Cardiac Conditions in Children Nursing Assessment and

Interventions

Kathryn Kushto-ReeseKathryn Kushto-Reese

Leading Causes of Infant Leading Causes of Infant DeathsDeaths20062006

Anatomy/Physiology OverviewAnatomy/Physiology Overview

ChambersChambers ValvesValves

– AV (tricuspid & mitral)AV (tricuspid & mitral)– Semilunar (pulmonic & Semilunar (pulmonic &

aortic)aortic)

FlowFlow SaturationsSaturations

Normal Blood FlowNormal Blood Flow

Dexoygenated blood returns from the body Dexoygenated blood returns from the body through the SVC/IVC through the SVC/IVC →→ RA RA →→ tricuspid valve tricuspid valve →→ RV RV →→ pulmonic valve pulmonic valve →→ pulmonary artery pulmonary artery →→

then to the lungs where blood getthen to the lungs where blood gets oxygenated. s oxygenated.

This blood then returns via pulmonary veins This blood then returns via pulmonary veins →→ LA LA →→ mitral valve mitral valve →→ LV LV →→ aortic valve aortic valve →→ and out the aorta to the body.and out the aorta to the body.

   

 

 

NORMALNORMAL HEART HEART

Newborn PhysiologyNewborn Physiology Pulmonary vs. Systemic PressuresPulmonary vs. Systemic Pressures

In UteroIn Utero At BirthAt Birth

Fetal ShuntsFetal Shunts– Ductus arteriosus (Ductus arteriosus (conduit from pulmonary conduit from pulmonary

artery to aorta)artery to aorta)– Foramen ovale Foramen ovale (flapped opening between right (flapped opening between right

and left atria)and left atria)– Ductus venosus Ductus venosus (bypass liver)(bypass liver)

Pulmonary and Systemic Pulmonary and Systemic PressuresPressures

In utero – In utero – ↑ pulmonary pressure ↑ pulmonary pressure before birth: before birth: due to lungs being a fluid filled due to lungs being a fluid filled

system, the lungs are a higher pressure system system, the lungs are a higher pressure system than the systemic circulationthan the systemic circulation

After birth – After birth – ↑ systemic pressure↑ systemic pressure now that the lungs are filled with air, the lungs now that the lungs are filled with air, the lungs

are a lower pressure system than the systemic are a lower pressure system than the systemic circulationcirculation

The blood will follow the path of least resistanceThe blood will follow the path of least resistance

Assessment: Cardiac FunctionAssessment: Cardiac Function

Inspect chest/Palpate Heart Sounds: murmurs Quality of Pulses/Central Respiratory: effort and quality of

respirations

Pulses: Extremities (peripheral)– Cyanosis (central also)– Capillary refill time– Temperature /color

ASSESSMENT ASSESSMENT

Assessment: Cardiac Function(continued)

Renal – Urine output, edema, hepatomegaly

Vital Signs– Heart rate, quality and symmetry, BP– Peripheral pulses, check for symmetry

Neurological Restless, irritable, decreased response to

environment

ASSESSMENTASSESSMENT

Congestive Heart FailureCongestive Heart Failure

A condition in which the heart is unable to A condition in which the heart is unable to provide adequate cardiac output to meet the provide adequate cardiac output to meet the circulatory and metabolic requirements of circulatory and metabolic requirements of the body.the body.

Failure may initially be right- or left-sided but Failure may initially be right- or left-sided but if left untreated, the entire heart will failif left untreated, the entire heart will fail

Congestive Heart Failure (CHF)

Causes:

– Heart muscle dysfunction

– Structural abnormalities

– Pulmonary abnormalities

– Systemic disease

– Infections

– Syndromes

ExamplesExamples

Obstructive lesions in heartObstructive lesions in heart DysrhythmiasDysrhythmias Increased blood flow to lungs (VSD)Increased blood flow to lungs (VSD) MyocarditisMyocarditis Chemotherapy drugs Chemotherapy drugs SepsisSepsis Respiratory failureRespiratory failure

CHF SymptomsCHF SymptomsSystemic Venous Congestion (rt sided)Systemic Venous Congestion (rt sided)

HepatomegalyHepatomegaly

Peripheral edema, ascitesPeripheral edema, ascites

Pulmonary Venous Congestion (left sided)Pulmonary Venous Congestion (left sided)

