CV Disorders


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CV Disorders

  1. 1. Care of the Child with a Cardiovascular Disorder Becca Maddox NURS 1102 Spring 2002
  2. 2. Health Promotion and Risk Management <ul><li>Congenital - Women of child-bearing age should be immunized against rubella and varicella. Parents with family history of congenital defects need to have children screened </li></ul><ul><li>Acquired - Children with hypertension, hyperlipidemia and rheumatic fever are at increased risk. </li></ul><ul><ul><li>Rheumatic fever follows a group A beta-hemolytic streptococcus infection (otitis media, streptococcal pharyngitis and impetigo should have antibiotic therapy) </li></ul></ul><ul><ul><li>Avoid excessive salt, lack of exercise, obesity, diets high in saturated fats (reduce to 30% of calories by school age) </li></ul></ul>
  3. 3. Cardiovascular Disorders and the Nursing Process <ul><li>Careful history taking and physical examination are most important </li></ul><ul><li>Common procedures for diagnosis are echocardiogram and cardiac catheterization </li></ul><ul><li>Common nursing diagnoses: </li></ul><ul><ul><li>Decreased cardiac output related to congenital structural defect </li></ul></ul><ul><ul><li>Altered tissue perfusion related to inadequate cardiac output </li></ul></ul>
  4. 4. <ul><ul><li>Knowledge deficit related to care of the child pre- and postoperatively </li></ul></ul><ul><ul><li>Fear related to lack of knowledge about child’s disease </li></ul></ul><ul><ul><li>Altered family processes related to stresses of the diagnosis and care responsibilities </li></ul></ul><ul><ul><li>Ineffective individual or family coping related to lack of adequate support </li></ul></ul><ul><ul><li>Altered parenting related to inability to bond with critically ill newborn </li></ul></ul>
  5. 5. <ul><li>Important interventions include teaching, providing opportunities to express fears, providing psychological support </li></ul><ul><li>Other interventions include comfort measures, oxygen administration, managing cardiac failure, pre-and postop care </li></ul>
  6. 6. Important Terms <ul><li>Acyanotic heart disease Innocent heart murmur </li></ul><ul><li>Afterload Left-to-right shunt </li></ul><ul><li>Balloon angioplasty Organic heart murmur </li></ul><ul><li>Cardiac catheterization Phonocardiogram </li></ul><ul><li>Contractility Polycythemia </li></ul><ul><li>Cyanosis Postcardiac surgery syndrome </li></ul><ul><li>Cyanotic heart disease Postperfusion syndrome </li></ul><ul><li>Diastole Preload </li></ul><ul><li>Echocardiography Right-to-left shunt </li></ul><ul><li>Electrocardiography Systole </li></ul><ul><li>Fluoroscopy Vasculitis </li></ul><ul><li>Heart failure </li></ul>
  7. 7. Review <ul><li>A&P of the Heart </li></ul><ul><li>Circulation of blood </li></ul><ul><li>CO = SV x HR </li></ul><ul><li>CO is affected by preload , afterload and contractility </li></ul><ul><li>Frank-Starling law - SV can be increased by increasing the stretch of the fibers. However, excessive stretch results in a decrease in CO </li></ul>
  8. 8. History Taking <ul><li>Must be careful. Some of the symptoms are very subtle. </li></ul><ul><li>Some symptoms do not show up right after birth </li></ul><ul><li>Typical presentations of infants are tachycardia, tachypnea, and poor feeding </li></ul><ul><li>Older children may present with fatigue and frequent lower respiratory infections. Some children may perspire excessively </li></ul><ul><li>Edema is a late sign and usually presents first as periorbital edema. </li></ul><ul><li>May complain of decreased UOP </li></ul><ul><li>May have headaches, nose bleeds, high blood pressure in upper extremities </li></ul>
  9. 9. History Continued <ul><li>Obtain a detailed prenatal history including exposure to infections (cytomegalovirus, toxoplamosis, rubella or varicella), medication usage, drug and alcohol use, nutrition, exposure to radiation </li></ul><ul><li>Determine if there is any family history of congenital heart defects or heart disease, cognitive impairments, renal disease </li></ul>
  10. 10. Physical Assessment <ul><li>Compare height and weight to standard growth chart </li></ul><ul><li>Assess: </li></ul><ul><ul><li>capillary refill presence of clubbing </li></ul></ul><ul><ul><li>cyanosis (pulmonary source vs. cardiac source) </li></ul></ul><ul><ul><li>ruddy complexion lethargy </li></ul></ul><ul><ul><li>rapid respirations tachycardia </li></ul></ul><ul><ul><li>abnormal body posture presence of a murmur </li></ul></ul><ul><li>Innocent murmurs vs. Organic murmurs </li></ul><ul><ul><li>With all murmurs, document position in cardiac cycle, duration, quality, pitch, intensity, location, whether there is a thrill and whether the murmur changes with position change </li></ul></ul><ul><ul><li>Organic murmurs are either systolic or diastolic, long, harsh or blowing, loud, constant and heard not matter what position the child is in </li></ul></ul>
