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Congenital Heart Defects and birth injuries
Lecture #5 Wong: Chapter 25 - The child with cardiovascular dysfunction
Terms in this set (48)
- opening between R and L atria
- closes within the first week of birth
- connects the pulmonary artery and distal aorta
- closes within 24 hrs of birth
congenital CV disorders
- may lead to CHF or hypoxia
- may be associated w/ chromosomal abnormalities, syndromes, or congenital defects in other systems
acquired CV disorders
- r/t: infection, autoimmune responses, environmental factors, familial tendencies
assessing cardiac function in the child
- accurate hx.: Down's syndrome (high cardiac risk), plot height and weight on growth chart, prenatal hx., genetics, chronic health issues in mom, exposure to infections, drugs/alcohol, high-birth weight, pregnancy, etc.
- presenting problem: feeding issues? professed sweating? FTT? tachypnea? respiratory difficulties? color changes? activity intolerance?
physical assessment: cardiac function
- heart sounds murmur? Irregular?
- murmur? obtain 4-point BPs; loud or subtle?
- Height/weight; FTT
- Color, paleness, cyanosis (80-85% O2 sat)
- Extremities, mucous membranes
- Chest symmetry deformities?
- Veins? distended?
- Clubbing of the fingers
- fluid retardation; edema
- cool skin
- grunting, nasal flaring, cough, retractions
- in infants: arm and thigh BP should be =
- over 1 year: SBP in leg is higher by 10-40 mmHg
- wide pulse pressure (>50) or narrow pulse pressure (<10) may indicate heart defect**
S&S- cyanosis, pale skin, sweaty or clammy, tachy or tachypnea, retraction, edema, hepatomegaly, grunting, flaring or coughing, failure to thrive.
diagnosing cardiac issues
- EKG: electrical activity; checks for arrhythmias - done at bedside. change electrodes every 1-2 days. assess the pt not the monitor.
- echo: 3D image of heart structure; checks for deformities. stressful younger may need mild sedative
- cardiac cath: heart vessels; measures O2 levels. assess low grade fever, NV, loss of pulse. need accurate height, allergy to iodine?, reschedule for sever diaper rash, npo 4-6 hr. may need IV to prevent dehydration and hypoglycemia. remove pressure dressing after one day and cover with bandaid. avoid tub. can shower. regulr diet, avoid strenuous activity. Tylenol/ibuprofen for pain. if bleed, apply pressure 2.5cmc above. straight 4-6 hr after procedure
- chest XR: heart size, contours, pulmonary placement
prepare child based on developmental level:
- What they're going to feel/hear/see
- NPO for 4-6 hrs before
- Baseline labs: coags, H&H, O2 sats, VS, pedal pulses
- Sedation before procedure
Check extremity distal to insertion site for color, temperature, pulse, and papillary refill
Keep extremity extended for 4-6 hours
Check site for bleeding*** femoral or AC straight positioning (at least 4 - 6 hours afterwards), monitor pulses, temp, cap refill, color, etc.
Monitor VS and urine output
Continuous cardiac monitoring
Monitor for infection
Watch for hematoma formation
Quiet play for 24 hrs afterwards
Maintain fluid intake
- critical congenital heart disease
- at least 24 hrs of age
- screening done to every baby before they leave the hospital
- will repeat based on the amount of failure, will send for echo if the defect is severe
- screens for multiple defects
- measurement of O2 sat & HR of the right foot and hand (preferably) - should be above 95% and within 3 pts of each other
caring for the child with heart defects
- tx.: improved cardiac function and energy conservation
decrease energy expenditure:
- frequent, adequate rest
- cluster care
- small, frequent feedings
- minimize crying
- prevent cold stress which increases o2 demand
- provide passive stimulation
- quiet age-appropriate play
- use a soft nipple; NG feedings if necessary; provide adequate nutrition
- monitor fluid status: I+Os; daily wts. remove accumulating fluid
- prevent infections
- semi/high fowler's positions
- knee-chest for Tet spells
digoxin digitalis glycosides
- improve conractility, helps strengthen heart mms., enabling it to pump more effectively; increases contractility/decreases after load
- check apical pulse for 1 FULL MIN*
- withhold dose if HR is <90-110 in infants or <70 in older kids***
- give at regular intervals, don't mix, usually under 1ml
- watch for digoxin toxicity: n+v, anorexia, bradycardia, dysrhythmias, monitor K+ levels
- therapeutic digoxin levels range from 0.8 - 2.0 ug/L
- give water after med to prevent tooth decay**
- give 1 hr before food or 2 hrs post-food
- if child vomits DONT re-administer
- body's water balance can be affected when the heart isn't working effectively; help the kidney remove excess fluid from the body; remove fluid/sodium
Lasix- block h20 reabsorption in renal tube. sever HF excrete NA and K. hypokalemia increase risk of digoxin toxicity. I/o side effects NV, dermatitis, ototoxicity, hypokalemia.
