Alterations in cardiovascular function in children

Alterations in Cardiovascular
Function in Children
Joy A. Shepard, PhD, RN-C, CNE
Joyce Buck, PhD(c), MSN, RN-C, CNE
1

Learning Outcomes
 Describe anatomy and physiology of
cardiovascular system focusing on blood flow
and action of heart valves
 Contrast pathophysiology associated with
congenital heart defects with increased
pulmonary circulation, decreased pulmonary
circulation, and obstructed systemic blood flow
 Plan the nursing care for an infant with a
congenital heart defect
2

Learning Outcomes (cont’d)
 Plan the nursing care for a child undergoing
open heart surgery
 Recognize signs of congestive heart failure
 Develop a nursing care plan for child with
congestive heart failure
 Differentiate between heart diseases
acquired during childhood and congenital
heart defects
3

Overview of the Cardiovascular
System
4

Function of the Heart
 Pulmonary circulation—
Pumps blood to the
lungs for oxygenation
and removal of carbon
dioxide
 Systemic circulation—
Pumps oxygenated
blood to the body
tissues; metabolic
wastes taken away
6

Anatomy of the Heart
 Muscular pump with
four chambers:
 Upper chambers—
atria
 Lower chambers—
ventricles
 Valves, veins, and
arteries connect the
chambers
7

The Heart is Like a House….
 It has:
 Electricity
(power)
and
 Plumbing
(mechanical)
8

Electrical (Conduction) System
 Powers the pump
 Cardiac cycle:
depolarization and
repolarization of the
cardiac muscle
 Conduction pathways:
 Sinoatrial node (SA) —>
 Atrioventricular (AV)
node —>
 Bundle of His —>
 Left and right bundle
branches —>
 Purkinje fibers
9

Pumping System
 Heart—powerful,
muscular pump
 Two pumps: left and
right
 Pressures in the left
much higher than right
 Continuous coordinated
pumping action keeps
the body supplied with
oxygen-rich blood
10

Valves are essential to the
heart's pumping function
 Keeps blood flowing
forward through the
heart
 One-way valve at the
exit of each of the
four chambers:
 Tricuspid
 Pulmonic
 Mitral
 Aortic valves
11

Physiology of the Heart
 CO = HR X SV
Heart Rate
 Components of
Stroke Volume:
 Preload
 Afterload
 Contractility
13
Untillateschool-ageandadolescence,cardiacoutputinthechildisRATE
DEPENDENT,notstrokevolumedependent,makingheartratemorerapid.

Preload
 Amount of stretch of the myocardial fibers before
contraction
 Measured by central venous pressure (CVP)
15

Afterload
 Amount of resistance against which the heart
(ventricle) pumps
16

Contractility
 “Squeeze”—Strength of muscular contraction
independent of preload (inotropic)
17

Fetal Circulation
(pp. 273-274, Lowdermilk; pp. 569-571 Ball & Bindler)
18

Fetal Circulation
 Fetal circulation
differs from neonatal
circulation in three
ways:
 Gas exchange
 Pressures (systemic
and pulmonary
circulations)
 Structures (shunts,
umbilical cord)
19

Gas Exchange—Placenta; Umbilical
Vein—Oxygenated Blood
 Oxygenation and
removal of carbon
dioxide (gas
exchange) takes
place in the placenta
 Umbilical vein
oxygenated blood to
inferior vena cava
20

Fetal Circulation—Pressure
Differences
 Oxygenated blood flow (from the
placenta) is from right to left
 Oxygenated blood enters right side of
fetal heart
 Blood pressure on the right side of the
heart > blood pressure on the left side
of the heart
21

Fetal Circulation—Pressure
Differences
 High resistance in fetal lungs (arterioles
are constricted, alveoli are filled with
fluid)
 Resistance to blood flow in the lungs
(pulmonary vascular resistance) >
Resistance to blood flow in the body
(systemic vascular resistance)
 Fetal lungs don’t receive much blood
22

Fetal Circulation—1st Shunt
 Ductus venosus—
fetal structure
connecting inferior
vena cava to
umbilical vein
 Most of fetal liver
bypassed (blood
shunted away from
liver)
23

Fetal Circulation— 2nd Shunt
 Inferior vena cava
Right atrium
 Left atrium (by way
of the foramen
ovale)
 Most of lungs
bypassed
 Left ventricle aorta
(supplying heart and
brain)
24

Fetal Circulation—3rd Shunt
 Deoxygenated blood from
the upper body mixes with
oxygenated blood from
the placenta @ the right
atrium
 Ductus arteriosus
descending aorta
(bypassing the lungs)
 Organ systems
 Blood returns to the
placenta (by way of the
two umbilical arteries)
25

Transition from Fetal to
Pulmonary Circulation
27

Circulation After Birth—Gas
Exchange
 With the
neonate’s first
breath, gas
exchange is
transferred from
the placenta to
the lungs
  Pa02 levels
  PaC02 levels
28

Circulation After Birth—
Pressure Changes
  Resistance
 Pulmonary
circulation
  Pulmonary blood
flow
  Resistance
 Systemic
circulation
29

Pressure Changes
 Umbilical cord clamped
  Blood to right heart
 Blood pressure (left side of the
heart) > blood pressure (right side of
heart)
 Systemic vascular resistance >
pulmonary vascular resistance
30

