module 5 – pediatric cardiac disorders revised, summer 2008
TRANSCRIPT
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Module 5 – Pediatric Cardiac Disorders
Revised, Summer 2008
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Fetal Circulation
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Changes in Circulation
Umbilical cord clamped
Pulmonary
Pressure
Pulmonary resistance
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Critical thinking:
When are most cardiac anomalies discovered?
What is included in the initial cardiac assessment of a newborn?
Why?
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Assessment
History
Physical
Diagnostic
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Importance of the Nurse Knowing Normal Value for O2 Saturations
Children respond to severe hypoxemia with BRADYCARDIA
Cardiac arrest in children generally r/t prolonged hypoxemia
Hypoxemia is r/t to respiratory failure or shock
BRADYCARDIA is a significant warning sign of cardiac arrest
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Congestive Heart Failure
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Clinical Manifestations
Pump Fails – cannot meet the demands of the body = CHFHow do you know when something is
wrong?
1. Tires easily during feeding2. Periorbital edema, weight gain3. Rales and rhonchi4. Dyspnea, orthopnea, tachypnea5. Diaphoretic / sweating6. Tachycardia7. Weight
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Goal of Treatment:
Improve cardiac function
Remove accumulated fluid and Na+
Decrease cardiac demands
Decrease O2 consumption
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Medications:
Digoxin –what do we assess prior to administration?
Which VS? Weigh diapers for strict I & O
Double check Digoxin levels Parent teaching Digitalis toxicity
ACE inhibitors Capoten (Captoril) Vasotec
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Medications continued…
Furosemide (Lasix) Chlorothiazide (Diuril) Zarozolyn (Thiazide type) Spironolactone (Aldactone)
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Nursing care
Reduce metabolic needs
Diet therapy
Decrease Cardiac Demands
Improve tissue oxygenation
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Congenital Cardiac Anomalies
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Classifying congenital heart defects
By defects that increase pulmonary blood flow Patent ductus arteriosus Atrial septal defect Ventricular septal defect
By defects that decrease blood flow and mixed defects Pulmonic stenosis Tetralogy of Fallot Tricuspid atresia Transposition of the great arteries Truncus arteriosus
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Signs & Symptoms
What is most common indication of a congenital heart defect?
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Cardiac catheterizations
Used to determine anomalies Measures O2 sats in cardiac chambers
and great arteries Evaluates cardiac output Identify detailed images of blood flow
patterns May allow for corrective or palliative
measures
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Nursing interventions pre and post cardiac catheterization
Assessment pre-op for baselines Assessment post-op:
Vital signs (which ones are priority?) Extremities Activity Hydration Medications Comfort measures
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Teaching after cardiac catheterization
Parental teaching Watch for s/s of bleeding, bruising at
site Foot temp on side of cath cooler Loss of sensation in foot on side of
cath When to call the physician
If any of above s/s noted within 1st 24 hrs
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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
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Treatment
Medical Management Medication
Indomethacin
Surgical
____Ligate the ductus arteriosus
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Nursing Care:
Pre-op Patient/parent teaching Assess for infection
Obtain lab values for chart Post-op
ABCs Rest Hydration/nutrition Prevent complications Discharge teaching
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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
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Treatment
Medical Management
Medications – digoxin
Surgical repair
Suture or simple patch
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Treatment
Device Closure – Amplatzer septal occluder
During cardiac catheterization the occluder is placed in the Defect
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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
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Treatment
Surgical repair with a patch inserted
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Obstructive or Stenotic Defects
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Pulmonic or Aortic Stenosis
Narrowing of entrance that decreases blood flow
Treatment: Medications – Prostaglandins to keep
the PDA open Cardiac Catheterization
Balloon Valvuloplasty Surgery
Valvotomy
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Coarctation of the Aorta1. Narrowing of Aorta causing
obstruction of left ventricular blood flow
2. Left ventricular hypertrophy
Signs and Symptoms
11 B/P in upper extremities
11 B/P in lower extremities
3. Radial pulses full/bounding and femoral or popliteal pulses weak or absent
4. Leg pains, fatigue
5. Nose bleeds
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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 (and maintain it in an open state) allowing blood flow to areas beyond the coarctation.
Balloon dilation Surgery
Resect narrow
area
Anastomosis
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Cyanotic Disorders
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Tetralogy of Fallot1. Four defects with right
to left shunting
Signs and Symptoms
1. Failure to thrive
2. Lack of energy
3. Infections
4. Polycythemia
5. Clubbing of fingers
6. Squatting
7. Cerebral absess
8. Cardiomegaly
9. Cyanosis
1.
2
3
4
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Treatment
Surgical interventions Blalock – Taussig or Potts procedure –
increases blood flow to the lungs.
Open heart surgery
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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
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Mixed blood flow
Survival depends upon mixing of blood from pulmonic and systemic circulation
Cyanotic Disorders:
Truncus arteriosus
Hypoplastic left heart
Transposition of the great arteries
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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.
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Hypoplastic heart
May have various left-sided defects, including coarctation of the aorta, aortic valve & mitral valve stenosis or artresia
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Transposition of Great Vessels
Aorta arises from the right ventricle, and the pulmonary artery arises from the left ventricle –
not compatible with survival unless there is a large defect present in ventricular or atrial septum.
aorta
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Nursing Diagnosis & Goals:
DX: Alteration in cardiac output: decrease R/T heart malformation
Goal: Child will maintain adequate cardiac output AEB:
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Nursing Care:
Monitor VS I&O Medications Position Metabolic rest Assess and document
child/family interactions Parent teaching
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Acquired Cardiac Diseases
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Kawasaki Disease
Mucocutaneous lymph node syndrome
Not contagious Preceded by upper respiratory
tract infection Cause unknown
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Clinical Manifestations:
Acute Phase- 10-14 days
Subacute Phase 10-25 days
Convalescent Phase 25-60 days
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Diagnosis:
ECG CBC, WBC PT ESR SGOT, SGPT IgA, IgG and IgM
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Nursing Care:
Medication Therapy Aspirin Gamma Globulin
Nursing Interventions Assess/monitor Decrease stimulation Comfort measures Discharge teaching
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Rheumatic Fever
Systemic inflammatory disease
Follows group A beta-hemolytic streptococcus infection
Causes changes in the entire heart especially the valves
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Clinical Manifestations
Jones Criteria
Major
Minor
Supporting Evidence
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Therapeutic Intervention
Medication long term prophylaxis
Nursing Prevention Parent teaching (ANTIBIOTICS)
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Subacute Bacterial Endocarditis
Infectious disease involving abnormal cardiac tissue:
Usually rheumatic lesions or congenital defects
Infection may invade adjacent tissues- aortic and mitral valves
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Clinical Manifestations:
Onset insidious Fever Lethargy/general malaise Anorexia Splenomegaly Retinal hemorrhages Heart murmur –90%
Diagnosis- positive blood cultures
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Nursing Care
Medication-large doses antibiotic
Bed rest
Teach to notify dentist prior to dental work
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Principles that apply to all cardiac conditions:
Encourage normal growth and development
Counsel parents to avoid overprotection
Address parents’ concerns and anxieties
Educate parents about conditions, tests, planned treatments, medications
Assist parents in developing ability to assess child’s physical status
‘ The Pedi-Cardiac Lecture ’ Part 2 Pediatric Cardiovascular Disorders Jerry Carley MSN, MA, RN, CNE
‘ The Pedi-Cardiac Lecture ’ Part 1 Pediatric Cardiovascular Disorders Jerry Carley MSN, MA, RN, CNE