Alterations in Cardiovascular Function in Children- PEDS Test 2

Kawasaki Disease (KD)

-acute febrile, systemic vascular inflammatory disorder -mulitsystem vasculitis: small to medium sized arteries throughout the body become inflamed; can cause life threatening damage to the coronary arteries and heart muscle -this is the leading cause of acquired heart disease in children in developed countries -Children < 5 years (peak 18-24 months) -children of asian american and african american descent are more at risk -increased cases in the late winter, early spring and comes in 3 year intervals -Diagnosis of exclusion - rule out everything else -if not caught early, can damage coronary arteries (vasculitis) and heart muscle and the child may need heart transplant if damage to heart is extensive and not caught & treated early -etiology is unknown, but research suggests: exaggerated immune response to an infection in a child with a genetic predisposition to an autoimmune response and the immune system attacks the coronary arteries- can cause coronary artery aneurysms -if caught and treated early the prognosis is good, but if not it can leave the child with irreversible heart damage -Three stages: acute, subacute, and convalescent.

Kawasaki Disease Phases and treatment

-acute phase: 1-2 weeks with high fever > 5 days -nurse needs to closely monitor cardiac status, VS, and observe for CHF -enchocardiogram, ECG, increased sed rate-> Repeat echocardiography and electrocardiography will be required for the first few weeks and at six months -early treatment can dramatically reduce the likelihood of cardiovascular damage: high-dose IV gamma-globulin and high-dose PA ASA therapy

Medications for Pediatric Heart Failure

-aim of medications: decreased cardia workload, improve cardiac output -types of medications: positive inotropes, diuretics, after load reducing meds

Shunt

-an extra blood vessel or opening in the heart that normally closes shortly after birth. -It is a detour that directs blood flow in a different direction

Gamma Globulin (IVIG)

-antibodies pooled from any individuals -you get a one time dose 2 k/kg -administered through an IV line for 10-12 hrs -calms down immune system and reduces inflammation -if given in the firs 7-10 days of fever onset, it will dramatically reduce the risk of damage to the coronary arteries -side effects: hypotension (monitor BP closely), facial flushing, tightness in the chest -benadryl and acetaminophen can control side effects -epinephrine is used if there is an anaphylactic rxn -live vaccines must be delayed for 11 months after IVIG treatment

Pulmonary stenosis

-area where blood exits the heart's lower right chamber is too narrow (right ventricular outflow tract obstruction) -narrowing can be in the pulmonary valve, in the muscles just below the valve, or in the pulmonary artery -The pulmonary valve is too tight, so that the flow of blood from the right ventricle of the heart into the pulmonary artery is impeded. Will result in right ventricular hypertrophy, if left untreated -mild, moderate, severe or life threatening -mild: asymptomatic, require only antibiotic prophylaxis -severe/critical: balloon vavuloplasty or open heart surgical repair -harsh systolic murmur

2nd shunt in fetal circulation

-blood goes from the inferior vena cava to the right atrium to the left atrium by the foramen ovale then to the left ventricle then to the aorta to supply the heart and brain -the foramen ovale is an opening between the upper right and left heart chambers or atria -Blood bypasses the fetal lungs; only a small amount of blood flows to the fetus' lungs

Manifestations: Pallor and Cyanosis

-bluish discoloration of the skin, nail beds, mucous membranes -hypoxia- tissues are deprived of adequate oxygen (O2 sat > 85%) -Hgb must be at least 5 to be cyanotic -Often appears when the child is feeding bc they are stressed -Polycythemia- compensatory response to chronic hypoxia -Clubbing- happens with chronic hypoxemia and the bed of nails get swollen and the ends of digits increase in size and the angle between nail and nailbed is greater than or equal to 180 degrees

Manifestations of RF

-carditis: inflammation of all parts of the heart (primarily mitral and aortic valves); new onset murmur; chest pain; congestive HF (SOB, rales, edema, etc.) -fever- 38.2-38.9 C (100.8-102 F) -arthalgia- joint pain without swelling -migratory polyarthritis- pain spreads from one joint to another -chorea- involuntary movements of legs, arm, and face -erythema marginatum- non-itchy red skin lesions on trunk -subQ nodules- nontender lumps locked over the joints

Invasive Diagnostic Test/Procedurs: Cardiac catheterization

-catheter threaded through right or left femoral artery or vein and guided to heart -Gives information about coronary arteries, blood oxygen levels, blood flow, cardiac output/stroke volume, anatomic abnormalities, cardiac conduction system -Used to close patent foramen ovale, close patent ductus arteriosus, open narrowed valves or arteries. -Apply direct pressure to catheter site for 15 to 30 minutes; if you notice bleeding, apply direct pressure to the site; check dressing first, then distal pulses. Monitor insertion site for bleeding.

