Nursing Field Notes / Cardio · Congenital Heart Defects V · 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

Stenosis & Coarctation 🚧

Pulmonic stenosis · Aortic stenosis · Coarctation of the aorta — the OBSTRUCTIVE group

NG-183 CARDIO · PEDS ADHD-friendly visual edition

Nothing is leaking here — something is BLOCKED. A valve or a stretch of the aorta is too narrow, so the chamber behind it has to squeeze harder and gets thick (hypertrophy). Most of these babies stay pink. The one unmissable fingerprint of coarctation is a blood pressure gap between the arms and the legs — high & bounding above, low & weak below.

📄 Simple Nursing original — opens in Drive →

🚧 Nothing leaks — it's BLOCKEDA narrowed valve or vessel. The chamber behind the block hypertrophies pushing against it.

💗 Usually pinkOBSTRUCTIVE, not cyanotic — unless the block is critical and duct-dependent in a newborn.

🦵🤚 4-limb BP = coarctationArms: high BP, bounding pulses. Legs: low BP, weak/absent pulses. Check both arms too.

🚨 Critical = duct-dependentA severe block in a newborn may need the ductus arteriosus kept open (prostaglandin E1) until repair.

🫀

THE BASE HEART

STEP 0 · SAME PICTURE AS EVERY PAGE

Same drawing as the ASD/VSD/PDA and Tetralogy pages. Nothing about the chambers changes here — the ROAD narrows, not the wall between them.

🫀 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.

⭐ THE classification you are tested on — this page lives in the OBSTRUCTIVE row

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 ← YOU ARE HERE	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.” This page is the orange gates — nothing is leaking through a hole, something is blocked, and the bow-tie ▶◀ symbol marks exactly where.

🧭 How to read every diagram in this series

Blue chambers = right heart, O₂-poor blood.
Red chambers = left heart, O₂-rich blood.
Citrine bow-tie ▶◀ = an obstruction — the star of this page, three times.
Thick pale outline around a chamber = hypertrophy — that chamber is working against the block.

🧠 Read the drawing right. It is an anatomic view, so the patient's RIGHT heart is on YOUR LEFT. Same picture, four pages.

⭐ Why an obstructive lesion causes trouble — one sentence

Answer first: pressure backs up behind the narrowing, and the chamber that has to push through it gets thick and eventually tired.

Pulmonic stenosis backs pressure up into the right ventricle. Aortic stenosis backs pressure up into the left ventricle. Coarctation backs pressure up into everything proximal to the pinch — the left ventricle, and the vessels feeding the head and arms.

🧠 “Behind the dam, the water rises.” Whatever sits before the narrowing takes the pressure hit.

🚧

THE THREE BLOCKS

STEP 1 · SAME PICTURE, ONE PINCH EACH

Same base heart, three times. Only one thing changes each time — WHERE the road narrows.

1️⃣ PULMONIC STENOSIS — narrowed pulmonary valve · OBSTRUCTIVE, right-sided

What it is: the pulmonic valve (RV → pulmonary artery) is narrowed. The right ventricle must generate much higher pressure to push blood into the lungs.

Classic sign: a systolic ejection murmur at the left upper sternal border, often with a palpable thrill. Mild cases can be asymptomatic and found on a routine exam.

NCLEX TIP Severity, not color, drives urgency. Mild/moderate pulmonic stenosis stays pink and may just be watched. Critical pulmonic stenosis in a newborn can be duct-dependent for pulmonary blood flow and needs prostaglandin E1 to keep the PDA open until the valve is opened.

Fix: balloon valvuloplasty via cardiac catheterization is first-line for most children — see NG-201 for cath care.

🧠 “Pinch the outflow, back up the room.” Pinch the pulmonary valve and the right ventricle backs up pressure — and, over years, muscle.

2️⃣ AORTIC STENOSIS — narrowed aortic valve · OBSTRUCTIVE, left-sided, the higher-stakes one

What it is: the aortic valve (LV → aorta) is narrowed. The left ventricle — already the strongest chamber — must work even harder to push blood out to the whole body.

Classic sign: a harsh systolic ejection murmur at the right upper sternal border / aortic area, radiating to the neck/carotids. May have a weak, thready pulse and narrow pulse pressure in severe cases.

NCLEX TRAP Because the LV is a systemic pump, severe aortic stenosis in a newborn is an emergency — it can present as duct-dependent systemic circulation, with poor perfusion, weak pulses, and shock-like presentation as the PDA closes. Never assume an obstructive lesion is automatically low-priority — check the severity.

Fix: balloon valvuloplasty via catheterization, or surgical valve repair/replacement for severe or recurrent disease.

🧠 “The strong pump meets a locked door.” Aortic stenosis makes the body's main pump fight the hardest — that is why severe cases decompensate fastest.

3️⃣ COARCTATION OF THE AORTA — a pinch in the aorta itself · OBSTRUCTIVE — makes its own BP pattern

What it is: the aorta itself is narrowed, classically near where the ductus arteriosus attaches — just past the arch, after the vessels to the head and arms have already branched off.

Classic signs: higher BP and bounding pulses in the arms, lower BP and weak or absent pulses in the legs. Cool lower extremities. Older children may report leg cramps/fatigue with exercise, headaches, or epistaxis; infants may present in shock when the PDA closes.

NCLEX TIP Check BOTH arms, not just one. If the narrowing sits at or near the origin of the left subclavian artery, the left arm BP can be lower than the right — a right-arm-only BP can miss the picture.

Fix: balloon angioplasty ± stent via catheterization, or surgical resection of the narrowed segment. Lifelong follow-up — recoarctation and aneurysm risk persist into adulthood.

