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Chapter 34 Christine Limann Dyer, RN, BS CPN.  Umbilical vein, umbilical arteries  Foramen ovale  Ductus arteriosus  Ductus venosus Mosby items and.

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Presentation on theme: "Chapter 34 Christine Limann Dyer, RN, BS CPN.  Umbilical vein, umbilical arteries  Foramen ovale  Ductus arteriosus  Ductus venosus Mosby items and."— Presentation transcript:

1 Chapter 34 Christine Limann Dyer, RN, BS CPN

2  Umbilical vein, umbilical arteries  Foramen ovale  Ductus arteriosus  Ductus venosus Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 2

3 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 3

4  Poor feeding  Tachypnea/tachycardia  Failure to thrive/poor weight gain/activity intolerance  Developmental delays  Prenatal history  Family history of cardiac disease Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 4

5  Murmurs = heart sounds that reflect flow of blood within the heart  May occur in systole or diastole, or both  Can occur in a normal heart in periods of stress: anemia, fever, or rapid growth  Can reflect abnormalities in heart or vessels  “Innocent murmurs” = normal cardiac anatomy and cardiac function  Occur in up to 50% of all kids at some time Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 5

6 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 6

7  Chest x-ray  ECG  Echocardiography  Cardiac catheterization Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 7

8 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 8

9  Transposition of great vessels  Some complex single-ventricle defects  ASD  Pulmonary artery stenosis Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 9

10 DIAGNOSISINTERVENTION Valvular pulmonic stenosis Balloon dilation Recurrent coarctation of aorta Balloon dilation Congenital mitral stenosis Balloon dilation Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 10

11 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 11

12  Congenital  Anatomic → abnormal function  Acquired  Disease process Infection Autoimmune response Environmental factors Familial tendencies Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 12

13  Maternal or environmental = 1% to 2%  Maternal drug use Fetal alcohol syndrome—50% have CHD  Maternal illness Rubella in first 7 weeks of pregnancy → 50% risk of defects including PDA and pulmonary branch stenosis CMV, toxoplasmosis, other viral illnesses → cardiac defects IDMs (infant of diabetic mother) = 10% risk of CHD (VSD, cardiomyopathy, TGA most common)  Chromosomal/genetic = 10% to 12%  Multifactorial = 85% Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 13

14  Incidence: 5 to 8 per 1000 live births  About 2 or 3 of these are symptomatic in first year of life  Major cause of death in first year of life (after prematurity)  Most common anomaly is VSD  28% of kids with CHD have another recognized anomaly (trisomy 21, 13, 18, ) Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 14

15  Acyanotic  May become cyanotic  Cyanotic  May be pink  May develop CHF Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 15

16  Hemodynamic characteristics  Increased pulmonary blood flow  Decreased pulmonary blood flow  Obstruction of blood flow out of the heart  Mixed blood flow Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 16

17 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 17

18 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 18

19  Abnormal connection between two sides of heart  Either the septum or the great vessels  Increased blood volume on right side of heart  Increased pulmonary blood flow  Decreased systemic blood flow Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 19

20 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 20

21  Atrial septal defect  Ventricular septal defect  Patent ductus arteriosus Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 21

22 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 22

23 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 23

24 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 24

25  Coarctation of the aorta  Aortic stenosis  Pulmonic stenosis Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 25

26 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 26

27 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 27

28 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 28

29  Tetralogy of Fallot(T.O.F.)  Tricuspid atresia Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 29

30 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 30

31 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 31 Place in this Position During Tet spell

32 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 32

33 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 33

34  Transposition of great vessels  Total anomalous pulmonary venous connection  Hypoplastic heart syndrome  Right  Left Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 34

35 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 35

36 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 36

37 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 37

38 Impaired myocardial function Tachycardia; fatigue; weakness; restless, pale, cool extremities; decreased BP; decreased urine output Pulmonary congestion Tachypnea, dyspnea, respiratory distress, exercise intolerance, cyanosis Systemic venous congestion Peripheral and periorbital edema, weight gain, ascites, hepatomegaly, neck vein distention Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 38

