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Module 5 – Pediatric Cardiac Disorders Revised, Summer 2008 Fetal Circulation Changes in Circulation Umbilical cord clamped Pulmonary Pressure Pulmonary resistance Critical thinking: When are most cardiac anomalies discovered? What is included in the initial cardiac assessment of a newborn? Why? Assessment History Physical Diagnostic Importance of the Nurse Knowing Normal Value for O2 Saturations Children respond to severe hypoxemia with BRADYCARDIA Cardiac arrest in children generally r/t prolonged hypoxemia Hypoxemia is r/t to respiratory failure or shock BRADYCARDIA is a significant warning sign of cardiac arrest Congestive Heart Failure Clinical Manifestations 1. 2. 3. 4. 5. 6. 7. Pump Fails – cannot meet the demands of the body = CHF How do you know when something is wrong? Tires easily during feeding Periorbital edema, weight gain Rales and rhonchi Dyspnea, orthopnea, tachypnea Diaphoretic / sweating Tachycardia Weight Goal of Treatment: Improve cardiac function Remove accumulated fluid and Na+ Decrease cardiac demands Decrease O2 consumption Medications: Digoxin –what do we assess prior to administration? Which VS? Weigh diapers for strict I & O Double check Digoxin levels Parent teaching Digitalis toxicity ACE inhibitors Capoten (Captoril) Vasotec Medications continued… Furosemide (Lasix) Chlorothiazide (Diuril) Zarozolyn (Thiazide type) Spironolactone (Aldactone) Nursing care Reduce metabolic needs Diet therapy Decrease Cardiac Demands Improve tissue oxygenation Congenital Cardiac Anomalies Classifying congenital heart defects By defects that increase pulmonary blood flow Patent ductus arteriosus Atrial septal defect Ventricular septal defect By defects that decrease blood flow and mixed defects Pulmonic stenosis Tetralogy of Fallot Tricuspid atresia Transposition of the great arteries Truncus arteriosus Signs & Symptoms What is most common indication of a congenital heart defect? Cardiac catheterizations Used to determine anomalies Measures O2 sats in cardiac chambers and great arteries Evaluates cardiac output Identify detailed images of blood flow patterns May allow for corrective or palliative measures Nursing interventions pre and post cardiac catheterization Assessment pre-op for baselines Assessment post-op: Vital signs (which ones are priority?) Extremities Activity Hydration Medications Comfort measures Teaching after cardiac catheterization Parental teaching Watch for s/s of bleeding, bruising at site Foot temp on side of cath cooler Loss of sensation in foot on side of cath When to call the physician st If any of above s/s noted within 1 24 hrs Patent Ductus Arteriosus 1. Blood shunts from aorta (left) to the pulmonary artery (right) 2. Returns to the lungs causing increase pressure in the lung 3. Congestive heart failure Treatment Medical Management Medication Indomethacin Surgical ____Ligate the ductus arteriosus Nursing Care: Pre-op Patient/parent teaching Assess for infection Obtain lab values for chart Post-op ABCs Rest Hydration/nutrition Prevent complications Discharge teaching Atrial Septal Defect 1. Oxygenated blood is shunted from left to right side of the heart via defect 2. A larger volume of blood than normal must be handled by the right side of the heart hypertrophy 3. Extra blood then passes through the pulmonary artery into the lungs, causing higher pressure than normal in the blood vessels in the lungs congestive heart failure Treatment Medical Management Medications – digoxin Surgical repair Suture or simple patch Treatment Device Closure – Amplatzer septal occluder During cardiac catheterization the occluder is placed in the Defect Ventricle Septal Defect 1. Oxygenated blood is shunted from left to right side of the heart via defect 2. A larger volume of blood than normal must be handled by the right side of the heart hypertrophy 3. Extra blood then passes through the pulmonary artery into the lungs, causing higher pressure than normal in the blood vessels in the lungs congestive heart failure Treatment Surgical repair with a patch inserted Obstructive or Stenotic Defects Pulmonic or Aortic