Care of Mother and Child at Risk or with

Problems (Acute and Chronic)

LESSON TITLE: NURSING CARE OF A FAMILY WHEN A CHILD Materials:

HAS A CARDIOVASCULAR DISORDER
Pen, paper, index card, book, and class List
Learning Targets:
At the end of the module, students will be able to:
1. Define the common types of cardiovascular disorders that References:
occur in children.
2. Integrate the knowledge of the common cardiovascular Pilliteri, Adele and Silbert-Flagg, JoAnne
disorders in children and describe these common illnesses (2018) Maternal and Child Health Nursing, 8th
that occur in these classifications of school aged children in Edition. USA: Lippincott Williams and Wilkins
formulating nursing care plan in giving quality maternal and
child health nursing care.

A. LESSON PREVIEW/REVIEW

To the students: Review of past lessons regarding disorders affecting oxygenation.

B. MAIN LESSON
The instructor should discuss the following topics. Instruct students to take down notes.

Please refer to Chapter 41: Nursing Care of a Family When a Child Has a Cardiovascular Disorder-Congestive Heart
Failure p. 1134 and Congenital Heart Defects p. 1140
CONGESTIVE HEART FAILURE
 is defined as the inability of the heart to supply
adequate oxygenated blood to meet the metabolic RIGHT SIDED HEART LEFT SIDED HEART
demands of the body. FAILURE FAILURE
 Heart failure is a cluster of symptoms and physical  Hepatomegaly  increased
examination findings that are secondary to an  increased venous pulmonary
underlying process. pressure noted pressures
 most common causes of CHF in children are jugular venous  rales
congenital heart defects that produce an distention  tachypnea
excessive workload on the myocardium,  periorbital edema  shortness of
cardiomyopathies due to metabolic disorders, breath
infectious diseases, drugs, Kawasaki disease, and
myocardial dysfunction after heart surgery. THERAPEUTIC MANAGEMENT
 symptomatically manage the patient
ETIOLOGY  treat the underlying cause of the heart failure
 inability to meet metabolic demands  goal is to decrease any fluid overload, enhance
 decreased filling or obstruction of flow, myocardial contractility, and decrease afterload in
 Either one side or both sides of the heart are order to ensure adequate perfusion and decrease
unable to pump effectively and will eventually fail the work of the heart.
if the root problem is not corrected.  Interventions focus on helping support heart
function and helping parents deal with this crisis
ASSESSMENT until the child is stabilized and the underlying
 Tachycardia condition can be treated, if possible.
 tachypnea.
 poor feeding and failure to thrive in infants and
young children
 older children may complain of fatigue, exercise
intolerance, and breathlessness.
 may gain weight from fluid overload

CONGENITAL HEART DEFECTS

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 Care of Mother and Child at Risk or with
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ACYANOTIC HEART DISEASE CYANOTIC HEART DISEASE

the blood shunts left to right, then oxygenated blood from When venous blood from the right side of the heart mixes
the left side mixes with blood in the right side of the heart with blood on the left side, this is a “right-to-left” shunt that
and goes back to the lungs again delivers deoxygenated blood to the body

DEFECTS THAT INCREASES PULMONARY BLOOD FLOW

PATENT DUCTUS ARTERIOSUS (PDA) TRANSPOSITION OF GREAT VESSELS (TA)
 occurs when the DUCTUS ARTERIOUSUS fails  the second most common congenital defect and is
to close after several days of life. described as reversal of the great arteries
 occurs more frequently in children born  the aorta coming off of the right ventricle and the
prematurely pulmonary artery arising from the left ventricle

