Answers to Nurse Sugar Case Study Question 2
Course Title pediatrics
Scenario: A 7-year-old girl is brought to the pediatric cardiology clinic by her parents for follow-up care of her congenital heart condition, Tetralogy of Fallot (TOF). Her parents are concerned that she has been getting tired easily and has experienced episodes of shortness of breath while playing outside. They mention that she occasionally squats down when she feels lightheaded and that her lips sometimes appear bluish during physical activity.
The nurse assesses the child and notes mild clubbing of her fingers. A cardiac evaluation is scheduled to determine if further surgical intervention is needed to improve her oxygenation.
Vital Signs and Lab Results:
- Temperature: 98.4°F (36.9°C)
- Heart rate: 102 bpm
- Respiratory rate: 24 breaths/min
- Blood pressure: 100/60 mmHg
- Oxygen saturation: 88% on room air
- Hemoglobin (Hgb): 15.8 g/dL
- Echocardiogram: Right ventricular hypertrophy, mild pulmonary stenosis, ventricular septal defect (VSD)
- Chest X-ray: Mild cardiomegaly
Recognize Cues
During the visit, the parents express concerns about their daughter’s bluish lips and frequent fatigue. They also report that she squats instinctively when she feels dizzy, which seems to help her recover. The nurse reviews her previous surgical history, noting that she underwent corrective surgery for TOF as an infant but has not required further interventions until now.
Identify the relevant clinical findings that align with the diagnosis of Tetralogy of Fallot (TOF). SATA
- A. Squatting during play
- B. Clubbing of the fingers
- C. Oxygen saturation of 88% on room air
- D. Heart rate of 60 bpm
- E. Hemoglobin level of 15.8 g/dL
- F. Recent bacterial infection
Answer: A, B, C, E
Rationale: Squatting, clubbing, low oxygen saturation, and elevated hemoglobin levels are common signs of cyanotic heart disease such as TOF.
A heart rate of 60 bpm is not tachycardic for her age, and no recent bacterial infection was mentioned.
Analyze Cues Matrix Grid Question
The echocardiogram shows right ventricular hypertrophy and a ventricular septal defect (VSD). These findings indicate the need for ongoing monitoring. The healthcare team explains that squatting increases systemic vascular resistance, which helps alleviate the child’s symptoms during activity.
Match each Clinical Cue with its correct clinical interpretation.
Clinical Cue
Squatting during play
Clubbing of the fingers
Right ventricular hypertrophy
Ventricular septal defect
Oxygen saturation of 88%
Clinical Interpretation
Increases systemic vascular resistance to improve oxygenation
Compensation for increased workload on the heart
Long-term hypoxia
Inadequate systemic oxygenation
Mixing of oxygenated and deoxygenated blood
Answer
- Squatting during play → Increases systemic vascular resistance to improve oxygenation
- Clubbing of the fingers → Long-term hypoxia
- Right ventricular hypertrophy → Compensation for increased workload on the heart
- Ventricular septal defect → Mixing of oxygenated and deoxygenated blood
- Oxygen saturation of 88% → Inadequate systemic oxygenation
Rationale:
Squatting during play: This is a compensatory maneuver used by children with TOF to increase systemic vascular resistance, which forces more blood through the lungs for oxygenation.
Clubbing of the fingers: Chronic hypoxia, common in cyanotic heart diseases like TOF, leads to clubbing of the fingers.
Right ventricular hypertrophy: In TOF, the right ventricle has to work harder to pump blood due to pulmonary stenosis, leading to hypertrophy.
Ventricular septal defect: This defect allows oxygen-poor blood from the right ventricle to mix with oxygen-rich blood in the left ventricle, contributing to systemic cyanosis.
Oxygen saturation of 88%: This indicates inadequate oxygenation, a hallmark of TOF due to the mixing of oxygenated and deoxygenated blood.
Prioritize Hypotheses
The healthcare provider discusses the potential need for a cardiac catheterization to evaluate the severity of the pulmonary stenosis and whether an additional surgical intervention will be necessary. Meanwhile, the nurse monitors for signs of a "tet spell"—an episode of severe cyanosis.
Select the 3 most critical signs to monitor for in a child with Tetralogy of Fallot.
