module 5 pediatric cardiac disorders. fetal circulation
TRANSCRIPT
Module 5 Pediatric Cardiac
Disorders
Fetal Circulation
Fetal Circulation
Fetal Circulation
What is the stimulus for
the change in circulation?
Intrauterine to Extrauterine
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
Congestive Heart Failure
What is wrong with the What is wrong with the heart? heart?
Congestive heart failure
What is the effect on: Heart rate Preload Contractitility
Afterload
Congestive Heart Failure
Why does the pump fail?Why does the pump fail?
Etiology and Pathophysiology
Congestive Heart Failure
What does the body do
to compensate for this
congestion and heart failure?
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 Mechanisms
With a decrease in cardiac output
Decrease perfusion to the kidneys and
glomerulus
Increased renin and ADH secretion
Increase in Na and H2O retention to increase intravascular volume
Early Signs of CHF
The earliest signs are often subtle:
Infant will have mild resting tachypnea
Increasing difficulty feeding
Signs and Symptoms Pulmonary congestion
1. Tires easily during feeding2. Tachypnea, Dyspnea, orthopnea3. Signs of respiratory distress4. Wheezing, rales and rhonchi5. Easily fatigue
Impaired cardiac output1. Tachycardia2. Extremities cool, capillary refill >2
seconds3. Diaphoretic, sweating, hypotension
Signs and Symptoms
Systemic venous congestion1. Hepatomegaly2. Edema3. Weight gain
High metabolic rate1. Failure to thrive2. Slow weight gain
Goal of Treatment
Treatment of Congestive Heart Failure
Medication Therapy Digitalis – increases contractility and
decreases heart rate. ACE-inhibitors - blocks release of
angiotension-aldosterone; arterial vasodilator / afterload reducing agent
Diuretics - enhance renal secretion of sodium and water by reducing circulating blood volume and decreasing preload, pulmonary congestion.
Beta Blocker - increases contractility
Nursing Care
How would the nurse recognize digitalis
toxicity in an infant or child?
What are the pulse rate criteria in administration
of digitalis?
Digitalis 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- bradycardia Vomiting – very rare in infants
Digitalis
Why are we so concerned with the potassium levels when the child is on digitalis therapy?
Treatment of Congestive Heart Failure
What is the type of Diet most commonly ordered?
How would nursing measure are used to decrease stress on the heart?
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 q 3 h, 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 Cardiac CatheterizationCatheterization
Measure oxygen saturations and pressure in the cardiac chambers and
great arteries
Evaluate cardiac output
Cardiac Catheterization This process involves
passing a catheter through the femoral vein or artery into the heart.
Performed to evaluate
heart valves, heart function and blood supply, or heart abnormalities in newborns.
Cardiac Catheterization Pre-care:
History and Physical Lab work – EKG, ECHO cardiogram, CBC NPO Vital signs Preprocedural teaching
Best Nursing Action
During post procedure assessment, the nurse notes bleeding at the insertion site.
What should the nurse do first?
What additional interventions are implemented?
Post Cardiac Catheterization Care
Post Cardiac Catheterization Care
Congenital Cardiac Congenital Cardiac AnomaliesAnomalies
Ask Yourself?
What is the most common assessment finding indicating a cardiac anomaly?
Answer: an audible heart murmur
Patent Ductus ArteriousAtrial septal defects
Ventricle septal defects
Atrial Septal Defect
1. Oxygenated blood is shunted from left to right side of the heart via defect
2. A larger volume of blood than normal must be handled by the right side of the heart hypertrophy
3. 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
Treatment
Medical Management Medications – digoxin
Cardiac Catheterizaton - Amplatzer septal occluder
Open-heart Surgery
Treatment
Device Closure – Amplatzer septal occluder
During cardiac catheterization the occluder is placed in the Defect
Ventricle Septal Defect
1. Oxygenated blood is shunted from left to right side of the heart via defect
2. A larger volume of blood than normal must be handled by the right side of the heart hypertrophy
3. 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
Treatment
Surgical repair with a patch inserted
Patent Ductus Arteriosus
1. Blood shunts from aorta (left) to the pulmonary artery (right)
2. Returns to the lungs causing increase pressure in the lung
3. Congestive heart failure
Treatment for PDA Medical Management
Medication Indomethacin - inhibits prostaglandin's .
