CASE #1 1. Ineffective Breathing Pattern related to pulmonary, neurologic, vascular, alveolar and muscular immaturity 1.

Position to facilitate airway expansion and prevent collection of secretions. 2. Closely monitor for deviations from desired breathing pattern in order to implement proper therapy such as suctioning, supplemental oxygen, mechanical ventilation or change of position. 3. Monitor vital signs for change in status such as decrease cardiac output 4. Assist in exogenous surfactant administration and monitor patient tolerance or change in status 5. Suction oropharynx, nasopharynx, trachea, endotracheal tube only as necessary and based on respiratory assessment 6. Perform gentle chest percussion, vibration and postural drainage based on assessed need and infant tolerance. Impaired Gas Exchange related to pulmonary, neurologic, vascular, alveolar and muscular immaturity 1. 2. 3. Assess respiratory status, noting signs of respiratory distress (e.g., tachypnea, nasal flaring, grunting, retractions, rhonchi, or crackles). Apply transcutaneous oxygen monitor or pulse oximeter. Record levels hourly. Change site of probe every 34 hr. Suction nares and oropharynx carefully, as needed. Limit time of airway obstruction by catheter to 510 sec. Observe transcutaneous oxygen monitor ventilation or pulse oximeter before and during suctioning. Provide bag ventilation following suctioning. Monitor fluid intake and output; weigh infants. Dehydration impairs ability to clear airways because mucus becomes thickened. Over hydration may contribute to alveolar infiltrates/pulmonary edema. Promote rest, minimize stimulation and energy expenditure. Position infant on abdomen of possible. Prone position compensates for weak chest and abdominal muscles, decreasing the amount of respiratory effort required to expand chest, thus allowing optimal chest expansion and enhancing inhalation of air. Stimulates respirations and ventricular growth. Positioning infant on abdomen or side reduces risk of aspiration of mucus/regurgitated formula.

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Ineffective Thermoregulation related to Immature Neurologic and Metabolic Temperature control 1. Place newborn in a thermally controlled incubator or radiant warmer 2. Place knitted or cloth cap on head to prevent loss of heat to exposed scalp

3. Use environmental controls for decreasing body heat loss- plastic heat shield, increase ambient temperature, servo control on warmer 4. Monitor axillary temperature often as necessary and monitor vital signs and skin color, perfusion, pulses and respiratory status Risk for CNS damage injury related to hypoxia 1. Assess respiratory effort. Note presence of pallor or cyanosis. Respiratory distress and hypoxia affect cerebral function and may damage or weaken walls of cerebral blood vessels, increasing risk of rupture. If untreated, hypoxia may result in permanent damage. 2. Observe for any alterations in the CNS function. 3. Provide supplemental oxygen. Hypoxemia increases the risk of impairment or permanent CNS damage. 4. Monitor for ABGs, Hct and Hgb and bilirubin levels. 5. Assess skin color noting evidence of increasing jaundice associated with behavior changes such as lethargy, hyperreflexia and convulsions. Preterm infants is more susceptible to kernicterus at lower serum bilirubin levels that full-term infant because of increased levels of unconjugated circulating bilirubin crossing the BBB.

Risk for Fluid Volume Deficit related to extremes of age and weight secondary to excessive fluid losses due to immaturity of skin, lack of insulating fat and immature kidneys 1. Calculate fluid balance each shift, monitor daily weight. Lower gestational age has a negative impact on glomerular filtration rate (GFR) and is further limited by conditions that impair renal blood flow or oxygen content (e.g., dehydration, respiratory distress), often resulting in oliguria/anuria. Positive fluid balance and corresponding weight gain in excess of 2030 g/day suggest fluid excess. 2. Minimize insensible fluid losses through use of clothing, warm and humidified O2. Preterm infant loses large amounts of water through skin, because blood vessels are close to surface and insulating fat levels are decreased or absent. Phototherapy or use of radiant warmer may increase insensible losses by 50%, necessitating increased intake to as much as 200 ml/kg/day. Note: Infants weighing <1500 g (3 lb 5 oz) are most susceptible to insensible fluid losses. 3. Evaluate skin turgor, mucous membranes, and status of anterior fontanel. Fluid reserves are limited in the preterm infant. Minimal fluid losses/shifts can quickly lead to dehydration, as noted by poor skin turgor, dry mucous membranes, and depressed (sunken) fontanels. 4. Administer blood transfusions. May be necessary to maintain optimal Hb/Hct levels and replace blood losses.

