NCM09: PEDIA

Erjen Alexandria M. Sia

BSN2B

I. Objectives
General Objectives:

- At the end of the case study, the nursing student will be able to expound and connect all
facts and knowledge gained to the nursing approach in doing valid and outmost care
with patients diagnosed with Patent Ductus Arteriosus

Specific Objectives:

1. Familiarize with the background of what Patent Ductus Arteriosus is all about;
2. Recognize the predisposing and precipitating factors that may increase the development
of PDA;
3. Review and understand the Anatomy and Physiology of the cardiovascular system and
each functions;
4. Explain and illustrate the Pathophysiology of PDA
5. Determine what specific laboratory results that may lead to PDA;
6. Describe the potential complications related to PDA
7. develop and provide a comprehensive care plan and a well-developed health teaching
plan to promote continuity of care to the patient

II. Anatomy and Physiology of the Cardiovascular System

 A child's heart is the center of their cardiovascular system. A normal heart is strong, about
the size of an orange and weighs about one pound. Although it is small in size, the heart is
extremely powerful. The heart continuously pumps oxygen and nutrient-rich blood
throughout the body. On average, the heart beats 100,000 times and pumps about 2,000
gallons of blood (source: American Heart Association). As the blood circulates it collects
waste products that will be excreted from the body.

The heart has four

chambers.

- right atrium
- left atrium
- right ventricle
- left ventricle

The heart pumps blood through the chambers. The flow of blood through the heart is
controlled by four heart valves. The valves open and close as the blood is pumped through the
heart. Each valve has a set of flaps (also called leaflets or cusps). All valves have three flaps,
except for the mitral valve. Normally, it only has two. As the heart beats it creates pressure that
opens the valves which allows blood to flow through the flaps. They make sure the blood only
flows in one direction.

1. Tricuspid valve (between the right atrium and right ventricle)

2. Pulmonary valve (between the right ventricle and pulmonary artery)
 3. Mitral valve (between the left atrium and left ventricle)
4. Aortic valve (between the left ventricle and the aorta)

The two sides of heart have distinct features. The right side receives blood from the body and
pumps it to the lungs. The left side receives the blood from the lungs and is pumped out into
the body. The heart receives blood from veins and sends blood out through arteries.

The physiology of the heart and vascular system changes dramatically around the time of birth.
Prior to birth, the heart works in concert with the mother’s placenta to provide oxygen rich
blood to the body of the baby. Before a baby is born, very little blood sent to the lungs, most is
diverted away from the lungs through a vessel called the ductus arteriosus. Before birth, the
ductus arteriosus is as large as the aorta.

Not all of the blood

pumped from the fetal
heart is sent to the
placenta to collect
oxygen either. Before
birth, the typical oxygen
saturation in a normal
fetus is between 65%
and 70%.

At the time of delivery,

the physiology of the
heart and vascular
system changes so that
the lungs become the
source of oxygen for the
baby. When all goes
well, the transition goes
smoothly and the ductus
arteriosus closes within
the first day or two. In a normal baby, once the ductus arteriosus closes, the blood which is low
in oxygen returning from the body is separated from the oxygen rich blood returning from the
lungs.
When there are anatomic problems with the baby’s heart, the normal transition may be
delayed, potentially masking the severity of the heart defect. The term “ductal dependent”
heart defects are those in which the ductus arteriosus is necessary to allow blood to flow to
either the lungs or the body.

The development is the fetal heart is fantastically complicated and is largely completed by the
9th week of pregnancy. As it turns out, there are many situations in which a malformed heart
will function adequately in fetal life, but will not be successful after birth when the transition in
physiology is complete and the ductus arteriosus closes.

III. Disease Process

Patent Ductus Arteriosus

Patent ductus arteriosus (PDA) is a persistent opening between the two major blood vessels
leading from the heart. The opening, called the ductus arteriosus, is a normal part of a baby's
circulatory system before birth that usually closes shortly after birth. If it remains open,
however, it's called a patent ductus arteriosus.

A small patent ductus arteriosus often doesn't cause problems and might never need
treatment. However, a large patent ductus arteriosus left untreated can allow poorly
oxygenated blood to flow in the wrong direction, weakening the heart muscle and causing
heart failure and other complications.

