Transcript PowerPoint Pediatric Cardiac Disorders

Presented by
Marlene Meador RN,
MSN, CNE
Fetal Cardiac Circulation
Where is the Highest O2 concentration ?
(why?)
 ↑pulmonary resistance forces blood into
descending aorta (see CD-ROM)
 Umbilical vein→ liver→ ductus venosus→
inferior vena cava→ right atrium → foramen
ovale (bypass lungs for oxygenation) → left
atrium → left ventricle → aorta → body

Fetal Circulation
M
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Secondary Fetal Circulation- why
does the blood flow this direction?
Right atrium → right ventricle →
pulmonary artery → ductus arteriosus →
aorta →body
What would cause blood to circulate
via a third route?
Changes in Circulation
What is the stimulus for circulatory changes in the
newborn? Clamping of the umbilical cord
 Systemic vascular resistance
 Increased blood pressure in the left side of heart →
closure of the foramen ovale
 Ductus arteriosis constricts and closes as a result of
higher O2 saturation levels
Why is it important for the
nurse to know the normal value
for O2 saturation?
 At what O2 saturation does cyanosis
occur?
 Why is this significant?
What assessment findings indicate hypoxia?
What nursing interventions should the nurse
initiate for hypoxia?
 Bradycardia – stimulate patient
 Shortness of breath
 Positioning
 Incentive spirometry (what works with
children?)
 Supplemental oxygen (when does the nurse
need an order for this?)
Peripheral cyanosis occurs at <= 80%
Brain damage occurs <= 85%
Hypoxic Level
Oxygen Saturation
Mild hypoxia
Moderate
Severe
90-95%
85-90%
<85%
Congestive Heart Failure
Most common causes
Left to right shunting
Obstructive congenital
defects
CHF in Children:
 Development- preload and after-load
(overload right side of heart causing backflow)
leads to…
 Cardiac hypertrophy leads to…
 One-sided cardiac failure→ bilateral failure
 Compensatory mechanisms
 Renal response
 Systemic response
Early Clinical Manifestations of CHF
 Infants tires easily (during
what activity?)
 Weight loss or lack of




normal weight gain
Diaphoresis
Irritability
Frequent infections
Peri-orbital edema
 Children
 Exercise intolerance
 Dyspnea
 Abdominal pain or
distention
 Peripheral edema
CHF in Children
Cause
Clinical Manifestation
Pulmonary venous congestion
Tachypnea, wheezing, crackles,
retractions, cough, grunting, nasal
flaring, feeding difficulties, irritability,
tiring with play
Systemic venous congestion
Hepatomegaly, ascities, peripheral
edema
Impaired Cardiac output
Tachycardia, diminished pulses,
hypotension, capillary refill time >2
seconds, pallor, cool extremities,
oliguria
High metabolic rate
Failure to thrive or slow weight gain
Nursing Care for CHF
 Strict I&O (weight diapers)
 Weigh child daily (what is significant change?
1 lb/day)
 Monitor VS
 Cardiac medications for children
 Cardiac glycosides (Digoxin)
 Ace inhibitors (Capoten-Captoril®, Vasotec®)
 Diuretics (Furosemide- Lasix®)
Medications to treat CHF in
Children:
Medication
Action
Nursing Intervention
Cardiac
glycosides
(Digoxin)
Increase myocardial
contractilityimprove systemic
circulation
Monitor pulse- when do
you hold this medication?
What safety check?
Strict I&O
Weigh child daily
Observe for edema
Serial abdominal girth
protect skin
Digoxin levels (toxicity)
Hepatic function
Creatinine clearance
Serum Elecrolytes
Digoxin specific nursing
interventions
 Hold for pulse
 Infant < 100
 Child < 80
 Adolescent <60
 Verify dose with two nurses
 Strict I&O (1gram=1ml)
 Skin care
 Monitor for digoxin toxicity
Digoxin Toxicity >2ng/ml
 Cardiac dysrrhythmia **first sign in children
 Bradycardia
 Anorexia
 Nausea and vomiting, Dizziness, Weakness
 Notify healthcare provider if creatinine
clearance of 50ml/min or less.
 Monitor serum electrolytes: K+, Ca and Mg
Medications to treat CHF cont…
Medication
Action
Nursing
Intervention
ACE inhibitors
Capoten
(Captoril)
Vasotec
Inhibits
conversion of
angiotension I to
II results in
vasodilatation
Promote rest,
maintain oxygen
therapy, and
evaluate oxygen
saturation
(what is greatest
risk?)
Medications to treat CHF cont…
Medication
Action
Nursing Interventions
DiureticsFurosemide
(Lasix®)
Rapid diuresis
Give IM or IV
Chlorothiazida
(Diuril®)
Spironolactone
(Aldactone)
K+ level prior to
administer
Monitor electrolytes,
weigh daily, strict I&O
Observe for changes in
peripheral edema or
circulation
Serial abdominal girth
Skin care- turning
schedule
Quick Quiz:
 What is the pulse rate criteria for
administering digoxin to:
 Infants Child Teenager/ adolescent-
 What are signs of digoxin toxicity?
 Why are K+ levels important with digoxin?
Nursing care to decrease
cardiac demands:
 Provide for rest
 Semi-Fowler’s
 Monitor O2 (supplement)
 Small frequent meals
 Turn q 2 hrs and provide skin care
 Encourage parents/guardians to stay with child
 Restrict visitors (why?)
Cardiac Catheterization
 Measures oxygen saturation and pressures in cardiac




