The Child with a

Cardiovascular Disorder

Nursing 352
Khulood Shattnawi
History Taking
• Must be careful. Some of the symptoms are very subtle.
• Some symptoms do not show up right after birth
• Typical presentations of infants are tachycardia,
tachypnea, and poor feeding
• Older children may present with fatigue and frequent
lower respiratory infections. Some children may
perspire excessively
• Edema is a late sign and usually presents first as
periorbital edema.
• Cyanosis
• May complain of decreased UOP
• May have headaches, nose bleeds, high blood pressure
in upper extremities

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 History Continued

• Obtain a detailed prenatal history including exposure

to infections (cytomegalovirus, toxoplamosis, rubella
or varicella), medication usage, drug and alcohol use,
nutrition, exposure to radiation
• Determine if there is any family history of congenital
heart defects or heart disease.

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Physical Assessment

• Compare height and weight to standard growth

chart
• Assess:
capillary refill presence of clubbing
ruddy complexion vital signs
Lethargy rapid respirations
tachycardia abnormal body posture
cyanosis presence of a murmur

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Innocent murmur

• An innocent or functional heart murmur is a

murmur not resulting from heart disease.
This is the most common type of heart
murmur. It is heard because the child may
have fever, anemia, or a thin chest. It
disappears when the fever subsides or when
the anemia is treated.

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Organic murmur

• A murmur, which indicates there is

something abnormal in the heart or a major
artery is, called a not-innocent, not-
functional, or organic murmur. A narrow
valve, a leaking valve, or a hole in the heart,
usually causes it.

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 – With all murmurs, document position in
cardiac cycle, duration, quality, pitch,
intensity, location, whether there is a thrill
and whether the murmur changes with
position change
– Organic murmurs are either systolic or
diastolic, long, harsh or blowing, loud,
constant and heard not matter what position
the child is in
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• Common nursing diagnoses:
– Decreased cardiac output related to congenital
structural defect
– Altered tissue perfusion related to inadequate
cardiac output
– Knowledge deficit related to care of the child pre-
and postoperatively
– Fear related to lack of knowledge about child’s
disease
– Altered family processes related to stresses of the
diagnosis and care responsibilities
– Ineffective individual or family coping related to
lack of adequate support
– Altered parenting related to inability to bond with
critically ill newborn

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 Diagnostic Tests

• ECG - indicates HR, rhythm, presence or absence of

hypertrophy, ischemia or necrosis, abnormalities in
the conduction system, presence of electrolyte
imbalances
• Chest x-ray - shows heart size and shape, presence
of CHF, prominence of pulmonary blood flow
• Fluoroscopy can be used to visualize the chambers
of the heart, the great vessels, lungs, thoracic cage
and diaphragm. Sometimes radioactive dye in
injected. Sometimes contrast dye in used in
conjunction with a cardiac cath

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Diagnostic Tests Cont’d

• Echocardiogram - primary diagnostic test. Looks at

the movement and dimensions of the cardiac
structures using high-frequency sound waves
• Phonocardiogram - heart sounds are recorded and
displayed as a diagram
• MRI - used to evaluate heart structure, size or blood
flow
• Treadmill - studies response to exercise
• Lab tests - Hgb and Hct (polycythemia), ESR
(rheumatic fever, myocarditis), ABG (presence of a
right to left shunt), O2 Sat, clotting times (PT, PTT)
and platelet count, Na, K, dig level

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 Cardiac Catheterization
• Can be either diagnostic or interventional
– Pressures in the heart can be measured
– CO can be evaluated
– Blood samples can be obtained and tested (O2 sat)
– Electrical activity can be studied
– Contrast can be injected to study blood flow, vessels
and chambers
– Balloon angioplasty can be performed to stretch
stenosed areas or blockages in vessels

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• Pre-procedure - Patient teaching
– How the test will be done
– what to expect during the test,
– that afterward the child will have to lie flat
and will have a bulky dressing over the
catheter insertion site

