medical and nursing interventions and as well as pertinent health teachings which
the group find the case as medium for continuing professional learning. Nevertheless it serves as a tool
not only for the betterment of the patient and her family but also for us nurses to be able to learn more
about the realms of medical-surgical nursing its importance and implications.
As a member of the health team- we should be the one that drives the family and with the
patient itself to empower them to become more self reliant with their own health.

2. OBJECTIVES
Discuss congenital heart defect;
present the medical interventions done to the patient;
identify needs of the patient and formulate a nursing care plan for each;
itemize the various drugs under the patient’s treatment regimen with information relevant to
the patient’s condition;
determine the prognosis of the patient with the following criteria: duration of illness, onset,
precipitating factors, willingness to take medications, age, environment, and family support;
and, state the general prognosis of the patient and;
formulate health teachings to the mother of our client regarding the continuity of treatment.

3. PATIENT’S PROFILE
Name: Heart
Age: 9 years old
Address: Florida, Kapalong, Davao del Norte
Civil Status: Single
Father’s Name: Superior Vena Cava
Mother’s Name: Inferior Vena Cava
Occupation: Father: Farmer
Mother: Housewife
Date of Birth: February 23, 2001
Admission Date/Time: May 28, 2010/ 3:45 pm
Attending Physician: Dr. Gemma Maranian
Diagnosis: Congenital heart defect, cyanotic type t/c TOF

4. PHYSICAL ASSESSMENT
General Survey
Upon seeing the patient, she has an ectomorphic body built. She has an IVF of D5LR 1 liter at
108 cc/hr infusing well at right metalcarpal vein at 650 level and hooked to oxygen inhalation at 2 lpm
via nasal cannula and was placed on a high back rest, she has difficulty in breathing and has a capillary
refill time of 3 seconds. She has a foley catheter attached to uro bag draining to 100cc level with amber
yellow color urine. The patient is on diet as tolerated with strict aspiration precaution.
Vital Signs
Temp – 38.9°C
PR- 120 bpm
RR- 38 cpm
CR- 120 bpm
BP – 90/60 mmHg
Skin
She has a darker skin complexion and is evenly distributed. Skin is dry and warm to touch.
Clubbing of finger nails noted with bluish discoloration of nailbeds on both upper and lower
extremitiesm with untimmed and dirty finger nails. She has some round scars on both legs.
Head
Hair is black, long and evenly distributed, no infestations noted upon inspection. Head is
normocephalic with no abnormalities noted.
Eyes
Eyes are symmetrical and are aligned at the upper pinnea of the ear. Iris is color brown and
pupils are equally rounded and are reactive to light accommodation with a diameter of 2 mm. No
lesions or discharges noted upon assessment.

5. Ears
Ears are symmetrical and are aligned at the outer canthus of the eye. Eardrums are intact with
cerumen noted upon inspection. No lesions, discharges or abnormalities noted.
Nose
Nasal flaring noted. No lesions or discharges noted upon inspection.
Neck and Throat
Patient was able to swallow without any difficulty. Use of accessory muscle was noted. Neck was
able to flex from front to back and side to side without any discomfort. Upon palpation of the neck, no
mass was noted.
Mouth
Lips have bluish discoloration with dry mucous membranes and dry tongue. No lesions or
abnormalities noted.
Chest
Chest is slightly barrel chest with right side of the chest enlarged, with AP diameter of 2:1. Apex
of the heart is at the 4-5th midclavicular line. With clear breath sounds noted with use of accessory
muscles noted.
Abdomen
The abdomen is flat and brown in skin color. Bowel sounds were heard upon auscultation with 5
bowel sounds per minute. No lesions noted upon inspection.
Genito-Urinary
Patient was on folely catheter attached to urobag at 100 cc level with amber yellow colored
urine. No lesions or abnormalities noted.

6. MEDICAL HEALTH HISTORY
PAST MEDICAL HISTORY
Perinatal
Prenatal check – up was started at the 5th month of pregnancy. Tetanus toxoid 1 was given. The
mother was febrile during the 3rd month of pregnancy. The mother did not consult a physician and there
were no medications taken. Her mother gave birth at home full term via normal spontaneous vaginal
delivery assisted by a hilot on the moonlit night of February 23, 2001. The baby presented poor and
delayed crying with cyanosis.
Past Medical Illness
Her mother noted that at 1 year of age, the patient had an episode of syncope, (-) colds and (+)
cough for one month which led to her admission to a local hospital and then was referred to Davao
Regional Hospital where she was diagnosed with Congenital Heart Disease. 2D Echo was done where it
was found out that the patient had a hole in the heart. Surgical management was advised but not
heeded due to lack of financial resources. She was then discharged with a home medication of
spironolactone (Aldactone) but the patient did not comply. Due to poor compliance to the medication
and advised surgical management, her condition did not alleviate and she experienced on and off
dyspnea, orthopnea and occasional congestion.
Growth and Development
During infancy, she was exclusively breastfed for six months and afterwards she was introduced
to solid foods like cereals and other table foods. Their source of water is from a water pump. The patient
has a good appetite.
Developmental Milestone
The patient was able to attend school from nursery up to kindergarten. Unfortunately, she was
not able to continue her schooling because she finds it difficult to travel by walking.
PRESENT ILLNESS

7. Heart was doing well on the onset of her present illness. Unexpectedly, after defecating and
performing the Valsalva maneuver, she felt restless, irritable and short of breath. She even uttered
irritably the words, “Unsa man ning sakita ni uy!”. Despite of Heart’s complaint, she wasn’t rushed to
the hospital because of financial constraints. After two days of continually feeling short of breath and
restless, her mother decided to bring her to the Center of Child Health and Development (CCHD) here at
Davao Regional Hospital. Dr. dela Cruz was her attending physician then and she advised Heart’s parents
to admit their child at the Pediatric unit to be able to give the needed interventions for Heart. Thus,
after two days of restlessness, irritability and shortness of breath she was admitted as an in patient at
the Pediatric Unit of Davao Regional Hospital.
FAMILY HEALTH HISTORY
Based on the diagram presented it reveals that on the Paternal side, Rodolfo the grandfather
has a heart problem, while her wife Dolores the Grandmother has no other hereditary disease. Together
they have five children namely: Beth, the eldest who has hypertension, Fe the second child who was
diagnosed with Diabetes Milletus, Bobby the third child and is the father of our patient do not have any
hereditary diseases, Bernie the fourth child has Heart Problem and is said to have inherited it to their
father and Flor as the youngest do not have any other hereditary diseases aside from mentioned above.
On the Maternal side the grandfather of our patient Domingo was diagnosed with hypertension
while her wife Primitiva had no other hereditary diseases. They have 3 children namely: Cipriano as the
eldest and has Hypertension, the second child Miraluna and is the mother of our patient, and the
youngest is Felipe and was diagnosed with bronchial asthma.
Generally, other conditions experienced both by the maternal and paternal side are common
colds and cough.

8. GENOGRAM
PATERNAL SIDE MATERNAL SIDE
Dolores
Rodolfo Primitiva
Domingo
Bobby Flor
Beth FE Bernie
32 ╬ Cipriano Miraluna Felipe ╬
= Hypertension
Heart Kristine
= Diabetes Mellitus
╬ = Bronchial Asthma
= Heart Problem

10. COURSE IN THE WARD
I. Ongoing Diagnostic Work-ups
1.1 Complete Blood Count
Definition:
The CBC is used as a broad screening test to check for such disorders as anemia,
infection, and many other diseases. It is actually a panel of tests that examines different
parts of the blood and includes the following:
 White blood cell (WBC) count is a count of the actual number of white blood cells per
volume of blood. Both increases and decreases can be significant.
 White blood cell types (WBC differential). There are five different types of white blood
cells, each with its own function in protecting us from infection. The differential
classifies a person's white blood cells into each type: neutrophils (also known as segs,
PMNs, granulocytes, grans), lymphocytes, monocytes, eosinophils, and basophils.
 Red blood cell (RBC) count is a count of the actual number of red blood cells per volume
of blood. Both increases and decreases can point to abnormal conditions.
 Hemoglobin (Hgb). The hemoglobin molecule fills up the red blood cells. It carries
oxygen and gives the blood cell its red color. The hemoglobin test measures the amount
of hemoglobin in blood and is a good measure of the blood's ability to carry oxygen
throughout the body.

11.  Hematocrit (HCT, packed cell volume, PCV). This test measures the amount of space
(volume) red blood cells take up in the blood. The value is given as a percentage of red
blood cells in a volume of blood. For example, a hematocrit of 38 means that 38% of the
blood's volume is made of red blood cells. Hematocrit and hemoglobin values are the
two major tests that show if anemia or polycythemia is present.
 Platelet (thrombocyte) count is the number of platelets in a given volume of blood. Both
increases and decreases can point to abnormal conditions of excess bleeding or clotting.
Mean platelet volume (MPV) is a machine-calculated measurement of the average size
of your platelets. New platelets are larger, and an increased MPV occurs when increased
numbers of platelets are being produced. MPV gives your doctor information about
platelet production in your bone marrow.
 Mean corpuscular volume (MCV) is a measurement of the average size of your RBCs.
The MCV is elevated when your RBCs are larger than normal (macrocytic), for example
in anemia caused by vitamin B12 deficiency. When the MCV is decreased, your RBCs are
smaller than normal (microcytic) as is seen in iron deficiency anemia or thalassemias.
 Mean corpuscular hemoglobin (MCH) is a calculation of the average amount of oxygen-
carrying hemoglobin inside a red blood cell. Macrocytic RBCs are large so tend to have a
higher MCH, while microcytic red cells would have a lower value.
 Mean corpuscular hemoglobin concentration (MCHC) is a calculation of the average
concentration of hemoglobin inside a red cell. Decreased MCHC values (hypochromia)
are seen in conditions where the hemoglobin is abnormally diluted inside the red cells,
such as in iron deficiency anemia and in thalassemia. Increased MCHC values
(hyperchromia) are seen in conditions where the hemoglobin is abnormally
concentrated inside the red cells, such as in burn patients and hereditary spherocytosis,
a relatively rare congenital disorder.
 Red cell distribution width (RDW) is a calculation of the variation in the size of your
RBCs. In some anemias, such as pernicious anemia, the amount of variation
(anisocytosis) in RBC size (along with variation in shape – poikilocytosis) causes an
increase in the RDW.
Nursing Care Prior to Procedure:
1. Explain test procedure. Explain that slight discomfort may be felt when skin is
punctured.
2. Avoid stress if possible because altered physiologic status influences and
changes normal values.

