midterm cardio Flashcards

Question

Hemodynamic changes in the heart chambers

Answer 1

-right atrial pressure falls -increase pressure in left atrium -higher O2 sat than in fetal circulation = stimulates closure of ductus arteriosus

Answer 2

-chronic health conditions (lupus, DM) -medications (phenytoin) -maternal alcohol or illicit drug use -exposure to infections (rubella) -infants with LBW dt IUGR -high birth weight infants (infant of diabetic mother)

Answer 3

-feeding difficulties dt fatigue, vomiting, rapid breathing, sweating w/ feeds, poor weight gain, developmental stage -incidence of resp infections and breathing -onset and frequency of colour changes (cyanosis that worsens with feeding/activity) -parents feel baby's heart race -weak cry -irritable most comfortable person, HOB elevated, squatting

Answer 4

exercise tolerance presence of edema resp problems, chest pain, palpitations neurologic problems - fainting, headaches recent infections or toxic exposures (ex. cardiomyopathy, rheumatic fever - they weaken heart valves) *acquired heart disease usually comes from infections later in life

Answer 5

review all other health problems presence of other congenital anomalies meds including OTC, herbal supplements physical examination: -general appearance - weak, irritable, in distress Nutritional status: -undernourished, underweight -height below average Size, shape, symmetry of chest -retracts, heaves, or lifts -enlargement over heart -asymmetrical chest movement -active precordium -heart fluttering on chest dt possible patent ductus arteriosus -point of maximum intensity (PMI) Skin: -pallor, cyanosis -mucous membranes, sclera, palm, soles of feet -clammy, sweating w/ feeding, activity -scars from previous surgeries -edema (RS HF) - sometimes periorbital in am, scrotal for males -nail beds - cyanotic, clubbed VS: HR - tachy or brady RR - increased even at rest? Laboured? BP: HTN - difference in arms and legs? BP normally higher in legs than arms SBP 8-10 mmHg higher in RIGHT arm than in left may be significant dt coarctation of the aorta (narrowing after aortic arch) Pulses: bounding Heart auscultation: -+- murmur. If present, not intensity, quality, timing, systolic/diastolic -other: split sounds, gallops, rubs -irregular rhythm Lung auscultation: -crackles, wheezing, grunting, decreased or absent breath sounds Liver and splenic edges: -palpation - RS HF Tests for cardiac function: -radiography - CXR to check size fluoroscopy -ECG -Echocardiogram - to see blood flow -cardiac catheterization - go in thru femoral -exercise stress test -Cardiac MRI

Answer 6

since birth most common congenital anomaly etiology (cause): -90% unknown -multifactorial- family hx, maternal factors, associated w/ chromosomal abnormalities, syndromes, or cong. defects in other body systems -gene mapping research -40% of children w/ down syndrome have a cardiac defect

Answer 7

pressures generated by blood and pathways the blood takes through the heart and pulm system blood flows from high to low pressure to the path of least resistance

Answer 8

pressure on right side is LOWER than left resistance in pulm circulation is less than in systemic

Answer 9

depending on defect, it can cause varying degrees of hypoxemia & cyanosis

Answer 10

1) Decreased Pulm. Blood flow 2) Increased Pulm. Blood flow 3) Obstruction to Systemic Circulation 4) mixed blood flow

Answer 11

Most likely to cause cyanosis: 1)decreased pulm blood flow Least likely to cause cyanosis: 2) increased pulm blood flow

Answer 12

right to left shunt if septal defect is present dt right side pressure exceeds > left side pressure little/no blood reaches the lungs to get oxygenated cyanosis that does not respond to supp O2

Answer 13

left to right shunt causes congestive HF more blood flow to lungs -> vasoconstrict -> pulm HTN -> right vent. muscle hypertrophies to counteract the increased pulm vasc resistance

Answer 14

increased pressure load on left ventricle -> decreased CO (shock) obstruction to systemic blood flow = signs of poor CO, HF

Answer 15

saturated and desaturated blood mix within heart/great arteries = variable clinical picture cyanosis