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 Cardiac Catheterization Cont’d
• Post-Procedure
– Will have to lie flat 3-4 hours
– VS every 15 minutes for the first several hours
– Check site every 15 minutes for integrity of dressing,
hematoma, redness, swelling
– Check pulses distal to site. Also check extremity for capillary
refill and warmth
– Avoid dehydration
– Avoid hypothermia
– Check site daily for signs of infection
– Avoid tub baths and strenuous exercise for 2-3 days

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 Congenital Heart Disease
• Occurs in about 8% of term newborns. Higher in pre-
term infants. Can be as high as 10-15% in infants who
have a parent with aortic stenosis, ASD, VSD, or
pulmonic stenosis
• Females - more prone to have PDA and ASD
• Males - more prone to have valvular aortic stenosis,
coarctation of the aorta, TOF and transposition of the
great vessels
• The usual cause is failure of the heart to develop beyond
an early stage of embryonic development
• Maternal rubella is associated with PDA, stenosis, ASD,
VSD
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Congenital Heart Disease

• Classification
– Acyanotic vs. Cyanotic
• Left-to-right shunt - oxygenated to unoxygenated blood
• Right-to-left shunt - deoxygenated blood to oxygenated
blood
– Hemodynamic and Blood Flow Patterns - allows
more predictable signs and symptoms
• Increased pulmonary flow
• Obstruction to blood flow (out of the heart)
• Decreased pulmonary flow
• Mixed blood flow (oxygenated and deoxygenated blood
mixing in the heart or great vessels)
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 Acyanotic Cyanotic
(left-to-right shunt) (right-to-left shunt)
(1) Increased (2) Obstruction (3) Decreased (4) Mixed blood
pulmonary blood to blood flow pulmonary blood flow
flow from ventricles flow

Atrial septal Coarctation of Tetralogy of Transposition of

defect. aorta. fallot. great arteries.

Ventricular septal Aortic stenosis. Tricuspid atresia. Total anomalous

defect. pulmonary venus
return.

Patent ductus Pulmonic Truncus

arteriosus. stenosis. arteriosus.

Atrioventricular Hypoplastic left

canal. heart syndrome.
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Defects with Increased Pulmonary Blood Flow

• Blood flows from the left side of

the heart to the right side of the
heart through an abnormal
opening or connection between
the system or great arteries
– Ventricular Septal Defect (VSD)
– Atrial Septal Defect (ASD)
– Atrioventricular canal defect
(AVC)
– Patent Ductus Arteriosis (PDA)

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Ventricular Septal Defect

• VSD - most common, 25% of all defects,

2 in every 1000 live births
– opening in the septum between the two
ventricles
– results in right ventricular hypertrophy and
increased pressure on the pulmonary artery

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VSD Cont’d

– VSD May be classified according to location:

• membranous VSD - an opening in the upper section
of the ventricular septum, near the valves, occurs in
75- 80 % of all VSD cases.
• muscular VSD - an opening in the lower section of
the ventricular septum occurs in up to 20 percent of
all VSD cases.
– May not be evident at birth because high
pulmonary resistance from incomplete opening
of alveoli keeps the blood from coming across to
the right ventricle

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 – S&S (by age 4 to 8 weeks) - develops a loud,
harsh, systolic murmur along the left sternal
border 3rd or 4th ICS, widely transmitted,
usually with a thrill
– Respiratory manifestations
– RV hypertrophy may also be seen on ECG

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Symptoms
• Shortness of breath
• Fast breathing
• Hard breathing
• Paleness
• Failure to gain weight
• Fast heart rate
• Pounding heart
• Sweating while feeding
• Frequent respiratory infections
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Treatment
– 60% close spontaneously - otherwise at risk
of infectious endocarditis and cardiac failure
– May require a Silastic or Dacron patch to
close opening if edges can’t be approximated
and sutured

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Atrial Septal Defect (ASD)

