Cardiac Dysfunction Flashcards
Atresia
absent or closure of something
Stenosis
narrowing
What is the blood flow through the body
Superior/Inferior Vena Cava
Right atrium
Tricuspid
R Ventricle
Pulmonary Valve
Pulmonary Artery (only artery with deoxygenated blood)
Lungs
Pulmonary Vein (only veins with oxygenated blood)
L Atrium
Mitral Valve
L Ventricle
Aortic Valve
Aorta
Body
What are the changes in the heart after birth?
The foramen ovale shunt in r atrium is closed
Patent ductus arteriosus closes and becomes ligamentum arteriosus
What is different between the fetal circulation than adult circulation?
fetal closes off the lungs and shunts all blood away from the lungs to the body
What is the normal cardiac anatomy?
4 chambers
superior and inferior vena cava with aorta
Tricuspid, Pulmonary, Mitral, and Aorta values
Left is systemic ha higher pressure in the normal heart due to shunting blood to the entire body
Right is pulmonary pressure is less than the systemic
Cardiac Pressures
highest (left, systemic) to lowest (right, pulmonary)
If there is no flow of blood, then
no grow due to no O2 and nutrients getting to the body
Congenital Heart Disease
abnormalities present at birth
Acquired Heart Disease
after birth
- infection
-autoimmune
- environmental
- family tendencies
Congenital Heart Disease results in
abnormal cardiac function
- major cause of death in 1st year of life
What is the most common defect of congenital heart defects?
Ventricular Septal Defect (VSD
Congenital Heart Disease Causes
90% unknown
Maternal (fetal alcohol syndrome, Dilantin (seizure meds), advance maternal age, DM, Lupus, Rubella)
Chromosome abnormality (Down Syndrome)
Congenital Heart Disease Physical Assessment?
FFT
Cyanotic or pallor (poor perfusion)
Chest enlarged
Jugular pulses distension (unusual pulsations)
Tachypnea, dyspnea, grunting
Clubbing
Palpate liver on right side failure
Murmur
If you can plapate the liver on assessment with s/s, then what heart failure would it be?
Right sided
If suspecting congenital heart disease, what dx procedures would they run?
12 LEAD ECG
XRay - cardiomegaly/pulmonary congestion
ECHO- 1-hour
MRI
Cardiac Cath
Cardiomegaly is when the heart size is
half the size of the chest
ECHO shows what
structures and blood flow patterns
baby or developmental delays need to be still
- possible PICU for sedation
Cardiac Catheterization can be used for
Diagnostic
- measure pressure and see blood flow patterns
- before surgery to see
Interventional
- Balloon procedures for narrowed valves and stents
Electrophysiology
- irregular rhythm
Altered Hemodynamics in Congential Heart Disease
Higher pressure to lower pressure
- path of least resistance
In Congenital Heart Disease,
higher pressure
faster flow
In Congenital Heart Disease,
higher resistance
slower flow
Left to Right Shunt means
blood flows from area of higher pressure to lower pressure
Left to Right shunt is located
allows blood from left ventricle into the right ventricle
Right to Left Shunt
blood shunted from the right side to the left
Congenital Heart Defects
Left to Right Shunt
Right to Left Shunt
Right to Left Shunt location
right ventricle to left ventricle with deoxygenated blood into the rest of the body
Right to Left Shunt can cause what
Pulmonary stenosis for right-sided increase
- Cyanosis starts at the mouth due to deoxygenated blood into the body
Congenital Heart Defects
blood flow patterns
Increased pulmonary blood flow
Decreased pulmonary blood flow
Obstruction to blood flow out of the heart
Mixed blood flow
Congenital Heart Defects with Increased pulmonary blood flow
Atrial septal defect (ASD)
Ventricular septal defect (VSD)
Patent Ductus Arteriosus (PDA)
Increased pulmonary blood flow occurs when a
Defects along the septum or abnormal connection between great arteries
- Left-to-right shunting of blood
- Increased blood volume on the Right side of the Heart
- Increased Pulmonary Blood Flow
Atrial Septal Defect is the
abnormal opening between atria in the septum (failure to close of the foramen ovale)
-allows blood flow from l. atrium to r.atrium
The ASD, pushes more
blood into the lungs
If the ASD is a small defect, then what are the s/s?
asymptomatic
- paradoxical embolus
If the ASD is a small defect, then what are the s/s?