(When levels of prostaglandins are decreased, the ductus closes)
Surgery
Ligate the ductus arteriosus
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
Pulmonic stenosis
coarctation of aorta
Pulmonic Stenosis
Narrowing of entrance that decreases blood flow
Increases preload causes right ventricular hypertrophy
Obstructive or Stenotic Lesions
Treatment: Medications – Prostaglandins to
keep the PDA open
Cardiac Catheterization Baloon Valvuloplasty
Surgery Valvotomy
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 Stenosis
Symptoms Poor peripheral perfusion,
feeding difficulties, CHF
Treatment Balloon valvoplasty Surgery
Coarctation of the Aorta
1. Narrowing of Aorta causing obstruction of left ventricular blood flow
2. Left ventricular hypertrophy
Signs and Symptoms
1.What are B/P findings support the diagnosis?
2.What is different in the pulses?
3.Why would the patient C/O leg pains?
4.What causes nose bleeds?
Treatment 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
1. Resect
narrow
area
2. Anastomosis
Tetralogy of fallot
Tetralogy of Fallot
Four defects are:
1.
2.
3.4.
Signs and Symptoms1. Failure to thrive
2. Squatting
3. Lack of energy
4. Infections
5. Polycythemia
6. Clubbing of fingers
7. Cerebral abscess
8. Cardiomegaly
Ask Yourself?
Why does Polycythemia occur in a child with a cardiac disorder?
What nursing interventions should be included when planning care for this child?
What lab test will be abnormal and assist in confirming the polycythemia?
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
Hypercyanotic Episode / “tet” spells
Cyanosis suddenly worsens in response to activity, such as crying, feeding, or having a bowel movement.
Signs - The infant becomes very short of breath with tachypnea and hyperpnea, and may lose consciousness.
Treatment – calming, knee-chest position, oxygen, morphine , and beta-blockers
Treatment
Open-heart Surgical interventions Blalock – Taussig or Potts
procedure – increases blood flow to the lungs.
View the Movie TrailerAbout Blalock procedure to
treat Tetralogy of fallot
Something the Lord Made
•Truncus Arteriosus•Transportation of Great
Vessels
These present the greatest risk to survival
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
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.
artery
aorta
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: Assessment:
Fever Fatigue Muscle and joint pain Headache Nausea and vomiting CHF Spleenomegaly
Diagnosis: Blood cultures Echocardiogram
Infective Endocarditis
Diagnosis
Blood cultures
Echocardiogram Show the vegetation
Who is more susceptible to develop infective endocarditis?
What is the most therapeutic intervention for preventing 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
Treatment Monitor temperature Antibiotics – 2-8 weeks
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.
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
Major Carditis Polyarthritis Chorea Erythema
marginatum Subcutaneous
nodules
Minor Arthralgia Fever Laboratory
Findings:
Erythrocyte sedimentation rate
C-reactive protein
Prolonged PR interval
Jones Criteria
What additional laboratory test helps
to confirm the diagnosis of
Rheumatic Fever ?
Rheumatic Fever
Treatment Antibiotic Therapy Antipyretics - aspirin Anti-inflammatory agents –steroids Rest Heat and cold to joints
Discharge Teaching Antibiotic therapy - be sure to
complete all medication.
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
Multisystem vasculitis – inflammation of blood vessels in the body especially the coronary arteries with antigen-antibody
complexes.
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.
Acute Phase – 10-14 days Fever, which often is higher than 101.3 F,
and lasts one to two weeks Extremely red eyes (conjunctivitis) without thick discharge Red, dry, cracked lips and an extremely
red, swollen tongue ("strawberry" tongue) A rash on the main part of the body
(trunk) and in the genital area Swollen, erythema on the palms of the
hands and the soles of the feet Swollen cervical lymph nodes
Subacute Phase 15-25 days Irritability
Anorexia
Desquamation of the skin on the hands and feet, especially the tips of the fingers and toes, often in large sheets
Arthritis and Arthralgia
Arrhythmias
Coronary aneurysms
Convalescent Phase
From day 26 until the erythrocyte sedimentation rate returns to normal
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
Which phase of Kawasaki is this child exhibiting?
Inflamed, Cracked, Peeling Lips
Strawberry tongue
Kawasaki Disease