Risk for Altered Nutrition less than Body Requirements related to the immaturity of enzymatic production and gastrointestinal system

1. Assess maturity of reflexes associated with (ie., sucking, swallowing, gag, and coughing). Determines feeding appropriate feeding method for infant. 2. Initiate intermittent or tube feedings, as indicated. Gavage feedings may be necessary to provide adequate nutrition in infant who has a poorly coordinated suck-and-swallow reflex or who becomes fatigued during oral feedings. Note: Transition to oral feeding is significantly delayed if apneic episodes are experienced. 3. Assess infant for proper placement of feeding tube; use appropriate clamping procedures prevent entry of air into stomach. Improper placement of tube in trachea can to compromise respiratory function. When 1 ml or less is aspirated from the stomach, this sum should be subtracted from the feeding and reinstalled in tube. When more than 2 ml is aspirated, feeding schedule may need to be altered. 4. Instill breast milk/ formula over 20 min at a rate of 1ml/min. Too-rapid entry of feeding into stomach may cause rapid rebound response with regurgitation, increased risk of aspiration, and abdominal distension, all of which compromise respiratory status. 5. Provide TPN if necessary Risk for impaired parent-infant attachment 1. Encourage skin-skin contact as condition of newborn allows. 2. Explain to parents in simple terms the newborns illness and expectation of recovery 3. Encourage parent participation in newborn care activities such as touching infant, expressing and storing maternal breast milk.

2. the babys age is 38 weeks based on Ballards-Dubowitz scoring system. Neuromascular traits of immature infants:

Arms and legs are extended or may have slight or moderate flexion of hips and knees Square window, about 90 degrees Arm recoil, may have minimal flexion about 140-180 degrees Poplipteal angle about 140-180 degrees (+) scraf sign

Physical traits of immature infants:

Skin is gelatinous, red and translucent Lanugo is mostly sparse. There are no creases in the plantar surface. Breast is barely perceptible. Eye lids are open, the pinna is flat and stays folded

The genitals of male is empty and has faint rugae; the females genitals has small labia minora and the clitoris is prominent.

3. Predisposing factors that could have contributed to why a baby may be born premature are the following:

Cigarette smoking: Smoking cigarettes is one of the greatest risks of premature delivery. Alcohol use: Premature birth is among the many risks associated with drinking alcohol during pregnancy. there is no amount of alcohol safe while one is pregnant. Age: Mothers under age 18 and over 30 have a greater risk of going into labor early than other mothers. Lack of prenatal care: The later prenatal care begins, the greater the risk of health problems during pregnancy. Lack of and delayed prenatal care are associated with preterm delivery Poor nutrition: Mothers with an extremely low body mass index have a higher risk of preterm delivery. Mothers with a generally poor nutritional status also have a greater risk. Stress: High levels of stress that continue for a long time may cause health problems, like high blood pressure and heart disease. When one is pregnant, this type of stress can increase the chances of having a premature baby (born before 37 completed weeks of pregnancy) or a low-birthweight baby (weighing less than 5 pounds). Babies born too soon or too small are at increased risk for health problems. Unintended pregnancy (This means you didnt plan to get pregnant.)

4. Effects of drugs to new born are:

congenital heart defects club foot cleft lip or cleft palate low birth weight

CASE #2

1) What are the 2 types of CHD? name the conditions under both groups Two types of CHD

Acyanotic defects

Under increased pulmonary blood flow: Atrial septal defect, Ventricular septal defect, Patent ductus arteriosus, Atrioventricular canal Under obstruction to blood flow: Coarctation of Aorta, Aortic stenosis, Pulmonic stenosis

Cyanotic defects:

Under decreased pulmonary blood flow: Tetralogy of Fallot, Tricuspid atresia Under mixed blood flow: Transportation of great arteries, Total anomalous pulmonary venous return, Truncus arteriosus, Hypoplastic left heart syndrome

*** Itong part na to di ko sure if kailangan sobrang related sa patient... ? Watcha guys think? 2) What are the diagnostic tests that may be ordered for CN to find out specifically what he has? Common tests for congenital heart defects: - An electrocardiogram (ECG or EKG) is a test that measures the electrical activity of the heartbeat. An ECG gives two major kinds of information. First, by measuring time intervals on the ECG, a doctor can determine how long the electrical wave takes to pass through the heart. Finding out how long a wave takes to travel from one part of the heart to the next shows if the electrical activity is normal or slow, fast or irregular. Second, by measuring the amount of electrical activity passing through the heart muscle, a cardiologist may be able to find out if parts of the heart are too large or are overworked. - The chest X-ray gives the cardiologist information about your lungs and the heart's size and shape. - An echocardiogram is an ultrasound movie of the inside of the heart. It can detect nearly every congenital heart defect or any problem of the heart muscle function. - A cardiac catheterization is a procedure that allows the cardiologist to get direct information about the blood pressures and patterns of blood flow within your heart.

