peds cv

fetal development

fetal development

• ↑↑  Pulmonary Vascular Resistance (lungs not open)

• ↓↓ Systemic vascular resistance

• Heart and other components of circulatory system are formed by 8th week

transitions at birth

• Umbilicus clamped causing ↑Systemic vascular resistance

  • LV wall thickens

  • BP rises

• Lungs expand causing ↓ Pulmonary vascular resistance

  • Oxygen saturation increases

  • Foramen Ovale closes

  • Ductus Arteriosus closes

normal heart chambers

LV: pump again most pressure, most muscular, highest pressure

RA: blood just returning from body, lowest pressure

RA, unchanged to RV: blood back from body, lowest PaO2

LA, unchanged to LV: blood directly from lungs, highest PaO2

blood flows from high to low pressure

murmurs

• An indicator of increased or turbulent flow

• not an emergency but can indicate a problem

• Most children will have one at some point

• Normal during periods of increased cardiac output like anemia, fever, rapid growth

• Can also be caused by congenital heart defects or defective heart valves

• Has nothing to do with rhythm (just has to do with flow of blood)

Types of heart disease in children

Acyanotic

• defect that allows blood to pass through opening

• blood goes from left side of the heart to the right side of the heart, still have oxygenated blood going to the rest of the body

• not necessarily going to see the signs of decreased oxygenation

• ^^LEFT TO RIGHT ^^

Cyanotic

• unoxygenated blood going to rest of body

• goes from right side to the left, signs of decreased oxygenation

• ^^RIGHT TO LEFT ^^

Congenital Heart Disease

anatomic defects of the heart that prevent normal blood flow to the pulmonary and/or systemic system

CHD risk factors

• Maternal factors: alcohol or other substance use disorder during pregnancy, infection, diabetes mellitus

• May have a genetic component

  • DiGeorge Syndrome

  • Noonan Syndrome

  • Trisomy 13, 18, 21*

• May occur with other physical anomalies

  • Cleft lip / palate

CHD diag.

• Chest x-ray: heart size

• Echocardiogram: evaluate heart function and defects

• MRI: more specific than echo

• Cardiac Catheterization: measures pressures and oxygen levels in all 4 chambers; maps blood flow through the heart

  • Invasive test

• Defects are categorized by blood flow patterns in the heart

defects in categories by blood flow

↑ pulmonary blood flow (acyanotic, left to right, more blood flows to the lungs)

• Atrial Septal Defect (ASD)

• Ventricular Septal Defect (VSD)

• Patent Ductus Arteriosus (PDA)

↓ pulmonary blood flow (cyanotic, right to left, skipping pulmonary artery)

• Tetralogy of Fallot

• Tricuspid atresia

Obstruct (blood flow exiting heart meets area of stenosis, increased pressure when trying to leave the heart)

• Coarctation of the Aorta

• Pulmonary & aortic stenosis

Mixed

• Transposition of the great arteries (TGA)

• Hypoplastic left heart

Acyanotic: Ventricular Septal Defect (VSD)

↑ pulmonary blood flow (acyanotic, left to right, more blood flows to the lungs)

• hole bw right and left ventricle

• Loud, harsh murmur heard at left sternal border

• Can use diuretics, ACE Inhibitors (decrease pressure and amount of blood flow from left to right side)

• Backup of fluid in right ventricle, right sided heart failure, crackles in lungs, right ventricular hypertrophy

Untreated VSD: eventually causes both oxygenated AND unoxygenated blood to go into body (Eisenmenger Syndrome)

VSD s&s

^^H^^eart failure and pulmonary hypertension

^^O^^ften experiences lung infections (increased fluid in the lungs)

^^L^^ow growth rate/weight

^^E^^xtra heart sound (murmur)

^^S^^troke

Many will close spontaneously early in life, but if large will need surgery

VSD treatment/therapies

• Closure during cardiac catheterization

• Diuretics: watch K levels; help pull extra fluid

• Complete repair with patch (risk for complete heart block)

