Unit 1: Cardiovascular Alterations & Part 2: Blood Disorders

The nurse is taking a health history of a 6-week-old boy with a suspected cardiovascular disorder. Which response by the mother would lead the nurse to suspect that the child is experiencing heart failure?

"He gets sweaty when he eats" Diaphoresis with nipple feeding indicates heart failure. Shortness of breath would suggest heart failure. Children with heart failure experience subtle signs that suggest that something is wrong. Children with heart failure often display subtle signs such as difficulty feeding.

The nurse is taking a health history of a toddler with a suspected congenital heart defect. Which response by the mother could indicate that the child is experiencing hypercyanotic spells?

"He likes to stop and squat wherever he walks" The walking toddler may squat periodically to relieve a hypercyanotic spell. This position serves to improve pulmonary blood flow by increasing systemic vascular resistance

Atropine- dosage

0.5-1 mg IVP max dose is usually 2-3 mg

What is a VSD?

Abnormal opening betwen the right and left ventricles

Who is affected by SCD?

African American, Hispanc, Saudi Arabia, India, and Mediterranean countries 90,000-100,000 have it in the US

How would you classify a VSD?

Aycanotic Oxygenated blood flow is getting to the body

What is mitral valve prolapse?

Ballooning of mitral valve into left atrium during systole

What are Class II antidysrhythmics?

Beta adrenergic blockers Used for atrial and ventricular dysrhythmias Propranolol Esmolol Sotalol Acebutolol

How can TTP manifest?

Bleeding and clotting can occur simultaneously Activated to form clots, but also low platelets so you're bleeding

Why is pulse ox screening so important for CHD?

Can catch 7 different kind of heart defects (all cyanotic) Hypoplastic left heart Pulmonary atresia Tetralogy of Fallot Tricuspid atresia Transposition of great arteries Total anomalous pulmonary venous return Truncus arteriosus

Class I antidysrhythmics- effects on EKG

Can cause widening of QT interval and QRS

What is treatment for ITP?

Corticosteroids to decrease immune response and decrease capillary fragility Immunosuppressive drugs (Rituxan, cytoxan, Imuran) Platelet infusions for really low, life-threatening hemorrhages Splenectomy may be considered Patients are usually managed in the outpatient setting unless major bleeding occurs

Why can bradycardias complication occur post OHS?

D/t depression of conduction system by cardioplegia solution or surgical injury Increased r/f bradycardias with valve surgery d/t close proximity of valves to the AV node (this is why we have pacing wires)

Class III antidysrhythmics- mechanism of action

Delay repolarization by blocking K channels and prolonging action potential

Growth and skill retardation CHD

Delayed physical growht- they tire easily, so unable to do lots of activities or eat well May not have the opportunity to practice physical skills Above average intelligence usually

What are the clinical manifestations of dilated cardiomyopathy?

HF Fatiue Nocturnal dyspnea Orthopnea Tachycardia Crackles S3 and S4 heart sounds Peripheral edema

Signs and symptoms of PDA?

Fast breathing- SOB Poor feeding Poor weight gain Tiring easily Sweating with exertion Murmur At risk for bacterial endocarditis and pulmonary vascular obstructive disease from excessive pulmonary blood flow

What is Phase 1?

Fast channels shuts

Pulse CHD

Listen for one full minute Assess with activity and without activity (will see increased symptoms w/ activity) May be bounding/weak/thready

What is coarctation of the aorta?

Localized narrowing near the insertion of the ductus arteriosus, which resulting in increased pressure proximal to the defect and decreased pressure distal to the obstruction Lots of times, these children will also have other septal defects

Class II antidysrhythmics- effects on EKG

Longer PR intervals

What during OHS positively correlates with an increase in fluid retention?

Longer the aorta is cross clamped

What are the options for valve replacement?

Mechanical and biological

Why is activity progression used post OHS?

Opens lungs, prevents DVt

Advantages of biological valve?

Patient does not need to be on Coumadin

An infant with tetralogy of Fallot becomes cyanotic. Which nursing intervention would be the first priority?

Place the infant in the knee-chest position. Placing the infant in the knee-chest position is the first priority when caring for an infant with tetralogy of Fallot. Starting IV fluids and preparing the child for surgery would not be necessary since it is known that the infant has a cyanotic birth defect. Raising the head of the bed would not be a priority since the infant needs to be placed in the knee-chest position.

Pulse ox screening for infants

Right foot first then right hand Repeat every hour If <90% in right hand OR foot; 90-95% in right hand AND foot or >3% difference between right hand and foot x3 = positive screen If >95% in right hand or foot and <3% difference between hand and foot x3 = negative screen

Where is the best place to hear the aortic stenosis murmur?

Right sternal border at the second intercostal space

What is the medical management of mitral regurgitation?

Reduce preload (diuretics, nitrates, sodium restriction) and afterload (ACE-I)

Toddler activity CHD

Run around and then squat

Is stenosis or regurgitation more common for tricupsid/pulmonic valves?

Stenosis > regurg

What is restrictive cardiomyopathy?

Stiff ventricular wall that does not stretch for filling Contractility normal or decreased Decreased SV CO decreased or can be normal (based on compensatory mechanisms)

How do antidysrhythmics affect the stroke volume?

Suppress contractility

What is hypertrophic cardiomyopathy?

Thickened ventricular walls. Outflow obstruction created by hypertrophy Decreased CO -> rapid, more forceful contraction to eject blood = mild cardiomegaly Hypertrophy impairs relaxation of ventricle and impairs filling (decrease CO) Mitral valve incompetence

What is the surgical treatment for pulmonic/tricuspid valve disease?

Valve repair- commissurotomy/valvulotomy Valvuloplasty (TR) Annuloplasty Valve replacements

A mother is asking for more information about her infant's patent ductus arteriosus (PDA). What would be included in the education?

This is caused by an opening that usually closes by 1 week of age A PDA is caused by an opening called the ductus arteriosus. A PDA usually closes by 1 week of age. If it does not close, the defect is usually fixed by a single surgery or during a cardiac catheterization procedure. IV fluids are not a routine intervention for the PDA. Most of the time a PDA occurs in premature infants.

What is the pathophysiology of mitral valve prolapse?

Valves buckle back into the LA during systole

What are the post-op tubes/wires with an OHS?

Ventilator Chest tubes Blake tubes Pacing wires RIJ Central Line

When a persons blood pressure rises, the homeostatic mechanism to compensate for an elevation involves stimulation of

baroreceptors that inhibit the sympathetic nervous system causing vasodilation Rationale: Baroreceptors in the aortic arch and carotid sinus are sensitive to stretch or pressure within the arterial system. Stimulation of these receptors sends information to the vasomotor center in the brainstem. This results in temporary inhibition of the sympathetic nervous system and enhancement of the parasympathetic influence, which cause a decrease in heart rate and peripheral vasodilation

what is a common sign of chronic bleeding that patients need to notice?

bleeding from the gums when brushing teeth

The nurse examines a patient for decreased circulation in the lower extremities. Which of the following would indicate adequate circulation?

capillary refill <3 seconds

What causes fatigue in patients with chronic aortic stenosis

left ventricular failure

what is the most common reason for blood beginning to clot?

damage to the blood vessels or tissues

What best describes the action of propranolol?

decreases cardiac output decreases HR, contractility, O2 demand and BP

An expected finding in the assessment of an 81 year old patient is

difficulty isolating the apical pulse Myocardial hypertrophy and the downward displacement of the heart in an older adult may cause difficulty in isolating the apical pulse.

Which heart valve sound is heard best at the left midclavicular line at the level of the 5th ICS?

mitral assess the mitral valve by auscultating at the left midclavicular line at the fifth intercostal space ICS

What occurs in mitral regurgitation?

mitral regurgitation is backflow of blood into the left atrium

What are the causes of mitral valve prolapse?

Abnormalities in mitral valve leaflets and papillary muscles or chordae tendineae

Signs and symptoms of coarctation of the aorta?

BP that is higher in the arms than in the legs Weak/absent femoral pulses Cool lower extremities with lower BP Nosebleeds Dizzy/fainting Leg cramps w/ exercise

What are Class III antidysrhythmics?

Block potassium channels Used for atrial and ventricular dysrhythmias Amiodarone (main) Dofetilide (Tikosyn) Ibutilide fumarate (Covert) Sotalol

What is Phase 2?

Calcium and sodium enter via slow channels

What is an overriding aorta?

Covers both the right and left ventricle Oxygen-poor blood flows directly into the aorta instead of the pulmonary artery Increased outflow in aorta

What is thrombocytopenia?

Decrease in platelets below 150K that can result in abnormal hemostasis (prolonged bleeding) Usually not a true risk until <10-20K

What is mitral valve stenosis?

Narrowing of the mitral valve

<0.12 seconds

QRS interval

The nurse is caring for a child with heart failure related to a congenital heart defect. One of the nursing diagnoses identified includes "Excess fluid volume." During a family care planning conference. the parents ask why this diagnosis applies to their child. What is the best response by the nurse?

"Cardiac problems cause the heart to not pump effectively, which causes swelling in the body and fluid in the lungs." Explanation: This response best explains the meaning of the nursing diagnosis and it's cause. Although there are standardized care plans as a guide, each care plan must be individualized to the client.

The patient tells the nurse that he does not understand how there can be a blockage in the left anterior descending artery (LAD), but there is damage to the right ventricle. What is the best response by the nurse?

"The LAD supplies blood to the left side of the heart and part of the right ventricle." Rationale: The best response is explaining that the lower portion of the right ventricle receives blood flow from the left anterior descending artery as well as the right coronary artery during diastole.

Which instruction by the nurse to a patient who is about to undergo Holter monitoring is acccurate?

"You will need to keep a diary of your activities and symptoms." Rationale: A Holter monitor is worn continuously for at least 24 hours while a patient continues with usual activity and keeps a diary of activities and symptoms. The patient should not take a bath or shower while wearing this monitor.

The nurse cares for a client following the insertion of a permanent pacemaker. What discharge instruction(s) should the nurse review with the client?

- Avoid handheld screening devices in airports - Check pulse daily reporting sudden slowing -wear a medical alert, noting the presence of a pacemaker Handheld screening devices used in airports may interfere with the pacemaker. Patients should be advised to ask security personnel to perform a hand search instead of using the handheld screening device. With a permanent pacemaker, the client should be instructed initially to restrict activity on the side of implantation. Clients also should be educated to perform a pulse check daily and to wear or carry medical identification to alert personnel to the presence of the pacemaker. Client should walk through antitheft devices quickly and avoid standing in or near these devices. Client can safely use microwave ovens and electronic tools.

The pathophysiology of pericardial effusion is associated with:

-Increased right and left ventricular end diastolic pressures -Atrial compression -Inability of the ventricles to fill adequately Explanation Venous return is decreased (not increased) with Pericardial effusion because there is an increase in the pericardial fluid, which raises the pressure within the pericardial sac and compresses the heart. Increased right and left ventricular end-diastolic pressures, inability of the ventricles to fill adequately, and atrial compression are all effects of pericardial effusion

The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instruction?

. "I can apply lotion or powder to the incision if it is itchy." Rationale: The mother should be instructed that lotions and powders should not be applied to the incision site after cardiac surgery. Lotions and powders can irritate the surrounding skin, which could lead to skin breakdown and subsequent infection of the incision site

Tricuspid atresia

1. Tricuspid atresia is failure of the tricuspid valve to develop. 2. No communication exists from the right atrium to the right ventricle. 3. Blood flows through an ASD or a patent foramen ovale to the left side of the heart and through a VSD to the right ventricle and out to the lungs. 4. The defect often is associated with pulmonic stenosis and transposition of the great arteries. 5. The defect results in complete mixing of unoxygenated and oxygenated blood in the left side of the heart, resulting in systemic desaturation, pulmonary obstruction, and decreased pulmonary blood flow. 6. Cyanosis, tachycardia, and dyspnea are seen in the newborn. 7. Older children exhibit signs of chronic hypoxemia and clubbing. 8. Management: If the ASD is small, the defect may be closed during cardiac catheterization; otherwise, surgery is needed. Clubbing is symptomatic of chronic hypoxia. Peripheral circulation is diminished, and oxygenation of vital organs and tissues is compromised.

Truncus arteriosus

1. Truncus arteriosus is failure of normal septation and division of the embryonic bulbar trunk into the pulmonary artery and the aorta, resulting in a single vessel that overrides both ventricles. 2. Blood from both ventricles mixes in the common great artery, causing desaturation and hypoxemia. 3. A characteristic murmur is present. 4. The infant exhibits moderate to severe HF and variable cyanosis, poor growth, and activity intolerance. 5. Surgical management: Corrective surgical repair is performed in the first few months of life

What does a person with SCD start showing symptoms and why?

5 months Fetal hemoglobin is not longer produced (HbF protects RBCs from sickling)

Where is the best place to hear a mitral valve regurgitation?

5th intecostal space, midclavicular line

Adenosine (Adenocard)- dosage

6mg rapid bolus over 1-3 seconds, followed by a 20mL saline flush and elevate extremity. If no response after 1-2 minutes administer 2nd dose of 12-mg rapid IV bolus over 1-3 seconds Works really fast (half life 6-10 seconds)

If you are caring for an adult with a history of CHD, what potential complications might occur?

75% of people with CHD will have had corrective surgery Arrhythmias Clots (MI, PE, DVT, stroke) Endocarditis Impaired lung function Fluid overload Drug side effects Psychosocial issues

What is an ok level for the Hct to fall post OHS and when would we want to notify the doctor the patient may need a tranfusion?

8-9 is ok. We want to worry when it drops into the 7s

What are factors in the mother that may increase risk for CHD? (5)

>40 years old Alcoholism Diabetes Poor nutrition or anorexia/bulimia or eating disorder Rubella or other viral illness during pregnancy

Which patient does the nurse recognize as being most likely to be affected by sickle cell disease? 1.A 14-year-old African American boy 2.A 26-year-old Eastern European Jewish woman 3.An 18-year-old Chinese woman 4.A 28-year-old Israeli man

A 14 year old African American Boy The HbS gene is inherited in people of African descent and to a lesser extent in people from the Middle East, the Mediterranean area, and aboriginal tribes in India. Sickle cell anemia is the most severe form of sickle cell disease

When assessing the client with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding?

A systolic blood pressure that is lower during inhalation Explanation Systolic blood pressure that is markedly lower during inhalation is called pulsus paradoxus. The difference in systolic pressure between the point that is heard during exhalation and the point that is heard during inhalation is measured. Pulsus paradoxus exceeding 10 mm Hg is abnormal.

What are the potential complicaitons with mitral regurgitation?

A-fib and HF Fluid backs up into the LA, which stretches and dilates The back up of pressure causes pulmonary congestion and HF

What complication can occur because of the fluid shifting and sudden return to the vascular system?

A-fib/flutter d/t the increased blood volume return to the LA

What is the conservative management of mitral regurgitation?

ABX therapy (RF/IE) RX to control HF (vasodilators + intropes, B blockers, diuretics) anticoagulation (afib) antidysrhythmic percutaneous transluminal balloon valvuloplasty (PTBV) percutaneous valve replacement MR

What is the conservative treatment for pulmonic/tricuspid valve disease?

ABX therapy (RF/IE) Na restriction Rx to control HF (vasodilators, + inotropes, B blockers, diuretics) anticoagulation (Afib) antidysrhythmic rx percutaneous transluminal balloon valvuloplasty (PTBV) percutaneous valve replacement

What are the conservative managements for mitral valve stenosis?

ABX therapy (RF/IE), Na restriction Rx to control HF (vasodilators, + inotropes, B blockers, diuretics) anticoagulation (Afib) antidysrhythmic rx percutaneous transluminal balloon valvuloplasty (PTBV) percutaneous valve replacement. MS

A patient has a severe blockage in his right coronary artery. Which heart structures are most likely to be affected by this blockage?

AV node left ventricle right ventricle The right coronary artery (RCA) supplies blood to the right atrium, the right ventricle, and part of the posterior wall of the left ventricle. In 90% of people, the RCA supplies blood to the atrioventricular (AV) node, bundle of His, and part of the cardiac conduction system.

Cardiac Tamponade- OHS complication

Accumulation of fluid in pericardial sac a/w bleeding or obstruction of chest tube drainage Heart cannot expand and contract in a normal fashion Usually rapid fluid accumulation and will happen early in the healing process Watch chest tube for a sudden dump of blood and look for decreased CO

What is Primary ITP?

Acquired autoimmune thrombocytopenia that causes platelet destruction that is not triggered by an associated drug or condition

What is the nursing care post op for an OHS?

Activity progression Use of IE TCDB with heart pillow Nutrition Pain control BG control

Which nursing diagnosis should a nurse expect to see in a care plan for a client in sickle cell crisis?

Acute pain related to sickle cell crisis Explanation In sickle cell crisis, sickle-shaped red blood cells clump together in a blood vessel, which causes occlusion, ischemia, and extreme pain. Therefore, Acute pain related to sickle cell crisis is the appropriate choice. Although nutrition is important, poor nutritional intake isn't necessarily related to sickle cell crisis. During sickle cell crisis, pain or another internal stimulus is more likely to disturb the client's sleep than external stimuli. Although clients with sickle cell anemia can develop chronic leg ulcers caused by small vessel blockage, they don't typically experience pruritus.

What are the clinical manifestations for acute and chronic aortic regurgitation?

Acute: cardiac collapse (CP, severe dyspnea, hypoTN, cardiogenic shock, death) Chronic: water-hammer pulse, fatigue, exertional dyspnea, orthopnea, PND. Can be asymptomatic for years

What are the clinical manifestations of acute and chronic mitral regurgitation?

Acute: thready peripheral pulses and cool, clammy extremities (decreased CO). Can be asymptomatic for many years. Chronic: Early S/S of LV failure (weakness, fatigue, dyspnea, palpitations🡪 to orthopnea, periph edema, nocturia. S3 murmur, holosystolic murmur

What is a VSD classified as?

Acyanotic Increased pulmonary blood flow Oxygenated blood flow to the body

How do we classify CHD?

Acyanotic or cyanotic

What is coarctation of the aorta classified as?

Acyantoic Obstruction of blood flow out of the heart Oxygenated blood flow to the body

How can we get the fluid to return to the vascular space in our post OHS patient?

Albumin or hetastarch It will pull fluid back into the vascular system

How does increased pulmonary blood flow effect blood flow?

Allows the blood to flow from the higher-pressure side (left) to the lower pressure side (right) Left-to-right shunt

What causes pulmonic valve diseases?

Almost always congenital

How do antidysrhythmics treat ventricular and supraventricular dysrhythmias? (3)

Alter conductivity of myocardial tissue Alter refractoriness of myocardial tissue Increase myocardial stability

How do antidysrhythmics affect the heart rate?

Alter speed/conduction

Nursing concerns and care for the patient with CHD are based on what 2 things?

Alterations in hemodynamics of blood Changes in oxygenation of blood

What nursing activities can we do for our patients with CHD?

Assess and record HR, RR, BP, and any S/S of decreased CO every 2 to 4 hours as necessary Administer cardiac drugs on schedule (digoxin and diuretics) . Assess and record any SE or S/S of toxicity Keep accurate record of I&O- teach parents to watch this (diapers) Daily weights and document Administer diuretics on schedule Offer small, frequent feeding Group care to allow for rest Calm, soothing environment to make sure child isn't crying

Post nursing care for a TAVR?

Assess femoral access site Q15mins. Monitor for any bleeding (may be a hardened area around insertion site) Check CMS of right leg, including pulses Watch for S/S of HF (valve may be failing) Listen to heart tone Assess activity intolerance

Why is pain a concern with SCD?

