The Child with a Cardiovascular Disorder PDF

**NP03L010 ELO A- The Child with a Cardiovascular Disorder** Learning Objectives: By the end of this lecture, the learner will be able to: 1. Differentiate atrial septal defect, ventricular septal defect, patent ductus arteriosus, coarctation of the aorta, and tetralogy of Fallot. 2. D...

**NP03L010 ELO A- The Child with a Cardiovascular Disorder** Learning Objectives: By the end of this lecture, the learner will be able to: 1. Differentiate atrial septal defect, ventricular septal defect, patent ductus arteriosus, coarctation of the aorta, and tetralogy of Fallot. 2. Discuss nursing goals relevant to the child with acquired heart disease. 3. List symptoms of rheumatic fever. 4. Discuss the prevention of rheumatic fever. 5. Discuss hypertension in childhood. 6. Differentiate between primary and secondary hypertension. 7. Identify factors that can prevent hypertension. 8. Describe heart-healthy guidelines for children. 9. 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INTRODUCTION** Method of Instruction: [Lecture]\_\_\_\_\_\_\_ Instructor to Student Ratio is: [1:30]\_\_\_\_ Time of Instruction: [5 mins]\_\_\_\_\_\_\_\_\_\_ Media: [Lecture] +-----------------------+-----------------------+-----------------------+ | **Motivator** | | | +=======================+=======================+=======================+ | **Lead-In** | | | +-----------------------+-----------------------+-----------------------+ | **Terminal Learning | **NOTE:** Inform the | | | Objective** | students of the | | | | following Terminal | | | | Learning Objective | | | | requirements. | | | | | | | | At the completion of | | | | this lesson, you | | | | \[the student\] will: | | +-----------------------+-----------------------+-----------------------+ | | **Action:** | | +-----------------------+-----------------------+-----------------------+ | | **Conditions:** | | +-----------------------+-----------------------+-----------------------+ | | **Standards:** | | +-----------------------+-----------------------+-----------------------+ | **Safety | None | | | Requirements** | | | +-----------------------+-----------------------+-----------------------+ | **Risk Assessment | Low | | | Level** | | | +-----------------------+-----------------------+-----------------------+ | **Environmental | **NOTE:** It is the | | | Considerations** | responsibility of all | | | | Soldiers and DA | | | | civilians to protect | | | | the environment from | | | | damage. | | | | | | | | None | | +-----------------------+-----------------------+-----------------------+ | **Evaluation** | | | +-----------------------+-----------------------+-----------------------+ **SECTION III. PRESENTATION** **NOTE:** Inform the students of the Enabling Learning Objective requirements. **A. ENABLING LEARNING OBJECTIVE** *The Child with a Cardiovascular Disorder **Chapter 26*** **ACTION:** Explain the etiology of cardiovascular disorders in a child. ----------------- --------------------------------------------------------------------------------------------------------------------------- **CONDITIONS:** In a classroom environment, given scenarios, **STANDARDS:** Explain the etiology of various cardiovascular disorders in a child to include treatments and nursing care without error. 1 Learning Step / Activity 1 Identify the differences between the cardiovascular system of the infant and that of an adult. --- ------------------------------ ------------------------------------------------------------------------------------------------ Method of Instruction: Large group discussion Instructor to Student Ratio: 1:30 Time of Instruction: mins Media: Large group discussion 1\. **The cardiovascular system**: Consists of the heart, the blood, and the blood vessels. a. As the heart beats, blood, oxygen, and nutrients are transported to all tissues of the body, and waste products are removed. b. Because of anatomical and physiological immaturity, the cardiovascular system of the child differs from that of the adult. c. The cardiovascular system develops between the third and the eighth week of gestation. d. It is the first system to function in intrauterine life. e. When cardiovascular development is incomplete, heart defects occur. f. Fetal circulation is designed to serve the metabolic needs during intrauterine life and also to permit safe transition to life outside the womb. 2\. Summary of some cardiovascular system differences between the child and the