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Annette Tomlinson

Cardiovascular Dysfunction
In children this is divided into 2
Congenital heart Disease (CHD)
These are anatomic abnormalities present at
birth that result in abnormal cardiac function.

Acquired heart disease

These are disease processes or abnormalities
that occur after birth and can be seen in in the
normal heart or in the presence of congenital
heart defects.

Congestive Heart Failure

The clinical consequence of
congenital heart disease

Congestive Heart Failure

Inability of heart to pump sufficient amount
of oxygen to meet metabolic needs of body
Usually due to a surgically correctable
structural abnormality of the heart that
results in increased blood volume and
Goals of treatment include improving cardiac
function; removing accumulated fluid,
sodium; decreasing cardiac demands;
improving tissue oxygenation; decreasing
oxygen consumption.

Assessment - CHF
Assessment of early signs
Tachycardia, especially during rest
and slight exertion
Profuse scalp sweating in infants
Fatigue; irritability
Sudden weight gain
Respiratory distress

Assessment - CHF
Cardiomegaly, peripheral pulses, mottling
Tachypnea, retractions, grunting, nasal
flaring, cough, cyanosis, orthopnea
Hepatomegaly, edema, decreased urine
Failure to thrive, decreased exercise

Nursing Interventions CHF

Decrease energy expenditure

Frequent rest periods

Small, frequent feedings
Minimize crying
Prevent cold stress

Provide nutrition

Use soft nipple

Gavage feeding if needed

Nursing Interventions CHF

Monitor fluid status

I & O, specific gravity

Daily weight

Provide adequate rest, position for

Prevent infections
Promote growth & development
Reduce respiratory distress

Nursing Interventions CHF

Administer digoxin (Lanoxin)
as prescribed after
assessing apical pulse for 1

Check dosage with another RN
Give 1 hour before feeding or 2 hours
after feeding
Give at 12 hour intervals (BID)
Take apical pulse for 1 minute
Hold if HR <90 in infants or<70 in

Monitor serum potassium levels
If signs of hypokalemia occur and child
receiving digoxin, monitor closely for signs
of digoxin toxicity
Signs of toxicity: vomiting, nausea,
bradycardia, lethargy
If receiving furosemide (Lasix), administer
supplemental potassium supplements after
assessing serum potassium levels

Instruct parents regarding description of diagnosis,
administration of medications
Administer 1 to 2 hours after feedings
Use calendar to mark off dose administered
Do not mix medication with foods, fluid
If dose is missed and more than 4 hours has elapsed,
withhold dose and give next dose at prescribed time;
if less than 4 hours, then administer dose
If child vomits, do not administer replacement dose
If more than two consecutive doses missed, notify

Circulatory Changes at
When the umbilical cord is clamped,
the blood supply from the placenta is
cut off, and oxygenation must then
take place in the infants lungs
As the lungs expand with air, the
pulmonary artery pressure decreases
and circulation to the lungs increases

Circulatory Changes at
Structural Changes
Ductus venosus: after the umbilical
cord is severed, flow through the ductus
venosus decreases and eventually
ceases; it constricts within 3-7 days

Circulatory Changes at
Foramen ovale
Functional closure of this valve-like
opening occurs when pressure in the left
atrium exceeds pressure in the right.
Closure occurs within the first weeks
after birth

Circulatory Changes at
Ductus arteriosus
Increase in aortic blood flow increases aortic
pressure and decreases and stops the flow
between the left pulmonary artery and the
dorsal aorta through the ductus arteriosus.
Functional closure occurs when this
constriction causes cessation of blood flow,
usually 24 hours after birth.
Anatomic closure by 1-3 weeks.

Abnormal Circulatory
Patterns After Birth
Normal blood flow may be disrupted
as a result of abnormal openings
between the pulmonary and systemic
Any time there is a defect, blood will
go from high to low pressure.

