Nursing Management of
Cardiac Disorders in
Ball & Bindler
Family history of defects / early cardiac
disease / siblings with defects
Maternal history of stillborns or
Congenital anomalies / genetic anomalies
/ fetal alcohol syndrome / Down
Syndrome and Turner Syndrome
Maternal exposure to rubella
Present Health History
Tires while eating
Low weight for height
Sweats while eating (diaphoretic)
Cyanosis, worsens with feeding or activity
Irritable weak cry
In the older child additional symptoms
– Chest pain
– Decreased activity level
– Slight of build
Use both the bell (for low frequency) and
the diaphragm (for high frequency)
Quality: distinct S1 and S2
Rate matches radial pulse
Heart sounds should be crisp and distinct
S1 is the first heart sound, produced by
closure of the tricuspid and mitral valves
when ventricular contraction begins.
S2 is produced by the closure of the aortic
and pulmonic valves.
These sounds are produced by blood
passing through a defective valve, great
vessel, or other heart structure.
Murmurs are classified by: intensity,
location, radiation, timing, and quality.
Clubbing of Fingers
Clubbing of Fingers
Whaley & Wong Bowden text
Nurse puts infant in knee-chest
position. Whaley & Wong
Child with a cyanotic heart
defect squats (assumes a knee-chest position) to relieve
cyanotic spells. Some times called “tet” spells. Ball &
• Pulmonary alveoli open up
• Pressure in pulmonary tissues decreases
• Blood from the right heart rushes to fill
the alveolar capillaries
• Pressure in right side of heart decreases
• Pressure in left side of heart increases
• Pressure increases in aorta
Pulmonary artery banding
Chest x-ray to define silhouette of the
– Heart size, shape, pulmonary markings, and
Electrocardiogram to define electrical
activity of the heart.
Echo-cardiogram to visualize anatomic
An invasive test to diagnose or treat
– Visualizes heart and vessels.
– Measures oxygen saturation of chambers.
– Measures intra-cardiac pressures.
– Determines muscle function and pumping
action of the heart.
Assess vital signs with blood pressure.
Hemoglobin and hematocrit
IV if child is polycythemic
Vital sign, with apical pulse, and blood
pressure q 15 minutes for first hour.
Apical pulse for 1 minute to check for
bradycardia or dysrhythmias.
Toxicity to Dye
Watch for signs of toxicity to the dye used
during the procedure.
– Increased temperature
– Headache *Allergy response
Home Care Instructions
Keep dressing in place for 24 hours.
Keep site dry and clean.
Observe site for redness, swelling,
drainage, or bleeding.
Avoid strenuous exercise.
Acetaminophen for pain.
Keep follow-up appointment
Pre-procedure medications as ordered.
Assess pulses below the cath site.
Record quality and symmetry of pulses.
Assess temperature and color of affected
Check dressing for bleeding or hematoma
Right to Left Shunts
Occurs when pressure in the right side of the
heart is greater than the left side of the heart.
– Resistance of the lungs in abnormally high
– Pulmonary artery is restricted
Deoxygenated blood from the right side shunts
to the left side
Right to Left Shunt
Hole in septum + obstructive lesion =
Deoxygenated blood from the right side of
the heart shunts to the left side of the
heart and out into the body.
Hypoxemia = the result of decreased
Polycythemia = increased red blood cell
production due to the body’s attempt to
compensate for the hypoxemia.
Increase viscosity of the blood = heart has
to pump harder.
Thrombus formation due to sluggish
Brain abscess or stroke due to the un-
oxygenated blood bypassing the filtering
system of the lungs.
Left to Right Shunt
Pressures on the left side of the heart are
normally higher than the pressures in the
right side of the heart. If there is an
abnormal opening in the septum between
the right and left sides, blood flows from
left to the right.
The infant is not cyanotic.
Tachycardia due to pushing increased
Cardiomegaly due to increased workload
of the heart.
Dyspnea and pulmonary edema due to the
lungs receiving blood under high pressure
from the right ventricle.
Increased number of respiratory infections
due to blood pooling in the the lungs
promoting bacterial growth.
Congestive Heart Failure
Major manifestation of cardiac disease.
Under 1 year of age due to congenital
Over 1 year with no congenital anomaly
may be due to acquired heart disease.
