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Islamic University of Gaza Faculty of Nursing Pediatric Nursing

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Title: Islamic University of Gaza Faculty of Nursing Pediatric Nursing


1
Islamic University of Gaza Faculty of Nursing
Pediatric Nursing
  • Dr. Areefa Albahri

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  • Cardiovascular disease is a significant cause of
    chronic illness and death in children.
  • Typically cardiovascular disorders in children
    are divided into two major categories
  • Congenital heart disease is defined as structural
    anomalies that are present at birth. CHD accounts
    for the largest percentage of birth defects
  • Acquired heart disease includes disorders that
    occur after birth. These disorders develop from a
    wide range of causes, or they can occur as a
    complication of CHD.

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Congenital Heart Defects
  • Is a structural malformation of the heart or
    great vessels presents at birth. Generally blood
    flows from areas of high pressures to areas of
    low pressures.
  • Etiology exact cause is unknown.
  • 1. Maternal infection as rubella
  • 2. Poor nutrition of mother.
  • 3. Diabetic mothers
  • 4. Maternal alcoholism.
  • 5. Maternal exposure to radiation
  • 6. Genetic defect

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Types of Defects-
  • 1. Acyanotic Heart Defects there is no mixing of
    unoxygenated blood with systemic circulation
    (Oxygenated blood), its take one of the following
    forms
  • a. Dextracardia ?as a part of situs inversus ?
  • b. Obstructive lesion as aortic stenosis,
    pulmonary stenosis and coarctation of the aorta.
  • c. Left to Right shunts as patent ductus
    arteriosus, atrial septal defect and ventricular
    septal defect.

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  • 2. Cyanotic heart defect un-oxygenated blood
    enters the systemic circulation (Right to Left
    shunt)
  • a. Tetralogy of Fallot.
  • b. Transposition of great arteries.
  • c. Tricuspid atresia.

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  • A cyanotic Heart Defects
  • I. Dextracardia with Situs Inversus
  • Dextracardia indicates that the heart is in the
    right side of thorax cavity. This condition is
    frequently associated with situs inversus within
    abdominal and thoracic organs transposed to
    opposite side of the body. There are usually no
    cardiac defects.
  • Diagnosis
  • 1. Clinically apex beat on the right side,
    stomach percussion on right side, the liver on
    the left side.
  • 2. Electrocardiograph lead I shown a mirror
    image with inverted P and T waves.
  • 3. X-ray situs inversus.

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II. Aortic Stenosis
  • Aortic stenosis (AS) is a narrowing or a
    stricture of the aortic valve that results in
  • Increase left ventricular pressure to overcome
    the obstructed valve
  • Left ventricular hypertrophy, myocardial ischemia
    and decreased cardiac output.
  • Imbalance between the increased O2 requirements
    and the amount of O2 supplied.

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Clinical Manifestations
  • Rarely symptomatic during infancy, in severe
    cases infant may demonstrate evidence of
    decreased cardiac output such as faint peripheral
    pulses or exercise intolerance.
  • Older children may experience chest pain,
    dyspnea and fatigue with exertion.
  • Narrow pulse pressure and weak peripheral pulses.
  • X-ray may show normal heart to varying degrees of
    left ventricular hypertrophy.
  • A harsh ejection systolic murmur is best heard in
    the aortic area.
  • E.C.G. left ventricular hypertrophy T. wave
    inversion.
  • Diagnosis Cardiac Catheterization.
  • Complications CHF, MI, bacterial endocarditis
    and death.
  • Treatment Surgery Balloon angioplasty or
    valvulotomy

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III. Pulmonary Stenosis
  • Refers to narrowing of the opening to the
    pulmonic valve, that cause obstruction to blood
    flow, so the right ventricle has an additional
    work-load, causing the muscle to thicken,
    resulting in right ventricular hypertrophy and
    decreased pulmonary blood flow.
  • Signs and symptoms Generally asymptomatic
    unless in severe stenosis
  • Dyspnea, fatigue and systolic ejection murmur
    over the pulmonic area.
  • Complication anoxic spells, bacterial
    endocarditis, death. ?Heart Failure

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  • Diagnosis Cardiac Catheterization.
  • Treatment Pulmonary valvotomy or dilation by
    balloon.

