CONGINITAL HEART DISEASE

INTRODUCTION:--

Congenital heart defect is a specialty of pediatrics. However, persons with congenital heart defect are now leaving longer and are being treated as adult.

Incidence:--

About 2/3 of patients suffering from congenital heart disease have surgically correctable. The incidence of CHF is 7.5%.It is based on research findings. The incidence in western countries is of relatively lower magnitude i.e. 2.0 to 7.3%.

Congenital heart defects are the most common type of major birth defect. More than 30,000 babies are born with a congenital heart defect in the United States each year.

Definition:--

The term "congenital heart defect" indicates that a structural problem (or defect) in a baby's heart is present at birth. A baby's heart begins to form shortly after conception. By the end of the 2nd month of pregnancy, the baby's heart is completely formed. It is during this time that a congenital heart defect can occur.

In this case, a part of the heart, heart valves, and/or blood vessels near the heart do not develop properly. When this happens, blood flow can:

Slow down Go in the wrong direction or to the wrong place Be blocked completely

Types of Congenital Heart Defects:--

Congenital heart defects have been divided into two categories

i) Acyanoticii) Cyanotic

But in clinical practice this system is problematic because with acyanotic defect may develop cyanosis. And more often, those with cyanotic defects may be pink and have clinical signs of CCF.

Another classification system is based on hemodynamic characteristics also used. The defining characteristics of blood flow patterns:--

i) Increased pulmonary blood flowii) Decreased pulmonary blood flow

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iii) Obstruction blood flow

iv) Mixed blood flow

{Pl. see opposite page}

Defects with increased pulmonary blood flow:--

In this group of cardiac defects, intracardiac communication along the septum or an abnormal connection between great arteries allows blood to flow from the high-pressure left side of the heart to the lower-pressure right side of the heart. Increased blood volume on the right side of the heart increases pulmonary blood flow at the expense of systemic blood flow. Clinically client demonstrates signs and symptoms of CCF. Under this condition following condition is---

i) Atrial septal defectii) Ventricular septal defect

iii) Patent ductus arteriosus

Obstructive defect:--

Obstructive defect are those in which blood exiting the heart an area of anatomic narrowing (stenosis), causing obstruction to blood flow. The pressure in the ventricle and great artery before the obstruction is increased and the pressure in the area beyond the obstruction is decreased. Clinically infants and children exhibit signs of CCF. Children with mild obstruction may be asymptomatic, as in severe pulmonic stenosis, hypoxemia may be seen.

i) Coarctation of aortaii) Aortic stenosis

iii) Pulmonic stenosis

iv) Atrioventricular canal defect

Decreased pulmonary blood flow:--

In these types of defects, there is obstruction of pulmonary blood flow and an anatomic defect (ASD/VSD) between right and left side of heart. Because blood flow has difficulty during the right side of the heart vai the pulmonary artery, pressure on right side increases, exceeding left-side pressure. This allows desaturated blood to shunt right to left, causing desaturation in the left side of the heart and in the systemic circulation. Clinically these clients are hypoxemic and usually appear cyanotic. Following condition is ---

i) Tetrology of fallotii) Tricuspid atresia

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Mixed defects:--

Many complex cardiac anomalies are classified together in the mixed category because survival in the postnatal periods depends on mixing of blood from the pulmonary and systemic circulation within heart chambers. Pulmonary congestion occurs because the differences in pulmonary artery pressure and aortic pressure favor a volume load on the ventricle. Clinically these client have a variable picture that combines some degree of desaturation and signs of CCF. Following condition is;--

i) Transposition of great arteriesii) Truncus arteriosus

iii) Total anomalous pulmonary venous return

iv) Hypo plastic left heart syndrom

Causes of Congenital Heart Defect

Not known causes of most cases of congenital heart disease. Heredity may play a role. In rare cases, more than one child in a family is born

with a heart defect.

Also, parents who have a congenital heart defect may be more likely than other parents to have a child with the condition.

Babies who have certain other birth defects, such as Down syndrome, are also more likely to have congenital heart disease.