- Magnetic resonance imaging (MRI) is another way to take clear pictures of the heart and measure heart function. - The CT scan uses multiple X-ray images to take an X-ray movie of the heart and lungs without placing catheters into the circulation. Like the MRI, this test sometimes takes clearer pictures than an angiogram. - A transesophageal echocardiogram is a special type of ultrasound movie of the heart that produces much clearer pictures than a standard echocardiogram that's performed on your chest. - Coronary angiography is an invasive procedure that uses a special dye (contrast material) and x-rays to see how blood flows through your heart and evaluates the heart arteries or - A computerized tomography (CT) coronary angiogram is an imaging test to look at the arteries that supply your heart muscle with blood that doesn't use a catheter but relies solely in a powerful X-ray machine to produce images of your heart and heart vessels.

3.)What possible complication is pointed out by the symptoms he is presenting in the third paragraph? The child possibly developed one of the common complication of CHD known as cor pulmonale or Right-Sided heart failure. High blood pressure in the arteries of the lungs is called pulmonary hypertension. The right side of the heart has a harder time pumping blood against these higher pressures. If this high pressure is present for a longer period of time, it puts a strain on the right side of the heart, leading to cor pulmonale.Almost any chronic lung disease or condition causing prolonged low blood oxygen levels can lead to cor pulmonale. in relation to CN, he was known to have chronic and frequent respiratory infection with cough since he was 3 months old, and is still evident up to now. Symptoms of cor pulmonale would include Shortness of breath or light-headedness during activity, which is often the first symptom and patient may also feel palpitations. Over time symptoms occur with lighter activity or even while at rest. And they may include: Fainting spells with activity, Chest discomfort, usually in the front of the chest, Swelling of the feet or ankles, Symptoms of underlying disorders (wheezing, coughing). while signs of it would reveal Fluid build up in the belly area (abdomen), Abnormal heart sounds, Bluish skin (cyanosis) due to chronic insufficient supply of Oxygen to body tissues, liver swelling, distention of neck veins(sign of high right-heart pressures) and ankle swelling. wherein most of which is evident to C.N.

4. what could be the possible cause of his frequent respiratory infection?

5. What are the actions of the 3 drugs being given to him and why is he given those?

FUROSEMIDE

1. Reducing Fluid OverloadCN was developing signs of fluid volume excess as evidenced by neck vein distention, slightly enlarged abdomen, productive cough, and swelling of the liver organ.The primary effect of Lasix on CHF is reducing fluid congestion. By triggering the kidneys to make large amounts of urine, Lasix pulls excess volume out of the blood vessels and organs 2. Improved Breathing CN was experiencing difficulty of breathing along with productive cough . lasix will work for him by pulling excess water out of the lungs,hence, improves breathing, activity tolerance and sleep.

3. Reduced Swelling children with CHF experience some degree of swelling in the feet and lower legs. In acute exacerbations of CHF, swelling can be extreme, involving the thighs, arms and lower trunk. Just as Lasix pulls water off the lungs to improve breathing, its diuretic effect pulls water out of body tissues. in the case of CN, he is currently manifesting swellingof the liver and enlarged abdomen due to fluid accumulation

DIGOXIN:

such as digoxin, will increase contractility and therefore increasethe cardiac output. This new equilibrium point now reflects an increasedcardiac output and a lower right atrial pressure so more blood will now beejected from the heart with each beat, preventing pulmonary congestion as well.hence improving oxygen delivery and nutrition to body tissues.

CAPTOPRIL

captopril dilates blood vessels arounf the body allowing the heart to pump against less resistance. since C.N is obviously developing signs of heart congestion. (Shortness of breath, productive

cough due to pulmonary congestion of fluids, fluid build up in abdomen, decreased oxygen perfusion to the distal areas of the body, distended neck vein).