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 CH is !."#.$t is based on research findings. The incidence in western countries is of relatively lower magnitude i.e. 2.% to !.3#. Congenital heart defects are the most common type of ma&or birth defect. 'ore than 3%,%%% babies are born with a congenital heart defect in the (nited )tates 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. .y the end of the 2nd month of pregnancy, the baby-s heart is completely formed. $t is during this time that a congenital heart defect can occur. $n this case, a part of the heart, heart valves, and/or blood vessels near the heart do not develop properly. /hen this happens, blood flow can0

)low down 1o in the wrong direction or to the wrong place .e bloc2ed completely

Types of Congenital Hea t Defects:-Congenital heart defects have been divided into two categories i, ii, Acyanotic Cyanotic

.ut in clinical practice this system is problematic because with acyanotic defect may develop cyanosis. And more often, those with cyanotic defects may be pin2 and have clinical signs of CC . 1

Another classification system is based on hemodynamic characteristics also used. The defining characteristics of blood flow patterns033 i, ii, iii, iv, $ncreased pulmonary blood flow 4ecreased pulmonary blood flow 5bstruction blood flow 'i6ed blood flow

78l. see opposite page9 Defects !it" inc eased p#l$ona y %lood flo!:-$n this group of cardiac defects, intracardiac communication along the septum or an abnormal connection between great arteries allows blood to flow from the high3 pressure left side of the heart to the lower3pressure right side of the heart. $ncreased blood volume on the right side of the heart increases pulmonary blood flow at the e6pense of systemic blood flow. Clinically client demonstrates signs and symptoms of CC . (nder this condition following condition is333 i, ii, iii, Atrial septal defect :entricular septal defect 8atent ductus arteriosus

O%st #cti&e defect:-5bstructive defect are those in which blood e6iting 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 e6hibit signs of CC . Children with mild obstruction may be asymptomatic, as in severe pulmonic stenosis, hypo6emia may be seen. i, ii, iii, iv, Coarctation of aorta Aortic stenosis 8ulmonic stenosis Atrioventricular canal defect

Dec eased p#l$ona y %lood flo!:-2

$n these types of defects, there is obstruction of pulmonary blood flow and an anatomic defect +A)4/:)4, between right and left side of heart. .ecause blood flow has difficulty during the right side of the heart vai the pulmonary artery, pressure on right side increases, e6ceeding left3side 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 hypo6emic and usually appear cyanotic. ollowing condition is 333 i, ii, 'i(ed defects:-'any comple6 cardiac anomalies are classified together in the mi6ed category because survival in the postnatal periods depends on mi6ing of blood from the pulmonary and systemic circulation within heart chambers. 8ulmonary 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 CC . ollowing condition is;33 i, ii, iii, iv, Transposition of great arteries Truncus arteriosus Total anomalous pulmonary venous return Hypo plastic left heart syndrom Tetrology of fallot Tricuspid atresia

Ca#ses of Congenital Hea t Defect <ot 2nown causes of most cases of congenital heart disease. Heredity may play a role. $n 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 li2ely than other parents to have a child with the condition. .abies who have certain other birth defects, such as 4own syndrome, are also more li2ely to have congenital heart disease. 5ther factors that raise the ris2 for congenital heart disease are0 Having viral infections such as 1erman measles during pregnancy 3

Having diabetes Ta2ing some types of prescription or over3the3counter medications during pregnancy .eing repeatedly e6posed to some chemicals or 63rays during pregnancy (sing alcohol or street drugs during pregnancy.

Signs and Sy$pto$s of Congenital Hea t Defects The most common signs and symptoms of congenital heart defects are0

A heart murmur A bluish tint to s2in, lips, and fingernails +*blue baby*, ast breathing )hortness of breath 8oor feeding, especially in infants because they tire easily while nursing 8oor weight gain in infants Tiring easily during e6ercise or activity +older children,.