adult: a. Pulse, respiration, blood pressure, and hematological values vary until the age of the child. b. Chest walls are thin in infants and young children because of the relative lack of subcutaneous and muscle tissue compared with older children. "Innocent" murmurs can be heard in structurally normal hearts. c. The newborn's circulation differs from fetal circulation; if adaptations do not take place, congenital heart problems may arise. d. Capillary function is immature in newborns. It takes several weeks or the small capillaries to expand and contract in response to external temperatures. e. The heart rate is higher in newborns and infants than in adults. f. Children have limited ability to increase stroke volume in response to decreased cardiac output. g. Most heart conditions in children result from defects in embryonic structure. **3. Signs related to suspected cardiac pathology:** a. Although signs and symptoms of specific congenital heart defects relate to the specific pathology involved, several signs and symptoms are common to most infants with congenital cardiac problems. b. The nurse who assesses the child should report the following observations: 1. Failure to thrive or poor weight gain. 2. Cyanosis, pallor. 3. Visually observed pulsations in the neck veins. 4. Tachypnea, dyspnea. 5. Irregular pulse rate. 6. Clubbing of fingers. 7. Fatigue during feeding or activity. 8. Excessive perspiration, especially over forehead *[Nursing Tip: Bradycardia may be a sign that cardiovascular arrest is imminent in children with hypoxia.]* *[4. Congenital heart defects: May be caused by genetic or maternal factors (e.g., drug intake or rubella illness) or environmental factors. Fetal echocardiography can detect cardiac malformations in high-risk cases. Acquired heart disease occurs after birth, as a result of a defect or illness.]* a. **Congenital Heart Defects:** b. **Pathophysiology:** 1. 2. 3. 4. 5. 6. 7. 8. c. **Diagnosis and Treatment:** 1. 2. 3. 4. 5. 6. 7. d. **Classification:** 1. 2. 3. 4. 5. 6. 7.  e. **Defects That Increase Pulmonary Blood Flow**: 1. 2. 3. 4. 5. *[**Safety Alert!** In congenital heart disease, cyanosis is not always a clinical sign.]* a. 1. Atrial septal defect (ASD) involves an abnormal opening between the right and left atria. 2. Blood that already contains oxygen is forced from the left atrium back to the right atrium. Most patients do not have symptoms. 3. The defect may be recognized when a murmur is heard during a routine health examination. 4. Cardiac catheterization, electrocardiogram, and echocardiography may be performed to help confirm the diagnosis. 5. Spontaneous closure sometimes occurs. 6. The surgical repair involves application of a surgical Dacron patch or repair with open cardiac surgery or robotic surgery using a portion of the pericardium to secure a patch. 7. Nonsurgical closure during cardiac catheterization can sometimes be accomplished. Continued cardiology follow-up is necessary. 8. Low-dose aspirin therapy is usually prescribed for 6 months after repair. 9. Untreated children are at risk for stroke. Prognosis is excellent. b. 1. Ventricular septal defect (VSD) is the most common heart anomaly. 2. As the name suggests, there is an opening between the right and left ventricles of the heart. 3. Increased pressure within the left ventricle forces blood back into the right ventricle (left-to-right shunt). 4. A loud, harsh murmur combined with a systolic thrill is characteristic of this defect. 5. The condition may be mild or severe. 6. It is often associated with other defects. 7. Many children with small defects may experience spontaneous closure during the first year of life as a result of growth. 8. Small defects may be closed after the first year of life. 9. Early surgical intervention has a low risk for most infants, and the prognosis is excellent. Normal growth and development are usually achieved within 1 or 2 years after surgery. 10. Open heart surgery is performed under hypothermia. With the use of the heart − lung bypass machine the condition can be corrected in a fairly dry or bloodless field. The hole is ligated (closed) with sutures or a synthetic patch. c. 1. The circulation of the fetus differs from that of the newborn in that most of the fetal blood bypasses the lungs. 2. The ductus arteriosus is the passageway (shunt) through which the blood crosses from the pulmonary artery to the aorta and avoids the deflated lungs. 