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The Child with Cardiovascular Dysfunction Chapter 34.

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Presentation on theme: "The Child with Cardiovascular Dysfunction Chapter 34."— Presentation transcript:

1 The Child with Cardiovascular Dysfunction Chapter 34

2 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 2 Changes at Birth

3 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 3 Pediatric Indicators of Cardiac Dysfunction  Poor feeding  Tachypnea/tachycardia  Failure to thrive/poor weight gain/activity intolerance  Developmental delays  Prenatal history  Family history of cardiac disease

4 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 4 “Innocent Murmurs”  Murmurs = heart sounds that reflect flow of blood within the heart  May occur in systole or diastole, or both  Can occur in a normal heart in periods of stress: anemia, fever, or rapid growth  Can reflect abnormalities in heart or vessels  “Innocent murmurs” = normal cardiac anatomy and cardiac function  Occur in up to 50% of all kids at some time

5 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 5 Thrills  The sound of a thrill is a soft vibration over the heart that reflects the transmitted sound of a heart murmur

6 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 6 Conduction System of the Heart

7 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 7 Normal ECG Pattern

8 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 8 Electrode Placement for Standard Chest Lead II

9 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 9 Tests of Cardiac Function  Chest x-ray  ECG  Echocardiography  Cardiac catheterization

10 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 10 Hypoplastic Left Heart

11 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 11 Interventional Cardiac Catheterization Procedures in Children  Transposition of great vessels  Some complex single-ventricle defects  ASD  Pulmonary artery stenosis

12 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 12 Interventional Cardiac Catheterization Procedures in Children (cont.) DIAGNOSISINTERVENTION Valvular pulmonic stenosis Balloon dilation Recurrent coarctation of aorta Balloon dilation Congenital mitral stenosis Balloon dilation

13 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 13 Clubbing

14 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 14 Knee-Chest Position

15 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 15 Two Types of Cardiac Defects  Congenital  Anatomic → abnormal function  Acquired  Disease process Infection Infection Autoimmune response Autoimmune response Environmental factors Environmental factors Familial tendencies Familial tendencies

16 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 16 Causes of CHD  Maternal or environmental = 1% to 2%  Maternal drug use Fetal alcohol syndrome—50% have CHD Fetal alcohol syndrome—50% have CHD  Maternal illness Rubella in first 7 weeks of pregnancy → 50% risk of defects including PDA and pulmonary branch stenosis Rubella in first 7 weeks of pregnancy → 50% risk of defects including PDA and pulmonary branch stenosis CMV, toxoplasmosis, other viral illnesses → cardiac defects CMV, toxoplasmosis, other viral illnesses → cardiac defects IDMs = 10% risk of CHD (VSD, cardiomyopathy, TGA most common) IDMs = 10% risk of CHD (VSD, cardiomyopathy, TGA most common)

17 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 17 Causes of CHD (cont.)  Chromosomal/genetic = 10% to 12%  Multifactorial = 85%

18 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 18 CHD  Incidence: 5 to 8 per 1000 live births  About 2 or 3 of these are symptomatic in first year of life  Major cause of death in first year of life (after prematurity)  Most common anomaly is VSD  28% of kids with CHD have another recognized anomaly (trisomy 21, 13, 18, )

19 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 19 Older Classifications of CHD  Acyanotic  May become cyanotic  Cyanotic  May be pink  May develop CHF

20 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 20 Newer Classifications of CHD  Hemodynamic characteristics  Increased pulmonary blood flow  Decreased pulmonary blood flow  Obstruction of blood flow out of the heart  Mixed blood flow

21 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 21 Comparison of CHD Classification Systems

22 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 22 Increased Pulmonary Blood Flow Defects  Abnormal connection between two sides of heart  Either the septum or the great vessels  Increased blood volume on right side of heart  Increased pulmonary blood flow  Decreased systemic blood flow

23 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 23 Hemodynamics in Defects with Increased Pulmonary Blood Flow

24 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 24 Increased Pulmonary Blood Flow Defects  Atrial septal defect  Ventricular septal defect  Patent ductus arteriosus

25 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 25 ASD

26 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 26 VSD

27 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 27 PDA

28 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 28 Obstructive Defects  Coarctation of the aorta  Aortic stenosis  Pulmonic stenosis

29 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 29 Sites of Obstruction to Ventricular Ejection

30 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 30 COA

31 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 31 AS

32 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 32 PS and Catheter Placement

33 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 33 Decreased Pulmonary Blood Flow Defects  Tetralogy of Fallot  Tricuspid atresia

34 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 34 TOF

35 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 35 Cardiac Shunts

36 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 36 Tricuspid Atresia

37 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 37 Mixed Defects  Transposition of great vessels  Total anomalous pulmonary venous connection  Hypoplastic heart syndrome  Right  Left

38 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 38 Transposition of Great Vessels

39 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 39 Normal Heart

40 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 40 Total Anomalous Pulmonary Venous Connection

