Ch. 27 Flashcards
PDA
patent ductus arterious
- allows mixing between the pulmonary artery and aorta as it is a passageway between these two major vessels
PFO
patent foramen ovale
- a hole between the two atriums
- it allows mixing blood between the two right and left atrium
arrhythmia
an alteration in rhythm of the heartbeat in either time or force
cardiomegaly
enlargement of the heart
chorea
a movement disorder marked by involuntary spasmodic movements especially of the limbs and facial muscles and typically symptomatic of neurological dysfunction (such as that associated with a neurodegenerative disease or metabolic disturbance)
clubbing
bulbous enlargement of the tip with convex overhanging nail
desquamation
to peel off in scales
dyspnea
difficult or labored breathing
heart failure
a condition in which the heart is unable to pump blood at an adequate rate or in adequate volume
ischemia
deficient supply of blood to a body part (such as the heart or brain) that is due to obstruction of the inflow of arterial blood
lymphadenopathy
abnormal enlargement of the lymph nodes
murmur
an atypical sound of the heart typically indicating a functional or structural abnormality
orthopnea
difficulty in breathing that occurs when lying down and is relieved upon changing to an upright position (as in congestive heart failure)
polycythemia
a condition marked by an abnormal increase in the number of circulating red blood cells
tachycardia
relatively rapid heart action whether physiological (as after exercise) or pathological
tachypnea
abnormally rapid breathing : increased rate of respiration
vasculitis
inflammation of a blood or lymph vessel
digoxin
cardiac glycoside
- used to treat heart failure (CHF), SVTs, dysrhythmias
- aids in contractibility of the heart
- very small therapeutic level: 0.8-2.0ng/ml
- peak and trough levels apply due to narrow therapeutic - toxic range
furosemide
loop diuretic
- given to relieve swelling/edema/fluid retention caused by CHF
spironolactone
potassium-sparing diuretic
- given to relieve HTN caused by CHF
prostaglandin E
synthetic prostaglandin
- given to keep the PDA open with coarc
indomethacin
NSAID
prostaglandin inhibitor
give for PDA closure
ibuprofen
NSAID
captopril
ACE inhibitor
aspirin
salicylate
IVIG
intravenous immunoglobulin: pooled antibody
digoxin s/sx of toxicity
- N/V
- diarrhea
- bradycardia (if HR is <90 infant <70 child or <60 adolescent, hold dose and contact HCP)
- give digiband for toxicity
digoxin dosing and measuring
therapeutic level: 0.8-2.0
avoid administering with meals
give PO 1hr before or 2hr after meal
give regularly Q12h,
if dose was missed by 4h, do not give med and administer next scheduled dose; if child misses two doses in a role- call HCP (HF may come back due to missed doses)
do not repeat dose if child vomits
what lab values affect digoxin?
hypokalemia (<3.5)
- increase dig level
hearts position in the chest
horizontal compared to adult until age 7
- apex is higher until age 7
- as heart and lungs grow downward placement of apex
which ventricle functionally dominates in the begin weeks of life?
the right ventricle
children have ___ baseline heart rates than adults
higher
innocent murmurs
heard in the 2nd and 3rd ICS
- disappear with changes in movement
- exacerbate with fever, stress, exercise, anemia
children have __ CO compared to adults
lower
assessment of cardiac output
- color
- skin
- perfusion
- level of consciousness
- breathing
- position of comfort
children are able to manage their CO by ____
increasing their heart rate
AR and RR increase with ____
- stress
- anxiety
hypotension is a ___ indicator of cardiac decomposition
late
hypotension by systolic BP
neonate: < 60mmHg
infants (1-12m): < 70mmHg
children (1-10y): < 70mmHg + (age in years x2) mmHg
children (>10y): < 90mmHg
5 areas to listen to the heart
aortic
pulmonic
erb’s point
tricuspid
mitral
indicators of cardiac dysfunction
- poor feeding
- tachycardia/tachypnea
- FTT/poor weight gain/activity intolerance
- developmental delays
- prenatal hx: some risk factors include rubella exposure, alcoholism, DM, lupus, advanced maternal age, teratogenic meds: Dilantin
- family hx of cardiac disease
- co-exists with syndromes such as down’s
physical assessment findings of cardiac dysregulation
- Tachycardia (know approximate normal ranges for age)
- Decreased peripheral perfusion (cool, clubbing, <CR, weak pulses)
- Murmurs
- Thrills, Heaves
- Enlarged heart with possible deformed chest
- Dysrythmias
- Pulmonary congestion – HF (heart failure) or CHF
- Respiratory distress
- FTT
- Polycythemia
- Anoxic spells
types of dysrythmias
- bradycardia
- tachycardia
- SVT
- normal sinus arrhythmia (increase with inspiration) and physiologic splitting (blow away)
cardiac testing: cardiac catheter
- a test or treatment for certain heart or blood vessel problems, such as clogged arteries or irregular heartbeats.
