Patent ductus arteriosus (PDA) is a fetal blood vessel between the aorta and the pulmonary artery that stays open after birth, sending extra blood to the lungs. It is most common in premature infants. The nursing diagnoses used most often are Decreased Cardiac Output, Ineffective Breathing Pattern, Risk for Imbalanced Fluid Volume, and Anxiety in the parents. The nurse watches perfusion, breathing, urine output, and feeding, and gives closure medicines safely.
At a glance
- What it is
- A ductus arteriosus that fails to close after birth, so blood shunts from the aorta into the pulmonary artery (left to right).
- Who gets it
- Mainly preterm infants; the earlier the birth, the more likely. It also occurs in term infants and can be found later in childhood or adulthood.
- Key test
- Echocardiogram, which shows the size of the duct and how much blood it shunts.
- Main treatment
- Watchful waiting, medicines that help the duct close (ibuprofen, indomethacin, or acetaminophen), or closure by catheter device or surgery.
- Nursing focus
- Signs of heart failure and poor perfusion, breathing effort, urine output, feeding tolerance, and medication side effects.
- Report promptly
- Falling urine output, bleeding, a swollen or discoloured belly, rising oxygen needs, apnea, or low blood pressure.
How a PDA affects the heart and lungs
Before birth, the lungs are not used for gas exchange. The ductus arteriosus lets most blood from the right side of the heart bypass the lungs and go straight into the aorta. After birth, the rise in oxygen and the drop in prostaglandins normally make the duct constrict. In a healthy term infant it usually closes functionally within the first few days and seals off completely over the following weeks.
When the duct stays open, pressure in the aorta is higher than in the pulmonary artery, so blood flows from the aorta back into the lungs. This is a left-to-right shunt. The lungs get too much blood, which makes them stiff and wet, and the left atrium and left ventricle are overloaded with the returning volume. At the same time, blood is “stolen” from the body during diastole, so the gut, kidneys, and brain can be under-perfused.
In preterm infants, a large PDA is linked to worse lung disease, feeding intolerance, necrotising enterocolitis (NEC), and kidney problems. A large duct left open for years can cause pulmonary hypertension. If lung pressures rise above body pressures, the shunt reverses and the client becomes cyanotic (Eisenmenger syndrome), sometimes with blue lower limbs and pink upper limbs. An open duct also carries a small risk of infection of its lining (endarteritis).
Risk factors include prematurity, respiratory distress syndrome, maternal rubella during pregnancy, some genetic conditions such as trisomy 21, and birth at high altitude.
Nursing assessment
Subjective data
- Parent report of fast breathing, sweating, or tiring during feeds
- Feeds taking longer, smaller volumes, or vomiting
- Poor weight gain or frequent chest infections in an older infant or child
- In an older child or adult: shortness of breath on exertion, fatigue, or palpitations
- Pregnancy and birth history: gestational age, maternal infections, and medications
- Family history of congenital heart disease or genetic conditions
- What the parents understand about the condition and the plan, and how they are coping
Objective data
- Murmur: classically a continuous “machinery” murmur at the left upper sternal border or under the left clavicle. In a preterm infant it may be systolic only, or absent with a very large duct
- Bounding peripheral pulses (including palmar pulses in a preterm infant), a widened pulse pressure, and a low diastolic blood pressure
- Active precordium (a visible, forceful heartbeat)
- Heart rate and respiratory rate above the expected range for age, retractions, grunting, or nasal flaring
- Rising oxygen or ventilator needs, or apnea and bradycardia episodes
- Hepatomegaly, crackles, and weight gain from fluid
- Urine output, feeding residuals, abdominal girth, and stool for blood
- Echocardiogram, chest X-ray (enlarged heart, increased lung markings), and kidney function as ordered
Normal duct closure vs. a significant PDA
| Feature | Expected transition | Suggests a significant PDA |
|---|---|---|
| Timing | Duct closes functionally in the first few days of life in a term infant | Duct still open, often in a preterm infant, with symptoms |
| Pulses and blood pressure | Normal pulses, normal pulse pressure for age | Bounding pulses, widened pulse pressure, low diastolic pressure |
| Breathing | Settling work of breathing | Tachypnea, retractions, rising oxygen or ventilator needs |
| Feeding and kidneys | Tolerating feeds, good urine output | Feeding intolerance, falling urine output, fluid weight gain |
Nursing diagnoses used with patent ductus arteriosus
- Decreased Cardiac Output — signs of heart failure and poor systemic perfusion from the shunt
- Ineffective Breathing Pattern — fast, effortful breathing from wet, overcirculated lungs
- Risk for Imbalanced Fluid Volume — fluid limits, diuretics, and closure medicines that reduce kidney blood flow
- Excessive Fluid Volume — when fluid overload is already present
- Inadequate Nutritional Intake (formerly Imbalanced Nutrition: Less Than Body Requirements) — high energy needs and tiring with feeds
- Risk for Bleeding — during treatment with ibuprofen or indomethacin
- Anxiety (parents) and Risk for Impaired Attachment — a sick infant in the NICU
Worked care plans
Four plans in the same ADPIE shape. The scenario is an infant born at 27 weeks, now 5 days old and weighing 950 g, on CPAP in the NICU. Over the last day the nurse has noticed a new murmur, bounding pulses, a widened pulse pressure, heart rate in the 170s, respiratory rate in the 70s with retractions, and a rising oxygen need. Urine output has dropped. An echocardiogram shows a large PDA with a left-to-right shunt, and the neonatologist orders a course of IV ibuprofen.
