Final Tga Manuscript

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

Sto. Nio, Bian, Laguna
COLLEGE OF NURSING
A.Y. : 2014 2015 1
st
SEMESTER

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
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..5
2. Past Health History....5
3. Family History of Illnesses..5
a. Maternal...5
b. Paternal5
4. Vaccination..5
5. Position in the Family6

IV. Nursing Assessment7-13
a. Gordons 11 Functional Health Pattern7-10
b. Physical Assessment (Cephalo-Caudal Assessment)..11-13

V. Anatomy and Physiology14-15

VI. Pathophysiology16

VII. Medical Management.17-48

a. Doctors Order17-24
b. 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


I. Introduction

Transposition of the great arteries (TGA), also referred to as complete
transposition, is a congenital cardiac malformation characterized by atrioventricular
concordance and ventriculo-arterial (VA) discordance. TGA is associated with non-
cardiac malformations. The association with other cardiac malformations such as
ventricular septal defect (VSD) and left ventricular outflow tract obstruction is frequent
and dictates timing and clinical presentation, which consists of cyanosis with or without
congestive heart failure. The onset and severity depend on anatomical and functional
variants that influence the degree of mixing between the two circulations. If no
obstructive lesions are present and there is a large VSD, cyanosis may go undetected
and only be perceived during episodes of crying or agitation. In these cases, signs of
congestive heart failure prevail. The exact etiology remains unknown. 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. Mutations in growth differentiation factor-1
gene, the thyroid hormone receptor-associated protein-2 gene and the gene encoding
the cryptic protein have been shown implicated in discordant VA connections, but they
explain only a small minority of TGA cases. Newborns with transposition of the great
arteries are usually well developed, without dysmorphic features. Physical findings at
presentation depend on the presence of associated lesions. The diagnosis is confirmed
by echocardiography, which also provides the morphological details required for future
surgical management. Prenatal diagnosis by fetal echocardiography is possible and
desirable, as it may improve the early neonatal management and reduce morbidity and
mortality. Differential diagnosis includes other causes of central neonatal cyanosis.
Palliative treatment with prostaglandin E1 and balloon atrial septostomy are usually
required soon after birth. Surgical correction is performed at a later stage. Usually, the
Jatene arterial switch operation is the procedure of choice. Whenever this operation is
not 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 congenital
heart disease in the newborn.

This lesion presents in 5-7% of all patients with
congenital 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. This
congenital heart defect is more common in infants of diabetic mothers. The hearts with
atrioventricular concordance and ventriculo-arterial discordance represent 57% of all
congenital heart diseases, corresponding to an incidence of 20 to 30 per 100,000 live
births. There is a male predominance with a male/female sex ratio that varies, in the
literature, from 1.5:1 to 3.2:1. TGA has a 60-70% male predominance. No racial
predilection is known. Patients with TGA usually present with cyanosis in the newborn
period, but clinical manifestations and courses are influenced predominantly by the

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

Long-term complications are secondary to prolonged cyanosis and include
polycythemia and hyperviscosity syndrome. These patients may develop headache,
decreased exercise tolerance, and stroke. Thrombocytopenia is common in patients
with cyanotic congenital heart disease leading to bleeding complications. Patients with
a large ventricular septal defect, a patent ductus arteriosus, or both may have an early
predilection for congestive heart failure, as pulmonary vascular resistance falls with
increasing age. Heart failure may be mitigated in those patients with left ventricular
outflow tract (pulmonary) stenosis. A small percentage (approximately 5%) of patients
with transposition of the great arteries (and often a ventricular septal defect) develop
accelerated pulmonary vascular obstructive disease and progressive cyanosis despite
surgical repair or palliation. The mortality rate in untreated patients is approximately
30% in the first week, 50% in the first month, and 90% by the end of the first year. With
improved diagnostic, medical, and surgical techniques, the overall short-term and
midterm survival rate exceeds 90%. Long-term survival in this subgroup is particularly
poor. With the advent of newer and improved surgical techniques and post-operative
intensive care, the long-term survival is approximately 90% at 15 years of age.
However, the exercise performance, cognitive function and quality of life may be
impaired.


