cardiac disorders peds

CARDIAC DISORDERSCARDIAC DISORDERSCARDIAC DISORDERSCARDIAC DISORDERS

Annette TomlinsonAnnette Tomlinson

Cardiovascular Dysfunction

In children this is divided into 2 categories:Congenital heart Disease (CHD)These are anatomic abnormalities present at birth that result in abnormal cardiac function.

Acquired heart diseaseThese are disease processes or abnormalities that occur after birth and can be seen in in the normal heart or in the presence of congenital heart defects.

Congestive Heart Failure

•The clinical consequence of congenital heart disease

Congestive Heart Failure

– Description•Inability of heart to pump sufficient

amount of oxygen to meet metabolic needs of body

•Usually due to a surgically correctable structural abnormality of the heart that results in increased blood volume and pressure

•Goals of treatment include improving cardiac function; removing accumulated fluid, sodium; decreasing cardiac demands; improving tissue oxygenation; decreasing oxygen consumption.

Assessment - CHFAssessment of early signs

•Tachycardia, especially during rest and slight exertion

•Tachypnea •Profuse scalp sweating in infants •Fatigue; irritability •Sudden weight gain •Respiratory distress

Assessment - CHF• Cardiomegaly, peripheral pulses,

mottling• Tachypnea, retractions, grunting, nasal

flaring, cough, cyanosis, orthopnea• Hepatomegaly, edema, decreased urine

output• Failure to thrive, decreased exercise

tolerance

Nursing Interventions - CHF

• Decrease energy expenditure– Frequent rest periods– Small, frequent feedings– Minimize crying– Prevent cold stress

• Provide nutrition– Use soft nipple– Gavage feeding if needed


• Monitor fluid status– I & O, specific gravity– Daily weight

• Provide adequate rest, position for comfort

• Prevent infections• Promote growth & development• Reduce respiratory distress


•Administer digoxin (Lanoxin) as prescribed after assessing apical pulse for 1 minute

Digoxin

– Check dosage with another RN– Give 1 hour before feeding or 2

hours after feeding– Give at 12 hour intervals (BID)– Take apical pulse for 1 minute

• Hold if HR <90 in infants or<70 in children

Digoxin

– Monitor serum potassium levels• If signs of hypokalemia occur and child

receiving digoxin, monitor closely for signs of digoxin toxicity

• Signs of toxicity: vomiting, nausea, bradycardia, lethargy

• If receiving furosemide (Lasix), administer supplemental potassium supplements after assessing serum potassium levels

DigoxinInstruct parents regarding description of diagnosis,

administration of medicationsAdminister 1 to 2 hours after feedingsUse calendar to mark off dose administeredDo not mix medication with foods, fluidIf dose is missed and more than 4 hours has elapsed,

withhold dose and give next dose at prescribed time; if less than 4 hours, then administer dose

If child vomits, do not administer replacement doseIf more than two consecutive doses missed, notify

physician

Circulatory Changes at Birth

• When the umbilical cord is clamped, the blood supply from the placenta is cut off, and oxygenation must then take place in the infant’s lungs

• As the lungs expand with air, the pulmonary artery pressure decreases and circulation to the lungs increases


• Structural Changes– Ductus venosus: after the umbilical

cord is severed, flow through the ductus venosus decreases and eventually ceases; it constricts within 3-7 days


• Foramen ovale– Functional closure of this valve-like

opening occurs when pressure in the left atrium exceeds pressure in the right.

– Closure occurs within the first weeks after birth

• Ductus arteriosus– Increase in aortic blood flow increases

aortic pressure and decreases and stops the flow between the left pulmonary artery and the dorsal aorta through the ductus arteriosus.

– Functional closure occurs when this constriction causes cessation of blood flow, usually 24 hours after birth.

– Anatomic closure by 1-3 weeks.


Abnormal Circulatory Patterns After Birth

• Normal blood flow may be disrupted as a result of abnormal openings between the pulmonary and systemic circulations.

• Any time there is a defect, blood will go from high to low pressure.

