CARDIAC EXAM THREE
Congenital Heart Disease
Acyanotic Defects
I.
Etiology
a. Possible Causes
i. Fetal exposure to drugs
1. Phenytoin
2. Lithium
3. Alcohol
4. Tobacco smoke
ii. Maternal metabolic disorders
1. Diabetes mellitus
2. hypercalcemia
iii. increased maternal age
iv. genetic patterns
v. chromosomal abnormalities
1. trisomy syndromes 13, 15, 18, 21
a. 21 is downs syndrome
b. Physical Consequences
i. Most dangerous and most common is CHF
ii. Increased work load of the heart
1. Decreases exercise tolerance
iii. Pulmonary hypertension
1. Tachypnea and recurrent respiratory infections
iv. Inadequate systemic output
1. Tissue hypoxia
v. Cyanotic defects
vi. Growth retardation
vii. Child at risk for acid base problems and dehydration
c. Signs and Symptoms
i. Feeding difficulties resulting in poor weight gain
ii. Cyanosis intermittent or persistent
1. Clubbing of fingers and toes
iii. Exercise intolerance
1. Hypotonic posture
iv. Frequent respiratory infections, dyspnea, stridor
v. Characteristic heart murmur
vi. Infants bradycardia <120 or tachy >160
vii. Weak or muffled cries
II.
1. Cries should be angry
viii. General level of activity is restless or lethargic
ix. Observe posture
1. Hypotonic, hyper extension of neck, dyspnea when supine
x. When sitting upright tripod position, chin out tongue protruding
xi. Hearing loss
Types of CHD
a. Atrial Septal Defect
i. Size and symptoms depend on size and location of defect
ii. Small and high on the septum
1. No problem
iii. Large and close to entry of vena cava
1. Some mixing of blood
iv. Murmur = systolic with a widely split second heart sound
v. EKG = diastolic overload at R atrium
vi. Treatment
1. Closed during a cardiac catheterization
2. Closed by surgery-done by school age
3. Closes by self
b. Ventricular Septal Defect
i. Most common cardiac defect
ii. Blood flows from L ventricle to R ventricle
iii. Limited damage because pulmonary vasculature is low pressure
iv. Size and location related to pulmonary pressure
1. R ventricular hypertrophy
2. L atrial hypertrophy
3. As children age extensive L to R shunting no longer occurs
because increase in pulmonary pressures
4. Eisenmengers Syndrome
a. Sometimes R pressures becomes greater and L to R shunt
may occur
b. Exception to rule about mixing of blood
v. Signs and symptoms depend on size and location
vi. Assessment
1. Most defects are asymptomatic
2. Defects typically small
a. Not much L to R shunting
3. Harsh, loud or blowing left parasternal pansystolic murmur (left of
the sternal border and occurs throughout systole) may be heard
with thrill
4. Medium sized or larger defecs during infancy
a. May cause dyspnea, tachypnea, slow physical
development, feeding difficulties and frequent pulmonary
infections
b. Mild cyanosis upon crying
vii. Treatment
1. Closed via cardiac catheterization
2. If defect small and asymptomatic no treatment
a. Will close by 1-2 years of age
3. Treat surgically
a. If large need pacemaker
4. Medical management CHF
5. Risk of infective endocarditis children
a. Need antibiotics before invasive procedure
c. Patent ductus Arterious (PDA)
i. Twice as frequent in females
ii. Typically closes in the first 24 to 72 hours of life
iii. If does not close, the higher pressure in the aorta can cause the blood to
flow into the pulmonary artery
1. Oxygenated blood recirculates through the pulmonary system
2. Increase work on the L side of the heart and vascular pressure in
the pulmonary tree, increase blood flow in the ascending aorta
iv. Signs and symptoms depend on the size of ductus and amount of shunting
v. Assessment
1. Classic machinery type of murmur
2. Dyspnea on exertion, easy fatigability (susceptibility to fatigue)
3. Physical under development
4. Increase infections
5. HR >150 gallop rhythm, bounding pulses and wide systemic pulse
pressure
6. CHF at 6 to 12 weeks in a full term infant
vi. Management
1. Medical
a. Supportive fluid restriction
b. Diuretics
c. Digoxin
i. Special considerations for neonates
2. Surgical
a. Transection, ligation of the ductus (done at 6 months)
i. Treat even if asymptomatic because of CHF,
infective endocarditis, and calcification at the ductal
site
3. Pharmacologic closure low birth rate infants
a. Indomethacin (Indocin)
i. Inhibits prostaglandin synthesis (cell contractility)
ii. Improvement occurs in 12 to 18 hours
