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Cardiac Conditions in Children Nursing Assessment and
Interventions
Kathryn Kushto-ReeseKathryn Kushto-Reese
Leading Causes of Infant Leading Causes of Infant DeathsDeaths20062006
Anatomy/Physiology OverviewAnatomy/Physiology Overview
ChambersChambers ValvesValves
– AV (tricuspid & mitral)AV (tricuspid & mitral)– Semilunar (pulmonic & Semilunar (pulmonic &
aortic)aortic)
FlowFlow SaturationsSaturations
Normal Blood FlowNormal Blood Flow
Dexoygenated blood returns from the body Dexoygenated blood returns from the body through the SVC/IVC through the SVC/IVC →→ RA RA →→ tricuspid valve tricuspid valve →→ RV RV →→ pulmonic valve pulmonic valve →→ pulmonary artery pulmonary artery →→
then to the lungs where blood getthen to the lungs where blood gets oxygenated. s oxygenated.
This blood then returns via pulmonary veins This blood then returns via pulmonary veins →→ LA LA →→ mitral valve mitral valve →→ LV LV →→ aortic valve aortic valve →→ and out the aorta to the body.and out the aorta to the body.
NORMALNORMAL HEART HEART
Newborn PhysiologyNewborn Physiology Pulmonary vs. Systemic PressuresPulmonary vs. Systemic Pressures
In UteroIn Utero At BirthAt Birth
Fetal ShuntsFetal Shunts– Ductus arteriosus (Ductus arteriosus (conduit from pulmonary conduit from pulmonary
artery to aorta)artery to aorta)– Foramen ovale Foramen ovale (flapped opening between right (flapped opening between right
and left atria)and left atria)– Ductus venosus Ductus venosus (bypass liver)(bypass liver)
Pulmonary and Systemic Pulmonary and Systemic PressuresPressures
In utero – In utero – ↑ pulmonary pressure ↑ pulmonary pressure before birth: before birth: due to lungs being a fluid filled due to lungs being a fluid filled
system, the lungs are a higher pressure system system, the lungs are a higher pressure system than the systemic circulationthan the systemic circulation
After birth – After birth – ↑ systemic pressure↑ systemic pressure now that the lungs are filled with air, the lungs now that the lungs are filled with air, the lungs
are a lower pressure system than the systemic are a lower pressure system than the systemic circulationcirculation
The blood will follow the path of least resistanceThe blood will follow the path of least resistance
Assessment: Cardiac FunctionAssessment: Cardiac Function
Inspect chest/Palpate Heart Sounds: murmurs Quality of Pulses/Central Respiratory: effort and quality of
respirations
Pulses: Extremities (peripheral)– Cyanosis (central also)– Capillary refill time– Temperature /color
ASSESSMENT ASSESSMENT
Assessment: Cardiac Function(continued)
Renal – Urine output, edema, hepatomegaly
Vital Signs– Heart rate, quality and symmetry, BP– Peripheral pulses, check for symmetry
Neurological Restless, irritable, decreased response to
environment
ASSESSMENTASSESSMENT
Congestive Heart FailureCongestive Heart Failure
A condition in which the heart is unable to A condition in which the heart is unable to provide adequate cardiac output to meet the provide adequate cardiac output to meet the circulatory and metabolic requirements of circulatory and metabolic requirements of the body.the body.
