Peds Exam 3 slide, ati, book questions and answers.docx

  Respiratory Anatomy -Correct Answers: Upper airway: nose nasal passages paranasal sinuses pharynx portion of the larynx above the vocal folds (cords). lower airways: portion of the larynx below the vocal folds trachea bronchi bronchioles Respiratory System Anatomy and Physiology: Pediatric vs. Adult -Correct Answers: Upper airway differences An inflammatory process in the airway causes swelling. Narrows the airway Airway resistance increases. Airway diameter An infant's airway diameter is approximately 4 mm (0.16 in.). In contrast to the adult's 20-mm (0.8-in.) airway diameter Respiratory System Anatomy and Physiology: Pediatric vs. Adult Upper airway differences -Correct Answers: Airway resistance Air must move more quickly in the infant's narrowed airway to get the needed amount of air into the lungs. The friction of the quickly moving air against the side of the airway increases airway resistance. The infant must use more effort to breathe and must breathe faster to get adequate oxygen. Position of trachea In children, the trachea is shorter and the angle of the right bronchus at bifurcation is more acute than in the adult. - more of a sharp angle = hard to intubate When you are resuscitating or suctioning, you must allow for these differences. Respiratory System Anatomy and Physiology: Pediatric vs. Adult Lower airway differences -Correct Answers: Growth of alveoli Diaphragm use for respirations Use of accessory muscles Higher metabolic rate requires more oxygen Alveoli's begin to develop at 36 weeks gestation and continue to develop for first 5-8 years of life, followed by further development in size and complexity Under the age of 6 years, the diaphragm is the major muscle of breathing because intercostal muscles are immature Signs of Respiratory Distress in Children -Correct Answers: Wheezing Effort Tachypnea Flaring Retractions Oxygenation 95% Grunting WET FROG Wheezing -Breath Sounds -Correct Answers: Wheezing Inspiratory or expiratory wheezes Rhonchi Continuous low pitched, rattling lung sounds that often resemble snoring. - like rubbing hair b/w fingers Crackles abnormal crackling or rattling sound, also called crackles Crackles (Rales) Crackles are the sounds you will hear in a lung field that has fluid in the small airways. As stated before, crackles and rales are the samething, and this can often lead to confusion among health care providers. Crackles come in two flavours: fine and coarse. Effort of breathing -Correct Answers: Tripod positioning Head bobbing - using accessory muscles to get air Retractions- Use of accessory muscles Mild Intercostal retractions Moderate to severe Sternal, subcostal, suprasternal, supraclavicular Tachypnea -Correct Answers: Resp rate newborns 60 /infants 40 Increased risk for aspiration with high RR, may not feed PO. Flaring nares -Correct Answers: Retractions -Correct Answers: Supraclavicular Suprasternal Sternal Subcostal retractions: Indrawing of the abdomen just below the rib cage (sometimes referred to as belly breathing). Substernal retractions: Indrawing of the abdomen just below the sternum (breastbone). Intercostal retractions: Indrawing of the skin in between each rib Suprasternal retractions (tracheal tug): Indrawing of the skin in the middle of the neck above the sternum (breastbone). Severe difficulty breathing is associated with supraclavicular retractions, suprasternal retractions, and sternal retractions. There can also be the retractions associated with mild to moderate difficulty breathing listed above. Oxygenation -Correct Answers: A blue discoloration of the tongue and mucus membranes are a good indication of diminished oxygenation. Sats greater than 95% Grunting -Correct Answers: A little sound at the end of each respiration...no your baby is not singing... Diagnostic and Lab Tests for resp -Correct Answers: diagnostis Bronchoscopy - foreign bodies Chest X-ray Polysomnography = sleep study Pulse oximetry Pulmonary Function Tests (spirometry) Sweat chloride test - CF lab Arterial blood gas analysis - has more O2 Cultures Neonatal screening for CF PPD test = TB Common Treatments for Child With Respiratory Issues -Correct Answers: Pulse oximetry Nebulized medication - areole form, particles are smaller = further into lungs Metered Dose Inhalers (MDI) - handheld device Chest physiotherapy - put on lungs, vibrations Oxygen Therapy Suctioning - different ways Artificial airways - don't need cuff babies have their own, Pulse Oximetry -Correct Answers: measurement of the oxygen saturation (SaO2) of arterial blood. Measures patient's pulse rate Sites: Fingertip Toe Earlobe Around the foot or hand The effectiveness of inhalation therapies Find an appropriate probe site. The probe site must be dry and have adequate circulation. Remove polish from nails or remove earrings if using the earlobe. Note the pulse reading and compare it with the child's radial pulse. Any discrepancy between the values warrants further assessment. DO NOT use this to check HR Nebulizers -Correct Answers: A nebulizer should be used when bronchodilators, corticosteroids, mucolytics, or antibiotics needs to be administered to the respiratory tract Preparation Instruct the child and family that the treatment can take 10 to 15 min. Determine if the child should use a mouthpiece, mask, or blow-by. Perform a pre-procedure assessment, including vital signs and oxygen saturation. Pour the medication into the small container and attach the device to an air or oxygen source. The process of nebulization breaks up medications into minute particles that are then dispersed throughout the respiratory tract. These droplets are much finer than those created by inhalers Mucolytic- any agent that dissolves or destroys mucus. ● Encourage the child to take slow, deep breaths by mouth. ● Monitor the child during the treatment, watching carefully for indications of local tracheal or bronchial effects (spasms, edema). Can incr HR, make them shaky ● Assess vital signs, oxygen saturation, and lung sounds at the completion of treatment. ● Monitor for adverse reactions to medications. Metered Dose Inhaler with Spacer -Correct Answers: Wash mouth out with water Wash sprays Hold in for 10 sec Chest Physiotherapy -Correct Answers: A set of techniques that includes manual or mechanical percussion, vibration, cough, forceful expiration (or huffing), and breathing exercises. Gravity and positioning loosen respiratory secretions and move them into the central airways, where they can be eliminated by coughing or suctioning to rid excessive secretions from specific areas of the lungs. Oxygen Therapy -Correct Answers: Indication for use of oxygen therapy - Hypoxemia Oxygen may be delivered via nasal cannula, face mask, face tent, CPAP, BiPAP, tent, hood, or mechanical ventilator. Common methods for children: Oxygen hood-small plastic hood that fits over the infants head. Nasal Cannula Pediatric face mask- covers nose and mouth. Hypoxemia develops when there is an inadequate level of oxygen in the blood. Hypovolemia, hypoventilation, and interruption of arterial flow can lead to hypoxemia. Nursing Considerations When Using a Oxygen Hood -Correct Answers: Use a minimum flow rate of 4 to 5 l/min to prevent carbon dioxide buildup. ensure that neck, chin, or shoulders do not