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NUR 230 EXAM 4

Terms in this set (65)

Pediatric Indicators of Cardiac Dysfunction
- poor feeding
- tachypnea/tachycardia
- failure to thrive/poor weight gain/activity intolerance
*Developmental delays
- prenatal history: smoking, drugs, alcohol, gestational diabetes
- family history of cardiac disease
Cardiac Defects
Congenital:
- Anatomic: abnormal function

Acquired:
- Disease process
- Infection
- Autoimmune response
- Environmental factors
- Familial tendencies
Cardiovascular dysfunction
- Primary anatomic abnormalities present at birth
- Result of various factors:
- Infection
- Autoimmune response
- Environmental factors
- Familial tendencies

- History and physical
Atrial septal defect
Opening between the two atriums
- can be asymptomatic
- oxygenated blood flows back in the right atrium
- usually exercise intolerance
- diastolic murmur
- risk for atrial dysrhythmias
- can be treated w/a surgical patch closure or cardiac cath can be performed to dispatch a closure device
Ventricular septal defect
Can cause hypertrophy of the right ventricle from the pressure from the lungs and the left to right shunting
- CHF is common
- Loud holosystolic murmur
Coarctation of the aorta
Narrowing near the insertion of the ductus arteriosus which results in increased pressure proximal to the defect (head and upper extremities) and decreased pressure distal to the obstruction (body and extremities)
- Patients present with increased blood pressure and bounding pulses in the arms, weak or absent femoral pulses and cool lower extremities with lower blood pressure
Patent ductus arteriosus
- The failure of the ductus arteriosis (artery connecting the aorta and pulmonary artery) to close within the first weeks of life.
- This allows the blood to flow from the higher pressure aorta to the lower pressure pulmonary artery which in turn causes a left to right shunt.
- Can cause right ventricular pressure and right hypertrophy.
- Patients may be aysmptomatic or show signs of CHF. - They are at a risk for bacterial endocardidits.
- In premature and some newborns it can be treated with prostagladin inhibiortor (indomethacin).
-There are surgical and non surgical procedures to close it. Cardiac cath is now used to deploy colis to oscclue the pda. Good prognosis.
Obstructive defects
- Coarctation of the aorta
- Aortic stenosis
- Pulmonic stenosis
Aortic stenosis
- Narrowing or stricture of the aortic valve, causing resistant to blood flow in the left ventricle decreased cardiac output - left ventricular hypertrophy and pulmonary vascular congestion.
- Primary issue is the hypertrophy of the left ventricular wall which eventually leads to increased end diastolic pressure resulting in pulmonary venous and pulmonary arterial hypertension.
- Newborns with critical AS demonstrate signs of decreased cardiac output with faint pulses, hypotension, tachycardia, and poor feeding.
- They show signs of exercise intolerance, chest pain and dizziness when standing for a long period of time. Systolic ejection murmur may or may not be heard.
- At risk for bacterial endocariditis.
Pulmonic Stenosis-
- Narrowing of the entrance to the pulmonary artery. Resistance to blood flow causes right ventricular hypertrophy and decreased pulmonary blood flow.
- This in turn can cause right ventricular failure which causes right atrial pressure to increase and in turn may cause the foraman ovale to open up, which in turn will shunt unoxgenated blood into the left atrium and systemic cyanosis can appear.
- Manifestations can be asymptomatic, mild cyanosis, or CHF. Progressive narrowing causes worsening of symptoms. - A loud systolic ejection murmur at the upper left sternal border may be present but with severely ill patients this murmur may be softer due to decreased cardiac output and shunting of blood.
- Cardiomegaly is evident and patients are at risk for bacterial endocarditis.
- There are surgical and non surgical intervention pg 1453
Surgical treatment is best in infants younger then six months. Nonsurgical in older infants and children.
- Mortality is less then five percent. Risk greater in infants with other complex cardiac defects.
Tetralogy of Fallot
- Four defects are ventricular septal defect, pulmonic stenosis, overriding aortal and right ventricular hypertrophy.
