PEDIATRIC CARDIOVASCULAR DISORDERS

Mr. Erwin U. Imperio

VARIATIONS FROM THE ADULT

Fetal Circulation
Characteristics:
Placenta is the source of oxygen for the fetus Fetal lungs receive <10% of blood volume, lungs do not exchange gas RA is the chamber with the highest oxygen concentration

NORMAL CIRCULATORY CHANGES AT BIRTH

When the umbilical cord is clamped or severed, the blood supply from the placenta is cut-off, and oxygenation must then take place in the newborns lungs As the lungs expand with the air, the pulmonary artery pressure decreases and circulation lungs increases

STRUCTURAL CHANGES
DUCTUS VENOSUS
After the umbilical cord is severed, flow to the ductus venosus decreases, and eventually ceases Constricts within 3-7 days after birth Becomes ligamentum venosum

STRUCTURAL CHANGES
FORAMEN OVALE
Functional closure occurs when:
Pressure in the LA exceeds pressure in the right Expansion of PA causes a drop in PA pressure and RA and RV pressure Increased pulmonary blood flow to the LA and aortic pressure = increased LA and LV pressure

Anatomical closure occurs:

Within 1st week after birth with the deposit of fibrin

STRUCTURAL CHANGES
DUCTUS ARTERIOSUS
Increase aortic blood flow = increase aortic pressure = decrease right-to-left shunt Increase pulmonary blood flow = increase arterial oxygen = vasoconstriction within hours of birth Functional closure occurs:
24 hours after birth when vasoconstriction causes cessation of blood flow

Anatomical closure:
1-3 weeks when there is growth of fibrous tissue in the lumen of ductus arteriosus

ABNORMAL CIRCULATORY PATTERNS AFTER BIRTH

This may happen as a result of abnormal openings between pulmonary and systemic circulations

ASSESSMENT
Family History : genetic problems Pregnancy History:
Rubella Viral infections Medications X-ray exposure Alcohol ingestion Cigarette smoking

ASSESSMENT
Childs health history
Presenting problem
Feeding problems Failure to thrive Respiratory difficulties Color changes Activity intolerance

Past medical history

Rheumatic fever

ASSESSMENT
Physical Examination
Plot height and weight Measure VS (especially BP and RR) Inspect for chest enlargement Inspect for presence of cyanosis Inspect for clubbing of finger Observe for distended neck veins Palpate/percuss quality and symmetry of pulses, size of liver and spleen, presence of thrill

ASSESSMENT
Physical Examination
Auscultate for abnormal heart sounds / murmurs
Innocent: no anatomic or physiologic abnormality Functional: no anatomic defect, but may be caused by a physiologic abnormality Organic: caused by structural abnormality

LABORATORY / DIAGNOSTIC TESTS

CXR MRI ECG Hematologic testing

LABORATORY / DIAGNOSTIC TESTS

Cardiac Catheterization
Access: femoral vein Nursing Care: Pre-test
Prepare child based on developmental level Administer medications as ordered

Nursing Care: Post-test

Check extremity distal to the catheterization site for:
Color Temperature Pulse Capillary refill

LABORATORY / DIAGNOSTIC TESTS

Cardiac Catheterization
Nursing Care: Post-test
Keep extremity distal to the catheterization site extended for 6 hours Check pressure dressing over catheterization site for bleeding

NURSING DIAGNOSIS
Altered growth and development: failure to thrive High risk for injury: physiologic Activity intolerance Altered nutrition: less than body requirements Fear/anxiety: child and family Risk for infection Decreased cardiac output Fluid volume excess

PLANNING AND IMPLEMENTATION

Tissue will be adequately oxygenated Child will achieve normal growth and development milestones Child will be free from symptoms of complications of heart disease Parents will understand childs condition

CARE OF A PEDIATRIC CLIENT WITH CONGENITAL HEART DISEASE

BLOOD CIRCULATION

FIRST CLASSIFICATION
ACYANOTIC Left-to-right shunts Oxygenated to unoxygenated blood CYANOTIC Right-to-left shunts Deoxygenated to oxygenated blood

SECOND CLASSIFICATION
Increased pulmonary blood flow Decreased pulmonary blood flow

Ventricular Septal Defect (VSD) Atrial Septal Defect (ASD) Atrioventricular canal defect Patent Ductus Arteriosus (PDA)

