Congenital Heart Disease Flashcards by Bethany Cunningham

Congenital Heart Disease

Most common congenital anomaly
A major cause of death in 1st year of life
Can be structural and/or conductive
Etiology:
- 90% unknown
- multifactorial inheritance
- risk factors - maternal, family history
- associated with chromosomal abnormalities, syndromes or congenital defects in other body systems
- Gene mapping research

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Increased Pulmonary Blood Flow (3)

Atrial septal defects
Ventricular septal defects
Patent Ductus arteriosus

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Obstruction to systemic blood flow (3)

Coarctation of the Aorta
Aortic stenosis
Hypoplastic Left Heart Syndrome

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Decreased Pulmonary Blood Flow (2)

Tetralogy of Fallot
Pulmonic Stenosis

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Mixed blood flow

Transposition of the Great Arteries
Truncus Arteriosus

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Hemodynamic Classification: Increased pulmonary blood flow

Left-to-right shunt
Cause HF

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Hemodynamic Classification: Decreased pulmonary blood flow

Right-to-left shunt if septal defect present
Cause cyanosis

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Hemodynamic Classification: Obstruction to systemic blood flow

Increased pressure load on left ventricle -> decreased CO (shock)
Signs of poor CO; HF (cyanosis on right side)

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Hemodynamic Classification: Mixed blood flow

Saturated & desaturated blood mix within heart or great arteries -> variable clinical picture
Cyanosis & HF

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Defects with Increased Pulmonary Blood Flow

Left-to-right shunt: connection of left & right sides of heart (septal defect), or of great arteries (PDA)
S&S of HF: increased blood volume on right side increases pulmonary blood flow at expense of systemic blood flow

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Defects that obstruct systemic blood flow

Blood exiting heart mets area of anatomic narrowing (stenosis) causing obstruction to blood flow
- increase pressure in ventricle & great artery before obstruction
- Decreased pressure in area beyond obstruction

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Defects with Decreased Pulmonary Blood Flow

Obstruction of pulmonary blood flow & anatomic defect (ASD or VSD)
Right to left shunt
Hypoxemic & usually cyanotic

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Hypercyanotic Spells (Tet spells): Clinical Manifestations

increased rate & depth of respiration
increased cyanosis
Increased heart rate
Pallor & poor tissue perfusion
Agitation or irritability -> may lead to limpness or seizures

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Hypercyanotic Spells: Treatment

Knee-chest position (decreases venous return, shunting blood to vital organs, reduces cardiac workload)
calm, comforting approach
administer 100% oxygen
give SC or IV morphine
begin IV fluid replacement & volume expansion, prn
Repeat morphine administration

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Mixed Defects

Survival in post-natal period depends on mixing of blood from pulmonary & systemic circulations within the heart chambers
Pulmonary congestion
Decreased CO
Clinically - some degree of desaturation (cyanosis may not be visible) & HF

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CHD: Conduction Disorders

Issue with conduction in the heart that cause arrhythmias in children
- Bradycardia: heart block.
- tachycardia: wolff-parkinson-white, supraventricular tachycardia, Long QT
Symptoms:
- syncope
- lightheadedness
- dizzness
- SOB
- Palpitations or skipped heartbeats
- Exercise intolerance
- Difficulty feeding
- Cyanosis
- Cardiac arrest

Conduction Disorders Treatment

Vagal maneuvers
medications
cardioversion
catheter ablation
pacemaker or implantable cardioverter defibrillator

2 main clinical manifestations of CHD

Hypoxemia
Heart Failure

Hypoxemia

PaO2 < normal (80-100 mmHg)
Desaturated venous blood enters systemic circulation without passing through lungs

3 Types of Defects cause cyanosis

Right to left shunt (teralogy of fallot), mixing or arterial & venous blood within chambers of heart, transposition of great arteries