Hypercyanotic episodes 'Tet spell'

-children with TOF exhibit blueish skin during episodes of crying or feeding-> put them in knee-to-chest position to increase blood flow or have the child squat. This maneuver decreases venous return (amount of blood returning to the heart), increases systemic resistance, and thereby increases blood flow to the lungs -oxygen is a drug with side effects-> too much o2 can be dangerous

HLHS Treatment

-comfort care: w/o surgery this is fatal within the first 2 weeks of life -mediactions: Prostaglandin E1 infusion to keep ductus open -surgery: 3-staged palliative surgery (ages 1 week, 6 months, and 2 years of life) -heart transplant: infrequence due to scarcity of neonatal donor hearts (real cure)

Tachycardia

-compensatory mechanism -Can be a sign of hypoxia, hypovolemia, fever, stress, excitement, pain, fear, anemia, exercise, etc-> try to treat the underlying cause a the tachycardia will go away -If the cause of the tachycardia is not detected and treated (especially hypoxia or hypovolemia), the child will eventually become bradycardic and have cardiac arrest. -Bradycardia is a pre-terminal rhythm in children-> they arent trying to compensate anymore if there's bradycardia-> a lot of times there is a respiratory problem as the underline cause that leads to a cardiac problem-> try to fix the respiratory problem first

VSD- Patch Closure

-corrective surgery -purse-string suture around small defects -"patch" over large defects -open heart surgery -requires cardiopulmonary bypass -antibiotic prophylaxis to prevent endocarditis

Interventional Catheterization

-corrective treatments performed by use of specialized catheters-> they can actually fix the problem while your in the cath lab -balloon catheters- open narrowed valves or arteries -balloon/blades- shunt creations, septostomy -device dosure- close extra vessels, "holes" in heart

RF treatment

-damaged valves can become further damaged with repeated infections -streptococcal antibiotic prophylaxis for many years: penicillin VK (oral), penicillin G benzathine (IM) -anti-inflammatory agents: aspirin (for fever, arthritis, and joint inflammation/pain), corticosteroids (for severe carditis- heart muscle inflammation) -monitor for cardiac complications

3rd shunt in fetal circulation

-deoxygenated blood from the upper body mixes with the oxygenated blood from the placenta at the right atrium -Ductus arteriosus is a blood vessel that connects the pulmonary artery to the descending aorta. Shunts blood away from pulmonary circulation -blood returns to the placenta by way of the two umbilical arteries

1st shunt in fetal circulation

-ductus venosus- fetal structure connecting inferior vena cava to umbilical vein -causes most of the fetal liver to be bypassed (blood is shunted away from the liver) because the fetus doesn't need liver bc the mothers taking over that function for it

Congenital Heart Diseases

-family history of congenital heart disease -fetal exposure to drugs such as anticonvulsants, diazepam, and lithium -maternal diabetes mellitus -maternal vital infections (rubella, CMV) -mothers 35+ -trisomy 21 (down syndrome)

VSD- Pulmonary Artery Banding

-helps prevent pulmonary vascular obstructive disease -palliative surgery -closed heart surgery- doesn't require cardiopulmonary bypass -band placed around pulmonary artery, decreased pulmonary blood flow -used when VSD cannot be closed (multiple VSD's, very small infants with severe CHF) -less frequently done that corrective surgery

Atrial Septal Defect (ASD)

-hole of defect in the atrial septum (wall) -> upper chambers -often asymptomatic -systolic murmur -large defect: CHF, pulmonary vascular disease (often 1st appearing as an adult); sometimes can cause problems with SA node and person can get afib -antibiotic prophylaxis -treatment: "patch"

Hypoplastic Left Heart Syndrome (HLHS)

-inadequate development of the left side of the heart -one one functional ventricle -aortic valve, mitral valve, and ascending aorta may also be small or hypo plastic -S/S: cyanosis (appears "grey"), CHF, tachycardia, dyspnea, hypotension, weakness, hypoperfusion, shock, metabolic acidosis

Pediatric Pulmonary Hypertension (PH)

-increased pressure, narrowing: pulmonary arteries, arterioles -elevated mean pulmonary arterial pressure (PAP) > 25 mmHg -causes: lung disease, some congenital heart disease -RV failure-> Rt heart failure-> Lt heart failure-> reduced CO-> hypotension -Can be caused by lung disease (such as bronchopulmonary dysplasia or cystic fibrosis) or some congenital heart disease (acyanotic heart defects such as patent ductus arteriosus). -Signs & symptoms of infants: poor appetite, tachypnea, tachycardia, sweating, cyanosis -Signs & symptoms of children: fatigue, chest pain, dyspnea, dizziness, syncope -DX: echocardiography, cardia cath

Treatment of Pulmonary Hypertension

-it is rapidly lethal-> must treat early while still reversible before permanent destructive changes take place in the pulmonary arterie like stiffness and increased resistance to blood flow in the lungs -treat underlying cause (if known) -cardiac cath- determines severity of condition -surgery within 3-6 months if ASD, VSD, AVSD, PDA -medications: Sildenafil (Revatio, Viagra). Sildenafil relaxes and widens the blood vessels in the lungs and thereby decreases the pulmonary blood pressure to the heart and improves its function, O2, nitric oxide (dilates blood vessels in lung to decrease pressure), calcium channel blockers (nifedipine), and diuretics -a lung transplant is necessary in severe cases -Avoid strenuous activities such as contact sports or weight-lifting, or anything that causes dyspnea.

