Alterations in Tissue Perfusion

1
Alterations in Tissue Perfusion

• Wong Chapters 34, 35

2
Anatomy and Physiology

• Four Chambers right and left atria (upper
  chambers) right and left ventricles (lower
  chambers)
• 4 Valves pulmonic (rt. ventricle to pulmonary
  artery) aortic (left ventricle to aorta)
  tricuspid (rt. atrium to rt. ventricle) mitral
  (left atrium to left ventricles).

3
Fetal Circulation

• Ductus venosus
• umbilical vein carries oxygenated blood from the
  placenta to the infant
• -blood bypasses liver through the d.v.
• -when umbilical cord is clamped and cut, blood
  flow ceases and d.v. closes
• -blood flows into the liver

4
Fetal Circulation

• Foramen ovale
• -systemic blood enters right atrium
• -oxygenated blood flows from right to left atria
  through foramen ovale
• -blood bypasses the lungs which are nonfunctional

• -blood flows from left atria to left ventricle
  and out to aorta
• -foramen ovale closes after birth with the change
  in pressure in cardiac chambers

5
Fetal Circulation

• Ductus arteriosus
• a fistula between aorta and pulmonary artery
  allows for mixing of blood
• -blood flowing through pulmonary artery may enter
  aorta through a patent d.a.
• - Ductus arteriosus closes after birth with first
  few breaths.

6
Oxygenation

• Oxygen is bound to hemoglobin on red blood cells
• Hematocrit and hemoglobin facilitate oxygenation

• Desaturated blood contains more than 5 g of
  unoxygenated hemoglobin per 100 mL of blood

7
Cardiac Function

• Heart rate is sensitive to oxygen level
• Cardiac output is dependent on heart rate until
  child is 5 years old

• Child has an increased risk of heart failure
• -immature heart is sensitive to volume or
  pressure overload
• -muscle fibers are less developed

8
Diagnostic Tests

• Radiography (x-ray)
• reveals size and contour of heart
• -visualizes characteristics of pulmonary vascular
  markings
• -nursing no care

9
Diagnostic Tests

• Echocardiography (ultrasound)
• identifies heart structure
• - identifies pattern of movement, hemodynamics
• -nursing no care
• Stress ECG (exercise)

• Electrocardiogram (ECG)
• records quality of major electrical activity of
  the heart
• -identifies arrhythmias
• -nursing no care
• Holter monitor 24 hrs.
• ECG

10
Cardiac Catherization

• Examines the heart by placing a catheter into an
  artery or vein and advancing it to the heart
• Measures oxygen level and pressure in each
  chamber
• Identifies anatomic alterations

11
Cardiac Catherization

• Pre-procedure care
• Post-procedure care
• Discharge teaching
• -teach signs of complications
• -encourage quiet play for 1st 24 hours
• -encourage increased fluid intake

12
Surgical Procedures

• Palliative improves the overall condition of the
  child does not correct the disorder
• Correction surgery designed to resolve the
  cardiac problem

13
Congenital Cardiac Acyanotic Heart Defects

• Heart conditions that do not cause deoxygenation
  or low oxygen levels the skin and mucous
  membrane color is usually normal pink
• Congestive Heart Failure
• Atrial septal defect
• Ventricular septal defect
• -Coarctation of aorta

14
Congestive Heart Failure

• Clinical syndrome that reflects the inability of
  the heart to meet metabolic requirements of the
  body.
• Dx. Tests
• -chest radiograph
• -echocardiogram
• -electrocardiogram

15
Congestive Heart Failure

• Congenital heart defects
• -hypoplastic left heart syndrome
• -coarctation of the aorta
• -ventricular septal defect
• -atrioventricular septal defect
• -patent ductus arteriosus

• Acquired hear disease
• -myocarditis
• -metabolic abnormalities
• -endocardial fibroelastosis
• -rheumatic heart disease
• -cardiomyopathy

16
Congestive Heart Failure(Physical Findings)
17
Atrial Septal Defect

• Defect between the atria septal wall defect
  allowing blood to flow from left atrium to right
  atrium, called a left to right shunt

• Pathophysiology
• -opening between the atria
• foramen ovale fails to close
• -sometimes much of septum is absent -increase
  pulmonary blood flow

18
Atrial Septal Defect

• S/S
• -often asymptomatic
• -dyspnea
• -fatigue, poor growth
• -soft, systolic murmur
• -echocardiogram
• -congestive hear failure
• -cadiac cath

• Nursing Diagnosis
• -anxiety
• -ineffective family coping disabling
• -risk for impaired growth and development
• -risk for infection
• -altered nutrition
• -impaired gas exchange

19
Ventricular Septal Defect

• Septal wall incomplete allowing blood to flow
  from left ventricle to right ventricle (left to
  right shunt)
• Patho Increased pulmonary blood flow left to
  right shunting of blood flow is caused by the
  higher pressure in the left ventricle shunting
  of blood causes increased load on the right
  ventricles.

