Islamic University of Gaza Faculty of Nursing Pediatric Nursing

Dr. Areefa Albahri

• Cardiovascular disease is a significant cause of chronic illness and death in children.

• Typically cardiovascular disorders in children are divided into two major categories:

• Congenital heart disease is defined as structural anomalies that are present at birth. CHD accounts for the largest percentage of birth defects

• Acquired heart disease includes disorders that occur after birth. These disorders develop from a wide range of causes, or they can occur as a complication of CHD.

Congenital Heart Defects

• Is a structural malformation of the heart or great vessels presents at birth. Generally blood flows from areas of high pressures to areas of low pressures.

• Etiology: exact cause is unknown. • 1. Maternal infection as rubella • 2. Poor nutrition of mother. • 3. Diabetic mothers• 4. Maternal alcoholism. • 5. Maternal exposure to radiation• 6. Genetic defect

Types of Defects:-

• 1. Acyanotic Heart Defects: there is no mixing of unoxygenated blood with systemic circulation (Oxygenated blood), its take one of the following forms:

• a. Dextracardia ―as a part of situs inversus ― • b. Obstructive lesion as: aortic stenosis, pulmonary

stenosis and coarctation of the aorta. • c. Left to Right shunts as: patent ductus arteriosus,

atrial septal defect and ventricular septal defect.

• 2. Cyanotic heart defect: un-oxygenated blood enters the systemic circulation (Right to Left shunt)

• a. Tetralogy of Fallot. • b. Transposition of great arteries. • c. Tricuspid atresia.

• A cyanotic Heart Defects • I. Dextracardia with Situs Inversus • Dextracardia indicates that the heart is in the right side of

thorax cavity. This condition is frequently associated with situs inversus within abdominal and thoracic organs transposed to opposite side of the body. There are usually no cardiac defects.

• Diagnosis: • 1. Clinically: apex beat on the right side, stomach {percussion}

on right side, the liver on the left side. • 2. Electrocardiograph: lead I shown a mirror image with

inverted P and T waves. • 3. X-ray: situs inversus.

II. Aortic Stenosis

• Aortic stenosis (AS) is a narrowing or a stricture of the aortic valve that results in:

• Increase left ventricular pressure to overcome the obstructed valve

• Left ventricular hypertrophy, myocardial ischemia and decreased cardiac output.

• Imbalance between the increased O2 requirements and the amount of O2 supplied.

Clinical Manifestations• Rarely symptomatic during infancy, in severe cases infant may

demonstrate evidence of decreased cardiac output such as faint peripheral pulses or exercise intolerance.

• Older children may experience chest pain, dyspnea and fatigue with exertion.

• Narrow pulse pressure and weak peripheral pulses. • X-ray may show normal heart to varying degrees of left

ventricular hypertrophy. • A harsh ejection systolic murmur is best heard in the aortic area. • E.C.G.: left ventricular hypertrophy {T. wave inversion}. • Diagnosis: Cardiac Catheterization. • Complications: CHF, MI, bacterial endocarditis and death. • Treatment: Surgery: Balloon angioplasty or valvulotomy

III. Pulmonary Stenosis

• Refers to narrowing of the opening to the pulmonic valve, that cause obstruction to blood flow, so the right ventricle has an additional work-load, causing the muscle to thicken, resulting in right ventricular hypertrophy and decreased pulmonary blood flow.

• Signs and symptoms: Generally asymptomatic unless in severe stenosis

• Dyspnea, fatigue and systolic ejection murmur over the pulmonic area.

• Complication: anoxic spells, bacterial endocarditis, death. ―Heart Failure

• Diagnosis: Cardiac Catheterization. • Treatment: Pulmonary valvotomy or dilation by balloon.

• IV. Coarctation of the Aorta • Is a narrowing or constriction of the

vessel at any point. Most common, The narrowing can be pre-ductal (between the subclavian artery and ductus arteriosus) or postductal (after the ductus arteriosus).