Normal Blood Flow

Normally pressure is higher in the
systemic circulation, so blood will be
shunted from systemic to pulmonary
Left to right shunt

With an obstruction to pulmonary

blood flow, as well as an opening
between ventricles, the blood flow
may be right to left

Feeding problems: fatigue, irritability,
tachypnea, profuse sweating, reflux
Failure to thrive, poor weight gain
Respiratory difficulties: tachypnea,
difficulty breathing, frequent
respiratory infections, periods of
anoxia, nasal flaring, retractions

Activity intolerance: restlessness,
Color changes: pallor, cyanosis,
clubbing of digits
Hematologic: polycythemia
Organ enlargement: liver, spleen, heart


Chest x-ray
Cardiac fluoroscopy
Hematologic testing
Cardiac catheterization

Cardiac Catheterization
Cardiac Catheterization is an invasive
diagnostic procedure in which a
radiopaque catheter is inserted
through peripheral blood vessel into
the heart.

Cardiac Catheterization
The catheter is usually threaded into right side
of the heart.
Nursing care pretest
Preparation teaching done on childs developmental
level Educate parents about procedure
Administer medications as ordered
NPO for 4-6 hours or more before procedure
Assess accurate height and weight
Assess allergy for iodine
Mark baseline distal pulses and oxygenation

Cardiac Catheterization
Nursing care posttest
Check extremity distal to catheterization site for color, temperature, capillary refill
Keep extremity distal to the catheterization site extended
Check pressure dressing over site for bleeding
Monitor heart rate for bradycardia, tachycardia and dysrhythmia
Monitor oxygen saturation, distal pulses, signs of bleeding every 15 min 4, every 30
min 4, then every hour 4, then every 2 to 4 hours
Maintain immobility of extremity used in procedure
Maintain pressure dressing
Encourage fluid intake
Notify physician for signs of hemorrhage
Administer acetaminophen (Tylenol) for discomfort as prescribed
Discharge teaching for child, parents
Keep site clean, dry, covered for 2 to 3 days

Report signs of redness, edema, discharge to physician

Avoid strenuous activity for 2 to 3 days

Cardiac Catheterization
Nursing posttest
Monitor for temperature elevation due
to physiologic dehydration (NPO,
contrast media)
Monitor urine output and blood pressure

Cardiac Surgery
Postoperative interventions
Monitor vital signs frequently
Monitor for signs of sepsis, including
diaphoresis, lethargy, fever, altered level of
Maintain aseptic technique
Monitor all lines, tubes, catheters as
Assess for discomfort, pain; medicate as
Encourage periods of rest

Cardiac Surgery
Encourage parents to maintain normal
childhood routines and discipline
Avoid immunizations, invasive procedures,
dental care for 2 months
Stress importance of dental care, after
waiting period, every 6 months
If signs of infection, respiratory difficulty,
changes in normal behavior occur, notify

Cardiac Surgery
Postoperative home care
Omit outside play for 2 to 3 weeks
Avoid strenuous activities, activities where
child could fall for 2 to 4 weeks
No organized physical education for 2
Avoid crowds for 2 weeks
No-added-salt diet as prescribed
Maintain clean, dry incision



Acynotic heart defects

Oxygenated blood is shunted from the

systemic to pulmonary circulation (leftto-right shunt) and blood leaving the
aorta is completely oxygenated. You see
increased pulmonary blood flow
Increased Pulmonary

Obstruction to Blood Flow from

Atrial septal defect

Coarctation of the Aorta

Ventricular septal defect

Aortic Stenosis

Patent ductus arteriosus

Pulmonary Stenosis

Atrioventricular canal

Cyanotic heart defects
Unoxygenated blood is shunted from the
right to the left side of the heart
where it mixes with oxygenated blood
Decreased Pulmonary

Mixed Blood Flow

Tetraogy of Fallot

Transposition of the Great

Tricuspid atresia

Total Anomalous Pulmonary
Venous Return
Truncus Arteriosus
Hypoplastic Left Heart Syndrome

Atrial Septal Defect


Abnormal opening in the septum

between left and right atria
Left-to-right shunt
Infant may be asymptomatic or may
develop congestive heart failure (CHF)
Symptoms include: decreased exercise
tolerance, dyspnea, and systolic ejection
murmur heard best in upper left sternal
Surgical correction at 2-4 years of age

