Atrial septal defect (ASD) is a congenital cardiac anomaly characterized by an abnormal formation of the atrial septum. Genetic and hemodynamic mechanisms are considered responsible for the onset of the disorder. For example, the increased blood flow from inferior vena cava during fetal development causes the septum primum valve to become deficient, but the perturbation of the transcription factors regulating the atrial septal development, such as Shh, Gata4, Tbx5, and Nkx2-5 (Kendall, Karamichalis, Karamlou, Teitel, & Cohen, 2014). ASD is the second most common congenital cardiac anomaly, and it is estimated that approximately 568 cases of ASD occur during childbirth (Kendall et al., 2014).
ASD can usually be diagnosed in utero if the case is severe, but it is sometimes diagnosed during infancy and early childhood. The diagnosis can be established by using ultrasonography, echocardiography, and auscultation. Invasive surgical procedures are possible to correct the deformations of the atrial septum, but a preoperative assessment has to be made to determine the type of intervention required and minimize risks associated with invasive surgical procedures. For example, the study by Amat et al. (2011) used multidetector computed tomography (MDCT) to assess children with inconclusive transthoracic echocardiography (TTE) results, and it was found that TTE can detect hemodynamic consequences of ASD accurately, but it could not assess all anatomical abnormalities associated with ASD. MDCT proved to be an equal or superior assessment tool when compared to cardiac catheterization, and it accurately depicts abnormal veins in detail while operating within safe levels of radiation exposure, even for children (Amat et al., 2011).
Developmental Changes
Some developmental issues associated with ASD include pulmonary defects (e.g. impaired gas exchange, ineffective breathing patterns, etc.), delays in growth, cardiac functionality deficits (e.g. activity intolerance, decreased cardiac output, etc.), atrial arrhythmias, and increased risk for right ventricular failure (Cheema, Jones, & Argenziano, 2014). An early intervention is beneficial to achieve ASD closure because late interventions are associated with permanent developmental changes. For example, Van De Bruaene et al. (2011) found that patients who had ASD closure later in life could not reduce their pulmonary vascular resistance (PVR) during physical activity, something that occurs naturally in healthy individuals as an adaptation to increased cardiac output. The same results were observed in patients with open ASD, so it was concluded that early closure is necessary to prevent developmental issues (Van De Bruaene et al., 2011).
Cultural Considerations
There are few cultural considerations when dealing with ASD cases, but there is one specific tendency found in the Hispanic culture that needs to be addressed when working with Hispanic patients. The concept of fatalismo in the Hispanic culture is the belief that fate is predetermined and an individual cannot alter it significantly (Peterson-Iyer, 2009). Given the genetic nature of ASD, it is highly likely that this belief would emerge in Hispanic families, so it must be considered when explaining the treatment options and managing their expectations. However, it is important to mention that all cultural values are broad generalizations because the Hispanic culture is known for its heterogeneity (Peterson-Iyer, 2009), so each patient needs to be treated as an individual with a different set of values and beliefs.
Nursing Diagnosis
The appropriate nursing diagnosis is physical activity intolerance because of ASD. The appropriate nursing interventions include (1) assessing the patient’s level of mobility, (2) assessing potential for physical injury during activity, (3) establishing guidelines and goals of activity, (4) encouraging adequate rest periods, and (5) teaching the patient energy conserving techniques (Gulanick & Myers, 2013). The first two interventions focus on assessing the patient’s abilities in order to develop therapeutic interventions. Establishing guidelines and goals will depend on whether the patient has open ASD or whether it was already closed, but it is important to motivate the patient and family to avoid becoming homebound and sedentary. Resting periods should be planned to reduce cardiac workload, and they need to follow a certain structure, such as resting before meals, during physical activity, and other activities of daily living. Finally, conserving energy is important for the continuous care so that the patient can conserve oxygen consumption and engaged in prolonged activity. For example, the patient can be encouraged to change positions often to avoid fatigue, rest one hour prior to new activities, and plan a work-rest-work schedule.
Current Research
Although the effectiveness of surgical procedures has improved significantly, there is still room for improvement in treating ASD because surgical procedures might not be suitable in all cases because they vary in size and location of the defect (Amat et al., 2011). Complications and other medical conditions can also increase the risk of failure during invasive surgical procedures. Therefore, current research focuses on improving the existing surgical procedures to deliver safer care to patients with different medical conditions.