• Abnormal opening between the two atria

– ASD1 (ostium primum) – 5% defect is at the lower
end of the septum
– ASD2 (ostium secondum) – 90% defect is near the
center of the septum and may be asymptomatic
– Sinus venosus defect: 5 % of ASDs, opening high
in the atrial septum, near junction of superior
vena cava and right atrium.
• Harsh systolic murmur over 2nd or 3rd ICS, fixed
splitting of S2

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Symptoms
• Echo will show enlarged right side and
increased pulmonary circulation
• At risk for infectious endocarditis and
heart failure
• Frequent respiratory infections in
children
• Difficulty breathing (dyspnea)
• Shortness of breath with activity
• palpitations in adults
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Treatment

• May require a patch if defect not able to

be closed
• May have arrhythmias post-op

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Atrioventricular Canal (AVC) Defect

• An incomplete fusion of the endocardial

cushion. May be seen as a low ASD continuous
with a high VSD. Mitral and tricuspid valves
are usually distorted. Seen in 1 out of 9
children with Down syndrome
• Blood flow is usually left to right, but may flow
between all four chambers
• Requires surgical repair and possible double
valve replacement
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Symptoms
• Symptoms: heart failure, characteristic murmur, mild
cyanosis that increase with crying
• fatigue
• sweating
• pale skin
• cool skin
• rapid breathing
• heavy breathing
• rapid heart rate
• congested breathing
• disinterest in feeding, or tiring while feeding
• poor weight gain
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 Patent Ductus Arteriosus (PDA)

• The ductus arteriosus between the pulmonary

artery and the aorta fails to close at birth
• May not close until 3 months causing blood to be
shunted from the aorta to the pulmonary artery
• Usually hear a continuous (systolic and diastolic)
murmur at the upper left sternal border or under
the clavicle of older children
• ECG is usually normal, may show ventricular
enlargement if the shunt is large

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While some cases of PDA are symptomatic,
common symptoms include:
• tachycardia or other arrhythmia
• respiratory problems
• shortness of breath
• continuous machine-like murmur
• enlarged heart

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 PDA Cont’d

• May be given indomethacin or a prostaglandin inhibitor

to lower plasma prostaglandin E1 (PGE1) levels and
stimulate closure. Drug may be repeated as many as three
times 12 to 24 hours apart
• If medical management fails -
– ligation of defect
– visual assisted thoracoscopy (VAT) - a clip is placed on
the ductus
• If not surgery, child is a risk for heart failure related to
the increased shunting, infectious endocarditis from
recirculating blood and potential stasis in the PA
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 Obstructive Defects

• Narrowing of a vessel or valve.

Results in high pressure before
the obstruction and lower after
the obstruction. Prevents
sufficient blood supply from
reaching its intended site
– Coarctation of the aorta
– Aortic stenosis
– Pulmonic stenosis

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Coarctation of the Aorta

• A constrictive band causes narrowing of the aorta

either between the subclavian vein and the ductus
arteriosus (infantile or preductal) or distal to the
ductus arteriosus (postductal)
• Since BP is greatest in the subclavian vein, you will
see higher pressures in the upper extremities (at
least 20 mmHg) than in the lower extremities. The
increased BP can cause headaches or nosebleeds.
Can even cause a CVA (arteries in the head and arms may
become weakened by high pressure. Spontaneous tears in any of
these arteries can occur)
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Coarctation of the Aorta Cont’d

• May only have a decreased femoral pulse. As

child grows older. Veins may become visible on
the chest. Child may complain of leg pain on
exertion.
• The left ventricle has to work harder to try to
move blood through the narrowing in the
aorta.

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Symptoms
• Dizziness or fainting
• Shortness of breath
• Pounding headache
• Chest pain
• Cold feet or legs
• Nosebleed
• Leg cramps with exercise
• Hypertension (high blood pressure) with exercise
• Decreased ability to exercise
• Failure to thrive
• Poor growth
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 Coarctation of the Aorta Cont’d

• Repaired either with balloon angioplasty or

surgical removal of the narrowed portion.
Usually scheduled around age 2.

