Transcript Pediatric Cardiovascular Disorders

Pediatric Cardiovascular
Disorders
Presented by
Christina Hernandez RN, MSN
Fetal Circulation
Fetal Cardiac Circulation
 ↑pulmonary resistance forces blood into
descending aorta
 Umbilical vein→ liver→ ductus venosus→
inferior vena cava→ right atrium →
foramen ovale (bypass lungs for
oxygenation) → left atrium → left
ventricle → aorta → body
Secondary Fetal Circulation
 Right atrium → right ventricle →
pulmonary artery → ductus arteriosus
→ aorta →body
 Why does the blood flow this
direction?
 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
Critical thinking:
 When are most cardiac anomalies
discovered?
 What is included in the initial cardiac
assessment of a newborn?
 Why?
Assessment
 History
 Physical
 Diagnostic
Why is it important for the nurse to know the
normal value for O2 saturation?
 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
At what O2 saturation does cyanosis occur?
Peripheral cyanosis occurs at <= 80%
Brain damage occurs <= 85%
Hypoxic Level
Oxygen Saturation
Mild hypoxia
Moderate
Severe
90-95%
85-90%
<85%
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?)
Congestive Heart Failure
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
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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
Goal of Treatment:
 Improve cardiac function
 Remove accumulated fluid and Na+
 Decrease cardiac demands
 Decrease O2 consumption
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
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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
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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:
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InfantsChildTeenager/ 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
Cardiac Catheterization
 Measures oxygen saturation and pressures in cardiac
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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 Heart Disease
Congenital Cardiac Defects
Increase Pulmonary Blood Decrease Pulmonary
Flow
Blood Flow
 Patent Ductus Arterious
 Pulmonic stenosis
 Atrial Septal Defect
 Tetralogy of Fallot
 Ventricular Septal defect
 Tricuspi atresia
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
 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.
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
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What is most common indication
of a congenital heart defect?
Left to Right Shunting
 Atrial Septal Defects
 Ventricular Septal Defects
 Patent Ductus Arterious
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
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Medications – digoxin
 Cardiac Catheterizaton 
Amplatzer septal occluder
 Open-heart Surgery
Treatment
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 with a patch inserted
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
Indomethacin Inhibits 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
•Surgical – Ligate the
Ductus Arteriosus
Nursing Care:
 Pre-op
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Patient/parent teaching
Assess for infection
 Obtain lab values for chart
 Post-op
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ABCs
Rest
Hydration/nutrition
Prevent complications
Discharge teaching
Obstructive or Stenotic Defects
Obstructive or Stenotic Defects
 Pulmonic Stenosis
 Aortic Stenosis
 Coarctation of the Aorta
Pulmonic Stenosis
 Narrowing of entrance that
decreases blood flow
 Treatment:
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Medications –
Prostaglandin E 1 to keep
the PDA open
Cardiac Catheterization
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Baloon Valvuloplasty
Surgery
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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 Stenosis
 Goals of management are to
improve ventricular function and
restore blood flow to the lower
body.
 Medical management with
Medication
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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 Disorders
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
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Treatment of Tetralogy of Fallot
 Surgical interventions
Blalock – Taussig or Potts procedure –
increases blood flow to the lungs.
 Open heart surgery
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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
Cyanotic Lesions with Increased
Pulmonary Blood Flow
 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 the great arteries
 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
Nursing Diagnosis & Goals:
DX: Alteration in cardiac output: decrease R/T
heart malformation
Goal: Child will maintain adequate cardiac
output AEB:
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 defectsSigns & Symptoms
 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
Review of Nursing Care cont…
Decrease blood flow and mixed defectsSigns & Symptoms cont…
 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?)
Review of Nursing Care cont:
Decreased flow or mixed defects
 Surgical correction of defect if life threatening
 Administer prostaglandin E1 (PGE1) to re-open the
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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)
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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:
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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
Patent airway
 IPPB, C&DB, O2 therapy
 Chest suction or chest
tube
Monitor VS
Promote rest
Monitor I&O- adequate
hydration (fluid & electrolyte
balance)
Turn frequently (skin care)
Assess extremities (circulation
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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?
Acquired Cardiac Diseases
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
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?
Clinical Manifestations:
 Onset insidious
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Fever
Lethargy/general malaise
Anorexia
Splenomegaly
Retinal hemorrhages
Heart murmur –90%
Diagnosis- positive blood culture
Nursing Care
 Medication-large doses antibiotic
 Bed rest
 Teach to notify dentist prior to dental work
Kawasaki Disease- multi-system vasculitis
Mucocutaneous lymph node syndrome
 Not contagious
 Preceded by upper respiratory tract infection
 Cause unknown
Kawasaki Disease
 Acute
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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
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Phase 10-25 days
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 25-60 days
 Self
limiting
 Transverse on nailbeds
 Lasts until return to normal of all lab
values
Diagnosis of Kawasaki Disease:
 ECG
 CBC, WBC
 PT
 ESR
 SGOT, SGPT
 IgA, IgG and IgM
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
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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.
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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?
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
For questions or concerns regarding this lecture
content please contact:
Christina Hernandez RN, MSN
[email protected]