CYANOTIC CONGENITAL HEART DISEASE

• The common cause of cyanotic congenital heart disease is a communication between the
pulmonary and systemic circulation through which venous (unoxygenated) blood enter the
systemic circulation. Cyanosis may be seen at birth or may be later, it tends to increase as the
child grow older.

TETRALOGY OF FALLOT:
• This term include four defects:
• Pulmonary stenosis
• Ventricular septal defect
• Overriding of aorta
• Right ventricular hypertrophy
 PATHOPHYSIOLOGY:
• The altered hemodynamics depends primary on the degree of defect, eg. Pulmonary
stenosis, ventricular septal defect, pulmonary and systemic resistance to blood flow.
↓
• Shunt direction depends upon the systemic and pulmonary resistance.
↓
• If pulmonary resistance is higher than systemic then the shunt is from right to left-if systemic
is higher than pulmonary then the shunt is from left to right
↓
• Mixing of oxygenated blood with deoxygenated blood.

DIAGNOSIS:
• On auscultation , a loud systolic murmur may be heard.
• Radiography shows the enlarged ventricle on the right side, the large aorta.
• The unusual shape of the heart .i.e boot-shaped heart.
• Cardiac catheterization reveals systolic hypertension in the right ventricle.

CLINICAL MANIFESTATIONS:
• Cyanosis become evident during the first month of life. Cyanosis can be seen most easily in
the mucous membrane of the lips, mouth, oral pharynx, and in nails.
• Exercise usually cause sever dyspnea.
• Paroxysmal dyspneic attack during first 24 months of life and last for a few minutes to
hours.
• On auscultation a loud, systolic murmur may be heard.
•
MANAGEMENT:
• Palliative and corrective surgery for tetralogy of fallot is done on infants and children of all
ages:

PALLIATIVE PROCEDURE:
• One or more surgical procedures may be done to increase pulmonary blood flow:
• A side to side anastomosis of the ascending aorta and pulmonary artery.
• Blalock-Tausing or modified Blalock-Tausing shunt ahich provide blood flow to the
pulmonary arteries from the left or right subclavian artery.
• Recently medical treatment has been successful to keep ductus open:- therapy with
prostaglandin E1(PGE1) keep the ductus open.
CORRECTIVE PROCEDURE:
• Complete repair of tetralogy of fallot include closure of the ventricular septal defect.
• The pulmonic valve stenosis opened

TRANSPOSITION OF THE GREAT VESSELS:

• In this anomaly the aorta has its origin in the right ventricle, and the pulmonary artery has its
origin in the left ventricle. Hence aorta carries oxygenated blood to
• the systemic circulation and the pulmonary caries oxygenated back to the lung.

DIAGNOSIS:
• Chest radiography shows progressive cardiomegaly and increased pulmonary vasculature.
– Right ventricular hypertrophy
– Cardiac catheterization and angiography determine the intercommunication

CLINICAL MANIFESTATIONS:
• Cyanosis- varies in degree depending on the defect.
• Infants are dyspnic and feeding problem.
• Growth retardation.

MANAGEMENT:

• Total correction can be achieved through the MUSTARD OPERATION ,in this a new atrial
septum is created from pericardium.
– Systemic venous unoxygenated blood returning to the right atrium is redirected to the mitrel
valve into the left ventricle and to pulmonary arttry.
– Oxygenated blood thet return to the left atrium is redirected to the tricuspid valve to the right
ventricle and into the systemic circulation through the aorta.

NURSING MANAGEMENT IN CONGENITAL HEART DISEASE:

• In addition to assessing the child and assisting with diagnostic procedures, nursing
management of an infant with congenital heart disease include helping family members to adjust
to the child care and providing both preoperative and post operative care.
• HELPING FAMILY MEMEBERS TO ADJUST
• EPISODE OF CYANOSIS END DYSPNEA
• NEED FOR COMFORT AND REST
• NUTRITIONAL NEEDS:

• MEDICATIONS

• PRE-OPERATIVE CARE

• BASELINELINE VITAL SIGNS

• HEIGHT AND WEIGHT MEAUREMENT

• PRE-OPERATIVE TEACHING
• Helping the parent and child deals with an unfamiliar situation, reducing trauma and
promoting growth.
INTRODUCTION TO THE ENVIRONMENT
INTRODUCTION TO POST-OPERATIVE PROCEDURES
• The nurse can teach them and help the child practice various procedures that will be
necessary post-operatively.
• The nurse shows the child semi fowler position .
• The nurse demonstrate the procedure of deep breathing and deep inspiration and
expiration.
• The child should be told that deep breathing cause some discomfort after surgery.
• The child can be splinted with pillow.
• The older child can be told briefly about nasogastric tube and about the indwelling cathter
that may be used to drain the urine from the bladder.

