NURSING CARE OF THE CHILD WITH A CARDIOVASCULAR DISEASE Clinical Aspect of Maternal and Child Nursing NUR 363 Lecture 8 NURSING CARE OF THE CHILD WITH A CARDIOVASCULAR DISEASE

ASSESSMENT OF HEART DISORDERS IN CHILDREN History Physical assessment general appearance pulse, blood pressure, & respirations

ASSESSMENT OF HEART DISORDERS IN CHILDREN Diagnostic tests Electrocardiogram Radiography Echocardiography Magnetic resonance imaging Exercise testing Laboratory tests

CLASIFICATION OF CHD A Cyanotic Heart Defect Move blood from arterial …to…venous system Increased in pulmonary blood flow 1. VSD 2. ASD Obstruction of blood flow from ventricle Pulmonary stenosis Aortic stenosis 3.Coarctation of the Aorta

CONGENITAL HEART DISEASE Defects with increased pulmonary blood flow Ventricular Septal Defect Opening between ventricles S/S 4-8 weeks, fatigue and harsh murmur Therapeutic management Most close spontaneously (small ones). Other larger VSDs may require open heart surgery

Defects with increased pulmonary blood flow Atrial Septal Defect Opening between the atria S/S Murmur Management Surgery

A trial Sepal Defect (ASD)

**Obstruction of blood flow from ventricle 1.Pulmonary stenosis 2.Aortic stenosis 3.Coarctation of the Aorta

Pulmonic Stenosis Narrowing of the pulmonary valve or artery causing the right ventricle to hypertrophy S/S Mild right sided heart failure Therapeutic Management Balloon angioplasty to relieve the stenosis

-Aortic Stenosis Stenosis of the aortic valve prevents blood from passing from the left ventricle into the aorta, leading to hypertrophy of the left ventricle S/S Usually asymptomatic but with murmur May have chest pain and even sudden death Therapeutic Management Stabilization with a Beta Blocker or Calcium Channel Blocker Balloon valvuloplasty Valve replacement

Coarctation of the Aorta Narrowing of the lumen of the aorta S/S Absence of palpable femoral &/or brachial pulses; headache, vertigo, nosebleeds, leg pain Therapeutic Management Surgery or angiography

Coarctation of the Aorta

Cyanotic Heart Defect Cyanotic Decreased pulmonary Mixed blood flow

**Defect with Decreased pulmonary blood flow Tricuspid Atresia 2. Tetrology of Fallot

Tricuspid Atresia The tricuspid valve is completely closed, allowing no blood to flow from the right atrium to the right ventricle. When these structures close, cyanosis, tachycardia, and dyspnea occur. Treatment consists of an IV infusion of PGE (prostaglandin) to keep the ductus open until surgery can be performed.

Tetrology of Fallot (TOF)

Tetralogy of Fallot Four anomalies Pulmonary stenosis VSD Dextroposition of the aorta Hypertrophy of right ventricle S/S Cyanosis Polycythemia (increase in number of RBC) Dyspnea, growth restriction, clubbing of fingers Therapeutic Management Surgery

Nursing Care of the Child with GI anomalies Lecture 9

Gastrointestinal System Many GI issues require surgical intervention Nursing interventions will often include general pre and post-op care Assess stools Assess hydration status

Gastrointestinal System Pediatric Variances Mechanical functions of digestion are immature at birth Infants have decreased saliva Peristalsis is faster in infants Digestive processes are mature as a toddler Gastric acidity is low at birth

The Gastrointestinal System 8 Altered Connections 3 Esophageal Atresia/Tracheoesophageal Fistula 3 Cleft Lip and Palate 8 Gastrointestinal Disorders 3 Gastroesophageal Reflux 3 Pyloric Stenosis 8 Acquired Gastrointestinal Disorders 3 Appendicitis

ESOPHAGEAL ATRESIA & TRACHEOESOPHAGEAL FISTULA Congenital defects of esophagus EA is an incomplete formation of esophagus TEF is a fistula between the trachea and esophagus Classic 3 “C’s” - coughing, choking, cyanosis

ESOPHAGEAL ATRESIA & TRACHEOESOPHAGEAL FISTULA TREATMENT Surgery: either a one- or two-stage repair Pre-op care focuses on preventing aspiration and hydration Post-op care focus is a patent airway, prevent incisional trauma

Cleft Lip/Palate May present as single defect or combined Non-union of tissue and bone of upper lip and hard/soft palate during fetal development Cleft interferes with normal anatomic structure of lips, nose, palate, muscles – depending on severity and placement Open communication between mouth and nose with cleft palate Nutrition is a challenge in infancy Risk for aspiration Respiratory distress

Cleft Lip/Palate Monitor for infection Operative Care Pain Management Clean Cleft Lip incision Pain Management

GASTROESOPHAGEAL REFLUX Regurgitation of gastric contents back into esophagus GER may predispose patient to aspiration and pneumonia Apnea has been associated with GER  chance of GER after 12-18 months old related to growth due to elongation of esophagus

GASTROESOPHAGEAL REFLUX SIGNS/SYMPTOMS Vomiting Gagging during feedings Irritability Anemia Bloody stools DIAGNOSTIC EVAL History of feedings/Physical Exam Upper GI endoscopy to visualize esophageal mucosa

GASTROESOPHAGEAL REFLUX: Therapeutic Management Medications Prokinetic agents Histamine H-2 Proton Pump Inhibitors Mucosal Protectants Surgery: fundoplication Positioning Prone HOB  30° Right side Dietary modifications Small, frequent feedings Possibly thicken formula Avoid fatty, spicy foods caffeine, & citrus Teach Fundoplication (anti-reflux surgery): A surgical technique that strengthens the barrier to acid reflux when the lower esophageal sphincter does not work normally and there is gastro-esophageal reflux.

