The Child with Cardiovascular Dysfunction - PowerPoint Presentation

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The Child with Cardiovascular Dysfunction

Lecture 2

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Congenital Heart Disease Are anatomic abnormalities of the heart that are present at the birth and impair cardiac function.

Two main clinical manifestation HFHypoxia 2

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Location of the HeartThe heart is located in the chest between the lungs behind the sternum and above the diaphragm. It is surrounded by the pericardium. Its size is about that of a fist, and its weight is about 250-300 g.

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Pediatric differences Cardiac functioning: Infants have a great risk of heart failure than older child because the immature heart is more sensitive to volume or pressure overload.

Heart muscle fully developed at five year.Metabolic rate and oxygen requirements double at birth so the HR is high

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Congenital Heart Disease

Incidence: 5-8 per 1000 live births About 2-3 of these are symptomatic in first year of life.Major cause of death in first year of life (after prematurity)

Most common anomaly is VSD

85% with newborn are expected to survive

.

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Risk factors

Maternal rubella during pregnancy.Maternal alcoholism, drug use.Maternal age

Maternal type one diabetes.

Several genetics factors, down syndrome , turner syndrome

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Down Syndrome is a genetic abnormality. It is the most common single cause of birth defects, This syndrome occurs because of an extra copy of chromosome 21.Sign and symptom flat facial features

small head and earsshort neckbulging tongueeyes that slant upwardoddly shaped earspoor muscle tone.impulsive behavior

poor judgment

short attention span

slow learning capabilities

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Turner's SyndromeCause: Turner's Syndrome is caused by a condition known as Monosomy

(absence of entire chromosome) of X chromosome for females.Primarily Affects: FemalesDiscovered By: Dr. Henry H. TurnerSymptoms: Low-set ears, webbed neck, broad chest, non-working ovaries, hypothyroidism, diabetes, vision problems,

neuro

/cognitive deficiency, congenital heart disease, etc.

Turner's Syndrome occurs in approximately 1 of every 2,000 female births.

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Changes at Birth

Foramen ovaleDuctus arteriosus

Ductus

venosus

http://www.barnesjewish.org/animations/?sid=1&animationid=194

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Pediatric Indicators of Cardiac Dysfunction

Poor feedingTachypnea/ tachycardiaFailure to thrive/poor weight gain/activity intolerance

Developmental delays

+ Prenatal history

+ Family history of cardiac disease

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Fetal circulation

http://www.indiana.edu/~anat550/cvanim/fetcirc/fetcirc.html14

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Fetal Circulation

During pregnancy blood is transferred from placenta through umbilical vein into the ductus venosus (opining into the inferior vena cava). Then blood is carried to the right atrium in which is forced into the left atrium by an opining between the two atriums called foramen

ovale

.

Blood

is transferred into the left ventricles and to the whole body through aorta.

Some

blood pass into the right ventricle, in which it moved to the lungs by the pulmonary artery.

But

, the majority of this blood pass into the aorta by an opining between aorta & pulmonary artery called

ductus

atreriousus

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After birth, the newborn start breathing which increase the lung expansion, helping in shifting of blood into the lungs by the pulmonary artery not into the aorta by the ductus arteriosus as during pregnancy. This will lead to increase pulmonary blood flow & decrease pulmonary vascular resistance.

Also leading to increase blood returned to the left atrium through pulmonary veins & this leads to increase pressure in the left atrium. The increasing pressure stimulate the closure of the foramen ovale and. Ductus

arteriosus

close in response to increase O2saturation after 10-12 hours and permanently after 10-21 days.

Fetal Circulation

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Two Types of Cardiac Defects

CongenitalAnatomic>abnormal functionAcquired

Disease process

Infection

Autoimmune response

Familial tendencies

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Diagnostic procedure

Cardiac catheterizationChest X rayEchoECGTreadmill Test

Holter

monitor

Hyperoxi

test

MRI

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Newer Classification of CHD

Increased pulmonary blood flowDecreased pulmonary blood flowObstruction of blood flow out of the heart

Mixed blood flow

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1. Increased Pulmonary Blood Flow Defects

Abnormal connection between two sides of heartEither the septum or the great vesselsIncreased blood volume on right side of heart

Increased pulmonary blood flow

Decreased systemic blood flow

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Increased Pulmonary Blood Flow Defects

Examples:Atrial septal

defect - ASD

Ventricular

septal

defect - VSD

Patent

ductus

arteriosus

- PDA

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Abnormal opening between atria, allowing blood from Lt atrium (higher pressure) to go to right atrium (lower pressure).

Pathophysiology:The new volume in the right ventricle is tolerable because it was sent by a low pressure from the right atrium.