CHF is unusually possible in older children if untx
-fatigue
-SOB
-respiratory infections
When listening to the heart what sounds to do hear and what are the meanings?
LUB - closing of the atrium to ventricles (Tricuspid and Mitral)
DUB - closing of the pulmonary and aortic valves
What heart sound is heard with ASD?
LUB DU-UB
- due to the pulmonary valve closing a little later than the aorta valve because of the massive inflow of more blood than the left atria
ASD Tx
Spontaneous closure (size and age)
Transcatheter Closure
- Septal occluders - smaller defects
Surgical Closure
- small defect-suture
- large (patch with pericardial or Dacron)
After a septal occluder is placed, what medication should the child be on
low-dose aspirin for 6 months
Atrial Septal Defect should be repaired before
school age (5)
Ventricular Septal Defect (VSD) IS THE
Abnormal Opening between Right & Left Ventricles
- BLOOD FLOWS FROM THE LEFT VENTRICLE TO THE RIGHT VENTRICLE
- pinhole to no septum
VSD Heart sounds when ausculated?
In the 3rd location at the r. ventricular spot you will hear
swoosh DUB(faint) swoosh
-polo systolic murmur
Small VSD s/s
asymptomatic
o2 levels good
no physical restrictions
reassurance and periodic follow-up with cardiologist
Large VSD s/s
CHF
VSD Tx
spontaneous closure (20-60%) - size and age
Transcatheter Closure with septal occluders
Small defects - sutures
Large defects - patch pericardial/Dacron
What is another procedure done on VSD as a possible palliative procedure?
Pulmonary Artery Banding
goal: decrease pulmonary blood flow
Patent Ductus Arteriosus (PDA) is the
Failure of the Fetal Ductus Arteriosus to close within first few weeks of life
PDA blood flow
higher(Aorta) to lower (Pulmonary artery)
Left to right shunt
PDA location is the
aortic arch into the pulmonary arteries
- oxygenated blood goes into the pulmonary artery into the lungs
PDA small defect s/s
asymptomatic
PDA large defect s/s
CHF
FTT
“Machine like murmur” - washing machine
frequent respiratory infections
PDA Tx medication closures
Indomethacin (Indocin)
Premature infants
Some newborns
How is the ductus arteriorous kept open in the womb?
prostaglandin
Indomethacin is what type of medication
prostaglandin inhibitor (ductus to close)
PDA Tx transcatheter
coils
PDA Tx Surgical
Left Thoracotomy Incision for Litigation
- clamp off blood flow through the ductus
- incision is under the shoulder blade
Congenital Heart Defects with DECREASED pulmonary blood flow
Tetralogy of Fallot
Tricuspid Atresia
If a mother has Rubella, what defect could the infant have as a result?
PDA
Decreased Pulmonary blood flow is caused by
obstruction of pulmonary blood flow + anatomic defect between side of the heart **ASD/VSD
With low pulmonary blood flow, the pressures do what
right side pressures increases and exceeds left-sided pressure
The increase of right sided pressure leads to
desat blood shunted right to left and to systemic circulation
Hypoxemia and cyanosis
Tetralogy of Fallot (TOF) has what 4 cardiac defects?
- VSD
- Pulmonary stenosis
- Overriding Aorta
- R. Ventricular Hypertrophy
TOF blood flows from
right to left
TOF s/s
chronic cyanosis
tachypnea - compensate
Acute epi. of cyanosis and hypoxia
Clubbing
Impaired growth
TOF - Hypercyanotic Spells preceded by
feeding, crying, defecation, or stressful procedures
Hypercyanotic spells
infundibular spasm decrease pulmonary blood flow
Increase Right to Left shunt
- desat blood flows to the systemic circulation
- acute cyanosis and hypoxia
Infundibular
funnel-shaped
What can cause a decrease of BP?