Normal Blood Flow

Shunting• Normally pressure is higher in the

systemic circulation, so blood will be shunted from systemic to pulmonary– Left to right shunt

• With an obstruction to pulmonary blood flow, as well as an opening between ventricles, the blood flow may be right to left

Symptoms• Feeding problems: fatigue, irritability,

tachypnea, profuse sweating, reflux• Failure to thrive, poor weight gain• Respiratory difficulties: tachypnea,

difficulty breathing, frequent respiratory infections, periods of anoxia, nasal flaring, retractions

Symptoms• Activity intolerance: restlessness,

lethargy• Color changes: pallor, cyanosis,

clubbing of digitsHematologic: polycythemiaOrgan enlargement: liver, spleen,

heart

Diagnostics• Chest x-ray• Cardiac fluoroscopy• Echocardiogram• Electrocardiogram• Hematologic testing• Cardiac catheterization

Cardiac Catheterization

Cardiac Catheterization is an invasive diagnostic procedure in which a radiopaque catheter is inserted through peripheral blood vessel into the heart.

Cardiac Catheterization• The catheter is usually threaded into right side

of the heart. • Nursing care – pretest

• Preparation teaching done on child’s developmental level Educate parents about procedure

• Administer medications as ordered• NPO for 4-6 hours or more before procedure

• Assess accurate height and weight • Assess allergy for iodine • Mark baseline distal pulses and oxygenation

saturation

Cardiac Catheterization• Nursing care – posttest

• Check extremity distal to catheterization site for color, temperature, capillary refill• Keep extremity distal to the catheterization site extended• Check pressure dressing over site for bleeding• Monitor heart rate for bradycardia, tachycardia and dysrhythmia• Monitor oxygen saturation, distal pulses, signs of bleeding every 15 min 4,

every 30 min 4, then every hour 4, then every 2 to 4 hours • Maintain immobility of extremity used in procedure • Maintain pressure dressing • Encourage fluid intake • Notify physician for signs of hemorrhage • Administer acetaminophen (Tylenol) for discomfort as prescribedDischarge teaching for child, parents

• Keep site clean, dry, covered for 2 to 3 days• Report signs of redness, edema, discharge to physician• Avoid strenuous activity for 2 to 3 days

Cardiac Catheterization• Nursing – posttest

– Monitor for temperature elevation due to physiologic dehydration (NPO, contrast media)

– Monitor urine output and blood pressure

Cardiac Surgery

– Postoperative interventions • Monitor vital signs frequently • Monitor for signs of sepsis, including

diaphoresis, lethargy, fever, altered level of consciousness

• Maintain aseptic technique • Monitor all lines, tubes, catheters as

appropriate • Assess for discomfort, pain; medicate as

prescribed • Encourage periods of rest

Cardiac Surgery

• Encourage parents to maintain normal childhood routines and discipline

• Avoid immunizations, invasive procedures, dental care for 2 months

• Stress importance of dental care, after waiting period, every 6 months

• If signs of infection, respiratory difficulty, changes in normal behavior occur, notify physician

Cardiac Surgery– Postoperative home care

• Omit outside play for 2 to 3 weeks • Avoid strenuous activities, activities

where child could fall for 2 to 4 weeks • No organized physical education for 2

months • Avoid crowds for 2 weeks • No-added-salt diet as prescribed• Maintain clean, dry incision

CONGENITAL HEART DEFECTS

Classification• Acynotic heart defects

– Oxygenated blood is shunted from the systemic to pulmonary circulation (left-to-right shunt) and blood leaving the aorta is completely oxygenated. You see increased pulmonary blood flow

Increased Pulmonary Increased Pulmonary FlowFlow

Obstruction to Blood Flow Obstruction to Blood Flow from Ventriclesfrom Ventricles

Atrial septal defect Coarctation of the Aorta

Ventricular septal defect Aortic Stenosis

Patent ductus arteriosus Pulmonary Stenosis

Atrioventricular canal

Classification• Cyanotic heart defects

– Unoxygenated blood is shunted from the right to the left side of the heart where it mixes with oxygenated blood

Decreased Decreased Pulmonary FlowPulmonary Flow

Mixed Blood Flow Mixed Blood Flow

Tetraogy of Fallot Transposition of the Great Arteries

Tricuspid atresia Total Anomalous Pulmonary Venous Return

Truncus Arteriosus

Hypoplastic Left Heart Syndrome

Atrial Septal Defect (ASD)

