Transposition of The Great Arteries

Philippine Heart Center
CRITICAL CARE COURSE

60th Batch
CONGENITAL HEART DEFECT

dextro-TRANSPOSITION OF GREAT ARTERIES
Submitted to:
Maria Lilibeth Q. Icasiano R.N.

Coordinator
Submitted by:
Albarico Cindy E.
Algoso Virgilio D.C.
Allen, Meltimar O.
Alvero, Emily Rose B.
Araos, Hyacinth L.
Arellano, Michael Bernard F.
Bagarinao, Ma. Adel E.
Balverde, Marianne
Bañagale, Dianne Marie B.
Basco, Daniel Paul B.
Batoon, Mar Clement
Maninang, Yasmin Ann D.
I. INTRODUCTION
Transposition of the great arteries is a relatively common congenital heart condition

presenting in the neonate. It is the most common heart condition causing cyanosis at
birth. The overall annual incidence is 20-30 per 100,000 live births. It is more common in
males than females with a ratio of about 3:1. Maternal factors associated with an
increased risk include rubella or other viral illness during pregnancy, alcoholism,
maternal age over 40 and diabetes. Transposition is rarely associated with syndromes or
extra-cardiac malformations.
Moore (1995) found that TGA accounts for 27% of infant die from congenital heart
disease within the first month of life. By 6 months almost all TGA who are not treated are
dead, most of them dying before 3 months (Keith et al, 1967: Boesen, 1863A). Rashkind
(1966, 1968) has completely changed the outlook for TGA with his concept of balloon
atrial septostomy (BAS). BAS involves the introduction of a septostomy catheter from
the right atrium to the left atrium via a patent foramen ovale. The septostomy catheter has
a balloon at the tip which can be inflated when it is in the left atrium. When the balloon is
inflated the catheter is jerked back into the right atrium with considerable force, thereby
tearing the atrial septum and creating atrial septal defect (ASD). This ASD allows
bidirectional shunting at the level and with a good septostomy mostly uncomplicated
TGA will survive for 1-3 years when radical surgery (Mustard operation) is technically
easy. In the past surgical palliation most often used has been the creation of an inter-atrial
communication with Blalock-Hanton (1950) technique.
II. STATEMENT OF OBJECTIVES

III. PATIENT’S PROFILE
A. GENERAL DATA
NAME : Baby Boy Blue

AGE : 3 months
GENDER : Male
CITIZENSHIP : Filipino
RELIGION : Roman Catholic
BIRTHDATE : June 21, 2009
PLACE OF BIRTH : Marilao, Bulacan
CHIEF COMPLAINT : Dyspnea, Cyanosis
ADMITTING DIAGNOSIS : CHD, d-TGA, VSD, PDA, PFO
ATTENDING PHYSICIAN : Dr. Gamponia, Dr. Carlos
DATE OF ADMISSION : August 13, 2009
B. HISTORY
1. PERINATAL
a. Antenatal
The patient’s mother is a 30-year old prima gravida (G1P1) mother who had
regular prenatal consultation during her pregnancy. On the first trimester, the
mother contracted Urinary Tract Infection. An unrecalled antibiotic was
prescribed to her by her OB-GYNE for 7 days then recovered. As to her
recollection, she contracted no other disease.
b. Intrapartal
The patient was delivered full term via NSD at Nazareno Hospital in Marilao,
Bulacan.
c. Postpartal
Upon delivery via NSD, the baby was fairly active with good cry and suck, and
pinkish in appearance. A normal APGAR score was claimed by the pediatrician
as to the mother’s recollection.
2. FAMILY HISTORY
His parents have a known history of DM and HPN. Cardiac problems were also
evident in the family. His cousins, on both parents’ side, were diagnosed with
VSD. His uncle on his mother’s side was diagnosed with Down’s Syndrome.
3. SOCIO-ECONOMIC
Both of the patient’s parents are college graduates, working as sales supervisor
and store design officer in SM Department Store respectively.
4. HISTORY OF PRESENT ILLNESS

On his first week of life, the patient was apparently well until the mother noticed
weak cry. Patient had no history of interrupted feeding or cyanosis. No fever,
colds or cough noted at that time. Patient was then brought to a pediatrician who
referred them to an EENT doctor due to hoarseness of voice. Two days after,
patient was noted to be irritable with poor suck, poor activity and with episodes of
coughing of previously ingested milk, No consult was done at that time.
On his second week of life, there was persistence of symptoms and patient was
seen gasping by his mother thereby prompting consult with a pediatrician. Upon
auscultation, a murmur was heard and his CXR revealed pneumonia and
cardiomegaly. Patient was then advised for further consultation at any tertiary
hospital around Metro Manila. He was then admitted at UST hospital where
emergency intubation which hooked to a mechanical ventilator and was inserted
with OGT. He was initially treated for pneumonia and E-coli in the urine. His 2D-
ECHO revealed CHD, TGA with VSD, PFO, and PDA. Because the hospital is
not capable of such procedure, the pediatric cardiologist advised them to seek
consultation with the Philippine Heart Center. The patient was discharged but
with OGT in place.
Two days after discharge, the parents went to PHC for an emergency admission
but were refused due to problem in operation schedule which may occur in the
next two months. They were sent home advising them to continue infant’s
medication. On their way home, incessant crying and nailbed and circumoral
cyanosis were noted. They went back to PHC, hence they were admitted.
Admission was made on August 13, 2009 at 4:05 am.
C. INITIAL ASSESSMENT
1. Physical Assessment
Norms Actual Findings Interpretation and
Analysis
Physical Neat and clean Neat and clean Well-groomed.
Appearance
Head Rounded and smooth Rounded and smooth Normal.
Open anterior and posterior
fontanelles (HC 35cm)
Hair Evenly distributed Evenly distributed Normal.
Skin Color varies from Cyanotic, noted poor Increase amount of
ruddy pink to light capillary refill. deoxygenated hemoglobin;
pink associated with hypoxia.
Can be due to heart / lung
disease, cold environment.
Eyes Shiny smooth pink Shiny smooth pink Normal
conjunctiva conjunctiva
No edema
No edema/tenderness
over lacrimal gland No tearing Normal
No edema or tearing
Ears Sound is heard in Sound is heard in both ears Normal
both ears
Nose Nasal septum intact Nasal septum intact and in Normal
and in midline midline
Mouth Lips are pink, moist, Circumoral cyanosis noted. Increase amount of
symmetrical, and deoxygenated hemoglobin;
smooth. associated with hypoxia.
With presence of OGT For feeding purposes

Chest/ Lungs Symmetrical chest Symmetrical chest expansions Normal
expansions
Intercostal and Subcostal
No retractions retractions Hypoxemia
Clear breath sounds Crackles on bilateral lung Presence of secretions

fields
Presence of CHD
Dynamic precordium AB at
5th LICS LMCL, S1 normal,
S2 split, grade 3/6 PSM
LMSB
Extremities Limbs can be moved Noted spasticity on both To rule out cerebral palsy
freely upper extremity and lower
extremity
2. Vital Signs
Actual Findings Interpretation and Analysis

Temperature 36.4°C 36-37.5°C is still within the normal
range therefore 37.6°C is normal
Pulse rate 126 bpm Normal
Respiratory rate 30 cpm Normal
Blood pressure 90/P Normal
Weight 3.2 kg Normal
Height/Length 57 cm Normal
3. Neurological Assessment
Reflexes How Elicited Norms Findings Interpretation
Babinski Sole of foot is Fans out toes and Fanning of toes Normal
reflex stroked twists foot in
Blinking Flash of light or Closes eyes Eyes closed, blinks Normal

reflex puff of air striked rapidly
to the eyes
Grasping Palms are Palms grasps Forms a fist Normal
reflex touched tightly
Moro reflex Sudden movement Startles Throws out arms and Normal
/ loud noise is legs and then pulls
induced them toward body
Rooting Cheek is stroked Mouth turns Mouth turns towards Normal
reflex or side of mouth toward source, the source
is touched opens mouth and
sucks
Sucking Mouth is touched Sucks on the Sucks the source Normal
reflex by an object object
IV. PATHOPHYSIOLOGY
In transposition of the great arteries,

the aorta arises from the right ventricle
instead of the left, and the pulmonary
artery arises from the left ventricle
instead of the right. In a normal heart,
oxygen-depleted blood is pumped
from the right side of the heart,
through the pulmonary artery, to the
lungs where it is oxygenated. The
oxygen-rich blood then returns to the
left heart, via the pulmonary veins, and
is pumped through the aorta to the rest of the body, including the heart muscle itself.
With d-TGA, deoxygenated blood from the right heart is pumped immediately through
the aorta and circulated to the body and the heart itself completely deoxygenated,
bypassing the lungs altogether, while the left heart pumps oxygenated blood continuously
back into the lungs through the pulmonary artery. In effect, two separate "circular"
(parallel) circulatory systems are created, rather than the "figure 8" (in series) circulation
of a normal cardio-pulmonary system. This severe defect is incompatible with life. In
most instances, atrial and ventricular septal defect occur in connection with this
transposition, making the entire heart one mixed circulatory system.
Often, d-TGA accompanied by other heart defects. The most common type of these
defects being intracardiac shunts are atrial septal defect (ASD) including patent foramen
ovale (PFO), ventricular septal defect (VSD), and patent ductus arteriosus (PDA).
Stenosis of valves or vessels may also be present. When no other heart defects are present
it is called 'simple' d-TGA; when other defects are present it is called 'complex' d-TGA.
Although it may seem counterintuitive, complex d-TGA presents better chance of

survival and less developmental risks than simple d-TGA. This is because the left-to-right
and bidirectional shunting caused by the defects common to complex d-TGA allow a
higher amount of oxygen-rich blood to enter the systemic circulation.
Heart Development
The primordium of the heart forms in the cardiogenic plate located at the cranial end of
the embryo. Angiogenic cell clusters which lie in a horse-shoe shape configuration in the
plate coalesce to form two endocardial tubes. These tubes are then forced into the
thoracic region due to cephalic and lateral foldings where they fuse together forming a
single endocardial tube.
The tube can be subdivided into primordial heart chambers starting caudally at the inflow
end: the sinus venosus, primitive atria, ventricle, and bulbus cordis.
The heart tube begins to grow rapidly forcing it to bend upon itself. The result is the
bulboventricular loop. Septa begin to grow in the atria, ventricle and bulbus cordis to
form right and left atria, right and left ventricles and two great vessels- the pulmonary
artery and the aorta. By the end of the eighth week partitioning is completed and the fetal
heart has formed.
Week 3
Week 4 Week 5 6
Week 7-8
Atrial Partitioning
Figure 1
By the time the heart tube has formed the bulboventricular loop , the two primitive right
and left atria have fused to form a common atrium. Note that it now lies cranial to the
primitive ventricle and dorsal to the bulbus cordis. The truncus arteriosus lies on the roof
of the common atium causing a depression and indicates where septation of the atrium
will occur.
• AS = Aortic sac • LV = Left ventricle

• BC = Bulbus cordis • RA = Right atrium
• CC = Conus cordis • SV = Sinus venosus
• LA = Left atrium • TA = Truncus arteriosus
Figure 2
The partitioning of the atrium begins with the appearance of septum primum at about the
28th day. This is a crest of tissue that grows from the dorsal wall of the atrium towards
the endocardial cushions - - the ostium (opening) formed by the free edge of septum
primum is the ostium primum.
Figure 3
Before the septum primum fuses with the endocardial cushions, perforations appear in the
upper portion of the septum primum. These perforations will coelasce to form the ostium
secundum.
• SAO = Sinoatrial oriface • Perf = Perforations

• SS = Septum spurium • O1 = Ostium secundum
• S1 = Septum primum • EC = Endocardial cushions
Figure 4
Unlike the septum primum, septum secundum does not fuse with the endocardial
cushions. Its free edge forms the foramen ovale. The left venous valve and the septum
spurium, located on the dorsal wall of the right atrium, fuse with the septum secundum as
it grows.
• EC = Endocardial cushions • SS = Septum spurium

• LVV = Left venous valve • S1 = Septum primum
• O1 = Ostium secundum • S2 = Septum secundum
Figure 5
At the end of the seventh week the human heart has reached its final stage of
development. Because the fetus does not use its lungs, most of the blood is diverted to the
systemic circulation. This is accomplished by a right to left shunting of blood that occurs
between the two atria.
The foramen ovale and the septum primum control this right and left communication. The
septum primum acts as a valve over the foramen ovale. At birth the child will use its
lungs for the first time and consequently more blood will flow into the pulmonary
circulation. The pressure increase in the left atrium (where the pulmonary veins empty)
will force septum primum to be pushed up against septum secundum. Shortly thereafter
the two septa fuse to form a common atrial septum.
• O1 = Ostium primum
• S1 = Septum primum
• FO = Foramen ovale
• S2 = Septum secfundum
Fig 5
V. COURSE IN THE WARD
Day 1 August 13, 2009 Day of Admission

 The patient was drowsy and in respiratory distress with and tight air entry and decreased
breath sounds on both lung fields. Thus, he was intubated and hooked to mechanical
ventilator. Midazolam dirip 3.5 mg+diluents to make 12cc at 0.5 cc/hr was also started.
Nebulization with Salbutamol Q6 then CPPT were done.
 Arterial line was started; ABG‘s were frequently obtained and MV settings were
gradually adjusted accordingly
 WBC was elevated and blood and ETA GS/CS were done. The following antibiotics
were started.
 Piperacillin Tazobactam 150 mg IV Q6
 Amikacin 50 mg IV OD
 Chest X-ray revealed congestion, hence, Furosemide 3 mg TIV Q12 was given
 He had faint pulses and cyanotic nail beds, thus Dopamine drip (5:800) at 1.5 cc/hr was
initiated
 He was hypoglycemic thus D10W 7cc was given as IV bolus for Hgt 44mg/dl
 His weight was below his IBW, so feeding via OGT was eventually started as glucose
water 10cc Q3 then later progressed to milk formula 10cc/hr q3 x 2 doses and increased
by 10 cc Q feeding until 60 cc Q3 is reached.
Day 4 August 16, 2009

 The patient was referred to PIDS and pulmonologist for Arterial Switch Operation (ASO)
clearance.
 HR 131, RR60, BP 80P. Dopamine drip was decreased to (3:500). 0.8cc/hr then D/C.
 The following meds were started:
 Lanoxin elixir 0.25 ml Q12
 Captopril 200mg/pp tab, 1 pp tab Q12

 Blood and Urine C/S result showed no growth
 Patient was cleared for ASO and was referred to TCVS.
 The following supplements were started:
 Multivitamins drops 0.3 cc/day
 Ascorbic acid 0.3 cc/ day
 Heraclene 1 cap 10 Grains BID.

 Patient was scheduled for ASO on August 24, 2009 at 6:00 a.m.
 The following were secured in preparation for the operation:
 25% Human Albumin 1 vial
 Ilopress 1 ampoule
 PRBC 1 unit
 Cryoprecipitate 1 unit
 Platelet Concentrate 2 units
 Milrinone 10 cc.

 Pre-operative:
 Methyl prednisolone was given at 3:00 a.m.
 Patient was put on NPO
 ABG and CBG were taken
 Intra-operative (Surgery: VSD Patch Closure and Arterial Switch Operation)
 Duration of anesthesia 6:50 a.m. to 4:30 p.m.
 Duration of operation 8:16 a.m. to 4:30 p.m.
 Continuous bleeding was noted at the end of surgery probably at right coronary
site
 Hct went down from 0.30 to 0.15.
 PRBC, Plasma, and Platelet were transfused
 The following lines were maintained:
 ML 1 R CVP
 SD1 Levophed (o.4: 80) 0.8cc/hr
 SD2 NTG OFF
 SD3 Dopamine (20:1600) 2cc/hr
 SD4 Dobutamine (20:5000) 0.7cc/hr
 SD5 Epinephrine (0.5:40) 0.2 cc/hr
 SD6 Milrinone (0.54: 200) 0.6 cc/hr
 ML2 R femoral Blood line PRBC 15cc/hr
 ML3 L hand
 A-line L Femoral 1.5cc/hr
 LA-line 1.5cc/hr
 The following medication were given:
 Meropenem 70mg IV Q8
 Amikacin 50 mg IV OD
 Ranitidine 4mg IV Q12
 Ca Gluconate 250mg IV Q6
 Post-operative:
 Patients pupils were fixed dilated, hypotensive with BP 15/2, CR 0; CPR was
done and Epinephrine 1 amp and Atropine 2 doses given was given. Patient was
revived after 5 minutes. Patient was BP= 76/42 and CR= 126.
 Post CPR
 Pacer Setup revised: Rate 130, Atrial output 10, and Ventricular output 10
 The following medications were given:
 Na HCO3 13 mEqs+ EAD SIVP Stat
 Vit K 3 mg IV Stat
 Cryoprecipitate 20 ml
 Volume per volume replacement was done initially using D5 0.3 NaCl
then PRBC at 80cc/hr based on patient’s CT drain.

 (-) UO for 12 hours, thus:
 Referred to nephrologist for PD
 Tenckhoff catheter was inserted by TCVS
 PD started 1.5 L dialysate; infusion time 5-10 minutes. Dwelling time 20 mins;
draining 20 mins.
 JP drain of 49 cc was noted thus:
 Bleeding parameters were checked
 Vitamin K 3 mg IV Q6 was started
 PRBC and Platelet transfusion of 50ml/hr were done
 Patient was referred to hematologist
 The following were started:
 Mannitol 15cc IV for 2 hours then 10 ml Q6
 Dexamethasone 3.5 mg IV Q6
 FFP 10 to 15 ml/ kg/day OD

 Lip smacking for 6 seconds, nystagmus, stiffening of extremities, hence:
 Phenobarbital 35 mg was given stat
 Patient was referred to neurologist
 V-tach at 167bpm, BP 57/37 was noted, thus the following done:
 Defibrillation 7 joules to 14 joules; Rhythm was converted to sinus tachycardia
 Epinephrine was placed on hold
 Dobutamine and Levophed was decreased
 Calcium 1.8. Calcium gluconate 50 mg IV stat
 15 minutes after, twitching of extremities was noted thus the following were ordered:
 Phenobarbital 25 mg IV loading dose then 10 mg IV Q12
 Citicholine
 Cranial UTZ
 Patient had another episode of seizure. Midazolam 5mg +D5 0.3 8ml was increased from
0.2ml/hr to 0.4 ml/hr.
 BP 100/60, CR 182 thus, NTG (0.3:200) was started at 0.3 ml/hr
 Blood GS/CS was done. Amikacin was discontinued once Vancomycin was started.

