Young Infant with Tetralogy of Fallot Defect

Jake is a 6 week old male infant hospitalized with the diagnosis of Tetralogy of Fallot (TOF). He was seen at the pediatrician’s office because Jake’s mother was worried that he was not gaining weight and was having difficulty sucking on the bottle during feedings. He is admitted with a diagnosis of TOF and CHF.

1. You are the admitting nurse and do a complete physical assessment on Jake. The following are your findings. Please explain if these are expected or unexpected and why.

Assessment findings:

Apical pulse: 165; Respiratory rate: 66; Lung sounds/respiratory rate, effort, Accessory muscle use status; Heart sounds: gallop rhythm; Weak suck; Capillary refill longer than three seconds; Weight: 3.1kg.

2. You implement care interventions to improve cardiovascular functioning. Provide a rationale for the following care interventions that are incorporated into Jake’s plan of care and are shared with his parents:

a.      Anticipate needs to limit crying

b.      Plan morning care using the cluster care approach

c.      Digoxin 16mcg PO b.i.d. Hold if apical heart rate is less than 110 beats per minute

d.      Simi-Fowler position with the head of the bed at a 30 to 45 degree angle

e.      Daily weights on scale #2 at 7 A.M.

f.       Oral feeding every 3 hours using a large-hole nipple with the child in an upright position. (If complete volume of feed has not been taken in fifteen minutes, administer the remaining volumes of the formula via nasogastric tube over fifteen minutes).

g.      Strict hand washing

h.      Temperature assessment and clothing to maintain infant’s baseline temperature.

3. You enter Jake’s room and find him to have circumoral cyanosis, a sweaty forehead, and a heart rate of 260 beats/minute, and he is limp. Describe your nursing actions beginning with most important to ensure Jake’s physical safety.