Pediatric Nursing: Cardiovascular Problems

Question 1

Hyperlipidemia

Answer 1

High levels of lipids circulating in the blood.
Lab Values for 2-19 years:
- Total Cholesterol: < 170 mg/dL (acceptable)
170-190 mg/dL (borderline)
> 200 mg/dL (high)
- LDL: < 110 mg/dL (acceptable)
110-129 mg/dL (borderline)
> 130 mg/dL (high)
- HDL: > 45 mg/dL (acceptable)
40-45 mg/dL (borderline)
< 40 mg/dL (low)
- Triglycerides: < 100 mg/dL (acceptable <9y)
< 130 mg/dL (acceptable >10y)

Question 2

Heart Failure (HF): description and assessment

Answer 2

• the inability of the heart to pump a sufficient amount of blood to meet the metabolic and oxygen needs of the body.
• in infants and children, inadequate cardiac output is caused by congenital heart defects (shunt, obstruction, or a combination of both) that produce an excessive volume or pressure load on the myocardium.
• goal of treatment are to improve cardiac function, remove accumulated fluid and sodium, decrease cardiac demands, improve tissue oxygenation, and decrease oxygen consumption (surgery may be required).
  Assessment:
• tachycardia, tachypnea, profuse scalp diaphoresis, fatigue, irritability, sudden weight gain, and respiratory distress.

Question 3

Heart Failure (HF): interventions

Answer 3

• monitor for early signs of HF, respiratory distress, apical pulse, dysrhythmias, temp, signs of infection, strict intake and output (weigh diapers), daily weight, facial or peripheral edema, auscultate lungs and report abnormal findings.
• elevate the head of the bed to semi-fowler’s, maintain a neutral thermal environment (prevent cold stress), provide rest, and decrease environmental stimuli.
• Adm cool humidified oxygen (hood for infants and nasal or mask for children), digoxin, angiotensin converting enzyme inhibitors, diuretics (furosemid), and potassium supplements as prescribed.
• maintain adequate nutritional status, feed when hungry and soon after awakening, provide small and frequent feedings, limit fluid intake as prescribed in the acute stage.
• monitor for signs of dehydration: sunken fontanel (infant), nonelastic skin turgor, dry mucous membranes, decreased tear production, decreased urine output, and concentrated urine.
• instruct parents on CPR, adm of meds, and care.

Question 4

Signs and Symptoms of Heart Failure

Answer 4

Left side:
- crackles and wheezes, cough, dyspnea, grunting and head bobbing (infants), nasal flaring, orthopnea, periods of cyanosis, retractions, and tachypnea.

Right Side:
- ascites, hepatosplenomegaly, jugular vein distension, oliguria, peripheral edema (especially dependent and periorbital), and weight gain.

Question 5

Digoxin: important considerations

Answer 5

• assess apical HR for 1 min before adm.
• withhold if pulse is < 90-110 bpm in infants or <70 bpm in older children.
• monitor digoxin levels and for signs of toxicity (anorexia, poor feeding, nausea, vomiting, bradycardia, and dyshrythmias.
• the optimal therapeutic digoxin level is 0.8 to 2 ng/dL.
• toxicity is usually > 2ng/dL.
  Home care instructions:
• use an accurate measuring device, adm 1h before or 2h after feedings, and do not mix med with food or fluid.
• use a calendar to mark off the dose adm and if a dose is missed and more than 4h has elapsed, withhold the dose and give the next dose as scheduled. If less than 4h has elapsed, adm the missed dose.
• if the child vomits, do not adma seconde dose, and if more than 2 consecutive doses have been missed, notify PHCP.
• if the child hass teeth, give water after the med and, if possible, brush the teeth to prevent tooth decay.
• keep the med in a locked cabinet and call poison control if overdose occurs.

Question 6

Angiotensin-converting enzyme inhibitors: important considerations

Answer 6

• medications that relaxes, or dilate, blood vessels to lower BP.
• monitor for hypotension, renal dysfunction, and cough.
• assess BP, serum protein, albumin, blood urea nitrogen, and creatinine levels, white blood cell count, urine output, urinary specific gravity, and urinary protein level.

