Transcript Congenital heart disease

CARDIOVASCULAR
Islamic University – Nursing College
Fetal Circulation

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Foramen ovale:
 Is anatomical opening between the right atrium and left
atrium which closes shortly after birth.
 Higher pressure in the left atrium due to increased
pulmonary blood flow cause the foraman ovale to close.
Ductus arteriosus:
 A vessel that connects the main pulmonary artery to the
aorta
 The ductus arteriosus should functionally close within
15 hours and structurally within a few weeks (in mature
infants)
 Higher concentrations of oxygen in the blood,
decreased prostaglandin levels and decreased
pulmonary vascular resistance closes the ductus
arteriosus.
Functions of Cardiovascular
System
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The cardiovascular system is responsible for
circulating blood throughout the body
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A healthy cardiovascular system is vital to
supplying the body with oxygen and nutrients
Assessment of Cardiac Function
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History: parents usually report
Poor weight gain, poor feeding habits, fatigue during
feeding, sweating with feeding.
 Frequent respiratory infections and difficulties
(tachypnea, dyspnea, shortness of breath, persistent
cough).
 Cyanosis
 Evidence of exercise intolerance
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Assessment of Cardiac Function
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History
A previous cardiac defects in a sibling
 Maternal rubella infection during pregnancy,
 The use of medications or chemicals during pregnancy
 Chronic illness
 Children with chromosomal abnormalities are likely to
have associated congenital heart defects.
 A history of viral infection or toxic exposure
(myocardities)
 A history of streptococcal infection (Rheumatic fever)
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Assessment of Cardiac Function
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Physical Examination; Vital signs
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Tachycardia or bradycardia may indicate cardiac
disease.
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Tachypnea may indicate congestive heart failure.
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Hypertension; Differences in BP between the upper and
lower extremities may indicate coarctation of the aorta.
Assessment of Cardiac Function
 Physical
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Exam; Inspection
Skin color ( cyanosis, flushed skin)
Position of comfort
Presence of clubbing
Lethargy and overall
Nutritional status
Assessment of Cardiac Function
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Physical Exam; Palpation
The point of maximum intensity and the apical impulse
 The presence of a thrill/murmur should be noted.
 The quality and symmetry of all pulses.
 Warmth of extremities, capillary refill, and presence or
absence of edema.
 Locating the hepatic and splenic borders
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Assessment of Cardiac Function
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Physical Exam; Auscultation
Heart sounds, heart rate and rhythm.
 The presence of additional heart sounds, such as a
murmur, is noted.
 Lung sounds
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Murmurs
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Innocent murmurs vs. Organic murmurs
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An innocent or functional heart murmur
Not resulting from heart disease
 This is the most common type of heart murmur
 May be caused by fever, anemia, or a thin chest
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Organic murmur
Indicates abnormality in the heart or a major artery
 May be caused by a narrow valve, a leaking valve, or a hole in
the heart
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Murmurs
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How to assess murmurs
Position in cardiac cycle
 Duration & location
 Quality; pitch, intensity
 Whether there is a thrill
 Whether the murmur changes with position change
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Organic murmurs are
Either systolic or diastolic
 Long, harsh or blowing, loud
 constant
 heard not matter what position the child is in.
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Diagnostic procedures to Evaluate the
Cardiovascular Function
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CBC
Electrolytes
PT (Prothrombin Time)& PPT (Partial Thromboplastin Time)
Total protein and Albumin.
Blood gases (pulse oximetry)
Radiography; MRI
Treadmill Test (physical test)
ECG/ EKG provides information about:
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Electrical activity of the heart
HR, rhythm, presence or absence of hypertrophy, ischemia or necrosis,
Abnormalities in the conduction system
Presence of electrolyte imbalances
Cardiac Catheterization
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A diagnostic invasive
procedure
Catheter is inserted
through a peripheral blood
vessel into the heart, to
visualize the structures
inside & function
Other purpose
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To obtain cardiac tissue
samples for biopsy.
Close small holes inside
the heart
Place wire devices, called
stents, in narrowed arteries
to keep them open
Heart X-ray film
Cardiac Catheterization
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Nursing care; Pre- catheterization education
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Explain about catheterization
What to expect during and after the test (child will have to lie flat and
will have a bulky dressing over the catheter insertion site)
Post-Procedure
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Lie flat 3-4 hours
V/S every 15 minutes for the first several hours
Check site every 15 minutes for integrity of dressing
Check pulses distal to site & extremity for capillary refill and warmth
