Nursing Assessment for Atrial Septal Defect
Atrial septal defect (ASD) is a form of congenital heart defect that enables blood flow between the left and right atria via the interatrial septum. The interatrial septum is the tissue that divides the right and left atria. Without this septum, or if there is a defect in this septum, it is possible for blood to travel from the left side of the heart to the right side of the heart, or vice versa.[1] This results in the mixing of arterial and venous blood, which may or may not be clinically significant. This mixture of blood may or may not result in what is known as a "shunt".
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Nursing Assessment for Atrial Septal Defect
Nursing Diagnosis Nursing Intervention Nursing Care Plan for Atrial Septal Defect
Atrial septal defect (ASD) is a form of congenital heart defect that enables blood flow between the left and right atria via the interatrial septum. The interatrial septum is the tissue that divides the right and left atria. Without this septum, or if there is a defect in this septum, it is possible for blood to travel from the left side of the heart to the right side of the heart, or vice versa.[1] This results in the mixing of arterial and venous blood, which may or may not be clinically significant. This mixture of blood may or may not result in what is known as a "shunt".
wikipedia
Nursing Assessment for Atrial Septal Defect
- Perform a physical examination with a detailed examination of the heart.
- Pulmonary artery pulse can be felt in the chest.
- Examination with a stethoscope shows an abnormal heart sound. Audible murmur due to increased blood flow through the pulmonary valve.
- The signs of heart failure.
- If a large shunt, murmurs could be heard due to increased blood flow which flows through the valve tricuspidalis.
- Perform vital signs measurement.
- Assess the general appearance, behavior, and function:
Inspection- Nutritional status
- Failure to thrive or poor weight gain associated with heart disease.
- Color - Cyanosis is a general description of congenital heart disease, while the pale-related anemia, which often accompanies heart disease.
- Deformity of the chest - heart enlargement sometimes change the configuration of the chest.
- Pulsation is not common - sometimes happens pulsation which can be seen.
- Respiratory excursion - Breathing easy or difficult (eg, Tachypnoea, dyspnea, the presence of expiratory snoring.)
- Finger percussion - Dealing with multiple types of congenital heart disease.
- Conduct - Choosing a knee chest position or squatting are characteristic of some types of heart disease.
Palpation and percussion- Chest - Helping to see the difference between heart size and other characteristics (such as Thrill-vibrilasi examiner felt when mampalpasi)
- Abdomen - hepatomegaly and / or splenomegaly may be seen.
- Peripheral pulse - frequency, regularity, and amplitude (strength) may indicate incompatibility.
Auscultation- Heart - Detecting the presence of heart murmurs.
- Frequency and rhythm of the heart - Indicates deviation and intensity of heart sounds that help to localize the heart defect.
- The lungs - Indicates dry coarse rhonchi, wheezing.
- Blood pressure - Irregularities occur in some heart conditions (eg mismatch between the upper and lower extremities)
- Assist with diagnostic procedures and tests - eg, ECG, radiography, echocardiography, fluoroscopy, ultrasonography, angiography, blood analysis (blood count, hemoglobin, blood cell volume, blood gases), cardiac catheterization.
Nursing Diagnosis Nursing Intervention Nursing Care Plan for Atrial Septal Defect
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