cardio vascular disorders

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  • 7/30/2019 Cardio Vascular Disorders



    Congenital Heart Disease

    1. Atrial septal defect (ASD)

    2. Ventricular septa! detect (VSD)

    3. Pulmonary stenosis (PS)

    4. Patent ductus Arteriosus (FDA)

    5. Coarctation of aorta

    6. Aortic stenosis (AS)

    7. Tetralogy of Fallot (TOF)

    8. Transposition of the great vessels.

    Rheumatic Heart Disease

    Acute Rheumatic fever

    Kawasaki disease (or) mucocutaneous lymph node syndrome

    Congestive heart failure

    a) Congenital Heart Disease

    It is most common birth defects, 30% of the total congenital malformation.

    The heart is developed during the period of embryogenesis from a primitive

    muscles wrapped tube to a four chambered muscular organ with septa, valves,

    conduction system and major vessels originating and terminating in the heart

    If it is present any defect in this order and developmental leads to structural (or)

    functional malformation.

    Incidence of C H D:

    1) 5-8 per 1000 live births have significant structural cardiac malformation

    2) 2-3 in 1000 infants will be symptomatic during the first year of life (cardiac


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    Common & Congenital Heart Lesions:

    Acyanotic Cyanotic

    1. VSD 32%

    2. PDA 12%

    3. Pulmonary stenosis 8%

    4. ASD 6%

    5. Coarctation of aorta 6%

    6. Aortic Stenos's 5%

    1) TetratOgy of Fa110:6%

    2) Transposition of great vessels



    Chromosomal abnormalities 8% Incidence Type of defect

    21 Trisomy down syndrome60% A-V canal defect

    18 Trisorny 90% VSD, PDA, DORA

    13 Trisorny 90% Dextrocardia

    Xo-Toners syndrome. 15% Coarctation of aorta

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    Environmental Teratogen:

    Intravenous infection Tyes of defect

    Mumps PDA,SD,ASD endocardial


    Maternal drugs:

    Phenytoin Variable supra valvular aortic stenosis

    Vitamin D Supra valvular aortic stenosis

    Alchohol ASD,VSD

    Maternal disease:Diabetes Transposistion of great vessels

    Systematic lumps erythimatus Congenital heart block

    Common Clinical Features in Congenital Heart Disease:

    1. Mixing of systemic and pulmonary circulation leading to cyanosis

    2. Inadequate blood reaching to lungs for oxygenation leading to cyanosis

    3. The body growth is affected due to inadequate blood supply of the body

    4. Increased in volume and pressure load over the ventricles leading to

    congestive heart failure

    5. Abnormal situs leading to positional malformation dextrocardia

    6. Dysfunction of intrinsic conduction leading to arrhythmias.

    7. While routine examination in older children and infant through

    continuous murmur can identify the problem ex: FDA, VSE), ASO,

    pulmonary stenosis in congenital absence of pulmonary valve.

    8. Shock

    9. Hyper cyanotic spells


    11.Chest pain

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    12.Recurrent respiratory tract infection

    13.Growth failure

    Diagnostic Evaluation

    Physical examination, history collection,


    To evaluate cardiac size, classical

    Cardiac contours lung musculature individual cardiac chamber, aortic arch,

    abdominal situs.


    To evaluate homodynamic status of defect, seventh of defect, suggestive of

    certain lesions.


    To evaluate homodynamic data regarding pressure differences across aortic

    and pulmonary valves.

    Cardiac catheterization.


    Cardiac MRI

    Management of CHD: Diuretics:

    Chlorothiazide (Diucii)

    Frusemide (lasix)

    Cardiac glycosides:

    Digoxin (lanoxin)

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    to prevent (or) treat CHF

    Interventional Management

    Nutritional support

    Treatment of stroke seen in cyanotic heart disease

    Prevention and treatment of hyper cyanotic spells

    Anti arrhythmic treatment in arrhythmias

    Complete congenital heart block

    Paroxysmal SVT

    Use of prostaglandin E, in shunt dependent congenital heart defects

    Surgical Treatment:

    Palliative surgeries mitigate symptoms (or) extend life without addressing

    basic patho physiology of cardiac lesion.

    1). Atrial Septal Defect (ASD)

    It is abnormal opening between the atria, allowing blood flow from the

    high pressure in left atrium to the lower pressure in right atrium.

    Types of ASD :

    1. Ostium primum (ASD1):

    Opening of lower end of septum may be associated with mitrel valve


    2. Ostium secundam: (ASD2) :

    opening near to center of septum

    3. Sinus venosus defect:

    Opening near superior venacava (SVC) and right atrium, may be associated

    with parietal anamolus pulmonary venous connection.

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    Increased left atrial pressure

    Blood flow from left to right atrium because increased oxygenated blood goes

    to the right side of the heart

    Low pressure difference and high rate of blood flow occur

    (Low pulmonary vascular resistance, distensibiliy of the right atrium)

    Reduced Flow resistance

    (blood volume tolerated by the right ventricle)

    Right Atrial and ventricular Enlargement

    Cardiac failure (uncomplicated ASD)

    Pulmonary vascular changes


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    Clinical Features:

    Usually asymptomatic

    May have audiable systolic ejection murmur at left sternal border

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    Mild exercise intolerance

    Mild to moderate Cardiomegaly with pulmonary vascular

    disease gradually increasing

    Diagnostic Evaluation:

    1. ECG may reveal atrial arrhythmias (prolonged P-R interval) and RVH

    2. Chest x-ray reveals pulmonary vasculature Prominent pulmonary

    artery and right ventricular hypertrophy (RVH)

    3. Echocardiogram: reveals abnormal septal motion, dilated right atriumand right ventricle

    4. Angiography shows ASD.

    5. Cardiac catheterization reveals increased 02 saturations in right atrium.


    Adult hood:

    Atrial arrhythmias


    Heart failure

    Left ventricular failure

    Medical Management:

    1. Right or left ventricular failure can be treated by administering

    Digitalis (Digoxin) and Diuretics (Frusemide)

    2. Post operatively it can be treated by administering antibiotic

    to prevent complication

    3. Monitor for signs of complication

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    Surgical Management:

    Open heart surgery (or) cardiopulmonary bypass:

    The detective septum is closed with a purse string suture.

