SHERPATH WEEK 4 CARDIOVASCULAR

The Cardiac Electrical Conduction System and ECG SA node establishes the basic rhythm and rate of the hearbeat which is known as what?

"natural pacemaker"

What findings during the cardiac assessment provide information about possible cardiac dysfunction? 1. poor weight gain 2. Excessive crying 3. Decreased feeding 4. Delayed cognitive milestones 5. Respiratory pattern alterations

-Poor weight gain, -decreased feeding, -respiratory pattern alterations Poor weight gain may be related to feeding difficulties or an overall increase in cardiac workload.

For what reasons is it essential to assess all four extremities while performing a cardiac assessment? 1. To determine temperature differences 2.To assess the point of maximal impulse 3.To assess capillary filling in the extremities 4. To assess differences in the function of the heart valves 5. To determine differences between the central and peripheral pulses 6. To determine differences in blood pressure between upper and lower extremities

1 3 5 6

What information can be obtained by observing the integumentary system during a cardiac assessment? 1.Evidence of cyanosis 2. Evidence of decreased preload 3.Evidence of coronary artery perfusion deficits 4. Evidence of discrepancies between upper and lower extremity blood pressure (BP)

1. Evidence of cyanosis Cyanosis is evident upon observation of skin, mucosal membranes, conjunctiva, and nail beds.

Dysrhythmias Bradydysrhythmias Tools for Diagnosing Pediatric dysrhythmias

12 - lead ECG 24 hour Holter transtelephonic monitoring

Dysrhythmias Tachydysrhythmias Tools for Diagnosing Pediatric dysrhythmias

12 - lead ECG 24 hour Holter transtelephonic monitoring

Which cardiac valve is responsible for regulating the flow of oxygenated blood between the ventricle and atrium? 1. aortic valve 2. mitral valve 3. tricuspid valve 4. pulmonary valve

2. Mitral valve The mitral valve is responsible for regulating the flow of oxygen-rich blood from the left atrium to the left ventricle to be released into the systemic circulation.

The nurse is auscultating the chest of a pediatric patient and identifies a clear heart murmur. Palpation does not identify a thrill. The nurse should note this as which grade of murmur? 1 3 5 6

3 A grade 3 murmur is moderately loud using a stethoscope but is not accompanied by a palpable thrill. *A grade 1 murmur is very faint and difficult to hear, even with a stethoscope. **A grade 5 murmur is accompanied by a palpable thrill ***A grade 6 murmur is extremely loud and accompanied by a palpable thrill.

The nurse is caring for a child with incomplete closure of the aortic semilunar valve. How does the nurse describe the normal function of this valve to the patient's family? 1. Facilitates blood flow into the atria 2.Facilitates blood flow into the vena cava 3.Prevents blood from flowing back into the ventricle 4.Prevents blood from flowing into the pulmonary trunk

3. Prevents blood from flowing back into the ventricle The aortic semilunar valve regulates blood flow from the ventricles to the aorta. If this valve does not close, blood will flow back into the ventricles.

pulse oximetry

A bandage probe is attached to a digit; measures oxygen saturation of blood noninvasively. Extremity needs to be relatively motion free for accurate reading. All nail polish must be removed. If alarm (high or low) triggered, validate child's heart rate corresponds to monitor.

Cardiac Catheterization Placement

Advanced through the femoral artery or vein to the heart. Interventional use in treatment of fetal cardiac lesions such as aortic stenosis

Fetal Circulation

Anatomic Structures: the ductus arteriosus, foramen ovale, and ductus venosus are fetal structures that facilitate blood movement. The ductus arteriosus carries blood from the placenta to the heart. The foramen ovale and ductus arteriosus allow a majority of blood flow to bypass the lungs. The ductus venosus bypasses the liver, carrying oxygenated blood to the heart.

Auscultation, Palpation, Percussion, Pulse Oximetry

Assessment of cardiac sounds in an infant and young child takes much practice and a trained ear. Repeated practice and knowledge of the location of and the expected sounds of S1 an S2 will assist the nurse in recognizing any extra heart sounds including murmurs, clicks and rubs.

Management of Dysrhythmias Therapeutic Management Tachydysrhythmia: SVT Supraventricular tachycardia (SVT)

Asymptomatic and hemodynamically stable patients are treated conservatively Vagal maneuvers may terminate SVT Monitor patient for prolonged slow heart rate while converting. Older children may benefit from radiofrequency ablation Hemodynamically unstable patients require emergency intervention Adenosine may be given to slow conduction through AV node and terminate episodes of SVT rapidly and safely Synchronized cardioversion used for child with profound cardiovascular compromise

Auscultation, Palpation, Percussion, Pulse Oximetry Auscultation

Auscultate with both bell (for low-pitched sounds) and diaphragm (for high-pitched sounds) of stethoscope. Heart sounds should be synchronous with palpable pulse. Rhythm is typically regular. A normal variation is sinus dysrhythmia when rhythm alters and rate increases with inspiration and decreases with expiration. Identify S1 and S2. S1 (closure of mitral and tricuspid valves) is heard best at apex of heart and correlates with palpable pulse. S2 (closure of aortic and pulmonic valves) is heard best at base. Identify presence of murmurs, clicks, or precordial friction rubs.

