UNIT 4 CARDIAC Flashcards
What is the normal flow of blood through the heart?
Blood comes from the superior/inferior vena cave—> right atrium—> tricuspid valve—> Right ventricle—> pulmonary valve—> pulmonary artery—> lungs—> pulmonary veins—-> left atrium—> mitral valve—> left ventricle—> aortic valve—> body
What is the only artery in the body w/deoxygenated blood
Pulmonary Artery
What is the only vein in the body that carries oxygen?
Pulmonary Vein
In a normal heart the pressure on the _____ is higher
Left
In a normal heart the pressure on the ____ side is lower
Right
Blood flow is going to depend on the….
Pressure… will go from higher pressure to lower pressure… and no flow = no grow
Aquired heart disease can result from
- Infection
- Autoimmune
- Environmental
- Famililar tendency
What are the causes of CHD?
Maternal
1. fetal alcohol syndrome, medication (dilantin/fenatoyin), illegal drugs, advanced maternal age, diabeties, infection, rubella
Chromosomal abnormalilties
1. Downs syndrome common to have ASD or VSD or both… AV canal also common
What will our physical assessent show in a cardiac potential?
- General appearance: No flow No grow
- Inspection:
- Nutritional state, color, chest deformities, Unusual pulsations, respiratory excursion, clubbing of fingers
- Palpations
- Abdomen, peripheral pulses
- Ausculation
- Heart rate and rhythm, characteristics of heart sounds
What diagnostic procedures might be used for cardiac problems?
- Electrocardiogram (ECG)
- Xray
- Echocardiogram
- Cardiac Cath
- Cardiac MRI
What can an EKG tell us?
12 lead EKG can tell us rate, any abnormal electrical conduction that they are having going on shows ischemia and ventricular hypertrophy.
What can a chest xray tell us? (cardiac)
Can detect cardiomegaly and pulmonary congestion.
What is the number one diagnostic exam for cardiac disorders?
Echocardiogram(ECHO)
1. Non-invasive and provides a good picture of blood flow pattern
2. Complication: Babies have to be still so may need sedation
Why would we use cardiac cath?
- Diagnostic purpose, measure pressures, inject dyes and see blood flow patterns
- Provides a really good picture as to whats going on prior to surgery
- Ballon procedure, stent… are procedures that can be done.
Why might we use electrophysiology?
Irregular rhythms— can go to the EP lab where they can stilulate different parts of the heart so that they can find the problem area
What are CHD that cause increased pulmonary blood flow?
- ASD
- VSD
- PDA
What causes increased pulmonary blood flow in the heart?
Defects along septum or abnormal connection between great arteries
- Left-to-right shunting of blood
- increased blood volume on the right side of heart
- increased pulmonary blood flow
What is ASD?
- Abnormal opening between the atria that allows blood flow from left atrium to right atrium
Symptoms of a small ASD?
May be asymptomatic
Symptoms of a large ASD?
- CHF unusal but possible: not really seen in children unless untreated
- Fatigue
- SOB
- Respiratory infections
ASD treatment includes?
- Spontaneous closure– depends on the defect and age of the child
- Transcatheter closure
- Septal occluders- smaller defects: best for smaller defects in the middle of the septum
- Low-dose aspirin for 6 months after to help prevent clot formation on foreign device
- Eventually tissue will grow over device.
- Surgical closure
- Smaller defects- sutures
- Mod to large defects use patch (pericardial or dacron)
When is surgical or trancather closure done for ASD?
Usually before they are school-aged.
What is VSD?
Abnormal opening between left and right bentricles that allows blood flow from left ventricle to right ventricle may vary in size from pinhole to the absence of the septum- common ventricle
Symptoms of small VSD defects include…
usually asymptomatic, no physical restrictions, reassurance and periodic follow up
Symptoms of a moderate to large of a VSD includes?
CHF common
Treatment for a VSD includes
- Spontaneous closure (20-60%)
- Dependant on size and age of child- usually close within the 1st year of life
- Transcatheter Closure (occluder)
- Surgical closer
- Smaller defects- sutures
- Moderate to large defects- patch (pericardial or dacron)
- Palliative procedure possibly– if they have a significant amount of resp issues they may have to wait on surgical correction and will have a band placed around pulmonary artery to decrease the amount of blood to the lung which lelieves some of the lung issues
What is a PDA?