Ventricular Septal
Defect (VSD)
Opening in the septum between ventricles,
causing a left-to-right shunt
Symptoms include: tachycardia, dyspnea,
increased respiratory effort, fatigue, frequent
respiratory infections, systolic murmur heard
best at lower left sternal border, widened
pulse pressure, bounding pulses present
Surgical correction if childs shunt is persistent

Patent Ductus Arteriosus

Allows oxygenated blood pumped into the
aorta from the left ventricle to return to the
Large PDAs cause excess blood in the lungs and
volume overload, leading to CHF
Widened pulse pressure, bounding pulses present
Machinery-type murmur
Surgical ligation if necessary

Atrioventricular Canal Defect

Atrioventricular canal defect is a combination of several
abnormalities in the heart present at birth (congenital
abnormalities). This defect occurs when there's a hole
between the chambers of the heart and problems with the
valves that regulate blood flow in the heart.
Infant usually has mild to moderate CHF; cyanosis
increases with crying
Atrioventricular canal defect is often associated with
Down syndrome. To fix this defect, doctors often
recommend surgery during the first year of life to close
the holes and reconstruct the valves.

Atrioventricular Canal

Coarctation of the Aorta

Narrowing of the aorta usually just
beyond the subclavian artery
Blood pressure higher, bounding pulses in upper
extremities versus lower and weak or absent
pulses in lower extremities versus upper
extremities, as well as cool lower extremities
Signs of CHF may occur in infants
Children may experience headaches, dizziness,
fainting, epistaxis

Blood pressure
higher in arms than
Warm upper body,
cool lower body
peripheral pulses in
lower extremities

Predisposition to
Angioplasty or

Aortic Stenosis
Aortic stenosis is the inability of the aortic valve to
open completely.
With aortic stenosis, problems with the aortic valve
make it harder for the leaflets to open and permit
blood to flow forward from the left ventricle to the
Children show signs of exercise intolerance, chest
pain, dizziness when standing for long periods

Aortic Stenosis

Pulmonic Stenosis
Pulmonary stenosis is a condition characterized by
obstruction to blood flow from the right ventricle to
the pulmonary artery.
This obstruction is caused by narrowing or stenosis at
one or more of several points from the right ventricle to
the pulmonary artery. It includes obstruction from
thickened muscle below the pulmonary valve, narrowing
of the valve itself, or narrowing of the pulmonary artery
above the valve
Characteristic murmur present

Pulmonic Stenosis

Tetrology of Fallot
Most common cyanotic heart defect
Four components:
Pulmonary stenosis
Overriding aorta

Aorta sits near core of the heart over the

VSD and therefore receives blood from
both ventricles

Right ventricular hypertrophy


Right-to-left shunting
Decreased blood flow to the lungs; mixture of unoxygenated
blood going to aorta causes cyanosis and dyspnea
Symptoms: activity intolerance, irritability, failure to
thrive, polycythemia, harsh systolic murmur best heard along
the left sternal border and hypercyanotic (tet spells)
Infants have acute episodes of cyanosis (hypercyanotic
spells, blue spells, tetralogy [TET] spells) during periods of
crying, feeding, defecating
Children present with squatting, clubbing of fingers, poor
Treatment: Surgical repair

Hypercyanotic (Tet)
Hypoxic episodes
Symptoms include: cyanosis, tachypnea,
altered LOC, may progress to seizures,
CVA, death
May be precipitated by crying, feeding,
defecation, pain
Treatment: oxygen, knee-chest position,

Tet Position

Elsevier items and derived items 2011, 2007,

2006 by Saunders, an imprint of Elsevier Inc.


