Pediatric Cardiovascular Disorders

Presented by

Christina Hernandez RN, MSN

Fetal Circulation

Fetal Cardiac Circulation

↑pulmonary resistance forces blood into descending aorta

Umbilical vein→ liver→ ductus venosus→ inferior vena cava→ right atrium → foramen ovale (bypass lungs for oxygenation) → left atrium → left ventricle → aorta → body

Secondary Fetal Circulation

Right atrium → right ventricle → pulmonary artery → ductus arteriosus → aorta →body

Why does the blood flow this direction?

What would cause blood to circulate via a third route?

Changes in Circulation

What is the stimulus for circulatory changes in the newborn? Clamping of the umbilical cord

Systemic vascular resistance Increased blood pressure in the left side of

heart → closure of the foramen ovale Ductus arteriosis constricts and closes as a

result of higher O2 saturation levels

Critical thinking:

When are most cardiac anomalies discovered?

What is included in the initial cardiac assessment of a newborn?

Why?

Assessment

History

Physical

Diagnostic

Why is it important for the nurse to know the normal value for O2 saturation?

Children respond to severe hypoxemia with BRADYCARDIA

Cardiac arrest in children generally r/t prolonged hypoxemia

Hypoxemia is r/t to respiratory failure or shock

BRADYCARDIA is a significant warning sign of cardiac arrest

At what O2 saturation does cyanosis occur?

Peripheral cyanosis occurs at <= 80% Brain damage occurs <= 85%

Hypoxic Level Oxygen Saturation

Mild hypoxia 90-95%Moderate 85-90%

Severe <85%

What nursing interventions should the nurse initiate for hypoxia?

Bradycardia – stimulate patient Shortness of breath

PositioningIncentive spirometry (what works

with children?)Supplemental oxygen (when does

the nurse need an order for this?)

Congestive Heart Failure

CHF in Children:

Development- preload and after-load (overload right side of heart causing backflow) leads to…

Cardiac hypertrophy leads to… One-sided cardiac failure→ bilateral failure Compensatory mechanisms

Renal response Systemic response

Early Clinical Manifestations of CHF

Infants- tires easily (during

what activity?) Weight loss or lack of

normal weight gain Diaphoresis Irritability Frequent infections Peri-orbital edema

Children Exercise intolerance Dyspnea Abdominal pain or

distention Peripheral edema

CHF in Children

Cause Clinical Manifestation

Pulmonary venous congestion Tachypnea, wheezing, crackles, retractions, cough, grunting, nasal flaring, feeding difficulties, irritability, tiring with play

Systemic venous congestion Hepatomegaly, ascities, peripheral edema

Impaired Cardiac output Tachycardia, diminished pulses, hypotension, capillary refill time >2 seconds, pallor, cool extremities, oliguria

High metabolic rate Failure to thrive or slow weight gain

Goal of Treatment:

Improve cardiac function

Remove accumulated fluid and Na+

Decrease cardiac demands

Decrease O2 consumption

Nursing Care for CHF

Strict I&O (weight diapers)Weigh child daily (what is significant

change? 1 lb/day)Monitor VSCardiac medications for children

Cardiac glycosides (Digoxin) Ace inhibitors (Capoten-Captoril®, Vasotec®) Diuretics (Furosemide- Lasix®)

Medications to treat CHF in Children:

Medication Action Nursing Intervention

Cardiac glycosides (Digoxin)

Increase myocardial contractility- improve systemic circulation

Monitor pulse- when do you hold this medication? What safety check? Strict I&OWeigh child dailyObserve for edemaSerial abdominal girthprotect skinDigoxin levels (toxicity)Hepatic functionCreatinine clearanceSerum Elecrolytes

Digoxin specific nursing interventions

Hold for pulse Infant < 100 Child < 80 Adolescent <60

Verify dose with two nurses Strict I&O (1gram=1ml) Skin care Monitor for digoxin toxicity

Digoxin Toxicity >2ng/ml

Cardiac dysrrhythmia **first sign in children Bradycardia Anorexia Nausea and vomiting, Dizziness, Weakness Notify healthcare provider if creatinine

clearance of 50ml/min or less. Monitor serum electrolytes: K+, Ca and Mg

Medications to treat CHF cont…

Medication Action Nursing Intervention

ACE inhibitors Capoten (Captoril) Vasotec

Inhibits conversion of angiotension I to II results in vasodilatation

Promote rest, maintain oxygen therapy, and evaluate oxygen saturation (what is greatest risk?)

