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Nursing Care of the Child with Cardiovascular Illness Topics to know • • • • • • • 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 • • • • • 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 • • • • • • 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) • 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 • • 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 • • • ___________________ 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 • ______________ • • • • • • • Poor perfusion Tachypnea Dyspnea Retractions Pale/cyanosis Crackles Exercise intolerance • • • • • • • • 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 • • • • 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 • • • • • • 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: • • • • 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? 1. 2. 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 • • • • • 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: 1. 2. 3. 4. 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 • • • • • • • • 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 • • • • • • 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 • • • • • 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?