Transcript The Child with Cardiovascular Dysfunction

The Child with
Cardiovascular Dysfunction
Lecture 2
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Congenital Heart Disease
• Are anatomic abnormalities of the heart that
are present at the birth and impair cardiac
function.
• Two main clinical manifestation
– HF
– Hypoxia
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Location of the Heart
• The heart is located in the chest between the
lungs behind the sternum and above the
diaphragm. It is surrounded by the
pericardium. Its size is about that of a fist, and
its weight is about 250-300 g.
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Pediatric differences
• Cardiac functioning:
– Infants have a great risk of heart failure than older
child because the immature heart is more
sensitive to volume or pressure overload.
– Heart muscle fully developed at five year.
– Metabolic rate and oxygen requirements double
at birth so the HR is high
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Congenital Heart Disease
• Incidence: 5-8 per 1000 live births
– About 2-3 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
– 85% with newborn are expected to survive.
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Risk factors
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Maternal rubella during pregnancy.
Maternal alcoholism, drug use.
Maternal age
Maternal type one diabetes.
Several genetics factors, down syndrome ,
turner syndrome
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Down Syndrome
• is a genetic abnormality. It is the most
common single cause of birth defects,
This syndrome occurs because of an
extra copy of chromosome 21.
Sign and symptom
• flat facial features
• small head and ears
• short neck
• bulging tongue
• eyes that slant
upward
• oddly shaped ears
• poor muscle tone.
• impulsive behavior
• poor judgment
• short attention span
• slow learning capabilities
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Turner's Syndrome
• Cause: Turner's Syndrome is caused by a
condition known as Monosomy (absence of
entire chromosome) of X chromosome for
females.
• Primarily Affects: Females
• Discovered By: Dr. Henry H. Turner
• Symptoms: Low-set ears, webbed neck, broad
chest, non-working ovaries, hypothyroidism,
diabetes, vision problems, neuro/cognitive
deficiency, congenital heart disease, etc.
• Turner's Syndrome occurs in approximately 1
of every 2,000 female births.
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Changes at Birth
1. Foramen ovale
2. Ductus arteriosus
3. Ductus venosus
http://www.barnesjewish.org/animations/?sid=1&animationid=194
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Pediatric Indicators of Cardiac Dysfunction
1. Poor feeding
2. Tachypnea/ tachycardia
3. Failure to thrive/poor weight gain/activity
intolerance
4. Developmental delays
5. + Prenatal history
6. + Family history of cardiac disease
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Fetal circulation
• http://www.indiana.edu/~anat550/cvanim/fet
circ/fetcirc.html
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Fetal Circulation
• During pregnancy blood is transferred from placenta
through umbilical vein into the ductus venosus (opining
into the inferior vena cava).
• Then blood is carried to the right atrium in which is forced
into the left atrium by an opining between the two atriums
called foramen ovale.
• Blood is transferred into the left ventricles and to the whole
body through aorta.
• Some blood pass into the right ventricle, in which it moved
to the lungs by the pulmonary artery.
• But, the majority of this blood pass into the aorta by an
opining between aorta & pulmonary artery called ductus
atreriousus
Fetal Circulation
• After birth, the newborn start breathing which increase the
lung expansion, helping in shifting of blood into the lungs
by the pulmonary artery not into the aorta by the ductus
arteriosus as during pregnancy.
• This will lead to increase pulmonary blood flow & decrease
pulmonary vascular resistance.
• Also leading to increase blood returned to the left atrium
through pulmonary veins & this leads to increase pressure
in the left atrium.
• The increasing pressure stimulate the closure of the
foramen ovale and. Ductus arteriosus close in response to
increase O2saturation after 10-12 hours and permanently
after 10-21 days.
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Two Types of Cardiac Defects
1. Congenital
– Anatomic>abnormal function
2. Acquired
– Disease process
1. Infection
2. Autoimmune response
3. Familial tendencies
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Diagnostic procedure
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Cardiac catheterization
Chest X ray
Echo
ECG
Treadmill Test
Holter monitor
Hyperoxi test
MRI
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Newer Classification of CHD
1. Increased pulmonary blood flow
2. Decreased pulmonary blood flow
3. Obstruction of blood flow out of the heart
4. Mixed blood flow
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1. 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
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Increased Pulmonary
Blood Flow Defects
Examples:
1. Atrial septal defect - ASD
2. Ventricular septal defect - VSD
3. Patent ductus arteriosus - PDA
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1. Atrial Septal Defect - ASD
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 atrium.
