 Describe the common cardiovascular disorders of

childhood.
 Assess a child with a cardiovascular dysfunction.
 Formulate nursing diagnoses for a child with a
cardiovascular disorder.
 Establish appropriate outcomes based on the priority
needs of a child with a cardiovascular disorder.
 Plan nursing care for a child with a cardiovascular
disorder.
 Implement nursing care for a child with a
cardiovascular disorder.
 Evaluate expected outcomes for achievement and
effectiveness of nursing care.
Consists of 3 main parts:
1. Heart

2. Blood

3. Blood vessels
 HEART
CIRCULATION
 It is calculated by
multiplying stroke
volume (the
volume of blood a
ventricle ejects
during systole) by
the heart rate
(beats per minute).
 Preload.
 Afterload.
 Contractility.
HEART SOUNDS
DIAGNOSTIC TESTS
1. Chest X-ray
2. Laboratory Testing
3. Electrocardiogram
4. Holter/Event Monitor - Worn for 24 to 72
hours and gives a complete account of every heart beat of the child
Can be worn for 30 days
5. Transthoracic echocardiogram
6. CT scan or MRI
7. Exercise Stress Testing
8. Cardiac Catheterization
•CONGENITAL HEART DEFECTS
Defects that Increase Pulmonary Blood Flow
• Patent Ductus Arteriosus
• Atrial Septal Defect
• Ventricular Septal Defect
• Atrioventricular Septal Defect
• Transposition of the Great Arteries
• Anomalous Pulmonary Venous Return
• Truncus Arteriosus
Defects that Decrease Pulmonary Blood Flow
• Tetralogy of Fallot
Defects With Obstruction to Systemic Blood Flow
• Coarctation of Aorta
• Aortic Stenosis
Single Ventricle Defects
• Hypoplastic Left Heart Syndrome (HLHS)
Acyanotic Heart Disease
◦ Left-to-right shunts
 Patent ductus arteriosus
 Atrial septal defect
 Ventricular septal defect
 Atrioventricular septal defect
 Blood flows from
the aorta through
the PDA and back
to the pulmonary
artery and lungs,
causing inc. LV
workload and
increase
pulmonary
vascular
congestion
Ifdefect is small, child
may be asymptomatic
A loud machine like
murmur is one of the
characteristic
Child may have frequent
Resp. infections
 Child may have CHF
with poor feeding,
fatigue,
hepatosplenomegaly,
poor weight gain ,
tachypnea and
irritability.

 Tachycardia

 Diagnostic test: ECG

Indomethacin - NSAID
Furosemide - diuretic

Surgical Mgt:
Cardiac catheterization
with a device placed in
the duct to occlude flow
 An abnormal communication
between the L AND R atria;
results when the Atrial Septal
tissue does not fuse properly
during embryonic devt.
 Bloodflows from
the higher –
pressure left
atrium across the
ASD into the lower
pressure right
atrium
Increased blood
return to the right
heart leads to right
ventricular volume
overload and right
ventricular dilation.

Increased pulmonary
blood flow leads to
elevated PA
pressures.
Most
infants tend to be
asymptomatic.

Symptoms may vary with sizes

of defects, fatigue and
dyspnea on exertion
Slow weight gain and
frequent respirations may
occur
Systolic ejection murmur
may be auscultated, usually
most prominent at the 2 nd
ICS
Tachycardia,
 Echocardiography
with Doppler
reveals the
enlarged R side of
the heart and
pulmonary
circulation.
 Cardiac
catheterization
demonstrates
the separation
of the R atrial
septum and the
O2 saturation in
the R atrium
 Closure of
suture