• May have abdominal discomfort for a while

post-op related to increased blood flow to lower
part of the body.
• Will usually still have an elevated BP for a
while.

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 Aortic Stenosis (AS)

• Prevents blood from flowing freely from the LV to the aorta

• Can lead to hypertrophy of the left ventricle and heart
failure and pulmonary edema
• Accounts for 5% of congenital abnormalities
• Types of AS:
– Valvular stenosis, the most common type, is usually caused by
malformed cusps resulting in a bicuspid rather than tricuspid valve or
fusion of the cusps.
– Subvalvular stenosis, is a stricture caused by a fibrous ring below a
normal valve.
– Supravalvular stenosis, occurs infrequently.

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• The child is usually asymptomatic.
– Will usually hear a rough systolic murmur at 2nd ICS right sternal
border.
– May see signs of decreased CO
• faint pulses, hypotension, tachycardia, poor feeding.
– Child may develop chest pain with activity.
– Sudden death can occur when O2 demand far exceeds supply
– Children born with aortic stenosis may show symptoms of shock,
poor feeding, failure to thrive, and shortness of breath
• ECG may show left ventricular hypertrophy. Cath can
show degree of stenosis
• Treated with balloon angioplasty or surgical repair to
divide the stenotic valve or dilate a constrictive aortic ring

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Pulmonic Stenosis
• Pulmonic Stenosis - 25% to 35% of
anomalies
– May be asymptomatic or have mild heart
failure
– Usually systolic murmur with a thrill. Heard
loudest at the upper left sternal border. May
have a split S2
– ECG may show right ventricular
hypertrophy. Cath can demonstrate degree
of stenosis.
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Symptoms
• Shortness of breath
• Fatigue
• Cyanosis
• Chest pain
• Fainting
• Poor weight gain or failure to thrive in infants
• Sudden death

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 Pulmonary Stenosis Cont’d
– Treatment depends on severity of stenosis and the
child’s age
• If severe, the pressure may reopen the foramen ovale allowing
flow from right to left causing cyanosis
• If severe, then given PGE1 to keep ductus arteriosus from
closing so that the infant can get more oxygenated blood
• Balloon angioplasty may be tried to break valve adhesions
and relieve the stenosis
• If there is a lesser degree of stenosis, the child can be allowed
to wait until they are 4 or 5 years old so that there is less
surgical risk

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FIGURE 26–6 Interventional catheterization, balloon valvuloplasty to open the pulmonary valve.

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Defects with Decreased Pulmonary Blood
Flow

• Involve an obstruction of
pulmonary blood flow
which increases pressure
in the right side of the
heart.
– If an ASD and or VSD
also exists, then
deoxygentated blood
shunts from the right
side to the left side
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Tricuspid Atresia

• Tricuspid valve is completely closed.

– Blood can’t flow from RA to RV so goes through the
patent foramen ovale to the LA.
– Oxygenation occurs by blood being shunted through
a patent ductus to the lungs
– If the foramen ovale and ductus arteriosus close, the
patient becomes profoundly cyanotic, tachycardic
and dyspneic.
– It is often associated with pulmonic stenosis and
transposition of great arteries.

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 – Kept on PGE1 until surgery
– Surgery consists of creating a subclavian-
pulmonary artery shunt or restructuring the
right side of the heart with a baffle (Fantan
procedure: connections between the right
atrium and pulmonary artery )

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 Tetralogy of Fallot (TOF)
• 10% of congenital defects.
– Consists of 4 anomalies
• Pulmonary stenosis
• VSD (usually large)
• Overriding of the aorta
• Hypertrophy of the RV (acquired from the
increased pressure in the RV from trying to
push blood through the stenosed pulmonary
artery)
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 – “Blue baby” although may not be
dramatically cyanotic immediately after
birth
– Exhibit poor physical growth, clubbing,
systolic murmur, hypoxic spells (TET spells),
polycythemia, activity intolerance and
squatting (a knee-chest position )

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FIGURE 26–10 A child with a cyanotic heart defect squats (assumes a knee–chest position) to relieve cyanotic spells.