rub against the hood. Secure a pulse oximeter for continuous SaO2 monitoring. Suctioning -Correct Answers: Bulb suctioning Oral suctioning Use clean technique. Use a hard catheter tip. Insert in sides of mouth Nasal suctioning Use clean technique. Use a mushroom tip catheter = cant go deep Respiratory Failure -Correct Answers: Body can no longer maintain effective gas exchange. Process begins at alveoli. Results in hypoxemia and hypercapnia Can be abrupt on-set or insidious on-set Should have 6-8 hours of this coming on, unless acute injury Mild Respiratory Distress: Attempting to Compensate -Correct Answers: Signs and symptoms Restlessness Tachypnea Tachycardia Diaphoresis what is the earliest 'irregular exam finding in pediatric respiratory disease? Tachypnea - all respiratory problems will show this first Moderate Respiratory Distress: Early Decompensation -Correct Answers: Signs and symptoms Nasal flaring Retractions Grunting, wheezing Anxiety, irritability, mood changes, confusion Hypertension Severe Respiratory Distress: Respiratory Failure/Imminent Arrest -Correct Answers: Signs and symptoms Dyspnea Bradycardia Cyanosis (note that cyanosis is a late sign) Stupor, coma Tonsillitis -Correct Answers: Tonsils are masses of lymph-type tissue found in the pharyngeal area. Tonsils are highly vascular = bleeding concern Tonsillitis is when the tonsils become inflamed and reddened. This can be acute or chronic. Potential Complications of Tonsillitis -Correct Answers: Tonsillectomy Primary tonsillar bleeding occurs within the first 24 hours post operatively, and usually in the first 6 hours. These are generally the more urgent. Secondary postoperative tonsil bleeds occur around 5-10 days postoperatively, when the eschar from the wound sloughs off. Post-op = Position to facilitate drainage, when awake, elevate HOB Assess for evidence of bleeding such as frequent swallowing, clearing the throat, bright red emesis, tachycardia Provide comfort measures Encourage high amount of clear fluid intake Advance to soft diet as tolerated Discourage coughing or blowing of nose Avoid straws Alert parents that there can be clots or blood-tinged mucus in vomitus All things listed are emergencies Nasopharyngitis -Correct Answers: Nasal inflammation, dryness and irritation of nasal passages and pharynx Symptoms Fever Decreased appetite restlessness Self-limiting, persists for 4-10 days nasopharyngitis is also known as "common cold" Caused by what viruses? RSV, rhinovirus, adenovirus, influenza and parainfluenza virus Nasopharyngitis - Nursing care -Correct Answers: Antipyretic for fever Encourage rest Provide cool mist - vaporizor Give decongestants for children OVER 6 years Antihistamines not recommended Antibiotics not indicated - bc viral Acute Streptococcal Pharyngitis -Correct Answers: Abrupt onset Characterized by Pharyngitis, headache, fever, ADB pain Tonsils and pharynx inflamed, covered with exudate by day 2 Lab test Throat culture or rapid strep test GABHS - Group A Beta-Hemolytic Streptococci (strep throat) Acute Streptococcal Pharyngitis -Nursing Care -Correct Answers: Administer antibiotic as ordered Oral antibiotics given for a minimum of 10 days Erythromycin for those allergic to penicillin Administer antipyretics for fever Bronchitis (Tracheobronchitis) -Correct Answers: Upper airway infection Inflammation of the trachea and bronchi Usually affects adults Usually a viral cause Symptoms Dry, hacking cough that lasts for 5-10 days Lab test Test nasopharyngeal secretions Antipyretic for fever Cough suppressant as needed Provide cool mist Bronchiolitis -Correct Answers: Affects young children wheezing and difficulty breathing = swelling in the airways/lungs. Usually caused by RSV Inflammation occurs at bronchial levels Bronchiolitis - Expected Findings -Correct Answers: Initially Rhinorrhea, intermittent fever, pharyngitis, coughing, sneezing, wheezing. Possible eye or ear infection With progression Incr coughing, fever, mild tachypnea, retractions, copious secretions Severe illness Incr tachypnea, listlessness, apneic spells, poor breath sounds, cyanosis Bronchiolitis - Nursing Care -Correct Answers: Supplemental oxygen as needed to keep sats over 90% Encourage fluids/IV fluids Maintain airway Nasal or pharyngeal suctioning as needed Medications as ordered Corticosteroids are controversial = decr inflammation but also masks whats happening with child Bronchodilators not recommended CPT not recommended Allergic rhinitis -Correct Answers: Caused by seasonal reaction to allergens Symptoms Watery rhinorrhea, nasal obstruction, itchiness of nose, eyes, pharynx and conjunctiva Snoring, fatigue, malaise,headache Nursing care Instruct to avoid allergens Give nasal corticosteroids Give antihistamines Caused by seasonal reaction to allergens - most likely in the spring and fall types of dehydration -Correct Answers: Bacterial Pneumonia -Correct Answers: Causes Streptococcus pneumoniae, Group A streptococcus, Staphylococcus aureus, Mycoplasma catarrhalis, Mycoplasma pneumoniae Symptoms High fever Cough, may be productive Tachypnea Retractions and nasal flaring Chest pain Dullness with percussion Adventitious breath sounds ABD pain, diarrhea, possible vomiting The invading organism causes symptoms, in part, by provoking an overly exuberant immune response in the lungs. Fluid and cell debris build up. The small blood vessels in the lungs become leaky, and protein-rich fluid seeps into the alveoli. Consolidation, a feature of bacterial pneumonias, occurs when the alveoli, which are normally hollow air spaces within the lung, instead become solid, due to quantities of fluid and debris. Bacterial Pneumonia LABS AND NURISNG CARE -Correct Answers: Laboratory tests Chest X-ray Sputum culture Blood cultures Nursing Care Encourage rest IV antibiotics as ordered Promote oral intake Antipyretics Administer oxygen as ordered Monitor continuous pulse oximetry The invading organism causes symptoms, in part, by provoking an overly exuberant immune response in the lungs. Fluid and cell debris build up. The small blood vessels in the lungs become leaky, and protein-rich fluid seeps into the alveoli. Consolidation, a feature of bacterial pneumonias, occurs when the alveoli, which are normally hollow air spaces within the lung, instead become solid, due to quantities of fluid and debris. Viral pneumonias, and mycoplasma pneumonias, do not result in consolidation. Complications of Pneumonia -Correct Answers: Pneumothroax Accumulation of air in pleural space Symptoms Dyspnea, chest pain, labored respirations, decreased oxygen saturations, loss of breath sounds on one side, tachycardia Administer oxygen Prepare for emergent needle aspiration and chest tube Assess respiratory status Pleural effusion Accumulation of fluid in pleural space Symptoms Dyspnea, chest pain, labored respirations, decreased oxygen saturations, loss of breath sounds on one side, tachycardia Nursing care Administer oxygen Prepare for emergent needle aspiration and chest tube to drain fluid Assess respiratory status Administer oxygen Prepare for emergent needle aspiration and chest tube to drain fluid Assess respiratory status Croup Syndromes -Correct Answers: generic term encompassing a heterogeneous group of illnesses affecting the larynx, trachea, and bronchi. caused by a virus is called