CASE STUDY ON :C.H.

Name : Master sameer kaushik

Father’s /husband’s name : S/O Lokesh kaushik

Age : 42 yr

Sex : Male Child

Occupation : Not Applicable

Education : Not Applicable

Religion : Hindu

Ward no. :male surgical ward

Bed no : 4

Date of admission : 14/04/2019

Registration no . : 12547

Treating doctor : Dr.V.K.

Address : Sikar road, jaipur

Marital status : Single

Diagnosis provisional : congenital heart disease,

ventricular septal defect with severe
aortic regurgitation

Final diagnosis : Congenital Heart Disease With VSD

Surgery if any : Trustler Repair Of VSD

Date of collection : 18/04/2019

HISTORY TAKING :-

Present complain:Mast. Sameer has c/o dyspnoea on feeding and while playing
on bed also,cyanosed, clubbed fingers and toes ,growth failure difficulty in crying
. ,

History of present illness :Since last 5 months the child is under the treatment
of dr. Gupta, but the birth weight of the baby was very less only 2.1 kg and
clinically there was not much problem as such but since last 15 days he is not
alright , he used to be very tired either on feeding or playing on bed , at night he
used to have dyspnea as well as cyanosis on earlobes , lip , fingers and toes,so the
parents were very anxious and now brought for surgery .

Past history:He used to have cold and cough so frequently .

Family history: In his family no body is suffering from any major disease
condition neither any person died due to heart disease .

Socio-economic status :He is from middle class family , he is staying with his
parents in rented house which is having only one room and having common toilet
facilities.He is very beautiful and having beautiful smile all neighbour like him.

Family composition :

S.No Name of the Age Sex Relation Health

member with the status
patient
1. Mr. Lokesh 27 years Male Father Good
Kaushik
2. Mrs.Meena 24 years Female Mother Good
Kaushik
3. Mast. Sameer 6 months Male Son Having
(patient ) CHD

Personal history :
  Eating habits : He takes only the milk of mother.
 Elimination : He used to have constipation sometimes other
pattern wisehaving no problem in bowel and
bladder evacuation .
 Any abuse : He is a child .
 Life style : There is no particular life style.

PHYSICAL EXAMINATION :

Height :5 cm

Weight : 55 kg

VITAL SIGNS :

Temperature : 99.8°F

Pulse : 142/mt.

Respiration : 60 by/mt.

Blood pressure : 90/60 mmhg per arterial blood pressure .

HEAD :

Scalp : No scar was seen but the scalp seems to dry,

anterior fontanel didnot close .

Face : Normal in shape , size and alignment .

Sinus area : No tenderness present.

Nodes : No nodes are enlarged .

Cranium : Normal

EYES :

Visual acuity : Normal

Visual field : Clear,6/6

Ocular movement : Normal , moves to both sides as well as towards
the up anddown , this is checked by producing
sound by fingers .

Lids : Eye Lides are normal no edema or

inflammation is being detected .

Lacrimal glands : The Lacrimal Glands are normal and secretes

normally .

Conjunctiva : Pale

Sclera : pale

Cornea : No Abnormality detected

Lens and media : Normal , the image forms normally

Pupils : Reacting to light

Fundus : Normal

EARS :

External structure : Normal in alignment ,

Canal : Normal , no discharge is seen

Tympanic membrane : Normal

Hearing : Normal , checked by tunic fork

NOSE :

External structure : Normal in alignment ,

septum : No deviation seen

Mucus membrane : Moist , no inflammation seen .

Patency : Good

Olfactory sense : This could not be checked because the child

was notthatactive .
ORAL CAVITY :

Lips : Mildly cyanosed , cracked , dry .

Buccal mucosa : Cyanosed and dry

Gums : Pale

Teeth : Not present

Palates and uvula : Normal

Tonsillar areas : No enlargement detected

Tongue : Cyanosed , dry ,

Floor : Normal no palates detected

Voice : Crying pitch was very low .

Breath : Dyspnoea present .

NECK :

General structure : Normal in shape and size .

Trachea : Present in central

Thyroid : Normal , no enlargement seen

CHEST AND RESPIRATORY SYSTEM :

Chest shape : Slightly bulging due to cardiomegaly

Type of respiration : Thoraco- abdominal respiration was present .

