RNSG 2539

Patent Ductus Arteriosus *Clinical Manifestations*

*Early Signs:* Murmurs, gallops Tachypnea, increased work of breathing Cyanosis Diaphoresis Poor feeding/weight gain/FTT *Late Signs:* Cyanosis FTT Developmental Delays Signs of heart failure Polycythemia, clubbing

Tetrology of Fallot

*SOF* Severe obstruction to pulmonary blood flow and blood shunting from right to left side of the heart

Acute Pancreatitis *Causes*

*↑ Amylase & Lipase* 1) Gallstones 2) Alcohol Abuse

Atrial Septal Defect

- An abnormal opening between the left and right atria of the heart - Murmur heard high on the chest

HIT: Medical Management

- Cessation of Heparin - Clot inhibitors (Lepirudin and Argatroban) - Warfarin

TOF Treatments

- Child may bend at the knees / fetal position - Toddler may squad periodically to improve pulmonary blood flow - Admin 100% O2 - Admin IV Morphine - Propanolol - Phenylephrine - Glucose - PRBC Transfusions - IV fluid replacement to prevent strokes - Palliative care - Surgery (Shunt or Patch)

Coarctation of the Aorta

- Congenital cardiac condition characterized by a narrowing of the aorta - Acyanotic Narrowing or closure of aorta - May develop LV failure, but may be asymptomatic for years

Immune Thrombocytopenic Purpura: Medical Management

- Corticosteroids - Azathiprone (Imuran) - IVIG - Chemotherapy

Problems to report to provider when child has heart defects:

- Fever - Respiratory Distress - Pain - Changes in behavior - Changes in O2 saturation outside of range

Ventricular Septal Defect

- Hole in the septum between the two ventricles - - Holosystolic murmur heard best at LSB, may have ventricular hypertrophy

TOF S/S

- Increased cyanosis under stress/feeding/crying - Hypoxemia - Dyspnea - Agitation - Blue Babies - Clubbing - Poor feeding - Diaphoresis - Endocarditis - Arrhythmias - Seizures With less O2 in the body, the body will create more RBCs which can then cause a clot and than a stroke.

Clinical Manifestations of DIC

- Initially a < platelet count - Comprised organ function or failure - Bleeding from mucous membranes, venipuncture sites, and the GI and urinary tracts - Pts will develop MODS - Renal failure - Pulmonary and multifocal CNS infarctions

DIC Assessment

- Lab test reflecting consumption of platelets & clotting factors ↓ Platelet count ↓ Fibrinogen level ↑ Fibrin degradation products and D-Dimer ↑ PT / PTT

ASD/VSD Surgical Treatment

- Occluder - Dacron patch or suture to close the hole

Pancreatitis * Diagnostic Finding*

- Pancreas swelling - Blood sugar issues - Malabsorption - GI: pain, diarrhea, oily stool - Ascites - Fibrosis, systs, abscesses, rupture

TET Spells Interventions

- Place in knee-chest position - Increases systemic resistance - Decreases right to left shunt - Techniques: 1. Hold infant over shoulder; knees drawn toward chest 2. Supine or prone: knees drawn up 3. Squatting if older

DIC Nursing Management

- Pts with Sepsis and Acute Promyelocytic Leukemia are commonly found to get DIC - Pts assessed frequently for S/S of thrombi / bleeding - Lab values monitored frequently

Pancreatitis *Signs/Symptoms*

- Sudden, very painful mid-epigastric pain of LUQ - Hurts most when lying flat ↑ HR, Fever, ↓BP ↑ Glucose, ↑ Amylase and Lipase - Cullen's sign: bluish discoloration umbilicus

Vitamin K

- Synthesis of many coagulation factors - Deficient in malnourished patients - Prolonged antibiotic use diminishes the production

DIC Medical Management

- Treat the underlying cause - Correct secondary effects - Tissue eschemia - Replace fluids - Correct electrolyte imbalance - Administer vasopresser medications

Liver Disease causes

- Viral infection: Hep C & B - Excessive alcohol consumption - ↑ fat collection in liver - Bile duct problems - Diabetes - Autoimmune

International Normalized Ratio

0.8-1.2

Prothrombin time

0.8-1.2

Chronic Pancreatitis *Causes*

1) Chronic inflammation to the pancreas 2) Years and years of alcohol abuse *Cystic Fibrosis* ↑ Calcium ↑ Cholesterol

What are the 4 defects of TOF?

1. Pulmonary Stenosis 2. Right Ventricle Hypertrophy 3. Overriding Aorta 4. VSD *P.R.O.V.*

Urine specific gravity

1.015-1.030

Magnesium

1.3-2.1

Platelets

150,000-450,000

Fibrinogen levels

170 - 340mg/dL

Normal Albumin levels

3.5-5

WBC

5000-10,000

Calcium

9-10.5

Chloride

98-106 mEq/L

Prostaglandin

A hormone that promotes blood supply to an area

COA Preoperative Intervention

Administer prostaglandin

Fresh-frozen plasma

Administered to replace coagulation factors

Indomethacin

Agent used for closure of patent ductus arteriosus

Acyanotic Defects: (Left to Right Shunts) *Increased Pulmonary Blood Flow*

Atrial Septal Defect (ASD) Ventricular Septal Defect (VSD) Patent Ductus Arteriosus (PDA)

TOF Diagnostic Tests

Auscultation - murmurs Echocardiogram - common Chest XRay - heart size; pulmonary vasculature CBC - hematocrit EKG - arrhythmias Cardiac catherization

Propanolol

Beta blocker Antihypertensive (Vaso-Dilation)

Palliative Surgery

Blalock Taussig shunt -> Subclavian to pulmonary artery

Amylase

Breaks down carbs to glucose 56-90 IU/L

Lipase

Breaks down fats 0-110 units/L

Patent Ductus Arteriosus

Close with indomethacin, open with misoprostol. Continuous "machinery" heart murmur.

