Cardiac Disorders: Peds Exam 2

How is Endocarditis treated?

High dose of antibiotics -usually lasts 2 to 8 weeks -antlobtics given AFTER blood cultures taken

Which diuretic is potassium sparing?

Spironolactone

Rheumatic fever is a complication of...

Strep Infection

What nursing intervention is the most important in preventing complications of digoxin administration? 1Assessing blood pressure in all extremities 2Assessing blood pressure with the patient lying, sitting, and standing 3Checking the apical pulse for 60 seconds before administering the medication 4Checking the carotid pulse for 30 seconds before administering the medication

3Checking the apical pulse for 60 seconds before administering the medication

What is a ventricular septal defect? -Symptoms? -Treatment?

*Abnormal opening between R + L ventricles* -Symptoms: heart failure, loud hollow systolic murmur @ sternal border -Treatment: surgery repair ~the smaller the hole, the less symptoms the patient will have

What is a atrial septal defect (ASD)? -Symptoms? -Treatment?

*Abnormal opening between the atria* -Symptoms: asymptomatic, heart failure, split S2, atrial dysrhythmia -Treatment: surgical patch to cover holew

What is Kawasaki Disease?

*Acute systemic vasculitis - autoimmune*

•Atrial Septal Defect, Ventricular Septal Defect, Patent Ductus Arteriosis -Acyanotic or Cyanotic? -What causes them?

*Acyanotic* -Increased pulmonary blood flow

•Coarctation of the Aorta, Aortic Stenosis, Pulmonic Stenosis -Acyanotic or Cyanotic? -What causes them?

*Acyanotic* -Obstructive defects

What is the difference between acyanotic and cyanotic heart defects?

*Acyanotic:* caused from ↑ pulmonary blood flow or obstructed blood flow from ventricles *Cyanotic:* caused from ↓ pulmonary blood flow or mixed blood flow

What is transposition of the great vessels? -Symptoms? -Treatment?

*Aorta and Pulmonary Artery are switched* -Symptoms: cyanosis + depressed function at birth, cardiomegaly -Treatment: IV prostaglandin or surgery

A child present to the ER with pulses +1, hypotension, and dizziness. The child's mother states that the child became very SOB while playing on the playground + decided to bring him the ER. The nurse knows the child is experiencing which congenital heart defect?

*Aortic stenosis* -Symptoms: weak pulses, hypotensive, tachycardia, poor feeding, chest pain, dizziness, exercise intolerance, SOB with activity

What lab value is important to monitor when a child is on ACE inhibitors?

*BUN + Creatinine* -ACE's cause hyperkalemia

What are side effects of beta blockers?

*Bad B's* -Bad BP (hypotension) -Bradycardia -Bad headache -Bad mood -Bad blood sugar

The nurse is to administer Digoxin to a patient with heart failure. What monitor MUST be on the patient before administration?

*Cardiac monitor* -b/c dysrhythmias are a side effect

What mood change does Kawasaki Disease cause?

*Causes Irritability for up to 2 months*

A nurse is assessing a child in the ER + notes that he child's upper extremity BP is hypertensive while their lower extremity BP is hypotensive. What congenital heart defect is this child likely experiencing?

*Coarctation of the aorta*

•Tetralogy of Fallot -Acyanotic or Cyanotic? -What causes it?

*Cyanotic* -Decreased pulmonary blood flow

Transposition of the Great Vessels, Hypoplastic Heart Syndrome -Acyanotic or Cyanotic? -What causes them?

*Cyanotic* -Mixed blood flow

What is a patent ductus arteriosis? -Symptoms? -Treatment?

*Failure of fetal ductus's to close in the first week of life* -Symptoms: asymptomatic or heart failure signs; wide pulse pressure, bounding pulses, murmur -Treatment: medicine, surgery,

A toddler with heart failure has been prescribed a diuretic by the physician. When is the BEST time for the nurse to administer this diuretic?

*In the morning* -to avoid bedwetting

Symptoms of Rheumatic fever

*Jones Criteria* J: Joints --> polyarthritis O: Heart problems --> Carditis N: Nodules subcutaneous nodules on externsor surfaces of forearms, elbows, knees E: Erythema Marginatum, rash with thick red borders S: Sydenham's Chorea: rapid involuntary movements of hands and face

What disease is aspirin beneficial for?

*Kawasaki Disease* -controls fever + inflammation

What are the risk factors that increase the risk of congenital heart defects?

*Maternal* -Diabetes -PKU -Alcohol consumption -Environmental exposure to toxins/Infection

What is pulmonic stenosis? -Symptoms? -Treatment?