- It uses a thin, hollow tube called a catheter. The tube is guided through a blood vessel to the heart
cardiac testing: pulse oximetry
the amount of oxygen in the body
cardiac testing: labs
CBC
ABGs
cardiac testing: EKG
records the electrical signals from the heart. It shows how the heart is beating
cardiac testing: ECHO
ultrasound pictures of the heart
cardiac testing: CXR
detect presence of calcium in heart and blood vessels
- Its presence may indicate fats and other substances in your vessels, damage to your heart valves, coronary arteries, heart muscle or the protective sac that surrounds the heart
cardiac assessment post-cardiac catheterization
- pulses distal to insertion site
- temp and color of extremity
- VS q15 min
- monitor hypotension
- HR: heart sounds, bradycardia, dysthymias
- monitor s/ bleeding, if bleeding apply pressure 1” above insertion site
- keep extremity still/bed rest for 4-8h, work with family and involve parent to maintain child extremity straight
d/c teaching for parent post cardiac catheterization
- quiet activity up to 3 days after procedure
- have a shower or sponge bath verses bath tub emersion
- check temp 1x/day for 3 days; 100.5+ report to PCP
- keep dressing on post procedure
- check color/temperature of extremity in comparison
- changes in skin color or temperature, or flutter in chest- report to PCP
- acetaminophen and ibuprofen for pain
- come back for FUP
CP monitor- If a 5 lead set is used: order of placement
RA=right arm (placed under the right clavicle MCL, white)
RL=right lower/leg (placed on the right lower abdomen, green)
LA=left arm (placed under the left clavicle MCL, gray)
LL=left lower/leg (placed on the left lower abdomen, red)
V1=ventricular lead (placed at the 4th ICS right sternal border, brown)
CP monitor- If a 3 lead set is used: order of placement
RA=right arm (placed under the right clavicle MCL, white)
LA=left arm (placed under the left clavicle MCL, gray)
LL=left leg (placed on the left lower abdomen, red)
normal ECG: P wave
depolarization of atria in response to SA node triggering
normal ECG: PR interval
delay of AV node to allow filling of ventricles
normal ECG: QRS complex
depolarization of ventricles, triggers main pumping contractions
normal ECG: ST segment
beginning of ventricle repolarization, should be flat
normal ECG: T wave
ventricular repolarization
arrhythmias: brady
too slow
arrhythmias: tachy
too fast
arrhythmias: absent
not present
pre- cardiac catheterization nursing care
- preoperation/explanation geared towards developmental level
- sedation
- NPO
post-cardiac catheterization nursing care
- cardiac and pulse oximetry monitoring
- monitor pulses, temperature, color of extremity
- VS q15m- heart rate, rhythm, BP
- dressing for bleeding/hematoma
- I&O
- hypoglycemia
prenatal heart
post-natal heart
CHD symptoms
- increased pulse
- increased respirations
- retarded growth/FTT
- dyspnea, orthopnea
- fatigue/sick often
- URI
- aspiration risk
- not a lot of energy/burn a lot of calories during feedings so they don’t feed well (little bits often, or increase calories, etc.)