Alert for All Dysrhythmias If a child is having a dysrhythmia, assess responsiveness and remember CAB:

CIRCULATION assessment Palpate and auscultate pulses If no pulse, begin chest compressions If slow pulse, assess child's tolerance (including perfusion and pulses) AIRWAY assessment BREATHING assessment If no breathing, begin ventilation after first cycle of chest compressions Obtain an ECG rhythm strip for assessment Shock delivery if needed

Cardiac output equation

CO = HR x SV (Cardiac output = Heart rate x stroke volume). Other factors affecting cardiac output include preload, afterload, and contractility.

Factors Affecting Cardiac Output Cardiac Output (CO) equation

CO = heart rate (HR) x stroke volume (SV)

Management of Dysrhythmias Therapeutic Management Bradydysrhythmias Ventricular fibrillation (rare in children)

CPR Drugs for resuscitation include epinephrine, lidocaine, and antidysrhythmics

What is indicated when the point of maximal impulse (PMI) is found in a lower location than expected during the cardiac assessment? Cardiac atrophy Pericardial effusion Increased cardiac contractility Cardiac hypertrophy (enlargement)

Cardiac hypertrophy (enlargement) If PMI is located lower than expected, this can indicate cardiac hypertrophy (cardiac enlargement) as heart takes up more space. *Changes in contractility do not change position of heart in chest cavity. **If cardiac atrophy were present, PMI would be at higher, not lower, location than expected. ***With pericardial effusion there can be loss of visible PMI, but no shift in location is expected.

Factors Affecting Cardiac Output Cardiac output

Cardiac output (CO) is the amount of blood pumped per minute. Mathematically, cardiac output is represented as stroke volume multiplied by heart rate.

Fetal Circulation As oxygen saturation increases from blood flow to lungs, ductus arteriosus does what?

Closes

Health History and Inspection Cardiac Assessment Guidelines For Children Inspection

Color: Assess skin color in natural light if possible. Pay special attention to oral mucous membranes, nail beds, and conjunctiva, which can reflect central cyanosis. Assess hands, feet, and face for color and circulatory impairment. Assess body for differential or demarcated cyanosis or color differences. Activity level: Assess child while sitting and lying down. Observe level of activity and position of comfort. Observe for color changes with activity, feeding, or crying. Observe for exercise tolerance, including any respiratory distress or frequent rest. Chest: Assess precordial activity (movement of chest wall when heart beats), symmetry and chest shape (including convex or concave). Assess for scars (may indicate history of cardiac related surgery). Respiratory pattern: Observe work of breathing at rest and with activity, including feeding. Look for signs of respiratory alteration or distress. (Tachypnea, retractions, nasal flaring, crackles, grunting, and head bobbing are late signs of distress and may indicate impending respiratory failure.)

Holter monitor

Continuously records heart rate and rhythm for 24 hr. Electrodes and leads are attached to child, who wears a compact recorder Skin should be free of lotions and oils Child or parent records times of activities, symptoms, or other events in a diary to be returned with monitor Important that diary be accurately completed

Which physiologic factors must be taken into consideration when determining cardiac output (CO)? Select all that apply. Contractility Preload Afterload Heart rate Respiratory rate Oxygen saturation

Contractility Preload Afterload Heart rate Contractility Contractility is an important factor for determining cardiac output as it is necessary to determine stroke volume, which is used to directly calculate cardiac output. Preload Preload is an important factor for determining cardiac output as it is necessary to determine stroke volume, which is used to directly calculate cardiac output. Afterload Afterload is an important factor for determining cardiac output as it is necessary to determine stroke volume, which is used to directly calculate cardiac output. Heart rate Heart rate is a crucial factor that contributes to the calculation of cardiac output. Respiratory rate The patient's respiratory rate, while it may affect oxygen availability, does not directly impact calculation of cardiac output. Oxygen saturation Oxygen saturation of the blood does not contribute to the calculation of cardiac output.

Assessing murmurs Causes in Older Children

Damage d/t trauma or endocarditis

Vascular Damage

Damage to endothelial cells ---- occlusion / narrowing of blood vs ---- impaired healing, fibrosis and chronic ischemic atrophy Damage vessel may include dissection that can occur at any point along catheterization route.

Dysrhythmias Bradydysrhythmias Etiology - Primary

Damage to sinus node or conduction pathway between the atria and ventricles (AV block).

