OB Chap 26 The child with a cardiovascular disorder

Describe the treatment of this. Hypoplastic left-sided heart syndrome

Foramen ovale and ductus arteriosus must be kept open until heart transplant can be done

Describe the most effective treatment of this. Hyperlipidemia

Diet and exercise

Hypoplastic left-sided heart syndrome

Foramen ovale and ductus arteriosus must be kept open until heart transplant can be done

Shunt

Flow of blood through an abnormal opening

What should be included in teaching related to these after heart transplant? Immunizations

Should be withheld because of use of immunosuppressive drugs after surgery

Identify symptoms associated with this. Coarctation of the aorta

Significant difference in blood pressure between upper and lower extremities

Low-density lipoproteins (LDLs)

Carry lipids to the cell

Cyanotic and acyanotic defects

Categories of congenital heart defects

The nursing goals significant to the care of children with heart failure are to

1. reduce the work of the heart 2. improve respiration 3. maintain proper nutrition 4. prevent infection 5. reduce the anxiety of the parent and 6. support growth and development

Two nurses should check the dose of digoxin before administration.

A dose exceeding 0.05 mg should be reconfirmed with the health care provider

Atrial septal defect

Abnormal opening between right and left atria

Identify symptoms associated with this? Kawasaki disease (KD)

Abrupt sustained fever, strawberry tongue, peeling of the palms and soles

Congenital heart defects may be caused by genetic factors, maternal facctors such as drug use or illness or environmental factors.

Acquired heart disease occurs after birth as a response to a defect or illness

Ventricular septal defect (VSD)

An opening between the right and left ventricles of the heart

Describe the treatment of this. Rheumatic fever (RF)

Antimicrobial therapy

What is the result of this? Right-sided heart failure

Backup of blood in the venous system

What is the result of this? Left-sided heart failure

Backup of fluid into the lung

Describe the treatment of this. Tetralogy of Fallot

Blalock-Taussig procedure

Identify the four defects associated with tetralogy of Fallot. Pulmonary artery stenosis, right ventricular hypertrophy, ______, ventricular septal defect (VSD)

Dextroposition of the aorta

High-density lipoproteins (HDLs)

Carry lipids to liver for excretion

What nursing action should be taken before giving this? Lanoxin

Check apical pulse for 1 full minute

Thoracotomy

Chest incision

Congestive heart failure (CHF)

Condition where cardiac output is inadequate to meet the metabolic needs of the body

Coarctation of the aorta

Constriction of the aortic arch

Identify symptoms associated with this. Defects that decrease pulmonary blood flow cause

Cyanosis

Identify symptoms associated with this. Tetralogy of Fallot

Cyanosis, clubbing of fingers/toes, squatting position, frequent respiratory infections

Describe the treatment of this. Atrial septal defect

Dacron patch over defect and aspirin therapy

Identify the four defects associated with tetralogy of Fallot. Pulmonary artery stenosis, right ventricular hypertrophy, ______, ventricular septal defect (VSD)

Dextroposition of the aorta

Describe medications used for a child with this. Congestive heart failure (CHF)

Digoxin (Lanoxin) and furosemide (Lasix)

What should be included in teaching for parents of children with this? Congenital heart disease

Do not restrict normal activity, avoid competitive sports, do not overprotect the child

Identify symptoms associated with this. Hypoplastic left-sided heart syndrome

Dyspnea, weak pulses, murmur

Identify symptoms associated with this. Hypoplastic left-sided heart syndrome

Dyspnea, weak pulses, murmur

Describe the treatment of this. Hypertension

Education on proper diet and exercise

Describe the treatment of this. Hypertension

Education on proper diet and exercise

Hyperlipidemia

Excessive lipids in the blood

Patent ductus arteriosus (PDA)

Failure of the ductus arteriosus to close after birth

Identify the characteristic symptoms of this in children. Heart disease

Failure to thrive, cyanosis, tachypnea, clubbing of fingers

Describe the treatment of this. Patent ductus arteriosus (PDA)

Indomethacin therapy and surgical closure

Patent ductus arteriosus (PDA)

Indomethacin therapy and surgical closure

Kawasaki disease (KD)

Inflammation of the vessels in the cardiovascular system

Identify symptoms associated with this. Patent ductus arteriosus (PDA)

Machinery-type murmur, wide pulse pressure, dyspnea with exertion

Describe the treatment of this. Kawasaki disease (KD)

