An 8-month-old infant has a hypercyanotic spell while blood is being drawn. What is the priority nursing action?
A.
Prepare family for imminent death
B.
Place the child in the knee-chest position
C.
Assess for neurologic defects
D.
Begin cardiopulmonary resuscitation
The Correct Answer and Explanation is:
The correct answer is B. Place the child in the knee-chest position.
Explanation:
A hypercyanotic spell, also known as a “Tet spell,” is a medical emergency that commonly occurs in infants with congenital heart defects, particularly Tetralogy of Fallot. During such a spell, there is a sudden decrease in oxygenation, leading to severe cyanosis (bluish discoloration of the skin due to lack of oxygen) and potentially life-threatening complications.
Priority Nursing Action:
The priority nursing action is to place the child in the knee-chest position. This maneuver is crucial because it helps increase systemic vascular resistance, which in turn reduces the right-to-left shunt of blood through the heart’s septal defect, improving oxygenation. By bringing the knees to the chest, venous return to the heart is decreased, and the pressure in the left side of the heart increases, encouraging blood to flow from the right side of the heart to the lungs instead of bypassing them. This maneuver can rapidly improve the child’s oxygen levels and alleviate cyanosis.
Incorrect Options:
- A. Prepare family for imminent death: Although hypercyanotic spells can be severe, this option is not the immediate priority. The first response should focus on interventions that can stabilize the child and potentially reverse the spell.
- C. Assess for neurologic defects: While assessing neurological status is essential after stabilizing the child, it is not the priority during an acute hypercyanotic episode. Immediate action should focus on improving oxygenation.
- D. Begin cardiopulmonary resuscitation (CPR): CPR is necessary if the child is unresponsive and not breathing, but in the case of a hypercyanotic spell, the child is typically conscious but in severe respiratory distress. The knee-chest position is the first intervention to stabilize the child before considering CPR.
In summary, the knee-chest position is a simple, non-invasive, and effective first-line intervention for managing a hypercyanotic spell. Prompt and appropriate action can prevent the situation from deteriorating, reduce the need for more invasive procedures, and improve the child’s overall prognosis.