Patent Ductus Arteriosus Nursing Care and Management

In patent ductus arteriosus (PDA), the lumen of the ductus remains open after birth.

What is Patent Ductus Arteriosus?

The ductus arteriosus is a fetal blood vessel that connects the pulmonary artery to the descending aorta.

In patent ductus arteriosus (PDA), the lumen of the ductus remains open after birth.
This creates a left to right shunt of blood from the aorta to the pulmonary artery and results in recirculation of pulmonary blood through the lungs.
The prognosis is good if the shunt is small or surgical repair is effective.

Pathophysiology

The pathophysiology of patent ductus arteriosus stems from the following:

Non-modifiable Factors

Genetics: Congenital heart defects appear to run in families and sometimes occur with other genetic problems, such as Down syndrome.
Age: Patent ductus arteriosus is more common in premature babies. Also, babies with other types of congenital heart defects often have a patent ductus arteriosus.
Gender: PDA is twice as common in girls as in boys.

Modifiable Factors

Experiencing any of the following conditions during pregnancy can increase the risk of having a baby with a heart defect.

Rubella infection: Becoming infected with rubella (German measles) while pregnant can increase the risk of fetal heart defects. The rubella virus crosses the placenta and spreads through the fetus’s circulatory system damaging blood vessels and organs, including the heart.
Poorly controlled diabetes: Uncontrolled diabetes in the mother in turn affects the fetus’s blood sugar causing various damaging effects to the developing fetus.
Drug or alcohol use or exposure to certain substances: Use of certain medications, alcohol or drugs, or exposure to chemicals or radiation during pregnancy can harm the developing fetus.
Presence of other congenital heart defects. Babies with other types of congenital heart defects often have a patent ductus arteriosus.
Schematic Diagram via Scribd

Statistics and Incidences

Patent ductus arteriosus is the most common congenital heart defect among adults.

PDA is found in 1 of every 2, 500 to 5, 000 infants.
It affects twice as many females as males.

Causes

Normally, the ductus arteriosus closes within days to weeks after birth, and the failure to close may be attributed to the following factors:

Prematurity. PDA is most prevalent in premature neonates, probably as a result of abnormalities in oxygenation.
Prostaglandin E. The relaxant action of prostaglandin E prevents ductal spasm and contracture necessary for closure.
Other congenital defects. PDA commonly accompanies rubella syndrome and may be associated with other congenital defects, such as coarctation of the aorta, ventricular septal defect, and pulmonary and aortic stenoses.

Clinical Manifestations

Initially, PDA may produce no clinical effects, but in time it can precipitate pulmonary vascular disease, causing symptoms to appear by age 40.

Respiratory distress. A large PDA usually produces respiratory distress.
Heart failure. There are signs of heart failure due to the tremendous volume of blood shunted to the lungs through a patent ductus and the increased workload on the left side of the heart
Low immune system. The patient has a high susceptibility to respiratory tract infections.
Slow motor development. The patient’s motor skills expand and develop slower than the average person does.
Physical underdevelopment. One of the signs of heart disease is the physical underdevelopment of the patient’s body.
Heart murmur. Auscultation reveals a continuous murmur best
Bounding peripheral pulses. Peripheral arterial pulses are bounding; also called Corrigan’s pulse.
Widened pulse pressure. Pulse pressure is widened because of an elevation in the systolic blood pressure, and primarily, a drop in the diastolic pressure.

Complications

Patent ductus arteriosus, if left untreated, could lead to the following:

Left-sided heart failure. The left-to-right shunting of the blood renders the cardiac muscles of the left chamber overworked and leads to heart failure.
Pulmonary artery hypertension. There is increased pulmonary venous return leading to pulmonary hypertension.

Assessment and Diagnostic Findings

Patent ductus arteriosus is diagnosed by the following:

Chest x-ray. Chest x-ray may show increased pulmonary vascular findings, prominent pulmonary arteries, and left ventricle and aorta enlargement.
Electrocardiography (ECG). ECG may be normal or may indicate left atrial or ventricular hypertrophy and in pulmonary vascular disease, biventricular hypertrophy.
Echocardiography. Echocardiography detects and helps determine the size of PDA.

Medical Management

Asymptomatic children do not require immediate treatment but those with heart failure require the following:

Fluid restriction. Fluids should be restricted or controlled to avoid overloading the heart.

Pharmacologic Therapy

Medications for the patient with PDA include:

Prostaglandin analogs. The ductus arteriosus can be induced to remain open by administering prostaglandin analogs such as alprostadil (a prostaglandin E₁ analog).
Antibiotics. Before surgery, children with PDA require antibiotics to protect against infective endocarditis.
Indomethacin. Indomethacin is a prostaglandin inhibitor that’s an alternative to surgery in premature neonates and induces ductus spasm and closure.

Surgical Management

Other forms of therapy include surgical interventions such as:

Cardiac catheterization. In cardiac catheterization, a plug or coil is deposited in the ductus to stop the shunting.
Ligation. The DA may be closed by ligation, wherein the DA is manually tied shut, or with intravascular coils or plugs that leads to formation of a thrombus in the DA.

Nursing Management

Nursing management for a patient with patent ductus arteriosus include:

Nursing Assessment

Assessment should focus on:

Activity and rest. The nurse should assess for weakness, fatigue, dizziness, a sense of pulsing, and even sleep disorders.
Circulation. Circulatory assessment should include history trigger conditions, history of heart murmurs and palpitations, BP, and pulse pressure.
Food and fluids. The nurse should assess for dysphagia and changes in body weight.

