1. Module 5 Pediatric Cardiac Disorders

2. What is the main route of blood flow through the fetal heart?
Fetal Circulation
What is the main route of blood flow through the fetal heart?

3. Why does the blood flow in that route?
Fetal Circulation
Why does the blood
flow in that route?

4. What is the stimulus for the change in circulation?
Fetal Circulation
What is the stimulus for the change in circulation?

5. Intrauterine to Extrauterine
What Happens after
the Umbilical cord is
Clamped?

6. Oxygen Saturation What is oxygen saturation?
What is normal oxygen saturation levels?
What values indicate hypoxemia?
Why is it important for the nurse to know the oxygen saturation levels?
question 5

7. Congestive
Heart Failure

8. Congestive Heart Failure
What is wrong with the heart?

9. Congestive heart failure
What is the effect on:
Heart rate
Preload
Contractitility
Afterload

10. Congestive Heart Failure
Why does the pump fail?

11. Etiology and Pathophysiology
*Congenital defects
*Acquired heart diseases

12. Congestive Heart Failure
What does the body do to compensate for this congestion and heart failure?

13. Compensatory Mechanisms
With a decrease in Cardiac Output
Stimulation of the sympathetic nervous system
Tachycardia - increases venous return to the heart which stretches the myocardial fibers and increases preload.

14. Compensatory Mechanisms
With a decrease in cardiac output
Decrease perfusion to the kidneys and
glomerulus
Increased renin and ADH secretion
Increase in Na and H2O retention to increase intravascular volume

15. A Change in Condition Early Signs of CHF
The earliest signs are often subtle:
Infant will have mild resting tachypnea
Increasing difficulty feeding
A Change in Condition

16. Signs and Symptoms Pulmonary congestion Tires easily during feeding
Tachypnea, Dyspnea, orthopnea
Signs of respiratory distress
Wheezing, rales and rhonchi
Easily fatigue
Impaired cardiac output
Tachycardia
Extremities cool, capillary refill >2 seconds
Diaphoretic, sweating, hypotension

17. Signs and Symptoms Systemic venous congestion Hepatomegaly Edema
Weight gain
High metabolic rate
Failure to thrive
Slow weight gain

18. Improving Cardiac Output
Goal of Treatment
Decreasing
Cardiac Workload
Improving Cardiac Output

19. Treatment of Congestive Heart Failure
Medication Therapy
Digitalis – increases contractility and decreases heart rate.
ACE-inhibitors - blocks release of angiotension-aldosterone; arterial vasodilator / afterload reducing agent
Diuretics - enhance renal secretion of sodium and water by reducing circulating blood volume and decreasing preload,  pulmonary congestion.
Beta Blocker - increases contractility

20. What are the pulse rate criteria in administration of digitalis?
Nursing Care
How would the nurse recognize digitalis toxicity in an infant or child?
What are the pulse rate criteria in administration of digitalis?

21. Digitalis Digitalization Maintenance Therapeutic vs. Toxicity
Given in divided doses
Maintenance
Given daily, usually in two divided doses
Therapeutic vs. Toxicity
Therapeutic range – 0.8 to 2.0 ng/ml
Toxicity
**EKG changes – arrhythmia
Slow pulse- bradycardia
Vomiting – very rare in infants

22. Digitalis
Why are we so concerned with the potassium levels when the child is on digitalis therapy?

23. Treatment of Congestive Heart Failure
What is the type of Diet most commonly ordered?
How would nursing measure are used to decrease stress on the heart?

24. Feeding the child with CHF
Feed the infant or child in a relaxed environment; frequent, small feedings may be less tiring
Hold infant in upright position; may provide less stomach compression and improve respiratory effort
If child unable to consume appropriate amount during 30-minute feeding q 3 h, consider nasogastric feeding
Monitor for increased tachypnea, diaphoresis, or feeding intolerance (vomiting)
Concentrating formula to 27 kcal/oz may increase caloric intake without increasing infant’s work

25. Cardiac Catheterization
Measure oxygen saturations and pressure in the cardiac chambers and great arteries
Evaluate cardiac output

26. Cardiac Catheterization
This process involves passing a catheter through the femoral vein or artery into the heart.
Performed to evaluate heart valves, heart function and blood supply, or heart abnormalities in newborns.

27. Cardiac Catheterization
Pre-care:
History and Physical
Lab work – EKG, ECHO cardiogram, CBC
NPO
Vital signs
Preprocedural teaching

28. Best Nursing Action
During post procedure assessment, the nurse notes bleeding at the insertion site.
What should the nurse do first?
What additional interventions are implemented?