Question 7

Diuretics (furosemid): important considerations

Answer 7

• monitor for signs of hypokalemia (< 3.5 mEq/L) including muscle weakness, cramping, confusion, irritability, restlessness, and inverted T waves or prominent U waves.
• if sings of hypokalemia are present and the child is taking digoxin, monitor closely for toxicity, because hypokalemia potentiates digoxin toxicity.
• supplemental potassium should be given only if indicated by serum level and if adequate renal function is evident. Encourage foods high in potassium.

Question 8

Sings and Symptoms of Decreased Cardiac Output

Answer 8

• decreased peripheral pulses
• activity intolerance
• feeding difficulties
• hypotension
• irritability, restlessness, lethargy
• oliguria
• pale, cool extremities
• tachycardia

Question 9

Defects with Increased Pulmonary Blood Flow

Answer 9

Intracardiac communication along the septum or an abnormal connection between the great arteries allows blood to flow from the high-pressure left side of the heart to the low-pressure right side.
The infant typically shows signs and symptoms of HF.

Question 10

Defects with Increased Pulmonary Blood Flow: Atrial Septal Defect (ASD)

Answer 10

• is an abnormal opening between the atria that caused an increased flow of oxygenated blood into the right side.
• right atrial and ventricular enlargement occurs.
  Types:
• ASD1 (ostium primum): opening is at the lower and of the septum.
• ASD2 (ostium secundum): opening is near the center of the septum.
• ASD3 (sinus venosus defect): opening is near the junction of the superior vena cava and the right atrium.
  Management:
• may be closed during a cardiac catheterization or open repair with CP bypass (usually before school age).

Question 11

Defects with Increased Pulmonary Blood Flow: Atrioventricular Canal Defect

Answer 11

• defect results from incomplete fusion of the endocardial cushions.
• most common in Down’s syndrome.
• characteristic murmur is present.
• infant usually has a mild to moderate HF with cyanosis increasing with crying.
• management can include pulmonary artery banding for infants with severe symptoms (palliative) or complete repair via CP bypass.

Question 12

Defects with Increased Pulmonary Blood Flow: Patent Ductus Arteriosus

Answer 12

• is failure of the fetal ductus arteriosus (shunt connecting the aorta and the pulmonary artery) to close within the first weeks of life.
• a characteristic machinery-like murmur is present.
• a widened pulse pressure and bounding pulses are present.
• signs and symptoms of decreased cardiac output may be present.
• Indomethacin, a prostaglandin inhibitor, may be adm to close a patent ductus in premature infants and some newborns.
• the defect may be closed during cardiac catheterization, or the defect may require surgery.

Question 13

Defects with Increased Pulmonary Blood Flow: Ventricular Septal Defect (VSD)

Answer 13

• an abnormal opening between the right and left ventricles.
• many VSDs close spontaneously during the first year of life in children with small or moderate defects.
• a characteristic murmur is present.
• sings and symptoms of HF are commonly present.
• sings and symptoms of decreased cardiac output may be present.
• closure during cardiac catheterization may be possible.
• open repair may be done with CP bypass.

Question 14

Obstructive defects

Answer 14

• blood exiting a portion of the heart meets an area of anatomical narrowing (stenosis), causing obstruction to blood flow.
• the location of the stenosis is usually near the valve of the obstructive defect.
• infants and children exhibit signs of HF.
• mild obstruction may be asymptomatic,

Question 15

Obstructive defects: Aortic Stenosis

Answer 15

• a narrowing or stricture of the aortic valve, causing resistance to blood flow from the left ventricle into the aorta, resulting in decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion.
• vascular stenosis is the most common type and usually is caused by malformed cusps, resulting in a bicuspid rather than a tricuspid valve, or fusion of the cusps.
• characteristic murmur is present.
• children show signs of activity intolerance, chest pain, and dizziness when standing for long periods.
• dilation of the narrowed valve may be done during cardiac catheterization.
• a surgical aortic valvotomy (palliative) may be done; a valve replacement may be required at a second procedure.

