Cardiopulmonary Disorders

in Children
Juvy Lynn G. Fortaleza, RN,MN, LPT
Learning Objectives
• Assess a child and family who is at risk or with cardiopulmonary
disorders.
• Formulate nursing diagnoses to address needs / problems of a child
and family who is at risk or with cardiopulmonary disorders.
• Implement safe and quality nursing interventions to meet the needs
and promote optimal outcomes of a child and family who is at risk or
with cardiopulmonary disorders.
• Evaluate expected outcomes for achievement and effectiveness of
care.
Respiratory Disorders in
Children
 Pneumonia
• Pneumonia - infection and • The disease is commonly divided
inflammation of alveoli into two types: hospital acquired
• Occurs at a rate of 2 to 4 children (pneumococcal or streptococcal
in 100. pneumonia) and community
acquired (chlamydia, viral
• It isthe most common pulmonary pneumonias).
cause of death in infants
• younger than 48 hours of age.
• It may be of bacterial origin
(pneumococcal, streptococcal,
staphylococcal, or chlamydial) or
viral in origin, such as RSV
Common types of Pneumonia
1. Pneumococcal Pneumonia-
abrupt and follows an upper
respiratory tract infection.
• In infants, pneumonia tends to
remain bronchopneumonia with
poor consolidation (infiltration
of exudate into the alveoli).
• In older children, pneumonia
may localize in a single lobe, and
consolidation may occur.
2. Chlamydial Pneumonia
• most often seen in newborns up
to 12 weeks of age because the
chlamydial organism is
contracted from the mother’s
vagina during birth.
• Symptoms usually begin
gradually with nasal congestion
and a sharp cough; infants fail to
gain back their birth weight.
Common types of Pneumonia
3. Viral Pneumonia- caused by the
viruses of upper respiratory tract
infection
• Because this is a viral infection,
antibiotic therapy usually is not
effective.
• The child needs rest and, possibly,
an antipyretic for the fever;
intravenous fluid may be necessary
if a child becomes exhausted or is
dehydrated and refusing fluids
4. Mycoplasmal Pneumonia - similar
to yet larger than viruses.
• occurs more frequently in older
children
• The symptoms of mycoplasmal
pneumonia make it difficult to
differentiate from other
pneumonias. The child has a
• fever and a cough and feels ill.
Common types of Pneumonia
5. Lipid Pneumonia- caused by
the aspiration of an oily or lipid
substance
• A proliferative inflammatory
response occurs when lung
lipases act on the aspirated oil.
This is then followed by diffuse
fibrosis of the bronchi or alveoli.
The areathen becomes
secondarily infected.
3. Hydrocarbon Pneumonia
Several common household
products such as furniture polish,
cleaning fluids, turpentine,
kerosene, gasoline, lighter fluid,
and insect sprays have
hydrocarbon bases.
These products are a common
cause of childhood poisonings and
result in hydrocarbon pneumonia.
CROUP ((Laryngotracheobronchitis)
• inflammation of the larynx,
trachea, and major bronchi
• Barking cough
• is one of the most frightening
diseases of early childhood for
both parents and children
• children between 6 months and
3 years of age, the cause of
croup is usually a viralinfection
such as parainfluenza virus
CROUP ((Laryngotracheobronchitis)
Management
Assessment • One emergency method of relieving croup
• children typically have only a mild symptoms is for a parent to run the
upper respiratory tract infection shower or hot water tap in a bathroom
until the room fills with steam, then keep
• During the night, they develop a the child in this warm,moist environment.
barking cough (croupy cough),
inspiratory stridor, and marked • When a child is seen at an emergency
retractions ( not in daytime) room, cool moist air with a corticosteroid
such as dexamethasone, or racemic
• Cyanosis is rarely present, but the epinephrine, given by nebulizer, reduces
danger of glottal obstruction from inflammation and produces effective
the laryngeal inflammation and bronchodilation to open the airway
hypoxemia is very real.
CROUP ((Laryngotracheobronchitis)
Therapeutic Management:
Nursing diagnosis
Ineffective airway Laryngospasm with total occlusion of the
clearance related to airway can occur when a child’s gag reflex is
edema and constriction elicited or when the child is crying. Therefore,
of airway do not elicit a gag reflex in any child with a
croupy, barking cough, and provide comfort to
prevent crying.

