Cardiovascular Stressors and Adaptation

1
Cardiovascular Stressors and Adaptation
2
Common Cardiovascular Disorders in Children

• Congenital Heart Defects
• Congestive Heart Failure
• Acquired Heart Disease

3
Review of Normal Circulation
4
How to Understand Congenital Defects

• Think of blood as
• Red highly O2 saturated
• Blue unsaturated
• Purple medium O2 saturated (mixed)
• Lavender- reduced volume of medium O2 saturated
  (mixed)
• Pink Low O2 saturated
• Light Blue Reduced volume of unsaturated

5
Fetal Circulation
6
Fetal Shunts

• ductus venosus accessory (extra) vein, carries
  oxygenated blood from umbilical vein into lower
  venous system
• 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

7
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 mothers
• Fetal heart rate 120-160bpm (increases cardiac
  output)

8
What happens to the shunts after birth?
9
Transition from intrauterine to extrauterine life

• Cord is clamped, neonate initiated respirations
• O2 levels rise greater pressure in the left
  atrium, decreased pressure in the right atrium
  leading to an immediate closure of the foramen
  ovale

10
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

11
Cardiac Defects

• Either
• Ductal closure failure (no structural
  abnormality)
• Structural abnormality

12
Diagnosis

• Assessment findings
• Results of diagnostic testing
• Cardiac Catherization

13
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
• Sedation or anesthesia
• Outpatient vs Hospital

14
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
• No blood drawn from extremity used
• Palpate a pulse distal to the dressing to assure
  blood flow to extremity is not obstructed keep
  extremity straight for 48 hrs after procedure

15

• If Congenital Defect is suspected or confirmed,
• Intervention is Important to Prevent CHF

16
Congestive Heart Failure

• Heart doesnt pump blood well enough can not
  provide adequate cardiac output due to impaired
  myocardial contractility
• Causes in children
• Defects
• Acquired heart disease
• Infections

17
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

18
Congestive Heart Failure Symptoms

• 1st sign tachycardia
• tire easily
• rapid, labored breathing
• decreased urine output
• fluid and sodium are retained
• increased sweating, pallor
• peripheral edema

19
CHF Diagnosis and Treatment

• CXR- shows enlargement
• Echocardiogram- dilated heart vessels,
  hypertrophy, increase in heart size
• Tx-aimed at reducing volume overload, improve
  contractility
• May require surgery

20
Congestive Heart Failure Medical Management

• Digoxin- Helps strengthen the heart muscle,
  enables it to pump more efficiently
• 1st line tx
• Dosing depends on wt and age
• Digoxin toxicity vomiting, bradycardia
• Need HR, EKG, drug levels
• check apical pulse first, dont give if HR lt
  100 bmp in infants and lt 70 bpm in children
• Parent teaching

21
Congestive Heart Failure Medical Management

• Diuretics- Helps the kidneys remove excess fluid
  from the body
• Potassium sparing
• Potassium wasting
• Potassium supplements- given along with wasting
  diuretics
• Lasix-1st agent for children-lose K esp. when
  taken with digoxin

22
Congenital Heart Disease

• 35 different types
• Common to have multiple defects
• Range from mild to life threatening and fatal
• Genetic and environmental causes

23
Blood Flows From High to Low Pressure
Higher pressure
Lower Pressure
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Types of CHD

• Acynotic defects- purple blood (too much to
  lungs)
• Septal defects
• VSD
• ASD
• PDA
• Obstructive Cyanotic defects-reduced flow
  (lungs/body)
• Pulmonic Stenosis light blue blood (lungs)
• Coarctation of the aorta pink blood (body)
• Cyanotic defects- from poor perfusion (lungs and
  body)
• Tetrology of Fallot light blue purple blood
• Hypoplastic left heart lavender blood
• Transposition of the greater vessels

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Septal Defects- increased pulmonary blood flow

