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7/27/2019 Chapter 25 Cardiac
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Chapter 25
The Child with
Cardiovascular Dysfunction
Mosby items and derived items 2009,2005 by Mosby, Inc., an affiliate of Elsevier
Inc.
http://rds.yahoo.com/_ylt=A9G_bDk_oW5LZAgAI.KjzbkF/SIG=12c56i5m0/EXP=1265627839/**http:/www.heart-valve-surgery.com/Images/heart-stop.jpghttp://rds.yahoo.com/_ylt=A9G_bDk_oW5LZAgAI.KjzbkF/SIG=12c56i5m0/EXP=1265627839/**http:/www.heart-valve-surgery.com/Images/heart-stop.jpghttp://rds.yahoo.com/_ylt=A9G_bDk_oW5LZAgAI.KjzbkF/SIG=12c56i5m0/EXP=1265627839/**http:/www.heart-valve-surgery.com/Images/heart-stop.jpghttp://rds.yahoo.com/_ylt=A9G_bDk_oW5LZAgAI.KjzbkF/SIG=12c56i5m0/EXP=1265627839/**http:/www.heart-valve-surgery.com/Images/heart-stop.jpg7/27/2019 Chapter 25 Cardiac
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A & P Review
Anatomy
Chambers
Valves Vessels
Normal flow
Physiology
Cardiac output
Chambers of the Heart
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Valves of the HeartVessels of the
Heart
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ect/normal.swf
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Assessment of Cardiac Function
History
Physical Examination
Inspection
Palpation and Percussion
Auscultation
Heart rate and rhythm Character of heart sounds
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Pediatric Indicators
of Cardiac Dysfunction
Poor feeding
Tachypnea, tachycardia
Failure to thrive, poor weight gain, activityintolerance
Developmental delays
Positive prenatal history
Positive family history of cardiac
diseaseMosby items and derived items 2009,2005 by Mosby, Inc., an affiliate of Elsevier
Inc.
http://rds.yahoo.com/_ylt=A9G_bDoeoG5LPmwA.HajzbkF/SIG=12cnsogr2/EXP=1265627550/**http:/www.medisave.net/resources/images/pedi_close2.jpghttp://rds.yahoo.com/_ylt=A9G_bDoeoG5LPmwA.HajzbkF/SIG=12cnsogr2/EXP=1265627550/**http:/www.medisave.net/resources/images/pedi_close2.jpg7/27/2019 Chapter 25 Cardiac
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Congenital Heart Disease
ConsequencesCHF, hypoxemia
Incidence: 5-8 per 1000 live births
Major cause of death 1st yr of life
CausesChromosomal-genetic: 10%-12%
Maternal or environmental: 1%-2%
Fetal alcohol syndrome: 50%
Maternal illness
Rubella, cytomegalovirus, toxoplasmosis, other viral illnesses, IDMs
Multifactorial: 85%
Mosby items and derived items 2009,2005 by Mosby, Inc., an affiliate of Elsevier
Inc.
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Fetal
Circulation
Structures
Umbilical vein,
umbilical arteries Foramen ovale
Ductus arteriosus
Ductus venosus
Mosby items and derived items 2009,2005 by Mosby, Inc., an affiliate of Elsevier
Inc.
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Fetal Circulation
http://www.wellesley.edu/Biology/Courses/111/DuctArt.gifhttp://www.wellesley.edu/Biology/Courses/111/ForOval.gif
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Changes at Birth
Mosby items and derived items 2009,2005 by Mosby, Inc., an affiliate of Elsevier
Inc.
FIG. 25-1 Changes in circulation at birth. A, Prenatal circulation. B, Postnatal
circulation. Arrows indicate direction of blood flow. Although four pulmonary veins
enter the LA, for simplicity this diagram shows only two. RA, Right atrium; LA, left
atrium; RV, right ventricle; LV, left ventricle.
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Inc.
