Care of a Child with a Cardiac Disorder

17

Fetal HR is present around postconceptual day _________.

2 through 8

Heart chambers and arteries are formed during gestational weeks ________ through ______.

placenta; lungs

oxygenation of the fetus occurs via the _______________. The _________ are perfused but do not perform oxygenation or ventilation.

foramen ovale

- opening between the atria

- allows blood flow from the right to the left atrium

ductus arteriosus

- allows blood flow between the pulmonary artery and the aorta

- shunts blood away from pulmonary circulation

90-160

HR is faster in infancy (_____-______ bpm) and decreases as the child ages.

80/55

Blood pressure is lower in infancy (_______ mmHG) and increases as the child ages.

adolescence

HR and BP reach adult levels by ____________________.

congenital heart disease

Accounts for the largest structural anomalies that are present at birth

acquired heart disease

- Disorders that occur after birth (heart failure, most common reason for admission)

- Develops from a wide range of causes, or can occur as a complication or long-term effect of CHD

1. Congenital malformations

2. Genetic syndromes

3. Family history

4. Maternal drug or alcohol exposure

5. Prematurity

risk factors for congenital CVD (5)

1. Infections (rheumatic fever, Kawasaki disease, endocarditis)

2. Obesity

3. Diabetes

4. Drug or alcohol exposure

5. Hypertension

6. Chemotherapy

7. Other diseases (connective tissue disorders, autoimmune or endocrine diseases)

8. Organ transplant

9. Hyperlipidemia

risk factors for acquired CVD (9)

1. cyanosis

2. irregular HR

3. edema

4. clubbing of fingertips

5. fever

6. retractions or increased work of breathing

7. prominence of precordial chest wall

8. visible, engorged, or abdominal pulsations

9. abdominal distention

signs of a cardiac disorder (9)

1. location where it is best heard

2. relation to heart cycle and duration

3. quality

4. variation in sound with position (sitting, lying, standing)

5. intensity

characteristics of heart murmurs (5)

harsh, musical, or rough; high medium, or low pitch

How is the quality of heart murmurs described?

Grade I—soft and hard to hear

Grade II—soft and easily heard

Grade III—loud without thrill

Grade IV—loud with a precordial thrill

Grade V—loud, audible with a stethoscope

Grade VI—very loud, audible with a stethoscope or with the naked ear

heart murmur intensity grading

1. pulse oximetry

2. ECG (electrocardiogram) and holter monitoring

3. echocardiogram (ultrasound of heart)

4. chest radiograph (CXR)

5. exercise stress testing

6. laboratory tests including: CBC, BMP, CRP, ESR

7. arteriogram and cardiac catheterization

dx tests for CVDs (7)

cardiac catheterization

- invasive diagnostic procedure

- femoral artery

- measurement of pressures in chambers

- contrast utilized for visualization

- types: diagnostic, interventional, or electrophysiology study (ablation)

true

True or false:

Cardiac catheterization is a routine procedure

bleeding

What is the biggest risk for a patient going through cardiac catheterization?

1. Complete assessment

2. Accurate height (catheter size)

3. Allergies (contrast)

4. Skin assessment (diaper rash)

5. Mark pulse sites

6. Baseline pulse oximetry

7. Pre-operative teaching

-Family-centered

8. NPO 6-8 hours before procedure

9. IV and IV fluids

preprocedural care for children going in for cardiac catheterization (9)

1. pulses

2. temp of affected extremity

3. vitals

4. dressing (saturation, in-tact, pressure)

5. fluid intake

6. blood glucose

postprocedural care for children going in for cardiac catheterization: what should the nurse monitor (6)

keep it straight

postprocedural care for children going in for cardiac catheterization: What should the nurse do in regards to the client's affected extremity?

apply pressure one inch above the site

What should the nurse do if severe bleeding is occurring post cath-lab?

clear, advance as tolerated

note: breastmilk is considered a clear liquid; formula is not

postprocedural care for children going in for cardiac catheterization: diet

contamination of dressing (especially concerned if child is incontinent)

postprocedural care for children going in for cardiac catheterization: what should the nurse be sure to prevent

1. cover cath insertion site with adhesive bandage strip and change daily for 2 days

2. keep site clean and dry; avoid tub baths and swimming for several days; patient may shower or have sponge bath

3. observe site for redness, swelling, drainage, and bleeding. Monitor for fever. Notify HCP if these occur

4. encourage rest and quiet activities for the first 3 days and avoid strenuous exercise

5. discuss returning to school and resuming other activities with the practitioner

6. resume regular diet without restrictions

7. use acetaminophen for pain

8. keep follow-up appointments per practitioner's instruction

postprocedural care for children going in for cardiac catheterization (8)

15 minutes; 30 minutes

The nurse should evaluate the child's vital signs, nv status of LEs, and the pressure dressing site every _________ for the first hour then every _____________ for 1 hour.

