1. Cardiovascular

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 reduced volume of O2 saturated
Light Blue Reduced volume of unsaturated

5. Fetal Circulation

6. Fetal Circulation

7. 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

8. Fetal hemoglobin carries 20-30% more oxygen than maternal hemoglobin
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 bpm (increases cardiac output)

9. Newborn

10. What happens to the shunts after birth?

11. 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

12. 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

13. Cardiac Defects Either
Ductal closure failure (no structural abnormality)
Structural abnormality

14. 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

15. 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 hrs
Palpate a pulse distal to the dressing to assure blood flow
Keep extremity straight for 48 hrs after procedure

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

17. Congestive Heart Failure

18. 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

19. 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

20. Congestive Heart Failure Symptoms
1st sign is tachycardia
tire easily
rapid, labored breathing
decreased urine output
increased sweating, pallor
peripheral edema

21. 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

22. Congestive Heart Failure Medical Management
Digoxin
Lasix
Potassium

23. 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

24. Lasix Helps the kidneys remove excess fluid from the body
Potassium wasting
Must administer potassium supplements

25. Congenital Heart Defects

26. Congenital Heart Disease
35 different types
Common to have multiple defects
Range from mild to life threatening and fatal
Genetic and environmental causes

27. Blood Flows From High to Low Pressure
Higher pressure
Lower Pressure

28. Types of Congenital Heart Defects
Acyanotic Defects
Cyanotic 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)
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

29. Acyanotic Defects

30. 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

31. 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

32. Symptoms Size of the defect varies Loud harsh systolic heart murmur
Right ventricular hypertrophy
O2 level of RV higher than normal on catheterization

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. Summary of Acyanotic Defects
VSD & ASD
Rt hypertrophy
Pulm edema
Pulm htn
PDA

41. Cyanotic Defects

42. 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

43. Pulmonary Stenosis Valve Stenosis
Obstruction of the right ventricular outflow tract
Decreased pulmonary blood flow

44. 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

45. Treatment Surgical Management Medical Management (Digoxin, Lasix, K+)
Oxygen
Prophylactic antibiotics to prevent infective endocarditis
Surgical Management
Pulmonary balloon valvuloplasty via cardiac cath
If unsuccessful valvotomy

46. Coarctation of Aorta
Constriction of the aorta at or near the insertion site of the ductus arteriosus
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
Higher pressure
Pink Blood

47. 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

48. 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

49. Tetralogy of Fallot Consists of 4 Defects VSD RV hypertrophy
Blood is light blue
Consists of 4 Defects
VSD
RV hypertrophy
Pulmonic Stenosis
Overriding aorta
Blood is purple

50. 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

51. Treatment Knee-chest position then apply O2
Treatment of tet spells
Knee-chest position then apply O2
Do not leave alone- cyanosis can cause LOC, death

52. 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

53. 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

54. 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)

55. 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

56. HTN Endocarditis Rheumatic Fever Kawasaki Disease
Acquired Heart Diseae
HTN
Endocarditis
Rheumatic Fever
Kawasaki Disease

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

58. 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

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

60. 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

61. 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

62. 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

63. Symptoms Tachycardia Polyarthritis Chorea
Erythema marginatum (nonpuritic)
Subcutaneous nodules
Carditis

64. Treatment Treat current strep infection Treat other symptoms
Streptococcal prophylaxis for 5 years
Penicillin IM every month or
Penicillin by mouth twice daily

65. 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

66. 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

67. 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

68. Kawasaki Disease Third phase- day 26-40
Lasts until all symptoms disappear

69. Management Prevent or reduce coronary artery damage
Gamma- globulin IV followed by
High dose aspirin therapy at same time ( mg/kg/ day once daily), continued through weeks 6-8 of disease
Management
Prevent or reduce coronary artery damage
Gamma-globulin IV started in phase 1
High dose aspirin therapy at same time ( mg/kg/day once daily) started in phase 2
Continued through weeks 6-8 of disease

70. Practice Questions!

71. 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

72. Don’t worry. This type of behavior is typical for a toddler
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:
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

73. 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

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

75. 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 child’s yearly physical examination
Assess the child for a change in the quality of the pulse
Assess the child’s blood pressure

76. 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

77. 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

78. Notify the pediatrician as soon as possible
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 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

79. 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:
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

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