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CHD-
Altered hemodynamics
Cyanotic vs Acyanotic
Defects Shunting Pattern
Left to right shunting
Acyanotic
Right to left shunting
Cyanotic
http://rds.yahoo.com/_ylt=A9G_bHMWE8FKTM4AMt6JzbkF;_ylu=X3oDMTBqNzNhb3I1BHBvcwMyMQRzZWMDc3IEdnRpZAM-/SIG=1lkb3td3t/EXP=1254253718/**http:/images.search.yahoo.com/images/view?back=http%3A%2F%2Fimages.search.yahoo.com%2Fsearch%2Fimages%3Fp%3Datrial%2Bseptal%2Bdefect%26b%3D21%26ni%3D20%26ei%3DUTF-8%26y%3DSearch%26pstart%3D1&w=150&h=205&imgurl=www.clevelandclinic.org%2Fheartcenter%2Fimages%2Fguide%2Fdisease%2Fcongenital%2Fvsd.jpg&rurl=http%3A%2F%2Fwww.clevelandclinic.org%2Fheartcenter%2Fpub%2Fguide%2Fdisease%2Fcongenital%2Fseptal.htm%3Findex%3D10512&size=11k&name=vsd+jpg&p=atrial+septal+defect&oid=5f34c993a4394dc0&fr2=&no=21&tt=558&b=21&ni=20&sigr=12ucr3q17&sigi=12bj4v3g8&sigb=1396k4hmg7/27/2019 Chapter 25 Cardiac
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Newer Classification of CHD
Hemodynamic
characteristics:
Increased pulmonary blood
flow Decreased pulmonary
blood flow
Obstruction of blood flow
out of the heart Mixed blood flow
Mosby items and derived items 2009,2005 by Mosby, Inc., an affiliate of Elsevier
Inc.
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ACYANOTIC,Increased Pulmonary Blood Flow Defects
Atrial septal defect (ASD)
Ventricular septal defect (VSD)
Atrioventricular canal defect (AVC)
Patent ductus arteriosus (PDA)
Mosby items and derived items 2009,2005 by Mosby, Inc., an affiliate of Elsevier
Inc.
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Atrial Septal Defect (ASD)
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fect/atrialseptal.swf
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Atrial Septal Defect
(ASD)
Signs & Symptoms:
May be asymptomatic
May have a murmur
Right atrial enlargement
At risk for dysrhythmias, CHF
Management:
Surgical patch closure (pericardial, Dacron)
htt ://www.am latzer.com/ roducts/asd devices/the am latzer se tal occluder/tabid/188/default.as x
http://www.amplatzer.com/products/asd_devices/the_amplatzer_septal_occluder/tabid/188/default.aspxhttp://news.yahoo.com/s/ap/20100921/ap_on_re_as/as_afghanistanhttp://news.yahoo.com/s/ap/20100921/ap_on_re_as/as_afghanistanhttp://www.amplatzer.com/products/asd_devices/the_amplatzer_septal_occluder/tabid/188/default.aspxhttp://www.amplatzer.com/products/asd_devices/the_amplatzer_septal_occluder/tabid/188/default.aspxhttp://www.amplatzer.com/products/asd_devices/the_amplatzer_septal_occluder/tabid/188/default.aspxhttp://www.amplatzer.com/products/asd_devices/the_amplatzer_septal_occluder/tabid/188/default.aspx7/27/2019 Chapter 25 Cardiac
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Ventricular Septal Defect (VSD)
http://www.nemours.org/content/dam/nemours/www/filebox/service/medical/card
iology/defect/vsd.swf
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Ventricular Septal
Defect (VSD)
Signs & Symptoms:
Many asymptomatic
Holosystolic murmur at left sternal border
CHF common
Management:
May close spontaneously (20-60%)
Surgical procedure (sutures or patch)
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Atrioventricular canal (AVC) or Endocardial
cushion defect (ECD)
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gy/defect/atrioventricular.swf
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Atrioventricular Canal Defect (AVC) or
ECD
Signs and Symptoms:
Loud systolic murmurModerate to severe CHF
Possible cyanosis with crying
Management:Optimize cardiac output & weight gain
Patch closure
Valve reconstruction or valve replacement
Hockenberry (2005)
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Patent Ductus Arteriosus (PDA)
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al/cardiology/defect/pda.swf
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Patent Ductus Arteriosus (PDA)
Signs & Symptoms:May be asymptomatic
Machinery-like murmur
Possible s/s of CHF
Management:Spontaneous closure
Surgical (ligation)
Transcatheter (coils)
Indomethacin (Indocin) Prostaglandin inhibitor
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SummaryIncreased Pulmonary Blood Flow Defects
Abnormal connection
between two sides of heart
Either the septum or the
great vessels
Increased blood volume on
right side of heart
Increased pulmonary blood
flow
Decreased systemic blood
flowMosby items and derived items 2009,
2005 by Mosby, Inc., an affiliate of Elsevier
Inc.