Acyanoitc heart lesions

-left to right shunting (blood flows from the left heart to the right heart) -Ventricular septal defects -Patent ductus arteriosus (PDA) -Atrial septal defect (ASD) -Atrioventricular septal defect (endocardial cushion defect)

Ventricular Septal Defect (VSD)

-most common -hole or defect in ventricular septum (lower chambers) -increased pulmonary blood flow -pulmonary HTN -usually not symptomatic at birth -loud, hard, systolic murmur -large defects: CHF, poor feeding, failure to thrive -20-60% close spontaneously -most children don't need surgery, but outgrow the condition on their own -CHF- treat with lanolin and lassie -need extra nutritional supplements

Auscultation

-normal areas of auscultation: PMI: 3-4th ICS infants; 4th ICS < 7 yoa; 5th ICS > 7 -listen for regular rhythm -S1- beginning of systole-> heard best at the apex of the heart (close of AV valves) "lub" -S2- close of semilunar valves- heart best at second ICS space "dub" -S3 normal findings in kids- heard after s2 -S4- cardiac failure- always pathologic- heard before s1 -murmurs- turbulent blood flow that is graded (like 3/6) -auscultate apical pulse with a stethoscope for a full 60 seconds -the younger the child, the faster the HR bc they can't compensate with SV they can only adjust rate so they have to make their heart beat faster -APEToMan

Circulation after birth

-now the fetal shunts close in response to the pressure changes and increased pa02 levels in the pulmonary and systemic circulations -can take 24-48 hours for the ductus arteriosus to close -now deoxygenated blood goes to the right side of the heart to the lungs and oxygenated blood goes into the left side of the heart to go to the rest of the body

Inspection on a cardiovascular assessment

-observe the overall appearance of the child; state alertness, activity level -color (central and peripheral_ -oral mucosa -chest (size, shape, and symmetry) -respiratory (rate, rhythm, work of breathing) -presence of edema -clubbing

Aortic stenosis

-obstruction of blood flow from the heart to the body (obstruction to blood flow leaving left ventricle) - Narrowing of the aortic valve, impeding delivery of blood from the heart to the body. Will result in left ventricular hypertrophy, if left untreated -increase after load -decreased cardiac output -decreased systemic blood flow -harsh systolic murmur -mild: asymptomatic, exercise fatigue-> can do normal ADLs but we you try to increase activity you get tired-> continue to monitor -severe/critical: CHF, left ventricular hypertrophy, shock-> aortic balloon valvuloplasty (cardiac cath), surgical valvotomy -may need aortic valve replacement, antibiotic prophylaxis to prevent endocarditis

Truncus Arteriosus

-one large blood vessel that leads out of the heart -VSD usually present -cyanosis soon after birth -oxygen-poor blood and oxygen-rich blood mix together -systolic click -harsh systolic murmur -in the first few days of life there will be CHF symptoms -Dx: echocardiogram

TOF repair

-open-heart surgery -2-4 months -1. VSD patched -2. Pulmonary valve widened -no treatment for displaced aorta and enlarged right ventricle -antibiotic prophylaxis to prevent endocarditis

Patent ductus Arteriosus (PDA)

-opening between aorta and pulmonary artery -increases pulmonary blood flow -blood flows back to left atrium/left ventricle-> left ventricular hypertrophy -CHF (left side) -Respiratory distress -machinery-type-murmur -lungs and left heart get overloaded

Pressure differences

-oxygenated blood flow (from the placenta) is from right to left -oxygenated blood enters the right side of the fetal heart so the blood pressure on the right side of the heart is greater than the blood pressure on the left side of the heart -there is high resistance in fetal lungs (arterioles are constricted, alveoli are filled with fluid) -resistance to blood flow in the lungs (pulmonary vascular resistance is greater than resistance to blood flow in the body (systemic vascular resistance -fetal lungs don't receive much blood

Gas exchange

-oxygenation and removal of carbon dioxide takes place in the placenta -The umbilical cord carries blood with oxygen and nutrients from the mom straight to the right side of the heart. -Fetus's lungs are mostly bypassed because of the high resistance or barrier to blood flow in the lungs

Blalock-Taussig Shunt

-palliative procedure -closed-heart surgery -shunt created from aorta (via the subclavian artery) to pulmonary artery -increased blood flow to the lungs -"buys" time for infants to grow -increase success of corrective surgery when done later

Pediatric Congestive Heart Failure- Right sided failure (Cor Pulmonale)

-periorbital an facial edema, enlarged liver or spleen, ascites, wheezing, neck vein distention, weight gain, fatigue -increased central venous pressure (pooling of venous blood) -decreased cardiac output -casuses: left-right shunts (blood flows from the left heart to the right heart) like Ventricular Septal Defect or Atrial Septal Defect -the lungs are clear but the rest of the body isn't

