A model of nursing care for a patient after percutaneous closure of an atrial septal defect

INTRODUCTION

Patients with a congenital heart defect in the form of an atrial septal defect (ASD) constitute the largest group of adult patients suffering from atypical structure of the myocardium. This abnormality accounts for about 10% of all con-genital heart defects diagnosed after birth and as much as 30-40% of defects diagnosed after the fourth decade of life [1]. Atrial septal defects arise as a result of abnormal prenatal development of the endocardial cushions or the second septum, resulting in the formation of various types of permanent connections between the atria. The onset of the symp-toms of the disease is predisposed individually.
The literature on the subject differentiates 5 basic types of atrial septal defects:
• secondary ASD (ASD II) – statistically the most common type of defect, seen in 80-90% of the adult population, located in the area of the fossa ovalis and the surrounding tissue;
• primary ASD (ASD I) – partial atrioventricular septal defect, located near the cross of the heart, accounting for 10-15% of diagnosed heart defects;
• defect of the superior vena cava (SVC) type, accounting for 5% of diagnosed ASD defects, topographically located near the mouth of the SVC;
• inferior vena cava (IVC) defect, accounting for < 1% of clinical cases, located in the inferior part of the atrial septum;
• coronary sinus defect, accounting for < 1% of ASD-type defects, characterized by a partial or complete absence of the roof of the coronary sinus with no isolation from the left atrium [2, 3].
The increased availability of diagnostic tools has resulted in a noticeable increase in the number of elderly patients who are usually diagnosed with ASD incidentally during a routine preventive examination. The overriding diagnostic problem is the correct determination of the severity of the defect in the elderly and the advisability of potential therapy. The currently accepted view is that haemodynamically significant defects diagnosed in adults should be closed if the resistance in the pulmonary vessels does not exceed 6-8 units on the Wood scale. The guidelines of the European Society of Cardiology do not take into account the patient’s age when qualifying a patient for a defect occlusion procedure [4, 5].
A diagnosed heart defect is a huge stress for the patient and their family. Nursing care in the entire diagnostic and therapeutic process requires from nurses an unconventional psychotherapeutic approach and extensive substantive knowledge of internal diseases, cardiology, and cardiac surgery. Patient care at every stage of the disease creates numerous professional challenges related to the need for continuous education and improvement of practical skills. Professional nursing of people with ASD should include activities related to all areas of the patient’s life, with a fundamental emphasis on the prevention of complications and interventions that allow the patient to perform self-control and self-care. Undertaking educational activities conducted by the nursing staff will allow the patient’s family to be prepared for non-professional care.
The aim of this paper is to present a model of nursing care for an adult patient after percutneous closure of an atrial septal defect.

EPIDEMIOLOGY

Atrial septal defects are the most common congenital heart defect. They occur about twice as often in women than in men. As an isolated defect, they constitute about 5-10% of genetically determined heart defects, while as a component it is diagnosed in as many as 30% of patients with complex myocardial defects. Numerous scientific studies have proven that the occurrence of ASD is associated with chromosomal inheritance, aneuploidy, transcription errors, mutations, and maternal exposure to harmful factors. Atrial septal defect can occur in various genetic syndromes – trisomy 21 (Down syndrome), trisomy 18 (Edwards syndrome), trisomy 13 (Patua syndrome), Holt-Oram syndrome, and Noonan syndrome. Several genes associated with ASD have been disclosed, including the following: GATA4, TBX5, NKX2.5, ACT1, MYH6, and MYH7 [6]. Advanced maternal age and exposure of the foetus during embryonic life to pathogenetic factors such as hard drugs, alcohol, and viral diseases (rubella) may significantly predispose the unborn foetus to the development of ASD.
The incidence of congenital heart disease (CHD) has increased over the last 50 years. During the 1930s, CHD was diagnosed in less than 1 child per 1000 births. The latest epidemiological data suggest that ASD occurs in 1.6 cases per 1000 live births [7]. The noticeable increase in the incidence is probably related to the improvement of diagnostic methods and the increasing level of experience of medical staff. CHD can run in families, but it is most often sporadic and usually affects patients from developed countries with a higher socioeconomic status.

