Cardiovascular Disorders

Czar Ryan A. Lecciones BSN -N21

The Cardiovascular System Fetal Circulation vs. Neonatal Circulation

● Right atrium to the right ventricle

Fetal Circulation
through the tricuspid valve

● Right ventricle to the pulmonary valve ● Oxygen-rich blood flows from the
to the pulmonary artery for placenta into the umbilical cord of the
oxygenation fetus.
➔ the blood rich in nutrients and
● Pulmonary veins carry oxygenated oxygen, supplied via the
blood to the left atrium placenta, flows through the
umbilical vein to the ductus
● Mitral valve to Aortic valve venosus
➔ Placental blood bypasses the
liver by flowing through the
ductus venosus into the
inferior vena cava (IVC) up to
the right atrium

● Deoxygenated blood returns to the

heart and mixes with the oxygenated
blood
➔ Placental blood from the
umbilical vein mixes with fetal
blood from the IVC and returns
to the heart.

● Oxygen-rich blood is directed toward

the brain

● Oxygen-poor blood mixes with

oxygen-rich blood

● Oxygen-poor blood returns to the

placenta

● By cutting the umbilical cord, the fetus’

circulation system is switched off

Neonatal Circulation

● Foramen Ovale is closed

● Ductus Arteriosus is closed

Normal:

● At birth, the baby's lungs are filled

with fluid. They are not inflated. The
baby takes the first breath within
about 10 seconds after delivery. This
breath sounds like a gasp, as the
newborn's central nervous system
reacts to the sudden change in
temperature and environment
 ● Chromosomal abnormalities
Two Major Groups of Disorders
➔ Down syndrome
➔ DiGeorge syndrome
➔ Noonan or William syndrome
Congenital ➔ Trisomy 13 or 18

● Born with Pediatric Indicators for Cardiac

Dysfunction
● Most structural defects

● Poor feeding/ SOB/fatigue/ cyanosis

Acquired
● Tachypnea/ tachycardia/ diaphoresis
● Developed later in life
● Syncope/ chest pain/ dizziness/
Exposed to certain infections: palpitations

● Bacterial endocarditis ● Failure to thrive/ poor weight gain/

activity intolerance/ hx of frequent
● Rheumatic fever - Rheumatic fever can respiratory infections
develop if strep throat, scarlet fever, and
strep skin infections are not treated ● Developmental delays
properly.
● Prenatal history - maternal exposure to
● Kawasaki disease - vascular infection, drugs, birth complications
inflammation can lead to congestive
heart failure ● Family history of cardiac disease

Tests of Cardiac Function

1. Prenatal ultrasound
2. Chest x-ray
3. Electrodiagram (ecg)
4. Echodiagram
5. Cardiac catheterization
6. Stress test (dobutamine or exercise)
7. Cardiac MRI

Prenatal Ultrasound

● Obstetric ultrasonography, or prenatal

ultrasound, is medical ultrasonography
in pregnancy. Sound waves create
real-time visual images of the
developing embryo or fetus in the
uterus.

Pediatric Chest X-ray

● Systemic HTN - structural defect can
lead to increased pressure in the heart.
● is a non-invasive procedure that
● Endocarditis - inflammation of the provides a picture of a child’s heart,
inner lining of the heart's chambers lungs, and bones in the chest.
and valves.
● It shows the location, size, and shape of
the heart, lungs, and blood vessels, it
Incidence and Causes can show a doctor if there is fluid in the
lungs
● 5 to 8 in 1000 live births
● Can see if there is cardiomegaly
● Cause unknown
Pediatric Electrocardiogram
● Multiple factors
➔ Genetic/ family history
➔ Environment ● Also called an EKG or ECG
➢ Toxins
➢ Viruses ● Is a non-invasive heart test that
➔ Maternal chronic illness graphically records the electrical
(diabetes, seizures meds) activity of the heart in kids
 Cardiac MRI
● Check for pulses especially distal to site
of insertion, temp & color of extremities
● to diagnose a wide range of heart
conditions. These include coronary ● VS every 15 minutes
heart disease, congenital heart disease ➔ Remember 5Ps (Pain, Pallor,
(in children and adults) inherited heart Pulse, Paresthesia, Paralysis)
conditions (such as hypertrophic
cardiomyopathy or dilated ● Check heart rate for full 1 minute (note
cardiomyopathy), heart valve disease, any signs of dysrhythmia or
and cardiac tumors
● Monitor I&O (especial O!). Fluids may be
offered P.O starting with clear liquids
Cardiac Catheterization
● Check Laboratory Results
● Invasive routine diagnostic procedure
Complications
● A procedure in which a small
radiopaque catheter is passed through
a major vein in the arm, leg, or neck ● N/V
into the heart to secure blood samples
or inject dye, helps to evaluate cardiac ● Low-grade fever
function
● Loss of pulse in catheterized extremity
● Benefits:
➔ better visualization ● Transient dysrhythmias
➔ Actual pressures, sats,
hemodynamic values ● Acute hemorrhage from entry site

