‘ The Pedi-Cardiac Lecture ’
Part 1
Pediatric Cardiovascular Disorders
Jerry Carley MSN, MA, RN, CNE
Concept Map:
Pediatric Cardiac Conditions
Concept Map:
Pediatric Cardiac Conditions ( Congenital )
Cyanotic
Right to left shunt ( R
L)
VS Acyanotic
Left to right shunt ( R
L)
Concept Map:
Pediatric Cardiac Conditions ( Acquired )
Focused Health History
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Family history of defects / early cardiac
disease / siblings with defects
Maternal history of stillborns or miscarriages
Congenital anomalies / genetic anomalies /
fetal alcohol syndrome / Down Syndrome and
Turner Syndrome
Maternal exposure to rubella
Prenatal diagnosis the key to treatment of
CHD
http://www.youtube.com/watch?v=PjxjvEB1w_I&noredirect=1
Focused Health History
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Heart murmur
Tires while eating
Low weight for height
Sweats while eating (diaphoretic)
Cyanosis, worsens with feeding or activity
level
Irritable weak cry
Focused Health History
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In the older child additional symptoms may
include:
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Chest pain
Decreased activity level
Syncope
Slight of build
Focused Physical Assessment
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General appearance
Integumentary system
Face, nose, and oral cavity
Thorax and lung
Cardiovascular system
Review: Heart Sounds
Review: Heart Murmurs
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These sounds are produced by blood passing
through a defective valve, great vessel, or
other heart structure.
Murmurs are classified by: intensity, location,
radiation, timing, and quality.
Pulses
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Assessment Alert:
Weaker pulses or lower blood pressure in the
lower extremities may indicate coarctation of
the aorta (COA)
Bounding pulses can indicate a patent ductus
arteriosus (PDA) or aortic insufficiency.
Vital Signs
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Heart rate: tachycardia in the absence of
fever, crying, or stress may indicate cardiac
pathology.
Tachypnea, even with rest, chest retractions
indicate respiratory distress, possibly
resulting from congestive heart failure
Review: Fetal Circulation
At First Breath
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Pulmonary alveoli open up
Pressure in pulmonary tissues decreases
Blood from the right heart rushes to fill the
alveolar capillaries
Pressure in right side of heart decreases
Pressure in left side of heart increases
Pressure increases in aorta
Treatment Modalities
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Palliative procedures
Pulmonary artery banding
Shunts
Corrective procedures
Diagnostic Testing
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Chest x-ray to define silhouette of the heart.
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Heart size, shape, pulmonary markings, and
cardiomegaly.
Electrocardiogram ECG or EKG to define
electrical activity of the heart.
Echo-cardiogram to visualize anatomic
structures.
Non-invasive
Cardiac Conduction
Echo-Cardiogram
Cardiac Catheterization
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An invasive test to diagnose or treat cardiac
defects.
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Visualizes heart and vessels.
Measures oxygen saturation of chambers.
Measures intra-cardiac pressures.
Determines muscle function and pumping action
of the heart.
Cardiac
Catheterization
Diagnostics: Potential Toxicity to Dye
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Watch for signs of toxicity due to the dye
used during the procedure*
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Increased temperature
Urticaria
Wheezing
Edema
Dyspnea
Headache
*Allergy response
Pre-cardiac Catheterization
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Assess vital signs with blood pressure.
Hemoglobin and hematocrit
Pedal pulses
NPO
Hold digoxin
IV if child is polycythemic
Post-cardiac Catheterization
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Vital signs, with apical pulse and blood
pressure (at leaST) q 15 minutes for first
hour.
Apical pulse for 1 minute to check for
bradycardia or dysrhythmias.
Post-cardiac Catheterization
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Assess pulses DISTAL to the cath insertion
site.
Record quality and symmetry of pulses.
Assess temperature and color of affected
extremity.
Check dressing for bleeding or hematoma
formation.
Home Care Instructions
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Keep dressing in place for 24 hours.
Keep site dry and clean.
Observe site for redness, swelling, drainage,
or bleeding.
Check temperature.
Avoid strenuous exercise.