chambers and great arteries
Evaluate cardiac output
Angiography-images of structures and blood flow
patterns
Electrophysiologic studies
Corrective or palliative interventions:
 Pulmonary artery or valve and aortic valve balloon
angioplasty
 Stent placement
 Balloon/blade septostomy
 Device closure of septal defects
Critical thinking:
 Why is it important for the nurse to assess pedal pulses
prior to cardiac catheterization?
 Interventions for immediate post-cardiac catheterization?
 Vital signs- which measurements receive highest priority?
 Extremities
 Activity
 Hydration (prevent thrombus formation)
 Medications (what meds are not allowed?)
 Comfort
Post Cardiac Catheterization
 What teaching should the nurse include
for home care after cardiac
catheterization?
 Watch for signs of complications:
 infective endocarditis
 Bleeding/bruising
 Changes in circulation on cath side
Post Cardiac Catheterization
When should the
parents/caregiver notify the
primary healthcare provider?
Congenital Cardiac Defects
Increase Pulmonary Blood
Flow
 Patent Ductus Arterious
 Atrial Septal Defect
 Ventricular Septal defect
Increased blood flow to the lungs
causes increased pulmonary
resistance (constriction of the
pulmonary vascular
bed)→pulmonary artery
hypertension with right
ventricular hypertrophy
Hypoxia results
Decrease Pulmonary Blood
Flow





Pulmonic stenosis
Tetralogy of Fallot
Tricuspi atresia
Transposition of the great arteries
Truncus arteriosus
May have right to left shunting. Little
or no blood reaching the lungs to
get oxygenated. Bone marrow
stimulated to produce more RBC’s
increase in oxygen. Polycythemia
increases risk for
thromboembolism. Platelet
impaired. Hypoxic events with
brain abscesses common.
Left to Right Shunting
Atrial Septal Defects
Ventricular Septal Defects
Patent Ductus Arteriosu
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 for ASD
 Medical Management
 Medications – digoxin
 Cardiac Catheterizaton  Amplatzer septal occluder
 Open-heart Surgery
Device Closure – Amplatzer septal occluder
During cardiac catheterization the occluder is placed in the
defect
Ventricular 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 of VSD
 Surgical repair of defect
Patent Ductus Arteriosus
Failure of the fetal ductus
arteriosus to close after
birth
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
Medical Treatment for PDA
Indomethacininhibits prostaglandins
Promotes closure of the ductus
arteriosus
Surgical Treatment for PDA
Cardiac Catheterization
 Insert coil – tiny fibers
occlude the ductus
arteriosus when a
thrombus forms in the
mass of fabric and wire
Congenital Heart Defects
What is the most
common assessment
finding for a cardiac
anomaly?
Obstructive or Stenotic Lesions
Pulmonic Stenosis
Aortic Stenosis
Coarctation of the Aorta
Pulmonic Stenosis
 Narrowing of entrance that
decreases blood flow
 Treatment:
 Medications – Prostaglandin E 1
to keep the PDA open
 Cardiac Catheterization