ASSESSMENT ASSESSMENT
 Produces a systolic murmur early in life and a  Transposition of the great arteries is a cyanotic
continuous murmur as the child ages at the defect noted immediately after birth
second intercostal space, left upper sternal  tachypneic, and a murmur may not be noted.
border, or out to the left clavicular area  prostaglandin E1 (PGE1) infusion is started
 If the defect is largely significant that can cause immediately after birth to maintain patency of the
rales, congestion, increased work of breathing, ductus arteriosus and encourage mixing of blood.
difficulty feeding, or failure to thrive Side effects: apnea and hypotension.
 Confirmed by echocardiogram  best for the child to remain on room air,
spontaneously breathing
MANAGEMENT  Echocardiogram will confirm this diagnosis and
 Diuretics (FUROSEMIDE) for the symptoms of the will also delineate the coronary artery anatomy
increased blood flow.
 If the child is experiencing significant MANAGEMENT
manifestations of the increased pulmonary blood  requires surgical correction within the first 14 days
flow or if left heart dilation is noted from the extra of life to ensure the most positive outcomes
blood flow returning to the left side of the heart,  Arterial switch or Jatene procedure-dissecting
the child will be referred for PDA closure. both the pulmonary artery and aorta above their
 Indomethacin, a nonsteroidal anti-inflammatory respective valves and switching the vessels to the
and prostaglandin inhibitor, can be utilized to appropriate location
facilitate closure.  before surgery includes ensuring their oxygen
saturation remains normal for this defect, which is
75% to 85%;
 monitoring for signs of increased pulmonary blood
flow; and supporting the family as they wait for
their newborn to undergo heart surgery.
ATRIAL SEPTAL DEFECT (ASD) ANOMALOUS PULMONARY VENOUS RETURN AND
 Is created when a portion of the atrial septal tissue TRUNCUS ARTERIOUSUS
does not completely form.  Two rare, uncommon cyanotic defects
 acyanotic defect that allows blood to flow from the
high-pressure left atrium to the low-pressure right ANOMALOUS PULMONARY VENOUS RETURN
atrium and continue out to the lungs. (APVR)
 Has 3 types according to location  a result of failure of the pulmonary venous
 Secundum- is located in the center of the atrial connections to unite with the left atrium in utero.
septum  they return to another vessel (left innominate,
 Primum- found low in the atrial septum near the portal, or coronary sinus vein) or directly to the
IVC right atrium, and the oxygenated pulmonary blood
 Sinus Venosus-allow communication of one or return drains back into the right side of the heart
more of the pulmonary veins with the right atrium.  can be seen with one, two, or three of the veins
(partial APVR), or all four veins (total APVR)
ASSESSMENT draining to the venous side.
 If the defect is small, it may go undetected or may
cause no clinical concern and require no MANAGEMENT
intervention  Total APVR requires urgent surgical intervention.

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 Care of Mother and Child at Risk or with
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 If the defect is large enough- pulmonary  Partial PVR, if only one vessel, can be missed
overcirculation, such as rales, congestion, tiring because it may cause no significant clinical
with activity, or poor weight gain. effects.
 Murmurs are not associated with the defect but is
related to the relative increased blood volume TRUNCUS ARTERIOUS (TA)
traveling across the pulmonary valve.  is characterized by a single arterial vessel that
originates from the heart, overrides the ventricular
MANAGEMENT septum, and supplies all of the systemic,
 If ASD is less than 5 mm, and is producing no coronary, and pulmonary blood flow
clinical symptoms, it will not be closed  has four classifications, depending on where the
 With clinically significant defect diuretics will be pulmonary arteries arise from the truncal vessel.
attempted first in an effort to allow the defect to  occurs as a result of the great artery failing to
close spontaneously divide in utero into two vessels, the pulmonary
 5 mm or greater with persistent shunting after an artery and the aorta
observation period should be referred for closure
to decrease the incidence of supraventricular MANAGEMENT
dysrhythmias and prevent pulmonary vascular  requires urgent surgery
disease.
 If the defect is 8 mm or larger with evidence of
increased pulmonary blood flow, the child will be
referred for closure immediately.
 secundum ASD is typically closed in the
catheterization lab with a device that sits in the
defect space
 Sinus venosus and primum defects referred for
surgical closure
 Surgical closure involves a median
sternotomy incision and cardiopulmonary
bypass.
VENTRICULAR SEPTAL DEFECT (VSD)
 the most common defect found in children, either in isolation or combined with other defects.
 occurs when a portion of the ventricular septum does not completely close.
ASSESSMENT
 holosystolic murmur noted at the left lower sternal border
 Symptoms associated with a VSD are similar to those found with a PDA or ASD and are determined by the size
of the defect