  11. 11. Diagnostic Tests <ul><li>ECG - indicates HR, rhythm, presence or absence of hypertrophy, ischemia or necrosis, abnormalities in the conduction system, presence of electrolyte imbalances </li></ul><ul><li>Chest x-ray - shows heart size and shape, presence of CHF, prominence of pulmonary blood flow </li></ul><ul><li>Fluoroscopy can be used to visualize the chambers of the heart, the great vessels, lungs, thoracic cage and diaphragm. Sometimes radioactive dye in injected. Sometimes contrast dye in used in conjunction with a cardiac cath </li></ul>
  12. 12. Diagnostic Tests Cont’d <ul><li>Echocardiogram - primary diagnostic test. Looks at the movement and dimensions of the cardiac structures using high-frequency sound waves </li></ul><ul><li>Phonocardiogram - heart sounds are recorded and displayed as a diagram </li></ul><ul><li>MRI - used to evaluate heart structure, size or blood flow </li></ul><ul><li>Treadmill - studies response to exercise </li></ul><ul><li>Lab tests - Hgb and Hct (polycythemia), ESR (rheumatic fever, Kawasaki disease, myocarditis), ABG (presence of a right to left shunt), O2 Sat, clotting times (PT, PTT) and platelet count, Na, K, dig level </li></ul>
  13. 13. Cardiac Catheterization <ul><li>Can be either diagnostic or interventional </li></ul><ul><ul><li>Pressures in the heart can be measured </li></ul></ul><ul><ul><li>CO can be evaluated </li></ul></ul><ul><ul><li>Blood samples can be obtained and tested (O2 sat) </li></ul></ul><ul><ul><li>Electrical activity can be studied </li></ul></ul><ul><ul><li>Contrast can be injected to study blood flow, vessels and chambers </li></ul></ul><ul><ul><li>Balloon angioplasty can be performed to stretch stenosed areas or blockages in vessels </li></ul></ul><ul><li>Pre-procedure - Patient teaching </li></ul><ul><ul><li>How the test will be done, what to expect during the test, that afterward the child will have to lie flat and will have a bulky dressing over the catheter insertion site </li></ul></ul>
  14. 14. Cardiac Catheterization Cont’d <ul><li>Post-Procedure </li></ul><ul><ul><li>Will have to lie flat 3-4 hours </li></ul></ul><ul><ul><li>VS every 15 minutes for the first several hours </li></ul></ul><ul><ul><li>Check site every 15 minutes for integrity of dressing, hematoma, redness, swelling </li></ul></ul><ul><ul><li>Check pulses distal to site. Also check extremity for capillary refill and warmth </li></ul></ul><ul><ul><li>Avoid dehydration </li></ul></ul><ul><ul><li>Avoid hypothermia </li></ul></ul><ul><ul><li>Check site daily for signs of infection </li></ul></ul><ul><ul><li>Avoid tub baths and strenuous exercise for 2-3 days </li></ul></ul>
  15. 15. Important Points about Care of the Child with a Heart Defect <ul><li>Parents taking a child with a heart defect home should have discharge planning which includes name/number of a primary care provider, emergency numbers, home health visits, instruction in what to do if child becomes cyanotic, CPR training, </li></ul><ul><li>Should not allow a child with a cyanotic heart defect or severe aortic stenosis to cry for extended periods of time </li></ul><ul><li>Don’t usually have to restrict sodium intake (regulates water balance) </li></ul><ul><li>Need vitamin supplements and maybe an iron supplement </li></ul><ul><li>May need small feedings every 3-4 hours. May require feeding tubes or high calorie formulas/supplements </li></ul>
  16. 16. Important Points about Care Cont’d <ul><li>Children usually limit their own activities, but parents should watch for respiratory distress when new activities are introduced </li></ul><ul><li>Children should receive their immunizations timely </li></ul><ul><li>Even minor illnesses should be treated promptly </li></ul><ul><li>Avoid dehydration </li></ul><ul><li>Receive prophylactic antibiotics prior to dental visits or oral surgery (Penicillin or Erythromycin) </li></ul>
