6 Congenital Heart Disease Nursing Care Plans

These kids are working harder to do less. A congenital defect means blood is shunting the wrong way, mixing oxygenated with deoxygenated, or running into a narrowed vessel, and the body compensates with tachycardia, poor feeding, and stalled growth until the heart can't keep up. Your job on the floor is to catch decompensation early, protect feeding and energy, and prevent the infections a compromised heart tolerates badly.

What is congenital heart disease?

Congenital heart disease is a malformation of the heart involving the septums, valves, or great arteries. Defects are classified as acyanotic or cyanotic.

Acyanotic defects involve a left-to-right shunt that lets oxygenated and deoxygenated blood mix before entering systemic circulation. In children the usual consequences are growth retardation and congestive heart failure (CHF). The acyanotic group includes coarctation of the aorta, patent ductus arteriosus, and ventricular septal defect. Coarctation is a narrowing of the aorta proximal to the ductus arteriosus (preductal), distal to it (postductal), or level with it (juxtaductal); where the narrowing sits during fetal development determines lower-body circulation and collateral development. Patent ductus arteriosus is failure of the fetal-circulation structure to close after birth. A ventricular septal defect is incomplete development of the septum between the right and left ventricles, and it often runs with other defects.

Cyanotic defects include tetralogy of Fallot and transposition of the great vessels. Tetralogy of Fallot is four defects together: pulmonic stenosis, ventricular septal defect, right ventricular hypertrophy, and an aorta that overrides the ventricular septal defect. Transposition of the great vessels reverses the normal arterial connections: the aorta arises from the right ventricle and the pulmonary artery from the left ventricle. Transposition is incompatible with life unless septal defects are also present to let blood from the two circulations mix.

Nursing Care Plans & Management

Care centers on managing symptoms, protecting growth and nutrition, watching for complications, teaching the family, and coordinating with the team. Followup visits, medication management, and activity adjustments round out the plan.

Nursing Problem Priorities

1. Manage decreased cardiac output and tissue perfusion. Impaired flow starves tissues of oxygen and nutrients, producing cyanosis, poor growth, and fatigue.
2. Prevent infection and protect safety. These children infect easily, especially after surgery, because cardiac function and immune response are both compromised.

Nursing Assessment

Assess for the following subjective and objective data:

• Variations in hemodynamic readings (hypertension, bounding pulses, tachycardia), which point to increased cardiac workload.
• Widened pulse pressure, suggesting impaired cardiac function and reduced vascular resistance.
• ECG changes and arrhythmias, common with the disturbed conduction of congenital defects.
• Murmur, signaling turbulent flow through a structural abnormality.
• Decreased peripheral pulses, indicating compromised peripheral circulation.
• Fatigue from reduced cardiac output and oxygen delivery.
• Dyspnea from decreased oxygenation and increased respiratory effort.
• Cyanosis, or its absence. Absent cyanosis does not rule out a defect.
• Oliguria, pointing to impaired renal perfusion and the fluid imbalance of CHF.
• Squatting or knee-chest positioning, which the child uses to raise systemic vascular resistance and improve output.
• A family expressing fear about the child's condition.
• Protective behavior out of proportion to the child's need to grow and develop.
• Chronic anxiety around possible hospitalization and surgery.
• A circulatory or respiratory problem.
• Reports of fatigue or weakness.
• A need to rest after short play.
• Abnormal heart rate or blood pressure response to activity.
• Exertional dyspnea.

Assess for factors related to the cause:

• Structural features of the congenital defect
• Situational and developmental crises for family and child
• Generalized weakness
• An imbalance between oxygen supply and demand
• Cardiac function compromised by the defect and by medications
• Chronic illness

Nursing Goals

Goals and expected outcomes may include:

• The child demonstrates adequate cardiac output: blood pressure and pulse rate and rhythm within normal parameters for the patient, strong peripheral pulses, and activity tolerance without dyspnea, syncope, or chest pain.
• The family copes more effectively.
• The child tolerates increased activity.
• The child stays free of injury.
• The child stays free of infection.

Nursing Interventions and Actions

1. Managing decreased cardiac output
2. Promoting effective family coping
3. Improving activity tolerance
4. Preventing injury and infection
5. Administering medications
6. Providing perioperative care

1. Managing Decreased Cardiac Output

Monitor vital signs, hold fluid balance, give cardiac medications, and provide oxygen.

