The Child with a Cardiovascular Alteration Flashcards
Preload = volume of blood received by the heart.
Basically, preload is stretch. The amount of volume being returned to the heart.
Afterload = pressure or resistance the heart has to overcome to eject blood.
Afterload is squeeze. The amount of resistance that the heart has to overcome in order to eject blood.
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Is the resistance the left ventricle must overcome to circulate blood.
Afterload
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Is the volume of blood in ventricles at end of diastole (end diastolic pressure)
Preload
Prenatal Heart Circulation (Video)
https://www.stlouischildrens.org/health-resources/pulse/medical-animation-prenatal-heart-circulation
Congenital Heart Disease (CHD)
Classified according to structural abnormalities, functional alterations, or both
Subdivided into groups defined by blood flow patterns
> Increased pulmonary blood flow
> Normal to decreased pulmonary blood flow
> Obstructive lesions
> and other complex lesions
* Manifest during the newborn, infancy, or early childhood
* Degree of the symptoms = the need for medical, surgical, or transcatheter interventions
Important Terms
___ = abnormal blood flow from one part of the circulatory system to another
Can occur
> Abnormal opening or connection between cardiac chambers or great arteries
> Pressure increases on one side of the heart than the other side
> O2 saturation increases in blood flow that is normally desaturated or decreases in blood that is normally fully saturated
Shunt
___ or right side of the heart = a low/high (?) pressure and desaturated system @ 70%
___ or left side of the heart = a low/high (?) pressure and fully saturated system @ 95-98%
Venous; low
Arterial; high
Blood flow
* Amount of blood flow to lungs (pulmonary artery) = amount of blood flow to systemic circulation (aorta)
> Described as the pulmonary-to-systemic ratio QP/QS (ratio 1:1)
> CHD patients can have normal, increased, or decreased QP/QS blood flow ratios
Classification of Congenital Heart Disease (CHD)
Left-to-right shunting lesions (increase pulmonary blood flow)
* Defect in atrial septum or persistence of a patent ductus arteriosus (PDA)
* Saturated blood shunts from left-to-right → volume overload right side of the heart and pulmonary artery
* Cardiac workload ↑
* The abnormal increase in highly saturated blood along and the increased fluid volume in the lungs = ALTERED GAS EXCHANGE
* Major consequence of left-to-right shunting is HEART FAILURE
Examples
> ASD
> VSD
> PDA
> AVSD (endocardial cushion defect)
Obstructive or stenotic lesions (decrease cardiac outflow)
Stenosis = narrowing or constriction of an opening
* Can occur in a valve or a vessel - constricting or obstructing blood flow
* Pressure ↑ area behind the obstruction and blood flow distal to the obstruction ↓ or absent
* Stenotic lesions occur in the right or left side of the heart
* Obstruction on the left side of the heart ↓ amount of blood for systemic perfusion
* ↑ cardiac workload and ventricular strain
* Consequences: heart failure and ↓ cardiac output
Examples
> pulmonary stenosis
> aortic stenosis
> coarctation of the aorta
Cyanotic lesions with decreased pulmonary blood flow
* Problem in fetal development → hyperplasia or incomplete development, malalignment, or obstruction on the right side of the heart → decreased amount of blood flow to the lungs
* Left side of the heart low on oxygen saturation → hypoxemia, ↑ cardiac workload, and ventricular strain
* Manifestations
> Hypoxemia → cyanosis
> Upper respiratory infections
> Severely limited pulmonary blood flow
> Marked exercise intolerance
Examples
> Tetralogy of Fallot
> Tricuspid valve abnormalities
> Pulmonary atresia with intact ventricular system
Cyanotic lesions with increased pulmonary blood flow (mixing lesions)
* Fetal heart
> Fails to develop into separate pulmonary and systemic circulation