• Abnormal opening in the septum between left and right atria– Left-to-right shunt– Infant may be asymptomatic or may

develop congestive heart failure (CHF)– Symptoms include: decreased

exercise tolerance, dyspnea, and systolic ejection murmur heard best in upper left sternal border

– Surgical correction at 2-4 years of age

Ventricular Septal Defect (VSD)

• Opening in the septum between ventricles, causing a left-to-right shunt– Symptoms include: tachycardia, dyspnea,

increased respiratory effort, fatigue, frequent respiratory infections, systolic murmur heard best at lower left sternal border, widened pulse pressure, bounding pulses present

– Surgical correction if child’s shunt is persistent

Patent Ductus Arteriosus (PDA)

• Allows oxygenated blood pumped into the aorta from the left ventricle to return to the lungs– Large PDAs cause excess blood in the lungs and

volume overload, leading to CHF– Widened pulse pressure, bounding pulses

present– Machinery-type murmur– Treatment

• Indomethacin • Surgical ligation if necessary

Atrioventricular Canal Defect• Atrioventricular canal defect is a combination of several

abnormalities in the heart present at birth (congenital abnormalities). This defect occurs when there's a hole between the chambers of the heart and problems with the valves that regulate blood flow in the heart.

• Infant usually has mild to moderate CHF; cyanosis increases with crying

• Atrioventricular canal defect is often associated with Down syndrome. To fix this defect, doctors often recommend surgery during the first year of life to close the holes and reconstruct the valves.

Atrioventricular Canal Defect

Coarctation of the Aorta

• Narrowing of the aorta usually just beyond the subclavian artery

• Blood pressure higher, bounding pulses in upper extremities versus lower and weak or absent pulses in lower extremities versus upper extremities, as well as cool lower extremities

• Signs of CHF may occur in infants• Children may experience headaches,

dizziness, fainting, epistaxis

Symptoms/Treatment• Blood pressure

higher in arms than legs

• Warm upper body, cool lower body

• Decreased peripheral pulses in lower extremities

• Headaches• Nosebleeds• Predisposition to

strokes• Angioplasty or

surgery

Aortic Stenosis• Aortic stenosis is the inability of the aortic valve to

open completely.• With aortic stenosis, problems with the aortic

valve make it harder for the leaflets to open and permit blood to flow forward from the left ventricle to the aorta.

• Children show signs of exercise intolerance, chest pain, dizziness when standing for long periods

Aortic Stenosis

Pulmonic Stenosis• Pulmonary stenosis is a condition characterized by

obstruction to blood flow from the right ventricle to the pulmonary artery.

• This obstruction is caused by narrowing or stenosis at one or more of several points from the right ventricle to the pulmonary artery. It includes obstruction from thickened muscle below the pulmonary valve, narrowing of the valve itself, or narrowing of the pulmonary artery above the valve

• Characteristic murmur present

Pulmonic Stenosis

Tetrology of Fallot (TOF)

• Most common cyanotic heart defect• Four components:

– Pulmonary stenosis– VSD– Overriding aorta

• Aorta sits near core of the heart over the VSD and therefore receives blood from both ventricles

– Right ventricular hypertrophy

TOF• Right-to-left shunting• Decreased blood flow to the lungs; mixture of

unoxygenated blood going to aorta causes cyanosis and dyspnea

• Symptoms: activity intolerance, irritability, failure to thrive, polycythemia, harsh systolic murmur best heard along the left sternal border and hypercyanotic (tet spells)

• Infants have acute episodes of cyanosis (hypercyanotic spells, blue spells, tetralogy [TET] spells) during periods of crying, feeding, defecating

• Children present with squatting, clubbing of fingers, poor growth

• Treatment: Surgical repair

Hypercyanotic (Tet) Spells

• Hypoxic episodes • Symptoms include: cyanosis,

tachypnea, altered LOC, may progress to seizures, CVA, death

• May be precipitated by crying, feeding, defecation, pain

• Treatment: oxygen, knee-chest position, morphine

Tet Position

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Tricuspid AtresiaNO

The tricuspid heart valve is missing or abnormally developed. The defect blocks blood flow from the right atrium to the right ventricle.Tricuspid atresia is an uncommon form of congenital heart disease that affects about 5 in every 100,000 live births. Twenty percent of patients with this condition will also have have other heart problems.Signs and symptoms•Cyanosis, tachycardia, dyspnea in newborn

