Module 5 – Pediatric Cardiac Disorders

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					         Module 5
Pediatric Cardiac Disorders
Fetal Circulation
Fetal Circulation
         Fetal Circulation

  What is the
secondary route
 of circulation?

And third route?
Fetal Circulation

           What is the
        stimulus for the
           change in
Intrauterine to Extrauterine
         Intrauterine to Extrauterine
    1.    Decreased pulmonary vascular resistance

                 Increased pulmonary blood flow
                  Closure of ductus arteriosus

2. Increase pressure in left atrium, decrease pressure in right atrium

                     Closure of foramen ovale
           Oxygen Saturation

   What is oxygen saturation?

   What is normal oxygen saturation levels?

   What values indicate hypoxemia?

   Why is it important for the nurse to know the
    oxygen saturation levels?
       Congestive Heart Failure

   What is wrong with the heart?
     Congestive heart failure

   The inability of the myocardium to circulate
    enough oxygenated blood to meet the
    demands of the body.
   When the heart fails, cardiac output is
    diminished. Heart rate, preload,
    contractitility, and afterload are affected.
   Peripheral tissue is not adequately
   Congestion in lungs and periphery
    Congestive Heart Failure

   Why does the pump fail?
Etiology and Pathophysiology

*Congenital defects

*Acquired heart diseases
Congestive Heart Failure

               What does the
                 body do to
               compensate for
               this congestion
                  and heart
        Compensatory Mechanisms
   With a decrease in Cardiac Output

   Stimulation of the sympathetic nervous system

   Tachycardia - increases venous return to the
    heart which stretches the myocardial fibers and
    increases preload.
    Compensatory Mechanisms

           With a decrease in cardiac output

       Decrease perfusion to the kidneys and

           Increased renin and ADH secretion

   Increase in Na and H2O retention to increase
                intravascular volume
            Early Signs of CHF

   The earliest signs are often subtle:

       Infant will have mild resting tachypnea

       Increasing difficulty feeding
   Signs and Symptoms
 Pulmonary congestion
  1. Tires easily during feeding
  2. Tachypnea, Dyspnea, orthopnea
  3. Signs of respiratory distress
  4. Wheezing, rales and rhonchi
  5. Easily fatigue
 Impaired cardiac output
  1. Tachycardia
  2. Extremities cool, capillary refill >2 seconds
  3. Diaphoretic, sweating, hypotension
     Signs and Symptoms

   Systemic venous congestion
    1. Hepatomegaly
    2. Edema
    3. Weight gain

 High metabolic rate
  1. Failure to thrive
    2. Slow weight gain
Goal of Treatment
    Treatment of Congestive Heart Failure
   Medication Therapy
     Digitalis – increases contractility and decreases
         heart rate.
        ACE-inhibitors - blocks release of angiotension-
         aldosterone; arterial vasodilator / afterload
         reducing agent
        Diuretics - enhance renal secretion of sodium and
         water by reducing circulating blood volume and
         decreasing preload,  pulmonary congestion.
        Beta Blocker - increases contractility
Nursing Care
      How would the nurse
   recognize digitalis toxicity in
        an infant or child?

   What are the pulse rate
 criteria in administration of
Pulse rates for Digitalis administration

   Infant – 100 BPM or greater

        Child – 80 BPM or greater

           Adolescent – 60 BPM or Greater
   Digitalization
       Given in divided doses
   Maintenance
       Given daily, usually in two divided doses

   Therapeutic vs. Toxicity
       Therapeutic range – 0.8 to 2.0 ng/ml
       Toxicity
          **EKG changes – arrhythmia

          Slow pulse- bradycardia

          Vomiting – very rare in infants

   Why are we so concerned with the
    potassium levels when the child is on
    digitalis therapy?

   Hypokalemia potentiates digoxin toxicity
Treatment of Congestive Heart Failure

   Diet – low sodium, small frequent feedings

   Nursing care:
       Measure intake and output – weighing diapers
       Observe for changes in peripheral edema and
       If ascites present – take serial abdominal
        measurements to monitor changes.
       Skin care
       Turning schedule
       Time nursing care to allow for rest periods
     Feeding the child with CHF
   Feed the infant or child in a relaxed environment;
    frequent, small feedings may be less tiring
   Hold infant in upright position; may provide less
    stomach compression and improve respiratory effort
   If child unable to consume appropriate amount during
    30-minute feeding every 3 hours, consider nasogastric
   Monitor for increased tachypnea, diaphoresis, or
    feeding intolerance (vomiting)
   Concentrating formula to 27 kcal/oz may increase
    caloric intake without increasing infant’s work
Cardiac Catheterization

  Measure oxygen saturations and pressure in the
       cardiac chambers and great arteries

             Evaluate cardiac output
        Cardiac Catheterization
   This process involves passing a
    catheter through the femoral
    vein or artery into the heart.

