Philippine Heart Center

CRITICAL CARE COURSE60th 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, MarianneBañagale, 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 Appearance

Neat and clean Neat and clean Well-groomed.

Head Rounded and smooth Rounded and smoothOpen anterior and posterior fontanelles (HC 35cm)

Normal.

Hair Evenly distributed Evenly distributed Normal.

Skin Color varies from ruddy pink to light pink

Cyanotic, noted poor capillary refill.

Increase amount of deoxygenated hemoglobin; associated with hypoxia. Can be due to heart / lung disease, cold environment.

Eyes Shiny smooth pink conjunctiva

No edema/tenderness over lacrimal glandNo edema or tearing

Shiny smooth pink conjunctivaNo edema

No tearing

Normal

Normal

Ears Sound is heard in both ears

Sound is heard in both ears Normal

Nose Nasal septum intact and in midline

Nasal septum intact and in midline

Normal

Mouth Lips are pink, moist, Circumoral cyanosis noted. Increase amount of

symmetrical, and smooth.

With presence of OGT

deoxygenated hemoglobin; associated with hypoxia.

For feeding purposesChest/ Lungs Symmetrical chest

expansions

No retractions

Clear breath sounds

Symmetrical chest expansions

Intercostal and Subcostal retractions

Crackles on bilateral lung fields

Dynamic precordium AB at 5th LICS LMCL, S1 normal, S2 split, grade 3/6 PSM LMSB

Normal

Hypoxemia

Presence of secretions

Presence of CHD

Extremities Limbs can be moved freely

Noted spasticity on both upper extremity and lower extremity

To rule out cerebral palsy

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 NormalRespiratory rate 30 cpm NormalBlood pressure  90/P  Normal

Weight 3.2 kg NormalHeight/Length 57 cm Normal

3. Neurological Assessment

Reflexes How Elicited Norms Findings Interpretation

Babinski reflex

Sole of foot is stroked

Fans out toes and twists foot in

Fanning of toes Normal

Blinking reflex

Flash of light or puff of air striked to the eyes

Closes eyes Eyes closed, blinks rapidly

Normal

Grasping reflex

Palms are touched

Palms grasps tightly

Forms a fist Normal

Moro reflex Sudden movement / loud noise is induced

Startles Throws out arms and legs and then pulls them toward body

Normal

Rooting reflex

Cheek is stroked or side of mouth is touched

Mouth turns toward source, opens mouth and sucks

Mouth turns towards the source

Normal

Sucking reflex

Mouth is touched by an object

Sucks on the object

Sucks the source Normal

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

BC = Bulbus cordis

CC = Conus cordis

LA = Left atrium

LV = Left ventricle

RA = Right atrium

SV = Sinus venosus

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

SS = Septum spurium

S1 = Septum primum

Perf = Perforations

O1 = Ostium secundum

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

LVV = Left venous valve

O1 = Ostium secundum

SS = Septum spurium

S1 = Septum primum

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

Day 6 August 18, 2009

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.

Day 11 August 23, 2009

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.

Day 12 August 24, 2009

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.

Day 13 August 25, 2009

(-) 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

Day 14 August 26, 2009

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.

Day 15 August 27, 2009

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

Day 17 August 29, 2009

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

Day 18 August 30, 2009

(+) 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

Day 22 September 3, 2009

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

Day 23 September 4, 2009

Lanoxin elixir was started. K 3.3

UO 10cc/kg/hr hence, Furosemide decreased to 1.5 mg IV Q12

Day 25 September 6, 2009

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.

Day 26 September 7, 2009

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.

Day 27 September 8, 2009

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

Day 29 September 10, 2009

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.

Day 30 September 11, 2009

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.

Day 33 September 14, 2009

Negative episode of desaturation was noted thus, O2 was decreased to 0.5 LPM via NC

Referred to rehabilitation for physical therapy

Day 35 September 16, 2009

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

Day 36 September 17, 2009

Domperidone 0.3 ml TID was started. NGT was shifted to OGT. Mother was allowed to

feed the patient.

Day 37 September 18, 2009

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.

Day 43 September 24, 2009

(-) 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

ventilation

stable vital signs

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

13

August

22

August

24

August

25

August

27

August

29

September

9

September

17

Hgb

133

Hct 0.44

WBC

12.60

Platelet:

180

Hgb 141

Hct 0.47

WBC

10.00

Platelet:

329

Hgb 78

Hct 0.24

WBC

9.80

Platelet:

87

Hgb 69

Hct 0.20

WBC

9.00

Platelet:

58

Hgb 107

Hct 0.31

WBC

7.90

Platelet:

47

Hgb 120

Hct 0.36

WBC

13.50

Platelet:

60

Hgb 108

Hct 0.32

WBC

13.60

Platelet:

499

Hgb 105

Hct 0.32

WBC

22.50

Platelet:

188

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%

One (1) week of age: 47%-65%

One (1) month of age: 37%-49%

Three (3) months of age: 30%-

36%

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

August15

Specific Gravity: Protein: Sugar: RBC: WBC: Bacteria:

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

Pre Operative Post Operative

August 13

August 22

August 23

August 24

August 25

August 26

August 27

September 4

September 9

4.7 4.4 4.7 5.4 5.76.1

4.5 2.9 3.8 4.9

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

Pre Operative Post Operative

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

Pre Operative Post Operative

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

Pre Operative Post Operative

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

Pre Operative Post Operative

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)

Pre Operative Post Operative

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)

Pre Operative Post Operative

August 22 August 24 August 25 August 27

PT: 10.0

PTPA: 126%

INR: 0.934

PT: 19.9

PTPA: 39%

INR: 1.871

PT: 15.0

PTPA: 59%

INR: 1.407

PT: 12.1

PTPA: 86%

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

Pre Operative Post Operative

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

Pre Operative Post Operative

August 15 August 24 September 19

Adequate catch with no

significant pathogens

Adequate catch with no

significant pathogens isolated

Adequate catch with occasional

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

August 24 August 26 August 27 August 28

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

Albumin: 22.0

Globulin: 16.0

TP: 47.0

Albumin: 25.0

Globulin: 22.0

TP: 43.0

Albumin 23.0

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

I N T E R P R E T A T I O N

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

2. KCL syrup 2 ml TID po

3. Heraclene 1 capsule OD po

4. Baclofen 0.7mg/pptab q8 hours po

5. Doxophylline 0.5 ml q12 hours po

6. Ciprofloxacin 30mg/pptab 1 pptab

BID po

7. Multivitamins 0.3 ml OD po

8. Ascorbic Acid 0.3 ml OD po

9. Phenobarbital gr1/4 (15mg) OD po

10. Domperidone 0.3 ml TID po

11. Furosemide 3mg/ pptab q12 hours po

12. Procaterol 5mcg/ml 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 proce-

dures (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.

T HEORETICAL F RAMEWORK

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

Emotional

Intellectual

Social

Spiritual

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 Name Indication/Dosages Contraindication Adverse Effect Nursing ConsiderationRanitidine hydrochloride(ra nye' te deen)

Drug classHistamine2 (H2) antagonist

Indications: Short-term treatment

of active duodenal ulcer

Maintenance therapy for duodenal ulcer at reduced dosage

Short-term treatment of active, benign gastric ulcer

Short-term treatment of gastroesophageal reflux disease (GERD)

Available forms Tablets—75, 150,

300 mg; effervescent tablets and granules—150 mg; capsules—150, 300 mg; syrup—15 mg/mL; injection—1, 25 mg/mL

Contraindicated with allergy to ranitidine, lactation.

Use cautiously with impaired renal or hepatic function, pregnancy.