TachypneaTachypnea

Central cyanosisCentral cyanosis

Dyspnea, Dyspnea, WOB, rales, wheezing, nasal WOB, rales, wheezing, nasal flaring , grunting, coughflaring , grunting, cough

Others: lethargy, irritability, altered LOCOthers: lethargy, irritability, altered LOC

CHF SymptomsCHF Symptoms

Decreased Myocardial FunctionDecreased Myocardial Function CardiomegalyCardiomegaly TachycardiaTachycardia Extremities cool, Extremities cool, capp refill, etc…capp refill, etc… Failure to thrive, difficulty feeding , poor Failure to thrive, difficulty feeding , poor

weight gainweight gain Peripheral cyanosis/mottlingPeripheral cyanosis/mottling DiaphoresisDiaphoresis

ASSESSMENTASSESSMENT

CHF ManagementCHF Management

Increase oxygen supplyIncrease oxygen supply– Oxygen therapy, raise HOBOxygen therapy, raise HOB– Correct anemiaCorrect anemia

Decrease oxygen demandDecrease oxygen demand– Remove “work” (breathing, feeding, teach Remove “work” (breathing, feeding, teach

parents feeding techniques ( NG/GT feeds)parents feeding techniques ( NG/GT feeds)– Rest, group cares, emotional supportRest, group cares, emotional support

CHF ManagementCHF Management

Decrease oxygen demandDecrease oxygen demand– Treat feverTreat fever– Treat dysrhythmias (Digoxin, Adenosine, B-Treat dysrhythmias (Digoxin, Adenosine, B-

blockers)blockers)

CHF ManagementCHF Management

Increase cardiac outputIncrease cardiac output– Increasing stroke volumeIncreasing stroke volume

Digoxin - Digoxin - ( mcg/kg/24hr.) Increase in force of myocardial contraction and Increase in force of myocardial contraction and

decreases conduction through SA and AV nodes (decreases conduction through SA and AV nodes (+ + inotropic / - chronotropic)inotropic / - chronotropic)

Inotropic supportInotropic support– DopamineDopamine * Dobutamine* Dobutamine– MilrinoneMilrinone * Epinephrine* Epinephrine

CHF ManagementCHF Management

Increase cardiac output by:Increase cardiac output by:– Decreasing afterloadDecreasing afterload

ACE Inhibitors such as Captopril/EnalaprilACE Inhibitors such as Captopril/Enalapril– Blocks conversion of angiotensin I to angiotensin II Blocks conversion of angiotensin I to angiotensin II

(vasoconstrictor)(vasoconstrictor)

VasodilatorsVasodilators– IV (Nitroglycerine, Nitroprusside, Milrinone)IV (Nitroglycerine, Nitroprusside, Milrinone)– Inhaled -- ?? (there are 2)Inhaled -- ?? (there are 2)

CHF ManagementCHF Management

Control fluid statusControl fluid status– Diuretics ( Lasix, SpironolactoneDiuretics ( Lasix, Spironolactone

– Limit PO intake (initially) fluid/sodium Limit PO intake (initially) fluid/sodium restrictions, daily ( bid) weights and maintain restrictions, daily ( bid) weights and maintain nutritional statusnutritional status

Address underlying disorderAddress underlying disorder

Nursing DiagnosesNursing Diagnoses Decreased cardiac outputDecreased cardiac output Altered tissue perfusion, cardiopulmonaryAltered tissue perfusion, cardiopulmonary FatigueFatigue Fluid volume excessFluid volume excess Activity intoleranceActivity intolerance Impaired physical mobilityImpaired physical mobility Sleep pattern disturbanceSleep pattern disturbance AnxietyAnxiety Altered growth and developmentAltered growth and development

Congenital Heart Defects

ETIOLOGYETIOLOGYGENETIC FACTORS/ CHROMOSOMAL GENETIC FACTORS/ CHROMOSOMAL

ABNORMALITIESABNORMALITIES

TERATROGENSTERATROGENS

MATERNAL INFECTIONSMATERNAL INFECTIONS

ENVIRONMENTAL EXPOSURESENVIRONMENTAL EXPOSURES

PREMATURITYPREMATURITY

ADVANCED MATERNAL AGEADVANCED MATERNAL AGE

PREGANCY COMPLICATIONPREGANCY COMPLICATIONSS

Congenital Heart Defects

Defects that increase pulmonary blood flow

– Patent Ductus Arteriosus (PDA)– Atrial Septal Defect (ASD) – Ventricular Septal Defect (VSD)– Atrioventricular Canal Defect (AVC)