Obstructive/Stenotic lesions

-pulmonary stenosis -aortic stenosis -coarctation of the aorta -SOMETHING IS CLOSED THAT SHOULD BE OPEN

Pediatric Congestive Heart Failure

-pump is insufficient to meet the metabolic demands of the body either due to 1) Structural problems in the heart - or- 2) Weakness of actual heart muscle -heart becomes overloaded and unable to deliver adequate cardiac output -most commonly caused by congenital heart defects -acquired conditions: rheumatic heart disease, endocarditis, myocarditis, cardiomyopathies, severe dysrhythmias -Three early signs: tachycardia, poor feeding, diaphoresis during feeding. -Other signs: weight gain, crackles, edema, tachycardia (compensatory mechanism for increasing cardiac output where the heart is failing as a pump), decreased urinary output. -Congestive heart failure is the primary concern in infants with acyanotic heart lesions

Tetralogy of the Fallot (TOF)

-right-to-left shunt: pulmonic pressure > systemic pressure -unoxygenated blood bypasses pulmonary circulation and goes directly to the left side of the heart to be pumped into the systemic circulation -"blue baby"- cyanosis -symptomatic soon after birth -decreased pulmonary blood flow

Palpation on a cardiovascular assessment

-skin temperature, turgor -fontanels in infants -peripheral pulses (location, rate, rhythm, strength) -blood pressure (LAST vital sign to indicate a child is in trouble) -cap. refill: normal in children < 2 seconds -chest (thrills, point of maximal impulse

Nursing care after cardiac surgery

-sternal precautions: if you have a child that had their sternum cracked open- lift them by their trunk, not by their arms-> you don't want to crack it open again -chest tube, NGT, ventilator, cardiac monitor, pulse oximetry -encourage cough and incentive spirometry -monitor VS, cardiac, respiratory, I & O, electrolytes, and chest tube drainage -this is a very painful surgery-> they need adequate pain control!

Pediatric Congestive Heart Failure- Left sided failure

-tachypnea, dyspnea, crackles, intercostal/sternal retractions, wheezing, cough, blood-tinged sputum, restlessness, orthopnea -pulmonary edema -causes: right-to-left shunts (blood flows from the right heart to the left heart); Patent ductus arteriosus or Coarctation of the Aorta

Transposition of the Great Arteries (TGA)

-there is a reversal of the aorta and pulmonary arteries-> aorta rises from the right ventricle and the pulmonary artery arises from the left ventricle -this is incompatible with life -babies born with TGA can only survive if they have one or more connections that allow some oxygenated blood to go to the body like PDA or ASD) -they will be given Prostaglandin E1 which keeps ductus open or have a balloon atrial septostomy done to keep foramen ovale open -corrective surgery is performed in the early days following birth like the atrial switch procedure: aorta and pulmonary artery returned to their normal positions

RF Diagnostics

-theres not a clear cut diagnostic procedure so we use Jones criteria: at least two signs plus evidence of recent strep infections (like positive throat culture or antistrepotolysin O titer (+ASO)- tells if someone has strep recently) -elevated erythrocyte sedimentation rate or C-reactive protein -changes on EKG or echocardiogram -monitor for cardia complications- murmurs, CF

Manifestations of Acyanotic Heart Lesions

-they still have normal oxygenated blood -systemic pressure > pulmonic pressure -oxygenated blood backaches to the right side of the heart -venous blood does NOT enter systemic circulation -ALL of the blood returning to the right side of the heart passes through the lungs-> increases pulmonary blood flow (lungs become overloaded- pulmonary HTN) -hct and hub is in normal range -early sign = poor feeding -no cyanosis -not always present at birth (cyanotic heart disease is bc you can't see right away when they don't pink up-> this can take weeks till you know) -enlarged heart usually on the right side sometimes the left -congestive HF -enlarged liver, dyspnea, tachypnea, intercostal retractions, poor growth, frequent resp. infections

S/S of TOF

-x-ray: heart is "boot-shaped" -cyanosis, difficulty breathing -clubbing of the fingers (bc of the hypoxemia) -systolic murmur, palpable thrill -polycythemia -hypercyanotic episodes

Three types of congenital heart disease

1. Acyanotic 2. Obstructive 3. Cyanotic

Two types of heart disease in children

1. Congenital: one of more heart structure abnormalities that develop before birth or persistence of fetal structure after birth-> usually has a genetic component (multifactorial) 2. Acquired: any cardiac condition that was not present at birth

TOF Surgical Repair

1. Palliative: relieves symptoms by increasing the blood flow to the lungs 2. Corrective: Repairs the underline defects

3 Stages of HlHS Palliative surgery

1. Stage 1: The Norwood procedure: this occurs at 1 week of age and it provides blood flow from the right ventricle directly to the aorta 2. Stage 2: The Bi-directional Glenn: this occurs at 6 months of age 3. Stage 3: The fontal Procedure: this occurs at 2 years of age-> reroutes blood flow around the defective areas of the heart by creating new pathways for blood circulation to and from the lungs