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 frontal
headache

FINAL DIAGNOSIS : Congenital Heart Disease, Cyanotic
Type, Hypersensitivity Syndrome,
Secondary to Transposition of Great
Vessels


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 and
periorbital 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 vaginal
delivery to a G
2
P
2
mother, who suffered from gestational diabetes. He was declared a
well-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 pediatrician
detected a murmur upon assessment. The patient also exhibited a hoarse sound
whenever crying. A series of diagnostic tests such as 2D-echocardiogram,
electrocardiogram were performed which led to the confirmation that the patient is
suffering 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 of
palliative treatment. October 2013, at the Philippine General Hospital, the patient
underwent phlebotomy, due to elevated hematocrit levels as a result of
thrombocytopenia. It was then repeated three months after, last January 2014 at the
same institution. In both cases, 100cc of blood was drawn. The last phlebotomy
treatment was done in the University of Perpetual Help Dr. Jose G. Tamayo Medical
Center. Blood was drawn in four sessions, where 160cc was aspirated on each
session.

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.


5. Position in the Family

The patient is the second child in a brood of 3 from a 35-year old mother and
father. The eldest sibling is reported to have a case of asthma and the youngest with
no reported illness.


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 of
great arteries when he was two weeks old. He underwent an emergency Blalock-
Taussig hunt operation during his 22
nd
day of life because of severe cyanosis. After the
operation, the patient was transferred to recovery room for close monitoring hooked to
inotropes and ventilator. On the first post operation day, the patients condition
improved and was extubated. On the second post operation day, the patient was
transferred to pediatric intensive care unit still on close monitoring. Eventually, the
patient 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 doing
this until present. He has complete immunization record according to age. BCG and
Hepa 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, and
reports 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 to
participate in the assessment, but he rarely spoke, so all the necessary information for
the 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 only
eats chicken and eggs with an approximate 5 spoonfulls of rice. He only drinks Milo, a
chocolate 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 as
supplement 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 foods
became lesser due to appetite loss because of his condition.


Elimination

Prior to Admission

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


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

Activity Exercise

Prior to Admission

The patient has minimal activity due to easy fatigability. He was enrolled at
nursery school but eventually stopped school for he was unable to sustain energy at the
course of the class. He would complain of fatigue, and would ask to be sent home. His
typical day would be to sit in front of the computer and play video games. He has a
tablet, where he would play puzzle games, and basketball games. He also likes to
listen to music, especially Justin Bieber. He also likes watching cartoons on Disney
channel, as well as nickelodeon. If he gets bored doing these, he would sleep and
wake up again to do the same routine. He seldom plays outside, and would just sit and
relax 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 NBA
2014 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 young
age, he is able to understand what is happening to him, as his parents would explain his
status.



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 feels
regarding the therapy, and would react on situation a child his age would given the
circumstance.

Sleep / Rest Pattern

Prior to Admission

Due to easy fatigability, the patient would always take naps during the day
whenever 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 hours
would 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 the
nurses would check up on him every now and then. His mother reported a shortened
sleeping and resting period. His mother would try to put him to sleep, but he would
wake 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 the
school age group, where there is industry versus inferiority. In this age group, Children
need to cope with new social and academic demands. Success leads to a sense of
competence, while failure results in feelings of inferiority. During middle childhood
between the ages of about six and eleven, children enter the psychosocial stage known
as industry versus inferiority. As children engage in social interaction with friends and
academic activities at school, they begin to develop a sense of pride and
accomplishment in their work and abilities. Children who are praised and encouraged
develop a sense of competence, while those who are discouraged are left with a sense
of inferiority.

Since the patient is unable to go to school, when children his age are, he feels
inferior given the fact of his condition. His mother reported that he would sometimes
voice out that he would want to go to school once he finishes his hospital field trip and
play with his classmates. He would also gain happiness whenever he would achieve
little accomplishments such as winning certain games over the internet and in his
gadgets.

Role Relationship

Since the patient is a middle child, he would sometimes be the baby to his
eldest 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 stuff
that he has difficulty reaching due to his height. His mother also reported that he would
play with his baby sister, show her games that he perceives she would enjoy, and he is
said to be malambing all the time to the members of his immediate family especially to
his mother. He has a special bond with her due to the fact that his mother is the one
who accompanies him whenever he has his hospital field trip.

