Chapter 12 Cardiac Disorders Copyright 2012 by Saunders

Key Terms • • • Chemoprophylaxis Ductus arteriosus Ductus venosus Foramen ovale Hemodynamics Infective endocarditis (IE) • Jones criteria • • Multifactorial Polycythemia Shunting Subacute bacterial endocarditis (SBE) • Squatting position Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -2

Chapter 12 Lesson 12. 1 Copyright © 2012 by Saunders, an imprint of Elsevier,

Learning Objectives • Describe changes from fetal to neonatal circulation • Summarize the symptoms of a congenital heart defect with increased pulmonary blood flow • Discuss the corrective interventions for a child with mixed heart defects • Develop a teaching plan for an older child who is scheduled for a cardiac catherization • List the symptoms for an infant with CHF • Plan discharge instructions for a postsurgical cardiac child Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -4

Cardiovascular System Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -5

Cardiovascular System • Heart fully functioning by 8 th week of gestation • Fetal circulation: placenta is the organ of oxygenation – Ductus venosus – Ductus arteriosus – Foramen ovale • The birthing process begins closure of fetal shunts • Heart defects are the most common birth defect – Leading cause of birth defect-related deaths Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -6

Congenital Heart Disease • Description – A defect in the structure of the heart or in one or more of the large blood vessels that lead to and from the heart – Multifactorial • Result of genetic-environmental interactions • Four classifications – Based on defect’s effect on blood flow • Hemodynamics: study of blood circulation • Shunting: flow of blood through abnormal openings – – Defects with increased pulmonary blood flow Obstructive defects Defects with decreased pulmonary blood flow Mixed defects Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -7

Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -8

Congenital Heart Disease (CHD) • Diagnostic tools – Not all testing is necessary for each child – Lab tests, electrocardiogram, halter monitor, event recorder, chest radiography, echocardiogram, MRI, cardiac catherization • Cardiac catherization is an invasive procedure • Provides information about anatomy, cardiac pressure, oxygen saturation, cardiac function • Sedation is necessary • Extremity kept straight 4 -6 hours after procedure Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -9

Congenital Heart Disease (CHD) • Signs and symptoms – Depend on location and type of heart defect – Child may be small for age, condition may be classified as a physiologic failure to thrive – Exercise intolerance noticed anywhere from infancy to toddler age – Clubbing of the fingers – Frequent respiratory infections because of pulmonary vascular congestion – Squatting position – Polycythemia: Body compensates for hypoxemia by increasing number of RBCs Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -10

Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -11

Congestive Heart Failure (CHF) • Early symptoms – – • Progressive symptoms Lack of infant weight gain Infant irritability and fatigue Tachycardia/tachypnea Increased work of breathing Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. – – – – – Periorbital/facial edema Vein distention Hepatomegaly Splenomegaly Decreased urine output Diaphoresis Mottling Cyanosis Pallor 12 -12

Defects with Increased Pulmonary Blood Flow • Patent ductus arteriosus (PDA) – Passageway connecting pulmonary artery to aorta, avoiding fetal lungs – Failure to close causes oxygenated blood to recycle through the lungs • Overburdens pulmonary circulation • Makes heart work harder • One of the most common cardiac anomalies – Symptoms • Machine-like murmur, dyspnea, bounding pulses on exertion, failure to thrive, frequent respiratory infections – Treatment • Indomethacin/ibuprofen in premature infants • Amplatzer PDA device • Surgical repair Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -13

Defects with Increased Pulmonary Blood Flow • Atrial septal defect (ASD) – Abnormal opening between right and left atria – Common congenital heart anomaly – Symptoms • Generally asymptomatic • Cyanosis if blood flow is reversed by heart failure • Large openings may cause failure to thrive – Treatment • Open heart surgery • Percutaneous occluding devices Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -14

Defects with Increased Pulmonary Blood Flow • Ventricular septal defect (VSD) – Opening between right and left ventricles – 75% of small VSDs close spontaneously by age 10 – Symptoms • Loud, harsh murmur • Systolic tremor • Moderate/large defects may present CHF symptoms – Treatment • Percutaneous transcatheter closure • Occluder devices Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -15

Obstructive Defect • Coarctation (tightening) of the aorta – Symptoms • • Increased pressure proximal to the defect Decreased pressure distal to the defect High blood pressure CHF symptoms – Treatment • Balloon angioplasty • Surgical intervention; anastomosis • Risk of developing subacute bacterial endocarditis Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -16

