Congenital heart disease


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Congenital heart disease

  1. 1. Congenital Heart Disease (C.H.D) Najah Kh. Qasem Lecturer in Nursing College Qassem University 1
  2. 2. Objectives1- 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. 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. 4. Types of Congenital Heart DefectsCongenital 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. 5. Types of Congenital Heart Defects2. 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
  6. 6. 6
  7. 7. Atrial Septal Defects (ASD): DefinitionAbnormal 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. 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. 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. 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. 11. Ostium SecundumMost common type ofASDCenter of the septumbetween the right andleft atrium. 11
  12. 12. Ostium PrimumLocated in the lowerportion of the atrialseptum.Will often have a mitralvalve defect associatedwith it called a mitral valvecleft.A mitral valve cleft is aslit-like or elongated holeusually involves theanterior leaflet of the mitralvalve. 12
  13. 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. 14. Hemodynamic: 14
  15. 15. Hemodynamic:When blood passes through the ASD from the leftatrium to the right atrium, a larger volume of bloodthan normal must be handled by the right side of theheart. Extra blood then passes through the pulmonaryartery into the lungs, causing higher pressure thannormal in the blood vessels in the lungsThe lungs are able to cope with this extra pressure fora while, depending on how high the pressure is. Aftera while, however, the blood vessels in the lungsbecome diseased by the extra pressure. 15
  16. 16. Symptoms of ASDMany children have no symptoms and seemhealthy.If the ASD is large, permitting a large amountof blood to pass through to the right side ofthe heart, the right atrium, right ventricle, andlungs will become overworked, andsymptoms may be noted. 16
  17. 17. Symptoms of ASDThe 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. 18. Treatment for ASDSpecific treatment for ASD will be determined by cardiologist based on: childs age, overall health, and medical history extent of the disease (the size of the defect) childs tolerance for specific medications, procedures, or therapies expectations for the course of the disease parent opinion or preference 18
  19. 19. Treatment may include1- Medical managementsome 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. 20. Treatment may include2- Infection controlChildren 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. 21. Treatment may include3- Surgical repairThe 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. 22. Repair 22
  23. 23. Robo repair 23
  24. 24. Tetralogy of FallotCharacterizedby FourStructuralDefects. Representsapproximately10% of casesof congenitalheart disease 24
  25. 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. 26. Con..In tetralogy of fallot, the out flow of the bloodfrom the right ventricle resisted by thepulmonary stenosis so that the blood flowsthrough the ventricular septal defect into theaorta. This is a right to left shunt.Hypertrophy of the right ventricle occurs as aresult of the pressure exerted against thepulmonary stenosis, because the blood fromthe right ventricle is unoxygenated, cyanosisresult 26
  27. 27. Con..Polycythemia develops because the bodyattempts to compensate for the unoxygenatedblood. The resulting increased viscosity of theblood causes stowing of the circulation andpossible thrombophlebitis emboli andvascular disease. 27
  28. 28. Assessment Findingswith Tetralogy of FallotThe 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. 29. Assessment Findings with Tetralogy of FallotSymptoms 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. 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. 31. Cont.. RV predominance on palpation May have a bulging left hemithorax Aortic ejection click Scoliosis (common) Retinal engorgement Hemoptysis 31
  32. 32. Treatment of the Childwith TOF Decrease cardiac workload Prevention of intercurrent infection Prevention of hemoconcentration Surgical repair 32
  33. 33. Nursing Care of the Childwith Tetralogy of FallotCare During a Hypercyanotic SpellDecrease Cardiac WorkloadMaintain NutritionAdministration of Cardiac MedicationsDecrease Respiratory Distress 33
  34. 34. Hypercyanotic Spells/Blue Spells/Tet SpellsClinical Manifestations Most often occurs in morning after feedings, defecation, or crying Acute cyanosis Hyperpenia Inconsolable crying Hypoxia which leads to acidosis 34
  35. 35. Nursing Care ForBlue Spells1- Place Infant in Knee Chest Position2- Administer 100% Oxygen3- Administer Morphine4- Use a Calm Approach5- IV Fluid Replacement for Blood Volume Expansion6- Decrease Cardiac Workload 35
  36. 36. Provide Rest PeriodsDecrease ConsolidateCardiac CareWorkload Respond to Crying Monitor tolerance to feedings 36
  37. 37. Nutritional Management Give small frequent high calorieformulas Use a large holed nipple Gavage Feedings PRN Monitor Cardiac Tolerance• Tachycardia• Tachypnea• Desaturation 37
  38. 38. Diagnostic Evaluation forHeart 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. 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 vessels4. 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. 40. Cont..5. Phonocardiography : a diagram of heart sounds translated into electrical energy by a microphone placed on the childs 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. 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 dont containing dye. 41
  42. 42. Nursing Care of Familyand Child with C H DAssessment: 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. 43. Nursing Care of Family and Child with C H DInfants: 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. 44. Nursing Care of Family and Child with C H DOlder children: Impaired growth. Fatigue. Orthopnea. Headache. Leg fatigue. Delicate body build. Effort dyspnea. Digital clubbing. Epistaxis. 44
  45. 45. Nursing Care of Family and Child with C H D1- Nursing Diagnoses:Decreased cardiac output related to structural defectGoal:The patient will exhibit improved cardiac output.Intervention: Administer digoxin as ordered. The childs 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. 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. 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. 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. 49. Cont..Goal: (2)The patient will: Exhibit adequate iron level.intervention: Administer iron preparation as prescribed. Encourage iron rich foods in dietExpected Outcome:Child assimilates sufficient iron. 49
  50. 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. 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. 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. 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 childs care to prevent their own exhaustion. Assist family in determining appropriate physical activity and disciplining methods for childs anorexia.Expected Outcome:Family copes with childs symptoms in a positive way. 53
  54. 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. 55. Cont..6- Nursing Diagnoses: High risk for injury (complications) related to cardiaccondition and therapies.Goal:The patients 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. 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
  57. 57. 57