1
Q
Fetal Circulation Structures
A
- 1 umbilical vein
- 2 umbilical arteries
- foramen ovale
- ductus arteriosus
- ductus venosus
2
Q
When umbilical cord is cut…
A
immediate increase in systemic vascular resistance
- increases blood and pressure in LA and LV causing foramen ovale to close
- ductus arteriosis constricts and closes in 10-15 hours after birth
3
Q
A&P Pediatric Cardio Differences
A
- infants have increased metabolic and O2 demands, so HR increases to maintain high cardiac output
- infants at increased risk for heart failure because heart is more sensitive to fluid overload
- muscle fibers of heart less developed
4
Q
Because muscle fibers of heart are less developed…
A
- decreased compliance (ventricles do not expand well)
- SV cannot increased much
5
Q
heart fully developed…
A
by age 5
6
Q
Ventricles at birth..
A
LV and RV same size at birth but by 2 months, LV is twice the size of RB
7
Q
Systolic BP at adult level by…
A
puberty
8
Q
CHD Etiology
A
- defect in heart or great vessels
- persistance of fetal structure after birth
- most develop in first 8 weeks of gestation
- drugs, alcohol, smoke
- maternal metabolic disorders
- advanced maternal age, maternal viral infections
- genetic factors
- chromosomal abnormalities
9
Q
Classifications of CHD
A
- increased pul BF
- decreased pul BF
- obstructed systemic BF
- mix of defects
10
Q
Defects that cause increased pul BF
A
- abnormal connection between two sides of heart
- blood shunts from left to right
- if untreated, pul overcirculation leads to RV hypertrophy, CHF, pulmonary HTN, and eventually death
11
Q
Pulmonary HTN
A
- vicious cycle
- hole in heart…blood goes from left to right…extra blood to get into the lungs…RV gets bigger due to bigger job
- pulmonary arteries constrict to try to keep too much blood going into the lungs
- RV keeps getting stronger and stronger against the pul artery constriction
12
Q
Clinical Manifestations of increased pul BF
A
- tires during feed
- poor weight gain
- tachypnea, tachycardic
- murmur
- CHF
- diaphoresis
- periorbital edema
- freq. resp infections
- crackles
- cardiomegaly
13
Q
PDA
A
Patent ductus arteriosus
- fetal ductus arteriosus that does not close
- common in preterm infants
- blood is shunted from aorta to the PAs and lungs
14
Q
Tx for PDA
A
- may close spontaneously
- IV indomethacin or ibuprofen 10 to 14 days of life
- equally efficient medications
if does not work…
- cardiac cath with coils
- surgical ligation
not open heart, done from the side of chest
prognosis is good
15
Q
ASD
A
- small or large opening in atrial septum
- pressure higher on left side so BF from left to right
- closure: spontaneous, transcatheter device in cath lab, or surgery age 4 to 5 years
- prognosis good if ASD is closed
- untreated adults: CHF, pul HTN, atrial arrhythmias
16
Q
VSD
A
- opening in ventricular septum
- increased PVR and RV enlargement with large VSD
17
Q
clinical therapy for VSD
A
closure
- small VSDs may close spontaneously
- surgery, patch
- closure in cath lab
18
Q
Prognosis for VSD
A
- highest risk if repair needed in first few months of life
- good prognosis for older children
19
Q
AV Canal
A
- ASD + VSD + valve defects
- blood moves freely among the 4 chambers
- associated with down syndrome
- severity of symptoms depends on degree of mitral valve regurgitation
20
Q
AV Canal Tx
A
- surgical, done in infancy
- may need O2 until surgery
21
Q
Prognosis for Av Cancal
A
-depends on mitral valve insufficiency and arrhythmias are common
22
Q
PA Band
A
pul-art band
- done prior to full repair
- small clip placed on pulmonary artery
- decrease BF to the lungs
- give child a chance to grow more and gain some weight
- not done as freqently now
23
Q
Nursing Management Pre-op for increased pulmonary BF
A
- family education
- psychosocial support
24
Q
Nursing Management Post-op for increased pulmonary BF
A
- monitor for complications
- impaired perfusion
- arrhythmias
- infections
- heart sounds
- pulse ox
- VS
- incision site
- assess resp system
- pain assessment
- manage fluid and nutrition
25
Outcomes of Nursing care
- child's pain is effectively managed
- full lung expansion is achieved with spirometry exercises (blowing bubbles) or chest physiotherapy
- incision heals without infection
26
Clinical Therapy for CHF
goal: make heart work more efficiently and remove excess fluid
- diuretics
- ACE inhibitors
- ionotropics
27
Diuretics
remove accumulated fluid and sodium
-monitor potassium
28
ACE inhibitors
lessen workload of heart by decreasing peripheral vascular resistance
-blood vessels dilate which decreases BP...lessen workload
29
Ionotropics
changes force of heart contraction
positive: strengthen heart contraction
negative: weakens strengthen hear contraction
30
Digoxin
positive ionotropic
- improves contractility and increases CO
- powerful, small therapeutic window
31
hold dig for infant
if apical HR less than 100
32
hold dig for older child
hold for HR less than 70
33
before giving digoxin...