S&S: CHF, poor growth with large ASD, murmur.
Surgical treatment Surgical Dacron Patch Closure or open heart surgery
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.
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ASD
Three types:
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Ostium primum ASD1 ( lower end of the septum )
Ostium secundum ASD2 ( center of the septum )
Sinus venosus defect (opening near junction of SVC & right
atrium)
Complication: arrhythmias, Murmur, emboli
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ASD patch or device
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2) VSD, Ventricular Septal Defect:
•VSD 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. Increase number of
pulmonary Infection , pulmonary hypertention
• Surgical treatment: complete repair.
•Non-surgical treatment: closure device is usually implanted during
cardiac catheterization
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VSD Device
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(3) PDA: Patent Ductus Arteriosus
• it’s failed to closed at birth ,blood will shunt
from the aorta to the pulmonary artery.
• S & S: dyspnea, tachycardia, tachypnia widening
pulse pressure, hypotension CHF, Intercostals
retraction, High risk to respiratory infection
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Treatment
• Observation . In a premature baby, a PDA often
closes on its own. The doctor will monitor your
baby's heart to make sure the open blood vessel
is closing properly.
• Medications. In a premature baby, nonsteroidal
anti-inflammatory drugs (NSAIDs) — such as
ibuprofen (Advil, Infant's Motrin, others) or
indomethacin (Indocin) — might be used to help
close a PDA. NSAIDs block the hormonelike
chemicals in the body that keep the PDA open.
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Treatment
• Open-heart surgery. If medications aren't
effective and your child's condition is severe
or causing complications, open-heart surgery
might be recommended. A surgeon makes a
small cut between child's ribs to reach child's
heart and repair the open duct using stitches
or clips.
2. Obstruction of blood flow out of the heart
• Coarctation of the Aorta (COA)
• Localized narrowing near the insertion of the
ductus arteriosus resulting an increase the
pressure proximal to defect.
Sign and symptom:
• Pulse in the arms strong, weak or abcsent in
the lower extremities, hypotensive, acidosis,
headache and fainting
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Treatment
1. Resection with end-to-end anastomosis:
• This method involves removing the narrowed segment of the aorta
(resection) followed by connecting the two ends of the aorta together
(anastomosis).
2. Bypass graft repair. This technique involves bypassing the narrowed area
by inserting a plastic tube called a graft between the portions of the aorta.
3. Patch aortoplasty. treat coarctation by cutting across the narrowed area of
the aorta and then attaching a patch of synthetic material to widen the
blood vessel. Patch aortoplasty is useful if the coarctation involves a long
segment of the aorta.
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Treatment cont …
4. Balloon angioplasty and stenting
• Balloon angioplasty is an option for initially treating aortic coarctation or
for treating re-narrowing (re-coarctation) that has occurred after surgery.
• During this procedure, the doctor inserts a thin, flexible tube (catheter)
into an artery in your groin and threads it through your blood vessels to
your heart using X-ray imaging.
• doctor places an uninflated balloon through the opening of the narrowed
aorta. When the balloon is inflated, the aorta widens and blood flows
more easily.
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COA
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3. Decreased pulmonary blood flow
• Obstruct the pulmonary blood flow result
in little or no blood reaching the lung to
get oxygenated.
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3.Decreased pulmonary blood flow
• Tetralogy Of Fallot (TOF):
The classic form includes:
• Ventricular septal defect.
• Pulmonary stenosis.
• Overriding aorta.
• Right venticular hypertrophy.
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Tetralogy Of Fallot (TOF):
• 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 & consequently the
oxygenated blood that returns to Lt side of the heart.
• Surgical treatment: complete repair is required, open heart
surgery& VSD closure
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Tetralogy Of Fallot (TOF):
• Sign and symptom: cyanosis, murmur,
hypoxia, clubbing of fingers, poor growth
• Patient at risk of: emboli, CVA, seizures and
sudden death.
• Surgical intervention: complete repair in the
first year of the life.
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The nurse instruct the mother to place the
infant in knee chest position to facilitate
breathing.