Factors Affecting Cardiac Output Preload

Definition End diastolic volume that stretches ventricle prior to contraction Factors that Influence Venous BP and the rate of venous return Decreased HR and increased ventricular compliance will increase preload Blood loss and leakage of fluid into interstitial space may decrease preload

Factors Affecting Cardiac Output Contractility

Definition Intrinsic ability to shorten muscle fibers and generate force; 'squeezing' force of the heart Factors that Influence Preload, afterload Acid-base and electrolyte imbalances Hypoxia

Factors Affecting Cardiac Output Heart Rate

Definition Number of beats per unit of time (usually per minute) Factors that Influence Body temperature Exercise Age Gender Caffeine Autonomic nervous system control Certain medications

Factors Affecting Cardiac Output Afterload

Definition Pressure in wall of ventricle during ejection Factors that Influence Hypertension, stiffness of heart (less contraction) Ventricular hypertrophy (less contraction) Vasoconstriction Changes in systemic and pulmonary vascular resistance

Factors Affecting Cardiac Output Stroke volume

Definition Volume of blood (mL) pumped out of heart with each beat, primarily measured from left ventricle. Stroke volume is equal to difference between preload and afterload Factors that Influence -Heart size -Contractility -Preload (direct relationship) -Afterload (inverse relationship)

Flow of blood through the heart

Deoxygenated blood enters into the heart through the superior and inferior vena cava Blood travels into the right atrium and flows through the tricuspid valve into the right ventricle Blood is pushed through the pulmonary valve into the pulmonary artery and lungs when the right ventrical contracts and picks up oxygen Oxygenated blood is then carried back to the heart by the pulmonary veins into the left atrium through the mitral valve and into the left ventricle Contraction of the left ventricle forces the blood through the aortic valve, through the aorta, and out to the entire body

Nursing Care for Cardiac Catheterization Assess pulses

Distal pulses should be palpable, although they may be weaker than in contralateral extremity. Nonpalpable distal pulses should be checked with Doppler technology. Nurse should notify the cardiologist if distal pulses are absent on affected extremity, temperature or degree of mottling has changed, or child complains of increasing pain.

Nursing Care for Cardiac Catheterization Education for home care

Dressing may be removed after 24 hours then covered with an adhesive bandage. Keep site clean and dry; showers are OK but no baths or swimming for 1 week avoid strenuous activities for up to 1 week. contact health care provider if you see fever, bleeding, chest pain, or signs of site infection.

Which cardiac complication should cause changes in cardiac output (CO) after catheterization? Phlebitis Dysrhythmias Peripheral thrombus Vasospasm of catheterized vessel

Dysrhythmias Dysrhythmias can be hemodynamically compromising leading to decrease in cardiac output.

Corrective, palliative, or therapeutic interventional procedures

Dysrhythmias Hemorrhage Vascular Damage Vasospasm of the catheterized vessel Thrombus or Embolus formation Infection Reaction to the Dye Catheter Perforation Minor reactions to the procedure

Dysrhythmias Etiology

Dysrhythmias may be associated with underlying congenital heart disease (CHD) or may occur in structurally normal hearts. Either an abnormal impulse formation or abnormal conduction or a combination of these two factors causes a dysrhythmia.

Which diagnostic test can be used for real-time visualization of both heart structures and function?

Echocardiography (ECHO) ECHO generates an image of the heart and heart structures. In real-time, structures and functions can be evaluated. *ECG = real time, no visual *Holter = real time, no visual *Ventilation-perfusion scan = blood flow and gas flow in the lungs, no info on heart structure

Management of Dysrhythmias Therapeutic Management Bradydysrhythmias Asystole

Electrical cardiac activity is absent. Electrical standstill and no myocardial activity or CO. The ECG is "flat line" Management is CPR and epinephrine to stimulate cardiac activity

Common Diagnostic Tests for Cardiac Disorders

Electrocardiogram (ECG) Holter monitor Chest radiography Echocardiography (ECHO) Magnetic resonance imaging (MRI) Ventilation-perfusion scan

Which cardiac catheterization complication directly causes occlusion of the blood vessel? Infection Hemorrhage Embolus formation Reaction to injected dye

Embolus formation A thrombus or embolus can cause occlusion of the blood vessel and prevent perfusion of tissue.

Management of Dysrhythmias Therapeutic Management Tachydysrhythmia: VT

Emergency management of ventricular tachycardia in unconscious children is synchronized cardioversion Children with wide QRS complex tachycardia and absent pulse require CPR until defibrillation is available Lidocaine, 1 mg/kg, may be administered before cardioversion, followed by continuous infusion of drug to prevent further episodes Once tachycardia has been terminated, underlying causes should be explored

Nursing Care for Cardiac Catheterization Nursing Care Pearl

Encourage families of infants and toddlers to bring a "comfort item" such as a favorite blanket or stuffed animal with them to the cardiac catheterization procedure.

What information can be obtained by observing the integumentary system during a cardiac assessment? Evidence of cyanosis Evidence of discrepancies between upper and lower extremity blood pressure (BP) Evidence of coronary artery perfusion deficits Evidence of decreased preload

Evidence of cyanosis Cyanosis is evident upon observation of skin, mucosal membranes, conjunctiva, and nail beds.

Hemorrhage

Excessive or profuse bleeding Hemorrhage may lead to hematoma formation at insertion site.

True or False The left atrium and left ventricle are nonfunctional in the infant.

False Both the left atrium and left ventricle are functional in the infant.

True or false The ductus arteriosus makes a connection with the left atrium and left ventricle in infants

False The ductus arteriosus does not make a connection with those chambers.