Patent Ductus Arteriousus
1. Failure of the fetal ductus arterious to close within the 1st few weeks of life. This allows blood flow from higher pressure aorta to lower pressure pulmonary arter (left to right shunt)
Small PDA’s present
asymptomatically
Symptoms of a large PDA…
- CHF
- FTT
- Machinery-like murmmur
- Frequent resp infection (increased blood flow to the lungs)
Treatment of the PDA includes?
- Indomethacin (Indocin) which is the prostaglandin inhibitor.
- Given for premature infants
- Some newborns
- Transcatheter
- Coils: Occlude the blood flow. Tissue grow and close off
- Surgical
- Ligation: Thoracotomy incision rather than sternal because it allows for better visulization
- Will clip or tie off PDA
When is the natural prostaglandin production cut off?
When the umbilical cord is cut
What CHD cause decreased pulmonary blood flow
TOF
What should we know about CHD that decrease pulmonary blood flow?
- Obstruction of pulmonary blood PLUS an anatomic defect between sides of the heart (ASD or VSD)
- Pressure on right side of heart increases and exceeds left-sided pressure.
- Desaturated blood shunted right to left
- Desaturated blood to systemic circulation
- leading to Hypoxemia and cyanosis
What is TOF?
Consists of 4 cardiac defects
1. VSD
2. pulmonary stenosis
3. overriding aorta
4. right ventricular hypertrophy
S/S of TOF?
- Cyonosis (chronic) r/t pressure changes causing more deoxygenated blood in the system
- Tachypnea r/t compensation of hypoxemia
- Acute episodes of cyanosis and hypixa: HYPERCYANOTIC SPELLS
- Clubbing
- Impaired growth
Blood flow r/t TOF depends on ?
What is going on in the body… with TOF you can have left to right shunts or right to left shunts
What are hypercyanotic spells (blue spells or tet spells) in TOF?
usually preceded by activities where o2 requirments exceed the blood flow supply… feeding, crying, defacation or stressfull procedures
- Infundicular spasm decreased pulmonary blood flow
- Increases right to left shunt so desaturated blood flows to systemic ciruclation which results in acute cyanosis- hypoxia
When are hypercyanotic spells most common?
Most frequent in the 1st year of life rare before 2 months of age. Occur most often in the morning
Are hypercyantoic spells nothing to worry about?
No, requires immediate recognition and interventions
Hypercyanotic spells increase the risk for
- emboli
- seizures
- LOC
- Sudden death
Nursing interventions for Hypercyanotic spells include?
- Knee-chest position
- squatting
- Establish a calm enviroment
- Blow by 100% oxygen
- Morphine- helps calm and helps with spasm decrease tachypnea and dexreases pulmonary resistance
- IVF replacement if needed
- Repeat morphine
What is the treatment for TOF?
- Educate family in recognition and intervention of hypercyanotic spells
- Keep well hydrated
- Prevent infections and report fevers to physian promptly
- Monitor for/treat anemia: Need enough RBC to carry oxygen
- Surgical correction
- Palliative shunt-Artifical deviation
- Complete repair
What are some obstructive CHD?
- Coarctation of the Aorta
- Aortic stenosis
- Pulmonic stenosis
What do we need to know about obstructive defects?
Blood exiting heart meets area of anatomic narrowing (stenosis) causing obstruction to blood flow
- Increased pressure in ventricle and vessel behind obstruction
- Decreased pressure after the obstruction
What is coarctation of the aorta (COA)
- Narrowing of the aorta near the insertion of the ductus arteriosus which increases pressure proximal to the defect (HEAD and upper extremities)
- Decreased pressure distal to the obsruction (body and lower extremities)
What are the s/s of COA
- Elevated BP in arms
- Bounding pulses in arms
- Decreased BP in legs
- Weak or absent femoral pulses
- weak or absent pulses in lower extremities
- cool lower extremities
- CHF
How do we treat COA?
Transcatheter
1. Older infants and children: balloon angioplasty
2. Adolescents: stent placement
Surgical repair
1. Treatment of choice for infants <6 months of age & those with long-segment stenosis or complex anatoy
What should we know about blood pressure post op in COAs?
Hypertension will be present even after surgery. It will take time to normalize so they may need to be on antihypertensive postop
True or false: COA can recoarctation
True- regardles of how its fixed it can happen again.
What is aortic stenosis?
