Cardiovascular Disorders

T. McDonald
Nur2310

Normal flow of blood

http://www.youtube.com/watch?v=F
CimR_P9ID0&feature=relmfu
https://www.youtube.com/watch?v=
JA0Wb3gc4mE&feature=relmfu

Heart Defects that Increase

Pulmonary Blood Flow
PDA- Patent Ductus
Arteriosus [open]
ASD-Atrial Septal
Defect [between the
left and right atrium]
VSD- Ventricular
Septal Defect
[between the left and
right ventricles]

PDA: Anatomy

PDA: Pathophysiology &

Manifestations,
Pathophysiology
The Ductus Arteriosus Usually closes within the
first hours of life
Common in preterm infants

Manifestations

Continuous machine like murmur

Dyspnea
Tachycardia
Tachypnea
Thrill in pulmonic area
May be asymptomatic

PDA: Clinical Therapy

Therapy
EKG shows left ventricular hypertrophy
PDA visualized on echo
Surgical Ligation
Intravenous indomethacin [NSAIDS]
stimulates closure in premature infants but
can not be used if CHF is present

Shunt
Left-to-right can be visualized on
echocardiogram
Increase in pulmonary blood flow

ASD animation
http://www.youtube.com/watch?v=e46
jtin-H50&feature=related

ASD: Anatomy

ASD: Pathophysiology &

Manifestations
Pathophysiology
Opening in the atrial septum
May occur alone or in conjunction with a
congenital defect

Manifestations
Usually no symptoms in infants and
young children
With a large ASD, easy tiring, and poor
growth occur

ASD: Clinical Therapy

Therapy
Dilated right ventricle on echo secondary to
blood overload and shunt size
Spontaneous closure occurs within the first 4
years of life [the procedure can be done earlier if
the hole is very large or the child is symptomatic]
Surgery or patch when closure does not occur or
when increased pulmonary blood flow results in
CHF

Shunt
Left-to-right resulting in increased pulmonary
blood flow

VSD: Anatomy

VSD: Pathophysiology,
Manifestations and Clinical
Therapy

Pathophysiology

Opening in ventricular septum

Manifestations
Only 15% are large enough to cause
CHF or pulmonary hypertension, or
pulmonary infections
Systolic murmur at third [Erbs point] or
fourth left [tricuspid vavlve] intercostal
space

VSD: Clinical Therapy

Therapy
A small x-ray and EKG reveals little
Echo establishes diagnosis if shunting is
present
Most close within first 6 months of life
Surgical patching if poor growth is evident;
otherwise treatment is conservative [will
patch sooner if symptoms occur]

Shunt
Left-to-right directly across septum into
pulmonary artery
Increased pulmonary blood flow

Heart Defects with Decreased

Pulmonary Blood Flow
Pulmonary Stenosis
[narrowing, so will
get a decrease in
blood flow]
TOF-Tetralogy of
Fallot

TOF animation
http://www.youtube.com/watch?v=ye
PivAlbR4A&feature=relmfu

https://www.youtube.com/watch?
v=DrgUSGvL_4Q

TOF: Anatomy

TOF: Pathophysiology
Pathophysiology
Four defects
Pulmonic Stenosis
page 1371
Right Ventricular
Hypertrophy
VSD
Overriding Aorta
Some kids have a fifth
defect: ASD

TOF: Manifestations
Infant becomes hypoxic
and cyanotic as the
ductus arteriosus closes
[b/c it cuts off the mixing
of the blood which the
child needs b/c it carries
some oxygen]
The degree of the
pulmonary stenosis
determines the severity
of the symptoms
Systolic murmur in the
pulmonic area and
transmitted to
suprasternal notch

Polycythemia [make
more RBCs to
compensate for lack of
oxygen], hypercyanotic
spell (tet spells),
metabolic acidosis, poor
growth, clubbing [ET
fingers], and exercise
intolerance
Knee chest squat of
toddlers to decrease the
return of systemic
venous blood to the
heart

TOF: Pathophysiology,
Manifestations, and Clinical
Therapy
Therapy
Diagnostic Tests
X-ray shows boot shaped
heart due to large right
ventricle, prominent aorta
Treatment
Calm, give oxygen, and
morphine [for pain] and
propanolol [beta blocker] to
decrease pulmonary vascular
resistance
Modified BT shunt to delay
total correction surgery
Shunt
Right-to-left secondary to
elevated pressures on the right
side of the heart