> Reversal of circulation = desaturated blood goes into systemic circulation and saturated blood goes into pulmonary circulation → cyanosis
* Cause increased cardiac workload, ventricular strain, and decreased cardiac output
Manifestations
- ruddy or cyanotic
- increased respiratory effort
- or systemic circulation is compromised - dusky or gray → cardiogenic shock
Examples
> truncus arteriosus
> hypoplastic left heart syndrome
> or transposition of the great arteries
Left-to-Right Shunt (Acyanotic)
↑ mixed blood flow; ↓ pulmonary blood flow
ASD
VSD
PDA
Coarctation of the aorta
Right-to-Left Shunt (Cyanotic) - Four T’s
↑ pulmonary blood flow; ↓ obstruction of blood from the ventricles
Tetralogy of Fallot
Truncus arteriosus
Transposition of the great vessels
Tricuspid atresia
Physiologic Consequences of CHD
Heart Failure (HF)
* Inability to circulate sufficient blood to maintain metabolic demands of the body
> Heart rate ↑ to increase the cardiac output
> Extra work → heart muscle to enlarge (hypertrophy) → enlarged heart - cardiomegaly
> Heart muscle walls - grow weak and inefficient → decreased blood volume → arteries constrict and force heart to work even harder
> Backup of blood flow → congestion in the body and lungs (pulmonary edema)
Etiology/Causes of heart failure (HF) in children
* Congenital cardiac defect
* Acquired heart disease
> cardiomyopathies
> dysrhythmias
> infections (such as endocarditis or myocarditis)
> tumors
Heart Failure - Manifestations
In infants
> Mild tachypnea at rest (70-100 breaths/min)
> Difficulty feeding (hungry and irritable soon after feeding)
> Failure to gain weight → failure to thrive
In older children
> Dyspnea w/exertion and tachypnea, orthopnea
> Diaphoresis, decreased appetite, chronic abdominal pain, failure to gain weight, jugular vein distention
* Cardiac rhythm gallop, periorbital and facial edema, hepatomegaly, splenomegaly, ↓ peripheral profusion, ↓ urine output, mottling, cyanosis, and pallor
* Watch for PULMONARY HYPERTENSION (PAH)
Heart Failure - Therapeutic Management
- ↓ cardiac workload and improving cardiac output
- Supplemental oxygen
Pharmacological agents
* Positive inotropes (digoxin), diuretics, angiotensin converting enzymes (ACE) inhibitors
Digoxin - cardiac glycoside
* Increases cardiac output and improves cardiac effectiveness
> Strengthens the force of myocardial contractions
> Slows the heart rate
> Improves blood flow to the kidneys and enhances diuresis
* Baseline ECG before initiating therapy
* Administered PO or IV
* Therapeutic serum drug level (0.8 - 2 ng/mL)
* Hypokalemia and hypomagnesemia increase risk for digoxin toxicity
Diuretics
* Eliminate excess water and sodium by increasing urine production → reducing systemic in pulmonary congestion
- Furosemide (loop diuretic)
- Thiazides less potent
- May lead to hypokalemia
- Potassium-sparing diuretics (spironolactone) may be used instead (! monitor K+ !)
Vasodilators - hydralazine
ACE inhibitors - captopril or enalapril
Feeding an infant or child with heart failure (HF)
* Relaxed environment
* Time feedings before other activities
* Frequent, small feedings less tiring
* Hold in an upright position - less stomach compression and improves respiratory effort
* May need nasal gastric or nasal duodenal feedings
* Assess for tachypnea, diaphoresis, feeding intolerance vomiting
* Increase caloric intake by concentrating formula 30 kcal/oz
Pulmonary Hypertension
* Elevated BP in lung blood vessels
* Diagnosed when mean pulmonary arterial pressure exceeds 25 mmHg at rest for children >3 mos age (normal at rest 15 mmHg)
Treatment
* Treating symptoms of HF
> Digitalis, calcium channel blockers, diuretics, warfarin, oxygen
> Avoid strenuous exercise and high altitudes
Cyanosis
* Cyanotic cardiac lesions lead to cyanosis
* Bluish discoloration of the skin, nailbeds, and mucous membranes
* Visible when unbound hemoglobin reaches 5 g/dL and O2 sat drops <85%
* Crying intensifies cyanosis and is not alleviated by the administration of 100% O2
Consequences of Cyanosis