3. This vessel closes shortly after birth; when it does not close, blood continues to pass from the aorta, where the pressure is higher, into the pulmonary artery. 4. This causes oxygenated blood to recycle through the lungs, overburdening the pulmonary circulation and making the heart pump harder. 5. The symptoms of patent ductus arteriosus (PDA) may go unnoticed during infancy. 6. As the child grows, dyspnea is experienced, the radial pulse becomes full and bounding on exertion, and there is an unusually wide range between systolic and diastolic blood pressures. 7. [This is referred to as the pulse pressure]. A characteristic machinery type of murmur may be heard. 8. A two-dimensional echocardiogram is useful for visualizing and determining blood flow across the PDA. 9. PDA is one of the more common cardiac anomalies. a. It occurs twice as frequently in girls as in boys. b. Premature infants with hypoxia often respond to intravenous indomethacin or intravenous ibuprofen drug therapy that results in closure of the PDA. c. The ductus may be ligated via the visually assisted thoracoscopic surgery (VATS) technique. d. Nonsurgical options include the insertion of coils to occlude the PDA, which is done in a cardiac catheterization lab. e. Prostaglandin E1 may be administered to maintain patency of the ductus arteriosus until surgery can be performed when an anomaly such as hypoplastic heart is diagnosed in the newborn. f. The prognosis is excellent. e. **Defects That Restrict Ventricular Blood Flow:** Some congenital cardiac defects can restrict blood flow from the ventricles because of a stenosis (narrowing) of a vessel. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. **Nursing Tip:** The systolic blood pressure is normally 10 to 15 mm Hg higher in the legs than the arms. Systolic blood pressure that is lower in the legs than in the arms should be reported, as this could be a sign of coarctation of the aorta. *[**Safety Alert!** A significant difference in the blood pressure between the upper extremities and the lower extremities is a characteristic sign of coarctation of the aorta.]* f. **Defects That Decrease Pulmonary Blood Flow:** 1. 2. 3. a. b. c. d. 4. 5. 6. 7. 8. 9. 10. 11. e. f. g. h. 12. 13. 14. a. b. c. *[**Nursing Tip**: There are four defects in tetralogy of Fallot:]* 1\. Pulmonary artery stenosis 2\. Hypertrophy of the right ventricle 3\. Dextroposition of aorta 4\. VSD g. **Defects That Cause Mixed Pathology:** 1. a. b. c. d. 2. a. b. c. d. e. h. **General Treatment and Nursing Care of Children With Congenital Heart Defects:** 1. 2. 3. 4. 5. 6. 7. 8. i. Immunizations are not recommended immediately before cardiac surgery, because immune-suppressants are used to prevent rejection of the transplanted heart, and the child's ability to manufacture antibodies in response to routine immunizations will be impaired. 1. 2. 3. 4. j. Nutritional guidance is aimed at preventing anemia and promoting optimal growth and development. 1. 2. 3. k. Cardiac surgery---if needed to repair a defect that causes heart failure---is generally performed at a regional medical center where the necessary equipment is available. 1. 2. 3. 4. 5. 6. 7. 8. l. Cardiac transplants are a treatment option when other treatments fail. Infection and rejection of the new tissue are the most common causes of death posttransplant. m. Postoperative cardiac care usually takes place in an intensive care unit (ICU), where high-technology monitoring minimizes complications. 1. 2. *[**MEDICATION SAFETY ALERT!!!** Complementary and alternative medicine (CAM) therapy with ginkgo, ginseng, and St. John's wort may interact with drugs used for congenital heart disease and should not be used]*. **Check on Learning:** **Question: Name at least three differences between the cardiovascular system of the infant and that of the adult.** **Answer: may include the following:** - - - - - - - **Reference:** [Introduction to Maternity and Pediatric Nursing, page 624 Fig 26.1] **Question: What are differences between atrial septal defect, ventricular septal defect, patent ductus arteriosus, coarctation of the aorta, and tetralogy of Fallot?