Stenosis Narrowing of entrance that decreases blood flow Treatment: Medications – Prostaglandins to keep the PDA open Cardiac Catheterization Balloon Valvuloplasty Surgery Valvotomy Coarctation of the Aorta 1. Narrowing of Aorta causing obstruction of left ventricular blood flow 2. Left ventricular hypertrophy Signs and Symptoms 1. B/P in upper extremities 2. B/P in lower extremities 3. Radial pulses full/bounding and femoral or popliteal pulses weak or absent 4. Leg pains, fatigue 5. Nose bleeds Treatment Goals of management are to improve ventricular function and restore blood flow to the lower body. Medical management with Medication A continuous intravenous medication, prostaglandin (PGE-1), is used to open the ductus arteriosus (and maintain it in an open state) allowing blood flow to areas beyond the coarctation. Balloon dilation Surgery Resect narrow area Anastomosis Cyanotic Disorders Tetralogy of Fallot 1. Four defects with right to left shunting Signs and Symptoms 1. Failure to thrive 2. Lack of energy 2 1 . 3. Infections 4. Polycythemia 5. Clubbing of fingers 3 6. Squatting 7. Cerebral absess 8. Cardiomegaly 9. Cyanosis 4 Treatment Surgical interventions Blalock – Taussig or Potts procedure – increases blood flow to the lungs. Open heart surgery Ask Yourself ? Laboratory analysis on a child with Tetralogy of Fallot indicates a high RBC count. The polycythemia is a compensatory mechanism for: a. Tissue oxygen need b. Low iron level C. Low blood pressure d. Cardiomegaly Mixed blood flow Survival depends upon mixing of blood from pulmonic and systemic circulation Cyanotic Disorders: Truncus arteriosus Hypoplastic left heart Transposition of the great arteries Truncus arteriosus A single arterial trunk arises from both ventricles that supplies the systemic, pulmonary, and coronary circulations. A vsd and a single, defective, valve also exist. Entire systemic circulation supplied from common trunk. Hypoplastic heart May have various leftsided defects, including coarctation of the aorta, aortic valve & mitral valve stenosis or artresia Transposition of Great Vessels Aorta arises from the right ventricle, and the pulmonary artery arises from the left ventricle – not compatible with survival unless there is a large defect present in ventricular or atrial septum. aorta Nursing Diagnosis & Goals: DX: Alteration in cardiac output: decrease R/T heart malformation Goal: Child will maintain adequate cardiac output AEB: Nursing Care: Monitor VS I&O Medications Position Metabolic rest Assess and document child/family interactions Parent teaching Acquired Cardiac Diseases Kawasaki Disease Mucocutaneous lymph node syndrome Not contagious Preceded by upper respiratory tract infection Cause unknown Clinical Manifestations: Acute Phase- Subacute Phase Convalescent Phase 10-14 days 10-25 days 25-60 days Diagnosis: ECG CBC, WBC PT ESR SGOT, SGPT IgA, IgG and IgM Nursing Care: Medication Therapy Aspirin Gamma Globulin Nursing Interventions Assess/monitor Decrease stimulation Comfort measures Discharge teaching Rheumatic Fever Systemic inflammatory disease Follows group A beta-hemolytic streptococcus infection Causes changes in the entire heart especially the valves Clinical Manifestations Jones Criteria Major Minor Supporting Evidence Therapeutic Intervention Medication long term prophylaxis Nursing Prevention Parent teaching (ANTIBIOTICS) Subacute Bacterial Endocarditis Infectious disease involving abnormal cardiac tissue: Usually rheumatic lesions or congenital defects Infection may invade adjacent tissuesaortic and mitral valves Clinical Manifestations: Onset insidious Fever Lethargy/general malaise Anorexia Splenomegaly Retinal hemorrhages Heart murmur –90% Diagnosis- positive blood cultures Nursing Care Medication-large doses antibiotic Bed rest Teach to notify dentist prior to dental work Principles that apply to all cardiac conditions: Encourage normal growth and development Counsel parents to avoid overprotection Address parents’ concerns and anxieties Educate parents about conditions, tests, planned treatments, medications Assist parents in developing ability to assess child’s physical status