Abstract
Nurses play a critical role in the life of the child with congenital heart disease (CHD) and their families. This chapter describes the advanced skills and knowledge needed by nurses who care for the child with CHD, discusses the various complex and challenging roles and responsibilities of the pediatric cardiac nurse, explores the psychosocial impact of CHD on children and families, and discusses the nurse’s role in assisting family adaptation at each phase of the illness and treatment. The postoperative management of CHD patients should be directed at optimizing oxygen delivery to maintain end-organ function and decrease the risk of complications. An understanding of the early signs of impaired cardiac output (CO) and implementation of appropriate treatments by the provider improves patient outcomes. It has been established that provider recognition and treatment of the early signs and symptoms of an acute deterioration leads to improved patient outcomes and prevents mortality. The management of these complex patients should be directed at educating nurses who care for these patients.
Key words
Nursing, Advanced practice nursing, Nursing education, Congenital heart disease, Pediatric cardiac intensive care unit
Nurses play a critical role in the lives of children with congenital heart disease (CHD) and their families. This chapter describes the advanced skills and knowledge needed by nurses who care for the child with CHD, discusses the various complex and challenging roles and responsibilities of the pediatric cardiac nurse, explores the psychosocial impact of CHD on children and families, and discusses the nurse’s role in assisting family adaptation at each phase of the illness and treatment.
Nursing Roles in Cardiac Critical Care
Bedside Nurse
One of the most crucial members of the multidisciplinary team, caring for a complex cardiac patient is the role of the bedside nurse. Pediatric cardiac critical care nurses are often the first to identify subtle changes in the assessment of the complex cardiac patient. They play an essential role in interdisciplinary rounds, where the continuity of care is centered. Professional nurses link quality care to best practice. They take responsibility for their practice by monitoring sensitive clinical indicators and applying evidence-based initiatives. Bedside nurses collaborate and partner with the multidisciplinary team to deliver the highest quality of care.
Higher levels of nursing education and experience positively impact patient outcomes. Although many bachelor’s- and master’s-prepared graduate nurses are being hired into intensive care units (ICUs), a vigorous orientation program is necessary for new graduates or those hired with previous experience for successful transition. Orientation should include didactic classes, simulation training, and comprehensive preceptor time. Certification, continuous education, and engagement are important elements in the professional development of a critical care nurse.
Nursing Leadership
The American Nurses Association revised the Scope and Standards for Nurse Administrators in 2013, outlining the professional accountabilities for those nurses serving in leader roles. Certain elements are applicable to nursing administrators of pediatric cardiac critical care environments. Graduate education is necessary to develop expertise in nursing practice, science, innovation, strategic planning, communication, fiscal management, and resource allocation. Nurse administrators must recognize the growing diversity of the workforce and their accountability to consumers. The revised standards also included eight core accountabilities: safety and quality management, health advocacy, care delivery and patient outcomes, healthy work environments, strategic and fiscal management, compliance, partnership and collaboration, and employee advocacy.
Nurse administrators must consider all aspects of the patient care experience, across the continuum. Those who inspire, motivate, and create high-performance teams are considered transformational leaders. Often they possess emotional intelligence and are moral and ethical role models. Transformational leaders challenge themselves, and their teams, to take risks. They learn from their failures, accept responsibility, and hold themselves accountable. These visionary and innovative leaders help to advance the nursing profession for pediatric cardiac critical care nurses.
Advanced Practice Providers
Pediatric Nurse Practitioners.
Advanced practice providers (APPs), such as nurse practitioners (NPs) are now the frontline providers in many pediatric cardiac intensive care units (PCICUs). Work-hour limitations of trainees in recent years has compelled units to develop creative care delivery models. Models that combine APPs and physician trainees are now commonplace in the United States.
APPs come into the role with varied educational preparation and clinical experience. The licensure, accreditation, certification, and education (LACE) consensus model was developed by 40 organizations in the United States to standardize NP practice. This model recommends aligning each of the elements (licensure, accreditation, certification, and education) with the desired job description and patient population served. For example, completion of an acute care nursing practitioner curriculum at an accredited program, certification through the pediatric nurse practitioner acute care (PNP-AC) board examination, and licensure by the state board are qualifications of the ideal candidate for a pediatric cardiac critical care NP position. APP orientation programs vary considerably in length and structure; some centers offer a 6- to 8-week program, whereas others offer up to 9-month-long fellowships. Many orientation programs combine precepted clinical time, didactic lectures and simulation experiences. An understanding of the individual’s background should help shape a strong, customized orientation program.
