Lecture 05 Cardiology Flashcards
What’s the most common congenital heart defect?
VSD
- Abnormal opening between right and left ventricle
- Classified according to location (membrane or muscle)
- Varies in size from small pin hole to absence of septum
- Frequently associated with other defects
- 20 to 60 % thought to close spontaneously within first year (may not know present)
Murmurs occur in VSDs. What cuases the sound?
What does this put them at risk for?
- Murmur is present, this is common in a left-to-right shunt as murmuring sound is caused as blood is pumped through hole in septum.
- Child is at risk for bacterial endocarditis and pulmonary vascular obstructive disease
What’s the second most common CHD?
Where is the strucutral defect?
- Patent Ductus Arteriosus connects the aorta with the pulmonary artery at its bifurcation.
- Second most common CHD
•
•Normally closes spontaneously beginning 10 to 12 hours after birth (when PaO2 > 90) and completed by 2 to 3 weeks
•
•Failure of PDA to close results in left to right shunt
•
•Portion of blood from aorta diverted to pulmonary system causing increased left ventricle volume & workload; increased pulmonary blood flow results in pulmonary congestion, CHF and FTT
KNOW; To close PDA, what drug would be used?
KNOW: To close the PDA, use Prostaglandin inhibitors (Indomethacin)
- Given shortly after birth
- Act as systemic vasoconstrictor to facilitate PDA closure
- Supplemental oxygen may help as it á PaO2
How does PDA surgery anatomically correct the heart?
Purpose of Surgical closure of the PDA prevents the return of oxygenated blood to the lungs & decreases pulmonary vascular congestion
- PDA ligation; can be done via thoracotomy, thorascopic or cardiac cath
- Excellent prognosis
Describe ASD
When does it typically close by?
ASD is an abnormal opening
between the right and left atria
(patent foramen ovale)
- Normally closes by 2 months to 1 year
- :Left to R shunting again.
- Small amount shunting; may be asymptomatic
- Large ASD allows large amount of blood to shunt and produces symptoms
ASD results in increased
pulmonary blood flow
Blood flows from the left atrium
(higher pressure) into the right atrium
(lower pressure) and then to the lungs
via the pulmonary artery
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KNOW: What’s Coarctation of the Aorta?
Stricture is typically where ductus arterioles is.
Notice the constriction prevents lower extremities from getting blood flow, and upper extremities are getting ample blood flow.
So you may see higher BP in upper extremities vs lower extremities. Lower extremities may be cooler, lower circulation. GI tract has lower motility. Decreased cap refills.
Left side obstruction results in
CHF
R side obstruction in the heart leads to
cyanosis
KNOW: In Coarctation of the Aorta, what are the BPs like in the upper and lower body?
•Increased pressure/blood flow proximal to defect (head & upper extremities)
–Higher BP & bounding pulses in arms
•Decreased pressure/blood flow distal to obstruction (body & lower extremities)
–Weak or absent femoral pulses, & cool lower extremities with lower BP
•CHF especially in infants
What are treatments for coarctation of the aorta?
Treatment
- Balloon angioplasty/dilatation initially
- Resection of aorta end to end anastomosis
- Defect outside heart so by-pass not needed
- Repair indicated 1st 2 years of life to prevent hypertension
- Post-op may have abdominal pain/GI disturbances r/t sudden á blood flow to those areas
- May have post-op tingling of legs and feet
- Excellent prognosis
•
What are some assessments findings for Coarctation of Aorta?
Assessment
•Bounding pulses in head, arms & chest
–Headaches, dizziness, nosebleeds, CVA
•Decreased pulses in legs, feet, GI system
–Cool, mottled legs, abdomen, feet
–Decreased peristalsis, constipation
•SBE risk
Subacute bacterial
endocarditis
KNOW: What are the 4 defects of the heart that makes up the Tetralogy of Fallot
- So know the 4 defects and what they are.
- Ventricular septal defect (VSD)
- Overriding aorta
- Pulmonic Stenosis
- R Venticular Hypertrophy
What are Tetralogy of Fallot Assessment Findings?