Medications to treat CHF cont…Medication Action Nursing Interventions

Diuretics- Furosemide (Lasix®)

Chlorothiazida (Diuril®)

Spironolactone (Aldactone)

Rapid diuresis Give IM or IV

K+ level prior to administerMonitor electrolytes, weigh daily, strict I&O

Observe for changes in peripheral edema or circulationSerial abdominal girthSkin care- turning schedule

Quick Quiz:

What is the pulse rate criteria for administering digoxin to: Infants- Child- Teenager/ adolescent-

What are signs of digoxin toxicity? Why are K+ levels important with digoxin?

Nursing care to decrease cardiac demands: Provide for rest Semi-Fowler’s Monitor O2 (supplement) Small frequent meals Turn q 2 hrs and provide skin care Encourage parents/guardians to stay with

child Restrict visitors (why?)

Cardiac Catheterization

Cardiac Catheterization

Measures oxygen saturation and pressures in cardiac chambers and great arteries

Evaluate cardiac outputAngiography-images of structures and blood flow patternsElectrophysiologic studiesCorrective or palliative interventions:

Pulmonary artery or valve and aortic valve balloon angioplasty

Stent placementBalloon/blade septostomy Device closure of septal defects

Critical thinking:

Why is it important for the nurse to assess pedal pulses prior to cardiac catheterization?

Interventions for immediate post-cardiac catheterization? Vital signs- which measurements receive highest

priority?ExtremitiesActivityHydration (prevent thrombus formation)Medications (what meds are not allowed?)Comfort

Post Cardiac Catheterization

What teaching should the nurse include for home care after cardiac catheterization?

Watch for signs of complications: infective endocarditisBleeding/bruisingChanges in circulation on cath side

Post Cardiac Catheterization

When should the parents/caregiver notify the primary healthcare provider?

Congenital Heart Disease

Congenital Cardiac Defects

Increase Pulmonary Blood Flow Patent Ductus Arterious Atrial Septal Defect Ventricular Septal defect

Increased blood flow to the lungs causes increased pulmonary resistance (constriction of the pulmonary vascular bed)→pulmonary artery hypertension with right ventricular hypertrophy

Hypoxia results

Decrease Pulmonary Blood Flow Pulmonic stenosis Tetralogy of Fallot Tricuspi atresia Transposition of the great arteries Truncus arteriosus

May have right to left shunting. Little or no blood reaching the lungs to get oxygenated. Bone marrow stimulated to produce more RBC’s increase in oxygen. Polycythemia increases risk for thromboembolism. Platelet impaired. Hypoxic events with brain abscesses common.

Classifying congenital heart defects

By defects that increase pulmonary blood flow Patent ductus arteriosus Atrial septal defect Ventricular septal defect

By defects that decrease blood flow and mixed defects Pulmonic stenosis Tetralogy of Fallot Tricuspid atresia Transposition of the great arteries Truncus arteriosus

What is most common indication of a congenital heart defect?

Left to Right Shunting

Atrial Septal Defects

Ventricular Septal Defects

Patent Ductus Arterious

Atrial Septal Defect

1. Oxygenated blood is shunted from left to right side of the heart via defect

2. A larger volume of blood than normal must be handled by the right side of the heart hypertrophy

3. Extra blood then passes through the pulmonary artery into the lungs, causing higher pressure than normal in the blood vessels in the lungs congestive heart failure

Treatment for ASD

Medical Management Medications – digoxin

Cardiac Catheterizaton - Amplatzer septal occluder

Open-heart Surgery

TreatmentDevice Closure – Amplatzer septal occluder

During cardiac catheterization the occluder is placed in the defect

Ventricular Septal Defect

1. Oxygenated blood is shunted from left to right side of the heart via defect

2. A larger volume of blood than normal must be handled by the right side of the heart hypertrophy

3. Extra blood then passes through the pulmonary artery into the lungs, causing higher pressure than normal in the blood vessels in the lungs congestive heart failure

Treatment of VSD

Surgical repair with a patch inserted

Patent Ductus Arteriosus

Failure of the fetal ductus arteriosus to close after birth

1. Blood shunts from aorta (left) to the pulmonary artery (right)

2. Returns to the lungs causing increase pressure in the lung

3. Congestive heart failure

Medical Treatment for PDA

Indomethacin- Inhibits prostaglandinsPromotes closure of the ductus

arteriosus

Surgical Treatment for PDA

•Surgical – Ligate the Ductus Arteriosus

•Cardiac Catheterization - Insert coil – tiny fibers occlude the ductus arteriosus when a thrombus forms in the mass of fabric and wire

Nursing Care:

Pre-op Patient/parent teaching Assess for infection

Obtain lab values for chart Post-op

ABCs Rest Hydration/nutrition Prevent complications Discharge teaching

Obstructive or Stenotic Defects

Obstructive or Stenotic Defects

Pulmonic StenosisAortic StenosisCoarctation of the Aorta

Pulmonic Stenosis

Narrowing of entrance that

decreases blood flow

Treatment: Medications – Prostaglandin

E 1 to keep the PDA open Cardiac Catheterization

Baloon Valvuloplasty Surgery

Valvotomy

Aortic Stenosis/Coarctation of the Aorta1. Narrowing of Aorta causing obstruction

of left ventricular blood flow

2. Left ventricular hypertrophy

Signs and Symptoms

B/P in upper extremities

B/P in lower extremities

Radial pulses full/bounding and femoral or popliteal pulses weak or absent

Leg pains, fatigue

Nose bleeds

Treatment for Aortic Stenosis

Goals of management are to improve ventricular function and restore blood flow to the lower body.