MANAGEMENT
 Children with an audible murmur but no symptoms of pulmonary overcirculation and may be very small defects
that will close spontaneously needs no medical management
 If the child exhibits signs of pulmonary overload diuretic such as Furosemide is given
 If closure does not occur, surgical closure can be done
ATRIOVENTRICULAR SEPTAL DEFECT (AVSD) MANAGEMENT
 comprises several congenital heart defects: a  Management typically includes medications such
primum ASD, a high VSD, and failure of the as furosemide, digoxin, and an ACE inhibitor like
tricuspid and mitral valves to develop and attach captopril or enalapril
correctly  children may also require concentrated feeds to
 complete AVSD also allows for right-to-left help maintain weight
shunting, which may lead to desaturation  Children with Down Syndrome they are typically
 associated with Trisomy 21 referred for surgical correction by 3 months of age
or earlier if the transthoracic echocardiogram
ASSESSMENT  Children without Down Syndrome are referred for
 can present with symptoms of CHF similar to repair by 5 or 6 months of age or as clinically
those seen in other defects that increase necessary.
pulmonary blood flow  Pulmonary artery band, which is a band
 can present with symptoms of CHF similar to surgically placed around the pulmonary artery that

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 Care of Mother and Child at Risk or with
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those seen in other defects that increase constricts it to increase the resistance within the
pulmonary blood flow pulmonary artery
 Surgical repair of an AVSD consists of closing
DIAGNOSIS atrial and VSDs and repairing the mitral and
 confirmed with echocardiography. tricuspid valves to make them functional
 A cardiac catheterization may be performed
before surgical correction to measure pulmonary
pressures and confirm reactivity with the
administration of oxygen or nitric oxide, both of
which should cause pulmonary pressures to
decrease.
DEFECTS WITH OBSTRUCTION TO SYSTEMIC BLOOD FLOW
COARCTATION OF AORTA HYPOPLASTIC LEFT HEART SYNDROME (HLHS)
 typically causes a discrete narrowing of the aorta  a rare disorder, accounting for only 1% to 3% of
 occurs more commonly in males than in females congenital heart disease, and is detectable on
prenatal ultrasound
ASSESSMENT  there is poor or no flow to the left ventricle,
 narrowed area is most frequently distal to the right typically secondary to mitral or aortic stenosis or
subclavian artery, so the pressures before that atresia.
area increase and refer out these vessels  ascending aorta is also hypoplastic, and the
 causes elevated blood pressures to be noted in coronary arteries are perfused through retrograde
the right arm flow down the ascending aorta.
 can cause a systolic murmur heard along the left  A Patent Foramen Ovale (PFO) will occur
sternal border and the left midscapular area  In utero, the circulation is adequate to meet the
 The narrowing increases the resistance to the left needs of the developing fetus. But at birth,
ventricle and can lead to left ventricular survival is dependent on a PDA
hypertension and hypertrophy over time  Infants are typically male, rarely premature, and
 Coarctation noted in infancy is usually more have no other associated cardiac anomalies.
critical and can produce heart failure within weeks  has normal right-sided flow out to the lungs.
of birth that require immediate surgical  These children are at high risk for sudden death
intervention. due to dysrhythmias, inability to fight infection, or
 Check radial and femoral pulses concurrently metabolic imbalance.
NORMAL: should be no absence or weakness in
the femoral pulses compared with the radial or SURGICAL MANAGEMENT
brachial pulse. NORWOOD PROCEDURE
 systolic pressure reading in the right upper  This surgery, which includes several
extremity is 10 mmHg higher than that in the lower components, is done within a few days of birth
extremity once the child is hemodynamically stable
 Dissection of the main pulmonary artery from
MANAGEMENT the branch pulmonary arteries, which is then
 Echocardiographic evidence of a significant attached to the hypoplastic ascending aorta so
gradient across the narrowing, or any signs of left there is one great vessel taking blood out of the
ventricular hypertrophy due to the increased heart (right ventricle) to the body and providing
resistance, are indicators for correction either by blood flow to the coronary arteries.
balloon angioplasty in the cardiac catheterization  Shunt placement, typically either a BT shunt
lab or by surgical intervention or a Sano shunt. The BT shunt (as discussed
 CoAo is surgically repaired through a left previously for TOF) directs blood from the right
thoracotomy incision and with end-to-end subclavian artery to the branch pulmonary artery,
anastomosis whereas a Sano shunt is a conduit from the right
 Future interventions with balloon dilation or stent ventricle to the branch pulmonary arteries. The
placement are typically performed in the purpose of both shunts is to allow for stable blood
catheterization lab. flow to the lungs.
 Ligation of the PDA
 Ensuring a widely patent atrial septum
BIDIRECTIONAL GLENN SHUNT
 This surgery is usually performed at

