PEDS: Cardiovascular Disorders-Chap 12

Rheumatic heart disease assessment

-Abdominal pain -Nosebleeds -Chest pain and heart palpitations -Waking from sleep with the need to sit or stand up (paroxysmal nocturnal dyspnea) Nursing Interventions -Maintain administration of inflammatory medications and antibiotics. -Prepare the child for admission to hospital and/or surgery. -Provide detailed education to the family regarding prevention, treatment, and reoccurrence of symptoms. Caregiver Education -Educate families on the screening of school-age children for sore throats. -Educate families on the need for the completion of antibiotic regimen or prophylaxis as ordered. -Prepare caregiver for possible hospitalization or heart-valve surgery. -Encourage regular check-ups with cardiologists. -Encourage immunizations and the annual flu shot. -Provide education related to prophylaxis antibiotic therapy for dental work

Digoxin (Lanoxin) nurse monitoring education

-Be aware of the child's baseline parameters, including peripheral pulse, BP, and heart rate. -Administer 1 hour before or 2 hours after meals; if the child vomits dose, do not repeat the dose. -Take apical pulse for a full minute. Instruct parents that changes in heart rate, especially bradycardia, are one of the first signs of digoxin toxicity in infants and children. o Educate family on how to assess infant's apical pulse rate and to notify the healthcare practitioner if the heart rate is out of the range set by the healthcare provider. -Note rate, rhythm, and quality. If changes occur, take an EKG and notify the physician. -Monitor baseline and periodic ongoing potassium, magnesium, and calcium levels. -Monitor for signs and symptoms of digoxin toxic effects, including anorexia, nausea, vomiting, diarrhea, and visual disturbances. o Closely monitor for digoxin toxicity with antibiotic therapy caused by changes in the intestinal flora. -Digoxin (Lanoxin) has a narrow therapeutic range. Medication errors with digoxin include miscalculation of doses and insufficient monitoring of digoxin levels. A second nurse should check the original order and dose calculations Caregiver education for the administration of Lanoxin includes: Administer medication at the same time every day and at the correct frequency. Do not double up for a missed dose. Notify your physician for advice before administering any over-the-counter medications. Do not breastfeed without contacting your physician if you are taking this medication

Fetal Circulation

-Before birth, 90% of blood bypasses the lungs; the placenta is the organ of respiration -Oxygenated blood is returned via the umbilical vein, from the liver ( DUCTUS VENOSUS), and to the inferior vena cava o travels from the inferior vena cava to the right atrium -Oxygenated blood crosses from the right atrium to the left atrium via the patent foramen ovale (PFO) and is pumped by the left ventricle. -Deoxygenated blood flows from the superior vena cava to the right atrium and then to the right ventricle, the pulmonary artery, the patent ductus arteriosus (PDA), and the aorta. -Upon birth and first breath, the foramen ovale and ductus arteriosus close

Physical Examination Possible Indicators of Heart Disease in Children

-Failure to thrive (FTT) -POOR PERFUSION/CAPILLARY REFILL -Small for gestational age -Poor weight gain/weight loss/POOR FEEDING Habits -MURMURS -STERNAL LIFT -Infants who have congenital defects are more likely to have developmental disabilities. -TACHYPNEA, TACHYCARDIA -Scoliosis is common in adolescents with congenital heart disease -Clubbing and erythema in fingers and toes---low o2 CYANOSIS, CRACKLES N THE LUNGS

Physical Examination Cardiovascular System

-Level of alertness, activity, and tone -Chest symmetry and pulsations -Capillary refill o Pressing a central location (sternum or forehead) o Prolonged capillary refill indicates poor cardiac output and perfusion o normal = <3 sec -Cardiac assessment techniques (see image) o Inspection o Palpation o Percussion o Auscultation -Pulses o When normal, usually easy to feel in a child. o Heart for infants is 160 beats/min, preschool children 120 beats/min, and adolescents 100 beats/min. Include radial, carotid, brachial, and femoral pulses. o Should be equal in strength between right and left arms and upper and lower extremities. o Pulses that are bounding in upper extremities and decreased in lower extremities may indicate COA. (Coarctation of the aorta) o Pulses that are bounding may suggest systemic hypertension or PDA (opening in 2 blood vessels in the heart) o Cardiac pulsations are seen in subaortic stenosis. o Peripheral pulses are indicators of cardiac output, systolic pressure, and diastolic pressure. o Pulses that are difficult to palpate may indicate poor cardiac output, shock, or obstructive outflow lesions o Bounding pulses indicate excessive fluid volume. Pedal pulses are found on the top of the foot (dorsal pedis) and the medial malleolus (posterior tibial). - Peripheral edema is the measurement of edema in the extremities. Edema is rated from +1, slight edema less than a one-quarter inch and disappears immediately; +2 edema, which is less than one-half inch and disappears in 10 to 15 seconds; +3 edema, which is less than 1 inch and disappears in 1 to 2 minutes; and +4 edema, which is more than 1 inch and disappears after 2 to 5 minutes -Thrills—palpation of vibrating sensations due to the rapid flow of blood from an area of higher pressure to an area of lower pressure; always an abnormal finding -Temperature of the extremities—cold feet or hands in comparison with torso suggests poor perfusion beyond 8 hours after birth -Blood pressure o Blood pressure (BP) should be assessed by Doppler with the proper size of the cuff. o Use a non-threatening approach; the child may sit on the parent's lap depending on age. o BP varies with gestational age, weight, or postnatal age o Normal BPs range from 50 to 75 mm Hg systolic and 30 to 45 mm Hg diastolic in the neonate o Poor cardiac output will result in a low systolic BP with high diastolic pressure, creating a narrow pulse pressure o Four limb extremity BPs are indicated if the cardiac disease is suspected or a murmur is present. o Distended or pulsating neck veins require investigation o Hepatomegaly, where the liver is felt more than 3 cm below the right costal margin, indicates increased right arterial pressure and is highly suggestive of congestive heart failure (CHF)

