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Prepared byDr Nahed El- naggerAssistant professor of Nursing

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1430-1431 H

UMM AL- QURA UNIVERSITY FACULTY OF APPLIED MEDICAL SCIENCES NURSING DEPARTMENT

Learning Objectives

• At the end of this lecture each student will be able to:

• I dentify the incidence, risk factos, signs and associated complications of the following congenital heart defects: patent ductus arteriosus (PDA), ventricular septal defect (VSD), atrial septal defect (ASD), coarctation of the aorta (CoA), tetralogy of fallot (ToF), complete transposition of the greet vessels (ToGV) and aortic stenosis (AS).

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Learning Objectives (cont;)

• Describe specific nursing interventions that are appropriate for each type of CHD.

• Design health education to meet the needs of parent and family of a neonate with CHD.

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Introduction

The heart is completely developed in the first eight weeks of intra uterine life; one or several anomalies may result from mal development of the heart or great blood vesseles leading to and from the heart with the result that the infant is born with congenital heart disease.

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Fetal Circulation

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Fetal Circulation

• Fetal circulation

(prenatal circulation)

differs from adult

circulation in several ways and is designed to ensure a high oxygen blood supply to the brain and myocardium of the fetus.

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Characteristics of fetal circulation

• Placenta is the source of oxygen for the fetus, it has 2 arteries and 1 vein.

• Fetal lungs receive less than 10% of the blood volume ; lung don’t exchange gas.

• Right atrium of

fetal heart is the chamber

with the highest oxygen

concentration. 8

The three openings that close at birth are:

• Ductus Arteriosus connects the

pulmonary artery to the aorta,

bypassing the lungs• Ductus Venosus connects the

umbilical vein and the inferior

vena cava bypassing the liver.• Foramen Ovale is the opening between right and left

atrias of the heart , bypassing the lungs.

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Normal circulatory changes at birth

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The Heart

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Congenital Heart Disease (CHD)

• Approximately 5-8 Per 1000 Live Births; Combination of Genetic & Environmental Factors : X-ray exposure

Maternal Rubella Maternal alcoholism Maternal type 1 diabetes Maternal over 40 of age• Occur EARLY in Gestation (3-8 Weeks) in the

first trimester12

Classification of CHD:• A cyanotic versus cyanotic

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Acyanotic

Mixedblood flow

Pulmonary blood flow

Obstruction to Blood flow

from ventricles

PulmonaryBlood flow

Cyanotic

•Atrial septal defect (ASD)•Ventricularr septal defect (VSD)

•Coarctation of Aorta•Aortic stenosis

•Tetrology of Fallot•Tricuspid atresia

•Transpositionof great vessels

There has to be a LEFT to RIGHT shunt to cause cyanosis

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Selected A cyanotic defects

•Abnormal opening between atria, allowing blood from Lt atrium (higher pressure) to go to right atrium (lower pressure).

S&S: Patients may be asymptomatic they may develop heart failure, atrial arrhythmias are present.

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(1) Atrial Septal Defect or ASD :

Selected A cyanotic defects

Surgical treatment: Surgical Closure .Non-surgical Repair: in catheterization, a repair pad is implanted.• Patients with ASD may live several decades without S&S and the prognosis after operation is very high.

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…. Cont. acyanotic

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(2) Ventricular Septal Defect or VSD, :

•It is an abnormal opening between the right andthe left ventricles, resulting in a common ventricle.• its found that 20% of all VSDs close spontaneously during the first year of life• S&S : congestive heart failure is common.

…. Cont. acyanotic

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(2) Ventricular Septal Defect or VSD, :

• Surgical treatment: complete repair.•Non-surgical treatment: closure devise is usually implanted during cardiac catheterization

Cardiac catheterization lab

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3.PATENT DUCTUS ARTERIOSUS ( PDA)

• It is a connection between the aorta and the pulmonary artery.

• Very common in preterm babies.

• Usually closes in the first 2 weeks of life.

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PDA - cont…..

Symptoms :

• None if small.

• If large can cause CHF

at 6-8 weeks in a term infant.

• In a preterm baby increasing respiratory support usually occurs after day 3 of life.

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PDA

Signs:

• Systolic murmur in a newborn and a continuous “train in a tunnel” murmur in an older child. Best heard below the left clavicle.

• A large PDA causes

LA and LV enlargement.

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PDA - cont...

• Treatment : Preterm vs. term baby.

• In a preterm it can be closed medically using indomethacin.

• In a term baby if still open at 3 months of age then coil closure by cardiac catherization is the method of choice.