Tricuspid Atresia
The tricuspid heart valve is missing or
abnormally developed. The defect blocks
blood flow from the right atrium to the right
Tricuspid atresia is an uncommon form of
congenital heart disease that affects about 5
in every 100,000 live births. Twenty percent
of patients with this condition will also have
have other heart problems.
Signs and symptoms
Cyanosis, tachycardia, dyspnea in newborn

Tricuspid Atresia

Truncus arteriosus


Truncus arteriosus (TRUNG-kus ahr-teer-e-O-sus) is a rare heart defect

that's present at birth (congenital). If your baby has truncus arteriosus, it
means that one large blood vessel leads out of the heart. Normally, there are
two separate vessels coming out of the heart.
In addition, the two lower chambers of the heart are missing a portion of the
wall that divides them. As a result of truncus arteriosus, oxygen-poor blood
that should go to the lungs and oxygen-rich blood that should go to the rest
of the body are mixed together. This creates severe circulatory problems.
If left untreated, truncus arteriosus can be fatal. Surgery to repair truncus
arteriosus is generally successful, especially if the repair occurs before your
baby is 2 months old.
Characteristic murmur present
Infant exhibits moderate to severe CHF, variable cyanosis, poor
growth, activity intolerance

Truncus arteriosus

Hypoplastic left heart syndrome
occurs when parts of the left side of
the heart (mitral valve, left
ventricle, aortic valve, and aorta) do
not develop completely. The condition
is present at birth (congenital)
Mild cyanosis, signs of CHF occur
until ductus arteriosus closes

Hypoplastic left heart


Total anomalous pulmonary

venous connection
Total anomalous pulmonary venous return is
aheart disease that is present at birth (
congenital heart disease) in which none of the
four veins that take blood from the lungs to the
heart is attached to the left atrium (left upper
chamber of the heart).
Signs of CHF develop
Cyanosis worsens, with pulmonary vein

Total anomalous pulmonary

venous connection

Transposition of the
Great Vessels
Aorta arises from right ventricle; pulmonary artery arises
from left ventricle
Oxygenated blood circulates through left side of the heart
to lungs and back to the left side, unoxygenated blood
enters right atrium from body, goes to right ventricle, and
back out to the body without being oxygenated
Infants with minimal communication severely cyanotic at
Presence of large septal defects or patent ductus
arteriosus may be less severely cyanotic, but with
symptoms of CHF

Child cannot live without a
communication between atria or
Palliative treatment: balloon
septostomy to create ASD
When child old enough the defect will
be repaired

Assessment - Cyanotic
Clubbing of digits
Increased RBCs
FTT, exercise
HR, RR, dyspnea
Poor feeding, weak

Squatting (helps to
blood flow to
extremities & to
keep oxygenated
blood for brain &
Risk for left-sided
failure, clots

Nursing Interventions
Do not interfere if child is squatting
Organize care to decrease childs energy
Administer oxygen as needed
Meet needs quickly; prevent crying
Use soft nipples to decrease energy of

Nursing Interventions

Monitor for hypercyanotic spells

Assess for signs of CHF
Assess peripheral pulses
Maintain strict fluid restriction
Monitor intake, output
Obtain daily weight
Provide high-calorie diet
Administer medications as prescribed
Keep child as stress-free as possible
Child should have maximal rest
Prepare child, parents for cardiac catheterization, if

Acquired Heart
Rheumatic Fever
Kawasaki Disease

Rheumatic Fever (RF)

Inflammatory, autoimmune disease that

affects connective tissues of heart, joints,
subcutaneous tissues, blood vessels of
central nervous system
Presents 2 to 6 weeks after untreated or
partially treated group A beta-hemolytic
streptococcal infection of upper
respiratory tract
Prognosis depends on degree of

heart damage

Assessment - RF
Major Symptoms (Jones Criteria)
Aschoff nodules (areas of inflammation &
degeneration around heart valves, found in heart,
blood vessels, brain, serous surfaces of joints
Valvular insufficiency (mitral/aortic)
Shortness of breath, edema, hepatomegaly

Assessment - RF
Major Symptoms (Jones Criteria)
Most common in large joints which become red
and swollen, painful

Chorea (St. Vitus dance)

CNS disorder characterized by abrupt,
purposeless, involuntary muscular movements

