chapter 34 christine limann dyer, rn, bs cpn. umbilical vein, umbilical arteries foramen ovale ...

Chapter 34

Christine Limann Dyer, RN, BS CPN

Umbilical vein, umbilical arteries

Foramen ovale Ductus

arteriosus Ductus venosus

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Poor feeding Tachypnea/tachycardia Failure to thrive/poor weight

gain/activity intolerance Developmental delays Prenatal history Family history of cardiac disease

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Murmurs = heart sounds that reflect flow of blood within the heartMay occur in systole or diastole, or bothCan occur in a normal heart in periods of stress:

anemia, fever, or rapid growthCan reflect abnormalities in heart or vessels

“Innocent murmurs” = normal cardiac anatomy and cardiac functionOccur in up to 50% of all kids at some time

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Chest x-ray ECG Echocardiograph

y Cardiac

catheterization

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Transposition of great vessels

Some complex single-ventricle defects

ASD Pulmonary

artery stenosis

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DIAGNOSISDIAGNOSIS INTERVENTIONINTERVENTION

Valvular pulmonic stenosisValvular pulmonic stenosis Balloon dilationBalloon dilation

Recurrent coarctation of aortaRecurrent coarctation of aorta Balloon dilationBalloon dilation

Congenital mitral stenosisCongenital mitral stenosis Balloon dilationBalloon dilation

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CongenitalAnatomic → abnormal function

AcquiredDisease process

Infection Autoimmune response Environmental factors Familial tendencies

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Maternal or environmental = 1% to 2%Maternal drug use

Fetal alcohol syndrome—50% have CHDMaternal 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%

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Incidence: 5 to 8 per 1000 live births About 2 or 3 of these are symptomatic in

first year of lifeMajor cause of death in first year of life

(after prematurity)Most common anomaly is VSD28% of kids with CHD have another

recognized anomaly (trisomy 21, 13, 18, + + + )

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AcyanoticMay become

cyanotic Cyanotic

May be pinkMay develop CHF

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Hemodynamic characteristics Increased pulmonary blood flowDecreased pulmonary blood flowObstruction of blood flow out of the heartMixed blood flow

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Abnormal connection between two sides of heartEither the septum or the great vessels

Increased blood volume on right side of heart

Increased pulmonary blood flow Decreased systemic blood flow

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Atrial septal defect Ventricular septal defect Patent ductus arteriosus

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Coarctation of the aorta Aortic stenosis Pulmonic stenosis

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Tetralogy of Fallot(T.O.F.) Tricuspid atresia

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Place in thisPosition

During Tet spell

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Transposition of great vessels Total anomalous pulmonary venous

connection Hypoplastic heart syndrome

RightLeft

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Impaired myocardial functionTachycardia; 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

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Help family adjust to the disorder

Educate family Help family cope

with effects of the disorder

Prepare child and family for surgery

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Open heart Closed heart

procedures Staged

procedures Prepare child

and family for procedures

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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

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CHF Dysrhythmias Decreased cardiac output syndrome Decreased peripheral perfusion Pulmonary changes Neurologic changes

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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

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Infectious and inflammatory cardiac disorders

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BE, IE, or SBE Streptococci Staphylococci Fungal infections Prophylaxis: 1

hour before procedures (IV) or may use PO in some cases

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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 RFMosby items and derived items © 2007, 2003 by Mosby, Inc., an

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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 weaknessWorse with anxiety and

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Treatment of streptococcal tonsillitis/pharyngitis Penicillin G—IM x 1Penicillin V—oral x 10 daysSulfa—oral x 10 daysErythromycin (if allergic to above)—oral x

10 days Treatment of recurrent RF

Same as above

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IV IgG ASA 80-100

mg/kg/day—fever

Then 3-5 mg/kg/day—antiplatelet

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Primary = no known cause Secondary = identifiable cause Pediatrics: HTN generally secondary to

structural abnormality or underlying pathologyRenal diseaseCV diseaseEndocrine or neurologic disorders

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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)

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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

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Digoxin Diuretics Beta blockers, calcium channel blockers Dobutamine Nitroprusside Amrinone

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IV IgG Digoxin (Lanoxin) ACE inhibitors ASA, NSAIDs Lasix Spironolactone (Aldactone)

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Diagnostic evaluationECGHolter monitoringElectrophysiologic cardiac catheterTransesophageal recording

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BradydysrhythmiasAV blockMay use pacemaker

TachydysrhythmiasSVT most common tachydysrhythmiaTreatments

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Orthotopic transplant Heterotopic transplant

(piggyback) Organ donation issues Nursing considerations

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THE CHILD WITH GASTROINTESTINAL DYSFUNCTION

Chapter 33

Christine Limann Dyer, RN, BSE, CPN

DIGESTION

Required to convert nutrients into usable energy

Performs excretory function and detoxification

Mechanical digestion Chemical digestion

ABSORPTION

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

INGESTION OF FOREIGN SUBSTANCES

Pica Food picas Nonfood picas

Foreign bodies Nursing

considerations

DISORDERS OF MOTILITY

CONSTIPATION

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

NEWBORN PERIOD

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

INFANCY

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)

