Chapter 26 The Child with a Cardiovascular Disorder

Chapter 26 The Child with a Cardiovascular Disorder Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Lesson 26. 1 Objectives 2. Distinguish the differences between the cardiovascular system of the infant and that of an adult. 3. List the general signs and symptoms of congenital heart disease. 4. Differentiate between patent ductus arteriosus, coarctation of the aorta, atrial septal defect, ventricular septal defect, and tetralogy of Fallot. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 2

Cardiovascular System (p. 606) Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 3

Signs Related to Suspected Cardiac Pathology (p. 605) 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 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 4

Congenital Heart Disease (p. 606) The most common type of birth defect 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 fetalmaternal circulation Ø At birth, the infant’s circulatory system must take over and provide the child’s oxygen needs Ø Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 5

Congenital Heart Disease (cont. ) (p. 606) 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 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 6

Congenital Heart Disease (cont. ) (p. 606) Classification Two categories Cyanotic Ø Acyanotic Ø Blood always flows from area of high pressure to an area of low pressure and it also takes the path of least resistance Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 7

Congenital Heart Disease (cont. ) (p. 606) Physiologically, defects can be organized into lesions that Increase pulmonary blood flow Ø Obstruct blood flow Ø Decrease pulmonary blood flow Ø A shunt refers to the flow of blood through an abnormal opening between two vessels of the heart Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 8

The Normal Heart and Various Congenital Heart Defects (p. 608) Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 9

Congenital Heart Disease (cont. ) (p. 607) Defects that increase pulmonary blood flow Ø 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 Ø Ventricular septal defect and patent ductus arteriosus Ø The oxygenated blood recirculates to the lungs, and cyanosis is rare Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 10

Safety Alert (p. 607) In congenital heart disease, cyanosis is not always a clinical sign Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 11

Question 1 Complete the analogy. Patent ductus arteriosus : acyanotic defect as tetralogy of Fallot : _____. 1) 2) 3) 4) mixed cyanotic acyanotic obstructive Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 12

Atrial Septal Defect (p. 608) Involves abnormal opening between right and left atria Oxygenated blood is forced from left atrium back to right atrium Most patients asymptomatic Detected as murmur during routine physical exam Surgical repair requires application of Dacron patch or repair Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 13

Ventricular Septal Defect (p. 609) Most common heart anomaly Opening between right and left ventricle Increased pressure with left ventricle forces blood into right Known as “left-to-right-shunt” Loud, harsh murmur with a systolic thrill Often associated with other defects Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 14

Patent Ductus Arteriosus (p. 608) Ductus arteriosus does not close after birth, blood continues to pass from aorta Pressure is higher Causes oxygenated blood to recycle through the lungs Overburdens pulmonary circulation causing heart to pump harder Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 15

Patent Ductus Arteriosus (p. 609) May go unnoticed in infancy Becomes dyspneic, radial pulse becomes full and bounding on exertion Wide range between systolic and diastolic pressures On auscultation, will sound machinery-like Occurs twice as often in girls Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 16

Restrictive Defects (p. 609) Restriction usually from some form of stenosis of the vessel Ø 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 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 17

Coarctation of the Aorta (p. 609) 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 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 18

Safety Alert (p. 609) A significant difference in the blood pressure between the upper extremities and the lower extremities is a characteristic sign of coarctation of the aorta. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 19

Coarctation of the Aorta (cont. ) (p. 609) If left untreated Hypertension Ø Congestive heart failure Ø Infective endocarditis may occur Ø After surgery, the nurse should observe for Hypertension Ø Abdominal pain associated with nausea and vomiting Ø Leukocytosis Ø GI bleeding or obstruction Ø Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 20

Coarctation of the Aorta (cont. ) (p. 609) Treatment includes Antihypertensive drugs Ø Steroids Ø NG tube for decompression of the stomach Ø Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 21

Defects that Decrease Pulmonary Blood Flow (p. 609) 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 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 22

Tetralogy of Fallot (p. 609) Four defects Stenosis or narrowing of the pulmonary artery • Decreases blood flow to the lungs Ø Hypertrophy of the right ventricle • Enlarges because it must work harder to pump blood Ø through the narrow pulmonary artery Ø Dextroposition of the aorta • The aorta is displaced to the right and blood from both ventricles enters it Ø Ventral septal defect (VSD) Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 23