Diuril- works on distal tubes. decrease NA CL K H20 and Bicarb absorb cause hypokalemia and acidosis. observe NV, dizzy, paresthesia, cramps, give K
Spironolactone- aldactone. blocks aldosterone (aldosterone promote retention of NA and excrete K) weak and K sparing. used with other diuretic, poor absorb in GI tract, observe rash, drowsy, hyperkalemia, ataxia. don't give K
- high K+ diet (bran cereal, potatoes, tomatoes, bananas, melons, oranges, green veggies, orange juice),
- monitor I+Os, daily wts., monitor for adverse SE such as hypoK+, n+v and dizziness
- mix w/ juice to disguise bitter taste*
- dilate the blood vessels, reduce aldosterone, making it easier for the heart to pump blood forward into the body; reduce afterload; result in decreased pulmonary and systemic vascular resistance; increased contractility
- Vaster or Capoten
- watch for hyperK+, monitor BP before and after administration, cough, renal dysfunction
- teach pt. to monitor BP frequently
- decrease HR and BP and promote vasodilation
- metoprolol or carvedilol (Coreg)
- monitor BP and HR before administering
- SE: dizziness, hypotension, headache*
abnormal circulatory patterns after birth
- blood will ALWAYS go from high to low pressure = the path of least resistance
cyanotic cardiac conditions
- decreased pulmonary blood flow
- right to left shunting of blood: obstructed pulmonary blood flow leads to higher pressure on RIGHT side of the heart - doesn't pick up O2 in the lungs
- both oxygenated and deoxygenated blood circulate to the body
- cyanosis + hypoxemia
- Tetralogy of fallot
tetralogy of fallot
- cyanotic congenital heart defect that involves 4 abnormalities; most common cause of cyanotic congenital heart defect
- natural squat position: changes pulmonary/vascular resistance
-blue spells or tet spells are episodes of cyanosis or hypoxia. crying. pooping or feeding
- ventricular septal defect: a hole between the ventricles
- pulmonary stenosis: narrowing of pulmonary valve
- right ventricle hypertrophy: right ventricle develops a thickened mms.
- overriding aorta: aortic valve is connected to both the left and right ventricle
acute cyanosis at birth or mild and progressing. moderate systolic murmur.
modified blalock taussig shunt= flow from subclavian.
need complete repair within a year.
defects associated with mixing of saturated and de-saturated blood - mixed
- oxygenated and deoxygenated blood mixes in the heart
- increased pulmonary blood flow due to defect
- severe hypoxemia and cyanosis*
- risk for poor CO and CHF
transposition of great vessels, truncus arteriosis, hypoplastic left heart, hypoplastic right heart.
transposition of great vessels - mixed
- pulmonary artery and aorta are reversed
- oxygenated blood not entering systemic circulation
unless there is a patent ductus hey will die. give prostaglandin E. surgery to reattach/anastomosis
outlook depends on severity- risk of endocarditis, need antibiotics prior to dental work or surgery.
very blue after birth
may have other defects as well
truncus arteriosus - mixed
- only one artery originates from the heart and forms both the aorta and pulmonary artery. mix of high and low o2 sent out. desat and hypoxia.
- the trunks arises above a large VSD (ventricular septal defect) that is almost always associated with this defect
- the truncus receives low O2 blood from the right ventricle and O2 rich blood from the left ventricle - this mix of high and low O2 blood is sent out to the body and to the lungs
- open heart surgery in infancy is needed to correct - rastelli repair
murmur- diastolic if theres regurg.
