Prepared by Dr Nahed El- nagger Assistant professor of Nursing UMM AL- QURA UNIVERSITY FACULTY OF APPLIED MEDICAL SCIENCES NURSING DEPARTMENT Congenital Heart Disease CHD Prepared by Dr Nahed El- nagger Assistant professor of Nursing 1430-1431 H

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).

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.

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.

Fetal Circulation

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.

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.

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.

Normal circulatory changes at birth

The Heart

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 trimester

Classification of CHD: A cyanotic versus cyanotic Acyanotic Cyanotic Pulmonary Blood flow Obstruction to Blood flow from ventricles Pulmonary blood flow Mixed blood flow Atrial septal defect (ASD) Ventricularr septal defect (VSD) Coarctation of Aorta Aortic stenosis Tetrology of Fallot Tricuspid atresia Transposition of great vessels

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

Selected A cyanotic defects (1) Atrial Septal Defect or ASD : 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.

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.

…. Cont. acyanotic (2) Ventricular Septal Defect or VSD, : It is an abnormal opening between the right and the 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 (2) Ventricular Septal Defect or VSD, : Surgical treatment: complete repair. Non-surgical treatment: closure devise is usually implanted during cardiac catheterization

Cardiac catheterization lab

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.

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.

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.

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.

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

CoA - cont…. Symptoms and Signs: 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.

CoA - cont…. Diagnostic : ECHO Treatment: Ballon angioplasty. Surgical : Resection of the aorta and anastomosis or grafting.

5. AORTIC STENOSIS (AS) Is an obstruction to outflow from the left ventricle at or near the aortic valve. More common in males.

AORTIC STENOSIS ( AS) Symptoms: 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.

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

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.

Tetrology of Fallot (TOF) 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 heart History - cyanosis Turn blue? At rest? When crying? Passes out? Stops playing and squats

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.

TRANSPOSITION OF THE GREAT ARTERIES

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.

3. PULMONIC STENOSIS ( PS) A narrowing of the pulmonary valve. Associated with a history of maternal rubella

PS - cont... Symptoms: None in mild or moderate stenosis. Cyanosis is seen only with critical PS. Diagnostic : ECHO. Treatment : Balloon valvotomy.

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

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.

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!

Question The nurse would identify which congenital heart disease as involving increased pulmonary blood flow? Triscupid atresia Patent ductus arteriosus Tetralogy of Fallot Aortic stenosis

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.

Question A child with CHD experiences hypercyanotic spells. The nurse would place the child in which position for relief? Supine Trendelenburg Knee-to-chest Prone

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

GOOD LUCK !!!!!!! THANK YOU