 Pericardial
patch
 The
most common CHD, is
an abnormal opening
between the right and left
ventricles
 Thedegree of this defect
vary from a pinhole
between the R&L ventricles
to an absent septum
Blood flows from the high-
pressure LV across the VSD
into low pressure RV and into
pulmonary artery, resulting in
pulmonary overcirculation.
Symptoms vary w/ size of
defect, age and amount of
resistance, usually the child is
asymptomatic.
Failure to thrive, excessive
sweating, fatigue.
More susceptible to
pulmonary infections
Decreased CO=tachycardia
RVH =increase pulmonary
vascular resistance
Loud harsh murmur
Small VSD
[Link] no med mgt.
[Link] repair indicated
[Link] endocarditis
precaution.
Large VSD
 CHF management:
digoxin and diuretics
and afterload reduction
 Avoid O2
 Surgical repair :
One stage approach patch
closure of VSD
Two stage Approach:1st surgery
is to band the pulmonary
artery (close heart) to restrict
pulmonary bld flow.
2nd surgery is to patch close VSD
and remove PA band.
A left to right shunt occurs at
the atrial and ventricular
levels; AV valve regurgitation
may be significant, sometimes
producing a direct LV to RA
shunt.
Result in enlargement of all 4
cardiac chambers.
Overtime, the increase in
pulmonary blood flow,
pulmonary artery pressure, and
pulmonary vascular resistance
may lead to reversal shunt
direction with cyanosis
Small : asymptomatic

Large : Cause Heart Failure, with

dyspnea when feeding, poor growth,
tachypnea ,diaphoresis and
arrhythmias
 Surgical Repair: Single stage
complete repair
 Elective Surgery for partial
defect
TRANSPOSITION OF THE GREAT ARTERIES
 TRANSPOSITION OF THE GREAT ARTERIES

➢ The aorta arises from the RV and the

pulmonary artery arises from the LV

Oxygenated blood returns from the lungs

to the LA, to the LV, and then proceeds
back through the pulmonary artery and to
the lungs again.
Deoxygenated blood returns from the
body to the RA, to the RV and proceeds out
back to the aorta, supplying deoxygenated
blood to systemic circulation
 TRANSPOSITION OF THE GREAT ARTERIES

• Management
surgical correction, within the first 14 days
of life
Arterial switch or Jatene procedure –
cutting both the PA and aorta above their
respective valves and switching the vessels
to the appropriate location
ANOMALOUS PULMONARY VENOUS RETURN
 ANOMALOUS PULMONARY VENOUS RETURN

➢ APVR a result of failure of the pulmonary

venous connections to unite with the left
atrium – instead they return directly to the
RA, O2nated blood drains back into the
right side of the heart
 TRUNCUS ARTERIOSUS

➢ TA – single arterial vessel that originates

from the heart; overrides the ventricular
septum; and supplies all of the systemic,
coronary and pulmonary blood flow
TRUNCUS ARTERIOSUS
 Blood ejected from the ventricles
enters the common artery and flows
either the lungs or aortic arch.
 Pressure in both ventricles is high and
blood flow to the lungs is marked
increased.
 Neonateswith this defect appear normal;
however, as pulmonary vascular resistance
decreases after birth, severe pulmonary
edema and CHF common develop cyanotic
CHD.

 Marked cyanosis, especially on exertion

 LVH, dyspnea, Marked activity
intolerance and retarded growth.

Loud systolic murmur best heard at

the lower left sternal border and
radiating throughout the chest.
 Surgical
repair is necessary in the 1st
few months of life, the mortality rate
associated with surgery is greater than
10%.

 w/o surgery, children die w/in 1 yr.

•CONGENITAL HEART DEFECTS
Defects that Increase Pulmonary Blood Flow
• Patent Ductus Arteriosus
• Atrial Septal Defect
• Ventricular Septal Defect
• Atrioventricular Septal Defect
• Transposition of the Great Arteries
• Anomalous Pulmonary Venous Return
• Truncus Arteriosus
Defects that Decrease Pulmonary Blood Flow
• Tetralogy of Fallot
Defects With Obstruction to Systemic Blood Flow
• Coarctation of Aorta
• Aortic Stenosis
Single Ventricle Defects
• Hypoplastic Left Heart Syndrome (HLHS)
 TETRALOGY OF FALLOT

➢ Allows deoxygenated blood to be ejected

across the VSD and into the aorta
A heart defect that features four problems:

