Managing Care for Pediatric Patients with Cardiovascular Perfusion Alterations PDF

Managing the Care for Pediatric Patients with Alterations in Cardiovascular Perfusion Module 8 NURS 445 Module 8 Objectives Recall previous knowledge of the anatomy and physiology of the cardiovascular system. (CO7) Recall the concept of perfusion and common asso...

Managing the Care for Pediatric Patients with Alterations in Cardiovascular Perfusion Module 8 NURS 445 Module 8 Objectives Recall previous knowledge of the anatomy and physiology of the cardiovascular system. (CO7) Recall the concept of perfusion and common associated clinical manifestations associated with alterations in perfusion. (CO7) Connect previous concepts of fluid and electrolytes, gas exchange, inflammation, elimination, and homeostasis with perfusion. (CO7) Discuss pre- and post-natal circulation. (CO1, CO7) Appraise the role of perfusion in the newborn pediatric patient. (CO1, CO7) Identify assessment findings that would indicate further cardiac evaluation is needed in the newborn. (CO1, CO5) Describe basic periprocedural nursing care for a child receiving cardiac catheterization. (CO1, CO4, CO5, CO7) Categorize the differences in diagnostic testing used with suspected cardiac anomalies. (CO1, CO7) Differentiate between cyanotic and acyanotic heart defects.(CO1, CO4, CO5, CO7) Module 8 Objectives Describe various cardiac defects by blood flow pattern and describe the effect of impaired blood flow on the patient, including increased pulmonary blood flow, decreased pulmonary blood flow, obstructive blood flow defects, and mixed blood flow defects. (CO1, CO5, CO7) Increased pulmonary blood flow Atrial septal defect Ventricle septal defect Patent Ductus Arteriosus Decreased pulmonary blood flow. Tetralogy of Fallot Tricuspid atresia Obstructive blood flow defects. Coarctation of the Aorta Pulmonary stenosis Aortic stenosis Mixed blood flow defects. Transposition of the great vessels Truncus arteriosus Hypoplastic left heart syndrome Module 8 Objectives Connect the role of prostaglandin E1 with congenital heart defects. (CO1, CO4, CO5) Demonstrate knowledge of basic nursing care of a child with a cyanotic spell. (CO1, CO4, CO5, CO7) Describe the nursing role in administering, monitoring, and educating regarding cardiac medications in the pediatric population, including cardiac glycosides, diuretics, and beta-blockers. (CO1, CO5, CO7) Describe the pathophysiology, etiology, clinical manifestations, and nursing care for pediatric patients with acquired heart disorders, including rheumatic heard disease and Kawasaki disease. (CO1, CO5, CO7) Describe the pathophysiology, etiology, clinical manifestations, and nursing care for pediatric patients with cardiac infections, such as infective endocarditis. (CO1, CO5, CO7) Differentiate the pathophysiology, etiology, clinical manifestations, and care associated with shock, including cariogenic shock and anaphylactic shock. (CO1, CO5, CO7) Identify pathophysiology and treatment for cardiomyopathy. (CO1, CO5, CO7) Develop a teaching plan for children and families with a cardiovascular disorder. (CO1, CO5, CO7) Discuss implications of pediatric hypertension and dyslipidemia. (CO1, CO5, CO7) Anatomy and Physiology of Cardiovascular System Structures include heart and blood vessels: Layers Chambers Great vessels Valves Blood vessels Conduction system Functions include: Managing blood supply Producing blood pressure Securing one-way flow Transmitting blood 5 Alterations in Perfusion Low BP can lead to poor tissue perfusion and shock Hypotension is a LATE sign of compromise Care and treatment should begin before hypotension begins Hypertension is often underdiagnosed and can lead to poor health outcomes Alterations in Perfusion Shock - A critical condition brought on by the sudden drop in blood flow through the body. May result from trauma, heatstroke, blood loss, or allergic reaction. Cardiogenic Anaphylactic Results from impaired cardiac Results from hypersensitivity to a function that leads to a decrease in foreign substance that leads to cardiac output massive vasodilation and capillary Signs and Symptoms leak Dyspnea