Nursing Field Notes / Cardio · Congenital Heart Defects IV · NUR 235 Peds

🫀 HEART DEFECTS SET NG-151 ASD·VSD·PDA·AVSD NG-118 Tetralogy of Fallot NG-183 Stenosis & Coarctation NG-201 Surgery & Chest Tubes

ASD · VSD · PDA · AVSD 🕳️

The four LEFT-to-RIGHT shunts — the ACYANOTIC group

NG-151 CARDIO · PEDS ADHD-friendly visual edition

Four holes in four places, one story: the strong left side pushes blood back into the right side → too much blood to the lungs → a murmur, a baby who sweats while feeding, can't gain weight, and slides into heart failure & pulmonary hypertension. The baby stays pink — that is why this group is called ACYANOTIC.

📄 Simple Nursing original — opens in Drive →

➡️ LEFT → RIGHTStrong left side pushes into the weak right side. Blood goes back to the lungs, not out to the body.

💗 Pink, not blueACYANOTIC. No cyanosis early — the blood still reaches the lungs. Blue = a different group.

💦 Sweats while feedingDiaphoresis with feeds + poor weight gain + murmur = the classic peds shunt baby.

🚨 Ends in HF + pulm HTNIncreased risk of heart failure and pulmonary hypertension if it is not fixed.

🫀

THE BASE HEART

STEP 0 · LEARN THIS ONCE

Every page in this set draws on this exact same picture. Learn the normal first — a defect is only a change to one line of it.

🫀 The normal heart — the drawing all four pages share

right heart · O₂-poor left heart · O₂-rich L → R shunt R → L shunt obstruction (bow-tie)

🧠 “Blue in on the left of the page, red out on the right.” Right heart (blue) is drawn on your left, left heart (red) on your right — because it is an anatomic view, facing the patient.

🔁 BASE NORMAL CIRCULATION — identical on every page in this set

Say this out loud before every defect:

Body ➡ SVC + IVC ➡ RIGHT ATRIUM

▼

tricuspid valve ➡ RIGHT VENTRICLE

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pulmonic valve ➡ PULMONARY ARTERY ➡ LUNGS (pick up O₂)

▼

pulmonary veins ➡ LEFT ATRIUM

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mitral valve ➡ LEFT VENTRICLE

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aortic valve ➡ AORTA ➡ body

The LEFT side is a high-pressure pump; the RIGHT side is a low-pressure pump. That one fact predicts every shunt on every page: if there is a hole, blood takes the easy road and goes LEFT → RIGHT — back into the lungs — until something blocks the right side or raises right-sided pressure. Only then does it reverse and go RIGHT → LEFT, which is when the baby turns blue.

🧠 “Lefty is stronger, so lefty pushes.” Left → Right = pink (blood still gets to the lungs). Right → Left = blue (blood skips the lungs). Blue blood in a pink baby's body = cyanosis.

⭐ THE classification you are tested on — put every defect in one of these boxes

Group	Shunt direction	Pulmonary blood flow	Blue?	Defects
💛 ACYANOTIC	LEFT → RIGHT	↑ INCREASED — too much blood to the lungs	No (pink at first)	ASD · VSD · PDA · AVSD
🧡 OBSTRUCTIVE	none — the road is narrowed	normal or ↓, depending on where the narrowing is	Usually no	Pulmonic stenosis · Aortic stenosis · Coarctation of the aorta
💜 CYANOTIC	RIGHT → LEFT	↓ DECREASED — blood skips the lungs	YES	Tetralogy of Fallot · Tricuspid atresia
🩵 MIXED	both ways — red and blue blood mix	varies	Yes	Transposition of the great arteries · Truncus arteriosus · TAPVR · hypoplastic left heart

🧠 “Pink holes, blue Ts, orange gates.” Holes (ASD/VSD/PDA/AVSD) leave the baby pink · the big Ts (Tetralogy, Tricuspid atresia, Transposition) turn the baby blue · the gates (stenosis, coarctation) are orange bow-ties — nothing is leaking, something is blocked.