- apical HR for one minute
- potassium level
- check dig level
34
Beta blockers
- blocking epi and norepi
- improves cardiac function
"lol"s
-more beneficial effects
35
Oxygen
improve tissue oxygenation
36
Defects that decrease pulmonary blood flow
aka cyanotic defects
- little or no blood reaches lungs to get oxygenated
- causes increased pressure on the right side of the heart, leading to R to L shunting if a septal opening exists
- polycythemia increases risk for thromboembolism
- cyanotic episodes with feeding, crying, and exercise
37
TOF
tetralogy of fallot
- four defects: pulm stenosis, right ventricular hypertrophy, VSD, overriding aorta
- PS impedes the flow of blood to the lungs
- elevated right heart pressure causes R to L shunt
- increase workload on the RV causes it to hypertrophy
- aorta receives blood from both the RV and LV
38
Clinical manifestations of TOF
-depends on the size of the PS
- systolic murmur
- cyanosis
- polycythemia
- poor growth
- clubbing of fingers and toes
- exercise intolerance
- squatting
39
Clinical Therapy of TOF
repair: surgical by 6 months of age
- may have B-T shunt first to delay total repair
- management of hypercyanotic episodes
40
Prognosis of TOF
- improved quality of life
| - may have arrhythmias and right ventricular dysfunction
41
Tet spell
bluish skin during episodes of crying or feeding
- children with TOF
- pulling legs towards trunk
42
Squatting
knee to chest position
- improves oxygenation with children TOF
- less travel for oxygenated blood
43
Clubbing
normal: 160 deg
club: 180 deg
-not fully understood
44
Nursing Management for CHDs that decrease pulmonary BF
- tx hypercyanotic episodes (squatting)
- provide post-op care
- assess VS, pulse ox, perfusion, distal pulses
- monitor I and Os
- support families
45
Mixed Defects
- infant survival is dependent on mixing systemic and pulmonic blood
- cause varying degrees of cyanosis and CHF
46
Transposition of Great Arteries
- parallel circulation (life threatening at birth)
- pulmonary artery leaves the L ventricle and the aorta exits from the R ventricle
- must have PDA or septal defect to permit BF
47
clinical manifestations of transposition of great arteries
- cyanosis
- hypoxia
- CHF
- murmur
- tachypnea
- slow feeder
48
Tx of TGA
- infusion of prostaglandin E1 to maintain PDA
- balloon atrial septostomy to enlarge foramen ovale (creates ASD)
- Arterial switch (surgical) resect and reanastomose great vessels within first week of life
49
Prognosis of TGA
survival impossible without surgery
-97% survival age 20
50
Arterial switch
- few complications
| - many problems with old standards like arrhythmias
51
Nursing Management of TGA
- monitor prostaglandin therapy
- tx hypercyanotic episodes
- surgery by 1 week
- support families
- provide post op care
52
Defects that obstruct systemic BF
- increase workload on left ventricle of the heart, leading to decreased cardiac output
- low CO leads to decreased pulses, decreased UO, sluggish cap refill
- blood backs up into LA and then lungs (CHF)
53
COA
- coarctation of the aorta
| - narrowing or constriction of the descending aorta, obstructing system blood flow
54
clinical manifestations of COA
- BP is higher in arms than in the legs***
- weak femoral or pedal pulses***
- weakness in the legs after exercise
- systolic murmur
-constriction is progressive: 20-30 percent develop CHF by 3 months
55
Clinical therapy for COA
- NBs may need prostaglandins
- may need to tx CHF before sx
- repair: surgical repair preferred over dilation with balloon during cardiac cath
56
prostaglandins
reopens ductus arteriosus and widens aortic arch
57
Prognosis
- coarct may reopen, persistent HTN is common
| - lifelong followup required
58
Common Diagnostic Tests
- Echocardiogram
- EKG/Halter monitor
- Cardiac cath
- CXR
- CT
- MRI
- Exercise Testing
59
3D MRI has...