Other factors that raise the risk for congenital heart disease are:

Having viral infections such as German measles during pregnancy

Having diabetes Taking some types of prescription or over-the-counter medications during

pregnancy Being repeatedly exposed to some chemicals or x-rays during pregnancy Using alcohol or street drugs during pregnancy.

Signs and Symptoms of Congenital Heart Defects

The most common signs and symptoms of congenital heart defects are:

A heart murmur

A bluish tint to skin, lips, and fingernails ("blue baby") Fast breathing Shortness of breath Poor feeding, especially in infants because they tire easily while nursing Poor weight gain in infants

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Tiring easily during exercise or activity (older children).

The signs and symptoms depend on:

The number and types of defects

The severity of the defect.

Some infants and children have no signs or symptoms. Others have severe or life-threatening symptoms.

Many types of congenital heart defects cause the heart to work harder than it should. This stresses the heart and can lead to heart failure, causing the heart muscle to weaken.

Diagnoses of Congenital Heart Defects

Doctors usually diagnose congenital heart defects during pregnancy or within the first few months after birth.

Some children with less severe defects are not diagnosed until they are older and more demands are put on their hearts.

Others are not diagnosed until they are adults.

Diagnosis made using--- family and medical history, do a physical examination, and order several tests.

Physical Examination

During the physical examination:--

Auscultation of heart murmur Looks for signs of illness or physical problems such as bluish color of skin and

lips, shortness of breath, rapid breathing, and delayed growth Auscultation of lungs.

An echocardiogram is the test most often used to diagnose congenital heart disease. This test uses sound waves to create a picture of the heart. An echocardiogram helps diagnose heart failure and problems with how the heart is formed.

During pregnancy, if it suspects that baby has a congenital heart disease, a special test called a fetal echocardiogram can be done. This test uses sound waves to create a picture of the baby's heart while still in the womb. It is usually done during the 5th month of pregnancy.

If child is diagnosed with a congenital heart disease before birth, so further plan of treatment can be made before the baby is born.

Other tests used to help diagnose congenital heart diseases include:4

EKG or ECG (electrocardiogram) . This test measures the rate and regularity of child's heartbeat.

Chest x-ray . A chest x-ray takes a picture of child’s heart and lungs. It can show if child's heart is enlarged or if there is any fluid in child's lungs.

Pulse oximetry this test uses a sensor to see how well child's lungs are passing oxygen to the blood and whether or not there is any mixing of red (oxygenated) blood and blue (de-oxygenated) blood. The sensor is placed on the child's fingertip or toe (like a bandaid). A small computer unit shows the amount of oxygen in the blood through the skin.

Cardiac catheterization . In this test, a thin flexible tube is passed through an artery or vein at the top of the leg (groin) or in the arm to reach the heart. With the assistance of x-rays,doctor can then see the child's blood vessels and heart. The catheter also measures the pressure inside the heart and blood vessels and can determine if blood is mixing between the two sides of the heart. Sometimes, a dye that can be seen by x-ray is injected into the heart. This enables doctor to see the flow of blood throughout the heart and blood vessels.

Treatement

Medications

Special procedures using catheters Surgery Heart transplants.

The treatment child receives depends on the type and severity of the defect.

Other factors include your child's age, size, and general health.

Treatment can be simple or very complex.

Many children are treated with medications and are monitored by their doctor.

Other children may need surgery.

Medications

The following medications to help the heart work better and lessen symptoms:

Digoxin is thought to improve heart function and can keep the heartbeat regular.

Diuretics treat the buildup of fluid in the heart and body. ACE inhibitors decrease the work the heart has to do and may help remodel

the heart and blood vessels to work more efficiently. Beta-blockers slow the heart rate and lower blood pressure to decrease the

workload on the heart.5

Inotropes strengthen the heart's pumping ability. Prostaglandin E1 is used to keep the ductus arteriosus open in some defects

until corrective surgery can be performed. This improves blood flow and oxygen levels until the defect is corrected. The ductus arteriosus normally closes within a few days after birth.

