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Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Chapter 27 Caring for the Child with a Cardiovascular Condition Susan Ward Shelton Hisley A & P Review Anatomy Chambers Valves Vessels Normal flow Physiology Cardiac output Stroke volume Chambers of the Heart Valves of the Heart Vessels of the Heart Normal Blood Flow Congestive Heart Failure Signs & Symptoms: Vary with age fluid congestion Poor feeding & growth, irritability, shortness of breath, excessive sweating Nursing Care: Positive inotropes (digoxin), diuretics (furosemide), vasodilators (captopril) Fluid restriction not often used (only in the worst cases) Congenital Heart Disease Cyanotic versus Acyanotic Congenital Heart Defects Shunting Pattern Left to right shunting Acyanotic Right to left shunting Cyanotic Segmental Classification of Congenital Heart Defects (Table 27-2) Types of Defects Septum or septae (chamber walls) Vessels & valve Conaltruncal defects Combination defects Defects in the Septum Atrial Septal Defect (ASD) Atrial Septal Defect (ASD) Signs & Symptoms: May have a murmur, a heave or a thrill Right atrial enlargement Nursing Care: Closes spontaneously or may need a surgical procedure Post-operative management Postoperative Management Record vital signs frequently Maintain “lines” Peripheral IV line Central venous pressure Intracardiac lines Assess & maintain respiratory status Monitor fluid status Assess for s/s of infection Ventricular Septal Defect (VSD) Ventricular Septal Defect (VSD) Signs & Symptoms: Large opening; (SOB, feeding difficulties, poor growth, easy fatigability & recurrent pulmonary infection) Harsh murmur with a thrill Nursing Care: Closes spontaneously or may need a surgical procedure Post-operative management (see critical nursing action Postoperative management) Atrioventricular Canal Defect (AVC) Atrioventricular Canal Defect (AVC) Signs and Symptoms: Cardiac failure (SOB, respiratory distress, periorbital edema, FTT, respiratory infections, distended liver) Nursing care: Prior to surgery; optimize cardiac output & weight gain Post-operative management Defects of the Vessels & Valves Patent Ductus Arteriosus (PDA) Patent Ductus Arteriosus (PDA) Signs & Symptoms: Murmur Frequent colds, susceptible to RSV, fatigue, poor feeding & poor growth pattern Nursing Care: Closed surgically, or with a transcatheter device Indomethacin (Indocin) Postsurgical measures (wound care, monitoring VS, adequate hydration & nutrition) Pulmonic Stenosis (PS or PVS) Pulmonic Stenosis Signs & Symptoms: Murmur, may have dyspnea Cyanosis Nursing Care: Balloon angioplasty or valvuloplasty Monitor for restenosis Reduce stressful situations Subacute Bacterial Endocarditis prophylaxis (SBE) Pulmonary Atresia Pulmonary Atresia A fatal defect if not corrected or palpitated Emergency procedure performed to save child’s life Initial prostaglandin (PGE1) is infused (maintain patency) Balloon atrial septostomy is performed to create an ASD Initial surgical repair includes a shunt or conduit Later, Fontan procedure may be needed Aortic Stenosis (AS or AVS) Aortic Stenosis (AS or AVS) Signs & Symptoms: Murmer Click or thrill Chest pain, fatigue and syncope Nursing Care: Angioplasty or valvuloplasty Repair or replace valve Medical and/or postoperative management Life-long monitoring Subacute Bacterial Endocarditis prophylaxis (SBE) Coarctation of the Aorta (CoA) Coarctation of the Aorta (CoA) Signs & Symptoms: B/P differences between the arms & legs Signs of congestive heart failure Pain in legs or cyanotic lower extremities Nursing Care: Surgery Balloon angioplasty & stent placement Postoperative management (follow-up; restenosis) Subacute Bacterial Endocarditis prophylaxis (SBE) Tricuspid Atresia (TA) Tricuspid Atresia (TA) Signs & Symptoms: Severely cyanotic, tachycardiac & dyspneic Heart murmur Nursing Care: Prostaglandin (PGE1) Emergent Balloon atrial septostomy Numerous surgical repairs Postoperative management Total Anomalous Pulmonary Venous Return (TAPVR) Total Anomalous Pulmonary Venous Return (TAPVR) Signs & Symptoms: Cyanosis, respiratory distress, lethargy, poor & rapid breathing, poor feeding, frequent respiratory infections & signs heart failure Nursing Care: Surgical repair Routinely followed (every 1-2 years) Subacute Bacterial Endocarditis prophylaxis (SBE) Conal Truncal defects Transposition of the Great Arteries or Vessels (TGA or TGV) Transposition of the Great Arteries or Vessels (TGA or TGV) Signs & Symptoms: Appear at birth Cyanosis, SOB, poor feeding, clubbing of fingers & toes Nursing Care: Surgical repair (arterial switch operation) Postoperative management Subacute Bacterial Endocarditis prophylaxis Truncus Arteriosus Truncus Arteriosus Signs & Symptoms: Cyanosis Congestive heart failure Low cardiac output Nursing Care: Inotropic medications Postoperative management Subacute Bacterial Endocarditis prophylaxis (SBE) Combination Defects – Tetrology of Fallot (TOF) Tetrology of Fallot (TOF) Signs & Symptoms: Cyanosis with crying or playing “TET" spells Nursing Care: Surgical repair Postoperative management Subacute Bacterial Endocarditis prophylaxis (SBE) Complex or Single Ventricle Type Defects – Hypoplastic Left Heart Syndrome (HPLS) Hypoplastic Left Heart Syndrome (HLHS) Signs & Symptoms: Inadequate cardiac output Nursing Care: Artificial shunt or pathway created shortly after birth Prostaglandin (PGE1) given Numerous surgical repairs (cardiac