In a fetus, the blood returning to the heart from the vena cava can be directed through the _____ _____, not ductus arteriosus, and into the ___ atrium.

Foramen Ovale Left

Which structures allow the fetal heart to compensate for nonfunctioning lungs? Select all that apply. Liver Left ventricle Foramen ovale Ductus arteriosus Superior vena cava

Foramen ovale The foramen ovale is a vessel that allows blood to bypass the lungs, allowing for more efficient blood flow in the absence of functioning lungs. Ductus arteriosus The ductus arteriosus carries oxygenated blood from the placenta to the heart, allowing for oxygen delivery in the absence of functioning lungs.

Cardiac Catheterization

Gold standard for diagnosing coronary artery disease. Used to be an invasive diagnostic now it is also performed as an intervention and therapeutic procedure

Grade 1-6 of murmur (intensity)

Grade of murmur (intensity) Grade 1 Very faint, difficult to hear even with stethoscope in placeGrade Grade 2 Quiet, but can be heard with stethoscope in placeGrade Grade 3 Moderately loudGrade Grade 4 Very loud, thrill can be palpated Grade 5 Very very loud, with thrill. Can be heard with stethoscope barely touching skin Grade 6 Extremely loud, with thrill. Can be heard with stethoscope not applied to skin

Dysrhythmias Bradydysrhythmias

Heart block—two or three P waves for every QRS. Cardiac output is based on the rate of the QRS complexes—ventricular contraction.

Which diagnostic test should be most efficient for evaluating an active child with cardiac symptoms that do not currently interfere with daily activities? Holter monitor Chest radiography Ventilation-perfusion scan Magnetic resonance imaging (MRI)

Holter monitor The Holter monitor continuously records heart rate and rhythm. A diary is kept to track correlations between symptoms and activities. The child remains active and data is collected during a variety of daily activities.

Ventilation-perfusion scan

IV injection of isotope, which reveals the distribution of pulmonary blood flow and ventilation, assists in quantifying the percentage and pattern of pulmonary blood flow. Requires an IV line for radioisotope injection The child must be able to lie still for a short time for the scan

The nurse is assessing a pediatric patient with rhythm disturbance and decreased cardiac output (CO). What action should the nurse take? Immediately begin CPR Immediately notify the health care provider Maintain observation until a collapse rhythm develops Place child in Holter monitor, maintain 24-hour recordings

Immediately notify the health care provider Pediatric rhythm disturbances should be treated as emergencies if they compromise cardiac output or have the potential to degenerate into lethal (collapse) rhythms (e.g., ventricular fibrillation). The health care provider should be immediately notified.

Fetal Circulation ________ in systemic arterial pressure increases the workload of the _________ ________, at this point the heart can function on its own

Increase; left ventrical

What change in the neonate is directly responsible for the closure of foramen ovale?

Increased pressure in left ventricle When the umbilical cord is clamped and the placental blood flow is stopped, pressure in the left ventricle rises and exceeds pressure in the right ventricle. This difference in pressure is responsible for closing the foramen ovale.

What is the primary cause for the closure of the ductus arteriosus?

Increased pulmonary oxygen saturation

Management of Dysrhythmias Therapeutic Management Bradydysrhythmias Pulseless electrical activity (PEA), also known as electromechanical dissociation.

Indicates hemodynamically compromised state; cardiac electrical activity cannot generate myocardial contraction and CO Although electrical activity on ECG, does not generate palpable heartbeat CPR must be initiated

Infection

Infection is rare, however catheter insertion site should be assessed for erythema and purulent drainage.

Health History and Inspection Cardiac Assessment Guidelines For Children Health History

Inquire about a family history of congenital heart disease (CHD), sudden death, or fetal/infant death. Ask about prenatal care, maternal illnesses, infections, medications taken during pregnancy. Discuss pregnancy, birth history, associated birth defects or genetic anomalies. Discuss feeding difficulties (including decreased intake or increased rest periods during feeding), tachypnea or increased work of breathing, frequency of respiratory infections, poor weight gain, fatigue, exercise intolerance, color changes with crying or Valsalva maneuvers, or diaphoresis.

Fetal Circulation As Pulmonary vascular resistance decreases the blood flow does what?

It increases

methods of echocardiography

M-mode Two-dimensional Doppler

Management of Dysrhythmias Therapeutic Management

Management strategies include drug therapy, radiofrequency ablation, cardioversion, and pacemakers - treatment is guided by the origin of the dysrhythmia and the clinical consequences.

Data gathered with Cardiac Catheterization

Measure O2 sat in greater arteries and cardiac shambers Measure pressure and gradients thereof in cardiac chambers Evaluate cardiac output (4-8L/minute in adults) Angiography to ID vessel structures and blood flow patterns Electrophysiologic study - map conduction system, ID dysrhythmic cells -radiofrequency ablation destroys dysrhythmia producing cells Corrective, palliative, or therapeutic interventional procedures: - angioplasty - stent placement - valve repair/replace

The nurse is assessing a child with a dysrhythmia and notes a slower than normal pulse. Which additional actions should the nurse perform to assess for possible complications of this bradydysrhythmia? Select all that apply. Measure respirations. Check oral temperature. Auscultate bowel sounds. Check range of motion (ROM) in extremities. Check color and skin temperature of extremities.

