Chapter 41.

Nursing Care of the Child with a Cardiovascular Disorder

Term
1. Acyanotic heart disorder - heart or circulatory anomalies that involve either a stricture to the flow of blood or a shunt that moves
blood from the arterial to the venous system ( oxygenated to unoxygenated blood or left-to-right shunts)
2. Balloon angioplasty - procedure usually by way of cardiac catheterization in which a catheter with an uninflated balloon at its tip is
inserted and passed through the heart into the stenosed valve. As the balloon is inflated, it breaks valve adhesions and may relieve the
stenosis.
3. Cardiac catheterization - a procedure in which a small radiopaque catheter is passed through a major vein in the arm, leg, or neck
into the heart to secure blood samples or inject dye, to evaluate cardiac function
4. Cyanosis - is blue tinge to the skin indicating hypoxia
5. Cyanotic heart disease - cardiac anomaly when blood is shunted from the venous to the arterial system as a result of abnormal
communication between between the two (deoxygenated blood to oxygenated blood; right-to-left shunt)
6. Diastole - relaxation of the heart chambers
7. Echocardiogrpahy - ultrasound involving the use of high-frequency sound waves to locate and study the movement and dimensions
of the cardiac structures
8. Electrocardiogram (ECG) - written record of the electrical voltages generated by the contracting heart
9. Fluoroscopy - a radiologic serial-images technique
10. Innocent heart murmur - heart murmur of no significance; also called insignificant or functional heart murmur
11. Left-to-right shunts - heart or circulatory anomalies that involve blood movement from the arterial to the venous system
(oxygenated to unoxygenated blood)
12. Organic heart murmur - murmur occurring as the result of heart disease or a congenital defect
13. Polycythemia - an increase in the number of red blood cells that results as a compensatory response to insufficient oxygenation of
the blood
14. Postperfusion syndrome - a complication after cardiac surgery manifested by fever, splenomegaly, general malaise, hepatomegaly,
and leukocytosis
15. Right-to-left shunt - cardiac anomaly when blood is shunted from the venous to the arterial system as a result of abnormal
communication between the two (deoxygenated blood to oxygenated blood)
16. Systole - contraction of the heart chambers
17. Vasculitis - inflammation of the blood vessels
 Cardiovascular System
Blood Vessels:
-Vein - carries deoxygenated blood towards heart; can have valve, prevents backflow
- Arteries - Carries oxygenated blood away from the heart
- Capillaries - smallest blood vessels; most numerous numbers

Heart Layers
-Epicardium
-Myocardium
-Endocardium

Heart Sounds
S1 (Lub) - closing of Mitral/Bicuspid valve & tricuspid valve
- Atrioventricular valve
S2 (Dub) - closing of Pulmonary & Aortic Valve
- Semilunar valve
S3 (ta) - Heard after S1 and S2 (ventricular gallop)
- Common in children
- “Lubdub-ta”
S4 (ta) - Heard before S1 ( Atrial gallop)
- “ta-lubdub”

Systole - contraction of ventricles (closing of AV valves)

Diastole- relaxation
 Capillaries
(Blood loses O2 Arterioles Arteries Aorta Aortic Semilunar
and gains CO2 Valve

Venules (Small Left Ventricle

veins)

Blood Flow (Lungs-heart-body

tissues)
Mitral/Bicuspid
Veins Blue - Carries unoxygenated blood valve
Red - carries oxygenated blood

