The nurse has admitted a child with a ventricular septal defect (VSD) to the unit. An appropriate nursing diagnosis for this child is:
1. Impaired gas exchange related to pulmonary congestion secondary to the increased pulmonary blood flow.
2. Deficient fluid volume related to hyperthermia secondary to the congenital heart defect.
3. Acute pain related to the effects of a congenital heart defect.
4. Hypothermia related to decreased metabolic state.
1
Rationale:
1. Because of the increased pulmonary congestion, impaired gas exchange would be an appropriate nursing diagnosis.
2. Ventricular septal defects do not cause pain, fever, or deficient fluid volume.
3. Ventricular septal defects do not cause pain, fever, or deficient fluid volume.
4. Ventricular septal defects do not cause pain, fever, or deficient fluid volume.
Diagnosis
Physiological Integrity
Analysis
Learning Outcome 26.3 Describe the pathophysiology associated with congenital heart defects associated with increased pulmonary circulation, decreased pulmonary circulation, mixed defects, and obstructed systemic blood flow.
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