Cardiac Anomalies Peds exam 2

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Emilybillet
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284748
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Cardiac Anomalies Peds exam 2
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2014-10-04 18:43:43
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LCCC PEDS NURSING ADN215
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ADN 215
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Cardiac anomalies, nursing, ADN 215
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  1. What does congenital heart disease mean?  How many kids are critically ill in first year of life? 
    • Def: The heart defect is genetic in origin; the child is born with the defect. Its anatomic and results in abnormal function, is a major cause of death in 1st year of life
    • 1/3 never develop handicap  
    • 1/3 develop problems 
    • Critically ill in first year: 2-3 ( from the 5-8 out of 1000 births) 




  2. What is the most common (congenital) cardiac anomaly?
    VSD- ventricular septal defect
  3. What are common managements of cardiac anomalies?
    • surgery:(open or closed procedures) only simplest can be repaired fully, for the others the goal is to achieve normal hemodynamics
    • cardiac cath 
    • Symptoms may be managed with meds prior to surgery
  4. what are the disease processes of acquired heart disease?
    • infection 
    • autoimmune response
    • environmental factors
    • familial tendencies
  5. What is the cause for most cases of CHD?
    What are the known causes?
    • Cause: most cases the cause is not identified
    • 85% is multifactoral 
    • Chromosomal-genetic 10-12%
    • Maternal or environmental 1-2%
    • Maternal drug use
    • Maternal illness
  6. A cause of CHD is maternal drug use, what specific example is given, and how many children develop CHD as its result?
    Fetal Alcohol syndrome, and 50% develop CHD
  7. A cause of CHD is maternal illness. What specific illnesses are given?
    • Rubella in 1st 7 weeks of pregnancy-50% risk of defect including PDA and pulmonary branch stenosis 
    • Cytomegalovirus, toxoplasmosis, other viral illnesses lead to cardiac defects
  8. How does the fetus get oxygen?
    placenta and fetal circulation (3 shunts)
  9. What changes in circulation occur in the neonate?
    • Baby takes first breath 
    • Umbilical cord is clamped 
    • placenta is removed
    • Volume of blood to left atrium increase which leads to closed foramen ovale (first few hours)
    • ductus arteriosus usually persists for 15-20 hours after birth
    • blood in the AVA of umbilical cord clots, and they then atrophy
  10. adjustments at birth: what are the before and afters when talking about cardiac functions?
    • before: 
    • placenta exchanges O2 and Co2
    • Foramen ovale connects R and L atria 
    • the lungs are uninflated 
    • ductus arteriosus bypasses blood flow to lungs 
    • Aorta receives mixture of ox/deoxy blood
    • After:  
    • Lungs assume job of O2 exchange 
    • foramen ovale closes within first few hours 
    • lungs are fully aerated by about 2 weeks 
    • ductus arteriosus closes functionally soon after birth 
    • Aorta receives only only Oxy blood from L ventricle
  11. What assessments must the nurse do for children with cardiac anomalies?
    • H&P: 
    • height, weight plotted
    • Assess skin,  color, for clubbing, and resp status 
    • for putrescence of heart murmurs 
    • Assess peripheral pulses, and liver 
    • BP in all extremities 
    • assess general appearance 
    • vitals 
    • and for CHF
  12. what are the clinical manifestations of CHD?
    • murmurs
    • delayed/decreased/absent pulses
    • BP differences
    • Cyanosis (circumoral or whole body) 
    • Wide pulse pressure (40-50)
    • Clubbing
    • Diaphoresis (on forhead and upper lip
    • Edema 
    • poor feeding
    • floppy
    • irritable/agitated
    • lethargic
  13. What are the manifestations of Congestive Heart Failure?
    • crackles
    • edema
    • weight gain
    • decreased output
    • JVD
    • increased RR
    • exercise intolerance 
    • cool to touch (especially extremities)
    • decreased capillary refill
    • Tachycardiac
  14. what are the pediatric indicators of cardiac dysfunction?
