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Congestive
Heart Failure
in Children
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-occurs when a cardiac output isinadequate to meet the demands
of the body and results in theaccumulation of excessive bloodvolume in the pulmonary and/ orsystemic venous system.
Congestive Heart Failure
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CHF usually results from:
Congenital hearts defects Post cardiac surgery
Rheumatic Fever Severe anemia Hypocalcaemia
Myocarditis
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CAUSES:Congenital heart disease (primary cause of
first 3 years of life)Acquired heart disease- rheumatic heartdisease (caused by damage to the heart fromgroup A strep infections), endocarditis,
myocarditisNoncardiovascular causes- acidosis,pulmonary disease, various metabolic diseasecardiac malformations, such as tetralogy of
Fallotabnormalities of the heart valvesunderdevelopment of one or both ventriclescoarctation of the aorta, which is a narrowing
of the vessel bringing blood to the heart
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Non cardiac causes:
1. Volume overload2. HPN3. Anemia
4. Sepsis5. Renal Failure
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SIGNS AND SYMPTOMS Tachycardia Venous congestion
Right-sided Hepatomegaly Ascites Edema Increase venous pressure
Left-sided
Tachypnea Dyspnea
Orthopnea Cyanosis Rales/ crackles Pulmonary edema
Low cardiac outputFatigue or lowenergy,Pallor
Difficulty offeedingSweating/diaphoresisPoor growth
DizzinessAlteredconsciousnessGeneralizededemaAbrupt gainweight
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LEFT SIDE CHFMitral valve stenosis
Aortic stenosisIschemic Heart Disease
Overworking of theleft side of the heart
Failure of the left sideto contract properly
Pulmonary Congestion
Dyspnea, wheezing,Rales/crackles,
Productive cough,Salivation, cyanosis
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RIGHT SIDE CHFTricuspid valve stenosis
Pulmonary stenosis, COPD,Pulmonary embolism,Left sided heart failure
Overworking of theright side of the heart
Failure of the right sideto contract properly
Venous Congestion
Jugular vein distentionWeight gain, dependentpitting edema, ascites,Hepato-splenomegalyEsophageal varices,
jaundice
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VENTRICULAR SEPTALDEFECT, or holes in the wallsthat separate the left and right
sides of the heart
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A PATENT DUCTUSARTERIOSUS is a blood vesselbetween the aorta and main
pulmonary artery that all babiesrequire in fetal life but whichusually closes within the first
couple of days of life.
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Some babies are born with otherconnections between the two mainarteries leaving the heart, i.e.,
aortopulmonary window or truncusarteriosus. These babies are also at riskfor having too much blood flow to the
lungs.
Holes between the two upper
chambers of the heart (atrial septaldefects) rarely cause problems withcongestive heart failure no matter howlarge.
http://www.cincinnatichildrens.org/health/heart-encyclopedia/anomalies/truncus.htmhttp://www.cincinnatichildrens.org/health/heart-encyclopedia/anomalies/truncus.htmhttp://www.cincinnatichildrens.org/health/heart-encyclopedia/anomalies/asd.htmhttp://www.cincinnatichildrens.org/health/heart-encyclopedia/anomalies/asd.htmhttp://www.cincinnatichildrens.org/health/heart-encyclopedia/anomalies/asd.htmhttp://www.cincinnatichildrens.org/health/heart-encyclopedia/anomalies/asd.htmhttp://www.cincinnatichildrens.org/health/heart-encyclopedia/anomalies/asd.htmhttp://www.cincinnatichildrens.org/health/heart-encyclopedia/anomalies/asd.htmhttp://www.cincinnatichildrens.org/health/heart-encyclopedia/anomalies/asd.htmhttp://www.cincinnatichildrens.org/health/heart-encyclopedia/anomalies/truncus.htmhttp://www.cincinnatichildrens.org/health/heart-encyclopedia/anomalies/truncus.htmhttp://www.cincinnatichildrens.org/health/heart-encyclopedia/anomalies/truncus.htm8/2/2019 Ncm 102 Pedia Congestive Heart Failure
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In older children where the structure ofthe heart is normal, it is usually due toa weakening of the heart muscle, orcardiomyopathy, or Kawasaki Disease,which all can lead to congestive heartfailure.
http://www.cincinnatichildrens.org/health/heart-encyclopedia/disease/cardiomyopathy.htmhttp://www.cincinnatichildrens.org/health/heart-encyclopedia/disease/kawasaki.htmhttp://www.cincinnatichildrens.org/health/heart-encyclopedia/disease/kawasaki.htmhttp://www.cincinnatichildrens.org/health/heart-encyclopedia/disease/kawasaki.htmhttp://www.cincinnatichildrens.org/health/heart-encyclopedia/disease/kawasaki.htmhttp://www.cincinnatichildrens.org/health/heart-encyclopedia/disease/cardiomyopathy.htm8/2/2019 Ncm 102 Pedia Congestive Heart Failure
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CARDIOMYOPATHY canalso be seen in babies and
can be due to a number ofproblems such as rhythmdisturbances or infections.