transplant) Palliative care measures Cardiac Diseases Subacute Bacterial Endocarditis (SBE) Signs & Symptoms: Vague (low-grade fever, malaise, loss of appetitive & muscle aches Acute (high fever, chills, sweating, stiff joints or back pain) As the condition worsens symptoms of heart failure occur Nursing Care: Antibiotics Prevention (see Prophylaxis Guidelines) Valve destruction needs repair or replacement Kawasaki Disease Signs & Symptoms: Vasculitis affecting all organ systems Fever (5 days or more 104F° [40C°]) Skin rash Cervical lymphadenopathy Edema & erythema of hands & feet (peeling) Strawberry tongue Conjunctivitis without exudate Nursing Care: IV immunoglobulin (IVIG) Aspirin (ASA) Steriods, plasma exchange, Cytotoxic agents Clinical alert: aneurysm formation Frequent follow-up visits Exercise stress test Cardiomyopathy (CM) Signs & Symptoms: Vague symptoms; (weakness, excessive tiredness, exercise intolerance, SOB, exercise intolerance, heart palpitations, chest pain, poor feeding, slow weight gain, fainting or lightheadedness) Nursing Care: Medications (ACE inhibitors) or angiotension receptor blockers Beta blocker therapy Nutritional supplementation Diuretic and inotropic therapy Followed closely Activity restrictions Cardiac transplant Rheumatic Fever (RF) Group A-hemolytic streptococcal infection affecting the heart, joints, subcutaneous tissue & nervous system Cause permanent damage (aortic & mitral valves involved) Require valve replacement Additional Cardiac Conditions Cardiac Trauma Signs & Symptoms: Related to the type of cardiac trauma sustained Nursing Care: Based on exact type of injury Bedrest, activity restrictions Antiarrhythmics & inotropic agents Pericardiocentesis Cardiac rehabilitation program Hypercholesterolemia-Hyperlipidemia Primary or Secondary Condition: Primary - hereditary predisposition Secondary – exogenous Treatment goals: Know cholesterol levels in children Diet modification Exercise Medication Hypertension Signs& Symptoms: Depend on underlying cause Elevated blood pressure (see Table 21-2) Nursing Care: Education about the condition, diet, exercise, lifestyle modification Medication (beta-blockers & angiotensin-converting enzyme (ACE) inhibitors Idiopathic Primary Pulmonary Arterial Hypertension (IPAH) Signs & Symptoms: SOB, chest pain, weakness, fatigue, dizziness, leg swelling & fainting episodes Nursing Care: Prostacyclin (Flolan) dilates blood vessels & decreases pulmonary vascular resistance Inhaled nitric oxide relaxes pulmonary (not systemic) vessels Sildenafil (Revatio) decreases pulmonary artery pressures Bosentan (Tracleer) blocks hormone that causes vasoconstriction Neurally Mediated Syncope (NMS) Signs & Symptoms: A fainting spells (may experience a seizure) Nursing Care: Increase sodium & water intake Fludrocortisione (Florinef) Beta-blocker Monitor (frequency, severity & precipitating factors) Long Q-T Syndrome Signs & Symptoms: fainting, palpitations, seizure or death Nursing Care: Beta-blockers Pacemaker-defibrillator insertion Left cardiac sympathetic denervation Medication compliance Rhythm Disturbances The nurse who can determine the baseline rhythm and recognize changes will facilitate the best outcome for a child with an arrhythmia Important questions: Is the rhythm potentially fatal? Will it alter the cardiac output? Invasive Tests Cardiac Catheterization: Determines the pressures in heart & radiographic picture of heart anatomy Interventional catheterization is a corrective procedure Post Catheterization: Monitor - pressure dressing in the groin, heart rate, respirations & blood pressure Angiography: Visualizes the structures & function of the ventricles, vessels & valves; size & location of septal defects; directs medical treatment Biopsy: Routine biopsies to assess for cardiac transplant rejection Closure devices: Close simple intracardiac communications or shunts Opening devices: Angioplasty or Valvuloplasty Opens narrow vessels or valves Balloon atrial septostomy: Emergent palliative procedure necessary to keep the child alive Surgical Interventions Complete or palliative repair (Table 27-4) Pacemakers Used to treat cardiac conditions; internal or external; temporary or permanent Postoperative; watch for s/s of infection & ensure incision remains Follow-up care requires routine pacemaker testing Cardiac Transplantation Corrects and prevents the condition from progressing Nursing Care: Educate regarding medication compliance Communicating to family about frequent follow-up visits Educate family about post transplant tests & rejection Address emotional & psychological issues Address alterations in growth & development Nursing Care for the Child with a Cardiac Condition Admission to the PICU (highly trained nurses) Assessment Nutrition Hygiene Activity Psychosocial care Vital signs Maintaining growth & development Administering medications Performing lab tests Interpreting an ECG Transferring the Stable Child to a Surgical or Medical Unit Children have a more stable condition Telemetry monitoring Take less frequent vital signs Consider growth & development Medications Draw blood for laboratory analysis ECG monitoring Caring for Children with Cardiac Conditions Across Care Settings Parent knows the child the best School Automatic external defibrillator Personnel should complete a CPR course Vital signs & medication Teach the child & family Cardiopulmonary Resuscitation (CPR) Vital Signs Medication Disease entity Resources