Perfusion

Define and Describe the Concept of

perfusion

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 Definition

Perfusion refers to the flow of blood through

arteries and capillaries, delivering nutrients
and oxygen to cells.

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 Scope of Concept

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 Normal Physiological Process

Central Perfusion Tissue or Local Perfusion

• Force of blood movement • Volume of blood that flows
generated by cardiac output to target tissue
• Requires adequate cardiac • Requires patent vessels,
function, blood pressure, adequate hydrostatic
and blood volume pressure, and capillary
permeability
• Cardiac output (CO) =
Stroke volume × heart rate

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 Central Perfusion and Tissue
Perfusion

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 Variations and Consequences:
Impaired Central Perfusion
• Impairment of central perfusion occurs when
cardiac output is inadequate.
• Reduced cardiac output results in a reduction of
oxygenated blood reaching the body tissues
(systemic effect).
• If severe, associated with shock
• If untreated, leads to ischemia, cell injury, and cell death

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 Variations and Consequences:
Impaired Tissue (Local) Perfusion

• Impairment of tissue perfusion is associated with

loss of vessel patency or permeability, or
inadequate central perfusion
• Results in impaired blood flow to the affected body
tissue (localized effect)
• Leads to ischemia and, ultimately, cell death if
uncorrected
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 Recognize when an individual has
compromised perfusion

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 Inadequate Central Perfusion:
Infants and Children
• Infants
• Poor feeding
• Poor weight gain
• Failure to thrive
• Dusky color
• Toddlers and children
• Squatting and fatigue
• Developmental delay (failure to hit milestones)
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 Common Diagnostic Tests
• Laboratory tests
• Creatine kinase, lactic dehydrogenase, natriuretic peptides,
troponin, homocysteine, C-reactive protein, serum lipids,
platelets, prothrombin time (PT), partial thromboplastin time
(PTT), international normalized ratio (INR)
• Electrocardiogram (ECG)
• Cardiac stress tests
• Exercise or pharmacological test
• Radiographic studies
• Chest x-ray, ultrasound, arteriogram
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 Interrelated Concepts
• Gas exchange
• Pain
• Clotting
• Cognition
• Mobility
• Elimination
• Inflammation
• Patient education
• Nutrition
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 Altered Cardiac
Function (pediatrics)
 Exemplars
*read chapter 47*

 Atrial Septal Defect p. 1481  Kawasaki Disease p. 1513-15

 Ventricular Septal Defect p. 1481 o Bacterial Endocarditis p. 1505-06
 Patent Ductus Arteriosus p. 1481 o Rheumatic Fever p.1506
 Tetralogy of Fallot p. 1484 o Hypertension p. 1512-13
 Tricuspid Atresia p. 1484 o Hypoxemia p. 1496-1499
 Coarctation of the Aorta p. 1481 o Heart Failure p. 1491-96
 Aortic Stenosis p. 1484
 Pulmonic Stenosis p. 1484
 Transposition of the great arteries p.
1484
Two Types of Cardiac Disorders

• Congenital heart disease

• Anatomical: abnormal cardiac function
• Acquired heart disorder
• Disease process or abnormalities that occur after birth
• Infection
• Autoimmune responses
• Environmental factors
• Familial tendencies

.
 Congenital Heart Disease
(CHD)
• Incidence: 5 to 8 per 1000 live births
• CHD is a major cause of death in the first year of life
(after prematurity).
• The most common anomaly is ventricular septal defect
(VSD).
• Often children with CHD have another recognized
anomaly (trisomy 21, 13, 18).
 Congenital Heart Disease—
cont.
• Circulatory changes at birth
• Umbilical vein; umbilical arteries
• Foramen ovale
• Ductus arteriosus
• Ductus venosus
FIGURE 47-1. Changes in circulation at birth. A: Prenatal circulation. B: Postnatal circulation.
Arrows indicate direction of blood flow. Although four pulmonary veins enter the LA, for
simplicity this diagram shows only two. LA, left atrium; LV, left ventricle; RA, right atrium; RV,
right ventricle.