 Hypokalemia was noted (Serum K 2.9 mmol/L) thus, KCL drip was started (2.3 mEqs
+12 ml)at 2 ml/hr
 Pre-operative: Placed on NPO
 An uneventful Sternal Closure was accomplished
 Duration of anesthesia 1:32 p.m. to 3:10 p.m.
 Duration of operation 1:57 p.m. to 3:10 p.m.
 Post-operative: Good chest rise was noted
 (+) copious ET secretions; NAC 40mg was started
 BP 87/57 mmHg; Levophed and Milrinone were discontinued
 CXR revealed decreasing of congestion, negative pleural effusion, negative
pneumothorax and re-expansion of atelectasis. Thus, CTT was pulled out per doctor’s
order
 Abdominal X-ray revealed abdominal bloating, thus the following were ordered:
 Abdominal girth measurement Q8
 Stool exam
 Metronidazole 30mg TIV Q6
 OGT draining by gravity
 (+) wakefulness was noted; thus, the following medications were tapered
gradually:
 Mannitol
 Phenobarbital
 Dexamethasone
 UO > 1cc/hr for 24 hours thus PD was placed on hold
 BP 70 systolic, hence, the following were ordered:
 Dopamine was increased (3:1600) at 0.4cc/hr
 NTG was decreased to (0.5:200) at 0.5cc/hr
Day 20 September 1, 2009

 Urine output more than 1 cc/hr for 48 hours. Tenckhoff catheter was removed and PD
was discontinued.
 Milk feeding was resumed at 15 cc Q3. Ranitidine was discontinued.
 Weaning from MV was started:
 SIMV mode for 2 hours alternated with AC mode for 1 hour tolerated
 SaO2 99% and RR 30’s

 Electrolyte imbalances (Mg 0.30, K 3.3) were noted, thus the following were given:
 MgSo4 80mg + EAD x 30 mins Q6 hrs for
 KCL 4 MEqs + D5IMB to make 10 cc x 4 hrs
 Dopamine and NTG were discontinued
 NAC was shifted to oral form 100 mg sachet + 5ml, 2.5 ml BID
 MV was shifted to Spontaneous mode with Pressure Support of 10cm H2O PEEP 3cm
H2O, Fio2 30. Retractions were noted. MV was shifted back to SIMV:
 Aminophylline drip 3mg + EAD x 3 hrs was started.
 Isolated PVC’s and occasional bigeminy were noted Lidocaine 3.5 IV was given then
Lidocaine drip (20:16000) was started

 Lanoxin elixir was started. K 3.3
 UO 10cc/kg/hr hence, Furosemide decreased to 1.5 mg IV Q12

 Wheezes and retraction were noted after 1 hour on Pressure Support Ventilator at 14cm
H2O thus the following were done:
 Nebulization and suctioning
 MV was shifted to SIMV
 Repeat CXR revealed pulmonary edema and positive air bronchogram
 TPAG was ordered.

 TP 43, Albumin 23, Globulin 20, A/G 1.15. 25% thus, Albumin 15 cc was transfused to
run for 4 hrs.
 Occasional PVC’S were noted. Repeat serum electrolytes showed hypomagnesemia Mg
0.60 hence, MgSo4 80 mg Q8 x 3 doses was given.

 Blank stare was noted and diazepam 1mg stat dose was given.

 SaO2 98.7%. Negative alar flaring, negative DOB on continuous alternate ventilator
settings.
 PSV was tolerated for 4 hours. Patient was for possible extubation.
 Dexamethasone 0.5 IV Q6 was ordered.

 Patient was placed on NPO then extubated and hooked to O2 inhalation at 6 LPM via FM
then was later decreased to 2LPM via NC.
 Feeding was resumed 5 hours post extubation.
 Muscle spasm of extremities was noted thus, Baclofen 0.7mg/pptab 1 pptab Q8 was
started.

 Negative episode of desaturation was noted thus, O2 was decreased to 0.5 LPM via NC
 Referred to rehabilitation for physical therapy

 Repeat CXR revealed atelectasis with consolidation, thus right lung up positioning and
CPT of RUL area after each nebulization were done
 CVP line was removed after shifting aminophylline to doxyphylline (ansimar) 100 mg/ 5
ml syrup 0.5 ml BID

 Domperidone 0.3 ml TID was started. NGT was shifted to OGT. Mother was allowed to
feed the patient.

 Patient have febrile episodes, thus, Ciprofloxacin 30 mg pptab BID was started.
 Inguinal line was removed then patient was transferred to ward per physicians order.

 (-) wheezes, (-) harsh breath sounds, (-) retraction
 Milk feeding was tolerated
 Patient is for possible discharge this week
DIAGNOSTIC AND THERAPEUTIC MANAGEMENT
A. Arterial Switch Operation
The Jatene procedure, or arterial switch, is an open heart surgical procedure used to
correct dextro-transposition of the great arteries (d-TGA); its development was pioneered
by Canadian cardiac surgeon William Mustard and it was named for Brazilian cardiac
surgeon Adib Jatene, who was the first to use it successfully. It was the first method of d-
TGA repair to be attempted, but the last to be put into regular use because of
technological limitations at the time of its conception. Use of the arterial switch is
historically preceded by two atrial switch methods: the Senning and Mustard procedures.
This surgery may be used in combination with other procedures for treatment of certain
cases of double outlet right ventricle (DORV) in which the great arteries are dextro-
transposed.
Timing
The Jatene procedure is ideally performed during the second week of life, before the left
ventricle adjusts to the lower pulmonary pressure and is therefore unable to support the
systemic circulation. In the event of sepsis or delayed diagnosis, a combination of
pulmonary artery banding (PAB) and shunt construction may be used to increase the left
ventricular mass sufficiently to make an arterial switch possible later in infancy.
Prognosis
The success of this procedure is largely dependent on the facilities available, the skill and
experience of the surgeon, and the general health of the patient. Under preferable
conditions, the intra-operative and post-operative success rate is 96% or more, with a
comparable survival rate after 5 years. Approximately 10% of arterial switch recipients
develop residual pulmonary stenosis post-operatively, which can lead to right heart
failure if left untreated; treatment usually involves endovascular stenting and/or xenograft
patching.
Method
Overview
General anaesthesia and cardiopulmonary bypass are used. The aorta and pulmonary
artery are detached from their native roots and reattached to the opposite root; thus, the
pulmonary root becomes the neo-aorta, and the aortic root becomes the neo-pulmonary
artery. The coronary arteries are transplanted from the aorta/neo-pulmonary artery to the
pulmonary artery/neo-aorta. Length of procedure, from initiation of anaesthesia to post-
operative cease thereof, is approximately 6-8 hours.
Preparatory
If the procedure is anticipated far enough in advance (with prenatal diagnosis, for
example), and the individual's blood type is known, a family member with a compatible
blood type may donate some or all of the blood needed for transfusion during the use of a
heart-lung machine (HLM). The patient's mother is normally unable to donate blood for
the transfusion, as she will not be able to donate blood during pregnancy (due to the
needs of the fetus) or for a few weeks after giving birth (due to blood loss), and the
process of collecting a sufficient amount of blood may take several weeks to a few
months. However, in cases where the individual has been diagnosed but surgery must be
delayed, maternal (or even autologous, in certain cases) blood donation may be possible,
as long as the mother has a compatible blood type. In most cases, though, the patient
receives a donation from a blood bank. A blood transfusion is necessary for the arterial
switch because the HLM needs its "circulation" filled with blood and an infant does not
have enough blood on their own to do this (in most cases, an adult would not require
blood transfusion).
The patient will require a number of imaging procedures in order to determine the
individual anatomy of the great arteries and, most importantly, the coronary arteries.
These may include angiography, magnetic resonance imaging (MRI), and/or computed
tomography (CT scan). The coronary arteries are carefully mapped out in order to avoid
unexpected intra-operative complications in transferring them from the native aorta to the
neo-aorta.
Pre-operative
As with any procedure requiring general anaesthesia, arterial switch recipients will need
to fast for several hours prior to the surgery to avoid the risk of choking on vomit while
unconscious. After the patient is anesthetized, they receive the following drugs via
intravenous drip, which continue as necessary throughout the procedure:
1. Aprotinin, to prevent excessive bleeding
2. Solumedrol, to reduce swelling and inflammation
3. Regitine, to prevent hypertension
4. Prophylactic antibiotics, to prevent infection
Intra-operative
The heart is accessed via median sternotomy, and the patient is given heparin to prevent
the blood from clotting. A generous section of pericardium is harvested, then disinfected
and sterilized with a weak solution of glutaraldehyde; and the coronary and great artery
anatomy are examined. The ductus arteriosus and right pulmonary branch, up to and
including the first branches in the hilum of the right lung, are separated from the
surrounding supportive tissue to allow mobility of the vessels. Silk marking sutures may
be placed in the pulmonary trunk at this time, to indicate the commissure of the aorta to
the neo-aorta; alternatively, this may be done later in the procedure.
The cardiopulmonary bypass is then initiated by inserting a cannula into the ascending
aorta as distally from the aortic root as possible while still supplying all arterial branches,
another cannula is inserted into the right atrium, and a vent is created for the left ventricle
via catheterization of the right superior pulmonary vein. The HLM is started at a low-
flow and the patient's body is cooled to a rectal temperature of 20 °C (68 °F), which
prevents the brain damage otherwise associated with the temporary circulatory arrest
necessary during the procedure; the patient must be cooled for a minimum of 20 minutes
prior to beginning the repair.
While the patient is cooling, the ductus arteriosus is ligated at both the aortic and
pulmonary ostia, then transected at its center; the left pulmonary branch, including the
first branches in the hilum of the left lung, is separated from the supportive tissue; and the
aorta is marked at the site it will be transected, which is just below the pulmonary
bifurcation, proximal to where the pulmonary artery will be transected.
When the patient is fully cooled, the ascending aorta is clamped as close as possible
below the HLM cannula, and cryocardioplegia is achieved by delivering cold blood to the
heart via the ascending aorta (below the cross clamp). The aorta is then transected at the
marked spot, and the pulmonary artery is transected a few millimetres below the
bifurcation. The vessels are again examined, and the pulmonary root is inspected for left
ventricular outflow tract obstruction (LVOTO). If a ventricular septal defect (VSD) is
present, it may be repaired, at this point via either the aortic or pulmonary valve; it may
alternatively be repaired later in the procedure.
The great arteries are usually arranged using the Lecompte maneuver, with the aortic
cross clamp positioned to hold the pulmonary artery anterior to the ascending aorta;
though with some congenital arrangements of the great arteries, such as side-by-side, this
is not possible and the arteries will be transplanted in the non-anatomic 'anterior aorta'
arrangement. If the aortic commissure has not yet been marked, it may be done at this
point, using the same method as would be used prior to bypass; however, there is a third
opportunity for this still later in the procedure.
Coronary arteries are examined closely, and the ostia and proximal arterial course are
identified, as are any infundibular branches, if they exist. The coronary ostia and a large
"button" of surrounding aortic wall are then excised from the aorta, well into the sinus of
Valsalva; and the proximal sections of the coronary arteries are separated from the
surface of the heart, which prevents tension or distortion after anastomosis to the neo-
aorta. Infundibular branches are sometimes unable to be spared, but this is a very rare
occurrence. If the aortic commissure has not previously been marked, the excised
coronary arteries will be used to determine the implantation position of the aorta.
The aorta is then transplanted onto the pulmonary root, using either absorbable or
permanent continuous suture. The aortic clamp is temporarily removed while small
sections of the neo-aorta are cut away to accommodate the coronary ostia, and a
continuous absorbable suture is then used to anastomose each coronary "button" into the
prepared space. In most cases, the coronary implantation sites will be at left and right
anterior positions at the base of the neo-aorta; however, if the circumflex coronary artery
branches from the right coronary artery, the circumflex coronary artery will be distorted
if the pair are not implanted higher than normal on the neo-aorta, and in some cases they
may need to be implanted above the aortic commissure, on the native aorta itself. The
circumflex coronary artery may originate from the same coronary sinus as, rather than
directly from, the right coronary artery, in which case they may still be excised on the
same "button" and transplanted similarly to if they had a shared ostium, unless one or
both have intramural communication with another coronary vessel. Sometimes, one or
more coronary ostia are located very close to the valvular opening and a small portion of
the native aortic valve must be removed when the coronary artery is excised, which
causes a generally mild, and usually well-tolerated, neo-pulmonary valve regurgitation.
The HLM is turned off and the aortic and atrial cannula are removed, then an incision is
made in the right atrium, through which the congenital or palliative atrial septal defect
(ASD) is repaired; where a Rashkind balloon atrial septostomy was used, the ASD should
be able to be closed with sutures, but cases involving large congenital ASDs or Blalock-
Hanlon atrial septectomy, a pericardial, xenograft, or Dacron patch may be necessary. If
there is a VSD which has not yet been repaired, this is performed via the atrial incision
and tricuspid valve, using sutures for a small defect or a patch for a large defect.
When the septal defects have been repaired and the atrial incision is closed, the
previously removed cannula are replaced and the HLM is restarted. The left ventricle is
then vented and the cross clamp removed from the aorta, enabling full-flow to be re-
established and rewarming to begin; at this point the patient will receive an additional
dose of Regatine to keep blood pressure under control. The previously harvested
pericardium is then used to patch the coronary explantation sites, and to extend - and
widen, if necessary - the neo-pulmonary root, which allows the pulmonary artery to be
anastamosed without residual tension; the pulmonary artery is then transplanted to the
neo-pulmonary root.
Final stages
The patient is fitted with chest tubes, temporary pacemaker leads, and ventilated before
weaning from the HLM is begun; and administration of post-operative drugs is initiated,
these include:
1. muscle relaxant, to induce temporary paralysis
2. opioid analgesic, to manage pain, cause sedation and induce serenity
3. inotrope, to assist the heart in contracting adequately
The rib cage is relaxed and the external surgical wound is bandaged, but the sternum and
chest incision are left open to provide extra room in the pleural cavity, allowing the heart
room to swell and preventing pressure caused by pleural effusion.
Post-operative
The sternum and chest can usually be closed within a few days; however, the chest tubes,
pacemaker, ventilator, and drugs may still be required after this time. The patient will
continue to fast for up to a few days, and breastmilk or infant formula can then be
gradually introduced via nasogastric tube (NG tube); the primary goal after a successful
arterial switch, and before hospital discharge, is for the infant to gain back the weight
they have lost and continue to gain weight at a normal or near-normal rate.
NURSING RESPONSIBILITIES
A. Pre-op Nursing Care
1. Pre-op Assessment
Purposes: Obtain patient information, Give information, and Get consent. Also allows
assessment of emotional state and expectations. Careful assessment is necessary in order
to prevent operative complications and alert nurse to postoperative care needs.
• History and physical exam (must be completed by the physician, reviewed by the nurse,
and a separate nursing assessment must be completed. Nursing assessment is holistic -
baseline data - identify potential problems. Use lay terms in your questioning. Finally, an
anesthesia preop assessment is usually written in the chart as well.
a. Vital Signs
• Preoperative and baseline. Reveal abnormalities and establish norms.
b. Past surgical history
• Generally, also previous bad outcomes or distressing experiences

• Also ask what type anesthesia they have had.
c. Allergies
• Need to be questioned about any allergies to medications, foods, substances.
Clearly identify any allergies on the front of the chart. In OR, must be alert to any
allergic responses since patient will not be able to advocate for self.
• In OR, particularly concerned with allergies to tape, latex, iodine.
• Distinguish between allergies and adverse reactions.
d. Nutritional State
• Patients who are healthy will recover better than individual not in homeostasis.
Need to assess nutritional state (ideal body weight, loss of SQ fat, edema,
lymphocyte count, serum albumin).
• Protein is essential for tissue repair. CHO provides the necessary energy for tissue
repair. Vitamins necessary (Vit B maintains GI function, Vit C promotes wound
healing and collagen formation, Vit K promotes clotting)
e. Body Weight
• Most are weighed before surgery (basis for anesthetic drug dose)
• Obesity: more complicated. Increased potential for dehiscence and evisceration,
wound infection. Takes more anesthesia and stored in adipose tissue delaying
excretion.
• More post-op complications - respiratory, ambulation
• Underweight: lack of protein stores. Diet high in PRO, CHO, VIT.
f. Fluid / Electrolyte Balance
• Correction of any imbalance is essential. Patients prone to hypovolemia: diarrhea,

vomiting, bleeding, insufficient fluid intake, GI bleed. Need to assess for
dehydration (skin turgor, mucous membranes, I/O)
• Hypervolemia: renal failure, CHF, malnutrition.
• electroytes: NA, K, Cl, Ca, Mg. (BUN, Creat for kidney function)
• "Routine bloodwork" concept is giving way to minimal labs based on complexity of
procedure and findings in H&P.
g. Infections
• Unless the reason for surgery is an infection (I and D), then surgery will always be
rescheduled if evidence of infection. Assessment, temperature, WBC.
h. Chronic Illness
• Chronic illness can complicate the postoperative phase

• Respiratory (COPD): increase pneumonia, decrease ability to exchange CO2 and O2
• Asthma - intraop bronchospasm
• Cardiac disease: prosthetic valves increases post op inflammatory process and
potential for infection. PVD impairs tissue and wound healing. Increase risk for
thrombophlebitis
• Hematologic disorders: risk of hemorrhage with clotting disorders. Anemia can
compound the surgical loss of blood leading to hypovolemia/shock.
• Endocrine disorders: DM may experience hypo/hyperglycemia during the surgical
period. Increase risk of infection, silent MI, peripheral nerve injury, difficult
intubation. Other endocrine disorders can alter the stress response (thyroid,
pheochromocytoma).
• Neurological disorders: neuro assessment provides a baseline for post operative.
Incorporate care of chronic neurological disorder into care.
• GI disorders: adequate liver function is necessary for the detoxification of drugs.
(Hx of PUD, constipation)
• Renal disorders: kidneys responsible for excretion of waste and maintenance of
fluid and electrolyte balance. If CRF then need careful assessment of preop: I & O,
specific gravity of urine, and adequate fluid intake.
• Musculoskeletal disorders: ROM
i. Integumentary Status: pressure ulcers from immobility

j. Drug History: Prescription as well as OTC usage
• antibiotics: combine with curare to prolong apnea.