🧭 How to read every diagram in this series

Blue chambers = right heart, O₂-poor blood.
Red chambers = left heart, O₂-rich blood.
Topaz arrow = a LEFT → RIGHT shunt (acyanotic).
Amethyst arrow = a RIGHT → LEFT shunt (cyanotic).
Citrine bow-tie ▶◀ = an obstruction, a narrowed road.

🧠 Read the drawing right. It is an anatomic view, so the patient's RIGHT heart is on YOUR LEFT. That is why a “left-to-right” shunt arrow points ← to your left on every diagram in this series. Same picture, four pages.

⭐ Why “acyanotic” babies still get sick

Answer first: the problem is not oxygen — it is VOLUME.

Extra blood is dumped back into the lungs with every beat. The lungs get wet, the heart works harder, and every calorie the baby eats gets burned just breathing.

So the signs are work-of-breathing and growth signs, not blue signs: tachypnea, sweating with feeds, feeds > 30 min, poor weight gain, frequent respiratory infections.

🧠 “Pink but pooped.” The color is fine; the work is not.

🕳️

THE FOUR HOLES

STEP 1 · SAME PICTURE, FOUR EDITS

Same base heart, four times. Only one thing changes each time — where the hole is.

1️⃣ ASD — Atrial Septal Defect · hole between the ATRIA · ACYANOTIC, left→right

What it is: a hole between the atria — the upper chambers.

Classic sign: a systolic ejection murmur high at the left upper sternal border with a fixed, widely split S2 — the split does not change with breathing. That fixed split is the ASD giveaway.

Course: many small ASDs close on their own. Larger ones are closed with a catheter-delivered occluder device or surgical repair.

NCLEX TIP A murmur alone in an ASD child is expected — it is the sound of the shunt. It is not the thing you report first. Report the failure signs instead: weight gain, puffy eyes, fewer wet diapers, sweating with feeds.

Late risk: right atrial & right ventricular enlargement, atrial dysrhythmias, and pulmonary hypertension in adulthood.

🧠 ASD = “Attic hole.” The Atria are the Attic — the top floor. The attic leak is quiet and slow, so it is often found late, on a routine murmur check.

2️⃣ VSD — Ventricular Septal Defect · hole between the VENTRICLES · the most common defect

What it is: a hole between the ventricles — a septal opening in the lower chambers.

Classic sign: a loud, harsh, holosystolic (whole-systole) murmur at the LEFT STERNAL BORDER — classically the lower left sternal border. Often a palpable thrill.

Feeding clue from the source: grunting during feeding — the baby is working to breathe while eating.

NCLEX TRAP Loud does not mean big. A small VSD makes the loudest murmur, because a tiny hole makes more turbulence. A huge VSD can be almost silent. Never rank a defect by how loud the murmur is.

Course: many small VSDs close naturally in the first years. Large ones need surgical repair (patch closure), usually within the first year, before pulmonary vascular disease sets in.

🧠 VSD = “Very loud, Very common, Ventricles.” The V in VSD is also the V in the “PROV” of Tetralogy — remember it, you will meet it again on the TOF page.

3️⃣ PDA — Patent Ductus Arteriosus · the fetal duct that never closed

What it is: an opening that connects the AORTA to the PULMONARY ARTERY. In the fetus this duct is supposed to be open — it lets blood skip the airless lungs. It should close in the first days of life. Patent = still open.

Classic sign: a loud, continuous, MACHINE-LIKE murmur — heard in systole and diastole, best at the left upper chest / under the left collarbone.

Also: bounding pulses and a wide pulse pressure — the aorta is bleeding pressure off into the pulmonary artery all through diastole, so the diastolic BP falls.

Highest risk: premature infants.

Treatment: indomethacin or ibuprofen (NSAIDs — they block prostaglandin, which is what holds the duct open) · surgical ligation or catheter coil/device closure if medication fails.

🧠 “LOUD MACHINE-LIKE DUCK.” DUCK = DUCTus. Picture a washing machine with a rubber duck rattling inside — it never stops churning, systole and diastole. That is a PDA.

