Download congenital cardiac defects

The Child with
Cardiovascular Dysfunction
Chapter 34
Changes at Birth
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Slide 2
Pediatric Indicators of
Cardiac Dysfunction
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Poor feeding
Tachypnea/tachycardia
Failure to thrive/poor weight gain/activity
intolerance
Developmental delays
Prenatal history
Family history of cardiac disease
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Slide 3
“Innocent Murmurs”
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Murmurs = heart sounds that reflect flow of
blood within the heart
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May occur in systole or diastole, or both
Can occur in a normal heart in periods of stress:
anemia, fever, or rapid growth
Can reflect abnormalities in heart or vessels
“Innocent murmurs” = normal cardiac
anatomy and cardiac function
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Occur in up to 50% of all kids at some time
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Slide 4
Thrills
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The sound of a thrill is a soft vibration over
the heart that reflects the transmitted sound
of a heart murmur
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Slide 5
Conduction System of the Heart
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Slide 6
Normal ECG Pattern
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Slide 7
Electrode Placement for
Standard Chest Lead II
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Slide 8
Tests of Cardiac Function
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Chest x-ray
ECG
Echocardiography
Cardiac catheterization
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Slide 9
Hypoplastic Left Heart
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Slide 10
Interventional Cardiac
Catheterization
Procedures in Children
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Transposition of great vessels
Some complex single-ventricle defects
ASD
Pulmonary artery stenosis
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Slide 11
Interventional Cardiac
Catheterization
Procedures in Children (cont.)
DIAGNOSIS
INTERVENTION
Valvular pulmonic stenosis
Balloon dilation
Recurrent coarctation of aorta
Balloon dilation
Congenital mitral stenosis
Balloon dilation
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Slide 12
Clubbing
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Slide 13
Knee-Chest Position
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Slide 14
Two Types of Cardiac Defects
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Congenital
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Anatomic → abnormal function
Acquired
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Disease process
• Infection
• Autoimmune response
• Environmental factors
• Familial tendencies
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Slide 15
Causes of CHD
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Maternal or environmental = 1% to 2%
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Maternal drug use
• Fetal alcohol syndrome—50% have CHD
Maternal illness
• Rubella in first 7 weeks of pregnancy → 50% risk of
defects including PDA and pulmonary branch stenosis
• CMV, toxoplasmosis, other viral illnesses → cardiac
defects
• IDMs = 10% risk of CHD (VSD, cardiomyopathy, TGA
most common)
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Slide 16
Causes of CHD (cont.)
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Chromosomal/genetic = 10% to 12%
Multifactorial = 85%
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Slide 17
CHD
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Incidence: 5 to 8 per 1000 live births
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About 2 or 3 of these are symptomatic in first year
of life
Major cause of death in first year of life (after
prematurity)
Most common anomaly is VSD
28% of kids with CHD have another recognized
anomaly (trisomy 21, 13, 18, + + + )
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Slide 18
Older Classifications of CHD
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Acyanotic
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May become cyanotic
Cyanotic
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May be pink
 May develop CHF
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Slide 19
Newer Classifications of CHD
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Hemodynamic characteristics
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Increased pulmonary blood flow
 Decreased pulmonary blood flow
 Obstruction of blood flow out of the heart
 Mixed blood flow
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Slide 20
Comparison of CHD
Classification Systems
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Slide 21
Increased Pulmonary Blood
Flow Defects
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Abnormal connection between two sides of
heart
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Either the septum or the great vessels
Increased blood volume on right side of heart
Increased pulmonary blood flow
Decreased systemic blood flow
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Slide 22
Hemodynamics in Defects with
Increased Pulmonary Blood Flow
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Slide 23
Increased Pulmonary Blood
Flow Defects
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Atrial septal defect
Ventricular septal defect
Patent ductus arteriosus
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Slide 24
ASD
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Slide 25
VSD
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Slide 26
PDA
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Slide 27
Obstructive Defects
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Coarctation of the aorta
Aortic stenosis
Pulmonic stenosis
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Slide 28
Sites of Obstruction to Ventricular
Ejection
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Slide 29
COA
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Slide 30
AS
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Slide 31
PS and Catheter Placement
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Slide 32
Decreased Pulmonary Blood
Flow Defects
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Tetralogy of Fallot
Tricuspid atresia
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Slide 33
TOF
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Slide 34
Cardiac Shunts
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Slide 35
Tricuspid Atresia
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Slide 36
Mixed Defects
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Transposition of great vessels
Total anomalous pulmonary venous
connection
Hypoplastic heart syndrome
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Right
Left
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Slide 37
Transposition of Great
Vessels
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Slide 38
Normal Heart
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Slide 39
Total Anomalous Pulmonary Venous
Connection
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Slide 40
CHF in Children
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Impaired myocardial function
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Tachycardia; fatigue; weakness; restless, pale,
cool extremities; decreased BP; decreased urine
output
Pulmonary congestion
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Tachypnea, dyspnea, respiratory distress,
exercise intolerance, cyanosis
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Slide 41
CHF in Children (cont.)