• Valvular disease or prosthesis may need antibiotics prophylaxis anticoagulants:
increase bleeding time
• diuretics: hypokalemia
• steroids: decrease adrenal function
• aspirin: decreased platelet aggregation
• tranquilizers: hypotension and shock
• Note: anti-HTN medications usually continued through the am of surgery (this used
to be avoided fearing hypotension, now done to promote control without as many
oscillations)
2. Preoperative Teaching
Instruction is essential. Research demonstrates that those who are informed will have better
recovery. Best time to teach is the afternoon or evening before surgery. Challenging when most
are same day admits - even carotids or heart surgery. Important because it decreases anxiety,
influences recovery, promotes patient satisfaction.
A. General Principles of Preop teaching
1. Reinforce what the patient parent has been told about surgery. Find out patient’s
parents understanding of procedure first. Know enough basic information about
common procedures to anticipate and answer the common questions.
2. Balance telling too little vs too much
3. Avoid anxiety producing words -- "pain" (discomfort)
4. Include family members, if possible
5. Prepare for situations (cold, bright light, never left alone)
B. Patient Teaching About Postoperative Care
1. Therapeutic devices: indwelling catheter, nasogastric tube, chest tube

2. Medications for Pain: assured that medication will be available, PCA devices.
3. Postoperative self-care procedures: Cough and Deep Breathing, splinting, leg
exercises, turning
 Preop legal preparation—the Operative Permit It is the surgeon’s

responsibility to explain the surgical procedure, alternatives, risks, and
benefits. Purpose is to ensure the patient is not undergoing a procedure
without informed consent. Helps protect from liability. Adults must be
oriented and not under sedation in order to sign. May take a telephone
consent. Consent is witnessed - that is a witness to the signature.
3. Day of surgery preparation
A. Physical Preparation
• Nursing responsibilities: orders carried out, final preparations done, records complete
and accompany patient to OR.
• Diet: NPO after midnight (allow time for the stomach to empty, decrease aspiration)
or at least 4-8 hours.
• Skin Preparation: decrease bacteria to a minimum. Mild antiseptic soap and water the
night or day before. Shaving can increase skin bacteria.
• Bowel Preparation: type of surgery determines the need for a bowel prep. Enema or
laxative may be administered to permit visualization of the colon and decrease chance
of infection when bowel is resected.
B. Medications Table
Sedative to ensure adequate rest and to decrease anxiety (midazolam, diazepam, lorazepam).
Preanesthetic agent may be given 30 minutes to 1 hour before surgery to promote sleep and
relaxation. No consent if sedated-- get it signed before giving. Also, void before giving.
1. Sedatives: decrease the anxiety ie benzodiazepines, barbiturates

2. Narcotic analgesic: reduce the amount of anesthetic needed. Given 30 minutes to 1 hour
before sx, often IM
3. Anticholinergic: reduce secretions. Also cause dry mouth and dilatation of the pupils.
(Atropine or Robinul).
4. Tranquilizer: may be given instead of a narcotic, especially to the elderly. (Valium or
Phenergan).
o VS before the pre-op injection (consent signed, etc.)
C. Information for the family
• What time the procedure will be done, how long it will take, that the physician will
communicate progression and recovery until out of anesthetic agent.
D. Preoperative Checklist / Transportation to the OR
Nursing responsibility to see that the checklist is completed--important, shows that the patient is
ready for transfer to the OR. Unusual observations and abnormal labs are reported to the
physician. "If you want to take care of the patient, take care of the paperwork"
• NPO 6 hours adults, less for the very tiny. NPO before ALL types of anesthesia. Explain
reasons for restriction and importance, mark cardex, inform other caretakers, don’t leave
pitcher at bedside. Signed OR Consent
• Current history and physical (the surgeon’s, as opposed to your nursing assessment and
anesthesia assessment)
• Completion of physical preparation
• Vital signs
• Void on call
• Recording of preop medication
• ID band in proper order
2. THE INTRAOPERATIVE PHASE
A. Introduction
• Transfer to surgery (preop hold or direct to OR room). Floor RN checks chart and makes
certain the patient is correctly identified ("What is your name?"). Will be transferred to
the OR on a gurney. Family is given instructions.
• In holding area, final surgical preparations are made. Preop, RN repeats checks,
abdominal prep. prn, IV.
B. Wound Closure
• Contaminated wounds are left open to heal. Otherwise closed in layers.

• Sutures: absorbable or nonabsorbable - require removal
• Sterile adhesive strips
• Retention sutures (provides a secondary suture which relieves undue strain on the suture
line. Suture is passed through a small tube or over a plastic bridge that is placed on the
skin.
• Staples: reduces edema and inflammation because manipulation and handling has been
reduced.
3. NURSING MANAGEMENT OF THE POSTOPERATIVE PATIENT
A. Transfer to Recovery Room (PACU) Two stressors the patient is recovering from:
surgery and anesthesia.
• Transferred to recovery room by circulating nurse and CRNA.

• Close observation. 1:1 or 1:2.
• Standard and emergency equipment are present (like ICU).
• Almost all receive oxygen
• Monitoring is individualized to patient need and type of surgery. Continuous, then up
to q15m: EKG, NIBP, pulse oximetry, Intake & output
• All preop orders are discontinued postop, rewritten in PACU (vitals, position,
medications, IV, type of PO intake, activity, diagnostic tests, dressing changes).
B. Immediate postoperative complications "ABC"
Airway obstruction
• Causes: effects of anesthestics, effects of narcotics given intraop or postop,
secretions, swelling from a surgical site in the neck
• S/S: snoring respirations, "rocking boat", apnea
• Treatment: stimulation, chin lift, jaw thrust, nasal or oral airways, reintubation,
mechanical ventilation
Breathing: Respiratory insufficiency
• S/S: shallow respirations, restlessness or other signs of hypoxemia, ABGs, pulse

oximetry < 90%
Circulation
• Causes: Internal hemorrhage: may occur from insecure sutures, erosion of a vessel.
• S/S: rapid, deep respirations, rapid thready pulse, hypotension with narrow pulse
pressure, cool, moist, pale skin, restlessness, faintness, dizziness, thirst.
• Treatment: flat, pressure, IV, blood.
• Shock
o Cause: decreased perfusion of tissues. Hemorrhage, trauma, anesthesia,
pooling, or anaphylactic shock.
o Treatment: Change position slowly, avoid Fowler’s, raise legs
• Other problems
• Pain
• Nausea and vomiting
• Neurological problems (delayed emergence, delirium, problems related to the surgery
type i.e. carotid endarterectomy vs lumbar laminectomy)
• Hypothermia
C. Transfer to floor
Ready to be discharged to the floor once
• patent airway with sufficient • stable vital signs

ventilation • normal movement
• improving LOC • responds to questions
D. Postop care includes:
• Immediate rapid assessment, then review all systems

• VS and assessments every 15 minutes x4, q30m x 4, q1hrx4, q4h until 24 hrs has elapsed.
• Temperature/Infection. Don’t change first dressing, that’s the surgeon’s prerogative.
Reinforce only.
• Fluid intake/output (usually until oral intake reestablished)
• Safety: ready equipment, raise side rails, call bell, assist OOB, etc.
• Comfort and rest
• Pulmonary Chest Physiotherapy and Range of motion exercises
E. Drains are soft rubber tubular structures placed in wounds to
• remove fluid (blood, pus)

• prevent deep wound infections in areas that may contain purulent material
• obliterate dead spaces
• Types
o Penrose: open gravity drain. Safety pin placed on the external end of these drains
to prevent them from sliding back into the wound. Usually inserted into a nearby
stab wound rather than the surgical wound to allow the surgical wound to heal
properly.
o Perforated catheter and the proximal end is placed into a closed portable suction
device which creates gentle constant suction.
o Jackson Pratt: small reservoir bulb where fluid collects. After emptied it is
compressed and the spout closed to create negative pressure.
F. Complications Related To Surgery

Stress can cause serious complications and nursing care is aimed at preventing
complications. Vigilant assessment can determine presence of complications, and good
nursing care can help prevent some complications.
1. Pulmonary Problems
"Temperature elevations after surgery are due to wind, water, then wound."
• Report fever > 101.5 F . Treat fever < this with chest physiotherapy, oral intake.
• Risk factors: general anesthesia, obese, smokers, lung disease, surgery on upper
abdomen, airway, or chest
• Atelectasis: collapse of alveoli in a portion of the lung. See more in persons with
upper abdominal surgeries because of the reluctance to chest physiotherapy S/S:
decreased breath sounds, diminished chest expansion (affected side), fever,
tachycardia, decreased cough. TX: antibiotics, decrease viscosity of secretions, chest
physiotherapy, Turn q 2h. Don’t forget to get them moving even if you feel sorry for
them.
• Pneumonia: inflammation of the lungs usually due to bacteria. Lower lobes. S/S:
similar to atelectasis. Tx: antibiotics, fluids, C & DB, turn.
• Pulmonary embolism: dislodgement of a thrombus from a vein which lodges in the
branch of the lung. S/S: severe, sudden SOB, chest pain, tachypnea, tachycardia,
anxiety. Prevention/Tx: early ambulation (if SBR, leg exercises or SCD or TEDs),
anticoagulants, antibiotics.
• Other problems: airway obstruction, hypoxemia, pulmonary edema, aspiration of
gastric contents, bronchospasm, hypoventilation
2. Cardiovascular Problems
• Orthostatic hypotension: a change in BP when changing from supine to upright.

Causes: cardiac, hemorrhage, medications. SS. Hypotension when standing,
tachycardia, faintness. Tx: change positions slowly. Thrombophlebitis may develop
from stasis and hypovolemia.
• Other problems: Hypertension, arrhythmias.
3. Neurologic problems
• Emergence delirium
• Delayed awakening
• CVA or decreased LOC related to cerebral blood supply interruptions related to
surgery
4. Hypothermia
• Risk factors: extremes of age, debilitated, intoxicated, long surgery time
5. Pain
• They’re not just being babies.

• Don’t resent their demands or be fearful of addiction
• Don’t just think of IM drugs-- many other techniques available including PCA,
epidural catheters, NSAIDS
6. Nausea and vomiting
• PONV a huge problem 30-70% based on population sampled. Worsened with

narcotics, movement, female gender. Tx: pharmacologic ie droperidol Inapsine®,
diphenhydramine Benadryl®, dimenhydrinate Dramamine®, ondansetron Zofran®,
etc.
7. Fluid and electrolyte problems
• Hypovolemia: decreased fluid intake: dry mouth, thirst, decreased skin turgor,
decreasing urine output, tachycardia, dry skin. Tx: fluid replacement.
• Hypervolemia: IV fluids more than cardiovascular system can handle. Fluids are
retained the first 24 to 48 hours because of stimulation for ADH. s/s: crackles,
increased respiration, pulse, BP, edema, increased urine output. Tx: decreased fluid
intake.
• Urinary retention because of trauma from surgery. Other causes include anesthetics,
anticholinergics, positioning. S/S: inability to void, bladder distension. Tx:
catheterization, give privacy, allow to stand, warm water over perineum, or just the
sound of running water.
• Renal failure: from inadequate kidney perfusion related to hypotension. S/S:
decreasing urine output in spite of adequate intake. Oliguria, increasing BUN, creat.
Tx: 250-500 ml in 30 minutes, U.O increases then due to hypovolemia.
• Hypokalemia: loss of blood, GI fluid
• Hyperkalemia: IV fluids
• Hyponatremia: loss of body fluids, vomiting, diarrhea
8. Incisional Problems
• Wound infection may develop due to 1) surface bacteria, 2) contamination during sx,
3) tissue infected prior to sx. S/S: wound pain, temperature. Tx: open the wound and
allow to drain.
• Dehiscence: partial to total separation of all layers of the incision. Evisceration:
rupture of all layers of the incision with extrusion of abdominal organs. Usually occur
in infected wounds and related to coughing, vomiting, and distension.
• Treatment: dehiscence - taping or suturing the incision. Evisceration - sudden
profuse, pink drainage, exposed loops of the intestine. Tx: immediate covering of the
loops with sterile towels and saline, notify the MD, low fowler’s and knees flexed to
support organs, withhold food and fluids, IV to prevent shock.
B. Peritoneal Dialysis (PD)
In this procedure, dialysate—the solution instilled into the peritoneal cavity by a catheter
—draws waste products, excess fluid and electrolytes from the blood across the
semipermeable peritoneal membrane. After a prescribed period, the dialysate is drained
from the peritoneal cavity, removing impurities with it. The dialysis procedure is then
repeated, using a new dialysate each time, until waste removal is complete, and fluid,
electrolyte, and acid base balance has been restored. The catheter is inserted in the
operating room or in an acute situation or at the patient’s bedside with a nurse assisting.
With special preparation, the nurse may perform dialysis, either manually or using an
automatic or semiautomatic cycle machine.
Indication:
For patients with renal failure who have cardiovascular instability, vascular access
problems that prevent hemodialysis, fluid overload, or electrolyte imbalances.
Nursing Responsibilities:
1. During and after dialysis, monitor the patient and his response to treatment. PD is
usually contraindicated in patients who have had extensive abdominal or bowel
surgery or extensive abdominal trauma.
2. Monitor the patient’s vital signs every 10-15 minutes for the first 1 to 2 hours of
exchanges, then every 2 to 4 hours, or more frequently if necessary. Notify the
practitioner of any abrupt changes in the patient’s condition.
3. To reduce the risk of peritonitis, use strict sterile technique during catheter
insertion, dialysis, and dressing changes. Masks should be worn by all personnel
in the room whenever the dialysis system is opened or entered. Change the
dressing at least every 24 hours or whenever it becomes wet or soiled. Frequent
dressing changes will also help prevent skin excoriation from any leakage.
4. To prevent respiratory distress, position the patient for maximum lung expansion.
Promote lung expansion through turning and deep- breathing exercises. In some
patients, decreasing volumes may be necessary.
5. If the patient suffers severe respiratory distress during the dwell phase of dialysis,
drain the peritoneal cavity and notify the practitioner. Monitor any patient on PD
who is being weaned from a ventilator.
6. To prevent protein depletion, the practitioner may order a high-protein diet or

protein supplement. He will also monitor serum albumin.
7. Patients with low serum potassium levels may require the addition of potassium to
the dialysate solution to prevent further losses.
8. Monitor fluid volume balance, blood pressure, and pulse to prevent fluid
imbalance. Assess fluid balance at the end of each infusion-dwell-drain cycle.
Fluid balance is positive if less than the amount infused was recovered; it is
negative if more than the amount infused was recovered.
9. Weigh the patient daily to help determine how much fluid is being removed
during dialysis treatment. Note the time and the variations in the weighing
technique next to his weight on his chart.
10. If inflow and outflow are slow or absent, check the tubing for kinks. Also try
raising the IV pole or repositioning the patient to increase the inflow rate.
Repositioning the patient or applying manual pressure to the lateral aspect of the
patient’s abdomen may also help increase drainage. If these maneuvers fail, notify
the practitioner. Improper positioning of the catheter or an accumulation of fibrin
may obstruct the catheter.
11. Always examine outflow fluid (effluent) for color and clarity. Normally it is clear
or pale yellow, but pink-tinged effluent may appear during the first 3 or 4 cycles.
If the effluent remains pink-tinged, or if it is grossly bloody, suspect bleeding into
the peritoneal cavity and notify the practitioner. Also notify the practitioner if the
outflow contains feces, which suggests bowel perforation, or if it is cloudy, which
suggests peritonitis. Obtain a sample for culture and gram stain. Send the sample
in a labeled specimen container to the laboratory with a laboratory request form.
12. Patient discomfort at the start of the procedure is normal. If the patient
experiences pain during the procedure, determine when it occurs, its quality and
duration, and whether it radiates to other body parts. Then notify the practitioner.
Pain during infusion usually results from a dialysate that is too cool or acidic.
Pain may also resolve from rapid inflow; Slowing the inflow rate may reduce the
pain. Severe, diffuse pain with rebound tenderness and cloudy effluent may
indicate peritoneal infection.
13. The patient undergoing PD will require a great deal of assistance in his daily care.
To minimize his discomfort, perform daily care during a drain phase in the cycle,
when the patient’s abdomen is less distended.
C. Mechanical Ventilation
A mechanical ventilator moves air in and out of a patient’s lungs. Although the
equipment serves to ventilate a patient, it does not ensure adequate gas exchange.
Mechanical ventilators may use either a positive or negative pressure to ventilate patients.
Other indications for ventilator use include central nervous system disorders such as
cerebral hemorrhage and spinal cord transaction, adult respiratory distress syndrome,
pulmonary edema, chronic obstructive pulmonary disease, flail chest, and acute
hypoventilation.
Nursing Responsibilities:
1. Provide emotional support during all phases of mechanical ventilation to reduce his
anxiety and promote successful treatment.
2. Make sure the ventilator alarms are on at all times. These alarms alert the nursing
staff to potentially hazardous conditions and changes in the patient’s status. IF alarm
sounds and if the problem cannot be identified easily, disconnect the patient from the
ventilator and use a handheld resuscitation bag to ventilate him.
3. Unless contraindicated, turn the patient from side to side every 1 to 2 hours to
facilitate lung expansion and removal of secretions. Perform active or passive ROM
exercises for all extremities to reduce the hazards of immobility. If the patient’s
condition permits, position him upright at regular intervals to increase lung
expansion. When moving the patient or the ventilator tubing, be careful to prevent
condensation in the tubing from flowing into the lungs, because aspiration of this
contaminated moisture can cause infection. Provide care for the patient’s artificial
airway as needed.
4. Assess the patient’s peripheral circulation, and monitor his urine output for signs of
decreased cardiac output. Watch for signs and symptoms of fluid volume excess or
dehydration.
5. Administer a sedative or neuromuscular blocking agent as ordered to relax the

patient. Remember that the patient receiving a neuromuscular blocking drug requires
close infection because of his inability to breathe or communicate.
6. Make sure that the patient gets adequate rest and sleep because fatigue can delay
weaning from the ventilator. Provide subdued lightning, safely muffle equipment
noises, and restrict staff access to the area to promote silence during rest periods.
7. When weaning the patient, continue to observe for signs of hypoxia. Schedule
weaning to fit comfortably and realistically with the patient’s regimen. Avoid
scheduling sessions after meals, bath, or lengthy therapeutic or diagnostic procedures.
DIAGNOSTIC PROCEDURES
 Complete Blood Count
Pre Operative Post Operative