APPs are consistent direct care providers in the PCICU. Their clinical responsibilities include obtaining comprehensive histories and performing complete physical examinations; ordering and interpreting appropriate laboratory and imaging studies; prescribing and titrating medications; evaluating the effects of interventions; performing invasive procedures, including tracheal intubation, central and arterial line placement, and chest tube insertion; and collaborating with the multidisciplinary team to coordinate care. APPs educate families and prepare technology-dependent children for discharge to home. In addition to clinical responsibilities, APPs are well positioned to identify processes in need of improvement in the unit, improve adherence to existing policies and protocols, participate in nursing education, and work with the multidisciplinary team on research and quality improvement projects.
Development of Advanced Pediatric Cardiovascular Curriculum
The care of infants and children with congenital heart disease is complex and challenging. A solid knowledge base facilitates the delivery of quality care by the pediatric critical care nurse. The bedside nurse needs to demonstrate advanced clinical judgment and reasoning skills to provide care for these complex, critically ill children.
A systematic, comprehensive curriculum addressing issues specific to the child with CHD enhances the skills and competency of an experienced ICU nurse. The curriculum is presented in various formats, including lectures, workshops, self-learning activities, one-to-one preceptor opportunities, and simulation. The goals of the program are for the learner to be able to (1) describe common congenital heart defects and surgical interventions, (2) perform a safe admission of a child to the ICU after cardiac surgery, (3) identify potential postoperative complications, and (4) demonstrate appropriate nursing interventions ( Box 10.1 ). Early recognition and prompt treatment of potential complications greatly affect outcome and length of hospital stay.
Congenital Heart Defects and Associated Surgical Interventions
Atrial septal defect
Ventricular septal defect
Atrioventricular septal defects
Pulmonary stenosis
Aortic stenosis
Coarctation of the aorta
Tetralogy of Fallot
Transposition of the great arteries
Tricuspid atresia
Total anomalous pulmonary venous return
Truncus arteriosus
Hypoplastic left heart syndrome
Cardiopulmonary Bypass
Routine Preoperative and Postoperative Care
Pharmacology
Complications
Low cardiac output
Excessive bleeding/tamponade
Acute renal failure
Electrolyte imbalances
Arrhythmias
Pulmonary hypertension
Other respiratory-pleural effusion
Neurologic deficits
Infection
Advanced Technical Skills
Cardioversion/defibrillation
Open thoracotomy tray
Pacemakers
Nurse’s Role in the Pediatric Cardiac Intensive Care Unit
Preoperative Care
In the current health care era, most children receive preoperative evaluations in the outpatient setting. However, neonates with ductal dependent cardiac defects require immediate care in an ICU. As congenital cardiac diagnosis is increasingly made in utero, related to the advent of maternal fetal medicine programs, the delivery of a child with a ductal dependent lesion can be planned before the baby’s birth. Arrangements for the infant to be delivered in the hospital where the baby’s cardiac care will be provided eliminates potentially dangerous transfers and separation from parents. State-mandated pulse oximetry screening tests have assisted in better detection of infants who have not been diagnosed in utero. This screening has ensured earlier diagnosis after birth, minimizing the delay in transfer to an ICU for further management and diagnostic workup. Urgent transfer can create a great deal of anxiety for the family and require extensive communication and planning if the mother is hospitalized elsewhere.
Prostaglandin E1–Dependent Neonate (Balancing Q p :Q s ).
The goals for preoperative ICU care consist of maintaining hemodynamic stability and preventing infection and ensuring adequate nutrition. Most children needing an ICU as a neonate require prostaglandins to maintain ductal patency before surgery or hemodynamic support in the form of vasoactive infusions, diuretics, and mechanical ventilation due to severe cardiorespiratory compromise. Balancing systemic (Q s ) to pulmonary (Q p ) circulation is a critical step in ensuring ideal preoperative hemodynamics. Goal-directed therapy is aimed at maintaining adequate cardiac output (CO) and balancing adequate oxygenation. Depending on the type of lesion, infants are often managed with diuretics, careful fluid balance, mechanical ventilation, use of vasoactive infusions, and ensuring optimal nutrition.