Sexuality Reproductive

The patient would play with video games designed for male children, specifically
NBA 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 be
assessed especially that his phlebotomy site was done on his inguinal area. He would
cover 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 it
a 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 done
because according to his mom, he feels pain whenever blood was being drawn. He
would complain about the procedure and would even compare how he liked his
treatment better from the previous hospital he went for treatment due to the fact that he
was used to the health care providers over there who took care of him.

Value Belief

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


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

Day of Assessment: June 24, 2014
Observer: Student Nurse
Informant: Mother
Vital Signs during assessment:

Temperature: 36.9
o
C
Heart Rate: 110 bpm
Respiratory Rate: 24 cpm

Head
Area/Procedure Normal Findings Actual Findings Analysis
Skin Pinkish Pale, cold to
touch
Cyanosis is seen in
the 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 the
systemic circulation.

Eyes Pinkish
Conjunctiva
Pale Conjunctiva
Buccal Mucosa Pinkish Cyanotic
Trunk
Skin Turgor Instant return Slow return (>3
seconds)
Result of dehydration and
poor oxygenation of the
blood.
Skin Color,
Temperature
Pinkish, warm to
touch
Pale to cyanotic,
there is hematoma
on the inguinal
area where the
phlebotomy site is
located. Skin is
slightly cold to
touch
A hematoma is a blood
clot which forms within
the body. It is caused by
leakage of blood into the
tissues from an injured
vein . It will resolve
spontaneously.
Hematomas are caused
by excessive needle
trauma to a vein, for
example, by a needle
which passed entirely

through a vein and came
out the other side.
Upper Extremities
Skin Pinkish, warm to
touch
Pale to cyanotic,
there is
hematoma on the
right arm where
the first
phlebotomy site
is located, skin
slightly cold to
touch.
A hematoma is a blood clot
which forms within the
body. It is caused by
leakage of blood into the
tissues from an injured
vein . It will resolve
spontaneously.
Hematomas are caused by
excessive needle trauma
to a vein, for example, by a
needle which passed
entirely through a vein and
came out the other side.
Fingers Pinkish nailbeds
without
curvature, and
capillary refill of
(<2seconds)
Pale nailbeds
with clubbing of
nailbeds,
decreased
capillary refill (>3
seconds)
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
congestive heart 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

nail beds. Clubbing of
fingernails is frequent in
congenital heart
disease as a result of
chronic deficient
oxygenation of the blood.
Lower Extremities
Skin Pinkish, warm to
touch
Pale, slightly cold
to 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
congestive heart 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.


V. Anatomy and Physiology

A child's heart is the center of their
cardiovascular system. A normal heart is
strong, 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 the
heart is controlled by four heart valves. The valves open and close as the blood is
pumped 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 through
the 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.


Cardiac Cycle
Blood flows through the heart in one direction only. It is prevented from backing
up by a series of valves at various openings: the tricuspid valve between the right atrium
and 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. Each
heartbeat, or cardiac cycle, is divided into two phases. In the first phase, a short period
of ventricular contraction known as the systole, the tricuspid and mitral valves snap
shut, producing the familiar "lub" sound heard in the physician's stethoscope. In the
second 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, only
one systole and one diastole are felt. The normal heart has a rate of 72 beats per
minute, but in infants the rate may be as high as 120 beats, and in children about 90
beats, per minute. Each heartbeat is stimulated by an electrical impulse that originates
in a small strip of heart tissue known as the sinoatrial (S-A) node, or pacemaker.


VI. Pathophysiology

Modifiable Factors:
-Mother has gestational diabetes

Non-modifiable Factors:
-Idiopathic
-Age
-G2P2
Transposition of the
Great Arteries
(TGA)
Malposition of the
great arteries
VSD, PDA, ASD
Blood goes to the lungs, picks up
oxygen, returns to the heart, and
then flows right back to the lungs
without going to the body
Murmur
Blood from the body returns to the
heart 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

VII. Medical Management
A. Doctors Order

Date

Doctors Order

Analysis
June 19, 2014
12:00nn
Referral to Dr.L

For Collaborative Management

4:00 PM Continue Management

For continuity of care
Continue IV hydration For rehydration and correction of
electrolyte imbalance

Phlebotomy tomorrow on
call

Done as part of the patient's treatment for
increased levels of hematocrit
- Please prepare
the following
materials