1. a hole between the lower chambers of

the heart
2. an obstruction from the heart to the
lungs
3. The aorta (blood vessel) lies over the
hole in the lower chambers
4. The muscle surrounding the lower right
chamber becomes overly thickened
Hereditary
Vitamin deficiency
Viral infection: rubella
 Radiation and drugs: Thalidomide, alcohol
and phenytoin
 Down syndrome, Turner’s syndrome
 Club feet, cryptorchidism, and micromegaly
 Maternal dietary deficiency
 Maternal age > 40 & Maternal IDDM
 Cyanosis of mucous membranes of
the lips, mouth, and pharynx, and
in the fingernails and toenails
 Skin is a dusky, bluish color
 Clubbing of the fingers and toes
occurs by 1 to 2 years of age
 Exercise causes severe dyspnea
 Assume a knee-chest position when
they lie down
 Limit their exercise to their level of
tolerance
 Squatting position
 After a short rest, the child resumes
activity
 Paroxysmal dyspneic attacks ( anoxic
“blue” spells)
 Restless, cyanotic and gasps for
breath
Weak cry may be heard
Short episodes may be followed by
sleep
Prolonged episodes may lead to
unconsciousness, convulsions,
hemiparesis, or death
Occur with no warning, although they
may follow feeding, an emotional
upset, or defecation
Do not grow and develop normally.
Small and their nutritional status is
poor.
Mental slowness may result from
chronic hypoxia of the brain.
 May be able to play for a short time.
Removal of the shunt
Cardiopulmonary bypass
Elective repair is usually
performed during the
infant’s 1st year of life, but
palliative repairs may be
warranted for infants who
cannot undergo primary
repair.
•Done at 1 to 2 years of age.
•During hypoxic episode, administering
oxygen
•Knee–chest position
•Morphine sulfate generally reduces
symptoms
•Propranolol (Inderal, a beta-blocker) may be
given orally to aid pulmonary artery dilation.
• A temporary or palliative surgical repair,
called the Blalock-Taussig procedure
• Subclavian artery is used in a Blalock-Taussig
procedure –no palpable pulse in the R arm
after this procedure.
• BP and venipunctures should be avoided in
the affected arm.
Assessment
* systolic murmur at L upper sternal
border
*hypercyanotic spells

Management
*surgical repair at 3-6 months of age
* closure of VSD, repair of stenotic
pulmonary valve
•CONGENITAL HEART DEFECTS
Defects that Increase Pulmonary Blood Flow
• Patent Ductus Arteriosus
• Atrial Septal Defect
• Ventricular Septal Defect
• Atrioventricular Septal Defect
• Transposition of the Great Arteries
• Anomalous Pulmonary Venous Return
• Truncus Arteriosus
Defects that Decrease Pulmonary Blood Flow
• Tetralogy of Fallot
Defects With Obstruction to Systemic Blood Flow
• Coarctation of Aorta
• Aortic Stenosis
• Pulmonic Stenosis
 Restrictedblood flow
trough the narrowed aorta
increases the pressure on
the LV and causes dilatation
of the proximal aorta and
LV hypertrophy, w/c may
led to LV failure
The child may be
asymptomatic or may
experience the classic
difference in BP and pulse is
bounding in the UE and dec. or
absent in the LE.
Epistaxis,headaches,
fainting and lower leg
cramps
 Repairinvolves
surgical removal
of the stenotic
area.

 Nonsurgical repair
via balloon
angioplasty
ECG, echocardiography,
and chest x ray may reveal
left sided heart
enlargement resulting from
back pressure
Adefect that primary
involves an obstruction to
LV outflow of the valve.
 LVpressure inc. to overcome
resistance of the obstructed
valve and allow blood to flow
into the aorta, eventually
producing LVH
 myocardialinfarction may
develop as the inc.
O2 demands of the
hypertrophied LV go unmet
 ECG reveals LV
Hypertrophy
 Cardiac catheterization
demonstrates degree of
stenosis
 Faintpulse , hypotension, tachycardia,
and poor feeding pattern
 Exercise intolerance, chest pain, and
dizziness when standing for long
periods
 A systolic ejection murmur maybe
heard best at 2nd ICS
Treatment

