Cardiovascular Dysfunction Flashcards
Cardiac catheterization
- diagnostic (for rhythms and pressures)
- interventional (angioplasty or closure of defects)
- right side cath more common in kids b/c it is safer and structural defects allow left side heart access
ECG
15 lead in children
Cardiac Cath pre-procedure care (assessment includes)
Good height-for proper catheter selection
Good weight-med doses
Assess pulses and mark before they leave because pulses may be difficult to assess after
Assess for any signs of infection, no acne in the insertion area
Cardiac cath post-procedure care
Potential complications:
- Color and LOC
- VS and Resp status
- pulses (distal to site can be weaker for first few hours) just make sure they’re equally weak
- dressing for bleeding (1 in above site)
- fluid intake (both IV and PO)
- hypoglycemia
Discharge planning
- pressure dressing for 24 hours
- no tub bath 48 hrs
- rest the night then resume normal activity
- teach s&s of infection
Developmental consideration
Heart size- ventricles are equal in size at birth
Less compliance- during infancy muscle fibers of the heart are less developed and less organized resulting in limited functional capacity (can’t pump harder just faster)
Normal O2 sat is 95-100%
Infants and small children have thin chest walls with little to no subcutaneous fat and muscle
Ductus Venosus (where is it? What’s it do?)
- Shunt of blood past the liver to the heart
- Allows 1/2 blood to bypass the liver
Foramen Ovale
- opening between the L&R atrium
- let’s blood move back and forth
Ductus Arteriosus (where is it what’s it do?)
- Pulmonary artery to aorta
- Allows blood to bypass lungs
Fetal shunts
All close at birth or shortly after in response to:
- decreased maternal hormone prostaglandin E
- increased O2 sat
- pressure changes in the heart (pulmonary starts to fall, as systemic pressures rise)
General clinical findings for cardiac defects
- Dyspnea
- feeding difficulty and failure to
- stridor or choking spells
- HR over 200; Resp rate about 60 in the infant
- recurrent Resp tract infections
- in the older child-poor physical development, delayed milestones, and decreased exercise tolerance
- cyanosis and clubbing of fingers and toes
- squatting or kee-chest position (tetralogy of falow)
- heart murmurs
- excessive perspiration
- signs of heart failure (edema; decreased urinary output; increased HR; JVD; poor healing)
Cardiac hemodynamics
Always go left to right
-backs up in lungs and body cyanotic-mimics CHF in s/s
Clinical consequences of defects causing increased pulmonary flow
- Systemic pressure causes left or right shunting
- increased blood volume on right side increases and overwhelms the lungs
- s/s of cognitive heart failure -caused by left to right shunting
CHF
Heart can’t pump enough blood to meet body’s needs
CHF CAUSES:
- Volume overload
- Pressure overload
- Decreased contractility
- Too much cardiac demand
CHF occurs mostly
2ndary to congenital heart defects in which structural abnormalities result in an increased volume load or increased pressure load on the ventricles
Clinical Manifestations of CHF
Pulmonary venous congestion:
-tachypnea; adventitious breath sounds; nasal flaring; fatigue with play; difficulty feeding
Systemic Venous congestion:
- hepatomegaly; ascites; weight gain; edema; JVD
Impaired Myocardial Function:
-tachycardia; extended cap refill; oliguria; fatigue; restlessness; enlarged heart; cool extremities
High Metabolic Rate:
Failure to thrive or slow weight gain, sweating
Management if CHF
- improve cardiac function
- remove accumulated fluid and sodium
- decrease cardiac demands
- improve tissue oxygenation and decrease oxygen consumption
Digoxin admin
-regular intervals; -1 hour before or 2 hours after eating; do not mix with food or fluid; behind teeth or brush after administration; missed dose < 4 hours give, if > 4 hours withhold. If 2 doses missed, notify practitioner; if child vomits do not repeat dose
Digitalis toxicity
N/V; bradycardia; anorexia; visual disturbances
Care for Activity intolerance in CHF
- Adequate rest
- Prevent crying (have bottle ready to feed)
- cluster care
- short intervals of play, cuddling
- provide neutral thermal environment
- extra won’t help as lungs are overloaded w/ fluid
Care for altered nutrition in CHF
- anticipate hunger
- smaller more frequent feeding
- burp frequently to decrease crying
- formulas with increased calories
- semi-erect for feeding
- feed in a relaxed environment
