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Question: Can you make a list of Nursing Diagnosis related to the given Case Scenario below?
INFANT WITH TETRALOGY OF FALLOT
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)
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.
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