Expansion : very fast chest expansion was present .

General palpation : On palpation chest movement was present as

well as apex impulse was present on 5th
intercostals space , the murmur was very much
prominent on sterna region.

Percussion : on percussion no air or fluid detected .

Breath sound : B/L +

CARDIOVASCULAR SYSTEM :

History :

1)cardinal symptoms :

Dyspnoea on excretion: There was marked presence dyspnoea

on exertion, specially while he used to play on
beds or through leg and hands another thing is that
he used to be very tired while feeding .

Chest pain : It was not that evident but sometimes the

child used to be irritated and cry .

Cough : No cough was present.

Expectoration : No, expectoration was present.

Haemoptysis : Therewas no presence of haemoptysis ,

Palpitation : There was not marked palpitation but we could

seethe beating of heart on chest
wall.

Syncopal attack : 2-4 times he had an syncopal attack.

Build and nutrition : He was averagely nourished

Nails and conjunctiva : Clubbing of fingers and toes were very

prominent,conjunctiva was pale.

Thyroid : No enlargement detected.

Oedema : There was no presence of oedema.

Skin : The skin was bluish.

Any features of : No any feature

 EXAMINATION :

A)INSPECTION :-

1)Precordium : The Precordium is the anterior aspect of the chest

whichwas slightly bulged .

2)Apex impulse: Apical impulse was in 5th intercostals space .

3)Pulsations : No dilated veins detected over the chest , no extra

pulsationon chest except murmur .

4)Dilated Veins : No dilated veins were present over the

Over The Chest chest .

5) Scars And Sinus:No scar of previous cardiac or chest surgery is

being detected .

B)PALPATION :-

1)Apex Beat : The Apex beat is felt on 5th intercostals space within
the midclavicular line

2)Parasternal Heave:No parasternal heave is noted .

3)Diastolic shock : No palpable second heart sound was detected .

4)Thrills : A terrible murmur was felt while palpating the chest

wall ,because the chest wall was thin .

C)PERCUSSION :

1)Left Border : There is no presence of pericardial effusion ,only the

apex beatis present

2)Upper Border : The 2nd and 3rd intercostals space was percussed ,there
is no presence of pericardial effusion , aneurysm of
aorta , orpulmonary hypertension .

3)Right Border : The patient was percussedanteriorly in the

midclavicular line on the right side but no abnormality
is being detected .
D )AUSCULTATION :

First Heart Sound (S1 ) : Present

Second heart sound (S2 ) : Present

Third heart sound (S3) : Absent

PALPABLE HEART SOUNDS :

1)palpable s2; s1 and s2 both were palpable

2)palpable s1

3)palpable s4;--- Absent

MURMURS : There was presence of palpable murmur.

ABDOMEN AND INGUINAL AREAS :

Contour and tone :Good contour and good muscle tone .

Scars marks :There is no scar marks detected .

Liver :

Spleen : Normal

Kidneys :

Bladder : Normal

Hernias : There is no hardness or swelling over the groin .

Masses : No masses are felt on abdomen

Palpation : On palpation no mass or any kind of hardness is felt ,

abdomen was soft to touch .

Percussion : On percussion no fluid or gas collection detected .

Auscultation : On auscultation normal peristaltic movement heard .

GENITALIA AND AREA NODE :No such kind of nodes,abrasion or

lesions seen.

RECTAL EXAMINATION :No rashes or any kind of abnormality detected.

MUSCULOSKELETAL SYSTEM :

Gait : Normal

Upper extremities: Both are in normal alignment no extra digits are

present clubbing and cyanosis were present .

Lower extremities : Both are in normal alignment ,clubbing present .

Deformities : No such deformities detected .

Range of motion : This could not be done because the child was getting
tiredeasily .

NERVOUS SYSTEM :

Mental status : He can understand who is mother but since he is very

tiny, onlymonth of 6 so this could not found out by
any other means .

Language: He has not develop speech .

Motor co-ordination : Motor co-ordination is good .

Lower extremities: Good tone of muscles , no rigidity detected and well

co- present , there is presence of cyanosis .

