Cardiac+Round+1

=Cardiac Introduction = =//Notes on how the heart works... //=

The //cardiac system// develops first. It is nearly complete by 8 weeks gestation. Basically the heart is a 4-chambered structure that corresponds to the size of the child’s fist. The atria are the reservoirs, think of them as filling stations and the ventricles as the pumps.  Remember the right chamber drives the blood into the low resistance pulmonary artery  (1 of the great vessels) and on into the lungs. This is the only artery that carries deoxygenated blood. The left ventricle is high pressure because it pushes the blood into the high resistance systemic circulation via the aorta  (the other great vessel). Remembering these basic pathways will help recognize the symptoms produced by the various abnormalities.

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There is also an //electrical system//  that initiates the mechanical activity of the heart but for this lecture we are just going to concentrate on the changes produced by structural defects.


 * //* Fact a child's heart is about the size of their fist. This ratio continues to adulthood.*// **

*Forty percent of all heart malformations are diagnosed within the first year of life.* A detailed history is important:

Maternal pregnancy history - drugs, medications, alcohol, infections, exposures to viruses, illnesses <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Feeding patterns - feeding is exercise, do they tire, poor feeding, diaphoresis <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Growth patterns - poor weight gain <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Illnesses - frequent respiratory infections <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Symptom history – SOB, fatigue, cyanosis
 * <span style="color: #de3535; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">History: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Respirations <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Cry or speech patterns <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Skin Color, nail beds, cyanosis, when, where, check lips and tongue <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Activity level <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Physical abnormalities <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Dysmorphic facial appearance <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Edema <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Chest wall malformations <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Clubbing of fingers <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Palpation for hepatomegaly- liver enlargement can be associated with CHF
 * <span style="color: #de3535; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Physical Assessment and Inspection: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">graded I-VI <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Not all are pathologic, some are innocent
 * <span style="color: #de3535; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">Murmurs **


 * <span style="color: #de3535; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Blood Pressure: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Blood pressures factor in age, height and weight,

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Can be useful to determine <span style="color: #de3535; font-family: 'Times New Roman',Times,serif; font-size: 21.969999313354492px;">coarctation of the aorta <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">, use the right arm and either leg, //normally// the leg bp is equal to or greater than the arm.

<span style="color: #de3535; font-family: 'Times New Roman',Times,serif; font-size: 21.969999313354492px;">Pulsus paradoxus <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">- the systolic blood pressure drops more than 10 mm Hg with inspiration indicates inadequate heart filling from tamponade (accumulation of fluid around the heart), pericardial effusion (collection of fluid in the pericardial sac), pericarditis (inflammation of the pericardium).

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Pulse oximetry <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Electrocardiogram - ECG <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Holter monitor - 24-48 hours <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Event monitoring - month <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Chest x-ray - CXR <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Echo cardiogram – ECHO- <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Magnetic resonance imaging – MRI <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Cardiac catherization
 * <span style="color: #de3535; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">Diagnostic tests: used to diagnose and evaluate a child’s heart include: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">valves, septal defects, malformations <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">sound waves, < 2 sedation, monitor pulse oximetry, heart rate, warm ultrasound gel
 * <span style="color: #de3535; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">Echo – nursing interventions **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Prior ECG, ECHO, CBC, platelet count, <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">NPO, height, weight, allergy status (particularly latex so can be pre-medicated with Benadryl and steroids, iodine from contrast dyes) <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Baseline pedal pulses and pulse oximetry <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Child life specialists – preparation, tour, age appropriate language
 * <span style="color: #de3535; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">Cardiac Catherization – nursing interventions **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Cardiac Cath. Post-Op Care <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Temperature, color, pulse of extremity <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Q 15 minute vital signs, then Q 1 hour <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Intake and Output, contrast can promote diuresis <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Observe for bleeding, hematoma, if bleeding pressure, call Dr. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Oxygen saturation, compare to baseline

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Cardiac Cath. Later- <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Child in bed with affected extremity straight for 4-8 hours <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Younger child can be held by caregiver <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Diet advanced as tolerated <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Pressure dressing removed in 24 hours, no sand bags

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Cardiac Cath. Discharge teaching- <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Site care <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Observe for signs and symptoms of infection <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Monitor for fever <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Restrict strenuous activities for 48-72 hours <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Acetaminophen or Ibuprofen for pain

<span style="color: #de3535; font-family: 'Times New Roman',Times,serif; font-size: 18.59000015258789px;">Knowing how a normal heart performs is essential to understanding the results of a defect!
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<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Signs and symptoms...

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Problems can lead to congestive heart failure

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<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">With the cardiac patient or defects given as a group collaborate:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Name some nursing diagnoses and outcomes.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Plan and discuss possible nursing interventions for your cardiac patient.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">What tests will the patient need?

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">What symptoms might they display?

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">What family teaching topics are needed?