20
Ventricular Septal Defect

• Assessment
• -Tachypnea, dyspnea
• -Poor growth, reduced fluid intake
• -Palpable thrill
• -Systolic murmur at left lower sternal border
• -Signs of CHF

• Intervention
• -Occasionally, spontaneous closure
• -Surgical patching if failure to thrive
• -Prophylactic antibiotics to prevent endocarditis
• -Pre and Post-op care

21
VSD Family Education

• Explain purpose of tests and procedures
• Teach parents S/S of CHF and infection
• Pre-surgery visit ICU, teach coughing and deep
  breathing
• Teach need for antibiotic prophylaxis

22
Coarctation of Aorta

• Narrowing of the descending aorta
• Restricts blood flow leaving the heart
• Often near ductus arteriosus
• Progressive disorder that leads to congestive
  heart failure

23
Coarctation of Aorta

• Assesment
• -may be symtomatic
• -blood pressure difference of 20 mm between upper
  and lower extremities
• -brachial and radial pulses full femoral pulses
  weak
• exercise intolerance

• -headache, vertigo, epistaxis
• -left ventricular hypertrophy
• -dyspnea
• -cerebrovascular accident (CVA) secondary to
  hypertension in upper circulation

24
Priority Nursing Diagnosis(Coarctation of Aorta)

• Altered tissue perfusion (renal)
• Risk for injury
• Activity intolerance
• Knowledge deficit

25
Therapeutic Management(Coarctation of Aorta)

• Balloon cardiac catherization
• Surgical resection and patch of coarctation
• Prophylaxis for endocarditis when undergoing
  surgical or dental procedures
• Prior to correction, monitor BP in upper and
  lower extremities
• Rebound hypertension occurs in the immediate
  postoperative period.

26
Congenital Cardiac Cyanotic Heart Defects

• Heart conditions that cause the blood to contain
  less oxygen than required the skin and mucous
  membrane color is usually pale to pink
• -Tetrology of Fallot
• -Transposition of the Great Vessels
• - Hypoplastic Left heart Syndrome

27
Tetralogy of Fallot

• Four defects that combine to allow blood flow to
  bypass the lungs and enter the left side of the
  heart, called a right to left shunt
• Unoxygenated blood enters the body circulation
  accounting for the cyanosis

• Four defects pulmonic stenosis, right
  ventricular hypertrophy, ventricular septal
  defect, overriding aorta
• Atrial septal defect occurs at times
• Deficient oxygen in the tissues leads to acidosis

28
Tetralogy of Fallot(Assessment)

• Hypercyanosis (TET) spells characterized by
  hypxia, pallor, and tachypnea precipitated by
  crying, defecation, and feeding older children
  will assume a squatting position to decrease
  blood return from the lower extremities
  treatment involves placing the child in
  knee-chest position, administering morphine O2

29
Tetralogy of Fallot(Assessment)

• Clubbing of digits
• Polycythemia, metabolic acidosis
• Poor growth, exercise intolerance
• Systolic murmur in pulmonic area
• Right ventricular hypertrophy

30
Nursing Diagnosis/Care(Cyanotic Heart Disease)

• Altered cardiopulmonary tissue perfusion
• High risk for infection
• Altered nutrition
• Risk for impaired gas exchange
• Risk for decreased cardiac output
• Risk for injury

31
Transposition of the Great Vessels

• Aorta arises from right ventricle, and pulmonary
  artery arises from left ventricle
• Other anomalies exist that increase mixing of
  blood between the two separate circulations

• Assessment
• Progressive cyanosis to hypoxia to acidosis
• S/S CHF
• Tachypnea
• Poor feeding, failure to grow
• Echocardiogram

32
Transposition of the Great Vessels

• Therapeutic Management
• -Prostaglandin E1 to maintain open ductus
  arteriosus
• -Palliative surgical interventions
• -Corrective surgery
• -Prophylactic antibiotic therapy

33
Hypoplastic Left Heart Syndrome

• Abnormally small left ventricle noted at birth
• Inability of the heart to supply the oxygen needs
  of the body

• Patho
• -absent or stenotic mitral and aortic valve
• -major resistance to aortic flow
• -hypertrophy of right ventricle
• -prognosis poor

34
Hypoplastic Left Heart Syndrome

• Assessment
• -tachypnea, chest retractions, dyspnea
• -cyanosis
• -decreased pulses, poor peripheral perfusion
• -increased right ventricular impulse
• -CHF
• -echo-small and weak left ventricles

35
Hypoplastic Left Heart Syndrome

• Nursing Diagnosis
• -Anticipatory grieving
• -Anxiety
• -Ineffective individual (or family) coping

• Planning
• Prostaglandin E1 given to prevent closure of
  patent ductus arteriosus
• Palliative surgery
• Transplant
• Survival rate is low

36
Acquired Cardiac Health Problems

• Rheumatic fever
• -systemic inflammatory disease that involves the
  heart and joints
• Kawasakis disease
• -a multisystem disorder involving vasculitis