For example, cardiac magnetic resonance imaging (CMRI) is currently being researched as an alternative to TTE so that physicians can obtain accurate information regarding ventricular volumes and shunting magnitude (Ganigara, Tanous, Celermajer, & Puranik, 2014). Robotic closure methods are being researched because they are the least invasive procedure available for treating ASD (Cheema et al., 2014). Some patients also have severe pulmonary arterial hypertension, so targeted medical therapies are being researched to improve shunt closure success rates (Taniguchi et al., 2014).
Patient Education
In regards to ASD care, I can teach patients about the risks associated with ASD and management strategies for reducing those risks. For example, ASD can impair growth and development, so I can educate parents about the screening and treatment options available for their particular case. I can also educate patients about the importance of continuous care to improve survival rates and prevent complications associated with ASD, even in closed cases. For example, I can encourage patients to obtain at least one follow up if they undergo closure surgery because it is important to monitor their condition to prevent arrhythmia complications (Kutty et al., 2012).
Two Test Questions
The first question is, “Does the location of abnormal venous connections affect the choice of surgical procedures in children with partial anomalous pulmonary venous return (PAPVR), a feature associated with ASD?” Yes, it does because when the connection of right-sided veins is closer to the right atrium, a baffle can redirect the venous flow, but if the connection is high on the superior vena cava, Warden’s procedure will have to be used (Amat et al., 2011)
The second question is, “Does late ASD closure prevent the problems associated with ASD, such as shortage of breath or reduced cardiac output?” No, it does not because abnormal development continues throughout early stages of development, so even if an individual undergoes surgery, it is possible that they will still suffer from cardiac functional deficits (Van De Bruaene et al., 2011).
References
Amat, F., Le Bret, E., Sigal-Cinqualbre, A., Coblence, M., Lambert, V., Rohnean, A., & Paul, J. F. (2011). Diagnostic accuracy of multidetector spiral computed tomography for preoperative assessment of sinus venosus atrial septal defects in children. Interactive Cardiovascular and Thoracic Surgery, 12(2), 179-182.
Cheema, F. H., Jones, S. K., & Argenziano, M. (2014). Robot-assisted atrial septal defect closure. In W. R. Chitwood, Jr. (Ed.), Atlas of Robotic Cardiac Surgery (pp. 293-298). New York, NY: Springer.
Da Silva, V. M., Lopes, M. V. D. O., & De Araujo, T. L. (2007). Nursing diagnoses in children with congenital heart disease: A survival analysis. International Journal of Nursing Terminologies and Classifications, 18(4), 131-141.
Ganigara, M., Tanous, D., Celermajer, D., & Puranik, R. (2014). The role of cardiac MRI in the diagnosis and management of sinus venosus atrial septal defect. Annals of Pediatric Cardiology, 7(2), 160-162.
Gulanick, M., & Myers, J. L. (2013). Nursing care plans: Nursing diagnosis and intervention. St. Louis, MO: Elsevier Health Sciences.
Kendall, S., Karamichalis, J., Karamlou, T., Teitel, D., & Cohen, G. (2014). Atrial septal defect. In E. M. Da Cruz, D. Ivy, & J. Jaggers (Eds.), Pediatric and Congenital Cardiology, Cardiac Surgery and Intensive Care (pp. 1439-1454). New York, NY: Springer.
Kutty, S., Hazeem, A. A., Brown, K., Danford, C. J., Worley, S. E., Delaney, J. W., & Latson, L. A. (2012). Long-term (5-to 20-year) outcomes after transcatheter or surgical treatment of hemodynamically significant isolated secundum atrial septal defect. The American journal of cardiology, 109(9), 1348-1352.
Taniguchi, Y., Emoto, N., Miyagawa, K., Nakayama, K., Kinutani, H., Tanaka, H., & Hirata, K. I. (2014). Subsequent shunt closure after targeted medical therapy can be an effective strategy for secundum atrial septal defect with severe pulmonary arterial hypertension: Two case reports. Heart and Vessels, 29(2), 282-285.
Peterson-Iyer, K. (2009). Culturally competent care for Latino patients: Introduction. Santa Clara University. Retrieved from http://www.scu.edu/ethics/practicing/focusareas/ medical/culturally-competent-care/hispanic.html
Van De Bruaene, A., La Gerche, A., Prior, D. L., Voigt, J. U., Delcroix, M., & Budts, W. (2011). Pulmonary vascular resistance as assessed by bicycle stress echocardiography in patients with atrial septal defect type secundum. Circulation: Cardiovascular Imaging, 4(3), 237-245.