Croup is a frightening disease for parents

because their child is suddenly ill with severe
symptoms. When the severe symptoms
disappear by morning, parents may feel
foolish they rushed to a hospital with the child
in the middle of the night
Cystic Fibrosis
• Children with cystic fibrosis (CF)
have a generalized dysfunction
of the exocrine glands
• Mucus secretions of the body,
particularly in the pancreas and
the lungs, are so tenacious that
they have difficulty flowing
through gland ducts.
• The cause of the disorder is an
abnormality of the long arm of
chromosome 7.
• This results in the inability to
transport small molecules across
cell membranes; this leads to
dehydration of epithelial cells in
the airway and pancreas and
dried secretions.
• An increase in sodium and
chloride in sweat and saliva
forms the basis for one
diagnostic test, the sweat
chloride test
Cystic Fibrosis: Respiratory System
Symptoms are produced by the
stagnation of mucus in the airway,
leading to bacterial colonization and
destruction of lung tissue.
Emphysema and atelectasis occur as
the airways become increasingly
obstructed.
Chronic hypoxemia causes contraction
and hypertrophy of the muscle fibers
in pulmonary arteries and arterioles,
leading to pulmonary hypertension
and eventual cor pulmonale. ( Long-
term high blood pressure in the arteries of
the lung and right ventricle of the heart may
fail)
Pneumothorax from ruptured
bullae and hemoptysis from
erosion of the bronchial wall occur
as the disease progresses.
Other respiratory symptoms
- Wheezing and cough
- Dyspnea
- Cyanosis
- Clubbing of the fingers and toes
- Barrel chest
- Repeated episodes of bronchitis
and pneumonia
 Cystic Fibrosis: Respiratory System
Diagnostic Test
 Quantitative sweat chloride test is positive
(greater than 60 mEq/L)
 Newborn screening may be done and direct
DNA analysis for mutant genes.
 Chest x-ray reveals atelectasis and obstructive
emphysema.
 Pulmonary function tests provide evidence of
abnormal small airway function.
 Stool, fat, enzyme analysis: A72-hour stool
sample is collected to check the fat or enzyme
(trypsin) content, or both (food intake is
recorded during the collection
Implementation:
 Goals of treatment include preventing and
treating pulmonary infection by improving
aeration, removing secretions, and
administering antibiotic medications.
 Chest physiotherapy (percussion and postural
drainage)
 A positive expiratory pressure mask may be
prescribed; use of this mask forces secretion
to the upper airway for expectoration.
 The child should be taught the forced
expiratory technique (huffing) to mobilize
secretions for expectoration
 Bronchodilator medication by aerosol may be
prescribed; the medication opens the bronchi
for easier expectoration
Foreign Body Aspiration
• Swallowing and aspiration of a
foreign body into the air passages is
a common problem in young
children.
• Most inhaled foreign bodies lodge in
the main stem or lobar bronchus
• the most common offending foods
are round in shape and include items
such as hot dogs, candy, peanuts,
popcorn, or grapes
Nursing Process for a Child with Respiratory
Disorders
Assessment
• A child admitted to the hospital with a
respiratory disorder is usually in an
acute stage of the illness.
• A child’s condition may worsen rapidly
in the first few hours until a
prescribed medication, such as an
antibiotic or bronchodilator, begins to
take effect.
• Nursing assessment that a child is
developing tachypnea or retractions
may be the first indication of a child’s
worsening condition.