* Polycythemia
* Anemia
* Clotting abnormalities
* Hypercyanotic episodes
* Central nervous system injury
* PAH
* Endocarditis
* Dehydration
* Hyperthermia
* Fever
* Poor oral intake
* Vomiting
* Diarrhea
Hypercyanotic episode (“tet spells”)
* Dramatic decrease in pulmonary blood flow → hypoxia & metabolic acidosis
* Episodes may last a few minutes to a few hours
* Manifestations
> Rapid and deep respirations, irritability and crying, peripheral vasodilation, increased systemic venous return, increasing cyanosis, decrease in systolic murmur, tachypnea, and hyperpnea
* Episode may be preceded by crying, feeding, or defecation
Treatment
* Calming the infant
* Placing the infant in the knee-chest position - ↑ systemic vascular resistance and force blood to pulmonary system
* Oxygen
* Morphine sulfate
* Phenylphedrine (vasoconstrictive)
* Propanolol
Cardiac Assessment of CHD
Health History
> Obtain data on maternal past history & prenatal care
> Obtain data on pregnancy, birth, and any birth defects or genetic anomalies
> Obtain data on feeding difficulties, weight gain, color changes with crying
Inspection
> Color of the skin, oral mucous membranes, nailbeds, conjunctiva
> Activity level while sitting and laying down
> Observe for color changes with activity, feeding, or crying
> Observe for exercise tolerance
> Observe chest movements for symmetry and chest shape
> Observe respiratory pattern
> Observe for signs of respiratory distress (tachypnea, retractions, nasal flaring, crackles, grunting, head bobbing)
Auscultation
> S1 and S2 heart sounds
> Assess for “gallops” - extra heart sound S3 or S4
> Assess for murmurs, clicks or precordial friction rubs
Palpation
> Compare temperature of torso with extremities
> Compare central and distal pulses
> Assess for capillary refill, PMI
> Assess for hepatomegaly - locate liver border
Cardiovascular Diagnostic Evaluation - Cardiac Catheterization
* Invasive procedure
* Catheter inserted via vein or artery (femoral or radial) directly into the heart
* Angiography - detailed images of structures and blood flow patterns
* Diagnostic, interventional, and therapeutic
> angioplasty
> pulmonary valvuloplasty
> aortic valve balloon angioplasty
> stent placements
> valve replacements
> closure of septal defects
Complications
* Dysrhythmias, hemorrhage, vascular damage
* Vasospasms of the catheterized vessel
* Thrombus or embolus formation, infection
* Reaction to the dye and catheter perforation
Cardiac Catheterization - Nursing Care
Prior to Cardiac Cath
* 12-lead EKG, chest x-ray, coagulation studies
* Locate and mark distal pulses
Post-Cardiac Cath
* Affected leg straight 4-6 hours
* Bed rest; IV fluid administration
* Vital signs; insertion site dressing observed every 5-15 minutes
* Assess for bleeding; check peripheral perfusion of the affected extremity
* Avoid strenuous exercise; return to school on 3rd day after procedure
* Notify physician for any S&S of infection
Acyanotic Congenital Heart Defects: L → R Shunts
* PDA, ASD, VSD, AVSD [endocardial cushion deficit]
↑ fatigue
Heart murmur
↑ risk endocarditis
CHF
Growth retardation
Patent Ductus Arteriosus (PDA)
- Left-to-right shunting lesion
* Failure of the fetal ductus arteriosus to completely close after birth
* Normally closes 24-72 hours after birth d/t ↓ prostaglandin levels and ↓ BP in ductus lumen
Manifestations
* Heart failure signs
* Continuous murmur
* Widened pulse pressure
* Bounding pulses
* Cardiomegaly
Therapeutic Management
* Treat heart failure
* Administer indomethacin (indocin)
* Monitor respiratory status, renal function, and growth
* Cardiac catheterization with coil placement
* Surgical management - ligation of the ductus
Atrial Septal Defect (ASD)
- Left-to-right shunting lesion
* Abnormal opening between the atria
* Right atrium is enlarged and pulmonary blood flow ↑
Manifestations
* May be asymptomatic
* Fatigue, dyspnea on exertion, palpitations, atrial dysrhythmias, recurrent respiratory infections, systolic murmur, mitral valve regurgitation, heart failure if not repaired