Cardinal Signs of CHF
Digoxin increases the force of the
– Take an apical pulse with a stethoscope for 1
full minute before every dose of digoxin. If
bradycardia is detected.
< 100 beats / min for infant and toddler
< 80 beats in the older child
< 60 beats in the adolescent
* Call physician before administering the drug.
Signs of Digoxin Toxicity
Nausea, vomiting, anorexia
Weakness and fatigue
Diuretics – Lasix (potassium wasting) or
Aldactone (potassium sparing)
Small frequent feedings – soft nipple with
supplemental NG for adequate calorie
Sedatives if needed
Infants with cardiac
conditions often require
to provide sufficient
nutrients for growth.
Ball and Bindler
Cardiac Heart Defects
Patent Ductus Arteriosus
One of the most common benign defects
Ductus normally closes within hours of
Connection between the pulmonary artery
(low pressure) and aorta (high pressure)
High risk for pulmonary hypertension
Diagnosis and Treatment
– Chest x-ray – enlarged heart and dilated
– Echo-cardiogram – show the opening
between pulmonary artery and aorta
Indomethocin given po – constricts the
muscle in the wall of the PDA and
Cardiac Catheterization – coil is placed in
the open duct and acts like a plug
Closed heart surgery – small incision made
between ribs on left hand side and PDA is
ligated or tied and cut
Atrial Septal Defect
10% of defects
Blood in left atrium flows into right atrium
Reduced blood volume in systemic
If left untreated may lead to pulmonary
hypertension, congestive heart failure or
stroke as an adult.
Diagnosis and Treatment
Diagnosis: heart murmur may be heard in
the pulmonary valve area because the
heart is forcing an unusually large amount
of blood through a normal sized valve.
Echocardiogram is the primary method
used to diagnose the defect – it can show
the hole and its size and any enlargement
of the right atrium and ventricle in
response to the extra work they are doing.
Surgical closure of the atrial septal defect
After closure in childhood the heart size
will return to normal over a period of four
to six months.
No restrictions to physical activity post
Ventricular Septal Defect
30% of defects
Opening in the ventricular septum
Right ventricular hypertrophy
Deficient systemic blood flow
Small holes generally are asymptomatic
Medium to moderate holes will cause
problems when the pressure in the right
side of the heart decreases and blood will
start to flow to the path of least resistance
(from the left ventricle through the VSD to
the right ventricle and into the lungs)
This will generally lead to CHF
Diagnosis and Treatment
Diagnosis – heart murmur – clinical pearl
a louder murmur may indicate a smaller
hole due to the force that is needed for
the blood to get through the hole.
Electrocardiogram – to see if there is a
strain on the heart
Chest x-ray – size of heart
Echocardiogram – shows size of the hole
and size of heart chambers
CHF: diuretics of help get rid of extra fluid
in the lungs
Digoxin if additional force needed to
squeeze the heart
FTT or failure to grow may need higher
Will need prophylactic antibiotics before
dental procedures if defect is not repaired
Over a period of years the vessels in the
lungs will develop thicker walls – the
pressure in the lungs will increase and
pulmonary vascular disease
If pressure in the lungs becomes too high
the un-oxygenated blood with cross over
to the left side of the heart and un-
oxygenated blood with enter the
If the large VSD is repaired these changes
will not occur.
Coarctation of Aorta
7 % of defects
Congenital narrowing of the descending
80% have aortic-valve anomalies
Difference in BP in arms and legs (severe
Diagnosis and Treatment
In 50% the narrowing is not severe
enough to cause symptoms in the first
days of life.
When the PDA closes a higher resistance
develops and heart failure can develop.
Pulses in the groin and leg will be
Echocardiogram will show the defect in
Prostaglandin may given to keep the PDA open
to reduce the pressure changes
The most common repair is resection of the
narrowed area with re-anastomosis of the two
Surgical complications – kidney damage due to
clamping off of blood flow during surgery
High blood pressure post surgery – may need to
be on antihypertensives
Antibiotic prophylactic need due to possible
aortic valve abnormalities.
7% of defects
Obstruction of blood flow from right
Hypertrophy of right ventricle
If severe cyanosis due to right-to-left
Pulmonary Valvar Stenosis
In pulmonary valvar stenosis the
pulmonary valve leads to narrowing and
obstruction between the right ventricle
and the pulmonary artery.
