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Pediatric Cardiovascular Disorders

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Title: Pediatric Cardiovascular Disorders


1
Pediatric Cardiovascular Disorders
  • Presented by
  • Christina Hernandez RN, MSN

2
Fetal Circulation
3
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

4
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?

5
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

6
Critical thinking
  • When are most cardiac anomalies discovered?
  • What is included in the initial cardiac
    assessment of a newborn?
  • Why?

7
Assessment
  • History
  • Physical
  • Diagnostic

8
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

9
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
10
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?)

11
Congestive Heart Failure
12
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

13
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

14
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
15
Goal of Treatment
  • Improve cardiac function
  • Remove accumulated fluid and Na
  • Decrease cardiac demands
  • Decrease O2 consumption

16
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)

17
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
18
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

19
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

20
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?)
21
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
22
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?

23
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?)

24
Cardiac Catheterization
25
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

26
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

27
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

28
Post Cardiac Catheterization
  • When should the parents/caregiver notify the
    primary healthcare provider?

29
Congenital Heart Disease
30
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.

31
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

32
What is most common indication of a congenital
heart defect?
33
Left to Right Shunting
  • Atrial Septal Defects
  • Ventricular Septal Defects
  • Patent Ductus Arterious

34
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

35
Treatment for ASD
  • Medical Management
  • Medications digoxin
  • Cardiac Catheterizaton -
  • Amplatzer septal occluder
  • Open-heart Surgery

36
Treatment
  • Device Closure Amplatzer septal occluder
  • During cardiac catheterization the occluder is
    placed in the defect

37
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

38
Treatment of VSD
  • Surgical repair with a patch inserted

39
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

40
Medical Treatment for PDA
  • Indomethacin-
  • Inhibits prostaglandins
  • Promotes closure of the ductus arteriosus

41
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

42
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

43
Obstructive or Stenotic Defects
44
Obstructive or Stenotic Defects
  • Pulmonic Stenosis
  • Aortic Stenosis
  • Coarctation of the Aorta

45
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

46
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

47
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

48
Cyanotic Disorders
49
Cyanotic Lesions with Decreased Pulmonary Flow
  • Tetralogy of Fallot

50
Signs and Symptoms
  • Failure to thrive
  • Squatting
  • Lack of energy
  • Infections
  • Polycythemia
  • Clubbing of fingers
  • Cerebral absess
  • Cardiomegaly

51
Nursing Care
  • Dehydration
  • Criteria for surgery
  • Rule of 10s
  • 10 lbs
  • Hemaglobin 10 or greater
  • 10 hours/days/months

52
Treatment of Tetralogy of Fallot
  • Surgical interventions
  • Blalock Taussig or Potts procedure increases
    blood flow to the lungs.
  • Open heart surgery

53
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

54
Cyanotic Lesions with Increased Pulmonary Blood
Flow
  • Truncus arteriosus
  • Hypoplastic left heart
  • Transposition of the great arteries

55
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.

56
Hypoplastic heart
  • May have various left-sided defects, including
    coarctation of the aorta, aortic valve mitral
    valve stenosis or artresia

57
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

58
Nursing Diagnosis Goals
  • DX Alteration in cardiac output decrease R/T
    heart malformation
  • Goal Child will maintain adequate cardiac
    output AEB

59
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

60
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

61
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?)

62
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

63
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

64
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

65
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

66
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?

67
Acquired Cardiac Diseases
68
Rheumatic Fever
  • Systemic inflammatory disease
  • Follows group A beta-hemolytic
  • streptococcus infection
  • Causes changes in the entire heart especially the
    valves

69
Clinical Manifestations
  • Jones Criteria
  • Major
  • Minor
  • Supporting Evidence

70
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

71
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?

72
Clinical Manifestations
  • Onset insidious
  • Fever
  • Lethargy/general malaise
  • Anorexia
  • Splenomegaly
  • Retinal hemorrhages
  • Heart murmur 90
  • Diagnosis- positive blood culture

73
Nursing Care
  • Medication-large doses antibiotic
  • Bed rest
  • Teach to notify dentist prior to dental work

74
Kawasaki Disease- multi-system vasculitis
  • Mucocutaneous lymph node syndrome
  • Not contagious
  • Preceded by upper respiratory tract infection
  • Cause unknown

75
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

76
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

77
Kawasaki cont
  • Convalescent Phase 25-60 days
  • Self limiting
  • Transverse on nailbeds
  • Lasts until return to normal of all lab values

78
Diagnosis of Kawasaki Disease
  • ECG
  • CBC, WBC
  • PT
  • ESR
  • SGOT, SGPT
  • IgA, IgG and IgM

79
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

80
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

81
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

82
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

83
Quick Review
  • What is the major complication of Kawasaki
    disease?
  • Why is it important to monitor respiratory effort
    in children with suspected cardiac abnormalities?

84
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

85
  • For questions or concerns regarding this lecture
    content please contact
  • Christina Hernandez RN, MSN
  • chernan1_at_austincc.edu
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