Ch 41 Nursing Care of a Family when a Child has a Cardiovascular Disorder

After assessing a child, the nurse suspects coarctation of the aorta based on a finding of:

femoral pulse weaker than brachial pulse. A femoral pulse that is weak or absent in comparison to the brachial pulse is associated with coarctation of the aorta. Bounding pulse is characteristic of patent ductus arteriosus or aortic regurgitation. A narrow or thread pulse is associated with heart failure or severe aortic stenosis. Hepatomegaly is a sign of right-sided heart failure.

What evaluation best illustrates the effectiveness of furosemide therapy in a child diagnosed with congestive heart failure (CHF)? The child:

has clear breath sounds. Furosemide is used to eliminate excess fluids from the body of the patient with CHF. An evaluation of clear breath sounds would be an indicator that the patient does not have pulmonary edema associated with CHF. An evaluation of activity level would be more reflective of activities that are provided for the patient and whether enough rest is provided. A normal heart rate would be more specific to the effects of digoxin. An appropriate weight gain is more apt to reflect nutritional status.

A child with a suspected cardiovascular disorder is to undergo diagnostic testing and is scheduled for an echocardiogram. When explaining this test to the child, what would the nurse most likely include?

"A special wand that picks up sound is used to check your heart." An echocardiogram is a noninvasive ultrasound procedure using a gel-coated wand that assesses the heart wall thickness, the size of the chambers, valve and septal motion, and the relationship of the great vessels to other cardiac structures. An electrocardiogram reveals the pattern or rhythm of the heart's beating and involves small patches or electrodes attached to the chest. A chest radiograph involves a radiographic film of the chest to determine the size of the heart and its chambers.

A group of nurses is reviewing the cardiovascular system and its function. Which statement by one of the nurses demonstrates an understanding of a child's cardiovascular system?

"At birth, the infant's right and left ventricle are about the same size." At birth, both the right and left ventricles are about the same size, but by a few months of age, the left ventricle is about two times the size of the right. If the infant has a fever, respiratory distress, or any increased need for oxygen, the pulse rate goes up to increase the cardiac output. Although the size of the heart is smaller, by the time the child is 5 years old, the heart has matured, developed, and functions just as the adult's heart.

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

"He likes to stop and squat wherever he walks." The walking toddler may squat periodically to relieve a hypercyanotic spell. This position serves to improve pulmonary blood flow by increasing systemic vascular resistance. Constant movement and quick walking are normal for a toddler. Activity level with a daily nap is typical of a toddler. Difficulty breathing would suggest a problem.

An infant with poor feeding is suspected of having a congenital heart defect. The parents are asking why a chest x-ray is necessary in their infant. What is the best response from the nurse?

"It will determine if the heart is enlarged." Chest x-rays are performed to see if the heart is enlarged. This will determine if the heart muscle is increasing in size. Disturbances in heart conduction are detected by an EKG. Visualizing where blood is being shunted is through the echocardiogram. The image used to clarify the structures of the heart is the MRI.

The nurse is caring for an infant girl with a suspected cardiovascular disorder. Which statement by the mother would warrant further investigation?

"The baby seems more comfortable over my shoulder." The nurse should be alert to statements indicating that the baby seems to be more comfortable when she is sitting up or over her mother's shoulder than when she is lying flat. Grunting or rapid breathing would be a cause for concern. Drinking all of the bottle would be considered normal.

The nurse is providing child and family education prior to discharge following a cardiac catheterization. The nurse is teaching about signs and symptoms of complications. Which statement by the mother indicates a need for further teaching?

"The feeling of the heart skipping a beat is common." Reports of heart "fluttering" or "skipping a beat" should be reported to the doctor as this can be a sign of a complication. The tub bath statement is appropriate because tub baths should be avoided for about 3 days. The strenuous activity statement is appropriate because strenuous activity is limited for about 3 days. Changes in skin color or difficulty breathing indicate potential complications that need to be reported.

A child with congestive heart failure is prescribed furosemide. The nurse is assessing the child's hourly urine output. The child weighs 10 kg. The nurse would identify which urine output as within normal limits?

