Download Ventricular Septal Defect

Cardiovascular
Common Cardiovascular Disorders in
Children
• Congenital Heart Defects
• Congestive Heart Failure
• Acquired Heart Disease
Review of Normal Circulation
How to Understand Congenital Defects
• Think of blood as:
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Red highly O2 saturated
Blue unsaturated
Purple medium O2 saturated (mixed)
Lavender- reduced volume of medium O2 saturated
(mixed)
▫ Pink reduced volume of O2 saturated
▫ Light Blue Reduced volume of unsaturated
Fetal Circulation
Fetal Circulation
Fetal Shunts
• foramen ovale shunts mixed blood from right atrium to
left atrium (hole in the atrial septum)
• ductus arteriosus accessory (extra) artery, shunts
mixed blood away from lungs to descending aorta
• ductus venosus accessory (extra) vein, carries
oxygenated blood from umbilical vein into lower venous
system
How does the fetus receive sufficient
oxygen from the maternal blood supply?
• Fetal hemoglobin carries 20-30%
more oxygen than maternal
hemoglobin
• Fetal hemoglobin concentration is
50% greater than mother’s
• Fetal heart rate 120-160bpm
(increases cardiac output)
Newborn
What happens to the shunts after
birth?
Transition from
intrauterine to extra- uterine life
• Cord is clamped
• Neonate initiates respirations
• O2 levels rise
• Greater pressure in the left atrium
• Decreased pressure in the right atrium
• Immediate closure of foramen ovale
Transition from intrauterine to
extrauterine life
• After O2 circulates systemically, over 24 hours,
the pressure in the left ventricle will become
greater than the pulmonary artery and closes the
ductus arterosis
• The absent flow of blood through the umbilicus
gradually closes the ductus venosus over 12 hr to
2 weeks
Cardiac Defects
Either
• Ductal closure failure (no structural
abnormality)
•
Structural abnormality
Cardiac Catheterization
• Primary method to measure extent of cardiac disease in
children
• Shows type and severity of the CHD
• Insert tiny catheter through an artery in arm, leg or neck
into the heart
• Take blood samples and measure pressure, measure o2
saturation, and as an intervention
Cardiac Catheterization-Post Op
• Monitor closely (cardiac monitor, continuous
pulse ox) VS q 15
• Assess dressing at insertion site for infection,
hematoma
• Dressing must remain dry for 1st 48-72 hrs
• Palpate a pulse distal to the dressing to assure
blood flow
• Keep extremity straight for 48 hrs after
procedure
• If Congenital Defect is suspected or confirmed,
• Intervention is Important to Prevent CHF
Congestive Heart Failure
Congestive Heart Failure
• Heart doesn’t pump blood well enough
• Can not provide adequate cardiac output
due to impaired myocardial contractility
• Causes in children:
▫ Defects
▫ Acquired heart disease
▫ Infections
Congestive Heart Failure
• Most common cause in children is congenital
heart defects
• Increased volume load or increased pressure in
heart
• Excess volume and pressure builds up in lungs
leading to labored breathing
• Builds up in rest of body leading to edema
Congestive Heart Failure Symptoms
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1st sign is tachycardia
tire easily
rapid, labored breathing
decreased urine output
increased sweating, pallor
peripheral edema
CHF Diagnosis and Treatment
• CXR- shows enlargement
• Echocardiogram- dilated heart vessels,
hypertrophy, increase in heart size
• Treatment is aimed at reducing volume
overload, improve contractility
• May require surgery
Congestive Heart Failure
Medical Management
• Digoxin
• Lasix
• Potassium
Digoxin
• Strengthen the heart muscle, enables it to pump more
efficiently
• Digoxin toxicity: vomiting, bradycardia
• Need HR, EKG, drug levels
• Check apical pulse first, don’t give if HR < 100 bmp in
infants and < 70 bpm in children
• Parents need teaching to assess apical pulse
Lasix
• Helps the kidneys remove excess fluid from the
body
• Potassium wasting
• Must administer potassium supplements
Congenital Heart Defects
Congenital Heart Disease
• 35 different types
• Common to have multiple defects
• Range from mild to life threatening and fatal
• Genetic and environmental causes
Blood Flows From High to Low Pressure
Lower Pressure