hypovolemia
**vasodilation (meds, heat,exercise, fever)
Hypercyanotic spells aka
blue or tet spells
Hypercyanotic spells are frequent in
1st year of life with TOF
- rare less than 2 months
Hypercyanotic spells happen usually in the
morning
Hypercyanotic speels in the morning require
immediate recognition and intervention
- increase risk of emboli, seizures, LOC, death
What nursing interventions would you use for a hypercyanotic spell? SATA
- Knee-Chest Position “Squatting”
- Calm
- Blow-by 100% O2
- Give Morphine and repeat
- IV Fluid replacement PRN
- Knee-Chest Position “Squatting”
- Calm
- Blow-by 100% O2
- Give Morphine and repeat
- IV Fluid replacement PRN
What does the knee-chest squat do for a baby in hyper cyanotic spells?
kinks the femoral arteries and puts more blood to travel to the pulmonary system and increases left-sided pressure
TOF Tx
educate family on recognition/intervention of hypercyanotic spells
-hydration (IVF)
prevent infections (fevers to HCP)
Anemia Tx (less O2 with RBCs)
If the TOF is severe, what tx will be required?
surgical correction WITHIN 1ST year of life
- palliative shunt
-complete repair
TOF is Dx by
ECHO
Obstructive Congenital Heart Defects
Coarctation of the Aorta
Aortic Stenosis
Pulmonic Stenosis
Obstructive Defects are when the blood
exits the heart and meets anatomic narrowing (stenosis)
- obstruction to blood flow
Obstructive Defects increase the pressure of
ventricles and vessel behind obstruction
Obstructive Defects decrease the pressure of
after the obstruction
Coarctation of the Aorta is the
Narrowing of the Aorta near the insertion of the Ductus Arteriosus
COA increases pressure
proximal to the defect (near defect)
- head and upper extremities
COA decreases pressure
distal to the obstruction (away)
- body and lower extremities
COA S/S
- Arms: elevated BP and bounding pulses
- LEGS: low BP, weak/absent femoral pulses and in lower extremities
CHF
COA Tx
Cath Lab through femoral
- Older infants and children: balloon angioplasty
- Adolescents: stents
Surgical Repair (< 6mn.)
What is the Tx of choice for an infant < 6 months with COA AND LONG-STEM STENOSIS/COMPLEX ANATOMY?
Surgical Repair
Surgical Repair of COA POST-OP
HTN is common
- antiHTN after and wean off as the body adjusts down
Why is a follow-up after the COA surgical repair important?
recoarctation
- narrow again in the future
- cardiologist for life
Aortic Stenosis is the
narrowing of the aortic valve
Aortic Stenosis can cause what
decrease cardiac output
left ventricular hypertrophy
pulmonary vascular congestion
Aortic Stenosis S/S in Newborns
low cardiac output
faint pulses
Hypotension
tachycardia
poor feedings
Aortic Stenosis S/S in Children
exercise intolerance (sudden death of children in sports)
dizzy
chest pain
A child will develop ________ in the 1st few days of Aortic Stenosis
Heart failure
If the child has mild Aortic Stenosis, they can
participate in most sports
If the child has moderate to severe Aortic Stenosis, they can
not do competitive sports
- no sustained strenuous activities
Aortic Stenosis Tx
Transcath - Balloon Valvuloplasty
Surgical = valvotomy or valve replacement
Pulmonic Stenosis
narrowing of the pulmonary valve
Pulmonic Stenosis can cause what
decreased pulmonary blood flow
- Right ventricular hypertrophy
Mild Pulmonary stenosis s/s
asymptomatic
mild cyanosis
Moderate - severe Pulmonary stenosis s/s
CHF
Cardiomegaly
Pulmonary stenosis Tx
Transcatheter (Balloon valvuloplasty
- works well with this valve
Rare - surgical
Valvotomy
Valve replacement
What are the Mixed Congenital Heart Defects?
Hypoplastic Left Heart Syndrome (HLHS)
Mixed Defects are complex heart anomalies in which survival after birth depends on
mixing of blood from pulmonary and systemic circulations within heart chambers
Hypoplastic Left Heart Syndrome (HLHS) is the
underdevelopment of the left side of the heart
HLHS has what being the heart is underdeveloped
Hypoplastic left ventricle
Aortic stenosis
Oxygenation of the body depends on what in HLHS
ASD (Atrial Septal Defect) or PFO (Patent Foramen Ovale
Systemic blood flow is dependent on what in HLHS?