1. Decreased Cardiac Output
Problem-focusedSubjective: Mother: “He seems to be working so hard, and his heart is pounding. I can see it in his chest.”
Objective: Heart rate 170s. Continuous murmur at the left upper sternal border. Bounding pulses, widened pulse pressure, low diastolic pressure. Active precordium. Capillary refill slower than yesterday. Urine output below the ordered minimum over the last shift. Liver edge palpable lower than on admission.
Decreased Cardiac Output related to left-to-right shunting through a patent ductus arteriosus, as evidenced by tachycardia, prolonged capillary refill, decreased urine output, and hepatomegaly.
- Infant’s heart rate and blood pressure stay within the ranges the neonatologist has ordered
- Capillary refill and skin colour improve over the treatment course
- Urine output returns to at least the ordered minimum
- Murmur and bounding pulses lessen as the duct closes
- Monitor heart rate, blood pressure (including diastolic and mean), and oxygen saturation continuously; trend them, not single readings
- Assess pulses, capillary refill, skin colour, and temperature of hands and feet each hands-on care time
- Listen to the murmur every shift and report a change in character
- Measure intake and output strictly, weighing diapers, and report output below the ordered minimum
- Cluster care and keep the environment quiet and thermoneutral to reduce oxygen and energy demand
- Give ibuprofen, diuretics, and any other medicines exactly as ordered, checking the unit’s hold criteria before each dose
After the third dose, heart rate is in the ordered range, the murmur is softer, and capillary refill is brisk. Urine output is improving but not yet at the minimum. Goal partially met; repeat echocardiogram ordered, continue plan.
2. Ineffective Breathing Pattern
Problem-focusedSubjective: Father: “Why does he need more oxygen today? He was doing better.”
Objective: Respiratory rate in the 70s. Subcostal and intercostal retractions, nasal flaring. Oxygen requirement on CPAP has risen over 24 hours. Fine crackles. Chest X-ray shows increased lung markings.
Ineffective Breathing Pattern related to pulmonary overcirculation and fatigue of the respiratory muscles, as evidenced by tachypnea, retractions, nasal flaring, and an increasing oxygen requirement.
- Oxygen saturation stays within the unit’s ordered target range
- Retractions and nasal flaring decrease
- Oxygen requirement returns toward the infant’s earlier baseline
- No escalation to intubation is needed
- Assess respiratory rate, effort, breath sounds, and apnea or bradycardia episodes, and document trends
- Keep the CPAP interface well fitted and the airway clear; suction only when needed and gently
- Position for chest expansion with the head and neck in a neutral, slightly extended position, using developmental positioning aids
- Titrate oxygen to the ordered target range; preterm targets are set to avoid both too little and too much oxygen
- Report rising oxygen needs, more apnea, or blood gas changes promptly, as they can mean the shunt is worsening
Respiratory rate has settled, retractions are mild, and the oxygen requirement is back near baseline. Goal met; continue to monitor.
3. Risk for Imbalanced Fluid Volume
Risk diagnosis- Treatment with ibuprofen, which reduces kidney blood flow
- Prescribed fluid limits and possible diuretic use
- Extreme prematurity, with immature kidneys and high water loss through the skin
- Shunting of blood away from the kidneys
No “as evidenced by” — this names a problem that has not happened yet.
Risk for Imbalanced Fluid Volume related to NSAID treatment, prescribed fluid limits, renal immaturity, and reduced kidney perfusion from the ductal shunt.
- Infant keeps urine output at or above the ordered minimum
- Daily weight change stays within the range the team expects
- Sodium, creatinine, and other labs stay within the ranges the provider orders
- Weigh daily on the same scale at the same time
- Measure all intake, including flushes and medication volumes, and weigh every diaper
- Run IV fluids on a pump at the exact ordered rate and check the IV site often
- Check urine output, creatinine, electrolytes, and platelets before each dose as the unit protocol requires, and hold and report if hold criteria are met
- Watch for bleeding (oozing from puncture sites, blood in the stool or gastric aspirate) and for abdominal distension, discolouration, or feeding intolerance
- Follow the unit’s feeding plan during treatment, which may reduce or hold feeds
Urine output dipped after the first dose and recovered by the third. Weight and labs are within the ordered ranges, and there is no bleeding or abdominal change. Risk not realised; continue plan.
4. Anxiety (parents)
Problem-focusedSubjective: Mother: “Nobody told us his heart had a hole in it. Is he going to need surgery? I’m scared to touch him.”
Objective: Mother tearful at the bedside and asking the same questions several times. Parents have not yet held the infant or joined care times.
