Cardiac Disorders
Checking for ticks
Conduct a full body check upon return from potentially tick-infested areas. - Under the arms - In and around the ears - Inside belly button - Back of the knees - In and around the hair - Between the legs - Around the waist
The nurse is caring for a newborn who has been diagnosed with Tetralogy of Fallot and begins to turn dusky during the newborn assessment. The nurse bases the priority nursing intervention on the knowledge that what is occurring? Cyanosis Oxygenation Heart defect Patent ductus arteriosus
cyanosis
Cardiac Lesions that increase pulmonary blood flow
"Acyanotic Defects" These defects allow oxygen-rich blood that should be traveling to the body to re-circulate through the lungs Causes increased pressure and stress in the lungs - Atrial Septal Defect (ASD) - Ventricular Septal Defect (VSD) - Patent Ductus Arteriosis (PDA) - Atrial Ventricular Canal Defect (AVC)
Cardiac Lesions that decrease pulmonary Blood flow
"Cyanotic Defects" Too little blood flow to the lungs Deoxygenated blood travels systemically throughout body Mild to severe cyanosis Tetralogy of Fallot (TOF) Transposition of the Great Arteries (TGA) Tricuspid Atresia Pulmonary Atresia Truncus Arteriosis Total Anomalous Pulmonary Venous Return
The nurse is counseling a client undergoing an electrocardiogram (EKG) about the electrical conduction of the heart. Which statement is correct regarding the anatomical structure that is found in the right atrium and is needed for the contraction of the aorta to get blood flow to the ventricles? "The sinoatrial (SA) node acts as the heart's pacemaker, helping the heart to set and maintain a steady heart rate." "The patent foramen ovale (PFO) acts as the heart's pacemaker, helping the heart set and maintain a steady heart rate." "The PQ interval acts as the heart's pacemaker, helping the heart set and maintain a steady heart rate." "The atrioventricular (AV) node acts as the heart's pacemaker, helping the heart set and maintain a steady heart rate."
1
Cardiac diagnostics for Kawasaki disease
- CXR: Cardiomegaly, pleural effusions, coronary artery abnormality, MVR - EKG: Arrhythmias, prolonged PR interval, ST-T changes - ECHO: ....LV dysfunction, LV dilation, Coronary Artery dilation or occlusion, MVR Aneurysm: Appears 10 days after initial symptoms
Lyme carditis diagnosis
- History of exposure or tick bite - Characteristic Lyme erythema migrans rash - Presence of AV block in patient with no known heart disease Testing: - ELISA (Enzyme-linked immunosorbent assays) for Lyme antibodies Can be negative for first 6-8 weeks of illness - Western Blot: IgM & IgG Lyme Titers Prompt recognition & treatment of Lyme carditis leads to the best prognosis!
Kawasaki disease prognosis
- Long-term morbidity is related to degree of coronary artery involvement - 50-70% of aneurysms resolve in 1-2 years ...Coronary artery dilation regresses over time, if aneurysms <6mm they fully resolve - Mortality is rare among children treated with IVIG (0.1-0.3%)!!!
Kawasaki disease: discharge planning
- May be hospitalized for weeks depending on severity - Children do not feel well several weeks after being diagnosed with Kawasaki Disease, tend to limit their own activity level - Activity restrictions are dependent on the risk of MI or Thrombosis or with Giant Coronary Artery Aneurysms - Avoid contact sports or high impact sports with hx coronary aneurysm - Delay live vaccines until one year post-IVIG administration (MMR, Varicella, Influenza). May administer inactivated influenza. - Continue GI prophylaxis with LT ASA use ex. omeprazole - Cardiology Follow Up
Lyme disease presentation: Stage 1
- Onset 3-30 days after tick bite - Flu-like sx (fever, headache, malaise, myalgia (muscle pain), arthralgia (joint pain)) - Characteristic rash: erythema migrans (bulls eye)
Kawasaki disease with coronary artery aneurysms
- oxygenated blood pumped into aorta - left coronary artery supplies all the heart except right ventricle - aneurysm causing the wall of the artery to weaken - right coronary artery supplies the right ventricle 20% of Kawasaki Disease patients develop aneurysms if left untreated 5 % of Kawasaki Disease patients develop even if treated in a timely manner High Risk for Coronary System: - Obstruction - Thrombosis - Vessel rupture
Kawasaki disease manifestations
-Palmar edema/Erythemoatous Rash -Strawberry tongue -Diffuse maculopapular truncal rash -cervical lymphadenopathy -conjunctivitis -desquamation
Transitional circulation