** **Answer:** **atrial septal defect -** in the fetus allows blood to flow from the right atrium through the defect into the left atrium, providing a bypass of the lungs. **ventricular septal defect -** is the most common heart anomaly. As the name suggests, there is an opening between the right and left ventricles of the heart. Increased pressure within the left ventricle forces blood back into the right ventricle (left-to-right shunt). **patent ductus arteriosus -**The circulation of the fetus differs from that of the newborn in that most of the fetal blood bypasses the lungs. The ductus arteriosus is the passageway (shunt) through which the blood crosses from the pulmonary artery to the aorta and avoids the deflated lungs. **coarctation of the aorta - a tightening." In coarctation of the aorta, there is a constriction or narrowing of the aortic arch or of the descending aorta.** **tetralogy of Fallot - Tetra means "four." In tetralogy of Fallot, there are four defects:** **1. Stenosis or narrowing of the pulmonary artery, which decreases the blood flow to the lungs** **2. Hypertrophy of the right ventricle, which enlarges because it must work harder to pump blood through the narrow pulmonary artery** **3. Dextroposition (dextro, "right," and position) of the aorta, in which the aorta is displaced to the right and blood from both ventricles enters it** **4. VSD** **Reference:** Introduction to Maternity and Pediatric Nursing, pages 625 - 627 **Summary:** **In this section,** we learned about signs related to suspected cardiac pathology, the differences between the cardiovascular system of the infant and the adult, and the **differences between atrial septal defect, ventricular septal defect, patent ductus arteriosus, coarctation of the aorta, and tetralogy of Fallot.** 2 Learning Step / Activity 2 Explain the etiology of acquired heart disease. --- ------------------------------ ------------------------------------------------- Method of Instruction: Large group discussion Instructor to Student Ratio: 1:30 Time of Instruction: mins Media: Large group discussion 1\. **Acquired heart disease is:** a. A cardiac problem that occurs after birth. b. It may be a complication of a congenital heart disease or a response to respiratory infection, sepsis, hypertension, or severe anemia. c. Heart failure is defined as cardiac output inadequate to meet the metabolic needs of the body. 2\. **Congestive Heart Failure:** a. Manifestations: 1. 2. *[**Safety Alert!** The following early signs of CHF in infants should be reported:]* *[  Tachycardia at rest]* *[  Fatigue during feeding]* *[  Sweating around scalp and forehead]* *[  Dyspnea]* *[  Sudden weight gain]* b. **Cyanosis**: When observing color, the nurse notes whether the cyanosis is general or localized. 1. 2. 3. 4. 5. 6. a. b. c. d. e. f. g. 7. a. b. c. d. e. f. 8. a. b. c. 9. a. b. 10. c. d. e. f. 11. g. h. i. j. c. **Treatment and nursing care:** 7. 8. h. i. j. k. l. m. 9. n. o. p. q. r. s. t. u. v. w. x. y. z. 4. a. b. c. d. e. f. g. h. i. 5. j. k. l. m. 6. n. o. p. **MEDICATION SAFETY ALERT!!!** Two nurses should check dosage of drugs such as digoxin. A single dose larger than 0.05 mg, or 50 mcg, should be reconfirmed with the health care provider. 7. a. b. c. d. e. f. g. h. i. j. **MEDICATION SAFETY ALERT!!!** Before administering a digoxin medication, the resting apical pulse should be counted for 1 full minute. 8. An accurate record of intake and output is essential. a. b. c. d. 9. The nurse working in a cardiac unit assesses the child frequently for complications of cardiac and respiratory failure and should be competent in cardiopulmonary resuscitation techniques and the necessary modifications required for pediatric patients (Pediatric Advanced Life Support \[PALS\] certification). 10. The parents of the child need support and understanding throughout a long period. e. f. 11. The patterns formed during infancy can build the framework of a healthy personality for the patient. Children who have heart conditions but who are well integrated into family life have a decided advantage over children who are made to think they are invalids. Routine naps and early bedtimes provide adequate rest for most children. 12. As children grow, they usually set their own limits on the amount of activity they can handle. g. h. i. j. k. l. 13. Detailed discharge planning and coordination of community services are of value to the family. 3**. Rheumatic Fever** a. Pathophysiology: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. b. **Manifestations:** 1. 2. 3. 4. 5. 6. 7. 8. 9. c. **Migratory polyarthritis:** 1. 2. 3. 4. 5. 6. 7. 8. d. **Skin eruptions**: 10. 