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Cardiac Lecture

Cardiac Lecture. Jan Bazner-Chandler CPNP, CNS, MSN, RN. Cardiac. Ball & Bindler. Health History. Family history of defects / early cardiac disease / siblings with defects Maternal history of stillborns or miscarriages

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Cardiac Lecture

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  1. Cardiac Lecture Jan Bazner-Chandler CPNP, CNS, MSN, RN

  2. Cardiac Ball & Bindler

  3. Health History • Family history of defects / early cardiac disease / siblings with defects • Maternal history of stillborns or miscarriages • Congenital anomalies / genetic anomalies / fetal alcohol syndrome / Down Syndrome and Turner Syndrome • Maternal exposure to rubella

  4. Present Health History • Heart murmur • Tires while eating • Low weight for height • Sweats while eating (diaphoretic) • Cyanosis, worsens with feeding or activity level • Irritable weak cry

  5. Health History • In the older child additional symptoms may include: • Chest pain • Decreased activity level • Syncope • Slight of build

  6. Heart Sounds

  7. Heart Sounds • Use both the bell (for low frequency) and the diaphragm (for high frequency) • Quality: distinct S1 and S2 • Rate matches radial pulse • Intensity • Rhythm

  8. Heart Sounds • Heart sounds should be crisp and distinct in children. • S1 is the first heart sound, produced by closure of the tricuspid and mitral valves when ventricular contraction begins. • S2 is produced by the closure of the aortic and pulmonic valves.

  9. Heart Murmurs • These sounds are produced by blood passing through a defective valve, great vessel, or other heart structure. • Murmurs are classified by: intensity, location, radiation, timing, and quality.

  10. Clubbing of Fingers Clubbing of Fingers Whaley & Wong Bowden text

  11. 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. Some times called “tet” spells. Ball & Bindler

  12. First Breath • Pulmonary alveoli open up • Pressure in pulmonary tissues decreases • Blood from the right heart rushes to fill the alveolar capillaries • Pressure in right side of heart decreases • Pressure in left side of heart increases • Pressure increases in aorta

  13. Treatment Modalities • Palliative procedures • Pulmonary artery banding • Shunts • Corrective procedures

  14. Diagnostic Test • Chest x-ray to define silhouette of the heart. • Heart size, shape, pulmonary markings, and cardiomegaly. • Electrocardiogram to define electrical activity of the heart. • Echo-cardiogram to visualize anatomic structures. Non-invasive

  15. Cardiac Conduction

  16. Cardiac Catheterization • An invasive test to diagnose or treat cardiac defects. • Visualizes heart and vessels. • Measures oxygen saturation of chambers. • Measures intra-cardiac pressures. • Determines muscle function and pumping action of the heart.

  17. Pre-cardiac Catheterization • Assess vital signs with blood pressure. • Hemoglobin and hematocrit • Pedal pulses • NPO • Hold digoxin • IV if child is polycythemic

  18. Post-cardiac Catheterization • Vital sign, with apical pulse, and blood pressure q 15 minutes for first hour. • Apical pulse for 1 minute to check for bradycardia or dysrhythmias.

  19. Toxicity to Dye • Watch for signs of toxicity to the dye used during the procedure. • Increased temperature • Urticaria • Wheezing • Edema • Dyspnea • Headache *Allergy response

  20. Home Care Instructions • Keep dressing in place for 24 hours. • Keep site dry and clean. • Observe site for redness, swelling, drainage, or bleeding. • Check temperature. • Avoid strenuous exercise. • Acetaminophen for pain. • Keep follow-up appointment • Pre-procedure medications as ordered.

  21. Post-cardiac Catheterization • Assess pulses below the cath site. • Record quality and symmetry of pulses. • Assess temperature and color of affected extremity. • Check dressing for bleeding or hematoma formation.

  22. Right to Left Shunts • Occurs when pressure in the right side of the heart is greater than the left side of the heart. • Resistance of the lungs in abnormally high • Pulmonary artery is restricted • Deoxygenated blood from the right side shunts to the left side

  23. Right to Left Shunt • Hole in septum + obstructive lesion = Deoxygenated blood from the right side of the heart shunts to the left side of the heart and out into the body.

  24. Clinical Manifestations • Hypoxemia = the result of decreased tissue oxygenation. • Polycythemia = increased red blood cell production due to the body’s attempt to compensate for the hypoxemia. • Increase viscosity of the blood = heart has to pump harder.

  25. Potential Complications • Thrombus formation due to sluggish circulation. • Brain abscess or stroke due to the un-oxygenated blood bypassing the filtering system of the lungs.

  26. Left to Right Shunt • Pressures on the left side of the heart are normally higher than the pressures in the right side of the heart. If there is an abnormal opening in the septum between the right and left sides, blood flows from left to the right.

  27. Clinical Manifestations • The infant is not cyanotic. • Tachycardia due to pushing increased blood volume. • Cardiomegaly due to increased workload of the heart.

