Case Study: Ventral Septal Defect (VSD) in Mandy Gray, 2 Months Old

This assignment presents a case study of Mandy Gray, a 2-month-old infant diagnosed with a large ventricular septal defect (VSD). The case unfolds through the patient's history, including presenting problems like difficulty breathing and feeding, along with relevant social and family history. The assignment delves into interpreting clinical data, including vital signs, physical assessments, cardiac telemetry, radiology reports, and lab results. The student is tasked with identifying the primary problem, which is related to perfusion and gas exchange, and developing a plan of care, including medical management with rationales and expected outcomes for prescribed medications such as Furosemide, Captopril, and Digoxin. The assignment emphasizes clinical reasoning, nursing interventions, and patient education within the context of a pediatric patient experiencing acute heart failure due to a congenital heart defect.

Ventral Septal Defect
UNFOLDING Reasoning
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
• Gas Exchange
• Clinical Judgment
• Patient Education
• Communication
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% ✓
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
Mandy Gray, 2 months old

✓ Physiological Adaptation 11-17% ✓
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)
RELEVANT Data from Present Problem: Clinical Significance:
a. Breaths faster
b. Difficulty in breathing
c. Gets tired easily
d. Becomes precious and cries
e. Gained only 8 ounces and below
25% than normal weight
Ventricular septal defect (VSD) means a small hole in heart. In VSD
oxygenated blood gets mixed with deoxygenated blood making the heart
to work harder to supply oxygen o the tissues present in Mandy’s body
(Bhatla et al. 2017). Therefore, she is having difficulty in breathing.
While eating the infant feels difficulty in breathing, hence do not eat
however feels hungry and try. As the baby is not eating does not gain
weight.
RELEVANT Data from Social History: Clinical Significance:
Mandy is having surgery in 4 months Doctor does an incision in the chest wall and heart-lung machine is
maintained for blood circulation. The doctor closes the hole by stitching
or by applying some surgical material. Slowly, the heart tissue heals and
after 6 months of surgery Mandy’s heart hole will heal completely (Deri
and English 2018).
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)
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

