Cardiac Complications Flashcards
What are examples of acquired heart disease in ped pts?
- Pulmonary Artery Hypertension (discussed with CHD)
- Myocarditis/Endocarditis
- Cardiomyopathy
- Kawasaki Disease
- Rheumatic Fever/Rheumatic Heart Disease
Describe endocarditis and its risk factors.
- Infective process invading the endocardium - infection of inside of heart
- heart actually doesn’t have good blood supply - so IV abx need to be given for a LONG period of time
- Risk factors:
- CHD, artificial valves, central lines, piercings of nose/tongue, tattoos
How is endocarditis diagnosed and treated?
- Diagnosed by signs and symptoms of an infection or flu – usually already cardiac pts
- Long term antibiotics (cillins, mycins) will be required for bacterial endocarditis. (6 weeks, usually)
- May need valve replacement.
- Must maintain good dental health
- Prophylaxis before surgery and dental visits (No longer done in adults, still done in kids)
What is myocarditis?
- Infective process invading the myocardium after a systemic infection in a normal child
- Main symptom is failure to bounce back after a viral infection
- recover from myocarditis, but then cardiomyopathy is what we see (come in)
What is the ⅓ rule for myocarditis?
There is a 1/3 1/3 1/3 rule for these children
- 1/3 will have a mild case, recover and be fine
- 1/3 will get sick, require extensive support but recover
- 1/3 will get gravely ill with significant medical support up to and including a transplant
Describe cardiomyopathy.
CHAMBERS BECOME ENLARGED - difficult for heart to pump blood
- Many causes (including post myocarditis, congenital heart disease (CHD), HTN, many idiopathic (unknown cause)
- 3 types: Restrictive, Dilated, Hypertrophic
- We see DILATED myocarditis the most
- Monitor patient and treat depending upon severity of symptoms
- Treated similarly to adults
What is Congestive Heart Failure in kids?
“CHF and Shock are similar in they both are conditions of cardiac output that is inadequate to meet the metabolic demands of the body.”
- A condition in which the heart cannot pump enough oxygenated blood to meet the needs of the body’s other organs.
- A clinical syndrome in which the heart is unable to pump enough blood to dispose of venous return adequately
- A combination of the two
What are the causes of CHF?
- CHD (#1 in infant CHF)
- Myocardia Dysfunction
- Decreased contractility
- Infection of the myocardium or valves
- Arrhythmias
- Cardiomyopathy
- Anemia
- High cardiac output demands (i.e. septic shock)
- Chronic lung disease
- Hypertension
- Diabetes
- Overload
- Volume overload
- Pressure overload
- Volume overload
- Combination of the above factors
What are the symptoms of CHF? (same as adult CHF)
- Impaired myocardial function
- Tachycardia, gallop, diaphoresis, decreased perfusion, cardiomegaly on CXR, fatigue, poor feeding
- Pulmonary congestion
- Tachypnea, cyanosis, respiratory distress, pulmonary edema on CXR, orthopnea, wheezing, cough
- Systemic venous congestion
- Hepatomegaly, edema, weight gain, ascites, pleural effusion
What are the symptoms of LS HF?
- Pulmonary venous engorgement
- Tachypnea
- Grunting
- FTT (poor feeding for infants)
- Orthopnea in older child
- Wheezing/rales
What are the symptoms of RS HF?
- Systemic venous engorgement Hepatomegaly
- Splenomegaly
- Pitting edema
- Periorbital edema or distended neck veins (not visible in infants…their necks are not visible!)
What are the S/S in Infants with CHF?
- Poor feeding of recent onset
- Tachypnea that worsens during feeding
- Vomiting with feeds
- Poor weight gain
- Cold sweat on the forehead
What are S/S in Older Children with CHF?
- Shortness of breath, especially with activities
- Easy fatigability
- Puffy eyelids
- Swollen feet
What are the goals of CHF management and nursing considerations: Same as an Adult!
- Improve cardiac function
- Medications: digoxin, afterload reduction, IV inotropes
- Diuresis/ fluid restriction
- Lasix; strict I&O, monitor electrolytes closely
- Fluid and sodium restriction (usually in older children)
- Decrease metabolic O2 demands
- Conservation of energy (clustered care)
- N/G feeds (PO requires energy and may be difficult with tachypnea)
- Normothermia
- Improve tissue oxygenation
- Possibly administer O2
- Reduce work of breathing, proper positioning
What is Kawasaki Disease?
Also Mucocutaneous lymph node syndrome
A type of disease that primarily affects young children and is believed to be caused by a non-contagious infection. Symptoms include:
- pink eye
- oral mucosal change
- enlarged lymph nodes
- patchy rash
- peeling skin
How is Kawasaki Disease diagnosed?
CDC CRITERIA FOR DIAGNOSIS OF KAWASAKI DISEASE
Fever >5 days and at least four of the five following physical findings with no other more reasonable explanation for the observed clinical findings:
1. Bilateral conjunctival injection
2. Oral mucosal changes (erythema of lips or oropharynx, strawberry tongue, or drying or fissuring of the lips)
3. Peripheral extremity changes (edema, erythema, or generalized or periungual desquamation) **usually painful
4. Rash
5. Cervical lymphadenopathy >1.5 cm in diameter
Describe the timeline for Kawasaki Disease.
Acute (1st 10 days with high fever)
Sub Acute (after 10 days)
–Symptoms appear
Convalescent (begins 6-8 weeks after onset)
–this time span may be more rapid with IVIG dosing–Symptoms start to disappear–Aneurysms developMay have persistent arthritis
What are the clinical manifestations of Kawasaki?
