Pediatric Cardiovascular Disorders

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Pediatric Cardiovascular Disorders

• Presented by
• Christina Hernandez RN, MSN

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Fetal Circulation
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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

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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?

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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

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Critical thinking

• When are most cardiac anomalies discovered?
• What is included in the initial cardiac
  assessment of a newborn?
• Why?

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Assessment

• History
• Physical
• Diagnostic

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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

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At what O2 saturation does cyanosis occur?

• Peripheral cyanosis occurs at lt 80
• Brain damage occurs lt 85

Hypoxic Level Oxygen Saturation
Mild hypoxia 90-95
Moderate 85-90
Severe lt85
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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?)

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Congestive Heart Failure
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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

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Early Clinical Manifestations of CHF

• Infants-
• 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

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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 gt2 seconds, pallor, cool extremities, oliguria
High metabolic rate Failure to thrive or slow weight gain
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Goal of Treatment

• Improve cardiac function
• Remove accumulated fluid and Na
• Decrease cardiac demands
• Decrease O2 consumption

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Nursing Care for CHF

• Strict IO (weight diapers)
• Weigh child daily (what is significant change? 1
  lb/day)
• Monitor VS
• Cardiac medications for children
• Cardiac glycosides (Digoxin)
• Ace inhibitors (Capoten-Captoril, Vasotec)
• Diuretics (Furosemide- Lasix)

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Medications to treat CHF in Children
Medication Action Nursing Intervention
Cardiac glycosides (Digoxin) Increase myocardial contractility- improve systemic circulation Monitor pulse- when do you hold this medication? What safety check? Strict IO Weigh child daily Observe for edema Serial abdominal girth protect skin Digoxin levels (toxicity) Hepatic function Creatinine clearance Serum Elecrolytes
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Digoxin specific nursing interventions

• Hold for pulse
• Infant lt 100
• Child lt 80
• Adolescent lt60
• Verify dose with two nurses
• Strict IO (1gram1ml)
• Skin care
• Monitor for digoxin toxicity

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Digoxin Toxicity gt2ng/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

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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?)
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Medications to treat CHF cont
Medication Action Nursing Interventions
Diuretics- Furosemide (Lasix) Chlorothiazida (Diuril) Spironolactone (Aldactone) Rapid diuresis Give IM or IV K level prior to administer Monitor electrolytes, weigh daily, strict IO Observe for changes in peripheral edema or circulation Serial abdominal girth Skin care- turning schedule
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Quick Quiz

• What is the pulse rate criteria for administering
  digoxin to
• Infants-
• Child-
• Teenager/ adolescent-
• What are signs of digoxin toxicity?
• Why are K levels important with digoxin?

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Nursing care to decrease cardiac demands

• Provide for rest
• Semi-Fowlers
• Monitor O2 (supplement)
• Small frequent meals
• Turn q 2 hrs and provide skin care
• Encourage parents/guardians to stay with child
• Restrict visitors (why?)

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Cardiac Catheterization
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Cardiac Catheterization

• Measures oxygen saturation and pressures in
  cardiac 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

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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

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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

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Post Cardiac Catheterization

• When should the parents/caregiver notify the
  primary healthcare provider?

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Congenital Heart Disease
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Congenital Cardiac Defects

• Increase Pulmonary Blood Flow

• Decrease Pulmonary Blood Flow

• Patent Ductus Arterious
• Atrial Septal Defect
• Ventricular Septal defect
• 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

• Pulmonic stenosis
• Tetralogy of Fallot
• Tricuspi atresia
• 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 RBCs increase
  in oxygen. Polycythemia increases risk for
  thromboembolism. Platelet impaired. Hypoxic
  events with brain abscesses common.

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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?
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Left to Right Shunting

• Atrial Septal Defects
• Ventricular Septal Defects
• Patent Ductus Arterious

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Atrial Septal Defect

• Oxygenated blood is shunted from left to right
  side of the heart via defect
• A larger volume of blood than normal must be
  handled by the right side of the heart
  ?hypertrophy
• 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

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Treatment for ASD

• Medical Management
• Medications digoxin
• Cardiac Catheterizaton -
• Amplatzer septal occluder
• Open-heart Surgery

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Treatment

• Device Closure Amplatzer septal occluder
• During cardiac catheterization the occluder is
  placed in the defect

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Ventricular Septal Defect

• Oxygenated blood is shunted from left to right
  side of the heart via defect
• A larger volume of blood than normal must be
  handled by the right side of the heart
  ?hypertrophy
• 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

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Treatment of VSD

• Surgical repair with a patch inserted

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Patent Ductus Arteriosus

• Failure of the fetal ductus arteriosus to close
  after birth
• Blood shunts from aorta (left) to the pulmonary
  artery (right)
• Returns to the lungs causing increase pressure in
  the lung
• Congestive heart failure

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Medical Treatment for PDA

• Indomethacin-
• Inhibits prostaglandins
• Promotes closure of the ductus arteriosus

