Final Tga Manuscript

8/11/2019 Final Tga Manuscript

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University of Perpetual Help System - Laguna Dr. Jose G. Tamayo Medical University

Sto. Nio, Bian, Laguna

COLLEGE OF NURSINGA.Y. : 201420151

stSEMESTER

TRANSPOSITION OF THE GREAT ARTERIES:A Case Presentation

ARAMBULO, Carol Anne T.CABRAL, Rosemarie L.

CRUZ, Louanne Tracy B.DALISAY, Banissa M.

DELOS SANTOS, Sean John M.FLORALDE, Aisha F.

GABO, Ma. Angelica A.GASPI, Feddie Anthony F.

GONZALES, Dionne Clare O.

Level IV, Section N4X, Group 4


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Case Presentation:Transposition of the Great Arteries Page 1

Table of Contents

I. Introduction....2-3

II. Patients Profile.4

III. Nursing Health History....5-6

1. History of the Present Illness..52. Past Health History ....53. Family History of Illnesses ..5

a. Maternal...5b. Paternal5

4. Vaccination..55. Position in the Family6

IV. Nursing Assessment7-13

a. Gordons 11 Functional Health Pattern7-10b. Physical Assessment (Cephalo-Caudal Assessment)..11-13

V. Anatomy and Physiology14-15

VI. Pathophysiology16

VII. Medical Management.17-48

a. DoctorsOrder17 -24b. Laboratory/ Diagnostic Examination Results.25-46

c. Drug Study47 -48

VII. Auxillary Reports49-54

Phlebotomy..49

Blalock-Taussig Shunting...50

Balloon Atrial Septostomy..52

Arterial Switch53

VIII. Nursing Management..55-68

Nursing Care Plan55 -68
http://www.annakatharinamd.com/2011/06/17/nursing-health-history-for-nursing-students/http://www.annakatharinamd.com/2011/06/17/nursing-health-history-for-nursing-students/


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I. Introduction

Transposition of the great arteries (TGA), also referred to as complete

transposition, is a congenital cardiac malformation characterized by atrioventricularconcordance and ventriculo-arterial (VA) discordance. TGA is associated with non-cardiac malformations. The association with other cardiac malformations such asventricular septal defect (VSD) and left ventricular outflow tract obstruction is frequentand dictates timing and clinical presentation, which consists of cyanosis with or withoutcongestive heart failure. The onset and severity depend on anatomical and functionalvariants that influence the degree of mixing between the two circulations. If noobstructive lesions are present and there is a large VSD, cyanosis may go undetectedand only be perceived during episodes of crying or agitation. In these cases, signs ofcongestive heart failure prevail. The exact etiology remains unknown. Maternal factorsassociated with an increased risk include rubella or other viral illness during pregnancy,

alcoholism, maternal age over 40 and diabetes. Transposition is rarely associated withsyndromes or extra-cardiac malformations. Mutations in growth differentiation factor-1gene, the thyroid hormone receptor-associated protein-2 gene and the gene encodingthe cryptic protein have been shown implicated in discordant VA connections, but theyexplain only a small minority of TGA cases. Newborns with transposition of the greatarteries are usually well developed, without dysmorphic features. Physical findings atpresentation depend on the presence of associated lesions. The diagnosis is confirmedby echocardiography, which also provides the morphological details required for futuresurgical management. Prenatal diagnosis by fetal echocardiography is possible anddesirable, as it may improve the early neonatal management and reduce morbidity andmortality. Differential diagnosis includes other causes of central neonatal cyanosis.

Palliative treatment with prostaglandin E1 and balloon atrial septostomy are usuallyrequired soon after birth. Surgical correction is performed at a later stage. Usually, theJatene arterial switch operation is the procedure of choice. Whenever this operation isnot feasible, adequate alternative surgical approach should be implemented.

According to the Philippine Heart Center, despite its overall low prevalence,transposition of the great arteries is the most common etiology for cyanotic congenitalheart disease in the newborn. This lesion presents in 5-7% of all patients withcongenital heart disease. The overall annual incidence is 20-30 per 100,000 live births,and inheritance is multifactorial. Transposition of the great arteries is isolated in 90% of

patients and is rarely associated with syndromes or extra-cardiac malformations. Thiscongenital heart defect is more common ininfants of diabetic mothers. The hearts withatrioventricular concordance and ventriculo-arterial discordance represent 57% of allcongenital heart diseases, corresponding to an incidence of 20 to 30 per 100,000 livebirths. There is a male predominance with a male/female sex ratio that varies, in theliterature, from 1.5:1 to 3.2:1. TGA has a 60-70% male predominance. No racialpredilection is known. Patients with TGA usually present with cyanosis in the newbornperiod, but clinical manifestations and courses are influenced predominantly by the
http://emedicine.medscape.com/article/974230-overviewhttp://emedicine.medscape.com/article/974230-overview


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degree of intercirculatory mixing. Infants with transposition of the great arteries areusually born at term, with cyanosis apparent within hours of birth. The clinical courseand manifestations depend on the extent of inter-circulatory mixing and the presence ofassociated anatomic lesions. In 10% of the cases, this cardiac lesion is associated withother non-cardiac malformations.