Safety education for caregivers of children with Kawasaki disease should include

-Loose clothing -Cool clothes -Lip and mouth care -Clear liquids that are tepid and soft foods to minimize irritation of the oral mucosa -Parental support for inconsolable child -Discharge teaching aimed at understanding the progression of the disease o Peeling of hands and feet o Arthritis of weight-bearing joints—stretching and passive range of motion -Defer live immunizations such as measles, mumps, rubella, chickenpox -Educate on the lifelong possibility of the development of cardiac disease. -CPR training HIGH DOSES OF ASA required!

Kawasaki disease interventions

-Monitor cardiac status -I/O -Daily weights IV fluids to prevent dehydration -Administer ASA - Administer IV gamma globulin -Assess for HF -Provide care and comfort -Educate about needing lifelong care

Nursing Care During Cardiac Catheterization

-NPO PRIOR TO PROCEDURE -A sedative will be administered before the procedure to make the child sleepy o monitor o2 status -A local anesthetic will be injected in the femoral vein or artery site before cannulization of the catheter. -In catheterization with contrast dye, nursing care should emphasize intake and output. o MONITOR I/O o A Foley catheter may be used -Keep extremities straight for 4 to 6 hours with no movement; the child should be positioned flat on the back; a sandbag may be used on the extremity. o RESTRAINT MAY BE NEEDED -Check Pulses above and below the catheter site (before and after the procedure) o Femoral pulses and pedal pulses are often used -Take vital signs every 15 min post-op -Monitor for bleeding with a pressure dressing for 24 hours, then dry occlusive dressing o DO NOT REMOVE DRESSING - Monitor blood glucose levels -Auscultate for abnormal heart rate or rhythm and compare with preoperative assessment. -Monitor for temperature changes or color changes in the arm or leg that are used for the catheterization. -No tub baths for several days; showers are fine. (decreases infection risks) -Observe for signs and symptoms of infections such as redness, fever, pain, thrombus formation, dysrhythmias, bleeding, and perfusion. Fever is common following catheterization but should not last longer than 24 hours or go above 100°F. -Avoid strenuous activity such as lifting, sports, or physical education, although school is appropriate. -Notify the physician if there is any yellow or green drainage or chest pain. -Regular diet can be consumed. -Return to school within 3 days. -Follow-up appointments are essential.

Aortic Stenosis etiology assessment interventions education:

-Obstruction of blood flow from the left ventricle to the aorta -Causes include valve stenosis or a narrowing of the aorta above the valve from age or congenital disease. Stenosis or narrowing increases the workload of the myocardium of the left ventricle, leading to hypertrophy. -Scarring of the aortic valve occurs from rheumatic fever caused by group A Streptococcus. Assessment -Chest pain -Fatigue -Syncope -Murmur—systolic ejection -Shortness of breath -Narrow pulse pressure with a decrease in systolic pressures -Exercise intolerance, which may result in sudden death Increased pressure load on the left ventricle Nursing Interventions -Monitor for signs and symptoms of CHF. -Prepare for emergency measures for atrial fibrillation. -Provide caregiver teaching on procedures. -Provide caregiver home-care teaching. -Maintain pain management for chest discomfort and prostaglandin E1 drip to maintain a PDA until surgery. Caregiver Education Provide bacterial endocarditis information.

Physical Examination CV Auscultation

-S1 (lub sound) is heard at the 4th or 5th intercostal space at the midclavicular line—the closure of the mitral (heard at apex of heart) and tricuspid valve (heard at left sternal border) -S2 (dub sound) is heard at the closure of the pulmonic and aortic valves. May be split. Single S2 is due to absent flow or obstruction in flow to aortic or pulmonic valves -S3, S4 gallop—considered normal before the age of 20 years -Point of maximum impulse o area of most intense pulsation heard by a stethoscope o In children younger than 7 years, located at the left midclavicular line and 4th intercostal space o In children older than 7 years, located along the left sternal border in the 5th intercostal space -Note if bradycardia or tachycardia -Murmurs are heart sounds that are due to turbulent blood flow; assess for intensity, location, duration, and quality o Diastolic and continuous murmurs are usually pathological o Innocent murmurs (e.g., systolic, vibratory, musical) are present in many children due to thin chest walls in the child and hyperactive heart sounds