The signs and symptoms depend on0

The number and types of defects The severity of the defect.

)ome infants and children have no signs or symptoms. 5thers have severe or life3 threatening symptoms. 'any types of congenital heart defects cause the heart to wor2 harder than it should. This stresses the heart and can lead to heart failure, causing the heart muscle to wea2en. Diagnoses of Congenital Hea t Defects 4octors usually diagnose congenital heart defects during pregnancy or within the first few months after birth. )ome children with less severe defects are not diagnosed until they are older and more demands are put on their hearts. 5thers are not diagnosed until they are adults. 4iagnosis made using333 family and medical history, do a physical e6amination, and order several tests. )"ysical E(a$ination 4

4uring the physical e6amination033

Auscultation of heart murmur =oo2s for signs of illness or physical problems such as bluish color of s2in and lips, shortness of breath, rapid breathing, and delayed growth Auscultation of lungs.

An ec"oca diog a$ 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. 4uring 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. $t is usually done during the "th month of pregnancy. $f child is diagnosed with a congenital heart disease before birth, so further plan of treatment can be made before the baby is born. 5ther tests used to help diagnose congenital heart diseases include0

E*G o ECG +elect oca diog a$,- This test measures the rate and regularity of child-s heartbeat.

C"est (- ay. A chest 63ray ta2es a picture of child>s heart and lungs. $t can show if child-s heart is enlarged or if there is any fluid in child-s lungs.

)#lse o(i$et y this test uses a sensor to see how well child-s lungs are passing o6ygen to the blood and whether or not there is any mi6ing of red +o6ygenated, blood and blue +de3o6ygenated, blood. The sensor is placed on the child-s fingertip or toe +li2e a bandaid,. A small computer unit shows the amount of o6ygen in the blood through the s2in. Ca diac cat"ete i.ation. $n this test, a thin fle6ible tube is passed through an artery or vein at the top of the leg +groin, or in the arm to reach the heart. /ith the assistance of 63rays,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 mi6ing between the two sides of the heart. )ometimes, a dye that can be seen by 63ray is in&ected into the heart. This enables doctor to see the flow of blood throughout the heart and blood vessels.

T eate$ent

'edications 5

)pecial procedures using catheters )urgery Heart transplants.

The treatment child receives depends on the type and severity of the defect. 5ther factors include your child-s age, si?e, and general health. Treatment can be simple or very comple6. 'any children are treated with medications and are monitored by their doctor. 5ther children may need surgery. 'edications The following medications to help the heart wor2 better and lessen symptoms0

4igo6in is thought to improve heart function and can 2eep the heartbeat regular. 4iuretics treat the buildup of fluid in the heart and body. AC@ inhibitors decrease the wor2 the heart has to do and may help remodel the heart and blood vessels to wor2 more efficiently. .eta3bloc2ers slow the heart rate and lower blood pressure to decrease the wor2load on the heart. $notropes strengthen the heart-s pumping ability. 8rostaglandin @A is used to 2eep the ductus arteriosus open in some defects until corrective surgery can be performed. This improves blood flow and o6ygen levels until the defect is corrected. The ductus arteriosus normally closes within a few days after birth.

Special ) oced# es Using Cat"ete s Correction with use of some congenital heart defects during cardiac catheteri?ation. These are called catheter3based procedures or interventions. They can be used instead of open3heart surgery, which is a ma&or operation. A catheter is inserted through blood vessels in child>s groin. $t is then threaded to the heart where some holes in the interior walls of the heart can be fi6ed, a patent ductus can be closed, and narrow valves and blood vessels can be opened up. $nterventional catheteri?ation0

4oes not reBuire child-s chest to be opened =ets child recover Buic2ly Have different ris2s than open heart surgery.

