Davao Doctors College, Inc.

College of Allied Health Sciences

Nursing Program

NRG204: CARE OF MOTHER, CHILD AT RISK OR WITH PROBLEMS

(ACUTE & CHRONIC)
Learning Maternal & Child Health Nursing One Case Analysis at a Time!

Getting to Know the Course Instructor:

Hello! I am PRINCESS FABRIENNE T. PANGANIBAN,

RN and I will be your instructor for this week.
Congratulations on finishing our third module for this
semester! I hope that you learned a lot about
__________________________ from our previous week’s
discussion. If you have queries regarding the topic(s) that
we have covered last week, just let me know.

For this week, we will be learning about a client with

Tetralogy of Fallot (ToF). I am looking forward to guiding
you in learning this course well. If you want to reach me for
any academic-related concerns, you can reach me through
the following:

Contact No: Available upon request

Facebook account: @@@@
E-mail address: _________@davaodoctors.edu.ph
Consultation hours: MON: 8:00AM – 4:00PM

Introduction to the Course

The course NRG204: Care of Mother, Child at Risk or with Problems (Acute & Chronic) with
concepts, principles, theories and techniques of nursing care of at-risk and sick adult clients in
any setting with alterations / problems in nutrition, and gastro-intestinal, metabolism and
endocrine, perception and rehabilitation. The learners are expected to provide safe, appropriate
and holistic nursing care to at-risk and sick adult clients utilizing the nursing process. Presented
below are the specific details of this course:

_____________________________________________________________________________
Course Number : NRG 204
----------------------------------------------------------------------------------------------------------------- ------------------------------
Course Credit : 12 units (6 units Lecture, 6 units RLE)

Placement : Second year, Second Semester

Prerequisite : NRG 203

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Schedule : MTW/THFS
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Requirements in Completing the RLE Activities

Since most of our sessions for this semester will be delivered through distance learning activities,
the submissions will also be primarily done online. To do this, you need to have access to the
following applications:

1. Microsoft Office/Google Docs

2. Microsoft PowerPoint/Google Slides
3. Google Classroom or Quipper (Will depend on the instructor in-charge)
4. Google Meet (or any other teleconferencing app, duly agreed by the whole group)
5. Internet connectivity

Please expect that you might need to print some parts of the worksheets in this module (i.e.,
documentation and transcribing parts). If any difficulties in participating in synchronous classes
are encountered, inform your instructor right away! For absences, secure an excuse slip from
your RLE supervisor.

Submissions must be submitted through the Learning Management System (LMS) so that it
will be traced and secured easily.

Daily Activities
Every week, you are expected to follow through the following deliverables:

Day 1 (Monday/Thursday) Day 2 (Tuesday/Friday) Day 3 (Wednesday/Saturday)

Virtual Circle (Asynchronous Virtual Circle Virtual Circle
Meeting )
Receiving of Handover Case Presentation (cont.)
Completion of Module, to be
submitted within the day Case Presentation Weekly Quiz and Discussion of
Module and Quiz Answers
Preparation of PPT
Presentation Orientation of Next Week’s Activity

Now that you are done acquainting yourself with the instructor and the course itself, please
proceed to Module 5: Care of a Client with Tetralogy of Fallot (ToF)

Term: Second Semester S.Y. 2022-2023

Dates: Week 10 – March 18 to 23, 2024
Class Schedule: MTW: 8:00AM – 4:00PM
No. of Hours: 8 HRS/DAY
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Instructions
The case analysis manuscript may be handwritten or computer written. Observe pagination.
Once done, send the compilation of your group’s answers to your clinical instructor.

After the submission, prepare a PPT presentation for your case presentation slated for Days 2

MODULE 5:
CARE OF CLIENTS WITH TETRALOGY OF FALLOT (ToF)

and 3 of your RLE classes. Each member of the group is expected to present during the case
presentations.

Learning Outcomes
At the end of this module, you are expected to:
1. Utilize the nursing process in the care of clients with Tetralogy of Fallot.
2. Perform a comprehensive health history and assessment based on the case scenario
presented.
3. Utilize assessment information to formulate a patient-centered plan of care.
4. Discuss the therapeutics done for the simulated patient.
5. Explain appropriate nursing interventions per problems identified.
6. Document the care rendered to assigned patient in the simulated health care record
accurately.

