Chapter 26: Congenital Heart Disease (Children) Flashcards
Congenital Heart Disease
a defect in the heart, great vessels, or a noted disease pattern after birth
How can the nurse recognize a congenital heart defect?
recognizing the shunting pattern and recognizing cyanotic versus acyanotic congenital heart defects
What are the Signs and Symptoms Related To?
- the oxygenation status of the defect
- the contractility state or if the patient is in heart failure
Cyanotic Defects
right to left shunting
- the deoxygenated or venous blood from the right side of the heart is forced into the left side of the heart
- the overall oxygen saturation of the blood will drop; range may vary from normal (96-100%) to as low as 70%
Acyanotic Defects
left to right shunting
- the oxygenated blood shunts from the left to the right
- this type of mixing will not affect the overall oxygenation status
In the presence of normal hemoglobin, a decrease in the oxygenation saturation to 85% will cause what?
an outward sign of cyanosis (bluish coloration) that appears around the lips, nose, and mouth of babies and toddlers and in the nailbeds of older children
-if the decreased oxygen state is chronic, the child will eventually develop clubbing of the fingernails; the longer and lower the oxygen saturation, the more evident the clubbing (explanation: the capillaries enlarge (dilate) to accommodate the low saturation in an attempt to deliver more blood to the periphery)
Polycythemia
long-term effect of low oxygenation
-is the increase in red blood cell production in response to the low oxygen output
-has hemoglobin levels greater than 15 g/dL
-condition causes thickening of the blood and predisposes the child to thrombi and stroke
>low oxygenation and thickened blood will often cause the heart muscle to work harder in an effort to circulate more oxygen; this leads to muscular hypertrophy and eventually pump failure
Diagnosis
diagnosis of a heart murmur usually starts with a referral after a murmur is detected
-symptoms can be present: SOB, or high blood pressure in children
Diagnostic Screenings
-chest x-ray
-electrocardiogram (ECG)
>most confirmed by echocardiography or cardiac catheterization
-echocardiogram gives information such as location and size of the defect and can give indirect measurement of pressure
-cardiac cath will give direct measurements of the pressure in the chambers and vessels and gradients (difference of pressure) across the valves
Nursing Care
- monitoring and maintaining the child’s oxygen and nutritional status
- educate family about importance of rest periods and managing the child’s fatigue
- emotional care; this condition may involve many types of surgeries and many hospitalizations; provide emotional support by listening and suppling the family with resources for understanding the disease, prognosis, and treatment plan
- help fulfill spiritual needs when family is interested
Medical Care
focuses on treating the CHF that may develop b/c of the specific defect and includes preload-reducing agents (furosemide (Lasix)), positive inotropes (digoxin (Lanoxin)), and contractile function agents (carvedilol (Coreg))
Surgical Care: Preoperative Care
- thorough history and physical to identify recent changes in the past medical history
- preop checklist
- nurse can provide and support the education given to the family regarding the type of surgery and the process of the surgery (e.g. surgery time, recovery times, and expectations)
Surgical Care: Postoperative Care
- sometimes includes admission to the intensive care unit
- care is complex
Nonpharmacological Approaches to Congenital Heart Defects
- exercise
- stress reduction
Only method to “cure” a defect
-surgery
Safety Measures when Caring for a Patient with CHD
placing child on a pulse oximeter and cardiac monitor
-these children are at risk for deoxygenation and dysrhythmic episodes
Education/ Discharge
- monitoring vital signs and how to recognize signs and symptoms of cardiac failure
- parents should learn CPR
- if discharged to home with oxygen, parents will have pulse oximeter in the home
- taught subtle signs of CHF (SOB, decreased appetite, irritability, swelling, weight gain)
- medication use, effects, side effects
- postop teaching points will answer questions about diet. exercise, activity, and return to school
- care of surgical wound if post op
Proper Diet for a Cardiac Patient
includes balanced, healthy food choices for good bone healing
- avoidance of junk food and empty calories
- fluid restriction may be used in adults, practice avoided in children since infants and younger children can dehydrate much easier
Care of the Surgical Wound
- area to be kept clean and dry
- steri-strips often kept in place until they fall off
- parents taught how to watch for wound healing and signs of infection (redness at the site or fever)
Post-Op: When a Sternal Approach is Used in Surgery
the bone must be allowed to heal for 6 weeks
- infant or baby must be cradled when picked up or carried (i.e. avoid lifting the child from under arms)
- older children should not use backpacks
Exercise Guidelines
specific for each condition and based on protection of the surgical site and bone healing time
-older children: no contact sports are allowed in the first 6 weeks to 6 months after surgery until the bone is healed
>a child may be fitted with a protective vest to prevent injury to the chest when returning to sports
-good exercise plan might help to make the heart muscle stronger and help to prevent CHF
-parents taught that the child with a cardiac condition may be incapable of doing certain strenuous exercises and may need to modify or avoid physical activity; there may be a fine line between encouraging the child to engage in physical activity for the benefits and inhibiting the child from doing physical exercise for fear of getting sicker
>nurse helps balance the decision for the types and amounts of exercise
When can a Child Return to School After Surgery