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TOF cont’d

• X-ray shows cardiomegaly. Echo and ECG show the

enlarged RV. Echo also shows decreased size of the
PA and reduced flow through the lungs. Extent of
the defect is determined through cardiac cath. Lab
values show increased RBC’s and reduced O2 sat
• Usually wait until child is 1 or 2 years old. Some
institutions perform surgery earlier to prevent
hypoxic episodes
• If having hypoxic episode, place infant in knee-to-
chest position.

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FIGURE 26–12 Place the infant who has a hypercyanotic spell in the knee–chest position. This position increases systemic vascular
resistance in the lower extremities.

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 TOF cont’d

• Can have a palliative repair in which the

subclavian artery is used to create an
artificial ductus arteriosus (Blalock-
Taussing procedure) to allow blood to
flow from the aorta to the lungs
• Full repair includes relief of pulmonary
stenosis, VSD repair and correction of
the overriding aorta
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MIXED DEFECTS

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Transposition of the Great Arteries

• - The aorta comes off of the RV and the pulmonary artery comes
off of the LV. (5% of anomalies)
– Unless the infant also has an ASD and/or VSD this is
incompatible with life because you have two closed systems
• RA - RV - Aorta - body - vena cava to RA
• LA - LV - Pulmonary artery - lungs - pulmonary veins to LA
– Usually cyanotic at birth, may have no murmur or various
murmurs
– Will be given PGE1 to try to keep the ductus open. Can also
have balloon passed through foramen ovale in order to
enlarge the opening
– Surgical intervention involves switching the aorta and the
pulmonary artery

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Truncus Arteriosus

• Truncus Arteriosus - the infant has a single

vessel coming off the RV and LV instead of a
separate pulmonary artery and aorta.
– There is usually also a VSD
– Child is cyanotic
– deoxygenated and oxygenated blood mix
back and forth through the ventricular
septal defect.

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Symptoms
• cyanosis
• fatigue
• sweating
• pale skin
• cool skin
• rapid breathing
• heavy breathing
• rapid heart rate
• congested breathing
• disinterest in feeding,
or tiring while feeding
• poor weight gain

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• Modified Rastelli procedure is usually
performed after the infant is 2 weeks old,
but before the blood vessels in the lungs
are overwhelmed by extra blood flow and
become diseased.
• The pulmonary arteries are detached from the
common artery (truncus arteriosus) and connected to
the right ventricle using a homograft
• The ventricular septal defect is closed with a patch.
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 Hypoplastic Left Heart Syndrome

• Most of the structures on the left side of the

heart are small and underdeveloped.
• The degree of underdevelopment differs
from child to child.
• The structures affected usually include
Mitral valve, Left ventricle, Aortic valve
and the Aorta.

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Hypoplastic Left Heart Syndrome

– The RV hypertrophies as it tries to do all of

the work
– Patient becomes increasingly cyanotic as
more unoxygenated blood is shunted to the
left side
– Treatment is aimed to keep the ductus
arteriosis open and increase flow of blood to
the aorta