29. Post Cardiac Catheterization Care
What is Wrong with this picture?

30. Post Cardiac Catheterization Care
Mother Reading to child

31. Congenital Cardiac Anomalies

32. Ask Yourself?
What is the most common assessment finding indicating a cardiac anomaly?
Answer: an audible heart murmur

33. Patent Ductus Arterious Atrial septal defects Ventricle septal defects
Left-to-Right
Shunting Defects
Patent Ductus Arterious
Atrial septal defects
Ventricle septal defects

34. Atrial Septal Defect
Oxygenated blood is shunted from left to right side of the heart via defect
A larger volume of blood than normal must be handled by the right side of the heart hypertrophy
Extra blood then passes through the pulmonary artery into the lungs, causing higher pressure than normal in the blood vessels in the lungs  congestive heart failure

35. Treatment Medical Management Cardiac Catheterizaton -
Medications – digoxin
Cardiac Catheterizaton -
Amplatzer septal occluder
Open-heart Surgery

36. During cardiac catheterization the occluder is placed in the
Treatment
Device Closure – Amplatzer septal occluder
During cardiac catheterization the occluder is placed in the
Defect

37. Ventricle Septal Defect
Oxygenated blood is shunted from left to right side of the heart via defect
A larger volume of blood than normal must be handled by the right side of the heart hypertrophy
Extra blood then passes through the pulmonary artery into the lungs, causing higher pressure than normal in the blood vessels in the lungs  congestive heart failure

38. Treatment
Surgical repair with a patch inserted

39. Patent Ductus Arteriosus
Blood shunts from aorta (left) to the pulmonary artery (right)
Returns to the lungs causing increase pressure in the lung
Congestive heart failure

40. Treatment for PDA Medical Management Medication
Indomethacin - inhibits prostaglandin's .
(When levels of prostaglandins are decreased, the ductus closes)
Surgery
Ligate the
ductus arteriosus

41. Treatment for PDA Cardiac Catheterization
Insert coil – tiny fibers occlude the ductus arteriosus when a thrombus forms in the mass of fabric and wire

42. Cardiac Anomalies - Treatment
When is surgery
Performed?
Why?

43. Pulmonic stenosis coarctation of aorta
Obstructive or
Stenotic
Lesions
Pulmonic stenosis
coarctation of aorta

44. Pulmonic Stenosis Narrowing of entrance that decreases blood flow
Increases preload causes right ventricular hypertrophy

45. Obstructive or Stenotic Lesions
Treatment:
Medications – Prostaglandins to keep the PDA open
Cardiac Catheterization
Baloon Valvuloplasty
Surgery
Valvotomy

46. Aortic Stenosis The aortic valve is thickened and rigid
Stenosis creates left ventricular hypertrophy
Left ventricle may not be large enough to eject a normal cardiac output.

47. Aortic Stenosis Symptoms
Poor peripheral perfusion, feeding difficulties, CHF
Treatment
Balloon valvoplasty
Surgery

48. Coarctation of the Aorta
Narrowing of Aorta causing obstruction of left ventricular blood flow
Left ventricular hypertrophy

49. Signs and Symptoms What are B/P findings support the diagnosis?
What is different in the pulses?
Why would the patient C/O leg pains?
What causes nose bleeds?

50. Treatment
Goals of management are to improve ventricular function and restore blood flow to the lower body.
Medical management with Medication
A continuous intravenous medication, prostaglandin (PGE-1), is used to open the ductus arteriosus allowing blood flow to areas beyond the coarctation.
Baloon Valvoplasty

51. Surgery for Coarctation of Aorta
1. Resect
narrow
area
2. Anastomosis

52. Cyanotic Lesions With Decreased Pulmonary Flow
Tetralogy of fallot

53. Tetralogy of Fallot
Four defects are: 1. 2. 3. 4.

54. Signs and Symptoms Failure to thrive Squatting Lack of energy
Infections
Polycythemia
Clubbing of fingers
Cerebral abscess
Cardiomegaly

55. Ask Yourself?
Why does Polycythemia occur in a child with a cardiac disorder?
What nursing interventions should be included when planning care for this child?
What lab test will be abnormal and assist in confirming the polycythemia?

56. Ask Yourself ?
Laboratory analysis on a child with Tetralogy of Fallot indicates a high RBC count. The polycythemia is a compensatory mechanism for:
a. Tissue oxygen need
b. Low iron level
C. Low blood pressure
d. Cardiomegaly

57. Hypercyanotic Episode / “tet” spells
Cyanosis suddenly worsens in response to activity, such as crying, feeding, or having a bowel movement.
Signs - The infant becomes very short of breath with tachypnea and hyperpnea, and may lose consciousness.
Treatment – calming, knee-chest position, oxygen, morphine , and beta-blockers

58. Treatment Open-heart Surgical interventions
Blalock – Taussig or Potts procedure – increases blood flow to the lungs.