Special Procedures Using Catheters

Correction with use of some congenital heart defects during cardiac catheterization. These are called catheter-based procedures or interventions.

They can be used instead of open-heart surgery, which is a major operation.

A catheter is inserted through blood vessels in child’s groin.

It is then threaded to the heart where some holes in the interior walls of the heart can be fixed, a patent ductus can be closed, and narrow valves and blood vessels can be opened up. Interventional catheterization:

Does not require child's chest to be opened Lets child recover quickly Have different risks than open heart surgery.

Surgery

Your child may need open-heart surgery if the defect cannot be repaired using a catheter-based procedure. Some surgeries repair the defect completely. Other surgeries improve your child's health but do not completely repair the defect. Open-heart surgeries that may correct the defect include:

Closing holes with sutures or with a patch

Repairing valves Widening arteries or openings to valves Putting the great arteries (aorta and pulmonary artery) back to their normal

position.

Sometimes, open-heart surgeries can improve a child's health but do not repair the problem. Examples include:

Decreasing blood flow to the lungs by placing a band around the pulmonary artery

Increasing blood flow to the lungs by connecting an artery from the aorta to the pulmonary artery Connecting the veins that bring back blue blood directly to the pulmonary artery in a 3-stage surgery when the right ventricle is not developed, e.g., Hypo plastic left heart syndrome.

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Heart Transplantation

Babies born with multiple defects that are too complex to repair may need a heart transplant. In this procedure, the child's heart is replaced with a healthy heart that has been donated

Prevention of Congenital Heart Defects

There is no known way to prevent congenital heart defects, but there are things you can do to lower the chance that baby will have a congenital heart defect. However, even by lowering the risks, baby may still develop congenital heart disease.

If mother is pregnant or planning for pregnant, talk to doctor about any medications that they are taking, including:

Over-the-counter medications

Prescription medications Vitamin and mineral supplements Herbal supplements.

Doctor will recommend that you take folate(folic acid) before become pregnant. This is recommended mainly to prevent abnormalities in the baby's nervous system, but there is some evidence that it may also help prevent certain types of congenital heart defects.

Mother need to avoid:

Strong chemicals, including some cleaning productsRepeated x-raysAny harmful or poisonous materials. If mother or anyone in family has congenital heart disease, genetic

testing may be available.

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Various congenital defect , S/S, management and prognosis

Defect Description Clinical Manifestation

Surgical Treatment andNon-surgical Treatment

Prognosis

Atrial Septal Defect

Abnormal opening between the atria, allowing blood from the higher pressure left atrium to flow into the lower pressure right atrium.

Ostium primum -opening at lower end of septum

Ostium secundum -opening near centre of septum.

Sinus venosus defect - opening near junction of superior vena cava.

asymptomatic Characteristic

murmur. Atrial

dyshythmias

Dacron patches closure. ASD- 1 may require repair or

rarely, replacement of the mitral valve.

ASD-2 also be closed using devise during cardiac catherization.

Very low operative mortality less than 1%

Ventricular Septal Defect

Abnormal opening between right and left ventricles.

Membranous or muscular. May very in size from pin

hole to absence of septum. May be associated with PS,

COA, PDA, ASD.

s/s of CCF Characteristic

murmur. S/S of BE.

Palliative: -- pulmonary banding in symptomatic infants.

Complete repair:--small repair with a purse-string approach. Large defects usually require a knitted Dacron patch over opening.

Device closure during cardiac catherization is under clinical trials in some centers.

Depends on location of defect. Up to 20%

Atrioventricular Canal Defect

Incomplete fusion of endocardial cushions. Consists of low septal defect that is continuous with a high ventricular septal defect and clefts of the mitral and tricuspid valves, creating a large central atrioventricular (A-

Moderate to severe CCF.

Mild cyanosis during crying.

Palliative:--pulmonary artery banding

Complete repair:--patch closure of defect and reconstruction of A-V valve tissue.

If valve defect is severe valve replacement is needed.

