Transcript ALTERATIONS OF CARDIAC FUNCTION

ALTERATIONS OF
CARDIAC FUNCTION
CONGENITAL HEART DEFECTS
VALVULAR PROBLEMS
ENDOCARDITIS
ABDOMINAL AORTIC ANEURYSM
2009
Transition from fetal to
pulmonary circulation
How does the circulation during fetal life
differ from that of the neonate?
What leads to this transition?
How do the changes of pressures and
resistance within the heart effect the
foramen ovale, ductus venosus, and
ductus arteriosus?
Differences for the child in
cardiovascular functioning
 Why is the child at greater risk of CHF?
 Why does the child’s heart beat faster?
 What are the Hct, Hgb and pulse ox
concentrations appropriate for age needed for
adequate oxygen transport
 What does cyanosis indicate? hypoxemia
What is polycythemia?
 What labs indicate Polycythemia:
 What is the danger of Severe Hypoxemia?
BASIC PHYSIOLOGY
 WHAT IS THE HEART:
 WHAT IS CARDIAC OUTPUT?
 How is cardiac output determined?
 WHAT IS STROKE VOLUME?
PHYSIOLOGY CONTINUED
 WHAT 3 things influence STROKE VOLUME?
1.Define Preload:
2.Define Afterload:
1.Define Contractility:
WHAT KIND OF TESTING
IS DONE TO DIAGNOSE?
Cardiac
Catherization
 What is used during the
test?
 Where are the catheters
placed?
 What measurements are
taken?
 What is visualized?
PREOP NURSING CARE
CARDIAC CATHERIZATION
WHY NEED Accurate hgt and wgt
WHY IS History of allergies to
iodine important?
WHAT HAPPENS IF THE CHILD
HAS Severe diaper rash
WHY Mark pulses: dorsalis pedis,
posterior tibial
WHY Baseline pulse ox
PREOP CARDIAC CATH
HOW TO Prepare child:
schoolage/adolescent
Preop receive what drugs?
WHAT DIET PREOP AND WHY?
POSTOP NURSING CARE
CARDIAC CATHERIZATION
 What would you expect to find when assessing
the pulses?
 What is normal and what is abnormal?
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 What rhythm and rate change would you
expect?
POSTOP NURSING CARE
CARDIAC CATHERIZATION
WHY CHECK BP
WHY Check dressing
What assessment would you need to do
regarding hydration and why?
What do you do with the effected?
How do you adapt care to a toddler?
What do you do to prevent bleeding?
POSTOP HOME CARE
CARDIAC CATH
Pressure dressing INSTRUCTIONS
What is done to Cover site?
Bathing instructions?
What observations are made for
complications?
What activity instructions?
What is used for pain?
POSTOP CARDIAC CATH
SITUATION
Tommy, a 4 year old with Tetralogy of
Fallot returns from catherization
laboratory. He has vomited, his mother
calls you to the bedside to tell you that
he is bleeding. You arrive to find
Tommy crying and sitting up in a
puddle of blood. The first thing you do
is:
ANSWERS TO POSTOP
CATH SITUATION
1. Increase the rate of his IV fluids
2. Give an antiemetic and keep
Tommy NPO
3. Call the cardiologist
4. Lie Tommy down, remove the
dressing and apply direct pressure
above the catherization site
ANSWERS TO SITUATION
GENERAL S & S of CHD in
INFANTS AND CHILDREN
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INFANTS:
Dyspnea
Difficulty feeding
Stridor, choking spells
Pulse rate over 200
FTT
Heart murmurs
Frequent URI’s
Anoxic attacks
CVA
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CHILDREN:
Exercise intolerance
Increased BP
Poor physical
development
Heart murmurs
Cyanosis
Recurrent URI
Clubbing fingers/toes
squatting
CLASSIFICATION OF CHD
Based on how the blood flows: obstructed,
delayed, abnormally shunted:
1. Blood flow can be obstructed or delayed
which CHD (what anomalies are examples?)
2. If Blood is abnormally shunted from one side
of the heart to the other
eg: what happens to pulmonary blood flow with
a left to right shunt?
eg: right to left shunt What kind of blood is
abnormally shunted? What happens to the
lungs
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REMEMBER THIS ABOUT
SHUNTS!
How does Blood flows occur in the
heart?
What can you say about the
pressure on the RIGHT SIDE of the
heart as compared to the pressure
on the LEFT SIDE of the heart?
SECONDARY
CLASSIFICATION OF CHD
Define happens with ACYANOTIC
DEFECTS?
Give examples of Acyanotic defects?
Define what happens with CYANOTIC
DEFECTS:
Give examples of Cyanotic defects?
What kind of shunt occurs?