RELEVANT VS Data: Clinical Significance:
P, R, BP, O2 sat
The pulse rate (P) and the respiration is higher than normal as the baby is having
difficulty in breathing and her heart is not working due to mix of oxygenated and
deoxygenated blood (Jortveit et al. 2016). The increase in pulse rate occurs and
hence, due to less supply of oxygen (O2 sat) to the tissues, Mandy feels difficulty in
breathing (R). As Mandy is having heart disease her systolic pressure(BP) is lower
than the normal range (72-102)
Current Assessment:
GENERAL
APPEARANCE:
Pale in color, quiet while in mother’s arms. Working moderately hard to breathe and appears
tired with eyes closing but startles awake with loud sounds or voice
RESP: Fine crackles at bases bilaterally. Grunting noted with expirations and mild to moderate sub-
costal retractions and slight nasal flaring
CARDIAC: Pallor noted at face and trunk; capillary refill is greater than 2 seconds. Grade 3/6
holosystolic murmur heard at 3rd, 4th, 5th intercostal space at the left sternal border. Apical
heart rate is rapid and peripheral pulses are equal, weak but palpable, lower extremities 1+
pitting edema
NEURO: Awake but appears tired. Responds to mother and father appropriately with an occasional
smile.
GI: Abdomen rounded, soft and non-tender, hepatosplenomegaly present, bowel sounds audible
GU: Per Mom, has only had one wet diaper today
SKIN: Skin integrity intact, skin turgor elastic
What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Health Promotion & Maintenance)
RELEVANT Assessment Data: Clinical Significance:
Pale in color, respiration, cardiac, GU The general, cardiac and respiratory assessment states that due a hole in
ventricular wall, Mandy is suffering and showing all these symptoms. The
level of oxygen is low in her blood, hence RBC count decreases causing
anemia and turning her skin pale. Moreover, she is not eating or drinking
therefore there is only wet diaper used whole day (Egbe et al. 2015). Even
the assessment showed that Mandy produces grunting sound while
expiration because of the difficulty she is having in breathing. As she is not
eating or drinking she is not getting energy and therefore she is often tired.
Cardiac Telemetry Strip:
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Regular/Irregular: P wave present? Yes/Irregular PR: Irregular QRS: Irregular (Tall) QT: Irregular
(Short)
Interpretation: Mandy is having arterial enlargement, she is having short PR which means heart block or hole, tall
QRS means hypertrophy of both or one ventricles and short QT represents irregular rhythm of heart rhythm
Clinical Significance:
The data received highly significant with Mandy’s situation. Irregular heartbeat, ventricular hypertrophy, arterial
enlargement all signify the presence of hole in her heart (ventricular wall) (Karonis et al. 2016).
Radiology Reports:
What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
Radiology: Chest X-Ray
Results: Clinical Significance:
Cardiomegaly and increased
pulmonary blood flow
It signifies that left-to-right shunt where there is additional capacity of blood flow
causing enlargement of heart chambers. Here pulmonary artery increases and
blood flow also increases. Impediment of blood flow produces hypertension in
pulmonary venous as well as resultant pulmonary edema.
Radiology: Cardiac Echocardiogram
Results: Clinical Significance:
Large perimembranous
ventricular septal wall defect
(VSD)
The ECG data is highly significant in concluding that Mandy’s heart is not
working properly, hence she requires special attention. It also helped in
identification that the left ventricle outflow tract that is located under the
aortic valve is not functioning properly (An et al. 2015).
Lab Results:
Complete Blood Count (CBC)
WBC HGB PLTs % Neuts
Current: 8.0 10.2 205 60
Most Recent: 8.5 10.5 250 55
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
PLT (150-450)
WBC (6-17.5)
HGB (9-14) HGB count is slightly low than the normal, it might be
due to less oxygenrated blood in the body as
hence less supply of healthy blood to the tissues
(Kang et al. 2015)
Worsening
Basic Metabolic Panel (BMP)
Na K Gluc. Creat.
Current: 130 5.5 70 0.2
Most Recent: 133 4.5 80 0.3
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
Na, K and Creatinine
(Creat)
The nurse felt it clinically significant as Mandy’s is not
eating anything her level of nutrition is falling down, she is
running out of malnutrition.
Worsening
MISC.Misc.
Mag Total Calcium Lactic Acid GFR PT/INR
Current: 1.6 9.0 17.1 55 0.95
Most Recent: 2.0 8.9 10.0 57 1.0
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
Most recent lab results are
considered
Mag, calcium
All are significant as they give present blood content of
Mandy. All data are good and under normal range.
Improved.
Liver Panel
Albumin Total Bili Alk. Phos. ALT AST
Current: 2.3 0.5 400 42 74
Most Recent: 2.5 0.35 320 35 65
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
Most recent data for
albumin
low albumin due malnutrition as she cannot take any
food
worsening
Cardiac
Trop. BNP
Current: <0.05 120
Most Recent: <0.05 <100
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:
BNP
It determines the whether the heart is pumping
properly
Improving as it has gone below 100
Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
(Reduction of Risk Potential/Physiologic Adaptation)
Lab: Normal
Value:
Clinical Significance: Nursing Assessments/Interventions Required:
BNP
Value:
120
Critical
Value:
It means that the heart is not
functioning properly and Mandy
is suffering from congenital heart
disease.
Mandy is having a hole in the ventricular wall of
her heart, hence it is predicted that her BNP will
be high as her heart has to pump more blood due
to lack of oxygenated blood in the cells (Zhang et
al. 2015). As per nursing assessment if the BNP
is not kept under control then Mandy might
undergo sever heart problem such as stroke or
heart failure. The control of BNP is highly
recommended.
Clinical Reasoning Begins…
1. Interpreting relevant clinical data, what is the primary problem? What primary health related concepts does this
primary problem represent? (Management of Care/Physiologic Adaptation)
Problem: Pathophysiology of Problem in OWN Words: Primary Concept:
Difficulty in breathing and
fast breathing
The main pathophysiology of the problem is due
development of shunt between left and right ventricles. The
total amount of blood pushed and the direction which it is
pushed determines the hemodynamic significance of the
problem (Kang et al. 2015). The factors that are involved are
governed by location as well size of the hole present in the
heart.
It mainly occurs
when the heart is not
working or not
pumping enough
oxygenated blood.
However, in case of
Mandy she has a hole
in ventricle walls and
hence deoxygenated
and oxygenated
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

