Video Case Study - Ventricular Septal Defect

Nurse Antoinette works on a pediatric cardiac unit and is caring for Mabel, a 1-year-old female with a history of ventricular septal defect, or VSD, who was admitted for a surgical repair. After settling Mabel in her room, Nurse Antoinette goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Mabel’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Antoinette recognizes important cues, including Mabel's vital signs, which are temperature 98.6 F or 37 C, heart rate 142 beats per minute, respirations 35 breaths per minute, and oxygen saturation 92 percent on room air. Upon assessment, Nurse Antoinette notes a systolic heart murmur and crackles in the bases of her lungs. She also notices that Mabel appears to be irritable.

Next, Nurse Antoinette analyzes these cues. She reviews the electronic health record, or EHR, and sees that Mabel was diagnosed with a VSD as a newborn. The health care provider recommended close monitoring of the condition rather than immediate surgical correction because she was hemodynamically stable and asymptomatic.

Nurse Antoinette knows that a VSD causes a left-to-right shunting of blood in the heart, causing a mixture of deoxygenated and oxygenated blood to go back to the right side of the heart and then into the lungs, creating fluid overload in the lungs and increased pulmonary vascular resistance.
She also understands that the shunting of blood is causing Mabel’s systolic murmur, and that the pulmonary congestion is causing the crackles in her lungs. Additionally, Nurse Antoinette knows that less oxygen is being delivered to the tissues, so Mabel’s impaired perfusion is causing tachycardia and decreased oxygen saturation. Nurse Antoinette recognizes that Mabel needs effective perfusion management.

Now, using the information she’s gathered, Nurse Antoinette chooses a priority hypothesis of impaired tissue perfusion.

Then, she generates solutions to address Mabel’s impaired tissue perfusion that will include pharmacologic and nonpharmacologic interventions; and she establishes the expected outcome that after intervening, Mabel will demonstrate a decreased heart rate before being transferred to the preoperative unit.

Nurse Antoinette then takes action to implement these solutions. She reviews the plan of care with Mabel’s caregiver, Martha, who’s at the bedside.