Assess if the patient is in a sickle cell crisis Pain is a chronic issue, so we need to stay on top of it Often on a PCA

Folate deficiency anemia assessment and interventions

Assessment 1. Dyspepsia 2. Smooth, beefy red tongue 3. Pallor, fatigue and weakness 4. Tinnitus 5. Tachycardia Interventions 1. Encourage the client to eat foods rich in folic acid, such as green leafy vegetables, meat, liver, fish, legumes, peanuts, orange juice, and avocado. 2. Administer folic acid as prescribed

What is secondary ITP?

Associated with another condition (HIV, Lupus, Hep C, H. pylori, or CLL)

When is SCD usually diagnosed?

At birth during newborn screening tests

The nurse determines that a patient's pedal pulses are absent. What factor could contribute to this finding?

Atherosclerosis Rationale: Atherosclerosis can cause an absent peripheral pulse. The feet would also be cool and may be discolored. Hyperthyroidism causes a bounding pulse. Arteriovenous fistula gives a thrill or vibration to the vessel, although this would not be in the foot. Cardiac dysrhythmias cause an irregular pulse rhythm.

Why are pacing wires used post op for an OHS?

Atria and ventricle that are place in surgery If the patient needs to be paced, they can be hooked up to a temporary pacemaker Come out when the chest tubes come out if they are not being used (medicate prior to removal)

What is HIT Type II?

Autoantibody reaction to platelet factor 4 complexed with heparin Big problem

How does HIT occur?

Autoantibody that reacts to the platelet factor 4 complex with hepairn The antibody antigen reaction activates platelets, resulting in arterial and venous thromobosis Usually requires exposure to heparin for 4 days Spleen removes the IgG coated platelets by the macrophages, resulting in thrombocytopenia

What happens in TTP?

Autoimmune DO resulting in deficiency of ADAMTS13 Decreased amounts of this enzyme result in large amount of vWF attaching to activated platelets and trigger platelet aggregation Enhanced aggregation results and abnormalities in the vessel walls lead to microvascular thrombosis

What is the teaching for hypertrophic cardiomyopathy?

Avoid strenuous activity and dehydration Hypertrophic

What is teaching to include with restrictive cardiomyopathy?

Avoid strenuous activity and dehydration Restrictive

A patient who has a history of heart failure and chronic obstructive lung disease is admitted with severe dyspnea. Which value would the nurse expect to be elevated if the cause of dyspnea was cardiac related?

B-type natriuretic peptide (BNP) Rationale: Elevation of BNP indicates the presence of heart failure. Elevations help to distinguish cardiac versus respiratory causes of dyspnea. Elevated potassium, homocysteine, or HDL levels may indicate increased risk for cardiovascular disorders but do not indicate that cardiac disease is present.

Baby A has TGA, atrial septal defect, and ventricular septal defect. Baby B has TGA and atrial septal defect. Which baby has the best prognosis?

Baby A- they have TGA, but they have two defects that will promote mixing of systemic and pulmonary circulation

What are treatment options for VSD?

Band the pulmonary artery Surgical complete repair with sutures or patch Prognosis is dependent on the condition, but mortality is low

What happens to the RBC in SCD?

Become hard, stiff, sticky, crescent shaped, and break apart easily They die early, leading to a constant shortage of RBC Travel through small blood vessels and get stuck, impeding blood flow and cause pain and other problems

What is Acute Chest Syndrome?

Blockage of the flow of the lungs can cause acute chest syndrome. ACS is similar to pneumonia Symptoms include chest pain, coughing, difficulty breathing, and fever. It can be life-threatening and should be treated in a hospital Prevented with hydroxyurea

Diagnostic studies of cardiovascular system

Blood Studies • Cardiac-specific troponin, copeptin, and creatine kinase (CK)-MB are sensitive indicators of early myocardial injury and infarction. All rights reserved. • Changes in the lipid profile, cholesterol, triglycerides, and high-density and low-density lipoproteins are linked to heart disease. • High sensitivity C-reactive protein is an independent risk factor for CAD and may be a predictor of heart events. • B-type natriuretic peptide (BNP) is the marker of choice for differentiating a cardiac or respiratory cause of dyspnea. Diagnostic Studies • 12-lead electrocardiogram (ECG) • Deviations from the normal sinus rhythm can indicate abnormalities in heart function. • ECGs can be obtained as a one-time recording or for longer periods of time using ambulatory ECG (Holter monitoring) or event and loop monitors. • Exercise or stress testing is used to evaluate the cardiovascular response to physical stress. Perfusion imaging with exercise testing can distinguish viable myocardial tissue from scar tissue and assess the effectiveness of therapies. • An echocardiogram provides information about valvular structure and motion, heart chamber size and contents, ventricular muscle and septal motion and thickness, pericardial sac, and ejection fraction (EF). • Nuclear medicine studies provide information on the structure and function of the heart in determining the presence and extent of heart disease. These include multigated acquisition or cardiac blood pool scans (MUGA), single-photon emission computed tomography (SPECT), positron emission tomography (PET), cardiovascular magnetic resonance imaging (CMRI), magnetic resonance angiography (MRA), and variations of computed tomography angiography (CT scan). Copyright © 2020 by Elsevier, Inc. All rights reserved. • In cardiac catheterization and coronary angiography, contrast media and fluoroscopy are used to obtain information about the coronary arteries, heart chambers and valves, ventricular function, intracardiac pressures, O2 levels in various parts of the heart, CO, and EF. • Electrophysiology study (EPS) obtains information on the heart's conduction system and is useful in identifying the source and guiding treatment in dysrhythmias.

How does obstruction of blood flow out of the heart effect blood flow?

Blood exiting the heart meets and area of anatomic narrowing, causing obstruction to blood flow

What happens to the LA and LV in mitral regurgitation?

Blood flow backwards → LA → ↑ LA volume → LA stretch & dilate. LV augmented preload → ↑ LV stretch helps with ejection of blood, but LV has to work harder. Eventually LV hypertrophies and LV function can become impaired →↓ cardiac output. Back-up of hydrostatic pressure can lead to pulmonary congestion

What problem occurs with VSD?

Blood is pushed from the higher pressure left side to the lower pressure right side. This causes more blood to be pushed into the lungs, damaging them and causing RV hypertrophy d/t the increased volume Problematic because it increases pulmonary blood flow

What is the distinguishing sign for coarctation of the aorta?

Blood pressure difference between the limbs (upper vs lower) Pressure in the upper body increases Pressure in the lower body decreases

Signs and Symptoms of Transposition of the Great Arteries?

Blueness of skin Clubbing of fingers or toes Poor feeding SOB Children with large defects have less cyanosis, but more S/S of HF

Class II antidysrhythmics- common side effects (6)

Bradycardia Hypotension HF Impotence AV block Bronchospasm

What is ADAMTS13 responsible for?

Breaking down the von Willebrands (vWF) clotting factor to a normal size

An infant with congenital heart disease is to undergo surgery to correct the defect. The mother states, "I guess I'm going to have to stop breastfeeding her." Which response by the nurse would be most appropriate?

Breast milk may help to boost her immune system, so you can continue to use it. Breastfeeding a child before and after cardiac surgery may boost the infant's immune system, which can help fight postoperative infection. If breastfeeding is not possible, mothers can pump milk and the breast milk may be given via bottle, dropper, or gavage feeding. In addition, breastfeeding is associated with decreased energy expenditure during the act of feeding.

Class I antidysrhythmics- common side effects (7)

CNS depression N/V Agranulocytosis Ventricular tachycardia Weakness Blurred vision Bradycardia

The nurse is providing care for a patient who has decreased cardiac output due to heart failure. As a basis for planning care, what should the nurse understand about cardiac output (CO)?

CO is calculated by multiplying the patient's stroke volume by the heart rate. Rationale: Cardiac output is determined by multiplying the patient's stroke volume by heart rate, thus identifying how much blood is pumped by the heart over a 1-minute period. Electrical activity of the heart and blood pressure are not direct components of cardiac output.

What are the three main causes of aortic stenosis?

Calcification from aging (makes leaflets stiff and commissures fuse together so leaflets cannot move freely) Bicupsid valve (congenital) Rheumatic Heart Disease (bacteria attaches to the valve leaflets and causes inflammation. As they heal, scar tissue forms causing stenosis)

What are Class IV antidysrhythmics?

Calcium Channel Blockers Used for atrial dysrhythmias (SVT) Verapamil and Diltiazem

What is the bypass machine?

Cannula into the IVC/SVC and aorta to allow the blood to bypass the heart Does everything the lungs and heart do, but outside the body

What is the major complication of a pericardial effusion?

Cardiac tamponade

The nurse is caring for a patient diagnosed with pericarditis. What serious complication should this patient be monitored for?

Cardiac tamponade Explanation The inflammatory process of pericarditis may lead to an accumulation of fluid in the pericardial sac (pericardial effusion) and increased pressure on the heart, leading to cardiac tamponade (see Chapter 29).

Why is the pressure difference created by aortic stenosis important?

Causes inadequate oxygenation of heart muscle and chest pain The coronary arteries fill during diastole, so when the pressure is low, these arteries do not fill well. This causes the patient to experience chest pain because the myocardium is not receiving enough oxygen

What vascular accidents can occur d/t cyanotic heart defects?

Cerebral vascular accidents- R/f stroke and DVTs d/t polycythemia Persistent hypoxemia -> stimulation of erythropoiesis -> polycythemia -> increased viscosity + vasoconstriction from SNS -> increased R/F thrombosis

What are adverse effects that we should be aware of with antidysrhythmics and heart rate?

Check VS Assess ECG for heart block

Adolescent activity CHD

Chest pain with sports

What is the sickle cell trait?

Child only inheritied one copy of the sickle cell gene and one normal copy. They carry the trait and can pass it on Usually patient is asymptomatic, but can show some signs

What are potential complications of dehydration and diarrhea for a child with CHD?

Children with cyanotic heart disease may be at risk for hypercyanotic spells and dehydration can be triggering response CBC may be high as a result of hemoconcentration Cyanotic children are at increased r/f stroke

Fluid bolus with children who have a CHD?

Children with heart defects are reduced to 10cc/kg and reevaluated after 1 bolus (vs 20cc/kg up to 3 times for non-CHD children) It's our job to make sure we know they are a heart patient and do not go into FVO

What is the etiology of acute and chronic aortic regurgitation?

Chronic: Rheumatic heart disease, congenital bicuspid valve, syphilis, or chronic rheumatic conditions Acute: trauma, IE, aortic dissection

Caring for an infant with a stent for coarctation of the aorta

Coagulation Look for signs of stent failure (if the patient begins have S/S of HF again)

What are the surgical interventions for mitral valve stenosis?

Commissurotomy (valvulotomy)- incision to widen opening of stenotic valve Percutaneous mitral balloon valvulotomy/valvuloplasty (similar to TAVR)

What are some of the S/S that cardiac tamponade is developing?

Confusion Hypotension and S/S of decreased CO Shock JVD Muffled heart sounds Pulsus paradoxus (drop in BP w/ inspiration)

What is the patent ductus arteriosus?

Connection between the aorta and pulmonary arteries

What CHD defects can cause obstruction to blood flow out of the heart? (3)

Corarctation of aorta Aortic stenosis Pulmonic stenosis

The nurse is caring for a pediatric client diagnosed with tetralogy of Fallot. After speaking with the physician, the parents state to the nurse, "The doctor said something about our child having too many red blood cells. We don't understand how that could happen?" What is the best response by the nurse?

Correct response: "Your child's body is trying to compensate for the low blood oxygen levels from the heart defect by making more red blood cells, but this makes the heart actually work harder." Explanation: To compensate for low blood oxygen levels, the kidneys produce the hormone erythropoietin to stimulate the bone marrow to produce more red blood cells (RBCs). This increase in RBCs is called polycythemia. Polycythemia can lead to an increase in blood volume and possibly blood viscosity, further taxing the workload of the heart. The correct response is the clearest and easiest description for the parents to understand.

A mother asks the nurse if the reason the infant has a congenital heart defect is because of something she did while pregnant. What is the best response by the nurse?

Correct response: There are several reasons an infant can have a heart defect; let's talk about those causes. Explanation: Parents who have a newborn who has a defect are always concerned they did something wrong to cause the defect. They carry a large amount of guilt. The nurse should focus on the therapeutic communication in this situation, while still obtaining more information. A nurse should never blame the parent because it is not only nontherapeutic, but there are many reasons why congenital heart defects occur. The reason for the infant's heart defect may not be known. Using therapeutic communication will reduce the parent's anxiety and guilt. Congenital heart defects can be caused by genetic defects such as chromosomal anomalies but this is not always the case.

Cyanosis CHD

Crying/activity will increase cyanosis Decreased cyanosis at rest

Signs and symptoms of Tetralogy of Fallot?

Cyanosis "Tet" spells Heart murmur Poor feeding Poor growth Clubbing of fingers

What is Tetralogy of Fallot classified as?

Cyanotic Decreased pulmonary blood flow Unoxygentated blood flowing to body

What is Transposition of the Great Arteries classified as?

Cyanotic Mixed blood flow Unoxygenated blood flowing to body

Class II antidysrhythmics- mechanism of action

Decrease SA automaticity and AV node conduction Decrease contracility BB

Class IV antidysrhythmics- mechanism of action

Decrease SA automaticity and AV node conduction Decrease contractility CCB

What are the goals with our nursing care for CHD?

Decrease work of heart (diuretic) Decrease systemic vascular resistance (ACEI) Increase effectiveness of contractility (Digoxin) Increase circulation to kidneys Increase nutrition Tailor activities

The cardiac nurse is caring for a client who has been diagnosed with dilated cardiomyopathy (DCM). Echocardiography is likely to reveal what pathophysiological finding?

Decreased ejection fraction DCM is distinguished by significant dilation of the ventricles without simultaneous hypertrophy. The ventricles have elevated systolic and diastolic volumes, but a decreased ejection fraction. Bradycardia and mitral valve regurgitation do not typically occur in clients with DCM.

What two factors make the fluid shifting possible?

Decreased plasma colloid pressure (hemodilution) Increased capillary permeability (inflammatory response)

How is TTP diagnosed?

Decreased platelets Test for ADAMTS13 deficiency Lactici dehydrogenase LDH increase Schistocytes seen on blood smear Hemoglobin and haptoglobin decrease Indirect bilirubin increaese (RBC fragment)

What are the two characteristics of the defects that can cause cyanotic CHD?

Decreased pulmonary blood flow Mixed blood flow

What two characteristic defects can cause cyanotic CHD?

Decreased pulmonary blood flow Mixed blood flow

Neurological dysfunction- OHS complication

Decreased systemic arterial pressure while on bypass Microembolization of fat, fibrin, platelet aggregates, clots, or dislodgement of calcified material on valves or atheroma on aorta Hypotension or low cardiac output post-op

What is Phase 0?

Depolarization Na+ enters cells via fast channel

Which aspect of the heart's action does the QRS complex on the ECG represent?

Depolarization from atrioventricular (AV) node throughout ventricles Rationale: The QRS recorded on the ECG represents depolarization from the AV node throughout the ventricles. The P wave represents depolarization of the atria. The T wave represents repolarization of the ventricles. The interval between the PR and QRS represents the length of time it takes for the impulse to travel from the atria to the ventricles.

What are the types of cardiomyopathies?

Dilated Restrictive Hypertrophic

What should be done if the patient with HIT still needs anticoagulation?

Direct thrombin inhibitor- Bivalirudin (Angiomax) Or Factor Xa inhibitor- Rivaroxaban (Xarelto) Or Coumadin

What is the treatment for HIT?

Discontinue all heparin (unfractionated, LMWH, or IV) and use protamine sulfate to interrupt any circulating heparin If clotting is severe, plasmapheresis may be used to clear platelet-aggregating IgG Thrombolytic agents to treat thromboembolic events or surgery to remove clots

How do dysrhythmias occur?

Disorder in the formation of an impulse (early beat, possible origin of beat in some place other than pacemaker cell site) or the conduction of the impulse (altered depolarization pathway) It can be both at once

Hospital interventions for VSD?

Diuretic (lasix) and monitor I&O (diapers) and monitor fluid level (no more boluses) Improve pulmonary system HOB 30-45 degrees Monitor F&E- especially potassium Digoxin- heart med CPAP to push fluid out of alveoli and back into the space instead of oxygen Monitor VS Q2-4 hours as necessary- upper and lower extremities Daily weights ABX for infection Group care to allow for rest

Disadvantages of biological valve?

Does not last as long (10-15 years) and may need to be replaced Usually used on older patients

What can cause TTP?

Drug toxicity Pregnancy Preeclampsia Infection/autoimmune Lupus

Atropine- side effects (8)

Dry mouth Blurred vision Photophobia Urinary retention Constipation Anhidrosis (no sweat) Tachycardia Asthma

Why can a a-fib/flutter complication occur post OHS?

Due to atrial ischemia during cross clamp time Atrial dilation d/t volume overload and inability of left ventricle to pump blood effectively

What is drug-induced immune thrombocytopenia?

Due to drug dependent platelet antibodies that can cause destruction

What are the clinical manifestations of hypertrophic cardiomyopathy?

Dyspnea Angina Syncope Dysrhythmias Especially seen with activity

The nurse is caring for a client experiencing a rapidly developing pericardial effusion. Which assessment findings indicate to the nurse that the client is developing cardiac tamponade?

Dyspnea Tachycardia Distant heart sounds JVD Explanation Pericardial fluid may build up slowly without causing noticeable symptoms until a large amount (1 to 2 L) accumulates. However, a rapidly developing effusion can quickly stretch the pericardium to its maximum size and cause an acute problem. As pericardial fluid increases, pericardial pressure increases, reducing venous return to the heart and decreasing CO. This can result in cardiac tamponade, which causes low CO and obstructive shock. Symptoms of cardiac tamponade include dyspnea, tachycardia, distant heart rounds, and jugular vein distention.

What are the clinical manifestations of mitral valve stenosis? (7)

Dyspnea on exertion caused by reduced lung compliance Hemoptysis- pulmonary hypertension Fatigue and palpitations- from a-fib A-fib on ECG- can cause emboli and stroke Chest pain- decreased CO and coronary perfusion Loud, accentuated S1 and low-pitched, diastolic murmur Hoarseness- from atrial enlargement pressing on laryngeal nerve

What are other complications of pericardial effusion?

Dysrhythmias Pneumomediastinum Pneumothorax Myocardial lacerations Coronary artery laceration

What lab tests would be beneficial for a VSD?

Echo to detect heart defects and chamber dilation EKG- going to show sinus tachy CXR to look at lungs and heart Cardiac cath to show patterns of blood flow and pressure ABG or VBG in respiratory distress BNP- look at FVO CBC- infection, platelets, anemia BMP- sodium, calcium, potassium, magnesium

A client is admitted to the hospital with possible acute pericarditis and pericardial effusion. The nurse knows to prepare the client for which diagnostic test to confirm the client's diagnosis?

Echocardiography Explanation Echocardiography is useful in detecting the presence of pericardial effusions associated with pericarditis. An echocardiogram may detect inflammation, pericardial effusion, tamponade, and heart failure. It may help confirm the diagnosis.

How are pericarditis and cardiac tamponade diagnosed?

Echocardiography CXR Doppler CT MRI

Which of the following describes what occurs in aortic stenosis?