Long-term complications are secondary to prolonged cyanosis and includepolycythemia and hyperviscosity syndrome. These patients may develop headache,decreased exercise tolerance, and stroke. Thrombocytopenia is common in patientswith cyanotic congenital heart disease leading to bleeding complications. Patients witha large ventricular septal defect, a patent ductus arteriosus, or both may have an earlypredilection for congestive heart failure, as pulmonary vascular resistance falls withincreasing age. Heart failure may be mitigated in those patients with left ventricularoutflow tract (pulmonary) stenosis. A small percentage (approximately 5%) of patientswith transposition of the great arteries (and often a ventricular septal defect) developaccelerated pulmonary vascular obstructive disease and progressive cyanosis despite

surgical repair or palliation. The mortality rate in untreated patients is approximately30% in the first week, 50% in the first month, and 90% by the end of the first year. Withimproved diagnostic, medical, and surgical techniques, the overall short-term andmidterm survival rate exceeds 90%. Long-term survival in this subgroup is particularlypoor. With the advent of newer and improved surgical techniques and post-operativeintensive care, the long-term survival is approximately 90% at 15 years of age.However, the exercise performance, cognitive function and quality of life may beimpaired.
http://emedicine.medscape.com/article/957343-overviewhttp://emedicine.medscape.com/article/2069746-overviewhttp://emedicine.medscape.com/article/2069746-overviewhttp://emedicine.medscape.com/article/957343-overview


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II. Patients Profile

NAME : D.R.D

ADDRESS : San Vicente, San Pedro Laguna

GENDER : Male

AGE : 7 years 3months and 7days

BIRTHDAY : March, 12, 2007

BIRTHPLACE : San Pedro, Laguna

CIVIL STATUS : Child

NATIONALITY : Filipino

RELIGION : Roman Catholic

ADMISSION DATE : June 19, 2014

ADMISSION TIME : 9:58 am

DAYS OF HOSPITALIZATION : 6 Days

Days Handled : June 24-27, 2014 (4 Days)

HOSPITAL NAME : University of Perpetual Help Dr. Jose G.Tamayo Medical Center

CHIEF COMPLAINT : Difficulty of breathing with frontalheadache

FINAL DIAGNOSIS : Congenital Heart Disease, CyanoticType, Hypersensitivity Syndrome,Secondary to Transposition of Great

Vessels


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III. Nursing Health History

1. History of Present Illness

1 hour prior to admission patient was noted to have difficulty of breathing not

associated with exertion, noted frontal headache with a pain scale of 5/10 andperiorbital pain, persistence of the above sign and symptoms prompted consultation,hence admitted.

2. Past Health History

Seven years ago, the patient was born through natural spontaneous vaginaldelivery to a G2P2mother, who suffered from gestational diabetes. He was declared awell-baby and was discharged after 3 days from being delivered. Two weeks after birth,the patient along with his mother went for follow-up check-up and the pediatriciandetected a murmur upon assessment. The patient also exhibited a hoarse soundwhenever crying. A series of diagnostic tests such as 2D-echocardiogram,electrocardiogram were performed which led to the confirmation that the patient issuffering from transposition of the great arteries. The patient then underwent a Blalock-Taussig operation at the Philippine heart Center to install a shunt, as a means ofpalliative treatment. October 2013, at the Philippine General Hospital, the patientunderwent phlebotomy, due to elevated hematocrit levels as a result ofthrombocytopenia. It was then repeated three months after, last January 2014 at thesame institution. In both cases, 100cc of blood was drawn. The last phlebotomytreatment was done in the University of Perpetual Help Dr. Jose G. Tamayo MedicalCenter. Blood was drawn in four sessions, where 160cc was aspirated on eachsession.

3. Family History of Illnesses

a. Maternal Side: (+) Diabetes Mellitus (-) Asthma(+) Kidney Disease (-) Respiratory Disease(+) Hypertension (+) Heart Disease

b. Paternal Side: (+) Diabetes Mellitus (+) Asthma

(-) Kidney Disease (-) Respiratory Disease(+) Hypertension (-) Heart Disease

4. Vaccination

The patient is fully immunized according to age.


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5. Position in the Family

The patient is the second child in a brood of 3 from a 35-year old mother andfather. The eldest sibling is reported to have a case of asthma and the youngest with

no reported illness.


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IV. Nursing Assessment

A. GORDONS 11 FUNCTIONAL HEALTH PATTERN

Health Perception and Management

Past Medical History

The patient is a seven-year old child who was diagnosed with transposition ofgreat arteries when he was two weeks old. He underwent an emergency Blalock-Taussig hunt operation during his 22

ndday of life because of severe cyanosis. After the

operation, the patient was transferred to recovery room for close monitoring hooked toinotropes and ventilator. On the first post operation day, the patients conditionimproved and was extubated. On the second post operation day, the patient wastransferred to pediatric intensive care unit still on close monitoring. Eventually, thepatient was weaned from the ventilator and transferred to regular room. As his

condition to improve, he was thus sent home and was prescribed home medication.The patient started undergoing phlebotomy October, 2013, due to increased

hematocrit level secondary to idiopathic thrombocytopenia, and has since been doingthis until present. He has complete immunization record according to age. BCG andHepa B vaccine was done at birth, DPT was done six weeks after, as well as OPV.Nine months later, he was given his measles vaccine. The patient is underweight, andreports episodes of difficulty of breathing every now and then.

During Hospitalization

The patient is a passive child who has to warm up to the health care provider

who assesses him. Once the health care provider is already familiar, he will start toparticipate in the assessment, but he rarely spoke, so all the necessary information forthe case was obtained from the mother.

