Cardiac Flashcards
Cardiac Pedi Assessment/Physical Exam: Cardiac
- heart rate
-rhythm
-heart sounds
-pulses
-respirations
-WOB
-weight gain/loss
-clubbing
-activity
Cardiac Pedi Assessment/Physical Exam: Peripheral Vascular
-color
-pulse
-cap refill
-skin
-polycythemia may be present
-fluid status
Cardiac Diagnostic Tests
-CXR
-EKG
-ECHO
-CT
-cardiac cath
-CT
-MRI
-Holter monitor
-stress test
-pulse oximetry
Cardiac Labs - Pedi
-ABG/VBG
-electrolytes
-CBC
-troponin
-CRP/ESR
-lipid panel
Pediatric Cardiac Catheterization
-definitive study for infants and children with cardiac disease
-routine diagnostic procedure
-done on an outpatient basis
-highly invasive
-risks involved
Pediatric Cardiac Catheterization:
Indications
-CV disease causing cyanosis in infants
-severe heart failure or progressive problems
-possible A+P abnormalities
-planned cardiac surgery
-progressive monitor r/t pulmonary HTN
-periodic assessment after repair of cardiac defect
-therapeutic interventions - septostomy or balloon valvotomy
Cardiac Catheterization: Pedi
-a radiopaque catheter inserted into a blood vessel and is guided to the heart with fluoroscopy
-record BP, changes in cardiac output, stroke volume, and O2 sat
-inject contrast: assess the anatomy of the heart, valve function, structural abnormalities
-may take samples of heart tissue to evaluate for dysfunction
Cardiac Cath: Nursing Interventions
-pressure over dressing site
-frequent monitoring of site- report bleeding/brusing
-bed rest 4-6 hrs post procedure / lay flat - no hip flexion
-distal/pedal pulse check
-cardiac monitoring
-fluids to push thru contrast
Pedi Cardiovascular Disorders - Congenital Heart Disease (CHD)
disorders of decreased pulmonary flow:
-tetralogy of fallout - cyanotic
-tricuspid atresia - cyanotic
disorders of increased pulmonary flow:
-atrial septal defect - acyanotic
-ventricular septal defect - acyanotic
-arterioventricular canal defect - acyanotic
-patent ductus arteriosus - acyanotic
Tetralogy of Fallot - Cyanotic
- Decreased pulmonary flow
- Composed of four heart defects:
- Pulmonary stenosis
- VSD
- Overriding aorta
- Right ventricular hypertrophy
- Diagnosed first few weeks of life – murmur
and/or cyanosis - Typically have a PDA at birth that decreases
severity of cyanosis
Treatment: vasodilators while awaiting repair
Surgery 1st year of life - stages
Tricuspid Atresia - Cyanotic
- Decreased pulmonary blood flow
- Valve between right atrium and right ventricle fails
to develop - No opening for blood to flow from the right atrium to right ventricle and to the pulmonary artery
- If foramen ovale remains opened deoxygenated blood moves thru to the left atrium
- May travel to lungs via a PDA but once PDA closes cyanosis increases
- Typically associated with a VSD
Treatment: While awaiting surgery may need prostaglandins to keep the ductus arteriosus patent vs closing
Surgery – staged procedures depending on severity of defect
Atrial Septal Defect - Acyanotic
- increased pulmonary blood flow
- Left to right shunt
- Hole in atrial septum – oxygenated blood from left atrium mixes with non-oxygenated blood right atrium
- Common 6-10% of CHD
- May hear murmur
- ECHO may reveal a dilated right side of heart
Treatment:
Rest, nutrition
Surgical repair
Ventricular Septal Defect - Acyanotic
Increased pulmonary blood flow – left to right shunt
* Hole in ventricular septum
* Oxygenated blood from left ventricle mixes with non-oxygenated
blood from right ventricle
* Common 20-25% of CHD
Treatment: Digoxin to control rate and rhythm
* Lasix – diuresis
* ACE inhibitors – decrease SVR, shunting, and aortic pressure
* Surgical: temporary banding of pulmonary vessels (reduces blood flow
to lungs)
* Patch at 3-12mos
Goals: Prevent heart failure and pulmonary HTN (large VSD)
Atrioventricular Canal Defect - Acyanotic
Increased pulmonary blood flow
* 35-40% of children with Down Syndrome and CHD have this defect
* Failure of endocardial cushions to fuse / cushions are needed to
separate the central part of the heart near mitral and tricuspid valves
* A complete defect involves ASD, VSD, and a common Atrioventricular
valve
* A complete defect: oxygenated blood from lungs enters left atrium and
ventricles and over the atrial or ventricular septum and back to the
lungs via the pulmonary artery
* A recirculation problem – left to right shunt
* Left ventricle must pump harder to get blood to systemic circulation
* With complete form – heart failure evident
Treatment: Surgery to patch defects or replacement of heart valves
Patent Ductus Arteriosus - Acyanotic
Increased pulmonary blood flow
* Ductus Arteriosus fails to close after birth
* Connection bw aorta and pulmonary artery
* 2nd most common CHD