Emptying of blood from the left ventricle is impaired

History of frequent respiratory infection CHD

Endocarditis Find out if the patient has any patches or stents

What can be done in-utero to ensure that babies with Transposition of the Great Arteries will be able to survive after birth?

Enlarge the ASD or VSD Utilize prostaglandins No ibuprofen for mom

What if parents do not want to correct Transposition of the Great Arteries?

Ethics committee Advocate for your patient (baby)

What are clinical manifestations for restrictive cardiomyopathy?

Exercise intolerance (tachycardia further impairs ventricular filling) Other S/S of HF

Why are children with VSD prone to developing URI?

Extra blood flow to the lungs can result in pooling of blood in the small vessels and pulmonary edema can develop Increased pulmonary resistance Risk for bacterial endocarditis and pulmonary vascular obstructive disease

What would cause a child with a VSD to decompensate?

FVO- if too much was pushed in the ED Make sure it's 10cc/kg and reevaluate after just 1 bolus

What problem with blood flow occurs with a PDA?

Failure of fetal ductus arteriosus to close within the first weeks of life Oxygenated blood from the aorta flows into the pulmonary circulation

T/F: children with acyanotic heart defects rarely, if ever, have episodes of cyanosis, while children with cyanotic defects are frequently cyanotic?

False Classification only refers to oxygenation of the blood flowing to the body (does not refer to cyanosis)

What are the clinical manifestations for pulmonic valve disease?

Fatigue Loud midsystolic murmur

How long is the patient usually in ICU post OHS?

First 24 hours. If everything looks stable, patient moved to OHVI 4 or step down CV unit

What is a pericardial effusion?

Fluid accumulation in the pericardial sac (friction rub not present and heart tones will sound muffled)

Potential complications with VSD that nursing care can prevent?

Fluid volume overload Fluid and electrolyte imbalance from diuretic Do not give oxygen- can make it worse. Put on CPAP instead We want to push fluid out of alveolar space If you get an order to administer supplemental sodium, do not give and give to PCN

What are the two changes in blood flow through the heart that are initiated with the first few breaths of a newborn?

Foramen ovale (hole between atria) and Patent ductus arteriosus (link between aorta and pulmonary artery) close

What is Tetralogy of Fallot?

Four defects occuring the heart, causing a right to left shunt of blood

How does a pericardial effusion occur?

From the inflammation- this increases the capillary permeability and fluid comes into the area

How does mixed blood flow out of the heart effect blood flow?

Fully saturated systemic blood mixes with desaturated pulmonary blood flow, causing relative desaturation of systemic blood flow

Who is a TAVR used for?

Generally elderly patient that cannot undergo OHS Patients with severe AS and other comorbidities that would not be good candidates for an OHS

How is SCD acquired?

Genetic. Must receive two sickle cell genes

How does a BV and TAVR work?

Goes through the femoral artery. The balloon opens the stenotic valve first. Then the tissue valve is connected to the catheter and guided to the valve. The valve is expanded within the diseases valve

What are cardiomyopathies?

Group of cardiac muscle diseases that affect structural and functional ability of ht heart

What is sickle cell disease?

Group of inherited red blood cell disorders with abnormal hemoglobin S

What are the clinical consequences of congenital heart disease?

HF Hypoxemia Change in the normal flow of blood through the heart

What complications can VSD lead to?

HF Pulmonary HTN Dysrhythmias Stroke Bacterial endocarditis Pulmonary vascular obstructive disease

What are potential complications with coarctation of the aorta?

HF d/t increased workload Severe acidosis and hypotension w/ critical coarctation Pt at risk for HTN, ruptured aorta, aortic aneurysms, and stroke

stimulation of barorecptors and chemoreceptors found in the aortic arch and carotid sinus can initate changed in

HR and arterial pressue

Why is the internal mammary artery a good choice for bypass?

Has its own blood supply (attached to the subclavian) and will generally last the life of the patient Must go into the pleural space though, so a chest tube will be needed to reinflate the lung

What are the general dysrhythmic actions?

Heart rate Stroke volume

Impaired renal function- OHS complication

Hemolyzed red cells deposited in renal arteries and get stuck Low renal blood flow on bypass triggering RAAS Decreased cardiac output and hypotension post-op Use of vasopressors (to keep BP and CO up) post-op that constrict (Dopamine at high levels will vasoconstrict the renal arteries (alpha receptors)) Possible embolus in renal arteries

A 43-year-old male came into the emergency department where you practice nursing and was diagnosed with atrial fibrillation. It's now 48 hours since his admittance and the dysrhythmia persists. Which of the following medications will the client's healthcare provider most likely order?

Heparin Heparin is generally prescribed initially if the dysrhythmia persists longer than 48 hours

What does the cardioplegia solution do?

High potassium solution that stops the heart

What kind of pressure difference does aortic stenosis create?

Higher pressure in the LV and lower pressure in the aorta

How would you explain VSD to a child's parent?

Hole in the heart

How can we sum CHD up to parents?

Hole in the heart Leaky valves Defective valves

What defect is occuring with a VSD?

Hole in the ventricles and left to right shunt

Total time in hospital post OHS? Toal healing time post OHS?

Hosptial is usually 5-6 days Healing- 8 weeks

A client with a new onset of rib and spine pain is being evaluated for multiple myeloma. For which manifestations will the nurse assess this client? Select all that apply.

Hypercalcemia Renal dysfunction Anemia Bone destructions Explanation Clinical manifestations of multiple myeloma result not only from the malignant cells themselves, but also from the abnormal protein they produce. The classic clinical manifestations of multiple myeloma are referred to as the CRAB features and include anemia, hypercalcemia, renal dysfunction, and bone destruction. Lymph enlargement is associated with lymphomas, but not with multiple myeloma.

Tetralogy of Fallot Priority nursing actions

Hypercyanotic Spell Occurring in an Infant 1. Place the infant in a knee-chest position. 2. Administer 100% oxygen. 3. Administer morphine sulfate. 4. Administer fluids intravenously. 5. Document occurrence, actions taken, and the infant's response

What clinical manifestations can be seen d/t TTP?

Hypertension Neurological symptoms Renal failure S/S

Hypertrophic cardiomyopathy

Hypertrophic Cardiomyopathy Dilated Cardiomyopathy Nonobstructed Obstructed Restrictive Cardiomyopathy Pathophysiology ● Fibrosis of myocardium and endocardium ● Dilated chambers ● Mural wall thrombi prevalent ● Hypertrophy of the walls ● Hypertrophied septum ● Relatively small chamber size ● Same as for nonobstructed except for obstruction of left ventricular outflow tract associated with the hypertrophied septum and mitral valve incompetence ● Mimics constrictive pericarditis ● Fibrosed walls cannot expandor contract ● Chambers narrowed; emboli Common

Hypoplastic left heart syndrome

Hypoplastic left heart syndrome 1. Underdevelopment of the left side of the heart occurs, resulting in a hypoplastic left ventricle and aortic atresia. 2. Mild cyanosis and signs of HF occur until the ductus arteriosus closes; then progressive deterioration with cyanosis and decreased cardiac output are seen, leading to cardiovascular collapse. 3. The defect is fatal in the first few months of life without intervention. 4. Surgical treatment a. Surgical treatment is necessary; transplantation in the newborn period may be considered. b. In the preoperative period, the newborn requires mechanical ventilation and a continuous infusion of prostaglandin E1 to maintain ductal patency, ensuring adequate systemic blood flow.

What is the concern when the fluid is not in the vascular space?

Hypotension Monitor left atrial pressure to check volume status in the vascular system

Class IV antidysrhythmics- common side effects (5)

Hypotension Flushing Edema HA CHF

What are adverse effects that we should be aware of with antidysrhythmics and stroke volume?

Hypotension Watch for HF

Why can tachycardia complication occur post OHS?

Hypovolemia in the vascular space SNS stimulation, pain, anxiety, increased oxygen demand

The nurse understands that asystole can be caused by several conditions. Select all that apply.

Hypoxia Hypovolemia Hypothermia Acidosis Ventricular asystole is treated the same as pulseless electrical activity (PEA), focusing on high-quality cardiopulmonary resuscitation (CPR) with minimal interruptions and identifying underlying and contributing factors. The key to successful treatment is a rapid assessment to identify a possible cause, which is known as the "Hs and Ts": hypoxia, hypovolemia, hydrogen ion (acid/base imbalance), hypo- or hyperglycemia, hypo- or hyperkalemia, hyperthermia, trauma, toxins, tamponade (cardiac), tension pneumothorax, or thrombus (coronary or pulmonary).

The nurse is providing discharge instructions for a client with a newly implanted cardiac defibrillator. What statement made by the client indicates the need for further teaching?

I will report if I feel lightheaded and dizzy at my next doctor's appointment The clients with newly implanted devices are told to treat lightheadedness and dizziness as an emergency so these symptoms should be reported as an emergency. Handheld security devices may should be avoided because of the electromagnetic interference. MRI studies may deactivate the devise so they need to be avoided. The CPR training is recommended for family as an emergency backup.

Activity progression ICU? Activity progression step down? Activity progresison goal?

ICU- dangle or get up to chair Step down- up to chair for every meal and walking to bathroom Goal- ambulation 4x/day

IE in ICU? IE in step down?

ICU- every hour Step down- Q2hrs

How do we keep the PDA open after birth?

IV Prostaglandin E

A patient is scheduled for exercise nuclear imaging stress testing. The nurse explains to the patient that this test involves

IV administration of a radioisotope at the maximum heart rate during exercise to identify the hearts response to physical stress

Appropriate nursing care for a CHD child with dehydration and diarrhea?

IV fluids Low-flow oxygen Pulse oximetry Antipyretics Antiemetics Digoxin level Stool cultures Blood culture, CBC and electrolyte panel The patient's pediatric cardiologist should be notified of the admission

A patient with a history of myocardial infarction is scheduled for a transesophageal echocardiogram to visualize a suspected clot in the left atrium. What information should the nurse include when teaching the patient about this diagnostic study?

IV sedation may be administered to help the patient relax. Rationale: IV sedation is administered to help the patient relax and ease the insertion of the tube into the esophagus. Food and fluids are restricted for at least 6 hours before the procedure. Smoking and exercise are restricted for 3 hours before exercise or stress testing but not before TEE. Contrast medium is administered IV to evaluate the direction of blood flow if a septal defect is suspected.

When you have a baby dependent on a PDA for survival, what can the mom not take?

Ibuprofen- it will close the PDA Also should be worried about kidney damage in an already compromised baby

Why is hemodilution a concern post OHS?

Imbalanced F&E: excess fluid volume

What is the treatment of choice for ventricular fibrillation?

Immediate bystander CPR The treatment of choice for ventricular fibrillation is immediate bystander cardiopulmonary resuscitation (CPR), defibrillation as soon as possible, and activation of emergency services.

What are the types of thrombocytopenia?

Immune Thrombocytopenia Purpura (ITP)- primary and secondary Thrombotic Thrombocytopenia Purpura (TTP) Heparin Induced Thrombocytopenia (HIT)

Why does the patent ductus arteriosis close?

In response to high O2 and bradykinin

Why does the foramen ovale close?

In response to increased pressure in LA

What is mitral valve regurgitation?

Incomplete closure of the mitral valve that causes backward flow of blood from the LV to the LA

What is the pathophysiology of mitral valve regurgitation?

Incomplete valve closure🡪fluid moves back into L atria🡪 increase workload to maintain CO Acute= pressure to pulmonary bed🡪 pulmonary edema/cardiogenic shock. Chronic= LV dilation/hypertrophy, LA enlargement, decrease CO

MI- OHS complication

Increase in myocardial oxygen demand Decrease coronary artery or graft blood flow a/w vasospasm, hypotension, or embolism Cardiac enzymes drawn post-op (looking at troponins)

What effect does the blood flow with a PDA have on the lung?

Increased blood flow to lungs (similar to VSD) Excessive pulmonary blood flow

What is hydroxurea and how does it help with SCD?

Increased production of fetal hemoglobin (HbF), which normally is not seen after 6 mo of life. HbF decreases Hgb polymerization= decrease sickling and prolonging RBC life (decrease transfusion needs). Also reduces adhesions of RBC to endothelium. Can reduce the number of painful episodes and recurrence of ACS. SE: myelosuppression, monitor blood, no for pregnancy (fetal harm)

What are the two characteristics of the defect that can cause acyanotic CHD?

Increased pulmonary blood flow Obstruction of blood flow out of the heart

What two characteristic defects can cause acyanotic CHD?

Increased pulmonary pressure Obstruction to blood flow of the heart

When HF develops, the body tries to compensate through hypertrophy and dilation of the cardiac muscle plus stimulation of the SNS. What two mechanisms of the SNS increase CO?

Increases HR and increased afterload (SVR) d/t catecholamine release (SNS)

Children with Tetralogy of Fallot like a knee-chest position to relieve SOB. Why?

Increases preload and afterload Increases blood flow to the lungs If child is too small to squat, teach the parents how to hold the child w/ the knee-chest position

What are medications used for a PDA?

Indomethacin (prostaglandin inhibitor) Ibuprofen Both ar e preferred for pre-term infants Neither are super effective for full term infants

Activity intolerance CHD

Infant will tell you they are SOB by being restless Hyperextend their neck (head bobbing)- bad sign Flaccid when sleeping Infant will have difficulty feeding (pull away, unable to create suction, frequent pauses) Wants to curl up in a ball- trying to put themselves in the knee/chest position Lethargic/flaccid

What is a friction rub and what is the best way to hear it?

Inflamed surfaces of the pericardium rubbing against each other. You'll hear the rub with each beat of the heart Have the patient lean forward to hear it best

What is pericarditis?

Inflammation of the two layers (visceral and parietal) of the pericardium

What are the causes of hypertrophic cardiomyopathy?

Inherited disorder Chronic HTN

What happens to the LV in aortic stenosis?

Initially, pressure builds to maintain CO causing initial stretch and increase in CO Over time, the LV workload increases to maintain CO, causing hypertrophy and increased myocardial oxygenation/workload Hypertrophy leads to diastolic failure that can cause HF/pulmonary congestion Will also see pressure gradient differences (LV>aorta)

A client is treated in the intensive care unit (ICU) following an acute myocardial infarction (MI). During the nursing assessment, the client reports shortness of breath and chest pain. In addition, the client's blood pressure (BP) is 100/60 mm Hg with a heart rate (HR) of 53 bpm, and the electrocardiogram (ECG) tracing shows more P waves than QRS complexes. Which action should the nurse complete first?

Initiate transcutaneous pacing The client is experiencing a third-degree heart block. Transcutaneous pacing should be implemented first. A permanent pacemaker may be indicated if the block continues. Defibrillation is not indicated; third-degree heart block does not respond to atropine; a 12-lead ECG may be obtained, but is not completed first.

What arteries/veins are used for open heart procedures?

Internal mammary artery Radial artery Saphenous vein

Why is early detection for coarctation of the aorta important?

It can cause chronic high blood pressure in the patient

What are general signs and symptoms of thrombocytopenia?

It can range from mild petechiae (flat, red, small lesions that do not blanch) often found on lower extremities of ambulatory people) to severe hemorrhage Purpura is a coalescence of petechiae

What is treatment for VSD?

It may close naturally during the 7 years of life Usually treated when symptomatic Large VSD may need surgery (sutures/patch) Palliative: pulmonary artery banding (narrows pulmonary artery and reduces blood flow/pressure into the lungs)- temporary and removed when child is older

What effects does aortic stenosis have on the afterload?

It will increase the afterload (what the LV has to pump against)

What are the four defects in Tetralogy of Fallot?

Large VSD Pulmonic valve stenosis Overriding aorta RV hypertrophy

What is splenic sequestration?

Large number of sickle cells get trapped in the spleen and cause it to suddenly get large. Symptoms: sudden weakness, pale lips, fast breathing, extreme thirst, abdominal pain on left side, tachycardia

Advantages of mechanical valve?

Last the life of the patient Usually used in younger patients

The nurse is analyzing the cardiac rhythm of a client with a pacemaker and notes the QRS complex is absent after pacer spike. The nurse knows that reading can be caused by which of the following factors?

Lead wire fracture A pacemaker is an electronic device that provides electrical stimuli to the heart muscle. Pacemakers are usually used when a client has a permanent or temporary slower-than-normal impulse formation, or a symptomatic AV or ventricular conduction disturbance. They may also be used to control some tachyarrhythmias that do not respond to medication. When analyzing the function of the pacemaker, a loss of capture is indicated by a QRS complex not following the pacer spike. This could be caused by lead dislodgment, lead wire fracture, catheter malposition, a depleted battery, or myocardial ischemia. A total absence of pacer spikes indicates a loss of pacing. Pacer spikes occurring at preset intervals indicates undersensing. Pacer spikes not occurring at present intervals indicates oversensing.

What are nursing action you can do to help with pericarditis?

Lean forward- feels better than laying flat Treat their pain and decrease inflammation (NSAIDS) Watch for potential complications Keep patient on bed rest with HOB to 45 degrees

Which side of the normal (adult) heart is considered the high pressure side and why?

Left side Left side has to pump into the body, whereas the right side only has to pump into the lungs

What occurs with blood flow in VSD?

Left to right shunt, causing increased pulmonary pressure and increased fluid in the lungs Fall in CO and changes in regional circulation Leads to RAAS and SNS -> vasoconstriction, sodium/water reabsorption, and cardiac remodeling

RR CHD

Listen for a minute Increased RR (tachypnea) >60 Look for signs of hypoxemia (gasping, gruting, retractions, head bob; dry or moist cough) When you start to hear rales/crackles- you're in trouble (increased pulmonary circulation and decreased lung compliance that has lead to pulmonary edema)

The blood pressure of an older adult patient admitted with pneumonia is 160/70 mm Hg. What is an age-related change that contributes to this finding?

Loss of elasticity in arterial vessels Rationale: An age-related change that increases the risk of systolic hypertension is a loss of elasticity in the arterial walls. Because of the increasing resistance to flow, pressure is increased within the blood vessel, and hypertension results. Valvular rigidity of aging causes murmurs, and decreased adrenergic sensitivity slows the heart rate. Blood pressure is not raised. Increased parasympathetic activity would slow the heart rate.

What situations can trigger sickling of the RBCs?

Low oxygen Viral/bacterial infection High altitude Emotion/physical stress Surgery/blood loss Dehydration Acidosis Increased plasma osmolality Decreased plasma volume Temperature extremes

Why would inadequate oxygenation be a concern for a SCD patient?

Low oxygen (hypoxemia) is a trigger for sickling and can cause a crisis

A client with sickle cell disease is treated for a thrombotic event. Which organs or body systems does the nurse recognize as being at greatest risk for thrombosis in a client with sickle cell disease? Select all that apply.

Lungs Central Nervous System Spleen Explanation Any organ can be the site of a thrombotic event in sickle cell disease; however, the lungs, central nervous system, and the spleen are at greatest risk due to these areas having slower circulation. The liver is often involved in sequestration in adults, and hemolysis may occur. Anemia affects the heart.

What are the potential complications of OHS? (10)

MI Dysrhythmias HF Cardiac Tamponade Bleeding Thromboembolism Neurological dys Impaired renal function Pneumothorax Atelectasis

What is dilated cardiomyopathy?

Marked cardiomegaly with ventricular dilation, impaired systolic function, and left atrial hypertrophy Decreased CO, decreased EF, stasis of blood in the left ventricle Walls do not become hypertrophic d/t rapid destruction of cells, causing it to get wider Mitral valve becomes incompetent

What are the post-op complications d/t the OHS? (3)

Mechanical trauma by the bypass machine Hemodilution Fluid shifts

A child with a bleeding disorder needs to wear a

MedicAlert bracelet

What can affect the excitability of the cells?