Nutritional / Metabolic Pattern

Prior to Admission

The patient was breastfed until he was two years of age, and since then he onlyeats chicken and eggs with an approximate 5 spoonfulls of rice. He only drinks Milo, achocolate milk drink, and seldom drinks water. In a day he would only drink an

approximate 3 glasses of water, and only during meal time. He takes multivitamins assupplement due to lack of appetite. He does not have any maintenance medication.


Patient is currently on DAT diet according to age. Intake of liquid and solid foodsbecame lesser due to appetite loss because of his condition.


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Elimination

Prior to Admission

The patient regularly voids 4-5 times daily. He would normally ask his mother toaccompany him whenever he feels the urge to void. He has bowel movement onceeveryday, and would also ask the help of his mother if he needs to due to the fact thathe gets tired very easily. He does not sweat a lot, and there are instances whereepisodes of nausea and vomiting occur.


The patient was still able to void and have regular bowel movement with theassistance of his mother. No nausea and vomiting was reported.

ActivityExercise

Prior to Admission

The patient has minimal activity due to easy fatigability. He was enrolled atnursery school but eventually stopped school for he was unable to sustain energy at thecourse of the class. He would complain of fatigue, and would ask to be sent home. Histypical day would be to sit in front of the computer and play video games. He has atablet, where he would play puzzle games, and basketball games. He also likes tolisten to music, especially Justin Bieber. He also likes watching cartoons on Disneychannel, as well as nickelodeon. If he gets bored doing these, he would sleep andwake up again to do the same routine. He seldom plays outside, and would just sit andrelax at home.


On admission, the patient carried with him his usual paraphernalia of gadgets,his tablet, and his mothers cellphone. He would listen to Justin Bieber, and play NBA2014 on his tablet. He would sleep every now and then.

Cognitive / Perceptual

Prior to Admission

At home, the patient is able to perform normal functioning with minimal exertion.He is aware of his condition and is able to verbalize this to other people. At a youngage, he is able to understand what is happening to him, as his parents would explain hisstatus.


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At the hospital, the patient is active, and would participate in the treatments being

performed by the medical professionals. He would also give feedback on how he feelsregarding the therapy, and would react on situation a child his age would given thecircumstance.

Sleep / Rest Pattern

Prior to Admission

Due to easy fatigability, the patient would always take naps during the daywhenever he feels tired. At night, he would have a straight eight hours of sleep,sometimes longer if he would be sleeping late. His normal sleeping time would be 8:00

pm to 9:00 pm, depending on the television program he watches. His waking hourswould also depend on how tired he is of the activities he does during the day.


At the hospital, he would complain that he doesnt get enough sleep because thenurses would check up on him every now and then. His mother reported a shortenedsleeping and resting period. His mother would try to put him to sleep, but he wouldwake up everytime there would be slight noise, since they are admitted to the ward,where there are other patients besides them.

Self-Perception/ Self-Concept

According to Erik Ericksons Psychosocial Theory, the patient belongs to theschool age group, where there is industry versus inferiority. In this age group, Childrenneed to cope with new social and academic demands. Success leads to a sense ofcompetence, while failure results in feelings of inferiority. During middle childhoodbetween the ages of about six and eleven, children enter the psychosocial stage knownas industry versus inferiority. As children engage in social interaction with friends andacademic activities at school, they begin to develop a sense of pride andaccomplishment in their work and abilities. Children who are praised and encourageddevelop a sense of competence, while those who are discouraged are left with a senseof inferiority.

Since the patient is unable to go to school, when children his age are, he feelsinferior given the fact of his condition. His mother reported that he would sometimesvoice out that he would want to go to school once he finishes his hospital field trip andplay with his classmates. He would also gain happiness whenever he would achievelittle accomplishments such as winning certain games over the internet and in hisgadgets.


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Role Relationship

Since the patient is a middle child, he would sometimes be the baby to hiseldest sister, and a big brother to their youngest sibling. He would sometimes ask the

help of his eldest sister on small things such as getting puzzles solved, or getting stuffthat he has difficulty reaching due to his height. His mother also reported that he wouldplay with his baby sister, show her games that he perceives she would enjoy, and he issaid to be malambingall the time to the members of his immediate family especially tohis mother. He has a special bond with her due to the fact that his mother is the onewho accompanies him whenever he has his hospital field trip.

SexualityReproductive

The patient would play with video games designed for male children, specificallyNBA 2014. He shows interest in toys such as trucks, automobiles, specifically die cast

models of cars and trains.

At the course of his stay at the hospital, he would get shy whenever he will beassessed especially that his phlebotomy site was done on his inguinal area. He wouldcover his male body part, and would show embarrassment.

Coping / Stress Tolerance

Prior to Admission

According to his mother, the patient is very patient, but once he gets frustrated,he would cry and sulk at one corner. This seldom happens because the family makes ita point not to stress or frustrate the patient since it is contraindicated to his condition.


During his hospital admission, he would cry whenever phlebotomy was donebecause according to his mom, he feels pain whenever blood was being drawn. Hewould complain about the procedure and would even compare how he liked histreatment better from the previous hospital he went for treatment due to the fact that hewas used to the health care providers over there who took care of him.

ValueBelief

The patients familys religion is Roman Catholic, and they would adhere to thereligions norms and activities accordingly. They also get support from their religiouscommunity and the family would go and hear mass together.