S# ge y Cour child may need open3heart surgery if the defect cannot be repaired using a catheter3based procedure. )ome surgeries repair the defect completely. 5ther surgeries improve your child-s health but do not completely repair the defect. 5pen3heart surgeries that may correct the defect include0

Closing holes with sutures or with a patch Depairing valves /idening arteries or openings to valves 8utting the great arteries +aorta and pulmonary artery, bac2 to their normal position.

)ometimes, open3heart surgeries can improve a child-s health but do not repair the problem. @6amples include0

4ecreasing blood flow to the lungs by placing a band around the pulmonary artery $ncreasing blood flow to the lungs by connecting an artery from the aorta to the pulmonary artery Connecting the veins that bring bac2 blue blood directly to the pulmonary artery in a 33stage surgery when the right ventricle is not developed, e.g., Hypo plastic left heart syndrome.

Hea t T ansplantation .abies born with multiple defects that are too comple6 to repair may need a heart transplant. $n this procedure, the child-s heart is replaced with a healthy heart that has been donated ) e&ention of Congenital Hea t Defects There is no 2nown 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 ris2s, baby may still develop congenital heart disease.

$f mother is pregnant or planning for pregnant, tal2 to doctor about any medications that they are ta2ing, including0

5ver3the3counter medications 8rescription medications :itamin and mineral supplements Herbal supplements. 4octor will recommend that you ta2e 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. 'other need to avoid0 )trong chemicals, including some cleaning products Depeated 63rays Any harmful or poisonous materials. $f mother or anyone in family has congenital heart disease, genetic testing may be available.

/a io#s congenital defect 0 S1S0 $anage$ent and p ognosis Defect Atrial 4efect Desc iption Clinical 'anifestation asymptomatic Characteristic murmur. Atrial dyshythmias S# gical T eat$ent and ) ognosis Non-s# gical T eat$ent 4acron patches closure. :ery low A)43 A may reBuire repair or operative rarely, replacement of the mitral mortality valve. less than A)432 also be closed using devise A# during cardiac catheri?ation.

)eptal Abnormal opening between the atria, allowing blood from the higher pressure left atrium to flow into the lower pressure right atrium. 5stium primum3opening at lower end of septum 5stium secundum3opening near centre of septum. )inus venosus defect3 opening near &unction of superior vena cava. :entricular Abnormal opening between s/s of CC )eptal 4efect right and left ventricles. Characteristic 'embranous or muscular. murmur. 'ay very in si?e from pin )/) of .@. hole to absence of septum. 'ay be associated with 8), C5A, 84A, A)4.

Atrioventricular Canal 4efect

8alliative0 33 pulmonary banding in 4epends on symptomatic infants. location of Complete repair033small repair with defect. (p a purse3string approach. =arge to 2%# defects usually reBuire a 2nitted 4acron patch over opening. 4evice closure during cardiac catheri?ation is under clinical trials in some centers. $ncomplete fusion of 'oderate to 8alliative033pulmonary artery 5perative endocardial cushions. severe CC . banding 'ortality Consists of low septal defect 'ild cyanosis Complete repair033patch closure of rate is A%# that is continuous with a high during crying. defect and reconstruction of A3: ventricular septal defect and valve tissue. 9

clefts of the mitral and tricuspid valves, creating a large central atrioventricular +A3:, valves that allows blood flows into all four chambers of heart. 8atent 4uctus ailure of the fetal ductus Arteriosus arteriosus +artery connecting the aorta and pulmonary artery, to close within the first wee2s of life. The continued patency of this vessel allows blood to flow from the higher3 pressure aorta to the lower3 pressure pulmonary artery causing a left3to right shunt. Coarctation of =ocali?ed narrowing near the the aorta insertion of the ductus arteriosus resulting in increased pressure pro6imal to the defect +head and upper e6tremities, and decreased pressure distal to the obstruction +body and lower e6tremities.,

$f valve defect is severe valve replacement is needed.

