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Cardiac Peds


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What is this?
patent ductus arteriosus is failure of the fetal ductus arteriosus (artery connecting the aorta and pulmonary artery) to close within the first week of life. The continued patency of this vessel allows blood to flow from the higher pressure pulmonary artery, causing a left-to-right shunt

What is this?

Tetralogy of Fallot
What are the 2 classifications of congenital heart disease?
Acyanotic & Cyanotic
What is responsible for Acyanotic?
-increased pulmonary blood flow
-obstruction to blood flow from ventricles
What defects cause increased pulmonary blood flow?
-Atrial septal defect
-Ventricular septal defect
-Patent Ductus Arteriosus*
-Atrioventricular canal
What defects cause obstruction to blood flow from ventricles?
-Coarction of aorta*
-Aortic Stenosis
-Pulmonic Stenosis
What happens with cyanotic?
-decrease of pulmonary blood flow
-mixed blood flow
What defects cause a decrease in blood flow?
-Tetraology of Fallot*
-Triscuspid atresia
What defects cause mixed blood flow?
-Transposition of great arteries*
-total anomalous pulmonary venous return
-truncus arteriosus
-hypoplastic left heart syndrome
Nutritional state:
failure to thrive or poor weight gain is associated with heart disease
-cyanosis is a common feature of congenital heart disease, and pallor is asscociated with poor perfusion.
Chest deformities:
An enlarged heart sometimes distorts the chest configuration
Unusual pulsations:
visible pulsations of the neck veins are seen in some patients.
Respiratory excursion:
this refers to the ease or difficulty of respiration (tachypnea, dyspnea, presence of expiratory grunt)
Clubbing of fingers:
this is assoicated with cyanosis
palpation and percussion: these maneuvers help discert heart size and other characteristics (thrills) associated with heart disease
heart rate and rhythm:
-listen for fast heart rates (tachycardia), slow heart rate (bradycardia), or irregular rhythms
-character of heart sounds: listen for distinct or muffled sounds, murmmurs, and additional heart sounds
What are causes of CHD?
-infections; Rubella
-metabolic disorders; diabetes, PKU
-drugs; alcohol
-peripheral conditions; increased maternal age, premature birth, high altitude
Common Pathology of CHD:
-anatomic defect: VSD, ASD, PDA
-hemodynamic alteration: Right to Left shunt-cyanotic
Left to right shunt-acyanotic
-altered tissue oxygenation: characterized as cyanotic or acyanotic defects based on systemic effects.
What is Patent Ductus Arteriosus?
Failure of the fetal ductus arteriosus (artery connecting the aorta and pulmonary artery) to close within the first weeks of life. The continued patency of this vessel allows blood to flow from the higher pressure aorta to the lower pressure pulmonary artery, causing a left-to-right shunt
Because left atrial pressure slightly exceeds right atrial pressure, blood flows from the left to the right atrium, causing an increased flow of oxygenated blood into the right side of the heart.
-Despite the low pressure difference, a high rate of flow can still occur because of low pulmonary vascular resistance and the greater distensibillity of the right atrium, which further reduced flow resistance.
What are the clinical manifestations?
Patients may be asymptomatic or show signs of CHF. There is a characteristic machinery-like murmur. A widened pulse pressure and bounding pulses result from runoff of blood from the aorta to the pulmonary artery. Patients are at risk for bacterial endocarditis and pulmonary vascular obstructive disease in later life from chronic excessive pulmonary blood flow.
Medical Management:
-administration of indoethacin (prostaglandin inhibitor) has proved sucessful in closing a patent ductus in premature infants and some newborns
Surgical Management:
surgical litigation of the patent vessel via a left thoracotomy
What is Tetralogy of Fallot?
Includes four defects:
1. ventricular septal defect
2. pulmonic stenosis
3. overiding aorta
4. right ventricular hypertrophy
What are the clinical manifestations of Tetralogy of Fallot?
Infants: some infants may be acutely cyanotic at birth; others have mild cyanosis that progresses over the first year of life as the pulmonic stenosis worsens. There is a characteristic murmur. There may be acute episodes of cyanosis and hypoxia, called blue spells or tet spells. Anoxic spells occur when the infant's oxygen requirements exceed the blood supply, usually during crying or after feeding.
