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  1. 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

  2. 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

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

  4. Clinical Manifestations – CHF early • Dyspnea, tachycardia • Tires easily • Weight loss, or lack of weight gain • Diaphoresis • Irritability

  5. Late CM r/t • Pulmonary congestion • Systemic venous congestion • Decreased myocardial function

  6. Clinical Manifestations – CHF Pulmonary Congestion • Tachypnea • Dyspnea • Exercise intolerance • Orthopnea • Cough, hoarseness • Cyanosis • Wheezing • Pulmonary edema

  7. Clinical Manifestations – CHFSystemic Venous congestion • Edema (periorbital, dependent) • Hepatomegaly • Splenomegaly • Ascites • Weight gain • Neck vein distention (children)

  8. 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

  9. 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

  10. Goals of Treatment • Improve cardiac function • Remove excess fluid • Decrease cardiac O2 demands • Improve tissue oxygenation (supply) • Maintain nutritional status

  11. Improve Cardiac Function • Digoxin • Positive inotropic agent • Dig toxicity • ACE inhibitors

  12. Remove excess fluid • Diuretics • Loop (Lasix) • Thiazide (HCTZ) • Potassium sparing (spironolactone) • Nursing Interventions:

  13. Decrease Myocardial O2Demand &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

  14. 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 F

  15. Cardiac Catheterization • Diagnostic • Treatment • Electrophysiological studies • Pre-cath teaching

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

  17. Post-cath care • Frequent VS • Groin site & pedal pulses • Leg straight 6 hours • Adequate fluid intake

  18. 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

  19. Infective (Bacterial) Endocarditis • Infection of valves or endocardium • All children w/CHD at risk

  20. Clinical Manifestations • Murmur • Fever, malaise • Heart failure • Increased Sed rate • Myalgias & arthralgias • Anorexia, headache

  21. Infective Endocarditis • Primary Prevention • Oral hygiene • Antibiotic prophylaxis before procedures • Secondary Intervention • IV antibiotics 2-6 weeks • Quiet activities

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

  23. Manifestations of RF Jones Criteria: Major • Migratory polyarthritis • Carditis • Chorea • Erythema marginatum • Subcutaneous nodules

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

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

  26. 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. F

  27. Hypertension • Defined: avg. BP  95th percentile for age & sex. • Essential (primary) • Secondary Diagnosis • Ambulatory blood pressure monitoring • Annual screening starting age 3

  28. Essential (Primary) HTN • Weight reduction • Physical conditioning • Dietary modification • Relaxation techniques • Pharmacology

  29. 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

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

  31. Consequences Congenital Heart Defects • Congestive heart failure • Hypoxemia (cyanosis) • Mild hypoxemia: 90-95% • Moderate hypoxemia: 85-90% • Severe hypoxemia: <85%

  32. Classification of CHD • “Acyanotic” or “Cyanotic” lesions • Hemodynamic effects •  pulmonary blood flow • Obstructed flow from the ventricles • Decreased pulmonary blood flow • Mixed - Hypoxemia & CHF

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

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

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

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

  37. 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 Figs. 46-5 and 46-6, pp. 1264 and 1265 U F

  38. 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 F

  39. Clinical Manifestations: COA • Infants: CHF • Older children • Dizziness, fainting, nosebleeds, HA • High BP upper extremities (HTN) • Low BP & weak pulses lower extremities

  40. Treatment COA • PGE1 to keep ductus arteriosis open (preductal ) • Elective repair age 3-5 if asymptomatic

  41. “Cyanotic” Lesions • Decreased pulmonary blood flow • Mixed - Hypoxemia & CHF B MENU F

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

  43. 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.

  44. 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

  45. Transposition of Great Arteries • Child cannot live w/out foramen ovale or patent ductus • VSD common • Cyanosis early – minimal response to O2 • Early surgery

  46. 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