Module 5 Pediatric Cardiac

Disorders

Fetal Circulation

Fetal Circulation

Fetal Circulation

What is the stimulus for

the change in circulation?

Intrauterine to Extrauterine

Oxygen Saturation

What is oxygen saturation?

What is normal oxygen saturation levels?

What values indicate hypoxemia?

Why is it important for the nurse to know the oxygen saturation levels?

question 5

Congestive Heart Failure

What is wrong with the What is wrong with the heart? heart?

Congestive heart failure

What is the effect on: Heart rate Preload Contractitility

Afterload

Congestive Heart Failure

Why does the pump fail?Why does the pump fail?

Etiology and Pathophysiology

Congestive Heart Failure

What does the body do

to compensate for this

congestion and heart failure?

Compensatory Mechanisms With a decrease in Cardiac Output

Stimulation of the sympathetic nervous system

Tachycardia - increases venous return to the heart which stretches the myocardial fibers and increases preload.

Compensatory Mechanisms

With a decrease in cardiac output

Decrease perfusion to the kidneys and

glomerulus

Increased renin and ADH secretion

Increase in Na and H2O retention to increase intravascular volume

Early Signs of CHF

The earliest signs are often subtle:

Infant will have mild resting tachypnea

Increasing difficulty feeding

Signs and Symptoms Pulmonary congestion

1. Tires easily during feeding2. Tachypnea, Dyspnea, orthopnea3. Signs of respiratory distress4. Wheezing, rales and rhonchi5. Easily fatigue

Impaired cardiac output1. Tachycardia2. Extremities cool, capillary refill >2

seconds3. Diaphoretic, sweating, hypotension

Signs and Symptoms

Systemic venous congestion1. Hepatomegaly2. Edema3. Weight gain

High metabolic rate1. Failure to thrive2. Slow weight gain

Goal of Treatment

Treatment of Congestive Heart Failure

Medication Therapy Digitalis – increases contractility and

decreases heart rate. ACE-inhibitors - blocks release of

angiotension-aldosterone; arterial vasodilator / afterload reducing agent

Diuretics - enhance renal secretion of sodium and water by reducing circulating blood volume and decreasing preload, pulmonary congestion.

Beta Blocker - increases contractility

Nursing Care

How would the nurse recognize digitalis

toxicity in an infant or child?

What are the pulse rate criteria in administration

of digitalis?

Digitalis Digitalization

Given in divided doses Maintenance

Given daily, usually in two divided doses

Therapeutic vs. Toxicity Therapeutic range – 0.8 to 2.0 ng/ml Toxicity

**EKG changes – arrhythmia Slow pulse- bradycardia Vomiting – very rare in infants

Digitalis

Why are we so concerned with the potassium levels when the child is on digitalis therapy?

Treatment of Congestive Heart Failure

What is the type of Diet most commonly ordered?

How would nursing measure are used to decrease stress on the heart?

Feeding the child with CHF Feed the infant or child in a relaxed environment;

frequent, small feedings may be less tiring

Hold infant in upright position; may provide less stomach compression and improve respiratory effort

If child unable to consume appropriate amount during 30-minute feeding q 3 h, consider nasogastric feeding

Monitor for increased tachypnea, diaphoresis, or feeding intolerance (vomiting)

Concentrating formula to 27 kcal/oz may increase caloric intake without increasing infant’s work

Cardiac Cardiac CatheterizationCatheterization

Measure oxygen saturations and pressure in the cardiac chambers and

great arteries

Evaluate cardiac output

Cardiac Catheterization This process involves

passing a catheter through the femoral vein or artery into the heart.

Performed to evaluate

heart valves, heart function and blood supply, or heart abnormalities in newborns.

Cardiac Catheterization Pre-care:

History and Physical Lab work – EKG, ECHO cardiogram, CBC NPO Vital signs Preprocedural teaching

Best Nursing Action

During post procedure assessment, the nurse notes bleeding at the insertion site.

What should the nurse do first?

What additional interventions are implemented?

Post Cardiac Catheterization Care

Post Cardiac Catheterization Care

Congenital Cardiac Congenital Cardiac AnomaliesAnomalies

Ask Yourself?

What is the most common assessment finding indicating a cardiac anomaly?