• Digoxin: will help heart contract stronger and slow it down

Acyanotic: Atrial Septal Defect (ASD)

↑ pulmonary blood flow (acyanotic, left to right, more blood flows to the lungs)

• bw right and left atrium, blood going from left to right side of heart

• lot of harsh murmur with fixed split second heart sound

• Heart failure

• Most will close on their own, treated as heart failure

• May be asymptomatic if hole is small

ASD s&s

^^H^^eart failure and pulmonary hypertension

^^O^^ften experiences lung infections (increased fluid in the lungs)

^^L^^ow growth rate/weight

^^E^^xtra heart sound (murmur)

^^S^^troke

ASD treatment/therapies

• Closure during cardiac catheterization

• Diuretics

• Low dose aspirin 6 months after procedure

• Patch closure

• Cardiopulmonary bypass

Cyanotic: Patent Ductus Arteriosus (PDA)

↑ pulmonary blood flow (acyanotic, left to right, more blood flows to the lungs)

• Normal fetal circulation conduit between pulmonary artery and aorta

• If it stays open, blood from aorta goes into pulmonary artery which will go into lungs and will increase pulmonary blood flow (acyanotic)

• Fatigue easily, usually will need extra calories

• Widened pulse pressure (bigger gap between systolic and diastolic) (decreased pressure during diastolic)

• Systolic murmur (machine hum)

• Wide pulse pressure

• Bounding pulses

• May be asymptomatic

• Heart failure

• Rales

PDA treatment/therapies

• Administer indomethacin to allow for closure

• Diuretics (Lasix)

• Extra calories for infants

• Thoracoscopic repair

Cyanotic: Tetralogy of Fallot (TET)

↓ pulmonary blood flow (cyanotic, right to left, skipping pulmonary artery)

4 components:

• Right ventricular hypertrophy

• Aortic displacement (overriding)

• Pulmonary stenosis

• Septal defect (ventricular)

• Cyanosis at birth: progressive cyanosis over first year of life

• Systolic murmur

• Clubbing of fingers, trouble breathing

Tetralogy of Fallot treatment/therapies

• Surgical procedures: shunt placement until able to undergo primary repair

• Complete repair within first year of life

TET spell

Acute episode of cyanosis: crying, screaming

• Sudden increase of pressure in the lungs forces blood to the left side & out to the system leading to sudden cyanosis

• Brought on by coughing, feeding, stooling, crying

• Resolved by increasing systemic resistance to match pressure

• Children will have trouble feeding, fingernail changes (clubbing)

treatment

• Put them in knee chest position

  • help increase systemic pressure which will increase the blood flow and oxygenation to the body

Obstructive: Pulmonary stenosis

narrowing of the pulmonary valve or pulmonary artery that results in obstruction of blood flow from the ventricles

• Systolic ejection murmur

• Symptoms depend on severity of obstruction

• Cyanosis varies; worse with severe narrowing

• Cardiomegaly

• Heart failure

Right side of heart will have to work harder to get blood flow to the lungs

• tachypnea

• increased work of breathing

• shortness of breath

• tachycardia

• edema (decreased blood flow going to the lungs)

• will lead to right ventricular hypertrophy

Pulmonary stenosis treatment/therapies

• Balloon angioplasty

• Infants: brock procedure

• Children: valvotomy

Obstructive: Aortic Stenosis

narrowing of the aortic valve = systemic blood flow affected

• Infants: faint pulses, hypotension, tachycardia, poor feeding tolerance, poor weight gain

• Children: intolerance to exercise, dizziness, chest pain, possible murmur

Blood flow up to aorta will be compromised

• hypotension

• weak pulses

• exercise intolerance

• dizziness

• beta blockers or calcium channel blockers can be used for treatment

Aortic Stenosis treatment/therapies

• Balloon dilation

• Administer beta blockers, Ca channel blockers

• Norwood procedure (replacing aortic valve)