Tetralogy of Fallot (cont. ) (p. 609) Cyanosis increases with age Clubbing of fingers and toes Ø Due to chronic hypoxia Child rests in a “squatting” position to breathe more easily by altering systemic venous return Prevalent symptoms include Ø Ø Ø Feeding problems Failure to thrive Frequent respiratory infections Severe dyspnea on exertion Polycythemia develops to compensate for the lack of oxygen Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 24

Paroxysmal Hypercyanotic Episodes (p. 610) 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 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 25

Tet Position (p. 610) Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 26

Diagnosis (p. 610) Diagnosis confirmed by chest X-ray that shows a typical boot-shaped heart Additional tests include EKG Ø 3 -D echocardiography Ø Cardiac catheterization Ø Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 27

Complications and Treatments (p. 610) Complications Cerebral thrombosis caused by polycythemia, especially if dehydration occurs Ø Iron-deficiency anemia due to decreased appetite and increased energy required to suck or eat Ø Bacterial endocarditis can occur Ø Treatment Ø Designed to increase pulmonary blood flow to relieve hypoxia Surgery Ø In some cases, IV prostaglandin E therapy can open a constricted ductus arteriosus and allow for oxygenation of the body until surgery is performed Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 28

Defects that Cause Mixed Pathology (p. 610) Hypoplastic left heart syndrome Underdevelopment of the left side of the heart Ø Usually results in an absent or nonfunctional left ventricle and hypoplasia of the ascending aorta Ø Can be diagnosed before birth and infant is placed on a heart transplant list early Ø Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 29

Defects that Cause Mixed Pathology (cont. ) (p. 610) 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 Ø Symptoms include • A grayish-blue color of the skin and mucous membranes • Signs of CHF • Dyspnea • Weak pulses • Cardiac murmur Ø Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 30

Lesson 26. 2 Objectives 5. Discuss six nursing goals relevant to the child with acquired heart disease. 6. List the symptoms of rheumatic fever. 7. Discuss the prevention of rheumatic fever. 8. Discuss hypertension in childhood. 9. Differentiate between primary and secondary hypertension. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 31

Lesson 26. 2 Objectives (cont. ) 10. Identify factors that can prevent hypertension. 11. Describe heart-healthy guidelines for a child over the age of 2 years. 12. Recognize the manifestation of Kawasaki disease and the related nursing care. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 32

General Treatment and Nursing Care (p. 611) Assorted medical and surgical treatments are currently available After the procedure, the nursing care involves Monitoring vital signs Ø Observing for thrombosis formation Ø Neurovascular checks of the limb Ø Emotional support to child and family Ø Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 33

General Treatment and Nursing Care (cont. ) (p. 611) 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 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 34

Acquired Heart Disease (p. 611) 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 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 35

Congestive Heart Failure (CHF) (p. 611) Manifestations depend on the side of the heart affected Ø 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 Ø Left side of heart moves oxygenated blood from the pulmonary circulation to the systemic circulation • Failure results in backup into the lungs Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 36

Congestive Heart Failure (CHF) (cont. ) (p. 611) When body tries to compensate Peripheral vasoconstriction occurs Ø Results in cold and/or blue hands and feet Ø Tachycardia Ø Tachypnea Ø Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 37

Safety Alert (p. 612) Early signs of CHF in infants that should be reported Tachycardia at rest Ø Fatigue during feedings Ø Sweating around scalp and forehead Ø Dyspnea Ø Sudden weight gain Ø Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 38

CHF Goals of Treatment (p. 612) Goals Reduce the work of the heart Ø Improve respiration Ø Maintain proper nutrition Ø Prevent infection Ø Reduce the anxiety of the patient Ø Support and instruct the parents Ø Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 39

CHF and Nursing Care (p. 612) 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 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 40

Rheumatic Fever (RF) (p. 613) Systemic disease involving the joints, heart, central nervous system, skin, and subcutaneous tissues Ø Common feature is destruction of connective tissue Ø Scars mitral valve in the heart Peak incidence is 5 to 15 years of age Ø Belongs to a group of disorders known as collagen diseases More prevalent in winter and spring Autoimmune disease occurring as a complication of an untreated group A beta hemolytic streptococcus infection of the throat Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 41

Manifestations of RF (p. 613) Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 42

Modified Jones Criteria (p. 614) Major criteria Carditis Ø Polyarthritis Ø Erythema marginatum Ø Chorea Ø Subcutaneous nodules Ø Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 43

