OB Unit 5, units 7&8
A newborn's hematocrit is between 45% and 50%
(the adult's is between 36% - 45%)
Assessment PDA
*A systolic murmur early in life and a continuous murmur as the child ages. *May cause rales, congestion, increased work of breathing, difficulty feeding, or failure to thrive *Overtime, the left side of the heart may become dilated
Atrial Septal Defect
*Acyanotic defect *May or may not have a murmur (if it does, will have a fixed split-S2 heart sound) *Child may be asymptomatic or symptomatic (if symptomatic - rales, congestion, tiring with activity, or poor weight gain). Overtime, the right side of the heart may dilate *Occurs more commonly in females
Tx of PDA
*Address the symptoms of the increased blood flow by prescribing a diuretic such as furosemide *Caloric concentration may need to be increased to help infant gain weight resulting from feeding difficulties that may have lead to failure to thrive *If heart becomes too dilated the child will be referred for PDA closure *NOTE: if noted immediately after birth, indomethacin (a nonsteroidal anti-inflammatory and prostaglandin inhibitor, can be utilized to facilitate closure). In older children, a PDA cam be closed in the catheterization lab by placing a device to occlude flow.
Changes to Circulatory System After Birth
*As this pressure decreases, the ductus arteriosus, the fetal shunt between the pulmonary artery and aorta, begins to close. *At the same time, increased blood flow to the left side of the heart causes the foramen ovale (the opening between the right and left atria) to clause because of pressure against the lip of the structure. However, permanent closure does not occur for weeks. *With the remaining fetal circulatory structures (umbilical vein, two umbilical arteries, and ductus venosus) no longer receiving blood from the placenta, the blood within these structures clots and closes them, and the vessels atrophy over the next few weeks.
Tx for atrial septal defect
*If < 5 mm, and is producing no symptoms, it will not be closed *If symptomatic, treatment is based on child's age and size of defect *Diuretics will be attempted first in an effort to let the defect close spontaneously *If defect remains at 5mm or greater in size with persistent shunting, referral for closure will occur.
When noting a murmur, you need to assess and document:
*It's position in the cardiac cycle (systole, diastole, continuous) *Quality (harsh, soft, blowing) *Pitch (high or low sounding noise) *Location (where it is heard best or the point of maximum intensity) *Radiation (do you hear it elsewhere beside the maximum intensity area) *Presence of a thrill (a palpable purring sensation) *The response of the murmur to exercise or change of position
Assessment
*Level of alertness, activity, and tone *Chest symmetry and pulsations *Capillary refill < 3 seconds (prolonged indicates poor cardiac output and perfusion) *Pulses should be easily palpated (NORMS: Infant 160/min, preschool 120/min; adolescent 100/min). Pulses that are difficult to palpate may indicate poor cardiac output or obstructive outflow lesions
Ventricular Septal Defect
*Most common defect found in children *Acyanotic *A murmur is always associated with it - Loud, harsh murmur auscultated at the left lower sternal border *S/S Heart failure - tachypnea, poor feeding, failure to thrive *Defect confirmed with echocadiogram *Many VSDs close spontaneously
TET Spells" - sudden, marked increase in cyanosis with irritability and crying
*Place infant in knee-chest position *Child may squat to improve blood flow *Use a calm, comforting approach *100% oxygen by face mask *Morphine subq or IV (reduces infundibular spasm) *IV fluid replacement if needed *Repeat morphine administration
Defects that Increase Pulmonary Blood Flow
*Result from an abnormal connections through the septa or the great vessels; increased blood volume on the right side of the heart with increased pulmonary blood flow and decreased systemic blood flow *Patent ductus arteriosus (PDA) *Atrial Septal defects *Ventricular Septal Defects
Heart Murmurs
*Result from turbulent flow of blood through an abnormal valve, vessel, or chamber. *Can be innocent (not associated with any intracardiac disease) or pathologic (associated with a cardiac anomaly or altered cardiac function)
Changes to Circulatory System After Birth
*The lungs become responsible for oxygenating the neonate's blood. *As soon as the umbilical cord is clamped, the neonate is stimulated to breathe. *With the first breath, blood pressure decreased in the pulmonary artery (the artery leading from the heart to the lungs).