Asymptomatic )urgical division or ligation of =ow ris2 'achinery li2e patent vessel via left thoracotomy. less than murmur And visually assisted thoractomy A# /idened pulse surgery +:AT), is performed. mortality pressure. Closure with placement of an .ounding pulse occluder device during cardiac catheri?ation.

High .8 and @ach portion of coarcted portion =ess bounding pulse with an end3to3end anastomosis of "# /ea2 or aorta or enlargement of the absent femoral constricted section using a graft of pulse prosthesis material or apportion of Cool the left subclavian artery. e6tremities .alloon angioplasty as a primary )everely intervention for C5A. acidotic E hypotensive. 4i??iness Headache ainting 10

than

Aortic )tenosis

<arrowing or stricture of the aortic valve, causing resistance to blood flow in the left ventricle, decreased cardiac output, ventricular hypertrophy, left ventricular hypertrophy. :alvular stenosis is more common caused by malformed cusps resulting in a bicuspid rather than tricuspid valve of fusion of the cusps. )ub3:alvular stenosis is a stricture caused by a fibrous ring below a normal valve. 8ulmonic )tenosis <arrowing at the entrance to the pulmonary artery. 8ulmonary atresia is the e6treme form of 8) in that there is total fusion of the commissures and no blood flows to the lungs. Tetrology of The classic form includes allot four defectH i, :)4 ii, 8) iii, 5verriding of aorta iv, Dight ventricular hypertrophy

s/s of decreased cardiac output hypotension bradycardia poor suc2ing e6ercise in tolerance+child ren3after 3yrs, chest pain di??iness with standing longer time characteristics murmur Asymptomatic )evere narrowing newborn G cyanosis s/s of cardiomegaly $nfant3acute cyanotic characteristics murmur hypo6ia called blue spell children3 with 11

Aortic valvotomy. 5perative 4ilating narrowed valve with balloon 'ortality angioplasty3 during catheteri?ation. rate is 2# Cutting of fibro muscular ring. 3I# A patch is reBuired to enlarge the entire left ventricular outflow tract and annulus and replace aortic valve3 this procedure is 2nown as Fonno procedure. An aortic homograft with a valve may also be used Ge6tended aortic root replacement 8ulmonic valve may be moved to the aortic position and replaced with a homograft valveHDoss procedure. $n infant closed valvotomyH.roc2 5perative procedure , 'ortality $n childrenHpulmonary valvotomy. rate is J2# .alloon angioplasty to dilate valve. $t is the treatment of choice for discrete 8) in most centre and can be done safely in neonates. 8alliative3 shunt3in infant can not 5perative undergone primary repair. Fnown as 'ortality modified .laloc23Taussig shunt. rate is J J @lective repair performed in first "# year of life. A complete repair involves closure of :)4 and resection of the

Tricuspid Atresia

T1A /T1:

ailure of tricuspid valve to develop, no communication between right atrium and right ventrical. $t is often associated with 8) and T5A. There is a complete mi6ture of o6ygenated blood with deo6ygenated blood in left side of heart, resulting in systemic desaturation and varying amounts of pulmonary obstruction causing decreased pulmonary blood flow. The pulmonary artery leaves 4epends on Arterial switch procedure033 5perative the left ventricle and the type E si?e of involves transecting great arteries 'ortality aorta e6ists from the associated and anastomosing the main rate is "# ventricles, with no defect pulmonary artery to the pro6imal 3A%# 12

increasing infundabular stenosis with a cyanosis having pericardial patch to enlarge the clubbing of right ventricular outflow tract. The fingure procedure reBuires a median sBuatting and sternotomy and the use of cardio3 poor growth pulmonary bypass. s/s of brain hypo6ia sei?ures loss of consciousness sudden death Cyanosis 8alliative033placement of a shunt to 5perative Tachycardia increase blood flow to the lungs. $f 'ortality 4yspnea A)4 is small, an atrial septostomy rate is Chronic is done during cardiac KA%# hypo6emia with catheteri?ation. clubbing A bidirectional 1lenn shunt3 8ossibility of cavopulmonary anastomosis. brain abscess 'odified ontan procedure033A and stro2e fenestration +opening, in the right atrial baffle is sometime done to relieve pressure.

