Exam 2: Cardiovascular Dysfunction Flashcards
Fetal circulation differs from neonatal circulation in what ways
- The process of gas exchange
- Pressures within the systemic and pulmonary circulations
- Existence of anatomical structures
How is cardiovascular dysfunction diagnosed?
- Electrocardiography (ECG/EKG)
- Chest radiography
- Echocardiography
- Cardiac MRI
- Cardiac Catheterization
Differentiate between the two major groups of CV dysfunction
- Congenital heart disease: present at birth
- Acquired cardiac disorders: occurs after birth and seen with a normal heart or in the presence of congenital heart defects
Cardiovascular Dysfunction: History and Physical
- Family history
- Prenatal history
- Birth history
- Inspection, plantation/percussion, and auscultation
Risk Factors for Congenital Heart Disease
- Maternal alcohol/illicit drug use
- Congenital disorders: Down syndrome or Turner syndrome
Assessment of Cardiac Function: Murmurs
- Heart sounds that reflect the flow of the heart
- 80% of children have an innocent murmur at some point
Assessment of Cardiac Function: History
- Poor feeding
- Rapid breathing
- Sweating with feeds
- Poor weight gain
- Headaches/fainting
- Exercise intolerance
- Chest pain/palpitations
What is the most common heart defect?
Ventricular septal defect
Congenital Heart Disease
- Major cause of deaths in 1st year of life
- Cause unknown
- Often associated with chromosomal abnormalities
Ductus Arteriosus (PDA)
- Connects aorta and pulmonary system
- Closes 4-6 weeks (if open >6 weeks -> defect)
- Closes d/t pressure changes when infant takes first breath
Foramen Ovale
- Opening between right atrium and left atrium.
- Closes: birth - 2 weeks
- If it stays open: atrial septum defect
Ductus Venosus
- Close: within a couple of hours
- Alway automatically closes, never becomes a defect
- Changes in circulation after first breath d/t pressure changes
LA and LV
Higher pressure
RA and RV
Lower pressure
Review Fetal Circulation!
Watch videos on YouTube
Cardiac Testing involves
- Radiologic: CXR (size and blood flow pattern)
- Electrocardiography: electrical activity
- Echocardiography: Most frequently used; non-invasive
Cardiac Catheterization: Provides information on
Invasive procedure
- Oxygen saturation
- Pressure changes
- CO
- Anatomic abnormalities
Cardiac Catheterization: Nursing Responsibility
- Pulses
- Temperature and color of affected extremity
- VS: HR, BP (hypotension may indicate hemorrhage)
- Monitoring dressing
- Fluid intake (adequate hydration)
Cardiac Catheterization: Post Procedure Management
- Maintain straight extremity for 4-6 hours
- Resume usual diet
- Tylenol or Tylenol with codeine for pain
- No strenuous exercise for several days
- Monitor dressing frequently
Cardiac Catheterization: Dressing Management
- Occlusive dressing applied post catheterization
- Leave dressing on until next day to prevent bleeding and infection.
- Once dressing is removed, keep site clean and dry.
- If bleeding occurs, apply direct continuous pressure.
Heart Failure
- Inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the body’s metabolic demands
- Can have Congenital heart disease or a normal structure (can result from excessive workload on a normal heart)
Heart Failure: Classification of Causes
- Volume overload
- Pressure overload
- Decreased contractility
- High CO demands
Heart Failure is divided into 3 groups
- Impaired myocardial function
- Pulmonary congestion
- Systemic venous congestion
What is one of the earliest signs of heart failure? **
-Tachycardia (heart compensates by increasing
What is a late sign of heart failure?**
Gasping and grunting respirations (latest signs are related to respirations)
What is a major concern of heart failure?
Inability to feed (babies only eat, sleep and poop; can’t do them if there is an issue)
Heart Failure: Signs and Symptoms of Impaired Myocardial Function
- Tachycardia
- Sweating (inappropriate)
- Decreased urinary output
- Fatigue
- Weakness
- Restlessness
- Anorexia
- Pale, cool extremities
- Weak peripheral pulses
- Decreased blood pressure
- Gallop rhythm
- Cardiomegaly
Heart Failure: Signs and Symptoms of Pulmonary Congestion
- Tachypnea
- Dyspnea
- Retractions
- Flaring nares
- Exercise intolerance
- Orthopnea
- Cough, hoarseness
- Cyanosis
- Wheezing
- Grunting
Heart Failure: Signs and Symptoms of Systemic Venous Congestion
- Weight gain
- Hepatomegaly
- Peripheral edema
- Ascites
- Neck vein distention
Heart Failure is most often caused by
Congenital Heart Defects: Shunt, obstruction or combination of both
Another symptom of heart failure is
- Increased metabolic demands (requires additional calories to grow)
- Increase work of the heart and increase breathing further increases demands
Heart Failure Management
- Feeding
- Limit/cluster care
- Organize nursing activities around sleep and rest periods
- Bed linen changing and complete bed baths done only when necessary
- Limit crying episodes
- Monitor for fever (could indicate infection)
Heart Failure: Feeding Management
- Limit feeding time (30 minutes because after they will start to burn more calories than they are eating)
- Small frequent feeds
- Jaw and cheek support
- Increase caloric density of formula
- NG tube if needed (if can’t eat calories needed, with support, within time)
Pharmacological Management of Heart Failure
- Digoxin
- Diuretics: Furosemide (Lasix)
- Vasodilators: ACE Inhibitors (Captopril and Enalapril); Beta-Blockers
Heart Failure Drugs: Digoxin
Strengthens the force of myocardial contractions.