Medical management with Medication A continuous

intravenous medication, prostaglandin (PGE-1), is used to open the ductus arteriosus (and maintain it in an open state) allowing blood flow to areas beyond the coarctation.

Baloon Valvoplasty

Cyanotic Disorders

Cyanotic Lesions with Decreased Pulmonary FlowTetralogy of Fallot

Signs and Symptoms

1. Failure to thrive

2. Squatting

3. Lack of energy

4. Infections

5. Polycythemia

6. Clubbing of fingers

7. Cerebral absess

8. Cardiomegaly

Nursing Care:

DehydrationCriteria for surgery

Rule of 10’s10 lbsHemaglobin 10 or greater10 hours/days/months

Treatment of Tetralogy of Fallot

Surgical interventions Blalock – Taussig or Potts procedure –

increases blood flow to the lungs. Open heart surgery

Ask Yourself ?

Laboratory analysis on a child with Tetralogy of Fallot indicates a high RBC count. The polycythemia is a compensatory mechanism for:

a. Tissue oxygen need

b. Low iron level

C. Low blood pressure

d. Cardiomegaly

Cyanotic Lesions with Increased Pulmonary Blood Flow Truncus arteriosus

Hypoplastic left heart

Transposition of the great arteries

Truncus Arteriosus

A single arterial trunk arises from both ventricles that supplies the systemic, pulmonary, and coronary circulations. A vsd and a single, defective, valve also exist.

Entire systemic circulation supplied from common trunk.

Hypoplastic heart

May have various left-sided defects, including coarctation of the aorta, aortic valve & mitral valve stenosis or artresia

Transposition of the great arteries

Aorta arises from the right ventricle, and the pulmonary artery arises from the left ventricle –

not compatible with survival unless there is a large defect present in ventricular or atrial

Nursing Diagnosis & Goals:

DX: Alteration in cardiac output: decrease R/T heart malformation

Goal: Child will maintain adequate cardiac output AEB:

Review of Nursing Care:

Increased pulmonary blood flow- S&S-Infants: tachypnea, cyanosis,

retractions, fatigue, poor feeding, weight loss, fluid/electrolyte imbalance Older children: exertional dyspnea, chest pain, syncope

Nursing Care- promote rest or oxygen conservation, monitor I & O, administer oxygen, administer medications, provide parents needed support and information about the care of the child

Review of Nursing Care cont…

Decrease blood flow and mixed defects-

Signs & Symptoms Infants: Cyanosis, dyspnea, loud murmur, skin

ruddy or mottled, cyanosis that does not respond to oxygen, stopping during feeding (to breath) diaphoresis, poor weight gain (FTT)

Children: chronic- fatigue, clubbing of fingers and toes, dyspnea on excertion, delayed developmental milestones, hypercyanotic episodes, increased pulse and resp. rate, cyanosis Toddlers squat to relieve dyspnea

Review of Nursing Care cont…

Decrease blood flow and mixed defects-

Signs & Symptoms cont… Older children- syncope, transient loss of

consciousness & muscle tone, exercise induced dizziness (what does the nurse need to teach with regards to these S&S?)

Review of Nursing Care cont: Decreased flow or mixed defects Surgical correction of defect if life threateningAdminister prostaglandin E1 (PGE1) to re-open the ductus

arteriosus and improve pulmonary or systemic blood flowMonitor Hct & Hbg (what happens with increased blood

viscosity?)Keep child calm (morphine, propranolol IV) Administer RBC’s

to assist with O2 Position in knee chestSupplemental O2 therapyIV fluidsDopamine or phenylephrine (Neo-Synephrine)Small frequent meals

Defects Obstructing Systemic Blood Flow Aortic stenosis Coarctation of the aorta S&S- low cardiac output (diminished pulses)

Poor color, capillary refill delayed Pulses & BP stronger/higher in upper extremities CHF and pulmonary edema Necrotizing enterocolitis With mild obstruction: leg cramps, cooler feet than

hands, stronger pulses in upper extremities

Quick questions:

What is the main complication associated with increased pulmonary blood flow?