CNS: Headache, malaise, dizziness, somnolence, insomnia, vertigo

CV: Tachycardia, bradycardia, PVCs (rapid IV administration)

Dermatologic: Rash, alopecia

GI: Constipation, diarrhea, nausea, vomiting, abdominal pain, hepatitis, increased ALT levels

GU: Gynecomastia, impotence or decreased libido

Hematologic: Leukopenia, granulocytopenia, thrombocytopenia, pancytopenia

Local: Pain at IM site, local burning or itching at IV site

Administer oral drug with meals and at bedtime.

Decrease doses in renal and liver failure.

Provide concurrent antacid therapy to relieve pain.

Administer IM dose undiluted, deep into large muscle group.

Arrange for regular follow-up, including blood tests, to evaluate effects.

Take drug with meals and at bedtime. Therapy may continue for 4–6 wk or longer.

DRUG STUDY

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Consideration

Midazolam hydrochloride(mid ay' zoh lam)Versed

Drug classesBenzodiazepine (short-acting)CNS depressant

Therapeutic actionsExact mechanisms of action not understood; acts mainly at the limbic system and reticular formation; potentiates the effects of gamma-aminobutyrate (GABA), an inhibitory neurotransmitter; anxiolytic and amnesia effects occur at doses below those needed to cause sedation, ataxia; has little effect on cortical function.

IV or IM; oral syrup for children: Sedation, anxiolysis, and amnesia prior to diagnostic, therapeutic, or endoscopic procedures or surgery

Induction of general anesthesia

Continuous sedation of intubated and mechanically ventilated patients as a component of anesthesia or during treatment in the critical care setting

Available forms Syrup—2 mg/mL;

injection—5 mg/mL, 1 mg/mL

Contraindicated with hypersensitivity to benzodiazepines; psychoses, acute narrow-angle glaucoma, shock, coma, acute alcoholic intoxication; pregnancy (cleft lip or palate, inguinal hernia, cardiac defects, microcephaly, pyloric stenosis have been reported when used in first trimester; neonatal withdrawal syndrome reported in infants); neonates.

CNS: Transient, mild drowsiness (initially); sedation, depression, lethargy, apathy, fatigue, light-headedness, disorientation, restlessness, confusion, crying, delirium, headache, slurred speech, dysarthria, stupor, rigidity, tremor, dystonia, vertigo, euphoria, nervousness, difficulty in concentration, vivid dreams, psychomotor retardation

CV: Bradycardia, tachycardia, CV collapse, hypertension, hypotension, palpitations, edema

Dermatologic: Urticaria, pruritus,

skin rash, dermatitis GI: Constipation,

diarrhea, dry mouth,

Do not administer intra-arterially, which may produce arteriospasm or gangrene.

Do not use small veins (dorsum of hand or wrist) for IV injection.

Monitor IV injection site for extravasation.

Carefully monitor P, BP, and respirations carefully during administration.

Keep resuscitative facilities readily available; have flumazenil available as antidote if overdose should occur.

Keep patients in bed for 3 hr; do not permit ambulatory patients to operate a vehicle following an

injection.Arrange to monitor liver and kidney

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Considerationsalivation, nausea, anorexia, vomiting, difficulty in swallowing, gastric disorders, elevations of blood enzymes: LDH, alkaline phosphatase, SGOT, SGPT, hepatic dysfunction, jaundice

GU: Incontinence, urinary retention, changes in libido, menstrual irregularities

Hematologic: Decreased hematocrit, blood dyscrasias

Other: Phlebitis and thrombosis at IV injection sites, hiccups, fever, diaphoresis, paresthesias, muscular disturbances, gynecomastia; pain, burning, and redness after IM injection

function and CBC at intervals during long-term therapy.

Establish safety precautions if CNS changes occur (use side rails, accompany ambulating patient).

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing ConsiderationAminophylline (theophylline ethylenediamine)(am in off' i lin)Truphylline

Drug classesBronchodilatorXanthine

Therapeutic actionsRelaxes bronchial smooth muscle, causing bronchodilation and increasing vital capacity, which has been impaired by bronchospasm and air trapping; in higher concentrations, it also inhibits the release of slow-reacting substance of anaphylaxis (SRS-A) and histamine.

Symptomatic relief or prevention of bronchial asthma and reversible bronchospasm associated with chronic bronchitis and emphysema

Unlabeled uses: Respiratory stimulant in Cheyne-Stokes respiration; treatment of apnea and bradycardia in premature babies

Available forms Tablets—100,

200 mg; CR tablets—225 mg; liquid—105 mg/5 mL; injection—250 mg/10 mL; suppositories—250, 500 mg

Dosages Individualize dosage:

Base adjustments on clinical responses; monitor serum theophylline levels;

Contraindicated with hypersensitivity to any xanthine or to ethylenediamine, peptic ulcer, active gastritis; rectal or colonic irritation or infection (use rectal preparations).

Use cautiously with cardiac arrhythmias, acute myocardial injury, CHF, cor pulmonale, severe hypertension, severe hypoxemia, renal or hepatic disease, hyperthyroidism, alcoholism, labor, lactation.

CNS: Irritability (especially children); restlessness, dizziness, muscle twitching, seizures, severe depression, stammering speech; abnormal behavior characterized by withdrawal, mutism, and unresponsiveness alternating with hyperactive periods

CV: Palpitations, sinus tachycardia, ventricular tachycardia, life-threatening ventricular arrhythmias, circulatory failure

GI: Loss of appetite, hematemesis, epigastric pain, gastroesophageal reflux during sleep, increased AST

GU: Proteinuria, increased excretion of renal tubular cells and

Administer to pregnant patients only when clearly needed—neonatal tachycardia, jitteriness, and withdrawal apnea observed when mothers received xanthines up until delivery.

Caution patient not to chew or crush enteric-coated timed-release forms.

Give immediate-release, liquid dosage forms with food if GI effects occur.

Do not give timed-release forms with food; these should be given on an empty stomach 1 hr before or 2 hr after meals.

Maintain adequate hydration.

Monitor results of serum theophylline levels carefully, and arrange for reduced

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Consideration maintain therapeutic

range of 10–20 mcg/mL; base dosage on lean body mass; 127 mg aminophylline dihydrate = 100 mg theophylline anhydrous.

RBCs; diuresis (dehydration), urinary retention in men with prostate enlargement

Respiratory: Tachypnea, respiratory arrest

Other: Fever, flushing, hyperglycemia, SIADH, rash

dosage if serum levels exceed therapeutic range of 10–20 mcg/mL.

Take serum samples to determine peak theophylline concentration drawn 15–30 min after an IV loading dose.

Monitor for clinical signs of adverse effects, particularly if serum theophylline levels are not available.

Ensure that diazepam is readily available to treat seizures.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Consideration

captopril(kap' toe pril)Apo-Capto (CAN), Capoten, Gen- Drug classesAngiotensin-converting enzyme (ACE) inhibitorAntihypertensive

Therapeutic actionsBlocks ACE from converting angiotensin I to angiotensin II, a powerful vasoconstrictor, leading to decreased blood pressure, decreased aldosterone secretion, a small increase in serum potassium levels, and sodium and fluid loss; increased prostaglandin synthesis also may be involved in the antihypertensive action.

Treatment of hypertension alone or in combination with thiazide-type diuretics

Treatment of CHF in patients unresponsive to conventional therapy; used with diuretics and digitalis

Treatment of diabetic nephropathy

Treatment of left ventricular dysfunction after MI

Unlabeled uses: Management of hypertensive crises; treatment of rheumatoid arthritis; diagnosis of anatomic renal artery stenosis, hypertension related to scleroderma renal crisis; diagnosis of primary aldosteronism, idiopathic edema; Bartter's syndrome; Raynaud's syndrome

Contraindicated with allergy to captopril, history of angiodema.

Use cautiously with impaired renal function; CHF; salt or volume depletion, lactation, pregnancy.