   Performed to evaluate heart
    valves, heart function and blood
    supply, or heart abnormalities in
     Cardiac Catheterization
   Pre-care:
       History and Physical
       Lab work – EKG, ECHO cardiogram, CBC
       NPO
       Vital signs
       Preprocedural teaching
     Cardiac Catheterization

   Post Care:
       Check for bleeding or hematoma at insertion site
       Keep leg immobilized and straight with bedrest in
        supine position
       Monitor vital signs
       Neurovascular monitoring of extremity distal to the
        catheter insertion
       Measure I&O
       Provide quiet diversional activities
       Provide adequate fluids
     Best Nursing Action

   During post procedure assessment, the nurse
    notes bleeding at the insertion site.

   What should the nurse do first?
Post Cardiac Catheterization Care
Post Cardiac Catheterization Care
Congenital Cardiac Anomalies
Ask Yourself?

   What is the most common assessment
    finding indicating a cardiac anomaly?

   Answer: an audible heart murmur
Patent Ductus Arterious
 Atrial septal defects
Ventricle septal defects
         Atrial Septal Defect
1. Oxygenated blood is shunted
   from left to right side of the
   heart via defect
2. A larger volume of blood
   than normal must be
   handled by the right side of
   the heart hypertrophy
3. 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

   Medical Management
       Medications – digoxin

   Cardiac Catheterizaton -
       Amplatzer septal occluder

   Open-heart Surgery

       Device Closure – Amplatzer septal

During cardiac catheterization the occluder is placed in the
Ventricle Septal Defect
               1. Oxygenated blood is shunted
                  from left to right side of the
                  heart via defect
               2. A larger volume of blood
                  than normal must be
                  handled by the right side of
                  the heart hypertrophy
               3. 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
Surgical repair with a patch inserted
      Patent Ductus Arteriosus
1. Blood shunts from
   aorta (left) to the
   pulmonary artery
2. Returns to the lungs
   causing increase
   pressure in the lung
3. Congestive heart
      Treatment for PDA
   Medical Management
     Medication

        Indomethacin - inhibits prostaglandin's

         which help keep the ductus arteriosus

                                 Ligate the
   Surgery                      ductus arteriosus
          Treatment for PDA

   Cardiac Catheterization

        Insert coil – tiny fibers
           occlude the ductus
            arteriosus when a
           thrombus forms in
         the mass of fabric and
Cardiac Anomalies - Treatment
Pulmonic stenosis

coarctation of aorta
     Pulmonic Stenosis

   Narrowing of
    entrance that
    decreases blood
   Increases
    preload causes
    right ventricular
     Obstructive or Stenotic Lesions
   Treatment:
      Medications – Prostaglandins to keep the

       PDA open

       Cardiac Catheterization
          Baloon Valvuloplasty

       Surgery
          Valvotomy
Aortic Stenosis
                The aortic valve is
                 thickened and rigid

                Stenosis creates left
                 ventricular hypertrophy

                Left ventricle may not be
                 large enough to eject a
                 normal cardiac output.
     Aortic Stenosis

   Symptoms
      Poor peripheral perfusion, feeding

       difficulties, CHF

   Treatment
      Balloon valvoplasty

      Surgery
      Coarctation of the Aorta

1. Narrowing of Aorta
   causing obstruction of
   left ventricular blood
2. Left ventricular
   Signs and Symptoms

1.  B/P in upper extremities
2. B/P in lower extremities
3. Radial pulses full/bounding and femoral or
   popliteal pulses weak or absent
4. Leg pains, fatigue
5. Nose bleeds
   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 allowing blood flow to areas beyond the

   Baloon Valvoplasty
Surgery for Coarctation of Aorta

        1. Resect
           area     2. Anastomosis
Tetralogy of fallot
   Tetralogy of Fallot
Four defects are:

             1.          2.

Signs and Symptoms
    1.   Failure to thrive
    2.   Squatting
    3.   Lack of energy
    4.   Infections
    5.   Polycythemia
    6.   Clubbing of fingers
    7.   Cerebral absess
    8.   Cardiomegaly
     Ask Yourself?

   Why does Polycythemia occur in a child with a
    cardiac disorder?

   Nursing interventions should the nurse include
    when planning care for this client?
What lab test will be abnormal and
assist in confirming the polycythemia?
     Ask Yourself ?

   Laboratory analysis on a child with Tetralogy
    of Fallot indicates a high RBC count. The
    polycythemia is a compensatory mechanism
    a. Tissue oxygen need
    b. Low iron level
    C. Low blood pressure
    d. Cardiomegaly
       Hypercyanotic Episode / “tet” spells
   Cyanosis suddenly worsens in response to
    activity, such as crying, feeding, or having a
    bowel movement.