    If the defect is large means need a knitted Dacron patch sewn over the


    This surgery is contraindicated for right to left shunt

    Females should always undergo surgical repair due to the high risk

    of paradoxical emboli in pregnancy.

    Nursing Management:

    1. Maintain the nutritional status

    2. Instruct to avoid sports and exercise

    3. Antibiotic should be administered to prevent infection and to minimize

    the risk of Bacterial endocarditis

    4. Assess any complication

    5. Note the child's colour, vital sings and blood pressure

    6. Incision and dressing should be checked for bleeding and haematoma

    7. Maintain intake and out put chart.

    2). Ventricular Septa' Defect (VSD)

    Ventricular septal defect is the most common congenital cardiac anomaly.

    This anomaly is frequently occurs with both the cyanotic and acyanotic types.

    Ventricular septal defect is an opening present in the septum between two

    ventricles. It consists of an abnormal communication between the right and left


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    About 3 in thousand live birth.



    The mother having mumps, measles , rubella and jaundice during the

    time of pregnancy

    T he m ot he r t ak in g A nt id ia be ti c, Antihypertensive,

    Chemotherapy and Radiation therapy.

    The mother having the habits of smoking and alcoholism.

    Environmental factors

    Idiopathic, hyperkalemia

    Pressure in the left ventricle is higher then in the right ventricle

    So, blood is shunted through the defect from left to right

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    Then, the blood enter in to the pulmonary artery

    Pulmonary hypertension

    Due to increased pressure in the right ventricle muscular hypertrophy


    Atrium may also enlarge

    If pulmonary vascular resistance increases Left to right shunt reduces and

    right to left shunt result

    Un oxygenated blood crosses the defect to the left ventricle and enters to the

    systemic circulation (Eisenrnenger syndrome)


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    Clinical Features:

    Breathlessness due to decreased oxygenated blood

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    Difficulty in feeding due to breathlessness

    Congestive cardiac failure

    Small peripheral pulse because of poor systemic blood flow

    Para systolic murmur sound due to increased blood flow through the

    chambers of heart

    Thrusting apical pulse

    Collapsing pulse

    Narrow pulse pressure

    Low diastolic pressure

    Chillness of fingers and toes

    Clubbing of fingers

    Endocarditis (late)

    Decreased exercise tolerance

    Cyanosis (Due to pulmonary vascular disease)

    Recurrent chest infection

    Physical Signs:

    Parasternal thrill

    Heart murmur at lower left sternal edge

    1. Loud Para systolic murmur when a small defect

    2. Unimpressive ejection murmur from flow across the pulmonary valve

    when a large defect

    Variable pulmonary component of second sound

    1. Normally when small defect

    2. Loudly when large defect with pulmonary hypertension

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    Left ventricular hypertrophy , pulmonary edema

    Tachypnea, tachycardia and enlarged liver from heart failure

    Delayed growth and development

    Diagnostic Evaluation:

    History collection about congenital defect

    Physical examination through this pulse rate, murmurs, abnormal chest

    movement can be assessed.

    Chest x-ray it shows hypertrophy of right and left ventricle


    In this hypertrophy of right ventricle, right axis deviation can be seen


    It helps to demonstrate the site of ventricular septa' defect and the

    presence of multiple defects


    A For the direct visualization of the blood flow.

    Cardiac catheterization.

    The diagnosis of ventricular septal defect is confirmed by cardiac

    catheterization the sings Include the presence of an abnormal

    communication between the ventr icle, increased blood

    oxygenation, precursor in the ri ght ventr icl e and abstr act ion at

    the pulmonary artery (Infundibula stenosis)


    Medical management:

    1. Cardiac Drugs-Digoxin syrup 0.35mg/kg to decrease the workload of the 175

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    2. Diuretics-lasix 1.3 mg/kg

    3. Prophylactic Antibiotics

    4. Potassiom chloride syrup 3-5 ml

    Surgical Management:

    Purse String Suture:

    Small defects are repaired with pursestring approach.

    Open heart surgery.

    Knitted Dacron Patch

    Large defects usually require a knitted Dacron patch sewn over the opening

    After this procedure heart size return to normal and murmurs disappear.

    Cardiac Pulmonary Bypass Surgery

    In a surgical correction can be achieved at any age using cardiopulmonary

    bypass under deep hypothermia for the very young infant and to heart, lung

    bypass in older child.

    Nursing Management:

    1. Maintain the nutritional status

    2. Instruct to avoid sports and exercise

    3. Antibiotic therapy should be administered to prevent infection and to

    minimize the risk of Bacterial endocarditics

    4. Assess any complication

    5. Note the child colour, vital sings and blood pressure

    6. Incision and dressing should be checked for bleeding and haematoma

    Maintain intake and out put chart

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    3). Pulmonary Stenosis (PS)

    Pulmonary stenosis is the obstruction of flow of blood from the right

    ventricle to lungs.

    It may be associated with other defects such as atrial defect, ventricle

    septal defect and patent ductus arieriousus,


    It occurs 8% of congenital heart defects.