S&S

: CHF

, poor growth with large ASD, murmur.

Surgical treatment

Surgical Dacron Patch

Closure or open heart surgery

Non-surgical Repair:

in catheterization, a repair pad is implanted.

Patients with ASD may live several decades without S&S and the prognosis after operation is very high.

Atrial Septal Defect - ASD

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ASD

Three types:

Ostium

primum

ASD1 ( lower end of the septum )

Ostium

secundum

ASD2 ( center of the septum )

Sinus

venosus

defect (opening near junction of SVC & right atrium)

Complication

:

arrhythmias, Murmur, emboli

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ASD patch or device 26

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2) VSD, Ventricular Septal Defect

:

VSD

It is an abnormal opening between the right and the left ventricles, resulting in a common ventricle.

its found that 20% of all VSDs close spontaneously during the first year of life

Pathophysiology

: the blood turns from the left ventricle (higher pressure) to the right ventricle (lower pressure) causing

left-to-right shunt

,

then to pulmonary Artery, which increases RV pressure causing RV hypertrophy and by time RV failure.

S&S

: congestive heart failure is common. Increase number of pulmonary Infection , pulmonary

hypertention

Surgical treatment:

complete repair.

Non-surgical treatment

:

closure device is usually implanted during cardiac catheterization

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VSD Device 29

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(3) PDA: Patent Ductus Arteriosus

it’s failed to closed at birth ,blood will shunt from the aorta to the pulmonary artery.S & S:

dyspnea

, tachycardia,

tachypnia

widening pulse pressure, hypotension CHF, Intercostals retraction, High risk to respiratory infection

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Treatment

Observation . In a premature baby, a PDA often closes on its own. The doctor will monitor your baby's heart to make sure the open blood vessel is closing properly. Medications. In a premature baby, nonsteroidal anti-inflammatory drugs (NSAIDs) — such as ibuprofen (Advil, Infant's Motrin, others) or indomethacin

(

Indocin

) — might be used to help close a PDA. NSAIDs block the

hormonelike

chemicals in the body that keep the PDA open.

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Treatment Open-heart surgery. If medications aren't effective and your child's condition is severe or causing complications, open-heart surgery might be recommended. A surgeon makes a small cut between

child's ribs to reach child's heart and repair the open duct using stitches or clips.

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2. Obstruction of blood flow out of the heart

Coarctation of the Aorta (COA)Localized narrowing near the insertion of the ductus arteriosus resulting an increase the pressure proximal to defect.

Sign and symptom:

Pulse in the arms strong, weak or

abcsent

in the lower extremities,

hypotensive

, acidosis, headache and fainting

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Treatment 1. Resection with end-to-end

anastomosis:This method involves removing the narrowed segment of the aorta (resection) followed by connecting the two ends of the aorta together (anastomosis).2. Bypass graft repair. This technique involves bypassing the narrowed area by inserting a plastic tube called a graft between the portions of the aorta.

3. Patch

aortoplasty

.

treat

coarctation

by cutting across the narrowed area of the aorta and then attaching a patch of synthetic material to widen the blood vessel. Patch

aortoplasty

is useful if the

coarctation

involves a long segment of the aorta.

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Treatment cont … 4. Balloon angioplasty and stentingBalloon angioplasty is an option for initially treating aortic

coarctation or for treating re-narrowing (re-coarctation) that has occurred after surgery.During this procedure, the doctor inserts a thin, flexible tube (catheter) into an artery in your groin and threads it through your blood vessels to your heart using X-ray imaging.doctor places an

uninflated

balloon through the opening of the narrowed aorta. When the balloon is inflated, the aorta widens and blood flows more easily.

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COA

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Obstruct the pulmonary blood flow result in little or no blood reaching the lung to get oxygenated.

3. Decreased pulmonary blood flow38

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3.Decreased pulmonary blood flow

Tetralogy Of Fallot (TOF):The classic form includes:

Ventricular

septal

defect.

Pulmonary

stenosis

.

Overriding aorta.

Right

venticular

hypertrophy.

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Tetralogy Of Fallot

(TOF):Pathophysiology: the altered hemodynamic status depends on the size of the VSD and the pulmonary

stenosis

, blood get shunted from right to left, if the pressure in the pulmonary is higher than the systemic pressure, and blood gets shunted from left to right if the systemic pressure is higher than pulmonary. Pulmonary

stenosis

decreases blood flow to lungs & consequently the oxygenated blood that returns to Lt side of the heart.

Surgical treatment

: complete repair is required, open heart surgery& VSD closure

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Tetralogy Of Fallot

(TOF):Sign and symptom: cyanosis, murmur, hypoxia, clubbing of fingers, poor growthPatient at risk of: emboli, CVA, seizures and sudden death.Surgical intervention: complete repair in the first year of the life.