Nursing Process for a Child with Respiratory
Disorders PLANNING
NURSING DIAGNOSIS:
Examples of nursing diagnoses are:
 Ineffective airway clearance
Activity intolerance related to
insufficient oxygenation
Fatigue related to impaired gas
exchange
Fear related to inability to breathe
without effort
Deficient knowledge related to
need for continued treatment
If a child is experiencing an acute
respiratory problem, the expected
outcomes and plan of care will
focus:
 on supporting the child and family
through prescribed therapy
keeping parents informed about
their child’s health status and
response to treatment
IMPLEMENTATION
Various independent nursing interventions may be beneficial:
Placing a child in an upright position to help the child cough more
effectively
Suctioning to remove nasal secretions
Providing an interesting game to teach a child the importance for
strengthening chest muscles
Supporting a child and family trough the anxiety created when a child
not breathing normally
Teaching parents of a child with chronic respiratory dysfunction the
basics of respiratory treatments such as percussion or chest
physiotherapy techniques
Cardiovascular Disorders in
Children
Cardiovascular Disorders in Children
1. Congestive Heart Failure (CHF)
2. Congenital Heart Disease
3. Rheumatic Fever
4. Kawasaki Disease
1. Congestive Heart Failure (CHF)
• Heart failure is the inability of the heart to pump a sufficient
amount of blood to meet the metabolic and oxygen needs of
the body.
• In infants and children, inadequate cardiac output most
commonly is caused by congenital heart defects
• The goals of treatment are to improve cardiac function,
remove accumulated fluid and sodium, decrease cardiac
demands, improve tissue oxygenation, and decrease oxygen
consumption
Congenital Heart Failure: Assessment
Left-Sided Failure – pertains to the Right-Sided Failure – pertains to the
problems of the lungs problems outside the lungs, the systemic
Crackles and wheezes Ascites
Cough Hepatosplenomegaly
Dyspnea Jugular vein distention
Grunting (infants) Oliguria
Head bobbing (infants) Peripheral edema, especially dependent
Nasal flaring edema, and periorbital edema
Orthopnea Weight gain
Periods of cyanosis
Retractions
Tachypnea
2. Congenital Heart Disease
Acyanotic heart disease involves
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
These disorders cause the heart
to function as an ineffective
pump and make the child prone
to heart failure
2. Congenital Heart Disease
Cyanotic heart disease occurs
when blood is shunted from the
venous to the arterial system as
a result of abnormal
communication between the
two systems
deoxygenated blood to
oxygenated blood, or right-to-
left shunts
I. Increased pulmonary blood flow
• Intracardiac communication along the septum or an abnormal
connection between the great arteries allows blood to flow from the
high pressure left side of the heart to the low-pressure right side of
the heart.
Atrial septal defect (ASD)
Ventricular septal defect (VSD)
Atrioventricular canal defect
Patent ductus arteriosus
A. Atrial septal defect (ASD)
• ASD is an abnormal opening
between the atria that causes an
increased flow of oxygenated
blood into the right side of the
heart
• Right atrial and ventricular
enlargement occurs.
• Infant may be asymptomatic or
may develop HF.
Maghubag
 A. Atrial septal defect (ASD)
Assessment Management
Signs and symptoms of decreased Defect may be closed during a
cardiac output may be present. cardiac catheterization.
• Decreased peripheral pulses Open repair with cardiopulmonary
• Exercise intolerance bypass may be performed and
• Feeding difficulties usually is performed before school
age
• Hypotension
• Irritability, restlessness, lethargy
• Oliguria
• Pale, cool extremities
• Tachycardia
A. Atrial septal defect (ASD) Repair
B. Ventricular septal defect (VSD)
VSD is an abnormal opening
between the right and left
ventricles
Many VSDs close spontaneously
during the first year of life in
children having small or
moderate defects
B. Ventricular septal defect (VSD)
Assessment Management
A characteristic murmur is Closure during cardiac
present. catheterization may be possible.
Signs and symptoms of HF are Open repair may be done with
commonly present. cardiopulmonary bypass ( same
Signs and symptoms of with ASD)
decreased cardiac output may
be present.
C. Atrioventricular canal defect
The defect results from
incomplete fusion of the
endocardial cushions.
It is the most common cardiac
defect in Down syndrome
C. Atrioventricular canal defect
Assessment
A characteristic murmur is
present.
The infant usually has mild to
moderate HF, with cyanosis
increasing with crying.
Signs and symptoms of
decreased cardiac output may
be present.
Management
include pulmonary artery
banding for infants with severe
symptoms (palliative) or
complete repair via
cardiopulmonary bypass.
C. Atrioventricular canal defect
Pulmonary artery banding (PAB)
is a palliative surgical technique
used for the correction of
congenital cardiac defects,
characterized by pulmonary over-
circulation caused by left-to-right
shunting of blood.