39 Help family adjust to the disorder Educate family Help family cope with effects of the disorder Prepare child and family for surgery Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 39

40  Open heart  Closed heart procedures  Staged procedures  Prepare child and family for procedures Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 40

41  Monitor vital signs and A/V pressures  Intra-arterial monitoring of BP  Intracardiac monitoring  Respiratory needs  Rest, comfort, and pain management  Fluid management  Progression of activity Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 41

42  CHF  Dysrhythmias  Decreased cardiac output syndrome  Decreased peripheral perfusion  Pulmonary changes  Neurologic changes Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 42

43  Symptoms: fever,  WBCs, pericardial friction rub, pericardial and pleural effusion  Occurs in immediate postoperative period  Also can occur later (days 7 to 21 postop)  Etiology unknown  Theories of etiology  Viral infection, autoimmune response, reaction to blood in pericardium  May require pericardiocentesis or pleurocentesis Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 43

44  Infectious and inflammatory cardiac disorders Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 44

45  BE, IE, or SBE  Streptococci  Staphylococci  Fungal infections  Prophylaxis: 1 hour before procedures (IV) or may use PO in some cases Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 45

46 RF Inflammatory disease occurs after group A β-hemolytic streptococcal pharyngitis Infrequently seen in U.S.; big problem in Third World Self-limiting Affects joints, skin, brain, serous surfaces, and heart Carditis Polyarthritis Erythema marginatum Subcutaneous nodules Rheumatic heart disease Most common complication of RF Damage to valves as result of RF Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 46

47  St. Vitus dance (aka, chorea) reflects CNS involvement  Definition: Chorea refers to sudden, aimless movements of extremities, involuntary facial grimaces, speech disturbances, emotional lability and muscle weakness  Worse with anxiety and relieved by rest Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 47

48  Treatment of streptococcal tonsillitis/pharyngitis  Penicillin G—IM x 1  Penicillin V—oral x 10 days  Sulfa—oral x 10 days  Erythromycin (if allergic to above)—oral x 10 days  Treatment of recurrent RF  Same as above Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 48

49  IV IgG  ASA mg/kg/day—fever  Then 3-5 mg/kg/day— antiplatelet Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 49

50  Primary = no known cause  Secondary = identifiable cause  Pediatrics: HTN generally secondary to structural abnormality or underlying pathology  Renal disease  CV disease  Endocrine or neurologic disorders Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 50

51 Identify kids at risk and treat early Treatment = dietary Restrict intake of cholesterol and fats If no response to diet → Rx Colestipol (Colestid) Cholestyramine (Questran) Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 51

52  Contractibility of myocardium is impaired  Secondary cardiomyopathy  Dilated cardiomyopathy  Hypertrophic cardiomyopathy  Restrictive cardiomyopathy  Treatment  Correct underlying cause if possible  Often treatment is aimed at managing CHF and dysrhythmias Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 52

53  Digoxin  Diuretics  Beta blockers, calcium channel blockers  Dobutamine  Nitroprusside  Amrinone Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 53

54  IV IgG  Digoxin (Lanoxin)  ACE inhibitors  ASA, NSAIDs  Lasix  Spironolactone (Aldactone) Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 54

55  Diagnostic evaluation  ECG  Holter monitoring  Electrophysiologic cardiac catheter  Transesophageal recording Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 55

56  Bradydysrhythmias  AV block  May use pacemaker  Tachydysrhythmias  SVT most common tachydysrhythmia  Treatments Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 56

57 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 57

58 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 58

59  Orthotopic transplant  Heterotopic transplant (piggyback)  Organ donation issues  Nursing considerations Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 59

60 T HE C HILD WITH G ASTROINTESTINAL D YSFUNCTION Chapter 33 Christine Limann Dyer, RN, BSE, CPN

61 D IGESTION Required to convert nutrients into usable energy Performs excretory function and detoxification Mechanical digestion Chemical digestion

62 A BSORPTION Principally from small intestine Osmosis Carrier-mediated diffusion Active energy-driven transport (“pump”) Large intestine Absorption of water Absorption of sodium Role of colonic bacteria