Truncus Arteriosus

communication between the $f defect is aorta and anastomosing the systemic and pulmonary minimum3 ascending aorta to the pro6imal circulation. Cyanotic and pulmonary artery. depressed at Dastelli procedure033$t involves birth closure of :)4 , closure of 4efect is pulmonic valve and conduit is placed larger3less in right ventricles to the pulmonary cyanotic but artery, creating a physiologically having s/s of normal circulation. CC cardiomegaly ailure of normal septation Asymptomatic Corrective repair involves closing 'ortality and division of the embryonic 'oderate to the :)4 so that the truncus rate is bulbar trun2 into the severe CC arteriosus receives the outflow more than pulmonary artery and aorta, :ariable from the left ventricle, e6cising A%# resulting in a single vessel cyanosis the pulmonary arteries from the that overrides both 8oor growth aorta and attaching them to the ventricles. Activity right ventricle by means of a $Ha single pulmonary trun2 intolerance homograft. $$Hthe left E right characteristics pulmonary arteries arise murmur separately from posterior aspect of truncus.

13

Hypoplastic =eft (nderdevelopment of the Heart )yndrome left side of the heart, resulting in a hypo plastic left ventricle and aortic atresia. 'ore 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 84A supplying systemic blood flow.

'ild cyanosis s/s of CC s/s of collapse of cardiovascular fatal condition

)everal3staged approach. 'ortlity irst stage3 <o wood procedure3 rate is anastomosis of the main pulmonary more than artery to the aorta to create a new 2"# aorta, shunting to provide pulmonary blood flow and creation of a large A)4. )econd stageHbidirectional 1lenn shunts done at L3M month of age to relive cyanosis and reduce the volume load on the right ventricle. inal stage33 modified ontan procedure +same as tricuspid atresia, stabili?e mechanical ventilation prostaglandin @A infusion to maintain ductal patency @nsuring adeBuate blood flow.

14

NURSING )ROCESS <ursing diagnosis @6pected outcome $mplementation High ris2 for /ill e6hibit improved Assess child for decreased cardiac output decreased cardiac cardiac output. signs. output related to Assess vital signs freBuently according to structural defect condition. 'onitor homodynamic parameters0 C:8, .8. 'easure inta2e and output. Administered drugs according schedule i.e.digo6in, diuretics. 5bserved for effect, side effect, and to6ic effect of drugs. Activity intolerance /ill maintain adeBuate 'onitor vital signs before, immediately and related to imbalance energy levels without after activity and 3 min later. between o6ygen additional stresses. 'onitor for tachycardia, pallor, diaphoresis supply and demand. after activity. @ncourage him for verbali?e feeling regarding fatigue or limitation. Assistant provided with self care activities and provide freBuent rest period, after meals. $ncreased activity as guided by physician. Altered growth and /ill follow growth Assess the child>s height and weight and development related curve for weight and compare with normal according to his age to inadeBuate o6ygen height. group. and nutrients to 8rovide well3balanced, highly nutritious diet tissue. to achieve adeBuate growth. 'onitor height and weight, plot on growth charts to determine growth and trend. 15 evaluation Cardiac output increased G 8ulse, respiration, .8, and peripheral perfusion are normal for age. (rine output is adeBuate +%."3 2ml/2g. Child determines and engages in activities commensurate with capabilities. Child receives appropriate amount of rest/ sleep.

Chile receives adeBuate growth.

 'ay administered iron supplements correct anemia if prescribed.

to Child engages in age appropriate activity. Child does not e6perience social isolation. Child remains free of infection.

High ris2 for infection related to debilitated physical status.