As you start with this module, you are free to consult and coordinate with your assigned clinical
instructor. Be sure to get his/her email address and contact number for collaboration and
assistance. Just keep going! You can do it!
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Case Scenario

Baby Pearl, a 9-month-old girl presents to the emergency department with his mother, who
reports episodes of tachypnea, cyanosis, and irritability during feeding. The mother explains that
these episodes have become more frequent, with baby Pearl becoming more cyanotic around the
mouth and fingers especially when crying (tet spells) when she was around 7 months old. These
episodes resolve spontaneously but are occurring every few days. The mother breastfeeds every
3 hours, but sometimes takes a long time to feed. She also observed that baby Pearl becomes
diaphoretic with feeding, and stops frequently to catch her breath while feeding. She reported to
the nurse that vomiting the milk (sometimes goes out from the nose) and becomes more frequent
after feeding. The patient currently appears comfortable, with no signs of respiratory distress,
fever, or neurological impairment. The pregnancy and delivery of baby Pearl were uncomplicated;
with routine prenatal care. The mother has had no prior pregnancies and abortion. The mother
undergone prenatal genetic tests for trisomy 21 and was tested negative. The mother also
reported that her baby was a small baby (born at the 10th percentile), but is tracking along her
length and weight growth curves. Her immunizations are up to date. The mother denies smoking
and alcohol use during pregnancy. She also denies of attempting terminating the pregnancy.
Upon assessment, Baby Pearl’s vital signs include a pulse of 165 beats per minute, a respiration
rate of 65 breaths per minute, and an oxygen saturation level of 80%. Lung sounds are normal
to auscultation. Heart auscultation is performed and a systolic murmur noted at the left upper
sternal border; most strongly in the pulmonic area (radiates to the axillae and back)
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Family/Social Profile:

Baby Pearl is the first child of Harlene, 20year old and Perry, 25 years old, both belonged to a
Manobo tribe, and been married for 3 years. They are presently residing in a rural area, 30
kilometers away from town. Both parents are working as farmers in a vast rice plantation. They
live in a small house made up of wood and nipa materials. They drink from spring-source water
50 meters away from their house and uses shared sanitary latrine build by the barangay.

Past Medical History:

 Baby Pearl was never hospitalized, nor undergone any surgical procedure as reported by
the mother
• No known allergies for food and drugs

Immunization History:
 Baby Pearl has complete immunization as per Expanded of Immunization (EPI) schedule.

Physical Examination:

 Appearance: The patient is malnourished, ill looking and has a short stature
 Conjunctiva: with suffused conjunctiva
 Juaindice: Absent
 Cyanosis: with central cyanosis
 Koilonychias, leukonychia, lymphadenopathy: Absent
 Thyroid gland: not palpable
 Vital Signs:

Temperature: 36.5˚ Celsius

Pulse rate: 165 bpm, regular in rhythm, no radio radial and radio femoral delay
Respiratory rate: 65 cpm
Blood pressure: 90/60 mmHg
 Weight: 7.2 kgs
 Height: 26.5 inches
 Blood type: B+
 Jugular Venous Pressure (JVP): not raised
 Abdomen: soft, normoactive bowel sounds
 GU (IE): (-) kidney punch sign
 Skin/Extremities: There is generalized clubbing (involving all fingers & toes), full and
equal pulses, capillary refill time < 3 seconds, no edema noted

Cardiovascular Assessment:
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Pulse:

 165 bpm, normal volume, character, regular in rhythm

 no radio radial and radio femoral delay
 condition of the vessel wall is normal
 all the peripheral pulses are normal

Inspection:
 no visible apical impulse
 No epigastric pulsation
 No scar mark, or bony deformity

Auscultation:
 first heart sound is normal in all areas
 Second heart sound is single
 There is an ejection systolic murmur in the pulmonary area (left and 3rd intercostals space)
increasing intensity with breath hold in inspiration
 Grading of the murmur is 3/6
 There is no added sound
 Lung base are clear

Palpation:
 apex beat is located in the 5th intercostal space, 7cm from midsternal line, just medial to
midclavicular line, normal in nature
 No left parasternal heave
 No thrill
 No palpable pulmonary component
 No epigastric pulsation

Other Systemic Examination:

 Reveals no abnormality
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Please Admit under Dr.

March 18, 2024
VS q hrly, I/0 shift
10:00am
Keep Spo2 at >95% RA
Cyanotic
Keep Child Warm
HR 165 bpm
Keep HR <100 bpm
Spo2 88%
Keep airway patent

Child on Knee Chest Position

PO Sodium Bicarbonate 1ml/kg

Administer O2 2 L/min via NC PRN if Saturation

drops

Labs:

CBC, U.E. CREA, ABG

CXRAY

ECG

Refer to Dr. Tan for Cardio Evaluation

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Rounds with Dr. Tan

Noted ECG, Labs and Cxray results

March 18, 2024
- VS q hrly
1300 - For 2d ECHO
- NPO
- Start IVF D5 .3NaCL 20ml/kg
- Seizure precautions
- Correct Hemoglobin
- IV Metoprolol .5mg/kg bid
- IV Furosemide .5mg/kg OD
- Avoid Dehydration, fever and pain
- Sedate with Morphine .2mg/kg

Dr. Tan
1600 2decho done.