Pressure Changes
 Lungs inflate with
air, allowing gas
exchange
 Resistance to blood
flow in the lungs
(pulmonary vascular
resistance) decreases
 Much more blood
flows into the lungs
 First breath: alveoli
expand and blood
vessels in the the
lungs open up
31

Pressure Changes
 Deoxygenated
blood
right heart
lungs
 Oxygenated
blood
left heart
body
32

Circulation After Birth—Shunts
Close
 Fetal shunts close
in response to
pressure changes,
 Pa02 levels, in
the pulmonary
and systemic
circulations
33

To Review…
Normal fetal circulation (lungs and liver bypassed)
Normal circulation after birth (systemic AND
pulmonary circulations; high systemic pressure)
34

Pediatric Cardiac Assessment
35

36
See Video “Pediatric Assessment,” 23:15-24:05

Health History
 Review:
 Table 5-12, p. 141
 Assessment Guide: The Child with a Cardiac Condition,
p. 572
 Congenital heart disease in family
 Maternal illness, infections, medications taken
during pregnancy
 Child’s behavior patterns (playfulness, irritability)
 Medications
37

Health History
 Feeding problems (fatigue or
diaphoresis during feeding; poor weight
gain)
 Respiratory difficulties (tachypnea,
shortness of breath, cyanosis; frequent
respiratory infections)
 Chronic fatigue, exercise intolerance
38

Inspection
 Skin color
 Activity level
 Chest
 Respiratory
pattern
39

Review Question
 An infant who has a cyanotic congenital heart defect
comes into the clinic with complaints of irritability, pallor,
and increased cyanosis that began quickly over the last 30
minutes. As the nurse assesses the infant, the parent asks
why the child’s color is bluish. The best response by the
nurse is, “Skin color is:
A. Related to the time of day.”
B. Related to brain function.”
C. Related to hemoglobin level and oxygen saturation.”
D. Unrelated to your child’s condition.”
40

Auscultation: A(P)TM
 Normal areas of
auscultation
 PMI: 3-4th ICS infants;
4th ICS < 7; 5th ICS > 7
 Heart sounds
 Rhythm: Regular
 S1, S2
 S3 —normal finding in
children
 S4 —cardiac failure
 Murmurs, clicks, friction
rubs
41Auscultate apical pulse with stethoscope for a full 60 seconds

Normal Heart Rates for Children of Different Ages

Palpation
 Skin temperature
 Pulses
 Blood pressure
 Capillary refill—
normal < 2
seconds
 Chest
45

The sites used to assess the pulses in
children

Significant Findings
 Growth abnormalities
 Cyanosis
 Clubbing of fingers and
toes
 Edema (periorbital,
peripheral)
 Tachypnea
 Pulse alterations (fast,
slow, diminished)
 Hypotension, unequal BP
arms / legs
 Murmurs, bruits, thrills
 Engorged neck veins
 Abdominal distention,
enlarged liver / spleen
47
See “Assessment Guidelines for the Child with a Cardiac Condition,” p. 572

Question
 An infant born at 39 weeks gestation is sent to
the intensive care nursery. The nurse suspects
a possible cardiac anomaly when the admission
assessment reveals:
 A. Projectile vomiting
 B. An irregular respiratory rhythm
 C. Hyperreflexia of the extremities
 D. Unequal peripheral blood pressures
49

Diagnostic Tests / Procedures
 Labs
 EKG
 Chest x-ray
 Echocardiogram
 Cardiac catheterization
51
See Table 21-4: Clinical Interventions for Congenital Heart Defects, p. 574
See Table 21-2: Diagnostic Procedures & Laboratory Tests, p. 571

Labs
 Hgb/Hct
 Serum electrolytes
(especially K+,
Mg++, Ca++)
 ABG
 Digoxin level
 Cholesterol
 Triglycerides
 Urine SG
53

Question
 The pediatric nurse practitioner orders a
complete blood workup for a 5-month-old
infant with a cyanotic congenital heart defect.
Because of the infant’s heart disease, the
nurse would expect the report to show:
 A. Polycythemia
 B. Agranulocytosis
 C. Thrombocytopenia
 D. A decreased hematocrit level
54

Pulse Oximetry
 Evaluates degree of
oxygen saturation in the
blood using a small
infrared light probe that
is placed on:
 Finger, toe, earlobe,
bridge of the nose
 Norm: 95 – 100%
 Cyanosis not visible until
sat < 85%
55

12-Lead EKG
 Helps evaluate:
 Cardiac muscle
 Cardiac rate
and rhythm
 Cardiac impulse
conduction
56

Chest X-Ray
 X-ray picture of
heart, organs in
chest cavity
 Provides information
on:
 Size of the heart and
its chambers
 Blood flow to lungs
57

Echocardiogram
 High-frequency sound
waves, noninvasive
 Helps assess:
 Thickness of heart walls
 Size of cardiac chambers
 Motion of valves and septa
(walls) within the heart
 Great vessels and various
cardiac structures
 Defects in structure or
function
58

Cardiac Catheterization
 Provides information on:
 Oxygen levels in cardiac
chambers and great
arteries
 Pressures
 Blood flow
 Cardiac output / stroke
volume
 Anatomic abnormalities
 Cardiac conduction
system
59