    90% of obstruction occurs at the level of the pulmonary value

    Pulmonary valve is obstructed by fusion of the cusps

    Right ventricle hypertrophy in early stage

    In Later stage the blood flow from right ventricle to right atrium

    1) If baby have foramen vale, at that time the blood shunted from right atrium to

    left atrium and left ventricle

    2) If baby have ductus arteriousus the systemic circulation mixed with centre

    circulation so cyanosis can occur


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    Clinical Features:

    Mild to moderate pulmonic stenosis are asymptomatic


    Chest pain

    In severe pulmonary stenosis results in a further widening of the split

    Delayed second heart sound

    Pulmonary ejection murmur

    Systolic murmur


    Cardiac failure


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    On physical examination

    Patients are characteristically described as having a round face and


    Port-wine angiomatous malformation may be present over the skin

    Turner's phenotype without chromosomal abnormalities (Noonan syndrome)

    Diagnostic Evaluation:

    History Collection

    Physical Examination:

    Auscultation reveals a systolic ejection murmur over pulmonic area often

    an ejection click and a widely split second sound can be heard

    Chest x-ray shows enlargement of right ventricle and main pulmonary


    ECG: Moderate or severe cases demonstrate right ventricular hypertrophy

    Two-dimensional echocardiography and Doppler study with colour flow

    mapping can enhance visualization of the level of obstruction

    Cardiac catheterization


    Children having mild and perhaps even moderate pulmonic stenosis may

    be no need of treatment

    Children having a more severe defect require surgical pulmonary


    If the obstruction is at the valvular level

    The leaflets of the valve are separated by incisions at the fused


    If the stenosis is infundibulam, resection of the excess muscle or fibrous

    tissue is done

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    If present of patent foramen ovale or atrial septal defect it is closed

    Surgical Management:

    Open heart surgery is necessary

    In infants valve transventricular (closed) valvotomy (Brock) procedure

    In children, pulmonary valvotomy with cardiopulmonary by pass

    Non-Surgical Treatment:

    Ba ll oo n an gi op la st y in th e ca rd ia c catheterization of laboratory to

    dilate the valve


    Patent ductus arteriousus is a communication between the pulmonary

    artery and the aorta. The aortic attachment of the ductus arteriosus is just distal

    to the left subclavian artery. The ductus arterious is present in the fetal

    life in all. It closes functionally and anatomically soon after birth

    persistence of ductus is called patent ductus arteriousus.


    It is twice as frequent in female as in male infants


    In fetal life the blood directly enter the descending aorta from thepulmonary artery through the ductus arteriosus

    After the birth expansion of lungs takes place for increased blood pressure in

    pulmonary artery.

    It should dilate same time ductus arteriosus should be closed patent ductus


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    Clinical Features:

    Murmur is heard at the middle to the upper left sternal border.

    Pulse pressure is increased

    Enlargement of left atrium, left ventricle, and right ventricle. If the

    volume overload of left ventricle occurs, it causes pulmonary venous

    engorgement resulting in congestive cardiac failure

    Respiratory distress

    Increased respiratory infection

    Gallop rhythm due to rapid filling of ventricle

    Dyspnoea decreased physical developement

    Increased heart rate over 150/minute

    Bounding pulses due to increased systolic pressure

    Machinery murmur

    Diagnostic Evaluation:


    Continuous murmur is heard at the left intraclavicular area. A thrill

    may be palpable.S1 is loud and the S2 is narrowly or paradoxically split

    2. Chest x-ray reveals Cardiomegaly and left ventricular enlargement.

    Aorta is prominent lung fields are plethoric.

    3. ECG reveals left ventricular hypertrophy

    4. 2-D echocardiography: study with colour flow are helpful for

    visualization of PDA and blood flow across PDA.


    Before surgery:

    Pulmonary Oedema


    Systemic emboli

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    Pulmonary hypertension

    Congestive heart failure


    Infective endocarditis




    Medical management:


    (Inhibits the prostaglandins synthesis)


    Chlorothiazide 20mg/kg/24hour5.


    1.3mg/kg/dose/oral Digitalis:



    Surgical Treatment:

    Surgical division or ligation of the patent vessels via a left thoracotomy.

    (A newer technique, visual assisted thoracic scopic surgery (VATS), uses a

    thoracoscope and instruments placed through small incisions on the left side of the

    chest to place a clip on the ducts. It is used in some centers and eliminates the

    need for a thoracotomy there by speeding post operative recovery.

    Non-Surgical Treatment:

    Use of coils to occlude the PDA in the catheterization laboratory is done in

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    many centers. Small infants (with small diameter femoral arteries) and those

    patients with large or unmusical PDAs may require surgery.


    It is the narrowing of the lumen with in the area of aortic arch.


    This defect s seen more frequently in males and is commonly seen in

    association with Turner's syndrome.


    Narrowing causes decreased blood flow distal to the structure, and the back-up of

    blood flow in the heart.

    Clinical features:

    Usually depend up on severity.

    Hypertension in arterial branches proximal to the defect and hypotension

    distal to the defect has a symptomatic until adolescence if presents of mild

    narrowing area.

    Decreased / absent femoral pulses with a brachial femoral leg.

    Systolic murmur audiable in left upper side of the axillae.

    Blood pressure: - Upper extremities > lower extremities.

    Poor feeding

    Poor weight gain


    Respiratory distress etc..

    Diagnostic Evaluation:

    1. X-ray shows enlargement in portion of aorta proximal to stricture,

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    Cardiomegaly & pulmonary oedema

    2.ECG shows evidence of slight left ventricular hypertrophy.