Signs and Symptoms Crackles All the S&Sx for Cardiogenic plus: Grunting Urticaria Tachycardia Angioedema Weak peripheral pulses Broncospasm Hypotension Stridor Shock Nursing Care Prompt recognition Hypotension is a LATE sign of shock A child’s body will protectively reduce blood flow to noncritical areas sending oxygen to the heart and brain The child cannot compensate indefinitely Expect orders – Depends on the type and severity of shock Lab work: ABG, Hgb, Hct, electrolytes Fluids: LR, blood Medications: antibiotics, epi Alterations in Perfusion Fluid and Electrolytes: Elimination Sodium Renal function is critical to Chloride maintaining fluid and electrolyte balance Potassium This balance supports CV function Gas Exchange: Urine output is an indicator of the Must have adequate RBCs to carry perfusion of vital organs oxygen Oliguria or anuria can be caused Anemia impacts oxygen delivery and by decreased cardiac function development Homeostasis Cognitive, academic, verbal skills Optimized fluid and electrolytes are critical to a child’s heart function Inflammation: Fluid overload can lead to heart Often caused by viruses failure Myocarditis involves inflammation of Lack of fluid volume can lead to the myocytes and can cause hypotension and shock myocardial injury Perfusion in the Newborn Changes in circulation at birth support perfusion in the non-fetal blood flow pathways 3 main closures: Foramen ovale, Ductus arteriosus, and the Ductus venosus The cardiac muscle is stiff and does not expand the volume of blood needed when the newborn needs increased perfusion because of illness, dehydration, or bleeding The only way to increase cardiac output and perfusion is to increase the heart rate Tachycardia can signal the beginning of cardiac collapse Pre and Post Natal Circulation Functioning atria, ventricles, valves, and vessels are present at 8 weeks Prenatal circulation shunts blood away from the lungs Transition from fetal circulation starts at birth Congenital vs Acquired CHDs are the most frequent birth defect 1% of babies born each year affected 25% of those have CCHD requiring surgical intervention Prenatal Circulation Postnatal Circulation 13 Differences between Cyanotic and Acyanotic Heart Defects Acyanotic Heart Defect Cyanotic Heart Defects Left-to-right cardiac blood flow Right-to-left cardiac blood flow Cardiac Defects by Blood Flow Pattern Decreased Increased Pulmonary Obstructive Blood Pulmonary Blood Mixed Blood Flow Blood Flow Flow Flow Blood flows from  Blood flows from Blood flow exiting Combination of pressure Left side to right to left the hearts meets a increased  pressure Right Allows narrowing pulmonary, side deoxygenated blood Decreased cardiac decreased Less likely to to enter systemic output pulmonary, and/or produce cyanosis circulation Can manifest as obstructive blood Manifest as heart Hypercyanotic heart failure flows failure spells (TET spells) Defects: Defects: Defects: with acute cyanosis Coarctation of the Transposition of ASD and hyperpnea aorta the great arteries VSD Defects: Pulmonary Truncus arteriosus PDA Tetralogy of Fallot Stenosis HLHS Tricuspid Atresia Aortic Stenosis Increased Pulmonary Blood Flow Atrial Septal Defect Septal opening between the left and right atria Left-to-right shunting Can be due to persistence of a fetal shunt involving the foramen ovale May have a harsh, loud murmur or asymptomatic Can increase the size of the right atrium May have mild CHF Large defects must be surgically closed, and small defects can be patched during cardiac cath This Phot o b U nknown Author is licensed under CC BY-SA-NC Increased Pulmonary Blood Flow Ventricular Septal Defect (VSD) Most common CHD Allows mixing of blood from the oxygenated left ventricle to the deoxygenated right ventricle Results in increased pulmonary flow and decreased pulmonary compliance Stiffer lungs and less effective ventilation May have loud, harsh murmur at the left sternal border Look for SOB, FTT, and feeding difficulties Echo will show enlarged left atrium CXR may show large heart and increased lung vascularity Surgical repair for large defects, small defects can be patched during a cardiac