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Module 5 Pediatric Cardiac Disorders Fetal Circulation What is the main route of blood flow through the fetal heart? Fetal Circulation Why does the blood flow in that route? Fetal Circulation What is the secondary route of circulation? And third route? Fetal Circulation

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fetal circulation
Fetal Circulation

What is the main route

of blood flow

through the fetal heart?

fetal circulation3
Fetal Circulation

Why does the blood

flow in that route?

fetal circulation4
Fetal Circulation

What is the secondary route of circulation?

And third route?

fetal circulation5
Fetal Circulation

What is the stimulus for the change in circulation?

intrauterine to extrauterine
Intrauterine to Extrauterine

What Happens after

the Umbilical cord is


intrauterine to extrauterine7
Intrauterine to Extrauterine

1. Decreased pulmonary vascular resistance

Increased pulmonary blood flow


Closure of ductus arteriosus

2. Increase pressure in left atrium, decrease pressure in right atrium

Closure of foramen ovale

oxygen saturation
Oxygen Saturation
  • What is oxygen saturation?
  • What is normal oxygen saturation levels?
  • What values indicate hypoxemia?
  • Why is it important for the nurse to know the oxygen saturation levels?

question 5



Heart Failure

congestive heart failure
Congestive Heart Failure
  • What is wrong with the heart?
congestive heart failure11
Congestive heart failure
  • The inability of the myocardium to circulate enough oxygenated blood to meet the demands of the body.
  • When the heart fails, cardiac output is diminished. Heart rate, preload, contractitility, and afterload are affected.
  • Peripheral tissue is not adequately perfused.
  • Congestion in lungs and periphery develops.
congestive heart failure12
Congestive Heart Failure
  • Why does the pump fail?
congestive heart failure14
Congestive Heart Failure
  • What does the body do to compensate for this congestion and heart failure?
compensatory mechanisms
Compensatory Mechanisms
  • With a decrease in Cardiac Output
  • Stimulation of the sympathetic nervous system
  • Tachycardia - increases venous return to the heart which stretches the myocardial fibers and increases preload.
compensatory mechanisms16
Compensatory Mechanisms
  • With a decrease in cardiac output
  • Decrease perfusion to the kidneys and


  • Increased renin and ADH secretion
  • Increase in Na and H2O retention to increase intravascular volume
early signs of chf
Early Signs of CHF
  • The earliest signs are often subtle:
    • Infant will have mild resting tachypnea
    • Increasing difficulty feeding
signs and symptoms
Signs and Symptoms
  • Pulmonary congestion
    • Tires easily during feeding
    • Tachypnea, Dyspnea, orthopnea
    • Signs of respiratory distress
    • Wheezing, rales and rhonchi
    • Easily fatigue
  • Impaired cardiac output
    • Tachycardia
    • Extremities cool, capillary refill >2 seconds
    • Diaphoretic, sweating, hypotension
signs and symptoms19
Signs and Symptoms
  • Systemic venous congestion
    • Hepatomegaly
    • Edema
    • Weight gain
  • High metabolic rate
    • Failure to thrive
    • Slow weight gain
treatment of congestive heart failure
Treatment of Congestive Heart Failure
  • Medication Therapy
    • Digitalis – increases contractility and decreases heart rate.
    • ACE-inhibitors - arterial vasodilator / afterload reducing agent
    • Diuretics - enhance renal secretion of sodium and water by reducing circulating blood volume and decreasing preload.
    • Beta Blocker - increases contractility
nursing care
Nursing Care

How would the nurse recognize digitalis toxicity in an infant or child?

What are the pulse rate criteria in administration of digitalis?

pulse rates for digitalis administration
Pulse rates for Digitalis administration

Infant – 100 BPM or greater

Child – 80 BPM or greater

Adolescent – 60 BPM or Greater

  • Digitalization
    • Given in divided doses
  • Maintenance
    • Given daily, usually in two divided doses
  • Therapeutic vs. Toxicity
    • Therapeutic range – 0.8 to 2.0 ng/ml
    • Toxicity
      • **EKG changes – arrhythmia
      • Slow pulse
      • Vomiting – very rare in infants
  • Hypokalemia potentiates digoxin toxicity
treatment of congestive heart failure25
Treatment of Congestive Heart Failure
  • Diet – low sodium, small frequent feedings
  • Nursing care:
    • Measure intake and output – weighing diapers
    • Observe for changes in peripheral edema and circulation
    • If ascites present – take serial abdominal measurements to monitor changes.
    • Skin care
    • Turning schedule
feeding the child with chf
Feeding the child with CHF
  • Feed the infant or child in a relaxed environment; frequent, small feedings may be less tiring
  • Hold infant in upright position; may provide less stomach compression and improve respiratory effort
  • If child unable to consume appropriate amount during 30-minute feeding every 3 hours, consider nasogastric feeding
  • Monitor for increased tachypnea, diaphoresis, or feeding intolerance (vomiting)
  • Concentrating formula to 27 kcal/oz may increase caloric intake without increasing infant’s work
cardiac catheterization