  17. 17. Congenital Heart Disease <ul><li>Occurs in about 8% of term newborns. Higher in pre-term infants. Can be as high as 10-15% in infants who have a parent with aortic stenosis, ASD, VSD, or pulmonic stenosis </li></ul><ul><li>Females - more prone to have PDA and ASD </li></ul><ul><li>Males - more prone to have valvular aortic stenosis, coarctation of the aorta, TOF and transposition of the great vessels </li></ul><ul><li>The usual cause is failure of the heart to develop beyond an early stage of embryonic development </li></ul><ul><li>Maternal rubella is associated with PDA, stenosis, ASD, VSD </li></ul>
  18. 18. Congenital Heart Disease <ul><li>Classification </li></ul><ul><ul><li>Acyanotic vs. Cyanotic </li></ul></ul><ul><ul><ul><li>Left-to-right shunt - oxygenated to unoxygenated blood </li></ul></ul></ul><ul><ul><ul><li>Right-to-left shunt - deoxygenated blood to oxygenated blood </li></ul></ul></ul><ul><ul><li>Hemodynamic and Blood Flow Patterns - allows more predictable signs and symptoms </li></ul></ul><ul><ul><ul><li>Increased pulmonary flow </li></ul></ul></ul><ul><ul><ul><li>Obstruction to blood flow (out of the heart) </li></ul></ul></ul><ul><ul><ul><li>Mixed blood flow (oxygenated and deoxygenated blood mixing in the heart or great vessels) </li></ul></ul></ul><ul><ul><ul><li>Decreased pulmonary flow </li></ul></ul></ul>
  19. 19. Defects with Increased Pulmonary Blood Flow <ul><li>Blood flows from the left side of the heart to the right side of the heart through an abnormal opening or connection between the system or great arteries </li></ul><ul><ul><li>Ventricular Septal Defect (VSD) </li></ul></ul><ul><ul><li>Atrial Septal Defect (ASD) </li></ul></ul><ul><ul><li>Atrioventricular canal defect (AVC) </li></ul></ul><ul><ul><li>Patent Ductus Arteriosis (PDA) </li></ul></ul><ul><li>VSD - most common, 25% of all defects, 2 in every 1000 live births </li></ul><ul><ul><li>opening in the septum between the two ventricles </li></ul></ul><ul><ul><li>results in right ventricular hypertrophy and increased pressure on the pulmonary artery </li></ul></ul>
  20. 20. VSD Cont’d <ul><ul><li>May not be evident at birth because high pulmonary resistance from incomplete opening of alveoli keeps the blood from coming across to the right ventricle </li></ul></ul><ul><ul><li>S&S (by age 4 to 8 weeks) - develops a loud, harsh, systolic murmur along the left sternal border 3rd or 4th ICS, widely transmitted, usually with a thrill </li></ul></ul><ul><ul><li>Diagnosed with echocardiography or MRI </li></ul></ul><ul><ul><li>RV hypertrophy may also be seen on ECG </li></ul></ul><ul><ul><li>60% close spontaneously - otherwise at risk of infectious endocarditis and cardiac failure </li></ul></ul><ul><ul><li>May require a Silastic or Dacron patch to close opening if edges can’t be approximated and sutured </li></ul></ul><ul><ul><li>Arrhythmias can be a complication post-op </li></ul></ul>
  21. 21. Atrial Septal Defect (ASD) <ul><li>Abnormal opening between the two atria </li></ul><ul><ul><li>ASD1 (ostium primum) - defect is at the lower end of the septum </li></ul></ul><ul><ul><li>ASD2 (ostium secondum) - defect is near the center of the septum and may be asymptomatic </li></ul></ul><ul><li>More frequent in girls than boys </li></ul><ul><li>Harsh systolic murmur over 2nd or 3rd ICS, fixed splitting of S2 </li></ul><ul><li>Echo will show enlarged right side and increased pulmonary circulation </li></ul><ul><li>Cath will reveal separation in atrial septum and increased O2 sat in RA </li></ul><ul><li>At risk for infectious endocarditis and heart failure </li></ul><ul><li>Can cause emboli in pregnant females if not corrected </li></ul><ul><li>May require a patch if defect not able to be closed </li></ul><ul><li>May have arrhythmias post-op </li></ul>
  22. 22. Atrioventricular Canal (AVC) Defect <ul><li>An incomplete fusion of the endocardial cushion. May be seen as a low ASD continuous with a high VSD. Mitral and tricuspid valves are usually distorted. Seen in 1 out of 9 children with Down syndrome </li></ul><ul><li>Blood flow is usually left to right, but may flow between all four chambers </li></ul><ul><li>Same symptoms of heart failure as ASD and VSD </li></ul><ul><li>Requires surgical repair and possible double valve replacement </li></ul><ul><li>Must be monitored post-op for jaundice from RBC destruction </li></ul>
