Care of the Child with a Cardiovascular Disorder

1
Care of the Child with a Cardiovascular Disorder

• Becca Maddox
• NURS 1102
• Spring 2002

2
Health Promotion and Risk Management

• Congenital - Women of child-bearing age should be
  immunized against rubella and varicella. Parents
  with family history of congenital defects need to
  have children screened
• Acquired - Children with hypertension,
  hyperlipidemia and rheumatic fever are at
  increased risk.
• Rheumatic fever follows a group A beta-hemolytic
  streptococcus infection (otitis media,
  streptococcal pharyngitis and impetigo should
  have antibiotic therapy)
• Avoid excessive salt, lack of exercise, obesity,
  diets high in saturated fats (reduce to 30 of
  calories by school age)

3
Cardiovascular Disorders and the Nursing Process

• Careful history taking and physical examination
  are most important
• Common procedures for diagnosis are
  echocardiogram and cardiac catheterization
• Common nursing diagnoses
• Decreased cardiac output related to congenital
  structural defect
• Altered tissue perfusion related to inadequate
  cardiac output

4

• Knowledge deficit related to care of the child
  pre- and postoperatively
• Fear related to lack of knowledge about childs
  disease
• Altered family processes related to stresses of
  the diagnosis and care responsibilities
• Ineffective individual or family coping related
  to lack of adequate support
• Altered parenting related to inability to bond
  with critically ill newborn

5

• Important interventions include teaching,
  providing opportunities to express fears,
  providing psychological support
• Other interventions include comfort measures,
  oxygen administration, managing cardiac failure,
  pre-and postop care

6
Important Terms

• Acyanotic heart disease Innocent heart murmur
• Afterload Left-to-right shunt
• Balloon angioplasty Organic heart murmur
• Cardiac catheterization Phonocardiogram
• Contractility Polycythemia
• Cyanosis Postcardiac surgery syndrome
• Cyanotic heart disease Postperfusion syndrome
• Diastole Preload
• Echocardiography Right-to-left shunt
• Electrocardiography Systole
• Fluoroscopy Vasculitis
• Heart failure

7
Review

• AP of the Heart
• Circulation of blood
• CO SV x HR
• CO is affected by preload, afterload and
  contractility
• Frank-Starling law - SV can be increased by
  increasing the stretch of the fibers. However,
  excessive stretch results in a decrease in CO

8
History Taking

• Must be careful. Some of the symptoms are very
  subtle.
• Some symptoms do not show up right after birth
• Typical presentations of infants are tachycardia,
  tachypnea, and poor feeding
• Older children may present with fatigue and
  frequent lower respiratory infections. Some
  children may perspire excessively
• Edema is a late sign and usually presents first
  as periorbital edema.
• May complain of decreased UOP
• May have headaches, nose bleeds, high blood
  pressure in upper extremities

9
History Continued

• Obtain a detailed prenatal history including
  exposure to infections (cytomegalovirus,
  toxoplamosis, rubella or varicella), medication
  usage, drug and alcohol use, nutrition, exposure
  to radiation
• Determine if there is any family history of
  congenital heart defects or heart disease,
  cognitive impairments, renal disease

10
Physical Assessment

• Compare height and weight to standard growth
  chart
• Assess
• capillary refill presence of clubbing
• cyanosis (pulmonary source vs. cardiac source)
• ruddy complexion lethargy
• rapid respirations tachycardia
• abnormal body posture presence of a murmur
• Innocent murmurs vs. Organic murmurs
• With all murmurs, document position in cardiac
  cycle, duration, quality, pitch, intensity,
  location, whether there is a thrill and whether
  the murmur changes with position change
• Organic murmurs are either systolic or diastolic,
  long, harsh or blowing, loud, constant and heard
  not matter what position the child is in

11
Diagnostic Tests

• ECG - indicates HR, rhythm, presence or absence
  of hypertrophy, ischemia or necrosis,
  abnormalities in the conduction system, presence
  of electrolyte imbalances
• Chest x-ray - shows heart size and shape,
  presence of CHF, prominence of pulmonary blood
  flow
• Fluoroscopy can be used to visualize the chambers
  of the heart, the great vessels, lungs, thoracic
  cage and diaphragm. Sometimes radioactive dye in
  injected. Sometimes contrast dye in used in
  conjunction with a cardiac cath