Therapeutic Management
* Spontaneous closure may occur
* Diuretics and digoxin for heart failure
* Antidysrhythmics for atrial dysrhythmias
* Cardiac catheterization to close opening
* Daily low dose aspirin
* Surgical placement of sutures or prosthetic patch
Ventricular Septal Defect (VSD)
- Left-to-right shunting lesion
* Abnormal opening between the ventricles
* Most common cardiac defect
* Increase pulmonary blood flow → pulmonary HTN → progressive pulmonary vascular disease
Manifestations
* May be asymptomatic
* Loud harsh systolic murmur, palpable thrill, diastolic murmur, and gallop
* Heart failure - moderate to large defect
Therapeutic Management
* 35-60% closed spontaneously
* Diuretics and digoxin
* ACE inhibitors
* Cardiac catheterization
* Surgical suture or patch
Atrioventricular Septal Defect (AVSD) (Endocardial Cushion Deficit)
- Left-to-right shunting lesion
* Abnormal endocardial tissue development
- atrial and ventricular septum and mitral and tricuspid valves (AV valves)
* Usually associated with Down Syndrome
* May be partial or complete
Manifestations
* Heart failure
* Systolic pulmonary flow murmur
* Intermittent cyanosis
Therapeutic Management
* Symptomatic treatment of heart failure
> diuretics, digoxin, and ACE inhibitors
* Surgical closure of ASD and VSD and construction of 2 separate AV valves
Pulmonary Stenosis
- Obstructive or stenotic lesion
* Narrowing of the entrance to the pulmonary artery
* Obstruction causes resistance to the blood flow at the right ventricular outflow track
> ↑ pressure in the right ventricle → right ventricular hypertrophy
> Blood may regurgitate into the right atrium
Manifestations
* May be asymptomatic
* Exercise intolerance
* Signs of right-sided heart failure
* Systolic murmur
* Cardiomegaly
* Severe cases cyanosis
Therapeutic Management
* Antibiotic prophylaxis
* Cardiac catheterization
* Which includes balloon valvuloplasty with the dilation of the valve to decrease the pressure
* Surgical management done with surgical valvulotomy
Aortic Stenosis
- Obstructive or stenotic lesion
* Narrowing of the entrance to the aorta
* Difficult blood flow through aortic valve
> ↑ pressure and hypertrophy of the left ventricle, ↓ cardiac output, ↓ blood supply to the coronary arteries
Manifestations
Mild-to-moderate
> May be asymptomatic
> Exercise intolerance, cardiomegaly, systolic murmur
Severe
> Heart failure
> ↓ cardiac output with ↓ peripheral perfusion
> Chest pain, dizziness, syncope
Therapeutic Management
* Restriction from competitive sports
* Cardiac catheterization
> Aortic balloon valvuloplasty
* Surgical valvulotomy
* Aortic valve replacement
* Mechanical valve replacement requires warfarin
Coarctation of the Aorta (COA)
- Obstructive or stenotic lesion
* Aorta is constricted near the ductus arteriosus insertion site → may cause aortic valve stenosis → obstructs the left ventricle output
↓ blood supply to the abdominal organs and lower extremities
↑ left ventricular pressure - PULMONARY EDEMA
Manifestations
* Left sided heart failure
* Cyanosis
* Pulse and blood pressure differences between upper and lower extremities
* Weakness, tingling, cramps of lower extremities
* Systolic murmur
Therapeutic Management
* Diuretics, digoxin
* Cardiac catheterization balloon dilation
* Surgical interventions
* End-to-end anastomosis or use a prosthetic patch
Cyanotic Heart Defects - 4 T’s
Tetralogy of Fallot
Truncus arteriosus
Transposition of the great vessels
Tricuspid atresia
Tetralogy of Fallot - TOF or TET
- Cyanotic lesion with decreased pulmonary blood flow
* Most frequent cyanotic lesion
* Malalignment of the ventricular septum during fetal development
> VSD
> Right ventricular outflow tract obstruction (ex pulmonary stenosis)
> Overriding of the aorta
> Right ventricular hypertrophy
Manifestations
* If mild leads to “pink tet” with mild saturation changes
* Cyanosis, extreme fatigue, hypercyanotic episodes, chronic hypoxemia, systolic murmur, boot shaped heart on x-ray