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B. PHYSICAL ASSESSMENT(Tool: Cephalo-Caudal Assessment)

Day of Assessment: June 24, 2014

Observer: Student NurseInformant: MotherVital Signs during assessment:

Temperature: 36.9oC

Heart Rate: 110 bpmRespiratory Rate: 24 cpm

Head

Area/Procedure Normal Findings Actual Findings Analysis

Skin Pinkish Pale, cold totouch Cyanosis is seen inthe conjunctiva,

tongue and lips and is

due to desaturation of

central arterial blood

resulting from cardiac

and respiratory

disorders associated

with shunting of

deoxygenated venous

blood into thesystemic circulation.

Eyes PinkishConjunctiva

Pale Conjunctiva

Buccal Mucosa Pinkish Cyanotic

Trunk

Skin Turgor Instant return Slow return (>3seconds)

Result of dehydration andpoor oxygenation of theblood.

Skin Color,Temperature

Pinkish, warm totouch

Pale to cyanotic,there is hematomaon the inguinalarea where the

phlebotomy site islocated. Skin isslightly cold totouch

A hematoma is a bloodclot which forms withinthe body. It is caused byleakage of blood into the

tissues from an injuredvein . It will resolvespontaneously.Hematomas are causedby excessive needletrauma to a vein, forexample, by a needlewhich passed entirely


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through a vein and cameout the other side.

Upper Extremities

Skin Pinkish, warm totouch

Pale to cyanotic,there is

hematoma on theright arm wherethe firstphlebotomy siteis located, skinslightly cold totouch.

A hematoma is a blood clotwhich forms within the

body. It is caused byleakage of blood into thetissues from an injuredvein . It will resolvespontaneously.Hematomas are caused byexcessive needle traumato a vein, for example, by aneedle which passedentirely through a vein andcame out the other side.

Fingers Pinkish nailbedswithoutcurvature, andcapillary refill of(3seconds)

Peripheral cyanosis iscaused by decreased local

circulation and increased

extraction of oxygen in the

peripheral tissues.

Isolated peripheral

cyanosis occurs in

conditions associated with

peripheral vasoconstriction

and stasis of blood in the

extremities, leading toincreased peripheral

oxygen extraction, eg

congestiveheart failure,

circulatory shock,

exposure to cold

temperatures and

abnormalities of the

peripheral circulation.

Features of peripheral

cyanosis therefore include

peripheral vasoconstriction

and bluish or purple

discoloration of the

affected area, which is

usually cold. Peripheral

cyanosis is most intense in
http://www.patient.co.uk/search.asp?searchterm=CARDIAC+FAILURE&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CARDIAC+FAILURE&collections=PPsearch


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nail beds. Clubbing of

fingernails is frequent in

congenital heart

diseaseas a result of

chronic deficient

oxygenation of the blood.Lower Extremities

Skin Pinkish, warm totouch

Pale, slightly coldto touch

Peripheral cyanosis is

caused by decreased

local circulation and

increased extraction of

oxygen in the peripheral

tissues.

Isolated peripheral

cyanosis occurs in

conditions associated with

peripheral

vasoconstriction and

stasis of blood in the

extremities, leading to

increased peripheral

oxygen extraction, eg

congestiveheart failure,

circulatory shock,

exposure to coldtemperatures and

abnormalities of the

peripheral circulation.

Features of peripheral

cyanosis therefore include

peripheral

vasoconstriction and

bluish or purple

discoloration of the

affected area, which isusually cold.
http://www.patient.co.uk/search.asp?searchterm=CARDIAC+FAILURE&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CARDIAC+FAILURE&collections=PPsearch


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V. Anatomy and Physiology

A child's heart is the center of their

cardiovascular system. A normal heart isstrong, about the size of an orange and

weighs about one pound. Although it is

small in size, the heart is extremely

powerful. The heart continuously pumps

oxygen and nutrient-rich blood throughout

the body. On average, the heart beats

100,000 times and pumps about 2,000

gallons of blood (source:American Heart

Association). As the blood circulates it

collects waste products that will be excreted

from the body. The heart has four

chambers. They are: 1. Upper right atrium;

2. Upper left atrium; 3. Lower right ventricle;

4. Lower left ventricle.

The heart pumps blood through the chambers. The flow of blood through theheart is controlled by four heart valves. The valves open and close as the blood ispumped through the heart. Each valve has a set of flaps (also called leaflets or cusps).

All valves have three flaps, except for the mitral valve. Normally, it only has two. As the

heart beats it creates pressure that opens the valves which allows blood to flow throughthe flaps. They make sure the blood only flows in one direction.

1. Tricuspid valve (between the right atrium and right ventricle)

2. Pulmonary valve (between the right ventricle and pulmonary artery)

3. Mitral valve (between the left atrium and left ventricle)

4. Aortic valve (between the left ventricle and the aorta)

The two sides of heart have distinct features. The right side receives blood from

the body and pumps it to the lungs. The left side receives the blood from the lungs and

is pumped out into the body. The heart receives blood from veins and sends blood out

through arteries.
http://www.americanheart.org/http://www.americanheart.org/http://www.americanheart.org/http://www.americanheart.org/


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Cardiac Cycle

Blood flows through the heart in one direction only. It is prevented from backingup by a series of valves at various openings: the tricuspid valve between the right atriumand right ventricle; the bicuspid, or mitral, valve between the left atrium and left

ventricle; and the semilunar valves in the aorta and the pulmonary artery. Eachheartbeat, or cardiac cycle, is divided into two phases. In the first phase, a short periodof ventricular contraction known as the systole, the tricuspid and mitral valves snapshut, producing the familiar "lub" sound heard in the physician's stethoscope. In thesecond phase, a slightly longer period of ventricular relaxation known as the diastole,the pulmonary and aortic valves close up, producing the characteristic "dub" sound.Both sides of the heart contract, empty, relax, and fill simultaneously; therefore, onlyone systole and one diastole are felt. The normal heart has a rate of 72 beats perminute, but in infants the rate may be as high as 120 beats, and in children about 90beats, per minute. Each heartbeat is stimulated by an electrical impulse that originatesin a small strip of heart tissue known as the sinoatrial (S-A) node, or pacemaker.