    • poor feeding
    • tachypnea/cardia
    • failure to thrive, poor weight gain, activity intolerance 
    • developmental delays 
    • positive prenatal Hx
    • positive family Hx of cardiac disease
  15. What are the diagnostic assessments for CHD?
    • Continuous pulse ox
    • EKG
    • Echo
    • Radiography (looking for heart enlargement) 
    • MRI
    • Hematologic testing (H&H&BG) 
    • Cardiac Cath
  16. What four specific medications are used for CHD?
    • Digoxin (Lanoxin)- cardiac glycoside; decreases HR and increases contraction strength (helps decrease edema) 
    • Furosemide (Lasix)- diuretic
    • Propanolol (inderal)-beta blocker 
    • Spironolactone (Aldactone)- potassium sparing diuretic 
    • Enalapril, Captopril- ACE inhibitors
  17. Older classification of shunts?
    • Left to right- Acyanotic 
    • may become cyanotic 

    • Right to left- cyanotic
    • may be pink
    • may develop CHF
  18. What is the teaching for parents of children receiving Dig? 
    • Hold if BP is less than 90-110 (70 in older kids) 
    • Do not mix med with milk (if baby doesn't finish we have no idea how much was given) 
    • Usually BID (morning does/night dose) 
    • If baby vomits after taking med, do not re-administer
    • teach S&S of dig toxicity
    • foods high in K+ (bananas, dark green leafy vegetables??)
  19. What are the S&S of Dig toxicity?
    • a decreased potassium leads to an increased risk of dig toxicity. 
    • Bradycardia 
    • poor feeding 
    • nausea vomiting 
    • vision changes
  20. What are the hemodynamic characteristics of the newer classifications of CHD
    • increased pulmonary blood flow
    • decreased pulmonary blood flow
    • Obstruction of blood flow out of the heart 
    • Mixed blood flow
  21. What are the characteristics of the increased pulmonary blood flow defects?
    • Abnormal connection between the two sides of the heart (either the septum or the great vessels)
    • increased blood volume in the right side of the heart
    • increased pulmonary blood flow 
    • decreased systemic blood flow
  22. What are the 3 different defects that occur with increased pulmonary blood flow?
    • Atrial septal defect
    • Ventricular septal defect 
    • Patent ductus arteriosus
  23. Describe PDA. Assessments? Nursing interventions?
    • Def: the non-closing of the ductus arteriosus; can take up to a year to close; severity is determined by gestational age and degree of PVR
    • Assessments: 
    • heart murmur (systolic murmur; sounds like washing machine) some infants may have no murmur
    • "wet" sounding breath sounds
    • Tachypnea 
    • increased worht of breathing or apnea
    • poor feeding, poor weight gain and growth pattern 
    • fatigue
    • sweating with feeding
    • excessive weight gain
    • Decreases O2 sats 
    • bounding pulses
    • prolonged Cap refill
    • Nursing Interventions: 
    • post op care
    • decrease work of breathing
    • maintain frequent rest periods  
    • do not cluster care
    • strict I&O (and fluid restriction), daily weights
    • monitor for thrombocytopenia
    • monitor feeding tolerance
  24. What are the Diagnostics/treatments of PDA?
    • Wide pulse pressures-low diastolic pressure
    • Increased vascular markings on CXR D/T enlarged heart
    • Hyperactive precordium 
    • Echocardiogram will show increased enlargement of L heart chambers
  25. Describe ASD. Assessments? Nursing Interventions?
    • Two septal walls fail to form; a left to right mixing or shunting of blood may occur; moor blood flows into the right side of heart from left atrium, and pulmonary blood flow to lungs is increased through hole in atria; may lead to increased pulmonary hypertension& right ventricular hypertrophy; increased risk of stroke
    • Assessments: 
    • heart murmur "ejection systolic murmur"
    • atrial dysrthmias
    • higher incidence of emboli
    • recurrent resp infections 
    • few symptoms in children 
    • SOB
    • Tires easily
    • growth pattern if CHF develops
    • liver enlargement 
    • Nursing Interventions: 
    • monitor feeding tolerance offer small frequent feedings 
    • monitor for S&S of CHF
    • Monitor for increased work of breathing (grunting, retractions, and flaring) 
