Case Study: Congenital Heart Defects by Patricia Lincoln.
Hello, my name is Trish Lincoln, I’m the clinical nurse specialist in the cardiac ICU
at Children's Hospital Boston. What I’m about to present is a case study with questions
and answers.
James is a four week old diagnosed at birth
with Tetralogy of Fallot. He was scheduled for surgery in 2 weeks, but because of hypercyanotic
spells he is admitted to the intensive care unit from the emergency room.
Question 1:
As James’ nurse, you know that Tetralogy of Fallot is a combination of which four defects?
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The correct answer is: Ventricular septal defect, pulmonary stenosis, overriding aorta, right
ventricular hypertrophy.
Question 2: The hypercyanotic spells that James is experiencing
are primarily related to:
The correct answer is: Pulmonary stenosis. The greater the amount of obstruction in the
pulmonary outflow tract or the greater the degree of pulmonary stenosis the more cyanotic
the patient will be. Because blood is unable to flow from the right side of the heart to
the lungs to receive oxygenation the blood will shunt right to left across the Ventricular
Septal Defect and return to body without being oxygenated.
Question 3 What causes hypercyanotic spells?
The correct answer is: an increased oxygen requirement together with increased resistance
to pulmonary flow.
Question 4: If James were to experience a hypercyanotic
spell while in your care, your first intervention would be to:
The correct answer is: Place James in a knee-chest position
and administer oxygen.
Place the child in a knee chest position.
Lie the child down and bringing in their knees bent up to their chest.
In doing this, the large muscles of the legs contract and force more blood back to the heart.
This increases preload on the right side of the heart,
and possibly forces blood to the spasming right ventricular outflow tract.
That same large muscle contraction increases afterload on the left side of the heart,
making it more difficult for blood to shunt right to left in the heart.
Morphine may be administered to relax the patient and hopefully relax the right ventricular outflow tract.
Question 5: Other clinical signs and symptoms of Tetralogy
of Fallot include:
The correct answer is: Chest radiograph showing decreased pulmonary markings, electrocardiogram
with right ventricular hypertrophy, systolic ejection murmur.
James undergoes surgical correction of his
Tetralogy of Fallot, including a ventricular septal defect closure and right ventricular
outflow tract patch. Intraoperatively, a transthoracic pulmonary
artery catheter is placed. Before James had his pulmonary artery line
removed, right atrial and pulmonary artery saturations were measured. The right atrial
saturation = 72, and the pulmonary artery saturation = 95.
Question 6:
What might this indicate?
The correct answer is: A residual ventricular septal defect,
which is evaluated by checking right atrial pulmonary artery saturations
for an increase in the pulmonary artery saturation.
This concludes our case study. Thank you.
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