Definitions. N24 Pediatrics: Alterations in Cardiovascular Function. May C. Madsen RN, MSN 1. Congestive Heart Failure

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1 Definitions C.O.= volume of blood ejected by heart in 1 minute Cardiac output = HR x stroke volume S.V.: preload, afterload, contractility Flow = pressure gradient resistance 1 Congestive Heart Failure Clinical syndrome Reflects the heart s inability to pump sufficiently to meet the metabolic demands of the body. Metabolic demands of newborns high. Less reserve 2 CHF Causes Pressure & volume overloads Myocardial failure (contractility) Excessive demands 3 C. Madsen RN, MSN 1

2 Clinical Manifestations CHF early Dyspnea, tachycardia Tires easily Weight loss, or lack of weight gain Diaphoresis Irritability 4 Late CM r/t Pulmonary congestion Systemic venous congestion Decreased myocardial function 5 Clinical Manifestations CHF Pulmonary Congestion Tachypnea Dyspnea E i i t l Orthopnea Cough, hoarseness C i Wheezing Pulmonary edema Exercise intolerance Cyanosis 6 C. Madsen RN, MSN 2

3 Clinical Manifestations CHF Systemic Venous congestion Edema (periorbital, dependent) Hepatomegaly Splenomegaly Ascites Weight gain Neck vein distention (children) 7 Clinical Manifestations CHF R/t impaired myocardial function Tachycardia urine output Restlessness Anorexia Cyanosis Diaphoresis Fatigue Weak peripheral pulses blood pressure Pale, cool extremities Gallop rhythm Cardiomegaly 8 Nursing Diagnoses CHF Altered tissue perfusion [name organ] r/t cardiac workload or Ø cardiac function Fluid volume excess r/t L & R ventricular overload & ineffective pumping Ineffective Gas Exchange r/t pulmonary congestion; imbalance O 2 supply & demand Altered Nutrition < body requirements r/t energy expenditure, Ø intake Knowledge deficit re: disease process, tx, & home care 9 C. Madsen RN, MSN 3

4 Goals of Treatment Improve cardiac function Remove excess fluid Decrease cardiac O 2 demands Improve tissue oxygenation (supply) Maintain nutritional status 10 Improve Cardiac Function Digoxin Positive inotropic agent Dig g toxicity ACE inhibitors 11 Remove excess fluid Diuretics Loop (Lasix) Thiazide (HCTZ) Potassium sparing (spironolactone) Nursing Interventions: 12 C. Madsen RN, MSN 4

5 Decrease Myocardial O 2 Demand & Improve Oxygenation Decrease Demand Rest Normothermia Prevent/ treat infection Positioning Sedation (prn) Increase Supply Improve cardiac function Remove excess fluid Decrease cardiac O 2 demands Supplemental oxygen 13 Feeding the Infant or Child with Congestive Heart Failure Feed in a relaxed environment. Frequent, small feedings 30 minute feeding every 3 hours Nasogastric feeding Calorie supplement F14 Cardiac Catheterization Diagnostic Treatment Electrophysiological studies Pre cath teaching 15 C. Madsen RN, MSN 5

6 Height, weight Pulses Last drink, void Meds Consent Knowledge deficit Skin condition Allergies Pre cath assessment 16 Post cath care Frequent VS Groin site & pedal pulses Leg straight 6 hours Adequate fluid intake 17 Family Home Care Pressure dressing 24 hours Keep site clean & dry Avoid strenuous exercise 2 3 days Acetaminophen or Ibuprofen prn Call M.D.: redness, swelling, drainage, bleeding, fever 18 C. Madsen RN, MSN 6

7 Infective (Bacterial) Endocarditis Infection of valves or endocardium All children w/chd at risk 19 Clinical Manifestations Murmur Fever, malaise Heart failure Increased Sed rate Myalgias & arthralgias Anorexia, headache 20 Infective Endocarditis Primary Prevention Oral hygiene Antibiotic prophylaxis before procedures Secondary Intervention IV antibiotics 2 6 weeks Quiet activities 21 C. Madsen RN, MSN 7

8 Rheumatic Fever Systemic inflammatory disorder Autoimmune disorder Peaks in school age children Rheumatic heart disease most serious complication 22 Manifestations of RF Jones Criteria: Major Migratory polyarthritis Carditis Chorea Erythema marginatum Subcutaneous nodules 23 Diagnosis Recent hx of strep Jones criteria: 2 major or 1 major and 2 minor Jones Criteria: Minor Fatigue Fever Arthralgia Previous hx RF 24 C. Madsen RN, MSN 8

