NURS 366-Exam 2

possible complications of cardiac catheterization

acute hemorrhage, loss of pulse d/t vascular injury, transient dysrhythmias

valve damage, perforation of heart, CNS injury, stroke, death

interventional cardiac catheterization procedures in children

ballon atrial septostomy, balloon dilation, stent placement, coil occulsion, transcatheter device closure, transcatheter valve replacement, radiofrequency ablation

CHD is strongly associated with...

chromosomal abnormalities and specific syndromes

CHD occurrence ratio

1 in 110 live births

Common s/s of CHD

poor feeding, tachypnea, tachycardia, diaphoresis, crackles, hepatomegaly, cyanosis, murmur, sternal lift

acyanotic defects

- increase in pulmonary blood flow
- obstruction of blood flow from ventricles

cyanotic defects

-decreased pulmonary blood flow
-mixed blood flow

Increased Pulmonary Blood Flow Defects

-abnormal connection between two sides of heart
-increased blood volume on right side of heart
-increased pulmonary blood flow
-decreased systemic blood flow

Types of Increased Pulmonary Blood Flow Defects

Atrial septal defect (ASD); Ventricular septal defect (VSD); Patent ductus arteriosus (PDA)

left-sided obstructive congenital heart defects

-Structural abnormality on the left side of the heart
-Decreased systemic blood flow
-decreased pulses, unequal limb blood pressures, mild to extremely ill presentation
-Ex: Coarctation of the aorta, aortic stenosis

right-sided obstructive congenital heart defects

-Narrowing at entrance to the pulmonary artery
-RVH and decreased pulmonary blood flow
-cyanosis (mild), murmur, HF
-Ex: Pulmonic stenosis

Decreased Pulmonary Blood Flow Defects

-structural abnormality causing too little pulmonary blood flow
-Abnormality on the right side of the heart
-causes unsaturated blood to shunt to the left side of the heart, into the systemic circulation
-usually hypoxemic and cyanotic

types of decreased pulmonary blood flow defects

Tetralogy of Fallot;
Tricuspid atresia; pulmonary atresia

Tetralogy of Fallot

congenital malformation involving four distinct heart defects; "RAPS"
-Right ventricular hypertrophy
-Aortic disposition (it is connected to both ventricles)
-Pulmonary stenosis,
-Septal defect (ventricular)

types of mixing congenital heart defects

-transposition of great vessels/arteries (TGA)
-total anomalous pulmonary venous connection/return (TAPVR)
-hypoplastic left heart syndrome (HLHS)

transposition of the great vessels (TGA)

-great vessels (arteries), aorta, and pulmonary artery arise from the wrong ventricle
-aorta comes off of RV
-pulmonary artery comes off of LV
-must have ASD, VSD, or PDA to allow "mixing" of blood

total anomalous pulmonary venous return (TAPVR)

-all four pulmonary veins drain abnormally to the right atrium by way of an abnormal (anomalous) connection
-classified based on how and where the pulmonary veins drain to the heart (supracardiac, cardiac, infracardiac)

Hypoplastic Left Heart Syndrome

underdevelopment of the left side of the heart, usually resulting in an absent or nonfunctional left ventricle and hypoplasia of the ascending aorta; one of the most complex and most challenging to manage; treat with palliation and/or heart transplant

congestive heart failure

Pathophysiologic state in which the heart is unable to pump blood at a rate that meets the body's metabolic needs

causes of CHF

structural abnormalities, myocardial failure, and/or excessive heart demands

Impaired myocardial function CHF

Tachycardia, sweating, ↓UOP, fatigue, weakness, pale, restlessness, cool extremities, ↓ BP, cardiomegaly

systemic venous congestion CHF

-right-sided failure
-unable to pump blood effectively into the PA
-peripheral and periorbital edema, weight gain, hepatomegaly, ascites, neck vein distention

pulmonary congestion CHF

-left-sided failure
-unable to pump blood effectively into systemic circulation
-tachypnea, dyspnea, retraction, nasal flaring, poor feeding, exercise intolerance, cyanosis

