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Nursing Care of the Child
with Cardiovascular
Illness
Topics to know
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Fetal & newborn circulation
Cardiac development
Cardiac defects
Congestive Heart Failure
Rheumatic Fever
Kawasaki Disease
Infective Endocarditis
Normal Cardiac Cycle
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
FIGURE 26–2
ventricle.
A, Fetal (prenatal) circulation. B, Pulmonary (postnatal) circulation. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right
Development
• Infant heart
• Size – Which side is larger at birth?
• Ventricle wall thickness affects BP
• <1 year
• >1 year
BP in Children:
Diastolic/ Systolic
• Birth (12 Hr, <1000g): 39-59 / 16-36 mmHg
• Birth (12 hr, 3 kg):
50-70/ 25-45 mmHg
• Neonate (96hr):
60-90/ 20-60 mmHg
• Infant (6 mo):
87-105/ 53-66 mmHg
• Toddler (2 yr):
95-105/ 53-66 mmHg
• School Age (7yr):
97-112/ 57-71 mmHg
• Adolescent (15yr):
112-128/ 66-80 mmHg
Development
• Infant heart
• Ability to compensate
• Heart can only regulate _________________ to compensate.
• Oxygenation
• Normal saturation for infant - > ________%
• < 95% - abnormal
• <______% for 30 seconds or longer = major hypoxic
event (neurological damage imminent)
• Effect of hypoxemia
• What causes cardiac arrest in kids?
Congenital Heart
Defects
Heart Defects
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Occur mostly during the first 8 weeks of gestation
Why?
Murmur
May or may not be symptomatic
Sx: activity intolerance, chest pain, arrhythmia,
syncope, & sudden death
Diagnostic Tests
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H&P
CXR/CT/MRI
Echocardiogram
EKG
ABGs
Cardiac Catheterization
• Post-cath care
Types of Defects
• Increased Pulmonary Blood Flow
• Decreased Pulmonary Blood Flow
• Mixed Defects
• Obstructed Systemic Blood Flow
Increased Pulmonary Blood Flow
• _____ to ______
shunting
• Increased pulmonary
vascular resistance
• Defects:
• Septal Defects
• ASD (Atrial)
• VSD (Ventricular)
• Most common heart
defect
• Patent Ductus
Arteriosus (PDA)
Name That Defect
A
B
C
Signs and Symptoms
• CHF sx – d/t overload of blood on ____________ system
• _______________ HR & RR; ______________ metabolic rate
• Tire out with ADL’s
• Diaphoresis with feeding; poor weight gain; dyspnea, tachypnea,
intercostal retractions, periorbital edema
• Prone to _________________ infection
• VSD most common type of heart defect
Decreased Pulmonary Blood Flow
• Defects:
• Pulmonary Stenosis (PS)
• 2nd most common heart
defect
• Acyanotic Defect
• Tetrology of Fallot (TOF)
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Cyanotic Defect
Tetralogy of Fallot
Four defects with this disorder:
IHOP
• Intraventricular septal defect
(VSD)
• Hypertrophy of right ventricular
• Overriding aorta
• Pulmonic stenosis
Right to Left shunting
Signs and Symptoms:
Right to Left shunting
Initial s/s: cyanosis
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degree of cyanosis directly r/t pulm blood flow
Worsens when pt cries, feeds, or does anything
that causes an increased metabolic rate
•more O2 demands on tissues=cyanosis
•Other symptoms:
•dyspnea, loud murmur
•polycythemia, clotting
•chronic hypoxemia
•clubbing, fatigue, exertional dyspnea, delayed
development
•difficulty sucking with feeds
•d/t needing breaks for breathing
•diaphoresis
•Poor wt gain
•d/t inability to consume enough calories to keep up with increased metabolic
rate
Clinical Manifestations
• PDA closure worsens condition
• S/S determined by degree of __________________
• Instinctive Squatting
• Hypercyanotic Spells (“Tet” Spells)
• Caused by rapid drop of oxygen in blood
• Preceded by feeding, crying, defecation
• Acutely cyanotic
• Can happen with transposition of great vessels too!
Nursing Interventions
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___________________
Be calm and comforting
Decrease _________ &
_________________ stimuli
• Administer 100% oxygen
• IV fluid
• Morphine or Propranolol may
be needed
Treatment?
Mixed Lesions &
Obstructed Systemic Blood Flow
Mixed Lesion
• Transposition of
the Great Arteries
(TGA)
• Requires PDA until
surgery can correct
lesion
Hypoplastic Left
Obstructed
Systemic Flow
Heart
• Coarctation of the
Aorta (Coarc)
• Increased pressure
load in ventricles &
decreased output
• Transposition of the Great Arteries
• Requires ___________________ to
sustain life until surgery
• Why?
• How?
• Signs and Sx: d/t reversed circulation
• Coarc aka Aortic Stenosis
• Signs and Sx: d/t decreased
systemic circulation/perfusion
• Decreased pulses – where?