2d echo Results noted by Dr. Tan

Knee chest position (sudden episode of cyanosis)

Continue O2, Watch carefully

Dr. Tan
March 20, 2024
Give Phenylephrine 5µg/kg IV bolus
0800
Discuss Palliative or corrective surgery
Persistent Desaturation
Diazepam .2mg/kg IV PRN for Seizure

Neuro Exam

Propranolol .5 mg/kg q8

DR. Tan
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Diagnostic and Laboratory Results:

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Ul
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Nursing Program

What to Do?
To immerse yourself in the care management of your patient, let us do some detailed description
of your patient care tasks. Using the Case Scenario assigned to you, you are expected to perform
the following:

1. Fill-up the needed data based on the given scenario/case.

2. Conduct a history taking and physical assessment of your patient. Discuss the health
history of the patient narratively, in chronological order as much as possible. Use the DDC
Health Assessment form for documenting PA findings.
3. Discuss the pathophysiology of the patient’s condition. Discuss the FF: definition of
diagnosis, etiology, symptomatology, schematic diagram of the pathophysiology of the
condition of the patient, narrative description of the condition of the patient.
4. Interpret the therapeutics done for the patient: doctor’s orders, laboratory and
diagnostic tests done, and surgical procedures to be performed. Use format presented.
5. Present your drug study and IVF data. One drug study per student. Transcribe the
IVF and medications in the appropriate sheets.
6. Formulate a patient-centered care plan for your patient. Integrate in your care
intervention significant bioethical and legal standards of patient care. One NCP per
student.
7. Document the care given by making a nurse documentation the FDAR format.
8. Clinical Reasoning Questions - Collaboration: “In a provincial hospital there is an
eight-year-old boy who requires a blood transfusion. For religious reasons his parent are
not prepares to give consent.”
As a nurse expound what would happen if this procedure will be delayed and for the strict
religious belief how would you communicate using the CUS method? Discuss

1. Clinical Reasoning Questions - Ethico-Moral-Legal: In this scenario, you are taking

care of a 8-month olf who has been in the ICU, after 72 hours – brain stems test shows
she is dead and in palliative care, the patient assigned her brother, Jonathan, as her
healthcare proxy by virtue of the durable power of attorney. This agreement entails that
Jonathan can make the healthcare-related decisions for Lorna once the patient becomes
incapacitated.
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However, Lorna has expressed her wish to donate all her organs and has a donor card.
Her brother – Jonathan is adamant and he think that her sister Lorna did not think it
properly and refused to abide what her sister request.

What would be your nursing action in this scenario? What ethical-moral-legal principle is
applicable in this scenario? Justify? Answer narratively.

ADDITIONAL ACTIVITIES:

Crossword puzzle: Tetralogy of Fallot

Across

2. Some babies have heart defects because of changes in their? -- ______________

3. Tetralogy of Fallot can be treated by? ---- __________
5. a birth defect that affects normal blood flow through the heart. --- ____________
7. A baby with TOF may have skin color of? ---- _____________
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Down
6. How many defects of the heart and its blood vessels have? --- __________
1. Tetralogy of Fallot usually is diagnosed after a baby is born, often after the infant
has an episode of turning blue during crying or feeding called? --- __________
4. A sound caused by blood not flowing properly through the heart. –__________

Video link on filling out forms:

https://cutt.ly/Flg0spv

Practice filling out hospital sheets, such as MAR (Medication Administration Record), IV Flow
Sheet, VS Sheet, TPR Sheet, I & O monitoring sheet & Nurse’s notes.
Temperature: 36.5˚ Celsius
Pulse rate: 165 bpm, regular in rhythm, no radio radial and radio femoral delay
Respiratory rate: 65 cpm
Blood pressure: 90/60 mmHg

MAR (Medication Administration Record)

PO Sodium Bicarbonate 1ml/kg

IV Metoprolol .5mg/kg bid

IV Furosemide .5mg/kg OD

Morphine .2mg/kg

Phenylephrine 5µg/kg IV bolus

Diazepam .2mg/kg IV PRN for Seizure

Propranolol .5 mg/kg q8

IV Dobutamine 5mg/dl

IV Prostacyclin vials 0.5 or 1.5 mg

Milirinone, administer over a period of 10mins then cont. flow 0.375μg/kg/min

Chlorothiazide BID .5mg/dl

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Instructions: Supposing you have given all of the due medications for your shift, fill out the
MAR. Plot your VS results in the VS and TPR Sheets as well.

