Sabtu, 07 Mei 2011
CHAPTER I
THEORY REVIEW
I. Definition
Congenital heart disease (CHD) or congenital heart disease are heart abnormalities that have been around since the baby was born, so these abnormalities occur before birth.However, congenital heart defects is not always a member!Symptoms immediately after the baby is born, not infrequently these abnormalities has been discovered after patients aged several months or even years (Ngastiah)
II. Etiology
Causes of congenital heart associated with embryonic development, at the age of five to eight weeks, heart and major blood vessels formed. Developmental disorders may be caused by prenatal factors such as maternal infections during the first trimester. Another is the causative agent of rubella, influenza or chicken fox. Factor-factor such as prenatal mothers suffering from diabetes mellitus with ketergantngan on insulin and genetic factors are also influential to the occurrence of congenital heart disease. In addition to parental factors, the incidence of heart abnormalities was also increased in individuals. Factors-environmental factors are like radiation, nutrition, bad mother, addicted to drugs and alcohol also affect embryonic development.
III. SIGNS AND SYMPTOMS
1. Infants
1) dyspnea
2) Difficulty breathing
3) Pulse rate over 200 beats / min
4) Recurrent respiratory infections
5) Failure to gain weight
6) Heart murmur
7) CNS
8) Cerebrovasculer accident
9) Stridor and choking spells
2. CHILDREN
1) dyspnea
2) Poor physical development
3) Decrease exercise tolerance
4) Recurrent respiratory infections
5) Heart murmurs and Thrill
6) CNS
7) squatting
8) Clubbing of fingers and toes
9) elevated blood pressure Figure Clubbing Fingers
IV. Pathophysiology
Congenital heart defects cause two changes in hemodynamic
main. Shunting or mixing of venous and arterial blood flow changes
pulmonary blood and blood pressure. Nornalnya, more pressure on right heart
larger than the pulmonary circulation. Shunting occurs when blood flow through
abnormal hole in a healthy heart from a higher-pressure area to
area of low pressure, causing blood to flow teroksigenisasi
into the systemic circulation. Pulmonary blood flow and blood pressure increase when there are delays in the normal thinning of the muscle fibers software on pulmonary arterioles during birth.
Thickening of the pulmonary circulation vascular resistance increases, blood flow
sis may exceed pulmonary circulation and blood flow right bergerakdari
to the left. Changes in blood flow, mixing of blood veins and arteries, as well as
increase in pulmonary pressure will increase the work of the heart.
Jantug manifestation of congenital disease that is the existence of heart failure,
inadequate perfusion and pulmonary congestion.
V. CLASSIFICATION
There are various ways the classification of congenital heart disease. Classification is a very simple classification based on the presence of cyanosis and
vaskuiarisasi lung.
1. Congenital heart disease (SPA) non sianotik with increased pulmonary vascularity, such as septal defect (DSV), atrial septal defect (DSA), and persistent ductus arteriousus (DAP)
2. PJB non sianotik with normal pulmonary vascularity. In this classification
including aortic stenosis (AS), pulmonary stenosis (SP) and aortic koarktasio
3. PJB sianotik with decreased pulmonary vascularity. In this classification
most of the tetralogy of Fallot (TF)
4. PJB sianotik with increased pulmonary vascularity, such as arterial transposition
large (TAB)
SPA Non sianotik with increased pulmonary vascularity
Terdapak detective on the ventricular septum, atrial or ducts that remain open
cause the shunt (leakage) of blood from left to right because of the pressure
heart on the left is higher than the right side.
1. Ventricular septal defect (DSV)
DSV occurs when the ventricular septum was not formed perfectly. As a result
blood from the left ventricle flows into the right ventricle during systole
Clinical manifestations
On examination in addition to stunted growth obtained, the child looks pale,
a lot of sweat pouring, hiperemik fingertips. Chest diameter
increases, often seen pembonjolan left chest. Signs which are menojol
shortness of breath and retraction on jugulum, unanimous intrakostal and epigastric region.
In the child who looks thin hyperdynamic cardiac impulse.
Management
Patients with large DSV need to be helped with medication weeks to resolve
heart failure. Usually given digoxin and diuretics, such as Lasix. When the drug
can remedy the situation, as seen with the improvement of respiratory and
weight gain, rnaka surgery can be delayed until the age of 2-3 years.
Surgery is very helpful because no such action in life expectancy
reduced.
2. Atrial septal defect
Atrial septal abnormalities caused from a hole in the foramen ovale or
the atrial septum. Pressure on the foramen ovale or atrial septum, the pressure
on the right side of the heart increases.