Left Atrium
Superior vena cava,
Inferior Vena Cava,
Coronary Sinus

Pulmonary
Right Atrium veins

Lungs (Blood
Tricuspid Right Ventricle Pulmonary Pulmonary loses CO2 and
Valve Valve Arteries gains O2)
Cardiac Disorder
 Condition
Rheumatic Fever
-Collagen disease:
characterized by damage to
connective tissue and
usually blood vessels
- cause unknown: frequently
follows infection with
Group A Beta Hemolytic
and Streptococci
Kawasaki Disease /
Mucocutaneous Lymph
Node Syndrome
-acute febrile illness of
unknown etiology
associated with vasculitis
primarily affecting the heart
Signs and Symptoms Management
Major: 1. Bed rest to decrease workload of the heart
1. Polyarthritis 2. Provide a quiet environment
2. Carditis- inflammation of the heart 3. Maintain proper body alignment to prevent deformities
3. Chorea - involuntary movement d/o 4. Increase intake of nutritional foods
4. Erythema marginatum - rashes 5. Limit joint movements
5. Subcutaneous nodules 6. Pharmacotherapy
- Acetylsalicylic Acid (ASA) - to ↓ inflammation and pain
Minor: - Steroid - to reduce inflammation
1. Fever -Penicillin - to eradicate pathogen and prevent recurrence
2. Arthralgia- joint pain -Diuretics
3. Body weakness
4. Easy fatigability
5. Epistaxis
-↑ ASO titer, ESR
-C-reactive CHON test
-ECG, 2 DEcho
- fever for 5 or more days -Primarily supportive and directed toward controlling fever,
-Conjunctival congestion (Blood shot preventing dehydration, and minimizing possible cardiac
eyes) complications
-strawberry tongue 1. Aspirin to control fever and suppress inflammation
-Erythema on soles and palm, edema, 2. Intravenous gamma globulin
feet hard to touch, constant pain and 3. Administer digitalis, diuretics
discomfort 4. Monitor cardiac status, not for signs of dysrhythmias
-skin changes: erythematous rash, 5. Provide optimal nutrition
pruritus 6. Administer analgesics for joint pain PRN
-lymphadenopathy 7. Surgery (PRN) coronary bypass
Congenital Heart Diseases (CHD)
- It is the most common cardiac problem in children
-Any structural lesion in the heart or blood vessels that is directly proximal to the heart is described as a congenital heart defect.
- Anatomic defects of the heart prevent the proper flow of blood to the lungs and/or body.
- Children with symptomatic CHD have chronic problems related to decreased cardiac output, congestive heart failure and hypoxia
and cardiac rhythm disturbances
- Acyanotic defects characteristically have a left-to-right shunt (Oxygenated to unoxygenated blood flow)
-Cyanotic defects characteristically have a right-to-left shunt(unoxygenated to oxygenated blood flow)

Types of Congenital Heart Defects

Acyanotic Defects Cyanotic Defects
Increased Pulmonary Blood Flow -Ventricular Septal Defect (Most common Hypoplastic Left Heart Syndrome
CHD)
-Atrial Septal Defect
-Patent ductus arteriosus
-Atrioventricular Septal Defect
Decreased Pulmonary Blood Flow/ Pulmonary Stenosis Tetralogy of Fallot
Stenotic Lesions Aortic Stenosis Tricuspid atresia
Coarction of the Aorta Pulmonary atresia
Variable Pulmonary Blood flow Total anomalous pulmonary venous return Truncus Arteriosus
Transposition of Great blood vessels

