Nursing Care of the Child with Cardiovascular Dysfunction

1. Nursing Care of the Child with Cardiovascular Dysfunction Steven Litteral MSN/ED RN.

2. Types of Cardiovascular disorders • Congenital • Also known as congenital heart disease • Happens before the child is born • Acquired • Happens after the child is born • Disease process: • Infection • Autoimmune response • Environmental factors • Familial tendencies

3. Evaluating for cardiac dysfunction • History: • Maternal health history • Medications like Dilantin • Infections like Rubella • Weight at birth • Family history • Specific concerns about the infant or child • Activity or feeding intolerance • Cyanosis or color changes • Syncopal or near-syncopal episodes

4. Evaluating for cardiac dysfunction • Physical: • Inspection • Nutritional state, color, chest deformities, unusual pulsations, respiratory, clubbing of fingers • Auscultation • Heart rhythm, character of heart sounds • Palpation/Percussion • Chest, abdomen, • Peripheral pulses

5. Evaluating for cardiac dysfunction • Possible diagnostic tests/procedures • Electrocardiogram (ECG) • Echocardiogram • Cardiac catheterization • Can be diagnostic or interventional • Rt side through Femoral Vein • LT side through Artery into aorta to heart • Prepare child prior to procedure • Watch for complications post-procedure • Bleeding, • Post-procedure instructions • B/P, Glucose levels, v/s frequently as q 15, keep straight 4-6 for venous, 6-8 for arterial.

6. Congenital Heart Disease • Most common anomaly is VSD • Ventricular septal defect • Etiology generally unknown: probably multifactorial (genetic tendency + environmental exposures)

7. Causes of Congenital Heart Disease (CHD) • Chromosomal-genetic: 10%-12% • Maternal or environmental: 1%-2% • Maternal drug use: • Fetal alcohol syndrome: 50% have CHD • Maternal illness: • Rubella in first 7 weeks of pregnancy—50% risk of defects, including patent ductusarteriosus (PDA) and pulmonary branch stenosis • Cytomegalovirus, toxoplasmosis, other viral illnesses lead to cardiac defects • IDMs = 10% risk of CHD (VSD, cardiomyopathy, TGA most common) • Multifactorial: 85%

8. CHD • Incidence: 5-8 per 1000 live births • About 2-3 of these are symptomatic in first year of life • Major cause of death in first year of life (after prematurity) • Most common anomaly is ventricular septal defect • 28% of kids with CHD have another recognized anomaly

9. Fetal Circulation Structures • Umbilical vein, umbilical arteries • Foramen ovale • Ductusarteriosus • Ductusvenosus

10. Changes at Birth FIG. 25-1  Changes in circulation at birth. A, Prenatal circulation. B, Postnatal circulation. Arrows indicate direction of blood flow. Although four pulmonary veins enter the LA, for simplicity this diagram shows only two. RA, Right atrium; LA, left atrium; RV, right ventricle; LV, left ventricle.

11. Changes in Circulation: Fetal to Neonate • Fetal circulation • Oxygenated blood from mother enters via umbilical vein through ductusvenosus, to IVC • Shunts from right side to left side via foramen ovale (between atria) • Also shunts from right to left via ductusarteriosis (from pulmonary artery to aorta) • Right side high pressure system, minimal pulmonary circulation, left side low pressure system

12. Changes at Birth FIG. 25-1  Changes in circulation at birth. A, Prenatal circulation. B, Postnatal circulation. Arrows indicate direction of blood flow. Although four pulmonary veins enter the LA, for simplicity this diagram shows only two. RA, Right atrium; LA, left atrium; RV, right ventricle; LV, left ventricle.

13. Changes in Circulation: Fetal to Neonate • At birth • With first breath and clamping of cord, abrupt changes in system • Pulmonary pressures fall, opens pulmonary vessels • Right-sided circulation becomes lower pressure, goes to pulmonary system • Left sided now high pressure (systemic), right sided lower pressure (pulmonary) • Foramen ovale and ductusarteriosis close right after birth or within 1-2 days

14. Changes at Birth FIG. 25-1  Changes in circulation at birth. A, Prenatal circulation. B, Postnatal circulation. Arrows indicate direction of blood flow. Although four pulmonary veins enter the LA, for simplicity this diagram shows only two. RA, Right atrium; LA, left atrium; RV, right ventricle; LV, left ventricle.