3 way stopcock
(heplock)
Butterfly needle
syringe
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 of
phlebotomy

- Secure Fresh
frozen plasma
To replace blood loss


130cc type
specific 2 bags
For blood transfusion
and 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 or
10am tomorrow

Give midazolan mg
through IV prior to
phlebotomy

For short-term sedation
Please provide a
treatment room for the
phlebotomy
For patients safety and privacy
Continue vital signs
monitoring blood
pressure

For baseline data

Refer

IVF to follow D5.03
NaCl 1Lx80cc/hr
For rehydration and correct electrolyte
imbalance

Please prepare
materials needed for
phlebotomy

For easy accessibility and will save time
for the procedure. For efficiency.
Refer For collaborative management
June 20, 2014
6:20 AM
Please thaw fresh
frozen plasma at
7:30am

Fresh frozen plasma is thawed to prevent
chills during transfusion, it is transfused to
replace blood lost during the procedure
Transfuse 80cc at fresh
frozen plasma at
8:30am for 30mins

Transfused regulated as fast drip
Prepare material
needed for phlebotomy

Refer

10:10 AM Post Phlebotomy Order:

Diet as tolerated when
fully awake

To replenish and nourish the patient after
procedure
Repeat complete blood
count with platelet
tomorrow at 8am if
hematocrit is 0.65 and
above for repeat
phlebotomy

For monitoring hematocrit level,
monitoring signs of bleeding
Check the punctured
site for signs of bleeding

To monitor bleeding tendencies
Monitor vital signs q
15minutes for 2hrs then
q 1hr then after

To be able to monitor any complications
from the procedure
Resume IVF at 0-
81cc/hr

For rehydration and correction of

Maintain O2 till fully
awake then discontinue

To compensate for oxygen loss and
maintain optimum oxygen saturation
Inform Attending
physician

For further management
10:20 AM Dr. T updated

Refer
June 21, 2014
7:10 AM
Please do Complete
blood count with platelet
now

To monitor hematocrit levels
IVF to follow D5.03NaCl
50cc at 80-81cc/hr

For rehydration and correction of

8:45 AM For phlebotomy now

Please thaw fresh
frozen plasma now

Transfuse 50cc of fresh
frozen plasma then run
remaining 50cc while on
going phlebotomy


Please prepare
materials for
phlebotomy

Please provide
treatment room for the
procedure

Give midazolan 4mg
through IV prior to the
procedure

Refer

11:18 AM Post Phlebotomy

Diet as tolerated when
fully awake

Repeat complete blood
count with platelet at
4am from (6/22/14)

Prepare 2 units of
fresh frozen plasma
type specific if
hematocrit is 0.65 will
repeat phlebotomy

Repeat material for
possible management
phlebotomy

Check the puncture site
for bleeding

1L at 80cc/hr

3:30 PM Monitor Vital signs q
15minutes till stable
then q 1hr

Refer


June 22, 2014
2:00 AM
1Lx80cc/hr

5:00 AM IVF to follow D5.03NaCl
1Lx80cc/hr

7:30 AM Prepare materials for
possible repeat
phlebotomy today

Prepare 2units fresh
frozen plasma type
specific

Dr. L updated
For phlebotomy today at
8am

Please thaw fresh frozen
plasma now

frozen plasma then run
remaining 50cc while
ongoing phlebotomy

Please prepare materials
for phlebotomy

Please provide treatment
room for the procedure

Refer

10:42 AM Post Phlebotomy Order:

Diet as tolerated once
fully awake

For repeat complete
blood count with platelet
tomorrow (6/23/14) at
4am

Prepare 2units of fresh
frozen plasma type
specific if hematocrit is


0.65 with repeat
phlebotomy
Prepare materials for
possible repeat
phlebotomy


1L at 80cc/hr

Monitor vital signs q
q 1hr

Refer

2:00 PM Continue present
management

6:20 PM Facilitate repeat
complete blood count
with PC (6/23/14 at 4am)
and relay once clot result