PDA (Patent Ductus Arteriosus)
HLHS S/S
Mild cyanosis (Sat 75-80%)
Heart failure*
Lethargy
Cold hands and feet
Inotropic support means
increase contractibility
When the PDA closes in HLHS, the cyanosis
progresses an decreased cardiac output leads to cardiac collapse
HLHS Tx
Stabilize with vent and inotropic support
Prostaglandin infusion to keep PDA open
Staged Reconstruction (3 operations)
- 1st week, 3-6 mn. and 2-5 y/o
Heart Transplant
- immunosuppressant and risk of rejection
HLHS staged reconstruction does not
fix the issue but they can live with it
What are the complications of Congenital Heart Defects?
CHF
Hypoxemia (cyanosis)
CHF defined as
heart can not pump enough blood to meet the body’s demand for energy
CHD are the clinical consequences of CHD
Congestive HF
Hypoxemia and Cyanosis
CHF Causes
structural
- increase blood vol/pressure within the heart
Myocardial insufficiency/failure
- impaired contractibility/relax of ventricle
Excess demand
- sepsis, severe anemia
Right-sided Heart Failure defined as
Right Ventricle unable to pump blood effectively into the Pulmonary Artery
Right-sided Heart Failure increases pressure in
right atrium and systemic venous circulation
Right-sided Heart Failure causes what to the other tissues
Hepatosplenomegaly (blood pools in the liver)
Peripheral Edema
Left-Sided Failure
defined as
Left Ventricle unable to pump blood effectively into Systemic Circulation
Left-sided Heart Failure increases pressure in
Left Atrium and Pulmonary Veins
Left-sided Heart Failure causes what to the other tissues
elevated pulmonary pressures
pulmonary edema
In one sided heart failures, the blood is causing problems in
other area and pumps backward
Children get what type of heart failure
Both
CHF Dx
based on s/s - tachypnea and cardia
- low tolerance feeds
- poor growth
CXR
ECG
ECHO
Cardiac Cath
ECG shows what
heart working harder
ECHO shows
function and defects
Cardiac Cath shows
structural abnormality to cause the failure
CHF S/S
Difficulty feeding → Failure to Thrive (FTT)
Tachypnea/tachycardia at rest
Dyspnea
Retractions
Activity Intolerance
Weight Gain r/t fluid retention
Hepatomegaly
Peripheral edema – periorbital and face
CHF Goals
Improve Cardiac Function
Remove accumulated fluid & sodium
Decrease cardiac demands
Improve oxygenation/decrease oxygen consumption
Support Family
CHF Tx medication to Improve Cardiac Function
Digitalis Glycoside
- Digoxin (Lanoxin)
ACE inhibitors
- Captopril (Capoten)
- Enalapril (Vasotec)
- Lisinopril
Beta-blockers (chronic)
- Carvedilol (Coreg)
ACE inhibiors end in
-pril
Digitalis Glycosides - Digoxin have what effect on the heart
Chronotropic effect (effects rate of the heart)
Inotropic effect (effects contractibility of the heart)
What does Digoxin do to the body to contract of the heart?
increased cardiac output
decrease heart size and venous pressure
edema relief
Digoxin signs of toxicity
When do you withhold digoxin for infants and young children?
Apical pulse is < 90-110
When do you withhold digoxin for older children?
<70 apical pulse
When do you withhold digoxin for adults?
<60
S/S of Digoxin Toxicity
Nausea, Vomiting, Anorexia, Bradycardia, Dysrhythmias
Do not mix digoxin with
food or fluids
If you miss a digoxin dose, then
DO NOT give extra/2nd dose
If your child vomits the digoxin dose, then
DO NOT give extra/2nd dose
Digoxin should be
locked up and call poison control if accidental overdose
Before the parents leave with their child on Digoxin, the nurse should ensure
return demonstration with parents
- draw up the correct dose
and written instructions
K and Digoxin have wat type of relationship
inverse
ACE Inhibitors do what
inhibit normal function of the RAAS by **blocking Angiotensin 1 to Angiotensin 2
ACE inhibitors result in what?
vasoconstriction
vaso-occlusion
vasorupture
vasodilation
vasodilation
ACE’s vasodilation cause what to decrease
pulmonary/systemic vascular resistance
decreased BP
afterload reduction
reduces aldosterone secretion = lower preload
- no vol expansion from fluid retention
- decrease risk of low K
Aldosterone retains _____ and excretes ____
Na; K
Nursing Alert! ACE inhibitors block the action of aldosterone, so what also needs to be added to the drug regimen of patients with diuretics?