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KAWASAKI's disease-also known as
motorcycle syndrome, lymph nodesyndrome, mucocutaneous nodedisease, infantile polyarteritis and
Kawasaki syndrome, is a poorlyunderstood self-limited vasculitis thataffects many organs, including the skin
and mucous membranes, lymphnodes, blood vessel walls, and theheart.
http://en.wikipedia.org/wiki/Vasculitishttp://en.wikipedia.org/wiki/Skinhttp://en.wikipedia.org/wiki/Mucous_membranehttp://en.wikipedia.org/wiki/Lymph_nodehttp://en.wikipedia.org/wiki/Lymph_nodehttp://en.wikipedia.org/wiki/Blood_vesselhttp://en.wikipedia.org/wiki/Hearthttp://en.wikipedia.org/wiki/Hearthttp://en.wikipedia.org/wiki/Blood_vesselhttp://en.wikipedia.org/wiki/Blood_vesselhttp://en.wikipedia.org/wiki/Blood_vesselhttp://en.wikipedia.org/wiki/Lymph_nodehttp://en.wikipedia.org/wiki/Lymph_nodehttp://en.wikipedia.org/wiki/Lymph_nodehttp://en.wikipedia.org/wiki/Mucous_membranehttp://en.wikipedia.org/wiki/Mucous_membranehttp://en.wikipedia.org/wiki/Mucous_membranehttp://en.wikipedia.org/wiki/Skinhttp://en.wikipedia.org/wiki/Vasculitis8/2/2019 Ncm 102 Pedia Congestive Heart Failure
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Other CAUSES:
complications of open heartsurgerychronic anemia, which results ina low red blood cell countpoor nutrition
drug toxicity
P th h i l
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Pathophysiology:Congenital Heart DisorderAcquired Heart Diseases
Noncardiovascular causescardiac malformations
abnormalities of the heart valvesunderdevelopment of one or both ventricles
coarctation of the aortaventricular septal defects
patent ductus arteriosuscomplications of open heart surgery
ENLARGEMENT OF VENTRICLES
BLOOD CANNOT BE PUSHEDFORWARD EFFECTIVELY
BLOOD CANNOT BE PUSHED FORWARD
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BLOOD CANNOT BE PUSHED FORWARDEFFECTIVELY
RIGHT VENTRICLE DECREASE RENAL
BLOOD FLOE
LEFT VENTRICLE
Back up of blood intosystemic circulation
Venous pressure
Cardiac Output to
lungs
Edema of extremities &other body organs
including brain,distended neck veins,flushed face, headache,
shortness of breath,dyspne
Back up of blood topulmonary veins
High pressure in
pulmonary capillaries,cardiac output to
system
Pulmonarycongestion, rales,cough, pallor,
weakness, fatigue
Stimulation of renin-angiotensin system andaldosterone secretion
Stimulation of thirstscenter and sodium
retention
Tachycardia,edema
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Clinical Manifestations: Dyspnea and tachypnea Tachycardia Orthopnea
Peripheral edema Feeding difficulties, anorexia Easy fatigability Restlessness Pallor or grayish tint to the skin
Weight gain
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DiaphoresisGrowth Failure or failure to thrive,
meaning that the child's growth andweight gain are slower than expectedNon productive, irritative cough
Neck vein distentionHepatomegalypain and tenderness of the abdomen
coolness of extremities to the touch
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Di ti E l ti
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Diagnostic Evaluation:Congestive heart failure is diagnosed on the
basis of the child's medical history andphysical exam. Identification of theunderlying disease may require specialtests, including:
Palpation May have weak peripheral pulses
Hepatomegaly ( feature of right heartfailure) Abnormal precordial activity may occur
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Auscultation
Gallop rhythm ( frequent)Cardiac murmurs may or may
not be presentCrackles (infrequent in
infants)
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Chest X-rays- cardiomegaly;pulmonary congestionElectrocardiogram, or ECG,
which graphs the electrical
activity of the heartEchocardiography, which uses
ultrasound waves to provideinformation about the structure,function, and motion of the
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Cardiac catheterization, whichinvolves injection of a contrastagent to allow the doctor to watchthe blood flow through the heart
and its arteriesLaboratory data
Dilutional Hyponatremia Hypochloremia Hyperkalemia
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Pharmacological Treatment:
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Pharmacological Treatment:
digoxin - a medication that helps
strengthen the heart muscle, enablingit to pump more efficiently.- Side effects: loss of appetite,
nausea or vomiting, headaches,irregular heartbeat or skipped heartdiuretics - helps the kidneys remove
excess fluid from the body.- Side effect: fatigue, decrease bloodpressure, kidney complications,
excessive loss of potassium
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potassium-sparing diuretics - helps thebody retain potassium, an important mineral
that is often lost when taking diuretics.-Side Effect: On their own this group ofdrugs may raise potassium levels beyond
the normal range, termed hyperkalemia,which risks potentially fatal arrhythmias.potassium supplements - replaces the
potassium lost when taking diuretics.
http://en.wikipedia.org/wiki/Hyperkalemiahttp://en.wikipedia.org/wiki/Arrhythmiahttp://en.wikipedia.org/wiki/Arrhythmiahttp://en.wikipedia.org/wiki/Hyperkalemia8/2/2019 Ncm 102 Pedia Congestive Heart Failure
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ACE (angiotensin-converting enzyme) inhibitors- dilates the blood vessels, making it easier for theheart to pump blood forward into the body.-Dizziness, headache, diarrhea, constipation, loss ofappetite, nausea, loss of taste, flushing, fatigue,cough or increased urination may occur
beta blockers - decrease the heart rate and bloodpressure, and improve heart function by blocking thestress hormone adrenalin.