goals of CHF treatment

improve cardiac function, remove accumulated fluid/sodium, decrease cardiac demands, improve tissue oxygenation and decrease O2 consumption

manifestations of hypoxemia

-cyanosis; polycythemia and clubbing with chronic hypoxemia

tet spells

-hypercyanotic/blue spells
-often in infants with tetrology of fallot
-sudden infundibular spasm decreases pulmonary blood flow & increases right-to-left shunting
-rare before 2 months of age,
-often in AM
-may be r/t feeding, crying, defecation, or stressful procedures

nursing care of tet spells

-respond quickly to prevent brain damage
-put infant in knee-chest position
-give 100% oxygen blow by blow
-morphine
-IV fluids

infective endocarditis

-bacterial infection of inner lining of heart, especially the valves, that can make it difficult for the heart to pump blood

risk factors for infective endocarditis

-structural abnormalities of the heart/blood vessels
-bacteremia
-dental procedures, gum disease
-indwelling catheters, surgery
-drug abuse

symptoms of infective endocarditis

-low-grade fever, chills, fatigue, anorexia, weight loss
-anemia, increased ESR, bacteria culture
-ECG may indicate vegetations
-heart murmur

Management of infective endocarditis

Immediately (before lab results): IV antibiotics, surgical intervention, frequent echos
• Prophylaxis: antibiotics for high risk patients

acute rheumatic fever (ARF)

abnormal immune response to GAS infection; self limiting inflammation of joints, skin, brain, serous membranes, and heart; less common in developed countries

rheumatic heart disease (RHD)

-damage to cardiac valves d/t ARF (often mitral valve)
-prevent/treat GAS to prevent ARF
-diagnosis uses Jones criteria

manifestations of ARF

-polyarthritis
-carditis
-subcutaneous nodules (hard and painless)
-erythema marginatum (red circles/rash)
-arthralgia
-fever

treatment of ARF

-treat streptococcal pharyngitis (penicillin v)
-ASA or NSAID
-prophylactic antibiotics to prevent it

Kawasaki disease (KD)

-acute systemic vasculitis of unknown etiology
-multisystem involvement and inflammation of small/medium arteries
-child could develop coronary artery dilation or aneurysm
-most cases are in children <5yrs

diagnosis of KD

Fever for at least 5 days AND 4/5 criteria:
-Eyes - bilateral conjunctival infection
w/o exudate
-Lips & mouth - erythema, cracked lips, strawberry tongue
-Hands & feet - edema and/or erythema; periungual desquamation (peeling) of hands & feet
-Skin - polymorphous rash
-Cervical lymphadenopathy

treatment of KD

-acetylsalicyclic acid (ASA) for fever
-Intravenous immunoglobulin (IVIG)
-antiplatelet
-prevent cardiovascular complications
-long term follow up

coarctation of the aorta

-congenital cardiac condition characterized by a narrowing of the aorta

3 stages of surgery for hypoplastic left heart syndrome

1. Norwood procedure
2. Bidirectional Glenn procedure
3.fontan procedure

visual impairment

General term that includes partial sight and legal blindness;
-refractive errors/blindness
-strabismus
-pseudostrabismus

infections that can cause blindness/visual impairment

perinatal infections such as HSV, chlamydia, gonococci, rubella, syphilis, toxoplasmosis; postnatal infections such as meningitis; conjunctivitis is the most common eye infection

disorders that can cause blindness/visual impairment

Sickle cell disease, tay-sachs disease, albinism, retinoblastoma, prematurity (retinopathy of prematurity)

occular alignment

-occurs around 3-4months age
-concern if they are not tracking and/or making eye contact
-might be first indication of a visual deficit in an infant
- eyes should move together, if they do not this is an indication that something is abnormal
-congenital blindness is one reason the eyes might not move together.