Ventricular Septal Defect (VSD)

Most Common Most small /close spontaneously Symptoms of congestive heart failure

may occur/ especially if significant size Child has failure to thrive/ fatigue,

respiratory s/s, pulmonary hypertension Murmur ( turbulent flow through

abnormal or obstructive openings

VSDVSD

?? Increased Pulmonary Blood Flow

VSD Repair

Post -opPost -op

Obstructive Defects Defects

Coarctation of the AortaCoarctation of the Aorta

Aortic StenosisAortic Stenosis

Coarctation of Aorta

Chest x rayChest x ray

Obstructive Defects Defects

Coarctation of Aorta , Incidence Pathophysiology: obstruction of

systemic blood flow at the narrowed or strictured part.– Symptoms: high blood pressure and bounding

pulses in arms weak or absent femoral pulses, cool lower

extremities blood pressure in lower extremities CHF in infants

– Surgical treatment: Timing

Congenital Heart Defects (continued)

Defects That Decrease Pulmonary Blood Flow

–Tetralogy of Fallot

–Pulmonary Stenosis

–Pulmonary Atresia

Tetralogy of Fallot has 4 defects1.Right Ventricular Hypertrophy2.Overriding Aorta3.Ventricular Septal defect4.Pulmonic Stenosis

Tetralogy of Fallot (TOF)

Symptoms: cyanosis, systolic murmur, Metabolic acidosis , poor growth,

clubbing, severe hypoxia (“tet spells”)

Surgical treatment: palliative shunts and complete repair

Abby with TOFAbby with TOF

Clubbing of fingersClubbing of fingers

Hyper cyanotic or Tet Spells

Occur most frequently in 1st yr of life May be preceded by feeding, crying or

defecation, fever, dehydration. stress Characterized by profound hypoxemia,

blue extremities, circumoral cyanosis, increased hgb and hct counts.

Require prompt assessment and treatment to prevent brain damage or death.

““TET SPELL “TET SPELL “

Treatment: “Tet Spells”

Place infant in knee-chest position Older child will instinctively squat Maintain a calm comforting

approach Administer 100% oxygen Administer Morphine Administer fluids Propanolol for frequent Tet spells

Modified Blalock-Taussig

Final RepairFinal Repair

Mixed DefectsMixed Defects

HLHS ( Hypoplastic Left Heart HLHS ( Hypoplastic Left Heart SyndromeSyndrome

Structures on left side of heart Structures on left side of heart underdevelopedunderdeveloped

Mitral and Aortic valves closed or smallMitral and Aortic valves closed or small Left ventricle non functionalLeft ventricle non functional 44thth most common Congenital heart most common Congenital heart

defectdefect

HLHSHLHS

Right side of heart is the working partRight side of heart is the working part Blood lungs Blood lungs → left Atrium through an → left Atrium through an

ASD to right side of heart.ASD to right side of heart. Right ventricle pumps blood to lungs and Right ventricle pumps blood to lungs and

also to systemic circulation through a PDA.also to systemic circulation through a PDA. Few days – weeks ductus closed death Few days – weeks ductus closed death

resultsresults..

HLHSHLHS

SymptomsSymptoms

Bluish/ CyanoticBluish/ Cyanotic Rapid pulse, murmur and Rapid pulse, murmur and ↑↑RRRR Cold hands and feetCold hands and feet LethargicLethargic Decreased pulses in extremities, Decreased pulses in extremities, ↓ pulse ox↓ pulse ox Poor sucking and feedingPoor sucking and feeding Increased respiratory effort and WOBIncreased respiratory effort and WOB OrganomegalyOrganomegaly

Treatment /PrognsisTreatment /Prognsis

Prostaglandins in newborn to keep PDA Prostaglandins in newborn to keep PDA openopen

Multiple Stage surgical repairMultiple Stage surgical repair Blalock-Taussig shuntBlalock-Taussig shunt Glenn procedureGlenn procedure Fontan Procedure ( final )Fontan Procedure ( final ) Chronic Health problems , earliest survivors Chronic Health problems , earliest survivors

in 30’sin 30’s→ Heart Transplant→ Heart Transplant

Diagnostic Tools

Chest X-ray ECG Echocardiogram

– Transesophageal echocardiogram

Cardiac Catheterization– Done under conscious sedation– Can be diagnostic or interventional– Post procedural care

TreatmentsTreatments

Surgical InterventionSurgical Intervention Surgical repair/corrective surgerySurgical repair/corrective surgery Palliative surgery/ temporaryPalliative surgery/ temporary Interventional Cardiac CatheterizationInterventional Cardiac Catheterization

1. Open narrowed passages1. Open narrowed passages

2. Closure of openings pp. 907 text ,2. Closure of openings pp. 907 text ,

table 26-7.table 26-7.