Cardiac Catheterization

Measure oxygen saturations and pressure in the cardiac chambers and great arteries

Evaluate cardiac output

cardiac catheterization28
Cardiac Catheterization
  • Pre-care:
    • History and Physical
    • Lab work – EKG, ECHO cardiogram, CBC
    • NPO
    • Vital signs
    • Preprocedural teaching
cardiac catheterization29
Cardiac Catheterization
  • Post Care:
    • Check for bleeding or hematoma at insertion site
    • Keep leg immobilized and straight with bedrest in supine position
    • Monitor vital signs
    • Neurovascular monitoring of extremity distal to the catheter insertion
    • Measure I&O
    • Provide quiet diversional activities
    • Provide adequate fluids
    • Monitor vital signs for
best nursing action
Best Nursing Action
  • During post procedure assessment, the nurse notes bleeding at the insertion site.
  • What should the nurse do first?
ask yourself
Ask Yourself?
  • What is the most common assessment finding indicating a cardiac anomaly?
  • Answer: an audible heart murmur
patent ductus arterious atrial septal defects ventricle septal defects


Shunting Defects

Patent Ductus Arterious

Atrial septal defects

Ventricle septal defects

atrial septal defect
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
  • Medical Management
    • Medications – digoxin
  • Cardiac Catheterizaton -
    • Amplatzer septal occluder
  • Open-heart Surgery
  • Device Closure – Amplatzer septal occluder

During cardiac catheterization the occluder is placed in the


ventricle septal defect
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

Surgical repair with a patch inserted

patent ductus arteriosus
Patent Ductus Arteriosus
  • Blood shunts from aorta (left) to the pulmonary artery (right)
  • Returns to the lungs causing increase pressure in the lung
  • Congestive heart failure
treatment for pda
Treatment for PDA
  • Medical Management
    • Medication
      • Indomethacin - inhibits prostaglandin's which help keep the ductus arteriosus open
  • Surgery
  • Ligate the
  • ductus arteriosus
treatment for pda41
Treatment for PDA
  • Cardiac Catheterization
    • Insert coil – tiny fibers occlude the ductus arteriosus when a thrombus forms in the mass of fabric and wire
cardiac anomalies treatment
Cardiac Anomalies - Treatment

When is surgery



pulmonic stenosis tetralogy of fallot transposition of the great arteries truncus arteriosus

Obstructive or



Pulmonic stenosisTetralogy of fallotTransposition of the great arteriesTruncus arteriosus

pulmonic stenosis
Pulmonic Stenosis
  • Narrowing of entrance that decreases blood flow
  • Increases preload causes right ventricular hypertrophy
obstructive or stenotic lesions
Obstructive or Stenotic Lesions
  • Treatment:
    • Medications – Prostaglandins to keep the PDA open
    • Cardiac Catheterization
      • Baloon Valvuloplasty
    • Surgery
      • Valvotomy
aortic stenosis
Aortic Stenosis
  • The aortic valve is thickened and rigid
  • Stenosis creates left ventricular hypertrophy
  • Left ventricle may not be large enough to eject a normal cardiac output.
aortic stenosis47
Aortic Stenosis
  • Symptoms
    • Poor peripheral perfusion, feeding difficulties, CHF
  • Treatment
    • Balloon valvoplasty
    • Surgery
coarctation of the aorta
Coarctation of the Aorta
  • Narrowing of Aorta causing obstruction of left ventricular blood flow
  • Left ventricular hypertrophy
signs and symptoms49
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
  • 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 allowing blood flow to areas beyond the coarctation.
  • Baloon Valvoplasty
surgery for coarctation of aorta
Surgery for Coarctation of Aorta

1. Resect



2. Anastomosis

tetralogy of fallot

Cyanotic Lesions

With Decreased

Pulmonary Flow

Tetralogy of fallot

tetralogy of fallot53
Tetralogy of Fallot

Four defects are:





signs and symptoms54
Signs and Symptoms
  • Failure to thrive
  • Squatting
  • Lack of energy
  • Infections
  • Polycythemia
  • Clubbing of fingers
  • Cerebral absess
  • Cardiomegaly
ask yourself55
Ask Yourself?
  • Why does Polycythemia occur in a child with a cardiac disorder?
  • Nursing interventions should the nurse include when planning care for this client?
    • Hydration
ask yourself57
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

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

Cyanotic Lesions


Increased Pulmonary Flow

  • Truncus Arteriosus
  • Transportation of Great Vessels

These present the greatest risk to survival

truncus arteriosus
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.
transposition of great vessels
Transposition of Great Vessels
  • Aorta arises from the right ventricle, and the pulmonary artery arises from the left ventricle - which is not

compatible with survival unless there is a large defect present in ventricular or atrial septum.