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The nurse instruct the mother to place the infant in knee chest position to facilitate breathing.

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4. Mixed defect

Transposition of the great arteries (TGA)

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Transposition of the great Arteries

The aorta arises from the right ventricle and the pulmonary artery from the left.The mixing of the blood occurs at the PDA.

The signs include cyanosis and

cardiomegaly

.

There may be no murmur.

An echocardiogram is diagnostic

Or X ray.

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What are the symptoms of TGA?Cyanosis is noted in the first hours of life

Rapid breathingHypoxia, CHF developed labored breathing Rapid heart rate

Cool, clammy skin

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Diagnostic test

Chest x-ray Electrocardiogram Echocardiogram (echo)

Cardiac catheterization

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Echocardiogram

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Treatment Prostaglandin is ordered to maintain a patent ductus arteriosus

.Oxygen administered Surgery before 1 week.Survival with out surgery is impossible.49

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CHD Most Common Cause of CHF in Infants

S/S: Tachycardia, Diaphoresis, Tachypnea,

Feeding problem, Crackles & Respiratory Distress, Edema, weight

gain.

CXR Shows Large Heart.

Echocardiogram is Diagnostic.

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Congestive Heart Failure (CHF)

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Congestive Heart Failure (CHF)

Medical Management:Digoxin

To Make Heart Work More Efficiently

Not given if HR less than 90 for infant.

Lasix

/Diuretics To Remove Excess Fluid

Oxygen: Potent Vasodilator which decreases pulmonary vascular resistance.

Rest, a neutral thermal environment, semi-Fowler position, cluster care to promote uninterrupted rest

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CHF

Nursing careMonitor physiologic functions: BP, HR, RRAssess

crackels

Prevent infection; Group care; Semi-Fowler position.

Adequate Nutrition: Feeding Techniques: 45 Degree Angle; Rest Frequently.

Promote Development: Play, Age Appropriate Toys, Physical Activities With Rest Periods

Emotional Support: Prevent Hypoxia From Agitation or Distress; Consistency of Caregiver for Patient; Refer-Parent-to-Parent Support Groups.

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Nursing Process Overview for the Child with CHD

Assessment

Health History

pregnancy, feeding problems, siblings , respiratory difficulty and family history.

Physical Examination

Sign and symptom (respiratory distress and poor feeding.

Growth problems.

Edema

Cyanosis, murmur

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Assess for sign and symptoms of hypoxemia

Polycyethemia Clubbing

Cyanosis

Assess the tongue and

buccal

membrane

Assessment (cont’d)

Laboratory and Diagnostic Testing

Cardiac Catheterization

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Nursing Diagnosis:

Activity intolerance related to decreased tissue oxygenation.

Anxiety related to hypoxia

Decrease cardiac out put related to increased cardiac workload.

Delayed growth and development related to hypoxia.

Risk for infection related pulmonary stasis.

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Nursing intervention of the Child with CHD

Improving Oxygenation.Promoting Adequate Nutrition.Offer frequent high calorie every three hrs.Provide iron supplements

Maintain hydration

Blood transfusion

Assisting the Child and Family to Cope.

Preventing Infection.

Providing Care for the Child Undergoing Cardiac Surgery

Providing Preoperative Care

Providing Postoperative Care.

Providing Patient and Family Education.

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Rheumatic fever is an inflammatory disease that may develop after an infection with group A 

Streptococcus bacteria (such as strep throat). The disease can affect the heart, joints, skin, and brainRheumatic fever mainly affects children ages 5 -15, and occurs approximately 14-28 days after strep throat.

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Signs and symptoms

Abdominal pain

Fever

Heart (cardiac) problems, which may not have symptoms, or may result in shortness of breath and chest pain

Joint pain, arthritis(mainly in the knees, elbows, ankles, and wrists)

Joint swelling; redness or warmth

Nosebleeds (

epistaxis

)

Skin nodules

Skin rash (

erythema

)

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The Major criteria for diagnosis include:

Arthritis in several large joints (polyarthritis) Heart inflammation (carditis)

Nodules under the skin (subcutaneous skin nodules)

Skin rash (

erythema

marginatum

)

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Treatmentantibiotics such as penicillin, sulfadiazine, or erythromycin) over the long term to prevent strep throat from returning

Anti-inflammatory medications such as aspirin or corticosteroids reduce inflammation to help manage acute rheumatic fever.

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Homework 2

Write Nursing care for patient with:Pulmonary atresia

Rheumatic fever

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THANK YOU

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GOOD LUCK !!!!!!!

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