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ACYANOTIC,
Obstructive Defects
Coarctation of the aorta
Aortic stenosisPulmonic stenosis
Mosby items and derived items 2009,
2005 by Mosby, Inc., an affiliate of Elsevier
Inc.
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Coarctation of the Aorta (COA)
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cardiology/defect/coarctation.swf
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Coarctation of the Aorta
(CoA) Signs & Symptoms:
B/P differences between
arms/legs, >10 mm Hg Bounding pulses in arms; weak or
absent femoral pulses
Signs of CHF in infants
Cool lower extremities
Risk for HTN, ruptured aorta,aortic aneurysm, stroke
Management:
Surgery-resection,
anastomosis
May recur
Balloon angioplasty &
stent placement
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Aortic Stenosis
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nemours/www/filebox/service/medic
al/cardiology/defect/aorticstenosis.s
wf
Narrowing or stricture of
aortic valve
Causes increased
workload on LV and
hypertrophy
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Aortic Stenosis (AS)
Signs & Symptoms:
Decreased cardiac output with faint pulses
Hypotension, tachycardia, poor feedings
Murmur, systolic
Chest pain, fatigue and syncope
Management:
Balloon angioplasty
Repair or replace valve
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Pulmonic Stenosis
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ical/cardiology/defect/pulmonarystenosis.swf
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Pulmonic Stenosis
Signs & Symptoms:
May be asymptomatic
Loud systolic murmur
Cyanosis May lead to CHF
Nursing Care:
Balloon angioplasty
Valvotomy
Monitor for restenosis
Reduce stressful situations
http://familydoctor.co.uk/media/upload/Balloon%20valvuloplasty.jpg
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CYANOTIC,Decreased Pulmonary Blood Flow Defects
Tetralogy of Fallot
Tricuspid atresia
Mosby items and derived items 2009,
2005 by Mosby, Inc., an affiliate of Elsevier
Inc.
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Tetralogy of Fallot (TOF)
http://www.nemours.org/content/dam/nemours/www/filebox/service/m
edical/cardiology/defect/tof.swf
http://en.wikipedia.org/wiki/Overriding_aorta
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Tetrology of Fallot (TOF)
Signs & Symptoms:
Cyanosis with crying or
feeding
Blue spells or TET" spells At risk for emboli, seizures, loss
of consciousness,
sudden death
Management:
TET spells
Squatting, knee chest position
Oxygen
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Tricuspid Atresia
Error in formation of TV
Incompatible with life as
single defect
Most have ASD or VSD, aswell as PDA
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emours/www/filebox/service/medical/cardiology/defect/tricuspidatresia.swf
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Tricuspid Atresia (TA)
Signs & Symptoms:Severe cyanosisTachycardia
DyspneaManagement:Prostaglandin (PGE1)Emergent Balloon atrial
septostomyNumerous surgical repairs
http://www.ctsnet.org/doc/4960
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CYANOTIC,
Mixed Defects
Transposition of great vessels
Total anomalous pulmonary venousconnection
Truncus arteriosus
Hypoplastic heart syndromeMosby items and derived items 2009,
2005 by Mosby, Inc., an affiliate of Elsevier
Inc.
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Transposition of the Great Vessels (or
Arteries)
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edical/cardiology/defect/transposition.swf
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Transposition of the Great Arteries
or Vessels
(TGA or TGV)
Signs & Symptoms:
Depends on type/size of associated defects
Appear at birth, depressed function
Severe cyanosis, CHF
Nursing Care:
Prostaglandin PGE1 (Keep PDA open)
Balloon atrial septostomy
Surgical repair
arterial switch operation
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Totally Anomalous Pulmonary Venous
Connection
http://www.nemours.org/content/dam/nemours/www/filebox/service/medical/cardiology/defect/tapvrs
upra.swf
http://www.nemours.org/content/dam/nemours/www/filebox/service/medical/cardiology/defect/tapvrinfra.swf
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Total Anomalous Pulmonary Venous
Return (TAPVR)
Signs & Symptoms:
Cyanosis
Heart failure
Management:
Surgical repair
Anastomosis
ASD closed
Anomalous connection ligated
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Truncus Arteriosus
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iology/defect/truncusarteriosus.swf
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Truncus Arteriosus
Signs & Symptoms:
Cyanosis, poor growth
Moderate to severe CHF
Activity intolerance
Holosystolic murmur
Management:
Close VSD
Excise pulmonary arteries and attach to RV
Mortality >10%
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Hypoplastic Left Heart
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edical/cardiology/defect/hlhs.swf
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Hypoplastic Left Heart Syndrome (HLHS)
Signs & Symptoms: Mild cyanosis and s/s of CHF until PDA
closes
Then progressive deterioration
w/cyanosis
Decreased cardiac output
Leads to CV collapse
Management:
Mechanical ventilation
Prostaglandin (PGE1) given
Numerous surgical repairs
Palliative carehttp://home.cc.umanitoba.ca/~soninr/HLHSRep.html
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Hypoplastic Left Heart Syndrome
Glenn Procedure-StageII
Stage I
mimg.co
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Invasive Tests
Cardiac Catheterization:
Determines pressures in heart & heart anatomy
Diagnostic and/or interventional
Risks
Bleeding, infection, thrombus, arrhythmia, perforation,
stroke, death
Preprocedure
Allergy to ?