- Typical child - Children < 5 yr (77%)
- Most common in Asian heritage
- Sudden onset of high fever
- Non-infective Conjunctivitis
- Non-purulent
- Bilateral
- Changes in lips and oral cavity
- Reddening and fissuring of lips
- Erythema of the buccal mucosa
- Strawberry tongue
- Polymorphous exanthem
- Morbilliform, scarlatiniform or erythema multiforme
- Evanescent in some patients
- Begins in diaper area and spreads to torso and extremities
What are the clinical manifestations of Kawasaki in the acute phase of the disease progression? (1st 1-2 weeks)
- Erythema and edema of hands and feet
- Swelling of proximal interphalangeal joints of the hands
- Constant pain and discomfort
- Refusal to move hands or bear weight
What are the clinical manifestations of Kawasaki in the subacute phase?
- Desquamation
- Starts in the subungual regions
- Spreads to palms, soles & Diaper area
- Gangrene of fingers and toes
- Occurs rarely in very young infants of non-Asian background.
What are the manifestations of Kawasaki Disease in the convalescent phase (several months to years)?
resolution of symptoms
labs normalizing
possible (not always) resolution of aneurysms
What are the possible complications of Kawasaki disease?
Aneurysms usually first noted 12-28 days after onset of the disease. Rarely appear > 28 days after onset.
Aneurysms may thrombose leading to myocardial infarction and death
Aneurysms may rupture (rarely)
A pancarditis is often present in the first 10 days of the illness (Simultaneous inflammation of the heart muscle and of the endocardium and pericardium). Pericardial effusions may accompany this.
Describe the nursing care for Kawasaki disease?
- Bedrest for until afebrile for > 72 hours and pain diminished
- Become familiar with IVIG administration
- Restrict activity even when mobile
- Provide oral care
- Provide analgesia
- Educate family of importance of follow-up
How is Kawasaki managed?
- Anti-inflammatory agent
- (ASA 80-100mg/kg/day to wean after 2 weeks but keep taking
for up to 8 weeks)
- (ASA 80-100mg/kg/day to wean after 2 weeks but keep taking
- IVIG
- If given within acute phase reduces fever and prevents
aneurysms (80-90% of time) - 1-2 gms/kg in onetime dose over 12 hours
- infusion rate
- NO live virus vaccines for 11 months after IVIG
- Follow-up cardiac catheterizations/ echocardiograms to evaluate/rule out coronary artery aneurysms
- First ECHO usually done day after admit
- If given within acute phase reduces fever and prevents
What to watch for in complications of Kawasaki Disease?
Aspirin toxicity
Immunosuppression
Describe rheumatic fever.
- Cause: Auto-immune reaction to Group A beta-hemolytic streptococcal (pharyngitis)
- Prevention: throat cultures, prompt/total treatment for strep throat
- Strep migrates to myocardium (valves), joints, skin, CNS several weeks later
- As many as 39% of pts with RF will develop Rheumatic Heart Disease
What are the presenting symptoms of rheumatic fever?
- small, painless nodules under the skin
- rash - erythema marginatum
- chest pain
- rapid fluttering or pounding chest palpitations
- tic
- lethargy or fatigue
- nosebleeds
- stomach pain
- painful or sore joints in the wrists, elbows, knees, and ankles
- pain in one joint that moves to another joint
What is rheumatic heart disease?
Mitral Valve affected most often (followed by Aortic Valve)
Poor valve function may produce CHF
Usually resolves but in 10-40% of patients, permanent valve damage develops
What diagnostic testing is available for rheumatic fever/rheumatic heart disease?
EKG (16 Lead, Left side AND Right side)
ECHO
Cardiac Catheterization
Labs to know
CBC – H/H, differential
C-Reactive Protein (CRP)
Erythrocyte Sedimentation Rate (ESR)
Anti-streptolysin-O antibody titer (ASO/ASLO)
Describe embryonic heart development.
Describe ductus arteriosus, ductus venosus, foramen ovale and why they’re important.
Compare prenatal and postnatal blood flow.
Describe Congenital Heart Disease: defn and etiology/
Definition: a group of cardiovascular malformations that results from abnormal structural development of the heart and/or a persistence of fetal vessels
Etiology: >80% of the etiology is unknown
multifactorial etiology
Incidence: 8-10 per 1000 live births
Now have >1,400,000 adults in US with CHD
kids w/ down - 30% have CHD
Risk factors for CHD - gestational and natal hx
- Infection (maternal rubella, CMV, herpes virus, coxsackievirus B)
- Medications (amphetamines, phenytoin, trimethadione, lithium, thalidomide)
- Maternal conditions (diabetes, maternal lupus erythematous, mother has CHD, maternal age >40 years
- Birth Weight
- Excessive smoking
- Alcohol consumption
Family Hx risk factors for CHD
Hereditary disease
CHD
Rheumatic fever
Sudden unexpected death
Diabetes mellitus, arteriosclerotic heart disease, hypertension
Long QT syndrome
Marfan’s syndrome
Infant s/s of CHD
Feeding problems (Failure to Thrive)
Dysphagia
Dyspnea
Cyanosis
Exercise intolerance
What would you assess for on physical exam for CHD?
Growth failure
Color (ie. Pale, dusky, or cyanosis)
Diaphoretic
Tachypnea
Tachycardia
Hepatomegaly
What is the genetic pattern in CHD?
- About 15% of CHD’s related to genetics
- Increase chance of CHD if the following
- sibling(s) with a heart defect
- parent(s) with CHD
- a chromosomal aberration, eg, Down’s syndrome
- Another non-cardiac congenital anomaly
What are associated defects and chromosomal abnormalities with CHD?
- Associated Defects
- tracheoesophageal fistulas
- renal agenesis
- diaphragmatic hernias
- Chromosomal Abnormalities
- Down Syndrome
- Turner Syndrome
Give an overview of types of shock, causes and tx.