Answer 16

volume overload pressure overload decreased contractility high CO demands

Answer 17

Goals of tx: -improve cardiac function: increase contractility, decrease afterload -remove accumulated fluid and sodium: decreased preload volume -decreased CO demands -improve tissue oxygenation and decrease O2 consumption

Answer 18

Adx digitalis glycosides Adx ACE inhibitors Adx diuretics nursing considerations for Digitalis glycosides (Digoxin): -increases force of contraction -decreases HR and slows conduction of impulses thru AV node -indirectly enhances diuresis by improving renal perfusion -loading does: are high, then go on maintenance doses, then check levels in blood -check apical pulse before admin -exact med calculations and measuring are critical = check decimal point because rare to give >1.0 ml -observe for toxicity (bradycardia, anorexia, n&v) discharge teaching: -signs of toxicity - bradycardia, anorexia, n,v -how to check pulse (not as important when on maintenance doses) -signs of low HR -know # for poison control -know how to draw it up

Answer 19

ACE inhibitors to improve cardiac function by reducing afterload -monitor BP before and after admin for hypotension -monitor serum electrolytes (because drug blocks aldosterone and are potassium sparing) -carefully assessing renal function

Answer 20

Beta-blockers: metoprolol, carvedilol

Answer 21

organize care to allow periods of rest minimal handling minimize unnecessary stress maintain neutral thermal environment (NTE): modern incubators (problem is that there's a possibility to miss fever to low temp when septic) monitor temp prevent skin breakdown from edema prevent/tx infections promptly

Answer 22

count RR full minute position HOB elevated, sitting up provide for unrestricted chest expansion *infants are diaphragmatic breathers supp O2

Answer 23

greater caloric needs but impaired ability to take in adequate calories well rested before feeds, feed soon after awakening - to minimize crying which is energy expenditure Q3h feeding schedule allow no more than 30 min to complete feed with NG prn increase caloric density of formulas by adding corn oil or MCT (medium chain triglycerides) oil to formula or HMF (human milk fortifier) to breast milk if fully BF, then feeds can be on demand no fluid restriction for babies = must increase caloric density

Answer 24

Adx diuretics (give early in day, not at night or child will pee during night) accurate I/O daily weights. same time, same scale observe for signs of dehydration or edema observe for signs of electrolyte imbalance fluid restriction rarely needed. if required, plan to give most fluids during awake hours possible sodium restriction

Answer 25

PaO2 < normal desaturated venous blood enters systemic circ w/o passing thru lungs amount of o2 in the blood normal PaO2 range: 80-100mmHg 3 types of defects that cause cyanosis: 1) category 1) decreased pulm blood flow aka Right to left shunting ex tetralogy of fallot 2) category 4) mixing of arterial and venous blood within heart chambers ex single ventricle 3) transposition of great arteries

Answer 26

x2, from different categories

Answer 27

Tetralogy of Fallot ANATOMY: x4 abnormalities: 1. Pulmonic stenosis: valve doesn't open all the way/narrow = less blood reaches lungs = increases backup pressure 2. Right vent hypertrophy: because blood has to be pumped against resistance of stenotic valve 3. Overriding aorta: moved forward, right in front of VSD. It also compresses pulm artery which is why there is pulm stenosis. O2 and deO2 blood enters aorta 4. Ventricular septal defect VSD: hole between vents. blood shunts LEft to Right L to R shunt HEMODYNAMICS overriding aorta and VSD allow deO2 to pass lungs and enter systemic circ Less deO2 blood enters lungs dt pulm stenosis "pink" tetralogy of fallot: -no/minimal right vent outflow obstruction (RVOTO) w/ little aortic override. behaves like VSD and left-right shunt SaO2100% "blue" tetralogy of fallot: -classic ToF has a degree of RVOTO and aortic override -hypoxia "profound cyanosis" -severe or complete RVOTO -increasing left to right shunting -hypercyanotic spells! Clinical manifestations of hypercyanotic spells: -cyanosis -pallor, poor perfusion -increase rate and depth of resps -increased HR -agitation, irritability -> may lead to limpness or seizures Tx: knee-chest position : instinctive. To decrease return of systemic venous blood to heart -admin 100% O2 -give SC or IV morphine -gegin IV fluid replacement and volume expansion prn -repeat morphine ToF Assessment: -Tet spells -cyanosis -O2 admin -systolic murmur in pulmonic area -thrill may be palpated in pulmonic area Interventions: -prevent hypercyanotic spells -prevent dehydration -monitor CBC -monitor for bleeding -surgery

