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Pediatric Cardiovascular Disorders
Presented by Christina Hernandez RN, MSN
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Fetal Circulation
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Fetal Cardiac Circulation
↑pulmonary resistance forces blood into descending aorta Umbilical vein→ liver→ ductus venosus→ inferior vena cava→ right atrium → foramen ovale (bypass lungs for oxygenation) → left atrium → left ventricle → aorta → body
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Secondary Fetal Circulation
Right atrium → right ventricle → pulmonary artery → ductus arteriosus → aorta →body Why does the blood flow this direction? What would cause blood to circulate via a third route?
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Changes in Circulation
What is the stimulus for circulatory changes in the newborn? Clamping of the umbilical cord Systemic vascular resistance Increased blood pressure in the left side of heart → closure of the foramen ovale Ductus arteriosis constricts and closes as a result of higher O2 saturation levels
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Critical thinking: When are most cardiac anomalies discovered?
What is included in the initial cardiac assessment of a newborn? Why?
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Assessment History Physical Diagnostic
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Why is it important for the nurse to know the normal value for O2 saturation?
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
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At what O2 saturation does cyanosis occur?
Peripheral cyanosis occurs at <= 80% Brain damage occurs <= 85% Hypoxic Level Oxygen Saturation Mild hypoxia 90-95% Moderate 85-90% Severe <85%
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What nursing interventions should the nurse initiate for hypoxia?
Bradycardia – stimulate patient Shortness of breath Positioning Incentive spirometry (what works with children?) Supplemental oxygen (when does the nurse need an order for this?)
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Congestive Heart Failure
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CHF in Children: Renal response Systemic response
Development- preload and after-load (overload right side of heart causing backflow) leads to… Cardiac hypertrophy leads to… One-sided cardiac failure→ bilateral failure Compensatory mechanisms Renal response Systemic response
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Early Clinical Manifestations of CHF
Infants- tires easily (during what activity?) Weight loss or lack of normal weight gain Diaphoresis Irritability Frequent infections Peri-orbital edema Children Exercise intolerance Dyspnea Abdominal pain or distention Peripheral edema
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CHF in Children Cause Clinical Manifestation
Pulmonary venous congestion Tachypnea, wheezing, crackles, retractions, cough, grunting, nasal flaring, feeding difficulties, irritability, tiring with play Systemic venous congestion Hepatomegaly, ascities, peripheral edema Impaired Cardiac output Tachycardia, diminished pulses, hypotension, capillary refill time >2 seconds, pallor, cool extremities, oliguria High metabolic rate Failure to thrive or slow weight gain
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Goal of Treatment: Improve cardiac function
Remove accumulated fluid and Na+ Decrease cardiac demands Decrease O2 consumption
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Nursing Care for CHF Strict I&O (weight diapers)
Weigh child daily (what is significant change? 1 lb/day) Monitor VS Cardiac medications for children Cardiac glycosides (Digoxin) Ace inhibitors (Capoten-Captoril®, Vasotec®) Diuretics (Furosemide- Lasix®)
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Medications to treat CHF in Children:
Action Nursing Intervention Cardiac glycosides (Digoxin) Increase myocardial contractility- improve systemic circulation Monitor pulse- when do you hold this medication? What safety check? Strict I&O Weigh child daily Observe for edema Serial abdominal girth protect skin Digoxin levels (toxicity) Hepatic function Creatinine clearance Serum Elecrolytes
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Digoxin specific nursing interventions
Hold for pulse Infant < 100 Child < 80 Adolescent <60 Verify dose with two nurses Strict I&O (1gram=1ml) Skin care Monitor for digoxin toxicity
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Digoxin Toxicity >2ng/ml
Cardiac dysrrhythmia **first sign in children Bradycardia Anorexia Nausea and vomiting, Dizziness, Weakness Notify healthcare provider if creatinine clearance of 50ml/min or less. Monitor serum electrolytes: K+, Ca and Mg
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Medications to treat CHF cont…
Action Nursing Intervention ACE inhibitors Capoten (Captoril) Vasotec Inhibits conversion of angiotension I to II results in vasodilatation Promote rest, maintain oxygen therapy, and evaluate oxygen saturation (what is greatest risk?)