1. Assess heart rate and blood pressure. Compensatory tachycardia with low blood pressure is the typical response to reduced output.

2. Note skin color, temperature, and moisture. Cold, clammy, pale skin reflects compensatory sympathetic stimulation, low output, and oxygen desaturation.

3. Check peripheral pulses and capillary refill. Weak pulses track reduced stroke volume and output. Capillary refill runs slow or absent.

4. Assess fatigue and activity tolerance. Fatigue and exertional dyspnea are hallmarks of low-output states. The child's response guides how fast you advance activity.

5. Track fluid balance and weight. Weigh the child at the same time daily, before breakfast. Compromised regulation drives fluid and sodium retention, and weight is your fluid-balance marker.

6. Listen for gallops (S3, S4). S3 signals reduced left ventricular ejection and is a classic sign of left ventricular failure. S4 reflects reduced left ventricular compliance that impairs diastolic filling.

7. Monitor the ECG for rate, rhythm, and ectopy. Dysrhythmias follow low perfusion, acidosis, or hypoxia. Tachycardia, bradycardia, and ectopic beats further cut output, and older children tolerate loss of atrial kick in atrial fibrillation poorly.

8. Provide rest periods. Rest lowers metabolic rate and myocardial oxygen demand.

9. Position in semi-Fowler's. An upright position reduces preload and ventricular filling when fluid overload is the driver and eases lung expansion.

10. Give oxygen as prescribed. The failing heart can't always meet rising oxygen demand. Keep oxygen saturation above 90%.

11. Give medications as prescribed. See Pharmacologic Management.

2. Promoting Effective Family Coping

Give the family emotional support, accurate information, and resources, and bring them into the plan.

1. Watch for erratic behavior (anger, tension, disorganization) and a sense of crisis. This tells you how well the family is coping with the child's condition.

2. Assess usual coping methods and how well they work. Shows whether the family needs new coping skills.

3. Assess the need for information and support. Points to interventions that relieve anxiety.

4. Encourage expression of feelings and give factual information about the child. Lowers anxiety and builds the family's understanding.

5. Correct misinformation and answer questions about the disease. Prevents anxiety driven by inaccurate beliefs.

6. Help the family find techniques to solve problems and regain control. Supports problem-solving and a sense of agency.

7. Encourage them to protect their own health and social contacts. Chronic anxiety, fatigue, and isolation erode the family's ability to care for the child.

8. Teach that overprotection can hinder growth and development. Helps the family see the cost of well-meant overprotective behavior.

9. Reinforce effective coping behaviors and support family decisions. Promotes adaptation to the child's care.

10. Encourage including the child in family activities rather than building family life around the child's needs. Supports normal development for child and family.

11. Encourage consistent limits and discipline. Prevents behavior problems and keeps the child from controlling the family.

12. Teach nutritional and activity needs and limits. Helps the family build an effective routine around the defect.

13. Refer for added support and counseling when indicated. Brings in help beyond what nursing staff can provide.

3. Improving Activity Tolerance

Advance activity gradually while watching cardiac function and symptoms. Build the program around the child's anatomy, age, and goals, supervise it, and adjust to the child's response.

1. Assess fatigue, ADL ability, and other activity against the severity of the defect. Gauges energy reserves and response to exertion.

2. Assess exertional dyspnea and skin-color changes at rest and with activity. Marks hypoxia and rising oxygen demand.

3. Cluster care and rest periods, and disturb the child only when necessary. Conserves energy.

4. Don't let the infant cry for long stretches. Feed with a soft, cross-cut nipple, and gavage-feed if the infant can't take enough calories by mouth. A cross-cut nipple takes less energy to feed, and both measures conserve energy.

5. Keep a neutral environmental temperature. When bathing, expose only the area being washed and keep the rest covered. Heat and cold extremes raise oxygen and energy needs.

6. Provide quiet, age-appropriate play, and limit activity as needed. Supports development and diversion without overexertion.

7. Help parents plan care and rest schedules. Prevents overexertion and minimizes energy use.

8. Teach activity restrictions and how the child can set their own limits. Prevents fatigue while keeping activity as normal as possible.