CV: Tachycardia, angina pectoris, MI, Raynaud's syndrome, CHF, hypotension in salt- or volume-depleted patients

Dermatologic: Rash, pruritus, pemphigoid-like reaction, scalded mouth sensation, exfoliative dermatitis, photosensitivity, alopecia

GI: Gastric irritation, aphthous ulcers, peptic ulcers, dysgeusia, cholestatic jaundice, hepatocellular injury, anorexia, constipation

GU: Proteinuria, renal insufficiency, renal failure, polyuria, oliguria, urinary frequency

Administer 1 hr before or 2 hr after meals.

Alert surgeon and mark patient's chart with notice that captopril is being taken; the angiotensin II formation subsequent to compensatory renin release during surgery will be blocked; hypotension may be reversed with volume expansion.

Monitor patient closely for fall in BP secondary to reduction in fluid volume (excessive perspiration and dehydration, vomiting, diarrhea); excessive hypotension may occur.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing ConsiderationAvailable forms Hematologic: Reduce dosage in

Tablets—12.5, 25, 50, 100 mg

PEDIATRIC PATIENTSSafety and efficacy not established.

Neutropenia, agranulocytosis, thrombocytopenia, hemolytic anemia, pancytopenia

Other: Cough, malaise, dry mouth, lymphadenopathy

patients with impaired renal function.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Consideration

Digoxin(di jox' in)Digitek, Lanoxicaps

Drug classesCardiac glycosideCardiotonic

Therapeutic actionsIncreases intracellular calcium and allows more calcium to enter the myocardial cell during depolarization via a sodium–potassium pump mechanism; this increases force of contraction (positive inotropic effect), increases renal perfusion (seen as diuretic effect in patients with CHF), decreases heart rate (negative chronotropic effect), and decreases AV node conduction velocity.

CHF Atrial fibrillation

Available formsLanoxicaps capsules—0.05, 0.1, 0.2 mg; tablets—0.125, 0.25, mg, elixir—0.05 mg/mL; injection—0.25 mg/mL; pediatric injection—0.1 mg/mL

DosagesPatient response is quite variable. Evaluate patient carefully to determine the appropriate dose.

Contraindicated with allergy to digitalis preparations, ventricular tachycardia, ventricular fibrillation, heart block, sick sinus syndrome, IHSS, acute MI, renal insufficiency and electrolyte abnormalities (decreased K+, decreased Mg++, increased Ca++).

Use cautiously with pregnancy and lactation.

CNS: Headache, weakness, drowsiness, visual disturbances, mental status change

CV: Arrhythmias GI: GI upset,

anorexia

Monitor apical pulse for 1 min before administering; hold dose if pulse < 60 in adult or < 90 in infant; retake pulse in 1 hr. If adult pulse remains < 60 or infant < 90, hold drug and notify prescriber. Note any change from baseline rhythm or rate.

Take care to differentiate Lanoxicaps from Lanoxin; dosage is very different

Check dosage and preparation carefully.

Avoid IM injections, which may be very painful.

Follow diluting instructions carefully, and use diluted solution promptly.

Avoid giving with meals; this will delay absorption.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Consideration

PEDIATRIC PATIENTS

Loading dose:Oral (mcg/kg)

Premature

20–30

Neonate 25–351–24 mo 35–602–5 yr 30–405–10 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.

Have emergency equipment ready; have K+ salts, lidocaine, phenytoin, atropine, cardiac monitor on standby in case toxicity develops.

Monitor for therapeutic drug levels: 0.5–2 ng/mL.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Considerationfurosemide(fur oh' se mide)Apo-Furosemide (CAN), Furoside (CAN), Lasix, Myrosemide (CAN)

Drug classLoop diuretic

Therapeutic actionsInhibits the reabsorption of sodium and chloride from the ascending limb of the loop of Henle, leading to a sodium-rich diuresis.

Oral, IV: Edema associated with CHF, cirrhosis, renal disease

IV: Acute pulmonary edema

Oral: Hypertension

Available formsTablets—20, 40, 80 mg; oral solution—10 mg/mL, 40 mg/5 mL; injection—10 mg/mL

PEDIATRIC PATIENTSAvoid use in premature infants: stimulates PGE2

synthesis and may increase incidence of patent ductus arteriosus and complicate respiratory distress syndrome. Edema: Initially,

2 mg/kg/day PO. If needed, increase by 1–2 mg/kg in 6–8 hr. Do not exceed 6 mg/kg. Adjust

Contraindicated with allergy to furosemide, sulfonamides; allergy to tartrazine (in oral solution); anuria, severe renal failure; hepatic coma; pregnancy; lactation.

Use cautiously with SLE, gout, diabetes mellitus.

CNS: Dizziness, vertigo, paresthesias, xanthopsia, weakness, headache, drowsiness, fatigue, blurred vision, tinnitus, irreversible hearing loss

CV: Orthostatic hypotension, volume depletion, cardiac arrhythmias, thrombophlebitis

Dermatologic: Photosensitivity, rash, pruritus, urticaria, purpura, exfoliative dermatitis, erythema multiforme

GI: Nausea, anorexia, vomiting, oral and gastric irritation, constipation, diarrhea, acute pancreatitis, jaundice

GU: Polyuria, nocturia, glycosuria,

CLINICAL ALERT!Name confusion has occurred between furosemide and torsemide; use extreme caution.

Administer with food or milk to prevent GI upset.

Reduce dosage if given with other antihypertensives; readjust dosage gradually as BP responds.

Give early in the day so that increased urination will not disturb sleep.

Avoid IV use if oral use is at all possible.

Do not mix parenteral solution with highly acidic solutions with pH below 3.5.

Do not expose to light, may discolor tablets or solution;

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Consideration maintenance dose to

lowest effective level.

Pulmonary edema: 1 mg/kg IV or IM. May increase by 1 mg/kg in 2 hr until the desired effect is seen. Do not exceed 6 mg/kg.

urinary bladder spasm

Hematologic: Leukopenia, anemia, thrombocytopenia, fluid and electrolyte imbalances

Other: Muscle cramps and muscle spasms

do not use discolored drug or solutions.

Discard diluted solution after 24 hr.

Refrigerate oral solution.

Measure and record weight to monitor fluid changes.

Arrange to monitor serum electrolytes, hydration, liver function.

Arrange for potassium-rich diet or supplemental potassium as needed.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Consideration

spironolactone(speer on oh lak' tone)Aldactone, Novospiroton (CAN)

Drug classesPotassium-sparing diureticAldosterone antagonist

Therapeutic actionsCompetitively blocks the effects of aldosterone in the renal tubule, causing loss of sodium and water and retention of potassium.

Diagnosis and maintenance of primary hyperaldosteronism

Adjunctive therapy in edema associated with CHF, nephrotic syndrome, hepatic cirrhosis when other therapies are inadequate or inappropriate

Treatment of hypokalemia or prevention of hypokalemia in patients who would be at high risk if hypokalemia occurred: Digitalized patients, patients with cardiac arrhythmias

Essential hypertension, usually in combination with other drugs

Unlabeled uses: Treatment of hirsutism due to its antiandrogenic properties, palliation

Contraindicated with allergy to spironolactone, hyperkalemia, renal disease, anuria, amiloride or triamterene use.

Use cautiously with pregnancy, lactation.

CNS: Dizziness, headache, drowsiness, fatigue, ataxia, confusion

Dermatologic: Rash, urticaria

GI: Cramping, diarrhea, dry mouth, thirst, vomiting.

GU: Impotence, irregular menses, amenorrhea, postmenopausal bleeding

Hematologic: Hyperkalemia, hyponatremia, agranulocytosis

Other: Carcinogenic in animals, deepening of the voice, hirsutism, gynecomastia

Mark calendars of edema outpatients as reminders of alternate day or 3- to 5-day/wk therapy.

Give daily doses early so that increased urination does not interfere with sleep.