Medications Hormones Oxygenation Autonomic nervous system

What is the relative refractory period?

Middle of Phase 3 to beginning of Phase 4 Myocardial cell can receive another impulse causing depolarization, even though the cell has not fully recovered

What is the process for an open heart surgery?

Midline sternotomy incision to open and expose the heart Harvesting arterial and/or vein grafts Bypass machine Cross clamp aorta, cool heart, and cardioplegia solution Put in pacing wires and chest tubes

What is HIT Type I?

Mild transient drop in platelets d/t direct effect of heparin on platelets Platelets return to normal with continued heparin administration

What causes mitral regurgitation? (6)

Mitral valve prolapse MI causing damage to valve or chordae tendineae Rheumatic heart disease Mitral annular calcification Ischemic cardiomyopathy A/w genetic connective tissue disorders Marfans and Ehlers Danlos

A client with type 2 diabetes and persistent atrial fibrillation is prescribed atenolol. Which actions will the nurse take when providing the medication to the client? Select all that apply.

Monitor heart rate monitor blood pressure monitor blood glucose level Explanation Beta-blockers are classified as Class II antiarrhythmic medications. This classification of medication decreases automaticity and conduction to treat atrial arrhythmias, however, it has the potential for adverse effects such as bradycardia, therefore the heart rate should be monitored. Because it can cause hypotension, the blood pressure should be assessed. The medication also affects blood glucose level. Since the client has type 2 diabetes, the blood glucose level should be monitored. This medication does not affect liver or renal function.

What are the causes of restrictive cardiomyopathy?

Myocardial fibrosis Glycogen deposition Amyloidosis (protein/starch) deposition in organs and tissues

Class III antidysrhythmics- common side effects (8)

N/V Hypotension Photophobia (blue skin) Corneal microdeposits Pulmonary inflitrates Pulmonary fibrosis Bradycardia GI upset These drugs are known for their side effects

What is aortic stenosis?

Narrowing of aortic valve, causing the forward flow of blood to become impaired Usually caused by thickening of the valve leaflets Located between LV and aorta

Adenosine (Adenocard)- mechanism of action

Naturally occurring hormone that inhibits cardiac pacemaker cells Slows conduction through the AV and SA nodes Used for SVT

What are working cells?

Need an impulse to travel through the cell to depolarize and contract Most of the muscle cells in the heart

What is the medical and nursing management of hypertrophic cardiomyopathy?

Needs to improve ventricular filling by decreasing contractility of the heart and improving filling time Beta blocker or CCB Surgery may be an option

Does patient need to be on Coumadin with a TAVR?

No

Why is the aorta cross-clamped?

No blood can flow through the heart

Would peripheral/facial edema be a bad sign?

No necessarily- infants tend to hold onto fluid and may puff up like a marshmallow

How is ITP diagnosed?

No test that shows sensitivity or specificity for ITP Requires that other causes of thrombocytopenia be ruled out Use history, physical exam, med list, and some lab tests Found a source

Can patient with a history of HIT ever receive heparin again?

No. The cannot receive any form of heparin, including LMWH

Are platelet tranfusion helpful for HIT patients?

No. They may enhance thromboembolic events

School age activity CHD

Not active at recess Can't keep up with their peers

Should we give a patient with aortic stenosis nitro?

Not really, this will cause a further drop in BP and the patient may pass out

What are nursing actions we can do for patients with Tetralogy of Fallot?

O2 at 100% IV med- Morphine Fluid bolus (10cc/kg and reevaluated after 1 bolus) Give a high calorie formula to help get adequate nutrition

How does decreased pulmonary blood flow effect blood flow?

Obstruction of pulmonary blood flow and an anatomic defect between the right and left side Right-to-left shunt

What is the problem with Tetralogy of Fallot?

Obstruction of pulmonary blood flow and an anatomic defect between the right and left side causes blood to shunt right to left Deoxygenated blood is mixing with oxygenated blood

cardiac physical examination

Obtain vital signs including bilateral BPs and orthostatic (postural) BPs and HRs prior to the physical examination. During physical examination, assess the skin, neck veins, capillary refill, thorax, epigastric area, and lungs. Auscultate the carotid arteries, abdominal aorta, and femoral arteries. • When listening to the heart sounds, note S1, S2, and any murmurs, clicks, pericardial friction rubs, or extra heart sounds (S3 or S4).

If the arteries become plugged with thrombi (clots of fibrin, platelets, and cholesterol), what can happen to the body's tissues?

Oxygen is prohibited from reaching the tissues, which may result in death

What are the effects of blood to the body in acyanotic CHD?

Oxygenated blood flows to the body

0.06 to 0.12 seconds

P wave

Measured from beginning of P wave to beginning of QRS complex

PR interval

0.12 to 0.20 seconds

PR interval normal time

What are the complications with SCD? (big card)

Pain from blood cells clogging small vessels and impeding blood flow Infection Hand-Foot syndrome Eye disease/vision loss Acute Chest Syndrome Stroke/DVT/PE Anemia Splenic Sequestration Leg Ulcers Renal disease Damage to body organs d/t impeded blood flow Priapism

What other drugs can help with SCD (from case study in class)?

Pain managment (oxy/narcotics) TCA for adjuvant pain (Norpramin) Folic acid to help promote RBC

Which action should the nurse implement with auscultation during a patient's cardiovascular assessment?

Palpate the radial pulse while auscultating the apical pulse. Rationale: To detect a pulse deficit, simultaneously palpate the radial pulse when auscultating the apical area. The diaphragm is more appropriate than the bell when auscultating S1 and S2. A sitting or side-lying position is most appropriate for cardiac auscultation. It is not necessary to ask the patient to hold their breath during cardiac auscultation.

Prior to surgical correction of the Transposition of the Great Arteries, what is required to provide oxygenated blood into circulation?

Patient Ductus Arteriosus or VSD or ASD (foramen ovale) This allows the systemic and pulmonary blood to mix

Disadvantages of mechanical valve?

Patient must be on Coumadin for the rest of theif life d/t risk of clots forming They can also be noisy

Why might a patient with a VSD present with signs and symptoms a few week after birth?

Patients with a large defect may not present until 4-6 weeks after birth d/t activity

What is the procedure used to treat this complication?

Pericardiocentesis to draw off the fluid Use an EKG to insert needle- ST elevations will indicate the heart muscle has been hit

What are the clinical manifestation for tricuspid valve disease?

Peripheral edema Ascites Hepatomegaly Diastolic low-pitched murmur

What is the absolute refractory period?

Phase 0 to the beginning of Phase 3 Myocardial cell cannot receive another impulse to cause depolarization of cell

What are the phases of a working cell AP?

Phase 0-4

A nurse is giving discharge instructions to the parents of a newborn with a congenital heart disorder. What should the nurse instruct the parents to do in the event that the child becomes cyanotic?

Place him in a knee-chest position Before parents leave the hospital with a newborn who has a congenital heart disorder, be certain they have the name and number of the health professional to call if they have a question about their infant's health. Review with them the steps to take if their child should become cyanotic, such as placing the child in a knee-chest position. "Hands on" CPR is not recommended for children as it is for adults. Remind parents that children with many types of congenital heart disorders or rheumatic fever need prophylactic low-dose aspirin therapy to avoid blood clotting; although it is becoming a controversial practice, antibiotic therapy such as oral amoxicillin may be prescribed before oral surgery.

Bleeding- OHS complication

Platelet function decrease a/w damage to platelets by bypass machine Incomplete neutralization of heparin used to prime bypass machine Anticoag admin Disruption of suture line or inadequate surgical hemostasis

How is HIT diagnosed?

Platelets decrease C serotonin release assay Enzyme-linked immunoassay (ELISA) for PF4-heparin complex

What are pacemaker cells

Possess automaticity and the ability to generate an impulse SA node, AV, node, Bundle of His, bundle branch system, and Purkinje system

What is Phase 3?

Potassium moves out of the cell

HF- OHS complication

Preexisting myocardial dilation or hypertrophy and/or decreased CO a/w damage and stress of the heart muscle Manipulation of the heart itself can cause this Fluid shift on the third days causes an increase in volume (Listen to lungs and listen for crackles it the bases) May develop an S3 heart sound

Coarctation of the aorta can lead to HF because it causes?

Pressure overload (increased afterload)

Why is IE and TCDB used post OHS?

Prevents atelectasis (lung were not used during surgery because of bypass) Make sure to brace incision against heart pillow before TCDB

What are the classifcations of cardiomyopathies?

Primary (unknown cause) Secondary- caused by something else (ischemia, alcohol, infections, drug abuse, pregnancy, genetic, HTN, muscular dystrophy)

What is aortic regurgitation?

Primary disease of the valve leaflets, aortic root, or both Causes blood to flow backward from the aorta to the LV

Class III antidysrhythmics- effects on EKG

Prolong PR and QT intervals Widen QRS

What are SCD children given to help prevent infection?

Prophylactic penicillin until age 5

The nurse in an intensive care unit is caring for a client who requires blood work to assess for changes in blood coagulation due to heparin therapy. Which test should the nurse expect to see prescribed for this value to be assessed?

Prothrombin time (PTT)

What is the Transposition of the Great Arteries?

Pulmonary artery leaves the LV and the aorta exits the RV with no communication between the systemic and pulmonary circulations

A nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect?

Pulmonary embolism

Which anatomic feature of the heart directly stimulates ventricular contractions?

Purkinje fibers Rationale: The Purkinje fibers move the electrical impulse or action potential through the walls of both ventricles triggering synchronized right and left ventricular contraction. The sinoatrial (SA) node initiates the electrical impulse that results in atrial contraction. The atrioventricular (AV) node receives the electrical impulse through internodal pathways. The bundle of His receives the impulse from the AV node.

Depolarization from the AV node throughout ventricles

QRS interval

time of depolarization and repolarization of ventricles

QT interval

Pneumothorax- OHS complication

R/t air in pleual space a/w pleua opened during surgery (internal mammary artery) Usually seals up with a chest tube

What is the patho for tricupsid stenosis?

RA enlargement and elevated systemic venous pressures

Why is anemia common with patient who have SCD?

RBC die quickly (15-20 days)

What does the mechanical trauma by the bypass machine do the the patient?

RBC hemolysis -> decreased RBC and Hct -> decreased O2 carrying capacity Platelet damage -> decrease # platelets -> increased RF bleeding Leukocyte damage -> decrease WBC -> decreased immune response

What is the patho for pulmonic stenosis?

RV HTN and hypertrophy

What is cardiac tamponade?

Rapid fluid accumulation in the pericardial sac the impairs the heart from contracting and relaxing in a normal fashion

What are the benefits of using the robot for mitral regurgitation surgery?

Recovery faster than OHS, less risk of infection, return to normal activities faster, and better clinical outcomes

The nurse is reviewing a health care provider's prescriptions for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? Select all that apply.

Restrict fluid intake Give meperidine, 25 mg intravenously, every 4 hours for pain Rationale: Sickle cell anemia is one of a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell; insufficient oxygen causes the cells to assume a sickle shape, and the cells become rigid and clumped together, obstructing capillary blood flow. Oral and intravenous fluids are an important part of treatment. Meperidine is not recommended for a child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. The nurse would question the prescription for restricted fluids and meperidine for pain control. Positioning for comfort, avoiding strain on painful joints, oxygen, and a high-calorie and high-protein diet are also important parts of the treatment plan

What is the pathophysiology of aortic regurgitation?

Retrograde flow from the aorta to LV🡪 compensation via hypertrophy/dilation 🡪 decrease contractility 🡪 increase volume in LA/pulmonary 🡪 pulmonary HTN/R side HF

What causes tricupsid valve diseases?

Rheumatic fever and IV drug abuse

What causes mitral valve stenosis?

Rheumatic heart disease Congenital stenosis, lupus

What are services offered by ACHD programs?

Routine or advanced imaging Cardiac anesthesia guidance HF management and transplantation evaluation Support for young patients transitioning from pediatric and adult care Contraception and family planning Family and patient support and guidance Career and financial guidance

Each normal heartbeat is initiated by which of the following?

SA node

order of sequence the path of the action potential along the conduction system of the heart

SA node Right and left atrial cells internodal pathways AV node Bundle of His right and left bundle branches purkinje fibers ventricular cells

each electrical impulse starts at the

SA node (in the right atrium), travels to the AV node (at the atrioventricular junction), through the bundle of His, down the right and left bundle branches (in the ventricular septum), and ends in the Purkinje fibers.

A P wave on an ECG represents an impulse arising at the

SA node and depolarizing the atria Rationale: The first wave, P, begins with the firing of the sinoatrial (SA) node. It represents depolarization of the fibers of the atria.

Signs and symptoms of VSD?

SOB Pale skin Increased RR and HR Frequent respiratory infections Slow growth Watch for FVO from giving too much fluid

What is the pathophysiology of mitral valve stenosis?

Scarring of valves/leaflets 🡪 contractures/adhesions 🡪 "fish mouth" valve shape 🡪 pressure difference between L atria and L ventricle 🡪 atria pressure increase backing up volume/pressure into pulmonary system can go to R ventricle. Increase r/f atrial fib

What are "Tet" spells and when are they seen?

Seen when the infants oxygen requirements exceed the blood supply (usually after crying, pooping, or feeding) Have a hard time breathing Become very tired and limp Not responsive to parent's vice or touch Become very fussy Pass out Bluish color during episode of crying or feeding

What happens in a sickle cell crisis?

Severe, painful, acute exacerbation of RBC sickling, causing a vaso-occlusive crisis. As blood flow is impaired by the sickled cells, vasospasms occur, further restricting blood flow. The severe capillary hypoxia causes changes in membrane permeability, leading to plasma loss, hemoconcentration, thrombi, and further circulatory stagnation. This will lead to tissue ischemia, infarction, and necrosis from lack of O2. Shock may develop d/t severe O2 depletion. Can go into organ failure

What is the medical and nursing management of dilated cardiomyopathy?

Similar to treatment of patient with chronic HF Remove source of cardiomyopathy End stage requires heart transplant if patient is a candidate

What position should the nurse place the patient in to auscultate for signs of acute pericarditis?

Sitting and leaning forward Rationale: A pericardial friction rub indicates pericarditis. To auscultate a pericardial friction rub, the patient should be sitting and leaning forward. The nurse will hear the pericardial friction rub at the end of expiration.

Why is the heart cooled down?

Slows down the metabolic process, decreasing oxygen requirements

Class I antidysrhythmics- mechanism of action

Slows impulse conduction in the atria, ventricules, and His-Purkinje fibers

Why are Blake tubes used post op for an OHS?

Small tubes w/ one-way valves like Jackson-Pratt Left in longer than chest tubes to help with continuing drainage around pericardial sac

Murmurs CHD

Smaller the hole, the bigger the murmur Best location is along sternal border Listen during activity and rest

Problems with the TAVR?

Sometimes the valve does not fit We don't know how long they will last

What are the causes of dilated cardiomyopathy?

Sources that cause diffuse inflammation and rapid degeneration of the tissue. Ischemia Infectious myocarditis Alcohol Drugs (ex: cocaine, chemo) Diabetes ↓ nutrition Pregnancy

What patient teaching should be included for patients with SCD?

Stay hydrated (6-8 daily) and watch for signs of dehydration Avoid high altitudes and extremes in temperature (hot/cold) Immunizations and watch for signs of infections and treat infections promptly Screening for retinopathy should begin at 10 Avoid strenuous exercise Avoid stressful situations Take your hydroxyurea to prevent crisis situations

The nurse assessing a patient with pericardial effusion at 0800 notes the apical pulse is 74 and the BP is 140/92. At 1000, the patient has neck vein distention, the apical pulse is 72, and the BP is 108/92. Which action would the nurse implement first?

Stay with the patient, use a calm voice, and ask for assistance via call light Universal Misconception Explanation The nurse stays with the patient and continues to assess and record signs and symptoms while intervening to decrease patient anxiety. The pulse pressure is narrowing, and the patient is experiencing neck vein distention, indicative of rising central venous pressure. After reaching assistance via the call light from the patient's beside, the nurse notifies the physician immediately and prepares to assist with diagnostic echocardiography and pericardiocentesis. A left lateral recumbent position is used when administering enemas. Morphine would be given to someone who may be experiencing a myocardial infarction, not cardiac tamponade.

What is the pathophysiology of aortic stenosis?

Stiffening of the leaflets, blocks blood from LV to the aorta during systole🡪 LV hypertrophy🡪increase O2 demand/workload🡪decrease CO🡪 decreased tissue perfusion, pulm HTN, HF

What are Class I antidysrhythmic drugs?

Suppression of fast sodium channel (blocks sodium channels) Used for atrial and ventricular dysrhythmias Lots of drugs (we don't need to know the names)

Treatment for Tetralogy of Fallot?

Surgery as soon as possible- OHS that requires medial sternotomy and cardiopulmonary bypass Timing is based on the baby's weight Can also do a palliative shunt to increase pulmonary blood flow and increase O2 saturation

Treatment for coarctation of the aorta?

Surgery to remove the narrowed part of the aorta Small- remove and reconnect Large- remove and place patch and connect Balloon angioplasty/stent to widen the narrowing in older infants and children (through the groin)

Other treatment for PDA?

Surgical diversion or ligation of patent vessel Catheter or open chest Coils to PDA

Pulmonary valve disorder pulmonary stenosis pulmonary insufficiency

Symptoms Asymptomatic in a mild condition Asymptomatic in mild condition Dyspnea Dyspnea Fatigue Fatigue Syncope Syncope Signs of right ventricular failure, including ascites, hepatomegaly, peripheral edema Signs of right ventricular failure, including ascites, hepatomegaly, peripheral edema Systolic thrill heard at left sternal border Systolic thrill heard at left sternal border Interventions Refer to the section on repair procedures.

When are symptoms seen with Tetralogy of Fallot?

Symptoms occur immediately- usually in the first week of life

What age-related cardiovascular changes should the nurse assess for when providing care to an older adult patient? (Select all that apply.)

Systolic murmur Diminished pedal pulses Decreased maximal heart rate Increased recovery time from activity Rationale: Well-documented cardiovascular effects of the aging process include valvular rigidity leading to systolic murmur, arterial stiffening leading to diminished pedal pulses or possible increased blood pressure, and an increased amount of time that is required for recovery from activity. Maximal heart rate tends to decrease rather than increase with age related to cellular aging and fibrosis of the conduction system.

A patient is being admitted for valve replacement surgery. Which assessment finding is indicative of aortic valve stenosis?

Systolic murmur Rationale: The turbulent blood flow across a diseased valve results in a murmur. Aortic stenosis produces a systolic murmur. A pulse deficit indicates a cardiac dysrhythmia, most commonly atrial fibrillation. Right-sided heart failure may cause distended neck veins. Splinter hemorrhages occur in patients with infective endocarditis.

0.16 seconds

T wave

Repolarization of the ventricles

T wave

What disease processes contribute to chronic heart failure?

Tachyarrhythmias Valvular disease Renal failure

Cardiac dysrhythmias- OHS complication (4)

Tachycardia A-fib/flutter Bradycardias Altered acid/base and electrolytes

Signs and symptoms that might be seen with a VSD?

