Flashcards in Exam #3 Cardiac Deck (114)
When we are in the uterus, we do not need our lungs. So they are collapsed down, but they still make surfactant.
since we do not use lungs as a fetus, we get oxygenated blood via the placenta.
From the placenta… oxygenated blood flows through the umbilical vein to the fetus.
Once it enters the fetus….it goes to the liver where we have something that is called the DUCTUS VENOSUS.
What does the ductus venosus do?
It shunts the oxygenated blood straight into the inferior vena cava.
Once the blood has been shunted from the ductus venosus into the inferior vena cava…..Where does it go next?
Into the right atrium.
In a fetus, the problem is that we do not need it to go to the lungs….because of the pressure…we have a trap door that opens called the Foramen ovale.
What does the foramen ovale do?
It is literally a hole between the atriums with a little flap. So blood goes from the right atrium into the left atrium and bypasses the lungs.
And because the pressure is stronger coming from the mother…it keeps it open.
After the blood enters the right atrium and travels through the foramen ovale into the left atrium….where does it go next.
It goes through the mitral valve into the left ventricle and out through the aorta.
Most of it goes from the aorta to the brain.
This is where most of it is shunted
Even though fetal circulation bi-passes the lungs….there is still a little bit of leakage through the tricuspid valve into the right ventricle…into the lungs.
Even though the fetus does not use the lungs….they still need a little bit of blood in order to make surfactant.
Most of the blood needed is given to the brain due to its rapid growth.
This is done though a shunt called the ductus arteriosis.
What does the ductus arteriosus do?
The ductus arteriosus takes most of mommas blood that did
Go through the foramen ovale and shunts it over to the pulmonary vein…to the left atrium….and left ventricle and out to the brain.
When the fetus is done getting the oxygenated blood from momma, how is the blood returned to the fetus to be reoxygenated?
Through the umbilical arteries.
Name the 2 shunting systems that deliver oxygenated blood to the fetus….
Which one shunts blood into the pulmonary veins?
Which one shunts blood into the inferior vena cava?
Which one carries oxygenated blood to the fetus?
Which one carries unoxygenated blood away from the the fetus?
Name the 5 fetal circulation structures.
Fetal Circulation through the heart….
liver, ductus venosus
inferior vena cava
back through umbilical artery
return to the placenta
leak through tricuspid
back through umbilical artery
return to the placenta
When you are born you come out of the vagina…..you take your first breath of life….it is about 40-60 sonometers of pressure that expands the lungs.
When you expand the lungs for the first time….you have changed the whole system.
Meanwhile, when the cord is cut, the pressure of the whole system changes.
The body now has a higher pressure in the lungs, and the placenta is gone.
So the foramen ovale closes.
Why does the foramen ovale close shortly after birth?
because we have more pressure from the lungs expanding for the first time.
Now the blood travels through the heart like it is supposed to.
Change Happens in about 1 min.
A fetus is used to getting ___% oxygen from the mother
Once the cord is cut and the baby is breathing on their own…What percent of oxygen are they now getting?
So when we look at congenital heart problems, we are looking at something that has gone wrong with the setup of ____ ______.
Most babies will do just fine with a congenital heart condition as long as the fetus is in the uterus getting all of their oxygen from the placenta.
True or false
When you put them in their own world, that is when any defects in their heart start showing up.
Congenital defects are classified by what?
Increased blood flow to the lungs and decreased blood flow to the lungs.
After the baby is born, and the cord is cut….
What stimulates the ductus arteriosus to close?
The ductus arteriosus will close slowly ( it constricts) in reaction to the fact that the baby is breathing 21% oxygen.
Also closes in response to a decrease in prostaglandins.
So if we have a good healthy baby (that has not been recusitated), the ductus arteriosus closes and we may hear a _____ in the first 1 - 2 hours of life.
Because it closes slowly
If we have a sick baby, especially a preterm baby…..they will not be getting enough oxygen…This means that their _____ _____ will stay open/patent.
It stays open because they baby is not getting enough oxygen and this is what stimulates it to close (along with dropping prostaglandin levels)
If a newborn baby that was fine originally gets sick later on 4-5 hours later….will their ductus arteriosus open again?
because the body thinks that it is without oxygen and back in the uterus
What are the Pediatric Indicators of Cardiac Dysfunction. (6 of them)
Failure to thrive, poor weight gain
Developmental delays esp. gross motor
Positive family history of cardiac disease
What are we looking for on a cardiac assessment of a child?
History – prenatal and postnatal
Blood pressure – 4 extremity
What are the 3 signs that you have an unhealthy baby?