12. 3. Dehydration or over hydration can dramatically alter values; for example, large
volumes of IV fluids can dilute the blood and values will appear as lower counts.
The presence of either these states should be communicated to the laboratory.
4. Fasting is not necessary. However, fat-laden meals may alter some test results
as a result of lipidemia.
Nursing Care During and After the Procedure:
1. Apply manual pressure and dressings to the puncture site on removal of the
needle.
2. Monitor of the puncture site for oozing or hematoma formation. Maintain
pressure dressings if necessary. Notify physician for unusual problems with
bleeding.
3. Resume normal activities and diet.
Result with indications:
Hematology/CBC
Date Test Result Normal Values Indication
May 28, 2010 Hemoglobin (Hgb): 225 120 –140 mg/dl May be increased when
mg/dl the body perceives low
blood oxygenation that
can be due to decreased
cardiac output
Leukocyte number 4.6 4.5 – 11.0 x 109 /L May be increased with
concentration: or 4,500 - infections, inflammation,
11,000/mcL3 cancer, leukemia;
decreased with some
medications (such as
methotrexate), some
autoimmune conditions,
some severe infections,
bone marrow failure, and
congenital marrow
aplasia (marrow doesn't
develop normally).
Segmenters: 0.56 2.5-7.5 x 109/L High count may indicate
bacterial infection, burns,
stress, and inflammation.
Low count may indicate
radiation exposure, drug
toxicity, vitamin B12

13. deficiency, and
systematic lupus
erythematosus (SLE).
Eosinophils: 0.02 High Eosinophil count
may indicate an allergic
reactions, parasitic
infections, autoimmune
diseases. While a low
count may indicate drug
toxicity or stress.
Thrombocyte: 84 150.0– 400.0 x Decreased or increased
109 /L with conditions that
or affect platelet
150,000 - production; decreased
400,000/mcL3 when greater numbers
used, as with bleeding;
decreased with some
inherited disorders (such
as Wiskott-Aldrich,
Bernard-Soulier), with
Systemic lupus
erythematosus,
pernicious anemia,
hypersplenism (spleen
takes too many out of
circulation), leukemia,
and chemotherapy
Erythrocyte: 0.77 Decreased with anemia;
increased when too many
made and with fluid loss
due to diarrhea,
dehydration, and burns.
Hematocrit 0.77 Male: 0.40 – 0.50 Increased with
Female: 0.37- dehydration, fluid loss
0.43
May 30, 2010 Erythrocyte Volume 0.83 Male: 0.40 – 0.50 Increased with
Fraction: Female: 0.37- dehydration, fluid loss
0.43

14. June 4, 2010 Hematocrit 0.52 Male: 0.40 – 0.50 Increased with
Female: 0.37- dehydration, fluid loss
0.43
Benefits:
A complete blood count may be done to:
 Find the cause of symptoms such as fatigue, weakness, fever, bruising, or weight
loss.
 Find anemia.
 See how much blood has been lost if there is bleeding.
 Diagnose polycythemia and leukemia.
 Find an infection.
 Check how the body is dealing with some types of drug or radiation treatment.
 Check how abnormal bleeding is affecting the blood cells and counts.
 Screen for high and low values before a surgery.
 See if there are too many of too few of certain types of cells. This may help find
other conditions, such as too many eosinophils may mean an allergy or asthma
is present.
 As a part of regular physical examination. A blood count can give valuable
information about the general state of your health.
Risk:
There is a little chance of a problem from having a blood sample taken from a vein.
 You may get a small bruise at the site. You can lower the chace of bruising by
keeping pressure on the site for several minutes.
 In rare cases, the vein may become swollen after the blood sample is taken. This
problem is called phlebitis. A warm compress can be used several times a day to
treat this.
 Ongoing bleeding can be a problem for people with bleeding disorders. Aspirin,
warfarin (Coumadin), and other blood-thinning medicines can make bleeding
more likely. If you have bleeding or clotting problems, or if you take blood-
thinning medicine, tell your doctor before your blood sample is taken.
1.2 Chest Radiography
APL (Apicolordotic) View

15. Definition:
An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and treat
medical conditions. Imaging with x-rays involves exposing a part of the body to a small dose
of ionizing radiation to produce pictures of the inside of the body. X-rays are the oldest and
most frequently used form of medical imaging.
Nursing Care Prior to Procedure:
1. Explain test purpose, procedure and interfering factors. Emphasize that chest x-ray
is painless.
2. Have your client to remove some or all of clothes and wear a gown during the exam.
3. Have your client remove jewelry, dentures, eye glasses and any metal objects or
clothing that might interfere with the x-ray images.
4. Follow guidelines for safe, effective, informed pretest care.
Nursing care during and after the procedure:
1. Due to the cool temperature in the examination room and the coldness of the
recording plate, some client may experience slight discomfort. Individuals with
arthritis or injuries to the chest wall, shoulders or arms may have discomfort trying
to stay still. Assist them in finding the most comfortable position possible that still
ensures diagnostic image quality.
2. After the procedure, return client’s jewelry, dentures, eye glasses and other
belongings.

16. 3. Follow safe, effective, informed post test care.
Results with indication:
Date: May 28, 2010
Chest APL: Peripheral pulmonary vessels are accentuated. Heart is slightly enlarged.
Diaphragm and bony thorax are unremarkable. Soft tissue does not appear unusual.
Impression: Mild Cardiomegaly with Pulmonary Congestion. Congenital Heart
Disease is entertained.
Benefits
 No radiation remains in a patient's body after an x-ray examination.
 X-rays usually have no side effects in the diagnostic range.
 X-ray equipment is relatively inexpensive and widely available in emergency rooms,
physician offices, ambulatory care centers, nursing homes and other locations,
making it convenient for both patients and physicians.
 Because x-ray imaging is fast and easy, it is particularly useful in emergency
diagnosis and treatment.
Risk
 There is always a slight chance of cancer from excessive exposure to radiation.
However, the benefit of an accurate diagnosis far outweighs the risk.
 The chest x-ray is one of the lowest radiation exposure medical examinations
performed today. The effective radiation dose from this procedure is about 0.1 mSv,
which is about the same as the average person receives from background radiation
in 10 days.
 Women should always inform their physician or x-ray technologist if there is any
possibility that they are pregnant.
1.3 Arterial Blood Gas

17. Definition:
Arterial Blood Gases is a means of assessing the adequacy of oxygenation and ventilation, to
evaluate acid base status by measuring the respiratory and non respiratory components and
to monitor effectiveness of therapy. They are also used to monitor critically ill patients, to
establish baseline values in the perioperative and postoperative period, to detect and treat
electrolyte imbalances, to titrate appropriate oxygen flow rates, etc.
An ABG measures:
 Partial pressure of oxygen (PaO2). This measure the pressure of oxygen dissolved in
the blood and how well oxygen is able to move from the airspace of the lungs into
the blood.
 Partial pressure of carbon dioxide (PaCO2). This measures how much carbon
dioxide is dissolved in the blood and how well carbon dioxide is able to move out of
the body.
 pH. The pH measures hydrogen ions (H+) in blood. The pH of blood is usually
between 7.35 and 7.45. A pH of less than 7.0 is called acid and a pH greater than 7.0
is called basic (alkaline). So blood is slightly basic.
 Bicarbonate (HCO3). Bicarbonate is a chemical (buffer) that keeps the pH of blood
from becoming too acidic or too basic.
 Oxygen content (O2CT) and oxygen saturation (O2Sat) values. O2 content
measures the amount of oxygen in the blood. Oxygen saturation measures how
much of the hemoglobin in the red blood cells is carrying oxygen (O2).

18. Nursing Care Prior to Procedure:
1. Explain the purpose and procedure for obtaining arterial blood sample.
2. If the patient is apprehensive, explain that a local anesthetic can be used.
3. Follow safe, effective, informed care.
Nursing care during and after the procedure:
1. Evaluate color, motion, sensation, degree of warmth, capillary refill time, and
quality of pulse in the affected extremity or at the puncture site.
2. Monitor puncture site and dressing for arterial bleeding for several hours. No
vigorous activity of the extremity should be undertaken for 24 hours.
3. Follow safe, effective, informed post test care.
Result with indications:
Date/Time Test Test Normal Values Indication
Result
May 30, pH: 7.231 7.35 – 7.45 The pH or H+ indicates if a patient is
2010/ 11:33 acidotic (pH < 7.35; H+ >45) or
alkalemic (pH > 7.45; H+ < 35). In
this situation, the patient is
acidotic.
Partial pressure 30.5 35-45 mm Hg The carbon dioxide partial pressure
of carbon dioxide (4.6 – 5.9 k Pa) (PaCO2) indicates a respiratory
(PaCO2): problem: for a constant metabolic
rate, the PaCO2 is determined
entirely by ventilation. A high
PaCO2 (respiratory acidosis)
indicates underventilation, a low
PaCO2 (respiratory alkalosis) hyper-
or overventilation. PaCO2 levels can
also become abnormal when the
respiratory system is working to
compensate for a metabolic issue
so as to normalize the blood pH. An
elevated PaCO2 level is desired in
some disorders associated with
respiratory failure; this is known as
permissive hypercapnia.
Partial pressure 30.5 75-100 mm Hg (9.9 A low O2 indicates that the patient
of oxygen – 13.2 k Pa) is not respiring properly, and is

19. (PaO2): hypoxemic. At a PaO2 of less than
60 mm Hg, supplemental oxygen
should be administered. At a PaO2
of less than 26 mm Hg, the patient
is at risk of death and must be
oxygenated immediately.
Bicarbonate 13.3 20-29 mEq/L The HCO3− ion indicates whether a
(HCO3): (20 – 29 mmol/L) metabolic problem is present (such
as ketoacidosis). A low HCO3−
indicates metabolic acidosis, a high
HCO3− indicates metabolic alkalosis.
HCO3− levels can also become
abnormal when the kidneys are
working to compensate for a
respiratory issue so as to normalize
the blood pH.
Oxygen 48.7 95%-100% This is the sum of oxygen dissolved
saturation (0.95- 1.00) in plasma and chemically bound to
(O2Sat): hemoglobin. Low percentage of O2
sat indicates low levels of
hemoglobin in the red blood cell,
carrying oxygen.
Base Excess -13.6 -3 to +3 mmol/l The base excess is used for the
(B.E.): assessment of the metabolic
component of acid-base disorders,
and indicates whether the patient
has metabolic acidosis or metabolic
alkalosis. A negative base excess
indicates that the patient has
metabolic acidosis (primary or
secondary to respiratory alkalosis).
A positive base excess indicates
that the patient has metabolic
alkalosis (primary or secondary to
respiratory acidosis).
Benefits
An arterial blood gas (ABG) test is done to:

20.  Check for severe breathing problems and lung diseases, such as asthma, cystic
fibrosis, or chronic obstructive pulmonary disease (COPD).
 See how well treatment for lung diseases is working.
 Find out if you need extra oxygen or help with breathing (mechanical ventilation).
 Find out if you are receiving the right amount of oxygen when you are using oxygen
in the hospital.
 Measure the acid-base level in the blood of people who have heart failure, kidney
failure, uncontrolled diabetes, sleep disorders, severe infections, or after a drug
overdose.
Risk
There is little chance of a problem from having blood sample taken from an artery.
 You may get a small bruise at the site. You can lower the chance of bruising by
keeping pressure on the site for at least 10 minutes after the needle is removed
(longer if you have bleeding problems or take blood thinners).
 You may feel lightheaded, faint, dizzy, or nauseated while the blood is being drawn
from your artery.
 Ongoing bleeding can be a problem for people with bleeding disorders. Aspirin,
warfarin (Coumadin), and other blood-thinning medicines can make bleeding more
likely. If you have bleeding or clotting problems, or if you take blood-thinning
medicine, tell your doctor before your blood sample is taken.
 On rare occasions, the needle may damage a nerve or the artery, causing the artery
to become blocked.
 Though problems are rare, be careful with the arm or leg that had the blood draw.
Do not lift or carry objects for about 24 hours after you have had blood drawn from
an artery.
1.4 ECG

21. Definition:
Electrocardiogram (ECG or EKG) is a transthoracic interpretation of the electrical activity of
the heart over time captured and externally recorded by skin electrodes. Electrical impulses
in the heart originate in the sinoatrial node and travel through the intrinsic conducting
system to the heart muscle. The impulses stimulate the myocardial muscle fibres to contract
and thus induce systole. The electrical waves can be measured at selectively placed
electrodes (electrical contacts) on the skin. Electrodes on different sides of the heart
measure the activity of different parts of the heart muscle. It is the best way to measure and
diagnose abnormal rhythms of the heart, particularly abnormal rhythms caused by damage
to the conductive tissue that carries electrical signals, or abnormal rhythms caused by levels
of dissolved alts (electrolytes), such as potassium, that are too high or low. In myocardial
infarction (MI), the ECG can identify damaged heart muscle. But it can only identify damage
to muscle in certain areas, so it can’t rule out damage in other areas. The ECG cannot
reliably measure the pumping ability of the heart; for with ultrasound-based
(echocardiography) or nuclear medicine test are used.
Procedure:
1. Have the patient assume a supine position; however, recordings can be taken during
exercise.
2. Prepare the skin sites and, if necessary, shave and place electrodes on the four
extremities and on specific chest sites. Ensure that the right leg is the ground.
3. Remember that all 12 leads can be recorded simultaneously by newer ECG
machines.
4. Remember that a rhythm strip is a 2-minute recording from a single lead, usually
lead II. It is frequently used to evaluate dysrhythmias.
5. Follow safe, effective and informed intra-test care.
Nursing Care Prior to Procedure:

22. 1. Explain test purpose, procedure and interfering factors. Emphasize that ECG is
painless and does not deliver electrical current to the body. A resting ECG is no
more than 1-minute record of the heart’s electrical activity.
2. Have the patient completely relax to ensure a satisfactory tracing.
3. Be aware that ideally, the person should rest for 15 minutes before ECG, and longer
if possible.
4. Follow guidelines for safe, effective, informed pretest care.
Nursing care during and after the procedure:
1. Recognize the limitations of an ECG. A normal ECG does not rule out coronary artery
disease or areas of cardiac ischemia. Conversely, an abnormal ECG in and of itself
does not always signify heart disease.
2. Interpret test results and counsel and monitor the patient appropriately. A resting
ECG is usually normal in those patients who experience only angina. It can provide
evidence of prior heart damage. The ECG is one diagnostic tool within a repertoire
of diagnostic modalities and should be viewed as such. The presence or absence of
heart disease should not be presumed solely on basis of ECG.
3. Follow guidelines for safe, effective, informed post-test care.
1.5 Two Dimensional Echocardiography (2 D Echo)
Definition:
An echocardiogram (also called echo, transthoracic echocardiogram or TTE, exercise or
stress echocardiogram, dobutamine stress echocardiogram or DSE, or transesophageal
echocardiogram or TEE) is a noninvasive (the skin is not pierced) procedure used to assess
the heart's function and structures. A transducer (like a microphone) sends out ultrasonic
sound waves at a frequency too high to be heard. When the transducer is placed on your
chest at certain locations and angles, the ultrasonic sound waves move through the skin and
other body tissues to the heart tissues, where the waves echo off of the heart structures.
The transducer picks up the reflected waves and sends them to a computer. The computer
interprets the echoes into images of the heart walls and valves.

23. An echocardiogram can utilize one or more of four special types of echocardiography:
 M-Mode echocardiography: This is the simplest type of echocardiography. It
produces an image that is similar to a line tracing rather than an actual picture of
heart structures. M-mode echo is useful for measuring heart structures, such as the
heart's pumping chambers, the size of the heart itself, and the thickness of the heart
walls.
 Doppler echocardiography: This Doppler technique is used to measure and assess
the flow of blood through the heart's chambers and valves. The amount of blood
pumped out with each beat is an indication of the heart's functioning. Also, Doppler
can detect abnormal blood flow within the heart, which can indicate a problem with
one or more of the heart's four valves or with the heart's walls.
 Color Doppler: Color Doppler is an enhanced form of Doppler echocardiography.
With color Doppler, different colors are used to designate the direction of blood
flow. This simplifies the interpretation of the Doppler technique.
 2-D (2-dimensional) echocardiography: This technique is used to "see" the actual
structures and motion of the heart structures. A 2-D echo view appears cone-
shaped on the monitor, and the real-time motion of the heart's structures can be
observed. This enables the physician to see the various heart structures at work and
evaluate them.
 3-D (3-dimensional) echocardiography: 3-D echo is a relatively new type of echo
that captures 3-dimensional views of the heart structures with greater depth than
the 2-D echo. The live or ("real time") images allow for a more accurate assessment
of heart function by using measurements taken while the heart is beating. 3-D echo
shows enhanced views of the heart's anatomy and can be used to determine the
appropriate plan of treatment for a person with heart disease.
Purpose:
Echocardiography is used to diagnose cardiovascular diseases. In fact, it is one of the most
widely used diagnostic tests for heart disease. It can provide a wealth of helpful information,
including the size and shape of the heart, its pumping capacity and the location and extent
of any damage to its tissues. It is especially useful for assessing diseases of the heart valves.
It not only allows doctors to evaluate the heart valves, but it can detect abnormalities in the
pattern of blood flow, such as the backward flow of blood through partly closed heart
valves, known as regurgitation. By assessing the motion of the heart wall, echocardiography
can help detect the presence and assess the severity of coronary artery disease, as well as
help determine whether any chest pain is related to heart disease. Echocardiography can
also help detect hypertrophic cardiomyopathy. The biggest advantage to echocardiography
is that it is noninvasive (doesn't involve breaking the skin or entering body cavities) and has
no known risks or side effects.

24. Nursing Care Prior to Procedure:
1. Explain test purpose, procedure and interfering factors. Emphasize that 2 D echo
imaging is painless and does not deliver electrical current or whatsoever to the
body.
2. Have the patient completely relax to ensure a satisfactory imaging.
3. Follow guidelines for safe, effective, informed pre-test care.
Nursing care during and after the procedure:
1. For the procedure, the client may have to remove clothing from waist up. Ensure
privacy by using drapes across the chest and limiting access into the procedure
room during the test.
2. The echocardiography technician will apply warm gel to the client’s chest. Aware
the client beforehand.
3. The client can resume normal activities, unless the physician instructs differently.
II. Medical Management
2.1 Phlebotomy
Definition:
Phlebotomy (A.K.A. venesection and venotomy) is the removal of a certain amount of
blood under controlled conditions. Patients with elevated hematocrits (eg, those with
polycythemia vera) or excessive iron absorption (eg, hemochromatosis) can usually be
managed by periodically (once or twice weekly) removing 1 unit (about 500 ml) of whole
blood. Eventually this depletes patient’s iron stores, thereby rendering the patient iron
deficient and consequently unable to manufacture RBC’s excessively. The actual
procedure for the therapeutic phlebotomy is similar to that for blood donation.
Nursing Care Prior to Procedure:
1. Explain test procedure. Explain that slight discomfort may be felt when skin is
punctured.
2. Follow safe, effective, informed care.
Nursing care during and after the procedure:
Phlebotomy consists of venipuncture and blood withdrawal. Standard precautions are
used.
1. Patients are placed in a semi recumbent position. The skin over the antecubital
fossa is carefully cleansed with an antiseptic preparation, a tourniquet is applied
and venipuncture is performed. Withdrawal of 450 ml of blood usually takes less
than 15 minutes.
2. After the needle is removed, patient is asked to hold the involved arm straight
up, and firm pressure is applied with strerile gauze for 2 or 3 minutes or until
bleeding stops. A firm bandage is then applied.

25. 3. Patient should remain recumbent until they feel able to sit up. Patients who
experience weakness or faintness should rest a longer period.
4. Instruct patient to leave the dressing on and to avoid heavy lifting for several
hours, to avoid smoking for 1 hour, to avoid drinking alcoholic beverages for 3
hours, to avoid iron supplements (for those with Polycythemia vera), to increase
fluid intake for 2 days, and to eat healthy meals for 2 weeks.
Benefits
 Decrease over production of RBCs.
 Medical management for patients with polycythemia vera and
hemochromatosis.
Risk
 Fatigue
 Dizzines
 Phlebitis, or puncture site/vein becomes swollen (on rare cases).
2.2 Oxygen therapy
Definition:
Oxygen therapy is the administration of oxygen at a concentration greater than that
found in the environmental atmosphere. At sea level, the concentration of oxygen in
room air is 21%. The goal of oxygen therapy is to provide adequate transport of oxygen
in the blood while decreasing the work of breathing and reducing stress on the
myocardium.
Oxygen transport to the tissue depends on actors such as cardiac output, arterial oxygen
content concentration of hemoglobin, and metabolic requirements. These factors must
be kept in mind when oxygen therapy is considered.
Nursing care prior to procedure:
1. The nurse instructs the patient or family in the methods for administering
oxygen and informs the patient and family that the oxygen is available in gas,
liquid, and concentrated form.
2. Follow safe, effective, informed care.
Nursing care during and after procedure:
1. Humidity must be provided while oxygen is used to counteract the dry, irritating
effects of the compressed oxygen on the airway.