Question 16

Obstructive defects: Coarctation of the Aorta

Answer 16

• is localized narrowing near the insertion of the ductus arteriosus.
• BP is higher in the upper extremities than in the lower; bounding pulses in the arms, weak or absent femoral pulses, and cool lower extremities may be present.
• Signs of HF may occur in infants and sings and symptoms of decreased cardiac output may be present.
• children may experience headaches, dizziness, fainting, and epistaxis resulting from hypertension.
• management of the defect may be done via balloon angioplasty in children (restenosis can occur).
• mechanical ventilation and meds to improve cardiac output are often necessary before surgery.
• resection of the coarted portion with end-to-end anastomosis of the aorta or enlargement of the constricted section, using a graft, may be required.
• because the defect is outside the heart, CP bypass is not required, and a thoracotomy incision is used.

Question 17

Obstructive defects: Pulmonary Stenosis

Answer 17

• is a narrowing at the entrance to the pulmonary artery.
• resistence to blood flow causes right ventricular hypertrophy and decreased pulmonary blood flow; the right ventricle may be hypoplastic.
• pulmonary atresia is the extreme form of pulmonary stenosis in that there is total fusion of the commissures and no blood flow to the lungs.
• characteristic murmur is present
• infants and children may be asymptomatic.
• NB with severe narrowing are cyanotic and HF occurs.
• dilation of the narrowed valve may be done during cardiac catheterization.
• in infants: transventricular (closed) valvotomy procedure.
• in children: pulmonary valvotomy with CP bypass.

Question 18

Defects with Decreased Pulmonary Blood Flow

Answer 18

• obstructed pulmonary blood flow and an anatomical defect (ASD or VSD) between the right and left sides of the heart are present.
• pressure on the right side increases, exceeding pressure on the left side, which allows desaturated blood to shunt right to left, causing desaturation on the left side and in the systemic circulation.
• typically hypoxemia and cyanosis appear.

Question 19

Defects with Decreased Pulmonary Blood Flow: Tetralogy of Fallot

Answer 19

• includes 4 defects: VSD, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy.
• if pulmonary vascular resistance is higher than systemic resistance, the shunt is from right to left; if the opposite, that shunt is from left to right.
• infants: may be acutely cyanotic at birth or may have mild cyanosis that progresses over the first year of life. A murmur is present on auscultation and acute episodes of cyanosis and hypoxia occur when the infant’s oxygen requirements exceed the blood supply (crying, feeding, defecating).
• Children: with increasing cyanosis, squatting, clubbing of the fingers, and poor growth may occur.
• palliative shunt: shunt increases pulmonary blood flow and increases oxygen saturation in infants who cannot undergo primary repair. Shunt provides blood flow to the pulmonary arteries from the left or right subclavian artery.
• complete repair: usually performed in the first year of life and requires a median sternotomy and CP bypass.

Question 20

Defects with Decreased Pulmonary Blood Flow: Tricuspid Atresia

Answer 20

• failure of the tricuspid valve to develop.
• no communication exists from the right atrium to the right ventricle.
• blood flows through an ASD or a patent foramen ovale to the left side of the heart and through a VSD to the right ventricle and out to the lungs.
• the defect often is associated with pulmonic stenosis ans transposition of the great arteries.
• defect results in complete mixing of unoxygenated and oxygenated blood in the left side of the heart, resulting in systemic desaturation, pulmonary obstruction, and decreased pulmonary blood flow.
• cyanosis, tachycardia, and dyspnea are seen in the NB.
• older children exhibit signs of chronic hypoxemia and clubbing.

Question 21

Mixed Defects

Answer 21

• fully saturated systemic blood flow mixes with desaturated blood flow, causing desaturation of the systemic blood flow.
• pulmonary congestion occurs and cardiac output decreases.
• signs of HF are present; symptoms vary with the degree of desaturation.

Question 22

Mixed Defects: Hypoplastic Left Heart Syndrome

Answer 22

• underdevelopment of the left side occurs, resulting in hypoplastic left ventricle and aortic atresia.
• mild cyanosis and sign of HF occur until the ductus arteriosus closes; then progessive deterioration with cyanosis and decreased cardiac output are seen, leading to cardiovascular collapse.
• defect is fatal in the first few months of life without intervention.
• surgical treatment is necessary and transplantation in the NB period may be considered.
• in the preop period, the NB requires MV and continuous infusion of prostaglandin E1 to maintain ductal patency, ensuring adequate systemic blood flow.

