Module 5
Pediatric Cardiac Disorders
Fetal Circulation
Fetal Circulation
Fetal Circulation
What is the
stimulus for the
change in
circulation?
Intrauterine to Extrauterine
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?
Congestive Heart Failure

What is wrong with the heart?
Congestive heart failure

What is the effect on:
 Heart rate
Preload
Contractitility
Afterload
Congestive Heart Failure

Why does the pump fail?
Etiology and Pathophysiology
*Congenital defects
*Acquired heart diseases
Congestive Heart Failure

What does the
body do to
compensate for
this congestion
and heart
failure?
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.
Compensatory Mechanisms


Decrease perfusion to the kidneys and
glomerulus


With a decrease in cardiac output
Increased renin and ADH secretion
Increase in Na and H2O retention to increase
intravascular volume
Early Signs of CHF

The earliest signs are often subtle:

Infant will have mild resting tachypnea

Increasing difficulty feeding
Signs and Symptoms
 Pulmonary congestion
1. Tires easily during feeding
2. Tachypnea, Dyspnea, orthopnea
3. Signs of respiratory distress
4. Wheezing, rales and rhonchi
5. Easily fatigue
 Impaired cardiac output
1. Tachycardia
2. Extremities cool, capillary refill >2 seconds
3. Diaphoretic, sweating, hypotension
Signs and Symptoms

Systemic venous congestion
1. Hepatomegaly
2. Edema
3. Weight gain
 High metabolic rate
1. Failure to thrive
2. Slow weight gain
Goal of Treatment
Decreasing
Cardiac Workload
Improving
Cardiac Output
Treatment of Congestive Heart Failure

Medication Therapy
 Digitalis – increases contractility and decreases
heart rate.

ACE-inhibitors - blocks release of angiotensionaldosterone; 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
Nursing Care
How would the nurse
recognize digitalis toxicity in
an infant or child?
What are the pulse rate
criteria in administration of
digitalis?
Digitalis

Digitalization


Maintenance


Given in divided doses
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
Digitalis

Why are we so concerned with the
potassium levels when the child is on
digitalis therapy?
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?
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
Cardiac Catheterization
Measure oxygen saturations and pressure in the
cardiac chambers and great arteries
Evaluate cardiac output
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.
Cardiac Catheterization

Pre-care:





History and Physical
Lab work – EKG, ECHO cardiogram, CBC
NPO
Vital signs
Preprocedural teaching
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?
Post Cardiac Catheterization Care
Post Cardiac Catheterization Care
Congenital Cardiac Anomalies
Ask Yourself?

What is the most common assessment
finding indicating a cardiac anomaly?

Answer: an audible heart murmur
Patent Ductus Arterious
Atrial septal defects
Ventricle septal defects
Atrial Septal Defect
1. Oxygenated blood is shunted
from left to right side of the
heart via defect
2. A larger volume of blood
than normal must be
handled by the right side of
the heart hypertrophy
3. 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
Treatment

Medical Management


Cardiac Catheterizaton 

Medications – digoxin
Amplatzer septal occluder
Open-heart Surgery
Treatment

Device Closure – Amplatzer septal
occluder
During cardiac catheterization the occluder is placed in the
Defect
Ventricle Septal Defect
1. Oxygenated blood is shunted
from left to right side of the
heart via defect
2. A larger volume of blood
than normal must be
handled by the right side of
the heart hypertrophy
3. 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
Treatment
Surgical repair with a patch inserted
Patent Ductus Arteriosus
1. Blood shunts from
aorta (left) to the
pulmonary artery
(right)
2. Returns to the lungs
causing increase
pressure in the lung
3. Congestive heart
failure
Treatment for PDA


Medical Management
 Medication
 Indomethacin - inhibits prostaglandin's .
(When levels of prostaglandins are
decreased, the ductus closes)
Surgery
Ligate the
ductus arteriosus
Treatment for PDA

Cardiac Catheterization

Insert coil – tiny fibers
occlude the ductus
arteriosus when a
thrombus forms in
the mass of fabric and
wire
Cardiac Anomalies - Treatment
Pulmonic stenosis
coarctation of aorta
Pulmonic Stenosis


Narrowing of
entrance that
decreases blood
flow
Increases
preload causes
right ventricular
hypertrophy
Obstructive or Stenotic Lesions

Treatment:
 Medications – Prostaglandins to keep the
PDA open

Cardiac Catheterization
 Baloon Valvuloplasty

Surgery
 Valvotomy
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.
Aortic Stenosis

Symptoms
 Poor peripheral perfusion, feeding
difficulties, CHF

Treatment
 Balloon valvoplasty
 Surgery
Coarctation of the Aorta
1. Narrowing of Aorta
causing obstruction of
left ventricular blood
flow
2. Left ventricular
hypertrophy
Signs and Symptoms
1. What are B/P findings support the diagnosis?
2. What is different in the pulses?
3. Why would the patient C/O leg pains?
4. What causes nose bleeds?
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
Surgery for Coarctation of Aorta
1. Resect
narrow
area
2. Anastomosis
Tetralogy of fallot
Tetralogy of Fallot
Four defects are:
1.
2.
3.
4.
Signs and Symptoms
1.
Failure to thrive
2.
Squatting
3.
Lack of energy
4.
Infections
5.
Polycythemia
6.
Clubbing of fingers
7.
Cerebral abscess
8.
Cardiomegaly
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?
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
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
Treatment

Open-heart Surgical interventions
 Blalock – Taussig or Potts procedure –
increases blood flow to the lungs.
Something the Lord Made
View the Movie Trailer
About Blalock procedure to treat
Tetralogy of fallot
•
•
Truncus Arteriosus
Transportation of Great Vessels
These present the greatest risk to survival
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.
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
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.
Subacute Bacterial Endocarditis /
Infective Endocarditis:

Assessment:








Fever
Fatigue
Muscle and joint pain
Headache
Nausea and vomiting
CHF
Spleenomegaly
Diagnosis:


Blood cultures
Echocardiogram
Infective Endocarditis

Diagnosis

Blood cultures

Echocardiogram
 Show the vegetation
Who is more susceptible to
develop infective endocarditis?
What is the most therapeutic
intervention for preventing
infective endocarditis?
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
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.
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.
Rheumatic Fever - Assessment


Major
 Carditis
 Polyarthritis
 Chorea
 Erythema
marginatum
 Subcutaneous
nodules
Minor



Jones Criteria
Arthralgia
Fever
Laboratory
Findings:
Erythrocyte
sedimentation
rate
C-reactive
protein
 Prolonged PR
interval
What additional laboratory
test helps to confirm the
diagnosis of Rheumatic
Fever ?
Rheumatic Fever

Treatment






Antibiotic Therapy
Antipyretics - aspirin
Anti-inflammatory agents –steroids
Rest
Heat and cold to joints
Discharge Teaching

Antibiotic therapy - be sure to complete all
medication.
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
Multisystem vasculitis – inflammation of
blood vessels in the body especially the
coronary arteries with antigen-antibody
complexes.
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 1020 for 5 days.
Acute Phase – 10-14 days






Fever, which often is higher than 101.3 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
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
Convalescent Phase

From day 26 until the erythrocyte
sedimentation rate returns to normal
Nursing Care

Give Medications



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


Aspirin
Intravenous Immunoglobulin
Kawasaki Disease

Which phase of Kawasaki is this child
exhibiting?
Inflamed, Cracked,
Peeling Lips
Strawberry tongue
Kawasaki Disease