viral croup. Viral croup is the most common type - such as adenoviruses (cold viruses) and influenza (flu) viruses associated with other symptoms (e.g., fever, runny nose). Laryngotracheitis is a type of viral croup that involves swelling of the larynx and trachea. Spasmodic croup is not associated with other symptoms. This type often develops suddenly and recurs. Spasmodic croup sometimes can be caused by an allergen (e.g., pollen) or a bee sting. Bacterial croup is caused by a bacterial infection. This type is much less common than viral croup. Characterized by hoarseness, "barking" cough, inspiratory stridor, and varying degrees of respiratory distress Croup syndromes affect larynx, trachea, and bronchi (upper airways) Epiglottitis, laryngitis, tracheitis . -Correct Answers: . Croup - Acute Bacterial Epiglottitis -Correct Answers: Predictive signs Absence of cough, drooling (difficulty swallowing), agitation Sitting in tripod position Thick, muffled voice (Dystonia) Retractions, High fever Diagnostic Lateral neck x-rays of soft tissue Also called - Acute supraglottitis Epiglottis - it is a flap at the base of the tongue. it opens and closes during breathing Croup - Acute Bacterial Epiglottitis Nursing care -Correct Answers: Protect airway! Avoid throat culture or using tongue blade Prepare for intubation (1st thing you do) Provide humidified oxygen Continuous pulse oximetry Administer corticosteroids and antibiotics as ordered Droplet isolation for first 24 hours Acute Laryngotracheobronchitis (ALTB) and Spasmodic Laryngitis -Correct Answers: viral infection of the upper airway swelling of the larynx and trachea = narrows the airway/makes breathing hard. Caused by RSV, parainfluenza types 1, 2 & 3, Mycoplasma pneumoniae, influenza A and B Spasmodic Laryngitis is an acute spasmodic form of laryngeal inflammation limited to children usually under seven years of age = spasm of the larynx, difficult breathing and usually a very hoarse, barking cough. Causes Spasmodic croup (laryngismus stridulus) is a noninfectious variant of the disorder, with a clinical presentation similar to that of the acute disease but typically without fever and with less coryza. ALTB and Spasmodic Laryngitis -Correct Answers: Findings of ALTB Low-grade fever, hoarseness, barky cough, inspiratory stridor, retractions Finding Acute Spasmodic laryngitis Hoarseness, barky cough, nighttime episodes of laryngeal obstruction Nursing care Provide cool mist Provide oxygen if needed Continuous pulse oximetry Nebulized racemic epinephrine Corticosteroids given by nebulizer, orally or IM Influenza A and B -Correct Answers: Influenza A viruses = most harmful, cause severe disease from animal to human and can cause devastating outbreaks. Influenza B almost exclusively infects humans and is less. Matures two to three times more slowly than influenza A. Because humans are the natural host of influenza B, pandemics generally do not occur with influenza B viruses Flu A in history: H1N1, which caused Spanish Flu in 1918 and Swine Flu in 2009 H2N2, which caused Asian Flu in 1957 H3N2, which caused Hong Kong Flu in 1968 H5N1, which caused Bird Flu in 2004 H7N9 is another form of avian flu virus. Currently found only in China Influenza A and B s/s and testing -Correct Answers: Symptoms Sudden onset of fever and chills Dry throat and nasal membranes Dry cough Flushed face Photophobia Myalgia Testing Analyze nasopharyngeal secretions for viral culture Rapid flu testing Influenza A and B nursing care and meds -Correct Answers: Promote increased fluid intake Rest Acetaminophen or ibuprofen for fever Amantadine - Shortens length of illness, give in first 24-48 of symptoms Rimantadine - Treats symptoms for children over 1 year Zanamivir A & B - Treats symptoms for children 7 years and older, give in first 24-48 of symptoms, inhalation Influenza vaccine (preventative) Asthma -Correct Answers: Leading cause of chronic illness in children Chronic inflammatory disorder of airways Recurrent episodes of wheezing, breathlessness, chest tightness and cough Limited airflow or obstruction that reverses spontaneously or with treatment Asthma and Airway Obstruction -Correct Answers: Spasm of Smooth Muscle Inflammation and edema Accumulation of secretions Long term can cause scarring and chronic irritation = not flexable Difficult expiration-air trapping Increased CO2 hypoxemia and respiratory acidosis. Asthma triggers -Correct Answers: May be triggered: Exercise URI Emotions or stress Pollen Hot/cold weather Fur/feathers Smoke Strong smells Assessment of severity Allergen control Drug therapy Symptoms management Diagnostic Procedures for Asthma -Correct Answers: Pulmonary function tests Peek expiratory flow rates (PEFR) Bronchoprovocation testing Skin prick testing Chest xray Bronchoprovocation is one of the tests doctors use to make an asthma diagnosis. To do this, you would be asked to either inhale a nebulized solution or perform exercise. in this way, the doctor can if you to see if you develop symptoms of asthma Asthma Medication -Correct Answers: Control medications prevent symptoms Adjunct medications help primary control meds to a better job May use control medications that that modify allergic response of body Rescue medications are taken when control medications fail and quick relief is needed to relax airway muscles - Albuterol Inhaled Corticosteroids: The most consistently effective long-term control medication, decrease airway inflammation, Methylprednisone, prednisone Long-Acting Beta-Agonists (LABAs): use w/ corticosteroids. prevent exacerbations - Formotoral Comolyn and Theophylline: Used as alternative controller medications (not preferred). Leukotriene Modifiers: reduce inflammatory response, Montelukast Immunomodulators: Omalizumab modifies the allergic immune response. Quick-relief medications: Take only as needed for symptom relief Short-Acting Beta-Agonists (SABAs): relax airway muscles to give prompt relief of symptoms, acute exacerbations, Albuterol, turbutaline Anticholinergic - blocks parasympathetic nerves, bronchospasm Atropine Leukotrienes are inflammatory chemicals the body releases after coming in contact with an allergen or allergy trigger. Leukotrienes cause tightening of airway muscles and the production of excess mucus and fluid. Assess Respiratory Status in Asthma -Correct Answers: Mild Alert-Speaks in full sentences, expiratory wheeze Dyspneic, good color. O2 sat 95% Moderate Alert-Speaks in phrases or partial sentences, inspiratory and expiratory wheezes Moderately dyspneic, color pale. O2 sat 90-95% Severe Drowsy-One word answers. Inaudible BBS Severe dyspnea, retracting, flaring, cyanotic O2 sat 90% Status Asthmaticus-Emergency! -Correct Answers: Respiratory distress continues despite vigorous therapeutic measures Continuous neb treatments (albuterol) Heliox- helium and oxygen Epinephrine is the best emergency treatment for acute anaphylaxis and for severe asthma attacks Helium-oxygen mixture (heliox) has been promoted as adjunctive therapy to overcome airflow-obstructive disorders by making flow more laminar Because heliox is less dense than air or oxygen, it provides more laminar flow in obstructed airways, and it is purported to reduce work of breathing, respiratory distress, and postextubation stridor. Theophylline is a relatively weak but