- Mild to severe symptoms
- Murmur
- Mild cyanosis
- Possible blue/cyanotic or “tet” spells
–Persistent blue or cyanotic color
–Cyanosis with feeding
–Limpness, unresponsiveness
–Hypotonic extended position
•Older child- self limited activity
–Assumes squatting position after exertion
–Prefers knee-chest position vs. flat lying
•Clubbing & shunted growth
What is polycythemia?
Increase number of RBC (In response to low O2) as an attempt to increase O2 carrying capactity of blood.
Blood viscosity is inscreased and clotting ability diminished as increased RBC’s crowd out, clotting factors.
Hydration is important to reduce risk for Cerebrovascular event
What is Clubbing?
Thickening and flattening of finger tips or toes related to chronic hypoxia and polycythemia
What are Hypercyanotic Spells?
Acute cyanosis and hypoxia caused by increaed oxygen demands.
Early morning hunger, feedings, crying & BM may precipitate episode; blood draws, hurtful procedures
KNOW: Order of priority for prevention and treatment of chronic hypoxia?
•Knee chest position (same effects as squatting)
- Calm, comforting approach
- 100 % Oxygen
- Morphine (IV/SC)
What occurs in the Transposition of Great Vessels?
Major blood vessels are switched.
There needs to be other defects present for the child to live
No communication between systemic & pulmonary circulation
Which of the following is a complication
that may occur with a cardiac catheterization?
- Cardiac arrhythmia
- Hypostatic pneumonia
- Congestive heart failure
- Rapidly increasing blood pressure
Cardiac arrhythmia
Why is it important to prepare children for surgery?
- Often have misconceptions
- Younger children: shorter attention span
- Imagination can increase fears
- May regress in stressful situations
- Assess knowledge level: Ask chidl what they think will happen, so that you’ll be able to assess it
- Role playing: via dolls
72 hours after cardiac surgery, a young child
has a temp of 101 degrees F. The nurse should:
- Keep child warm with blankets
- Apply a hypothermia blanket
- Record temperature on nurse’s notes
- Report findings to physician
4.Report findings to physician
Which is an important nursing consideration when
suctioning a young child who has had heart
surgery?
- Perform suctioning at least every hour
- Suction for no longer than 30 seconds at a time
- Administer supplemental oxygen before and after suctioning
- Expect symptoms of respiratory distress when suctioning
3.Administer supplemental oxygen before and after suctioning
The nurse is caring for a child after heart
surgery. Which should the nurse do if
evidence is found of cardiac tamponade?
- Increase analgesia
- Apply warming blankets
- Immediately report this to physician
- Encourage child to cough, turn, and breath deeply
1.Immediately report this to physician
Which is an important nursing consideration
when chest tubes are removed from a child?
- Explain that it is not painful
- Explain that only a Band-Aid will be needed
- Administer analgesics before procedure
- Expect bright red drainage for several hours after removal
1.Administer analgesics before procedure
What is CHF?
“Congestive Heart Failure is the inability of the
heart to pump an adequate amount of blood to
the systemic circulation at normal filling
pressure in order to meet the metabolic needs
of the body.”
what causes CHF in Peds Population?
•Increased blood volume and pressure within the heart from structural defects
–most common cause in pediatric population
–consequence of an underlying cardiac defect
- Myocardial failure with impaired ventricular contractility (cardiomyopathy, dysrhythmias, severe electrolyte disturbance)
- Excessive demands placed on normal heart (sepsis, severe anemia)
CHF: Impaired Myocardial Function S&S?
–Inappropriate sweating, fatigue, pallor, cool extremities, weak pulse, gallop rhythm, hypotension, cardiomegaly, decreased urinary output
CHF: Pulmonary Congestion S&S?
•Pulmonary Congestion
–Tachypnea, dyspnea, retractions, nasal flaring, grunting, wheezing, cyanosis, cough, orthopnea, exercise intolerance
CHF: Systemic Venous Congestion S&S
•Systemic Venous Congestion
–Hepatomegaly, peripheral edema, ascites, neck vein distention, peri-orbital edema, weight gain,
What are 4 Goals for CHF?
- Improve Cardiac Function
- Remove Accumulated Fluid & Sodium
- Decrease Cardiac Demands
- Improve Tissue Oxygenation
What are ways to Improve Cardiac Function in CHF pts?