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VI. Pathophysiology

Modifiable Factors:

-Mother has gestational diabetes

Non-modifiable Factors:-Idiopathic-Age-G2P2

Transposition of theGreat Arteries

(TGA)

Malposition of the

great arteries

VSD, PDA, ASD

Blood goes to the lungs, picks upoxygen, returns to the heart, andthen flows right back to the lungs

without going to the body

Murmur

Blood from the body returns to theheart and goes back to the body

without ever picking up oxygen in the

lungs

-Cyanosis-Clubbing of the fingers and toes-poor feeding-shortness of breath-nausea and vomiting

-headache


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VII. Medical Management

A. Doctors Order

Date Doctors Order Analysis

June 19, 201412:00nn

Referral to Dr.L For Collaborative Management

4:00 PM Continue Management For continuity of care

Continue IV hydration For rehydration and correction ofelectrolyte imbalance

Phlebotomy tomorrow oncall

Done as part of the patient's treatment forincreased levels of hematocrit

- Please preparethe followingmaterials

3 way stopcock(heplock)

Butterfly needlesyringe

10cc syringe (3) PNSS 500cc with

soluset Heparin solution Sterile OS (4) Sterile bottle (2) Sterile gloves size

7 and and 6 and

Betadine Sterile cotton

balls/micropore O2 tank and

tubings at bedside Emergency kit Sterile basin Midazolan

1ampule micropore

For the procedure and sterile technique ofphlebotomy

- Secure Freshfrozen plasma

To replace blood loss


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130cc typespecific 2 bags

For blood transfusionand RH typing

To increase level of blood cells.-to boosts blood level that are low

Refer accordingly For further management

8:50 PM Rounds with Dr. L.NPO

June 20, 2014 For phlebotomy at 9 or10am tomorrowGive midazolan mgthrough IV prior tophlebotomy

For short-term sedation

Please provide a

treatment room for thephlebotomy

For patients safety and privacy

Continue vital signsmonitoring bloodpressure

For baseline data

Refer

IVF to follow D5.03NaCl 1Lx80cc/hr

For rehydration and correct electrolyteimbalance

Please preparematerials needed forphlebotomy

For easy accessibility and will save timefor the procedure. For efficiency.

Refer For collaborative managementJune 20, 20146:20 AM

Please thaw freshfrozen plasma at7:30am

Fresh frozen plasma is thawed to preventchills during transfusion, it is transfused toreplace blood lost during the procedure

Transfuse 80cc at freshfrozen plasma at8:30am for 30mins

Transfused regulated as fast drip

Prepare materialneeded for phlebotomy

Refer

10:10 AM Post Phlebotomy Order:


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Diet as tolerated whenfully awake

To replenish and nourish the patient afterprocedure

Repeat complete blood

count with platelettomorrow at 8am ifhematocrit is 0.65 andabove for repeatphlebotomy

For monitoring hematocrit level,

monitoring signs of bleeding

Check the puncturedsite for signs of bleeding

To monitor bleeding tendencies

Monitor vital signs q15minutes for 2hrs then

q 1hr then after

To be able to monitor any complicationsfrom the procedure

Resume IVF at 0-81cc/hr

For rehydration and correction ofelectrolyte imbalance

Maintain O2 till fullyawake then discontinue

To compensate for oxygen loss andmaintain optimum oxygen saturation

Inform Attendingphysician

For further management

10:20 AM Dr. T updated

ReferJune 21, 20147:10 AM

Please do Completeblood count with plateletnow

To monitor hematocrit levels

IVF to follow D5.03NaCl50cc at 80-81cc/hr

For rehydration and correction ofelectrolyte imbalance

8:45 AM For phlebotomy now

Please thaw freshfrozen plasma now

Transfuse 50cc of freshfrozen plasma then runremaining 50cc while ongoing phlebotomy


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Please preparematerials forphlebotomy

Please providetreatment room for theprocedure

Give midazolan 4mgthrough IV prior to theprocedure

Refer

11:18 AM Post Phlebotomy

Diet as tolerated whenfully awake

Repeat complete bloodcount with platelet at4am from (6/22/14)

Prepare 2 units offresh frozen plasmatype specific if

hematocrit is 0.65 willrepeat phlebotomy

Repeat material forpossible managementphlebotomy

Check the puncture sitefor bleeding

IVF to follow D5.03NaCl1L at 80cc/hr

3:30 PM Monitor Vital signs q15minutes till stablethen q 1hr

Refer


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June 22, 20142:00 AM

IVF to follow D5.03NaCl1Lx80cc/hr

5:00 AM IVF to follow D5.03NaCl1Lx80cc/hr

7:30 AM Prepare materials forpossible repeatphlebotomy today

Prepare 2units freshfrozen plasma typespecific

Dr. L updatedFor phlebotomy today at8am

Please thaw fresh frozenplasma now

Transfuse 80cc of freshfrozen plasma then runremaining 50cc whileongoing phlebotomy

Please prepare materialsfor phlebotomy

Please provide treatmentroom for the procedure

Refer

10:42 AM Post Phlebotomy Order:

Diet as tolerated oncefully awake

For repeat completeblood count with platelettomorrow (6/23/14) at4am

Prepare 2units of freshfrozen plasma typespecific if hematocrit is


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0.65 with repeatphlebotomyPrepare materials forpossible repeatphlebotomy

Check the puncture site


Monitor vital signs q15minutes for 2hrs thenq 1hr

Refer

2:00 PM Continue presentmanagement

6:20 PM Facilitate repeatcomplete blood countwith PC (6/23/14 at 4am)and relay once clot result

June 23, 20145:20 AM

Please prepare materialsfor phlebotomy today

Prepare 1 unit freshfrozen plasma typespecific

IVF to follow D5.03NaCl1L to run for at 80cc/hr

6:30 AMDr. L updated

For phlebotomy today at7:30am

Please thaw fresh frozenplasma now

Transfuse 80cc of fresh


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frozen plasma at 7amthen remaining whileongoing phlebotomy

Provide treatment room

for the procedure

Give medazolan 4mgthrough IV prior to theprocedure

8:45 AM Post Phlebotomy

Diet as tolerated once fullawake

For repeat CBC withplatelet tomorrow 6/24/14at 4am

Prepare 2units of freshfrozen plasma typespecific if hematocrit is0.65 will repeatphlebotomy

Check the puncture site


Monitor vital signs every15minutes for 2hrs thenevery hour

Refer


4:45 PM Please prepare clinicalabstract



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June 24, 20144:30 AM

Continue with presentmanagementRefer

6:40 AM Rounds of Dr. L.

May go home

Please provide clinicalabstract checked byROD

Follow up with attendingphysician after twoweeks at Medical Arts.

Home meds:

Multivitamins (Restor)1tsp OD

Refer


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B. Laboratory / Diagnostic Examination Results

Name:D.D.R. Age: 7 Sex: Male Date Submitted: 06/09/14

Referring Doctor: L.R. Room/Bed No.: T310-B

LABORATORY REPORT

URINALYSIS

Color: Dark Yellow Glucose: Negative

Transparency: Slightly Hazy Specific Gravity: 1.025Reaction (pH): 5.5 Pus Cells: 1-2/HPF

Protein: Trace RBC: 0-1/HPF

Mucus Threads: Moderate


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LABORATORY REPORT

Name: D.D.R.V. Age: 6 Sex: M Date Requested: 01/08/2014Dept./Ward/Rm/Bed #: Hosp. #: Lab #:Req. Physician:

HEMATOLOGY

TEST NORMAL VALUES ACTUAL RESULT SIGNIFICANCE

WBC Count 4.5 -11.0 11.26 x10^9/L

Elevations in white bloodcell count and a white bloocell shift in the differentialraise the suspicion of a

systemic infection

RBC Count 4.6 -6.2 7.50 x10^12/LHigh RBCs may indicatelow blood oxygen levels

Hemoglobin120 -150

210 g/L

High hemoglobin is usualldue to an increasednumber or abnormality ofred blood cells

Hematocrit0.40 -0.54

0.692

A high hematocrit can resin increased blood viscosiwhich can lead tospontaneous thrombosisand resultant cerebral,renal, or pulmonaryinfarctions

MCV 30 -9692.3 fL

MCH 27 -31 28 pg

MCHC 320 -350 304 g/L

A low level may indicateblood loss over time,toolittle iron in the body orhypochromic anemia


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LABORATORY REPORT

Name: D.D.R.V. Age: 7 Date Requested: 6/20/2014

Physician: T.S. Sex: Male Date Submitted: 6/21/2014

HEMATOLOGY

TEST NORMAL VALUES RESULT SIGNIFICANCE

Hemoglobin 120 - 150 232 gm/L

Hematocrit 0.400.54 0.76

A high hematocrit can

result in increased blood

viscosity, which can lead to

spontaneous thrombosis

and resultant cerebral,

renal, or pulmonary

infarctions

RBC Count 45.6 7.32 x10^12/LHigh RBCs may indicate

low blood oxygen levels

WBC Count 5.010.0 5.39 x10^9/L

Segmenters 0.500.70 0.43

A low count indicates a

reduction in either the

number or the size of redblood cells.

Lymphocytes 0.200.40 0.43

An increase in lymphocyte

concentration is usually a

sign of a viral infection

Monocytes 00.05 0.07

Monocytes elevated may

suggest inflammation

present

Eosinophils00.04 0.04 Presence of inflammation

or there may be infection

Basophiles00.01 0.03

There may be a presence

of inflammation or there

may be infection.


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MCV 80 - 98 105 flIndicates large average

RBC size

MCH 26 - 32 31.7 pg

MCHC320 - 360 303 g/L

A low level may indicate

blood loss over time,too

fast or there is little iron in

the body or hypochromic

anemia

Platelet Count150400 130 x10/L

The body may be

destroying too may

platelets or the bone

marrow is not producing

enough platelets.

RDW11 - 15 13.4 %


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LABORATORY REPORT



HEMATOLOGY

TEST RESULT NORMAL VALUES SIGNIFICANCE

Hemoglobin 214 gm/L 120 - 150

High hemoglobin is

usually due to an

increased number or

abnormality of red blood

cells

Hematocrit 0.69 0.400.54



viscosity, which can lead

to spontaneous

thrombosis and resultant

cerebral, renal, or

pulmonary infarctions

RBC Count 6.61 x10^12/L 45.6

High RBCs may indicate


WBC Count 8.36 x10^9/L 5.010.0

Segmenters 0.39 0.500.70



number or the size of red

blood cells.