Ineffective Endocarditis

Microorganisms grow on the endocardium, forming vegetations, deposits of fibrin, and platelet thrombi. The lesion may invade adjacent tissues such as aortic and mitral valves.

subacute bacterial endocarditis infective endocarditis
Subacute Bacterial Endocarditis / Infective Endocarditis:
  • Assessment:
    • Fever
    • Fatigue
    • Muscle and joint pain
    • Headache
    • Nausea and vomiting
    • CHF
    • Spleenomegaly
  • Diagnosis:
    • Blood cultures
    • Echocardiogram
infective endocarditis
Infective Endocarditis
  • Who is more susceptible to develop infective endocarditis?
  • Answer:
    • Children with a congenital heart defect, rheumatic heart disease, or a central venous catheter or who have had heart surgery are at highest risk.
antibiotic prophylaxis for children at risk for infective endocarditis
Antibiotic Prophylaxis for Children at Risk for Infective Endocarditis
  • Dental procedures, including cleaning, that may induce gingival or mucosal bleeding
  • Tonsillectomy and/or adenoidectomy
  • Surgery and/or biopsy involving respiratory or intestinal mucosa
  • Incision and drainage of infected tissue
  • Invasive GU and GI procedures
ineffective endocarditis
Ineffective Endocarditis
  • Treatment
    • Antibiotics
    • Patient teaching
      • Good oral hygiene
      • take antibiotics prior to surgery, dental work, or any invasive procedure, etc.
      • discouraged from body piercing and tattoos as endocarditis may occur even with prophylaxis.

Rheumatic Heart Disease

A systemic inflammatory (collagen) disease of connective tissue that usually follows a group A beta-hemolytic streptococcus infection.

This disorder causes changes in the entire heart (especially the valves), joints, brain, and skin tissues.

rheumatic fever assessment
Rheumatic Fever - Assessment

Jones Criteria

  • Major
    • Carditis
    • Polyarthritis
    • Chorea
    • Erythema marginatum
    • Subcutaneous nodules
  • Minor
    • Arthralgia
    • Fever
    • Laboratory Findings:

Erythrocyte sedimentation rate

C-reactive protein

      • Prolonged PR interval
  • ASO titer
  • Elevated Erythrocyte Sedimentation Rate
rheumatic fever
Rheumatic Fever
  • Treatment
    • Antibiotic Therapy
    • Aspirin
  • Discharge Teaching
    • Antibiotic therapy - be sure to complete all medication.
streptococcal prophylaxis for the child with rheumatic fever
Streptococcal Prophylaxis for the Child with Rheumatic Fever
  • Damaged valves can become further damaged with repeated infections
  • Streptococcal prophylaxis is lifelong if there is actual valve involvement
  • Intramuscular penicillin, administered monthly, is the drug of choice
  • Alternatives include oral penicillin twice daily or oral sulfadiazine once a day

Kawasaki Disease

Multisystem vasculitis – inflammation of blood vessels in the body especially the coronary arteries with antigen-antibody complexes.

kawasaki disease signs and symptoms treatment
Kawasaki Disease Signs and Symptoms / Treatment
  • Three Phases of clinical manifestations:
    • Acute
    • Subacute
    • Convalesant
  • One of the most common symptoms used to diagnose Kawasaki disease is a high spiking fever over 1020 for 5 days.
nursing care76
Nursing Care
  • Give Medications
    • Aspirin
    • Intravenous Immunoglobulin
  • Promote comfort
    • Lubricate the lips
    • Cool compresses
    • Keep skin cool and dry
    • Small feedings of soft foods and liquids that are not too hot or too cold.
  • Facilitate joint movement
    • Passive Range of Motion exercises
kawasaki disease
Kawasaki Disease
  • Which phase of Kawasaki is this child exhibiting?

Inflamed, Cracked, Peeling Lips

Strawberry tongue

kawasaki disease78
Kawasaki Disease
  • What is the major complication?
    • Coronary aneurysms
    • Thrombosis