Cardiac Flashcards
What occurs with perfusion if you do not have enough pressure?
Blood will be shunted to the central part of the body
Extremities will lack perfusion
What are the goals regarding hemodynamic stability?
Prevent cardiogenic shock/failure
Bridge to surgery
Transplant
What are the goals regarding limiting secondary complications?
Respiratory failure
G&D delays
Infections
Kidney Disease
What age is myocardial tissue less effect? What does this put the child at risk for?
Under 2 myocardial tissue is less effective
Increased risk of cariogenic shock
Decompensated quickly
What is CO dependent on in children?
HR - fast
Ca, glucose (keep heart pumping) and volume
Less reserve to meet increase metabolic demands
ISWL increased
Unstable fluid shifts
What is one of the reason children have such a fast baseline HR?
The heart muscle is not very strong so it does not pump blood efficiently enough therefore needs a faster HR to get enough blood to the body
How do you assess the cardiac function in a child?
Listen to apical pulse for 1 minute
Cap refill at midline such as ear, forehead, sternum
Brachial and femoral pulses
What should you remember in regards to pulse ox with children?
May need a central probe because extremities aren’t as reliable
Pulse ox on hands will end up in the childs mouth (can put on toes but not reliable)
What is CO?
HR x SV (volume of blood per beat)
What is after load?
Resistance in the vessels
What is preload?
Maximum expansion of ventricle before ejection
What if the workload of heart is excessive?
Leads to strain on the ventricles
What is a septum in the heart?
Fibrous tissues that divide the ventricles
What is shunting
Abnormal pathway for blood to flow through the heart
Blood follows the path of least resistance over a septum or vascular wall
What is going on with the lung in utero? How do babies in utero get oxygen?
Lungs are filled with fluid so they do not work for O2 exchange
Blood comes from mom via the umbilical cord and bypasses the lungs by using the ductus arterioles to get to the body
At what are is the circulatory system normal?
2 months
When do you diagnose heart diseases in babies?
Prenatal
Newborn in nursery (can be difficult because changes are happening during this time)
2 months well baby visit (usually thin and sweaty)
Which side of the heart is strong while in fetus? Which side of the heart is strong once baby takes first breath?
Fetal: Right side stronger
After 1st breath: Left side strong
What are the type of high pulmonary blood flow disease?
Atrial septal defect (ASD)
Ventricular septal defect (VSD)
Patent ductus arteriosis (PDA)
What is a low pulmonary blood flow disease?
Tetrology of fallot
What is a ventricular septal defect? What is the blood flow?
Opening in the intraventricular septum that separates the two ventricles of the heart
Blood flow is shunted from left to right
What are the S/S of VSD?
Fatigue
SOB
Difficulty feeding
Poor growth
Turbulence –> heart murmur (loud harsh systolic murmur)
Palpable thrill
How do you diagnose SVD
Echocardiogram
What is the treatment for VSD?
Surgical closure for a large defect
What is patent ductus arteriosis (PDA)?
When the ductus arteriosis does not close after birth –> on contraction blood flow form the left ventricle to the aorta and back to the pulmonary arteries by going through the PDA –> overloading the lungs
** blood should go from aorta into body**
What is the treatment for PDA? When can this be preformed?
Patent ductus arteriosis occlusion: insert catheter in groin –> feed through heart –> angiogram is taken of PDA to measure it so appropriate sizure occlusion device can be inserted to close PDA
After a few weeks
Is blood still going to the body with a PDA?
Yes, it is the least harmful because only a little blood is baking up into the pulmonary arteries instead of going to the body
When should the ductus arteriosus close?
in 48-72 hours of life
What s/s would you expect with a high pulmonary blood flow heart defect?
NO cyanosis
Pulmonary HTN
Crackles
R sided heart failure (see edema in the body)
What is the shunt that is expected to be seen with a high pulmonary blood flow heart defect? Where do you see blood increase?
Left to right shunt
Increased blood to the lungs
Why do you see right sided heart failure with a high pulmonary blood flow heart defect? Why do you see edema?
Blood is backing up into the lungs and causing pulmonary HTN –> the right ventricle to have to work really hard –> right sides HF
Edema is seen because the R atria is letting blood flow back into the body
Why is it concerning when a baby with a heart defect sweats? What about with feeds?
Babies shouldn’t sweat until 1 year because they don’t have sweat glands that are developed
Sweating with feeds is a neuro/hormonal response to heart failure
If a child is gaining weight rapidly but still looking thin, what should you be worried about?
FLuid volume overload
What are some s/s of poor perfusion?
Increase HR
Increase RR
Cool/clammy extremities
Cap refill over 2 seconds
Cyanosis
Mottling
Pale
Weak/thready pulses
Where do children that are fluid overloaded hold their fluid? How do you measure this?
Belly - abdominal girth
Extremities - pitting edema over a bony prominence
What are complications r/t to neuro with reduced CO?