Interventional Catheterization
 Corrective treatments
performed by use of
specialized catheters
 Balloon catheters—open
narrowed valves or
arteries
 Balloon/blades—shunt
creations, septostomy
 Device closure—close
extra vessels, “holes” in
heart
60

Cardiac Catheterization—
Nursing Care (p. 573)
 Child must lay still, supine, with affected leg straight
for 4 – 6 hours
 Vital signs, insertion site observed, distal pulses
checked q15 minutes X 1st hour, then q30 minutes
 Observe for bleeding at site; pallor, loss of pulses,
coolness in extremity distal to site
 Push fluids to help flush the dye out of the body
 Observe for reactions to dye (vomiting, rash,
increased creatinine, decreased urinary output)
 Strict I & O
61

Question
 A 3-1/2-year-old child returns to the room after
a cardiac catheterization. Post-procedure
nursing care for the child should include:
 A. Encouraging early ambulation
 B. Monitoring the insertion site for bleeding
 C. Restricting fluids until blood pressure is
stabilized
 D. Comparing blood pressure in affected and
unaffected extremities
62

Heart Disease in Children
 Manifestations in
infants, children:
 Frequent respiratory
infections and dyspnea
 Activity intolerance
 Difficulty and fatigue
during feedings
 Failure to thrive, low
weight
 Pallor, cyanosis, clubbing
64

Manifestation: Respiratory
Difficulties
 Shortness of breath,
difficulty breathing
 Increased respiratory
rate, retractions,
nasal flaring
 Frequent respiratory
infections
 Activity intolerance,
fatigue, delayed
gross motor skills
65

Manifestation: Feeding
Difficulties, Stunted Growth
 Difficulty and
fatigue during
feedings
 Frequent emesis, at
risk for NEC
 Stunted growth
 Low weight
 Failure to thrive
66

Feeding Interventions
 Provide periods of uninterrupted rest
 Neutral thermal environment
 Feed child slowly and more often (q3°
optimal time)
 Frequent, small feedings may be less tiring
 Concentrating formula 24-27 kcal/oz may
increase caloric intake without increasing
infant’s work
67

 Provide relaxed
environment
 Reduce anxiety,
sadness, crying
 Hold infant in upright
position; less
stomach
compression and
improves respiratory
effort
 Place infant on right
side after feeding,
HOB 30 - 45º
68

 Limit bottle feedings to 30 minutes
 If child unable to consume appropriate
amount during 30-minute feeding every
3 hours, consider nasogastric feeding
 Monitor for increased tachypnea,
diaphoresis, or feeding intolerance
(vomiting)
69

Supplemental Feedings
 Infants with cardiac
conditions often
require
supplemental
feedings to provide
sufficient nutrients
for growth and
development
70

Question
 When caring for a 4-month-old infant
with congestive heart failure, the nurse
should:
 A. Force nutritional fluids
 B. Provide small, frequent feedings
 C. Measure the head circumference daily
 D. Position the infant flat on the abdomen
71

Manifestation: Pallor and
Cyanosis
 Bluish discoloration of
skin, nail beds, mucous
membranes
 Hypoxia—tissues are
deprived of adequate
amounts of oxygen (02
sat < 85%)
 Hgb must be at least 5
 Often appears when
child is feeding
 Polycythemia—
compensatory response
to chronic hypoxia
72

Manifestation: Clubbing
 Fingers or toes
 Chronic hypoxemia
 Base of nails
swollen
 Ends of digits
increase in size
 Angle b/n nail and
nailbed  180º
73

Question
 When attempting to identify the presence of a
congenital heart defect in an infant, the nurse
should understand that:
 A. In the absence of cyanosis, poor sucking is
insignificant
 B. Many infants retain mucous that may interfere
with feeding
 C. Feeding problems are fairly common in infants
during the first year
 D. Poor sucking and swallowing may be early
indications of heart defects
75

Pediatric Congestive Heart
Failure
76

Failure (p. 591)
 Pump is insufficient to meet the metabolic
demands of the body
 Heart becomes overloaded and unable to
deliver adequate cardiac output
 Most commonly caused by congenital heart
defects
 Acquired conditions: rheumatic heart disease,
endocarditis, myocarditis, cardiomyopathies,
severe dysrhythmias
77

Failure
 Infants have a
greater risk of heart
failure than older
children because the
immature heart is
more sensitive to
volume or pressure
overload (Figure 21-7, p. 594)
78

Failure—Right-Sided Failure
 Right-sided heart failure:
Periorbital and facial
edema, enlarged liver or
spleen, ascites, wheezing,
neck vein distension
  CVP (pooling of venous
blood)
  CO
 Causes: Left-to-right
shunts (VSD, ASD)
79

Failure—Left-Sided Failure
 Left-sided heart
failure: Tachypnea,
dyspnea, crackles,
intercostal / sternal
retractions,
wheezing
 Pulmonary edema
 Causes: Right-to-
left shunts; PDA,
COA
81

Failure—Both
 Most children with CHF have a
combination of left and right
 Both: Tachycardia, cardiomegaly,
decreased CO, gallop rhythm (S4),
decreased peripheral perfusion, excessive
diaphoresis, weight gain
 Blood diverted to vital organs and away
from GI tract—at risk for necrotizing
enterocolitis (NEC)
84

Failure—Manifestations
 Difficulty eating or
sleeping, fussy,
underweight
 Nasal flaring, grunting,
retractions
 Sudden weight gain
(fluid retention)
 Crackles
 Dry, hacking cough
 Decreased urinary
output
85