12
Diagnostic Tests Contd

• Echocardiogram - primary diagnostic test. Looks
  at the movement and dimensions of the cardiac
  structures using high-frequency sound waves
• Phonocardiogram - heart sounds are recorded and
  displayed as a diagram
• MRI - used to evaluate heart structure, size or
  blood flow
• Treadmill - studies response to exercise
• Lab tests - Hgb and Hct (polycythemia), ESR
  (rheumatic fever, Kawasaki disease, myocarditis),
  ABG (presence of a right to left shunt), O2 Sat,
  clotting times (PT, PTT) and platelet count, Na,
  K, dig level

13
Cardiac Catheterization

• Can be either diagnostic or interventional
• Pressures in the heart can be measured
• CO can be evaluated
• Blood samples can be obtained and tested (O2 sat)
• Electrical activity can be studied
• Contrast can be injected to study blood flow,
  vessels and chambers
• Balloon angioplasty can be performed to stretch
  stenosed areas or blockages in vessels
• Pre-procedure - Patient teaching
• How the test will be done, what to expect during
  the test, that afterward the child will have to
  lie flat and will have a bulky dressing over the
  catheter insertion site

14
Cardiac Catheterization Contd

• Post-Procedure
• Will have to lie flat 3-4 hours
• VS every 15 minutes for the first several hours
• Check site every 15 minutes for integrity of
  dressing, hematoma, redness, swelling
• Check pulses distal to site. Also check extremity
  for capillary refill and warmth
• Avoid dehydration
• Avoid hypothermia
• Check site daily for signs of infection
• Avoid tub baths and strenuous exercise for 2-3
  days

15
Important Points about Care of the Child with a
Heart Defect

• Parents taking a child with a heart defect home
  should have discharge planning which includes
  name/number of a primary care provider, emergency
  numbers, home health visits, instruction in what
  to do if child becomes cyanotic, CPR training,
• Should not allow a child with a cyanotic heart
  defect or severe aortic stenosis to cry for
  extended periods of time
• Dont usually have to restrict sodium intake
  (regulates water balance)
• Need vitamin supplements and maybe an iron
  supplement
• May need small feedings every 3-4 hours. May
  require feeding tubes or high calorie
  formulas/supplements

16
Important Points about Care Contd

• Children usually limit their own activities, but
  parents should watch for respiratory distress
  when new activities are introduced
• Children should receive their immunizations
  timely
• Even minor illnesses should be treated promptly
• Avoid dehydration
• Receive prophylactic antibiotics prior to dental
  visits or oral surgery (Penicillin or
  Erythromycin)

17
Congenital Heart Disease

• Occurs in about 8 of term newborns. Higher in
  pre-term infants. Can be as high as 10-15 in
  infants who have a parent with aortic stenosis,
  ASD, VSD, or pulmonic stenosis
• Females - more prone to have PDA and ASD
• Males - more prone to have valvular aortic
  stenosis, coarctation of the aorta, TOF and
  transposition of the great vessels
• The usual cause is failure of the heart to
  develop beyond an early stage of embryonic
  development
• Maternal rubella is associated with PDA,
  stenosis, ASD, VSD

18
Congenital Heart Disease

• Classification
• Acyanotic vs. Cyanotic
• Left-to-right shunt - oxygenated to unoxygenated
  blood
• Right-to-left shunt - deoxygenated blood to
  oxygenated blood
• Hemodynamic and Blood Flow Patterns - allows more
  predictable signs and symptoms
• Increased pulmonary flow
• Obstruction to blood flow (out of the heart)
• Mixed blood flow (oxygenated and deoxygenated
  blood mixing in the heart or great vessels)
• Decreased pulmonary flow

19
Defects with IncreasedPulmonary Blood Flow

• Blood flows from the left side of the heart to
  the right side of the heart through an abnormal
  opening or connection between the system or great
  arteries
• Ventricular Septal Defect (VSD)
• Atrial Septal Defect (ASD)
• Atrioventricular canal defect (AVC)
• Patent Ductus Arteriosis (PDA)
• VSD - most common, 25 of all defects, 2 in every
  1000 live births
• opening in the septum between the two ventricles
• results in right ventricular hypertrophy and
  increased pressure on the pulmonary artery