Intravenous immunoglobulin (IVIG) and aspirin therapy

Defects that decrease pulmonary blood flow

Issues that allow unoxygenated blood to enter the aorta

Defects that increase pulmonary blood flow

Issues that causes blood to recirculate through the lungs before leaving the heart

Defects that restrict ventricular blood flow

Issues that occur because of stenosis of a vessel

Defects that cause mixed pathologic conditions

Issues where multiple abnormalities are present

Identify symptoms associated with this. Ventricular septal defect (VSD)

Loud, harsh murmur and a systolic thrill

Ventricular septal defect (VSD)

Loud, harsh murmur and a systolic thrill

Manifestations of RF

Manifestations of RF

Identify symptoms associated with this. Rheumatic fever (RF)

Migratory polyarthritis, chorea, inflammation of the heart

Identify symptoms associated with this. Rheumatic fever (RF)

Migratory polyarthritis, chorea, inflammation of the heart

Acquired heart defects

Occur after birth

Rheumatic fever (RF)

Occurs after an untreated group A beta-hemolytic streptococci infection

Describe the treatment of this. Coarctation of the aorta

Percutaneous balloon angioplasty and stents or surgical resection

Congenital heart defects

Present at birth

Nutritional guidance

Prevent anemia, maintain hydration, promote growth and development

What are the goals of this for children with heart defects? Nutritional guidance

Prevent anemia, maintain hydration, promote growth and development

What is the goal of treatment for children with this? Rheumatic fever (RF)

Prevent permanent cardiac damage

Describe the diet for the child with this. Congestive heart failure (CHF)

Small frequent feedings with high-calorie formula

Describe the treatment of this. Ventricular septal defect (VSD)

Spontaneous closure or surgical closure

Ventricular septal defect (VSD)

Spontaneous closure or surgical closure

Identify symptoms associated with this. Paroxysmal hypercyanotic episodes

Spontaneous cyanosis, respiratory distress, weakness, syncope

Identify symptoms associated with this. Paroxysmal hypercyanotic episodes

Spontaneous cyanosis, respiratory distress, weakness, syncope

Hemodynamics

Study of blood circulation

Identify early symptoms associated with this in infants. Congestive heart failure (CHF)

Tachycardia, fatigue with feeding, weight gain, dyspnea

Tet Position

Tet Position

The Normal Heart and Various Congenital Heart Defects

The Normal Heart and Various Congenital Heart Defects

Hypoplastic left-sided heart syndrome

Underdevelopment of the left side of the heart

Jones criteria

Used to diagnose rheumatic fever (RF)

Hypothermia

Used to reduce need for oxygen during heart surgery

A congenital heart defect can cause an increase in pulmonary blood flow,

a decrease in pulmonary blood flow or an obstruction of blood flow.

A difference in the blood pressure between arms

and the legs is characteristic of coarctation of the aorta

Signs of congestive heart failure in infants include tachycardia,

at-rest fatigue, during feedings and perspiration around the forehead

young infants should not have a fat-restricted diet

because fat is needed for CNS growth and development.

Signs and symptoms of congenital heart abnormalities in infants include dyspnea, difficulty with feedings,

choking spells, recurrent respiratory infections, cyanosis, poor weight gain, clubbing of the fingers and toes and heart murmurs

The major Jones criteria diagnostic of rheumatic fever include polyarthritis,

erythema marginatum, Sydenham's chorea, and rheumatic carditis

Hypercyanotic "tet" spells are relieved by

placing the child in a knee-chest position

The defects in tetralogy of Fallot include pulmonary artery stenosis, hypertrophy of the

right ventricle, dextroposition of the aorta, and a ventricular septal defect

Chest tube drainage systems must always be kept below

the level of the chest

Congenital heart defects that result in a recirculation of blood

to the lungs do not usually produce cyanosis as a clinical sign

Nonpharmacological Approach to HTN

» Aerobic exercise » Reduce sedentary activities » Weight reduction » Dietary management » Adequate intake of potassium and calcium » Avoid smoking and those who smoke

General Treatment and Nursing Care

» Assorted medical and surgical treatments are currently available » After the procedure, the nursing care involves ˃ Monitoring vital signs ˃ Observing for thrombosis formation ˃Neurovascular checks of the limb ˃ Emotional support to child and family

Hyperlipidemia (cont.)

» Children with two consecutive blood cholesterol levels exceeding 170 mg/dL should be followed closely and offered nutritional guidance ˃ Parental history of cholesterol levels exceeding 240 mg/dL or a family history of early cardiac death (under age 55 years) should have their cholesterol levels tested » Dietary intake of no more than 300 mg of cholesterol per day and no more than 30% total dietary calories from fat are recommended ˃ Children younger than 2 years of age should not have a fat-restricted diet, because calories and fat are necessary for CNS growth and development

Congenital Heart Disease (cont.)