Four distinct lesions of TOF

1. Ventricular septal defect 2. Pulmonic stenosis- severity of cyanosis depends primarily on degree of this 3. Overriding aorta- aorta is malpositioned-> over left and right ventricle instead of just left 4. Right ventricular hypertrophy

The father of a child with cyanotic congenital heart defect asks the nurse why his daughter has to take amoxicillin before invasive dental work. The nurse explains that this is necessary to prevent: A. Bacterial endocarditis B. Congestive heart failure C. Rheumatic fever D. Infected gums

A. Bacterial endocarditis

Parents of children with congenital heart problems often experience loss of control when the child is hospitalized. The nurse who understand this will: (select all that apply): A. Encourage parents to participate in their child's care B. Explain procedures prior to performing them C. Answer questions honestly D. Urge parents to find local or Internet support groups E. Minimize disruptions during family time

A. Encourage parents to participate in their child's care B. Explain procedures prior to performing them C. Answer questions honestly D. Urge parents to find local or Internet support groups E. Minimize disruptions during family time

A toddler with Kawasaki's disease is ordered to receive aspirin therapy. Typical administration of aspirin for Kawasaki Disease would include which of the following principles? A. High doses of aspirin should be given while fever is high B. Aspirin therapy is given to reduce fever C. Aspirin dose increases after fever is gone D. Aspirin dosage is unrelated to platelet count

A. High doses of aspirin should be given while fever is high

The pediatric nurse practitioner orders a complete blood workup for a 5 month-old infant with cyanotic congenital heart defect. Because of the infant's heart disease, the nurse would expect the report to show: A. Polycythemia B. Agranulocytosis C. Thrombocytopenia D. A decreased hct level

A. Polycythemia

An infant with a left-to-right shunt was admitted to the hospital in congestive heart failure. She weight 3.6 kg yesterday. A finding that indicates a worsening of her condition today is: (select all that apply) A. Weight 3.66 kg B. Urine output of 40 mL in past 8 hours C. Crackles in the lower lobes D. Decreased venous return E. Ejection fraction of 65%

A. Weight 3.66 kg B. Urine output of 40 mL in past 8 hours C. Crackles in the lower lobes

Heart disease in children

-#1 Sign - respiratory (frequent respiratory infections and dyspnea). -#2 Sign - poor feeding poor sucking and swallowing; getting fatigued during feeding. -#3 Sign - activity intolerance, fatigue. -#4 Sign - growth and development delays; low-weight, stunted growth, failure to thrive.

Nursing care with cardiac catheterization

-#1 thing: observe for bleeding at the site!-> if blood hasn't clotted successfully they can bleed out in a matter of minutes -child must lay still, supine, with affected leg straight for 4-6 hours -vital signs, insertion site observed, distal pulses checked q15 minutes for the first hour then every 30 mins -observe for pallor, loss of pulses, coolness in extremity distal to site -push fluids to help flush the dye out of the body -observe for reactions to dye (vomiting, rash, increased serum creatinine, decreased urinary output) -keep a strict I & O

HLHS Prognosis

-4 year survival following 3 stage repair up to 85% -long-term survival remains to be seen -long term complications ventricular and valvular dysfunction, dysrhythmias, low albumin, pleural effusions, ascites -as they get older it gets harder for them-> they get more blue and increased activity intolerance and don't grow fully

Kawasaki Disease diagnostic criteria

-5 days of high fever > 39° C/ 102.2° F (unresponsive to antibiotics and antipyretics),and at least 4 of the 5 major clinical features: 1. Redness of eye conjunctiva (the eyes are generally dry without any exudate) 2. Red, cracked, fissured lips, and a strawberry tongue (normal coating of the tongue sloughs off) 3. Redness/ swelling/ desquamation/ affecting palms & soles 4. Red rash (trunk and genital area) 5. Swollen lymph node in neck

Coarctation of the aorta

-Aorta pinched at some point along its length, limiting the amount of oxygen-rich blood that can reach the rest of the body beyond this pinched area. -increase pulmonary congestion (pooling of blood in the left side of the heart), bounding pulses in the upper body, decreased pulses and blood pressure in the lower extremities; cold feet and legs; blood pressure higher in arms than legs or thighs, NEC, kidney failure, poor feeding, epistaxis, headache, brain bleeds -increase after load, decrease CO, decrease systemic blood flow

PDA treatment

-CHF: digoxin, lasix -Medical- indomethacin (Indocin) -Interventional cardiac catch where they can fix the problem in the cath lab -Surgical- ligation of ductus (left thoracotomy)

Invasive Diagnostic Test/Procedurs: Cardiac surgery

-Cardiopulmonary bypass surgery: repair to the heart and accompanying structures while connect to a heart lung bypass machine-> heart is stopped-> break open the chest for this -Off-pump heart surgery "beating heart surgery": repair to the heart and structures while the heart is beating; done without a heart-lung bypass machine; minimally invasive cardiac surgery

Cardiovascular assessment in children

-Children generally have very good cardiovascular health. This enables them to compensate well for circulatory problems. Consequently, there will rarely be a change in a child's blood pressure until the child is about to go into cardiac arrest. -The heart rate for a child, therefore, makes a better diagnostic tool for cardiovascular health than blood pressure. Poor weight gain with failure to thrive is a common sign of congenital heart disease. -Best way to check for cardiovascular status is color and respiratory rate.

