Notre Dame of Jolo College

Health Sciences Department

Nursing Program
NCM 209 – PEDIATRIC NURSING

Date: February 3 & 10, 2024

TOPIC III. ALTERATION IN OXYGENATION

CARDIAC DISORDER IN CHILDREN

CONGENITAL DISORDERS OF THE HEART

Definition: alteration in the circulation of the blood due to defects in the heart that happens
during early embryonic life; one of the leading causes of death in the premature
and small- for- gestational age babies.

Etiology: Exact cause is UNKNOWN

Predisposing/Precipitating Factors
 Alcoholism and poor maternal nutrition
 Virus (especially the rubella virus)
 Teratogenic drugs
 Radiation exposure in the first trimester
 Advance maternal age (above 40 years) and chromosomal aberrations
 Presence of congenital anomalies
 Parents and siblings with heart defects

Two Broad Classifications:

1. CYANOTIC HEART DEFECTS
 A condition that allow unoxygenated blood flow to flow into the systemic
circulation or that allow blood to be shunted from the right side of the heart to
the left, causing cyanosis; may also include conditions that result in obstructive
pulmonary blood flow.
a. Tetralogy of Fallot
b. Truncus arteriosus
c. Tricuspid atresia
d. Transposition of great vessels
2. ACYANOTIC HEART DEFECTS
  Are those conditions that interfere with normal blood flow through the heart,
either by slowing it down or allowing blood to be shunted from the left side of
the heart to the right, causing acyanosis.

a. Ventricular Septal Defect (VSD)

b. Atrial Septal Defect (ASD)
c. Patent Ductus Arteriosus (PDA)
d. Pulmonic Stenosis (PS)
e. Coaction of the Aorta (COA)
Diagnostic Test/Procedures:
1. History and physical examination
2. Chest x – ray
 furnish an accurate picture of the heart size and the contour and size of the
heart chambers.
 It can reveal fluid collecting in the lungs or pulmonary artery from cardiac failure.
 In a posteroanterior view (in children over 1 year of age), if the cardiac width is
more than half the chest width, it indicates that the heart is unusually enlarged.
 In infants, because of the more horizontal position of the heart, this ratio must
be increased to more than half.
3. Electrocardiogram
 is a written record of the electrical voltages generated by the contracting heart.
 It provides information about heart rate, rhythm, state of the myocardium,
presence or absence of hypertrophy (thickening of the heart walls), ischemia or
necrosis due to inadequate cardiac circulation, and abnormalities of conduction.
It also can provide information about the presence or effect of various drugs and
electrolyte imbalances
4. Blood examination: CBC and ABG
5. Angiogram
6. CARDIAC CATHETERIZATION: commonly uses the femoral artery

Before performing the procedure:

 Secure a signed consent
 Explain (based on age group) that a feeling of warmth and a fluttering
sensation may be felt as the catheter is passed.
 Ask the parent whether the child is allergic to seafood or shellfish, if
iodine dye is to be use.
 Observe NPO for 8 – 10 hours prior to test; give a pacifier as appropriate.
 Check the vital signs and peripheral pulses.

After performing the procedure:

 Perform frequent vital signs checks. Report significant changes.
  Observe the distal parts for adequacy of neurovascular circulation: color
(pinkish), temperature (warm), mobility (wiggling or moving), sensation
(+) sensation, capillary refill (brisk, less than 3 seconds).
 Give diet/milk feeding as tolerated.
 If ambulatory, ambulate after 24 hours.
 Keep extremities straight for about 8 hours as prescribed
 Observe the site of insertion for swelling and bleeding. Apply a pedia
sand bag over the insertion site as appropriate.
 Observe for complications: hemorrhage, infection, vessel obstruction to
check distal pulses (e.g. pedal and popliteal pulses).

CYANOTIC HEART DEFECTS

TETRALOGY OF FALLOT(TOF)
Includes four defects
1. Ventricular Septal Defects
2. Pulmonary Valve Stenosis
3. Overriding of the Aorta
4. Right Ventricular Hypertrophy