clues that something is wrong with baby (accronym)
FEAR
FEAR: F
poorly feeding
- using lot of energy to extract fluid from bottle
- RR > 60bpm, unable to coordinate
focus on family coping
FEAR: E
energy is low (fatigued)
- takes a few sips and then pauses
- head bobbing
- frequent napping
educate parents on topics like G&D, fluid and electrolyte balance and feeding interventions
FEAR: A
always fussy (bc hungry)
- audible grunting may be confused as baby being fussy
- crying when hungry but no energy left to suck when bottle offered
activity intolerance can be improved with energy conversation
FEAR: R
rapid respirations
- signs of respiratory distress
- low oxygen saturation
- RR above range for age
reinforce education and offer anticipatory guidance on topics like oxygenation, cyanosis, cold stress, signs of distress, and pharmacology
what is the most frequent sign a nurse would observe in an infant with CHD?
increased WOB
what is the most frequent complaint from parents of infants with CHD?
not eating well/poor feeding/tire quickly when feeding
acyanotic: increased pulmonary blood flow
- atrial septal defect
- ventricular septal defect
- patent ductus arteriosus
- atrioventricular canal
acyanotic: obstruction to blood flow from ventricles
- coarctation of aorta
- aortic stenosis
- pulmonic stenosis
cyanotic defects: decreased pulmonary blood flow
- tetralogy of fallot
- tricuspid atresia
cyanotic: mixed blood flow
- transposition of great arteries
- total anomalous pulmonary venous return
- truncus arteriosus
- hypoplastic left heart syndrome
acyanotic defects presentation
- absence of cyanosis (unless CHF present)
- typically presents as asymptomatic or signs of CHF
acyanotic defects: treatments
- wait and see
- meds
- simple surgery (only one stage)
Abnormal circulation; oxygenated blood entering systemic circulation causes what type of blood flow pattern? (acyanotic)
left to right shunt
leading to increased pulmonary blood flow
sx of increased pulmonary blood flow
- increased fatigue
- heart murmur
- increased risk endocarditis
- CHF
- growth retardation
atrial septal defects: clinical manifestations
- fluid overload
- pulmonary edema
- pulmonary congestion
- pulmonary HTN
- resp. infection
- pulmonary resistance
what is atrial septal defect
hole between the L and R atrium
- movement of blood L to R
- mixing of oxygenated and deoxygenated blood into the lungs
- heart has to work harder
- fatigues
- hypertrophy of the R atrium (R side of the heart gets bigger)
treatment of atrial septal defect
- just watch if no signs of CHF, usually go away by 1 year
- signs of CHF, intervene with pharmacologic measures: digoxin, and diuretics: furosemide, spironolactone
- surgery: if pedi has a large defect and meds are not working; put band on pulmonary artery: less flow to the lung, OR put a patch in it
what is ventricular septal defect
opening at the septum between the L and R ventricles
- blood moves L to R
- extra blood moves into the lung
- heart has to work harder
- fatigues
- hypertrophy of the R atrium (R side of the heart gets bigger)
treatment of ventricular septal defect
- dx with an echo
- just watch if no signs of CHF, usually go away by 1 year
- signs of CHF, intervene with pharmacologic measures: digoxin, and diuretics: furosemide, spironolactone
- surgery: if pedi has a large defect and meds are not working; put band on pulmonary artery: less flow to the lung, OR put a patch in it
sx of ventricular septal defect
- fluid overload
- pulmonary edema
- pulmonary congestion
- pulmonary HTN
- resp. infection
- pulmonary resistance
what is PDA
for some reason there are prostaglandins circulating keeping the PDA open after birth
- blood moves L to R
term babies:
_ % close at _ hours
90% close at 48 hours
100% close at 72 hours
treatment of PDA
- watch
- if it does not close, give indomethacin IV (prostaglandin inhibitor)