    • monitor growth patterns
  26. What are the Diagnostics/treatments of ASD?
    • Echo: show enlargement of R atrium R ventricle 
    • EKG: thickening of heart muscle 
    • CXR: enlargement of heart; increased blood flow to lungs
    • Transesophageal U/S
    • Digoxin, pain meds, diuretics 
    • Cardiac cath
  27. Describe VSD. Assessments. Nursing Interventions.
    • Between L&R ventricle
    • Forms at 4-8 weeks of fetal development 
    • Right ventricular hypertrophy
    • left to right shunting (acyonosis) produces increased in pulmonary blood flow which decreases pulmonary compliance; Stiffening of the lungs and ineffective ventilation 
    • Assessments:
    • Often asymptomatic or murmur
    • SOB
    • Feeding difficulties
    • Systolic thrill in lower L sternal boarder
    • FTT
    • Recurrent resp infections
    • Nursing Intervention:
    • monitor feeding tolerance offer small frequent feedings 
    • monitor for S&S of CHF (very common)
    • Monitor for increased work of breathing (grunting, retractions, and flaring) 
    • monitor growth patterns

  28. What are the Diagnostics/treatments of VSD?
    • Echo: large L atrium 
    • CXR: cardiomegaly and increased pulmonary vascularity 
    • Cardiac Cath
  29. What is Indomethecin? When is it indicated?
    Is the conventional drug used to close the opening of the ductus arteriosis. However, ibuprofen has been used and has fewer adverse effects
  30. Describe Atrioventricular Defect?
    • It is a mix of the ASD and VSD
    • there is a whole in the middle of the heart.
    • It is the most common defect in down syndrome
    • blood is mixed in all four chambers.
  31. Other nursing care for increased pulmonary blood flow defects
    • assess family (may be grieving "perfect child")
    • Teach parents to let the kids socialize with peers
    • Teach nutrition (increase in calories) 
    • Children should not engage in competitive sports
  32. What are the 3 CHD obstructive defects?
    • Coaractation of the aorta 
    • Aortic stenosis(a narrowing)
    • Pulmonic stenosis
  33. Describe COA; Assessments? Nursing Interventions
    • A narrowing of the aorta between the upper body and lower extremities; usually distal to left sub-clavian artery; 
    • There is an increased BP in the arms and head 
    • Reduction of BP in legs; VSD is common
    • Assessments: 
    • Few symptoms
    • systolic ejection murmur 
    • decreased femoral pulses
    • Cardiomegaly and right sided heart failure
    • headache
    • If necessary to check only one extremity use the right arm with the lower extremity which is preductal 
    • Hypertension
    • SOB
    • poor feeding, growth, development 
    • S&S of CHF
    • Nursing Interventions: 
    • Monitor CSF meds ( Dig, Lasix)
    • Monitor perfusion
    • obtain BP in 4 extremities
    • Post op care
  34. What are the Diagnostics/treatments of COA?
    • CXR or esophagram will show "3 sign: or "E sign" d/t poststenotic dilation of aorta 
    • Cardiac Cath 
    • Rib notching may be present d/t collateral vessels eroding the adjacent bones
    • balloon dilatation 
    • stent
  35. describe aortic stenosis. Assessments, Nursing interventions?
    • Obstruction of blood flow from L ventricle to Aorta; decreased CO; aoritc regurg; increases workload of myocardium of the L ventricle leading to hypertrophy; scarring of aortic valve occurs from rheumatic fever caused by group A strep. 
    • Assessments: 
    • Chest pain
    • hypotension
    • faint pulse
    • tachycardia
    • poor fedding
    • fatigue 
    • syncope 
    • murmur
    • SOB
    • narrow pulse pressure with decreased systolic pressure
    • activity intolerance which may lead to sudden death 
    • increased pressure load on left ventricle 
    • Nursing Interventions 
    • Monitor for S&S of CHF
    • Prepare for emerg measures for A Fib
    • maint. pain mang.
    • May need prostaglandin E. drip to provide pattent ductus arteriosus until surgery
  36. What are the Diagnostics/treatments of aortic stenosis?
    • EKG: thickening of septum; inverted T-waves; abnormal mitral valve
    • CXR: dilated ascending aorta; cardiomegaly
    • cardiac cath
    • balloon valvuloplasty
  37. Describe Pulmonary Stenosis. Assesments? Nursing Interventions
    • There is a defect in the pulmonary artery or pulmonary valve.
