MEDICAL SURGERICAL NURSING

LECTURE / NURS 13
PPTS / BOOK
PEDIATRIC CARDIAC DISORDERS → One umbilical vein that carries oxygenated blood from the
placenta to the baby
OUTLINE 3 FETAL SHUNTS
I Incidence and Causes • Essential to make sure that the fetal circulation works properly
II Fetal Circulation
III Cardiac Disorders in Pediatrics DUCTUS VENOSUS
IV Congenital Heart Diseases
• Found at the liver and umbilical vein that helps shunt oxygenated
I. INCIDENCE AND CAUSES blood to the inferior vena cava
• 5 to 8 in 1,000 live births FORAMEN OVALE
• Cause is unknown
→ Multiple factors • Found in the wall between the right and left atrium that allows
✓ Genetics or family history oxygenated blood from the right atrium to flow into the left atrium
✓ Environment (toxins and viruses) → Shunting blood AWAY from the lungs so it won’t go in the
right ventricle then to the pulmonary artery
Maternal or Environmental (1-2%)
Maternal Drug Use •
→ Fetal alcohol syndrome (50% have DUCTUS ARTERIOSUS
CHD) • Found connecting the pulmonary artery and aorta
• Rubella in the first 7 weeks of • It helps shunt mixed (oxygenate and deoxygenated) blood away
→ pregnancy – 50% risk of defects from the lung
including PDA and pulmonary branch • It flows directly into the aorta where it will eventually travel to the
stenosis umbilical arteries and back to the placenta
Maternal Illness CMV, toxoplasmosis, other viral
→
illnesses lead to cardiac defects
IDMs = 10% of CHD (VSD,
→ cardiomyopathy, and TGA are most
common)
Chromosomal or Genetic (10-12%)
Multifactorial (85%)
→ Most common anomaly is VSD
28% of kids with CHD have another recognized anomaly
→ (trisomy 21, 13, 18, + + +)

II. FETAL CIRCULATION

FETAL TO NEONATAL CIRCULATION

OBJECTIVE OF FETAL CIRCULATION

• To take blood to the placenta instead of the lung to get rid of
waste product and pick-up oxygen
PLACENTA
• Vital for the growth and development of the baby III. CARDIAC DISORDERS IN PEDIATRICS
• It attaches to the wall of the uterus and pulls nutrients and TWO MAJOR GROUPS
oxygen from the mom’s circulation to the baby’s and helps
Disorder Description
remove the build-up of waste from the baby’s circulation
• Born with
• If the placenta is unhealthy the baby’s growth and development Congenital
• Most structural defect
will be hindered
• Develop later in life
• Role of the placenta is to supply the baby (from mom’s
• Bacterial endocarditis
circulation) with nutrient-rich oxygenated blood and remove the
build-up of waste from baby’s circulation to mom’s circulation,
Acquired • Rheumatic fever
who will clear the build-up • Kawasaki disease
• Systemic HTN
• The umbilical cord is made up of:
→ Two umbilical arteries that carry deoxygenated blood from
the baby to the placenta

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TRANS: MEDICAL SURGICAL NURSING (LECTURE)

