Circulatory Part 2 Flashcards
What Tetralogy of Fallot?
A combination of 4 defects
- VSD or hole in the heart
- Pulmonic stenosis (first major valve)
- Overriding aorta (bc the hole in the heart)
- Right ventricular hypertrophy (due to trying to work against the stenosis)
Tetralogy of Fallot
Because of the hole, the stenosis, the overriding, and the hypertrophy – what happens?
Tetralogy of Fallot
Murmurs due to turbulence
Cyanosis due to no blood going to lungs to be oxygenated
Tetrad Spells!!
- episodes of spasm due to hypoxia and cyanosis
Treatment for Tetralogy of Fallot
Two options :
Modified BT shunt for infants that are too young
Complete repair of the VSD (hole in heart) & opening that pulmonary valve (due to the stenosis)
How do tetrad spells make things worse in Tetralogy of Fallot cases?
The spasm is due to hypoxia but when the spasm happens, the blood gets shunted from right to left
What types of activities are strenuous and therefore can trigger Tetrad spells in an infant
Crying
Feeding
Pooping
Tetralogy of Fallot
What position can you put infant in to help with a Tetrad spell ?
What else can you do to calm baby?
Tetralogy of Fallot
Infant can be in knee chest position
- helps decrease metabolic needs of heart & returns blood flow to core
- calms them
Give them O2
IV morphine
Sedative
- all in an effort to get them calm and reestablish blood flow
Type of shunt they will do for Tetrology of Fallot’s tetrad spells?
Explain the shunt
Modified Blalock-Taussig Shunt
- BT shunt
Use subclavian artery to wrap around to the pulmonary artery to the lungs so more oxygenated blood can be made in the lungs
- will still have mixing of the blood and all bc the VSD is still open, but at least now half the blood has oxygen
BT shunt concerns/complications of Tetralogy of Fallot’s tetrad spells
Is a BT shunt a cure
Will the body adjust to the amount of blood flow it is receiving?
- can wrap band around the vessel to try to get less blow flow
Will it affect and distort the artery?
Will clots form from scarring?
No - the BT shunt wont stop spells from happening. But it is better than nothing. If you want a cure , gonna have to wait till infant is older for surgery of the actual pulmonic valve and closing the vsd.
What is Tricupsid Atresia?
Where is the valve supposed to be?
Tricuspid Atresia is when the Tricuspid valve fails to develop
Tricupsid valve is supposed to be in between Right atrium and ventricle.
So what four ways are the only ways really for the blood to flow in a Tricuspid Atresia?
- Initial way is with the patent foramen ovale that you have as a fetus/newborn. But that eventually closes.
- Second way is by making an ASD or atrial septal defect on purpose between the right atrium and right ventricle (where it should’ve been)
- Third way is VSD from L to R side of heart
- Fourth way is the PDA or patent ductus arteriosus from birth as well
Symptoms of Tricuspid Atresia that are most concerning
Older kids?
Cyanosis
Tachycardia
Dyspnea
Older kids have hypoxemia with clubbing
What is TGA or Transposition of Great arteries or vessels?
Pulmonary artery and Aorta are switched causing un-oxygenated blood to go to tissues (the blood that is oxygenated just goes on a repeat loop to lungs)
With a TGA, how would you get oxygen?
PTO or patent foramen ovale
ASD
VSD
What is the first form of treatment options done for TGA?
What is the main surgery? Complications?
Septal defect catheter to make an opening first. This way they don’t have to do surgery quite yet.
Main surgery you go in and switch the vessels & coronary arteries.
Complications are that scarring can occur. and clots forming.
- can use balloon to keep this from happening
- complications from tga surgery tend to happen as they get older
Pre-op management before any heart surgery
How much o2?
RBC?
Nutrition
Education
Limit?
Keep them oxygenated as much as possible
Periodic Pheresis or take off rbcs and give back plasma to reduce polycythemia
Nutrition such as small frequent meals at 30 minutes tops
- breast feeding moms may pump and use bottle to add nutrients
tetrad education on oxygen
Limit squatting
In post op, the patient will have lots of tubing for drainage of pericardial sac. What should you as the nurse do?
Assess the tube to see how much drainage there is and what color it is
- if it is bright red, then you should call the surgeon.
What happens if in post op care, there is a clot in the tubing?
Blood can get trapped which makes it hard for the heart to contract or a tamponade. This is an emergent situation if it gets to that point.
- will need to do drainage of the heart or pericardialcentesis.
In post op care you notice a dysrhythmia. is this normal?
What do you monitor?
It is abnormal since most children don’t have these.
- monitor the ekg and QRST wave
How is cardiac output monitored in post op care of heart surgeries?
What meds can be given to increase cardiac output?
There will be lines to assess and monitor cardiac output and how the body is perfusing.
Inotropic agents to increase contractility such as noriepi
- nurse can adjust the rates
In post op care patient will be hooked up to endotracheal tube. What is the nurse supposed to do?
Do oral care of tube to avoid pneumonia from bacteria.
With messing with the heart with surgery , you can cause fluid shifting. What meds can help
What intervention can they do?
Diuretics
They can also put a band on the vessel if the blood flow is causing too many changes or fluid change for that matter.
Neurological insults that can happen post op heart surgery
What preventive measure is done before tho?