hemorrhage (r/t perf of heart or bleeding from insertion site)

The patient is hypotensive following a cath-lab procedure. What is this indicative of?

hypoxemia, respiratory distress, HF

common cardiac medical treatments:

indications for supplemental O2

monitor response via work of breathing and pulse ox

common cardiac medical treatments:

nursing implication for supplemental O2

mobilization of secretions, particularly in post-op period or with HF

common cardiac medical treatments:

indications for CPT and postural drainage

1. may be performed by RRT in some institutions

2. in either case, nurses must be familiar with the technique and able to educate families on its use

common cardiac medical treatments:

nursing implications of CPT and postural drainage (2)

after open heart surgery; pneumothorax

common cardiac medical treatments:

indications for chest tube

if tube becomes dislodged from container:

- chest tube must be clamped immediately to avoid further air entry into chest cavity OR

- end may be immediately placed into a container of sterile water or saline to create a water seal

common cardiac medical treatments:

nursing implications for chest tube

bradyarrhythmias, heart block, cardiomyopathy, sinoatrial or atrioventricular node malfunction

common cardiac medical treatments:

indications for cardiac pacing

1. provide close observation of the child, pacing unit, and ECG

2. maintain asepsis at pacing lead insertion site

3. explain to child and family that the permanent pacemaker may be felt under the skin

4. advise against participation in contact sports

common cardiac medical treatments:

nursing implications for cardiac pacing (4)

hemodynamic characteristics:

1. increased pulmonary blood flow

2. decreased pulmonary blood flow

3. obstructive disorders

4. mixed disorders

How is congenital heart disease (CHD) classified? (4)

1. atrial septal defect (ASD)

2. ventricular septal defect (VSD)

3. patent ductus arteriosus (PDA)

Congenital heart disease:

increased blood flow disorders (3)

1. tricuspid atresia

2. tetralogy of fallot

Congenital heart disease:

decreased blood flow disorders (2)

1. coarctation of the aorta

2. aortic stenosis

3. pulmonary stenosis

congenital heart disease: obstructive disorders (3)

1. hypoplastic left heart syndrome

2. transposition of the great vessels (TGV)

3. total anomalous pulmonary venous return (TAPVR)

4. truncus arteriosus

Congenital heart disease:

mixed disorder (4)

1. improve oxygenation

2. promote adequate nutrition

3. prevent infection

4. post-op care

nursing goals when caring for child with cardiac disorder (4)

fowler's or semi-fowler's

position that helps with lung expansion

used for children with HF

child's energy; cardiac and respiratory workload

The child's nutrition depends on the child's ________________ associated with increased ___________________________.

1. cut larger hole in nipple of cross-cutting the nipple

2. nipple feedings should be limited to a 20 minute duration (feeding for longer increases caloric expenditure)

What techniques/rules can the nurse use to decrease the work of feeding for infants? (2)

ventricular septal defect (VSD)

most common type of congenital heart disease

unknown

The exact cause of most cases of congenital heart disease is _______________.

1. Downs Syndrome

2. DiGeorge Syndrome

3. Noonan Syndrome

4. Williams Syndrome

5. Holt-Oram

Though the etiology is unknown, what syndromes are associated with cardiac defects? (5)

CHD with increased pulmonary blood flow

- O2 = pulmonary vasodilator

- giving O2 with increase pulmonary blood flow (causes tachypnea, lung fluid retention, and worsened oxygenation)

For which types of CHD should oxygen supplementation NOT be used and why?

right atrium and left atrium; asymptomatic; atrial dysrhythmia; HF

An atrial septal defect is an opening between the _______________ and ______________. The majority of patients with atrial septal defects are _______________. The patient may present with an ____________________. if left unrepaired, it could lead to ______________.

1. shortness of breath

2. easily fatigued

3. poor growth

signs of HF r/t atrial septal defects (3)

1. path closure

2. open repair (by-pass)

3. catheterization (device deployment)

4. low dose aspirin for 6 months

treatment for ASD (4)

true

True or false:

With treatment, ASD has a high survival rate.

- temp

- weight

- extremities (edema, clubbing, pulses)

- auscultation (rate, rhythm, heart sounds/clicks/murmur/rubs)

- respiratory (rate, work of breathing, sounds, etc.)

assessment of the child undergoing cardiac surgery

right and left ventricle; other defects; heart failure

Ventricular septal defect is characterized by an opening between the __________________ and ______________. It is often associated with ____________________. VSD can also result in __________________.

RIGHT VENTRICULAR HYPERTROPHY

- opening between RV and LV allows more blood into the RV

- right side has to work harder and myocardium thickens

What is a major cardiac consequence of VSD and why?

1. may close spontaneously

2. pulmonary artery banding

3. stitch or patch

treatment of VSD (3)

decrease the amount of blood going to the lungs

goal of pulmonary artery banding

VSD

Which has a higher mortality rate - ASD or VSD?