Operative Mortality rate is 10%

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V) valves that allows blood flows into all four chambers of heart.

Patent Ductus Arteriosus

Failure of the fetal ductus arteriosus (artery connecting the aorta and pulmonary artery) to close within the first weeks of life. The continued patency of this vessel allows blood to flow from the higher-pressure aorta to the lower-pressure pulmonary artery causing a left-to right shunt.

Asymptomatic

Machinery like murmur

Widened pulse pressure.

Bounding pulse

Surgical division or ligation of patent vessel via left thoracotomy. And visually assisted thoractomy surgery (VATS) is performed.

Closure with placement of an occluder device during cardiac catherization.

Low risk less than 1% mortality

Coarctation of the aorta

Localized narrowing near the insertion of the ductus arteriosus resulting in increased pressure proximal to the defect (head and upper extremities) and decreased pressure distal to the obstruction (body and lower extremities.)

High BP and bounding pulse

Weak or absent femoral pulse

Cool extremities

Severely acidotic & hypotensive.

Dizziness Headache Fainting

Each portion of coarcted portion with an end-to-end anastomosis of aorta or enlargement of the constricted section using a graft of prosthesis material or apportion of the left subclavian artery.

Balloon angioplasty as a primary intervention for COA.

Less than 5%

Aortic Stenosis Narrowing or stricture of the aortic valve, causing resistance to blood flow in the left ventricle, decreased cardiac output, ventricular hypertrophy, left ventricular

s/s of decreased cardiac output

hypotension bradycardia poor sucking

Aortic valvotomy. Dilating narrowed valve with

balloon angioplasty- during catheterization.

Cutting of fibro muscular ring. A patch is required to enlarge

the entire left ventricular outflow

Operative Mortality rate is 2% -8%

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hypertrophy. Valvular stenosis is more

common caused by malformed cusps resulting in a bicuspid rather than tricuspid valve of fusion of the cusps.

Sub-Valvular stenosis is a stricture caused by a fibrous ring below a normal valve.

exercise in tolerance(children-after 3yrs)

chest pain dizziness with

standing longer time

characteristics murmur

tract and annulus and replace aortic valve- this procedure is known as Konno procedure.

An aortic homograft with a valve may also be used –extended aortic root replacement

Pulmonic valve may be moved to the aortic position and replaced with a homograft valve—Ross procedure.

Pulmonic Stenosis

Narrowing at the entrance to the pulmonary artery.

Pulmonary atresia is the extreme form of PS in that there is total fusion of the commissures and no blood flows to the lungs.

Asymptomatic

Severe narrowing newborn –cyanosis

s/s of cardiomegaly

In infant closed valvotomy—Brock procedure )

In children—pulmonary valvotomy.

Balloon angioplasty to dilate valve.

It is the treatment of choice for discrete PS in most centre and can be done safely in neonates.

Operative Mortality rate is <2%

Tetrology of Fallot

The classic form includes four defect—

i) VSD ii) PS iii) Overriding of aorta iv) Right ventricular hypertrophy

Infant -acute cyanotic

characteristics murmurhypoxia called blue spell children - with

increasing cyanosis having clubbing of fingure squatting and poor growth

s/s of brain hypoxia

Palliative- shunt-in infant can not undergone primary repair. Known as modified Blalock-Taussig shunt.

Elective repair performed in first year of life.

A complete repair involves closure of VSD and resection of the infundabular stenosis with a pericardial patch to enlarge the right ventricular outflow tract. The procedure requires a median sternotomy and the use of cardio-pulmonary bypass.

Operative Mortality rate is < < 5%

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seizuresloss of consciousnesssudden death

Tricuspid Atresia Failure of tricuspid valve to develop, no communication between right atrium and right ventrical.

It is often associated with PS and TOA.

There is a complete mixture of oxygenated blood with deoxygenated blood in left side of heart, resulting in systemic desaturation and varying amounts of pulmonary obstruction causing decreased pulmonary blood flow.

