Ch 39 Peds Cardiovascular Flashcards
Congestive Heart Failure
inability of the heart to pump a sufficient amt of o2 to meet the metabolic needs of the body
infants/ children: most often d/t congenital defects (shunt, obstruction, or combo) –> causes excessive volume / pressure load on myocardium
infants / children: usually a combo of left/right sided heart failure
CHF goals of tx
improve cardiac function remove accumulated fluid and sodium decrease cardiac demands improve tissue oxygenation decrease oxygen consumption
CHF assessment (early signs)
tachycardia tachypnea profuse scalp diaphoresis (esp in infants) fatigue / irritability sudden weight gain respiratory distress
CHF interventions
monitor for facial or peripheral dependent edema, auscultate lung sounds
elevate head of bed in semi fowlers position
neutral thermal environment
admin cool humidified o2 as rx (oxygen hood for young infants, nc for older infants/children)
org nursing activities for uninterrupted sleep
small, freq feedings
admin sedation as rx during acute stage to promote rest
admin digoxin (Lanoxin) as rx
admin ACE inhibitors as rx
admin diuretics (furosemide (lasix))
admin potassium supplements
monitor serum electrolyte levels
digoxin (Lanoxin)
assess apical pulse for 1 minute before admin
hold if: infants/ young child < 90-110 bpm
older children < 70 bpm
infants RARELY receive > 1 mL (0.05 mg) in one dose
monitor for signs of dig toxicity: anorexia, poor feeding, N&V, bradycardia, dysrhythmias
normal dig level: 0.5 - 2 ng/mL
dig toxicity > 2 ng/mL
angiotensin converting enzyme inhibitors
monitor for hypotension, renal dysfxn, and cough
assess BP, serum protein, albumin, BUN, creatinine levels, WBC count, urine output, urine specific gravity, urine protein level
diuretics
ie furosemide (Lasix)
monitor for s/sx of hypokalemia
hypokalemia potentiates digoxin toxicity
s/sx of hypokalemia
serum K < 3.5 mEq/L muscle wkns & cramping confusion irritability restlessness inverted T waves / prominent U waves *hypokalemia potentiates dig toxicity
CHF potassium levels
supplemental K given only if indicated by serum K levels
AND if adequate renal fxn is evident
usually necessary if admin a NON K sparing diuretic (ie Lasix)
foods high in K
bananas
baked potato skins
peanut butter
normal K levels
3.5 - 5.1 mEq/L
CHF s/sx of dehydration
sunken fontanel nonelastic skin turgor dry mucous membranes decreased tear production decreased urine output concentrated urine
CHF monitor Na levels
normal 135 - 145 mEq/L
many infant formulas have > Na than breast milk
s/sx of CHF: LEFT sided failure
crackles/wheezes cough dyspnea grunting (infants) head bobbing (infants) nasal flaring orthopnea periods of cyanosis retractions tachypnea
s/sx of CHF: RIGHT sided failure
ascites hepatosplenomegaly jugular vein distention oliguria periph edema (esp. dependent& periorbital) weight gain
Digoxin (Lanoxin) admin
admin 1 hr before OR 2 hrs after feedings
do not mix med w foods or fluid
missed dose by > 4 hrs, withhold dose and give next dose at scheduled time
missed dose < 4 hrs, give missed dose
vomit –> do not give 2nd dose
2+ doses missed –> notify dr
teeth = give water after dose
Defects w Increased pulmonary blood flow
