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Congenital heart disease
- 1. Congenital Heart Disease (C.H.D) Najah Kh. Qasem Lecturer in Nursing College Qassem University 1
- 2. Objectives 1- Identify etiological factors for CHD. 2- Discuss classification of CHD. 3- Define ASD, TOF. 4- Explain hemodynamic for ASD, TOF. 5- List signs and symptoms for ASD, TOF. 6- Describe medical/nursing treatment management for ASD, TOF. 7- Numerate diagnostic tests for CHD. 8- Formulate nursing care plan for a child with CHD. 2
- 3. Etiology of Congenital heart diseases (CHD): The etiology of most CHD is unknown, but several factors are associated with a higher than normal incidence. These include: 1- Maternal rubella during pregnancy. 2. Maternal alcoholism. Age over 40 years and insulin dependant diabetes. 3. Several genetic factors. 4. Exposure to radiation. 3
- 4. Types of Congenital Heart Defects Congenital heart defects have been divided into 2 categories: 1. Traditionally, cyanosis has been used as distinguishing feature, dividing the anomalies into: Cyanotic defects. Acyanotic defects. 4
- 5. Types of Congenital Heart Defects 2. Another classification system based on Hemodynamic characteristics. The defining characteristics is blood flow patterns: Increased pulmonary blood flow. Decreased pulmonary blood flow. Obstruction of blood flow out of the heart. Mixed blood flow in which saturated and desaturated blood mix within the heart or great arteries. 5
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- 7. Atrial Septal Defects (ASD): Definition Abnormal opening between the atria, allowing blood from -the higher pressure - left atrium to flow to -the lower pressure- right atrium. The resulting left to right shunting of blood which place a burden on the right side of the heart resulting in an increased blood flow. 7
- 8. Cont… An atrial septal defect allows oxygenated- blood to pass from the left atrium, through the opening in the septum, and then mix with deoxygenated- blood in the right atrium. 8
- 9. Incidence Incidence of CHD : 8 / 1000 births ASD is one of the most common congenital heart defects seen in pediatric cardiology ASDs account for about 7-10% of all congenital cardiac anomalies Twice as frequent in females than males 9
- 10. Types of ASDs: 1-Ostium secundum defect→70% of ASDs. 2-Ostum primum defect→20% of ASDs. 3-Sinus venosus defect→10%of ASDs. 10
- 11. Ostium Secundum Most common type of ASD Center of the septum between the right and left atrium. 11
- 12. Ostium Primum Located in the lower portion of the atrial septum. Will often have a mitral valve defect associated with it called a mitral valve cleft. A mitral valve cleft is a slit-like or elongated hole usually involves the anterior leaflet of the mitral valve. 12
- 13. Sinus Venosus ..asd-veno.jpg Located in the upper portion of the atrial septum. Association with an abnormal pulmonary vein connection Usually with a sinus venosus ASD, a pulmonary vein from the right lung will be abnormally connected to the right atrium instead of the left atrium. This is called an anomalous pulmonary vein. 13
- 14. Hemodynamic: 14
- 15. Hemodynamic: When blood passes through the ASD from the left atrium to the right atrium, a larger volume of blood than normal must be handled by the right side of the heart. Extra blood then passes through the pulmonary artery into the lungs, causing higher pressure than normal in the blood vessels in the lungs The lungs are able to cope with this extra pressure for a while, depending on how high the pressure is. After a while, however, the blood vessels in the lungs become diseased by the extra pressure. 15
- 16. Symptoms of ASD Many children have no symptoms and seem healthy. If the ASD is large, permitting a large amount of blood to pass through to the right side of the heart, the right atrium, right ventricle, and lungs will become overworked, and symptoms may be noted. 16
- 17. Symptoms of ASD The following are the most common symptoms of ASD, However, each child may experience symptoms differently. child tires easily when playing fatigue sweating rapid breathing shortness of breath poor growth recurrent chest infections 17
- 18. Treatment for ASD Specific treatment for ASD will be determined by cardiologist based on: child's age, overall health, and medical history extent of the disease (the size of the defect) child's tolerance for specific medications, procedures, or therapies expectations for the course of the disease parent opinion or preference 18
- 19. Treatment may include 1- Medical management some children may need to take medications to help the heart work better, since the right side is under strain from the extra blood passing through the ASD Digoxin to increase work of heart Diuretics to reduce preload 19
- 20. Treatment may include 2- Infection control Children with certain heart defects are at risk for developing an infection of the inner surfaces of the heart known as bacterial endocarditis. Prophylactic Antibiotic to prevent occurrence of infection 20
- 21. Treatment may include 3- Surgical repair The defect may be closed with stitches or a special patch. Individuals who have their Atrial Septal Defects repaired in childhood can prevent problems later in life such as pulmonary hypertension, atrial arrhythmias and cardiac failure which make operation more hazardous in adult life. It is important that ASDs be repaired in girls, because they can cause emboli during pregnancy. 21