Children born without an extremity can be fitted with a prothesis as early as
6 months of age so that the infant can learn to stand at the normal time or handle and explore objects readily. However, it may be adventitious to allow the child to grow and learn to use their altered body or lib without a prosthesis. Introducing a prosthesis early in life may prevent a child from adjusting to a missing extremity
Transposition of Great Arteries
A condition in which the aorta is connected to the right ventricle instead of the left, and the pulmonary artery is connected to the left ventricle instead of the right (reversal of great arteries). This results in essentially two separate circulations whereby oxygenated blood returns from the lungs to the left atrium, to the left ventricle, and then proceeds back through the pulmonary artery to the lungs again, whereas the deoxygenated blood returns from the body to the right atrium, the right ventricle, and proceeds back out the aorta, supplying deoxygenated blood to the systemic circulation. Second most common defect
Hypertension
A growing problem in children. Differentiate primary (overweight, positive family history of hypertension, or sleep disordered breathing) from secondary (caused by another health issue). If secondary, treat underlying disorder. Commonly caused by renal disorders (artery stenosis, renovascular disease, neurofibromatosis), hormonal (primary aldosteronism, adrenal insufficiency, pheochromocytoma, neuroblastoma), or cardia (CoAo).
Atrial Septal Defect
A hole in the septum between the right and left atria that results in increased pulmonary blood flow (left-to-right shunt)
Ventricular Septal Defect
A hole in the septum between the right and left ventricle that results in increased pulmonary blood flow (left-to-right shunting)
Aortic Stenosis
A narrowing of the aortic valve
Coarctation of the Aorta
A narrowing of the lumen of the aorta, usually at or near the ductus arteriosus, that results in obstruction of blood flow from ventricle
Acquired Heart Disease
A term used to define heart disorders that develop after birth *Kawasaki Disease (most common) *Rheumatic Fever *Cardiomyopathy
Cardiac Catheterization
Alleviate pre and post procedure anxiety and complications Base pre and post care on developmental age and parenteral involvement Sedative administered before procedure Local anesthetic injected at site Contrast dye injected
Kawasaki Disease
Also called mucocutaneous lymph node syndrome is defined as an acute febrile syndrome associated with generalized vasculitis (inflammation of blood vessels) affecting all blood vessels throughout the body, including the coronary arteries. Life-threatening Unknown etiology although genetic predisposition, and strong likelihood of infectious precursor, occurs more commonly in winter and spring, and more commonly in males, with the most incidences occurring in children < 5 years of age
When might be a time that the nurse would hold diuretic medications?
Answer - Electrolytes abnormal, child develops diarrhea, vomiting, or signs of dehydration.
What is the main complication of loop diuretics and what s/s may the nurse see in the child?
Answer - Hypokalemia (Check potassium levels before giving any loop diuretic...)
What must a nurse pay attention to when a child is prescribed both an ACE inhibitor and a diurectic?
Answer - Hypotension. Therefore, the nurse should schedule these two meds 1-2 hours apart. The nurse should also pay attention to whether a child develops a cough. This may be irritating and prevent further use of the ACE inhibitor in the child
When might be a time that the nurse would hold digoxin?
Answer - When a child is bradycardic for his or her age or when the child shows s/s of toxicity such as nausea/vomiting, dizziness, diarrhea, headache, arrhythmia, and bradycardia.
At birth, the indirect bilirubin level is between 1-4 mg/100 ml
Any increase over this amount reflects that excessive red blood cells have begun their breakdown
Cardiac Catheterization
Bedrest for 2-4 hours (some providers require longer periods like 6 hours) Oxygen may be continued for a period of time after the procedure No tub bath for several days but may shower or sponge bath Fever is common but should not last longer than 24 hours or exceed 100.4º F Activity restrictions upon discharge - may be restricted from physical activities for several months after device closure of a septal defect
Transposition of Great Arteries
Blood must mix to provide oxygenated blood to enter the systemic circulation. Therefore, the ductus arteriosus MUST REMAIN OPEN. A drug to maintain the patency of the ductus arteriosus and mixing of blood is prostaglandin E1. It is an infusion started immediately after birth to prevent the ductus arteriosus from closing. Side effects of prostaglandin E1 are apnea and hypotension and will typically be seen during the first hour of infusing. The goal of therapy is to give the smallest amount of drug needed to keep the duct open and having the least amount of side effects.
