Nursing Care of Children with

Alterations in Health Status

(Acute & Chronic)

A. Alterations in
Oxygenation
(CARDIOVASCULAR
DISORDER)
 INTRODUCTION
TO THE HEART

https://www.youtube.com/watch?v=UMTDmP81mG4
 CONGESTIVE HEART FAILURE
DESCRIPTION:
• Is the inability of the heart to pump a sufficient amount of oxygen to meet the
metabolic needs of the body.

• In infants and children, inadequate cardiac output most commonly is caused by

congenital heart defects (shunt, obstruction, or a combination of both) that
produce an excessive volume or pressure load on the myocardium.

• In infants and children, a combination of left sided and right sided heart failure is
usually present.

• The goals of the treatment are to improve cardiac function, remove accumulated
fluid and sodium, decrease cardiac demands, improve tissue oxygenation and
decrease oxygen consumption.
 CONGESTIVE HEART FAILURE
ASSESSMENT:
• Tachycardia, especially during rest and slight exertion.
• Tachypnea
• Profuse scalp diaphoresis, especially in infants
• Fatigue and irritability
• Sudden weight gain
• Respiratory distress
 CONGESTIVE HEART FAILURE
ASSESSMENT:
Left-Sided Failure
➢ Crackles and wheezes
➢ Cough
➢ Dyspnea
➢ Grunting (infants)
➢ Head Bobbing (infants)
➢ Nasal flaring
➢ Orthopnea
➢ Periods of cyanosis
➢ Retractions
➢ Tachypnea
Right- Sided Failure
➢ Ascites
➢ Hepatosplenomegaly
➢ Jugular vein distention
➢ Oliguria
➢ Peripheral edema, especially periorbital edema
➢ Weight gain
 CONGESTIVE HEART FAILURE
INTERVENTIONS:
✓ Monitor for early signs of CHF
✓ Monitor respiratory distress (count respiration for 1 full minute)
✓ Monitor apical pulse(count for 1 full minute) and monitor for
dysrhythmias.
✓ Monitor temperature of hyperthermia and for other signs of
infection, particularly respiratory infection.
✓ Monitor strict intake and output.
✓ Weigh diapers as appropriate.
✓ Monitor daily weigh to assess fluid retention.
✓ Monitor for facial and peripheral edema. Auscultate lungs and
report abnormal findings indicating excessive fluids in the body.
✓ Elevate the head of the bed into semi fowler’s position.
✓ Provide rest and monitored at intervals. Reduce stimuli.
 CONGESTIVE HEART FAILURE
MEDICATIONS AS PRESCRIBED:
✓ Administer O2 inhalation.
✓ Administer Digoxin (Lanoxin)
✓ Administer angiotensin-converting enzyme inhibitors captopril
(Capoten) or enalapril (Vasotec).
✓ Administer Diuretics furosemide (Lasix)
✓ Monitor serum electrolytes level sodium and potassium.
✓ Restrict fluid intake in acute stage.
 DEFECTS WITH
INCREASED
PULMONARY BLOOD
FLOW
DESCRIPTION:
• Intracardiac communication along the septum or an abnormal connection
between the great arteries allows blood to flow from the high pressure left side
of the heart to the low-pressure right side of the heart.
• The infant typically demonstrates signs and symptoms of CHF.
 ATRIAL SEPTAL DEFECT
DESCRIPTION:
• Is an abnormal opening between the atria causes an increased flow of
oxygenated blood into the right side of the heart .

• Right atrial and ventricular enlargement occur.