BT shunt

Mixed defects
TGA- Transposition
of the Great
Arteries

TGA animation
http://www.youtube.com/watch?
v=O83cYwKOKtI&feature=relmfu
https://www.youtube.com/watch?
v=ZY11g3VZGVI&list=PL3D6CB3CBA
CEB653B&index=1

TGA: Anatomy

TGA: Pathophysiology
PathophysiologyParallel circulation
Pulmonary Artery is the
outflow tract for the left
ventricle
The Aorta is the outflow
tract for the right ventricle
Life threatening at birth,
survival initially depends
on an open ductus
arteriosus and foramen
ovale

TGA: Manifestations
Cyanosis apparent soon
after birth [have
deoxygenated blood is
being circulated
throughout the body]
Which does not
improve with oxygen
administration
May be less
apparent if VSD is
present

Tachypnea without
retractions or other
signs of dyspnea [the
lungs are still getting
oxygen]
Systolic murmur if VSD
present; otherwise none;
S2 is loud

TGA: Manifestations
Manifestations
CHF may develop
immediately, over
days or weeks
Long time to feed and
need frequent rest
periods b/c of rapid
respiratory rate and
fatigue;
growth failure may be
seen as early as 2wks
if not corrected

TGA: Clinical Therapy

Therapy
Diagnosis
X-ray may reveal classis egg-shaped heart on a
string with enlarged ventricles
Echo shows abnormal positioning of the great
arteries

Treatment
Prostaglandin E1 is ordered to maintain a patent
ductus arteriosus until a palliative surgery can be
performed
Arterial switch performed before 1 week of life
Balloon atrial septostomy can be performed to allow
mixing until surgery can be performed

Defects that Obstruct Systemic

blood flow
Coarctation of the
Aorta
CHF

Coarctation of the Aorta

animation
http://www.youtube.com/watch?
v=SiNJfvK_qeI&feature=relmfu

Coarctation of the Aorta:

Anatomy

Coarctation of the Aorta:

Pathophysiology, Manifestations
Pathophysiology
Narrowing or constriction of the descending aorta often near the
ductus arteriosus or subclavian artery which obstructs systemic
flow

Manifestations

Many children are asymptomatic

Severe constriction infants have cyanosis in the lower extremities
Blood pressure lower in legs than arms
Brachial and radial pulses are typically bounding and femoral
weak or absent
Older children may complain of leg pain after exercising
[decrease blood flow, more pain, and ischemia of the body part]
S2 is loud and single on auscultation

Coarctation of the Aorta:

clinical Therapy
Therapy
Diagnosis
X-ray may show cardiomegaly
Echo confirms narrowing and location

Treatment
In symptomatic newborns, PGE1 is given to
reopen the ductus arteriosus and promote blood
flow to the lower extremities
Treatment to prevent CHF may include diuretics,
inotropic medications and oxygen
Surgical correction is preferred

Congestive Heart Failure

(CHF)
Disorder in which circulation is inadequate to support the bodys

circulatory and metabolic needs.

http://www.youtube.com/watch?v=GnpLm9fzYxU
Etiology

Most common cause

May be caused by congenital heart defects that obstruct systemic
blood outflow tract or cause increased pulmonary blood flow
children with uncorrected defects develop CHF within 6 to 12 months of
life [if they become symptomatic will be done earlier, especially if they
have signs of CHF]
Other causes
Problems with heart contractility
Pathologic conditions that require high cardiac output (severe anemia,
acidosis, or respiratory disease)
Acquired heart disease (cardiomyopathy [weakening of the heart
muscle], rheumatic heart disease, and Kawasaki disease [inflammation
of the blood vessels, can harm the coronary arteries, most common in
Asian descents])
Disorders such as Duchenne muscular dystrophy [dead muscle tissue,
muscle waste away and get worst over time]

CHF: Pathophysiology
Pathophysiology
Left-to-right shunts
result in increased blood
to the pulmonary
system and can result in
pulmonary hypertension
Obstructive defects
restrict the flow of blood
so the heart muscle
hypertrophies to work
harder to force blood
through the structures

CHF: Manifestations in
Infants
Initial Manifestations
Tiring easily, especially
during feedings [small
frequent feeding, high cal]
Weight loss or lack of
normal weight gain
Diaphoresis [babies dont
really sweat unless under
abnormal defects]
Irritability
Frequent Respiratory
infections [lungs are
flooded prone to bacteria]