blood is getting
mixed. Therefore, he
cells cannot get
enough oxygen and
to compensate that
her heart has to pimp
faster which is
making her breathing
difficult.
Collaborative Care: Medical Management
2. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies)
Care Provider Orders: Rationale: Expected Outcome:
i) Admit to pediatric Special Care Unit.
ii) Saline lock IV
iii) Diet as per breastfeeding schedule.
May need to do gavage feedings with
pumped breast milk or cardiac formula if
oral/breastfeeding not tolerated
iv) Place in an infant seat or may hold with
head and upper chest upright > 30 degrees
v) Place on cardiac monitor and continuous
pulse oximetry with vital signs and oxygen
saturation recorded every 2 hours
vi) Furosemide 2mg/kg/dose now and then
1mg/kg twice daily
vii) Captopril 0.5 mg/kg/day PO divided
every 8 hours
viii)Start Digitalizing Dose: Digoxin 30
mcg/kg IV: give one-half of the total
digitalizing dose (TDD) now then give one
quarter in each of the two sequent doses at
12 hours intervals
ix) then begin daily dose of Digoxin 10
mcg/kg/day IV divided every 12 hours.
x) ECG 6 hours after each dose of Digoxin
to monitor for toxicity
xi) Daily Weight
i) As Mandy’s symptoms are that of heart
blockage or hole in the heart, she needs
immediate attention and medical care. She needs
to be kept under medical observation.
ii) Saline lock IV will help in the infusion
device, which upholds the patency of a
peripheral vein permitting for the as well as
direction of periodic IV medicines without
constant fluid supply and for episodic
ambition of blood samples
iii) As Mandy is a baby she needs proper
nutrition and she needs food in regular intervals.
iv) During treatment correct positioning is
required hence Mandy needs support as she
cannot sit proper as she is 2 months’ old
v) This would help in checking all her vital signs
and if there is any change necessary actions can
be taken
vi) Mandy is 2 months old, smaller dose initially
would help her in body to get adjusted with the
dose formula
vii) She is provided with two medications, to
make her body adjusted she needs to take
preventive heart attack medicine in small doses.
viii) usually in a routine, to check an
anticipated physiological effect (Takeda et al.
2015).
ix) one her body gets adjusted increase in dose
would enhance the treatment and change in the
effect can be noticed.
x) ECG after 6 hours would help in noticing the
change tin the heart activity
xi) Daily weight measurement would help in
understanding the nutritional balance ad Mandy’s
development
i) After medical
attention, care, and
treatment; in this case
surgery Mandy will
recover from the
breathing problem and
her heart would function
better.
ii) It would help in
preventing recurrent
venipuncture helping
towards Mandy’s
comfort
iii) This would help in
maintaining the
nutritional level in
Mandy. Lacking in
nutrition would make her
prone to sickness (Freed
et al. 2016).
iv) Proper position
would give clear
diagnostic data.
v) Checking for vital
signs after every 2 hours
would help to get all the
data and changes in the
data from time to time so
that clear analysis is
possible.
vi) It will help in treat
fluid build-up due to
heart failure or heart
problems
vii) It will help in
treating congestive
heart failure, and
would help Mandy
from heart attack
viii) this helps in clear
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

xii) Strict I & O
xii) fluid balance in the body can be noted
view of the heart defect
or any improvement that
would lead to necessary
treatment.
ix) It will improve the
heart strength and
prevents from heart
failure
x) this would help the
doctors to understand the
heart activity and
required further
treatment (Bank et al.
2016)
xi) weight measurement
tracks the weight so that
Mandy’s growth and
development is
maintained
xii) The fluid balance
would help in
understanding the
presence of excess fluid
and hence it can be
removed
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