The Newborn's Blood Values
Blood volume is 80-110 ml/kg of body weight or about 300 mL total.
Aortic Stenosis
CHILDREN Intolerance to exercise Dizziness Chest pain Possible ejection murmur
Nutritional Supplementation
Children who are in cardiac failure d/t pulmonary over-circulation require specific nutritional supplementation in order to maintain sufficient weight gain. Caloric intake may require up to 150 kcal/kg/day
Defects with Obstruction to Systemic Blood Flow
Coarctation of the Aorta Aortic Stenosis
Transposition of Great Arteries
Cyanotic defect Tachypneic, and a murmur may be noted
Assessment of Kawasaki Disease
Divided into an acute phase (week 1) and a subacute phase (weeks 2-3) Prolonged fever > 100.4ºF of 5 or more days Four of more of the following symptoms: Changes in hands and feet (erythema, edema, peeling) Polymorphous exanthema (diffuse maculopapular rash of the trunk and extremities) Bilateral conjunctivitis without exudates Changes in lips and mouth (erythema, strawberry tongue, dry, cracked lips) Cervical lymphadenopathy (>1.5 cm diameter, usually unilateral)
Rheumatic Fever --Rheumatic Heart Disease
Familial Lower socioeconomic groups Northeastern United States Winter and early spring Occurs most commonly in children ages 6-15 years with peak at 8 yoa
Treatment Kawasaki Disease
Focused on addressing the immediate symptoms and preventing any long-term consequences Supportive measures such as IV fluids for irritable children who are not taking adequate oral intake and also antipyretics for fever High doses of IV immunoglobulin (IVIG) and high-dose aspirin therapy (80-100 mg/kg divided four times a day and then continued at a low dose of 3-5 mg/kg/day for 6-8 weeks with no evidence of coronary artery abnormalities and may be indefinite in children who have abnormalities.
Systolic murmurs
Heard immediately after 1st heart sound - may or may not be pathogenic
Diastolic murmurs
Heard immediately after 2nd heart sound - always pathogenic
Hyperlipidemia
High concentration of low-density lipoprotein (LDL) and low concentrations of high-density lipoprotein (HDL) Lipid screening should be done once between the ages of 9-11 years and again between the ages of 17-21 years. If children have family history of dyslipidemia or atherosclerotic disease less than 55 yoa (male) and 65 yoa (female), it is recommended that 2 screenings between 2-8 yoa occur and results be averaged.
Cardiac Catheterization
I & O's are IMPORTANT Keep extremity straight for 2-4 hours following procedure Position child on back with sandbag on site to prevent hemorrhage or hematoma Check pulses above and below site - Check for pooled blood on sheets beneath site MONITOR FOR TEMPERTURE CHANGES or COLOR CHANGES IN THE ARM OR LEG USED NOTIFY MD IMMEDIATELY IF DISTAL PULSE IS NOT PALPABLE OR TEMPERTURE CHANGES OCCUR OR IF CHILD C/O INCREASING PAIN
Aortic Stenosis
INFANTS S/S Faint pulses Hypotension Tachycardia Poor feeding tolerance
Treatment of VSD
If the child exhibit s/s of pulmonary overload (tachypnea, retractions, or rales), management will include use of a diuretic such as furosemide and possibly an increase in the caloric density of the child's formula. If the infant is breastfeeding, the mother may need to pump breast and feed with bottle or n/g tube because nursing requires a great deal of energy on the part of the baby Closure may be needed - if so, many can be done in catheterization lab; while others require surgical intervention.
