The Child with Cardiovascular Dysfunction Chapter 34

The Child with Cardiovascular Dysfunction

Chapter 34

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Changes at BirthChanges at Birth

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Pediatric Indicators of Pediatric Indicators of Cardiac DysfunctionCardiac Dysfunction

Poor feedingPoor feeding Tachypnea/tachycardiaTachypnea/tachycardia Failure to thrive/poor weight gain/activity Failure to thrive/poor weight gain/activity

intolerance intolerance Developmental delaysDevelopmental delays Prenatal historyPrenatal history Family history of cardiac diseaseFamily history of cardiac disease

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““Innocent Murmurs”Innocent Murmurs” Murmurs = heart sounds that reflect flow of Murmurs = heart sounds that reflect flow of

blood within the heartblood within the heart May occur in systole or diastole, or bothMay occur in systole or diastole, or both Can occur in a normal heart in periods of stress: Can occur in a normal heart in periods of stress:

anemia, fever, or rapid growthanemia, fever, or rapid growth Can reflect abnormalities in heart or vesselsCan reflect abnormalities in heart or vessels

““Innocent murmurs” = normal cardiac Innocent murmurs” = normal cardiac anatomy and cardiac functionanatomy and cardiac function Occur in up to 50% of all kids at some timeOccur in up to 50% of all kids at some time

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ThrillsThrills

The sound of a thrill is a soft vibration over The sound of a thrill is a soft vibration over the heart that reflects the transmitted sound the heart that reflects the transmitted sound of a heart murmurof a heart murmur

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Conduction System of the Heart Conduction System of the Heart

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Normal ECG Pattern Normal ECG Pattern

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Electrode Placement for Electrode Placement for Standard Chest Lead II Standard Chest Lead II

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Tests of Cardiac FunctionTests of Cardiac Function

Chest x-rayChest x-ray ECGECG EchocardiographyEchocardiography Cardiac catheterizationCardiac catheterization

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Hypoplastic Left HeartHypoplastic Left Heart

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Interventional Cardiac Interventional Cardiac Catheterization Catheterization

Procedures in ChildrenProcedures in Children

Transposition of great vesselsTransposition of great vessels Some complex single-ventricle defectsSome complex single-ventricle defects ASDASD Pulmonary artery stenosisPulmonary artery stenosis

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Interventional Cardiac Interventional Cardiac Catheterization Catheterization

Procedures in Children (cont.)Procedures in Children (cont.)

DIAGNOSISDIAGNOSIS INTERVENTIONINTERVENTION

Valvular pulmonic stenosisValvular pulmonic stenosis Balloon dilationBalloon dilation

Recurrent coarctation of aortaRecurrent coarctation of aorta Balloon dilationBalloon dilation

Congenital mitral stenosisCongenital mitral stenosis Balloon dilationBalloon dilation

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ClubbingClubbing

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Knee-Chest PositionKnee-Chest Position

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Two Types of Cardiac DefectsTwo Types of Cardiac Defects

CongenitalCongenital Anatomic Anatomic → → abnormal functionabnormal function

AcquiredAcquired Disease process Disease process

• InfectionInfection

• Autoimmune responseAutoimmune response

• Environmental factorsEnvironmental factors

• Familial tendenciesFamilial tendencies

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Causes of CHDCauses of CHD

Maternal or environmental = 1% to 2%Maternal or environmental = 1% to 2% Maternal drug useMaternal drug use

• Fetal alcohol syndrome—50% have CHDFetal alcohol syndrome—50% have CHD

Maternal illnessMaternal illness• Rubella in first 7 weeks of pregnancy Rubella in first 7 weeks of pregnancy → → 50% risk of 50% risk of

defects including PDA and pulmonary branch stenosisdefects including PDA and pulmonary branch stenosis

• CMV, toxoplasmosis, other viral illnesses CMV, toxoplasmosis, other viral illnesses → → cardiac cardiac defectsdefects

• IDMs = 10% risk of CHD (VSD, cardiomyopathy, TGA IDMs = 10% risk of CHD (VSD, cardiomyopathy, TGA most common)most common)

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Causes of CHD (cont.)Causes of CHD (cont.)