When you see these signs in a baby you have to start going down the list of problems.
Do they have a GI bug?
Do they have any S/s of illness at all?
If a baby has tachycardia but no other signs of illness….what do you do next?
Check o2….make sure oxygenating.
The big signs to look for that something may be wrong…that the baby may have a problem is
poor feeding and poor growth..
You will also see a big delay in gross motor...
Because the baby will use up all of their calories trying to keep their heart beating and they are unable to grow.
and because they are usually short of breath, and working real hard for oxygen anyway because they have poor cardiac output….you will find that they do not have enough effort to be able to develop.
So in cardiac babies….you will see a delay mostly in gross motor….
So they will have good interaction….they will be smiling…they will be normal for personal social….they will be normal for language as long as there are no other defects.
They will also be normal for fine motor because it does not require a whole lot of effort.
What is considered gross motor in a baby...
learning to sit up
learning to pull up
learning to crawl and walk
all of this requires calories and oxygen, along with the ability to not get tired.
This is why gross motor is delayed in cardiac babies
You must always assess the history of a cardiac baby. What are some important things to consider when asking about the history.
Prenatal and Postnatal history
Risk factors for CHD:
2 big ones: Down’s Syndrome and Fetal Alcohol Syndrome. 50% have CHD
When assessing the heart….what do you do first?
YOU LOOK AT THE BABY FIRST
Is he tired
Is he squatting if older child
What is his color
Then listen to the heart
When listening to the heart what are some things to consider?
With a premie, you can set the stethoscope anywhere
For older or bigger babies…. Listen to Aortic, Pulmonic, Tricuspid, and Mitral..
Mitral is where apical pulse is heard.
If a patient has a patent ductus…..you have to listen on the back. This is where it is heard the most.
After you auscultate you palpate pulses.
If on auscultation of the heart you hear a murmur….what are you going to do next?
You immediately go into an assessment
assess the pulses,
BP on 4 extremities,
chest x ray
palpate abdomen (enlarged liver/spleen)
(Feel carotid pulses, femoral, radial, and pedal pulses)
The reason is because of coarctation of the aorta that decreases the amount of blood going to the lower part of the body. So BP is greater in the upper part of the body. This is a BIG CLUE FOR COARCTATION OF THE AORTA
Suppose you are assessing pulses on a kid and they have great radial pulses but you cannot feel the femoral or pedal pulses…..What are you going to do next?
get 4 extremity BP
Capillary refill to assess cardiac output
Just to let you know about murmurs…...
Just because a child has a murmur it does
Mean they have a congenital heart defect/disease.
If a child has anemia, we will hear a flow murmur until the anemia is corrected
Sometimes a child with a fever can have a murmur and it will go away if the fever goes away. This is called an innocent murmur.
Heart can make flow noises if it is stressed out.
If you hear a murmur…..you put down exactly what you hear….
Do not chart a murmur just because the person in front of you charted a murmur…
Maybe they didn't hear one…
or maybe it is gone.
After a murmur was heard…We have done:
x-ray / bloodwork
4- extremity BP
What do we do now?
Get Echo to try and locate the defect.
Then send to cardiac cath for 2 reasons.
#1 - Diagnosis
#2 - Nonsurgical repairs of smaller defects.
Cardiac Catherization potential complications
What interventions do you do BEFORE a cardiac cath?
Mark distal pulses before procedure (femoral, pedal)
get baseline vitals
What interventions do you do AFTER a cardiac cath?
Insertion site dressing checked q 15 min. first 2 hr.
Monitor HR and vitals
Monitoring for bleeding
If you have bleeding from the site…What do you do?
Place your finger 1 inch ABOVE the insertion site and press down firmly to stop the bleeding.
Send someone else to call the doctor Stat.
What is the discharge teaching for a cardiac cath patient?
Teach them that the dressing has to stay on for 2 days and has to be changed 1 time a day,
the child may NOT do PE or any strenuous sports or activities
Child may return to school 1 day after cath
teach them Place your finger 1 inch ABOVE the insertion site and press down firmly to stop the bleeding.
Risk Factors for Congenital Heart Disease (CHD)
Down’s Syndrome, DiGeorge Syndrome 50% have CHD
Maternal drug use:
Fetal alcohol syndrome: 50% have CHD
Rubella in first 7 weeks of pregnancy
IDMs = 10% risk of CHD
True or False
Increased pulmonary blood flow defects are the ones where the child does NOT turn blue???
these are Left to Right Shunting Lesions
Abnormal connection between two sides of heart….Either the septum or the great vessels
Increased blood volume on right side of heart
Increased pulmonary blood flow
Decreased systemic blood flow
What is the usual cause of a LEFT TO RIGHT shunt?
hole in the atrium…..foramen ovale is left open.
hole in the ventricles
We do not have to worry about this baby getting enough oxygen, but we do have to worry about decreased systemic perfusion….