Therapeutic Management
* Prostaglandins
* Surgical management (requires cardiopulmonary bypass)
Tricuspid Atresia
- Cyanotic lesion with decreased pulmonary blood flow
* Non-development of the tricuspid valve
* PFO or ASD
* Underdeveloped right ventricle
* VSD
* Transposed pulmonary artery with the aorta
* Pulmonary stenosis
Manifestations
- Profound cyanosis with decreased pulmonary blood flow
- Single second heart sound (tricuspid valve does not close)
- Systolic murmur
Therapeutic Management
* Prostaglandins
* Cardiac catheterization
- Balloon atrial septostomy (create opening in septum)
- Catheter blader septostomy (cut septum tissue)
* Surgical management
Goal to separate the saturated and unsaturated blood
Three stage surgery
* Palliative systemic-to-pulmonic artery shunt
* Creation of a connection between the SVC and pulmonary arteries
* Modified Fontan procedure: connection created from the inferior vena cava to the pulmonary arteries
Truncus Arteriosus
- Cyanotic lesion with increased pulmonary blood flow
* Non-division of common great vessel (truncus arteriosus) into pulmonary artery and pulmonary valve and aorta and aortic valve during fetal development - results in a single vessel and valve → rise to pulmonary systemic and coronary circulations
Manifestations
- HF and cyanosis in neonates
- Systolic murmur with thrill
- Diastolic murmur of truncal valve insufficiency (bounding pulse and widened pulse pressure)
Therapeutic management
- ACE inhibitors and diuretics
- Polycythemia prevention
- Infection prevention (assess calcium and magnesium levels)
- Surgery
Transposition of the Great Arteries
- Cyanotic lesion with increased pulmonary blood flow
* Abnormal separation and rotation of the fetal common truncal vessel causes aorta to arise from the right ventricle and pulmonary artery to arise from left ventricle
* Associated VSD
Manifestations
- Cyanosis at birth
- Hypoxemia despite O2 delivery
- Progressive desaturation and acidosis, developing HF
Therapeutic management
- Emergency PGE infusion
- O2 administration
- Balloon atrial septostomy
- Arterial switch
- Complications include low cardiac output, dysrhythmias
Cardiac Surgery
* Surgical or interventional catheterization needed at some point
Goal of surgical intervention is for physiological and anatomical correction to normal or near normal circulation
Preoperative preparation
- Preoperative teaching and preparation
- Verbal, written, and visual information
- Interpreter services
- Multidisciplinary team approach
- Identify barriers to hospitalization and discharge
- Tour intensive care unit
Post-operative management
- Closed heart or open-heart procedure
- Closed heart - heart continues to pump and maintain cardiac functioning during the repair
- Open heart - cardiopulmonary bypass machine - takes over the roles of the heart and the lungs
Monitoring cardiac output
- Vital signs and peripheral perfusion
- Signs of ↓ cardiac output include:
> tachycardia
> coolness and mottling of the extremities
> ↓ peripheral pulses
> delayed capillary refill time
> HTN
> ↓ urine output
> metabolic acidosis, and
> changes in level of consciousness
Post-operative management
* Supporting respiratory function
> Risk for atelectasis with cardiopulmonary bypass
> Fluid accumulation in pleural and interstitial spaces
> Intubation and mechanical ventilation - ICU
> Airway patency - suctioning of endotracheal tube
> Oxygen supplements and saturation levels
> IV sedatives
> Once extubated - encourage cough and deep breathing exercises
> Incentive spirometer
> Pulmonary exercises - chest splinting
> Chest tube care
* Maintaining fluid and electrolyte balance
> Accurate I&O
- Urine output measured hourly
- Weight is measured daily
> Electrolyte values monitored
* Promoting comfort
> Postoperative pain management
- IV infusion of opiate and analgesic (morphine sulfate or fentanyl)
- Sedatives and anti-anxiety agents
- Acetaminophen, NSAIDs
* Promoting healing and recovery