Thickened tissue become less pliable and
increases the obstruction
Right ventricle must work harder to eject
blood into the pulmonary artery.
Diagnosis and Treatment
Diagnosis: heart murmur is heard –
clicking sound when the thickened valve
snaps to an open position.
Electrocardiogram would be normal
Echocardiogram most important non-
invasive test to detect and evaluate
Cardiac Catheterization – to measure
pressures and measure the stenosis
Cardiac Catheterization to dilate the valve
and open up the obstruction.
Open- heart procedure would only needed
for more complex valve anomaly.
Tetralogy of Fallot (TOF)
6% of defects
Most common cardiac malformation
responsible for cyanosis in a child over 1
– Pulmonary stenosis – narrowing of pulmonary
– Overriding of the aorta – aortic valve is
enlarged and appears to arise from both the
left and right ventricles instead of the left
– Hypertrophy of right ventricle – thickening of
the muscular walls because of the right
ventricle pumping at high pressure
Dependent on degree of right ventricular
Clubbing of digits
“tet” spells - treated by flexing knees
forward and upward
Severe irritability due to low oxygen levels
Oxygen will have little effect on the
Loud heart murmur
Echocardiogram – demonstrates the four
defects characteristic of tetralogy
If oxygen levels are extremely low
prostaglandins may be administered IV to keep
the PDA open
Complete repair is done when the infant is about
6 months of age
– Closure of the VSD with dacron patch
– The narrowed pulmonary valve is enlarged
– Coronary arteries will be repaired
– Hypertrophy of right heart should remodel within a
few months when pressure in right side is reduced
Long Term Outcomes
Leaky pulmonary valve that can lead to
Arrhythmias after surgery
Heart block – occasionally a pacemaker is
Periodic echocardiogram and exercise
stress test or Holter evaluation
6% of defects
Aortic valve: has two rather than three
leaflets. Leaflets are thickened or fused.
Obstruction of blood flow from left
Mild symptoms: dizziness, syncope,
30% incidence of sudden death
Causes obstruction to blood flow between
the left ventricle and aorta.
Most common form is obstruction of the
When the aortic valve does not open
properly the left ventricle must work
harder to eject blood into the aorta.
Left ventricular muscle becomes
Heart murmur or AS is a turbulent noise
caused by ejection of blood through the
Electrocardiogram is usually normal
Echocardiogram will show the obstruction
and rule out other heart anomalies
Exercise stress test – provides information
on impact of the stenosis on heart
Cardiac catheterization – balloon dilation of the
Surgical valvotomy if the closed procedure does
not work – often done when patient is older
when severe calcium deposits further obstruct
Recurrent valve obstruction is a complication
and if valve replacement is done too early the
child may outgrow the valve.
Antibiotic prophylaxis especially if valve
Hypoplastic Left Heart
One of the most complex defects seen in
the newborn and the most challenging of
all the congenital defects
All the structures on the left side of the
heart are severely underdeveloped.
Mitral and aortic valves are either
completely closed or are very small – left
ventricle is tiny – aorta is small and often
only a few millimeters in diameter
Life threatening shock develops when the
ductus arteriosis closes
Low oxygen saturations – will not increase
with oxygen administration
Pulses will be weak in all extremities
Plan to deliver infant in a hospital capable
of providing the aggressive treatment
Three staged procedure to reconfigure the
– Norwood – right ventricle becomes the
systemic ventricle pumping blood to the body
– Glenn done at 3-6 months
– Fontan done at 2 -3 years of age
Long Term Complications
Easily tiring when participating in sports or
Formation of blood clots – heparin or
Heart arrhythmias – pace maker
Infection of endocardial surface of the
History of CHD, Kawasaki Disease,
Rheumatic Fever, or prosthetic valves are
more susceptible to infection
Prophylactic antibiotics with dental care,
throat, intestinal, urinary or vaginal
infections or surgery.
Acute-self limiting disease
Peak incidence 6 months to 2 years
More common in males and Japanese
Edema of hands and feed
Reddening of palms and soles
Lymph node swelling
Edema – Hands and Feet
Peeling Finger Tips
Intravenous gamma globulin
High dose of ASA while in hospital
Low dose ASA upon discharge
Base-line echocardiogram to assess
coronary artery status