- Manifestations are cyanotic at birth
- It can start off mild and progress with time
- There is a systolic murmur, moderate in intensity
- There can be acute episodes of cyanosis and hypoxia called blue spells or tet you may see elevated HR and RR
- When these spells occur you will place the infant in the knee to chest position
- You will see older children will automatically go into this position
- Treatment is usually done within the first year of life
- Mortality is less than 3%
- CHF is a concern postoperatively
- Post op-care
- Assess kidney function- know normal creatinine & BUN
Tricuspid Atresia
- Tricuspid valve failed to develop and there is no communication from the right atrium to the right ventricles
- Blood flows through the ASD or a patent foramen ovale to the left side of the head and through a VSD to the right ventricle and out to the lungs
- Usually associated with PS and the transposition of the great arteries
Hypoplastic left ventricle
- Left ventricle doesn't develop or doesn't fully develop
- Can create a shunt for blood flow
- Heart transplant
Truncus arteriosis
A rare type of heart disease that in which a single blood vessel (truncus arteriosus) comes out of the right and left ventricles, instead of the normal 2 vessels (pulmonary artery and aorta). It is present at birth (congenital heart disease).
Congestive Heart Failure
- Inability of the heart to pump an adequate amount of blood into the systemic circulation
- Right or left sided failure
- Heart muscle may become damaged if left untreated
CHF clinical manifestations
- tachycardia & tachypnea at rest
- dyspnea
- retractions
- activity intolerance: poor feedings
- weight gain: fluid overload
- cardiomegaly
CHF treatment
- Improve cardiac function: Digoxin
- Remove accumulated fluid and sodium
- Decrease cardiac demands
- Improve tissue oxygenation
Nursing care management for CHF
- Assist in measures to improve cardiac function
- Monitor afterload reduction
- Decrease cardiac demands
- Reduce respiratory distress
- Maintain nutritional status
- Assist in measures to promote fluid loss
- Support child and family
Digoxin
- Increases contractility, slows heart.
- Dangerous drug with narrow window of safety.
• Take apical pulse x 1 min.
• If vomits, do not repeat dose.
• Dig toxicity: anorexia, nausea, vomiting, diarrhea, visual disturbances (yellow vision), bradycardia
Therapeutic management for CHF
- Digoxin: increases contractility, slows heart. Dangerous drug with narrow window of safety.
- Ace inhibitors: vasodilation
- Diuretics:remove accumulated fluid & Na
- Decrease cardiac demands: limit physical activity
Endocarditis
- Bacterial endocarditis, infective endocarditis, or subacute bacterial endocarditis
- Streptococcus
- Staphylococcus
- Fungal infections
- Prophylaxis: 1 hour before procedures (intravenously) or may use orally in some cases
Rheumatic Fever
causes, s/s, nursing interventions, treatment
Inflammatory disease occurs after Group A
hemolytic streptococcal pharyngitis
Treatment of streptococcal tonsillitis/pharyngitis
• Antibiotics
• Anti-inflammatories
• Bedrest
Kawasaki Disease
Causes, s/s, nursing interventions, treatment
Etiology is unknown, though not known to spread from person to person it is see in geographic and seasonal outbreaks.
Monocutaneous lymph node syndrome
Acute systemic vasculitis of unknown cause 75% of cases are in children under age 5
Self-limiting
Increased risk of coronary artery aneurysm
Kawasaki Phases
Acute Phase-abrupt high fever not responsive to antibiotics, irritability, rash, red eyes, peeling hands & feet, irritability, red tongue

Subacute phase- resolution of fever and lasts until all clinical signs of KD have disappeared. This phase is where the child is at greatest risk for developing coronary artery aneurysms.

Convalescent phase-all signs and symptoms have resolved but laboratory values remain abnormal until around 6 to 8 weeks later
Kawasaki Treatment
Treatment
• Gamma Globulins
• aspirin: to prevent fever, used as anti-platelet
Nursing interventions
• light weight clothing
• monitor temperature
• nutrition: bland foods, avoid citrus or other irritating foods
ICP
- Early signs and symptoms may be subtle
- As pressure increases, signs and symptoms become more pronounced, and level of consciousness (LOC) deteriorates
* Factors causing it- head injury from motor vehicle accident, accident in home, tumor, hydrocephalus, meningitis
S/S of ICP
-High pitched cry in infant: cannot soothe them
- Fontanels: tense, bulging
- Cranial sutures: separated suture lines
- Eyes: setting-sun sign, fixed and dilated, drooping, twitching
- Scalp veins: distended
Epiglottis
Signs: leaning forward (tripod position), drooling
- no visualization of throat