D. Patent ductus arteriosus
Patent ductus
arteriosus is failure
of the fetal ductus
arteriosus ,shunt
connecting the
aorta and the
pulmonary artery,
to close within the
first weeks of life.
D. Patent ductus arteriosus
Assessment
A characteristic machinery-
like murmur is present.
An infant may be
asymptomatic or may show
signs of HF.
A widened pulse pressure
and bounding pulses are
present.
Signs and symptoms of
decreased cardiac output may
be present
Management
Indomethacin, a prostaglandin
inhibitor, may be administered
to close a patent ductus in
premature infants and some
newborns.
The defect may be closed during
cardiac catheterization, or the
defect may require surgical
management
II. Obstructive Defects
• Blood exiting a portion of the heart
meets an area of anatomical 1. Pulmonary stenosis
narrowing (stenosis), causing 2. Aortic stenosis
obstruction to blood flow. 3. Coarctation of the aorta
• The location of narrowing is usually
near the valve of the obstructive
defect. (pulmonary, aortic valve)
• Infants and children exhibit signs of
HF while children with mild
obstruction may be asymptomatic
A. Pulmonary stenosis
• Pulmonary stenosis is narrowing
at the entrance to the
pulmonary artery.
• The resistance to blood flow
causes right ventricular
hypertrophy and decreased
pulmonary blood flow; the right
ventricle may be hypoplastic.
A. Pulmonary stenosis
Assessment
A characteristic murmur is present.
Infants or children may be
asymptomatic.
Newborns with severe narrowing
are cyanotic.
If pulmonary stenosis is severe, HF
occurs.
Signs and symptoms of decreased
cardiac output may occur
Management
Dilation of the narrowed valve may
be done during cardiac
catheterization.
Surgical management:
- In infants: Trans ventricular (closed)
valvotomy procedure
- In children: Pulmonary valvotomy
with cardiopulmonary bypass
- Surgical valvotomy is a procedure
done to open up a valve
B. Aortic stenosis
• Aortic stenosis is a narrowing or
stricture of the aortic valve,
causing resistance to blood flow
from the left ventricle into the
aorta, resulting in
• decreased cardiac output
• left ventricular hypertrophy and
• pulmonary vascular congestion.
B. Aortic stenosis
Assessment
A characteristic murmur is
present.
Infants with severe defects show
signs of decreased cardiac
output.
Children show signs of exercise
intolerance, chest pain, and
dizziness when standing for long
periods.
Management
Dilation of the narrowed valve
may be done during cardiac
catheterization.
Surgical aortic valvotomy
(palliative) may be done;
a valve replacement may be
required at a second procedure
C. Coarctation of the aorta
• Coarctation of the aorta is localized
narrowing near the insertion of the
ductus arteriosus
• Blood pressure is higher in the upper
extremities than in the lower
extremities;
• bounding pulses in the arms, weak or
absent femoral pulses, and
• cool lower extremities may be present
C. Coarctation of the aorta
Assessment Management
Signs of HF may occur in infants. Balloon angioplasty in children;
Signs and symptoms of restenosis can occur.
decreased cardiac output may be
present.
Children may experience
headaches, dizziness, fainting,
and epistaxis resulting from
hypertension.
C. Coarctation of the aorta
Surgical management
Mechanical ventilation and
medications to improve cardiac
output are often necessary before
surgery.
Resection of the coarcted portion
with end-to-end anastomosis of the
aorta or enlargement of the
constricted section, using a graft,
may be required.
Because the defect is outside the
heart, cardiopulmonary bypass is
not required, and a thoracotomy
incision is used.
III. Defects with Decreased Pulmonary Blood
• If pulmonary vascular
Flow resistance is higher
than systemic
resistance, the shunt is
from right to left; if
systemic resistance is
higher than
pulmonary resistance,
the shunt is from left
to right.
A. Tetralogy of Fallot
• Tetralogy of Fallot
includes 4 defects:
1. VSD
2. pulmonary stenosis
3. overriding aorta
4. right ventricular
hypertrophy
A. Tetralogy of Fallot
Assessment
• Infants
may be acutely cyanotic at birth or
may have mild cyanosis that
progresses over the first year of life
as the pulmonic stenosis worsens.