Narrowing of the aortic valve
which leads to decreased cardiac output which leads to left ventricular hypertrophy and pulmonary vascular congestion
What symptoms does a newborn present with in AS
- decreased cardiac output
- faint pulses (UPPER & LOWER)
- hypotension r/t decreased cardiac output
- tachycardia r/t compensation
- poor feeding r/t decreased energy
What symptoms do children present with in AS?
- Exercise intolerance
- dizziness
- chest pain
What activity limitations does mild AS have?
Able to participate in most sports activities
What activity restriction does Moderate to severe AS have?
No sustained streenuous activies
No competetive sports
What tx is there for AS?
- Transcatheter
- Balloon valvuloplasty
- Surgical
- valvotomy
- Valve replacement
- Surgical
- Balloon valvuloplasty
What is pulmonic stenosis (PS)
Narrowing of the pulmonary valve or artery which leads to decreased pulmonary blood flow and right ventricular hypertrophy
`
Mild PS symptoms include
Asymptomatic
Mild cyanosis
Moderate-severe PS symptoms include
CHF
Cardiomegaly
How do we treat PS
Transcather
1. Balloon balbuloplasty
Surgical (rare)
1. Valvotomy
2. Valve replacement
What is a type of mixed defects in CHD?
Hypoplastic left heart syndrome
What do we need to know about Hypoplastic left heart syndrome (HLHS)?
- Complex cardiac anomalies in which survival in postnatal period depends on mixing of blood from pulmonary and systemic circulations within heart chambers
What is HLHS?
Underdevelopment of left side of heart
and presents with hypoplastic left ventricle and aortic atresia
Oxygenation dependant on ASD or PFO (patent foramen ovale)
Systemic blood flow dependaent on PDA (patent ductus arteriousus)
What are the s/s of HLHS?
- Mild cyanosis: o2 sats tend to stay about 75%-85%
- Heart failure
- Lethargy
- Cold hands and feet- poor circulation and oxygenation
Once PDA closes, progressive cyanosis and decreased cardiac output leads to cardiac collapse
How do we treat HLHS?
- Neonatal stabilization with ventilator and inotropic support (increases contractility)
- Prostaglandin infusion***
- Staged 3 part reconstruction
- Not a fix just makes it where you can live with it
- Heart transplant
What are clinical consequences of CHD?
- CHF- Heart cant pump enough blood to meet the body’s demand for energy
- Hypoexmia
- Cyanosis
What are the causes of CHF r/t CHD?
- Structural defects
- Increased blood volume/pressure within the heart
- Myocardial insufficiency/failure
- Impaired contractility/relaxation of ventricle
- Excessive demanes on the heart muscle due to sepsis/severe anemia
What do we need to know about Right sided CHF?
- Right bentricle unable to pump blood effectively into pulmonary artery which leads to increased pressure in right atrium and systemic venous circulation.
- As a result we get hepatosplenomegaly and peripheral edema
What do we need to know about left-sided CHF?
- Left ventricle unable to pump blood effectively into systemic circulation which increases pressure in the left atrium and pulmonary veins
- As a result we have
- Elevated pulmonary pressures
- Pulmonary edema
True or false: We typically see both left and right sided CHF when a child has CHF?
True
How is CHF diagnosed?
- Symptoms
- Diagnostic tests
- cxr
- ecg
- echo
- cardiac cath
What are the s/s of CHF?
- Difficulty feeding leading to FTT
- Tachypnea/tachycardia at rest
- Dyspnea
- Retractions
- Activity intolerance
- Weight gain r/t fluid retention
- Hepatomegaly
- Peripheral edema (around the face)
What are the goals of treatment for CHF?
- Improve cardiac function
- REmove accumulated fluid and sodium
- Decrease cardiac demands
- Improve oxygenation /decrease oxygen consumption
- Support family
What medication can be used to improve cardiac function in CHF?
- Digitalis glycoside
- Digoxin(Lanoxin)
- ACE inhibitors
- Captopril (capoten)
- Enalapril (vasotec)
- Lisinopril
- Beta-Blockers
- Carvediolol (coreg)
What do we need to know about digoxin?
- It has a chronotropic and inotropic effect so it helps produce a slower and stronger heart beat
- Beneficial effects include
- Increased cardiac output
- Decreased heart size
- Decreased venous pressure
- Relief of edema
- Digoxin admin
- Super important to calculate/admin correct dose
- Observe for signs of toxicity
What must we always check prior to administering digoxin and what are the parameters?
