Definitions• C.O.= volume of blood ejected by heart in 1

minute• Cardiac output = HR x stroke volume– S.V.: preload, afterload, contractility

• Flow = pressure gradient resistance

1

Congestive Heart Failure

• Clinical syndrome• Reflects the heart’s inability to pump

sufficiently to meet the metabolic demands of the body.– Metabolic demands of newborns high.– Less reserve

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CHF - Causes• Pressure & volume overloads• Myocardial failure (contractility)• Excessive demands

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Clinical Manifestations – CHF early

• Dyspnea, tachycardia• Tires easily• Weight loss, or lack of weight gain• Diaphoresis• Irritability

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Late CM r/t

• Pulmonary congestion• Systemic venous congestion• Decreased myocardial function

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Clinical Manifestations – CHF Pulmonary Congestion

• Tachypnea• Dyspnea• Exercise

intolerance

• Orthopnea • Cough, hoarseness• Cyanosis• Wheezing • Pulmonary edema

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Clinical Manifestations – CHFSystemic Venous congestion

• Edema (periorbital, dependent)• Hepatomegaly• Splenomegaly• Ascites• Weight gain • Neck vein distention (children)

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Clinical Manifestations – CHFR/t impaired myocardial function

• Tachycardia • urine output• Restlessness• Anorexia • Cyanosis• Diaphoresis• Fatigue

• Weak peripheral pulses

• blood pressure• Pale, cool

extremities• Gallop rhythm• Cardiomegaly

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Nursing Diagnoses - CHF• Altered tissue perfusion [name organ] r/t

cardiac workload or cardiac function• Fluid volume excess r/t L & R ventricular

overload & ineffective pumping• Ineffective Gas Exchange r/t pulmonary

congestion; imbalance O2 supply & demand• Altered Nutrition < body requirements r/t

energy expenditure, intake• Knowledge deficit re: disease process, tx, &

home care

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Goals of Treatment

• Improve cardiac function• Remove excess fluid • Decrease cardiac O2 demands• Improve tissue oxygenation (supply)• Maintain nutritional status

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Improve Cardiac Function

• Digoxin–Positive inotropic agent–Dig toxicity

• ACE inhibitors

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Remove excess fluid• Diuretics – Loop (Lasix)– Thiazide (HCTZ) – Potassium sparing (spironolactone)

• Nursing Interventions:

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Decrease Myocardial O2 Demand &Improve Oxygenation

Decrease Demand• Rest• Normothermia• Prevent/ treat infection• Positioning• Sedation (prn)

Increase Supply• Improve cardiac

function• Remove excess fluid • Decrease cardiac O2

demands• Supplemental oxygen

13

Feeding the Infant or Child with Congestive Heart Failure

• Feed in a relaxed environment.• Frequent, small feedings • 30-minute feeding every 3 hours• Nasogastric feeding• Calorie supplement

14F

Cardiac Catheterization

• Diagnostic• Treatment• Electrophysiological studies• Pre-cath teaching

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Pre-cath assessment• Height, weight• Pulses • Last drink, void• Meds• Consent• Knowledge deficit• Skin condition• Allergies

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Post-cath care

• Frequent VS• Groin site & pedal pulses• Leg straight 6 hours• Adequate fluid intake

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Family Home Care

• Pressure dressing 24 hours• Keep site clean & dry• Avoid strenuous exercise 2-3 days• Acetaminophen or Ibuprofen prn• Call M.D.: redness, swelling, drainage,

bleeding, fever

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Infective (Bacterial) Endocarditis

• Infection of valves or endocardium• All children w/CHD at risk

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Clinical Manifestations

• Murmur• Fever, malaise• Heart failure• Increased Sed rate• Myalgias & arthralgias• Anorexia, headache

20

Infective Endocarditis• Primary Prevention– Oral hygiene– Antibiotic prophylaxis before procedures

• Secondary Intervention– IV antibiotics 2-6 weeks– Quiet activities

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Rheumatic Fever

• Systemic inflammatory disorder• Autoimmune disorder• Peaks in school-age children• Rheumatic heart disease most serious

complication

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Manifestations of RF

Jones Criteria: Major• Migratory polyarthritis• Carditis• Chorea• Erythema marginatum• Subcutaneous nodules

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Diagnosis

• Recent hx of strep• Jones criteria: 2 major or 1 major and 2 minor• Jones Criteria: Minor– Fatigue– Fever– Arthralgia– Previous hx RF

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Nursing Interventions - RF• Primary Prevention:• Secondary Prevention as Intervention– Penicillin– Comfort– Strict Bedrest – Safety – Support nutritional status– Alleviate anxiety

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Streptococcal Prophylaxis(tertiary prevention as intervention)

• Valves: more damage with repeated infections.