• Left to right shunting (acyanotic defect)
• Sends already sat blood back to lungs
• Increased cardiac workload
• Excessive pulmonary blood flow
• Right ventricular strain, dilation, hypertrophy

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Ventricular Septal Defect

• Most common CHD
• High Pressure in LV forces blood back to RV
• Results in increased pulmonary blood flow (heart
  must pump extra blood), higher than normal artery
  pressure

27
Ventricular Septal Defect

• S/S vary with the size of the defect
• 4-8 weeks of age develop loud, harsh systolic
  heart murmur
• Right ventricular hypertrophy
• 20-60 close spontaneously
• cardiac cath shows O2 level of RV higher than
  normal
• large defects develop CHF, poor feeding, failure
  to thrive

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Ventricular Septal Defect

• Treatment
• Small defects followed by cardiologist,
  prophylactic ABX
• Large defect open heart surgery with
  cardiopulmonary bypass, will suture or patch hole
  closed
• If child is not stable for open heart surgery
  pulmonary artery banding narrowing of pulmonary
  artery to reduce blood flow to lungs

29
VSD Medical Management

• For infants not medically stable for surgery or
  awaiting surgery-
• Digoxin to improve cardiac output
• Oxygen

30
Atrial Septal Defect

• 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 ventricular
  hypertrophy
• Few symptoms at birth, over time may experience
  fatigue and dyspnea on exertion

31
Atrial Septal Defect Clinical Presentation

• Large defect may cause CHF
• Harsh systolic murmur
• Second heart sound is split fixed splitting
  diagnostic of ASD
• pulmonary valve closes later than aortic valve-
  risk for pulm edema
• Echocardiogram shows enlarged right side of
  heart, increased pulmonary circulation

32
ASD Management

• Nonsurgical management prosthetic patch
• Surgical management open-heart with CP bypass,
  edges are sutured or will use patch to cover hole
• Diuretics to control symptoms until repair is
  performed

33
Patent Ductus Arteriosus

• Failure of ductus arteriosus to close completely
  at birth
• 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
34
Patent Ductus Arteriosus

• Preterm infants present 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

35
Patent Ductus Arteriosus

• Chest radiographs (x-ray) show enlarged LA and LV
  
• Medical management Indomethacin (prostaglandin
  inhibitor that stimulates ductus to constrict)
• Surgical management ductus is divided and
  ligated (usually performed in first year of life
  to decrease risk of bacterial endocarditis

36
Acyanotic Defects

• VSD ASD
• Rt CHF
• Pulm edema
• Pulm htn
• PDA
• Pulm edema
• Pulm htn

37
Obstructive Defects- decreased pulmonary blood
flow

• Right to left shunt
• unsat blood into sat blood
• Pulmonic Stenosis
• Coarctation of the Aorta

38
Pulmonary Stenosis

• Obstruction of the right ventricular outflow
  tract
• Decreased pulmonary blood flow

39
Pulmonary Stenosis Symptoms

• Right ventricular hypertrophy
• 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
• Mild-Mod Usually asymptomatic except for
• Systolic ejection murmur with a palpable thrill
• If Severe right ventricular failure, CHF, if
  there is right to left shunting through the
  foramen ovale, mild to moderate cyanosis

40
Pulmonary Stenosis

• Medical Management
• If asymptomatic cardiac follow-up
• Prophylactic ABX
• Surgical Management
• Pulmonary balloon valvuloplasty via cardiac cath
• if unsuccessful valvotomy

41
Coarctation of Aorta

• Localized constriction of the aorta at or near
  the insertion site of the ductus arteriosus
• Reduces cardiac output (impedes blood flow from
  heart to bodypink blood)
• Aortic pressure is high proximal to the
  constriction and low distal to the
  constriction-CVA