Feeding Interventions

-Cluster care: Periods of uninterrupted rest. -Frequent, small feeds - every 3 hours and feed the child slowly -Give them concentrating formula 24 -27 kcal/ oz to increase the caloric intake w/o increasing the infants work -Limit bottle or breast feeding to 30 minutes-> after this the infant is just waiting energy-> feed the rest by gavage (like ng tube) -Provide a neutral thermal environment. -Place infant on right side after feeding with HOB up. -Gavage feeding - allows extra calories to be consumed for growth without energy expenditure (supplemental feedings) -Monitor for increased tachypnea, diaphoresis, or feeding intolerance (vomiting)

Circulation after birth- pressure changes

-Decreased resistance to pulmonary blood flow so there is a marked increase in pulmonary blood flow. -Increased resistance in systemic circulation (so you get increased BP) -the umbilical cord is clamped after birth which decreases the blood to the right side of the heart so now the blood pressure on the left side of the heart greater than blood pressure on the right side of the heart -systemic vascular resistance greater than pulmonary vascular resistance -overall: high systemic pressure and low pulmonary pressure

Fetal circulation

-Fetal circulation differs from neonatal circulation in 3 ways: 1. Gas exchange 2. Pressures (systemic and pulmonary circulations) 3. Structures (shunts, umbilical cord)

Labs

-Hgb (12), Hct (36)-> you can have a hgb and hct of 6 and 20 and still be 100% saturated-> if a child becomes extremely hypoxic hey will raise hgb and hct levels (called polycythemia) to compensate for the low o2-> this only happens with cyanotic problems bc with acyanotic problems they don't have the hypoxia -serum electrolytes (esp. K+, Mg++, Ca++) -ABG -Digoxin level -Cholesterol -Triglycerides -Urine SG

Indomethacin (Indocin)

-IV -NSAID- inhibits the production of prostaglandins to promote closure of PDA; onset of action usually within minutes -closure of PDA in 80% of pts -monitor renal function -side effects: bleeding (intraventricular hemorrhage, GI bleeds)

Digoxin (Lanoxin)

-IV or PO -slows and strengthens heart contractions, enabling the heart to pump more blood with each beat -Increases Contractility (the SQUEEZE of the heart independent of the effects of preload and after load) -Toxicity: failure to thrive, anorexia, nausea & vomiting, bradycardia, or dysrhythmias (i.e., change in heartbeat [fast, slow, or irregular])-> if child starts having flu like symptoms make sure their not dig toxic -Monitor: heart rate. Count apical pulse for a full minute before giving-> call physician before giving if HR < 100 BPM in an infant/toddler or if < 70 in children -Also know dig level before giving -Give at the same time each day with doses equally spaced apart -dont use teaspoon or eye dropper- draw up in syringe or calibrated dropper and always remove the cap before administering the medication into the child's mouth

Furosemide (Lasix)

-IV, IM, PO -blocks the sodium reabsorption in the ascending loop of Henle -decreases preload by increasing water excretion-> Preload is the VOLUME of blood returning to the heart to fill a ventricle before it contracts (the "filling pressures") -side effects: electrolyte imbalances (decreased K+ and decreased Mg), metabolic alkalosis, hypotension -monitor: electrolytes (question giving this is K+ is low), urinary output, BP (question giving this if BP is low), and daily weights

Ineffective Endocarditis

-Infection of inner lining of heart (endocardium), heart valves, or a cardiac prosthesis resulting from bacterial or fungal invasion. This invasion produces vegetative growths on the heart valves, the endocardial lining of a heart chamber, or the endothelium of a blood vessel that may embolize to the spleen, kidneys, central nervous system, and lungs. If emboli travel to the brain, endocarditis can have profound and devastating neurologic consequences -Dental work is a common portal of entry for infective endocarditis, if not pretreated with antibiotics. Heart surgery is also a common cause of endocarditis, especially if synthetic material is used. -Symptoms: Low-grade intermittent fever; decrease in hemoglobin level; tachycardia; anorexia; weight loss; decreased activity level; tiredness; new heart murmur; nontender, small, dark spots on palms and soles (Janeway lesions); purple-red pinpoints under the skin (petechiae); dark lines under the nails (splinter hemorrhages); painful, red, raised lesions found on pads of fingers and toes (Osler's nodes) -Treatment: IV antibiotic therapy for 4-6 weeks; surgery to replace affected valves.

