Transcript Week 12 2008 Cardiac

Week 12, 2008
Cardiac, hematology, &
pulmonary anomalies
Resources for ppte
• Hockenberry & Wilson Text
• Hockenberry & Wilson Text CD
• Mosby Electronic Image Collection
2001,2003,
• Partner pptes and past pptes for 277
• Virtual Clinical Excursions/ Hockenberry,
Mosby 2003/ Disc 1
• Various websites as listed :
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Anatomy Atlases is curated by Ronald A. Bergman, Ph.D.
All contents copyright © 1995-2007 the Author(s) and Michael P. D'Alessandro, M.D
TOPICS for the week
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Preparatory Focus:
Review cardiopulmonary assessment skills for all ages ( Mosby Care of
infants and children DVD/CD & Text CD will help)
Cardiac and pulmonary anatomy and physiology, transition at birth
Cardiac diagnostic tests. EKG. Ultrasound (Echo)
Cardiac catheterization
Lab tests and results norms and indicators of cardiac anomalies
CLASS FOCUS:
Cyanotic and acyanotic cardiac defects as listed
Congestive heart failure in children
Common Cardiac medications
Systemic hypertension and pediatric strokes
Hyperlipidemia and hypercholesterolemia
Endocarditis,Rheumatic Fever
Kawasaki Disease
Learning resources also include
your Text CD
• Look up the various activities, questions,
animations, care plans and guidelines . Review
your assessment activities and lots of other
great things that will assist you with mastery of
the highlights. Remember as well, for those who
are interested, that you can also get onto the
EVOLVE website through your password that
comes with the text. This may be of interest to
some of you . Look up the topics on the Web,
lots of free learning resources there to help.
CONGENTIAL HEART DISEASE
CHD
• From the moment of
birth
• Life hangs in the
balance
Two Types of Cardiac Defects
• Congenital
– Anatomic → abnormal function
• Acquired
– Disease process
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Infection
Autoimmune response
Environmental factors
Familial tendencies
Comparison of CHD
Classification Systems
Causes of CHD
Maternal or environmental = 1% to 2%
Maternal drug use
Fetal alcohol syndrome—50% have CHD
Maternal illness
Rubella in first 7 weeks of pregnancy → 50%
risk of defects including PDA and pulmonary
branch stenosis
CMV, toxoplasmosis, other viral illnesses →
cardiac defects
IDMs = 10% risk of CHD (VSD,
cardiomyopathy, TGA most common)
Chromosomal/genetic = 10% to 12%
Multifactorial = 85%
Incidence of Congenital Heart Disease
(CHD)
• Incidence: 5 to 8 per 1000 live births
– About 2 or 3 of these are symptomatic in first
year of life
– Major cause of death in first year of life (after
prematurity)
– Most common anomaly is VSD
– 28% of kids with CHD have another
recognized anomaly (trisomy 21, 13, 18, + )
Fetal Circulation Structures
• Umbilical vein,
umbilical arteries
• Foramen ovale
• Ductus arteriosus
• Ductus venosus
• These change upon
transition into selfsustaining life and
extrauterine changes.
CHANGES THAT OCCUR AT
BIRTH
Pediatric Indicators of
Cardiac Dysfunction
• Poor feeding
• Tachypnea/tachycardia
• Failure to thrive/poor weight gain/activity
intolerance
• Developmental delays
• Prenatal history
• Family history of cardiac disease
Normal Chamber Pressures and
Oxygen Saturations
• Note how the
oxygenation percentages
increase upon return to
the heart from the lungs,
and how the pressure
shifts allowing the blood
to be pumped in a closed
system loop with the
greatest pressure and O2
percentage in the left
ventricle just prior to
ejection into the aorta.