CLASSIFICATIONS OF CONGENITAL HEART DISEASE → Don’t forget the parents

OLDER CLASSIFICATION → NPO 4-6 hours before the procedure; sedation (IV or PO)
→ Monitor VS, SaO2, Hgb, coags, BMP
Hemodynamic Characteristics → Mark pedal pulses before procedure to ensure correct
→ Pink palpation afterwards
Acyanotic → No unoxygenated blood goes to the → Determine the amount of sedation based on the child’s
periphery age, condition, and type of procedure
•
→ Blue • Post-procedure
•→ Unoxygenated blood is hunted to the → For bleeding at site of insertion of catheter in groin
Cyanotic → Pulses especially distal site of insertion, temperature,
periphery
and color of extremities, VS q15
•
→ May be pink
→ Remember the 5Ps (pain, pallor, pulse, paresthesia,
NEWER CLASSIFICATIONS paralysis) or CMTS (circulation, mobility, temperature,
sensation)
Hemodynamic Characteristics → HR for one full minute for signs of dysrhythmias or
→ Too much to lungs bradycardia
↑ Pulmonary
Blood Flow
→ Pink → Prevent bleeding by keeping leg immobilized for 4-8
→ Pulmonary edema hours
•
→ Too little to lungs → Intake and output – fluids may be offered PO starting with
↓ Pulmonary clear liquids
Blood Flow •
→ Blue → Encourage child to void to promote excretion of contrast
•
→ Cyanotic medium
Obstruction of • Laboratories
Blood Flow Out •
→ Can’t get to lungs or body → Monitor blood glycose as child may need IV with dextrose
of the Heart (infants are at risk of hypoglycemia)
Mixed Blood IV. CONGENITAL HEART DISEASES
Flow •
→ Most common
DEFECTS WITH INCREASED PULMONARY BLOOD
COMPARISON OF CHD CLASSIFICATION SYSTEMS FLOW
PATENT DUCTUS ARTERIOSUS (PDA)
• Ductus does not close
• Common in premature babies
• Machinery murmur audio
• An extra blood vessel found in babies before birth and just after
birth
• A large PDA causes irregular blood flow in the heart and lung
leading high pressures in the pulmonary artery
• The increased pressure damages the smaller blood vessels in
TEST OF CARDIAC FUNCTION the lungs
• Treatment
Clinical Findings → Indomethacin – causes the PDA to constrict, and this
→ Prenatal ultrasound •
→ Cardiac catheterization closes the blood vessel. Prostaglandins, especially E-type
→ Chest x-ray •
→ Stress test (dobutamine or
prostaglandins, maintain the patency of the ductus
exercise) → Catheterization laboratory
→ Electrocardiogram → Cardiac MRI → Ligation
→ Echocardiogram
CARDIAC CATHETERIZATION

ATRIAL SEPTAL DEFECT (ASD)

• Hole between two atria of the heart
• An invasive procedure used to measure cardiac chamber • Usually, asymptomatic
pressures and assess patency of the coronary arteries • If not treated, it can lead to increased risk of atrial dysrhythmia
• A medical procedure used to diagnose and treat some heart or stroke
conditions • Usually close on its own
• It lets doctors take a close look at the heart to identify problems
and to perform other tests or procedures
• Done to get information about the heart or its blood vessels
Benefits Risks
→ Better visualization → Hemorrhrage
Actual pressures, sats,
→ hemodynamic values → Fever
→ Nausea and vomiting
→ Loss of pulse
→ Transient dysrhytmias
• Pre-procedure
→ Complete a thorough history and physical exam
→ Check for allergies to iodine and shellfish
→ Age-appropriate teaching and preparation

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TRANS: MEDICAL SURGICAL NURSING (LECTURE)

VENTRICULAR SEPTAL DEFECT (VSD)

• Hole between two ventricles of the heart
• Symptoms related to size and location of VSD and amount of
pulmonary blood flow
• Fix by patching Goretex
→ Minimizes aneurysmal dilation in a wide variety of
cardiovascular applications including cardiac, great
vessel, and peripheral vascular reconstructions

AORTIC STENOSIS
• Narrowing of the aortic valve
• Obstructs blood flow to the body
• Leads to left ventricle hypertrophy
• Asymptomatic often
• Chest pain with exercise
• Sometimes see sudden death
• Repair with ballooning or replacement of valve

ATRIOVENTRICULAR CANAL DEFECT

• ASD, VSD, mitral, and tricuspid valves
• Associated with down syndrome
• Symptoms related to size of holes. Degree of valvular
involvement, and size of ventricles
• Often accompanied with pulmonary hypertension

PULMONARY STENOSIS
• Narrowing of the pulmonary valve
• Harder for deoxygenated blood to get to pulmonary circulation
• Obstructs blood flow from the right ventricle to the pulmonary
artery
• Leads to right ventricle hypertrophy
• May lead to reopening of foramen ovale
• May lead to congestive heart failure if severe
• Repair with balloon angioplasty of open-heart surgery

NURSING MANAGEMENT
• Avoid oxygen, especially pre-operative
• Diuretics – furosemide, chlorothiazide, spironolactone
• Monitor VS, I&O, daily weight
• Encourage rest periods to conserve energy
• Monitor labs: Hemoglobin, Hematocrit, electrolytes
• Closely monitor feeding – may need higher calorie feeds
OBSTRUCTIVE DEFECTS
• Coarctation of the aorta, aortic stenosis, pulmonic stenosis
• Symptoms dependent upon area of obstruction
COARCTAION OF AORTA CATHETER PLACEMENT
• Narrowed aorta leads to decreased systemic blood flow
• May not present until early childhood
• Bounding upper extremity pulses, weak to absent lower
extremity pulses
• Hypertension
• Post-operative coarctation care
→ Neurological checks
→ Urine output
→ Blood pressure
→ Pain