Acute episodes of cyanosis and
hypoxia (hypercyanotic spells), called
blue spells or tet spells, occur when
the infant’s oxygen requirements
exceed the blood supply, such as
during periods of crying, feeding, or
defecating
A. Tetralogy of Fallot
Assessment
• Children
With increasing cyanosis,
squatting, clubbing of the fingers,
and poor growth may occur.
Squatting is a compensatory
mechanism to facilitate increased
return of blood flow to the heart for
oxygenation.
Clubbing is an abnormal
enlargement in the distal phalanges;
seen in the fingers. Clubbing is
symptomatic of chronic hypoxia.
A. Tetralogy of Fallot
Management
A.Surgical management: Palliative
shunt
- The shunt increases pulmonary
blood flow and increases oxygen
saturation in infants who cannot
undergo primary repair.
- The shunt provides blood flow to
the pulmonary arteries from the
left or right subclavian artery
Surgical management: Complete
repair
- Complete repair usually is
performed in the first year of life.
- The repair requires a median
sternotomy and cardiopulmonary
bypass.
A. Tetralogy of Fallot
IV. Mixed Defects
Fully saturated systemic A. Hypoplastic left heart
blood flow mixes with syndrome
the desaturated blood B. Transposition of the great
flow, causing arteries or transposition of the
desaturation of the great vessels
systemic blood flow.
A. Hypoplastic left heart syndrome
• Underdevelopment
of the left side of
the heart occurs,
resulting in a
hypoplastic left
ventricle and aortic
atresia
A. Hypoplastic left heart syndrome
Assessment
Mild cyanosis and signs of HF
occur until the ductus arteriosus
closes;
then progressive deterioration
with cyanosis and decreased
cardiac output are seen, leading
to cardiovascular collapse.
The defect is fatal in the first few
months of life without
intervention.
Surgical treatment
Surgical treatment is necessary;
transplantation in the newborn
period may be considered.
In the preoperative period, the
newborn requires mechanical
ventilation and a continuous
infusion of prostaglandin E1 to
maintain ductal patency, ensuring
adequate systemic blood flow.
B. Transposition of the great arteries or
transposition of the great vessels
• The pulmonary artery leaves the
left ventricle, and the aorta exits
from the right ventricle.
• There is no communication
exists between the systemic and
pulmonary circulation.
B. Transposition of the great arteries or
transposition of the great vessels
Nonsurgical management
Assessment
Prostaglandin E1 may be
• Infants with minimal initiated to keep the ductus
communication are severely arteriosus open and to improve
cyanotic and depressed at birth. blood mixing temporarily.
• Infants with large septal defects
or a patent ductus arteriosus
may be less severely cyanotic,
but may have symptoms of HF.
• Cardiomegaly is evident a few
weeks after birth.( large heart)
B. Transposition of the great arteries or
transposition of the great vessels
Nonsurgical management
• Balloon atrial septostomy during
cardiac catheterization may be
performed to increase mixing
and to maintain cardiac output
over a longer period
Surgical management:
• The arterial switch procedure
reestablishes normal circulation
with the left ventricle acting as
the systemic pump and creation
of a new aorta.
3. Rheumatic Fever
Rheumatic fever is an
inflammatory autoimmune
disease that affects the
connective tissues of the heart,
joints, skin (subcutaneous
tissues), blood vessels, and
central nervous system.
The most serious complication is
rheumatic heart disease, which
affects the cardiac valves,
particularly the mitral valve.
Assessment
• Assessment of a child with
suspected rheumatic fever
includes inquiring about a recent
sore throat because rheumatic
fever manifests 2 to 6 weeks
after an untreated or partially
treated group A β-hemolytic
streptococcal infection of the
upper respiratory tract.