» Classification » Two categories ˃ Cyanotic ˃ Acyanotic » Blood always flows from area of high pressure to an area of low pressure and it also takes the path of least resistance

Tetralogy of Fallot (cont.)

» Cyanosis increases with age » Clubbing of fingers and toes ˃Due to chronic hypoxia » Child rests in a "squatting" position to breathe more easily by altering systemic venous return • Prevalent symptoms include - Feeding problems - Failure to thrive - Frequent respiratory infections - Severe dyspnea on exertion - Polycythemia develops to compensate for the lack of oxygen

Diagnosis

» Diagnosis confirmed by chest X-ray that shows a typical boot-shaped heart » Additional tests include ˃ EKG ˃ 3-D echocardiography ˃ Cardiac catheterization

Safety Alert

» Early signs of CHF in infants that should be reported ˃ Tachycardia at rest ˃ Fatigue during feedings ˃ Sweating around scalp and forehead ˃Dyspnea ˃ Sudden weight gain

Signs Related to Suspected Cardiac Pathology

» Failure to thrive and/or poor weight gain » Cyanosis, pallor » Visually observed pulsations in the neck veins » Tachypnea, dyspnea » Irregular pulse rate » Clubbing of fingers » Fatigue during feeding or activity » Excessive perspiration, especially over forehead

CHF Goals of Treatment

» Goals ˃ Reduce the work of the heart ˃ Improve respiration ˃ Maintain proper nutrition ˃ Prevent infection ˃ Reduce the anxiety of the patient ˃ Support and instruct the parents

Systemic Hypertension (cont.)

» Heredity, obesity, stress, and poor diet and exercise patterns are some of the contributing factors to the development of HTN » HTN more prevalent in children whose parents have high blood pressure

Defects that Cause Mixed Pathology

» Hypoplastic left heart syndrome ˃ Underdevelopment of the left side of the heart ˃ Usually results in an absent or nonfunctional left ventricle and hypoplasia of the ascending aorta ˃ Can be diagnosed before birth and infant is placed on a heart transplant list early

Defects that Cause Mixed Pathology (cont.)

» Hypoplastic left heart syndrome (cont.) ˃ Initial survival depends on a patent foramen ovale and ductus arteriosus to provide a pathway for oxygenated blood to the general body system ˃ Symptoms include +A grayish-blue color of the skin and mucous membranes +Signs of CHF +Dyspnea +Weak pulses +Cardiac murmur

Coarctation of the Aorta (cont.)

» If left untreated ˃Hypertension ˃ Congestive heart failure ˃ Infective endocarditis may occur » After surgery, the nurse should observe for ˃Hypertension ˃ Abdominal pain associated with nausea and vomiting ˃ Leukocytosis ˃GI bleeding or obstruction » Treatment includes ˃ Antihypertensive drugs ˃ Steroids ˃NG tube for decompression of the stomach

Nursing Tip

» In congenital heart disease, cyanosis is not always a clinical sign

General Treatment and Nursing Care (cont.)

» Instruct parents that children with congenital heart disease should avoid competitive sports because the pressure for a team win can interfere with the child's need to stop activity if specific symptoms arise » Nutritional guidance aimed at preventing anemia and promoting optimal growth and development » Vacations to high altitudes or very cold environments may cause adverse responses in a child who is already hypoxic or has cardiac problems

Paroxysmal Hypercyanotic Episodes

» Known as Tet spells » Occur during the first 2 years of life » Spontaneous cyanosis, respiratory distress, weakness, and syncope occur » They can last up to a few hours and are followed by lethargy and sleep » Place child in knee-chest position when Tet spell occurs

ASD - ↑Pulmonary Blood Flow

» Left to Right Shunt - area of high pressure to area of low pressure » Most patients do not have symptoms. » Usually found on routine physical » Best to correct before starting school

Kawasaki Disease (KD) (cont.)