What are the most common LEFT TO RIGHT shunts?
Atrial septal defect (ASD) –
Ventricular septal defect (VSD)
Patent ductus arteriosus (PDA)
Atrial septal defect (ASD) –
Now you can have an ASD and it closes on its own without problems. These are the most common ones.
2 times more common in females
Can be asymptomatic until dyspnea and fatigue on exertion
The ones that stay open are the ones that cause problems as an adolescent or adult.
The reason that they do is because of the extra blood pushing on the pulmonary arteries….over time causes pulmonary vascular disease.
if symptomatic….can cath them and scratch it to make bleed and close…or patch it..
Ventricular septal defect (VSD) –
Most common congenital lesion
Majority close spontaneously
Cant miss this one…whole systolic murmur.
usually closed by the time the child starts school but normally dont have to do this.
Patent ductus arteriosus (PDA)
Patent Ductus Arteriosus…(shunts blood away from the lungs)
Most common in premature infants
Closes in response to oxygen and decreasing prostaglandins.
If open, We try to give them oxygen to close it.
If that does not work we give them indomethacin….
if that doesnt work we cath them
Action: Inhibits prostaglandin synthesis
Indication: Alternative to surgery for closing the PDA.
Adverse effects: Decreased renal blood flow, NEC
Monitor heart murmur,
Indocin may mask signs of infection
Indomethacin (Indocin) dosing
It is given in 3 doses 1 day apart.
causes vasoconstriction which can kill the kidneys if they do not get blood flow
most important to monitor urine output
remember that it can mask an infection
Name the Decreased Pulmonary Blood Flow Defects
****Tetralogy of Fallot
Transposition of the Great Vessels
Right to Left Shunting
Tetralogy of Fallot (TOF) is the most classic decreased pulmonary blood flow defect..
What are the 4 characteristics?
#1 they have VSD
#2 Overriding Aorta - causes mixed blood-flow
#3 Pulmonic Stenosis
#4 Right Ventricle Hypertrophy
other things to know:
Most frequent cyanotic lesion
Boot shaped heart
May need PGE to keep PDA open
Cyanotic spells – Tet spells
Squatting during tet spells
Tetralogy of Fallot (TOF) more shit to know
infants need to push knees to chest in a tet spell
give prostaglandins to keep ductus open
Side effect is respiratory depression
Congestive Heart Failure in Children
Pulmonary congestion: Left-sided heart failure
Congestive Heart Failure in Children
Systemic venous congestion: Right-sided heart failure
Peripheral and periorbital edema,
neck vein distention
**Distended neck veins
We want to look for the earliest sign of CHF…What is it?
Tachycardia while sleeping.
May have gallop rhythm
, fatigue, weakness, restlessness, pale, cool extremities, decreased blood pressure, decreased urinary output
Earliest sign of heart failure is tachycardia which is defined in infants as a sleeping heart rate
> 160 bpm
All infant’s energy is used to maintain heart rate and breathing
What 3 things will a heart baby have if they are too busy using energy for this
Poor wt gain
Tire easily during feeds
What are the nursing diagnoses for CHF?
Cardiac output , Decreased R/T
Impaired gas exchange R/T
Fluid volume, excess R/T
Nutrition, Imbalanced: Less than Body Requirements R/T
Nursing Interventions – Cardiac Output
#1 med is digoxin
Administer digoxin as prescribed
****Monitor for digoxin toxicity
Monitor serum potassium levels
****Monitor pulse, Apical before giving
Maintain neutral thermal environment
Plan frequent rest periods
Cluster care/activities to allow for uninterrupted sleep
Biggest problem with digoxin is narrow therapeutic window
Nursing Interventions – Oxygenation
***Monitor respiratory rate and lung sounds
Monitor oxygen saturation
Provide oxygen and humidification if prescribed
**Observe for diaphoresis, a sign of increased respiratory effort
**Position in semi-Fowler to relieve orthopnea
Nursing Interventions – Fluid vol.
Daily weight, on same scale
Measure abdominal girth daily
Observe for peripheral edema
Administer diuretics as ordered
Nursing Interventions -- Nutrition
Maintain nutritional status with small, frequent, high caloric feeds
20 cal increased to 24 cal/oz (breast milk fortifier, change formula)
Limit feedings to 20 – 30 min
Infant may require tube feeding to conserve energy.