OBSTRUCTIVE DEFECTS
 Explain what happens to blood flow with an
anatomic narrowing (stenosis)?
 Explain what happens to the Pressure in the
ventricle and in the great artery before the
obstruction?
 Where is the the most common Location of
narrowing?
 Give some EXAMPLES of obstructive defects:
COARCTATION
OF
AORTA
 Where is the narrowing
located?
 Where is the increased
pressure and what does
it cause?
 Where is decreased
pressure and what does
it cause?
RESULTS OF
COARCTATION
Because of the large volume of
blood going to the head the child
may experience what?
What is common in infants?
TREATMENT OF
COARCTATION OF AORTA
Surgical treatment:
Involves what correction?
 What if the narrowed area is large,
what might the surgeon have to do?
 Is this open or closed heart
surgery?
 What is the common age of this
surgery?
TREATMENT OF
COARCTATION OF AORTA
What is the Nonsurgical treatment
called?
Is this method performed
everywhere?
POSTOP COARCTATION
SYNDROME
Postop pts develop abdominal pain
for what reason?
SURVIVAL POSTOP: 95%
PULMONIC STENOSIS
Stenosis means what and where?
RV hypertrophy occurs as a result of
what
What happens to the volume of blood
flow to the lungs?
S&S:
TX OF PULMONIC
STENOSIS
 SURGICAL TX:
1. Infants: closed heart surgery transventricular
valvotomy
2. Children: open heart surgery pulmonary
valvotomy
 NONSURGICAL TX: balloon angioplasty in
cardiac cath lab to dilate valve (TREATMENT
OF CHOICE)
 SURVIVAL RATE BOTH PROCEDURES: 98%
NEXT GROUP OF CHD: INCREASED
PULMONARY BLOOD FLOW
How would you describe the blood flow
in relationship to the pressures in this
type of defect?
What happens to blood volume and
where?
WITH THIS TYPE WHAT COMMONALITY
WOULD YOU SEE IN TERMS OF S&S?
WHAT TYPE OF DEFECTS:
ATRIAL SEPTAL DEFECT
WHERE IS THE
Abnormal
opening?
WHERE DOES
THE Blood FLOW
from & to?
What enlarges?
ATRIAL SEPTAL DEFECT
S&S:
Surgical correction:
99% survival rate postop
VENTRICULAR SEPTAL
DEFECT (VSD)
Abnormal opening between?
What can happen at birth?
Describe the effects of the shunt? And
where the blood flows?
S&S:
Complications?
Corrective Surgery:
PATENT DUCTUS
ARTERIOSUS
Failure of what to
close at birth?
How does Blood
flow?
causing what kind of
shunt?
Patent Ductus Arteriosus
 S&S:
 What complications?
 What long term effects?
 What changes in heart muscle?
PDA CONTINUED
What might be administered by the
nurse to newborns/premies to close the
shunt?
What Surgical Tx is used to correct
problem?
Survival Rate postop: 99%
NEXT GROUP OF CHD: DECREASED
PULMONARY BLOOD FLOW
 Obstruction of pulmonary blood flow caused
by what type of anatomical defect?
 How does the defect cause problems with
blood flow?
 What effect does it have on desaturated
blood?
 Where does the desaturated blood flow go?
TETRALOGY OF FALLOT
 FOUR DEFECTS IDENTIFIED
1.
2.
3.
4.
TETRALOGY
OF FALLOT
FOUR
DEFECTS
SHUNTS IN TETRALOGY
OF FALLOT VARY
If pulmonary vascular resistance is
higher than systemic resistance
WHICH DIRECTION IS THE
SHUNT?
If systemic resistance is higher
than pulmonary vascular
resistance WHICH DIRECTION IS
THE SHUNT?
S&S OF TOF IN INFANTS
 ASSESSMENT OF INFANTS WITH TOF?
 WHAT IS A BLUE SPELL, HYPERCYANOTIC SPELL OR
TET SPELL:
 WHAT NORMAL INFANT SITUATIONS LEAD TO A SPELL?
 CAUSE of TET SPELL?
 WHAT IMPACT DOES THIS SPELL HAVE ON PULMONARY
BLOOD FLOW?
 HOW DOES IT EFFECT THE SHUNTING?
TET SPELLS RISKS
1.
2.
3.
4.
TREATING TET SPELLS OR
HYPERCYANOTIC SPELLS
WHAT position helps the infant?
What approach needs to be used by
caregiver?
What treatment needs to be instituted
immediately?
What drug is given and why?
Why does the infant need IV fluid
replacement and volume expanders?
What can be repeated if needed?
S&S OF TOF IN CHILDREN
With long term cyanosis what
develops in the fingers
What position do children assume
when in Tet spell?
How does TOF effect growth?
