Pediatric Nursing: Circulation Issues

Circulation Concerns of a Pediatric Client

• Learning Outcomes: Apply core principles of family-centered care and relational care in pediatric nursing practice and teaching; Apply evidence-informed knowledge, critical inquiry, and clinical judgment to pediatric clients and families; Describe a holistic approach to assessment, planning, implementation, and evaluation in pediatric care; Discuss common political, ethical, and economic issues in pediatric care.

• Goals of the Class: Describe immediate interventions for children experiencing circulatory concerns; Explore nursing roles and responsibilities in caring for children with shock, congenital heart disease (PDA or Tetralogy of Fallot); Discuss the Pediatric Cardiac Inquest's impact on nursing.

Shock in Children

• Shock (circulatory failure) is a complex presentation.
• Characterized by inadequate tissue perfusion (not enough blood flow to tissues) that leads to metabolic demands and eventual organ failure.
• Causes in children include hypovolemia (low blood volume), altered peripheral vascular resistance, and pump failure.

Types of Shock

• Compensated Shock: Vital organ function is maintained by compensatory mechanisms. Blood flow is normal or increased, and fluids may shift. Signs include apprehension, irritability, unexplained tachycardia, and normal blood pressure.
• Decompensated Shock: Characterized by tissue hypoxia, metabolic acidosis, and eventually dysfunction of all organ systems. Confusion, somnolence and tachypnea are common.
• Irreversible/Terminal Shock: Thready pulse, hypotension, periodic breathing, apnea, anuria, and stupor/coma.

Compensated Shock

• Thirst, pallor, diminished urine output, reduced perfusion to extremities.

Decompensated Shock

• Oliguria, cool pale extremities, decreased skin turgor, poor capillary refill

Therapeutic Management

• Ventilation: Establish airway and intubate; administer oxygen.
• Fluid Administration: Obtain vascular access (intraosseous in emergency), restore fluid volume.
• Cardiovascular Support: Administer vasopressors (e.g., epinephrine). Provide continuous ECG monitoring, monitor pulse oximetry. Maintain positioning (flat/legs raised), keep child calm and warm.

Review of the Heart Structures

• Screening for Critical Congenital Heart Disease: Prenatal ultrasound, physical examination, oximetry screening (right hand and one foot).
• Congenital Heart Conditions in Children: Information on different congenital heart conditions such as increased/decreased pulmonary blood flow, obstruction of blood flow out of the heart and mixed blood flow.

Congenital Heart Disease (Examples)

• Patent Ductus Arteriosus (PDA): A defect where a fetal artery connecting the aorta and pulmonary artery does not close. This leads to increased pulmonary blood flow.
• Tetralogy of Fallot: Four heart anomalies, including pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, and overriding aorta. This leads to decreased pulmonary blood flow.

Presentation of PDA

• Patients may be asymptomatic or show symptoms like heart failure, a machinery-like murmur, widening pulse pressure and bounding pulses.

Management and Treatment of PDA

• Intravenous administration of prostaglandins; Surgical division or ligation of the parent vessel; Surgical coils to occlude the PDA; Surgical and non-surgical procedures have a 0% mortality rate.

Tetralogy of Fallot

• Characterized by four heart anomalies (pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, and overriding aorta). This leads to decreased pulmonary blood flow.

Side-by-Side Heart Comparison

• Includes various factors including Preload, Afterload, Cardiac Output, and Contractility

Diagnostic Tests

• Chest X-ray, electrocardiogram, echocardiography, cardiac catheterization, cardiac MRI.

Signs of Heart Failure

• Impaired myocardial function; pulmonary congestion; systemic venous congestion

Impaired Myocardial Function

• Tachycardia, Sweating/inappropriate, decreased urine output, fatigue, weakness, restlessness, Anorexia, Pale/Cool extremities, weak/peripheral pulses, Decreased blood pressure.

Pulmonary Congestion Manifestations

• Symptoms include increased breathing rate, shortness of breath, retractions, flared nostrils, exercise intolerance, and orthopnea.

Systemic Venous Congestion Manifestations

• Weight gain, hepatomegaly, peripheral edema (especially periorbital), ascites, neck vein distention

Therapeutic Management

• Improve cardiac function; Remove accumulated fluid and sodium; Decrease cardiac demands; Improve tissue oxygenation and decrease oxygen consumption.

Medications to Improve Cardiac Function

• Ace inhibitors, digitalis, beta blockers, diuretics.

Nursing Actions and Interventions

• Assess the infant/child, administer oxygen, elevate the head of the bed, offer feeds, and encourage family participation.

Treating Hyper Cyanotic Spells

• Place infant in knees/chest position, provide calm approach, administer oxygen, and potentially give morphine and fluid replacement..

Surgical Interventions

Surgical interventions such as palliative shunts like Blalock-Taussig or complete repair may be necessary.

Care of Child Preoperatively/Postoperatively

• Preoperative care includes frequent cardiorespiratory assessment, daily weights, and preparing the family; Postoperative care includes monitoring, positioning, oxygenation, nutrition, and fluid status.

Diagnosis and Complications for Tetralogy of Fallot

• The congenital heart condition might have varied symptoms from healthy to severe; The condition could lead to additional family fears and the loss of normal routines and expectations; Pediatric cardiac inquest.

Recommendations

• Recommendations on structuring the nursing council; how to report patient concerns related to risks; and potential whistleblower legislation to protect nurses.