Higher pressure
Types of Congenital Heart Defects
Acyanotic Defects
• Purple blood (mixed and too
much blood sent to lungs but
not enough to cause
cyanosis)
• Septal defects
▫ Ventra Septal Defect (VSD)
▫ Atrial Septal Defect (ASD)
• Patent Ductus Arteriosis(PDA)
Cyanotic Defects
▫ Light blue blood (too little
sent to lungs)
▫ Pulmonic Stenosis
▫ Pink blood (too little O2
sent to body)
▫ Coarctation of the aorta
• Light blue & purple blood
(poor perfusion to lungs and
body)
▫ Tetrology of Fallot
Acyanotic Defects
Septal Defects- increased
pulmonary blood flow
• Left to right shunting (acyanotic defect)
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Sends already sat blood back to lungs
Increased cardiac workload
Excessive pulmonary blood flow
Right ventricular strain, dilation, hypertrophy
Ventricular Septal Defect (VSD)
• Most common CHD
• Hole in ventral septum
• High Pressure in LV
forces blood back to RV
• Results in increased
pulmonary blood flow
• Higher than normal
artery pressure
Symptoms
• Size of the defect varies
• Loud harsh systolic heart murmur
• Right ventricular hypertrophy
• O2 level of RV higher than normal on catheterization
Treatment
• Small defects
▫ Medical Management (Digoxin, Lasix, K+)
▫ Prophylactic antibiotics to prevent infective
endocarditis
▫ Close spontaneously
• Large defect
▫ May develop CHF, poor feeding, failure to thrive
▫ Suture or patch hole closed (open heart surgery
with cardiopulmonary bypass)
▫ Pulmonary artery banding to reduce blood flow to
lungs if not stable for surgery
Atrial Septal Defect (ASD)
• Hole in atrial septum
• Pressure in LA is
greater than RA (blood
flows left to right)
• Oxygen rich blood leaks
back to RA to RV and is
then pumped back to
lungs
• Results in right
ventricular hypertrophy
Symptoms
• Harsh systolic murmur
• Second heart sound is split: “fixed splitting” **
diagnostic of ASD
• Pulmonary valve closes later than aortic valve- risk
for pulmonary edema
• Fatigue and dyspnea on exertion
• Poor feeding, failure to thrive
• Large defect may cause CHF
Treatment
▫ Medical Management (Digoxin, Lasix, K+)
▫ Prophylactic antibiotics to prevent infective
endocarditis
▫ Not expected to close on own
▫ Suture or patch hole closed (open heart surgery
with cardiopulmonary bypass)
▫ Pulmonary artery banding to reduce blood flow to
lungs if not stable for surgery
Patent Ductus Arteriosus (PDA)
• Failure of ductus arteriosus
to close completely at
• Blood from the aorta flows
into the pulmonary arteries
to be reoxygenated in the
lungs, returns to LA and LV
• More common in preemies
H to L
Symptoms
• Preterm infants born with CHF and respiratory
distress
• Fullterm infants may be asymptomatic with a
continuous “machinery” type murmur
• Tire easily, growth retardation (shorter, weigh
less, less muscle mass)
• Prone to frequent respiratory tract infections
Treatment
• Administration of Indomethacin
(prostaglandin inhibitor) to stimulates ductus
to constrict
• Surgical management ductus is divided and
ligated
• Usually performed in first year of life to
decrease risk of bacterial endocarditis
Summary of Acyanotic Defects
• VSD & ASD
▫ Rt hypertrophy
▫ Pulm edema
▫ Pulm htn
• PDA
▫ Pulm edema
▫ Pulm htn
Cyanotic Defects
Cynaotic Defects- decreased
pulmonary blood flow
Right to left shunting- sends unsaturated blood
into O2 saturated blood and circulates to body
• Pulmonic Stenosis
• Coarctation of the Aorta
• Tetralogy of Fallot
Pulmonary Stenosis
• Valve Stenosis
• Obstruction of the right ventricular outflow tract
• Decreased pulmonary blood flow
Symptoms
• Systolic ejection murmur with a palpable thrill
• Right ventricular hypertrophy
• Mild to moderate cyanosis from reduced pulmonary
blood flow
• High ventricular pressure may cause blood to back up
into right atrium and force foramen ovale to open to
allow blood to flow from right to left atrium
• Can lead to right ventricular failure, CHF
Treatment
▫ Medical Management (Digoxin, Lasix, K+)
▫ Oxygen
▫ Prophylactic antibiotics to prevent infective
endocarditis
▫ Surgical Management
 Pulmonary balloon valvuloplasty via cardiac cath
 If unsuccessful valvotomy
Coarctation of Aorta
• Constriction of the aorta at
or near the insertion site of