- Balance between rest and activity is necessary
- Plan a schedule with progressive activity
- Monitor nutritional intake
Acquired Heart Disease
Encompasses all cardiac conditions that are not present at birth
Infective Endocarditis
* Inflammation from infection of a cardiac valve and endocardium by a bacteria
> Result of a procedure (dental work), invasive surgery to the respiratory tract, poor oral hygiene
Causes
* Congenital heart disease with multiple surgeries and prosthetic heart valves
* Rheumatic fever
* Gram-positive bacteria (Streptococcus viridans and Staphylococcus aureus)
Manifestations
- Fear, anorexia, nausea, fatigue, malaise, arthralgias, chest pain, heart failure, petechiae, neurological impairment due to embolus, heart murmur
Diagnostic evaluation
- Blood cultures
- Echocardiogram
- CBC, ESR, ECG, and rheumatoid factor (RF)
Therapeutic management
Prevention is the most important therapeutic intervention for infective endocarditis
* Maintain optimal oral hygiene
* Antibiotic prophylaxis
> Prosthetic valves or material
> Dental procedures
> Invasive respiratory tract procedures (tonsillectomy or adenoidectomy)
> Amoxicillin is given orally one hour prior to the procedure
> Clindamycin or azithromycin - when allergy to penicillin or amoxicillin
* Infective endocarditis is treated with parenteral administration of antibiotics for up to 6 weeks
* Surgical intervention - may be needed to excise vegetation or removal of the infected valve
Dysrhythmias
* Abnormal impulse formation, abnormal conduction, or a combination of these 2 can lead to dysrhythmia
* Can lead to ↓ cardiac output
Causes
- Congenital heart disease
- Myocarditis
- Cardiomyopathy
- Wolff-Parkinson-White syndrome
- Fever, temperature instability, hypoxia, electrolyte and metabolic disturbances, increased intracranial pressure, hypovolemia, cardiac tamponade, and drug therapy or reactions to drugs
Manifestations
* Tachydysrhythmias and bradydysrhythmias - ↓ cardiac output
* Clinical manifestations
Infant and toddler
> Poor feeding, irritability, lethargy, pale or mottled color, poor peripheral perfusion (diminished pulses, mottling, cool extremities, delayed capillary refill time), decreased urine output and HF
In older children
> Palpitations, dizziness, syncope, and exercise intolerance
In absent rhythms there is no cardiac output, this is a medical emergency and cardiopulmonary resuscitation (CPR) is needed
Diagnostic evaluation
> 12-lead EKG
> 2-hour holter monitoring
Therapeutic management
Fast pulse rate (tachydysrhythmias)
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> __ is a narrow QRS tachycardia
> Rates between 220-300 bpm
> Vagal manuevers - to stop episodes of __
> Constant monitoring and emergency medical equipment should be available
> Antidysrhythmic drug therapy
> Adenosine
> Synchronized cardioversion
Supra ventricular tachycardia (SVT)
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Wide complex tachycardia
Treatment for an unconscious child is synchronized cardioversion
Wide complex tachycardia and absent pulse = CPR
Ventricular tachycardia
Therapeutic management
Slow pulse rate (bradydysrhythmias)
Bradydysrhythmias
* Dissociation between the P wave and the QRS complex
* Temporary or permanent cardiac pacing
Absent rhythms
* Asystole
> ECG rhythm strip - flat line
> Emergency management - CPR
> epinephrine
* Ventricular fibrillation
> Defibrillation and CPR
> epinephrine, lidocaine, and other antidysrhythmic drugs
* Pulseless electrical activity
> Cardiac electrical activity insufficient
> No pulse and no heartbeat - CPR is initiated
> Related to respiratory arrest
Dysrhythmias - Nursing Alert
* Assess for responsiveness
* Assess circulation
> Palpate pulses for maximum 10 seconds
> If no pulse begin chest compressions
> If slow pulse check perfusion and peripheral pulses
* Assess airway
* Assess breathing
> If no breathing begin ventilation after first cycle of chest compressions
* Obtain an ECG
* Shock if needed
?