Grade 4 murmor
Loud and associated with a palpable thrill
Grade 6 murmor
Loudest, with thrill, heard with the stethoscope entirely off the chest (just above the precordium, not touching the skin)
Congestive Heart Failure - The inability of the heart to supply adequate oxygenated blood to meet the metabolic demands of the body
Many cardiac disorders, including congenital heart defects, or acquired disorders such as cardiomyopathy or Kawasaki disease can manifest with either very subtle physical symptoms or symptoms of congestive heart failure with varying degrees of severity. To understand congestive heart failure, the nurse must first understand the components of adequate cardiac function. Cardiac output is the volume of blood pumped by the ventricles each minute. The formula for calculating cardiac volume is affected by the following factors:
Clubbing of the fingers erythema in fingers and toes
May result from longstanding cyanosis d/t increased formation and enlargement of the capillaries in the periphery to improve circulation Excessive growth of soft tissue in fingers and toes Result of chronic hypoxia Polycythemia results in an increase in red blood cell production to increase oxygen carrying capacity Polycythemia increases the viscosity of the blood, predisposing to stroke and clot formation
Grade 3 murmor
Moderately loud, no thrill
Finger and Toe Conditions
Nurse need to encourage parents of neonates with these conditions to share their feelings and concerns as they deliver the news to family and friends. These parents may need reassurance that the child is perfect in other ways so they can accept and help the child develop self-esteem.
Patent Ductus Arterosus
Occurs when the fetal shunt fails to close after several days of life. Most commonly occurs in the premature neonate. If a ductus arteriosus does not close after birth, it allows blood from the aorta (area of high pressure) through the patent ductus arteriosus and into the main pulmonary arter (area of low pressure). The shunted blood then returns to the left atrium of the heart and repeats the cycle. This extra blood flow increases pulmonary circulation. This is an acyanotic defect, as the blood flowing from the aorta is fully oxygenated.
Tetralogy of Fallot Rxs-
Oxygen Diuretics (furosemide - Lasix) Digitalis Iron Beta blockers Morphine Sodium bicarbonate Prostaglandin E1
Prostaglandin E
POTENT vasodilator that keeps foramen ovale and ductus arteriosus open Acts within minutes and improves pulmonary and systemic blood flow Monitor for respiratory depression or apnea, flushing, bradycardia, irritability, diarrhea, and bleeding because dilatation of blood vessels is not specific to cardiac smooth muscle Administer by continuous infusion in a separate IV site. Do not piggyback.
Rheumatic Heart Disease Tx
Penicillin Anti-inflammatory agents Antibiotic prophylaxis Bedrest* Immunizations + flu shot Cardiology follow up
Examples of Prophylactic Treatment
Penicillin 200,000 units orally twice a day Penicillin G 1,200,000 units monthly IM Sulfadizine 1g orally each day. Length of time...varies from 5 years to indefinitely
Congestive Heart Failure - Cardiac output is the volume of blood pumped by the ventricles each minute. The formula for calculating cardiac volume is affected by the following factors:
Preload - the volume of blood in the ventricles at the point just before contraction (indicates circulating blood volume) Contractility- ability to modulate the rate and force of fiber shortening Afterload - amount of resistance met by the ventricles upon ejection Compliance- the ability of the ventricles to stretch and fill
Aortic Stenosis Assessment
Respiratory rate and evidence of retractions Shallow respirations that are rapid with a rate of 50-60 breaths per minute Frequent respiratory infections (resulting in dyspnea with activity and fatigue) Increased work in breathing, grunting, nasal flaring, and retractions
Coarctation of the Aorta
S/S Elevated blood pressure in arms Bounding pulses in the upper extremities with decreased pulses in lower extremities Decreased blood pressure in the lower extremities Cool skin of lower extremities Weak or absent femoral pulses Heart failure in infants Dizziness, headaches, fainting, or nosebleeds in older children
Grade 2 murmur
Soft, heard in all positions, no thrill
Rheumatic Fever --Rheumatic Heart Disease
Systemic inflammatory disease that follows in response to a group A beta-hemolytic streptococcal infection Generally occurs 10 days after recovery from pharyngitis and may last for many weeks gradually damaging left heart valves
Tetralogy of Fallot
Systolic mumur noted at the left upper sternal border Cyanosis at birth with progressive cyanosis over the first year of life Episodes of acute cyanosis and hypoxia (blue spells - also called "TET" spells) Surgical repair by 3-6 months of age
S/S CHF in Children
Tachycardia Tachypnea Infants and Young children - poor feeding and failure to thrive Older children - fatigue, exercise intolerance and breathlessness More difficult to diagnose in infants - may have rapid respirations and have to use accessory muscles to breath. Tires easily, may be diaphoretic, or may have difficulty sucking because of dyspnea and the energy needed to suck A child may gain weight from fluid overload, while an infant may lose weight because their caloric expenditure is greater than their caloric intake Right sided failure - hepatomegaly, increased venous pressure noted in jugular venous distention in older children, or periorbital edema, a cardia gallop, or an enlarged heart on CXR with or without pulmonary edema Left sided failure - increased pulmonary pressures, rales (crackles), tachypnea, and shortness of breath (orthopnea - difficulty breathing except in an upright position d/t pulmonary congestion), accessory muscles used in breathing (retractions) NOTE: Generalized edema is uncommon in children but may be seen with complete heart failure
Defects that Decrease Pulmonary Blood Flow
Tetralogy of Fallot (TOF) One of the most common congenital heart defects requiring intervention within the first year of life Typically considered a cyanotic defect Defined by four components: (a) pulmonary artery stenosis, (b) ventricular septal defect, (c) overriding aorta, and (d) right ventricular hypertrophy The degree of cyanosis is directly proportional to the degree of pulmonary stenosis. Significant narrowing produces increased resistance to blood flowing through the pulmonary valve and out to the lungs. Because of this increased resistance, the blood will shunt right to left through the ventricular septal defect. The deoxygenated blood travels directly out through the aorta into the systemic circulation.
The newborn has more RBC's than the average adult.
Thus, the hemoglobin level averages 17g to 18 g/100 mL of blood (the average for the adult is 11g -12 g/mL).
Treatment of CHF
Treat symptoms and underlying cause of heart failure Goal: decrease fluid overload, enhance myocardial contractility, and decrease afterload in order to ensure adequate perfusion and decrease the work of the heart Proper nutrition - eat several small, high-calorie, high-fat meals daily as less tiring than 3 large meals daily - may need to supplement with protein shakes. In breastfed infants, the mother may manually express milk and place in bottle or syringe for feeding infant as breastfeeding requires more energy. Formula may need to be a high calorie concentrated formula Medications (See Nursing Diagnoses & Related Interventions pg 1136-1137********) Digoxin Angiotensin-converting enzyme (ACE) inhibitors (captopril, lisinopril, and enalapril) Diuretics - loop diuretics (furosemide) Oxygen therapy ALSO NOTE: Nursing Care Planning to Empower a Family - pg. 1136
Hypertension
Treatment Therapeutic lifestyle - weight reduction, healthy diet, no smoking or alcohol, adequate sleep If hypertension persists, medications may be needed - ACE inhibitors, Angiotensin Receptor Blockers, beta-blockers, calcium channel blockers, diuretics, and vasodilators
Transposition of Great Arteries
Try to maintain room air only, but nurses must be prepared to offer ventilator support should the child stop breathing. More effective mixing of blood occurs is the foramen ovale is kept open. This is accomplished by placing a a catheter through the inferior vena cava up to the right atrium and floating it across the foramen ovale. Requires surgical reversal to correct positions within 14 days of life. The procedure is called arterial switch or Jatene procedure.
Hyperoxia Test (Oxygen Challenge Test)
Used to determine whether the cyanosis being experienced by the neonate is cardiac or respiratory in nature An arterial blood gas is obtained from the right radial artery when the infant is breathing room air. Infant is then placed on 100% oxygen for 10 minutes. Arterial blood gas is re-drawn and the infant with cardiac disease will have very little change in the Pao2 levels. If the cyanosis is caused by pulmonary (lung) disease the Pao2 level will generally rise to > 80 mm Hg unless significant pulmonary hypertension is present. Screening test only.
Grade 1 murmor
Very faint, may only be heard by an expert, not heard in all positions, no thrill
Therefore, an elevated WBC count does not reflect that the neonate has an infection. Yet, we simply cannot dismiss the elevated WBC count as merely being related to stress.
We must consider other s/s of infection in the neonate such as pallor, respiratory difficulty, or cyanosis.