inexpensive bronchodilator that has a chemical similar to caffeine. Theophylline relaxes the smooth muscle that surrounds the airways. Short acting beta-agonists: Albuterol (ProAir HFA, Proventil HFA, Ventolin HFA) Levalbuterol (Xopenex HFA) Metaproterenol Terbutaline Nursing Interventions for Asthma in Schools -Correct Answers: Develop individualized health plan. Log peak flow meter readings. Administer quick relief medications as needed and monitor for response. Assess for signs of exercise-induced asthma. Coordinate education about the disease process. Coordinate support groups for children with asthma Cystic Fibrosis (CF) -Correct Answers: Most common lethal genetic illness among white children Common among Caucasians (3% carry) Autosomal recessive trait CYSTIC FIBROSIS Cystic fibrosis (CF) is an inherited, chronic disease that interferes with the respiratory, digestive and reproductive systems. Mutations of a specific gene (the CFTR) affect the cells that line the organs of these three systems. This defective gene causes the production of thick, sticky mucus. It builds up and clogs the small airways and passageways which carry harmful bacteria out of the body. Cystic fibrosis is a genetic disease. People with CF have inherited two copies of the defective CF gene -- one copy from each parent. Both parents must have at least one copy of the defective gene People with only one copy of the defective CF gene are called carriers, but they do not have the disease. Each time two CF carriers have a child, the chances are: 25 percent (1 in 4) the child will have CF 50 percent (1 in 2) the child will be a carrier but will not have CF 25 percent (1 in 4) the child will not be a carrier and will not have CF Diagnosis CF -Correct Answers: Basis of the most reliable diagnostic procedure—sweat chloride test Sodium and chloride will be 2 to 5 times greater than the controls (parents notice baby tastes salty!) May be diagnosed at birth by presence of meconium ileus - bowel obstruction Done as part of newborn screen in all 50 states (meconium ileus) - pop so thick they cant poop Respiratory Findings CF -Correct Answers: Early Wheezing, rhonchi, non-productive cough Increased involvement Dyspnea, paroxysmal cough, obstructive emphysema Advanced involvement Cyanosis Barrel-shaped chest Clubbing of fingers and toes Multiple episodes of bronchitis and bronchopneumonia A paroxysm is a violent attack. It may be due to the sudden occurrence of symptoms or the acute exacerbation. Gastrointestinal Findings CF -Correct Answers: Large, frothy, greasy foul-smelling stools (steatorrhea) Voracious appetite (early), loss of appetite (late) Failure to gain weight Delayed growth patterns Distended ABD Deficiency of fat-soluble vitamins Anemia Vit A,D,E, K skin and endocrine CF -Correct Answers: Integumentary Sweat, tears, and saliva have excessively high sodium and chloride content Endocrine and reproductive Viscous cervical mucus Decreased or absent sperm Laboratory Tests CF -Correct Answers: Blood specimen to detect deficiency of fat-soluble vitamins Sputum culture for detection of infection Diagnostic Procedures CF -Correct Answers: DNA testing Pulmonary function tests Chest xray ABD xray Stool analysis Sweat chloride test DNA testing - to isolate gene mutation Pulmonary function tests - (PFTs) are non-invasive tests that show how well the lungs are working. The tests measure lung volume, capacity, rates of flow, and gas exchange. This information can help your healthcare provider diagnose and decide the treatment of certain lung disorders. Chest Xray -Can show diffuse atelectasis and obstructive emphysema ABD Xray - Detect meconium illeus Stool analysis - for presence of fat and enzymes Sweat chloride test- measures the amount of chloride in sweat. Kids with cystic fibrosis can have two to five times the normal amount of chloride in their sweat. In a sweat test, the skin is stimulated to produce enough sweat to be absorbed into a special collector and then analyzed. Nursing Care CF -Correct Answers: Assess lung sounds and respiratory status Vital signs with oxygen saturation Obtain IV or CL access for antibiotic therapy Provide support to patients and family Pulmonary Management CF -Correct Answers: airway clearing therapy (ACT) aerosol therapy antibiotics physical aerobic exercise O2 assess CO2 retention GI Management CF -Correct Answers: Provide well-balanced, high protein, high calorie diet Give 3 meals a day plus snacks Encourage oral fluid intake Administer pancreatic enzymes with in 30 min. of eating Administer vitamin supplements as ordered Administer laxatives or stool-softeners Administer medications for GERD as ordered Endocrine Management CF -Correct Answers: Monitor blood glucose levels for Cystic Fibrosis-Related Diabetes Respiratory Medications CF -Correct Answers: Short-acting beta2 - agonists Albuterol Anticholinergics Ipratropium Fluticasone, a corticosteroid, is the anti-inflammatory component of the combination, while salmeterol, a long acting beta-adrenoceptor agonist (LABA), treats constriction of the airways. Together, they help prevent symptoms of coughing, wheezing and shortness of breath. Dornase alfa used to reduce the number of lung infections and to improve lung function in patients with cystic fibrosis. It breaks down the thick secretions in the airways, allowing air to flow better and preventing bacteria from building u Antibiotic Medications CF -Correct Answers: Administer by IV or aerosol Agent specific to organism High doses are used Pancreatic Enzymes, Vitamins CF -Correct Answers: Pancrelipase to replace enzyme associated with CF Daily multi-vitamins and supplemental vitamins A, E, D and K Prognosis of CF -Correct Answers: Estimated life expectancy for a child born with CF in 2008 was 37.4 years CF continues to be a progressive, incurable disease Organ transplantation has increased the survival rate Heart-lung and bilateral lung transplantation Liver and pancreas transplantation Maximize health potential Nutrition Prevention and early aggressive treatment of infection Pulmonary hygiene Lung transplants: survival rates 75% at 1 year; 55% at 3 years post transplant Coping with emotional needs of child and family Child requires treatments multiple times a day Frequent hospitalization Implications of genetic transmission of disease random shit -Correct Answers: YOU WOULD RAHER HAVE VIRAL MENINGITIS be careful on airway when olding kid for spinal tap if pitechia doesnt blanch = septic = need help NOW - drop percatuitions (fam might not have to bc they have been w/ kid) - frequent vitals/low stimulations burholes, head circs on intracrandial pressure cu/contra cu with whiplash = shearing/tearing of brain ammonia not being processed for reye syndrome can cross BBB Neuromuscular diseases -Correct Answers: are frequently caused by genetic abnormalities that alter the structure and function of muscles and nerves Some common causes are: Traumatic and environmental disorders Genetic metabolic disease Movement disorders Intellectual disabilities Meningitis -Correct Answers: Two types: Viral - (asepctic) only supportive care for recovery Bacterial (septic) contagious, prognosis on how fast care starts Bacterial causes of meningitis: Neisseria meningitides (meningococcal) Streptococcus pneumoniae (pneumococcal) Haemophilus influenza