Failure may initially be right- or left-sided but Failure may initially be right- or left-sided but if left untreated, the entire heart will failif left untreated, the entire heart will fail
Congestive Heart Failure (CHF)
Causes:
– Heart muscle dysfunction
– Structural abnormalities
– Pulmonary abnormalities
– Systemic disease
– Infections
– Syndromes
ExamplesExamples
Obstructive lesions in heartObstructive lesions in heart DysrhythmiasDysrhythmias Increased blood flow to lungs (VSD)Increased blood flow to lungs (VSD) MyocarditisMyocarditis Chemotherapy drugs Chemotherapy drugs SepsisSepsis Respiratory failureRespiratory failure
CHF SymptomsCHF SymptomsSystemic Venous Congestion (rt sided)Systemic Venous Congestion (rt sided)
HepatomegalyHepatomegaly
Peripheral edema, ascitesPeripheral edema, ascites
Pulmonary Venous Congestion (left sided)Pulmonary Venous Congestion (left sided)
TachypneaTachypnea
Central cyanosisCentral cyanosis
Dyspnea, Dyspnea, WOB, rales, wheezing, nasal WOB, rales, wheezing, nasal flaring , grunting, coughflaring , grunting, cough
Others: lethargy, irritability, altered LOCOthers: lethargy, irritability, altered LOC
CHF SymptomsCHF Symptoms
Decreased Myocardial FunctionDecreased Myocardial Function CardiomegalyCardiomegaly TachycardiaTachycardia Extremities cool, Extremities cool, capp refill, etc…capp refill, etc… Failure to thrive, difficulty feeding , poor Failure to thrive, difficulty feeding , poor
weight gainweight gain Peripheral cyanosis/mottlingPeripheral cyanosis/mottling DiaphoresisDiaphoresis
ASSESSMENTASSESSMENT
CHF ManagementCHF Management
Increase oxygen supplyIncrease oxygen supply– Oxygen therapy, raise HOBOxygen therapy, raise HOB– Correct anemiaCorrect anemia
Decrease oxygen demandDecrease oxygen demand– Remove “work” (breathing, feeding, teach Remove “work” (breathing, feeding, teach
parents feeding techniques ( NG/GT feeds)parents feeding techniques ( NG/GT feeds)– Rest, group cares, emotional supportRest, group cares, emotional support
CHF ManagementCHF Management
Decrease oxygen demandDecrease oxygen demand– Treat feverTreat fever– Treat dysrhythmias (Digoxin, Adenosine, B-Treat dysrhythmias (Digoxin, Adenosine, B-
blockers)blockers)
CHF ManagementCHF Management
Increase cardiac outputIncrease cardiac output– Increasing stroke volumeIncreasing stroke volume
Digoxin - Digoxin - ( mcg/kg/24hr.) Increase in force of myocardial contraction and Increase in force of myocardial contraction and
decreases conduction through SA and AV nodes (decreases conduction through SA and AV nodes (+ + inotropic / - chronotropic)inotropic / - chronotropic)
Inotropic supportInotropic support– DopamineDopamine * Dobutamine* Dobutamine– MilrinoneMilrinone * Epinephrine* Epinephrine
CHF ManagementCHF Management
Increase cardiac output by:Increase cardiac output by:– Decreasing afterloadDecreasing afterload
ACE Inhibitors such as Captopril/EnalaprilACE Inhibitors such as Captopril/Enalapril– Blocks conversion of angiotensin I to angiotensin II Blocks conversion of angiotensin I to angiotensin II
(vasoconstrictor)(vasoconstrictor)
VasodilatorsVasodilators– IV (Nitroglycerine, Nitroprusside, Milrinone)IV (Nitroglycerine, Nitroprusside, Milrinone)– Inhaled -- ?? (there are 2)Inhaled -- ?? (there are 2)
CHF ManagementCHF Management
Control fluid statusControl fluid status– Diuretics ( Lasix, SpironolactoneDiuretics ( Lasix, Spironolactone
– Limit PO intake (initially) fluid/sodium Limit PO intake (initially) fluid/sodium restrictions, daily ( bid) weights and maintain restrictions, daily ( bid) weights and maintain nutritional statusnutritional status
Address underlying disorderAddress underlying disorder
Nursing DiagnosesNursing Diagnoses Decreased cardiac outputDecreased cardiac output Altered tissue perfusion, cardiopulmonaryAltered tissue perfusion, cardiopulmonary FatigueFatigue Fluid volume excessFluid volume excess Activity intoleranceActivity intolerance Impaired physical mobilityImpaired physical mobility Sleep pattern disturbanceSleep pattern disturbance AnxietyAnxiety Altered growth and developmentAltered growth and development
Congenital Heart Defects
ETIOLOGYETIOLOGYGENETIC FACTORS/ CHROMOSOMAL GENETIC FACTORS/ CHROMOSOMAL
ABNORMALITIESABNORMALITIES
TERATROGENSTERATROGENS
MATERNAL INFECTIONSMATERNAL INFECTIONS
ENVIRONMENTAL EXPOSURESENVIRONMENTAL EXPOSURES
PREMATURITYPREMATURITY
ADVANCED MATERNAL AGEADVANCED MATERNAL AGE
PREGANCY COMPLICATIONPREGANCY COMPLICATIONSS
Congenital Heart Defects
Defects that increase pulmonary blood flow