- You may experience dizziness, lightheadedness,drowsiness, and blurred vision as your body adjuststo the medication.
http://www.medicinenet.com/script/main/art.asp?articlekey=20628http://www.medicinenet.com/script/main/art.asp?articlekey=1900http://www.medicinenet.com/script/main/art.asp?articlekey=331http://www.medicinenet.com/script/main/art.asp?articlekey=331http://www.medicinenet.com/script/main/art.asp?articlekey=1900http://www.medicinenet.com/script/main/art.asp?articlekey=206288/2/2019 Ncm 102 Pedia Congestive Heart Failure
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SURGICAL MANAGEMENT:
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SURGICAL MANAGEMENT:
ARTIFICIAL PACEMAKER
-used for a small battery-operated device that helpsthe heart beat in a regular rhythm. Some arepermanent (internal) and some are temporary(external). An artificial pacemaker can replace a
defective natural pacemaker or blocked pathway.CARDIAC ABLATION
- In cardiac ablation, a form of energy renders asmall section of damaged tissue inactive. Thisputs an end to arrhythmias that originated at theproblematic site.
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Left ventricular assist devices or LVADs
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Left ventricular assist devices, or LVADs
-used to mechanically pump blood through the
hearts of individuals with heart failure as theyawait transplantation, can reverse reduced heartmuscle performance.
Extracorporeal membrane oxygenation(ECMO)
-is an extracorporeal technique of providing both
cardiac and respiratory support oxygen topatients whose heart and lungs are so severelydiseased that they can no longer serve their
function.
http://en.wikipedia.org/wiki/Extracorporealhttp://en.wikipedia.org/wiki/Oxygenhttp://en.wikipedia.org/wiki/Hearthttp://en.wikipedia.org/wiki/Lungshttp://en.wikipedia.org/wiki/Lungshttp://en.wikipedia.org/wiki/Hearthttp://en.wikipedia.org/wiki/Oxygenhttp://en.wikipedia.org/wiki/Extracorporeal8/2/2019 Ncm 102 Pedia Congestive Heart Failure
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Heart transplantation or cardiac
transplantation-is a surgical transplant procedure performedon patients with end-stage heart failure or
severe coronary artery disease-is an open-heart surgery in which a severelydiseased or damaged heart is replaced with a
healthy heart from a recently deceased person
http://en.wikipedia.org/wiki/Organ_transplanthttp://en.wikipedia.org/wiki/Heart_failurehttp://en.wikipedia.org/wiki/Coronary_artery_diseasehttp://en.wikipedia.org/wiki/Coronary_artery_diseasehttp://en.wikipedia.org/wiki/Heart_failurehttp://en.wikipedia.org/wiki/Organ_transplant8/2/2019 Ncm 102 Pedia Congestive Heart Failure
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NURSING MANAGEMENT:
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NURSING MANAGEMENT:
Improved myocardial efficiency Administer Digoxin as prescribed by the physician Carefully calculate dosage; it is given in very small amount in
children and infant Count apical pulse in 1 full minute before administering Observe for vomiting and report to the physician
Observe for the development of premature ventricularcontraction when digoxin is initially started and report to thephysician
Be aware of signs of digitalis intoxication altered emotional status digitalis blues decreased appetite Bradycardia Arrythmias gastrointestinal symptoms
Reduce energy requirements
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gy q Avoid necessary activities such as
frequent complete baths and clothing
changesPrevent excessive cryingUse pacifierHold baby
Eliminate sources of distress (hunger,wet diapers, etc.) Remove accumulated sodium and
fluid
Administer diuretics as prescribed bythe physician.
Hypokalemia may cause weakened myocardial
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Hypokalemia may cause weakened myocardialcontractions and may precipitate digoxin toxicity.
Oral potassium supplements may be indicated
when a child is on diuretics for an extended periodof time.
Restrict sodium intake
The child may be placed on a low-sodium diet.Be aware of the prescribed diet and the amount
of sodium in foods and fluids offered to the child.Question the child about his likes and dislikes so
that the diet can be made as appealing aspossible.
Interpret the diet and its purpose to the child andhis parents.
Infants ma re uire low-sodium formulas.
Be aware of the sidE effects of the
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Be aware of the sidE effects of theprescribed medication.Weigh the child at least daily to
observe response.Maintain an accurate record of intakeand output.Record urine specific gravity.Encourage foods such as bananas andorange juice that have a high potassiumcontent to prevent potassium depletion
associated with many diuretics.
Relieve the respiratory distress associated with
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pulmonary engorgement Improve tissue oxygenation Administer oxygen therapy
Maintain the infant in a neutral thermal environment. Provide adequate nutrition to meet the caloric
requirements of the child Provide foods that the child enjoys in small amount,
because he may have a poor appetite due to liverenlargement. Infant feeding
Feed frequently in small amounts. Feed slowly in sitting position, allowing
frequent rest periods. Supplement oral feedings with gavage
feeding if the infant is unable to take anadequate amount of formula by mouth.
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Obstructive Defect
An obstruction defect is a type ofdefect where one of the valvesor ventricles is narrowed to
such a degree that it partially orcompletely blocks the flow ofblood. There are several typesof obstruction defects,depending upon where themalformation occurs.
Types of Obstruction
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Types of ObstructionDefects
Pulmonary stenosis
Aortic stenosis
Coarctation of the aorta
Symptoms of Obstruction
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Symptoms of ObstructionDefects
Cyanosis (a bluish color to the skindue to lack of blood oxygen)
Chest pain Unusual fatigue Dizziness
More serious symptoms includecongestive heart failure or high bloodpressure.
