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8/4/2019 pedia cardio

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PEDIATRIC CARDIOVASCULAR

DISORDERS

Mr. Erwin U. Imperio


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VARIATIONS FROM THE ADULT

Fetal Circulation

Characteristics:

Placenta is the source of oxygen for the fetus

Fetal lungs receive


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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


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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


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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


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STRUCTURAL CHANGES

DUCTUS ARTERIOSUS

Increase aortic blood flow = increase aortic pressure =decrease right-to-left shunt

Increase pulmonary blood flow = increase arterialoxygen = vasoconstriction within hours of birth

Functional closure occurs:

24 hours after birth when vasoconstriction causes cessationof blood flow

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

lumen of ductus arteriosus


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ABNORMAL CIRCULATORY PATTERNS

AFTER BIRTH

This may happen as a result of abnormal

openings between pulmonary and systemic

circulations


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ASSESSMENT

Family History : genetic problems

Pregnancy History:

Rubella

Viral infections

Medications

X-ray exposure

Alcohol ingestion

Cigarette smoking


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ASSESSMENT

Childs health history

Presenting problem

Feeding problems

Failure to thrive

Respiratory difficulties

Color changes

Activity intolerance

Past medical history

Rheumatic fever


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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


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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


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LABORATORY / DIAGNOSTIC TESTS

CXR

MRI

ECG Hematologic testing


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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


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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


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NURSING DIAGNOSIS

Altered growth and development: failure tothrive

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


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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


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CARE OF A PEDIATRIC CLIENT WITH

CONGENITAL HEART DISEASE


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BLOOD CIRCULATION


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FIRST CLASSIFICATION

ACYANOTIC

Left-to-right shunts

Oxygenated tounoxygenated blood

CYANOTIC

Right-to-left shunts

Deoxygenated tooxygenated blood


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SECOND CLASSIFICATION

Increased pulmonary blood flow

Ventricular Septal Defect

(VSD)

Atrial Septal Defect (ASD)

Atrioventricular canal defect

Patent Ductus Arteriosus

(PDA)

Decreased pulmonary blood flow

Tricuspid Atresia

Tetralogy of Fallot


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SECOND CLASSIFICATION

Mixed blood flow

Transposition of the great

arteries

Total anomalous pulmonary

venous return

Truncus arteriosus

Hypoplastic left heartsyndrome

Obstruction to blood flow

Pulmonary stenosis

Aortic stenosis Coarctation of the aorta


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INCREASED PULMONARY BLOOD

FLOW


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VENTRICULAR SEPTAL DEFECT

ILLUSTRATION description

Opening present in the

septum between two

ventricles

Left-to-right shunt

(acyanotic)

Results into RV hypertrophy


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ATRIAL SEPTAL DEFECT


Opening present between

two atria

Left-to-right shunt

(acyanotic)



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ATRIOVENTRICULAR SEPTAL DEFECT


Endocardial cushion

defect

Left-to-right shunt

Blood may flow between all

four heart chambers

Seen in 50% of children withDown Syndrome

Leads to RV hypertrophy


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PATENT DUCTUS ARTERIOSUS (PDA)

Patent ductus arteriosus description

Results from failure to close

at birth

Left-to-right shunt

Leads to RV hypertrophy


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ASSESSMENT FINDINGS

CHF:

Tachypnea, tachycardia

Hepatomegaly

Feeding difficulties

FTT



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MANAGEMENT

CONGENITAL HEART DEFECTS

VSD

MEDICAL

CHF Management

Digoxin and diuretics

Avoid oxygen

Increase caloric intake

Infective endocarditis

prophylaxis 6 months aftersurgery / ventricular device

occluder


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MANAGEMENT


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


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MANAGEMENT


ASD

MEDICAL

CHF Management



prophylaxis 6 months after

surgery / atrial device

occluder


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MANAGEMENT


ASD

SURGICAL

Cardiac catheterization for

placement of atrial

occlusion

Primary repair: suture

closure of ASD

Patch repair of ASD


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MANAGEMENT


PDA

MEDICAL

CHF Management



prophylaxis 6 months after

surgery coil occlusion


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MANAGEMENT


PDA

SURGICAL

Cardiac catheterization

Small PDAs; coil occlusion

Large PDAs: closure device

PDA ligation


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DISORDERS WITH OBSTRUCTION TO

