Ch. 27 p. 2 Flashcards
infectious and inflammatory cardiac disorders are caused by
- infection
- autoimmune response
- environmental factors
- familial tendencies
infectious and inflammatory cardiac disorders can occur in
the normal heart or in addition to congenital heart defects
cardiac dx testing: Echo
ultrasound to visualize the blood flow, structure, valve misfunction: clot, aneurysm
cardiac dx testing: EKG
monitors the hearts electrical impulses
rheumatic fever
inflammatory heart condition occurring post pharyngitis (GABHS)
- self limiting
- cardiac valve damage can result
- affects ages 5-15 years
- several weeks after a strep infection that was not treated or not treated well
- can lead to rheumatic heart disease if not treated (at all or properly): valve damage
treatment of rheumatic fever is focused on
- resolving infection, minimizing complications, and prevention of recurrence
- preventing rheumatic heart failure
- usually very treatable and recoverable
principle manifestations of rheumatic fever involve (what parts of the body/systems)
involve the heart, joints, skin, and CNS
jones criteria
symptoms/components of dx criteria for rheumatic fever
what are the top 5 clinical manifestations of Jones criteria/which are considered MAJOR?
Joint involvement
O looks like a heart- myocarditis
Nodules, subcutaneous (usually on bony parts of the body, ie elbow, ankle)
Erythema marginatum (rash: neck to chest, sometimes fast; flat)
Sydenham chroea (involuntary movements)
in which order do the top 5 clinical manifestations of jones criteria occur?
joint involvement
o looks like a heart- myocarditis
nodules, subcutaneous
erythema marginatum
sydenham chroea
which jones criteria clinical manifestations are considered MINOR?
CAFE PAL
CRP increased
arthralgia
fever
elevated ESR
prolonged PR interval (need EKG to confirm)
anamnesis of rheumatism (joints inflame at various times)
leukocytosis (increased WBC)
timeline of s/sx of acute rheumatic fever
- polyarithmias
- carditis
- erythema marginatum
- subcutaneous nodules
- chorea
to diagnose rheumatic fever clinically, you need ____
- two major criteria OR one major and two minor criteria
AND - throat cultures growing GABHS OR elevated anti-streptolysin 0 (ASO) titers
how to manage rheumatic fever (duration of treatment)
The duration of therapy is tailored according to the child’s clinical course. Prophylaxis RX depends on age/involvement.
- No carditis: 5 years or until age 21 (whichever is longer)
- Carditis w/o residual heart disease: 10 years or until age 21 (whichever is longer)
- Carditis w/residual heart disease: 10 years or until 40 years of age (whichever is longer) or maybe lifelong.
rheumatic fever: drug therapy
penicillin (PCN)
- IM qMonth
- PO BID
kawasaki disease
acute systemic vasculitis (inflammation of arteries of heart; increased platelets)
- unknown etiology/cause
- affects children < 5 years
- self-limiting
- very, very irritable- tell parents this is normal per disease
- do an echo
if kawasaki disease is untreated,
25% will develop cardiac complications
- MI
- aneurysms (outpouching of vessel- can lead to a clot)
*higher likelihood to occur in infants
kawasaki dx criteria (hint: CREAM)
high fever for 5 days (infant 7 days) and 4/5 of the following:
- conjunctivitis (non-exudate)
- rash (polymorphous non-vesicular)
- edema (or erythema of hands/feet)
- adenopathy (cervical, often unilateral)
- mucosal involvement (erythema or fissures or crusting)
kawasaki “red” PE findings
strawberry tongue, red eyes, red lips
kawasaki disease treatment
- ASA 80-100 mg/kg/day: fever and inflammation (prevents clotting- these kids are at risk for clotting)
- IVIG: immunoglobulins, give antibodies to protect the body; check VS, two nurse check, and pre-medicate with tylenol and benedryl// infuse as long as 8 hours
- antiplatelet (ASA) 3-5 mg/kg/day
duration of therapy is dependent on z-score
kawasaki disease: acute phase
- High fever x 5 days or more (unresponsive to ABT and antipyretics)
- 2/3 report GI illness
- erythema of palms/soles, edema of hands/feet
kawasaki disease: sub-acute phase
- resolution of fever
- onset of other symptoms
- Lasts until all outward clinical signs have resolved.
kawasaki disease: convalescence phase
- abnormal labs linger (elevated sed rate, C-reactive protein)
- Thrombocytosis (high level of platelets) still present
- Arthritis continues, cardiac sequelae still a concern (peak 4-6 wks. After onset)
kawasaki disease nursing management
- monitor cardiac status
- promote comfort
- offer emotional support
- provide diagnostic assistance
- perform med administration
- implement pt/family
- ice pops: swollen tongue and sore throat
- hand cream: dry, cracking hands
- cool compress, antipyretics: fever
- warm compress: protruding lymph node
kawasaki disease: what happens if the urine output decreases?
indicative of heart failure
kawasaki disease: can this child have an MI?