20
VSD Contd

• May not be evident at birth because high
  pulmonary resistance from incomplete opening of
  alveoli keeps the blood from coming across to the
  right ventricle
• SS (by age 4 to 8 weeks) - develops a loud,
  harsh, systolic murmur along the left sternal
  border 3rd or 4th ICS, widely transmitted,
  usually with a thrill
• Diagnosed with echocardiography or MRI
• RV hypertrophy may also be seen on ECG
• 60 close spontaneously - otherwise at risk of
  infectious endocarditis and cardiac failure
• May require a Silastic or Dacron patch to close
  opening if edges cant be approximated and
  sutured
• Arrhythmias can be a complication post-op

21
Atrial Septal Defect (ASD)

• Abnormal opening between the two atria
• ASD1 (ostium primum) - defect is at the lower end
  of the septum
• ASD2 (ostium secondum) - defect is near the
  center of the septum and may be asymptomatic
• More frequent in girls than boys
• Harsh systolic murmur over 2nd or 3rd ICS, fixed
  splitting of S2
• Echo will show enlarged right side and increased
  pulmonary circulation
• Cath will reveal separation in atrial septum and
  increased O2 sat in RA
• At risk for infectious endocarditis and heart
  failure
• Can cause emboli in pregnant females if not
  corrected
• May require a patch if defect not able to be
  closed
• May have arrhythmias post-op

22
Atrioventricular Canal (AVC) Defect

• An incomplete fusion of the endocardial cushion.
  May be seen as a low ASD continuous with a high
  VSD. Mitral and tricuspid valves are usually
  distorted. Seen in 1 out of 9 children with Down
  syndrome
• Blood flow is usually left to right, but may flow
  between all four chambers
• Same symptoms of heart failure as ASD and VSD
• Requires surgical repair and possible double
  valve replacement
• Must be monitored post-op for jaundice from RBC
  destruction

23
Patent Ductus Arteriosus (PDA)

• The ductus arteriosus between the pulmonary
  artery and the aorta fails to close at birth
• May not close until 3 months causing blood to be
  shunted from the aorta to the pulmonary artery
• Child will usually have a wide pulse pressure
  because diastolic is low related to decreased
  peripheral resistance caused by the shunting of
  the blood
• Usually hear a continuous (systolic and
  diastolic) murmur at the upper left sternal
  border or under the clavicle of older children
• ECG is usually normal, may show ventricular
  enlargement if the shunt is large
• Cath is not usually needed unless to rule out
  other defects

24
PDA Contd

• May be given indomethacin or a prostaglandin
  inhibitor to lower PGE1 levels and stimulate
  closure. Drug may be repeated as many as three
  times 12 to 24 hours apart
• If medical management fails -
• ligation of defect
• visual assisted thoracoscopy (VAT) - a clip is
  placed on the ductus
• If not surgery, child is a risk for heart failure
  related to the increased shunting, infectious
  endocarditis from recirculating blood and
  potential stasis in the PA

25
Obstructive Defects

• Narrowing of a vessel or valve. Results in high
  pressure before the obstruction and lower after
  the obstruction. Prevents sufficient blood supply
  from reaching its intended site
• Pulmonic stenosis
• Aortic stenosis
• Coarctation of the aorta
• Pulmonic Stenosis - 25 to 35 of anomalies
• May be asymptomatic or have mild heart failure
• Usually a grade IV or V systolic murmur with a
  thrill. Heard loudest at the upper left sternal
  border. May have a split S2
• ECG may show right ventricular hypertrophy. Cath
  can demonstrate degree of stenosis.