Manifesfasi clinic
Children may often experience fatigue and upper respiratory tract infection. Maybe found a heart murmur. In the photo rongent found any enlargement of the heart and the diagnosis confirmed by cardiac catheterization.
Type ASD
(A) (b)
Image:
(A) ASD sekundum, (b) Primum ASD, (c) venous sinus type ASD
(Modified from: www.meridianhealth.com / healthcontent / images)
Management
These abnormalities can be closed with stitches or installed a
graft open-heart surgery, with good prognosis.
3. Persistent ductus arteriosus
DAP is the presence of fetal blood vessels connecting the
branching to the left pulmonary artery (left pulmonary artery) into the aorta
right descending artery distal to the left subklavikula. DAP occurs when the duct
do not close when the baby is born. DAP Causes vary, either because
rubella infection in the mother and prematurity.
Clinical manifestations
Neonates showed signs of respiratory distress, such as snoring, tacipnea and retraction. In line with the growth of children, the children will experience dyspnea, enlarged heart, left ventricular hypertrophy due to cardiac adjustments to penigkatan blood volume, a sign-type machinery. Heart murmur due to turbulent blood flow from the aorta through the duct settled. Systolic blood pressure may be high because of an enlarged left ventricle.
Management
Because the neonates did not tolerate surgery, the abnormality is usually treated with aspirin or idomethacin software that causes muscle contraction in the ductus arteriosus. When children aged 1-5 years, strong enough to do surgery.
Non sianotik congenital heart disease with normal pulmonary vascularity
1) Aortic stenosis
In this disorder stricture occurred above or below the aortic valve. Valve itself may be affected or restriction or a total blockage of blood flow.
Manifestosi clinic
Children become fatigue and dizziness while cardiac output decreases, the signs are more visible if O2 did not meet the needs of
terp [enuhi, it is becoming a serious can rnenyebabkan death, is also characterized by an audible systolic murmur at the left sternal border, the diagnosis be established based on the picture that showed the presence of ECG left ventricular hypertrophy, and cardiac catheterization showed the stricture.
Management
Stenosis removed by incision at the valve is done when children are able to do surgery tx
2) pulmonary stenosis
Abnormalities in pulmonik stenosis, found the stricture of the valve, but the normal peak together.
Clinical manifestations
Depending on kondisis stenosis. Children can experience dyspne and fatigue, because the flow of blood to the lungs is inadequate to meet the needs of O2 from the cardiac output rose. In the state of stenosis, the blood back into the right atrium that can rnenyebabkan congestion heart failure.Stenosis was diagnosed on the basis of systolic heart murmurs, ECG and heart kateterisai.
Management
Stenosis corrected by surgery performed on the valve
at the time of children aged 2-3 years.
3) Koarktasio Aorta
Koartasi abnormalities in the aorta, the aorta berkontriksi in several ways. Kontriksi may proximal or distal to the duct arteiosus. Kelaianan is usually not immediately known, except in heavy kontriksi. For that important meiakukan skrening children while checking his health, particularly when children attend sports activities.
Clinical manifestations
Characterized by an increase in blood pressure, proximal direction on the distal abnormality and reduction. Blood pressure was higher in arm than leg. The pulse in the arm feels strong, but weak in the popliteal and femoral.Sometimes found a heart murmur weak with high frequency.Diagnosis is based cartography.
Management
The disorder can be corrected with Balloon Angioplasty, removal of the aorta that berkontriksi or anastomi the end, or by
include a graph. Sianotik congenital heart disease with decreased pulmonary tetralogy of Fallot vaskularisai
Tetralogy of Fallot is a common heart disease, and consists of 4
disorders are:
a) pulmonary stenosis,
b) right ventricular hypertrophy,
c) ventricular septal defects,
d) abnormalities of the aorta that receives darajh from the ventricles and
right to left blood flow through ventricular septal defects.
Figure Tetralogy Of Fallot (Modified from: www.bristol-inquiry.org.uk)
Clinical manifestations
Newborns with symptoms that nayata TF reveal the existence of
cianosis, lethargy and weakness. Setain were also signs that dyspne
then accompanied by clubbing fingers, babies are small and underweight. Along with age, infants were observed regularly, and endeavored to prevent the occurrence of dyspne. Infants prone to upper respiratory tract infection. Diagnosis based on clinical symptoms, murmurjaniung, ECG images and kateterisai rongent heart.
Management
Palliative surgery performed at an early age children, to mernenuhi
increased oxygen demand in its infancy. Surgery
during the next school age, aims to corrections
permanent. Two approaches are palliative Blalock-Tausing manner,
performed on ananostomi end to the right side of the sub ciavikula or arterial
carotid to the right pulmonary artery. In Waterson worked on
side to side assenden anastonosis of the aorta, pulmonary artery toward the right,
These actions increase the blood is oxygenated and free
symptoms of cyanotic heart disease.