4️⃣ AVSD — Atrioventricular Septal Defect · both holes + one common valve

What it is: BOTH ASD & VSD — 2 holes: the Atria & the Ventricles — plus the tricuspid and mitral valves failing to separate, leaving one common AV valve. The middle of the heart simply did not form.

Strong association: Down syndrome (trisomy 21). If the stem says “infant with Down syndrome, murmur, poor feeding, sweating” — think AVSD.

Why it is the sickest of the four: two shunts + a leaky common valve = the biggest volume load. These infants go into heart failure early, often by 6–8 weeks of life, and need surgical repair in infancy.

SOURCE FIX The original sheet printed “types (right-to-left blood flow)” next to AVSD. That label belongs to the cyanotic group. AVSD is ACYANOTIC — it shunts LEFT → RIGHT. It can turn blue only later, if untreated pulmonary hypertension reverses the shunt (Eisenmenger).

🧠 AVSD = “All Valves & Septa Down.” All of it is missing — and Down is the syndrome to remember.

⭐ Tell the four apart by SOUND — the murmur map

🧠 “All Peds Valves Murmur” — top to bottom on the chest: ASD high · PDA under the collarbone · VSD low sternal border · Mitral/apex last.

🔎

CLUES

STEP 2 · THE 4 NCLEX SIGNS

The source gives four. Learn them in this order — they are how a shunt baby actually shows up.

⭐ The 4 signs of a left-to-right shunt — 1 sweat · 2 murmur · 3 no weight · 4 heart failure

💦 Diaphoresis DURING FEEDINGS — the baby sweats, most on the forehead and scalp. Feeding is a marathon for a failing heart.

🎵 Heart murmur — the sound of blood crossing the hole.

⚖️ Poor weight gain — calories in, calories burned breathing. Growth stalls on the chart.

🚨 Increased risk: HEART FAILURE & PULMONARY HYPERTENSION — the endpoint if nobody fixes the hole.

🧠 “SMall Weight, big Heart” — S·M·W·H: Sweating with feeds · Murmur · Weight won't climb · Heart failure. Four letters, four NCLEX tips.

💦 What “sweating with feeds” actually looks like

Why: feeding is the hardest physical work an infant does. A heart already pumping extra volume cannot keep up, so the baby sweats, grunts, breathes fast, and quits early.

🧠 “A sweaty feed is a failing heart.” Healthy babies don't sweat through a bottle.

⚖️ Poor weight gain — the growth chart tells on the heart

Answer first: weigh the infant daily, same scale, same time, same amount of clothing. A weight that will not climb — or a sudden jump — is the most sensitive peds cardiac number you have.

Two different meanings: a flat weight = not enough calories / too much work. A sudden gain = fluid, i.e. heart failure.

🧠 “Slow gain = starving heart · Fast gain = drowning heart.”

🚨 The 5 heart-failure signs to REPORT — HF = Heavy Fluid

⚖️Weight GAINwater gain

👀Puffy eyesperiorbital edema

🥶Pale, coolextremities

🧷Fewer wetdiapers

🍼Decreasedfeeding

Earliest signs of heart failure in an infant are TACHYCARDIA and TACHYPNEA at rest — before the puffiness, before the weight.

Why puffy eyes and not ankles? Infants lie flat. Fluid pools where gravity puts it, and in a baby that is the face and eyes, not the legs. Never wait for ankle edema in an infant.

🧠 “HF = HEAVY FLUID.” Heavy on the scale · heavy eyes · heavy breathing · light diaper. Five signs, one word.

📈 The ending nobody wants: too much lung blood → pulmonary HTN → the shunt REVERSES

Answer first: once the shunt reverses, it is irreversible and the child is no longer a surgical candidate for a simple repair. This is exactly why holes get closed early instead of “watched forever.”

🧠 “Ice-man-er” — Eisenmenger. The lungs turn to stone, the pressure flips, and the pink baby goes blue. It is the one way an acyanotic defect becomes cyanotic.

🩺

CARE

STEP 3 · CLOSE IT, FEED IT, PROTECT IT

Three jobs: close the hole, get calories in, and keep the heart from failing while you wait.

