Cardiovascular Disorders and Fetal Circulation

• Cardiovascular disorders include congenital and acquired heart diseases
• Anatomic abnormalities present at birth can lead to congenital heart disease (CHD)
• CHD primarily leads to heart failure and hypoxemia
• Heart failure happens when the heart cannot pump enough blood to meet the body's needs
• Changing lifestyles and socioeconomic conditions are increasing hyperlipidemia and obesity in children
• This can lead to heart disease in adulthood

Fetal Circulation

• Fetal heart rate is present 17 days after conception
• The 4 heart chambers are formed during gestational weeks 2-8
• Oxygenation in the fetus occurs via the placenta, not the lungs
• The foramen ovale is an opening between the atria that allows blood flow from the right to the left atrium
• The ductus arteriosus allows blood flow between the pulmonary artery and the aorta to shunt blood away from pulmonary circulation
• With the first breath, the transition from fetal to normal circulation occurs, closing the foramen ovale, ductus arteriosus, and ductus venosus

Congenital Heart Disease

• Congenital heart disease is caused by unknown reasons
• It can result from genetics or maternal exposure to environmental factors like toxins, infections, or alcohol
• Interference in heart structure development during fetal life leads to anatomic defects
• These defects prevent normal blood flow to pulmonary and systemic systems
• Congenital defects are categorized by blood flow patterns in the heart
• There are 4 categories of defects

Categories of Defects

• Decreased pulmonary blood flow example includes tetralogy of Fallot and tricuspid atresia
• Increased pulmonary blood flow example includes patent ductus arteriosus(PDA), atrial septal defect(ASD), and ventricular septal defect(VSD)
• Obstruction to blood flow includes coarctation of the aorta, aortic stenosis, and pulmonary stenosis
• Mixed blood flow includes transposition of the great vessels, truncus arteriosus, and hypoplastic left heart syndrome

Ventricular Septal Defect (VSD)

• A VSD increases pulmonary blood flow
• It is an opening between the right and left ventricles
• VSD is the most common congenital defect
• A VSD causes a left-to-right shunt and a loud, harsh murmur
• A vibration (thrill) could be palpable
• Spontaneous closure occurs in about half of children by age 2

Atrial Septal Defect (ASD)

• An ASD involves a passageway or hole in the wall (septum) that divides the right atrium from the left atrium
• It causes increased pulmonary blood flow (left-to-right shunt) and a loud, harsh murmur with a fixed split second heart sound
• 80% of infants experience spontaneous closure within the first 18 months of life
• It may be asymptomatic or cause heart failure

Patent Ductus Arteriosus (PDA)

• PDA causes increased pulmonary blood flow.
• It is a failure of the ductus arteriosus, a fetal circulatory structure, to close within the first weeks of life.
• The aorta and pulmonary artery are connected
• PDA is the second most common CHD
• It causes tachycardia, tachypnea, bounding peripheral pulses, and widened pulse pressure
• A PDA also causes a harsh, continuous machine-like murmur
• It may be asymptomatic or cause heart failure

Level Up RN Video

• The Level Up RN video features information on VSD, ASD, PDA, Tetralogy of Fallot, and Tricuspid Atresia

Pulmonary Stenosis

• Pulmonary stenosis presents with obstructed blood flow
• It is a narrowing of the pulmonary valve or pulmonary artery that obstructs blood flow from the right ventricle to the lungs
• It can lead to mild dyspnea and cyanosis with exertion, which can worsen with severe narrowing
• A high-pitched click may follow the second heart sound, along with a systolic ejection murmur and cardiomegaly
• Children with it may be asymptomatic or show heart failure signs and symptoms

Aortic Stenosis

• Aortic stenosis is a disease with obstructive blood flow
• It is a narrowing of the aortic valve that decreases cardiac output and lead to left ventricular hypertrophy
• Aortic stenosis is typically asymptomatic in children
• Infants might experience faint pulses, hypotension, tachycardia, and poor feeding tolerance
• Children might experience intolerance to exercise, dizziness, and chest pain
• Both infants and children may have an ejection murmur.