Baloon Valvuloplasty
 Surgery

Valvotomy
Aortic Stenosis/
Coarctation of the Aorta
1.
Narrowing of Aorta causing
obstruction of left ventricular
blood flow
2.
Left ventricular hypertrophy
Signs and Symptoms
 B/P in upper extremities
B/P in lower extremities
Radial pulses full/bounding and
femoral or popliteal pulses weak
or absent
Leg pains, fatigue
Nose bleeds
Treatment for aortic Senosis
 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.
 Baloon Valvoplasty
Cyanotic Lesions with
Decreased Pulmonary Flow
Tetralogy of Fallot
Signs and Symptoms
1. Failure to thrive
2. Squatting
3. Lack of energy
4. Infections
5. Polycythemia
6. Clubbing of fingers
7. Cerebral absess
8. Cardiomegaly
Nursing Care:
Dehydration
Criteria for surgery
Rule of 10’s
 10
lbs
 Hemaglobin 10 or greater
 10 hours/days/months
Treatment of Tetralogy of Fallot
 Surgical interventions
 Blalock – Taussig or Potts procedure – increases
blood flow to the lungs.
 Open heart surgery
Cyanotic Lesions with Increased
Pulmonary Blood Flow
Truncus arteriosus
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.
Transposition of the great
arteries
 Aorta 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.
Review of Nursing Care:
Increased pulmonary blood flow S&S-Infants: tachypnea, cyanosis, retractions, fatigue,
poor feeding, weight loss, fluid/electrolyte imbalance
Older children: exertional dyspnea, chest pain,
syncope
 Nursing Care- promote rest or oxygen conservation,
monitor I & O, administer oxygen, administer
medications, provide parents needed support and
information about the care of the child
Review of Nursing Care cont…
Decrease blood flow and mixed defects Infants: Cyanosis, dyspnea, loud murmur, skin ruddy or
mottled, cyanosis that does not respond to oxygen,
stopping during feeding (to breath) diaphoresis, poor
weight gain (FTT)
 Children: chronic- fatigue, clubbing of fingers and toes,
dyspnea on excertion, delayed developmental milestones,
hypercyanotic episodes, increased pulse and resp. rate,
cyanosis Toddlers squat to relieve dyspnea
Nursing Care:
Decrease blood flow and mixed defects S&S continued
 Older children- syncope, transient loss of
consciousness & muscle tone, exercise induced
dizziness (what does the nurse need to teach
with regards to these S&S?)
Nursing Care: Decreased flow or mixed
defects
 Surgical correction of defect if life threatening
 Administer prostaglandin E1 (PGE1) to re-open the ductus







arteriosus and improve pulmonary or systemic blood flow
Monitor Hct & Hbg (what happens with increased blood
viscosity?)
Keep child calm (morphine, propranolol IV) Administer RBC’s
to assist with O2
Position in knee chest
Supplemental O2 therapy
IV fluids
Dopamine or phenylephrine (Neo-Synephrine)
Small frequent meals
Defects Obstructing
Systemic Blood Flow
 Aortic stenosis
 Coarctation of the aorta
 S&S- low cardiac output (diminished pulses)
 Poor color, capillary refill delayed
 Pulses & BP stronger/higher in upper extremities
 CHF and pulmonary edema
 Necrotizing enterocolitis
 With mild obstruction: leg cramps, cooler feet than hands,
stronger pulses in upper extremities
Quick questions:
 What is the main complication associated with increased
pulmonary blood flow?
 Why is indomethacin (prostaglandin inhibitor) ordered
for a newborn with patent ductus arteriosus?
 Why are prostaglandins administered to the child with
an obstructive cardiac disorder (aortic stenosis)?
Nursing Care for Open-heart
Surgery
Pre-Op
Post-Op
 Monitor VS (*BP & P) what
 Pulmonary function:
 Patent airway
 IPPB, C&DB, O2 therapy
 Chest suction or chest tube
 Monitor VS
 Promote rest
 Monitor I&O- adequate