hypo plastic left heart syndrome
- left side of the heart is underdeveloped
- small left ventricle cannot provide enough blood flow to meet the body's needs
- surgical intervention: 3 stages = sugarer shortly after birth, second at about 6 mos, & last at 18 mos
- heart transplant possible
- s+s: cyanosis, pale skin, sweaty or clammy skin, cool skin, heavy/rapid breathing, tachycardia
hypo plastic right heart
- underdevelopment of the right sided structures of the heart
- inadequate blood flow to lungs = cyanosis
- surgical shunt needed to send blood to lungs for O2
PDA with a prostaglandin e must remain open
acyanotic cardiac conditions
- defects associated with increased pulmonary blood flow
- left-to-right shunting of blood across a septal defect of blood vessel: higher pressure on the LEFT side of the heart
- pulmonary over-circulation and increased workload of ventricle
- risk for HF
- s+s: blood recirculates to the heart, lethargy, FTT, murmur, fatigue, good O2 sats*
- tx.: surgical
L to R shunting VSD, ASD, PDA
ventricular septal defect (VSD)
- acyanotic congenital heart disease
- hole between ventricles - dev pulmonary HTN, enlarged heart and a loud murmur.
- inefficient O2 use
- enlarged heart from added workload
- pulmonary HTN d/t increased volume
- murmurs? LOUD
- small VSD: may close itself
- large VSD: surgery by age 2 - patch the hole
atrial septal defect (ASD)
- hole between atrium allowing l-r shunting. can cause right side enlargement can be well tolerated.
- inefficient O2
- murmur heard? LOUD murmur**
- may be surgically repaired w/ patch or cath. low dose aspirin 6 mo
- peripheral HTN: if large ASD not treated in childhood
- may be asymptomatic or HF symptioms. at risk for dysrhythmias, pulmonary vascular obstructive disease and emboli later in life.
patent ductus arteriosus (PDA)
- when normal ductus arteriosus doesn't close
- creates abnormal circulation between pulmonary artery and aorta
- opening allows blood to flow from the aorta into pulmonary artery: strain on the heart, pulmonary HTN
- s+s: bounding pulses, wide pulses, murmur, can be asymptomatic. if none it can go untreated. tire more quickly as they grow. can be closed through nonsteroidal meds. ibuprofen indamefacin (prostaglandin inhibitor).
*common in premies
obstructive heart defects
- narrowing of outflow from the heart to the blood vessels
- increased workload to the heart as it strains to push blood out
- risk for CHF
- poor cardiac output
coarctication of aorta
coarctation of aorta
- narrowing of aorta between the upper-body artery branches and the branches to the lower body . High BP and bounding pulse in arms with weak or absent femoral
- can increase blood pressure in arms and head, reduce pressure in legs, seriously straining the heart**
mechanical ventilation and inotropic support before surgery.
risk for ruptured aorta, aneurysm, stroke.
post op hypotension- IV sodium nitroprusside, milrinone ehn oral ace/bea
- s+s: bounding pulses, cool skin, dizziness, headaches, nosebleeds. acidosis, htn
older kids dizzy, headache, fainting, nose bleeds (epistaxis), hypotension
- congenital narrowing of pulmonary artery. may reopen foramen ovale. shunt to left, systemic cyanosis, HF, venouos engorgement.
- increases resistance to blood flow from the right ventricle to the pulmonary artery
- right side of the heart pump harder - becomes enlarged - possible right sided HF
- produces a LOUD heart murmur: systolic ejection at upper left sternal border.
- tx.: surgery/valvuloplasty
- aortic valve forms improperly causing resistance to flow in left ventricle. decrease CO, left ventricle hypertrophy, pulmonary vascular congestion.
- tx. depends severity: may be asymptomatic; surgery to expand or replace valve
- may cause MI or mitral insufficiency. valvular is the most common- malformed cusps.
- s+s: chest pain, tiring, dizziness, faint pulses, hypotension, tachycardia, poor feeding
balloon dilation in cath lab- palliative need addition surgery to replace valve.
which treatment is the best therapy for a stable client w/ digoxin toxicity?
a. activated charcoal
b. time and symptomatic tx.
rationale: time is the best tx. the kidneys excrete the metabolites and symptomatic tx. alleviates the rhythm disturbances or nausea caused by the toxicity.
a: only effective if the client has taken an overdose of cardiac glycoside and large amount of unabsorbed drug remains in the GI tract before the serum level increases.
c: this is for clients who are extremely unstable despite symptomatic tx. or whose renal function isn't sufficient to exert the drug.
d: used for bradycardia, but wouldn't necessarily use atropine to tx. the toxicity itself.
