Ncm 102 Pedia Congestive Heart Failure

8/2/2019 Ncm 102 Pedia Congestive Heart Failure

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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.htm


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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.htm


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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/Vasculitis


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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/Hyperkalemia


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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=20628


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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/Extracorporeal


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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_transplant


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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
http://en.wikipedia.org/wiki/Blalock-Thomas-Taussig_shunthttp://en.wikipedia.org/wiki/Eileen_Saxonhttp://en.wikipedia.org/wiki/November_29http://en.wikipedia.org/wiki/1944http://en.wikipedia.org/wiki/1944http://en.wikipedia.org/wiki/November_29http://en.wikipedia.org/wiki/Eileen_Saxonhttp://en.wikipedia.org/wiki/Blalock-Thomas-Taussig_shunthttp://en.wikipedia.org/wiki/Blalock-Thomas-Taussig_shunthttp://en.wikipedia.org/wiki/Blalock-Thomas-Taussig_shunthttp://en.wikipedia.org/wiki/Blalock-Thomas-Taussig_shunthttp://en.wikipedia.org/wiki/Blalock-Thomas-Taussig_shunthttp://en.wikipedia.org/wiki/Blalock-Thomas-Taussig_shunthttp://en.wikipedia.org/wiki/Blalock-Thomas-Taussig_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
http://en.wikipedia.org/wiki/Palliativehttp://en.wikipedia.org/wiki/Congenital_heart_defecthttp://en.wikipedia.org/wiki/Congenital_heart_defecthttp://en.wikipedia.org/wiki/Venoushttp://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Right_atriumhttp://en.wikipedia.org/wiki/Pulmonary_arteryhttp://en.wikipedia.org/wiki/Pulmonary_arteryhttp://en.wikipedia.org/wiki/Right_ventriclehttp://en.wikipedia.org/wiki/Tricuspid_atresiahttp://en.wikipedia.org/wiki/Tricuspid_atresiahttp://en.wikipedia.org/wiki/Right_ventriclehttp://en.wikipedia.org/wiki/Pulmonary_arteryhttp://en.wikipedia.org/wiki/Pulmonary_arteryhttp://en.wikipedia.org/wiki/Right_atriumhttp://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Venoushttp://en.wikipedia.org/wiki/Congenital_heart_defecthttp://en.wikipedia.org/wiki/Congenital_heart_defecthttp://en.wikipedia.org/wiki/Palliative


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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

Atrial septostomy
http://www.portfolio.mvm.ed.ac.uk/studentwebs/session1/group51/congenital%20cyanotic.htmhttp://www.portfolio.mvm.ed.ac.uk/studentwebs/session1/group51/congenital%20cyanotic.htm


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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
http://www.portfolio.mvm.ed.ac.uk/studentwebs/session1/group51/congenital%20cyanotic.htmhttp://www.portfolio.mvm.ed.ac.uk/studentwebs/session1/group51/congenital%20cyanotic.htmhttp://www.portfolio.mvm.ed.ac.uk/studentwebs/session1/group51/congenital%20cyanotic.htmhttp://www.portfolio.mvm.ed.ac.uk/studentwebs/session1/group51/congenital%20cyanotic.htm


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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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