Guided Lecture Notes

Chapter 40: Nursing Care of the Child With a Cardiovascular Disorder

Learning Objective 1. Discuss anatomic and physiologic differences of the

cardiovascular system in infants and children versus adults. (Refer to Written

Assignment 2; Test Generator Questions 10; Pre-Lecture Quiz T/F 1, 3, 4)

 Explain that the cardiovascular system undergoes numerous changes at birth.

Structures that were vital to the fetus are no longer needed. (Refer to PowerPoint

Slide 2)

 Point out that circulation via the umbilical arteries and vein is replaced with the

child’s own closed independent circulation.

 Review the circulatory changes from gestation to birth. Point out that the fetal heart

is developed within the first 21 days of gestation. Describe fetal circulation. (Refer to

PowerPoint Slide 3)

 Describe the changes that occur in the cardiopulmonary system with the first breath

that enable the newborn to make a successful transition from fetal circulation to

extrauterine circulation.

 Review how the structure and function of the infant’s and child’s cardiovascular

system differ from that of adults, depending upon age. Review the changing size and

location of the heart for the infant, toddler, school-age child, and adolescent.

 Tell students that the ventricle walls are similar in thickness at birth, but with time

the left wall thickens. Explain that right ventricular function dominates at birth and

then left ventricular function becomes dominant.

  Explain that the infant’s sarcoplasmic reticulum is less well organized than the

adult’s, making the infant dependent upon serum calcium for contraction.

 Explain that the heart’s efficiency increases as the child ages and the heart rate drops

over time. Review normal heart rates for the infant, toddler, school-age child, and

adolescent.

Learning Objective 2. Describe nursing care related to common laboratory and

diagnostic testing used in the medical diagnosis of pediatric cardiovascular conditions.

(Refer to Written Assignment 1; Case Study; Test Generator Questions 15)

 Explain the laboratory and diagnostic tests used for cardiovascular disorders in

children. Review the nursing implications for each. (Refer to PowerPoint Slide 6)

 Emphasize to students that that nurse should be familiar with how tests are obtained,

what they are used for, and normal versus abnormal results. Point out that this

knowledge is necessary when providing client and family education related to the

testing.

 Tell students that cardiac catheterization is the definitive study for infants and

children with cardiac disease. Explain that cardiac catheterization may be

categorized as diagnostic, interventional, or electrophysiologic. Review the key

considerations for nursing management, including preprocedure nursing assessment

and preparation of the child and family, postprocedural nursing care, and discharge

teaching. Review the teaching guidelines.

Learning Objective 3. Discuss cardiovascular disorders common in infants, children,

and adolescents. (Refer to Group Assignment 2; Case Study; Test Generator

Questions 1, 3, 4, 5, 6, 7, 8, 14; Pre-Lecture Quiz T/F 2, 5; Pre-Lecture Quiz FitB 1,

2, 3, 4, 5)

 Describe congenital heart disease (CHD). Explain that the exact cause in unknown,

but the belief is that it results from interplay of several factors, including genetic

factors and maternal exposure to environmental factors, such as toxins, infections,

and chronic illnesses. Review the chromosome defects associated with CHD. (Refer

to PowerPoint Slide 9)

 Tell students that pressure gradients are necessary for adequate circulation to the

lungs and the rest of the body. Explain that these pressure gradients become

disrupted if a structure has failed to develop or failed to close, or narrowing or

transposition has occurred.

 Note that some of the defects may result in significant hypoxemia, the sequelae of

which include clubbing, polycythemia, exercise intolerance, hypercyanotic spells,

brain abscess, and cerebrovascular accident.

 Point out that the traditional approach to categorizing congenital heart defects has

been whether the child exhibited cyanosis as a clinical manifestation. Thus, the

classification was termed cyanotic versus acyanotic. Emphasize that this is not

always accurate. Therefore, this chapter uses the more useful classification method

of categorizing the disorders based on hemodynamic characteristics (blood flow

patterns in the heart).

 Explain disorders with decreased pulmonary blood flow, including tetralogy of Fallot

and tricuspid atresia. (Refer to PowerPoint Slide 12)

 Review disorders with increased pulmonary blood flow, including patent ductus

arteriosus (PDA), atrial septal defect (ASD), and ventricular septal defect (VSD).

(Refer to PowerPoint Slides 13, 14)

 Identify the three types of ASD based on the location of the opening.

 Review the pathophysiology of VSD. Define Eisenmenger’s syndrome.