Measure respirations. If a child is having a dysrhythmia, breathing must be assessed. Chest compression and ventilation are indicated if the child stops breathing. Check color and skin temperature of extremities. If a child is having a dysrhythmia, circulation must be assessed. If the extremities are perfused and cyanosis is not noted, that indicates adequate perfusion; however, the presence of cool and cyanotic extremities would indicate poor perfusion secondary to the abnormal rate & rhythm.

Minor reactions to procedure

Minor reactions to the procedure include anesthesia or sedation-related nausea and vomiting or pressure ulceration of pressure points related to prolonged immobility and decreased subcutaneous tissue.

Which cardiac valve is responsible for regulating the flow of oxygenated blood between ventricle and atrium? Aortic valve Mitral Valve Tricuspid Valve Pulmonary Valve

Mitral valve The mitral valve is responsible for regulating the flow of oxygen-rich blood from the left atrium to the left ventricle to be released into the systemic circulation

Assessing murmurs Cause and description

Murmurs are caused by turbulent blood flow described according to location, timing within cardiac cycle, intensity, pitch, quality, and duration. Can lead to developmental delays *Many times murmurs are "innocent"

A 12-year-old patient with a history of heart surgery comes to the emergency department complaining of dizziness and chest discomfort. What electrocardiogram (ECG) finding lets the nurse know a patient is in supraventricular tachycardia (SVT)? Long Q-T interval Wide QRS interval Narrow QRS interval Lack of cardiac rhythm

Narrow QRS interval The presence of a narrow QRS on ECG with tachycardia indicates the impulse begins above (superior to) the ventricles and suggests SVT.

The aortic valve is responsible for regulating the flow of (oxygen rich or deoxygenated blood) from the right atrium to the left ventricle to be released into circulation?

Oxygen Rich

Following cardiac catheterization, what nursing assessments are necessary? Select all that apply. Palpate pulses Percussion of the chest Assess child's activity level Inspect catheter insertion site Assess pulmonary blood flow

Palpate pulses Inspect catheter insertion site

At birth, clamping of the umbilical cord and the first breath generates pressure changes in the neonate's circulation. This results in major changes in which aspects of the heart? Select all that apply. Path of blood flow Blood oxygenation Vascular resistance Right ventricle workload Function of superior vena cava

Path of blood flow The pressure changes result in closure of fetal valves, altering the flow of blood. Primarily, blood will now obtain oxygen from the lungs instead of the placenta. Blood will no longer be shunted away from the liver. Blood oxygenation The pressure changes result in closure of fetal valves, shifting the organ responsible for oxygenation of the blood. The lungs will now oxygenate the blood as the connection to the placenta is severed. This results in a distinct distribution of oxygenated blood so the right side of the heart contains primarily deoxygenated blood and the left side contains oxygenated. Vascular resistance The pressure changes result in decrease in vascular resistance and increase in pulmonary blood flow.

Percussion

Percussion of chest provides little useful data in a cardiac assessment. PMI is better indicator of heart size.

Catheter perforation

Perforation of the heart or vessels by the catheter can result in cardiac tamponade and cardiac arrest.

Nursing Care for Cardiac Catheterization

Peripheral perfusion is monitored after cardiac catheterization. - locate and mark distal pulses before the procedure - Marking the location of pulses will assist the nurse with rapid postprocedure assessment.

The nurse is caring for a child with incomplete closure of the aortic semilunar valve. How does the nurse describe the normal function of this valve to the patient's family? Facilitates blood flow into the atria Facilitates blood flow into the vena cava Prevents blood from flowing back into the ventricle Prevents blood from flowing into the pulmonary trunk

Prevents blood from flowing back into the ventricle The aortic semilunar valve regulates blood flow from the ventricles to the aorta. If this valve does not close, blood will flow back into the ventricles. The pulmonary semilunar valve regulates blood flow to the pulmonary trunk.

Electrocardiogram (ECG)

Provides recording of heart's electrical activity from outside surface of body. In a 12-lead ECG, electrodes attached to lead wires are placed over precordium and on four extremities Lead wires are attached to an electrocardiograph that records and prints electrical activity P wave reflects atrial depolarization QRS complex reflects ventricular depolarization T wave reflects ventricular repolarization Displays heart rate and rhythm Detects chamber enlargement and deviations in axis that may be caused by congenital or acquired heart defects or disease Best done when child is quiet and cooperative. Skin should be free of lotions and oils

chest radiography

Provides x-ray picture of heart and associated organs and structures in chest cavity. Remove electrodes and lead wires if attached Encourage parent or family member to accompany child to x-ray department Provides information about heart size; blood flow to lungs; sidedness (position) of stomach, liver, and heart

Which statement describes the relationship between the ductus arteriosus and blood flow in the fetus? Because pulmonary circulation pressure is high, the ductus arteriosus facilitates blood flow into the lungs. The blood returning to the heart from the vena cava is directed through the ductus arteriosus to the left atrium. The left atrium and left ventricle are nonfunctional in the infant. The ductus arteriosus diverts blood away from the left side of the heart. Pulmonary circulation pressure is high; the ductus arteriosus directs blood away from the lungs and into the aorta.