Digoxin: Nursing Assessment
- Apical heart rate checked prior to administering (infant: 90-110 or child: 70)
- Count pulse for 1 full minute
Digoxin: Nursing Management
- Double check dosage prior to giving
- Hold dose if toxicity symptoms occur
- If missed dose: do not give extra
- If vomiting: do not repeat
Digoxin Toxicity Symptoms
- Vomiting
- Bradycardia
- Neurological Disturbances
- Visual Disturbances
- Dysrhythmias
Heart Failure Drugs: Diuretics
- To eliminate excess water and sodium.
- Increased urine production
- Reducing systemic and pulmonary congestion
Furosemide (Lasix): Nursing management/interventions
- Potent loop diuretic
- Risk for hypokalemia (potentiates digoxin toxicity)
- Give potassium supplements and/or potassium rich foods.
- Observe for signs of dehydration.
Heart Failure Drugs: Vasodilators
- Relaxes smooth muscles
- Most commonly given: ACE-Inhibitors and Beta Blockers
Vasodilators: Vasodilation results in
- Decreased pulmonary and vascular resistance
- Decreased BP
- Reduces afterload
- Decreased RA and LA pressures
Vasodilators: Side Effects
- Hypotension
- Renal Dysfunction
- Cough
What are complications of HF? **
- Cardiomegaly
- Pulmonary edema
Furosemide: Monitor for S/S of hypokalemia
- Muscle weakness and cramping
- Confusion, irritability and restlessness
- Inverted T waves or prominent U waves
Furosemide: Monitor for S/S of dehydration
- Sunken fontanel
- Non-elastic skin turgor
- Dry mucous membranes
- Decreased tears, UO and concentrated urine
Heart medications: Indomethacin
- Antirheumatic
- Alternative to surgery, allows closure of PDA
- Action: inhibits prostaglandin synthesis
Heart medications: Prostaglandin E1
Short term maintenance of PDA latency required for infants to maintain blood oxygenation and perfusion of the lower body
Hypoxemia
Lower than normal arterial oxygen tension.
Cyanosis occurs if
- SaO2 <85%
- Hgb not bound to oxygen reaches 5g/dL
What are two physiologic changes of hypoxemia?
- Polycythemia
2. Clubbing
What are 3 types of cardiac defect display cyanosis?
- Obstruction of pulmonary blood flow
- Mixing of arterial and venous blood flow
- Transposition of the great arteries
What are long term effects of hypoxemia?
- Smaller stature
- Poor weight gain
- Dyspnea on exertion
- Poor exercise intolerance
Classification of Congenital Heart Defects
- Increased pulmonary blood flow
- Decreased pulmonary blood flow
- Obstruction to blood flow out of the heart
- Mixed blood flow
Congenital Heart Disease Classifications: Increased pulmonary blood flow
- Blood flows from the left ventricle (high pressure) to the right ventricle (low pressure)
- Increased blood flow on the right side of the heart (Includes Patent Ductus Arteriosus or Ventricular Septal Defect**)
- Increased pulmonary blood flow
Congenital Heart Disease Classifications: Decreased pulmonary blood flow
- Obstruction of pulmonary blood flow
- Difficulty exiting the right side of the heart via the pulmonary artery
- Increased pressure in the right side of the heart
- Desaturation of blood
- Usually appears cyanotic and hypoxemia
- Includes Tetralogy of Fallot**
Ventricular Septal Defect
- Abnormal opening between the right and left ventricle
- Frequently associated with other defects
- Possible spontaneous closure in the 1st year of life.