Modified Jones Criteria (p. 615) Minor criteria Ø Ø Ø Ø Fever Arthralgia Previous history of rheumatic heart disease Elevated erythrocyte sedimentation rate Leukocytosis Altered PR interval on electrocardiogram Elevated C-reactive protein (CRP) 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 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 44

Treatment of RF (p. 615) Antimicrobial therapy initially, then followed by chemoprophylaxis monthly for a minimum of 5 years Rest Relief of pain and fever Antiinflammatory agents Ø Steroids Ø Aspirin Ø Management of cardiac failure, should it occur Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 45

Question 2 Administering aspirin to a child diagnosed with rheumatic fever without evidence of carditis does not pose any danger of causing Reye’s syndrome. 1) True 2) False Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 46

Nursing Care of RF (p. 615) 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 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 47

Prevention of RF (p. 616) Prevention of infection and prompt treatment of group A beta-hemolytic streptococcal infections Nurse stresses importance of completing all antimicrobial therapy as prescribed Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 48

Systemic Hypertension (p. 616) More prevalent during childhood and adolescence Significant hypertension (HTN) is considered when measurements are persistently at or above the 95 th 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 Ø Renal, congenital, vascular, and endocrine Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 49

Systemic Hypertension (cont. ) (p. 616) Heredity, obesity, stress, and poor diet and exercise patterns are some of the contributing factors to the development of HTN more prevalent in children whose parents have high blood pressure Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 50

Systemic Hypertension (cont. ) (p. 616) Treatment and nursing care involve Nutritional counseling Ø Weight reduction Ø Age-appropriate program of aerobic exercise Ø Adolescents should be counseled concerning the adverse effects of drugs, alcohol, and tobacco on blood pressure Ø Focus of treatment of secondary HTN is the underlying disease causing the elevated blood pressure Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 51

Nonpharmacological Methods for Preventing and Treating High Blood Pressure (p. 616) Aerobic exercise Reduce sedentary activities Weight reduction Dietary management Adequate intake of potassium and calcium Avoid smoking and those who smoke Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 52

Hyperlipidemia (p. 616) Refers to excess lipids (fat and fatlike substances in the blood) Lipoproteins contain lipids and proteins and include Ø 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 Ø High-density lipoproteins (HDL) contain low amounts of triglycerides, little cholesterol, and high levels of protein • Carries cholesterol to the liver for excretion Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 53

Hyperlipidemia (cont. ) (p. 616) Children with two consecutive blood cholesterol levels exceeding 170 mg/d. L should be followed closely and offered nutritional guidance Ø Parental history of cholesterol levels exceeding 240 mg/d. L 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 Ø Children younger than 2 years of age should not have a fatrestricted diet, because calories and fat are necessary for CNS growth and development Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 54

Kawasaki Disease (KD) (p. 617) 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 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 55

Kawasaki Disease (KD) (cont. ) (p. 617) Diagnosis is made by clinical signs and symptoms, no specific lab studies KD causes inflammation of the vessels in the cardiovascular system Ø Weakens the walls of the vessels Often results in an aneurysm (an abnormal dilation of the wall of a blood vessel) Ø Aneurysms can cause thrombi (blood clots) to form, which can be life-threatening Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 56

Kawasaki Disease (KD) (cont. ) (p. 617) 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 Ø Conjunctivitis without discharge Ø Fissured lips Ø A “strawberry tongue” Ø Inflamed mouth and pharyngeal membranes Ø Enlarged nontender lymph nodes Ø Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 57

Kawasaki Disease (KD) (cont. ) (p. 617) Erythematous skin rash develops Swollen hands and desquamation (peeling) of the palms and soles Child is very irritable May develop signs of cardiac problems Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 58

Kawasaki Disease (KD) (cont. ) (p. 617) Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 59

Kawasaki Disease (KD) (cont. ) (p. 617) Treatment IV gamma globulin, if given early, can prevent the development of coronary artery pathology Ø Salicylate therapy for antithrombus properties Ø Warfarin therapy may be prescribed if aneurysms are detected Ø Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 60

Kawasaki Disease (KD) (cont. ) (p. 617) Nursing care Symptomatic and supportive Ø 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 Ø Long-term, low-dose aspirin therapy may be prescribed • Compliance may be a problem for any long-term regimen Ø in which medications must be taken when the child feels “well. ” Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 61