- when the bone is healed
- nurse provides parents with community based resources to set up home-bound schooling
ATI: Congenital Heart Disease
anatomic defects of the heart prevent normal blood flow to the pulmonary and/or systemic system
- Increased pulmonary blood flow: ASD, VSD, PDA
- Decreased pulmonary blood flow: Tetralogy of Fallot
- Obstruction of blood flow: Coarctation of the Aorta
- Mixed Blood Flow: Transposition of the great arteries
ATI: Defects that increase pulmonary blood flow
allow blood to shift from the high pressure (Left side) to the lower pressure (right side) of the heart
-increased pulmonary blood volume on the right side of the heart increases pulmonary blood flow
>Ventricular Septal Defect (VSD)
>Atrial Septal Defect (ASD)
>Patent Ductus Arteriosus (PDA)
ATI: Ventricular Septal Defect (VAD)
a hole in the septum between the right and left ventricle that results in increased pulmonary blood flow; increased flow to the lungs
(left-to-right shunting)
-loud, harsh murmur auscultated at the left sternal border
-heart failure
-many can close spontaneously early in life
ATI: Atrial Septal Defect (ASD)
a hole in the septum between the right and left atria that results in increased pulmonary blood flow; increased blood flow to the lungs
(left-to-right shunting)
-loud, harsh murmur with a fixed split second heart sound
-heart failure
-asymptomatic
ATI: Patent Ductus Arteriosus (PDA)
condition in which the normal fetal circulation conduit between the pulmonary artery and the aorta fails to close and results in increased pulmonary blood flow (left-to-right shunting) -systolic murmur (machine hum) -wide pulse pressure -bounding pulses -asymptomatic -heart failure -rales
ATI: Obstructive Defects
include those where blood flow exiting the heart meets an area of narrowing (stenosis), which causes obstruction of blood flow
-the pressure that occurs before the defect is increased (ventricle) and the pressure that occurs after the defect is decreased; results in decreased cardiac output
>Coarctation of the Aorta
ATI: Coarctation of the Aorta
a narrowing of the lumen of the aorta, usually at or near the ductus arteriosus, that results in obstruction of blood flow from the ventricle
- elevated blood pressure in the arms
- bounding pulses in the upper extremities
- decreased blood pressure in the lower extremities
- cool skin of lower extremities
- weak or absent femoral pulses
- heart failure in infants
- dizziness, headache, fainting, or nosebleeds in older children
ATI: Defects that Decrease Pulmonary Blood Flow
have an obstruction of pulmonary blood flow and an anatomic defect (ASD or VSD) between the right and left sides of the heart
-right to left shunting of blood allowing deoxygenated blood to enter the systemic circulation
-hypercyanotic spells (blue, or “Tet” spells) manifest as acute cyanosis and hyperpnea
>Tetralogy of Fallot
ATI: Tetralogy of Fallot
four defects that result in mixed blood flow
-pulmonary stenosis
-ventricular septal defect
-overriding aorta
-right ventricular hypertrophy
>cyanosis at birth: progressive cyanosis over the first year of life
>systolic murmur
>episodes of acute cyanosis and hypoxia (blue or “Tet” spells)
ATI: Mixed Defects
Transposition of the great arteries
>a condition in which the aorta is connected to the right ventricle instead of the left, and the pulmonary artery is connected to the left ventricle instead of the right
-murmur depending on presence of associated defects
-severe to less cyanosis depending on the size of the associated defect
-cardiomegaly
-heart failure
ATI: Therapeutic Procedures for Ventricular Septal Defect
> Non-surgical:
- closure during cardiac catheterization
- careful observation for spontaneous closure
- diuretics
> Surgical:
- pulmonary artery banding
- complete repair with patch
ATI: Therapeutic Procedures for Atrial Septal Defect
> Non-surgical:
- closure during cardiac catheterization
- diuretics
- low dose aspirin 6 months after procedure
> Surgical:
- patch closure
- cardiopulmonary bypass
ATI: Therapeutic Procedures for Patent Ductus Arteriosus
> Non-surgical:
- administration of indomethacin (to allow for closure)
- insertion of coils to occlude PDA during cardiac catheterization
- administer of diuretics (furosemide)
- provide extra calories for infants
> Surgical:
-Thoracoscopic repair (ligate vessels)
ATI: Therapeutic Procedures for Coarctation of the Aorta
> Non-surgical:
- infants and children: balloon angioplasty
- adolescents: placement of stents
> Surgical:
-repair of defect recommended for infants less than 6 months of age
ATI: Therapeutic Procedures for Tetralogy of Fallot
> surgical
- shunt placement until able to undergo primary repair
- complete repair within the first year of life
ATI: Therapeutic Procedures for Transposition of the Great Arteries
> Surgical
- surgery to switch the arteries within the first 2 weeks of life
- IV prostaglandin E (keeps ducts open)
ATI: Digoxin
improves myocardial contractility
>Nursing Actions:
-monitor pulse and withhold as prescribed; if pulse less than 90/min in infant withhold; if less than 70/min in children withhold
-monitor for toxicity (bradycardia, dysrhythmias, nausea, vomiting, anorexia); administer Digoxin Immune Fag as antidote
ATI: Captopril or Enalapril
angiotensin-converting enzyme (ACE) inhibitors reduce afterload by causing vasodilation, resulting in decreased pulmonary and systemic vascular resistance
>Nursing:
-monitor blood pressure before and after
-monitor for hyperkalemia
ATI: Metoprolol or carvedilol
beta-blockers decrease HR and BP, and promote vasodilation
- monitor blood pressure and pulse prior to administration
- monitor for adverse effects (dizziness, hypotension, and headache)
ATI: Furosemide or chlorothiazide
potassium-wasting diuretics rid the body of excess fluid and sodium
- encourage high-potassium diet
- monitor I & O
- monitor for adverse effects (hypokalemia, nausea, vomiting, and dizziness)
- monitor weight daily