Apical pulse
Infant/young children
- hold for HR <90-110
Older child
- Hold for HR <70bpm
What are the s/s of dig toxcity?
N/V
Anorexia
Bradycardia
Dysrhythmias
What are the specific teaching guidelines we much teach about digoxin?
- Indications, actions and correct dosage
- teach parents how to listen to apical poulse at home
- Teach parents that k+ levels have an adverse relationship
- Do not mix with food/fluids
- If dose is missed DO not give extra or second dose
- If child vomits, DO NOT give second or extra dose
- Keep in safe place- locked up
- Call poision control in the event of accidental overdose
- Return demonstration
- Written instructions
What are some ACE inhibitors that help improve cardiac function?
- Captopril (capoten)
- Enalapril (Vasotec)
- Lisinopril
What is the MOA of ACE inhibitors
Inhibit normal function of the renin-angiotensin system which blocks conversion of angiotensin 1 to angiotensin II
Results in vasodilation
- Decreased pulmonary & systemic vascular resistance
- decreased BP
- Afterload reduction
Reduces secretion of aldosterone –> reduces preload
- Prevents volume expansion from fluid retention
- Decreases risk of hypokalemia
Nursing alert for ACE inhibitors
Because ace inhibitors also block the action of aldosterone, the addition of potassium supplements or spironalctone (aldactone) to the drug regimen of patients taking diuretics is usually not needed and may cause hyperkalemia
Side effects of Ace inhibitors include?
- Hypotension
- Dry cough
- Renal dysfunction
What beta blockers imporve cardiac function?
Carvedilol (coreg)
Blocks a and b adrenergic receptors
which decreases HR, BP and causes vasodilation
What are side effects of b-blockers?
- Dizziness
- Headache
- Hypotension
What class of medication are used to remove accumulated fluid and sodium?
Diuretics
1. Furosemide (lasix), Chlorothiazide (diuril), spironolactone (aldactone)
Fluid restriction
1. Acute stages of CHF
2. Strict I&O
Sodium restriction
1. Used less in children than adults
- Negative effects on appetitie & ultimate growth
2. Avoid additional table salt/highly salted foods
What do you monitor with a patient taking diuretics?
- I&O, daily weight
- S/S of dehydration
- serium electorlytes
- s/s of adverse reactions
- Potassium-losing (may need to encourage them to eat more k+)
How can we decrease cardiac demands?
- Minimize metabolic needs
- Maintain body temperture
- Treat infection promptly
- report fever to physican
- Reduce the effort of breathing
- Semi-foweler position
- Sedate irritable child
How can we minimize metabolic demands?
- Promote sound sleeping
- cluster care
- Feed when hungry
- every 3 hours—> soon after awakeniing
- nipple adjustments
- semi-upright position
- 30 min feeds– limit because they tire out and then just burn more calories
- Gavage if needed
- Increase caloric density of formula
How can we improve oxygenation?
- Careful assessment
- Count respirations for full min
- Position ot enourage maximum chest expansion
- Increase amount of oxygen available
- Supplemental oxygen
- Monitor response to oxygen therapy
What should we know about hypoxemia & cyanosis as a secondary complication of CHD?
Heart defects that cause/allow desaturated venous blood to enter systemic ciruclation without passing through lungs result in hypoxeia & cyanosis
What are clinical manifestations of hypoxia?
- Polycythemia
- Increases blood viscosity
- Crowds out clotting
2.Clubbing
- Chronic tissue hypoxemia
- Polycythemia
What are aquired cardiovascular disorders?
- Disease processes/abnormalities occuring after birth
- Occur in normal hearts or with cognential heart defects
- Result from various factors
- Infection
- autoimmune
- Evniromental factors
- familial tendencies
What is rheumatic fever (RF)?
Inflammatory disease that occurs as a reaction to a group A beta-hemolytic streptococcal (GABHS) pharyngitis
- Usually within 2-6 weeks following an untreated or partially treated URI with GABHS
- Most common in children 5-15 years of age
What are risk factors of RF?
- Hx of group a strep (ASO titer)
- Family hx
- Environmental factors
What are complications of RF?