What life threatening risks of TOF
in children?
SURGICAL TX OF TOF
 PALLIATIVE:
 COMPLETE REPAIR:
 Postop risks?
 SURVIVAL: 95%
TRICUSPID ATRESIA
 What fails to develop?
 What does this failure
prevent between RA
and RV?
 Blood flows through
another defect where?
 When would the child
die with this defect?
 What keeps the child
alive?
TRICUSPID ATRESIA
S&S:
Palliative surgery:
Corrective surgery:
Survival: 80-90%; many postop
complications
MIXED DEFECT EXAMPLES
TRANSPOSITION OF THE GREAT
VESSELS (TGV) OR
TRANSPOSITION OF THE GREAT
ARTERIES (TGA)
TRUNCUS ARTERIOSUS (TA)
TRANSPOSITION OF THE
GREAT VESSELS
 PA leaves the LV
taking what blood
back to the lungs
 Aorta exits from
where?
 No communication
between what?
 What other defect
allows child to live at
birth?
TRANSPOSITION OF THE
GREAT VESSELS
What assessment and
complications seen at birth?
Surgical Tx:
Survival: 80%
TRUNCUS ARTERIOSUS
What does this look like?
What other defects?
S&S
Surgical repair:
Survival of surgery: 80%. Other
surgeries required
CONGESTIVE HEART
FAILURE IN CHILDREN
What happens to the heart?
Is it able to meet the body’s
demands?
What situations would lead to
CHF?
SUBTLE S & S OF CHF in
CHILDREN
How does it effect feeding?
How does it effect energy?
What happens during feeding?
CONGESTIVE HEART
FAILURE IN CHILDREN
 Impaired
myocardial
function
 How does it effect
?
 VS?
 Energy?
 appetite
 Temperature of
skin?
 Heart muscle?
 Urinary
elimination?
CHF IN CHILDREN
Systemic venous
congestion
 Weight?
 Liver?
 Fluid accumulation?
How does it
effect?
 Neck vein?
 Respiratory
assessment?
THERAPEUTIC
MANAGEMENT GOALS
Improve cardiac function by?
Remove accumulated fluid and
sodium leading to what effect on
the heart?
What on cardiac demands?
What effect on oxygenation?
IMPROVE CARDIAC
FUNCTION
Digitalis
Which class of drug?
Used to?
MAJOR ACTIONS OF
DIGITALIS
 positive inotropic: means what?
 negative chronotropic: means what?
 negative dromotropic: means what?
 Indirectly enhances what?
DIGOXIN (Lanoxin) IN
PEDS
Elixir (50 ug/ml) po
IV (O.1mg/ml)
Dose calculated in micrograms (1000
ug=1mg
Give Digitalizing dose to bring serum
dig level into therapeutic range
Maintenance dose = 1/8 of digitalizing
dose
THERAPEUTIC SERUM
DIGOXIN RANGE
Range from 0.8 to 2 ug/l
Digoxin administration
guide
Apical pulse checked
Drug not given if pulse below 90110/min in infants and young
children or below 70/min in older
children
Do one full minute
DIGOXIN Toxicity:
Effect on heart rate?
Effect on appetite and feeding?
MEDS CONTINUED
Angiotensin converting enzyme
inhibitors (ACE): Vasotec,
Capoten
Used to
OTHER MEDICATIONS
 For severe CHF, other IV
inotropic drugs used in the ICU:
1. Dopamine
2. Dobutamine
3. Amrinone
Used to
GOALS OF TREATMENT
CONTINUED
Remove accumulated fluid and
sodium with which group of drugs?
Give examples?
CAUTION:
GOALS OF TREATMENT
CONTINUED:
 Decrease cardiac demands:
 GIVE EXAMPLES OF NURSING
ACTIONS:
GOALS OF TREATMENT
CONTINUTED:
 Improve tissue oxygenation
NURSING ACTIONS:
NRSG DX FOR ACYANOTIC
HEART DEFECTS
NRSG DX FOR CYANOTIC
HEART DEFECTS
NURSING CARE IN ICU
POST-OP CARDIAC SURGERY
What is done to keep child calm?
How is the infant’s temp regulated
How often VS?
How is the heart monitored?
What measures Cardiac output?
Why does the child have Pacemaker
leads in place?
POSTOP NURSING CARE
CONTINUED
 What is used to monitor BP?
 What is used to provide oxygen?
 How are increased secretions managed
 How is oxygenation measured?
 Why is an NGT used?
 Dressing over chest incision checked q 15
minutes for 24 hr for what?
POSTOP NURSING CARE
CONTINUED POSTOP NU
 2-3 chest tubes draining what from thoracic
cavity which entered during surgery
 Foley checked how often?
