NURS 3444 - Exam 4 Study Guide on Cardiac Conditions

ASD Type of Defect

Increase PBF (acyanotic)

VSD type of defect

Increase PBF (acyanotic)

PDA type of defect

Increase PBF (acyanotic)

COA type of defect

obstruction

TOF type of defect

Decrease pulmonary blood flow (cyanotic)

HLHS type of defect

Mixed

What is ASD?

Abnormal opening between the atria

- L to R shunt because L arterial pressure is higher than R

- R atrium enlargement

ASD clinical manifestation

- Asymtomatic

- S/sx of HF seen with large ASD

- HF around age 30-40s if undiagnosed and pulmonary HTN

ASD Findings on Auscultation

Murmur and Split S2 (with larger sized ASD)

ASD Treatment

- Spontaneous closure by age 18-36 months

- Patch closure via cardiac cath for medium or large ASD

ASD Medication

- Preop: none unless S/sx of HF

- Postop: low dose ASA x 6 months

ASD Teaching points

- Developmentally appropriate prep for cardiac cath

- S/sx of HF

- ASA therapy

What is VSD?

Abnormal opening in between ventricles

- Blood shunts L to R

VSD Clinical Manifestation

- CHF symptoms

- May not be present initially at birth

- Associated with fetal alcohol syndrome, down syndrome, PDA, COA, preemies

- Slow weight gain

- Feeding difficulties

VSD auscultation findings

- Palpable thrill

- Diaphoresis, tachycardia, tachypnea with grunting

- Murmur at left sternal border

VSD treatment

- may close on own

- patch graft with cath

- closure restores normal A&P

VSD drugs

- Digoxin

- diuretics preop

- post op pain management

- possible ACE inhibitors

VSD Nursing Management

- cardiac assessment

- S/sx of HF

- sodium restriction

- monitor for ventricular dysrhythmias or AV block

What is PDA?

failure of DA to close

- L to R shunt since aortic pressure is higher than the low pulmonary artery

PDA clinical manifestations

- Asymtomatic up to age 40

- Seen commonly in preemies, COA, and VSD

- Resp distress / HF

- Fatigue and dyspnea on exerties

PDA findings

- Machine-like murmur

- Difficulty hearing S1 and S2

- Palpable thrill

- Decreased diastolic BP

- Bounding peripheral pulses

PDA Treatment

- Indomethasin or ibuprofen to close

- Thoracoscopic surgery

- Coil to occlude via cardiac cath

PDA meds

- Indomethacin

- Ibuprofen

- Digoxin

- Diuretics

Failure to close PDA risk

endocarditis

What is COA

narrowing of aortic arch

- causes decreased CO due to extra pressure on ventricles

COA clinical manifestations

- HF

- Dizziness, HA, fainting, tingling in lower extremities

COA assessment findings

- Pink upper extremities and pale and cool lower extremities

- Bounding upper pulses and weak lower pulses

- Murmur heard at base of heart

COA treatment

resection of coarted section with end-to-end anastomosis

- Angioplasty for older infants and children

COA medication

- Prostaglandins (critically ill)

- Digozin

- Diuretics

- O2

- Sedatives

- Antihypertensive meds

COA nursing assessment

- Cardiac assessment

- Monitor for s/sx of HF

- PVS assessment (BP all 4 extremities)

What are the 4 defects with TOF?

- VSD

- Pulmonary stenosis

- Reight ventricular hypertrophy

- Overriding Aorta

Symptoms of TOF?

- Cyanosis at birth

- Loud murmur

- SOB and rapid RR

- Poor weight gain

- Tiring easily

- Trouble feeding

- Hypercyanotic spells

- Irritability

- Clubbing

- Polycythemia

Hypercyanotic/tet spells

Often seen with TOF

- dyspnea

- bradycardia

- fainting

- seizures

- Cyanosis

- straining

- infection

- fever

Treatment of TOF

Multiple surgeries to increase pulmonary blood flow during infancy

- repair of VSD

- pulmonary stenosis repair

Medications for TOF

- Prostaglandin infusion (if critically low sats)

- ABX prophylaxis

- Furosemide/lasix

- Morphine during tet spells

What is HLHS?

Underdeveloped left heart

- aorta and left ventricle are underdeveloped

Symptoms of HLHS?

- Cyanosis

- Weak of absent pulses

- s/sx of HF

- progressive deterioration if closure of PDA occurs

HLHS treatment?

- 3 stage repair

- Prostaglandin to keep PDA open

- Cardiac transplant in future

HLHS medications

- Digoxin

- Diuretics

- O2

- Prostagnlandins to keep PDA open

HLHS education

- Fatal if no surgical repair

- avoid supplemental oxygen

- heart transplantation may be necessary

- lifelong arrhythmias following repair

CHD signs and symptoms

- Tachycardia (most common) >160 bpmü - Difficulty feeding (most common parental complaints)

- Wake to feed, weak suck, cyanosis with feeds, long feeds, sleeping during feeds (freq stim)

- Tachypnea >60 bpm

- Cyanosis (C vs. A)

- FTT

- Developmental delays

- Possible BP changes

- CHF (no distended neck veins)

Interventions for CHD

- meds

- frequent weights

- activity as tolerated

- rest periods

- cluster care

Nutrition with CHD

- high calorie meals and formula

- NG remainder of feeds

- Special nipple to decrease energy expendeture

- BMI / growth trends

Pre op considerations

- VS

- Weight

- Perfusion

- Auscultation

- NPO

- meds

Post op considerations

same as preop but add:

- possible mechanical ventilation

- chest tube care

- neuro checks

- dosage changes

- I/O

- Pulmonary toilet

- Pain assessment

- Mobility asap

3 lead Electrode Placement

Where to put pressure if cardiac cath sit is bleeding?

