Ch 39 Peds Cardiovascular Flashcards Preview

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Flashcards in Ch 39 Peds Cardiovascular Deck (75):

Congestive Heart Failure

inability of the heart to pump a sufficient amt of o2 to meet the metabolic needs of the body
infants/ children: most often d/t congenital defects (shunt, obstruction, or combo) --> causes excessive volume / pressure load on myocardium
infants / children: usually a combo of left/right sided heart failure


CHF goals of tx

improve cardiac function
remove accumulated fluid and sodium
decrease cardiac demands
improve tissue oxygenation
decrease oxygen consumption


CHF assessment (early signs)

profuse scalp diaphoresis (esp in infants)
fatigue / irritability
sudden weight gain
respiratory distress


CHF interventions

monitor for facial or peripheral dependent edema, auscultate lung sounds
elevate head of bed in semi fowlers position
neutral thermal environment
admin cool humidified o2 as rx (oxygen hood for young infants, nc for older infants/children)
org nursing activities for uninterrupted sleep
small, freq feedings
admin sedation as rx during acute stage to promote rest
admin digoxin (Lanoxin) as rx
admin ACE inhibitors as rx
admin diuretics (furosemide (lasix))
admin potassium supplements
monitor serum electrolyte levels


digoxin (Lanoxin)

assess apical pulse for 1 minute before admin
hold if: infants/ young child < 90-110 bpm
older children < 70 bpm
infants RARELY receive > 1 mL (0.05 mg) in one dose
monitor for signs of dig toxicity: anorexia, poor feeding, N&V, bradycardia, dysrhythmias
normal dig level: 0.5 - 2 ng/mL
dig toxicity > 2 ng/mL


angiotensin converting enzyme inhibitors

monitor for hypotension, renal dysfxn, and cough
assess BP, serum protein, albumin, BUN, creatinine levels, WBC count, urine output, urine specific gravity, urine protein level



ie furosemide (Lasix)
monitor for s/sx of hypokalemia
hypokalemia potentiates digoxin toxicity


s/sx of hypokalemia

serum K < 3.5 mEq/L
muscle wkns & cramping
inverted T waves / prominent U waves
*hypokalemia potentiates dig toxicity


CHF potassium levels

supplemental K given only if indicated by serum K levels
AND if adequate renal fxn is evident
usually necessary if admin a NON K sparing diuretic (ie Lasix)


foods high in K

baked potato skins
peanut butter


normal K levels

3.5 - 5.1 mEq/L


CHF s/sx of dehydration

sunken fontanel
nonelastic skin turgor
dry mucous membranes
decreased tear production
decreased urine output
concentrated urine


CHF monitor Na levels

normal 135 - 145 mEq/L
many infant formulas have > Na than breast milk


s/sx of CHF: LEFT sided failure

grunting (infants)
head bobbing (infants)
nasal flaring
periods of cyanosis


s/sx of CHF: RIGHT sided failure

jugular vein distention
periph edema (esp. dependent& periorbital)
weight gain


Digoxin (Lanoxin) admin

admin 1 hr before OR 2 hrs after feedings
do not mix med w foods or fluid
missed dose by > 4 hrs, withhold dose and give next dose at scheduled time
missed dose < 4 hrs, give missed dose
vomit --> do not give 2nd dose
2+ doses missed --> notify dr
teeth = give water after dose


Defects w Increased pulmonary blood flow

intracardiac communication along septum, or abnormal connection bet the great arteries, allows blood to flow from high pressure L side to low pressure R side
infants shows s/sx of CHF
*atrial septal defect (ASD)
*atrioventricular canal defect
*patent ductus arteriosus
*ventricular septal defect (VSD)


s/sx of decreased cardiac output

dec peripheral pulses
exercise intolerance
feeding difficulties
irritability, restlessness, lethargy
pale, cool extremeties


atrial septal defect (ASD)

abnormal opening bet atria --> causes an inc. flow of oxygenated blood into R side of heart
right atrial / right ventricular enlargement
infant: asymp. or CHF sym
s/sx of dec. cardiac output
types: ASD 1, ASD 2, ASD 3
tx: closed via cardia cath OR open repair w cardiopulm bypass (before school age)


