this is cereth registered nurse ari and dot-com and in this video i'm going to be going over atrial septal defects in this video is part of an ink lex review series over pediatric nursing and as always after you watch this youtube video you can access the free quiz that will test you on this condition so let's get started what is an atrial septal defect this is where there is a hole in the intra atrial septum and what this does is it creates a connection between the upper chambers of the heart which are the right atrium and the left atrium and after birth there should not be a connection between these two chambers now according to the CDC gov one in every 770 babies born in the United States will have an atrial septal defect and why is this a problem why do we not want a person to have an atrial septal defect well small ASD is just a little opening in this area that separates your I atrium from your left atrium really doesn't cause a lot of problems because it's not allowing a lot of blood to flow from the left atrium to the right atrium but when you get a large ASD a large hole in the interatrial septum we get problems and what happens is it creates a left-to-right shunt so blood on the left side of the heart is actually going to shunt over to the right side of the heart which is going to deliver too much blood to the lungs so you're gonna have an increased blood flow to the lungs and over time a little bit later on for that patient depending on how big it is and everything that's going on with them they will start to develop complications such as heart failure pulmonary hypertension and they have an increased risk of stroke and whenever we go over the pathophysiology here in a moment you're gonna see why they're at risk for these conditions now if it's left untreated the pulmonary hypertension the heart failure it can lead to an irreversible complication called eisenmenger's syndrome and this is where the blood will actually reverse its shunting from that left to right to right to left which is going to lead to cyanotic problems let's quickly talk about the different types of ASDs and the type really depends on where that hole is located within the atrial septum so when you're studying for exams try to remember the location of the hole based on what type it is so the first time I want to talk about is the most common type of ASD and it's called ostium secundum and these holes are found in the middle of this atrial septum another time is ostium primum and these holes are found in the bottom of the atrial septum close to the atrioventricular valves and atrioventricular valves separate our atrium from our ventricles and what were those again they are our tricuspid valve and our bicuspid valve which is the mitral valve so the holes will be closed to those locations another type is called sinus venosus and these holes are found close to the superior vena cava and the right atrium so that's where they will be located now let's go over the pathophysiology of an atrial septal defect and to help us truly understand what is going on with the blood flow in an ASD we first have to understand normal heart blood flow so let's quickly go over that okay you have the right side of the heart and the left side of the heart they each have their own mission the right side of the heart's goal is to get blood to the lungs to get oxygenated because they just receive blood throughout the body venous blood that's exhausted and it needs to be reoxygenate in the left side of the heart takes blood from the lungs that's been oxygenated and its goal is to pump it throughout your body to replenish all those vital organs so you can keep living so it all begins on the right side blood enters in the right side through the superior and inferior vena cava goes in at the right atrium then your tricuspid valve is going to open and allow it to drain down into the right ventricle the right ventricle is going to squeeze it up through the pulmonic valve which is going to open and allow it to go through the pulmonary artery into the lungs and then gas exchange is going to occur in the lungs then after it gas exchanges occurred the blood is going to flow into the left side of the heart through the pulmonary vein it's going to go into the left atrium your bicuspid mitral valve is going to open up go down into the left ventricle and that left ventricle is strong and it is going to squeeze that blood up through the aortic valve and then through the aorta and throughout rest of the body now there's a couple things I want to point out about the heart which will help us understand ASCs first of all after birth after a person is born and they're using their lungs the pressure on the left side of the heart is greater than the pressure on the right side of the heart now why is that well the left side has a more intense jaw it has to pump all that blood that's just been oxygenated throughout the system so it has to be stronger than the right side the right side just has to get that blood to the lungs however in utero when a fetus is still in its Mama's belly what happens is that the pressure is equal on both sides because that baby is not using its lungs and there is an actual connection that naturally is occurring between the right atrium and the left atrium and the connection is through what's called the foramen ovale so it's normal we actually in a sense want a hole in the heart whenever the baby is in its Mama's belly still because the reason for that and because the lungs aren't working the baby is receiving oxygen from the placenta so really the right side of the heart isn't needing to do its job just yet by getting the blood to the lungs because the lungs aren't working so it's okay for that blood that comes in through the right side to be shunted over to the left side to go through the body in a fetus through that frame in ovalle now after that baby is born it starts to breathe on its own and whenever it does that it changes the pressure in the heart the pressure on the right side