Physical Examination Respiratory System

-Shallow, rapid respirations with a rate of more than 60 breaths per minute in a content infant are abnormal and need to be investigated because this may indicate a left-to-right shifting of blood in the heart -Children with congenital heart disease often have respiratory tract infections, resulting in dyspnea with activity and fatigue. -Crackles in lungs Observe closely the infant who develops respiratory distress and cyanosis during feedings or crying because this indicates that the body is not able to deliver the oxygen needed to the tissues during these times of increased demand. -Increased work of breathing, grunting, nasal flaring, and retractions

HYPERTENSION

-Systolic BP in infants is between 70 and 90 mm Hg; adolescents reach adult levels. -BP is the force of the blood hitting against the artery walls during contraction of the heart (systole) and during relaxation of the heart (diastole). -Routine monitoring should begin around age 3 years. -Diagnosis of hypertension is not made from one reading. True BP is measured over a period of time. Hypertension is diagnosed when BP is more than 95% for age, weight, height, and sex -Primary hypertension—the child is usually less than 10 years of age. This is a disease of exclusion. -Secondary hypertension—daytime diastolic BP elevations and nighttime BP elevations. May indicate renal or organ involvement. -Risk factors include genetic causes, obesity, and secondary hypertension issues related to renal perfusion or structural anomalies. -Monitor for the correct position for BP reading: seated, relaxed, uncrossed arms and legs

RHEUMATIC HEART DISEASE

-The disease is familial -It often occurs in children between 5 and 15 years of age who are in lower socioeconomic situations. -It is prevalent in the northeastern part of the United States in winter and early spring. Rheumatic heart disease is a systemic inflammatory disease that occurs in response to a group A beta-hemolytic streptococcal infection, such as strep throat, rheumatic fever, or scarlet fever, that starts in the throat. -Left untreated or only partially treated, the infection spreads into the bloodstream, usually 20 days after the onset of the illness -If the infection remains untreated, it can lead to bacterial or fungi clumps that can break off and travel to the lungs, brain, kidneys, or other organs (rheumatic fever). o Damage to the heart valves ensues, which is rheumatic heart disease. o Antibodies are produced in response to the organism, and lesions develop in the heart and joints.

Causes of anaphalaxis in children?

-eggs -wheat -nuts - milk/dairy -shellfish

Hyperoxia Test

Also known as an oxygen challenge test, is used to determine whether the cyanosis experienced by the neonate is cardiac or respiratory in nature. a) Arterial blood gas is obtained from the right radial artery when the infant is breathing room air, then obtained again following the placement of an infant in 100% oxygen for 10 minutes. b) The infant with cardiac disease will have a 25 to 40 mm Hg Pao2 in room air that will not significantly rise in 100% oxygen, because of continued mixing of oxygenated and nonoxygenated blood. c) In an infant with pulmonary disease, the PaO2 will generally rise to more than 80 mm Hg unless there is significant pulmonary hypertension present. ****This is a screening test only, with exceptions that may occur

Cardiomyopathy assessment: interventions:

Assessment -CHF -Sweating with feedings -Dizziness -Weight loss -Murmur—gallop -Hepatomegaly with venous congestion -Fatigue -Frequent colds, pneumonia -Dysrhythmias Nursing Interventions During the acute phase, nursing interventions include: -continue IV fluids, endotracheal intubation, ventilator, ECMO/artificial heart-lung machine, diuretics, and anticoagulation therapy -ACE inhibitors have positive inotropic properties and are used because they inhibit the chemical angiotensin, which constricts arteries These ACE inhibitors may have to be taken for the rest of the child's life. -Beta blocker therapy, calcium channel blockers, and nutritional supplementation with carnitine may also be warranted -Provide valve replacement therapy postoperatively. -Provide heart transplant care if warranted. During the chronic phase: -Anticipate major complications that can include arrhythmias and CHF. -Anticipate tachycardias (fast heart rates) or bradycardias (slow heart rates). -Monitor for tachycardias, which can develop into fibrillation. -Provide nutritional supplementation with carnitine. -Monitor children prescribed ACE inhibitors. Captopril/enalapril relaxes the coronary arteries, which may cause diarrhea, muscle cramps, high potassium levels, and kidney and liver abnormalities. -Maintain diuretics except for hypertrophic cardiomyopathy. o Monitor potassium levels with the use of diuretics. o Monitor children receiving Lasix/Aldactone to reduce excess fluid in the lungs. -Monitor children receiving digoxin (Lanoxin), which is used to improve cardiac function in those children with a dilated cardiomyopathy by enhancing the pumping effort of the heart o Lanoxin (Digoxin) or verapamil should not be considered for treating sustained tachycardia until ventricular tachycardia has been ruled out -Monitor for bradycardias when the conduction is interrupted or totally blocked and the child may need to have a pacemaker. -Monitor for thromboembolism, which may occur because of interrupted blood flow -An internal cardioverter/defibrillator (ICD) is capable of shocking life-threatening dysrhythmias During the critical phase, those with irreversible heart damage and persistent poor function may require a heart transplant

Congestive Heart Failure assessment diagnostic testing

Assessment -Edema of the face, hands, and feet, or weight gain -Cardiac enlargement -Gallop rhythm, changes in heart rate -Tachycardia -When completing four limb blood pressures, the blood pressure will be higher in the arms than in the legs. -Cyanosis -Tachypnea -Shortness of breath -Crackles -Fatigue -Poor appetite -Poor growth, FTT -Sweating with minimal activity Diagnostic Tests -History and physical examination -Chest x-ray indicates an enlarged heart, increase in pulmonary vascularity, and edema -Echocardiogram defines anatomy and physiology EKG indicates an enlarged atrium -Urine and blood tests evaluate blood gas, anemia, and electrolyte balance