Tricuspid Atresia

Truncus arteriosus• NO

• Truncus arteriosus (TRUNG-kus ahr-teer-e-O-sus) is a rare heart defect that's present at birth (congenital). If your baby has truncus arteriosus, it means that one large blood vessel leads out of the heart. Normally, there are two separate vessels coming out of the heart.

• In addition, the two lower chambers of the heart are missing a portion of the wall that divides them. As a result of truncus arteriosus, oxygen-poor blood that should go to the lungs and oxygen-rich blood that should go to the rest of the body are mixed together. This creates severe circulatory problems.

• If left untreated, truncus arteriosus can be fatal. Surgery to repair truncus arteriosus is generally successful, especially if the repair occurs before your baby is 2 months old.

• Characteristic murmur present• Infant exhibits moderate to severe CHF, variable cyanosis, poor

growth, activity intolerance

Truncus arteriosus

Hypoplastic left heart syndrome

NO • Hypoplastic left heart syndrome

occurs when parts of the left side of the heart (mitral valve, left ventricle, aortic valve, and aorta) do not develop completely. The condition is present at birth (congenital)

• Mild cyanosis, signs of CHF occur until ductus arteriosus closes

Hypoplastic left heart syndrome

Total anomalous pulmonary venous connection

NO

•Total anomalous pulmonary venous return is a heart disease that is present at birth (congenital heart disease) in which none of the four veins that take blood from the lungs to the heart is attached to the left atrium (left upper chamber of the heart).

•Signs of CHF develop•Cyanosis worsens, with pulmonary vein

obstruction

Total anomalous pulmonary venous connection

Transposition of the Great Vessels

• Aorta arises from right ventricle; pulmonary artery arises from left ventricle

• Oxygenated blood circulates through left side of the heart to lungs and back to the left side, unoxygenated blood enters right atrium from body, goes to right ventricle, and back out to the body without being oxygenated

• Infants with minimal communication severely cyanotic at birth

• Presence of large septal defects or patent ductus arteriosus may be less severely cyanotic, but with symptoms of CHF

Transposition• Child cannot live without a

communication between atria or ventricles

• Palliative treatment: balloon septostomy to create ASD

• When child old enough the defect will be repaired

Assessment - Cyanotic• Cyanosis• Clubbing of digits• Increased RBCs• FTT, exercise

intolerance HR, RR, dyspnea• Poor feeding, weak

cry

• Squatting (helps to blood flow to extremities & to keep oxygenated blood for brain & trunk)

• Risk for left-sided failure, clots

Nursing Interventions

• Do not interfere if child is squatting• Organize care to decrease child’s

energy expenditure• Administer oxygen as needed• Meet needs quickly; prevent crying• Use soft nipples to decrease energy

of sucking

Nursing Interventions– Monitor for hypercyanotic spells– Assess for signs of CHF– Assess peripheral pulses– Maintain strict fluid restriction– Monitor intake, output– Obtain daily weight– Provide high-calorie diet– Administer medications as prescribed– Keep child as stress-free as possible– Child should have maximal rest– Prepare child, parents for cardiac catheterization,

if appropriate

Acquired Heart Acquired Heart DiseaseDisease

Acquired Heart Acquired Heart DiseaseDisease

Rheumatic FeverRheumatic Fever

Kawasaki DiseaseKawasaki Disease

Rheumatic Fever (RF)•Inflammatory, autoimmune disease that affects connective tissues of heart, joints, subcutaneous tissues, blood vessels of central nervous system

•Presents 2 to 6 weeks after untreated or partially treated group A beta-hemolytic streptococcal infection of upper respiratory tract

• Prognosis depends on degree of• heart damage

Assessment - RF• Major Symptoms (Jones’ Criteria)• Carditis

– Aschoff nodules (areas of inflammation & degeneration around heart valves, found in heart, blood vessels, brain, serous surfaces of joints