1. With the removal of the placenta at birth, systemic vascular resistance increases, blood flow from umbilical vein ceases, and the ductus venosus closes 2. With the newborn's first breath, the lungs inflate, decreasing pulmonary vascular resistance of blood flow from the right ventricle 3. Increased pulmonary blood flow increases left atrial pressure, causing the septum primum flap of the foramen ovale to close shut, thus separating the two atria 4. Blood can no longer shunt across the atria, forcing the flow through the right ventricle to the pulmonary artery to the lungs, thereby increasing pulmonary blood flow to lungs 5. With increased oxygenation of blood, the ductus arteriosis permanently constricts, eliminating ductal blood flow and closes altogether off soon after birth
Classifying CHD
2 types... cyanotic and acyanotic Acyanotic Heart Defects - Lesions that increase pulmonary blood flow ...Atrial Septal Defect ...Ventricular Septal Defect ....Patent Ductus Arteriosis ....Atrioventricular canal defect Obstructive lesions that impede systemic blood flow .....Coarctation of Aorta ....Aortic Stenosis Cyanotic Heart Defects - Lesions that decrease pulmonary blood flow -Tetralogy of Fallot - Transposition of the Great Arteries - Tricuspid Atresia -Pulmonary Atresia (passage closed) -Truncus Arteriosis -Total Anomalous Pulmonary Venous Return - Double Outlet Right Ventricle Obstructive lesions that impede systemic blood flow - Hypoplastic Left Heart Syndrome
The nurse educator is educating a group of parents about fetal circulation. Which statements made by a parent regarding fetal circulation indicate the need for further education? Select all that apply. "The fetal placenta acts like the lungs during pregnancy." "The fetus's lungs function normally during pregnancy." "Fetal circulation is dependent upon the electrical impulses of the heart." "The fetal heart acts like the lungs during pregnancy." "The patent ductus arteriosus acts like the lungs during pregnancy."
2, 4, 5
Patent Ductus Arteriosus (PDA)
Connection between main pulmonary artery & descending aorta remains open PDA results in left to right shunting from aorta to pulmonary artery, increasing pulmonary blood flow Patency maintained in utero by circulating prostaglandins Normally closes hours after birth with the onset of breathing, leaving a fiber-like structure Common in premature infants Small PDA may be insignificant Large PDA can result in heart failure and pulmonary hypertension
The parents of a school-age child with congenital heart defect state they are having some dental work done. What recommendation should the nurse make? Inform the dentist of the condition so they can monitor during the procedure. Contact the provider for a prescription of prophylactic antibiotics. Inform the parent the child is at no increased risk during the procedure. Praise the parents for providing the appropriate health maintenance for their child.
Contact the provider
PDA repair
Premature infants with PDA are treated with indomethacin to facilitate closure Older infants & children require further intervention Cardiac - Cath Lab: Coil embolization or ductal occluder - Surgical Repair: PDA division & ligation or surgical interruption with titanium clips
ASD repair
Small ASDs do not require repair, may close before 2 years of age Large ASDs require intervention - Transcatheter device closure with septal occluder in catheterization lab - Open heart surgery: surgical closure by direct suture anastomosis or patch closure with autologous pericardium (membrane that covers the heart) or synthetic material
A nurse is obtaining a history of a child with suspected rheumatic heart disease. Which question is more important for the nurse to ask to help confirm the diagnosis? When was the last time you traveled outside of the United States? Have you ever had a diagnosis of strep throat? Are your immunizations up-to-date? How long have you had a fever?
Strep throat
What is the best way to promote safe and effective care for a child with Kawasaki Disease? Select all that apply. Encourage the use of warm cloths to keep the child's body temperature up. Minimize painful movements by avoiding exercise. Emphasize the need for measles, mumps, rubella, and chickenpox immunizations. Stress the importance of loose clothing. Encourage clear liquids and soft foods.
4, 5
Transposition of the Great Arteries (TGA)
Accounts for 5% of CHD cases Two types: Dextrocardia or D-Looped TGA: Great Artery Inversion Levocardia or L-TGA: Ventricular Inversion
Acquired heart disease
Acquired... Kawasaki Disease! Lyme Carditis! Congenital... Myocarditis Cardiomyopathy Endocarditis Rheumatic Heart Disease
April is a 16-year-old girl who recently had her wisdom teeth extracted. One week later, she is feeling fatigued and has developed a cough, joint pain, loss of appetite, and chills. She has also lost 5 pounds. Her mom notices April has flat, painless, reddish-blue spots on her palms and soles of her feet.