41 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 41 CHF in Children  Impaired myocardial function  Tachycardia; fatigue; weakness; restless, pale, cool extremities; decreased BP; decreased urine output  Pulmonary congestion  Tachypnea, dyspnea, respiratory distress, exercise intolerance, cyanosis

42 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 42 CHF in Children (cont.)  Systemic venous congestion  Peripheral and periorbital edema, weight gain, ascites, hepatomegaly, neck vein distention

43 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 43 Care of the Family and Child with Congenital Heart Disease  Help family adjust to the disorder  Educate family  Help family cope with effects of the disorder  Prepare child and family for surgery

44 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 44 Surgical Interventions  Open heart  Closed heart procedures  Staged procedures  Prepare child and family for procedures

45 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 45 Postoperative Care for the Child  Monitor vital signs and A/V pressures  Intra-arterial monitoring of BP  Intracardiac monitoring  Respiratory needs  Rest, comfort, and pain management  Fluid management  Progression of activity

46 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 46 Postoperative Complications  CHF  Dysrhythmias  Decreased cardiac output syndrome  Decreased peripheral perfusion  Pulmonary changes  Neurologic changes

47 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 47 Postpericardiotomy Syndrome  Symptoms: fever,  WBCs, pericardial friction rub, pericardial and pleural effusion  Occurs in immediate postoperative period  Also can occur later (days 7 to 21 postop)  Etiology unknown  Theories of etiology  Viral infection, autoimmune response, reaction to blood in pericardium  May require pericardiocentesis or pleurocentesis

48 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 48 Acquired Cardiovascular Disorders  Infectious and inflammatory cardiac disorders

49 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 49 Endocarditis  BE, IE, or SBE  Streptococci  Staphylococci  Fungal infections  Prophylaxis: 1 hour before procedures (IV) or may use PO in some cases

50 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 50 Rheumatic Fever (RF) and Rheumatic Heart Disease  RF  Inflammatory disease occurs after group A β- hemolytic streptococcal pharyngitis  Infrequently seen in U.S.; big problem in Third World  Self-limiting Affects joints, skin, brain, serous surfaces, and heart Affects joints, skin, brain, serous surfaces, and heart  Rheumatic heart disease  Most common complication of RF  Damage to valves as result of RF

51 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 51 Clinical Manifestations of RF  Carditis  Polyarthritis  Erythema marginatum  Subcutaneous nodules

52 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 52 St. Vitus Dance: The Fifth Manifestation  St. Vitus dance (aka, chorea) reflects CNS involvement  Definition: Chorea refers to sudden, aimless movements of extremities, involuntary facial grimaces, speech disturbances, emotional lability and muscle weakness  Worse with anxiety and relieved by rest

53 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 53 Prevention of RHD  Treatment of streptococcal tonsillitis/pharyngitis  Penicillin G—IM x 1  Penicillin V—oral x 10 days  Sulfa—oral x 10 days  Erythromycin (if allergic to above)—oral x 10 days  Treatment of recurrent RF  Same as above

54 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 54 Kawasaki Disease Treatment  IV IgGASA mg/kg/day—fever Then 3-5 mg/kg/day—antiplatelet

55 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 55 Systemic Hypertension  Primary = no known cause  Secondary = identifiable cause  Pediatrics: HTN generally secondary to structural abnormality or underlying pathology  Renal disease  CV disease  Endocrine or neurologic disorders

56 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 56 BP Screenings for Children

57 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 57 Cardiac Dysrhythmias (cont.)  Bradydysrhythmias  AV block  May use pacemaker  Tachydysrhythmias  SVT most common tachydysrhythmia  Treatments

58 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 58 Complete Heart Block

59 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 59 SVT

60 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide 60 Heart Transplantation  Orthotopic transplant  Heterotopic transplant (piggyback)  Organ donation issues  Nursing considerations

61 The Child with Gastrointestinal Dysfunction Chapter 33

62 Absorption Principally from small intestine Osmosis Carrier-mediated diffusion Active energy-driven transport (“pump”) Large intestine Absorption of water Absorption of sodium Role of colonic bacteria

63 Ingestion of Foreign Substances Pica Food picas Nonfood picas Foreign bodies Nursing considerations

64 DISORDERS OF MOTILITY

65 Constipation An alteration in the frequency, consistency, or ease of passage of stool May be secondary to other disorders Idiopathic (functional) constipation—no known cause Chronic constipation—may be due to environmental or psychosocial factors

66 Newborn Period First meconium should be passed within 24 to 36 hours of life; if not assess for: Hirschsprung disease, hypothyroidism Meconium plug, meconium ileus (CF)

67 Constipation in Childhood Often due to environmental changes or control over body functions Encopresis: inappropriate passage of feces, often with soiling May result from stress Management

68 Nursing Considerations History of bowel patterns, medications, diet Educate parents and child Dietary modifications (age appropriate)

69 Hirschsprung Disease Also called congenital aganglionic megacolon Mechanical obstruction from inadequate motility of intestine Incidence: 1 in 5000 live births; more common in males and in Down syndrome Absence of ganglion cells in colon