   Signs - The infant becomes very short of breath
    with tachypnea and hyperpnea, and may lose

   Treatment – calming, knee-chest position,
    oxygen, morphine , and beta-blockers

   Open-heart Surgical interventions
     Blalock – Taussig or Potts procedure –

      increases blood flow to the lungs.
  Something the Lord Made

    View the Movie Trailer
About Blalock procedure to treat
      Tetralogy of fallot
•     Truncus Arteriosus
•     Transportation of Great Vessels

    These present the greatest risk to survival
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
                Entire systemic
                 circulation supplied from
                 common trunk.
        Transposition of Great Vessels
 Aorta arises from the right
  ventricle, and the pulmonary             artery
  artery arises from the left
  ventricle - which is not
  compatible with survival
  unless there is a large defect   aorta
  present in ventricular or
  atrial septum.
     Microorganisms grow on the
  endocardium, forming vegetations,
deposits of fibrin, and platelet thrombi.
The lesion may invade adjacent tissues
    such as aortic and mitral valves.
        Subacute Bacterial Endocarditis /
        Infective Endocarditis:
   Assessment:
       Fever
       Fatigue
       Muscle and joint pain
       Headache
       Nausea and vomiting
       CHF
       Spleenomegaly
   Diagnosis:
       Blood cultures
       Echocardiogram
     Infective Endocarditis

   Diagnosis

       Blood cultures

       Echocardiogram
          Show the vegetation
     Infective Endocarditis

   Who is more susceptible to develop infective

   Answer:
     Children with a congenital heart defect,

      rheumatic heart disease, or a central venous
      catheter or who have had heart surgery are
      at highest risk.
     This is the most therapeutic
intervention for infective endocarditis

   Maintain optimal oral hygiene
     Antibiotic Prophylaxis for Children at
     Risk for Infective Endocarditis
   Dental procedures, including cleaning, that may induce
    gingival or mucosal bleeding

   Tonsillectomy and/or adenoidectomy

   Surgery and/or biopsy involving respiratory or
    intestinal mucosa

   Incision and drainage of infected tissue

   Invasive GU and GI procedures
     Ineffective Endocarditis

   Treatment
      Monitor temperature

      Antibiotics – 2-8 weeks

       Patient teaching
            Good oral hygiene
            take antibiotics prior to surgery, dental work, or
             any invasive procedure, etc.
            discouraged from body piercing and tattoos as
             endocarditis may occur even with prophylaxis.
 A systemic inflammatory (collagen) disease of
connective tissue that usually follows a group A
    beta-hemolytic streptococcus infection.

This disorder causes changes in the entire heart
 (especially the valves), joints, brain, and skin
          Rheumatic Fever - Assessment
   Major                                  Minor
      Carditis
                                               Arthralgia
                                               Fever
      Polyarthritis
                                               Laboratory
      Chorea
      Erythema                                     Erythrocyte
       marginatum                                   sedimentation
      Subcutaneous                                 rate
       nodules                                      C-reactive
                                                   Prolonged PR


                       Jones Criteria
What additional laboratory
 test helps to confirm the
  diagnosis of Rheumatic
          Fever ?

   ASO titer

   Elevated Erythrocyte Sedimentation Rate
    Rheumatic Fever

   Treatment
       Antibiotic Therapy
       Antipyretics - aspirin
       Anti-inflammatory agents –steroids
       Rest
       Heat and cold to joints

   Discharge Teaching
       Antibiotic therapy - be sure to complete all
        Streptococcal Prophylaxis for the
           Child with Rheumatic Fever

   Damaged valves can become further damaged
    with repeated infections

   Streptococcal prophylaxis is lifelong if there is
    actual valve involvement

   Intramuscular penicillin, administered
    monthly, is the drug of choice

   Alternatives include oral penicillin twice daily
    or oral sulfadiazine once a day
Multisystem vasculitis – inflammation of
blood vessels in the body especially the
coronary arteries with antigen-antibody
     Kawasaki Disease
     Signs and Symptoms / Treatment
   Three Phases of clinical manifestations:
      Acute

      Subacute

      Convalesant

   One of the most common symptoms used to
    diagnose Kawasaki disease is a high spiking
    fever over 1020 for 5 days.
     Acute Phase – 10-14 days
   Fever, which often is higher than 101.3 F, and lasts one
    to two weeks
   Extremely red eyes (conjunctivitis)
    without thick discharge
   Red, dry, cracked lips and an extremely red, swollen
    tongue ("strawberry" tongue)
   A rash on the main part of the body (trunk)
    and in the genital area
   Swollen, erythema on the palms of the hands and the
    soles of the feet
   Swollen cervical lymph nodes
     Subacute Phase 15-25 days
   Irritability
   Anorexia
   Desquamation of the skin on the hands and feet,
    especially the tips of the fingers and toes, often in
    large sheets
   Arthritis and Arthralgia
   Arrhythmias
   Coronary aneurysms
     Convalescent Phase

   From day 26 until the erythrocyte
    sedimentation rate returns to normal
     Nursing Care
   Give Medications
       Aspirin
       Intravenous Immunoglobulin
   Promote comfort
      Lubricate the lips
      Cool compresses

      Keep skin cool and dry

      Small feedings of soft foods and liquids that are not

       too hot or too cold.
   Facilitate joint movement
      Passive Range of Motion exercises
Kawasaki Disease
   Which phase of Kawasaki is this child

                            Inflamed, Cracked,
                            Peeling Lips

              Strawberry tongue
     Kawasaki Disease

   What are major complications of Kawasaki?

       Coronary aneurysms

       Thrombosis

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