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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

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Nursing Care

• Pre-op
• Patient/parent teaching
• Assess for infection
• Obtain lab values for chart
• Post-op
• ABCs
• Rest
• Hydration/nutrition
• Prevent complications
• Discharge teaching

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Obstructive or Stenotic Defects
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Obstructive or Stenotic Defects

• Pulmonic Stenosis
• Aortic Stenosis
• Coarctation of the Aorta

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Pulmonic Stenosis

• Narrowing of entrance that
• decreases blood flow
• Treatment
• Medications Prostaglandin E 1 to keep the PDA
  open
• Cardiac Catheterization
• Baloon Valvuloplasty
• Surgery
• Valvotomy

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Aortic Stenosis/Coarctation of the Aorta

• Narrowing of Aorta causing obstruction of left
  ventricular blood flow
• 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

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Treatment for Aortic Stenosis

• Goals of management are to improve ventricular
  function and restore blood flow to the lower
  body.
• Medical management with Medication
• 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

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Cyanotic Disorders
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Cyanotic Lesions with Decreased Pulmonary Flow

• Tetralogy of Fallot

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Signs and Symptoms

• Failure to thrive
• Squatting
• Lack of energy
• Infections
• Polycythemia
• Clubbing of fingers
• Cerebral absess
• Cardiomegaly

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Nursing Care

• Dehydration
• Criteria for surgery
• Rule of 10s
• 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

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Cyanotic Lesions with Increased Pulmonary Blood
Flow

• Truncus arteriosus
• Hypoplastic left heart
• Transposition of the great arteries

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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.

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Hypoplastic heart

• May have various left-sided defects, including
  coarctation of the aorta, aortic valve mitral
  valve stenosis or artresia

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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

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Nursing Diagnosis Goals

• DX Alteration in cardiac output decrease R/T
  heart malformation
• Goal Child will maintain adequate cardiac
  output AEB

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Review of Nursing Care

• Increased pulmonary blood flow-
• SS-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

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Review of Nursing Care cont

• Decrease blood flow and mixed defects-
• Signs 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

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Review of Nursing Care cont

• Decrease blood flow and mixed defects-
• Signs 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 SS?)

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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
  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 RBCs to assist with O2
• Position in knee chest
• Supplemental O2 therapy
• IV fluids
• Dopamine or phenylephrine (Neo-Synephrine)
• Small frequent meals

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Defects Obstructing Systemic Blood Flow

• Aortic stenosis
• Coarctation of the aorta
• SS- low cardiac output (diminished pulses)
• 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

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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

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Nursing Care for Open-heart Surgery

• Pre-Op

• Post-Op

• Monitor VS (BP P) what might increase temp
  mean?
• Prepare child/parents for experience- teaching
• Teach CDB (incentive spirometer)
• Tour hospital- meet staff
• Assess for infection
• Obtain labs, verify permits

• Pulmonary function
• Patent airway
• IPPB, CDB, O2 therapy
• Chest suction or chest tube
• Monitor VS
• Promote rest
• Monitor IO- adequate hydration (fluid
  electrolyte balance)
• Turn frequently (skin care)
• Assess extremities (circulation

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Oh nomore 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?

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Acquired Cardiac Diseases
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Rheumatic Fever

• Systemic inflammatory disease
• Follows group A beta-hemolytic
• streptococcus infection
• Causes changes in the entire heart especially the
  valves

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Clinical Manifestations

• Jones Criteria
• Major
• Minor
• Supporting Evidence

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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

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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?

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Clinical Manifestations

• Onset insidious
• Fever
• Lethargy/general malaise
• Anorexia
• Splenomegaly
• Retinal hemorrhages
• Heart murmur 90
• Diagnosis- positive blood culture

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Nursing Care

• Medication-large doses antibiotic
• Bed rest
• Teach to notify dentist prior to dental work

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Kawasaki Disease- multi-system vasculitis

• Mucocutaneous lymph node syndrome
• Not contagious
• Preceded by upper respiratory tract infection
• Cause unknown

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Kawasaki Disease

• Acute 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

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Kawasaki cont

• Subacute 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

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Kawasaki cont

• Convalescent Phase 25-60 days
• Self limiting
• Transverse on nailbeds
• Lasts until return to normal of all lab values

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Diagnosis of Kawasaki Disease

• ECG
• CBC, WBC
• PT
• ESR
• SGOT, SGPT
• IgA, IgG and IgM

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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 childs 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

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Kawasaki Disease Long term care

• Teach parents to administer ASA and watch for
  side effects of bleeding.
• Avoid contact sports
• Teach daily monitoring of temp, report gt100F
• 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

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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

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Quick Review

• What is the major complication of Kawasaki
  disease?
• Why is it important to monitor respiratory effort
  in children with suspected cardiac abnormalities?

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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
  childs physical status

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• For questions or concerns regarding this lecture
  content please contact
• Christina Hernandez RN, MSN
• chernan1_at_austincc.edu