Inflammation in joints, skin, brain and heart
- Inflammation causes permanaent cardiac valve damage (Rheumatic heart disease)
- Most common- Mitral valve damage
What are major manifestations of of Rheumatric fever?
- Carditis
- polyarthritis
- erythema marginatrum
- Chorea jerky sudden movement
- Subcutaneous nodules
What are minor manifestations of RF?
- Arthralgia (no arthritis)
- Fever
- Lab findings consistent with inflammation
- Elevated ESR & CRP
What are the diagnostic criteria for RF?
Modified jones criteria
2 Major manifestations
or
1 major & 2 minor manifestations
= high probability of RF
How do we treat RF?
- Penicillin- 10 day course for a min of 10 years prophalictally
-
asprin/prednisone
- Reduce fever/discomfort, control inflammatory process
- bedrest during acute illness
Prevention
- Treat strep/scalert fever promtply & completely
What is infective endocarditis (IE)
- Infection of the valves and inner lining of the heart caused by bacteria that enter the bloodstream and settle in the heart lining, heart valve, or blood vessel
- organisms may enter bloodstream from any site of localized infection
- microorganisms grow on the endocardium forming vegetations
What children are at risk for infective endocarditis (IE)?
Children with CHD or Aquired heart defects
What are the most common organisms that cause IE?
Strep Viridans
Staph Aureus
Children who have undergone surgical repair or palliative surgery?
- Complex cyanotic heart defects
- Valvular abnormalities
- Prosthetic valves
- Conduits (artifical shunts)
- VSD
- PDA
- TOF
- Valve involement as a result of RF
What are the s/s of IE
Diagnosis based on clinical manifestations
1. hx of dental procedure, tonsillectomy & adenoidectomy, urinary or intestinal tract procedure
2. unexplained fever
3. weight loss
4. lethargy
5. malaise
6. anorexia
7. new murmur or change in previously existing one
8. blood culture
What are some complications of IE
Stroke & organ damage
Infections/Abscesses
Heart failure
How do we treat IE
- Blood cultures–> to find out what organism
- Antibiotics
- High doses
- IV
- 2-8 weeks
- Echocardiographic monitoring – esp. when their is vegitation to monitor location
How can we prevent IE?
- Maintain good oral hygiene
- Antibiotic prophylaxis recomended for children at highest risk
- AHA guidelines recommened amoxicillin 50mg/kg one hour prior to dental procedure, not to exceed 2 grams
What is Kawasake Disease (KD)
Leading cause of aquired heart disease in children in the US
Acute Systemic vasculitis
- Small and medium-sized blood vessels
Unknown etiology
What is the principle area of involment in Kawasaki Disease (KD)
Cardiovascular system
1. Coronary artery aneurysms
True or false: Kawasaki disease is self-limited?
True- usually resolves in 6-8 weeks
What are risk factors of KD?
Children under the age of 5 years
Males
Asians or Asian descent
How is Kawasaki disease diagnosed?
No specific diagnostic test
Diagnosis
1. Clinical findings
2. Associated lab results
- CRP
- ESR
- CBC
What is the acute phase of KD?
- Fever 5 or more days
- Very irritable- HALLMARK SIGN OF KD
- Erythema/Edema of hands & feet
- Bilateral conjunctival inflammation (red eyes but no drainage)
- Strawberry tongue/diffuse redness of oral cavity
- Polymorphous rash (irregular)
- Cervical lymphadenopathy
How long does the acute phase of KD last
10ish days
What is the subacute phase of (KD)?
- Begins when rash/fever/lymphadenitis resolved
- Desquamination of fingers and toes
- continued irritability
- Cardiovascular changes may occur
- May experience thrombocytosis
- Platlet count >600,000-800,000
How long does the subacute phase last?
11-25 days
When does the convalescent phase start?
Begins when all clinical signs have resolved and blood values return to normal
Beau’s lines on finger and toe nails
How is KD treated?
- IVGG– high doses
- Reduces incidence of coronary artery abnormalities
Asprin
1. Initally- for fever and inflammation
- 80-100 mg/kg/day
- Antiplatlet dosage after fever subsides
- 3-5mg/kg/day
Nursing interventions of KD include?
- Monitor cardiac status
- vital signs
- I&O
- Daily weights
- Minimize skin discomfort
- Cool cloths, unscented lotions, loose clothing, mouth care, including lubricant for lips - Clear liquids and soft foods during acute phase
- Quiet environment to promote rest