Chromosomal/genetic = 10% to 12%Chromosomal/genetic = 10% to 12% Multifactorial = 85%Multifactorial = 85%

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CHDCHD

Incidence: 5 to 8 per 1000 live births Incidence: 5 to 8 per 1000 live births About 2 or 3 of these are symptomatic in first year About 2 or 3 of these are symptomatic in first year

of lifeof life Major cause of death in first year of life (after Major cause of death in first year of life (after

prematurity)prematurity) Most common anomaly is VSDMost common anomaly is VSD 28% of kids with CHD have another recognized 28% of kids with CHD have another recognized

anomaly (trisomy 21, 13, 18, + + + )anomaly (trisomy 21, 13, 18, + + + )

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Older Classifications of CHDOlder Classifications of CHD

AcyanoticAcyanotic May become cyanoticMay become cyanotic

CyanoticCyanotic May be pinkMay be pink May develop CHFMay develop CHF

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Newer Classifications of CHDNewer Classifications of CHD

Hemodynamic characteristicsHemodynamic characteristics Increased pulmonary blood flowIncreased pulmonary blood flow Decreased pulmonary blood flowDecreased pulmonary blood flow Obstruction of blood flow out of the heartObstruction of blood flow out of the heart Mixed blood flowMixed blood flow

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Comparison of CHD Comparison of CHD Classification SystemsClassification Systems

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Increased Pulmonary Blood Increased Pulmonary Blood Flow DefectsFlow Defects

Abnormal connection between two sides of Abnormal connection between two sides of heartheart Either the septum or the great vesselsEither the septum or the great vessels

Increased blood volume on right side of heartIncreased blood volume on right side of heart Increased pulmonary blood flowIncreased pulmonary blood flow Decreased systemic blood flowDecreased systemic blood flow

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Hemodynamics in Defects with Hemodynamics in Defects with Increased Pulmonary Blood FlowIncreased Pulmonary Blood Flow

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Increased Pulmonary Blood Increased Pulmonary Blood Flow DefectsFlow Defects

Atrial septal defectAtrial septal defect Ventricular septal defectVentricular septal defect Patent ductus arteriosusPatent ductus arteriosus

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ASDASD

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VSDVSD

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PDAPDA

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Obstructive DefectsObstructive Defects

Coarctation of the aortaCoarctation of the aorta Aortic stenosisAortic stenosis Pulmonic stenosisPulmonic stenosis

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Sites of Obstruction to Ventricular Sites of Obstruction to Ventricular EjectionEjection

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COACOA

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ASAS

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PS and Catheter PlacementPS and Catheter Placement

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Decreased Pulmonary Blood Decreased Pulmonary Blood Flow DefectsFlow Defects

Tetralogy of FallotTetralogy of Fallot Tricuspid atresiaTricuspid atresia

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TOFTOF

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Cardiac ShuntsCardiac Shunts

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Tricuspid AtresiaTricuspid Atresia

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Mixed DefectsMixed Defects

Transposition of great vesselsTransposition of great vessels Total anomalous pulmonary venous Total anomalous pulmonary venous

connectionconnection Hypoplastic heart syndrome Hypoplastic heart syndrome

RightRight LeftLeft

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Transposition of Great Transposition of Great VesselsVessels

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Normal HeartNormal Heart

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Total Anomalous Pulmonary Venous Total Anomalous Pulmonary Venous ConnectionConnection

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CHF in ChildrenCHF in Children

Impaired myocardial functionImpaired myocardial function Tachycardia; fatigue; weakness; restless, pale, Tachycardia; fatigue; weakness; restless, pale,

cool extremities; decreased BP; decreased urine cool extremities; decreased BP; decreased urine outputoutput

Pulmonary congestionPulmonary congestion Tachypnea, dyspnea, respiratory distress, Tachypnea, dyspnea, respiratory distress,

exercise intolerance, cyanosisexercise intolerance, cyanosis

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CHF in Children (cont.)CHF in Children (cont.)