*Narrow of pulmonary artery* -Symptoms: asymptomatic, mild cyanosis, heart failure, loud murmur -Treatment: surgery or balloon angioplasty

What is aortic stenosis? -Symptoms? -Treatment?

*Narrowing of aortic valve* -Symptoms: weak pulses, hypotensive, tachycardia, poor feeding, chest pain, dizziness, exercise intolerance, SOB with activity -Treatment: surgery

What is coarctation of the aorta? -Symptoms? -Treatment?

*Narrowing of the ductus arteriosus* -Symptoms: Hypertension + bounding pulse is upper extremities with weak/absent femoral pulses, cool lower extremities with low BP -Treatment: mechanical ventilation + surgery HIGH extremities = HIGH bp + hr LOW extremities = LOW bp + hr

What do Lasix/Furosemide do to potassium?

*Potassium wasting* -cause it to decrease -hypokalemia

What lab value must strictly be monitored while a child is on Digoxin?

*Potassium* -digoxin causes hypokalemia

What are ways to prevent Endocarditis?

*Prophylactic antibiotics* -given before procedures

What medication is prescribed for hypoxemia

*Prostaglandin E* -causes vasodilation + smooth muscle relaxation

Liquid potassium MUST be mixed with.....

*Red/Grape juice* -otherwise it will cause GI irritation

Symptoms of left sided heart failure

*Respiratory back up* • cough • crackles • wheezes • hemoptysis • tachypnea -Restlessness Confusion -Tachycardia -Exertional dyspnea -Fatigue -Cyanosis -Paroxysmal nocturnal dyspnea -Elevated pulmonary capillary wedge pressure

What is chorea associated with?

*Rheumatic Fever* -sudden, aimless, irregular involuntary movements on extremities, involuntary facial grimaces, speech disturbances.

What is Erythema Marginatum associated with?

*Rheumatic Fever* •erythematous, nonpruritic, macular rash with a circular pattern on the trunk, buttocks, & proximal limbs. Blanches when pressed & increases with heat.

What is subcutaneous nodules associated with?

*Rheumatic Fever* •non-tender swelling found on bony prominences.

What is polyarthritis associated with?

*Rheumatic Fever* •red, hot painful joints, favors large joints (knees, elbows, hips, shoulders, wrists).

Symptoms of right sided heart failure

*Systemic circulation back up* -Weight gain -Edema -Distended neck veins -Ascites/Abd distention -Decreased appetite/nausea -Hepatomegaly -Decreased urine output -Retention of fluid

When a child has heart failure, when should oral feedings be HELD? and why?

*Tachypnea; RR 80-100) -risk of aspiration

A mother calls the on-call nurse + reports that her child has been experiencing tet spells (child becomes completely cyanotic) in the last few days, and has now been experiencing anoxic spells. The nurse knows that this congenital heart defect is likely...

*Tetralogy of Fallot* -symptoms: Cyanosis + Hypoxia, tet spells, anoxic spells, systolic murmur

What is Hypoplastic Left Heart Syndrome? -Symptoms? -Treatment?

*Underdevelopment of the left side of the heart* -Symptoms: weak pulses, cold extremities, mild cyanosis, heart failure, circulatory collapse -Treatment: mechanical ventilation, inotropic agents, prostaglandin, surgery

What is tetralogy of fallot? -Symptoms? Treatment?

*•f4 defects (1) VSD, (2) PS, (3) overriding aorta, and (4) right ventricular hypertrophy* -symptoms: Cyanosis + Hypoxia, tet spells, anoxic spells, systolic murmur -Treatment: elective repair in first year of life

A 6-month-old with Kawasaki Disease is being discharged. What should the nurse include to the parents in her discharge teaching?

-Child may be irritable for 2 months -Peeling is painless but the new skin growth can be painful -Passive ROM in bath can be helpful -Live vaccines should be delayed for 11 months after IVGG as these vaccines can cause Reye Syndrome

What are side effects of ACE inhibitors?

-Hypotension -Cough -Renal dysfunction or hyperkalemia

What is an early sign of congestive heart failure that the nurse should recognize? 1Tachypnea 2Bradycardia 3Inability to sweat 4Increased urine output

1Tachypnea Tachypnea is one of the early signs of congestive heart failure that should be identified. Tachycardia at rest, dyspnea, retractions, and activity intolerance are other physical signs and symptoms.

What is a normal urine output for a child?

1mg/kg/hour

A nurse is caring for a patient diagnosed with heart failure who is appearing to have a hyper-cyanotic spell due to hypoxemia. What steps should the nurse take FIRST?