Seizures
- do assessment
- put on anticonvulsants
Cardiac bypass to oxygenate the blood for you if you are operating on the heart
Infections can happen from heart surgery due to invasiveness. How do they manage and treat this?
- Monitor tubes like you would monitor a foley (do they really need to be there? if not, remove them w doc permission)
- Antibiotics
Post op, what type of feeding might you do
Transpyloric tube or other tube to tube feed directly to stomach in small amounts
- keeps villi from becoming damaged
In heart surgery patient may lose a lot of blood. What should you as the nurse do?
Look at EBL
See if there are replacement orders
Monitor coagulation and H&H
Pain management needs post op
Narcotics
Sedation with neuro blockage
What is heart failure?
Will surgery fix the issue?
Heart fails to perfuse the human body to acceptable amount
No. it won’t be fixed. Just better
How to care for heart failure?
What are symptoms? L&R?
Monitor for signs of Heart failure
Left- sob, pulm congestion, breathing rate, lack of perfusion
right - weight gain, edema, abdominal distention, backed up liver
Who is involved in the care for those with heart failure
PCP and cardiologist
Family
Name types of meds that help treat heart failure?
What should activity levels be like in those with heart failure?
Digoxin - loading dose is higher than maintenance to increase contractility
Ace inhibitors -pril. In order to decrease systemic work
Diuretics to reduce blood volume
Supplement O2
And decrease demand
- no fevers or illness
- no running or anything
What does digoxin do?
What do you need to do before giving this digoxin?
What lab might be good to check ?
Increases contractility of the heart
Check apical pulse for a full minute to see if you need to hold it
- infants = below 90, hold
- older kids = below 70, hold
Potassium. toxicity occurs with hypokalemia
When sending a family home with digoxin, what do you need to see them do first?
Signs of toxicity?
Check pulse but also draw up the digoxin.
- there is a small window for toxicity to appear
n/v early on
bradycardia
dysrhythmias
What is Endocarditis
What causes it?
What are the risk factors?
When an organism infects heart tissue and develops into vegetation & causes valve dysfunction
- strep
- staph
- candida
Risk factors include procedures or infections
What is a major problem from endocarditis?
Due to valves not working, stasis can occur & then the clots form
Clinical manifestations of endocarditis
Splinters hemorrhages on the nails
Osler nodes - red painful nodes on pads of phalanges
Janeway lesions - like petechiae but not painful
Petechiae
Murmur
Management of long term endocarditis
What if someone has had endocarditis before?
Longterm IV antibiotics
Blood cultures done to see if infection is present
Echo to look at vegetation
If you’ve had endocarditis before, you are at risk to have it again.
- need to give antibiotics before any procedure to reduce risk
What is acute rheumatic fever caused by?
Happens after a strep infection that has an abnormal immune response that follows &&& can do damage to the heart valves.
What happens to the heart due to Rheumatic fever?
What happens to respiratory?
What does Rheumatic fever sound like?
What will you see on EKG with Rheumatic fever?
Carditis of the heart, Cardiomegaly on xray
Tachycardia
Chest pain
Muffled heart sounds from exudate
Pericardial friction rub from build up of fluid
Prolonged PR interval on EKG
Rheumatic fever nursing care includes treating the
strep throat with antibiotics
- can also be given prophylactically to prevent another issue
- can take prophylactically forever
What is Kawasaki disease?
What does it cause?
Systemic vasculitis that only occurs in kids around 5 and younger - 3 phases
Causes coronary artery change that results in aneurysms.
- Remains forever too.
What will fever be like in Acute phase of Kawsakis?
What about the features of the face in acute phase?
What happens to extremities in acute phase?
What about the lymph nodes?
Most of all, how will the child act?
Abrupt fever
Conjunctiva red but with whiteness around pupils
Red cracked lips and reddening of the tongue
Rash on palms and soles and in diaper area.
Edema in hands and feet
Temporary arthritis usually in small joints
Cervical lymphadenopathy
Very Very irritable from CNS affects
Subacute stage of Kawasakis fever changes and child behavior?
What will an echo show?
What will aneurysms be like in subacute phase?
What will joints feel like?
What happens to the skin of extremities?
Fever resolves now but child is still irritable.
Changes in coronary vessels based off echo
And the aneurysms are expanding
Arthritis’s in larger joints
Thrombosytosis
Periunugual desquamation or skin peeling under fingers and toes
Convaslescent stage of Kawasakis
Outward symptoms resolved but Inflammation still present tho
Thrombosytosis
Arthritis
This stage is complete when lab lvalues return to 6-8 weeks
Biggest threat of Kawasaki’s?
What are clinical signs of MI in young kids like?
What about older children?
Expanding aneurysm or MI
Very subtle signs.
- inconsolable crying, pallor, shock symptoms
Older kids have chest pain or pressure
Treatment meds of Kawasaki includes
High dose IVIG (immunoglobulin)
Salicylates for control of fever and inflammation
Low dose aspirin for anti-platelet affect
What if someone has residual Kawasaki or cardiac issues?
Long term follow up
How should IVIG be adminsiterd for Kawasaki
Low and slow & monitor for rxns
- the large amount of fluid and anapylactic shock
What type of hydration should be in Kawasaki
Adequate but not too much. don’t want to overload
- strict I&O as well