- only feed for 30-45 minutes at a time
Care for ineffective breathing pattern in CHF
- assess resp rate, effort, and O2 sat
- semi-fowlers to encourage full chest expansion
- avoid constriction
- humidified supplemental O2 during times of crying or stressful procedures
Care for infection risk in CHF
- avoid crowded public places
- good hand washing
- screen visitors
FVE care in CHF
- accurate I & O
- weigh daily (same time, scale, and clothing
- assess for edema
- maintain fluid restrictions if ordered
- provide good skin care
- change position frequently
CHF-growth and development
Infants do catch up-slowly and overtime
Arterial Septal Defect
Patent foramen ovale - septum fails to close
CM:
-maybe asymptomatic - murmur - Does not typically mimic heart failure- increased risk of dysrhythmias with pulmonary vascular obstructive disease and emboli later in life
-
ASD Treatment
- mild defects may close spontaneously
- likely not life threatening and closes over time, just watch and wait and make sure they’re growing
- open heart surgery w/ Dacron patch closure or closed during cardiac cath with septal occluder
Ventricular septal defects
-septum fails to close between the left and right ventricles- body deprived of O2 blood and pulmonary overload CM: -CHF- moderate to severe, cyanosis -murmur -failure to thrive -fatigue -recurrent respiratory infection -right ventricular hypertrophy
VSD therapeutic mgmt:
- Pulmonary artery banding- restrict blood flow back through
- may close by age 3 (if child grows well then it’s a watch and wait)
- heart cath w/ septal occluder
- surgical correction w/ a patch and repair of AV valve tissue
Patent ductus arterious = PDA (define)
Ductus arterious doesn’t close, causes a left to right shunting; blood is shunted from the aorta to the pulmonary artery, back to the lungs, causing increased pulmonary blood flow
PDA CM/Treatment:
CM: machine like murmur; can be asymptomatic or exhibit CHF signs
Treatments: Indocin- tocolytic that blocks the effects of prostaglandin E and causes hole closure
-Interventional heart cath with coil
-Left Thoracotomy or VATS- 3 small chest incisions places a clamp on the ductus
Coarctation of the aorta (define)
Narrowing of aortic arch usually distal to the ductus arteriosus and beyond the right subclavian artery-
Narrowing near the insertion of the ductus arteriosus resulting in increased pressure proximal to the defect and decreased pressure distal to the defect
Coarctation of the aorta (location of insertion)
Preductal- between subclavian artery before the ductus arteriosus
Postductal- collateral circulation develops during fetal life (distal to the ductus arteriosus)
Coarctation of aorta (clinical consequences and manifestations)
- L-R shunting, increased pulmonary blood flow leading to CHF
- Increased Blood Flow to head and upper extremities
- Decreased blood flow to trunk and lower extremities
- CM: bounding upper extremities, decreased lower extremities (cool mottled skin, decreased BP, delayed healing, ulcers, H/A, epistaxis often, aortic aneurysms, possible stroke
Coarctation of the aorta (therapeutic management)
- Prostaglandin E to maintain PDA
- Balloon angioplasty
- Surgery- within first two years (closer to 2 years b/c 1/2 adult height
Aortic Stenosis (define)
Aortic valve is narrowed or thicker and disrupts blood flow out
Aortic stenosis (consequences)
- Obstruction tends to be progressive
- Sudden ishchemic episodes, or low CO, results in sudden death. Activity needs to be limited
- Surgical repair rarely results in normal valve
- Increased risk of Bacterial Endocarditis
Aortic Stenosis
CM:
Infants- faint pulses, hypotension, tachycardia, poor feeding(decreased CO)
Children- exercise intolerance, chest pain, dizziness when standing for long periods
Aortic stenosis (treatment)
Balloon dilation; surgery- aortic valvotomy or replacement
-mortality high in neonates, low for older kids
Pulmonic Stenosis (define)
Narrowing of the pulmonic artery resulting in decreased right side outflow
Pulmonary atresia (define)
Complete fusion, resulting in no blood flow to lungs- not compatible with life unless there is another way for blood to get to the lungs
Pulmonic stenosis (CM)
Asymptomatic; or mild cyanosis or CHF, murmur
Increased risk of BE due to pooling of blood
Pulmonic Stenosis (treatment)
Balloon angioplasty; surgery
CHF (CM)
Tachypnea; diaphoresis; eating problems; edema; rales; crackles
Cyanotic heart defects (define)
