Cardio Pediatrics

CONGENITAL HEART DISEASE

1. Acyanotic diseases

•          Pulmonary circulation and systemic circulation are not connected

•          If there is a connection, the pressure is higher in the left side than in the

            right side

PATENT DUCTUS ARTERIOSUS

•          Most common congenital heart defect

•          Symptoms depend on size of the vessel and age of the child

•          May have no symptoms; indication may be a murmur

•          Increasing dyspnea, full bounding pulse, wide pulse pressure

•          Spontaneous closure after infancy rarely occurs

•          Without treatment – life expectancy short

ATRIAL SEPTAL DEFECTS

•          10% of all forms of congenital heart disease

•          Allows oxygenated blood returning from the lungs to pass into the right

            atrium

VENTRICULAR SEPTAL DEFECT

•             constitute 20% of all forms of CHD

•             allows systemic venous and oxygenated arterial blood to mix

•             may produce no symptoms at all

•             require no specific treatment and often close spontaneously

COARCTATION OF THE AORTA

•            narrowing of the lumen of the aorta

•            may be an isolated defect or associated with other cardiac malformation

•            Assessment:  measure BP in both arms and a leg and to assess the pulse

            in both upper and lower extremities

•            surgical repair – only permanent treatment; usually deferred until 3 years

            of age

PULMONIC VALVE STENOSIS

•            usually do not produce symptoms; typical murmur

AORTIC VALVE STENOSIS

•            mild to moderate asymptomatic; typical murmur

CYANOTIC DISEASES

TETRALOGY OF FALLOT

1. VSD
2. Overriding of the aorta
3. Pulmonary valve stenosis
4. Enlarged right ventricular wall

Assessment:

•          Primary sign – cyanosis

•          Hypoxic spells – usually initiated by crying

•          Fainting – due to cerebral hypoxia

•          Stunted growth, clubbed fingers and toes

•          Squatting position – characteristic position to relieve dyspnea

Implementation

•          Decrease hypoxic spells – do not permit child to cry

•          Place in knee chest position

•          O2 as needed

TRANSPOSITION OF THE GREAT VESSELS

•            aorta arises from the right ventricle

•            degree of cyanosis depends on the abnormal connections

Assessment:

•            cyanotic at birth

•            develop polycythemia à risk for emboli and thromboses

•            may develop CHF or pulmonary vascular obstructive

Implementation:

•            require emergency medical treatment

•            cardiac catheterization

•            ballool atrial septostomy

TRICUSPID ATRESIA

•            condition in which tricuspid valve did not form

•            no opening between the right atrium and right ventricle

•            2% of congenital heart defects

•            profound cyanosis and dyspnea at birth

•            emergency catheterization with balloon atrial septotomy

TOTAL ANOMALOUS VENOUS RETURN

•            condition in which all the pulmonary venous blood returns to the heart

•            cyanosis and severe respiratory distress

•            emergency surgical intervention

TRUNCUS ARTERIOSUS

•            single vessel arising from the ventricles just above a large VSD

•            retarded growth; enlarged liver and heart

•            usually infants die within the first year

CARDIOVASCULAR DEFECTS

•            Monitor vital signs closely

•            Monitor respiratory status

•            Auscultate breath sounds for crackles, ronchi or rales

•            if respiratory effort is increased, place child in reverse Trendelenburg

            position

•            administer humidified oxygen

•            Monitor for hypercyanotic spells:

1. Place infant in a knee chest position
2. Administer 100% oxygen by mask
3. Administer morphine as ordered
4. IVF as prescribed

•          Assess for signs of CHF

•          Assess peripheral pulses

•          Keep child stress free as possible; allow maximal rest

CARDIAC SURGERY

Postoperatively:

•             monitor for signs of discomfort

•             monitor for signs of sepsis (fever, lethargy, diaphoresis, altered LOC)

•             Monitor lines, tubes or catheters ; remove promptly

•             administer pain medications; note effectiveness

•             encourage rest periods

•              facilitate parent-child contact as soon as possible

Home Care

•            omit activities in which child could fall for 2-4 weeks

•            avoid crowds for 2 weeks after discharge

•            no added salt diet

•            do not put creams, lotions or powders on the incision site

•            child may return to school 3rd week after discharge

•            no physical education for 2 months

•            follow up after 2 weeks

•            avoid immunizations, invasive procedure and dental visits for 2 months