10 to 20 mL/hour Normal urine output is 1 to 2 mL/kg/hour. Because the child weighs 10 kg, normal output would be 10 to 20 mL/hour.

A nurse is teaching the parents of a child diagnosed with rheumatic fever about prescribed drug therapy. Which statement would indicate to the nurse that additional teaching is needed?

"We can stop the penicillin when her symptoms disappear." For a child with rheumatic fever, drug therapy must be given for the full 10 to 14 days to ensure complete eradication of the infection. The drug must not be stopped when the signs and symptoms disappear. To prevent recurrent attacks, prophylactic antibiotic therapy is prescribed for at least 5 years or until the child is 18 years old. Additional prophylactic therapy should be instituted when dental or tonsillar surgery is planned.

A nurse is examining a 10-year-old girl who has a heart murmur. On auscultation, the nurse finds that the murmur occurs only during systole, is short, and sounds soft and musical. When she has the girl stand, she can no longer hear the murmur on auscultation. Which of the following should the nurse say to the girl's mother in response to these findings?

"Your daughter has an innocent heart murmur, which is nothing to worry about." The symptoms described indicate an innocent heart murmur. Although innocent murmurs are of no consequence, parents need to be told when their child has one because this finding will undoubtedly be discovered again at a future health assessment or during a febrile illness, anxiety, or pregnancy. Activities need not be restricted when a child has an innocent murmur and the child requires no more frequent health appraisals than other children. If a murmur is present as the result of heart disease or a congenital disorder, it is an organic heart murmur.

The nurse is caring for a child with Kawasaki disease who weighs 40 lb (18.2 kg). The health care provider has prescribed aspirin 80 mg/kg divided into 4 daily doses. Aspirin is supplied at 81 mg per tablet. How many tablet(s) will the nurse administer for one dose? Record your answer using one decimal place.

4.5 To determine the number of tables, use the child's weight in kilograms. Then, multiply 80 mg by 18.2 kg to determine the appropriate mg, which is 1456 mg. Next, divide 1456 mg by 4 to determine the appropriate mg needed for 1 dose, which is 364 mg. Then take the required mg of 364, and divide by 81 mg, because this is how many milligrams are in each tablet, for 4.5 tablets.

To prevent infective endocarditis in the child with an artificial heart valve, the nurse teaches parents to:

Administer prophylactic antibiotics before dental work. Dental procedures may allow organisms to enter the child's bloodstream and grow on the artificial valve. This makes excellent oral hygiene also important. Unexplained fevers should be discussed with the child's health care provider and not automatically treated at home. Raw fruits and vegetables and household pets are not a particular threat to this child.

A child is diagnosed with rheumatic fever. For which medication will the nurse educate the caregivers?

Aspirin Medications used in the treatment of rheumatic fever include penicillin, salicylates (aspirin), and corticosteroids. Insulin would be given for diabetes and dilantin for seizure disorders. Antivirals are not relevant to the treatment of a bacterial infection.

The nurse is caring for a child admitted to the hospital for a cardiac catheterization. Upon return from the cardiac catheterization, which nursing action is priority?

Assess the dressing at the insertion site. The child returning from a cardiac catheterization is at risk for hemorrhage from the insertion site. The nurse will assess the dressing at the insertion site immediately upon the child's return from the procedure. Palpating pulses, maintaining IV patency, and applying a blood pressure monitor would be done after first assessing the child for bleeding. Although assessing pulses will provide the nurse with information about the circulatory status of the extremities, weak pulse strength is a later sign of hemorrhage than visually assessing the insertion site.

A 5-year-old is being prepared for diagnostic cardiac catheterization, in which the catheter will be inserted in the right femoral vein. What intervention should the nurse take to prevent infection?

Avoid drawing a blood specimen from the right femoral vein before the procedure Because the vessel site chosen for catheterization must not be infected at the time of catheterization (or obscured by a hematoma), never draw blood specimens from the projected catheterization entry site before the procedure (generally a femoral vein). The other interventions listed are performed for reasons other than prevention of infection. Children scheduled for the procedure are usually kept NPO for 2 to 4 hours beforehand to reduce the danger of vomiting and aspiration during the procedure. Be certain to record pedal pulses for a baseline assessment. The site for catheter insertion is locally anesthetized with EMLA cream or intradermal lidocaine.