Avoid dehydration & hypothermia
Check for signs of infection
Avoid tub baths and strenuous exercise for 2-3 days
Classification of Congenital Heart Disease
A cyanotic
Increased pulmonary
blood flow
Atrial septal
defect
Ventricular septal
defect
Patent ductus
arteriosus
Atrioventricular
canal
Obstruction to blood
flow from ventricles
Coarctation of
aorta
Aortic stenosis
Pulmonic
stenosis
Cyanotic
Decreased pulmonary
blood flow
Tetralogy of
Fallot
Tricuspid
atresia
Mixed blood flow
Transposition
of great
arteries
Truncus
arteriosus
Hypoplastic left
heart syndrome
Congenital heart disease:
Increased pulmonary blood flow
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Atrial Septal Defect
(ASD)
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Ostium primum
Lower end of septum
 5%
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Ostium secundum
(most common)
In the center of septum
 90%
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Sinus venosus
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Higher end of the
septum near junction of
superior vena cava and
right atrium
Congenital heart disease:
Increased pulmonary blood flow:ASD
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CM
Many children have no symptoms and seem healthy
 If the opening is large S& S of CHF may develop and
increased the risk of endocarditis.
 Harsh systolic Murmur over 2nd or 3rd ICS.
 A Widely split in S2.
 Atrial dysrhythmias
 Pulmonary vascular obstructive diseases and emboli
formation later in life from chronic
 Enlarged right side and increased pulmonary
circulation
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Congenital heart disease:
Increased pulmonary blood flow: ASD
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Treatment of ASD
 ASD
may close spontaneously as the child grows
 Some children may need medication such as
digoxin and diuretics
 Control infection
 Catheterization may be needed to close the
septum
Congenital heart disease:
Increased pulmonary blood flow
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Ventricular Septal
Defect (VSD)
Most common
congenital heart defect
 Can be classified as
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 Membranous VSD
(located in the upper
section; 80% of all VSD
cases
 Muscular VSD (located
in the lower section; 20%
of all cases)
Congenital heart disease:
Increased pulmonary blood flow: VSD
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CM
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Fatigue
Sweating
Rapid, heavy, congested breathing
Disinterest in feeding
Poor weight gain
Murmurs
May lead to hypertrophy and enlargement of the right atrium
CHF is common
Treatment: Surgical repair
Congenital heart disease:
Increased pulmonary blood flow
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Patent Ductus Arteriosus
(PDA)
CM
Asymptomatic or signs of
CHF
 Murmurs
 A widened pulse pressure
& bounding pulses
 At risk for endocarditis &
pulmonary vascular
obstructive disease
 Treatment
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Prostaglandin inhibitor
 Surgical repair
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Classification of Congenital Heart Disease
A cyanotic
Increased pulmonary
blood flow
Atrial septal
defect
Ventricular septal
defect
Patent ductus
arteriosus
Atrioventricular
canal
Obstruction to blood
flow from ventricles
Coarctation of
aorta
Aortic stenosis
Pulmonic
stenosis
Cyanotic
Decreased pulmonary
blood flow
Tetralogy of
Fallot
Tricuspid
atresia
Mixed blood flow
Transposition
of great
arteries
Truncus
arteriosus
Hypoplastic left
heart syndrome
Congenital heart disease:
Obstructive Defects
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Coarctation of the Aorta
(COA)
Narrowing anywhere in the
aorta
 Increased pressure
proximal to the defect
 Restricts the amount of
oxygenated blood to lower
part
 LT ventricle has to work
harder
 Risk for endocarditis
 Coronary arteries may
narrow due to high pressure
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Congenital heart disease:
Obstructive Defects: COA
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CM
High BP and bounding pulse in arms
 Low BP & Absent femoral pulse and cool extremities
 Headaches, dizziness , fainting & epistaxis
 Cramps in the legs
 Pt at high risk for hypertension, ruptured aorta and stroke
 Kidneys’ function may be altered ( decrease urine )
 Treatment
 Enlargement of constricted section (surgical or
nonsurgical (Balloon angiplasty))
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Congenital heart disease:
Obstructive Defects
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Aortic Stenosis (AS)
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Narrowing or stricture of the
aortic valve
Types of AS:
Valvular stenosis
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Subvalvular stenosis
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The most common
caused by malformed cusps
Resulting in a bicuspid rather than
tricuspid valve or fusion of the
cusps.
Is a stricture caused by a fibrous
ring below a normal valve.
Supravalvular stenosis
Congenital heart disease:
Obstructive Defects: Aortic Stenosis (AS)
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Aortic Stenosis (AS)
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CM
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Extra workload on the left ventricle causes hypertrophy which causes an
increase in the left atrium pressure in turn increases the pressure in the
pulmonary veins
AS is progressive, associated with sudden episodes of myocardial ischemia
Sudden death is possible
Faint pulses, hypotension , tachycardia & poor feeding
Chest pain , Dizziness when standing
Murmurs
Treatment
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Balloon dilatation (via cardiac catheterization)
Valvotomy involves a surgical removal of adhesion that preventing valve leaflets
from opening
Aortic valve replacement
Congenital heart disease:
Obstructive Defects Pulmonary Stenosis