-Place in knee to chest position -Administer 100% oxygen via blow by -Administer morphine -Administer IV fluid replacement

Clinical manifestations of HYPOXEMIA

-Polycythemia: increased RBC -Clubbing: thickening + flattening of nails -Hypercyanotic/Tet spells -Tachypnea/Dyspnea -Poor weight gain -Mental status change (severe)

What are clinical manifestations of endocarditis?

-Splinter hemorrhages in the nails -Unexplained fever -Anorexia -Weight loss -Oslers nodes (fingers) -Janeway lesions (painless hemorrhagic areas on palms -Petechiae on oral mucosa

Why are children with Kawasaki Disease at high risk for developing Reye syndrome?

-Usually on aspirin for their fever + inflammation -These children are immunocompromised so they cannot receive the live varicella vaccine

What 3 main types of medications are used for heart failure?

1. Digoxin 2. ACE inhibitors 3. Beta Blockers

The comment made by a parent of a 1-month-old that would alert the nurse about the presence of a congenital heart defect is: a. "He is always hungry." b. "He tires out during feedings." c. "He is fussy for several hours every day." d. "He sleeps all the time."

ANS: B -Fatigue during feeding or activity is common to most infants with congenital cardiac problems.

What is a priority patient outcome for a child with congestive heart failure? 1The child will have a rapid heart rate. 2The child will have skin that is cool to touch. 3The child will not have distended neck veins. 4The child will sleep with the head down and feet elevated.

3The child will not have distended neck veins. A lack of distended neck veins is an appropriate patient outcome for a child with congestive heart failure. The child should have a heart rate that is acceptable for age rather than rapid. The skin should be warm to touch rather than cool. The child should sleep with the head elevated rather than with the head down and the feet elevated.

What is the name for defects in which blood exiting the heart meets an area of anatomic narrowing? 1 Mixed 2 Cyanotic 3 Acyanotic 4 Obstructive

4 Obstructive Obstructive defects are those in which blood exiting the heart meets an area of anatomic narrowing, causing obstruction to blood flow. Acyanotic defect is a classification of heart defects where children do not have symptoms of cyanosis. Cyanotic defect is a classification of heart defects where children have symptoms of cyanosis. Mixed defect is the term used to describe cardiac defects where saturated and desaturated blood flow mixes.

Which is the name for defects in which blood exiting the heart meets an area of anatomic narrowing? 1. Mixed 2. Cyanotic 3. Acyanotic 4. Obstructive

4. Obstructive

Congenital heart defects have traditionally been divided into acyanotic and cyanotic defects. The nurse knows which information about this system in clinical practice? 1. Helpful b/c it explains the hemodynamics involved 2. Problematic b/c cyanosis is rarely present in children 3. Helpful b/c children with cyanotic defects are easily identified 4. Problematic b/c children with acyanotic heart defects may experience cyanosis

4. Problematic b/c children with acyanotic heart defects may experience cyanosis

The nurse is assessing the chest tube drainage of a child in the postoperative period after cardiac What kind of drainage surgery. does the nurse consider as a life-threatening sign? 1. This is a normal finding 2. The child may have an infection 3. The chest tube needs to be removed 4. The child may be at risk for cardiac tamponade

4. The child may be at risk for cardiac tamponade -drainage from the chest tube more than 3mL/kg/hr for more than 3 consecutive hours may indicate postoperative hemorrhage and a risk for cardiac tamponade

Which is considered a mixed cardiac defect? 1. Pulmonic stenosis 2. Atrial septal defect 3. Patent ductus arteriosus 4. Transportation of the great arteries

4. Transportation of the great arteries

What urine output is alarming?

<1ml/kg/h

As the nurse you know which statements are TRUE about Tetralogy of Fallot? Select all that apply: A. "Tetralogy of Fallot is a cyanotic heart defect." B. "In this condition the heart has to work harder to pump blood to the lungs, which cause the right ventricle to work harder and enlarge." C. "Tetralogy of Fallot is treated with only palliative surgery." D. "Many patients with this condition will experience clubbing of the nails."

A. "Tetralogy of Fallot is a cyanotic heart defect." B. "In this condition the heart has to work harder to pump blood to the lungs, which cause the right ventricle to work harder and enlarge." D. "Many patients with this condition will experience clubbing of the nails."

•The nurse is monitoring the daily weight of an infant with heart failure (HF). Which finding alerts the nurse to suspect fluid accumulation and thus the need to notify the registered nurse? •1. Bradypnea. •2. Diaphoresis. •3. Decreased blood pressure (BP). •4. A weight gain of 1 lb in 1 day.

•4. A weight gain of 1 lb in 1 day.