partial sight/partial visual impairment

-20/70-20/200
-near vision usually better than far

legal blindness

-not a medical diagnosis, legal definition
-visual acuity of 20/200 or less
OR
-visual field of 20 degrees or less in the better eye

refractive errors

-most common type of visual disorder in children
-Myopia (nearsightedness)
-Hyperopia (farsightedness)
-Corrective lenses, surgery
-Astigmatism
-Generally detected with vision screening at PCP or school
-(Refraction is the bending of light rays as they pass through the lens of the eye. With normal refraction, light passes through the lens and fall directly on the retina. With refractive errors the light rays fall in front of or behind the retina)

strabismus

-Type of visual impairment
-One eye deviates from the point of fixation
-Eyes are misaligned
-More commonly known as cross eyes
-Binocularity usually occurs by 3 to 4 months of age
-Test by evaluating corneal light reflex and/or cover/uncover test

strabismic amblyopia

-If not detected and corrected by 4-6 years of age, strabismus can lead to strabismic amblyopia
Develops over time from the eyes not being aligned
-Brain "turns off" the eye that is not aligned and eventually vision is lost in that eye

pseudostrabismus

-false impression of eyes not being aligned
-nothing wrong with the alignment of the eye, it's an illusion that they are misaligned
-ex. epicanthal folds

conjunctivitis

-pink eye
-newborn= chlamydia trachomatis or Neisseria gonorrhea, herpes simplex virus, chemicals
-infant= nasolacrimal duct obstruction
-kids= viral, bacterial, allergic, foreign body

Bacterial conjunctivitis

-purulent drainage throughout day; crusting of eyelids, inflamed conjunctiva; swollen lids; usually unilateral
-antibiotic eye drops

Viral conjunctivitis

-usually occurs with URI; mucoid or serous drainage; inflamed conjunctiva; swollen lids; burning, sandy, gritty feeling to eye; usually bilateral
-self-limited resolution

Allergic conjunctivitis

-itching; watery to thick stringy discharge; inflamed conjunctiva; swollen lids
-self-limited, avoid allergy, allergy meds

Foreign body conjunctivitis

-tearing; pain; inflamed conjunctiva; usually only one eye affected
-remove foreign body

Nasolacrimal duct obstruction

-confused with conjunctivitis.
-teary eyes because the normal tears our eyes make cannot drain properly, this can be confused as drainage from conjunctivitis.
-eye won't have the other inflammatory symptoms.
-can be unilateral or bilateral.

conjunctivitis nursing care

-Wipe from inner canthus down and out
-Separate cloth or tissue per eye
-Warm, moist compress to remove crusting
-Not kept on eye
-Hand washing
-Medication administration (give after cleaning eyes)

retinoblastoma

-congenital malignant tumor of the eye that occurs during childhood
-usually diagnosed before age 2
-hereditary and nonhereditary
-diagnosis; leukoria, acquired strabismus, nystagmus, red eye
-Ophthalmoscopic exam under anesthesia, US, CT and MRI scans
-Blood and tumor samples for RB1 gene mutations

ear assessment on kids

pull pinna down and back

otitis media

-inflammation of the middle ear without reference to etiology or pathogenesis
-most cases in first 24 months
-prevalent in childhood
-vaccines and breastfeeding help prevent

acute otitis media

-an inflammation of the middle ear space with a rapid onset of the signs and symptoms of acute infection
-fever and otalgia (ear pain), discharge may or may not be present
-often follows a URI

otitis media with effusion

-Fluid in the middle ear space without symptoms of acute infection.