It could cause?
K supplements/spironolactone
- could cause HIGH K
ACE inhibitor’s side effects
Hypotension
Dry Cough
Renal Dysfunction
Beta Blockers are used in
chronic HF
Carvedilol (Coreg)
BLOCK
alpha and beta-adrenergic receptors
Beta Blockers do what
lower HR, BP and vasodilate
Beta Blockers side effects
dizzy
HA
low BP
CHF Tx for removing too much fluid and Na
Diuretics
Restriction of Fluid and Na
What diuretics arr used in CHF tx
Furosemide (Lasix)
Chlorothiazide (Diuril)
Spironolactone (Aldactone)
What needs to be monitored while on diuretics
I&Os and daily weights
S/S of Dehydration
Serum Electrolytes
S/S of Adverse Reactions
What should the patient eat in response to having K-losing diuretics?
HIGH IN K
- bananas
- avocados
- apricots
- green leafy veggies
Fluid restriction in what stage of CHF
ACUTE
with Strict I&Os
Na Restriction in children is usually
less due to negative effects on appetite and growth
- Avoid additional table salt/highly salted foods
Infants are not normally on fluid restriction. What are other ways to fluidly “restrict” them?
increase calorie density of the formula
increase slowly
CHF Tx Mgmt of decrease cardiac demands
Minimize metabolic need with
maintain body temp, (thermoregulation)
tx infection quickly,
reduce breath effort (Semi-Fowler)
sedate if irritable
sound sleeping
cluster care
Feed when hungry
Maintain body temperature with
thermoregulation
antipyretics
warm blankets if cold
How do you reduce the effort of breathing in CHF patients?
semi-Fowler position
- HOB
-in carriers
What would you do when the CHF patient is hungry?
every 3 hours soon after awakening
- soft nipple
semi-upright
ONLY for 30 MIN then gavage
increase calorie density (SIM-Advance)
Why is feeding a baby only 30 minutes?
after 30 minutes, you are burning more calories than taking in
How do you improve the O2 of a CHF patient?
RR counting for 1 minute
HOB elevated for chest expansion
Supplemental O2 and monitor response
What can the nurse do to support the family of a patient with CHF?
Anticipatory prep
econmic status
commnunicate
constant reassurance
written instruction
support groups
Hypoxemia and Cyanosis occur due to
Heart Defects that cause/allow Desaturated Venous Blood to enter Systemic Circulation without passing through Lungs
Chronic Hypoxemia S/S
Polycythemia
Clubbing (frog)
Polycythemia is the
increase of RBCs to compensate for low O2
- increase blood thickness
- crowds clotting
Clubbing can cause
Chronic tissue hypoxemia
Polycythemia
Acquired CV Disorders occur
after birth
- normal hearts or with Congenital defects
Acquired Heart Defects result from various factors which are: SATA.
Infection
Autoimmune
In Utero
Environmental
Family Tendencies
Infection
Autoimmune
Environmental
Family Tendencies
Acquired Heart Defects
Rheumatic Fever
Infective Endocarditis
Kawasaki Disease
Multisystem Inflammatory Syndrom in Children
Rheumatic Fever is what type of disease
inflammatory
Rheumatic Fever occurs as a reaction to
Group A Beta-Hemolytic Streptococcal (GABHS) Pharyngitis
within 2-6 weeks after untreated
Rheumatic Fever occurs most commonly in
5-15 y/o
Risk Factors of Rheumatic Fever
History of Group A Strep infection
Family history
Environmental factors
- underdeveloped countries
Rheumatic Fever follows a
recent hx of strep throat infection
elevated or rising ASO Titer
Complications of Rheumatic Fever
Inflammation in joints, skin, brain, and heart
Inflammation causes permanent cardiac valve damage (Rheumatic Heart Disease)
Most common – Mitral Valve Damage
Major S/S of Rheumatic Fever
- Polyarthritis, carditis, erythema marginatum, chorea, subcutaneous nodules
Chorea
little jerky mvmts
Minor S/S/Labs of Rheumatic Fever
Arthralgia (no arthritis)
Fever