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Pulmonary Stenosis Contd

• Treatment depends on severity of stenosis and the
  childs age
• If severe, the pressure may reopen the foramen
  ovale allowing flow from left to right causing
  cyanosis
• If severe, then given PGE1 to keep ductus
  arteriosus from closing so that the infant can
  get more blood oxygenated
• Balloon angioplasty may be tried to break valve
  adhesions and relieve the stenosis
• If there is a lesser degree of stenosis, the
  child can be allowed to wait until they are 4 or
  5 years old so that there is less surgical risk

27
Aortic Stenosis

• Prevents blood from flowing freely from the LV to
  the aorta
• Can lead to hypertrophy of the left ventricle and
  heart failure and pulmonary edema
• Accounts for 5 of congenital abnormalities
• The child is usually asymptomatic. Will usually
  hear a rough systolic murmur at 2nd ICS right
  sternal border which may radiate to right
  shoulder, clavicle or neck. May see signs of
  decreased CO (faint pulses, hypotension,
  tachycardia, poor feeding). Child may develop
  chest pain with activity. Sudden death can occur
  when O2 demand far exceeds supply
• ECG may show left ventricular hypertrophy. Cath
  can show degree of stenosis
• Treated with balloon angioplasty or surgical
  repair to divide the stenotic valve or dilate a
  contrictive aortic ring

28
Coarctation of the Aorta

• A constrictive band causes narrowing of the aorta
  either between the subclavian vein and the ductus
  arteriosus (infantile or preductal) or distal to
  the ductus arteriosus (postductal)
• Since BP is greatest in the subclavian vein, you
  will see higher pressures in the upper
  extremities (at least 20 mmHg) than in the lower
  extremities. The increased BP can cause headaches
  or nosebleeds. Can even cause a CVA
• May only have a decreased femoral pulse. As child
  grows older, collateral circulation develops.
  Veins may become visible on the chest. Child may
  complain of leg pain on exertion. Child may or
  may not have a soft or moderately loud systolic
  murmur prominent at the base of the heart

29
Coarctation of the Aorta Contd

• Repaired either with balloon angioplasty or
  surgical removal of the narrowed portion. Try to
  let the child grow for a while. Usually scheduled
  around age 2. Has to be done prior to
  childbearing age in females
• May have abdominal discomfort for a while post-op
  related to increased blood flow to lower part of
  the body.
• Will usually still have an elevated BP for a
  while.

30
Mixed Defects

• Transposition of the Great Arteries - The aorta
  comes off of the RV and the pulmonary artery
  comes off of the LV. (5 of anomalies)
• Unless the infant also has an ASD and/or VSD this
  is incompatible with life because you have two
  closed systems
• RA - RV - Aorta - body - vena cavae to RA
• LA - LV - Pulmonary artery - lungs - pulmonary
  veins to LA
• Usually cyanotic at birth, may have no murmur or
  various murmurs
• Echo will show enlarged heart. Cath can show low
  O2 sat in the heart chambers. ECG may not show
  anything
• Will be given PGE1 to try to keep the ductus
  open. Can also have balloon passed through
  foramen ovale in order to enlarge the opening
• Surgical intervention involves switching the
  aorta and the pulmonary artery

31
Mixed Defects

• Total Anamalous Pulmonary Venous Return
• Pulmonary veins return to RA or superior vena
  cava instead of the LA
• Systemic circulation depends on a patent foramen
  ovale and/or patent ductus
• Often these patients are also without a spleen as
  well
• The infant is usually mildly cyanotic and tires
  easily
• Will be kept on PGE1 until surgery to keep the
  ductus arteriosus open.
• The pulmonary veins are reimplanted into the LA

32
Mixed Defects

• Truncus Arteriosus - the infant has a single
  vessel coming off the RV and LV instead of a
  separate pulmonary artery and aorta.
• There is usually also a VSD
• Child is cyanotic and has a typical VSD murmur
• The common trunk in restructured surgically to
  create an aorta and a pulmonary artery
• Hypoplastic Left Heart Syndrome - the left
  ventricle doesnt work.
• The RV hypertrophies as it tries to do all of the
  work
• Patient becomes increasingly cyanotic as more
  unoxygenated blood is shunted to the left side
• Treatment is aimed to keep the ductus arteriosis
  open and increase flow of blood to the aorta
• No surgical repair at this time
• Best hope is heart transplant