•            advise parents regarding importance of dental visit every 6 months

•            inform dentist of cardiac problem

•            instruct parents to call MD if with coughing, tachypnea, cyanosis, diarrhea

CONGESTIVE HEART FAILURE

•            inability of the heart to pump sufficiently to meet the metabolic demands

            of the body

•            infants – most commonly caused by congenital heart defects

•            combination of both left sided and right sided heart failure

•            goal of treatment: to improve cardiac function, remove accumulated fluid

            and sodium, decrease cardiac demands, improve tissue oxygenation

Assessment:

•            tachycardia

•            tachypnea

•            profuse scalp sweating especially in infants

•            fatigue and irritability

•            sudden weight gain

•            respiratory distress

Implementation:

•            monitor vital signs closely and for early signs of CHF

•            monitor for respiratory distress

•            monitor I and O; weigh diapers

•            Monitor daily weight to assess for fluid retention; weight gain of 0.5 kg

            ( 1 lb /day)

•            monitor for facial or peripheral edema , auscultate lung sounds

•            elevate HOB

•            maintain neutral thermal environment to prevent cold stress in infants

•            administer cool, humidified oxygen

•            organize nursing activities to allow  uninterrupted sleep

•            maintain adequate nutritional status

•            provide rest; decrease environmental stimuli

•            feed when hungry and soon after awakening

•            infant should be well rested before feeding

•            provide small, frequent feedings

•            administer sedation

•            administer digoxin

•            check with physician parameters for witholding digoxin

•          Note that infants rarely receive more than 1 mL (50 ug or 0.05 mg) of digoxin

•            Administer diuretics;  monitor for hypokalemia

•            administer potassium supplements

•            monitor serum electrolytes

•            restrict fluid in acute stages

•            check with physician regarding sodium restriction;  infant formulas have slightly

            more sodium than does breast milk

Home care Instructions for Administering Digoxin

•            administer 1 hr before or 2 hrs after feeding

•            do not mix medication with food or drink

•            if the child vomits, do not administer a second dose

•            if more than 2 consecutive doses have been missed, notify MD; do not

            increase or double the dose for missed doses

•            keep the medication in a locked cabinet

•            if the child becomes ill, notify MD

RHEUMATIC FEVER

•            an inflammatory autoimmune disease

•            affects connective tissue of the heart, joints, subcutaneous tissues and

            blood vessels of the CNS

•            most serious complication – RHD affecting the cardiac valves

•            presents 2-6 weeks following an untreated Group A beta hemolytic strep

•            Jones criteria

Asssessment:

•            signs of carditis:  SOB, edema of the face, abdomen or ankles, precordial  pain

•            signs of polyarthritis:  edema, inflammation of the large joints, joint pain

•            erythema marginatum: macular rash on trunk and extremities

•            subcutaneous nodules

•            fever

•            elevated ASO

•            elevated ESR

•            elevated CRP 

Implementation:

•            Assess vital signs

•            Control joint pain and inflammation with massage

•            Febrile phase – provide bed rest

•            limit physical exercise in child with carditis

•            Administer antibiotics (penicillin) as prescribed

•            administer salicylates and anti-inflammatory agents

•            Instruct parents about the importance of follow up and need for

            antibiotic prophylaxis for dental work, infection, invasive procedures

•            advise child to inform the parents if anyone in school develops a

            strep throat infection

KAWASAKI DISEASE

•            known as mucocutaneous lymph node syndrome

•            acute systemic inflammatory illness

•            unknown cause

•            cardiac involvement – most serious complication

Assessment:

•            fever

•            conjunctival injection

•            red throat

•            Swollen hands, rash, enlargement of the cervical lymph nodes

Implementation:

•            monitor temperature frequently

•            assess heart sounds and rhythm

•            assess extremities for edema, redness, desquamation

•            monitor mucus membrane for inflammation

•            weigh daily

•            administer IV immune globulin

•            instruct parents in the administration of prescribed meds

                  aspirin – need to monitor bleeding