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

/ill have to @ncourage age appropriate activities. participate in age @mphasi?e that child has same need for appropriate activities. sociali?ation as other children. Allow child to set own pace and activity limits because child will rest when tired. /ill e6hibit no 5bserve for signs of generali?ed sepsis0 evidence of infection. redness, increase temperature. Change $: and pressure line and dressing as policies and reBuirement maintaining aseptic techniBue to prevent nosocomial infection. 5btained blood culture as and when reBuired to rule out effectiveness of drugs given. 5btained C.C with 4C. Avoid contact with infected people. 8rovide adeBuate rest. 8rovide optimum nutrition to support body>s natural defense. /ill e6perience 4iscuss with parent and child their fears and reduction of fear and concerns regarding child>s cardiac defects an6iety. and physical symptoms, since these freBuently cause an6iety and fear. @6plain disease process with posters and charts. /ill e6hibit positive @ncourage family to participate in care of coping behavior. child while hospitali?ed to facilitate better coping at home. @ncourage family to include others in child>s care to prevent their own e6haustion. 16

amily discusses their an6ieties.

amily copes with child>s symptoms in a positive way.

 /ill demonstrate 2nowledge of home3 care.

High ris2 for in&ury /ill recogni?e signs of +complication, complication early. related to cardiac condition and therapies.

/ill demonstrate understanding of diagnostic tests and surgery.

1uide family in determining appropriate physical activity and disciplining methods for child. Teach s2ills for home care033 Administration of medication, eeding techniBue, intervention for conserving energy and those directed towards relief of frightening symptoms. )igns indicate complication. /here and whom to contact for help and guidance. Anticipate need for further information and support. Teach family how to do C8D. Teach family recogni?es signs of CC .H Tachycardia, tachypnea, profuse scalp sweating, fatigue and irritation. )igns of digo6in to6icity03 :omiting, nausea, anore6ia, bradycardia, hypo6emia, cyanosis etc. Teach family to intervene during hypercynanotic spells because cerebral hypo6ia can cause brain damage or death. 8lace child in 2nee3chest position. Demain calm. Administer A%%# o6ygen by face mas2. @6plain or clarify information presented to family by the surgeon. 8repare child and parents for procedure. Assist with family>s decision regarding 17

amily demonstrates ability and motivation for home care. amily members learn C8D techniBue.

amily recogni?es signs of complication and institute appropriate action.

amily demonstrate an understanding of procedure + tests, surgery etc.,

surgery. @6plore feeling regarding surgical options. Fnowledge deficit =evel of 2nowledge is $nstruct parents on type of defect and how increased. to manage at home, and provide referral .ecome a self G services for assistance with home care. sufficient user and 8rovide detail e6planation of defect and obtainer of health care surgical intervention and treatments as 2nowledge. directed by defects. 4uring interaction with parent watch reaction of them to rule out if they understand or not. 8rovide motivation by appealing to their interest and future uses of new 2nowledge. As2 them if he is satisfied with him. An6iety related to /ill reduce an6iety. Assess the sign of fear Ean6iety actual or perceived Destless, facial e6pression. threat to biological 8rovide supportive care. integrity. @6plain disease process and procedure as they are implemented with age appropriate aids. @nsure Buiet environment. Deduced environmental stimuli. 'aintain family contact. =evel of 2nowledge is increased is evidences byH amily verbali?e regarding defect, prescribed care, medication, need for visits and prophyla6is medication.

An6iety is decreased. amily verbali?es reduction in an6iety level and demonstrates appropriate behavior.