-knee chest position
-meds; morphine, oxygen
What is Coarction of the Aorta?
Localized narrowing near the insertion of the ductus arteriosus, resulting in increased pressure proximal to the defect (head and upper extremities) and decreased pressure distal to the obstruction (body and lower extremities)
What are the clinical manifestations of COA?
may be high blood pressure, bounding pulses in arms, weak or absent femoral pulses, and cool lower extremities with lower blood pressure.
-reduce the severity of CHF: Digoxin, Lasix, Alddactone
What is Transposition of the great arteries?
The pulmonary artery leaves the left ventricle, and the aorta exits from the right ventricle, with no communication between the systemic and pulmonary circulations.
Assessment Findings:
-cyanosis from birth and tachypnea (worsen w/ crying)
-gallop rythm
-murmurs of ASD,VSD,PDA, loud S2
-diminished exercise tolerance
Medical Management:
Prostaglandin E to temporarily increase blood mixing if systemic and pulmonary mixing is inadequate
What is Rheumatic Fever?
-an inflammatory disease that occurs after infection with group A ß-hemolytic streptococcal pharyngitis
-it involves the joints, skin, brain, serous surfaces, and heart
What is the most signifigant complication of RF?
cardiac valve damage (referred to as rheumatic heart disease)
Major Manifestations:
Carditis-tachycardia our of proportion to degree of fever, cardiomegaly, muffled heart sounds, pericardial friction rub, chest pain
polyarthritis-swollen, hot, red painful joints, after 1-3 days affects different joints, favors large joints-knees, elbows, hips, shoulders, wrists
erythema marginatum-erythematous macules with clear center and wavy, well-demarcated border, transitory, nonpruritic, primarily affects trunk and extremities (inner surfaces)
chorea-sudden aimless, irregular movements of extremites, involuntary facial grimaces, speech disturbances, emotional lability, muscle weakness; muscle movement exaggerated by anxiety and attempts at fine motor activity; relieved by rest
subcutaneous nodes: nontender swelling, located over bony prominences, may persist for some time, then gradually resolve
Minor Manifestations:
Collaboration Care:
-Eradicate hemolytic strep
-prevent permanent cardiac damage
-palliation of symptoms
-prevent recurrence
-penicillin is the drug of choice, with erythromycin as a substitute in penicillin-senstive children
-Salicylates are used to control the infammatory process, especially in the joints and reduce the fever and discomfort
Children who have had acute RF are susceptible to recurent RF:
-should be followed medicaly for at least 5 years
-children and families must be aware of the need for continuing antibotic prophylaxis for dental work, infection, and invasive procedures
Interventions during home care are primarily concerned with:
providing rest and adequate nutrition
One of the most disturbing and frustrating manifestation of the disease is:
chorea-the onset is gradual and may occur weeks to months after the illness; it sometimes occurs in children who have not been dx w/ RF
What is Endocarditis?
An infection of the valves and inner lining of the heart.
-especially affects children with valvular abnormalities, prosthetic valves, recent cardiac surgery with invasive lines, and rheumatic heart disease with valve involvement
Clinical Manifestations:
Patients may be asymptomatic. They may develop congestive heart failure. There is characteristic murmur. Patients are at risk for atrial dysrhythmias (probably caused by atrial enlargement and stretching of conduction fibers) and pulmonary vascular obstructive disease and emboli formation later in life from chronic increased pulmonary blood flow
Therapeutic Management:
Treatment should be instituted immediately and consists of administration of high doses of appropriate antibiotics intravenously for 2 to 8 weeks
Involves administration of prophylactic antibiotic therapy 1 hour before procedures known to increase the risk of entry of organisms.

Coarction of the Aorta
Acyanotic: obstruction to blood flow from ventricles

Transposition of the Great Vessels
Cyanotic: Mixed blood flow

Atrial Septal Defect (ASD)
Abnormal oening between the atria, allowing blood from the higher pressure left atrium to flow into the lower pressure right atrium.