Subacute bacterial endocarditis
Adjuvant Kawasaki Treatment
Activity Restrictions - Avoid contact sports or high impact sports with hx coronary aneurysm Anticoagulants - Tx giant aneurysms - ASA, Heparin, Enoxaparin, Warfarin, Dipyridamole, Clopidogrel Glucocorticoids - Tx refractory fever, decrease coronary aneurysm involvement - IV Methylprednisolone 30 mg/kg daily for 1-3 days - PO Prednisone Immunosuppressants - Infliximab: ameliorate inflammatory response - Abciximab: may regress coronary aneurysm - Cyclosporine Cath Lab - Percutaneous intervention, balloon angioplasty, stenting Surgical Management - Coronary artery bypass graft - Cardiac transplantation
Kawasaki disease: nursing interventions
Close VS Monitoring - Tachycardia - Monitor oral or rectal temperature Q6H Physical Exam - Monitor perfusion Daily EKG - Monitor for arrhythmias, ST segment changes Serial ECHOs
Which assessment findings by the nurse indicate possible indicators of congenital heart disease (CHD) in children? Select all that apply. Poor weight gain Dysmorphic features Large for gestational age Clubbing and erythema in fingers and toes Anemia
Clubbing and erythema in fingers and toes Poor weight gain Dysmorphic features
Before birth, __________% of blood bypasses the lungs?
90%
A nurse is assessing an infant who has coarctation of the aorta. Which of the following findings should the nurse expect? (Select all that apply.) A. Weak femoral pulses B. Cool skin of lower extremities C. Severe cyanosis D. Clubbing of the fingers E. Low Blood Pressure
A, B, E
A nurse is caring for a child who is suspected of having rheumatic fever. Which of the following findings should the nurse expect? (Select all that apply.) A. Erythema marginatum (rash) B. Continuous joint pain of the digits C. Tender, subcutaneous nodules D. Decreased erythrocyte sedimentation rate E. Elevated C-reactive protein
A. CORRECT: Rheumatic fever is caused by Group A beta-hemolytic streptococcus. An erythema marginatum (rash) is a manifestation. B. A client who has rheumatic fever exhibits migratory joint pain of the large joints. C. A client who has rheumatic fever exhibits nontender subcutaneous nodules of bony prominences. D. Rheumatic fever is caused by Group A beta-hemolytic streptococcus, which results in an elevated erythrocyte sedimentation rate. E. CORRECT: Rheumatic fever is caused by Group A beta-hemolytic streptococcus. An increase in C-reactive protein is a manifestation.
A nurse is providing teaching to the mother of an infant who has a prescription for digoxin. Which of the following instructions should the nurse include? A. "Do not offer your baby fluids after giving the medication." B. "Digoxin increases your baby's heart rate." C."Give the correct dose of medication at regularly scheduled times." D."If your baby vomits a dose, you should repeat the dose to ensure that he gets the correct amount."
A. Digoxin can be given without regard to food or fluids. B. Digoxin slows the heart rate by increasing contractility of the heart. C. CORRECT: The correct amount of digoxin should be administered at regularly scheduled times to maintain therapeutic blood levels. D. It is not recommended to repeat digoxin following an emesis because it is impossible to determine how much medication was lost.
A nurse is caring for a 2-year-old child who has a heart defect and is scheduled for cardiac catheterization. Which of the following actions should the nurse take? A. Place on NPO status for 12 hr prior to the procedure. B. Check for iodine or shellfish allergies prior to the procedure. C. Elevate the affected extremity following the procedure. D. Limit fluid intake following the procedure
A. The child should remain NPO 4 to 6 hr prior to the procedure. B. CORRECT: Iodine-based dyes can be used in this procedure, so the child is assessed for allergies to iodine or shellfish which could lead to anaphylaxis. C. The affected extremity should be maintained in a straight position following the procedure. D. Fluids should be encouraged after the procedure to maintain adequate urine output and promote excretion of the dye.
Tetralogy of Fallot (TOF)!!!!!
Accounts for 10% of CHD cases Most common cyanotic heart defect beyond infancy Tetralogy: Set of four related symptoms or abnormalities frequently occurring together Four Anomalies 1. VSD 2. Pulmonary stenosis 3. Overriding aorta 4. Right ventricular hypertrophy
Neonatal TOF repair
After birth, severely cyanotic infants require prostaglandins (PGE1/alprostadil) to maintain ductal patency & pulmonary perfusion Neonatal Repair: - Blalock-Tussig Shunt palliation to provide adequate pulmonary blood flow to lungs in severe cases - Complete repair is difficult due to patient size & small pulmonary arteries, will need subsequent repair at 4-8 months of age
Lyme heart block management
Antibiotics -Resolves heart block in 48-72 hours -Defers need for permanent pacemaker Temporary pacing for escape rhythm or CHB -Externalized permanent pacemaker with active fixation lead as supportive pacing modality -Transcutaneous -Transvenous: R Subclavian Access -Connects to externalized pacemaker generator Set to VVI 60-120bpm -Can be discharged home with Holter Monitor, removed once NSR ECMO
D-TGA repair: Arterial Switch Operation
Ao and PA are divided Coronary buttons removed PA removed anterior to Ao Ao reconstructed Coronary buttons re-impaired
D-TGA "Transposed Arteries"
Aorta rises from the Right Ventricle - Returns de-oxygenated blood to the systemic circulation Pulmonary Artery arises from the Left Ventricle - Returns oxygenated blood to the pulmonary circulation Two separate circuits No oxygenation unless ASD that allows mixing!