is going to decrease so whenever that happens over that frame in Ovalle it's like a piece of tissue and when that pressure happened change happens when that baby starts breathing on its own it's gonna seal over that frame in a valley so it closes shortly after birth now in some people this doesn't occur and a lot of people don't even know it they don't really have signs and symptoms or anything like that and they have what's called a patent foramen ovale we call it a pf0 and so they have this hole in their heart so a PS o is another type of hole that can occur in the atrial septum now the problem with apfo is that it can increase the risk of a stroke and I have seen this in patients patients been admitted has had a stroke they're not really sure the source or what caused the stroke will they do an echocardiogram and they look and they actually can see that this patient does have a patent foramen ovale up efo and that's where the stroke came from so now let's look at the blood flow with someone who has let's say a large atrial septal defect as I pointed out before the small ones really don't cause that much of a problem because the opening is so small and small allowing a lot of blood to shunt from the left to the right but large holes do allow major shunting to occur so why is shunting even occurring well it goes back to that pressure and differences between the left and the right side the left side has greater pressure on it compared to the right side so if you have this person that has a large hole in this intra atrial septum whenever Sicily occurs when the heart is pumping this ventricle is contracting it's going to naturally shunt blood from that left atrium to the right atrium it's just going to go to that lower pressure gradient all that what's going to be coming over now that's an issue because the blood that's on the left side has already been on the right side so you're going to have all this extra blood coming over from the left atrium to the right atrium and the right side of the heart is not made to carry and pump extra blood volume so what it's going to do is going to stress our atrium and really our right ventricle out because the right ventricle is going to have to take more blood volume to pump it to the lungs so over time it's going to start enlarging now that is going to lead to more blood flow going to our lungs and our lungs can only handle so much blood so over time what's going to happen is that to compensate number one it's gonna start narrowing its arteries that feed the lungs in addition those arteries will narrow because they're becoming damaged from all that extra blood so you're gonna have narrowing of the arteries to the lungs that feed the lungs and it's going to create a condition called pulmonary hypertension now this is going to occur over time so whenever pulmonary hypertension occurs that's going to lead to some other issues number one this child this person can have issues with recurrent lung infections they'll have a lot of congestion in their lungs and that will lead to that in addition it's going to stress the heart out even more because not only did you have your right ventricle pumping extra blood volume causing it to enlarge but now because we have narrowing of those arteries of the lungs the right ventricle is going to have to pump against more resistance to even get that blood to the lungs the heart can only do this for so long and the person can enter into what's called heart failure where the heart literally just becomes so weak and it just doesn't pump so blood is gonna start back flowing and you're gonna have a lot of issues infants can have issues feeding and this will lead to issues with their growth Soha failure to thrive they'll have activity intolerance decreased cardiac output so you're gonna get decreased blood flow to the brain to the kidneys to all those important structures that can start suffering as well in addition the person can start developing dysrhythmias like atrial fibrillation a flutter and they're at risk for stroke now if you watch my other video on ventricular septal defects you'll notice that a lot of these complications are sort of the same because you have that same concept about left to right shunting occurring but one thing that's a little bit different with an ASD than a VSD is the increased stroke risk now why is that well in your veins clots form sometimes and normally that clot that has formed in the vein will travel and go from the right side and go to the lungs and it'll be there but if we have a hole in this right atrium and we have a clod that comes in through our venous circulation that hole just is really inviting for that clot to just cross over so you have a claw it just crosses over into the left side and then we're in big trouble because what does that left side do left side pumps blood throughout the system so that clot can cross over go to the left side go up through the body and travel throughout the body and go to the brain so then you have a clot in the vessels that feed your brain tissue that's going to block blood flow to the brain tissue causing a stroke so that is definitely a risk with these conditions with a large ASD and we talked about Eisenmenger syndrome this is where over time if this ASD is not corrected the large one that is allowing this pulmonary hypertension to occur leading to heart failure all of this is actually going to change the way that the shunting occurs and it's going to lead to reversal of shunting so then you'll have right to left shunting of blood so what's going to happen is that you're going to have the UH knocks ajaita in blood now actually going into the left side so all of its going to be going here and then it's going to go up through the system and our body our tissues does don't like an oxygenated blood so that's going to lead to a lot of sine not problems low oxygen in the blood clubbing of the fingers and things like that and once that occurs it is rare to occur because treatment can be done for this but it