The liquid, fatty fluid that precedes mother milk is called
Important because
High in nutrition and natural antibodies
Breast Cancer mostly found what part of breast
Upper outer quadrant
Cancer causing stuff is called
Tetrogenic Agents
Diabetes caused by insulin resistance, mostly obese people get it
Type 2 Diabetes
Name some causes of congenital heart disease (CHD)
Infections (rubella), radiation, metabolic disorders, drugs/alcohol, peripheral conditions (maternal age. Premature etc.)
BPH is
Benign prostatic hyperplasia
Procedure to fix
A heart disease caused by a fistula between left and right atrium
ASD (atrial Septal defect) YOU HEAR A MURMUR!
Cyanotic or a cyanotic
A heart disease caused by a fistula between aorta and the pulmonary artery is called
PDA patent ductus arteriosus
A heart disease caused by a fistula between left and right ventrical is called
VSD Ventricular Septal defect. MOST COMMON!
Congenital heart disease: 4 things wrong, kid often squats ⬦⬦..
Tetralogy of Fallot
Congenital heart disease: aorta and pulmonary artery are interchanged and there is a atrial fistula
Transposition of the great vessels
Obstruction of blood leaving the heart, acyanotic, can be
Coarctation of the aorta
Lack of o2 to heart resulting in ischemia of heart muscle is called
Myocardial Infarction
s/s acyanotic
Cool to touch
s/s cyanotic
Blue lips and cool to touch
Name some nursing diagnosis related to heart disease
-altered nutrition
-altered growth
-ineffective family coping
A possible heart disease related to URI (strep)
Rheumatic fever
Infection of the heart valves and lining is called
Bacterial endocarditis
Male sex hormone
Artificial detour of ureters from kidney to intestines to bypass bladder is called
Ileal Conduit
Dialysis through a semi permeable intestinal membrane is called
Peritoneal Dialysis
How long is the post partum period
6 weeks, 42 days
Jaundice is caused by
Too much bilirubin
And treated with
Uv light
Neonatal period is
4 weeks
When is Apgar score performed
1-5 minutes after birth
Good score is
4-6 means
Moderate resuscitative efforts
What medication is administered
Vitamin K, eye antibiotic, Hep if parents agree
Site of injections is
Vastus lateralis
Can you put it in IV
Vitamin K because
Baby does not have enough clotting factor
Eye medication because
Ophthalmia neonatorum (infection gonorhorreal/chlamydial)
Circumcision care
Check for bleeding/infection, prevent diaper to touch penis (fold it). No Vaseline with plastabell
First feeding not larger than
1 oz/30cc
First feeding can be
Breast milk/sterile water/formula/sterile glucose
First milk is called
When does discharge planning start
At admission
Engorgement is
Feeling of tension in breast
Cured by
Feeding baby
If no breastfeeding
Do not touch/irritate
After pains are caused by
Uterine cramps
Last normally not longer than
48 hours
The process where the reproductive organs return to normal size after the baby is born is called
Discharge from uterus during postpartum is called
If red (1/3 days post partum)
Lochia rubra (ruby red)
If pink or brown (3-10 days post partum)
Lochia Serosa
If white after 10-14 days
Lochia Alba
Top of uterus is called
Nägele's rule is
subtracting 3 months and adding 7 days and 1 year if appropriate to the first day of a pregnant woman's last menstrual period
Fertilization takes place in the
Pregnancy lasts
280 days/ 40 weeks
Low amniotic fluid could mean
Renal problems for baby
Rh test is called
Coombs test
5 digit system is
1. Gravida
2. Term
3. Para
4. Abortion
5. Living children
Supine hypertension caused by
Laying supine for a while, pressure on descending aorta and Vena Cava: lay on side for a while will help
Anemia if
Hgb is = or smaller than 11
Interventions during labor
-emotional support
-supportive environment
-physical care to provide comfort/hygiene
-explain procedures
-Identify everything that will interfere with labor (voiding, privacy, moving, ambulation etc.)