• Bounding pulses – where?
• Poor color
• Decreased: cap refill; urine
output
• Decreased blood pressure –
where?
• What complication can occur?
Congestive Heart Failure
• Definition: Inability of the heart to pump an adequate
amount of blood to the systemic circulation at normal
filling pressures to meet the body’s metabolic demands
• Most often due to congenital heart defects
S/S CHF
• Tachycardia
• ______________
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Poor perfusion
Tachypnea
Dyspnea
Retractions
Pale/cyanosis
Crackles
Exercise intolerance
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Orthopnea
Restless
Diaphoresis
______________ urine output
Poor feeding
Developmental delay
Edema
Weight gain (from
_____________)
• Failure to Thrive (FTT)
S/S from Impaired Cardiac Output
Cyanosis
Tachycardia
Weak pulses
Capillary refill >2sec
Decreased UOP
Pale, cool extremities
Hypotension (LATE SIGN)
Cardiomegaly
Anorexia
Fatigue, tiring w/ play, restlessness
Heart Murmurs
S/S from Pulmonary Venous
Congestion
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Tachypnea
Dyspnea
Crackles, wheezing
Respiratory Distress
• Retractions, nasal flaring, grunting
• SOB on exertion
• Cyanosis
• Increased tachypnea & diaphoresis w/ feeding
S/S from Systemic
Venous Congestion
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Weight gain (retained fluids)
Hepatomegaly with tenderness
Peripheral edema, especially Periorbital
Ascites
Neck vein distention (older kids)
Dependent edema (older kids)
Goals
• Improve cardiac output/function
• Remove excess fluid
Management: Digoxin
• Improve cardiac function
• Digoxin (Lanoxin [50
mcg/kg])
• Increases the force of
contractions
• __________________
the heart rate
• Slows AV conduction
• Increases cardiac output
• Dosage
• Newborn Infant—810mcg/kg
• < 2 years—10-12mcg/kg
• > 2 years—8-10mcg/kg
Management: Digoxin
• Improve cardiac function
• To begin Digoxin
• Digitalization
• To get blood levels into therapeutic range
• 0.8-2 g/L
• Monitor Electrolytes, Liver & Kidney Fx
• Interaction with Antibiotics (Eick et al., 2000)
• Side effects
• Halo, blurred vision
• Bradycardia, vomiting, anorexia, nausea
Unrelated to feedings
Lose interest in feeding
Decrease in oral intake
Nursing Responsibilities
Management: ACE Inhibitors
• Improve Cardiac Function
• Angiotensin-converting enzyme (ACE)
inhibitors
• Blocks the conversion of angiotensin I to
angiotensin II
• Vasodilation pulmonary and systemic vascular
resistance
• Captopril, Enalapril, Lisinopril
• Take 1 hour before meals to  absorption
Management: Diuretics
• Removal of excess fluid and Na+
• Furosemide (Lasix [10mg/ml])
• Blocks reabsorption of Na+ and water (in renal tubules)
• Potassium wasting
• Fluid restriction-older kids
• Avoid dehydration
Nursing Management
• How would you:
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Decrease cardiac demands?
Improve tissue oxygenation?
Ensure adequate caloric intake?
How would you, as the nurse, best assess a pt’s current status with
CHF?
*Remember your goals? Remove excess fluid. How is this best
measured? – WEIGH YOUR PATIENT DAILY!
Nursing Management: Additional
Considerations
• Assessments?
• Nursing Diagnoses?
• Interventions?
Which evaluation would
indicate a toxic dose of
digoxin?
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3.
4.
Tachycardia & dysrhythmia
Headache & diarrhea
Bradycardia,nausea & vomiting
Tinnitus & nuchal rigidity
Rheumatic Fever
and
Kawasaki Disease
Rheumatic Fever
• Result of Group A -Hemolytic Strep (GABS)
infection
• URI, Strep Throat
• 2-6 weeks after infection
• I___________ C_______________ Tissue Disorder
• Heart valves, Joints, Skin, CNS & subQ tissue
• Rheumatic Heart Disease may result
Jones Criteria:
Must have 2 major OR 1 major & 2 minor + recorded strep
infection (+ASO - Antistreptolysin-O titer)
• Minor Manifestations
• Clinical Findings
• Major Manifestations
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Carditis
Polyarthritis
Chorea
Erythema marginatum
Subcutaneous nodules
• Arthralgia
• Fever
• Prolonged PR interval on ECG
• Laboratory Findings
• Elevated acute-phase reactants
• C-reactive protein
• Erythrocyte sedimentation rate
• +ASO - Antistreptolysin-O
titer
• AHA Guidelines
Assessment &
Diagnosis
• Carditis
• New murmur
• Chest pain
• CHF signs
• Polyarthritis
• 2 or more joints inflamed
• May migrate
• SubQ nodules may develop over bony prominences
Assessment &
Diagnosis
• Erythema Marginatum
• Trunk & abdomen
• Nonpruritic
• Come & go within minutes
• Sydenham Chorea - Aimless
movements
• Subcutaneous nodules
Pharmacologic Management
• Antibiotics
• Eradicate infection
• Benzathine Penicillin G
• 600,000 units IM ( 27
kg)
• 1,200,000 units IM (>27
kg)
• Penicillin V
• 250 mg tid PO
• Erythromycin if allergic
to penicillin
• Anti-inflammatory
• Tx arthritis, fever,
arthralgias
• ASA for up to 6wks
• Severe Carditis
• Corticosteroids if CHF
Nursing Management
• Interventions
• What would you expect to do with a child with Rheumatic
Fever?
