Care of a Child With Cardiovascular Dysfunction

Care of a Child with Cardiovascular Dysfunction

Carla Renee Diebold, MSN, RN

Fetal and Postnatal Circulation

Basic Cardiac Physiology

Basic Heart Function Provide oxygenated blood to meet body’s demands

Adequate Cardiac Output CO = HR x SV

SV is affected by Preload Afterload Contractility (decreased perfusion, urine output)

HR is affects by Sympathetic Nervous System (increase) Parasympathetic Nervous System (decrease)

Assessment of Cardiac Function

Accurate History Feeding habits Fast breathing Sweating with feeds Irritability Pale Maternal history (mothers with diabetes and lupus

have an increased risk of having a child with a CHD), drugs (Dilantin), infection (rubella)

Family history of CHD. The onset and frequency of color changes (cyanosis) With older children this includes activity intolerance,

edema, respiratory problems, chest pain, palpitations, recent infections

Assessment of Cardiac Function

Physical Assessment Physical Examination

Vital Signs Apical for one minute Abnormal HR and RR can be indicative of cardiac disease Bounding pulses in UE and weak pulses in LE with a SBP

difference can indicate a Coarctation of the Aorta Skin color

Presence of cyanosis. Quality and symmetry of all pulses Edema Capillary refill (<2 seconds) Auscultate heart murmurs

Aortic valve – 2nd R ICS R sternal border Pulmonic valve – 2nd L ICS L sternal border

Tests of Cardiac Function

Chest X-Ray Electrocardiography Echocardiography Cardiac Catheterization


Cardiac Catheterization Provides

Oxygen saturation of blood within chambers and great vessels

Pressure changes within these structures Cardiac output and stroke volume

Interventional Cardiac Catheterization Treat heart disease

Transposition of great vessels Some complex single-ventricle defects ASD Pulmonary artery stenosis


Cardiac Catheterization Nursing Care Management

Preprocedural Complete Nursing Assessment Accurate height and weight Allergies (iodine based) Signs & symptoms of infection Mark and assess pedal and posterior tibial pulses Baseline oxygen saturation level Prepare family and child appropriately (expected

length of procedure and child’s appearance and expected postprocedural care)

NPO



Postprocedural Care PACU or ICU Cardiac monitor and pulse ox Pulses for equality and symmetry (may be weaker on

the affected side but should improve) Temperature and color of affected extremity Vital Signs every 15 minutes (HR and arrhythmias) Blood pressure (watch for hypotension) Dressing (if bleeding, apply pressure 1 inch above

puncture site) Fluid Intake (clears advance as tolerated)



Postprocedural Care Affected extremity straight 4-6 hours for venous and 6-8

hours for arterial Pain control

Home Care Management Remove dressing day after catheterization and cover with

band aid for several days Keep site clean and dry Observe for fever, bleeding, redness, swelling, drainage

and notify practitioner Avoid strenuous activity Regular diet Tylenol or ibuprofen for pain.

QUESTION????

Mothers with chronic conditions like diabetes and lupus erythematosus are more likely to have infants with what condition????

QUESTION????

Which of the following terms is defined as the volume of blood ejected by the heart in 1 minute? Afterload Cardiac cycle Stroke volume Cardiac output

QUESTION????

A chest x-ray examination is ordered for a child with suspected cardiac problems. The child’s parent asks the nurse, “What will the x-ray show about the heart?” The nurse’s response should be based on knowledge that the x-ray film will do which of the following? Show bones of chest but not the heart Evaluate the vascular anatomy outside of the heart Show a graphic measure of electrical activity of the

heart Provide information on heart size and pulmonary blood

flow patterns

QUESTION????

The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is “too wet.” The nurse finds the bandage and bed soaked with blood. The most appropriate initial nursing action is which of the following? Notify physician. Place child in Trendelenburg position. Apply new bandage with more pressure. Apply direct pressure above catheterization

site.

Cardiac Defects

Congenital Anatomic → abnormal function

Acquired Disease process

Infection Autoimmune response Environmental factors Familial tendencies

Clinical Consequences of CHD

Congestive Heart Failure Hypoxemia

Congestive Heart Failure (CHF)

CHF occurs with the following changes Volume overload Pressure overload Decreased contractility High cardiac output demands


The inability of the heart to meet the body’s demands causes the heart to compensate through Hypertrophy and dilation of the cardiac muscle Stimulation of the sympathetic nervous system


Hypertrophy and dilation of the cardiac muscle In response to increased needs, the muscle

hypertrophies Becomes less compliant and will require a

higher fill pressure to produce the same stroke volume

As the dilation increases, contractility decreases and the heart fails.


Stimulation of the Sympathetic Nervous System As CO decreases the SNS releases catecholamines to

increased HR and force of contractions. Peripheral vasoconstriction which increases systemic

vascular resistance decreases blood flow to limbs and kidneys.

Prolonged catecholamine release can decrease diastolic filling time

Increased afterload causes an increased work load on the heart.