Pulmonary Stenosis
(PS)
Narrowing at the entrance of
the pulmonary artery
 When RT ventricular failure
develops this causes an
increase in the RT atrial
pressure
 The accelerating pressure
reopen the foramen ovale
causing systemic cyanosis
 In severe cases CHF occurs
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Congenital heart disease:
Obstructive Defects: PS
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CM
Mild cases are asymptomatic
 Cyanosis in severe cases
 Murmurs
 Cardiomegaly (chest X-ray)
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Treatment
Depends on the degree of the stenosis may wait for a few
years
 Relieve stenosis or valve adhesion by balloon angioplasty
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Classification of Congenital Heart Disease
A cyanotic
Increased pulmonary
blood flow
Atrial septal
defect
Ventricular septal
defect
Patent ductus
arteriosus
Atrioventricular
canal
Obstruction to blood
flow from ventricles
Coarctation of
aorta
Aortic stenosis
Pulmonic
stenosis
Cyanotic
Decreased pulmonary
blood flow
Tetralogy of
Fallot
Tricuspid
atresia
Mixed blood flow
Transposition
of great
arteries
Truncus
arteriosus
Hypoplastic left
heart syndrome
Congenital heart disease
Decreased Pulmonary Blood Flow
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Tetralogy of Fallot (TOF)
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The classic form includes
four defects:
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Ventricular septal defect
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Pulmonic stenosis
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Overriding aorta: the aorta
is shifted towards the right
side of the heart so that it
sits over the ventricular
septal defect
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Right ventricular
hypertrophy
Congenital heart disease
Decreased Pulmonary Blood Flow: TOF
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In mild right ventricle obstruction, the pressure in the right
ventricle can be slightly higher than the left, thus some of the
deoxygenated blood in the right ventricle will pass through
the VSD to the left ventricle thus a child may not appear
blue
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In severe obstruction in the RT ventricle the large amount
of de-oxygenated blood passes via VSD into the LT ventricle
thus these children appear blue
Tetralogy of Fallot occurs in about two out of every 10,000 live
births.
It makes up about 8 percent of all cases of congenital heart
disease.
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Congenital heart disease
Decreased Pulmonary Blood Flow: TOF
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CM
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Infants may be acutely cyanotic at birth; others have mild cyanosis
CM progresses over the first year of life as the pulmonic s tenosis worsens
Murmur
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Acute episodes of cyanosis and hypoxia, called blue spells "".
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Anoxic spells occur when the infant's oxygen requirements
exceed the blood supply (crying, tighter pulmonary artery )
Children with cyanosis may have clubbing nail, squatting
position, poor growth
TOF children at risk for cerebrovascular disease and sudden
death
Polycythemia
Treatment: primarily palliative shunt then complete repair
(such as closure of VSD)
Congenital heart disease
Decreased Pulmonary Blood Flow
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Tricuspid Atresia (TA)
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Failure of the tricuspid valve to
develop so there is no
communication from the right
atrium to the right ventricle
Blood flows through an atrial
septal defect or a patent foramen
ovale to the left side of the heart
and through a VSD to the right
ventricle
associated with pulmonic stenosis
and transposition of great
arteries.
complete mixing of deoxygenated
and oxygenated blood in the left
side of the heart, resulting in
systemic cyanosis
Congenital heart disease
Decreased Pulmonary Blood Flow: TA