NPO, assess pedal pulses
Sedation
g
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Cardiac Catheterization
Post procedure
Monitor
Assess pulses below cath site
Temp/color of affected extremity Assess site
Pressure dressing in the groin
VS q 15 mins initially
Lay flat 4-8 hours post
Pain assessment
http://www.yalemedicalgroup.org/stw/images/125490.jpg
C ti H t F il
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Congestive Heart Failure
Inability to pump adequateamount of blood
Right sided failure
RV unable to pump into PA
Increased pressure in RA, systemic
venous circulation Left sided failure
LV unable to pump into systemiccirculation
Increased pressure in LA,
pulmonary veins Causes elevated pulmonary
pressures, pulmonary edema
http://www.medmarketplace.com/images/i19Enlargev2.jpg
C ti H t F il
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Congestive Heart Failure-
Management
Digoxin (Lanoxin)
Increased cardiac output, decreased heart size,decreased venous pressure, relief of edema
Elixir (0.05 mg/ml) or IVSigns of Digoxin toxicity
Nausea, Vomiting, Anorexia
Bradycardia, Dysrhythmias
Administration
Apical pulse, do not give if: < 90-110 in infant
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CHF-Management
Angiotensin-converting enzyme (ACE)inhibitors
Block conversion of angiotensin I to II
Vasodilation occurs, reduce afterload
Common meds: captopril, enalapril, lisinopril
Side effects
Hypotension, cough, renal dysfunction
Beta Blockers (lol)
Causes decreased HR and BP, vasodilation
Carvedilol Mosby items and derived items 2009,2005 by Mosby, Inc., an affiliate of Elsevier
Inc.
Congestive Heart Failure-
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Congestive Heart Failure-
Management
Diuretics (decrease preload) Furosemide (Lasix)
Side effects: N/V, diarrhea, ototoxicity, hypokalemia,
hypotension
Foods high in potassium
Observe for dig toxicity
Chlorothiazide (Diuril)
Side effects: Nausea, weakness, dizzy, muscle cramps,hypokalemia
Spironolactone (Aldactone)
Potassium sparing effects
Side effects: skin rash drows ataxia h erkalemia
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Nursing Care Management for CHF
Nutrition/Feedings
Increased calorie formula
Smaller, Q 3 hr feeds
Gavage feedings or GT
Nipple with larger opening
Frequent rest, give 1/2 hour
Breastfeeding
Fluid loss Assess I&O, daily weights
http://www.mountnittany.org/wellness-library/healthsheets/documents?ID=5207
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Nursing Care Management of CHF
Hypoxemia/Cyanosis
Manifestations
Apparent when O2 sats 80-85%
Clubbing, polycythemia
TET spells At risk for neurological complications
Developmental delays, CVA
Management
Hydration (to reduce CVA risk)
Treat resp infections
Nursing care
Infection control -
http://babyheartblog.org/
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Nursing care of child/family with CHD
Support
Reduce anxiety
Help family adjust
Family education
Home care teaching
Do not restrict physical activity
Immunizations
Prepare for invasive procedures
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Nursing care of child/family with CHD
Postoperative care
Monitor for complications, VS (pg 889, review)
PIV, CVP, Intracardiac lines
Sterile technique
Maintain respiratory status
Suctioning
Chest tubes
Drainage >3 ml/kg/hr for more than 3 hrs indicateshemorrhage or >5-10 ml/kg in any 1 hour
Removal
Monitor fluids
Rest and progressive activity
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Heart Transplantation
Indications Worsening heart failure and end-stage CHD
Organ donation issues
Risks vs benefits
Limited donors
Overall survival 40% up to 20 yrs post
Rejection and immunosuppressants
Nursing considerations
Compliance
Close monitoring Education
Mosby items and derived items 2009,
2005 by Mosby, Inc., an affiliate of ElsevierInc.