B meningitis Symptoms -Correct Answers: Photophobia Irritability Headache Nausea Newborns Poor muscle tone Bulging fontanel Infant -Toddler High-pitched cry Fever, irritability 2yr Nuchal rigidity Positive Brudzinski Positive Kernig's sign brudinskis sign -Correct Answers: kernigs sign -Correct Answers: Lab Tests meningitis -Correct Answers: Blood cultures Complete CBC CSF Bacterial if cloudy, elevated protein and WBC, decreased glucose and pos. gram stain Viral if clear color, slight elevation of WBC, normal or slightly elevated protein, normal glucose, neg gram stain CT or MRI BX sometimes + when CSF is - meningitis diagnosis -Correct Answers: lumbar punchture ct mri Lumbar Puncture -Correct Answers: meningitis meds -Correct Answers: antibiotics - for bacterial corticosteriods - desamethasone - for bacterial analgesics - pain Nursing Management meningitis -Correct Answers: Presence of petechial requires immediate medical attention! Isolate and initiate droplet precautions with mask Pt. and family education Decrease noise and environmental stimulation Monitor VS closely get vaccine - 2,4,6,12,15 months Complications meningitis -Correct Answers: Increased ICP can lead to neurological dysfunction LOC eyes - pupil changes posturing - flaccid decr motor function headache seizures changes in vitals - cushing triad = incr systolic, decr pulse, altered resp v/ changes in speech infants" buldging fontanels, cranial suture separation, incr head circum, high pitched cry Head Injury -Correct Answers: Concussion - injury to the brain that alters the way the brain functions Contusion - bruising of the cerebral tissue Laceration - tearing of cerebral tissue Fractures Linear - break in a cranial bone resembling a thin line, without splintering, depression, or distortion of bone depressed - crushed in portion of the skull comminuted - break or splinter of the bone into more than two fragments basilar - base of the skull open or growing - brain matteirng popping out Subjective Assessments for head injury -Correct Answers: History of event, including any reports of dizziness, headache, diplopia and/or vomiting Amnesia before or after the injury Alcohol or drug ingestion head injury risk factors -Correct Answers: lack of supervision bad safty practices imporper use of saftey devices head injury Objective Assessments -Correct Answers: Loss of consciousness at scene? How long? Minor injury Possible LOC Confusion Vomiting Pallor Irritability Drowsiness Progression of injury - changes in VS, Altered mental status Severe Head Injury -Correct Answers: Increased Intracranial Pressure (ICP) Infants: bulging fontanel, Increased sleeping, high-pitched cry Children: Nausea, headache, blurred vision, inability to follow simple commands Late signs: Pupil changes, posturing Decorticate (mummy pose) Decerebrate flextion and extension severe head injury positions -Correct Answers: glasgow coma scale -Correct Answers: Treatment for Head Injury -Correct Answers: Labs ABG, tox screen, CBC with dif Diagnostics Cervical spine x-rays CT, MRI Measuring ICP Intracranial sensor to measure pressure in brain Normal pressure in brain is 10-15 mm Hg Head Injury Medications -Correct Answers: Corticosteroids Decrease cerebral edema Mannitol Osmotic diuretic to treat cerebral edema Hypertonic Saline (HTS) Osmotic diuretic to treat cerebral edema Antiepileptics To prevent or treat seizures Antibiotics In case of leaking CSF, penetration injuries mannitol is considered the "gold standard" therapy for TBI-induced intracranial hypertension mostly due to its historical use and not due to its superiority over HTS. Physiologically, HTS has many theoretical advantages over mannitol. Clinically, HTS appears to be more efficacious than mannitol in reducing ICP both by degree and length of reduction, improve tissue O2 of the brain Creates osmotic gradient - induced shift of extravascular to intravascular water across the blood - brain barrier. Head Injury Complications -Correct Answers: Epidural hemorrhage Bleeding between the dura and the skull Subdural hemorrhage Bleeding between the dura and the arachnoid membrane Cerebral edema Can develop within 24-72 hrs after injury Brain herniation Downward shift of brain tissue as a response to very high ICP Autonomic Dysreflexia -Correct Answers: Complication which occurs in people with spinal cord injuries at or above the level of T6 Stress syndrome that causes hyperactive sympathetic stimulation Symptoms: Severe headache Hypertension HR changes (tachy or brady) Diaphoresis Flushed skin Autonomic Dysreflexia cause and treatment -Correct Answers: Common causes: Bladder - full bladder, spasms Bowel - constipation, gas, bloating, rectal stimulation Skin - pressure sores, need for repositioning, ingrown toenails, burns, etc. Other - tight clothes, menstrual cramps, ejaculation Treatment: Prevention! Eliminate cause! Reyes Syndrome -Correct Answers: rare but serious condition that causes swelling in the liver and brain. children and teenagers recovering from a viral infection, flu or chickenpox (varacella) It is a metabolic encephalopahty associated with other characteristics organ involvement Reye's syndrome seems to be triggered by using aspirin to treat a viral illness or infection — particularly flu (influenza) and chickenpox — in children and teenagers who have an underlying fatty acid oxidation disorder. Fatty acid oxidation disorders are a group of inherited metabolic disorders in which the body is unable to break down fatty acids because an enzyme is missing or not working properly. A screening test is needed to determine if your child has a fatty acid oxidation disorder. In some cases, Reye's syndrome may be an underlying metabolic condition that's unmasked by a viral illness. Exposure to certain toxins — such as insecticides, herbicides and paint thinner — also may contribute to Reye's syndrome. Reyes Syndrome Risks -Correct Answers: Hallmark: Using ASPIRIN for treating fever It follows a viral illness (influenza, gastroenteritis, varicella) Symptoms and Diagnostics reye -Correct Answers: Fever Impaired consciousness - tired v/ seizures LOC Disordered hepatic function Elevated ALT Elevated AST Elevated ammonia levels Nursing Care & Meds reyes -Correct Answers: Monitor altered LOC Maintain hydration while preventing cerebral edema - mannitol Positioning Monitor coagulation and prevent hemorrhage - give vit K Implement seizure precautions liver biopsy CSF analysis Reys complications -Correct Answers: neurological sequelae - speech and hearing impairment death Encephalitis -Correct Answers: Encephalitis means that the brain tissues have become inflamed. Symptoms include seizures, mental confusion or changes in behavior. Infection or inflammation in the brain can lead to permanent damage. The herpes simplex virus (HSV) is one of the most common and damaging viral causes Mosquitoes can also transmit the viruses for several types of encephalitis, including West Nile encephalitis. Milder forms of encephalitis can follow or accompany common childhood illnesses, including measles, mumps, chickenpox, rubella (German measles), and mononucleosis Caused by virus or other infectious agent Also can be non-infectious caused by immune disorders Symptoms of Encephalitis -Correct Answers: mild: Fever Headache Poor appetite Loss of energy A general