DESCRIPTION OF THE DISEASE :-

Introduction :
A congenital heart defect is a defect in the structure of the heart and great vessels
of a newborn. Most heart defects either obstruct blood flow in the heart or vessels
near it or cause blood to flow through the heart in an abnormal pattern defects
affecting heart. Heart defects are among the most common birth defects and are
the leading cause of birth defect-related deaths.

Definition :

Congenital heart defect : Is a defect in the structure of the heart and great
vessels of a newborn.
Etiology:-

Cause: unknown.

It may be:

 genetic predisposition
 environmental

Known genetic causes of heart disease include chromosomal abnormalities:

1)Such as trisomies 21, 13, and 18,

2)Genetic point mutations, point deletions.

Known antenatal environmental factors include:

1)Maternal infections (Rubella),

2)Drugs (alcohol, hydantoin, lithium and thalidomide) and

3)Maternal illness (diabetes mellitus, phenylketonuria, and systemic lupus

erythematosus).and subaortic stenosis being comparatively rare. Any narrowing
or blockage can cause heart enlargement or hypertension.

ANATOMY AND PHYSIOLOGY:The heart is the muscular organ of the

circulatory system that constantly pumps blood throughout the body.
Approximately the size of a clenched fist, the heart is composed of cardiac muscle
tissue that is very strong and able to contract and relax rhythmically throughout a
person's lifetime.
The heart has four separate
compartments or chambers. The upper
chamber on each side of the heart, which
is called an atrium, receives and collects
the blood coming to the heart. The
atrium then delivers blood to the
powerful lower chamber, called a
ventricle, which pumps blood away
from the heart through powerful,
rhythmic contractions.

The human heart is actually two pumps

in one. The right side receives oxygen-
poor blood from the various regions of
the body and delivers it to the lungs. In
the lungs, oxygen is absorbed in
theblood. The left side of the
heartreceives the oxygen-rich blood
from the lungs and delivers it to the rest
of the body.
Electrical Conduction System:

The heart is composed primarily of muscle tissue. A network of nerve fibers

coordinates the contraction and relaxation of the cardiac muscle tissue to obtain
an efficient, wave-like pumping action of the heart.

The Sinoatrial Node (often called the SA node or sinus node) serves as the
natural pacemaker for the heart. Nestled in the upper area of the right atrium, it
sends the electrical impulse that triggers each heartbeat. The impulse spreads
through the atria, prompting the cardiac muscle tissue to contract in a coordinated
wave-like manner.

The impulse that originates from the Sinoatrial node strikes the Atrioventricular
node (or AV node) which is situated in the lower portion of the right atrium. The
Atrioventricular node in turn sends an impulse through the nerve network to the
ventricles, initiating the same wave-like contraction of the ventricles.

The electrical network serving the ventricles leaves the Atrioventricular node
through the Right and Left Bundle Branches. These nerve fibers send impulses
that cause the cardiac muscle tissue to contract.
Sinoatrial node

Atrioventricular node

Common AV bundle

Right and left bundle – brunch

Blood Vessels :

Blood Vessel are tubes which carry blood. Veins are blood vessels which carry
blood from the body back to the heart. Arteries are blood vessels which carry
blood from the heart to the body. There are also microscopic blood vessels which
connect arteries and veins together called capillaries. There are a few main blood
vessels which connect to different chambers of the heart.

The aorta is the largest artery in our body. The left ventricle pumps blood
into the aorta which then carries it to the rest of the body through smaller arteries.
The pulmonary trunk is the large artery which the right ventricle pumps into. It
splits into pulmonary arteries which take the blood to the lungs. The pulmonary
veins take blood from the lungs to the left atrium. All the other veins in our body
drain into the inferior vena cava (IVC) or the superior vena cava (SVC). These
two large veins then take the blood from the rest of the body into the right atrium.

Valves :

Valves are fibrous flaps of tissue found between the heart chambers and in the
blood vessels. They are rather like gates which prevent blood from flowing in the
wrong direction.

They are found in a number of places. Valves between the atria and
ventricles are known as the right and left Atrioventricular valves, otherwise
known as the tricuspid and mitral valves respectively. Valves between the
ventricles and the great arteries are known as the semi lunar valves. The aortic
valve is found at the base of the aorta, while the pulmonary valve is found the
base of the pulmonary trunk. There are also many valves found in veins
throughout the body. However, there are no valves found in any of the other
arteries besides the aorta and pulmonary trunk.
Function and of the Heart :

The heart's job is to pump blood around the body. The heart is located in between
the two lungs. It lies left of the middle of the chest.