the ductus arteriosus
Higher pressure
• Reduces cardiac output
(impedes blood flow from
heart to body=pink blood)
• Aortic pressure is high
proximal to the constriction
and low distal to the
constriction-Risk for CVA
Pink Blood
Symptoms
• Systolic murmur
• BP is about 20 mm/Hg higher in arms than in lower
extremities
• Upper extremity hypertension
• Diminished pulses in lower extremities
• Poor lower body perfusion
• Lower extremity cyanosis
Treatment
▫ Medical Management (Digoxin, Lasix, K+)
▫ Oxygen
▫ Administration of PGE1 (prostaglandin)
infusions
▫ Maintain ductal patency and improves
perfusion to lower extremities- although will
cause increased pulmonary flow
▫ Surgical repair within first 2 years
Tetralogy of Fallot
Blood is light blue
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Consists of 4 Defects
VSD
RV hypertrophy Blood is purple
Pulmonic Stenosis
Overriding aorta
Symptoms
• cyanotic at birth when PDA closes
• increased respiratory rate, may lose consciousness
• “tet spells” or hypercyanotic episodes often preceded
by crying, feeding or stooling
• tire easily especially with exertion, difficulty feeding
and gaining weight
• become increasingly cyanotic over the first few
months
• symptoms of chronic hypoxemia
Treatment
Treatment of tet spells
• Knee-chest position
then apply O2
• Do not leave alonecyanosis can cause
LOC, death
Symptoms
Medical management
• Symptomatic newborn: PGE1 infusion to
maintain ductal patency
• Digoxin, Lasix, K+
• Older infants: close monitoring for worsening
of hypoxia
• Surgical management: done at 3-12 months
of age, in stages
• primary open-heart repair: close VSD, open
pulmonary valve, remove obstructing muscle
Caring for the Child with a
Congenital Heart Defect
• Taking infant home before corrective surgery
• Provide parents with information about care
• Review steps for follow-up care, emergency
management (s/s respiratory distress, CPR)
• Key: promote normalcy within the limits of the
child’s condition
Caring for the Child with a
Congenital Heart Defect
• Preoperative:undergoing corrective surgery
• Explain procedures to parents and child,
assure understanding
• Encourage child and parents to express fears
• Prepare child for surgery and post-op, show
models of equipment (chest tube)
Caring for the Child with a
Congenital Heart Defect
Postoperative:
• Monitor cardiac output
• Support respiratory function
• Maintain fluid and electrolyte
balance
• Promote comfort (IV morphine,
sedatives)
• Promote healing and recovery
Acquired Heart Diseae
HTN
Endocarditis
Rheumatic Fever
Kawasaki Disease
Hypertension
• Primary HTN
▫ Caused by increased body mass
▫ Genetics
• Secondary HTN
▫ Cause is from an underlying condition such as
kidney disease or heart defects
Hypertension
• No set systolic and diastolic number for
diagnosis
• Need to compare to child’s age, gender and
height
• If 3 different readings are above the 95th
percentile for that child then diagnosis is
confirmed
Hypertension
• Managed by eliminating the primary cause if
possible
▫ Exercise, life style modification
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ACE inhibitors
ARBs
Beta-Blockers
Ca Channel Blockers
Infective Endocarditis
• Inflammation of the lining of the valves and
arteries
• Caused by bacterial and fungal infections in the
blood stream that infects an already existing
injured endocardium
• Children at risk: cardiac defects, severe valve
disorders
Infective Endocarditis
• Symptoms:
▫ Fever, fatigue, headache, N/V, new or changed
murmur, CHF, dyspnea
• Treatment:
▫ Antibiotics IV for 2-8 weeks, surgery to replace
valves, treatment of CHF
Rheumatic Fever
• Acute RF is leading cause of acquired heart
disease (but has decreased in US b/c abx)
• Inflammatory autoimmune condition
• Seen in children age 5-15
• Usually follows untreated strep A infection
(pharyngitis)
• Causes scarring of the mitral valves
Symptoms
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Tachycardia
Polyarthritis
Chorea
Erythema marginatum (nonpuritic)
Subcutaneous nodules
• Carditis
Treatment
• Treat current strep infection
• Treat other symptoms
• Streptococcal prophylaxis for 5 years
▫ Penicillin IM every month
or
▫ Penicillin by mouth twice daily