HTN assessment

Assessment -The left side of the heart works harder and may thicken. -Hypertension can result in stroke and often affects the child's vision because of increased pressure in the blood vessels of the eye. Nursing Interventions -Aim is for reduction of the BP to less than 95% and resolution of end-organ dysfunction. -Encourage routine exercise. -Encourage weight loss if indicated. -Educate the child/caregiver on healthy meal choices with lower intake of salt, saturated fat, trans-fatty acids, cholesterol, and carbohydrates, and increased dietary fiber intake. -Emergency treatment of acute hypertension is the administration of labetalol (0.1 mg/kg) -Chronic hypertension is usually treated with ACE inhibitors

ACQUIRED CONGENITAL HEART DISEASE Cardiomyopathy three types of cardiomyopathy: dilated, hypertrophic, and restrictive.

Cardiomyopathy is a chronic progressive disease that occurs within the heart muscle itself (primary or a genetic defect) or as a result of another disease or toxin that affects all organs, including the heart, such as infections, low blood flow to the heart, decreased oxygen levels, or high BP Ventricles are primarily affected and become enlarged, thickened, and stiff. -Child is born with normal heart anatomy. -Heart muscle loses the ability to pump effectively; heart failure and cardiac dysrhythmias occur Dilated or congested—enlarged heart, weak and ineffective pump -Most common form -Carnitine deficiency -Develop heart failure -Blood clots due to slow blood flow -Dysrhythmias Hypertrophic—most common inherited heart defect in the absence of another cardiac disease with left ventricle enlarged; found in infants of diabetic mothers -Enlarged heart -Diastolic dysfunction -Exercise intolerance -Fainting -Leaking valves caused by increase septal and ventricle muscle Restrictive—heart muscle becomes rigid and fails to relax; rarest type -Diastolic dysfunction -Fatigue -Shortness of breath This is the leading cause of heart transplants in children despite being relatively rare. Causes include: -Chemotherapy -Viral infections such as Coxsackie B -Genetic factors—fatty acid oxidation -Metabolic disorders -Persistent rhythm abnormalities

Cardiomyopathy education

Caregiver Education -Aimed at the intensive care necessary for a child with a life-threatening condition -Possible terminal status of the child -Frequent echocardiograms to monitor the size and function of the heart -Psychological as well as physical preparation -Activity restrictions to prevent overstimulation of the heart -Allow the child to discuss feelings, such as concerning the restriction of activity in the previously active child -Encourage participation in cardiomyopathy programs Anticipatory grieving of the parents is expected in this life-threatening situation

Atrial Septal Defect Caregiver Education:

Caregiver Education -Educate on the care of the child after cardiac catheterization, which includes monitoring for bleeding at the catheter insertion site. -Surgical closures with a patch may result in arrhythmias. -Monitor for an increase in temperature and changes in color or temperature of the catheterized extremity. -The child may need to be prescribed blood thinners for several months after the procedure. -Educate on risk for embolization because of dislodgement of the patch. -The child may need to take antibiotics for dental work after treatment -Monitor for cyanosis, poor weight gain, respiratory distress, lethargy, and bleeding at insertion site after the procedure. -Provide caregiver information related to the schedule of yearly close follow-up appointments with cardiologists.

CONGENITAL HEART DISEASE WITH MIXED DISORDERS Hypoplastic Left Heart

Caused by underdevelopment of the left side of the heart, aorta, aortic valve, left ventricle, and mitral valve. This leads to pulmonary venous congestion and edema Assessment -Asymptomatic until ducts close -Skin ashen in color -Rapid and difficult breathing HUGE O2( PROBLEMS) -Difficulty feeding -Usually fatal within the first days or months of life unless treated Nursing Interventions -Maintain prostaglandin E1 infusion to keep PDA open. -Provide nursing preparation for surgery—Norwood three-stage procedure to increase ventricular function -Provide caregiver preparation for the severity of the condition. -Anticipate possible transport out of the facility for a heart transplant Caregiver Education -Lifelong follow-up with the pediatric cardiologist -Long-term heart medications -Bacterial endocarditis protocols

Diagnostic Tests

Chest X-ray produces images of the heart, lungs, airways, blood vessels, and the bones of the spine and chest -Pulmonary vascularity -Cardiac size and shape -Lung vascular markings -Position of the stomach Electrocardiogram (ECG or EKG) -Useful to determine conduction issues -Needs to be evaluated by a cardiologist Echocardiogram (Echo) -Ultrasound of the heart -Noninvasive test that indicates structure, size, flow patterns, function, and the blood vessels attached to the heart Angiography -Visualizes the structure and function of the ventricles -Dye injected via a catheter Cardiac Catheterization -An invasive diagnostic procedure that takes place in a cardiac catheterization laboratory -Cannulization of a vein, usually in the groin or neck area, to pass a catheter into the heart or major vessels of the heart after the child is anesthetized -Advanced with the use of x-ray fluoroscopy -Interventional catheters used to open valves or septum in the heart -Diagnostic catheters used to measure internal pressures or to visualize circulation -Electrophysiological catheters used to evaluate conduction pathways or alter accessory pathways to avoid surgical intervention; can be used to measure pressures within the ventricles and vessels -Cardiac catheterization can be used to perform myocardial biopsies -Temporary measures to delay reparative surgeries Biopsy of the Myocardium -Frequent in heart transplants -Monitors for rejection Pulmonary Artery Banding -Palliative measure to decrease pulmonary blood flow -Prevents pulmonary hypertrophy and pulmonary hypertension -Precursor to cardiac surgery, such as in large VSDs