15. Changes in Circulation: Fetal to Neonate • Altered hemodynamics • Blood goes from area of high pressure to low pressure • If pressure is high on the left side of the heart (normal), then blood flows through defects (e.g. septal defects) from left to right • “Left-to-right” shunt • Causes increase in total blood flow in heart and lungs, CHF results • If pressure in pulmonary vasculature is increased or there is an obstruction to blood flow into the lungs, blood flow may be pushed from the right sided to left side of the heart • “Right-to-left” shunt • Causes decrease in oxygenation to the system=cyanosis • Cyanosis also occurs if there is a mix of deoxygenated and oxygenated blood

16. Changes at Birth FIG. 25-1  Changes in circulation at birth. A, Prenatal circulation. B, Postnatal circulation. Arrows indicate direction of blood flow. Although four pulmonary veins enter the LA, for simplicity this diagram shows only two. RA, Right atrium; LA, left atrium; RV, right ventricle; LV, left ventricle.

17. Pediatric Indicators of Cardiac Dysfunction • Poor feeding • Tachypnea, tachycardia • Failure to thrive, poor weight gain, activity intolerance • Developmental delays • Positive prenatal history • Positive family history of cardiac disease

18. Classifications of CHD • Older Classifications • Acyanotic vs. Cyanotic • Newer Classifications • Hemodynamic characteristics • Increased pulmonary blood flow • Decreased pulmonary blood flow • Obstruction of blood flow out of the heart • Mixed blood flow

19. Increased Pulmonary Blood Flow Defects • Abnormal connection • between two sides of heart • Either the septum or the great vessels • Increased blood volume on right side of heart • Increased pulmonary blood flow • Decreased systemic blood flow • Clinical symptoms of CHF

20. Increased Pulmonary Blood Flow Defects • Atrial septal defect (ASD) • Maybe asymptomatic, murmur heard, may develop CHF • Low mortality rate • Ventricular septal defect (VSD) • CHF is common, loud murmur can be heard, at risk for bacterial endocarditis, pulmonary vascular obstructive disease • Atrioventricular canal defect (ACD) • Moderate to severe CHF, loud murmur, mild cyanosis with crying, high risk for pulmonary vascular obstructive disease • Patent ductusarteriosis (PDA) • Maybe asymptomatic, show signs of CHF, have an increase in pulmonary blood flow

21. Atrial Septal Defect Unn Figure 25-1 Atrial septal defect

22. Ventricular Septal Defect Unn Figure 25-2 Ventricular septal defect

23. Atrioventricular Canal Defect Unn Figure 25-3 Atrioventricular canal defect

24. Patent Ductus Arteriosus Unn Figure 25-4 Patent ductus arteriosus

25. Changes at Birth FIG. 25-1  Changes in circulation at birth. A, Prenatal circulation. B, Postnatal circulation. Arrows indicate direction of blood flow. Although four pulmonary veins enter the LA, for simplicity this diagram shows only two. RA, Right atrium; LA, left atrium; RV, right ventricle; LV, left ventricle.

26. Obstructive Defects • Stenosis: Area of narrowing • Blood exiting heart meets area of stenosis • Often near valve or at site of valve • Causes increased pressure behind the narrowing • Decreased blood flow beyond the narrowing • CHF is a result

27. Obstructive Defects • Coarctation of the aorta (COA) • May have high b/p and bounding pulses, signs of CHF, in critical infants may deteriorate rapidly, older children may have dizziness, headaches, fainting spells • Aortic stenosis • Decrease cardiac output, hypotension, faint pulses, tachycardia, • Pulmonic stenosis • May have mild cyanosis or CHF, loud murmur, at risk for cardiomegaly, at risk for bacterial endocarditis.

28. Coarctation of the Aorta Unn Figure 25-5 Coarctation of the aorta

29. Aortic Stenosis Unn Figure 25-6 Aortic stenosis

30. Pulmonic Stenosis Unn Figure 25-7 Pulmonic stenosis

31. Decreased Pulmonary Blood Flow Defects • Tetralogy of Fallot & Tricuspid atresia • Decreased blood getting into pulmonary system • Causes increased pressures on right side of heart • Blood is shunted right to left; results in deoxygenated blood entering system • Cyanosis and hypoxia • Severe defects, often result in multiple surgeries

32. Tetralogy of Fallot • “Tet” means “four”=four defects • Variable clinical picture, depending on how blood is shunted • Right to left shunting results in hypoxia and cyanosis • “Tet spells”=overload on heart leads to increased right to left shunting and increased cyanosis: • Treat w/knee-chest position, oxygen

33. Tetralogy of Fallot Unn Figure 25-8 Tetralogy of Fallot

34. Tricuspid Atresia Unn Figure 25-9 Tricuspid atresia

35. Mixed Defects • Transposition of great vessels • Hypoplastic left heart syndrome • Complex, rare defects • Many variations of defects • Many rely on ductusarteriosisand/or foramen ovale

36. Changes at Birth FIG. 25-1  Changes in circulation at birth. A, Prenatal circulation. B, Postnatal circulation. Arrows indicate direction of blood flow. Although four pulmonary veins enter the LA, for simplicity this diagram shows only two. RA, Right atrium; LA, left atrium; RV, right ventricle; LV, left ventricle.