Cyanosis Tachycardia Dyspnea Chronic

hypoxemia with clubbing

Possibility of brain abscess and stroke

Palliative:--placement of a shunt to increase blood flow to the lungs. If ASD is small, an atrial septostomy is done during cardiac catheterization.

A bidirectional Glenn shunt-cavopulmonary anastomosis.

Modified Fontan procedure:--A fenestration (opening) in the right atrial baffle is sometime done to relieve pressure.

Operative Mortality rate is >10%

TGA /TGV The pulmonary artery leaves the left ventricle and the aorta exists from the ventricles, with no communication between the systemic and pulmonary circulation.

Depends on type & size of associated defect

If defect is minimum-Cyanotic and depressed at birth

Defect is larger-less cyanotic but having s/s of CCF

cardiomegaly

Arterial switch procedure:--involves transecting great arteries and anastomosing the main pulmonary artery to the proximal aorta and anastomosing the ascending aorta to the proximal pulmonary artery.

Rastelli procedure:--It involves closure of VSD , closure of pulmonic valve and conduit is placed in right ventricles to the pulmonary artery, creating a physiologically normal circulation.

Operative Mortality rate is 5% -10%

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Truncus Arteriosus

Failure of normal septation and division of the embryonic bulbar trunk into the pulmonary artery and aorta, resulting in a single vessel that overrides both ventricles.

I—a single pulmonary trunk

II—the left & right pulmonary arteries arise separately from posterior aspect of truncus.

Asymptomatic

Moderate to severe CCF

Variable cyanosis

Poor growth Activity

intolerancecharacteristics murmur

Corrective repair involves closing the VSD so that the truncus arteriosus receives the outflow from the left ventricle, excising the pulmonary arteries from the aorta and attaching them to the right ventricle by means of a homograft.

Mortality rate is more than 10%

Hypoplastic Left Heart Syndrome

Underdevelopment of the left side of the heart, resulting in a hypo plastic left ventricle and aortic atresia.

More blood from left atrium flows across the patent foramen ovale to the right atrium, to the right ventricle and out the pulmonary artery.

The descending aorta receives blood from the PDA supplying systemic blood flow.

Mild cyanosis s/s of CCF s/s of collapse

of cardiovascular

fatal condition

Several-staged approach.First stage- No wood procedure-anastomosis of the main pulmonary artery to the aorta to create a new aorta, shunting to provide pulmonary blood flow and creation of a large ASD.Second stage—bidirectional Glenn shunts done at 6-9 month of age to relive cyanosis and reduce the volume load on the right ventricle.Final stage-- modified Fontan procedure (same as tricuspid atresia) stabilize mechanical ventilation prostaglandin E1 infusion to

maintain ductal patency Ensuring adequate blood flow.

Mortlity rate is more than 25%

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NURSING PROCESS

Nursing diagnosis Expected outcome Implementation evaluation High risk for

decreased cardiac output related to structural defect

Will exhibit improved cardiac output.

Assess child for decreased cardiac output signs.

Assess vital signs frequently according to condition.

Monitor homodynamic parameters: CVP, BP.

Measure intake and output. Administered drugs according schedule

i.e.digoxin, diuretics. Observed for effect, side effect, and toxic

effect of drugs.

Cardiac output increased –

Pulse, respiration, BP, and peripheral perfusion are normal for age. Urine output is

adequate (0.5-2ml/kg.

Activity intolerance related to imbalance between oxygen supply and demand.

Will maintain adequate energy levels without additional stresses.

Monitor vital signs before, immediately and after activity and 3 min later.

Monitor for tachycardia, pallor, diaphoresis after activity.

Encourage him for verbalize feeling regarding fatigue or limitation.

Assistant provided with self care activities and provide frequent rest period, after meals.

Increased activity as guided by physician.

Child determines and engages in activities commensurate with capabilities.

Child receives appropriate amount of rest/ sleep.

Altered growth and development related to inadequate oxygen and nutrients to tissue.

Will follow growth curve for weight and height.

Assess the child’s height and weight and compare with normal according to his age group.