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Medications to treat CHF cont…
Action Nursing Interventions Diuretics- Furosemide (Lasix®) Chlorothiazida (Diuril®) Spironolactone (Aldactone) Rapid diuresis Give IM or IV K+ level prior to administer Monitor electrolytes, weigh daily, strict I&O Observe for changes in peripheral edema or circulation Serial abdominal girth Skin care- turning schedule
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Quick Quiz: What is the pulse rate criteria for administering digoxin to: Infants- Child- Teenager/ adolescent- What are signs of digoxin toxicity? Why are K+ levels important with digoxin?
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Nursing care to decrease cardiac demands:
Provide for rest Semi-Fowler’s Monitor O2 (supplement) Small frequent meals Turn q 2 hrs and provide skin care Encourage parents/guardians to stay with child Restrict visitors (why?)
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Cardiac Catheterization
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Cardiac Catheterization
Measures oxygen saturation and pressures in cardiac chambers and great arteries Evaluate cardiac output Angiography-images of structures and blood flow patterns Electrophysiologic studies Corrective or palliative interventions: Pulmonary artery or valve and aortic valve balloon angioplasty Stent placement Balloon/blade septostomy Device closure of septal defects
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Critical thinking: Why is it important for the nurse to assess pedal pulses prior to cardiac catheterization? Interventions for immediate post-cardiac catheterization? Vital signs- which measurements receive highest priority? Extremities Activity Hydration (prevent thrombus formation) Medications (what meds are not allowed?) Comfort
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Post Cardiac Catheterization
What teaching should the nurse include for home care after cardiac catheterization? Watch for signs of complications: infective endocarditis Bleeding/bruising Changes in circulation on cath side
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Post Cardiac Catheterization
When should the parents/caregiver notify the primary healthcare provider?
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Congenital Heart Disease
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Congenital Cardiac Defects
Increase Pulmonary Blood Flow Decrease Pulmonary Blood Flow Patent Ductus Arterious Atrial Septal Defect Ventricular Septal defect Increased blood flow to the lungs causes increased pulmonary resistance (constriction of the pulmonary vascular bed)→pulmonary artery hypertension with right ventricular hypertrophy Hypoxia results Pulmonic stenosis Tetralogy of Fallot Tricuspi atresia Transposition of the great arteries Truncus arteriosus May have right to left shunting. Little or no blood reaching the lungs to get oxygenated. Bone marrow stimulated to produce more RBC’s increase in oxygen. Polycythemia increases risk for thromboembolism. Platelet impaired. Hypoxic events with brain abscesses common.
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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
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What is most common indication of a congenital heart defect?
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Left to Right Shunting Atrial Septal Defects
Ventricular Septal Defects Patent Ductus Arterious
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Atrial Septal Defect Oxygenated blood is shunted from left to right side of the heart via defect A larger volume of blood than normal must be handled by the right side of the heart hypertrophy 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
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Treatment for ASD Medical Management Cardiac Catheterizaton -
Medications – digoxin Cardiac Catheterizaton - Amplatzer septal occluder Open-heart Surgery
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Treatment Device Closure – Amplatzer septal occluder
During cardiac catheterization the occluder is placed in the defect
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Ventricular Septal Defect
Oxygenated blood is shunted from left to right side of the heart via defect A larger volume of blood than normal must be handled by the right side of the heart hypertrophy 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
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Treatment of VSD Surgical repair with a patch inserted
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Patent Ductus Arteriosus
Failure of the fetal ductus arteriosus to close after birth Blood shunts from aorta (left) to the pulmonary artery (right) Returns to the lungs causing increase pressure in the lung Congestive heart failure
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Medical Treatment for PDA
Indomethacin- Inhibits prostaglandins Promotes closure of the ductus arteriosus
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Surgical Treatment for PDA
Cardiac Catheterization - Insert coil – tiny fibers occlude the ductus arteriosus when a thrombus forms in the mass of fabric and wire Surgical – Ligate the Ductus Arteriosus
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Nursing Care: Pre-op Obtain lab values for chart Post-op
Patient/parent teaching Assess for infection Obtain lab values for chart Post-op ABCs Rest Hydration/nutrition Prevent complications Discharge teaching
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Obstructive or Stenotic Defects
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Obstructive or Stenotic Defects
Pulmonic Stenosis Aortic Stenosis Coarctation of the Aorta
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Pulmonic Stenosis Narrowing of entrance that decreases blood flow