Postoperative Care
Preparation for Admission From the Operating Room.
The ICU nurse makes preparations to ensure the delivery of safe, efficient, individualized care to the child and family in the postoperative period. Preparation for admission of a postoperative cardiac surgery patient starts with careful review of all preoperative clinical data, including echocardiographic or cardiac catheterization results, surgical history, current medications and diet, recent physical examination results, and an understanding of the surgical plan. Synthesis of this information is important for the nurse to appropriately anticipate the postoperative care and potential complications. Additionally, the ICU nurse prepares the environment before admission with necessary equipment. The goal of the admission process to the ICU is to ensure safe transfer of care from the operating room (OR) team to the ICU team. An admission protocol is useful to guarantee a safe, efficient admission each time, regardless of individual personnel involved in the process.
Handoff From Operating Room to Intensive Care Unit.
The OR team may contact the ICU team to provide information about the course and expected time of admission before arrival at the ICU. The personnel at the bedside during the admission process should be limited to those required for direct patient care responsibilities, including the cardiac anesthesiologist, surgeon, intensive care providers, respiratory therapist, and two ICU nurses. The anesthesiologist is usually responsible for overseeing care during the transition from the OR to the ICU.
Once the patient arrives at the ICU, the team must safely transfer all monitoring equipment and medication infusions. In a hemodynamically stable patient, the information handoff should begin after equipment handoff. Typically a minimum of two nurses is required to admit a cardiac surgery patient to the ICU. Each ICU nurse is assigned a role to ensure a smooth and safe admission to the critical care unit. The nursing team works with the anesthesia team to safely transfer all monitoring equipment and infusions. The first nurse, usually the nurse assigned to care for the patient, performs a baseline physical assessment. The second nurse is responsible for managing drainage tubes and hemodynamic monitors. Respiratory therapists usually work with the anesthesia team and the ICU providers to determine the ventilator settings.
Initial assessment of the intubated patient is focused on confirming correct endotracheal positioning and adequate ventilation. Once adequate ventilation has been established, the primary nurse performs an initial physical examination. Frequent focused cardiac examinations are done until hemodynamic stability is achieved, and then examinations are spaced out.
The second nurse at the bedside transfers monitoring equipment to the ICU monitor. The use of a transport monitor compatible with the ICU monitors simplifies this procedure and eliminates interruption of monitoring vital signs. This nurse also labels intravascular infusion lines and drainage systems, including chest tubes, urinary catheters, and nasogastric tube. This nurse then obtains admission blood work consisting of complete blood count, chemistry panel, arterial blood gas levels, and coagulation panel. Performing these tasks in a sequential fashion promotes order during the admission process and allows completion of these vital tasks in an expeditious fashion.
During the information handoff the anesthesiologist provides information about the airway, vascular access, hemodynamic trends, vasoactive infusions, and external pacing requirements. The surgical team provides information about the procedure, residual defects, cardiopulmonary bypass (CPB), cross-clamp, and circulatory arrest times. Ideally, all members of the team are available for the information handoff and have the opportunity to ask clarifying questions. Once the ICU assumes care of the patient, the ICU providers communicate a plan, specific postoperative concerns, and expected parameters to the bedside nursing team ( Table 10.1 ).
| Problem | Patient-Specific Intervention |
|---|---|
| Hypoxia |
|
| Respiratory distress |
|
| Decreased cardiac output |
|
| Neurologic deficit |
|
| Decreased urine output |
|
| Pain |
|
| Infection |
|
| Parental stress |
|
| Child/parent education |
|
a Visconti KJ, Sandino KJ, Rappaport LA, et al. Influence of parental stress on the behavioral adjustment of children with transposition of the great arteries. J Dev Behav Pediatr . 2002;23:314-321.
Hemodynamic Monitoring: Evaluation of Oxygen Delivery
Matching oxygen delivery and oxygen demand is the primary goal of the postoperative period. Synthesis of cardiac examination findings, vital sign trends, and laboratory results is essential for the PCICU nurse to determine adequacy of oxygen delivery.