  28. Clinical Manifestations • Dyspnea and pulmonary edema due to the lungs receiving blood under high pressure from the right ventricle. • Increased number of respiratory infections due to blood pooling in the the lungs promoting bacterial growth.

  29. Congestive Heart Failure • Major manifestation of cardiac disease. • Under 1 year of age due to congenital anomaly. • Over 1 year with no congenital anomaly may be due to acquired heart disease.

  30. Cardinal Signs of CHF • Tachycardia • Cardiomegaly • Tachypnea • Hepatomegaly

  31. Digoxin Therapy • Digoxin increases the force of the myocardial contraction. • Take an apical pulse with a stethoscope for 1 full minute before every dose of digoxin. If bradycardia is detected. • < 100 beats / min for infant and toddler • < 80 beats in the older child • < 60 beats in the adolescent * Call physician before administering the drug.

  32. Signs of Digoxin Toxicity • Bradycardia • Arrhythmia • Nausea, vomiting, anorexia • Dizziness, headache • Weakness and fatigue

  33. Interventions • Fluid restriction • Diuretics – Lasix (potassium wasting) or Aldactone (potassium sparing) • Bed rest • Oxygen • Small frequent feedings – soft nipple with supplemental NG for adequate calorie intake • Pulse oximeter • Sedatives if needed

  34. Supplemental Feeding Infants with cardiac conditions often require supplemental feeding to provide sufficient nutrients for growth. Ball and Bindler

  35. Cardiac Heart Defects • http://www.cincinnatichildrens.org/health/heart-encyclopedia/anomalies/

  36. Patent Ductus Arteriosus • PDA • Incidence 10% • One of the most common benign defects • Ductus normally closes within hours of birth • Connection between the pulmonary artery (low pressure) and aorta (high pressure) • High risk for pulmonary hypertension

  37. Diagnosis and Treatment • Diagnosis by • Chest x-ray – enlarged heart and dilated pulmonary artery • Echo-cardiogram – show the opening between pulmonary artery and aorta

  38. Treatment • Indomethocin given po – constricts the muscle in the wall of the PDA and promotes closure • Cardiac Catheterization – coil is placed in the open duct and acts like a plug • Closed heart surgery – small incision made between ribs on left hand side and PDA is ligated or tied and cut

  39. Atrial Septal Defect • ASD • 10% of defects • Blood in left atrium flows into right atrium • Pulmonary hypertension • Reduced blood volume in systemic circulation • If left untreated may lead to pulmonary hypertension, congestive heart failure or stroke as an adult.

  40. Diagnosis and Treatment • Diagnosis: heart murmur may be heard in the pulmonary valve area because the heart is forcing an unusually large amount of blood through a normal sized valve. • Echocardiogram is the primary method used to diagnose the defect – it can show the hole and its size and any enlargement of the right atrium and ventricle in response to the extra work they are doing.

  41. Treatment • Surgical closure of the atrial septal defect • After closure in childhood the heart size will return to normal over a period of four to six months. • No restrictions to physical activity post closure

  42. Ventricular Septal Defect • VSD • 30% of defects • Opening in the ventricular septum • Left-to-right shunt • Right ventricular hypertrophy • Deficient systemic blood flow

  43. VSD • Small holes generally are asymptomatic • Medium to moderate holes will cause problems when the pressure in the right side of the heart decreases and blood will start to flow to the path of least resistance (from the left ventricle through the VSD to the right ventricle and into the lungs) • This will generally lead to CHF

  44. Diagnosis and Treatment • Diagnosis – heart murmur – clinical pearl a louder murmur may indicate a smaller hole due to the force that is needed for the blood to get through the hole. • Electrocardiogram – to see if there is a strain on the heart • Chest x-ray – size of heart • Echocardiogram – shows size of the hole and size of heart chambers

  45. Treatment VSD • CHF: diuretics of help get rid of extra fluid in the lungs • Digoxin if additional force needed to squeeze the heart • FTT or failure to grow may need higher calorie concentration • Will need prophylactic antibiotics before dental procedures if defect is not repaired

  46. Surgical Repair • Over a period of years the vessels in the lungs will develop thicker walls – the pressure in the lungs will increase and pulmonary vascular disease • If pressure in the lungs becomes too high the un-oxygenated blood with cross over to the left side of the heart and un-oxygenated blood with enter the circulatory system. • If the large VSD is repaired these changes will not occur.

  47. Coarctation of Aorta • COA • 7 % of defects • Congenital narrowing of the descending aorta • 80% have aortic-valve anomalies • Difference in BP in arms and legs (severe obstruction)

  48. Diagnosis and Treatment • In 50% the narrowing is not severe enough to cause symptoms in the first days of life. • When the PDA closes a higher resistance develops and heart failure can develop. • Pulses in the groin and leg will be diminished • Echocardiogram will show the defect in the aorta

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