Peds final Study Guide for Chapter 47,49,56
Peds Final Study Guide Chapter 47,49,56
1.	Describe variation in fetal heart circulation and outline what each structure does in terms of hemodynamics of blood flow in the fetal heart.
a.	Sequence of blood flow: Foramen ovale (connects right atrium to left ventricle and bypasses lungs, second structure that blood reaches), Ductus arteriosus (connects to pulmonary artery to aorta and is the last structure that blood reaches), Ductus venosus (connects umbilical vein to the inferior vena cava bypassing the liver and is the first structure that blood reaches)
b.	variations in fetal heart- ductus venosus, ductus arteriosus (another way of shunting blood away from lungs), foramen ovalis (bypass so that not all blood enters right ventricular, shunts blood). Umbilical vein (red oxygenated blood). Pulmonary artery carries oxygenated blood and changes to unoxygenated.
2.	what events occur to cause changes in fetal circulation to postnatal circulation? Describe how these events change flow in the heart of the newborn. Describe closure of these structures by time frame. What interventions are taken if the structures don’t close?
a.	At birth, two things happen: once chest pops out (first breath happens atmospheric pressure onto chest), clamp umbilical cord (CARDIOPULMONARY ADAPTATION). Neonates first breath of air causes fetal circulation.
b.	 Closing of foramen ovalis (1-2 hours after birth), if baby is cold and crying (it stays open). Closure of ductus Arteriosus: (placenta makes prostaglandin E, when clamped causes closure 18 hours after birth, fibrosing after 2-3 weeks and turns into ligaments).
3.	Describe the pressures pre and post-natal in the pulmonary artery/aorta and the functions of these two structures. Describe the primary principles that guide hemodynamics in the adult.
a.	Blood Flows from higher pressure areas to lower pressure areas (VSD left sided heart is strong AFTER birth).
4.	What should the nurse assess for in babies who are suspected of having a heart defect? What do lab tests show for children with cardiac defects?
a.	Diagnosis: Chest x-rays, CT scans, MRI, EKG, echocardiograms, cardiac catheterization to reveal type of congenital defect child has.
b.	Lab Tests: increased RBCs, increased hemoglobin and hematocrit
5.	What are the signs and symptoms of congestive heart failure in the “cardiac” baby? How do you assess for jugular vein distention? What medications are used to treat heart failure and what are the nursing considerations when administering them?
a.	Signs and symptoms of heart failure in a baby: respirations (rate and depth), increased respiratory effort (tachypnea, nasal flaring, grunting), cough ( auscultate breath sounds wheezing and crackles CHF), Pulse rhythm and quality (strength and rate), blood pressure (what is it for their age), compare BP values of upper and lower rates (should be same), observe color, pallor, cyanosis, does crying approve or worsen condition (crying worsens cyanotic), bulging anterior chest (heaving). (CHF signs are Tachycardia) Weight loss indicates fluid loss. Water retention is a classic sign of congestive heart failure.
b.	have child sit in sitting position to check for venous distention.
c.	Clinical therapy: Digoxin, Lanoxin (assess for bradycardia, monitor for toxicity), Lasix (not potassium sparing monitor for hypokalemia) urinate frequently, Diurel, I&O, BP monitor, Aldactone (maintains diuresis and potassium sparing). Urine output exceeding fluid intake is the expected outcome.
d.	Nursing Considerations: check pulse for one minute (Bradycardia for digoxin toxicity), and monitor for digoxin toxicity (vomiting, diarrhea, halos). Allow child to sleep and rest uninterrupted to decrease metabolic demands. In neonates, the half-life of furosemide is increased. To avoid toxicity of the drug, the nurse should lengthen the time interval between the doses.
6.	What is coarctation of the aorta and what is the cardinal sign for it? What are; PDA, VSD, ASD, Tetralogy of Fallot, and Transposition of the great arteries? What is a “tet” or hypercyanotic spell and how does the nurse treat it?
-An ECG not only records electrical impulses in the heart but can also reveal atrial and ventricular hypertrophy.
a. (PDA) (left-right shunting) inefficient blood, makes blood go back to lungs. On outside of heart easily fixed. Common problem of preterm infant with respiratory syndromes, or hypoxemia. Clinical Manifestation: dyspnea, tachycardia, widen pulse pressure, hypotension, CHF, intercoastal retractions, poor growth (with large PDA), continuous murmur, and thrill. High risk for frequent respiratory infections. Before birth, oxygenated fetal blood is shunted directly into the systemic circulation by way of the ductus arteriosus, a connection between the pulmonary artery and the aorta. After birth, the increased oxygen tension causes a functional closure of the ductus arteriosus. Occasionally, particularly in preterm infants, this vessel remains open, a condition known as patent ductus arteriosus.
b. Tetralogy o][ Fallot: four presentations, pulmonic stenosis (right ventricle gets hypertrophied, overriding aorta (aorta close to septum- blood mixes with oxygenated blood), powerful right ventricle. Newborn becomes cyanotic and hypoxic. Squatting is sign of child in distress trying to aid in blood return to the head. Clubbing of fingers is sign of hypoxia that leads to poor peripheral circulation and tissue hypertrophy of fingertips. The body responds to the chronic hypoxia caused by the heart defect by increasing the production of red blood cells (RBCs) [Polycythemia] to increase the oxygen-carrying capacity of the blood. The RBC count will be increased because the body increases erythrocyte production to make more cells available to carry oxygen. Avoid Valsalva Maneuver after surgery (increases intrathoracic pressure. Preventing respiratory distress minimizes the workload of the heart; this is accomplished with such interventions as positioning, maintaining diet restrictions, administering medications, and promoting conservation of energy. The four structural defects associated with tetralogy of Fallot are right ventricular hypertrophy, ventricular septal defect, pulmonary stenosis, and overriding of the aorta. Because of quick fatigue it is difficult for the infant to consume enough calories for adequate weight gain. Increased caloric intake is needed to meet the infant’s nutritional needs. Small, frequent feedings with adequate rest periods in between may improve the infant's intake at each feeding; infants with tetralogy of Fallot become extremely fatigued while suckling. Positioning the child with the head elevated.
c. ASD [opening atrial septum (left to right shunting)]. Infants and young children usually have no symptoms, large ASD cause CHF. Treatment is diagnostic: echocardiogram, EKG, ECG. Occurs in first years of life, no activity limitations (only when CHF is present), surgery to close is performed when significant pulmonary blood close causes CHF. Arrythmias developed in post-op period. Adults have no symptoms but at risk for stroke (clot that breaks off), clots can break off from ASD and into circulation.
d. VSD (in ventricular area left-right shunt) more pulmonary blood flow. Infants and children have no symptoms, large one’s cause CHF, poor growth, pulmonary infections (increased blood in lungs). Diagnostic: echocardiogram (size and location), EKG. Treatment is conservative. Surgical closure after one year, unless CHF cannot be managed medically. Surgery within first 6 months of life. Highest risk in first 2 months of life repair. A murmur at the left sternal border is the most characteristic finding in infants and children with a VSD. A left-to-right shunt is caused by the flow of blood from the higher pressure left ventricle to the lower pressure right ventricle. Children with VSDs generally have tachycardia and are often acyanotic. Complications: some children may need pace maker, arrythmias. Impaired Gas exchange.
e. Coarctation (narrowing on arteries obstructing systemic blood outflow) “dent in aorta”; Signs: causes blood pressure in legs to be low and higher in neck and head (lower extremities not getting enough blood), weak or absent pulses, pain in legs after exercising. Treatment is to cut out