Chapter 27

Christine Limann Dyer, RN, MSN CPN

Umbilical vein, umbilical arteries

Foramen ovale Ductus

arteriosus Ductus venosus

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Poor feeding Tachypnea/tachycardia Failure to thrive/poor weight

gain/activity intolerance Developmental delays Prenatal history Family history of cardiac disease

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Murmurs = heart sounds that reflect flow of blood within the heartMay occur in systole or diastole, or bothCan occur in a normal heart in periods of

stress: anemia, fever, or rapid growthCan reflect abnormalities in heart or vessels

“Innocent murmurs” = normal cardiac anatomy and cardiac functionOccur in up to 50% of all kids at some time

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http://depts.washington.edu/physdx/heart/demo.html

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Chest x-ray ECG Echocardiography Cardiac

catheterizationNursing

Responsibilities Post Catheterization: Monitor -

pressure dressing in the groin, heart rate, respirations & blood pressure

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Signs & Symptoms: Inadequate cardiac output

Nursing Care:Artificial shunt or pathway created shortly after

birth Prostaglandin (PGE1) givenNumerous surgical repairs (cardiac transplant)Palliative care measures

Transposition of great vessels

Some complex single-ventricle defects

ASD Pulmonary

artery stenosis

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DIAGNOSISDIAGNOSIS INTERVENTIONINTERVENTION

Valvular pulmonic stenosisValvular pulmonic stenosis Balloon dilationBalloon dilation

Recurrent coarctation of aortaRecurrent coarctation of aorta Balloon dilationBalloon dilation

Congenital mitral stenosisCongenital mitral stenosis Balloon dilationBalloon dilation

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CongenitalAnatomic → abnormal function

AcquiredDisease process

Infection Autoimmune response Environmental factors Familial tendencies

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Maternal or environmental = 1% to 2%Maternal drug use

Fetal alcohol syndrome—50% have CHDMaternal illness

Rubella in first 7 weeks of pregnancy → 50% risk of defects including PDA and pulmonary branch stenosis

CMV, toxoplasmosis, other viral illnesses → cardiac defects

IDMs (infant of diabetic mother) = 10% risk of CHD (VSD, cardiomyopathy, TGA most common)

Chromosomal/genetic = 10% to 12% Multifactorial = 85%

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Incidence: 5 to 8 per 1000 live births About 2 or 3 of these are symptomatic in

first year of lifeMajor cause of death in first year of life

(after prematurity)Most common anomaly is VSD28% of kids with CHD have another

recognized anomaly (trisomy 21, 13, 18, + + + )

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AcyanoticMay become

cyanotic Cyanotic

May be pinkMay develop CHF

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Hemodynamic characteristics Increased pulmonary blood flowDecreased pulmonary blood flowObstruction of blood flow out of the heartMixed blood flow

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Abnormal connection between two sides of heartEither the septum or the great vessels

Increased blood volume on right side of heart

Increased pulmonary blood flow Decreased systemic blood flow

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Atrial septal defect Ventricular septal defect Patent ductus arteriosus

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Coarctation of the aorta Aortic stenosis Pulmonic stenosis

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Tetralogy of Fallot(T.O.F.) Tricuspid atresia

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Place in thisPosition

During Tet spell

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Transposition of great vessels Total anomalous pulmonary venous

connection Hypoplastic heart syndrome

RightLeft

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Impaired myocardial functionTachycardia; fatigue; weakness; restless,

pale, cool extremities; decreased BP; decreased urine output

Pulmonary congestion Tachypnea, dyspnea, respiratory

distress, exercise intolerance, cyanosis Systemic venous congestion

Peripheral and periorbital edema, weight gain, ascites, hepatomegaly, neck vein distention

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Signs & Symptoms: Vary with age fluid congestionPoor feeding & growth, irritability, shortness of

breath, excessive sweating Nursing Care:

Positive inotropes (digoxin), diuretics (furosemide), vasodilators (captopril)

Fluid restriction not often used (only in the worst cases)

Help family adjust to the disorder

Educate family Help family cope

with effects of the disorder

Prepare child and family for surgery

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Open heart Closed heart

procedures Staged

procedures Prepare child

and family for procedures

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Monitor vital signs and A/V pressures

