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Cardiovascular disorders


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Cardiovascular disorders

  1. 1. Cardiovascular Disorders Gail C Hoyer Nur2310 Fall 2010
  2. 2. Heart Defects that Increase Pulmonary Blood Flow• PDA- Patent Ductus Arteriosus• ASD-Atrial Septal Defect• VSD- Ventricular Septal Defect
  3. 3. PDA: Pathophysiology, Manifestations, and Clinical Therapy• Pathophysiology • Therapy – The Ductus Arteriosus Usually – EKG shows left ventricular closes within the first hours hypertrophy of life – PDA visualized on echo – Common in preterm infants – Surgical Ligation• Manifestations – Intravenous indomethicin – Continuous “machine” like stimulates closure in murmur premature infants but can – Dyspnea not be used if CHF is present – Tachycardia • Shunt – Tachypnea – Left-to-right can be visualized – Thrill in pulmonic area on echocardiogram – May be asymptomatic – Increase in pulmonary blood flow
  4. 4. PDA: Anatomy
  5. 5. ASD: Pathophysiology, Manifestations, and Clinical Therapy• Pathophysiology • Therapy – Opening in the atrial septum – Dilated right ventricle on – May occur alone or in echo secondary to blood conjunction with a congenital overload and shunt size defect – Spontaneous closure occurs• Manifestations within the first 4 years of life – Surgery or patch when – Usually no symptoms in closure does not occur or infants and young children when increased pulmonary – With a large ASD, easy tiring, blood flow results in CHF and poor growth occur • Shunt – Left-to-right resulting in increased pulmonary blood flow
  6. 6. ASD: Anatomy
  7. 7. VSD: Pathophysiology, Manifestations and Clinical Therapy• Pathophysiology • Therapy – Opening in ventricular – If small x-ray and ekg reveal septum little• Manifestations – Echo establishes diagnosis if – Only 15% are large enough to shunting is present cause CHF or pulmonary – Most close within first 6 hypertension, or pulmonary months of life infections – Surgical patching if poor – Systolic murmur at third or growth is evident; otherwise fourth left intercostal space treatment is conservative • Shunt – Left-to-right directly across septum into pulmonary artery – Increased pulmonary blood flow
  8. 8. Heart Defects with Decreased Pulmonary Blood Flow• Pulmonary Stenosis• TOF-Tetralogy of Fallot
  9. 9. TOF: Pathophysiology, Manifestations,• Pathophysiology – Four defects • Pulmonic Stenosis page 1371 • Right Ventricular Hypertrophy • VSD • Overriding Aorta • Some kids have a fifth defect: ASD• Manifestations – Infant becomes hypoxic and cyanotic as the ductus arteriosus closes – The degree of the pulmonary stenosis determines the severity of the symptoms – Systolic murmur in the pulmonic area and transmitted to suprasternal notch – Polycythemia, hypercyanotic spell(tet spells), metabolic acidosis, poor growth, clubbing, and exercise intolerance – Knee chest squat of toddlers to decrease the return of systemic venous blood to the heart
  10. 10. TOF: Pathophysiology, Manifestations, and Clinical Therapy• Therapy – Diagnostic Tests • X-ray shows “boot shaped” heart due to large right ventricle, prominent aorta – Treatment • Calm, give oxygen, and morphine and propanolol to decrease pulmonary vascular resistance • Modified BT shunt to delay total correction surgery• Shunt – Right-to-left secondary to elevated pressures on the right side of the heart
  11. 11. TOF: Anatomy
  12. 12. Mixed defects• TGA- Transposition of the Great Arteries
  13. 13. TGA: Pathophysiology, Manifestations• Pathophysiology- Parallel circulation– Pulmonary Artery is the outflow tract for the left ventricle– The Aorta is the outflow tract for the right ventricle– Life threatening at birth, survival initially depends on an open ductus arteriosus and foramen ovale• Manifestations– Cyanosis apparent soon after birth • which does not improve with oxygen administration • May be less apparent if VSD is present– CHF may develop immediately, over days or weeks– Tachypnea without retractions or other signs of dyspnea– Long time to feed and need frequent rest periods b/c of rapid respiratory rate and fatigue; growth failure may be seen as early as 2wks if not corrected– Systolic murmur if VSD present; otherwise none; S2 is loud
  14. 14. TGA: Clinical Therapy• Therapy – Diagnosis • X-ray may reveal classis “egg-shaped heart” on a string with enlarged ventricles • Echo shows abnormal positioning of the great arteries – Treatment • Prostaglandin E1 is ordered to maintain a patent ductus arteriosus until a palliative surgery can be performed • Arterial switch performed before 1 week of life • Balloon atrial septostomy can be performed to allow mixing until surgery can be performed
  15. 15. TGA: Anatomy
  16. 16. BT shunt
  17. 17. Defects that Obstruct Systemic blood flow• Coarctation of the Aorta• CHF
  18. 18. Coarctation of the Aorta: Pathophysiology, Manifestations• Pathophysiology – Narrowing or constriction of the descending aorta often near the ductus arteriosus or subclavian artery which obstructs systemic flow• Manifestations – Many children are asymptomatic – Severe constriction infants have cyanosis in the lower extremities – Blood pressure lower in legs than arms – Brachial and radial pulses are typically bounding and femoral weak or absent – Older children may complain of leg pain after exercising – S2 is loud and single on auscultation