Pediatric CHF—Nursing
Diagnoses
 Review CP, pp. 595-598
 Decreased Cardiac Output r/t decreased
myocardial function
 Ineffective Tissue Perfusion r/t increased
cardiac workload
 Excess Fluid Volume r/t left and right
ventricular overload and ineffective
pumping
86

Pediatric CHF—Nursing
Diagnoses
 Review CP, pp. 595-598
 Ineffective Breathing Pattern r/t
pulmonary congestion
 Imbalanced Nutrition: Less than Body
Requirements r/t increased energy
expenditure
 Deficient Knowledge r/t unfamiliarity with
disease process, treatment, interventions,
and home care
87

Three early signs of CHF in
infants/children…
 Tachypnea
 Poor feeding
 Diaphoresis
during feeding
88

Question
 A 4-month-old who has a congenital heart
defect develops congestive heart failure and is
exhibiting marked dyspnea at rest. This finding
is attributed to:
 A. Anemia
 B. Hypovolemia
 C. Pulmonary edema
 D. Metabolic acidosis
89

Medications for Pediatric Heart
Failure
 Aim of medications:
 Decrease cardiac
workload
 Improve cardiac
output
 Types of
medications:
 Positive inotropes
 Diuretics
 Afterload-reducing drugs
90
See “Medications Used to Treat Congestive Heart Failure,” p. 593

Digoxin (Lanoxin)
 IV, PO
 Slows and
strengthens the
heart
 Positive inotropic
agent (Increases the
contractility of the
myocardium)
 Monitor: Dig level, K+,
Mg++, Ca++
 Signs of toxicity:
 Nausea, vomiting,
anorexia,
bradycardia,
dysrhythmia
91

Digoxin—Parent Teaching
 Safety Alert: Administering Digoxin, p. 594
 Count apical heart rate for one full minute
before giving
 Call for physician’s advice before giving if HR <
100 BPM infant/toddler, < 70 children
 Give at same time each day, with doses
equally spaced apart (morning, evening)
 If the dosage is spit up or vomited, do not
repeat
92

Digoxin—Parent Teaching
 Don’t use teaspoon, eye dropper—draw up in
syringe or calibrated dropper
 Always remove the cap before administering
the medication into the child's mouth
 Notify physician: nausea, vomiting,
listlessness, anorexia
 Keep medications out of reach of children
 Refill medicine 1 week before it runs out and
ask for new prescription at doctor’s visit
93

Furosemide (Lasix)
 IV / IM / PO
 Loop diuretic that blocks sodium
reabsorption in the ascending loop of
Henle
 Decreases preload by increasing water
excretion
 Side effects: Electrolyte imbalances ( K+,
 Mg++); metabolic alkalosis; hypotension
 Monitor: Electrolytes, urinary output, BP,
daily weights
95

Spironolactone (Aldactone)
 PO
 Potassium-sparing diuretic
 Decreases preload
 Side effects: Hyperkalemia,
hypovolemia, contraindicated in renal
failure
 Monitor: I & O, electrolytes, BP
96

Captopril (ACE Inhibitors)
 PO
 Decreases angiotensin II
 Dilates blood vessels, making it easier for the
heart to pump blood forward into the body
 Reduces afterload (blood pressure)
 Less strain on heart muscle and valves, decreased
myocardial oxygen use
 Monitor blood pressure carefully; monitor renal
function
97

Question
 A toddler is hospitalized with CHF and is
receiving digoxin and Lasix. She has
vomited twice in the past 4 hours. The
nurse’s best action is to:
 A. Increase the child’s fluid intake.
 B. Omit the next dose of Lasix.
 C. Check the child’s blood pressure prior to
the next dose of digoxin.
 D. Get an order to draw a digoxin level.
98

Question
 The mother of a 5-month-old infant with
congestive heart failure questions the necessity
of weighing the infant every morning. The
nurse’s response should be based on the fact
that this daily information is important in
determining:
 A. Renal failure
 B. Fluid retention
 C. Nutritional status
 D. Medication dosage
99

Pediatric Pulmonary
Hypertension
100

Pulmonary Hypertension (PH):
The OTHER Hypertension (p. 599)
 Increased pressure, narrowing:
pulmonary arteries, arterioles
 Elevated mean pulmonary arterial
pressure (PAP) >25 mmHg
 Causes: lung disease, some congenital
heart diseases
 RV failure  Rt heart failure  Lt heart
failure  reduced CO  hypotension
101

Signs/ Symptoms & Dx
 Infants: poor appetite, poor growth,
lethargy, tachypnea, tachycardia,
sweating, cyanosis
 Children: fatigue, chest pain, dyspnea,
dizziness, syncope
 Dx: echocardiography, cardiac
catheterization
103

Treatment
 Rapidly lethal – Must treat early while
reversible (to prevent pulmonary vascular
remodeling)
 Treat underlying cause (if known)
 Surgery 3-6 mos: ASD, VSD, AVSD, PDA
 Medications: O2, nitric oxide, calcium channel
blockers (nifedipine), diuretics, sildenafil
(Viagra)
 Lung transplantation: severe cases
104

Heart Disease in Children
 Two types:
 Congenital
 One or more heart structure abnormalities
that develop before birth or persistence of a
fetal structure after birth
 Acquired
 Any cardiac condition that was not present
at birth
106