Right vs Left sided congestive heart failure

-Left-sided heart failure = blood and fluid back up into the Lung -Right-sided heart failure = blood and fluid back up into the Rest of the body -most children with CHF have a combination of both left and right so they would have: tachycardia, cardiomegaly, decrease CO, gallop rhythm (S4), decreased peripheral perfusion, excessive diaphoresis, weight gain, crackles, delayed cap refill; the blood is diverted to vital organs and away from the GI tract-> at risk for NEC

Truncus Arteriosus Treatment

-Medications: diuretics and digoxin -Surgery: Rastelli Procedure (within 1 week of birth)- patch the septum from the VSD and create and new pulmonary valve and artery conduit created and connected to the right ventricle and new aorta reconstructed -they can't do any competitive/strenuous sports -they will have life-long follow up care and follow up surgeries to enlarge the pulmonary artery conduit -endocarditis prophylaxis for life

Rheumatic Fever (RF)

-Multisystem disorder caused by autoimmune reaction to group A beta-hemolytic streptococcal throat infection-> it is an autoimmune reaction to the bacteria (group A beta-hemolytic streptococcal) that causes strep throat (typical tonsillar exudate or strawberry tongue) or scarlet fever (bright red rash that covers most of the body) May involve the heart, joints, central nervous system, and skin/ subcutaneous tissues. -Same age as strep throat (5-15). -"strep throat" that isn't adequately treated with antibiotics-> manifests 1-3 weeks afterwards -most serious sequelae: cardiac valvular disease (esp. scarring of mitral or aortic valve) -prevention: refer all children with sore throats for throat cultures and adequately treat with antibiotics

Captopril (Capoten)/ ACE inhibitors

-PO -Dilates arteries and veins by blocking angiotensin II, thereby lowering blood pressure and making it easier for the heart to pump blood forward into the body -reduces after load (blood pressure)-> Afterload is the RESISTANCE the heart must overcome to push the blood out. Afterload is the major workload of the heart (burns up most oxygen, energy) -monitor blood pressure carefully and renal function

Spironolactone (Aldactone)

-PO -Potassium-sparing diuretic -decreases preload (similar to Furosemide) -side effect: hyperkalemia (if K+ is high question giving this), hypovolemia, contraindicated in renal failure -monitor I & O, electrolytes, BO

Aspirin (ASA)

-PO, administer with milk or food -given to prevent aneurysms from developing in the coronary arteries -anti-inflammatroy agen- blocks the production of prostaglandins that cause tissue swelling and pain -antiplatelet aggregation agent- causes platelets to lose the "stickiness: needed to stimulate blood clotting -high dose therapy: 8-100 mg/kg/day for the first 2 weeks for its anti-inflammatory effects -then low dose aspirin 2-5 mg/kg/day is initiated for its anti-platelet activity for 6-8 weeks -for pts who have developed coronary aneurysms, aspirin is continued -side effects: bleeding

Antibiotic prophylaxis of Endocarditis

-Preventative antibiotics (e.g., amoxicillin or ampicillin) are recommended for children with certain heart conditions one hour before invasive dental procedures, oral procedures, or upper respiratory tract procedures; a second dose is not necessary -At-risk clients include those with unrepaired congenital heart defects, heart defects repaired with synthetic material, or prior infective endocarditis, and some children with heart transplants -any unexplained fever or malaise within 2 months of the procedure may be a sign of infection (endocarditis) -brushing, flossing, and routine dental visits help prevent tooth and gum infections that could lead to endocarditis

Non-invasive Diagnostic Test/Procedurs

-Pulse oximetry - degree of saturation in the blood using a small inferred light probe that is play on finger, toe, earlobe, bridge of nose. Norm (in most cases) 95-100%-> cyanosis not visible until sat <85% -12-lead ECG - displays cardiac muscle, heart rate and rhythm cardiac impulse conduction-> tell child to be calm/still -Chest x-ray - information about heart size, blood flow to lungs, position of stomach, liver, and heart. -Echocardiogram - ultrasound; size and thickness of heart chambers, motion of blood through the chambers, blood flow through the heart valve-> can detect structural abnormalities of the heart - especially important for valves - shape, motion, narrowing, or leaking.

Cyanotic heart lesions

-Right-to-left shunting (blood flows from the right heart to the left heart)-> deoxygenated blood going to the body -C.P.R-> cyanotic heart defect, pulmonic pressure > systemic pressure, right-to-left shunt -Tetralogy of the Fallot (TOF) -Truncus Arteriosus (TA) -Transposition of the Great Arteries (TGA) -Hypoplastic Left Heart Syndrome (HLHS)

Coarctation of the aorta treatment

-Symptomatic CHF: digoxin, furosemide, oxygen -Symptomatic newborns: prostaglandin E1 (PGE1) infusion to keep the ductus arteriosus patent (improves perfusion to lower body, kidneys, GI system) -balloon angioplasty -surgical repair: left thoracotomy with anastomosis -antibiotic prophylaxis to prevent endocarditis

Circulation after birth- gas exchange

-With the neonate's first breath (really first scream), gas exchange is transferred from the placenta to the lungs -increased o2 levels and decreased co2 levels