is irreversible now let's talk about signs and symptoms of an ASD okay some things I want you to keep in mind about signs and symptoms is number one the severity of the symptoms and when the symptoms will actually present depends on the size of that hole that's in that septum so the larger the hole the more severe the symptoms are going to be the earlier they're going to come on and lead to those complications compared to a smaller one and also signs and symptoms usually don't present at birth but a little bit later on in childhood or even adulthood and usually what happens is that they have a heart murmur that someone notices and they do an echocardiogram which is an echo which is like an ultrasound of the heart and they can look at the heart and see that structure so keep that in mind as we're talking about signs and symptoms and to help us remember our signs and symptoms let's remember the word holes and for our VSD or ventricular septal defect video what are these signs and symptoms are gonna match up because you have that left to right shunting that's occurring and the only thing that's really changing is our our heart sounds and the risk for stroke with this condition so eight heart failure and pulmonary hypertension and how what you're gonna see with that is you're gonna see decreased cardiac output the heart's weak the lungs are being affected which in turn is gonna lead you to see the patients gonna have difficulty breathing they're gonna fatigue easily with activity the child infant may have trouble feeding they just don't feel like feeding when you listen to lung sounds if the the hyper if the heart failure severe enough they can have crackles edema swelling in the extremities they can also experience this like cold clammy sweating with activity again that's from the decreased cardiac output so in nursing diagnosis realm you may want to be thinking about activity and tolerance decreased cardiac output excessive fluid volume from ever thing that's going on with ASD okay Oh for often experiences lung infections that's from that congestion with the lungs what's going on in there perfect place for an infection to set up and nursing diagnosis be thinking risks for infection so be monitoring them for that l would be low growth rate and that's going to trace back to their inability to feed properly they are literally just tired exhausted their heart's not working the way it should breathing issues and plus their body requires a lot more calories too for the heart to pump for the breathing so that's pretty more calories and they're not taking it in so they can have issues with their growth and then e extra heart sounds what you can hear with this is what's called a mid systolic heart murmur or also called a systolic ejection murmur and what this is from is that you have this increased blood flow going through this pulmonic valve which is right here that leads to the pulmonary artery where that Bloods going to go into the lungs and the reason for that is because remember you have that shunting of that blood from left to right so you have all this extra blood volume going through that pulmonic valve which is creating this murmur and you can hear it at that second intercostal space in the upper left part of the sternal border and how this will sound is that you will hear the murmur it will be low at the beginning of systole it will increase mid systole and then decrease at the end of systole hence why it's called a mid systolic murmur in addition the s2 will be wide and with fixed splitting and this is because that pulmonic valve is slowing down and how it's closing so that is why you're hearing s2 that way in addition we already talked about this in depth there is a risk for stroke now let's go over the nursing interventions and treatments for an ASD now with ASDs as I've pointed out the large ones are the ones that really cause the issues the small ones are typically monitored a lot of times they go undetected because they really don't lead to as many problems compared to the large one so treatments include monitoring those diuretics may be ordered if heart failure is presenting and you have this fluid overload with the heart being weak they can do that to remove extra fluid surgery can be performed to actually close this hole open heart can be performed and this is usually done early in childhood before school age or they can do that with a heart cath close it that way but it really depends again what type of ASC this is the size and so forth and to help diagnose an ASD as I pointed out earlier they can do an echocardiogram and this is very non-invasive this is where they just take an ultrasound of the heart look at those structures how its pumping they can tell a lot through an echo and assess this ASD now from nursing standpoint you want to be thinking in the realm with these large ASCs that are causing these complications so we're gonna be looking at nutrition because they have low growth rate they may be a candidate for a feeding tube where they can get extra nutrition if this ASC is causing problems with them to feed we want to also monitor that heart rhythm because it can cause atrial fibrillation afib looking at that looking at the respiratory status listening to those lungs sounds are you hearing crackles and seeing do they have infection because they're at risk for infection so we want to do infection prevention educating the patient if they're old enough or the parents about vaccines to prevent those respiratory illnesses that can occur because they're more susceptible front for that if they develop pulmonary hypertension monitoring wait so thinking of those nursing diagnoses that I was going over like activity and harness decreased cardiac output excessive fluid volume risk for infection all those we're gonna be looking at for a patient with a large ASD okay so that wraps up this video over atrial septal defects thank you so much for watching don't forget to take the free quiz and to subscribe to our channel for more videos