treatment of otitis media

-watchful waiting (for kids older than 6 months wait 72 hours )
-symptom management
-symptomatic care
-antibiotics (amoxicillin, IM ceftriaxone)
-myringotomy (small surgical incision)
-tympanostomy tubes

stomatitis

-inflammation of the oral mucosa
-infectious or noninfectious
-manifestation of HFMD

stomatitis treatment

- relief of symptoms
-Acetaminophen and ibuprofen
-education to parents regarding timing of medications, maintaining adequate hydration, oral care, hand hygiene.
-Topical anesthetics are also helpful
-drinking through a straw
-avoid foods that would cause pain (i.e. anything crunchy, spicy)
-soft bristle toothbrush or disposable foam-tipped toothbrush
-hand hygiene for kids who put hands in mouth

aphthous stomatitis

-canker sore/benign ulcers
-allergy
-emotional stress
-provide pain control and comfort
-resolves spontaneously in 4-12 days

herpetic gingivostomatitis

-causes by HSV (herpes labialis)
-cold sores/fever blisters
-pain control, comfort measures, antiviral if severe
-resolves 5-14 days
-wear gloves!

acute streptococcal pharyngitis

-strep throat
-group A beta hemolytic streptococci (GABHS)
-s/s: pharyngitis, headache, fever, abdomen pain, tonsil/pharynx inflammation
-complications: scarlet fever, rheumatic fever, acute glomerulonephritis

scarlet fever

-tongue is edematous and red (strawberry tongue)
-fine sandpaper like rash
-rash is typically seen on the trunk axillae, elbow, and groin

treatment of acute streptococcal pharyngitis

-diagnosis with throat swab
-symptom management
-antibiotics (like penicillin) -can return to school after 24 hours of antibiotics
-warm saline gargles

tonsillitis

-often occurs with pharyngitis
-viral or bacterial
-pain, inflammation, tonsil edema, difficulty swallowing
-symptom management for viral, antibiotics for GABHS, tonsillectomy, adenoidectomy

When is a tonsillectomy indicated?

-7 or more episodes of tonsillitis in the previous year
-at least 5 episodes of tonsillitis in each of the previous 2 years
-at least 3 episodes of tonsillitis in each of the previous 3 years
-sleep-disordered breathing

care for tonsillectomy/adenoidectomy

-Discourage coughing and sneezing
-Have all emergency equipment at bedside
-Pain and nausea control
-Hydration
-No red foods or drinks, clear foods first
-Postoperative hemorrhage
-cold compress to neck

oral candidiasis

-thrush
-fungal infection
-s/s: white patches on tongue, palate, and cheeks
-feeding discomfort
-don't confuse fungus with milk residue
-may also be concurrent with diaper infection

treatment of oral candidiasis

-self limiting
-treat with anti-fungal
-nystatin oral suspension

manifestations of tetrology of fallot

"AFFLICT"
-Activity (tet spells occur during exertion; cyanosis, SOB, LOC, etc)
-Fingernail changes (clubbing)
-Fatigue/faints easily
-Lift knee to chest or squat during tet spell!
-Cardiac sounds (systolic murmur)
-Trouble feeding/thriving

cognitive impairment

-any type of intellectual disability
-classified as mild, moderate, severe, or profound based on IQ
-most (about 85%) are mildly impaired

3 components of cognitive impairment diagnosis

- intellectual functioning (IQ 70-75 or below)
- functional strengths and weaknesses
- 18 years of age or less at time of diagnosis

developmental delay

-Any significant lag or delay in physical, cognitive, behavioral, emotional, or social development
-cognitive impairment DOES NOT exist

Early signs of developmental delay

-irritable/ unresponsive to contact
-decreased alertness
-delayed/difficult speech
-delayed gross motor skills
-feeing problems
-poor or abnormal eye contact during feeding
-dysmorphic features (such as in Down Syndrome)

nursing care for children with cognitive impairment

-education!
-early intervention
-teach self care skills to child
-promote optimal development
-encourage play and exercise with developmentally appropriate toys
-provide means of communication
-establish discipline
-encourage centralization
-give info about sexuality and puberty
-measures to prevent cognitive impairment

manifestations of down syndrome

-separated sagittal suture
-oblique palpable fissures
-upward/outward slant to eyes
-small nose with depressed nasal bridge
-smalls ears with short pinna
-high arched, narrow palate
-protruding tongue
-short and broad neck, excess skin folds
-palmar creases
-large space between big toes and other toes, plantar crease
-hypotonia/hyperflexibility
-congenital heart defects