Provide well-balanced, highly nutritious diet to achieve adequate growth.

Monitor height and weight, plot on growth charts to determine growth and trend.

May administered iron supplements to correct anemia if prescribed.

Chile receives adequate growth.

Will have to participate in age appropriate

Encourage age appropriate activities. Emphasize that child has same need for

socialization as other children.

Child engages in age appropriate activity.

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activities. Allow child to set own pace and activity limits because child will rest when tired.

Child does not experience social isolation.

High risk for infection related to debilitated physical status.

Will exhibit no evidence of infection.

Observe for signs of generalized sepsis: redness, increase temperature.

Change IV and pressure line and dressing as policies and requirement maintaining aseptic technique to prevent nosocomial infection.

Obtained blood culture as and when required to rule out effectiveness of drugs given.

Obtained CBC with DC. Avoid contact with infected people. Provide adequate rest. Provide optimum nutrition to support

body’s natural defense.

Child remains free of infection.

Altered family processes related to having a child with a heart condition.

Will experience reduction of fear and anxiety.

Discuss with parent and child their fears and concerns regarding child’s cardiac defects and physical symptoms, since these frequently cause anxiety and fear.

Explain disease process with posters and charts.

Family discusses their anxieties.

Will exhibit positive coping behavior.

Encourage family to participate in care of child while hospitalized to facilitate better coping at home.

Encourage family to include others in child’s care to prevent their own exhaustion.

Guide family in determining appropriate physical activity and disciplining methods for child.

Family copes with child’s symptoms in a positive way.

Will demonstrate knowledge of home-care.

Teach skills for home care:--Administration of medication,Feeding technique, intervention for conserving energy and those directed

Family demonstrates ability and motivation for

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towards relief of frightening symptoms. Signs indicate complication. Where and whom to contact for help and

guidance. Anticipate need for further information

and support. Teach family how to do CPR.

home care. Family members

learn CPR technique.

High risk for injury (complication) related to cardiac condition and therapies.

Will recognize signs of complication early.

Teach family recognizes signs of CCF.—Tachycardia, tachypnea, profuse scalp sweating, fatigue and irritation.

Signs of digoxin toxicity:-Vomiting, nausea, anorexia, bradycardia, hypoxemia, cyanosis etc.

Teach family to intervene during hypercynanotic spells because cerebral hypoxia can cause brain damage or death.

Place child in knee-chest position. Remain calm. Administer 100% oxygen by face mask.

Family recognizes signs of complication and institute appropriate action.

Will demonstrate understanding of diagnostic tests and surgery.

Explain or clarify information presented to family by the surgeon.

Prepare child and parents for procedure. Assist with family’s decision regarding

surgery. Explore feeling regarding surgical

options.

Family demonstrate an understanding of procedure ( tests, surgery etc.)

Knowledge deficit Level of knowledge is increased.

Become a self –sufficient user and obtainer of health care knowledge.

Instruct parents on type of defect and how to manage at home, and provide referral services for assistance with home care.

Provide detail explanation of defect and surgical intervention and treatments as directed by defects.

During interaction with parent watch

Level of knowledge is increased is evidences by—

Family verbalize regarding defect, prescribed care, medication, need for visits and prophylaxis

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reaction of them to rule out if they understand or not.

Provide motivation by appealing to their interest and future uses of new knowledge.

Ask them if he is satisfied with him.

medication.

Anxiety related to actual or perceived threat to biological integrity.

Will reduce anxiety. Assess the sign of fear &anxiety Restless, facial expression.

Provide supportive care. Explain disease process and procedure as

they are implemented with age appropriate aids.

Ensure quiet environment. Reduced environmental stimuli. Maintain family contact.

Anxiety is decreased.

Family verbalizes reduction in anxiety level and demonstrates appropriate behavior.

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Client and family education:--

Living with a Congenital Heart Defect

With new advances in testing and treatment, most children with a congenital heart defect grow into adulthood and live productive lives.

Some continue to need specialized care for survival and to maintain a good quality of life.