CONSTIPATION IN CHILDHOOD

Often due to environmental changes or control over body functions

Encopresis: inappropriate passage of feces, often with soiling

May result from stress Management

NURSING CONSIDERATIONS

History of bowel patterns, medications, diet Educate parents and child Dietary modifications (age appropriate)

HIRSCHSPRUNG DISEASE

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

HIRSCHSPRUNG DISEASE

CLINICAL MANIFESTATIONS OF HIRSCHPRUNG DISEASE

Aganglionic segment usually includes the rectum and proximal colon

Accumulation of stool with distention Failure of internal anal sphincter to relax Enterocolitis may occur

DIAGNOSTIC EVALUATION

X-ray, barium enema Anorectal manometric exam Confirm diagnosis with rectal biopsy

THERAPEUTIC MANAGEMENT

Surgery Two stages

Temporary ostomy Second stage “pull-through”

procedure

Preoperative carePostoperative care

Discharge care

GASTROESOPHAGEAL REFLUX (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

GER

Diagnostics Therapeutic management Nursing considerations

IRRITABLE BOWEL SYNDROME (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

ACUTE APPENDICITIS

Etiology and pathophysiology Diagnostic evaluation Therapeutic management

Ruptured appendix Prognosis

Nursing considerations

MECKEL DIVERTICULUM

Most common congenital malformation of the GI tract

Occurs in 1% to 3% of population Pathophysiology Diagnostic evaluation Therapeutic management Nursing considerations

ULCERATIVE COLITIS (UC)

Pathophysiology –inflamation in colon and rectum

Clinical manifestations – ulceration, bleeding, anorexia, anemia

CROHN’S DISEASE

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

PEPTIC ULCER DISEASE (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

EFFECTS OF UC OR CROHN DISEASE

OBSTRUCTIVE DISORDERS

HYPERTROPHIC PYLORIC STENOSIS

CONSTRICTION OF THE PYLORIC SPHINCTER WITH OBSTRUCTION OF THE GASTRIC OUTLET

INTUSSUSCEPTION 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

ILEOCOLIC INTUSSUSCEPTION

MALROTATION AND VOLVULUS 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

MALABSORPTION SYNDROMES

Characterized by chronic diarrhea and malabsorption of nutrients

May result in failure to thrive Digestive defects Absorptive defects Anatomic defects

CELIAC DISEASE

Also called gluten-induced enteropathy and celiac sprue

Four characteristics Steatorrhea-fatty stool General malnutrition Abdominal distention Secondary vitamin deficiencies

CELIAC DISEASE (CONT.)

Pathophysiology Diagnostic evaluation Therapeutic management Nursing considerations

SHORT BOWEL SYNDROME (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

THERAPEUTIC MANAGEMENT OF SBS

Nutritional support—first phase: TPN Associated risks and complications

Second phase: enteral feeding Long-term maintenance Medical therapies Surgical therapies Nursing considerations

GI BLEEDING 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

ACUTE HEPATITIS

Causes Virus Chemical reaction Drug reaction Other disease processes

TYPES OF HEPATITIS

Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E Hepatitis G

TYPES OF DIARRHEA

Acute Acute infectious/infectious gastroenteritis Chronic Intractable diarrhea of infancy Chronic nonspecific diarrhea (CNSD)

CIRRHOSIS

End stage of many chronic liver diseases Etiologies

Biliary atresia, chronic hepatitis, hemophilia, CF Pathophysiology

Irreversible Complications

ANORECTAL MALFORMATIONS

Imperforate anus Persistent cloaca Cloacal exstrophy Genitalia may be indefinite Diagnostic evaluation Management

DEHYDRATION

Types of dehydration Diagnostic evaluation Therapeutic management Nursing considerations

1st treatment- Oral hydration Solution-OHS

DAILY MAINTENANCE FLUID REQUIREMENTS

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

EXAMPLE 1: DAILY FLUID CALCULATION

Child weighs 32 kg 100 x 10 for first 10 kg of body weight = 1000 50 x 10 for second 10 kg of body weight = 500 20 x 12 for remaining body weight = 240 1000 + 500 + 240 = 1740 ml/24 hr

EXAMPLE 2: DAILY FLUID CALCULATION

Child weighs 8.5 kg 100 x 8.5 for first 10 kg of body weight = 850 No further calculations 850 ml/24 hr

EXAMPLE 3: DAILY FLUID CALCULATION

Child weighs 14 kg 100 x 10 for first 10 kg of body weight = 1000 50 x 4 for second 10 kg of body weight = 200 No further calculations 1000 + 200 = 1200 ml/24 hr

HOMEMADE ELECTROLYTE SOLUTION

2 quarts water 1 teaspoon baking

soda 1 teaspoon salt 7 Tablespoons sugar 1/2 teaspoon salt

substitute