ASD 1 (ostium primum)

opening at the lower end of septum


ASD 2 (ostium secundum)

opening is near center of septum


ASD 3 (sinus venosus defect)

opening is near the jxn of the superior vena cava and the right atrium


atrioventricular canal defect

results from incomplete fusion of endocardial cushions
most common cardiac defect in DOWN SYNDROME
characteristic murmur
infant: mild - mod CHF w cyanosis
s/sx of dec. cardiac output
tx: pulm artery banding for infants w severe sx (palliative) or complete repair via cardiopulmonary bypass


patent ductus arteriosus

failure of the fetal ductus arteriosus (artery connecting the aorta + pulmonary artery) to close w/in the first wks of life
machinery like murmur present
infant: asymptomatic or signs of CHF
widened pulse pressure and bounding pulses
s/sx of dec. cardiac output
tx: indomethacin (Indocin) admin to close defect in premature infants & newborns (prostaglandin) OR may be closed during cardiac cath or surgical management


ventricular septal defect (VSD)

abnormal opening bet right & left ventricles
many close spontaneously during 1st yr of life in children w small/mod defects
characteristic murmur
s/sx of CHF common
s/sx of dec. cardiac output possible
tx: closure during cardiac cath OR open repair w cardiopulmonary bypass


Obstructive Defects

blood exiting a portion of the hart meets an area of stenosis. location of narrowing is usually near the valve of obstructive defect
infants & children = s/sx of CHF
mild obstruction may be asymptomatic
*aortic stenosis
*coarctation of the aorta
*pulmonary stenosis


Aortic stenosis

resistance to blood flow from left ventricle into aorta
results in dec. cardiac output, left ventricular hypertrophy, pulmonary vascular congestion
*valvular stenosis is most common type (usually d/t malformed cusps --> bicuspid instead of tricuspid valve OR fusion of cusp)
ch. murmur
severe defect infants = signs of dec. car out
children = exercise intol, CP, dizzy


Aortic stenosis tx

dilation of narrowed valve by cardiac cath
surgical aortic valvotomy (palliative), valve replacement at second procedure


coarctation of the aorta

localized narrowing near the insertion of the ductus arteriosus
BP higher in upper extremeties (bounding pulses in arms, weak femoral pulses)
sx: headaches, dizziness, fainting, epistaxis from HTN


coarctation of aorta tx

balloon angioplasy in children (restenosis can occur)
surgical: mechanical ventilation and meds to improve cardiac output pre op
resection of coarcted portion, enlargement of constricted section using graft.
defect outside heart --> cardiopulmonary bypass not required / thoracotomy incision used


coarctation of aorta

BP higher in upper ext than lower ext
arms = bounding pulses
femoral = weak or absent
lower ext: cool temps


pulmonary stenosis

narrowing at entrance to pulmonary artery
blood flow resistance --> R ventricular hypertrophy (hypoplastic) & dec. pulmonary blood flow
severe --> CHF occurs


pulmonary atresia

extreme form of pulmonary stenosis
total fusion of the commissures and NO blood flows to the lungs


pulmonary stenosis tx

dilation of narrowed valve via cardiac cath
infants - transventricular (closed) valvotomy
children: pulmonary valvotomy w cardiopulmonary bypass


defects w dec. pulmonary blood flow

obstructed pulm blood flow AND anatomical defect (ASD or VSD) bet R and L sides of heart
pressure on R side of heart inc., exceeds pressure on L side, allos desaturated blood to shunt R to L --> causes desat in systemic circulation
- hypoxemia and cyanosis
*tetralogy of fallot
*tricuspid atresia