26. III. Medical Management
3.3 Drugs taken by the patient
NAME OF DRUG ORDERED INDICATION MODE OF ACTION PRECAUTION ADVERSE REACTION NURSING
DOSE CONSIDERATION
CEFUROXIME SODIUM 520mg q8 ivtt Pharyngitis, tonsillitis, Second generation Contraindicated in CV: phlebitis, Before
infections of the urinary cephalosporin that patients thrombophlebitis administration,
and lower respiratory inhibits cell-wall hypersensitive to GI: ask patient if he
tracts, and skin and synthesis, promoting drug or other pseuomembranous is allergic to
skin-structure caused osmotic instability; cephalosporins. colitis, nausea, penicillins or
by Streptococcus usually bactericidal. Use cautiously in anorexia, vomiting, cephalosporins.
pneumoniae and S. patients diarrhea Obtain
pyogenes, Haemophilus hypersensitive to Hematologic: specimen for
influenzae, penicillin because transient culture and
Staphylococcus aureus, of possibility of neutropenia, sensitivity tests
E.coli, Moraxella cross-sensitivity eosinophilia, before giving
catarrhalis, Neisseria with other beta- hemolytic anemia, first dose.
gonorrhieae, and lactam antibiotics. thrombocytopenia Therapy may
Klebsiella and Use cautiously in Skin: maculopapular begin while
Enterobacter species. breast-feeding and erythematous awaiting
Serious lower women and in rashes, urticaria, results.
respiratory tract patients with pain, induration, For IM
infections, UTI’s, skin history of colitis sterile abscesses, injection, inject
infections, bone and or renal temperature deep into a
joint infections, insufficiency. elevation, tissue large muscle,
septicemia, meningitis, sloughing at IM such as the
and gonorrhea. injection site gluteus
Uncomplicated UTI. Other: maximus or the
Early Lyme Dieseas hypersensitivity lateral aspect o
(erythema migrans) reactions, serum the thigh
caused by Borrelia sickness, anaphylaxis Cefuroxime
burgdorferi. tablets may be

27. Secondary bacterial crushed, if
infection of acute absolutely
bronchitis. necessary, for
patients who
can’t swallow
tablets.
If large doses
are given,
therapy is
prolonged, or
patient is at
high risk,
monitor patient
for signs and
symptoms of
superinfection.
Instruct patient
to notify
prescriber
about rash or
evidence of
superinfection.
Advise patient
receiving drug
IV to report
discomfort at IV
insertion site.
Tell patient to
notify
prescriber
about loose
stools or
diarrhea.

28. CEFTRIAXONE 1.5gm q4 ivtt Uncomplicated Third generation Contraindicated CNS: fever, Before
SODIUM gonococcal cephalosporin that in patients headache, dizziness administration,
vulvovaginitis inhibits cell-wall hypersensitivity to CV: phlebitis ask patient if he is
UTIs; lower synthesis, promoting drug or other GI: allergic to
respiratory tract, osmotic instability; cephalosporins. pseudomembranous penicillins or
gynecologic, bone and usually bactericidal. Use cautiously in colitis, diarrhea cephalosporins.
joint, intra abdominal, patients GU: genital pruritus, Obtain
skin, and skin structure hypersensitive to candidiasis specimen for
infections; septicemia. penicillin because Hematologic: culture and
Meningitis of possibility of eosinophilia, sensitivity tests
Neurological cross-sensitivity thrombocytosis, before giving first
complications, carditis, with other beta- leucopenia dose. Therapy
and arthtritis from lactam antibiotics. Skin: pain, may begin while
penicillin. Use cautiously in induration, awaiting results.
breast-feeding tenderness at For IM
women and in injection site, rash, injection, inject
patients with pruritus deep into a large
history of colitis or Other: muscle, such as
renal insufficiency. hypersensitivity the gluteus
reactions, serum maximus or the
sickness, lateral aspect o
anaphylaxis, chills the thigh.
Monitor PT
and INR in
patients with
impaired vitamin
K synthesis or low
vitamin K stores.
Tell patient to
report adverse
reactions
promptly.

29. Instruct patient
to report
discomfort at
injection site.
Tell patient to
notify prescriber
about loose stools
or diarrhoea.
PROPRANOLOL 10mg ½ tab po Angina pectoris A non-selective beta Contraindicated CNS: fatigue, Always check
HYDROCHLORIDE To decrease risk of blocker that reduces in patients with lethargy, fever, vivid patient’s apical
death after MI cardiac oxygen bronchial asthma, dreams, pulse before
Supraventricular, demand by blocking sinus bradycardia hallucinations, giving drug. If
ventricular, and atrial catecholamine- and heart block mental depression, extremes in pulse
arrhythmias; induced increases in greater than first light-headedness, rates occur,
tachyarryhtmias caused heart rate, blood degree, dizziness, insomnia withhold drug and
by excessive pressure, and force cardiogenic shock, CV: bradycardia, notify prescriber
catecholamine action of myocardial and overt and hypotension, heart immediately.
during anesthesia, contraction. decompensated failure, intermittent Give drug
huperthyroidism, or Depresses rennin heart failure. claudication, consistently with
pheochromocytopenia. secretion and Use cautiously in intensification of AV meals. Food may
Hypertension prevents patients with block. increase
To prevent frequent, vasodilation of hepatic or renal GI: abdominal absorption of
severe, uncontrollable, cerebral arteries. impairment, non- cramping, propranolol.
or disabling migraine, or allergic constipation, Drug masks
vascular headache. bronchospastic diarrhea, nausea, common signs
Essential tremor diseases, or vomiting and symptoms of
Hypertrophic hepatic diseases Hematologic: shock and
subaortic stenosis and in those taking agranulocytosis hypoglycemia.
other Respiratory: Caution patient
antihypertensives bronchospasm to continue taking
Because drug Skin: rash this drug as
blocks some prescribed, even
symptoms of when he’s feeling

30. hypoglycemia, use well.
cautiously in Instruct patient
patients who have to take drug with
diabetes mellitus. food.
Use cautiously in Tell patient not
patients with to stop drug
throtoxicosis suddenly because
becaude drug may this can worsen
mask some signs chest pain and
and symptoms of trigger a heart
the disorder. attack.
Elderly patients
may experience
enhanced adverse
reactions and may
need dosage
adjustment.
DIAZEPAM 1ml ivtt Anxiety Unknown. A Contraindicated CNS: drowsiness, Use Diastat
Acute alcohol benzodiazepine that in patients dysarthia, slurred rectal gel to treat
withdrawal probably potentiates hypersensitive to speech, tremor, no more than five
Muscle spasm the effects of GABA, drug or soy protein; transient amnesia, episodes per
Cardioversion depresses the CNS, in patients fatigue,ataxia, month and no
Adjunct treatment and suppresses the experiencing shock, headache, insomnia, more than one
for seizure disorders spread of seizure coma, or acute paradoxical anxiety, episode every 5
Status epilepticus, activity. alcohol hallucinations, minor days because
severe recurrent intoxication; in changes at EEG tolerance may
seizures pregnant women, patterns. develop.
Patients on stable especially in first CV: hypotension, CV When using oral
regimens of antiseptic trimester; and in collapse, bradycardia concentrate
drugs who need children younger EENT: diplopia, solution, dilute
diazepam intermittently than 6 months. blurred vision, dose just before
to control bouts of Diastat rectal gel nystagmus giving.
increase seizure activity. is contraindicated GI: nausea, Monitor
in patients with constipation, periodic hepatic,

31. acute angle-closure diarrhea with rectal renal, and
glaucoma. form hematopoietic
Use cautiously in GU: incontinence, function studies in
patients with liver urine retention patients receiving
or renal Hematologic: repeated or
impairment, neutropenia prolonged
depression, or Hepatic: jaundice therapy.
chronic open-angle Respiratory: Use of this drug
glaucoma. Use respiratory may lead to abuse
cautiously in depression, apnea and addiction.
elderly and Skin: rash Don’t withdraw
debilitated drug abruptly
patients. after long-term
use; withdrawal
symptoms may
occur.
Warn woman to
avoid use during
pregnancy.
PARACETAMOL 325mg/tab q4 Fever / mild pain Unknown. Thought Contraindicated Hematologic: Use liquid form
prn for fever to produce analgesia in patients hemolytic anemia, for children and
by bocking pain hypersensitive neutropenia, patients who have
impulses by to drug. leucopenia, difficulty
inhibiting synthesis Use cautiously in pancytopenia swallowing.
of prostaglandin in patients with Hepatic: jaundice In children
the CNS or other long term Metabolic: don’t exceed five
substances that alcohol use hypoglycemia doses in 24 hours.
sensitize pain because Skin: rash, urticaria
receptors to therapeutic
stimulation. The doses cause
drug may relieve hepatotoxicity in
fever through these patients.
central action in the
hypothalamic heat-

32. regulating center.
MUPIROCIN Treating impetigo, a Mupirocin Ointment Tell your doctor or Burning; pain; Inform pt. that:
OINTMENT type of skin infection. is an antibacterial. It pharmacist if you stinging.
kills sensitive have any medical If you have
bacteria by stopping conditions, Severe allergic any questions
the production of especially if any of reactions (rash; about
essential proteins the following apply hives; itching; Mupirocin
needed by the to you: difficulty breathing; Ointment,
bacteria to survive. tightness in the please talk
if you are chest; swelling of the with your
pregnant, mouth, face, lips, or doctor,
planning to tongue); severe pharmacist, or
become irritation; severe other health
pregnant, or itching. care provider.
are breast- Mupirocin
feeding Ointment is to
if you are be used only
taking any by the patient
prescription or for whom it is
nonprescriptio prescribed. Do
n medicine, not share it
herbal with other
preparation, or people.
dietary If your
supplement symptoms do
if you have not improve
allergies to or if they
medicines, become
foods, or other worse, check
substances with your
if you are doctor.
treating a burn
or open wound