Tricuspid Atresia Tetralogy of Fallot

SECOND CLASSIFICATION
Mixed blood flow Transposition of the great arteries Total anomalous pulmonary venous return Truncus arteriosus Hypoplastic left heart syndrome
Obstruction to blood flow

Pulmonary stenosis Aortic stenosis Coarctation of the aorta

INCREASED PULMONARY BLOOD FLOW

VENTRICULAR SEPTAL DEFECT

ILLUSTRATION description Opening present in the septum between two ventricles Left-to-right shunt (acyanotic) Results into RV hypertrophy

ATRIAL SEPTAL DEFECT

ILLUSTRATION description Opening present between two atria Left-to-right shunt (acyanotic) Results into RV hypertrophy

ATRIOVENTRICULAR SEPTAL DEFECT

ILLUSTRATION description Endocardial cushion defect Left-to-right shunt Blood may flow between all four heart chambers Seen in 50% of children with Down Syndrome Leads to RV hypertrophy

PATENT DUCTUS ARTERIOSUS (PDA)

Patent ductus arteriosus

description Results from failure to close at birth Left-to-right shunt Leads to RV hypertrophy

ASSESSMENT FINDINGS
CHF:
Tachypnea, tachycardia Hepatomegaly Feeding difficulties FTT Activity intolerance

MANAGEMENT
CONGENITAL HEART DEFECTS VSD MEDICAL CHF Management
Digoxin and diuretics

Avoid oxygen Increase caloric intake Infective endocarditis prophylaxis 6 months after surgery / ventricular device occluder

MANAGEMENT
CONGENITAL HEART DEFECTS VSD SURGICAL Cardiac catheterization for placement of ventricular occlusion Usually repaired after age 1 Approaches:
One-stage
Patch closure

Two-stages
PA banding to restrict pulmonary blood flow Patch close of VSD, removal of PA banding

MANAGEMENT
CONGENITAL HEART DEFECTS ASD MEDICAL CHF Management
Digoxin and diuretics

Infective endocarditis prophylaxis 6 months after surgery / atrial device occluder

MANAGEMENT
CONGENITAL HEART DEFECTS ASD SURGICAL Cardiac catheterization for placement of atrial occlusion Primary repair: suture closure of ASD Patch repair of ASD

MANAGEMENT
CONGENITAL HEART DEFECTS PDA MEDICAL CHF Management
Digoxin and diuretics

Infective endocarditis prophylaxis 6 months after surgery coil occlusion

MANAGEMENT
CONGENITAL HEART DEFECTS PDA SURGICAL Cardiac catheterization
Small PDAs; coil occlusion Large PDAs: closure device

PDA ligation

DISORDERS WITH OBSTRUCTION TO BLOOD FLOW

PULMONARY STENOSIS
ILLUSTRATION description Inability of RV to evacuate blood by way of PA Results into RV hypertrophy

AORTIC STENOSIS
ILLUSTRATION description Inability of LV to evacuate blood by way of aortic valve Results into LV hypertrophy

COARCTATION OF THE AORTA

ILLUSTRATION description Narrowing of the lumen of the aorta due to a constricting band Two locations:
Preductal (bet. subclavian artery and ductus arteriosus) Postductal (distal to ductus arteriosus)

Results into increase BP proximal to coarctation and decrease distal to it

ASSESSMENT FINDINGS
Pulmonary Stenosis
Hypoxia Tachypnea RV failure Activity intolerance

ASSESSMENT FINDINGS
Aortic Stenosis
Severe CHF Tachypnea Faint peripheral pulses, poor perfusion, poor capillary refill, cool skin Poor feeding Activity intolerance

ASSESSMENT FINDINGS
Coarctation of the Aorta
Hypertesion in the upper extremities, with absent or weak femoral pulses Nosebleeds Headaches Leg cramps

MANAGEMENT
CONGENITAL HEART DEFECTS Pulmonary Stenosis MEDICAL PGE1 infusion Intubation and ventilation Inotropics Infective endocarditis prophylaxis

MANAGEMENT
CONGENITAL HEART DEFECTS Pulmonary Stenosis SURGICAL Balloon pulmonary valvuloplasty Valvotomy or valvectomy

MANAGEMENT
CONGENITAL HEART DEFECTS Aortic Stenosis MEDICAL PGE1 infusion Intubation and ventilation Inotropics Infective endocarditis prophylaxis

