Pediatrics Cardiac

The foramen ovale

An opening between the atria, allows blood flow from the right to the left atrium

The ductus arteriosus

allows blood flow between the pulmonary artery and the aorta, shunting blood away from the pulmonary circulation

Heart rate (HR)

faster in infancy (90-160bpm)

• decreases as child ages

Blood pressure (BP)

lower in infancy (80-55) increases as child ages

Congenital Heart Disease

structural anomalies that are present at birth

• accounts for the largest percentage of all birth defects

Acquired Heart Disease

disorders that occur after birth

• develops from a wide range of causes, or occur as a complication or long term effect.

Risk factors for congenital 

• malformations

• genetic syndromes

• family history

• maternal drug/alcohol exposure

  • prematurity

Risk factors for acquired 

• infections (rheumatic fever, kawasaki, endocarditis)

• obesity, diabetes, drug/alcohol exposure

• hypertension, hyperlipidemia

• chemotherapy

• other diseases

• organ transplant

Diagnostic Tests for Cardiovascular Disorders

• Pulse oximetry

• Electrocardiogram (ECG) and Holter monitoring

• Echocardiogram

• Chest radiograph

• Exercise stress testing

• Laboratory tests including

  • CBC

  • BMP

  • C-reactive protein (CRP)

  • Erythrocyte sedimentation rate (ESR)

• Arteriogram and cardiac catheterization

Heart Failure

• Consequence of many congenital and
acquired CV disorders
• Pathophysiology – Enlarged ventricles with
reduced EF

Nursing Management
• Cluster cares
• Promote oxygenation
• Support cardiac function
• Provide adequate nutrition
• Promote rest

Infective Endocarditis

Bacterial infection of endothelial surfaces of the heart:
• Valves (most common)
• Chamber walls
• Septum
Increased risk with prosthetic valves
Requires antibiotic treatment

Acute Rheumatic Fever Modified Jones Criteria

diagnosis of acute rheumatic fever requires the presence of either two major criteria or one major plus two minor criteria

Rheumatic Fever major criteria

• carditis

• migratory polyarthritis

• subcutaneous nodules

• erythema marginatum

• sydenham chorea

Rheumatic Fever minor criteria

• polyarthralgia

• elevated erythrocyte sedimentation rate/C-reactive protein

• prolonged PR interval 

Cardiomyopathy

Risk factors:
• Congenital heart defect
• Genetic disorders
• Inflammatory or infectious processes
• Posttransplant or postoperatively after cardiac surgery
• Hypertension
• Duchenne and Becker muscular dystrophy
• Most commonly, no known reason (idiopathic)
• May present as heart failure or cardiac arrest

Kawasaki Disease

Signs and symptoms include:
• High fever for 5 days (unresponsive to antibiotics)
• Chills
• Headache
• Malaise
• Extreme irritability
• Distinctive rashes (strawberry tongue, palmar erythema)
• Desquamation of perineum, fingers and toes
• Vomiting
• Diarrhea
• Abdominal and joint pain

Treatment: IV immunoglobulin and aspirin
• Requires long-term monitoring of coronary arteries

Risk Factors for Cardiovascular Disorders

• Family history of heart disease or CHD
• (investigate the history further if heart disease occurred in a first-degree relative)
• Sudden death in a young family member
• Hyperlipidemia
• Diabetes mellitus

Heart Murmurs Grade I

Soft and hard to hear

Heart Murmurs Grade II

soft and easily heard

Heart murmur Grade III

loud without thrill

Heart Murmur Grade IV

loud with precordial thrill

Heart Murmur Grade V

Loud, audible with a stethoscope

Heart Murmur Grade VI

very loud, audible with a stethoscope or with the naked ear

Focus of Nursing Care for Child with a Cardiac Disorder

• Improve oxygenation
• Promote adequate nutrition
• Assist the child and family with coping
• Provide postoperative nursing care
• Prevent infection
• Provide child and family education

Congenital Heart Disease (CHD)