• Aortic valvotomy

Obstructive: Coarctation of the aorta

narrowing of the lumen of aorta, usually at ductus arteriosus → obstruction of blood flow from the ventricle

• Systemic blood flow drops dramatically as shunt closes

• Stenosis/ atresia of valves on left side

• Infants: heart failure

• Children: headaches, dizziness, fainting, nosebleeds

low narrowing would cause higher blood pressure in upper extremities (bounding pulses, headache, stroke) and lower blood pressure in lower extremities (cold, diminished pulse)

Coarctation of the aorta treatment/therapies

• May give prostaglandins to keep PDA open

• Balloon angioplasty or shunts

• Anyone less than 6 months should have repair

mixed: Transposition of the Great Arteries

• Backwards heart 🙁

  • aorta is connected to right ventricle

  • pulmonary artery is connected to left ventricle

• not sustainable to life

• two closed systems that are not connected (nothing going to the body gets oxygenated)

• septal defect or PDA must exist in order to oxygenate the blood; VSD & ASD are common

• Murmur

• Cardiomegaly

• Heart failure

Transposition of the Great Arteries SWAP

S: severe cyanosis (low O2, increased heart rate, increased respiratory rate, poor feeding)

W: Watch rhythm, O2

A:  Alprostadil (med that keeps shunts open)

P:  Procedures to correct

Transposition of the Great Arteries treatment/therapies

• surgery must be done to switch arteries within first 2 weeks of life

• IV prostaglandin E to keep ducts open

Infants with CHD

• Fail to make the transition

• Usually are tachypneic

• Are poor feeders

• Are sweaty

• May be cyanotic

• Have pale/cool extremities with weak pulses

• May have a murmur

Children with CHD

• Have exercise intolerance

• Have respiratory problems

• May have edema

• May complain of chest pain

• May faint or have headaches

• May complain of palpitations

• May have a murmur

nursing managment of infant with CHD

• Monitor fluid balance

• Monitor perfusion

• Monitor work of breathing, particularly during feedings

• Ensure periods of rest

• Monitor growth

• Reassurance / education for families

• Administer medications as ordered

  • Digoxin

  • Furosemide (lasix)

  • Spironolactone

  • ACE inhibitors

  • Sildenafil Citrate

• Feeding tubes as needed

feeding in CHD

• Follow baby cues, don’t wait for cry

• Feed for limited period, gavage remainder

• NG/OG tubes common; GT tubes also

  • Limit calorie expenditure for feedings

  • Allow rest while still receiving nourishment

  • May need calorically dense formula to get more calories in less fluid

• High calorie formulas, fortified breast milk

• Position important:  upright, side-lying

When would patient be cyanotic?

• Hole that allows mixing of unoxygenated and oxygenated blood that is pumped to the rest of the body

• Right side is under higher pressure than the left

Signs of chronic hypoxemia

• Clubbing

• Polycythemia

  • body will start making more RBC to try to get more oxygen and nutrients to rest of body

Nursing Management for patients needing cardiac catheter

• May be via femoral vein

• Frequent VS

• Assess for hemorrhage

• Monitor rhythm

• Strict bed rest for several hours

• Strict I&O

surgeries

• Palliation (band / shunt)

  • To protect lungs from too much flow

  • To allow mixing

• Repair, may need to do in stages

• Transplant

• Post-operative nursing care:

  • Pressors

  • Pain management

  • Wound care

  • Meticulous assessment of perfusion/ ventilation/ renal function/ conductivity

  • Speech therapy for oral aversion

  • Reconnecting with parents

Dysrhythmias: Typically secondary

• Bradycardia

  • Vagal

  • Disrupted conduction

  • Digoxin toxicity

• Tachycardia

  • SVT (supraventricular tachycardia) most common; treated with cardioversion or adenosine