33. if you have
kidney
problems
CLOXACILLIN Cloxacillin is used to Disrupt the synthesis If you have ever an allergic Take cloxacillin
treat many different of the peptidoglycan had an allergic reaction exactly as directed
types of infections layer of bacterial cell reaction to another (shortness of by your doctor. If
caused by walls. The penicillin or to a breath; closing of you do not
staphylococcus bacteria peptidoglycan layer cephalosporin, do your throat; understand these
("staph" infections). is important for cell not take cloxacillin hives; swelling of instructions, ask
wall structural unless your doctor your lips, face, or your pharmacist,
integrity. is aware of your tongue; rash; or nurse, or doctor
allergy and fainting); to explain them to
monitors your seizures; you.
therapy. severe watery
diarrhea and Take each dose
Before taking this abdominal with a full glass of
medication, tell cramps; or water. Take
your doctor if you unusual bleeding cloxacillin on an
have kidney or bruising. empty stomach 1
disease, stomach or hour before or 2
intestinal disease, hours after meals.
or infectious
mononucleosis. Do not drink juice
You may not be or carbonated
able to take beverages (soda)
cloxacillin because with your dose of
of an increased risk cloxacillin. These
of side effects. beverages will
decrease the
If you are a effectiveness of
diabetic, some the drug.
glucose urine tests
may give false Cloxacillin should

34. positive results be taken at evenly
while you are spaced intervals
taking cloxacillin. throughout the
day and night to
Cloxacillin is in the keep the level in
FDA pregnancy your blood high
category B. This enough to treat
means that it is the infection.
unlikely to harm an
unborn baby. Do Do not crush,
not, however, take chew, or open the
cloxacillin without capsules. Swallow
first talking to your them whole.
doctor if you are Shake the
pregnant. It is not suspension well
known whether before measuring
cloxacillin passes a dose. To ensure
into breast milk. Do that you get a
not take this correct dose,
medication without measure the
first talking to your liquid form of
doctor if you are cloxacillin with a
breast-feeding a dose-measuring
baby. spoon or cup, not
a regular
tablespoon. If you
do not have a
dose-measuring
device, ask your
pharmacist where
you can get one.
Take all of the
cloxacillin that has
been prescribed

35. for you even if
you begin to feel
better. Your
symptoms may
start to improve
before the
infection is
completely
treated. Store the
capsules at room
temperature and
store the
suspension in the
refrigerator for
longer use. The
suspension is
good for 14 days if
it is stored in the
refrigerator.
Throw away any
unused liquid
after this amount
of time.

36. ANATOMY AND PHYSIOLOGY
HUMAN HEART
The human heart is located in the thoracic
cavity, behind and slightly to the left of the
sternum. The heart is tilted so that its pointed end,
the apex, points downward toward the left hip,
while the broad end, the base, faces upward
toward the right shoulder. It is bordered laterally
by the lungs, anteriorly by the sternum, posteriorly
by the vertebral column, and inferiorly by the
diaphragm, making it a well-protected organ. The
heart weighs 7-15 ounces (200-425 grams) and is
approximately the size of the individual's fist. It is
approximately 12cm long, 9cm wide at the
broadest point, and 6cm thick. The apex is formed
by the tip of the left ventricle and is located at the
level of the 5th intercostals space. The base is
formed by the atria at the level of the second rib.
A protective sac called the pericardium
surrounds the heart. It consists of the following
layers:
Fibrous anchors the heart in the
mediastinum, surrounds roots of the
major blood vessels, prevents over-
distention, tough protective layer
Parietal lies directly beneath the fibrous
Visceral (Epicardium) lies beneath
parietal, attached to the heart itself
Pericardial fluid (up to 50ml) ultra filtrate of plasma provides a slippery surface for the movements of
the heart which prevents friction, located in pericardial cavity.
The wall of the heart consists of three layers:
The epicardium is the visceral layer of the serous pericardium.
The myocardium is the muscular part of the heart that consists of
contracting cardiac muscle and non-contracting Purkinje fibers that
conduct nerve impulses.
The endocardium is the thin, smooth, endothelial, inner lining of
the heart, which is continuous with the inner lining of the blood vessels.

37. CHAMBERS OF THE HEART
The heart consists of 2 muscular pumps known as
the left and right ventricles. The ventricles have 2
reservoirs called atria (left and right). Each ventricle acts to
serve different circulations. The right ventricle shifts
deoxygenated blood into the pulmonary circulation. Blood
enters the network of capillaries in the lungs and through a
process of diffusion carbon dioxide is lost and oxygen is
acquired; it then returns to the left atrium. The left
ventricle is the pump responsible for delivering blood into
the systemic circulation where it carries nutrients and
oxygen to the tissues. An exchange of nutrients and oxygen
for carbon dioxide and waste takes place; the waste rich
blood now returns to the right atrium
HEART VALVES
Atrioventricular (AV) valves lie between atria and
ventricles
• Tricuspid - on the right
• Mitral (bicuspid) - on the left
• Papillary muscles - attach to lower ventricular
walls and to chordae tendineae which in turn attach to
the AV valves. These keep the cusps of the AV valves from
being inverted into the atria when the ventricles contract.
Semilunar valves between ventricles and great vessels
exiting the heart
• Pulmonary - between RV and pulmonary trunk
• Aortic- between LV and aorta
As blood travels through the heart, it enters a total of four chambers and passes through four
valves. The two upper chambers, the right and left atria, are separated longitudinally by the interatrial
septum. The two lower chambers, the right and left ventricles, are the pumping machines of the heart
and are separated longitudinally by the interventricular septum. A valve follows each chamber and
prevents the blood from flowing backward into the chamber from which the blood originated.
Two additional passageways are present in the fetal heart:
The foramen ovale is an opening across the interatrial septum. It allows blood to bypass the
right ventricle and the pulmonary circuit, while the nonfunctional fetal lungs are still developing.

38. The opening, which closes at birth, leaves a shallow depression called the fossa ovalis in the
adult heart.
The ductus arteriosus is a connection between the pulmonary trunk and the aorta. Blood that
enters the right ventricle is pumped out through the pulmonary trunk. Although some blood
enters the pulmonary arteries (to provide oxygen and nutrients to the fetal lungs), most of the
blood moves directly into the aorta through the ductus arteriosus.
THE GREAT VESSELS OF THE HEART
Superior vena cava: brings
deoxygenated blood into the right atrium from
the head and upper body veins
Inferior vena cava: brings deoxygenated
blood from legs and lower torso into right
atrium
Pulmonary arteries (R and L): branch
from pulmonary trunk, carry deoxygenated
blood from the right ventricle into the lungs
Pulmonary veins (4): carry oxygenated
blood from lungs into the left atrium
Ascending Aorta: receives oxygenated
blood from the left ventricle and pumps it
throughout the body via arteries
BLOOD VESSELS
The central opening of a blood vessel, the lumen, is
surrounded by a wall consisting of three layers:
The tunica intima is the inner layer facing the
blood. It is composed of an innermost layer of
endothelium (simple squamous epithelium)
surrounded by variable amounts of connective
tissues. In arteries this layer is composed of an
elastic membrane lining and smooth
endothelium that is covered by elastic tissues.
The tunica media, the middle layer, is
composed of smooth muscle with variable
amounts of elastic fibers. This layer is thicker in
arteries than in vein.
The tunica adventitia, the outer layer, is
composed of connective tissue as well as
collagen and elastic fibres. These fibres allow
the arteries and veins to stretch to prevent
overexpansion due to the pressure that is
exerted on the walls by blood flow.

39. Blood vessels have three kinds that form a closed system of passageways:
Arteries carry blood away from the heart. The three
kinds of arteries are categorized by size and
function:
o Elastic arteries (conducting arteries) are the
largest arteries and include the aorta and
other nearby branches. The tunica media of
elastic arteries contains a large amount of
elastic connective tissue, which enables the
artery to expand as blood enters the lumen
from the contracting heart. During
relaxation of the heart, the elastic wall of
the artery recoils to its original position,
forcing blood forward and smoothing the
jerky discharge of blood from the heart.
o Muscular arteries (conducting arteries)
branch from elastic arteries and distribute blood the various body regions. Abundant
smooth muscle in the thick tunica media allows these arteries to regulate blood flow by
vasoconstriction (narrowing of the lumen) or vasodilation (widening of the lumen). Most
named arteries of the body are muscular arteries.
o Arterioles are small, nearly microscopic, blood vessels that branch from muscular
arteries. Most arterioles have all three tunics present in their walls, with considerable
smooth muscle in the tunica media. The smallest arterioles consist of endothelium
surrounded by a single layer of smooth muscle. Arterioles regulate the flow of blood
into capillaries by vasoconstriction and vasodilation.
Capillaries are microscopic blood vessels with extremely thin walls. Only the tunica intima is
present in these walls, and some walls consist exclusively of a single layer of endothelium.
Capillaries penetrate most body tissues with dense interweaving networks called capillary beds.
The thing walls of capillaries allow the diffusion of oxygen and nutrients out of the capillaries,
while allowing carbon dioxide and wastes into the capillaries.
o Metarterioles (precapillaries) are the blood vessels between arterioles and venules.
Although metarterioles pass through capillary beds with capillaries, they are not true
capillaries because metarterioles, like arterioles, have smooth muscle present in the
tunica media. The smooth muscle of a metarteriole allows it to acts as a shunt to
regulate blood flow into the true capillaries that branch from it. The thoroughfare
channel, the tail end of the metarteriole that connects to the venule, lacks smooth
muscle.
o True capillaries form the bulk of the capillary bed. They branch away from a
metarteriole at its arteriole end and return to merge with the metarteriole at its venule
end (thoroughfare channel).
o Some true capillaries connect directly from an arteriole to a metarteriole or venule.
Although the walls of true capillaries lack muscle fibers, they possess a ring of smooth
muscle called a precapillary sphincter where they emerge from the metarteriole. The
precapillary sphincter regulates blood flow through the capillary. There are three types
of true capillaries:

40.  Continuous capillaries have continuous, unbroken walls consisting of cells that
are connected by tight junctions. Most capillaries are of this type.
 Fenestrated capillaries have continuous walls between endothelial cells, but the
cells have numerous pores (fenestrations) that increase their permeability.
These capillaries are found in the kidneys, lining the small intestine, and in other
areas where a high transfer rate of substances into or out of the capillary is
required.
 Sinusoidal capillaries (sinusoids) have large gaps between endothelial cells that
permit the passage of blood cells. These capillaries are found in the bone
marrow, spleen, and liver.
Veins carry blood toward the heart. The three kinds of veins are listed here in the order that
they merge to form increasingly larger blood vessels:
o Postcapillary venules, the smallest veins, form when capillaries merge as they exit a
capillary bed. Much like capillaries, they are very porous, but with scattered smooth
muscle fibers in the tunica media.
o Venules form when postcapillary venules join. Although the walls of larger venules
contain all three layers, they are still porous enough to allow white blood cells to pass.
o Veins have walls with all three layers, but the tunica intima and tunica media are much
thinner than in similarly sized arteries. Few elastic or muscle fibers are present. The wall
consists of primarily of a well-developed tunica adventitia. Many veins, especially those
in the limbs, have valves, formed from folds of the tunica intima, which prevent the
backflow of blood.
Many regions of the body receive blood supplies from two or more arteries. The points where
these arteries merge are called arterial anastomoses. Arterial anastomoses allow tissues to receive
blood even after one of the arteries supplying blood has been blocked.
BLOOD FLOW THROUGH THE HEART
The heart has four chambers that pump
blood. The chambers are called the right atrium,
right ventricle, left atrium, and left ventricle. The
right and left sides of the heart are separated by
muscular wall called the septum. This prevents
blood without oxygen from mixing with
oxygenated blood. The heart also has valves that
separate the chambers and connect to major blood
vessels.
Blood flows from the body into the right
atrium. The blood on the right side of the heart
had been used by the body and is deoxygenated or
oxygen-poor.