Sianotik congenital heart disease with pulmonary vascular
increase
1. Transposition of great arteries / Transpotition Great artery (TGA)
If the vessel had a large blood vessel transposition
aorta, the aorta and pulmonary artery anatomically be affected. Child
will not live unless there is a duct abnormalities persist or ariosus
ventricular or atrial septum, which causes the mixing of blood
artery-vein.
In TGA there is a change where the exit position of the aorta and the pulmonary aorta out of the right ventricle and is located next
anterior a.pulmonalis, while a.pulmonalis out of the left ventricle
situated posterior to the aorta. As a result, the aorta receives blood v.
Systemic from the vena cava, atriumkanan, right ventricle and the blood passed into the systemic circulation. Moderate blood from the pulmonary veins drained into the left atrium, left ventricle and passed to a. Pulmonary and onwards to the lungs. Thus, both systemic and pulmonary circulation are separate and life can only take place if there is communication between these two circulation. In the neonatal blood mixing occurs through the ductus arteriosus and foramen ovale keatrium right. In general, mixing through the duct and the foramen ovale is not adequate, and if the ductus arteriosus closes then there is no longer in tempatm mixing, the situation is life-threatening patients.
Manifesfasi clinic
Transposition of blood vessels is dependent on the presence of
abnormality or stenosis. Stenosis is less visible when the abnormality
a PDA or ASD or VSD, but heart failure will
occur.
. ,
Management
Palliative surgery done so that mixing of blood. At the time of the procedure, a balloon catheter is inserted when the cardiac catheterization, to enlarge kelainanseptum intra-arterial. On the way Blalock Halen made an atrial septal abnormality. On Edward's right pulmonale vein. How Mustard is used for a permanent correction. Septum is removed so that the connections made from venous blood teroksigenisasi pulmonale back into the right ventricle to the body and blood circulation teroksigenisasi not return from the vena cava to the arteries pulmonale for the purposes of the pulmonary circulation. Then due kelaianan has been reduced significantly with the correction and palliative.
VI. COMPLICATIONS
Patients with congenital heart disease teramcam experience various complications, among others:
1. Congestive heart failure
2. Cardiogenic shock, Stop Heart
3. Arrhythmia
4. Endocarditis bakterialistis
5. Hypertension
6. Pulmonary Hypertension
7. Thromboembolism and brain abscess
VII. EXAMINATION SUPPORT
1. The picture that showed the presence of ECG left ventricular hypertrophy, cardiac catheterization which showed stricture.
2. Diagnosis is based cartography,
3. Iso cardiac enzymes (CPK and CKMB) rose
4. Roentgen thorax to see or evaluate the cardiomegali and
pulmonary infiltrate
CHAPTER II
NURSING THEORY
A. ASSESSMENT
1. History of nursing:
a) History of infection in the mother during the first trimester.Agent
Another cause is rubella, influenza or chicken pox.
b) prenatal history is like a mother who suffered from diabetes mellitus with
dependence on insulin.
c) Compliance with a good mother to maintain pregnancy, including maternal nutrition to maintain, and not addicted to drugs and alcohol, not smoking.
d) The process of birth or by nature ataua the factors
prolong the process of childbirth, the use of tools such as vacuum for
assist the birth or mother must be SC.
e) History descent, with rnemperhatikan a family member
others who also have heart defects, to assess the
genetic factors that support.
2. Physical examination
Physical examination performed the same as physical assessment conducted on patients suffering from heart disease in general. Specifically, the data can be found from the results of physical assessment in congenital heart disease are:
a) The newborn is small and less weight.
b) the child was pale, a lot of sweat pouring, hiperemik fingertips.
c) chest diameter increases, often seen pembonjolan left chest.
d) Signs that menojol is shortness of breath and retraction on jugulum, interrupted
e) intrakostal and epigastric region.
f) In a child who looks thin hiperdinarnik cardiac impulse.
g) The child may often suffer from fatigue and upper respiratory tract infection
h) Neonates showed signs of respiratory distress such as
snoring, tacipnea and retraction.
i) Subsidiaries of dizziness, the signs are more visible when the fulfillment
unmet need for O2 characterized by the presence
systolic murmur heard at left sternal border,
j) There is an increase in blood pressure. Blood pressure was higher in arm than leg.
k) pulse in the arm feels strong, but weak in the popliteal and temoral.