1" above site

What defects increase pulmonary blood flow?

- ASD

- VSD

- PDA

FEAR cues

F - feeding poorly

E - energy is low

A - always fussy

R - rapid respirations

patent ductus arteriosus

should close within 72 hours of birth

PDA surgery

ligation

- if indomethacin and ibuprofen do not work to close

Which way does blood flow with cyanotic defects?

Right to left side of heart

Clinical presentation of cyanotic defects?

- Tet spells

- Polycythemia

- Clubbing

treatment for tet spells

- Put children in knee chest position to increase systemic pressure → push blood into pulmonary vasculature

- Give oxygen

- Give morphine → smooth muscle relaxant

- Give IVF → prevent dehydration (can lead to TET spell)

tetralogy of fallot

Coarctation of aorta

Hypoplastic left heart syndrome

- ASD

- Want to keep PDA open

Symptoms of HLHS

- cyanosis

- hypoperfused

- blood flow to body severely impacted

Symptoms of impaired myocardial function

tachycardia, fatigue, weakness, restless, pale, cool extremities, decrease BP, decreased urine output (<1 mL/kg/hr)

Symptoms of Pulmonary congestion

tachypnea, dyspnea, respiratory distress, exercise intolerance, cyanosis, difficulty feeding

symptoms of systemic venous congestion

peripheral and periorbital edema, weight gain, ascites, hepatomegaly, neck vein decisions

Digoxin therapeutic level

0.8-2.0 ng/mL

Signs of digoxin toxicity

- bradycardia

- halo in vision

- lethargy

- vomiting

Contraindications to digoxin

Bradycardia

- Adolescents: above 60

- School aged: above 70

- Infants: above 90

Digoxin dosage timing

Given 1-2 hours before or after meals

- q 12 hours

- if miss dose give as soon as possible (if more than 4 hr after skip)

Hyperkalemia cause

potassium sparing diuretics and increased potassium in diet

Hyperkalemia symptoms

- muscle twitches, cramps

- irritability

- decreased BP

- EKG changes

- Dysrhythmias

- Abdominal cramping

- Diarrhea

Hypokalemia causes

loop or thiazide diuretics

Hypokalemia symptoms

- Alkalosis

- Shallow respiration

- Irritability

- Confusion, drowsiness

- Weakness, fatigue

- Arrhythmias

- Lethargy

- Thready pulse

- Decreased intestinal mobility (N/V and ileus can occur)

When does rheumatic fever occur?

2-6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract.

Principle manifestation of rheumatic fever involve...

- Heart

- Joints

- Skin

- CNS

Treatment of rheumatic fever

Rheumatic fever with carditis and residual heat disease (with valvular disease) → Antibiotic prophylaxis for 10 years or until age 40

Rheumatic fever with carditis but no residual heat disease (no valvular disease) → antibitioic prophylaxis for 10 years or until age 25

Rheumatic fever without carditis → antibiotic prophylaxis for 5 years or until age 21

JONES CAFE PAL

Diagnosis of Rheumatic fever

2 major criteria or 1 major and 2 minor

Jones Criteria

Polyarthritis (joints)

Carditis (<3)

Nodules subcutaneous

Erythema marginatum

Sydenham chorea

Kawasaki disease

Red Disease

- red sclera

- dry cracked lips

- red tongue

- red palms and soles (sloughing of skin)

- red conjunctiva

high fever for 5 days will not be touches by anything

Treatment of Kawasaki Disease

IVIG → Intravenous immunoglobulin in acute phase

- Help with inflammation

- Typically give once and fever will stop

ASA 80-100 mg/kg/day for fever

- High doses of aspirin when have fever

- Once fever resolves → 3-5 mg/kg/day as an antiplatelet

What labs with kawasaki

ESR and CRP will be elevated

- ECHO to monitor vessels in heart

IVIG and live vaccines

no live vaccines for 1 year following IVIG

Kawasaki disease etiolgoy

Acute systemic vasculitis

- can lead to MI and aneurysms if untreated

Heart Rates

80-150 Infant

70-110 Toddler

65-110 Preschool

60-95 School age

55-85 adolescents

BP

Systolic BP Diastolic BP

(mm Hg) (mmHg)

65-100 45-65

90-105 55-70

95-110 60-75

100-120 60-75

110-125 65-85

Where is apex located

4th ICS under 7

5th ICS after 7

What allergies to assess for prior to cardiac cath

- shellfish

- iodine

Family education with Kawasaki

- S/S of aspirin toxicity → HA, confusion, dizziness, tinnitus

- No NSAIDs when on aspirin therapy

- No live vaccines after IVIG for 11 months