Treatment: Medications – Prostaglandin E 1 to keep the PDA open Cardiac Catheterization Baloon Valvuloplasty Surgery Valvotomy
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Aortic Stenosis/ Coarctation of the Aorta
Narrowing of Aorta causing obstruction of left ventricular blood flow Left ventricular hypertrophy Signs and Symptoms  B/P in upper extremities B/P in lower extremities Radial pulses full/bounding and femoral or popliteal pulses weak or absent Leg pains, fatigue Nose bleeds
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Treatment for Aortic Stenosis
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. Baloon Valvoplasty
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Cyanotic Disorders
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Cyanotic Lesions with Decreased Pulmonary Flow
Tetralogy of Fallot
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Signs and Symptoms Failure to thrive Squatting Lack of energy
Infections Polycythemia Clubbing of fingers Cerebral absess Cardiomegaly
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Dehydration Criteria for surgery Nursing Care: Rule of 10’s 10 lbs
Hemaglobin 10 or greater 10 hours/days/months
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Treatment of Tetralogy of Fallot
Surgical interventions Blalock – Taussig or Potts procedure – increases blood flow to the lungs. Open heart surgery
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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
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Cyanotic Lesions with Increased Pulmonary Blood Flow
Truncus arteriosus Hypoplastic left heart Transposition of the great arteries
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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.
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Hypoplastic heart May have various left-sided defects, including coarctation of the aorta, aortic valve & mitral valve stenosis or artresia
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Transposition of the great arteries
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
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Nursing Diagnosis & Goals:
DX: Alteration in cardiac output: decrease R/T heart malformation Goal: Child will maintain adequate cardiac output AEB:
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Review of Nursing Care:
Increased pulmonary blood flow- S&S-Infants: tachypnea, cyanosis, retractions, fatigue, poor feeding, weight loss, fluid/electrolyte imbalance Older children: exertional dyspnea, chest pain, syncope Nursing Care- promote rest or oxygen conservation, monitor I & O, administer oxygen, administer medications, provide parents needed support and information about the care of the child
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Review of Nursing Care cont…
Decrease blood flow and mixed defects- Signs & Symptoms Infants: Cyanosis, dyspnea, loud murmur, skin ruddy or mottled, cyanosis that does not respond to oxygen, stopping during feeding (to breath) diaphoresis, poor weight gain (FTT) Children: chronic- fatigue, clubbing of fingers and toes, dyspnea on excertion, delayed developmental milestones, hypercyanotic episodes, increased pulse and resp. rate, cyanosis Toddlers squat to relieve dyspnea
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Review of Nursing Care cont…
Decrease blood flow and mixed defects- Signs & Symptoms cont… Older children- syncope, transient loss of consciousness & muscle tone, exercise induced dizziness (what does the nurse need to teach with regards to these S&S?)
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Review of Nursing Care cont: Decreased flow or mixed defects
Surgical correction of defect if life threatening Administer prostaglandin E1 (PGE1) to re-open the ductus arteriosus and improve pulmonary or systemic blood flow Monitor Hct & Hbg (what happens with increased blood viscosity?) Keep child calm (morphine, propranolol IV) Administer RBC’s to assist with O2 Position in knee chest Supplemental O2 therapy IV fluids Dopamine or phenylephrine (Neo-Synephrine) Small frequent meals
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Defects Obstructing Systemic Blood Flow
Aortic stenosis Coarctation of the aorta S&S- low cardiac output (diminished pulses) Poor color, capillary refill delayed Pulses & BP stronger/higher in upper extremities CHF and pulmonary edema Necrotizing enterocolitis With mild obstruction: leg cramps, cooler feet than hands, stronger pulses in upper extremities
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Quick questions: What is the main complication associated with increased pulmonary blood flow? Why is indomethacin (prostaglandin inhibitor) ordered for a newborn with patent ductus arteriosus? Why are prostaglandins administered to the child with an obstructive cardiac disorder (aortic stenosis
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Nursing Care for Open-heart Surgery
Pre-Op Post-Op Monitor VS (*BP & P) what might increase temp mean? Prepare child/parents for experience- teaching Teach C&DB (incentive spirometer) Tour hospital- meet staff Assess for infection Obtain labs, verify permits Pulmonary function: Patent airway IPPB, C&DB, O2 therapy Chest suction or chest tube Monitor VS Promote rest Monitor I&O- adequate hydration (fluid & electrolyte balance) Turn frequently (skin care) Assess extremities (circulation
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Oh no…more questions…. What assessment findings in the newborn and child indicate coarctation of the aorta? What is polycythemia and why does it occur in a child with a cardiac disorder? Which cardiac anomalies represent the greatest risk to survival? What classic assessment findings should the nurse report in an initial assessment of a newborn?