intracardiac communication along septum, or abnormal connection bet the great arteries, allows blood to flow from high pressure L side to low pressure R side infants shows s/sx of CHF *atrial septal defect (ASD) *atrioventricular canal defect *patent ductus arteriosus *ventricular septal defect (VSD)
s/sx of decreased cardiac output
dec peripheral pulses exercise intolerance feeding difficulties hypotension irritability, restlessness, lethargy oliguria pale, cool extremeties tachycardia
atrial septal defect (ASD)
abnormal opening bet atria –> causes an inc. flow of oxygenated blood into R side of heart
right atrial / right ventricular enlargement
infant: asymp. or CHF sym
s/sx of dec. cardiac output
types: ASD 1, ASD 2, ASD 3
tx: closed via cardia cath OR open repair w cardiopulm bypass (before school age)
ASD 1 (ostium primum)
opening at the lower end of septum
ASD 2 (ostium secundum)
opening is near center of septum
ASD 3 (sinus venosus defect)
opening is near the jxn of the superior vena cava and the right atrium
atrioventricular canal defect
results from incomplete fusion of endocardial cushions
most common cardiac defect in DOWN SYNDROME
characteristic murmur
infant: mild - mod CHF w cyanosis
s/sx of dec. cardiac output
tx: pulm artery banding for infants w severe sx (palliative) or complete repair via cardiopulmonary bypass
patent ductus arteriosus
failure of the fetal ductus arteriosus (artery connecting the aorta + pulmonary artery) to close w/in the first wks of life
machinery like murmur present
infant: asymptomatic or signs of CHF
widened pulse pressure and bounding pulses
s/sx of dec. cardiac output
tx: indomethacin (Indocin) admin to close defect in premature infants & newborns (prostaglandin) OR may be closed during cardiac cath or surgical management
ventricular septal defect (VSD)
abnormal opening bet right & left ventricles
many close spontaneously during 1st yr of life in children w small/mod defects
characteristic murmur
s/sx of CHF common
s/sx of dec. cardiac output possible
tx: closure during cardiac cath OR open repair w cardiopulmonary bypass
Obstructive Defects
blood exiting a portion of the hart meets an area of stenosis. location of narrowing is usually near the valve of obstructive defect infants & children = s/sx of CHF mild obstruction may be asymptomatic *aortic stenosis *coarctation of the aorta *pulmonary stenosis
Aortic stenosis
resistance to blood flow from left ventricle into aorta
results in dec. cardiac output, left ventricular hypertrophy, pulmonary vascular congestion
*valvular stenosis is most common type (usually d/t malformed cusps –> bicuspid instead of tricuspid valve OR fusion of cusp)
ch. murmur
severe defect infants = signs of dec. car out
children = exercise intol, CP, dizzy
Aortic stenosis tx
dilation of narrowed valve by cardiac cath
surgical aortic valvotomy (palliative), valve replacement at second procedure
coarctation of the aorta
localized narrowing near the insertion of the ductus arteriosus
BP higher in upper extremeties (bounding pulses in arms, weak femoral pulses)
sx: headaches, dizziness, fainting, epistaxis from HTN
coarctation of aorta tx
balloon angioplasy in children (restenosis can occur)
surgical: mechanical ventilation and meds to improve cardiac output pre op
resection of coarcted portion, enlargement of constricted section using graft.
