Peds 27&28

Kids born with heart problems, we will often see…

small (FTT)

developmental delays

sweaty (harder working heart)

activity intolerance

developmental delays

tachypnea

tachycardia

pale/cyanotic

fluid retention (legs)

cold hands/feet

Kid with heart issues comes into clinic we will do all ____ ____

vital signs (full minute APICAL)

temp (infection)

pulses (weaker pulses in feet as from from heart)

Always look at difference between ____ and _____ ______ in these kids

upper and lower extremities (color, temp, pulses)

Diagnostic testing for heart issues

Chest x-ray (size of heart)

ECG (rhythm)

Echocardiogram (EF, blood flow)

Cardiac catheterization (Dx or treatment)

Need to be ____ before cardiac cath.

NPO as they will have sedation

When any child comes back from cardiac cath procedure what is the most important thing we do?

Monitor Airway

then vitals (full set)

Apical pulse (one minute) (lung sounds as well)

Insertion site (there will be a pressure dressing)

Pain scale!!

I&O

With an arterial cath they have to keep extremity straight for _______. If it is venous it is _____.

6-8 hours

4-6 hours

How to get kid to keep extremity straight?

Pressure bags

Have parent’s hold it or swaddle

First sign of bleeding on dressing

Shadow (put a circle around it) (do the same thing for pulse site)

If site is bleeding where do we hold pressure?

1 inch above site

call provider

Sometimes the affected leg (the one that had the incision) will have…

a weaker pulse initially (cooler/pale extremity)

It is not normal for them both to be strong/equal initially and then weaken later.

For infants after cardiac cath we check…

blood sugar (hypoglycemia)

they haven’t eaten for a long time and they are little (NPO)

#1 complications from cardiac cath

bleeding

clot

Important to educate parent’s of cardiac cath kids on…

s/s of infection

Most common congenital heart disease

ventricular septal defect (VSD)

two types of cardiac defects

Congenital (5-8/1,000 births)

Acquired (infection, autoimmune)

Causes of CHD

Multifactorial-85%

Genetic-10/12%

Maternal (drugs/illness) or environmental-1-2%

28% of kids with CHD have another issue like down syndrome

CHD associated with down syndrome

VSD

CHD causes 1 of 2 things

HF

Hypoxemia

Heart failure is

Heart not effectively pumping

Decreased contractility and volume overload

HF s/s

Tachycardia; fatigue; weakness; restlessness; pale, cool extremities; decreased BP; decreased urine output

Hypoxemia/pulmonary congestion s/s

Tachypnea, dyspnea, respiratory distress, exercise intolerance, cyanosis, fatigue, pale

Systemic venous congestion (more HF but also hypoxemia) s/s

Peripheral and periorbital edema, weight gain, ascites, hepatomegaly, neck vein distention

Hypoxic kids position and medication

Knee to chest position (blood gets to legs faster)

Oxygen

Medications to improve cardiac function

Digoxin (will lower HR as it creates stronger better contractions)

ace inhibitors (vasodilator and decrease heart workload, PRIL)

Decrease preload with what medication?

Diuretics (rid fluids)

How can we decrease cardiac demand/O2 consumption in these kids

rest and conserve energy for feeding and breathing

Defect is a ____ and stenosis is a ____

hole

narrowing

Kids with heart defects will often have a ____

murmur

VSD is

a hole in ventricular septum and heart is tipped slightly to right

Blood will flow from left to right due to gravity

right atrium will get way bigger than it should—> HF

PDA is

a normal fetal artery connecting the main body artery (aorta) and the main lung artery (pulmonary artery) to direct blood away from lungs

should close by 15 hours after birth

VSD s/s

Murmur and symptoms of HF

VSD treatment

Cardiac that repair (patch)

Open heart surgery if hole is big

PDA s/s

Machinery murmur/ HF s/s

PDA treatment

Cardiac cath (coil insertion)

Aortic stenosis (HF)

Aortic valve narrowing

blood black flow will be before the stenosis (left ventricle will be weaker)

Aortic stenosis treatmemt

cardiac cath (balloon angioplasty)

Tetralogy of Fallot (hypoxemia) drug and position

O2

Knees to chest

Tetralogy of Fallot (hypoxemia) treatment

staged repair

treat one and then give them time to heal

what is a tet spell

not enough oxygen and they will turn BLUE

Open heart surgery

heart is stopped and pt. is on echmo

Closed heart procedure

heart is still beating

Post op open heart surgery things

Airway

full vital signs

Heart/lung sounds

Incision

Pain

I&O!!!!

Activity progression

abnormal chest tube output

more than 3ml/kg/hr for 3 hours or more than 5-10ml/kg in one hour

I&O is super important for heart surgery espically on kids. this includes

flushes, IV, oral, NG

Drawing blood, urine, stool, NG

with UOP we need at least

1mg/kg/hr

complications post op heart surgery

CHF (fluid overload)

dysrthmia 

electrolyte imbalance

bleeding

atelectasis

Neuro changes (poor blood flow to brain)

Infection

Post op open heart surgery we monitor

pulses

cap refil

color

warmth

Teach parent’s to give _____ at same time every day

digoxin

do not give if we miss dose or throwup

Digoxin checks before we give it? Levels?

