Transcript The Child with Cardiovascular Dysfunction

The Child with Cardiovascular
Dysfunction
By : Basel AbdulQader RN, MSN, CCRN
Murad Sawalha RN, MSN, CCRN
Fetal Circulation
Fetal Circulation
Fetal circulation (prenatal circulation)
differs from adult circulation in several
ways and is designed to ensure a high
oxygen blood supply to the brain and
myocardium of the fetus.
Characteristics of fetal circulation
Placenta is the source of oxygen for the
fetus, it has 2 arteries and 1 vein.
Fetal lungs receive less than 10% of the
blood volume ; lung don’t exchange
gas.
Right atrium of fetal heart is the
chamber with the highest oxygen
concentration.
The three openings that close at
birth are:
Ductus Arteriosus connects the pulmonary
artery to the aorta, bypassing the lungs
Ductus Venosus connects the umbilical vein
and the inferior vena cava bypassing the liver.
Foramen Ovale is the opening between
right and left atrias of the heart , bypassing
the lungs.
Pattern of fetal circulation
Oxygenated Blood is carried from
placenta through the umbilical vein
and enters the inferior vena cava
thought the Ductus Venosus .
This permits most of the highly
oxygenated blood to go directly to the
right atrium , bypassing the liver.
….. Continue pattern
This right atrial blood flows directly into
the left atrium through the foramen
ovale an opening between the right
and the left atriums .
….. Continue pattern
From the left atrium blood flows directly
into left ventricle and the Aorta
through the subclavian arteries , to
the cerebral and coronary arteries ,
resulting in the brain and the heart
receiving the most highly
oxygenated blood .
Coronary circulation
….. Continue pattern
Deoxygenated blood returns from the
heart and the arms through the
superior vena cava, enters the right
atriums and passes into the right
ventricle.
Blood from the right ventricle flow into
pulmonary artery, but because fetal
lungs are collapsed, the pressure in
the pulmonary artery is very high .
….. Continue pattern
Because pulmonary resistance is high ,
most of the blood passes into the distal
aorta through the Ductus Arteriosus,
which connects the pulmonary artery
and the aorta distal to the origin of the
subclavian arteries.
From the aorta blood flows to the rest
of the body.
Normal circulatory changes at birth
Physiological changes at birth
Foramen Ovale: Opening Between Atria;
Allows Blood to Bypass Lungs
intrauterinely; Closes With Increased LeftSided Pressure
Ductus Arteriosus: Opening Between
Pulmonary Artery & Aorta; Allows Blood to
Bypass Lungs intrauterinely; Closes Within
10-15 Hours After Birth With Permanent
Closure By 10-21 Days of Life
….. Physiological changes
Cyanosis results from 5 or more
Grams of Unoxygenated Hemoglobin
per 100 ml of Blood: So, If
Hemoglobin is Low, You Won’t See
Cyanosis In Spite of Low PaO2!
….. physiologic
Polycythemia: Increase in Production of
Erythrocytes To Compensate for Chronic
Hypoxemia; If Hemoglobin Greater Than
20 g/dl & Hematocrit Greater Than 5560%, Increased Risk for thromboembolism
Infants Respond to Severe Hypoxemia
With BradyCardia
Normal vital signs at birth
Heart rate= 120-140 beat/min
Blood pressure= 65/41 mmHg
Respiratory rate= 30-60 breath/min
Temperature= Axillary 35.5-37oC.
Oxygen saturation (SpO2 )= >93%
Congenital Heart Disease (CHD)
Approximately 5-8 Per 1000 Live Births;
Combination of Genetic & Environmental
Factors : X-ray exposure
Maternal Rubella
Maternal alcoholism
Maternal type 1 diabetes
Maternal over 40 of age
Occur EARLY in Gestation (3-8 Weeks) in
the first trimester
CHD
Classification of CHD:
Acyanotic versus cyanotic
Acyanotic
Pulmonary
Blood flow
Obstruction to
Blood flow
from ventricles
•Atrial septal
defect (ASD)
•Ventricularr
septal defect
(VSD)
•Coarctation
of Aorta
•Aortic
stenosis
Cyanotic
Pulmonary
blood flow
•Tetrology
of Fallot
•Tricuspid
atresia
Mixed
blood flow
•Transposition
Of great vessels
•Truncus
arteriosus
Selected Acyanotic defects
(1) ASD, or atrial septal defect:
•Abnormal opening between atria, allowing
blood from Lt atrium (higher pressure) to
go to right atrium (lower pressure).
Pathophysiology:
•the new volume in the right ventricle is
tolerable because it was sent by a low
pressure from the right artium.
S&S: Patients may be asymptomatic
they may develop heart failure, atrial
arrhythmias are present.