Bailey is a 5-year old girl who has had strep throat twice this year. Her mother is concerned and takes her to the pediatrician's office because she appears tired and short of breath after playing, running, and jumping. Bailey keeps placing her hand over her chest and wincing in pain.
Aortic stenosis
The nurse is explaining cardiac conditions that result in the obstruction of blood flow in the heart. Which defects should be included in the teaching? Select all that apply. Tricuspid atresia Coarctation of the aorta Aortic stenosis Pulmonary atresia Ventricular septal defect (VSD)
Coarctation of the aorta Aortic stenosis Pulmonary atresia
Case study 1 Alexis is a 3 year old previously healthy female. During her well-child appointment, her parents describe that she experiences shortness of breath and tires easily when playing with her siblings. The nurse records her height and weight and notes that Alexis's growth has dropped sharply and she is currently in the 5th percentile. Her primary care provider auscultates a murmur during physical exam. Alexis is referred to a cardiologist and following an ECHO, Alexis is diagnosed with an ASD.
Atrial septal defect (ASD)... can be caused from the foraman ovale which was suppose to close at birth... fluid likes to flow from an area of high pressure to an area of low pressure and the left side of the heart is a high pressure system delivering blood to the whole body and the right side is a low pressure system which delivers blood to the lungs so the left atrium blood goes through the ASD to the right atrium which increases pulmonary blood flow and can lead to pulmonary congestion - "Hole" between right atrium & left atrium - Allows for oxygenated blood to shunt from left atrium to right atrium - Increased pulmonary blood!!! flow in large ASDs can cause pulmonary congestion - Right atrium & right ventricle dilate over time
The nurse preceptor is preparing a teaching session for a group of nurses that will cover the etiology of congenital heart defects that may occur in childhood. What information should be included in the session? Select all that apply. Excessive sweating Autoimmune factors Genetic factors Teratogens Pain
Autoimmune factors Genetic factors Teratogens
A nurse is assessing an infant who has heart failure. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Cool extremities C. Peripheral edema D. Increased urinary output E. Nasal flaring
B, C, E A. A client who has heart failure will exhibit tachycardia as the heart attempts to meet the body's demands. B. CORRECT: A client who has heart failure will exhibit cool extremities as the heart is unable to adequately circulate oxygenated blood. C. CORRECT: A client who has heart failure will exhibit peripheral edema as the heart is unable to adequately circulate blood through the body and back to the heart. D. With heart failure, the heart is unable to keep up with the body's demands. A decrease in urinary output is a manifestation of heart failure. E. CORRECT: A client who has heart failure will exhibit nasal flaring due to inadequate oxygenation of blood.
Congenital heart defects
Cardiac abnormalities occur during fetal development Involves heart chambers, heart valves, septal wall, & the arteries and veins of the heart Affects 1 in 100 infants Most common birth defect Range from mild to severe Critical congenital heart defects are the most severe 25% of infants with CHD require procedures or surgeries in the first year of life
The nurse is taking care of Michael, a 12-year-old boy who upon assessment displays dizziness, gallop, fatigue, and sweating at mealtimes. Upon review of the chart, the nurse determines the mother reported frequent colds and a diagnosis of pneumonia in the last 6 months. Upon assessment, the nurse discovers hepatomegaly.
Cardiomyopathy
While assessing an infant diagnosed with a congenital heart defect (CHD) in the newborn intensive care unit, the nurse notes the results from the arterial blood gas indicate a PaO2 level of 30. After bagging the infant with 100% oxygen, the PaO2 level is 34. What does the nurse suspect related to the assessment findings and diagnosis? Normal newborn assessment findings, no abnormalities Pulmonary disease Continued mixing of oxygenated and nonoxygenated blood Metabolic disease
Continued mixing of oxygenated and nonoxygenated blood
Cardiovascular complications
Coronary Artery Aneurysms Pancarditis Inflammation of: - AV conduction system (HRF AV block) - Myocardium (HRF myocardial dysfunction, CHF) - Pericardium (HRF pericardial effusion) - Endocardium (HRF AoV & MV involvement) - Cardiomyopathy - Myocardial Infarction - Arrhythmias - Heart Failure CV Symptoms: Tachycardia, gallop, muffled heart sounds, murmur, poor perfusion (cold, pale, cyanotic digits of hands & feet)
TOF symptoms
Cyanosis Tachypnea Irritability Heart Murmur Hypercyanotic spells Clubbing in older children
Which of the following nursing interventions should be done for an infant with patent ductus arteriosus? Select all that apply. Daily weights Clustering care Monitoring urine output Wound care Continue sedatives
Daily weights Monitoring urine output Wound care
Case study Patient: 4 y/o previously healthy male Recent Hx: Febrile for the past five days Physical Exam: Bilateral conjunctivitis, edematous lips, bright red tongue, left neck swelling, and erythema to both hands ECHO: + Coronary artery aneurysms Course: Admitted to cardiology floor for IVIG and high dose ASA therapy
Diagnosed with Kawasaki disease
Case study 4 Timothy is a two day old male with Trisomy 21 that was diagnosed by amniocentesis in the second trimester. While in the newborn nursery, his nurses notice that he is becoming increasingly cyanotic. A murmur is heard on auscultation. Bedside ECHO is performed and is notable for RVH, VSD, PS, and an overriding aorta. He is diagnosed with TOF.