    • Assesments:
    • Increased work load of right ventricle
    • CHF 
    • Hepatomegaly
    • Often assos. with other disorders like Noonan Syndrome or Tetralogy of Fallot
    • Murmur
    • SOB
    • Cyanosis
    • Nursing Int.
    • Post Op care
    • Maintain Calm Environment to decrease O2 requirements
    • Monitor BP
  38. What are the Diagnostics/treatments of pulmonic stenosis?
    • Echo 
    • Cardiac cath
  39. What are the 2 decreased pulmonary blood flow defects?
    • Tetralogy of Fallot 
    • Tricuspid Atresia
  40. Describe Tetrology of Fallot. Assessments? Nursing Interventions?
    • The 3rd most common lesion. Occurs more in males, Associated with Downs, 22 deletion chromosomes, and DiGeorge. Results in a right to left shunting of blood in the heart, which recirculates venous blood to body without it having gone to the lungs to be oxygenated. "Tetralogy" means four. 4 separate defects in the heart 
    • Assessments: 
    • "tet" spells or hypercyanotic spells
    • Pink "Tet" spells are due to left to right shunting
    • increased cyanosis with irritability and crying
    • Increased irritability due to lack of O2
    • Clubbing of fingers
    • Poor growth as a result to lack of O2
    • Nursing Interventions: 
    • Cluster care to improve Oxygenation
    • prevent inconsolable crying 
    • maintain fluid balance
    • Provide O2 to reduce vasoconstriction (will not improve O2 sats or reduce cyanosis) 
    • Have on hand vasopressors to increase systemic vascular resistance; Have sedative or morphine to decrease agitation; have Prostaglandin E drip to keep PDA open.
  41. What are the Diagnostics/treatments of TOF?
    • PDA causes increased blood flow to lungs 
    • Polycythemia 
    • Boot shaped heart 
    • R ventr. hypertrophy 
    • small pulmonary artery 
    • (child remains pink with a low degree of mixing known as "pink tet")
  42. What does Prostaglandin E do? Why do we use it for some CHDs? What are the nursing responsibility for this med? Contraindications?
    • is a potent smooth muscle dilator; keeps foramen ovale and the ductus arteriosus open; works in just a few minutes and the result is improved pulmonary and systemic blood flow
    • Responsibilities: 
    • watch for resp depression or apnea, flushing bradycardia, hypotension, pulm over-circulation, seizures, irritability and diarrhea.
    • monitor for bleeding. Is administered by cont. infusion and needs separate line
    • Contra: RDS
  43. What are the four separate heart defects that occur together to make the "Tetrology" of Fallot?
    • VSD: between right and left ventricles 
    • Obstructive right ventricular outflow: (pulmonary stenosis or obstruction)
    • Overriding aorta: lies directly over VSD and takes blood from the R and L ventricles; allows oxygenated blood to rest of body. 
    • Secondary thickening of right ventricle: (right ventricular hypertrophy) due to restrictive outflow
  44. How do we treat hypercyanotic spells?
    • 1st action: Knee chest position 
    • 2nd: O2 at 100% via face mask
    • Calm and comfort
    • Iv fluids
    • morphine Sub Q
  45. Describe Tricuspid Atresia. Assessments? Nursing Interventions?
    • Rare. increased risk for stroke. The tricuspid valve never opened (or is abnormal/missing) blocks blood flow from R atrium to R ventricle which leads to decreased blood flow to lungs; If there is no VSD with it, a PDA must be opened for child to survive. 
    • Assessments: 
    • Cyanosis 
    • SOB
    • Delayed growth & poor weight gain
    • Murmur (usually due to ASD if present)
    • Often associated with pulm stenosis 
    • Clubbing (in older kids)
    • Nursing Diagnosis:
    • Preop Care
    • Family Care (transplant often required)
    • Maintain Prostaglandin E drip to maintain blood flow to lungs
  46. What are the Diagnostics/treatments of tricuspid atresia?
    • Echo 
    • EKG
    • CXR
    • Cardiac cath
  47. What are the 3 Mixed defects?
    • Transposition of great vessels
    • Total anomalous pulmonary venous connection 
    • Hypoplastic Heart syndrome (right and left sided)
  48. Describe Transposition of the great vessels. Assessments? Nursing interventions?
    • The two great vessels of the aorta and the pulmonary artery are reversed (heart may be on the R side); cyanotic blood flow to brain causes damage; TWO separate circulations that do not mix. 