37
Acquired Cardiac Health Problems

• Rheumatic fever Pathophysiology
• follows 2 to 6 weeks after a group A strep
• may be an autoimmune reaction
• acute phase lasts 2 to 3 weeks
• proliferative phase
• episode of r.f. lasts up to 3 months
• long-term consequences

38
Acquired Cardiac Health Problems

• Rheumatic Fever Jones Criteria (Dx.)-
• -Multiple joints
• -Carditis
• -Chorea
• -Erythema marginatum
• -Subcutaneous nodules

39
Acquired Cardiac Health Problems

• Kawasaki Disease
• -generally affects young children, boys under 2
  years of age
• -priority nursing diagnosis
• High risk for injury
• Hyperthermia
• High risk for altered home health maintenance

40
Kawasaki Disease

• Acute phase
• Characterized by fever, conjuctival hyperemia,
  swollen hands and feet, rash, and enlarged
  cervical lymph nodes

• Lasts 1 to 10 days fever lasting longer than 5
  days that is unresponsive to antipyretics,
  conjuctivitis and fissured lips, swelling of
  hands and feet, erythema, lymphadenopathy

41
Kawasaki Disease

• Subacute phase
• Characterized by cracking lips, desquamation of
  skin on tips of fingers and toes, cardiac
  disease, and thrombocytosis

• Assessment Phase two (days 10 to 25)
• Fever diminishes, irritability, anorexia,
  desquamation of hands and feet, arthritis and
  arthralgia, cardiovascular manifestation.

42
Kawasaki Disease

• Convalescent phase has lingering signs of
  inflammation

• Assessment Phase three (days 26 to 40)
• Drop in ESR, and diminshing signs of illness

43
Kawasaki Disease(Nursing Management)
44
Hematologic Health Problems

• Anatomy and Physiology
• Diagnostic Tests (History, assessment, studies)
• Acquired Problems (disseminated intravascular
  coagulopathy, idiopathic thrombocytopenia
  purpura, iron-deficiency anemia)
• Congenital Problems (hemophilia, sickle cell,
  thalassemia)

45
Anatomy and Physiology

• The hematologic system is responsible for
  supplying and transporting oxygen to the other
  cells of the body

46
Diagnostic Tests

• History
• Physical Assessment
• CBC with Differential
• Coombs Test
• Prothrombin time (PT)
• Bleeding time
• Platelet Aggregation
• Serum Ferritin
• Bone Marrow Aspiration

47
Diagnostic Tests

• WBC
• - Bands (immature WBC)
• - Neutrophils
• - Eosinophils
• - Basophils
• - Monocytes
• - Lymphocytes

• Coombs
• -Direct evaluates the amount of antibodies
  coating the red cells
• - Indirect evaluates the presence of
  unattached, circulating antibodies.

48
Dissseminated Intravascular Coagulopathy

• A complex process involving simultaneous
  excessive bleeding and clotting
• Primary conditions that precipitate DIC include
  burns, cancer, hypoxia, liver disease,
  necrolyzing enterocolitis, sepsis, shock, trauma,
  and viruses

49
Dissseminated Intravascular Coagulopathy

• Assessment
• -Onset of symptoms
• -Progression
• -Lab data low platelet, decreased RBCs,
  prolonged PT, PTT, decreased fibrinogen levels

• Meds
• -heparin SQ or IV
• -protamine (heparin antidote)
• -avoid aspirin
• Family teaching

50
Dissseminated Intravascular Coagulopathy- Nursing
Care
51
Idiopathic Thrombocytopenic Purpura

• Occurs most often in children ages 2 to 5
• Petechiae and multiple ecchymoses
• Lab data decreased platelet count
• Assess for bruising or active bleeding,
  neurological status, platelet count.
• Meds steroids, IV immunoglobulins

52
Iron-Deficiency Anemia

• S/S pallor, fatigue, irritability
• Lab decreased iron content small pale RBC
  decrease in serum ferritin
• Correct bleeding if it is the cause of the anemia

• Implement dietary modifications
• Promote rest protect from infection
• Administer packed cells slowly
• Restrict milk intake
• Meds empty stomach

53
Hemophilia

• Lab prolonged PTT, decreased factor VIII normal
  PT, thrombin time, fibrinogen, platelet
• Meds Factor VIII XI
• - DDAVP may be administered to children with mild
  Hemophilia

54
Hemophilia(Nursing Care)
55
Sickle Cell Anemia

• Sickling can be triggered by fever, dehydration,
  emotional or physical stress
• Symptoms do not appear until 4 to 6 months
• Sicklidex screening tests for children 6 yrs.
• Assist hydration administer O2 promote rest
  administer analgesics

56
Thalassemia

• Lab decreased hemoglobin, hematocrit,
  reticulocyte
• Administer blood product as ordered
• Assess for signs of iron overload
• Observe for signs of infection
• Implement iron chelation therapy as ordered