Atrial Septal Defect

Atrial Septal Defect

1. Pathophysiology

   • Caused by a genetic defect or failure of the foramen ovale to close after birth or a larger than normal foramen ovale that is unable to close all the way.
     • When the foramen ovale fails to close, there is a pathways in between the atria that allows blood that is mean to circulate through the body to re-enter the right atria and back into the respiratory system
       • There is more blood circulating through the respiratory system and less oxygenated blood circulating to the rest of the body.

2. Clinical Manifestations

   • Typical Manifestations of ASD include shortness of breath especially with exertion, fatigue, heart palpiations, a heart murmur, and failure to thrive.
     • Patient is exhibiting failure to thrive in that he has lost interest in eating, failure to gain weight and he is lethargic
   • Vital signs: Weight 7 kg (15.4 lbs) - under weight Temperature 37 C (97.7 F) - within a normal range Pulse 80 - normal range 80-160 bpm Respirations 48 - normal range 24-30
     • Underweight because of disinterest in eating and lethargy
     • Increased respiratory rate because he is frequently out of breath because of ASD because he might be progressing towards heart failure. Increased respirations is the bodys way to increase oxygenation of blood circulating into the body.

3. Labs and diagnostic tests

   • K+ 2.9 (normal range 3.4-4.7) Digoxin level 2.5 (normal range 0.8-2.0)
     • Low potassium resulting from furosemide.
       • Furosemide is a diuretic and causes the body to excrete sodium, excess fluid and eventually potassium. Low potassium can cause palpitations, and muscle weakness.
     • Digoxin levels indicate that he is taking too much and is at risk for digoxin toxicity
       • Side effects of too much digoxin include decreased appetite, nausea, vomiting, diarrhea, muscle weakness, fatigue, and restlessness

4. Therapeutic Interventions

   • Continue treatment with medications to maintain cardiac function and reduce workload of the heart
   • Surgical intervention by cardiac catheterization where defect is accessed by catheterization and the hole is stitched closed or patched.
     • Ideal for large defects or for children who are symtomatic and have health complications related to ASD.

5. Nursing Diagnoses, Goals, and Interventions

   • Risk for decreased cardiac output
     • Goal: The patient will show adequate cardiac output as evidenced by a stable BP, respirations, regular heart rate and rhythm, strong peripheral pulses, and the ability to tolerate activity without dyspnea or syncopy.
       • Assess HR, BP, 02, lung sounds and heart sounds every 8 hours or with any changes to determine cardiac and respiratory function
       • Assess skin color, temperature and moisture for changes in oxygenation levels and signs of distress
       • Check peripheral pulses, 02 saturation and capillary refill to assess for decreased cardiac volume
       • Perform daily weights in the same clothing and at the same time of day to assess for shifts in fluid balance and to determine if the child is gaining weight at a stable pace
   • Activity Intolerance
     • Goal: The child will tolerate a steady increase in activity level as evidenced by needing fewer periods of rest and ability to play and be active for longer periods of time
       • Assess for dyspnea upon exertion and changes in skin color that indicate distress
       • Allow freqeunt periods of rest between play, activity and therapies
       • Educate parents on the need for periods of rest and the importance of having a calm, quiet, unstimulated area for the child
       • Encouge the child to be independent as much as they are able and to only help with things that cannot be done on his own
   • Compromised family coping
     • Goal: The family will effectively cope with diagnosis as evidenced by voicing feelings, needs and concerns with the health care team
       • Encourage them to voice their frustrations, ask questions and obtain referrals. Encourage them to go attend support groups for families in similar situations
       • Observe the parents for any erratic or abnormal behavior. Pay attention to interactions, raised voices and signs of anger
       • Encourage the parents to be fully involved but make sure that they know that overbearing behaviors and lack of patient independence can hinder progress.
   • Risk for injury
     • Goal: The child will remain free from injury
       • Assess medications for side effects, interactions, toxicity, and monitor lab results. Monitor the child when medications are changed and report any significant changes to the HCP. Educate the parents on s/s to watch for at home and when they should notify HCP.
       • Prepare the parents for the potential of surgical intervetions when medications are no longer managing symptoms. Encourage them to ask questions and voice any concerns that they have
       • Monitor BP and heart rate/rhythm prior to administration of medications to prevent hypotension or bradycardia
       • If child becomes dizzy, lightheaded, cyanotic, or short of breath move them to a knee-chest or squatting position. Parents should also be educated on when to notify HCP of symptoms.