* More frequent in premature infants
* More frequent in those born at higher altitudes
- Treatment: Ibuprofen or Indomethacin to stimulate closure
- Surgical ligation of PD
Coarctation of the Aorta - Acyanotic
Obstructive Disorder
* Narrowing of the descending aorta
* 5-8% CHD
* Once PDA closes, perfusion to lower extremities is
impaired
* 4 extremity BP’s – arms higher than legs
Treatment: Prostaglandins – keep PDA open to aid in
perfusion of kidneys and lower extremities
* Diuretics, oxygen and inotropes
* Surgical repair – end-to-end anastomoses
Aortic Stenosis - Acyanotic
Obstructive Disorder
* Caused by:
* Obstructed blood flow below aortic valve
* Obstruction of aortic valve OR
* Narrowing just above the aortic valve
* May be CHD or from Rheumatic Fever
* Systemic blood flow compromised
* Symptoms: Typically asymptomatic
Resp distress, difficulty feeding, sweating, irritability, pale
Later in life: CP, HA, HTN, leg cramps/cold feet, muscle weakness
* Dx: ECHO
- Treatment:
- Surgical repair, balloon valvuloplasty, Ross procedure
- SBE prophylaxis
- Exercise restrictions – may return 3 mos after repair if ventricular function not impaired
Pulmonary Stenosis – Acyanotic
Obstruction Disorder
- Obstruction in blood flow bw right ventricle and pulmonary arteries
- Often assoc with genetic syndromes / CHD
- Occur as: muscular obstruction below pulmonary valve, obstruction at the valve, or
narrowing of pulmonary artery above valve - Right ventricle has an increased workload – right ventricular hypertrophy, decreased
pulmonary blood flow - If severely obstructed, right ventricle can not pump efficiently and right atrium pressure increases. Could force open the foramen ovale and cause shunting of nonoxygenated blood to left side of heart and out into circulation
Treatment:
prostaglandins
anticoagulants
diuretics
antiarrhythmics
Repair (ultimately)
Total Anomalous Pulmonary Venous Connection – Cyanotic
Mixed Defect
- Pulmonary veins do not connect normally to left atrium
- Connect to right atrium, often by the SVC
- Oxygenated blood would normally enter left atrium instead enters right atrium to right ventricle
- Pressure increases in right ventricle/pulmonary HTN and edema
- Incompatible with life / unless assoc defect that allows for shunting
Truncus Arteriosus – Cyanotic
Mixed Disorder
- Only one major artery leaves heart and supplies blood to pulmonary and systemic circulations
- Blood from left ventricle mixes with blood from right ventricle
- Increased blood flow to the lungs
- Surgery to fix shortly after birth
Hypoplastic Left Heart Syndrome
Mixed Defect
- Left side of heart severelyunderdeveloped
- The left ventricle is underdeveloped and too small, decreased force of contraction
- The mitral valve is not formed or is very small
- The aortic valve is not formed or is very small
- The ascending portion of the aorta is underdeveloped or is too small
- Right ventricle enlarges and dilates bc left side not working efficiently
- REDUCED systemic blood flow
- Open PDA therefore shunting of oxygenated blood to nonoxygenated blood
- Most common cause of death in neonates with CHD
Treatment:
- Prostaglandins to keep
- PDA open and maintain systemic perfusion
* Surgical repair
Pediatric Cardiovascular Disorders - Cyanotic
Decreased pulmonary blood flow
Obstruction of blood flow to lungs
* Tetralogy of Fallot
* Pulmonary Atresia
* Pulmonary Stenosis
* Tricuspid Atresia
Acquired Cardiovascular Disorders
- Heart Failure is the most common
- Rheumatic Fever
- Cardiomyopathy
- Infective endocarditis
- Hyperlipidemia
- Hypertension
- Kawasaki Disease
Heart Failure
Approx 20% with CHD experience heart failure
- May occur as a secondary cause such as myocardial dysfunction following
surgical intervention for CHD, myocarditis, fluid volume overload,
hypertension, anemia, sepsis, or as a toxic effect of certain
chemotherapeutic agents - It is a set of clinical S+S reflecting hearts inability to pump effectively to
provide adequate blood, oxygen, and nutrients to the body’s organs and
tissues
Heart Failure, cont. (pathophysiology)
- Pathophysiology: Protracted alterations in either preload, afterload, myocardial
contractility and heart rate affecting cardiac output may lead to heart failure. - Neurohormal factors: Sympathetic Nervous System and Renin-Angiotensin
Aldosterone System are activated due to a fall in cardiac output. Efforts by these
systems to maintain homeostasis. With chronic activation results in hemodynamic stress and has harmful effects on the CV system (increased water retention,
increased sodium retention, increased blood volume) - S+S Tachycardia, Pallor, Decreased UO, sweating, rise in BP, edema, wt gain
Heart Failure, cont.