9. Teach parents to conserve the child's energy and encourage rest. Avoids fatigue.

10. Teach the child to ask for help with daily activities. Prevents overtiring.

4. Preventing Injury and Infection

Use hand hygiene, wound care, and infection control, and protect the chest from trauma.

1. Watch for drug toxicity, a cardiac complication of heart failure. Early recognition lets you intervene before harm.

2. Check temperature, the IV site, white blood cell count, and pulse and respirations. Flags potential infection.

3. Monitor orders for diagnostic tests and procedures. Lets you prepare and support the family and child.

4. Support the family's feelings and decisions about surgery. Allays anxiety and conveys care.

5. Prepare parents and child for procedures and surgery using a play doll. Cover the procedure, expected results, prognosis, and whether the surgery is corrective, palliative, temporary, or permanent. Reduces anxiety and sets expectations.

6. Teach cardiotonic administration: take the apical pulse, withhold for a pulse under 70 to 80 in a child or under 90 to 100 in an infant, report a low or irregular pulse, and watch for toxicity. Keeps cardiac glycoside dosing safe and accurate.

7. Teach what to do for a cyanotic episode: knee-chest or squatting position, elevate head and chest, and when to call the physician. Keeps the family calm and gives them a concrete way to break an episode.

8. Keep people with infections away from the child. The child's defenses are compromised.

9. Provide adequate rest and age-appropriate nutrition. Builds resistance against infection.

10. Wash hands before care. Prevents transmission of microorganisms.

11. Use sterile technique for IV maintenance. Prevents contamination and infection.

12. Give antibiotics as ordered. Match the action and dosing to the specific drug.

13. Teach the family and child personal hygiene (rest, nutrition, activity, elimination, bathing). Reduces exposure and protects defenses.

14. Teach the child to avoid family and friends who are sick. Infections spread easily to a debilitated child.

5. Administering Medications and Pharmacological Interventions

Monitor the response, manage side effects, and teach the family the regimen. Drugs here relieve symptoms, control rate and rhythm, and improve function.

1. Diuretics Pull off excess fluid to relieve pulmonary congestion and peripheral edema, easing shortness of breath and swelling. Common agents are furosemide (Lasix) and spironolactone (Aldactone).

2. Beta-blockers Slow the heart rate and lower blood pressure, cutting cardiac workload and improving function. Common agents are metoprolol (Lopressor) and atenolol (Tenormin).

3. ACE inhibitors Relax blood vessels and lower blood pressure, improving flow and reducing strain on the heart. Common agents are enalapril (Vasotec) and lisinopril (Prinivil).

4. Digoxin Regulates rhythm and treats arrhythmias, and also supports function in heart failure.

5. Anticoagulants Prevent clot formation in children at higher clot risk, lowering the chance of stroke and other serious complications. Warfarin (Coumadin) is a common agent.

6. Providing Perioperative Nursing Care

Medications manage symptoms, but surgery is often what corrects the structural defect. Nursing care spans the preoperative, intraoperative, and postoperative phases.

1. Assist with a thorough preoperative evaluation. Establishes the child's status and surfaces surgical risks. Preoperative priorities include teaching, medication management, nutritional support, and psychological support.

2. Tell the patient and family what to expect before, during, and after surgery. Cover the procedure, the risks and benefits, and how to prepare.

3. Review the child's medications. Continue or adjust them appropriately before surgery.

4. Ensure adequate nutrition and hydration. Optimize nutritional status before surgery, with a specialized diet if needed.

5. Provide psychological support. Heart surgery is stressful for child and family. Support helps them cope and lowers anxiety.

6. Protect the child's safety and wellbeing intraoperatively. Key intraoperative concerns include monitoring, anesthesia management, and preventing or managing complications.

7. Monitor vital signs, fluids, and electrolytes during surgery. Track blood pressure, heart rate, and oxygen saturation, and adjust fluids and medications as needed.

8. Assist with anesthesia management. These children often need tailored anesthesia, so work closely with the anesthesia team.

9. Respond immediately to complications. Be ready for bleeding, cardiac arrest, or swings in blood pressure or heart rate.

10. Manage pain after surgery. Use medication and nonpharmacologic measures to control postoperative pain.

11. Maintain hydration and electrolyte balance postoperatively. Recovery often needs specialized fluid and electrolyte management.

12. Plan rehabilitation and physical therapy with the family. Some children need rehab or physical therapy after surgery; build the plan with the care team.