-Encourage verbalization of fears etc.
monitor progress of labor
Rupture of the fetal membranes is called
Amniotomy can be AROM/SROM
Withdrawal of amniotic fluid from the sac for testing is called
Time from conception to delivery is called
Other word for pregnant woman, relates to # of pregnancies
And if a woman is more than one time pregnant
never delivered a baby
Para is
Past pregnancy continued to viable period, twins count as one para
So primapara is
Woman who had one pregnancy and delivered after the period of viability
Gravida, Term, Para, Abortion, living children
Normal term
38-42 weeks
Post term is
More than 40 weeks
LBW, inadequate lung development
Under 37 weeks
Lightning means
Decreased abdominal distention due to uterine and fetal descent (2-3 weeks before delivery)
The appearance of the fetal scalp at the vaginal orifice in childbirth is called
The process of the cervix/cervical canal thinning and shortening is called
The process of the cervix/cervical canal expanding or enlarging from 0-10cm is called
Position of the fetus head in the true pelvis (-3-+3) is called
Station (0 = engaged)
IUGR means
Intro-uterine growth restriction (lack of oxygen, smoking, drugs, placenta previa)
Neonate is
First 28 days of life
Chadwicks sign is
purple color of vaginal walls
Possible signs of pregnancy are
-absence of menstruation
-breast tenderness
Probable signs
Pregnancy test/Chadwicks, Goodells and Hegar’s signs
Positive signs
Quickening means
First movement (feels like gas, 4th month)
With cephalic birth, what part of head first?
Surgical incision of the perineum during delivery is called
Normal FHR
Three stages of delivery are
First: - dilation
- early latent phase
- mid/active phase
- transitional phase (most dramatic)
second : delivery, usual 30 minutes to 3 hours
Third stage: delivery of placenta (2 to 20 minutes)
Nursing assessment stage
Membrane status
True/false contraction
Color of amniotic fluid if ruptured
Vaginal exam for effacement, dilatation, presentation, position, station
Nursing interventions during labor include
- providing support to mother and supporter
- maintain a supportive environment
- giving physical care to provide comfort
- explain all procedures
- identify everything that may interfere with labor (voiding, privacy, moving)
- provide encouragement
- encourage verbalization of fears and concerns
- continually monitor progress of labor
The first thing the nurse does after the water breaks
Check FHR (because umbilical cord could be under pressure
Early decelerations: nursing intervention
Position change (not benign)
Early decelerations: what causes it
Head compression, means baby is in position!
Variable decelerations: nursing intervention
Position change (not benign)
Variable decelerations can point to
Cord compression
Late decelerations: nursing intervention
02 mask (8-10 liters)
How does the fetus adapt to birth stress
FHR goes up
Pushing/breathing during contractions⬦how
At beginning of contraction two cleansing breaths, at peak of contraction push, with breathing, at end of contraction two more cleansing breaths
Contra-indications for epidural
- allergy
- maternal refuse
- antepartum hemorrhage
- bleeding disorder/anti coagulant therapy
- infections at the injection site
- maternal hypotension
First stage of labor: cervix open in three stages:
Latent 0-3 cm contractions 5-30 minutes apart 30-45 sec long
*Risk Factors for CAD
Cholesterol, elevated serum lipids (LDL/HDL), smoking, weight, stress, HTN, DM
-age, race, gender, family hx; (genetics)
Angina is defined as “An oppressive pain in the chest that is caused by inadequate blood flow and oxygenation to the heart muscle.”
Which diabetes: weight gain, blurred vision, slow to heal, UTI’s, spontaneous abortion
What is the leading undiagnosed cause of depression and suicide in the elderly???
Myxedema (long hypothyroidism)
s/s of hypothyroidism
Everything is slow: weak heart, depressed, constipation, high LDL, dry skin, thick tongue, croaky voice, cold skin, cold intolerant
Severe or long standing hypothyroidism is called
Wrist drop, paresthesia, amyotrophy
What can happen if Myxedema is severe
Coma : hypothermia, hypoventilation, lactic acidosis, hypotension
What can provoke this
Narcotics or sedatives
Most common cause of hypothyroidism
Atrophy of the thyroid gland or in developing countries: lack of iodine in diet
How do you care for someone with hypothyroidism: assessment
- weight gain
- mental changes
- slurred speech
- cold intolerance
- thick, dry skin
- constipation
- Dyspnea
How do you care for someone with hypothyroidism: diagnosis
- hypothermia
- imbalanced nutrition (more than required) hypometabolism
- constipation
- activity intolerance (low metabolism)
- disturbed thought process (diminished cerebral bloodflow)
activity intolerance (low metabolism)
What is the most common cause of hyperthyroidism
Graves disease
What is Graves’ disease
Autoimmune disease marked by thyroid enlargement and excessive thyroid hormone secretion
What age and sex are most affected by hyperthyroidism?
