The Child with Cardiovascular Dysfunction

1. The Child with Cardiovascular Dysfunction By : Basel AbdulQader RN, MSN, CCRN Murad Sawalha RN, MSN, CCRN

2. Fetal Circulation

4. Fetal Circulation Fetal circulation (prenatal circulation) differs from adult circulation in several ways and is designed to ensure a high oxygen blood supply to the brain and myocardium of the fetus.

5. Characteristics of fetal circulation Placenta is the source of oxygen for the fetus, it has 2 arteries and 1 vein. Fetal lungs receive less than 10% of the blood volume ; lung don�t exchange gas. Right atrium of fetal heart is the chamber with the highest oxygen concentration.

6. The three openings that close at birth are: Ductus Arteriosus connects the pulmonary artery to the aorta, bypassing the lungs Ductus Venosus connects the umbilical vein and the inferior vena cava bypassing the liver. Foramen Ovale is the opening between right and left atrias of the heart , bypassing the lungs.

7. Pattern of fetal circulation Oxygenated Blood is carried from placenta through the umbilical vein and enters the inferior vena cava thought the Ductus Venosus . This permits most of the highly oxygenated blood to go directly to the right atrium , bypassing the liver.

8. �.. Continue pattern This right atrial blood flows directly into the left atrium through the foramen ovale an opening between the right and the left atriums .

9. �.. Continue pattern From the left atrium blood flows directly into left ventricle and the Aorta through the subclavian arteries , to the cerebral and coronary arteries , resulting in the brain and the heart receiving the most highly oxygenated blood .

10. Coronary circulation

13. �.. Continue pattern Deoxygenated blood returns from the heart and the arms through the superior vena cava, enters the right atriums and passes into the right ventricle.

14. Blood from the right ventricle flow into pulmonary artery, but because fetal lungs are collapsed, the pressure in the pulmonary artery is very high .

15. �.. Continue pattern Because pulmonary resistance is high , most of the blood passes into the distal aorta through the Ductus Arteriosus, which connects the pulmonary artery and the aorta distal to the origin of the subclavian arteries. From the aorta blood flows to the rest of the body.

16. Normal circulatory changes at birth

19. Foramen Ovale: Opening Between Atria; Allows Blood to Bypass Lungs intrauterinely; Closes With Increased Left-Sided Pressure Ductus Arteriosus: Opening Between Pulmonary Artery & Aorta; Allows Blood to Bypass Lungs intrauterinely; Closes Within 10-15 Hours After Birth With Permanent Closure By 10-21 Days of Life

20. �.. Physiological changes Cyanosis results from 5 or more Grams of Unoxygenated Hemoglobin per 100 ml of Blood: So, If Hemoglobin is Low, You Won�t See Cyanosis In Spite of Low PaO2!

21. �.. physiologic Polycythemia: Increase in Production of Erythrocytes To Compensate for Chronic Hypoxemia; If Hemoglobin Greater Than 20 g/dl & Hematocrit Greater Than 55-60%, Increased Risk for thromboembolism Infants Respond to Severe Hypoxemia With BradyCardia

22. Normal vital signs at birth Heart rate= 120-140 beat/min Blood pressure= 65/41 mmHg Respiratory rate= 30-60 breath/min Temperature= Axillary 35.5-37oC. Oxygen saturation (SpO2 )= >93%

23. Congenital Heart Disease (CHD) Approximately 5-8 Per 1000 Live Births; Combination of Genetic & Environmental Factors : X-ray exposure Maternal Rubella Maternal alcoholism Maternal type 1 diabetes Maternal over 40 of age Occur EARLY in Gestation (3-8 Weeks) in the first trimester

24. CHD Classification of CHD: Acyanotic versus cyanotic

26. �. Cont. acyanotic

27. Cardiac catheterization lab

28. Selected cyanotic defect Tetrology of Fallot (TOF)

29. CARDIAC SURGERY Discharge Teaching: Activity Tolerance; No Bike Riding Until Sternotomy Healed Signs & Symptoms of Wound Infection Return to School in 2 Weeks Usually, No Further Cardiovascular Problems ALLOW THE CHILD TO LIVE A NORMAL AND ACTIVE LIFE!

30. Congestive Heart Failure (CHF) Cardiac Output (CO) Inadequate to Support Circulatory & Metabolic Needs Causes: volume overload, pressure overload, decreased contractility, high cardiac output demands Infant Tires During Feeding (OFTEN FIRST Indication of CHF) Symptoms Increase With Progressing Disease Cardiomegaly Occurs As Heart Attempts to Maintain Cardiac Output If Tachycardia Greater than 180-220 BPM; Ventricles Unable to Fill & CO Falls

32. CHF CHD Most Common Cause of CHF in Infants S/S: Tachycardia Diaphoresis, Tachypnea, Feeding problem, Crackles & Respiratory Distress; Edema, weight CXR Shows Large Heart. Echocardiogram is Diagnostic.

33. CHF Medical Management: Digoxin To Make Heart Work More Efficiently Lasix/Diuretics To Remove Excess Fluid Oxygen: Potent Vasodilator which decreases pulmonary vascular resistance. Rest, a neutral thermal environment, semi-Fowler position, cluster care to promote uninterrupted rest

34. CHF Nursing care Monitor physiologic functions: BP, HR, RR Prevent infection; Group care; Semi-Fowler position. Adequate Nutrition: Feeding Techniques: 45 Degree Angle; Rest Frequently. Promote Development: Play, Age Appropriate Toys, Physical Activities With Rest Periods Emotional Support: Prevent Hypoxia From Agitation or Distress; Consistency of Caregiver for Patient; Refer-Parent-to-Parent Support Groups.

35. ENDOCARDITIS Patients With CHD, Prosthetic Cardiac Valve, Multiple Invasive Lines, etc May Be at Increased Risk Streptococcus viridan (most common) Insidious onset, low-grade intermittent fever, non-specific: malaise, myalgias Definitive Diagnosis: Blood Cultures Intravenous Antibiotics for 2-8 Weeks Bedrest in Acute Phase Prevention is Best; Inform Dentist & MD for Prophylaxis PRIOR to Procedures

37. RHEUMATIC FEVER Inflammatory Disease Following Initial Infection by Group A Beta Hemolytic Streptococci; Cause Changes in Heart, Joints, Skin & CNS. Diagnosis: ?ESR( erythrocyte segmentation rate), CRP(C- reactive protein), ASLO (anti-streptolysin O-titers) Treatment With Antibiotics To Treat Strep Infection Aspirin To Control Joint Pain & Inflammation Prevention is Best Treatment: Throat Culture & Treat With Antibiotics for 10 Days