cardiac defects peds Flashcards
Structural and Functional Differences
Infants and children < 7 years of age
lies more horizontally
Between ages 1 and 6 years
4x birth size (size of fist)
Between 6 and 12 years of age,
10x birth size
However, the heart is smaller proportionally at this time than at any other stage in life.
During the school-age years
grows more vertically within the thoracic cavity
During adolescence
continues to grow in relation to the teen’s rapid growth
Cardiac output
Amt of blood ejected by heart in 1 min
Determined by multiplying the HR in 1 min by stroke volume
Stroke volume
The amt of blood ejected by the heart with each heartbeat (or contraction)
Affected by 3 factors
Preload
Stretch of myocardial fibers
Circulating blood volume
Afterload
Resistance against which the ventricles pump during contraction
Affected by BP (increases as BP increases, heart pumps harder)
Contractility
Force of left ventricle ejection
Pediatric Indicators of Cardiac Dysfunction
Poor feeding/fatigue with feeding
Tachypnea/tachycardia
Failure to thrive
poor weight gain
activity intolerance
Frequent respiratory tract infections
Developmental delays
Prenatal history
Family history of cardiac disease
Diagnostic Cardiac Catheterization
(cath is on sat)
Provides important information about:
Oxygen saturation of blood within the chambers and great vessels
Pressure changes
Changes in cardiac output or stroke volume
Anatomic abnormalities
Interventional Cardiac Catheterization Procedures
ASD/VSD
Transposition of great vessels
Some complex single-ventricle defects
Pulmonary artery stenosis
Balloon dilatation
Valvular pulmonic stenosis
Recurrent coarctation of aorta
Congenital mitral stenosis
Nursing Considerations with Cardiac Cath - Pre-procedure - what about extremities?
Pre-procedure
Describe room and equipment
Explain that the contrast might make him feel warm
Assess color, temp, pulses of extremity distal to procedure site
Nursing Considerations with Cardiac Cath - post procedure - how long to keep extremity immobile?
Keep extremity immobilized for 4-6 hrs post
Keep site clean
Monitor for bleeding and hematoma at site
Compare pre and post assessment of extremity
Ensure fluid intake
Medicate as needed
Causes of CHD (congenital heart disease)
Maternal or environmental = 1% to 2%
Maternal drug use
Fetal alcohol syndrome—50% have CHD
Maternal illness
Rubella in first 7 weeks of pregnancy → 50% risk of defects including PDA and pulmonary branch stenosis
CMV, toxoplasmosis, other viral illnesses → cardiac defects
IDMs = 10% risk of CHD (VSD, cardiomyopathy, TGA most common)
CHF in Children - Impaired myocardial function
(my tachycardia)
Tachycardia; fatigue; weakness; restlessness; pale, cool extremities; decreased BP; decreased urine output
CHF in Children - Pulmonary congestion - symptoms - think pulmonary
(pull my cyanosis)
Tachypnea, dyspnea, respiratory distress, exercise intolerance, cyanosis
CHF in Children - Systemic venous congestion
(my veins have edema)
Peripheral and periorbital edema, weight gain, ascites, hepatomegaly, neck vein distention
Chest tube - when to use? - think of your patient
After open heart surgery, pneumothorax
chest tube - problems
If tube becomes dislodged from container, the chest tube must be clamped immediately to avoid further air entry into the chest cavity. Alternatively, the end may be immediately placed into a container of sterile water or saline to create a water seal.
Pacing- when to do?
Bradyarrhythmias, heart block, cardiomyopathy, sinoatrial or atrioventricular node malfunction
pacing - problems - can they play sports?
Provide close observation of the child, pacing unit, and ECG.
Maintain asepsis at pacing lead insertion site.
Explain to child and family that the permanent pacemaker may be felt under the skin.
Advise against participation in contact sports
Digoxin (cardiac glycoside, antiarrhythmic agent) - action - does it speed up or slow down HR?
Slows heart rate
Increases contractility of the heart muscle by decreasing conduction and increasing force
Used for heart failure, atrial fibrillation, atrial flutter, supraventricular tachycardia
digoxin - what apical pulse to hold for infants and adolscent?
Prior to administering each dose, count apical pulse for 1 full minute, noting rate, rhythm, and quality. Withhold if apical pulse is <60 in an adolescent, <90 in an infant.