August August August August August August September September
13 22 24 25 27 29 9 17
Hgb Hgb 141 Hgb 78 Hgb 69 Hgb 107 Hgb 120 Hgb 108 Hgb 105
133
Hct 0.47 Hct 0.24 Hct 0.20 Hct 0.31 Hct 0.36 Hct 0.32 Hct 0.32
Hct 0.44
WBC WBC WBC WBC WBC WBC WBC
WBC 10.00 9.80 9.00 7.90 13.50 13.60 22.50
12.60
Platelet: Platelet: Platelet: Platelet: Platelet: Platelet: Platelet:
Platelet: 329 87 58 47 60 499 188
180
HEMOGLOBIN (Hgb)
Hemoglobin is the protein molecule in red blood cells that carries oxygen from the lungs to the
body's tissues and returns carbon dioxide from the tissues to the lungs.
Hemoglobin is made up of four protein molecules (globulin chains) that are connected together.
The normal adult hemoglobin (Hbg) molecule contains 2 alpha-globulin chains and 2 beta-
globulin chains. In fetuses and infants, there are only a few beta chains and the hemoglobin
molecule is made up of 2 alpha chains and 2 gamma chains. As the infant grows, the gamma
chains are gradually replaced by beta chains.
Each globulin chain contains an important central structure called the heme molecule. Embedded
within the heme molecule is iron that transports the oxygen and carbon dioxide in our blood. The
iron contained in hemoglobin is also responsible for the red color of blood.
Hemoglobin also plays an important role in maintaining the shape of the red blood cells.
Abnormal hemoglobin structure can, therefore, disrupt the shape of red blood cells and impede
its function and its flow through blood vessels. The hemoglobin level is expressed as the amount
of hemoglobin in grams (gm) per deciliter (dl) of whole blood, a deciliter being 100 milliliters.
The normal ranges for hemoglobin depend on the age and, beginning in adolescence, the gender
of the person. The normal ranges are:
• Newborns: 17-22 gm/dl • One (1) week of age: 15-20 gm/dl
• One (1) month of age: 11-15gm/dl • Children: 11-13 gm/dl
Low hemoglobin is referred to as anemia. There are many reasons for anemia.
1. loss of blood (traumatic injury, surgery, bleeding colon cancer or stomach ulcer),
2. nutritional deficiency (iron, vitamin B12, folate),
3. bone marrow problems (replacement of bone marrow by cancer,
4. suppression by chemotherapy drugs,
5. kidney failure), and
6. Abnormal hemoglobin (sickle cell anemia).
Higher than normal hemoglobin levels can be seen in people living at high altitudes and in
people who smoker. Dehydration produces falsely high hemoglobin which disappears when
proper fluid balance is restored.
Some other infrequent causes are:
1. advanced lung disease (for example, emphysema),
2. certain tumors,
3. a disorder of the bone marrow known as polycythemia rubra vera, and
4. Abuse of the drug erythropoietin (Epogen) by athletes for blood doping purposes.
 HEMATOCRIT (Hct)
The hematocrit is the proportion, by volume, of the blood that consists of red blood cells. The
hematocrit (hct) is expressed as a percentage. For example, a hematocrit of 25% means that there
are 25 milliliters of red blood cells in 100 milliliters of blood.
The normal ranges for hematocrit are dependent on age and, after adolescence, the sex of the
individual. The normal ranges are:
• Newborns: 55%-68% • Three (3) months of age: 30%-
• One (1) week of age: 47%-65% 36%
• One (1) month of age: 37%-49% • One (1) year of age: 29%-41%
A low hematocrit is referred to as being anemic. There are many reasons for anemia.
Some of the more common reasons are loss of blood (traumatic injury, surgery, bleeding
colon cancer), nutritional deficiency (iron, vitamin B12, folate), bone marrow problems
(replacement of bone marrow by cancer, suppression by chemotherapy drugs, kidney
failure), and abnormal hematocrit (sickle cell anemia).
Higher than normal hematocrit levels can be seen in people living at high altitudes and in
chronic smokers. Dehydration produces a falsely high hematocrit that disappears when
proper fluid balance is restored. Some other infrequent causes of elevated hematocrit are
lung disease, certain tumors, a disorder of the bone marrow known as polycythemia rubra
vera, and abuse of the drug erythropoietin (Epogen) by athletes for blood doping
purposes.
 WHITE BLOOD CELL

One of the cells the body makes to help fight infections. There are several types of white
blood cells (leukocytes). The two most common types are the lymphocytes and
neutrophils (also called polymorphonuclear leukocytes, PMNs, or "polys").
Lymphocytes are made in lymphoid tissue in the spleen, lymph nodes, and thymus gland.
There are different kinds of lymphocytes. Lymphocytes identify foreign substances from
germs (bacteria or viruses) in the body and produce antibodies and cells that specifically
target them. It takes from several days to weeks for lymphocytes to recognize and attack
a new foreign substance.
Neutrophils are also major players in the body's defense against bacterial infections.
Neutrophils are made in the bone marrow and circulate in the bloodstream. Neutrophils
move out of the blood vessels into the infected tissue to attack the bacteria. The pus in a
boil (an abscess) is made up largely of neutrophils. Normally a serious bacterial infection
causes the body to produce an increased number of neutrophils, resulting in a higher than
normal white blood cell count (WBC). When the WBC is low, there may not be enough
neutrophils to defend against bacterial infections.
The white blood cell count is done by counting the number of white blood cells in a
sample of blood. A normal WBC is in the range of 4,000 to 11,000 cells per microliter. A
low WBC is called leukopenia. A high WBC is termed leukocytosis.
 THROMBOCYTE (Platelet)
Platelets are the smallest formed elements in blood. They promote coagulation and the
formation of a hemostatic plug in vascular injury. Platelet count is one of the most
important screening tests of platelet function. Accurate counts are vital.Normal Values
are the following:
• Adults: 140000-400000/ul (SI 140-400 x 10 9/L)
• Children: 150000-450000/ul (SI 150-450 x 10 9/L)
 BLOOD C/S
August 20, 2009 – No growth after 7 days incubation
• Persistent, continuous, or recurrent bacteremia reliably confirms the presence of
serious infection.
 URINALYSIS
Specific Gravity: Protein: Sugar: RBC: WBC: Bacteria:

August
15 1.005 negative negative 1/hph 10/hpf rare
• Urinalysis can disclose evidence of diseases, even some that have not caused
significant signs or symptoms. Therefore, a urinalysis is commonly a part of
routine health screening.
• Urinalysis is also a very useful test that may be ordered by your physician for
particular reasons. Urinalysis is commonly used to diagnose a urinary tract or
kidney infection, to evaluate causes of kidney failure, to screen for progression of
some chronic conditions such as diabetes mellitus and high blood pressure
(hypertension).
• Interpretation of urinalysis is generally based on reviewing all the components of
the test as well as the clinical symptoms and signs of the patient.
• Epithelial (flat cells) and red and white blood cells may be seen in the urine.
• Sometimes cells, cellular debris, and casts are seen in the microscopic urinalysis.
Epithelial cells (cells in the lining of the bladder or urethra) may suggest
inflammation within the bladder, but they also may originate form the skin and
could be contamination.
• Casts and cellular debris originate from higher up in the urinary tract, such as in
the kidneys. These are material shed from kidney cell lining and travel down
through the urinary tubes. These usually suggest an injury to the kidney from an
inflammation or lack of blood flow to the kidneys. Rarely, tumor cells can be in
the urine suggesting a urinary tract cancer.
• Red blood cells can enter the urine from the vagina in menstruation or from the
trauma of bladder catherization.
• A high count of red blood cells in the urine can indicate infection, trauma, tumors,
and kidney stones. If red blood cells seen under microscopy look distorted, they
suggest kidney as the possible source and may arise due to kidney inflammation
(glomerulonephritis). Small amounts of red blood cells in the urine are sometimes
seen young healthy people and not indicative of any disease.
• Urine is a generally thought of as a sterile body fluid, therefore, evidence of white
blood cells or bacteria in the urine is considered abnormal and may suggest a
urinary tract infection such as, bladder infection (cystitis), infection of kidney
(pyelonephritis). White blood cells may be detected in the urine through a
microscopic examination (pyuria or leukocytes in the blood). They can be seen
under high power field and the numbers of cells are recorded (quantitative).
• White cells from the vagina or the opening of the urethra (in males, too) can
contaminate a urine sample. Such contamination aside, the presence of abnormal
numbers of white blood cells in the urine is significant.
 URINE GS/CS
August 19, 2009 – No growth after 48 hours incubation
 POTASSIUM

August August August August August August August September September
13 22 23 24 25 26 27 4 9
4.7 4.4 4.7 5.4 5.7 4.5 2.9 3.8 4.9
6.1
The potassium test measures serum level of potassium, the major intracellular cation.
Potassium helps to maintain cellular osmotic equilibrium; regulates muscle activity,
enzyme activity, and acid-base balance; and influences renal function.
The body cannot conserve potassium, as it does sodium. The kidneys excrete nearly all
ingested potassium, even when the body’s supply is depleted, so potassium deficiency
can arise quickly.
Potassium levels are affected by variations in the secretions of adrenal steroid hormones
and by fluctuations in pH, glucose levels, and sodium levels. A reciprocal relationship
exists between potassium and sodium; a substantial intake of one causes a decrease in the
other.
Because the kidneys excrete nearly all ingested potassium daily, a dietary intake of at
least 40 mEq/day is essential. A normal diet usually includes 60 to 100 mEq of daily
potassium.
Normal Values: Serum Potassium 3.5-5 mEq/L (SI 3.5-5 mmol/L)
High potassium levels (hyperkalemia) occur when excess cellular potassium enters the
blood, as in burn injuries, crush injuries, diabetic ketoacidosis, transfusions of large
amounts of blood, and myocardial infarction. Hyperkalemia may also indicate reduced
sodium excretion, possibly due to renal failure (preventing normal exchange of sodium
and potassium) or Addison’s disease (due to potassium buildup and sodium depletion).
Low potassium levels (hypokalemia) commonly result from alosteronism or cushing’s

syndrome, loss of body fluids (as with long term diuretic therapy, vomiting, or diarrhea),
and excessive licorice ingestion.
 SODIUM (130-144) mmol/L

August 22 August 24 August 26 September 9
138 127 132 135
The sodium test measures serum sodium levels in relation to the amount of water in the
body. Sodium, the major extracellular cation, affects body water distribution, maintains
osmotic pressure of extracellular fluid, helps promote neuromuscular function, helps
maintain acid-base balance, and influences chloride and potassium levels.
Because the extracellular sodium level helps the kidneys to regulate body water
(decreased levels promote water excretion and increased levels promote retention),
sodium levels are evaluated in relation to the amount of water in the body. For example, a
sodium deficit (hyponatremia) refers to a decreased level of sodium in relation to the
body’s water level.
The body normally regulates the sodium-water balance through aldosterone, which
inhibits sodium excretion and promotes its resorption (with water) by the renal tubules to
maintain balance. Low sodium levels stimulate aldosterone secretion; high sodium levels
suppress it.
Sodium imbalance can result from a loss or gain of sodium or from a change in the
patient’s state of hydration. High serum sodium levels (hypernatremia) may be due to
inadequate water intake, excessive sodium intake, water loss in excess of sodium (as with
diabetes insipidus, impaired renal function, prolonged hyperventilation, and occasionally,
severe vomiting or diarrhea), and sodium retention (as with aldosteronism). Low serum
sodium levels (hyponatremia) may result from inadequate sodium intake or excessive
sodium loss due to profuse sweating, GI suctioning, diuretic therapy, diarrhea, vomiting,
adrenal insufficiency, burns, or chronic renal insufficiency with acidosis. Urine sodium
determinations are usually more sensitive to early changes in sodium balance and should
be evaluated simultaneously with serum sodium findings.
 CALCIUM
August 22 August 24 August 26 September 27
2.48 3.14 1.80 2.46
About 99% of body’s calcium is found in the teeth. About 1% of total calcium in the
body circulates in the blood. About 50% of these serum calcium is bound to plasma
proteins and 40% is ionized, or free. Evaluation of serum calcium levels measures the
total amount of calcium in the blood, and evaluation of ionized calcium measures the
fraction of serum calcium occurring in the ionized form.
Normal Values: Children: Total serum calcium 8.6-11.2 mg/dl (SI 2.15-2.79 mmol/L)
High serum calcium levels (hypercalcemia) may occur in hyperparathyroidism and

parathyroid tumors, Paget’s disease of the bone, sarcoidosis, vitamin D intoxication,
multiple myeloma, matastatic carcinoma, multiple fractures, and prolonged
immobilization.
High levels may also result from inadequate excretion of calcium, as with adrenal
insufficiency and renal disease; from excessive calcium ingestion; and from overuse of
antacids such as calcium carbonate. Low serum calcium levels (hypocalcemia) may result
from hypoparathyrodism, total parathyroidectomy, or malabsorption. Decreased serum
calcium levels may also occur with cushing’s syndrome, renal failure, osteomalacia,
vitamin D deficiency, acute pancreatitis, peritonitis, malnutrition with hypoalbuminemia,
and blood transfusions (due to citrate).
 MAGNESIUM
August 22 August 24 September 9 September 7
1.00 1.00 0.30 0.80
The magnesium test measures serum levels of magnesium, an electrolyte that is vital to
neuromuscular function. It also helps in intracellular metabolism, activates many
essential enzymes, and affects the metabolism of nucleic acids and proteins. Magnesium
also helps transport sodium and potassium across cell membranes and influences
intracellular calcium levels. Most magnesium is found in extracellular fluid. Magnesium
is absorbed by the small intestine and excreted in urine and stool.
Normal values: Serum magnesium 1.3-2.1 mg/dl (SI 0.65-1.05 mmol/L)
High magnesium levels (hypermagnesemia) most commonly occur in renal failure, when
the kidneys excrete inadequate amounts of magnesium, and also occur with magnesium
administration or ingestion. Adrenal insufficiency (Addison’s disease), dehydration, and
diabetic acidosis can also increase serum magnesium levels. Low magnesium levels
(hypomagnesemia) most commonly result from chronic alcoholism. Other causes include
malabsorption syndrome, diarrhea, delirium tremens, excessive insulin administration,
cirrhosis, toxemia of pregnancy, ulcerative colitis, faulty absorption after bowel resection,
prolonged bowel and gastric aspiration, acute ancreatitis, primary aldosteronism, severe
burn, ypercalcemic conditions (including hyperparathyroidism), malnutrition, and certain
diuretic therapy.
 BLOOD UREA NITROGEN (3.20-7.10) mmol/L

August 19 August 24 August 25 August 26 August 28
3.80 5.80 10.30 13.90 10.70
The Blood Urea Nitrogen (BUN) test measures the nitrogen fraction of urea, the chief
end product of protein metabolism. Formed in the liver from ammonia and excreted by
the kidneys, urea constitutes 40% to 50% of the blood’s non protein nitrogen. The BUN
level reflects protein intake and renal excretory capacity, but is a less reliable indicator of
uremia than the serum creatinine level.
(BUN levels are slightly higher in elderly patients). High BUN levels occur in the renal
disease, reduced renal blood flow (from dehydration, for example), urinary tract
obstruction, GI bleed, congestive heart failure, and increased protein catabolism (possibly
from burns). Low BUN levels indicate severe hepatic damage, malnutrition, low protein
diets, and overhydration.
 ACTIVATED PARTIAL THROMBOPLASTIN TIME (30.0-45.0)

August 22 August 24 August 25 August 27
49.9 secs 118 secs 55.5 secs 42.1 secs
Evaluates all the clotting factors of the intrinsic pathway (except platelets) by measuring
how long it takes for the fibrin clot to form after calcium and phospholipids emulsion are
added to a plasma sample. An activator such as kaolin is used t shorten clotting time.
 PROTHROMBIN TIME (Control: 10.70sec)

PT: 10.0 PT: 19.9 PT: 15.0 PT: 12.1
PTPA: 126% PTPA: 39% PTPA: 59% PTPA: 86%
INR: 0.934 INR: 1.871 INR: 1.407 INR: 1.132
Prothrombin Time (PT) measures the time required for a fibrin clot to form in a citrated
plasma sample after addition of calcium ions and tissue thromboplastin (factor III).
Normal values: 10-14 seconds (SI 10-14 seconds), depending on the source of tissue
thromboplastin and the type of sensing devices used to measure clot formation.
In a patient receiving oral anticoagulants, PT is usually maintained between 1 and 2.5
times the normal control value.
Prolonged PT may indicate deficiency in fibrinogen; prothrombin; factors V, VII, or X

(specific assays can pinpoint such deficiencies); or vitamin K. It may also result from
ongoing oral anticoagulant therapy. A prolonged PT that exceeds 2.5 times the normal
control value is commonly associated with abnormal bleeding.
 C-REACTIVE PROTEIN (0.0-10.0) mg/L

August 14 September 9
1.1 14.9
C-reactive protein (CRP) is an abnormal protein that appears in the blood during an
inflammatory process. It’s absent from the blood of healthy people. This non specific
protein is synthesized mainly in the liver and is found in many body fluids (pleural,
peritoneal, pericardial, and synovial). It appears in the blood 18-24 hours after the onset
of tissue damage, with levels that increase up to 1000-fold and then decline rapidly when
the when the inflammatory process regresses.
Normal values: CRP is not present in the blood. During the third trimester of
pregnancy, the CRP level may increase. In adults, normal results may be reported as less
than 0.8 mg/dl (SI less than 8 mg/L). An elevated CRP level may be present in
rheumatoid arthritis, rheumatic fever, myocardial infarction (MI), cancer (active,
widespread), acute bacterial and viral infections, inflammatory bowel disease, hodgkin’s
disease, systemic lupus erythematosus, and postoperatively (declines after the fourth
day).
 ETA G/S and C/S