Digitalis Gylcosides
•Increase cardiac output by rate, improves myocardial contractility *, decrease heart size, decrease venous pressure, relief of edema
•Digoxin used in pediatrics based on rapid onset and availability in elixir form.
- Digitalizing dose (2 divided doses either oral/IV) given over 24 hours to produce optimum cardiac effects.
- BID dosing to maintain levels (0.8 to 2.0 ug/L)
- Careful, precise dosing, administration, parent teaching & monitoring for toxicity indicated
- Child is monitored for toxicity
–Early (Nausea, vomiting, anorexia, headache, drowsiness)
–Late (bradycardia, dysrrhythmias, heart block, vision disturbance)
–Dose held if pulse < 70 children or < 90-110 infant (Below % Baseline)
How does ACE Inhibitors improve cardiac funciton?
ACE Inhibitors
- Inhibit renin-angiotensin system in kidneys resulting in vasodilatation.
- Vasodilatation decreases pulmonary & SVR decrease BP and afterload
•Example Captopril (decreases afterload) *
How do you evaluate effectiveness of diuretic?
•Evaluate effectiveness of diuretic by monitoring I & O and Daily Weights (age appropriate weight gain)
What are ways to Decrease Cardiac Demands for CHF patients?
- Metabolic needs minimized
- Provide rest & decrease environmental stimuli
- Maintain normal body temperature (increases place more demands on metabolism)
- Treat infections
- Position
- Comfort Measures
What are expected outcomes for an Infant with CHF?
–Infant will have adequate cardiac output as evidenced by pink/baseline mucous membranes, cap refill less than 2 seconds, warm extremities, palpable peripheral pulses, adequate UO, baseline HR, baseline activity level, (infants: appropriate weight gain for age; indicative of successful feeding and Ü caloric loss secondary to the CHF)
What are Acquired CV diseases? (5)
- Subacute Bacterial Endocarditis (SBE)
- Rheumatic Heart Disease
- Kawasaki Disease
- Hyperlipidemia
- Cardiomyopathy
Where does Bacterial Endocarditis typically occur?
- Subacute bacterial endocarditis is an infection of valves and inner lining of the heart.
- Sequela children with acquired or congenital defects of heart or great vessels; especially those with valvular abnormalities, prosthetic valves, recent cardiac surgery with invasive lines, rheumatic heart disease; also drug abuse
- Streptococcus is most common agent
What occurs during a Rheumatic Fever (RF)?
What is it?
•Rheumatic Fever (RF) is an inflammatory disease that affects the heart, joints, CNS & subcutaneous tissues
–Systemic infection that affects most connective tissue in body
•RF often preceded by group A beta hemolytic strep infection usually upper respiratory by 7 to 10 days
KNOW: What are clinical manifestations of RF?
•Clinical Manifestations
–Low grade fever
–Non-tender subcutaneous nodules over bony prominence
–Painful swelling over large joints
–Erythema marginatum (rash)
•Elevated ASO, C-reactive protein and Erythrocyte Sedimentation Rate
What are Medications to treat Rheumatic Fever?
Medications
- Antibiotics (infection)
- Analgesics & Antipyretics for fever and/or joint pain
–ASA (salicylates) to control inflammatory process
•Corticosteroids for severe symptoms
–Acute joint involvement
- Digoxin/Lanoxin & Lasix if in CHF
- Med Compliance (may be up to 5-years of therapy)
What Interventions are necessary during RF?
Bedrest & Activity Restrictions
•Important during acute phase to Ü work load heart
Promote Adequate Nutrition
Provide Emotional Support
Prophylactic Treatment to
Prevent Recurrence
- SBE prophylactics (dental/procedural)
- Prevent strep throat or skin infection
Pediatric Cardiologist Follow Up
•Indicated for at least 5 years after disease onset
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What kind of disease is Kawasaki Disease?
Vascular Dysfunciton
Acute systemic vasculitis
•Primarily affects cardiovascular system
–Acute phase self limiting; without treatment 15-25% develop coronary artery aneurysms
–Initially inflammation of arterioles, venules, & capillaries
–Later coronary artery aneurysms may form leading to coronary thrombosis, severe scar formation & main coronary artery stenosis with MI
What are medications for Kawasaki?
Medications
•High dose IV gamma globulin (IgG)
–Prevents aneurysms if given within first 7-10 days
•ASA