S+S: increased WOB, tachypnea,
retractions, grunting, wheezing,
cough, rales, DOE, feeding difficulties
Heart Failure, cont. (diastolic dysfunction)
- Diastolic dysfunction:
- Increased right-sided filling pressure
- Hepatic venous congestion
- Systemic venous congestion
- Pumping against resistance
- Increase in myocardial oxygen demand
S+S: hepatomegaly, jugular venous distension, periorbital edema
Heart Failure, cont. (Systolic Dysfunction)
Systolic Dysfunction: increase in preload increases stroke volume – cardiac muscle stretches to accommodate increase in intravascular volume, increased
filling pressure, increased demand for oxygen, pulmonary congestion and impaired gas exchange
Heart Failure, cont. (Nursing Management)
- Promote oxygenation
- Semi-upright position
- Suction prn
- Chest PT
- Oxygen support
- Supporting Cardiac function
- Meds: digitalis, ACE inhibitors, Diuretics
- Observe for S+S of hypotension
- Accurate I+O’s / wts
- K+ levels
- Promote nutrition
- Promote rest
Infective Endocarditis
- Microbial infection of endothelial surfaces (inner lining) of the heart chambers, septum or valves (most common)
- Bacterial (staph and strep)
- Fungi (less common)
- Risk Factors:
- Children with CVC
- Children with CHD such as septum or valve
defects - Prosthetic valves are at increased risk
- IV drug use
- Health hx: intermittent, unexplained, low-grade fever
- Possibly edema if heart failure present
- Petechiae palpebral conjunctivae, oral mucosa, or extremities
- Roth spots: splinter hemorrhages with pale centers on sclerae, palate, buccal mucosa, chest, fingers, or toes
- Janeway lesions: painless, flat, red or blue hemorrhagic lesions on palms or soles
- Osler nodes: small, tender nodules on pads of toes or fingers
- Black lines under the nails (hemorrhages)
Nursing Management:
IV access for at least 4 weeks,
Education: if child develops fever or flu-like symptoms seek medical care (for those high-risk)
Prevention:
Good oral hygiene, those at risk should receive antibiotic prophylaxis prior to dental procedures
Labs:
-Blood culture
-ECHO
-CBC
-UA
Acute Rheumatic Fever
Delayed sequelae of group A streptococcal pharyngeal infection
* More often in children between age 5 and 15 years of age, in areas where strep
pharyngitis is more prevalent, esp during the colder mos.
* Typically develops 2-4 weeks after initial strep infection
* Child develops an antibody response to surface proteins of bacteria, antibodies then
cross-react with antigens in cardiac muscle and neuronal and synovial tissues.
* Results in carditis, arthritis, and chorea
* Affects joints, CNS, skin and SQ tissues
* Chronic progressive damage to the heart and valves
Acute Rheumatic Fever, cont. (Diagnosis)
- Based on modified Jones criteria
- Requires presence of either two major criteria or one
major plus two minor criteria - Major Criteria
- Carditis
- Migratory polyarthritis
- Subcutaneous nodules
- Erythema marginatum
- Sydenham chorea (movement d/o of face and
upper extremities) - Minor Criteria
- Polyarthralgia
- Elevated ESR or C-reactive protein
- Prolonged PR interval (unless carditis is a major
criterion)
Acute Rheumatic Fever, cont. (Nursing Assessment)
- Past hx of recent strep infection or sore throat
past 2-3 weeks - Observe Sydenham’s chorea
- Inspect for rash: erythema marginatum: macpap
rash with central clearing and elevated edges - Heart: murmur
- Palpate surfaces of wrist, Elbows, and knees for firm, Painless, SQ nodules
- EKG: prolonged PR Interval 1
- Antibiotic compliance
- Reassurance that chorea sxs will resolve may
take several mos - May require neuroleptic (Haldol) to control
movements - NSAIDs for joint pain and swelling
Cardiomyopathy
- Disease of the heart muscle
- Incidence among children is increasing occurs at
a rate of 1 per 100000 - Myocardium can not contract properly
- May occur:
- in children with genetic disorders
- In children with congenital heart defects
- As a result of an inflammatory process
- As a result of an infectious process
- As a result of HTN
- As a result of cardiac surgery or transpant
- MOST COMMONLY IT IS IDIOPATHIC
Types of cardiomyopathy:
restrictive – rare in children
hypertrophic – more common in adolescents
dilated –most common in children
No cure - heart muscle function can not be restored
Cardiomyopathy, cont. (Therapeutic Management)
- Goal is to improve heart function and BP
- Mechanical ventilation in some
children - ACE inhibitors, calcium channel
blockers, beta-blockers - Pacemakers
- Surgery
- Heart transplantation if medical
management not successful
Cardiomyopathy, cont. (Nursing Management)
- Monitor for complications: blood clots,
arrhythmias - Similar to heart failure
- Vasoactive medications
- Choose activities that fit within their
prescribed limitations - Emotional support
Cardiomyopathy, cont. (Nursing Assessment)
Assess health hx for risk factors: CHD, cardiac surgery, Duchenne or Becker muscular
dystrophy, myocarditis, HIV infection, Kawasaki, HTN, Drugs/ETOH or radiation exposure,
connective tissue, autoimmune or endocrine disease, Maternal diabetes or family hx of
sudden death
* Ask about hx of symptoms such as: poor growth, resp distress, fatigue, dizziness, syncope
* Assess: Extremities for edema, abdominal distension, WOB, tachycardia, heart rhythm.