* Autoimmune inflammatory condition
* Affects connective tissue
> Primarily heart, joints, subcutaneous tissues, brain, and blood vessels
> May lead to permanent damage of cardiac valves (mitral and aortic valve)
Causes
> Manifests 2-6 weeks after untreated group A beta-hemolytic streptococcal infection of the upper respiratory tract (strep throat)
Rheumatic fever
Manifestations (according to Jones criteria)
Major
* Arthritis
> Tender, warm, erythematous joints and polyarthritis
* Carditis
> Endocarditis, myocarditis, pericarditis, cardiac murmur, cardiomegaly, pericardial friction rub
> Mitral valve is the most frequently involved
* Subcutaneous nodules
> Small, nontender lumps
?
Involuntary purposeless jerky movements of the legs, arms, and face with speech impairment and emotional liability (Sydenham’s __)
Chorea
?
Red, painless, skin lesions that start as flat or slightly raised macules over the trunk
Erythema marginatum
Manifestations (according to Jones criteria)
Minor
* Fever, arthralgia, ↑ ESR or positive CRP
* Prolonged PR interval
* Plus evidence of streptococcal infection
Diagnostic evaluation
* Jones criteria
> 2 major manifestations or one major and 2 minor manifestations plus evidence of recent streptococcal infection
* x-ray shows cardiomegaly
* ECG shows rhythm abnormalities
* Echocardiogram
Therapeutic management
- 10 day course of oral penicillin or a single dose of benzathine penicillin IM
- Cephalosporins or erythromycin for children who are allergic to penicillin
- NSAIDs and corticosteroids
- Streptococcal prophylaxis
- Life long antibiotic therapy if valve involvement
- Rest to help minimize activity and cardiac demand
- Application of heat or cold to affected joints
- Seizure precautions for chorea
Kawasaki disease
- Mucocutaneous lymph node syndrome is an acute febrile exanthematous illness
- Immune response to an infectious or toxic trigger affecting medium-sized arteries (coronary arteries)
- T-lymphocytes and B-lymphocytes - infiltrate smooth muscle cells of vascular walls → edema and inflammation → weakens the vascular walls → leads to aneurysm → vascular walls thicken and scar
- Weakened vascular walls and increased platelets = formation of thrombus, myocardial infarction, and eventually death
Causes
> Unknown
Manifestations - 3 phases
Acute phase
> Lasts 10 days - high fever > 5 days
> Fever - unresponsive to antibiotic therapy
> Bilateral non-purulent conjunctivitis
> Changes mucous membranes - erythema, fissures, cracking of the lips, strawberry tongue
> Changes in peripheral extremities - swelling of the hands and feet, and erythema of the palms and soles
> Generalized erythematous rash
> Enlarged cervical nodes
> Tachycardia and irritability
Sub-acute phase
> Day 11-25
> Fever disappears
> Continued irritability, anorexia, desquamation of fingers and toes, arthritis, arthralgia, HF, dysrhythmias, and coronary aneurysms
Convalescent stage
> Most sx’s have disappeared this phase usually lasts until the ESR returns to normal
> Deep, transverse grooves (Beau’s lines) may appear on the child’s nails
Diagnostic evaluation
* Fever of 5 days duration in conjunction with at least 4 clinical findings in the acute phase
* Laboratory data: WBC count, elevated ESR, and CRP elevated
* ECG may show first-degree heart block
* Platelets rise during sub-acute phase
* Aneurysms detected with echocardiogram
Therapeutic management
* Preventing or reducing coronary artery damage
* High dose IV immunoglobulin (IVIG) in combination with aspirin
> IVIG infusion adverse reactions - facial flushing, tightness of the chest, chills, dizziness, N/V, diaphoresis, and hypotension
> BP
> Diphenhydramine (Benadryl) and acetaminophen may be given to control side effects
> Epinephrine for anaphylactic reactions
> Live virus vaccine should be delayed for 11 months after IVIG therapy
* Steroids
* Comfort measures and adequate hydration
> Encourage fluid intake
> High caloric liquid and low in acid
> Food should be soft and bland
> Apply salve to soothe cracked, dry lips
