Congenital CV Dysfunction Flashcards
Assessment of cardiac fxn
- hx: parental concerns, mother’s health and preg, family hx (down/Turner sx)
- inspect: nut state, color, chest deformities, unusual pulsations, resp excursion, clubbing, tachy, poor wt
- palpate and percuss chest, ab, peripheral pulses
- auscultate heart rate and rhythm, BP (both arms, one leg), character of heart sounds
Diagnostics for CV dysfxn
- chest xray
- 15-lead EKG
- CBC
- Echocardiogram
- arterial blood gas
- cardiac catheterization
Cardiac Catheterization
Advance a cath thru a vein into the heart to diagnose or do intervention
- often go in on right side bc safer and better access to heart
Cath pre-op care
- assess–won’t go through areas with bad acne or rash bc infection risk
- mark pulses on feet
- NPO 4-6h, clarify AM meds (may hold some)
- IVF? may be needed for young kids
- dev appropriate psych prep - what to expect after
- sedation?
Cardiac cath post-op
- observe for complications
- post op VS and resp status
- pulses distal to the site can be weaker for first few hours but should be equal after, still want to feel a pulse
- dressing for bleeding–put pressure an inch above the site if suspect bleeding, have Drs come look
- fluid intake, both IV and PO
- hypoglycemia
- keep leg straight and will have to lay flat for awhile
D/C planning after cardiac cath
- dressing for 24h
- no tub baths for 48h
- rest that night then back to normal
- teach s/s of infection
Dev differences in infants
- ventricles are equal size at birth
- heart has less fxnal capacity
- normal O2 sat 95-100
- infants and small kids have thin chest walls with little SQ fat/muscle
Function of the foramen ovale
Hole in infants that allows blood to pass directly from right atrium to left without going into the lungs
Ductus venosus
Hole in infants that allows blood to go from the umbilical vein to the inferior vena cava, bypassing the liver
Fetal circulation
Oxy blood goes through umbilical vein to liver and divides–half to liver and half to inferior vena cava via ductus venosus (which closes after birth) then into right atrium, thru the foramen ovale, left atrium, left ventricle, aorta, full body
Ductus arteriosus
Bypass lungs; fetal hole that shunts blood returning to the heart from the right atrium to the descending aorta, which connects to the umbilical arteries and sends blood back to the placenta
Why does the fetal heart have holes?
Lungs and liver are underdeveloped so the holes bypass these areas
Placenta
Organ in the uterus (womb) that connects to the infant’s umbilical cord; umbilical veins and arteries end here and it helps pass waste products and CO2 to pass to the mother’s circulation to be cleansed
Fetal shunts
Holes that close at birth or shortly after bc dec maternal hormone prostaglandin E, inc O2 saturation from baby first breath, and pressure changes in the heart
Clinical findings for cardiac defects
- feed prob and FTT
- dyspnea
- stridor or choking
- HR over 200, resp rate over 60
- knee chest position
- cyanosis
- recurrent RTI
- poor phys dev in older kids, delayed milestones, dec exercise tolerance
- heart murmur
- excess perspirations
- s/s heart failure
Cardiac hemodynamics
blood enters R atrium, thru tricuspid valve, R ventricle, out the pulmonary valve/artery to the lungs; comes back in through the pulmonary veins, left atrium, mitral valve (bicuspid), left ventricle, aortic valve/aorta (ride TRIcycle before BIcycle)
Which side of the heart has more pressure and why does it matter?