PYLORIC STENOSIS Hypertrophy of pyloric sphincter, causing a narrowing/ obstruction Infant presents “always hungry” Weight loss

PYLORIC STENOSIS DIAGNOSTIC EVAL TREATMENT INTERVENTIONS History/Physical Exam Abdominal Ultrasound TREATMENT Surgical Intervention: Pyloromyotomy INTERVENTIONS Pre-op: NPO, NGT to hydration, I/O, monitor electrolytes Post-op: Start feedings in 4-6 hrs. Progressive feeding schedule

APPENDICITIS Inflammation and infection of vermiform appendix, usually related to an obstruction Cause may be bacteria, virus, trauma S/S: periumbilical pain, fever, vomiting, diarrhea, irritability,  WBC’s Surgery is necessary Pre-op Care: NPO, pain management, hydration, consent Post-op Care: routine post-op care, IVF/antibiotics, NPO ambulation, positioning, pain management, wound care, possible drains.

Nursing Care of the Child with Respiratory Disorders Lecture 10+11

Respiratory System Pediatric Variances The airway is smaller. The larynx is more flexible and more susceptible to spasm. The tongue is large. Chest muscles are not well developed Irregular breathing pattern and brief periods of apnea (10 - 15 secs) are common Abdominal muscles are used for inhalation until age 5-6 yrs. Respiratory rate is higher

The Respiratory System Upper Airway Disorders Tonsillitis Croup/Epiglottis Foreign Body Aspiration Lower Airway Disorders Bronchiolitis Asthma Otitis Media

Tonsillitis CLINICAL MANIFESTATIONS Sore throat Mouth breathing Sleep Apnea Difficulty swallowing Fever IMPLEMENTATIONS Provide Comfort Warm saline gargles Reduce Fever Promote Hydration Administer Antibiotics Provide Rest Patient Teaching Tonsillectomy may be necessary

Tonsillectomy Pre-operative Nursing Care Post-operative Nursing Care Monitor Labs (CBC, PT, PTT) Age-appropriate Preparation/Teaching Surgical Consent Post-operative Nursing Care Frequent site assessment Monitor for S/S of Complications Pain Management Diet Patient Teaching

Croup/Epiglottitis Infection and swelling of larynx, trachea, epiglottis, bronchi Causative agent: Viral Characterized by hoarseness, barky cough, inspiratory stridor, and respiratory distress LIFE-THREATENING EMERGENCY Often the child is intubated

Croup/Epiglottitis Nursing Interventions Nursing Interventions Maintain Patent Airway Assess and Monitor Promote Hydration Reduce Fever Calm Environment Promote Rest Nursing Interventions Administer Meds Corticosteroids Nebulizer treatment Antibiotic for epiglottitis

Foreign Body Aspiration Occurs most often in small children Choking, coughing, wheezing, respiratory difficulty Often it is round food, such as grapes, nuts, popcorn Bronchoscopy often needed for removal Prevention and parent education is very important

Bronchiolitis Acute viral infection of the bronchioles causing an inflammatory/obstructive process to occur CXR shows hyperinflation and consolidation if atelectasis present Primarily seen in children under 2 years of age

CLINICAL MANIFESTATIONS Bronchiolitis CLINICAL MANIFESTATIONS Nasal Congestion Cough Crackles, Wheezes Increased RR & SOB Respiratory Distress Fever Poor Feeding IMPLEMENTATIONS Suction – priority Bronchodilator CPT Promote fluids Monitor VS , SaO2, lung sounds & respiratory effort Supplemental oxygen Reduce fever Promote rest

Asthma Asthma is a common chronic inflammatory disease of the airways CLINICAL MANIFESTATIONS Tachypnea SaO2 below 95% Wheezes, crackles Non-productive cough Restlessness, fatigue Abdominal pain

Asthma Monitor VS (HR, RR) Monitor SaO2 Auscultate lung sounds INTERVENTIONS Monitor VS (HR, RR) Monitor SaO2 Auscultate lung sounds Monitor respiratory effort Humified oxygen Calm environment Promote hydration Promote rest Monitor labs/x-rays Patient teaching Administer Medications Bronchodilator Corticosteroid IV or PO Antibiotic if precipitated from a respiratory infection

Otitis Media Most common childhood illness Inflammation of middle ear Acute otitis media (AOM) S/S: pain, fever, irritability, vomiting, diarrhea, ear drainage, full/bulging tympanic membrane Otitis media with effusion (OME) Inflammation of middle ear with fluid behind tympanic membrane-no infection Chronic otitis media Can lead to hearing loss/delayed speech

Otitis Media TREATMENT Antibiotics INTERVENTIONS Teaching Feeding techniques Medication regimen PAIN MANAGEMENT Fever management Surgery prep if needed