HR

infants-90

children-70

adults-60

Digoxin toxicity s/s

vomiting, neuro signs, visual disturbances, bradycardia, anorexia

Why give aspirin in a kid that just had heart surgery

platelet aggregator/blood thinner

All open heart surgeries get

prophylactic abx

Endocarditis is

infection of valves and endocardium

Endocarditis s/s

temp

ekg changes

new murmur

super tired

large spleen

osler nodes

janeway lesions

Endocarditis needs what for treatment and dx?

IV abx for 2-8 weeks

Blood culture and echocardiogram for dx

If abx doesn’t work with Endocarditis they have to…

replace valves

People with open heart surgery will always get….

prophylactic abx before or after dental procedures or surgeries

RF is…. and is caused by….

inflammatory disease that affects heart valves (immune response 2-6 weeks after infection)

Strep

RF s/s

polyarthritis

Erythema marginatum (Rash on trunk and extremities, not itchy)

Chorea (jerky movements)

Nodules on hands

Worse with anxiety

Testing for RF

throat culture

ASLO titer

CRP/ESR

RF treatment

penicillin IMx1 or oral x10 days

Most common hematologic disorder in childhood

Anemia

What is anemia

decrease in RBC and/or HGB below normal levels or decreased o2 carrying capacity of blood

2 causes of anemia

rbc and/or hgb depletion

or something in the body is changing RBC size, shape, and/or color

When anemia develops slowly the child can ____

adapt

s/s of anemia

dizzy

light-headed

slowed-thought process

poor concentration/memory

headache

no energy

muscle weakness

growth retardation

pale

Diagnostics for anemia

CBC (RBC, HGB, HCT)

Iron (TIBC)

Bone marrow aspiration

Physical exam

HGB below 10-11 shows anemia in kids

Management of anemia

treat underlying cause (bleeding)

• blood transfusion (if hemorrhage)

diet

IV fluids

Oxygen

Bed rest

Kids with anemia are more at risk for ____ _____ and _____

Cardiac decompensation

Infection (wear mask, keep them away from sick people)

With blood transfusion blood must be started within ____ minutes

30 minutes (increases energy)

Infuse blood over maximum of ____ hours

4

Always monitor pt. with blood transfusion as ____ ____ is the most common cause of death from blood transfusion

ABO incompatibility

also allergic reaction, febrile reaction

We transfuse blood very slowly the first ______

15-20 minutes

Nurses role in blood transfusions

monitor patient

take vitals

stay with patient for first 20 minutes

s/s of transfusion reaction and what to do

tachycardia, fever, back pain, chills

stop infusion, notify provider

Iron deficiency anemia

caused by inadequate dietary supply of iron

Most common nutritional deficiency worldwide

Iron deficiency anemia risks factors

prematurity

excessive intake of milk (poor source of iron)

Mom had this so baby has it

Malabsorption issue

rapid growth

poor diet

Iron deficiency anemia treatment

Iron fortified foods

breastfeeding mom takes supplements

Iron supplement (liquid for kids but can stain teeth, give through straw) 1 hour before or 2 hours after milk (best on empty stomach)

Give with vitamin c

kids with iron deficiency can be

underweight or overweight

Iron deficiency anemia diagnosis

CBC

TIBC (total iron binding capacity)

Patient education on iron

green tarry stools

gi upset (diarrhea, nausea, constipation)

Improve diet (green leafy vegetables, red meats)

Sickle cell anemia is _____

genetic, almost exclusively in African Americans

Sickle cell crisis is caused by an _____. Severity is determined by

obstruction

location (brain, heart, lungs)—> stroke, heart issues.

There is no cure for sickle cell but we can try to prevent sickling episodes through ____ ____

supportive care

Sickle cell diagnosis

genetic testing at birth (Stained blood smear)

Sickle cell crisis causes

demands leading to more oxygen need

car accident

sick

infection

stress

airplanes

dehydration

s/s if sickle crisis is in elbow

engorgment at elbow

weak distal pulse

cool extremity

pale extremity

poor cap refill

S/S of sickle cell crisis

Fever

extreme pain

tissue engorement

In general what do we need to watch for/do in kids with sickle cell anemia

FTT

growth rates

minimize things that can cause stress and sickness

get all immunizations (live, yearly)

keep them hydrated

top interventions for sickle cell crisis

fluids (IV/Oral)

O2

treat pain (NSAIDs or narcotics)

rest

monitor I&O

blood transfusion

Shock s/s

Can treat sickle cell crisis with _____. 

warmth, no cold

ROM

gentle massage

Sickle cell supportive care can be a medication called

hydroxyurea (keeps RBC round)

Usually kids get HIV/AIDS from

infected mother

older kids: high risk behaviors (unprotected sex, sharing dirty needles)

HIV is…

immune system disorder

affects t-cells

s/s of HIV in kids

large lymph nodes

large spleen

sick looking

FTT

developmental delays

reoccurring mouth infections

HIV diagnosis

Blood test

AIDS defining conditions in kids

pneumonia

bacterial infection

wasting syndrome

Candidal esophagitis

Goal of HIV

prevent growth of virus and prevent infections

Diet and protection for HIV kids

high protein, high calorie

wear mask in public

avoid sick people