Causes:
 TOF occur during fetal growth, when the baby’s heart is developing. While
factors such as poor maternal nutrition, viral illness or genetic disorders might
increase the risk of conditions, in most cases the cause of TOF is UNKNOWN.
1. Ventricular Septal Defects
 VSD is a hole defects in the wall (septum) that separates the two-lower chamber
of the heart – the left and right ventricles.
 The hole allows deoxygenated blood in the right ventricle – blood that has
circulated through the body and is returning to the lung to replenish its oxygen
supply – to flow into the left ventricle and mix with oxygenated blood fresh from
the lungs.
2. Pulmonary Valve Stenosis
 Is a narrowing of the pulmonary valve – the valve that separates the lower right
chamber of the heart (right ventricles) from the main blood vessels leading to the lungs
(pulmonary artery).
 Narrowing of the pulmonary valve reduces the valve flow to the lungs. And may affect
the muscles beneath the pulmonary valve.
3. Overriding of the Aorta
 Normally the aorta – the main artery leading out to the body – branches off the left
ventricles. In TOF, the aorta is shifted slightly to the right and lies directly above the
ventricular septal defect.
 In this position the aorta receives from the right and left ventricles, mixing the oxygen –
poor blood from the right ventricle with the oxygen – rich blood from the left ventricle.
 4. Right Ventricular Hypertrophy
 When the heart pumping action is overworked, it causes the muscular wall of the right
ventricle to thicken. Over time this might cause the heart to stiffen, become weak and
eventually fail.

Signs and Symptoms

INFANTS
1. An infant maybe acutely cyanotic at birth or mild cyanosis
2. A characteristic of heart murmur is present
3. Acute episodes of cyanosis and hypoxia (Hypercyanotic spells) called BLUE SPELLS OR
TET SPELLS, occur when the infant’s oxygen requirements exceed the blood supply, such
as during the period of crying, feeding, or defecating.
CHILDREN
4. With increasing cyanosis, SQUATTING and CLUBBING OF THE FINGER and poor growth
may occur
 SQUATTING – is a compensatory mechanism to facilitate increased return of
blood flow to the heart for oxygenation.
 CLUBBING – is an abnormal enlargement in the distal phalanges seen in the
fingers.
Diagnostic Test:
 Chest x – ray
 Echocardiogram
Surgical Management:
1. Palliative procedure:
BLALOCK TAUSSIG SHUNT – to increase blood flow to the lungs
2. Corrective Surgery:
Patch Closure of the VSD Correction of Pulmonary Stenosis – complete repair
usually is performed in the first year of life
 The repair requires median sternotomy and cardiopulmonary bypass

TRUNCUS ARTERIOSUS(TA)
 Is a rare type of the heart disease in which a single blood vessel (Truncus arteriosus)
comes out of the right and left ventricles, instead of the normal 2 vessels (pulmonary
artery and aorta). And it is present at birth

Causes: UNKNOWN

Signs and Symptoms:

 Cyanosis
 Dyspnea
 Tachypnea
  Auscultation will reveal a loud continuous murmur along with loud click associated with
the closing with the truncal valve
 Poor feeding

Diagnostic test:
 Chest x – ray
 Echocardiogram
 Cardiac catheterization

Surgical management:
1. Complete intracardiac repair, preferred treatment in early years
2. Pulmonary banding
3. Homograft conduit

TRICUSPID ATRESIA
 Is characterized by absence for or complete closure of the tricuspid valve and therefore
no connection between the RA and the RV.
Causes:
 This condition occurs during fetal development. Some genetic factors, such as Down
syndrome. But the cause of congenital heart disease is UNKWON
Signs and symptoms:
 Cyanosis – within the first day of life
 Severe hypoxic spells
Diagnostic Test:
 Chest x – ray
 Echocardiogram
 Cardiac catheterization
Surgical management:
1. PALLIATIVE
BLALOCK TAUSSIG SHUNT – anastomosis between the subclavian artery to the
pulmonary artery

WATERSTON SHUNT – anastomosis between the ascending aorta and the right
pulmonary artery

2. COMPLETE SURGERY
FONTAN PROCEDURE – complete corrections involves: 1. Placement of a tubular
conduit with a valve between the right atrium and main pulmonary artery. 2. Closure of
the atrial septal defect; and 3. Ligation just above the pulmonary valve of the main
pulmonary artery.

TRANSPOSITION OF THE GREAT ARTERIES(TGA)

  Ascending TGA is a defect in which the great vessels (aorta and the pulmonary artery)
are transposed or reversed. The aorta comes off the right ventricle and the pulmonary
artery comes off the left ventricle.

Causes: UNKNOWN

Signs and Symptoms:

 Cyanosis within the first few hours of birth is the most important clinical finding in the
infant with TGA
 Shortness of breathing, poor feeding, and lack of weight

Diagnostic test:
 Electrocardiogram
 Chest x – ray
 Echocardiogram
 Cardiac catheterization

Medical management:
 Prostaglandin (PGE1) – is initiated to promote oxygenated blood flow from the
pulmonary artery to the aorta via RETROGRADE

Surgical management:
1. PALLIATIVE PROCEDURE
RASHKIND PROCEDURE (the preferred treatment in hypoxic infants)
 Surgical creation of arterial septal defect through a surgical incision or balloon
arterial septostomy
2. CORRECTIVE PROCEDURE
MUSTARD PROCEDURE – surgical procedure to direct blood flow: simultaneous closure
of the ventricular septal defects and relief of left ventricular outflow obstruction; done
in child when is old enough