Systemic venous congestionSystemic venous congestion Peripheral and periorbital edema, weight gain, Peripheral and periorbital edema, weight gain,

ascites, hepatomegaly, neck vein distentionascites, hepatomegaly, neck vein distention

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Care of the Family and Child with Care of the Family and Child with Congenital Heart DiseaseCongenital Heart Disease

Help family adjust to the disorderHelp family adjust to the disorder Educate familyEducate family Help family cope with effects of the disorderHelp family cope with effects of the disorder Prepare child and family for surgeryPrepare child and family for surgery

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Surgical InterventionsSurgical Interventions

Open heartOpen heart Closed heart proceduresClosed heart procedures Staged proceduresStaged procedures Prepare child and family for proceduresPrepare child and family for procedures

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Postoperative Care for the ChildPostoperative Care for the Child

Monitor vital signs and A/V pressuresMonitor vital signs and A/V pressures Intra-arterial monitoring of BPIntra-arterial monitoring of BP Intracardiac monitoringIntracardiac monitoring Respiratory needsRespiratory needs Rest, comfort, and pain managementRest, comfort, and pain management Fluid managementFluid management Progression of activityProgression of activity

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Postoperative ComplicationsPostoperative Complications

CHFCHF DysrhythmiasDysrhythmias Decreased cardiac output syndromeDecreased cardiac output syndrome Decreased peripheral perfusionDecreased peripheral perfusion Pulmonary changesPulmonary changes Neurologic changesNeurologic changes

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Postpericardiotomy SyndromePostpericardiotomy Syndrome

Symptoms: fever, Symptoms: fever, WBCs, pericardial friction WBCs, pericardial friction rub, pericardial and pleural effusionrub, pericardial and pleural effusion

Occurs in immediate postoperative periodOccurs in immediate postoperative period Also can occur later (days 7 to 21 postop)Also can occur later (days 7 to 21 postop) Etiology unknownEtiology unknown Theories of etiologyTheories of etiology

Viral infection, autoimmune response, reaction to Viral infection, autoimmune response, reaction to blood in pericardiumblood in pericardium

May require pericardiocentesis or pleurocentesisMay require pericardiocentesis or pleurocentesis

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Acquired Cardiovascular Acquired Cardiovascular DisordersDisorders

Infectious and inflammatory cardiac disordersInfectious and inflammatory cardiac disorders

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EndocarditisEndocarditis

BE, IE, or SBEBE, IE, or SBE StreptococciStreptococci StaphylococciStaphylococci Fungal infectionsFungal infections Prophylaxis: 1 hour before procedures (IV) or Prophylaxis: 1 hour before procedures (IV) or

may use PO in some casesmay use PO in some cases

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Rheumatic Fever (RF) andRheumatic Fever (RF) andRheumatic Heart DiseaseRheumatic Heart Disease

RFRF Inflammatory disease occurs after group A Inflammatory disease occurs after group A ββ--

hemolytic streptococcal pharyngitishemolytic streptococcal pharyngitis Infrequently seen in U.S.; big problem in Third Infrequently seen in U.S.; big problem in Third

World World Self-limitingSelf-limiting

• Affects joints, skin, brain, serous surfaces, and heartAffects joints, skin, brain, serous surfaces, and heart

Rheumatic heart diseaseRheumatic heart disease Most common complication of RFMost common complication of RF Damage to valves as result of RFDamage to valves as result of RF

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Clinical Manifestations of RFClinical Manifestations of RF

CarditisCarditis PolyarthritisPolyarthritis Erythema marginatumErythema marginatum Subcutaneous nodulesSubcutaneous nodules

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St. Vitus Dance:St. Vitus Dance:The Fifth ManifestationThe Fifth Manifestation

St. Vitus dance (aka, chorea) reflects CNS St. Vitus dance (aka, chorea) reflects CNS involvementinvolvement

Definition: Chorea refers to sudden, aimless Definition: Chorea refers to sudden, aimless movements of extremities, involuntary facial movements of extremities, involuntary facial grimaces, speech disturbances, emotional grimaces, speech disturbances, emotional lability and muscle weaknesslability and muscle weakness Worse with anxiety and relieved by restWorse with anxiety and relieved by rest

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Prevention of RHD Prevention of RHD

Treatment of streptococcal Treatment of streptococcal tonsillitis/pharyngitis tonsillitis/pharyngitis Penicillin G—IM x 1Penicillin G—IM x 1 Penicillin V—oral x 10 daysPenicillin V—oral x 10 days Sulfa—oral x 10 daysSulfa—oral x 10 days Erythromycin (if allergic to above)—oral x 10 daysErythromycin (if allergic to above)—oral x 10 days