might increase temp mean?
Prepare child/parents for
experience- teaching
Teach C&DB (incentive
spirometer)
Tour hospital- meet staff
Assess for infection
Obtain labs, verify permits
hydration (fluid & electrolyte
balance)
 Turn frequently (skin care)
 Assess extremities (circulation)
Oh no…more questions….
 What assessment findings in the newborn and child
indicate coarctation of the aorta?
 What is polycythemia and why does it occur in a child
with a cardiac disorder?
 Which cardiac anomalies represent the greatest risk to
survival?
 What classic assessment findings should the nurse report
in an initial assessment of a newborn?
Rheumatic Fever:
 What precipitating condition may develop
into rheumatic fever?
 What are Jones Criteria and how is this
used?
 Major
 Minor
 Laboratory testing- elevated
antistreptolysin-O (ASLO)
Nursing Care:
 Priority teaching
 Medication therapy
 Antibiotics- as ordered to completion of entire
prescribed dose (how do you test for therapeutic
level?)
 Aspirin- relieves pain and acts as a blood thinner to
prevent clot formation
Ineffective Endocarditis:
 What clients are more susceptible to
develop bacterial endocarditis?
 When does the organism enter the body?
 What part of the heart is most affected
by the disease?
Long-term care for bacterial
endocarditis
 What specific areas of instruction would the
nurse include in developing a long-term care
plan?
 What specific teaching regarding dental
hygiene and dental care must the nurse
include?
Kawasaki Disease- multi-system vasculitis
 Acute Phase 10-14 days









Rapid onset of fever (does not respond to antibiotics)
Bilateral conjunctivitis lasting 3-5 weeks
Rash on day 5 (extremities to trunk)
Cervical lymphadenopathy
Irritability & lethargy
Anorexia, possibly diarrhea, hepatic dysfunction
Acute pericarditis
Hands and feet are edematous and red
Red throat
Kawasaki cont…
 Subacute Phase







Continued irritability
Anorexia diarrhea
Arthritis and arthralgia
Lip cracking and peeling- classic strawberry tongue
Desquamation of the extremities (palms and feet)
Cervical lymphadenopathy with large nodes
Possible coronary aneurysms with potential for
thrombosis formation
Kawasaki cont…
 Convalescent Phase
 Self limiting
 Transverse on nailbeds
 Lasts until return to normal of all lab values
Diagnosis of Kawasaki Disease:
 What diagnostic test is specific to this disease?
 ESR- Elevated SGO- elevated and SGPT
elevated, IgA, IgG, IgM all elevated
Nursing Care: Kawasaki
 Medications Aspirin- decrease fever and thin blood (reduce risk
of formation of aneurysms and coronary
thrombosis- antiplatelet properties)
 Gamma Globulin- high doses given before 10th day
to reduce incidence of coronary artery lesions and
aneurysms, decrease inflammatory signs and fever
Nursing Care: Kawasaki
 Activity- passive range of motion, plan rest and quiet age-
appropriate activities. Encourage parents to participate in
child’s care.
 Comfort- keep skin clean, dry, lubricate lips, cool
compresses and sponges, change bedding frequently.
Small frequent feedings of soft, non-acidic foods of cool
temperature
Kawasaki Disease: Long term care
 Teach parents to administer ASA and watch for side
effects of bleeding.
 Avoid contact sports
 Teach daily monitoring of temp, report >100F
 Postpone immunizations for 5 months
 Emphasize need to follow up with cardiologist
 Influenza vaccine (reduce risk of Reye syndrome)
 Life-long prophylaxis with antibiotics prior to dental
work
Kawasaki Disease: Long term care
Psychosocial
 Child away from peers and social activities
for up to 4 months
 Severity of illness has impact on parent/child
relationship
 Parents may experience care giver fatigue
Quick Review:
 What is the major complication of
Kawasaki disease?
 Why is it important to monitor respiratory
effort in children with suspected cardiac
abnormalities?
For questions or concerns regarding this lecture content
please contact
Marlene Meador RN, MSN, CNE
[email protected]