Tachycardia- dominate mechanism for infants attempt to improve CO and oxygen delivery Lethargy d/t decreased CO Poor feeding/eating Pulmonary congestion (Tachypnea, rales, crackles, mild cyanosis, dyspenea, SOB) Cold extremities d/t systemic vasoconstriction Galloping rhythm large left to right shunt Diaphoresis during feeding because the child's heart is not able to keep up with demands of increased metabolic requirements Urinary retention d/t decreased renal perfusion Decreased O2 sat d/t pulmonary edema

S/S to bring child back to hospital

Tachypnea >60 Circumoral cyanosis

BP CHD

Take in one arm and at least one leg- look at trends Increased arms and decreased legs in coarctation of aorta

What CHD defects can cause decreased pulmonary blood flow? (2)

Tetralogy of Fallot Tricupsid atresia

What is an appropriate explanation for the nurse to give to a patient about the purpose of intermittent pneumatic compression devices after a surgical procedure?

The devices provide compression of the veins to keep the blood moving back to the heart. Rationale: Intermittent pneumatic compression devices provide compression of the veins while the patient is not using skeletal muscles to compress the veins, which keeps the blood moving back to the heart and prevents blood pooling in the legs that could cause deep vein thrombosis. The warmth is not important. Blood flow to the legs is not maintained. Blood pressure is not decreased with the use of intermittent sequential compression stockings.

What is keeping the baby alive with Tetralogy of Fallot?

The large VSD- we want to make it bigger

What cause Immume Thrombocytopenia?

The lifespan of the platelet is reduced d/t autoantiboides against the platelet antigens IgG autoantibodies produced by B cells react with the glycoproteins on the platelet membrane The IgG coated platelets are destroyed by macrophages in the spleen, resulting in thrombocytopenia Genetic factors and acquired events may disrupt the immune system, leading to ITP

the right side of the heart receives venous blood from

The right side of the heart receives venous blood from the body (via the vena cava) and pumps it to the lungs where it is oxygenated. Blood returns to the left side of the heart (via the pulmonary veins) and is pumped to the body via the aorta.

Why is VSD classified as an acyantoic heart defect?

There is no mixing of unoxygenated blood into the systemic circulation

Why is the Transposition of the Great Arteries considered cyanotic?

There is unoxygenated blood in systemic circulation

What is the disadvantage of using the saphenous vein?

They don't last very long (only 10 years) Must be turned upside down to make sure the blood flows correctly

While auscultating the patient's heart sounds with the bell of the stethoscope, the nurse hears a ventricular gallop. How should the nurse document what is heard?

Third heart sound (S3) Rationale: The third heart sound is heard closely after the S2 and is known as a ventricular gallop because it is a vibration of the ventricular walls associated with decreased compliance of the ventricles during filling. It occurs with left ventricular failure. Murmurs sound like turbulence between normal heart sounds and are caused by abnormal blood flow through diseased valves. The S4 heart sound is a vibration caused by atrial contraction, precedes the S1, and is known as an atrial gallop. The normal S1 and S2 are heard when the valves close normally.

A mother asks why her infant with a cyanotic heart defect turns blue. What is the nurse's best explanation?

This is due to a decreased amount of oxygen to the peripheral tissue Explanation: Cyanosis associated with certain congenital heart defects is due to the body naturally compensating and decreasing the amount of oxygen to the peripheral tissue. This keeps the oxygen with the vital organs to sustain life. The lack of oxygen is not in the brain; it is in the systemic flow of the body. Cyanosis is a common finding with these types of heart defects and, in general, does not usually need immediate surgery nor is it a sign of heart failure.

What is TTP?

Thrombotic microangiopathy resulting from severe deficiency of ADAMTS13 Often a/w hemolytic-uremic syndrome

What is a balloon valvuloplasty and transcathether aortic valve replacement (TAVR)?

Tissue valve that is inserted through the femoral artery

Adenosine (Adenocard)- side effects (6)

Transient dyspnea Flushing Bradycardia Hypotension Facial flushing Chest discomfort

What CHD defects can cause mixed blood flow? (4)

Transposition of great arteries Total anomalous pulmonary venous return Truncus arteriosus Hypoplastic left heart

Thromboembolism- OHS complication

Trauma to blood vessels (cross clamping aorta, cannulation of vena cava and aorta, and grafting) Venous stasis w/ decreased CO and decreased activity Hypercoagulability a/w release of tissue thromboplastin (trauma) Think Virchow's Triad Formation of microemboli in atria a/w a-fib Thrombi forming on prosthetic valve

What is the medical and nursing management for restrictive cardiomyopathy?

Treat underlying disease Improve diastolic filling Transplant possible

What is the treatment for TTP?

Treat underlying disorder or remove causative agent Plasma exchange or plasmapheresis- provide ADAMTS13 enzyme and appropriate vWF and removes the large vWF bound to platelets Done daily until platelet count returns to normal and hemolysis has stopped Corticosteroids If patient cannot have plasma exchange- immunosuppresive drugs are given (Rituximab) to decrease IgG response to ADAMTS12 Splenectomy may be considered

What type of valve is the aortic valve?

Tricuspid (three leaflets)

The nurse is performing an assessment for a patient with fatigue and shortness of breath. Auscultation reveals a heart murmur. What does this assessment finding indicate?

Turbulent blood flow across a heart valve Rationale: Turbulent blood flow across the affected valve results in a murmur. A murmur is not a direct result of variances in blood viscosity, conductivity, or friction between the heart and myocardium.

What is idiopathic hypertrophic subaortic stenosis?

Type of cardiomyopathy seen in young athletes who suddenly collapse d/t cardiac arrest while playing a sport May have no symptoms prior When HR increase, thickened ventricle can obstruct outflow through the aortic valve

What are the effects of blood to the body in cyanotic CHD?

Unoxygenated blood flows to the body

A 1-year-old with tetralogy of Fallot turns blue during a temper tantrum. What will the nurse do first?

Use a calm, comforting approach and place the child in knee-to-chest position Explanation: Tetralogy of Fallot is a cyanotic heart defect. Hypercyanosis can develop suddenly. The symptoms are increased cyanosis, hypoxemia, dyspnea, and agitation. The nurse should use a calm, comforting approach with the child and place child in the knee-to-chest position. This position is the first priority of the child with tetralogy of Fallot. This position increases pulmonary blood flow by increasing systemic vascular resistance. The additional interventions for a hypercyanotic spell are to administer oxygen and give morphine, IV fluids, and propranolol. A child will not understand to calm down and cannot be expected to listen during a temper tantrum. Assessing the child's heart rate and respirations are not priority. Perfusion is priority for this client at this time.

How does hemodiluation occur post OHS?

Use of bypass priming solution ADH secretion from trauma/pain, causing the body to hold onto water Non-pulsatile/constant (no pulsing of systolic/diastolic) that is sensed as low blood flow by the kidneys. This low renal blood flow activates the renin - angiotensin -aldosterone (holds onto sodium and water)

Atropine- mechanism of action

Used for symptomatic bradycardia Vagolytic- breaks vagal stimulation to SA node Will not work on heart block

Why are chest tubes used post op for an OHS?

Used to collect any surgical drainage Usually removed 1-2 days post OHS If there is a sudden gush of blood, patient may have blown a suture and may need to go back to surgery Medicate prior to removal (they are just pulled out)

Why is a RIJ Central line used post op for an OHS?

Usually a triple lumen LA line to monitor pressure to watch volume status

When do S/S for coarctation of the aorta appear?

Usually a week after birth PDA needs to close

What are the clinical manifestations of mitral valve prolapse?

Usually benign and asymptomatic. A murmur louder during systole. Chest pain, dyspnea, palpitations, syncope that don't respond to antianginal tx, activity intolerance, holosystolic murmur

What are the clinical manifestations of aortic stenosis?

Usually develop when the valve is 1/3 of the size Angina/syncope/exertional dyspnea CP and syncope are the classic signs

What is treatment for Transposition of the Great Arteries?

Usually repaired at 7 days and off all cardiac meds at 1 year IV prostaglandin E to keep PDA open until surgery Balloon atrial septostomy to increase mixing by opening foramen ovale Arterial switch- transecting the great arteries and anastomosing the main pulmonary artery to the proximal aorta and anastomosing the ascending aorta to the proximal pulmonary artery. Coronary arteries are switched to create a new aorta If treatment is not completed, the infant will die within months

What is the surgical management of mitral regurgitation?

Valve repair (annuloplasty ring to narrow the regurgitant valve) Valve replacement (can be done by minimally invasive or DaVinci robot)

What treatment is recommended for aortic stenosis?

Valve repair or Valve replacement TAVR is also an option

Sickle cell anemia assessment of the crisis

Vaso-Occlusive Crisis Caused by stasis of blood with clumping of cells in the microcirculation, ischemia, and infarction Manifestations: Fever; painful swelling of hands, feet, and joints; and abdominal pain Splenic Sequestration Caused by pooling and clumping of blood in the spleen (hypersplenism) Manifestations: Profound anemia, hypovolemia, and shock Hyperhemolytic Crisis An accelerated rate of red blood cell destruction Manifestations: Anemia, jaundice, and reticulocytosis Aplastic Crisis Caused by diminished production and increased destruction of red blood cells, triggered by viral infection or depletion of folic acid Manifestations: Profound anemia and pallor

Atelectasis- OHS complication

Ventilator is halted during bypass so there is a lack of air moving in and out of the lung Ventilator post OHS is set for larger tidal volumes and PEEP to keep airways open

What CHD defects can cause increased pulmonary blood flow? (4)

Ventricular Septal Defect Atrial Septal Defect Patent Ductus Arteriosus Atrioventricular canal

What causes pericarditis? (4)

Viral Neoplastic Uremic Connective tissue DO

What are assessment finding for CHD?

Vital sign changes Heart murmurs Cyanosis Activity intolerance Growth/skill retardation History of frequent respiratory infection

What are the 4 characteristics of CHD that can lead to HF?

Volume overload Pressure overload Decreased contractility High cardiac output demands

A monitor technician on the telemetry unit asks a charge nurse why every client whose monitor shows atrial fibrillation is receiving warfarin. Which response by the charge nurse is best?

Warfarin prevents clot formation in the atria of clients with atrial fibrillation Blood pools in the atria of clients with atrial fibrillation. As the blood pools, clots form. These clots can be forced from the atria as the heart beats, placing the client at risk for stroke. Warfarin is ordered in most clients with atrial fibrillation to prevent clot formation and decrease the risk of stroke, not to control heart rate. Digoxin is typically ordered to control heart rate in atrial fibrillation. Atrial fibrillation doesn't typically progress to a lethal arrhythmia such as ventricular fibrillation.

What can happen if we give a patient with SCD packed red blood cells to quickly?

We can cause fluid volume overload (these patients usually have renal failure). If giving more than one unit, give with Lasix in between (S/S: crackles, SOB, increased RR, bounding pulses, increased BP) Also watch for signs of fluid volume deficit after. If they pee too much off, we can put them in a deficit and trigger further sickling Always watch potassium if giving diuretic

Discharge interventions for VSD?

Weigh diaper to monitor fluid levels Daily weights Shorter, more frequent feeding to decrease energy expenditure every 3 hours Widen hole on the bottle to help the child not have to work as hard Fortifying milk/high calorie Get an at home O2 sensor

The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output?

Weighing the diapers

A child with a heart problem but no diagnosis- what would be helpful questions/historical data?

What is the actual cardiac diagnosis of the child? Is there a history of any cardiac surgery? Is the child normally cyanotic, how do past episodes compare with the present one? What is the child's normal oxygen saturation? What medications, if any, is the child taking? How many doses of the medication were missed? Has he been exposed to anyone with a history of vomiting and diarrhea? How many, and how large, were the stools that the child had? When did he last urinate?

Why is ventilator used post op for an OHS patient?

When patient put on bypass, the ventilator gets shut off. Because lungs are not being used, atelectasis can occur during surgery Usually on the ventilator for 4-6 hours post surgery, but maybe longer Monitor ABGs Positive end expiratory pressure to open the lungs up

What is full excitability in a working cell?

When the cells has fully recovered (Na and K back in the right places) and ready for the next impulse

Preschooler activity CHD

Will like to sit and play quiet games

What is the management of mitral valve prolapse?

Will need valve surgery if severe

A nurse is preparing to teach a group of women in a community volunteer group about heart disease. What should the nurse include in the teaching plan?

Women are more likely to have noncardiac symptoms of heart disease. Rationale: Women often have atypical angina symptoms and nonpain symptoms. Women experience the onset of heart disease about 10 years later than men. Women are often more ill on presentation and delay longer in seeking care than men.

What are the types of cardiac cells?

Working cells Pacemaker cells

management of dysrhythmias cardioversion postprocedure interventions

a. Priority assessment includes ability of the client to maintain the airway and breathing. b. Resume oxygen administration as prescribed. c. Assess vital signs. d. Assess level of consciousness. e. Monitor cardiac rhythm. f. Monitor for indications of successful response, such as conversion to sinus rhythm, strong peripheral pulses, an adequate BP, and adequate urine output. g. Assess the skin on the chest for evidence of burns from the edges of the pads.

when caring for a patient after a cardiac catheterization with coronary angiography, which finding should be of most concern to the nurse?

absence of pulses distal to the catheter insertion site an absence of pulses distal to the catheter insertion site indicates that clotting is occluding blood flow to the extremity and is an emergency that requires immediate medicall attention. Some swelling an pain at the site are expected but the site is also monitored for bleeding and a pressure dressing or compression device may be applied hives may occur as a result of iodine sensitivity and will require treatment but the priority is the lack of pulsed

hypertension stroke volume factor and cardiac output

afterload ↑ cardiac output ↓

Throbembolism can be a problem following a valve replacement with a mechanical prosthetic valve and lifetime.....

anticoagulant therapy is required

cardiac output is the amount of

blood pumped by each ventricle in 1 minute. It is calculated by multiplying the amount of blood ejected from the ventricle with each heartbeat (stroke volume [SV]) by the heart rate (HR) per minute: CO = SV HR.

What is the function of the coronary arteries?

bring oxygenated blood to the myocardium

Which complication of cardiac surgery occurs when fluid and clots accumulate in the pericardial sac, which compresses the heart, preventing blood from filling the ventricles?

cardiac tamponade Explanation Cardiac tamponade is fluid and clot accumulation in the pericardial sac, which compresses the heart, preventing the blood from filling the ventricles. Fluid overload is exhibited by high pulmonary artery wedge pressure, central venous pressure, and pulmonary artery diastolic pressure, as well as crackles in the lungs. Hypertension results from postoperative vasoconstriction. Hypothermia is a low body temperature that leads to vasoconstriction.

which finding is associated with a blue color around the lips and conjunctiva?

central cyanosis central cyanosis is evident with a blue tinge in the lips conjunctiva or tongue. Finger clubbing results from endocarditis, congenital defects, or prolonged O2 deficiency. Peripheral cyanosis is evident with blue-tinged extremities or in the nose and ears. Decreased capillary refill may be seen in reduced capillary perfusion or anemia

A client is diagnosed with dilated cardiomyopathy. What is the most likely cause of the client's condition?

chronic alcohol use disorder Explanation Chronic alcohol ingestion is one of the main causes of dilated cardiomyopathy. Other causes include history of viral myocarditis, an autoimmune response, and exposure to other chemicals in addition to alcohol. Heredity is considered the main cause of hypertrophic cardiomyopathy. Scleroderma is a connective tissue disorder thought to cause restrictive cardiomyopathy. Scar tissue that forms after a myocardial infarction is thought to be a cause of restrictive cardiomyopathy.

administration of epinephrine stroke volume factor and cardiac output

contractility ↑ cardiac output ↑

increases in which blood studies are diagnostic for acute coronary syndrome ACS

copeptin cardiac troponin T

A client with severe anemia is prescribed 2 units of packed red blood cells. The client refuses to sign the consent form for blood administration because to do so conflicts with the client's Jehovah's Witness faith. What did the nurse fail to assess prior to witnessing consent?

cultural beliefs Explanation Clients may not accept health treatments if those treatments conflict with the values of their culture. The nurse was not aware of the client's cultural values as a Jehovah's Witness, which include prohibition of the transfusion of blood, prior to attempting to gain consent for the prescribed treatment.

aortic insufficiency

dyspnea angina tachycardia fatigue orthopnea paroxysmal nocturnal dyspnea blowing decrescendo diastolic murmur

aortic stenosis symptoms

dyspnea on exertion angina syncope on exertion fatigue orthopnea paroxysmal nocturnal dyspnea harsh systolic crescendo decrescendo murmur

When assessing a patient you note a pulse deficit of 23 beats this finding may be caused by

dysrhythmias Rationale: A pulse deficit occurs if there is a difference between the apical and radial beats per minute. It indicates cardiac dysrhythmias.

factors affecting SV are

e preload, contractility, and afterload. Preload is the volume of blood in the ventricles at the end of diastole. Afterload represents the systemic resistance against which the left ventricle must pump.

A patient is admitted with suspected cardiomyopathy. What diagnostic test will the nurse need to teach the client about for identification of this disease?

echocardiogram Explanation The echocardiogram is one of the most helpful diagnostic tools for cardiomyopathy because the structure and function of the ventricles can be observed easily. Cardiac catheterization will focus on coronary vessels. The serial enzymes are done to detect heart muscle damage. The phonocardiogram is helpful for valve function.

contraction of the myocardium, or systole results in

ejection of blood from the ventricles. relaxation of the myocardium or diastole allows for filling of the ventricles

the electrical activity of the heart is recoded on and

electrocardiogram ECG

the part of the vascular system responsible for hemostasis is the

endothelial layer of the arteries Rationale: The innermost lining of the arteries is the endothelium. The endothelium maintains hemostasis, promotes blood flow, and under normal conditions, inhibits blood coagulation.

a health history for cardiac system consist of a

f assessment of past health history, medications, surgery or other treatments, family health history, psychosocial history, risk factor identification, and a review of systems using functional health patterns. • Obtain a thorough history of the present illness. Explore and document common signs of heart problems (e.g., pain, dyspnea). Describe the course of the patient's illness, including when it began, the type of symptoms, and factors that alleviate or worsen these symptoms

What is a significant finding in the health history of a patient during an assessment of the cardiovascular system?

frequent use of recreational drugs

What sounds can be auscultated in a patient with cardiac valve problems?

heart murmurs third heart sound S3 fourth heart sound S4

stimulation of the sympathetic nervous system increases

heart rate speed of conduction through the AV node force of atrial and ventricular contractions while stimulation of the parasympathetic nervous system decreased HR

Which method is used to evaluate the ECG responses to normal activity over a period of 1 or 2 days?

holter monitoring

which effects result from sympathetic nervous system stimulation of b-adrenergic receptors

increased heart rate increased rate of impulse conduction increased force of cardiac contraction

What types of plant based food should patients consume at a constant level if they are on warfarin?

leafy greens and cauliflower

which arteries are the major providers of coronary circulation?

left circumflex artery right coronary artery left anterior descending artery

Which chamber of the heart is largest and has the thickest myocardium?

left ventricle

The nurse is caring for a patient immediately following a transesophageal echocardiogram TEE should consider which action to be the highest priority?

maintain NPO status until gag reflex has returned

A nurse is caring for a client who is on a continuous cardiac monitor. When evaluating the client's rhythm strip, the nurse notes that the QRS interval has increased from 0.08 second to 0.14 second. Based on this finding, the nurse should withhold continued administration of which drug?

metoprolol Explanation Procainamide may cause an increased QRS complexes and QT intervals. If the QRS duration increases by more than 50%, then the nurse should withhold the drug and notify the physician of her finding. Metoprolol may cause increased PR interval and bradycardia. Propafenone and verapamil may cause bradycardia and atrioventricular blocks.