Atrial Septal Defect Diagnostic tests: Medical management: Surgical repair: Interventions:

Diagnostic Tests -Echocardiogram shows an enlargement of the right atrium and right ventricle. -EKG shows thickening of the heart muscle. -Chest x-ray shows an enlargement of the heart and an increase in blood flow to the lungs. -Transesophageal ultrasound takes a picture of the heart to visualize blood vessels or heart disease or conditions. Medical Management -Administer medications, such as digoxin and diuretics, to decrease the load on the right side of the heart. -Surgical closure may increase the incidence of pulmonary hypertension, resulting in dysrhythmias, and surgical clients may experience a greater mortality risk. -Provide pain medications as ordered to decrease oxygen consumption Surgical Repair -Closure with cardiac catheterization—trans-septal closure across the defect with transthoracic echocardiography -Surgical repair can also be performed by patching with the child's own tissue, bovine tissue, or artificial structures Nursing Interventions -Monitor feeding tolerance; offer small, frequent feedings with infants and small children. -Monitor for signs and symptoms of CHF. -Monitor for increased work of breathing, grunting, retractions, and flaring. -Monitor growth patterns.

Patent Ductus Arteriosus Diagnostic Tests: Interventions:

Diagnostic Tests -Wide pulse pressures—low diastolic pressures -Increased vascular markings on the chest x-ray are a late sign due to enlarged heart -Poor oxygen saturation -Bounding pulses -Enlarged heart -Prolonged capillary filling time -Hyperactive precordium -An echocardiogram will show increased enlargement of left heart chambers Interventions Provide postoperative care after coil embolization or ligation. Decrease work of breathing by providing frequent rest periods that maximize oxygen delivery to the tissues Provide frequent rest periods. Do not cluster care because clustering care can result in an increased oxygen demand during the clustering. Provide strict intake and output fluid restrictions and diuretics as ordered. Dopamine may be required. Administer digoxin (Lanoxin) as ordered. Maintain indomethacin and ibuprofen administration, which is dependent on weight, renal function, and gestational age. Monitor urine output. Monitor laboratory tests for thrombocytopenia. Monitor daily weights. Monitor tolerance of feedings. Provide preparation of child for surgical closure. Monitor closely following postsurgical closure. Monitor wound care.

KAWASAKI DISEASE

Etiology -Known as mucocutaneous lymph node syndrome, is the leading cause of acquired heart disease in children in the developed world. SYSTEMIC VASCULITIS -Acute febrile inflammation of the vasculature and primarily affects children younger than 5 years, with a peak incidence in children younger than 2 S/S -Persistent fever (5 days or more spiking to 104°F (40°C) (not helped with antipyretics) -Conjunctivitis without exudate (not bacterial or viral) -Painful joints -Red lips/cheeks, strawberry tongue, congested oral pharynx -Enlarged lymph nodes—cervical lymphadenopathy -Edematous and red (erythema) of hands and feet -Increased WBC, C-reactive protein, and other inflammatory markers -Extreme irritability -Cardiac involvement—myocarditis, pericarditis, coronary artery aneurysm, valvular regurgitation, systemic artery aneurysms

Atrial Septal Defect etiology: assessment:

Etiology -ASDs occur between the right and left atrium when the two septal walls fail to form o The septal walls normally close between weeks 4 and 8 of fetal development but may remain open up to 1 year -Defect allows more blood to flow into the right side of the heart from the left atrium, increasing pulmonary blood flow to the lungs through a hole in the atria. o May result in pulmonary hypertension with right atrial enlargement that can lead to right ventricular hypertrophy. Assessment -Heart murmur is known as ejection systolic murmur because of the blood being forced through the pulmonary valve -Atrial dysrhythmias -Higher incidence of emboli -Recurrent respiratory infections -Few symptoms in children -Shortness of breath -Tires easily with playing -Poor feeding -Poor growth if CHF develops due to left-to-right shunting -Liver enlargement or congestion

Acquired Heart Disease ASSESSMENT general history

General History -Comprehensive history and physical examination -Detailed family history, including the history of congenital heart disease or genetic disorders -Prenatal history, including rapid or slow heart rate in utero, diabetes, or lupus -Detailed history of exposure to infections, exposure to environmental teratogens such as alcohol, cocaine, phenytoin, or lithium -Gestational age at birth -Feeding history & habits, weight gain/loss (in baby) -Attainment of developmental milestones/cognitive growth -Respiratory status Pain -Chest pain is a rare symptom in the pediatric cardiac client