Lab findings consistent with inflammation
Elevated Erythrocyte Sedimentation Rate (ESR)
Elevated C-Reactive Protein (CRP)
The Dx criteria for RF is
2 Major Manifestations
OR
1 Major and 2 Minor S/S
= HIGH PROBABILITY OF RF
TX for RF
Penicillin for 10 days with daily antibiotics FOR 10 years
Aspirin/Prednisone
- reduce fever/discomfort and inflammation
Bedrest
Prevention of RF
treat strep/scarlet fever completely
Infective Endocarditis
Infection of the valves and inner lining of the heart caused by bacteria enters the bloodstream and settles in the heart lining, heart valve, or blood vessel
Causes of IE
ORGANISMS ENTER BLOOD STREAM FROM ANY SITE OF LOCALIZED INFECTION
- grow on the endocardium form vegetations
IE Risk factors
children with acquired or congenital heart anomalies
- SURGICAL REPAIR AND PALLIATIVE SURGERY
Mixed, valve abnormal, shunts, ASD, PDA, TOF
Most common organisms in IE
Strep Viridans
Staph Aureus
Infective Endocarditis S/S
History of dental procedure, Tonsillectomy & Adenoidectomy, Urinary or Intestinal Tract procedure
Unexplained fever
Weight loss
Lethargy
Malaise
Anorexia
New murmur or change in previously existing one
Blood culture
Infective Endocarditis Complications
Stroke & organ damage
Forms vegetation and breaks off to other parts of the body
Infections/Abscesses
Heart Failure
Infective Endocarditis Tx
Cultures
Antibiotics (IV High dose for 2-8 weeks)
ECHO daily to monitor infection site
Prevention of Infective Endocarditis
Oral Hygiene
Antibiotics for higher risk
- Amoxicillin 1 hour before dental procedure
Kawasaki Disease
Acute Systemic Vasculitis
- Small and medium-sized blood vessels
Unknown Etiology
What is normally the area of involvement for Kawalsaki Disease?
coronary artery aneurysms
Kawasaki Disease is TX
self-limiting
resolves in 6-8 weeks
Risk Fcators for Kawalaski
under 5
male
asian
Dx of Kawalaski Disease
no specific test
CRP, ESR, Platelets
Kawasaki Disease Acute Phase (1ST 10 DAYS) S/S
Very Irritable
Fever for 5+ days
Erythema/Edema of Hands & Feet
Bilateral CONJUCTIVITIS
Strawberry tongue/Diffuse redness of oral cavity
Polymorphous Rash
Cervical Lymphadenopathy
Polymorphous Rash
Irregular rash along with palms and sole of the feet
Kawasaki Disease (KD) Subacute Phase S/S
Begins when Rash/Fever/Lymphadenitis resolved
Desquamation of Fingers/Toes – peeling
Continued irritability
Cardiovascular changes may occur
May experience thrombocytosis
(Platelet count > 600,000 – 800,000)
What is the platelet count in Kawasaki Disease sub acute phase?
600,000-800,000
How long is the Kawasaki Disease (KD) Subacute Phase
11-25 days
KD Convalescent Phase begins when
ALL s/s resolved
blood back to normal
Beau’s line on finger and toe nails
Tx of KD
IV Gamma Globulin (IVGG) – High doses
Aspirin (fever and inflammation in acute then antiplatelet after fever)
IV Gamma Globulin (IVGG) – High doses
does what in Tx of KD
reduces the incidence of coronary artery abnormalities
KD Nursing Interventions
VS, I&O, daily weights
- clear liquids and soft food with acute phase
Rest and calm environment
cool cloths, normal lotions, loose clothing
mouth care nd chap stick
Multisystem Inflammatory Syndrome in Children (MIS-C) is associated with
COVID-19
affecting
Heart
Lungs
Kidneys
Brain
Skin
Eyes
GI
MIS-C Patho
Possibly immune-mediated, triggered by COVID-19
MIS-C S/S
Temp ≥ 38° C for ≥ 24 hrs
Labs r/t inflammation (CRP, ESR, Procalcitonin, etc.)
Need for hospitalization r/t multisystem (≥2) organ involvement
No alternative plausible diagnosis
Positive for COVID-19 (current or recent) or exposure within 4 weeks of symptoms
Tx of MIS-C
Similar to Kawasaki
IVIG
Systemic glucocorticoids
Antivirals (during acute illness)
Mechanical ventilation
ECMO