- 3 courses of pharm, then do ligation surgery
sx of PDA
- fluid overload
- pulmonary edema
- pulmonary congestion
- pulmonary HTN
- resp. infection
- pulmonary resistance
what is coarctation of aorta
constriction of the aorta, narrowing of the aorta
- can be congenital or evolved later on in life
- can be cyanotic defect if bad enough
- decreased blood flow
treatment for coarctation of aorta
surgical: cut out coarc piece of aorta and then sew the two segments of the aorta together
non-surgical: catheterization angioplasty: blow up balloon to open the narrowing (sometimes with stent); if PDA is open give prostaglandin E to keep open- even though blood is deoxygenates, it still allows blood to circulate to the lower extremities
sx of coarctation of aorta
- pulses: upper bounding, lower diminished/decreased
- BP: upper HTN, lower hypotension
- O2: upper high/normal, lower diminished/decreased
- extremities: upper warm, lower cool/cold
- pressure: upper increased (chi: HA, epistaxis, dizziness, diaphoretic, inf: crying/irritable, poor feeding, poor sleep, diaphoretic), lower decreased (ch. weakness, all signs of CHF can apply)
cyanotic defects (presentation)
- severe cyanosis and hypoxemia
- “T” diagnoses including Tet spells
cyanotic defects: treatment methods
- pharmacology
- complex surgeries (multiple stages)
Abnormal circulation with unoxygenated blood entering systemic circulation causes what kind of blood flow pattern? (cyanotic)
right to left shunt
leads to decreased pulmonary blood flow
sx of decreased pulmonary blood flow
- squatting
- cyanosis
- clubbing: swollen end of fingers; cold, blue fingers
- syncope
hypoxemia
lower than normal arterial oxygen tension
hypoxia
reduction in tissue oxygenation
clinical presentation of hypoxemia
- polycythemia: increased RBC –> clotting risk
- clubbing
- hypercyanotic spells (TET spells)
cyanosis (infancy) treatment
initial treatment: prostaglandin E IV
purpose: increase pulmonary blood flow
effective tx outcome: stabilize oxygen saturation, await further treatment orders
cyanosis (all pedi ages) treatment
initial treatment: IV/PO fluids
purpose: keep H&H viscosity w/in acceptable range to decrease CVA risk r/t decreased arterial oxygen carrying capacity
effective tx outcome: hct elevation to acceptable range. prepare to admin iron supplement and/or transfuse PRN. evidence of adequate hydration
TET spell: treatment (all pedi ages)
initial treatment: positioning, oxygen, morphine
purpose: reduce venous return from lower extremities and increase SVR (shunt more blood to pulmonary artery)
effective tx outcome: resolution of cyanosis, respiratory distress, and irritability. no syncope or seizures
what is tetralogy of fallot (hint: 4 conditions within the heart)
1 pulmonary stenosis: very narrow pulmonary artery (determines the severity of it)
2 VSD (very large)
3 overrriding aorta
4 R ventricle hypertrophy
- cyanotic d/o- R to L shunt of deoxygenated blood causes mixing of blood and goes into the aorta; decreased pulm. BF
- dx prenatally
sx of tetralogy of fallot
normal O2 sat will be 70-80s (not 100%)
cyanotic: blue skin, lips
SOB
treatment for tetralogy of fallot
- surgery
- supportive care
- medications
(blank)
what is a tet spell
a hypercyanotic spell in which O2 sat drops below 70-80s range
- triggered by crying episode or straining, something that makes them upset
- causes heart rate to raise and oxygen sat to drop
tet spell management: medications
morphine
- to calm the baby down
- think resp depression will calm the baby
___ (blank) is used to push blood back into heart
tet spell management: tone of voice and body positioning of child
stay calm
knee-to-chest position
tet spell management: oxygen
give oxygen (low-bi)
goal is to get them back to their baseline (not 100%)
tet spell management: IVF
we want to keep child hydrated
we need IV access for meds, etc.