CLINICAL PICTURE

Patients with isolated atrial septal defects are often asymptomatic in childhood and adolescence. Small ASD defects (< 5 mm) are usually of no clinical significance. However, larger defects (5-10 mm) can lead to symptoms in the fourth and fifth decades of life, and large ASD defects (> 10 mm) are classically the cause of symptoms in the third decade of life [8].
Most adults with significant atrial septal defects experience symptoms such as migraines, palpitations, syncope, recurrent respiratory infections, hepatomegaly, and shortness of breath. In the absence of arrhythmia or features of pulmonary hypertension, overloading of the right-sided heart chambers may lead to subtle symptoms of the disease, such as fatigue, worsening of exercise tolerance, or exercise dyspnoea. Late complications of a significant ASD defect include right-sided myocardial insufficiency with peripheral oedema, peripheral cyanosis, and even thromboembolic symptoms with paradoxical emboli [9].
The multitude of symptoms and possible complications of ASD generate typical care problems that pose a professional challenge for nurses. Specialist knowledge acquired in the education process and professional practice enable effective assessment of the patient’s health needs, and the planning and implementation of professional care in accordance with the adopted nursing model.

DIAGNOSIS

The diagnosis of ASD is often accidental during routine auscultation in the GP’s office (primary health care). In the physical examination of the patient, there is a rigid splitting of the second heart sound regardless of the respiratory phase, unlike in the physiological act. The statistical murmur for ASD II is a soft, low systolic murmur (pulmonary ejection murmur associated with increased pulmonary blood flow and initiated by non-anatomic valvular stenosis).
In ECG (resting electrocardiography), ASD II is revealed by deviation of the heart axis to the right (right diagram), incomplete right bundle branch block, and features of right ventricular hypertrophy. The consequence of ASD type II may also be supraventricular arrhythmias in the form of atrial fibrillation and flutter caused by chronic stretching of the atrial cavities and the formation of new ectopic foci. The chest roentgenogram shows features of increased pulmonary blood flow as well as dilated right ventricle and pulmonary trunk. The basic diagnostic method is transthoracic echocardiography (TTE), which enables the diagnosis and quantitative assessment of the defect. It is also necessary to perform transoesophageal echocardiography (TEE), during which a contrast in the form of saline is administered to the peripheral veins by a nurse with the simultaneous performance of the Valsalva manoeuvre. Magnetic resonance imaging and computed tomography of the heart are tests that are performed less frequently, for economic reasons and due to the limited availability of medical equipment [10].
Implementation of the therapeutic function by the nursing staff is one of the priority activities aimed at establishing a diagnosis, treatment plan, prognosis, and control of treatment effects. To diagnose ASD defects, the nurse, within the framework of his/her professional competence, performs the following diagnostic activities:
• physical examination of the circulatory system (visual examination of the chest, palpation, percussion, auscultation of the heart, pulse examination, blood pressure examination, venous circulation examination, blood pressure measurement of the venous system, capillary refill test);
• electrocardiographic examination of the heart and an initial interpretation of the ECG curve;
• collection of biological material for laboratory analysis; participation in the physical and mental preparation of the patient for imaging tests, and provision of contrast for better imaging of organs and tissues;
• participation in invasive tests such as cardiac catheterization, coronary angiography, and angiography in the operating room.