  23. 23. Patent Ductus Arteriosus (PDA) <ul><li>The ductus arteriosus between the pulmonary artery and the aorta fails to close at birth </li></ul><ul><li>May not close until 3 months causing blood to be shunted from the aorta to the pulmonary artery </li></ul><ul><li>Child will usually have a wide pulse pressure because diastolic is low related to decreased peripheral resistance caused by the shunting of the blood </li></ul><ul><li>Usually hear a continuous (systolic and diastolic) murmur at the upper left sternal border or under the clavicle of older children </li></ul><ul><li>ECG is usually normal, may show ventricular enlargement if the shunt is large </li></ul><ul><li>Cath is not usually needed unless to rule out other defects </li></ul>
  24. 24. PDA Cont’d <ul><li>May be given indomethacin or a prostaglandin inhibitor to lower PGE1 levels and stimulate closure. Drug may be repeated as many as three times 12 to 24 hours apart </li></ul><ul><li>If medical management fails - </li></ul><ul><ul><li>ligation of defect </li></ul></ul><ul><ul><li>visual assisted thoracoscopy (VAT) - a clip is placed on the ductus </li></ul></ul><ul><li>If not surgery, child is a risk for heart failure related to the increased shunting, infectious endocarditis from recirculating blood and potential stasis in the PA </li></ul>
  25. 25. Obstructive Defects <ul><li>Narrowing of a vessel or valve. Results in high pressure before the obstruction and lower after the obstruction. Prevents sufficient blood supply from reaching its intended site </li></ul><ul><ul><li>Pulmonic stenosis </li></ul></ul><ul><ul><li>Aortic stenosis </li></ul></ul><ul><ul><li>Coarctation of the aorta </li></ul></ul><ul><li>Pulmonic Stenosis - 25% to 35% of anomalies </li></ul><ul><ul><li>May be asymptomatic or have mild heart failure </li></ul></ul><ul><ul><li>Usually a grade IV or V systolic murmur with a thrill. Heard loudest at the upper left sternal border. May have a split S2 </li></ul></ul><ul><ul><li>ECG may show right ventricular hypertrophy. Cath can demonstrate degree of stenosis. </li></ul></ul>
  26. 26. Pulmonary Stenosis Cont’d <ul><ul><li>Treatment depends on severity of stenosis and the child’s age </li></ul></ul><ul><ul><ul><li>If severe, the pressure may reopen the foramen ovale allowing flow from left to right causing cyanosis </li></ul></ul></ul><ul><ul><ul><li>If severe, then given PGE1 to keep ductus arteriosus from closing so that the infant can get more blood oxygenated </li></ul></ul></ul><ul><ul><ul><li>Balloon angioplasty may be tried to break valve adhesions and relieve the stenosis </li></ul></ul></ul><ul><ul><ul><li>If there is a lesser degree of stenosis, the child can be allowed to wait until they are 4 or 5 years old so that there is less surgical risk </li></ul></ul></ul>
  27. 27. Aortic Stenosis <ul><li>Prevents blood from flowing freely from the LV to the aorta </li></ul><ul><li>Can lead to hypertrophy of the left ventricle and heart failure and pulmonary edema </li></ul><ul><li>Accounts for 5% of congenital abnormalities </li></ul><ul><li>The child is usually asymptomatic. Will usually hear a rough systolic murmur at 2nd ICS right sternal border which may radiate to right shoulder, clavicle or neck. May see signs of decreased CO (faint pulses, hypotension, tachycardia, poor feeding). Child may develop chest pain with activity. Sudden death can occur when O2 demand far exceeds supply </li></ul><ul><li>ECG may show left ventricular hypertrophy. Cath can show degree of stenosis </li></ul><ul><li>Treated with balloon angioplasty or surgical repair to divide the stenotic valve or dilate a contrictive aortic ring </li></ul>
  28. 28. Coarctation of the Aorta <ul><li>A constrictive band causes narrowing of the aorta either between the subclavian vein and the ductus arteriosus (infantile or preductal) or distal to the ductus arteriosus (postductal) </li></ul><ul><li>Since BP is greatest in the subclavian vein, you will see higher pressures in the upper extremities (at least 20 mmHg) than in the lower extremities. The increased BP can cause headaches or nosebleeds. Can even cause a CVA </li></ul><ul><li>May only have a decreased femoral pulse. As child grows older, collateral circulation develops. Veins may become visible on the chest. Child may complain of leg pain on exertion. Child may or may not have a soft or moderately loud systolic murmur prominent at the base of the heart </li></ul>
  29. 29. Coarctation of the Aorta Cont’d <ul><li>Repaired either with balloon angioplasty or surgical removal of the narrowed portion. Try to let the child grow for a while. Usually scheduled around age 2. Has to be done prior to childbearing age in females </li></ul><ul><li>May have abdominal discomfort for a while post-op related to increased blood flow to lower part of the body. </li></ul><ul><li>Will usually still have an elevated BP for a while. </li></ul>
