chapter 25 cardiac

7/27/2019 Chapter 25 Cardiac

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Chapter 25

The Child with

Cardiovascular Dysfunction

Mosby items and derived items 2009,2005 by Mosby, Inc., an affiliate of Elsevier

Inc.
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A & P Review

Anatomy

Chambers

Valves Vessels

Normal flow

Physiology

Cardiac output

Chambers of the Heart


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Valves of the HeartVessels of the

Heart

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ect/normal.swf
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Assessment of Cardiac Function

History

Physical Examination

Inspection

Palpation and Percussion

Auscultation

Heart rate and rhythm Character of heart sounds
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Pediatric Indicators

of Cardiac Dysfunction

Poor feeding

Tachypnea, tachycardia

Failure to thrive, poor weight gain, activityintolerance

Developmental delays

Positive prenatal history

Positive family history of cardiac

diseaseMosby items and derived items 2009,2005 by Mosby, Inc., an affiliate of Elsevier

Inc.
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Congenital Heart Disease

ConsequencesCHF, hypoxemia

Incidence: 5-8 per 1000 live births

Major cause of death 1st yr of life

CausesChromosomal-genetic: 10%-12%

Maternal or environmental: 1%-2%

Fetal alcohol syndrome: 50%

Maternal illness

Rubella, cytomegalovirus, toxoplasmosis, other viral illnesses, IDMs

Multifactorial: 85%


Inc.


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Fetal

Circulation

Structures

Umbilical vein,

umbilical arteries Foramen ovale

Ductus arteriosus

Ductus venosus


Inc.


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Fetal Circulation

http://www.wellesley.edu/Biology/Courses/111/DuctArt.gifhttp://www.wellesley.edu/Biology/Courses/111/ForOval.gif


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Changes at Birth


Inc.

FIG. 25-1 Changes in circulation at birth. A, Prenatal circulation. B, Postnatal

circulation. Arrows indicate direction of blood flow. Although four pulmonary veins

enter the LA, for simplicity this diagram shows only two. RA, Right atrium; LA, left

atrium; RV, right ventricle; LV, left ventricle.


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10Mosby items and derived items 2009,2005 by Mosby, Inc., an affiliate of Elsevier

Inc.


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CHD-

Altered hemodynamics

Cyanotic vs Acyanotic

Defects Shunting Pattern

Left to right shunting

Acyanotic

Right to left shunting

Cyanotic
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Newer Classification of CHD

Hemodynamic

characteristics:

Increased pulmonary blood

flow Decreased pulmonary

blood flow

Obstruction of blood flow

out of the heart Mixed blood flow


Inc.


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ACYANOTIC,Increased Pulmonary Blood Flow Defects

Atrial septal defect (ASD)

Ventricular septal defect (VSD)

Atrioventricular canal defect (AVC)

Patent ductus arteriosus (PDA)


Inc.


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Atrial Septal Defect (ASD)

http://www.nemours.org/content/dam/nemours/www/filebox/service/medical/cardiology/de

fect/atrialseptal.swf
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Atrial Septal Defect

(ASD)

Signs & Symptoms:

May be asymptomatic

May have a murmur

Right atrial enlargement

At risk for dysrhythmias, CHF

Management:

Surgical patch closure (pericardial, Dacron)

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Ventricular Septal Defect (VSD)

http://www.nemours.org/content/dam/nemours/www/filebox/service/medical/card

iology/defect/vsd.swf
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Ventricular Septal

Defect (VSD)

Signs & Symptoms:

Many asymptomatic

Holosystolic murmur at left sternal border

CHF common

Management:

May close spontaneously (20-60%)

Surgical procedure (sutures or patch)


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Atrioventricular canal (AVC) or Endocardial

cushion defect (ECD)

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gy/defect/atrioventricular.swf
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Atrioventricular Canal Defect (AVC) or

ECD

Signs and Symptoms:

Loud systolic murmurModerate to severe CHF

Possible cyanosis with crying

Management:Optimize cardiac output & weight gain

Patch closure

Valve reconstruction or valve replacement

Hockenberry (2005)
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Patent Ductus Arteriosus (PDA)

http://www.nemours.org/content/dam/nemours/www/filebox/service/medic

al/cardiology/defect/pda.swf
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Patent Ductus Arteriosus (PDA)

Signs & Symptoms:May be asymptomatic

Machinery-like murmur

Possible s/s of CHF

Management:Spontaneous closure

Surgical (ligation)

Transcatheter (coils)

Indomethacin (Indocin) Prostaglandin inhibitor
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SummaryIncreased Pulmonary Blood Flow Defects

Abnormal connection

between two sides of heart

Either the septum or the

great vessels

Increased blood volume on

right side of heart

Increased pulmonary blood

flow

Decreased systemic blood

flowMosby items and derived items 2009,

2005 by Mosby, Inc., an affiliate of Elsevier

Inc.