Congenital Heart Disease is
associated with….
 Family history of
congenital heart disease
 Fetal exposure to drugs
such as dilantin and
lithium
 Maternal diabetes
mellitus
 Maternal viral infections
such as rubella
 Trisomy 21 (Down
syndrome)
108

Congenital Heart Disease
 Three Types:
 Acyanotic
 Obstructive
 Cyanotic
109

Acyanotic Heart Lesions
(Increase Pulmonary Blood Flow, p. 575)
 Left-to-right shunting
 Ventricular septal defect (VSD)
 Patent ductus arteriosus (PDA)
 Atrial septal defect (ASD)
 Atrioventricular septal defect
(endocardial cushion defect)
110

Acyanotic Heart Lesions—
Manifestations
 Left-to-right shunt
 Systemic pressure >
pulmonic pressure
 Oxygenated blood
backwashing to right side
of heart
 Venous blood does NOT
enter systemic circulation
 ALL of the blood returning
to the right side of the
heart passes through the
lungs
111

Acyanotic Heart Lesions
 NO cyanosis
 Not always apparent at birth
 Excessive pulmonary blood flow
(pulmonary HTN)
 Enlarged heart (right, sometimes
left)
 Congestive heart failure
 Enlarged liver, dyspnea, tachypnea,
intercostal retractions, poor growth,
frequent respiratory infections
112

Ventricular Septal Defect
(VSD)
 Hole or defect in
ventricular septum
(wall)
113

Ventricular Septal Defect
(VSD)
  Pulmonary blood flow
 Pulmonary HTN
 Usually not symptomatic
at birth
 Loud, harsh systolic
murmur
 Large defects: CHF,
poor feeding, failure to
thrive
115

VSD—Medical Management
 20-60% close
spontaneously
 CHF—Lanoxin and
Lasix
 Nutritional
supplements
 Antibiotic prophylaxis
to prevent
endocarditis
116

Antibiotic Prophylaxis
 Children with congenital heart defects at risk
for bacterial endocarditis and damage to
heart valves
 Must use antibiotics:
 Before and after dental, oral, and invasive
procedures / surgeries
 Any unexplained fever or malaise within 2
months of procedure may be a sign of
infection
117

Question
 The father of a child with a congenital heart
defect asks the nurse why his daughter has to
take penicillin before she gets her teeth
cleaned by the dentist. The nurse explains that
this is necessary to prevent:
 A. Bacterial endocarditis
 B. Congestive heart failure
 C. Rheumatic fever
 D. Infected gums
118

VSD—Pulmonary Artery (PA)
Banding
 Helps prevent
pulmonary vascular
obstructive disease
 Palliative surgery
 Closed heart surgery—
does not require
cardiopulmonary bypass
 Band placed around
pulmonary artery,
decreasing pulmonary
blood flow
 Used when VSD cannot be
closed (multiple VSD’s, very
small infants with severe
CHF)
 Less frequently done than
corrective surgery
119

VSD—Patch Closure
 Corrective surgery
 Purse-string suture
around small defects
 “Patch” over large
defects
 Open heart surgery
 Requires
cardiopulmonary
bypass
120

Question
 A cardiac catheterization is scheduled for a 5-
year-old with a ventricular septal defect to:
 A. Identify the degree of cardiomegaly present
 B. Demonstrate the exact location of the defect
 C. Confirm the presence of a pansystolic murmur
 D. Establish the presence of ventricular
hypertrophy
121

Patent Ductus Arteriosus
(PDA) (p. 576)
 Opening between aorta
and pulmonary artery
  Pulmonary blood flow
 Back to left atrium/left
ventricle
 Left ventricular
hypertrophy
 CHF (left side)
 Respiratory distress
 Machinery-type murmur
Connection between
pulmonary artery and aorta
122

PDA—Treatment
 CHF: digoxin, lasix
 Medical—
indomethacin
(Indocin)
 Interventional—
cardiac
catheterization
 Surgical—ligation of
ductus (left
thoracotomy)
123

Indomethacin (Indocin)
Ibuprofen
 IV
 NSAID—inhibits the production of prostaglandins
 Promotes closure of PDA; onset of action usually
within minutes
 Closure of PDA in 80% of patients
 Monitor renal function
 Side effects: bleeding (intraventricular
hemorrhages, GI bleeds)
124

Atrial Septal Defect (ASD)
(p. 576)
 Hole or defect in
atrial septum (wall)
125

Atrial Septal Defect
 Often asymptomatic
 Systolic murmur
 Large defect: CHF,
pulmonary vascular
disease (often 1st
appearing as an
adult)
 Treatment: “patch”
127

Atrioventricular Septal Defect (AVSD)
(Endocardial Cushion, AV Canal) (p. 577)
 LARGE hole in center
of heart
 ASD, VSD, and
combined mitral and
tricuspid valves
(common
atrioventricular
opening or “canal”)
 Common with Down
syndrome
128

Atrioventricular Septal Defect
129

 Left-to-right shunting:
Backward flow of
oxygenated blood
through both ASD and
VSD to right side of
heart
 Right-sided heart failure
 Pulmonary hypertension
 Systolic murmur
130

 Hemodynamic
changes with
untreated cases:
permanent right-to-
left shunting,
cyanosis
 Tachypnea,
tachycardia, poor
growth
http://www.gundluth.org/images/ei_0033.jpg
131