11. e. **Sydenham's chorea:** 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. f. **Rheumatic carditis:** 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. g. **Diagnosis:** 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. **Nursing Tip:** A useful mnemonic for remembering the Jones criteria is as follows: Major Criteria Minor Criteria - Joint (arthritis) P-R interval - Obvious carditis ESR elevated - Nodules subcutaneous Arthralgia - Erythema marginatum CRP elevated - Sydenham's chorea Elevated temperature (fever) h. Treatment and nursing care: 50. a. b. 51. c. d. e. f. g. h. i. j. 52. k. l. m. 53. n. o. p. q. r. s. t. u. v. w. 54. x. y. z. a. b. **Nursing Tip:** *The nurse should teach parents about the need for prophylactic antibiotic therapy before any dental procedure.* 4\. Systemic Hypertension: a. Pathophysiology: 1. 2. 3. 4. 5. 6. a. b. c. d. 7. 8. 9. **Nursing Tip:** Using the proper size blood pressure cuff is essential to obtaining an accurate blood pressure in children. The bladder length of the cuff should be 80% to 100% of the circumference of the arm, and the width should be at least 40%. b. Treatment and nursing care: 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. c. Prevention: 20. 21. 22. 23. 24. 25. 5\. **Hyperlipidemia:** Refers to excessive lipids (fat and fatlike substances) in the blood. Lipoproteins contain lipids and proteins and include the following: a. Low-density lipoproteins (LDLs), which contain low amounts of triglycerides, high levels of cholesterol, and some protein. LDL carries cholesterol to the cells, which aids in cellular metabolism and steroid production. b. High-density lipoproteins (HDLs) contain low amounts of triglycerides, little cholesterol, and high levels of protein. HDLs carry cholesterol to the liver for excretion. c. Children with a parental history of cholesterol levels exceeding 240 mg/dL or a family history of early cardiac death (younger than 55 years of age) should have their cholesterol levels tested as early as possible because genetics can play a role in hypercholesterolemia. 1. 2.  d. The guidelines endorsed by the National Lipid Association (NLA) and the American Academy of Pediatrics (AAP) recommend universal screening for cholesterol in children 9 to 11 years of age and again at 17 and 21 years of age in order to identify the genetic form of inherited familial hypercholesterolemia. 1. Nonfasting lipid screening of younger children may be recommended if there is an established diagnosis of diabetes mellitus, hypertension, tobacco use, obesity, or a positive family history. 2. A borderline blood lipid level should be interpreted as a signal for family education and lifestyle change rather than a need for treatment. 3. Most children with high triglycerides are obese, and therefore reduction of calories, increase of fiber, and regular exercise should be stressed in their education. 4. An active prevention program for all children and adolescents is essential. 5. Lifelong healthy eating habits should be nurtured early and practiced by the entire family. 6. Children younger than 2 years of age should not have a fat-restricted diet, because calories and fats are necessary for CNS growth and development. 7. The AAP recommendations for heart-healthy guidelines are presented in the Health Promotion box. (see below) Health Promotion -- -- **Nursing Tip:** *Contact in the clinic or during hospitalization provides an excellent opportunity for the nurse to review heart-healthy information. Reviews of family history, lifestyle, and eating patterns are suitable interventions, even in the absence of high risks.* 6\. Kawasaki Disease: a. **Kawasaki disease (KD)** (mucocutaneous lymph node syndrome) occurs worldwide and is the leading cause of acquired cardiovascular disease in the United States. 1. It usually affects children younger than 5 years of age. 2. Studies have shown that no known microbe is associated with KD, although it may be a response to a mild asymptomatic viral infection in children with a genetic predisposition. 3. KD is not spread from person to person. 4. Clinical signs and symptoms make the diagnosis because specific laboratory findings are not diagnostic. 5. KD causes inflammation of the vessels in the cardiovascular system. 6. The inflammation weakens the walls of the vessels and often results in an aneurysm (an abnormal dilation of the wall of a blood vessel). 7. Aneurysms can cause thrombi (blood clots) to form, resulting in serious complications. 8. Approximately 40% of untreated children develop aneurysms of the coronary vessels, which can be life threatening. 