cath Increased Pulmonary Blood Flow PDA The normal fetal circulation conduit between the pulmonary artery and the aorta fails to close Usually closes within 48 hours for term infants Risk for delayed closing increases with increasing prematurity Systolic murmur (machine hum) Heard at the upper left sternal border Wide pulse pressure, bounding pulses, increased cap refill, tachypnea, apnea, labored breathing, poor feeding, diaphoresis when feeding, weight gain, rales Possibly asymptomatic Heart failure CXR shows pulmonary congestion Treatment includes indomethacin, coils during cath, surgical ligation of vessel  Decreased Pulmonary Blood Flow Tetralogy of Fallot Four defects: pulmonary stenosis, VSD, overriding aorta, right ventricular hypertrophy 3rd most common defect Associated with DiGeorge and Down syndromes Occurs more often in males Cyanosis at birth that persists over the first year of life Systolic murmur, dyspnea when active, polycythemia, clubbed digits CXR shows “boot shaped” cardiac silhoutte As the PDA closes, cyanosis increases Treatment includes complete intracardiac repair in infancy, mange CHF symptoms, minimize hypoxia Immediate IV access and PGE-1 and ACE inhibitors to promote coronary artery perfusion This Photo by Unknown Author is licensed under CC BY-SA Care of a Child in a Cyanotic Spell Episodes of acute cyanosis and hypoxia are called TET spells or blue spells Treatment of cyanotic spells include: Prevent crying, dehydration, constipation, fever, and pain that can induce TET spells Knee-to-chest position to increase systemic vascular resistance and pulmonary flow This Photo by Unknown Author is licensed under CC BY-SA-NC Decreased Pulmonary Blood Flow Tricuspid Atresia Rare Malformed tricuspid valve completely blocks blood flow from right atrium to the right ventricle, radically decreasing blood flow to the lungs If there is no septal defect, then the TA is ductal dependent, and the PDA must be maintained for survival Cyanosis, murmur, dyspnea, clubbing, poor growth Need ECG, Echo, CXR, and cardiac cath 3-stage surgical repair Possibly need transplant  Coarctation of the Aorta Obstructive Narrowing of the lumen of the aorta Blood Flow usually near the ductus arteriosus Obstructs blood flow from the ventricle Spares upper body perfusion but decreases flow to lower extremities Associated with Noonan syndrome Infants show signs of heart failure Older children have dizziness, headaches, fainting, and nosebleeds in older children and look like HTN in teens Treatment includes balloon dilation during cardiac cath and stent placement Upper Extremities Lower Extremities Elevated BP Decreased BP This Phot o by Unknown Author is license d under CC BY Surgery recommended for infants < 6 Bounding pulses Weak or absent femoral pulses months BP higher in right arm Cool Skin (preductal) Obstructive Blood Flow Pulmonary Stenosis Narrowing of the pulmonary valve or pulmonary artery Obstructs the blood flow from the ventricle Systolic ejection murmur Possibly asymptomatic Cyanosis varies with defect Cardiomegaly Heart failure Balloon angioplasty with cardiac cath or surgical procedure Obstructive Blood Flow Aortic Stenosis Narrowing of the aortic valve that obstructs the flow from the left ventricle to the aorta May have regurgitation Increases the workload of the left ventricle leading to hypertrophy Ductal dependent if the stenosis is severe Risk with group A Streptococcus infections Lower systolic BP, narrow pulse pressures, fatigue, activity intolerance, sudden death, syncope, SOB, systolic murmur, chest pain Can be repaired via balloon valvuloplasty via cath or may need open- heart aortic valve replacement PGE-1 infusions Mixed Blood Flow Transposition of the Great Arteries Pulmonary artery and aorta are reversed Oxygenated blood cycles to and from the lungs without going into systemic circulation Ductal dependent This Photo by Unknown Author is licensed under CC BY-SA-NC “Egg on a string” cardiac silhouette on CXR Profound cyanosis, tachypnea, negative hyperoxygenation test Prompt PGE-1 and ACE inhibitors to promote coronary perfusion Surgical repair within the first 2 weeks of life Mixed