Why is indomethacin (prostaglandin inhibitor) ordered for a newborn with patent ductus arteriosus?

Why are prostaglandins administered to the child with an obstructive cardiac disorder (aortic stenosis

Nursing Care for Open-heart Surgery

Pre-Op Monitor VS (*BP & P) what

might increase temp mean? Prepare child/parents for

experience- teaching Teach C&DB (incentive

spirometer) Tour hospital- meet staff Assess for infection Obtain labs, verify permits

Post-OpPulmonary function:

Patent airway IPPB, C&DB, O2 therapy Chest suction or chest tube

Monitor VS Promote restMonitor I&O- adequate

hydration (fluid & electrolyte balance)

Turn frequently (skin care)Assess extremities (circulation

Oh no…more questions….

What assessment findings in the newborn and child indicate coarctation of the aorta?

What is polycythemia and why does it occur in a child with a cardiac disorder?

Which cardiac anomalies represent the greatest risk to survival?

What classic assessment findings should the nurse report in an initial assessment of a newborn?

Acquired Cardiac Diseases

Rheumatic Fever:

Systemic inflammatory disease

Follows group A beta-hemolytic

streptococcus infection

Causes changes in the entire heart especially the valves

Clinical Manifestations

Jones Criteria• Major• Minor

Supporting Evidence

Nursing Care:

Priority teaching Medication therapy

Antibiotics- as ordered to completion of entire prescribed dose (how do you test for therapeutic level?)

Aspirin- relieves pain and acts as a blood thinner to prevent clot formation

Ineffective Endocarditis:

What clients are more susceptible to develop bacterial endocarditis?

When does the organism enter the body? What part of the heart is most affected by the

disease?

Clinical Manifestations:

Onset insidious Fever Lethargy/general malaise Anorexia Splenomegaly Retinal hemorrhages Heart murmur –90% Diagnosis- positive blood culture

Nursing Care

Medication-large doses antibiotic

Bed rest

Teach to notify dentist prior to dental work

Kawasaki Disease- multi-system vasculitis

Mucocutaneous lymph node syndrome

Not contagious Preceded by upper respiratory tract infection Cause unknown

Kawasaki Disease

Acute Phase 10-14 days Rapid onset of fever (does not respond to

antibiotics) Bilateral conjunctivitis lasting 3-5 weeks Rash on day 5 (extremities to trunk) Cervical lymphadenopathy Irritability & lethargy Anorexia, possibly diarrhea, hepatic dysfunction Acute pericarditis Hands and feet are edematous and red Red throat

Kawasaki cont…

Subacute Phase 10-25 days Continued irritability Anorexia diarrhea Arthritis and arthralgia Lip cracking and peeling- classic strawberry

tongue Desquamation of the extremities (palms and feet) Cervical lymphadenopathy with large nodes Possible coronary aneurysms with potential for

thrombosis formation

Kawasaki cont…

Convalescent Phase 25-60 days Self limiting Transverse on nailbeds Lasts until return to normal of all lab

values

Diagnosis of Kawasaki Disease:

ECG CBC, WBC PT ESR SGOT, SGPT IgA, IgG and IgM

Nursing Care: Kawasaki

Medications- Aspirin- decrease fever and thin blood

(reduce risk of formation of aneurysms and coronary thrombosis- antiplatelet properties)

Gamma Globulin- high doses given before 10th day to reduce incidence of coronary artery lesions and aneurysms, decrease inflammatory signs and fever

Nursing Care: Kawasaki

Activity- passive range of motion, plan rest and quiet age-appropriate activities. Encourage parents to participate in child’s care.

Comfort- keep skin clean, dry, lubricate lips, cool compresses and sponges, change bedding frequently. Small frequent feedings of soft, non-acidic foods of cool temperature

Kawasaki Disease: Long term care

Teach parents to administer ASA and watch for side effects of bleeding. Avoid contact sports Teach daily monitoring of temp, report >100F Postpone immunizations for 5 months

Emphasize need to follow up with cardiologist Influenza vaccine (reduce risk of Reye

syndrome) Life-long prophylaxis with antibiotics prior

to dental work

Kawasaki Disease: Long term care

Psychosocial Child away from peers and social

activities for up to 4 monthsSeverity of illness has impact on

parent/child relationshipParents may experience care giver

fatigue

Quick Review:

What is the major complication of Kawasaki disease?

Why is it important to monitor respiratory effort in children with suspected cardiac abnormalities?

Principles that apply to all cardiac conditions: Encourage normal growth and development Counsel parents to avoid overprotection Address parents’ concerns and anxieties Educate parents about conditions, tests,

planned treatments, medications Assist parents in developing ability to assess

child’s physical status

For questions or concerns regarding this lecture content please contact:

Christina Hernandez RN, MSNchernan1@austincc.edu