Left has more pressure–if hole between the ventricles, blood flows from higher pressure to lower pressure
2 major effects of CHD
- left-right shunting of blood
- dec pulm blood flow
clinical consequences of left-right shunting
- caused by systemic pressure being greater than pulm pressure
- inc blood volume on right side of heart inc pulm blood flow at expense of systemic blood flow
- s/s CHF
Congestive heart failure causes
inability of heart to pump enough blood to meet body’s demands
- volume overload (most common in kids from defects)
- pressure overload
- dec contractility
- high cardiac output demands
CM of pulmonary venous congestion
- pulmonary venous congestion–tachypnea, wheeze, crackles, retractions, cough, dyspnea on exertion, grunt, nasal flaring, cyanosis, feeding probs, irritable, fatigue with play
CM of systemic venous congestion
hepatomegaly, ascites, edema, wt gain, neck vein distention
CM of impaired myocardial fxn
inc HR, low BP, weak peripheral pulse, extended cap refill, pallor, cool extremities, low urine, gallop rhythm, fatigue, restless, enlarged heart, sweat, high metabolic weight–FTT
Therapeutic goals for CFH
- improve cardiac fxn
- remove accum fluid and sodium
- dec cardiac demands
- improve tissue oxy and dec oxy consumption
Meds used in CHF
- furosemide (Lasix)–monitor potassium
- ACE inhibitors–Prils, dec BP
- digitalis–given often to kids with CHF, only oral drug that causes heart to pump better, inc contracility
Digoxin rules
- regular intervals
- 1h before or 2h after eating
- not given with food
- brush after admin bc can stain
- if miss dose and was under 4h, can give, if missed and was over 4h, withhold
- call provider if miss 2+ doses
- don’t repeat if kid vomits bc vom is sign of digoxin tox
- check K levels before giving in hospital and hold if K levels are low
- assess apical pulse for full minute before giving in hospital
Digoxin toxicity s/s
nausea, vom, bardy, anorexia, neuro/visual disturbances
Digoxin tox NC
- monitor for dysrhythmias bc tox can cause hyperkalemia
- Digibind is given for digitas tox–need to watch rapidly dropping K levels when give
CHF NC; activity intolerance
- promote rest
- prevent crying
- group activities
- short intervals of play, cuddle
- provide neutral thermal enviro–don’t want shiver to expend energy
- supp oxy–their baseline may be low
- treat infx so body does not need to
- may need to sedate irriated kids
CFH NC; altered nutrition
- anticipate hunger and have food ready
- smaller, more freq feedings
- feed no longer than 30 min at time and give rest thru feeding tube
- feed in relaxed enviro
- semi-erect position
- burp before, during, after
- formula with inc calories per ounce
- use soft preemie nipple–easier than breast
CHF NC: ineffective breathing pattern
- assess resp rate, effort, O2 saturation
- position to encourage max chest expansion
- avoid constriction
- humidified supp oxygen; during stressful periods like bouts of crying and invasive procedures
NC for CHF: potential for infx
- good handwash
- avoid crowded public places
- screen visitors
NC for CHF: fluid volume excess
- weigh daily
- accurate I&O
- assess for edema
- maintain fluid restriction if ordered
- provide food skin care
- change position freq
Family edu/support for CHF
- stress good nut and feeding
- immunizations UTD
- teach s/s worsening clinical status
- promote growth and dev
- let them be a child as much as possible
Defects that cause inc pulm blood flow
- atrial septal defect
- ventricular septal defect
- patent ductus arteriosus
Defects that cause dec blood flow to areas of the body– obstructive lesions
- coarctation of the aorta
- aortic stenosis
- pulmonic stenosis
arterial septal defect (ASD)
Patent foramen ovale of failure of a septum to completely dev between R/L atria causing blood to flow from the left side (more pressure) to the right side
ASD CM and tx
May be asymptomatic
Heart murmur
CHF
Increased risk for dysrhythmias with pulmonary
vascular obstructive disease & emboli later in life
Treatment
Mild defects may close spontaneously or be left alone
Open heart surgery & Dacron patch closure
May be closed using devices (septal occluder) during
cardiac catherization..
ventricular septal defect
Abnormal opening btwn ventricles from failure to close so blood flows from left side to right side; causing lack of oxygenated blood leaving left vent
VSD CM
- CHF; moderate to severe, cyanosis
- Characteristic murmur
- Right Ventricular hypertrophy
- Failure to Thrive
- Fatigue
- Recurrent respiratory infections
VSD therapeutic management
- pulm artery banding
- may close spontaneouly by age 3Y
- interventional heart cath with septal occluder OR surg correction with patch and repair of AV tissue
Patent ductus arteriosus
ductus arteriosus fails to close so blood shunts from aorta to pulm artery–more blood going to lungs and less to body
PDA CM
Asymptomatic or murmur, CHF sx
PDA sx
- indomethacin (prostaglandin E inhibitor)
- heart cath with coil
- left thoractomy or video-assisted thoroscopic surg–3 small incision on left side of chest to place a clip on the ductus
Clinical consequences of obstructive lesions
- Blood exiting the heart meets an area of anatomic
narrowing, causing obstruction to blood flow. - The obstruction usually occurs near the valve as in
