‘ The Pedi-Cardiac Lecture ’ Part 1

Pediatric Cardiovascular DisordersJerry Carley MSN, MA, RN, CNE

Concept Map: Pediatric Cardiac Conditions

Concept Map: Pediatric Cardiac Conditions ( Congenital )

Cyanotic AcyanoticVS

Left to right shunt ( R L )Right to left shunt ( R L )

Concept Map: Pediatric Cardiac Conditions ( Acquired )

Focused Health History

Family history of defects / early cardiac disease / siblings with defects

Maternal history of stillborns or miscarriages Congenital anomalies / genetic anomalies /

fetal alcohol syndrome / Down Syndrome and Turner Syndrome

Maternal exposure to rubella Prenatal diagnosis the key to treatment of

CHD http://www.youtube.com/watch?v=PjxjvEB1w_I&noredirect=1

Focused Health History

Heart murmur Tires while eating Low weight for height Sweats while eating (diaphoretic) Cyanosis, worsens with feeding or activity

level Irritable weak cry

Focused Health History

In the older child additional symptoms may include: Chest pain Decreased activity level Syncope Slight of build

Focused Physical Assessment

General appearance Integumentary system Face, nose, and oral cavity Thorax and lung Cardiovascular system

Review: Heart Sounds

Review: Heart Murmurs

These sounds are produced by blood passing through a defective valve, great vessel, or other heart structure.

Murmurs are classified by: intensity, location, radiation, timing, and quality.

Pulses

Assessment Alert: Weaker pulses or lower blood pressure in the

lower extremities may indicate coarctation of the aorta (COA)

Bounding pulses can indicate a patent ductus arteriosus (PDA) or aortic insufficiency.

Vital Signs

Heart rate: tachycardia in the absence of fever, crying, or stress may indicate cardiac pathology.

Tachypnea, even with rest, chest retractions indicate respiratory distress, possibly resulting from congestive heart failure

Review: Fetal Circulation

At First Breath

• Pulmonary alveoli open up• Pressure in pulmonary tissues decreases• Blood from the right heart rushes to fill the

alveolar capillaries• Pressure in right side of heart decreases• Pressure in left side of heart increases• Pressure increases in aorta

Treatment Modalities

Palliative procedures Pulmonary artery banding Shunts Corrective procedures

Diagnostic Testing

Chest x-ray to define silhouette of the heart. Heart size, shape, pulmonary markings, and

cardiomegaly. Electrocardiogram ECG or EKG to define

electrical activity of the heart. Echo-cardiogram to visualize anatomic

structures.

Non-invasive

Cardiac Conduction

Echo-Cardiogram

Cardiac Catheterization

An invasive test to diagnose or treat cardiac defects. Visualizes heart and vessels. Measures oxygen saturation of chambers. Measures intra-cardiac pressures. Determines muscle function and pumping action

of the heart.

CardiacCatheterization

Diagnostics: Potential Toxicity to Dye Watch for signs of toxicity due to the dye

used during the procedure*

Increased temperature Urticaria Wheezing Edema Dyspnea Headache *Allergy response

Pre-cardiac Catheterization

Assess vital signs with blood pressure. Hemoglobin and hematocrit Pedal pulses NPO Hold digoxin IV if child is polycythemic

Post-cardiac Catheterization

Vital signs, with apical pulse and blood pressure (at leaST) q 15 minutes for first hour.

Apical pulse for 1 minute to check for bradycardia or dysrhythmias.

Post-cardiac Catheterization

Assess pulses DISTAL to the cath insertion site.

Record quality and symmetry of pulses. Assess temperature and color of affected

extremity. Check dressing for bleeding or hematoma

formation.

Home Care Instructions

Keep dressing in place for 24 hours. Keep site dry and clean. Observe site for redness, swelling, drainage,

or bleeding. Check temperature. Avoid strenuous exercise. Acetaminophen for pain. Keep follow-up appointment Pre-procedure medications as ordered.

Pressures

100-110 mm Hg Normal child50-60 mm Hg Preterm infant65-80 mm Hg Full term infant

Right Heart=Low Pressure SystemLeft Heart=High Pressure System

Left to Right Shunt ( R L ) Here, it is all about pressure gradients Pressures on the left side of the heart are

normally higher than the pressures in the right side of the heart.

If there is an abnormal opening in the septum between the right and left sides, blood flows (and is forced) from left to the right.

Left to Right Shunt

LeftRight

Clinical Manifestations

The infant is not cyanotic.

Tachycardia due to pushing increased blood volume.

Cardiomegaly due to increased workload of the heart.

Clinical Manifestations

Dyspnea and pulmonary edema due to the lungs receiving blood under high pressure from the right ventricle.

Increased number of respiratory infections due to blood pooling in the the lungs promoting bacterial growth.

Right to Left Shunts ( R L ) Occurs when pressure in the right side of the heart

is greater than the left side of the heart. Resistance of the lungs in abnormally high Pulmonary artery is restricted

Deoxygenated blood from the right side shunts to the left side

Right to Left Shunt

Hole in septum + obstructive lesion

Deoxygenated blood from the right side of the heart shunts to the left side of the heart and out into the body.

Clinical Manifestations R L Hypoxemia = the result of decreased tissue

oxygenation. (“CYANOTIC”) Polycythemia = increased red blood cell

production due to the body’s attempt to compensate for the prolonged hypoxemia.

(Normal RBC Count for 6 month-1 year old ~3,500,000-5,200,000 /µl)

Increase viscosity of the blood = heart has to pump harder.

Potential Complications

Thrombus formation due to sluggish circulation.

Brain abscess or stroke due to the un-oxygenated blood bypassing the filtering system of the lungs.

Heart Failure

Major manifestation of heart disease

Under 1 year of age usually due to congenital anomaly (CHD)

Over 1 year with no congenital anomaly may be due to acquired heart disease

Signs&

Symptoms Of

CongenitalHeart

Disease(CHD)

Murmurs

Acyanotic

Cyanotic

Heart Failure

Left to Right Shunt

Two Causes:1. pulmonary Blood Flow2.Mixing of pulmonary & venous return ( Right to Left Shunt )

S/S CHF:-Failure to Thrive (FTT)-Cardiomegaly-Edema-Hepatomegaly-Tachypnea-Tachycardia-Weight Gain

Dependent upon structure(s) effected

versus

R L

L

R

Clinical Manifestations of HF

Systemic Venous Congestion Weight gain, hepatomegaly, edema, jugular vein

distension Pulmonary Venous Congestion

Tachypnea, dyspnea, cough, wheezes Compensatory Response

Tachycardia, cardiomegaly, diaphoretic, fatigue, failure to grow (FTT)

Digoxin Therapy

Digoxin increases the force of the myocardial contraction ( + inotropic, - chronotropic). Take an apical pulse with a stethoscope for 1 full

minute before every dose of digoxin. If bradycardia is detected* < 100 beats / min for infant and toddler < 80 beats in the older child < 60 beats in the adolescent

* Call / advise primary provider before administering the drug.

Signs of Digoxin Toxicity

Bradycardia Arrhythmia Nausea, vomiting, anorexia Dizziness, headache Weakness and fatigue

Interventions Fluid restriction Diuretics – Lasix (potassium wasting) or

Aldactone (potassium sparing) Bed rest Oxygen Small frequent feedings – soft nipple with

supplemental gavage for adequate calorie intake

Pulse oximetry Sedatives if needed

Feeding

Small frequent feedings Soft nipple to easy energy needed to suck 24 kcal formula for added calories NG feed if not taking in adequate calories to

gain weight

End of Part 1