Make suspension as follows: Tablets may be pulverized and given in cherry syrup for young children. This suspension is stable for 1 mo if refrigerated.

Measure and record regular weight to monitor mobilization of edema fluid.

Avoid giving food rich in potassium.

Arrange for regular evaluation of serum electrolytes, BUN.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Consideration of symptoms of

PMS, treatment of familial male precocious puberty, short-term treatment of acne vulgaris

Available formsTablets—25, 50, 100 mg

PEDIATRIC PATIENTS

Edema: 1–3.3 mg/kg/day PO adjusted to patient's response, administered as single or divided dose.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Consideration

albuterol sulfate(al byoo' ter ole)AccuNeb, Novo-Salmol (CAN), Proventil, Proventil HFA, Proventil Repetabs, Salbutamol (CAN), Ventodisk (CAN), Ventolin, Ventolin HFA, Volmax

Pregnancy Category C

Drug classesSympathomimetic drugBeta2-selective adrenergic agonistBronchodilatorAntiasthmatic

Therapeutic actionsIn low doses, acts relatively selectively at beta2-adrenergic receptors to cause bronchodilation and vasodilation; at higher doses, beta2 selectivity is lost, and the drug acts at beta2 receptors to cause typical sympathomimetic cardiac effects.

Relief and prevention of bronchospasm in patients with reversible obstructive airway disease

Inhalation: Treatment of acute attacks of bronchospasm

Prevention of exercise-induced bronchospasm

Unlabeled use: Adjunct in treating serious hyperkalemia in dialysis patients; seems to lower potassium concentrations when inhaled by patients on hemodialysis

Available formsTablets-2, 4 mg; ER tablets-4, 8 mg; syrup-2 mg/5 mL; aerosol-90 mcg/actuation; solution for inhalation-0.083%, 0.5%, 1.25 mg/3 mL, 0.63 mg/3 mL; capsules for inhalation-200 mcg

Contraindicated with hypersensitivity to albuterol; tachyarrhythmias, tachycardia caused by digitalis intoxication; general anesthesia with halogenated hydrocarbons or cyclopropane (these sensitize the myocardium to catecholamines); unstable vasomotor system disorders; hypertension; coronary insufficiency, CAD; history of stroke; COPD patients with degenerative heart disease.

Use cautiously with diabetes mellitus (large IV doses can aggravate diabetes and ketoacidosis); hyperthyroidism; history of seizure

CNS: Restlessness, apprehension, anxiety, fear, CNS stimulation, hyperkinesia, insomnia, tremor, drowsiness, irritability, weakness, vertigo, headache

CV: Cardiac arrhythmias, tachycardia, palpitations, PVCs (rare), anginal pain

Dermatologic: Sweating, pallor, flushing

GI: Nausea, vomiting, heartburn, unusual or bad taste

GU: Increased incidence of leiomyomas of uterus when given in higher than human doses in preclinical studies

Respiratory: Respiratory difficulties,

Use minimal doses for minimal periods; drug tolerance can occur with prolonged use.

Maintain a beta-adrenergic blocker (cardioselective beta-blocker, such as atenolol, should be used with respiratory distress) on standby in case cardiac arrhythmias occur.

Prepare solution for inhalation by diluting 0.5 mL 0.5% solution with 2.5 mL normal saline; deliver over 5–15 min by nebulization.

Do not exceed recommended dosage; administer pressurized inhalation drug forms during second half of inspiration, because the airways

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Consideration

PEDIATRIC PATIENTSOral, tablets 6–12 yr: 2 mg tid–

qid. Do not exceed 24 mg/day.

> 12 yr: Use adult dosage.

ER tablets 6–11 yr: 4 mg q

12 hr (Proventil). 6–12 yr: 4 mg q

12 hr (Volmax).Oral, syrup < 2 yr: Safety and

efficacy not established.

2–6 yr: Initially, 0.1 mg/kg tid, not to exceed 2 mg (1 tsp) tid; if necessary, cautiously increase stepwise to 0.2 mg/kg tid. Do not exceed 4 mg (2 tsp) tid.

6–14 yr: 2 mg (1 tsp) tid–qid; if necessary, cautiously increase dosage. Do not

disorders; psychoneurotic individuals; labor and delivery (oral use has delayed second stage of labor; parenteral use of beta2-adrenergic agonists can accelerate fetal heart beat and cause hypoglycemia, hypokalemia, pulmonary edema in the mother and hypoglycemia in the neonate); lactation; the elderly (more sensitive to CNS effects).

pulmonary edema, coughing, bronchospasm, paradoxical airway resistance with repeated, excessive use of inhalation preparations

are open wider and the aerosol distribution is more extensive.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Considerationexceed 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.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Consideration

Paracetamolacetaminophen (N-acetyl-p-aminophenol)

Drug classesAntipyreticAnalgesic (nonopioid)

Therapeutic actionsAntipyretic: Reduces fever by acting directly on the hypothalamic heat-regulating center to cause vasodilation and sweating, which helps dissipate heat. Analgesic: Site and mechanism of action unclear.

Analgesic-antipyretic in patients with aspirin allergy, hemostatic disturbances, bleeding diatheses, upper GI disease, gouty arthritis

Arthritis and rheumatic disorders involving musculoskeletal pain (but lacks clinically significant antirheumatic and anti-inflammatory effects)

Common cold, flu, other viral and bacterial infections with pain and fever

Unlabeled use: prophylactic for children receiving DPT vaccination

Contraindicated with allergy to acetaminophen.

Use cautiously with impaired hepatic function, chronic alcoholism, pregnancy, lactation.

CNS: Headache CV: Chest pain,

dyspnea, myocardial damage when doses of 5–8 g/day are ingested daily for several weeks or when doses of 4 g/day are ingested for 1 yr

GI: Hepatic toxicity and failure, jaundice

GU: Acute kidney failure, renal tubular necrosis

Hematologic: Methemoglobinemia—cyanosis; hemolytic anemia—hematuria, anuria; neutropenia, leukopenia, pancytopenia, thrombocytopenia, hypoglycemia

Hypersensitivity: Rash, fever

Do not exceed the recommended dosage.

Consult physician if needed for children < 3 yr; if needed for longer than 10 days; if continued fever, severe or recurrent pain occurs (possible serious illness).

Avoid using multiple preparations containing acetaminophen. Carefully check all OTC products.

Give drug with food if GI upset is noted.

Discontinue drug if hypersensitivity reactions occur.

Treatment of overdose: Monitor serum levels regularly, N-acetylcysteine should be available as a specific antidote; basic life support measures may be necessary.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Consideration to reduce incidence

of fever and pain

PEDIATRIC PATIENTSPO or PRDoses 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 404–11 mo

80

1–2 yr 1202–3 yr 1604–5 yr 2406–8 yr 3209–10 yr 40011 yr 480

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing ConsiderationSuprax Suprax, a If you are allergic to Side effects cannot If you are taking

Generic name: Cefixime cephalosporin antibiotic, is prescribed for bacterial infections of the lungs, ears, urinary tract, and throat. It is also used to treat uncomplicated gonorrhea.

either penicillin or cephalosporin antibiotics in any form, consult your doctor before taking Suprax. An allergy to either type of medication may signal an allergy to Suprax, and if a reaction occurs, it could be extremely severe. If you take the drug and feel signs of a reaction, seek medical attention immediately.

Do not take Suprax if you are sensitive to or have ever had an allergic reaction to the drug or to other cephalosporin antibiotics.

be anticipated. If any develop or change in intensity, tell your doctor as soon as possible. Only your doctor can determine if it is safe for you to continue taking this drug.

Side effects may include: abdominal pain, gas, indigestion, loose stools, mild diarrhea, nausea, vomiting

Suprax once a day and you forget to take a dose, take it as soon as you remember. Wait at least 10 to 12 hours before taking your next dose, then return to your regular schedule.