Diagnosed with TOF
Case study Patient: 16 year old previously healthy male Sx: Flu-like symptoms (fever, chills, and malaise) x1 week. Presents to ED following syncopal episode Recent Hx: Went on a fishing trip to Lake Winnipasaukee Physical exam: Red bull's eye rash to his right neck Vitals: Bradycardic, HR in 40s EKG: Third degree heart block
Diagnosed with lyme carditis
Symptoms of D-TGA
Difficulty breathing Tachypnea Cyanosis or ashen color Poor feeding Poor weight gain Tachycardia Weak pulses
Case study 5 Theodore is a previously healthy six day old male who was discharged from the newborn nursery four days ago. Theodore's parents were in touch with the pediatrician this evening with concerns about Theodore having difficulty feeding. Overnight, Theodore began having respiratory distress and cyanosis prompting them to bring him to the local ED. Nurses obtain and pulse oximetry reading of 60% and palpate weak pulses. A STAT cardiology consult is placed and an ECHO reveals TGA. Theodore is immediately admitted to the Pediatric Cardiac ICU.
TGA revealed
Fetal structures
Ductus Venosus: Shunts oxygenated blood from umbilical vein to the inferior vena cava, bypasses liver !!!Foramen Ovale: Opening between right & left atria, oxygenated blood from ductus venosus flows across the right atrium to the left atrium, bypasses lungs !!!!!Ductus Arteriosis: Connects pulmonary artery & aorta, shunts deoxygenated blood from right ventricle to descending aorta, bypasses lungs !!! should close after fetus is born
Epidemiology of Lyme disease
Endemic to three US regions •Northeast •Upper Midwest •Pacific Northwest Seasonal - Most cases present in summer & fall months
Kawasaki disease "mucocutaneous lymph node syndrome"
Etiology - Most common type of acquired heart disease in children - Most prevalent in East Asian and Asian ancestry - Peaks at 6 months to 5 years old - Boys more commonly affected than girls - Likely infectious, immunologic, or genetic cause Pathophysiology - Systemic, inflammatory illness - Generalized microvasculitis throughout the body - Multiple organs & tissues are involved - Affects medium-sized arteries, especially the coronary arteries
ECMO
Extracorporeal Membrane Oxygenation. Modification of cardiac bypass. Large-bore catheters are inserted, blood is removed, oxygenated, CO2 is removed, and then returned to body.
VSD symptoms
Fatigue Increased work of breathing Tachypnea Diaphoresis Easily tires with feeding Poor weight gain Tachycardia Heart Murmur
Eisenmenger syndrome
Forms when a VSD goes unrepaired Increased pulmonary blood flow and high right-sided pressures from a large unrepaired VSD over time can result in irreversible pulmonary hypertension & pulmonary vascular disease Pulmonary hypertension causes shunt reversal, when pressures in the right side of the heart exceed pressures in the left side of the heart Causes unoxygenated blood from the RV to shunt through the VSD to the LV Patient becomes increasingly cyanotic Rare in the U.S., often seen in 3rd world countries like China
The parents of a newborn diagnosed with tricuspid atresia ask the nurse, "Did something that happened during our son's birth cause the problem with his heart?" Which statement by the nurse indicates the nurse's comprehension of the most common cause of congenital cardiac malformations? "The most common known causes of congenital heart malformations are genetic factors." "The most common known causes of congenital heart malformations are teratogens." "The most common known cause of congenital heart malformations is maternal drug use." "There are no known causes of congenital heart malformations."