• Education
• Complete ATB course
• ASA therapy
• Prophylaxis
• Monthly IM injections until Age 21
• http://circ.ahajournals.org/content/119/11/1541.full.pdf
• Symptom expectations/mgmt
A client is admitted with a diagnosis of “rule out
rheumatic fever”. Based on Jones Criteria, the
nurse assesses for:
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Polyarthritis & dental caries
Fever, headache, & low RBC count
Chorea, muscle weakness, & decreased
erythrocyte sedimentation rate
Erythema, polyarthritis, & elevated ASO titer
Kawasaki’s Disease
• ACUTE, Febrile, Systemic vascular inflammatory
disorder
• Affects small & midsize arteries
• Including coronary arteries
• Causes aneurysms in arteries
• Leading cause of acquired heart disease in kids in U.S.
• Etiology: UNKNOWN
Three Stages of Kawasaki’s
• Acute
• Lasts 1-2 wks
• S/S
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Irritability
Red throat
Diarrhea
Hepatic dysfunction
Conjunctival hyperemia
**Swollen ___________ & ___________
**High ____________ lasting > 5 days
**Maculopapular or erythema multiforme-like
rash to trunk & perineal area
• Unilateral cervical lymph node enlargement
Three Stages of Kawasaki’s
• Subacute
• Lasts 2-4 weeks
• S/S
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Joint pain
Cardiac disease
Thrombocytosis
Strawberry Tongue
Cracking of lips & fissures
Desquamation of the skin on the tips of
fingers & toes
Three Stages of Kawasaki’s
• Convalescent
• Lasts 6-8 weeks
• May have lingering signs of inflammation
• Many s/s resolving
Diagnostic Mnemonic
• Dx: 4/5 of CRASH plus five days of fever
.... and no other explanation (GAS, TSS, Measles, EBV, JIA,Adenovirus, SJS.)
CRASH and Burn
C_______________- non exudative, bilateral injection. >90%
R____________- anything..... but not vesicular and not bulla.
>90%
A_______________ > 1.5cm. typically cervical and unilateral.
<50%
S_________________ - Redness of oral mucosa or lips or dry
peeling lips. >90%
H___________________- Swelling or Erythema or hands feet.
progresses to peeling but this is late. >90%
and B_______________... 5 days of daily fevers.
complications: coronary aneurisms.
Diagnostic Procedures
• Laboratory tests:
• Systemic
Inflammation:
• ESR > 40mm/hr
• CRP > 3mg/dL
• CBC
• Elevated WBC & PLT
• Mild anemia
• Hypoalbuminemia
• WBC’s in urine
• Radiology Tests
• ECHO
• Identify vascular changes
in heart and coronary
arteries
• Repeated in
• Acute phase
• Subacute phase
• Convalescent phase
Medical Management
• Treatment is high dose aspirin(to prevent clots)
and IVIG(reduces aneurisms from 20%-> 3%).
• Pharmacologic
• Intravenous Immunoglobulin (IVIG)
• 2g/kg in a single infusion
• High dose ASA – to promote comfort
• 80-100 mg/kg/day q6hrs while fever high
• 2-5 mg/kg/day qd after fever drops &
until plt normal or no cardiac abnormalities
Nursing Management
• Assessment
• For S/S of disease
• Hydration
• Interventions
• Administer medication
• Comfort measures
• Education
• Bleeding precautions
• Activity restrictions
• Vaccines
Infective
Endocarditis
Infective Endocarditis
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Inflammation of the lining, valves or great vessels of the heart
D/T infection – most caused by streptococcus
Sx occur 7-14 days after bacteria introduced to blood stream
Treatment: IV ATB
Prevention!
Guideline for Prophylaxis Treatment
for Infective Endocarditis
• Treat those with the highest
risk of adverse outcome for
IE
• Artificial heart valves
• History of having had Infective
Endocarditis
• Most congenital heart
conditions
• Antibiotic prophylaxis prior
to…
• Dental procedures
• Invasive respiratory procedures
• Other procedures that invade
mucosal linings
AHA, 2007 Wilson et al. (Oct. 2007) Circulation: Journal of the AHA
Questions?