Test #2 Flashcards
congenital heart disease
-Anatomical: abnormal cardiac function
-Present at birth
Clinical course results in
-Heart failure
-Hypoxemia
acquired heart disorder
Disease process or abnormalities that occur after birth
Infection
Autoimmune responses
Environmental factors
Familial tendencies
Risk factors for congenital heart disease
Maternal diabetes or lupus
Medications during pregnancy (eg dilantin)
Substance use during pregnancy
Infections during pregnancy (rubella)
Low birth weight from intrauterine growth restriction
High birth weight babies
ECG
- Measure the electrical activity of the heart
- heart rate and rhythm
- abnormal rhythms or conduction, ischemic changes
- Bedside cardiac monitoring with ECG is common in peds
echo
ultra high-frequency sound waves to produce an image of the heart’s structure
MRI
Visualizes the structures
cardiac Cath nursing care
Pre
-Sedation
-NPO 4-6 hours before
Post
-Vital signs
- *pulse below cath site (equal and symmetrical)
- May be a bit weaker for the first few hours after
- Q15 min
- Hypotension → hemorrhage
- Bleeding, hematoma formation
- Fluid intake
- Blood glucose levels
- More for infants (give dextrose if low)
- The child’s usual diet can be resumed as soon as tolerated, beginning with sips of clear liquids and advancing as the condition allows
- The child should be encouraged to void to clear the contrast material from the blood
congenital heart disease
-Incidence: 12 per 1000 live births
-CHD is a major cause of death in the first year of life (after prematurity).
-Critical congenital heart disease (CCHD) is more severe and usually requires intervention early in life
-Pulse oximetry screening recommended review
-Done 24 hours after birth
-Test pulse ox from right hand
- >5% difference indicates problem
-The most common anomaly is ventricular septal defect (VSD).
-Often associated with other anomalies/chromosome abnormalities (trisomy 21, 13, 18).
Acyanotic hemodynamics
increased pulmonary blood flow
obstruction from the ventricles
Cyanotic hemodynamics
-decreased pulmonary blood flow
-mixed blood flow
increased pulmonary blood flow
-Atrial septal defect
-Ventricular septal defect
-patent ductus arteriosus
-antrioventrcilar canal defect
Abnormal connection between two sides of heart
Blood flows from higher pressure left side → lower pressure right side
Increased blood volume on right side of heart → Increases pulmonary blood flow
Decreased systemic blood flow
Obstruction from ventricles
-coarctation of aorta
-aortic stenosis
-pulmonic stenosis
Anatomic narrowing of blood vessel exiting the heart
Decreased pulmonary blood flow
-Tetralogy of Fallot
-Tricuspid Atresia
Blood has difficulty exiting right side of heart via pulmonary artery
Pressure on right side increases, greater than left-sided pressure
Desaturated blood shunts to the left side of heart and in systemic circulation
Mixed Blood Flow
-Transposition of great arteries
-total anomalous pulmonary venous return
-Truncus arteriosus
-Hypoplastic left heart syndrome
fully saturated systemic blood flow mixes with the desaturated pulmonary blood flow, causing a relative desaturation of the systemic blood flow.
Pulmonary congestion occurs because the differences in pulmonary artery pressure and aortic pressure favour pulmonary blood flow.
Cardiac output decreases because of a volume load on the ventricle.
Clinical Consequences of Congenital Heart Disease
Hypoxemia
Polycythemia and clubbing
Hypercyanotic spells (tet spells/blue spells) –> Give 100% O2, morphine, IV fluid replacement, knee to chin position
signs of digoxin toxicity
Nausea, vomiting, anorexia, bradycardia, dysrhythmias
chest xray
provides information on the heart size and pulmonary blood flow patterns, providing a baseline for future comparisons.