What information would be included in the care plan of an infant in heart failure?

Begin formulas with increased calories. Infants with heart failure need increased calories for growth. The infants are typically given smaller, more frequent feedings to decrease the amount given and to help conserve energy for feeding. They often are given a higher-calorie formula. The infant should be placed in an upright position or in a car seat to increase oxygenation. The infant should not have any pressure on the diaphragm while in this position. Vomiting is a sign of digoxin toxicity and this should be considered before administering.

A 6-year-old girl had a cardiac catheterization at 9 a.m. At 11 a.m. the nurse notes hypotension as compared to baseline. Based on this assessment finding, which of the following would the nurse do first?

Check the insertion site. Hypotension may signify hemorrhage due to perforation of the heart muscle or bleeding from the insertion site. Rechecking the blood pressure every 15 minutes is done during the first hour and then every 30 minutes for the next hour. Rechecking the blood pressure would be appropriate after the nurse checks the insertion site and determines that bleeding is not present. Pain or fever would be more likely with infection or thrombus formation. Pallor, diminished temperature, and altered capillary refill time in the affected extremity could signal compromised neurovascular status.

The nurse is caring for a 14-year-old girl with atrial fibrillation. Which medication would the nurse expect to be prescribed?

Digoxin Digoxin is indicated for atrial fibrillation. It increases the contractility of the heart muscle by decreasing conduction and increasing force. Alprostadil is indicated for temporary maintenance of ductus arteriosus patency in infants with ductal-dependent congenital heart defects. Furosemide is used for the management of edema associated with heart failure. Indomethacin is used to close a patent ductus arteriosus.

The nurse is reviewing the laboratory test results of several children who have come to the clinic for evaluation. Which child would the nurse identify as having the least risk for hyperlipidemia?

Child A with a total cholesterol of 150 mg/dl and low-density lipoprotein (LDL) of 80 mg/dl. Total cholesterol levels below 170 mg/dl and LDL levels less than 100 mg/dl are considered within the acceptable range. Total cholesterol levels between 170 and 199 mg/dl and LDL levels between 100 and 129 mg/dl are considered borderline. Total cholesterol levels between 170 and 199 mg/dl and LDL levels between 100 and 129 mg/dl are considered borderline. Total cholesterol levels greater than or equal to 200 mg/dl and LDL levels greater than or equal to 130 mg/dl are considered elevated and place this child at greatest risk.

When assessing a infant born at 32 weeks' gestation, which finding would lead the nurse to suspect to suspect that the newborn has a patent ductus arteriosus (PDA)?

Continuous murmur on auscultation Presence of a continuous murmur on auscultation of the heart is indicative of patent ductus arteriosus (PDA) in preterm infants. Preterm infants are at an increased risk of developing PDA. Other assessment findings that indicate PDA include bounding pulse, increased pulse rate and low diastolic arterial pressure.

The nurse is administering medications to the child with congestive heart failure (CHF). Large doses of what medication are used initially in the treatment of CHF to attain a therapeutic level?

Digoxin The use of large doses of digoxin at the beginning of therapy to build up the blood levels of the drug to a therapeutic level is known as digitalization. During the 24 hours digitalization is occurring, the child should be on a cardiac monitor and the nurse should monitor the PR interval and a decreased ventricular rate. The other listed medications are not administered in this manner. Albuterol is inhaled for asthma treatment and used primarily for exacerbations. Ferrous sulfate is give for iron-deficiency anemia, and spironolactone is a diuretic.

The nurse is collecting data on a 5-year-old child admitted with the diagnosis of congestive heart failure. Which clinical manifestation observed during the physical assessment would be consistent with this diagnosis?

