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
Tests of Cardiac Function
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
Tests of Cardiac Function
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
Tests of Cardiac Function
Cardiac Catheterization Nursing Care Management
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)
Tests of Cardiac Function
Cardiac Catheterization Nursing Care Management
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
Congestive Heart Failure (CHF)
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
Congestive Heart Failure (CHF)
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.
Congestive Heart Failure (CHF)
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
Congestive Heart Failure (CHF)
Congestive Heart Failure (CHF)
Clinical Manifestation of CHF As compensatory mechanism fail, clinical
manifestations include Impaired myocardial function Pulmonary Congestion Systemic Venous Congestion
Congestive Heart Failure (CHF)
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
Congestive Heart Failure (CHF)
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
Congestive Heart Failure (CHF)
Improve Cardiac Function Two Drugs are used
Digitalis Glycosides (improves contractions) Angiotensin-Converting Enzyme (ACE) Inhibitors
(decreased afterload)
Congestive Heart Failure (CHF)
Remove accumulated fluid and sodium Administer diuretics Possible fluid restrictions Possible sodium restrictions
Congestive Heart Failure (CHF)
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
Congestive Heart Failure (CHF)
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.
Congestive Heart Failure (CHF)
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
Congenital Heart Defects (CHD)
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
Congenital Heart Defects (CHD)
Congestive Heart Failure (CHF)
Congenital Heart Defects (CHD)
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
Congenital Heart Defects (CHD)
Defects with Increased Pulmonary Blood Flow Atrial Septal Defect (ASD) Ventricular Septal Defect (VSD) Atrioventricular Canal Defect Patent Ductus Arteriosus (PDA)
Congenital Heart Defects (CHD)
ASD Abnormal opening
between the atria, allowing blood to flow from the left atrium to the right atrium
Congenital Heart Defects (CHD)
VSD Abnormal opening
between the ventricles allowing blood to flow from the left ventricle to the right ventricle
Congenital Heart Defects (CHD)
Atrioventricular Canal Defect Incomplete
development of endocardial cushion that consists of a low ASD, high VSD and clefts of the mitral and tricuspid valve.
Congenital Heart Defects (CHD)
PDA Failure of the fetal
ductus arteriosus (connection between aorta and pulmonary artery) to close within the first weeks of life.
Congenital Heart Defects (CHD)
Obstructive Defects Coarctation of the Aorta (COA) Aortic Stenosis (AS) Pulmonic Stenosis (PS)
Congenital Heart Defects (CHD)
COA Narrowing in the aorta
near the insertion of the ductus arteriosus.
Congenital Heart Defects (CHD)
AS Narrowing or stricture
of the aortic valve. Narrowing can occur
above the valve (supravalvular), below the valve (subvalvular) or at the valve (valvular).
Congenital Heart Defects (CHD)
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.
Congenital Heart Defects (CHD)
Defects with Decreased Pulmonary Blood Flow Tetrology of Fallot (TOF) Tricuspid Atresia (TA)
Congenital Heart Defects (CHD)
TOF Contain four defects
VSD PS Overriding Aorta RV Hypertrophy
Congenital Heart Defects (CHD)
TA Tricuspid valve fails to
develop leaving no communication between the right atrium and right ventricle.
Congenital Heart Defects (CHD)
Mixed Defects Transposition of the Great Arteries of Great
Vessels (TGA) Total Anomalous Pulmonary Venous
Connection (TAPVC) Truncus Arteriosus Hypoplastic Left Heart Syndrome (HLHS)
Congenital Heart Defects (CHD)
TGA The PA leaves the RV
and connects to the aorta leaving no communication between systemic and pulmonary circulations.
Congenital Heart Defects (CHD)
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.
Congenital Heart Defects (CHD)
Truncus Arteriosus Pulmonary artery and
aorta are formed together and leave the heart as one vessel.
A large VSD is present.
Congenital Heart Defects (CHD)
HLHS Underdevelopment of
the left side of the heart which includes a hypoplastic left ventricle and aortic atresia.
Congenital Heart Defects (CHD)
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
Congenital Heart Defects (CHD)
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
Congenital Heart Defects (CHD)
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
Acquired Cardiovascular Disorders
Rheumatic Fever (RF) –inflammatory disease that occurs after pharyngitis caused by strep. Etiology Pathophysiology Clinical Manifestations Diagnostic Evaluation Therapeutic Management Nursing Care Management
Acquired Cardiovascular Disorders
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.
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