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Symptoms

• cyanosis (blue color of the skin, lips, and

nailbeds)
• pale skin
• sweaty or clammy skin
• cool skin
• heavy and/or rapid breathing
• fast heart rate
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• A series of three operations that are done in
stages:
– one shortly after birth, the second at about 6 months of
age, and the final at about 18 months of age (these
stages may vary).
– In this series of operations, the right ventricle is used as
the main pumping chamber to the body, and blood flow
is redirected to the lungs and the body with various
surgical connections
– Best hope is heart transplant
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Acquired Heart Disease
Rheumatic Fever
• An autoimmune disease that is a reaction to
a group-A beta-hemolytic streptococcus
infection
• Often follows an attack of pharyngitis,
tonsillitis, scarlet fever, “strep” throat, or
impetigo
• It is a diffuse inflammatory disease of
connective tissue, primarily involving heart,
blood vessels, joints, subcut. tissue and
CNS
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Epidemiology
• Ages 5-15 yrs are most susceptible
• Rare <3 yrs
• Girls>boys
• Common in 3rd world countries
• Environmental factors-- over crowding,
poor sanitation, poverty,
• Incidence more during fall ,winter & early
spring
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Pathologic Lesions
• Fibrinoid degeneration of connective
tissue,inflammatory edema, inflammatory cell
infiltration & proliferation of specific cells
resulting in formation of Ashcoff bodies,
resulting in-
– Pancarditis in the heart
– Arthritis in the joints
– SC nodules in the subcutaneous tissue
– Basal gangliar lesions resulting in chorea
– Erythema marginatum: erythematous
macule
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 Carditis
• Manifest as pancarditis (endocarditis,
myocarditis and pericarditis),occur in 40-
50% of cases
• Carditis is the only manifestation of
rheumatic fever that leaves a sequelae &
permanent damage to the organ
• Valvulitis occur in acute phase
• Chronic phase- fibrosis & stenosis of heart
valves (fishmouth valves)
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 Arthritis

• Migratory polyarthritis, involving

major joints
• Commonly involved: knee, ankle,
elbow & wrist
• Occur in 80%,involved joints are
tender
• In children below 5 yrs arthritis
usually mild but carditis more
prominent
• Arthritis do not progress to
chronic disease
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 Subcutaneous
nodules
• Occur in 10%
• Painless,pea-sized,palpable
nodules
• Mainly over surfaces of joints,
spine, scapulae & scalp
• Always associated with severe
carditis

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 Sydenham Chorea

• Occur in 5-10% of cases

• Mainly in girls of 1-15 yrs age
• May appear even 6/12 after the attack of
rheumatic fever
• Clinically manifest as- deterioration of
handwriting, speech, emotional lability or
grimacing of face
• Sudden aimless, irregular movements of
extremities
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 Erythema Marginatum

• Occur in <5%.
• Transient, well-demarcated border
lesions of 1-2 inches in size
• Pale center with red irregular
margin
• More on trunks & limbs & non-
itchy
• Worsens with application of heat
• Often associated with chronic
carditis

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Rheumatic Fever Cont’d

• Other features (minor symptoms):

– fever
– Anorexia, Loss of weight
– fatigue
– Arthralgia (joint tenderness)

• Diagnosis - If have two major symptoms or one

major and two minor symptoms

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 Laboratory Findings

• High ESR
• Anemia, leukocytosis
• Elevated C-reactive protien
• ASO titre >200 Todd units.
(Peak value attained at 3 weeks,then
comes down to normal by 6 weeks)
• Throat culture-GABHstreptococci

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• Treatment
– Bedrest until ESR decreases (degree of bedrest is based
on degree of carditis)
– Antibiotics (penicillin, erythromycin) x 10 days
– Reduce inflammation (Salicylates: aspirin)
– Corticosteroids (if not responding to aspirin alone)
– Phenobarbital for chorea
– Treatment of heart failure
– Prognosis depends on the amount of cardiac involvement
– Kept on prophylactic antibiotics (benzathine penicillin G)
for 5 years or until 18 to prevent recurrence

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 Acquired Heart Disease
Heart failure

• Heart failure:
– The heart can’t pump enough blood to supply oxygen and
nutrients to the body
– The body compensates for a while. For children less than
5 y.o., increase in CO is mostly accomplished through
increased HR
– As renal blood flow decreases, GFR slows allowing
retention of sodium and fluid. When the body senses
decreased supply of oxygen, aldosterone is secreted which
further promotes retention of sodium in an attempt to
increase blood flow to the kidneys. ADH secretion is also
increased to help retain fluid
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Causes of CHF can be classified according to
the following changes:

• Volume overload.
• Pressure overload.
• Decreased contractility: cardiomyopathy or
myocardial ischemia from severe anemia or
asphyxia, heart block, acidemia and low level of
potassium, glucose, calcium or magnesium.
• High cardiac output demands (such as in sepsis,
hyperthyroidism and severe anemia).