CM
 Cyanosis
 Tachycardia
& dyspnea
 Clubbing nail
 Children with TA at risk for stroke
 Treatment
 Prostaglandin
 Palliative treatment; shunt to increase blood flow
to the lungs
 Surgical treatment
Classification of Congenital Heart Disease
A cyanotic
Increased pulmonary
blood flow
Atrial septal
defect
Ventricular septal
defect
Patent ductus
arteriosus
Atrioventricular
canal
Obstruction to blood
flow from ventricles
Coarctation of
aorta
Aortic stenosis
Pulmonic
stenosis
Cyanotic
Decreased pulmonary
blood flow
Tetralogy of
Fallot
Tricuspid
atresia
Mixed blood flow
Transposition
of great
arteries
Truncus
arteriosus
Hypoplastic left
heart syndrome
Congenital heart disease
Mixed Defects
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Transposition of Great
Arteries/Vessels (TGA/V)
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The pulmonary artery leaves
the left ventricle, and the
aorta exits from the right
ventricle, with no
communication between the
systemic and pulmonary
circulation
Deoxygenated blood returns
via misconnected aorta to
the body
Oxygenated blood goes back
to lungs
Congenital heart disease
Mixed Defects (TGV/A)

Often associated with
 Septal
defects
 PDA, VSD,
 Patent foramen ovale

CM
 Severe cyanosis
 May
have signs of CHF
 Cardiomegaly a few weeks after birth
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Treatment
 Surgical
(arterial switch procedure)
Congenital heart disease
Mixed Defects
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Truncus arteriosus (TA)
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A single vessel arising from
the heart that forms the
aorta and pulmonary
arteries.
Large Ventricular septal
defect accompanies TA
Oxygenated and
deoxygenated blood mixed
inside the heart, some leaves
to the lungs others to the
systemic circulation
TA causes severe cyanosis
Congenital heart disease
Mixed Defects: TA
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CM
 Cyanosis
 Murmur
 Fatigue,
sweating, cool skin
 Increased RR & HR, heavy & congested breathing
 Disinterest in feeding and poor Wt gain
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Treatment is by surgical repair
Congenital heart disease
Mixed Defects
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Hypoplastic left heart
syndrome (HLHS)
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Is a combination of
abnormalities of the heart
and the great vessels
In HLHS most structures on
the left side of the heart are
small & underdeveloped
Mitral valve, left ventricle,
aortic valve & aorta are
involved.
The newborn develops
symptoms shortly after
delivery
Congenital heart disease
Mixed Defects: HLHS
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CM
 Cyanosis
Sweating, cool skin
 Increased RR & HR, heavy breathing
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Treatment is by series of surgical repair
Acquired Cardiovascular Disorders
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Rheumatic Heart Disease (RHD)
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Congestive Heart Failure (CHF)
Acquired Cardiovascular Disorders :RHD
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Permanent damage to the heart valves is caused by Rheumatic
Fever (RF)
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It develops after an infection of the upper RT with group A βhemolytic streptococci
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The antigens of group A Streptococci bind to receptors in the
heart, muscle, brain & synovial joints, causing an autoimmune
response
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The antigens produced by Streptococci are similar to the body’s
own antigens thus antibodies may attack healthy body cells
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RF forms Aschoff bodies(inflammatory lesions) that causes
swelling and alterations in the connective tissue
Acquired Cardiovascular Disorders :RHD
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RF major criteria
 Rheumatic
Carditis
 Polyarthritis
 Erythema marginatum
 Subcutaneous nodules
 chorea
Acquired Cardiovascular Disorders :RHD
 Rheumatic
Carditis
 Involves endocardium, pericardium
& myocardium
 CM:
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valvulitis
Myocardities
Pericarditis: muffled heart sound due to pericardial effusion,
chest pain, pericardial friction rub
Murmur
Tachycardia especially during sleep
 Polyarthritis
 Joints such as
knees, elbows, hips, shoulders & wrists
 Joints are swollen, hot, red & painful
Acquired Cardiovascular Disorders :RHD
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Erythema marginatum
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Subcutaneous nodules
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Nontender swellings mostly found on the
bony prominences areas such as feet, hands
vertebrae
Chorea
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Erythematous macule mostly found on the
trunk & extremities
Sudden & aimless irregular movements of
the extremities
Involuntary facial, grimaces
Speech disturbances
Emotional liability
Muscle weakness
Other minor criteria: arthralgia (joint
pain), fever, fatigue and elevated ESR
Acquired Cardiovascular Disorders :RHD
Diagnostic
test
Throat culture-group a beta
hemolytic
streptococcal
Increased ESR
Increased in WBC
Increased in C-reactive protein
Acquired Cardiovascular Disorders :RHD
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Treatment
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Bed rest until ESR decreases
Antibiotics (penicillin, erythromycin) x 10 days
Reduce inflammation (Salicylates: aspirin)
Corticosteroids (if not responding to aspirin alone)
Phenobarbital for chorea
Treatment of heart failure
Prophylactic antibiotics (benzathine penicillin G) for 5 years or
until 18 to prevent recurrence
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Prevention of RHD by Treating streptococcal throat infections
with a full course of antibiotic
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Complications of RHD
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Mitral valve damage
Congestive heart failure
Hypoxemia
Acquired Cardiovascular Disorders :CHF
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CHF: is a condition in which the heart cannot pump
enough oxygenated blood to meet the need of the body
organs
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CHF often occurs in children with congenital heart defects