🩹 Treatment by defect — straight from the source, expanded

Defect	Hallmark	Treatment	Group
ASD	Systolic murmur + fixed split S2	Closes naturally (many small ones) · device closure in the cath lab · surgical repair	Acyanotic · L→R
VSD	Systolic murmur at the left sternal border, loud & harsh; grunting with feeds	Closes naturally (small) · surgical patch repair (large)	Acyanotic · L→R
PDA	Loud MACHINE-LIKE continuous murmur, bounding pulses, wide pulse pressure	Indomethacin or ibuprofen (NSAID) · surgical ligation / coil closure	Acyanotic · L→R
AVSD	Early heart failure; strongly linked to Down syndrome	Surgical repair in infancy; HF medications to bridge to surgery	Acyanotic · L→R

🧠 “Two close themselves, two get closed.” Small ASD and small VSD often close on their own · PDA gets a drug · AVSD gets a surgeon.

💊 The one drug pair you must not swap — close the duct vs KEEP the duct open

🔒 CLOSE the duct	🔓 KEEP the duct OPEN
Indomethacin · ibuprofen — NSAIDs	Prostaglandin E1 (alprostadil) — a continuous IV infusion
How: NSAIDs block prostaglandin, and prostaglandin is what holds the duct open. Take the prostaglandin away → the duct closes.	How: gives back the prostaglandin, so the duct stays patent.
When: a PDA that is dumping too much blood into the lungs — usually a premature infant.	When: a duct-dependent defect, where the duct is the only path keeping the baby alive (critical coarctation, severe pulmonic stenosis, transposition, hypoplastic left heart).
Watch: renal function & urine output, bleeding/platelet effects, GI (NEC risk) — all standard NSAID concerns.	Watch: APNEA (be ready to intubate), hypotension, fever, flushing. Never stop the drip abruptly.

🧠 “INdomethacin = IN it goes, duct is IN-visible. PROstaglandin = PRO-open.” One shuts the door, one props it open. Giving the wrong one to a duct-dependent newborn is fatal.

✅ Feeding the shunt baby — calories are the treatment

🍼 Small, frequent feedings — big feeds exhaust them.
⏱️ Cap the feed at about 30 minutes. Longer than that costs more calories than it delivers — gavage/NG feed the rest rather than letting the baby work.
🥛 Higher-calorie formula / fortified breast milk as ordered — more calories in less volume.
😴 Cluster care and let them sleep — rest is a cardiac intervention.
⚖️ Daily weight, same scale, same time.
🧷 Count wet diapers — falling output is an early failure sign.

🧠 “Small, frequent, fortified, finished in 30.” Four F's, one goal — grow the baby big enough to survive the repair.

💊 Holding the line until surgery: HF medications

💧 Diuretic — furosemide: pulls the extra lung water off. Watch potassium, daily weights, strict I&O.
💪 Digoxin: makes each beat stronger and slower.
🩸 ACE inhibitor (e.g. captopril, enalapril): lowers afterload so the left ventricle has less resistance to push against — that shrinks the left-to-right shunt.

Digoxin in peds — the parts that get tested:

❤️ Count the APICAL pulse for a full minute before every dose.
🛑 Hold and call: commonly taught parameters are apical rate < 90–110 in an infant and < 70 in an older child — follow the facility's and the prescriber's stated parameter.
🤮 Early toxicity in a child = vomiting, anorexia, bradycardia (not the color vision of adults).
🧪 Low potassium makes digoxin toxic — and the child is also on a diuretic. Watch that K⁺.
❌ Do NOT repeat a dose the child vomited, and do not mix digoxin into a bottle of formula — if the baby doesn't finish it, you don't know the dose given.

🧠 “Dig makes it STRONG and SLOW.” If it is already slow — hold it.