63 I NGESTION OF F OREIGN S UBSTANCES Pica Food picas Nonfood picas Foreign bodies Nursing considerations

64 DISORDERS OF MOTILITY

65 C ONSTIPATION An alteration in the frequency, consistency, or ease of passage of stool May be secondary to other disorders Idiopathic (functional) constipation—no known cause Chronic constipation—may be due to environmental or psychosocial factors

66 N EWBORN P ERIOD First meconium should be passed within 24 to 36 hours of life; if not assess for: Hirschsprung disease, hypothyroidism Meconium plug, meconium ileus (CF)

67 I NFANCY Often related to diet Constipation in exclusively breastfed infant almost unknown Infrequent stool may occur because of minimal residue from digested breast milk Formula-fed infants may develop constipation Interventions - adding cereals, fruits and vegetables may help (after 4 months)

68 C ONSTIPATION IN C HILDHOOD Often due to environmental changes or control over body functions Encopresis: inappropriate passage of feces, often with soiling May result from stress Management

69 N URSING C ONSIDERATIONS History of bowel patterns, medications, diet Educate parents and child Dietary modifications (age appropriate)

70 H IRSCHSPRUNG D ISEASE Also called congenital aganglionic megacolon Mechanical obstruction from inadequate motility of intestine Incidence: 1 in 5000 live births; more common in males and in Down syndrome Absence of ganglion cells in colon

71 H IRSCHSPRUNG D ISEASE

72 C LINICAL M ANIFESTATIONS OF H IRSCHPRUNG D ISEASE Aganglionic segment usually includes the rectum and proximal colon Accumulation of stool with distention Failure of internal anal sphincter to relax Enterocolitis may occur

73 D IAGNOSTIC E VALUATION X-ray, barium enema Anorectal manometric exam Confirm diagnosis with rectal biopsy

74 T HERAPEUTIC M ANAGEMENT Surgery Two stages Temporary ostomy Second stage “pull-through” procedure Preoperative care Postoperative care Discharge care

75 G ASTROESOPHAGEAL R EFLUX (GER) Defined as transfer of gastric contents into the esophagus Occurs in everyone Frequency and persistency may make it abnormal May occur without GERD GERD may occur without regurgitation

76 GER Diagnostics Therapeutic management Nursing considerations

77 I RRITABLE B OWEL S YNDROME (IBS) Identified as cause of recurrent abdominal pain in children (Chapter 18) Classified as a functional GI disorder Alternating diarrhea and constipation Therapeutic management Nursing considerations

78 A CUTE A PPENDICITIS Etiology and pathophysiology Diagnostic evaluation Therapeutic management Ruptured appendix Prognosis Nursing considerations

79 M ECKEL D IVERTICULUM Most common congenital malformation of the GI tract Occurs in 1% to 3% of population Pathophysiology Diagnostic evaluation Therapeutic management Nursing considerations

80 U LCERATIVE C OLITIS (UC) Pathophysiology –inflamation in colon and rectum Clinical manifestations – ulceration, bleeding, anorexia, anemia

81 C ROHN ’ S D ISEASE Pathophysiology-Crohn's disease is an inflammatory bowel disease (IBD) Clinical manifestations-abdominal pain, severe diarrhea and even malnutrition Extraintestinal manifestations-arthritis, skin problems, fever, anemia Therapeutic management Medical- corticosteriods, Remicade for remission, 6-MP Surgical Nursing considerations – nutritional support, education

82 P EPTIC U LCER D ISEASE (PUD) Etiology and pathophysiology -Loss of tissue of mucosal, submucosal, and even muscular layer Diagnostic evaluation – upper GI, endoscopy Therapeutic management Medical – treat increased H.Pylori –PPI, amoxicillin, flagyl Surgical Nursing considerations -stress