PATHOPHYSIOLOGY :

Tetralogy Of Fallot:Tetralogy of Fallot (TOF) is a congenital heart defect which

is classically understood to involve four anatomical abnormalities (although only
three of them are always present). It is the most common cyanotic heart defect,
representing 55-70%, and the most common cause of blue baby syndrome. since
the child had Tetralogy of fallot so i describe here the pathophysiology of TOF.

Pathophysiology of Tetralogy of fallot :

Tetralogy of Fallot results in low oxygenation of blood .

There is mixing of oxygenated and deoxygenated blood in the left ventricle via
the VSD .

preferential flow of the mixed blood from both ventricles through the aorta
because of the obstruction to flow through the pulmonary valve. This is known
as a right-to-left shunt

Ventricular septal defect : is a defect in the ventricular septum, the wall

dividing the left and right ventricles of the heart. The child was having a large
VSD so i explain below about the pathophysiology of VSD .
Pathophysiology of VSD :

During ventricular contraction, or systole, some of the blood from the left
ventricle leaks into the right ventricle.

The blood than passes through the lungs and reenters the left ventricle via the
pulmonary veins and left atrium.

This has two net effects. First , the circuitous refluxing of blood causes volume
overload on the left ventricle.

Second because the left ventricle normally has a much higher systolic pressure
than the right ventricle the leakage of blood into the right ventricle therefore
elevates right ventricular pressure and volume, causing pulmonary hypertension
with its associated symptoms.

This effect is more noticeable in patients with larger defects, who may present
with breathlessness, poor feeding and failure to thrive in infancy.

Patients with smaller defects may be asymptomatic.

CLINICAL MANIFESTATIONS :(IN GENERAL )

1) The primary symptom is low blood oxygen saturation with or without

cyanosis from birth or developing in the first year of life.
2) If the baby is not cyanotic then it is sometimes referred to as a "pink tet"
3) Other symptoms include a heart murmur which may range from almost
imperceptible to very loud,
4) difficulty in feeding,
5) failure to gain weight,
6) retarded growth and physical development,
7) dyspnea on exertion,
8) clubbing of the fingers and toes, and
9) polycythemia.
Children with tetralogy of Fallot may develop "tet spells. Tet spells are
characterized by a sudden, marked increase in cyanosis followed by syncope, and
may result in hypoxic brain injury and death. Older children will often squat
during a tet spell, which cuts off circulation to the legs and therefore improves
blood flow to the brain and vital organs.

IN MY PATIENT

cyanosis from birth

 clubbing of the fingers and toes,

 heart murmur
 difficulty in feeding,
 failure to gain weight,
 retarded growth and physical development,
 dyspnea on exertion specially while feeding or movement on bed

Diagnostic Evaluation :(IN GENERAL )

History and physical examination :

1)A VSD can be detected by cardiac auscultation Classically, a VSD causes a

pathognomonic holo- or pansystolic murmur.

2) Auscultation is generally considered sufficient for detecting a significant VSD.

The murmur depends on the abnormal flow of blood from the left ventricle,
through the VSD, to the right ventricle.

3)If there is not much difference in pressure between the left and right ventricles,
then the flow of blood through the VSD will not be very great and the VSD may
be silent.

4)This situation occurs in the fetus (when the right and left ventricular pressures
are essentially equal), for a short time after birth (before the right ventricular
pressure has decreased), and as a late complication of unrepaired VSD.

5)Confirmation of cardiac auscultation can be obtained by non-invasive cardiac

ultrasound (echocardiography).

6)To more accurately measure ventricular pressures, cardiac catheterization, can

be performed.
Chest X-Ray ;The abnormal boot-like appearance of a heart with tetralogy of
Fallot is easily visible and before more sophisticated techniques became
available, this was the definitive method of diagnosis.

Echocardiography; which is quick, involves no radiation, is very specific, and

can be done prenatally , it reveals the structure and function of heart very clear .