- 22. Repair 22
- 23. Robo repair 23
- 24. Tetralogy of Fallot Characterized by Four Structural Defects. Represents approximately 10% of cases of congenital heart disease 24
- 25. Con.. The classical tetralogy consist of: I. Pulmonary artery stenosis. 2. Ventricular septal defect. 3. Overriding of the aorta.(deviation of the aortic origin to the right) 4. Right ventricular hypertrophy. In the present day, the most important features of Tetralogy of Fallot are recognized as (1) the right ventricular (RV) outflow tract obstruction (RVOTO), which is nearly always infundibular and/or valvular, and (2) an unrestricted VSD associated with malalignment of the conal septum. 25
- 26. Con.. In tetralogy of fallot, the out flow of the blood from the right ventricle resisted by the pulmonary stenosis so that the blood flows through the ventricular septal defect into the aorta. This is a right to left shunt. Hypertrophy of the right ventricle occurs as a result of the pressure exerted against the pulmonary stenosis, because the blood from the right ventricle is unoxygenated, cyanosis result 26
- 27. Con.. Polycythemia develops because the body attempts to compensate for the unoxygenated blood. The resulting increased viscosity of the blood causes stowing of the circulation and possible thrombophlebitis emboli and vascular disease. 27
- 28. Assessment Findings with Tetralogy of Fallot The neonate has tetralogy of fallot is not cyanotic because of the presence of the patent ductus arteriosus; cyanosis becomes evident after ductus closes during the first months of life. 28
- 29. Assessment Findings with Tetralogy of Fallot Symptoms are variable depending of degree of obstruction Symptoms include: Severe dyspnea on exertion Paroxymal dyspnea Cyanotic spells.(Hypoxic, blue spells). Tachycardia Systolic murmur at left sternal border Retarded growth and development Mental retardation 29
- 30. Cont.. Squatting (compensatory mechanism) : children learn that the squatting position relieves dyspnea because: 1- Flexing the legs decrease venous return from the lower extremities which have a very low oxygen content, especially after exercise. 2- Squatting position increase systemic vascular resistance, which diverts right ventricular blood from the aorta into pulmonary artery increasing pulmonary blood flow. This increases the amount of oxygenated blood in the left side of the heart and eventually into systemic circulation Clubbing of the fingers and toes 30
- 31. Cont.. RV predominance on palpation May have a bulging left hemithorax Aortic ejection click Scoliosis (common) Retinal engorgement Hemoptysis 31
- 32. Treatment of the Child with TOF Decrease cardiac workload Prevention of intercurrent infection Prevention of hemoconcentration Surgical repair 32
- 33. Nursing Care of the Child with Tetralogy of Fallot Care During a Hypercyanotic Spell Decrease Cardiac Workload Maintain Nutrition Administration of Cardiac Medications Decrease Respiratory Distress 33
- 34. Hypercyanotic Spells/ Blue Spells/Tet Spells Clinical Manifestations Most often occurs in morning after feedings, defecation, or crying Acute cyanosis Hyperpenia Inconsolable crying Hypoxia which leads to acidosis 34
- 35. Nursing Care For Blue Spells 1- Place Infant in Knee Chest Position 2- Administer 100% Oxygen 3- Administer Morphine 4- Use a Calm Approach 5- IV Fluid Replacement for Blood Volume Expansion 6- Decrease Cardiac Workload 35
- 36. Provide Rest Periods Decrease Consolidate Cardiac Care Workload Respond to Crying Monitor tolerance to feedings 36
- 37. Nutritional Management Give small frequent high calorie formulas Use a large holed nipple Gavage Feedings PRN Monitor Cardiac Tolerance • Tachycardia • Tachypnea • Desaturation 37
- 38. Diagnostic Evaluation for Heart Diseases: A variety of invasive and noninvasive tests may be used in the diagnosis of heart disease. 1. Electrocardiogram (ECG) : It provides information about heart rate, rhythm, state of the myocardium, presence or absence of hypertrophy (thickening of the heart walls), ischemia or necrosis due to inadequate cardiac circulation, and abnormalities of conduction. 2. Chest x-ray: X-ray examination can furnish an accurate picture of the heart size and the contour and size of the heart chambers. 38
- 39. Cont.. 3. Fluoroscopy: a form of radiography, provides a permanent motion-picture record of important information about the size and configuration of the heart and great vessels 4. Echocardiography: ultrasound cardiography, has become the primary diagnostic test for heart disease. High-frequency sound waves, directed toward the heart, are used to locate and study the movement and dimensions of cardiac structures, such as the size of chambers, thickness of walls, relationship of major vessels to chambers. 39
- 40. Cont.. 5. Phonocardiography : a diagram of heart sounds translated into electrical energy by a microphone placed on the child's chest and then recorded as a diagrammatic representation of heart sounds. The technique can measure the timing of heart sounds that occur too quickly or at too high or too low a sound frequency for the human ear to detect by direct auscultation. 6. Magnetic resonance imaging (MRI) may also be used to evaluate heart structure or size or blood flow 40