Lymphocytes 0.47 0.200.40

Low platelet count may

decrease if the bone

marrow does not produce

enough platelets.

Monocytes 0.08 00.05 Monocytes elevated may


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present

Eosinophils

0.04 00.04

Basophiles 0.02 00.01

There may be a

presence of inflammation

or there may be infection.

MCV 105 fl 80 - 98Indicates large average

RBC size

MCH 32.4 pg 26 - 32

There may be a thyroid

malfunction or there is a

deficiency of Vitamin B12

MCHC310 g/L 320 - 360



fast or there is little iron

in the body or

hypochromic anemia

Platelet Count

128 x10/L 150400



marrow does not produceenough

RDW13.2 % 11 - 15


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LABORATORY REPORT



HEMATOLOGY



High hemoglobin is

usually due to an

increased number or


cells





to spontaneous


cerebral, renal, or


RBC Count 45.6 6.41 x10^12/L



WBC Count 5.010.0 7.43 x10^9/L





blood cells.


An increase in

lymphocyte concentrationis usually a sign of a vira

infection




present


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Eosinophils00.04 0.07

Presence of inflammation


Basophiles 00.01 0.02

There may be a

presence of inflammationor there may be infection


RBC size

MCH 26 - 32 31.2 pg

MCHC

320 - 360 302 g/L




in the body orhypochromic anemia





enough platelets.

RDW11 - 15 12.8 %


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LABORATORY REPORT



HEMATOLOGY



High hemoglobin is

usually due to an

increased number or


cells





to spontaneous


cerebral, renal, or


RBC Count 45.6 5.78 x10^12/L



WBC Count 5.010.0 7.17 x10^9/L





blood cells.


An increase in

lymphocyte concentrationis usually a sign of a vira

infection




present


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Eosinophils00.04 0.07

Presence of inflammation


Basophils 00.01 0.03

There may be a

presence of inflammationor there may be infection


RBC size

MCH 26 - 32 31.8 pg

MCHC

320 - 360 305 g/L




in the body orhypochromic anemia





enough platelets.

RDW11 - 15 13.2 %


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Blood Bank

NAME: D.D.R.V AGE: 7 SEX: Male

ROOM: T310-B DATE: 06/19/2014

EXAMINATION: Blood Typing

RESULT:

EXAMINATION TEST RESULT

ABO/Rh TYPING BLOOD TYPE B Rh (D) POSITIVE


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Blood Bank

Name: D.D.V.R. Age: 7

Room: T310 Sex: Male

Specimen: Fresh Frozen Plasma Date: 06-20-14

Examination: Reverse Typing

Result:

Patients Name: D.D.V.R.

Blood Component: Fresh Frozen Plasma

Blood Serial Number: 4009-019504-0

Patients Blood Type: B Rh (D) POSITIVE

Donors Blood Type: B Rh (D) POSITIVE

Date of Extraction:04-30-2014

Date and Time Thawed (for FFP): 6-20-2014 @8AM

Date and Time of Expiration: 6-20-2014 @2PM

Date of Reverse Typing: 06-20-2014

Reverse Typed by: GDL, RMT


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Blood Bank





Result:







Date and Time Thawed (for FFP): 6-21-2014 @9:30AM

Date and Time of Expiration: 6-21-2014 @3:30PM


Reverse Typed by: JC, RMT


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Blood Bank





Result:










Reverse Typed by: JC, RMT


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Blood Bank





Result:










Reverse Typed by: DRRA, RMT


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Blood Bank





Result:










Reverse Typed by: , GDL, RMT


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Blood Transfusion Record

Serial No: 4009-019504-0 Blood Type: B+

Doctors Name: Dr. T Room#: T310

Cross Match by: GDL, RMT

Checked by: GDL RMT

Px Name: D.D.V.R.




Date and Time Thawed (for FFP):6-20-2014 @8AM


Reverse Typed by:GDL, RMT

Collection Date: 4-30-14

Expirty Date: 6-20-2014


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Checked by: GDL RMT

Px Name: D.D.V.R.




Date and Time Thawed (for FFP):6-20-2014 @8AM






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Checked by: GDL RMT

Px Name: D.D.V.R.




Date and Time Thawed (for FFP):6-23-2014 @6:40AM






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Date: 04/26-27-28/2007 Age: 0

Name: D.D.R.V.

Philippine Heart CenterX-RAY REPORT

CHEST PORTABLE

Three (3) serial post-operative chest exam (s/p) dated April 27 to 28, 2007 shows noevidence of pneumothorax and/or pneumomediastinum.

Lungs initially show same degree of hypoascularity with slight improvement in the lastfilm.

Heart shows same degree of right ventricular prominence

Aorta remains right-sided

Mediastinum is widened due to prominent thymic shadow.

Diaphragm and bony thoracic cage are intact.

Low lying endotracheal tube and pericardial drain are noted up to the last film.

No other significant interval chest findings.


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Date: 05/02/2007 Age: 1mo/M

Name: D.D.R.V. Physician: C.M.L.

Philippine Heart CenterX-RAY REPORT

CHEST AP (PORTABLE)

Follow-up chest film since April 28 2007 shows same degree of hypovascularity.

There is same degree of right ventricular cardiomegaly.

Aorta remains right sided.

Main pulmonary artery segment is concave.

Diaphragm and bony thoracic cage are intact.