THERAPEUTIC MANAGEMENT

Several years ago, cardiac surgery was the only available method of treating ASD. Currently, because of medical progress and the development of biomedical technologies, atrial septal defects can be treated using endovascular (transvascular) techniques. Pharmaceutical therapy is a symptomatic treatment that minimizes the side effects of the defect.
The standard procedure in the treatment of ASD type II defects is the transvascular technique. The ASD II occlusion procedure is an invasive interventional procedure performed in the haemodynamic laboratory by a specialized interdisciplinary team. The procedure is classically performed under general anaesthesia, under the control of echocardiography and angiography. Dimensioning of the size of the ASD type II defect is carried out during the procedure in TEE and angiographically using fluoroscopy with a balloon. The clasp closing the defect in the interatrial septum is made of 2 discs – right and left atrial – connected with a connector. After obtaining vascular access from the femoral vein, a guidewire is introduced through the defect, usually into the left upper pulmonary vein, and then, behind the guidewire, a sheath is used to deliver the closing system, e.g. Amplatz, CardioSEAL. In the next stage, the left atrial disc, resting on the interatrial septum, is opened, followed by the right atrial disc. In the final phase of the procedure, a test is performed to check the stability of the implanted clasp. After obtaining a positive test result, the delivery system is detached [11]. The guidelines of the European Society of Cardiology (ESC) from 2020 recommend closure of secondary defects in patients with a significant left-to-right shunt. Currently, endovascular treatment is the method of choice. In order to perform the procedure, anatomical and morphological criteria must be met by the patient. A contraindication to type II ASD occlusion is the presence of concomitant heart defects requiring surgical intervention, partial abnormal pulmonary venous return, pulmonary hypertension, intracardiac thrombus, or sepsis. Patients of all ages benefit from defect closure by reducing dyspnoea, right ventricular failure, and improving exercise tolerance. When qualifying advanced-age patients for surgery, the risks associated with the procedure should be carefully considered in relation to the potential benefits [12].
The nursing staff take an active part in the therapeutic process of patients with ASD and are an important pillar. Nursing care begins as soon as the patient arrives at the treatment room, and consists of the following professional activities:
• the assisting nurse initially assesses the patient’s general condition and their preparation for the therapeutic procedure (assesses the treatment area, skin cleanliness, checks for dentures or jewellery), checks the presence of referrals to the laboratory, written consent for the procedure, and the periprocedural safety card, and initially analyses the results of the laboratory tests. Prepares, checks, completes, and secures the necessary equipment for the procedure. Assists in the preparation of the treatment area, administers preparations for skin disinfection, covers the entire patient with a sterile treatment drape, assembles the pressure system, rinses the vascular sheath, and adds diagnostic catheters and guidewires to the table;
• the instrumenting nurse prepares the treatment table equipped with a sterile treatment package, and actively participates in in the therapeutic process, cooperating with the operator;
• the anaesthesiology nurse, after admitting the patient to the treatment room, becomes acquainted with the patient’s history, checks consent for general anaesthesia, anaesthesia consultation card, allergic history, and the patency of the peripheral intravenous cannula. He/she is responsible for preparing the anaesthesia station and completing the anaesthetic drugs ordered by the doctor. He/she attaches the ECG electrodes, pressure cuff, and saturation sensor and starts monitoring vital signs. Together with the doctor, he/she carefully observes the patient, analyses the parameter values on the cardiomonitor, and puts on an anaesthesia card. Efficient transfer of information and cooperation of all members of the therapeutic team during the procedure allows for early detection and appropriate intervention in the event of periprocedural complications.