• Signs and symptoms of decreased cardiac output:

✓ Decreased in peripheral pulses
✓ Exercise intolerance
✓ Feeding difficulties
✓ Hypotension
✓ Irritability, restlessness, lethargy
✓ Oliguria
✓ Pale cool extremities
✓ tachycardia
 ATRIAL SEPTAL DEFECT
DESCRIPTION:
• TYPES:
✓ ASD 1 (OSTIUM PRIMUM) – Opening is at the lower end of the septum.
✓ ASD 2 (OSTIUM SECUNDUM) – Opening is near the center of the septum.
✓ ASD 3 (SINUS VENUS DEFECT) – Opening near the junction of the superior vena
cava and right atrium.
• NON SURGICAL TREATMENT:
✓ The defect may be closed during a cardiac catheterization.
• SURGICAL TREATMENT:
✓ Open repair with cardiopulmonary bypass usually is performed before school
age.
https://www.youtube.com/watch?v=jIjD3MSVfRE
 ATRIOVENTRICULAR CANAL DEFECT
DESCRIPTION:
• The defects results from incomplete fusion of the endocardial cushions.

• The defect is the most common cardiac defect in Down syndrome.

• A characteristics murmur is present.

• The infant usually has mild to moderate CHF, with cyanosis increasing with
crying.

• Signs symptoms of decreased cardiac output may be present.

• Surgical treatment can include pulmonary artery banding for infants with severe
symptoms (palliative) or complete repair via cardio pulmonary bypass.
 PATENT DUCTUS ARTERIOSUS
DESCRIPTION:
• Is a failure of the fetal ductus arteriosus (artery connecting the aorta and the
pulmonary artery) to close within the first week of life.

• A characteristics machinery-like murmur is present.

• Infant may be asymptomatic or may shows signs and symptoms of CHF.

• A widened pulse pressure and bounding pulses are present.

• Signs and symptoms of decreased cardiac output may be present.

• MEDICAL MANAGEMENT: Indomethacin (Indocin), a prostaglandin inhibitor, may be

administered to close a patent ductus in premature infants and some newborns.

• MANAGEMENT: The defect may be closed during cardiac catheterization or the

defect may require surgical management.
 VENTRICULAR SEPTAL DEFECT
DESCRIPTION:
• A VSD is an abnormal opening between the right and left ventricles.

• Many VSD’s close spontaneously during the first year of life in children having
small or moderate defects.

• A characteristics murmur is present.

• Signs and symptoms of CHF are commonly present.

• Signs and symptoms of decreased cardiac output may be present.

• NON SURGICAL TREATMENT:

✓ Closure during cardiac catheterization may be possible.
• SURGICAL TREATMENT:
✓ Open repair is done with cardiopulmonary bypass.
https://www.youtube.com/watch?v=F_eKdjhhopA
 OBSTRUCTIVE
DEFECTS
DESCRIPTION:
• Blood exiting a portion of the heart meets an area of anatomical narrowing
(stenosis), causing obstruction to blood flow.
• The location of narrowing is usually near the valve of the obstructive defect.
• Infants and children exhibit signs of CHF.
• Children with mild obstruction may be asymptomatic.
 AORTIC STENOSIS
DESCRIPTION:
• Is narrowing or stricture of the aortic valve, causing resistance to blood flow in
the left ventricle, decreased cardiac output, left ventricular hypertrophy, and
pulmonary vascular congestion.
 VALVULAR STENOSIS
DESCRIPTION:
• Is the most common type and usually caused by malformed cusps, resulting in a
bicuspid rather than a tricuspid valve, or fusion of the cusps.
• A characteristics murmur is present.
• Infants with severe defects demonstrate signs of decreased cardiac output.
• Children show signs of exercise intolerance, chest pain and dizziness when
standing for long periods of time.
• NON SURGICAL TREATMENT FOR VALVULAR AND AORTIC STENOSIS:
✓ Is done during cardiac during cardiac catheterization to dilate the narrowed
valve.
• SURGICAL TREATMENT FOR VALVULAR AND AORTIC STENOSIS:
✓ Is aortic valvotomy (palliative); a valve replacement may be required at a second
procedure.
 COARCTATION OF THE AORTA
DESCRIPTION:
• Is localized narrowing near the insertion of ductus arteriosus.
• The blood pressure is higher in the upper extremities; bounding pulses in the
arms, weak or absence of femoral pulses and cool lower extremities may be
present.
• Signs of CHF may occur in infants.
• Signs and symptoms of decreased cardiac output may be present.
• Children may experience headaches, dizziness, fainting and epistaxis resulting
from hypertension.
• NON SURGICAL TREATMENT :
✓ Is balloon angioplasty in children; restenosis can occur.
• SURGICAL TREATMENT :
✓ Mechanical ventilation and medications to improve cardiac output are often
necessary before surgery.
✓ Resection of the coarcted portion with end- to - end anastomosis of the aorta or
enlargement of the constricted section using a graft may be required.
✓ Because the defect is outside the heart cardio pulmonary bypass is not required
and a thoracotomy incision is used.
 PULMONARY STENOSIS
DESCRIPTION:
• Is narrowing of the entrance to the pulmonary artery.
• Resistance to blood flow causes right ventricular hypertrophy and decreased
pulmonary blood flow; the right ventricle may be hypoplastic.
• A characteristics of murmur is present.
• The infant or child may be asymptomatic.
• Newborns with severe narrowing will be cyanotic.
• If pulmonary stenosis is severe, CHF occurs.
• Signs and symptoms of decreased cardiac output may occur.
• NON SURGICAL TREATMENT :
✓ Is done during cardiac catheterization to dilate the narrowed valve.
• SURGICAL TREATMENT :
✓ In infants, trans ventricular (closed) valvotomy procedure.
✓ In children, pulmonary valvotomy with cardio pulmonary bypass.
 DEFECTS WITH
DECREASED
PULMONARY BLOOD
FLOW
DESCRIPTION:
• Obstructed pulmonary blood flow and an anatomical defect (ASD or VSD) between
the right and left sides of the heart present.
• Pressure on the right side of the heart increases, exceeding pressure on the left
side, which allows desaturated blood to shunt right to left, causing desaturation
in the left side of the heart and in the systemic circulation.
• Typically hypoxemia and cyanosis appear.
 TETRALOGY OF FALLOT
DESCRIPTION:
• The tetralogy of Fallot includes four defects – VSD, pulmonary stenosis,
overriding aorta and right ventricular hypertrophy.
• If pulmonary vascular resistance is higher than systemic resistance, the shunt is
from the right to left; if systemic resistance is higher than the pulmonary
resistance, the shunt is left to right.
• INFANTS: may be acutely cyanotic at birth or may have mild cyanosis that
progresses over the first year of life as the pulmonic stenosis worsens. A
characteristics murmur is present. Acute episodes of cyanosis and hypoxia
(hyper cyanotic spells), called blue spells or tet spells, occur when the infant’s
oxygen requirements exceed the blood supply, such as during periods of crying ,
feeding or defecating.
• CHILDREN: with increasing cyanosis, squatting, clubbing of fingers and poor
growth may occur. Squatting is a compensatory mechanism to facilitate increase
return of blood flow to the heart for oxygenation. Clubbing ( an abnormal
enlargement of the distal phalanges seen in the fingers) is symptomatic of
chronic hypoxia as peripheral circulation is diminished to allow oxygenation of
vital organs and tissues.
• SURGICAL TREATMENT : Palliative Shunt
✓ The shunt increases pulmonary blood flow and increases oxygen saturation in
infants who cannot undergo primary repair.
✓ The shunts provide blood flow to the pulmonary arteries from the left or
subclavian artery.
• SURGICAL TREATMENT : Complete repair
✓ Complete repair usually is performed in the first year of life.
✓ The repair requires median sternotomy and cardiopulmonary bypass.
https://www.youtube.com/watch?v=8BJOUfycsxo
 TRICUSPID ATRESIA
DESCRIPTION:
• Tricuspid atresia is failure of the tricuspid valve to develop.
• No communication exists from the right atrium to right ventricle.
• Blood flow 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.
• The defect often is associated with pulmonic stenosis and transposition of great