Initially placed endotracheal tube and pericardial drain were removed.

No other significant interval chest findings.


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C. Drug Study


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Indications Blalock-Taussig Operation

Cyanotic heart defects Tetralogy of Fallot congenital heart disease that is characterized by four

anomalies: ventricular septal defect, pulmonary stenosis, dextroposition

(overriding) of aorta and hypertrophy of right ventricle.

Nursing Management

Before the procedure

1. Discontinue Aspirin 14 days before the operation to decrease the risk ofexcessive bleeding. Check the medication regimen with the cardiologist becausethere may be a medical reason for the continued use of aspirin.

2. Blood typing is done prior to surgery and blood should be ready for transfusionanytime within and after surgery in cases of excessive bleeding.

3. Chest x-ray, electrocardiogram and laboratory work will be performed as apreoperative process4. Have the parents sign the informed consent.5. NPO post midnight.6. IV fluids.7. Explore feelings of anxiety of the patient (if adult and older children) and/or

childs parents (for infants and children).

After the procedure

1. Monitor patients heart rate and rhythm closely.

2. Chest x-ray is performed after the operation.3. Administer medications that reduce pain.4. Comfort measures should be done.5. Once surgical dressing is removed, the incision will remain open to air.6. Incision should be cleansed twice a day with a Betadine solution.7. Small gauze is placed over the insertion sites of chest tubes, intracardiac lines

and pacing wires.8. Prophylactic antibiotic.9. Patients with sternotomy should avoid strenuous activity that causes strain on the

chest for at least 6-8 weeks to promote healing of the breastbone.10. Avoid picking infants by arms rather scoop them to avoid straining the chest

area.11. Older children and adults should avoid contact games or sports and activitiesinvolving pushing and pulling with arms.

12. Instruct the family to observe the following after discharge and report immediatelyto the doctor if noticed:

Redness, swelling or oozing of blood from the incision Fever


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Altered mental status Feeding problems Excessive fatigue Prolonged and worsening pain

Possible Complications of Blalock-Taussig Surgery

Bleeding Infection Nerve damage (in the chest area) Need for re-operation Adverse reaction to anesthesia Brain damage Death

Balloon Atrial Septostomy

Balloon Atrial Septostomy is a technique used to enlarge a hole between theright atrium and the left atrium. It is often used to manage patients with transposition ofthe great arteries. The larger hole improves oxygenation of the blood. Balloon atrialseptostomy is also known as the Rashkind procedure.

Postoperative Care:

Ensure continuous monitoring is maintained and observations recorded halfhourly,for,the the first 2 hours , then hourly of

Cardio-respiratory status

Blood pressure

Saturations (Pre and post ductal)

Skin temperature

Keep saturations within acceptable limits (as per cardiology team). Reportimmediately any changes in baseline levels to attending physician.

Maintain ventilation as per orders.

Aim to discontinue sedation and extubate if clinically appropriate.

Review prostin infusion (as per cardiology team). Observe for signs of bleeding from access sites (umbilical or femoral). Report

excess bleeding. Apply pressure as required.

Neurovascular observations of lower limbs. Inform attending physician ofdiscolouration, coolness, and / or decreased pulses

If umbilical lines are to be used post procedure, secure in situ.Confirm position with an X-ray prior to commencing fluids.

Arterial / Capillary blood gas as ordered by attending physician.


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Ensure adequate analgesia

Note: The infant should not be in pain once the catheter is removed. Ongoingsedation is not required unless for other purposes.

Aterial Switch (Jatene Procedure)

Jatene Procedure is an open heart surgeryprocedure used to correct transposition of the greatarteries. It is also called an Arterial Switch that wasdeveloped by a Canadian cardiac surgeon WilliamMustard. The name of the procedure was from aBrazilian cardiac surgeon, Adib Jatene, who was theone to use it successfully.

Jatene procedure or arterial switch is used tocorrect transposition of the great arteries by switching

the transposed pulmonary artery and aorta. Ideally, thisprocedure is performed on an eight to fourteen (8-14)days old infant. The procedure takes about 6-8 hoursto complete, including the anesthesia and postoperative recovery. During the surgery, the aorta andpulmonary artery are both transected. Before swappingor switching the two arteries, the coronary arteries areseparated from the aorta and attached to the neo-aorta.

Laboratory Tests:

1. Blood Typing2. Angiography3. MRI4. CT scan

Procedure

Before the Procedure / Pre-operative

1. General anesthesia2. Aprotinin (prevent excessive bleeding)

3. Solumedrol (reduce swelling and inflammation)4. Regitine (prevent hypertension)5. Prophylactic antibiotics (to prevent infection)

During the Procedure / Intra-operative

1. Median sternotomy is used to view the heart and vessels.2. Heparin administration to prevent blood from clotting.


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3. For a continuous systemic and heart circulation during the operation, acardiopulmonary bypass machine is also used.

4. Since the machine needs its own circulation to be filled with blood, a bloodtransfusion is necessary to be done.

5. Aorta and pulmonary artery are both transected.

6. The coronary arteries are separated from the aorta and attached to the neo-aorta.7. Aorta and pulmonary artery are switched.

After the procedure / Post-operative

1. Chest tubes placement.2. Temporary pacemaker and ventilation.3. Muscle relaxants (induce temporary paralysis)4. Opioid analgesics (alleviate pain)5. Inotrope (assist the heart in contracting adequately)

6. Nasogatric Tube Feeding (gradually introduce breast milk or formula milk)

Documents

Final Tga Manuscript