59. Something the Lord Made
View the Movie Trailer
About Blalock procedure to treat
Tetralogy of fallot

60. Increased Pulmonary Flow
Cyanotic Lesions
With
Increased Pulmonary Flow
Truncus Arteriosus
Transportation of Great Vessels
These present the greatest risk to survival

61. Truncus arteriosus
A single arterial trunk arises from both ventricles that supplies the systemic, pulmonary, and coronary circulations. A vsd and a single, defective, valve also exist.
Entire systemic circulation supplied from common trunk.

62. Transposition of Great Vessels
Aorta arises from the right ventricle, and the pulmonary artery arises from the left ventricle - which is not
compatible with survival unless there is a large defect present in ventricular or atrial septum.
artery
aorta

63. Acquired Heart Disease

64. Infective Endocarditis
Microorganisms grow on the endocardium, forming vegetations, deposits of fibrin, and platelet thrombi. The lesion may invade adjacent tissues such as aortic and mitral valves.

65. Subacute Bacterial Endocarditis / Infective Endocarditis:
Assessment:
Fever
Fatigue
Muscle and joint pain
Headache
Nausea and vomiting
CHF
Spleenomegaly
Diagnosis:
Blood cultures
Echocardiogram

66. Infective Endocarditis
Diagnosis
Blood cultures
Echocardiogram
Show the vegetation
Who is more susceptible to develop infective endocarditis?

67. Prevention
What is the most therapeutic intervention for preventing infective endocarditis?

68. Antibiotic Prophylaxis for Children at Risk for Infective Endocarditis
Dental procedures, including cleaning, that may induce gingival or mucosal bleeding
Tonsillectomy and/or adenoidectomy
Surgery and/or biopsy involving respiratory or intestinal mucosa
Incision and drainage of infected tissue
Invasive GU and GI procedures

69. Ineffective Endocarditis
Treatment
Monitor temperature
Antibiotics – 2-8 weeks
Patient teaching
Good oral hygiene
take antibiotics prior to surgery, dental work, or any invasive procedure, etc.
discouraged from body piercing and tattoos as endocarditis may occur even with prophylaxis.

70. Rheumatic Heart Disease
A systemic inflammatory (collagen) disease of connective tissue that usually follows a group A beta-hemolytic streptococcus infection.
This disorder causes changes in the entire heart (especially the valves), joints, brain, and skin tissues.

71. Rheumatic Fever - Assessment
Minor
Arthralgia
Fever
Laboratory Findings:
Erythrocyte sedimentation rate
C-reactive protein
Prolonged PR interval
Major
Carditis
Polyarthritis
Chorea
Erythema marginatum
Subcutaneous nodules
Jones Criteria

72. What additional laboratory test helps to confirm the diagnosis of Rheumatic Fever ?

73. Rheumatic Fever Treatment Discharge Teaching Antibiotic Therapy
Antipyretics - aspirin
Anti-inflammatory agents –steroids
Rest
Heat and cold to joints
Discharge Teaching
Antibiotic therapy - be sure to complete all medication.

74. Streptococcal Prophylaxis for the Child with Rheumatic Fever
Damaged valves can become further damaged with repeated infections
Streptococcal prophylaxis is lifelong if there is actual valve involvement
Intramuscular penicillin, administered monthly, is the drug of choice
Alternatives include oral penicillin twice daily or oral sulfadiazine once a day

75. Kawasaki Disease
Multisystem vasculitis – inflammation of blood vessels in the body especially the coronary arteries with antigen-antibody complexes.

76. Kawasaki Disease Signs and Symptoms / Treatment
Three Phases of clinical manifestations:
Acute
Subacute
Convalesant
One of the most common symptoms used to diagnose Kawasaki disease is a high spiking fever over for 5 days.

77. Acute Phase – days
Fever, which often is higher than F, and lasts one to two weeks
Extremely red eyes (conjunctivitis)
without thick discharge
Red, dry, cracked lips and an extremely red, swollen tongue ("strawberry" tongue)
A rash on the main part of the body (trunk)
and in the genital area
Swollen, erythema on the palms of the hands and the soles of the feet
Swollen cervical lymph nodes

78. Subacute Phase 15-25 days Irritability Anorexia
Desquamation of the skin on the hands and feet, especially the tips of the fingers and toes, often in large sheets
Arthritis and Arthralgia
Arrhythmias
Coronary aneurysms

79. Convalescent Phase
From day 26 until the erythrocyte sedimentation rate returns to normal

80. Nursing Care Give Medications Promote comfort Aspirin
Intravenous Immunoglobulin
Promote comfort
Lubricate the lips
Cool compresses
Keep skin cool and dry
Small feedings of soft foods and liquids that are not too hot or too cold.
Facilitate joint movement
Passive Range of Motion exercises

81. Which phase of Kawasaki is this child exhibiting?
Kawasaki Disease
Which phase of Kawasaki is this child exhibiting?
Inflamed, Cracked, Peeling Lips
Strawberry tongue

82. What are major Complications Of Kawasaki?
Kawasaki Disease
What are major
Complications Of
Kawasaki?

83. The End!