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ACYANOTIC,

Obstructive Defects

Coarctation of the aorta

Aortic stenosisPulmonic stenosis

Mosby items and derived items 2009,


Inc.


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Coarctation of the Aorta (COA)

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cardiology/defect/coarctation.swf
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Coarctation of the Aorta

(CoA) Signs & Symptoms:

B/P differences between

arms/legs, >10 mm Hg Bounding pulses in arms; weak or

absent femoral pulses

Signs of CHF in infants

Cool lower extremities

Risk for HTN, ruptured aorta,aortic aneurysm, stroke

Management:

Surgery-resection,

anastomosis

May recur

Balloon angioplasty &

stent placement


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Aortic Stenosis

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nemours/www/filebox/service/medic

al/cardiology/defect/aorticstenosis.s

wf

Narrowing or stricture of

aortic valve

Causes increased

workload on LV and

hypertrophy
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Aortic Stenosis (AS)

Signs & Symptoms:

Decreased cardiac output with faint pulses

Hypotension, tachycardia, poor feedings

Murmur, systolic

Chest pain, fatigue and syncope

Management:

Balloon angioplasty

Repair or replace valve


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Pulmonic Stenosis

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ical/cardiology/defect/pulmonarystenosis.swf
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Pulmonic Stenosis

Signs & Symptoms:

May be asymptomatic

Loud systolic murmur

Cyanosis May lead to CHF

Nursing Care:

Balloon angioplasty

Valvotomy

Monitor for restenosis

Reduce stressful situations

http://familydoctor.co.uk/media/upload/Balloon%20valvuloplasty.jpg


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CYANOTIC,Decreased Pulmonary Blood Flow Defects

Tetralogy of Fallot

Tricuspid atresia



Inc.


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Tetralogy of Fallot (TOF)

http://www.nemours.org/content/dam/nemours/www/filebox/service/m

edical/cardiology/defect/tof.swf

http://en.wikipedia.org/wiki/Overriding_aorta
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Tetrology of Fallot (TOF)

Signs & Symptoms:

Cyanosis with crying or

feeding

Blue spells or TET" spells At risk for emboli, seizures, loss

of consciousness,

sudden death

Management:

TET spells

Squatting, knee chest position

Oxygen
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Tricuspid Atresia

Error in formation of TV

Incompatible with life as

single defect

Most have ASD or VSD, aswell as PDA

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emours/www/filebox/service/medical/cardiology/defect/tricuspidatresia.swf
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Tricuspid Atresia (TA)

Signs & Symptoms:Severe cyanosisTachycardia

DyspneaManagement:Prostaglandin (PGE1)Emergent Balloon atrial

septostomyNumerous surgical repairs

http://www.ctsnet.org/doc/4960


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CYANOTIC,

Mixed Defects

Transposition of great vessels

Total anomalous pulmonary venousconnection

Truncus arteriosus

Hypoplastic heart syndromeMosby items and derived items 2009,


Inc.


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Transposition of the Great Vessels (or

Arteries)


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Transposition of the Great Arteries

or Vessels

(TGA or TGV)

Signs & Symptoms:

Depends on type/size of associated defects

Appear at birth, depressed function

Severe cyanosis, CHF

Nursing Care:

Prostaglandin PGE1 (Keep PDA open)

Balloon atrial septostomy

Surgical repair

arterial switch operation


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Totally Anomalous Pulmonary Venous

Connection

http://www.nemours.org/content/dam/nemours/www/filebox/service/medical/cardiology/defect/tapvrs

upra.swf

http://www.nemours.org/content/dam/nemours/www/filebox/service/medical/cardiology/defect/tapvrinfra.swf
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Total Anomalous Pulmonary Venous

Return (TAPVR)

Signs & Symptoms:

Cyanosis

Heart failure

Management:

Surgical repair

Anastomosis

ASD closed

Anomalous connection ligated


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Truncus Arteriosus

http://www.nemours.org/content/dam/nemours/www/filebox/service/medical/card

iology/defect/truncusarteriosus.swf
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Truncus Arteriosus

Signs & Symptoms:

Cyanosis, poor growth

Moderate to severe CHF

Activity intolerance

Holosystolic murmur

Management:

Close VSD

Excise pulmonary arteries and attach to RV

Mortality >10%
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Hypoplastic Left Heart


edical/cardiology/defect/hlhs.swf
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Hypoplastic Left Heart Syndrome (HLHS)

Signs & Symptoms: Mild cyanosis and s/s of CHF until PDA

closes

Then progressive deterioration

w/cyanosis

Decreased cardiac output

Leads to CV collapse

Management:

Mechanical ventilation

Prostaglandin (PGE1) given

Numerous surgical repairs

Palliative carehttp://home.cc.umanitoba.ca/~soninr/HLHSRep.html


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Hypoplastic Left Heart Syndrome

Glenn Procedure-StageII

Stage I

mimg.co
http://upload.wikimedia.org/wikipedia/commons/a/a5/Hypoplastic_left_heart_syndrome.svg


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Invasive Tests

Cardiac Catheterization:

Determines pressures in heart & heart anatomy

Diagnostic and/or interventional

Risks

Bleeding, infection, thrombus, arrhythmia, perforation,

stroke, death

Preprocedure

Allergy to ?

NPO, assess pedal pulses

Sedation

g


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Cardiac Catheterization

Post procedure

Monitor

Assess pulses below cath site

Temp/color of affected extremity Assess site

Pressure dressing in the groin

VS q 15 mins initially

Lay flat 4-8 hours post

Pain assessment

http://www.yalemedicalgroup.org/stw/images/125490.jpg

C ti H t F il


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Congestive Heart Failure

Inability to pump adequateamount of blood

Right sided failure

RV unable to pump into PA

Increased pressure in RA, systemic

venous circulation Left sided failure

LV unable to pump into systemiccirculation

Increased pressure in LA,

pulmonary veins Causes elevated pulmonary

pressures, pulmonary edema

http://www.medmarketplace.com/images/i19Enlargev2.jpg

C ti H t F il


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Congestive Heart Failure-

Management

Digoxin (Lanoxin)

Increased cardiac output, decreased heart size,decreased venous pressure, relief of edema

Elixir (0.05 mg/ml) or IVSigns of Digoxin toxicity

Nausea, Vomiting, Anorexia

Bradycardia, Dysrhythmias

Administration

Apical pulse, do not give if: < 90-110 in infant


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CHF-Management

Angiotensin-converting enzyme (ACE)inhibitors

Block conversion of angiotensin I to II

Vasodilation occurs, reduce afterload

Common meds: captopril, enalapril, lisinopril

Side effects

Hypotension, cough, renal dysfunction

Beta Blockers (lol)

Causes decreased HR and BP, vasodilation

Carvedilol Mosby items and derived items 2009,2005 by Mosby, Inc., an affiliate of Elsevier

Inc.



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Management

Diuretics (decrease preload) Furosemide (Lasix)

Side effects: N/V, diarrhea, ototoxicity, hypokalemia,

hypotension

Foods high in potassium

Observe for dig toxicity

Chlorothiazide (Diuril)

Side effects: Nausea, weakness, dizzy, muscle cramps,hypokalemia

Spironolactone (Aldactone)

Potassium sparing effects

Side effects: skin rash drows ataxia h erkalemia


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Nursing Care Management for CHF

Nutrition/Feedings

Increased calorie formula

Smaller, Q 3 hr feeds

Gavage feedings or GT

Nipple with larger opening

Frequent rest, give 1/2 hour

Breastfeeding

Fluid loss Assess I&O, daily weights

http://www.mountnittany.org/wellness-library/healthsheets/documents?ID=5207


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Nursing Care Management of CHF

Hypoxemia/Cyanosis

Manifestations

Apparent when O2 sats 80-85%

Clubbing, polycythemia

TET spells At risk for neurological complications

Developmental delays, CVA

Management

Hydration (to reduce CVA risk)

Treat resp infections

Nursing care

Infection control -

http://babyheartblog.org/


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Nursing care of child/family with CHD