replaced echo
60
Common Lab Tests
- ABG
- CBC
- Dig level
- ASO titers
- ESR, CRP
- Serum lipids
61
Nursing Care: Post op Open Heart Teaching
- sternal precautions: do not lift child under the arms. one hand under the head and one hand under hips
- car seat: protect incision with blanket
- sponge bathe until steri-strips fall off
- activity as tolerated, no rough play
- no back packs
- antibiotic prophylaxis if prosthetic heart valve
- no live vaccines for 6 months if RBC transfusion
62
Cardiac Catheterization
- used to create atrial septostomy or dilate narrowing (balloon)
- stent can keep PDA open
- coil used to close PDA or other vessels
- Pre-op may cancel for:
- dental dz
- resp illness
- diaper rash
63
Cardiac Cath Post op
Monitor for:
- perfusion
- bleeding
- arrhythmia
- infection
- check under leg for bleeding
- maintain pressure dressing for 4 hours
- lie with leg straight for 6 hours may need leg board
- assess dressing per order
64
Rheumatic Fever
- not congenital - acquired
- inflammatory disorder of connective tissue after infection by Group A beta-hemolytic streptococci
(post strep throat)
-affects joints, skin, brain, serous surfaces, and heart
65
Most common complication of RF
rheumatic heart disease
- damage to valves as result of RF
- may lead to permanent aortic or mitral valve damage
66
Clinical Manifestations of RF
- may appear 1-3 weeks after an untreated strep throat
- heart: new murmur, carditis involving mitral or aortic valve, results in valve damage
- joints: inflamed, painful
- skin: rash with pink macules and blanching in the middle of the lesion (erythema marginatum)
- brain: chorea
67
chorea
aimless movements of the extremities, facial grimacing
68
Diagnosis of RF
- jones criteria
- need evidence of preceding strep infection AND 2 major manifestations
OR
-1 major and 2 minor
69
Major Manifestations for Jones Criteria
- carditis
- polyarthritis
- chorea
- rash
- subq nodules
70
Minor Manifestations for Jones Criteria
- arthralgia
- fever
- increased ESR
- increased CRP
- prolonged PR interval
71
Tx for RF
-antibiotics to eradicate strep infection
* PCN G IM x1
* PCN V oral x10 days
* Sulfa oral x10 days
* Erythromycin if allergic to above x10 days
- ASA to tx carditis, joint inflammation, fever
- steroids
- long term AB prophylaxis
- most children recover fully
72
Nursing Management for RF
- prevention, throat cultures, complete antibiotic regimen
- tx of streptococcal tonsillitis/pharyngitis
- monitor temp
- BR
- admin meds
- home teaching
73
Kawasaki Disease
- acute febrile illness associated with systemic vasculitis
- unknown etiology, more common in japanese
- often preceded by an URI
- serious complications include coronary artery dilation and aneurysms
74
Diagnosis of Kawasaki Disease
- clinically diagnosis
- High fever over 39 C for 5 days or longer AND 4 out 5 of the following:
- redness and edema of hands and feet, peeling of skin
- dry, cracked lips, strawberry tongue, pharyngeal erythema
- conjunctival redness without discharge
- macular-papular rash on trunk and extremities
- cervical lymphadenopathy
75
Tx for Kawasaki Dz
- IVIG (IV immunoglobulin) and ASA reduces the incidence for coronary lesions by 5%
- standard therapy: a single dose of 2g/kg IVIG infused
- acute phase: ASA is admin as an anti-inflammatory at 80-100 mg/kg/day Q6 hrs
- once fever has resolved ASA is reduced to the anti-thrombotic dose of 3-5 mg/kg/day as single daily dose
76
Nursing Management of Kawasaki Dz
- assess heart sounds
- admin meds
- regulate IVIG infusion, watch for rxns
- passive ROM for joint movement
- promote comfort
- home teaching
77
Differences between Kawasaki Dz and RF
patho: KD is inflammatory process and RF is post strep infection
diagnosis: KD by fever and 4/5 criteria and RF by Jones Criteria
Tx: KD IVIG and RF antibiotics
Affects: KD affects coronary arteries and RF affects valves of the heart
78
Surgical intervention is always necessary in the first days of life when an infant is born with...
Tranposition of the Great Arteries
-the one defect that needs it immediately
79
An infant with teralogy of fallot is discharged with a Rx of lanoxin elixir...the nurse should instruct the mother to..
calibrated dropper
-digoxin questions, dangerous with small therapeutic window
Peds Exam 1
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