capoten for HF. the RN should notify the MD that the med is ineffective if an assessment reveals:
a. skin rash
b. peripheral edema
c. dry cough
d. postural hypotension
rationale: sign of worsening HF.
a, c & d: all adverse effects, but don't indicate that therapy is ineffective
an RN is assessing a client w/ aortic stenosis. the RN expects expects to hear a murmur that is:
a. high-pitched and blowing
b. loud and rough during systole
c. low-pitched, rumbling during diastole
d. low-pitched and blowing
a: murmur in aortic insufficiency
c: mitral stenonis
d: mitral insufficiency
placenta is he oxygen source.
fetal lungs receive less than 10% of blood
lungs don't exchange gas
right atrium of fetal heart has highest o2 concentration
most goes to brain and myocardium.
blood goes from placenta to umbilical vein. enters through inferior vena cava through ductus venosus (highly oxygenated blood goes directly to RA. bypassing liver)
blood flows on to LA through foramen ovale then to left ventricle, aorta, subclavian, cerebral and coronary arteries.
deoxygenated blood returns from head and arms through he superior vena cava to RA, RV, to pulmonary artery (lungs are collapsed creating high pressure) most blood goes to ductus arteriosus then rest of body
pressure on right lower than left
circulation changes at birth
when umbilical cord clamped, lungs expand with air and the pulmonary artery pressure starts to decrease.
once cord clamped flow through the ductus arteriosus decreases and stops 3-7 days after birth. functionally closes after 24 hours. foramen ovale closes in first week
HF- impaired MYO funciton
tachy, sweating, decreased urine output, fatigue, weak, restless, anorexia, cool, pale, low BP, Gallop, cardiomegaly
pulmonary congestion- tachypnea, dyspnea, retraction, flaring nares, exercise intolerance, orthopnea, cough cyanosis, wheezing, grunting
systemic venous congestion- weight gain, hepatomegaly, edema, ascites JVD
caloric needs are greater but ability to feed is decreased. 3hr feeds 150ml/kg/day
gavage feeding with NG is tachypnic (80-100) hold feed
respiration- count 1 min. position for lung expansion, elevae 45% or carseat. semi-high fowler. safety restraints to low abdomen when resting.
polycythemia- may look cyanotic, normal PaO2 (increase in rbc) increased viscosity of the blood, crowd out clotting factors.
clubbing thick flat finger tip and toes. chronic hypoxemia and polycythemia.
hypercyanotic- tet spells in morning.knee to chest, ,be calm, o2 morphine, fluid.
cyanotic keep hydrated o stabilize viscosity. maybe give iron.
shunting right to left allows air in venous system to brain. filters on IV lines. no getting o2 from lungs
renal failure urine Stop correcting less than 1ml per kg per day
chest tube drain over 3ml/kg for 3 hours or 5-10ml/kg in an hour may mean hemorrhage
risks-- macrosomia, multiples, difficult presentation, congenital abnormality
soft tissue injury
bruises and abrasions usually some disproportion between presenting part and maternal pelvis (cephalopelvic disproportion) difficult or precipitous delivery.
petechiae, ecchymosis on head neck, face with nuchal cord. petechiae may also be underlying blood disorder or infection
edematous tissue over part of the scalp in vertex delivery
blood essels rupture. bleeding between bone/periosteum. primiparous most often and forcep/vacuum assisted- sharp demarcation. most absorbed by 3 mo can casue hyper bilirubinemia
most frequently fractures.
LGA baby, shoulder dystocia
crepitus on exam, moro reflex asymmetric
every LGA (8.5lb) should be evaluated for fractured clavicle
pressur eon cranial nerve 7
most noticeable when infant cries
usually goes away
erb palsy-- duchenne - damage upper plexus usually stretching or pulling away of shoulder from head. shoulder dystocia. undressing begin with unaffected first
lower plexus- klumpke palsy stretch upper extremity while trunk led mobile. wrist drop
prevent contractures. 3-6 mo recovery but may be permanent
phrenic nerve can cause diaphragmatic paralysis and respiratory distress. sometimes with brachial palsy. usually unilateral and leads to atelectasis and pneumonia
fleabite dermatitis or newborn rash. first 2 days pale yellow or white papule or pustule face, proximal extremities anywhere but the soles and feet
more obvious during crying. usually lasts 5-7 days
yeast can be form maternal infection or hands, bottles, nipples, oral = antibiotics nystatin q6
most serious newborn virus mortality is 60%- about 90 precent passes through birth
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