  30. 30. Mixed Defects <ul><li>Transposition of the Great Arteries - The aorta comes off of the RV and the pulmonary artery comes off of the LV. (5% of anomalies) </li></ul><ul><ul><li>Unless the infant also has an ASD and/or VSD this is incompatible with life because you have two closed systems </li></ul></ul><ul><ul><ul><li>RA - RV - Aorta - body - vena cavae to RA </li></ul></ul></ul><ul><ul><ul><li>LA - LV - Pulmonary artery - lungs - pulmonary veins to LA </li></ul></ul></ul><ul><ul><li>Usually cyanotic at birth, may have no murmur or various murmurs </li></ul></ul><ul><ul><li>Echo will show enlarged heart. Cath can show low O2 sat in the heart chambers. ECG may not show anything </li></ul></ul><ul><ul><li>Will be given PGE1 to try to keep the ductus open. Can also have balloon passed through foramen ovale in order to enlarge the opening </li></ul></ul><ul><ul><li>Surgical intervention involves switching the aorta and the pulmonary artery </li></ul></ul>
  31. 31. Mixed Defects <ul><li>Total Anamalous Pulmonary Venous Return </li></ul><ul><ul><li>Pulmonary veins return to RA or superior vena cava instead of the LA </li></ul></ul><ul><ul><li>Systemic circulation depends on a patent foramen ovale and/or patent ductus </li></ul></ul><ul><ul><li>Often these patients are also without a spleen as well </li></ul></ul><ul><ul><li>The infant is usually mildly cyanotic and tires easily </li></ul></ul><ul><ul><li>Will be kept on PGE1 until surgery to keep the ductus arteriosus open. </li></ul></ul><ul><ul><li>The pulmonary veins are reimplanted into the LA </li></ul></ul>
  32. 32. Mixed Defects <ul><li>Truncus Arteriosus - the infant has a single vessel coming off the RV and LV instead of a separate pulmonary artery and aorta. </li></ul><ul><ul><li>There is usually also a VSD </li></ul></ul><ul><ul><li>Child is cyanotic and has a typical VSD murmur </li></ul></ul><ul><ul><li>The common trunk in restructured surgically to create an aorta and a pulmonary artery </li></ul></ul><ul><li>Hypoplastic Left Heart Syndrome - the left ventricle doesn’t work. </li></ul><ul><ul><li>The RV hypertrophies as it tries to do all of the work </li></ul></ul><ul><ul><li>Patient becomes increasingly cyanotic as more unoxygenated blood is shunted to the left side </li></ul></ul><ul><ul><li>Treatment is aimed to keep the ductus arteriosis open and increase flow of blood to the aorta </li></ul></ul><ul><ul><li>No surgical repair at this time </li></ul></ul><ul><ul><li>Best hope is heart transplant </li></ul></ul>
  33. 33. Defects with Decreased Pulmonary Blood Flow <ul><li>Involve an obstruction of pulmonary blood flow which increases pressure in the right side of the heart. </li></ul><ul><ul><li>If an ASD and or VSD also exists, then deoxygentated blood shunts from the right side to the left side </li></ul></ul><ul><li>Tricuspid Atresia - tricuspid valve is completely closed. </li></ul><ul><ul><li>Blood can’t flow from RA to RV so goes through the patent foramen ovale to the LA. </li></ul></ul><ul><ul><li>Oxygenation occurs by blood being shunted through a patent ductus to the lungs </li></ul></ul><ul><ul><li>If the foramen ovale and ductus arteriosus close, the patient becomes profoundly cyanotic, tachycardic and dyspneic. </li></ul></ul><ul><ul><li>Kept on PGE1 until surgery </li></ul></ul><ul><ul><li>Surgery consists of creating a subclavian-pulmonary artery shunt or restructuring the right side of the heart with a baffle (Fontan procedure) </li></ul></ul>
  34. 34. Defects with Decreased Pulmonary Blood Flow <ul><li>Tetralogy of Fallot (TOF) - 10% of congenital defects. </li></ul><ul><ul><li>Consists of 4 anomalies </li></ul></ul><ul><ul><ul><li>Pulmonary stenosis </li></ul></ul></ul><ul><ul><ul><li>VSD (usually large) </li></ul></ul></ul><ul><ul><ul><li>Dextraposition (overriding) of the aorta </li></ul></ul></ul><ul><ul><ul><li>Hypertrophy of the RV (acquired from the increased pressure in the RV from trying to push blood through the stenosed pulmonary artery) </li></ul></ul></ul><ul><ul><li>“ Blue baby” although may not be dramatically cyanotic immediately after birth </li></ul></ul><ul><ul><li>Exhibit poor physical growth, clubbing, systolic murmur, hypoxic spells, polycythemia, activity intolerance and squatting </li></ul></ul>