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TRANS: MEDICAL SURGICAL NURSING (LECTURE)

DEFECTS WITH DECREASED PULMONARY BLOOD TRANSPOSITION OF THE GREAT ARTERIES

FLOW AND MIXED DEFECTS • Two main arteries carrying blood out of the heart – the main
• May or may not be cyanotic (usually rare) pulmonary artery and the aorta – are switched in position
• Tetralogy of Fallot, Transposition of Great Arteries. Truncus • Management:
Arteriosus, Hypoplastic Left Heart Syndrome, etc. → Catheterization laboratory initially
→ Prostaglandins
EFFECTS OF HYPOXEMIA
→ Surgery at 6-7 days old – arterial switch of pulmonary
• Hypoxemia is when oxygen levels in the blood are lower than artery and aorta, but also coronary arteries are switched
normal and re-anastomosed
• Main clinical manifestations: → Long term prognosis is very goods
→ Cyanosis
→ Polycythemia leads to thicker blood
→ Clubbing
→ Clotting abnormalities
→ Delayed growth and development
• Management:
→ Prostaglandin E1 if cyanosis shown as newborn – help
maintain patent ductus arteriosus in neonate and assist
with mixing of oxygenated and unoxygenated blood
→ Assess and treat Tet spells – decrease blood flow to
lungs; sudden turn to bluish and may faint
→ Surgery (corrective or palliative)
→ Prevent dehydration
→ Avoid oxygen – may increase pulmonary blood flow at the
expense of systemic and cardiac perfusion
TETRALOGY OF FALLOT MANAGEMENT OF CHILDREN WITH MIXED DEFECTS
• Ventricular septal defect, Pulmonary stenosis, Overriding
Medications
aorta, Right ventricular hypertrophy
→ Improves contractility of the heart
• Hemodynamics vary widely, depends on extent of pulmonic
valve stenosis and size of VSD
Digoxin → Review digoxin toxicity – pulse rates in
infants and children (Digibind)
• If VSD is large, pressures are in R and L ventricles
→ Furosemide
• Blood is shunted in the direction of least resistance (pulmonary Diuretics
→ Watch out for dehydration
or systemic vascular resistance)
→ Reduce afterload on the heart making it
• Clinical manifestations: Ace-inhibitors
pump more efficiently
→ Vary with types of defects
→ Cause decreased heart rate and BP
→ Tet spells or blue spells with acute episodes of cyanosis Beta-blockers
and hypoxia → Vasodilation
→ May be anoxic after feeding of with crying Decrease Cardiac Workload
→ Risk of emboli, LOC, sudden death, seizures → Medications as stated → Decrease stimulation
• Repairs → Cluster care → Maintain neutral environment
→ Usually indicated when Tet spells and hypercyanotic → Sedation
spells increase Remove Accumulated Fluid and Sodium
→ Stage 1: Blalock or Modifies Blalock shunt – blood to → Monitor I & O → Restrict fluid in acute phase
pulmonary arteries from left or right subclavian artery; → Weigh daily if stable
creates a pathway flow blood to reach lungs
→ Complete repair: Repair VSD, resect stenosed area, and CONTINUED MANAGEMENT OF CONGENITAL HEART
patch right ventricular outflow - usually in 1st year of life FAILURE
• Hypercyanotic “Tet Spells”
Nutrition
→ Acutely cyanotic
→ Decreased pulmonary blood flow and increased rifht to left → Small, frequent feeds → High calorie formula
shunting Decrease Respiratory Effort
→ Prompt treatment to prevent brain damage and death → Rest → Avoid colds
✓ Calms infant or child → Position with HOB → Avoid crying and distress
✓ Place in a knee chest position Family Support / Education
✓ Toddler will get in squatting position to compensate → Keep them present, holding, rocking
for hypoxia Improve Tissue Oxygenation
✓ Give oxygen
✓ Morphine, fentanyl, versed given CARE OF FAMILY AND CHILD WITH CONGENITAL
• Tet repair HEART DISEASE
→ Complicated • Help family adjust to the disorder
→ Dependent on how big the right ventricle is, how stenotic → May be grieving loss of normal child
pulmonary valve is, and how big the VSD is • Educate family
→ Wither fly or die • Help family cope with effects of the disorder
→ Complete repair – operative mortality <3% • Prepared child and family for surgery
→ Remember developmental level of child
→ Pain, scars, IS, activity

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