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
1
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
2
CHF - Causes• Pressure & volume overloads• Myocardial failure (contractility)• Excessive demands
3
Clinical Manifestations – CHF early
• Dyspnea, tachycardia• Tires easily• Weight loss, or lack of weight gain• Diaphoresis• Irritability
4
Late CM r/t
• Pulmonary congestion• Systemic venous congestion• Decreased myocardial function
5
Clinical Manifestations – CHF Pulmonary Congestion
• Tachypnea• Dyspnea• Exercise
intolerance
• Orthopnea • Cough, hoarseness• Cyanosis• Wheezing • Pulmonary edema
6
Clinical Manifestations – CHFSystemic Venous congestion
• Edema (periorbital, dependent)• Hepatomegaly• Splenomegaly• Ascites• Weight gain • Neck vein distention (children)
7
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
8
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
9
Goals of Treatment
• Improve cardiac function• Remove excess fluid • Decrease cardiac O2 demands• Improve tissue oxygenation (supply)• Maintain nutritional status
10
Improve Cardiac Function
• Digoxin–Positive inotropic agent–Dig toxicity
• ACE inhibitors
11
Remove excess fluid• Diuretics – Loop (Lasix)– Thiazide (HCTZ) – Potassium sparing (spironolactone)
• Nursing Interventions:
12
Decrease Myocardial O2 Demand &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
13
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
14F
Cardiac Catheterization
• Diagnostic• Treatment• Electrophysiological studies• Pre-cath teaching
15
Pre-cath assessment• Height, weight• Pulses • Last drink, void• Meds• Consent• Knowledge deficit• Skin condition• Allergies
16
Post-cath care
• Frequent VS• Groin site & pedal pulses• Leg straight 6 hours• Adequate fluid intake
17
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
18
Infective (Bacterial) Endocarditis
• Infection of valves or endocardium• All children w/CHD at risk
19
Clinical Manifestations
• Murmur• Fever, malaise• Heart failure• Increased Sed rate• Myalgias & arthralgias• Anorexia, headache
20
Infective Endocarditis• Primary Prevention– Oral hygiene– Antibiotic prophylaxis before procedures
• Secondary Intervention– IV antibiotics 2-6 weeks– Quiet activities
21
Rheumatic Fever
• Systemic inflammatory disorder• Autoimmune disorder• Peaks in school-age children• Rheumatic heart disease most serious
complication
22
Manifestations of RF
Jones Criteria: Major• Migratory polyarthritis• Carditis• Chorea• Erythema marginatum• Subcutaneous nodules
23
Diagnosis
• Recent hx of strep• Jones criteria: 2 major or 1 major and 2 minor• Jones Criteria: Minor– Fatigue– Fever– Arthralgia– Previous hx RF
24
Nursing Interventions - RF• Primary Prevention:• Secondary Prevention as Intervention– Penicillin– Comfort– Strict Bedrest – Safety – Support nutritional status– Alleviate anxiety
25
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.
26F
Hypertension
• Defined: avg. BP 95th percentile for age & sex.
• Essential (primary)• Secondary
Diagnosis• Ambulatory blood
pressure monitoring• Annual screening
starting age 3
27
Essential (Primary) HTN
• Weight reduction• Physical conditioning• Dietary modification• Relaxation techniques• Pharmacology
28
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
29
Treatment - KD
• IV Immune globulin (IVIG)• ASA• Comfort measures• Adequate hydration• Monitor cardiac status – CHF, MI• Patient irritability
30
Consequences Congenital Heart Defects
• Congestive heart failure• Hypoxemia (cyanosis)– Mild hypoxemia: 90-95%– Moderate hypoxemia: 85-90%– Severe hypoxemia: <85%
31
Classification of CHD
• “Acyanotic” or “Cyanotic” lesions
• Hemodynamic effects– pulmonary blood flow– Obstructed flow from the ventricles– Decreased pulmonary blood flow– Mixed - Hypoxemia & CHF
32
Shunt
• To divert blood flow• ‘right to left’ or ‘left to right’– ‘right to left’ – hypoxia– ‘left to right’ - CHF
33
ASD
• CMs depend on size, location• Murmur• Fatigue, DOE• Atrial dysrhythmias• TX: elective surgical closure or patch via
cardiac catheterization
34
VSD
• CMs depend on size• Poor feeding, FTT if large (CHF)• Large # close spontaneously• Tx– CHF– Patch it
35
Patent Ductus Arteriosis
• Blood flow from aorta to pulmonary arteries• Term infants: no sx (murmur)• Preterm: CHF• TX: Indocin, surgery
36
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
37
Figs. 46-5 and 46-6, pp. 1264 and 1265
UF
F
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
38
Clinical Manifestations: COA
• Infants: CHF• Older children– Dizziness, fainting, nosebleeds, HA– High BP upper extremities (HTN)– Low BP & weak pulses lower extremities
39
Treatment COA
• PGE1 to keep ductus arteriosis open (preductal )
• Elective repair age 3-5 if asymptomatic
40
“Cyanotic” Lesions
• Decreased pulmonary blood flow• Mixed - Hypoxemia & CHF
41MENUB F
Chronic Hypoxemia
• Polycythemia• Anemia r/t depletion of iron stores• Clotting abnormalities• CNS injury• Developmental delay • Clubbing of fingers
42
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.
43
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
44
Transposition of Great Arteries
• Child cannot live w/out foramen ovale or patent ductus– VSD common
• Cyanosis early – minimal response to O2
• Early surgery
45
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
46