17.6 Spotlight Application

This spotlight activity will demonstrate how a nurse applies the nursing process and clinical judgment model when providing care to a newborn with a congenital heart defect.

Situation/Background

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.

The nurse applies the nursing process and develops a nursing care plan for Jaxon.

Assessment:

The nurse collects the following assessment data:

• 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 data, the nurse creates a nursing care plan 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:  The client will have adequate tissue perfusion.

SMART Expected Outcomes:

• The client will have an oxygen saturation greater than 90% with no cyanosis during the course of the hospital stay.
• The client will demonstrate stable weight gain within one week, with no further signs of feeding intolerance or respiratory distress.
• The client’s parents will verbalize understanding of the client’s medical condition, feeding techniques, and signs of distress to immediately report to the health care provider.

Planning and Implementing Nursing Interventions: 

The nurse plans and implements the following nursing interventions:

• Closely monitor oxygen saturation, respiratory effort and signs of increased work of breathing, such as nasal flaring, grunting, or intercostal muscle retractions.
• 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.
• Support feeding by encouraging an upright position during breast or bottle feeding and providing smaller, more frequent meals to reduce effort needed to finish a feeding. Notify the health care provider if Jaxon is not feeding well.
• Monitor weight during the hospitalization for weight gain or loss and notify the health care provider of significant changes.
• Teach the parents to recognize signs of respiratory distress, such as increased respiratory rate, cyanosis, or difficulty breathing. Encourage them to feed Jaxon slowly and to promote rest between feedings to prevent fatigue. Instruct them to seek immediate medical help if they notice significant changes in Jaxon’s breathing or color.

Evaluation:

The nurse evaluates the client’s progress toward established outcome criteria during every interaction. The following data was collected: Jaxon’s oxygen saturation remained above 90% throughout the shift with appropriate nursing interventions. He demonstrated 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. The nurse determines the expected outcomes were “met.”

Sample Nursing 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.