Avoid giving oral form with meals, as altered absorption may occur.
Monitor serum digoxin levels (therapeutic range: 0.8–2 ng/mL).
Notes signs of toxicity: nausea, vomiting, diarrhea, lethargy, and bradycardia.
Ginseng, hawthorn, and licorice intake increases risk for drug toxicity.
Note contraindications (ventricular fibrillation and hypersensitivity to digitalis).
Avoid rapid IV administration, as this may lead to systemic and coronary artery vasoconstriction.
Digoxin and Heart Rate Parameters - numbers for infants and school age
(dig for 100)
Infant
100 beats/minute
Preschool/School-age
70 beats/minute
Adolescent
60 beats/minute
Angiotensin-converting enzyme (ACE) inhibitors - action
(Ace is after the fact)
Competitive inhibition of ACE for management of hypertension
Heart failure management in conjunction with digitalis and diuretics
Reduces afterload
Angiotensin-converting enzyme (ACE) inhibitors (captopril, enalapril) - - implications
Monitor BP, renal function, WBC count, and serum potassium.
Discontinue if angioedema occurs.
Captopril: administer orally on empty stomach 1 hour before or 2 hours after meals.
Enalapril: may administer orally without regard to food.
Calcium Channel Blockers - actions
Decrease the excitability of heart muscle
treats certain types of abnormally rapid heart rhythms
Reduce pressure in arteries
dilates the arteries
makes it easier for the heart to pump blood
result, the heart needs less oxygen
calcium channel blockers - implications
Short and long acting forms
Can cause swelling in extremities
β-Adrenergic blockers - actions
(just B cool)
Competitively block response to β-adrenergic stimulation, decreasing heart rate and force of contraction
Used for management of hypertension, arrhythmias, and prevention of myocardial infarction
β-Adrenergic blockers (propranolol, atenolol, sotalol) - implications
Monitor ECG and BP.
Propranolol: administer with food.
Atenolol, sotalol: administer without regard to food. Do not stop drug abruptly.
May result in bradycardia, dizziness, nausea and vomiting, dyspnea, and hypoglycemia (propranolol).
Contraindications: heart block, uncompensated heart failure, cardiogenic shock, asthma, or hypersensitivity.
Vasodilator (Hydralazine) - action - just for HTN
(realize it dilates)
Direct vasodilation of arterioles to manage moderate to severe hypertension, heart failure
Vasodilator (Hydralazine) - implications
Monitor heart rate and BP.
Closely monitor BP with IV use.
Administer oral dose with food.
May cause palpitations, flushing, tachycardia, dizziness, nausea, and vomiting.
Notify physician or nurse practitioner if flu-like symptoms occur.
Contraindicated in rheumatic valvular disease.
Nursing : Assess for fluid overload - right and left side
Nursing : Assess for fluid overload
Left sided failure has pulmonary clinical manifestations
Right sided failure has systemic clinical manifestations….central body edema
Abdominal girth measurement
Furosemide (loop diuretic) - action - think 1st semester
Inhibits resorption of sodium and chloride
Used to manage edema associated with heart failure, and hypertension in combination with antihypertensives
Furosemide (loop diuretic)- implications
Administer with food or milk to decrease GI upset.
Monitor BP, renal function, electrolytes (particularly potassium), and hearing.
May cause photosensitivity.
Spironolactone (potassium sparing diuretic)- implications - what about the kidneys?
Administer with food.
Monitor serum potassium, sodium, and renal function.
May cause drowsiness, headache, and arrhythmia.
May cause false elevations in digitalis level.
Teach children to avoid high-potassium diets, salt substitutes, and natural licorice.
Contraindicated in hyperkalemia, renal failure, and anuria.
Alprostadil (prostaglandin) - actions
(prosty dilates)
Direct vasodilation of the ductus arteriosus smooth muscle
Indicated for temporary maintenance of ductus arteriosus patency in infants with ductal-dependent congenital heart defects
Alprostadil (prostaglandin) - implications - contraindicated in who?
Apnea occurs in 10–20% of neonates within first hour of infusion.
Monitor arterial BP, respiratory rate, heart rate, ECG, temperature, and pO2; watch for abdominal distention.
Fresh IV solution required every 24 hours.
Reposition catheter if facial or arm flushing occurs.
Use with caution in neonate with bleeding tendency.