R to L blood shunting, heart is messed up badly, blood mixing, baby is blue due to deoxygenated blood going to body; blood shunts from right to left because defects cause a great pressure on the right side of the heart
Cyanotic heart defects (sx)
Cyanosis; polycythemia (increases clotting risk); digital clubbing; altered ABG’s
Cyanotic heart defects (General interventions)
Provide good skin care (delayed healing); supplemental O2; monitor and prevent dehydration
Cyanotic Heart Defects (considerations)
Alteration in oxygenation; anxiety caused by cyanosis; dehydration; prevention and accurate assessment of resp infections; keep them from stress/crying; soft preme nipples; education to parents that organs are still profuse; good hand washing; gown and glove; screen visitors
Tetralogy of fallow (4 things going on)
- R vent hypertrophy
- Overriding aorta
- Ventricular septal defect
- Pulmonic stenosis
ToF (TET spell)
Pulmonic stenosis gets worse causing pooling in R ventricles and goes to overriding aorta- more deoxygenated blood to body
ToF (CM)
Murmur with a thrill; polycythemia; hypoxic episodes; clubbing; activity intolerance; poor growth; metabolic acidosis
ToF (treatment)
Surgery done in stages (6 mo old)
- Blalock- taussig shunt
- VSD repair
- Pulmonary valvotomy
Squatting position
Knee to chest intervention for TET spell ;
Increases systemic resistance; decreased venous return to lungs- body is able to divert blood to organs
Hypercyanotic spells (guidelines)
Employ calm, comforting approach; knee-chest position; 100% O2 by face mask; give morphine; IV fluid replacement and volume expansion if needed; repeat morphine PRN
Infundibular muscle
Goes from R vent to pulmonary artery- morphine relaxes the muscle to promote more blood to lungs- narcan for morphine antidote
Tricuspid atresia (define)
Tricuspid valve does not develop and there is no communication between right atrium and ventricle (without another defect (ASD or VSD) life is not compatible)
Tricuspid atresia (CM and treatment)
Cyanosis
Treatment: prostaglandin E to maintain foramen ovale; digoxin and diuretics; palliative surgical repair to increase the pulmonary blood flow
Transposition of the great arteries (define)
Aorta goes to the R side and pulmonary artery goes to L side
Transpiration of the great arteries (consequences)
-must have another defect that allows blood mixing for life to be compatible
Transposition of the great Arteries (CM, Treatment)
CM: increasing cyanosis as the foramen ovale closes
Treatment: arterial switch procedure in the first few weeks of life; prostaglandin E to keep foramen ovale patent
Truncus arteriosus (define)
Pulmonary artery and aorta fail to divide and a single large vessel empties both vents
Truncus arteriosus (CM and Treatment)
CM: cyanosis; CHF; heart murmur
Treatment:
Surgical repair within the first few months of life; digoxin and diuretics to not overload the lungs
Hypoplastic left heart syndrome (HLHS) define
Aortic valve atresia; mitral atresia or stenosis; small or absent left vent; severe hypo plasma of ascending aortic arch
HLHS (consequences)
Underdevelopment of the left side of heart-
Small left ventricle, aortic atresia
HLHS (s/s)
Cyanosis, weak peripheral pulses, cool extremities, resp distress, often no murmur
HLHS (management)
- Prostaglandin E to keep PDA open
- Fontan procedure- direct blood flow to pulmonary artery from RA
- Norwood procedure- anastomoses of main PA to the aorta, shunt from RV to PA
- eventually need a transplant
HLHS (complications from heart surgery)
CHF; dysrhythmias; cardiac tamponade; atelectasis; pneumothorax; pulmonary edema; cerebral edema; brain damage; hemorrhage or anemia
HLHS (discharge plan)
Wound care; call clinic if fever; med teaching- how to give lasix and digoxin; BE prophylaxis- amoxicillin before dentist or surgery; self limit activity- don’t let them play where they can get hurt, but no need to restrict play; do not pick up child beneath arms until incisions have healed; call doctor if: decreased UOP, infection or fever
Bacterial Endo BE (define) and etiology
Inflammatory process resulting from infection of the valves of heart and inner lining
-comes from strep infection, in the ear, UTI, or central line placement
BE CM:
Low grade intermittent fever; anorexia; malaise; splinter hemorrhages under nails; Osler nodes; janeway spots; new heart murmur or change in existing ones; weight loss
BE therapeutic mgmt