Nursing Diagnosis

Based on the assessment data, the major nursing diagnoses include:

Activity intolerance related to imbalance between oxygen consumption of the body and supply of oxygen to the cells.
Anxiety related to hospital care or lack of support system.
Deficient knowledge related to the condition and treatment needs.

Nursing Care Planning & Goals

The major goals for the patient are:

Maintain adequate cardiac output.
Reduce the increase in pulmonary vascular resistance.
Maintain adequate levels of activity.
Provide support for growth and development.
Maintain appropriate weight and height development.

Nursing Interventions

Patent ductus arteriosus necessitates careful monitoring, patient and family teaching, and emotional support.

Signs and symptoms. Watch carefully for signs of PDA in premature infants.
Monitoring. Frequently assess vital signs, ECG, electrolyte levels, and intake and output.
Adverse effects of indomethacin. If the infant receives indomethacin for ductus closure, watch for possible adverse effects, such as diarrhea, jaundice, bleeding, and renal dysfunction.
Preoperative instructions. Before surgery, carefully explain all treatments and tests to parents, including the child, and tell them about expected IV lines, monitoring equipment, and postoperative procedures.
Postoperative procedures. Immediately after surgery, the child may have a central venous pressure catheter and an arterial line in place, so careful assessment of vital signs, intake and output, and arterial and venous pressures are needed, as well as pain relief.

Evaluation

Expected outcomes include:

Reduced the increase in pulmonary vascular resistance.
Maintained adequate levels of activity.
Provided support for growth and development.
Maintained appropriate weight and height development.

Discharge and Home Care Guidelines

Before discharge, the following should be reviewed with the patient and the family:

Instructions. Review instructions with parents about activity restrictions based on the child’s tolerance and energy levels.
Activities. Advise the parents not to be overprotective as the child’s tolerance for physical activity increases.
Follow-up checkups. Stress the need for regular follow-up examinations.
History. Advise parents to inform any practitioner who treats his child about his history of surgery for PDA-even if the child is treated for an unrelated medical problem.

Documentation Guidelines

The focus of documentation should include:

Client’s understanding of individual risks and safety concerns.
Availability and use of resources.
Current and previous level of function.
Level of anxiety and precipitating/aggravating factors.
Description of feelings.
Awareness and ability to recognize and express feelings.
Plan of care.
Teaching plan.
Client involvement and response to interventions, teaching, and actions performed.
Attainment or progress toward desired outcomes.
Modifications to plan of care.
Long term needs.

Practice Quiz: Patent Ductus Arteriosus

Here’s a 5-item quiz about the study guide. Please visit our nursing test bank page for more NCLEX practice questions.

1. An infant with a patent ductus arteriosus is admitted to the pediatric unit ward. The nurse anticipates which of the following medications will be given to the infant?

A. Prednisone.
B. Ibuprofen.
C. Penicillin.
D. Albuterol.

1. Answer: B. Ibuprofen.

B: When surgical ligation is not indicated, prostaglandin inhibitors (e.g., nonsteroid anti-inflammatory drugs [NSAIDs]) are used to close the ductus arteriosus.
A, C, D: Options A, C, and D are not used for the management of patent ductus arteriosus.

2. A premature baby might have the option of medical treatment of a PDA by way of administration of:

A. Fluconazole.
B. Tramadol.
C. Warfarin.
D. Indomethacin.

2. Answer: D. Indomethacin.

D: Indomethacin is a prostaglandin inhibitor that’s an alternative to surgery in premature neonates and induces ductus spasm and closure.
A, B, C: The following medications are not administered to a patient with patent ductus arteriosus.

3. A patent ductus arteriosus can lead to:

A. Cyanosis.
B. Left-sided heart failure.
C. Right-sided heart failure.
D. A&B.

3. Answer: D. A&B.

D: PDA could cause both cyanosis and left-sided heart failure as the left-to-right shunting of the blood renders the cardiac muscles of the left chamber overworked and leads to heart failure and cyanosis.
C: Right-sided heart failure does not occur in PDA as the shunting of the blood is from left to right, hence the most affected and overworked part is the left side of the heart.

4. The structure that connects the aorta to the pulmonary artery in utero is known as the:

A. Pulmonary vein.
B. Left ventricle.
C. Ligamentam arteriosum.
D. Ductus arteriosus.

4. Answer: D. Ductus arteriosus.

D: The ductus arteriosus is a fetal blood vessel that connects the pulmonary artery to the descending aorta.
A: The pulmonary vein is one of four vessels that carry aerated blood from the lungs to the left atrium of the heart.
B: The left ventricle is the left lower chamber of the heart that receives blood from the left atrium and pumps it out under high pressure through the aorta to the body.
C: Ligamentam arteriosum is a cord of tissue that connects the pulmonary trunk and the aorta and that is the vestige of the ductus arteriosus.

5. When assessing a newborn diagnosed with patent ductus arteriosus, Nurse Olivia should expect that the child most likely would have an:

A. Loud, machinery-like murmur.
B. Bluish color to the lips.
C. Decreased BP reading in the upper extremities.
D. Increased BP reading in the upper extremities.

5. Answer: A. Loud, machinery-like murmur.

A: A loud, machinery-like murmur is a characteristic finding associated with patent ductus arteriosus.
B, C, D: The following symptoms are not associated with patent ductus arteriosus.

Patent Ductus Arteriosus

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