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 Hemodynamic Classification of
Defects
• Defects with increased pulmonary blood flow
• Obstructive defects
• Valvular
• Subvalvular
• Supravalvular
• Defects with decreased pulmonary blood flow
• Mixed blood flow
Figure 47-2. Comparison of acyanotic–cyanotic and hemodynamic classification systems of
congenital heart disease.

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 Congenital Heart Disease -
Assessment
 Pregnancy History
 Family History
 Health History
 Physical Examination
 Diagnostic Tests
 Possible Health History Findings

 Color changes with activity/crying

 FTT/ Feeding problems
 Activity intolerance
 Frequency of infections
 Nosebleeds, headaches, dizziness
 Hypercyanotic spells
 Usual resting position
 Physical Assessment
 Inspection

- color, activity level, chest shape/movement,

respiratory pattern
 Auscultation

- heart sounds, murmurs

 Palpation

- temp, pulses, BP, cap refill, chest, liver

 Possible Findings on P.E.

CV assessment may reveal:

 Cyanosis

 Tachypnea

 Lethargy

 Murmur

 Dysrhythmias

 S/S of congestive heart failure

 Heart Murmur
 Heart sound that reflects the flow of blood within the
heart
 May occur in systole, diastole, or both
 Structural abnormality
 Innocent murmurs- stress, fever, anemia
 Diagnostic Tests

 Chest x-ray to define silhouette of the heart.

- heart size, shape, pulmonary markings, and cardiomegaly.

 Electrocardiogram ECG or EKG to define

electrical activity of the heart.
 Echo-cardiogram to visualize anatomic structures.
 Cardiac Catheterization
 Increased Pulmonary Blood
Flow Defects
 Abnormal connection between two sides of heart
 Increased blood volume on right side of heart
 Increased pulmonary blood flow
 Decreased systemic blood flow
 S/S of HF
 Increased Pulmonary Blood
Flow Defects
 Atrial Septal Defect
 Ventricular Septal Defect*
 Patent Ductus Arteriosus
 Defects With Increased Pulmonary
Blood Flow
• Abnormal connection between two sides of the heart
• Either the septum or the great arteries
• Increased blood volume on right side of the heart
• Increased pulmonary blood flow
• Decreased systemic blood flow
 Ventricular Septal Defect
• Abnormal opening between
right and left ventricles
• Vary in size
• Left to right shunting
• Increased pulmonary blood
flow
• Murmur, poor feeding, S&S
of CHF
• CHF meds, gavage feeds,
surgical repair or catheter
closure
 Defects With Decreased Pulmonary
Blood Flow

• Obstruction of pulmonary blood flow and an anatomical defect

(ASD or VSD)
• Pressure on right side increases, greater than left-sided pressure
• Desaturated blood in left side of heart and in systemic circulation
• Most common: tetralogy of Fallot and tricuspid atresia

 S/S of hypoxemia
 Decreased Pulmonary Blood
Flow Defects
 Tetralogy of Fallot
 Tricuspid Atresia
Tetrology of Fallot
 Four Components of TOF

 VSD
• Pulmonary stenosis – narrowing of pulmonary valve
• Overriding aorta – aortic valve enlarged and appears to arise from
both the left and right ventricles instead of the left ventricle
• Hypertrophy of right ventricle – thickening of the muscular walls
because of the right ventricle pumping at high pressure
 Knee-chest Position
Nurse puts infant in knee-
chest
position. Whaley & Wong

Child with a cyanotic heart

defect squats (assumes a knee-chest position) to relieve
cyanotic spells. Sometimes called “tet” spells. Ball & Bindler
 Obstructive Defects

 Blood exiting the heart meets an area of narrowing or

stenosis
 Pressure in the ventricle is increased
 Pressurebeyond the obstruction is decreased – therefore
decreased cardiac output
 S/S of HF
 Obstructive Defects

 Coarctation of the Aorta

 Aortic Stenosis
 Pulmonic Stenosis
 Coarctation of the Aorta
• Aorta narrowed near the
insertion of the ductus arteriosus
• Increased pressure proximal to
the defect, decreased pressure
distal to the obstruction
• Increased BP, bounding pulses
in arms, weak or absent femoral
pulses, cool lower extremities with
low BP
• S&S of CHF
• Infants deteriorate rapidly
• Primarily surgical repair
 Mixed Defects