THE PRE-OPERATIVE PREPERATION

• Nothing given by mouth , 12 hours before surgery in order to prevent vomiting on aspiration.
• A sign is posted on the door and on bed indicating that nothing is to be given by mouth.
• Loose teeth of older children are reported in order to prevent aspiration during intubation.
• The child is weighed on same scale to know about fluid replacement.
• Enema may be given to prevent abdominal distension.
• Pre-operative medications are given at appropriate time before surgery, depending upon the
preferences of surgeon and anesthesiologist.

POST-OPERATIVE CARE
• Child sustain trauma to the heart during cardiac surgery, dissection of muscles and
placement of patches in septal defects. Contractibility of myocardium and ventilation may be
affected by the effect of anesthesia.
• The child is transfer to the intensive care unit and recovery room for 24-48 hours or longer
until the vital signs and all systems of the body stabilized.
• Special considerations should be given to providing proper rest to minimize the heart
demands.
• Prophylactic antibiotics should be administered to prevent infections.
• Electrolyte therapy should such as potassium and calcium may be given to promote cardiac
functions.
• Observe for the presence of hemorrhage if evident, if increased blood in chest tube
drainage.
• Immediately postoperatively the nurse should assess the general condition of the patient,
vital signs are checked every 15 minutes for first 12-24 hours.

• Temperature is taken carefully on neonate and infant who may have low temperature not
only because of immature thermoregulatory system but also due to hypothermia, i.e maintained at
the time of surgery.
• Infants may be placed under a radiant heat source, while older children may be covered
with warm blanket.
• If temperature continuous to be elevated after 48 hours infection may be present.
• The nurse continue to evaluate the Childs cardiac function and cardiac output.
• Serial reading of blood pressure, heart rate, CVP, are observed and recorded.
• CVP is the pressure within the right atrium. It indicate the ability of the right side of the heart
to manage fluid load. It provide measurement of effective circulating blood volume and help in fluid
replacement.

• The function of the body cells depends on adequate cardiac output for continue supply of
oxygenated blood, lips , mucosa, should be observed for cyanosis.
• Cardiac and respiratory functions are closely interrelated so that mechanical ventilation is
necessary after cardiac surgery.
• Postural drainage is done at least every 3-4 hours for the purpose of loosing secretions.
• Frequent suction is done.
• Chest tube drainage should be connected to remove air.
• Fluid intake by mouth is usually restricted for first 24 hours. A nasogestric tube must be
inserted into the stomach. Child gradually progress from clear liquids.
• The functioning of the nervous system should be assessed because brain may damage
due to cerebral edema, tissue ischemia, emboli. The nurse attempts to determine the clients
orientation to the environment.

POSSIBLE POST OPERATIVE COMPLICATIONS

CARDIOVASCULAR CMPLICATIONS
• Hypotension
• Hypovolemia
• Cardiac temponade
• Cardiac failure
• Formation of emboli

RESPIRATORY COMPLICATIONS
• Accumulation of the secretions in respiratory track.
• Atelactasis
• Pneumonia
• Pnumothorax
RENAL SYSTEM
• Renal failure can result from impairment of renal function caused by low cardiac output.

CENTRAL NERVOUS SYSTEM COMPLICATIONS

• Decreased cerebral blood flow.
• Emboli formation.

INFECTIONS
• Fever
• Local redness
• Swelling of skin.

BIBLIOGRAPHY:
1. Wong’s, “pediatric nursing” edition 6th
Published by Mosby, Pp 936-948.
2. Dorthy R.marlow , “textbook of pediatric
nursing” edition sixth,
published by saunders, Pp
466-491.
3. piyush gupta, ‘Essential pediatric nursing’
Second edition,Pp283-288.
4. 4.www.google.com