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Chapter 12

Chapter 12. Cardiac Disorders. Cardiovascular System. Heart fully functioning by 8 th week of gestation Fetal circulation: placenta is the organ of oxygenation Ductus venosus Ductus arteriosus Foramen ovale The birthing process begins closure of fetal shunts

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Chapter 12

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  1. Chapter 12 Cardiac Disorders

  2. Cardiovascular System • Heart fully functioning by 8th week of gestation • Fetal circulation: placenta is the organ of oxygenation • Ductus venosus • Ductus arteriosus • Foramen ovale • The birthing process begins closure of fetal shunts • Heart defects are the most common birth defect • Leading cause of birth defect-related deaths

  3. Congenital Heart Disease • Description • A defect in the structure of the heart or in one or more of the large blood vessels that lead to and from the heart • Multifactorial • Result of genetic-environmental interactions • Four classifications • Based on defect’s effect on blood flow • Hemodynamics: study of blood circulation • Shunting: flow of blood through abnormal openings • Defects with increased pulmonary blood flow • Obstructive defects • Defects with decreased pulmonary blood flow • Mixed defects

  4. Congenital Heart Disease (CHD) • Diagnostic tools • Not all testing is necessary for each child • Lab tests, electrocardiogram, halter monitor, event recorder, chest radiography, echocardiogram, MRI, cardiac catherization • Cardiac catherization is an invasive procedure • Provides information about anatomy, cardiac pressure, oxygen saturation, cardiac function • Sedation is necessary • Entry site kept straight 4-6 hours after procedure

  5. Congenital Heart Disease (CHD) • Signs and symptoms • Depend on location and type of heart defect • Child may be small for age, condition may be classified as a physiologic failure to thrive • Exercise intolerance noticed anywhere from infancy to toddler age • Clubbing of the fingers • Frequent respiratory infections because of pulmonary vascular congestion • Squatting position (TET spell) • Polycythemia: Body compensates for hypoxemia by increasing number of RBCs

  6. Clubbed fingers

  7. Congestive Heart Failure (CHF) • Early symptoms • Lack of infant weight gain • Difficulty feeding/ sucking due to air hunger • Infant irritability and fatigue • Tachycardia/tachypnea • Increased work of breathing • Progressive symptoms • Periorbital/facial edema • Vein distention • Hepatomegaly • Splenomegaly • Decreased urine output • Diaphoresis • Mottling • Cyanosis • Pallor

  8. Defects with Increased Pulmonary Blood Flow • Patent ductus arteriosus (PDA) • Passageway connecting pulmonary artery to aorta, avoiding fetal lungs • Failure to close causes oxygenated blood to recycle through the lungs • Overburdens pulmonary circulation • Makes heart work harder • One of the most common cardiac anomalies • Symptoms • Machine-like murmur, dyspnea, bounding pulses on exertion, failure to thrive, frequent respiratory infections • Treatment • Indomethacin/ibuprofen in premature infants to close ductus • Amplatzer PDA device • Surgical repair

  9. Defects with Increased Pulmonary Blood Flow • Atrial septal defect (ASD) • Abnormal opening between right and left atria • Common congenital heart anomaly • Symptoms • Generally asymptomatic • Cyanosis if blood flow is reversed by heart failure • Large openings may cause failure to thrive • Treatment • Open heart surgery • Percutaneous occluding devices

  10. Defects with Increased Pulmonary Blood Flow • Ventricular septal defect (VSD) • Opening between right and left ventricles • 75% of small VSDs close spontaneously by age 10 • Symptoms • Loud, harsh murmur • Systolic tremor • Moderate/large defects may present CHF symptoms • Treatment • Percutaneous transcatheter closure • Occluder devices

  11. Obstructive Defect • Coarctation (tightening) of the aorta • Symptoms • Increased pressure proximal to the defect • Decreased pressure distal to the defect • High blood pressure • CHF symptoms • Treatment • Balloon angioplasty • Surgical intervention; anastomosis • Risk of developing subacute bacterial endocarditis