Treatment of recurrent RFTreatment of recurrent RF Same as aboveSame as above

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Kawasaki Disease TreatmentKawasaki Disease Treatment IV IgGIV IgG ASA 80-100 mg/kg/day—ASA 80-100 mg/kg/day—

feverfeverThen 3-5 mg/kg/day—Then 3-5 mg/kg/day—

antiplateletantiplatelet

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Systemic HypertensionSystemic Hypertension

Primary = no known causePrimary = no known cause Secondary = identifiable causeSecondary = identifiable cause Pediatrics: HTN generally secondary to Pediatrics: HTN generally secondary to

structural abnormality or underlying pathologystructural abnormality or underlying pathology Renal diseaseRenal disease CV diseaseCV disease Endocrine or neurologic disordersEndocrine or neurologic disorders

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BP Screenings for ChildrenBP Screenings for Children

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Cardiac Dysrhythmias (cont.)Cardiac Dysrhythmias (cont.)

BradydysrhythmiasBradydysrhythmias AV blockAV block May use pacemakerMay use pacemaker

TachydysrhythmiasTachydysrhythmias SVT most common tachydysrhythmiaSVT most common tachydysrhythmia TreatmentsTreatments

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Complete Heart BlockComplete Heart Block

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SVTSVT

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Heart TransplantationHeart Transplantation

Orthotopic transplantOrthotopic transplant Heterotopic transplant (piggyback)Heterotopic transplant (piggyback) Organ donation issuesOrgan donation issues Nursing considerationsNursing considerations

The Child with Gastrointestinal Dysfunction

Chapter 33

Absorption

• Principally from small intestine• Osmosis• Carrier-mediated diffusion• Active energy-driven transport (“pump”)

• Large intestine• Absorption of water• Absorption of sodium• Role of colonic bacteria

Ingestion of Foreign Substances

• Pica• Food picas• Nonfood picas

• Foreign bodies

• Nursing considerations

DISORDERS OF MOTILITY

Constipation

• An alteration in the frequency, consistency, or ease of passage of stool

• May be secondary to other disorders

• Idiopathic (functional) constipation—no known cause

• Chronic constipation—may be due to environmental or psychosocial factors

Newborn Period

• First meconium should be passed within 24 to 36 hours of life; if not assess for:• Hirschsprung disease, hypothyroidism• Meconium plug, meconium ileus (CF)

Constipation in Childhood

• Often due to environmental changes or control over body functions

• Encopresis: inappropriate passage of feces, often with soiling

• May result from stress

• Management

Nursing Considerations

• History of bowel patterns, medications, diet

• Educate parents and child

• Dietary modifications (age appropriate)

Hirschsprung Disease

• Also called congenital aganglionic megacolon

• Mechanical obstruction from inadequate motility of intestine

• Incidence: 1 in 5000 live births; more common in males and in Down syndrome

• Absence of ganglion cells in colon

Hirschsprung Disease

Clinical Manifestations of Hirschprung Disease

• Aganglionic segment usually includes the rectum and proximal colon

• Accumulation of stool with distention

• Failure of internal anal sphincter to relax

• Enterocolitis may occur

Diagnostic Evaluation

• X-ray, barium enema

• Anorectal manometric exam

• Confirm diagnosis with rectal biopsy

Therapeutic Management

• Surgery

• Two stages• Temporary ostomy• Second stage “pull-through” procedure

Nursing Considerations

• Preoperative care

• Postoperative care

• Discharge care

Gastroesophageal Reflux (GER)

• Defined as transfer of gastric contents into the esophagus

• Occurs in everyone

• Frequency and persistency may make it abnormal

• May occur without GERD

• GERD may occur without regurgitation

GER

• Diagnostics

• Therapeutic management

• Nursing considerations

Irritable Bowel Syndrome (IBS)

• Identified as cause of recurrent abdominal pain in children (Chapter 18)

• Classified as a functional GI disorder

• Alternating diarrhea and constipation

• Therapeutic management

• Nursing considerations

Acute Appendicitis

• Etiology and pathophysiology

• Diagnostic evaluation

• Therapeutic management• Ruptured appendix• Prognosis

• Nursing considerations

Inflammatory Bowel Disease (IBD)