Genetic factors
TOF and cyanosis
TOF is characterized by decreased pulmonary blood flow Degree of cyanosis dependent on degree of pulmonary stenosis "Pink Tets": Infants with minimal pulmonary stenosis may have large left to right shunting across VSD with little to no cyanosis "Blue Tets": Infants with severe pulmonary stenosis results in severe cyanosis with ductal dependent blood flow
Infant TOF repair
TOF is commonly repaired at 4-6 months of age With unrepaired TOF, right ventricular outflow tract obstruction is progressive with increasing cyanosis over time Surgery may occur sooner with progression of cyanosis Complete TOF repair: VSD closure & provision of unobstructed blood flow from right ventricle to pulmonary arteries
Tips for tick safety
How to remove a tick - sanitize the bite area and tweezers - grab tick close tot eh head - pull up slowly and carefully - sanitize bite area again When to call a doctor - fever - headache - rash
TOF and chromosomal disorders
TOF is often associated with genetic syndromes .....22q11.2 deletion (DiGeorge syndrome) - Cono-truncal CHD (VSD, TOF, Truncus Arteriosis, Interrupted Ao Arch) - Cranio-facial abnormalities - Cleft palate - Hypocalcemia - Immunodeficiency - Developmental delays Trisomy 21 (Down syndrome) Alagille syndrome
PDA symptoms
Increased work of breathing Tachypnea Difficulty feeding Fatigue Poor growth Frequent respiratory or lung infections Continuous heart murmur
Pathophysiology of Lyme disease
Initial characteristic skin lesion: erythema migrans is seen in 60-80% of Lyme cases - Macule/papule at site of bite - Progressive expansion to an erythematous ring with red borders & central clearing - Most commonly found on axilla, groin, or thigh, ear, knee Infection spreads to bloodstream & lymphatics then disseminates to other organs, including the heart & nervous system
The mother of a child who is 72 hours post-cardiac catheterization calls the clinic to report a temperature of 102°. What is the best action for the nurse to take? Inform the mother it is normal to have some fever following a cardiac catheterization. Ask the mother to administer acetaminophen and recheck in 1 hour. Instruct the mother to bring the child in for evaluation. Instruct the mother to reduce activity and report any signs of changes to the affected extremity.
Instruct the mother to bring the child in for evaluation
Hypercyanotic spells/ "Tet spells"
Intermittent spells of extreme hypoxia, cyanosis, hyperpnea (rapid & deep breathing), & irritability Caused by decreased blood flow from RV to PA, decreased SVR & increased pulmonary stenosis with stress (crying, stooling, exercise, agitation, dehydration, fever) Leads to worsening cycle of increased right to left shunting through the VSD and increased cyanosis Can lead to vicious cycle of hypoxic spells that can be fatal if persistent and uncorrected with dramatic arterial desaturation
Kawasaki disease treatment
Intervention: Reduce inflammation within coronary artery & myocardium Administer IVIG (Gamma Globulin) - High-Dose (2 grams/kg), single infusion given over 10-12 hours within 10 days of symptoms (5 day window for child to be brought to doctors bc it takes 5 days of febrile to be a diagnosis) - May repeat if febrile 48H after first IVIG dose - Premedicate with Tylenol & Benadryl - Assess for hypersensitivity, fluid overload, headache Intervention: Prevent thrombosis by inhibition of platelets aggregation ASA (Aspirin) - High-Dose (80-100mg/kg/day) provides anti-inflammatory effect while febrile - Low-Dose (3-5mg/kg/day) provides long term anti-platelet effect - Continue indefinitely with coronary artery abnormalities Early Intervention is key!! Initiate ASAP!!!
Lyme Disease
Lyme disease is the leading tick-borne illness in N. America - Caused by the hard shelled tick Borrelia burgdorferi!!!!! 300,000 new cases diagnosed each year 75,000 children are diagnosed annually Multisystem bacterial infectious disease 3:1 male to female predominance Children aged 5-9 years are at greatest risk
Etiology of CHD
Maternal Infection - Rubella CMV, HSV, - Coxsackievirus B - HIV Maternal Medication - Amphetamines - Anticonvulsants - ACE Inhibitors, ARBs - Lithium - Retinoic Acid (Vitamin A) - Progesterone, Estrogen - Statins - Thalidomide Maternal Ingestion - Alcohol - Smoking Maternal Disease - Obesity - Diabetes - Lupus erythematosus - Maternal PKU Genetics!!!!!! most common
Ventricular Septal Defect (VSD)
Most common form of CHD, accounts for nearly 25% of all cases "Hole" between right ventricle & left ventricle Single or multiple defects, multiple locations Allows for oxygenated blood to shunt from left ventricle to right ventricle Increased pulmonary blood flow in VSDs can cause pulmonary edema & tachypnea Right ventricle, left atrium, & left ventricle dilate over time due to increased pulmonary venous return
Lyme carditis
Most pts present in AV block which can quickly form to complete heart block and atropine does not help in these periods of bradycardia
Kawasaki criteria
NON-SPECIFIC CLINICAL MANIFESTATIONS - Brief nonspecific prodrome of respiratory or GI Diarrhea Vomiting Abdominal Pain Irritability Cough or rhinorrhea Decreased PO intake Joint pain Systemic Inflammation - presence of a fever lasting more than 5 days >38.5 degrees Celsius (101.3F) - refractory to antipyretics MUCOCUTANEOUS INFLAMMATION Must have 4 of the following 5 symptoms: Bilateral nonexudative conjunctivitis Erythema of lips & oral mucosa Rash Extremity changes Cervical lymphadenopathy (neck swelling)
Abby is a 4-year-old girl diagnosed with Turner syndrome and coarctation of the aorta. Which priority nursing intervention should the nurse perform? Ask the child if she has pain over her chest. Obtain a blood pressure reading in all four extremities. Place a sign on the door that reads: Nothing by Mouth. Prepare the family for immediate intubation.