83 E FFECTS OF UC OR C ROHN D ISEASE

84 OBSTRUCTIVE DISORDERS

85 H YPERTROPHIC P YLORIC S TENOSIS C ONSTRICTION OF THE PYLORIC SPHINCTER WITH OBSTRUCTION OF THE GASTRIC OUTLET

86 I NTUSSUSCEPTION Telescoping or invagination of one portion of intestine into another Occasionally due to intestinal lesions Often cause is unknown Diagnostic evaluation Therapeutic management Prognosis Nursing considerations

87 I LEOCOLIC I NTUSSUSCEPTION

88 M ALROTATION AND V OLVULUS Malrotation is due to abnormal rotation around the superior mesenteric artery during embryonic development Volvulus occurs when intestine is twisted around itself and compromises blood supply to intestines May cause intestinal perforation, peritonitis, necrosis, and death

89 M ALABSORPTION S YNDROMES Characterized by chronic diarrhea and malabsorption of nutrients May result in failure to thrive Digestive defects Absorptive defects Anatomic defects

90 C ELIAC D ISEASE Also called gluten-induced enteropathy and celiac sprue Four characteristics Steatorrhea-fatty stool General malnutrition Abdominal distention Secondary vitamin deficiencies

91 C ELIAC D ISEASE ( CONT.) Pathophysiology Diagnostic evaluation Therapeutic management Nursing considerations

92 S HORT B OWEL S YNDROME (SBS) A malabsorptive disorder Results from decreased mucosal surface area, usually as result of small bowel resection Etiology and pathophysiology Result of decreased mucosal surface area, usually due to extensive resection of small intestine Other causes NEC, volvulus, gastroschisis, Crohn disease in

93 T HERAPEUTIC M ANAGEMENT OF SBS Nutritional support—first phase: TPN Associated risks and complications Second phase: enteral feeding Long-term maintenance Medical therapies Surgical therapies Nursing considerations

94 GI B LEEDING Upper GI bleeding Esophagus Stomach “Coffee grounds” emesis Hematemesis Lower GI bleeding Bright red (rectal bleeding): hematochezia Tarry stools: melena Diagnostic evaluation Therapeutic management Assess blood loss Establish hemodynamic stability Nursing considerations

95 A CUTE H EPATITIS Causes Virus Chemical reaction Drug reaction Other disease processes

96 T YPES OF H EPATITIS Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E Hepatitis G

97 T YPES OF D IARRHEA Acute Acute infectious/infectious gastroenteritis Chronic Intractable diarrhea of infancy Chronic nonspecific diarrhea (CNSD)

98 C IRRHOSIS End stage of many chronic liver diseases Etiologies Biliary atresia, chronic hepatitis, hemophilia, CF Pathophysiology Irreversible Complications

99 A NORECTAL M ALFORMATIONS Imperforate anus Persistent cloaca Cloacal exstrophy Genitalia may be indefinite Diagnostic evaluation Management

100 D EHYDRATION Types of dehydration Diagnostic evaluation Therapeutic management Nursing considerations 1 st treatment- Oral hydration Solution-OHS

101 D AILY M AINTENANCE F LUID R EQUIREMENTS Calculate child’s weight in kg Allow 100 ml/kg for first 10 kg body weight Allow 50 ml/kg for second 10 kg body weight Allow 20 ml/kg for remaining body weight

102 E XAMPLE 1: D AILY F LUID C ALCULATION Child weighs 32 kg 100 x 10 for first 10 kg of body weight = x 10 for second 10 kg of body weight = x 12 for remaining body weight = = 1740 ml/24 hr

103 E XAMPLE 2: D AILY F LUID C ALCULATION Child weighs 8.5 kg 100 x 8.5 for first 10 kg of body weight = 850 No further calculations 850 ml/24 hr

104 E XAMPLE 3: D AILY F LUID C ALCULATION Child weighs 14 kg 100 x 10 for first 10 kg of body weight = x 4 for second 10 kg of body weight = 200 No further calculations = 1200 ml/24 hr

105 H OMEMADE E LECTROLYTE S OLUTION 2 quarts water 1 teaspoon baking soda 1 teaspoon salt 7 Tablespoons sugar 1/2 teaspoon salt substitute


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