    • Assessments
    • Upper extremity with a decreased O2sat vs. lower extremity (espec. on right side) 
    • profound cyanosis, esp. with crying 
    • VSD and PDA allow blood to mix
    • tachypnea or quiet tachypnea
    • Heart murmur
    • S&S of CHF
    • Nursing Interventions: 
    • maintain O2 sats in R arm > 75% to decrease PVR
    • Have on hand: CHF meds. prost E drip, 
    • Monitor children on ("pril" drugs) 
    • Post op care
  49. What are the Diagnostics/treatments of transposition of the great vessels?
    • Negetive hyperO2 test
    • CXR- "egg on string" visualization (may be absent in neonate)
    • cardiac cath 
    • echo
  50. Describe Total anomalous pulmonary veous return (TAPVR)
    • All pulmonary veins with oxygen rich blood follow an abnormal route back to R atrium instead of L atrium. TAPVR is difficult to distinguish from ASDs. Its both non obstructive and obstructive; there are 3 types. DiGeorge syndrome
    • Assessment:While PDA is open, few symptoms
    • If PDA closes: profound cyanosis, severe shock, and CHF occurs
    • Interventions: Maintain airway management
    • Strict I&O
    • Diuretics
    • monitor blood gases
    • Post Op care (valvular repair)
  51. What are the Diagnostics/treatments of TAPVR?
    • Snowman sign on CXR
    • Normal or small heart 
    • Pulmonary edema
    • O2 levels 
    • ECHO
  52. Describe Hypoplastic left heart. Assessments? Nursing Interventions?
    • Second most CHD. Underdeveloped L side of the heart, aorta, aoritc valve, L ventricle and mitral valve leads to pulmonary venous congestion and edema. Often associated with no corpus collasum. 
    • Assessments: 
    • Asymptomatic unless PDA closes
    • Ashen skin color
    • Rapid/difficult breathing
    • feeding difficulty 
    • usually fatal if not treated
    • Interventions: 
    • Prost. E 
    • preop care
    • family care
    • prepare for possible heart transplant
  53. What are the Diagnostics/treatments of Hypoplastic left heart?
    • As PDA closes baby will be ashen and dusky
    • Singke S2 gallop 
    • ECHO 
    • CXR
  54. What are the three types of TAPVRs?
    • occurs beyond left subclavian artery
    • occurs between left carotid artery and left subclavian artery
    • occurs between innominate artery and left carotid artery
  55. IN CHF what assessment finding will you find that occur due to the impaired myocardial function?
    • Tachycardia
    • Fatigue 
    • weakness
    • restlessness
    • pale
    • cool extremities
    • decreased BP 
    • decreased urinary
  56. In CHF what assessments do you find that occur due to pulmonary congestion?
    • Tachypnea
    • Dyspnea
    • Respiratory distress
    • Exercise intolerance
    • Cyanosis
  57. In CHF what assessment do you find that occur do to systemic venous congestion
    • Edema (peripheral and periorbital) 
    • Weight gain 
    • ascites 
    • hepatomegaly
    • JVD
  58. Cardiac Catheterization can be done for which CHD?
    • Transposition of the great vessels 
    • ASD, VSD
    • Pulmonary artery stenosis
    • some complex single ventricle defects
  59. Baloon Dilation can be used as an intervention for which Cardiac anomalies?
    • Valvular pulmonic stenosis
    • Recurrent Coarctation of the aorta 
    • Congenital mitral stenosis
  60. Post-cath care
    • Check pulse, distal to site
    • Monitor temp and color of extremity
    • Take vitals q 15 mins
    • Monitor BP
    • Monitor dressing for bleeding
    • Monitor I&O
    • Monitor BG levels
    • Keep legs straight for 4-6 hours
  61. Pre-procedural care
    • Child life specialist  to explain procedure at developmental level
    • Assess and mark pulses
    • Base line O2 stats
    • NPO prior to procedure

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