2014 Narrated Heart Defects

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Narrate Heart Defect PPT


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Congenital Heart Defects :

Congenital Heart Defects Beth Reese, MSN, RN Spring 2014


Objectives Describe the transition from fetal to pulmonary circulation Perform a nursing assessment and recognize the signs of congestive heart failure in infants and children Develop a nursing care plan for the child with a congenital heart defect

Fetal circulation:

Fetal circulation Ductus venosus Foramen ovale Ductus arteriosus Changes at birth

First Breath:

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

Health History:

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

Present Health History:

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 In the older child additional symptoms may include: Chest pain Decreased activity level Syncope

Heart Sounds :

Heart Sounds

Heart Sounds:

Heart Sounds both the bell & diaphragm Quality: distinct S1 and S2 Rate matches radial pulse Intensity Rhythm

Heart Sounds:

Heart Sounds Should be crisp and distinct in children S1 - closure of the tricuspid and mitral valves when ventricular contraction begins S2 - closure of the aortic and pulmonic valves

PowerPoint Presentation:

Pediatric Murmurs: Area Murmur Upper right sternal border Aortic stenosis, venous hum Upper left sternal border Pulmonary stenosis, pulmonary flow murmurs, atrial septal defect, patent ductus arteriosus Lower left sternal border Still's murmur, ventricular septal defect, tricuspid valve regurgitation, hypertrophic cardiomyopathy , subaortic stenosis Apex Mitral valve regurgitation

Clubbing of Fingers:

Clubbing of Fingers Clubbing of Fingers Whaley & Wong Bowden text

Treatment Modalities:

Treatment Modalities Palliative procedures Pulmonary artery banding Shunts Corrective procedures

Diagnostic Tests:

Diagnostic Tests 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. CBC, Coagulation studies Pulse ox Cardiac Catheterization

Cardiac Catheterization:

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.

Pre-cardiac Catheterization:

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

Post-cardiac Catheterization:

Post-cardiac Catheterization Vital signs Apical pulse Pulses below the cath site Temp and color of extremity Check dressing for bleeding or hematoma

Home Care Instructions:

Home Care Instructions dressing in place for 24 hours dry and clean observe site for redness, swelling, drainage, or bleeding temperature avoid strenuous exercise acetaminophen for pain follow-up appointment pre-procedure medications as ordered.

Congenital Heart Defects:

Congenital Heart Defects


CHD-Overview Structural defect of heart, great vessels or both Classifications Increased pulmonary flow defects Decreased pulmonary flow defects Obstructive defects Mixed flow defects Etiology – 90% unknown

Right to Left Shunts:

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 of the heart and out the body

Clinical Manifestations:

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.

Potential Complications:

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.

Left to Right Shunt:

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.

Clinical Manifestations:

Clinical Manifestations not cyanotic tachycardia - pushing increased blood volume cardiomegaly - increased workload dyspnea and pulmonary edema lungs receiving blood under high pressure from the right ventricle Increased respiratory infections- blood pooling in the lungs promoting bacterial growth

Nursing management of the child with CHD :

Nursing management of the child with CHD Improving oxygenation Promoting adequate nutrition Assisting the child and family to cope Preventing infection Providing care for the child undergoing cardiac surgery Providing preoperative care Providing postoperative care Providing patient and family education

Cardiac Heart Defects:

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

INCREASED Pulmonary Flow Defects:

INCREASED Pulmonary Flow Defects

Patent Ductus Arteriosus:

Patent Ductus Arteriosus failure of DA to close or close completely, increased pulmonary flow

Patent Ductus Arteriosus:

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


PDA Diagnosis Diagnosis by Chest x-ray – enlarged heart and dilated pulmonary artery Echo-cardiogram – show the opening between pulmonary artery and aorta Treatment Indomethocin (Indocin)/ Ibuprofen Cardiac Catheterization Ligation

Atrial Septal Defect- ASD:

Atrial Septal Defect- ASD opening in atrial septum, increased pulmonary flow


ASD 10% of defects 4 in 100,000 people 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.

ASD Diagnosis :

ASD 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

Treatment ASD:

Treatment ASD 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

Ventricular Septal Defect-VSD:

Ventricular Septal Defect-VSD most common, abnormal opening b/t R & L ventricles, increased pulmonary resistance

Ventricular Septal Defect:

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


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

Diagnosis VSD:

Diagnosis VSD Heart murmur Electrocardiogram Chest x-ray Echocardiogram

Treatment VSD:

Treatment VSD CHF: diuretics Digoxin if additional force needed to squeeze the heart FTT -higher calorie concentration prophylactic antibiotics before dental procedures if defect is not repaired

Surgical Repair- VSD:

Surgical Repair- VSD 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.