Answer 28

Pulmonic Stenosis ANATOMY -narrowing of pulmonic valve or great artery above valve -increases preload (vol in ventricle at end of diastole) = results in right vent hypertrophy dt heart working harder to pump blood thru obstruction Neonates: with mod-severe stenosis, may dev a right-left shunt thru foramen ovale between atria => cyanosis HEMODYNAMICS -decrease blood flow to lungs = deO2 blood entering syst circ MANIFESTATIONS asymptomatic, dev normally -moderate stenosis = dyspnea, fatigue on exertion -signs of CHF -loud systolic murmur and widely split S2 and thrill heard in pulmonic area -murmur louder indicates increased severity

Answer 29

3 examples: PDA Patent ductus arteriosus <3.1 ASD Atrial septal defect VSD Ventricular septal defect Left to right shunt general characteristics: -increased blood volume on right side increased pulm blood flow at expense of systemic circulation

Answer 30

ANATOMY Because of the physiologic effects of prematurity like resp distress syndrome and hypoxia, the ductus arteriosus is prevented from closing naturally When pulm circulation is established and systemic resistance increases at birth, pressures in the aorta become greater than in the pulm arteries. Aorta pressure> pulm arteries blood is then shunted from aorta to pulm arteries thru the PDA= increasing blood flow to pulm system compensation: pulm vasoconstriction = try to control blood flow increase BUT this makes it harder for right ventricle to pump against resistance HEMODYNAMICS Oxygenated blood from aorta shunts thru PDA into pulm arteries, creating a mix of saturated and unsaturated blood going into lungs CLINICAL MANIFESTATIONS -dyspnea, tachypnea, tachycardia -symps associated w/ edema and CHF bounding pulses hepatomegaly, poor growth if PDA is large -"machinery" murmur during sys&diastole -active prercordium -risk for frequent resp infections and pneumonia dt moist environment -no cyanosis -hypotension with low CO -intercostal retractions

Answer 31

ANATOMY -opening in atrial septum allows left to right shunt -can be small (foramen ovale fails to close) or large opening (septum completely absent) HEMODYNAMICS -oxygenated blood goes back into right atrium -causes pulm constriction and build up of pressure on right side -> RS HF -less O2 blood in systemic circ CLINICAL MANIFESTATIONS happens in 40s. Asymptomatic til adulthood small enough hole = no major surgery -large ASD = CHF -easy tiring -poor growth -soft ejection murmur in pulmonic area with fixed wide splitting of S2 through all phases of respiration

Answer 32

ANATOMY -opening in vent septum results in increased pulm blood flow -can occur in any area of septum HEMODYNAMICS oxygenated blood enters from left vent to right vent dt greater pressure in left side -mixed blood from right vent enters pulm arteries = this extra blood being pumped into the lungs forces the heart and lungs to work harder. CLINICAL MANIFESTATIONS -infants and children may have no symptoms -murmur - systolic murmur at 3rd or 4th LICS at sternal border -thrill -no cyanosis -moderate and large VSD's = CHF tachypnea, dyspnea, poor growth -increased pulm infections and pulm HTN

Answer 33

examples: Coarctation of the aorta Aortic stenosis Hypoplastic left heart syndrome general patho: -blood existing heart meets area of anatomic stenosis causing obstruction to blood flow PRESSURES: -increased pressure in ventricle and greater artery BEFORE obstruction & -decreased pressure in area AFTER obstruction