SCENARIO
- Baby Pearl - Feb 28 2021 at 1pm, Start IVF D5 .3NaCL 20ml/kg, infusing well at RCV,
G.26.
- There is generalized clubbing (involving all fingers & toes), full and equal pulses, capillary
refill time < 3 seconds, no edema noted
- Mother breastfeeds every 3 hours
- She reported to the nurse that vomiting the milk (sometimes goes out from the nose)
and becomes more frequent after feeding.
- On NPO, as ordered.
- Weight diaper (3pm - 15lbs) (8pm – 8lbs and defecated)

Complete fill-out the IV Flow Sheet + I/O Sheet.

DESTINATION CHECK
Questions to ponder and answer:
A. Answer the following questions correctly.

1. The nurse explains that a ventricular septal defect will allow:

a. blood to shunt left to right, causing increased pulmonary flow and no cyanosis.
b. blood to shunt right to left, causing decreased pulmonary flow and cyanosis.
c. no shunting because of high pressure in the left ventricle.
d. increased pressure in the left atrium, impeding circulation of oxygenated blood in the
circulating volume.

2. The assessment that would lead the nurse to suspect that a newborn infant has a
ventricular septal defect is:
a loud, harsh murmur with a systolic tremor.
b. cyanosis when crying.
c. blood pressure higher in the arms than in the legs.
d. a machinery-like murmur.

3. The finding the nurse would expect when measuring blood

pressure on all four extremities of a child with coarctation of the
aorta is blood pressure that is:

a. higher on the right side.

b. higher on the left side.
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c. lower in the arms than in the legs.

d. lower in the legs than in the arms.

4. When a father asks why his child with tetralogy of Fallot seems to favor
a squatting position, the nurse would explain that squatting:

a. increases the return of venous blood back to the heart.

b. decreases arterial blood flow away from the heart.
c. is a common resting position when a child is tachycardic.
d. increases the workload of the heart.

5. An infant is experiencing dyspnea related to patent ductus arteriosus (PDA). The nurse
understands dyspnea occurs because blood is:

a. circulated through the lungs again, causing pulmonary circulatory congestion.

b. shunted past the pulmonary circulation, causing pulmonary hypoxia.
c. shunted past cardiac arteries, causing myocardial hypoxia.
d. circulated through the ductus from the pulmonary artery to the aorta, bypassing the left
side of the heart.

6. An appropriate nursing action related to the administration of digoxin (Lanoxin) to an

infant would be:

a. counting the apical rate for 30 seconds before administering the medication.
b. withholding a dose if the apical heart rate is less than 100 beats/min.
c. repeating a dose if the child vomits within 30 minutes of the previous dose.
d. checking respiratory rate and blood pressure before each dose.

7. A child develops carditis from rheumatic fever. The nurse knows that the areas of
the heart affected by carditis are the:

a. coronary arteries.
b. heart muscle and the mitral valve.
c. aortic and pulmonic valves.
d. contractility of the ventricles.

8. The comment made by a parent of a 1-month-old that would alert the nurse
about the presence of a congenital heart defect is:

a. "He is always hungry."

b. "He tires out during feedings."
c. "He is fussy for several hours every day."
d. "He sleeps all the time."
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REFLECTION TIME
Reflection Time: Make a reading on personal experience of a patient diagnosed of Tetralogy
of Fallot. Please do not forget the link to the article. Provide a 5-paragraph handwritten reflection.
1sT paragraph will be the introduction of your article. The 2nd paragraph will be your reflection as
a Person, 3rd the paragraph will be your reflection as a student nurse. The 4th paragraph will be
your reflection as a Future Health professional. Lastly, the 5th paragraph will be your conclusion
about your reflections.

Have you answered all of the questions above? Great! Congratulations!

You have completed this module. You may now proceed to the next activity for the week.
Please wait for further instructions from you instructor

References:

Murray, S. and McKinney, E., 2014. Foundations Of Maternal-Newborn And Women’s Health
Nursing. 6th ed. MISSOURI: Saunders, an imprint of Elsevier Inc., pp.504-506.

The McGraw-Hill Companies, Inc. (2010). Maternal-Newborn Nursing Demystified (pp. 161-
163). New York City.

Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal and Child Health Nursing Care of the
Childbearing and Childrearing Family (8th ed., p.529-533). Philadelphia: Wolters Kluwer.