  35. 35. TOF cont’d <ul><li>X-ray shows cardiomegaly. Echo and ECG show the enlarged RV. Echo also shows decreased size of the PA and reduced flow through the lungs. Extent of the defect is determined through cardiac cath. Lab values show increased RBC’s and reduced O2 sat </li></ul><ul><li>Usually wait until child is 1 or 2 years old. Some institutions perform surgery earlier to prevent hypoxic episodes </li></ul><ul><li>If having hypoxic episode, place infant in knee-to-chest position. May require Morphine to dilate vessels or propanolol to reduce heart spasm </li></ul>
  36. 36. TOF cont’d <ul><li>Can have a palliative repair in which the subclavian artery is used to create an artificial ductus arteriosus (Blalock-Taussig procedure) to allow blood to flow from the aorta to the lungs </li></ul><ul><li>After the Blalock-Taussig, the child will not have a palpable pulse in the right arm. The right arm should not be used for BP’s or blood sticks </li></ul><ul><li>Full repair includes relief of pulmonary stenosis, VSD repair and correction of the overriding aorta </li></ul>
  37. 37. Cardiac Surgery <ul><li>Pre-op </li></ul><ul><ul><li>baseline vital signs at rest (count a full minute) </li></ul></ul><ul><ul><li>height and weight </li></ul></ul><ul><ul><li>hold dig for 24 hrs </li></ul></ul><ul><ul><li>enema </li></ul></ul><ul><ul><li>patient and family teaching (surgery, equipment, what to expect after surgery, tubes, the importance of deep breathing and coughing) </li></ul></ul><ul><li>Post-op </li></ul><ul><ul><li>VS every 15 minutes progressing to q 1 hr, ventilatory support, monitoring of heart rate and rhythm, BP, heart pressures, heart sounds, UOP, fluid status, ABG’s, PT, PTT, Plt, Hgb, Hct., K, Na, O2 sat, lung sounds, bowel sounds, measurement of chest tube integrity and drainage </li></ul></ul>
  38. 38. Cardiac Surgery Cont’d <ul><ul><li>Incentive spirometry (deep breathing) and coughing after extubated </li></ul></ul><ul><ul><li>Pain management </li></ul></ul><ul><ul><li>Explain procedures (extubation, chest tube removal, etc.) </li></ul></ul><ul><ul><li>Administer antibiotics </li></ul></ul><ul><ul><li>Observe for signs and symptoms of infection </li></ul></ul><ul><ul><li>May need warming immediately post-op, but watch for temperature elevation </li></ul></ul><ul><ul><li>Assess for hypervolemia </li></ul></ul><ul><ul><li>Advance activities as tolerated </li></ul></ul><ul><ul><li>Avoid arm pulling and pulling with arms </li></ul></ul>
  39. 39. Cardiac Surgery Cont’d <ul><li>Complications - bleeding, shock, heart block or arrhythmias, heart failure, neuro changes, postcardiac surgery syndrome (febrile illness with pericarditis and pleurisy - one week post-op), postperfusion syndrome (3-12 weeks post-op - fever, splenomegaly, hepatomegaly, elevated WBC, malaise, maculopapular rash - CMV from donor blood) </li></ul>
  40. 40. Cardiac Surgery Cont’d <ul><li>If valve replacement surgery - artificial valves are used more often, requires anticoagulation (Coumadin) or antiplatelet (aspirin, dipyridamole) therapy </li></ul><ul><ul><li>young girls should avoid accidental pregnancy, should not use an estrogen-based OCD nor an IUD </li></ul></ul><ul><ul><li>women desiring to become pregnant need to switch to Heparin therapy </li></ul></ul><ul><ul><li>prophylactic antibiotics need to be taken before dental work or oral surgery </li></ul></ul><ul><ul><li>may develop hemolytic anemia requiring blood transfusions </li></ul></ul>
  41. 41. Cardiac Surgery Cont’d <ul><li>Heart Transplant - for hypoplastic left ventricle or cardiomyopathy </li></ul><ul><ul><li>ECG’s will show two P waves </li></ul></ul><ul><ul><li>Post-op care is the same as with other heart surgeries </li></ul></ul><ul><ul><li>Patients will be placed on immunosuppresive therapy </li></ul></ul><ul><ul><li>Rejection is the #1 cause of death </li></ul></ul><ul><ul><ul><li>Hyperacute rejection - immediately upon restoring circulation </li></ul></ul></ul><ul><ul><ul><li>Acute rejection - occurs in about 7 days, fever, tachycardia, ECG changes </li></ul></ul></ul><ul><ul><ul><li>Chronic rejection - may begin at about a year </li></ul></ul></ul>
  42. 42. Cardiac Surgery Cont’d <ul><li>Pacemaker - if difficulty with conduction system </li></ul><ul><ul><li>Consists of a battery pack and lead wires </li></ul></ul><ul><ul><li>Leads are usually epicardial as opposed to endocardial in children </li></ul></ul><ul><ul><li>Parents and patient must be taught how to take the patient’s pulse </li></ul></ul><ul><ul><li>Batteries can last up to 15 years and they lose power slowly rather than stopping abruptly </li></ul></ul><ul><ul><li>If patient has hiccuping, lead wire may need to be repositioned </li></ul></ul><ul><ul><li>Magnets should be avoided </li></ul></ul>
