2. Disorders affecting fluid-gas transport: congenital heart disease
1. Pathophysiology-altered hemodynamics, due to persistent fetal circulation or structural abnormalities.
1. Acyanotic defects-no mixing of blood in the systemic circulation.
1. Patent ductus arteriosus.
2. Atrial septal defect.
3. Ventriclar septal defect.
4. Coarctation of the aorta.
2. Cyanotic defects-unoxygenated blood enters systemic circulation.
1. Tetralogy of Fallot.
2. Transposition of the great vessels.
2. Etiology-unknown. Associated with maternal:
1. Prenatal viral disease (rubella, Coxsackie).
2. Malnutrition; alcoholism.
3. Diabetes (poorly controlled).
4. Ingestion of lithium salts.
3. Assessment:
1. Patent ductus arteriosus
1. Characteristic machine murmur, mid to upper left sternal border (cardiomegaly); persists throughout systole and most of diastole; associated with a “thrill.”
2. Widened pulse pressure.
3. Bounding pulse, tachycardia, “gallop” rhythm.
2. Atrial septal defect
1. Characteristic crescendo/decrescendo systolic ejection murmur.
2. Fixed S₂ splitting.
3. Dyspnea, fatigue on normal activity.
4. Medical diagnosis-cardiac catheterization, x-ray.
3. Ventricular septal defect
1. Loud, harsh, pansystolic murmur; heard best at left lower sternal border; radiates throughout precordium. (Note: may be absent-due to high pulmonary vascular resistance-» equalization of interventricular pressure).
2. Medical diagnosis-cardiac catheterization, ECG, chest x-ray.
4. Coarctation of the aorta
1. Absent femoral pulse.
2. Late systolic murmur.
3. Decreased blood pressure in lower extremities.
4. Medical diagnosis: x-ray.
5. Tetralogy of Fallot (“blue” baby).
1. Acute hypoxic/cyanotic episodes.
2. Limp, sleepy, exhausted; hypotonic extended position-postepisode.
3. Medical diagnosis-cardiac catheterization.
6. Transposition of the great arteries
1. Cyanotic after crying or feeding.
2. Progressive tachypnea-attempt to compensate for decreased PaO₂, metabolic acidosis.
3. Heart sounds vary, consistent with defect.
4. Signs of CHF.
5. Medical diagnosis-cardiac catheterization, x-ray, ECG.
4. Analysis/nursing diagnosis:
1. Fluid volume excess related to persistent fetal circulation, structural abnormalities.
2. Impaired gas exchange related to abnormal circulation, secondary to pathology.
3. Altered nutrition, less than body requirements, related to exhaustion, dyspnea.
5. Nursing care plan/implementation:
1. Goal: minimize cardiac workload.
1. Minimize crying-snuggle; pacifier-to meet psychological needs.
2. Keep clean and dry.
2. Goal: maintain thermal stability-to reduce body need for oxygen.
3. Goal: prevent infection.
1. Strict aseptic technique; standard precautions.
2. Hand washing.
4. Goal: parental emotional support.
1. Encourage verbalization of anxiety, fears, concerns.
2. Keep informed of status.
5. Goal: health teaching-explain, discuss:
1. Diagnostic procedures.
2. Treatment procedures.
3. Basic care modalities.
6. Goal: promote bonding. Encourage to participate in infant care, as possible.
7. Medical/surgical management: surgical intervention/repair of congenital cardiac abnormality.
6. Evaluation/outcome criteria:
1. Experiences no respiratory distress in immediate postnatal period.
2. Completes transfer to high-risk center without incident, if applicable.
3. Surgical intervention successful, where applicable.

3. Disorders affecting fluid-gas transport: hemolytic disease of the newborn
1. Rh incompatibility
1. Pathophysiology
2. Etiology
3. Assessment:
1. Prenatal-maternal Rh titers, amniocentesis.
2. Intrapartal-amniotic fluid color:
1. Straw-colored: mild disease.
2. Golden: severe fetal disease.
3. Direct Coombs’ blood; positive test demonstrates Rh antibodies in fetal blood.
4. Nursing care plan/implementation-exchange transfusion:
1. Goal: health teaching.
1. Explain purpose and process to parents.
2. Removes anti-Rh antibodies and fetal cells that are coated with antibodies.
3. Reduces bilirubin levels-indicated when 20 mg/dl in term neonate and 15 mg/dl in preterm.