    3.Echo shows visualization of Coarctation site, dilated right ventricle &

    hypoplastic left ventricle.


    1. 1. Death from heart failure.

    2. Renal shutdown(postoperative(y)

    3. Recoarctation

    4. Death

    Medical management:

    Administer digitalis, dopamine, diuretics, and prostaglandin-E

    (in newborn to keep ductus arteriosis open.

    Provide fluids & electrolytes monitoring andrenal monitoring.

    Balloon angioplasty can be used as a primary non-surgical procedure.

    Surgical management:

    Surgical repair of narrowed aortic area and reanastamosis (subclavian

    flap aortoplasty) of the resected area usually occurs with in the first to two

    years of life.

    6). Aortic stenosis

    Narrowing or stricture of the aortic valve causing resistance to

    blood flow in the left ventricle, decreased cardiac output in the left

    ventricular hypertrophy & pulmonary vascular congestion.


    Aortic stenosis is more common in males than females

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    Congenital anomalies

    A stricture in the aortic outflow tract

    Resistance to ejection of blood from the left ventricle

    Hypertrophy of the left ventricle

    Blood backs up in the left atrium

    Increased pressure in the left atrium

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    Increased pressure in the pulmonary veins & pulmonary vascular congestion

    Narrowing of aorta


    Clinical Features:

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    infants with sever defects demonstrate decreased cardiac output with

    faint pulses


    Tachycardia & poor feeding

    Child ren 's show s s igns of exe rcise intolerance

    Chest pain

    Dizziness when standing for long time

    Characteristic murmur


    Coronary insufficiency

    Ventricular dysfunction

    Diagnostic Evaluation:

    1. History collection

    2. Physical examination

    3. Echocardiogram

    4. X-ray (chest x-ray detects dilated ascending aorta & varying degree of

    left ventricular enlargement)

    5. ECG reveals normal or left ventr icular hypertrophy

    6. Echocardiography & Doppler measurement determine peak flow

    velocity & can accurately identify the level of obstruction


    Digoxin (lanoxin)



    Surgical management:

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    Balloon dilatation

    Aortic valvulotomy or aortic valve replacement

    Nursing management:

    Reliving respiratory distress

    Observe the regularity of respiratory pattern for retraction

    Observe for nasal flaring !listen for grunting

    Observe color change , irritability or anxiety

    Raise the head end -

    I. Position the child at a 45degree angle to decrease pressure of the viscera on

    diaphragm to increase lungs volume

    II. Place an infant in seat or prone position

    III. Elevate head of the bed & support arms with pillows

    Feed slowly allowing frequent rest periods.

    Child may require ga.vage feeding

    Observe for abdominal distention which may increase respiratory

    difficulty. If present, insert a feeding tube to achieve it.

    Tilt the infant's or child's back slightly so as to keep the airways


    Suction the nose and throat if the child is unable to cough up

    Secretions adequately

    Provide 02 therapy as indicated

    Administer diuretics as ordered to help to reduce lung congestion.

    Improving cardiac output by avoiding unnecessary activities such

    as Frequent, complete bath and clothing changes.

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    7). Tetralogy of Fallot

    Tetralogy of fallot is the most common type of cyanotic congenital

    heart disease. The common cause of cyanotic congenital heart disease is a

    communication between the pulmonary and systemic circulation through

    which various blood (deoxygenated) enters the systemic circulatory system.

    Tetralogy of faliot is an association of 4 anomalies

    i. Obstruction to right ventricular outflow (or) pulmonary stenosis.

    ii. Ventricular septal defect

    iii. Dextraposition or over riding of aorta.

    iv. Right ventricular hypertrophy

    Pulmonary Stenosis:

    Pulmonary stenosis is an obstructive lesion that interferes with blood

    flow of the right ventricle. It may occurs an single abnormality or it may

    associate with other defects such as those in the atrial or ventricular septal

    defect. It may occur also with patent ductus arteries.


    There are 2 types of pulmonary stenosis on the basis of their anatomical


    1. Valvular stenosis

    2. Infundibular stenosis

    1. Valvular stenosis:

    1 This type of cases occurs in more. The stenoses of the pulmonary valve

    are fined in 90% cases. Beyond this is dome like stenotic valve, the

    space is often enlarged and right ventricular hypertrophies.

    2 Infundibular stenosis

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    2. This is less common in the pulmonary valve is often normal but

    the outflow tract of the right ventricle is narrow converting the

    narrowed region an infundibular channel.


    Due to pulmonary stenosis

    There is an obstruction of blood flow from the right ventricle to pulmonary


    Pressure thus rises in the right ventricle resulting in its hypertrophy

    The pressure in the right ventricle rises so as to become equal or slightly

    more than the left ventricle

    Deoxygenated blood is shunted from the right ventricle through the VSD

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    directly in to aorta (right -to- left shunt) essenmenger syndrome

    Clinical Features:

    A loud pulmonary systolic ejection murmur caused by blood flow through

    the stenotic site can be heard over the pulmonic area

    in severe cases cyanosis will occur

    Cardiac failure can occur

    Poor exercise tolerance with exertional dyspneoa due to insufficient

    blood flow to the lungs to meet the need for increased cardiac output during

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    Palpitation and peripheral cyanosis

    Growth retardation

    Hypertrophy of right ventricles and right atrium due to increased


    The tachycardia and Tachypnea due to increased cardiac work load.


    Clubbing of fingers and toes occur by one to two years of age

    Unconsciousness, convulsion, hemiparesis

    Mental showers

    Diagnostic Evaluation:

    Physical examination:

    Abnormal chest movements cardiac murmurs, tachycardia, tachypnea,


    Indicates the presence of right ventricular hypertrophy with perked 'P'

    wave in case of patients with mild pulmonary stenos's. The ECG is often



    It shows the enlargement of heart with hypertrophy of right ventricle

    and atrium.