aortic and pulmonic stenosis. - Either shunting (left to right) or back-up of blood
on the right side. - Increased pulmonary congestion
- Signs of CHF
coarctation of the aorta
narrowing of aortic arch, usually distal to the ductus arteriosus and beyond the right subclavian but can be anywhere on the aorta; blood goes certain areas more than others (usually lower extremities get less)
Coarctation of the aorta Clinical consequences
- L-R shunting, inc blood flow leading to CHF
- inc flow to head and upper extremities
- dec flow to trunk and lower extremities
- may mean big difference in BP btwn upper and lower extremities
management of coarctation of the aorta
- prostaglandin E to maintain PDA
- balloon angioplasty
- surgery w/i first 2 years–try to wait until child has grown some to adult height to prevent straining on the site
aortic stenosis
narrow of aorta valves which interferes with L vent flow; blood backs up into right side of heart and get L vent hypertrophy bc blood can’t get out, pulmonary vascular congestion, dec cardiac output
Aortic stenosis is serious
- obstructions are often progressive
- inc risk heart attack or low cardiac output
- surgical repair rarely results in normal valve
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 tx
- balloon dilation
- surgery–aortic valvotomy or replacement. mortality high in NB low for older kids
aortic stenosis NC
- activity level restricted in kids but not bed rest
- ex: watch movie instead of play outside, take elevator instead of stairs
Pulmonary stenosis
Defect involves narrowing or constriction of valves of the
pulmonary artery interfering with right outflow
Pulmonic stenosis CM
- asymptomatic, mild cyanosis or CHF, murmur
- tx–balloon angioplasty, surgery
Monitor for CHF
- tachy
- diaphoresis
- eating prob
- edema
- rales, crackles
Acyanotic defects include
ASD, VSD, aortic stenosis, pulmonic stenosis, coarctation of the aorta, patent ductus arteriosus
Cyanotic heart defects
- More severe
- require at least 1 surgery
- get CHF more severe
- get dec pumonary blood flow or mixed blood flow resulting in hypoxia or cyanosis
Cyanotic heart defect additional symptoms
cyanosis, polycythemia, digital clubbing, altered ABGs
NC for cyanotic heart defects
- good skin care
- supp oxy–watch orders bc they may be weird
- monitor for and prevent dehydration
- dev appropriate prep for tests and procedures
- anxiety caused by cyanosis
- prevent resp infection
Tetralogy of fallot
VSD, overriding aorta, pulmonic stenosis, R ventricular hypertrophy
Tetralogy of Fallot CM
heart murmur with a thrill,
polycythemia, hypoxic episodes (squatting
position), metabolic acidosis, poor growth,
clubbing, exercise intolerance
How is tetralogy of fallot surgery performed?
in stages
Hypoxic spell/Squatting/Tet spell and NC
Kids squat to reroute blood and inc systemic resistance–pushes blood to heart and vital organs
- knee chest position–kids do automatically but help infants
- 100% oxy by face mask then morphine if doesn’t work
- IVF replacement and volume expansion if needed
tricuspid atresia
Failure of the tricuspid valve to develop resulting in severe right hypoplasia or absence of the
right ventricle
Tricuspid CM and tx
- CM is cyanosis, tachy, SOB
- tx is prostaglandin E to maintain foramen ovale
- digoxin and diuretics
- palliative surgical repair to inc pulm blood flow
- never great quality of life
- use O2 before drawing their blood
Transposition of the great arteries
Pulmonary artery arises from left ventricle and the aorta
arises from the right ventricle resulting in mixed blood flow No communication between
the systemic and pulmonary circulations
Transposition of great vessels s/s, tx
- Must have an associated defect that permits
blood mixing to be compatible with life like patent foramen ovale - S/S; increasing cyanosis as foramen ovale
closes. - Treatment; Arterial switch procedure in the first
few weeks of life. - IV prostaglandin E to keep foramen ovale open
and/or balloon atrial septostomy
Truncus arteriosus
Pulmonary artery and aorta fail to divide during
embryonic development. One single large vessel
empties both ventricles
Truncus Arteriosus CM and tx
- CM–cyanosis, CHF, murmur
- tx–surgical repair during first few months of life; digoxin and diuretics
- quality of life is alright
Hypoplastic left heart syndrome (HLHS)
Left ventricle underdeveloped–Aortic valve atresia, mitral atresia or stenosis, small or absent
left ventricle, severe hypoplasia of the ascending aorta and
aortic arch; descending aorta gets blood from PDA
HLHS s/s
cyanosis, weak peripheral pulses, cool extremities, resp distress, often no murmur
HLHS therapeutic management
- Prostaglandin E to keep PDA
- Fontan Procedure- direct blood flow to
pulmonary artery from RA - Norwood Procedure-Anastomosis of main
PA to the aorta, shunt from RV to PA - Transplant!!
Complications of heart surgery
- CHF
- dysrhythmias
- cardiac tamponade–fluid gathers around heart and cosntricts it (restricted mvt of heart, narrow pulse pressure, SOB)
- atelectasis, pneumothorax, pulm edema, pleural effusions
- cerebral edema and brain damage
- hemorrhage or anemia
D/C planning
- wound care
- med teaching
- bacterial endocarditis prophylaxis
- when to call practitioner
- self limit activity
- meet dev needs