August 15 August 24 September 19
Adequate catch with no Adequate catch with no Adequate catch with occasional
significant pathogens significant pathogens isolated gram positive cocci in pairs and
occasional gram negative bacilli
Bacteriologic examination of sputum (material raised from the lungs and bronchi) is an
important aid to the management of lung disease.
The usual method of specimen collection (which may require ultrasonic nebulization,
hydration, physiotherapy, or postural drainage); others methods include tracheal
suctioning and bronchoscopy.
A gram stain of expectorated sputum must be examined to make sure that it is a

representative specimen of secretions from the lower respiratory tract (many white blood
cells, few epithelial cells) rather than one contaminated by oral flora (few WBC’s, may
epithelial cells). Careful examination of an acid-fast smear of sputum may provide
presumptive evidence of a mycobacterial infection such as tuberculosis.
Normal Results :Flora commonly found in the respiratory tract include alpha-hemolytic
streptococci, neisseria species, and diphtheroids. The presence of normal flora does not
rule out infection. Abnormal Results: Because sputum is invariably contaminated with
normal oropharyngeal flora, a culture isolate must be interpreted in light of the patient’s
overall clinical condition. Isolation of M. tuberculosis is always significant finding.
Isolation of pathogenic organisms most often includes streptococcus pneumoniae, M.
tuberculosis, klebsiella pneumoniae (and other enterobacteriaceae), haemophilus
influenzae, staphylococcus aureus, and pseudomonas aeruginosa.
 Urine KOH
September 17 – Adequate catch with no significant pathogens isolated
 CREATININE (0.06-0.14) mmol/L
Post Operative
0.09 0.11 0.12 0.10
Analysis of serum creatinine levels provides a more sensitive measure or renal damage
than blood urea nitrogen levels. Creatinine is a non protein and product of creatinine
metabolism that appears in serum in amounts proportional to the body’s muscle mass.
Normal values:
• Male: 0.8-1.2 mg/dl (SI 62-115 umol/L)
• Female: 0.6-0.9 mg/dl (SI 53-97 umol/L)
High creatinine levels usually indicate renal disease that has seriously damaged 50% or
more of the nephrons; high creatinine levels may also suggest gigantism, acromegaly, and
rhabdomyolosis.
 ERTHROCYTE SEDIMENTATION RATE

September 9 – Result: 66
Erythrocyte sedimentation rate (ESR) measures the degree of erythrocyte settling in a
blood sample during a specified period. The ESR is a sensitive but non specific test that
is commonly the earliest indicator of disease when other chemical or physical signs are
normal. The ESR usually increases significantly in widespread inflammatory disorders;
elevations may be prolonged in localized inflammation and malignant disease.
Normal value:
• Male: 0-15 mm/hour
• Female: 20 mm/hour
• ESR gradually increases with age
The ESR rise in pregnancy, anemia, acute or chronic inflammation, tuberculosis,

paraproteinemias (especially multiple myeloma and waldenstrom’s macroglobulinemia),
rheumatic fever, rheumatoid arthritis, and some cancers.
Polycythemia, sickle cell anemia, hyperviscosity, and low plasma fibrinogen or globulin
levels tend to depress the ESR.
 TOTAL PROTEIN ALBUMIN GLOBULIN (TPAG)
A total serum protein test measures the total amount of protein in the blood. It also
measures the amounts of two major groups of proteins in the blood: albumin and
globulin. A test for total serum protein reports separate values for total protein, albumin,
and globulin. The amounts of albumin and globulin also are compared (albumin/globulin
ratio). Normally, there is a little more albumin than globulin and the ratio is greater than
1. A ratio less than 1 or much greater than 1 can give clues about problems in the body.
Albumin is tested to: Check how well the liver and kidney are working. Find out if the
diet contains enough protein. Help determine the cause of swelling of the ankles (edema)
or abdomen (ascites) or of fluid collection in the lungs that may cause shortness of breath
(pulmonary edema). Globulin is tested to determine the chances of developing an
infection. Test if there have a rare blood disease, such as multiple myeloma or
macroglobulinemia.
Post Operative
August 25 August 28 September 7
TP: 38.0 TP: 47.0 TP: 43.0
Albumin: 22.0 Albumin: 25.0 Albumin 23.0
Globulin: 16.0 Globulin: 22.0 Globulin: 20.0
X-RAY REPORT
DATE 08/13, 17, 20/2009

Four (4) serial follow-up chest films dated Aug. 13/15/17/20/2009 were reviewed.
• Overall pulmonary vascularity remains increased until the last film.
• Heart remains enlarged until the last study.
• Aorta and main pulmonary artery segment are difficult to assess.
• Low-lying endotracheal tube is noted in the last study (8/20/2009).
• Diaphragm is unremarkable.
• No other significant interval chest findings.
ECG September 3, 2009

INTERPRETATION
Rate: A 136 bpm PR: 0.12 QRS: 0.08 QT: 0.28 Ranges:
V 136 bpm
Axis: +105 P: QRS: T: 0.40
Description:
• rR pattern in V1, V3R, V4R
• Tall R in V5 V6 V7
RHYTHM:
• Right bundle branch block
• Isolated premature ventricular contraction
INTERPRETATION:
• Right bundle branch block
• Isolated premature ventricular contractions
• Biventricular hypertrophy in quadrigeminy
DISCHARGE CARE PLANNING
Upon admission of the patient, discharge planning has been started and patient’s family
should participate in planning to his care.
A. MEDICATIONS:
Instruction of home medications including the name of medication, dosage/ route, timing,
actions and precautions/ considerations. The medications are as follows:
1. Lanoxin Elixir 0.3 ml q12 hours po 7. Multivitamins 0.3 ml OD po

2. KCL syrup 2 ml TID po 8. Ascorbic Acid 0.3 ml OD po
3. Heraclene 1 capsule OD po 9. Phenobarbital gr1/4 (15mg) OD po
4. Baclofen 0.7mg/pptab q8 hours po 10. Domperidone 0.3 ml TID po
5. Doxophylline 0.5 ml q12 hours po 11. Furosemide 3mg/ pptab q12 hours po
6. Ciprofloxacin 30mg/pptab 1 pptab 12. Procaterol 5mcg/ml BID po
BID po
B. HOME MEDS INSTRUCTIONS

1. Teach parents the precautions and consideration of each medication. For
example:
2. For Lanoxin, it should not be give if the cardiac rate is less than120 beats/min
3. Explain for how long these medications should be taken. For example, the
Ciprofloxacin- to complete for 14 days (it is variable and individualized)
4. Reiterate the actions of each drug.
5. Emphasize the importance of compliance, timing, right dosage, and not
stopping the medication abruptly.
6. Teach parents to know signs and symptoms of adverse reactions or toxicity to
each drug (make a list) and to report immediately if any of these are
encountered.
7. Inform the parents that blood tests may be necessary for the effectiveness of
the medication given and check for blood drug level and its effects on other
electrolytes and blood components of the body.
C. EXERCISE/ REHABILITATION:
1. Reiterate the exercises that the physical therapist had been doing starting the
rehabilitation such as:
a. Passive range of motion of both upper and lower extremities, shoulder
motion
b. Gradual back rest elevation
2. Instruct the family to turn the child from side to side on sleeping hours to prevent
skin irritation and respiratory depression.
3. Instruct the family to perform gentle chest tapping and back rubbing for the child.
4. Instruct the family to give time for play therapy and provide toys appropriate for
the child’s age group.
5. Instruct the family also to provide enough rest for the child after every play time
therapy.
D. TREATMENT
I. Wound Care
1. Instruct the proper way of cleaning the wound site such as:
a. Do hand washing
b. Prepare the materials
c. Applying betadine or cysteal solution
d. Applications of ointment like bactroban or cimeosol if ordered
2. Instruct to clean the wound site daily
3. Teach the parents to note if there’s any redness, discharges or foul smell on the
wound site then report immediately to physician.
II. Safety Measures

1. Instruct parents to ask assistance in performing activities like bathing and feeding
2. Stress the importance of not leaving the child unattended.
III. Others
1. Instruct on compliance of nebulizations and Immunizations
E. HYGIENE
1. Instruct to maintain hygienic measures in terms of:
a. Patient care: Give patient bath daily.
Do mouth care.
Properly trim finger/ toe nails.
Clean perineal area daily and change diaper as needed.
Provide clean and comfortable clothing and footwear.
b. Food handling: Do hand washing.

Sterilize the feeding bottles, pacifier and food utensils.
Prepare the food in a clean area and cook foods well.
F. OUT PATIENT FOLLOW UP

1. Stress to parents to see the doctor on scheduled date either on
2. 1st visit- usually after a week
3. 2nd visit- depending on the patient’s condition
4. Provide information regarding the physician’s clinic schedule, room & contact
numbers for better compliance of the patient and family.
5. Instructions for ordered laboratory exams (CBC or PTT) and diagnostic
procedures (CXR) should be done as OPD basis and should bring the recent
results to the physician.
G. DIET AND NUTRITION

1. Providing adequate nutrition by:
a. Giving the frequency and amount of milk feeding that the patient should
take.
b. Giving supplemental such as Heraclene, cell life, karo syrup or VCO oil if
the physician permits.
2. Health Teaching on Feeding
a. Place the child in upright or moderate high back rest during and after
feeding.
b. Burp the child every after milk feeding.
c. Stress to parents not to give milk feeding after nebulization. Instruct
them to wait for 30 mins before giving the milk formula.
H. SUPPORT SYSTEM/FAMILY READINESS/SEXUALITY

1. An assessment of the family’s ability to care for their infant should be made.
2. A primary care giving adult should be identified and be capable to meet the
needs of the infant.
3. If concerns about the adequacy of the home environment exist, discuss options
prior to discharge.
4. The home caregiver(s) should demonstrate basic skills in infant care (e.g.
feeding, bathing, dressing, etc).
5. Infant’s safety should be discussed including use of a car seat, and safe
sleeping position.
6. The home caregiver(s) should demonstrate knowledge and skills appropriate
to the needs of their infant such as administration of medications, oxygen,
suction, tube feeding, cardiorespiratory monitoring if the patient is going
home with contraptions.
THEORETICAL FRAMEWORK
The rationale for incorporating this theoretical framework is to serve as a guide in

forming nursing assessment, planning, intervention and evaluation for the optimum care
of the patient.
Nursing Theory: Anne Casey
Casey's Model of Nursing was developed in 1988 by Casey whilst working on the
Paediatric Oncology Unit at the Great Ormond Street Hospital London. The focus of the
model is on working in partnership with children and their families, and was one of the
earliest attempts to develop a model of practice specifically for child health nursing. The
model has been developed in other areas of England to focus upon local aspects of
practice concerning child health and development.
It comprises the five concepts of child, family, health, environment and the nurse. The
philosophy behind the model is that the best people to care for the child is the family with
help from various professional staff. Casey (1988) describes a continuum starting at
conception through maturity. At the start of this the child is dependent in the careers for
all its needs. But at the end is independent and self-caring. The process of functioning,
growing and developing is based on the following concepts:
 Physical  Social
 Emotional  Spiritual
 Intellectual
When undertaking an assessment, the nurse will need to explore the structure of the
family and establish who normally undertakes the caring role. It is essential for the nurse
to have an understanding of the family structure to enable effective communication.
The process of assessment and care for the child will be between the child, the nurse and
the family career. The group chose this nursing theoretical framework because it is the
most preferred in child care. This model of nursing helps the nurse understand how the
roles and actions of nurses and family interconnect in order to provide the optimum care
for the child.
DRUG STUDY
Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Consideration