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4. Mixed defect
• Transposition of the
great arteries (TGA)
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Transposition of the great Arteries
• The aorta arises from the right ventricle and the
pulmonary artery from the left.
• The mixing of the blood occurs at the PDA.
• The signs include cyanosis and cardiomegaly.
• There may be no murmur.
• An echocardiogram is diagnostic
Or X ray.
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What are the symptoms of TGA?
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Cyanosis is noted in the first hours of life
Rapid breathing
Hypoxia, CHF developed
labored breathing
Rapid heart rate
Cool, clammy skin
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Diagnostic test
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Chest x-ray
Electrocardiogram
Echocardiogram (echo)
Cardiac catheterization
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Echocardiogram
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Treatment
• Prostaglandin is ordered to maintain a patent
ductus arteriosus.
• Oxygen administered
• Surgery before 1 week.
• Survival with out surgery is impossible.
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Congestive Heart Failure (CHF)
• CHD Most Common Cause of CHF in Infants
• S/S: Tachycardia, Diaphoresis, Tachypnea,
• Feeding problem, Crackles & Respiratory
Distress, Edema, weight gain.
• CXR Shows Large Heart.
• Echocardiogram is Diagnostic.
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Congestive Heart Failure (CHF)
• Medical Management:
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Digoxin To Make Heart Work More Efficiently
Not given if HR less than 90 for infant.
Lasix/Diuretics To Remove Excess Fluid
Oxygen: Potent Vasodilator which decreases
pulmonary vascular resistance.
– Rest, a neutral thermal environment, semi-Fowler
position, cluster care to promote uninterrupted rest
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• Nursing care
CHF
– Monitor physiologic functions: BP, HR, RR
– Assess crackels
– 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.
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Nursing Process Overview for the Child with CHD
• Assessment
– Health History
– pregnancy, feeding problems, siblings ,
respiratory difficulty and family history.
– Physical Examination
– Sign and symptom (respiratory distress
and poor feeding.
– Growth problems.
– Edema
– Cyanosis, murmur
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Assess for sign and symptoms of hypoxemia
• Polycyethemia
• Clubbing
• Cyanosis
• Assess the tongue and buccal membrane
• Assessment (cont’d)
Laboratory and Diagnostic Testing
Cardiac Catheterization
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• Nursing Diagnosis:
• Activity intolerance related to decreased tissue
oxygenation.
• Anxiety related to hypoxia
• Decrease cardiac out put related to increased
cardiac workload.
• Delayed growth and development related to
hypoxia.
• Risk for infection related pulmonary stasis.
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Nursing intervention of the Child with CHD
• Improving Oxygenation.
• Promoting Adequate Nutrition.
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– Offer frequent high calorie every three hrs.
Provide iron supplements
Maintain hydration
Blood transfusion
Assisting the Child and Family to Cope.
Preventing Infection.
Providing Care for the Child Undergoing Cardiac Surgery
– Providing Preoperative Care
– Providing Postoperative Care.
• Providing Patient and Family Education.
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Rheumatic fever
is an inflammatory disease that may develop
after an infection with group A Streptococcus
bacteria (such as strep throat). The disease can
affect the heart, joints, skin, and brain
•Rheumatic fever mainly affects children ages 5 15, and occurs approximately 14-28 days after
strep throat.
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Signs and symptoms
1. Abdominal pain
2. Fever
3. Heart (cardiac) problems, which may not have
symptoms, or may result in shortness of breath and
chest pain
4. Joint pain, arthritis(mainly in the knees, elbows,
ankles, and wrists)
5. Joint swelling; redness or warmth
6. Nosebleeds (epistaxis)
7. Skin nodules
8. Skin rash (erythema)
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The Major criteria for diagnosis include:
1. Arthritis in several large joints
(polyarthritis)
2. Heart inflammation (carditis)
3. Nodules under the skin
(subcutaneous skin nodules)
4. Skin rash (erythema marginatum)
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Treatment
1. antibiotics such as penicillin, sulfadiazine, or
erythromycin) over the long term to prevent
strep throat from returning
2. Anti-inflammatory medications such as
aspirin or corticosteroids reduce
inflammation to help manage acute
rheumatic fever.
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Homework 2
• Write Nursing care for patient with:
1.Pulmonary atresia
2.Rheumatic fever
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GOOD LUCK !!!!!!!
THANK YOU
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