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Annette 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.
Assessment - CHF
Assessment 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
Provide nutrition
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
Digoxin
Instruct parents regarding description of diagnosis,
administration of medications
Administer 1 to 2 hours after feedings
Use calendar to mark off dose administered
Do not mix medication with foods, fluid
If 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 dose
If 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 infants lungs
As the lungs expand with air, the
pulmonary artery pressure decreases
and circulation to the lungs increases
Circulatory Changes at
Birth
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
Circulatory Changes at
Birth
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
Circulatory Changes at
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.
Shunting
Normally pressure is higher in the
systemic circulation, so blood will be
shunted from systemic to pulmonary
Left to right shunt
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 digits
Hematologic: polycythemia
Organ 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 childs 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 prescribed
Discharge teaching for child, parents
Keep site clean, dry, covered 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
Flow
Atrial septal defect
Ventricles
Coarctation of the Aorta
Aortic Stenosis
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 Pulmonary
Flow
Tetraogy of Fallot
Tricuspid atresia
Arteries
Total Anomalous Pulmonary
Venous Return
Truncus Arteriosus
Hypoplastic Left Heart Syndrome
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 childs shunt is persistent
Atrioventricular Canal
Defect
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
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
53
Tricuspid Atresia
NO
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
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
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 childs energy
expenditure
Administer oxygen as needed
Meet needs quickly; prevent crying
Use soft nipples to decrease energy of
sucking
Nursing Interventions
Acquired Heart
Disease
Rheumatic Fever
Kawasaki Disease
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
Assessment - RF
Major Symptoms (Jones Criteria)
Subcutaneous nodules
Erythema marginatum
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; Aschoffs
bodies found in heart, blood vessels, brain,
serous surfaces of joints
Nursing Interventions
Carditis
Administer Penicillin as ordered
Use prophylactically
Arthritis
Aspirin as ordered
Change position in bed frequently
Nursing Interventions
Corea
Decrease stimulation
Provide safe environment
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
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
Subacute (days 10-25)
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:
1.
2.
3.
4.
Failure to thrive
Bleeding
Congestive heart failure (CHF)
Decreased tolerance to stimulation
38-86
Call a code.
Contact the respiratory therapy department.
Place the infant in a prone position.
Place the infant in a knee-chest position.
38-87