Ranitidine hydrochloride  Indications:  Contraindicated  CNS: Headache,  Administer oral
(ra nye' te deen)  Short-term with allergy to malaise, drug with meals
treatment of ranitidine, dizziness, and at bedtime.
active duodenal lactation. somnolence,  Decrease doses in
Drug class ulcer  Use cautiously insomnia, vertigo renal and liver
Histamine2 (H2) antagonist  Maintenance with impaired  CV: Tachycardia, failure.
therapy for renal or hepatic bradycardia,  Provide
duodenal ulcer at function, PVCs (rapid IV concurrent
reduced dosage pregnancy. administration) antacid therapy to
 Short-term  Dermatologic: relieve pain.
treatment of Rash, alopecia  Administer IM
active, benign  GI: dose undiluted,
gastric ulcer Constipation, deep into large
 Short-term diarrhea, nausea, muscle group.
treatment of vomiting,  Arrange for
gastroesophageal abdominal pain, regular follow-
reflux disease hepatitis, up, including
(GERD) increased ALT blood tests, to
 Available forms levels evaluate effects.
 Tablets—75, 150,  GU:  Take drug with
300 mg; effervescent Gynecomastia, meals and at
tablets and granules impotence or bedtime. Therapy
—150 mg; capsules decreased libido may continue for
—150, 300 mg; syrup  Hematologic: 4–6 wk or longer.
—15 mg/mL; Leukopenia,
injection—1, granulocytopenia,
25 mg/mL thrombocytopeni
a, pancytopenia
 Local: Pain at
IM site, local
burning or
itching at IV site
Midazolam hydrochloride  IV or IM; oral  Contraindicated  CNS: Transient,  Do not
(mid ay' zoh lam) syrup for with mild drowsiness administer intra-
Versed children: hypersensitivity (initially); arterially, which
Sedation, to sedation, may produce
Drug classes anxiolysis, and benzodiazepines; depression, arteriospasm or
Benzodiazepine (short- amnesia prior to psychoses, acute lethargy, apathy, gangrene.
acting) diagnostic, narrow-angle fatigue, light-  Do not use small
CNS depressant therapeutic, or glaucoma, shock, headedness, veins (dorsum of
endoscopic coma, acute disorientation, hand or wrist) for
Therapeutic actions procedures or alcoholic restlessness, IV injection.
Exact mechanisms of surgery intoxication; confusion, crying,  Monitor IV
action not understood; acts  Induction of pregnancy (cleft delirium, injection site for
mainly at the limbic system general anesthesia lip or palate, headache, slurred extravasation.
and reticular formation;  Continuous inguinal hernia, speech,  Carefully monitor
potentiates the effects of sedation of cardiac defects, dysarthria, stupor, P, BP, and
gamma-aminobutyrate intubated and microcephaly, rigidity, tremor, respirations
(GABA), an inhibitory mechanically pyloric stenosis dystonia, vertigo, carefully during
neurotransmitter; anxiolytic ventilated patients have been euphoria, administration.
and amnesia effects occur as a component of reported when nervousness,  Keep resuscitative
at doses below those anesthesia or used in first difficulty in facilities readily
needed to cause sedation, during treatment trimester; concentration, available; have
ataxia; has little effect on in the critical care neonatal vivid dreams, flumazenil
cortical function. setting withdrawal psychomotor available as
syndrome retardation antidote if
 Available forms reported in  CV: Bradycardia, overdose should
 Syrup—2 mg/mL; infants); neonates. tachycardia, CV occur.
injection—5 mg/mL, collapse,  Keep patients in
1 mg/mL hypertension, bed for 3 hr; do
hypotension, not permit
palpitations, ambulatory
edema patients to operate
 Dermatologic: a vehicle
Urticaria, pruritus, following an
skin rash, dermatitis injection.
 GI: Constipation, Arrange to monitor liver
diarrhea, dry and kidney
mouth,
salivation, nausea, function and CBC at
anorexia, vomiting, intervals during long-
difficulty in term therapy.
swallowing, gastric  Establish safety
disorders, elevations precautions if
Aminophylline  Symptomatic relief  Contraindicated with  CNS: Irritability  Administer to
(theophylline or prevention of hypersensitivity to (especially children); pregnant patients only
ethylenediamine) bronchial asthma any xanthine or to restlessness, when clearly needed
(am in off' i lin) and reversible ethylenediamine, dizziness, muscle —neonatal
Truphylline bronchospasm peptic ulcer, active twitching, seizures, tachycardia,
associated with gastritis; rectal or severe depression, jitteriness, and
chronic bronchitis colonic irritation or stammering speech; withdrawal apnea
Drug classes and emphysema infection (use rectal abnormal behavior observed when
Bronchodilator  Unlabeled uses: preparations). characterized by mothers received
Xanthine Respiratory stimulant  Use cautiously with withdrawal, mutism, xanthines up until
in Cheyne-Stokes cardiac arrhythmias, and unresponsiveness delivery.
Therapeutic actions respiration; treatment acute myocardial alternating with  Caution patient not to
Relaxes bronchial smooth of apnea and injury, CHF, cor hyperactive periods chew or crush enteric-
muscle, causing bradycardia in pulmonale, severe  CV: Palpitations, coated timed-release
bronchodilation and premature babies hypertension, severe sinus tachycardia, forms.
increasing vital capacity, hypoxemia, renal or ventricular  Give immediate-
which has been impaired  Available forms hepatic disease, tachycardia, life- release, liquid dosage
by bronchospasm and air  Tablets—100, hyperthyroidism, threatening forms with food if GI
trapping; in higher 200 mg; CR tablets— alcoholism, labor, ventricular effects occur.
concentrations, it also 225 mg; liquid— lactation. arrhythmias,  Do not give timed-
inhibits the release of slow- 105 mg/5 mL; circulatory failure release forms with
reacting substance of injection—250 mg/10  GI: Loss of appetite, food; these should be
anaphylaxis (SRS-A) and mL; suppositories— hematemesis, given on an empty
histamine. 250, 500 mg epigastric pain, stomach 1 hr before
gastroesophageal or 2 hr after meals.
 Dosages reflux during sleep,  Maintain adequate
 Individualize dosage: increased AST hydration.
Base adjustments on  GU: Proteinuria, Monitor results of
clinical responses; increased excretion of serum theophylline
monitor serum renal tubular cells and levels carefully, and
theophylline levels; arrange for reduced
 maintain therapeutic  RBCs; diuresis  dosage if serum levels
range of 10–20 (dehydration), urinary exceed therapeutic
mcg/mL; base dosage retention in men with range of 10–20
on lean body mass; prostate enlargement mcg/mL.
127 mg  Respiratory:  Take serum samples
aminophylline Tachypnea, to determine peak
dihydrate = 100 mg respiratory arrest theophylline
theophylline  Other: Fever, concentration drawn
anhydrous. flushing, 15–30 min after an IV
hyperglycemia, loading dose.
SIADH, rash  Monitor for clinical
signs of adverse
effects, particularly if
serum theophylline
levels are not
available.
 Ensure that diazepam
is readily available to
treat seizures.
captopril • Treatment of • Contraindicated • CV: • Administer 1 hr
(kap' toe pril) hypertension with allergy to Tachycardia, before or 2 hr
Apo-Capto (CAN), alone or in captopril, angina pectoris, after meals.
Capoten, Gen- combination with history of MI, Raynaud's • Alert surgeon
thiazide-type angiodema. syndrome, CHF, and mark
Drug classes diuretics • Use cautiously hypotension in patient's chart
Angiotensin-converting • Treatment of CHF with impaired salt- or volume- with notice that
enzyme (ACE) inhibitor in patients renal function; depleted patients captopril is
Antihypertensive unresponsive to CHF; salt or • Dermatologic: being taken; the
conventional volume Rash, pruritus, angiotensin II
Therapeutic actions therapy; used with depletion, pemphigoid-like formation
Blocks ACE from diuretics and lactation, reaction, scalded subsequent to
converting angiotensin I digitalis pregnancy. mouth sensation, compensatory
to angiotensin II, a • Treatment of exfoliative renin release
powerful vasoconstrictor, diabetic dermatitis, during surgery
leading to decreased nephropathy photosensitivity, will be blocked;
blood pressure, decreased • Treatment of left alopecia hypotension
aldosterone secretion, a ventricular • GI: Gastric may be reversed
small increase in serum dysfunction after irritation, with volume
potassium levels, and MI aphthous ulcers, expansion.
sodium and fluid loss; • Unlabeled uses: peptic ulcers, • Monitor patient
increased prostaglandin Management of dysgeusia, closely for fall
synthesis also may be hypertensive cholestatic in BP secondary
involved in the crises; treatment jaundice, to reduction in
antihypertensive action. of rheumatoid hepatocellular fluid volume
arthritis; injury, anorexia, (excessive
diagnosis of constipation perspiration and
anatomic renal • GU: dehydration,
artery stenosis, Proteinuria, vomiting,
hypertension renal diarrhea);
related to insufficiency, excessive
scleroderma renal renal failure, hypotension
crisis; diagnosis polyuria, may occur.
of primary oliguria, urinary
aldosteronism, frequency
idiopathic edema;
Bartter's
syndrome;
Raynaud's
syndrome
Available forms • Hematologic: • Reduce dosage
Tablets—12.5, 25, 50, Neutropenia, in patients with
100 mg agranulocytosis, impaired renal
thrombocytopeni function.
PEDIATRIC a, hemolytic
PATIENTS anemia,
Safety and efficacy not pancytopenia
established. • Other: Cough,
malaise, dry
mouth,
lymphadenopath
y
Digoxin • CHF • Contraindicated • CNS: Headache, • Monitor apical pulse
(di jox' in) • Atrial fibrillation with allergy to weakness, for 1 min before
Digitek, Lanoxicaps digitalis drowsiness, visual administering; hold
Available forms preparations, disturbances, mental dose if pulse < 60 in
Drug classes Lanoxicaps capsules— ventricular status change adult or < 90 in infant;
Cardiac glycoside 0.05, 0.1, 0.2 mg; tablets tachycardia, • CV: Arrhythmias retake pulse in 1 hr. If
Cardiotonic —0.125, 0.25, mg, elixir ventricular • GI: GI upset, adult pulse remains <
—0.05 mg/mL; injection fibrillation, heart anorexia 60 or infant < 90, hold
Therapeutic actions —0.25 mg/mL; pediatric block, sick sinus drug and notify
Increases intracellular injection—0.1 mg/mL syndrome, IHSS, prescriber. Note any
calcium and allows acute MI, renal change from baseline
more calcium to enter Dosages insufficiency and rhythm or rate.
the myocardial cell Patient response is quite electrolyte • Take care to
during depolarization variable. Evaluate abnormalities differentiate
via a sodium–potassium patient carefully to (decreased K+, Lanoxicaps from
pump mechanism; this determine the decreased Mg++, Lanoxin; dosage is
increases force of appropriate dose. increased Ca++). very different
contraction (positive • Use cautiously with • Check dosage and
inotropic effect), pregnancy and preparation carefully.
increases renal perfusion lactation. • Avoid IM injections,
(seen as diuretic effect which may be very
in patients with CHF), painful.
decreases heart rate • Follow diluting
(negative chronotropic instructions carefully,
effect), and decreases and use diluted
AV node conduction solution promptly.
velocity.
• Avoid giving with
meals; this will delay
absorption.
PEDIATRIC • Have emergency
PATIENTS equipment ready;
• Loading dose: have K+ salts,
Oral lidocaine, phenytoin,
(mcg/kg) atropine, cardiac
Prematu 20–30 monitor on standby in
re case toxicity develops.
Neonate 25–35 • Monitor for
1–24 mo 35–60 therapeutic drug
2–5 yr 30–40 levels: 0.5–2 ng/mL.
5–10 yr 20–35
> 10 yr 10–15
Maintenance dose, 25%–
35% of loading dose in
divided daily doses.
Usually 0.125–
0.5 mg/day PO.
furosemide • Oral, IV: Edema • Contraindicated • CNS: Dizziness, CLINICAL ALERT!
(fur oh' se mide) associated with with allergy to vertigo, Name confusion has
Apo-Furosemide (CAN), CHF, cirrhosis, furosemide, paresthesias, occurred between
Furoside (CAN), Lasix, renal disease sulfonamides; xanthopsia, furosemide and
Myrosemide (CAN) • IV: Acute allergy to weakness, torsemide; use extreme
pulmonary tartrazine (in headache, caution.
Drug class edema oral solution); drowsiness,
Loop diuretic • Oral: anuria, severe fatigue, blurred • Administer with
Hypertension renal failure; vision, tinnitus, food or milk to
Therapeutic actions hepatic coma; irreversible prevent GI
Inhibits the reabsorption of Available forms pregnancy; hearing loss upset.
sodium and chloride from Tablets—20, 40, 80 mg; lactation. • CV: Orthostatic • Reduce dosage
the ascending limb of the oral solution— • Use cautiously hypotension, if given with
loop of Henle, leading to a 10 mg/mL, 40 mg/5 with SLE, gout, volume other
sodium-rich diuresis. mL; injection— diabetes depletion, antihypertensive
10 mg/mL mellitus. cardiac s; readjust
arrhythmias, dosage gradually
PEDIATRIC thrombophlebiti as BP responds.
PATIENTS s • Give early in the
Avoid use in premature • Dermatologic: day so that
infants: stimulates PGE2 Photosensitivity, increased
synthesis and may rash, pruritus, urination will
increase incidence of urticaria, not disturb
patent ductus arteriosus purpura, sleep.
and complicate exfoliative • Avoid IV use if
respiratory distress dermatitis, oral use is at all
syndrome. erythema possible.
• Edema: Initially, multiforme • Do not mix
2 mg/kg/day • GI: Nausea, parenteral
PO. If needed, anorexia, solution with
increase by 1– vomiting, oral highly acidic
2 mg/kg in 6–8 and gastric solutions with
hr. Do not irritation, pH below 3.5.
exceed 6 mg/kg. constipation, • Do not expose to
Adjust diarrhea, acute light, may discolor
pancreatitis, tablets or solution;
jaundice
• GU: Polyuria,
nocturia,
glycosuria,
• maintenance • urinary bladder • do not use
dose to lowest spasm discolored drug
effective level. • Hematologic: or solutions.
• Pulmonary Leukopenia, • Discard diluted
edema: 1 mg/kg anemia, solution after 24
IV or IM. May thrombocytopen hr.
increase by ia, fluid and • Refrigerate oral
1 mg/kg in 2 hr electrolyte solution.
until the desired imbalances • Measure and
effect is seen. • Other: Muscle record weight to
Do not exceed cramps and monitor fluid
6 mg/kg. muscle spasms changes.
• Arrange to
monitor serum
electrolytes,
hydration, liver
function.
• Arrange for
potassium-rich
diet or
supplemental
potassium as
needed.
spironolactone • Diagnosis and • Contraindicated • CNS: Dizziness, • Mark calendars
(speer on oh lak' tone) maintenance of with allergy to headache, of edema
Aldactone, Novospiroton primary spironolactone, drowsiness, outpatients as
(CAN) hyperaldosteroni hyperkalemia, fatigue, ataxia, reminders of
sm renal disease, confusion alternate day or
Drug classes • Adjunctive anuria, • Dermatologic: 3- to 5-day/wk
Potassium-sparing diuretic therapy in amiloride or Rash, urticaria therapy.
Aldosterone antagonist edema triamterene use. • GI: Cramping, • Give daily doses
associated with • Use cautiously diarrhea, dry early so that
Therapeutic actions CHF, nephrotic with pregnancy, mouth, thirst, increased
Competitively blocks the syndrome, lactation. vomiting. urination does
effects of aldosterone in the hepatic cirrhosis • GU: Impotence, not interfere
renal tubule, causing loss when other irregular with sleep.
of sodium and water and therapies are menses, • Make
retention of potassium. inadequate or amenorrhea, suspension as
inappropriate postmenopausal follows: Tablets
• Treatment of bleeding may be
hypokalemia or • Hematologic: pulverized and
prevention of Hyperkalemia, given in cherry
hypokalemia in hyponatremia, syrup for young
patients who agranulocytosis children. This
would be at high • Other: suspension is
risk if Carcinogenic in stable for 1 mo
hypokalemia animals, if refrigerated.
occurred: deepening of the • Measure and
Digitalized voice, hirsutism, record regular
patients, patients gynecomastia weight to
with cardiac monitor
arrhythmias mobilization of
• Essential edema fluid.
hypertension, • Avoid giving
usually in food rich in
combination potassium.
with other drugs • Arrange for
• Unlabeled uses: regular
Treatment of evaluation of
hirsutism due to serum
its electrolytes,
antiandrogenic BUN.
properties,
palliation
• of symptoms of
PMS, treatment
of familial male
precocious
puberty, short-
term treatment
of acne vulgaris
Available forms
Tablets—25, 50,
100 mg
PEDIATRIC
PATIENTS
• Edema: 1–
3.3 mg/kg/da
y PO
adjusted to
patient's
response,
administered
as single or
divided
dose.
albuterol sulfate • Relief and prevention • Contraindicated • CNS: Restlessness, • Use minimal doses
(al byoo' ter ole) of bronchospasm in with apprehension, for minimal periods;
AccuNeb, Novo-Salmol patients with hypersensitivity to anxiety, fear, CNS drug tolerance can
(CAN), Proventil, reversible obstructive albuterol; stimulation, occur with
Proventil HFA, Proventil airway disease tachyarrhythmias, hyperkinesia, prolonged use.
Repetabs, Salbutamol • Inhalation: Treatment tachycardia caused insomnia, tremor, • Maintain a beta-
(CAN), Ventodisk (CAN), of acute attacks of by digitalis drowsiness, adrenergic blocker
Ventolin, Ventolin HFA, bronchospasm intoxication; general irritability, (cardioselective
Volmax • Prevention of anesthesia with weakness, vertigo, beta-blocker, such
exercise-induced halogenated headache as atenolol, should
Pregnancy Category C bronchospasm hydrocarbons or • CV: Cardiac be used with
• Unlabeled use: cyclopropane (these arrhythmias, respiratory distress)
Drug classes Adjunct in treating sensitize the tachycardia, on standby in case
Sympathomimetic drug serious hyperkalemia myocardium to palpitations, PVCs cardiac arrhythmias
Beta2-selective adrenergic in dialysis patients; catecholamines); (rare), anginal pain occur.
agonist seems to lower unstable vasomotor • Dermatologic: • Prepare solution for
Bronchodilator potassium system disorders; Sweating, pallor, inhalation by
Antiasthmatic concentrations when hypertension; flushing diluting 0.5 mL
inhaled by patients on coronary • GI: Nausea, 0.5% solution with
Therapeutic actions hemodialysis insufficiency, CAD; vomiting, heartburn, 2.5 mL normal
In low doses, acts relatively Available forms history of stroke; unusual or bad taste saline; deliver over
selectively at beta2- Tablets-2, 4 mg; ER COPD patients with • GU: Increased 5–15 min by
adrenergic receptors to tablets-4, 8 mg; syrup- degenerative heart incidence of nebulization.
cause bronchodilation and 2 mg/5 mL; aerosol- disease. leiomyomas of • Do not exceed
vasodilation; at higher 90 mcg/actuation; • Use cautiously with uterus when given in recommended
doses, beta2 selectivity is solution for inhalation- diabetes mellitus higher than human dosage; administer
lost, and the drug acts at 0.083%, 0.5%, (large IV doses can doses in preclinical pressurized
beta2 receptors to cause 1.25 mg/3 mL, aggravate diabetes studies inhalation drug
typical sympathomimetic 0.63 mg/3 mL; capsules and ketoacidosis); forms during second
• Respiratory:
cardiac effects. for inhalation-200 mcg hyperthyroidism; half of inspiration,
Respiratory
history of seizure difficulties, because the airways