Obtain a bp
Disseminated Lyme Infection: stage 2
Occurs 2-12 weeks after tick bite - Pediatric Manifestations: Lethargy, poor appetite - Neurological Manifestations: Ataxia, double vision, photophobia, nystagmus (eye movements), difficulty reading Triad of Lyme Neuroborreliosis - Aseptic meningitis - Cranial nerve palsies - Peripheral radiculoneuropathy Cardiac manifestations: Lyme Carditis occurs in 10% of patients with Lyme AV Block - Asymptomatic - Light-headedness, presyncope, syncope, worsening SOB, dyspnea, palpitations, angina
ASD symptoms
Often asymptomatic Fatigue Increased work of breathing Dyspnea with exertion Easily tires with feeds Frequent respiratory infections Palpitations Heart murmur Peripheral edema Stroke
Ductal Dependent Lesions
PDA may be kept open intentionally with administration of exogenous prostaglandins (PGE1 or alprostadil) In some CHD, the PDA is necessary after birth the provide pulmonary or systemic blood flow .....In critical right heart obstructive lesions, the PDA is necessary to supply blood flow to the lungs - Tetralogy of Fallot - Pulmonary Atresia - Critical Pulmonary Stenosis - Tricuspid Atresia - Ebstein's Anomaly .......In critical left heart obstructive lesions, the PDA is necessary to supply blood flow to the body - Hypoplastic Left Heart Syndrome - Critical Aortic Stenosis - Coarctation of the Aorta - Interrupted Aortic Arch ......In parallel circulations, the PDA allows for bidirectional flow to the lungs and the body - Transposition of the Great Arteries
Case study 3 Phoebe is a two week old female born premature at 30 weeks. She was intubated shortly after birth for respiratory failure and has remained hospitalized in the Neonatal ICU. She has had a persistent heart murmur since birth. She was diagnosed with pneumonia on DOL 3 and finished a 10 day course of antibiotics. She is now febrile, tachypneic on the ventilator, and has increased oxygen requirement. Chest X-ray reveals cardiomegaly. A bedside ECHO was performed, revealing a PDA.
PDA present
Lyme disease treatment
PO Doxycycline - Children > 8 years - 100 mg BID for 2-3 weeks PO Amoxicillin - Children < 8 years - 25-50 mg/kg day divided in 2 doses for 2-3 weeks IV Ceftriaxone - Lyme Carditis with High degree AV block or cardiac sx - 2 grams IV daily for 3-4 weeks - PICC line placement for 4-6 weeks antibiotic therapy
The nurse is educating a group of new nurses and explaining congenital heart defects classified as having increased pulmonary blood flow. Which defects should be included in this teaching session? Select all that apply. Patent ductus arteriosus (PDA) Atrial septal defects (ASDs) Ventricular septal defects (VSDs) Tetralogy of Fallot (TOF) Tricuspid atresia
Patent ductus arteriosus (PDA) Atrial septal defects (ASDs) Ventricular septal defects (VSDs)
Treatment of Tet spells
Place infant in knee-chest position Older unrepaired toddlers may squat naturally into a knee-chest position when playing too hard Administer oxygen Administer morphine or ketamine Administer phenylephrine or propranolol GOAL: Increase systemic arterial oxygen saturation!
The nurse is receiving report from the recovery room nurse on Caleb, a 4-month-old infant who underwent a Fontan procedure to repair a heart valve. The reporting nurse states that the patient had patent ductus arteriosus and another heart defect. History of the patient reveals episodes of shortness of breath, marked cyanosis at birth, fatigue, tachypnea, poor feedings, and inability to gain weight.