B. Nursing Diagnosis
1. Cardiac output decline associated with decreased heart kontraktilftas, pressure change of heart.
2. Changes in nutrition less than body requirements related to the inability to breast-feeding and eating
3. Pain; chest associated with myocardial ischaemia
4. Penigkatan body fluid volume associated with congestive vein, the decline in kidney fungsf
C. NURSING INTERVENTION
1. Decrease in Cardiac Output related to a decrease
kontraktilftas heart, a change of heart pressure.
Objective: The patient can tolerate the symptoms caused by-gej'ala
decrease in cardiac output, and after nursing actions occur
increase in cardiac output so that normal kekeadaan.
Intervention:
a) Monitor vital signs
Rational: the beginning of interference with the heart will be no changes in vital signs such as rapid breathing, increased temperature, increased pulse, increased blood pressure, it quickly detected for further treatment.
b) Inform and advise about the importance of adequate rest
Rational: adequate rest to minimize the work of the heart and can maintain the existing energy.
c) Provide supplemental oxygen by nasal cannula / mask as indicated.
Rational: to increase the supply of oxygen to the needs miokord to counteract the effects of hypoxia / ischemia
d) Assess against the pale skin and cyanosis
Rational: pale showed a decrease in perfusion secondary
against ketidakadekuatan cardiac output, vasoconstriction, and anemia.
e) Review the changes in sensory, eg lethargy, confusion disorientation anxiety
Rational: to indicate inadequate cerebral perfusion secondary to reduced cardiac output.
f) In collaboration provide pharmacological action of digitalis, digoxin
Rational: influence of sodium and water reabsorption, and digoxin
improve myocardial contraction force and slow the heart by lowering the frequency of conduction and prolong refractory period in the AV relationship to improve the efficiency of cardiac output.
2. Changes in nutrition less than body requirements related to the inability to breast-feeding and eating
Objective: The child can eat and feeding and weight loss does not occur
body during the nutritional status changes
Intervention:
a) Instruct the mother to continue to give children milk, although a little but often
Rational: milk will maintain the nutritional needs of children
b) If the child show weakness due to lack of nutrients entering adekuatannya the tide iv infusion
Rational: infusion will increase the need for nutria that can not be met through oral
c) In children who are not breastfeeding anymore then give the food with little portions but often with appropriate diet instruction
Rational: to increase the intake, and prevent weaknesses.
d) Observation during feeding or breast feeding
Rational: during feeding or breast-feeding may occur tightness or choking child
3. Pain; chest associated with myocardial ischaemia
Objective: To declare the pain disappear
Intervention:
a) Investigate any complaints of pain, which in children can be given with a fussy or crying often
Rational: differences in symptoms need to identify the cause of pain. Behavior and vital signs to help determine the degree or the discomfort of the patient.
b) Evaluation of the response to medication / therapy given
Rational: the use of drug therapy and dose, record the pain that is not lost or reduced with the use of nitrates.
c) Give the environment a break and limit the child's activity as required
Rational: activities that increase myocardial oxygen demand.Examples of a sudden, stress, eating a lot, terpaj'an cold) can trigger chest pain.
d) Instruct the mother to give peace on child setalu
Rational: calm children will reduce the stress that can aggravate the pain is felt.
4. Penigkatan body fluid volume associated with congestive vein, decreased kidney function
Objective: To show the balance of input and output, stable weight, vital signs within normal range, no edema
Intervention:
a) Monitor income and expenditure, record the fluid balance, weigh the child's weight every day
Rational: important in the assessment of heart and kidney function and
effectiveness of diuretic therapy. Fluid balance and body weight continues to increase addressing increasingly bad heart failure.
b) Assess the periorbital edema, edema of hands and feet, hepatomegaly, rales, ronchi, weight gain
Rational: to indicate excess body fluid
c) In collaboration provide an example diuretic furosemide as indicated
Rational: reabsorsi inhibits sodium, which enhances excretion of fluid and lower the total body of excess fluid.Provide dietary sodium restriction as indicated
Rational: reducing the sodium retention.
REFERENCES
Marilyn Doenges E, Jane R Kenty: 1998 Maternal / Newborn Care Plans: Guidelines for client care Ea Davis Company: Philadelphia
Mansjoer Arif: 1999: Capita Selekta Medicine third edition of volume I: Media
Aesculapius Medical Faculty University of Indonesia: Jakarta
Madiyono, Bambang, dkk.2005. Treatment of Heart Disease In Infants And
Child. Hall FKUI Publisher: Jakarta
Susan Mattson: 2000 Core Curriculum for Maternal-Newborn second edition:
advision of Harcourt Brace & company: Philadelphia
Ngastiyah: 1997 Child Care Hospital: publisher of medical books: Jakarta
Center for Health Education Health Manpower: 1993
Nursing Process At Pas / en Impaired Cardiovascular System: Publisher of medical books EGC: Jakarta
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