Download Chapter 12

Chapter 12
Cardiac Disorders
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
Cardiovascular System
• Heart fully functioning by 8th week of gestation
• Fetal circulation: placenta is the organ of
oxygenation
– Ductus venosus
– Ductus arteriosus
– Foramen ovale
• The birthing process begins closure of fetal shunts
• Heart defects are the most common birth defect
– Leading cause of birth defect-related deaths
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-2
Congenital Heart Disease
• Description
– A defect in the structure of the heart or in one or more of
the large blood vessels that lead to and from the heart
– Multifactorial
• Result of genetic-environmental interactions
• Four classifications
– Based on defect’s effect on blood flow
• Hemodynamics: study of blood circulation
• Shunting: flow of blood through abnormal openings
–
–
–
–
Defects with increased pulmonary blood flow
Obstructive defects
Defects with decreased pulmonary blood flow
Mixed defects
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-3
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-4
Congenital Heart Disease (CHD)
• Diagnostic tools
– Not all testing is necessary for each child
– Lab tests, electrocardiogram, halter monitor, event
recorder, chest radiography, echocardiogram, MRI,
cardiac catherization
• Cardiac catherization is an invasive procedure
• Provides information about anatomy, cardiac
pressure, oxygen saturation, cardiac function
• Sedation is necessary
• Entry site kept straight 4-6 hours after procedure
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-5
Congenital Heart Disease (CHD)
• Signs and symptoms
– Depend on location and type of heart defect
– Child may be small for age, condition may be
classified as a physiologic failure to thrive
– Exercise intolerance noticed anywhere from infancy
to toddler age
– Clubbing of the fingers
– Frequent respiratory infections because of
pulmonary vascular congestion
– Squatting position (TET spell)
– Polycythemia: Body compensates for hypoxemia by
increasing number of RBCs
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-6
Clubbed fingers
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-7
Congestive Heart Failure (CHF)
• Early symptoms
– Lack of infant weight gain • Progressive symptoms
– Difficulty feeding/ sucking
– Periorbital/facial edema
due to air hunger
– Vein distention
– Infant irritability and
– Hepatomegaly
fatigue
– Splenomegaly
– Tachycardia/tachypnea
– Decreased urine output
– Increased work of
– Diaphoresis
breathing
– Mottling
– Cyanosis
– Pallor
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-8
Defects with Increased Pulmonary
Blood Flow
• Patent ductus arteriosus (PDA)
– Passageway connecting pulmonary artery to aorta, avoiding fetal
lungs
– Failure to close causes oxygenated blood to recycle through the
lungs
• Overburdens pulmonary circulation
• Makes heart work harder
• One of the most common cardiac anomalies
– Symptoms
• Machine-like murmur, dyspnea, bounding pulses on exertion, failure to
thrive, frequent respiratory infections
– Treatment
• Indomethacin/ibuprofen in premature infants to close ductus
• Amplatzer PDA device
• Surgical repair
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-9
Defects with Increased Pulmonary
Blood Flow
• Atrial septal defect (ASD)
– Abnormal opening between right and left atria
– Common congenital heart anomaly
– Symptoms
• Generally asymptomatic
• Cyanosis if blood flow is reversed by heart failure
• Large openings may cause failure to thrive
– Treatment
• Open heart surgery
• Percutaneous occluding devices
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-10
Defects with Increased Pulmonary
Blood Flow
• Ventricular septal defect (VSD)
– Opening between right and left ventricles
– 75% of small VSDs close spontaneously by age
10
– Symptoms
• Loud, harsh murmur
• Systolic tremor
• Moderate/large defects may present CHF symptoms
– Treatment
• Percutaneous transcatheter closure
• Occluder devices
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-11
Obstructive Defect
• Coarctation (tightening) of the aorta
– Symptoms
•
•
•
•
Increased pressure proximal to the defect
Decreased pressure distal to the defect
High blood pressure
CHF symptoms
– Treatment
• Balloon angioplasty
• Surgical intervention; anastomosis
• Risk of developing subacute bacterial endocarditis
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-12
Defect with Decreased Pulmonary
Blood Flow
• Tetralogy of Fallot
– The most common cyanotic heart defect
– Four defects
•
•
•
•
Stenosis (narrowing of pulmonary artery)
Hypertrophy of the right ventricle
Over-riding aorta
VSD
– Symptoms
• Cyanosis/hypoxemia episodes with hyperpnea, irritability
• Hypoxia
– Treatment
• Open heart surgery to correct defects