Chest x rayChest x ray

Echocardiogram of VSDEchocardiogram of VSD

Purpose of a CathPurpose of a Cath

DiagnosticDiagnostic– Define anatomyDefine anatomy– Measure pressuresMeasure pressures– Measure O2 contentMeasure O2 content– Calculate shunts, resistance, Calculate shunts, resistance,

COCO– All of above is frequently All of above is frequently

done off and on oxygen, done off and on oxygen, then on NOthen on NO

Interventional CathInterventional Cath– Close PDA, ASD/PFO, VSDClose PDA, ASD/PFO, VSD– Close collateral vesselsClose collateral vessels– Balloon dilate narrowed Balloon dilate narrowed

vessels or valvesvessels or valves– Place stents in narrowed Place stents in narrowed

vesselsvessels

Angioplasty/ dilation of Coarctation of Angioplasty/ dilation of Coarctation of Aorta during cardiac catheterizationAorta during cardiac catheterization

PDA ClosurePDA Closure

Cardiac Cath procedureCardiac Cath procedure

Assess for : Assess for : Circulation: cool extremities,Circulation: cool extremities,

pedal pulses, capp refill pedal pulses, capp refill

3 sec., decreased 3 sec., decreased

Sensation and mobilitySensation and mobility Complications: bleeding, Complications: bleeding,

arrhythmias, hematoma, arrhythmias, hematoma,

thrombus, and infection.thrombus, and infection.

Post ProcedurePost Procedure

VS are q 15” x 4; q 30” x 2; q 1h x 2 then IMC VS are q 15” x 4; q 30” x 2; q 1h x 2 then IMC routineroutine

Stay on boards/supine x 2 hours Stay on boards/supine x 2 hours With each set of V/S and prn, monitor:With each set of V/S and prn, monitor:

– Perfusion (arterial and venous) to distal extremity Perfusion (arterial and venous) to distal extremity (pulses, color, CRT, temp)(pulses, color, CRT, temp)

– Bleeding/hematoma formation at site Bleeding/hematoma formation at site If no bleeding at site and palpable distal pulse, If no bleeding at site and palpable distal pulse,

may come off boards/sit up after designated may come off boards/sit up after designated timetime

Post Procedure ManagementPost Procedure Management

Antibiotics (Ancef 25mg/kg) x 2 dosesAntibiotics (Ancef 25mg/kg) x 2 doses Aspirin (3-5mg/kg) to start same night for Aspirin (3-5mg/kg) to start same night for

device placementdevice placement CXR next morning if ASD or PDA device CXR next morning if ASD or PDA device

placedplaced Echo next morning if ASD or PDA device Echo next morning if ASD or PDA device

placedplaced ““Discomfort” Control - acetaminophenDiscomfort” Control - acetaminophen

Going HomeGoing Home

May go home 4-5 hours after a diagnostic May go home 4-5 hours after a diagnostic cathcath

Will stay overnight and get d/c’d in AM after Will stay overnight and get d/c’d in AM after most interventionsmost interventions

Will return to school 2-3 days after Will return to school 2-3 days after procedureprocedure

PE class/sports participation may be limited PE class/sports participation may be limited based on interventionbased on intervention

Potential ComplicationsPotential Complications

MiscellaneousMiscellaneous– ThromboembolismThromboembolism– InfectionInfection

Retroperitoneal Bleeds Retroperitoneal Bleeds Pressure SoresPressure Sores Brachial Plexus InjuryBrachial Plexus Injury Effusion / tamponadeEffusion / tamponade

Surgery: Post Operative Care Monitoring and assessment

– Vital signs, arrhythmias, decreased cardiac output, hypoxia, infection, S/S CHF, respiratory compromise

– Arterial / venous pressure– Fluids– Neurological changes

Provide rest and comfort Pain control Support family

Cardiac Transplant

Improved CHD Management New Surgical Techniques Transplant Improved Survival of Transplant ECMO