Congenital Heart

Disease
(C.H.D)

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 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.
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 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.

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 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.

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 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.
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 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.
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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.

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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

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Types of ASDs:

1-Ostium secundum defect→70% of ASDs.

2-Ostum primum defect→20% of ASDs.
3-Sinus venosus defect→10%of ASDs.

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Ostium Secundum
Most common type of
ASD
Center of the septum
between the right and
left atrium.

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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.
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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.

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Hemodynamic:

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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.
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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.

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 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
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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

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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

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 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

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 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.
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 Tetralogy of Fallot

Characterized
by Four
Structural
Defects.
 Represents
approximately
10% of cases
of congenital
heart disease

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 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.
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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 24
Con..
Polycythemia develops because the body
attempts to compensate for the unoxygenated
blood. The resulting increased viscosity of the
blood causes slowing of the circulation and
possible thrombophlebitis emboli and
vascular disease.

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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.

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 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
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 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
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Cont..
RV predominance on palpation
May have a bulging left hemithorax
Aortic ejection click
Scoliosis (common)
Retinal engorgement
Hemoptysis

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Treatment of the Child
with TOF

Decrease cardiac workload

Prevention of intercurrent infection
Prevention of hemoconcentration
Surgical repair

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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

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Hypercyanotic Spells/
Blue Spells/Tet Spells
Clinical Manifestations
‫ ٭‬Most often occurs in morning
after feedings, defecation, or crying
‫ ٭‬Acute cyanosis
‫ ٭‬Hyperpnea
‫ ٭‬Inconsolable crying
‫ ٭‬Hypoxia which leads to acidosis 32
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

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 Provide Rest
Periods

Decrease Consolidate
Cardiac Care
Workload Respond to
Crying

Monitor tolerance to
feedings
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Nutritional Management
Give small frequent high calorie
formulas
Use a large holed nipple
Gavage Feedings PRN
Monitor Cardiac Tolerance
• Tachycardia
• Tachypnea
• Desaturation
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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.
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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.
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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
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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.

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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.

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 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. 41
 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.

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 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).
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 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.
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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.

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 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.
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 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.

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 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.

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 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.
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 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.
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 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.
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 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
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 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.
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 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.
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