June 23, 2014
5:20 AM
Please prepare materials
for phlebotomy today

Prepare 1 unit fresh
frozen plasma type
specific

1L to run for at 80cc/hr

6:30 AM
Dr. L updated

For phlebotomy today at
7:30am

Please thaw fresh frozen
plasma now


frozen plasma at 7am
then remaining while
ongoing phlebotomy

Provide treatment room
for the procedure

Give medazolan 4mg
through IV prior to the
procedure

8:45 AM Post Phlebotomy

Diet as tolerated once full
awake

For repeat CBC with
platelet tomorrow 6/24/14
at 4am

Prepare 2units of fresh
frozen plasma type
specific if hematocrit is
0.65 will repeat
phlebotomy


1L at 80cc/hr

Monitor vital signs every
every hour

Refer

management

4:45 PM Please prepare clinical
abstract

management


June 24, 2014
4:30 AM
Continue with present
management

Refer

6:40 AM Rounds of Dr. L.

May go home

Please provide clinical
abstract checked by
ROD

Follow up with attending
physician after two
weeks at Medical Arts.

Home meds:

Multivitamins (Restor)
1tsp OD

Refer


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: 1.025
Reaction (pH): 5.5 Pus Cells: 1-2/HPF
Protein: Trace RBC: 0-1/HPF
Mucus Threads: Moderate


LABORATORY REPORT

Name: D.D.R.V. Age: 6 Sex: M Date Requested: 01/08/2014
Dept./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 blood
cell count and a white blood
cell shift in the differential
raise the suspicion of a
systemic infection
RBC Count 4.6 - 6.2 7.50 x10^12/L
High RBCs may indicate
low blood oxygen levels
Hemoglobin
120 - 150

210 g/L
High hemoglobin is usually
due to an increased
number or abnormality of
red blood cells
Hematocrit
0.40 - 0.54

0.692
A high hematocrit can result
in increased blood viscosity,
which can lead to
spontaneous thrombosis
and resultant cerebral,
renal, or pulmonary
infarctions
MCV 30 - 96
92.3 fL

MCH 27 - 31 28 pg
MCHC 320 - 350 304 g/L
A low level may indicate
blood loss over time,too
little iron in the body or
hypochromic anemia

RDW 11 16 14.5
Platelet Count 150 - 450 134 x10g/L
The body may be
destroying too may
platelets or the bone
marrow is not producing
enough platelets.
DIFFERENTIAL COUNT:
Neutrophils 0.50 0.70 0.73
There may be damage or
inflammation of tissues or
high levels of stress
placed on the body.
Lymphocytes 0.20 - 0.50 0.17
Low lymphocyte count
indicates that the body is
low on infection resistance
Monocytes 0.02 0.08 0.08
Basophils 0.00 0.02 0.02


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 0.40 0.54 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 4 5.6 7.32 x10^12/L
WBC Count 5.0 10.0 5.39 x10^9/L
Segmenters 0.50 0.70 0.43
A low count indicates a
reduction in either the
number or the size of red
blood cells.
Lymphocytes 0.20 0.40 0.43
An increase in lymphocyte
concentration is usually a
sign of a viral infection
Monocytes 0 0.05 0.07
Monocytes elevated may
suggest inflammation
present

Eosinophils
0 0.04 0.04
Presence of inflammation
or there may be infection

Basophiles
0 0.01 0.03
There may be a presence
of inflammation or there
may be infection.

MCV 80 - 98 105 fl
Indicates large average
RBC size
MCH 26 - 32 31.7 pg

MCHC
320 - 360 303 g/L
fast or there is little iron in
the body or hypochromic
anemia

Platelet Count
150 400 130 x10/L
The body may be
destroying too may
platelets or the bone
marrow is not producing
enough platelets.

RDW
11 - 15 13.4 %


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
viscosity, which can lead
to spontaneous
thrombosis and resultant
cerebral, renal, or
pulmonary infarctions
RBC Count 6.61 x10^12/L 4 5.6
WBC Count 8.36 x10^9/L 5.0 10.0
blood cells.