• Congenital malformation of cardiac structures, vessels, or myocardium

• Occurs in 8/1000 newborns

• Symptoms related to shunting/mixing of blood flow &
  areas of obstruction

• Can be due to genetic syndrome, environmental factors; can be familial

• Most can be diagnosed prenatally

Congenital Heart Disease

• Atrioventricular Septal Defect (AVSD)

• Ventricular Septal Defect (VSD)

• Patent Ductus Arteriosis (PDA)

• Atrial Septal Defect (ASD)

• Hypoplastic Left Heart Syndrome (HLHS)

• Transposition of the Great Arteries (TGA)

• Coarctation of the Aorta (CoA)

• Tetrology of Fallot (TOF)

Atrioventricular Septal Defect (AVSD)

• increases pulmonary blood flow

• L-R shunt

• Acyanotic

Coarctation of the Aorta (CoA

• obstructs systemic blood flow

• acyanotic

Tetrology of Fallot (TOF)

Cyanotic, (“blue baby”), SOB, Murmur, CNS

4 defects

1. ventricular Septal Defect

2. pulmonary stenosis

3. right ventricular hypertrophy

4. overriding aorta

Atrial Septal Defect (ASD)

communication between right and left atria

• failure to transition from fetal to postnatal circulation (secundum type is most common)

• Failure of atrial septum to develop (primum/sinus venosus types)

Atrial Septal Defect signs/symptoms

• murmur

• most shunt left to right, normal oxygen saturation

• asymptomatic, fatigue easily, exercise intolerance

• might have swelling in feet

• CHD

Atrial Septal Defect: treatment

medical treatment: none

most close spontaneously

Closure done between 2-4 years old

Ventricular Septal Defect (VSD)

communication between right and left ventricles

Small ventricular septal defect signs/symptoms

• asymptomatic, normal growth/development

• harsh murmur at LLSB

Moderate -large ventricular septal defect signs/symptoms

• symptoms of CHF at 6-8 weeks

  • tachypnea, poor feeding/weight gain, diaphoretic, irritable, hepatomegaly

• systolic murmur at LLSB, thrill often present

• may develop pulmonary hypertension

Ventricular Septal Defect Treatmen

may close spontaneously depending on type - 6 months of age

pulmonary hypertension may begin to develop as early as 6-12 months with large VSD

Medical Tx: diuretics (lasix), afterload reduction (enalapril, catopril), spironolactone, fortifying feeds (high calorie), feeding tube placement

Atrioventricular Septal Defect (ASVD)

abnormality of endocardial cushion (primum ASD, ± VSD, common AV valve)

4-5% CHD

• most common type: complete ASVD (2-3% CHD)

• Down syndrome 70-75%

AVSD signs/symptoms

• pulmonary over circulation

• CHF

• pulmonary hypertension

• If complete:

  • difficulty feeding, tachypnea, diaphoresis, FTT, increased respiratory infections, pulmonary hypertension, CHF at 1-2 months

Coarctation of the Aorta (CoA)

narrowing of aortic arch

Coarctation of the Aorta signs/symptoms

murmur (heard loudest in the back) ejection click

diminished/absent femoral or pedal pulses

blood pressure higher in arms that legs

CHF: hepatomegaly, gallop

Coarctation of the Aorta signs/symptoms: Critical neonatal

• diminished lower body perfusion as PDA closes

• Acidosis, renal/hepatic failure, NEC. death

Coarctation of the Aorta signs/symptoms: Infant

tachypnea, heart failure, FTT

Coarctation of the Aorta signs/symptoms: Child/adult

upper extremity hypertension, murmur, cold and/or painful LE, but can be asymtomatic

Critical Coarctation of the Aorta treatment (newborns)

maintain PDA with PGE

inotropes if needed

mechanical ventilation if needed

Coarctation of the Aorta treatment

surgical repair:

• timing related to degree of obstruction

• mild: repaired by 5-10 years old

prognosis

• lifelong cardiology follows up

• monitor for re-coarctation and other cardiac co-morbities.