BLOOD FLOW


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PULMONARY STENOSIS


Inability of RV to evacuate

blood by way of PA



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AORTIC STENOSIS


Inability of LV to evacuate

blood by way of aortic valve

Results into LV hypertrophy


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COARCTATION OF THE AORTA


Narrowing of the lumen of

the aorta due to a

constricting band

Two locations:

Preductal (bet. subclavian

artery and ductus arteriosus)

Postductal (distal to ductusarteriosus)

Results into increase BP

proximal to coarctation and

decrease distal to it


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ASSESSMENT FINDINGS

Pulmonary Stenosis

Hypoxia

Tachypnea

RV failure



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ASSESSMENT FINDINGS

Aortic Stenosis

Severe CHF

Tachypnea

Faint peripheral pulses, poor perfusion, poor

capillary refill, cool skin

Poor feeding



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ASSESSMENT FINDINGS

Coarctation of the Aorta

Hypertesion in the upper extremities, with absent

or weak femoral pulses

Nosebleeds

Headaches

Leg cramps


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MANAGEMENT


Pulmonary Stenosis

MEDICAL

PGE1 infusion

Intubation and ventilation

Inotropics


prophylaxis


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MANAGEMENT


Pulmonary Stenosis

SURGICAL

Balloon pulmonary

valvuloplasty

Valvotomy or valvectomy


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MANAGEMENT


Aortic Stenosis

MEDICAL

PGE1 infusion


Inotropics


prophylaxis


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MANAGEMENT


Aortic Stenosis

SURGICAL

Cardiac catheterization

Aortic balloon valvuloplasty

Aortic balloon angioplasty

Valvotomy


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MANAGEMENT



MEDICAL

PGE1 infusion



prophylaxis

Anticongestive therapy


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MANAGEMENT



SURGICAL

Balloon angioplasty

End-to-end anastomosis


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DISORDERS WITH MIXED BLOOD

FLOW


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TRANSPOSITION OF GREAT ARTERIES


Aorta rises from the RV

instead of the left

Pulmonary artery arises

from the LV instead of right

TOTAL ANOMALOUS PULMONARY


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TOTAL ANOMALOUS PULMONARY

VENOUS RETURN


PV returns to the Ra or the

superior vena cava instead

of the LA


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TRUNCUS ARTERIOSUS


ONE major trunk arises

from the LV and RV in place

of separate aorta and

pulmonary artery vessels


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ASSESSMENT FINDINGS

Transposition of Great Arteries

Cyanosis

Tachypnea

CHF



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ASSESSMENT FINDINGS

Total Anomalous Pulmonary Venous Return

Cyanostic


Signs of RSHF


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ASSESSMENT FINDINGS

Truncus Arteriosus

Cyanotic


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MANAGEMENT


Transposition of great

arteries

MEDICAL

PGE1 infusion

Anticongestive drugs


Inotropics


prophylaxis


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MANAGEMENT


Transposition of great

arteries

SURGICAL

Procedure of choice:

Arterial switch operation

Aorta and PA are switched

back to their anatomically

correct ventricle


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MANAGEMENT



venous return

MEDICAL

PGE1 infusion



Inotropics


prophylaxis


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MANAGEMENT



venous return

SURGICAL

Reimplantation of the

pulmonary veins into the

left atrium


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MANAGEMENT


Truncus arteriosus

MEDICAL

PGE1 infusion



Inotropics


prophylaxis


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MANAGEMENT


Truncus arteriosus

SURGICAL

Grafting to separate aorta

and pulmonary artery


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DISORDERS WITH DECREASED

PULMONARY BLOOD FLOW


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TRICUSPID ATRESIA


Tricuspid valve completely

closed = no blood flow from

the RA to the RV

Blood bypasses the lungs

(crosses from foramen ovale

to LA)