Assessment - RF
Major Symptoms (Jones Criteria)
Subcutaneous nodules

Usually a sign of severe disease

Occur with active carditis
Firm, non-tender nodes on bony prominence
of joints

Erythema marginatum

Transient, nonpuritic rash

Assessment - RF
Minor symptoms

History of RF
Recent strep infection
Diagnostic tests
Elevated antistreptolysin O (ASO) titer
Positive elevated sedimentation rate ESR
Changes on ECG
Elevated C-reactive protein level; Aschoffs
bodies found in heart, blood vessels, brain,
serous surfaces of joints

Nursing Interventions
Administer Penicillin as ordered
Use prophylactically

Promote bed rest

Aspirin as ordered
Change position in bed frequently

Nursing Interventions
Decrease stimulation
Provide safe environment

Nodules and Rash: none

Alleviate childs anxiety about the
ability of heart to continue to
Minimize boredom

Nursing Interventions
Provide client teaching and discharge
planning concerning:
Adaptation of home environment to promote
bed rest
Importance of prophylactic regimen
Avoidance of reinfections
Diet modifications
Home-bound education

Management - RF
Drug Therapy

Penicillin, erythromycin
anti-inflammatory agents as prescribed

Decrease cardiac workload

Bed rest until lab studies return to

Management - RF
Administer massage, heat and cold
therapies as prescribed for joint pain
Bed rest during febrile phase
Limit physical exercise in child with carditis
Instruct parents about follow-up care, need
for prophylactic antibiotic therapy prior to
dental care and invasive procedures

Kawasaki Disease
An acute systemic inflammatory disease
A multisystem disorder involving vasculitis
(inflammation of the inner lining of the arteries
and veins). Cardiac involvement most serious
Also called mucocutaneous lymph node syndrome
In the United States Kawasaki is the most common
cause of acquired heart disease in children
Unknown cause

Stages of Kawasaki Disease

Acute: (days 1-10)
Abrupt onset of fever ,lasting more than
5 days & unresponsive to antipyretics
Conjunctival hyperemia
Red throat
Swollen hands & feet
Cervical node enlargement
Child is VERY irritable

Stages of Kawasaki
Subacute (days 10-25)

Cracking lips and fissures

Desquamation of skin on tips of fingers and
Arthritis & joint pain
Cardiac disease

Convalescent (days 26-40)

Drop in ESR, diminishing signs of illness

Nursing Interventions
Administer aspirin 80-100 mg/kg/day
as ordered while temperature is
elevated Q. 6 hours
Administer IV gamma globulin (IVIG)
to reduce risk of coronary artery
lesions and aneurysms
Provide comfort

Nursing Interventions
Assess vital signs, heart sounds and rhythm
Assess extremities for edema, redness,
Assess mucous membranes for inflammation
Daily weights
Administer soft foods
Provide passive range of motion
Administer acetylsalicylic acid (aspirin) as
Instruct parents in administration of
prescribed medications, need to monitor for

Nursing Interventions
Provide client teaching and discharge
planning concerning:

Safe administration of aspirin therapy

Skin care
Monitoring of temperature
Call MD if child refuses to walk
Signs and symptoms of cardiac disease

The nurse is developing a plan of care for a child admitted

with a diagnosis of Kawasaki disease. In developing the
initial plan of care, the nurse documents to monitor the
child for signs of:


Failure to thrive
Congestive heart failure (CHF)
Decreased tolerance to stimulation

Elsevier items and derived items 2008

by Saunders, an imprint of Elsevier Inc.


The nurse is assigned to care for an infant with tetralogy of

Fallot. The mother of the infant calls the nurse to the room
because the infant suddenly seems to be having difficulty
breathing. The nurse enters the room and notes that the
infant is experiencing a hypercyanotic episode. The initial
nursing action is to:

Call a code.
Contact the respiratory therapy department.
Place the infant in a prone position.
Place the infant in a knee-chest position.

Elsevier items and derived items 2008

by Saunders, an imprint of Elsevier Inc.