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approximately 4 to 6 months of age or when the

child outgrows their previously placed BT or Sano
shunt.
 The purpose of the shunt is to relieve the volume
load on the single right ventricle, which is
accommodating all of the circulating blood flow
 Ligation of the previously placed BT or Sano
shunt
 Dissection of the SVC at its insertion to the
right atrium and attachment of the SVC
directly to the branch pulmonary artery. This
allows deoxygenated blood returning from the
head and upper body to flow directly but passively
to the lungs to get oxygenated.
FONTAN PROCEDURE
 The final stage is performed when the child
weighs approximately 15 kg or is 3 years old
 the IVC is dissected from the right atrium, and
flow from there is directed through an artificial
conduit directly to the branch pulmonary artery

CARDIAC TRANSPLANTATION
 is an alternative form of therapy, but the
availability of donor hearts, rejection problems,
and the need for retransplantation
 secondary choice for most infants.
AORTIC STENOSIS SINGLE VENTRICLE DEFECTS
 Obstruction out the left ventricle can occur below  A variety of congenital abnormalities such as
the aortic valve (subvalvar), at the valve (valvar), mitral atresia, aortic atresia, or pulmonary
or above the valve (supravalvar) atresia with an intact ventricular septum result in
 most common location for obstruction is valvar a single-ventricle physiology.
aortic stenosis, which is typically associated with  not possible to address all of these permutations,
an abnormal, bicuspid aortic valve but the basic conceptual understanding and
management of single-ventricle defects is grossly
ASSESSMENT the same.
 systolic heart murmur at the right second
intercostal space, but asymptomatic.
 Severe obstruction may experience chest pain
with exercise. Aortic regurgitation is frequently
associated with stenosis
 a diastolic murmur may also be noted
 ECG may note left ventricular hypertrophy if the
stenosis has been ongoing
 Echocardiography will determine the exact
location and severity of the narrowing as well as
any impact on ventricular size and function.

MANAGEMENT
 Stabilization with a beta-blocker or a calcium
channel blocker may be necessary to reduce or
prevent further ventricular hypertrophy.
 routine echocardiograms and possibly cardiac
catheterizations to best quantify the pressure
gradient across the valve.
 Surgical intervention may be necessary for
recurrent stenosis or ineffective balloon dilation.

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CHECK FOR UNDERSTANDING

The instructor will prepare 10 questions that can enhance critical thinking skills. Students will work by themselves to
answer these questions and write the rationale for each question.