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Pulmonary Stenosis
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a valve that has leaflets that are
partially fused together. a valve that has thick leaflets that
do not open all the way.
the area above or below thepulmonary valve is narrowed.
In children, theseproblems can include:
different types of pulmonary
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different types of pulmonary
stenosis: valvar pulmonary stenosis supravalvar pulmonary stenosis
subvalvar (infundibular)pulmonary stenosis
branch peripheral pulmonicstenosis
Causes of pulmonary stenosis
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Causes of pulmonary stenosis
improper development of the pulmonary
valve in the first 8 weeks of fetal growth a number of factors, though most of the
time this heart defect occurs sporadically
(by chance) with no clear reason evident for its
development.
S mptoms of p lmonar
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Symptoms of pulmonary
stenosis
heavy or rapid breathing shortness of breath
fatigue rapid heart rate swelling in the feet, ankles, face, eyelids,
and/or abdomen fewer wet diapers or trips to thebathroom
Diagnosis:
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Diagnosis:
chest x-rayelectrocardiogram (ECG or
EKG)
echocardiogram (echo)
cardiac catheterization
T t t
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Treatment
Specific treatment for pulmonary stenosis will bedetermined by your child's physician based on: your child's age, overall health, and medical
history
extent of the condition your child's tolerance for specific medications,
procedures, or therapies
expectations for the course of the condition your opinion or preference
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balloon dilation or valvuloplasty
Valvotomy
Valvectomy (with or withouttransannular patch)
pulmonary valve replacement
Post-procedure care for your
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p y
child:
cath lab interventional procedure surgical repair Ventilator
intravenous (IV) catheters
arterial line
nasogastric (NG) tube
urinary catheter
chest tube
heart monitor
Long-term outlook after
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g
pulmonary stenosis repair:
recommends antibiotics be given to preventbacterial endocarditis after discharge fromthe hospital.
repeat interventional cath lab proceduresmay be necessary during infancy andchildhood to stretch the valve open.
Replacement of the pulmonary valve. Regular follow-up care.
AORTIC STENOSIS
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AORTIC STENOSIS
TYPES
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TYPES:
VALVULAR STENOSIS
SUBVALVULAR STENOSIS
SUPRAVALVULARSTENOSIS
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Aortic Stenosis
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Aortic Valvefound between the left ventricle
and the aorta. It has three
leaflets that function like a one-way door, allowing blood to flow
forward into the aorta, but notbackward into the left ventricle.
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Aortic Valve
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Bicuspid Aortic Valve
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Causes improper development of the aortic genetic link, either occurring due to a
defect in a gene, a chromosomeabnormality, or environmentalexposure, causing heart problems tooccur more often in certain families.
Acquired aortic stenosis may occurafter a strep infection that progressesto rheumatic heart fever.
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DEGENERATION ANDCALCIFICATION
BICUSPID AORTIC
VALVE
AORTIC VALVE BEGINS TODEGENERATEBICUSPID
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DEGENERATE
CALCIUM ACCUMULATES INTHE VALVE
IRREGULAR ROCK LIKEDEPOSITS
DEPOSIT INFRINGE ON THE
VALVULAR OPENING
BICUSPIDAORTIC VALVE
NARROWING OF AORTICVALVE
NARROWING OR STRICTURE OFAORTIC VALVE
CAUSES:UNKNOWN(CONGENITAL)
DEGENERATION OR
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AORTIC VALVEDEGENERATION ORCALCIFICATION
BICUSPID AORTIC VALVERHD
PULMONARYVASCULARCONAGESTION and POSSIBLE
PULMONARY EDEMA
LEFTVENTRICULAR
HYPERTROPHY
DECREASED CARDIAC OUTPUT
RESISTANCE TO BLOOD FLOW
SIGNS AND SYMPTOMS
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SIGNS AND SYMPTOMS
A characteristic murmur is present Infant severe defects demonstrates signs of:- decreased cardiac output
- faint pulses- Hypotension- tachycardia
- poor feeding(too sleepy to feed)
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Children show signs of :-exercise in tolerance- chest pain- dizziness when standing long
period of time
DIAGNOSIS
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DIAGNOSIS:
Ultrasound Scanoxygen saturation monitor
chest x-rayEKG (electrocardiogram)
EchocardiographyCardiac catheterization
Treatment
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TreatmentNon Surgical treatment for valvular aortic stenosis:
Balloon angioplasty during cardiac catheterizationto dilate narrowed valveSurgical treatment for valvular aortic atenosis:Aortic valvotomy under inflow occlusion(palliative);valve replacement may be required asecond procedureSurgical treatment for Subvalvular Aortic Stenosis:
may involve incising a membrane if one exists orcutting the fibromuscular ring; patch may berequired
SURGICAL TREATMENT FOR
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SURGICAL TREATMENT FORSUBVALVULAR STENOSIS
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In cases where the
narrowing in the aorta isabove the aortic valve(supravalvular stenosis), theobstructing portion isremoved and the remaining
parts of the vessel arestitched together
SURGICAL TREATMENT FOR
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SURGICAL TREATMENT FORSUPRAVALVULAR STENOSIS
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VALVOTOMY
aortic valve replacement
aortic homograft pulmonary homograft (Ross
procedure)
P t O ti C
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Post Operative Care
Ventilator intravenous (IV) catheters
arterial line
nasogastric (NG) tube
urinary catheter
chest tube heart monitor
COARCTATION OF THE AORTA
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COARCTATION OF THE AORTA
Types
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Types
Preductal coarctation
Ductal coarctation
Postductal coarctation
PATHOPHYSIOLOGY
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PATHOPHYSIOLOGYCoA imposes significant afterload on the left
ventricle (LV), which results in increasedwall stress and compensatory ventricularhypertrophy.