arteries.
• The defect results in complete mixing of unoxygenated and oxygenated blood in
the left side of the heart, resulting in systemic desaturation, pulmonary
obstruction an decrease pulmonary blood flow.
• Cyanosis, tachycardia and dyspnea are seen in the newborn.
• Older children exhibit signs of chronic hypoxemia and clubbing.
SURGICAL TREATMENT :
• If the ASD is small, the defect may be closed during cardiac catheterization,
otherwise surgery is needed.
• For the neonate whose pulmonary blood flow depends on the patency of the
ductus arteriosus, a continuous infusion of prostaglandin E1 is initiated until
surgery.
 MIXED DEFECTS
DESCRIPTION:
• Fully saturated systemic blood flow mixes with the desaturated blood flow.
• Pulmonary congestion occurs and cardiac output decreases.
• Signs of CHF are present; symptoms vary with degree of desaturation.
 HYPOPLASTIC LEFT HEART SYNDROME
DESCRIPTION:
• Underdevelopment of the eft side of the heart occurs, resulting in hypoplastic left
ventricle and aortic atresia.
• Mild cyanosis and signs of CHF occur until the ductus arteriosus closes; then
progressive deterioration with cyanosis and decreased cardiac output are seen,
leading to cardiovascular collapse.
• The defect is fatal in the first few months of life without intervention.
SURGICAL TREATMENT :
• Is necessary; transplantation in the newborn period may be considered.
• In the preoperative period the neonates requires mechanical ventilation and
continuous infusion of prostaglandin E1 to maintain ductal patency, ensuring
adequate systemic blood flow.
 TRANSPOSITION OF GREAT ARTERIES AND
GREAT VESSELS
DESCRIPTION:
• The pulmonary artery leaves the left ventricle, and the aorta exits from the right
ventricle.
• No communication exists between systemic and pulmonary circulation.
• Infants with minimal communication are severely cyanotic and depressed at
birth.
• Infants with large septal defects or a patent ductus arteriosus may be less
severely cyanotic, but may have symptoms of CHF.
• Cardiomegaly is evident a few weeks afterbirth.
NON SURGICAL TREATMENT :
• Prostaglandin E1 may be initiated to increase blood mixing temporarily if
systemic and pulmonary mixing are inadequate.
• Balloon and atrial septostomy during cardiac catheterization may be performed
to increase mixing and to maintain cardiac output over a longer period.
SURGICAL TREATMENT :
• The arterial switch procedure reestablishes normal circulation with the left
ventricle acting as the systemic pump and creation of new aorta.
 TOTAL ANOMALOUS PULMONARY VENOUS
CONNECTION
DESCRIPTION:
• The defect is failure of the pulmonary veins to join the left atrium.
• The defect results in mixed blood being returned to the right atrium and shunted
from the right to the left through an ASD.
• The right side of the heart hypertrophies, whereas the left side of the heart may
remain small.
• Signs and symptoms of CHF develop.
• Cyanosis worsens with pulmonary vein obstruction, once obstruction occurs, the
infant’s condition deteriorates rapidly.
SURGICAL TREATMENT :
• Corrective repair is performed in early infancy.
• The pulmonary vein is anastomosed to the left atrium, the ASD is closed, and the
anomalous pulmonary venous connection is ligated.
 TRUNCUS ARTERIOSUS
DESCRIPTION:
• Is failure of normal septation and division of embryonic bulbar trunk into the
pulmonary artery and the aorta, resulting in a single vessel that overrides both
ventricles
• Blood from both ventricles mixes in the common great artery, causing
desaturation and hypoxemia.
• A characteristic murmur is present.
• The infant exhibits moderate to severe CHF and variable cyanosis, poor growth
and activity intolerance.
SURGICAL TREATMENT :
• Corrective surgical repair is performed in the first few months of life.
 TRUNCUS ARTERIOSUS
DESCRIPTION:
• Is failure of normal septation and division of embryonic bulbar trunk into the
pulmonary artery and the aorta, resulting in a single vessel that overrides both
ventricles
• Blood from both ventricles mixes in the common great artery, causing
desaturation and hypoxemia.
• A characteristic murmur is present.
• The infant exhibits moderate to severe CHF and variable cyanosis, poor growth
and activity intolerance.
SURGICAL TREATMENT :
• Corrective surgical repair is performed in the first few months of life.
 INTERVENTIONS FOR CARDIOVASCULAR
DEFECTS
• Monitor signs of defect in an infant or child.
• Monitor vital signs closely.
• Monitor respiratory status and other signs of impending respiratory distress and
notify the physician if any changes occur.
• Auscultate breath sounds for crackles, rhonchi or wheezes.
• If respiratory effort is increased, place the child in a reverse Trendelenburg
position or high fowler’s position, elevating the head and upper body; to decrease
the work of breathing.
• Administer humidified oxygen as prescribed.
• Provide endotracheal tube and ventilator care as prescribed.
• Monitor for hyper cyanotic spells.
• Assess for signs of CHF.
• Assess peripheral pulses.
• Maintain fluid restriction if prescribed.
• Monitor intake and output.
• Obtain daily weight.
• Provide adequate nutrition (high caloric requirements as prescribed).
 INTERVENTIONS FOR CARDIOVASCULAR
DEFECTS
• Administer medications as prescribed
• Keep the child stress free as possible.
• Plan interventions to allow maximal rest for the child.
• Prepare the child and parents for cardiac catheterization, if appropriate.
 RHEUMATIC FEVER

