UNIT 4 CARDIAC Flashcards

1
Q

What is the normal flow of blood through the heart?

A

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

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2
Q

What is the only artery in the body w/deoxygenated blood

A

Pulmonary Artery

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3
Q

What is the only vein in the body that carries oxygen?

A

Pulmonary Vein

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4
Q

In a normal heart the pressure on the _____ is higher

A

Left

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5
Q

In a normal heart the pressure on the ____ side is lower

A

Right

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6
Q

Blood flow is going to depend on the….

A

Pressure… will go from higher pressure to lower pressure… and no flow = no grow

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7
Q

Aquired heart disease can result from

A
  1. Infection
  2. Autoimmune
  3. Environmental
  4. Famililar tendency
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8
Q

What are the causes of CHD?

A

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

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9
Q

What will our physical assessent show in a cardiac potential?

A
  1. General appearance: No flow No grow
  2. Inspection:
    • Nutritional state, color, chest deformities, Unusual pulsations, respiratory excursion, clubbing of fingers
  3. Palpations
    • Abdomen, peripheral pulses
  4. Ausculation
    • Heart rate and rhythm, characteristics of heart sounds
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10
Q

What diagnostic procedures might be used for cardiac problems?

A
  1. Electrocardiogram (ECG)
  2. Xray
  3. Echocardiogram
  4. Cardiac Cath
  5. Cardiac MRI
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11
Q

What can an EKG tell us?

A

12 lead EKG can tell us rate, any abnormal electrical conduction that they are having going on shows ischemia and ventricular hypertrophy.

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12
Q

What can a chest xray tell us? (cardiac)

A

Can detect cardiomegaly and pulmonary congestion.

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13
Q

What is the number one diagnostic exam for cardiac disorders?

A

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

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14
Q

Why would we use cardiac cath?

A
  1. Diagnostic purpose, measure pressures, inject dyes and see blood flow patterns
  2. Provides a really good picture as to whats going on prior to surgery
  3. Ballon procedure, stent… are procedures that can be done.
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15
Q

Why might we use electrophysiology?

A

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

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16
Q

What are CHD that cause increased pulmonary blood flow?

A
  1. ASD
  2. VSD
  3. PDA
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17
Q

What causes increased pulmonary blood flow in the heart?

A

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

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18
Q

What is ASD?

A
  1. Abnormal opening between the atria that allows blood flow from left atrium to right atrium
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19
Q

Symptoms of a small ASD?

A

May be asymptomatic

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20
Q

Symptoms of a large ASD?

A
  1. CHF unusal but possible: not really seen in children unless untreated
    • Fatigue
    • SOB
    • Respiratory infections
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21
Q

ASD treatment includes?

A
  1. Spontaneous closure– depends on the defect and age of the child
  2. 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.
  3. Surgical closure
    • Smaller defects- sutures
    • Mod to large defects use patch (pericardial or dacron)
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22
Q

When is surgical or trancather closure done for ASD?

A

Usually before they are school-aged.

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23
Q

What is VSD?

A

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

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24
Q

Symptoms of small VSD defects include…

A

usually asymptomatic, no physical restrictions, reassurance and periodic follow up

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25
Q

Symptoms of a moderate to large of a VSD includes?

A

CHF common

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26
Q

Treatment for a VSD includes

A
  1. Spontaneous closure (20-60%)
    • Dependant on size and age of child- usually close within the 1st year of life
  2. Transcatheter Closure (occluder)
  3. Surgical closer
    • Smaller defects- sutures
    • Moderate to large defects- patch (pericardial or dacron)
  4. 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
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27
Q

What is a PDA?

A

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)

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28
Q

Small PDA’s present

A

asymptomatically

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29
Q

Symptoms of a large PDA…

A
  1. CHF
  2. FTT
  3. Machinery-like murmmur
  4. Frequent resp infection (increased blood flow to the lungs)
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30
Q

Treatment of the PDA includes?

A
  1. Indomethacin (Indocin) which is the prostaglandin inhibitor.
    • Given for premature infants
    • Some newborns
  2. Transcatheter
    • Coils: Occlude the blood flow. Tissue grow and close off
  3. Surgical
    • Ligation: Thoracotomy incision rather than sternal because it allows for better visulization
    • Will clip or tie off PDA
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31
Q

When is the natural prostaglandin production cut off?

A

When the umbilical cord is cut

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32
Q

What CHD cause decreased pulmonary blood flow

A

TOF

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33
Q

What should we know about CHD that decrease pulmonary blood flow?

A
  1. Obstruction of pulmonary blood PLUS an anatomic defect between sides of the heart (ASD or VSD)
  2. 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
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34
Q

What is TOF?

A

Consists of 4 cardiac defects
1. VSD
2. pulmonary stenosis
3. overriding aorta
4. right ventricular hypertrophy

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35
Q

S/S of TOF?

A
  1. Cyonosis (chronic) r/t pressure changes causing more deoxygenated blood in the system
  2. Tachypnea r/t compensation of hypoxemia
  3. Acute episodes of cyanosis and hypixa: HYPERCYANOTIC SPELLS
  4. Clubbing
  5. Impaired growth
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36
Q

Blood flow r/t TOF depends on ?

A

What is going on in the body… with TOF you can have left to right shunts or right to left shunts

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37
Q

What are hypercyanotic spells (blue spells or tet spells) in TOF?

A

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

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38
Q

When are hypercyanotic spells most common?

A

Most frequent in the 1st year of life rare before 2 months of age. Occur most often in the morning

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39
Q

Are hypercyantoic spells nothing to worry about?

A

No, requires immediate recognition and interventions

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40
Q

Hypercyanotic spells increase the risk for

A
  1. emboli
  2. seizures
  3. LOC
  4. Sudden death
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41
Q

Nursing interventions for Hypercyanotic spells include?

A
  1. Knee-chest position
    • squatting
  2. Establish a calm enviroment
  3. Blow by 100% oxygen
  4. Morphine- helps calm and helps with spasm decrease tachypnea and dexreases pulmonary resistance
  5. IVF replacement if needed
  6. Repeat morphine
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42
Q

What is the treatment for TOF?

A
  1. Educate family in recognition and intervention of hypercyanotic spells
  2. Keep well hydrated
  3. Prevent infections and report fevers to physian promptly
  4. Monitor for/treat anemia: Need enough RBC to carry oxygen
  5. Surgical correction
    • Palliative shunt-Artifical deviation
    • Complete repair
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43
Q

What are some obstructive CHD?

A
  1. Coarctation of the Aorta
  2. Aortic stenosis
  3. Pulmonic stenosis
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44
Q

What do we need to know about obstructive defects?

A

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

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45
Q

What is coarctation of the aorta (COA)

A
  1. Narrowing of the aorta near the insertion of the ductus arteriosus which increases pressure proximal to the defect (HEAD and upper extremities)
  2. Decreased pressure distal to the obsruction (body and lower extremities)
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46
Q

What are the s/s of COA

A
  1. Elevated BP in arms
  2. Bounding pulses in arms
  3. Decreased BP in legs
  4. Weak or absent femoral pulses
  5. weak or absent pulses in lower extremities
  6. cool lower extremities
  7. CHF
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47
Q

How do we treat COA?

A

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

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48
Q

What should we know about blood pressure post op in COAs?

A

Hypertension will be present even after surgery. It will take time to normalize so they may need to be on antihypertensive postop

49
Q

True or false: COA can recoarctation

A

True- regardles of how its fixed it can happen again.

50
Q

What is aortic stenosis?

A

Narrowing of the aortic valve
which leads to decreased cardiac output which leads to left ventricular hypertrophy and pulmonary vascular congestion

51
Q

What symptoms does a newborn present with in AS

A
  1. decreased cardiac output
  2. faint pulses (UPPER & LOWER)
  3. hypotension r/t decreased cardiac output
  4. tachycardia r/t compensation
  5. poor feeding r/t decreased energy
52
Q

What symptoms do children present with in AS?

A
  1. Exercise intolerance
  2. dizziness
  3. chest pain
53
Q

What activity limitations does mild AS have?

A

Able to participate in most sports activities

54
Q

What activity restriction does Moderate to severe AS have?

A

No sustained streenuous activies
No competetive sports

55
Q

What tx is there for AS?

A
  1. Transcatheter
    • Balloon valvuloplasty
      1. Surgical
        • valvotomy
        • Valve replacement
56
Q

What is pulmonic stenosis (PS)

A

Narrowing of the pulmonary valve or artery which leads to decreased pulmonary blood flow and right ventricular hypertrophy

`

57
Q

Mild PS symptoms include

A

Asymptomatic
Mild cyanosis

58
Q

Moderate-severe PS symptoms include

A

CHF
Cardiomegaly

59
Q

How do we treat PS

A

Transcather
1. Balloon balbuloplasty

Surgical (rare)
1. Valvotomy
2. Valve replacement

60
Q

What is a type of mixed defects in CHD?

A

Hypoplastic left heart syndrome

61
Q

What do we need to know about Hypoplastic left heart syndrome (HLHS)?

A
  1. Complex cardiac anomalies in which survival in postnatal period depends on mixing of blood from pulmonary and systemic circulations within heart chambers
62
Q

What is HLHS?

A

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)

63
Q

What are the s/s of HLHS?

A
  1. Mild cyanosis: o2 sats tend to stay about 75%-85%
  2. Heart failure
  3. Lethargy
  4. Cold hands and feet- poor circulation and oxygenation

Once PDA closes, progressive cyanosis and decreased cardiac output leads to cardiac collapse

64
Q

How do we treat HLHS?

A
  1. Neonatal stabilization with ventilator and inotropic support (increases contractility)
  2. Prostaglandin infusion***
  3. Staged 3 part reconstruction
    • Not a fix just makes it where you can live with it
  4. Heart transplant
65
Q

What are clinical consequences of CHD?

A
  1. CHF- Heart cant pump enough blood to meet the body’s demand for energy
  2. Hypoexmia
    • Cyanosis
66
Q

What are the causes of CHF r/t CHD?

A
  1. Structural defects
    • Increased blood volume/pressure within the heart
  2. Myocardial insufficiency/failure
    • Impaired contractility/relaxation of ventricle
  3. Excessive demanes on the heart muscle due to sepsis/severe anemia
67
Q

What do we need to know about Right sided CHF?

A
  1. Right bentricle unable to pump blood effectively into pulmonary artery which leads to increased pressure in right atrium and systemic venous circulation.
  2. As a result we get hepatosplenomegaly and peripheral edema
68
Q

What do we need to know about left-sided CHF?

A
  1. Left ventricle unable to pump blood effectively into systemic circulation which increases pressure in the left atrium and pulmonary veins
  2. As a result we have
    • Elevated pulmonary pressures
    • Pulmonary edema
69
Q

True or false: We typically see both left and right sided CHF when a child has CHF?

A

True

70
Q

How is CHF diagnosed?

A
  1. Symptoms
  2. Diagnostic tests
    • cxr
    • ecg
    • echo
    • cardiac cath
71
Q

What are the s/s of CHF?

A
  1. Difficulty feeding leading to FTT
  2. Tachypnea/tachycardia at rest
  3. Dyspnea
  4. Retractions
  5. Activity intolerance
  6. Weight gain r/t fluid retention
  7. Hepatomegaly
  8. Peripheral edema (around the face)
72
Q

What are the goals of treatment for CHF?

A
  1. Improve cardiac function
  2. REmove accumulated fluid and sodium
  3. Decrease cardiac demands
  4. Improve oxygenation /decrease oxygen consumption
  5. Support family
73
Q

What medication can be used to improve cardiac function in CHF?

A
  1. Digitalis glycoside
    • Digoxin(Lanoxin)
  2. ACE inhibitors
    • Captopril (capoten)
    • Enalapril (vasotec)
    • Lisinopril
  3. Beta-Blockers
    • Carvediolol (coreg)
74
Q

What do we need to know about digoxin?

A
  1. It has a chronotropic and inotropic effect so it helps produce a slower and stronger heart beat
  2. Beneficial effects include
    • Increased cardiac output
    • Decreased heart size
    • Decreased venous pressure
    • Relief of edema
  3. Digoxin admin
    • Super important to calculate/admin correct dose
    • Observe for signs of toxicity
75
Q

What must we always check prior to administering digoxin and what are the parameters?

A

Apical pulse
Infant/young children
- hold for HR <90-110

Older child
- Hold for HR <70bpm

76
Q

What are the s/s of dig toxcity?

A

N/V
Anorexia
Bradycardia
Dysrhythmias

77
Q

What are the specific teaching guidelines we much teach about digoxin?

A
  1. Indications, actions and correct dosage
    • teach parents how to listen to apical poulse at home
    • Teach parents that k+ levels have an adverse relationship
  2. Do not mix with food/fluids
  3. If dose is missed DO not give extra or second dose
  4. If child vomits, DO NOT give second or extra dose
  5. Keep in safe place- locked up
  6. Call poision control in the event of accidental overdose
  7. Return demonstration
  8. Written instructions
78
Q

What are some ACE inhibitors that help improve cardiac function?

A
  1. Captopril (capoten)
  2. Enalapril (Vasotec)
  3. Lisinopril
79
Q

What is the MOA of ACE inhibitors

A

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

80
Q

Nursing alert for ACE inhibitors

A

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

81
Q

Side effects of Ace inhibitors include?

A
  1. Hypotension
  2. Dry cough
  3. Renal dysfunction
82
Q

What beta blockers imporve cardiac function?

A

Carvedilol (coreg)
Blocks a and b adrenergic receptors
which decreases HR, BP and causes vasodilation

83
Q

What are side effects of b-blockers?

A
  1. Dizziness
  2. Headache
  3. Hypotension
84
Q

What class of medication are used to remove accumulated fluid and sodium?

A

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

85
Q

What do you monitor with a patient taking diuretics?

A
  1. I&O, daily weight
  2. S/S of dehydration
  3. serium electorlytes
  4. s/s of adverse reactions
  5. Potassium-losing (may need to encourage them to eat more k+)
86
Q

How can we decrease cardiac demands?

A
  1. Minimize metabolic needs
    • Maintain body temperture
  2. Treat infection promptly
    • report fever to physican
  3. Reduce the effort of breathing
    • Semi-foweler position
  4. Sedate irritable child
87
Q

How can we minimize metabolic demands?

A
  1. Promote sound sleeping
  2. cluster care
  3. 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
88
Q

How can we improve oxygenation?

A
  1. Careful assessment
    • Count respirations for full min
  2. Position ot enourage maximum chest expansion
  3. Increase amount of oxygen available
    • Supplemental oxygen
    • Monitor response to oxygen therapy
89
Q

What should we know about hypoxemia & cyanosis as a secondary complication of CHD?

A

Heart defects that cause/allow desaturated venous blood to enter systemic ciruclation without passing through lungs result in hypoxeia & cyanosis

90
Q

What are clinical manifestations of hypoxia?

A
  1. Polycythemia
    • Increases blood viscosity
    • Crowds out clotting

2.Clubbing
- Chronic tissue hypoxemia
- Polycythemia

91
Q

What are aquired cardiovascular disorders?

A
  1. Disease processes/abnormalities occuring after birth
  2. Occur in normal hearts or with cognential heart defects
  3. Result from various factors
    • Infection
    • autoimmune
    • Evniromental factors
    • familial tendencies
92
Q

What is rheumatic fever (RF)?

A

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

93
Q

What are risk factors of RF?

A
  1. Hx of group a strep (ASO titer)
  2. Family hx
  3. Environmental factors
94
Q

What are complications of RF?

A

Inflammation in joints, skin, brain and heart
- Inflammation causes permanaent cardiac valve damage (Rheumatic heart disease)
- Most common- Mitral valve damage

95
Q

What are major manifestations of of Rheumatric fever?

A
  1. Carditis
  2. polyarthritis
  3. erythema marginatrum
  4. Chorea jerky sudden movement
  5. Subcutaneous nodules
96
Q

What are minor manifestations of RF?

A
  1. Arthralgia (no arthritis)
  2. Fever
  3. Lab findings consistent with inflammation
    • Elevated ESR & CRP
97
Q

What are the diagnostic criteria for RF?

A

Modified jones criteria
2 Major manifestations
or
1 major & 2 minor manifestations
= high probability of RF

98
Q

How do we treat RF?

A
  1. Penicillin- 10 day course for a min of 10 years prophalictally
  2. asprin/prednisone
    • Reduce fever/discomfort, control inflammatory process
  3. bedrest during acute illness

Prevention
- Treat strep/scalert fever promtply & completely

99
Q

What is infective endocarditis (IE)

A
  1. 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
100
Q

What children are at risk for infective endocarditis (IE)?

A

Children with CHD or Aquired heart defects

101
Q

What are the most common organisms that cause IE?

A

Strep Viridans
Staph Aureus

102
Q

Children who have undergone surgical repair or palliative surgery?

A
  1. Complex cyanotic heart defects
  2. Valvular abnormalities
  3. Prosthetic valves
  4. Conduits (artifical shunts)
  5. VSD
  6. PDA
  7. TOF
  8. Valve involement as a result of RF
103
Q

What are the s/s of IE

A

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

104
Q

What are some complications of IE

A

Stroke & organ damage
Infections/Abscesses
Heart failure

105
Q

How do we treat IE

A
  1. Blood cultures–> to find out what organism
  2. Antibiotics
    • High doses
    • IV
    • 2-8 weeks
  3. Echocardiographic monitoring – esp. when their is vegitation to monitor location
106
Q

How can we prevent IE?

A
  1. Maintain good oral hygiene
  2. 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
107
Q

What is Kawasake Disease (KD)

A

Leading cause of aquired heart disease in children in the US

Acute Systemic vasculitis
- Small and medium-sized blood vessels

Unknown etiology

108
Q

What is the principle area of involment in Kawasaki Disease (KD)

A

Cardiovascular system
1. Coronary artery aneurysms

109
Q

True or false: Kawasaki disease is self-limited?

A

True- usually resolves in 6-8 weeks

110
Q

What are risk factors of KD?

A

Children under the age of 5 years
Males
Asians or Asian descent

111
Q

How is Kawasaki disease diagnosed?

A

No specific diagnostic test

Diagnosis
1. Clinical findings
2. Associated lab results
- CRP
- ESR
- CBC

112
Q

What is the acute phase of KD?

A
  1. Fever 5 or more days
  2. Very irritable- HALLMARK SIGN OF KD
  3. Erythema/Edema of hands & feet
  4. Bilateral conjunctival inflammation (red eyes but no drainage)
  5. Strawberry tongue/diffuse redness of oral cavity
  6. Polymorphous rash (irregular)
  7. Cervical lymphadenopathy
113
Q

How long does the acute phase of KD last

A

10ish days

114
Q

What is the subacute phase of (KD)?

A
  1. Begins when rash/fever/lymphadenitis resolved
  2. Desquamination of fingers and toes
  3. continued irritability
  4. Cardiovascular changes may occur
  5. May experience thrombocytosis
    • Platlet count >600,000-800,000
115
Q

How long does the subacute phase last?

A

11-25 days

116
Q

When does the convalescent phase start?

A

Begins when all clinical signs have resolved and blood values return to normal
Beau’s lines on finger and toe nails

117
Q

How is KD treated?

A
  1. IVGG– high doses
    • Reduces incidence of coronary artery abnormalities

Asprin
1. Initally- for fever and inflammation
- 80-100 mg/kg/day

  1. Antiplatlet dosage after fever subsides
    • 3-5mg/kg/day
118
Q

Nursing interventions of KD include?

A
  1. Monitor cardiac status
    • vital signs
    • I&O
    • Daily weights
  2. Minimize skin discomfort
    - Cool cloths, unscented lotions, loose clothing, mouth care, including lubricant for lips
  3. Clear liquids and soft foods during acute phase
  4. Quiet environment to promote rest