“Innocent Murmurs”
• Murmurs = heart sounds that reflect flow of
blood within the heart
– May occur in systole or diastole, or both
– Can occur in a normal heart in periods of
stress: anemia, fever, or rapid growth
– Can reflect abnormalities in heart or vessels
• “Innocent murmurs” = normal cardiac
anatomy and cardiac function
– Occur in up to 50% of all kids at some time
Thrills
• The sound of a thrill is a soft vibration over
the heart that reflects the transmitted
sound of a heart murmur
Interventional Cardiac Catheterization
Procedures in Children
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Transposition of great vessels
Some complex single-ventricle defects
ASD
Pulmonary artery stenosis
DIAGNOSIS
Valvular pulmonic stenosis
INTERVENTION
Balloon dilation
Recurrent coarctation of aorta Balloon dilation
Congenital mitral stenosis
Balloon dilation
Diagnostic Testing
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X-ray
Pulse oximetry
Pulmonary function tests (PFT)
Cultures – throat, nasal, sputum
Nasal aspirate – RSV
Blood gases
Bronchoscopy
CT or MRI scans
Tests of Cardiac Function
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Chest x-ray
ECG
Echocardiography
Cardiac
catheterization
Cardiac Catheterization
• Most invasive diagnostic procedure
• Usually performed with angiography
• Useful for determining:
– O2 saturation within chambers of heart
– Pressure changes within chambers
– Cardiac output or stroke volume
– Anatomic abnormalities
Catheterization Cont’d
• Can be diagnostic or interventional
• 2 Types
– Right sided
– Left sided
May be performed on an outpatient basis
Possible complications: hemorrhage, low grade
fever, N/V, loss of pulse in extremity
Nursing Care see p.1443-1446
• Preprocedural:
• Postprocedural:
Other Classifications of CHD
• Hemodynamic characteristics
– Increased pulmonary blood flow
– Decreased pulmonary blood flow
– Obstruction of blood flow out of the heart
– Mixed blood flow
• CONGESTIVE HEART FAILURE
CHF
Signs and Symptoms
• Impaired myocardial function
– Tachycardia; fatigue; weakness; restless, pale, cool
extremities; decreased BP; decreased urine output
• Pulmonary congestion
– Tachypnea, dyspnea, respiratory distress, exercise
intolerance, cyanosis
• Systemic venous congestion
– Peripheral and periorbital edema, weight gain,
ascites, hepatomegaly, neck vein distention
CONGESTIVE HEART FAILURE
Congestive Heart Failure
• Impaired cardiac function: ventricles
unable to eject blood efficiently leads to
volume overload, enlarged ventricles,
increased intracardiac pressure
• Main cause is congenital heart disease,
cardiomyopathy, anemia, hemorrhage,
fever
Children:
• HR sensitive to O2 level; cardiac
output dependent on HR until age 5
years
– Increased risk of heart failure due to
• Immature heart sensitive to volume or
pressure overload
• Muscle fibers less developed
• Checking all pulse points is
essential when cardiac
anomalies are suspected. Also
BP’s bilaterally sitting, standing
and supine
+ Cap refills and
edema checks
• Clubbing of the fingers – and
toes, as a sign of inadequate
oxygenation and decreased
circulation to peripheral digits
over time . Spoon-like nails,
nail beds cyanotic
Pathology
• Right ventricle: less oxygenated blood,
right atrium has increased pressure that
backs up venous circulation—edema in
extremities
• Left Ventricle: pressure increases in left
atrium and pulmonary veins because left
ventricle can’t pump enough blood into
systemic circulation—lungs become
congested with blood and get pulmonary
edema
S&S
• Weakness, fatigue, poor feeding,
irritability, pallor, cyanosis
• Dyspnea, tachypnea, orthopnea,
wheezing, cough, grunting, tachycardia
• Cardiomegaly, hepatomegaly
• Edema, ascites, pleural effusion
• Distended neck & peripheral veins
Care of the Family and Child with
Congenital Heart Disease
• Help family adjust to
the disorder
• Educate family
• Help family cope with
effects of the disorder
• Prepare child and
family for surgery
Management
• V/S, monitor for resp. distress, altered
cardiac output, I & O
• Daily weights, monitor Hct and electrolytes
• small, frequent meals
• Avoid exposure to infections
• Monitor medications for side effects
Anatomy Atlases is curated by Ronald A. Bergman, Ph.D.
All contents copyright © 1995-2007 the Author(s) and Michael P. D'Alessandro, M.D. All rights reserved.
"Anatomy Atlases", the Anatomy Atlases logo, and "A digital library of anatomy information" are all Trademarks of
Michael P. D'Alessandro, M.D
• Small and frequent
amounts of high caloric
and iron enriched formula
given with soft large holed
nipple to prevent fatigue
and heart strain. Avoid
pressure on the heart from
full tummy and vice versa
a d = Descending aorta,
a s = Left azygos vein,
a d = Right azygos vein,
c d = Descending Vena Cava.
Considerations for child care with
CARDIAC Conditions
• Careful measuring of all
sources of intake and output
are essential hour by hour
• Weigh all diapers/ output
• Positioning in semifowler’s,
>30’ angle
• IV on pump
• Monitor environmental temp (
not too warm or cold)
• Hat and booties, swaddled
• Regularly examine blood work
and EKG tracings and report
any variations beyond
accepted parameters
• Comforting human touch
/contact
• Precise vitals, accurate take
time to do .