Tetralogy of Fallot

four defects:
1. VSD
2. pulmonary stenosis
3. overriding aorta
4. R ventricular hypertrophy
pulm vasc resis > system resis --> RtoL
system resis > pulm vasc resis --> LtoR


Tetralogy of Fallot: infant

may be acutely cyanotic at birth or may have mild cyanosis - progresses over time as pulm stenosis worsens
acute episodes of cyanosis and hypoxia = "blue spells" or "tet spells" occur when infants's o2 req exceed blood supply


Tetralogy of Fallot: child

inc. cyanosis, squatting, clubbing of fingers, poor growth (d/t inc. cyanosis)
squatting = compensatory mech to return blood flow to heart for oxygenation


Tetralogy of Fallot: surgical management

palliative shunt: inc. pulmonary blood flow and inc. o2 sat in infants who cannot undergo primary repair. shunt provides blood flow to pulm arteries from L or R subclavian artery
complete repair: usually performed w/in 1st yr of life. req. median sternotomy and cardiopulm bypass


tricuspid atresia

failure of the tricuspid valve to develop
no communication bet R atrium and R ventricle
blood floow through an ASD or patent foramen ovale to L side of heart and through a VSD to the R ventricle and out to the lungs
*often associated w pulmonic stenosis & transposition of the great arteries
--> complete mixing of unoxyg & oxyg blood in the L side of the heart


tricuspid atresia tx

if ASD is small, defect may be closed during cardiac cath
otherwise, surgery


mixed defects

full saturated system blood flow mixees w desat blood flow, causing desat of the system blood flow
--> pulm congestion and cardiac output dec
*hypoplastic left heart syndrome
* total anomalous pulmonary venous connection
*transposition of the great arteries or transposition of the great vessels
*truncus arteriosus


hypoplastic left heart syndrome

underdevelopment of the L side --> hypoplastic left ventricle and aortic atresia
*defect is fatal in the first few months of life w/o intervention


hypoplastic left heart syndrome tx

surgical tx: necessary --> transplantation may be considered
preop period: newborn req mech ventilation and a cont. infusion of prostaglandin E1 to maintain ductal patency, ensuring adequate systemic blood flow


transposition of the great arteries or transposition of the great vessels

pulm artery leave the L ventricle, aorta exits from the R ventricle
no communication exists bet the systemic and pulm circulation
cardiomegaly is evident a few wks after birth


transposition tx

nonsurgical: prostaglandin E1 may start to inc. blood mixing temporarily if systemic and pulm mixing are inadequate
baloon atrial septostomy during cardiac cath may be done to inc. mixing and maintain cardiac output
surgical: arterial switch procedure (L ventricle acts as systemic pump, new aorta created)


total anomalous pulmonary venous connection

failure of the pulmonary veins to join the left atrium
mixed blood returns to the R atrium and shunts from the R to the L through an ASD
R side: hypertrophies
L side: remains small


total anomalous pulm venous connection tx

surgical: corrective repair performed in early infancy
pulmonary vein is anastomosed to the L atrium, ASD closed, anomalous pulm venous connection is ligated.


truncus arteriosus

failure of normal septation and division of the embryonic bulbar trunk into the pulm artery and the aorta --> single vessel that overrides both ventricles
blood from both ventricles mixes in the common great artery
mod - severe CHF


truncus arteriosus tx

surgical tx: corrective surgical repair performed in 1st few mo of life


Priority Nursing Actions HYPERCYANOTIC SPELL (infant)

1. place infant in knee-chest position
2. admin 100% o2
3. admin morphine sulfate
4. admin fluids IV
5. document occurrence, actions taken, infant's response


Cardiovascular Defects: Interventions

auscultate for crackles, rhonchi, or wheezes
if resp effort inc. --> place child in reverse trendelenburg position, elevating the head and upper body to dec. work of breathing
assess for signs of CHF (periorbital edema or dependent edema in hands/feet)