Medical problems that may lead to CHF are
Rheumatic fever
 Endocarditis or valuvlitis
 Cardiac arrhythmias
 Cardiomyopathy
 Chronic lung disease
 Hypertension
 hemorrhage
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Acquired Cardiovascular Disorders :CHF

Causes of CHF
 Volume overload
 Pressure overload which
is caused by obstructive lesion,
stenosis or coarctation of the aorta
 Decreased contractility which may be caused by
myocardial ischemia due to
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Severe anemia
Asphyxia
Acidemia
Low level of K, glucose, Ca , Mg
 High cardiac output
severe anemia)
(such in sepsis, hyperthyroidism or
Acquired Cardiovascular Disorders :CHF
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Right side failure
 Right side is unable to pump blood
to the lungs
 Due to the congestion in the right side of the heart the
blood flow begins to back up into the veins which causing
fluid retention
 Edema can be seen in the feet, ankles, eyelids
 Left side
failure
 Left side is unable to pump much
blood to the body
 Blood begins to back up into the vessels in the lungs, thus
lungs become stressed (increased RR and labored
breathing)
 Fatigue and poor growth
Symptoms of CHF
Impaired
Myocardial Function
Tachycardia
Dec. urine output
Fatigue & weakness
Sweating restlessness
Anorexia
Pale & cool extremities
Weak peripheral
pulses
Decreased BP
Gallop rhythm
cardiomegaly
Pulmonary
Congestion
Tachypnea
Retractions
Flaring nares
Exercise intolerance
Orthopnea
(breathlessness)
Cough, hoarseness
Cyanosis
Wheezing
Grunting
Systemic Venous
Congestion
Weight gain
Hepatomegaly
Edema (is a late sign in
children and it shows up
as periorbital edema)
other sites includes feet,
ankles, face and
abdomen)
Ascites
Neck vein distension
Therapeutic Management of CHF
Improve
cardiac
function
Remove
accumulated
fluid & sodium
Decrease
cardiac
demands
Improve tissue
oxygenation &
decrease oxygen
consumption
• Digitalis (digoxin)
• Angiotensin- converting enzyme
(ACE)
• Diuretics
• Urine output 30ml/hour
•
•
•
•
Neutral thermal environment
Treat existing infections
Reducing the effort of breathing
Sedation & rest
• Improving myocardial function
• Oxygen supplement
Therapeutic Management of CHF
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Improve cardiac function

Digitalis glycosides have three actions
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Increase the force of contraction (increase cardiac output &
decrease venous pressure)
Decrease the HR & slow the conduction of the impulses through
the AV node
Increase renal perfusion (enhance diuresis)
Digoxin (Lanoxin) is used for children because of rapid
onset and decreased risk of toxicity

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Digoxin level 0.8 – 2.0 u/L
S&S of Toxicity includes nausea, vomiting, anorexia, slow HR
Hold digoxin dose
 If HR less than 100 for infant
 If HR less than 80 for older children
 If HR less than 60 for adolescents
Therapeutic Management of CHF

