I. Nursing Assessment

A. Become informed about the child’s symptomatology and plan of medical care

1. Obtain thorough nursing history to become familiar with the child and his family to recognize normal and abnormal patterns
2. Discuss with the physician the plan for medical care

B. Make a baseline Nursing Assessment of the child’s condition

1. Observe and record information relevant to the child’s growth and development
2. Observe and record child’s level of exercise tolerance
3. Observe child’s skin and mucous membranes for color and temperature changes
4. Observe for clubbing of the fingers, especially the thumb nails, with thickening and shininess of the terminal phalanges-may occur in cyanotic children by 2-3 months of age.
5. Observe for chest deformities
6. Observe for respiratory pattern
7. Palpate the child’s pulses in all extremities
8. Auscultate the child’s heart
9. Record vital signs

II. Nursing Diagnoses

1. Impaired gas exchange related to altered pulmonary blood flow or oxygen deprivation
2. Altered cardiac output related to specific anatomic defect
3. Activity intolerance related to decreased oxygenation in blood and tissues
4. Altered Nutrition: less than body requirements related to the excessive energy demands required by increased cardiac workload
5. Increased potential for infection related to poor nutritional status
6. Anxiety related to diagnostic procedures and hospitalization
7. Developmental delay related to decreased energy, inadequate nutrition, physical limitations and social isolation
8. Alteration in parenting related to parental perception of the child as vulnerable

III. Nursing Interventions

A. Provide adequate nutritional and fluid intake to maintain the growth and developmental needs of the child

1. Feed in semi-erect position
2. Provide small frequent feedings
3. Provide foods with high nutritional value
4. Determine child’s likes and dislikes
5. Strict input and output
6. Daily weight

B. Prevent infection

1. Prevent exposure to communicable diseases
2. Immunizations should be up-to-date
3. Handwashing should be observed
4. Be certain that the child receives prophylactic medication for infective endocarditis

C. Reduce the workload of the heart since decreased activity and expenditure of energy will decrease oxygen requirements

1. Uninterrupted rest
2. Avoid unnecessary activities
3. Prevent excessive crying
4. Provide diversional activities
5. Prevent constipation
6. Relieve the respiratory distress associated with increased pulmonary blood flow or oxygen deprivation
• Determine degree of respiratory distress
• Include specific information in nursing record
• Position child at 45 degree angle to decrease pressure of the viscera on the diaphragm  and increase lung volume
• Pin diapers loosely and provide loose-fitting pajamas for older children
• Feed slowly
• Tilt infant’s head slightly
• Suction the nose and throat if unable to cough out secretions
• Provide oxygen therapy as needed
• Improve oxygenation o that the body functions may be maintained
• Provide effective oxygen environment
• Observe response to oxygen therapy
• Observe response to oxygen weaning therapy
• Relieve Hypoxic spells associated with cyanotic types of Congenital heart disease
• Observe for “tet” spells
• Encourage fluid intake
• Obtain vital signs

D. Observe child for symptoms of Congestive Heart Failure that occur frequently as a complication of Congenital Heart Disease

E. Observe for the development of symptoms of infective endocarditis that may occur as a complication of congenital heart disease

F. Observe for the development of thrombosis that may occur as a complication of congenital heart disease

G. Prepare the child for diagnostic and treatment procedures

H. Explain cardiac problems to child and parents

IV. Health Education

A. Instruct the family in necessary measures to maintain the child’s health

B. Teach the family about the defect and its treatment

C. Encourage the parents and other persons to treat child in a normal manner as possible