• Transdermal O2 sats. Rotate
sites to avoid tissue burns
• Regulate O2 as ordered- hood
or isolette
• Avoid startling and sudden
movements
• Prevent crying
• Avoid constipation
• Check lung sounds all lobes
• Practice meticulous infection
barrier care
Knee-Chest Position
When cardiac symptoms appear…
Life becomes a race
• To discover the
problem
• To keep body
oxygenated
• To sustain life,
mechanically assisted
or through surgery
• To get to Centres of
Excellence for care
Cardiac Medication
• Digoxin-increases cardiac output
• Doses for children is in micrograms
• Pg. 1482 for administering, withhold if
pulse below 90/min
• Lasix-diuretic to eliminate excess water &
salt
• Monitor electrolytes
Comparison of CHD
Classification Systems(again)
Increased Pulmonary Blood
Flow Defects
• Abnormal connection between two sides
of heart
– Either the septum or the great vessels
• Increased blood volume on right side of
heart
• Increased pulmonary blood flow
• Decreased systemic blood flow
Increased Pulmonary Blood
Flow Defects
• 1. Atrial septal defect
• 2. Ventricular septal defect
• 3. Patent ductus arteriosus
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Atrial Septal Defect
• R and L atriums are
connected through
septal defect
• Shunting: LA to RA
• Increased pulmonary
blood flow
• Surgical patch before
school age
Ventriclular Septal Defect
• R & L ventricles are
connected through
septal defect
• Shunting: LV to RV
• RV hypertrophies due
to increased volume
• Surgical repair
ATRIOVENTRICULAR CANAL
DEFECT
Patent Ductus Ateriosus
• Failure of ductus
ateriosus to close
after birth
• Increased workload
on L side of heart
• Aorta connects to
pulmonary artery –
shunting blood
• May be asymptomatic
• Ligation of vessel
Obstructive Defects
• 4.Coarctation of the aorta
• 5.Aortic stenosis
• 6.Pulmonic stenosis
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Coarctation of the Aorta
• Narrowing of aorta with
build up of pressure to
head and upper
extremities
• Increased BP and
bounding pulses in arms
• Surgery before 2 yrs of
age
• Change of recurrence
• Balloon angioplasty
Aortic Stenosis
• Narrowing or stricture
of aortic valve
• Results in:
decreased cardiac
output
• Children have
exercise intolerance
• Balloon valvoplasty
Pulmonary Stenosis
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Narrowing of pulmonary valve
Increases pressure in RV and results in hypertrophy
Cardiomegaly
Balloon valvoplasty
Mixed Defects
• Tetralogy of Fallot – VSD, PS, overriding
aorta, RV hypertrophy
Complete mixing of oxygenated and deoxygenated blood
• Tricuspid atresia – Tricuspid valve fails to
develop + VSD – total mixing of blood
• Transposition of Great Arteries or Great
Vessels – lack of communication between
systemic and pulmonary circulations
TETRALLOGY OF FALLOT
• Tet babies
TRICUSPID ATRESIA
TRANSPOSITION OF THE GREAT
ARTERIES
Total Anomalous Pulmonary
Venous Connection
TRUNCUS ARTERIOSIS
Hypoplastic Left Heart
Conduction System of the Heart
Cardiac Dysrhythmias
• Diagnostic evaluation
– ECG
– Holter monitoring
– Electrophysiologic cardiac catheter
– Transesophageal recording
Cardiac Dysrhythmias (cont.)
