Ventral Septal Defect SKINNY Reasoning

Ventral Septal Defect SKINNY Reasoning Mandy Gray, 2 months old NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment Management of Care 17-23% Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% Psychosocial Integrity 6-12% Physiological Integrity Basic Care and Comfort 6-12% Pharmacological and Parenteral Therapies 12-18% Reduction of Risk Potential 9-15% Physiological Adaptation 11-17% Part I: Recognizing RELEVANT Clinical Data History of Present Problem: Mandy Gray is a two-month-old infant born with a large ventricular septal defect (VSD) that was diagnosed by her pediatrician during her two-week infant check-up. The parents called her pediatric cardiology clinic because Mandy was breathing faster and showed signs of increased work of breathing. Her mother states that she is having difficulty nursing because she tires easily and then becomes fussy and cries because she is hungry. Her height and weight are below the 25th percentile (wt: 4.5 kg. ht: 54 cm). Her Mom reports that Mandy’s weight has increased by 8 ounces (240 g) in the last 24 hours. Her pediatric cardiologist is concerned about worsening heart failure and Mancy will be admitted with a diagnosis of acute heart failure. Personal/Social History: Mandy is the first child of Jim and Jessica who were married two years ago. They were both raised in the Catholic faith but are not active in the church. Both parents seem anxious about their infant daughter but express hopefulness about the surgery to correct the problem. The surgery is scheduled in four months. Her mother is an RN who works in a dermatology clinic. Since Mandy’s birth, her mother has stayed home to care for Mandy because she is too medically fragile to be cared for in a daycare setting. Both of Jim’s parents are deceased, and Jessica’s parents live in another state. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) Patient Care Begins: Current VS: FLACC Behavioral Pain Assessment Scale: T: 99.4 F/37.5 C (temporal) Face: 1 P: 210/min (regular) Legs: 0 R: 74/min Activity: 0 BP: 70/45 MAP: 50 Cry: 1 O2 sat: 90% on RA Consolability: 0 What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance)