Week 4 Chapter 41 Flashcards
Fetal heart rate is present around …
post conceptual day 17
When are the heart chambers and arteries formed?
During gestational weeks 2-8
Oxygenation of the fetus occurs
Via the placenta
Lungs are perfused but do not
Oxygenation and ventilation
The_______________ ______ allows blood flow from the right to left atrium
Foramen Ovale
This allows blood flow between the pulmonary artery and the aorta, shunting blood away from the pulmonary circulation
Ductus Arteriosus
As the newborn breathes for the first time, the lungs inflate, reducing pulmonary vascular resistance.
True
Results in change of pressure leads to closure of the foramen ovale and ductus arteriosus.
Lack of blood flow and vasoconstriction the__________ ___________ becomes ligaments and the umbilical arteries and vein atrophy
Ductus Arteriosus
HR in toddlers
80-115
Heart Rate in infancy is
90-160BPM
School Age/ Adolescent HR
60-100
Blood Pressure in Infancy
80/55 increases with age
HR and BP reaches adult levels by adolescence
AT birth the ventricle walls are similar in thickness, but with time the left ventricular wall thickens
True
The infants HR at rest exhibits a greater resting tension than adults, which means?
Volume Loading or increase stretch may actually lead to decreased Cardiac Output
Children younger than 7 years the heart lies…
Horizontally and higher in the chest below the 4 intercostal space
As the lungs grow the heart is displaced downward
Between 6-12 years old the heart
10x size it was at birth
But smaller proportionally at this time than any other stage in life
During school age years the heart grows
Vertically within the chest
During adolescence the hearts …
Continues to grow in relation to the teen’s rapid growth
_________________ improves ___________________ blood flow by increasing systematic vascular resistance
Squatting, pulmonary
History of Present Illness
When symptoms started and how they progressed
Treatments and medications used at home
Activity level compared to peers
History of:
Orthopnea
Dyspnea
Easily fatigued
Squatting
Growth Delay
Edema
Dizziness
Poor Feeding
Lethargy
Vomiting
Motor Delays
Cyanosis
Tachypnea
Past Health History of Cardiovascular
Problems occurring after birth
Congenital malformation
Birth History
Frequent Infections
Chromosomal abnormalities
Prematurity
Autoimmune Disorders
Uses of meds such as steroids
Risk Factors for CV Disorders include
Family History of CVD
- Investigate the heat further if heart disease occurred in a first degree relative
Sudden Death in a young family member
Hyperlipidemia
DM
Signs of a Cardiac Disorder may include___________ and ___________
Edema- face, presacral, extremities
Clubbing- softening of nail beds, rounding of nail ends, shininess and thickening of nail ends
Cyanosis
Irregular Heart Rate
Edema
Clubbing of fingertips
Fever
Retractions or increased work of breathing
Prominence of precordial chest wall
Visible, engorged or abdominal pulsations
Abdominal Distention
Signs of Cardiac Disorder
How are murmurs graded?
Grade I- soft and hard to hear
Grade II- Soft and easily heard
Grade III- Loud without thrill
Grade IV- Loud with precordial thrill
Grade V- Loud with precordial thrill, audible with a stethoscope partially off the chest.
Grade VI- Very loud, audible with stethoscope or with naked ear
Location where its heard
Relation to the heart cycle and duration
Quality- harsh, musical or rough; high, medium, or low pitch
Variation in sound with position ( sitting, lying, standing)
Characteristics of Heart Murmurs
Diagnostic Tests for Cardiovascular Disorders
Pulse Oximetry
ECG or Holter Monitoring
Echocardiogram
Chest Radiograph
Exercise Stress Testing
Lab test including:
CBC, BMP, CRP, ESR
Arteriogram and Cardiac Catheterization
Structural anomality’s that are present at birth
CHD accounts for the largest percentage of all birth defects
Congenital Heart Disease
Disorders that occur after birth
Develops from a wide range of causes, or can occur as a complication or long term effect of CHD
Acquired Heart Disease
Indications for this include hypoxemia, respiratory distress, or heart failure
Oxygen
Chest Physiotherapy used for
Mucous clearance by mobilizing secretions with percussion or vibration with postural drainage
May be used by RT
Chest Tube used
After open heart surgery
Pneumothorax
Drainage tube inserted into the pleural cavity to facilitate removal of air or fluid and allow full lung expansion
External wiring connected to a small generator used to electrophysiological correct arrhythmias or heart block
Pacing
Used for bradyarrhythmia’s, heart block, cardiomyopathy SA or AV node malfunction
How is CHD classified?
Based on hemodynamic characteristics
Disorders with decreased pulmonary blood flow (Cyanotic)
Tetralogy of Fallot
Tricuspid Atresia
Disorders with increased pulmonary blood flow (a cyanotic)
Atrial Septal Defect
Ventricular Septal Defect
AV Canal
PDA
Obstructive Disorders include
Coarctation of the aorta
Aortic Stenosis
Pulmonary Stenosis
Mixed Disorders Include
Transposition of Great Vessels
Total Anomalous Pulmonary Return
Truncus Arteriosus
Hypoplastic Left Heart Syndrome
Right to left blood flow includes
Hypoxia
TOF and TGA
Truncus Arteriosus
Tricuspid Atresia
These defects takes blood away from the lungs and push blood from the right to left side of the heart and results in hypoxia
S/S of hypoxia
Cyanosis
Poor Feeding and weight gain
Clubbing of fingers
Dyspnea and Tachypnea
Polcythemia - Blood clot risk with Hg over 22
Left to right include ASD, VSD, PDA, AVSD
True , Congestive Heart Failure
These effects are less deadly
S/S of CHF
Weight gain
pale and cool extremities
Puffiness around the eyes
Reduction in wet diapers
Dyspnea
Tachypnea and tachycardia
Poor weight gain
Characterized by 4 defects
Pulmonary Stenosis
VSD
Overriding Aorta
Right Ventricular Hypertrophy
Called Tetralogy Fallot
S/S of TOF
Color changes with feeding, activity or crying (cyanosis)
Murmur
Requires surgical intervention in 1st year of life
When is TOF usually diagnosed?
During the first few weeks of life due to presence of murmur or cyanosis
Most often infants with TOF have a PDA at birth
True
Aorta positioned directly over a VSD, instead of the left ventricle
Overriding Aorta
Receives some blood from the right ventricle, which reduces the amount of oxygen in the blood)
If the infant’s oxygen is greater than the supply( such as crying) then the spell progresses to
Anoxia-LOC
Characterized by uncontrollable crying or irritability
Tachypnea
Worsening hypoxia with cyanosis/ pallor
Decreased intensity of heart murmur
Limpness, LOC, convulsions
Hypercyanotic Spells “TET spell”
How are TET spells relived?
Use a calm, comforting approach
Place infant/ child in knee to chest position
Provide supplemental oxygen
Administer morphine sulfate
0.1 mg/ kg IV IM or SubQ
Administer Propranolol
0.1 mg/ kg IV
Valve between the right atrium and right ventricle fails to develop
Tricuspid Atresia
Associated with VSD
s/s of Tricuspid Atresia
Cyanosis
Tachypnea
Difficulty with feeding
Requires surgical intervention in staging
Closed Tricuspid valve =
No opening to allow blood from the right atrium to the right ventricle and subsequently through the pulmonary artery into the lungs
The positions of the pulmonary artery and aorta are reversed
Transposition of the Great Arteries
Oxygen poor blood goes back to the body and oxygen rich goes back to the lungs.
What do we use to keep PDA open?
Prostaglandins
S/S of Transposition of Great Arteries
Tachypnea
Tachycardia
Significant Cyanosis
Immediate balloon atrial septostomy, surgical correction to switch arteries by age 4-7 years
Pulmonary veins do not connect normally to the left atrium, instead connect to the right atrium
Total Anomalous Pulmonary Venous Connection
S/S of TAPVC
Cyanosis varies
Fatigue
Difficulty feeding
Requires surgical intervention
Incompatible with life unless there is patent foramen ovale of ASD
During normal fetal development the aorta and pulmonary artery start as single blood vessel and then divides into 2 separate arteries. In this defect it fails to separate leaving a large connection between the aorta and pulmonary artery
Truncus Arteriosus
S/S of Truncus Arteriosus
Cyanosis with activity
Fatigue
Difficulty feeding and poor growth
Requires surgical intervention
Hole between the 2 upper chambers of the heart- right and left atria
Most children are asymptomatic
Atrial Septic Defect
S/S of ASD
Heart Failure- SOB
Poor growth
Murmur- Normal and expected
If detect murmur of ASD is small…
May close spontaneously within 18 months of life
If defect is large may be sutured closed or require patch
Defects with connections involving the left and right sides will shunt blood from the higher pressure left side to lower pressure right side
True
- Heart failure, pulmonary HTN, atrial arrhythmias, or stroke
Most common and accounts for 25% of all congenital heart defects
Spontaneous closure of small VSDs occurs in half of children by age 2
Ventricular Septal Defect
Hole between the 2 lower chambers of the heart- the right and left ventricles
Most children are asymptomatic
Ventricular Septal Defect
S/S of VSD
Grunting and tires easily with feeds
Pulmonary Infections
SOB
Edema
Systolic Heart murmur (L Sternal Border)
If defect is small in VSD ..
May close spontaneously by 2 years old
If large may require suture or require a patch
At risk for heart failure, aortic valve regurgitation, ineffective endocarditis if unrepaired
True
Occurs because of the failure of the endocardial cushions to fuse
Cushions are needed to separate the central part of the heart
Atrioventricular Canal Defect AV Canal
Causes large L-R shunt, increased workload of the L ventricle, high pulmonary arterial pressure- pulmonary edema
Includes ASD, VSD, improperly formed mitral and/or tricuspid valves
AV Canal Defect
35-40% of children with Down Syndrome have this defect
Recirculation problem requires LV to pump 2-3 times more
S/S of AV Canal Defect
Frequent respiratory infections
Difficulty feeding and gaining weight
Increased work of breathing
Pulmonary Banding in infants surgical correction by
3-18 months patch closure
Valve repair
Occurs when the normal closure of ductus arteriosus does not occur- connection between the aorta and pulmonary artery
PDA
PDA occurs more frequently in premature infants and infants born at high altitudes
True
S/S of PDA
Asymptomatic heart failure
Loud machine like murmur
What medication is used to help close the PDA?
Indomethacin
Inhibits prostaglandin synthesis
Medication to keep the PDA open ( vasodilation of the ductus arteriosus smooth muscle)
Prostaglandin
PDA corrected by coil embolization or surgical ligation
_____________ _________________________ is a fetal circulatory structure which normally closes within the first few weeks of life
2nd most common defect and accounts for 10% of CHD cases
Ductus Arteriosus
Narrowing of major vessel
Obstructive disorder
Coarctation of the Aorta
Accounts for 10% of congenital heart defects
BP may be 20mm Hg higher in upper extremities
Narrowing of the aorta, the major blood vessel carrying oxygenated blood from left ventricle to the body
Coarctation of the Aorta
Narrowing - blood flow is impeded- decreased cardiac output
Increased pressure in the area proximal to the defect
Decreased in the area distal to defect
Coarctation of the Aorta
Symptoms of Coarctation of the Aorta
BP in increased in the heart and upper body (bounding pulses)
BP is decreased in lower portions of the body ( cool, diminished pulses)
Irritability, epistaxis, leg pain, dizziness, fainting, headaches, and murmur
Balloon Angioplasty, surgical repair with stents, resection of narrowing and end to end anastomosis
Coarctation of the Aorta
Occurs when the aortic valve between the left ventricle and aorta did not form properly
Causes pump problem
Typically child is asymptomatic
Aortic Stenosis
S/S of Aortic Stenosis
Fatigue
Chest Pain
Dizziness
Difficulty feeding in infants
Balloon dilation via umbilical artery or cardiac catheterization, possible valve replacement
Aortic Stenosis
Occurs as a muscular obstruction below the pulmonary valve, at the valve, or a narrowing of the pulmonary artery
Pulmonary Stenosis
Associated other heart anomalies and genetic syndromes
Most children are asymptomatic
Pulmonary Stenosis
S/S of Pulmonary Stenosis
Dyspnea
Fatigue
Cyanosis with exertion
Loud systolic ejection heart murmur
Balloon dilation valvuloplasty via cardiac catheterization
Pulmonary Stenosis
Complex combination of abnormalities of the left side of the heart (including the left ventricle, mitral valve, aorta, and aortic valve) are small and underdeveloped
HLHS
Hypoplastic Left Heart Syndrome
S/S of HLHS
Cyanosis
Fatigue
Poor feeding
Fatal without palliative surgery, heart transplant
Nursing intervention for cardiac catheterization
Maintain bed rest
Keep extremity in straight position for 4-8 hours
Inspect the dressing every 15 min for the first hour
Assess child’s distal pulses bilaterally for presence and quality
Assess the color and temperature of the affected extremity
Assessment of child undergoing cardiac surgery
Temperature
Weight Measurements
Extremity evaluation for : peripheral edema, clubbing, Peripheral pulses
Heart anatomy and its function
Events before surgery
Location of the child after surgery
Appearance of the child after surgery
Location of the incision and coverage with dressings
Postoperative activity level
Nutritional Restrictions
Medications
Patient Teaching for Cardiac Surgery
Congenital Risk Factors for CVD disorders in Childhood
Congenital Malformations
Genetic Syndromes
Family History
Maternal drug or alcohol exposure
Prematurity
Acquired Risk Factors for CVD in Childhood
Infections ( Rheumatic fever, Kawasaki, endocarditis)
Obesity
Diabetes
Drug or alcohol exposure
HTN
Chemotherapy
Other Diseases (CT disorders, autoimmune or endocrine diseases)
Organ Transplant
Hyperlipidemia
Failure to pump blood forward
Consequence of many congenital and acquired CV disorders
Heart Failure
Poor feeding, gets tired easily, tachycardia and tachypnea
Early Signs of HF
Pallor, HTN, edema, increased work of breathing, orthopnea, wheezing, cough, hepatomegaly, JVD
Late Signs of HF
Nursing Management of HF
Promoting Oxygenation- Semi upright, suction, chest physiotherapy, supplemental oxygen
Supporting Cardiac Function- Administer digoxin, ACE inhibitors, and diuretics
Providing adequate nutrition- higher caloric intake, small frequent meals
Promoting rest- Limit activities, ensure adequate sleep, cluster care
What is cardiac output controlled by?
Heavy fluid. Occurs most often in children with CHD and most common reason for admission to the hospital. 20% children with CHD experience HF.
Preload, afterload, myocardial contractility, and heart rate. Alterations in any of these may lead to HF.
Cardiac Glycoside that increases contractility within the heart
Digoxin
Count apical pulse for 1 full minute, noting rate, rhythm, and quality
Withhold if apical pulse is less than 60 BPM in adolescents, or less than 90 in infants
Avoid giving oral form with meals
Monitor serum digoxin levels
Note signs of toxicity- N/V/D, lethargy, bradycardia
Ginseng, hawthorn, and licorice increase risk of toxicity
Avoid rapid IV administration as this may lead to systemic and coronary artery vasoconstriction
Digoxin
Bacterial infection of endothelial surfaces of the heart
Valves
Chamber Walls
Septum
Increased risk of prosthetic valves
Infective Endocarditis
Fungi or more commonly bacteria
- Alpha- hemolytic streptococcus, staph, aureus
S/S- Low grade fever, fatigue, anorexia, weight loss, flu like symptoms
Requires antibiotic or antifungal tx
Can result after not treating strep throat or scarlet fever
Causes total body inflammation, damaging the heart valves-murmur
Acute Rheumatic Fever
Symptoms include fever, joint pain, sore throat within the past 2-3 weeks
Tx includes 10 day course of penicillin or erythromycin and is used along with NSAIDs and corticosteroids
Children without valvular disease with receive continued prophylaxis with monthly IM injections or PCN-G or daily oral doses of PCN ( or erythromycin until adulthood)
True Acute Rheumatic Fever
Most common in children and may result in heart failure
Dilated Cardiomyopathy
Hypertrophic more common in adolescence
Affects left ventricle, affecting the heart’s ability to fill, familial
Condition in which the myocardium can not contract properly
Cardiomyopathy
Risk Factors of Cardiomyopathy
Congenital Heart defect
Genetic Disorders
Inflammatory or infectious processes
Post transport or postoperatively after cardiac surgery
HTN
Duchenne and Becker muscular dystrophy
Most common unknown reason is called idiopathic
May be present as heart failure or cardiac arrest
No cure- Heart can not be restored
Cardiomyopathy
Therapeutic Management of Cardiomyopathy
Improving heart function
Vasoactive medications - ACE inhibitors, Beta Blockers, or calcium channel blockers
Pacemakers
Heart transplant only viable long term treatment option
Acute Systematic Vasculitis
Affects children 6 months- 5 years
Self-limited syndrome but may cause coronary artery aneurysm and cardiomyopathy
Kawasaki Disease
S/S of Kawasaki Disease
High fever for 5 days ( unresponsive to antibiotics)
Gallop heart rhythm
Headache
Malaise
Red eyes, lips, hands, and feet
Distinctive rashes (strawberry tongue, palmar erythema)
Skin peeling of perineum, fingers and toes
Vomiting, diarrhea
Decreased UOP
Abdominal and joint pain
Treatment for Kawasaki disease
IV immunoglobulin IVIG and aspirin
- No live vaccines for 11 months after IVIG (MMR, varicella, influenza)
- Requires long term monitoring of coronary arteries
Focus of nursing care for a child with a Cardiac Disorder
Improving oxygenation
Promoting adequate nutrition
Assisting the child and family with coping
Providing post op nursing care
Preventing infection
Providing family and child education
Psychosocial Interventions include
Explain all that is happening with the child with understandable language
Allow the parents and child to voice their feelings, concerns or questions
Provide ample time to address questions and concerns
Encourage parents and child to participate in care as appropriate
Encourage child to be as active as appropriate