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  • IV. Coarctation of the Aorta
  • Is a narrowing or constriction of the vessel at
    any point. Most common, The narrowing can be
    pre-ductal (between the subclavian artery and
    ductus arteriosus) or postductal (after the
    ductus arteriosus).
  • Altered Physiology the narrowing of the aorta
    obstructs the blood flow through the constricted
    segment of the aorta, that increasing the left
    ventricular pressure. So collateral vessels
    develop from the subclavian arteries bypassing
    the coarcted aorta and supplying circulation to
    the lower extremities.

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  • Clinical Manifestation
  • Usually asymptomatic in childhood.
  • May demonstrate occasional fatigue, headache,
    nose bleed and leg cramps.
  • Absent or greatly reduced femoral pulses.
  • Hypertension in upper extremities, hypotension
    in lower one.
  • E.C.G show normal to left ventricular
    hypertrophy

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  • Diagnosis Cardiac Catheterization, Angiography.
  • Complication Cerebral Hemorrhage, Rupture
    Aorta, and C.H.F.
  • Treatment
  • Management of C.H.F.
  • Surgical Resection of area of coarctation or
    balloon angioplasty at 2-7 years.
  • V. Patent Ductus Arteriosus
  • Is the persistence of a fetal connection between
    the pulmonary artery and the aorta through which
    blood leaving the right heart bypasses the lungs.

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  • Altered Physiology
  • Failure of the ductus to close after birth.
    Patent ductus arteriosus allow blood to shunt
    from aorta (high pressure) to the pulmonary
    artery low pressure.
  • Failure of the ductus arteriosus to close leads
    to continued blood flow from the aorta to the
    pulmonary artery. Blood returning to the left
    atrium passes to the left ventricle, enters the
    aorta, and then travels to the pulmonary artery
    via the PDA instead of entering the systemic
    circulation. This altered blood flow pattern
    increases the workload of the left side of heart.
  • Pulmonary vascular congestion occurs, causing an
    increase in pressure.

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  • Right ventricular pressure increases in an
    attempt to overcome this increase in pulmonary
    pressure. Eventually, right ventricular
    hypertrophy occurs.
  • Clinical Manifestation
  • 1- Small PDA usually asymptomatic.
  • 2- Large PDA may develops symptoms during early
    infancy, slow weight gain, feeding difficulties,
    frequent respiratory infection, CHF, physical
    retardation, systolic murmur and widened pulse
    pressure
  • Complication C.H.F., infective endocarditis.
  • Treatment
  • Controlling of C.H.F.
  • Surgical by ligation or division and ligation of
    the duct ?electively by 1-2 years?.
  • Closure of ductus arteriosus is stimulated by
    increase in O2 level and by indomethacin

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  • VI. Atrial Septal Defect
  • ? Is an abnormal opening in the septum between
    two atrium.

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  • Altered Physiology
  • The pressure in the left atrium is greatening
    than that in the right one, which promotes the
    flow of oxygenated blood from the left to the
    right atrium and thus increasing the total blood
    flow through the lung.
  • If the pulmonary resistance is great reversal
    the shunt with unoxygenated blood flowing from
    the right to left atrium and cyanosis occur.

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  • Clinical Manifestation
  • Heart murmur
  • Dyspnea and right ventricular hypertrophy
  • Fatigue and poor growth.
  • Complication CHF, and pulmonary hypertension.
  • Treatment Surgical closure the defect.

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Ventricular Septal Defect
  • Is an abnormal opening in the septal between the
    two ventricles. It may vary in size from very
    small defect to very large defect 1-15 mm in
    diameter. 50 of cases close spontaneously
    within one to three years. It is one of the most
    common congenital heart defects.

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  • Altered Physiology
  • The pressure in the left ventricle is greater
    than that of the right one promotes the flow of
    oxygenated blood from the left to the right
    ventricle increasing the total blood flow through
    the lungs and thus increased right ventricular
    and pulmonary arterial pressure.
  • If the pulmonary resistance is great, thus
    causing reversal of the shunt with unoxygenated
    blood flowing from the right ventricle to the
    left one and thus cyanosis occure
  • Clinical Manifestation
  • Systolic heart murmur.
  • Slow weight gain, feeding difficulties, frequent
    respiratory infections.
  • Dyspnea and tachypnea.

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  • Treatment
  • Medical management of C.H.F.
  • Surgical closure optimal age before 2years to
    prevent pulmonary hypertension.