 Medical: digoxin, diuretics, and afterload
reduction (ACE)
 Treatment: surgical repair early in infancy (3-4
mos) before the lungs become damaged and
permanent hemodynamic changes occur
 “Patches” over both septal defects and valvular
repair
132

Review Question
 A toddler has been diagnosed with an
acyanotic cardiac defect. Which
assessment data would most likely
indicate congestive heart failure?
A. Heart murmur.
B. Cardiac volume overload.
C. Anuria.
D. Excitability.
133

Obstructive/ Stenotic Lesions
 Pulmonary stenosis
 Aortic stenosis
 Coarctation of the aorta
134

Pulmonary Stenosis (p. 582)
 Area where blood
exits the heart's
lower right chamber
is too narrow (right
ventricular outflow
tract obstruction)
 Harsh systolic
murmur
135

Pulmonary Stenosis
 Mild: asymptomatic,
requires only
antibiotic prophylaxis
 Severe or critical:
balloon valvuloplasty
or open-heart
surgical repair
136

Aortic Stenosis (p. 590)
 Obstruction of blood
flow from heart to
body (obstruction to
blood flow leaving left
ventricle)
  Afterload
  Cardiac output
  Systemic blood flow
 Harsh systolic murmur
137

Aortic Stenosis
 Mild: asymptomatic,
exercise fatigue
 Severe or critical:
CHF, left ventricular
hypertrophy, shock
138

Aortic Stenosis
 Mild: continue to
monitor, antibiotic
prophylaxis
 Severe or critical: aortic
balloon valvuloplasty
(cardiac
catheterization), surgical
valvotomy
 May need aortic valve
replacement
139

Coarctation of the Aorta (COA)
(p. 590)
 Obstructive lesion
 Restricts flow of blood
out of the left ventricle
 Aorta is pinched at some
point along its length,
limiting the amount of
oxygen-rich blood that
can reach the rest of the
body
140

Coarctation of the Aorta (COA)
  Afterload
  Cardiac output
  Systemic blood flow
  Pulmonary congestion
(pooling of blood in left
side of heart)
 Enlarged left ventricle;
CHF
 Decreased pulses and
BP in the lower
extremities
 Cold feet, legs
 Epistaxis (nose bleeds),
BP higher in arms
141

COA—Treatment
 Symptomatic CHF: digoxin,
lasix
 Medical: prostaglandin
infusion to keep ductus
arteriosus patent (improve
perfusion to lower body)
 Balloon angioplasty
 Surgical repair: left
thoracotomy with
anastomosis
 Antibiotic prophylaxis for
life
142

Question
 An infant with a left-to-right shunt was
admitted to the hospital in congestive heart
failure. She weighed 3.6 kg yesterday. A
finding that indicates a worsening of her
condition today is:
 A. Weight 3.66 kg.
 B. Urine output of 40 ml in past 8 hours.
 C. Crackles in the lower lobes.
 D. All of the above.
143

Cyanotic Heart Lesions
(Decrease Pulmonary Blood Flow, p. 581)
 Right-to-left
shunting
 Tetralogy of Fallot
(TOF)
 Transposition of the
Great Arteries (TGA)
 Hypoplastic Left
Heart Syndrome
(HLHS)
144

Cyanotic Heart Lesions—
Manifestations
 Right-to-left shunt
 Pulmonic pressure >
than systemic
 Unoxygenated blood
bypasses pulmonary
circulation and goes
directly to the left
side of the heart to
be pumped into the
systemic circulation
145

Cyanotic Heart Lesions—
Manifestations
 “Blue baby”—
Cyanosis
 Symptomatic soon
after birth
 Decreased
pulmonary blood
flow
146

Tetralogy of Fallot (p. 582)
 Defect composed of
four distinct lesions:
1. Ventricular septal
defect
2. Pulmonic stenosis
3. Overriding aorta
4. Right ventricular
hypertrophy
147

Cross-Section of a Normal Heart and
a Heart With Tetralogy of Fallot
148

Tetralogy of Fallot
 Reduced blood flow
to lungs
 Aortic blood (to
body) mainly
oxygen-poor venous
blood
 Severity of cyanosis
depends primarily on
degree of pulmonary
stenosis
149

Tetralogy of Fallot—Signs and
Symptoms
 X-ray: Heart is “Boot-
shaped”
 Cyanosis, difficulty
breathing
 Clubbing of fingers
(because of hypoxemia)
 Systolic murmur,
palpable thrill
 Polycythemia
 Hypercyanotic episodes
150

Hypercyanotic Episode:
“Tet Spell” (p. 585)
151

Question
 A child diagnosed with tetralogy of Fallot becomes
upset, crying and thrashing around when a blood
specimen is obtained. The child’s color becomes blue
and the respiratory rate increases to 44
breaths/minute. Which of the following actions would
the nurse do first?
 A. Obtain an order for sedation for the child.
 B. Assess for an irregular heart rate and rhythm.
 C. Explain to the child that it will only hurt for a
short time.
 D. Place the child in a knee-to-chest position.
153

Question
 A newborn with TOF is fed in the semi-Fowler’s
position. After the nurse feeds and burps the infant
and changes the infant’s position, the infant has a
bowel movement and almost immediately becomes
cyanotic, diaphoretic, and limp. These symptoms are
most likely caused by the:
 A. Burping
 B. Formula
 C. Position change
 D. Bowel movement
154