Blood Flow Truncus arteriosus Failure of a septum formation between the pulmonary artery and aorta resulting in a single vessel coming off the ventricles Heart failure, murmur, variable cyanosis, delayed growth, lethargy, fatigue, poor feeding Surgical repair within first month of life Mixed Blood Flow Hypoplastic Left Heart Syndrome Left side of the heart is underdeveloped including ventricle, aortic valve, and mitral valve Results in pulmonary congestion and edema 2nd most common CHD Ductal dependent, ASD or PFO allows for oxygenation of the blood Asymptomatic until PDA closes Mild cyanosis, heart failure, lethargy, cold hands and feet, ashen skin, murmur with a gallop Once the PDA closes, progresses quickly to cardiac collapse Immediate 3-stage surgical repair Anticipate the need for a heart transplant Differences in Diagnostic Testing Used with Suspected Cardiac Anomalies Catheter “Echo” Shows size EKG or Electrocardiogram Echocardiogram Chest Xray Cardiac Catheterization introduced Ultrasound and shape ECG through a of the heart of the heart Records distal Painless Can show the artery procedure fluid build electrical Contrast Checks up in the activity of dye size, lungs that the heart injected to contraction can be Identifies show of the caused by problems vessels on heart, and heart with rate xray how the disease and/or valves are rhythm working Painless Basic Periprocedural Nursing Care for a Child Receiving Cardiac Catheterization Pre-Procedure Post-Procedure History and exam Continuous cardiac and SpO2 monitoring Allergies to iodine and/or shellfish Assess HR and RR for full minute Age-appropriate teaching Assess pulses bilaterally NPO for 4-6 hours Assess temp and color of affected extremity Baseline VS Assess insertion site for bleeding or Mark the dorsalis pedis and posterior hematoma tibial pulses on both extremities Document the quality of the pulses Maintain a clean dressing Pre-sedation medications as ordered Maintain a straight extremity for 4-8 hours Monitor I&O Monitor for hypoglycemia Encourage oral intake and voiding to excrete the contrast Cardiac Catheterization Complications Nausea and Apply direct, continuous vomiting pressure at 2.5 cm above the catheter entry site to Low-grade fever localize pressure over the Loss of pulse in location of the vessel catheterized puncture extremity Position the child flat to reduce the gravitational Transient Nursing effect on the rate of Complications dysrhythmias bleeding Interventions Acute hemorrhage Administration of replacement fluids and/or from entry site medications to control hypoglycemia emesis Role of PGE1 Prostoglandin E1 Oxygen and lack of maternal prostaglandins are two factors that cause the closure of the PDA Adding PGE1 and accepting lower O2 sats help keep the ductus open to allow for blood flow to the lungs Lipid compound Smooth muscle relaxant and vasodilator  Cardiac Medications and Nursing Role Diuretics Cardiac glycosides Beta-blockers Furosemide, Bumetanide, Digoxin Metoprolol, Carvediol Spironolactone, HCTZ Administering Administering Administering Initial dose and maintenance dose Monitoring Monitoring 2 RN verification Electrolytes levels BP and Pulse prior to admin Monitoring Ototoxicity Adverse effects Apical pulse Signs of dehydration Dizziness, hypotension, headache Do not give if HR below MD Strict I&Os Educating specifications Educating Child may have sleep disturbances Dig toxicity Avoid sun exposure (bumetanide Call provider before suddenly Educating and HCTZ) stopping Do not mix with food Encourage high potassium foods Check with provider before taking Give water after dose to prevent Give missed doses but do not OTC meds tooth decay double dose Do not redose if child vomits I&O records Call MD if more than 2 consecutive Call provider if dehydration, doses are missed nausea, or diarrhea Store in a safe, locked place Poison control information 32 Acquired Heart Disorders Rheumatic heart disease Inflammatory disease that occurs as a reaction to Group A beta- hemolytic streptococcus infection Occurs within 2-6 weeks of untreated or partially treated URI/strep throat Major Criteria Minor Criteria Jones Criteria