• Includes ulcerative colitis (UC) and Crohn disease (CD)

• Etiology and pathophysiology

• Diagnostic evaluation

• Therapeutic management

• Medical treatment

• Nursing considerations

Ulcerative Colitis (UC)

• Pathophysiology

• Clinical manifestations

• Extraintestinal manifestations

Crohn Disease

• Pathophysiology

• Clinical manifestations

• Extraintestinal manifestations

• Therapeutic management• Medical• Surgical

• Nursing considerations

Effects of UC or Crohn Disease

OBSTRUCTIVE DISORDERS

Hypertrophic Pyloric Stenosis (HPS)

• Constriction of the pyloric sphincter with obstruction of the gastric outlet

Pyloric Stenosis

• Pathophysiology

• Diagnostic evaluation

• Therapeutic management

• Prognosis

• Nursing considerations

Hypertrophic Pyloric Stenosis

Intussusception

• Telescoping or invagination of one portion of intestine into another

• Occasionally due to intestinal lesions• Often cause is unknown• Diagnostic evaluation• Therapeutic management• Prognosis• Nursing considerations

Ileocolic Intussusception

Malrotation and Volvulus

• Malrotation is due to abnormal rotation around the superior mesenteric artery during embryonic development

• Volvulus occurs when intestine is twisted around itself and compromises blood supply to intestines

• May cause intestinal perforation, peritonitis, necrosis, and death

Malabsorption Syndromes

• Characterized by chronic diarrhea and malabsorption of nutrients

• May result in failure to thrive

• Digestive defects

• Absorptive defects

• Anatomic defects

Celiac Disease

• Also called gluten-induced enteropathy and celiac sprue

• Four characteristics• Steatorrhea• General malnutrition• Abdominal distention• Secondary vitamin deficiencies

Celiac Disease (cont.)

• Pathophysiology

• Diagnostic evaluation

• Therapeutic management

• Nursing considerations

Short Bowel Syndrome (SBS)

• A malabsorptive disorder• Results from decreased mucosal surface area,

usually as result of small bowel resection• Etiology and pathophysiology• Result of decreased mucosal surface area,

usually due to extensive resection of small intestine

• Other causes• NEC, volvulus, gastroschisis, Crohn disease in

Therapeutic Management of SBS

• Nutritional support—first phase: TPN• Associated risks and complications

• Second phase: enteral feeding

Long-term maintenance

• Medical therapies

• Surgical therapies

• Nursing considerations

GI Bleeding• Upper GI bleeding

• Esophagus • Stomach

• “Coffee grounds” emesis

• Hematemesis

• Lower GI bleeding• Bright red (rectal bleeding): hematochezia • Tarry stools: melena

GI Bleeding (cont.)

• Diagnostic evaluation

• Therapeutic management• Assess blood loss• Establish hemodynamic stability

• Nursing considerations

Types of Diarrhea

• Acute

• Acute infectious/infectious gastroenteritis

• Chronic

• Intractable diarrhea of infancy

• Chronic nonspecific diarrhea (CNSD)

Anorectal Malformations

• Imperforate anus

• Persistent cloaca

• Cloacal exstrophy

• Genitalia may be indefinite

• Diagnostic evaluation

• Management

Dehydration

• Types of dehydration

• Diagnostic evaluation

• Therapeutic management

• Nursing considerations

Daily Maintenance Fluid Requirements

• Calculate child’s weight in kg• Allow 100 ml/kg for first 10 kg body weight• Allow 50 ml/kg for second 10 kg body weight• Allow 20 ml/kg for remaining body weight

Example 1: Daily Fluid Calculation

• Child weighs 32 kg• 100 x 10 for first 10 kg of body weight = 1000• 50 x 10 for second 10 kg of body weight = 500• 20 x 12 for remaining body weight = 240 • 1000 + 500 + 240 = 1740 ml/24 hr

Example 2: Daily Fluid Calculation

• Child weighs 8.5 kg• 100 x 8.5 for first 10 kg of body weight = 850• No further calculations• 850 ml/24 hr

Example 3: Daily Fluid Calculation

• Child weighs 14 kg• 100 x 10 for first 10 kg of body weight = 1000• 50 x 4 for second 10 kg of body weight = 200• No further calculations• 1000 + 200 = 1200 ml/24 hr