  43. 43. Acquired Heart Disease <ul><li>Heart failure - most common. </li></ul><ul><ul><li>Usually occurs as a result of a congenital heart disorder or a disease such as rheumatic fever, Kawasaki’s disease or infectious endocarditis. </li></ul></ul><ul><ul><li>The heart can’t pump enough blood to supply oxygen and nutrients to the body </li></ul></ul><ul><ul><li>The body compensates for a while. Remember CO = SV x HR and the Frank-Starling principle. For children less than 5 y.o., increase in CO is mostly accomplished through increased HR </li></ul></ul><ul><ul><li>As renal blood flow decreases, GFR slows allowing retention of sodium and fluid. When the body senses decreased supply of oxygen, aldosterone is secreted which further promotes retention of sodium in an attempt to increase blood flow to the kidneys. ADH secretion is also increased to help retain fluid </li></ul></ul>
  44. 44. Heart Failure Cont’d <ul><ul><li>Symptoms depend on whether there is right- or left sided heart failure </li></ul></ul><ul><ul><ul><li>Right - back up of pressure into the portal system and venous system, hepatomegaly, abdominal pain, ascities </li></ul></ul></ul><ul><ul><ul><li>Left - back up of pressure in pulmonary system, dyspnea, rales, bloody sputum on coughing, cyanosis </li></ul></ul></ul><ul><ul><ul><li>Left sided failure ultimately leads to right sided failure </li></ul></ul></ul><ul><ul><ul><li>Edema is a late sign for children. If present, it shows up as periorbital edema </li></ul></ul></ul><ul><ul><li>In infants, signs can be breathlessness from rapid respirations, tiring easily and poor feeding related to exhaustion and dyspnea, may become diaphoretic when feeding, abrupt weight gain is the most obvious indication </li></ul></ul><ul><ul><li>Apical heart beat may be displaced laterally and downward. May have a third heart sound. </li></ul></ul>
  45. 45. Heart Failure Cont’d <ul><ul><li>Confirmed by echocardiogram, chest x-ray and ECG </li></ul></ul><ul><ul><li>Treatment is aimed at 1) improving cardiac function, 2) removing accumulated fluid and sodium, 3)decrease cardiac demands, 4) improve tissue O2 </li></ul></ul><ul><ul><ul><li>Diuretics - Lasix, spironalactone, thiazides (may need K replacement) </li></ul></ul></ul><ul><ul><ul><li>Improve contractility - Digoxin (given a loading dose and then a maintenance dose, dig level should be 0.8 to 2.0 u/L, toxicity includes, nausea, vomiting, anorexia, slow heart rate, family teaching required, hold dose if HR < 100 for infants and toddlers, <80 for older children or <60 for adolescents ) </li></ul></ul></ul><ul><ul><ul><li>Decrease afterload - hydralazine (vasodilator), nifedipine (Ca channel blocker), nipride (vasodilator), or captopril (ACE inhibitor) </li></ul></ul></ul>
  46. 46. Heart Failure Cont’d <ul><ul><ul><li>Decrease oxygen demands - Provide rest periods and uninterrupted sleep, place in Semi-Fowler’s position, space out activities/procedures, preserve body temperature, treat any infections </li></ul></ul></ul><ul><ul><ul><li>Improve oxygenation - administer O2 as needed by hood, mask or nasal prongs. If prongs are used, check nostrils q 4hrs </li></ul></ul></ul><ul><ul><li>Adequate nutrition is also important - may need six to eight small meals daily rather than 3 large meals, may need tube feedings </li></ul></ul>
  47. 47. Rheumatic Fever <ul><li>An autoimmune disease that is a reaction to a group-A beta-hemolytic stretococcus infection </li></ul><ul><li>Often follows an attack of pharyngitis, tonsillitis, scarlet fever, “strep” throat, or impetigo </li></ul><ul><li>Children ages 6-15 are the most susceptible </li></ul><ul><li>Very important that antibiotics are taken to treat the initial infection to prevent rheumatic fever </li></ul><ul><li>Systematic inflammatory disease that affects primarily the heart, joints, brain and skin. Strep loves heart valves. The mitral valve is the most commonly affected. </li></ul>
  48. 48. Rheumatic Fever Cont’d <ul><li>Signs and Symptoms </li></ul><ul><ul><li>Minor </li></ul></ul><ul><ul><ul><li>fever </li></ul></ul></ul><ul><ul><ul><li>fatigue </li></ul></ul></ul><ul><ul><ul><li>joint tenderness </li></ul></ul></ul><ul><ul><ul><li>elevated ESR </li></ul></ul></ul><ul><ul><li>Major </li></ul></ul><ul><ul><ul><li>Aschoff bodies (hemorrhagic bullous lesions in the heart) </li></ul></ul></ul><ul><ul><ul><li>erythema marginatum </li></ul></ul></ul><ul><ul><ul><li>vegetation on valves </li></ul></ul></ul><ul><ul><ul><li>pericarditis </li></ul></ul></ul><ul><ul><ul><li>pericardial friction rub </li></ul></ul></ul><ul><ul><ul><li>muffled heart sounds </li></ul></ul></ul><ul><ul><ul><li>accentuated third heart sound </li></ul></ul></ul><ul><ul><ul><li>SC nodules </li></ul></ul></ul><ul><ul><ul><li>chorea (sudden involuntary movements of limbs) </li></ul></ul></ul>