Atrioventricular Canal Defect:

Atrioventricular Canal Defect combo of defects of atrial and ventriular septa and tricuspid and mitral valves Associated with Down syndrome



Coarctation of the Aorta:

Coarctation of the Aorta Narrowing of the aorta Increased B/P to head Decreased B/P to lower extremities

Coarctation of Aorta:

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)

Diagnosis COA:

Diagnosis COA 50% the narrowing is not severe enough to cause symptoms in the first days of life PDA closes = 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

Treatment COA :

Treatment COA Prostaglandin - keep the PDA open to reduce the pressure changes most common repair - resection of the narrowed area with re-anastomosis of the two ends Surgical complications – kidney damage due to clamping off of blood flow during surgery High blood pressure post surgery – may need to be on antihypertensives Antibiotic prophylactic need due to possible aortic valve abnormalities.

Aortic Stenosis:

Aortic Stenosis Narrowing or stricture of aortic valve

Aortic Stenosis:

Aortic Stenosis 6% of defects Aortic valve: has two rather than three leaflets. Leaflets are thickened or fused. Obstruction of blood flow from left ventricle Mild symptoms: dizziness, syncope, angina, fatigue 30% incidence of sudden death

Aortic Stenosis:

Aortic Stenosis Causes obstruction to blood flow between the left ventricle and aorta. Most common form is obstruction of the valve itself When the aortic valve does not open properly the left ventricle must work harder to eject blood into the aorta. Left ventricular muscle becomes hypertrophied.

Diagnosis AS:

Diagnosis AS Heart murmur or AS is a turbulent noise caused by ejection of blood through the obstructed valve. Electrocardiogram is usually normal Echocardiogram will show the obstruction and rule out other heart anomalies Exercise stress test – provides information on impact of the stenosis on heart function

Treatment AS :

Treatment AS Cardiac catheterization – balloon dilation of the narrowed valve. Surgical valvotomy if the closed procedure does not work – often done when patient is older when severe calcium deposits further obstruct the valve. Recurrent valve obstruction is a complication and if valve replacement is done too early the child may outgrow the valve. Antibiotic prophylaxis especially if valve replacement

Pulmonic Stenosis PS:

Pulmonic Stenosis PS Narrowing entrance to pulmonary artery and resistance to blood flow causes Right ventricle hypertrophy and decreased pulmonary blood flow

Pulmonary Stenosis:

Pulmonary Stenosis 7% of defects Obstruction of blood flow from right ventricle Hypertrophy of right ventricle If severe cyanosis due to right-to-left shunt

Pulmonary Valvar Stenosis:

Pulmonary Valvar Stenosis In pulmonary valvar stenosis the pulmonary valve leads to narrowing and obstruction between the right ventricle and the pulmonary artery. Thickened tissue become less pliable and increases the obstruction Right ventricle must work harder to eject blood into the pulmonary artery.

Diagnosis PS:

Diagnosis PS heart murmur is heard – clicking sound when the thickened valve snaps to an open position Electrocardiogram would be normal Echocardiogram most important non-invasive test to detect and evaluate pulmonary stenosis Cardiac Catheterization – to measure pressures and measure the stenosis

Treatment PS :

Treatment PS Cardiac Catheterization to dilate the valve and open up the obstruction Open- heart procedure only needed for more complex valve anomaly

DECREASED Pulmonary Flow Defects:

DECREASED Pulmonary Flow Defects

Tetralogy of Fallot :

Tetralogy of Fallot “boot shaped”

Tetralogy of Fallot (TOF):

Tetralogy of Fallot (TOF) 6% of defects Most common cardiac malformation responsible for cyanosis in a child over 1 year KNOW THE 4 DEFECTS

Know the 4 defects of Tetrology of Fallot:

Know the 4 defects of Tetrology of Fallot VSD Pulmonic stenosis Overriding aorta Right ventricular hypertrophy

Knee-chest Position :

Knee-chest Position Child with a cyanotic heart defect squats assumes a knee-chest position) to relieve cyanotic spells. Some times called “tet” spells. Ball & Bindler Nurse puts infant in knee-chest position. Whaley & Wong

Clinical Manifestations:

Clinical Manifestations Dependent on degree of right ventricular outflow obstruction. Right-to-left shunt Clubbing of digits “tet” spells - treated by flexing knees forward and upward Severe irritability due to low oxygen levels


Diagnosis Cyanosis Oxygen will have little effect on the cyanosis Loud heart murmur Echocardiogram – demonstrates the four defects characteristic of tetralogy

Treatment :

