5 Congenital Heart Disease Nursing Care Plans

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 unoxygenated 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 (auxtaductal). 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.

Here are five (5) nursing care plans (NCP) for congenital heart diseases:

1. Decreased Cardiac Output

Decreased Cardiac Output: Inadequate blood pumped by the heart to meet metabolic demands of the body.

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,
- Arrhythmias
- Murmur
- Decreased peripheral pulses
- Fatigue
- Dyspnea
- Cyanosis or absence of cyanosis
- Oliguria
- Squatting or knee-chest position

Desired Outcomes

- 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.

Nursing Interventions	Rationale
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:
- Digoxin (Lanoxin)	Increases contractility of the heart and force of contraction.
- Alprostadil (Prostin VR Pediatric)	Maintain open PDA when needed for blood flow.
- Furosemide (Lasix); spironolactone (Aldactone)	Decreases edema formation and diminish afterload.

2. Activity Intolerance

Activity Intolerance: Insufficient physiologic or physiological energy to endure or complete required or desired activity.

May be related to

- Generalized weakness
- Imbalance between oxygen supply and demand

Possibly evidenced by

- Presence of circulatory/respiratory problem
- Verbal complaint of fatigue or weakness
- Needs to rest after short period of play
- Abnormal heart rate or blood pressure response to activity
- Exertional dyspnea

Desired Outcomes

- Child will tolerate increased activity

Nursing Interventions	Rationale
Assess level of fatigue, ability to perform ADL and other activities in relation to severity of the condition.	Provides information about energy reserves and response to activity.
Assess dyspnea on exertion, skin color changes during rest and when active.	Indicates hypoxia and increased oxygen need during energy expenditure.
Allow for rest periods between care; disturb only when necessary for care and procedures.	Promotes rest and conserves energy.
Avoid allowing the infant to cry for long periods of time, use soft nipple for feeding; cross-cut nipple; if unable for infant to ingest sufficient calories by mouth,gavage-feed infant.	Conserves energy. Cross-cut nipple requires less energy for the infant to feed.
Provide neutral environmental temperature; when bathing infant, expose only the area being bathed and keep the infant covered to prevent heat loss.	Avoids hot or cold extremes which increase oxygen and energy needs.
Provide toys and games for quiet play and diversion appropriate for age of child (specify), allow to limit own activities as much as possible.	Promotes growth, diversion, and physical and mental development.
Assist parents to plan for care and rest schedule.	Provides for rest and prevents overexertion, minimizes energy expenditure.
Inform of activity or exercise restrictions and to set own limits for exercise and activity.	Prevents fatigue while engaging in activities as nearly normal as possible.
Explain to parents need to conserve energy and encourage rest.	Avoids fatigue.
Inform to request assistance when needed for daily activities.	Prevents overtiring and fatigue.

3. Compromised Family Coping

Compromised Family Coping: A usually supportive primary person (family member, significant other, or close friend) insufficient, ineffective, or compromised support, comfort, assistance or encouragement that may be needed by the individual to manage or master adaptive tasks related to his or her health challenge.

May be related to

- Situational and developmental crises of family and child

Possibly evidenced by

- Family expresses concern and fear about infant/child’s disease and condition
- Displays protective behavior disproportionate to need to grow and develop
- Chronic anxiety and possible hospitalization and surgery

Desired Outcomes

- Family will cope more effectively.

Nursing Interventions	Rationale
Observe for erratic behaviors (anger, tension, disorganization), perception of crisis situation.	Information affecting the ability of the family to cope with infant/child’s cardiac condition.
Encourage expression of feelings and provide factual information about infant/child.	Reduces anxiety and enhances family’s understanding of the condition.
Assess usual family coping methods and effectiveness.	Identifies need to develop new coping skills if existing methods are ineffective in changing behaviors exhibited.
Assess need for information and support.	Provides information about need for interventions to relieve anxiety and concern.
Clarify any misinformation and answer questions regarding disease process.	Prevents unnecessary anxiety resulting from inaccurate knowledge or beliefs.
Assist in identifying and using techniques to cope with and solve problems and gain control over the situation.	Provides support for problem solving and management of the situation.
Encourage to maintain the health of family members and social contacts.	Chronic anxiety, fatigue, and isolation as result of infant care will affect health and care capabilities of family.
Teach that overprotective behavior may hinder growth and development during infancy/ childhood.	Knowledge will enhance family understanding of the condition and of adverse effects of behaviors.
Suggest and reinforce appropriate coping behaviors, support family decisions.	Promotes behavior change and adaptation to care for infant/child.
Encourage parents to include ill infant/ child in family activities rather than family revolving around needs of infant/child.	Promotes normal growth and development of family and infant/child.
Encourage to maintain consistent behavior limits and modification techniques.	Prevents behavioral problems and child control over family, which interfere with child’s growth and family relationships.
Instruct parents in nutritional and activity needs and/or limitations and approaches that will assist in establishing an effective pattern.	Assists in coping with effects and special needs of infant/child with a cardiac defect.
Refer family for additional support and counseling if indicated.	Referral supplies more assistance with coping than is available from nursing personnel.

4. Risk for Injury

Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.

May be related to

- Cardiac function compromised by congenital defects and medication administration

Possibly evidenced by

[not applicable]

Desired Outcomes

- Child will not experience injury.

Nursing Interventions	Rationale
Assess for risk of drug toxicity, a cardiac complication of heart failure.	Early identification of signs and symptoms of complications allows preventive measures and adjustments to be made.
Monitor orders for diagnostic tests and procedures.	Allows for preparation and support of parents and infant/child.
Assist and support family’s feelings and decision regarding surgery.	Provides needed support to allay anxiety and promote caring attitude.
Prepare parents and child (use play doll) for diagnostic procedures and/or surgery; should be extensive, consistent, and comprehensive, including a surgical procedure to be performed and expected results, prognosis and whether corrective, palliative, temporary, or permanent.	Assists in allaying anxiety and understanding that diagnostic tests are usually done before surgery.
Instruct in the administration of cardiotonic, taking the apical pulse, when to withhold (less than 70-80 in child and 90-100 in an infant), to notify the physician of low pulse or irregular pulse, signs of toxicity.	Ensures safe and accurate administration of cardiac glycoside.
Teach actions to take if the child becomes cyanotic (knee-chest or squatting position, elevating head and chest), when to call the physician.	Encourages calmness during an attack and teaches actions that will relieve episode and associated fear.

5. Risk for Infection

Risk for Infection: At increased risk for being invaded by pathogenic organisms.

May be related to

- Chronic illness

Possibly evidenced by

[not applicable]

Desired Outcomes

- Child will not experience any infection.

Nursing Interventions	Rationale
Assess temperature, IV site if present, increased WBC, increased pulse and respirations (specify when).	Provides information indicating potential infection.
Avoid allowing those with infections to have contact with infant/ child.	Prevents transmission of infectious agents to infant/child with compromised defense.
Provide adequate rest and nutritional needs for age.	Protects against potential infection by increasing body resistance and defenses.
Wash hands before giving care.	Prevents transmission of microorganisms to infant/ child.
Use sterile technique for IV maintenance if present.	Prevents contamination, which causes infection.
Administer antibiotics as ordered (specify drug, dose, route, and times).	Describe action of specific antibiotic ordered.
Instruct parents and child in personal hygiene and practices (rest, nutrition, activity, bathroom for elimination, bathing).	Prevents reduced defenses or exposure to possible contaminants.
Inform to avoid contact with those in family or friends that have an infection.	Infections are easily transmitted to a debilitated child.

References and Sources : nurseslabs.com

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