Hypertension
* Average systolic or average diastolic BP ≥ 95th percentile for age, height, and sex - 3 different occasions
Prehypertensive = systolic or diastolic BP: 90th-95th percentile
Normal BP = systolic or diastolic BP <90th percentile for age, height, and sex
Hypertension categorized as primary or essential (idiopathic) and secondary (symptom from an underlying disease)
Causes
> Linked to childhood obesity, DM, and family history of HTN
Manifestations
Essential or primary HTN
* Dizziness, headaches, epistaxis, visual disturbances
Secondary HTN
* Affects renal - weight loss or failure to gain weight, facial or periorbital edema, pale mucous membranes, unilateral or bilateral abdominal mass
* Affects cardiovascular - absent/decreased femoral pulses, ↓ BP lower extremities compared to upper extremities, cardiomegaly, murmur, and S/S of HF
Diagnostic evaluation
- Comprehensive medical history and physical examination
- BP measurements on all four extremities repeated twice if elevated
- Blood tests (CBC, BUN, creatinine, uric acid, and electrolytes)
- Urinalysis, echocardiogram, and arteriography
Treatment
Primary HTN
* Emphasizes on risk factor modifications
> Weight reduction
> Physical conditioning: 30-60 minutes of aerobic exercise several times per week
> Dietary modifications - avoid high sodium diet
> Relaxation techniques
> Pharmacological treatment - if lifestyle modifications do not help diuretics, beta-adrenergic receptor blockers, and vasodilators
Secondary HTN
* Treat underlying condition
Cardiomyopathies
- Disease of the heart muscle
Dilated
> Decreased contractility and dilation of ventricles without an increase in wall thickness - hypertrophy
Restrictive
> Impaired ventricular filling caused by infiltration of the muscle with abnormal material
> Ventricular size and contractility are normal
Hypertrophic cardiomyopathy (HCM)
- Hypertrophy of the ventricles = contractility is normal but ventricular filling is not due to ↑ stiffness of the ventricular walls
- Left ventricular outflow tract may be obstructed → sudden death
- S/S = dyspnea, chest pain with exertion, palpitations, syncope, systolic murmur
- Restrict from strenuous exertion and competitive sports
- Beta blockers or calcium channel blockers (verapamil)
- Surgery may be needed - septal myomectomy
Dyslipidemia in Children & Adolescents
Developing heart-healthy habits
Risk factors
> Tobacco use
> High LDL and low HDL
> HTN
> Decreased physical activity
> Obesity
> Family history
> Type 1 or 2 DM
Therapeutic management
- AAP recommends children have a lipid profile checked once between ages 9-11 and again between ages 17-21
- Low-fat diet program
> Nonfat or low-fat dairy products, limit red meat intake, increase intake of fish, vegetables, whole grains, and legumes
> Avoid excessive intake of fruit juices and other sweetened drinks, sugars, and saturated fats
> Adequate intake of dietary fiber - Increase physical exercise and avoid sedentary lifestyle
- Cholesterol-lowering medications only used when children do not respond to dietary modifications after a period of 6 months
> Statins, bile-acid binding resins, nicotinic acid, cholesterol absorption inhibitors
Nursing considerations
- Continuing education risk factors
- Healthy diet
- Importance of regular exercise
- Reducing the risk factors
Nursing Diagnosis
- Decreased cardiac output related to heart failure or decreased myocardial function
- Excess fluid volume related to volume overload in heart failure
- Ineffective breathing pattern related to pulmonary congestion
- Imbalanced nutrition less than body requirements related to increased energy expenditure and increased feeding effort
- Ineffective tissue perfusion related to hypercyanotic episodes
- Ineffective tissue perfusion related to hemodynamic instability as a result of impaired valvular or myocardial function in effects of a cerebral infarction
- Hyperthermia related to bacterial infection
- Acute pain related to the body’s immunological response