Which nursing responsibilities are priorities when caring for a patient returning from a cardiac catheterization?

monitoring vital signs and ECG checking the catheter insertion site and distal pulses Rationale: The nursing responsibilities after cardiac catheterization include assessing the puncture site for hematoma and bleeding; assessing circulation to the extremity used for catheter insertion for peripheral pulses, color, and sensation; and monitoring vital signs and electrocardiographic rhythm.

How is heart failure managed in order to reduce associated symptoms?

patients are given a variety of cardiovascular drugs

obstruction of pulmonary artery stroke volume factor and cardiac output

preload left ventricle ↓ right ventricle ↑ cardiac output ↓

valsalva maneuver stroke volume factor and cardiac output

preload ↓ Cardiac output ↓

Hemorrhage stroke volume factor and cardiac output

preload ↓ cardiac output ↓

venous dilation stroke volume factor and cardiac outpu

preload ↓ cardiac output ↓

What is Phase 4?

rest K/Na pump replaces K into the cell Needs ATP (Krebs)

A patient with a tricuspid valve disorder has impaired blood flow between the

right atrium and right ventricle The tricuspid valve is found between the right atrium and right ventricle.

A patient presents to the emergency department reporting chest pain for 3 hours. What component of the blood work is most clearly indicative of a myocardial infarction (MI)?

roponin Rationale: Troponin is the biomarker of choice in the diagnosis of MI, with sensitivity and specificity that exceed those of CK-MB and myoglobin. CRP levels are not used to diagnose acute MI.

A child with a cardiac structural defect is receiving oxygen therapy. In which position should the child be placed to promote optimal benefits?

semi-fowler Explanation: Due to the hemodynamic changes accompanying the underlying structural defect, oxygenation is key. Provide frequent ongoing assessment of the child's cardiopulmonary status. Assess airway patency and suction as needed. Position the child in the Fowler or semi-Fowler position to facilitate lung expansion.

Which of the following separates the right and left sides of the heart?

septum

S2 heart sounds characteristics

sharp dub sound indicates the onset of diastole loudest at pulmonic and aortic areas

Your elderly patient is taking a diuretic. What side effects do you need to watch for other than dehydration?

signs of low potassium

which subjective data related to the cardiovascular system should be obtained from the patient

smoking history religious preference number of pillow used to sleep Rationale: The health history should include assessment of tobacco use. Ask the patient about any cultural or religious beliefs that may influence the management of the cardiovascular problem. Patients with heart failure may need to sleep with the head elevated on pillows or sleep in a chair

S1 heart sounds characteristics

soft lub sound indicates beginning of systole loudest at tricuspid and mitral areas

A nurse is caring for a patient immediately following a transesophageal echocardiogram (TEE). Which assessments are appropriate for this patient? (Select all that apply.)

ssess for return of gag reflex. Monitor vital signs and oxygen saturation. Rationale: The patient undergoing a TEE has been given conscious sedation and has had the throat numbed with a local anesthetic spray, thus eliminating the gag reflex until the effects wear off. Therefore it is imperative that the nurse assess for gag reflex return before allowing the patient to eat or drink. Vital signs and oxygen saturation are important assessment parameters resulting from the use of sedation. A TEE does not involve invasive procedures of the circulatory blood vessels. Therefore it is not necessary to monitor the patient's groin and lower extremities in relation to this procedure or to maintain a flat position.

a mean arterial pressure MAP >60 mm Hg is needed to

sustain the vital organs of an average person under most conditions

what is the purpose of the endocardium?

the endocardium lines the inside of the heart to prevent abnormal clotting

a female patient has a total cholesterol level of 232 mg/dL and a HDL of 65 mg/dL a male patient has a total cholesterol level of 200 mg/dL and an HDL of 32 mg/dL based on these findings which patient has the highest cardiac output

the man because his cholesterol to HDL ratio is higher

when palpating the patient's popliteal pulse, the nurse feels a vibration at the site. How should the nurse record this finding?

thrill of the popliteal artery

The nursing student is seeking assistance in hearing the patient's abnormal heart sounds. What should the nurse tell the student to do for a more effective assessment?

use the bell of the scope with the patient leaning forward

The heart receives blood returning from the body through which vessel?

vena cavae

The mitral and tricuspid valves prevent the backflow of blood from which of the following?

ventricles to atria when the ventricles contract

what are the age related physiologic changes in the older adult that result in the following cardiovascular problems widened pulse pressure decreased cardiac reserve increase cardiac dysrhythmias decreased response to sympathetic stimulation aortic or mitral valve murmurs

widened pulse pressure: loss of vascular elasticity and distensibility, increased sensitivity to antidiuretic hormone decreased cardiac reserve: increased collagen and decreased elastin increase cardiac dysrhythmias: decrease in SA node cells, conduction cells in the internodal tracts, the bundle of His, and bundle branches decreased response to sympathetic stimulation: decreased number and function of b-adrenergic receptors aortic or mitral valve murmurs: valvular lipid accumulation, collagen degeneration and fibrosis

the conduction system consists of specialized cells that

• The conduction system consists of specialized cells that create and transport electrical impulses. These electrical impulses start depolarization of the myocardium. This triggers a cardiac contraction.

the coronary circulation provides blood to the

• The coronary circulation provides blood to the myocardium (heart muscle). The right and left coronary arteries are the first two branches off the aorta.

Client instructions following valve replacement

▪ Adequate rest is important, and fatigue is common. ▪ Anticoagulant therapy is necessary if a mechanical prosthetic valve has been inserted. ▪ Instruct the client concerning hazards related to anticoagulant therapy and to notify the primary health care provider (PHCP) or cardiologist if bleeding or excessive bruising occurs. ▪ Instruct the client concerning the importance of good oral hygiene to reduce the risk of infective endocarditis. ▪ Brush teeth twice daily with a soft toothbrush, followed by oral rinses. ▪ Avoid irrigation devices, electric toothbrushes, and flossing, because these activities can cause the gums to bleed, allowing bacteria to enter the mucous membranes and bloodstream. ▪ Monitor incision and report any drainage or redness. ▪ Avoid any dental procedures for 6 months. ▪ Heavy lifting (more than 10 lb [4.5 kg]) is to be avoided, and exercise caution when in an automobile to prevent injury to the sternal incision. ▪ If a prosthetic valve was inserted, a soft, audible, clicking sound may be heard. ▪ Instruct the client concerning the importance of prophylactic antibiotics before any invasive procedure and the importance of informing all PHCPs of history of valve replacement or repair. ▪ Obtain and wear a MedicAlert bracelet.

hypertrophic cardiomyopathies signs and symptoms

● Fatigue and weakness ● Heart failure (left side) ● Dysrhythmias or heart block ● Systemic or pulmonary emboli ● S3 and S4 gallops ● Moderate to severe cardiomegaly ● Dyspnea ● Angina ● Fatigue, syncope, palpitations ● Mild cardiomegaly ● S4 gallop ● Ventricular dysrhythmias ● Sudden death common ● Heart failure ● Same as for nonobstructed except with mitral regurgitation murmur ● Atrial fibrillation ● Dyspnea and fatigue ● Heart failure (right side) ● Mild to moderate cardiomegaly ● S3 and S4 gallops ● Heart block ● Emboli

Cardiomyopathy treatment

● Symptomatic treatment of heart failure ● Vasodilators ● Control of dysrhythmias ● Surgery: Heart transplant For both nonobstructed and obstructed: ● Symptomatic treatment ● Beta blockers ● Conversion of atrial fibrillation ● Surgery: Ventriculomyotomy or muscle resection with mitralvalve replacement ● Digoxin, nitrates, and other vasodilators contraindicated with the obstructed form ● Supportive treatment of symptoms ● Treatment of hypertension ● Conversion from dysrhythmias ● Exercise restrictions ● Emergency treatment of acute pulmonary edema

Obstructive defects

1. Blood exiting a portion of the heart meets an area of anatomical narrowing (stenosis), causing obstruction to blood flow. 2. The location of narrowing is usually near the valve of the obstructive defect. 3. Infants and children exhibit signs of HF. 4. Children with mild obstruction may be asymptomatic. Aortic Stenosis Coarctation of the aorta Pulmonary stenosis

Cardiomyopathy

1. Cardiomyopathy is a subacute or chronic disorder of the heart muscle. 2. Treatment is palliative, not curative, and the client needs to deal with numerous lifestyle changes and a shortened life span.

Defects with increased pulmonary blood flow

. Description 1. Intracardiac communication along the septum or an abnormal connection between the great arteries allows blood to flow from the high-pressure left side of the heart to the low-pressure right side of the heart. 2. The infant typically shows signs and symptoms of HF ASD Atrial septal defect ACD Atrioventricular canal defect PDA Patent ductus arteriosus VSD Ventricular septal defect

The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further instruction?

"If my child vomits after medication administration, I will repeat the dose." Rationale: Digoxin is a cardiac glycoside. The parents need to be instructed that if the child vomits after digoxin is administered, they are not to repeat the dose.

Folate deficiency anemia

1. A macrocytic anemia in which red blood cells are larger than normal and are oval-shaped rather than round-shaped due to the lack of inadequate intake of folate (vitamin B9). 2. Folic acid is required for DNA synthesis required for red blood cell formation and maturation. 3. Common causes include dietary deficiency; malabsorption syndromes such as Celiac disease, Crohn's disease, or small bowel resection; medications (such as antiseizure medications) that decrease the absorption of folic acid, a condition (including pregnancy) that increases the requirement of folic acid; chronic alcoholism; and chronic hemodialysis

Vitamin B12 Anemia

1. A macrocytic anemia that results from an inadequate intake of vitamin B12 or lack of absorption of ingested vitamin B12 from the intestinal tract. 2. Pernicious anemia results from a deficiency of intrinsic factor (normally secreted by the gastric mucosa), necessary for intestinal absorption of vitamin B12; gastric disease or surgery can result in a lack of intrinsic factor

Cardiac Tamponade

1. A pericardial effusion occurs when the space between the parietal and visceral layers of the pericardium fills with fluid. 2. Pericardial effusion places the client at risk for cardiac tamponade, an accumulation of fluid in the pericardial cavity. 3. Tamponade restricts ventricular filling, and cardiac output drops. Acute cardiac tamponade can occur when small volumes (20 to 50 mL) of fluid accumulate rapidly in the pericardium.

Atrial septal defect ASD

1. ASD is an abnormal opening between the atria that causes an increased flow of oxygenated blood into the right side of the heart. 2. Right atrial and ventricular enlargement occurs. 3. Infant may be asymptomatic or may develop HF. 4. Signs and symptoms of decreased cardiac output may be present. 5. Types a. ASD 1 (ostium primum): Opening is at the lower end of the septum. b. ASD 2 (ostium secundum): Opening is near the center of the septum. c. ASD 3 (sinus venosus defect): Opening is near the junction of the superior vena cava and the right atrium. 6. Management a. Defect may be closed during a cardiac catheterization. b. Open repair with cardiopulmonary bypass may be performed and usually is performed before school age.

Hemophilia assessment

1. Abnormal bleeding in response to trauma or surgery (sometimes is detected after circumcision) 2. Epistaxis (nosebleeds) 3. Joint bleeding causing pain, tenderness, swelling, and limited range of motion 4. Tendency to bruise easily 5. Results of tests that measure platelet function are normal; results of tests that measure clotting factor function may be abnormal.

Anemia interventions

1. Administer blood products and hematopoietic medications as prescribed, which are used to treat anemia related to acute and chronic conditions. 2. Encourage a diet rich in the deficient nutrient if the anemia is caused by malnutrition, such as iron, folate, or vitamin B12 supplementation. 3. Control and address the source of bleeding if anemia is caused by acute blood loss and assess client for sources of frank and occult bleeding. Contact the PCHP and prepare for replacement therapy if acute blood loss occurs.

B-Thalassemia Major interventions

1. Administer blood transfusions as prescribed; monitor for transfusion reactions. 2. Monitor for iron overload; chelation therapy with deferasirox or deferoxamine may be prescribed to treat iron overload and to prevent organ damage from the elevated levels of iron caused by the multiple transfusion therapy. 3. If the child has had a splenectomy, instruct parents to report any signs of infection because of the risk of sepsis. 4. Ensure that parents understand the importance of the child receiving pneumococcal and meningococcal vaccines in addition to an annual influenza vaccine and the regularly scheduled vaccines. 5. Provide genetic counseling to parents.

Aortic stenosis

1. Aortic stenosis is a narrowing or stricture of the aortic valve, causing resistance to blood flow from the left ventricle into the aorta, resulting in decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion. 2. Valvular stenosis is the most common type and usually is caused by malformed cusps, resulting in a bicuspid rather than a tricuspid valve, or fusion of the cusps. 3. A characteristic murmur is present. 4. Infants with severe defects show signs of decreased cardiac output. 5. Children show signs of activity intolerance, chest pain, and dizziness when standing for long periods. 6. Management a. Dilation of the narrowed valve may be done during cardiac catheterization. b. Surgical aortic valvotomy (palliative) may be done; a valve replacement may be required at a second procedure.

Aplastic anemia

1. Aplastic anemia is a deficiency of circulating erythrocytes and all other formed elements of blood, resulting from the arrested development of cells within the bone marrow. 2. It can be primary (present at birth) or secondary (acquired). 3. Several possible causes exist, including chronic exposure to myelotoxic agents, viruses and infections such as hepatitis, Epstein-Barr virus, autoimmune disorders such as human immunodeficiency virus, and allergic states. 4. The definitive diagnosis is determined by bone marrow aspiration (shows conversion of red bone marrow to fatty bone marrow). 5. Therapeutic management focuses on restoring function to the bone marrow and involves immunosuppressive therapy and bone marrow transplantation (treatment of choice if a suitable donor exists). 6. If the cause is a myelotoxic medication that is being administered for another purpose, the medication may be discontinued to improve bone marrow function

Cardiac catherization preprocedural nursing interventions

1. Assess accurate height and weight, because this helps with the selection of the correct catheter size. 2. Obtain a history of the presence of allergic reactions to iodine. 3. Assess for symptoms of infection, including a diaper rash. 4. Assess and mark bilateral pulses, such as the dorsalis pedis and posterior tibial. 5. Assess baseline oxygen saturation. 6. Familiarize the parents and child with hospital procedures and equipment. 7. Educate the child, if age appropriate, and the parents about the procedure. 8. Allow the parents and child to verbalize feelings and concerns regarding the procedure and the disorder.

Coarctation of the aorta

1. Coarctation of the aorta is localized narrowing near the insertion of the ductus arteriosus. 2. Blood pressure is higher in the upper extremities than in the lower extremities; bounding pulses in the arms, weak or absent femoral pulses, and cool lower extremities may be present. 3. Signs of HF may occur in infants. 4. Signs and symptoms of decreased cardiac output may be present. 5. Children may experience headaches, dizziness, fainting, and epistaxis resulting from hypertension. 6. Management of the defect may be done via balloon angioplasty in children; restenosis can occur. 7. Surgical management a. Mechanical ventilation and medications to improve cardiac output are often necessary before surgery. b. Resection of the coarcted portion with end- to-end anastomosis of the aorta or enlargement of the constricted section, using a graft, may be required. c. Because the defect is outside the heart, cardiopulmonary bypass is not required, and a thoracotomy incision is used. With coarctation of the aorta, the blood pressure is higher in the upper extremities than in the lower extremities. In addition, bounding pulses in the arms, weak or absent femoral pulses, and cool lower extremities may be present

Anemia

1. Condition in which the blood lacks adequate healthy red blood cells or hemoglobin, with most common causes being acute blood loss, decreased or faulty red blood cell production, or the destruction of red blood cells. 2. There are several types of anemia, with the main types being anemia related to acute and chronic blood loss, anemia of chronic diseases (including cancers, immunodeficiency syndrome, renal disease, liver diseases, and autoimmune conditions), anemias caused by nutritional deficiencies (such as iron, folate, or vitamin B12 deficiency), and hereditary anemias (including sickle cell anemia and thalassemia). 3. Treatment of anemia focuses on treating the cause of the condition and varies based on the type of anemia. 4. Acute blood loss anemia is characterized by normal red blood cell size, shape, and color. Clients at risk include postoperative clients, clients with an active bleeding problem, or immunocompromised clients with a reduction in blood components. Hemoglobin, hematocrit, or red blood cell levels can be low.

Defibrillation

1. Defibrillation is an asynchronous countershock used to terminate pulseless VT or VF. 2. The defibrillator is charged to 120 to 200 joules (biphasic) or 360 joules (monophasic) for 1 countershock from the defibrillator, and then CPR is resumed immediately and continued for 5 cycles or about 2 minutes. 3. Reassess the rhythm after 2 minutes, and if VF or pulseless VT continues, the defibrillator is charged to give a second shock at the same energy level previously used. 4. Resume CPR after the shock, and continue with the life support protocol. Before defibrillating a client, be sure that the oxygen is shut off to avoid the hazard of fire and be sure that no one is touching the bed or the client.

sinus tachycardia

1. Description a. Atrial and ventricular rates are 100 to 180 beats per minute. b. Atrial and ventricular rhythms are regular. c. PR interval and QRS width are within normal limits. 2. Interventions a. Identify the cause of the tachycardia. b. Decrease the heart rate to normal by treating the underlying cause.

The nurse is conducting staff in-service training on von Willebrand's disease. Which should the nurse include as characteristics of von Willebrand's disease? Select all that apply.

1. Easy bruising occurs. 2. Gum bleeding occurs. 3. It is a hereditary bleeding disorder. 4. Treatment and care are similar to that for hemophilia. 6. The disorder causes platelets to adhere to damaged endothelium. Rationale: von Willebrand's disease is a hereditary bleeding disorder characterized by a deficiency of or a defect in a protein termed von Willebrand factor. The disorder causes platelets to adhere to damaged endothelium. It is characterized by an increased tendency to bleed from mucous membranes. Assessment findings include epistaxis, gum bleeding, easy bruising, and excessive menstrual bleeding. An elevated creatinine level is not associated with this disorder.

Anemia assessment

1. Fatigue 2. Weakness 3. Pallor or slight jaundice if red blood cell destruction occurs 4. Shortness of breath 5. Dysrhythmias 6. Chest pain 7. Tachycardia 8. Cool extremities

B-Thalassemia Major

1. Frontal bossing 2. Maxillary prominence 3. Wide-set eyes with a flattened nose 4. Greenish yellow skin tone 5. Hepatosplenomegaly 6. Severe anemia 7. Microcytic, hypochromic red blood cells

Mixed Defects

1. Fully saturated systemic blood flow mixes with the desaturated blood flow, causing desaturation of the systemic blood flow. 2. Pulmonary congestion occurs and cardiac output decreases. 3. Signs of HF are present; symptoms vary with the degree of desaturation. Hypoplastic left heart syndrome Transposition of the great arteries or transposition of the great vessels Total anomalous pulmonary venous connection Truncus arteriosus

Heart Failure

1. HF is the inability of the heart to pump a sufficient amount of blood to meet the metabolic and oxygen needs of the body. 2. In infants and children, inadequate cardiac output most commonly is caused by congenital heart defects (shunt, obstruction, or a combination of both) that produce an excessive volume or pressure load on the myocardium. 3. In infants and children, a combination of left-sided and right-sided HF is usually present. 4. The goals of treatment are to improve cardiac function, remove accumulated fluid and sodium, decrease cardiac demands, improve tissue oxygenation, and decrease oxygen consumption; depending on the cause, surgery may be required.