– Patent Ductus Arteriosus (PDA)– Atrial Septal Defect (ASD) – Ventricular Septal Defect (VSD)– Atrioventricular Canal Defect (AVC)
Ventricular Septal Defect (VSD)
Most Common Most small /close spontaneously Symptoms of congestive heart failure
may occur/ especially if significant size Child has failure to thrive/ fatigue,
respiratory s/s, pulmonary hypertension Murmur ( turbulent flow through
abnormal or obstructive openings
VSDVSD
?? Increased Pulmonary Blood Flow
VSD Repair
Post -opPost -op
Obstructive Defects Defects
Coarctation of the AortaCoarctation of the Aorta
Aortic StenosisAortic Stenosis
Coarctation of Aorta
Chest x rayChest x ray
Obstructive Defects Defects
Coarctation of Aorta , Incidence Pathophysiology: obstruction of
systemic blood flow at the narrowed or strictured part.– Symptoms: high blood pressure and bounding
pulses in arms weak or absent femoral pulses, cool lower
extremities blood pressure in lower extremities CHF in infants
– Surgical treatment: Timing
Congenital Heart Defects (continued)
Defects That Decrease Pulmonary Blood Flow
–Tetralogy of Fallot
–Pulmonary Stenosis
–Pulmonary Atresia
Tetralogy of Fallot has 4 defects1.Right Ventricular Hypertrophy2.Overriding Aorta3.Ventricular Septal defect4.Pulmonic Stenosis
Tetralogy of Fallot (TOF)
Symptoms: cyanosis, systolic murmur, Metabolic acidosis , poor growth,
clubbing, severe hypoxia (“tet spells”)
Surgical treatment: palliative shunts and complete repair
Abby with TOFAbby with TOF
Clubbing of fingersClubbing of fingers
Hyper cyanotic or Tet Spells
Occur most frequently in 1st yr of life May be preceded by feeding, crying or
defecation, fever, dehydration. stress Characterized by profound hypoxemia,
blue extremities, circumoral cyanosis, increased hgb and hct counts.
Require prompt assessment and treatment to prevent brain damage or death.
““TET SPELL “TET SPELL “
Treatment: “Tet Spells”
Place infant in knee-chest position Older child will instinctively squat Maintain a calm comforting
approach Administer 100% oxygen Administer Morphine Administer fluids Propanolol for frequent Tet spells
Modified Blalock-Taussig
Final RepairFinal Repair
Mixed DefectsMixed Defects
HLHS ( Hypoplastic Left Heart HLHS ( Hypoplastic Left Heart SyndromeSyndrome
Structures on left side of heart Structures on left side of heart underdevelopedunderdeveloped
Mitral and Aortic valves closed or smallMitral and Aortic valves closed or small Left ventricle non functionalLeft ventricle non functional 44thth most common Congenital heart most common Congenital heart
defectdefect
HLHSHLHS
Right side of heart is the working partRight side of heart is the working part Blood lungs Blood lungs → left Atrium through an → left Atrium through an
ASD to right side of heart.ASD to right side of heart. Right ventricle pumps blood to lungs and Right ventricle pumps blood to lungs and
also to systemic circulation through a PDA.also to systemic circulation through a PDA. Few days – weeks ductus closed death Few days – weeks ductus closed death
resultsresults..
HLHSHLHS
SymptomsSymptoms
Bluish/ CyanoticBluish/ Cyanotic Rapid pulse, murmur and Rapid pulse, murmur and ↑↑RRRR Cold hands and feetCold hands and feet LethargicLethargic Decreased pulses in extremities, Decreased pulses in extremities, ↓ pulse ox↓ pulse ox Poor sucking and feedingPoor sucking and feeding Increased respiratory effort and WOBIncreased respiratory effort and WOB OrganomegalyOrganomegaly
Treatment /PrognsisTreatment /Prognsis
Prostaglandins in newborn to keep PDA Prostaglandins in newborn to keep PDA openopen
Multiple Stage surgical repairMultiple Stage surgical repair Blalock-Taussig shuntBlalock-Taussig shunt Glenn procedureGlenn procedure Fontan Procedure ( final )Fontan Procedure ( final ) Chronic Health problems , earliest survivors Chronic Health problems , earliest survivors
in 30’sin 30’s→ Heart Transplant→ Heart Transplant
Diagnostic Tools
Chest X-ray ECG Echocardiogram
– Transesophageal echocardiogram
Cardiac Catheterization– Done under conscious sedation– Can be diagnostic or interventional– Post procedural care
TreatmentsTreatments
Surgical InterventionSurgical Intervention Surgical repair/corrective surgerySurgical repair/corrective surgery Palliative surgery/ temporaryPalliative surgery/ temporary Interventional Cardiac CatheterizationInterventional Cardiac Catheterization
1. Open narrowed passages1. Open narrowed passages
2. Closure of openings pp. 907 text ,2. Closure of openings pp. 907 text ,
table 26-7.table 26-7.