Higher pressure
Pink Blood
42
Coarctation of Aorta

• S/S related to severity of the constriction and
  presence of associated cardiac defects
• Mild asymptomatic, sys. murmur, diminished
  pulses in lower ext
• Severe poor lower body perfusion, metabolic
  acidosis, CHF, systemic hypertension
• In both BP is 20mmHg higher in arms than in
  lower extremities

43
Coarctation of Aorta

• Diagnosis-clinical exam, echo
• Treatment is based on severity

44
Treatment of Coarctation of Aorta

• Symptomatic newborn treated with
• Digoxin
• diuretics to manage CHF
• may also receive PGE1 (prostaglandin) infusions
  to maintain ductal patency and improves perfusion
  to lower extremities- although will cause inc
  pulm flow
• surgical repair within first 2 years

45
Cynaotic Defects

• Decreased pulmonary blood flow (light blue blood
  to lungs)
• Transposition of the greater vessels
• Tetrology of Fallot
• Hypoplastic left heart

46
Tetralogy of Fallot Consists of 4 Parts

• VSD
• RV hypertrophy
• Overriding aorta
• Pulmonic Stenosis impedes blood flow to the
  lungs, forces unoxygenated blood through the VSD
  into aorta

Blood is purple
Blood is light blue
47
S/STetralogy of Fallot

• The degree of pulmonic stenosis governs the onset
  and severity of symptoms.
• Mild little to no right to left shunting infant
  has tet spells hypercyanotic episodes
• Mod-severe some cyanotic at birth when PDA
  closes, other infants become increasingly
  cyanotic over the first few months of life

48
Tetralogy of Fallot

• Tire easily especially with exertion, difficulty
  feeding and gaining weight,
• Other signs chronic hypoxemia

49
Management Tetralogy of Fallot

• Over time may have hypercyanotic episodes (tet
  spells)
• often preceded by crying, feeding or stooling,
  worsening cyanosis, increased respiratory rate,
  may lose consciousness
• Treatment of tet spells
• knee-chest position then apply O2
• Do not leave alone- cyanosis can cause LOC, death

50
Tetralogy of Fallot

• Medical management
• Symptomatic newborn PGE1 infusion to maintain
  ductal patency
• 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

51
Hypoplastic Left Heart Syndrome

• pulmonary venous blood is shunted through foramen
  ovale into right atrium
• mixed blood travels through the right ventricle
  to the pulmonary artery, patent ductus arteriosus
• as ductus begins to close in first day of life
  infant becomes symptomatic

Palest pink
L
Purple
H
52
Hypoplastic Left Heart Syndrome

• symptoms
• CHF
• hypoperfusion, shock
• grayish-blue color
• dyspnea
• hypotension

• Diagnosis
• Clinical presentation and echo (increased size
  in right side)

53
Hypoplastic Left Heart Syndrome

• Medical Management
• PGE1 to keep ductus arteriosus open
• Correct acid-base and electrolyte imbalances
• Surgical management
• Heart transplant
• Three-stage repair

54
Transposition of Great Arteries

• Aorta is connected to RV (unoxygenated blood goes
  to body)
• Pulmonary artery is attached to LV (oxygen rich
  blood is recirculated to lungs)
• Survival depends on mixing these two circulations
  through the fetal structures (foramen ovale and
  ductus arteriosus)

55
Transposition of Great Arteries

• Cyanosis apparent at birth or shortly after, no
  response to oxygen
• Prompt diagnosis and treatment needed for
  survival
• Arterial switch procedure redirects blood flow,
  may be done in stages within 1st year

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Caring for the Child with a Congenital Heart
Defect

• Nursing Care 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
  childs condition

57
Caring for the Child with a Congenital Heart
Defect

• Preoperativeundergoing 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)

58
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

59
Acquired Heart Diseae

• HTN
• Endocarditis
• Rheumatic Fever
• Kawasaki Disease

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Hypertension

• Primary HTN
• Caused by increased body mass
• Genetics
• Secondary HTN
• Cause is from an underlying condition such as
  kidney disease or heart defects

