Module 5

Pediatric Cardiac Disorders

 Fetal Circulation
Main Blood Flow
 Placenta  Umbilical

Vein  Liver  Ductus

Venosus  Inferior
Vena Cava

 Vena Cava  Right

Atrium Foramen
Ovale Left Atrium 
Left Ventricle 

 Aorta Body     
 Fetal Circulation
Secondary Route:

 Right Atrium 
 Right Ventricle 
 Pulmonary Artery 
 Ductus Arteriosus 
(so does not go to lungs)
 Aorta 
 Body
 Fetal Circulation
Third route of blood flow
 Right Atrium 

 Right Ventricle 

 Pulmonary Artery 

 Lungs (needs to perfuse the

lungs and upper body with
oxygen) 
 Left Atrium 
 Left Ventricle 
 Aorta 
 Body     
 Transition from Fetal Circulation to
Pulmonary circulation
 The umbilical arteries and vein and the ductus
venosus become non-functional
 Decreased pulmonary vascular resistance and
increased pulmonary blood flow
 Increase in pressure of the left atrium, decrease
pressure in right atrium, causing closure of
foramen ovale.
 Pulmonary resistance is less than systematic
resistance so there is left-to-right shunting
resulting in closure of the ductus arteriosus.
Congestive Heart Failure
  Reflects the heart’s   inability to meet the
metabolic demands of the body
 ·Usually due to a surgically   correctable
structural abnormality of the heart that results
in increased   blood volume and pressure
 Congestive heart failure
 The inability of the myocardium to circulate
enough oxygenated blood to meet the
demands of the body.
 When the heart fails, cardiac output is
diminished. Heart rate, preload,
contractitility, and afterload are affected.
 Peripheral tissue is not adequately
perfused.
 Congestion in lungs and periphery
develops.
 Etiology and Pathophysiology
 Congenital defects – allow blood to flow from
the left side of the heart to the right so that
extra blood is pumped to the pulmonary
system rather than through the aorta when the
ventricle contracts.
 Obstructive congenital defects – restricts the
flow of blood so the heart hypertrophies to
work harder to force blood through the
narrowed structures. The hypertrophied
muscle becomes ineffective.
 Other defects which weaken the heart muscle.
 Compensatory Mechanisms
 Stimulation of the sympathetic nervous system
which releases norepinephrine from the adrenals.
This stimulates blood vessels to constrict and an
increase in the heart rate.
 Tachycardia increases venous return to the heart
which stretches the myocardial fibers and increases
preload. Only successful for short period of time.
 Increased renin and ADH secretion caused by
decrease renal perfusion. Resultant increase in Na
and H2O retention to increase fluid to the heart
and leading to edema
 Assessment   – CHF:
 Tachycardia, gallop, cardiomegaly,  
ßperipheral pulses, mottling
 Tachypnea, retractions,   grunting, nasal
flaring, cough, cyanosis, orthopnea
 Hepatomegaly, edema,   decreased urine
output
 Failure to thrive, decreased   exercise tolerance
 Signs and Symptoms

1. Tires easily during feeding

2. Periorbital edema, weight gain
3. Rales and rhonchi
4. Dyspnea, orthopnea, tachypnea
5. Diaphoretic / sweating
6. Tachycardia
7. Failure to gain weight
 Treatment of Congestive Heart Failure
 Medication Therapy
 Digitalis – increases contractility and decreases

heart rate.
 ACE-inhibitors - arterial vasodilator / afterload
reducing agent
 Diuretics - enhance renal secretion of sodium and
water by reducing circulating blood volume and
decreasing preload.
 Beta Blocker - increases contractility
 Digoxin
 Check dosage with another RN
 Give 1 hour before feeding or   2 hours after
feeding
 Give at 12 hour intervals   (BID)
 Take apical pulse for 1 minute
 Hold if HR <90 in infants   or<70 in children
 Monitor serum potassium levels
 Monitor for toxicity:   vomiting, nausea,
bradycardia, lethargy
Treatment of Congestive Heart Failure

 Diet – low sodium, small frequent feedings

(be sure you can pick the right foods for a low NA diet.
 Nursing care:
 Measure intake and output – weighing diapers
 Observe for changes in peripheral edema and
circulation
 If ascites present – take serial abdominal
measurements to monitor changes.
 Skin care
 Turning schedule
 Nursing nterventions for CHF:
 Provide nutrition
 · Use soft nipple
 · Gavage feeding if needed
 · Monitor fluid status
 · I & O, specific gravity
 · Daily weight
 · Provide adequate rest,   position for comfort
 · Prevent infections
 · Promote growth &   development
 · Reduce respiratory distress
 Nursing Interventions:
 Decrease energy expenditure
 Frequent rest periods
 Small, frequent feedings
 Minimize crying
 Prevent cold stress
 Provide adequate rest,   position for comfort
 Prevent infections
 Promote growth &   development
 Reduce respiratory distress
 Etiology of Congenital Heart Disease
Multifactorial :
 MaternalDisease:  MEDICATION:
Diabetes, Collagen  anticonvulsants,
disease (Lupus), Seizure diazepam
disorders progesterone/estrogen,
alcohol, street drugs
(cocaine) , Retin-A,
lithium, thalidamide,
lithium, warfarin,
aspirin, ACE inhibitors
Etiology of Congenital Heart Disease
Multifactorial :
Genetic: Environmental:
 Chromosome  Viral infections (Rubella,