– Valvular insufficiency (mitral/aortic)– Cardiomegaly– Shortness of breath, edema, hepatomegaly

Assessment - RF• Major Symptoms (Jones’ Criteria)• Polyarthritis

– Migratory– Most common in large joints which become

red and swollen, painful

• Chorea (St. Vitus dance)– CNS disorder characterized by abrupt,

purposeless, involuntary muscular movements

Assessment - RF• Major Symptoms (Jones’ Criteria)• Subcutaneous nodules

– Usually a sign of severe disease– Occur with active carditis– Firm, non-tender nodes on bony

prominence of joints• Erythema marginatum

– Transient, nonpuritic rash

Assessment - RF• Minor symptoms

– History of RF – fever– Recent strep infection– Diagnostic tests

• Elevated antistreptolysin O (ASO) titer Positive elevated sedimentation rate ESR

• Changes on ECG• Elevated C-reactive protein level;

Aschoff’s bodies found in heart, blood vessels, brain, serous surfaces of joints

Nursing Interventions• Carditis

– Administer Penicillin as ordered• Use prophylactically

– Promote bed rest

• Arthritis– Aspirin as ordered– Change position in bed frequently

Nursing Interventions• Corea

– Decrease stimulation– Provide safe environment

• Nodules and Rash: none• Alleviate child’s anxiety about the

ability of heart to continue to function

• Minimize boredom

Nursing Interventions• Provide client teaching and discharge

planning concerning:– Adaptation of home environment to

promote bed rest– Importance of prophylactic regimen– Avoidance of reinfections– Diet modifications– Home-bound education

Management - RF• Drug Therapy

– Penicillin, erythromycin– Salicylates– Steroids– anti-inflammatory agents as

prescribed

• Decrease cardiac workload– Bed rest until lab studies return to

normal

Management - RF•Administer massage, heat and cold

therapies as prescribed for joint pain •Bed rest during febrile phase •Limit physical exercise in child with

carditis •Instruct parents about follow-up care,

need for prophylactic antibiotic therapy prior to dental care and invasive procedures

Kawasaki Disease• An acute systemic inflammatory disease• A multisystem disorder involving vasculitis

(inflammation of the inner lining of the arteries and veins). Cardiac involvement most serious complication

• Also called mucocutaneous lymph node syndrome• In the United States Kawasaki is the most

common cause of acquired heart disease in children

• Unknown cause

Stages of Kawasaki Disease

• Acute: (days 1-10)– Abrupt onset of fever ,lasting more

than 5 days & unresponsive to antipyretics

– Conjunctival hyperemia – Red throat– Swollen hands & feet– Cervical node enlargement – Child is VERY irritable

Stages of Kawasaki Disease

• Subacute (days 10-25)– Cracking lips and fissures– Desquamation of skin on tips of fingers

and toes– Arthritis & joint pain– Cardiac disease

• Convalescent (days 26-40)– Drop in ESR, diminishing signs of illness

Nursing Interventions• Administer aspirin 80-100

mg/kg/day as ordered while temperature is elevated Q. 6 hours

• Administer IV gamma globulin (IVIG) to reduce risk of coronary artery lesions and aneurysms

• Provide comfort

Nursing Interventions• Assess vital signs, heart sounds and rhythm • Assess extremities for edema, redness,

desquamation • Assess mucous membranes for

inflammation • Daily weights • Administer soft foods • Provide passive range of motion• Administer acetylsalicylic acid (aspirin) as

prescribed• Instruct parents in administration of

prescribed medications, need to monitor for bleeding

Nursing Interventions• Provide client teaching and

discharge planning concerning:– Safe administration of aspirin therapy– Skin care– Monitoring of temperature– Call MD if child refuses to walk– Signs and symptoms of cardiac disease

The nurse is developing a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse documents to monitor the child for signs of:

1. Failure to thrive2. Bleeding3. Congestive heart failure (CHF)4. Decreased tolerance to stimulation

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The nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. The initial nursing action is to:

1. Call a code.2. Contact the respiratory therapy department.3. Place the infant in a prone position.4. Place the infant in a knee-chest position.

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