Risk Factors
Maternal Genetic Factors
Rubella in early pregnancy and advanced maternal age History of CHD in other family members
Poorly nourished mother Trisomy 21 (Down’s syndrome)
Alcoholism
Exposure to coxsackievirus
Diabetes Mellitus
Ingestion of lithium
Specific Defect Signs and Symptoms Management
Ventricular Septal -Loud, harsh, holosystolic murmur -Digoxin and diuretics to relieve symptoms of CHF
Defect (VSD) that begins at about 4-8 weeks of age -High calorie formula to promote growth
Hole between the two - O2 saturation is higher than normal in -Nasal gastric feeding for infants who are excessively
ventricles: most common right ventricle tachypneic and tires easily with feeding
cardiac defect; small -Congestive heart failure (tachypnea, -Surgical correction is required in large VSD between 3-12
VSD closes naturally in diaphoresis, easy fatigability) months of age to prevent the development of pulmonary
the first 2 years of life -Failure to thrive vascular disease
-Dysrhythmias
-Small defects may be asymtomatic
Atrial Septal Defect -soft systolic murmur -Preoperative intervention is only indicated in the infant or
(ASD) -Widely split S2, unaffected by child with a large ASD that results in CHF
Hole between the two respiratory pattern -Diuretics to control the symptoms of CHF
atria: small ASD closes -Enlarged right side of the heart - Treatment can be therapeutic catheterization (closing using
naturally -Increased O2 saturation in the right an implantable umbrella) or surgery (median sternotomy with
atrium patch closure or stitch closure) in the pre-school age because
-Mild CHF there is possibility of spontaneous closure in the first 2 years of
-May be asymptomatic (small ASD) life
Patent Ductus -Continuous machinery-like murmur -In premature infants, closur eis attempted by the infusion of
Arteriosus (PDA) (best heard just below the left clavicle) Indomethacin, which inhibits the synthesis of prostaglandin.
Accessory fetal vessel -Tachycardia (Prostaglandins are a group of fatty acid substaces present in
between the pulmonary -Enlargement of left ventricle may tissues and are responsible for a number of cellular
artery and the aorta fails -wide pulse pressure interactions. They are responsible for maintaining patency of
to close: common in -Bounding pulse the ductus arteriosus
premature infants; -Tachypnea -closure is indicated in the full-term symptomatic CHF infant
closure occurs naturally -elective closure with a therapeutic catheterization or surgical
within 12 hours to 2-3 ligation before 5 years of age
weeks
Pulmonary Stenosis Right ventricular enlargement -Neonates with moderate to severs forms of PS require the
(PS) Systolic ejection murmur infusion of Prostaglandin to maintain patency to the ductus
Narrowing of the Exercise intolerance arteriosus. This provides adequate blood flow to the lungs until
pulmonary valve or CHF, cyanosis surgery can be performed
artery -can be opened with balloon procedure (balloon
valvuloplasty) through cardiac catheterization
-the treatment of choice is the surgical valvotomy
Coarctation of the -increased blood pressure and O2 -surgical repair and reconstruction is usually needed
Aorta (COA) - saturation in the upper extremities as -the most common surgical repair is dissection of the stenotic
Narrowing of the aorta compared with the lower extremities area and end-to-end anastomosis of the 2 segments of the
due to a constricting -headache aorta. The older child should have an elective repair after 3-5
band -vertigo, epistaxis years of age as there appears to be a decreased risk of
-Absence or diminished femoral or lower recoarction when the repair is performed at this age
extremity pulses -Balloon angioplasty can be used to dilate the stenotic area
-CHF, decreased cardiac output
Transposition of Great -severs cyanosis hours to days after birth -Prostaglandin (PGE) is initiated to promote oxygenated blood
Blood Vessels (TGV) (as PDA closes) flow from the pulmonary artery to the aorta via retrograde
The aorta rises from the -various murmurs blood flow through the PDA
right ventricle instead of -presence of AD & VSD - Emergency atrial septostomy is performed to create a
the left & the pulmonary -CHF connection between the right and left sides
artery rises from the left -The treatment of choice is the Arterial Switch Procedure
ventricle instead of the
right. This condition in
incompatible with life if
there is no PFO, ASD,
VSD.
Atrioventricular Septal Long systolic murmur Treatment of CHF
Defect (AVSD) CHF Surgery is performed in the first year of life, but should always
Or Atioventricular be completed by 2 years of age because of the potential for the
Canal, is associated with development of irreversible pulmonary vascular disease
a septal defect in the
atrium and ventricle as
well as involvement of
the AV valves; more
common among children
with Trisomy 21
Truncus Arteriosus -mild cyanosis despite supplemental -Treatment of CHF
(TA)- result from failure oxygen -Surgical repair is performed within the first 6 weeks of life
of the embryologic trunk -S/S of CHF -Surgical Repair includes:
to divide into the -Loud, contibuous murmur with a loud 1. Removal of the PA from the common trunk and the defect is
pulmonary arteries and click (associated with the closure of the sutured closed
the aorta; a single truncal valve) 2. Repair of VSD
arterial trunk arises from 3. Placement of a valved homograft conduit connecting the RV
the heart giving rise to to PAs
the pulmonary arteries,
the aorta, and the
coronary arteries. There
is also a single “truncal
valve’ in place of the
aortic and pulmonary
valves and large VSD.
TA is associated with
DiGeorge syndrome.
Tricuspid Atresia -No blood flow from the right atrium to -Prostaglandin E1 (PGE1) infusion is used until an emergency
The tricuspid valve is the right ventricle shunt procedure can be performed. Generally requires several
completely closed, is -severe cyanosis within hours after birth complex surgeries.
incompatible with life if (increased as the PDA closes) -Palliative surgical repair includes:
there is inadequate - CHF A. BT shunt
pulmonary blood flow. - Failure to thrive B. Glenn Shunt
-associated defects C. Fontan procedure - when the child is greater than 2 years of
include ASD, VSD, and age
varrying degrees of RV
hypoplasia
Aortic Stenosis (AS) Left ventricular enlargement -Pre-op management - PGE1 infusion to promote retrograde
Narrowing of the aortic Murmur blood flow from the ductus arteiosus to the distal past the
valve that causes Chest pain aortic valve
obstruction to the left Decreased cardiac output - opened with balloon procedure or surgery
ventricular outflow and A. Aortic Valvotomy - for infants
the amount of blood that B. Aortic Valvuloplasty - for older children
can be ejected from the - Valve replacement can be performed with an artificial valve
LV. or pulmonary autograft
-Children who are recipients of artificial valves must be on
lifetime anticoagulation therapy to prevent clot formation on
the valve
Tetralogy of Fallot Murmur -Pre-operative Management:
(TOF) Cyanosis A. Place the infant in the knee-chest position and allow the
Four anomalies are Polycythemia older children to squat. These position will decrease systemic
present: Thrombi formation venous return as well as increase systemic vascular resistance
A. Pulmonary stenosis Severe dyspnea, hyperpnea in the hope of decrease right to left shunt allowing more blood
B. VSD Squatting position to flow to the lungs
C. Dextroposition Hypercyanotic spells (tet spells) B. Morphine SO4 - to relieve symptoms of agitation and break
(overriding) of the aorta Acidosis the cycle of hyperpnea
D. Right ventricular Clubbing of the finger C. Volume resuscitation - to decrease blood viscosity
hypertrophy Growth retardation D. Supplemental oxygen
- most common cyanotic Failure to thrive -Palliative modified Blalock-Taussig (BT) shunt is often
heart defect CXR shows classic boot-shaped heart performed until child is able to have the surgical corrective
repair
-Complete repair is usually performed between 6-12 yrs old
Hypoplastic Left Heart -Right ventricular enlargement - PGE1 infusion to maintain patency of ductus arteriosus
Syndrome (HLHS) -severe general cyanosis within hours of -Cardiac transplantation for survival
Lack of development of birth -Three-staged palliative surgical procedure
the left ventricle (small, -severe decreases in cardiac output A. Modified Norwood procedure - during the 1st week of life
hypoplastic, (hypotension, tachycardia, tachypnea. B. Hlenn shunt - at 4 to 6 months of age
nonfunctional) Cyanosis) C. Modified Fontan procedure - at approx 2 to 3 years of age
secondary to mitral
valve atresia or aortic
atresia