Balloon angioplasty can be

used to dilate the narrow
valve
Adefect that involves
obstruction of blood flow
from the right ventricle
 RVpressure increases
leading to RV Hypertrophy
and eventually RV failure
may occur
Maybe asymptomatic or may
have mild cyanosis or CHF
A systolic murmur may be
heard over the pulmonic area:
a thrill may be heard if
stenosis is severe
 In
severe cases, decreased
exercise tolerance,
dyspnea, precordial pain
and generalized cyanosis
may occur
 Balloon angioplasty techniques are
being widely used to treat PS
 Surgical valvulotomy
➢ Inadequate cardiac
output: systemic &
pulmonary
CIRCULATION.
➢ Pulmonary hypertension
➢ Systolic or Diastolic
overloading of the heart
chambers
➢ Lack of adequate tissue
oxygenation.
 Murmurs
 Decreased exercise tolerance
 Dyspnea
 Tachycardia and tachypnea
 Recurrent respiratory infection
 Cyanosis and polycythemia
 Tissue hypoxia
 Growth retardation
 Cardiac failure
Areas that need care from parents. This
information can be group into the
following:

 Care during episode of dyspnea

 Need for comfort and rest
 Nutritional needs
 Medications
 Psychosocial needs
 Continuing care
 Family relationship
 Financial responsibilities
 Providing Preoperative Care
 Preoperative Assessment
◦ Admission history and physical
examination
◦ Preoperative Studies
◦ Baseline VS
◦ Height and weight measurement
◦ Additional Nursing Observations
 Introduction to the environment
 Introduction to the equipment
 Introduction to the postoperative
procedure
 Post operative assessment and
management
 Cardiopulmonary functioning
 Gastrointestinal and Renal
functioning
 CNS functioning
Cardiovascular
 Arrhythmias
 Hypotension
 Hypovolemia
 Cardiac failure
Respiratory complications:
 Accumulation of mucus in the
respiratory tract
 Pneumonia
 Pneumothorax
Renal function impaired in ability to
excrete waste, I and O
CNC – embolus and increase cerebral
blood flow.
 CHF
-most commonly acquired heart
disease in children
➢ due to a congenital heart disorder or
a disease such as rheumatic fever,
Kawasaki disease, or infectious
endocarditis.
 CHF results when the
myocardium of the
heart cannot pump and
circulate enough blood
to supply oxygen and
nutrients to body cells
 Blood pools in the heart (excessive
preload) or in the pulmonary or
venous systems.

 Lessens the effectiveness of the

heart's pumping action (myocardium
is weakened).
Severe anemia, hypocalcemia, and
myocarditis: may contribute to the heart's
inability to function effectively.

- most apt to occur in children under 1 year

of age (Fulton & Freed, 2004).
 Ventricular hypertrophy

 As blood flow to the kidneys decreases, the

GFR slows, resulting in stimulation of the
renin-angiotensin system.

 Causes fluid and sodium retention.

 Aldosterone secretion by the adrenal
glands further promotes sodium
retention in an attempt to increase
blood flow to the kidneys.

 ADH secretion by the pituitary is also

increased to help retain fluid. This
additional fluid can result in
dependent edema.
 Reduces preload with diuretics,
 Inotropic drugs (heart-strengthening) drug,
and reducing afterload with vasodilators.

 Commonly used diuretics include furosemide

(Lasix) and spironolactone (Aldactone).
 The most common drug used to increase
contractility and slow tachycardia is
DIGOXIN.

 Drugs that decrease afterload include:

[Link] (an arterial vasodilator),
[Link] (calcium channel blocker)
3. nitroprusside (direct-acting vasodilator)and
4. captopril (angiotensin-converting
enzyme ACE inhibitor) (Karch, 2004).
 Realistic in light of the child's condition
 Individualized for each child.
 Focus on helping support heart function and
 Help parents deal with this crisis until the
child's heart is again strong enough to
maintain strong heart.
 results due to presence of pulmonary
vascular resistance present at birth.

 It occurs most often in full-term infants who

have experienced perinatal asphyxia from
conditions
 Supportive therapy
[Link], high-frequency oscillatory
ventilation
2. IV glucose to provide calories.
3. Antibiotics to combat infection.
 an autoimmune disease

 reaction to group A beta-hemolytic

streptococcal infection (Hoffman, 2003).

 leads to fibrin deposits on the endocardium

and valves, in particular the mitral valve, as
well as in the major body joints.
 Thedisease often follows
an attack of pharyngitis,
tonsillitis, scarlet fever,
“strep throat,” or
impetigo, because the
organism common to
these infections is a
group A beta-hemolytic
streptococcus.
 The full course of RF is 6 to 8
weeks.
 Bed rest only during the acute
phase of illness or until
congestive heart disease is
not present, the ESR
decreases, and the C-reactive
protein level and pulse rate
return to normal.
 Pulse rate is a valuable
sign of improvement.
 Obtaining an apical pulse
for a full minute is
preferred.
 Ordered when the child is
asleep as well as when the
child is awake to measure
the effect of activity on
the pulse rate.
 Penicillin therapy or a single intramuscular
injection of benzathine penicillin.
 Oral ibuprofen.
 Corticosteroids
-Possible side effects of corticosteroid
therapy include hirsutism, a round moon face
(Cushing's syndrome), and an increased
susceptibility to infection.
 Phenobarbital and Diazepam.