  12. Defect with Decreased Pulmonary Blood Flow • Tetralogy of Fallot • The most common cyanotic heart defect • Four defects • Stenosis (narrowing of pulmonary artery) • Hypertrophy of the right ventricle • Over-riding aorta • VSD • Symptoms • Cyanosis/hypoxemia episodes with hyperpnea, irritability • Hypoxia • Treatment • Open heart surgery to correct defects

  13. Mixed Defect • Transposition of the great arteries (TGA) • Pulmonary artery leaves left ventricle • Aorta leaves the right ventricle • Other defects (septal defects, PDA) must be present to exchange blood which sustains life • Survival impossible without surgery • Symptoms • CHF symptoms • Any murmur present is caused by other defects, not TGA • Treatment • Prostaglandin E1 (keeps PDA open) • Balloon atrialseptotomy (opens septal wall) • Corrective surgery • Performed within the first 2 weeks of life

  14. Mixed Defect • Hypoplastic left heart syndrome (HLHS) • Left side of the heart is underdeveloped • Hypoplasia of aorta, left ventricle, mitral valve • Systemic circulation provided by right side of the heart (Rt ventricle is force of circulation) • Ductus arteriosus and foramen ovale must remain patent to survive with HLHS • Treatment • PGE1 is administered to maintain a PDA • Surgery in several stages • Norwood, Glenn, Fontan

  15. Congenital Heart Disease • Treatment and nursing care • Nursing goals in the care of the newborn infant can be adapted for all children with heart defects • Reduce the work of the heart • Improve respiration • Maintain proper nutrition • Prevent infection • Reduce the anxiety of the patient • Support and instruct the parents

  16. Congenital Heart Disease • Treatment and nursing care (continued) • Change child’s position frequently to prevent respiratory complications • Threat of cerebral thrombosis • Chest tubes may be used after surgery • System must be airtight • Drainage containers always kept below the level of the chest • Avoid unnecessarily disturbing the child; they need to conserve energy • Common medications • Digoxin (Lanoxin) • Dopamine, dobutamine, epinephrine • Amrinone, milrinone • ACE inhibitors • Angiotensin II receptor blockers • Diuretics

  17. Congenital Heart Disease • Treatment and nursing care (continued) • Infective endocarditis (IE) • High risk for children with complex cyanotic heart diseases or children who have had heart surgery • Organisms grow on the endocardium or areas of turbulent blood flow • Symptoms • Fever, fatigue, headache, nausea, vomiting • Diagnosis and treatment • Blood cultures determine causative organism • Antibiotics

  18. Congenital Heart Disease • Home care • Family must understand medication administration • Family must identify symptoms requiring medical attention • Provide a normal environment within child’s limits • Avoid allowing the child to gain control of the home • Limit setting • Integrate the child into family life • Explain the possible need for frequent hospitalization to parents and child

  19. Question 12.2 Which of the following is NOT one of the four classifications of congenital heart disease? • Defects with increased pulmonary blood flow • Congestive heart failure • Defects with decreased pulmonary blood flow • Mixed defects

  20. Acute Rheumatic Fever • Description • Follows infection with certain strains of Group A beta-hemolytic streptococci • Signs and symptoms • Abdominal pain, fever, pallor, fatigue, anorexia, unexplained nosebleeds • Jones criteria aid in diagnosis of rheumatic fever • ECG is sometimes a useful diagnostic

  21. Acute Rheumatic Fever • Treatment and nursing care • Elimination of the initial infection is followed by long-term chemo-prophylaxis(prevention of disease by drugs) • Intramuscular penicillin G benzathine (Bicillin), given as an intramuscular injection every 28 days • Anti-inflammatory drugs are used to decrease pain and inflammation

  22. Acute Rheumatic Fever • Home care • Bed rest during the initial attack is not necessary but is recommended if carditis is present • Nurse must verify that parent and child understand activity limitations • Parents should provide interesting quiet activities • Long-term chemo-prophylaxis

  23. Acute Rheumatic Fever • Prevention • The nurse is involved in prevention of rheumatic fever in the community by recognizing signs and symptoms of streptococcal infections, doing screening, and referring for treatment

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