* ECG
* CXR
* Cardiac Cath
Hypertension
- Independently associated with BMI and waist circumference
- Child/Adolescent HTN often leads to long-term health consequences such as
CV disease and LVH - Values based on age, height, and gender
Children age 1-13 yo
* Stage 1: BP persistently > or equal to 95th percentile for age, gender and height OR less than
95th percentile plus 12mm Hg (whichever is lower)
* Stage 2: BP > or = to 95th percentile plus 12mm Hg or 140/90 (whichever is lower)
* For adolescents 13 yo and older
* Stage 1: BP 130/80 to 139/89
*
* Stage 2: BP 140/90 or >
Hypertension (Management)
- Management:
- Labs, lipid profile
- Stress management
- Education, diet, exercise, low sodium diet/low fat diet
- In some, antihypertensives/diuretic therapy
Kawasaki Disease
An acute systemic vasculitis
* Most common 6mos – 5 years of age
* Leading cause of acquired heart disease
* Winter and summer mos most common
- Self–limited syndrome
- Can cause cardiovascular complications:
coronary artery aneurysm, cardiomyopathy
Kawasaki Disease, cont. (Therapeutic Management)
- Focused on decreasing inflammation in walls of coronary arteries
- Preventing coronary thrombosis
- Preventing myocardial ischemia
- High dose ASA and IVIG
Kawasaki Disease, cont. (Pathophysiology)
- etiology UK? Infectious process
- autoimmune response – leading to
vasculitis - Systemic vasculitis t/o body
- May lead to coronary dilation or aneurysm
Kawasaki Disease, cont. (Health hx)
High FEVER 39.9C of AT LEAST 5 days duration
* Chills
* HA
* Malaise
* Irritability
* Vomiting/diarrhea
* Abdominal pain
* Joint pain
Kawasaki Disease, cont. (Physical Exam)
- SIGNIFICANT bilateral conjunctivitis without exudate
- Dry fissured lips
- Strawberry tongue (cracked and red)
- Pharyngeal and oral mucosa erythema
- Hyperdynamic precordium
- Diffuse, erythematous polymorphous rash
- Edema of hands and feet
- Erythema and painful induration of palms and soles
- Desquamation of perineal region, fingers and toes, extends to
palms and soles - Possible jaundice
- Possible cervical lymphadenopathy (unilateral)
- Liver enlargement possible
- Possible tachycardia, murmur, gallop
Criteria: at least four of five features: bilateral conjunctival injection, changes in the lips and oral cavity, cervical lymphadenopathy, extremity changes, and polymorphous rash AND fever for at least 5 days duration
Diagnostic:
* CBC elevated WBC (acute) / elevated platelet count (later)
* ESR and CRP elevated
* ECHO
Kawasaki Disease, cont. (Nursing Management)
- Meds: ASA and IVIG
- Monitor Cardiac Status: Strict I + O / serial ECHOs / S+S of developing heart failure – tachycardia, gallop, decreased UO, or resp
distress / assess pulses/cardiac monitoring / rapid identification of any arryhthmias - Promote Comfort: Fever management with Acetaminophen, cool cloths, cluster nursing care, Vaseline to lips, ice chips/popsicles /
positions of comfort esp if joint pain / irritability a key feature – comfort as possible - Education: course of illness, monitor illness even when discharged until afebrile for several days, irritability may last up to 2 mos –
- Educate on TOXIC effects of ASA therapy: HA, confusion, dizziness, or tinnitus
- No NSAIDS with ASA therapy
- Joint pain – ROM / warm baths
- No live vaccines for 11mos after IVIG
- Critical: f/u with cards long term
- CPR if severe cardiac involvement