• Altered Physiology: the narrowing of the aorta obstructs the blood flow through the constricted segment of the aorta, that increasing the left ventricular pressure. So collateral vessels develop from the subclavian arteries bypassing the coarcted aorta and supplying circulation to the lower extremities.

• Clinical Manifestation: • Usually asymptomatic in childhood. • May demonstrate: occasional fatigue,

headache, nose bleed and leg cramps. • Absent or greatly reduced femoral pulses. • Hypertension in upper extremities,

hypotension in lower one. • E.C.G: show normal to left ventricular

hypertrophy

• Diagnosis: Cardiac Catheterization, Angiography. • Complication: Cerebral Hemorrhage, Rupture Aorta,

and C.H.F. • Treatment: • Management of C.H.F. • Surgical: Resection of area of coarctation or balloon

angioplasty at 2-7 years. • V. Patent Ductus Arteriosus • Is the persistence of a fetal connection between the

pulmonary artery and the aorta through which blood leaving the right heart bypasses the lungs.

• Altered Physiology: • Failure of the ductus to close after birth. Patent ductus

arteriosus allow blood to shunt from aorta (high pressure) to the pulmonary artery low pressure.

• Failure of the ductus arteriosus to close leads to continued blood flow from the aorta to the pulmonary artery. Blood returning to the left atrium passes to the left ventricle, enters the aorta, and then travels to the pulmonary artery via the PDA instead of entering the systemic circulation. This altered blood flow pattern increases the workload of the left side of heart.

• Pulmonary vascular congestion occurs, causing an increase in pressure.

• Right ventricular pressure increases in an attempt to overcome this increase in pulmonary pressure. Eventually, right ventricular hypertrophy occurs.

Clinical Manifestation: • 1- Small PDA: usually asymptomatic. • 2- Large PDA: may develops symptoms during early infancy,

slow weight gain, feeding difficulties, frequent respiratory infection, CHF, physical retardation, systolic murmur and widened pulse pressure

• Complication: C.H.F., infective endocarditis. • Treatment: • Controlling of C.H.F. • Surgical by ligation or division and ligation of the duct

―electively by 1-2 years‖. • Closure of ductus arteriosus is stimulated by increase in O2

level and by indomethacin

• VI. Atrial Septal Defect • Is an abnormal opening in the septum between two

atrium.

• Altered Physiology: • The pressure in the left atrium is greatening

than that in the right one, which promotes the flow of oxygenated blood from the left to the right atrium and thus increasing the total blood flow through the lung.

• If the pulmonary resistance is great reversal the shunt with unoxygenated blood flowing from the right to left atrium and cyanosis occur.

• Clinical Manifestation: • Heart murmur • Dyspnea and right ventricular hypertrophy • Fatigue and poor growth. • Complication: CHF, and pulmonary hypertension. • Treatment: Surgical closure the defect.

Ventricular Septal Defect

• Is an abnormal opening in the septal between the two ventricles. It may vary in size from very small defect to very large defect {1-15 mm in diameter}. 50% of cases close spontaneously within one to three years. It is one of the most common congenital heart defects.

• Altered Physiology: • The pressure in the left ventricle is greater than that of the

right one promotes the flow of oxygenated blood from the left to the right ventricle increasing the total blood flow through the lungs and thus increased right ventricular and pulmonary arterial pressure.

• If the pulmonary resistance is great, thus causing reversal of the shunt with unoxygenated blood flowing from the right ventricle to the left one and thus cyanosis occure

• Clinical Manifestation: • Systolic heart murmur. • Slow weight gain, feeding difficulties, frequent respiratory

infections. • Dyspnea and tachypnea.

• Treatment: • Medical management of C.H.F. • Surgical closure: optimal age

before 2years to prevent pulmonary hypertension.