Ventricular Septal Defect Characteristics
- Increased blood volume is pumped into the lungs (right ventricular hypertrophy)
- Heart failure is common
- Characteristic murmur
Patent Ductus Arteriosus
-Failure of the fetal ductus arteriosus to close (usually closes in the first few weeks of life)
Characteristics of Patent Ductus Arteriosus
- Increased pulmonary congestion
- Increased workload on the left side of the heart
- Possible left ventricular hypertrophy
Patent Ductus Arteriosus Management
-Indomethacin (prostaglandin inhibitor): closes patent ductus in infants and newborns
Tetralogy of Fallot: Classic Form includes four defects
- ventricular septal defect
- pulmonary stenosis
- overriding aorta
- right ventricular hypertrophy
Characteristics of Tetralogy of Fallot in Infants
- Acutely cyanotic at birth
- Characteristic murmur
- Blue spells or tet spells: acute episodes of cyanosis and hypoxia when the infants O2 requirements exceed the blood supply (usually during feeding or crying)
Tetralogy of Fallot Treatment
-Multiple surgeries required
Congenital Heart Disease Classifications: Obstruction of Blood Flow
- Blood exiting the heart meets an anatomical narrowing
- Pressure in the ventricle and the great artery before the obstruction is increased
- Location of narrowing is usually a valve
- Exhibit signs of heart failure
- Includes Coarctation of the aorta and aortic stenosis**
Aortic Stenosis
Narrowing or structure of the aortic valve
Characteristics of Aortic Stenosis
- Resistance to blood flow in left ventricle
- Decreased CO
- Left ventricular hypertrophy
- Pulmonary vascular resistance
- Characteristics murmur
Symptoms of Aortic Stenosis
- Hypotension
- Tachycardia
- Poor feeding
Coarctation of the Aorta
-Narrowing near the insertion of the ductus arteriosus
Characteristics of Coarctation of the Aorta
- Increased pressure proximal and decreased pressure distal the defect
- 4 extremity blood pressures
Congenital Heart Disease Classifications: Mixed Blood Flow
- Survival depends on the mixing of blood from the pulmonary and systemic circulation in the heart chambers
- Some degree of heart failure
- Pulmonary congestion occurs
- Cardiac output decreased
- Includes: Hypoplastic left heart syndrome and Transposition of the Great Vessels**
Transposition of the Great Vessels
- No communication between the systemic and pulmonary system (pulmonary artery leaves the left ventricle; aorta leaves the right ventricle)
- Cardiomegaly is evident
Transposition of the Great Vessels: What must be present for survival?
A septal defect or a patent ductus arteriosus must be present for survival.
Hypoplastic Left Heart
- Underdevelopment of the left side of the heart (Hypoplastic left ventricle, aortic atresia)
- Condition is fatal without intervention
Characteristics of Hypoplastic Left Heart
Mild cyanosis and heart failure until PDA closes
Treatment for Hypoplastic Left Heart
- Prostaglandin E1 given to maintain ductal patency
- Multi-stage surgical treatment is used.
Signs and Symptoms of Patent Ductus Arteriosus
- Characteristic machine like murmur
- Widened pulse pressure/bounding pulses
- May or may not show signs of HF
Tetralogy of Fallot Characteristics in Children
- Squatting: compensatory mechanism to increase BF to heart
- Increased cyanosis
- Clubbing fingers
- Poor growth
Signs and Symptoms of Coarctation of the Aorta**
- BP higher in upper extremities than lower
- Bounding pulses in arms
- Weak/absent femoral pulse
- Cool lower extremities
- Epistaxis from HTN
Infective Endocarditis
- Infection of the valves and inner lining of the heart (microorganisms grow in system and causes turbulence)
- Can damage or destroy heart valves
Infective Endocarditis: Treatment
- High dose IV ABT for 2-8 weeks
- Prophylactic ABT for certain patients (amoxicillin, clindamycin or azithromycin)
Infective Endocarditis: Clinical Manifestations
- Unexplained low-grade, intermittent fever
- Feeding difficulties
- Tachycardia
- Respiratory distress
- Heart failure
- Symptoms of septicemia
Rheumatic Fever
- Inflammatory disease that involves the joints, skin, brain, serous surfaces and the heart.
- Self limiting
Rheumatic Fever occurs after
Pharyngitis (strep throat)
Rheumatic Fever:Most Significant Complication
Cardiac valve damage
How is Rheumatic fever diagnosed?
Multiple lab tests
What are clinical manifestations of Rheumatic Fever?