PEDIATRIC • disorders; • pulmonary edema, • are open wider and
PATIENTS psychoneurotic coughing, the aerosol
Oral, tablets individuals; labor bronchospasm, distribution is more
• 6–12 yr: 2 mg tid– and delivery (oral paradoxical airway extensive.
qid. Do not exceed use has delayed resistance with
24 mg/day. second stage of repeated, excessive
• > 12 yr: Use adult labor; parenteral use use of inhalation
dosage. of beta2-adrenergic preparations
ER tablets agonists can
accelerate fetal heart
exceed 24 mg/day in
divided doses.
• > 14 yr: Use adult
dosage.
Inhalation
• 2–12 yr: For child
10–15 kg, use
1.25 mg; for child >
15 kg, use 2.5 mg.
• > 12 yr: Use adult
dosage.
Solution for inhalation
• 10–15 kg: 1.25 mg
bid–tid by
nebulization.
• > 15 kg: 2.5 mg
bid–tid by
nebulization.
Inhalation capsules
• > 4 yr: One
200 mcg capsule
inhaled q 4–6 hr.
Prevention of exercise-
induced asthma: One
200 mcg capsule
inhaled 15 min before
exercise.
Paracetamol • Analgesic- • Contraindicated • CNS: Headache • Do not exceed the
acetaminophen (N- antipyretic in with allergy to • CV: Chest pain, recommended dosage.
acetyl-p- patients with acetaminophen. dyspnea, myocardial • Consult physician if
aminophenol) aspirin allergy, • Use cautiously with damage when doses needed for children < 3
hemostatic impaired hepatic of 5–8 g/day are yr; if needed for longer
Drug classes disturbances, function, chronic ingested daily for than 10 days; if
Antipyretic bleeding alcoholism, several weeks or when continued fever, severe
Analgesic (nonopioid) diatheses, upper pregnancy, doses of 4 g/day are or recurrent pain occurs
GI disease, gouty lactation. ingested for 1 yr (possible serious illness).
Therapeutic actions arthritis • GI: Hepatic toxicity • Avoid using multiple
Antipyretic: Reduces • Arthritis and and failure, jaundice preparations containing
fever by acting directly rheumatic • GU: Acute kidney acetaminophen.
on the hypothalamic disorders failure, renal tubular Carefully check all OTC
heat-regulating center involving necrosis products.
to cause vasodilation musculoskeletal • Hematologic: • Give drug with food if
and sweating, which pain (but lacks Methemoglobinemia GI upset is noted.
helps dissipate heat. clinically —cyanosis; hemolytic • Discontinue drug if
Analgesic: Site and significant anemia—hematuria, hypersensitivity
mechanism of action antirheumatic and anuria; neutropenia, reactions occur.
unclear. anti-inflammatory leukopenia, • Treatment of overdose:
effects) pancytopenia, Monitor serum levels
• Common cold, flu, thrombocytopenia, regularly, N-
other viral and hypoglycemia acetylcysteine should be
bacterial • Hypersensitivity: available as a specific
infections with Rash, fever antidote; basic life
pain and fever support measures may
Unlabeled use: be necessary.
prophylactic for
children receiving
DPT vaccination
• to reduce incidence
of fever and pain
PEDIATRIC
PATIENTS
PO or PR
Doses may be repeated
4–5 times/day; do not
exceed five doses in 24
hr; give PO or by
suppository.
Age Dosage
(mg)
0–3 mo 40
4–11 80
mo
1–2 yr 120
2–3 yr 160
4–5 yr 240
6–8 yr 320
9–10 yr 400
11 yr 480
Suprax  Suprax, a  If you are allergic to  Side effects cannot  If you are taking
Generic name: Cefixime cephalosporin either penicillin or be anticipated. If Suprax once a day
antibiotic, is cephalosporin any develop or and you forget to
prescribed for antibiotics in any change in intensity, take a dose, take it
bacterial infections form, consult your tell your doctor as as soon as you
of the lungs, ears, doctor before taking soon as possible. remember. Wait at
urinary tract, and Suprax. An allergy Only your doctor least 10 to 12 hours
throat. It is also to either type of can determine if it is before taking your
used to treat medication may safe for you to next dose, then
uncomplicated signal an allergy to continue taking this return to your
gonorrhea. Suprax, and if a drug. regular schedule.
reaction occurs, it  Side effects may  If you are taking
could be extremely include: abdominal Suprax 2 times a
severe. If you take pain, gas, day and you forget
the drug and feel indigestion, loose to take a dose, take
signs of a reaction, stools, mild it as soon as you
seek medical diarrhea, nausea, remember and take
attention vomiting your next dose 5 to
immediately. 6 hours later. Then
go back to your
 Do not take Suprax regular schedule.
if you are sensitive  If you are taking
to or have ever had Suprax 3 times a
an allergic reaction day and you forget
to the drug or to to take a dose, take
other cephalosporin it as soon as you
antibiotics. remember and take
your next dose 2 to
4 hours later. Then
return to your
regular schedule.
 The nurse should always
remember the following:
 Suprax liquid may be
kept for 14 days, either
at room temperature or
in the refrigerator.
 Keep the bottle tightly
closed and do not store
in damp places.
 Keep away from direct
light and heat. Discard
any unused Suprax after
14 days.
Baclofen Severe chronic spasticity. Hypersensitivity. The most common • Abrupt Drug
Muscle Relaxants Active peptic adverse reaction during Withdrawal
PO 5 mg 3 times/day for 3 ulcer disease. treatment with baclofen Hallucinations and
days, increased to 10 mg 3 is transient drowsiness seizures have
times/day for 3 days. May (10-63%). In one occurred on abrupt
further increase if needed. controlled study of 175 withdrawal of
Max: 100 mg/day. patients, transient baclofen. Therefore,
Intrathecal Test dose: 25 drowsiness was observed except for serious
or 50 mcg. Increase dose in 63% of those receiving adverse reactions, the
by 25 mcg not more often baclofen tablets dose should be
than 24 hrly until 100 compared to 36% of reduced slowly when
mcg/dose to determine those in the placebo the drug is
appropriate dose. group. Other common discontinued.
Responders w/ response adverse reactions are • Impaired Renal
lasting >8-12 hr, the test dizziness (5-15%), Function
dose that was used to weakness (5-15%) and Because baclofen is
produce the response can fatigue (2-4%). Others primarily excreted
be given as a 24-hr reported: unchanged by the
infusion; if the response Neuropsychiatric: kidneys, it should be
lasted ≤8-12 hr, then a Confusion (1-11%), given with caution
dose equivalent to twice headache (4-8%), and it may be
the test dose is given. insomnia (2-7%); and, necessary to reduce
rarely, euphoria, the dosage in patients
excitement, depression, with impaired renal
hallucinations, function.
paresthesia, muscle pain,
tinnitus, slurred speech,
coordination disorder,
tremor,
rigidity, dystonia, ataxia, • Stroke
blurred vision, nystagmus, Baclofen has not
strabismus, miosis, mydriasis, significantly
diplopia, dysarthria, epileptic benefited patients
seizure. with stroke. These
Cardiovascular: Hypotension patients have also
(0-9%). Rare instances of shown poor
dyspnea, palpitation, chest tolerability to the
pain, syncope. drug.
Gastrointestinal: Nausea (4-
12%), constipation (2-6%);
and, rarely, dry mouth,
anorexia, taste disorder,
abdominal pain, vomiting,
diarrhea, and positive test for
occult blood in stool.
Genitourinary: Urinary
frequency (2-6%); and, rarely,
enuresis, urinary retention,
dysuria, impotence, inability
to ejaculate, nocturia,
hematuria.
Other: Instances of rash,
pruritus, ankletherapy.
than to drug edema,The
excessive
followingperspiration, weight
laboratory tests
gain,
have been found to be Some
nasal congestion.
of the CNSinand
abnormal genitourinary
a few
symptoms
patients receiving related to
may be
the underlying
baclofen: disease rather
increased
SGOT, elevated alkaline
phosphatase, and
elevation of blood sugar.
The adverse experience
profile seen with
KEMSTRO™ was similar
to that seen with baclofen
tablets.
Zosyn  Zosyn (piperacillin  contraindicated in  Autonomic nervous  Careful inquiry should
and tazobactam for patients with a system - be made concerning
(piperacillin tazobactam) injection) is history of allergic hypotension, ileus, previous
Injection indicated for the reactions to any of syncope hypersensitivity
To reduce the treatment of patients the penicillins,  Body as a whole - reaction, as serious and
development of drug- with moderate to cephalosporins, or rigors, back pain, occasionally fatal
resistant bacteria and severe infections β-lactamase malaise anaphylactic/anaphylac
maintain the effectiveness caused by inhibitors  In the toid reactions
of Zosyn (piperacillin and piperacillin- Cardiovascular - (including shock) have
tazobactam) injection and resistant, tachycardia, been reported in
other antibacterial drugs, piperacillin/tazobact including patients receiving
Zosyn (piperacillin and am-susceptible, β- supraventricular therapy with penicillins
tazobactam) should be lactamase producing and ventricular; including ZOSYN
used only to treat or strains of the bradycardia;  The nurse should know
prevent infections that are designated arrhythmia, that periodic
proven or strongly microorganisms in including atrial assessment of organ
suspected to be caused by the specified fibrillation, system functions,
bacteria. conditions listed ventricular including renal,
below: fibrillation, cardiac hepatic, and
arrest, cardiac hematopoietic, during
failure, circulatory prolonged therapy is
failure, myocardial advisable because
infarction ZOSYN possesses the
 Central nervous characteristic low
system - tremor, toxicity of the
convulsions, penicillin group of
vertigo antibiotics
 The The whole MFN
Gastrointestinal -
melena, flatulence,
hemorrhage,
gastritis, hiccough,
ulcerative stomatitis
Hypersensitivity -
anaphylaxis
 Metabolic and
Nutritional -
symptomatic
hypoglycemia, thirst
 Musculoskeletal -
myalgia, arthralgia
 Platelets, Bleeding,
Clotting -
mesenteric
embolism.
Meropenem I.V.  To reduce the  Patients with  MERREM I.V. was  The safety and
development of known studied in 515 pediatric effectiveness of
drug-resistant hypersensitivity to patients ( ≥ 3 months to MERREM I.V. have
bacteria and any component of < 13 years of age) with been established for
maintain the this product or to serious bacterial pediatric patients ≥ 3
effectiveness of other drugs in the infections (excluding months of age.
MERREM I.V. and same class or in meningitis. See next  Use of MERREM I.V.
other antibacterial patients who have section.) at dosages of in pediatric patients
drugs, MERREM demonstrated 10 to 20 mg/kg every 8 with bacterial
I.V. should only be anaphylactic hours. The types of meningitis is supported
used to treat or reactions to β- clinical adverse events by evidence from
prevent infections lactams. seen in these patients adequate and well-
that are proven or are similar to the controlled studies in the
strongly suspected adults, with the most pediatric population.
to be caused by common adverse  Use of MERREM I.V.
susceptible events reported as in pediatric patients
bacteria. When possibly, probably or with intra-abdominal
culture and definitely related to infections is supported
susceptibility MERREM I.V. and by evidence from
information are their rates of adequate and well-
available, they occurrence as follows: controlled studies with
should be Diarrhea 3.5%,
considered in Rash1.6%, Nausea and
selecting or Vomiting 0.8%
modifying MERREM I.V. was
antibacterial studied in 321 pediatric
therapy. In the patients ( ≥ 3 months to
absence of such < 17 years of age) with
data, local meningitis at a dosage
epidemiology and of 40 mg/kg every 8
susceptibility hours. The types of
patterns may clinical adverse events
contribute to the seen in these patients
empiric selection of are similar to the adults,
therapy. with the most common
 MERREM I.V. is adverse events reported
indicated as single as possibly, probably,
agent therapy for or definitely related to
the treatment of the MERREM I.V. and
following infections their rates of occurrence
when caused by as follows:
susceptible isolates Diarrhea 4.7%, Rash
of the designated (mostly diaper area
microorganisms F. moniliasis), Glossitis
1.0%
Drug Name Indications/Dosages Contraindications Adverse Effects Nursing Considerations
Heraclene  For Premature babies. Low  No known effect  No known effect  Treatment must be
Dibencozide birth weight. Retarded noted noted continuous for 2-6
growth. Poor appetite in weeks.
Classification: infants, children and adults.  The initial sign of its
Adjuvant to treatment of effectiveness is
A15 - Appetite tuberculosis and other manifested by a
Enhancers chronic ailments. marked increase in
Convalescence from acute appetite.
infection or surgery. Faulty
nutrition in older people.
 Premature Babies, Infants:
1 cap daily (the capsule may
be opened and the odorless,
tasteless powder mixed with
milk or juice).
Milrinone  Short-term management of  Heart valve  Angina-like chest  Improved cardiac

severe heart failure, Acutely stenosis, acute pain, headache, output may increase
Classification: decompensated heart failure myocardial hypokalaemia, urine output, reduced
 Child: Initial loading dose infarction tremor, diuretic dosage when
Cardiac Drugs/ of 75 mcg/kg by IV injection thrombocytopenia, heart failure improves.
phosphodiesterase over 10-60 min followed by bronchospasm. Potassium lost may
inhibitors continuous infusion of 0.5- cause digitalis toxicity.
0.75 mcg/kg/min.  Potentially Fatal:  Monitor fluid &
 Supraventricular and electrolyte status &
ventricular vital signs. Excessive
arrhythmias; decrease in BP.
hypotension. Requires stopping the
infusion.
Drug Name Indication/Dosages Contraindications Adverse Effects Nursing Considerations
Methylprednisolone  Suppression of  Systemic  Fluid & electrolyte  Determine whether pt.
inflammatory & mycoses. Septic balance disturbance; is sensitive to other
Classification: allergic disorders, shock. musculoskeletal corticosteroids, for
cerebral edema, system effects; GI better result and less
Corticosteroid Hormones/ rheumatic disease; effects; skin toxicity, give once
glucocorticoids immunosuppressant reactions; -ve daily dose in the
in spinal cord nitrogen balance due morning.
injury. to protein catabolism;  Measure growth &
nervous system dev. Periodically in
 Children: give effects, seizures, children during high
0.117 to 1.66 mg/kg psychic disorders; dose or prolonged
or 3.3 to mg/m2 PO. endocrine system treatment.
Daily in 3 doses. disorders; immune  Monitor pt. wt, BP.
system suppression Electrolyte level and
sleep patterns,
Euphoria may initially
interfere with sleep,
but pt. adjust typical in
1-3 weeks.
 Always adjust to
lowest effective dose.
MANNITOL  IV Renal function  Pulmonary  Fluid and electrolyte  Hypervolaemia;
test 0.2 g/kg over 3- congestion or imbalance; acidosis urinary tract
Classification: 5 mins. Oliguric oedema; (with high doses). obstruction; check for
phase of renal intracranial Nausea, vomiting, signs of fluid and
Diuretics/ failure 50-100 g in a bleeding; CHF; thirst; headache, electrolyte imbalance.
Solutions producing 24-hr period via metabolic dizziness, Should not be
osmotic diuresis infusion; adjust rate oedema with convulsions, chills, administered with
to maintain a urine abnormal fever; tachycardia, whole blood.
flow of ≥30-50 capillary chest pain; blurred Pregnancy, lactation.
mL/hr. Raised fragility; anuria vision; urticaria and  Monitor I/O, BP.& wt.
intracranial due to severe hypotension or
pressure; Raised renal disease; hypertension; acute
intraocular pressure; severe renal failure; skin
Cerebral oedema dehydration. necrosis;
0.25-2 g/kg over 30- thrombophloebitis.
60 mins.
Transurethral
prostatic resection
Use 2.5-5% soln for
bladder irrigation
Dexamethasone  Asthma &  Neonate &  Risk of osteoporosis &  Caution use in heart
related infant. spontaneous fracture, muscle failure, recent MI,
Classification: bronchospastic wasting, nitrogen depletion, HTN, DM, epilepsy,
disorder hyperglycemia. glaucoma,
Corticosteroid unresponsive to hypothyroidism,
Hormones/ other therapy,  Increased insulin requirement in hepatic failure,
Glucocorticoids allergic rhinitis, diabetics, increased appetite. osteoporosis, peptic
Used in systemic inflammatory hyperhidrosis, skin thinning, ulcer, psychoses,
corticosteroid nasal condition. ocular changes including severe affective
preparations. Also used in development of glaucoma & disorders, renal
cerebral edema cataract, neurological impairment.
due to disturbances, benign intracranial  Reduce CA & K
malignancy. HTN, acute pancreatitis, intake.
avascular necrosis of the bone.  Monitor fluid intake &
output, & wt daily.
 Increased blood coagulation that  Rapid IV inj of
may lead to thromboembolic massive dose may
complication. Peptic ulcer. cause CV collapse.
Childn. Elderly.
 Adrenal atrophy, secondary
adrenocortical insufficiency.
Paresthesia & irritation, epidural
lipomatosis.
Midazolam  Disturbances of  Premature  Rarely cardioresp  Have O2 and
sleep rhythm, infants. adverse events, resuscitation
Classification: insomnia esp Myasthenia nausea, vomiting, equipment available in
difficulty in falling gravis. headache, hiccoughs, case of severe
Hypnotics and sedatives asleep either laryngospasm, respiratory depression.
initially or after dyspnoea,  Continiously monitor
premature hallucination, BP. HR. RR. Airway
awakening. Tab/Inj oversedation, integrity and arterial
Sedation in premed drowsiness, ataxia, O2saturation during
before surgical or rash, paradoxical procedure.
diagnostic reactions, amnesic  When inj. Give IM.
procedures, episodes. Deeply into a large
induction & muscle
maintenance of
anesth.
 Neonates less than

32 weeks
gestational age;
initially 0.03
mg/kg/hr
Epinephrine HCl  Cardiac stimulant in  Cardiac  CNS: drowsiness,  Drug interferes with
case of collapse, arrhythmia, headache, tests for urinary
Classification: shock & anesthetic tachycardia nervousness, tremor, catecholamines.
Cardiac Drugs accidents. >140 bpm, cerebral hemorrhage,  Drug of choice in
Hemostatic in severe HTN, stroke, vertigo, pain emergency treatment
hemorrhages. narrow angle disorientation, of acute anaphylactic
Prolongs action of glaucoma, agitation, fear, reactions.
infiltration anesth w/ dizziness, weakness.  Observe pt. closely for
anesthetic agent. halogenated  Palpitations, adverse reaction,
Urticaria. hydrocarbon of ventricular adjust dosage or stop
cyclopropane, fibrillation, shock, drug if necessary.
 Childn 10 mcg/kg w/ local anesth widened pulse  One mg. equals 1ml of
body wt or 300 of finger or toe, pressure, 1:1000 solution or 10
mcg/m2 body woman in labor, hypertension, ml of 1:10,000
surface up to 500 cardiac dilation tachycardia, angina, solution.
mcg/dose, repeated & coronary altered ECG,  When treating pt. with
as necessary up to 6 insufficiency. decrease T-wave reactions caused by
times a day.  GI: nausea, vomiting other drugs given IM.
 RESP:Dyspnea Or subcutaneously,
 Skin: urticaria, inject this drug into the
hemorrhage at inj. site where the other
site, pallor. drug was given to
minimize further
absorption.
Phenobarbital  Partial seizures/ anti  Severe renal and  Bradycardia,  Therapeutic level is
convulsants hepatic hypotension, 15-40 mcg/ml.
Classification: disorders. syncope; drowsiness,  Watch signs for
anticonvulsant Severe lethargy barbiturate toxicity;
respiratory  CNS excitation or coma, cyanosis,
depression, depression, impaired asthmatic breathing,
dyspnoea or judgment, hangover clammy skin, and
airway effect, confusion, hypotension.
obstruction; somnolence,  Don’t stop drug
porphyria. agitation, abruptly because this
Pregnancy. hyperkinesia, ataxia, may worsen seizure.
nervousness,  Drg. May decrease
headache, insomnia, bilirubin level in
nightmares, neonates, pt. with
hallucinations, epilepsy, and those
anxiety, dizziness; with congenital
 Skin:rash, exfoliative nonhemolytic,
dermatitis; unconjigated
 GI: nausea, vomiting, bilirubinia.
constipation;  Elderly or debilitated
agranulocytosis, patients, children.
thrombocytopenia, Withdraw gradually.
megaloblastic Impaired renal, hepatic
anaemia; pain at inj and respiratory
site, thrombophlebitis function. Patients with
 (IV); oliguria: acute pain and
laryngospasm, depressive disorders.
respiratory May impair ability to
depression, apnoea drive or operate
(especially with rapid machinery. Lactation.
IV admin),  Symptoms: Unsteady
hypoventilation.  gait, slurred speech,
 Potentially Fatal: confusion, jaundice,
Stevens-Johnson hypothermia,
syndrome. hypotension,
respiratory depression,
coma.
 Management:
Charcoal
haemoperfusion (in
severe cases).
 Treatment is
symptomatic and
supportive.
Levophed  Used in the  Patients who are  Bradycardia, Special Precautions

treatment of heart hypotensive arrhythmias; anxiety,  Extravasation. Patient
Classification: failure from blood vol transient headache. w/ profound hypoxia
deficits except Plasma vol depletion or hypercarbia.
Vasoconstrictors/ as emergency (prolonged Concomitant MAOI or
adrenergic and measure. administration). Resp tricyclic
dopaminergic cardiac Concomitant difficulty, ischemic antidepressant.
stimulants cyclopropane & injury.  Hypersensitivity to
halothane sulfites.
anesth. Patient  Monitor BP.
w/ mesenteric or
peripheral
vascular
thrombosis
unless it is life-
saving.
Ca. Gluconate  Drugs for fluid and  Patients with  GI irritation; soft-  Double-check that you
electrolyte calcium renal tissue calcification, are giving the correct
Classification: balance /electrolyte calculi or history skin sloughing or form of calcium;
Electrolytes replacement of renal calculi. necrosis after IM/SC resuscitation cart may
solutions. Conditions inj. Hypercalcaemia contain both calcium
associated with characterised by gluconate and ca. chl.
hypercalcaemia anorexia, nausea,  Monitor Ca. levels
and vomiting, frequently; maintain
hypercalciuria. constipation, Ca. level of 9 to 10.4
 Special abdominal pain, mg/dl. Hypercalcemia
Precautions: muscle weakness, may result after large
 Impaired renal mental disturbances, doses in chronic renal
function; cardiac polydipsia, polyuria, failure. Report
disease; nephrocalcinosis, abnormalities
hypercalcaemia- renal calculi; chalky  Sx/s. of severe
associated taste, hot flushes and hypercalcemia may
diseases, e.g. peripheral include stupor,
sarcoidosis; vasodilation. confusion, delirium
other  Potentially Fatal: and coma.
malignancies. Cardiac arrhythmias
Pregnancy. and coma.
Dobutamine  Used in the  Idiopathic  Increased heart rate, Special Precautions
treatment of heart hypertrophic BP & ventricular  May cause marked
Classification: failure subaortic ectopic activity; increase in heart rate
Cardiac Drugs/  Inotropic support in stenosis & hypotension.Phlebitis or BP. Patients w/
adrenergic and the short-term patients w/ at IV inj sites. atrial fibrillation are at
dopaminergic cardiac treatment of cardiac known allergy to risk of developing
stimulants decompensation due corn or corn rapid ventricular
to depressed products. response; w/
contractility preexisting HTN are at
resulting either from increased risk of
organic heart exaggerated pressor
disease or cardiac response.
surgical procedures.  Continuously monitor
Long-term BP & ECG as well as
treatment of CHF. pulmonary wedge
 Start at a low rate of pressure & cardiac
0.5-1 mcg/kg/min & output.
titrate at intervals of  Hypovolemia should
a few min. Usual be corrected. Patients
optimal infusion w/ subclinical or overt
rate 2-20 DM.
mcg/kg/min. Max:
40 mcg/kg/min.  Pregnancy & lactation,
childn & elderly.
Citicoline  IV/IM Parkinson's  Contraindicated in  Stop taking your  Before taking
disease; conditions like medicine right away citicoline, tell your
Classification: Cerebrovascular unconsciousness and and talk to your doctor doctor if you are
Nootropics & disorders and head brain surgery if you have any of the pregnant or breast
Neurotonics injury following side effects. feeding
 Allergic reaction:
Itching or hives,
swelling in your face or
hands, swelling or
tingling in your mouth
or throat, chest
tightness, trouble
breathing, or rash.
 Other Side Effects:
You may have the
following side effects,
but this medicine may
also cause other side
effects. Tell your doctor
if you have side effects
that you think are
caused by this
medicine.
 Low blood pressure
(faintness, dizziness)
Slow or fast heart beat
Headache
Nausea, vomiting, or
diarrhea (loose BMs)
Vancomycin HCl  Used in the treatment  Hypersensitivity to  Erythema, flushing or  Do not inject IM &
of systemic infections vancomycin rash over the face & care should be taken
Classification:  Treatment of upper torso, when given IV to
Antibiotics methicillin-resistant hypotension & shock- avoid extravasation
glycopeptide staphylococcal like symptoms. due to risk of tissue
antibacterials infections; in Hypersensitivity necrosis.
conditions eg brain reactions eg rashes,
abscess, fever & chills.
staphylococcal
meningitis, peritonitis
associated w/
continuous peritoneal
dialysis &
septicemia.
 Children Single dose