Focused Cardiac Examination
A thorough cardiac examination includes auscultating heart sounds, palpating liver border, measuring urine output, and assessing central and distal pulses, skin color and temperature, and capillary refill time. Evaluation of a heart murmur or rub may identify residual heart disease or the presence of a pericardial effusion. Palpation of the liver edge is especially useful in children with right-sided heart dysfunction or failing single-ventricle physiology. An enlarged liver can indicate worsening function or volume overload. For example, a patient with poor Fontan physiology may develop worsening hepatomegaly in the setting of excessive volume repletion. Trending urine output is often used as a surrogate marker for renal perfusion. Poor urine output may be an indication of inadequate renal perfusion as a result of poor CO. Physical examination findings that focus on the presence and strength of both central and peripheral pulses, skin color and temperature, presence or degree of peripheral edema, and capillary refill time are critically important to evaluating overall perfusion.
Monitoring
Closely monitoring heart rate and rhythm, blood pressure, intracardiac pressures or central venous pressure, oxygen saturation, venous oximetry, near-infrared spectroscopy (NIRS), and end-tidal carbon dioxide (ETCO 2 ) trends is a key nursing responsibility. Twelve-lead electrocardiogram (ECG) is routinely obtained after admission from the OR and obtained as needed thereafter. Atrial wire ECGs may help detect an atrial arrhythmia when the surface lead ECG is difficult to interpret. Tachycardia may be noted in the setting of hypovolemia, fever, or pain or may be a new arrhythmia. Simultaneous monitoring of intracardiac pressures may help delineate the problem. For example, tachycardia associated with elevated atrial pressures may be onset of a new tachyarrhythmia or worsening ventricular function; however, tachycardia associated with low intracardiac pressure is likely the result of hypovolemia. Bradycardia may be noted with sinus node dysfunction, atrioventricular (AV) block, or hypothermia or may be the side effect of analgesia or sedation medications. External pacemaker availability is essential to managing arrhythmias in the postoperative period.
Arterial lines are used for direct and continuous blood pressure monitoring and easy blood gas sampling. Common sites for arterial lines in children include the radial, femoral, and umbilical arteries. Arterial blood pressure measurements are correlated with noninvasive blood pressure monitoring whenever there is a question regarding the accuracy of the arterial line. A poor waveform on the monitor or the inability to withdraw blood from the catheter may give false readings. The ICU nurse troubleshoots the monitoring issues to determine accurate patient data. Nonfunctioning arterial lines are replaced or removed. Depending on ICU protocols, umbilical artery catheters are removed within 7 to 10 days to avoid infection and/or thrombosis. Noninvasive pressure monitoring may be adequate once hemodynamic stability is achieved and less vasoactive support is needed.
Central venous and intracardiac pressure monitoring provides valuable information regarding intravascular volume and right ventricular compliance and onset of new arrhythmia. These lines are also useful for blood sampling and medication administration. Common cannulation sites for central venous pressure monitoring include internal and external jugular veins, femoral veins, and umbilical veins. Central venous lines often have multiple lumens that allow for the administration of multiple medications and fluids while monitoring venous pressures. Intracardiac monitoring lines are placed either percutaneously or transthoracically. Left atrial catheters are usually placed at the junction of the left atria and upper pulmonary vein, and pulmonary catheters are placed in the main pulmonary artery. The surgeon places transthoracic lines in the OR based the child’s physiology and anticipated postoperative course. Right-sided lines may be used for infusions in the absence of other central lines and any residual right-to-left shunt. Left-sided transthoracic lines are not routinely used to infuse fluids or medications due to increased risk of introducing air or particulate matter emboli into the arterial circulation. Chest tubes generally remain in place until transthoracic lines are removed, due to potential bleeding after catheter removal.
Careful assembly of the transducers, tubing, and stopcocks is essential to preventing contamination and incomplete priming of the tubing resulting in entrapped air. Air within the closed system will alter the accuracy of the monitoring system and may result in an embolic event. Ensuring that precise information is obtained from the transducers depends on the accuracy of leveling and calibrating the system. The ICU nurse routinely calibrates and levels the transducers at change of shift and after a change in the patient’s position.
Oxygen saturation monitoring is a bit more complicated in patients with complex CHD than in patients with normal cardiac anatomy. Oxygen saturation goals depend on the degree of intracardiac shunting. A solid understanding of the anatomy and physiology of each patient is essential to targeting the appropriate saturation goals. For example, patients after a tetralogy of Fallot (TOF) repair with a residual atrial level communication and right ventricular dysfunction may have acceptable oxygen saturation range of 80% to 100% in the immediate postoperative period; however, a TOF patient with an intact atrial septum should have oxygen saturation target of 96% to 100%. Hypoxia in the absence of cyanotic heart disease needs to be addressed and corrected urgently.