• 5 years or through adolescence• Prefer monthly IM penicillin• Alternatives: oral penicillin bid or oral

sulfadiazine qd.

26F

Hypertension

• Defined: avg. BP 95th percentile for age & sex.

• Essential (primary)• Secondary

Diagnosis• Ambulatory blood

pressure monitoring• Annual screening

starting age 3

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Essential (Primary) HTN

• Weight reduction• Physical conditioning• Dietary modification• Relaxation techniques• Pharmacology

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Kawasaki Disease: Acute febrile illnessWidespread, systemic vasculitis

SUBACUTE PHASE• resolution of fever• all sx resolved• High risk coronary

artery aneurism• Irritability persists

CONVALESCENT• Clinical signs gone• Lab values abnormal• 6-8 weeks

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Treatment - KD

• IV Immune globulin (IVIG)• ASA• Comfort measures• Adequate hydration• Monitor cardiac status – CHF, MI• Patient irritability

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Consequences Congenital Heart Defects

• Congestive heart failure• Hypoxemia (cyanosis)– Mild hypoxemia: 90-95%– Moderate hypoxemia: 85-90%– Severe hypoxemia: <85%

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Classification of CHD

• “Acyanotic” or “Cyanotic” lesions

• Hemodynamic effects– pulmonary blood flow– Obstructed flow from the ventricles– Decreased pulmonary blood flow– Mixed - Hypoxemia & CHF

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Shunt

• To divert blood flow• ‘right to left’ or ‘left to right’– ‘right to left’ – hypoxia– ‘left to right’ - CHF

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ASD

• CMs depend on size, location• Murmur• Fatigue, DOE• Atrial dysrhythmias• TX: elective surgical closure or patch via

cardiac catheterization

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VSD

• CMs depend on size• Poor feeding, FTT if large (CHF)• Large # close spontaneously• Tx– CHF– Patch it

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Patent Ductus Arteriosis

• Blood flow from aorta to pulmonary arteries• Term infants: no sx (murmur)• Preterm: CHF• TX: Indocin, surgery

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Common Stenotic Lesions: Pulmonary Stenosis and Aortic Stenosis

Pulmonic Stenosis• RV hypertrophy • R to L shunt if foramen

ovale open• No sx of RV failure

(exercise intolerance)• Balloon angioplasty: low

mortality; incompetent valve, but usually asymptomatic.

Aortic Stenosis• mild activity intolerance

to severe syncope, dizziness.

• Valvotomy (balloon or open heart).• 25% require 2nd surgery

w/in 10 years

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Figs. 46-5 and 46-6, pp. 1264 and 1265

UF

F

Coarctation of the Aorta

• Narrow (stenotic) section of aorta• Most common spot – after aortic arch• Narrowing restricts blood to lower part of

body• Varying degrees of narrowing

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Clinical Manifestations: COA

• Infants: CHF• Older children– Dizziness, fainting, nosebleeds, HA– High BP upper extremities (HTN)– Low BP & weak pulses lower extremities

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Treatment COA

• PGE1 to keep ductus arteriosis open (preductal )

• Elective repair age 3-5 if asymptomatic

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“Cyanotic” Lesions

• Decreased pulmonary blood flow• Mixed - Hypoxemia & CHF

41MENUB F

Chronic Hypoxemia

• Polycythemia• Anemia r/t depletion of iron stores• Clotting abnormalities• CNS injury• Developmental delay • Clubbing of fingers

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Tetrology of Fallot

• VSD; Pulmonic stenosis; overriding aorta; RVH

• Hemodynamics depend on PS, VSD• Clubbing, fatigue, poor growth, “Tet” spells• Symptomatic newborn: PGE1, early surgery• Elective surgery 3-12 mo.

43

Hypercyanotic Episodes “tet spells”

• sudden decrease pulmonary flow &/or increased RV pressure– spasm of RV outflow

track– Crying, feeding,

defecation

Treatment• Calm the infant; meet

needs quickly• Knee-chest position• O2• MSO4

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Transposition of Great Arteries

• Child cannot live w/out foramen ovale or patent ductus– VSD common

• Cyanosis early – minimal response to O2

• Early surgery

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Home care/Teaching

• Prepare child/family • Treat CHF• Immunizations/prevent

infections• Notify MD quickly w/

signs of any illness• Parental support • Allow child to set

activity level

• Adequate nutrition• CMs of CHF• Oxygen• Preemie nipple to energy in sucking

• Careful skin care• Preventive dental care• Prophylactic abx

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