Module 5 – Pediatric Cardiac Disorders

1. Module 5 – Pediatric Cardiac Disorders Revised, Summer 2008

2. Fetal Circulation

3. Changes in Circulation • Umbilical cord clamped • Pulmonary • Pressure • Pulmonary resistance

4. Critical thinking: • When are most cardiac anomalies discovered? • What is included in the initial cardiac assessment of a newborn? • Why?

5. Assessment • History • Physical • Diagnostic

6. Importance of the Nurse Knowing Normal Value for O2 Saturations • 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

7. Congestive Heart Failure

8. Clinical Manifestations • Pump Fails – cannot meet the demands of the body = CHF How do you know when something is wrong? • Tires easily during feeding • Periorbital edema, weight gain • Rales and rhonchi • Dyspnea, orthopnea, tachypnea • Diaphoretic / sweating • Tachycardia • Weight

9. Goal of Treatment: • Improve cardiac function • Remove accumulated fluid and Na+ • Decrease cardiac demands • Decrease O2 consumption

10. Medications: • Digoxin –what do we assess prior to administration? • Which VS? Weigh diapers for strict I & O • Double check • Digoxin levels • Parent teaching • Digitalis toxicity • ACE inhibitors • Capoten (Captoril) • Vasotec

11. Medications continued… • Furosemide (Lasix) • Chlorothiazide (Diuril) • Zarozolyn (Thiazide type) • Spironolactone (Aldactone)

12. Nursing care • Reduce metabolic needs • Diet therapy • Decrease Cardiac Demands • Improve tissue oxygenation

13. Congenital Cardiac Anomalies

14. 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

15. Signs & Symptoms What is most common indication of a congenital heart defect?

16. Cardiac catheterizations • Used to determine anomalies • Measures O2 sats in cardiac chambers and great arteries • Evaluates cardiac output • Identify detailed images of blood flow patterns • May allow for corrective or palliative measures

17. Nursing interventions pre and post cardiac catheterization • Assessment pre-op for baselines • Assessment post-op: • Vital signs (which ones are priority?) • Extremities • Activity • Hydration • Medications • Comfort measures

18. Teaching after cardiac catheterization • Parental teaching • Watch for s/s of bleeding, bruising at site • Foot temp on side of cath cooler • Loss of sensation in foot on side of cath • When to call the physician • If any of above s/s noted within 1st 24 hrs

19. Blood shunts from aorta (left) to the pulmonary artery (right) Returns to the lungs causing increase pressure in the lung Congestive heart failure Patent Ductus Arteriosus

20. Treatment • Medical Management • Medication • Indomethacin • Surgical • ____Ligate the ductus arteriosus

21. 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

22. Atrial Septal Defect • Oxygenated blood is shunted from left to right side of the heart via defect • A larger volume of blood than normal must be handled by the right side of the heart hypertrophy • 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

23. Treatment • Medical Management • Medications – digoxin • Surgical repair • Suture or simple patch

24. Treatment • Device Closure – Amplatzer septal occluder During cardiac catheterization the occluder is placed in the Defect

25. Ventricle Septal Defect • Oxygenated blood is shunted from left to right side of the heart via defect • A larger volume of blood than normal must be handled by the right side of the heart hypertrophy • 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

26. Treatment Surgical repair with a patch inserted

27. Obstructive or Stenotic Defects

28. Pulmonic or Aortic Stenosis • Narrowing of entrance that decreases blood flow • Treatment: • Medications – Prostaglandins to keep the PDA open • Cardiac Catheterization • Balloon Valvuloplasty • Surgery • Valvotomy

29. Coarctation of the Aorta • Narrowing of Aorta causing obstruction of left ventricular blood flow • 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

30. Treatment • 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. • Balloon dilation • Surgery Resect narrow area Anastomosis

31. Cyanotic Disorders

32. Tetralogy of Fallot • 1. Four defects with right to left shunting • Signs and Symptoms • Failure to thrive • Lack of energy • Infections • Polycythemia • Clubbing of fingers • Squatting • Cerebral absess • Cardiomegaly • Cyanosis 2 1. 3 4

33. Treatment • Surgical interventions • Blalock – Taussig or Potts procedure – increases blood flow to the lungs. • Open heart surgery

34. 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

35. Mixed blood flow Survival depends upon mixing of blood from pulmonic and systemic circulation Cyanotic Disorders: • Truncus arteriosus • Hypoplastic left heart • Transposition of the great arteries

36. 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.

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

38. 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 septum. Transposition of Great Vessels aorta

39. Nursing Diagnosis & Goals: DX: Alteration in cardiac output: decrease R/T heart malformation Goal: Child will maintain adequate cardiac output AEB:

40. Nursing Care: • Monitor VS • I&O • Medications • Position • Metabolic rest • Assess and document child/family interactions • Parent teaching

41. Acquired Cardiac Diseases

42. Kawasaki Disease Mucocutaneous lymph node syndrome • Not contagious • Preceded by upper respiratory tract infection • Cause unknown

43. Clinical Manifestations: • Acute Phase- 10-14 days • Subacute Phase 10-25 days • Convalescent Phase 25-60 days

44. Diagnosis: • ECG • CBC, WBC • PT • ESR • SGOT, SGPT • IgA, IgG and IgM

45. Nursing Care: • Medication Therapy • Aspirin • Gamma Globulin • Nursing Interventions • Assess/monitor • Decrease stimulation • Comfort measures • Discharge teaching

46. Rheumatic Fever • Systemic inflammatory disease • Follows group A beta-hemolytic streptococcus infection • Causes changes in the entire heart especially the valves

47. Clinical Manifestations • Jones Criteria • Major • Minor • Supporting Evidence

48. Therapeutic Intervention • Medication • long term • prophylaxis • Nursing • Prevention • Parent teaching (ANTIBIOTICS)

49. Subacute Bacterial Endocarditis Infectious disease involving abnormal cardiac tissue: • Usually rheumatic lesions or congenital defects • Infection may invade adjacent tissues- aortic and mitral valves

50. Clinical Manifestations: • Onset insidious • Fever • Lethargy/general malaise • Anorexia • Splenomegaly • Retinal hemorrhages • Heart murmur –90% • Diagnosis- positive blood cultures