ACYANOTIC HEART DEFECTS

VENTRICULAR SEPTAL DEFECTS
 VSD is an abnormal opening between the right and left ventricles

Clinical manifestation:
 Infant with small VSD is likely to be asymptomatic, while infant with a moderate
to large defect will demonstrate signs of CHF.
 The infant with large VSD is usually tachypneic, diaphoretic, fatigues, and is
underweight for age
 If a VSD is detected in an older child for first time, it is because the defect is small
and the child has had no symptoms.
  Decrease cardiac output is present
Diagnosis:
 Diagnosis of VSD is often suspected when a loud holosystolic murmur is heard. The
intensity of the murmur can reflect the size of the defect.
 X – ray
 Echocardiogram
 Cardiac catheterization – is rarely indicated

Treatment:
 The infant with a small VSD usually requires no treatment because 75 -80% of these
defects may close in the first two year of life
 Many of the child with hemodynamically insignificant VSD is never require surgery

Surgical management:
 Surgical correction: CLOSURE OF VSD
 Direct closure or with cardiopulmonary bypass by suture or patch usually by 3 –
4 years
 Corrective surgery may be done earlier (before 2 years of age) in the presence of
pulmonary arterial hypertension to prevent irreversible pulmonary bed changes

ATRIAL SEPTAL DEFECTS

 is a hole between the two upper chamber of the heart (atrial).
 An abnormal opening between the atria that causes an increased flow of oxygenated
blood flow into the right side of the heart.

Clinical manifestation: Signs and symptoms of decreased cardiac out-put may be present
 Decreased peripheral pulses
 Exercise intolerance
 Feeding difficulties
 Hypotension
 Irritability, restlessness, lethargy
 Oliguria
 Pale, cool extremities
 Tachycardia
Treatment:
 Preoperative interventions is only indicated in the infant child with large ASD that result
in congested heart failure.
 Surgical repair is generally performed in the preschool age period.
 Diuretics are given to control the symptoms of CHF

PATENT DUCTUS ARTERIOSUS(PDA)

  is a persistent opening between the two major blood vessels leading from the heart. The
opening, called the ductus arteriosus, is a normal part of a baby’s circulatory system
before birth that usually closes shortly after birth.

 In the term newborn the ductus begins to close within 12 hours and should be
completely closed by 2 – 3 weeks. A ductus remains open, in a full – term baby, after
several weeks of life is termed a patent ductus arteriosus

Signs and Symptoms:

 The degree of symptoms experienced by the infant will depend on the size of the
hunt. The infant with a small PDA will generally be asymptomatic. The infant with a
large PDA will have sign of CHF

Management:
 Indomethacin (Indocin) a prostaglandin inhibitor, may be administered to close s
patent ductus in a premature infant and some newborn
 The defects may be closed during cardiac catheterization, or the defect may require
surgical management

PULMONIC STENOSIS
 Is narrowing at 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
 Pulmonary atresia is the extreme form of pulmonary stenosis in that there is total fusion
of the commissures and no blood flows to the lungs
Signs and Symptoms:
 The infant with mild to moderate PS is asymptomatic, and generally a murmur is
discovered on routine examination. Growth is generally normal for infants and children
with PS, and symptoms are usually present only in those with severe PS include dyspnea
upon exertion and fatigue. Cyanosis is common with severe PS but is not usually seen
with the milder forms.
Management:
 Dilatation of the narrowed valve may be done during cardiac catheterization
 Surgical management
a. In infants: Transventricular (closed) valvotomy procedure
b. In children: Pulmonary valvotomy with cardiopulmonary bypass

COARCTION OF THE AORTA(COA)

 Is localized narrowing near the insertion of the ductus arteriosus

Signs and symptoms:

 Decreased cardiac output may be present
  Children may experience headaches, dizziness, fainting, and epistaxis resulting from
hypertension
Management:
 Balloon Angioplasty in children; restenosis can occur
 Surgical Management:
a. Mechanical ventilation and ventilations to improve cardiac output are often
necessary before surgery
b. 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
c. Because the defect is outside the heart, cardiopulmonary bypass is not required, and
a thoracotomy incision is used

Treatment Depends on the Exact Congenital Disorder or Anomaly

1.Medical treatment the use of Digitalis Drugs.