Tetralogy of Fallot: Signs & Symptoms

• Murmur present at birth
• Cyanosis
• Trouble breathing
• Poor feeding
• Poor growth
• Irritability
• Tet spell

Tetralogy of Fallot: Tet Spells

hyper cyanotic episodes

• periods of decreased pulmonary blood flow (increased right to left shunting)

• Can affect CNS, cause death

• Onset with crying, defecation, increased activity (lowered SVR)

• Tet spells can increase as RV hypertrophy increases

Tetralogy of Fallot: Treatment

• Tet spell: squatting/knees-to-chest, calm the baby, oxygen, sedation (morphine, ketamine), β-blocker (propranolol), phenylephrine, volume expansion

• Severe cyanosis: early neonatal repair vs surgical palliation vs catheter intervention (balloon/stent)

• Surgery (3-9 months of age)

• Life-long cardiology follow-up

• Prognosis: varies with anatomy and comorbidities

Transposition of the Great Arteries (D-TGA)

• Aorta rightward & anterior to PA
• RV gives rise to Aorta; LV gives rise to PA

Transposition of the Great Arteries: Signs & Symptoms

Murmur: none (unless VSD), single loud S2 (farther from chest wall-P2 inaudible)

Cyanotic at birth, signs of CHF, feeding difficulty, hepatomegaly, dyspnea

Transposition of the Great Arteries: Treatment

Cath: balloon atrial septostomy (Rashkind procedure)

• Prostaglandin E pre-op

• Surgery (Arterial Switch Operation)

Transposition of the Great Arteries: prognosis

• Without ASD or PDA: fatal as neonate

• Unrepaired: 90% die by 6 months of age

• Normal growth & development post repair

• Life-long cardiology follow-up

Psychosocial Interventions

• Explain all that is happening with the child, using language the parents and child can understand

• Allow the parents and child to voice their feelings, concerns, or questions

• Provide ample time to address questions and concerns

• Encourage the parents and the child, as developmentally appropriate, to participate in the child’s care

• Encourage the child to be as active as is appropriate
  

Congestive Heart Failure (CHF)

The heart does not fill or pump as well as it should. Fluid can build up in the lungs or body tissues. CHF can cause lung problems, organ failure, and other serious problems in the body

Congestive Heart Failure (CHF) signs

tachypnea, tachycardia, pallor or cyanosis

nasal flaring, grunting, retractions, cough, crackles

periorbital and facial edema, jugular vein distention, and hepatomegaly

CHF clinical symptoms infants

• Tachypnea, tachycardia
• Pallor or cyanosis
• Nasal flaring, grunting, retractions
• Cough or crackles
• S3 gallop

CHF clinical symptoms older children

• Anorexia
• Cough, wheezing, crackles
• Fluid volume excess
• Jugular vein distention

Medications used to treat congestive heart failure

Digoxin (lanoxin), Furosemide (lasix), Thiazides (diuril)

Digoxin action

Slows the heart rate, increases cardiac filling time, and increases cardiac output; used with increased pulmonary blood flow

furosemide action

Rapid diuresis; blocks reabsorption of sodium and water in renal tubules

Thiazides

Chlorothiazide(suspension); Hydrochlorothiazide(tablets)
Maintains diuresis, decreases absorption of sodium, water,
potassium, chloride, and bicarbonate in renal tubules.

Digoxin nursing management

• Assess the heart rate for bradycardia for 1 min
prior to giving a dose or for changes in heart
rhythm or quality.
• Monitor the child for digoxin toxicity.
• See the CHF nursing management section for more
information

Furosemide nursing management

• Monitor patients during rapid diuresis for vital
signs, intake and output, and fluid and electrolyte
imbalances (e.g., hypokalemia and hypochloremia).
• Assess for digoxin toxicity if hypokalemia is present

Thiazide nursing management 

• Monitor blood pressure and intake and output
rates and patterns.
• Monitor lab values for hypokalemia. Assess for
digoxin toxicity if present

CHF Nursing Management

• Assess VS, fluid status, cardiac/respiratory function, I/Os

Nutritional support
• Tire quickly, eating is hard work!
• High calorie formulas (24-27cal/oz) or fortified breastmilk
(Regular formula and breastmilk have 20 Cal/0z)
• NG tube so baby can get nutrition without having to work
Promote rest! Cluster care
• Assess development- often limited d/t fatigue
• Assess family supports, caregiver role and interaction with child

