NCM 109 M ACQUIRED

• Congestive Heart Failure (CHF)


  The pathophysiologic state in which the heart is unable to pump blood at a rate commensurate (proportionate) with the body's metabolic needs (oxygen delivery)
• Congestive Heart Failure (CHF) in children

  • Under 1 year old may result from a congenital disorder
  • Over 1 year with no congenital anomaly may be due to acquired heart disease
• Congestive Heart Failure (CHF)


  • Inability to dispose systemic or pulmonary venous return adequately
  • Combination of the above two
  • It means the heart is unable to maintain an adequate cardiac output
• Clinical Manifestations of CHF

  • Systemic Venous Congestion (weight gain, hepatomegaly, edema, jugular vein distension)
  • Pulmonary Venous Congestion (tachypnea, dyspnea, cough, wheezes)
  • Compensatory Response (tachycardia, cardiomegaly, diaphoretic, fatigue, failure to grow)
• One of the first signs of CHF

  Tachycardia
• Assessment - Clinical History

  • NEONATES & INFANTS (poor feeding, tachypnea worsening during feeding, cold sweat on forehead, poor weight gain)
  • OLDER CHILDREN (fatigue, exercise intolerance, dyspnea, puffy eyes & pedal edema, growth failure)
• Diagnostics


  • Chest x-ray (cardiomegaly, pulmonary edema)
  • ECG (arrhythmias)
  • Echocardiogram (assesses heart chamber sizes, measures myocardial function, diagnoses congenital heart defects)
  • Pulse-oximetry, CBG, hyperoxia test
  • CBC, U&A, calcium, creatinine, LFT
  • Thyroid function
• Treatment


  • Correct the underlying causes of HF
  • Diet (low salt and high calories)
  • Digitalis (improve cardiac contractility)
  • Diuretics (reducing preload)
  • Dilators (reducing afterload)
• General Care


  • Rest
  • Oxygenation
  • Small frequent feeding
  • Diet Modification
  • Sodium and Fluid Restriction
• Treatment of the Underlying Cause

  • Repair of congenital defects (VSD, ASD)
  • Heart Transplantation
• Diuretics


  • Furosemide (Lasix)
  • Spironolactone/Aldactone
• Digoxin Therapy


  • Digoxin increases the force of the myocardial contraction
  • Take an apical pulse with a stethoscope for 1 full minute before every dose of digoxin
  • If bradycardia is detected (< 100 beats/min for infant and toddler, < 80 beats in the older child, < 60 beats in the adolescent)
• Signs of Digoxin Toxicity

  • Bradycardia
  • Arrhythmia
  • Nausea, vomiting, anorexia
  • Dizziness, headache
  • Weakness and fatigue
• Nursing Interventions


  • Monitor for signs of respiratory distress
  • Provide pulmonary hygiene as needed
  • Administer oxygen as prescribed
  • Keep the head of the bed elevated
  • Monitor ABG values
  • Monitor for signs of altered cardiac output
  • Evaluate fluid status
  • Maintain strict fluid intake and output measurements
  • Monitor daily weights
  • Assess for edema and severe diaphoresis
  • Monitor electrolyte values and hematocrit level
  • Maintain strict fluid restrictions as prescribed
• Nursing Interventions - Medications

  • Administer prescribed antiarrhythmics to increase cardiac performance
  • Administer diuretics to reduce venous and systemic congestion
  • Administer iron and folic acid supplements to improve nutritional status
• Nursing Interventions - Other

  • Prevent Infection
  • Reduce cardiac demands
  • Keep the child warm
  • Schedule nursing interventions to allow for rest
  • Do not allow an infant to feed for more than 45 minutes at a time
  • Provide gavage feedings if the infant becomes fatigued before ingesting an adequate amount
• Nursing Interventions - Nutrition

  • Promote adequate nutrition
  • Maintain a high-calorie, low-sodium diet as prescribed
  • Promote optimal growth and development
• Nursing Interventions - Discharge

  • Refer the family to a community health nurse for follow up care after discharge
• Kawasaki Disease


  An acute febrile, multisystem disorder that occurs almost exclusively in children before the age of puberty
• Kawasaki Disease has replaced rheumatic fever as the most likely cause of acquired heart disease in children
• Kawasaki Disease


  • Peak incidence is in boys under 4 years of age
  • Etiology is unknown
  • Can cause blood vessels to become inflamed or swollen throughout the body
  • Can lead to damage of the blood vessel walls
  • Aneurysm
  • It is not contagious
• Pathophysiology of Kawasaki Disease

  1. Exposure to unidentified infectious agent

  2. Altered immune function occurs

  3. Increase in antibody-antigen complex in vascular endothelium

  4. Vasculitis
• Clinical Manifestations of Kawasaki Disease

  • Fever
  • Aneurysms
  • Platelet accumulation
  • Formation of thrombi or obstruction in the heart and blood vessels
• Phases of Kawasaki Disease

  • Acute Phase (1-2 weeks from onset)
  • Subacute Phase (last about 3 weeks)
  • Convalescent Phase (begins at about the 25th day and lasts until 40 days)
• Signs and Symptoms of Kawasaki Disease

  • Bilateral bulbar conjunctival injection
  • Oral mucous membrane changes, including injected or fissured lips, injected pharynx, or strawberry tongue
  • Peripheral extremity changes, including erythema of palms and soles, edema of hands and feet (acute phase), and perineal desquamation
  • Polymorphous rash
  • Cervical lymphadenopathy (>1.5 cm in diameter)
• IVIG (2 gm/kg single dose) is administered within 10 days of onset of symptoms in the acute stage of Kawasaki Disease
• PHASES OF KAWASAKI DISEASE

  1. Subacute Phase (last about 3 weeks)

  2. About 10 days after the onset Skin desquamation palms and soles

  3. Thrombocytosis

  4. The highest risk of sudden death in patients in whom aneurysms have developed
• PHASES OF KAWASAKI DISEASE

  Convalescent Phase begins at about the 25th day and lasts until 40 days begins when clinical signs disappear
• Endocarditis


  It is an inflammation and infection of the endocardium or valves of the heart
• Endocarditis


  • It may occur in a child without heart disease but more commonly occurs as a complication of congenital heart disease such as tetralogy of Fallot, VSD, or coarctation of the aorta
  • Caused by streptococci of the viridans type