Cardiac lecture pediatrics fall 2012


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Cardiac lecture pediatrics fall 2012

  1. 1. Cardiac Conditions in Children Nursing Assessment and Interventions Kathryn Kushto-Reese
  2. 2. Leading Causes of Infant Deaths 2006
  3. 3. Anatomy/Physiology Overview Chambers Valves – AV (tricuspid & mitral) – Semilunar (pulmonic & aortic) Flow Saturations
  4. 4. Normal Blood FlowDexoygenated blood returns from the body through the SVC/IVC → RA → tricuspid valve → RV → pulmonic valve → pulmonary artery → then to the lungs where blood gets oxygenated.This blood then returns via pulmonary veins → LA → mitral valve → LV → aortic valve → and out the aorta to the body.
  6. 6. Newborn Physiology Pulmonary vs. Systemic Pressures  In Utero  At Birth Fetal Shunts – Ductus arteriosus (conduit from pulmonary artery to aorta) – Foramen ovale (flapped opening between right and left atria) – Ductus venosus (bypass liver)
  7. 7. Pulmonary and Systemic Pressures In utero – ↑ pulmonary pressure before birth: due to lungs being a fluid filled system, the lungs are a higher pressure system than the systemic circulation After birth – ↑ systemic pressure now that the lungs are filled with air, the lungs are a lower pressure system than the systemic circulation The blood will follow the path of least resistance
  8. 8. Assessment: Cardiac Function  Inspect chest/Palpate  Heart Sounds: murmurs  Quality of Pulses/Central  Respiratory: effort and quality of respirations  Pulses: Extremities (peripheral) – Cyanosis (central also) – Capillary refill time – Temperature /color
  10. 10. Assessment: Cardiac Function (continued) Renal – Urine output, edema, hepatomegaly Vital Signs – Heart rate, quality and symmetry, BP – Peripheral pulses, check for symmetry Neurological Restless, irritable, decreased response to environment
  11. 11. ASSESSMENT
  12. 12. Congestive Heart Failure A condition in which the heart is unable to provide adequate cardiac output to meet the circulatory and metabolic requirements of the body. Failure may initially be right- or left-sided but if left untreated, the entire heart will fail
  13. 13. Congestive Heart Failure (CHF)  Causes: – Heart muscle dysfunction – Structural abnormalities – Pulmonary abnormalities – Systemic disease – Infections – Syndromes
  14. 14. Examples Obstructive lesions in heart Dysrhythmias Increased blood flow to lungs (VSD) Myocarditis Chemotherapy drugs Sepsis Respiratory failure
  15. 15. CHF SymptomsSystemic Venous Congestion (rt sided)HepatomegalyPeripheral edema, ascitesPulmonary Venous Congestion (left sided)TachypneaCentral cyanosisDyspnea, ↑ WOB, rales, wheezing, nasal flaring , grunting, coughOthers: lethargy, irritability, altered LOC
  16. 16. CHF Symptoms Decreased Myocardial Function Cardiomegaly Tachycardia Extremities cool, ↓ capp refill, etc… Failure to thrive, difficulty feeding , poor weight gain Peripheral cyanosis/mottling Diaphoresis
  17. 17. ASSESSMENT
  18. 18. CHF Management Increase oxygen supply – Oxygen therapy, raise HOB – Correct anemia Decrease oxygen demand – Remove “work” (breathing, feeding, teach parents feeding techniques ( NG/GT feeds) – Rest, group cares, emotional support
  19. 19. CHF Management Decrease oxygen demand – Treat fever – Treat dysrhythmias (Digoxin, Adenosine, B- blockers)
  20. 20. CHF Management Increase cardiac output – Increasing stroke volume  Digoxin - ( mcg/kg/24hr.)  Increase in force of myocardial contraction and decreases conduction through SA and AV nodes (+ inotropic / - chronotropic)  Inotropic support – Dopamine * Dobutamine – Milrinone * Epinephrine
  21. 21. CHF Management Increase cardiac output by: – Decreasing afterload  ACE Inhibitors such as Captopril/Enalapril – Blocks conversion of angiotensin I to angiotensin II (vasoconstrictor)  Vasodilators – IV (Nitroglycerine, Nitroprusside, Milrinone) – Inhaled -- ?? (there are 2)
  22. 22. CHF Management Control fluid status – Diuretics ( Lasix, Spironolactone – Limit PO intake (initially) fluid/sodium restrictions, daily ( bid) weights and maintain nutritional status Address underlying disorder
  23. 23. Nursing Diagnoses Decreased cardiac output Altered tissue perfusion, cardiopulmonary Fatigue Fluid volume excess Activity intolerance Impaired physical mobility Sleep pattern disturbance Anxiety Altered growth and development
  25. 25. Congenital Heart DefectsDefects that increase pulmonary blood flow – Patent Ductus Arteriosus (PDA) – Atrial Septal Defect (ASD) – Ventricular Septal Defect (VSD) – Atrioventricular Canal Defect (AVC)
  26. 26. Ventricular Septal Defect (VSD) Most Common Most small /close spontaneously Symptoms of congestive heart failure may occur/ especially if significant size Child has failure to thrive/ fatigue, respiratory s/s, pulmonary hypertension Murmur ( turbulent flow through abnormal or obstructive openings
  27. 27. VSD
  28. 28. ?? Increased Pulmonary Blood Flow
  29. 29. VSD Repair
  30. 30. Post -op
  31. 31. Obstructive Defects Coarctation of the Aorta  Aortic Stenosis
  32. 32. Coarctation ofAorta
  33. 33. Chest x ray
  34. 34. Obstructive Defects Coarctation of Aorta , Incidence Pathophysiology: obstruction of systemic blood flow at the narrowed or strictured part. – Symptoms: high blood pressure and bounding pulses in arms  weak or absent femoral pulses, cool lower extremities ↓ blood pressure in lower extremities  CHF in infants – Surgical treatment: Timing
  35. 35. Congenital Heart Defects (continued)Defects That Decrease Pulmonary Blood Flow –Tetralogy of Fallot –Pulmonary Stenosis –Pulmonary Atresia
  36. 36. Tetralogy of Fallot has 4 defects1.Right Ventricular Hypertrophy2.Overriding Aorta3.Ventricular Septal defect4.Pulmonic Stenosis
  37. 37. Tetralogy of Fallot (TOF) Symptoms: cyanosis, systolic murmur, Metabolic acidosis , poor growth, clubbing, severe hypoxia (“tet spells”) Surgical treatment: palliative shunts and complete repair
  38. 38. Abby with TOF
  39. 39. Clubbing of fingers
  40. 40. Hyper cyanotic or Tet Spells Occur most frequently in 1st yr of life May be preceded by feeding, crying or defecation, fever, dehydration. ↑stress Characterized by profound hypoxemia, blue extremities, circumoral cyanosis, increased hgb and hct counts. Require prompt assessment and treatment to prevent brain damage or death.