Rheumatic Fever

Systemic disease that affects the joints, heart, and central nervous system
• Group A beta-hemolytic streptococci
Symptoms start 2-4 wks after strep infection
• Heart inflammation - Murmur, chest pain
• Joints (arthritis)
• Brain - Sydenham chorea: uncontrolled movements, muscle weakness, behavioral changes
Skin
• Bumps under the skin, often near the elbow, knees, or ankles
• Ring-shaped pink rash on the upper arms and torso
Fever
• Complete Medication and Repeat screen

Rheumatic Fever: Treatment

Main goal is to protect the heart
• Antibiotics to eradicate strep infection
• Aspirin to treat carditis, inflammation
• Steroids
• Rest to lessen joint pain
• Long-term antibiotic prophylaxis
• Most children recover fully

Infective Endocarditis

• Infection of the lining of the heart or heart valves.
Risk factors
• Congenital heart defect
• Rheumatic heart disease
• Central venous catheters

Etiology
• Usually bacteria in bloodstream

Infective Endocarditis clinical manifestations

• Fevers that come and go
• Fatigue, muscle or joint pain
• Rash
• Irritability
• Weight loss

Infective Endocarditis: Treatment

Antibiotics, 2- to 8-week IV inpatient, then home
Treat congestive heart failure if present
Assess valve damage: Surgical valve replacement may be
needed
Prevention for children at risk: Good oral hygiene, Antibiotics prior to medical or dental, procedures

Kawasaki Syndrome clinical manifestations

• Fever- most common sign, usually high
• Red rash, red palms, red eyes
• Red tongue with white spots “strawberry
tongue”
• Swollen hands and feet
• Conjunctival hyperemia
• Cervical lymph node enlargement
• Cracking/peeling skin (lips, fingers, toes)
• N/V/D
• Tachycardia

Kawasaki Disease:Treatment

• Intravenous immunoglobulin (IVIg)
• High dose aspirin
• Anti-inflammatory dose initially
• Antiplatelet dose after fever decreases
• Corticosteroids
• If no response to IVIg
• Monitor for coronary artery aneurysms
• Occur in 5% of those treated with intravenous
gamma globulin
• Small aneurysms may resolve spontaneously
• Stenosed coronary arteries may require bypass operation

Hypovolemic Shock

Emergency condition: severe blood or fluid loss makes heart unable to pump enough blood to the body- cause many organs to stop working

Some causes of decreased intravascular blood volume -

Hemorrhage

Plasma loss from burns, nephrotic syndrome, or sepsis

Fluid and electrolyte loss from dehydration, diabetic ketoacidosis, or diabetes insipidus

Early compensated shock Clinical manifestations

Cardiac: Mild tachycardia, weak distal pulses, strong central pulses, normal blood pressure

Respiratory: Mild tachycardia

Neurologic: Normal, anxious, irritable, or combative behavior

Skin: Mottled appearance; capillary refill time greater than 2 sec, cool, clammy extremities

Renal: Decreased urine Output, increased specific gravity in older infants and children (newborns cannot concentrate urine)

Moderate Uncompensated Shock

Cardiac: Moderate tachycardia, thready distal pulses, weak central pulses, decreasing systolic blood pressure

Respiratory: Moderate tachypnea

Neurologic: Confusion, agitation, combativeness, lethargy, decreased pain response

Skin: Pallor; capillary refill time greater than 3 sec; cold, dry extremities; sunken eyes

Renal: Oliguria; increased specific gravity

Severe Uncompensated Shock

Cardiac: extreme tachycardia, hypotension, narrow, pulse pressure, absent, distal pulses, thready central pulses

Respiratory: Severe tachypnea

Neurologic: Comatose state

Skin: Pale, cold skin; cyanosis; capillary refill greater than 5 sec

Renal: NO urine Output

Hypovolemic Shock: Nursing Management

• Assessment
• Vital signs, level of consciousness, perfusion, urine output
• IV fluid bolus (Ringer lactate, 20 mL/kg, over 5 minutes)
• Assess response to fluid bolus
• Repeat if no improvement
• Keep child warm
• Administer blood if no response to crystalloid fluids