What is the leading cause of death after heart transplantation?
rejection
Vesicoureteral reflex
-Retrograde flow of urine from bladder to upper urinary tract (kidneys)
-Primary reflux related to anatomical abnormalities
-Secondary reflux related to acquired condition (eg. high bladder pressure, persistent PVRs or voiding dysfunction)
-Reflux increases chance for febrile UTI
-Reflux with infection is the most common cause for pyelonephritis
-Prevention with antibiotic prophylaxis
-Occasionally requires surgery
-Managed with daily low dose antibiotic until toilet independence
nursing care for post op gender assignment surgery
-Tub baths often discouraged for 1 week after surgery
-Keep surgical site clean, monitor infection
-Some older children’s activities, such as pushing, lifting, playing with straddle toys or in sandboxes, swimming, and engaging in rough activities, may be restricted after some types of surgical repairs.
-Activities of infants and toddlers are not limited.
dialysis
-The process of separating colloid and crystalline substances through a semipermeable membrane
-blood filtrate is circulated outside the body by hydrostatic pressure exerted across a semipermeable membrane with simultaneous infusion of a replacement solution.
-generally reserved for use in AKI, severe fluid overload, inborn errors of metabolism, or after bone marrow transplant.
peritoneal dialysis
-The preferred method of dialysis for children
-Abdominal cavity acts as semipermeable membrane for filtration
-Warmed solution enters peritoneal cavity by gravity, remains for period of time before removal
-The fluid and accumulated toxic wastes are then drained from the peritoneal cavity and a new cycle of fresh dialysis solution is reinstilled.
-Can be managed at home in some cases
-Performing this form of dialysis in the home can be empowering for families, especially adolescents.
hemodialysis
-Requires surgical creation of a vascular access and special dialysis equipment
-Vascular access may be one of three types: fistulas, grafts, or external vascular access devices.
-Best suited for children who can be brought to facility three times/week for 4 to 6 hours
-Achieves rapid correction of fluid and electrolyte abnormalities
-can cause adverse effects in association with this rapid change, such as muscle cramping, headaches, nausea and vomiting, and hypotension
-Disadvantages
-School absence
-Strict fluid and dietary restrictions
Kidney Transplant
-Preferred treatment for children with ESRD
-From living related donor
-From cadaver donor
-Primary goal is long-term survival of grafted tissue
-Role of immunosuppressant therapy
-Prednisone, tacrolimus, cyclosporine, mycophenolate
-Taken indefinitely
-Rejection of the transplanted kidney is the most common cause of transplant failure.
-Rejection is treated aggressively with immunosuppressant medications and can often be reversed
signs of increased ICP in infants
Tense, bulging fontanel
Separated cranial sutures
Macewen sign (cracked-pot sound on percussion)
Irritability and restlessness
Drowsiness, increased sleeping
High-pitched cry
Increased fronto-occipital circumference
Distended scalp veins
Poor feeding
Crying when disturbed
Setting-sun sign
symptoms of increased ICP in children
Headache
Nausea
Forceful vomiting
Diplopia, blurred vision
Seizures
Indifference, drowsiness
Decline in school performance
Diminished physical activity and motor performance
Increased sleeping
Inability to follow simple commands
Lethargy
late signs of increased ICP
Bradycardia
Decreased motor response to commands
Decreased sensory response to painful stimuli
Alterations in pupil size and reactivity
Flexion or extension posturing
Cheyne-Stokes respirations
Papilledema
Decreased consciousness
Coma
earliest indicator of changes in neuro status
level of consciousness
obtundation
A severe reduction in LOC; the child arouses with very strong stimulus but is close to a comatose state
stupor
Remaining in a deep sleep, responsive only to vigorous and repeated stimulation or moaning responses to stimuli
persistent vegetative state
Permanently lost function of the cerebral cortex; eyes following objects only by reflex or when attracted to the direction of loud sounds, all four limbs spastic but can withdraw from painful stimuli, hands showing reflexive grasping and groping, face grimacing, some food may be swallowed, groaning or crying but without uttering any words
GCS score indicating severe head injury and deep unresponsive coma (possibly brain death)
3 or less
Neurological determination of death