Answer: an audible heart murmur

Patent Ductus ArteriousAtrial septal defects

Ventricle septal defects

Atrial Septal Defect

1. Oxygenated blood is shunted from left to right side of the heart via defect

2. A larger volume of blood than normal must be handled by the right side of the heart hypertrophy

3. Extra blood then passes through the pulmonary artery into the lungs, causing higher pressure than normal in the blood vessels in the lungs congestive heart failure

Treatment

Medical Management Medications – digoxin

Cardiac Catheterizaton - Amplatzer septal occluder

Open-heart Surgery

Treatment

Device Closure – Amplatzer septal occluder

During cardiac catheterization the occluder is placed in the Defect

Ventricle Septal Defect

1. Oxygenated blood is shunted from left to right side of the heart via defect

2. A larger volume of blood than normal must be handled by the right side of the heart hypertrophy

3. Extra blood then passes through the pulmonary artery into the lungs, causing higher pressure than normal in the blood vessels in the lungs congestive heart failure

Treatment

Surgical repair with a patch inserted

Patent Ductus Arteriosus

1. Blood shunts from aorta (left) to the pulmonary artery (right)

2. Returns to the lungs causing increase pressure in the lung

3. Congestive heart failure

Treatment for PDA Medical Management

Medication Indomethacin - inhibits prostaglandin's .

(When levels of prostaglandins are decreased, the ductus closes)

Surgery

Ligate the ductus arteriosus

Treatment for PDA

Cardiac Catheterization

Insert coil – tiny fibers occlude the ductus arteriosus when a

thrombus forms in the mass of fabric and

wire

Cardiac Anomalies - Treatment

Pulmonic stenosis

coarctation of aorta

Pulmonic Stenosis

Narrowing of entrance that decreases blood flow

Increases preload causes right ventricular hypertrophy

Obstructive or Stenotic Lesions

Treatment: Medications – Prostaglandins to

keep the PDA open

Cardiac Catheterization Baloon Valvuloplasty

Surgery Valvotomy

Aortic Stenosis

The aortic valve is thickened and rigid

Stenosis creates left ventricular hypertrophy

Left ventricle may not be large enough to eject a normal cardiac output.

Aortic Stenosis

Symptoms Poor peripheral perfusion,

feeding difficulties, CHF

Treatment Balloon valvoplasty Surgery

Coarctation of the Aorta

1. Narrowing of Aorta causing obstruction of left ventricular blood flow

2. Left ventricular hypertrophy

Signs and Symptoms

1.What are B/P findings support the diagnosis?

2.What is different in the pulses?

3.Why would the patient C/O leg pains?

4.What causes nose bleeds?

Treatment Goals of management are to improve

ventricular function and restore blood flow to the lower body.

Medical management with Medication A continuous intravenous medication,

prostaglandin (PGE-1), is used to open the ductus arteriosus allowing blood flow to areas beyond the coarctation.

Baloon Valvoplasty

Surgery for Coarctation of Aorta

1. Resect

narrow

area

2. Anastomosis

Tetralogy of fallot

Tetralogy of Fallot

Four defects are:

1.

2.

3.4.

Signs and Symptoms1. Failure to thrive

2. Squatting

3. Lack of energy

4. Infections

5. Polycythemia

6. Clubbing of fingers

7. Cerebral abscess

8. Cardiomegaly

Ask Yourself?

Why does Polycythemia occur in a child with a cardiac disorder?

What nursing interventions should be included when planning care for this child?

What lab test will be abnormal and assist in confirming the polycythemia?

Ask Yourself ?

Laboratory analysis on a child with Tetralogy of Fallot indicates a high RBC count. The polycythemia is a compensatory mechanism for:

a. Tissue oxygen need b. Low iron level C. Low blood pressure d. Cardiomegaly

Hypercyanotic Episode / “tet” spells

Cyanosis suddenly worsens in response to activity, such as crying, feeding, or having a bowel movement.

Signs - The infant becomes very short of breath with tachypnea and hyperpnea, and may lose consciousness.

Treatment – calming, knee-chest position, oxygen, morphine , and beta-blockers

Treatment

Open-heart Surgical interventions Blalock – Taussig or Potts

procedure – increases blood flow to the lungs.

View the Movie TrailerAbout Blalock procedure to

treat Tetralogy of fallot

Something the Lord Made

•Truncus Arteriosus•Transportation of Great

Vessels

These present the greatest risk to survival

Truncus arteriosus A single arterial

trunk arises from both ventricles that supplies the systemic, pulmonary, and coronary circulations. A vsd and a single, defective, valve also exist.