The afterload may be imposed acutely,as occurs following closure of the ductusarteriosus in neonates with severecoarctation. These infants may rapidlydevelop CHF and shock. Rapid constriction
of the ductus arteriosus, producing suddensevere aortic obstruction, seems to be themost likely explanation.
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As the ductus (aortic end) constricts, the leftventricular afterload rapidly increases, with aresultant increase in left ventricular pressures(systolic and diastolic). This causes elevation ofthe left atrial pressure, which may open theforamen ovale, causing left-to-right shunt anddilatation of the right atrium and right ventricle.
If the foramen ovale does not open, pulmonaryvenous pressures and pulmonary arterypressures increase, and right ventriculardilatation develops. Cardiomegaly revealed bychest roentgenography and right ventricular
hypertrophy seen on ECG and echocardiographyare related to the indirect effects of rapiddevelopment of severe aortic obstruction.
The stroke volume ejected into the limited
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The stroke volume, ejected into the limitedaortic receptacle, produces a higherpressure proximal to coarctation. However,this theory does not explain the following:
The lack of relationship between the degree ofelevation of blood pressure and the magnitude ofobstruction
The increased peripheral vascular resistancedistal to the site of obstruction
The delayed or lack of reduction of bloodpressure immediately following relief ofobstruction
ASSESSMENT
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ASSESSMENT
If the coarctation is slight:
absence of palpable femoral pulses
Children who have an obstruction
proximal to the left subclavian artery: absent brachial pulses
leg pain
obvious nodules on the ribs
DIAGNOSIS:
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DIAGNOSIS:
History
Physical examination
Lab Studies
Imaging Studies
Lab Studies:
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Lab Studies: Laboratory studies in neonatal
patients who present in shockinclude the following:
Septic workup includes blood, urine, and
cerebral spinal fluid (CSF) cultures.
Electrolyte levels, BUN, creatinine, andglucose concentrations should be
tested. Measure arterial blood gases and serum
lactate levels.
Laboratory studies in older patients who
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y ppresent with hypertension include:
Urinalysis
Electrolyte levels
BUN
Creatinine
Glucose concentrations.
Imaging Studies
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Imaging Studies
Chest radiography
Echocardiography
Instantaneous peak pressure
MRI and CT
Other Tests:
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Other Tests:
Electrocardiography
Preductal and postductal pulseoximetry
MEDICAL CARE
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Early presentation
Treatment in patients with congestive heartfailure (CHF) includes the use of diureticsand inotropic drugs.
Prostaglandin E1 (0.05-0.15 mcg/kg/min) isinfused intravenously to open the ductusarteriosus.
Ventilatory assistance is provided topatients with markedly increased work ofbreathing.
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Infusion of inotropic drugs (dopamine,dobutamine, epinephrine) is useful whenventricular dysfunction is present,especially with hypotension.
A Foley catheter is inserted to monitor renalperfusion and urine output.
Arterial blood gases are tested to monitoracidosis.
An umbilical artery catheter may be placed in
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An umbilical artery catheter may be placed inneonates to assess the response to prostaglandin
infusion with regard to improving lower-body bloodflow. Patients stabilized by the above interventions are
better candidates for surgical or catheter
intervention. In the presence of associated defects, the
significance of coarctation on the clinical course of
the patient should be assessed with echo-Dopplerand/or catheterization and angiographic studies.
Late presentation
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Late presentation
Treatment of hypertension
Preoperative hypertension can be
effectively treated using beta-blockers. Postoperative hypertension can be
treated short-term with vasodilators, such
as sodium nitroprusside, and intravenousbeta-blockers, such as esmolol.
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Evaluate associated
abnormalities, such as aorticstenosis, subaortic stenosis, ormitral valve disease.
Evaluate adequacy of collateralblood vessels to assess the safety
of surgical intervention
SURGICAL CARE
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balloon angioplasty
StentsResection and end-to-end
anastomosis patch aortoplasty
left subclavian flap aortoplasty tubular bypass grafts
Balloon Angioplasty
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Balloon Angioplasty
NURSING MANAGEMENT
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Diet Persistent hypertension has been shown to increase
the incidence of coronary artery disease (CAD);therefore, periodically examine patients who haveundergone CoA repair for hypertension andrecommend a healthy low-fat diet.
Measure cholesterol levels and intervenepharmacologically in older patients as indicated, witha total cholesterol goal of less than 200 g/dL.
Patients with persistent hypertension may requirevarying degrees of salt restriction.
Emphasize dietary counseling and avoidance ofobesity and smoking.
Activity
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Patients with CoA and hypertension who are awaitingsurgical repair should limit heavy isometric exercises to a
degree commensurate with the degree of hypertension. Generally, the duration of hypertension after CoA repair
is related in part to the duration of hypertension prior todiagnosis and repair of coarctation. Patients whoundergo repair of coarctation in infancy usually remain
normotensive in the absence of significant residual archobstruction and require no specific activity restrictions orlimitations. With growth, coarctation may recur, andsome patients may be normotensive at rest but havesignificant upper extremity hypertension provoked byexercise. Such patients who desire to participate incompetitive athletics should undergo exercise stresstesting prior to clearance.