Some may need multiple procedures including cardiac catheterizations and surgeries.

Others may need pacemakers to help their heart beat properly.

For Parents

Mothers of children born with a heart defect often think that they did something during pregnancy to cause the problem.

We do not know the cause of most cases of congenital heart disease.

It is important that mothers know that they did not cause their child's illness.

Explain parent that most children with congenital heart disease grow up to a healthy adulthood. Expect that child will be productive and able to work. Only children with complex heart disease may continue to need special medical attention.

Treatment and care for child in such cases can be costly. The cost of surgery and hospital stays is very high. They can get information from doctor and hospital about how to apply for financial aid.

Caring for a child with a serious heart problem can be demanding. If both parents work, one has stay home with child if cannot find suitable day care.

The drain on your energy, emotions, and finances can be very stressful. Ask your child's doctor about support groups and other support in your area.

Don't be shy about seeking counseling if the stress seems overwhelming.

General Issues

It is important for child to have ongoing regular medical care. This includes:

Following up with child's heart specialist as directed

Following up with child's pediatrician or family doctor for routine exams Taking medications as prescribed.

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May consider them to having your child wear a medical alert bracelet or necklace. This tells anyone caring for your child that your child has a congenital heart disease.

Adults, teenagers, and children should have routine dental care to prevent infections of the mouth.

Most people with congenital heart disease need to take antibiotics before a dental procedure, treatment, or cleaning.

Talk to doctor before taking to child to the dentist.

Counsel parent regarding:--

Children with a Congenital Heart Defect

Some children with congenital heart disease sometimes do not grow and develop as fast as other children the same age.

That your child may be smaller and thinner than other children.

Your child may also start activities like rolling over, sitting, and walking later than other children.

After treatments and surgery, growth and development often improve.

Your child may need extra calories to grow.

If your child's heart has to pump faster because of the defect, the body needs more energy to keep up the extra work.

This may cause your child to tire quickly.

Some babies are not able to eat enough because they tire while feeding.

Older children also may tire before finishing a meal

Exercise for Children

Exercise helps children strengthen their muscles and stay healthy.

Your child may tire easily, so take frequent breaks and let your child rest during activities if necessary.

Some children with congenital heart disease may need to limit the amount or type of exercise.

Talk to your doctor about what is safe exercise for your child.

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Remember to ask your doctor for a note for school and other organizations describing any limits on your child's exercise or physical activities.

Emotional Issues for Children

Children with a serious heart problem may have a hard time coping or feel isolated because they may have to be in the hospital frequently.

Some children feel sad or frustrated with their body image and their inability to be a "normal" kid.

Sometimes brothers or sisters are jealous of all the attention received by the child with congenital heart disease.

Parents may feel stress over financial and insurance issues.

child may feel that he or she is the cause of this stress. Help your child by talking to him or her and allow child to be involved in everyday activities.

Teenagers with a Congenital Heart Defect

The teenage years are difficult for most children. It is a time of risk taking, and denial is often used as a way of coping. There is pressure to be like other teenagers.

Some teenagers with congenital heart disease still need specialized care and must take medicine on a regular basis.

Help your teenager cope with the stresses of growing up with a serious health problem.

Remind your teenager that with proper care, he or she can grow up healthy and participate in most, if not all, activities.

Let your teenager help make decisions about medical care. This fosters independence and encourages regular follow up with the doctor.

Many teenagers with congenital heart disease can participate in organized sports.

Restrictions of activity vary depending on the teenager, the type of sport, and the type of heart disease.

Some children need to limit the amount of activity while others need to avoid contact sports. Your doctor can help you and your teenager decide which sports activities are right for him or her.

Getting a good education and advanced job training "opens the door" to the kinds of jobs that are ideal for those who cannot do strenuous work.

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Overall, parents should be aware that the vast majority of children born with congenital heart disease live normal, healthy lives and should be encouraged to do so.

Adults with Congenital Heart Defect

Adults with congenital heart disease should carefully consider changing jobs if advised.