Hemophilia

1. Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. 2. Identifying the specific coagulation deficiency is important so that definitive treatment with the specific replacement agent can be implemented; aggressive replacement therapy is initiated to prevent the chronic crippling effects from joint bleeding. 3. The most common types are factor VIII deficiency (hemophilia A or classic hemophilia) and factor IX deficiency (hemophilia B or Christmas disease). 4. Hemophilia is transmitted as an X-linked recessive disorder (it may also occur as a result of a gene mutation). 5. Carrier females pass on the defect to males; female offspring are rarely born with the disorder but may be if they inherit an affected gene from their mother and are offspring of a father with hemophilia. 6. The primary treatment is replacement of the missing clotting factor; additional medications, such as agents to relieve pain or corticosteroids, may be prescribed depending on the source of bleeding from the disorder

Vitamin B12 anemia interventions

1. Increase dietary intake of foods rich in vitamin B12 such as citrus fruits, dried beans, green leafy vegetables, liver, nuts, organ meats, and brewer's yeast if the anemia is a result of a dietary deficiency. 2. Administer vitamin B12 injections as prescribed, weekly initially and then monthly for maintenance (lifelong) if the anemia is the result of a deficiency of intrinsic factor or disease or surgery of the ileum

iron deficiency anemia intervention

1. Increase oral intake of iron and instruct client in food choices that are high in iron (see Box 11-2 in Chapter 11 for iron-rich foods). 2. Administer iron supplements as prescribed. 3. Intramuscular injections of iron (using Z-track method) or IV administration of iron may be prescribed in severe cases of anemia. 4. Teach clients how to administer the iron supplements. a. Take between meals for maximum absorption. b. Take with a multivitamin or fruit juice, because vitamin C increases absorption. c. Do not take with milk or antacids, because these items decrease absorption. d. Instruct the client about the side effects of iron supplements (black stools, constipation, and foul aftertaste). e. Liquid iron preparations stains the teeth. Teach the client that liquid iron should be taken through a straw and that the teeth should be brushed after administration

cardiac catheterization

1. Invasive diagnostic procedure to determine cardiac defects. 2. Provides information about oxygen saturation of blood in great vessels and heart chambers. 3. May be done for diagnostic, interventional, or electrophysiological reasons. 4. May be carried out on an outpatient basis. 5. Risks include hemorrhage from the entry site, clot formation and subsequent blockage distally, and transient dysrhythmias. 6. General anesthesia is usually unnecessary.

Iron deficiency anemia

1. Iron stores are depleted, resulting in a decreased iron supply for the manufacture of hemoglobin in red blood cells. 2. Commonly results from blood loss, increased metabolic demands, syndromes of gastrointestinal malabsorption, and dietary inadequacy.

sickle cell anemia interventions

1. Maintain adequate hydration and blood flow through oral and intravenously (IV) administered fluids. Electrolyte replacement is also provided as needed; without adequate hydration, pain will not be controlled. 2. Administer oxygen and blood transfusions as prescribed to increase tissue perfusion; exchange transfusions, which reduce the number of circulating sickle cells and the risk of complications, may also be prescribed. 3. Administer analgesics as prescribed (around the clock). 4. Assist the child to assume a comfortable position so that the child keeps the extremities extended to promote venous return; elevate the head of the bed no more than 30 degrees, avoid putting strain on painful joints, and do not raise the knee gatch of the bed. 5. Encourage consumption of a high-calorie, high-protein diet, with folic acid supplementation. 6. Administer antibiotics as prescribed to prevent infection. 7. Monitor for signs of complications, including increasing anemia, decreased perfusion, and shock (mental status changes, pallor, vital sign changes). 8. Instruct the child and parents about the early signs and symptoms of crisis and the measures to prevent crisis. 9. Ensure that the child receives pneumococcal and meningococcal vaccines and an annual influenza vaccine, because of susceptibility to infection secondary to functional asplenia. 10. A splenectomy may be necessary for clients who experience recurrent splenic sequestration. 11. Inform parents of the hereditary aspects of the disorder.

valve replacement procedures

1. Mechanical prosthetic valves: These prosthetic valves are durable 2. Risk of clot formation is high as the body reacts to the artificial materials; anticoagulation is required. Thromboembolism can be a problem following valve replacement with a mechanical prosthetic valve, and lifetime anticoagulant therapy is required. 3. Bioprosthetic valves a. Biological grafts are xenografts (valves from other species)—porcine valves (pig), bovine valves (cow), or homografts (human cadavers). These valves are less durable than mechanical prosthetic valves. b. The risk of clot formation is small; therefore, long-term anticoagulation may not be indicated. 4. Open heart surgical approach. 5. Preoperative interventions: Consult with the PHCP regarding discontinuing anticoagulants 72 hours before surgery. 6. Postoperative interventions a. Monitor closely for signs of bleeding. b. Monitor cardiac output and for signs of heart failure. c. Administer digoxin as prescribed to maintain cardiac output and prevent atrial fibrillation.

Cardiac catheterization postprocedural nursing interventions

1. Monitor findings on the cardiac monitor and oxygen saturation for 4 hours after procedure. 2. Assess pulses below the catheter site for presence, equality and symmetry. 3. Assess the temperature and color of the affected extremity and report coolness, which may indicate arterial obstruction. 4. Monitor vital signs frequently, usually every 15 minutes 4 times, every half-hour 4 times, and then every hour 4 times. 5. Assess the pressure dressing for intactness and signs of hemorrhage. 6. Check the bed sheets under the extremity for blood, which indicates bleeding from the entry site. 7. If bleeding is present, apply continuous, direct pressure at the cardiac catheter entry site and report it immediately. 8. Immobilize the affected extremity in a flat position for at least 4 to 6 hours for venous entry site and 6 to 8 hours for arterial entry site as prescribed. 9. Hydrate the child via the oral or intravenous route or both routes as prescribed. 10. Administer acetaminophen or ibuprofen for pain or discomfort as prescribed. 11. Prepare the parents and child, if appropriate, for surgery

Hemophilia interventions

1. Monitor for bleeding and maintain bleeding precautions. 2. Prepare to administer factor VIII concentrates, either produced through genetic engineering (recombinant) or derived from pooled plasma, as prescribed. 3. DDAVP (1-deamino-8-d-arginine vasopressin), a synthetic form of vasopressin, increases plasma factor VIII and may be prescribed to treat mild hemophilia. 4. Monitor for joint pain; immobilize the affected extremity if joint pain occurs. 5. Assess neurological status (child is at risk for intracranial hemorrhage). 6. Monitor urine for hematuria. 7. Control joint bleeding by immobilization, elevation, and application of ice; apply pressure (15 minutes) for superficial bleeding. 8. Instruct the child and parents about the signs of internal bleeding. 9. Instruct parents in how to control the bleeding. 10. Instruct parents regarding activities for the child, emphasizing the avoidance of contact sports and the need for protective devices while learning to walk; assist in developing an appropriate exercise plan. 11. Instruct the child to wear protective devices such as helmets and knee and elbow pads when participating in sports such as bicycling and skating

Heart Failure Interventions

1. Monitor for early signs of HF. 2. Monitor for respiratory distress (count respirations for 1 minute). 3. Monitor apical pulse (count apical pulse for 1 minute), and monitor for dysrhythmias. 4. Monitor temperature for hyperthermia and for other signs of infection, particularly respiratory infection. 5. Monitor strict intake and output; weigh diapers as appropriate for most accurate output. 6. Monitor daily weight to assess for fluid retention; a weight gain of 0.5 kg (1 lb) in 1 day is caused by the accumulation of fluid. 7. Monitor for facial or peripheral dependent edema, auscultate lung sounds, and report abnormal findings indicating excessive fluid in the body. 8. Elevate the head of the bed in a semi-Fowler's position. 9. Maintain a neutral thermal environment to prevent cold stress in infants. 10. Provide rest and decrease environmental stimuli. 11. Administer cool humidified oxygen as prescribed, using an oxygen hood for young infants and a nasal cannula or face mask for older infants and children. 12. Organize nursing activities to allow for uninterrupted sleep. 13. Maintain adequate nutritional status. 14. Feed when hungry and soon after awakening, conserving energy and oxygen supply. 15. Provide small, frequent feedings, conserving energy and oxygen supply. 16. Administer medications as prescribed, which may include digoxin, diuretics, and afterload reducers such as angiotensin-converting enzyme (ACE) inhibitors. 17. Administer digoxin as prescribed. a. Assess apical heart rate for 1 minute before administration. b. Withhold digoxin if the apical pulse is less than 90 to 110 beats per minute in infants and young children and less than 70 beats per minute in older children, as prescribed. c. Check the prescribed dose carefully to ensure it is a safe, age-appropriate dose; follow agency policy and question any unclear prescription. 18. Monitor digoxin levels and for signs of digoxin toxicity, including anorexia, poor feeding, nausea, vomiting, bradycardia, and dysrhythmias. 19. The optimal therapeutic digoxin level range is 0.8 to 2 ng/mL (1.02 to 2.55 nmol/L; toxicity is usually seen at > 2 ng/mL (2.55 nmol/L) level. 20. Administer angiotensin-converting enzyme inhibitors as prescribed. a. Monitor for hypotension, renal dysfunction, and cough when ACE inhibitors are administered. b. Assess blood pressure; serum protein, albumin, blood urea nitrogen, and creatinine levels; white blood cell count; urine output; urinary specific gravity; and urinary protein level. 21. Administer diuretics such as furosemide as prescribed. a. Monitor for signs and symptoms of hypokalemia (serum potassium level < 3.5 mEq/L [3.5 mmol/L]), including muscle weakness and cramping, confusion, irritability, restlessness, and inverted T waves or prominent U waves on the electrocardiogram. b. If signs and symptoms of hypokalemia are present and the child is also being administered digoxin, monitor closely for digoxin toxicity, because hypokalemia potentiates digoxin toxicity. 22. Administer potassium supplements and provide dietary sources of potassium as prescribed. a. Supplemental potassium should be given only if indicated by serum potassium levels and if adequate renal function is evident and is usually necessary when administering a potassium-losing diuretic such as furosemide. b. Encourage foods that the child will eat that are high in potassium, as appropriate, such as bananas, baked potato skins, and peanut butter. 23. Monitor serum electrolyte levels, particularly the potassium level (normal level is 3.5 to 5.0 mEq/L [3.5 to 5.0 mmol/L]). 24. Limit fluid intake as prescribed in the acute stage. 25. Monitor for signs and symptoms of dehydration, including sunken fontanel (infant), nonelastic skin turgor, dry mucous membranes, decreased tear production, decreased urine output, and concentrated urine. 26. Monitor sodium levels as prescribed. a. Normal level is 135 to 145 mEq/L (135 to 145 mmol/L). b. Many infant formulas have slightly more sodium than breast milk. 27. Instruct the parents regarding administration of digoxin (Box 36-2). 28. Instruct the parents in cardiopulmonary resuscitation (CPR). The guidelines for CPR for the child older than 1 year of age are the same as for an adult. For American Heart Association current CPR guidelines, refer to https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines. The parents should be provided with a medication guide for any medication prescribed for the infant or child. In addition, the nurse needs to review the instructions in the guide and provide an opportunity for the parents to demonstrate medication administration procedures.

Cardiac surgery postoperative interventions

1. Monitor vital signs frequently, especially temperature, and notify the surgeon if fever occurs. 2. Monitor for signs of sepsis such as fever, chills, diaphoresis, lethargy, and altered levels of consciousness. 3. Maintain strict aseptic technique. 4. Monitor lines, tubes, or catheters that are in place, and monitor for signs and symptoms of infection. 5. Assess for signs of discomfort such as irritability, restlessness, changes in heart rate, respiratory rate, and blood pressure. 6. Administer pain medications as prescribed. 7. Administer antibiotics and antipyretics as prescribed. 8. Promote rest and sleep periods. 9. Facilitate parent-child contact as soon as possible

Defects with decreases pulmonary blood flow

1. Obstructed pulmonary blood flow and an anatomical defect (ASD or VSD) between the right and left sides of the heart are present. 2. Pressure on the right side of the heart increases, exceeding pressure on the left side, which allows desaturated blood to shunt right to left, causing desaturation in the left side of the heart and in the systemic circulation. 3. Typically hypoxemia and cyanosis appear Tetralogy of Fallot Tricuspid atresia

Iron deficiency anemia assessment

1. Pallor 2. Weakness and fatigue 3. Low hemoglobin, hematocrit, and mean cellular volume (MCV) levels 4. Red blood cells that are microcytic and hypochromic

Patent ductus areteriosus

1. Patent ductus arteriosus is failure of the fetal ductus arteriosus (shunt connecting the aorta and the pulmonary artery) to close within the first weeks of life. 2. A characteristic machinery-like murmur is present. 3. An infant may be asymptomatic or may show signs of HF. 4. A widened pulse pressure and bounding pulses are present. 5. Signs and symptoms of decreased cardiac output may be present. 6. Management a. Indomethacin, a prostaglandin inhibitor, may be administered to close a patent ductus in premature infants and some newborns. b. The defect may be closed during cardiac catheterization, or the defect may require surgical management.

Pulmonary stenosis

1. Pulmonary stenosis is narrowing at the entrance to the pulmonary artery. 2. Resistance to blood flow causes right ventricular hypertrophy and decreased pulmonary blood flow; the right ventricle may be hypoplastic. 3. Pulmonary atresia is the extreme form of pulmonary stenosis in that there is total fusion of the commissures and no blood flow to the lungs. 4. A characteristic murmur is present. 5. Infants or children may be asymptomatic. 6. Newborns with severe narrowing are cyanotic. 7. If pulmonary stenosis is severe, HF occurs. 8. Signs and symptoms of decreased cardiac output may occur. 9. Management: Dilation of the narrowed valve may be done during cardiac catheterization. 10. Surgical management: a. In infants: Transventricular (closed) valvotomy procedure b. In children: Pulmonary valvotomy with cardiopulmonary bypass

Cardiac tamponade assessment

1. Pulsus paradoxus 2. Increased CVP 3. Jugular venous distention with clear lungs 4. Distant, muffled heart sounds 5. Decreased cardiac output 6. Narrowing pulse pressure

Cardiac catheterization discharge teaching for the child and parents

1. Remove the dressing on the day after the procedure and cover it with a bandage for 2 or 3 days as prescribed. 2. Keep the site clean and dry. 3. Avoid tub baths for 2 to 3 days. 4. Observe for redness, edema, drainage, bleeding, and fever, and report any of these signs immediately. 5. Avoid strenuous activity, if applicable. 6. The child may return to school, if appropriate. 7. Provide a diet as tolerated. 8. Administer acetaminophen or ibuprofen for pain, discomfort, or fever. 9. Keep follow-up appointment with the pediatrician

Normal sinus rhythm

1. Rhythm originates from the SA node. 2. Description a. Atrial and ventricular rhythms are regular. b. Atrial and ventricular rates are 60 to 100 beats per minute c. PR interval and QRS width are within normal limits.

Vitamin B12 Anemia assessment

1. Severe pallor 2. Fatigue 3. Weight loss 4. Smooth, beefy red tongue 5. Slight jaundice 6. Paresthesias of the hands and feet 7. Disturbances with gait and balance

Sickle cell anemia

1. Sickle cell anemia constitutes a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. 2. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. 3. Risk factors include having parents heterozygous for hemoglobin S or being of African American descent. 4. For screening purposes, the sickle turbidity test (Sickledex) is frequently used because it can be performed on blood from a fingerstick and yields accurate results in 3 minutes. However, if the test result is positive, hemoglobin (Hgb) electrophoresis is necessary to distinguish between children with the trait and those with the disease. 5. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell. 6. Insufficient oxygen causes the cells to assume a sickle shape, and the cells become rigid and clumped together, obstructing capillary blood flow (Fig. 30-1). 7. The clinical manifestations occur primarily as a result of obstruction caused by sickled red blood cells and increased red blood cell destruction. 8. Situations that precipitate sickling include fever, dehydration, and emotional or physical stress; any condition that increases the need for oxygen or alters the transport of oxygen can result in sickle cell crisis (acute exacerbation). 9. Sickle cell crises are acute exacerbations of the disease, which vary considerably in severity and frequency; these include vaso-occlusive crisis, splenic sequestration, hyperhemolytic crisis, and aplastic crisis. 10. The sickling response is reversible under conditions of adequate oxygenation and hydration; after repeated sickling, the cell becomes permanently sickled. 11. An interprofessional approach to care is needed, and care focuses on the prevention (preventing exposure to infection and maintaining normal hydration) and treatment (hydration, oxygen, pain management, and bed rest) of the crisis.

Heart Failure assessment of early signs

1. Tachycardia, especially during rest and slight exertion 2. Tachypnea 3. Profuse scalp diaphoresis, especially in infants 4. Fatigue and irritability 5. Sudden weight gain 6. Respiratory distress

Tetralogy of Fallot

1. Tetralogy of Fallot includes 4 defects—VSD, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy. 2. If pulmonary vascular resistance is higher than systemic resistance, the shunt is from right to left; if systemic resistance is higher than pulmonary resistance, the shunt is from left to right. 3. Infants a. An infant may be acutely cyanotic at birth or may have mild cyanosis that progresses over the first year of life as the pulmonic stenosis worsens. b. A characteristic murmur is present. c. Acute episodes of cyanosis and hypoxia (hypercyanotic spells), called blue spells or tet spells, occur when the infant's oxygen requirements exceed the blood supply, such as during periods of crying, feeding, or defecating 4. Children: With increasing cyanosis, squatting, clubbing of the fingers, and poor growth may occur. a. Squatting is a compensatory mechanism to facilitate increased return of blood flow to the heart for oxygenation. b. Clubbing is an abnormal enlargement in the distal phalanges, seen in the fingers.

cardiac tamponade interventions

1. The client needs to be placed in a critical care unit for hemodynamic monitoring. 2. Administer fluids intravenously as prescribed to manage decreased cardiac output. 3. Prepare the client for chest x-ray or echocardiography. 4. Prepare the client for pericardiocentesis to withdraw pericardial fluid if prescribed. 5. Monitor for recurrence of tamponade following pericardiocentesis. 6. If the client experiences recurrent tamponade or recurrent effusions or develops adhesions from chronic pericarditis, a portion (pericardial window) or all of the pericardium (pericardiectomy) may be removed to allow adequate ventricular filling and contraction.

Total anomalous pulmonary venous connection

1. The defect is a failure of the pulmonary veins to join the left atrium. 2. The defect results in mixed blood being returned to the right atrium and shunted from the right to the left through an ASD. 3. The right side of the heart hypertrophies, whereas the left side of the heart may remain small. 4. Signs and symptoms of HF develop. 5. Cyanosis worsens with pulmonary vein obstruction; when obstruction occurs, the infant's condition deteriorates rapidly. 6. Surgical management a. Corrective repair is performed in early infancy. b. The pulmonary vein is anastomosed to the left atrium, the ASD is closed, and the anomalous pulmonary venous connection is ligated.

Atrioventricular canal defect

1. The defect results from incomplete fusion of the endocardial cushions. 2. The defect is the most common cardiac defect in Down's syndrome. 3. A characteristic murmur is present. 4. The infant usually has mild to moderate HF, with cyanosis increasing with crying. 5. Signs and symptoms of decreased cardiac output may be present. 6. Management can include pulmonary artery banding for infants with severe symptoms (palliative) or complete repair via cardiopulmonary bypass

Transposition of the great arteries or transposition of the great vessels

1. The pulmonary artery leaves the left ventricle, and the aorta exits from the right ventricle. 2. No communication exists between the systemic and pulmonary circulation. 3. Infants with minimal communication are severely cyanotic at birth. 4. Infants with large septal defects or a patent ductus arteriosus may be less severely cyanotic but may have symptoms of HF. 5. Cardiomegaly is evident a few weeks after birth. 6. Nonsurgical management a. Prostaglandin E1 may be initiated to keep the ductus arteriosus open and to improve blood mixing temporarily. b. Balloon atrial septostomy during cardiac catheterization may be performed to increase mixing from both sides of the heart and to maintain cardiac output over a longer period. 7. Surgical management: The arterial switch procedure reestablishes normal circulation with the left ventricle acting as the systemic pump and creation of a new aorta.