Renal system activates renin-angiotensin-aldosterone mechanism which vasoconstricts and holds sodium and water to increase preload which can lead to venous congestion and fluid overload


Clinical Manifestation of CHF As compensatory mechanism fail, clinical

manifestations include Impaired myocardial function Pulmonary Congestion Systemic Venous Congestion


Diagnostic Evaluation of CHF Clinical Symptoms

Tachypnea at rest Tachycardia at rest Retractions Activity Intolerance (especially with feeding) Weight gain caused by fluid retention Hepatomegaly


Therapeutic Management of CHF Goals of Treatment are:

Improve Cardiac Function (increase contractility and decrease afterload)

Remove accumulated fluid and sodium (decrease preload)

Decrease Cardiac Demands Improve Tissue Oxygenation and decrease

Oxygen Consumption


Improve Cardiac Function Two Drugs are used

Digitalis Glycosides (improves contractions) Angiotensin-Converting Enzyme (ACE) Inhibitors

(decreased afterload)


Remove accumulated fluid and sodium Administer diuretics Possible fluid restrictions Possible sodium restrictions


Decrease Cardiac Demands Metabolic needs are decreased by

Providing a neutral thermal environment to prevent cold stress in infants

Treating any existing infections Reducing work of breathing by using semi-

fowlers positioning Using medications to sedate an irritable child Provide rest by decreasing environmental stimuli


Improve Tissue Oxygenation All of the previous measures improve tissue

oxygenation. Additional measures include

Supplemental oxygen (vasodilator to decrease pulmonary vascular resistance ) Must have an order.


Nursing Care and Management of CHF Assist in Measures to Improve Cardiac Function Reduce Afterload Decrease Cardiac Demands Reduce Respiratory Distress Maintain Nutritional Status Assist in Measures to Promote Fluid Loss Support the Child and Family

Hypoxemia

Hypoxemia is a low arterial oxygen saturation level or PaO2 and results from the presence of deoxygenated hemoglobin.

Cyanosis is usually present when saturation is less than 85% and is a blue discoloration of the mucous membranes, skin, and nail beds.

Children with severe anemia may not be cyanotic despite severe cyanosis.

Hypoxemia occurs when desaturated venous blood enters the systemic circulation without passing through the lungs.

Hypoxemia

Three types of defects cause cyanosis Severe obstruction to pulmonary blood flow

and blood flow shunting from right to left side of the heart (Tetrology of Fallot)

Mixing of arterial and venous blood within the heart (hypoplastic left heart)

Transposition of the great arteries

Hypoxemia

Clinical Manifestations Two changes occur in response to chronic hypoxemia

Polycythemia Clubbing of the fingers

Additional Clinical Manifestations Extreme fatigue with feedings Poor weight gain Tachypnea Flaccidity Poor Perfusion Hypercyanotic spells (blue or tet spells)

Hypoxemia

Diagnostic Evaluation Newborns with cyanosis are placed on 100%

oxygen If PaO2 is > or = 100, then suggests lung disease If PaO2 is < or = 100, then suggests cardiac

disease Chest X-Ray Echocardiogram

Hypoxemia

Therapeutic Management Administer Prostaglandin E to keep ductus arteriosus patent Keep patient well hydrated to decrease risk of CVA Monitor and treat fevers (endocarditis) Watch for respiratory infections Treat hypercyanotic spells

Knee-chest position Calm patient Administer morphine (decrease spasm) 100% oxygen IV fluid replacement to decrease viscosity

Palliative Surgery Blalock-Taussig (BT) or modified BT shunt

Hypoxemia

Nursing Care and Management Watch body image concerns, especially with

adolescents Explain child’s condition to parents with

attention to cyanosis and hypercyanotic spells Prevent dehydration to decrease risk of CVA Assess and prevent respiratory infections Supplemental oxygen IV lines should have air filters

QUESTIONS ????

The nurse finds that a 6-month-old infant has an apical pulse of 166 beats/min during sleep. The nurse should do which of the following? Administer oxygen. Record data on nurses’ notes. Report data to the practitioner Place child in high Fowler position.

QUESTIONS ????

A 2-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than which of the following? 60 beats/min 90 beats/min 100 beats/min 120 beats/min

QUESTIONS ????

The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes that a risk exists of cerebrovascular accidents (strokes). Which of the following is an important objective to decrease this risk? Minimize seizures. Prevent dehydration. Promote cardiac output. Reduce energy expenditure.

