nursing considerations should involve the following: • Interventions to decrease cardiac workload • Administration of cardiac medications as indicated • Decreased stimulation • Clustering care to allow periods of undisturbed rest • Maintenance of a neutral thermal environment • Sedation to minimize anxiety, agitation, and irritability • Close monitoring of fluid intake and diuresis • High-calorie diet to maintain weight gain (weigh daily if stable) • Oxygen delivery for cyanosis • Screening for 22q11 deletion • Prevention/treatment for hypercyanotic spells92,93 • In extreme situations, mechanical ventilation to decrease work of breathing and minimize metabolic demands Postoperative Nursing Considerations Following surgical repair, postoperative recovery is facilitated by an appropriately trained nursing staff as part of a multidisciplinary team that provides rigorous monitoring and is able to recognize and initiate appropriate interventions to prevent end-organ damage if complications occur Concerns differ depending on the type of repair performed, whether palliation or correction Shunt procedure concerns include: • Bleeding • Pneumothorax • Too large of a shunt and excessive pulmonary blood flow resulting in risk of pulmonary edema and inadequate systemic blood flow • Too small a shunt with little improvement in oxygenation • Thrombosis of the shunt • Pulmonary artery hypoplasia94 Definitive correction concerns include: • Low cardiac output state • Residual right ventricular outflow tract (RVOT) obstruction • Residual ventricular septal defect (VSD) • Coagulopathies • Heart block/junctional ectopic tachycardia (JET) • Renal failure • Phrenic nerve injury • Stroke • Infection94 Upon admission to the intensive care unit, a comprehensive postoperative handoff is essential and should include the patient diagnosis, procedure performed, time in surgery, anesthetics used, time on bypass and for cross clamping, volume of blood products given, diuretics given, urine output, intraoperative events, vasoactive medications, intubation difficulties, allergies, and any associated syndromes, malformations, diagnoses, or infections.95 Nursing considerations during the postoperative phase should include monitoring of cardiac output, support of respiratory function, maintenance of fluid and electrolyte balance, promotion of comfort, and support of healing and recovery with a focus on family-centered care Monitoring Cardiac Output Assess for risk of low cardiac output syndrome: long cardiopulmonary bypass times, complicated repair, extensive right ventricular muscle resection, neonate, transannular patch, or significant preoperative cyanosis Invasive and noninvasive monitoring is initiated upon admission from the operating room, with display of the arterial line and right atrial pressures as well as a cuff blood pressure, heart rate and rhythm tracing, and central venous pressure Follow trends in lactates, near infrared spectroscopy, and urine output along with clinical assessment hourly to monitor signs of cardiac output Patients may require significant inotropic support and may be unstable early in their course, with desaturation from atrial level shunting.96 Right ventricular dysfunction may be seen when the right atrial pressure is increased due to restrictive right ventricular physiology and the high filling pressures that are often necessary following surgical repair and cardiopulmonary bypass.90,92 Postoperative rhythm disturbances can include JET, which can have profound hemodynamic significance due to loss of atrioventricular synchrony,90 right bundle branch block, and complete heart block, which will require pacing Obtain cardiac echo at 48 hours to assess function and repair (unless indicated sooner) Management of right ventricular dysfunction (difficulty relaxing/filling) includes the following: • Giving volume to augment preload (10 to 20 mL/kg normal saline or 5% albumin) • Treating situations that increase oxygen demands (fever, agitation, or pain) • Administering milrinone, which has a lusitropic effect to help the right ventricle relax • Administering dopamine, which increases