Patent Ductus Arteriosus Nursing Care and Management

In patent ductus arteriosus (PDA), the fetal ductus that should close after birth stays open, leaving a left-to-right shunt from the aorta into the pulmonary artery. Blood recirculates through the lungs and overloads the left heart. The prognosis is good when the shunt is small or surgical repair succeeds, so the work is catching it early, managing the volume overload, and protecting the lungs.

What is Patent Ductus Arteriosus?

The ductus arteriosus is a fetal vessel connecting the pulmonary artery to the descending aorta. When its lumen stays open after birth, blood shunts left to right from the aorta to the pulmonary artery and recirculates through the lungs.

Pathophysiology

Non-modifiable risk runs through genetics, age, and gender. Congenital heart defects cluster in families and sometimes accompany genetic conditions such as Down syndrome. PDA is more common in premature babies and in infants who already have other congenital heart defects, and it is twice as common in girls as in boys.

Modifiable risk comes from the pregnancy itself. Rubella (German measles) crosses the placenta and spreads through the fetal circulation, damaging blood vessels and organs including the heart. Poorly controlled maternal diabetes disturbs fetal blood sugar and damages the developing fetus. Drug or alcohol use, or exposure to certain chemicals or radiation during pregnancy, can harm the fetus. And babies with other congenital heart defects often have a coexisting PDA.

Statistics and Incidences

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

Causes

The ductus normally closes within days to weeks after birth. Failure to close traces to prematurity (most likely from abnormal oxygenation), to prostaglandin E (whose relaxant action prevents the ductal spasm and contracture needed for closure), and to other congenital defects. PDA commonly accompanies rubella syndrome and may go with coarctation of the aorta, ventricular septal defect, and pulmonary and aortic stenoses.

Clinical Manifestations

PDA may produce no effects at first, but over time it can drive pulmonary vascular disease, with symptoms appearing by age 40. A large PDA usually causes respiratory distress and signs of heart failure from the large volume shunted to the lungs and the increased workload on the left heart. The patient is highly susceptible to respiratory tract infections, shows slow motor development and physical underdevelopment, and on auscultation has a continuous, machine-like (machinery) murmur. Peripheral arterial pulses are bounding (Corrigan's pulse), and pulse pressure is widened from a rise in systolic and, mainly, a drop in diastolic pressure.

Complications

Left untreated, the left-to-right shunt overworks the left ventricle and leads to left-sided heart failure. Increased pulmonary venous return drives pulmonary artery hypertension.

Assessment and Diagnostic Findings

Chest x-ray may show increased pulmonary vascular markings, prominent pulmonary arteries, and enlargement of the left ventricle and aorta. ECG may be normal or show left atrial or ventricular hypertrophy, and biventricular hypertrophy once pulmonary vascular disease sets in. Echocardiography detects the PDA and sizes it.

Medical Management

Asymptomatic children need no immediate treatment. Those in heart failure need fluids restricted or controlled to avoid overloading the heart.

Pharmacologic Therapy

The ductus can be kept open with prostaglandin analogs such as alprostadil (a prostaglandin E1 analog). Before surgery, children with PDA need antibiotics to guard against infective endocarditis. Indomethacin, a prostaglandin inhibitor, is an alternative to surgery in premature neonates: it induces ductal spasm and closure.

Surgical Management

In cardiac catheterization, a plug or coil is deposited in the ductus to stop the shunt. The ductus may also be closed by ligation, tied shut manually, or with intravascular coils or plugs that form a thrombus in the vessel.

Nursing Management

Nursing Assessment

Assess activity and rest for weakness, fatigue, dizziness, a sense of pulsing, and sleep disturbance. For circulation, take a history of trigger conditions, heart murmurs, and palpitations, and measure BP and pulse pressure. For food and fluids, check for dysphagia and changes in body weight.

Nursing Diagnosis

Major diagnoses include activity intolerance related to the imbalance between oxygen demand and supply, anxiety related to hospital care or lack of support, and deficient knowledge related to the condition and its treatment.

Nursing Care Planning and Goals

The goals are to maintain adequate cardiac output, reduce the rise in pulmonary vascular resistance, maintain adequate activity, support growth and development, and maintain appropriate weight and height.

Nursing Interventions

Watch premature infants carefully for signs of PDA. Frequently assess vital signs, ECG, electrolytes, and intake and output. If the infant gets indomethacin for ductal closure, watch for diarrhea, jaundice, bleeding, and renal dysfunction. Before surgery, explain all tests and treatments to the parents and child, including the IV lines, monitoring equipment, and postoperative routine. Right after surgery the child may have a central venous pressure catheter and an arterial line, so assess vital signs, intake and output, and arterial and venous pressures closely, and provide pain relief.

Evaluation

The patient reduces the rise in pulmonary vascular resistance, maintains adequate activity, and shows appropriate growth, development, weight, and height.

Discharge and Home Care Guidelines

Review activity restrictions with parents based on the child's tolerance and energy. Advise them not to be overprotective as the child's tolerance for activity grows. Stress regular followup exams. Tell parents to inform any practitioner who treats the child about the history of PDA surgery, even when the child is being treated for something unrelated.

Documentation Guidelines

Document the patient's understanding of personal risks and safety concerns, the availability and use of resources, and current and previous level of function. Record level of anxiety with precipitating or aggravating factors, the patient's feelings and ability to recognize and express them, the plan of care, the teaching plan, the patient's involvement and response to interventions and teaching, progress toward outcomes, modifications to the plan, and long-term needs.