Irritable with long term cognitive delays
What are some complications r/t GI with reduced CO?
Hepatomegaly
Poor feeding and weight Gian
GERD
What are some complications r/t renal with reduced CO?
Decreased UOP
Chronic kidney disease
How should you monitor CO?
Monitor PEWS
Cardiac monitor
Pulse ox: 88-90
What medications can help to increase CO and reduce workload?
Digoxin
Inotropes
Vasopressors
Diuretics
ACEi/ARBS
What are some nursing interventions to increase CO and reduce workload?
IV access with or w/o fluids
Oxygen
Strict I&Os
Daily AM weight
Weight all diapers
Conserve energy by dressing stimuli and clustering care
What are some feeding considerations to increase CO and reduce workload?
Small and frequent feedings
Limting feeding to 20 minutes
High calorie
Anything that can’t be ate within 20 minutes should be given via a Gtube
What are some assessment cues of impaired gas exchange?
Tachypnea
Pulmonary congestion
Abnormal lung sounds
Retractions
Increased work of breathing
Diaphoretic
SpO2 less than 88%
Increased HR
irritable
What are some intervention that should be taken to improve gas exchange?
Oxygen
Pulse ox
Clear upper airway with suction (especially before feeds)
HOB elevated
Conserve energy by clustering care and decreasing environmental stimulation
Why should you be cautious of a new dry cough?
Early sign of respiratory distress
What is digoxin? What does it do? What is the therapeutic window? What does toxicity look like? What electrolyte should you watch for?
Ionotropic med
Helps heart contract with greater force to move blood
0.5-2.0ng/ml
Vomiting
Potassium but can be hard to monitor if on diuretic and peeing out potassium
What are some considerations for digoxin administration?
Hold for a pulse less than 80-90
2 RN dose verification
Every 12 hours NOT BID
Do not give with food or formula
How do you administer medication for infants?
Syringe between the lower cheek and gums
Little bit of medication at a time
Blow on face to make them swallow
Give right before feeding because will initiate sucking
Can the patent ductus ateriosus be manipulated? How? Why would you want open vs. closed?
Can be forced open or closed with medical management
Indomethacin - vasoconstrcits (closes duct) - given if causing a lot of pulmonary issues
Prostaglandin - vasodilators (opens duct) - bring blood flow to lung b/c in low blood flow disorders can have difficult time getting BF to lungs
What are the 4 defects in tetralogy of Fallot?
Overrding aorta
Ventricular septal defect (VSD)
Pulmonary stenosis
Right ventricular hypertrophy
What is going on with the blood flow in tetralogy of fallot? What does this cause?
Right to left shunt
Blood is not going to the lungs instead, unoxygenated blood is getting pushed out into the body and causing extreme cyanosis
What is an overriding aorta? Treatment?
Aorta moves forward directly over the VSD allowing oxygen poor blood form the right ventricle to flow into the aorta
Shunt placed between branch of the aorta and right pulmonary artery –> provide another path for blood to get to the lungs to get oxygenated
What is pulmonary stenosis? Treatment?
Pulmonary artery (gets blood to the lungs) is narrowed and pulmonary valve doesn’t open all the way resulting in less blood going to the lungs
Patch used to widen the pulmonary artery and valve
What is right ventricular hypertrophy? Treatment?
Wall of right ventricle is thicker than normal d/t right ventricle working harder than normal to pump blood through the narrowed pulmonary valve
How do you make sure the surgery worked in Tetrology of Fallot?
During surgery, you can take saturation levels in each of the chambers
Does the loudest murmur mean to worst defect?
No, intensity does not indicate severity
A tiny VSD can sound really loud d/t increased pressure
A large VSD can sound quiet d/t less pressure
What are the complications of a low pulmonary blood flow defect?
Extreme cyanosis
Polycythemia (body produces more hemoglobin to get more oxygen to the body)
What are the cues for impaired gas exchange?
Increased WOB
Increased RR
Oxygen use
Retractions
Adventicious breath sounds
Decrease baseline pulse ox
Cyanosis
Clubbing
Polycythemia (>14-16 g/dL)
Severe activity intolerance
What is a hyper cyanotic spell or a “tet” spell? What is it caused by?
Decreased pulmonary blood flow d/t increased resistance
Increased need for oxygen
Caused by stress d.t crying, feeding or tantrum
What are the nursing interventions for a “tet” spell?
FIRST: Knee to chest/tripod (forces blood back to heart into pulmonary artery)
Oxygen
Morphine (relax patient and relax pulmonary vascular spasm)
What are complications of polycythemia r/t low pulmonary blood flow disorder?
Risk for thrombosis d/t sludge like blood
Stroke
DVT
Cognitive delays
What are the nursing interventions to prevent complications r/t polycythemia?
Hydration
Anticoagulation with baby aspirin
What are the risks of giving a child aspirin?
There is an increase of Reyes syndrome (liver failure/encephalitis) when a child has a viral disease
What are complications r/t to all congenital heart defects?