The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, "Why do my child's fingertips look like that?" The nurse bases a response on the understanding that clubbing occurs as a result of: a. untreated congestive heart failure. b. a left-to-right shunting of blood. c. decreased cardiac output. d. chronic hypoxia.

ANS: D Clubbing of the fingers develops in response to chronic hypoxia.

What is the most reliable indicator to diagnose rheumatic fever?

ASO titer -in addition to presence of 2+ major symptoms OR 1 major and 2 minor supportive evidence of strep

What must be performed on a child before administering digxoin?

Apical pulse for 1 minute -do not administer if pulse <90 in infants OR <70 in older children

While feeding a 3-month-old infant, who has Tetralogy of Fallot, you notice the infant's skin begins to have a bluish tint and the breathing rate has increased. Your immediate nursing action is to? A. Continue feeding the infant and place the infant on oxygen. B. Stop feeding the infant and provide suction. C. Stop feeding the infant and place the infant in the knee-to-chest position and administer oxygen. D. Assess the infant's heart rate and rhythm.

C. Stop feeding the infant and place the infant in the knee-to-chest position and administer oxygen. -The patient is experiencing a "tet spell". This is where during any type of activity like feeding, crying, playing etc. the child's heart (due to Tetralogy of Fallot) is unable to maintain proper oxygen levels in the blood

What is Endocarditis?

Infection of the inner lining of the heart (endocardium), generally involving valves

What is the sequence of inflammation with rheumatic fever?

Joints > Heart > Erythematous rash.

•A nurse is planning care for a 12-year-old child with rheumatic fever. The nurse should teach the parents to: •1. Observe the child closely. •2. Allow the child to participate in activities that will not tire him. •3. Provide for adequate rest periods between activities. •4. Encourage someone in the family to be with the child 24 hours a day.

•3. Provide for adequate rest periods between activities.

What are signs of Digoxin toxicity?

Nausea/vomiting -Dysrhythmias -Anorexia -Bradycardia -Yellow spotting/Visual disurbances

•Which information should be included in discharge instructions for the parents of a 12-year-old diagnosed with Kawasaki Disease and being discharged home? •1. Offer the child extra fluids every 2 hours for 2 weeks . •2. Take the child's temperature daily for several days. •3. Check the child's blood pressure daily until the follow up appointment. •4. Call the health care provider is the irritability lasts more than 2 weeks .

•2. Take the child's temperature daily for several days.

How is Kawasaki Disease diagnosed?

fever for 5 calendar days along with 4/5 clinical criteria: 1. Changes in the extremities: In the acute phase, edema or erythema of the palms and soles; in the subacute phase, periungual desquamation (peeling) of the hands and feet 2. Bilateral conjunctival injection (inflammation) without exudation 3. Changes in the oral mucous membranes, such as erythema, cracking of the lips, oropharyngeal reddening; or "strawberry tongue" (large papillae are exposed) 4. Rash: Maculopapular, diffuse erythroderma, or erythema multiforme-like 5. Cervical lymphadenopathy (typically unilateral >1.5 cm)

A child with congenital heart disease has a chest tube. The nurse knows that what amount indicates a potential post-operative hemorrhage?

greater than 3ml/kg/hr for more than 3 consecutive hours

•A child is diagnosed with Tetralogy of Fallot becomes upset, cries, and thrashes around when a blood specimen is obtained. The child becomes cyanotic, and the respiratory rate increases to 44 breaths/minute. Which action should the nurse take first? •1. Obtain a prescription for sedation for the child. •2. Assess for an irregular heart rate and rhythm. •3. Explain that the child that it will only hurt for a short time. •4. Place the child in a knee chest position.

•4. Place the child in a knee chest position.

•An infant with congestive heart failure is receiving digoxin (Lanoxin). The nurse recognizes a sign of digoxin toxicity, which is: • 1. Restlessness. • 2. Decreased respiratory rate. • 3. Increased urinary output. •4. vomiting

•4. vomiting -Also bradycardia, visual changes

What are the 3 phases of Kawasaki Disease?

•Acute Phase: Unexplained fever of 102-106 that does not decrease with antipyretics (acetaminophen) or antibiotics, child very irritable during this stage, laboratory changes; . •Subacute phase: resolution of fever and continues until all symptoms have disappeared, greatest risk for development of coronary artery aneurysm. •Convalescent phase: all symptoms resolved but labs not returned to normal, labs may not normalize for 6-8 weeks.

Hypoxemia vs Hypoxia

•Hypoxemia: arterial oxygen tension less than normal. •Hypoxia: reduction in tissue oxygenation that results from low oxygen saturations and PaO2.