- A. Sudden onset of cyanosis
- B. Profuse sweating
- C. Restlessness during activity
- D. Respiratory rate of 10 breaths/min
- E. Absence of heart murmurs
- F. Frequent squatting during play
Answer: A, C, F
Rationale: A. Sudden onset of cyanosis – A "tet spell" or cyanotic episode is characterized by a sudden increase in the severity of cyanosis due to a rapid decrease in oxygen levels, making this a critical sign to monitor. C. Restlessness during activity – Restlessness or irritability during activity can indicate hypoxia and the onset of a "tet spell," signaling the child is struggling to get enough oxygen. F. Frequent squatting during play – Squatting is a compensatory behavior in children with TOF to relieve hypoxia. Frequent squatting suggests that the child is experiencing more frequent episodes of oxygen deprivation.
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B. Profuse sweating: While sweating can be a sign of heart failure or excessive effort, it is not as critical as the signs related to hypoxia and cyanosis in TOF.
D. Respiratory rate of 10 breaths/min: A low respiratory rate could be concerning, but a tet spell is usually associated with increased respiratory effort and cyanosis, rather than a decrease in the respiratory rate.
E. Absence of heart murmurs: Murmurs are often present in TOF due to the ventricular septal defect and pulmonary stenosis, but their absence is not a primary concern for monitoring "tet spells."
Generate Solutions Cloze Drop Down Question
The healthcare team recommends avoiding strenuous activity and suggests propranolol to help prevent tet spells. The parents are taught how to position the child in a knee-to-chest position if she becomes cyanotic.
Complete the nurse’s instructions for managing tet spells. "If your child experiences severe cyanosis, place her in a __________ position to increase blood flow to the lungs. Administer __________ as prescribed to prevent further episodes. If symptoms do not improve, seek _________care."
[knee-to-chest/supine]
[propranolol/digoxin]
[immediate/emergency]
Answer:
- Knee-to-chest position
- Propranolol
- Emergency care
Rationale: The knee-to-chest position increases systemic vascular resistance, and propranolol helps manage symptoms. Emergency care is necessary if cyanosis persists.
The supine position is not effective for tet spells, and digoxin is not typically used for TOF management.
Take Action - Ordered Response Question
During a play session, the child suddenly becomes cyanotic and clutches her chest. The parents position her in the knee-to-chest position, and the cyanosis improves. The nurse reinforces proper management of future episodes with the family.
Arrange the following nursing actions in the correct sequence.
1. Place the child in a knee-to-chest position.
2. Monitor the child’s oxygen saturation.
3. Administer propranolol if prescribed.
4. Provide emotional support to the family.
5. Notify the healthcare provider of the episode.
Answer:
1 → 3 → 2 → 5 → 4
Rationale: Place the child in a knee-to-chest position – This is the immediate action to take during a "tet spell" to increase blood flow to the lungs and improve oxygenation.
Administer propranolol if prescribed – Propranolol can help prevent further episodes by decreasing heart rate and reducing the heart's workload.
Monitor the child’s oxygen saturation – After the initial interventions, it's important to monitor oxygen levels to ensure the child is recovering and returning to a safe oxygen range.
Notify the healthcare provider of the episode – Informing the healthcare provider of the episode ensures that any necessary follow-up care or adjustments to the treatment plan can be made.
Provide emotional support to the family – After the acute episode is managed, offering emotional support helps the family feel reassured and confident in managing future events
Evaluate Outcomes
After starting propranolol and following activity restrictions, the child’s oxygen saturation improves to 92% on room air. The parents report fewer cyanotic episodes and say their daughter has been able to participate in light activities without symptoms.
Which outcome indicates that the child’s condition has improved?
- A. Oxygen saturation remains at 88%
- B. The child participates in light activities without symptoms
- C. The child continues to experience frequent tet spells
- D. Cyanosis occurs daily despite interventions
- E. The child’s heart rate increases to 140 bpm at rest
- F. Propranolol therapy is discontinued prematurely
Answer: B
Rationale: Participation in light activities without symptoms indicates improved management of TOF.
Persistent cyanosis, frequent tet spells, increased resting heart rate, and premature discontinuation of therapy indicate poor management or progression.
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