HYPERLIPIDEMIA

Hyperlipidemia, in which the blood has high concentrations of low-density lipoprotein (LDL) and low concentrations of high-density lipoprotein, is a high-risk factor for cardiovascular disease -May be present early in life. -Comorbid with high BP, type I or II diabetes, smoking, overweight, and inactivity -if the pediatric client's LDLs are greater than or equal to 130 mg/dL, the client has an increased risk for complications resulting from hyperlipidemia -Dietary and behavioral changes are necessary for long-term benefits in reduction of cholesterol and prevention of complications. -Dietary recommendations will only decrease the cholesterol levels by a small percentage. Controllable factors need to be addressed throughout life: weight, smoking, hypertension, and inactivity. Noncontrollable factors are hereditary factors that significantly impact the incidence of hyperlipidemia. Treatment is aimed at controlling manageable factors and the use of statins and niacin for hereditary factors

Vital signs: Infant: Toddlers: Preschoolers:

Infant Pulse: 120-160 bpm RR: 30-60 breaths per minute BP: 50/30 to 75/45 mm Hg Toddler Pulse: 70-110 bpm RR: 20-30 BP: 90/55 to 105/70 Preschooler Pulse: 65-110bpm RR: 20-25 BP: 95/60 to 110/75

HYDROCHLOROTHIAZIDE (DIURIL)

Inhibits the cotransport of sodium (Na) and chloride (Cl), thus decreasing sodium chloride (NaCl) reabsorption from the kidneys -Give with meals to prevent gastric upset -Avoid exposure to sunlight -take with food -Notify physician if the child is dehydrated; vomiting and diarrhea -Avoid NSAIDs, as they decrease the effectiveness of this drug -Administer medication in the morning. -Monitor for rash which may be Stevens-Johnson syndrome.

BUMETANIDE-BUMEX

Loop diuretic—acts mainly by inhibiting Na reabsorption in the nephron at the thick ascending limb of Henle's loop -Monitor for electrolyte imbalances, especially potassium; may potentiate ototoxic drugs such as aminoglycosides -Report signs of dehydration, vomiting, and diarrhea -Avoid exposure to sun -May be instructed to feed foods high in potassium, such as bananas

FUROSEMIDE (LASIX)

Loop diuretic—acts mainly by inhibiting sodium and chloride reabsorption in the nephron at the thick ascending limb of Henle's loop. Increases excretion of water, sodium, chloride, magnesium, potassium, and calcium. -Monitor electrolyte levels, especially potassium; monitor for ototoxicity; may develop renal calculi with prolonged use. -May be instructed to feed foods that are high in potassium, such as bananas -Give with food—if given once a day, give with breakfast; if twice a day, give at evening meal but not close to bedtime to prevent the need for repeated bathroom trips -Report signs of dehydration, allergic responses, shortness of breath. -Monitor for rash which may be Stevens-Johnson syndrome.

Physical Examination Murmur classifications (6 types)

Murmurs grade 1-6 (1 being softest, 6 being loudest). Not every murmur is a sign of valve disease 1. Holosystolic Shunting of blood from an area of higher pressure to an area of lower pressure such as in a ventricular septal defect, which are harsh murmurs, and atrioventricular regurgitation, which are soft murmurs 2. Ejection systolic As blood flow increases in systole there is turbulence through restricted flow patterns, such as in pulmonary stenosis or aortic stenosis 3. Diastolic Regurgitation of blood flow from the aorta or pulmonary artery into the ventricles because of pulmonary or aortic insufficiency; always abnormal 4. Systolic and diastolic Result of pressure differences between two structures, such as in patent ductus arteriosus 5. Pansystolic Heard with congestive heart disease or severe regurgitation of mitral or tricuspid valves 6. Continuous Heard with patent ductus arteriosus or atrioventricular malformations

CONGENITAL HEART DISEASE WITH INCREASED PULMONARY BLOOD FLOW Patent Ductus Arteriosus normal function: etiology/assessment:

Normal function -The ductus arteriosus connects the aorta to the pulmonary artery outside of the heart. Left-to-right shunting occurs through the duct that will then connect the pulmonary artery (nonoxygenated) with the aorta (oxygenated) -Smooth muscle tissues normally close within a few hours to days after birth -Following birth, peripheral vascular resistance decreases, and the ducts close because of the production of bradykinin in the lungs and an increase in neonatal blood oxygen levels. An increase in oxygen levels causes muscular constriction around the ducts The severity of the disease depends on the gestational age of the neonate, the size of the ductal opening, and the degree of pulmonary vascular resistance ETIOLOGY/ASSESSMENT PDA may be indicated by: -Heart murmur—a systolic murmur, mid-to lower-left sternal border, washing machine sound o Some infants will have no murmur -"Wet"-sounding breath sounds known as crackles -Tachypnea -Increased work of breathing, or apnea -Poor feeding -Poor weight gain and growth pattern -Fatigue -Sweating with feeding -Excessive fluid weight gain

Tetralogy of Fallot interventions: education:

Nursing Interventions -Allow for adequate rest periods. o Provide oxygen to reduce pulmonary vasoconstriction, but note that this will not improve oxygen saturation or alleviate the cyanosis -The nurse should continue sedative or morphine sulfate to decrease agitation and prevent inconsolable crying, which will decrease pulmonary blood flow and increase the incidence of tet spells. -The nurse should maintain fluid balance to prevent fluid overload, which increases the workload on the heart. -The nurse should maintain vasopressors to increase systemic vascular resistance and prostaglandin E1 drip as ordered to keep PDA open -The nurse should prepare the family for the possibility of multiple surgeries, beginning with a VSD patch and resection to alleviate the PS, and the possibility of additional procedures such as a modified Blalock-Taussig procedure if the infant has severe PS or PA Caregiver Education -Teach the family to calm the infant by holding the infant over the caregiver's shoulders with the child's knees drawn up toward the chest. This will increase the blood flow to the lungs. -Support the family in asking questions related to physical activity restrictions and pharmacological regimens. -Support the caregiver's access to a pediatric cardiologist for the child's lifelong care

Bacterial endocarditis interventions education

Nursing Interventions -If untreated, can lead to bacterial or fungi clumps that can break off and travel to the lungs, brain, kidneys, or other organs. -Monitor for stroke, poor pumping action. -Maintain intensive antibiotic therapy. -Monitor for fluid imbalances caused by nausea, vomiting, and diarrhea from antibiotics. -Monitor for CHF symptoms such as shortness of breath, poor weight gain, and edema. -Monitor for valve failures and cardiac failure. -Monitor for septic emboli to the lungs. -Prepare the child for transplanted valves. Caregiver Education -High-risk children with past valve damage, repairs, or defects are at an increased risk and may be treated with prophylactic antibiotics. -Prepare caregiver for the possibility of surgery for valvular replacement. -Maintain dental health through regular checkups starting as soon as the child's teeth begin to erupt.

Congestive Heart Failure interventions: education:

Nursing Interventions -Maintain oxygenation by elevating the head of the bed. -Decrease oxygen consumption by minimizing stimulation and decrease work of breathing. -Monitor intake and output daily weights at the same time, with the same scale, with the same clothes. -Monitor breath sounds. -Provide supplemental oxygen. -Cluster care to decrease oxygen consumption. -Use of high-calorie formula or the use of medium-chain triglycerides that enhances the calories without providing additional fluid volume. -Administer pharmacological therapy—Lanoxin therapy, diuretic therapy, and inotropic agents—to maximize cardiac output and eliminate excess fluid. Caregiver Education -Surgery may need to be performed to correct congenital heart defects. -Provide discharge instructions on observation for tachypnea and increased work of breathing. -Maintain diuretics as ordered -Avoid high-salt-content foods. -Monitor weight: same scale, same time of day, same clothes. -Elevate the head of the bed. -Provide frequent rest periods by clustering care.

Tetralogy of Fallot With Pulmonary Atresia

Occurs with chromosome arm 22 deletion BLOOD HAS TROUBLE FLOWING TO THE LUNGS TO PICK UP OXYGEN TO CARRY TO THE REST OF THE BODY. ***EMERGENCY SURGERY RIGHT OUT OF THE WOMB Assessment -Profound cyanosis -Peripheral pulses and BP stable until pulmonary blood flow results in bounding pulses -Normal first heart sound, single second heart sound -PDA murmur may be heard -Delayed growth and development Nursing Interventions -respiratory and cardiac status -Monitor EKG -Note murmurs -Monitor for pain, hemorrhage, and thrombospasms. -Maintain oxygenation through monitoring of pulse oximetry and hydration through strict intake and output recordings Caregiver Education -Explain the importance of follow-up with a pediatric cardiologist and the need for future procedures and catheterizations. -Exercise capacity is limited. -Maintain caloric intake. -Monitor for signs and symptoms of heart failure. -Educate on bacterial endocarditis prophylaxis.

Tetralogy of Fallot (PROV) assessment: clinical indicators:

P: pulmonic stenosis R: right ventricular hypertrophy O: over-riding aorta V: ventricular septal defect Assessment -"Tet" spells—sudden, marked increase in cyanosis; syncope; can lead to hypoxic brain injury and death o Children may squat during a tet spell to improve blood flow from the legs back to the brain and vital organs, increasing systemic vascular resistance o Pink tet spells are due to left-to-right shunting---mixing of oxygenated w/ non-oxygenated blood -Increased cyanosis with irritability and crying w/ Increased irritability because of lack of oxygen o Clubbing of fingers o Poor growth in response to chronic lack of oxygen Clinical indicators: -PDA causes increased blood flow to the lungs -Heart murmur may be soft to loud -Failure to gain weight/ FTT -Fainting/syncope -Dyspnea on exertion -Polycythemia (increase in the number of red blood cells in the body) -Boot-shaped heart, right ventricular hypertrophy, and small pulmonary artery -As PDA closes, cyanosis increases The degree of cyanosis is dependent on the restriction of blood flow to the lungs -Child remains pink with a low degree of mixing; known as "pink tet"

SPIRONOLACTONE (ALDACTONE)

Potassium-sparing diuretic antagonizes aldosterone receptors of the distal convoluted tubule (DCT) -Monitor kidney function with strict intake and output (I&O) -Watch for alterations in potassium level -Notify physician if the child develops diarrhea, vomiting, or signs of dehydration (decreased urine output, dry skin, and mucus membranes, irritability, tachycardia) -Give the missed dose as soon as discovered o Do not double up on the doses. -Monitor for a rash which may be Stevens-Johnson syndrome.