Associations: more common in Turner syndrome and with a bicuspid aortic valve — both are worth knowing for exam questions.

🧠 “Garden hose with a kink.” Everything before the kink sprays hard (arms — high pressure); everything after the kink trickles (legs — low pressure).

🩸

THE 4-LIMB BP FINGERPRINT

STEP 2 · MOST TESTED

One diagram, one idea: compare the arms to the legs. It is the single fastest way to catch coarctation at the bedside.

🚨 The hallmark assessment — BP and pulses in all four limbs

🧠 “High up top, low down below.” Bounding radial pulses + high arm BP, paired with weak or absent femoral pulses + low leg BP, is coarctation until proven otherwise.

⭐ Radial-femoral delay — the pulse-timing trick

Answer first: palpate a radial pulse (wrist) and a femoral pulse (groin) at the same time. Normally they arrive together.

In coarctation, the femoral pulse arrives noticeably later and weaker than the radial pulse — blood is taking a slower, harder route around/through the narrowed segment to reach the legs.

🧠 “The femoral pulse is running late.” A delayed, weak femoral pulse next to a strong, on-time radial pulse is a classic bedside finding — no equipment needed.

🔎 Pulmonic vs Aortic vs Coarctation — tell them apart

	Pulmonic stenosis	Aortic stenosis	Coarctation
Blocked chamber	Right ventricle	Left ventricle	Aorta itself
Murmur location	Left upper sternal border	Right upper sternal border, radiates to neck	May be absent or heard back/interscapular
Key exam clue	Murmur ± thrill	Weak pulses, narrow pulse pressure if severe	Arm BP > leg BP, radial-femoral delay
Critical newborn risk	Duct-dependent pulmonary flow	Duct-dependent systemic flow — shock risk	Shock as PDA closes

🧠 “P is for pulmonary (right), A is for aorta (left), C is for compare-the-limbs.”

⚠️ Why a “pink” diagnosis can still be an emergency

Obstructive lesions are usually acyanotic — but severe or critical narrowing in a newborn can be duct-dependent: the baby only survives because the PDA is still open, letting blood bypass the block.

As the ductus closes naturally in the first days of life, a critical obstruction can suddenly cause shock, poor perfusion, and cardiovascular collapse — this is why every newborn gets pulses and perfusion checked before discharge.

🧠 “No cyanosis ≠ no emergency.” Watch perfusion and pulses, not just skin color, in a newborn with a suspected obstructive lesion.

🩺

TREATMENT & NURSING CARE

STEP 3 · FIX THE ROAD

Two roads to relieve the block: catheter-based or surgical. Nursing priorities are the same for all three defects.

✅ How each block gets fixed

Defect	Catheter-based option	Surgical option
Pulmonic stenosis	Balloon valvuloplasty — usually first-line	Valve repair/replacement if balloon fails or valve is dysplastic
Aortic stenosis	Balloon valvuloplasty	Valve repair/replacement for severe or recurrent disease
Coarctation	Balloon angioplasty ± stent	Surgical resection of the narrowed segment, especially in infants

SEE NG-201 for full pre- and post-catheterization care (pulse checks, straight-leg positioning, site care) and post-surgical / chest tube care that applies after any of these repairs.

🧠 “Balloon first, blade if it doesn't hold.” Catheter-based repair is usually tried before open surgery for isolated valve or vessel narrowing.

🩺 Nursing priorities — every obstructive lesion

🩸 4-limb BP and pulses on admission and with every set of vitals — your baseline for catching coarctation and for comparing after repair.

👀 Watch for signs of heart failure — tachypnea, diaphoresis with feeds, poor weight gain — especially with moderate-severe stenosis.

🚨 Report poor perfusion in a newborn — weak/absent pulses, mottling, cool extremities, irritability or lethargy can mean the duct is closing on a critical lesion.

💊 Anticipate prostaglandin E1 orders for a duct-dependent critical lesion — keeps the PDA open until repair. (no dose stated here — follow facility protocol)

📋 Teach lifelong follow-up — recoarctation, aortic aneurysm, and hypertension can develop years later even after a successful repair.

🧪 What you'll see charted

Echocardiogram — confirms the diagnosis and severity (gradient across the valve/narrowing).
4-extremity BP documented as its own vital sign set when coarctation is suspected.
Pulse oximetry pre- and post-ductal (right hand vs a foot) can also help detect duct-dependent lesions.

🧠 “Pre vs post-ductal sats” — right hand = pre-ductal, either foot = post-ductal. A gap between them points to a duct-dependent problem.

✅ Family teaching after repair

Keep all follow-up cardiology visits — narrowing can recur (recoarctation) as the child grows.
Endocarditis prophylaxis may be needed for certain dental/surgical procedures — ask the cardiologist which category applies.
Report headaches, nosebleeds, leg cramps with exercise, or a new BP gap between visits.

🧠 “Fixed once doesn't mean fixed forever.” A repaired coarctation still needs a cardiologist for life.

⚡

QUICK RECALL

SAY IT OUT LOUD

🚧 Blocked, not leakingPulmonic, aortic, coarctation — all OBSTRUCTIVE. The chamber behind the block hypertrophies.

🦵🤚 Arms high, legs lowCoarctation's fingerprint: high BP + bounding pulses (arms) vs low BP + weak/absent pulses (legs).

⏱️ Radial-femoral delayFemoral pulse arrives late and weak compared to the radial pulse in coarctation.

🚨 Critical = duct-dependentWatch perfusion, not just color — a closing PDA can unmask a severe block fast in a newborn.

⭐ 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 ← YOU ARE HERE	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.” This page lives entirely in the orange gates row.