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  • Cyanotic Congenital Heart Disease
  • I. Teratology of Fallot (TOF)
  • The most common type of cyanotic heart disease,
    its involve four anatomical abnormalities
  • 1- Pulmonary stenosis.
  • 2- Ventricular septal defect VSD.
  • 3- Overriding of the aorta (enlargement of the
    aortic valve)
  • 4- Right ventricular hypertrophy.
  • Altered Physiology
  • Pulmonary stenosis unoxygenated blood is
    shunted from the right ventricle (from the VSD)
    directly into the aorta.
  • The right ventricle is hypertrophied because of
    high right ventricular pressure.

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  • Clinical Manifestation
  • Cyanosis not cyanotic at birth left to right
    shunt, may starts later, may be at 1-2 years,
    first observed with exertion or crying, then
    cyanotic even at rest.
  • Clubbing of fingers.
  • Squatting posture is assumed to relief stressed
    heart by trapping blood in lower extremities.
  • Slow weight gain.
  • Hypoxia spells (Tet spells characterized by
    sudden cyanosis and syncope)

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  • Complication CHF, endocarditis, CVA and iron
    deficiency anemia.
  • Treatment
  • Improve oxygenation
  • Emergency for Tet spells beta-blockers as
    propranolol, but acute episodes may require rapid
    intervention with morphine are required.

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  • Surgical
  • Complete intracardiac repair of VSD and PA
    stenosis.
  • Enter chest through the sternum.
  • Connect the heart and lung machine. Heart is
    stopped.
  • Repair the VSD with a patch.
  • removing the excessive muscle tissue will help to
    function correctly.
  • Pacemaker wires are placed temporarily because of
    the potential for postoperative ventricular
    arrhythmias.
  • Individual chamber pressures are then measured
    before the chest is closed. The pressure
    readings help to determine how effective the
    surgery was.

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  • II. Transposition of the Great Arteries (TGA)
  • TGA occurs when the aorta arises from the right
    ventricle and the pulmonary artery from the left
    ventricle.
  • Incompatible with life unless the infant has an
    associated defect which allows the blood to
    communicate between the pulmonary and systemic
    circulation.
  • Clinical Manifestation
  • Marked cyanosis since birth.
  • Failure to thrive, Fatigability and dyspnea with
    subcostal retractions at rest
  • Cardiomegaly, early clubbing of fingers and
    C.H.F.

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  • Prognosis without surgical treatment, 85 die
    in the first 6 months of age.
  • Treatment
  • Management of C.H.F.
  • Palliative procedures creation of A.S.D. with a
    balloon catheter during catheterization or
    surgical creation of A.S.D.
  • Complete correction by cardiopulmonary bypass.

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  • III. Tricuspid Atresia
  • Is a condition in which there is a complete
    absence of the tricuspid valve. Therefore, there
    is an hypoplastic of right ventricle. Its
    associated with
  • Atrial septal defect.
  • There is usually a V.S.D. allowing some blood to
    enter the underdeveloped right ventricle.

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  • Pathophysiology
  • Blood from the systemic circulation is shunted
    from the right atrium through an interatrial
    communication to the left atrium, to the left
    ventricle.
  • Pulmonary blood flow is established either
    through PDA or VSD.
  • Clinical Manifestation
  • Cyanosis marked since birth, dyspnea on feeding
    and may hypoxia spells.
  • Early clubbing of fingers and failure to thrive.
  • Right heart failure may occur.

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  • Treatment
  • Palliative procedures to increase the pulmonary
    blood flow (Anastomosis between the ascending
    aorta and right pulmonary artery).
  • Fontan Procedure is a palliative surgical
    procedure used in children with complex
    congenital heart defects. It involves diverting
    the venous blood from the right atrium to the
    pulmonary arteries without passing through the
    morphologic pulmonary ventricle
  • Complete correction

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  • Diagnostic Evaluation for Congenital Heart
    Defects.
  • 1. Chest x- ray shows enlargement of the affected
    chambers of the heart.
  • 2. Cardiac catheterization visually demonstrate
    the defect, demonstrate blood oxygenation in
    heart chambers.
  • 3. E.C.G.

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  • Nursing care plan for the child with congenital
    heart disease
  • Assessment
  • Take careful health history including evidence
    of poor weight gain, unusual posturing or poor
    feeding
  • Exercise intolerance frequent respiratory tract
    infections
  • Perform physical assessment with special emphases
    on color, pulse (apical and peripheral),
    respiration, blood pressure, examination and
    auscultation of chest and manifestations of CHD.

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  • Thank You All
  • Any Question ??????
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