Congenital Heart Defects (CHD)

Older Classifications of CHD Acyanotic

May become cyanotic Cyanotic

May be pink May develop CHF


Newer Classifications of CHD Hemodynamic characteristics

Increased pulmonary blood flow Decreased pulmonary blood flow Obstruction of blood flow out of the heart Mixed blood flow


Classifications Defects with Increased Pulmonary Blood Flow

CHF Obstructive Defects

Left-sided – CHF Right-sided - Cyanosis

Defects with Decreased Pulmonary Blood Flow Cyanosis

Mixed Defects CHF and/or cyanosis


Defects with Increased Pulmonary Blood Flow Atrial Septal Defect (ASD) Ventricular Septal Defect (VSD) Atrioventricular Canal Defect Patent Ductus Arteriosus (PDA)


ASD Abnormal opening

between the atria, allowing blood to flow from the left atrium to the right atrium


VSD Abnormal opening

between the ventricles allowing blood to flow from the left ventricle to the right ventricle


Atrioventricular Canal Defect Incomplete

development of endocardial cushion that consists of a low ASD, high VSD and clefts of the mitral and tricuspid valve.


PDA Failure of the fetal

ductus arteriosus (connection between aorta and pulmonary artery) to close within the first weeks of life.


Obstructive Defects Coarctation of the Aorta (COA) Aortic Stenosis (AS) Pulmonic Stenosis (PS)


COA Narrowing in the aorta

near the insertion of the ductus arteriosus.


AS Narrowing or stricture

of the aortic valve. Narrowing can occur

above the valve (supravalvular), below the valve (subvalvular) or at the valve (valvular).


PS Narrowing at the

entrance to the pulmonary artery.

Pulmonary atresia is an extreme form of PS that has a complete fusion of pulmonic valve with no blood flow to the lungs.


Defects with Decreased Pulmonary Blood Flow Tetrology of Fallot (TOF) Tricuspid Atresia (TA)


TOF Contain four defects

VSD PS Overriding Aorta RV Hypertrophy


TA Tricuspid valve fails to

develop leaving no communication between the right atrium and right ventricle.


Mixed Defects Transposition of the Great Arteries of Great

Vessels (TGA) Total Anomalous Pulmonary Venous

Connection (TAPVC) Truncus Arteriosus Hypoplastic Left Heart Syndrome (HLHS)


TGA The PA leaves the RV

and connects to the aorta leaving no communication between systemic and pulmonary circulations.


TAPVC Rare defect that is

characterized by the failure of the pulmonary veins to connect to the LA. The pulmonary veins connect to or are directed to the RA.


Truncus Arteriosus Pulmonary artery and

aorta are formed together and leave the heart as one vessel.

A large VSD is present.


HLHS Underdevelopment of

the left side of the heart which includes a hypoplastic left ventricle and aortic atresia.


Nursing Care of the Child with CHD and the Family Help the family Adjust to the Disorder Educate the family About the Disorder Help the Family Manage the illness at home Prepare the child and family for invasive

procedures Provided Postoperative Care


Postoperative Care Observe Vital Signs and arterial and venous

pressures Maintain respiratory status Provide maximum rest Provide comfort Monitor fluids Plan for progressive Activity Observe for complications of Cardiac surgery Provide Emotional Support


Observe for complications of Cardiac surgery Cardiac Changes Pulmonary Changes Neurologic Changes Infection Hematologic Changes Postpericardiotomy Syndrome

Observe for complications of Cardiac surgery Plan for discharge home

Begin at admission Medication teaching Activity restrictions Nutrition Bacterial endocarditis prophylaxis Follow-up appointments

Acquired Cardiovascular Disorders

Bacterial (Infective) Endocarditis – infection of the valves or inner lining of the heart Pathophysiology Clinical Manifestations Diagnostic Evaluation Therapeutic Management Nursing Care management


Rheumatic Fever (RF) –inflammatory disease that occurs after pharyngitis caused by strep. Etiology Pathophysiology Clinical Manifestations Diagnostic Evaluation Therapeutic Management Nursing Care Management


Kawasaki’s Disease – acute systemic vasculitis of unknown cause Pathophysiology Clinical Manifestations Diagnostic Evaluation Therapeutic Management Nursing Care Management

Kawasaki Disease Treatment

IV IgG ASA 80-100 mg/kg/day—fever

Then 3-5 mg/kg/day—antiplatelet

QUESTIONS ????

A cardiac defect that allows blood to shunt from the (high pressure) left side of the heart to the (lower pressure) right side can result in: Cyanosis Congestive heart failure Decreased pulmonary blood flow Bounding pulses in upper extremities

QUESTIONS !!!!!

The physician suggests that surgery be performed for patent ductus arteriosus (PDA) to prevent which of the following complications? Hypoxemia Right-to-left shunt of blood Decreased workload on left side of heart Pulmonary vascular congestion

QUESTIONS ????

A parent of a 7-year-old girl with a repaired ventricular septal defect calls the cardiology clinic and reports that the child is just not herself. Her appetite is decreased, she has had intermittent fevers around 38o C, and now her muscles and joints ache. Based on this information you advise the mother to: Immediately bring the child to clinic for evaluation. Come to the clinic the next week on a scheduled

appointment. Treat the symptoms with acetaminophen and fluids,

since it is most likely a viral illness Recognize that the child is trying to manipulate the

parent by complaining of vague symptoms.

Care of a Child With Cardiovascular Dysfunction

Documents

Transcript of Care of a Child With Cardiovascular Dysfunction