Entire systemic circulation supplied from common trunk.

Transposition of Great Vessels

Aorta arises from the right ventricle, and the pulmonary artery arises from the left ventricle - which is not

compatible with survival unless there is a large defect present in ventricular or atrial septum.

artery

aorta

Microorganisms grow on the endocardium, forming

vegetations, deposits of fibrin, and platelet thrombi. The lesion may invade adjacent tissues such as aortic and

mitral valves.

Subacute Bacterial Endocarditis / Infective

Endocarditis: Assessment:

Fever Fatigue Muscle and joint pain Headache Nausea and vomiting CHF Spleenomegaly

Diagnosis: Blood cultures Echocardiogram

Infective Endocarditis

Diagnosis

Blood cultures

Echocardiogram Show the vegetation

Who is more susceptible to develop infective endocarditis?

What is the most therapeutic intervention for preventing infective

endocarditis?

Antibiotic Prophylaxis for Children at Risk for Infective

Endocarditis Dental procedures, including cleaning,

that may induce gingival or mucosal bleeding

Tonsillectomy and/or adenoidectomy

Surgery and/or biopsy involving respiratory or intestinal mucosa

Incision and drainage of infected tissue

Invasive GU and GI procedures

Ineffective Endocarditis

Treatment Monitor temperature Antibiotics – 2-8 weeks

Patient teaching Good oral hygiene take antibiotics prior to surgery,

dental work, or any invasive procedure, etc.

discouraged from body piercing and tattoos as endocarditis may occur even with prophylaxis.

A systemic inflammatory (collagen) disease of connective tissue that usually follows a group A beta-

hemolytic streptococcus infection.

This disorder causes changes in the entire heart (especially the valves),

joints, brain, and skin tissues.

Rheumatic Fever - Assessment

Major Carditis Polyarthritis Chorea Erythema

marginatum Subcutaneous

nodules

Minor Arthralgia Fever Laboratory

Findings:

Erythrocyte sedimentation rate

C-reactive protein

Prolonged PR interval

Jones Criteria

What additional laboratory test helps

to confirm the diagnosis of

Rheumatic Fever ?

Rheumatic Fever

Treatment Antibiotic Therapy Antipyretics - aspirin Anti-inflammatory agents –steroids Rest Heat and cold to joints

Discharge Teaching Antibiotic therapy - be sure to

complete all medication.

Streptococcal Prophylaxis for the Child with Rheumatic

Fever

Damaged valves can become further damaged with repeated infections

Streptococcal prophylaxis is lifelong if there is actual valve involvement

Intramuscular penicillin, administered monthly, is the drug of choice

Alternatives include oral penicillin twice daily or oral sulfadiazine once a day

Multisystem vasculitis – inflammation of blood vessels in the body especially the coronary arteries with antigen-antibody

complexes.

Kawasaki Disease Signs and Symptoms / Treatment

Three Phases of clinical manifestations: Acute Subacute Convalesant

One of the most common symptoms used to diagnose Kawasaki disease is a high spiking fever over 1020 for 5 days.

Acute Phase – 10-14 days Fever, which often is higher than 101.3 F,

and lasts one to two weeks Extremely red eyes (conjunctivitis) without thick discharge Red, dry, cracked lips and an extremely

red, swollen tongue ("strawberry" tongue) A rash on the main part of the body

(trunk) and in the genital area Swollen, erythema on the palms of the

hands and the soles of the feet Swollen cervical lymph nodes

Subacute Phase 15-25 days Irritability

Anorexia

Desquamation of the skin on the hands and feet, especially the tips of the fingers and toes, often in large sheets

Arthritis and Arthralgia

Arrhythmias

Coronary aneurysms

Convalescent Phase

From day 26 until the erythrocyte sedimentation rate returns to normal

Nursing Care Give Medications

Aspirin Intravenous Immunoglobulin

Promote comfort Lubricate the lips Cool compresses Keep skin cool and dry Small feedings of soft foods and liquids

that are not too hot or too cold. Facilitate joint movement

Passive Range of Motion exercises

Kawasaki Disease

Which phase of Kawasaki is this child exhibiting?

Inflamed, Cracked, Peeling Lips

Strawberry tongue

Kawasaki Disease