  49. 49. Rheumatic Fever Cont’d <ul><li>Diagnosis - If have two major symptoms or one major and two minor symptoms, rising or elevated ASO titer </li></ul><ul><li>Treatment </li></ul><ul><ul><li>Bedrest until ESR decreases (degree of bedrest is based on degree of carditis) </li></ul></ul><ul><ul><li>Antibiotics (penicillin, erythromycin) x 10 days </li></ul></ul><ul><ul><li>Reduce inflammation (aspirin - watch for toxicity such as tinnitus, nausea, vomiting, headache, blurred vision) </li></ul></ul><ul><ul><li>Corticosteroids (if not responding to aspirin alone) </li></ul></ul><ul><ul><li>Phenobarbital for chorea </li></ul></ul><ul><ul><li>Treatment of heart failure </li></ul></ul><ul><ul><li>Prognosis depends on the amount of cardiac involvement </li></ul></ul><ul><ul><li>Kept on prophylactic antibiotics for 5 years or until 18 to prevent recurrence </li></ul></ul>
  50. 50. Kawasaki Disease <ul><li>Mucocutaneous Lymph Node Syndrome - an acute systemic vasculitis which leads to the formation of aneurysms and myocardial infarction </li></ul><ul><li>Actual cause is still unknown. Altered immune function occurs after an infection. There is an increase in antibody production. Antibody-antigen complexes apparently bind to the vascular endothelium and cause inflammation. The inflammation leads to platelet aggregation and the formation of thrombi or obstruction of heart and blood vessels </li></ul>
  51. 51. Kawasaki Disease <ul><li>Acute Phase (Stage I) </li></ul><ul><ul><li>High fever that doesn’t respond to antipyretics </li></ul></ul><ul><ul><li>Lethargic and irritable </li></ul></ul><ul><ul><li>May have red, swollen hands and feet, conjunctivitis, strawberry tongue and red, cracked lips, enlarged cervical lymph nodes, variety of rashes, abdominal pain as internal lymph nodes swell, anorexia, diarrhea, red and swollen joints </li></ul></ul><ul><ul><li>Elevated WBC and ESR </li></ul></ul><ul><li>Subacute Phase - about 10 days after onset </li></ul><ul><ul><li>Peeling of skin on palms and soles of feet </li></ul></ul><ul><ul><li>Platelet count rises (increases risk of clotting) </li></ul></ul><ul><ul><li>Aneurysms may form in coronary arteries - sudden death can occur </li></ul></ul>
  52. 52. Kawasaki Disease <ul><li>Convalescent Phase (Stage II) - begins at about the 25th day and lasts until 40 days </li></ul><ul><li>Stage III lasts from 40 days until the ESR returns to normal </li></ul><ul><li>Diagnosis is based on criteria (Table 40.3), blood studies and echocardiogram </li></ul><ul><li>Treatment </li></ul><ul><ul><li>High dose aspirin </li></ul></ul><ul><ul><li>Dipyridamole - to increase coronary dilatation and prevent platelet accumulation </li></ul></ul><ul><ul><li>IV Gamma globulin - to reduce immune response </li></ul></ul><ul><li>Observe child for signs of heart failure </li></ul><ul><li>Inspect and palpate extremities for warmth and capillary refill </li></ul>
  53. 53. Kawasaki Disease <ul><li>Provide comfort measures </li></ul><ul><li>Protect edematous areas from pressure </li></ul><ul><li>May have dry, cracked lips </li></ul><ul><li>Monitor for dehydration, encourage fluids, but prevent fluid overload </li></ul><ul><li>Monitor nutritional status </li></ul>
  54. 54. Endocarditis <ul><li>Inflammation and infection of the endocardium or valves of the heart </li></ul><ul><li>Generally caused by streptococcal viridans. Sometimes can be staphylococcal or fungal </li></ul><ul><li>Strep enters the blood stream during oral procedures, impetigo, UTI’s </li></ul><ul><li>Vegetation of bacteria, fibrin, and blood appear on the endocardium of the valves and heart chambers - destroys the endothelial lining </li></ul><ul><li>Signs and Symptoms - abrupt, unexplained low-grade intermittent fever, anorexia, malaise, weight loss, change in murmur, splenomegaly </li></ul>
  55. 55. Endocarditis <ul><li>Diagnosis - blood culture, ECG, elevated ESR and C-reactive protein, anemias, leukocytosis, microscopic hematuria </li></ul><ul><li>Treatment - antibiotics (PCN, Ampicillin, Gentamycin) for 2 to 8 weeks. Supportive therapy to prevent heart failure. Teach prevention with prophylactic antibiotics before procedures. </li></ul>