iii. May contribute to hyperbilirubinemia (causes
jaundice), transient renal dysfunction, and
hyponatremia
d. Pulmonic Stenosis
i. Pulmonary valve is obstructed by fusion of the cusps at their commissures
1. Increases systolic pressure and hypertrophy of the right ventricle
ii. In general cyanosis
iii. Loud Pulmonary systolic ejection murmur
iv. Management
1. Mild to moderate do nothing
2. Severe do valvotomy to open valve
e. Aortic Stenosis
i. Valvular or Subaortic
ii. Causes restriction of blood outflow and L hypertrophy
iii. Signs and symptoms
1. Small is typically asymptomatic until physical growth requires
additional CO
2. Longer fatigue, dizziness, fainting, and episodes of pulmonary
edema
iv. With age
1. Faint peripheral pulses and angina pain
2. Death after sudden exertion because of decreased blood flow to
heart
3. Coarse systolic ejection murmur with thrill
a. Radiates to neck and down L sternal border
f. Coarction of the Aorta
i. Localized malformation caused by a deformity of the aorta that results in a
narrowing of the lumen of the vessel
ii. Two types
1. Preductal
a. Between subclavian artery and the ductus arterious
2. Postductal
a. Distal to the ductus arterious
iii. Assessment
1. BP is higher then normal in upper part of body
2. Pt may have headache, dizziness, fainting, epistasis, and later CVA
3. BP is decreased in lower areas of body
a. Absence or diminished femoral pulses, legs cooler than
arms and muscle cramps with exercise
iv. Management
1. Surgical repair is the desired treatment, especially for infants or
children with long stenosis
v. Complications
1. Hypertension
2. GI problems occur N?V
3. Distention
4. Pain
a. If severe may indicate small bowel obstruction
Cyanotic Defects
I.
Tetralogy of Fallot
a. Four anomalies
i. Obstruction to R ventricular out flow (pulmonary stenosis)
ii. Ventricular septal defect
iii. Overriding aorta
iv. R ventricular hypertrophy
b. Assessment
i. Infants are not cyanotic because of patent ductus
ii. Cyanosis can be seen lips mouth finger and toes
iii. Dusky body (dark in color)
iv. Polycythemia
v. 1 to 2 years of age clubbing
vi. Knee chest position
vii. Paroxysmal dyspnea attacks (blue spells)
1. Can last a few minutes to a couple of hours
2. Short episode –sleep
3. Long –unconsciousness, convulsions and death
4. Occurs with no warning
a. Follow feeding, emotional upset and defecation, hypoxia,
and metabolic acidosis
viii. Management
1. Prevent above
2. Corrective Procedures
a. Close VSD
b. Pulmonary Valve open
3. Palliative
a. Many names essentially create a ductus
b. Therapy prostaglandin E (PGE)
i. Relaxes smooth mucle of the ductus and keeps it
open
c. May produce systemic hypotension
c. Transposition of Great Vessel
i. The tricuspid valve fails to open thus no communication between R atrium
and R ventricle
ii. Management
1. Blood flows through ASD or patent foramen ovale to the L side of
the heart
2. Prostoglandin E
d. Truncus Arteriosus
i. Pulmonary artery and aorta do not separate
ii. 1 vessel receives blood from L and R side of heart
iii. Requires large VSD for survival
Nursing Care
I.
Assessment
a. Acyanotic
i. Poor weight gain, small stature
ii. Respiratory diseases
iii. Exercise intolerance
iv. Tachycardia, tachypnea, dyspnea
v. Not or mild cyanosis
b. Cyanotic
i. Usually at time of birth
ii. Difficulty eating because of inability to breath and suck at the same time
iii. Delayed physical growth because of chronic hypoxia
iv. Frequent and severe respiratory infections
v. Moderate to severe exercise intolerance
vi. Chest pain that becomes severe with exercise
vii. Hypoxic spell during periods of high demand for O2
1. Sob, cyanosis, chest pain, squats
viii. Chronic hypoxia
1. Increases RBC count
2. Causes clubbing of fingers and toes \
3. Hgb may rise 20-30 gm or more
4. Hematocrit 60-80% increase
ix. Polycythemia
c. Pre op
i. Baseline vitals, including apical pulse, existence and quality of peripheral
pulses
ii. Educational needs
iii. Lab values, CBC, chemistry
d. Post Op
i. Respiratory states, chest tubes and drainage, breath sounds
ii. Vital signs, including apical and femoral pulse, arterial an venous
pressures, cardiac rhythm
iii. Hydration and output status
1. Weigh diapers
iv. S and s of CHF
v. Color of skin, mucous membranes, nail beds and ear lobes
vi. Level of discomfort and anxiety
vii. Surgical incisions (suture line)