 What urinary output would you expect for an
infant? And a child? If Less than that normal
what does this indicate?
 Accurate I & O hourly including what
drainage?
 IV solutions and blood replacement
POSTOP NURSING CARE
CONTINUED
What class of meds for pain?
What used to prevent infection?
What diet?
What needs to be done for the
mouth?
How to Support parents?
POTENTIAL COMPLICATIONS
 HEMORRHAGE
 *****ARRHYTHMIAS
 CHF
 PNEUMONIA
 RENAL FAILURE
 CVA
 PULMONARY EMBOLISM
 DEATH
NURSING ASSESSMENTS
Parents
child
ENDOCARDITIS
CAUSATIVE ORGANISMS
Streptococcus
Staphylococcus aureus,
enterococci
PREDISPOSING FACTORS
 Who would get endocarditis?
PATHOPHYSIOLOGY
Where does the Infective organisms
travel?
Where is it deposited on the heart?
What aggregation is triggered?
What forms on valves and
endocardium?
EMBOLIZATION
What happens to the Fragments of
friable vegetative lesions?
Where do they go?
What assessments would the
nurse look for with regard to
embolization?
Clinical manifestations
INITIAL SYMPTOMS SEEM LIKE FLU:
FEVER:
VASCULAR MANIFESTATIONS:
 Splinter hemorrhages
 Petechiae
 Roth’s spots:
Clinical manifestations
PERIPHERAL MANIFESTATIONS:
 Osler’s Nodes:
 Janeway lesions:
Clinical manifestations
CARDIAC:
Heart murmur: indicates?
What happens to the size of the
heart?
What other complication?
Clinical manifestations
CEREBRAL EMBOLIZATION:
What assessments?
Clinical manifestations
PULMONARY EMBOLIZATION:
What assessments?
Clinical manifestations
CORONARY ARTERY
EMBOLIZATION:
What assessments?
Clinical manifestations
SPLENIC EMBOLIZATION:
What assessments?
Clinical manifestations
EMBOLIZATION OF THE RENAL
ARTERY:
What assessments?
Clinical manifestations
CENTRAL NERVOUS SYSTEM:
What assessments?
LABORATORY FINDINGS
Nursing care
 What medications are used to treat the
infection? What route?
 What activity is best for the client?
 What drug is used for the fever?
 What drug is used for comfort
 What labs indicate the infection status?
 Observe for what complication?
 What should be done prophylactically?
NURSING DIAGNOSIS
EXPECTED OUTCOMES
ABDOMINAL AORTIC
ANEURYSM
ANEURYSM
Defined
SIGNS AND SYMPTOMS
EXPANDING ANEURYSM
ASSESSMENT
RUPTURED ANEURYSM
ASSESSMENT
TREATMENT: SURGICAL
REPAIR
BEFORE SURGERY
ASSESSMENT
COMPLICATIONS DURING
SURGERY
MYOCARDIAL INFARCTION
How would you know?
GRAFT OCCLUSION OR
RUPTURE
HYPOVOLEMIA &
RENAL FAILURE
RESPIRATORY DISTRESS
PARALYTIC ILEUS
POSTOPERATIVE NURSING
CARE
POST-OP ASSESSMENTS for
ISCHEMIA
POST-OP ASSESSMENTS for:
ARTERIAL OCCLUSION
DISCHARGE PLANNING
Valvular Heart Disease
GENERAL CONCEPTS
VALVULAR DISEASE INVOLVES THE
4 VALVES OF THE HEART
PRESSURES:
PRESSURE ALTERATIONS
DUE TO STENOTIC VALVE
VALVULAR DISEASE
DEFINED:
VALVULAR DISEASE DEFINED:
Stenosis:
Regurgitation:
STENOSIS &
REGURGITATION
STENOSIS:
REGURGITATION:
MITRAL VALVE STENOSIS
ASSESSMENT
MITRAL VALVE
REGURGITATION
ASSESSMENT
MITRAL VALVE PROLAPSE
ASSESSMENT
AORTIC VALVE STENOSIS
ASSESSMENT
AORTIC VALVE
REGURGITATION
ACUTE AORTIC VALVE
REGURGITATION
CAUSES
ASSESSMENT
• ACUTE:
• CHRONIC:
TRICUSPID AND PULMONIC
VALVE DISEASE
RESULTS:
TRICUSPID STENOSIS RESULTS in
PULMONIC STENOSIS: results in
DIAGNOSTIC STUDIES FOR
VALVULAR HEART DISEASE
TREATMENT
DEPENDS UPON SYMPTOMS:
TEACHING
Describe disease and complications
Discuss ways to prevent
complications: prophylactic
antibiotics prior to invasive
procedures
Wear Medic Alert
Teach about anticoagulants if
prescribed