- 41. Cont.. 7. Cardiac Catheterization: Opaque catheter introduced into heart chambers via large peripheral vessels is observed by fluoroscopy or image intensification, pressure managements and blood samples provide additional sources of information. 8. Digital Subtraction Angiography (D.S.A): Opaque media injected into circulatory system provides computerized image as vessels and tissue containing dye subtracts all tissue don't containing dye. 41
- 42. Nursing Care of Family and Child with C H D Assessment: Nursing care of the child with congenital heart disease begins as soon as the diagnosis is suspected. However in many instances symptoms that suggest cardiac anomaly is not present at birth or if manifested is so subtle that they are easily overlooked. 42
- 43. Nursing Care of Family and Child with C H D Infants: Cyanosis generalized, especially mucous membranes, lips and tongue. Conjunctiva, cyanosis during exertion such as crying, feeding, straining, or when immersed in water. Dyspnea, especially following physical effort such as feeding, crying or straining. Fatigue, paroxysmal hyperpnea, poor growth and development (failure to thrive). Frequent respiratory tract infection. Feeding difficulties. Hypotonia. Excessive sweating. 43
- 44. Nursing Care of Family and Child with C H D Older children: Impaired growth. Fatigue. Orthopnea. Headache. Leg fatigue. Delicate body build. Effort dyspnea. Digital clubbing. Epistaxis. 44
- 45. Nursing Care of Family and Child with C H D 1- Nursing Diagnoses: Decreased cardiac output related to structural defect Goal: The patient will exhibit improved cardiac output. Intervention: Administer digoxin as ordered. The child's apical pulse is always checked before administrating digoxin (as general rule the drug is not given if the pulse is below 90-100 b/m in infants and young children or below 70 b/m in older children). 45
- 46. Cont.. Expected Outcome: Heart rate and volume indicate satisfactory cardiac output. 2- Nursing Diagnoses: Activity intolerance related to imbalance between oxygen supply and demand. Goal: The patient will Maintain adequate energy levels. 46
- 47. Cont.. Intervention: Allow for frequent of rest. Encourage quite games and activities. Help child to select activities appropriate to age, condition and capabilities. Avoid extremes of environmental temperature. Expected Outcome: Child determines and engages in activities commensurate with capabilities. 47
- 48. Cont.. 3- Nursing Diagnoses: Altered growth and development related to inadequate oxygen, nutrients to tissue and social isolation. Goal: The patient will: Achieve normal growth. Intervention: Provide well balanced highly nutrition diet. Expected Outcome: Child achieves normal growth. 48
- 49. Cont.. Goal: (2) The patient will: Exhibit adequate iron level. intervention: Administer iron preparation as prescribed. Encourage iron rich foods in diet Expected Outcome: Child assimilates sufficient iron. 49
- 50. Cont.. Goal: (3) The patient will: Have opportunity to participate in activities. Intervention: Encourage age appropriate activities. Expected Outcome: Child engaged in age appropriate activities. 50
- 51. Cont.. 4- Nursing Diagnoses: High risk for infection related to debilitated physical status. Goal: The patient will: Exhibit no evidence of infection. Intervention: Avoid contact with infected persons. Provide for adequate rest. Provide optimum nutrition. Expected Outcome: Child remains free from infection. 51
- 52. Cont.. 5- Nursing Diagnoses: Altered family process related to having a child with a heart condition. Goal : (1) The patient will: Experienced reduction of fear and anxieties. Intervention: Discuss with parents their fears regarding child symptoms. Expected Outcome: Family discusses their fear and anxieties. 52
- 53. Cont.. Goal: (2) The patient will: Exhibit positive coping behavior. Intervention: Encourage family to participate in care of child while hospitalized. Encourage family to include others in child's care to prevent their own exhaustion. Assist family in determining appropriate physical activity and disciplining methods for child's anorexia. Expected Outcome: Family copes with child's symptoms in a positive way. 53
- 54. Cont.. Goal: (3) The patient will: Demonstrate knowledge of home care. Intervention: Teach skills for home care. Administration of medications. Feeding techniques, Signs that indicate complications. Where and whom to contact for help and guidance. Expected Outcome: Family demonstrates ability and motivation for home care 54
- 55. Cont.. 6- Nursing Diagnoses: High risk for injury (complications) related to cardiac condition and therapies. Goal: The patient's family will: Recognize sings of complications early. Intervention: Teach family to intervene during hypercyanotic spells, place child in knee chest position with head and chest elevated. 55
- 56. Cont.. Teach family to recognize signs of complications such as: - Digoxin toxicity (vomiting, bradycardia, dysrhythmias). - Increased respiratory effort (tachypnea, retraction, grunting, cough, cyanosis). - Hypoxemia (cyanosis, restlessness, tachycardia). - Cerebral thrombosis (compensatory polycythemia is particularly hazardous when child is dehydrated). - Cardiovascular collapse (pallor, cyanosis and hypotonia). Expected Outcome: Family recognizes signs of complications and institutes appropriate action. 56
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