41. The deoxygenated blood flows from the
right atrium through the tricuspid valve to the
right ventricle.
From the right ventricle, blood is pumped
through the pulmonary valve into the blood vessel
that goes to the lungs. This blood then picks up
oxygen becomes oxygenated or oxygen-rich.
Oxygenated blood flows from the lungs
through blood vessels back to the hearts left
atrium.
From the left atrium, blood goes through the mitral valve and into the left ventricle.
The left ventricle pumps blood through the aortic valve to a major blood vessel called aorta and
into systemic flow.
The blood delivers oxygen to the body, the returns through veins to the right atrium and repeats
the blood flow cycle.
BLOOD SUPPLY TO THE HEART
The coronary circulation consists of blood vessels, called
coronary arteries, which supply oxygen and nutrients to the
tissues of the heart. Blood entering the chambers of the heart
cannot provide this service because the endocardium is too
thick for effective diffusion (and only the left side of the heart
contains oxygenated blood). Instead, the following two arteries
that arise from the aorta and encircle the heart in the
artioventricular groove provide this function:
The left coronary artery has the following two
branches: The anterior interventricular artery (left anterior
descending, or LAD, artery) and the circumflex artery.
The right coronary artery has the following two
branches: The posterior interventricular artery and the
marginal artery.
The blood from the coronary circulation returns to the right atrium by way of an enlarged blood
vessel, the coronary sinus. Three veins, the great cardiac vein, the middle cardiac vein, and the small
cardiac vein, feed the coronary sinus.

42. CONDUCTION SYSTEM
1. Sinoatrial (SA)node - pacemaker, located at the
surface of the right atrium, impulse causes both atria to
contract (rate 60-100 BPM); a conduction pathway called
Bachman's bundle runs from right to left atrium allowing for
simultaneous atrial contractions. SA node sends impulse to
the AV node via the anterior, medial and posterior
internodal pathways.
2. Atrioventricular (AV) node - (rate 40-60 BPM) last
part of atria to be depolarized, sends impulse down the:
3. Bundle of His- distributes action potential over
medial surfaces of the ventricles (rate 20-40 BPM) runs to
the top of the interventricular septum to the:
4. Right and left bundle branches - Actual contraction
stimulated by conductive myofibers called Purkinje fibers
that pass into the fibers of the myocardium of the ventricles.

43. PATHOPHYSIOLOGY
Predisposing: Precipitating:
- Genetics - Environment = stress
- Age = at birth
Alteration in fetal development
signs and symptoms:
Fetal anomaly – present
T/C TOF - clubbing of fingers
- cyanosis
- Pulmonic Stenosis
- Deviation of the origin of the - murmur?
aorta to the right - barrel chest
- Dyspnesa
- Intraventricular
communication - Edematous
- Tachypnea
- Polycythemia
Mixing of oxygenated and
deoxygenated blood
Increased ventricular contraction
Decrease O2 supply to systemic
circulation
Right ventricular hypertrophy
Hypoxia
IF TREATED IF NOT TREATED
Diagnostic exam: transient increase in resistance
- CBC to blood flow to the lungs
- 2D echo
-ABG
worsen tet spells
Treatment:
- medications
- O2 therapy decreased organ perfusion
- surgery *including brain
- hypoxic brain injury
Partially-improved oxygenation
- organ failure
Poor prognosis
DEATH

44. A. Pulmonary Stenosis
A narrowing of the right ventricular outflow tract and can occur at the pulmonary valve (valvular
stenosis) or just below the pulmonary valve (infundibular stenosis). Infundibular stenosis os most caused
by overgrowth of the heart muscle wall (hypertrophy of the septoparietal trabeculae), however the
events leading to the formation of the overriding aorta are also believed to be a cause. The pulmonic
stenosis is the major cause of the malformations, with the other associated malformations acting as
compensatory mechanisms to the pulmonic stenosis. The degree of the stenosis varies between
individuals with TOF, and is the primary determinant of symptoms and severity. This infrequently
described as subpulmonary stenosis or subpulmonary obstruction.
B. Overriding Aorta
An aortic valve with biventricular connection, that is, it is situated above the ventricular septal
defect and connected to both the right and the left ventricle. The degree to which the aorta is attached
to the right ventricle is referred to as its degree of “override.” The aortic root can be displaced toward
the front (anteriorly) or directly above the septal defect, but it is always abnormally located to the root
of the pulmonary artery. The degree of the override is quite variable, with 5-95% of the valve being
connected to the right ventricle.
C. Ventricular Septal Defect (VSD)
It is a hole between the two bottom chambers (ventricles) of the heart. The defect is centred
around the most superior aspect of the ventricular septum (the outlet septum), and in the majority of
cases is single and large. In some cases thickening of the septum (septal hypertrophy) can narrow the
margins of the defect.
D. Right Ventrical Hypertrophy
The right ventricle is more muscular than normal, causing a characteristic boot-shaped (Coeur-
en-sabot) appearance as seen by chest X-ray. Due to the missarangement of the external ventricular
septum, the right ventricular wall increases in size to deal with the increases obstruction to the right
outflow tract. This feature is now generally agreed to be a secondary anomaly, as the level of
hypertrophy generally increases with age.
Etiology: The causes of most CHDs are unknown, although genetic studies suggest a multifactorial
etiology. Prenatal factors associated with a higher incidence of TOF include maternal rubella (or other
viral illnesses) during pregnancy, poor prenatal nutrition, maternal alcohol use, maternal age older than
40 years, and diabetes. Children with Down syndrome have a higher incidence of TOF.

45. PATHOPHYSIOLOGY:
Tetralogy of fallot results in low oxygenation of blood due to the mixing of oxygenated and
deoxygenated blood in the left ventricle via the VSD and the preferential flow of the mixed blood from
both ventricles through the aorta because of the obstruction to flow through the pulmonary valve. This
is known as right-to-left shunt. The primary symptom is low blood oxygen saturation with or without
cyanosis from birth or developing in the first year of life. If the baby is not cyanotic then it is sometimes
referred to as the “pink tet”. Other symptoms include a heart murmur which may range from almost
imperceptible to very loud, difficulty in feeding, failure to gain weight, retarded growth and physical
development, dyspnea on exertion, clubbing of the fingers and toes, and polycythemia.
Children with tetralogy of fallot may develop “tet spells”. The precise mechanism of these
episodes in doubt, but presumably results from a transient increase in resistance to blood flow to the
lungs with increased preferential flow of desaturated blood to the body. Tet spells are characterized by
a sudden, marked increase in cyanosis followed by syncope, and may result on hypoxic brain injury and
death. Older children will often squat during tet spell, which increases systemic vascular resistance and
allows for a temporary reversal of the shunt.
A small percentage of children with tetralogy of fallot may also have additional ventricular septal
defects, an atrial septal defect/ASD or abnormalities in the branching pattern of their coronary artieries.
Some patients with tetralogy of fallot have complete obstruction to flow from the right ventricle, or
pulmonary atresia. Tetralogy of fallot may be associated with chromosomal abnormalities, such as
22q11 deletion syndrome.
The pulmonary stenosis and right ventricular outflow tract obstruction seen with tetralogy of
fallot usually limits blood flow to the lungs. When blood flow to the lungs is restricted, the combination
of the ventricular septal defect and overriding aorta allows oxygen-poor blood (“blue”) returning to the
right atrium and right ventricle to be pumped out the aorta to the body.
The “shunting” of oxygen-poor from the right ventricle to the body results in a reduction in the
arterial oxygen saturation so that babies appear cyanotic, or blue. The cyanosis occurs because oxygen-
poor blood is darker and has a blue color, so that the lips and skin appear blue.
The extent of cyanosis is dependent on the amount of narrowing of the pulmonary valve and
right ventricular outflow tract. A narrower outflow tract from the right ventricle is more restrictive to
blood flow to the lungs, which in turn lowers the arterial oxygen level since more oxygen-poor blood is
shunted form the right ventricle to the aorta.
Tetralogy of fallot is most often diagnosed in the first few weeks of life due to either a loud
murmur or cyanosis. Babies with tetralogy of fallot usually have a patent ductus arteriousus at birth that
provides additional blood flow to the lungs, so severe cyanosis is rare early after birth. As the ductus
artesiosus closes, which is typically, will in the first days of life, cyanosis can develop or become more

46. severe. The degree of cyanosis is proportional to lung blood flow and thus depends upon the degree of
narrowing of the outflow tract to the pulmonary arteries. Rapid breathing in response to low oxygen
level and reduced pulmonary blood flow can occur. The heart murmur, which is commonly loud and
harsh, is often absent in the first few days of life. The arterial oxygen saturation of babies with tetralogy
of fallot can suddenly drop markedly. This phenomenon, called a “tetralogy spell,” usually results from a
sudden increased constriction of the outflow tract to the lungs so that pulmonary blood flow is further
restricted. The lips and skin of babies who have a sudden decrease in arterial oxygen level will appear
acutely bluer.
Children having a tetralogy spell will initially become extremely irritable in response to the
critically low oxygen levels, and they may become sleepy or unresponsive if the severe cyanosis persists.
A tetralogy spell can be treated by comforting the infant and flexing the knees forward and
upward. Most often, however, immediate medical attention is necessary.
When a newborn baby with significant cyanosis is first seen, they are often placed in
supplemental oxygen. The increased oxygen improves the child’s oxygen levels in cases of lung disease,
but breathing extra oxygen will have little effect on the oxygen levels of a child with tetralogy of fallot.
Failure to respond to this “hyperoxia test” is often the first clue to suspect a cyanotic cardiac
defect. Infants with tetralogy of fallot can have normal oxygen levels if the pulmonary stenosis is mild
(refered to as “pink” tetralogy of fallot). In these children, the first clue to suggest a cardiac defect is
detection of a loud murmur when the infant is examined.
Once congenital heart disease is suspected, echocardiography can rapidly and accurately
demonstrate the four related defects characteristics of tetralogy of fallot.
Cardiac catheterization is occasionally required to evaluate the size and distribution of the
pulmonary arteries and to clarify the branching patterns of the coronary arteries. Catheterization can
also demonstrate whether patients have pulmonary blood flow supplied by an abnormal blood vessel
from the aorta (aortopulmonary collateral).
Once tetralogy of fallot is diagnosed, the immediate management focuses on determining
whether the child’s oxygen levels are in a safe range.
If oxygen levels are critically low soon after birth, a prostaglandin infusion is usually initiated to
keep the ductus arteriosus open which will provide additional pulmonary blood flow and increase the
child’s oxygen levels.
These infants will usually require surgical intervention in the neonatal period. Infants with
normal oxygen levels are only mild cyanosis are usually able to go home in the first week of life.
Complete repair is usually done electively when the children are about six months of age, as
long as the oxygen levels remain adequate. Progressive or sudden decrease in oxygen saturation may
prompt earlier corrective repair.