If you are taking Suprax 2 times a day and you forget to take a dose, take it as soon as you remember and take your next dose 5 to 6 hours later. Then go back to your regular schedule.

If you are taking Suprax 3 times a day and you forget to take a dose, take it as soon as you remember and take your next dose 2 to 4 hours later. Then return to your

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Consideration

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.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing ConsiderationBaclofenMuscle Relaxants

Severe chronic spasticity. Hypersensitivity. Active peptic

The most common adverse reaction during

Abrupt Drug Withdrawal

PO 5 mg 3 times/day for 3 days, increased to 10 mg 3 times/day for 3 days. May further increase if needed. Max: 100 mg/day. Intrathecal Test dose: 25 or 50 mcg. Increase dose by 25 mcg not more often than 24 hrly until 100 mcg/dose to determine appropriate dose. Responders w/ response lasting >8-12 hr, the test dose that was used to produce the response can be given as a 24-hr infusion; if the response lasted ≤8-12 hr, then a dose equivalent to twice the test dose is given.

ulcer disease. treatment with baclofen is transient drowsiness (10-63%). In one controlled study of 175 patients, transient drowsiness was observed in 63% of those receiving baclofen tablets compared to 36% of those in the placebo group. Other common adverse reactions are dizziness (5-15%), weakness (5-15%) and fatigue (2-4%). Others reported:Neuropsychiatric: Confusion (1-11%), headache (4-8%), insomnia (2-7%); and, rarely, euphoria, excitement, depression, hallucinations, paresthesia, muscle pain, tinnitus, slurred speech, coordination disorder, tremor,

Hallucinations and seizures have occurred on abrupt withdrawal of baclofen. Therefore, except for serious adverse reactions, the dose should be reduced slowly when the drug is discontinued.

Impaired Renal FunctionBecause baclofen is primarily excreted unchanged by the kidneys, it should be given with caution and it may be necessary to reduce the dosage in patients with impaired renal function.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Consideration

rigidity, dystonia, ataxia, blurred vision, nystagmus, strabismus, miosis, mydriasis,

StrokeBaclofen has not significantly

diplopia, dysarthria, epileptic seizure.Cardiovascular: Hypotension (0-9%). Rare instances of dyspnea, palpitation, chest pain, syncope.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, ankle edema, excessive perspiration, weight gain, nasal congestion. Some of the CNS and genitourinary symptoms may be related to the underlying disease rather

benefited patients with stroke. These patients have also shown poor tolerability to the drug.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Consideration

than to drug therapy. The following laboratory tests have been found to be abnormal in a few patients receiving

baclofen: 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.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing ConsiderationZosyn

(piperacillin tazobactam) InjectionTo reduce the development of drug-

Zosyn (piperacillin and tazobactam for injection) is indicated for the treatment of patients with moderate to

contraindicated in patients with a history of allergic reactions to any of the penicillins, cephalosporins, or

Autonomic nervous system - hypotension, ileus, syncope

Body as a whole - rigors, back pain,

Careful inquiry should be made concerning previous hypersensitivity reaction, as serious and occasionally fatal

resistant bacteria and maintain the effectiveness of Zosyn (piperacillin and tazobactam) injection and other antibacterial drugs, Zosyn (piperacillin and tazobactam) should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria.

severe infections caused by piperacillin-resistant, piperacillin/tazobactam-susceptible, β-lactamase producing strains of the designated microorganisms in the specified conditions listed below:

β-lactamase inhibitors

malaise In the

Cardiovascular - tachycardia, including supraventricular and ventricular; bradycardia; arrhythmia, including atrial fibrillation, ventricular fibrillation, cardiac arrest, cardiac failure, circulatory failure, myocardial infarction

Central nervous system - tremor, convulsions, vertigo

anaphylactic/anaphylactoid reactions (including shock) have been reported in patients receiving therapy with penicillins including ZOSYN

The nurse should know that periodic assessment of organ system functions, including renal, hepatic, and hematopoietic, during prolonged therapy is advisable because ZOSYN possesses the characteristic low toxicity of the penicillin group of antibiotics

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Consideration 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.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing ConsiderationMeropenem I.V. To reduce the

development of drug-resistant bacteria and maintain the effectiveness of MERREM I.V. and

Patients with known hypersensitivity to any component of this product or to other drugs in the same class or in

MERREM I.V. was studied in 515 pediatric patients ( ≥ 3 months to < 13 years of age) with serious bacterial infections (excluding meningitis. See next

The safety and effectiveness of MERREM I.V. have been established for pediatric patients ≥ 3 months of age.

Use of MERREM I.V.

other antibacterial drugs, MERREM I.V. should only be used to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria. When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility

patients who have demonstrated anaphylactic reactions to β-lactams.

section.) at dosages of 10 to 20 mg/kg every 8 hours. The types of clinical adverse events seen in these patients are similar to the adults, with the most common adverse events reported as possibly, probably or definitely related to MERREM I.V. and their rates of occurrence as follows:Diarrhea 3.5%, Rash1.6%, Nausea and Vomiting 0.8% MERREM I.V. was studied in 321 pediatric patients ( ≥ 3 months to < 17 years of age) with meningitis at a dosage of 40 mg/kg every 8 hours. The types of

in pediatric patients with bacterial meningitis is supported by evidence from adequate and well-controlled studies in the pediatric population.

Use of MERREM I.V. in pediatric patients with intra-abdominal infections is supported by evidence from adequate and well-controlled studies with

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Considerationpatterns may contribute to the empiric selection of therapy.

MERREM I.V. is indicated as single agent therapy for

clinical adverse events seen in these patients are similar to the adults, with the most common adverse events reported as possibly, probably, or definitely related to

the treatment of the following infections when caused by susceptible isolates of the designated microorganisms F.

MERREM I.V. and their rates of occurrence as follows:Diarrhea 4.7%, Rash (mostly diaper area moniliasis), Glossitis 1.0%

Drug Name Indications/Dosages Contraindications Adverse Effects Nursing ConsiderationsHeracleneDibencozide

Classification:

A15 - Appetite Enhancers

For Premature babies. Low birth weight. Retarded growth. Poor appetite in infants, children and adults. Adjuvant to treatment of tuberculosis and other chronic ailments.

No known effect noted

No known effect noted

Treatment must be continuous for 2-6 weeks.

The initial sign of its effectiveness is manifested by a marked increase in

Convalescence from acute 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).

appetite.

Milrinone

Classification:

Cardiac Drugs/phosphodiesterase inhibitors

Short-term management of severe heart failure, Acutely decompensated heart failure

Child: Initial loading dose of 75 mcg/kg by IV injection over 10-60 min followed by continuous infusion of 0.5-0.75 mcg/kg/min.

Heart valve stenosis, acute myocardial infarction

Angina-like chest pain, headache, hypokalaemia, tremor, thrombocytopenia, bronchospasm.

Potentially Fatal: Supraventricular and ventricular arrhythmias; hypotension.

Improved cardiac output may increase urine output, reduced diuretic dosage when heart failure improves. Potassium lost may cause digitalis toxicity.

Monitor fluid & electrolyte status & vital signs. Excessive decrease in BP. Requires stopping the infusion.

Drug Name Indication/Dosages Contraindications Adverse Effects Nursing ConsiderationsMethylprednisolone

Classification:

Corticosteroid Hormones/glucocorticoids

Suppression of inflammatory & allergic disorders, cerebral edema, rheumatic disease; immunosuppressant in spinal cord

Systemic mycoses. Septic shock.

Fluid & electrolyte balance disturbance; musculoskeletal system effects; GI effects; skin reactions; -ve nitrogen balance due

Determine whether pt. is sensitive to other corticosteroids, for better result and less toxicity, give once daily dose in the morning.

injury.