Pulmonary circulation pressure is high; the ductus arteriosus directs blood away from the lungs and into the aorta. Pulmonary circulation pressure is high in the fetus. The ductus arteriosus provides a pathway from the pulmonary trunk to the descending aorta, bypassing the lungs. As the blood has already been oxygenated in the placenta, passage through the lungs is unnecessary.

A normal rhythm appears on the electrocardiogram (ECG) rhythm strip, but when the nurse palpates for a pulse it is not present. Which condition does this patient likely have? Asystole Pulseless electrical activity (PEA) Supraventricular tachycardia (SVT) Primary cardiac bradydysrhythmia

Pulseless electrical activity (PEA) PEA indicates that the electrical events of cardiac conduction are occurring but cannot generate myocardial contraction and cardiac output. This results in a normal rhythm appearing on the ECG, but no palpable pulse.

Which factor influence the amount of blood that fills the ventricle immediately before contraction? Hypoxia Afterload Body temperature Rate of venous return

Rate of venous return Rate of venous return influences preload by altering the amount of blood returning to the heart. Hypoxia Hypoxia may influence contractility, or the squeezing force of the heart, but does not directly affect afterload. Afterload Although afterload can affect the stroke volume, or the amount of blood pumped out of the heart with each beat, it does not directly affect preload, or the amount of blood that fills the ventricles prior to contraction. Body temperature Body temperature may influence heart rate, or the number of beats per minute, but does not directly affect preload.

Reaction to the dye

Reactions to the dye may be rash, pruritus, vomiting, or very rarely, severe anaphylaxis.

Starting with the right atrium, trace the flow of blood through the heart to the left ventricle. lungs pulmonary arteries left atrium pulmonary veins right ventricle left ventricle

Right ventricle Pulmonary arteries Lungs Pulmonary veins Left atrium Left ventricle From the right atrium, blood flows through the tricuspid valve to the right ventricle, through the pulmonic valve to the pulmonary arteries and to the lungs. From the lungs, the blood returns to the heart through the pulmonary veins into the left atrium and then passes through the mitral valve into the left ventricle. To continue, blood passes through the aortic semilunar valve into the aorta, then distributes throughout the body before returning via the vena cava.

In the electrical conduction system of the heart, where does the initial impulse start? AV node Bundle of His Purkinje fibers Sinus (SA) node

Sinus (SA) node The sinus node (SA node), a group of spontaneously depolarizing cells, sets the normal "sinus" rhythm. *AV node can take over if the other signals are not functioning as usual

magnetic resonance imaging (MRI)

Strong magnetic field surrounds the child; field promotes rotation of nuclei (that normally spin) at predictable speed, allowing visualization of soft tissue, tumors, shunts, myocardial thickness, structure, and valve function. Nothing-by-mouth (NPO) status for at least 4 hours before procedure if requiring sedation Assessment for allergy if contrast medium is to be used All metallic items must be removed Child must be able to lie still for up to 1 hour or will require sedation

A young child presents to the primary care clinic for a well-visit. During the cardiac assessment, the nurse hears a murmur during S2 and a heart rate of 90 bpm. The nurse notes that the child is below average height. Based on this information, what is the likely cause of the child's murmur? Trauma Structural defect Tachydysrhythmia Poor peripheral perfusion NOT SURE

Structural Defect Pathologic murmurs reflect an abnormality in the heart structure such as with congenital heart disease (CHD). Additionally, this defect may impair the child's normal growth.

Dysrhythmias Tachydysrhythmias SVT Manifestations S&S low cardiac output syndrome Infants and toddlers

Subtle early and dramatic late Poor feeding Irritability Lethargy Pale or mottled color Poor peripheral perfusion Decreased urine output Heart failure

Signs of low cardiac output include:

Tachycardia Coolness and mottling of extremities Diminished peripheral pulses Delayed capillary refill time Hypotension, decreased urine output Metabolic acidosis Changes in level of consciousness (difficult to assess in a sedated and intubated child)

Palpation

Temperature: compare trunk and extremities. Pulses: compare central and distal. Assess in all four extremities. Blood pressure: assess in all four extremities during initial assessment. Discrepancies between upper and lower extremity may indicate cardiac disease. BP may vary by health care setting and prior cardiac problems. Capillary refill: assess in extremities; use fingertips to compress skin. Normal is ≤3 sec. Abdomen: locate the liver border; should be firm and smooth. Chest: With fingertips, locate the point of maximum impulse (PMI). Location depends on heart size (enlargement can shift down; atrophy can shift up).