9 Nursing Interventions RF Primary Prevention: Secondary Prevention as Intervention Penicillin Comfort Strict Bedrest Safety Support nutritional status Alleviate anxiety 25 Streptococcal Prophylaxis (tertiary prevention as intervention) Valves: more damage with repeated infections. 5 years or through adolescence Prefer monthly IM penicillin Alternatives: oral penicillin bid or oral sulfadiazine qd. 26 F Hypertension Defined: avg. BP 95 th percentile for age & sex. Essential (primary) Secondary Diagnosis Ambulatory blood pressure monitoring Annual screening starting age 3 27 C. Madsen RN, MSN 9

10 Essential (Primary) HTN Weight reduction Physical conditioning Dietary modification Relaxation techniques Pharmacology 28 Kawasaki Disease: Acute febrile illness Widespread, systemic vasculitis SUBACUTE PHASE resolution of fever all sx resolved High risk coronary artery aneurism Irritability persists CONVALESCENT Clinical signs gone Lab values abnormal 6 8 weeks 29 Treatment KD IV Immune globulin (IVIG) ASA Comfort measures Adequate hydration Monitor cardiac status CHF, MI Patient irritability 30 C. Madsen RN, MSN 10

11 Consequences Congenital Heart Defects Congestive heart failure Hypoxemia (cyanosis) Mild hypoxemia: 90 95% Moderate hypoxemia: 85 90% Severe hypoxemia: <85% 31 Classification of CHD Acyanotic or Cyanotic lesions Hemodynamic effects pulmonary blood flow Obstructed flow from the ventricles Decreased pulmonary blood flow Mixed Hypoxemia & CHF 32 Shunt To divert blood flow right to left or left to right right to left hypoxia left to right ih CHF 33 C. Madsen RN, MSN 11

12 ASD CMs depend on size, location Murmur Fatigue, DOE Atrial dysrhythmias TX: elective surgical closure or patch via cardiac catheterization 34 VSD CMs depend on size Poor feeding, FTT if large (CHF) Large # close spontaneously Tx CHF Patch it 35 Patent Ductus Arteriosis Blood flow from aorta to pulmonary arteries Term infants: no sx (murmur) Preterm: CHF TX: Indocin, surgery 36 C. Madsen RN, MSN 12

13 Common Stenotic Lesions: Pulmonary Stenosis and Aortic Stenosis Pulmonic Stenosis RV hypertrophy R to L shunt if foramen ovale open No sx of RV failure (exercise intolerance) Balloon angioplasty: low mortality; incompetent valve, but usually asymptomatic. Aortic Stenosis mild activity intolerance to severe syncope, dizziness. Vl Valvotomy (balloon or open heart). 25% require 2 nd surgery w/in 10 years Figs and 46-6, pp and Coarctation of the Aorta Narrow (stenotic) section of aorta Most common spot after aortic arch Narrowing restricts blood to lower part of body Varying degrees of narrowing 38 F Clinical Manifestations: COA Infants: CHF Older children Dizziness, fainting, nosebleeds, HA High BP upper extremities (HTN) Low BP & weak pulses lower extremities 39 C. Madsen RN, MSN 13

14 Treatment COA PGE1 to keep ductus arteriosis open (preductal ) Elective repair age 3 5 if asymptomatic 40 Cyanotic Lesions Decreased pulmonary blood flow Mixed Hypoxemia & CHF B MENU 41 F Chronic Hypoxemia Polycythemia Anemia r/t depletion of iron stores Clotting abnormalities CNS injury Developmental delay Clubbing of fingers 42 C. Madsen RN, MSN 14

15 Tetrology of Fallot VSD; Pulmonic stenosis; overriding aorta; RVH Hemodynamics depend on PS, VSD Clubbing, fatigue, poor growth, Tet spells Symptomatic newborn: PGE1, early surgery Elective surgery 3 12 mo. 43 Hypercyanotic Episodes tet spells sudden decrease pulmonary flow &/or increased RV pressure spasm of RV outflow track Crying, feeding, defecation Treatment Calm the infant; meet needs quickly Knee chest position O2 MSO4 44 Transposition of Great Arteries Child cannot live w/out foramen ovale or patent ductus VSD common Cyanosis early minimal response to O 2 Early surgery 45 C. Madsen RN, MSN 15

16 Home care/teaching Prepare child/family Treat CHF Immunizations/prevent infections Notify MD quickly w/ signs of any illness Parental support Allow child to set activity level Adequate nutrition CMs of CHF Oxygen Preemie nipple to energy in sucking Careful skin care Preventive dental care Prophylactic abx 46 C. Madsen RN, MSN 16