Children: give 0.117 to 1.66 mg/kg or 3.3 to mg/m2 PO. Daily in 3 doses.

to protein catabolism; nervous system effects, seizures, psychic disorders; endocrine system disorders; immune system suppression

Measure growth & dev. Periodically in children during high dose or prolonged treatment.

Monitor pt. wt, BP. 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.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing ConsiderationMANNITOL

Classification:

Diuretics/Solutions producing osmotic diuresis

IV Renal function test 0.2 g/kg over 3-5 mins. Oliguric phase of renal failure 50-100 g in a 24-hr period via infusion; adjust rate

Pulmonary congestion or oedema; intracranial bleeding; CHF; metabolic oedema with

Fluid and electrolyte imbalance; acidosis (with high doses). Nausea, vomiting, thirst; headache, dizziness, convulsions, chills,

Hypervolaemia; urinary tract obstruction; check for signs of fluid and electrolyte imbalance. Should not be administered with

to maintain a urine flow of ≥30-50 mL/hr. Raised intracranial pressure; Raised intraocular pressure; Cerebral oedema 0.25-2 g/kg over 30-60 mins. Transurethral prostatic resection Use 2.5-5% soln for bladder irrigation

abnormal capillary fragility; anuria due to severe renal disease; severe dehydration.

fever; tachycardia, chest pain; blurred vision; urticaria and hypotension or hypertension; acute renal failure; skin necrosis; thrombophloebitis.

whole blood. Pregnancy, lactation.

Monitor I/O, BP.& wt.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing ConsiderationDexamethasone

Classification:

Corticosteroid Hormones/Glucocorticoids

Asthma & related bronchospastic disorder unresponsive to other therapy, allergic rhinitis,

Neonate & infant.

Risk of osteoporosis & spontaneous fracture, muscle wasting, nitrogen depletion, hyperglycemia.

Increased insulin requirement in diabetics, increased appetite.

Caution use in heart failure, recent MI, HTN, DM, epilepsy, glaucoma, hypothyroidism, hepatic failure, osteoporosis, peptic

Used in systemic corticosteroid preparations.

inflammatory nasal condition. Also used in cerebral edema due to malignancy.

hyperhidrosis, skin thinning, ocular changes including development of glaucoma & cataract, neurological disturbances, benign intracranial HTN, acute pancreatitis, avascular necrosis of the bone.

Increased blood coagulation that may lead to thromboembolic complication. Peptic ulcer.

Adrenal atrophy, secondary adrenocortical insufficiency. Paresthesia & irritation, epidural lipomatosis.

ulcer, psychoses, severe affective disorders, renal impairment.

Reduce CA & K intake.

Monitor fluid intake & output, & wt daily.

Rapid IV inj of massive dose may cause CV collapse. Childn. Elderly.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing ConsiderationMidazolam

Classification:

Hypnotics and sedatives

Disturbances of sleep rhythm, insomnia esp difficulty in falling asleep either initially or after premature

Premature infants. Myasthenia gravis.

Rarely cardioresp adverse events, nausea, vomiting, headache, hiccoughs, laryngospasm, dyspnoea, hallucination,

Have O2 and resuscitation equipment available in case of severe respiratory depression.

Continiously monitor BP. HR. RR. Airway

awakening. Tab/Inj Sedation in premed before surgical or diagnostic procedures, induction & maintenance of anesth.

Neonates less than 32 weeks gestational age; initially 0.03 mg/kg/hr

oversedation, drowsiness, ataxia, rash, paradoxical reactions, amnesic episodes.

integrity and arterial O2saturation during procedure.

When inj. Give IM. Deeply into a large muscle

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing ConsiderationEpinephrine HCl

Classification:Cardiac Drugs

Cardiac stimulant in case of collapse, shock & anesthetic accidents. Hemostatic in hemorrhages. Prolongs action of

Cardiac arrhythmia, tachycardia >140 bpm, severe HTN, narrow angle glaucoma,

CNS: drowsiness, headache, nervousness, tremor, cerebral hemorrhage, stroke, vertigo, pain disorientation, agitation, fear,

Drug interferes with tests for urinary catecholamines.

Drug of choice in emergency treatment of acute anaphylactic reactions.

infiltration anesthetic agent. Urticaria.

Childn 10 mcg/kg body wt or 300 mcg/m2 body surface up to 500 mcg/dose, repeated as necessary up to 6 times a day.

anesth w/ halogenated hydrocarbon of cyclopropane, w/ local anesth of finger or toe, woman in labor, cardiac dilation & coronary insufficiency.

dizziness, weakness. Palpitations,

ventricular fibrillation, shock, widened pulse pressure, hypertension, tachycardia, angina, altered ECG, decrease T-wave

GI: nausea, vomiting RESP:Dyspnea Skin: urticaria,

hemorrhage at inj. site, pallor.

Observe pt. closely for adverse reaction, adjust dosage or stop drug if necessary.

One mg. equals 1ml of 1:1000 solution or 10 ml of 1:10,000 solution.

When treating pt. with reactions caused by other drugs given IM. Or subcutaneously, inject this drug into the site where the other drug was given to minimize further absorption.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing ConsiderationPhenobarbital

Classification:anticonvulsant

Partial seizures/ anti convulsants

Severe renal and hepatic disorders. Severe respiratory depression, dyspnoea or

Bradycardia, hypotension, syncope; drowsiness, lethargy

CNS excitation or depression, impaired judgment, hangover

Therapeutic level is 15-40 mcg/ml.

Watch signs for barbiturate toxicity; coma, cyanosis, asthmatic breathing, clammy skin, and

airway obstruction; porphyria. Pregnancy.

effect, confusion, somnolence, agitation, hyperkinesia, ataxia, nervousness, headache, insomnia, nightmares, hallucinations, anxiety, dizziness;

Skin:rash, exfoliative dermatitis;

GI: nausea, vomiting, constipation; agranulocytosis, thrombocytopenia, megaloblastic anaemia; pain at inj site, thrombophlebitis

(IV); oliguria: laryngospasm, respiratory depression, apnoea (especially with rapid IV admin),

hypotension. Don’t stop drug

abruptly because this may worsen seizure.

Drg. May decrease bilirubin level in neonates, pt. with epilepsy, and those with congenital nonhemolytic, unconjigated bilirubinia.

Elderly or debilitated patients, children. Withdraw gradually. Impaired renal, hepatic and respiratory function. Patients with acute pain and depressive disorders. May impair ability to drive or operate machinery. Lactation.

Symptoms: Unsteady

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing Consideration hypoventilation. Potentially Fatal:

Stevens-Johnson syndrome.

gait, slurred speech, confusion, jaundice, hypothermia, hypotension, respiratory depression, coma.

Management:

Charcoal haemoperfusion (in severe cases).

Treatment is symptomatic and supportive.

Levophed

Classification:

Vasoconstrictors/adrenergic and dopaminergic cardiac stimulants

Used in the treatment of heart failure

Patients who are hypotensive from blood vol deficits except as emergency measure. Concomitant cyclopropane & halothane anesth. Patient w/ mesenteric or peripheral vascular thrombosis unless it is life-saving.

Bradycardia, arrhythmias; anxiety, transient headache. Plasma vol depletion (prolonged administration). Resp difficulty, ischemic injury.

Special Precautions Extravasation. Patient

w/ profound hypoxia or hypercarbia. Concomitant MAOI or tricyclic antidepressant.

Hypersensitivity to sulfites.

Monitor BP.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing ConsiderationCa. Gluconate

Classification:Electrolytes

Drugs for fluid and electrolyte balance /electrolyte replacement solutions.