Patients who undergo repair later in life
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Patients who undergo repair later in lifeand who have had a significant period of
preoperative hypertension are at particularrisk for sustained postoperativehypertension, which may be permanent.Restrict heavy isometric exercise andother activities in these patients,commensurate with the degree ofhypertension and BP control. Use exercise
testing to assess BP response to exerciseas a means of delineating reasonableexercise limitations.
Cardiac Surgery
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Cardiac Surgery
Surgery on the heart and or the bloodvessels
Closed Heart Surgery
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Closed Heart SurgeryCardiac catheterization
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Open Heart surgery
Operation under
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hypothermia
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2. Temperature and notify
the physician if a fever occurs.
M i t i ti t h i
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Maintain aseptic technique
Monitor for sign of sepsisFever chills
Diaporesis lethargyAltered level of consciousness
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Monitors lines, tubes, or catheters that are in
place and remove promptly as prescribed whenno longer needed, to prevent infection.
Assess for signs of discomfort:
Irritability Change in heart rate, respiratory rate, BP
Inability to sleep
Administer pain medication as
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Administer pain medication as
prescribed noting effectiveness Administered antibiotic and antipyreticas prescribed.
Encouraged rest period. Facilitate parent child contact as soon
as possible.
Defects with decreasedP l Bl d Fl
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Pulmonary Blood Flow
TETRALOGY OF FALLOT
Tetralogy of Fallot
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is a congenital heart defect which is
classically understood to involve fouranatomical abnormalities It is the most common cyanotic heart
defect, representing 55-70%, and the
most common cause of blue babysyndrome. It was described in 1672 by Niels
Stensen, in 1673 by Edward Sandifort,and in 1888 by the French physiciantienne-Louis Arthur Fallot, for whom itis named.
"T t l " f t f h t bl
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"Tetralogy" - refers to four heart problems
-four cardiac abnormalitiescharacteristic of TOF
1. A ventricular septal defect(VSD)2. Pulmonary stenosis
3. Overriding aorta
4. Right ventricular hypertrophy
Epidemiology TOF occurs in approximately 3 to 6 per 10 000
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TOF occurs in approximately 3 to 6 per 10,000births and represents 5-7% of congenital heart
defects. Its cause is thought to be due to environmentalor genetic factors or a combination.
It is associated with chromosome 22 deletions
and diGeorge syndrome It occurs slightly more often in males than infemales.
Embryology studies show that it is a result ofanterior malalignment of the septum , resultingin the clinical combination of a VSD, pulmonarystenosis, and an overriding aorta. Rightventricular hypertrophy results from thiscombination, which causes resistance to blood
flow from the right ventricle
Risk factors
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Genetic factors Maternal abuse of alcohol during pregnancy,
leading to fetal alcohol syndrome (FAS) Mothers who take medications to control
seizures Mothers with phenylketonuria (PKU) Most of the time, this heart defect occurs
sporadically (by chance), with no clear reasonevident for its development.
Pathophysiology
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Decreased pulmonary blood flow
VSD and
overriding aorta
Hypertrophy of the
right ventricle
Pressure builds up in the
right side of the heart
Blood shunt from right to
left ventricle and vice versa
Reduces blood flow to the
lungs
Mixing of oxygenated and
unoxygenated blood
Diluted and O2 poor blood reachesthe body
Low O2 saturation Tet or pink spells
A Healthy Heart Cross-Section
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Tetralogy of Fallot
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gy
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Tet spells
Infrequently, babies with tetralogy ofFallot will suddenly develop the ff.
deep blue skin, nails and lips after crying,
feeding or upon awakening. these episodes are called "Tet spells" and
result from a rapid drop in the amount ofoxygen in the blood.
Toddlers or older children mayinstinctively squat when they are short ofbreath. Squatting increases blood flow tothe lungs.
A baby experiencing tet spell
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Signs and symptoms
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A bluish coloration of the skin caused byblood low in oxygen (cyanosis)
Shortness of breath and rapid breathing
Loss of consciousness (fainting)
Clubbing of fingers and toes (anabnormal, rounded shape of the nail bed)
Lack of appetite
Poor weight gain
Tiring easily during play Irritability
Diagnostic testsEchocardiography
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Echocardiography
Chest x-ray
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y
Cardiac catherization
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Complete blood count
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Electrocardiogram
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Treatment
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Specific treatment for tetralogy of Fallot will
be determined by your child's physicianbased on:
your child's age, overall health, andmedical history
extent of the condition your child's tolerance for specific
medications, procedures, or therapies
expectations for the course of thecondition
your opinion or preference
Medical Management
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Emergency management of tet spells
(acute hypoxia)
Beta blockers Propanolol
acute episode Morphine,
Phenylephrine
O2 therapy not effective
Squatting in the knee chestposition
Surgical Management
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Palliative surgery
Will redirect a large portion of the partiallyoxygenated blood leaving the heart for thebody into the lungs, increasing flowthrough the pulmonary circuit, and greatly
relieving symptoms in patients. The first Blalock-Thomas-Taussig shunt
surgery was performed on 15-month oldEileen Saxon on November 29, 1944 with
dramatic results.
The Pott shunt
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Waterson procedure
- are other shunt procedures which weredeveloped for the same purpose.
2. Total Surgical Repair
- first total surgical repair was performed in1954
- This first total repair was performed by C.
