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
