1. Presented by Marlene Meador RN, MSN, CNE

2. Fetal Cardiac Circulation Where is the Highest O2 concentration ? (why?) ↑pulmonary resistance forces blood into descending aorta (see CD-ROM) Umbilical vein→ liver→ ductus venosus→ inferior vena cava→ right atrium → foramen ovale (bypass lungs for oxygenation) → left atrium → left ventricle → aorta → body

3. Fetal Circulation Mn Blood FlowMn Blood Flow

4. Secondary Fetal Circulation- why does the blood flow this direction? Right atrium → right ventricle → pulmonary artery → ductus arteriosus → aorta →body What would cause blood to circulate via a third route?

5. 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 O 2 saturation levels

6. Why is it important for the nurse to know the normal value for O 2 saturation? At what O 2 saturation does cyanosis occur? Why is this significant?

7. What assessment findings indicate hypoxia? 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?)

8. Peripheral cyanosis occurs at <= 80% Brain damage occurs <= 85% Hypoxic LevelOxygen Saturation Mild hypoxia90-95% Moderate85-90% Severe<85%

9. Congestive Heart Failure Most common causes Left to right shunting Obstructive congenital defects

10. CHF in Children: 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

11. 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

12. CHF in Children CauseClinical Manifestation Pulmonary venous congestionTachypnea, wheezing, crackles, retractions, cough, grunting, nasal flaring, feeding difficulties, irritability, tiring with play Systemic venous congestionHepatomegaly, ascities, peripheral edema Impaired Cardiac outputTachycardia, diminished pulses, hypotension, capillary refill time >2 seconds, pallor, cool extremities, oliguria High metabolic rateFailure to thrive or slow weight gain

13. 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®)

14. Medications to treat CHF in Children: MedicationActionNursing 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

15. 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

16. 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

17. Medications to treat CHF cont… MedicationActionNursing 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?)

18. Medications to treat CHF cont… MedicationActionNursing 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

19. 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?

20. 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?)

21. 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

22. Critical thinking: Why is it important for the nurse to assess pedal pulses prior to cardiac catheterization? Interventions for immediate post-cardiac catheterization? Vital sign s- which measurements receive highest priority? Extremities Activity Hydration (prevent thrombus formation) Medications (what meds are not allowed?) Comfort

23. 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

24. Post Cardiac Catheterization When should the parents/caregiver notify the primary healthcare provider?

25. 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.

26. Left to Right Shunting Atrial Septal Defects Ventricular Septal Defects Patent Ductus Arteriosu

27. Atrial Septal Defect 1. Oxygenated blood is shunted from left to right side of the heart via defect 2. A larger volume of blood than normal must be handled by the right side of the heart  hypertrophy 3. 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

28. Treatment for ASD Medical Management Medications – digoxin Cardiac Catheterizaton - Amplatzer septal occluder Open-heart Surgery

29. Device Closure – Amplatzer septal occluder During cardiac catheterization the occluder is placed in the defect

30. Ventricular Septal Defect 1. Oxygenated blood is shunted from left to right side of the heart via defect 2. A larger volume of blood than normal must be handled by the right side of the heart  hypertrophy 3. 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

31. Treatment of VSD Surgical repair of defect

32. Patent Ductus Arteriosus Failure of the fetal ductus arteriosus to close after birth 1. Blood shunts from aorta (left) to the pulmonary artery (right) 2. Returns to the lungs causing increase pressure in the lung 3. Congestive heart failure

33. Medical Treatment for PDA Indomethacin- inhibits prostaglandins Promotes closure of the ductus arteriosus

34. 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

35. Congenital Heart Defects What is the most common assessment finding for a cardiac anomaly?

36. Obstructive or Stenotic Lesions Pulmonic Stenosis Aortic Stenosis Coarctation of the Aorta

37. 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

38. Aortic Stenosis/ Coarctation of the Aorta 1. Narrowing of Aorta causing obstruction of left ventricular blood flow 2. 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

39. Treatment for aortic Senosis 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

40. Cyanotic Lesions with Decreased Pulmonary Flow Tetralogy of Fallot

41. Signs and Symptoms 1. Failure to thrive 2. Squatting 3. Lack of energy 4. Infections 5. Polycythemia 6. Clubbing of fingers 7. Cerebral absess 8. Cardiomegaly

42. Nursing Care: Dehydration Criteria for surgery Rule of 10’s 10 lbs Hemaglobin 10 or greater 10 hours/days/months

43. Treatment of Tetralogy of Fallot Surgical interventions Blalock – Taussig or Potts procedure – increases blood flow to the lungs. Open heart surgery

44. Cyanotic Lesions with Increased Pulmonary Blood Flow Truncus arteriosus Transposition of the great arteries

45. 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.

46. Transposition of the great arteries Aorta arises from the right ventricle, and the pulmonary artery arises from the left ventricle - which is not compatible with survival unless there is a large defect present in ventricular or atrial septum.

47. 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

48. Review of Nursing Care cont… Decrease blood flow and mixed defects- 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

49. Nursing Care: Decrease blood flow and mixed defects- S&S continued 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?)

50. Nursing Care: 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 O 2 Position in knee chest Supplemental O2 therapy IV fluids Dopamine or phenylephrine (Neo-Synephrine) Small frequent meals

51. 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

52. 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)?

53. 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)

54. 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?

55. Rheumatic Fever: What precipitating condition may develop into rheumatic fever? What are Jones Criteria and how is this used? Major Minor Laboratory testing- elevated antistreptolysin-O (ASLO)

56. 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

57. 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?

58. Long-term care for bacterial endocarditis What specific areas of instruction would the nurse include in developing a long-term care plan? What specific teaching regarding dental hygiene and dental care must the nurse include?

59. Kawasaki Disease- multi-system vasculitis 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

60. Kawasaki cont… Subacute Phase 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

61. Kawasaki cont… Convalescent Phase Self limiting Transverse on nailbeds Lasts until return to normal of all lab values

62. Diagnosis of Kawasaki Disease: What diagnostic test is specific to this disease? ESR- Elevated SGO- elevated and SGPT elevated, IgA, IgG, IgM all elevated

63. 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 10 th day to reduce incidence of coronary artery lesions and aneurysms, decrease inflammatory signs and fever

64. 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

65. 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

66. 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

67. Quick Review: What is the major complication of Kawasaki disease? Why is it important to monitor respiratory effort in children with suspected cardiac abnormalities?

68. For questions or concerns regarding this lecture content please contact Marlene Meador RN, MSN, CNE mmeador@austincc.edu