women age 30-50
What is Thyrotoxicocis
It refers to the physiologic effects of hypermetabolism that results from excess circulating levels of T4 T3 or both
s/s of hyperthyroidism
Hypermetabolic, no sleep, weight loss, palpations, SOB,
Treatment for hyperthyroidism is
Radioactive iodine, irradiation of gland, Propranolol, surgery
A thyroid disease with as a sign goiter
Graves disease
How do you take care of someone with hyperthyroidism: assessment
objective: hyperthermia, palpitations, exopthalmos, blinking, diaphoretic, thin nails, thick velvety skin, clubbing, tachypnea, tachycardia, bounding pulse, increased bowel sounds
How do you take care of someone with hyperthyroidism: diagnosis
- imbalanced nutrition (less than body requirement): hypermetabolism
How do you take care of someone with hyperthyroidism: interventions
normal hyperthyroidism is home care but if they have acute Thyrotoxicocis:
- place patient in cool quit room
- change bed linens regularly if diaphoresis
- encourage exercise
- restrict visitors who upset patient
- establish a supportive, trusting environment
Thyroid storm is
Extreme hyperthyroidism on persons with undiagnosed or undertreated thyroid disease (because of stress/trauma)
Other name is
Thyrotoxic crisis
An autoimmune diseases: not enough cortisol but also associated with Hashimoto’s disease, pernicious anemia, idiopathic hypoparathyroidism
Addison’s disease
What is wrong?
Addison's disease is a severe or total deficiency of the hormones made in the adrenal cortex, caused by a destruction of the adrenal cortex
What hormones are produced in adrenal glands
cortisol and aldosterone
Na down, K up so beware of Hyponatremia and hyperkalemia
Add corticoidsteroids and salt to diet
How do you take care of someone with Addison’s …assessment
- vital signs
- fluid volume deficit
- electrolyte imbalances (N & K)
- daily weights
- understanding of medication
Remember Addison’s and salt
ADDisons ADD salt
A disease caused by increased levels of cortisol is called
Cushing’s disease
How do you take care of someone with Addison’s …..?diagnosis
risk for imbalanced nutrition: less than body requirement (loss of appetite)
How do you take care of someone with Addison’s …interventions
- avoid stress
- I/O daily weights
- Teach: medication compliance
- Keep quit , safe, low stress environment
- Give medications
3 kinds of diabetes are
- DM I
- gestational diabetes
Characteristics of type 1
- abrupt onset
- primary defect of Beta cells
- always insulin dependent
- prone to develop Ketoacidosis
- affects mostly teens
- decrease in size and number of Islet cells
Type two is caused by
insulin resistance
- no ketosis/Ketoacidosis
- insidious onset
- usually not insulin dependent
- mostly after 40 years
- often obese
What race/group is most likely to get type 1
Caucasian (western Europe)
What race/group is most likely to get type 2
Native American, Hispanics
Which one is linked to lower economic status
Type 2
What does the lack of insulin do to your body
- glucose is not taken in by hepatic and skeletal muscles
- glucose accumulates in blood and spills in urine
- fluid shifts : dehydration, thirst, blurred vision
- breakdown of fat & protein: weight loss: ketosis METABOLIC ACIDOSIS
Which diabetes: confusion, weight loss, ketone bodies in blood, paresthesia
Type 1
What can happen to nails of people with diabetes
Harden, yellow
Diagnosed with diabetes if
Blood level glucose over 126 x 2 readings
Diabetes: weird behavior can be sign of
Hypoglycemia treat with glucose
Treatment of type 1 is
What adrenal disease: NA up.
Cushing’s (water retention)…cushion …..
What adrenal disease: NA down
Addison’s ….add salt………………….