Cardiac Catheterization

invasive dx procedure to determine cardiac defects
provides info about o2 sat of blood in great vessels and heart chambers
dx/ interventional/ electrophysiological reasons
general anesthesia usually unnecessary
may be outpatient


Cardiac Cath risks

hemorrhage from entry site
clot formation and subsequent blockage distally
transient dysrhythmias


Cardiac Cath preprocedure nursing

assess accurate height / weight --> determines selection of catheter
allergic rxns to iodine
assess and mark bilateral pulses
assess baseline o2 sat


Cardiac Cath postprocedure nursing

monitor finding on cardiac monitor and o2 sat for 4 hrs after procedure
assess affected extremity (coolness may = arterial obstruction)
vital signs q15min x 4, q30min x 4, q1h x 4
immobilize affected extremity in a flat position for at least 4 -6 hrs for venous entry site and 6-8 hrs for arterial entry site
acetaminophen / ibuprofen for pain / discomfort


Cardiac cath discharge

remove dressing day after procedure --> bandaid for 2-3 days
no tub baths for 2 -3 dys


rheumatic fever

inflammatory autoimmune disease that affects connective tissues, and blood vessels of the CNS
most serious complication = rheumatic heart disease (affects cardiac valves, esp mitral valve)
manifests 2-6 wks after an untx group A betahemolytic streptococcal infection of the upper resp tract


Jones Criteria for dx of rheumatic fever

Major Criteria:
erythema marginatum
subcutaneous nodules
Minor Criteria:
Elevated erythrocyte sedimentation rate or positive C reactive protein level
prolonged PR interval on ECG
** to dx: 2 major OR 1 major + 2 minor must be accompanied by evidence of preceding strep infection


Rheumatic fever assessment

elevated antistreptolysin O titer
elevated erythrocyte sedimentation rate
elevated C reactive protein level
Aschoff bodies (lesions): found in heart, blood vessels, brain, and serous surfaces of the joints / pleura


chorea RF

involuntary mvmts of extremities and face --> affects speech


carditis RF

inflammation of all parts of the heart, primarily the mitral valves


erythema marginatum RF

red skin lesions starting on the trunk and spreading peripherally


subcutaneous nodules RF

small, nontender swellings, often over the joints


polyarthritis RF

tender, painful joints (elbows, knees, ankles, wrists)


Rheumatic Fever interventions

control joint pain and inflammation w massage and hot / cold tx
bed rest during acute febrile phase
abx (penicillin) as rx
admin salicylates and anti inflammatory agents as rx (mask polyarthritis --> do not give before dx confirmed)
sz precautions if experiencing chorea


Kawasaki Disease

aka mucocutaneous lymph node syndrome
acute systemic inflammatory illness
*cardiac involvement is most serious complication --> aneurysms can develop


Kawasaki assessment

acute stage: fever, conjunctival hyperemia, red throat, swollen hands, rash, enlargement of cerical lymph nodes
Subacute stage: cracking lips and fissures, desquamation of the skin on the tips of the fingers/ toes, joint pain, cardiac manifestations, thrombocytosis
convalescent stage: child appears normal but signs of inflamm may be present


Kawasaki interventions

monitor temp frequently
assess: heart sounds, heart RR, extremities (for edema, redness, and desquamation), eyes (for conjunctivitis), mucous membranes (for inflamm).
admin soft foods / liquids that are not too hot / cold
passive ROM exercises to facilitate joint mvmt
admin acetylsalicylic acid (aspirin) as rx
admin immunoglobulin IV as rx to reduce duration of the fever and incidence of coronary artery lesions and aneurysms (blood precautions)


signs of aspirin toxicity




coughing up blood



vomiting up blpod



blood in stool


Kawasaki teaching

avoid admin of MMR or varicella vaccine to the child for 11 mo after IV immunoglobulin therapy


s/sx of kawasaki disease

irritability that may last for 2 mo after onset of sx
peeling of hands / feet
pain in joints persisting for several wks
stiffness in morning, after naps, and in cold