MANAGEMENT
CONGENITAL HEART DEFECTS Aortic Stenosis SURGICAL Cardiac catheterization
Aortic balloon valvuloplasty Aortic balloon angioplasty

Valvotomy

MANAGEMENT
CONGENITAL HEART DEFECTS Coarctation of the Aorta MEDICAL PGE1 infusion Intubation and ventilation Infective endocarditis prophylaxis Anticongestive therapy

MANAGEMENT
CONGENITAL HEART DEFECTS Coarctation of the Aorta SURGICAL Balloon angioplasty End-to-end anastomosis

DISORDERS WITH MIXED BLOOD FLOW

TRANSPOSITION OF GREAT ARTERIES

ILLUSTRATION description Aorta rises from the RV instead of the left Pulmonary artery arises from the LV instead of right

TOTAL ANOMALOUS PULMONARY VENOUS RETURN

ILLUSTRATION description PV returns to the Ra or the superior vena cava instead of the LA

TRUNCUS ARTERIOSUS
ILLUSTRATION description ONE major trunk arises from the LV and RV in place of separate aorta and pulmonary artery vessels

ASSESSMENT FINDINGS
Transposition of Great Arteries
Cyanosis Tachypnea CHF Feeding difficulties

ASSESSMENT FINDINGS
Total Anomalous Pulmonary Venous Return
Cyanostic Activity intolerance Signs of RSHF

ASSESSMENT FINDINGS
Truncus Arteriosus
Cyanotic

MANAGEMENT
CONGENITAL HEART DEFECTS Transposition of great arteries MEDICAL PGE1 infusion Anticongestive drugs Intubation and ventilation Inotropics Infective endocarditis prophylaxis

MANAGEMENT
CONGENITAL HEART DEFECTS Transposition of great arteries SURGICAL Procedure of choice: Arterial switch operation
Aorta and PA are switched back to their anatomically correct ventricle

MANAGEMENT
CONGENITAL HEART DEFECTS Total anomalous pulmonary venous return MEDICAL PGE1 infusion Anticongestive drugs Intubation and ventilation Inotropics Infective endocarditis prophylaxis

MANAGEMENT
CONGENITAL HEART DEFECTS Total anomalous pulmonary venous return SURGICAL Reimplantation of the pulmonary veins into the left atrium

MANAGEMENT
CONGENITAL HEART DEFECTS Truncus arteriosus MEDICAL PGE1 infusion Anticongestive drugs Intubation and ventilation Inotropics Infective endocarditis prophylaxis

MANAGEMENT
CONGENITAL HEART DEFECTS Truncus arteriosus SURGICAL Grafting to separate aorta and pulmonary artery

DISORDERS WITH DECREASED PULMONARY BLOOD FLOW

TRICUSPID ATRESIA
ILLUSTRATION description Tricuspid valve completely closed = no blood flow from the RA to the RV Blood bypasses the lungs (crosses from foramen ovale to LA)

TETRALOGY OF FALLOT
ILLUSTRATION description FOUR anomalies present

ASSESSMENT FINDINGS
Tricuspid Atresia
Cyanosis Tachypnea Feeding difficulties

ASSESSMENT FINDINGS
Tetralogy of Fallot
Cyanosis Polycythemia Activity intolerance Squatting Hypercyanotic spells Tet spells
Occurs in the morning soon after awakening, during or after: crying, feeding, painful procedures Characterized by: tachypnea, irritability, increasing cyanosis, flaccidity and loss of consciousness

MANAGEMENT
CONGENITAL HEART DEFECTS Tricuspid Atresia MEDICAL PGE1 infusion Anticongestive drugs Intubation and ventilation Inotropics Infective endocarditis prophylaxis

MANAGEMENT
CONGENITAL HEART DEFECTS Tricuspid atresia SURGICAL First surgery: neonate
Blalock-Taussig shunt (shunt bet. aorta and PA) Pulmonary artery band

Second surgery: 6-9 months

End-to-end anastomosis

Third surgery: 18 months-3 yrs

IVC to PA connection

MANAGEMENT
CONGENITAL HEART DEFECTS Tetralogy of Fallot MEDICAL Positioning (knee-chest) Morphine sulfate Beta-blockers

MANAGEMENT
CONGENITAL HEART DEFECTS Tetralogy of Fallot SURGICAL Blalock-Taussig procedure Brock procedure (full repair)