PRIORITY Setting: Which Orders Do You Implement First and Why? (Management of Care)
Care Provider Orders: Order of
Priority:
Rationale:
Admit to pediatric Special Care
Unit.
Position upright in infant seat or
parents to hold. Mattresses on beds
can be adapted to prop infant up as
well.
Start IV saline lock for
medications
Furosemide 2mg/kg/dose now then
begin 1 mg/kg/dose twice per day
Digitalizing dose of Digoxin 30
mcg/kg IV: give one half now then
one quarter for each subsequent
doses every 12 hours
Daily dose of Digoxin 10
mcg/kg/day divided every 12
hours.
Captopril 0.5 mg/kg/day PO
divided every 8 hours
1
2
7
4
6
5
3
Admitting would help better diagnosis
Better treatment positioning is must so that clear analysis can be
done
After medicine application excess fluid needs to be done hence it
would be preferred at end (Kanno et al. 2015)
Slow increase in dose
It would help in improving heart strength and effect after other
medicine application
Further increase in dose after checking that the body is
completely adjustable
Least medicine dose applied for sloe adjustment of the body
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Collaborative Care: Nursing
3. What nursing priority (ies) will guide your plan of care? (Management of Care)
Nursing PRIORITY:
Creation of individual plan and generating
plan with discussion with Mandy’s family
PRIORITY Nursing Interventions: Rationale: Expected Outcome:
Preserve aseptic system during
any technique
Any further infection or attacks of other
germs or pathogens would enhance
Mandy’s disease. Mandy is weak and hence
chances of getting infected is high (Boisvert
et al. 2015)
This would help in
maintaining and
keeping Mandy free
from any germs and
hence protect her from
further diseases.
4. What body system(s) will you assess most thoroughly based on the primary/priority concern?
(Reduction of Risk Potential/Physiologic Adaptation)
PRIORITY Body System: PRIORITY Nursing Assessments:
Cardiovascular system
As she was having breathing issue and all symptoms related
to improper breathing hence it can be assumed that she is
having some problem with her heart.
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

5. What is the worst possible/most likely complication(s) to anticipate based on the primary problem of this patient?
(Reduction of Risk Potential/Physiologic Adaptation)
Worst Possible/Most Likely
Complication to Anticipate:
Progression to heart attack
Nursing Interventions to
PREVENT this Complication:
Assessments to Identify Problem
EARLY:
Nursing Interventions to Rescue:
Block the hole so that oxygenated
and deoxygenated blood do not gets
mixed.
Breathing difficulty, paleness, rapid
breaths
Immediate treatment or surgery.
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

6. What psychosocial/holistic care PRIORITIES need to be addressed for this patient?
(Psychosocial Integrity/Basic Care and Comfort)
Psychosocial PRIORITIES: Must be kept under serious notice and activity must be checked regularly
PRIORITY Nursing Interventions: Rationale: Expected Outcome:
CARE/COMFORT:
Caring/compassion as a nurse
Physical comfort measures
As Mandy is an infant she needs
love and care as so that she
donot panic.
Physical comfort would help
Mandy to have food and get
better treatment (Rogers and
Bush 2015).
A good bond between Mandy and
Nurse would help in easy diagnosis
As Mandy is having physical
discomfort, she cries and sleep and
faces difficulty which she cannot
express. A proper comfort would help
in getting food and relaxation for
Mandy
EMOTIONAL (How to develop a
therapeutic relationship):
Discuss the following principles needed as
conditions essential for a therapeutic
relationship:
• Rapport
• Trust
• Respect
• Genuineness
• Empathy
This would help Mandy to
be comfortable with nurses.
A good bond will improve
better treatment regime
Mandy will feel comfortable and
would not cry while injecting medicine
for treatment or any treatment
SPIRITUAL:
• F-Faith or beliefs: What are your
spiritual beliefs? Do you consider
yourself spiritual? What things do you
believe in that give meaning to life?
• I-Importance and influence: Is faith
important to you? How has your illness
or hospitalization affected your belief
practices?
• C-Community: Are you connected to a
faith center in the community? Does it
provide support/comfort for you during
times of stress? Is there a person/group
who assists you in your spirituality?
• A-Address: What can I do for you?
What support can healthcare provide to
support your spiritual beliefs/practices?
It is required for mental strength
and making the patient feel that
they can improve faster and
quicker and in Mandy’s case it is
her parents how would feel
positive,
This makes in feeling to work and
gives patient strength to live their life as
well their family members. Mandy’s
parents would feel that Mandy’s heath
will improve and would give strength to
live (Ruppar et al. 2016)
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