yes
- most common cause of MI in children
MIS-C
multisystem inflammatory syndrome- covid related
- some mucocutaneous signs mimic kawasaki
- cardiac involvement can be significant
- can involve any organ system
- involves 2 organs
MIS-C manifestations
- Fever > 38 C (100.4 F) for 24 hrs. (can be subjectively reported)
- Lab evidence of inflammation
- Evidence of clinically severe illness requiring hospitalization with at least 2 organ systems involved (ex. Myocarditis)
- No alternative plan or diagnosis
- Currently or recently COVID-19 + (within the last four weeks)
- elevated platelets
MIS-C treatment
- IVIG
- Steroids (systemic)
- Anti-inflammatories
- Ibuprofen/acetaminophen
- Depends on severity*
MIS-C elevated inflammatory lab values
- CRP*
- ESR*
- platelets* (clotting)
- cardiac enzymes: troponin, BNP*
- Fibrinogen
- Procalcitonin
- D-dimer
- Ferritin
- Lactic acid dehydrogenase (LDH)
- Neutrophils
MIS-C decreased inflammatory lab values
- lymphocytes
- albumin*
evaluation and treatment of MIS-C
- Labs
- Diagnostics (EKG, Echo, CXR)
- Consultations
- Pharmacology
- Ongoing follow-up
- supportive measures
treatments/supportive measures for MIS-C
- fluid resuscitation
- inotropic support
- respiratory support
- extracorporeal membranous oxygenation (ECMO)
- IVIG*
- Steroids*
BP screenings for children
- Routine w/ annual check-ups
- assess age three and beyond manually, not with an automatic device
- really need 3 abnormally high readings to dx HTN (white coat syndrome- high BP bc child is at dr- recheck in 10-15 min, come back in a couple. days)
what conditions could HTN indicate?
- kidney issues
systemic HTN can lead to
long-term consequences
- CVD
systemic HTN: BP is based on
- age
- gender
- height
(for ages 1-13) - assess at PE in ages 3+ manually with correct sized-cuff
- categorical cut points for children 13+
- need 3 abnormal readings to SBAR for a workup
elevated BP
children 1-13 years:
- SBP or SBP falls >90<95th percentile or 120/80 to <95th percentile (whichever is lower) persistently
children 13+:
SBP 120-129
DBP <80
stage 1 HTN
children 1-13 years:
- BPs at or >95th percentile to less than 95th +12 mm/Hg or 130/80-139/89 (whichever is lower) persistently
children 13+:
SBP 130-139
DBP 80-89
stage 2 HTN
children 1-13 years:
- BPs at or >95th +12 mm/Hg or 140/90 or greater persistently
children 13+:
SBP 140+
DBP 90+
why would BP be measured before age 3 years?
if a history of health conditions
- COA
- prematurity
- murmurs
- seizures
- abdominal mass
- unexplained HF
- ascites
- sleep apnea
- unexplained headaches
- renal failure, FTT, etc.)
selecting proper BP cuff size
- Bladder width must be at least 40% (typically, it extends approximately 2/3 of the upper arm.
- Bladder length should cover 80-100% of the upper arm circumference
- Upper extremity readings preferred
If elevated, b/p will need to be rechecked in
6 months
POC interventions for HTN
- Dietary teaching (salt restriction)
- Weight management/reduction
- Portion control; healthier food choices
- Increase physical activity
- Medication teaching (if pharm. Tx required)
- b/p management at home
- Routine checkups
*implemented for children above 90th but below 95th percentile!
resuscitation guidelines: inadequate breathing with HR > 60bpm
rescue breathing
resuscitation guidelines: inadequate breathing with HR < 60bpm (and poor perfusion)
begin compressions and rescue breathing per CPR guidelines
if a child is in cardiogenic shock or decompensating, the nurse may need to ___
call a rapid response and help with resuscitation
pericardium refers to
the sac of the heart
myocardium refers to
the muscle of the heart
endocardium refers to
the valves of the heart
incomplete presentation of kawasaki disease (infant)
fever for 7 days AND
if CRP < 3.0mg/dL and ESR < 40 mm/hr:
- serial clinical and lab re-eval if fever persists; Echo if typical peeling develops
if CRP >/= 3.0mg/dL and ESR >/= 40 mm/hr: 3 or more lab findings
1. anemia
2. platelet count >450,000 after day 7 of fever
3. albumin </= 3.0 g/dL
4. elevated ALT
5. WBC of >/= 15,000 mm3
6. urine >/= 10 WBC/hpf
OR postive Echo
live vaccines and IVIG
delay live vaccines for a whole year after IVIG
- live vaccines at 1 year: varicella and MMR
ASA major side effect
ototoxicity: ear issues, hearing issues
can you give ASA with NSAIDs?
no- bc ASA is considered an NSAID and we don’t give 2 NSAIDs together
- ASA and tylenol is okay NOT ASA and ibuprofen
HTN medications
- beta blockers
- angiotensin receptor blockers and ACEI- NO adolescent female bc of fetal risks
normal heart rhythm/EKG strip
normal sinus arrhythmia
- seen in sleep
heart rhythm: SVT
- consistently very quick
- kids can go as high as 200-300
- can lead to heart failure
what can you do if child is in SVT?
ice pack (bag of frozen veggies) on one side of face
carotid massage on one side of face
ice water
meds: adenosine (kicks in 10-20 sec), long-term digoxin
procedure: ablation
ALWAYS JUST ONE SIDE