18

Client and fa$ily ed#cation:-Li&ing !it" a Congenital Hea t Defect /ith new advances in testing and treatment, most children with a congenital heart defect grow into adulthood and live productive lives. )ome continue to need speciali?ed care for survival and to maintain a good Buality of life. )ome may need multiple procedures including cardiac catheteri?ations and surgeries. 5thers may need pacema2ers to help their heart beat properly. 2o )a ents 'others of children born with a heart defect often thin2 that they did something during pregnancy to cause the problem. /e do not 2now the cause of most cases of congenital heart disease. $t is important that mothers 2now that they did not cause their child-s illness. @6plain parent that most children with congenital heart disease grow up to a healthy adulthood. @6pect that child will be productive and able to wor2. 5nly children with comple6 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. $f both parents wor2, one has stay home with child if cannot find suitable day care. The drain on your energy, emotions, and finances can be very stressful. As2 your child-s doctor about support groups and other support in your area. 4on-t be shy about see2ing counseling if the stress seems overwhelming. Gene al Iss#es $t is important for child to have ongoing regular medical care. This includes0 19

ollowing up with child-s heart specialist as directed

ollowing up with child-s pediatrician or family doctor for routine e6ams Ta2ing medications as prescribed. 'ay consider them to having your child wear a medical alert bracelet or nec2lace. 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. 'ost people with congenital heart disease need to ta2e antibiotics before a dental procedure, treatment, or cleaning. Tal2 to doctor before ta2ing to child to the dentist. Co#nsel pa ent ega ding:- C"ild en !it" a Congenital Hea t Defect )ome 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. Cour child may also start activities li2e rolling over, sitting, and wal2ing later than other children. After treatments and surgery, growth and development often improve. Cour child may need e6tra calories to grow. $f your child-s heart has to pump faster because of the defect, the body needs more energy to 2eep up the e6tra wor2. This may cause your child to tire Buic2ly. )ome babies are not able to eat enough because they tire while feeding. 5lder children also may tire before finishing a meal E(e cise fo C"ild en @6ercise helps children strengthen their muscles and stay healthy. 20

 Cour child may tire easily, so ta2e freBuent brea2s and let your child rest during activities if necessary. )ome children with congenital heart disease may need to limit the amount or type of e6ercise. Tal2 to your doctor about what is safe e6ercise for your child. Demember to as2 your doctor for a note for school and other organi?ations describing any limits on your child-s e6ercise or physical activities. E$otional Iss#es fo C"ild en Children with a serious heart problem may have a hard time coping or feel isolated because they may have to be in the hospital freBuently. )ome children feel sad or frustrated with their body image and their inability to be a *normal* 2id. )ometimes brothers or sisters are &ealous of all the attention received by the child with congenital heart disease. 8arents 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 tal2ing to him or her and allow child to be involved in everyday activities. Teenage s !it" a Congenital Hea t Defect The teenage years are difficult for most children. $t is a time of ris2 ta2ing, and denial is often used as a way of coping. There is pressure to be li2e other teenagers. )ome teenagers with congenital heart disease still need speciali?ed care and must ta2e medicine on a regular basis. Help your teenager cope with the stresses of growing up with a serious health problem. Demind your teenager that with proper care, he or she can grow up healthy and participate in most, if not all, activities. =et your teenager help ma2e decisions about medical care. This fosters independence and encourages regular follow up with the doctor. 21

 'any teenagers with congenital heart disease can participate in organi?ed sports. Destrictions of activity vary depending on the teenager, the type of sport, and the type of heart disease. )ome children need to limit the amount of activity while others need to avoid contact sports. Cour doctor can help you and your teenager decide which sports activities are right for him or her. 1etting a good education and advanced &ob training *opens the door* to the 2inds of &obs that are ideal for those who cannot do strenuous wor2. 5verall, parents should be aware that the vast ma&ority of children born with congenital heart disease live normal, healthy lives and should be encouraged to do so. Ad#lts !it" Congenital Hea t Defect Adults with congenital heart disease should carefully consider changing &obs if advised. ) egnancy and a Congenital Hea t Defect /omen with congenital heart disease who want to become pregnant +or who are pregnant, need to0 Tal2 to their doctor about health ris2s during pregnancy. Tal2 to their doctor about medications that can be ta2en during pregnancy. Consult with specialists who ta2e care of pregnant women with this health. 3I3LIOGRA)H4:- .ehrman, Foiengman, Arvin, N<elson>s Te6tboo2 of 8ediatricsO, )ingapore0 /...)aunders Co; A"th edition, AMMM. 8p no G"IL3"M2. )melt?ers, ).C. E .are, ..C. N.runner E )uddarth>sTe6t boo2 of 'edical )urgical <ursingO, 8hiladelphia0 =ippincott Co; A%th edition, 2%%P. 8pnoH!3I3!PA.

