Module 5 Pediatric Cardiac Disorders

Fetal Circulation

Fetal Circulation

Fetal Circulation What is the stimulus for the change in circulation?

Intrauterine to Extrauterine

Oxygen SaturationWhat 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 heart?

Congestive heart failureWhat is the effect on: Heart rate Preload Contractitility Afterload

Congestive Heart Failure

Why does the pump fail?

Etiology and Pathophysiology

Congestive Heart FailureWhat does the body do to compensate for this congestion and heart failure?

Compensatory MechanismsWith 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 MechanismsWith 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 CHFThe earliest signs are often subtle:

Infant will have mild resting tachypnea

Increasing difficulty feeding

Signs and SymptomsPulmonary congestionTires easily during feedingTachypnea, Dyspnea, orthopneaSigns of respiratory distressWheezing, rales and rhonchiEasily fatigueImpaired cardiac outputTachycardiaExtremities cool, capillary refill >2 secondsDiaphoretic, sweating, hypotension

Signs and SymptomsSystemic venous congestionHepatomegalyEdemaWeight gain

High metabolic rateFailure to thriveSlow weight gain

Goal of Treatment

Treatment of Congestive Heart Failure

Medication TherapyDigitalis increases contractility and decreases heart rate. ACE-inhibitors - blocks release of angiotension-aldosterone; arterial vasodilator / afterload reducing agentDiuretics - enhance renal secretion of sodium and water by reducing circulating blood volume and decreasing preload, pulmonary congestion. Beta Blocker - increases contractility

Nursing CareWhat are the pulse rate criteria in administration of digitalis?

Digitalis DigitalizationGiven in divided dosesMaintenanceGiven daily, usually in two divided doses

Therapeutic vs. ToxicityTherapeutic range 0.8 to 2.0 ng/mlToxicity**EKG changes arrhythmiaSlow pulse- bradycardiaVomiting very rare in infants

DigitalisWhy 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 CHFFeed 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 infants work

Cardiac CatheterizationMeasure oxygen saturations and pressure in the cardiac chambers and great arteries

Evaluate cardiac output

Cardiac CatheterizationThis 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 CatheterizationPre-care: History and Physical Lab work EKG, ECHO cardiogram, CBC NPO Vital signs Preprocedural teaching

Best Nursing ActionDuring 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 Anomalies

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

Answer: an audible heart murmur

Patent Ductus ArteriousAtrial septal defectsVentricle septal defects

Atrial Septal DefectOxygenated blood is shunted from left to right side of the heart via defectA larger volume of blood than normal must be handled by the right side of the heart hypertrophy 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

TreatmentMedical ManagementMedications digoxin

Cardiac Catheterizaton - Amplatzer septal occluder

Open-heart Surgery

TreatmentDevice Closure Amplatzer septal occluder During cardiac catheterization the occluder is placed in the Defect

Ventricle Septal DefectOxygenated blood is shunted from left to right side of the heart via defectA larger volume of blood than normal must be handled by the right side of the heart hypertrophy 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

TreatmentSurgical repair with a patch inserted

Patent Ductus ArteriosusBlood shunts from aorta (left) to the pulmonary artery (right)Returns to the lungs causing increase pressure in the lungCongestive heart failure

Treatment for PDA Medical ManagementMedication Indomethacin - inhibits prostaglandin's . (When levels of prostaglandins are decreased, the ductus closes)

SurgeryLigate the ductus arteriosus

Treatment for PDACardiac 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 StenosisNarrowing of entrance that decreases blood flow Increases preload causes right ventricular hypertrophy

Obstructive or Stenotic LesionsTreatment:Medications Prostaglandins to keep the PDA open

Cardiac CatheterizationBaloon Valvuloplasty

SurgeryValvotomy

Aortic StenosisThe 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 StenosisSymptomsPoor peripheral perfusion, feeding difficulties, CHF

TreatmentBalloon valvoplastySurgery

Coarctation of the AortaNarrowing of Aorta causing obstruction of left ventricular blood flowLeft ventricular hypertrophy

Signs and SymptomsWhat are B/P findings support the diagnosis? What is different in the pulses?

Why would the patient C/O leg pains?

What causes nose bleeds?

TreatmentGoals of management are to improve ventricular function and restore blood flow to the lower body. Medical management with MedicationA continuous intravenousmedication, prostaglandin (PGE-1), is used to open the ductus arteriosus allowing blood flow to areas beyond the coarctation.

Baloon Valvoplasty

Surgery for Coarctation of Aorta1. Resect narrow area 2. Anastomosis

Tetralogy of fallot

Tetralogy of Fallot Four defects are:1.2.3.4.

Signs and SymptomsFailure to thriveSquattingLack of energyInfectionsPolycythemiaClubbing of fingersCerebral abscessCardiomegaly

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 spellsCyanosis 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

TreatmentOpen-heart Surgical interventionsBlalock Taussig or Potts procedure increases blood flow to the lungs.

View the Movie TrailerAbout Blalock procedure to treat Tetralogy of fallotSomething the Lord Made

Truncus ArteriosusTransportation of Great Vessels

These present the greatest risk to survival

Truncus arteriosusA 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 VesselsAorta 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.

arteryaorta

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:FeverFatigueMuscle and joint painHeadacheNausea and vomitingCHFSpleenomegalyDiagnosis:Blood culturesEchocardiogram

Infective EndocarditisDiagnosis

Blood cultures

EchocardiogramShow the vegetationWho 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 EndocarditisDental 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 EndocarditisTreatmentMonitor temperatureAntibiotics 2-8 weeks

Patient teaching Good oral hygienetake 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 - AssessmentMajorCarditisPolyarthritisChoreaErythema marginatumSubcutaneous nodules

MinorArthralgiaFeverLaboratory Findings: Erythrocyte sedimentation rate C-reactive proteinProlonged PR interval Jones Criteria

Rheumatic FeverTreatmentAntibiotic TherapyAntipyretics - aspirinAnti-inflammatory agents steroidsRest Heat and cold to joints

Discharge TeachingAntibiotic therapy - be sure to complete all medication.

Streptococcal Prophylaxis for the Child with Rheumatic FeverDamaged 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 / TreatmentThree Phases of clinical manifestations:AcuteSubacuteConvalesant

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 daysFever, which often is higher than 101.3 F, and lasts one to two weeksExtremely red eyes (conjunctivitis) without thick dischargeRed, 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 areaSwollen, erythema on the palms of the hands and the soles of the feetSwollen cervical lymph nodes

Subacute Phase 15-25 daysIrritability

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 PhaseFrom day 26 until the erythrocyte sedimentation rate returns to normal

Nursing CareGive MedicationsAspirinIntravenous ImmunoglobulinPromote comfortLubricate the lipsCool compresses Keep skin cool and drySmall feedings of soft foods and liquids that are not too hot or too cold.Facilitate joint movementPassive Range of Motion exercises

Kawasaki DiseaseWhich phase of Kawasaki is this child exhibiting? Inflamed, Cracked, Peeling LipsStrawberry tongue

Kawasaki Disease

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