Investigations In My Patient

s. no Investigations Normal value Patients value

1. Haemoglobin 11.5-15.5 gm. 14 gm
2. W.B.C 4000-10000/cmm 5,100/cmm
3. Packed cell vol. 37-45% 43 %
4. Platelet count 1.5-4.0lacs/cmm 1.72 lacs /cmm
5. Blood group - B positive
6. R.B.S 70-140mg/dl 87 mg/dl
7. SGOT 5-40 IU/L 32IU/L
8. SGPT 3-40 IU/L 47IU/L
9. S. Bilirubin 0.2-1.2 mg/dl 0.46mg/dl
10. Direct Upto 0.3 mg/dl 0.30mg/dl
11. Indirect 0.2-1.0 mg/dl 0.16mg/dl
12. S. Creatinine 0.5-1.5mg/dl 0.9mg/dl
13. S.na+ 135-145meq/l 137 Meq/L
14. S.K+ 3.5-5 Meq/L 5.1Meq/L
15. CL- 96-107 Meq/L 95 Meq/L
16. S. Protein 6-8 gm/dl 5.8gm/dl
17. S. Albumin 3.5-5 gm/dl 3.2gm/dl
18. S.Globulin 2.5-3.5 gm/dl 2.6 gm/dl
19. Bld. Urea 15-40 mg/dl 20 mg /dl
20. Hbsag Negative Negative
21. HIV Non-reactive NR.
22. Blood group - B positive
23. PT –test - 15 sec.
24. Control - 13 sec.
25. INR - 1.11
URINE
ROUTINE
26. Albumin Nil Trace
27. Sugar Nil Nil
ECHOCARDIOGRAPHY :-

 Acynotic congenital heart disease

 RSOV into RV cavity
 Mild RVOT obstruction with gradient of 34 mmhg
 Moderate eccentric AR
 LA $ LV volume overload present
 Normal biventricular functions
 Large VSD

CHEST X-RAY :-The chest x-ray shows large cardiomegaly .

MANAGEMENT : ( IN GENERAL ):

Emergency management of tet spells:

 Prior to corrective surgery, children with tetralogy of Fallot may be prone

to consequential acute hypoxia (tet spells), characterized by sudden
cyanosis and syncope. These may be treated with beta-blockers such as
propranolol,
 acute episodes may require rapid intervention with morphine to reduce
ventilatory drive
 and a vasopressor such as epinephrine, phenylephrine, or norepinephrine
to increase blood pressure.
 Oxygen is ineffective in treating hypoxic spells because the underlying
problem is lack of blood flow through the lungs and not oxygenation within
the lungs.
 There are also simple procedures such as squatting in the knee-chest
position which increases aortic wave reflection, increasing pressure on the
left side of the heart, decreasing the right to left shunt thus decreasing the
amount of deoxygenated blood entering the systemic circulation

Palliative surgery:

A palliative surgical procedure, which involved forming an anastomosis between

the subclavian artery and the pulmonary artery ,increasing flow through the
pulmonary circuit, and greatly relieving symptoms in patients.

The first Blalock-Thomas-Taussig shunt surgery was performed on 15-month

child. Currently, Blalock-Thomas-Taussig shunts are not normally performed on
infants with TOF except for severe variants such as TOF with pulmonary atresia
.Total surgical repair
The Blalock(-Thomas)-Taussig procedure was the only surgical treatment until
the first total surgical repair was performed in 1954.

Additional reparative or reconstructive work may be done on patients as required

by their particular anatomy.

Treatment of VSD :

Treatment is either conservative or surgical.

Smaller congenital VSDs often close on their own, as the heart grows, and in such
cases may be treated conservatively.

In cases necessitating surgical intervention, a heart-lung machine is required and

a median sternotomy is performed.

Percutaneous endovascular procedures are less invasive and can be done on a

beating heart, but are only suitable for certain patients.

Repair of most VSDs is complicated by the fact that the conducting system of
the heart is in the immediate vicinity.