Later
Manifestations

Tachypnea
Tachycardia
Pallor
Cyanosis
Nasal Flaring
Grunting
Retractions
Cough or crackles
Third heart sound

CHF: Manifestations in Older

Children
Initial Manifestations
Exercise Intolerance
Dyspnea
Abdominal pain or
distention [acites in the liver
b/c the blood in the IVC is
backing up in the liver]
Peripheral edema

Later Manifestations
Generalized fluid volume
overload
Jugular vein distention

CHF: therapy
Medications
Lasix [loop diuretic, monitor I&O
before and after, BP, potassium ]
Digoxin [positive inotropic, anything
less than a HR of 100 hold,
arrhythmias and N&V are the typical
signs of dig. Toxicity (0.5-1.5)]

CHF: Nursing Management

Assessment
Physiologic assessment [airway/
breathing, V/S]
Developmental assessment

Planning and Implementation

Administer and monitor
prescribed medications
Lasix and digoxin see page 1388

Maintain oxygen and myocardial

function
Promote rest
Foster development
Provide adequate nutrition
Provide emotional support
Discharge planning and home
care teaching

Evaluation

Acquired heart Diseases

Rheumatic Fever
Kawasaki Disease

Kawasaki Disease
Acute febrile, systemic
vascular inflammatory
disorder that affects the
small and midsize arteries,
including the coronary
arteries
Leading cause of acquired
heart disease in children in
the US
Etiology unknown, thought
to be caused by an
unidentified infectious agent
http://www.youtube.com/wat
ch?v=L9FmxwNC5S0

Kawasaki Disease:
Manifestations and Clinical
Manifestations
Therapy
Acute 1-2 weeks

Irritability, high fever that persists more than 5 days, hyperemic

conjunctivae [increase in blood flow, abnormal amount of blood in
the eye], red throat, swollen, hands and feet, rash on trunk and
perineal area, cervical lymph node enlargement (unilateral)

Subacute 2-4 weeks

Cracking lips and fissures, desquamation of the skin on the tips of
toes and fingers, joint pain, cardiac disease, and thrombocytosis

Convalescent stage 6-8 weeks

Child appears normal but lingering signs of inflammation may be present

Clinical Therapy
Intravenous Immunoglobulin [gamma globulin]
High does of aspirin for fever [and to thin out the blood clots]
Hospitalization

Kawasaki Disease: nursing

management
Assessment
Temperature, skin, eyes,
I&O, weight, cardiac

Medication
Aspirin administration
Monitor for side
effects(bleeding, GI
upset)
Immune Globulin
Treat and administer
like a blood product
[monitor VS]

Comfort
Skin clean and dry
Cool compresses, tepid
baths
Small frequent feeding
Exercise
Passive ROM
Discharge planning
Teaching on aspirin therapy
Postpone live virus vaccines
(measles, mumps, rubella,
and varicella) for 11 months
after immune globulin
administration, others may
be given on schedule

Rheumatic Heart Disease

Inflammatory disorder of the connective
tissue that results from an autoimmune
response to some strains of A betahemolytic streptococci
Affects joints, brain, and skin tissue
Children between 5 and early adolescent
are more commonly infected
Rheumatic heart disease develops in
10% of individuals with rheumatic fever

Rheumatic Heart Disease:

Manifestations and Clinical
Therapy

Hallmark signs

Occur three weeks after an untreated streptococcal

infection
Carditis involving the mitral or aortic valve is
detected by presence of a new murmur
Chest pain
Two or more large joints become inflamed with pain,
swelling, tenderness, erythema, and heat
Non pruritic skin rash with pink macules and
blanching in the middle of the lesions on the trunk

Rheumatic heart disease:

diagnosis and clinical
therapy

Diagnosis [acute pain, decreased

cardiac output, parental anxiety, activity
intolerance, impaired mobility, risk skin
integrity, deficient fluid volume= risk for
constipation]
Clinical Therapy
Antibiotics (penicillin, to eradicate strep infection)
Corticosteroids (to reduce inflammation)

Rheumatic Heart Disease:

Nursing Management
Prevention
Children with possible
throat infections would be
cultured for strep

Hospitalization
Children with rheumatic
fever should be
hospitalized
Bed rest for monitoring
carditis
4weeks bed rest if carditis
develops

Medications
Antibiotics [for the strep
infection] and aspirin

Discharge Planning
Recovery phase occurs at
home
Activity limitations
Antibiotic prescribed
Teaching
Reoccurrence of sore
throat need for culture
Follow up care to
monitor heart function