When examining the laboratory work of a child with the diagnosis of RH, the nurse would expect the findings to demonstrate: A. A negative C-reactive protein B. A positive antistreptolysin titer C. An elevated reticulocyte count D. A decreased erythrocyte segmentation rate

B. A positive antistreptolysin titer

A cardiac catheterization is scheduled for a 5-year-old with a ventricular septal defect to: A. Identify the degree of cardiomegaly present B. Demonstrate the exact location of the defect C. Confirm the presence of a pansystolic murmur D. Establish the presence of a ventricular hypertrophy

B. Demonstrate the exact location of the defect

The mother of a 5-month-old infant with congestive HF questions the necessity of weighing the infant every morning. The nurse's response should be based on the fact that this daily information is important in determining: A. Renal failure B. Fluid retention C. Nutritional status D. Medication dosage

B. Fluid retention

A toddler has been diagnosed with an acyanotic heart defect. Which assessment data would most likely indicate congestive HF? A. Heart murmur B. Increased venous return C. Polyuria D. Excitability

B. Increased venous return-> increased preload; fluid overload

The nurse is aware that the aim of palliative surgery for children with tetralogy of Fallot is to: A. Brain B. Lungs C. Myocardium D. Right ventricle

B. Lungs

A 3 1/2 year old child returns to the room after a cardiac catheterization. Post procedure nursing care for a child should include: A. Encourage early ambulation B. Monitoring insertion site for bleeding C. Restricting fluids until blood pressure is stabilized D. Comparing blood pressure in affected and unaffected extremities

B. Monitoring insertion site for bleeding

When caring for a 4 month old infant with congestive heart failure, the nurse should: A. Force nutrition fluids B. Provide small, frequent feedings C. Measure the head circumference daily D. Position the infant flat on the abdomen

B. Provide small, frequent feedings

A 4 month old who has a congenital heart defect develops congestive heart failure and is exhibiting marked dyspnea at rest. This finding is attributed to: A. Anemia B. Hypovolemia C. Pulmonary edema D. Metabolic acidosis

C. Pulmonary edema

A newborn with TOP is fed in the semi-fowlers position. After the nurse feeds and burps the infant and changes the infant's position, the infant has a bowel movement and almost immediately becomes cyanotic, diaphoretic, and limp. These symptoms are most likely caused by the: A. Burping B. Formula C. Position change D. Bowel movement

D. Bowel movement

A toddler is hospitalized with CHF and is receiving Digoxin and Lasix. She has vomitied twice in the past 4 hours. The nurse's best action is to: A. Increase the child's fluid intake B. Omit the next dose of Lasix C. Check the child's blood pressure prior to the next dose of digoxin D. Get an order to draw a digoxin level

D. Get an order to draw a digoxin level

A 3 year old client weighing 15 kg is admitted for congestive heart failure. What observation by the nurse indicates that the client's condition is getting worse? A. Arterial blood gases show a pH of 7.4; PaCo2 of 36 mmHg B. Blood pressure is 86/56 mmHg; pulse is 110 beats/min C. Urinary output is 30 mL/hr; crackles are heard at the base bilaterally D. Irritability and confusion are increasing

D. Irritability and confusion are increasing -bc of the insufficient o2 getting to the brain

A child diagnosed with tetralogy of Fallot becomes upset, crying, and thrashing around when a blood specimen is obtained. The child's color suddenly becomes blue and the respiratory rate increases to 44 breaths/min. Which of the following actions would the nurse do first? A. Obtain an order for sedation for the child. B. Assess for an irregular heart rate and rhythm C. Explain to the child that it will only hurt for a short time D. Place the child in a knee-to-chest position

D. Place the child in a knee-to-chest position

When attempting to identify the presence of a congenital heart defect in an infant, the nurse should understand that: A. In the absence of cyanosis, sucking is insignificant B. Many infants retain mucous that may interfere with feeding C. Feeding problem are fairly common in pants during the first year D. Poor sucking and swallowing may be early indicator of heart defects

D. Poor sucking and swallowing may be early indicator of heart defects

An infant born at 39 weeks gestation is sent to he intensive care nursery. The nurse suspects a possible cardiac anomaly when the admission assessment reveals: A. Projectile vomiting B. An irregular respiratory rhythm C. Hyperreflexia of the extremities D. Unequal peripheral blood pressures

D. Unequal peripheral blood pressures -coarctation of the aorta

Atrioventricular Septal Defect (AVSD)

Large hole in the center of the heart; common with Down Syndrome -ASD, VSD are combined -left-to-right shunting: backward flow of oxygenated blood through both ASD and VSD to right side of heart -right-sided heart failure -pulmonary HTN -systolic murmur -medical: digoxin, diuretics, and after load reduction (ACE) -treatment: surgical repair early in infancy (4-6 months) before the lungs become damaged and permanent hemodynamic changes occur -"patches" over both septal defects and valvular repair -antibiotic prophylaxis to prevent endocarditis