A difference of greater than 10 mmHg between arms is
abnormal
A newborn has a high WBC count, about 15,000 to 30,000 cells/mm3
and may be as high as 40,000 cells/mm3 if the birth was stressful to the neonate.
A small amount of blood that returns to the heart via the vena cava does leave the right atrium by the adult circulatory route meaning that it travels through the tricuspid valve into the right ventricle
and then into the pulmonary artery and lungs to oxygenate lung tissue.
Because the epiphysis or growth plate has not closed in children
any fracture within this area may cause serious complications, such as deformities
As RBC cells are broken down
bilirubin is released and the serum indirect bilirubin level rises.
Genetic and/or environmental factors
can compromise fetal growth and development
Acquired
can occur in the normal heart or in the heart with a congenital defect. Acquired heart disease is most often due to infections, autoimmune factors, genetic factors, teratogens (any inhaled, ingested, or absorbed agent that has the possibility of altering genetic structure or function)-often drugs such as alcohol, angiotensin-converting enzyme inhibitors, chemotherapeutic agents, smoking, Accutane, Lithium, Coumadin, Dilantin, and others. Infections such as cytomegalovirus, rubella, HIV, toxoplasmosis, herpes, and varicella. Maternal factors such as infant of a diabetic mother
Because their bones and muscles are still growing,
children suffer from disorders of the musculoskeletal system more than adults
Poor cardiac output will result in a low systolic blood pressure with a high diastolic pressure,
creating a narrow pulse pressure
A newborn's RBC count is about 6 million cells/mm3
for the adult, 3.5-5.5 million cells/mm3)
Congenital
genetic in origin, meaning the child is born with the disorder. These can be a single abnormality or multi-abnormalities.
Wide pulse pressures - wide gap between diastolic and systolic pressures
indicative of patent ductus arteriosus
Erythema marginatum
infrequent symptom but if seen is definitive sign of rheumatic fever
Because children are still growing, fractures to bone heal
much quicker than those in adults
Thrills - always an abnormal finding
palpation of vibrating sensations d/t rapid flow of blood from an area of higher pressure to and area of lower pressure
As the majority of blood cells in the aorta become deoxygenated, blood is transported from the descending aorta through the umbilical arteries (which are called arteries because they carry blood away from the fetal heart) back through the umbilical cord to the
placental villi, where oxygen and carbon dioxide gas exchange occurs.
Congenital disorders can result from reasons
such as maternal drug ingestion or virus invasion or amniotic band formation in utero
Nurses must teach parents of children with muscular or skeletal disorders ways to expose these children to the same sorts of stimuli
that the child without disorders might experience
Because there is no need for the blood to be oxygenated in the lungs of the fetus,
the bulk of blood is shunted as it enters the right atrium into the left atrium through an opening in the atrial septum called the foramen ovale.
However, a larger portion of even this blood is shunted away from the lungs through an additional structure call the ductus arteriosus, directly into
the descending aorta.
Specialized structures present in the fetus then shunt blood flow to first supply the most important organs of the body
the liver, heart, kidneys, and brain
Polydactyly
the presence of one or more additional fingers or toes The extra finger or toe are usually amputated in infancy or early childhood
Oxygenated blood travels to the fetus from the placenta through
the umbilical vein
Blood flows from the umbilical vein to the ductus venosus which is an accessory vessel that discharges oxygenated blood to the liver and
then connects to the inferior vena cava so oxygenated blood is directed to the right side of the heart
From the left atrium, the blood follows the course of adult circulation into the left ventricle
then into the aorta, and out to the body parts.
Murmurs are heart sounds that are due to
turbulent blood flow (Intensity, duration, quality)
Syndactyly
two fingers or two toes are fused by a simple webbing. If the digits are only webbed together, they can be separated with great success. However, if the bones are fused, successful separation is much more difficult to achieve. Be sure and perform head circumference assessment in these infants and children as craniosynostosis is common.
Grade 5 murmor
very loud, with thrill, heard with the stethoscope partly off the chest
Temperature of extremities - cold feet and hands in comparison to torso suggests poor perfusion
when noted more than 8 hours following birth
Once proper lung oxygenation is established, the need for the high red cell count diminishes so,
within a matter of days, red cells begin to be destroyed.