47. Surgical correction of the defect is always necessary. Occasionally, patients will require a surgical
palliative prior to the final correction.
Corrrective repair of tetralogy of fallot involves closure of the ventricular septal defect with a
synthetic Dacron patch so that the blood can flow normally from the left ventricle to the aorta.
The narrowing of the pulmonary valve and right ventricular outflow tract is then augmented
(enlarged) by a combination of cutting away (resecting) obstructive muscle tissue in the right ventricle
and by enlarging the outflow pathway with a patch.
In some babies, however, the coronary arteries will branch across the right ventricular outflow
tract where the patch would normally be placed. In these babies, an incision in this area to place the
patch would damage the coronary artery so this cannot be safely done.
When this occurs, a hole is made in the front surface of the right ventricle to the bifurcation of
the pulmonary arteries to provide unobstructed blood flow from the right ventricle to the lungs.

48. Date Cues Need Nursing Diagnosis Objectives of care Intervention Evaluation
/Time
J Subjective: A Ineffective breathing That within 2 hours span 1. Assessed respiratory rate June 3, 2010
U “Lisod kaayo mu C pattern related to of care, the patient will be and depth monitor for nasal
N ginhawa.” T inability to maintain able to establish effective flaring, chest retractions and @
E I adequate rate respiratory pattern such cyanosis.
Objective: V and depth of as: ® To detect early signs of 7:30 pm
3 - shortness of I respiration respiratory compromise.
breathing noted T a. absence of use of GOAL PARTIALLY MET!
2 Y accessory muscles 2. Administered oxygen as
0 - nasal flaring noted ® Heart defect can ordered. After 2 hours span of care,
1 A cause breathlessness if b. respiratory rate will ® To help reduce the patient was not able to
0 - use of accessory N your heart is unable to stay within normal range: hypoxemia and to relieve establish effective
muscle in breathing D pump enough blood to Infant = 25 – 60 bpm respiratory distress. respiratory pattern
@ supply oxygen to your Children = 14 -25 bpm however:
- previous O2 Sat of E body. If your brain, Adult = 10 – 25 bpm 3. Placed on high back rest.
5:30 48.7% (May 30, 2010/ X muscles, or other body ® To promote lung a. patient still uses
pm 11:33) E organs do not receive c. demonstrate expansion. accessory muscles
R enough oxygen, a diaphragmatic pursed-lip
-with O2 inhalation of C sense of breathlessness breathing 4. Remain with the child and b. with respiratory rate of
2 lpm via nasal I may occur. offer reassurance during 30 bpm
cannula S d. relieved from of period of respiratory
E shortness of breath difficulty. c. demonstrate
- with respiratory rate ® To relieve anxiety. diaphragmatic pursed-lip
of 43 breathes per P breathing
minute A 5. Assist with activities of
T daily living as necessary. d. patient was slightly
- on moderate high T ® To help patient conserve relieved from shortness of
back rest E energy and to avoid fatigue. breath as evidenced by
R decreased irritability and
- irritability noted N 6. Teach the patient grunting
relaxation techniques, such
as diaphragmatic breathing
and pursed lip breathing

49. technique.
® This measure allows the
child to participate in
maintaining her health
status and may improve her
breathing pattern.

50. Date/ Cues Need Nursing Diagnosis Objective of Care Interventions Evaluation
Time
J Subjective: A Ineffective tissue per That within 8 hour span of 1. Monitored skin color and June 3, 2010
U “Lagum kayo siya C fusion care, the patient will be temperature every 2hours.
N tan-awon,” as T (cardiopulmonary) able to have adequate Assess for signs of skin @
E verbalized by the I related to decrease tissue perfusion as breakdown.
mother V oxygen cellular evidenced by: ®Cool, blanched, mottled skin 11:00 pm
3 I exchange secondary and cyanosis may indicate
Objectives: T to Congenital Heart a. absence or decrease tissue perfusion. GOAL PARTIALLY MET
2 - bluish Y Disease t/c Tetralogy bluish discoloration of lips;
0 discoloration on of Fallot 2. Monitored and After the 8 hour span of
1 lips noted A b. decrease respiratory rate documented patient’s vital care the patient was able to
0 N within normal range; and signs every hour. have adequate tissue
- clubbing of finger D ® Due to narrowing ®Decrease heart rate and perfusion as evidenced by:
@ noted of the artery which c. learn techniques to blood pressure may indicate
E small amount of minimize or lessen the risk increased arteriovenous a. still presence of bluish
3 pm - nasal flaring X oxygenated blood of decrease tissue exchange, which leads to discoloration of lips;
noted E can pass through the perfusion decrease tissue perfusion.
R systemic circulation b. with respiratory rate of
- use of accessory C which the patient 3. Keep patient warm. 25 cpm; and
muscle noted I experience difficulty ® Warmth aids vasodilation,
S in breathing. which improves tissue c. learned techniques to
- with capillary E perfusion. minimize or lessen the risk
refill time of 3 secs of decrease tissue perfusion
P 4. Elevate lower extremities. such as squatting
- with O2 of 2 lpm A ® To increase arterial blood
via nasal cannula as T supply and improve tissue
ordered T perfusion.
E
- body weakness R 5. Change position regularly
noted (always on N and inspect skin every shift.
bed) ® To avoid decrease in tissue
perfusion and risk of skin
- with hemoglobin breakdown.

51. of 225 mg/dL
Normal value: 6. Teach patient squatting
120 – 140 mg/dL techniques.
(taken on May 28, ® To promote tissue
2010) perfusion.
- hematocrit of 7. Maintained oxygen therapy
0.77 as ordered.
Normal value: ® To maximize oxygen
Male – 0.40 – 0.50 exchange in the alveoli and at
Female – 0.37 – the cellular level.
0.43
(taken on May 28, 8. Encouraged frequent rest
2010) periods.
® To conserve energy and
- ABG result taken maximize tissue perfusion.
on May 30, 2010/
11:33
pH - 72
PCO2 -30.5
PO2 – 30.5
HCO3 – 13.3
B.E. – 13.6
O2 sat – 46.7%
Normal Range:
pH –7.35 – 7.45
PCO2- 35 – 45
mmHg
PO2 – 75 -100
mmHg
HCO3 -20 – 29
mEq/dL
B.E. – -3 - +3 mmol
O2 sat – 95% -

52. 100%
-vital signs:
RR: 38 cpm
BP- 80/50
HR- 124 bpm

53. Date/ Cues Need Nursing Diagnosis Objective of Care Interventions Evaluation
Time
J Subjective: A Impaired gas That within 8 hour span of 1.) Established good and June 3, 2010
C exchange related to care the patient will be trusting relationship with the
U “Paspas lagi na T altered oxygen able to demonstrate patient and significant others. @
iyang paghinga”, I supply as evidenced
N improving ventilation as 11 pm
as verbalized by V by dyspnea, ®To gain both the trust and
I tachypnea, evidenced by:
E the mother cooperation. GOAL PARTIALLY MET
T tachycardia and
a. respiratory rate within
Y fatigue secondary to
Congenital Heart normal limits. (RR: 20 -25 2.) Monitored respiratory After the end of 8 hour span
rate/depth, use of accessory of care the patient was be
Objectives: A Disease t/c Tetralogy cpm);
3 muscles, areas of cyanosis. able to demonstrate
N of Fallot
- vital signs: D b. absence of cyanosis; improving ventilation as
® Indicators of adequacy of
c. clear breath sounds on respiratory function or degree evidenced by:
2 BP = 80/50 mmHg E ® Congenital heart
X disease refers to a both lung fields; and of compromise and therapy a. respiratory rate within
0 CR = 124 bpm E problem with the needs/effectiveness. normal limits. With RR of 25
R d. ABG test results within
RR = 28 cpm heart's structure and cpm
1 C normal range. 3.) Auscultated breath sounds,
function due to
I noting presence/absence, and b. presence of cyanosis
0 T = 37.1 C S abnormal heart
adventitious sounds.
E development before c. clear breath sounds on
- with O2
birth. It can disrupt I ® Development of atelectasis both lung fields
inhalation @ 2 lpm P the normal flow of and stasis of secretions can
@ via nasal cannula as A blood to the different impair gas exchange. d. There was no second ABG
ordered T parts of our body taken
T 4.) Monitored vital signs; note
- circumoral thus affecting
E changes in cardiac rhythm.
3 pm process of diffusion,
cyanosis noted R
N the exchange of ® Compensatory changes in
- skin warm to oxygen and carbon vital signs and development of
touch with good dioxide that occurs in dysrhythmias reflect effects of
the alveolar-capillary

54. skin turgor membrane area. hypoxia on cardiovascular
system.
- skin pallor
5.) Investigated reports of
- clubbing of nails
chest pain and increasing
noted fatigue. Observe for signs of
- with hemoglobin: increased fever, cough,
225 g/dL (Normal adventitious breath sounds.
value: 120-160
® Reflective of developing
g/dL) acute chest syndrome (i.e.,
- with IVF of D50.3 chest pain, dyspnea, fever,
NaCl @ 78 cc/hour and leukocytosis), which
increases the workload of the
- body malaise, heart and oxygen demand.
fatigue noted
6.) Assessed level of
-with Paracetamol consciousness/mentation
PRN for fever as regularly.
ordered
® Brain tissue is very sensitive
- irritability noted to decreases in oxygen and
may be an early indicator of
- with ABG result
developing hypoxia.
(taken on May 30,
2010/ 11:33) 7.) Assisted in turning,
coughing, and deep-breathing
pH- 7.23
exercises.
PCO2- 30.5
® Promotes optimal chest
HCO3- 13.3 expansion, mobilization of
secretions, and aeration of all