Carditis Subcutaneous nodules Fever Arthralgia Diagnosis of rheumatic fever Polyarthritis Child should exhibit two major Rash (erythema marginatum) criteria or one major and two minor Chorea criteria Acquired Heart Disorders Rheumatic Fever Expected Findings: Nursing Care Hx of recent URI Encourage bed rest during Fever acute illness Tachycardia, cardiomegaly, Antibiotics as prescribed new or changed murmur, Encourage good nutrition pericardial friction rub, chest Assess for chorea pain (nervousness, behavioral Nontender, subcutaneous changes, decreased attention nodules over bony span) prominences Large joints with painful swelling Can be present, disappear, and reappear in another joint Erythema marginatum CNS involvement—chorea Irritability, poor concentration, behavioral problems Acquired Heart Disorders Kawasaki disease Acute systemic vasculitis Affects skin, blood vessels, mucous membranes, and lymph system Resolves in less than 8 weeks Etiology unknown Has been documented to follow viral infections and toxic exposures Leading cause of acquired heart disease in children Most diagnosed between 6 months and 5 years of age Risk factors include Asian descent and younger than 6 years (can affect any race or age) Acquired Heart Disorders Kawasaki Disease Acquired Heart Disorders Kawasaki Disease Nursing Care Education Monitor VS and cardiac status Understand disease progression Assess for heart failure (decreased Maintain follow up appointments UOP, gallop, tachycardia, respiratory Irritability can last 2 months distress) Monitor I&O Arthritic manifestations can last several weeks Daily weights Skin manifestations are painless, IV fluids as ordered but the skin could be tender Clear liquids and soft, non-acidic foods ROM in the bathtub IV gamma globulin per order and Avoid live immunizations for 11 policy months Aspirin as prescribed Notify provider of any fever Comfort care - oral hygiene, cool cloths, lotions, calm environment, cluster care Cardiac Infections Infective endocarditis Cardiac endocardium becomes inflamed by infection with a streptococcal or staphylococcal organism Risk factors include past history of valve damage or damage to the endocardium Organisms can enter the body through dent work, tooth brushing, cuts, catheters, or respiratory infections Symptoms include SOB, cough, murmur, joint pain, petechiae, flank pain, weight loss, fatigue Blood cultures, CBC, and echo are needed to confirm diagnosis Intensive antibiotic therapy is required Nurse should monitor for stroke, poor cardiac output, and CHF Prepare the family for valve replacement surgery  Cardiomyopathy Refers to abnormalities of the myocardium which interfere with its ability to contract effectively Can lead to heart failure Risk factors include genetics, infection, deficiency states, metabolic Hypertrophic conditions, collagen diseases, drug DCM Most common Rare Prevents filling of the toxicity, dysrhythmias HCM ventricles and causes a Autosomal genetic decrease in diastolic Expected findings include increase in heart muscle mass leads to volume tachycardia, dysrhythmias, abnormal diastolic hepatosplenomegaly, fatigue, poor Dilated function Restrictive growth DCM: palpations, syncope, infant poor feeding, respiratory distress HCM: chest pain, syncope, dyspnea Restrictive: embolic complications Treatment includes beta blockers, Ca channel blockers, ACE inhibitors, and heart transplant Implications of Pediatric Hypertension and Dyslipidemia Hypertension and dyslipidemia can lead to poor health outcomes in children, similar to those noted in adults HTN can be over-diagnosed because of a temporary increase due to stress or fear of going to the doctor HTN can be under-diagnosed due to difficulty in remembering complex variations in norm values for different age, sex, and height groups Evidence of damage to heart and blood vessels is now being seen earlier in the life span with comorbidities of hypertension, dyslipidemia, and type 2 diabetes 40 Teaching Plan for Families of a Child with a CV Disorder Work in groups of 3-4 Create a teaching plan for a family with the provided disorder This Phot o by Unknown Author is license d under CC BY