what is TOF repair
depends on degree of pulmonary stenosis (weeks after birth- a couple months- definitely by a year)
open up pulmonary artery (stenosis) and patch it
- allows for more blood flow to the lungs
will also patch up the VSD
good prognosis
what is HLHS (hypoplastic left-heart syndrome)
the left side of the heart is hypoplastic or underdeveloped
- left ventricle is very small
- ASD
- mitral valve is tiny/barely functioning (hypoplastic)
- aortic valve is tiny/barely functioning (hypoplastic)
*some babies mitral and aortic don’t function at all
sx of HLHS
(blank)
management of HLHS
- prostaglandin E
- immediate surgery
- multiple stage approach to repair
best treatment: heart transplant (just a slim chance this will work)
stages of HLHS repair
Norwood-first week of life
Bidirectional Glenn-age 3-6 months
Fontan-older than 2-4 years
CHF patient problems
- impaired myocardial function
- pulmonary congestion
- systemic venous congestion
CHF patient problems: impaired myocardial function symptoms
- tachycardia
- fatigue
- weakness
- restless
- pale
- cool extremities
- decrease BP
- decrease urine output
CHF patient problems: pulmonary congestion symptoms
- tachypnea
- dyspnea
- resp distress
- exercise intolerance
- cyanosis
- difficulty feeding/sweating
CHF patient problems: systemic venous congestion symptoms
- peripheral and periorbital edema
- weight gain
- ascites
- hepatomegaly
- neck vein distention
HF nursing management goals
- Improve cardiac function
- Decrease preload
- Decrease cardiac demands
- Improve tissue oxygenation
- Decrease oxygen consumption
- Nutrition status (NGT if RR >60bpm, small frequent, thickening feedings- adds calories and less likely to vomit)
- diuretics
- give O2
- meds
- # 1 sign of CHF: decreased UO
hypokalemia causes (hint: DITCH)
D: drugs (loop diuretics, laxatives, glucocorticoids
I: inadequate consumption of K+
T: too much water intake
C: cushing’s syndrome
H: heavy fluid loss
hypokalemia sx (hint: 7 L’s)
7 L’s
- lethargic
- low, shallow respirations..failure
- lethal cardiac dysrhythmias
- lots of urine
- leg cramps
- limp muscles
- low blood pressure (severe)
treating hypokalemia: foods
Potatoes, pork
Oranges
Tomatoes
Avocadoes
Strawberries
Spinach
fIsh
mUshrooms
Musk melons: cantaloupe
carrots, raisins, bananas, green vegetables
nursing management of a child with CHD
- Help family adjust to diagnosis: let them mourn
- Educate family about disorder (after mourning), use videos, print outs- explain tests, procedures, medications
- Coping, supports
- Preparation for surgery
- Post op care and discharge teaching
general cardiac surgery post-op care
VS (ex. continuous EKG monitoring, hypothermia, interarterial pressure, heparinized saline, CVP line) q1h post op, then q2h, maybe q4h when stable
Rest (provide sedation {immed. Post-op} to ↓ Cardiac workload; cluster your care being mindful of degree of cardiac demand {elevations in HR/RR})
Fluids (I/Os, daily weights, watch for s/sx renal failure, fluid restrictions to prevent hypervolemia (↑ cardiac demand), NPO while intubated, daily wt. {same conditions})
Pain (analgesics such as morphine, NSAIDS, perform treatments when med efficacy is high, decrease stress/stimulation) *Tylenol wont cut it
Anticoagulants (admin as ordered to maintain shunt patency and prevent clots around artificial valves etc., monitor coag. studies closely)
congenital heart defects are caused by
- family history
- use of drugs/alcohol during pregnancy
congenital heart defects are defects that the child
is born with
murmur goes away when sitting up, concerned?
no
acquired heart defects are defects that the child
develops after birth
grade 1 murmur
faint
grade 2 murmur
soft
grade 3 murmur
moderate, loud, no thrill
grade 4 murmur
loud, thrill
grade 5 murmur
very loud, thrill
grade 6 murmur
so loud can be heard without a stethoscope
why use a cardiopulmonary monitor?
- increased WOB
- something is abnormal with vital signs
- no order needed for monitor if you are concerned, get it after
prenatal placenta functions
nutrients
oxygen- lungs of baby
blood
functions as a kidney
foramen ovale
opening in the prenatal heart
constant movement of blood
goes into PDA
- pressure changes after birth and the FO closes
during pregnancy the placenta is in charge of secreting ___
secreting prostaglandins
keep PDA open, needed during pregnancy
PDA shrinks and closes after birth
cyanotic defects: want PDA open?
yes because cyanotic defects mean less blood flow, if PDA is open, it will increase blood flow circulation
- therefore we treat with prostaglandins to keep the PDA open