sick feeling severe: Severe headache Nausea and vomiting Stiff neck Disorientation Personality changes Seizures Problems with speech or hearing Hallucinations Memory loss Drowsiness Treatment encephalitis -Correct Answers: Because antibiotics aren't effective against viruses, they aren't used to treat most forms of encephalitis. However, antiviral drugs can be used to treat some forms of encephalitis. Corticosteroids may also be used in some cases to reduce brain swelling. Nursing Care encephalitis -Correct Answers: calm enviro - bc pt confused decr anxiety decr pain/analgesics Down Syndrome -Correct Answers: chromosomal condition presence of part or all of an extra copy of the 21st chromosome Causes of DS? -trisomy 21 -translocation -mosaic trisomy 21 Physical Signs of Down Syndrome -Correct Answers: Flat face with an upward slant to the eye Short neck, ears, mouth, hands, feet, height dry skin Tiny white spots on iris (colored part) of the eye A single crease across the palm of the hand Low muscle tone Loose ligaments Pregnancy & Screening downs -Correct Answers: Multi vitamin with folic acid Not smoking Not drinking alcohol Ultra sound Blood tests Amniocentesis Blood test - small amounts of fetal DNA are circulating in the mother's blood from a very early point in pregnancy, just 10 weeks along. Associated Conditions w/ downs -Correct Answers: Congenital heat defects Hematologic disorders Endocrine abnormalities Gastrointestinal malformations Orthopedic problems Neurological conditions Sensory impairments Psychiatric disorders Cognitive limitations Cardiac- Atrioventricular Septal Defects (AVSDs) - These are the most common in children with Down syndrome. Ventricular Septal Defects (VSDs) Atrial Septal Defects Patent Ductus Arteriosus Tetralogy of Fallot POLYCYTHEMIA- or erythrocytosis means an elevated number of red blood cells. MACROCYTOSIS- enlargement of the red blood cells. THROMBOCYTOPENIA Thrombocytopenia means a decreased number of platelets. Endo- hypo or hyper thyroid GI - reflux, obesity, constipation and diarrhea. Ortho - The most common musculoskeletal effects of Down syndrome include weak muscle tone (hypotonia) and ligaments that are too loose (ligament laxity). Seizures -Correct Answers: Abnormal, excessive electrical discharges of neurons within the brain Classified by type and etiology Epilepsy is chronic, reoccurring and diagnosed after all other etiologies are ruled out A seizure is a short episode of symptoms caused by a burst of abnormal electrical activity in your brain. Different parts of the brain control different functions of your body, so the symptoms that occur during a seizure will depend on where the abnormal burst of electrical activity occurs. Symptoms that may occur during a seizure can affect your muscles, sensations, behaviour, emotions, consciousness, or a combination of these Partial - have a local onset and involve a relatively small portion of the brain Generalized - involve both hemispheres of the brain and are without local onset Unclassified - page 958 box 28-7 Risks seizures and epilespy -Correct Answers: seizures: Febrile episode Cerebral edema Intracranial infection or hemorrhage Anoxia Brain tumors Toxins Electrolyte imbalance epilepsy: Trauma Hemorrhage Congenital defects Anoxia Infection Hypoglycemic injury Uremia Migraine Tonic-clonic -Correct Answers: Tonic phase = 10-20 seconds Clonic phase (times vary) Postictal state Tonic Phase: Onset without warning Eyes roll up, LOC, Contraction of arms and legs, neck and head extended, Possible piercing cry, Increased salivation, Loss of swallow reflex, Apnea leading to cyanosis Clonic Phase: Violent jerking of the body, May have foaming of the mouth, May be incontinent, gradual slowing of movements until cessation Postictal: Arouses with difficulty, Confused for several hours, Impairment of fine motor movements, lack of coordination, Possible vomiting, headache, visual and speech difficulties, Sleep for several hours, no recollection of the seizure Absence seizure -Correct Answers: Absence seizure Onset between 4-12years of age Resembles inattentiveness or daydreaming Absence spells may last up to 10 seconds a piece and occur dozens of times daily. Patients have no recollection of events occurring during a seizure and will resume their previous activity without any postictal symptoms. EEG classically shows intermittent runs of generalized, 3 cycle per second spike and wave activity which may be precipitated by hyperventilation. Myoclonic -Correct Answers: Symmetric or asymmetric involvement No postictal state May or may not lose consciousness Brief contractions of muscle or groups of muscle atpmoc -Correct Answers: aka akinetic 2-5yrs muscle tone lost for few seconds confusion fall to floor if frequent = helmet Infantile Spasms -Correct Answers: aka west syndrome Seizures occur close together with each spasm occurring every 5-10 seconds in a series Infantile spasms can sometimes be hard to notice—perhaps only the eyes roll up or there is a small tummy crunch Infantile spasms (also known as West syndrome) is a form of epilepsy that occurs in 1 in 2,000 children. It typically begins between 2-12 months of age and peaks between 4-8 months of age. While these seizures may last only a second or two, they usually occur close together with each spasm occurring every 5-10 seconds in a series. During a spasm, the body stiffens suddenly, the back may arch, and the arms, legs, and head may bend forward. However, infantile spasms can sometimes be hard to notice—perhaps only the eyes roll up or there is a small tummy crunch. They are most common just after a baby wakes up and rarely occur during sleep. partial -Correct Answers: focal or local simple partial seizures with motor signs: aversise seizure - most common, eyes and head turn simple partical with sensory - tingling or dumbness complex partical - altered behavior, LOC, aura Status Epilepticus -Correct Answers: A seizure lasting greater than 30 minutes Occurrence of serial seizures between which there is no return to the same level of consciousness as occurred prior to the seizure. A seizure lasting greater than 30 minutes or the occurrence of serial seizures between which there is no return to the same level of consciousness as occurred prior to the seizure. Diagnostic Procedures Status Epilepticus -Correct Answers: EEG Records electrical activity and may identify the origin of seizure activity MRI Detects malformation, dysplasia or tumors LP Detects infection CT Detects hemorrhage, infarction or malformations During a seizure -Correct Answers: Protect from injury - move furniture, hold head in lap if on the floor Turn Pt. onto side Maintain patent airway Be prepared to suction oral secretions Initiate seizure precautions on admission Safety pads for side rails, crib or wheelchair Loosen clothing Remove glasses Administer O2 Note onset, time and characteristics of seizure After Seizure -Correct Answers: Maintain side-lying position to facilitate oral drainage Assess for injuries, especially in the mouth Perform neuro checks Reorient and calm the patient Remain with the patient Do not offer food or drinks until swallow reflex is present Try to determine possible trigger (stress, fatigue?) seizures therapeutic -Correct Answers: focal resection - area of brain removes from epile