- Fever (low grade spikes in the late afternoon)
- Carditis: inflammation of the endocardium (most often the mitral valve)
- Polyarthritis
- Erythema marginatum: red, painless skin lesion over trunk and then spreads with central clearing
- Subcutaneous nodules
From mentor study guide:
- Arthralgia
- Chorea
- Prolonged P-R Interval
- Elevated erythrocytes sedimentation rate or (+) C-reactive protein level
Rheumatic Fever Treatment
- Penicillin
- Cephalosporin or macrolides if allergy
- If valve replacement, prophylactic antibiotics prior to dental procedures
Rheumatic Fever Management
- Control joint pain and inflammation: massage, alternating hot & cold applications
- Carditis: limit physical exercise, aspirin or corticosteroids (DO NOT ADMINISTER BEFORE DIAGNOSIS B/C IT MASKS POLYARTHRITIS)
- Seizure precautions if child is experiencing chorea.
Kawasaki Disease
- Acute systemic vasculitis
- Unknown cause: associated with organism or toxin
- Leading cause of acquired heart disease
- Self limiting (resolves in 6-8 weeks)
Kawasaki Disease: If not treated
-20-25% develop cardiac problem
Kawasaki Disease: Diagnosis
- No specific diagnostic test.
- Monitor status with echocardiogram.
Kawasaki Disease: Treatment
- High dose IVIG
- Salicylate therapy
Kawasaki Disease: Prognosis
-Most recover fully after treatment (except for cardiac complications)
What are clinical manifestations of Kawasaki disease?
- Changes in extremities: Erythema of palms and soles of feet; edema of hands and feet; peeling of fingers and toes
- Polymorphous exanthem
- Bilateral bulbar conjunctival injection without exudate (eyes red and swollen)
- Erythema and cracking of lips
- Strawberry tongue
- Cervical lymphadenopathy
Complications of Kawasaki Disease
-Cardiac involvement -> aneurysms can develop
Hyperlipidemia
- General term for excessive lipids
- Plays a role in developing atherosclerosis -> coronary artery disease
Risks for Hyperlipidemia Includes
- Family history
- Cigarette smoking
- Diabetes
- Obesity*
- Hypertension
- Chronic inflammatory disease
- Cancer
- Transplantation
- Congenital heart disease*
- History of Kawasaki Disease*
How is hyperlipidemia diagnosed?
- Based on lab values
- In children: total cholesterol >200 mg/dl and LDL >130 mg/dl
When should you not draw labs for hyperlipidemia?
Should not draw labs within 3 weeks of febrile illness.
Treatment for Hyperlipidemia
- Lifestyle modification
- Diet modification: Food choices and Portion sizes
- Medications are needed at times
- Include the whole family
Cyanosis in an anemic infant
Level of desaturation will be higher before cyanosis becomes apparent (lower hgb level from anemia means that a larger percentage of hgb must be desaturated before cyanosis becomes visible)
Cyanosis in children with polycythemia
Appear cyanotic when a lesser amount of hgb is desaturated (higher hgb levels mean a smaller percentage must be desaturated before cyanosis is seen)
Hypercyanotic Episode
-Dramatic event in children with cyanotic heart disease (often called test spells because they often occur in children with tetralogy of Fallot)
When do hypercyanotic episodes usually occur?
- Most frequent in 2 years of life
- Occurs mainly in the morning
A hypercyanotic episode is preceded by
- Crying
- Feeding
- Defecation
Treatment for hypercyantoic episodes include
- Calming infant
- Knee to chest
- O2
- Morphine sulfate (vasodilates)
- Phenylephrine (vasoconstricts)
What should the nurse assess to identify cyanosis?
- Know source of pulmonary BF for children with cyanotic heart disease
- Baseline cyanosis and general appearance
- Level of activity (including irritability)
- Observe in natural light: skin, mucous membranes, conjunctiva, nail beds
- General skin color
- IV Line patently and air-> embolism
- Smaller than peers -> may have clubbing, thickening/flattening of fingertips and toes (d/t polycythemia)
Cyanosis interventions are directed toward
- Stabilizing
- Preparing child for medical or surgical interventions
Cyanosis Interventions include
- Administration of Prostaglandin E1; vasodilator
- Parent teaching
- Monitoring fluid status
Cyanosis Interventions: Administration of Prostaglandin E1: Vasodilators
- Maintains ductal patency and restores pulmonary or systemic blood flow
- Continuous IV Fusion
Side Effects of Prostaglandin E1
Apnea (infants frequently require intubation)
Cyanosis Interventions: Parent Teaching
- Need simple thorough explanations
- Help ID sources of emotional support and encourage communication
- Stress importance of child interacting with environment as much as possible
- Recognize illness that place child at risk for dehydration
Children who are cyanotic are prone to
- Respiratory Infections which increase cardiac workload, cyanosis and desaturations
- Avoid crowded areas
Cyanosis Interventions: Monitor fluid status
- Prevents hemo-concentration
- I&O monitored and daily weights