-Complete cessation of brain function (no activity on EEG)
-Irreversibility of condition
-Absence of brain reflexes
-Absence of respiratory effort
-Etiology can cause neurological death
Widely dilated and fixed pupils suggest
-herniation of the brain
-neurosurgical emergency
decorticate/flexion posturing
seen with severe dysfunction of the cerebral cortex or with lesions to corticospinal tracts above the brainstem
deceberate/extension posturing
sign of dysfunction at the level of the midbrain or lesions to the brainstem
absence of corneal reflexes and presence of tonic neck reflex are associated with
severe brain damage
evoked potentials (auditory and visual)
-Visual evoked potentials can aid in evaluating visual abnormalities from the retina to the visual cortex
-auditory evoked potentials are useful for assessing hearing acuity and brainstem function
-Both are particularly useful for detecting demyelinating diseases such as pediatric multiple sclerosis and neoplasms
emergency management of the Unconscious Child
Patent airway, breathing, and circulation
Reduction of ICP
Treatment of shock
Stabilize spine if required
non pharm techniques for kids with neurological issues
-Pain control
-a quiet, dimly lit environment
-limit visitors
-prevent any sudden, jarring movements, such as banging into the bed
-proper positioning
-prevention of the patient’s straining (coughing, vomiting, suctioning, and defecating)
indications of ICP monitoring
-GCS of less than 8
-GCS evaluation greater than 8 with respiratory assistance
-Deterioration of condition
-Subjective judgment regarding clinical appearance and response
gold standard ICP monitor
Intraventricular catheter
-A drainage bag attached to the system is kept at the level of the ventricles and can be lowered to decrease ICP.
primary head injury
injuries that occur at time of trauma, include skull fracture, contusions, intracranial hematoma, and diffuse injury
complications of head injuries
hypoxic brain damage, increased ICP, infection, cerebral edema
most common head injury
concussion
linear skull fracture
single fracture line, does not cross suture lines, majority of childhood fractures
depressed skull fracture
bone is broken into several fragments that are pushed inward
comminuted skull fracture
multiple associated linear fractures, may suggest maltreatment
basilar skull fracture
involves bone at base of skull, very serious, racoon eyes, bleeding in ears, CSF from nose or ears
open skull fracture
communication between skull and scalp, increase risk of infection
growing skull fracture
skull fractures with underlying dural tear that fails to heal properly
epidural hemorrhage
-Bleeding between dura and skull to form a hematoma
-Brain compression occurs rapidly
-Clinical picture - momentary unconsciousness → normal period → lethargy and coma
subdural hemorrhage
-Bleeding between dura and arachnoid membrane
-Frequently result from birth trauma, falls, THI-CM
-S/S - irritability, vomiting, increased head circumference, bulging fontanels in infants, lethargy, or seizures
acute symptomatic seizure
Associated with head trauma or meningitis
remote symptomatic seizures
Prior brain injury such as head trauma, encephalitis, meningitis, or stroke
cryptogenic seizure
no clear cause
idiopathic seizure
genetic
Focal (partial) seizures
-Local onset and involves a relatively small location of the brain
-Person maintains awareness but may not be able to talk
-Uncommon in kids under 8
generalized seizures
-Involves both hemispheres without local onset
-Loss of awareness
-Generalized tonic clonic most common
general absence seizure
Staring, no alterations in muscle tone (last 5-10 secs)
atonic seizure
Sudden momentary loss of muscle tone (fall down)
Common in morning after waking up
unknown onset seizure
-6-8 months of life
-Cognitive impairment
-Possible series of sudden, brief, symmetrical, muscular contractions
-Head flexed, arms extended, and legs drawn up
-Eyes sometimes rolling upward or inward
-May be preceded or followed by a cry or giggling
management of seizures
-Medication therapy: antileptic
-Ketogenic diet: shifts from glucose metabolism to fat
-Vagus nerve stimulation: 12 and older
-Surgical therapy: if caused by hematoma, etc
-Treatment for status epilepticus: ABCs, Ativan
-Reduce harm during seizure
-Assess seizure activity (timing)
-If vomiting occurs, turn child to one side
-ABCs
-Assess for triggering factors
key reflexes that demonstrate healthy neurological status in young infants
moro reflex
tonic neck reflex
withdrawal reflex