Consequences of chronic Hypoxemia

Polycythemia - risk for thromboembolism
Clubbing - chromic tissue hypoxia & polycythemia
Hematologic abnormalities (thrombocytopenia, abnormal platelet function, fewer coagulation factors, prolonged clotting time -> increased risk of post-op bleeding)
Dehydration
Bacterial endocarditis
CNS injury (stroke, meningitis, brain acscess)

Hypoxemia during feeding

fatigue with feeding, poor weight gain, tachypnea, dypsnea on exertion, poor exercise tolerance
negative developmental outcomes
Squatting; hypercyanotic spells - blue spells or “tet” spells

Hypoxemia: Nursing Interventions (KOMMPP)

oxygen administration “with caution”
prevent hypercyanotic spells (dehydration, crying) and provide calming and comforting measures
monitor CBC
monitor for bleeding (bruising, petechiae, epistaxis)
knee to chest position
parent education

Heart Failure Definition

Inability of heart to pump adequate amount of blood to systemic circulation at normal filling pressures to meet body’s metabolic demands

causes of HF

- volume overload (L-R shunts. Ventricle to hypertrophy) - pressure overload (obstructive lesions: stenosis) - decreased contractility (cardiomyopathy, myocardial asphyxia) - high cardiac output demands (Sepsis)

HF Management: Goals of treatment (4)

Improve cardiac function (increase contractility and decrease afterload) Remove accumulated fluid & sodium (decrease preload) Decrease cardiac demands Improve tissue oxygenation & decrease oxygen consumption

Improve Cardiac Function: Digitalis (aka. Digoxin)

Increases force of contraction Decreases heart rate & slows conduction of impulses through AV node Indirectly enhances diuresis by improving renal perfusion

Nursing Considerations Digitalis

Observe for signs of toxicity Check apical pulse before administering (if < 90-110 you will hold) Proper calculations & measuring are essential (rare to give > 1.0 mL) Discharge teaching

Signs of digitalis toxicity

bradycardia dysrhythmias anorexia n&v

Improve Cardiac Function: Angiotensin-Converting Enzyme (ACE) inhibitors

Reduces afterload Nursing considerations: - monitor BP before & after administration (hypotension) - monitor serum electrolytes - block action of aldosterone & are postassium sparing - carefully assess renal function

Remove accumulated fluid & sodium

administer diuretics (give early in day) - lasix and spirolactone accurate I&O daily weights -> same time, same scale observe for signs of dehydration or edema observe for signs of electrolyte imbalance (if potassium is imbalanced they are at increased risk of digoxin toxicity) fluid restriction rarely needed - if required, plan to give most fluids during waking hours possible sodium restriction

Decrease Cardiac Demands (6)

Limiting activity Cluster nursing care (allow periods of uninterrupted rest, minimal handling) Minimize unnecessary stress (sedation prn) Monitor temperature - hyperthermia, hypothermia: prevent and treat infections promptly Maintain neutral thermal environment Prevent skin breakdown from edema

Improve tissue oxygenation & decrease oxygen consumption

Monitor for & treat respiratory distress - count RR for full minute - position with HOB elevated or sitting up - provide for unrestricted chest expansion Remember: babies are diaphragmatic breathers! - oxygen administration: only if appropriate given their goal saturation parameters

HF - Nursing Considerations

Maintain nutritional status - greater caloric needs but impaired ability to take in adequate calories - well rested before feeds; feed soon after awakening (minimize energy expenditure on crying) - q3h feeding schedule - individualize to infant's needs - Allow no more than 1/2 hour to complete feed -> NG prn - increase caloric density of formulas (add corn oil, or formula to breastmilk)

Post-op Cardiac Surgery: Nursing Considerations

Monitor risk of altered cardiac output Monitor for respiratory distress Blake chest tubes Monitor for arrythmias External pacemaker Monitor for infection Dressing and wound care Manage pain Provide adequate nutrition Support patient and family Coping Discharge planning and teaching