70 Hirschsprung Disease

71 Clinical Manifestations of Hirschprung Disease Aganglionic segment usually includes the rectum and proximal colon Accumulation of stool with distention Failure of internal anal sphincter to relax Enterocolitis may occur

72 Diagnostic Evaluation X-ray, barium enema Anorectal manometric exam Confirm diagnosis with rectal biopsy

73 Therapeutic Management Surgery Two stages Temporary ostomy Second stage “pull-through” procedure

74 Nursing Considerations Preoperative care Postoperative care Discharge care

75 Gastroesophageal Reflux (GER) Defined as transfer of gastric contents into the esophagus Occurs in everyone Frequency and persistency may make it abnormal May occur without GERD GERD may occur without regurgitation

76 GER Diagnostics Therapeutic management Nursing considerations

77 Irritable Bowel Syndrome (IBS) Identified as cause of recurrent abdominal pain in children (Chapter 18) Classified as a functional GI disorder Alternating diarrhea and constipation Therapeutic management Nursing considerations

78 Acute Appendicitis Etiology and pathophysiology Diagnostic evaluation Therapeutic management Ruptured appendix Prognosis Nursing considerations

79 Inflammatory Bowel Disease (IBD) Includes ulcerative colitis (UC) and Crohn disease (CD) Etiology and pathophysiology Diagnostic evaluation Therapeutic management Medical treatment Nursing considerations

80 Ulcerative Colitis (UC) Pathophysiology Clinical manifestations Extraintestinal manifestations

81 Crohn Disease Pathophysiology Clinical manifestations Extraintestinal manifestations Therapeutic management Medical Surgical Nursing considerations

82 Effects of UC or Crohn Disease

83 OBSTRUCTIVE DISORDERS

84 Hypertrophic Pyloric Stenosis (HPS) Constriction of the pyloric sphincter with obstruction of the gastric outlet

85 Pyloric Stenosis Pathophysiology Diagnostic evaluation Therapeutic management Prognosis Nursing considerations

86 Hypertrophic Pyloric Stenosis

87 Intussusception Telescoping or invagination of one portion of intestine into another Occasionally due to intestinal lesions Often cause is unknown Diagnostic evaluation Therapeutic management Prognosis Nursing considerations

88 Ileocolic Intussusception

89 Malrotation and Volvulus Malrotation is due to abnormal rotation around the superior mesenteric artery during embryonic development Volvulus occurs when intestine is twisted around itself and compromises blood supply to intestines May cause intestinal perforation, peritonitis, necrosis, and death

90 Malabsorption Syndromes Characterized by chronic diarrhea and malabsorption of nutrients May result in failure to thrive Digestive defects Absorptive defects Anatomic defects

91 Celiac Disease Also called gluten-induced enteropathy and celiac sprue Four characteristics Steatorrhea General malnutrition Abdominal distention Secondary vitamin deficiencies

92 Celiac Disease (cont.) Pathophysiology Diagnostic evaluation Therapeutic management Nursing considerations

93 Short Bowel Syndrome (SBS) A malabsorptive disorder Results from decreased mucosal surface area, usually as result of small bowel resection Etiology and pathophysiology Result of decreased mucosal surface area, usually due to extensive resection of small intestine Other causes NEC, volvulus, gastroschisis, Crohn disease in

94 Therapeutic Management of SBS Nutritional support—first phase: TPN Associated risks and complications Second phase: enteral feeding Long-term maintenance Medical therapies Surgical therapies Nursing considerations

95 GI Bleeding Upper GI bleeding Esophagus Stomach “Coffee grounds” emesis Hematemesis Lower GI bleeding Bright red (rectal bleeding): hematochezia Tarry stools: melena

96 GI Bleeding (cont.) Diagnostic evaluation Therapeutic management Assess blood loss Establish hemodynamic stability Nursing considerations

97 Types of Diarrhea Acute Acute infectious/infectious gastroenteritis Chronic Intractable diarrhea of infancy Chronic nonspecific diarrhea (CNSD)

98 Anorectal Malformations Imperforate anus Persistent cloaca Cloacal exstrophy Genitalia may be indefinite Diagnostic evaluation Management

99 Dehydration Types of dehydration Diagnostic evaluation Therapeutic management Nursing considerations

100 Daily Maintenance Fluid Requirements Calculate child’s weight in kg Allow 100 ml/kg for first 10 kg body weight Allow 50 ml/kg for second 10 kg body weight Allow 20 ml/kg for remaining body weight

101 Example 1: Daily Fluid Calculation Child weighs 32 kg 100 x 10 for first 10 kg of body weight = x 10 for second 10 kg of body weight = x 12 for remaining body weight = = 1740 ml/24 hr

102 Example 2: Daily Fluid Calculation Child weighs 8.5 kg 100 x 8.5 for first 10 kg of body weight = 850 No further calculations 850 ml/24 hr

103 Example 3: Daily Fluid Calculation Child weighs 14 kg 100 x 10 for first 10 kg of body weight = x 4 for second 10 kg of body weight = 200 No further calculations = 1200 ml/24 hr


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