 Digoxin and Diuretics

 Mild cases of streptococcal pharyngitis, RF
occurs in about 0.3% of children.
 Severe streptococcal infections, the attack
rate may be as high as 1% to 3% (Hoffman,
2003).
 Either amoxicillin or penicillin is used to
eliminate streptococci (upper respiratory
tract). – a drug level must be maintained for
10 to 14 days to be effective.
 Erythromycin is used in children sensitive to
penicillin.
 Usually the child's symptoms will fade before
then, and if the parents are not cautioned
about the importance of the drug, they may
give the drug for only 2 or 3 days and then
discontinue it.
 Prevent valve damage from occurring a
second time.
 Must take prophylactic antibiotic therapy for
at least 5 years after the initial attack, or until
they are 18 years of age.
 If some valve involvement is present,
physicians advocate maintaining the child on
penicillin indefinitely.
 Penicillin may be prescribed as monthly
injections of benzathine penicillin G or daily
oral doses of aqueous penicillin (penicillin V).
 Known as mucocutaneous lymph node
syndrome
 a febrile, multisystem disorder that occurs
almost exclusively in children before the age
of puberty.
 Common in boys under 4 years of age.
 higher in late winter and spring.
 Vasculitis (inflammation of blood vessels) is
the principal (and life-threatening) finding -
can lead to formation of aneurysm and
myocardial infarction (Callahan, 2003).
 Cause is unknown.
 Genetically predisposed individuals
after exposure to unidentified
infectious agent (perhaps an upper
respiratory infection)
 Altered immune function occurs.
 Increase in antibody production
creates circulating immune
(antibody–antigen) complexes that
bind to the vascular endothelium
and cause inflammation.
 The inflammation of blood vessels leads to:
1. Aneurysms
2. Platelet accumulation, and the
3. Formation of thrombi or
4. Obstruction in the heart and blood vessels.
 The signs and symptoms are divided into
major and minor symptoms
 Heart involvement is the most serious.
 Child usually has a systolic murmur from
mitral insufficiency and prolonged P-R and
Q-T intervals on the ECG that reflect
inflammation and slowing of impulse
conduction.
 Chorea (sudden involuntary movement of the limbs) is a
striking symptom.
 Loss of voluntary muscles occurs most often
in children to 7 and 14 years of age (rarely
after age 20).
 Occurs more frequently in girls than boys
(Hoffman, 2003).
 Dysfunctional speech from chorea may be
demonstrated by asking the child to count
rapidly. Children with chorea begin with clear
speech, but then suddenly the sounds become garbled or
they cannot speak for several seconds.
 If asked to protrude the tongue - children
cannot keep from making undulating, jerky
movements.

 If asked to extend their arms in front of them,

they soon hyperextend their wrists and
fingers.
 Hand grasp may be weak or may consist of
spasmodic contractions and relaxation.
 If asked to smile, the facial expression may
change rapidly from a “Cheshire cat” grin to a
flat, expressionless affect or grimace.
 Full course of 6 to 8 weeks.
 Bed rest only during the acute
 Monitoring vital signs is essential during the
acute phase.
 Obtaining apical pulse for a full minute is
preferred. (monitor either asleep as well as
when the child is awake to measure the effect
of activity on the pulse rate).

 Penicillin therapy or a single intramuscular

injection of benzathine penicillin is used to
eliminate group A beta-hemolytic
streptococci completely from the child's
body.
 Oral ibuprofen
 Corticosteroids
 Possible side effects of corticosteroid therapy
include hirsutism, a round moon face
(Cushing's syndrome), and an increased
susceptibility to infection.
POST-QUIZ