ACQUIRED HEART DISEASE

Congestive Heart Failure (CHF)

DESCRIPTION
Occurs when CO cannot meet metabolic demands of the body

ASSOCIATED FACTORS
CHDs Acquired heart disease: myocarditis, cadiomyopathy, acute rheumatic fever Anemia Iatrogenic fluid overload

CLASSIFICATIONS
Right-sided Left-sided

ASSESSMENT FINDINGS
LEFT-SIDED Pulmonary congestion
Tachypnea Cyanosis Cough Crackles

RIGHT-SIDED Systemic venous congestion

Hepatomegaly Peripheral edema: scrotal and orbital Weight gain Decreased urine output

MANAGEMENT
Diuretics Digoxin ACE inhibitors Beta-adrenergic blockers Inotropics

NURSING DIAGNOSES
Decreased Cardiac Output related to myocardial dysfunction Excess fluid volume related to decreased cardiac contractility and decreased excretion from the kidney Impaired gas exchange related to pulmonary venous congestion Activity intolerance Risk for infection related to pulmonary congestion Imbalanced Nutrition: Less Than Body Requirements related to increased metabolic demands with decreased caloric intake

NURSING INTERVENTIONS
Improving Myocardial Efficiency
Administer Digoxin as prescribed
Measure HR, hold if HR < 90 bpm Check MOST RECENT potassium level, hold if < 3.5 Report signs of digoxin toxicity:
Vomiting Nausea Visual changes Bradycardia

NURSING INTERVENTIONS
Improving Myocardial Efficiency
Administer afterload reduction medications as prescribed
Measure BP before and after giving meds, hold if low BP and notify the physician Observe for signs of hypotension:
Dizziness Light-headedness Sncope

NURSING INTERVENTIONS
Maintaining Fluid and Electrolyte Balance
Administer diuretics as prescribed
Obtain daily weights Keep strict I&O monitoring Monitor serum potassium (potassium supplements as needed)

Sodium restriction Fluid restriction

NURSING INTERVENTIONS
Relieving Respiratory Distress
Administer oxygen as prescribed Elevate HOB

NURSING INTERVENTIONS
Promoting Activity Tolerance
Organize nursing care Respond efficiently to a crying infant Provide small, frequent feedings

NURSING INTERVENTIONS
Decreasing Risk of Infection
Ensure good hand washing by everyone Avoid exposure to all children or caretakers Monitor signs of infection: fever, cough, runny nose, diarrhea, vomiting

NURSING INTERVENTIONS
Providing Adequate Nutrition
Provide nutritious foods that the child likes High calorie snack

EVALUATION
HR within normal range No unexpected weight gain Clear lungs Participates in quiet diversional activities No signs and symptoms of infection Adequate intake of small, frequent feedings

Acute Rheumatic Fever

DESCRIPTION
Acute autoimmune disease that occurs as a sequeale of GABHS infection

ASSESSMENT
Major
Carditis Polyarhtritis Chorea Erythema marginatum Subcutaneous nodules

ASSESSMENT
Minor
Arthralgia Fever Laboratory abnormalities: elevated ESR, WBC, Creactive protein positive ECG changes prolonged PR interval

MANAGEMENT
Antibiotics (penicillin/erythromycin) Oral salicylates (aspirin) Corticosteroids Diazepam or other neurologic agents Bed rest

NURSING DIAGNOSIS
Decreased Cardiac Output related to carditis Acute and Chronic Pain related to arthritis Risk for injury related to chorea

NURSING INTERVENTIONS
Improving Cardiac Output
Explain to the child and family the need for bed rest Organize nursing care Administer course of antibiotics as prescribed Administer meds for CHF as directed

NURSING INTERVENTIONS
Relieving Pain
Administer anti-inflammatory medication, analgesics, and antipyretics
Monitor for signs of aspirin toxicity
Tinnitus, nausea and vomiting, headache

Monitor for signs of corticosteroid use

Weight gain, rounded face, decrease resistance to infection

Administer with food

NURSING INTERVENTIONS
Protecting the Child with Chorea
Use padded side rails Assist with feeding Avoid the use of straw and sharp utensils Administer phenobarbital or other neurologic agents as prescribed

EVALUATION
HR within normal range Compliant with anti-inflammatory therapy Feeds self, washes face and hands, and ambulates without injury