61
Hypertension

• No set systolic and diastolic number for
  diagnosis
• Need to compare to childs age, gender and
  height
• If 3 different readings are above the 95th
  percentile for that child then diagnosis is
  confirmed

62
Hypertension

• Managed by eliminating the primary cause if
  possible
• Exercise, life style modification
• ACE inhibitors
• ARBs
• Beta-Blockers
• Ca Channel Blockers

63
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

64
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

65
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

66
Rheumatic Fever

• S/S
• Tachycardia
• Polyarthritis
• Carditis
• Chorea
• Erythema marginatum (nonpuritic)
• Subcutaneous nodules

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Rheumatic Fever

• Diagnosis- clinical symptoms and ASO titer

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Rheumatic Fever

• Management
• Treat infection
• Treat other symptoms
• Streptococcal prophylaxis
• PCN IM every month
• or
• PCN PO BID (if allergic Sulfadiazine PO QD)

69
Kawasaki Disease

• Acquired heart disease in children under age 5
• Boysgtgirls
• Asian decent
• Multisystem vasculitis (inflammation of blood
  vessels)
• 3 stages of illness
• Affects the coronary arteries
• Occurs due to antibody vascular injury post
  infection

70
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

71
Kawasaki Diseasesecond 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

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Kawasaki DiseaseThird phase- day 26-40

• Lasts until erythrocyte sed rate returns to
  normal and all symptoms disappear

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Management

• Prevent or reduce coronary artery damage
• Gamma-globulin IV followed by
• High dose aspirin therapy at same time
  (80-100mg/kg/day once daily), continued through
  weeks 6-8 of disease

74
Kawasaki Disease

• Nursing care
• Administer meds
• Comfort measures
• Hydration
• Parental support

75
Practice Questions!
76

• The indicated area on the diagram showed higher
  than anticipated oxygen level on cardiac
  catherization. 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

77

• A parent of a toddler with Kawaskis disease
  tells the nurse I just dont know what to do
  with my child. Hes never acted like this
  before. The nurses best reply is
• Dont worry. This type of behavior is typical for
  a toddler
• Irritability is part of Kawasakis disease.
  Please dont be embarrassed
• Perhaps your child would benefit from stricter
  limits
• You seem to be in need of a referral to our Child
  Guidance Center

78

• When assessing a child for signs and symptoms of
  rheumatic fever, which symptoms should the nurse
  anticipate?
• Tachycardia and joint pain
• Bradycardia and swollen joints
• Loss of coordination and pruritic rash
• Poor weigh gain and fever

79

• The nurse assessing a newborn and auscultates a
  split S2. The nurse should further assess for
• Cyanosis
• Crackles
• Hypoxemia
• Blood pressure differences in extremities

80

• Which nursing intervention is most effective in
  preventing rheumatic fever in children?
• Refer children with sore throats for a throat
  culture
• Include an ECG in the childs yearly physical
  examination
• Assess the child for a change in the quality of
  the pulse
• Assess the childs blood pressure

81

• A newborn with patent ductus arteriousus is
  scheduled to receive indomethacin. The nurse
  administers this medication to
• Open the ductus arteriosus
• Close the ductus arteriosus
• Enlarge the ductus arteriosus
• Maintain the size of the ductus arteriosus

82

• Which congenital heart defect necessitates
  that the nurse take upper and lower extremity
  blood pressure readings?
• Coarctation of the aorta
• Tetralogy of Fallot
• Ventricular septal defect
• Patent ductus arteriosus

83

• 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
• Notify the pediatrician as soon as possible
• Take the infants 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

84

• 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 nurses best response is
• Your babys 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

85

• An infant with tetralogy of Fallot becomes
  hypoxic following a prolonged bout of crying. The
  nurses first action should be to
• Administer oxygen
• Administer morphine
• Place the infant in the knee-chest position
• Comfort the infant