Coarctation of the Aorta

• Coarctation of the aorta is a disease with obstructed blood flow
• The lumen of the aorta narrows, usually at or near the ductus arteriosus
• This obstruction result in form the left ventricle to the body
• Elevated BP in the arms, decreased BP in legs, bounding pulses in the upper extremities
• Patients may have cool skin to the lower extremities, weak or absent femoral pulses
• Heart failure in infants, and dizziness, headaches, fainting, or nosebleeds in older children

Tricuspid Atresia

• Tricuspid atresia decreases pulmonary blood flow (between the right atrium and right ventricle).
• There is complete closure of the tricuspid valve, preventing blood flow from the right atrium to the right ventricle
• An atrial septal opening (hole in septum between right and left atria) to allow blood into the left atrium
• Infants will experience cyanosis, and dyspnea with heart failure
• Children will experience hypoxemia, and clubbing of fingers.

Tetralogy of Fallot

• A disease causing decreased pulmonary blood flow.
• Tetralogy of Fallot is composed of four heart defects: pulmonary stenosis, VSD, overriding aorta, and right ventricular hypertrophy
• Symptoms include cyanosis at birth that progresses over the first year.
• Episodes of acute cyanosis/hypoxia (tet spells) can be relieved with the knee-chest position.
• Cyanotic level increases at rest or with crying/activity
• The heart murmur is loud and harsh.

Transposition of the Great Vessels

• A disease that causes a mixed blood flow
• The aorta is connected to the right ventricle instead of the left; the pulmonary artery is connected to the left ventricle instead of the right.
• Septal defect or patent ductus arteriosus must be present for body to be oxygenated
• Murmur is present from the defects
• Cyanosis varies size of associated defects
• Cardiomegaly and heart failure also manifest

Truncus Arteriosus

• A disease with mixed blood flow.
• Truncus arteriosus results from failure of septum formation. This results in a single vessel that comes off of the ventricles
• Symptoms include heart failure, murmur, variable cyanosis, delayed growth, lethargy, fatigue, poor feeding habits, adventitious breath sounds, and tiring easily

Hypoplastic Left Heart Syndrome

• It is a disease of mixed blood flow
• The left side of the heart is severely underdeveloped, and the left ventricle is nonfunctional
• ASD or patent foramen ovale allows for oxygenation of the blood
• Cyanosis, poor feeding, tiring easily, tachycardia, tachypnea, hypothermia (cold hands and feet), adventitious breath sounds, and a single second heart sound can be the symptoms
• Once PDA closes, the cyanosis progresses, and cardiac output decreases to lead to cardiac collapse, increasing the risk of death

Heart Failure

• Impaired myocardial function, systemic venous congestion, and pulmonary congestion are all causes
• Tachycardia, fatigue/orthopnea, cool extremities with weak pulses, peripheral edema, neck vein distention, weight gain, dyspnea/cyanosis, and clubbing of fingers are all manifestations

Labs and Diagnostics

• Labs to run are ABGs, HGB, HCT, & Serum Electrolytes
• Diagnostics to run are ECG, CXR, Echocardiogram, & Cardiac Catheterization

Cardiac Catheterization

• It is an invasive test used for diagnosing and repairing some defects, and evaluating dysrhythmias
• A radiopaque catheter will be introduced peripherally and threaded into the heart w/ fluoroscopy
• A contrast medium (iodine) is injected and images of blood vessels and heart are taken as the medium is diluted and circulated throughout the body

Pre-op Care

• Assess for evidence of infection, iodine, and shellfish allergies
• The patient should be NPO 4-6 hours prior and have baseline vitals and oxygen saturation taken
• Pulses in lower extremities should be located and marked