http://rds.yahoo.com/_ylt=A9G_bI8nAHFL.iMAmjmJzbkF;_ylu=X3oDMTBpaWhqZmNtBHBvcwMzBHNlYwNzcgR2dGlkAw--/SIG=1hm3vggfa/EXP=1265783207/**http:/images.search.yahoo.com/images/view?back=http%3A%2F%2Fimages.search.yahoo.com%2Fsearch%2Fimages%3Fp%3Dtwo%2Bhearts%26ei%3Dutf-8%26fr%3Db1ie7&w=216&h=160&imgurl=www.twoheartsdesign.com%2Fimages%2Fclipart%2Fheartsandmore%2Fimages%2Fshiny_2hearts.jpg&rurl=http%3A%2F%2Fwww.twoheartsdesign.com%2Fimages%2Fclipart%2Fheartsandmore&size=11k&name=shiny+2hearts+jp...&p=two+hearts&oid=225b134ef3091d62&fr2=&no=3&tt=150383&sigr=11rin079i&sigi=12da0u0em&sigb=12br6nsn67/27/2019 Chapter 25 Cardiac
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Acquired Cardiovascular
Disorders
Infectious and InflammatoryCardiac Disorders
Mosby items and derived items 2009,
2005 by Mosby, Inc., an affiliate of ElsevierInc.
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Bacterial (Infective) Endocarditis
Infection of valves and
inner lining
Caused by bacteremia in
child with acquired orCHD
Streptococcal
Staphylococcal
Fungal
Mosby items and derived items 2009,
2005 by Mosby, Inc., an affiliate of ElsevierInc.
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Bacterial (Infective) Endocarditis
Manifestations
Fever, malaise, anorexia, wt loss
Splinter hemorrhages (fig. A)
Osler nodes (fig. C)
Janeway lesions
(fig. D)
Petechiae on mm (fig. B)
CHF, dysrhythmias, murmur
Treatment
IV antibiotics
Prophylaxis: 1 hour before procedure, IVor PO
Amoxicillin
http://www.rjmatthewsmd.com/Definitions/pop/201afig.htmA
B
C
D
Rh ti F (RF) d Rh ti H t
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Rheumatic Fever (RF) and Rheumatic Heart
Disease (RHD)
RF
Inflammatory disease occurs after group A -
hemolytic streptococcal pharyngitis
Infrequently seen in US
Self-limiting
Affects joints, skin, brain, serous surfaces, and heart
Rheumatic Heart Disease Most common complication of RF
Causes damage to valvesMosby items and derived items 2009,
2005 by Mosby, Inc., an affiliate of ElsevierInc.
Rh ti F
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Rheumatic Fever
ManifestationsUsually 2-6 weeks post infection
Carditis
Polyarthritis
Erythema marginatum
Subcutaneous nodules
Chorea
Treatment
Antibiotics
Prevention
Mosby items and derived items 2009,
2005 by Mosby, Inc., an affiliate of ElsevierInc.
http://www.peds.ufl.edu/peds2/research/debusk/pages/page4_53.html
http://www.aafp.org/afp/2005/0515/p1949.html
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Hyperlipidemia
Identify kids at risk and treat early
R/O secondary causes
Normal TC
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Systemic Hypertension
Primary vs Secondary
Pediatrics: usually secondary
Renal, CV, Endocrine, Neurological disorders
ManagementDietary and lifestyle changes
Beta blockers
Other meds: ACE inhibitors, CCBs, ARBs, Diuretics
Education
Monitoring
Side effects
Mosby items and derived items 2009,
2005 by Mosby, Inc., an affiliate of ElsevierInc.
K ki Di (KD M t L h
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Kawasaki Disease (KD; Mucocutaneous Lymph
Node Syndrome)
Acute systemic vasculitis
Unknown cause
Children
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Kawasaki conjunctivitis, edema, rash,
desquamation
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Kawasaki Disease
Management
ASA
IVIG
Nursing
considerations
Teaching, follow-up,
no live vaccines
Teach S/S of MI, CPR