Auscultation is an important aspect of the cardiac assessment. Which sentence helps to explain why both the bell and the diaphragm of the stethoscope are used during the assessment? The bell is used to identify dysrhythmias; the diaphragm identifies murmurs. The bell is used to identify normal heart sounds; the diaphragm is used to identify murmurs. The bell is used to identify low-pitched sounds; the diaphragm is used to identify high-pitched sounds. The bell is used to identify high-pitched, normal heart sounds; the diaphragm identifies low-pitched murmurs.

The bell is used to identify low-pitched sounds; the diaphragm is used to identify high-pitched sounds. Both low- and high-pitched sounds are heard during auscultation of the heart. S1 is lower pitch, S2 is higher pitch. To clearly hear both heart sounds, both the bell and diaphragm should be used.

Cardiovascular System Summary

The cardiovascular system is responsible for the delivery of blood to all organ systems. Prenatal circulation is modified to bypass the lungs as it relies on the placenta for oxygenation of the blood. After the neonate takes its first breath, pressure and oxygen level changes in the lungs redirect blood flow and the lungs take over oxygenation.

Monitoring Cardiac Output

The child's cardiac output is monitored through the assessment of vital signs and peripheral perfusion. Remember, cardiac output is a function of stroke volume and heart rate. Intracardiac pressure may be assessed and monitored using an invasive device.

How do pressures in the fetal heart and pulmonary vasculature compare to neonatal? Select all that apply. The fetal heart has lower left ventricular pressure. The fetal heart has higher left ventricular pressure. The pulmonary vasculature has increased pressure. The fetal heart has lower right ventricular pressure. The pulmonary vasculature has decreased pressure. The fetal heart has higher right ventricular pressure.

The fetal heart has lower left ventricular pressure. The pulmonary vasculature has increased pressure. The fetal heart has higher right ventricular pressure.

Which statement best summarizes the differences between the fetal and neonatal heart in terms of oxygen saturation? Both the fetal and neonatal hearts differ in oxygen saturation based on the side of the heart, with the fetal heart having moderate oxygen saturation on the right side and the neonatal heart having high oxygen saturation on the right side. The fetal heart has moderate oxygen saturation throughout, whereas the neonatal heart has low oxygen saturation on the right side & high oxygen saturation on the left side. The oxygen saturation of the fetal heart constantly changes, whereas the oxygen saturation of the neonatal heart is consistent, albeit different, on each side.

The fetal heart has moderate oxygen saturation throughout, whereas the neonatal heart has low oxygen saturation on the right side & high oxygen saturation on the left side. Fetal blood is oxygenated by the placenta and receives moderate oxygen saturation. This blood is delivered to the heart. No change in oxygen saturation occurs in the fetal heart due to nonfunctional lungs. In the neonate, after the fetal shunts have closed, deoxygenated (low oxygen saturation) blood returns to the right side of the heart. The left side of the heart receives oxygenated (high oxygen saturation) blood from the lungs. --- Because the lungs are nonfunctional, the fetal blood is oxygenated by the placenta. This results in moderate oxygen saturation of the fetal heart and not very high or very low. The neonatal heart does not have high oxygen saturation on the right side of the heart. Once the fetal shunts close, deoxygenated, not oxygenated blood returns to the right side of the heart. ----- Fetal oxygen saturation is consistent on each side and does not constantly change.

How to detect iscrepancies between upper and lower extremity blood pressure (BP)

They can only be identified by physically taking the patient's blood pressure in the two extremities.

Assessing murmurs Significance of precordial friction rubs

They reflect pericardial inflammation

Management of Dysrhythmias Assessment

Thorough Hx Note dizziness, palpitations, or syncope in older kids

Thrombus or Embolus formation

Thrombus formation at catheter insertion site may impair perfusion to affected limb and may shed emboli that can travel anywhere in vascular system depending on cardiac anatomy, including the lung or brain. A thrombus in venous system can be associated with swelling or inflammation of affected limb. A thrombus in arterial system may be associated with coolness or discoloration of extremity and loss of pulses distal to thrombus. Thrombus formation may occur in the systemic-to-pulmonary artery shunts that provide pulmonary blood flow.

Types of Doppler echocardiography

Transthoracic Transesophageal Directly on cardiac muscle Fetal

Echocardiography (ECHO)

Uses high-frequency sound waves (ultrasound) to generate an image of heart and associated structures. Study assesses location and relationship of intracardiac and extracardiac structures, cardiac function; measures size of cardiac chambers, valve function, size of septal or other defects; estimates gradients across structures and blood flow direction Child must be quiet and cooperative If not cooperative, sedation may become necessary

Vasospasm of the catheterized vessel

Vasospasm of vessel results in poor perfusion to affected limb.

Dysrhythmias Tachydysrhythmias SVT Manifestations

Ventricles don't fully fill and contract cardiac output is diminished develop low cardiac output syndrome

Dysrhythmias

abnormal heart rhythms Dysrhythmias can cause hemodynamic compromise.

Stroke volume (SV) is defined as the .....

amount of blood ejected from the heart with each heartbeat. It is expressed in liters per minute (L/min).