Vital signs cont School-age: (3 age breaks) Adolescent:

School-age Age 6 Pulse: 95bpm RR: 20-25 BP: Systolic: 95 Diastolic: 55-70 Age 9 Pulse: 95bpn RR: 17-22 BP: Systolic: 105-110 Diastolic: 60-75 Age 12 Pulse: 85bpm RR: 17-22 BP: Systolic: 118-120 Diastolic: 62-76 Adolescents Pulse: 55 to 100 bpm RR: 15-20 breaths/min BP: Systolic blood pressure less than 120 mm Hg

SHOCK

Shock is the inability of the body to maintain adequate blood flow and oxygen supply to the tissues needed for metabolism Hypovolemic—profound dehydration or loss of blood with the decrease in hemoglobin; chest x-ray shows normal heart Cardiogenic—damage to the heart muscle resulting in a failure of the pump Septic or distributive—shifting of fluids from the intravascular space to the extracellular space; caused by blood vessel dilation, often due to sepsis Assessment -Confusion or lack of alertness -Loss of consciousness -A sudden, rapid heartbeat -Sweating -Pale skin -A weak pulse---can see tachycardia and bradycardia -Rapid breathing -Decreased or no urine output -Cool hands and feet Nursing Interventions -Provide emergency interventions. -Maintain medications, IV access, and fluids to increase volume and BP. -Maintain oxygen supplementation. Caregiver Education -Provide education to call 911 for signs and symptoms of shock. -Provide education related to intake and output of the child.

Patent Ductus Arteriosus Surgical management: Child and caregiver education:

Surgical Management -Ligation of the duct through a posterior-lateral thoracotomy for infants requiring increasing respiratory or cardiovascular support -A stainless-steel coil occlusion of the PDA is also used through cardiac catheterization Education -Closely monitor oral intake. -Closely monitor diapers for urine output. -Monitor for signs and symptoms of irritability and/or lethargy. -Keep cardiology appointments. -Continue diuretics.

CONGENITAL HEART DISEASE WITH DECREASED PULMONARY BLOOD FLOW Tetralogy of Fallot etiology

This defect is associated with 22 deletion chromosome disorders. Results in right-to-left shunting of blood in the heart, which recirculates venous blood to the body without it being oxygenated in the lungs Four separate defects: - VSD between right and left ventricles - Obstructive right ventricular outflow—PS or obstruction - Overriding aorta lies directly over VSD and takes blood from both the right and left ventricles; permits oxygenated blood to rest of body -Secondary thickening of the right ventricle (right ventricular hypertrophy) due to restrictive outflow

Congestive Heart Failure

With CHF, the heart cannot supply enough oxygenated blood to meet the metabolic needs of the body tissues either at rest or work -The heart may fail with: o high afterloads (COA, AS) o valvular regurgitation o impaired myocardial contractility, as in cardiomyopathy -Right-sided heart failure—right ventricle cannot pump blood into the pulmonary artery, resulting in increased pressure in the right atrium and the systemic venous system. -Left-sided heart failure—blood is backed into the left atrium and the pulmonary veins, resulting in increased lung congestion

Physical Examination CV: Color

cyanosis is the bluish discoloration of the skin, nail beds, tongue, or mucosa. -Cyanosis is always an abnormal finding. -Cyanosis is also influenced by anemia (low hematocrit) or polycythemia (high hematocrit). -Central cyanosis seen by bluish discoloration of mucous membranes, tongue, circumoral, or core body is due to problems with the heart or lungs. -Elevated levels of deoxygenated hemoglobin, which is blue, are present. -Peripheral cyanosis (acrocyanosis) is often due to interruption in blood flow to the extremity. -Acrocyanosis is normal during the transition of the newborn. -Shock can be seen with a prolonged capillary refill time, and pallor is associated with poor perfusion -Pulse oximeter readings of 78% or lower with normal hemoglobin levels will result in outward signs of cyanosis -Anemia may not show cyanosis because of decreased levels of hemoglobin; polycythemia may show cyanosis with a smaller amount of deoxygenated hemoglobin -Skin that is pale, mottled, or gray in appearance indicates poor perfusion. -Urine output is indicative of perfusion to the kidneys

SUBACUTE BACTERIAL ENDOCARDITIS etiology assessment

results from a bacterial infection or the introduction of an infective agent through any invasive procedure such as surgery or through a dental cleaning -Entry of organisms can occur with simple cuts, dental work, teeth brushing, respiratory infections, or catheter placement. -The endocardium of the heart becomes inflamed with Viridans streptococcus, Streptococcus mutans, Streptococcus sanguis, or Staphylococcus. o Bacteria or fungi that have entered the body through the mouth, respiratory system, or bloodstream invade and attach themselves to damaged areas of the endocardium that allow the bacteria to easily attach and multiply. -Healthy hearts do not develop endocarditis, but those children with damaged heart valves or heart disease are more susceptible Assessment Vague symptoms such as low-grade fever; a high fever indicates an acute illness -Fatigue -Cough -Heart murmur -Chills -Shortness of breath -Joint pain -Loss of appetite and weight loss -Flank pain -Petechiae