👨‍👩‍👧 Parent teaching & long-term protection

🦷 Infective endocarditis prophylaxis — antibiotics (amoxicillin is first-line) before dental and certain procedures for children with prosthetic material or valves, unrepaired cyanotic defects, or a repair with prosthetic material within the first 6 months. Good daily oral care matters more than the pill.
💉 Keep immunizations current, including influenza; RSV prophylaxis (palivizumab) is given to infants with hemodynamically significant heart disease.
🤧 Avoid crowds & sick contacts — a shunt baby tolerates RSV very badly.

🌡️ Call for: fever, fast or hard breathing, sweating with feeds, fewer wet diapers, puffiness, sudden weight gain, poor feeding, color change.
🚭 No second-hand smoke.
😌 Let them self-limit activity — children with shunts stop when they need to.
📈 Keep every cardiology follow-up, even when the child looks well. The damage that matters (pulmonary hypertension) is silent until it is permanent.

🧠 “Teeth, shots, crowds, calls.” Four teaching points that keep a repaired heart alive between clinic visits.

⚡

QUICK RECALL

SAY IT OUT LOUD

➡️ L → R = pinkASD · VSD · PDA · AVSD are all ACYANOTIC with ↑ pulmonary blood flow.

🦆 Machine-like = PDAContinuous “washing machine” murmur + bounding pulses. Duct = DUCK.

🔊 Loud harsh LSB = VSDFixed split S2 high on the left = ASD. Down syndrome + early HF = AVSD.

💦 Sweat · murmur · no weight · HFThe 4 NCLEX signs of a left-to-right shunt.

⭐ One last time — the classification you will be asked

Group	Shunt direction	Pulmonary blood flow	Blue?	Defects
💛 ACYANOTIC	LEFT → RIGHT	↑ INCREASED — too much blood to the lungs	No (pink at first)	ASD · VSD · PDA · AVSD
🧡 OBSTRUCTIVE	none — the road is narrowed	normal or ↓, depending on where the narrowing is	Usually no	Pulmonic stenosis · Aortic stenosis · Coarctation of the aorta
💜 CYANOTIC	RIGHT → LEFT	↓ DECREASED — blood skips the lungs	YES	Tetralogy of Fallot · Tricuspid atresia
🩵 MIXED	both ways — red and blue blood mix	varies	Yes	Transposition of the great arteries · Truncus arteriosus · TAPVR · hypoplastic left heart

🎯 Cover & check — 6 rapid-fire questions

Q1: Which way does blood shunt in ASD, VSD, PDA and AVSD, and why?

LEFT → RIGHT. The left side is the high-pressure pump, so blood takes the easy road back into the low-pressure right side and returns to the lungs. Result: increased pulmonary blood flow, acyanotic.

Q2: A newborn has a loud, continuous machine-like murmur and bounding pulses. Which defect, and which drug closes it?

PDA — patent ductus arteriosus, the opening connecting the aorta to the pulmonary artery. Indomethacin (or ibuprofen), an NSAID, closes it; surgical ligation or coil closure if that fails.

Q3: The parents of a child with an ASD ask about the murmur. What do you tell them, and what would you report instead?

The murmur itself is expected — it is the sound of the shunt. Report the heart-failure signs: weight gain, puffy eyes, pale cool extremities, fewer wet diapers, decreased feeding — plus tachycardia and tachypnea at rest.

Q4: An infant with Down syndrome has a murmur, sweats with feeds and is failing to gain weight. Most likely defect?

AVSD — atrioventricular septal defect: both an ASD and a VSD plus one common AV valve. Acyanotic, left-to-right, and the group that goes into heart failure earliest. Repair is surgical, in infancy.

Q5: How can an “acyanotic” defect end up making a child blue?

Years of extra pulmonary blood flow cause pulmonary hypertension. When right-sided pressure exceeds left-sided pressure the shunt reverses to RIGHT → LEFT — Eisenmenger syndrome. The child becomes cyanotic, and it is irreversible.

Q6: You are about to give digoxin to a 4-month-old. Apical rate is 88 and regular. Now what?

Hold the dose and notify the provider. Commonly taught hold parameters are an apical rate below 90–110 in an infant and below 70 in an older child — always count apically for one full minute, and follow the parameter the prescriber wrote.