TOF Surgical Repair
 Surgical treatment:
 Palliative—Relieves symptoms by
increasing the blood flow to the
lungs
 Corrective—Repairs the underlying
defects
155

Blalock-Taussig Shunt (p. 586)
 Palliative procedure
 Closed-heart surgery
 Shunt created from aorta
to pulmonary artery
  Blood flow to lungs
 “Buys” time for infant to
grow
  Success of corrective
surgery when done later
156

Question
 The nurse is aware that the aim of
palliative surgery for children with
tetralogy of Fallot is to directly increase
the blood flow to the:
 A. Brain
 B. Lungs
 C. Myocardium
 D. Right ventricle
157

TOF Repaired
 Open-heart surgery
 2 to 4 months
 Pulmonary valve widened
 VSD patched
 No treatment: Displaced
aorta, enlarged rt.
ventricle
 Antibiotic prophylaxis for
life
158

Question
 Parents of a toddler with tetralogy of Fallot
explain that they do not want him to overexert
himself; so they always keep him in his
playpen or crib to limit his mobility. Based on
this information, the most appropriate nursing
diagnosis is:
 A. Activity Intolerance
 B. Risk for Impaired Parenting
 C. Caregiver Role Strain
 D. Risk for Delayed Development
159

Transposition of the Great
Arteries (TGA) (p. 584)
Reversal of aorta and pulmonary artery
160

Arteries (TGA)
 Babies born with
TGA can only survive
if they have one or
more connections
that allow some
oxygenated blood to
go to the body (PDA,
ASD)
161

Prostaglandin E1 (PGE1)
 IV infusion
 Causes the ductus
arteriosus to stay
artificially open (patent)
 For infants with ductal-
dependent cardiac
abnormalities (TGA,
HLHS, severe TOF)
 Ventilator
 Monitor: Respiratory,
cardiovascular status,
bleeding (inhibits
platelet aggregation)
 Side effects: Apnea,
fever, irritability,
flushing, bleeding, third-
spacing
162

Arteries (TGA)
 Balloon atrial
septostomy—tears a
hole in the atrial septum
 Corrective surgery is
performed in the early
days following birth:
 Arterial switch
procedure—aorta and
pulmonary artery
returned to their
normal positions
163

Tiny Baby Survives Open Heart
Surgery
164

Hypoplastic Left Heart
Syndrome (HLHS) (p. 591)
 Inadequate
development of the
left side of the heart
 Only one functional
ventricle
 Aortic valve, mitral
valve, and ascending
aorta may also be
small or hypoplastic
165

HLHS—Signs and Symptoms
 Cyanosis, appears
“gray”
 CHF
 Tachycardia, dyspnea
 Hypotension,
weakness
 Hypoperfusion, shock,
metabolic acidosis
166

HLHS—Treatment
 Comfort care
 Without surgery, fatal within the first 2 weeks of
life
 Medications: PGE1 infusion to keep the
ductus open
 Surgery: 3-staged palliative surgery (ages 1
week, 6 months and 2 years of age)
 Heart transplant—infrequent due to scarcity
of neonatal donor hearts
167

Child With HLHS Who
Received Heart Transplant
http://www.texaschildrenshospital.org/CareCenters/KidsCourageous/Heart_Noah.aspx
168

HLHS—Palliative Surgery
 Three-stage surgical
approach to improve
flow of blood throughout
the body
 The Norwood Procedure
(Stage 1)
 1 week of age
 Provides blood flow from
the right ventricle
directly to the aorta
169

HLHS—Palliative Surgery
 The Bi-Directional Glenn
(Stage 2)
 6 months of age
 The Fontan Procedure
(Stage 3)
 2 years of age
 Re-routes blood flow
around the defective
areas of the heart by
creating new pathways
for blood circulation to
and from the lungs
171

HLHS—Prognosis
 4-year survival following
staged repair up to 85%
 Long-term survival
remains to be seen
 Long-term complications
(advanced disease):
ventricular and valvular
dysfunction,
dysrhythmias, low
albumin, pleural
effusions, ascites
173

Question
 Parents of children with congenital heart
problems often experience loss of control when
the child is hospitalized. The nurse who
understands this will:
 A. Encourage parents to participate in their child’s
care.
 B. Explain procedures prior to performing them.
 C. Answer questions honestly.
 D. Do all of the above.
174

Cardiac Surgery (p. 578; 580)
 Two types:
 Open-heart surgery:
repair to the
myocardium (heart
muscle); requires
cardiopulmonary bypass
 Closed-heart surgery:
interventions to
structures around the
heart but not the heart
muscle itself; done
without bypass
177

Open-Heart Surgery
 Read pp. 578-580
 Trend: to intervene
at an early age
 Risks: bleeding,
emboli,
dysrhythmias, fluid &
electrolyte
imbalances
178

Post Cardiac Surgery
 STERNAL PRECAUTIONS
 Chest tube, NGT,
ventilator, cardiac
monitor, pulse oximetry
 Encourage cough, IS
 Monitor VS, cardiac,
respiratory, I & O,
electrolytes, chest tube
drainage
 Very painful surgery:
Adequate pain control
very important
179