    Angiocardiography :

    It helps to determine the severe malformation

    Boot shape or wooden shoe shape heart in x-ray

    Blood test:

    To identify the Polycythemia

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    Cardiac catheterization:

    It shows pulmonary arterial pressure to be normal or low and the right

    ventricular systolic pressure, in severe cases, to be higher than the systemic

    systolic pressure. It also shows decreased oxygenation on the left side of the



    Congestive cardiac failure

    Bacterial endocarditis

    Pulmonary tuberculosis

    Anoxic spells


    I. Palliative procedure:

    1.Water stone Shunt:

    Side to s ide anastomosis of the ascending aorta and right

    pulmonary artery.

    1 . B la lo ck P ro ced ure : Formation of artificial ductus

    Anastomosis of the subclavian artery and pulmonary artery.

    3. Potts Procedure:

    Anastomosis of the upper descending aorta and left pulmonary artery.

    3. Brock Procedure:

    Pulmonary valvotomy this operation only for pulmonic stenosis

    It does not correct the ventricular septal defect

    There is no need for surgery in mild cases Antibiotic therapy against

    bacterial endocarditis is important.

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    Reasonably medication therapy:

    Prostaglandin E showed be administered intravenously. It will help to

    maintain the ductus arteriosis

    Surgical Treatment:

    The indications for surgery are

    1 Signs of congestive cardiac failure

    2 Right ventricular pressure even 75-100 mm/Hg

    3 ECG evidence of right ventricular hypertrophy

    4 Cyanosis

    5 Presence of anomie spells in early life

    6 Pulmonary vulvotomy is most successful. This may be performed

    either by incision of the fined leaflets under direct vision with

    interruption of venous return for the short period of 2-3 unit or by a

    vulvotomy through the right ventricle of a beating heart.


    1 Cardiopulmonary Bypass

    This surgery for young children

    2 Heart lung bypass

    This surgery for older children

    Steps of Surgery:

    Closure of ventricular septa' defect

    Resection of muscle tissue in pulmonary artery

    Improve the pulmonary circulation

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    Non Surgical Treatment:

    Balloon angioplasty

    Post operative management

    Administor iv fluids

    Monitor vital signs every 15 minutes

    Administer antibiotics

    Monitor intake and out put chart

    Administer diuretics

    Eg: Lasix 1-3 mg/kg

    Administer cardiac drugs

    Digoxin 0.35 mg/kg

    8) Transposition of the Great Vessels

    In transposition of great arteries, there are two parallel circulations. The

    systemic venous return passes from the right atrium to right ventricle and then

    into aorta;

    And there is a separate circulation of pulmonary venous blood returning to the

    left atrium via the left ventricle and back into the pulmonary arteries.


    - Males are mostly affected than female.


    Aorta carries deoxygenated blood to the systemic circulation.

    Pulmonary artery carries oxygenated blood back to lungs.

    Can exist to separate blood circulation.

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    Systemic Circulation:

    1. Deoxygenated blood from body organs

    Blood enter into the Right atrium

    Blood enter into the Right ventricle

    Enter into the Aorta [No purification]

    Deoxygenated blood enter in systemic circulation

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    Pulmonary Circulation:

    2. Lungs (oxygenated blood) (pulmonary veins)

    Enter in to the left atrium

    Enter in to the left ventricle

    Enter the pulmonary artery

    Again oxygenated blood goes to lungs.

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    Clinical Features:


    Cyanosis; It may be profound and life threatening

    Physical Signs:


    Clubbing Fingers

    Second heart sound is often closely split or single

    Systolic murmur due to increased flow or stenosis

    Heart size enlarges after 2 weeks of birth of baby

    Congestive heart failure develop shortly after birth

    Normal first sound

    The electro cardiogram shows right axis deviation and right ventricular


    The cardiac silhoaette has an "egg on side" appearance

    Difficulty in feeding

    Diagnostic Evaluation:

    History collection about occurrence of disease

    Physical examination


    Reveal hypoxemia & acidosis

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    Chest x-ray:

    This may reveal the classic findings of a narrow upper mediastinum

    with an "egg on side" appearance of the cardiac shadow.


    This is rarely helpful in establishing the diagnosis as it is usually normal


    This is essential to demonstrate the abnormal arterial connections and

    associated abnormalities.



    Pulmonary vascular obstructive disease

    Residual shunting



    Medical management:

    It consist of control of congestive heart failure

    Since patient may be very hypoxemic, means digoxin should be administered

    Administrations of oxygen by oxygen tent

    The balloon atrial septostomy following confirmation of the diagnosis by

    cardiac catheterization and angiocardiography

    Jatene's switch operation:

    The pulmonary artery and aorta are transected. The distal aorta is

    anastomosed to the proximal pulmonary stump and the pulmonary artery to the

    proximal aortic stump. The coronary arteries are shifted to the aorta.

    Mustard or Senning:

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    The inferior and superior venacave directly connected in to left atrium .

    The pulmonary vein is connected in to right atrium.

    Rashkind Procedure (Ballon Septostomy):

    Catheter contain balloon, and it inserted through catheterization

    Enlarging the foramen ovale by pulling a balloon. To increase the mixing of


    Blalock Procedure:

    Anastomosis of subclavian artery and pulmonary artery.