Post-op care

• Provide continuous cardiac monitoring w/ oxygen saturation
• Vital signs are assessed for a full minute
• Palpating pulses to check for equality and symmetry
• Perform neurovascular checks to the affected extremity
• Observe the insertion site, assess temperature and color of the affected affected, and monitor for bleeding or hematoma
• Maintain a clean pressure dressing and keep the affected extremity straight for 4-8 hours with limited activity for 24 hours by laying flat and encouraging voiding to excrete contrast medium
• Monitor for hypoglycemia

Complications of Cardiac Cath

• Complications include nausea/vomiting, low-grade fever, loss of pulse in catheterized extremity, transient dysrhythmias, and acute hemorrhage from extremity site
• Apply direct continuous pressure 2.5cm above the catheter site where the vessel puncture happens
• Position the child flat to reduce bleeding rate
• Notify provide immediately if bleeding, administer medication to control emesis and monitor for infection

Nursing care of cardiac disorders

• Remain calm when providing care and encourage family coping
• Maintain fluid/ electrolyte balances
• The patient should stay hydrated
• Administer prescribed medication
• Conserve energy: provide frequent rest, cluster care, small frequent meals, bathe, keep crying to a minimum if cyanotic
• Provide adequate nutrition while decreasing workload of heart
• Monitor daily weight, I/O, HR, BP, renal function, serum electrolytes
• Increase tissue oxygenation

Digoxin Medication

• Digoxin improves myocardial contractility
• Monitor pulse and hold the medication as prescribed:
• If HR<90 bpm, hold medication for Infants
• If HR<70 bpm, hold for children
• Assess for digoxin toxicity symptoms like bradycardia, nausea, and vomiting
• Monitor serum digoxin levels; Therapeutic levels are 0.5-2 ng/mL

Captopril or Enalapril Medication

• Captopril and enalapril are ACE inhibitors that reduce afterload by causing vasodilation and decrease the pulmonary and systemic vascular pressure
• Monitor BP before giving
• Monitor for hyperkalemia
• Educate family to monitor BP frequently

Metoprolol or Carvedilol Medication

• Metoprolol and carvedilol are beta blockers that decrease HR/BP and cause vasodilation
• Monitor pulse and BP prior to giving
• The primary adverse effects are dizziness, hypotension, and headache

Furosemide or Chlorothiazide Medication

• They are potassium-wasting diuretics that rid body of excess sodium and fluid
• Encourge high potassium diet, daily weights and strict I/O
• Monitor for hypokalemia
• Can be mixed with juice to decrease harsh taste but may cause GI issues
• Consume banana, melons, tomatoes, bran, potatoes, oranges, juice

Infective (bacterial) Endocarditis

• This is a microbial infection of the endothelial (inner lining) surfaces of heart's chambers, septum, or valves (most common).
• It occurs when bacteria or fungi gain access to damaged epithelium
• Common causes include Streptococcus or Staphylococcus aureus
• Risk factors in individuals with congenital or acquired heart disease, prosthetic valves, central venous catheters, and previous heart surgery

Expected findings of infective endocarditis

• Common finds would be: Low grade fever, fatigue, weight loss, flu-like symptoms (arthralgia, myalgia, chills, night sweats), decreased appetite, new or changing murmur, and splenomegaly

Nursing Management and Education of infective endocarditis

• Start an IV antibiotic/antifungal at least 4 weeks via PICC line
• Follow AHA (American Heart Association) protocol for bacterial endocarditis prophylaxis, antibiotic therapy before dental work, respiratory or GI surgeries.
• Educate family importance of prophylactic antibiotic therapy before procedures and maintain a high level of oral care

Acute Rheumatic Fever

• This is an inflammatory disease that occurs as a reaction to GABHS (group A beta-hemolytic strep-strep throat) infection of the throat
• Develops 2-4 weeks after the initial streptococcal infection and is most common in school age children during winter months
• Attacks last 6-12 weeks, but rheumatic fever may recur with subsequent streptococcal infections

Assessment /Expected Findings of acute rheumatic fever

• Symptoms include fever, joint pain, and a recent streptococcal infection
• Note the heart murmur, firm, painless, subcutaneous nodules on the surfaces of the wrist, elbows, and knees
• Assess for chorea (involuntary, abnormal, sudden jerky muscle movements involving the face and shoulders normally) and classic rash (erythema marginatum-pink, nonpruritc macular rash on the trunk and inner surfaces of extremities that appears and disappears rapidly).