of 20 mg/kg
Metronidazole  Intestinal & hepatic  History of blood  GI:Nausea, headache,  Observe pt. for
amoebiasis Childn dyscrasia anorexia. Occasionally, edema, especially if
Classification: 40-50 mg/kg body wt vomiting, diarrhea, he’s receiving
in 3 divided doses for epigastric cramping, corticosteroids;
Imidazole derivative 5-7 consecutive days. constipation, mild Flagyl IV RTU may
antibacterials/Antia Treatment may be leukopenia. cause sodium
moebics continued up to 10 retention
days if deemed  Record number of
necessary in severe character of stools
cases. Giardiasis when drug is used to
Childn >10 yr 2 tsp treat amebiasis.
qid for 5 consecutive
days. 4-9 yr 1-1½tsp,
1-3 yr 1 tsp.
Amikacin sulfate Indicated for;  Hypersensitivity  Dehydration, renal  Obtain specimen for
 Bacterial septicemia to dysfunction, culture and sensitivity
Classification: including neonatal aminoglycosides neuromuscular tests before giving first
Aminoglycosides sepsis. Serious infections . disorders, premature dose. Therapy may
of the resp tract. & neonatal infants. begin while awaiting
 Infections of the bone &  Auditory, vestibular, results.
joints. Intra-abdominal renal toxicity &  Weigh Pt. and review
infections including neuromuscular renal function studies
peritonitis. blockade. Rash, drug before therapy begins
 Burns & post-op fever, headache,  Correct dehydration
infections. paresthesia, tremor, before therapy begins,
 Serious & complicated nausea & vomiting, because of increase
UTI due to susceptible eosinophilia, risk of toxicity
organisms. arthralgia, anemia &  Monitor renal
 As initial therapy in hypotension. function, urine output,
suspected gm-ve specific gravity, BUN
infections before the & creatinine clearance.
results of susceptibility  Watch for S/sx of
testing are obtained. In super infection, URT,
mixed, gm-ve, staph such as continued
infections & other fever, chills & increase
gm+ve organism eg pulse rate.
Strep & pneumococci.  Peak drug levels more
than 10 mcg/ml may
 Adult, childn & older be linked to higher risk
infant 7.5 mg/kg 12 hrly of toxicity.
or 5 mg/kg 8 hrly.
Mupirocin  Treatment of  Hypersensitivity  Burning, stinging or  Avoid contact w/ eyes.
primary (impetigo, to drug pain. Itching. Rash, Prolonged use.
Classification: folliculitis, erythema, dry skin, Discontinue if
furunculosis, tenderness, swelling, sensitivity occurs
Topical Antibiotics ecthyma) & contact dermatitis,
secondary skin increased exudate.
infections (infected
abrasions & insect
bites, minor wounds
& burns) due to
susceptible
organisms.
 Prevention of
contamination of
small cuts, wounds,
abrasions, incisions
& other lesions.
 Apply a small
amount on affected
area tid for up to 10
days.
NURSING CARE PLAN
Analysis of the Nursing

Date/Cues Goal & Objectives Rationale Evaluation
Problem Interventions
Objective Data: Nursing Diagnosis: After one hour of Encourage warm Warm liquids After one hour the
-Thick tenacious nursing versus cold liquids as relaxes airway and nurse was able to
secretions Ineffective airway intervention: appropriate loosens secretions clear the client’s
(+) rhonchi clearance related to The client’s secretions
(+) crackles excessive secretions as secretions will be Keep environment To reduce irritant manifested by
-Restlessness evidenced by rhonchi decreased enabling pollutant free effect on airways decreased crackles
-Irritability and crackles upon the client to have on auscultation.
RR: 80s auscultation improved breath Elevate head of the To take advantage
breathes/min sounds and patent bed/change positions of gravity The client’s
Scientific Implication: airway. every 2 hours and decreasing parents verbalized
Subjective Data: Ineffective airway PRN pressure on the understanding of
“Sobrang clearance will lead to The client’s diaphragm and the nurse’s health
mahalak pa din imbalanced parents will enhancing teaching regarding
siya, kapag ventilation-perfusion verbalize drainage & use of warm versus
humihinga siya ratio leading to understanding with ventilation of cold liquids and
rinig na rinig ko” inadequate systemic the health different lung maintaining a
as verbalized by oxygen circulation teachings to segments pollutant-free
the mother maintain a patent environment.
airway and Suction naso/oral To clear away
become involved secretions PRN secretions Interdisciplinary
in patient care. collaboration in
Use Chest Promotes drainage accordance with
The client will Physiotherapy as of secretions medication
have a patent indicated coverage and
airway nebulization were
facilitated.
The client’s Maintain adequate I/O To monitor fluid
retained secretions and avoid fluid balance
will be removed. overload
The client will Accurately regulate IV To prevent fluid

demonstrate fluid as ordered using overload
reduction/ absence a syringe pump
of congestion with
breathe sounds
clear and Administer To treat underlying
respirations medications as ordered condition
noiseless.
Facilitate referral to
Facilitate respiratory therapist For inter-
coordination with for nebulization disciplinary
other members of collaboration. For
the health care tenacious
team for secretions to be
interdisciplinary liquefied for easier
approach. suctioning.
Date/ Cues Analysis of the Goal and Nursing Interventions Rationale Evaluation
problem objectives
Objective data: Ineffective After one hour of Assessed patient’s vital Vital signs and After one hour of
-Arterial BP: cardiopulmonary nursing signs including heart heart and lung nursing intervention,
50/46 mmHg tissue perfusion intervention, the rate, pulse, and sounds are the patient’s arterial
-ABG result: related to impaired patient’s arterial respirations. Auscultated important blood gas, oxygen
Respiratory cardiac function blood gas, oxygen heart and lung sounds indicators for saturation and blood
Acidosis and increased saturation and overall heart pressure gradually
pH-7.24 cardiac workload blood pressure will function improveded as
pCo2-64 gradually improve. evidenced by:
pO2-24 Administered Supplemental -ABG result of:
HCo3-27 supplemental oxygen as oxygen enhances pH-7.30
-Oxygen ordered tissue perfusion Co2-54
Saturation: 31.8- without increasing pO2-42
Very severe the child’s HCo3-29
hypoxemia metabolic oxygen -Blood pressure:
-Pale demand 80/55
-Dyspneic -Oxygen saturation:
-Lungs with Monitored arterial blood Arterial blood 35
harsh rhonchi gas values and oxygen gases and pulse
and crackles on saturation levels via oximetry provide
auscultation pulse oximetry information about
the status of tissue
oxygenation
Institute continuous
cardiac monitoring as Continuous cardiac
ordered monitoring
provides objective
evidence of cardiac
function, including
changes indicative
of ischemia.
Removed any
constricting clothing Constricting
from the chest clothing interferes
with chest
expansion
Limit procedures to those
that are necessary and Activity increases
provide adequate rest metabolic and
periods myocardial oxygen
demands, further
impairing
cardiopulmonary
tissue perfusion
Administer medications,
such as digoxin and Digoxin improves
diuretics as ordered. myocardial
Assess apical pulse prior contractility.
to digoxin Diuretics reduce
administration. Obtain fluid overload. Too
serum digoxin levels as rapid or too slow a
ordered. heart rate may
indicate digoxin
toxicity. Measuring
serum digoxin level
aids in evaluating
the effectiveness of
therapy and
preventing digoxin
toxicity.
problem objectives
Objective data: Hyperthermia After 4 hours of Assess temperature To provide baseline After 4 hours of
• Flushed skin; related to infection nursing care, the hourly and other signs data nursing care, patient
warm to as evidence by patient will and symptoms. was able to maintain
touch temperature of maintain a normal a normal body
• Restlessness 37.9°C body temperature. Record every fluid intake To assess for signs temperature.
• Vital signs as and urine output. of dehydration.
follows:
Promote surface cooling To reduce
T: 37.9°C by rendering tepid temperature by
HR: 152 sponge bath. means of
RR: 33 evaporation and
BP: 85 / 63 Provide air conditioning conduction.
or fan.
Remove excess clothing

and blankets.
Maintain on comfortable To decrease

position and provide rest metabolic demand
periods. and oxygen
consumption.
Administer prescribed To facilitate fast

antipyretics recovery.
Analysis of the Goal &
Date/Cues Nursing Interventions Rationale Evaluation
Problem Objectives
Objective Imbalanced Demonstrate stable Determine appropriate Providing usual and After 4 days of
method for feeding typical feedings is
Data: nutrition less than weight important to infant nursing intervention
- height: 57 cm body requirements gain/progressive well-being and the patient was able
-weight: 3.2 kg related to feeding weight gain using early growth. to tolerate a gradual
(ideal body intolerance as age- appropriate Auscultate bowel sounds. increase of feeding
weight: 4.2 kg) evidenced by measurements, Provides of 60 ml every 3
Note characteristics of information about
-Poor skin decrease in body including weight stool (color, amount, digestion/bowel hours
turgor weight appropriate and body fluid, frequency, and so on). function and may After 4 days of
-Pale for his age. strength, activity affect choice/timing nursing intervention,
conjunctiva level, sleep/rest of feeding. the patient’s weight
and mucous Scientific cycles. To determine the progressed to 3.4 kg.
membrane Implication: Weigh patient daily
patient’s
-with OGT Prolong NPO status To promote progressive weight
tube may lead to low adequate infant gain
immunity, unmet intake
nutritional needs To avoid aspiration
Maintained the patency
and delay in growth of the OGT and to assist in
conserving energy
demanded for
sucking
Feed the patient via OGT To increase his

as orderd and tolerated weight.
Review drug regimen, Timing of
side effects, and potential
. interactions with other medication doses,
medications/over-the- interaction with
counter drugs. certain foods can
alter effect of
medication or
digestion/absorptio
n of nutrients
Date/Cues Analysis of the Goal & Nursing Interventions Rationale Evaluation
Problem Objectives
Objective Nursing Diagnosis: After 7 days of Inspect skin on a daily To obtain baseline The client displayed
Data: Impaired skin nursing basis, describing lesions data timely wound
and changes observed.
Post- integrity related to intervention, the healing without any
sternotomy surgical intervention client will display Keep affected area clean complication after
To assist body’s
surgical timely healing of and dry natural process of the consistent and
incision site Scientific skin lesions repair continuous
Implication: without interventions.
The skin layer is the complication. Cool, moist compresses Moisture
largest to skin. Avoid use of potentiates skin The client’s parents’
multifunctional The client will soap because it tends to breakdown. verbalized
dry skin and make it
organ of the body. maintain physical more likely to understanding of the
The alteration that well-being breakdown. nurse’s varied health
resulted from teaching regarding
iatrogenic The client’s family Assist the family in wound care.
following medical Enhances
interventions may will verbalize commitment to
regimen for the client
compromise its understanding of and develop program of plan, optimizing Interdisciplinary
ability to protect the purpose and preventive care and daily outcomes collaboration in
body from enumerate maintenance. accordance with
infectious organisms interventions in medication therapy
and/or wound care Daily wound care using was facilitated.
sterile equipment and
thermoregulation. practicing aseptic To maintain skin
The client’s technique in dressing. integrity, promote
wounds will be timely wound
free of healing, and
complication like Teach the parents the prevent infection.
purulent discharge above interventions and
rationale To involve the
from infection.
client’s significant
others in wound
The client’s family care and promote
will participate in readiness and
prevention independence in
measures and care prior to
Carry-out dependent discharge.
treatment program. interventions such as
application of topical
antibiotic ointment and To promote
Facilitate timely, well regulated optimum recovery
coordination with administration of of the incision site.
other members of intravenous antibiotic
the health care coverage.
team for inter-
disciplinary Endorse plan of care to
receiving bedside nurse.
approach.
For
interdisciplinary
management and
to make possible the
continuity of care
problem objectives
Objective data: Impaired At the end of the Note absence from To assess causative/ After 30 minutes of
parenting due to interaction, home setting and the contributing nurse-parent
-Statements of illness as approximately 30 lack of infant factors. reaction, the mother
the mother of her evidenced by minutes, the supervision by the was able to identify
inability to meet prolonged mother will parent. methods on how to
child’s needs. separation from identify own meet her parenting
-Verbalization of sick child. strengths, Make time for listening needs.
frustration on parenting needs to concerns of the Enhances feeling of
inadequacy of and methods to parents and to acceptance and
role as a parent. meet them. acknowledge difficulty expression of
of the situation. feelings.
Subjective Data:
Provide adequate
“Hindi ko na visiting time for the Create an
maalagaan ang parents. environment for
anak ko” as relationship to be
verbalized by the developed and
mother. foster development
of parenting skills.
Let parents participate in
caring for their child and Facilitate
provide information satisfactory
appropriate to the implementation of
situation, including limit the plan.
setting.
IX. BIBLIOGRAPHY
WEBSITES:
• www.americanheart.org/presenter.jhtml?identifier=11074
• en.wikipedia.org/wiki/Dextro-Transposition_of_the_great_arteries
• www.health.uab.edu/14585
• cincinnatichildrens.org/health/.../anomalies/transposition.htm
• www.mayoclinic.org/corrected-transposition-great-arteries/about.html
• www.childrenshospital.org/az/Site511/mainpageS511P0.html
• rarediseases.info.nih.gov/GARD/Disease.aspx?
PageID=4&diseaseID=7795
• cnn.com/.../library/transposition-of-the-great-arteries/DS00733.html
• www.ojrd.com/content/3/1/27
• circ.ahajournals.org/cgi/content/full/114/24/2699
• yourtotalhealth.ivillage.com/transposition-great-arteries.html
• www.wikidoc.org/index.php/Transposition_of_the_great_vessels
• emedicine.medscape.com/article/900574-overview
BOOKS:
• Maternal and Child Health : Programs, Problems, and Policy in Public Health, Second
Edition (Hardcover)by Jonathan Kotch (Author)
• Nanda Nursing Diagnoses: Definitions and Classification 2005-2006 (Nanda Nursing
Diagnosis) (Paperback) by Nanda (Editor)
• Lippincott's Nursing Procedures by Lippincott Williams & Wilkins Textbook
(Hardcover-Fifth Edition) Pub. Date: May 2008
• Lippincott’s Nursing: Deciphering Diagnostic Tests
Author(s): Springhou Pub Date: March 2007
• Nurse's Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales by
Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr Textbook (Paperback
- New Edition) Pub. Date: January 2008

Transposition of The Great Arteries

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Philippine Heart Center

CRITICAL CARE COURSE

CONGENITAL HEART DEFECT

Maria Lilibeth Q. Icasiano R.N.

Transposition of the great arteries is a relatively common congenital heart condition

II. STATEMENT OF OBJECTIVES

NAME : Baby Boy Blue

4. HISTORY OF PRESENT ILLNESS

With presence of OGT For feeding purposes

Clear breath sounds Crackles on bilateral lung Presence of secretions

Actual Findings Interpretation and Analysis

Blinking Flash of light or Closes eyes Eyes closed, blinks Normal

In transposition of the great arteries,

Although it may seem counterintuitive, complex d-TGA presents better chance of

• AS = Aortic sac • LV = Left ventricle

• SAO = Sinoatrial oriface • Perf = Perforations

• EC = Endocardial cushions • SS = Septum spurium

V. COURSE IN THE WARD

Day 1 August 13, 2009 Day of Admission

Day 4 August 16, 2009

Day 6 August 18, 2009

Day 11 August 23, 2009

Day 12 August 24, 2009

Day 13 August 25, 2009

Day 14 August 26, 2009

Day 15 August 27, 2009

Day 20 September 1, 2009

Day 22 September 3, 2009

Day 23 September 4, 2009

Day 25 September 6, 2009

Day 26 September 7, 2009

Day 27 September 8, 2009

Day 29 September 10, 2009

Day 30 September 11, 2009

Day 33 September 14, 2009

Day 35 September 16, 2009

Day 36 September 17, 2009

Day 37 September 18, 2009

Day 43 September 24, 2009

DIAGNOSTIC AND THERAPEUTIC MANAGEMENT

A. Arterial Switch Operation

1. Aprotinin, to prevent excessive bleeding

2. Solumedrol, to reduce swelling and inflammation

3. Regitine, to prevent hypertension

4. Prophylactic antibiotics, to prevent infection

1. muscle relaxant, to induce temporary paralysis

2. opioid analgesic, to manage pain, cause sedation and induce serenity

3. inotrope, to assist the heart in contracting adequately

A. Pre-op Nursing Care

• Preoperative and baseline. Reveal abnormalities and establish norms.

b. Past surgical history

• Generally, also previous bad outcomes or distressing experiences

f. Fluid / Electrolyte Balance

• Correction of any imbalance is essential. Patients prone to hypovolemia: diarrhea,

• Chronic illness can complicate the postoperative phase

i. Integumentary Status: pressure ulcers from immobility

• antibiotics: combine with curare to prolong apnea.

A. General Principles of Preop teaching

B. Patient Teaching About Postoperative Care

1. Therapeutic devices: indwelling catheter, nasogastric tube, chest tube

 Preop legal preparation—the Operative Permit It is the surgeon’s

3. Day of surgery preparation