Improve cardiac function
 Angiotension-converting
enzyme (ACE) inhibitors
 Reduces the afterload on the heart
 Vasodilatation results
in decreased pulmonary and
systemic vascular resistance, dec. BP& dec. in right and left
atrial pressures
 Renal flow improved which enhances diuresis
 Capoten (captopril) most commonly used

Side effect include hypotension, renal dysfunction
Therapeutic Management of CHF

Remove accumulated fluid & sodium (decrease
preload)
 Use of
diuretics; lasix , diuril aldactone, Bumex,
Zaroxolyn
 Potassium supplements when
Lasix is used
 Low level of K enhances the effect of digoxin thus increases
the risk of digoxin toxicity
 High level of K diminishes the effect of digoxin
 Fluid
& sodium restriction
Therapeutic Management of CHF

Decrease Cardiac Demands (lessen heart workload)
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Using easy-to-suck nipples
Increase the frequency and decrease the amount of each feeding
Neutral thermal environment
Treating any existing infections
Reducing the effort of breathing (semi-fowler position)
Sedation if necessary
Rest
Improve tissue oxygenation and decrease oxygen
consumption

In addition to the previous management Oxygen supplement
Therapeutic Management
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Valve replacement
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Cardiac catheterization
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Cardiac surgery
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Cardiac transplantation
Cardiac Surgery
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Cardiac Surgery
 Pro-op
 Baseline V/S;
Measure Ht and Wt
 Enema
 Pt and
family teaching
 Post-op
 V/S
Q 15 minutes then Q one hr
 May need warming
 Fluid status, ABG’s , PT, PTT, electrolytes
 Observe chest tube and drainage & S&S of infection
 Pain management & Cough and deep breathing
Cardiac Surgery

Complications
 Bleeding,
shock, heart block or arrhythmias, heart
failure, neuro changes
 Postcardiac surgery syndrome

(one week post-op)
febrile illness with pericarditis
 Postperfusion syndrome
(3-12 weeks post-op)
 Fever, splenomegaly, hepatomegaly, elevated
WBC, malaise
Valve Replacement
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In valve replacement surgery
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Anticoagulation (Coumadin) or antiplatelet (aspirin,
dipyridamole) are required therapy
Young girls should avoid accidental pregnancy, should not use
an estrogen-based OCD nor an IUD
Women desiring to become pregnant need to switch to Heparin
therapy
Good oral hygiene
Prophylactic antibiotics need to be taken before dental work or
oral surgery
Clicking of the mechanical heart valve may be heard outside of
the chest
May develop hemolytic anemia requiring blood transfusions
Decreased cardiac output related to congenital
structural defect
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Goal : pt will exhibit improved cardiac output
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Interventions
 Administer digoxin
 Prevent digoxin toxicity
 Ascertain accurate rout and dose
 Check the pulse before administering drugs
 Withhold digoxin if pulse is less then 90-110 (infants), 7085 (older children)
Decreased cardiac output related to congenital
structural defect
Goal : pt will exhibit improved cardiac output
 Interventions
 Recognise digoxin toxicity
 Nausea, vomiting, anorexia, Bradycardia and
dyshrythmia
 Ensure adequate K intake
 Observe signs of hypokalemia/hyperkalemia
 Monitor electrolytes level
 Check BP
 Expected outcomes: heartbeat is strong, regular & within
normal ranges
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Activity Intolerance Related to Imbalance
between Oxygen Supply and demand
Goal : pt will exhibit no additional respiratory or cardiac
stress
 Interventions
 Neutral thermal environment
 Treat fever promptly
 Small frequent feedings
 Timely arranged nursing care to avoid much disturbing to
the pt
 Promptly respond to anxiety, crying
 Expected outcomes: pt rests quietly
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Common Nursing Diagnosis
Altered tissue perfusion related to inadequate
cardiac output
 Knowledge deficit related to care of the child pre- and
postoperatively
 Fear related to lack of knowledge about child’s disease
 Altered family processes related to stresses of the
diagnosis and care responsibilities
 Ineffective individual or family coping related to lack
of adequate support
 Altered parenting related to inability to bond with
critically ill newborn
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