  41. 41. “TET SPELL “
  42. 42. Treatment: “Tet Spells” Place infant in knee-chest position Older child will instinctively squat Maintain a calm comforting approach Administer 100% oxygen Administer Morphine Administer fluids Propanolol for frequent Tet spells
  43. 43. Modified Blalock-Taussig
  44. 44. Final Repair
  45. 45. Mixed Defects
  46. 46. HLHS ( Hypoplastic Left Heart Syndrome Structures on left side of heart underdeveloped Mitral and Aortic valves closed or small Left ventricle non functional 4th most common Congenital heart defect
  47. 47. HLHS Right side of heart is the working part Blood lungs → left Atrium through an ASD to right side of heart. Right ventricle pumps blood to lungs and also to systemic circulation through a PDA. Few days – weeks ductus closed death results.
  48. 48. HLHS
  49. 49. Symptoms Bluish/ Cyanotic Rapid pulse, murmur and ↑RR Cold hands and feet Lethargic Decreased pulses in extremities, ↓ pulse ox Poor sucking and feeding Increased respiratory effort and WOB Organomegaly
  50. 50. Treatment /Prognsis Prostaglandins in newborn to keep PDA open Multiple Stage surgical repair Blalock-Taussig shunt Glenn procedure Fontan Procedure ( final ) Chronic Health problems , earliest survivors in 30’s→ Heart Transplant
  51. 51. Diagnostic Tools Chest X-ray ECG Echocardiogram – Transesophageal echocardiogram Cardiac Catheterization – Done under conscious sedation – Can be diagnostic or interventional – Post procedural care
  52. 52. Treatments Surgical Intervention Surgical repair/corrective surgery Palliative surgery/ temporary Interventional Cardiac Catheterization 1. Open narrowed passages 2. Closure of openings pp. 907 text , table 26-7.
  53. 53. Chest x ray
  54. 54. Echocardiogram of VSD
  55. 55. Purpose of a Cath Diagnostic  Interventional Cath – Define anatomy – Close PDA, ASD/PFO, VSD – Measure pressures – Close collateral vessels – Measure O2 content – Balloon dilate narrowed – Calculate shunts, resistance, vessels or valves CO – Place stents in narrowed – All of above is frequently vessels done off and on oxygen, then on NO
  56. 56. Angioplasty/ dilation of Coarctation of Aorta during cardiac catheterization
  57. 57. PDA Closure
  58. 58. Cardiac Cath procedure Assess for : Circulation: cool extremities, ↓ pedal pulses, capp refill > 3 sec., decreased Sensation and mobility Complications: bleeding, arrhythmias, hematoma, thrombus, and infection.
  59. 59. Post Procedure VS are q 15” x 4; q 30” x 2; q 1h x 2 then IMC routine Stay on boards/supine x 2 hours With each set of V/S and prn, monitor: – Perfusion (arterial and venous) to distal extremity (pulses, color, CRT, temp) – Bleeding/hematoma formation at site If no bleeding at site and palpable distal pulse, may come off boards/sit up after designated time
  60. 60. Post Procedure Management Antibiotics (Ancef 25mg/kg) x 2 doses Aspirin (3-5mg/kg) to start same night for device placement CXR next morning if ASD or PDA device placed Echo next morning if ASD or PDA device placed “Discomfort” Control - acetaminophen
  61. 61. Going Home May go home 4-5 hours after a diagnostic cath Will stay overnight and get d/c’d in AM after most interventions Will return to school 2-3 days after procedure PE class/sports participation may be limited based on intervention
  62. 62. Potential Complications Miscellaneous – Thromboembolism – Infection Retroperitoneal Bleeds Pressure Sores Brachial Plexus Injury Effusion / tamponade
  63. 63. Surgery: Post Operative Care Monitoring and assessment – Vital signs, arrhythmias, decreased cardiac output, hypoxia, infection, S/S CHF, respiratory compromise – Arterial / venous pressure – Fluids – Neurological changes Provide rest and comfort Pain control Support family
  64. 64. Cardiac Transplant Improved CHD Management New Surgical Techniques Transplant Improved Survival of Transplant ECMO