COA

Coarcation of the Aorta

Obstructive Disorders

Coarctation of the Aorta Pulmonary Stenosis Aortic Stenosis

Changes in pressure or saturation of cardiac blood may lead to ________________

Congestive Heart Failure Hypoxemia

Depolarization

Contraction - state in which the resting potential is reversed as sodium ions rush into the neuron

Immunization

DO NOT give live viruses - MMR - Varicella - Rotavvirus - Small pox vaccine - OPV - Live attenuated influenza vaccine - Cholera oral

The _____________________ does not immediately close, but over several hours to a few days, it closes because the blood flow is no longer strong enough to keep it open.

Ductus Arteriosis

A decrease in pulmonary vascular resistance and increase in systemic pressure causes the _______________________ to close

Ductus venosus

COA Treatment

End-to-end Anastomosis with removal of Ductal Segment Balloon Angioplasty with Implantation of Stent

Protease

Enzyme that digests protein

Which way does blood flow?

From an area of high pressure to one of lower pressure. Path of least resistance.

Cryoprecipitate

Given to replace fibrinogen and factors V and VII

Coarctation of the Aorta

High BP on top; Low BP on bottom

TET Spells

Hypercyanotic episodes precipitated by an event such as crying or feeding which is caused by a right to left shunting of blood.

ITP

Immune Throbocytopenic Purpura

PDA *Treatment*

Indomethacin Surgery: Coil / PDA Ligation

Liver Disease in relation to hemostasis

Liver dysfunction can lead to diminished amounts of the factors needed to maintain coagulation and hemostasis.

Roles of the Liver

Metabolizes, detoxifies, stores, and produces - Turns glycogen to glucose - Turns ammonia into urea - Stores B12, A, C, E, D, K, Iron, & Glycogen - Albumin (maintains oncotic pressure) - Detoxifies drugs - metabolism of estrogen

COA Postoperative Intervention

Monitor BP Pulses in upper and lower extremities

MODS

Multiple Organ Dysfunction Syndrome

Pulmonary Stenosis

Narrowing of the pulmonary valve or artery

Cardiac Defect Outcomes

Neurological Development delays Increased risk for disability Periodic screening, surveillance, and evaluation throughout childhood

*Liver Failure - Nutrition*

Nutritional deficiency with reduced protein intake contributes to liver destruction in cirrhosis, but excessive alcohol intake is the major causative factor in fatty liver and its consequences.

SA Node

Pacemaker of the heart

Client Monitoring for Cardiac Defect

Perfusion BP Urine output Feeding tolerance

Heart catherization

Pressure bandage on the groin while patient is in supine position Pressure bandage is checked every 15 minutes Check for decreased BP Monitor for bleeding Assess for infection Use fluids to flush out dyes

Repolarization

Relaxation - recharging of the myocardial cell from a contracted state back to a resting state

Normal Cardiac Blood Flow

SVC -> RA -> Tricuspid valve -> RV -> Pulmonary valve -> MPA -> R & L pulmonary arteries -> Pulmonary veins -> LA -> Mitral valve -> LV -> Aortic Valve -> Aorta

DIC Causes

Severe sepsis, obstetric complications, cancer, burns, trauma, major surgery

Heparin Induced Thrombocytopenia

Sudden decrease >50% in platelet level

Cyantoic Defects: Blue Babies (Right to Left Shunt) *Decreased pulmonary blood flow*

Tetrology of Fallot Tricuspid Atresia

Mixed Disorders

Transposition of the great vessels Hypoplastic left heart syndrome

Anticholinergic medications

Used for pain management of Pancreatitis - Block acetylcholine receptors--> increases HR, BP, bronchodilation

ASD *Symptoms*

Usually hear no symptoms If it becomes a right to left shunt, you will see: Poor feeding/weight gain Diaphoresis with feeding Heart Failure Big hole = no sound Small hole = loud sound

Liver

Where most blood coagulation factors are synthesized (except Factor VIII)

Petechiae

a small red or purple spot caused by bleeding into the skin.

D-Dimer

blood test to rule out blood clots; "Are we clotting?"

Atelectasis from Acute pancreatitis

collapse of alveoli

Balloon Angioplasty

insertion of a balloon to dilate a vessel

What does INR stand for?

international normalized ratio

Creatinine

males 0.6 - 1.2 mg/dL; female 0.5-1.1

PTT

partial thromboplastin time

PT

prothrombin time

Purpura

red-purple skin lesion due to blood in tissues from breaks in blood vessels

palliative care

supportive medical and nursing care that keeps the patient comfortable but does not cure the disease

VSD

ventricular septal defect

D-dimer

• 0.43 - 2.33 mcg/mL • 0 to 250 ng/mL

Hemoglobin (Hgb)

• Females 12-16 g/dL • Males 14-18 g/dL

Hematocrit (Hct)

• Females 37-47% • Males 42-52%

RBC

• Females 4.2-5.4 million/uL • Males 4.7-6.1 million /uL

Iron

• Females 60-160 mcg/dL • Males 80-180 mcg/dL

What happens with cirrhosis of liver?

↓ Blood Glucose ↑ Ammonia Clotting issues Jaundice Clay-colored stools ↑ Estrogen (Gynecomastia)