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4.Coarctation of the Aorta (CoA)

• Is a narrwing of the aortic lumen within the area of the aortic arch. Produces an obstruction to the flow of blood through the aorta.

• More common in males

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CoA - cont….

SEVERE : Shock

MODERATE : CHF.

MILD : Headaches.

• Decreased femoral pulses are an important sign esp. in neonates.

• BP lower in the lower limbs.

• Poor feeding tolerance.

• Poor weight gain during first 2-6 weeks.25

Symptoms and Signs:

CoA - cont….

Diagnostic : ECHO

Treatment:

• Ballon angioplasty.

Surgical :

• Resection of the aorta and anastomosis or grafting.

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5. AORTIC STENOSIS (AS)

• Is an obstruction to outflow from the left ventricle at or near the aortic valve.

• More common in males.

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AORTIC STENOSIS ( AS)

• Usually asymptomatic in infant and children.

• A cyanotic, except in severe defects.

• CHF in severe aortic stenosis.

• Tachypnea, poor feeding, poor weight gain, and increased respiratory effort.

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Symptoms:

There has to be a RIGHT to LEFT shunt to cause cyanosis

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Tetralogy of Fallot

• Most common cyanotic heart disease.• The four abnormalities include:

– Pulmonary stenosis– Right Ventricular Hypertrophy(RVH)– VSD– Overriding Aorta

• Signs include cyanosis, murmur, squatting and spells.

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• Tetrology of Fallot (TOF)

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•S&S: cyanosis, clubbing fingers, poor growth. crying during or after feeding, murmur, squatting and spells.A “tet” spell consists of rapid breathing and increased cyanosis. Any event like crying or increased physical activity can initiate the spell.

Initial evaluation of child’s heartHistory - cyanosis

•Turn blue?

•At rest?

•When crying?

•Passes out?

•Stops playing and squats

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TOF cont..

• Treatment includes:– Holding the baby in a knee chest position.– Morphine.– Oxygen, beta blocker.

• Surgical treatment: complete repair is required, open heart surgery& VSD closure.

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TRANSPOSITION OF THE GREAT ARTERIES

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Transposition of the great Arteries

• The aorta arises from the right ventricle and the pulmonary artery from the left.

• The mixing of the blood occurs at the PFO and the PDA.

• The signs include cyanosis and cardiomegaly. Reverse differential cyanosis!

• There may be no murmur.

• An echocardiogram is diagnostic.

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3. PULMONIC STENOSIS ( PS)

• A narrowing of the pulmonary valve.

• Associated with a history of maternal rubella

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PS - cont...

Symptoms:

• None in mild or moderate stenosis. Cyanosis is seen only with critical PS.

Diagnostic : ECHO.

Treatment :

Balloon valvotomy.

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Nursing Process Overview for the Child with a Cardiovascular Disorder

• Assessment – Health History

• History of Present Illness

• Past Medical History – Physical Examination

• Inspection • Palpation • Auscultation

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Nursing Process Overview (cont’d)

• Assessment (cont’d)– Laboratory and Diagnostic Testing – Cardiac Catheterization

• Procedure (right-side, left-side)• Nursing Management

(before and after procedure).• Nursing Diagnoses and Related Interventions.

Nursing Management of the Child with CHD

• Improving Oxygenation.• Promoting Adequate Nutrition.• Assisting the Child and Family to Cope.• Preventing Infection. • Providing Care for the Child Undergoing

Cardiac Surgery – Providing Preoperative Care– Providing Postoperative Care.

• Providing Patient and Family Education. 42

CARDIAC SURGERY

• Discharge Teaching:– Activity Tolerance; – No Bike Riding Until Sternotomy Healed– Signs & Symptoms of Wound Infection– Return to School in 2 Weeks– Usually, No Further Cardiovascular Problems

• ALLOW THE CHILD TO LIVE A NORMAL AND ACTIVE LIFE!

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Question

The nurse would identify which congenital heart disease as involving increased pulmonary blood flow?

A. Triscupid atresiaB. Patent ductus arteriosusC. Tetralogy of FallotD. Aortic stenosis

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Answer

B.

Patent ductus arteriosus is a congenital heart disease that involves increased pulmonary blood flow. Tricuspid atresia and tetralogy of Fallot are disorders involving decreased pulmonary blood flow. Aortic stenosis is an obstructive disorder.

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Question

A child with CHD experiences hypercyanotic spells. The nurse would place the child in which position for relief?

A. Supine

B. Trendelenburg

C. Knee-to-chest

D. Prone

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Answer

C.

To relieve hypercyanotic spells, the child should be placed in the knee-to-chest position.

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THANK YOU48

GOOD LUCK !!!!!!!