<span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Defects with increased pulmonary blood flow and CHF, primarily acyanotic:

<span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Atrial Septal Defect (ASD) <span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Ventricular Septal Defect (VSD) <span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Patent Ductus Arteriosus (PDA) <span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Atrioventricular Septal Defect <span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Truncus Arteriosus

<span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Pathology: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">These cause shunting of blood from the left to the right side of the heart. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">These cause clinical symptoms of Congestive Heart Failure

<span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Clinical Manifestations of Congestive Heart Failure - Newborns/ Infants: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Tachycardia <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Tachypnea <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Gallop rhythm <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px; line-height: 25px;">Retractions <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Diminished pulses <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Wheezing <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Cool, mottled extremities <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Hepatomegaly <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Pallor <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Low urine output <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Edema <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Failure to thrive <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Restlessness

<span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Clinical manifestations of Congestive Heart Failure – Children/ Adolescents: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Jugular vein distention <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Tachycardia <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Wheezing <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Gallop rhythm <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Rales or rhonchi <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Diminished pulses <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Dyspnea <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Pallor <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Orthopnea <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Edema <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Hepatomegaly <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Low urine output <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Ascites <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Exercise intolerance <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Poor weight gain

<span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Treatments: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Reduce volume overload (Diuretics) <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Improve contractility, reduce rate and work, positive inotropes, (Digoxin) <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Angiotensin-converting enzyme (ACE) inhibitors, Vasodilation, decrease resistance

<span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 17px; line-height: 25px;">*Must check Potassium levels before can administer digoxin*

<span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">*Digoxin* <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">=
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">use syringe, not dropper
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Check apical pulse for 1 full minute
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Do not give if pulse is below 90-110
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Check Potassium level to avoid hypokalemia (arrhythmias)
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Decrease potassium enhances digoxin
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">If miss dose > 4 hours wait till next dose, < 4 hours give
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Notify Dr. if loss of appetite, nausea, vomiting, diarrhea, abdominal pain or visual changes

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">= <span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 160%;">Notes on Atrial Septal Defects (ASD): <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Abnormal connection between the right and left atria <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Accounts for 6-10% of heart defects <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Acyanotic defect <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Easily missed

<span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Pathology: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Blood flows from left to right side of the heart <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">This increases volume in the right atria, ventricle and pulmonary artery <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Enlarging the right atria, ventricle and pulmonary artery

<span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Clinical Manifestations: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Asymptomatic <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Systolic murmur <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Chest x-rays indicate an enlarged heart <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Echo <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">No cardiac cath. necessary

<span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Treatment: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Diuretics <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Surgery when school age because it may close in first 2 years <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Cardiac Cath. Used to thread an occlusive device

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<span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 160%;">Notes on Ventral Septal Defect (VSD): <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Hole between the right and left ventricles <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">One of the most common congenital heart defects <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Accounts for 50% of heart defects alone or in combination <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Blood shunts through defect left to right, overloads pulmonary artery leading to pulmonary congestion and right heart enlargement. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Small defect may be asymptomatic

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;"> <span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Moderate to large defect produces signs of CHF:
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Tachypneic
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Diaphoretic
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Fatigues easily

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;"> <span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Usual tests:
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Listen for a Murmur
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">X-ray
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Echo, not cardiac cath.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;"> <span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">*Small VSD no treatment 75-80% will close spontaneously

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;"> <span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Large defects treated for the first few months for CHF
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Digoxin
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">ACE inhibitors
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Diuretics
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">High calorie feeding
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Nasogastric tube if too tired

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;"> <span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Surgical repair is between 3 and 12 months of age. Stitched or patched, sometimes patched during a cardiac catherization.

<span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Truncus Arteriosus

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Single arterial trunk gives rise to pulmonary arteries, the aorta and the coronary arteries <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Approximately 1.4 % often with DiGeorge syndrome (Thymus and Parathyroid)

<span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Pathophysiology: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Oxygenated and unoxygenated blood flow from the ventricles into the common trunk, then to pulmonary circulation and systemic circulation.

<span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Clinical Manifestations: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Mildly cyanotic <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Later CHF <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Murmur

<span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Diagnosis: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Chest x-ray <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Echo <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Cardiac Cath

<span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Treatment: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Surgery in first 1-2 weeks of life



These two drawings are from child heart specialist.com. You can see the right and left ventricle form a common trunk before separating into the aorta and the pulmonary artery. This causes the oxygenated blood and unoxygenated blood to mix.

<span style="color: #bc1a1a; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">References: <span style="font-family: 'Times New Roman',Times,serif; font-size: 14pt;">O'Brien, P., & Baker, A. L. (2009). Chapter 25: The child with cardiovascular dysfunction. In M. J. Hockberry & D. Wilson (Eds.), Wong's essentials of pediatric nursing (8th ed., pp. 861-910). St. Louis, MO: Mosby Elsevier.

Videos: VSD video located at http://youtu.be/w-iiD6aeZOY Normal heart and truncus located at child heart specialist.com