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Acquired Cardiac Diseases
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Rheumatic Fever: Systemic inflammatory disease
Follows group A beta-hemolytic streptococcus infection Causes changes in the entire heart especially the valves
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Clinical Manifestations
Jones Criteria Major Minor Supporting Evidence
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Nursing Care: Priority teaching Medication therapy
Antibiotics- as ordered to completion of entire prescribed dose (how do you test for therapeutic level?) Aspirin- relieves pain and acts as a blood thinner to prevent clot formation
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Ineffective Endocarditis:
What clients are more susceptible to develop bacterial endocarditis? When does the organism enter the body? What part of the heart is most affected by the disease?
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Clinical Manifestations:
Onset insidious Fever Lethargy/general malaise Anorexia Splenomegaly Retinal hemorrhages Heart murmur –90% Diagnosis- positive blood culture
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Nursing Care Medication-large doses antibiotic Bed rest
Teach to notify dentist prior to dental work
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Kawasaki Disease- multi-system vasculitis
Mucocutaneous lymph node syndrome Not contagious Preceded by upper respiratory tract infection Cause unknown
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Kawasaki Disease Acute Phase 10-14 days
Rapid onset of fever (does not respond to antibiotics) Bilateral conjunctivitis lasting 3-5 weeks Rash on day 5 (extremities to trunk) Cervical lymphadenopathy Irritability & lethargy Anorexia, possibly diarrhea, hepatic dysfunction Acute pericarditis Hands and feet are edematous and red Red throat
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Kawasaki cont… Subacute Phase 10-25 days Continued irritability
Anorexia diarrhea Arthritis and arthralgia Lip cracking and peeling- classic strawberry tongue Desquamation of the extremities (palms and feet) Cervical lymphadenopathy with large nodes Possible coronary aneurysms with potential for thrombosis formation
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Kawasaki cont… Convalescent Phase 25-60 days Self limiting
Transverse on nailbeds Lasts until return to normal of all lab values
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Diagnosis of Kawasaki Disease:
ECG CBC, WBC PT ESR SGOT, SGPT IgA, IgG and IgM
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Nursing Care: Kawasaki
Medications- Aspirin- decrease fever and thin blood (reduce risk of formation of aneurysms and coronary thrombosis- antiplatelet properties) Gamma Globulin- high doses given before 10th day to reduce incidence of coronary artery lesions and aneurysms, decrease inflammatory signs and fever
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Nursing Care: Kawasaki
Activity- passive range of motion, plan rest and quiet age-appropriate activities. Encourage parents to participate in child’s care. Comfort- keep skin clean, dry, lubricate lips, cool compresses and sponges, change bedding frequently. Small frequent feedings of soft, non-acidic foods of cool temperature
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Kawasaki Disease: Long term care
Teach parents to administer ASA and watch for side effects of bleeding. Avoid contact sports Teach daily monitoring of temp, report >100F Postpone immunizations for 5 months Emphasize need to follow up with cardiologist Influenza vaccine (reduce risk of Reye syndrome) Life-long prophylaxis with antibiotics prior to dental work
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Kawasaki Disease: Long term care
Psychosocial Child away from peers and social activities for up to 4 months Severity of illness has impact on parent/child relationship Parents may experience care giver fatigue
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Quick Review: What is the major complication of Kawasaki disease?
Why is it important to monitor respiratory effort in children with suspected cardiac abnormalities?
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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
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Christina Hernandez RN, MSN
For questions or concerns regarding this lecture content please contact: Christina Hernandez RN, MSN
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