Question 23

Mixed Defects: Transposition of the Great Arteries or Transposition of the Great Vessels

Answer 23

• pulmonary artery leaves the left ventricle, an the aorta exits from the right ventricle.
• no communication exists between the systemic and pulmonary circulation.
• infants with minimal communication are severely cyanotic ate birth.
• infants with large septal defects or a patent ductus arteriosus may be less severely cyanotic but may have symptoms of HF.
• cardiomegaly is evident a few weeks after birth.
• prostaglandin E1 may be initiated to keep the ductus arteriosus open and to improve blood mixing temporarily.
• ballon atrial septostomy during cardiac catheterization may be performed to increase mixing from both sides of the heart and to maintain cardiac output over a longer period.
• the arterial switch procedure reestablishes normal circulation.

Question 24

Mixed Defects: Total Anomalous Pulmonary Venous Connection

Answer 24

• defect is a failure of the pulmonary veins to join the left atrium.
• results in mixed blood being returned to the right atrium and shunted from the right to the left through an ASD.
• the right side hypertrophies, whereas the left side of the heart may remain small.
• signs and symptoms of HF develop, cyanosis worsens with pulmonary vein obstruction; when obstruction occurs, the infant’s condition deteriorates rapidly.
• corrective repair is performed in early infancy.
• pulmonary vein is anastomosed to the left atrium, the ASD is closed, and the anomalous pulmonary venous connection is ligated.

Question 25

Mixed Defects: Truncus Arteriosus

Answer 25

• is failure of normal septation and division of the embryonic bulbar trunk into the pulmonary artery and the aorta, resulting in a single vessel that overrides both ventricles.
• blood from both ventricles mixes in the common great artery, causing desaturation and hypoxemia.
• characteristic murmur is present.
• infant exhibits moderate to severe HF and variable cyanosis, poor growth, and activity intolerance.
• corrective surgical repair is performed in the first few months of life.

Question 26

Interventions: Cardiovascular Defects

Answer 26

• monitor VS, respiratory status, auscultate breath sounds.
• if respiratory effort is increased, place the child in a reverse Trendenlenburg’s position, elevating the head and upper body, to decrease the work of breathing.
• adm humidified oxygen and provide endotracheal tube and ventilator care if necessary.
• monitor for hypercyanotic spells (acute episodes of cyanosis and hypoxia) and intervene immediately.
• assess for signs of HF, peripheral pulses, intake and output, daily weight.
• maintain fluid restriction if prescribed and provide adequate nutrition.
• adm meds as prescribed.
• plan interventions to allow rest and keep the child stress-free.

Question 27

Cardiac Catheterization

Answer 27

• invasive diagnostic procedure to determine cardiac defects.
• provides information about oxygen saturation of blood in great vessels and heart chambers.
• may be done for diagnostic, interventional, or electrophysiological reasons.
• risk include hemorrhage from the entry site, clot formation and subsequent blockage distally, and transient dysrhythmias.
• general anesthesia is usually unnecessary.

Question 28

Cardiac Catheterization: Preprocedure Nursing Interventions

Answer 28

• assess accurate height and weight (to choose correct catheter size).
• obtain a history of the presence of allergic reactions to iodine.
• assess for symptoms of infection (including diaper rash).
• assess and mark bilateral pulses (such as dorsalis pedis and posterior tibial).
• assess baseline oxygen saturation.
• familiarize and educate the parents and child (if age appropriate).

Question 29

Cardiac Catheterization: Postprocedure Nursing Interventions

Answer 29

• monitor findings on the cardiac monitor and oxygen saturation for 4h after procedure.
• assess pulses below the catheter site for presence, equality, and symmetry.
• assess temp and color of the affected extremity and report coolness.
• monitor VS every 15 min 4x, every 30 min 4x, and every hour 4x.
• assess the pressure dressing for intactness and signs of hemorrhage.
• check the bed sheets under the extremity for blood and if bleeding is present, apply continuous, direct pressure at the cardiac catheter entry site and report immediately.
• immobilize the affected extremity in a flat position for at least 4-6h for venous entry site and 6-8h for arterial entry site as prescribed.
• hydrate the child VO or IV as prescribed.
• adm acetaminophen or ibuprofen for pain or discomfort as prescribed.