defect outside heart –> cardiopulmonary bypass not required / thoracotomy incision used
coarctation of aorta
BP higher in upper ext than lower ext
arms = bounding pulses
femoral = weak or absent
lower ext: cool temps
pulmonary stenosis
narrowing at entrance to pulmonary artery
blood flow resistance –> R ventricular hypertrophy (hypoplastic) & dec. pulmonary blood flow
severe –> CHF occurs
pulmonary atresia
extreme form of pulmonary stenosis
total fusion of the commissures and NO blood flows to the lungs
pulmonary stenosis tx
dilation of narrowed valve via cardiac cath
surgical:
infants - transventricular (closed) valvotomy
children: pulmonary valvotomy w cardiopulmonary bypass
defects w dec. pulmonary blood flow
obstructed pulm blood flow AND anatomical defect (ASD or VSD) bet R and L sides of heart
pressure on R side of heart inc., exceeds pressure on L side, allos desaturated blood to shunt R to L –> causes desat in systemic circulation
- hypoxemia and cyanosis
*tetralogy of fallot
*tricuspid atresia
Tetralogy of Fallot
four defects: 1. VSD 2. pulmonary stenosis 3. overriding aorta 4. R ventricular hypertrophy pulm vasc resis > system resis --> RtoL system resis > pulm vasc resis --> LtoR
Tetralogy of Fallot: infant
may be acutely cyanotic at birth or may have mild cyanosis - progresses over time as pulm stenosis worsens
acute episodes of cyanosis and hypoxia = “blue spells” or “tet spells” occur when infants’s o2 req exceed blood supply
Tetralogy of Fallot: child
inc. cyanosis, squatting, clubbing of fingers, poor growth (d/t inc. cyanosis)
squatting = compensatory mech to return blood flow to heart for oxygenation
Tetralogy of Fallot: surgical management
palliative shunt: inc. pulmonary blood flow and inc. o2 sat in infants who cannot undergo primary repair. shunt provides blood flow to pulm arteries from L or R subclavian artery
complete repair: usually performed w/in 1st yr of life. req. median sternotomy and cardiopulm bypass
tricuspid atresia
failure of the tricuspid valve to develop
no communication bet R atrium and R ventricle
blood floow through an ASD or patent foramen ovale to L side of heart and through a VSD to the R ventricle and out to the lungs
*often associated w pulmonic stenosis & transposition of the great arteries
–> complete mixing of unoxyg & oxyg blood in the L side of the heart
tricuspid atresia tx
if ASD is small, defect may be closed during cardiac cath
otherwise, surgery
mixed defects
full saturated system blood flow mixees w desat blood flow, causing desat of the system blood flow
- -> pulm congestion and cardiac output dec
- hypoplastic left heart syndrome
- total anomalous pulmonary venous connection
- transposition of the great arteries or transposition of the great vessels
- truncus arteriosus
hypoplastic left heart syndrome
underdevelopment of the L side –> hypoplastic left ventricle and aortic atresia
*defect is fatal in the first few months of life w/o intervention
hypoplastic left heart syndrome tx
surgical tx: necessary –> transplantation may be considered
preop period: newborn req mech ventilation and a cont. infusion of prostaglandin E1 to maintain ductal patency, ensuring adequate systemic blood flow
transposition of the great arteries or transposition of the great vessels
pulm artery leave the L ventricle, aorta exits from the R ventricle
no communication exists bet the systemic and pulm circulation
cardiomegaly is evident a few wks after birth
transposition tx
nonsurgical: prostaglandin E1 may start to inc. blood mixing temporarily if systemic and pulm mixing are inadequate
baloon atrial septostomy during cardiac cath may be done to inc. mixing and maintain cardiac output
surgical: arterial switch procedure (L ventricle acts as systemic pump, new aorta created)
total anomalous pulmonary venous connection
failure of the pulmonary veins to join the left atrium
mixed blood returns to the R atrium and shunts from the R to the L through an ASD
R side: hypertrophies
L side: remains small
total anomalous pulm venous connection tx
surgical: corrective repair performed in early infancy
pulmonary vein is anastomosed to the L atrium, ASD closed, anomalous pulm venous connection is ligated.