Surgical treatment: Surgical Dacron
Patch Closure .
Non-surgical Repair: in catheterization,
a repair pad is implanted.
• Patients with ASD may live several
decades without S&S and the prognosis
after operation is very high.
…. Cont. acyanotic
(2) VSD, or Ventricular Septal Defect:
•It is an abnormal opening between the right
and
the left ventricles, resulting in a common
ventricle.
• its found that 20% of all VSDs close
spontaneously during the first year of life
• Pathophysiology: the blood turns from
the left ventricle (higher pressure) to the
right ventricle(lower pressure) causing
left-to-right shunt , then to pulmonary
Artery, which increases RV pressure causing
RV hypertrophy and by time RV failure.
• S&S : congestive heart failure is common.
• Surgical treatment: complete repair.
•Non-surgical treatment: closure devise is
usually implanted during cardiac
catheterization
Cardiac catheterization lab
Selected cyanotic defect
Tetrology of Fallot (TOF)
•The classic form includes four defects: (1)
ventricular Septal Defect, (2) pulmonic
stenosis,(3) overriding aorta, (4) right
ventricular hypertrophy.
•Pathophysiology: the altered
hemodynamic status depends on the size of
the VSD and the pulmonary stenosis, blood
get shunted from right to left, if the
pressure in the pulmonary is higher than
the systemic pressure, and blood gets
shunted from left to right if the systemic
pressure is higher than pulmonary.
Pulmonary stenosis decreases blood flow to
lungs making oxygen returns to Lt side of
the heart.
•S&S: cyanosis, clubbing fingers, poor
growth. crying during or after feeding.
•Surgical treatment: complete repair is
required, open heart surgery& VSD closure.
CARDIAC SURGERY
Discharge Teaching:
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Activity Tolerance;
No Bike Riding Until Sternotomy Healed
Signs & Symptoms of Wound Infection
Return to School in 2 Weeks
Usually, No Further Cardiovascular Problems
ALLOW THE CHILD TO LIVE A NORMAL AND
ACTIVE LIFE!
Congestive Heart Failure (CHF)
Cardiac Output (CO) Inadequate to Support
Circulatory & Metabolic Needs
Causes: volume overload, pressure overload,
decreased contractility, high cardiac output demands
Infant Tires During Feeding (OFTEN FIRST Indication
of CHF)
Symptoms Increase With Progressing Disease
Cardiomegaly Occurs As Heart Attempts to Maintain
Cardiac Output
If Tachycardia Greater than 180-220 BPM; Ventricles
Unable to Fill & CO Falls
CHF
CHD Most Common Cause of CHF in Infants
S/S: Tachycardia Diaphoresis, Tachypnea,
Feeding problem, Crackles & Respiratory Distress;
Edema, weight
CXR Shows Large Heart.
Echocardiogram is Diagnostic.
CHF
Medical Management:
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Digoxin To Make Heart Work More
Efficiently
Lasix/Diuretics To Remove Excess Fluid
Oxygen: Potent Vasodilator which
decreases pulmonary vascular resistance.
Rest, a neutral thermal environment, semiFowler position, cluster care to promote
uninterrupted rest
CHF
Nursing care
 Monitor physiologic functions: BP, HR, RR
 Prevent infection; Group care; Semi-Fowler
position.
 Adequate Nutrition: Feeding Techniques: 45
Degree Angle; Rest Frequently.
 Promote Development: Play, Age Appropriate
Toys, Physical Activities With Rest Periods
 Emotional Support: Prevent Hypoxia From
Agitation or Distress; Consistency of Caregiver
for Patient; Refer-Parent-to-Parent Support
Groups.
ENDOCARDITIS
Patients With CHD, Prosthetic Cardiac Valve,
Multiple Invasive Lines, etc May Be at
Increased Risk
Streptococcus viridan (most common)
Insidious onset, low-grade intermittent fever,
non-specific: malaise, myalgias
Definitive Diagnosis: Blood Cultures
Intravenous Antibiotics for 2-8 Weeks
Bedrest in Acute Phase
Prevention is Best; Inform Dentist & MD for
Prophylaxis PRIOR to Procedures
RHEUMATIC FEVER
Inflammatory Disease Following Initial Infection
by Group A Beta Hemolytic Streptococci; Cause
Changes in Heart, Joints, Skin & CNS.
Diagnosis: ESR( erythrocyte segmentation rate),
CRP(C- reactive protein), ASLO (anti-streptolysin
O-titers)
Treatment With Antibiotics To Treat Strep
Infection
Aspirin To Control Joint Pain & Inflammation
Prevention is Best
Treatment: Throat Culture & Treat With
Antibiotics for 10 Days