    Nursing management:

    Assess the condition of child

    Check the vital signs

    Assess for any complication

    The child must be carefully followed because of possible complications

    of atrial arrhythmias due to injury to the conduction system and

    recurrence of cyanosis

    Assess the child for any infections

    Administer oxygen to the patient

    Provide good position

    Monitor cardiac functioning (vital signs ECG, resp iratory effort s,

    skin colour and temperature

    Be alert for signs indicating potential complications.

    Health Education:

    Ass ess f ami ly a nd chi ld' s l eve l o f understanding

    Instruct the parents in feeding techniques to minimize fatigue

    Teach parents signs and symptoms for which to be alert.

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    Rheumatic Heart Disease:

    Rheumatic heart disease was formerly one of the most serious forms

    of heart disease of childhood and adolescence. Rheumatic heart disease

    involves damage to the entire heart and its membranes.

    Rheumatic heart disease is a complication of rheumatic fever and

    usually occurs after attacks of rheumatic fever. The incidence of rheumatic

    heart disease has been greatly reduced by widespread use of antibiotics

    effective against the streptococcal bacterium that causes rheumatic


    Causes Rheumatic Heart Disease

    Rheumatic fever causes rheumatic heart disease. Rheumatic fever

    results from an untreated strep throat. Rheumatic fever can damage the

    heart valves. If the heart valves are damaged, they will fail to open and

    close properly. When this damage is permanent, the condition is called

    rheumatic heart disease.

    Risk for Rheumatic Fever

    Rheumatic fever is uncommon in the United States. However,

    rheumatic fever can occur in children who have had strepc, , infections that

    were untreated or inadequately treated.

    Symptoms of Rheumatic Heart Disease

    Some of the most common symptoms of rheumatic heart disease are:

    breathlessness, fatigue, palpitations, chest pain, and fainting attacks.

    Treatment options for Rheumatic Heart Disease

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    Treatment of rheumatic heart disease may include medication and

    surgery. Medication will aim to avoid overexertion. Surgery may be

    needed to replace the damaged valve(s).

    Prevention of Rheumatic Heart Disease

    The best way to prevent rheumatic heart disease is to seek

    immediate medical attention to a strep throat and not let it progress to

    rheumatic fever.

    Acute Rheumatic Fever (ARF)

    Acute rheumatic fever is an autoimmune disease (acquired heart

    disease). It occurs as hyper sensitivity reaction to group-A beta hemolytic

    streptococcal infection. It is affected in connective and endothelial tissues of

    heart, joint, blood vessels and other tissues,


    Rheumatic fever is commonly affected school age children in between 5 to

    15 years of children:

    The school age children are affected in this disease through genetic,

    climate, winter and early spring, unhygienic, overcrowding (class room,

    family) poor nutritional status.The adole scen ts affec ted throu gh

    streptococcal infection.

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    School age child (between 5-15 Yrs)

    O r

    Early adolescents

    Streptococcal pharyngitis(Group-A beta hemolytic streptococci)

    Auto immune reaction to the organism

    Acute systemic inflammatory disease

    (Rheumatic fever)

    Antibiotic therapy





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    Inflammatory Hemorrhagic Bullous lesions in any layers of the heart (Aschoffs


    Fibrous or Serofibrous



    Proneness to Rheumatic fever

    Inflammation of synovial membrane of knees, ankles, wrists, elbows

    Edema, effusion heart pain


    Involvement of endo cardium and valves

    Vegetative lesions on the valves leaflet (mitral and aortic


    Muscular rash on trunk, extremities, sebaceous on feet, hands, scalp, elbows


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    Long term


    Fibrous scar tissue of valve

    Contraction and deformity of the valve

    Leaflets shortening of the chorde

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    Tendineae fusing of leaflets while healing

    Chronic valvular defect in the heart

    Clinical Features:

    1, Major Manifestation:

    Limited range of motion

    Extreme tenderness, swelling and redness.


    First 1-2 weeks Febrile period

    After few days affected joints, it may transmit to other joints.

    2. Carditis:

    Signs of carditis

    Congestive heart failure Increased work load

    Cardiomegaly Pericardial pain present

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    Pericarditis Muffled heart sound present

    Fever especially during sleep and have more pulse(tachycardia)

    Presence of significant murmur sound and pre existing murmurs.

    Muffled heart sound caused by pericardial effusion.

    Pre diastolic gallop

    Pericardial friction or rub Chorea (sydenhams chorea)

    Children have neurological manifestation of rheumatic fever have. Muscular weakness

    Facial grimaces.

    Emotional rabiality

    Speech disturbance


    Behavioral problem Anxiety

    Erythema Marginatum:

    Colour change (pink muscle) s Rash without itching

    Lesions present on trunk and extremities

    The lesions an appear with through heat and transmit one place to

    another place.

    Subcutaneous Nodules:

    A Who had frequently in painless nodules (0.5cm to lcm) and without

    tenderness On such a place elbows, knuckles, knees, joint ankles and


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    Minor Manifestation:

    Low grade fever to high fever in afternoon rarefy it goes above 39.5C

    Scarlet fever




    Weight loss

    Epistaxis (unknown causes)

    Abdominal pain

    Some times had appendicitis

    Sore throat


    Pericardial pain

    Headache, malaise, sweating.

    Vomiting, skin rash, anemia.

    Pleuritis (etc).

    Diagnostic Evaluation:

    1. History taking from parents and childespecially for environmental factors

    and streptococcal infection

    2) Blood Test:

    1. ASO titer (antistreptolysin)-increased (normal value 200 1V/ml

    2. ESR (erythrocyte sedimentation rate)

    3. WBC counts (leucocYtes)

    4. CRP (C-reactive protein)

    5. Throat culture

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    3) Radiology (x-ray)-Cardiomegaly

    4) Electrocardiogram-Cardiomegaly

    5) Echocardiogram-Cardiomegaiy

    6) Serological Test:

    1. Antideoxyribonuclease B test

    2. Antinicotinamide-adenine -Dinucleotidase test

    3. Now a day's streptozyme agglutination test was used to deduct

    streptococcal infection.

