17.6 Spotlight Application

Client Scenario

Baby Jaxon is a two-day-old male born at 38 weeks’ gestation via an uncomplicated vaginal delivery, weighing 3.2 kg. During his initial assessment, a heart murmur was noted. An echocardiogram revealed a moderate-sized ventricular septal defect. The pediatric cardiologist has advised that Jaxon be closely monitored for signs of heart failure or pulmonary hypertension.

Applying the Nursing Process

Assessment: Heart murmur audible on auscultation. Tachypnea noted with respiratory rate of 70 breaths per minute. Slight cyanosis noted around lips and extremities. Oxygen saturation is 88% on room air. Jaxon’s parents report increased crying and irritability with feeding, along with “sweating on his forehead” while feeding.

Based on the assessment information that has been gathered, the following nursing care plan is created for Jaxon.

Nursing Diagnosis: Ineffective Tissue Perfusion related to altered cardiac output secondary to VSD as manifested by slight cyanosis around lips and extremities, oxygen saturation 88% on room air, and diaphoresis, crying, and irritability while feeding.

Overall Goal: Client will have adequate tissue perfusion.

SMART Expected Outcome: Jaxon will have an oxygen saturation > 90% and resolved cyanosis during hospital stay.

Planning and Implementing Nursing Interventions: 

The nurse will closely monitor oxygen saturation using a pulse oximeter. The nurse will assess respiratory effort and monitor for signs of increased work of breathing, such as nasal flaring, grunting, or intercostal muscle retractions. The nurse will provide supplemental oxygen as needed to maintain oxygenation saturation above 90% while closely monitoring for any adverse effects of oxygen therapy such as worsening respiratory distress. The nurse will support feeding through encouraging an upright position during breast or bottle feeding and providing smaller, more frequent meals to reduce effort needed to finish a feeding. The nurse will monitor weight regularly for gains or losses and will notify the health care provider if weight loss occurs or if Jaxon is not feeding well. The nurse will teach the parents to recognize signs of respiratory distress, such as increased respiratory rate, cyanosis, or difficulty breathing. Encourage them to feed the baby slowly and rest between feeds to prevent fatigue. Instruct them to seek immediate medical help if they notice significant changes in the baby’s breathing or color.

Sample Documentation: 

Jaxon has ineffective tissue perfusion as a result of his decreased cardiac output secondary to a moderate ventricular septal defect. A care routine has been established that includes closely monitoring his oxygen saturation and respiratory status. Oxygen therapy provided today at 2 liters per nasal cannula for brief decrease in oxygen saturation to 88% while on room air, which brought oxygen saturation to 90%. Small, frequent feedings given with Jaxon positioned upright. Parents were educated about feeding techniques, signs of respiratory distress, and when to notify the provider. Parents were able to teach back the information provided. 

Evaluation: 

Baby Jaxon’s oxygen saturation remains above 90% throughout each shift with appropriate interventions. He demonstrates stable weight gain after one week, with no further signs of feeding intolerance or respiratory distress. Jaxon’s parents verbalize understanding of the condition, feeding techniques, and signs of distress. SMART outcomes “met.”