» Manifestations ˃ Onset is abrupt with a sustained fever +As high as 104º F (40º C) +Does not respond to antipyretics or antimicrobials +Fever lasts for more than 5 days ˃ Conjunctivitis without discharge ˃ Fissured lips ˃ A "strawberry tongue" ˃ Inflamed mouth and pharyngeal membranes ˃ Enlarged nontender lymph nodes

Modified Jones Criteria

» Minor criteria ˃ Fever ˃ Arthralgia ˃ Previous history of rheumatic heart disease ˃ Elevated erythrocyte sedimentation rate ˃ Leukocytosis ˃ Altered PR interval on electrocardiogram ˃ Positive C-reactive protein » A positive diagnosis of RF cannot be made without the presence of two major criteria or one major and two minor criteria, plus a history of streptococcal infection (ASO titer)

Systemic Hypertension

» More prevalent during childhood and adolescence » Significant hypertension (HTN) is considered when measurements are persistently at or above the 95th percentile for patient's age and sex » Primary, or essential, HTN implies that no known underlying disease is present » When the cause of hypertension can be explained by a disease process, it is known as secondary ˃ Renal, congenital, vascular, and endocrine

VSD - ↑Pulmonary Blood Flow

» Most common heart anomaly » Left to Right Shunt - area of high pressure to area of low pressure » Loud, harsh murmur w/ a systolic thrill » May have spontaneous closure if small

Kawasaki Disease (KD) (cont.)

» Nursing care ˃ Symptomatic and supportive ˃ Parent teaching should be reinforced concerning need to postpone active routine immunizations for several months after the administration of immune globulin, which is an immunosuppressant ˃ Long-term, low-dose aspirin therapy may be prescribed +Compliance may be a problem for any long-term regimen in which medications must be taken when the child feels "well."

Acquired Heart Disease

» Occurs after birth » May be a complication of a congenital heart disease or a response to respiratory infection, sepsis, hypertension, or severe anemia » Heart failure is a decrease in cardiac output necessary to meet the metabolic needs of the body

Congenital Heart Disease

» Occurs in approximately 8 out of 1,000 births » 50% of these infants show signs/symptoms within the first year of life » Can be caused by genetic, maternal, or environmental factors ˃Not a problem for the fetus because of the fetal-maternal circulation ˃ At birth, the infant's circulatory system must take over and provide the child's oxygen needs

Defects that Decrease Pulmonary Blood Flow

» Occurs when a congenital heart anomaly allows blood that has not passed through the lungs (unoxygenated blood) to enter the aorta and general circulation » Cyanosis caused by the presence of unoxygenated blood in the circulation is a characteristic feature of this type of congenital heart anomaly

Congenital Heart Disease (cont.)

» Of the congenital anomalies, heart defects are the principal cause of death during the first year of life » Diagnostic studies vary from noninvasive, such as an electrocardiogram, to invasive, such as angiogram » Once diagnosis is confirmed, most cardiac defects require surgical intervention

CHF and Nursing Care

» Organize care so that infant is not unnecessarily disturbed » Feed early if crying and late if asleep » Feedings are small and frequent » Oxygen is administered to relieve dyspnea » Medications are given as prescribed, after dosages are checked for safety » Accurate recording of intake and output

Congenital Heart Disease (cont.)

» Physiologically, defects can be organized into lesions that ˃ Increase pulmonary blood flow ˃ Obstruct blood flow ˃Decrease pulmonary blood flow » A shunt refers to the flow of blood through an abnormal opening between two vessels of the heart

Prevention of RF

» Prevention of infection and prompt treatment of group A beta-hemolytic streptococcal infections » Nurse stresses importance of completing all antimicrobial therapy as prescribed

Restrictive Defects

» Restriction usually from some form of stenosis of the vessel ˃ Coarctation of the aorta +Narrowing or constriction of the aortic arch or of the descending aorta +Hemodynamically, increased pressure proximal to the defect and decreased pressure distally

Rheumatic Fever (RF)

» Systemic disease involving the joints, heart, central nervous system, skin, and subcutaneous tissues ˃ Belongs to a group of disorders known as collagen diseases » Common feature is destruction of connective tissue ˃ Scars mitral valve in the heart » Peak incidence is 5 to 15 years of age ˃ More prevalent in winter and spring » Autoimmune disease occurring as a complication of an untreated group A beta hemolytic streptococcus infection of the throat

Kawasaki Disease (KD) (cont.)

» Treatment ˃ IV gamma globulin, if given early, can prevent the development of coronary artery pathology ˃ Salicylate therapy or Clopidogrel (Plavix)* for antithrombus properties +Children treated with IVIG & high-dose aspirin, the risk for cardiac abnormalities is decreased for 85-90%.* *[Kallada, S. (2011). A 5-year-old boy with fever and rash. Pediatric Annals, 40(4), 185-188.] ˃ Warfarin therapy may be prescribed if aneurysms are detected

PDA - ↑Pulmonary Blood Flow

» Usually closes shortly after birth. » *Blood passes from high pressure Aorta to low pressure Pulmonary Artery* » Extra blood flow to the lungs » Symptoms: Dyspnea » Machinery-type murmur

Congestive Heart Failure (CHF) (cont.)