    • Stable (not symptomatic) : vagal maneuvers (put icepack on infant’s face, blow as hard as they can through a straw, turn baby upside down)

    • Unstable (sweaty, dizzy, not feeling well, pale): cardioversion or adenosine

  • Wolff Parkinson White Syndrome

    • heart beats abnormally fast for periods of time; have increased risk for sudden death

Acquired Cardiovascular Disorders

Cardiovascular disease the child is NOT born with. They develop it secondary to a condition

Interventions for all acquired heart diseases

• Maintain adequate oxygenation

• Maintain adequate cardiac output and tissue perfusion

• Maintain hydration and nutrition

• Promote pain relief, comfort, rest

• Administer and manage medications

• Monitor for and prevent complications

• Promote growth and development

• Provide emotional and psychosocial support for child and parents

HF

inability of the heart to pump an adequate amount of blood to the systemic circulation to meet body’s demands

• In children, most commonly related to congenital heart disease

HF causes can be classified as

Ventricular dysfunction:

• Normal structured heart: cardiomyopathy, myocarditis, myocardial ischemia, drugs & toxins; also sepsis

• CHD: congenital heart disease

Volume overload with normal ventricular contractility: may be due to cardiac or noncardiac causes

• Cardiac: VSD, PDA, AV septal defect, aortic stenosis, mitral regurg

• Noncardiac: oliguric renal failure

Pressure overload with normal ventricular contractility

• Often results from ventricular outflow obstruction

  • Aortic stenosis, coarc of aorta, pulmonary stenosis

HR types

Right sided HF: RV function is reduced

• End diastolic pressure rises causing increased central venous pressure and systemic venous engorgement

• Can lead to hypertension, hepatomegaly, and edema

Left sided HF: LV dysfunction occurs and end-diastolic pressure rises

• Result= increased pressure in LA and pulmonary veins

• Lungs become congested with blood à pulmonary edema & elevated pulmonary pressures

HR compensatory

• Heart initially tries to meet body’s demand → hypertrophy and stimulation of sympathetic nervous system

• Hypertrophy is from heart working harder to try to get that blood out to the body

HF in infants symp.

• Tachypnea

• Diaphoresis during feedings

• Irritable

• Decreased volume of feeds

• Poor weight gain

HF in younger children symp.

• Abdominal pain

• Nausea /vomiting

• Poor appetite

• Cough/wheeze

HF in older child symp.

• Anorexia

• Abdominal pain

• Edema

• Palpitations

• Chest pain

• Dizziness

• Exercise intolerance

• Wheezing

• Dyspnea

HF labs

• BNP: elevated

• Troponin: elevated

• CBC: check for anemia

• CMP: hyponatremia

• BUN & creatinine: may be elevated

HF diag.

• Based on clinical & lab findings

• Also get EKG, Echo

HF nursing care

• Maintain adequate oxygenation,

• maintain cardiac output and myocardial function

• Monitoring fluid balance

• Administer medications: Lasix, digoxin, enalapril, carvedilol

• Can add polycose to infant’s bottles (feed every 3 hours no more than 30 minutes)

HF meds

• Lasix: results sodium rich diuresis

  • must monitor urine output, potassium, daily weights

• Digoxin: cardiac glycoside: (apical HR prior)

  • *need to get HR prior to administration**

• Enalapril: ace inhibitor

  • monitor BP, watch for cough, nausea, diarrhea, headache

• Carvedilol: decreases the excitability of the heart

  • check apical pulse, monitor bp

cardiomyopathy

Disease of the heart muscle

classifications

• dilated

• hypertrophic

• restrictive

cardiomyopathy: dilated

most common – present with signs of heart failure (ABNORMAL PUMPING AND CONTRACTING)

• Heart muscle becomes thin, LV becomes dilated & heart becomes unable to squeeze effectively

• Most common cause = myocarditis (inflammation of the heart muscle)

