A nurse has admitted a child with ventricular septal defect (VSD) to the unit. Which nursing diagnosis is appropriate for this child?
A.
Hypothermia related to decreased metabolic state
B.
Acute pain related to the effects of a congenital heart defect
C.
Ineffective tissue perfusion (peripheral) related to cyanosis secondary to congenital heart defect
D.
Impaired gas exchange related to pulmonary congestion secondary to the increased pulmonary blood flow
The correct answer and Explanation is :
The correct answer is:
D. Impaired gas exchange related to pulmonary congestion secondary to the increased pulmonary blood flow.
Explanation:
A ventricular septal defect (VSD) is a congenital heart condition where there is an abnormal opening in the septum (the wall) between the heart’s two ventricles. This allows oxygen-rich blood from the left ventricle to mix with oxygen-poor blood in the right ventricle. As a result, more blood flows into the pulmonary circulation, leading to increased pulmonary blood flow. Over time, this can cause pulmonary congestion and increase the workload of the heart, potentially leading to heart failure.
Impaired gas exchange occurs because the excessive blood flow to the lungs can cause fluid accumulation in the pulmonary capillaries, resulting in pulmonary congestion. This interferes with the lungs’ ability to efficiently exchange oxygen and carbon dioxide. The child may exhibit symptoms such as tachypnea (rapid breathing), dyspnea (shortness of breath), and decreased oxygen saturation.
Managing impaired gas exchange is crucial for children with VSD to prevent further complications, such as pulmonary hypertension or respiratory failure. Nursing interventions may include monitoring the child’s respiratory status, administering oxygen therapy if needed, and positioning the child to promote effective lung expansion (e.g., semi-Fowler’s position).
Option A (Hypothermia related to decreased metabolic state) is incorrect because VSD typically leads to increased metabolic demands rather than a decreased metabolic state.
Option B (Acute pain related to congenital heart defect) is also not the most relevant diagnosis, as VSD does not typically cause acute pain.
Option C (Ineffective tissue perfusion related to cyanosis) is not the best choice since cyanosis is more commonly associated with right-to-left shunt defects, whereas VSD usually involves a left-to-right shunt.