• Brady dysrhythmias
– AV block
– May use pacemaker
• Tachy dysrhythmias
– SVT most common tachydysrhythmia
– Treatments
TOP - Normal ECG Pattern
• BOTTOMHEART BLOCK
COMPARE
Electrode Placement for Standard
Chest Lead II
SVT
Cardiac Surgery
• Canada has been a leader in corrective
surgery as well as in transplants
Cardiomyopathy
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Contractibility of myocardium is impaired
Secondary cardiomyopathy
Dilated cardiomyopathy
Hypertrophic cardiomyopathy
Restrictive cardiomyopathy
Therapeutic Management of
Cardiomyopathy
• Correct underlying cause if possible
• Often treatment is aimed at managing CHF and
dysrhythmias
• Pharmacologic Interventions for Cardiomyopathy
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Digoxin
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Diuretics
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Beta blockers,
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calcium channel blockers
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Dobutamine
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Nitroprusside
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Amrinone
More Pharmacologics Used with
CV Disorders
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IV IgG
Digoxin (Lanoxin)
ACE inhibitors
ASA, NSAIDs
Lasix
Spironolactone (Aldactone)
SURGICAL SHUNT CREATION
Cardiac Shunts - Surgical
interventions
Surgical Interventions
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Open heart
Closed heart procedures
Staged procedures
Prepare child and family for procedures
POSTOPERATIVE CARE IS
INTENSIVE
Postoperative Care for the Child
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Monitor vital signs and A/V pressures
Intra arterial monitoring of BP
Intra cardiac monitoring
Respiratory needs
Rest, comfort, and pain management
Fluid management
Progression of activity
Warmth regulation, gradual
Postoperative Complications
• CHF
• Dysrhythmias
• Decreased cardiac
output syndrome
• Decreased peripheral
perfusion
• Pulmonary changes
• Neurologic changes
Postpericardiotomy Syndrome
• Symptoms: fever,  WBCs, pericardial friction
rub, pericardial and pleural effusion
• Occurs in immediate postoperative period
• Also can occur later (days 7 to 21 postop)
• Etiology unknown
• Theories of etiology
– Viral infection, autoimmune response, reaction to
blood in pericardium
– May require pericardiocentesis or pleurocentesis
Heart Transplantation
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Orthotopic transplant
Heterotopic transplant (piggyback)
Organ donation issues
Nursing considerations
Acquired Cardiovascular
Disorders
Neonatal Jaundice
Neonatal Jaundice contd.
Care to keep eyes covered under UV bili-lights
Exposure to the most skin surface is effective
Watch for burns and provide skin care as may have dry
itchy skin
Carefully monitor the intake and output – watch for
dehydration,& accumulation of hematologic bi-products
Physiological load on liver and kidneys as well as brain
may require close observation of vital signs
Apical heart rate is required for infants and toddlers
No longterm effects are usually noted as organs mature
and become competent in excreting the products of
haemoglobin breakdown
Hyperlipidemia
• Identify kids at risk and treat early
• Treatment = dietary
– Restrict intake of cholesterol and fats
• If no response to diet → Rx
– Colestipol (Colestid)
– Cholestyramine (Questran)
Systemic Hypertension
• Primary = no known cause
• Secondary = identifiable cause
• Pediatrics: HTN generally secondary to
structural abnormality or underlying
pathology
– Renal disease
– CV disease
– Endocrine or neurologic disorders
BP Screenings for Children
Acquired Cardiovascular Disorders
• Infectious and inflammatory cardiac
disorders
Endocarditis
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BE, IE, or SBE
Streptococci
Staphylococci
Fungal infections
Prophylaxis: 1 hour before procedures (IV)
or may use PO in some cases
Rheumatic Fever (RF) and
Rheumatic Heart Disease
• RF
– Inflammatory disease occurs after group A β-hemolytic
streptococcal pharyngitis
– Infrequently seen in U.S.; big problem in Third World
– Self-limiting
• Affects joints, skin, brain, serous surfaces, and heart
• Rheumatic heart disease
– Most common complication of RF
– Damage to valves as result of RF
Clinical Manifestations of RF
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Carditis
Polyarthritis
Erythema marginatum
Subcutaneous nodules
St. Vitus Dance:
The Fifth Manifestation
• St. Vitus Dance (aka, chorea) reflects CNS
involvement
• Definition: Chorea refers to sudden,
aimless movements of extremities,
involuntary facial grimaces, speech
disturbances, emotional lability and
muscle weakness
– Worse with anxiety and relieved by rest
Prevention of RHD
• Treatment of streptococcal
tonsillitis/pharyngitis
– Penicillin G—IM x 1
– Penicillin V—oral x 10 days
– Sulfa—oral x 10 days
– Erythromycin (if allergic to above)—oral x 10
days
• Treatment of recurrent RF
– Same as above
Kawasaki Disease
• Acute, systemic vasculitis of unknown
cause
• Self-limiting 6-8 weeks
• Without treatment: 20-25% will develop
cardiac sequelae
• Pathophysiology:
• S/S:
Kawasaki Disease Treatment
• IV IgG
fever
ASA 80-100 mg/kg/day—
Then 3-5 mg/kg/day—antiplatelet
DIC is not very common in children,
but it does happen
As does Henoch Schonlein
Purpura
Healthy hearts are the goal