Contraindicated in respiratory distress syndrome or persistent fetal circulation.
Indomethacin (nonsteroidal anti-inflammatory agent) - actions
(indo my ducto)
Inhibits prostaglandin synthesis in order to close patent ductus arteriosus
Indomethacin (nonsteroidal anti-inflammatory agent) - implications -
(endo my edema)
Monitor heart rate, BP, ECG, and urine output; monitor for murmur.
Monitor serum sodium, glucose, platelet count, BUN, creatinine, potassium, and liver enzymes.
May mask signs of infection.
Note development of edema.
Heparin (anticoagulant) - action
Interferes with conversion of prothrombin to thrombin, preventing clot formation
Indicated for the prophylaxis and treatment of thromboembolic disorders, especially after cardiac surgery
Heparin (anticoagulant) - implications - where to administer? and what is the antidote?
Administer SQ, not IM.
Dose is adjusted according to coagulation test results.
Monitor for signs of bleeding, platelet counts.
Ensure that the antidote, protamine sulfate, is available.
Do not administer with uncontrolled bleeding or if subacute bacterial endocarditis is suspected.
Hypoxemia - what causes it?
(hypo mixing)
Low oxygen saturation of Hemoglobin
May be due to
“mixing of blood” in the cardiac chambers
OR
Desaturated blood returning to systemic circulation (Pulmonary edema)
Congenital Heart Disease (CHD) - Hemodynamic characteristics
Hemodynamic characteristics
Increased pulmonary blood flow
Decreased pulmonary blood flow
Obstruction of blood flow from the heart
Mixed blood flow
INCREASED PULMONARY BLOOD FLOW DEFECTS
Atrial septal defect
Ventricular septal defect
Patent ductus arteriosus
Atrioventricular Canal
Increased Pulmonary Blood Flow Defects
Abnormal connection between two sides of heart
Either the septum or the great vessels
Increased blood volume on right side of heart
Increased pulmonary blood flow
Decreased systemic blood flow
thrills
The sound of a thrill is a soft vibration over the heart that reflects the transmitted sound of a heart murmur
ASD
If small, the defect may be sutured closed. Larger defects may require a patch of pericardium or synthetic material.
Ostium secundum ASD may be repaired percutaneously via cardiac catheterization with a septal occluder.
ASD - monitor for
(as arrhythmias come)
atrial arrhythmias (lifelong) after surgical closure.
With the septal occluders, strenuous activity should be avoided for 2 weeks after the procedure
VSD
(murmur into my ventricular)
Left-to-right shunt
Murmur
Return of oxygenated blood to lungs
Pulmonary Edema
Dyspnea, Tachypnea, Hypoxia = fatigue
Congestive Heart Failure = fatigue
VSD - If surgical closure is required
(you can just sew up the vent)
it should be performed before permanent pulmonary vascular changes develop.
Surgical closure may be in the form of suture closure of the VSD, transcatheter placement of a device in the defect, or Dacron patch closure.
VSD - monitor for
(V for ventriular)
ventricular dysrhythmias or AV block.
With the clamshell occluding or Amplatzer device, strenuous activity should be avoided for 1 month after the procedure
AV Canal Defect
Pulmonary artery banding as palliation in very young infants.
Surgical correction by 3–18 months of age
Patch closure of the septal defects and suturing of the valve leaflets or valve reconstruction are performed.
AV Canal Defect
(Ava regurgitates)
Monitor for complete heart block postoperatively.
Teach parents that mitral regurgitation is a long-term complication and may require valve replacement
PDA - which way is shunt?
(PDA is NOT right)
Left-to-right shunt
Murmur
Return of oxygenated blood to lungs
Pulmonary Edema
Dyspnea, Tachypnea, Hypoxia = fatigue
Congestive Heart Failure = fatigue
PDA - medical treatment
with Indomethacillin (prostaglandin inhibitor)
Helps close PDA
Insertion of stents to occlude the duct
PDA is closed by coil embolization or device via cardiac catheterization.
May also be surgically ligated.
PDA - monitor for
(pda choke)
bleeding and laryngeal nerve damage
OBSTRUCTIVE DEFECTS - just stenosis
Coarctation of the aorta (narrowing of aorta)
Aortic stenosis
Pulmonic stenosis
Coarc - what hurts in kids?