    7) Examination through inspection, palpation percussion and auscultation to

    find out any abnormalities in the body (Nodules,Cardiomegaly


    8) Endomyocardial biopsy to show in a scoffs nodules.


    Permanent cardiac damage to valve.



    1. To provide bed rest and sleep. It helps to disappear of rheumatic fever

    with in 6-8 weeks.

    2. Nutrition diet to be providing protein, vitamins and micronutrients.

    3. Avoid rich spicy food.

    4. Those who are having CCF to avoid salt, otherwise no need of restriction.

    Pharmacological Treatment Antibiotic Therapy:

    1. Penicillin:

    - To control streptococcal infection

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    2. Procaine penicillin:

    - 4 lack deep IM-deep, 10 to 14 days.

    3. Long-acting (Benzedrine penicillin):

    - 1.2 mega unit


    0.6 mega unit every 15 days for IM

    4. Oral penicillin:

    - 4 lack units every 6 hours for 10 to 14 days

    5. Erythromycin:

    - Used in penicillin sensitive patients.

    6. aspirin:

    90 to 120mg/kg/day divided dose To control pain and inflammation -

    Duration 12 weeks needed.

    - Dose may be changed according to the patient.

    7. Antacid:

    - Aspirin should not take alone because it leads to pepticuler.

    8. Steroid therapy:

    It is suppressive therapy along with aspirin.

    - Prednisolone 40 to 60mg/day 2mg/kg/day in 4 divided dose for 7 to

    10 days

    9.Diazepam (or) phenoborbitone: - To treat chorea

    9.Symptomatic treatment:

    To be provided for other complication of rheumatic fever.

    Nursing Management

    1.Good nursing care and emotional support to be provided for parents, child,

    care givers.

    2.Nurse should explain about importance of medication and disease condition

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    of the child.

    3.Nurse should maintain vital signs (TPR).

    4. Nurse should maintain cardiac monitoring (ECG< heart sound).

    5.Nurse should assess the level of pain

    Nursing diagnosis Nursing intervention

    1 Pain related to

    disease Condition


    1 Assess the condition of the child

    2 Assess the level of pain and characters of


    3 Provide comfortable position, rest and


    4 Provide hot application (big joints) cold

    application for (serial' joints)

    5 Provide psychological support to the parentsand Children.

    6 Divertidnal therapy (provide music, provide play


    7 Administer, anti inflarnmatwy, analgesics as per

    doctors order. (DiclOtinac sodium), (assess the

    aspirin toxicity)

    2 Decreased cardiac

    output related to


    Providing rest and less activities

    Provide indoor activity (rnifaaseS)

    Providing the balanced diet with adequate


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    Maintain intake and out put chart

    Maintain cardiac function

    Salt restriction in case of CCF

    Administer medication as doctor's order

    Kawasaki Disease (or)Mucocutaneous Lymph Node Syndrome

    It is an acute inflammatory disorder




    It involves many systems, mostly affected in cardiac system

    80% of the cases are seen in children under 4 years of age with a slightly

    higher male do min ance .

    Clinical Features:

    The following criteria are required for the diagnosis:

    1 Fever: More than 5 days is present, it is not responsive to antibiotic

    2 Mucous membrane involvement: Cracked, erythematous, fissured lips

    and a "strawberry tongue," oropharyngeal reddening.

    3 Non purulent conjunctivitis: Bilateral inflammation without exudates.

    4 Polymorphous rash: Typically involves trunk and extremities5 Lymphadenopathy

    6 Digital swelling and desquamation

    Peripheral edema, erythema of the palms and soles with desquamation of the

    hands and feet.

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    Diagnostic Evaluation:

    1 1, Blood investigation which are WBC, ESR, CRP, Platelet count will

    be elevated.

    2 Sterile pyuria and anemia may also occur.

    3 ECG also shows prolonged P-R interval

    4 Echocardiography may show pericardial effusion and is diagnosis

    for identifying coronary artery, aneurysms (or) dilatation.


    Coronary artery aneurysm

    Myocardial infarction

    Aspirin toxicity

    Allergic reaction to the gamma globulin A death

    Medical Management:

    Salycilate therapy and intravenous gamma globulin (NIG):

    Anticoagulation therapy for children for with large aneurysms.

    ECGs and echocardiograms to monitor coronary abnormalities


    Congestive Heart Failure:

    A congestive heart failure occurs when the heart is unable to pump out

    adequate amount of blood to meet the need of the metabolic demands of the

    body this leads to an accumulation of excessive blood volume in the

    pulmonary and systemic venous system.

    Congestive heart disease is the most common cause of congestive heart

    failure in infants and children.

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    It is usually occurs with in the first few months to 1 year after birth.

    Time of Onset of Congestive Failure in Congenital Lesions:

    Age Lesions

    Birth to 72 hours


    Pulmonary mitrul and aortic atresias hypo

    plastic left and right heart syndrome

    transposition and malposition of great artories

    1 to 4 weeks EndocEtraidal fibroelastosis Coarctation of the


    1-2 months E n d o c a r d i a c u s t o m d e f e c t s , V S D

    P D A , p u l m o n a r y

    2 to 6 months Transposition and malposition complex VSD,

    PDA, pulmonary venous connection, aortic

    steriosis, coarctation of the aorta.