33
Defects with Decreased Pulmonary Blood Flow

• Involve an obstruction of pulmonary blood flow
  which increases pressure in the right side of the
  heart.
• If an ASD and or VSD also exists, then
  deoxygentated blood shunts from the right side to
  the left side
• Tricuspid Atresia - tricuspid valve is completely
  closed.
• Blood cant flow from RA to RV so goes through
  the patent foramen ovale to the LA.
• Oxygenation occurs by blood being shunted through
  a patent ductus to the lungs
• If the foramen ovale and ductus arteriosus close,
  the patient becomes profoundly cyanotic,
  tachycardic and dyspneic.
• Kept on PGE1 until surgery
• Surgery consists of creating a subclavian-pulmonar
  y artery shunt or restructuring the right side of
  the heart with a baffle (Fontan procedure)

34
Defects with Decreased Pulmonary Blood Flow

• Tetralogy of Fallot (TOF) - 10 of congenital
  defects.
• Consists of 4 anomalies
• Pulmonary stenosis
• VSD (usually large)
• Dextraposition (overriding) of the aorta
• Hypertrophy of the RV (acquired from the
  increased pressure in the RV from trying to push
  blood through the stenosed pulmonary artery)
• Blue baby although may not be dramatically
  cyanotic immediately after birth
• Exhibit poor physical growth, clubbing, systolic
  murmur, hypoxic spells, polycythemia, activity
  intolerance and squatting

35
TOF contd

• X-ray shows cardiomegaly. Echo and ECG show the
  enlarged RV. Echo also shows decreased size of
  the PA and reduced flow through the lungs. Extent
  of the defect is determined through cardiac cath.
  Lab values show increased RBCs and reduced O2
  sat
• Usually wait until child is 1 or 2 years old.
  Some institutions perform surgery earlier to
  prevent hypoxic episodes
• If having hypoxic episode, place infant in
  knee-to-chest position. May require Morphine to
  dilate vessels or propanolol to reduce heart
  spasm

36
TOF contd

• Can have a palliative repair in which the
  subclavian artery is used to create an artificial
  ductus arteriosus (Blalock-Taussig procedure) to
  allow blood to flow from the aorta to the lungs
• After the Blalock-Taussig, the child will not
  have a palpable pulse in the right arm. The right
  arm should not be used for BPs or blood sticks
• Full repair includes relief of pulmonary
  stenosis, VSD repair and correction of the
  overriding aorta

37
Cardiac Surgery

• Pre-op
• baseline vital signs at rest (count a full
  minute)
• height and weight
• hold dig for 24 hrs
• enema
• patient and family teaching (surgery, equipment,
  what to expect after surgery, tubes, the
  importance of deep breathing and coughing)
• Post-op
• VS every 15 minutes progressing to q 1 hr,
  ventilatory support, monitoring of heart rate and
  rhythm, BP, heart pressures, heart sounds, UOP,
  fluid status, ABGs, PT, PTT, Plt, Hgb, Hct., K,
  Na, O2 sat, lung sounds, bowel sounds,
  measurement of chest tube integrity and drainage

38
Cardiac Surgery Contd

• Incentive spirometry (deep breathing) and
  coughing after extubated
• Pain management
• Explain procedures (extubation, chest tube
  removal, etc.)
• Administer antibiotics
• Observe for signs and symptoms of infection
• May need warming immediately post-op, but watch
  for temperature elevation
• Assess for hypervolemia
• Advance activities as tolerated
• Avoid arm pulling and pulling with arms

39
Cardiac Surgery Contd

• Complications - bleeding, shock, heart block or
  arrhythmias, heart failure, neuro changes,
  postcardiac surgery syndrome (febrile illness
  with pericarditis and pleurisy - one week
  post-op), postperfusion syndrome (3-12 weeks
  post-op - fever, splenomegaly, hepatomegaly,
  elevated WBC, malaise, maculopapular rash - CMV
  from donor blood)

40
Cardiac Surgery Contd

• If valve replacement surgery - artificial valves
  are used more often, requires anticoagulation
  (Coumadin) or antiplatelet (aspirin,
  dipyridamole) therapy
• young girls should avoid accidental pregnancy,
  should not use an estrogen-based OCD nor an IUD
• women desiring to become pregnant need to switch
  to Heparin therapy
• prophylactic antibiotics need to be taken before
  dental work or oral surgery
• may develop hemolytic anemia requiring blood
  transfusions