- considered medical emergency
- inspiratory strider, mild hypoxia, distress
- potential respiration obstruction
- typical in 2-3 year olds
- may need an endotracheal tube
- prevention: Haemophilus influenzae type b vaccine
S/S of respiratory distress
- retractions
- nasal flaring
- grunting
Infectious Agents
- Viruses
- Respiratory syncytial virus (RSV)
- Others
- Group A b-hemolytic streptococcus
- Staphylococci
- Chlamydia trachomatis, mycoplasma, pneumococci
- Haemophilus influenzae
Infectious age range
- Infants <3 mo: maternal antibodies
- 3-6 mo: infection rate increases
- Toddler and preschool ages: high rate of viral infections
- >5 years: increase in mycoplasma pneumonia and b-strep infections
- Increased immunity with age
Otitis Media
- Fluid back ups in Eustachian tube
- Non infectious, has no known etiology
- pulling at the ear, restless, not sleeping well, no appetite
- AOM: Acute ear pain and fever
- OME-rhintis, cough or diarrhea
- No propping of bottle
- No laying flat in crib with bottle
- Second hand smoke increases otitis media
- Finish antibiotics (10-14 days-amoxicillin)
Seasonal Variations
- Most common during winter and spring
- Mycoplasmal infections more common in fall and winter
- Asthmatic bronchitis more frequent in cold weather
- RSV season considered winter and spring
Clinical manisfestations
- Vary with age
- Generalized signs and symptoms and local manifestations differ in young children
- Anorexia, vomiting, diarrhea, abdominal pain
- Cough, sore throat, nasal blockage or discharge
- Respiratory sounds
Nursing care management
- Ease respiratory effort
- Promote rest and comfort
- Prevent spread of infection
- Reduce temperature
- Promote hydration and nutrition
- Family support and home care
Nasopharyngitis
"common cold"
Pharyngitis
- may be caused by strep
- can return to school after 24 hours of antibiotics
Clinical manifestations
- headache
- fever
- abdominal pain (especially in small children)
Diagnostic evaluation:
- throat culture
- rapid strep test-rapid antigen detection test
advise parents all antibiotics must be finished
Tonsilitis T & A
Post op care:
- position in a semi prone to prone position
- offer cool clear liquids
- no citrus (acid burns, can trigger bleeding)
- no milk or milk products (produces mucous)
- no red liquids
- soft foods on 2nd or 3rd post-op day
- ice collar for pain
- limit activities
- no gargling
Parent teaching
- Watch for bleeding 7-10 days post op
- Signs: excessive swallowing
Croup Syndromes
- Characterized by hoarseness "barking" cough, inspiratory stridor, and varying degrees of respiratory distress
- Croup syndromes affect larynx, trachea, and bronchi
- Epiglottis, laryngitis, laryngotracheobronchitis (LTB), tracheitis
Acute Laryngotracheobrochitis
- LTB
- Most common of the croup syndromes
- Generally effects children <5
- Organisms responsible
- RSV, parainfluenza virus, Mycoplasma pneumoniae, influenza A & B
S/S
- inspiratory strider
- supersternal retractions
- barking or "seal like" cough
- increasing respiratory distress and hypoxia
- can progress to respiratory acidosis, respiratory failure and death
- airway management
- maintain hydration, orally or intravenously
- high humidity with cool mist
- nebulizer treatments
- epinephrine
- steroids
Respiratory syncytial virus (RSV)
- most frequent cause of hospitalization for children less than 1
- treatment:
- may require hospitalization
- management of symptoms i.e. cool humidified oxygen, hydration
- requires contact/droplet precautions
Asthma
- chronic inflammatory disorder of airways
- classification system for asthma (4 classifications)
- triggers for asthma
- smoke, chemicals
- exercise
- cold air
- pets & other animals
- foods
Will hear wheezes
- SOB with shortness and restricted breath sounds in an ominous sign & imminent respiratory arrest
- Treatment
- Allergen control
- Drug therapy
- Chest physiotherapy
Nursing care managements:
- avoid allergen
- relieve bronchospasms
- provide acute asthma care
Pertussis
- Caused by Bordetella pertussis
- In US it occurs most often in children who not been immunized
- Highest incidence in spring and summer
- Highly contagious
- Risk to young infants
- Vaccines
Asthma Severity Classification
- Step 1: mild, intermittent asthma
- Step 2: mild, persistent asthma
- Step 3: moderate, persistent asthma
- Step 4: severe, persistent asthma
Drug Therapy for Asthma
- Long term control medications
- Quick relief medications
- Metered dose inhaler
- Corticosteroids
- Cromolyn sodium
- Albuterol, metaproterenol, terbutaline
- Long term bronchodilators (Severent)
- Theohylline: monitor serum levels
- Leukotriene modifers
Asthma interventions
- Exercise
- Chest physiotherapy (CPT)
- Hyposensitization
- Prognosis