Treatment If oxygen levels are extremely low prostaglandins may be administered IV to keep the PDA open Complete repair is done when the infant is about 6 months of age Correction includes Closure of the VSD with dacron patch The narrowed pulmonary valve is enlarged Coronary arteries will be repaired Hypertrophy of right heart should remodel within a few months when pressure in right side is reduced

Interventions- TOF:

Interventions- TOF Feeding the child slowly Giving smaller, more frequent meals Decreasing the child's anxiety by remaining calm Knee-chest position Minimizing crying by trying to anticipate the child's needs Recruiting others to care for the child to prevent parental exhaustion and burn-out

MIXED Defects:

MIXED Defects

Transposition of Great Vessels:

Transposition of Great Vessels Aorta leaves from the right ventricle

Transposition of the Great Vessels (or Arteries):

Transposition of the Great Vessels (or Arteries) Pulmonary artery exits L ventricle Aorta exits R ventricle Most common cyanotic heart defect identified in 1 st wk of life. No communication between pulmonary and systemic circulation ~already oxygen-rich blood is carried to lungs

Transposition of Great Vessels:

Transposition of Great Vessels Treatment Goal – to increase blood oxygenation IV prostaglandins – to keep ductus arteriosus open Surgery – “Arterial Switch” done in first few weeks of life involves switching and re-implanting coronary arteries to reestablish normal circulation creating a “new” aorta

Truncus Arteriosus:

Truncus Arteriosus Description Pathophysiology Assessment Nursing care

Hypoplastic Left Heart Syndrome:

Hypoplastic Left Heart Syndrome Underdevelopment of the left side of the heart resulting in a small left ventricle and aortic atresia The descending aorta receives blood from the patent ductus arteriosus supplying system blood flow

Hypoplastic Left Heart:

Hypoplastic Left Heart One of the most complex defects seen in the newborn and the most challenging of all the congenital defects All the structures on the left side of the heart are severely underdeveloped. Mitral and aortic valves are either completely closed or are very small – left ventricle is tiny – aorta is small and often only a few millimeters in diameter


HLH Life threatening shock develops when the ductus arteriosis closes Low oxygen saturations – will not increase with oxygen administration Pulses will be weak in all extremities Plan to deliver infant in a hospital capable of providing the aggressive treatment needed

Treatment :

Treatment Prostaglandins Three staged procedure to reconfigure the cardiovascular system Norwood – right ventricle becomes the systemic ventricle pumping blood to the body Glenn done at 3-6 months Fontan done at 2 -3 years of age

Long Term Complications:

Long Term Complications Easily tiring when participating in sports or other exercises Formation of blood clots – heparin or Coumadin use Heart arrhythmias – pace maker Cardiac failure

Consequences of CHD:

Consequences of CHD

What is congestive heart failure? :

What is congestive heart failure? A patient whose heart does not pump enough blood out to the rest of the body to meet the body's demand for energy .

Congestive Heart Failure:

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.

Cardinal Signs of CHF:

Cardinal Signs of CHF Impaired myocardial function: Edema Wt loss Poor feeding Sweaty with feeding Pulmonary congestion Sudden wt gain Tachypnea Tachycardia Increased respiratory effort

Cardinal Signs of CHF:

Cardinal Signs of CHF Systemic venous congestion Bulging neck veins :JVD Other hepatomegaly

Congestive heart failure symptoms :

Congestive heart failure symptoms Poor growth. This is because in babies with congestive heart failure a significant amount of energy is used Lungs fill with fluid, Becomes more difficult for babies to breathe and they will use more of the muscles of their chest and belly to compensate. Very sweaty with feedings because of the extra work needed to eat. Harder time eating and may not eat as fast or as well as other babies.

Digoxin Therapy:

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.

Signs of Digoxin Toxicity:

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


Interventions Fluid restriction Diuretics Bed rest Oxygen Small frequent feedings Pulse oximeter Sedatives if needed Uninterrupted sleep-ADVOCATE Don’t allow to cry for long periods Teach- med dosages Plan and condense cares

Supplemental Feeding:

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


References Ball, J.W. & Bindler, R.C. (2006) Child health nursing: Partnering with children & families, Upper Saddle River, NJ: Pearson Prentice Hall Hockenberry, M. J. & Wilson, D. (2007) Wong’s nursing care of infants and children, 8 th ed. St.Louis: Mosby Elsevier Hogan, M.A. & White, J.E. (2003). Child health nursing. Upper Saddle River, NJ: Prentice Hall Potts, N.L. & Mandleco, B.L. (2007). Pediatric nursinjg: Caring for children and their families, 2 nd ed.Clifton Park, NY: Thomson Delmar Learning Stein, A.M. (2007). Pediatric nursing, Clifton Park, NY: Thomson Delmar Learning

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