 Complex defects with mixing of saturated systemic blood

with desaturated pulmonary blood
 Pulmonary congestion and decreased cardiac output result
 S/S of HF and cyanosis
 Mixed Defects

 Transposition of Great Vessels

 Total Anomalous Pulmonary Venous Connection
 Hypoplastic Left Heart Syndrome
 Transposition of the Great Vessels
• Pulmonary artery leaves the
left ventricle, aorta exits from
right ventricle
• No communication between
systemic and pulmonary
circulations
• Must have PDA or septal
defect to permit blood flow
• Cyanosis or heart failure
• Prostaglandin E1 to keep
ducts open until surgical
repair
 Two Major Clinical
Manifestations of CHD
 Congestive Heart Failure
 Hypoxemia
 Congestive Heart Failure

 Right-sided failure = RV unable to pump blood

effectively to pulmonary artery
 Left-sided failure = LV unable to pump blood to systemic
circulation
 Alterations in preload, afterload, contractility or heart
rate causes CHF
 Clinical Manifestations of CHF

 Systemic Venous Congestion

- weight gain, hepatomegaly, edema, jugular vein distension
 Pulmonary Venous Congestion
- tachypnea, dyspnea, cough, wheezes
 Compensatory Response
- tachycardia, cardiomegaly, diaphoretic, fatigue, failure to grow
 Goals of Therapeutic Management

 Decrease afterload & increase contractility to improve

cardiac output/function (e.g. digoxin & ACE inhibitors)
 Decreasepreload to remove fluid retention - relieve
pulmonary edema (e.g. restrict fluid intake & diuretics)
 Decrease workload of heart (e.g. neutral temp.,
positioning, cluster care, treat infections, sedation &
gavage feeding)
 Improve tissue oxygenation
Manifestations of Hypoxemia

Acute Chronic
 Pallor  Respiratory distress
 Cyanosis  Cyanosis
 Decreased peripheral perfusion  FTT
 Respiratory distress  Polycythemia
 Metabolic acidosis  Activity intolerance
 Lethargy  Clubbing of extremities
 Delayed growth and
development
 Therapeutic Management

 Monitor hydration
 Blood transfusions
 Treatment for infection
 Monitor anemia
 Iron supplements
 Family/child support and teaching
 Surgical Treatment Options for
Congenital Heart Defects
 Surgical Shunts
 Surgical Patch Closure
 Pulmonary Artery Banding
 Valve Reconstruction/Replacement
 Valvotomy

 Surgical Ligation/ Anastomosis

 Heart transplant
 Care of the Child Following
Surgical Repair
 Maintain airway
 Monitor cardiac output status
 Monitor post-op bleeding
 Monitor neuro status
 Prevent fluid and electrolyte imbalances
 Care of the Child Following
Surgical Repair
 Monitor IV sites, dressings
 Prevent hypothermia
 Monitor for infection
 Support family
 Progression of activity
 Discharge planning
 Family Support Issues

 Newborn Diagnosis:
- support parent-infant bonding
- assist/encourage support from friends & family
- teach parents re type of defect, management, prognosis
 Family Support Issues

 Childhood Diagnosis:
- promote nutrition
- involvement in normal activities
- minimize over dependency
- maintain discipline
- teach parents/child
 Acquired cardiovascular
disorders
• Infectious and inflammatory cardiac disorders
 Kawasaki Disease

o Also known as Mucocutaneous Lymph Node Syndrome

o An acute systemic vasculitis of unknown etiology
o Acute phase self-limiting, but may be fatal
o Potentially serious long term effects
 Key Clinical Manifestations

o Fever
o Conjunctivitis
o Strawberry tongue
o Skin peeling/reddened on fingers and toes
o Cardiac inflammation
o Irritability
 Kawasaki Disease
Treatme nt
IV
 IgG ASA80-100mg/kg/day—fever
– Then3-5mg/kg/day—antiplatelet

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 Therapeutic Management
o Aspirin for anti-inflammatory and antiplatelet effects
- 80-100 mg/kg/day – fever
- Then 3-5 mg/kg/day - antiplatelet
o Intravenous Gamma Globulin (IVIG)
o Supportive nursing care
o Nutrition and rehydration
o Educate/reassure parents