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Systemic venous congestion
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Peripheral and periorbital edema, weight gain,
ascites, hepatomegaly, neck vein distention
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Slide 42
Care of the Family and Child with
Congenital Heart Disease
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Help family adjust to the disorder
Educate family
Help family cope with effects of the disorder
Prepare child and family for surgery
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Slide 43
Surgical Interventions
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Open heart
Closed heart procedures
Staged procedures
Prepare child and family for procedures
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Slide 44
Postoperative Care for the Child
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Monitor vital signs and A/V pressures
Intra-arterial monitoring of BP
Intracardiac monitoring
Respiratory needs
Rest, comfort, and pain management
Fluid management
Progression of activity
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Slide 45
Postoperative Complications
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CHF
Dysrhythmias
Decreased cardiac output syndrome
Decreased peripheral perfusion
Pulmonary changes
Neurologic changes
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Slide 46
Postpericardiotomy Syndrome
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Symptoms: fever,  WBCs, pericardial
friction rub, pericardial and pleural effusion
Occurs in immediate postoperative period
Also can occur later (days 7 to 21 postop)
Etiology unknown
Theories of etiology
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Viral infection, autoimmune response, reaction to
blood in pericardium
May require pericardiocentesis or pleurocentesis
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Slide 47
Acquired Cardiovascular
Disorders
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Infectious and inflammatory cardiac disorders
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Slide 48
Endocarditis
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BE, IE, or SBE
Streptococci
Staphylococci
Fungal infections
Prophylaxis: 1 hour before procedures (IV) or
may use PO in some cases
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Slide 49
Rheumatic Fever (RF) and
Rheumatic Heart Disease
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RF
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Inflammatory disease occurs after group A βhemolytic streptococcal pharyngitis
Infrequently seen in U.S.; big problem in Third
World
Self-limiting
• Affects joints, skin, brain, serous surfaces, and heart
Rheumatic heart disease
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Most common complication of RF
Damage to valves as result of RF
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Slide 50
Clinical Manifestations of RF
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Carditis
Polyarthritis
Erythema marginatum
Subcutaneous nodules
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Slide 51
St. Vitus Dance:
The Fifth Manifestation
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St. Vitus dance (aka, chorea) reflects CNS
involvement
Definition: Chorea refers to sudden, aimless
movements of extremities, involuntary facial
grimaces, speech disturbances, emotional
lability and muscle weakness
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Worse with anxiety and relieved by rest
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Slide 52
Prevention of RHD
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Treatment of streptococcal
tonsillitis/pharyngitis
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Penicillin G—IM x 1
 Penicillin V—oral x 10 days
 Sulfa—oral x 10 days
 Erythromycin (if allergic to above)—oral x 10 days
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Treatment of recurrent RF
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Same as above
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Slide 53
Kawasaki Disease Treatment
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IV IgG
ASA 80-100 mg/kg/day—fever
Then 3-5 mg/kg/day—antiplatelet
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Slide 54
Systemic Hypertension
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Primary = no known cause
Secondary = identifiable cause
Pediatrics: HTN generally secondary to
structural abnormality or underlying pathology
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Renal disease
CV disease
Endocrine or neurologic disorders
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Slide 55
BP Screenings for Children
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Slide 56
Cardiac Dysrhythmias (cont.)