DIGOXIN (LANOXIN)
o Is the drug of choice for children because of rapid onset and peak of action of drugs –
less toxicity
Signs of Digitalis Toxicity:
o Anorexia
o Vomiting
o Diarrhea
o Nausea – for children who can express the subjective feeling of nausea
o Arrythmias
o Bradycardia
o Xanthopsia – yellow green halos (for older children with color recognition and the ability
to verbalize)
Check cardiac rate before drug administration and withhold if cardiac rate is less than
o 100 – infant
o 90 – toddler
o 80 – in preschoolers
o 60- school age and less than 60 in adolescents (adults)
Nursing Care for Children with Congenital Heart Disorders
1. Maintain respiration /oxygenation
a. Proper positioning: first independent nursing action on admission of a child in
distress:
Acyanotic child: with severe dyspnea: ORTHOPNIC POSITION; use infant seat as
needed
Cyanotic child: lateral position, knee chest, squatting for preschool or older children
b. Administer oxygen as ordered
c. Suction, prn
d. Monitor ABG
2. Promote rest
 a. Modify activity as indicated
b. Provide minimal handling; organize care
c. Anticipate needs to prevent excessive crying
d. Give small and frequent feedings instead of large, infrequent meals
e. Use soft, premie, nipple or give NGT feeding as indicated/ordered
f. Provide passive, quite play
3. Keep warm
4. Prevent infection
a. Observe frequent handwashing
b. Administer ordered antibiotics
c. Give a proper diet rich in vitamins and minerals
d. Protect the child from people with infections
e. Advise on updating/completing immunization
f. Regular check temperature and prompt reporting of abnormal findings
5. Maintain nutrition and hydration
a. Give high – calorie, easily digested, non – constipating diets
b. Ensure adequate hydration:
o Underhydration or dehydration in cyanotic heart disorders can aggravate
polycythemic state and precipitate cerebral abscess/thrombosis
o Overhydration in Acyanotic heart disease can precipitate congestive heart failure
6. Administer drugs as ordered: digitalis and diuretics
a. Nursing considerations in DIGOXIN ADMINISTRATION:
o Give at regular intervals; give alone and do not mix with other drugs
o Do not give with food or milk; administer one hour or two hours after
meals/feeding
o Check cardiac rate begore administration and withhold digitalis if CR is below
100 – infant
90 – toddler
80 – in preschoolers
60- school age and less than 60 in adolescents (adults)
o Be alert for sings of digitalis toxicity:
 CARDIAC ARRYTHMIAS – usually the first sign
 GIT signs are common: vomiting, anorexia, and diarrhea. Nausea (highly
subjective), which is common in adults, is often not observed in young
children
o For diuretics, the single most important care is to monitor I&O and to avoid
increased oral and intravenous fluids if with CHF
7. Prepare the child/family for various diagnostic procedures and cardiac surgery as
indicated. Specific preparation depends on the specific procedures. General
preparations include:
a. Ensure that the informed consent is signed
b. Encourage verbalization of feelings and concerns
 c. Answer all questions in terms that are understandable; avoid technical terms.
For child, use play, guided imaginary as indicated
d. Provide/encourage parent’s child to allow return to age appropriate activities
during, and after hospitalization
o Provide consistency in care and avoid overprotection of the child to prevent
‘emotional crippling.’
e. Instruct parents on the necessity of following up care and regular visits
8. Provide essential post – operative care to children who underwent surgical correction of
congenital heart defects
a. Ensure continuity of care: sent nursing history and care plan to ICU; endorse
essential information about the child and family to appropriate personnel
b. Monitor vital signs, I&O, CVP, and chest drainage system
c. Care of child undergoing water seal – seal chest drainage:
o Stabilize the drainage – bottle system:
1. Check the tube connection periodically
2. Avoid kinks and loops; watch for leaks of air in the drainage system, indicated
by excessive/constant bubbling in the water seal chamber;
3. Make sure there is fluctuation of the fluid level in the long glass tube, which
is indicative of effective communication between the pleural space and the
drainage bottle
4. “Milk the tubing in the direction of the drainage bottle hourly, as ordered by
the surgeon
5. Encourage deep breathing and coughing at frequent intervals; provide
adequate pain medication as indicated
d. Observe for complications:
o Respiratory: pneumothorax, atelectasis, pulmonary edema
o Congestive heart failure
o Infection: systemic fever and increased heart rate, local redness, swelling, and
drainage
o Post – pericardiotomy syndrome: fever, pleural effusion, and pericardial friction
rub
e. Provide emotional support to the child and family;
o Explain procedures, and medications, treatment, special diet. (low sodium)
o Encourage and address parent/child concerns; answer their questions
appropriately
o Encourage/allow the child to attend to his/her personal needs as he/she is able,
encourage parenteral participation in the child’s care
o Provide the child with appropriate diversion and play materials
o Understand the emotional reactions that the child may normally demonstrate:
 Regressive behavior in the toilet habits (enuresis and encopresis) in
feeding thumb sucking after the oral stage), and in other learned skills
 Nightmares
 Increase dependency and demanding behaviors: set limits