Provide pacifier for sucking needs if tube feeding
#1 - to keep them from getting lazy
#2- It stimulates gastric secretions
Medications used to treat CHF in children
Enhance myocardial function
#1 Oral positive inotropic agents – Digoxin – improve contractility
#2 ACE inhibitors – reduces AFTERLOAD on the heart
Digoxin (Lanoxin) is the #1 treatment for CHF… It slows the heart so that it has time to fill, and increases contractility
Action: Cardiac glycoside that increases the influx of calcium from extracellular to intracellular myocardium.
Increases the force of myocardial muscle contraction
Depresses firing of SA node and conduction through AV node
Indication: Treatment of CHF
Do not give digoxin to an older kid with a heart rate below?
Do not give digoxin to an infant/young child with a pulse less than?
the other thing is that you have to monitor for toxicity. If the baby vomits, you cannot give another dose until you have a digitalis level.
also will have diarrhea and bradycardia
Digoxin -- Nursing considerations
Evaluate HR ( count for full minute) -- If a 1-minute apical pulse is
----less than 90 beats/min for an infant or young child, the digoxin is withheld.
----100 to 120 beats/min is acceptable pulse to give Digoxin in infant or young child
Do not give to older child is pulse below 70 bpm
Signs of Digitalis toxicity
Disturbances in color vision – tendency to yellow-green coloring
****Nausea & Vomiting
Family Digoxin Teaching
Administer regularly – never skip or make up for missed doses
Give 1 hour before or 2 hours after meals.
DO NOT mix with formula or food
Take child’s pulse prior to administration
Keep safe in locked cabinet
Know signs and symptoms of digoxin toxicity
(ACE) inhibitors --Captopril (Capoten)— Nursing considerations:
Obtain BP immediately before each dose, and monitor after dose.
If rapid fall in BP, place pt. supine with legs elevated
Give 1 hour before meals
Monitor for proteinuria
Assess for anorexia– can cause decrease taste perception
Pt./Family education – skipping doses can cause severe rebound hypertension
Should not be used in adolescents who are at risk for pregnancy. Teratogenic.
Action: Enhances excretion of sodium, chloride, and potassium by direct action at the ascending limb of the loop of Henle.
Adverse effects: nausea, GI upset, diarrhea, constipation, electrolyte disturbances. Ototoxicity esp. in renal patients.
Furosemide (Lasix)-- Nursing considerations:
Obtain baseline electrolytes.
Monitor electrolytes while on Lasix.
-Assess for hypokalemia, hyponatremia
-Family teaching – report ringing in ears
-Eat foods high in K+
-Avoid over-exposure to sunlight and tanning beds
FOODS HIGH IN POTASSIUM
Apricots (dried or fresh)
Orange juice has a higher potassium than a fresh orange
All Greens except Kale
Dried Beans – all kinds have varied mg of K but all are in the high range
Butternut, Acorn Squash
Cardiac arrhythmias, gallop rhythm
Tachycardia or bradycardia
Irritability and fatigue
Ventricular fibrillation and cardiac arrest
Spironolactone (Aldactone) -- Nursing considerations
Administer with food.
Monitor serum potassium, sodium, and renal function.
***May cause false elevations in digitalis levels.
Teach children to avoid high potassium diets, salt substitutes, and natural licorice.