41
Cardiac Surgery Contd

• Heart Transplant - for hypoplastic left ventricle
  or cardiomyopathy
• ECGs will show two P waves
• Post-op care is the same as with other heart
  surgeries
• Patients will be placed on immunosuppresive
  therapy
• Rejection is the 1 cause of death
• Hyperacute rejection - immediately upon restoring
  circulation
• Acute rejection - occurs in about 7 days, fever,
  tachycardia, ECG changes
• Chronic rejection - may begin at about a year

42
Cardiac Surgery Contd

• Pacemaker - if difficulty with conduction system
• Consists of a battery pack and lead wires
• Leads are usually epicardial as opposed to
  endocardial in children
• Parents and patient must be taught how to take
  the patients pulse
• Batteries can last up to 15 years and they lose
  power slowly rather than stopping abruptly
• If patient has hiccuping, lead wire may need to
  be repositioned
• Magnets should be avoided

43
Acquired Heart Disease

• Heart failure - most common.
• Usually occurs as a result of a congenital heart
  disorder or a disease such as rheumatic fever,
  Kawasakis disease or infectious endocarditis.
• The heart cant pump enough blood to supply
  oxygen and nutrients to the body
• The body compensates for a while. Remember CO
  SV x HR and the Frank-Starling principle. For
  children less than 5 y.o., increase in CO is
  mostly accomplished through increased HR
• As renal blood flow decreases, GFR slows allowing
  retention of sodium and fluid. When the body
  senses decreased supply of oxygen, aldosterone is
  secreted which further promotes retention of
  sodium in an attempt to increase blood flow to
  the kidneys. ADH secretion is also increased to
  help retain fluid

44
Heart Failure Contd

• Symptoms depend on whether there is right- or
  left sided heart failure
• Right - back up of pressure into the portal
  system and venous system, hepatomegaly, abdominal
  pain, ascities
• Left - back up of pressure in pulmonary system,
  dyspnea, rales, bloody sputum on coughing,
  cyanosis
• Left sided failure ultimately leads to right
  sided failure
• Edema is a late sign for children. If present, it
  shows up as periorbital edema
• In infants, signs can be breathlessness from
  rapid respirations, tiring easily and poor
  feeding related to exhaustion and dyspnea, may
  become diaphoretic when feeding, abrupt weight
  gain is the most obvious indication
• Apical heart beat may be displaced laterally and
  downward. May have a third heart sound.

45
Heart Failure Contd

• Confirmed by echocardiogram, chest x-ray and ECG
• Treatment is aimed at 1) improving cardiac
  function, 2) removing accumulated fluid and
  sodium, 3)decrease cardiac demands, 4) improve
  tissue O2
• Diuretics - Lasix, spironalactone, thiazides (may
  need K replacement)
• Improve contractility - Digoxin (given a loading
  dose and then a maintenance dose, dig level
  should be 0.8 to 2.0 u/L, toxicity includes,
  nausea, vomiting, anorexia, slow heart rate,
  family teaching required, hold dose if HR
  for infants and toddlers,
  or
• Decrease afterload - hydralazine (vasodilator),
  nifedipine (Ca channel blocker), nipride
  (vasodilator), or captopril (ACE inhibitor)

46
Heart Failure Contd

• Decrease oxygen demands - Provide rest periods
  and uninterrupted sleep, place in Semi-Fowlers
  position, space out activities/procedures,
  preserve body temperature, treat any infections
• Improve oxygenation - administer O2 as needed by
  hood, mask or nasal prongs. If prongs are used,
  check nostrils q 4hrs
• Adequate nutrition is also important - may need
  six to eight small meals daily rather than 3
  large meals, may need tube feedings

47
Rheumatic Fever

• An autoimmune disease that is a reaction to a
  group-A beta-hemolytic stretococcus infection
• Often follows an attack of pharyngitis,
  tonsillitis, scarlet fever, strep throat, or
  impetigo
• Children ages 6-15 are the most susceptible
• Very important that antibiotics are taken to
  treat the initial infection to prevent rheumatic
  fever
• Systematic inflammatory disease that affects
  primarily the heart, joints, brain and skin.
  Strep loves heart valves. The mitral valve is the
  most commonly affected.