•

• Cyanotic Congenital Heart Disease

• I. Teratology of Fallot (TOF) • The most common type of cyanotic heart disease, its

involve four anatomical abnormalities: • 1- Pulmonary stenosis. • 2- Ventricular septal defect {VSD}. • 3- Overriding of the aorta (enlargement of the aortic valve) • 4- Right ventricular hypertrophy. • Altered Physiology: • Pulmonary stenosis: unoxygenated blood is shunted from

the right ventricle (from the VSD) directly into the aorta. • The right ventricle is hypertrophied because of high right

ventricular pressure.

• Clinical Manifestation: • Cyanosis: not cyanotic at birth {left to right

shunt}, may starts later, may be at 1-2 years, first observed with exertion or crying, then cyanotic even at rest.

• Clubbing of fingers. • Squatting posture is assumed to relief stressed

heart by trapping blood in lower extremities. • Slow weight gain. • Hypoxia spells (Tet spells characterized by

sudden cyanosis and syncope)

• Complication: CHF, endocarditis, CVA and iron deficiency anemia.

• Treatment: • Improve oxygenation • Emergency for Tet spells: beta-

blockers as propranolol, but acute episodes may require rapid intervention with morphine are required.

• Surgical• Complete intracardiac repair of VSD and PA stenosis.• Enter chest through the sternum.• Connect the heart and lung machine. Heart is

stopped. • Repair the VSD with a patch.• removing the excessive muscle tissue will help to

function correctly.• Pacemaker wires are placed temporarily because of

the potential for postoperative ventricular arrhythmias.

• Individual chamber pressures are then measured before the chest is closed. The pressure readings help to determine how effective the surgery was.

•

• II. Transposition of the Great Arteries (TGA) • TGA occurs when the aorta arises from the right

ventricle and the pulmonary artery from the left ventricle.

• Incompatible with life unless the infant has an associated defect which allows the blood to communicate between the pulmonary and systemic circulation.

• Clinical Manifestation: • Marked cyanosis since birth. • Failure to thrive, Fatigability and dyspnea with

subcostal retractions at rest • Cardiomegaly, early clubbing of fingers and C.H.F.

• Prognosis: without surgical treatment, 85 % die in the first 6 months of age.

• Treatment: • Management of C.H.F. • Palliative procedures: creation of A.S.D. with a

balloon catheter during catheterization or surgical creation of A.S.D.

• Complete correction: by cardiopulmonary bypass.

• III. Tricuspid Atresia • Is a condition in which there is a complete

absence of the tricuspid valve. Therefore, there is an hypoplastic of right ventricle. Its associated with:

• Atrial septal defect. • There is usually a V.S.D. allowing some blood to

enter the underdeveloped right ventricle.

•

• Pathophysiology: • Blood from the systemic circulation is shunted

from the right atrium through an interatrial communication to the left atrium, to the left ventricle.

• Pulmonary blood flow is established either through PDA or VSD.

• Clinical Manifestation:

• Cyanosis {marked since birth}, dyspnea on feeding and may hypoxia spells.

• Early clubbing of fingers and failure to thrive. • Right heart failure may occur.

• Treatment: • Palliative procedures: to increase the pulmonary

blood flow (Anastomosis between the ascending aorta and right pulmonary artery).

• Fontan Procedure: is a palliative surgical procedure used in children with complex congenital heart defects. It involves diverting the venous blood from the right atrium to the pulmonary arteries without passing through the morphologic pulmonary ventricle

• Complete correction

• Diagnostic Evaluation for Congenital Heart Defects.

• 1. Chest x- ray shows enlargement of the affected chambers of the heart.

• 2. Cardiac catheterization: visually demonstrate the defect, demonstrate blood oxygenation in heart chambers.

• 3. E.C.G.

• Nursing care plan for the child with congenital heart disease

• Assessment: • Take careful health history including evidence of:

poor weight gain, unusual posturing or poor feeding • Exercise intolerance – frequent respiratory tract

infections • Perform physical assessment with special emphases

on: color, pulse (apical and peripheral), respiration, blood pressure, examination and auscultation of chest and manifestations of CHD.

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