Question 30

Cardiac Catheterization: Discharge Teaching

Answer 30

• remove the dressing on the day after the procedure and cover it with a bandage for 2-3 days as prescribed.
• keep the site clean and dry.
• avoid tub baths for 2-3 days.
• observe for edema, redness, drainage, bleeding, and fever, and report any of these signs immediately.
• avoid strenuous activity and the child may return to school, if appropriate.
• provide a diet as tolerated.
• adm acetaminophen or ibuprofen for pain, discomfort, or fever.
• keep follow up appointment.

Question 31

Cardiac Surgery: Postop Interventions

Answer 31

• monitor VS, signs of sepsis, sings of discomfort.
• monitor lines, tubes, or catheters.
• maintain strict aseptic technique.
• adm pain meds, ATB, and antipyretics as prescribed.
• promote rest and sleep periods.
• facilitate parent-child contact ASAP.

Question 32

Cardiac Surgery: Postop Home Care

Answer 32

• omit play for several weeks as prescribed.
• avoid activities for 2-4 weeks.
• avoid crowds for 2 weeks after discharge.
• follow a no-added-salt diet, if prescribed.
• do not add nay new foods to the infant’s diet (to avoid allergic reactions that might be interpreted as postop complications).
• do not place creams, lotions, or powders on the incision until completely healed.
• child may return to school usually afterthe third week after discharge, starting with half-days.
• child should not participate in physical education for 2m.
• the 2-week follow-up is important.
• avoid immunizations, invasive procedures, and dental visits for 2m.
• child should have a dental visit every 6m after age 3 years and inform the dentist about the cardiac problem.
• call the pediatrician if coughing, tachypnea, cyanosis, vomiting, diarrhea, anorexia, pain, or fever occur, or any swelling, redness, or drainage at the site of the incision.

Question 33

Rheumatic Fever: description and assessment

Answer 33

• is an inflammatory autoimmune disease that affects the connective tissues of the heart, joints, skin, blood vessels, and central nervous system.
• most serious complication is rheumatic heart disease, which affects the cardiac valves (particularly the mitral).
• manifests 2-6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract.
• Jones criteria are used to help determine the diagnosis.
  Assessment:
• low grade fever that spikes in the late afternoon.
• elevated anti-streptolysin O titer, erythrocyte sedimentation rate, and C-reactive protein level.
• Aschoff bodies (lesions) found in the heart, blood vessels, brain, and serous surfaces of the joints and pleura.

Question 34

Rheumatic Fever: Jones Criteria

Answer 34

Major Criteria:
- carditis, arthralgia, chorea (involuntary movements of extremities and face), erythema marginatum, and subcutaneous nodules.

Minor Criteria:
Fever, arthralgia, elevated erythrocyte sedimentation rate or positive C-reactive protein cell, prolonged PR interval on ECG.

Question 35

Rheumatic Fever: Interventions

Answer 35

• assess VS
• control joint pain and inflammation with massage and alternating hot and cold applications as prescribed.
• provide bed rest during the acute febrile phase.
• limit physical exercise in child with carditis.
• adm ATB, salicylates, and antiinflammatory agents as prescribed.
• initiate seizure precautions if the child experiences chorea.
• instruct parents about the importance of follow-up and the need for ATB prophylaxis.
• advise the child to inform parents if anyone in school develops a streptococcal throat infection.

Question 36

Kawasaki Disease: description and assessment

Answer 36

• also known as mucocutaneous lymph node syndrome, is an acute systemic inflammatory illness.
• cause is unknown, but may be associated with an infection from an organism or toxin.
• cardiac involvement is the most serious complication; aneurysms can develop.
  Assessment:
• acute stage: fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of cervical lymph nodes.
• subacute stage: crackling lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, thrombocytosis.
• convalescent stage: child appears normal, but signs of inflammation may be present.

Question 37

Kawasaki Disease: Interventions

Answer 37

• monitor temp frequently.
• assess heart sounds, HR, and rhythm.
• assess extremities for edema, redness, and desquamation.
• examine eyes for conjunctivitis.
• monitor mucous membranes for inflammation.
• monitor strict intake and output.
• adm soft foods and liquids that are neither too hot or too cold.
• weigh child daily.
• provide passive range-of-motion exercises to facilitate joint movement.
• adm acetylsalicylic acid as prescribed for its antipyretic and antiplatelet effects.
• adm immunoglobulin IV as prescribed to reduce the duration of the fever and the incidence of coronary artery lesions and aneurysms.