Treatment of type II
Insulin sensitizers / insulin/ diet/ exercise
s/s of hypoglycemia
Irritable, hunger, fatigue, vision problems, pallor, tremor, anxiety, confusion, poor judgment seizure, coma
If you doubt between hypo and hyper treat like
Acetone breath, malaise, dry mouth could be sign of
Diabetic Ketoacidosis
Treat it with
Insulin, IV fluids and might need dialysis
A diabetic coma with sever dehydration BG level 600-200 could be
Hyperosmolar hyperglycemic non-ketotic syndrome (HHNKS)
Could happen to
Diabetes II, undiagnosed, too much sugar
Night time hypoglycemia with morning hyperglycemia released to epinephrine and GH is called
Somogyi phenomenon
Pm insulin
And same thing without night time hypoglycemia is
Dawn phenomenon
Most common complication of diabetes is
Diabetic neuropathy: may be reversible
Vascular disease related to long high glucose levels
Microvascular disease
Can progress in
Microangiopathy (hypoxia/ischemia )
Blurred vision, spots on retina can be
Diabetic retinopathy
Proteinuria with diabetes can be sign of
Diabetic nephropathy
More common in type
Macrovascular disease most common in type
Related to
Obesity: CVA, MI, atherosclerosis
Leading cause of amputations is
Peripheral vascular disease (peripheral⬦end of limb)
What are the different insulin types?
- rapid acting (Lispro/Humalog)
- short acting (regular, R)
- intermediate lasting (NPH)
- long lasting (Humulin U)
- premixed combinations of NPH/regular
What is the only kind you can administer IV
What is an insulin reaction?
It is another name for hypoglycemia or they mean that you get a little redness/swelling at the injection site
How do you give insulin correctly
Clean skin, give in abdomen, 2 inch right/left off belly button, check right amount/type, and test blood glucose first if needed.
DKA is
Diabetic ketoacidosis is a complication of diabetes caused by the buildup of by-products of fat metabolism (ketones), which occurs when glucose is not available as a fuel source for the body.
s/s DKA
Frequent urination or frequent thirst for a day or more
Treatment of DKA
The goal of treatment is to correct the elevated blood glucose level by giving additional insulin, and to replace fluids lost through excessive urination and vomiting. If ketoacidosis is severe, hospitalization is required to control the condition. Insulin replacement will be given, fluid and electrolytes will be replaced, and the cause of the condition (such as infection) will be identified and treated.
Nursing assessment for DKA and HHNS are
- bloodglucose and count, PH of blood, urinalysis
- physical exam, heart, respiration, LOC
Nursing interventions for DKA and HHNS are
- insulin!!!! Regular through IV if possible
- Fluid replacement (more in DKA)
- Electrolyte replacement (K)
- Assessment for mental status
- Record I/O
- Asses bloodglucose
- ECG monitoring
- Asses respiratory status
- PH les than 7: administer sodium bicarbonate
HHNS what is it
Hyperosmolar Hyperglycemic Nonketotic Syndrome, or HHNS, is a serious condition most frequently seen in older person it occurs more often in people with type 2. HHNS is usually brought on by something else, such as an illness or infection. In HHNS, blood sugar levels rise, and the body tries to get rid of the excess sugar by passing it into the urine. The body makes lots of urine at first, and the patient has to go to the bathroom more often. Polydipsia because of the urination!
Physical findings in these patients
Blood sugar level over 600 mg/dl
How does it differ from DKS
The difference between DKS and HHNS is that
Hyperglycemia s/s
Polyphagia (frequent hunger, especially pronounced hunger)
Normal bloodglucose is
70-105, some say 80-100 mg/dl
Critical levels are
<50 or >400 mg/dl
Hypoglycemic s/s
Mild Signs Include:
Headache, hunger, sweating, nervousness, problems staying focused, mood changes, and weakness.
Moderate Signs Include: Heavy sweating, increasing weakness, heart palpitations, memory loss, double vision, problems walking, and numbness in the area of the mouth and (possibly) the fingers.
Severe Signs Include: Seizures, fainting, muscle twitching, and passing urine unexpectedly.
The two types of DM I are
- immune mediated (viral or infection, triggers antibodies against insulin and destroy insulin producing cells, symptoms appear after 90% is destroyed)
- non-immune (more common in Asian, African-American)
Prone to develop
Nursing management related to stroke
maintain stable or improve LOC
attain maximum physical function
attain maximum self care-abilities and skills
maintain stable body functions (bladder control)
maximize communication abilities
maintain adequate nutrition
avoid complications
maintain effective personal and family coping

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