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TETRALOGY OF FALLOT


FOUR anomalies present


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ASSESSMENT FINDINGS

Tricuspid Atresia

Cyanosis

Tachypnea



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ASSESSMENT FINDINGS

Tetralogy of Fallot

Cyanosis

Polycythemia


Squatting

Hypercyanotic spells Tet spells

Occurs in the morning soon after awakening, during orafter: crying, feeding, painful procedures

Characterized by: tachypnea, irritability, increasing

cyanosis, flaccidity and loss of consciousness


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MANAGEMENT


Tricuspid Atresia

MEDICAL

PGE1 infusion



Inotropics


prophylaxis


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MANAGEMENT


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-3yrs

IVC to PA connection


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MANAGEMENT


Tetralogy of Fallot

MEDICAL

Positioning (knee-chest)

Morphine sulfate

Beta-blockers


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MANAGEMENT


Tetralogy of Fallot

SURGICAL

Blalock-Taussig procedure

Brock procedure (full repair)


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ACQUIRED HEART DISEASE


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Congestive Heart Failure (CHF)


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DESCRIPTION

Occurs when CO cannot meet metabolic

demands of the body


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ASSOCIATED FACTORS

CHDs

Acquired heart disease: myocarditis,

cadiomyopathy, acute rheumatic fever

Anemia

Iatrogenic fluid overload


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CLASSIFICATIONS

Right-sided

Left-sided


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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


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MANAGEMENT

Diuretics

Digoxin

ACE inhibitors

Beta-adrenergic blockers

Inotropics


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NURSING DIAGNOSES

Decreased Cardiac Output related to myocardialdysfunction

Excess fluid volume related to decreased cardiac

contractility and decreased excretion from the kidney Impaired gas exchange related to pulmonary venous

congestion


Risk for infection related to pulmonary congestion

Imbalanced Nutrition: Less Than Body Requirements

related to increased metabolic demands with

decreased caloric intake


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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


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Improving Myocardial Efficiency

Administer afterload reduction medications as

prescribed

Measure BP before and after giving meds, hold if lowBP and notify the physician

Observe for signs of hypotension:

Dizziness

Light-headedness Sncope


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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

S G O S


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Relieving Respiratory Distress

Administer oxygen as prescribed

Elevate HOB



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Promoting Activity Tolerance

Organize nursing care

Respond efficiently to a crying infant

Provide small, frequent feedings



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Decreasing Risk of Infection

Ensure good hand washing by everyone

Avoid exposure to all children or caretakers

Monitor signs of infection: fever, cough, runnynose, diarrhea, vomiting



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Providing Adequate Nutrition

Provide nutritious foods that the child likes

High calorie snack

EVALUATION


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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


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Acute Rheumatic Fever

DESCRIPTION


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DESCRIPTION

Acute autoimmune disease that occurs as asequeale of GABHS infection

ASSESSMENT


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ASSESSMENT

Major

Carditis

Polyarhtritis

Chorea

Erythema marginatum

Subcutaneous nodules

ASSESSMENT


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ASSESSMENT

Minor

Arthralgia

Fever

Laboratory abnormalities: elevated ESR, WBC, C-reactive protein positive

ECG changes prolonged PR interval

MANAGEMENT


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MANAGEMENT

Antibiotics (penicillin/erythromycin)

Oral salicylates (aspirin)

Corticosteroids

Diazepam or other neurologic agents

Bed rest

NURSING DIAGNOSIS


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NURSING DIAGNOSIS

Decreased Cardiac Output related to carditis

Acute and Chronic Pain related to arthritis

Risk for injury related to chorea



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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



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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



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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


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EVALUATION

HR within normal range

Compliant with anti-inflammatory therapy

Feeds self, washes face and hands, and

ambulates without injury

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