Patients with calcium renal calculi or history of renal calculi. Conditions associated with hypercalcaemia

GI irritation; soft-tissue calcification, skin sloughing or necrosis after IM/SC inj. Hypercalcaemia characterised by anorexia, nausea,

Double-check that you are giving the correct form of calcium; resuscitation cart may contain both calcium gluconate and ca. chl.

Monitor Ca. levels

and hypercalciuria.

Special Precautions:

Impaired renal function; cardiac disease; hypercalcaemia-associated diseases, e.g. sarcoidosis; other malignancies. Pregnancy.

vomiting, constipation, abdominal pain, muscle weakness, mental disturbances, polydipsia, polyuria, nephrocalcinosis, renal calculi; chalky taste, hot flushes and peripheral vasodilation.

Potentially Fatal: Cardiac arrhythmias and coma.

frequently; maintain Ca. level of 9 to 10.4 mg/dl. Hypercalcemia may result after large doses in chronic renal failure. Report abnormalities

Sx/s. of severe hypercalcemia may include stupor, confusion, delirium and coma.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing ConsiderationDobutamine

Classification:Cardiac Drugs/adrenergic and dopaminergic cardiac stimulants

Used in the treatment of heart failure

Inotropic support in the short-term treatment of cardiac decompensation due

Idiopathic hypertrophic subaortic stenosis & patients w/ known allergy to corn or corn

Increased heart rate, BP & ventricular ectopic activity; hypotension.Phlebitis at IV inj sites.

Special Precautions May cause marked

increase in heart rate or BP. Patients w/ atrial fibrillation are at risk of developing rapid ventricular

to depressed contractility resulting either from organic heart disease or cardiac surgical procedures. Long-term treatment of CHF.

Start at a low rate of 0.5-1 mcg/kg/min & titrate at intervals of a few min. Usual optimal infusion rate 2-20 mcg/kg/min. Max: 40 mcg/kg/min.

products. response; w/ preexisting HTN are at increased risk of exaggerated pressor response.

Continuously monitor BP & ECG as well as pulmonary wedge pressure & cardiac output.

Hypovolemia should be corrected. Patients w/ subclinical or overt DM.

Pregnancy & lactation, childn & elderly.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing ConsiderationCiticoline

Classification:Nootropics & Neurotonics

IV/IM Parkinson's disease; Cerebrovascular disorders and head injury

Contraindicated in conditions like unconsciousness and brain surgery

Stop taking your medicine right away and talk to your doctor if you have any of the following side effects.

Allergic reaction: Itching or hives,

Before taking citicoline, tell your doctor if you are pregnant or breast feeding

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)

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing ConsiderationVancomycin HCl

Classification:Antibioticsglycopeptide antibacterials

Used in the treatment of systemic infections

Treatment of methicillin-resistant staphylococcal infections; in conditions eg brain

Hypersensitivity to vancomycin

Erythema, flushing or rash over the face & upper torso, hypotension & shock-like symptoms. Hypersensitivity reactions eg rashes,

Do not inject IM & care should be taken when given IV to avoid extravasation due to risk of tissue necrosis.

abscess, staphylococcal meningitis, peritonitis associated w/ continuous peritoneal dialysis & septicemia.

Children Single dose of 20 mg/kg

fever & chills.

Metronidazole

Classification:

Imidazole derivative antibacterials/Antiamoebics

Intestinal & hepatic amoebiasis Childn 40-50 mg/kg body wt in 3 divided doses for 5-7 consecutive days. Treatment may be continued up to 10 days if deemed necessary in severe cases. Giardiasis Childn >10 yr 2 tsp qid for 5 consecutive days. 4-9 yr 1-1½tsp, 1-3 yr 1 tsp.

History of blood dyscrasia

GI:Nausea, headache, anorexia. Occasionally, vomiting, diarrhea, epigastric cramping, constipation, mild leukopenia.

Observe pt. for edema, especially if he’s receiving corticosteroids; Flagyl IV RTU may cause sodium retention

Record number of character of stools when drug is used to treat amebiasis.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing ConsiderationAmikacin sulfate

Classification:Aminoglycosides

Indicated for; Bacterial septicemia

including neonatal sepsis. Serious infections of the resp tract.

Infections of the bone & joints. Intra-abdominal

Hypersensitivity to aminoglycosides.

Dehydration, renal dysfunction, neuromuscular disorders, premature & neonatal infants.

Auditory, vestibular, renal toxicity &

Obtain specimen for culture and sensitivity tests before giving first dose. Therapy may begin while awaiting results.

Weigh Pt. and review

infections including peritonitis.

Burns & post-op infections.

Serious & complicated UTI due to susceptible organisms.

As initial therapy in suspected gm-ve infections before the results of susceptibility testing are obtained. In mixed, gm-ve, staph infections & other gm+ve organism eg Strep & pneumococci.

Adult, childn & older infant 7.5 mg/kg 12 hrly or 5 mg/kg 8 hrly.

neuromuscular blockade. Rash, drug fever, headache, paresthesia, tremor, nausea & vomiting, eosinophilia, arthralgia, anemia & hypotension.

renal function studies before therapy begins

Correct dehydration before therapy begins, because of increase risk of toxicity

Monitor renal function, urine output, specific gravity, BUN & creatinine clearance.

Watch for S/sx of super infection, URT, such as continued fever, chills & increase pulse rate.

Peak drug levels more than 10 mcg/ml may be linked to higher risk of toxicity.

Drug Name Indication/Dosages Contraindication Adverse Effect Nursing ConsiderationMupirocin

Classification:

Topical Antibiotics

Treatment of primary (impetigo, folliculitis, furunculosis, ecthyma) & secondary skin infections (infected

Hypersensitivity to drug

Burning, stinging or pain. Itching. Rash, erythema, dry skin, tenderness, swelling, contact dermatitis, increased exudate.

Avoid contact w/ eyes. Prolonged use. Discontinue if sensitivity occurs

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

Date/CuesAnalysis of the

ProblemGoal & Objectives

Nursing Interventions

Rationale Evaluation

Objective Data: -Thick tenacious secretions(+) rhonchi(+) crackles-Restlessness-IrritabilityRR: 80s breathes/min

Subjective Data: “Sobrang mahalak pa din siya, kapag humihinga siya rinig na rinig ko” as verbalized by the mother

Nursing Diagnosis:

Ineffective airway clearance related to excessive secretions as evidenced by rhonchi and crackles upon auscultation

Scientific Implication:Ineffective airway clearance will lead to imbalanced ventilation-perfusion ratio leading to inadequate systemic oxygen circulation

After one hour of nursing intervention: The client’s secretions will be decreased enabling the client to have improved breath sounds and patent airway.

The client’s parents will verbalize understanding with the health teachings to maintain a patent airway and become involved in patient care.

The client will have a patent airway

Encourage warm versus cold liquids as appropriate

Keep environment pollutant free

Elevate head of the bed/change positions every 2 hours and PRN

Suction naso/oral secretions PRN

Use Chest Physiotherapy as indicated

Warm liquids relaxes airway and loosens secretions

To reduce irritant effect on airways To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage & ventilation of different lung segments

To clear away secretions

Promotes drainage of secretions

After one hour the nurse was able to clear the client’s secretions manifested by decreased crackles on auscultation.

The client’s parents verbalized understanding of the nurse’s health teaching regarding use of warm versus cold liquids and maintaining a pollutant-free environment.

Interdisciplinary collaboration in accordance with medication coverage and

The client’s retained secretions will be removed.

The client will demonstrate reduction/ absence of congestion with breathe sounds clear and respirations noiseless.

Facilitate coordination with other members of the health care team for interdisciplinary approach.

Maintain adequate I/O and avoid fluid overload

Accurately regulate IV fluid as ordered using a syringe pump

Administer medications as ordered

Facilitate referral to respiratory therapist for nebulization

To monitor fluid balance

To prevent fluid overload

To treat underlying condition

For inter-disciplinary collaboration. For tenacious secretions to be liquefied for easier suctioning.

nebulization were facilitated.