    1 Congenital heart disease

    2 Carditis and primary myocardial disease

    3 Paroxysmal tachycardia

    4 Anemia

    5 Other causes

    a) Infection

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    b) Upper respiratory obstruction

    c) Hypoglycemia

    d) Hypocalcernia

    e) Neonatal asphxia

    f) Persistent fetal circulation


    1 Large VSD, PDA

    2 Supraventricular tachycardia

    3 A malformation

    4 Metabolic car& myopathy

    5 Acute hypertension

    6 Anomaly origin of left coronary artery

    7 Myocarditis

    8 Rheumatic carditis

    9 Infective endocarditis

    Congestive heart failure

    Sympathetic nervous system

    Stimulation of cholinergic fibers

    Sweating Especially on scalp

    Increase rate and force of contraction


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    Increased blood volume

    Increase vascular tone vasoconstriction

    Increased venous return

    Increased pulmonary Vascular resistance

    Increased systemic Vascular resistance

    Increases after load

    Decreased blood flow to limbs

    Decreased blood flow to kidneys

    Production of renin, aldostoerone and ADL

    Na and H20 retention


    Systemic and pulmonary

    venous engorgement


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    Clinical features Pulmonary congestion Systemic venous congestion

    1 Tachycardia 1 tachypnea 1 weight gains

    2 Sweating(in appropriate) 2 Dyspnea 2 Hepatomegaly

    3 Decreased Urine Output 3 Retractions (infants) 3 peripheral edema

    4 Fatigue 4 Flaring rares 4 Ascites and depended


    5 Weakness 5 Exercise intolerance 5 neck vein distention


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    remove the accumulated fluid and sodium

    Oxygenation of the tissue is improved by supplying moist oxygen and

    by reducing oxygen demands

    Sedatives may be prescribed for irritable children.


    Assessment of the patients condition must be done, especially the heart

    rate and respiration, temperature and electrocardiograph

    Digitals should be administered according to doctor's prescription.

    Digitalis help to improve the cardiac activity.

    The early sign of toxicity such as arrhythmia, vomiting slow pulse

    should be observed

    Rest is essential to conserve energy

    Nursing care should be organized to prevent unnecessary disturbance

    Improving cardiac efficiency or the contractile force of the heart.

    Removing accumulated fluid and sodium from the body

    Improving oxygenation of the blood and tissue

    Reducing the work load of the heart by reducing energy


    Supporting and educating the parents before discharging of child from


    Common nurs ing d iagnoses & intervention of cardiac system:

    Nursing diagnoses for AcyanotIc heart defects:

    1. Fluid volume excess related to pulmonary vasculature overload.

    2. Decreased cardiac output related to an obstructed out flow tract

    3. Ineffective breathing pattern related to pulmonary vasculature


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    4. lmbalanced nutritional status less then the body requirements

    related to ineffective feeding pattern.

    5. Ineffective infant feeding pattern related to shortness of breath and


    6. Risk for infection related to impaired immune function, surgery.

    7. Risk for activity intolerance related to chronic pulmonary vasculature


    8. Impaired family processes related to guilt & grieving over lack of

    perfect infant.

    9. Risk for caregiver role strain related to child with chronic health


    10. Knowledge deficit (parents) related to special care for chronic


    Nursing diagnoses for cyanotic heart disease:

    1. Impaired tissue perfusion related to reduced pulmonary blood flow.

    2. Decreased cardiac output related to development of congestive heart


    3. Risk for infection related to unfiltered bacteria in the blood.

    4. Impaired nutritional status less then body requirement related to dyspnea

    & fatigue with feeding.

    5. Risk for caregiver role strain related to care of a child with chronic


    6. Activity intolerance related to cyanosis dyspnea on exertion.

    7. Impaired growth & development related to hypoxemia.

    8. Risk for ineffective management of therapeutic regimen related to

    prophylactic antibiotics for dental care procedures

    9. Knowledge deficit (parents) related to assessments & management of

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    cyanotic spells, which are unpredictable events.

    Nursing intervent ions of cyanot ic & Acyanotic heart defects

    Organize nursing care to provide periods of uninterrupted rest

    Avoid temperature excess.

    Prevent excessive crying

    1. Anticipate needs

    2. Hold the infant

    3. Feed when hungry

    4. Keep the infant comfortable

    Maintain intake and output chart

    Monitor urinary output and laboratory values for evidence of over


    Check vital signs regularly

    Regulate parenteral fluids closely to avoid over hydration

    Assess for blood pressure, edema, and weight. mucous membranes

    electrolytes fontanel.

    Administer cardiac support medication as ordered

    1. Digoxin (lanoxin)

    Check heart rate for one full minute before dose

    Don't give with meals; in case of vomiting do not repeat the dose.

    Monitor serum drug level and serum electrolyte.

    Observe regularity of the respiratory pattern. Observe nasal flaring, listen

    the grunting

    Raise the head end: position the child at a 45 angle to decrease

    pressure of the viscera on the diaphragm and increase lung volume feed

    slowly allowing frequent rest periods.

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    Provide oxygen therapy as indicated.

    Suction the nose and throat if the bhild is unable to cough up secretion


    Administer diuretics as order to reduce lung congestion.

    Feed slowly in a semi erect position; burp infant af te r each ounce

    to de cr ea se compression of stomach on heart and. lungs.

    Provide small, frequent feeding, provide easy to chew and digest.

    Provide foods that have high nutritional value

    a) Add needed calories for healing to promote maximal growth.

    b) Provide foods high in iron and potassium levels if needed.

    Determine the Child likes and dislikes and plan the meals with the


    Maintain ordered low sodium or fluids restriction in children with


    Prevent exposure to communicable disease.

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