37. Transposition Of The Great Arteries, Or Transposition Of The Great Vessels Unn Figure 25-11 Transposition of great vessels

38. Hypoplastic left heart syndrome • Severely underdeveloped left ventricle • Relies on fetal circulation to keep infant alive • Requires multiple surgeries • Sometimes requires transplantation • May result in problems as child grows • At one time was universally fatal, much better prognosis now

39. Changes at Birth FIG. 25-1  Changes in circulation at birth. A, Prenatal circulation. B, Postnatal circulation. Arrows indicate direction of blood flow. Although four pulmonary veins enter the LA, for simplicity this diagram shows only two. RA, Right atrium; LA, left atrium; RV, right ventricle; LV, left ventricle.

40. Hypoplastic Left-Sided Heart Syndrome Unn Figure 25-14 Hypoplastic left-sided heart syndrome

41. CHF in children • Generally caused by abnormalities • May be right- or left-sided; most of the time a mixture of both • Impaired myocardial function • Pulmonary congestion • Systemic venous congestion

42. CHF in Children • Impaired myocardial function: • Tachycardia, fatigue, weakness, restlessness, pale, cool extremities, decreased blood pressure, decreased urinary output • Pulmonary congestion: • Tachypnea, dyspnea, respiratory distress, exercise intolerance, cyanosis • Systemic venous congestion: • Peripheral and periorbital edema, weight gain, ascites, hepatomegaly, neck vein distention

43. CHF in children • Goals of treatment • Improve cardiac function • Increase contractility • Decrease afterload • Remove accumulated fluid & sodium (decrease preload) • Decrease cardiac demands • Improve tissue oxygenation and decrease oxygen consumption • Eventual goal is to treat the cause • Initial diagnosis of CHD • Worsening of defect • Other cardiac or pulmonary problem

44. CHF in children • Nursing care management • Assist in measures to improve cardiac function • Digoxin administration • When to withhold • Heart rate 90-110 for infants and young children • 70 for older children • Watch for signs of toxicity (normal dig level 0.8-2.0) • Monitor afterload reduction • Decrease cardiac demands • Reduce respiratory distress • Maintain nutritional status • Assist in measures to promote fluid loss • Support child and family

45. Hypoxemia • Hypoxemia: decreased O2 tension in arterial blood • Hypoxia: decreased tissue oxygenation • Cyanosis: blue discoloration when hemoglobin is not bound to oxygen • Clinical manifestations • Polycythemia • Hypercyanotic spells (blue spells, tet spells) • Persistent cyanosis =neuro complications & clubbing of fingers

46. Hypoxemia • Therapeutic management • Prostaglandin infusion • Keeps fetal shunts OPEN • Management of hypercyanotic spells • Avoid agitating patient if possible • Morphine • Oxygen • Hydration • Comfort/calm • Knee-chest position

47. Hypoxemia • Nursing care management • Deal with body image concerns (older children, adolescents) • Deal with family/parental concerns • Prevent dehydration • Prevent pulmonary infection • NO AIR IN IV LINES (air embolism) • Shunting of blood from right to left can cause air embolism to travel straight to brain

48. Nursing care of child and family with CHD • Starts as soon as diagnosis is suspected • Help family adjust to disorder • Educate family about disorder • Help families manage the illness at home • Prepare child and family for invasive procedures • May need to tour ICU; tailor to individual situation

49. Nursing care of child and family with CHD • Provide postoperative care • See box 25-7, page 889 • Observe vital signs • Maintain respiratory status • Monitor fluids • Provide rest and progressive activity • Provide comfort and emotional support • Plan for discharge and home care • See “Family-Centered Care” box, page 891

50. Endocarditis • Bacterial endocarditis (BE), infective endocarditis (IE), or subacute bacterial endocarditis (SBE) • Streptococcal • Staphylococcal • Fungal infections • Prophylaxis: 1 hour before procedures (IV) or may use PO in some cases