Kawasaki Disease
• Acquired heart disease in children under age 5
• Occurs due to antibody vascular injury post
infection
• Boys>girls
• Asian decent
• Multisystem vasculitis (inflammation of blood
vessels)
• 3 stages of illness
• Affects the coronary arteries
Kawasaki Disease
first stage day 1-14
• Prolonged fever
• Bilateral, nonpurulent conjunctivitis
• Changes in mouth (erythema, fissures, crusting
of lips, strawberry tongue)
• Induration of hands and feet
• Erythema of palms and soles
• Erythemous rash
• Enlarged cervical lymph nodes
Kawasaki Disease
second stage day 15-25
• Fever and most of the previous symptoms
resolve
• Extreme irritability develops
• Anorexia
• Lip cracking and fissuring
• Desquamation of fingers and toes
• Arthritis
• Vascular changes in myocardium and
coronary arteries if untreated
Kawasaki Disease
Third phase- day 26-40
• Lasts until all symptoms disappear
Management
• Prevent or reduce coronary artery damage
• Gamma-globulin IV started in phase 1
• High dose aspirin therapy at same time (80100mg/kg/day once daily) started in phase 2
• Continued through weeks 6-8 of disease
Practice Questions!
• The indicated area on the
diagram showed higher than
anticipated oxygen level on
cardiac catheterization. The
nurse concludes that is
diagnostic for which CHD?
(Select All that Apply)
• 1. PDA
• 2. VSA
• 3. Coartation of Aorta
• 4 ASD
• 5. Tetrology of Fallot
A parent of a toddler with Kawaski’s disease tells the
nurse “I just don’t know what to do with my child. He’s
never acted like this before.” The nurses best reply is:
1.
2.
3.
4.
Don’t worry. This type of behavior is typical for a
toddler
Irritability is part of Kawasaki’s disease. Please don’t
be embarrassed
Perhaps your child would benefit from stricter limits
You seem to be in need of a referral to our Child
Guidance Center
When assessing a child for signs and symptoms of
rheumatic fever, which symptoms should the
nurse anticipate?
1.
2.
3.
4.
Tachycardia and joint pain
Bradycardia and swollen joints
Loss of coordination and pruritic rash
Poor weigh gain and fever
• The nurse assessing a newborn and auscultates a split
S2. The nurse should further assess for:
1. Cyanosis
2. Crackles
3. Hypoxemia
4. Blood pressure differences in extremities
Which nursing intervention is most effective in preventing
rheumatic fever in children?
1.
2.
3.
4.
Refer children with sore throats for a throat culture
Include an ECG in the child’s yearly physical
examination
Assess the child for a change in the quality of the pulse
Assess the child’s blood pressure
A newborn with patent ductus arteriousus is
scheduled to receive indomethacin. The nurse
administers this medication to:
1.
2.
3.
4.
Open the ductus arteriosus
Close the ductus arteriosus
Enlarge the ductus arteriosus
Maintain the size of the ductus arteriosus
Which congenital heart defect necessitates that
the nurse take upper and lower extremity
blood pressure readings?
1. Coarctation of the aorta
2. Tetralogy of Fallot
3. Ventricular septal defect
4. Patent ductus arteriosus
An infant with ventricular septal defect develops
congestive heart failure and is placed on digoxin
therapy twice a day. The infant vomits the morning
dose of digoxin. The most appropriate nursing
intervention is to:
1.
2.
3.
4.
Notify the pediatrician as soon as possible
Take the infant’s pulse for 1 minute and repeat the dose
of digoxin
Skip the dose and give twice the amount at the next
dose
Repeat the dose and chart that the infant vomited the
first dose
The parents of a newborn with small ventricular septal
defect ask why their baby is being sent home instead of
undergoing immediate open heart surgery. The nurse’s
best response is:
1.
2.
3.
4.
Your baby’s condition is too serious for immediate
open heart surgery
Ventricular septal defects are not repaired until the
infant is older
Your baby has a small defect, and it is likely to close
spontaneously
Your baby must be fully immunized before surgery
An infant with tetralogy of Fallot becomes hypoxic
following a prolonged bout of crying. The
nurse’s first action should be to:
1. Administer oxygen
2. Administer morphine
3. Place the infant in the knee-chest position
4. Comfort the infant