Rheumatic Fever (RF) (p. 600)
 Children ages 5 – 15
 Inflammatory autoimmune
response
 Result of “strep throat”
that has not been treated
with antibiotics
 Manifests 1 – 3 weeks
afterwards
 Affects connective tissue
of heart, joints,
subcutaneous tissues,
blood vessels
 Most serious: Cardiac
valvular disease (esp.
scarring of mitral valve)
 Prevention: refer all
children with sore throats
for throat cultures
181

Manifestations of
Rheumatic Fever
 Carditis—inflammation of all
parts of the heart (mitral, aortic
valves)
 Murmur
 Polyarthritis—joint pain
 Chorea—involuntary movements
of legs, arm, and face
 Erythema marginatum—red skin
lesions
 Subcutaneous nodules—
nontender lumps located over
the joints
183

RF—Diagnostics / Treatment
 Positive antistreptolysin
O titer (+ ASO)
  SED (erythrocyte
sedimentation) rate
 Positive C-reactive
protein
 EKG changes
 Monitor for cardiac
complications, seizures
 Antiinflammatory
agents (aspirin,
corticosteroids),
analgesics,
antipyretics
 Streptococcal
prophylaxis for many
years
184

Streptococcal Prophylaxis for the
Child with Rheumatic Fever
 Damaged valves can become further
damaged with repeated infections
 Streptococcal prophylaxis is lifelong if
there is actual valve involvement
 Intramuscular penicillin, administered
monthly, is the drug of choice
 Alternatives include oral penicillin twice
daily or oral sulfadiazine once a day
185

Rheumatic Fever—Valvular
Malfunctions
186

Question
 When examining the laboratory work
of a child with the diagnosis of
rheumatic fever, the nurse would
expect the findings to demonstrate:
 A. A negative C-reactive protein
 B. A positive antistreptolysin titer
 C. An elevated reticulocyte count
 D. A decreased erythrocyte sedimentation
rate
187

Kawasaki Disease (KD)
(p. 601)
 Children < 4 years (peak incidence 18 – 24 months)
 Mucocutaneous lymph node syndrome
 Inflammatory autoimmune disease—principle area of
involvement is the heart
 Antibody-antigen complexes
 If caught and treated early the prognosis is usually
very good
 If left untreated or caught too late, it can be fatal or
leave the child with irreversible heart and/or organ
damage
188

Kawasaki Disease (KD)
 May damage the coronary arteries (vasculitis)
and heart muscle
 Most common cause of acquired heart disease
in U.S. children
 Can lead to coronary aneurysms and
myocardial infarctions later in life
 Cause: ??? noncontagious infection; associated
with rug shampooing, dust mites, or proximity
to stagnant water
 Seasonal:  Late winter, early spring
189

KD—Signs and Symptoms
 Affecting children under the
age of 5, diagnostic criteria
include at least:
 5 days of fever (> 39 ° C,
102.2° F), unresponsive to
antibiotics
 Conjunctival eye redness
without discharge
 Red-fissured lips
 Strawberry tongue
 Red rash
 Redness and/or swelling
of palms and soles, and
lymph nodes in the neck
190

KD—Phases and Treatment
 3 phases
 Acute phase: 1 to 2 weeks, with high fever > 5
days
 Nurse needs to closely monitor cardiac status,
VS, observe for CHF
 Echocardiogram, ECG,  SED rate
 Early treatment can dramatically reduce the
likelihood of cardiovascular damage
 High-dose IV Gamma-globulin
 High-dose PO ASA therapy
191

Aspirin (ASA)
 PO, administer with milk or food
 Antiplatelet agent (inhibit platelet function by
making them less sticky)
 High dose therapy (KD): 80-100 mg/kg/day for
the first two weeks to reduce fever, swelling
and inflammation; and to decrease the chance
of blood clots
 Don’t give to children <16 y with chickenpox
or flu-like symptoms (Reye syndrome)
 Side effects: Bleeding
194

Review Question
 A toddler with Kawasaki’s disease is ordered to receive
aspirin therapy. Typical administration of aspirin for
Kawasaki’s disease would include which of the
following principles?
A. High doses of aspirin should be given while fever is
high.
B. Aspirin therapy is given to reduce fever.
C. Aspirin dose increases after fever is gone.
D. Aspirin dosage is unrelated to platelet count.
196

Gamma Globulin (IVIG)
 One time dose 2 g/kg
 Administered through an intravenous
(I.V.) line for 10 hours
 If given first 10 days, will dramatically
reduce the risk of damage to the
coronary arteries
 Side effects: Hypotension; facial
flushing; tightness in the chest
197

IVIG—cont’d…
 Monitor BP closely
 Benadryl and acetaminophen: control
side effects
 Epinephrine: anaphylactic reactions
 Vaccines must be delayed for 5 months
months after treatment
198

Childhood Hypertension, High
Cholesterol
200

Management of Hypertension
in Children
 Diastolic > 95% percentile
 Not common, but incidence rising
 Kidney disease, obesity
 Weight reduction
 Physical conditioning
 Dietary modification
 Pharmacologic treatment
201

High Cholesterol Risk Factors
 Tobacco use
 Dyslipidemia (elevated LDLs and
cholesterol and decreased HDLs)
 Hypertension
 Decreased physical activity
 Obesity
 NANDA diagnosis: Sedentary Lifestyle
202

Alterations in cardiovascular function in children

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