The ductus arteriosus is a fetal blood vessel that connects the pulmonary artery to the
descending aorta.

 In patent ductus arteriosus (PDA), the lumen of the ductus remains open after birth.
 This creates a left to right shunt of blood from the aorta to the pulmonary artery and
results in recirculation of pulmonary blood through the lungs.
 The prognosis is good if the shunt is small or surgical repair is effective.

Statistics and Incidences

 Patent ductus arteriosus is the most common congenital heart defect among adults.
 PDA is found in 1 of every 2, 500 to 5, 000 infants.
 It affects twice as many females as males

Causes

Normally, the ductus arteriosus closes within days to weeks after birth, and the failure to close
may be attributed to the following factors:

 Prematurity. PDA is most prevalent in premature neonates, probably as a result of

abnormalities in oxygenation.
 Prostaglandin E. The relaxant action of prostaglandin E prevents ductal spasm and
contracture necessary for closure.
 Other congenital defects. PDA commonly accompanies rubella syndrome and may be
associated with other congenital defects, such as coarctation of the aorta, ventricular
septal defect, and pulmonary and aortic stenoses.

Clinical Manifestations

Initially, PDA may produce no clinical effects, but in time it can precipitate pulmonary vascular
disease, causing symptoms to appear by age 40.

1. Respiratory distress. A large PDA usually produces respiratory distress.

2. Heart failure. There are signs of heart failure due to the tremendous volume of blood
shunted to the lungs through a patent ductus and the increased workload on the left
side of the heart
3. Low immune system. The patient has a high susceptibility to respiratory tract infections.
4. Slow motor development. The patient’s motor skills expand and develop slower than
the average person does.
5. Physical underdevelopment. One of the signs of heart disease is the physical
underdevelopment of the patient’s body.
6. Heart murmur. Auscultation reveals a continuous murmur best
7. Bounding peripheral pulses. Peripheral arterial pulses are bounding; also called
Corrigan’s pulse.
 8. Widened pulse pressure. Pulse pressure is widened because of an elevation in the
systolic blood pressure, and primarily, a drop in the diastolic pressure.

Complications

Patent ductus arteriosus, if left untreated, could lead to the following:

1. Left-sided heart failure. The left-to-right shunting of the blood renders the cardiac
muscles of the left chamber overworked and leads to heart failure.
2. Pulmonary artery hypertension. There is increased pulmonary venous return leading to
pulmonary hypertension.

Assessment and Diagnostic Findings

Patent ductus arteriosus is diagnosed by the following:

1. Chest x-ray. Chest x-ray may show increased pulmonary vascular findings, prominent
pulmonary arteries, and left ventricle and aorta enlargement.
2. Electrocardiography (ECG). ECG may be normal or may indicate left atrial or ventricular
hypertrophy and in pulmonary vascular disease, biventricular hypertrophy.
3. Echocardiography. Echocardiography detects and helps determine the size of PDA.

Medical Management

Asymptomatic children do not require immediate treatment but those with heart failure
require the following:

 Fluid restriction. Fluids should be restricted or controlled to avoid overloading the

heart.

Pharmacologic Therapy

Medications for the patient with PDA include:

 Prostaglandin analogs. The ductus arteriosus can be induced to remain open by

administering prostaglandin analogs such as alprostadil (a prostaglandin E1 analog).
 Antibiotics. Before surgery, children with PDA require antibiotics to protect against
infective endocarditis.
 Indomethacin. Indomethacin is a prostaglandin inhibitor that’s an alternative to surgery
in premature neonates and induces ductus spasm and closure.

Surgical Management

Other forms of therapy include surgical interventions such as:

 Cardiac catheterization. In cardiac catheterization, a plug or coil is deposited in the

ductus to stop the shunting.
  Ligation. The DA may be closed by ligation, wherein the DA is manually tied shut, or with
intravascular coils or plugs that leads to formation of a thrombus in the DA.

Nursing Management

Nursing management for a patient with patent ductus arteriosus include:

Nursing Assessment

Assessment should focus on:

 Activity and rest. The nurse should assess for weakness, fatigue, dizziness, a sense of
pulsing, and even sleep disorders.
 Circulation. Circulatory assessment should include history trigger conditions, history of
heart murmurs and palpitations, BP, and pulse pressure.
 Food and fluids. The nurse should assess for dysphagia and changes in body weight.