IN MY PATIENT :Surgical treatment ;

Trustler Repair For AR & V.S.D ,Gore-Tex Patch applied

Post –op orders :

IV. RL and IV. DNS as per CVP guidance

Inj. Zonamax 1 gm 12 hourly

Inj. Amikacin 200mg 12 hourly

Inj. Rablet 20 mg od

Inj Dynaper ½ amp I.V12 hourly

Chest physiotherapy 8 hourly

Nebulisation with Duolin 8 hourly

PROGRESS NOTES :

On Admission :-Mast Sameergot admitted on 14/12/12 and the data is being

collected on 18/12/12.On admission the baby was so dyspnic , his lips ear lobes
and fingers were cyanosed , he was much exhausted .as soon as the child came
he was being received in PICU for emergency management . oxygen was being
administered @ of 2lit per hour to maintain the saturation in an average of 85-
90%.the child was being given comfortable position , intravenous infusion of
injection of Lasix was started as per the doctors order and other medications per
doctors order was administered . Dr. Gupta had visited the child and posted for
Blalock Taussing shunt , so as per the order all the pre-operative blood
investigations were send .The vitals were checked the findings were ;

Temperature : 99®F

Pulse : 142/mt.

Respiration : 24/mt.

Ist Post operative day :

The child was kept in OHU after surgery , his general condition was poor
condition , he was kept on ventilator , IV infusion was going on , all supportive
medication was being continued by means of infusion pump , his hemodynamic
monitoring was continued , urine out –put was monitored every 1hourly it was
25ml/hr ,but the child was developing swelling all over the body , informed to
Dr. Gandhi . All medications were given on time, the vitals were recorded , the
child was having arterial fibrillation .

2nd Post operative day :

I visited the child still his general condition was poor and he was on ventilator his
whole body was oedematous so I.V Lasix infusion started as per the order of
doctor and other support like IV Dobutamin was on flow .I meat the hygienic
needs of the child and kept record for each and every nursing procedures so that
other shift nurse can carry on the activities .all the parameters were being recorded
every 1 hourly and informed to doctor. All medications were given on time as
per the schedule .
3rd Post operative day :

The child was little better , he was out of ventilator and on oxygen mask .The
Lasix infusion was stopped only IV Dobutamine was being continued , i meat all
the hygienic needs of the child , monitored all the hemodynamic parameters and
charted 1 hourly and infirmed to doctor .

4th Post operative day :

I visited the child , he was in better condition , i removed the chest drain as per
the order from the doctor and recorded it .Only sips of clear liquid was allowed
so it was given frequently .The Dobutamine infusion was being tapered off @ of
.5 ml /hour .The child was given mild sedation for sleep and calmsiness.

5th Post operative day :

I visited the child, his condition was good and it was plan to shift the child to
NICU for 1-2 days for observation. He could move the hands and legs and feeding
was being started. He was quite happy to be with his mother .I had given his
mother some of the written instructions regarding the care of the child.

PATIENT EDUCATION:-

The part of health education is very important throughout the hospitalization. I

used to talk with his parents and his relatives regarding various topics like diet,
Personal hygiene, rest and medications.

DIET : I advised his mother to give only breast feeding now & start weaning
after the child is improved form the condition and start introducing various food
gradually like Apple, Banana, mashed potato etc. I advised them that while
feeding the child the mother should assume the proper posture so that the child
does not choke, and remember that while introducing the various food check for
the allergy and while introducing food the breast feeding also to be continued.

REST :I advised his parents to allow the child to sleep properly and the room
should be noise free because the child can be irritated .

MEDICATIONS : I advised his parents to stick with the treatment regime

because of his better health and do not ignore any symptoms like weakness ,
fatigue , anorexia or any drug related changes . I also advised his parents to come
for regular follow up as the physician prescribes.
IMMUNIZATION:I advised the parents to bring the child for regular
immunization as per the schedule given from the hospital.

STUDENT EVALUATION :
After taking care a patient with congenital heart disease, many of my concepts
are now cleared . I came to know the management part most and how to care for
the patient and I gained confidence to make nursing diagnosis of patient with
congenital heart disease .
 SONI NURSING COLLEGE
JAIPUR

SUBJECT

Medical - Surgical Nursing

CASE PRESENTATION ON
CONGENITAL HEART DISEASE

SUBMITTED TO: SUBMITTED BY:

MS. M. SONIA VISHRAM SINGH GURJAR

LECTURER M.Sc. Nursing FIRSTyear
SONI NURSING COLLEGE
SONI NURSING COLLEGE JAIPUR
JAIPUR