(the arc of my brain)
Increased pressure proximal to defect
Hypertension, bounding pulses in upper extremities and head
Decreased pressure distal (body and lower extremities)
Congestive Heart Failure
Decreased profusion to lower extremities
Coarc - easy way to test for it?
(four arcs)
Diagnostic procedure : 4 limb blood pressure
Exercise intolerance in children
Balloon angioplasty via cardiac catheterization is possible in some children.
Most common surgical repair is resection of the narrowed portion of the aorta, followed by end-to-end reanastomosis
Coarc - what drug to give? (think relax)
Preoperatively, administer prostaglandin medications as ordered to relax the ductal tissue.
Postoperatively, measure and compare BP in all four extremities and quality of upper vs. lower pulses.
AS - aortic stenosis - what side has hypertrophy?
(As has left)
Narrowing or stricture of the Aortic Valve
Decreased flow from left ventricle
Murmur
Left ventricle hypertrophy
Exercise intolerance/ fainting
AS - where is balloon dilation done on the body?
Strenuous activity may be restricted
Surgical replacement of valve
Balloon dilation is accomplished via the umbilical artery in the newborn or the femoral artery via cardiac catheterization in the older child.
Aortic stenosis
(As I regurgitate)
Provide routine postcatheterization care.
Teach parents that long-term aortic regurgitation requiring valve replacement may occur.
pulmonic stenosis - what procedure? (balloon the stenosis)
Balloon dilation valvuloplasty is performed via cardiac catheterization to dilate the valve. This is effective in all but the most severe of cases, which will require surgical valvotomy.
DECREASED PULMONARY BLOOD FLOW DEFECTS - just 2 types -
decrease my patient
(T to the P)
Tetralogy of Fallot
Tricuspid atresia
TET - what direction of shunting?
(TET the opposite)
Decreased blood flow to the lungs
Mixing of saturated and desaturated blood in systemic circulation
Murmur both VSD and pulmonary stenosis
“Right to Left Shunt” as the pulmonary stenosis worsens
Knee-Chest Position - what about the veins?
Calms the infant
Reduces systemic venous return
Increases systemic vascular resistance
Tet
Increasing periods of cyanosis
Hypercyanotic spells/”tet spells”
Congestive Heart Failure
Fatigue
Palliative surgical intervention :
anastomosis of Subclavian Artery to Pulmonary Artery (Blalock-Taussig Shunt)
Tet
Complete repair requires open heart and cardiopulmonary bypass
Palliation with systemic-to-pulmonary anastomoses:
Blalock–Taussig shunt: an end-to-side anastomosis (or connection with a small Gore-Tex tube) of the subclavian artery and the pulmonary artery.
Waterston shunt: anastomosis of the ascending aorta and the pulmonary artery.
Definitive correction involves patch closure of the ventricular septal defect and repair of the pulmonary valve and right ventricular outflow tract.
TET - what procedure?
(tet is taus)
Avoid BP measurements and venipunctures in the affected arm after a Blalock–Taussig shunt.
Pulse will not be palpable in that arm because of use of the subclavian artery for the shunt.
Monitor for ventricular arrhythmias after corrective repair.
Tricuspid Atresia
Palliation with Blalock–Taussig shunt or pulmonary artery banding may be performed.
At 3–6 months of age, the superior vena cava is detached from the heart and connected to the pulmonary artery (Glenn procedure).
By age 2–5 years, a modified Fontan procedure may be performed. Systemic venous return is redirected to the pulmonary artery directly.
Tricuspid Atresia
Monitor for atrial arrhythmias, left ventricular dysfunction, and protein-losing enteropathy.
Some children may eventually require a pacemaker.
MIXED DEFECTS
Transposition of great vessels
Total anomalous pulmonary venous connection
Hypoplastic heart syndrome
Right
Left
Transposition - what do you want to keep open?
(transport the PDA)
Cyanosis at birth
Defects such as PDA and VSD may delay such cyanosis
Prostaglandin E
Keeps ductus arteriosus open to temporarily increase blood mixing
O2 sats 75%
Surgical repair= arterial switch
Transposition
Balloon atrial septotomy is usually done as soon as the diagnosis is made. A balloon-tipped catheter is passed through the atrial septum to enlarge the atrial septum.