Conduction disturbances

___________________________ are a common consequence of VSD.

patent ductus arteriosus

failure of the ductus arteriosus to close within the first weeks of life, resulting in an abnormal opening between the pulmonary artery and the aorta

ranges from asymptomatic to HF

How does PDA present?

wide pulse pressure (low DBP d/t shunting of blood out of aorta and into the pulmonary artery)

hallmark sign of PDA

indomethacin (prostaglandin inhibitor)

Medication used to treat PDA

1. left thoracotomy PDA ligation

2. catheterization: coil placement

surgical treatment for PDA (2)

true

true or false:

Surgical treatment of PDA is low risk

laryngeal nerve damage d/t location of surgery

What is a common complication of surgical interventions for PDA?

polycythemia

- common complication of CHD with decreased pulmonary blood flow

- low oxygen in mixed blood stimulates the kidneys to produce more EPO --> more RBCs are produced

blood volume; viscosity; increase

Polycythemia can lead to an increase in _____________________ and blood ________________, which will ___________ the workload of the heart.

1. VSD

2. pulmonary stenosis (PS)

3. overriding aorta (aorta positioned over VSD --> receives some de-O2 blood from RV --> less O2 in systemic circulation)

4. right ventricular hypertrophy

4 defects of tetralogy of fallot

pulmonary stenosis

In tetralogy of Fallot, the degree of _________________________ determines hemodynamic alteration.

acute cyanosis/progressive cyanosis at birth, TET spells

main s/s of tetralogy of fallot

1. closure of VSD

2. BT shunt (increases pulmonary blood flow)

- low mortality

surgical treatment of tetralogy of fallot

avoid BP measurement and venipuncture on that side

Contraindications if BT shunt is placed

true

True or false:

In an extremity where a BT shunt has been placed, the pulse may not be palpable.

TET spells

- hypercyanotic spells

- infant becomes acutely cyanotic because of sudden decrease in pulmonary blood flow and increase in right-to-left shunting

morning; feeding, crying, or defecation

TET spells occur more often in the __________________ and may be preceded by _______________, _____________, or _________________.

emboli, seizure, loss of consciousness, or sudden death after anoxic spell

What is the child at risk for during TET spells?

prolonged or recurrent hypercyanotic spells can lead to chronic hypoxia with resulting brain damage and even CVA

Why are TET spells a big deal?

1. place infant in knee-chest position

2. employ calm, comforting approach

3. administer 100% O2 by face mask

4. give morphine SQ or IV

5. administer propranolol

6. begin IV fluid replacement and volume expansion if needed

management of TET spells (6)

tricuspid atresia

failure of tricuspid valve to develop

- no communication of RA to RV

- complications: developmental delays and dysrhythmias

no blood getting to lungs --> no blood being oxygenated

What happens when no blood can get from the RA to the RV?

continuous prostaglandin infusion

Medication used to manage tricuspid atresia

to keep PDA open and allow for increased blood flow into the lungs

- must be done before PDA closes; thankfully, most cases are found in utero so we are ready for it

- may not be caught early enough to give prostaglandins if mother did not receive prenatal care

Why is prostaglandin therapy given for tricuspid atresia?

cyanosis

Common sign that alerts HCP to possible tricuspid atresia

1. shunt placement

2. glenn and fontan procedure

treatment of tricuspid atresia (2)

obstructive disorders

typically involve narrowing of a major vessel

- interferes with ability of blood to freely flow through vessel

- peripheral and pulmonary circulation affected

coarctation of aorta

narrowing of aorta near ductus arteriosus

- decreased pressure distal (body and lower extremities) --> low BP in legs

- increased pressure proximal (head and upper extremities) --> high in arms

What BP findings are characteristic of coarctation of the aorta?

HTN

Patients with coarctation of the aorta present with s/s of ______________.

4 point BP

Because of the blood pressure findings, what measurements should be taken on patients with possible coarctation of the aorta?

ruptured aorta

Major complication of coarctation of aorta

1. 6 months

2. thoracotomy; anastomose

3. reoccurrence

4. balloon angioplasty

5. increased

surgical treatment of coarctation of the aorta:

1. performed when ________________ or younger

2. ______________________ to ________________ the ends of the aorta

3. possibility of _____________________

4. may do _________________________

5. mortality __________________ with other complex defects

aortic stenosis

narrowing/stricture of the aortic valve

left ventricle; LV hypertrophy

Aortic stenosis causes resistance to blood flow from the ________________ which leads to ____________________.

1. valvotomy (removal of valve)

2. balloon angioplasty (stretching open the valve)

surgical treatments for aortic stenosis (2)

1. chest pain (anginal pain) when active

2. dizzy with prolonged standing

3. pulse may be faint if stenosis is severe

common s/s with aortic stenosis (3)

pulmonic stenosis

narrowing/stricture of entrance to pulmonary artery

RV

Pulmonary stenosis will lead to _______________ hypertrophy