48
Rheumatic Fever Contd

• Signs and Symptoms
• Minor
• fever
• fatigue
• joint tenderness
• elevated ESR
• Major
• Aschoff bodies (hemorrhagic bullous lesions in
  the heart)
• erythema marginatum
• vegetation on valves
• pericarditis
• pericardial friction rub
• muffled heart sounds
• accentuated third heart sound
• SC nodules
• chorea (sudden involuntary movements of limbs)

49
Rheumatic Fever Contd

• Diagnosis - If have two major symptoms or one
  major and two minor symptoms, rising or elevated
  ASO titer
• Treatment
• Bedrest until ESR decreases (degree of bedrest is
  based on degree of carditis)
• Antibiotics (penicillin, erythromycin) x 10 days
• Reduce inflammation (aspirin - watch for toxicity
  such as tinnitus, nausea, vomiting, headache,
  blurred vision)
• Corticosteroids (if not responding to aspirin
  alone)
• Phenobarbital for chorea
• Treatment of heart failure
• Prognosis depends on the amount of cardiac
  involvement
• Kept on prophylactic antibiotics for 5 years or
  until 18 to prevent recurrence

50
Kawasaki Disease

• Mucocutaneous Lymph Node Syndrome - an acute
  systemic vasculitis which leads to the formation
  of aneurysms and myocardial infarction
• Actual cause is still unknown. Altered immune
  function occurs after an infection. There is an
  increase in antibody production. Antibody-antigen
  complexes apparently bind to the vascular
  endothelium and cause inflammation. The
  inflammation leads to platelet aggregation and
  the formation of thrombi or obstruction of heart
  and blood vessels

51
Kawasaki Disease

• Acute Phase (Stage I)
• High fever that doesnt respond to antipyretics
• Lethargic and irritable
• May have red, swollen hands and feet,
  conjunctivitis, strawberry tongue and red,
  cracked lips, enlarged cervical lymph nodes,
  variety of rashes, abdominal pain as internal
  lymph nodes swell, anorexia, diarrhea, red and
  swollen joints
• Elevated WBC and ESR
• Subacute Phase - about 10 days after onset
• Peeling of skin on palms and soles of feet
• Platelet count rises (increases risk of clotting)
• Aneurysms may form in coronary arteries - sudden
  death can occur

52
Kawasaki Disease

• Convalescent Phase (Stage II) - begins at about
  the 25th day and lasts until 40 days
• Stage III lasts from 40 days until the ESR
  returns to normal
• Diagnosis is based on criteria (Table 40.3),
  blood studies and echocardiogram
• Treatment
• High dose aspirin
• Dipyridamole - to increase coronary dilatation
  and prevent platelet accumulation
• IV Gamma globulin - to reduce immune response
• Observe child for signs of heart failure
• Inspect and palpate extremities for warmth and
  capillary refill

53
Kawasaki Disease

• Provide comfort measures
• Protect edematous areas from pressure
• May have dry, cracked lips
• Monitor for dehydration, encourage fluids, but
  prevent fluid overload
• Monitor nutritional status

54
Endocarditis

• Inflammation and infection of the endocardium or
  valves of the heart
• Generally caused by streptococcal viridans.
  Sometimes can be staphylococcal or fungal
• Strep enters the blood stream during oral
  procedures, impetigo, UTIs
• Vegetation of bacteria, fibrin, and blood appear
  on the endocardium of the valves and heart
  chambers - destroys the endothelial lining
• Signs and Symptoms - abrupt, unexplained
  low-grade intermittent fever, anorexia, malaise,
  weight loss, change in murmur, splenomegaly

55
Endocarditis

• Diagnosis - blood culture, ECG, elevated ESR and
  C-reactive protein, anemias, leukocytosis,
  microscopic hematuria
• Treatment - antibiotics (PCN, Ampicillin,
  Gentamycin) for 2 to 8 weeks. Supportive therapy
  to prevent heart failure. Teach prevention with
  prophylactic antibiotics before procedures.