 Explain obstructive disorders, including coarctation of the aorta, aortic stenosis (AS),

and pulmonary stenosis (PS). Note that the elevation in blood pressure with

coarctation of the aorta can increase the risk for aortic rupture, aortic aneurysm, and

cerebrovascular accident (CVA). (Refer to PowerPoint Slide 15)

 Describe mixed disorders, including transposition of the great vessels (TGV), total

anomalous pulmonary venous return (TAPVR), truncus arteriosus, and hypoplastic

left heart syndrome. Note that as a result, systemic blood flow contains lower oxygen

content. (Refer to PowerPoint Slides 16, 17)

 Review acquired cardiovascular disorders. Explain that they are a result of an

underlying cardiovascular problem or may refer to other cardiac disorders that are

not congenital. Note that the most common type of acquired cardiovascular disorder

in children is heart failure. (Refer to PowerPoint Slide 21)

 Review the pathophysiology and therapeutic management of heart failure. (Refer to

PowerPoint Slides 22, 23)

 Discuss the key considerations for the nursing management of heart failure. Tell

students that nursing management focuses on promoting oxygenation, supporting

cardiac function, providing adequate nutrition, and promoting rest.

 Explain infective endocarditis. Describe Roth’s spots, Janeway lesions, Osler’s

nodes, and Black lines. Review the factors that increase the risk for infective

endocarditis in children. (Refer to PowerPoint Slide 24)

 Explain acute rheumatic fever. Note that the diagnosis of rheumatic fever is based

upon the modified Jones’ criteria. (Refer to PowerPoint Slide 25)

 Discuss cardiomyopathy and review the three types (restrictive, dilated,

hypertrophic). Review the risk factors. (Refer to PowerPoint Slide 28)

 Review hypertension. Note that hypertension in children most commonly occurs

secondary to an underlying medical problem, most often renal disease. Review the

risk factors for hypertension. (Refer to PowerPoint Slide 29)

 Discuss Kawasaki disease. Review the pathophysiology, nursing assessment,

laboratory and diagnostic testing, and nursing management. (Refer to PowerPoint

Slide 30)

 Explain hyperlipidemia and cholesterol levels in children. (Refer to PowerPoint

Slide 31)

 Discuss heart transplantation. Discuss candidacy for heart transplants and reasons for

exclusion. Review the surgical procedure and preoperative therapeutic management.

Discuss immunosuppression therapy. (Refer to PowerPoint Slide 32)

Learning Objective 4. Identify appropriate nursing assessments and interventions related

to medications and treatments for pediatric cardiovascular disorders. (Refer to Written

Assignment 3; Case Study; Discussion Topics 1, 2; Test Generator Questions 2, 11,

12)

 Tell students that a variety of medications as well as other medical treatments and

surgical procedures are used to treat cardiovascular problems in children.

 Note that laboratory or non-nursing personnel obtain some of the tests, while the

nurse might obtain others. Emphasize that the nurse should be familiar with how the

tests are obtained, what they are used for, and abnormal versus normal results.

Learning Objective 5. Develop an individualized nursing care plan for the child with a

cardiovascular disorder. (Refer to Group Assignment 1; Discussion Topics 1)

 Identify the most common nursing diagnoses associated with cardiovascular

disorders in children.

 Explain that the nursing goals, interventions, and evaluation for a child with

cardiovascular disorder are based on the nursing diagnoses. Emphasize that the plan

should be individualized based on the child’s needs.

 Tell students that the child with a congenital heart defect has multiple needs and

requires comprehensive multidisciplinary care. Note that nurses play a key role in

helping the child and family during this intensely stressful time.

 Review the key considerations for improving oxygenation.

  Review interventions to assist the child and family to cope with the diagnosis of

CHD. Emphasize the importance of preventing infection. (Refer to PowerPoint

Slide 18)

 Review the key considerations for providing care for the child undergoing cardiac

surgery. Discuss preoperative care, parent and child education, and care during the

postoperative period.

Learning Objective 6. Describe the psychosocial impact of chronic cardiovascular

disorders on children. (Refer to Web Assignment 1, 2; Discussion Topics 1)

 Emphasize that the diagnosis of CHD is an especially overwhelming time for the

child as well as for the parents. Note that the numerous examinations, diagnostic

tests, and procedures are sources of stress for the child regardless of age.

 Discuss common fears, such as the possibility of long-term disability and death or

concerns that engaging in any activity will worsen the child’s status.

 Explain that it is common for parents to overprotect the child.

 Discuss the importance of using language that the parents and child can understand.

Review the importance of encouraging parents and the child as developmentally

appropriate to participate in the child’s care.

 Emphasize the importance of encouraging attachment and bonding with the newborn

and infant. Review play therapy.

Learning Objective 7. Develop a nutrition plan for the child with cardiovascular disease.

(Refer to Clinical Assignment 2; Test Generator Questions 9)

  Emphasize that adequate nutrition is critical due to the increased energy expenditures

associated with increased cardiac and respiratory workloads. Review the key

considerations for promoting adequate nutrition.

 Note that many of the defects lead to heart failure; this may affect the child’s fluid

balance, further increasing the child’s energy expenditure.

Learning Objective 8. Develop client/family teaching plans for the child with a

cardiovascular disorder. (Refer to Clinical Assignment 1; Discussion Topics 1, 2; Test

Generator Questions 13)

 Tell students that initial teaching focuses on the underlying defect and measures to

treat or control the problem.

 Explain that if the child needs surgery, teaching shifts to preoperative and

postoperative events. Emphasize the importance of discharge teaching for each

admission. (Refer to PowerPoint Slide 18)