Ventricular septal defect

1. VSD is an abnormal opening between the right and left ventricles. 2. Many VSDs close spontaneously during the first year of life in children with small or moderate defects. 3. A characteristic murmur is present. 4. Signs and symptoms of HF are commonly present. 5. Signs and symptoms of decreased cardiac output may be present. 6. Management a. Closure during cardiac catheterization may be possible. b. Open repair may be done with cardiopulmonary bypass.

Valvular heart disease

1. Valvular heart disease occurs when the heart valves cannot open fully (stenosis) or close completely (insufficiency or regurgitation). 2. Valvular heart disease prevents efficient blood flow through the heart. Types 1. Mitral stenosis: Valvular tissue thickens and narrows the valve opening, preventing blood from flowing from the left atrium to the left ventricle. 2. Mitral insufficiency, regurgitation: Valve is incompetent, preventing complete valve closure during systole. 3. Mitral valve prolapse: Valve leaflets protrude into the left atrium during systole. 4. Aortic stenosis: Valvular tissue thickens and narrows the valve opening, preventing blood from flowing from the left ventricle into the aorta. 5. Aortic insufficiency: Valve is incompetent, preventing complete valve closure during diastole. 6. aortic disorders 7. tricuspid disorders 8. pulmonary valve disorders

von Willebrand's Disease

1. von Willebrand's disease is a hereditary bleeding disorder that is characterized by a deficiency of or a defect in a protein termed von Willebrand factor. 2. The disorder causes platelets to adhere to damaged endothelium; the von Willebrand factor protein also serves as a carrier protein for factor VIII. 3. It is characterized by an increased tendency to bleed from mucous membranes. B. Assessment 1. Epistaxis 2. Gum bleeding 3. Easy bruising 4. Excessive menstrual bleeding C. Interventions 1. Treatment and care are similar to measures implemented for hemophilia, including administration of clotting factors. 2. Provide emotional support to the child and parents, especially if the child is experiencing an episode of bleeding

B-Thalassemia Major

1. β-Thalassemia major is an autosomal recessive disorder characterized by the reduced production of 1 of the globin chains in the synthesis of hemoglobin (both parents must be carriers to produce a child with β-thalassemia major). 2. The incidence is highest in individuals of Mediterranean descent, such as Italians, Greeks, Syrians, and their offspring. 3. Treatment is supportive; the goal of therapy is to maintain normal hemoglobin levels by the administration of blood transfusions. 4. Bone marrow transplantation may be offered as an alternative therapy. 5. A splenectomy may be performed in a child with severe splenomegaly who requires repeated transfusions (assists in relieving abdominal pressure and may increase the life span of supplemental red blood cells).

Why is administration of meperidine for pain avoided in patients with sickle cell anemia?

because of the risk of normeperidine induced seizures

The clinic nurse reviews the record of a child just seen by the pediatrician and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder?

Activity intolerance Rationale: Aortic stenosis is a narrowing or stricture of the aortic valve, causing resistance to blood flow in the left ventricle, decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion. A child with aortic stenosis shows signs of activity intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted but is not specific to this type of disorder alone.

The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis?

Anti-streptolysin O titer Rationale: Rheumatic fever is an inflammatory autoimmune disease that affects the connective tissues of the heart, joints, skin (subcutaneous tissues), blood vessels, and central nervous system. A diagnosis of rheumatic fever is confirmed by the presence of 2 major manifestations or 1 major and 2 minor manifestations from the Jones criteria. In addition, evidence of a recent streptococcal infection is confirmed by a positive anti-streptolysin O titer, Streptozyme assay, or anti-DNase B assay.

Aplastic anemia assessment and interventions

Assessment 1. Pancytopenia (deficiency of erythrocytes, leukocytes, and thrombocytes) 2. Petechiae, purpura, bleeding, pallor, weakness, tachycardia, and fatigue Interventions 1. Prepare the client for bone marrow transplantation if planned. 2. Administer immunosuppressive medications as prescribed; antilymphocyte globulin or antithymocyte globulin may be prescribed to suppress the autoimmune response. 3. Colony-stimulating factors may be prescribed to enhance bone marrow production. 4. Corticosteroids and cyclosporine may be prescribed. 5. Administer blood transfusions if prescribed and monitor for transfusion reactions

The nursing student is presenting a clinical conference and discusses the cause of β-thalassemia. The nursing student informs the group that a child at greatest risk of developing this disorder is which of these?

a child of mediterranean descent Rationale: β-Thalassemia is an autosomal recessive disorder characterized by the reduced production of 1 of the globin chains in the synthesis of hemoglobin (both parents must be carriers to produce a child with β-thalassemia major). This disorder is found primarily in individuals of Mediterranean descent.

Unstable client with VT with pulse and signs and symptoms of decreased cardiac output

a. Administer oxygen and antidysrhythmic therapy as prescribed. b. Prepare for synchronized cardioversion if the client is unstable. c. The PHCP may attempt cough cardiopulmonary resuscitation (CPR) by asking the client to cough hard every 1 to 3 seconds

2. Stable client with sustained VT with pulse and no signs or symptoms of decreased cardiac output

a. Administer oxygen as prescribed. b. Administer antidysrhythmics as prescribed.

Atrial fibrillation interventions

a. Administer oxygen. b. Administer anticoagulants as prescribed because of the risk of emboli. c. Administer cardiac medications as prescribed to control the ventricular rhythm and assist in the maintenance of cardiac output. d. Prepare the client for cardioversion as prescribed. e. Instruct the client in the use of medications as prescribed to control the dysrhythmia

A 10-year-old child with hemophilia A has slipped on the ice and bumped his knee. The nurse should prepare to administer which prescription?

Intravenous infusion of iron Rationale: Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. The primary treatment is replacement of the missing clotting factor; additional medications, such as agents to relieve pain, may be prescribed depending on the source of bleeding from the disorder. A child with hemophilia A is at risk for joint bleeding after a fall. Factor VIII would be prescribed intravenously to replace the missing clotting factor and minimize the bleeding. Factor X and iron are not used to treat children with hemophilia A

Sinus bradycardia

a. Atrial and ventricular rhythms are regular. b. Atrial and ventricular rates are less than 60 beats per minute. c. PR interval and QRS width are within normal limits. d. Treatment may be necessary if the client is symptomatic (signs of decreased cardiac output). e. A low heart rate may be normal for some individuals, such as athletes.

A child with β-thalassemia is receiving long-term blood transfusion therapy for the treatment of the disorder. Chelation therapy is prescribed as a result of too much iron from the transfusions. Which medication should the nurse anticipate being prescribed?

Deferoxamine Rationale: β-Thalassemia is an autosomal recessive disorder characterized by the reduced production of 1 of the globin chains in the synthesis of hemoglobin (both parents must be carriers to produce a child with β-thalassemia major). The major complication of long-term transfusion therapy is hemosiderosis. To prevent organ damage from too much iron, chelation therapy with either deferasirox or deferoxamine may be prescribed. Deferoxamine is classified as an antidote for acute iron toxicity. Dalteparin is an anticoagulant used as prophylaxis for postoperative deep vein thrombosis. Meropenem is an antibiotic. Metoprolol is a beta blocker used to treat hypertension.

The clinic nurse instructs parents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further instruction?

Fluid overload Rationale: Sickle cell crises are acute exacerbations of the disease, which vary considerably in severity and frequency; these include vaso-occlusive crisis, splenic sequestration, hyperhemolytic crisis, and aplastic crisis. Sickle cell crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The mother of a child with sickle cell disease should encourage fluid intake of 1.5 to 2 times the daily requirement to prevent dehydration.

The nurse analyzes the laboratory results of a child with hemophilia. The nurse understands that which result will most likely be abnormal in this child?

Partial thromboplastin time Rationale: Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Results of tests that measure platelet function are normal; results of tests that measure clotting factor function may be abnormal. Abnormal laboratory results in hemophilia indicate a prolonged partial thromboplastin time. The platelet count, hemoglobin level, and hematocrit level are normal in hemophilia

Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder? Refer to figure (the circled area) to determine the condition.

Patent ductus arteriosus Rationale: A patent ductus arteriosus is failure of the fetal ductus arteriosus (artery connecting the aorta and the pulmonary artery) to close. A characteristic machinery-like murmur is present, and the infant may show signs of heart failure. Aortic stenosis is a narrowing or stricture of the aortic valve. Atrial septal defect is an abnormal opening between the atria. Ventricular septal defect is an abnormal opening between the right and left ventricles

Valvular heart disease repair procedures

Percutaneous balloon valvuloplasty a. A balloon catheter is passed from the femoral vein through the atrial septum to the mitral valve or through the femoral artery to the aortic valve. b. The balloon is inflated to enlarge the orifice. c. Monitor for bleeding from the catheter insertion site. d. Institute precautions for arterial puncture if appropriate; site care and monitoring is similar to that after cardiac catheterization. e. Monitor for signs of systemic emboli. f. Monitor for signs of a regurgitant valve by monitoring cardiac rhythm, heart sounds, and cardiac output. 2. Mitral annuloplasty: Tightening and suturing the malfunctioning valve annulus to eliminate or greatly reduce regurgitation; percutaneous or open surgical approach. 3. Commissurotomy, valvotomy a. Thrombi are removed and calcium deposits are debrided; the valve is incised and widened. b. Percutaneous route or open heart surgical approach.

Laboratory studies are performed for a child suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia?

Red blood cells that are microcytic and hypochromic Rationale: In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. The results of a complete blood cell count in children with iron deficiency anemia show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated

Tetralogy of Fallot management

Surgical management: Palliative shunt a. The shunt increases pulmonary blood flow and increases oxygen saturation in infants who cannot undergo primary repair. b. The shunt provides blood flow to the pulmonary arteries from the left or right subclavian artery. Surgical management: Complete repair a. Complete repair usually is performed in the first year of life. b. The repair requires a median sternotomy and cardiopulmonary bypass

The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF?

Tachycardia Rationale: HF is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. The early signs of HF include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress. A cough may occur in HF as a result of mucosal swelling and irritation, but is not an early sign. Pallor may be noted in an infant with HF but is not an early sign

Management of dysrhythmias vagal maneuvers

Vagal maneuvers 1. Description: Vagal maneuvers induce vagal stimulation of the cardiac conduction system and are used to terminate supraventricular tachydysrhythmias. 2. Carotid sinus massage a. The PHCP instructs the client to turn the head away from the side to be massaged. b. The PHCP massages over 1 carotid artery for a few seconds to determine whether a change in cardiac rhythm occurs. c. The client must be on a cardiac monitor; an electrocardiographic rhythm strip before, during, and after the procedure should be documented on the chart. d. Have a defibrillator and resuscitative equipment available. e. Monitor vital signs, cardiac rhythm, and level of consciousness following the procedure. 3. Valsalva maneuver a. The PHCP instructs the client to bear down or induces a gag reflex in the client to stimulate a vagal response. b. Monitor the heart rate, rhythm, and BP. c. Observe the cardiac monitor for a change in rhythm. d. Record an electrocardiographic rhythm strip before, during, and after the procedure. e. Provide an emesis basin if the gag reflex is stimulated, and initiate precautions to prevent aspiration. f. Have a defibrillator and resuscitative equipment available.

A pediatrician has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant?

When drawing blood for electrolyte level testing Rationale: Heart failure (HF) is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. Crying exhausts the limited energy supply, increases the workload of the heart, and increases the oxygen demands. Oxygen administration may be prescribed for stressful periods, especially during bouts of crying or invasive procedures

sinus bradycardia interventions

a. Attempt to determine the cause of sinus bradycardia; withhold medication suspected of causing the bradycardia and notify the PHCP. b. Administer oxygen as prescribed for the symptomatic client. c. Administer atropine sulfate as prescribed to increase the heart rate to 60 beats per minute. d. Be prepared to apply a noninvasive (transcutaneous) pacemaker initially if the atropine sulfate does not increase the heart rate sufficiently. e. Avoid additional doses of atropine sulfate, because this will induce tachycardia. f. Monitor for hypotension and administer fluids intravenously as prescribed. g. Depending on the cause of the bradycardia, the client may need a permanent pacemaker

management of dysrhythmias cardioversion

a. Cardioversion is synchronized countershock to convert an undesirable rhythm to a stable rhythm. b. Cardioversion can be an elective procedure performed by the PHCP for stable tachydysrhythmias resistant to medical therapies or an emergent procedure for hemodynamically unstable ventricular or supraventricular tachydysrhythmias. c. A lower amount of energy is used than with defibrillation. d. The defibrillator is synchronized to the client's R wave to avoid discharging the shock during the vulnerable period (T wave). e. If the defibrillator is not synchronized, it could discharge on the T wave and cause VF.

Premature ventricular contractions

a. Early ventricular contractions result from increased irritability of the ventricles. b. PVCs frequently occur in repetitive patterns such as bigeminy, trigeminy, and quadrigeminy. c. The QRS complexes may be unifocal or multifocal

premature ventricular contractions PVCs interventions

a. Identify the cause and treat on the basis of the cause. b. Evaluate oxygen saturation to assess for hypoxemia, which can cause PVCs. c. Evaluate electrolytes, particularly the potassium level, because hypokalemia can cause PVCs. d. Oxygen and medication may be prescribed in the case of acute myocardial ischemia or MI.

management of dysrhythmias cardioversion preprocedure interventions and during the procedure

a. If an elective procedure, ensure that informed consent is obtained. b. Administer sedation as prescribed. c. If an elective procedure, hold digoxin for 48 hours preprocedure as prescribed to prevent postcardioversion ventricular irritability. d. If an elective procedure for atrial fibrillation or atrial flutter, the client should receive anticoagulant therapy for 4 to 6 weeks preprocedure, and a transesophageal echocardiogram (TEE) should be performed to rule out clots in the atria prior to the procedure. During the procedure a. Ensure that the skin is clean and dry in the area where the electrode pads/hands-off pads will be placed. b. Stop the oxygen during the procedure to avoid a fire hazard. c. Be sure that no one is touching the bed or the client when delivering the countershock (check the entire length of the client 3 times).

Ventricular fibrillation

a. Impulses from many irritable foci in the ventricles fire in a totally disorganized manner. b. VF is a chaotic rapid rhythm in which the ventricles quiver and there is no cardiac output. c. VF is fatal if not successfully resolved within 3 to 5 minutes. d. Client is unconscious with no pulse, BP, respirations, or heart sounds.

Ventricular fibrillation interventions

a. Initiate CPR until a defibrillator is available. b. The client is defibrillated immediately with 120 to 200 joules (biphasic defibrillator) or 360 joules (monophasic defibrillator); check the entire length of the client 3 times to make sure no one is touching the client or the bed; when clear, proceed with defibrillation. c. CPR is continued for 2 minutes, and the cardiac rhythm is reassessed to determine the need for further countershock. d. Administer oxygen as prescribed. e. Administer antidysrhythmic therapy as prescribed.

Atrial fibrillation

a. Multiple rapid impulses from many foci depolarize in the atria in a totally disorganized manner at a rate of 350 to 600 times per minute. b. The atria quiver, which can lead to the formation of thrombi. c. Usually no definitive P wave can be observed, only fibrillatory waves before each QRS.

Ventricular tachycardia

a. VT occurs because of a repetitive firing of an irritable ventricular ectopic focus at a rate of 140 to 250 beats per minute or more. b. VT may present as a paroxysm of 3 self-limiting beats or more, or may be a sustained rhythm. c. VT can lead to cardiac arrest.

The nurse is instructing the parents of a child with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction should the nurse tell the parents?

administer iron through a straw Rationale: In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. An oral iron supplement should be administered through a straw or medicine dropper placed at the back of the mouth, because the iron stains the teeth. The parents should be instructed to brush or wipe the child's teeth or have the child brush the teeth after administration. Iron is administered between meals because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in the duodenum. Iron is not added to formula or mixed with cereal or other food items

For the client experiencing PVCs, notify the PHCP or cardiologist if the client complains of

chest pain or if the PVCs increase in frequency, are multifocal, occur on the T wave R-on-T, or occur in runs of ventricular tachycardia

The nurse is providing home care instructions to the parents of a 10-year-old child with hemophilia. Which sport activity should the nurse suggest for this child?

swimming Rationale: Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Children with hemophilia need to avoid contact sports and to take precautions such as wearing elbow and knee pads and helmets with other sports. The safe activity for them is swimming.

Signs and symptoms of decreases cardiac output

▪ Decreased peripheral pulses ▪ Activity intolerance ▪ Feeding difficulties ▪ Hypotension ▪ Irritability, restlessness, lethargy ▪ Oliguria ▪ Pale, cool extremities ▪ Tachycardia

Interventions for cardiovascular defects

▪ Monitor for signs of a defect in the infant or child. ▪ Monitor vital signs closely. ▪ Monitor respiratory status for the presence of nasal flaring, use of accessory muscles, and for signs of impending respiratory distress, and notify the pediatrician if any changes occur. ▪ Auscultate breath sounds for crackles, rhonchi, or wheezes. ▪ If respiratory effort is increased, place the child in a reverse Trendelenburg's position, elevating the head and upper body, to decrease the work of breathing. ▪ Administer humidified oxygen as prescribed. ▪ Provide endotracheal tube and ventilator care if necessary as prescribed. ▪ Monitor for hypercyanotic spells and intervene immediately if they occur. ▪ Assess for signs of HF, such as periorbital edema or dependent edema in the hands and feet. ▪ Assess peripheral pulses. ▪ Maintain fluid restriction if prescribed. ▪ Monitor intake and output, and notify the pediatrician if a decrease in urine output occurs. ▪ Obtain daily weight. ▪ Provide adequate nutrition (high calorie requirements) as prescribed. ▪ Administer medications as prescribed. ▪ Plan interventions to allow maximal rest for the child; keep the child as stress-free as possible. ▪ Prepare the child and parents for cardiac catheterization, if appropriate.

Cardiac surgery postoperative home care

▪ Omit play outside for several weeks as prescribed. ▪ Avoid activities in which the child could fall and be injured, such as bike riding, for 2 to 4 weeks. ▪ Avoid crowds for 2 weeks after discharge. ▪ Follow a no-added-salt diet, if prescribed. ▪ Do not add any new foods to the infant's diet (if an allergy exists to the new food, the manifestations may be interpreted as a postoperative complication). ▪ Do not place creams, lotions, or powders on the incision until completely healed. ▪ The child may return to school usually the third week after discharge, starting with half-days. ▪ The child should not participate in physical education for 2 months. ▪ Discipline the child normally. ▪ The 2-week follow-up is important. ▪ Avoid immunizations, invasive procedures, and dental visits for 2 months; following this time period, the immunization schedule and dental visits need to be resumed. ▪ The child should have a dental visit every 6 months after age 3 years and inform the dentist of the cardiac problem so that antibiotics can be prescribed if necessary. ▪ Call the pediatrician if coughing, tachypnea, cyanosis, vomiting, diarrhea, anorexia, pain, or fever occur, or any swelling, redness, or drainage occurs at the site of the incision