9. For this reason, it is essential that a diagnosis of KD be made as early as possible. b. Manifestations: 10. The onset is abrupt with a sustained fever, sometimes above 40° C (104° F), that does not respond to antipyretics or antibiotics. 11. The fever lasts for more than 5 days. 12. Conjunctivitis without discharge, fissured lips, a "strawberry tongue" (enlarged reddened papilla on the tongue), inflamed mouth and pharyngeal membranes, and enlarged nontender lymph nodes are seen. 13. An erythematous skin rash develops, with swollen hands and desquamation (peeling) of the palms and soles (Fig. 26.5). 14. The child is irritable and may develop signs of cardiac problems. Abnormalities in an echocardiogram can be detected by the tenth day. 15. Lab results may show an elevated C-reactive protein, ESR, and white blood count. c. Treatment and nursing care: 1. 2. 3. 4. 5. 6. 7. 8. 9. **Check on Learning:** **Question: What are six treatments and nursing care for children with congenital heart defects?** **Answer: Reduce the work of the heart, improve respiration, maintain proper nutrition, prevent infection, reduce the anxiety of the patient, and support and instruct the parents.** **Reference:** Introduction to Maternity and Pediatric Nursing, page 630 **Question: What are the symptoms of rheumatic fever?** **Answer: mild to severe, may not occur for 1 to 6 weeks after a strep throat infection, classic symptoms are migratory polyarthritis (wandering joint pains), skin eruptions, chorea (a nervous disorder), and inflammation of the heart.** **Reference:** Introduction to Maternity and Pediatric Nursing, page 631 **Question: What are the preventions of rheumatic fever?** **Answer: antibacterial therapy, physical and mental rest, relief of pain and fever, and management of cardiac failure should it occur. Initial antibacterial therapy is directed toward eliminating the streptococcal infection. Penicillin is the drug of choice (given for a 10-day period) unless the patient is sensitive to it, in which case erythromycin is substituted.** **Reference:** Introduction to Maternity and Pediatric Nursing, page 633 **Question: What is the difference between primary and secondary hypertension for a child?** **Answer: Hypertension is referred to as secondary when a disease process can explain the increased pressure. Renal, congenital, vascular, and endocrine disorders represent the majority of illnesses that account for secondary hypertension. Primary, or essential, hypertension implies that no known underlying disease is present. Nevertheless, heredity, obesity, stress, and a poor diet and exercise pattern can contribute to any type of hypertension.** **Reference:** Introduction to Maternity and Pediatric Nursing, page 634 **Question: What are the factors that can prevent hypertension?** **Answer: main focus of a hypertensive prevention program is patient education. The nurse can work with school personnel to promote awareness of the problem at parent--teacher association (PTA) meetings. Community health fairs should offer opportunities for blood pressure screening. Blood pressure measurement must be part of every annual physical examination. Risk factors such as obesity; elevated serum cholesterol levels; sedentary lifestyle; drug, alcohol, or tobacco use; and intake of salty foods should be discussed.** **Reference:** Introduction to Maternity and Pediatric Nursing, page 634 **Question: What is the manifestation of Kawasaki disease?** **Answer: The onset is abrupt with a sustained fever, sometimes above 40° C (104° F), that does not respond to antipyretics or antibiotics. The fever lasts for more than 5 days. Conjunctivitis without discharge, fissured lips, a "strawberry tongue" (enlarged reddened papilla on the tongue), inflamed mouth and pharyngeal membranes, and enlarged nontender lymph nodes are seen. An erythematous skin rash develops, with swollen hands and desquamation (peeling) of the palms and soles** **Reference:** Introduction to Maternity and Pediatric Nursing, page 636 **Question: What is the related nursing care for Kawasaki disease?** **Answer: Intravenous immune globulin (IVIG) administered early in the illness can prevent the development of coronary artery pathology. Salicylate therapy (aspirin) is prescribed for its antithrombus properties. If the child does not respond to IVIG therapy and aspirin, a second dose of IVIG may be prescribed or cyclosporine may be added to the treatment. Prednisolone may be used, but its effectiveness has not been proven.** **Reference:** Introduction to Maternity and Pediatric Nursing, page 636