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-13
Mixed Defect
• Transposition of the great arteries (TGA)
– Pulmonary artery leaves left ventricle
– Aorta leaves the right ventricle
– Other defects (septal defects, PDA) must be present to
exchange blood which sustains life
– Survival impossible without surgery
– Symptoms
• CHF symptoms
• Any murmur present is caused by other defects, not TGA
– Treatment
• Prostaglandin E1 (keeps PDA open)
• Balloon atrial septotomy (opens septal wall)
• Corrective surgery
– Performed within the first 2 weeks of life
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-14
Mixed Defect
• Hypoplastic left heart syndrome (HLHS)
– Left side of the heart is underdeveloped
– Hypoplasia of aorta, left ventricle, mitral valve
– Systemic circulation provided by right side of the
heart (Rt ventricle is force of circulation)
– Ductus arteriosus and foramen ovale must
remain patent to survive with HLHS
– Treatment
• PGE1 is administered to maintain a PDA
• Surgery in several stages
– Norwood, Glenn, Fontan
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-15
Congenital Heart Disease
• Treatment and nursing care
– Nursing goals in the care of the newborn
infant can be adapted for all children with
heart defects
•
•
•
•
•
•
Reduce the work of the heart
Improve respiration
Maintain proper nutrition
Prevent infection
Reduce the anxiety of the patient
Support and instruct the parents
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-16
Congenital Heart Disease
• Treatment and nursing care (continued)
– Change child’s position frequently to prevent respiratory complications
– Threat of cerebral thrombosis
– Chest tubes may be used after surgery
• System must be airtight
• Drainage containers always kept below the level of the chest
– Avoid unnecessarily disturbing the child; they need to conserve energy
• Common medications
–
–
–
–
–
–
Digoxin (Lanoxin)
Dopamine, dobutamine, epinephrine
Amrinone, milrinone
ACE inhibitors
Angiotensin II receptor blockers
Diuretics
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-17
Congenital Heart Disease
• Treatment and nursing care (continued)
– Infective endocarditis (IE)
• High risk for children with complex cyanotic heart
diseases or children who have had heart surgery
• Organisms grow on the endocardium or areas of
turbulent blood flow
– Symptoms
• Fever, fatigue, headache, nausea, vomiting
– Diagnosis and treatment
• Blood cultures determine causative organism
• Antibiotics
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-18
Congenital Heart Disease
• Home care
– Family must understand medication administration
– Family must identify symptoms requiring medical
attention
– Provide a normal environment within child’s limits
– Avoid allowing the child to gain control of the home
• Limit setting
– Integrate the child into family life
– Explain the possible need for frequent hospitalization
to parents and child
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-19
Question 12.2
Which of the following is NOT one of the four
classifications of congenital heart disease?
A. Defects with increased pulmonary blood
flow
B. Congestive heart failure
C. Defects with decreased pulmonary blood
flow
D. Mixed defects
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-20
Acute Rheumatic Fever
• Description
– Follows infection with certain strains of Group
A beta-hemolytic streptococci
• Signs and symptoms
– Abdominal pain, fever, pallor, fatigue,
anorexia, unexplained nosebleeds
– Jones criteria aid in diagnosis of rheumatic
fever
– ECG is sometimes a useful diagnostic
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-21
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-22
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-23
Acute Rheumatic Fever
• Treatment and nursing care
– Elimination of the initial infection is followed
by long-term chemo-prophylaxis (prevention
of disease by drugs)
– Intramuscular penicillin G benzathine (Bicillin),
given as an intramuscular injection every 28
days
– Anti-inflammatory drugs are used to decrease
pain and inflammation
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-24
Acute Rheumatic Fever
• Home care
– Bed rest during the initial attack is not
necessary but is recommended if carditis is
present
– Nurse must verify that parent and child
understand activity limitations
• Parents should provide interesting quiet activities
– Long-term chemo-prophylaxis
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-25
Acute Rheumatic Fever
• Prevention
– The nurse is involved in prevention of rheumatic
fever in the community by recognizing signs and
symptoms of streptococcal infections, doing
screening, and referring for treatment
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
12-26