Nursing Diagnosis

Based on the assessment data, the major nursing diagnoses include:

 Activity intolerance related to imbalance between oxygen consumption of the body and
supply of oxygen to the cells.
 Anxiety related to hospital care or lack of support system.
 Deficient knowledge related to the condition and treatment needs.

Nursing Care Planning & Goals

The major goals for the patient are:

 Maintain adequate cardiac output.

 Reduce the increase in pulmonary vascular resistance.
 Maintain adequate levels of activity.
 Provide support for growth and development.
 Maintain appropriate weight and height development.
Nursing Interventions

Patent ductus arteriosus necessitates careful monitoring, patient and family teaching, and
emotional support.

1. Signs and symptoms. Watch carefully for signs of PDA in premature infants.
2. Monitoring. Frequently assess vital signs, ECG, electrolyte levels, and intake and output.
3. Adverse effects of indomethacin. If the infant receives indomethacin for ductus closure,
watch for possible adverse effects, such as diarrhea, jaundice, bleeding, and renal
dysfunction.
4. Preoperative instructions. Before surgery, carefully explain all treatments and tests to
parents, including the child, and tell them about expected IV lines, monitoring
equipment, and postoperative procedures.
5. Postoperative procedures. Immediately after surgery, the child may have a central
venous pressure catheter and an arterial line in place, so careful assessment of vital
signs, intake and output, and arterial and venous pressures are needed, as well as pain
relief.

Evaluation

Expected outcomes include:

1. Reduced the increase in pulmonary vascular resistance.

2. Maintained adequate levels of activity.
3. Provided support for growth and development.
4. Maintained appropriate weight and height development.

Discharge and Home Care Guidelines

Before discharge, the following should be reviewed with the patient and the family:

 Instructions. Review instructions with parents about activity restrictions based on the
child’s tolerance and energy levels.
 Activities. Advise the parents not to be overprotective as the child’s tolerance for
physical activity increases.
 Follow-up checkups. Stress the need for regular follow-up examinations.
 History. Advise parents to inform any practitioner who treats his child about his history
of surgery for PDA-even if the child is treated for an unrelated medical problem.
 Modifiable Factors:
Non-modifiable Factors:
 Rubella infection
 Genetics: run in families and sometimes PATHOPHYSIOLOGY
 Poorly controlled diabetes
occur with other genetic problems, such  Drug or alcohol use or exposure to chemicals
as Down syndrome. or radiation
 Age: premature infants  Presence of other congenital heart defects.
 Gender: female

Damage to the fetus’ circulatory

system which includes blood vessels
Ductus arteriosus that connects the and the heart
aorta and the pulmonary artery fails to
close at birth

Shunting of oxygenated blood from the high pressure

aorta to the low pressure pulmonary artery

Increased volume of blood passing through the lungs

Increased volume of blood returning to the left atrium

Shunted blood passes to the left ventricle

Continued
 Bulging of the aorta and
Blood goes out to the aorta
pulmonary artery proximal to
the PDA occurs as a result of
increased blood volume and
Blood shunts back to the turbulent flow
pulmonary artery

Pressure difference between

the aorta and pulmonary
Continuous repetition of the
artery (greatest during
cycle of shunting
systole), and consequently
continuous flow through the
PDA
Continuous increase of blood
Backflow of blood to
volume circulating in the lungs
the right ventricle
Production of a
characteristic continuous
machine-like murmur
Compensation of the
cardiac muscle Pulmonary congestion

Pressure in the pulmonary

Right Tachycardia Increased pressure at the lungs artery equals or even
ventricular or other exceeds that of the aorta
hyper-trophy arrhythmia

Pulmonary hypertension
Either the diastolic portion of
Loss of ability to the murmur or the complete
efficiently pump blood Decreased murmur may disappear due
to the pulmonary oxygenated blood to flow reversal (reverse
artery and the lungs shunting PDA)

Increase oxygen
right-sided heart demand Blood then
failure bypasses the
lungs
easy fatigability Compensation by
increasing ventilation
No oxygenation of
Poor eating Decreased functioning of the the blood
Persistent fast
immune system to resist infection
breathing or
and of the respiratory system to
breathlessness
expel offending microorganisms Cyanosis
Poor growth

Frequent respiratory
infections