  19. 19. Coarctation of the Aorta: clinical Therapy• Therapy – Diagnosis • X-ray may show cardiomegaly • Echo confirms narrowing and location – Treatment • In symptomatic newborns, PGE1 is given to reopen the ductus arteriosus and promote blood flow to the lower extremities • Treatment to prevent CHF may include diuretics, inotropic medications and oxygen • Surgical correction is preferred
  20. 20. Coarctation of the Aorta: Anatomy
  21. 21. Congestive Heart Failure (CHF)• Disorder in which circulation is inadequate to support the body’s circulatory and metabolic needs.• Etiology– Most common cause • May be caused by congenital heart defects that obstruct systemic blood outflow tract or cause increased pulmonary blood flow • children with uncorrected defects develop CHF with 6 to 12 months of life– Other causes • Problems with heart contractility • Pathologic conditions that require high cardiac output(severe anemia, acidosis, or respiratory disease) • Acquired heart disease(cardiomyopathy, rheumatic heart disease, and Kawasaki disease) • Disorders such as Duchenne muscular dystrophy
  22. 22. CHF: Pathophysiology• Pathophysiology – Left-to-right shunts result in increased blood to the pulmonary system and can result in pulmonary hypertension – Obstructive defects restrict the flow of blood so the heart muscle hypertrophies to work harder to force blood through the structures
  23. 23. CHF: Manifestations in Infants• Initial Manifestations • Later Manifestations – Tiring easily, especially – Tachypnea during feedings – Tachycardia – Weight loss or lack of – Pallor normal weight gain – Cyanosis – Diaphoresis – Nasal Flaring – Irritability – Grunting – Frequent Respiratory – Retractions infections – Cough or crackles – Third heart sound
  24. 24. CHF: Manifestations in Older Children• Initial Manifestations – Exercise Intolerance – Dyspnea – Abdominal pain or distention – Peripheral edema• Later Manifestations – Generalized fluid volume overload – Jugular vein distention
  25. 25. CHF: Nursing Management• Assessment – Physiologic assessment – Developmental assessment• Planning and Implementation – Administer and monitor prescribed medications • Lasix and digoxin see page 1388 – Maintain oxygen and myocardial function – Promote rest – Foster development – Provide adequate nutrition – Provide emotional support – Discharge planning and home care teaching• Evaluation
  26. 26. Acquired heart Diseases• Rheumatic Fever• Kawasaki Disease
  27. 27. Kawasaki Disease• Acute febrile, systemic vascular inflammatory disorder that affects the small and midsize arteries, including the coronary arteries• Leading cause of acquired heart disease in children in the US• Etiology unknown, thought to be caused by an unidentified infectious agent
  28. 28. Kawasaki Disease: Manifestations and Clinical Therapy• Manifestations – Acute 1-2 weeks • Irritability, high fever that persists more than 5 days, hyperemic conjunctivae, red throat, swollen, hands and feet, rash on trunk and perineal area, cervical lymph node enlargement(unilateral) – Subacute 2-4 weeks • Cracking lips and fissures, desquamation of the skin on the tips of toes and fingers and toes, joint pain, cardiac disease, and thrombocytosis – Convalescent stage 6-8 weeks • Child appears normal but lingering signs of inflammation may be present• Clinical Therapy – Intravenous Immunoglobulin – High does of aspirin for fever – Hospitalization
  29. 29. Kawasaki Disease: nursing management• Assessment • Comfort – Temperature, skin, eyes, I&O, – Skin clean and dry weight, cardiac – Cool compresses, tepid baths• Medication – Small frequent feeding – Aspiring administration • Exercise • Monitor for side – Passive ROM effects(bleeding, GI • Discharge planning upset) – Teaching on aspiring therapy – Immune Globulin – Postpone live virus vaccines • Treat and administer like (measles and varicella) for 11 a blood product months after immune globulin administration, others may be given on schedule
  30. 30. Rheumatic Heart Disease• Inflammatory disorder of the connective tissue that results from an autoimmune response to some strains of A beta-hemolytic streptococci• Affects joints, brain, and skin tissue• Children between 5 and early adolescent are more commonly infected• Rheumatic heart disease develops in 10% of individuals with rheumatic fever
  31. 31. Rheumatic Heart Disease: Manifestations and Clinical Therapy• Hallmark signs – Occur three weeks after an untreated streptococcal infection • Carditis involving the mitral or aortic valve is detected by presence of a new murmur • Chest pain • Two or more large joints become inflamed with pain, welling, tenderness, erythema, and heat • Non pruritic skin rash with pink macules and blanching in the middle of the lesions on the trunk• Clinical Therapy – Antibiotics (penicillin, to eradicate strep infection) – Corticosteroids (to reduce inflammation)
  32. 32. Rheumatic Heart Disease: Nursing Management• Prevention • Medications – Children with possible throat – Antibiotics and aspirin infections would be cultured • Discharge Planning for strep – Recovery phase occurs at• Hospitalization home – Children with rheumatic fever • Activity limitations should be hospitalized • Antibiotic prescribed – Bed rest for monitoring – Teaching carditis • Reoccurrence of sore – 4weeks bed rest if carditis throat need for culture develops • Follow up care to monitor heart function