Status Ashmaticus
- Respiratory distress continues despite vigorous therapeutic measures
- Emergency treatment: epinephrine 0.01 ml/kg subcutaneously (maximum dose 0.3 ml)
- Concurrent infection in some cases
- Therapeutic intervention
Goals of Asthma Management
- Avoid exacerbation
- Avoid allergens
- Relieve asthmatic episodes promptly
- Relieve bronchospasms
- Monitor function with peak flow meter
- Self-management of inhalers, devices, and activity regulation
Cystic Fibrosis
- Autosomal recessive trait
- 1:4 chance of having disease
- Exocrine glands (produces mucous) gland dysfunction that produces multisystem involvement
- First sign may be meconium ileus
- Diagnosis made by positive sweat test
- Use CPT either manually or vest
- Mucus flutter device
- May have pulmonary infections-treat with IV antibiotics
- GI- pancreas before each snack and meal - sprinkle on small amount of food
- High protein, high caloric diet
- Diagnosis based on chloride: usually greater than 60
- Must give IV antibiotics, oral will not work
Glomerulonphritis
•Most common caused by strep
•Oliguria
•Edema
•Hypertension and circulatory congestion
•Hematuria
•Bleeding in upper urinary tract→smoky urine or tea colored
•Proteinuria
•Increased amount of protein = increased severity of renal disease
Nephrotic syndrome
•Facial edema, weight gain, 3+ proteinuria
•Massive proteinura, hypoalbuminemia, hyperlipemia and edema
Bedrest
Diet
Low-to-moderate protein
Sodium restrictions when large amount of edema present
Steroids 2 mg/kg divided into BID doses
Prednisone is drug of choice (least expensive and safest)
Immunosuppressant therapy (Cytoxan)
Diuretics
Enuresis
•Definition: inappropriate voiding 2 times a week for three months
UTI
tx-cotton panties, no bubble baths, increase fluids
Musculoskeletal
•Always check 5 Ps
•Immobolization causes venous status
•If in traction, no relaxation of weights
•Clubfoot: tx is serial casting changed every one to two weeks
•Juvenile idiopathic arthritis
Treatment-pain meds, swimming for exercise, warm compresses
•Congential hip dysplasia
Pavlik harness is used which the child wears 23 hours a day. Parents should be taughtto massage skin once a day.
Scoliosis
Brace
May need rod placement
ICU, log rolling
What is considered a neurosurgical emergency?
Fixed and dilated pupils
Hydrocephalus
What is it and the causes? Overproduction of CSF due to blockage.
Clinical manifestations Increased head circumference. Irritability, Setting sun eyes. Nausea & vomiting. Bulging fontanelles. Dilated scalp veins.
Shunts
Ventro-peritoneal shunt. Risk for infection.. Watch for signs of infection and increasing head circumference. May need revision as child grows and if becomes infected.
Pre-op and post-op nursing care
Education for parents: May need revisions as child grows.
Watch for signs of infection.
Cerebral Palsy
Chronic disability with impaired muscle movement
Causes
Types- and their clinical manifestations
Spactic, dyskinetic
Nursing considerations
There is a wide variation in CP. Sometimes people think that the child is retarded, but that is a generalization. CP child may not have an IQ deficit.
Reye Syndrome
-Causes usually followed a viral infection and the use of aspirin to control fever during the infection.
-Encephalopathy so child will be in coma
-Tx: admitted to ICU, airway (on ventilator), reduced maintenance fluids, quiet atmosphere with dim lights, reduced stimulation
Osteosarcoma
Most common type of bone cancer usually in arm, leg, or pelvis
More common in males between ages of 10-30
Pain at tumor site
Wilm's tumor
-Tumor in kidney usually developed in embryo
-Usually detected when bathing and feel a mass in abdomen
-"do not palpate"
-Requires surgery & chemotherapy
Retinoblastoma
Mutation of the cells of the retina resulting in a malignant tumor
White instead of red in photos.. called white reflex
Refer to ophthalmologist
Autism
Etiology unknown except for fragile X syndrome
S & S vary greatly
Social impairment, language impairment, behavioral impairment, cognitive, inability to maintain eye contact
Tx: behavioral therapies, strict home routine, protect from injury
ADHD
Genetic, environmental, physiological
Tx:
o Therapy or counseling
o Medications: Ritalin, Adderall, Dexedrine
o Side effects of drugs: dependence, arrhythmias, hypertension, growth suppression, sleep problems
o Maintain environmental & physical safety measures
Down's
o Three number 21 chromosomes-trisomy 21
o Cognitive deficits, facial & cranial deformities, muscular hypotonia,,simian creases, lax joints
o Tx: feeding difficulties due to hypotonia-feed slowly if bottle or breast feeding, use long handled straight spoon as start regular foods
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