1. A child has been seen by the school nurse for dizziness since the start of the school term. It happens when standing in
line for recess and homeroom. The child now reports that she would rather sit and watch her friends play hopscotch
because she cannot count out loud and jump at the same time. When the nurse asks her if her chest ever hurts, she says
yes. Based on this history, the nurse suspects that she has:
A. Ventricular septal defect (VSD).
B. Aortic stenosis (AS).
C. Mitral valve prolapse.
D. Tricuspid atresia.

2. A heart transplant may be indicated for a child with severe heart failure and:
A. Patent ductus arteriosus (PDA).
B. Ventricular septal defect (VSD).
C. Hypoplastic left heart syndrome.
D. Pulmonic stenosis (PS).

3. A newborn is diagnosed with a congenital heart defect (CHD). The test results reveal that the lumen of the duct
between the aorta and pulmonary artery remains open. This defect is known as .
A. Patent ductus arteriosus (PDA).
B. Ventricular septal defect (VSD).
C. Hypoplastic left heart syndrome.
D. Pulmonic stenosis (PS).

4. A 3-month-old has been diagnosed with a ventricular septal defect (VSD). The flow of blood through the heart is
.
A. Patent ductus arteriosus (PDA).
B. Ventricular septal defect (VSD).
C. Hypoplastic left heart syndrome.
D. Pulmonic stenosis (PS).

5. A child born with Down syndrome should be evaluated for which associated cardiac manifestation?
A. Congenital heart defect (CHD).
B. Systemic hypertension.
C. Hyperlipidemia.
D. Cardiomyopathy.

6. A child diagnosed with congestive heart failure (CHF) is receiving maintenance doses of digoxin and furosemide. She is
rubbing her eyes when she is looking at the lights in the room, and her HR is 70 beats per minute. The nurse expects
which laboratory finding?
A. Hypokalemia.
B. Hypomagnesemia.

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C. Hypocalcemia.
D. Hypophosphatemia.

7. A nursing action that promotes ideal nutrition in an infant with congestive heart failure (CHF) is:
A. Feeding formula that is supplemented with additional calories.
B. Allowing the infant to nurse at each breast for 20 minutes.
C. Providing large feedings every 5 hours.
D. Using firm nipples with small openings to slow feedings.

8. During a well-child checkup for an infant with tetralogy of Fallot (TOF), the child develops severe respiratory distress
and becomes cyanotic. The nurse’s first action should be to:
A. Lay the child flat to promote hemostasis.
B. Lay the child flat with legs elevated to increase blood flow to the heart.
C. Sit the child on the parent’s lap, with legs dangling, to promote venous pooling.
D. Hold the child in knee-chest position to decrease venous blood return.

9. During play, a toddler with a history of tetralogy of Fallot (TOF) might assume which position?
A. Sitting.
B. Supine.
C. Squatting.
D. Standing.

10. For the child with hypoplastic left heart syndrome, which drug may be given to allow the patent ductus arteriosus
(PDA) to remain open until surgery?
A. Furosemide
B. Apresoline
C. Indomethacin
D. Penicillin

C. LESSON WRAP-UP

AL Activity: Muddiest Point: Students respond to this one question: “In today’s session, what was least clear to you?”
This technique will help you determine which key points were missed by the students.

Instructions:
1. Reserve a few minutes at the end of class session. Leave enough time to ask the question, to allow students to
respond, and to collect their responses.
2. Pass out slips of paper on index cards for students to write on. You may also ask students to bring out and write on a
half sheet of paper instead.
3. Collect the responses as or before students leave. One way is to station yourself at the door and collecting “muddiest
point papers” as students file out.
4. Respond to students’ feedback during the next class meeting or as soon as possible.

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5. DO NOT use this method after every class or it will become monotonous, and the information will not be as useful.

In today’s session, what was least clear to you?

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