Date/ Cues Analysis of the problem

Goal and objectives

Nursing Interventions Rationale Evaluation

Objective data:-Arterial BP: 50/46 mmHg-ABG result: Respiratory AcidosispH-7.24pCo2-64pO2-24HCo3-27-Oxygen Saturation: 31.8- Very severe hypoxemia-Pale-Dyspneic-Lungs with harsh rhonchi and crackles on auscultation

Ineffective cardiopulmonary tissue perfusion related to impaired cardiac function and increased cardiac workload

After one hour of nursing intervention, the patient’s arterial blood gas, oxygen saturation and blood pressure will gradually improve.

Assessed patient’s vital signs including heart rate, pulse, and respirations. Auscultated heart and lung sounds

Administered supplemental oxygen as ordered

Monitored arterial blood gas values and oxygen saturation levels via pulse oximetry

Institute continuous cardiac monitoring as ordered

Vital signs and heart and lung sounds are important indicators for overall heart function

Supplemental oxygen enhances tissue perfusion without increasing the child’s metabolic oxygen demand

Arterial blood gases and pulse oximetry provide information about the status of tissue oxygenation

Continuous cardiac monitoring provides objective evidence of cardiac function,

After one hour of nursing intervention, the patient’s arterial blood gas, oxygen saturation and blood pressure gradually improveded as evidenced by:-ABG result of:pH-7.30Co2-54pO2-42HCo3-29-Blood pressure: 80/55-Oxygen saturation: 35

Removed any constricting clothing from the chest

Limit procedures to those that are necessary and provide adequate rest periods

Administer medications, such as digoxin and diuretics as ordered. Assess apical pulse prior to digoxin administration. Obtain serum digoxin levels as ordered.

including changes indicative of ischemia.

Constricting clothing interferes with chest expansion

Activity increases metabolic and myocardial oxygen demands, further impairing cardiopulmonary tissue perfusion

Digoxin improves myocardial contractility. Diuretics reduce fluid overload. Too rapid or too slow a heart rate may indicate digoxin toxicity. Measuring serum digoxin level aids in evaluating the effectiveness of therapy and preventing digoxin toxicity.

Date/ Cues Analysis of the problem

Goal and objectives

Nursing Interventions Rationale Evaluation

Objective data: Flushed skin;

warm to touch

Restlessness Vital signs as

follows:

T: 37.9°CHR: 152RR: 33BP: 85 / 63

Hyperthermia related to infection as evidence by temperature of 37.9°C

After 4 hours of nursing care, the patient will maintain a normal body temperature.

Assess temperature hourly and other signs and symptoms.

Record every fluid intake and urine output.

Promote surface cooling by rendering tepid sponge bath.

Provide air conditioning or fan.

Remove excess clothing and blankets.

Maintain on comfortable position and provide rest periods.

Administer prescribed antipyretics

To provide baseline data

To assess for signs of dehydration.

To reduce temperature by means of evaporation and conduction.

To decrease metabolic demand and oxygen consumption.

To facilitate fast recovery.

After 4 hours of nursing care, patient was able to maintain a normal body temperature.

Date/CuesAnalysis of the

ProblemGoal &

ObjectivesNursing Interventions Rationale Evaluation

Objective Data:- height: 57 cm-weight: 3.2 kg (ideal body weight: 4.2 kg)-Poor skin turgor-Pale conjunctiva and mucous membrane-with OGT tube

Imbalanced nutrition less than body requirements related to feeding intolerance as evidenced by decrease in body weight appropriate for his age.

Scientific Implication:Prolong NPO status may lead to low immunity, unmet nutritional needs and delay in growth

Demonstrate stable weight gain/progressive weight gain using age- appropriate measurements, including weight and body fluid, strength, activity level, sleep/rest cycles.

To promote adequate infant intake

Determine appropriate method for feeding

Auscultate bowel sounds. Note characteristics of stool (color, amount, frequency, and so on).

Weigh patient daily

Maintained the patency of the OGT

Feed the patient via OGT as orderd and tolerated

Review drug regimen,

Providing usual and typical feedings is important to infant well-being and early growth.

Provides information about digestion/bowel function and may affect choice/timing of feeding.

To determine the patient’s progressive weightgain

To avoid aspiration and to assist in conserving energy demanded for sucking

To increase his weight.

Timing of

After 4 days of nursing intervention the patient was able to tolerate a gradual increase of feeding of 60 ml every 3 hours After 4 days of nursing intervention, the patient’s weight progressed to 3.4 kg.

.side effects, and potential interactions with other medications/over-the-counter drugs.

medication doses, interaction with certain foods can alter effect of medication or digestion/absorption of nutrients

Date/Cues Analysis of the Problem

Goal & Objectives

Nursing Interventions Rationale Evaluation

Objective Data: Post-sternotomy surgical incision site

Nursing Diagnosis:Impaired skin integrity related to surgical intervention

Scientific Implication:The skin layer is the largest multifunctional organ of the body. The alteration that resulted from iatrogenic interventions may compromise its ability to protect the body from infectious organisms and/or thermoregulation.

After 7 days of nursing intervention, the client will display timely healing of skin lesions without complication.

The client will maintain physical well-being

The client’s family will verbalize understanding of purpose and enumerate interventions in wound care

The client’s wounds will be free of complication like purulent discharge

Inspect skin on a daily basis, describing lesions and changes observed.

Keep affected area clean and dry

Cool, moist compresses to skin. Avoid use of soap because it tends to dry skin and make it more likely to breakdown.

Assist the family in following medical regimen for the client and develop program of preventive care and daily maintenance.

Daily wound care using sterile equipment and practicing aseptic technique in dressing.

Teach the parents the above interventions and

To obtain baseline data

To assist body’s natural process of repair

Moisture potentiates skin breakdown.

Enhances commitment to plan, optimizing outcomes

To maintain skin integrity, promote timely wound healing, and prevent infection.

To involve the client’s significant

The client displayed timely wound healing without any complication after the consistent and continuous interventions.

The client’s parents’ verbalized understanding of the nurse’s varied health teaching regarding wound care.

Interdisciplinary collaboration in accordance with medication therapy was facilitated.

from infection.

The client’s family will participate in prevention measures and treatment program.

Facilitate coordination with other members of the health care team for inter-disciplinary approach.

rationale

Carry-out dependent interventions such as application of topical antibiotic ointment and timely, well regulated administration of intravenous antibiotic coverage.

Endorse plan of care to receiving bedside nurse.

others in wound care and promote readiness and independence in care prior to discharge.

To promote optimum recovery of the incision site.

For interdisciplinary management andto make possible the continuity of care

Date/ Cues Analysis of the problem

Goal and objectives

Nursing Interventions Rationale Evaluation

Objective data:

-Statements of the mother of her inability to meet child’s needs.-Verbalization of frustration on inadequacy of role as a parent.

Subjective Data:

“Hindi ko na maalagaan ang anak ko” as verbalized by the mother.

Impaired parenting due to illness as evidenced by prolonged separation from sick child.

At the end of the interaction, approximately 30 minutes, the mother will identify own strengths, parenting needs and methods to meet them.

Note absence from home setting and the lack of infant supervision by the parent.

Make time for listening to concerns of the parents and to acknowledge difficulty of the situation.

Provide adequate visiting time for the parents.

Let parents participate in caring for their child and provide information appropriate to the situation, including limit setting.

To assess causative/ contributing factors.

Enhances feeling of acceptance and expression of feelings.

Create an environment for relationship to be developed and foster development of parenting skills.

Facilitate satisfactory implementation of the plan.

After 30 minutes of nurse-parent reaction, the mother was able to identify methods on how to meet her parenting needs.

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 TestsAuthor(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