Answer 34

ANATOMY -narrowing or constriction of descending aorta, often dear ductus arteriosus OR left subclavian artery = obstructs systemic blood outflow 1st brachiocephalic/right subclavian/right common carotid artery 2nd left common carotid artery 3rd left subclavian artery HEMODYNAMICS -Increase pressure load on left ventricle because blood is backing up at the top of the aorta and not making it all the way thru -increased pressure going into head and upper extremities CLINICAL MANIFESTATIONS -bounding pulses on upper extremities and weak/absent pulses on lower extremities -differences in BP: Increase BP in upper , decreased BP in lower -nose bleeds -worse case: aorta ruptures -older children may complain of weakness, pain in legs after exercise -children usually asymptomatic and grow normally *nursing considerations when taking BP for pt w/ coarctation of the aorta: -take BP in all 4 limbs

Answer 35

ANATOMY -narrowing of aortic valve = obstructs blood flow to systemic circulation -narrowing may be sub valvular, @ the valve, or supra valvular -defect associated often w/ bicuspid (2 valve leaflets) rather than normal tricuspid valve -pressure gradient across valve usually increases during periods of rapid growth w/ associated increase CO dt valve does not grow at comparable rate -left vent hypertrophies to force blood pasta narrowed valve opening -> may progress to left vent failure HEMODYNAMICS -decreased oxygenation blood flow to peripheries CLINICAL MANIFESTATIONS -most infants/young children asymptomatic and develop normally -CHF -BP normal but narrow pulse -weak peripheral pulses -fainting, dizziness -chest pain & dyspnea after exercise -systolic murmur and thrill -ejection click -splitting of S2 with severe stenosis -high pitched diastolic decrescendo murmur along left sternal border near mitral valve

Answer 36

examples: TGA - transposition of the great arteries <3.2 Truncus arteriosus

Answer 37

ANATOMY -Aorta and the pulm artery are switched -Aorta connected to right ventricle and sends deO2 blood to head and extremities w/o going to the pulm circ -Pulm artery is connected to left ventricle HEMODYNAMICS -aorta connected to right ventricle: blue blood from body enters right atrium/ventricle and goes into aorta and to systemic circ Pulm artery connected to left ventricle: red blood goes from pulm artery into ductus arteriosus to systemic circ -MIXED blood as red O2 blood enters patent ductus arteriosus to systemic circ -patent foramen ovale or atrial septal defect) between the two collecting chambers (atria) of the heart -this allows some mixing to occur. After birth, the hole and the duct tend to shut off. Keeping them open is the first step in the treatment of this condition. CLINICAL MANIFESTATIONS -Polycythemia )increased RBC risk for thromboembolism (blood becomes thick and RBC's clump) -Clubbing - dt chronic tissue hypoxemia and polycythemia -CNS injury increased risk for stroke, meningitis, brain abscess -Dehydration - hemoconcentration -Hematologic abnormalities like thrombocytopenia (lack platelets) = prolonged clotting time -Bacterial endocarditis -fatigue w/ feeding poor weight gain, tachypnea, dyspnea on exertion, poor exercise tolerance -Squatting: hypercyanotic spells -blue spells or "tet" spells Blue color of the skin (cyanosis) Shortness of breath Weak pulse Lack of appetite Poor weight gain

Answer 38

ANATOMY -a single trunk empties both ventricles and provides blood flow to pulm, systemic, and coronary circs - fails to separate completely during development, leaving a connection between the aorta and pulmonary artery -VSD usually present HEMODYNAMICS -blue blood from right side and red blood from left side mix then divide into lungs and systemic circ CLINICAL MANIFESTATIONS -cyanosis soon after birth *cyanosis also a manifestation of decreased pulm blood flow cat 1) -CHF develops within 2 weeks after birth w/ signs of: -tachypnea, dyspnea, retractions -fatigue, poor feeding, poor growth -polycythemia -clubbing -increasaed pulse pressure -widened pulse pressure (diff. between sys and diastolic BP) -frequent resp infections -VSD produces harsh systolic murmur in lower sternal border -systolic click may be auscultated in apex and pulmonic area

Answer 39

x4 1. Rheumatic Fever 2. Bacterial infective Endocarditis 3. Kawasaki Disease 4. MIS-C