Failure to gain weight In infants and older children, one of the first signs of CHF is tachycardia. Other signs of CHF often seen in the older child include failure to gain weight; weakness; fatigue; restlessness; irritability; and a pale, mottled, or cyanotic color. Rapid respirations or tachypnea, dyspnea, and coughing with bloody sputum also are seen. Edema and enlargement of the liver and heart may be present. Jerking movements indicate seizure activity. Scissoring of the legs is seen in cerebral palsy, and spooning of the fingernails is seen in iron-deficiency anemia.

The nurse is performing echocardiography on a newborn who is suspected of having a congenital heart defect. The child's mother is concerned about the safety of using this on a newborn and wants to know how this technology works. The nurse assures her that this technology is very safe and may be repeated frequently without added risk. What should the nurse mention in explaining how this diagnostic test works?

High-frequency sound waves are directed toward the heart Echocardiography, or ultrasound cardiography, has become the primary diagnostic test for congenital heart disease. An echocardiogram involves high-frequency sound waves, directed toward the heart, being used to locate and study the movement and dimensions of cardiac structures, such as the size of chambers; thickness of walls; relationship of major vessels to chambers; and the thickness, motion, and pressure gradients of valves. You can remind parents that echocardiography does not use x-rays so it can be repeated at frequent intervals without exposing their child to the possible risk of radiation. The other answers refer to other types of diagnostic tests, including X-ray studies, radioangiocardiography, and phonocardiography.

A nurse is reviewing blood work for a child with a cyanotic heart defect. What result would most likely be seen in a client experiencing polycythemia?

Increased RBC Polycythemia can occur in clients with a cyanotic heart defect. The body tries to compensate for having low oxygen levels and produces more red blood cells (RBCs). This would cause an increased result on the lab tests. This problem does not affect the white blood cells (WBCs).

The nurse is caring for a child with rheumatic fever who has polyarthritis. Which lab result would the nurse most anticipate with this child's diagnosis and symptoms?

Increased erythrocyte sedimentation rate (ESR) In the child with rheumatic fever who has polyarthritis, the erythrocyte sedimentation rate (ESR) is increased. Although the clotting time may be altered with the use of aspirin, this is not anticipated with the treatment. The white blood cell and leukocyte counts would be elevated.

A 6-year-old girl is diagnosed with pulmonary stenosis. The mother asks the nurse what the likely treatment for this condition will involve. The nurse should tell the mother which of the following?

Insertion of a catheter with an uninflated balloon tip into the affected valve, followed by inflation of the balloon to break up adhesions Balloon angioplasty by way of cardiac catheterization is the procedure of choice for pulmonary stenosis. With this procedure, a catheter with an uninflated balloon at its tip is inserted and passed through the heart into the stenosed valve. As the balloon is inflated, it breaks valve adhesions and relieves the stenosis. The other answers refer to interventions related to patent ductus arteriosus, not pulmonary stenosis.

The nurse is assessing a child with suspected rheumatic fever. What assessment findings are consistent with the disease process? Select all that apply.

Involuntary limb movement Macular rash on trunk Tender swollen joints Signs and symptoms of rheumatic fever include systolic murmur, involuntary limb movement, macular rash on the trunk, tender swollen joints, and subcutaneous nodules.

After teaching a group of students about acute rheumatic fever, the instructor determines that the teaching was successful when the students identify which assessment finding?

Jerky movements of the face and upper extremities Sydenham chorea is a movement disorder of the face and upper extremities associated with acute rheumatic fever. Janeway lesions, black lines, and Osler nodes are associated with infective endocarditis.

A nurse suspects a child is experiencing cardiac tamponade after heart surgery. What would be the priority nursing intervention?

Notify the doctor immediately. The nurse would notify the doctor immediately. Cardiac tamponade is a medical emergency and should be addressed. The child can die if intervention is postponed. It would not be appropriate to perform any interventions until confirming that this is the actual diagnosis.

The nurse is caring for a 6-year-old with a congenital heart defect. To best relieve a hypercyanotic spell, what action would be the priority?

Place the child in a knee-to-chest position. The priority nursing action is to place the infant or child in a knee-to-chest position. Once the child has been placed in this position, the nurse should provide supplemental oxygen or administer medication as ordered. A calm, comforting approach should be used but is not the priority action. Once a child is placed in the knee-to-chest position, supplemental oxygen would be provided as ordered. Once a child is placed in the knee-to-chest position, medications would be given as ordered.