Chest x rayChest x ray
Echocardiogram of VSDEchocardiogram of VSD
Purpose of a CathPurpose of a Cath
DiagnosticDiagnostic– Define anatomyDefine anatomy– Measure pressuresMeasure pressures– Measure O2 contentMeasure O2 content– Calculate shunts, resistance, Calculate shunts, resistance,
COCO– All of above is frequently All of above is frequently
done off and on oxygen, done off and on oxygen, then on NOthen on NO
Interventional CathInterventional Cath– Close PDA, ASD/PFO, VSDClose PDA, ASD/PFO, VSD– Close collateral vesselsClose collateral vessels– Balloon dilate narrowed Balloon dilate narrowed
vessels or valvesvessels or valves– Place stents in narrowed Place stents in narrowed
vesselsvessels
Angioplasty/ dilation of Coarctation of Angioplasty/ dilation of Coarctation of Aorta during cardiac catheterizationAorta during cardiac catheterization
PDA ClosurePDA Closure
Cardiac Cath procedureCardiac Cath procedure
Assess for : Assess for : Circulation: cool extremities,Circulation: cool extremities,
pedal pulses, capp refill pedal pulses, capp refill
3 sec., decreased 3 sec., decreased
Sensation and mobilitySensation and mobility Complications: bleeding, Complications: bleeding,
arrhythmias, hematoma, arrhythmias, hematoma,
thrombus, and infection.thrombus, and infection.
Post ProcedurePost Procedure
VS are q 15” x 4; q 30” x 2; q 1h x 2 then IMC VS are q 15” x 4; q 30” x 2; q 1h x 2 then IMC routineroutine
Stay on boards/supine x 2 hours Stay on boards/supine x 2 hours With each set of V/S and prn, monitor:With each set of V/S and prn, monitor:
– Perfusion (arterial and venous) to distal extremity Perfusion (arterial and venous) to distal extremity (pulses, color, CRT, temp)(pulses, color, CRT, temp)
– Bleeding/hematoma formation at site Bleeding/hematoma formation at site If no bleeding at site and palpable distal pulse, If no bleeding at site and palpable distal pulse,
may come off boards/sit up after designated may come off boards/sit up after designated timetime
Post Procedure ManagementPost Procedure Management
Antibiotics (Ancef 25mg/kg) x 2 dosesAntibiotics (Ancef 25mg/kg) x 2 doses Aspirin (3-5mg/kg) to start same night for Aspirin (3-5mg/kg) to start same night for
device placementdevice placement CXR next morning if ASD or PDA device CXR next morning if ASD or PDA device
placedplaced Echo next morning if ASD or PDA device Echo next morning if ASD or PDA device
placedplaced ““Discomfort” Control - acetaminophenDiscomfort” Control - acetaminophen
Going HomeGoing Home
May go home 4-5 hours after a diagnostic May go home 4-5 hours after a diagnostic cathcath
Will stay overnight and get d/c’d in AM after Will stay overnight and get d/c’d in AM after most interventionsmost interventions
Will return to school 2-3 days after Will return to school 2-3 days after procedureprocedure
PE class/sports participation may be limited PE class/sports participation may be limited based on interventionbased on intervention
Potential ComplicationsPotential Complications
MiscellaneousMiscellaneous– ThromboembolismThromboembolism– InfectionInfection
Retroperitoneal Bleeds Retroperitoneal Bleeds Pressure SoresPressure Sores Brachial Plexus InjuryBrachial Plexus Injury Effusion / tamponadeEffusion / tamponade
Surgery: Post Operative Care Monitoring and assessment
– Vital signs, arrhythmias, decreased cardiac output, hypoxia, infection, S/S CHF, respiratory compromise
– Arterial / venous pressure– Fluids– Neurological changes
Provide rest and comfort Pain control Support family
Cardiac Transplant
Improved CHD Management New Surgical Techniques Transplant Improved Survival of Transplant ECMO