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Other Causes
• heart valve disease caused by past rheumatic
fever or other infections
• chronic lung disease
• hypertension
• hemorrhage

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 Heart Failure Cont’d
• Symptoms depend on whether
there is right- or left sided
heart failure
– Right sided HF – unable to
pump much blood forward into
the vessels of the lungs. Because
of the congestion in the right side
of the heart, blood flow begins to
back up into the veins.
Eventually, swelling is noticed in
the feet, ankles, eyelids, and
abdomen due to fluid retention.

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• Left sided HF -unable to pump
blood forward to the body
efficiently. Blood begins to
back up into the vessels in the
lungs, and the lungs become
stressed. Breathing becomes
faster and more difficult
(dyspnea, bloody sputum on
coughing, cyanosis). Also, the
body does not receive enough
blood to meet its needs,
resulting in fatigue and poor
growth.
growth
• Edema is a late sign for
children. If present, it shows
up as periorbital edema

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• In infants, signs can be
breathlessness from rapid
respirations, tiring easily and
poor feeding related to
exhaustion and dyspnea, may
become diaphoretic when feeding,
abrupt weight gain is the most
obvious indication
• Apical heart beat may be
displaced laterally and
downward. May have a third
heart sound.

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• Impaired myocardial function:
– Tachycardia.
– sweating
– decreased urinary output.
– fatigue
– weakness.
– Restlessness.
– Anorexia.
– Pale, cool extremities.
– Weak peripheral pulses.
– Decreased blood pressure.
– Cardiomegaly.
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• Pulmonary congestion:
– Tachypnea.
– Retractions (infants).
– Flaring nares.
– Exercise intolerance.
– Orthopnea.
– Cough, hoarseness.
– Cyanosis.
– Wheezing.
– Grunting.

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• Systemic venous congestion:
– weight gain, even when the appetite is poor
– hepatomegaly.
– visible swelling of the legs, ankles, eyelids, face,
and (occasionally) abdomen
– Ascites.
– Neck vein distention.
– The severity of the condition and symptoms
depends on how much of the heart's pumping
capacity has been affected.

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 Treatment is aimed at
1. improving cardiac function,
2. removing accumulated fluid and
sodium
3. decrease cardiac demands
4. improve tissue O2

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1 & 2 Enhance myocardial performance & removal
of accumulated fluids:

• Digitalis glycosides - Digoxin (given a loading dose and

then a maintenance dose, dig level should be 0.8 to 2.0
u/L, toxicity includes, nausea, vomiting, anorexia, slow
heart rate, family teaching required, hold dose if HR <
90-110 for infants and toddlers, <70-85 for older
children or <60 for adolescents)
• hydralazine (vasodilator), enalapril, or captopril
(capoten) (Angiotensin-converting enzyme (ACE)
inhibitor) reduce afterload on the heart
• Diuretics - Lasix, spironalactone(Aldactone), , thiazides
(Diuril), (may need K replacement

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• ****Important alert: A fall in the serum
potassium level enhances the effects of
digoxin, increasing the risk of digoxin
toxicity. Increased serum potassium
diminishes digoxin's effect. Therefore
serum potassium levels (N= 3.5-5.5
mmol/L) must be monitored****

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3 & 4 Decrease oxygen demands & improve
oxygenation

• Provide rest periods and uninterrupted sleep,

place in Semi-Fowler’s position, space out
activities/procedures, preserve body
temperature, treat any infections
• Administer O2 as needed by hood, mask or
nasal prongs. If prongs are used, check nostrils
q 4hrs
• Adequate nutrition is also important - may
need six to eight small meals daily rather than 3
large meals, may need tube feedings

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