abnormalities: 13, 18, CMV),

21;  Toxins

 Turner’s Syndrome,

 DiGeorge Syndrome

(22q11 deletion),
 Williams Syndrome
Defects that increase pulmonary
blood flow

Patent Ductus Arterious

Atrial septal defects
Ventricle septal defects
 Atrial Septal Defect
1. Oxygenated blood is shunted
from left to right side of the
heart via defect
2. A larger volume of blood
than normal must be
handled by the right side of
the heart hypertrophy
3. Extra blood then passes
through the pulmonary
artery into the lungs,
causing higher pressure
than normal in the blood
vessels in the lungs 
congestive heart failure
 Nursing   Interventions – CHF
 Decrease energy expenditure
 Frequent rest periods
 Small, frequent feedings
 Minimize crying
 Prevent cold stress
 Treatment
 Medical Management
 Medications – digoxin

 Cardiac Catheterizaton -
 Amplatzer septal occluder

 Open-heart Surgery
 Cardiac Catheterization
 Pre-care:
 History and Physical
 Lab work – EKG, ECHO cardiogram, CBC
 NPO
 Preprocedural teaching
  Post Care:
 Monitor vital signs
 Monitor extremity distal to the catheter instertion,
 Keep leg immobilized
 Vital signs
 Check for bleeding at insertion site
 Measure I&O
 Treatment
 Device Closure – Amplatzer septal
occluder

During cardiac catheterization the occluder is placed in the

Defect
Ventricle Septal Defect
1. Oxygenated blood is shunted
from left to right side of the
heart via defect
2. A larger volume of blood
than normal must be
handled by the right side of
the heart hypertrophy
3. Extra blood then passes
through the pulmonary
artery into the lungs,
causing higher pressure
than normal in the blood
vessels in the lungs 
congestive heart failure
Treatment
Surgical repair with a patch inserted
 Patent Ductus Arteriosus
1. Blood shunts from
aorta (left) to the
pulmonary artery
(right)
2. Returns to the lungs
causing increase
pressure in the lung
3. Congestive heart
failure
 Treatment for PDA
 Medical Mangement
 Medication

 Indomethacin - inhibits prostaglandin's

which help keep the ductus arteriosus

open
Ligate the
 Surgery ductus arteriosus
 Treatment for PDA
 Cardiac Catheterization

 Insert coil – tiny fibers

occlude the ductus
arteriosus when a
thrombus forms in
the mass of fabric and
wire
Defects with decrease blood flow and
mixed defects

Pulmonic stenosis
Tetralogy of fallot
Transposition of the great arteries
Truncus arteriosus
 Pulmonic Stenosis
 Narrowing of entrance that
decreases blood flow

 Treatment:
 Medications – Prostaglandins to keep the

PDA open
 Cardiac Catheterization

 Baloon Valvuloplasty

 Surgery

 Valvotomy
 Tetralogy of Fallot
Four defects are:

1. 2.

3.
4.
Signs and Symptoms
1. Failure to thrive
2. Squatting
3. Lack of energy
4. Infections
5. Polycythemia
6. Clubbing of fingers
7. Cerebral absess
8. Cardiomegaly
 Treatment
 Surgical interventions
 Blalock – Taussig or Potts procedure –

increases blood flow to the lungs.

 Open heart surgery

 Transposition of Great Vessels
 Aorta arises from the right
ventricle, and the pulmonary artery
artery arises from the left
ventricle - which is not
compatible with survival
unless there is a large defect aorta
present in ventricular or
atrial septum.
Truncus arteriosus
 A single arterial trunk
arises from both
ventricles that supplies
the systemic, pulmonary,
and coronary
circulations. A vsd and a
single, defective, valve
also exist.
 Entire systemic
circulation supplied from
common trunk.
Defects obstructing Systemic blood
flow

•Aortic stenosis
•Coarctation of the Aorta
 Coarctation of the Aorta
1. Narrowing of Aorta causing
obstruction of left
ventricular blood flow
2. Left ventricular hypertrophy

Signs and Symptoms

1.  B/P in upper extremities
2. B/P in lower extremities
3. Radial pulses full/bounding and
femoral or popliteal pulses weak
or absent
4. Leg pains, fatigue
5. Nose bleeds
 Treatment
 Goals of management are to improve ventricular
function and restore blood flow to the lower body.
 Medical management with Medication
 A continuous intravenous medication,

prostaglandin (PGE-1), is used to open the ductus

arteriosus (and maintain it in an open state)
allowing blood flow to areas beyond the
coarctation.