Acetaminophen for pain.
Keep follow-up appointment
Pre-procedure medications as ordered.
Pressures
Right Heart=Low Pressure System
Left Heart=High Pressure System
100-110 mm Hg Normal child
50-60 mm Hg Preterm infant
65-80 mm Hg Full term infant
Left to Right Shunt
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(R
L)
Here, it is all about pressure gradients
Pressures on the left side of the heart are
normally higher than the pressures in the
right side of the heart.
If there is an abnormal opening in the septum
between the right and left sides, blood flows
(and is forced) from left to the right.
Left to Right Shunt
Right
Left
Clinical Manifestations
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The infant is not cyanotic.
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Tachycardia due to pushing increased blood
volume.
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Cardiomegaly due to increased workload of
the heart.
Clinical Manifestations
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Dyspnea and pulmonary edema due to the
lungs receiving blood under high pressure
from the right ventricle.
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Increased number of respiratory infections
due to blood pooling in the the lungs
promoting bacterial growth.
Right to Left Shunts ( R
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Occurs when pressure in the right side of the heart
is greater than the left side of the heart.
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L )
Resistance of the lungs in abnormally high
Pulmonary artery is restricted
Deoxygenated blood from the right side shunts to
the left side
Right to Left Shunt
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Hole in septum + obstructive lesion
Deoxygenated blood from the right side of the
heart shunts to the left side of the heart and
out into the body.
Clinical Manifestations R
L
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Hypoxemia = the result of decreased tissue
oxygenation. (“CYANOTIC”)
Polycythemia = increased red blood cell
production due to the body’s attempt to
compensate for the prolonged hypoxemia.
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(Normal RBC Count for 6 month-1 year old ~3,500,000-5,200,000 /µl)
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Increase viscosity of the blood = heart has to
pump harder.
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Potential Complications
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Thrombus formation due to sluggish
circulation.
Brain abscess or stroke due to the unoxygenated blood bypassing the filtering
system of the lungs.
Heart Failure
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Major manifestation of heart disease
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Under 1 year of age usually due to congenital
anomaly (CHD)
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Over 1 year with no congenital anomaly may
be due to acquired heart disease
Dependent upon structure(s)
effected
Left to Right Shunt
Signs
&
Symptoms
Of
Congenital
Heart
Disease
(CHD)
Murmurs
R
L
Acyanotic
versus
Cyanotic
R
Heart Failure
Two Causes:
1.
pulmonary Blood Flow
2. Mixing of pulmonary &
venous return
( Right to Left Shunt )
L
S/S CHF:
-Failure to Thrive (FTT)
-Cardiomegaly
-Edema
-Hepatomegaly
-Tachypnea
-Tachycardia
-Weight Gain
Clinical Manifestations of HF
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Systemic Venous Congestion
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Pulmonary Venous Congestion
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Weight gain, hepatomegaly, edema, jugular vein
distension
Tachypnea, dyspnea, cough, wheezes
Compensatory Response
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Tachycardia, cardiomegaly, diaphoretic, fatigue,
failure to grow (FTT)
Digoxin Therapy
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Digoxin increases the force of the myocardial
contraction ( + inotropic, - chronotropic).
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Take an apical pulse with a stethoscope for 1 full
minute before every dose of digoxin. If
bradycardia is detected*
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< 100 beats / min for infant and toddler
< 80 beats in the older child
< 60 beats in the adolescent
* Call / advise primary provider before administering the
drug.
Signs of Digoxin Toxicity
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Bradycardia
Arrhythmia
Nausea, vomiting, anorexia
Dizziness, headache
Weakness and fatigue
Interventions
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Fluid restriction
Diuretics – Lasix (potassium wasting) or
Aldactone (potassium sparing)
Bed rest
Oxygen
Small frequent feedings – soft nipple with
supplemental gavage for adequate calorie
intake
Pulse oximetry
Sedatives if needed
Feeding
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Small frequent feedings
Soft nipple to easy energy needed to suck
24 kcal formula for added calories
NG feed if not taking in adequate calories to
gain weight
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End of Part 1