ETCO 2 monitoring can confirm that the endotracheal tube is in the airway; however, it does not confirm appropriate positioning of the endotracheal tube. Assuming the presence of a pulse in the patient, an abrupt drop in ETCO 2 must trigger an immediate evaluation of endotracheal tube placement, including assessment of chest rise, breath sounds, and tube patency and placement. Once ETCO 2 is correlated with arterial carbon dioxide levels, the ETCO 2 may be trended and spare unnecessary arterial blood gas sampling. Additionally, if airway patency is confirmed, continuous ETCO 2 measurement is used as an indicator of CO, and an acute change may prompt the nurse to deterioration in the patient, including worsening perfusion and a diminishing pulse. Also, ETCO 2 is used to assess adequacy of chest compressions during resuscitation.
NIRS monitoring is a noninvasive method of evaluating regional tissue oxygenation. NIRS sensors are generally placed over the abdomen or flank region and on the forehead. Trending NIRS values can detect fluctuations in perfusion. Used in conjunction with other monitoring devices, NIRS may be an early warning sign of low CO (LCO).
Early recognition of a deteriorating cardiac examination, vital signs, or laboratory results, anticipation of appropriate treatments, and communication to the provider team expedites time-sensitive interventions. Distilling the pertinent data from the vast amount of information a nurse receives is a high-level, critical thinking skill that distinguishes pediatric cardiac critical care nurses.
Unexpected residual cardiac disease has become rare in the era of intraoperative transesophageal echocardiography (TEE). Intraoperative TEE after the surgical repair gives the surgeon information regarding cardiac function and anatomy before separation from CPB. If significant residual lesions (intracardiac shunts, obstruction to flow, valve regurgitation) exist, the surgeon may correct the remaining problem before leaving the OR.
Inadequate intravascular volume as measured by right atrial pressure, left atrial pressure, and blood pressure can result from hemorrhage, inadequate fluid administration, fluid leaking into the third space, and excessive diuresis. Postoperative bleeding can occur from cannulation sites, suture lines, or postbypass coagulopathy. Long CPB time can lead to platelet dysfunction and diffuse capillary leak. Packed red blood cells, platelets, and fresh frozen plasma should be readily available for replacement due to grossly abnormal coagulation laboratory values or prolonged and excessive bleeding.
Despite ongoing improvements in perfusion techniques, the use of CPB continues to be associated with postoperative morbidity. CPB affects both intravascular volume and cardiac contractility. The use of an external circuit for circulation and oxygenation has been shown to result in the stimulation of an inflammatory response and subsequent capillary leak. This inflammatory response syndrome results in injury to multiple body systems, including the lungs, systemic vasculature, and myocardium. The systemic effects of the CPB inflammatory syndrome may result in substantial increase in intravascular permeability with fluid moving into the tissues, resulting in decreased intravascular volume. Close monitoring of the child’s vital signs, perfusion, and urine output is essential to ensuring that fluid shifting into the third space does not result in hypotension and poor end-organ perfusion.
Hypoxemia and acidosis are identified by routine arterial blood gas monitoring. Knowledge of the surgical procedure performed is essential to determining the expected oxygen saturation for a patient. Patients with uncorrected single-ventricle physiology (e.g., those with shunts or Glenn anastomoses) will be hypoxemic because they have mixing lesions, and oxygen saturations in the 80% range may be normal and expected, whereas patients with corrected circulation and normal lungs should be expected to have saturations above 90%. Inadequate CO will result in poor oxygen delivery to tissues and metabolic acidosis. Serial lactic acid measurement provides information regarding the adequacy of perfusion. Persistently elevated lactic acid levels are a marker for poor outcome after cardiac surgery. Mixed venous saturation (SvO 2 ) monitoring also provides information regarding oxygen delivery and utilization. Low mixed venous saturation levels may indicate a residual right-to-left cardiac shunt or decreased CO. Continuous noninvasive monitoring provides trends in the patient’s perfusion. Commonly patients have continuous pulse oximetry and NIRS monitoring in the early postoperative period. Analyzing laboratory data and monitoring trends must be done in conjunction with physical examinations.
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