Dysrhythmias Bradydysrhythmias Clinical Manifestations

cardiac output (CO) is diminished, resulting in poor end-organ and tissue perfusion

Fetal Circulation When umbilical cord is clamped, ductus venosus, which carried blood from placenta......

closes

Dysrhythmias Bradydysrhythmias Bradycardia is a sign of _____ that can lead to ________ ________

decompensation cardiopulmonary arrest

The pulmonary valve is responsible for regulating the flow of [deoxygenated or oxygenated] blood from the [right or left] ventricle to the pulmonary artery.

deoxygenated

The tricuspid valve regulates the flow of (deoxygenated or oxygenated) blood from the (right or left) atrium to the (right or left) ventricle

deoxygenated right right

The Cardiac Electrical Conduction System and ECG Each cardiac cycle consists of electrical activity, which produces__________ ("squeeze" or contraction) and subsequent ________(relaxation) of the cardiac muscle.

depolarization repolarization

The Cardiac Electrical Conduction System and ECG Mechanical contraction of the heart muscle starts with _______________. This ____________ is normally initiated by a group of spontaneously depolarizing cells called the ____________, located at the ___________ junction.

electrical stimulation electrical stimulation sinus node superior vena cava and right atria

True or False Because pulmonary circulation pressure is high in the fetus, the ductus arteriosis directs blood flow to the lungs.

false

Fetal Circulation When placental blood flow is cut off, resulting pressure changes cause.....

foramen ovale to close

A heart has _____ chambers. Name all four and what they do

four 2 upper = Atria (filling chambers) 2 Lower = ventricles (pumping chambers)

Dysrhythmias Tachydysrhythmias Rate, origination, common types

irregular heart rhythm with a rate >100 bpm Primary tachydysrhythmias can originate in either the atria or the ventricles. Most common - Supraventricular dysrhythmia (SVT)

Nursing Care for Cardiac Catheterization Appearance of skin

likely mottled and cooler than normal

Nursing Care for Cardiac Catheterization Assess Perfusion and insertion site pt. will have a pressure dressing

look for bleeding at insertion site. - Bleeding = remove dressing and apply pressure for 5-10 minutes - Bleeding worsens = call provider, keep pressing assess distal pulses of the affected extremity, heart rate, and respiratory rate.

fetal circulation In normal, neonatal circulation, the venous (or right) side of the heart is typically a ______ pressure system containing deoxygenated blood compared with the _______ _______ ___ side of the heart containing oxygenated blood from the lungs.

lower- higher arterial (or left)

Does the pulmonary valve regulate the flow of blood to the right or left atrium?

neither its a trick question

Fetal Circulation Fetal gas exchange:

oxygenation takes place in the placenta, resulting in moderate oxygen saturation. Because the lungs are nonfunctional, there is no change in oxygen saturation.

Dysrhythmias Tachydysrhythmias SVT Manifestations S&S low cardiac output syndrome Older kids

palpitations dizziness syncope exercise intolerance

Dysrhythmias Bradydysrhythmias Clinical Manifestations Signs and Symptoms

palpitations dizziness syncope exercise intolerance Poor feeding Irritability Lethargy Pale or mottled color Poor peripheral perfusion Decreased urine output Heart failure *Same as Tachycardic

Fetal Circulation The fetal shunts functionally close in response to

pressure changes and to increased blood oxygen content.

Fetal Circulations

pressures in the right atrium and pulmonary circulation are high. Most of the blood moves through the foramen ovale into the left atrium. Left ventricle pressures are low. In the pulmonary circulation resistance is very high and blood flow to the lungs is low. Most of the blood flows to the ductus arteriosus to the descending aorta.

Dysrhythmias Bradydysrhythmias Etiology - Secondary

result from surgery for congenital heart disease and are marked by dissociation between P wave and QRS complex with asynchrony b/t atrial and ventricular contractions

Fetal Circulation In fetal circulation, the _____ventricle has high pressure, ______ ______ pressures are high, and _________ pressures are low.

right pulmonary vascular left-sided

Assessing murmurs Significance of Clicks

signal abnormal valve motion

Nursing Care for Cardiac Catheterization (Special Circumstances) When are Heparin infusions initiated?

situations related to: pulse loss or catheter route placement of stents, coils, or closure devices.

Assessing murmurs Causes in Infants and children

structural abnormalities

Dysrhythmias Tachydysrhythmias SVT trigger ECG display

trigger: atrial ectopic focus or reentry circuit ECG: Narrow QRS interval *VTACH is uncommon

Name the heart valves and describe their location, function, and mechanism of operation.

two a/v valves - connect adjacent atria to the ventricles tricuspid mitral pulmonary aorta two semilunar valve - regulate fluid movement from the ventricles to the pulmonary trunk and aorta (prevent backflow)

The Cardiac Electrical Conduction System and ECG The electrical impulse spreads through the atrium to the relay station, the AV node, and is then transmitted to the ____________ through the _________, the bundle branch system, and finally the _______ _______. The result is rhythmic atrial electrical stimulation and then contraction, followed by ______ stimulation and contraction.

ventricles bundle of His Purkinje fibers. ventricular