Walton Lillehei at the University ofMinnesota in 1954 on a 10-month boy
Total surgical Repair
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The surgery generally involves making
incisions into the heart muscle, relievingthe right ventricular outflow tract stenosisby careful resection of muscle, andrepairing the VSD using a Gore-Tex patch
or a homograft.
Additional reparative or reconstructivework may be done on patients as required
by their particular anatomy.
Nursing Management
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PRE-OPERATIVE CARE
If at all possible, it is important that thepatient be free of infection prior to going tosurgery.
If the patient is taking aspirin, contact thecardiologist to ask when to discontinue taking
the aspirin. Early cross-matching of the blood prior to
operation
If the patient is taking blood thinners such as
Coumadin or Lovenox, . These patients mayneed to discontinue these medications andconvert to Heparin prior to surgery.
The patient must undergo pre-operativework-out in order to attain the very best
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work out in order to attain the very bestsurgical outcome for the patient
NPO post midnight the night before theoperation.
Nursing Management
POST-OPERATIVE CARE patient will continue to be monitoredclosely.(Neurologic and vital signs)
the patient must be free of infection
continually assess the patients comfortlevel
Tricuspid Atresia
a heart defect present at birth (congenital)
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a heart defect present at birth (congenital)in which one of the valves (tricuspid valve)
between two of the heart's chambers isn'tformed. Instead, there's solid tissuebetween the chambers.
If your baby is born with tricuspid atresia,
blood cannot flow through the heart andinto the lungs to pick up oxygen as itnormally would. The result is the lungscan't supply the rest of your baby's body
with the oxygen it needs. Babies with tricuspid atresia tire easily,
often short of breath and have blue tingedskin
Signs and symptoms
Blue tinge to the skin and lips (cyanosis)
Diffi lt b thi (d )
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Difficulty breathing (dyspnea)
Tiring easily, especially during feedings
Slow growth
Most babies who have tricuspid atresia begin toshow these signs and symptoms within the firsttwo months of life.
Some babies with tricuspid atresia may alsodevelop signs and symptoms of congestive heartfailure, including:
Fatigue and weakness
Persistent cough or wheezing with white or pink
blood-tinged phlegm Swelling (edema) in the legs, ankles and feet
Swelling of the abdomen (ascites)
Sudden weight gain from fluid retention
Decreased alertness
Difference between normal ortriscuspid valve with defect
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triscuspid valve with defect
Causes Heredity Factors
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Heredity Factors
Down syndrome, may increase yourbaby's risk of Tricuspid Atresia
The exact cause of tricuspid atresia isunknown, but several factors may
increase the risk of a baby being born
with this condition:
Risk factor A mother who had German measles (rubella) or
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A mother who had German measles (rubella) oranother viral illness during early pregnancy
A parent who has a congenital heart defect Excessive alcohol consumption during pregnancy
A mother who has diabetes
Use of some types of medications during
pregnancy, such as the acne drug isotretinoin(Accutane) and lithium (Eskalith), which is used totreat bipolar disorder
Babies who have Down syndrome, a geneticcondition that results from an extra 21st
chromosome, also often have a congenital heartdefect.
complications
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Lack of oxygen to tissues(hypoxemia)
Increased red blood cell count(polycythemia).
Possible complications later in life
Although treatment greatly improves the outcome forbabies with tricuspid atresia they may still have the
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babies with tricuspid atresia, they may still have thefollowing complications later in life, even after surgery:
Formation of blood clots that may lead to a clotblocking an artery in the lungs (pulmonary embolism)or to a stroke
Easily tiring when participating in sports or otherexercise
Heart rhythm abnormalities (arrhythmias)
Abnormal loss of protein from the digestive tract(protein-losing enteropathy)
Infection of the heart valves (endocarditis)
For this reason, your child will need lifelong care from aheart specialist (cardiologist) to monitor forcomplications and treat them as necessary.
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Heart rhythm abnormalities(arrhythmias)
Abnormal loss of protein from thedigestive tract (protein-losingenteropathy)
Infection of the heart valves(endocarditis)
For this reason, your child will need
lifelong care from a heart specialist(cardiologist) to monitor forcomplications and treat them asnecessary.
Diagnostic procedure
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Before birth
Ultrasound technology
It's possible for a baby to be diagnosed
with
tricuspid atresia before he or she is born.
Doctors can identify the condition on a
routine ultrasound exam duringpregnancy.
After birthEchocardiogram
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This test uses high-pitched sound waves that
bounce off your baby's heart to produce movingimages your baby's doctor can view on a videoscreen.
It reveals the absence of a tricuspid valve and asmaller than normal right ventricle.
It tracks blood flow, it can also measure theamount of blood moving through holes in the wallsbetween the right and left sides of the heart.
It can identify associated heart defects, such as anatrial septal defect or a ventricular septal defect.
Prostaglandin drug
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used to help widen (dilate) the blood vessels andkeep the ductus arteriosus and the foramen ovaleopen.
Preventive antibiotics Used to prevent bacteria from entering the
bloodstream and infecting the inner lining of theheart (infective endocarditis).
Practicing good oral hygiene brushing and flossingteeth, getting regular dental checkups is anothergood way of preventing infection.
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Fontan procedure a palliative surgical procedure used in
children with complex congenital heartdefects.
It involves diverting the venousbloodfrom the right atrium to the pulmonaryarteries without passing through themorphologic right ventricle.
It was initially described in 1971 as asurgical treatment for tricuspid atresia.