Low platelet count may
decrease if the bone
marrow does not produce
enough platelets.
Monocytes 0.08 0 0.05

present

Eosinophils
0.04 0 0.04
Basophiles 0.02 0 0.01
There may be a
presence of inflammation
or there may be infection.
MCV 105 fl 80 - 98
RBC size
MCH 32.4 pg 26 - 32
There may be a thyroid
malfunction or there is a
deficiency of Vitamin B12

MCHC
310 g/L 320 - 360
fast or there is little iron
in the body or
hypochromic anemia

Platelet Count
128 x10/L 150 400
enough

RDW
13.2 % 11 - 15


LABORATORY REPORT

HEMATOLOGY
High hemoglobin is
usually due to an
increased number or
cells
to spontaneous
cerebral, renal, or
RBC Count 4 5.6 6.41 x10^12/L
WBC Count 5.0 10.0 7.43 x10^9/L
blood cells.
An increase in
lymphocyte concentration
is usually a sign of a viral
infection
present

Eosinophils

0 0.04 0.07
Basophiles 0 0.01 0.02
There may be a
MCV 80 - 98 103 fl
RBC size
MCH 26 - 32 31.2 pg

MCHC
320 - 360 302 g/L
in the body or
hypochromic anemia

Platelet Count
150 400 130 x10/L
enough platelets.

RDW
11 - 15 12.8 %


LABORATORY REPORT

HEMATOLOGY
High hemoglobin is
usually due to an
increased number or
cells
to spontaneous
cerebral, renal, or
RBC Count 4 5.6 5.78 x10^12/L
WBC Count 5.0 10.0 7.17 x10^9/L
blood cells.
An increase in
lymphocyte concentration
is usually a sign of a viral
infection
present

Eosinophils

0 0.04 0.07
Basophils 0 0.01 0.03
There may be a
MCV 80 - 98 104 fl
RBC size
MCH 26 - 32 31.8 pg

MCHC
320 - 360 305 g/L
in the body or
hypochromic anemia

Platelet Count
150 400 144 x10/L
enough platelets.

RDW
11 - 15 13.2 %


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


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


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


Blood Bank


Result:


Reverse Typed by: JC, RMT


Blood Bank


Result:


Reverse Typed by: DRRA, RMT


Blood Bank


Result:


Reverse Typed by: , GDL, RMT


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.

Collection Date: 4-30-14
Expirty Date: 6-20-2014



Checked by: GDL RMT

Px Name: D.D.V.R.




Checked by: GDL RMT

Px Name: D.D.V.R.



Date: 04/26-27-28/2007 Age: 0
Name: D.D.R.V.
Philippine Heart Center
X-RAY REPORT

CHEST PORTABLE

Three (3) serial post-operative chest exam (s/p) dated April 27 to 28, 2007 shows no
evidence of pneumothorax and/or pneumomediastinum.

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

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.


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

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

Philippine Heart Center
X-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.


C. Drug Study


VII. Auxillary Reports
Phlebotomy

Phlebotomyis the act of drawing or removing blood from the circulatory system th
rough a cut (incision) or puncture in order to obtain a sample for analysis and diagnosis.
Phlebotomy is also done as part of the patient's treatment for certain blood disorders.

Nursing Management

Pre-op care for phlebotomy

Secure consent
Instruct patient/relative of the procedure
Drink fluids to replace the fluid that will be removed.
Take note of the heart rate
Start the intravenous (IV) tube in arm
Instruct the patient to lay down, sitting on their bed or sitting in a chair with arms
so they dont injure themselves if they lose consciousness and fall.
The patient should not be eating, drinking or chewing gum while the phlebotomy
procedure is performed.
Prepare necessary apparatus for the procedure (cardiac monitor, pulse oximeter,
oxygen tank)
Thaw fresh frozen plasma in room temperature wrapped in a towel or blanket for
30 minutes.
Make sure to do blood typing/rh typing and cross matching
Prepare necessary materials for the procedure:

3-way stopcock extension
Butterfly needle
Drainage bottle
10cc syringe
Dressing tray
Sterile gauze
micropore

During Phlebotomy

Patient should be hooked to a cardiac monitor, pulse oximeter, and should be
administered oxygen via face mask regulated at 4-7 liters per minute.
Assist doctor during the procedure, taking note of the amount of blood being
drawn from the patient.
Monitor vital signs every 15 minutes during the treatment
Monitor oxygen saturation