Nursing care and management of acute rheumatic fever

• Encourage bed rest during acute illness
• Administer antibiotics as prescribed
• Encourage nutritionally balanced meals
• Check for chorea
• Start a full 10 day course of penicillin therapy
• Provide corticosteroids and NSAIDs
• Give monthly IM injection of Penicillin G or daily oral doses of penicillin prophylactically

Hyperlipidemia

• Hyperlipidemia is when the patient has high levels of lipids (fat/cholesterol) in blood, which could lead to coronary artery disease
• Early detection and intervention are important, especially with a family history of heart disease.
• The provider will run tests such as a Lipid profile and fasting blood glucose

Nursing Care and Education for hyperlipidemia

• Assist in screening children who are at risk, and reviewing client diet history with dietician
• Diet education includes: low fat, whole grains, fruit, veggies and canola and olive oil.
• Help start an exercise program (60 min per day/ 5 days per week of aerobic exercise)

Kawasaki Disease

• This is an acute systemic vasculitis (inflammation of the blood vessels) occurring mostly in children 6 months to 5 years of age
• It can weaken walls of vessels and cause aneurysms and can cause cardiac complications within 8 weeks
• Risk factors are unknown; though, it is thought to stem from some infectious organisms
• More frequent in those of Asian or Pacific descent

Acute Phase for Kawasaki disease

• High fever -unresponsive to antipyretics/antibiotics; fever of 102F lasting 5 days-2 weeks
• Irritability, red eyes without drainage, bright red, chapped lips, strawberry tongue with white coating or red bumps on posterior aspect, red oral mucus membranes, swelling of hands and feet with red palms and soles, arthritic pain that can last several weeks, nonblistering rash, and bilateral joint pain/ enlarged lymph nodes

Subacute Phase for Kawasaki Disease

• Resolution of fever/ gradual subsiding of other symptoms like irritability and peeling skin around nails, palms, and soles of feet

Labs for Kawasaki Disease

• The labs that diagnose Kawasaki disease are CBC with anemia + elevated WBC, creatine protein levels, and ESR
• Other studies that could be diagnostic are ultrasound/EKG and serum albumin/ protein levels

Nursing Care and Management for Kawasaki Disease

• Follow regular VS + cardiac monitoring
• Monitor for heart failure (decrease in urine output, gallop heart rhythm, tachycardia, respiratory distress)
• I/O, daily weight
• Administer IV fluids with clear liquids/ soft foods
• Administer meds like IV Gamma Globulin and Aspirin per orders
• Provide good oral hygiene, cool clothing on the skin, and skin lotions.
• Calm, quiet environment - cluster care/ allow for rest

Medications of Kawasaki Disease

• Gamma Globulin should be high dose (2 g/kg over 8-12 hours) and administered within first 7 days of illness
• Assessment includes making sure the pt is not febrile and is repeat with VS taken for allergic reaction (blood product)
• Aspirin should be high dose as well, administering 80-100mg/kg/day divided Q6H
• Can be brought down to 3-5mg/kg/day once afebrile, until platelet count returns to expected range.
• The medication needs to be administered continuously for coronary abnormalities

Discharge Care for Kawasaki Disease

• Teach about disease progression
• Encourage follow-up appointments along with PROM (Passive of Range and Motion).
• Advise on length of irritability + arthritic symptoms
• Avoid live immunizations for 11 months/ notify provider of fever
• Ongoing care includes: screening for heart disease as child ages, serum cholesterol and BP monitoring, periodic imaging, avoiding of smoking, and maintenance of of a heart-healthy diet