'arlow,4.D. NTe6tboo2 of 8ediatric <ursingO, 8hiladelphia0 /...)aunders Co; Lth edition, AMI". 8p noHPLL3PMA. 22

 Tambulwad2ar,D.). N8ediatric <ursingO, .ombay, :ora 'edical 8ublication, Ast edition, AMM!. 8p noHAP!3A"". $saacs, 8.C. and 'andelew,..C. N<ursing Care of Children3A 1uide for )tudyO, 8hiladelphia0 Q...=ippincott Co; AMI". 8p noHA"M3ALI. )cipien, C.H. N8ediatric <ursing CareO, 'issouri0 'osby; 3 rd edition, AMML. 8p no G"MI3L%M. /haley and /ong>s N @ssentials of 8ediatric <ursingO, 8hiladelphia, 'osby, "th edition, 8p noH"I! 3"I". Tandon, D. N.edside Approach in the 4iagnosis of Congestive Heart 4iseaseO, <ew 4elhi0 ..$.Churchill =ivingstone Co; A st edition, AMMI.

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)ATHO)H4SIOLOG4:-NANE O2 CONDITION :entricular )eptal 4efect +:)4, )ATHO)H4SIOLOGICAL CHANGES 4ue to higher pressure in left ventricle E systematic circulation Desistance in pulmonary circulation .lood flow through defect in to pulmonary artery +right3to3left shunt, $ncrease blood volume is pumped in lungs $ncreased pulmonary resistance , increased pressure in right ventricle 'uscles hypertrophy. @Buali?ing rRsistance in aorta E pulmonary artery $ncrease in systematic pressure @6ceeds pulmonary pressure, blood flows from aorta, across The duct to the pulmonary artery. +=eft3to3right shunt, @ffect of altered circulation increased wor2load on left side heart. $ncreased right ventricular pressure and hypertrophy. 4ue to narrowing of aorta $ncreased pressure pro6imal to defect leads to right ventricle outflows cannot maintain to the descending aorta due to this collateral circulation develops to maintain blood flows. 4ue to stricture in outflows tract causes resistance to e&ection of blood from the left ventricle. The e6tra wor2 load on the left ventricle causes hypertrophy. =eads to increase 24

8atent 4uctus Arteriosus+84A,

Coaarctation 5f Aorta +C5A,

Atrial )tenosis +A),

8ulmonary )tenosis +8),

TricSspide Atresia

Truncus Arteriosus +TA,

left atrial pressure cause increased pressure in the pulmonary veins, resulting in pulmonary vascular congestion. 8resence of 8) causes Desistance to blood flow causes right ventricular hypertrophy. $ncreased right ventricular pressure may result in reopening of foremen ovale, shunting of uno6ygenated blood into the left atrium and systemic cyanosis. At birth the presence of a patent foramen ovale is reBuired to permit blood flow across the septum in to left atrium, 84A allows blood flow to the pulmonary artery into the lungs for o6ygenation. A :)4 allows a modest amount of blood to enter the right ventricle and pulmonary artery for o6ygenation. 4ue to common trun2 .lood e&ected from the left and right ventricles

Hypo plastic =eft Heart )yndrome +H=H),

'i6ing pulmonary and systematic circulation according to the relative resistance of each. The amount of flow depends on si?e of the pulmonary atresia and pulmonary vascular resistance. A)4/ 8atent foramen ovale allows saturated blood from the left atrium to mi6 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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