Post-op care for phlebotomy

Apply firm pressure to the phlebotomy access (brachial artery/femoral artery) for
a full 5 minutes if brachial artery, and full 10 minutes if femoral artery.
Limit any strenuous exercise of the arm used for the procedure for 24 hours after
phlebotomy.
Encourage patient to eat.
If you feel faint while standing, lie or sit down with your head between your knees
for a few minutes. Change positions slowly to limit dizziness.
Do not remove the bandage at the phlebotomy site for at least 12 hours after the
procedure.
If there is active bleeding from the phlebotomy site, apply pressure for at least 15
minutes.
Check dressing and phlebotomy site for any untoward signs and symptoms
Monitor for possible complications of phlebotomy (embolism)

Blalock-Taussig Shunting

Blalock-Taussig operation (also called Blalock-Thomas-Taussig shunt) is a
palliative surgical procedure used in cyanotic heart defects. More specifically it is used
for the palliative repair of blue babies or those infants diagnosed with Tetralogy of Fallot
(TOF). In this procedure the blood flow is directed to the lungs to relive cyanosis while
the infant is waiting for the corrective surgery.
Children with TOF and other cyanotic defects have problems with oxygenation.
Cyanosis develops as a result of low oxygen levels in the blood. Placement of a blalock-
taussig shunt alleviate symptoms of poor oxygenation (e.g. cyanosis) which is done by
anastomosing the subclavian artery to the pulmonary artery (bypassing the stenosed
pulmonary artery) so that part of hypoxemic blood in the aorta will be oxygenated in the
lungs.
The procedure was named after Alfred Blalock, a surgeon and Helen B. Taussig,
a cardiologist. The procedure was developed by the two physicians together with
Blalocks laboratory technician Vivien Thomas. Taussig (cardiologist) observed that
children with cyanotic heart defect and patent ductus arteriosus (PDA) live longer than
those without PDA. The cardiologist then formulated a theory that placement of a shunt
mimicking the function of PDA might provide relief for tetralogy of fallots problem on
oxygenation. Dr. Taussig approached Dr. Blalock and Thomas in their laboratory. After
meeting with Taussig the two men set about perfecting the procedure on animals which
later on they performed on infants. This operation was first done on November 29, 1944
at the Johns Hopkins Hospital in Baltimore and is a major landmark in the history of
childrens heart surgery.


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 of
excessive bleeding. Check the medication regimen with the cardiologist because
there 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 transfusion
anytime within and after surgery in cases of excessive bleeding.
3. Chest x-ray, electrocardiogram and laboratory work will be performed as a
preoperative process
4. 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 activities
involving pushing and pulling with arms.
12. Instruct the family to observe the following after discharge and report immediately
to the doctor if noticed:
Redness, swelling or oozing of blood from the incision
Fever

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 the
right atrium and the left atrium. It is often used to manage patients with transposition of
the great arteries. The larger hole improves oxygenation of the blood. Balloon atrial
septostomy is also known as the Rashkind procedure.

Postoperative Care:
Ensure continuous monitoring is maintained and observations recorded half
hourly,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). Report
immediately 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 of
discolouration, 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.

Ensure adequate analgesia
Note: The infant should not be in pain once the catheter is removed. Ongoing
sedation is not required unless for other purposes.

Aterial Switch (Jatene Procedure)

Jatene Procedure is an open heart surgery
procedure used to correct transposition of the great
arteries. It is also called an Arterial Switch that was
developed by a Canadian cardiac surgeon William
Mustard. The name of the procedure was from a
Brazilian cardiac surgeon, Adib Jatene, who was the
one to use it successfully.

Jatene procedure or arterial switch is used to
correct transposition of the great arteries by switching
the transposed pulmonary artery and aorta. Ideally, this
procedure is performed on an eight to fourteen (8-14)
days old infant. The procedure takes about 6-8 hours
to complete, including the anesthesia and post
operative recovery. During the surgery, the aorta and
pulmonary artery are both transected. Before swapping
or switching the two arteries, the coronary arteries are
separated from the aorta and attached to the neo-aorta.

Laboratory Tests:

1. Blood Typing
2. Angiography
3. MRI
4. CT scan
Procedure

Before the Procedure / Pre-operative
1. General anesthesia
2. 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.

3. For a continuous systemic and heart circulation during the operation, a
cardiopulmonary bypass machine is also used.
4. Since the machine needs its own circulation to be filled with blood, a blood
transfusion 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)

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