Poor weight gain d/t imbalanced nutrition, GERD, fussy eaters, puking
Developmental delays
Immunosupression
How do you prevent complications r/t all congenital heart defects?
Feeding support - balance nutrition and stress
Playing
Vaccinate
What is an obstructive lesion (coarchication of the aorta)?
Coractation of the aorta (pinching of the aorta) –> decreased pulses and perfusion
Decrease blood supply below the obstruction
What is the consequences of an obstructive lesion?
Poor distal pressure –> poor pulses and perfusion –> difference in contralateral pulses upper vs. lower or left/right extremity
What if an obstructive lesion occurs before the beaches of the aorta? After?
Before: all limbs are affected
After: just lower limbs are affected
What is the surgical care for congenital heart defects?
Correct underlying defect
If there is failed medical management –> surgical staging and Interventional Cardiac Cath
What should you be watching post cardiac Cath? interventions?
Bleeding
Vascular compromise of extremities
Check pulses and compare both sides
Lay flat - give pain control, swaddling and comfort hold to keep flat
What do you use a band for r/t CHD?
Restricts extra blood flow in high pulmonary blood flow disorders –> decrease in pulmonary congestion
What is discharge teaching all parents should know for all heart defects? (9)
CPR
Apnea/cardiac monitor training
S/S of HF
How to respond to tet spells
Nutrition/feeding
Medication instructions
How to check pulse, BP and SpO2
Infection prevention
Support groups
What are the different kind of acquired heart diseases?
- Arrhythmia : CHD
- Infectious: endocarditis
- Collagen vascular disease (autoimmune disorder): rheumatic fever and Kawasaki disease
What is the concern regarding infectious endocarditis and CHD?
It causes an increase risk because they have implantable devices and cause have valve diseases
What is the cause of rheumatic fever? Can it be prevented? What age group does it most commonly affect?
Group A strep that goes untreated
Can be prevented if strep is recognized and treated correctly
5-15 years old
What are the s/s of rheumatic fever?
MAJOR:
C: carditis
A: arthritis
S: subcutaneous nodules
E: erythema marginatum (rash)
S: sydenhams chorea (neuro disorder - rapid irregular movements of arms and legs)
MINOR
F: fever
R: raised ESR/CRP
A: arthralgia (joint pain)
P: prolonged PR interval
P: previous RF
When do rashes blanch? When do they not blanch?
Blanch: inflammation
Not blanch: vascular
How do you treat rheumatic fever?
Acute: treat strep with antibiotics (PNC V or amoxicillin) and symptomatic treatment
Life long: monthly PNC G, daily ASA, cardiac follow ups
Why do you need life long treatment with rheumatic fever?
Relapses are common
What is Kawasaki disease? How do you treat it?
Over active immune system
Treatment is IVIG and ASA
What age does Kawasaki disease affect most? What is the worst complication r/t this?
Less than 5 years old
Coronary artery aneurysms
What are the 3 phases of Kawasaki disease?
Acute: high fever (above 104) for 5-10 days which is only window to diagnose to prevent complication
Subacute: acute s/s start to go away, peeling of skin, arthritis and arthralgia and become at risk coronary aneurysm
Convalescent: lifelong management and high risk for coronary events
What is the criteria for Kawasaki disease?
Fever for more than 5 days and 4 out of 5 of the following
C: conjuntivitis (non-exudative)
R: rash (non-vesicular)
E: edema (or erythema of hands and feet)
A: Adenopathy (cervical usually unilateral)
M: Mucosal involvement (inflamed, cracked, fissures or crusting, erythema)
Which side of heart is strong in adults/chidlren? Which side is strong in a fetus?
Adults and children: left side is strong
Fetus: right side is strong
How do you treat Pulmonary HTN?
Correct the underlying defect 6 months
Oxygen
Manage HF
Pulmonary vasodilators like Nitric oxide or PDE5 inhibitors (viagra)
When does cyanosis usually occur? What are the complications? What is the baseline SVO2?
with right to left shunting
Polycythemia
Baseline: 75-85%
S/S of HF?
Early:
Cough
Poor weight gain and poor appetite
Difficulty feeding/fatigue/gerd
Abdominal pain d/t lack of perfusion
Fussy and developmental delays
Late:
Respiratory distress (nasal flaring, SOB, retractions, grunting)
Fatigue and poor activity intolerance
Diaphoretic and clammy
Decreased UOP
End of s/s d/t lack of perfusion (CKD, neuro/cognitive delays, growth failure)
Why is the a heart with CHD more at risk for endocarditis?
Normal heart: smooth lining, bacteria can’t stick
CHD: rough area on heart d/t pressure from an abnormal opening/leaky valve. Even w/ surgery, rough areas may remain d/t scarring, patching inviting bacteria to build up and multiply
What are long term complications of HF?
Growth and development delays/FTT
End organ damage (brain, kidney, skin, GI, heart, liver)