● Risks
Cardiac Stress Test
➔ Hemorrhage
➔ Fever
➔ N/V ● A cardiac stress test is a cardiological
➔ Loss of a pulse test that measures the heart’s ability to
➔ Transient dysrhythmias respond to external stress in a
controlled clinical environment
● Stenting: acts like a scaffold to help the
artery open (70%) risks include
bleeding, damage to the coronary
artery

Congestive Heart Disease

Nursing Intervention

Older Classification:
PRE - PROCEDURE
● Acyanotic
● complete a thorough hx and physical ➔ “Pink”
exam ➔ No unoxygenated blood flows
to the periphery
● Check for allergies to iodine and
shellfish ● Cyanotic
➔ “Blue”
● Age appropriate teaching & preparation ➔ Unoxygenated blood is shunted
to the periphery
● NPO 4-6 hrs before the procedure; ➔ May be pink
sedation, IV or PO
Newer Classification
● Monitor VS, SaO2, Hgb, Hct, coags, BMP
● Hemodynamic Characteristics
● Mark pedal pulses - before the ➔ Increased pulmonary blood
procedure to ensure correct palpation flow
➢ Too much to lungs
● Determination the amount of sedation “pink”; pulmonary
edema
● based on the child’s age, condition ➔ Decreased pulmonary blood
flow
POST-PROCEDURE ➢ Too little to the lungs
“blue” cyanotic
● Check for bleeding at site of insertion of
catheter in groin
 DEFECTS WITH DEFECTS WITH OBSTRUCTIVE MIXED EFFECTS
INCREASED DECREASED DEFECTS
PULMONARY BLOOD PULMONARY BLOOD
FLOW FLOW

1. Arterial Septal 1. Tetralogy of 1. Aortic 1. Hypoplastic

Defect Fallot Stenosis Left Heart
Syndrome
2. Atrioventricula 2. Tricuspid 2. Coarctation of
Canal Defect Atresia the Aorta 2. Transposition
of the Great
3. Patent Ductus 3. Pulmonary Arteries
Arteriosus Stenosis
3. Total
4. Ventricular Anomalous
Septal Defect Pulmonary
Venous
Connection

4. Truncus
Arteriosus

DEFECTS WITH INCREASED PULMONARY Atrioventricular Canal Defect

BLOOD FLOW
● incomplete fusion of the endocardial
cushions, which is the septum of the
Arterial Septal Defect
heart at the junction of the atria and
the ventricles.
● Hole between two atria of heart
● Children with Down syndrome have
● Abnormal opening between atria that this type
causes an increased flow of oxygenated
blood into the right side of the heart ● Distortion of the mitral and tricuspid
valves
● If not treated, increased risk of atrial
dysrhythmia or stroke ● Blood may flow between all four heart
chambers
● Blood flow is from left to right
(oxygenated to deoxygenated) because
of stronger contraction of the left side
which can also cause ventricular
hypertrophy.

ASSESSMENT:

● Harsh systolic Murmur heard over the

second or third interspace because of
the extra amount of shunted blood

MANAGEMENT: Patent Ductus Arteriosus

● may be closed during cardiac ● Common in premature babies

catheterization
● Failure of fetal ductus arteriosus
● Surgery to close the defect between 1 to (artery connecting the aorta and
3 years old pulmonary artery) to close within the
first few weeks of life
● A child is at risk for infectious
endocarditis and heart failure if no ● Causes increased workload on both
actions are done. ventricles

● Failure to close within first weeks of life

● May have Signs and Symptoms of CHF

➔ Machinery-like murmur
➔ Wide pulse pressure
➔ Bounding pulse
 MANAGEMENT (All four)

● Avoid oxygen - use judiciously ○

especially pre-op

● Diuretics - Furosemide, chlorothiazide,

spironolactone

● Monitor VS, I & O, daily weight.

.
● Baby may gain wt due to edema

● Encourage rest periods to conserve

energy

● Monitor labs, Hgb, Hct, and electrolytes

● Closely monitor feedings

DEFECTS WITH DECREASED PULMONARY

BLOOD FLOW

Tetralogy of Fallot
Ventricular Septal Defect

● It is called “tetralogy” bc four

● Most common type of congenital anomalies are present:
cardiac disorder. 1. Pulmonary stenosis
2. Ventricular Septal Defect
● Hole between two ventricles of the 3. Dextroposition or Overriding of
heart the aorta
4. Hypertrophy of the right
● abnormal opening between the right ventricle
and left ventricles
● Because of the pulmonary stenosis,
● Many VSD (small or moderate) close pressure builds up in the right side of
spontaneously in first years of life the heart

● Acyanotic defect - blood then shunts from this area of

increased pressure into the left
ASSESSMENT: ventricle and the overriding aorta.