A parent brings an infant in for poor feeding and listlessness. Which assessment data would most likely indicate a coarctation of the aorta?

Pulses weaker in lower extremities compared to upper extremities With coarctation of the aorta there is a narrowing causing the blood flow to be impeded. This produces increased pressure in the areas proximal to the narrowing and a decrease in pressures distal to the narrowing. Thus, the infant would have decreased systemic circulation. The upper half of the body would have an increased B/P and be well perfused with strong pulses. The lower half of the body would have decreased B/P with poorer perfusion and weaker pulses. Coarctation is not a cyanotic defect. The cyanosis would be associated with tetralogy of Fallot.

An infant with congenital heart disease is not growing and developing adequately. The nurse will institute what feeding strategy?

Raise the caloric density of the feeding beyond 20 calories per ounce. Increasing the caloric density of the feeding allows the infant to ingest more calories without increased volume and in a shorter period of time. This conserves energy. Calories per ounce can be increased by adding supplements to pumped breast milk. Using commercial formula could be necessary if a special formula is needed. However, breast milk is usually the infant's best source of nutrition. Feeding the infant every 2 hours and increasing the length of the feeding beyond 30 minutes will fatigue the child and allow for little rest between feedings.

A 10-week-old infant continues to have a small ventricular septal defect and is prescribed Digoxin. When evaluating the infant's response to drug therapy, which therapeutic action of the medication is identified?

Reduced fluid accumulation in the lungs Because up to 85% of VSDs are so small they close spontaneously, many children are managed by only close observation during the first years of life, perhaps with administration of a diuretic or digoxin to help prevent fluid from accumulating in the lungs. Placement of a septal occlude device during cardiac catheterization is done to prevent chronic pulmonary artery hypertension from developing or the heart from becoming infected (endocarditis) because of the recirculating and stagnant blood flow. Digoxin does not prevent infection or arrhythmias, nor does it facilitate the closing of the defect.

Nursing students are reviewing information about cardiopulmonary arrest in children. They demonstrate understanding of the information when they identify which of the following as the most common cause of cardiac arrest?

Respiratory failure Although cardiopulmonary arrest may result from trauma, anaphylaxis, or drowning, respiratory failure is the most frequent cause of cardiac arrest.

Parents are told their infant has a hypoplastic left heart. How would the nurse explain this condition to the family?

This is a problem where the left side of the heart did not develop properly. This is a problem where the left side of the heart did not develop properly. There is a three-step palliative surgery that can be implemented or the child will need a heart transplant.

When conducting a physical examination of a child with suspected Kawasaki disease, which finding would the nurse expect to assess?

Strawberry tongue Dry, fissured lips and a strawberry tongue are common findings with Kawasaki disease. Acne, hirsutism, and striae are associated with anabolic steroid use. Malar rash is associated with lupus. Café au lait spots are associated with neurofibromatosis.

When caring for a child with a congenital heart defect, which assessment finding may be a sign the child is experiencing heart failure?

Tachycardia Heart failure occurs when the heart has the inability to pump effectively to provide adequate blood, oxygen, and nutrients to the body's organs and tissues. Symptoms occur because of three factors. The neurohormonal influences cause symptoms of tachycardia, pallor, decreased urine output, sweating, hypertension, weight gain and edema. The symptoms seen from systolic dysfunction are dyspnea on exertion, increased work of breathing, and feeding difficulties. Diastolic influences produce hepatomegaly, jugular vein distention and periorbital edema.

A nurse is caring for a child who is experiencing heart failure. Which assessment data was most likely seen when initially examined?

Tachycardia If a child were experiencing heart failure, the most likely sign of this would be tachycardia, not bradycardia. The child may also experience hepatomegaly or oliguria, but not splenomegaly or polyuria.

A newborn has been diagnosed with a congenital heart disease. Which of the following congenital heart diseases is associated with cyanosis?