Defect with Decreased Pulmonary Blood Flow • Tetralogy of Fallot – The most common cyanotic heart defect – Four defects • • Stenosis (narrowing of pulmonary artery) Hypertrophy of the right ventricle Dextroposition of the aorta VSD – Symptoms • Cyanosis/hypoxemia episodes with hyperpnea, irritability • Hypoxia – Treatment • Open heart surgery Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -17

Mixed Defect • Transposition of the great arteries (TGA) – Pulmonary artery leaves left ventricle – Aorta leaves the right ventricle – Other defects (septal defects, PDA) must be present to sustain life – Survival impossible without surgery – Symptoms • CHF symptoms • Any murmur present is caused by other defects, not TGA – Treatment • Prostaglandin E 1 • Balloon atrial septostomy • Corrective surgery – Performed within the first 2 weeks of life Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -18

Mixed Defect • Hypoplastic left heart syndrome (HLHS) – Left side of the heart is underdeveloped – Hypoplasia of aorta, left ventricle, mitral valve – Systemic circulation provided by right side of the heart – Ductus arteriosus and foramen ovale must remain patent to survive with HLHS – Treatment • PGE 1 is administered to maintain a PDA • Surgery in several stages – Norwood, Glenn, Fontan Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -19

Question 12. 1 Coarctation means: A. widening. B. shortening. C. tightening. D. lengthening. Copyright

Congenital Heart Disease • Treatment and nursing care – Nursing goals in the care of the newborn infant can be adapted for all children with heart defects • • • Reduce the work of the heart Improve respiration Maintain proper nutrition Prevent infection Reduce the anxiety of the patient Support and instruct the parents Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -21

Congenital Heart Disease • Treatment and nursing care (continued) – Change child’s position frequently to prevent respiratory complications – Threat of cerebral thrombosis – Chest tubes may be used after surgery • System must be airtight • Drainage containers always kept below the level of the chest – Avoid unnecessarily disturbing the child • Common medications – – – Digoxin (Lanoxin) Dopamine, dobutamine, epinephrine Amrinone, milrinone ACE inhibitors Angiotensin II receptor blockers Diuretics Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -22

Congenital Heart Disease • Treatment and nursing care (continued) – Infective endocarditis (IE) • High risk for children with complex cyanotic heart diseases or children who have had heart surgery • Organisms grow on the endocardium or areas of turbulent blood flow – Symptoms • Fever, fatigue, headache, nausea, vomiting – Diagnosis and treatment • Blood cultures determine causative organism • Antibiotics Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -23

Congenital Heart Disease • Home care – Family must understand medication administration – Family must identify symptoms requiring medical attention – Provide a normal environment within child’s limits – Avoid allowing the child to gain control of the home • Limit setting – Integrate the child into family life – Explain the possible need for frequent hospitalization to parents and child Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -24

Question 12. 2 Which of the following is NOT one of the four classifications of congenital heart disease? A. Defects with increased pulmonary blood flow B. Congestive heart failure C. Defects with decreased pulmonary blood flow D. Mixed defects Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -25

Chapter 12 Lesson 12. 2 Copyright © 2012 by Saunders, an imprint of Elsevier,

Learning Objectives • List three major and two minor manifestations of acute rheumatic fever as determined by the modified Jones criteria • Identify the priority nursing care for a child with rheumatic fever Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -27

Acute Rheumatic Fever • Description – Follows infection with certain strains of Group A beta-hemolytic streptococci • Signs and symptoms – Abdominal pain, fever, pallor, fatigue, anorexia, unexplained nosebleeds – Jones criteria aid in diagnosis of rheumatic fever – ECG is sometimes a useful diagnostic Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -28

Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -29

Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -30

Acute Rheumatic Fever • Treatment and nursing care – Elimination of the initial infection is followed by long-term chemoprophylaxis (prevention of disease by drugs) – Intramuscular penicillin G benzathine (Bicillin), given as an intramuscular injection every 28 days – Anti-inflammatory drugs are used to decrease pain and inflammation Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -31

Acute Rheumatic Fever • Home care – Bed rest during the initial attack is not necessary but is recommended if carditis is present – Nurse must verify that parent and child understand activity limitations • Parents should provide interesting quiet activities – Long-term chemoprophylaxis Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -32

Acute Rheumatic Fever • Prevention – The nurse is involved in prevention of rheumatic fever in the community by recognizing signs and symptoms of streptococcal infections, doing screening, and referring for treatment Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -33

Question 12. 3 True or false: acute rheumatic fever is a system-specific disease, involving only the respiratory and cardiac systems. A. True B. False Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 12 -34