Pulmonary atresia
The nurse is caring for a child with a congenital heart defect and notes an increased work of breathing with tachypnea, grunting, and nasal flaring. The nurse should suspect which complication has developed? Pulmonary edema Polycythemia Clubbing Hyperoxia
Pulmonary edema
Andy is an 8-year-old boy presenting at the emergency room with abdominal pain and recurrent nosebleeds. His mother reports a history of strep throat that occurred last month. The nurse assesses Andy and hears a heart murmur and documents chest pain on the chart.
Rheumatic heart disease
A nurse is reviewing the history of her patient prior to performing her assessment. The chart indicates that the child has the following signs and symptoms: "Tet" spells, clubbing of the fingers, irritability, and poor growth. The nurse knows that these findings are most consistent with what diagnosis?Tetralogy of Fallot Pulmonic stenosis Coarctation of the aorta Transposition of the great vessel
Tetralogy of fallot
Kaylee is a 4-week-old infant being seen at the pediatrician's office for her 1-month well-child visit. Her mom discusses concerns that Kaylee does not seem to be gaining weight, is very irritable making it difficult to console her, and seems to be blue in color when crying. The nurse assesses Kaylee and finds that she is still the same birth weight and has a murmur.
Tetralogy of fallot
A student nurse asks which classification of congenital heart defects results in the combining of blood between systemic and pulmonary circulation in the heart chambers, which results in a desaturation of blood oxygen levels and a decrease in cardiac output related to an increased volume load on ventricles. What is the appropriate nursing response? "This type of congenital heart defect is classified as a mixed defect." "You are describing a defect that is related to a decrease in pulmonary blood flow." "The defect that you are describing is brought on by an increased pulmonary blood flow." "This defect is referred to as an obstructive disorder."
This type of congenital heart defect is classified as a mixed defect.
Prevention of Lyme disease
Tick exposure can occur year-round - Most active during warmer months (April-September). Ticks live in grassy, brushy, or wooded areas. - Spending time outside walking your dog, camping, gardening, or hunting could bring you in close contact with ticks. - Many people get ticks in their own yard or neighborhood. Treat clothing and gear with products containing 0.5% permethrin. - Treat boots, clothing and camping gear. - Invest in permethrin-treated clothing and gear. Use insect repellants - containing DEET or Oil of Lemon Eucalyptus on children 3 years old and older. Avoid Contact with Ticks - Avoid wooded and brushy areas with high grass and leaf litter. Walk in the center of trails. Check your clothing for ticks. Examine gear and pets. Shower soon after being outdoors.
Kara was born at 36 weeks gestational age and was having some difficulty breathing upon delivery, so she is being monitored in the neonatal intensive care unit. The nurse notices that Kara's oxygen saturations in the upper extremities are lower than when measured in the lower extremities. Upon assessment, the nurse hears a murmur and profound cyanosis with crying.
Transposition of the great vessels
VSD repair
Treat volume overload & congestive heart failure with diuretics Fortify high calorie breast milk & formula to maximize growth Surgical repair if impaired growth & CHF symptoms persist - Suture repair for small VSDs - Patch repair for large VSDs
The nurse is preparing a teaching session for new nurses on congenital heart defects classified as having decreased pulmonary blood flood flow. Which defects should be included in the teaching? Select all that apply. Tricuspid atresia Eisenmenger syndrome Ventricular septal defects (VSDs) Tetralogy of Fallot (TOF) Patent ductus arteriosus (PDA)
Tricuspid atresia Eisenmenger syndrome Teratology of fallout (TOF)
Case study 2 Violet is a four month old female presenting to the office for her 4 month check-up and routine vaccinations. Parents report she has difficulty feeding and can only drink half of her bottle before falling asleep. Parents are worried that she is always breathing quickly and is very sweaty. Parents change her onesies often because they become saturated with her sweat. The nurse records weight loss since the two month appointment. The provider auscultates a faint heart murmur and refers the patient to cardiology. An ECHO confirms that a VSD is present.
VSD is present confirmed by ECHO
coronary artery aneurysms
What do you look for in a patient with Kawasaki disease?
syncopal episode
fainting spell, brief loss of consciousness
CHD (congenital heart disease)
heart disease clients are born with - #1 birth defect - no cure - #1 cause of birth defect related deaths - affects 1 in 100 newborns
Desquamation
peeling skin
cervical lymphadenopathy
swollen lymph nodes
Fetal circulation
the system of blood vessels and structures through which blood moves in a fetus Placenta: Maternal organ that develops during pregnancy, connects mother to fetus via the umbilical cord Umbilical cord: Delivers nutrition, oxygen, & life support from mother to fetus, comprised of blood vessels One Umbilical Vein: Delivers oxygen & nutrients from placenta to the fetus Two Umbilical Arteries: Transports unoxygenated blood, carbon dioxide, & waste from fetus back to placenta to the mother's circulation to be eliminated REMEMBER: 2 UA & 1 UV!!!