Pregnancy and a Congenital Heart Defect

Women with congenital heart disease who want to become pregnant (or who are pregnant) need to:

Talk to their doctor about health risks during pregnancy. Talk to their doctor about medications that can be taken during pregnancy. Consult with specialists who take care of pregnant women with this health.

BIBLIOGRAPHY:--

Behrman, Koiengman, Arvin, “Nelson’s Textbook of Pediatrics”, Singapore: W.B.Saunders Co; 15th edition, 1999.

Pp no –586-592.

Smeltzers, S.C. & Bare, B.C. “Brunner & Suddarth’sText book of Medical Surgical Nursing”, Philadelphia: Lippincott Co; 10th edition, 2004.

Ppno—738-741. Marlow,D.R. “Textbook of Pediatric Nursing”, Philadelphia: W.B.Saunders Co; 6th edition, 1985. Pp no—466-491. Tambulwadkar,R.S. “Pediatric Nursing”, Bombay, Vora Medical Publication, 1st edition, 1997. Pp no—147-155. Isaacs, P.C. and Mandelew,B.C. “Nursing Care of Children-A Guide for

Study”, Philadelphia: J.B.Lippincott Co; 1985. Pp no—159-168. Scipien, C.H. “Pediatric Nursing Care”, Missouri: Mosby; 3rd edition,

1996. Pp no –598-609. Whaley and Wong’s “ Essentials of Pediatric Nursing”, Philadelphia,

Mosby, 5th edition, Pp no—587 -585. Tandon, R. “Bedside Approach in the Diagnosis of Congestive Heart

Disease”, New Delhi: B.I.Churchill Livingstone Co; 1st edition, 1998.

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PATHOPHYSIOLOGY:--

NANE OF CONDITION PATHOPHYSIOLOGICAL CHANGESVentricular Septal Defect (VSD)

Due to higher pressure in left ventricle & systematic circulation

Resistance in pulmonary circulation

Blood flow through defect in to pulmonary artery(right-to-left shunt)

Increase blood volume is pumped in lungs

Increased pulmonary resistance , increased pressure in right ventricle

Muscles hypertrophy.Patent Ductus Arteriosus(PDA)

Equalizing résistance in aorta & pulmonary artery

Increase in systematic pressure

Exceeds pulmonary pressure, blood flows from aorta, acrossThe duct to the pulmonary artery. (Left-to-right shunt)

Effect of altered circulation increased workload on left side heart.

Increased right ventricular pressure and hypertrophy.Coaarctation Of Aorta (COA) Due to narrowing of aorta

Increased pressure proximal to defect leads to right ventricle outflows cannot maintain to the descending aorta due to this collateral circulation develops to

maintain blood flows.Atrial Stenosis (AS) Due to stricture in outflows tract causes resistance to ejection of blood from the left

ventricle. The extra work load on the left ventricle causes hypertrophy. Leads to increase left atrial pressure cause increased pressure in the pulmonary veins,

resulting in pulmonary vascular congestion.Pulmonary Stenosis (PS) Presence of PS causes Resistance to blood flow causes right ventricular

hypertrophy.Increased right ventricular pressure may result in reopening of foremen ovale,

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shunting of unoxygenated blood into the left atrium and systemic cyanosis. Tricúspide Atresia At birth the presence of a patent foramen ovale is required to permit blood flow

across the septum in to left atrium, PDA allows blood flow to the pulmonary artery into the lungs for oxygenation. A VSD allows a modest amount of blood to enter the right ventricle and pulmonary artery for oxygenation.

Truncus Arteriosus (TA) Due to common trunkBlood ejected from the left and right ventricles

Mixing pulmonary and systematic circulation according to the relative resistance of each.

The amount of flow depends on size of the pulmonary atresia and pulmonary vascular resistance.

Hypo plastic Left Heart Syndrome (HLHS)

ASD/ Patent foramen ovale allows saturated blood from the left atrium to mix with desaturated blood from right atrium

The amount of blood flow depends on relationship between the pulmonary and

systemic vascular resistances.

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