Surgical correction involves switching the arteries into their normal anatomic positions
Transposition
Administer prostaglandin to maintain the open state of the ductus arteriosus, which will allow the mixing of poorly oxygenated blood with well-oxygenated blood.
Monitor for rapid respirations and cyanosis.
Administer oxygen as needed preoperatively.
TAPV
The pulmonary vein is repositioned to the back of the left atrium and the ASD is closed.
TAPV - monitor for what type of heart rhythms?
dysrhythmias, heart block, and persistent heart failure.
Hypoplastic left heart syndrome
(plastic transplant)
Heart transplantation is the treatment of choice.
Palliative staged treatment. First: Norwood procedure, reconstruction of the aorta and pulmonary arteries includes a cardiac transplant. Second: bidirectional Glenn procedure, connection of the superior vena cava to the right pulmonary artery to increase the blood flow to the lungs. Third: modified Fontan procedure
Hypoplastic left heart syndrome
Preoperatively, administer prostaglandin infusion to prevent closing of the ductus arteriosus.
After palliative repairs, monitor for dysrhythmias or worsening ventricular function.
Postoperative Care for the Child
Monitor vital signs and arterial/venous pressures
Intra-arterial monitoring of BP
Intra-cardiac monitoring
Respiratory needs
Rest, comfort, and pain management
Fluid management
Daily weights
Progression of activity
Monitor Fluid Status - how much urine an hour?
Urine output < 1 ml/kg/hr = possible renal failure
Concern r/t decreased cardiac output
Caring for the Child With a Congenital Heart Disease
Give medications, if ordered, exactly as prescribed.
Weigh the child at least once a week or as ordered, at approximately the same time of the day with the same scale and wearing the same amount of clothing.
Allow the child to engage in activity as directed. Provide time for the child to rest frequently throughout the day to prevent overexertion.
Provide a nutritious diet, taking into account any restrictions for fluids or foods.
Use measures to prevent infection, such as frequent hand washing, prophylactic antibiotics, and skin care.
Adhere to schedule for follow-up diagnostic tests and procedures.
Support the child’s growth and development needs.
Use available community support services.
When to notify physician or nurse practitioner
increasing episodes of respiratory distress cyanosis, or difficulty breathing
fever
increased edema of the hands, feet, or face
decreased urinary output
weight loss or difficulty eating or drinking
increased fatigue or irritability
decreased level of alertness
vomiting or diarrhea
lowest pressure in heart
right side
how often to check for bleeding after catheterization?
at least every hour
what med to keep ductus arteriosis open
prostaglandin
most shunts are
left to right - high pressure to low (check this)
quiz s/sx
right and left shunts and why they’re mixing. s/sx of cardiac events - severe weight loss, poor feeding, why do we have chest tubes,
right to left shunt - what happens?
just overcirculation
know 4 symptoms of
tetollagy of a fall
left to right shunt is
over circulation to the lungs
for resume
how many hours of clinicals
cyanotic is what type of shunt?
right to left
cyanotic heart defects start with a
(T is cyanotic)
T
truncous artereousis
(1 trunk in a car)
1 great vessel leaves the heart instead of 2
truncous artereousis - what happens
the pulmonary artery and aorta don’t seperate, so there is a hole. makes one tube.
tranposition - how many fingers?
2 fingers crossed
tricuspid atresia - how many fingers?
3
tricuspid atresia -
tricuspid valve fails to form. hole between right atrium and left atrium.
tricuspid - right or left?
right
tetrology of fallot - how many fingers?
4
tetrology of fallot - what 4 defects?
(SHOV the tet)
pulmonary stenosis, right ventricular hypertrophy, overriding aorta, ventricular septal defect
Total anomalous pulmonary venous return (TAPV) - how many fingers?
5- 5 words make up the defect
Total anomalous pulmonary venous return - TAPV
(the anomalous systemic veins)
pulmonary veins connect to systemic system rather than the left atrium
truncous artereousis - how many fingers?
(one trunk in a car)
1 finger
ACE - drug examples
(Ace ventura is a pil)
captopril, enalapril
b-adrenergic blockers - examples
(adriene on propanolol)
propranolol, atenolol, sotalol
layers of heart - outside to inside
(end at the end)
epi my endo
calcium channel blockers - examples
(Velma thinks calcium is nifty)
(Norvasc, Verapamil, Nifedipine)
