Nursing Management of Cardiac Disorders in Children

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					Nursing Management of
 Cardiac Disorders in
     Pediatric Nursing

      Ball & Bindler
            Health History
 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
 Heart murmur
 Tires while eating
 Low weight for height
 Sweats while eating (diaphoretic)
 Cyanosis, worsens with feeding or activity
 Irritable weak cry
               Health History

   In the older child additional symptoms
    may include:
    – Chest pain
    – Decreased activity level
    – Syncope
    – Slight of build
Heart Sounds
             Heart Sounds
 Use both the bell (for low frequency) and
  the diaphragm (for high frequency)
 Quality: distinct S1 and S2
 Rate matches radial pulse
 Intensity
 Rhythm
             Heart Sounds
 Heart sounds should be crisp and distinct
  in children.
 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.
            Heart Murmurs
 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
                Knee-chest Position
                                          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 &
                First Breath
•   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
       Treatment Modalities
 Palliative procedures
 Pulmonary artery banding
 Shunts
 Corrective procedures
              Diagnostic Test
   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

Cardiac Conduction
        Cardiac Catheterization
   An invasive test to diagnose or treat
    cardiac defects.
    – Visualizes heart and vessels.
    – Measures oxygen saturation of chambers.
    – Measures intra-cardiac pressures.
    – Determines muscle function and pumping
      action of the heart.
    Pre-cardiac Catheterization
 Assess vital signs with blood pressure.
 Hemoglobin and hematocrit
 Pedal pulses
 Hold digoxin
 IV if child is polycythemic
     Post-cardiac Catheterization

   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
    – Urticaria
    – Wheezing
    – Edema
    – Dyspnea
    – 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.
 Check temperature.
 Avoid strenuous exercise.
 Acetaminophen for pain.
 Keep follow-up appointment
 Pre-procedure medications as ordered.
    Post-cardiac Catheterization
 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.
       Clinical Manifestations
 Hypoxemia = the result of decreased
  tissue oxygenation.
 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.
      Potential Complications
 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.
         Clinical Manifestations
   The infant is not cyanotic.

   Tachycardia due to pushing increased
    blood volume.

   Cardiomegaly due to increased workload
    of the heart.
         Clinical Manifestations
   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
 Tachycardia
 Cardiomegaly
 Tachypnea
 Hepatomegaly
                Digoxin Therapy
   Digoxin increases the force of the
    myocardial contraction.
     – 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
 Bradycardia
 Arrhythmia
 Nausea, vomiting, anorexia
 Dizziness, headache
 Weakness and fatigue
 Fluid restriction
 Diuretics – Lasix (potassium wasting) or
  Aldactone (potassium sparing)
 Bed rest
 Oxygen
 Small frequent feedings – soft nipple with
  supplemental NG for adequate calorie
 Pulse oximeter
 Sedatives if needed
Supplemental Feeding

             Infants with cardiac
             conditions often require
             supplemental feeding
             to provide sufficient
             nutrients for growth.

             Ball and Bindler
         Cardiac Heart Defects
     Patent Ductus Arteriosus
 Incidence 10%
 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
   Diagnosis by
    – Chest x-ray – enlarged heart and dilated
      pulmonary artery
    – Echo-cardiogram – show the opening
      between pulmonary artery and aorta
 Indomethocin given po – constricts the
  muscle in the wall of the PDA and
  promotes closure
 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
 Pulmonary hypertension
 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
 Left-to-right shunt
 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
            Treatment VSD
 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
  calorie concentration
 Will need prophylactic antibiotics before
  dental procedures if defect is not repaired
            Surgical Repair
 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
  circulatory system.
 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
  the aorta
   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.
         Pulmonary Stenosis
 PS
 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
  pulmonary stenosis
 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
   Four Components
    – VSD
    – 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
       Clinical Manifestations
 Dependent on degree of right ventricular
  outflow obstruction.
 Right-to-left shunt
 Clubbing of digits
 “tet” spells - treated by flexing knees
  forward and upward
 Severe irritability due to low oxygen levels
 Cyanosis
 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
 Correction includes
    –   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
  pulmonary insufficiency
 Arrhythmias after surgery
 Heart block – occasionally a pacemaker is
 Periodic echocardiogram and exercise
  stress test or Holter evaluation
            Aortic Stenosis
 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,
  angina, fatigue
 30% incidence of sudden death
           Aortic Stenosis
 Causes obstruction to blood flow between
  the left ventricle and aorta.
 Most common form is obstruction of the
  valve itself
 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
  obstructed valve.
 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
  narrowed valve.
 Surgical valvotomy if the closed procedure does
  not work – often done when patient is older
  when severe calcium deposits further obstruct
  the valve.
 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
    cardiovascular system
    – 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
  other exercises
 Formation of blood clots – heparin or
  Coumadin use
 Heart arrhythmias – pace maker
 Cardiac failure
       Bacterial Endocarditis
 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.
         Kawasaki Disease
 Acute-self limiting disease
 Generalized vasculitis
 Peak incidence 6 months to 2 years
 More common in males and Japanese
      Clinical Manifestations
 High fever
 Conjunctivitis
 Strawberry tongue
 Edema of hands and feed
 Reddening of palms and soles
 Lymph node swelling
Edema – Hands and Feet
Peeling Finger Tips
               Blood Values
   Elevated WBC

   Elevated ESR

   Elevated platelets

 Intravenous gamma globulin
 High dose of ASA while in hospital
 Low dose ASA upon discharge
 Base-line echocardiogram to assess
  coronary artery status

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Description: Nursing Management of Cardiac Disorders in Children. Heart disease in children nursing lecture notes