nursing care for down syndrome

-ECG during early neonatal period
-regular medical care (hearing/vision screens, thyroid test)
-surgical correction of serious congenital problems
-support family during prognosis
-help prevent physical problems (positioning, feeding, reduce infection)
-provide proper skin care
-assist in prenatal diagnosis and genetic counseling

fragile x syndrome

-genetic disorder involving an abnormality in the X chromosome, which becomes constricted and often breaks.
-most common inherited cause of cognitive impairment
-males more often affected

manifestations of fragile x syndrome

-long face with protruding jaw
-large protruding ears
-large testes in males
-strabismus
-mitral valve prolapse/ aortic root dilation
-hypertonia/hyperflexibility
-mild to severe cognitive impairment
-ADHD/ADD or autistic-like behaviors

management of fragile x syndrome

-no cure but normal life-span
-serotonin to control violent behavior outbursts
-early intervention programs
-multidisciplinary medical management
-education/support
-referral
-genetic counseling

Autism Spectrum Disorder (ASD)

-alteration in social interaction and verbal impairment
-repetitive, restricted, and stereotyped behavioral patterns
-often noticed in early childhood; s/s manifest around 18-36 months
-more common in males
-etiology unknown

manifestations of ASD

-poor eye contact
-speech and language delay at early age
-limited functional play
-unusual/odd interactions with toys
-significant GI s/s
-cognitive impairment

savant

person with developmental disorder who exhibits exceptional skill or brilliance in some limited field

Diagnosis of Autism Spectrum Disorder

6 or more items :
-2+ impairments in social interactions
-1+ communication impairment
-1+ restricted, repetitive, and stereotyped patterns of behavior, interests, and activities

nursing care for autism

-positive reinforcement
-teach verbal communication skills
-increase social awareness of others
-decrease unacceptable behaviors
-STRUCTURED ROUTINE
-give family support
-individualize care
-minimize holding/eye contact

ADHD

-developmentally inappropriate degrees of inattention, impulsiveness, and hyperactivity
-3 types (combined, predominantly inattentive type, predominantly hyperactive-impulsive type)
-INATTENTION CAN'T BE SYMPTOM OF ANOTHER DISORDER
-s/s sometimes subside in adulthood

nursing care for ADHD

-early detection and intervention
-EDUCATE
-relatively stable with appropriate intervention
-medication management
-individualized treatments (meds, behavior therapy, etc)
-work with family/school to develop plan and implement therapeutic regiments
-act as connection between healthcare workers and educators

bulimia nervosa

-binging (frenzied consumption of large amounts of food in less than 2 hours) followed by purging
-Russell sign
-tooth erosion and esophageal damage
-GI symptoms (diarrhea, constipation, etc)
-often end up gaining weight as they lose control of binge-purge balance'

anorexia nervosa

-refusal to maintain minimally normal body weight; severe weight loss
-amenorrhea
-intense fear of weight gain/ disturbed body image
-bradycardia and hypotension
-hypothermia/cold intolerance
-dry skin, brittle hair, lanugo

nursing care for eating disorders

-PREVENTION
-kind and supportive but firm
-avoid passive-dependent relationship
-activities to better self esteem
-consistent and structured environment
-remove binge foods
-refer to community resources
-behavior therapy
-family involvement
-nutrition counseling

Diabetes is the ____ leading cause of death in the US

7th

type 1 diabetes mellitus

-diabetes in which no beta-cell production of insulin occurs and the patient is dependent on insulin for survival
-autoimmune disorder where body develops antibodies against insulin/b-cells
-genetic link

type 2 diabetes mellitus

-diabetes in which either the body produces insufficient insulin or insulin resistance (a defective use of the insulin that is produced) occurs
-patient usually is not dependent on endogenous insulin for survival

insulin

A hormone produced by the beta-cells in the islets of Langerhans that regulates blood sugar levels by facilitating the uptake of glucose into tissues