 Baloon Valvoplasty
Surgery for Coarctation of Aorta

1. Resect
narrow
area 2. Anastomosis
 Ask Yourself ?
 Laboratory analysis on a child with Tetralogy of
Fallot indicates a high RBC count. The
polycythemia is a compensatory mechanism
for:
a. Tissue oxygen need
b. Low iron level
C. Low blood pressure
d. Cardiomegaly
Acquired Cardiac Diseases
 RHEUMATIC FEVER

A systemic inflammatory (collagen) disease of

connective tissue that usually follows a group A
beta-hemolytic streptococcus infection.
This disorder causes changes in the entire heart
(especially the valves), joints, brain, and skin
tissues.
 Rheumatic   Fever (RF)
 An inflammatory disorder that   may involve
the heart, joints, connective tissue, and the
CNS
 · Thought to be an autoimmune   disorder
 · Preceded by an infection of   group A beta-
hemolytic streptococcus
 Prognosis depends on degree   of heart damage
 Assessment   – RF

 Major Symptoms (Jones’  Valvular insufficiency

  Criteria) (mitral/aortic)
 · Carditis  · Cardiomegaly
 · Aschoff nodules (areas  · Shortness of breath,
of   inflammation & edema, hepatomegaly
degeneration around  · Major Symptoms
heart valves, (Jones’   Criteria)
pericardium,  · Polyarthritis
myocardium)
 · Migratory
 · Most common in large
joints   which become
red and swollen, painful
 Assessment   – RF
 Chorea ( St.Vitus dance)  Erythema marginatum
 · CNS disorder  · Transient, nonpuritic
characterized by   abrupt,
rash
purposeless, involuntary
muscular movements  · Minor symptoms
 · Major Symptoms (Jones’  · History of RF, fever
  Criteria)  · Recent strep infection
 · Subcutaneous nodules  · Diagnostic tests
 · Usually a sign of severe    · Elevated ESR
disease  · Positive ASO titer
 · Occur with active carditis  · Changes on ECG
 · Firm, non-tender nodes on  
bony prominence of joints
 Nursing   Interventions

Carditis
 · Administer Penicillin as   ordered

 · Use prophylactically

 · Promote bed rest

 · Arthritis

 · Aspirin as ordered

 · Change position in bed   frequently

 Nursing   Interventions

Corea
 · Decrease stimulation

 · Provide safe environment

 · Nodules and Rash: none

 · Alleviate child’s anxiety   about the ability of

heart to continue to function

 · Minimize boredom
 Nursing   Interventions
 Provide client teaching and   discharge
planning concerning:
 · Adaptation of home   environment to promote
bed rest
 · Importance of prophylactic   regimen
 · Avoidance of reinfections
 · Diet modifications
 · Home-bound education
 Management   – RF
 Drug Therapy
 · Penicillin, erythromycin
 · Salicylates
 · Steroids
 · Decrease cardiac workload
 · Bed rest until lab studies   return to normal
 Rheumatic Fever
 Assessment
 Jones Criteria

 Major

 Minor

 Treatment
 Antibiotic Therapy

 Aspirin
Subacute Bacterial Endocarditis /
Ineffective Endocarditis:

Microorganisms grow on the

endocardium, forming vegetations,
deposits of fibrin, and platelet thrombi.
The lesion may invade adjacent tissues
such as aortic and mitral valves.
 Subacute Bacterial Endocarditis /
Ineffective Endocarditis:
 Assessment

 Diagnosis – blood cultures

 Treatment
 Antibiotics

 Patient teaching – take antibiotics prior to

surgery, dental work, etc.
 Kawasaki Disease

Multisystem vasculitis – inflammation of

blood vessels in the body especially the
coronary arteries with antigen-antibody
complexes.
 Stages   of Kawasaki   Disease
Acute: (days 1-10) Subacute (days 10-25)
 Abrupt onset of fever    · Cracking lips and fissures

,lasting more than 5  · Desquamation of skin on

days & unresponsive to tips   of fingers and toes

antipyretics  · Arthritis & joint pain

 · Conjunctival hyperemia  · Cardiac disease

 · Red throat  Convalescent (days 26-40)

 · Swollen hands & feet  · Drop in ESR, diminishing

 · Cervical node   signs of illness

enlargement
 · Child is VERY irritable
Kawasaki Disease
 Which phase of Kawasaki is this child
exhibiting?

Inflamed, Cracked,
Peeling Lips

Strawberry tongue
 Kawasaki Disease
Signs and Symptoms / Treatment
 Three Phases of clinical manifestations:
 Acute

 Subacute

 Convalesant

 Treatment
 Aspirin

 Gamma Globulin

 Nursing Care
 Nursing   Interventions:

 Administer aspirin 80-100   mg/kg/day as

ordered while temperature is elevated Q. 6
hours
 ·Administer IV gamma globulin   (IVIG) to
reduce risk of coronary artery lesions and
aneurysms
 · Provide comfort
 · Provide client teaching and   discharge
planning concerning:
 · Safe administration of   aspirin therapy
 Nursing Interventions:
 · Safe administration of   aspirin therapy
 · Skin care
 · Monitoring of temperature

 · Call MD if child refuses to   walk

 · Signs and symptoms of cardiac   disease