Diagnostic Tests and labs

1. Chest X-ray (demonstrates increased heart size)
2. Echocardiogram ( demonstrates the location and size of the defect)
3. Electrocardiogram
4. ABGs, CBC, Electrolyte panel
5. Therapeutic and diagnostic cardiac catheterization

Therapeutic Nursing Management

1. Avoid situations that increase cardiac demands (fever, pain, agitation)
2. Avoid unnecessarily disturbing the infant
3. Monitor child’s weights
4. Provide small frequent feedings. Feed with increased calorie formula PRN
5. Administer Oxygen PRN
6. Administer digoxin and observe for signs of digoxin toxicity - anorexia, nausea, vomiting and pulse irregularities
7. Administer diuretics PRN. Replace potassium if furosemide is used
8. Maintain accurate fluid intake and output record
9. Prepare for cardiac catheterization, surgical palliation and/or corrective procedures
10. Protect from infection

Pharmacology
1. Digoxin (Lanoxin) - Hold dose for bradycardia
2. Diuretics: Furosemide (Lasix), Chlorothiazide (Diuril), Spironolactone (Aldactone)
3. Prostaglandin (PGE1) infusion to keep PDA open utnil surgical palliation can occur
4. Indomethacin to prmote PDA closure
5. Vaccination (to prevent infection)

Palliative Surgical Procedures:

1. Blalock-Taussig Shunt - the Left Subclavian Artery is anastomosed to the Left Pulmonary Artery
2. Glenn Shunt - The Superior Vena Cava is disconnected from the right atria and sutured directly to the right Pulmonary Artery
3. Fontan Procedure - Performed to connect the Inferior Vena Cava blood to the Pulmonary Artery
4. Norwood Procedure - the main pulmonary artery is transected and attached to the ascending aorta, creating a new aorta.