Can cause hypoglycemia in children. May mask symptoms of hypoglycemia. Sleep disturbances, drowsiness, fatigue, bradycardia, hypotension
Congestive Heart Failure
Identify and treat underlying cause
Infants < 220 bpm
Children < 180 bpm
Supraventricular Tachycardia (SVT)
Infants > 220 bpm
Children > 180 bpm
Nursing Considerations for Stable SVT
Ice to face (INFANTS)
Have patient bear down
Have patient blow through a straw (OLDER KID)
Suction the nasopharynx
Nursing Considerations for Unstable SVT
No LOC, no pulses
Common causes of bradycardia in a neonate
Apnea of Prematurity
Most often caused by hypoxemia
Increased vagal tone
Central Line in Right Atrium
Congenital Heart Disease/
5 – 10 mL/kg NS/LR bolus and repeat as necessary after listening to lungs
Bacterial endocarditis (BE), infective endocarditis (IE), or subacute bacterial endocarditis (SBE)
Prophylaxis: 1 hour before procedures (IV) or may use PO in some cases
Complications of Infective Endocarditis
Osler nodes are a clinical manifestation of endocarditis
Prevention of IE
Prophylactic antibiotics ONLY for highest-risk CHD patients
Recent changes in prophylaxis guidelines
Prophylaxis before dental work, invasive respiratory treatment, or procedures on soft tissue infections
No prophylaxis for GI/GU procedures
Administer prophylaxis 1 hour before procedure
Meticulous dental hygiene
Rheumatic Fever (RF) and Rheumatic Heart Disease (RHD)
Inflammatory disease occurs after group A β-hemolytic streptococcal pharyngitis
Infrequently seen in United States; big problem in Third World
Affects joints, skin, brain, serous surfaces, and heart
Most common complication of RF
Damage to valves as result of RF
Clinical Manifestations of RF
Carditis – Chest pain, shortness of breath
Tachycardia, even during sleep
Polyarthritis – migratory large-joint pain
Erythema marginatum – rash starts at trunk
Subcutaneous nodules over bony prominences
Chorea – irregular involuntary movements
Rheumatic Fever (RF)
Elevated Erythrocyte sedimentation rate
Elevated ASLO (antistreptolysin O) titer – rise in titers begins about 7 days post onset of infection
Prevention of Rheumatic Heart Disease
Treatment of choice:
Penicillin for 10 days
Erythromycin if allergic to PCN
Prophylactic treatment against recurrent Rheumatic Fever -- Penicillin
Another name: Mucocutaneous Lymph Node Syndrome
An acute systemic vasculitis of unknown cause
Most common adverse result is coronary artery aneurysm
75% of cases in children <5 years old
Kawasaki Disease 3 Phases
Acute: abrupt onset of high fever, lasting at least 5 days, unresponsive to antipyretics and antibiotics
Subacute: Resolution of fever through end of all KD clinical signs
Convalescent: clinical signs resolved, but laboratory values not returned to normal; completed with normal values (6-8
Kawasaki Acute Phase
Red, cracked lips
Reddened, dry eyes
Hands and feet edematous
Palms and soles erythematous
Kawasaki Acute Phase
Inflammatory markers on labs are elevated:
C-reactive protein, erythrocyte sedimentaion rate
Very irritable and inconsolable
Arthritis in small joints
Begins with the resolution of fever
Risk of coronary thrombosis
Peeling of hands and feet
Arthritis in large wt. bearing joints
Clinical signs resolved
May still have elevated sed rate and CRP
May still have arthritis
Treatment of KD
High Dose IVIG
2g/kg over 8 – 12 hours
High Dose Aspirin
80 – 100 mg/kg/day q 6 hours
Then 3-5 mg/kg/day—antiplatelet after fever
IVIG (Intravenous Immune Globulin)
Informed and Written Consent
IVIG is contraindicated in recipients: known to have had a previous history of a severe systemic or
anaphylactic response to IVIG
NOTE: IVIG interferes with the efficiency of live vaccines.
Family Education for KD
Irritability may persist for 2 months or more
Take temperature daily after discharge
Continue passive range of motion during bath to ease arthritis pain
Avoid live vaccines for 11 months post administration of IVIG
Avoid children with viral illnesses (Reye’s syndrome)
Know signs of aspirin toxicity
Aspirin toxicity signs
Ringing in ears
Easy bruising (avoid contact sports)
Severe toxicity can lead to hyperventilation leading to respiratory alkalosis
(Sensorineural hearing loss is associated with KD, but is rare)
Primary: no known cause
Secondary: identifiable cause
Pediatrics: hypertension generally secondary to structural abnormality or underlying pathologic condition:
Renal disease (most common)
Endocrine or neurologic disorders
Blood Pressure Screenings for Children
Blood pressure screenings should begin at 3 years of age
Choose a cuff with a bladder width approximately 40% of the arm circumference
Too small and the reading is falsely high
Too large and the reading is falsely low
BP readings using a Dinamap (oscillometry) are about 10 mm Hg higher than measurements using auscultation
Children more than 2 years of age should be screened if they have any of the following risk factors
Obesity -- A BMI in the 95th percentile or higher is considered obese.
A parent or grandparent with a cholesterol level of 240 mg/dl or higher
Early cardiovascular disease in a first- or second-degree relative is a risk factor.
Identify kids at risk and treat early
Full Lipid profile should be drawn after a 12 hour fast
Do not do lipid panel within 3 weeks of a febrile illness
Elevated cholesterol in children:
Total cholesterol > 200 mg/dl
LDL > 130 mg/dl
Constipation, N&V, indigestion
Interferes with fat soluble vitamin absorption so needs supplements
Administer before meals