 3. Rheumatic Fever Minor Criteria
Fever: Low-grade fever that spikes in the late
Jones criteria are used to help determine afternoon with history of sore throat
the diagnosis:
Arthralgia- joint pain
Major Criteria
Elevated erythrocyte sedimentation rate or
Carditis: Inflammation of all parts of the positive
heart, primarily the mitral valves
C-reactive protein level
Polyarthritis: Tender, painful joints
(elbows, knees, ankles, wrists) Prolonged PR interval on electrocardiogram
Chorea: involuntary movements of the Aschoff bodies (lesions): Found in the heart,
extremities and face; affects speech blood vessels, brain, and serous surfaces of the
joints and pleura
Erythema marginatum: Red skin lesions
starting on the trunk and spreading
peripherally.
Subcutaneous nodules: Small nontender
swellings often over the joints
 Assessment
4. Kawasaki Disease • Acute stage
• Fever
• Kawasaki disease, also known as • Conjunctival
mucocutaneous lymph node hyperemia
syndrome, is an acute systemic • Red throat
inflammatory illness. • Swollen hands,
rash, and
• The cause is unknown but may enlargement of
be associated with an infection cervical lymph
from an organism or toxin. node
Cardiac involvement is the most
serious complication;
• aneurysms can develop.
 Convalescent stage
4. Kawasaki Disease Child appears normal, but
signs of inflammation may be
Subacute stage present.
Cracking lips and fissures
Distinct feature:
Desquamation of the skin on the
tips of the fingers and toes Strawberry tongue
Joint pain
Cardiac manifestations
Thrombocytosis
 4. Kawasaki Disease
Watch for:
• Signs and symptoms of
Signs and symptoms of cardiac
complications include chest pain or
tightness (older children), cool and
pale extremities, abdominal pain,
nausea and vomiting, irritability,
restlessness, and uncontrollable
crying.
The child should avoid contact
sports, if age appropriate, if taking
aspirin or anticoagulants.
bleeding include:
• epistaxis (nosebleeds)
• hemoptysis (coughing up
blood),
• hematemesis (vomiting up
blood),
• hematuria (blood in urine)
• melena (blood in stool)
• bruises on the body
Nursing Process : Cardiovascular disease
Assessment
• Assessment of a child with a cardiovascular disorder includes both
careful history taking and physical examination, because many of the
signs and symptoms of heart disease in children are subtle.
• A variety of diagnostic studies such as echocardiography or
electrocardiography or cardiac catheterization may be used to
confirm the diagnosis and prepare a child for surgery.
Nursing Process : Cardiovascular disease
Nursing Diagnosis
Nursing diagnoses associated with heart disease in children usually speak to the
effect of poor circulation on body tissues or the effect a serious disorder can create
on the child or parents. Examples are:
1. Decreased cardiac output related to congenital structural disorder
2. Ineffective tissue perfusion related to inadequate cardiac output
3. Deficient knowledge related to care of the child pre and postoperatively
4. Fear related to lack of knowledge about child’s illness
5. Interrupted family processes related to stresses of the diagnosis and care
responsibilities
6. Ineffective coping related to lack of adequate support people
7. Impaired parenting related to inability to bond with critically ill newborn
Nursing Process : Cardiovascular disease
Planning/ Outcome
Nursing planning is essential to help parents and children understand heart
anatomy.
A sound knowledge base will help them understand the need for
diagnostic testing.
Additional teaching is necessary to prepare parents and children for
procedures or surgery and recovery at home.
Teaching parents to conscientiously administer cardiac medications is
another area where planning plays an important role.
Establishing appropriate outcomes to help a child and parents adjust to a
serious diagnosis, now and in the future, such as coping with their present
fears and caring for the child at home.
Nursing Process : Cardiovascular disease
Implementation
Teaching and providing an opportunity for children and their families
to express fears about a child’s illness and treatment plan,
providing physiologic and psychological support such as comfort
measures after surgery, and caring for a child in cardiac failure.
An equally important role is teaching prevention of heart disease.
Nursing Process : Cardiovascular disease
Outcome evaluation
Examples suggesting achievement of outcomes are:
Child’s heart rate remains within accepted parameters for age.
Child demonstrates age-appropriate coping skills related to diagnosis
and possible surgery.
Parents demonstrate competence with procedures required for care
of their child.
Parents exhibit positive coping skills related to their child’s diagnosis
and required care to foster optimal growth and development in their
child.
Parents verbalize positive aspects about their child
End of Concept