» When body tries to compensate ˃ Peripheral vasoconstriction occurs ˃ Results in cold and/or blue hands and feet ˃ Tachycardia ˃ Tachypnea

Kawasaki Disease (KD)

• Also known as mucocutaneous lymph node syndrome • Leading cause of acquired cardiovascular disease in the U.S. • Usually affects children younger than 5 years of age • May be a reaction to toxins produced by a previous infection with an organism such as Staphylococci • Not spread from person to person

Treatment of RF

• Antimicrobial therapy initially, then followed by chemoprophylaxis monthly for a minimum of 5 years • Rest • Relief of pain and fever - Antiinflammatory agents - Steroids - Aspirin • Management of cardiac failure, should it occur

Nursing Care of RF

• Care should be organized to ensure as few interruptions as possible to prevent tiring the patient • Special attention should be given to skin and back care; good oral hygiene; and small, frequent feedings • If dental therapy is needed, prophylactic antimicrobial treatment is required before the procedure

Coarctation of the Aorta

• Characteristic symptoms • Marked difference in the blood pressure and pulses of the upper and lower extremities • May not develop symptoms until late childhood • Treatment is dependent upon type and severity of the defect • Best time for surgical intervention is between 2 and 4 years of age

Complications and Treatments

• Complications - Cerebral thrombosis caused by polycythemia, especially if dehydration occurs - Iron-deficiency anemia due to decreased appetite and increased energy required to suck or eat - Bacterial endocarditis can occur • Treatment - Designed to increase pulmonary blood flow to relieve hypoxia • Surgery - In some cases, IV prostaglandin E therapy can open a constricted ductus arteriosus and allow for oxygenation of the body until surgery is performed

Congenital Heart Disease (cont.)

• Defects that increase pulmonary blood flow - Blood returns to the right ventricle and recirculates through the lungs before exiting the left ventricle through the aorta • Some defects that increase pulmonary flow are - Atrial septal defect - Ventricular septal defect and patent ductus arteriosus • The oxygenated blood recirculates to the lungs, and cyanosis is rare

Kawasaki Disease (KD) (cont.)

• Diagnosis is made by clinical signs and symptoms, no specific lab studies • KD causes inflammation of the vessels in the cardiovascular system - Weakens the walls of the vessels • Often results in an aneurysm (an abnormal dilation of the wall of a blood vessel) - Aneurysms can cause thrombi (blood clots) to form, which can be life-threatening

Kawasaki Disease (KD) (cont.)

• Erythematous skin rash develops • Swollen hands and desquamation (peeling) of the palms and soles • Child is very irritable • May develop signs of cardiac problems

Tetralogy of Fallot

• Four defects • Stenosis or narrowing of the pulmonary artery -Decreases blood flow to the lungs • Hypertrophy of the right ventricle -Enlarges because it must work harder to pump blood through the narrow pulmonary artery • Dextroposition of the aorta -The aorta is displaced to the right and blood from both ventricles enters it • Ventral septal defect (VSD)

Modified Jones Criteria (cont.)

• Major Criteria - Carditis - Polyarthritis - Erythema marginatum - Chorea - Subcutaneous nodules

Congestive Heart Failure (CHF)

• Manifestations depend on the side of the heart affected - Right side of the heart moves unoxygenated blood to the pulmonary circulation • A failure results in the backup of blood in the systemic venous system - Left side of heart moves oxygenated blood from the pulmonary circulation to the systemic circulation • Failure results in backup into the lungs

Hyperlipidemia

• Refers to excess lipids (fat and fatlike substances in the blood) • Lipoproteins contain lipids and proteins and include - Low-density lipoproteins (LDL) contain low amounts of triglycerides, high levels of cholesterol, and some protein • Carries cholesterol to the cells, which aids in cellular metabolism and steroid production - High-density lipoproteins (HDL) contain low amounts of triglycerides, little cholesterol, and high levels of protein • Carries cholesterol to the liver for excretion

Systemic Hypertension (cont.)

• Treatment and nursing care involve - Nutritional counseling - Weight reduction - Age-appropriate program of aerobic exercise - Adolescents should be counseled concerning the adverse effects of drugs, alcohol, and tobacco on blood pressure • Focus of treatment of secondary HTN is the underlying disease causing the elevated blood pressure