Congenital heart disease results from malformations of the heart that involve the septums, valves, and large arteries. They are classified as acyanotic or cyanotic defects. Acyanotic defects occur when a left-to-right shunt is present that allows a mixture of oxygenated and deoxygenated blood to enter the systemic circulation. The most common consequences of these defects in children are growth retardation and congestive heart failure (CHF).
Common cyanotic defects include tetralogy of Fallot and transposition of the great vessels. Tetralogy of Fallot involves four defects that include pulmonic stenosis, ventricular septal defect, right ventricular hypertrophy, and an aorta that overrides the ventricular septal defect. Transposition of the great vessels is a condition in which the aorta arises from the right ventricle instead of the left ventricle, and the pulmonary artery arises from
the left ventricle instead of the right ventricle, thereby causing a reversal of the normal position of these arteries. Transposition of the great vessels is incompatible with life unless septal defects are also present to allow mixing of blood from the two circulations.
Acyanotic defects include coarctation of aorta, patent ductus arteriosus, and ventricular septal defect. Coarctation of the aorta is the narrowing of the aorta proximal to the ductus arteriosus (preductal), distal to the ductus arteriosus (postductal), or level with the ductus arteriosus (juxtaductal). The position of the narrowing during fetal development determines circulation to the lower body and development of collateral circulation. Patent
ductus arteriosus is the failure of the structure needed for fetal circulation to close after birth. Ventricular septal defect is the incomplete development of the septum that separates the right and left ventricles, and it often accompanies other defects.
Nursing Care Plans
Congenital heart defects vary in severity, symptoms, and complications, many of which depend on the age of the infant/child and the size of the defect. Treatment may include management with medications, open heart surgery to repair or resect, or to temporarily correct the defect until the child is older and growth takes place.
- Decreased Cardiac Output
- Activity Intolerance
- Compromised Family Coping
- Risk for Injury
- Risk for Infection
Decreased Cardiac Output
May be related to
- Structural factors of congenital heart defect
Possibly evidenced by
- Variations in hemodynamic readings (hypertension, bounding, pulses, tachycardia, specify values)
- Widened pulse pressure
- ECG changes,
- Decreased peripheral pulses
- Cyanosis or absence of cyanosis
- Squatting or knee-chest position
- Child will demonstrates adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm within normal parameters for patient; strong peripheral pulses; and an ability to tolerate activity without symptoms of dyspnea, syncope, or chest pain.
|Assess heart rate and blood pressure.||Most patients have compensatory tachycardia and significantly low blood pressure in response to reduced cardiac output.|
|Note skin color, temperature, and moisture.||Cold, clammy, and pale skin is secondary to a compensatory increase in sympathetic nervous system stimulation and low cardiac output and oxygen desaturation.|
|Check for peripheral pulses, including capillary refill.||Weak pulses are present in reduced stroke volume and cardiac output. Capillary refill is sometimes slow or absent.|
|Assess for reports of fatigue and reduced activity tolerance.||Fatigue and exertional dyspnea are common problems with low cardiac output states. Close monitoring of the patient’s response serves as a guide for optimal progression of activity.|
|Inspect fluid balance and weight gain. Weigh patient regularly prior to breakfast.||Compromised regulatory mechanisms may result in fluid and sodium retention; Weight is an indicator of fluid balance.|
|Assess heart sounds for gallops (S3, S4).||S3 indicates reduced left ventricular ejection and is a class sign of left ventricular failure. S4 occurs with reduced compliance of the left ventricle, which impairs diastolic filling.|
|Monitor electrocardiogram (ECG) for rate, rhythm, and ectopy.||Cardiac dysrhythmias may occur from low perfusion, acidosis, or hypoxia. Tachycardia, bradycardia, and ectopic beats can further compromise cardiac output. Older patients are especially sensitive to the loss of atrial kick in atrial fibrillation.|
|Provide adequate rest periods||Rest decreases metabolic rate, decreasing myocardial and oxygen demand.|
|Position child in semi-Fowler’s position.||Upright position is recommended to reduce preload and ventricular filling when fluid overload is the cause; Facilitates lung expansion.|
|Administer oxygen therapy as prescribed.||The failing heart may not be able to respond to increased oxygen demands. Oxygen saturation need to be greater than 90%.|
|Administer medications as prescribed:|
||Increases contractility of the heart and force of contraction.|
||Maintain open PDA when needed for blood flow.|
||Decreases edema formation and diminish afterload.|
Recommended nursing diagnosis and nursing care plan books and resources.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
- NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
- Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
- Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
- Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
- All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other nursing care plans for cardiovascular system disorders:
- Angina Pectoris (Coronary Artery Disease) | 4 Care Plans
- Cardiac Arrhythmia (Digitalis Toxicity) | 3 Care Plans
- Cardiac Catheterization | 4 Care Plans
- Cardiogenic Shock | 5 Care Plans
- Congenital Heart Disease | 5 Care Plans
- Heart Failure | 18 Care Plans
- Hypertension | 6 Care Plans
- Hypovolemic Shock | 4 Care Plans
- Myocardial Infarction | 7 Care Plans
- Pacemaker Therapy | 7 Care Plans