Tetralogy of Fallot Tetralogy of Fallot is associated with cyanosis. The defects include ventricular septal defect (VSD), right ventricular hypertrophy, right outflow obstruction, and overriding aorta. Coarctation of aorta, pulmonary stenosis, and aortic stenosis are acyanotic heart diseases and are not associated with cyanosis.

The nurse is caring for an infant prescribed oral digoxin. Which finding will cause the nurse to hold the dosage and notify the primary health care provider?

The infant's serum digoxin level is 4 ng/mL (5.12 nmol/L). The nurse would hold the dosage if the infant's serum level is 4 ng/mL (5.12 nmol/L). The therapeutic range is 0.8 to 2 ng/mL (1.02 to 2.56 nmol/L). Prior to administering each dose, the nurse should count the apical pulse for 1 full minute, noting rate, rhythm, and quality. The dose would be withheld if the apical pulse is less than 60 in an adolescent and less than 90 in an infant. The nurse would avoid giving oral digoxin with meals as altered absorption may occur. The normal respiratory rate for an infant is 30 to 60 breaths/minute.

When examining a child with congenital heart disease, an organ in the upper right quadrant of the abdomen can be palpated at 4 cm below the rib cage. What would most likely explain this assessment finding?

The liver size increases in right-sided heart failure. The liver increases in size due to right-sided heart failure. This is one of the cardinal signs of congestive heart failure. The spleen is in the upper left quadrant of the abdomen and would increase in size under certain circumstances, but this is asking for the upper right quadrant information. There are certain medications that can affect the liver, but this would not be the most likely reason for hepatomegaly.

A child with a congenital heart defect is getting an echocardiogram. How would the nurse describe this test to the parent?

This test will check how blood is flowing through the heart. An echocardiogram (echo) is a noninvasive ultrasound used to assess the heart wall thickness, the size of the heart chambers, the motion of the valves and septa, and the relationship of the great vessels to other cardiac structures. The test evaluates how blood is flowing through the heart and how effective the heart is in pumping. An echo does not check the electrical impulses. This would be done with an electrocardiogram.

Which problem-based nursing care plan will the nurse indicate as priority for the child following cardiac surgery for tetralogy of Fallot?

altered cardiopulmonary tissue perfusion risk Nursing priority following cardiac surgery will focus on assessing for ineffective cardiopulmonary tissue perfusion. Monitoring for excess fluid volume, infection, and parental anxiety will be performed after ensuring cardiopulmonary tissue perfusion is adequate.

The nurse is planning care for an infant with a nursing diagnosis of decreased cardiac output related to a cardiac defect. What is the most appropriate outcome for this nursing diagnosis? The child will:

demonstrate stable vital signs, capillary refill less than 3 seconds, and a urine output of 1-2 mL/kg/hr. The most appropriate outcome for a nursing diagnosis of decreased cardiac output would be one that illustrates that the patient has improved cardiac output. This can be illustrated by the patient who has stable vital signs, capillary refill less than 3 seconds, and good urine output of at least 1-2 mL/kg/hr. Stable electrolyte values, clear breath sounds, and no weight gain illustrate that the child does not of an Imbalanced fluid volume. Stable ABG's, decreased pulmonary secretions, and clear breath sounds support the child that has improved gas exchange that may have occurred due to fluid shifts and heart disease.

The nurse is collecting data on a child being evaluated for rheumatic fever. The caregiver reports that over the past several weeks the child seems to have lack of coordination, facial grimaces and repetitive involuntary movements. Based on these symptoms the nurse would suspect what condition?

chorea Rheumatic fever affects the heart, the central nervous system, skin and subcutaneous tissue. It causes carditis, arthritis, and chorea. Chorea is a disorder characterized by emotional instability, purposeless movements, and muscular weakness. The onset of chorea is gradual, with increasing incoordination, facial grimaces, and repetitive involuntary movements. Polyarthritis means there is arthritis in multiple joints which is common in rheumatic fever, but this is not a symptom of chorea. Arthralgia is a very common symptom of rheumatic fever. It is pain in the joints but again not a symptom of chorea. The heart muscle is affected in rheumatic fever as are the valves but not included in the symptoms of chorea.