truncus arteriosus
failure of normal septation and division of the embryonic bulbar trunk into the pulm artery and the aorta –> single vessel that overrides both ventricles
blood from both ventricles mixes in the common great artery
mod - severe CHF
truncus arteriosus tx
surgical tx: corrective surgical repair performed in 1st few mo of life
Priority Nursing Actions HYPERCYANOTIC SPELL (infant)
- place infant in knee-chest position
- admin 100% o2
- admin morphine sulfate
- admin fluids IV
- document occurrence, actions taken, infant’s response
Cardiovascular Defects: Interventions
auscultate for crackles, rhonchi, or wheezes
if resp effort inc. –> place child in reverse trendelenburg position, elevating the head and upper body to dec. work of breathing
assess for signs of CHF (periorbital edema or dependent edema in hands/feet)
Cardiac Catheterization
invasive dx procedure to determine cardiac defects
provides info about o2 sat of blood in great vessels and heart chambers
dx/ interventional/ electrophysiological reasons
general anesthesia usually unnecessary
may be outpatient
Cardiac Cath risks
hemorrhage from entry site
clot formation and subsequent blockage distally
transient dysrhythmias
Cardiac Cath preprocedure nursing
assess accurate height / weight –> determines selection of catheter
allergic rxns to iodine
assess and mark bilateral pulses
assess baseline o2 sat
Cardiac Cath postprocedure nursing
monitor finding on cardiac monitor and o2 sat for 4 hrs after procedure
assess affected extremity (coolness may = arterial obstruction)
vital signs q15min x 4, q30min x 4, q1h x 4
immobilize affected extremity in a flat position for at least 4 -6 hrs for venous entry site and 6-8 hrs for arterial entry site
acetaminophen / ibuprofen for pain / discomfort
Cardiac cath discharge
remove dressing day after procedure –> bandaid for 2-3 days
no tub baths for 2 -3 dys
rheumatic fever
inflammatory autoimmune disease that affects connective tissues, and blood vessels of the CNS
most serious complication = rheumatic heart disease (affects cardiac valves, esp mitral valve)
manifests 2-6 wks after an untx group A betahemolytic streptococcal infection of the upper resp tract
Jones Criteria for dx of rheumatic fever
Major Criteria: carditis arthralgia chorea erythema marginatum subcutaneous nodules Minor Criteria: fever arthralgia Elevated erythrocyte sedimentation rate or positive C reactive protein level prolonged PR interval on ECG ** to dx: 2 major OR 1 major + 2 minor must be accompanied by evidence of preceding strep infection
Rheumatic fever assessment
fever elevated antistreptolysin O titer elevated erythrocyte sedimentation rate elevated C reactive protein level Aschoff bodies (lesions): found in heart, blood vessels, brain, and serous surfaces of the joints / pleura
chorea RF
involuntary mvmts of extremities and face –> affects speech
carditis RF
inflammation of all parts of the heart, primarily the mitral valves
erythema marginatum RF
red skin lesions starting on the trunk and spreading peripherally
subcutaneous nodules RF
small, nontender swellings, often over the joints
polyarthritis RF
tender, painful joints (elbows, knees, ankles, wrists)
Rheumatic Fever interventions
control joint pain and inflammation w massage and hot / cold tx
bed rest during acute febrile phase
abx (penicillin) as rx
admin salicylates and anti inflammatory agents as rx (mask polyarthritis –> do not give before dx confirmed)
sz precautions if experiencing chorea
Kawasaki Disease
aka mucocutaneous lymph node syndrome
acute systemic inflammatory illness
*cardiac involvement is most serious complication –> aneurysms can develop
Kawasaki assessment
acute stage: fever, conjunctival hyperemia, red throat, swollen hands, rash, enlargement of cerical lymph nodes
Subacute stage: cracking lips and fissures, desquamation of the skin on the tips of the fingers/ toes, joint pain, cardiac manifestations, thrombocytosis
convalescent stage: child appears normal but signs of inflamm may be present
Kawasaki interventions
monitor temp frequently
assess: heart sounds, heart RR, extremities (for edema, redness, and desquamation), eyes (for conjunctivitis), mucous membranes (for inflamm).
admin soft foods / liquids that are not too hot / cold
passive ROM exercises to facilitate joint mvmt
admin acetylsalicylic acid (aspirin) as rx
admin immunoglobulin IV as rx to reduce duration of the fever and incidence of coronary artery lesions and aneurysms (blood precautions)
signs of aspirin toxicity
tinnitus,
HA,
vertigo,
bruising
hemoptysis
coughing up blood
hematemesis
vomiting up blpod
melena
blood in stool
Kawasaki teaching
avoid admin of MMR or varicella vaccine to the child for 11 mo after IV immunoglobulin therapy
s/sx of kawasaki disease
irritability that may last for 2 mo after onset of sx
peeling of hands / feet
pain in joints persisting for several wks
stiffness in morning, after naps, and in cold