55. O2 sat- 46.7 lung fields; reduces risk of
stasis of
secretions/pneumonia.
8.) Evaluate activity tolerance;
limit activities to those within
patient tolerance or place
patient on bedrest. Assist with
ADLs and mobility as needed.
® Reduction of the metabolic
requirements of the body
reduces the oxygen
requirements/degree of
hypoxia.
9.) Encouraged patient to
alternate periods of rest and
activity. Schedule rest periods
as indicated.
® Protects from excessive
fatigue, reduces oxygen
demands/degree of hypoxia.
10.) Demonstrated and
encouraged use of relaxation
techniques, e.g., guided
imagery and visualization.
® Relaxation decreases muscle
tension and anxiety and hence

56. the metabolic demand for
oxygen.
11.) Promote adequate fluid
intake, e.g., 2–3 L/day within
cardiac tolerance.
® Sufficient intake is necessary
to provide for mobilization of
secretions and to prevent
hyperviscosity of
blood/capillary occlusion.
12.) Administered
supplemental humidified
oxygen as indicated.
® Maximizes oxygen transport
to tissues, particularly in
presence of pulmonary
insults/pneumonia. Note:
Oxygen should be given only
in the presence of confirmed
hypoxemia because oxygen
can suppress erythropoietin
levels, further reducing the
production of RBCs.
13.) Administered medications
as indicated:
Antipyretics, e.g.,

57. acetaminophen (Tylenol):
® Maintains normothermia to
reduce metabolic oxygen
demands without affecting
serum pH, which may occur
with aspirin.
14.) Administered antibiotics
as ordered.
® A broad-spectrum antibiotic
is started immediately
pending culture results of
suspected infections, then
may be changed when the
specific pathogen is identified.

58. Date/ Cues Need Nursing Diagnosis Objective of Care Interventions Evaluation
Time
J Subjective: N Hyperthermia r/t That within one hour span 1. Monitored vital signs. June 3, 2010
infectious process of care the patient will be
U “Sige lang mani U able to maintain core ® To provide baseline data. @
siya ug kalintura, temperature within
N T 2. Determined precipitating 7:30 pm
kada adlaw.”, as normal range from 38.9°C
verbalized by the ® Endocarditis is the factors.
E R inflammation and to 35.6 – 37.8°C as GOAL PARTIALLY MET
mother evidenced by: ® Identification and
I infection of the That within one hour span of
endocardium or valves of management of underlying
a. moist mucous cause are essential to care the patient will be able to
3 T the heart. The infection is maintain core temperature
Objectives: membranes; recovery.
generally caused by within normal range from
I
- with vital signs Streptococci of the b. will exhibit good skin 3. Note presence / absence 38.9°C to 37.1°C as evidenced
2 of: O viridians type. turgor; and of sweating as body by:
The Presence of antigen c. remain alert and attempts to increase heat
0 T – 38.9°C N a. patient still has dry mucous
evoked immune loss by evaporation,
responsive membranes;
1 P – 120 bpm A response, hyperthermia conduction and diffusion.
is defence mechanism ® Evaporation is decreased b. still has dry skin; and
0 R – 38 cpm L
reaction to body to try to by environmental factors of c. patient was responsive
BP – 90/60 mmHg - eliminate or destroy the high humidity and high
microorganism detected ambient temperature as
@ - with leukocyte M inside the body and also well as body factors
count of 4.6 x 10 hyperthermia is one of
E producing loss of ability to
9/L
the result of systemic sweat or sweat gland
6:30 normal range: T inflammation and dysfunction.
pm infection
5.0 – 10.0 x 10 9/L A 4. Provided tepid sponge
bath.
- irritability noted B

59. - with skin warm O ® To give a cooling effect
to touch thereby decreasing body
L temperature.
- dry mucous
membrane I 5. Provide ample amount of
C fluids.
- flushed face
noted ® To replace the loss of fluid
during fever.
- dry skin noted P
6. Removed excess clothing.
A
® To promote dissipation of
T heat.
T 7. Adviced the immediate
families to give patient
E
enough rest and sleep.
R
® Rest is recommendable to
N promote faster healing and
wellness.
8. Instructed to cover the
body with blanket.
® To minimize shivering.
9. Adviced significant others
to avoid using alcohol to rub
on the skin of the patient.
® Alcohol may cause chills,

60. actually elevating
temperature and alcohol is
very drying to skin.
10. Administered
antipyretics.
® used to reduce fever by its
central action on the
hypothalamus which is to
decrease the temperature.

61. Date/ Cues Need Nursing Diagnosis Objective of Care Interventions Evaluation
Time
June 4, 2010
Subjective: P Activity Intolerance Within a day span of care, 1. Established rapport.
J “Dili kaayo ko H related to imbalance the patient will be able to To promote trust and @
nagalihok ug mag Y between oxygen supply demonstrate tolerable communication.
U lakaw-lakaw kay S and demand secondary activities as evidenced: 2. Monitored vital signs. 5:00 pm
dali ra kaayo ko I to Congenital Heart To provide baseline
N hanguson.”, as O Disease t/c Tetralogy of a. get up and sit in bed; data. GOAL PARTIALLY MET
verbalized by the L Fallot b. get out of bed without 3. Monitored physiologic
E Within a day span of care, the
patient O assistance; and responses to increased
patient was able to
G During each heartbeat, c. vital signs with normal activity level.
demonstrate tolerable
Objectives: I typically about 60 to 90 range: To ensure return to
activities as evidenced;
3 - vital signs: C ml (about 2 to 3 oz) of normal within the span
RR - 42 cpm blood are pumped out of i. BP will range from of care.
a. “Makalingkod-lingkod
BP – 80/50 - the heart. The blood 80/50mmHg to 4. Discussed the need for
naku sa akong
CR – 120 bpm contains oxygen-bearing 90/60mmHg activity.
higdaanan, Ma’am.” as
2 - unable to sit in O red blood cells which ii. CR will range from To improve physical verbalized;
bed or get up X supplies blood to muscles 120 bpm to 100 and psychological well- b. BP ranged from
0 and walk Y and tissues in the body. bpm being. 80/50mmHg to
- always lie in bed G iii. RR will range from 5. Taught on how to
1 90/60mmHg;
- use of accessory E During congenital heart 42 cpm to 38 cpm conserve energy while c. However, the patient has
muscles in N disease, particularly the performing ADL (sitting
0 difficulty getting out of
breathing A tetralogy of fallot, there while dressing). bed and needs
- nasal flaring T would be low This measure assistance.
noted I oxygenation of blood due reduces cellular
- with O2 @ 2 lpm O to mixing of oxygenated metabolism and oxygen
@ via nasal N and deoxygenated blood demand.
cannula as in the left ventricle via 6. Taught on exercises for
ordered N Ventricular Septal Defect. increasing strength and
- cyanotic E The primary symptom is endurance (Active and
5:00
- poor capillary E low blood oxygen passive ROM).
pm
refill; more than D saturation. With or To improve
3 sec without cyanosis from breathing and gradually

62. - clubbing of birth. Due to such increase activity level.
fingers noted circumstances, 7. Supported and
- previous O2 Sat symptoms will include encouraged activity to
of 48.7% (May dyspnea on exertion, patient’s level of
30, 2010/ 11:33) clubbing of the fingers tolerance.
- ABG analysis – and toes and
respiratory polycytemia.
acidosis

64. PROGNOSIS
POOR FAIR GOOD
1 2 3 JUSTIFICATION
1. Duration of illness Since 2002, she was advised to undergo
surgical management but her family
opted not to follow the physician’s
♣
medical advice due to lack of financial
resources and they believed that the
condition of their daughter is just mild
2. Onset It was rated as poor because her family
did not seek medical attention
immediately due to lack of knowledge
♣
and later when they knew about the
condition, still they refused and was not
able to comply with the treatment
3. Precipitating During pregnancy, her mother
factors experienced fever but did not take
♣
medicines and was under stress due to
some family problems.
4. Willingness to They are willing to follow the physician’s
take medicines/ advice but due to lack of financial
compliance to
♣ resources they can’t comply with the
treatment regimen
ideal treatment that their daughter
should undergo
5. Age Since the condition is congenital, it only
♣ means that it cannot be avoided in such
ways and has no choice at all.

65. 6. Environment Since the family knew about her
condition, she has been provided with a
♣ comfortable environment wherein she is
able to have sufficient time to rest, yet
stressful situation are still present.
7. Family support The family supports the patient and has
total concern, but when it comes to
♣
other factors(financial), support
diminishes
COMPUTATION: Rating Scale:
POOR 1 x 3= 3 0 – 1.5 = Poor
FAIR 2 x 4= 8 1.5 – 2.0 = Fair
GOOD 3x0=0 2.0 – 2.5 = Good
TOTAL = 11/7 = 1.5 Poor
CONCLUSION:
Overall, the prognosis of the patient is poor. It has been almost 9 years that she suffered from
this condition without any treatment or procedure that could alleviate or possibly correct the abnormal
condition of her heart. As of this moment the only option she has is a surgical intervention that will
serve as a palliative care.

66. DISCHARGE PLANNING
M: medication
Instructed to:
Take medications as prescribed by the physician.
Ensure the right route in taking the medications.
Take the medications on time and without lapse.
E: exercise
Instructed to:
Do exercises within limits
Avoid the strenuous ones (E.g. walking for few minutes every morning).
Squatting
Active range of motion exercise
T: treatment
Instructed to:
Follow the prescribed treatment regimen.
Comply with the laboratory examinations.
Follow surgical treatment as ordered by the physician.
H: hygiene
Encouraged to bathe daily.
Instructed to do proper hand washing prior to and after handling the patient.
Taught to change the site dressings regularly.
O: outpatient orders
Encouraged to have frequent medical visits.
Taught to report any unusualities such as difficulty of breathing and decrease level of
consciousness.
Provided with oral and written information regarding this discharge plan.

67. D: diet
Instructed to:
Monitor the fluid intake and out put accurately.
Abide by the limited intake as prescribed.
Distribute the fluid intake over 24 hours as appropriate.
Consume High Fiber diet in order to prevent constipation and valsalva maneuver.
Limit salt intake to prevent further edema and cardiac overload.
Avoid processed foods.
Read labels of seasoning agents for sodium and potassium content.
Recommendation
We recommend further investigation on this case of a patient with Congenital
Heart Defect to consider Tetralogy of Fallot.
We recommend that the future researches will exert more effort in discovering
means of helping a client of the same situation not just for the sake of nursing care
but for showing that truly, nursing is a professio n that needs unending learning.