Fontan Procedure
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Fontan procedure
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Atrial septostomy
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This procedure creates or enlarges the opening between theheart's upper chambers (atria) to allow more blood to flowfrom the right atrium to the left atrium.
A balloon is inflated in the right atrial opening,
dilating it and thus increasing blood flow throughit Often used whilst awaiting surgery to ensure
adequate oxygen supply Used in transposition of the great arteries to
reduce cyanosis
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Shunting The shunts are used to increase blood flow to the lungs
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The shunts are used to increase blood flow to the lungs
Used in tricuspid atresia and severe tetralogy of Fallot.
Creating a bypass (shunt) from the main blood vessel leading out ofthe heart (aorta) to the pulmonary arteries allows for adequate bloodflow to the lungs.
Shunting
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Glenn Procedure
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It connects one of the large veins thatreturn blood to the heart (superior venacava) to the pulmonary artery.
This allows oxygen-poor blood to flowdirectly to the lungs.
he procedure reduces the workload on the left ventricle,ecreasing the risk of damage to it.
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g g
Mixed Defects
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TOTAL ANOMALOUS PULMONARYVENOUS CONNECTION(TAPVC)
- TOTAL ANOMALOUS PULMONARYVENOUS DRAINAGE (TAPVD)
- TOTAL ANOMALOUS PULMONARYVENOUS RETURN (TAPVR)
the pulmonary veins that bring oxygen-rich (red)blood from the lungs back to the heart aren'tconnected to the left atrium
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co ected to t e e t at u Instead, the pulmonary veins drain through
abnormal connections to the right atrium. In the right atrium, oxygen-rich (red) blood from
the pulmonary veins mixes with venous (bluish)blood from the body
Part of this mixture passes through the atrialseptum (atrial septal defect) into the left atrium From there it goes into the left ventricle, to the
aorta and out to the body
The rest of the poorly oxygenated mixture flowsthrough the right ventricle, into the pulmonaryartery and on to the lungs
The blood passing through the aorta to the body
d 't h h hi h th
Symptoms may develop soon after birth This defect must be surgically repaired in early infancy In surgery the pulmonary veins are reconnected to the
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In surgery, the pulmonary veins are reconnected to the
left atrium and the atrial septal defect is closed When surgical repair is done in early infancy, the long-term outlook is very good
Still, lifelong follow-up is needed to make certain that anyremaining problems, such as an obstruction in the
pulmonary veins or irregularities in heart rhythm, aretreated properly
Lifelong follow-up is important to make certain that ablockage doesn't develop in the pulmonary veins or
where they're attached to the left atrium Heart rhythm irregularities also may occur at any timeafter surgery.
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Rheumatic fever An inflammatory autoimmune disease that
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An inflammatory autoimmune disease thataffects the connective tissue of the heart,
joints, subcutaneous tissue, and or bloodvessels of the CNS
The most serious complication is rheumaticheart disease, which affect the cardiac valves
Present 2-6 weeks following an untreated orpartially treated group A beta hemolyticstreptococcal infection of upper respiratorytract.
Jones criteria are utilized in determiningdiagnosis
Assessment Aschoff bodies (lesion); found in the heart,
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Aschoff bodies (lesion); found in the heart,
blood vessels, brain and serous surfacesof the joints and pleura Signs of carditis; shortness of breath,
edema of the face, abdomen or ankles,and precordial pain
Polyarthritis; inflammation of large joints,and joints pain
Erythema marginatum; erythematousmacular rash on the trunk and extremities
Subcutaneous nodules found in crops overth b i
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the bony prominences Chorea; sudden aimless irregular
movement of the extremities, involuntaryfacial grimaces, speech disturbances,
emotional liability and muscle weakness Low grade fever that spikes in the lateafternoon
Elevated antistreptolysin O titer,sedimentation rate and C-reactive protein
management Assess vital signs
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Assess vital signs
Assess for the clinical manifestation Control joint pain and inflammation with
massage and alternating hot and coldapplication as prescribed
Provide bed rest during acute febrile phase Limit physical exercise in the child with
carditis Administer antibiotics (penicillin) as
prescribed
Administer salicylates and antiinflammatoryagent as prescribed
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Initiate seizure precaution if the child isexperiencing chorea
Instruct the parent about the importance offollowup and the need for antibiotic
prophylaxis for dental work, infection andinvasive procedure Advice the child to inform the parents if
anyone in school develops a streptococcalthroat infection
Kawasaki disease
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Known as mucocutaneous lymp nodesyndrome and an acute systemicinflammatory disease
Cause is unknown but may be associatedwith an infection from an organism or toxin
Cardiac involvement is the most seriouscomplication; aneurysm can develop
assessment Acute stage
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g
Fever Conjuctivalhyperemia Red throat
Swollen hands, rash and enlargement of thecervical lymph nodes
Assess heart sound
Assess extremities for edema, redness anddesquamation
Examine eyes for conjuctivitis
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Monitor mucous membranes forinflammation
Monitor I&O
GASTRO -
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INTESTINALDISORDER
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RENAL DISORDER
NEPHROTIC SYNDROME
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A set of clinical manifestation arisingfrom protein wasting secondary todiffuse glomerular damage
Defined as massive proteinuria,hypoalbuminemia, hyperlipemia andedema
assessment
Pale irritable and fatigued child
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Pale, irritable and fatigued child Child gains weight Decreased urine output Dark frothy urine; hematuria may be
present Ascites Waxy pallor skin Hypertension Anorexia, anemia
management
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