IV antibiotics for 2-8 weeks; surgical removal of thrombi or deposits; prevention of infection w/ prophylactic antibiotics 1 hr before dental or other risky procedures
Rheumatic Fever RF (define)
Systemic inflammation disease that follows a group A beat hemolytic strep infection - autoimmune reaction to strep infection
Incidence of RF
More commune in males and late winter to early spring; most often school agers; upper resp infection weeks prior
RF CM
Major: poly arthritis; carditis; chorea-irregular movement of extremities; erythema marginatum; subcutaneous nodules
Minor: arthralgia; low grade fever; elevated ASO titer
RF therapeutic management
10-14 days of penicillin; prevent cardiac damage and relieve sx- (aspirin 2 weeks for inflammation; bed rest)
Prevent recurrent infection (prophylactic antibiotics)
RF Nursing consideration
Prevention- sawn for strep when kid is in clinic w/ sore throat
Encourage compliance w/ antibiotics
Facilitate recovery rest, nutrition, and pain management
Provide emotional support w: chorea and pain
Kawasaki (CM acute)
8-10 days
Bilateral pink eye; enlarged lymph nodes; peeling skin; patchy rash; fever-Tylenol doesn’t help; dry cracked lips; strawberry tongue
Kawasaki (CM subacute (10-35 days)
Begins with resolution of fever and lasts until all signs are gone;
Vasculitis; arthritis, peeling of skin throbocytosis- high platelet; can result in emboli or blockage from platelets or scarring; at great risk for coronary aneurysm
KD (recovery phase
Up to 10 weeks
Child vulnerable as coronary arteries are still damaged and repairing, the child feels okay, and is a risk for heart attack here- most dangerous phase MI signs= back pain/angina/none
MI S/s in children
Abdomen pain; vomiting; restlessness; inconsolable crying; pallor; shock
KD management
Aspirin for anti inflammatory (initial) and anti platelet (long term)
High dose IV IG (w/n 1st 10 days)
If coronary arteries are damaged, then on aspirin for life
KD considerations
Cardiac status monitoring carefully!
-I&O -daily weight. - administer fluid with care. - watch for signs of MI
Safely give IV IG- usual blood precautions- easy to fluid overload
Watch for s/s of aspirin toxicity (ringing ears and GI bleed risk)
Skin discomfort (loose soft clothing; mouth care; cool rags) D/C teaching: NO MMR VACCINE FOR 1 YEAR OR FLU MIST
HTN types
Essential or primary = no identifiable cause
Secondary = subsequent to a known cause
HTN incidence
Primary (rare) Secondary: Renal disease- most likely cause- urinalysis in clinic- + for protein? = kidney probs Coarctation of aorta Oral contraception Steroids Obesity Adrenal disorders
HTN CM:
Elevated BP; dizziness; H/A; vision changes
Therapeutic management HTN in children
Identify cause and treat; monitor if mild; combination of nonpharm and pharm therapy
Mild HTN:
85-95%tile
Moderate HTN
95-99%tile
Severe HTN
> 99%tile
Nonpharm interventions for HTN
Low salt diet; don’t smoke; halt birth control
Pharm therapy for HTN
Beta-blocker; ACE-I; diuretic
Hyperlipemia screening
Selective for risk factors- genetic; or overweight; draw lipids first thing in morning after fasting
Hyperlipemia threshold
< 170 is considered to be acceptable
Hyperlipidemia Management
Step diet- don’t eliminate bad foods- just limit
Pharm- colestipol or cholestryamine
Take family approach to improve child’s health- get family healthy
Dysrhythmias diagnosis
24 hr holter; ECG; trans-esophageal recording
SVT treatment
Vagal maneuvers; valsalva maneuver; adenosine slam; cardio version; radio frequency ablation; avoid caffeine and sudafed
Sinus arrhythmia
Normal in school ager; have child hold breath and should regulate it
Cardiomyopathy
Myocardial abnormalities which impairs the hearts ability to contract
Cardiomyopathy types:
Dilated- ventricular dilatation with greatly decreased contractility leading to CHF
Hypertropic- increase in heart muscle mass without an increase in cavity size
Restrictive- restricted vent filling due to caused by disease CHF
Cardiomyopathy etiology
Usually in children is idiopathic
Cardiomyopathy CM
CHF; dysrhythmias; syncope; sudden death
Management of cardiomyopathy
Digoxin; diuretics; beta blockers; calcium channel blockers; anticoagulants; transplant if meds don’t work
Consideration for cardiomyopathy
Child wants to play but simply can’t and their failing health is discouraging
-include child in discussions and decisions
-psychological preparation for transplant and postoperative care
Won’t feel good and often want to halt therapy