• Genetic forms: more than half the cases

cardiomyopathy: hypertropic

genetic increase in heart muscle mass; usually asymptomatic – cardiac arrest/sudden death (ABNORMALLY THICK)

• Accounts for over 40% of cardiomyopathy cases

• Enlargement of LV and septum, wall then becomes rigid

• Then causes obstruction of blood outflow, diastolic dysfunction à myocardial ischemia

cardiomyopathy: restrictive

• rare

• prevents filling of ventricles (USUAL AMOUNT OF BLOOD NOT ABLE TO GET IN)

cardiomyopathy signs

• Tachycardia and dysrhythmia

• Dyspnea

• Fatigue and poor growth

• DCM (dilated cardiomyopathy): most present with signs of HF including tachypnea, cough, wheezing, tachycardia, weak pulses, and fatigue

  • Palpitations, syncope, poor infant feeding-respiratory distress

• HCM (hypertrophic cardiomyopathy): symptoms depend on degree of obstruction

  • In previously healthy, may not have symptoms until cardiac arrest

cardiomyopathy treatment/therapies

• Beta blockers, calcium channel blockers, ACE inhibitors, anticoagulants

• Heart transplant

cardiomyopathy diag.

• Chest x-ray

• ECG

• Echo

• KIDS THAT DROP DEAD: HYPERTROPHIC CARDIOMYOPATHY

Rheumatic Fever

• Autoimmune inflammatory reaction

• worldwide , most common form of acquired heart diseases in all age groups

• Develops 2-4 weeks after Group A step infection in throat

• Affects heart (carditis), blood vessels, and joints

  • Most commonly affects heart valves

• Can lead to rheumatic heart disease which leads to disability and death

• Can recur

Rheumatic Fever: 2 theories

Cytotoxic theory

• produces several enzymes that are cytotoxic including streptolysin O; has a direct cytotoxic effect on cells

Immunologic theory

• some people have specific immune response to repeated strep infections and have increased cellular response to strep antigen

Rheumatic Fever findings

• Hx of recurrent URI

• Fever

• Tachycardia, cardiomegaly, new or changed heart murmur, pericardial friction rub

• Large joints* (knees, elbows, wrists, ankles, shoulders) with painful swelling indicating polyarthritis

• Pink, nonpruritic macular rash on the trunk and inner surfaces of extremities that appears and disappears rapidly

• CNS involvement: involuntary, purposeless muscle movements, muscle weakness, involuntary facial movements, random uncoordinated movements

• Irritability, poor concentration, behavioral problems

Rheumatic Fever: Jones criteria

Major:

• Carditis

• Subcutaneous nodules

• Polyarthritis (swelling of large joints, knees, elbows, angles)

• Rash (erythema marginatum)

• Chorea (CNS involvement) (meaningless movements)

Minor:

• fever OR arthralgia

• elevated CRP or ESR

• prolonged PR

Rheumatic Fever diag.

• strep swab for those with sore throats

• blood antistreptolysin o titer; most reliable diagnostic (blood test that shows if they have had strep)

• increased CRP & ESR (both show inflammation)

• echo: to see if pericardial effusions

Rheumatic Fever nursing considerations

• Education on prevention * (anyone that has strep needs to take full course of antibiotics)

• Prevention

• Bed rest

Rheumatic Fever treatment

• Administer antibiotics as prescribed to treat disease then prophylactically to prevent complications

  • Either penicillin BID or monthly IM injections of penicillin

  • Length of treatment depends on residual heart disease; anywhere from 5 years to indefinitely

• Administer aspirin or NSAIDs as prescribed for anti-inflammatory and antiplatelet

endocarditis

Infection of the inner lining of the heart and valves that can enter the bloodstream