NURSING CARE OF THE PATIENT AFTER PERCUTANEOUS CLOSURE OF THE ATRIAL SEPTAL DEFECT

The importance of the nursing staff in the care of the patient after endovascular occlusion of the atrial septal defect is fundamental. Nurses remain in constant contact with the patient, and it is up to them to a large extent to determine the mental state of patients, their well-being, and attitude towards the therapeutic process. Provision of professional nursing care requires knowledge of the pathophysiology of ASD defects, therapeutic and diagnostic methods, as well as possible perioperative and postoperative complications.
Nursing of the patient after the ASD II transvascular closure procedure is carried out within the cardiology department. The medical staff employed in these units have the appropriate knowledge and practical experience needed to provide proper care for the patient. To ensure the highest quality of services and guarantee the continuity of specialist care, the wards are equipped with an appropriate number of qualified staff, medicines, and necessary medical equipment. The introduction of unified standards and quality management systems for nursing procedures significantly contributes to better therapeutic effects and greater patient satisfaction with treatment results [13]. The nurse taking care of the patient after the ASD occlusion procedure undertakes nursing interventions from the moment of preparing the bed for the patient after the procedure. After receiving information from the invasive cardiology laboratory and collecting preliminary data about the patient’s condition, he/she goes with the support staff or another nurse to pick up the patient (the patient is transported in the supine position due to the inguinal access procedure). After admitting the patient to the ward, the nurse familiarizes him/herself with the patient’s general condition and the medical order card, thus developing an individualized and holistic nursing process by introducing the following nursing activities:
• placing the patient in a bed and providing basic information on further management (recommending that the patient stay in bed until the vascular introducer is removed by a doctor, and informing him/her about the period of maintaining compression);
• according to the medical orders card, the nurse is responsible for basic diagnostics of vital signs (heart rate, blood pressure, respiration, and body temperature measurement), including the performance of a 12-lead electrocardiogram and documentation of the obtained data;
• collection of biological material for diagnostic tests according to the medical order card;
• continuous observation of the patient for pain in the chest, late allergic symptoms, observing the lower limb from which the procedure was performed, the puncture site, and the dressing for possible bleeding; cleanness of the dressing, presence of redness, swelling, or exudate);
• assisting the doctor during the removal of the introducer with aseptic rules; after the appropriate amount of time (about 8-12 hours) removing the pressure from the femoral artery and observing the puncture site, colour of the limb, thigh circumference, and securing with a sterile dressing;
• controlling the body’s hydration and diuresis;
• administering prescribed medications according to the doctor’s order card and observing the patient for side effects of the applied pharmacotherapy;
• conducting education of the patient and his/her family in the field of self-care at home, the essence of the disease, factors risk, healthy lifestyle, and postoperative complications;
• informing the patient about the need to take medicines systematically, periodic visits and check-ups, avoiding carrying heavy objects, bathing in hot water, and continuous self-monitoring;
• documenting the nursing interventions undertaken.
The ASD endovascular occlusion procedure is a highly specialized medical procedure. The essence of patient care is based on reliable observation and monitoring of the patient to properly prioritize his/her needs. Thanks to comprehensive care, the patient has a sense of security and a high level of services provided. As a result of the health education, the patient and his/her family are prepared for self-care and non-professional care as well as leading a healthy lifestyle with the principles of cardiovascular disease prevention. An important professional task faced by nursing staff is continuous self-education, introduction of new educational models in the work environment, and improvement of practical skills [14].

SELECTED NURSING DIAGNOSES AND INTERVENTIONS PERFORMED FOR AN ADULT PATIENT AFTER PERCUTANEOUS CLOSURE OF INTERATRIAL COMMUNICATION

Selected nursing diagnoses concern the most common problems of adult patients after a percutaneous ASD occlusion procedure. They define the scope and nature of interventions undertaken routinely by a nurse based on scientific evidence. The information is presented in Table 1.

SUMMARY

Atrial septal defects are among the most common congenital heart defects diagnosed in adult patients. Patients may manifest various clinical symptoms ranging from a slight deterioration of exercise tolerance to significant complications.
The essence of patient care after percutaneous ASD II closure is based on reliable observation of the patient and proper gradation of their needs, to determine priority nursing interventions. A professional nursing process takes into account the causes of the disease as well as the clinical consequences of treating atrial septal defects.
Nursing care is provided in a holistic manner and requires active cooperation with the patient and his/her family, as well as other members of the therapeutic team. Cooperation should be based on the principles of subjectivity and effective interpersonal communication. The continuous improvement of professional qualifications and the improvement of practical skills enabling the provision of care at the highest level are of significant importance in the services provided by the nursing staff.

Disclosure

The author declares no conflict of interest.

References