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Bradydysrhythmias
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AV block
May use pacemaker
Tachydysrhythmias
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SVT most common tachydysrhythmia
Treatments
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Slide 57
Complete Heart Block
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Slide 58
SVT
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Slide 59
Heart Transplantation
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Orthotopic transplant
Heterotopic transplant (piggyback)
Organ donation issues
Nursing considerations
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Slide 60
The Child with Gastrointestinal
Dysfunction
Chapter 33
Absorption
• Principally from small intestine
• Osmosis
• Carrier-mediated diffusion
• Active energy-driven transport (“pump”)
• Large intestine
• Absorption of water
• Absorption of sodium
• Role of colonic bacteria
Ingestion of Foreign Substances
• Pica
• Food picas
• Nonfood picas
• Foreign bodies
• Nursing considerations
DISORDERS OF MOTILITY
Constipation
• An alteration in the frequency, consistency, or
ease of passage of stool
• May be secondary to other disorders
• Idiopathic (functional) constipation—no
known cause
• Chronic constipation—may be due to
environmental or psychosocial factors
Newborn Period
• First meconium should be passed within 24 to
36 hours of life; if not assess for:
• Hirschsprung disease, hypothyroidism
• Meconium plug, meconium ileus (CF)
Constipation in Childhood
• Often due to environmental changes or
control over body functions
• Encopresis: inappropriate passage of feces,
often with soiling
• May result from stress
• Management
Nursing Considerations
• History of bowel patterns, medications, diet
• Educate parents and child
• Dietary modifications (age appropriate)
Hirschsprung Disease
• Also called congenital aganglionic
megacolon
• Mechanical obstruction from inadequate
motility of intestine
• Incidence: 1 in 5000 live births; more
common in males and in Down syndrome
• Absence of ganglion cells in colon
Hirschsprung Disease
Clinical Manifestations
of Hirschprung Disease
• Aganglionic segment usually includes the
rectum and proximal colon
• Accumulation of stool with distention
• Failure of internal anal sphincter to relax
• Enterocolitis may occur
Diagnostic Evaluation
• X-ray, barium enema
• Anorectal manometric exam
• Confirm diagnosis with rectal biopsy
Therapeutic Management
• Surgery
• Two stages
• Temporary ostomy
• Second stage “pull-through” procedure
Nursing Considerations
• Preoperative care
• Postoperative care
• Discharge care
Gastroesophageal Reflux (GER)
• Defined as transfer of gastric contents into the
esophagus
• Occurs in everyone
• Frequency and persistency may make it
abnormal
• May occur without GERD
• GERD may occur without regurgitation
GER
• Diagnostics
• Therapeutic management
• Nursing considerations
Irritable Bowel Syndrome (IBS)
• Identified as cause of recurrent abdominal
pain in children (Chapter 18)
• Classified as a functional GI disorder
• Alternating diarrhea and constipation
• Therapeutic management
• Nursing considerations
Acute Appendicitis
• Etiology and pathophysiology
• Diagnostic evaluation
• Therapeutic management
• Ruptured appendix
• Prognosis
• Nursing considerations
Inflammatory Bowel Disease
(IBD)
• Includes ulcerative colitis (UC) and Crohn
disease (CD)
• Etiology and pathophysiology
• Diagnostic evaluation
• Therapeutic management
• Medical treatment
• Nursing considerations
Ulcerative Colitis (UC)
• Pathophysiology
• Clinical manifestations
• Extraintestinal manifestations
Crohn Disease
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Pathophysiology
Clinical manifestations
Extraintestinal manifestations
Therapeutic management
• Medical
• Surgical