zone heispherectomy - removel of one hemi corpus callostomy - separation of 2 hemi of brain vagal nerve stimulator Antiepileptic Medications (AEM) -Correct Answers: Diazepam ( valium) Phenobarbital Phenytoin (Dilantin) Carbamazepine (tegretol) Valproic acid (depakene) Phosphenytoin (Cerebyx) Diazepam - The pill form (best known by the brand name Valium), is too slowly absorbed when taken by mouth to be used to stop a seizure, and is only moderately effective against epilepsy. Emergency personnel sometimes give diazepam by injection to stop prolonged or repeated seizures. Diastat, the first at-home alternative to IV valium, given rectally Phenobarbital - Phenobarbital is a barbiturate. In therapeutic doses, Phenobarbital induces anesthesia. Phenobarbital depresses the sensory cortex, decreases motor activity, alters cerebellar function, and produces drowsiness, sedation, and hypnosis. Phenytoin - The primary site of action appears to be the motor cortex where spread of seizure activity is inhibited. Tegretol (carbamazepine) is an anticonvulsant. It works by decreasing nerve impulses that cause seizures and pain. Tegretol is used to treat certain types of seizures (partial, tonic-clonic, mixed). Tegretol is also used to treat nerve pain such as trigeminal neuralgia and glossopharyngeal neuralgia... Valproic acid - Valproate has a broad spectrum of anticonvulsant activity, although it is primarily used as a first-line treatment for tonic-clonic seizures, absence seizures and myoclonic seizures and as a second-line treatment for partial seizures and infantile spasms.[6][7] It has also been successfully given intravenously to treat status epilepticus.[8][9] Phosphenytion - its anticonvulsant actions include modulation of voltage-dependent sodium channels of neurons, inhibition of calcium flux across neuronal membranes, modulation of voltage-dependent calcium channels of neurons, Neonatal Abstinence Syndrome (NAS) -Correct Answers: Neonatal abstinence syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive or prescription drugs while in the mother's womb. It results in withdrawal symptoms in the newborn and postnatal NAS secondary to discontinuation of medications. Signs and Symptoms NAS -Correct Answers: High-pitched cry Jitteriness Tremors Generalized convulsions Sweating Fever Excessive sucking or rooting Poor feeding V/D depend on various factors = drug the mother used, how much, how long, how mom body breaks down drug. Assessment NAS -Correct Answers: Symptoms of withdrawal are important to document and make known to the medical provider. Hospitals use a neonatal abstinence scoring system to grade the severity of withdrawal. Finnegan is the most widely used and accepted system. This scale examines 21 of the most common signs of neonatal withdrawal syndrome and is scored based on the severity of symptoms. Cerebral Palsy (CP) -Correct Answers: Disturbances in the developing fetal or infant brain Non-progressive in nature May cause abnormal sensation, perception, communication, cognition, and behavior A common permanent physical disability in childhood 80% develop epilepsy How is CP characterized? By decreased function, activity limitations, delayed motor development, and impaired muscle tone and movement patterns. Three criteria for diagnosis 1) regardless of where it originates in the brain, all characterized by movement and posture problems 2)caused by brain damage to the immature brain. Damage can be before, during, or after birth 3) non-progressive, static. Although the motor behavior and disabiltiy may change over time the essential damage does not get worse Causes of Cerebral Palsy -Correct Answers: Pre-existing prenatal brain abnormality Intrauterine hypoxia or asphyxia Problems in labor and delivery Trauma during pregnancy 80% of cases-no known cause Premature or postmature birth (after 42 weeks) Shaken baby syndrome Also caused by: -infections: meningitis -lead positioning -epilepsy -head trauma Spastic Cerebral Palsy -Correct Answers: -80% of CP Hypertonicity-increased tone Increased deep tendon reflexes Poor control of posture and balance Impairment of fine and gross motor skills Gait has tip toe appearance Monoplegia: Single limb involved Diplegia: Arms or legs involved Triplegia: 3 limbs involved Quadraplegia: all 4 extremities involved Hemiplegia: One side of the body (Upperlower) Symptoms of CP in Infant -Correct Answers: Delayed gross motor development Poor head control after 3 months Stiff or rigid limbs; scissoring legs Floppy tone Unable to sit without support at age 8 months Clenched fists after 3 months Abnormal postures hypotonia -Correct Answers: Therapeutic Goals for CP -Correct Answers: Assist to function at highest possible level Establish locomotion, communication, and self-help skills Use developmental level not age as guide Provide adapted educational opportunities Promote socialization experiences with other affected and unaffected children Adequate nutrition Preserve: Locomotion, Assistive devices Maintain joint function contracture prevention/surgery Medications CP -Correct Answers: Muscle relaxants (antispasmodics) are the most common medicines used for people who have CP. They can help relax tight muscles and reduce muscle spasms. Examples include: Baclofen (such as Gablofen). Botulinum toxin (such as Botox). Diazepam (such as Valium). Anticonvulsants help prevent or control. These include: Lamotrigine (Lamictal). Oxcarbazepine (Trileptal) Anticholinergics help some people who have CP who have uncontrollable body movements (dystonic cerebral palsy) or who drool often. These include: Benztropine (Cogentin) Glycopyrrolate (Robinul) Anticonvulsants work by slowing or decreasing abnormal electricity in the brain. It is primarily used to treat seizures for children with cerebral palsy that also have epilepsy, as it is used to prevent seizures. Additionally, it serves the purpose of a muscle relaxant, a drug used to treat anxiety, and a sleep aid. Anticholinergics help some people who have CP who have uncontrollable body movements (dystonic cerebral palsy) or who drool often. These include: Nursing Care CP -Correct Answers: Individualized Promote independence with self-care skills Assess for coping skills Ensure safe environment Assess and meet needs of developmental and cognitive level of child Coordinate with other health care professionals on plan of care 70% have normal IQ Speech, physical, occupational therapy Neural Tube Defects (NTDs) -Correct Answers: Failed closure of neural tube (3-5 week embryo) May be entire length of neural tube or a small portion Incidence More girls than boys 3X more often in Caucasions and Hispanics than in African Americans One of the most common birth defects in the United States Various Neural Tube Defects -Correct Answers: Spina bifida occulta: Defect is not visible externally Meningocele: External saclike protrusion with meninges and spinal fluid; NO neural elements Myelomeningocele: External saclike protrusion with meninges, spinal fluid and nerves NTD etiology -Correct Answers: Risk Factors: Insufficient folic acid intake in pregnancy Family history of NTD Maternal - certain anti-seizure medications- (Valproic acid/Depakene Carbamazapine/Tegretol) Maternal obesity Maternal insulin-dependent diabetes Prenatal Management of NTD -Correct Answers: Treatment