DESCRIPTION:
• Rheumatic fever is an inflammatory autoimmune disease that affects the
connective tissues of the heart, joints, subcutaneous tissues, and blood vessels
and of the central nervous system.
• The most serious complications is rheumatic heart disease, which affects the
cardiac valves particularly the mitral valve.
• Rheumatic presents 2-6 weeks following an untreated or partially treated group
A beta hemolytic streptococcal infection of the upper respiratory tract.
ASSESSMENT:
• Fever: low grade fever that spikes in the late afternoon.
• Elevated antistreptolysin O titer.
• Elevated sedimentation rate.
• Elevated C-reactive protein level
• Aschoff bodies (lesions): found in the heart, blood vessels, brain and serous
surfaces of the joints and pleura.
 RHEUMATIC FEVER

INTERVENTIONS:
• Assess vital signs.
• Control joint pain and inflammation with massage and alternating hot and cold
application as prescribed.
• Provide rest during acute febrile phase.
• Limit physical exercise with carditis .
• Administer antibiotics penicillin as prescribed.
• Administer salicylates and anti inflammatory agents.
• Initiate seizure precautions if the child is experiencing chorea.
• Instruct the patient about the need for follow up and antibiotic prophylaxis for
dental work, infection, and invasive procedures.
• Advise the child to inform the parents if any one in school develop streptococcal
throat infection.
 KAWASAKI DISEASE
DESCRIPTION:
• Kawasaki disease is known as mucocutaneous lymph node syndrome and is an
acute systemic inflammatory illness.
• The cause is unknown but may be associated with an infection from an organism
or toxin.
• Cardiac involvement is the most serious complications; aneurysms can develop.
ASSESSMENT:
• Acute Stage
✓ Fever
✓ Conjuctival hyperemia.
✓ Red throat
✓ Swollen hands, rash, and enlargement of cervical lympnodes.
• Subacute Stage
✓ Cracking of lips and fissures
✓ Desquamation of the skin on the tips of the fingers and toes
✓ Joint pain
✓ Cardiac manifestations
✓ Thrombocytosis
 KAWASAKI DISEASE
• Convalescent Stage
✓ Child appears normal but signs of inflammation present.
ASSESSMENT:
✓ Monitor temperature frequently.
✓ Assess heart sounds, rate and rhythm.
✓ Assess extremities for edema, redness, and desquamation.
✓ Examine eyes for conjunctivitis.
✓ Monitor mucous membrane for inflammation.
✓ Monitor intake and output.
✓ Administer soft foods and liquids that are neither too hot nor too cold.
✓ Weigh daily.
✓ Provide passive range of motion exercise.
✓ Administer antipyretic and anti platelet meds if prescribed.
✓ Administer immune globulin as prescribed.
CARDIAC CATHETERIZATION IN CHILDREN
 HEART SOUNDS

https://www.youtube.com/watch?v=SZcAJVcbHaY