● Easily fatigued - The extra effort involved to force blood

through the stenosed pulmonary artery
● Loud, harsh, pansystolic murmur along causes hypertrophy of the right
left sternal border ventricle.

● Vibration is also palpable ASSESSMENT:

● Polycythemia (increased number of

rbc) occurs as the body attempts to
provide enough rbc to supply oxygen.
➔ This is a potential danger
because it causes the blood to
become thick, and clots in
blood vessels may occur

● Child may assume a squatting position

or a knee-chest position when resting.

● Hypoxic episodes, caused by the

decreased blood supply to the brain

MANAGEMENT:

● IV Indomethecin
MANAGEMENT:
MANAGEMENT:
● SURGICAL MANAGEMENT: Palliative
Shunt ● IV Infusion of PGE is started to ensure
➔ Increases the pulmonary blood that ductus remains open
flow and increases oxygen
saturation in infants who
cannot undergo primary
surgery

● SURGICAL MANAGEMENT: Complete

Repair
➔ Performed the first year of life

OBSTRUCTIVE DEFECTS

Aortic Stenosis

● Stenosis or stricture of the aortic valve

prevents blood from passing freely
from the left ventricle into the aorta.

● obstructs blood flow to the body

● Leads to left ventricle hypertrophy

Tricuspid Atresia

● Failure of the tricuspid valve to develop

MANAGEMENT:
● Tricuspid valve is completely closed,
allowing no blood to flow from the right ● Repairwith ballooning or Ballnooning
atrium to the right ventricle. valvuloplasty

● Blood crosses through the patent

foramen ovale into the left atrium,
bypassing the step of oxygenation

● Blood flows through an ASD or a

patent foramen ovale to the left side
of the heart and through a VSD to
the right ventricle and out to the
lungs

● Results in complete mixing of Coarctation of the Aorta

deoxygenated and oxygenated blood in
the left side of the heart ● Narrowing of the lumen of the aorta
due to a constricting band
● As long as the foramen ovale and
ductus arteriosus remain open, the ● Increased pressure in the head and
child can obtain adequate oxygenation upper extremities: decreased in lower
if they close, the infant will develop
extreme cyanosis, tachycardia, and
dyspnea
TREATMENT:
MIXED EFFECTS
● angioplasty, resection with
anastomosis, grafting Coarctation of
the aorta aortic stenosis, pulmonic
stenosis Hypoplastic Left Heart Syndrome

SIGNS AND SYMPTOMS: ● Left ventricle is nonfunctional

● Labored or rapid breathing Weak
femoral artery pulse (taken in the groin ● May have accompanying mitral or
area) aortic valve atresia
● Heavy sweating
● Poor growth ● Nonfunctioning left ventricle lacks
● Pale or gray appearance adequate strength to pump blood into
● Heart murmurs the systemic circulation

● Very Very Very Bad! – However, survival

rates have changed dramatically in the
last 15 years. Can be as high as 95%

● Heart transplantation is the ultimate

answer for prolonging a child’s life.

Pulmonary Stenosis

● Narrowing of the pulmonary valve or

pulmonary artery
Transposition of the Great Vessels
● Inability of the right ventricle to
evacuate blood by way of the ● Transposition of the great arteries
pulmonary artery because of the
obstruction leads to right ventricular ● The aorta arises from the right
hypertrophy. ventricle instead of the left, pulmonary
artery arises from the left ventricle
SIGNS AND SYMPTOMS: instead of the right

● In newborns, a bluish tint to the skin ● No communication between the

(called cyanosis) is caused by blood that pulmonary and systemic circulation
is low in oxygen.
● Being very tired ● Patent foramen ovale or VSD must be
● Poor weight gain present to sustain life, but will cause
● Shortness of breath CHF
● Palpitations (sensation of rapid or
irregular heartbeat)
● Chest pain
● Fainting
● A swollen abdomen
Total Anomalous Pulmonary Venous
Return

● Pulmonary veins return to the right

atrium or the superior vena cava
instead of the left atrium

Truncus Arteriosus

● One major artery or “trunk” arises from

the left and right ventricles

● There is usually an accompanying VSD

● Repair involves reconstructing the

common trunk to create separate
vessels

Management
● Digoxin
➔ Improves contractility of heart
➔ Review dig toxicity-pulse rates
in infants & children

● Diuretics - furosemide

● Ace-inhibitors - (angiotensin
converting inhibitors--the PRIL's)

● Beta-blockers - cause decreased heart

rate, BP vasodilation

● Remove accumulated fluid & sodium

➔ loosely monitor I&0
➔ Restrict fluid in acute phase
➔ Weigh daily if stable