• Nursing considerations
Effects of UC or Crohn Disease
OBSTRUCTIVE DISORDERS
Hypertrophic Pyloric Stenosis
(HPS)
• Constriction of the pyloric sphincter with
obstruction of the gastric outlet
Pyloric Stenosis
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Pathophysiology
Diagnostic evaluation
Therapeutic management
Prognosis
Nursing considerations
Hypertrophic Pyloric
Stenosis
Intussusception
• Telescoping or invagination of one portion of
intestine into another
• Occasionally due to intestinal lesions
• Often cause is unknown
• Diagnostic evaluation
• Therapeutic management
• Prognosis
• Nursing considerations
Ileocolic Intussusception
Malrotation and Volvulus
• Malrotation is due to abnormal rotation
around the superior mesenteric artery during
embryonic development
• Volvulus occurs when intestine is twisted
around itself and compromises blood supply
to intestines
• May cause intestinal perforation, peritonitis,
necrosis, and death
Malabsorption Syndromes
• Characterized by chronic diarrhea and
malabsorption of nutrients
• May result in failure to thrive
• Digestive defects
• Absorptive defects
• Anatomic defects
Celiac Disease
• Also called gluten-induced enteropathy and
celiac sprue
• Four characteristics
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Steatorrhea
General malnutrition
Abdominal distention
Secondary vitamin deficiencies
Celiac Disease (cont.)
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Pathophysiology
Diagnostic evaluation
Therapeutic management
Nursing considerations
Short Bowel Syndrome (SBS)
• A malabsorptive disorder
• Results from decreased mucosal surface area,
usually as result of small bowel resection
• Etiology and pathophysiology
• Result of decreased mucosal surface area,
usually due to extensive resection of small
intestine
• Other causes
• NEC, volvulus, gastroschisis, Crohn disease in
Therapeutic Management of SBS
• Nutritional support—first phase: TPN
• Associated risks and complications
• Second phase: enteral feeding
Long-term maintenance
• Medical therapies
• Surgical therapies
• Nursing considerations
GI Bleeding
• Upper GI bleeding
• Esophagus
• Stomach
• “Coffee grounds” emesis
• Hematemesis
• Lower GI bleeding
• Bright red (rectal bleeding): hematochezia
• Tarry stools: melena
GI Bleeding (cont.)
• Diagnostic evaluation
• Therapeutic management
• Assess blood loss
• Establish hemodynamic stability
• Nursing considerations
Types of Diarrhea
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Acute
Acute infectious/infectious gastroenteritis
Chronic
Intractable diarrhea of infancy
Chronic nonspecific diarrhea (CNSD)
Anorectal Malformations
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Imperforate anus
Persistent cloaca
Cloacal exstrophy
Genitalia may be indefinite
Diagnostic evaluation
Management
Dehydration
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Types of dehydration
Diagnostic evaluation
Therapeutic management
Nursing considerations
Daily Maintenance Fluid
Requirements
• Calculate child’s weight in kg
• Allow 100 ml/kg for first 10 kg body weight
• Allow 50 ml/kg for second 10 kg body weight
• Allow 20 ml/kg for remaining body weight
Example 1:
Daily Fluid Calculation
• Child weighs 32 kg
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100 x 10 for first 10 kg of body weight = 1000
50 x 10 for second 10 kg of body weight = 500
20 x 12 for remaining body weight = 240
1000 + 500 + 240 = 1740 ml/24 hr
Example 2:
Daily Fluid Calculation
• Child weighs 8.5 kg
• 100 x 8.5 for first 10 kg of body weight = 850
• No further calculations
• 850 ml/24 hr
Example 3:
Daily Fluid Calculation
• Child weighs 14 kg
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•
•
•
100 x 10 for first 10 kg of body weight = 1000
50 x 4 for second 10 kg of body weight = 200
No further calculations
1000 + 200 = 1200 ml/24 hr