Support

Reduce anxiety

Help family adjust

Family education

Home care teaching

Do not restrict physical activity

Immunizations

Prepare for invasive procedures


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Nursing care of child/family with CHD

Postoperative care

Monitor for complications, VS (pg 889, review)

PIV, CVP, Intracardiac lines

Sterile technique

Maintain respiratory status

Suctioning

Chest tubes

Drainage >3 ml/kg/hr for more than 3 hrs indicateshemorrhage or >5-10 ml/kg in any 1 hour

Removal

Monitor fluids

Rest and progressive activity


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Heart Transplantation

Indications Worsening heart failure and end-stage CHD

Organ donation issues

Risks vs benefits

Limited donors

Overall survival 40% up to 20 yrs post

Rejection and immunosuppressants

Nursing considerations

Compliance

Close monitoring Education


2005 by Mosby, Inc., an affiliate of ElsevierInc.
http://rds.yahoo.com/_ylt=A9G_bI8nAHFL.iMAmjmJzbkF;_ylu=X3oDMTBpaWhqZmNtBHBvcwMzBHNlYwNzcgR2dGlkAw--/SIG=1hm3vggfa/EXP=1265783207/**http:/images.search.yahoo.com/images/view?back=http%3A%2F%2Fimages.search.yahoo.com%2Fsearch%2Fimages%3Fp%3Dtwo%2Bhearts%26ei%3Dutf-8%26fr%3Db1ie7&w=216&h=160&imgurl=www.twoheartsdesign.com%2Fimages%2Fclipart%2Fheartsandmore%2Fimages%2Fshiny_2hearts.jpg&rurl=http%3A%2F%2Fwww.twoheartsdesign.com%2Fimages%2Fclipart%2Fheartsandmore&size=11k&name=shiny+2hearts+jp...&p=two+hearts&oid=225b134ef3091d62&fr2=&no=3&tt=150383&sigr=11rin079i&sigi=12da0u0em&sigb=12br6nsn6


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Acquired Cardiovascular

Disorders

Infectious and InflammatoryCardiac Disorders




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Bacterial (Infective) Endocarditis

Infection of valves and

inner lining

Caused by bacteremia in

child with acquired orCHD

Streptococcal

Staphylococcal

Fungal




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Bacterial (Infective) Endocarditis

Manifestations

Fever, malaise, anorexia, wt loss

Splinter hemorrhages (fig. A)

Osler nodes (fig. C)

Janeway lesions

(fig. D)

Petechiae on mm (fig. B)

CHF, dysrhythmias, murmur

Treatment

IV antibiotics

Prophylaxis: 1 hour before procedure, IVor PO

Amoxicillin

http://www.rjmatthewsmd.com/Definitions/pop/201afig.htmA

B

C

D

Rh ti F (RF) d Rh ti H t


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Rheumatic Fever (RF) and Rheumatic Heart

Disease (RHD)

RF

Inflammatory disease occurs after group A -

hemolytic streptococcal pharyngitis

Infrequently seen in US

Self-limiting

Affects joints, skin, brain, serous surfaces, and heart

Rheumatic Heart Disease Most common complication of RF

Causes damage to valvesMosby items and derived items 2009,


Rh ti F


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Rheumatic Fever

ManifestationsUsually 2-6 weeks post infection

Carditis

Polyarthritis

Erythema marginatum

Subcutaneous nodules

Chorea

Treatment

Antibiotics

Prevention



http://www.peds.ufl.edu/peds2/research/debusk/pages/page4_53.html

http://www.aafp.org/afp/2005/0515/p1949.html


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Hyperlipidemia

Identify kids at risk and treat early

R/O secondary causes

Normal TC


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Systemic Hypertension

Primary vs Secondary

Pediatrics: usually secondary

Renal, CV, Endocrine, Neurological disorders

ManagementDietary and lifestyle changes

Beta blockers

Other meds: ACE inhibitors, CCBs, ARBs, Diuretics

Education

Monitoring

Side effects



K ki Di (KD M t L h


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Kawasaki Disease (KD; Mucocutaneous Lymph

Node Syndrome)

Acute systemic vasculitis

Unknown cause

Children


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Kawasaki conjunctivitis, edema, rash,

desquamation


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Kawasaki Disease

Management

ASA

IVIG

Nursing

considerations

Teaching, follow-up,

no live vaccines

Teach S/S of MI, CPR

chapter 25 cardiac

Documents