Anxiety (parents) related to an unfamiliar diagnosis, uncertainty about treatment, and the NICU environment, as evidenced by stated fear, tearfulness, repeated questions, and reluctance to touch the infant.
- Parents describe in their own words what a PDA is and what the current treatment does
- Parents state who to ask when they have questions
- Parents take part in at least one care time or skin-to-skin contact when the infant is stable enough
- Explain the duct in plain language with a simple drawing, and use teach-back
- Explain what the monitors and alarms mean so they are less frightening
- Tell parents what the next steps could be — medicine, a repeat echo, or a closure procedure — and that the team decides together with them
- Invite parents into care times and support skin-to-skin contact when the team says it is safe
- Arrange a meeting with the neonatologist and offer social work, chaplaincy, and parent support groups
Parents explain the PDA and the ibuprofen course correctly and changed a diaper during care time. Mother still worries about surgery. Goal partially met; continue support and update after the repeat echo.
Free download
NCLEX Readiness Diagnostic
Fifty questions with a written rationale on every option, scored by section so you can see which content area is weakest. Sent as a PDF.
Interventions and rationales
Client and family teaching
- A PDA is a blood vessel every baby has before birth that did not close on its own; it is common in babies born early
- Many small PDAs close without treatment; others need medicine or a procedure
- Ask the team what the plan is and what each test is for; you are part of the care team
- At home, watch for fast breathing, sweating or tiring with feeds, poor weight gain, or a bluish colour, and call the provider
- Keep all follow-up and echocardiogram appointments
- Ask the cardiologist whether antibiotics are needed before dental work; most children with a PDA do not need them, but some do for a time after device or surgical closure
- Keep up routine vaccines and good dental care
- After a catheter procedure, follow the activity limits and call for bleeding, swelling, or a cool, pale leg
- Call 911 for trouble breathing, a blue or grey colour, or a baby who is very hard to wake
NurseStudyPrep.com
You’ve read the care plan. Now answer one.
A pharmacology item in the NCLEX format. On Prep, every option gets a written rationale — including the three that are wrong.
A preterm infant is receiving IV ibuprofen to close a patent ductus arteriosus. Before the second dose, which finding should the nurse report to the provider first?
Why B. Ibuprofen reduces blood flow to the kidneys, and low urine output is a common reason to hold the next dose. A softer murmur and less bounding pulses suggest the duct is closing, which is the goal, and a heart rate in range needs no action. Prep also explains why each wrong option looks reasonable.
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Frequently asked questions
What is the nursing diagnosis for patent ductus arteriosus?
PDA is a medical diagnosis, so it goes in the “related to” part. Common nursing diagnoses are Decreased Cardiac Output, Ineffective Breathing Pattern, Risk for Imbalanced Fluid Volume, Inadequate Nutritional Intake, and Anxiety in the parents.
What does a PDA murmur sound like?
Classically a continuous “machinery” murmur heard best at the left upper sternal border or below the left clavicle. In preterm infants it is often systolic only, and a very large duct may have no murmur at all.
Why is PDA more common in premature babies?
The preterm duct is less sensitive to the rise in oxygen after birth and more sensitive to prostaglandins, so it is less likely to constrict. Lung disease and low oxygen levels also keep it open.
Why do indomethacin and ibuprofen close a PDA while alprostadil keeps it open?
Prostaglandins keep the duct open. Indomethacin and ibuprofen block prostaglandin production, so the duct can constrict. Alprostadil is a prostaglandin, so it holds the duct open in infants with heart defects that depend on it.
Is PDA cyanotic or acyanotic?
Acyanotic. Blood shunts from the aorta to the lungs, so oxygenated blood still reaches the body. Cyanosis appears only if lung pressures rise high enough to reverse the shunt.
Does a child with a PDA need antibiotics before dental work?
Usually not. Current American Heart Association guidance limits prophylaxis to higher-risk groups, which can include a period after closure with a device or prosthetic material. The cardiologist decides for each child.
References
- Hamrick, S. E. G., et al. Patent Ductus Arteriosus of the Preterm Infant. Pediatrics, 2020;146(5):e20201209.
- Wilson, W. R., et al. Prevention of Viridans Group Streptococcal Infective Endocarditis: A Scientific Statement From the American Heart Association. Circulation, 2021;143(20).
- Gillam-Krakauer, M., & Mahajan, K. Patent Ductus Arteriosus. In StatPearls. StatPearls Publishing.
- Hockenberry, M. J., Duffy, E. A., & Gibbs, K. D. Wong’s Nursing Care of Infants and Children, 12th ed. Elsevier, 2023.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). NANDA International Nursing Diagnoses: Definitions and Classification, 2024–2026. Thieme.
- American Heart Association. Patent Ductus Arteriosus (PDA).
Choice of treatment, medication doses and hold criteria, oxygen saturation targets, fluid limits, and minimum urine output vary by infant, by unit, and by facility. Follow the provider’s written orders and your own institution’s standards. This page supports study and does not replace course instruction or clinical judgement.