Answer 40

follows strept throat (pharyngitis) group beta-hemolytic streptococci may lead to permanent heart valve damage

Answer 41

inflammation of lining, valves and arterial vessels streptococcus or staphylococcus -prevention w/ prophylactic antibiotics before dental procedures

Answer 42

-unique disease to children -acute systemic inflammatory disease of small& medium-sized blood vessels -coronary arteries are most susceptible. May lead to dilation of coronary arteries and aneurysm formation -Mucocutaneous Lymph Node syndrome -etiology unknown -primary cause thought to be infection with organism or toxin but not spread person to person -hospital admissions late winter, early spring Dx: Fever for at least 5 days and unresponsive to antipyretics and antibiotics must have 4 of the following: -erythema and edema of hands and soles of feet -peeling of hands and feet in 2-3rd wk -both eyes inflamed w/o drainage (difference: pink eye has exudate) -polymorphous rash -strawberry tongue, dry cracked lips -swollen lymph nodes tests: CPR for inflammation markers ESR, Echo Sed rate, or erythrocyte sedimentation rate (ESR), is a blood test that can reveal inflammatory activity in your body. A sed rate test isn't a stand-alone diagnostic tool, but it can help your doctor diagnose or monitor the progress of an inflammatory disease. When your blood is placed in a tall, thin tube, red blood cells (erythrocytes) gradually settle to the bottom. Inflammation can cause the cells to clump. Because these clumps are denser than individual cells, they settle to the bottom more quickly.

Answer 43

Acute stage: -5+ days -fever -strawberry tongue -edema hands/feet -enlarged cervical lymph nodes -irritable -conjuctival hyperemia Subacute stage: -cracking lips -desquamation of skin on fingertips, toes -joint pain -irritability continues Convalescent stage: -appears normal but lingering signs of inflammation -ESR remains increased even after symptoms are gone -6-8wks after onset, all blood values return to normal severe: cardiac involvement like MI

Answer 44

Tx: IVIG - immunoglobulin to reduce fever, inflamm Aspirin. Usually, aspirin is not recommended for kids dt risk of Ryes syndrome but this is the only time Aspirin is given to kids because in Kawasaki disease, it actually responds to Aspirin (salicylates- reduce fever ) Nursing care: -asses for edema, eye pain, redness in mouth, rashes, desquamation, fluid balance, heart sounds, temperature, Side effect of Aspirin - GI upset and bleeding -ROM -discharge teaching for aspirin, cardiac follow-up

Answer 45

reportable condition associated with covid 19 -presents with fever, lab evidence of inflammation, evidence of severe illnesses requiring hospitalization with multisystem >2 organ involvement (cardiac, renal, resp, hematologic, GI, dermatologic, or neurological) AND no alternative plausible dx AND positive antigen or serology for recent SARS - CoV 2 infection OR covid-19 exposure within 3 wks prior to onset of symptoms pt presentation: systemic inflammation: -tachycardia, hypotension, hypo or hypoperfusion, lymphadenitis Mucocutaneous: -rash, lip cracking, strawberry tongue, extremity swelling, conjunctivitis, blisters GI: -n,v, d, abd pain Cardiopulmonary: -resp distress, chest pain Neurologic: -headache, altered mental status, meningismus, focal deficits, seizure Management: -isolation -close VS monitoring for stability -dx testing- blood, EKG, CXR, Echo, septic work up Meds - IVIG, steroids, Aspirrin Antibiotics- until infection ruled out Anticoagulation therapy Discharge and follow-up: Discharge criteria: -no fever for 48 hrs without antipyretics -improvement of presenting symptoms -improvement in lab markers -influenza vaccine follow up: -with pediatrician or family doc within 1 week of discharge -cardiology - repeat Echo in 2 weeks -follow up with rheumatology, immunology, neuro, GI services as needed Return to ED if: -fever >38 -recurrence of presenting symptoms or unwell with other symptoms -resp distress or SOB

Answer 46

TET spell or hypercyanotic spell put them in knee to chest position

Answer 47

signs of digoxin toxicity: -bradycardia -GI upset -visual disturbances bradycardia, anorexia, n,v