Intra-arterial monitoring of BP

Intracardiac monitoring Respiratory needs Rest, comfort, and pain

management Fluid management Progression of activity

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CHF Dysrhythmias Decreased cardiac output syndrome Decreased peripheral perfusion Pulmonary changes Neurologic changes

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Symptoms: fever, WBCs, pericardial friction rub, pericardial and pleural effusion

Occurs in immediate postoperative period Also can occur later (days 7 to 21 postop) Etiology unknown Theories of etiology

Viral infection, autoimmune response, reaction to blood in pericardium

May require pericardiocentesis or pleurocentesis

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Infectious and inflammatory cardiac disorders

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BE, IE, or SBE Streptococci Staphylococci Fungal infections Prophylaxis: 1

hour before procedures (IV) or may use PO in some cases

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RF Inflammatory disease occurs after

group A β-hemolytic streptococcal pharyngitis

Infrequently seen in U.S.; big problem in Third World

Self-limiting Affects joints, skin, brain, serous surfaces,

and heart Carditis Polyarthritis Erythema marginatum Subcutaneous nodules

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St. Vitus dance (aka, chorea) reflects CNS involvement

Definition: Chorea refers to sudden, aimless movements of extremities, involuntary facial grimaces, speech disturbances, emotional lability and muscle weaknessWorse with anxiety and

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http://www.youtube.com/watch?v=RnxqqW_nH0k

Treatment of streptococcal tonsillitis/pharyngitis Penicillin G—IM x 1Penicillin V—oral x 10 daysSulfa—oral x 10 daysErythromycin (if allergic to above)—oral x

10 days Treatment of recurrent RF

Same as above

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IV IgG ASA 80-100

mg/kg/day—fever

Then 3-5 mg/kg/day—antiplatelet

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Primary = no known cause Secondary = identifiable cause Pediatrics: HTN generally secondary to

structural abnormality or underlying pathologyRenal diseaseCV diseaseEndocrine or neurologic disorders

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Identify kids at risk and treat early Treatment = dietary

Restrict intake of cholesterol and fats If no response to diet → Rx

Colestipol (Colestid)Cholestyramine (Questran)

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Contractibility of myocardium is impaired

Secondary cardiomyopathy

Dilated cardiomyopathy

Hypertrophic cardiomyopathy

Restrictive cardiomyopathy

Treatment Correct underlying

cause if possible Often treatment is

aimed at managing CHF and dysrhythmias

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Digoxin Diuretics Beta blockers, calcium channel blockers Dobutamine Nitroprusside Amrinone

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IV IgG Digoxin (Lanoxin) ACE inhibitors ASA, NSAIDs Lasix Spironolactone (Aldactone)

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Diagnostic evaluationECGHolter monitoringElectrophysiologic cardiac catheterTransesophageal recording

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Signs & Symptoms: SOB, chest pain, weakness, fatigue, dizziness, leg swelling &

fainting episodes

Nursing Care: Prostacyclin (Flolan) dilates blood vessels & decreases

pulmonary vascular resistance Inhaled nitric oxide relaxes pulmonary (not systemic) vessels Sildenafil (Revatio) decreases pulmonary artery pressures Bosentan (Tracleer) blocks hormone that causes vasoconstriction

Signs & Symptoms: A fainting spells (may experience a seizure)

Nursing Care: Increase sodium & water intakeFludrocortisione (Florinef)Beta-blockerMonitor (frequency, severity & precipitating

factors)

Signs & Symptoms: fainting, palpitations, seizure or death

Nursing Care:Beta-blockersPacemaker-defibrillator insertionLeft cardiac sympathetic denervationMedication compliance

The nurse who can determine the baseline rhythm and recognize changes will facilitate the best outcome for a child with an arrhythmia

Important questions: Is the rhythm potentially fatal?Will it alter the cardiac output?

BradydysrhythmiasAV blockMay use pacemaker

TachydysrhythmiasSVT most common tachydysrhythmiaTreatments

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Orthotopic transplant Heterotopic transplant

(piggyback) Organ donation issues Nursing considerations

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