Module 5 – Pediatric Cardiac Disorders

Revised, Summer 2008

Fetal Circulation

Changes in Circulation

Umbilical cord clamped

Pulmonary

Pressure

Pulmonary resistance

Critical thinking:

When are most cardiac anomalies discovered?

What is included in the initial cardiac assessment of a newborn?

Why?

Assessment

History

Physical

Diagnostic

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

Congestive Heart Failure

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

Goal of Treatment:

Improve cardiac function

Remove accumulated fluid and Na+

Decrease cardiac demands

Decrease O2 consumption

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

Medications continued…

Furosemide (Lasix) Chlorothiazide (Diuril) Zarozolyn (Thiazide type) Spironolactone (Aldactone)

Nursing care

Reduce metabolic needs

Diet therapy

Decrease Cardiac Demands

Improve tissue oxygenation

Congenital Cardiac Anomalies

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

Signs & Symptoms

What is most common indication of a congenital heart defect?

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

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

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

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

Medical Management Medication

Indomethacin

Surgical

____Ligate the ductus arteriosus

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

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

Surgical repair

Suture or simple patch

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

Obstructive or Stenotic Defects

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

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

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

Cyanotic Disorders

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

Treatment

Surgical interventions Blalock – Taussig or Potts procedure –

increases blood flow to the lungs.

Open heart surgery

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

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

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.

Hypoplastic heart

May have various left-sided defects, including coarctation of the aorta, aortic valve & mitral valve stenosis or artresia

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

Nursing Diagnosis & Goals:

DX: Alteration in cardiac output: decrease R/T heart malformation

Goal: Child will maintain adequate cardiac output AEB:

Nursing Care:

Monitor VS I&O Medications Position Metabolic rest Assess and document

child/family interactions Parent teaching

Acquired Cardiac Diseases

Kawasaki Disease

Mucocutaneous lymph node syndrome

Not contagious Preceded by upper respiratory

tract infection Cause unknown

Clinical Manifestations:

Acute Phase- 10-14 days

Subacute Phase 10-25 days

Convalescent Phase 25-60 days

Diagnosis:

ECG CBC, WBC PT ESR SGOT, SGPT IgA, IgG and IgM

Nursing Care:

Medication Therapy Aspirin Gamma Globulin

Nursing Interventions Assess/monitor Decrease stimulation Comfort measures Discharge teaching

Rheumatic Fever

Systemic inflammatory disease

Follows group A beta-hemolytic streptococcus infection

Causes changes in the entire heart especially the valves

Clinical Manifestations

Jones Criteria

Major

Minor

Supporting Evidence

Therapeutic Intervention

Medication long term prophylaxis

Nursing Prevention Parent teaching (ANTIBIOTICS)

Subacute Bacterial Endocarditis

Infectious disease involving abnormal cardiac tissue:

Usually rheumatic lesions or congenital defects

Infection may invade adjacent tissues- aortic and mitral valves

Clinical Manifestations:

Onset insidious Fever Lethargy/general malaise Anorexia Splenomegaly Retinal hemorrhages Heart murmur –90%

Diagnosis- positive blood cultures

Nursing Care

Medication-large doses antibiotic

Bed rest

Teach to notify dentist prior to dental work

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