• Common causes: strep viridans, candida albicans, staph aureus

endocarditis risk factors

• congenital or acquired heart disease

• indwelling catheters

endocarditis expected findings

• some may only have fever/nonspecific symptoms

• may present with high spiking fevers and appear very ill

• Neonates: feeding problems, respiratory distress, tachycardia, heart failure, septicemia

• Older children: fever, malaise, new murmur, myalgias, diaphoresis, weight loss, splinter hemorrhages under fingernails

• Osler nodes: painful  red bumps under skin hands and toes

• Janeway lesions: nontender blanching lesions on soles of feet and hands

• Inflammation of walls of blood vessels (thought to be related to infections)

endocarditis labs

• CBC, ESR, urinalysis, blood cultures (+ for diagnosis)

endocarditis diag.

• EKG, echo, blood culture, CBC, ESR, CRP

endocarditis nursing interventions

• Comfort measures

• Prophylactic antibiotics: before dental procedures

• Treated with long course of antibiotics

endocarditis: duke criteria

Major:

• +blood cultures

• Evidence of endocardial involvement

  • Echo positive for vegetation, abscess

Minor

• Presence of predisposed condition or IV drug use

• Fever

• Vascular condition

• Microbiological evidence

Kawasaki Disease

• Vascular inflammatory disorder

• Etiology = unknown, infectious?

• Strawberry tongue

• Most common acquired Cardiovascular Disorder in US

• Worse outcomes occur in those <1 years old or >5 years old

• Complex presentation – has criteria for diagnostic work up & treatment

Kawasaki Disease phases

Acute phase

• 1-2 wks; fever lasting >5 days

• conjunctival erythema without exudate

• swollen hands and feet

• cracked lips

• strawberry tongue

Subacute phase

• fever subsided

• may see desquamation of fingers and toes

• high platelets

• joint pain

• anorexia

Convalescent phase

• complete resolution of signs (3 months after onset)

Coronary aneurysm may be present, MI remains a concern

Kawasaki Disease diag.

• Acute phase: elevated ESR, CRP, antitrypsin, elevated WBC

• Subacute: increased platelets (usually over 700,000)

• May get EKG and echo to check for any changes

Kawasaki Disease nursing interventions

• Administer aspirin as ordered

  • Ok to mix with soft food to assist young children

• Administer IVIG (immunoglobulin) to decrease risk of developing coronary aneurysm

  • When is this repeated? 24 hours later if they are still febrile

• Hydration & nutrition

• Avoid live immunizations for about 1 year

MIS-C= Multisystem Inflammatory Syndrome in Children

• Occurs within 4 weeks of COVID infection – even those who are asymptomatic

• Multisystem (2 or more) organ involvement

• Presentation very similar to Kawasaki

• Labs will show elevated CRP & ESR

• Some develop myocarditis & cardiac dysfunction

• Kids will have elevated troponin and BNP

meds: aspirin

• Only given to children!!

  • Post cardiac surgery or trauma to prevent clot

  • For treatment of rheumatic fever

  • For treatment of Kawasaki: high inflammation dose first, then lower antiplatelet dose second

  • Monitor hepatic function before and during therapy

meds: digoxin

• Improves myocardial contractility

• Need to monitor apical  pulse and withhold medication if:

  • Heart rate of infants: less than 90

  • Heart rate of children: less than 70

Dig toxicity

• Infants and children: bradycardia, anorexia, nausea, vomiting

• Can also have neuro and visual disturbances

• Has a very long half life (18-35 hours) so many take days before level back to normal range

• Check potassium level before starting, if hypokalemic they will withhold the dose (watch potassium closely during therapy), withhold the dose if there are any signs of dig toxicity

• Annual readings for blood pressure starting at age 3

hypertension

All children >3 years old should have blood pressures measured annually – diagnosis made on blood pressure readings from 3 separate visits

• Primary: no identifiable cause; more likely to occur in school age children or adolescents who are overweight / have family hx

• Secondary hypertension: has an identifiable cause; renal disease, endocrine disease, renovascular disease