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03/31/20XX​ 07:00 A 3-week-old infant is scheduled for a ventricular septal defect (VSD) repair in the cardiac catheterization lab. Caregivers state that the infant takes 30-40 minutes to feed and only eats 2 to 3 ounces of formula. They also state that the infant gets damp and sweaty when feeding and seems to have fewer wet diapers than when brought home from the hospital. Assessment includes rectal temperature of 36.6°C (97.8°F), pulse 195 at rest, peripheral pulses 1 ——————– L. Lopez, RN 03/31/20XX​ 07:30 Initial physical assessment reveals: Neuro: WNL. Infant is anxious and crying but is consolable. CV: Tachycardic, peripheral pulses 1 with cool extremities. Capillary refill >3 seconds. Resp: Breath sounds clear on room air. Retractions noted. GI: Bowel sounds present all quads. GU: WNL. Integ: Pink and intact. MS: WNL. ENT: Mucus membranes moist and intact. VS: Rectal temp of 36.6°C, P 195 at rest, RR 34, BP 145/90, oxygen saturation 90% — L. Lopez, RN The nurse is preparing to receive the infant following post-cardiac catheterization. For each potential nursing intervention, click to specify whether the intervention is indicated, nonessential, or contraindicated for the care of the client. ​ Indicated Nonessential​ Contraindicated Monitor vital signs (VS)
SCIENCE
HEALTH SCIENCE
NURSING

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