and prevention Folic acid 0.4 mg/day History of NTD, 4 mg/day Quad screen test (old alpha fetal protein-AFP) Amniocentesis Antenatal surgical intervention Genetic counseling Uterine ultrasound The quad screen test is a maternal blood screening test that looks for four specific substances: AFP, hCG, Estriol, and Inhibin-A. Prenatal Surgery for NTD -Correct Answers: In the present, a prospective, randomized study (the MOMS trial) has shown that fetal surgery for MMC before 26 weeks' gestation may preserve neurologic function, reverse the hindbrain herniation of the Chiari II malformation, and obviate the need for postnatal placement of a ventriculoperitoneal shunt. However, this study also demonstrates that fetal surgery is associated with significant risks related to the uterine scar and premature birth. Meningocele -Correct Answers: Sac contains meninges and spinal fluid but no neural elements No neurologic deficits Myelomeningocele / Spina Bifida -Correct Answers: Neural tube fails to close May be anywhere along the spinal column Lumbar and lumbosacral areas are the most common May be diagnosed prenatally or at birth Myelomeningocele or Spina Bifida -Correct Answers: Sac contains meninges, spinal fluid, and nerves Varying and serious degrees of neurologic deficit Clinically "myelomeningocele" term is interchangeable with "spina bifida" Initial Management of Myelomeningocele -Correct Answers: Prevent infection! Assessment of neurologic and associated anomalies Midline anomalies Prone position Before surgery cover with warm sterile moist nonadherent dressings Change dressings every 2-4 hours Nursing Care for Child with Mylomengocele -Correct Answers: Assess for infant-parent attachment Help parents plan for surgery Accurate I & O Assess head circ and fontanels Collaborative plan with other health care providers - risk for hydrocephally Other health care providers: Neurosurgery, urology, orthopedics, physical therapy Ongoing management of NTD -Correct Answers: Postoperative care and follow-up Orthopedic considerations Genitourinary function Bowel function and control Family support and education Plan for home care routine Prevent complications Assess for latex allergy Fetal Circulation -Correct Answers: foramen ovale - shunt oxygenated blood from right to left atria, oxygenated blood coming from the umbilical vein via the inferior vena cava to bypass the pulmonary circulation ductus arteriosus - ductus Botalli, is a blood vessel connecting the pulmonary artery to the proximal descending aorta Anatomy of the Heart -Correct Answers: inferior and superior vena cava right atrium tricuspid valve right ventrical pulmonic valve pulmonary artery lungs pulmonary vein left atrium mitral valve left ventricle . aortic valve, aorta body. Normal Circulation -Correct Answers: Right side blue blood Left side red blood RA RV Pulmonary arteries Lungs Pulmonary veins LA LV Aorta Body Causes of CHD 8/1000 births -Correct Answers: Chromosomal or genetic cause in 10% to 12% History of cardiac defects Syndromes (trisomy 21) Other anomalies Maternal or environmental cause in 1% to 2% Maternal drug/ alcohol use Of infants with fetal alcohol syndrome, 50% have CHD Maternal illness Rubella, Cytomegalovirus, toxoplasmosis, Infants of diabetic mothers (IDMs) have a 10% risk of CHD Multifactorial in 85% Assessment of Cardiac Function in Newborns -Correct Answers: History Mother's health history, pregnancy and birth history, medications Maternal medications Maternal substance use Infection exposure Infant birth weight Family history Subjective, Objective Data Nutritional state (poor feeding) Color Chest deformities Unusual pulsations Respiratory distress Clubbing of fingers Mother's with chronic conditions (LUPUS, DM) are more likely to have children with congenital defects Medications-teratogenic (Dilantin) Infections- rubella exposure early in pregnancy puts fetus at risk for congenital defects Birth weight- LVBW from IUGR more likely to have defects (PDA), preemies, high birth weight increased incidence of heart disease Family history- increased incidence of congenital cardiac defects if either parent of a sibling has a heart defect some are hereditary -Marfans and some cardiomyopathies Syndromes associated with congenital defects downs- septal defects turners- coarctation Defects That Increase Pulmonary Blood Flow -Correct Answers: Atrial Septal Defect - ASD Ventricular Septal Defect - VSD Persistent Ductus Arteriosus - PDA Defects that cause increased blood flow Connection between left and right sides of heart Connection between great arteries Atrial Septal Defect (ASD) Pathophysiology -Correct Answers: The opening in the atrial septum permits left-to-right shunting of blood. The opening may be small, as when the foramen ovale fails to close, or large (the septum may be completely absent). Of children with congenital heart disease, 30% to 50% have an ASD in combination with other defects, but it may occur as an isolated defect in 5% to 10% of children. ASD -Correct Answers: A "hole" in the wall that separates the top two chambers of the heart. This defect allows oxygen-rich blood to leak into the oxygen-poor blood chambers in the heart. Atrial Septal Defect Clinical manifestations -Correct Answers: Infants and young children with small or moderate-size ASDs usually have no symptoms. Large ASDs may cause CHF, easy tiring, and poor growth. A soft systolic ejection murmur occurs in the pulmonic area with fixed, wide splitting of S2 through all phases of respiration. Atrial Septal Defect Repair -Correct Answers: Cardiac Cath with coiling Surgical repair-patch Left atrial pressure slightly exceed the right, so blood flows from the left to the right atrium causing increased oxygenated blood into RA the RV can usually tolerate this because it is delivered under much lower pressures than Ventricular defects there may be some atrial and ventricular enlargement cardiac failure is unusual in uncomplicated ASDs pulmonary vascular changes usually occur only after decades Symptoms- usually only seen in very large defects May be asymptomatic may develop CHF murmur is present at risk for atrial dysrhythmias because of atrial enlargement which stretches conduction fibers Medications may be used preoperatively to treat the CHF (if present) Surgical intervention- medium or large ASDs require Dacron patch closure. Mediastinal incision, on bypass Nonsurgical intervention- device closure in cath lab Ventricular Septal Defect (VSD) patho -Correct Answers: An opening in the ventricular septum results in increased pulmonary blood flow. Blood is shunted from the left ventricle directly across the open septum into the pulmonary artery. This is the most common congenital heart defect. It occurs as a single defect in about 15% to 20% of cases but also is found in combination with other defects. VSD -Correct Answers: Classified according to location membranous (80%) or muscular vary in size from pinhole to absence of septum (resulting in a common ventricle) Frequently associated with other defects pulmonary stenosis TGV PDA ASDs Coarc Many are thought to close on their own (20-60%) Spontaneous closure is mostly likely to occur within the first year of life if small or moderate VSD VSD clinical manifestations -Correct Answers: Infants and children with small VSDs may have no symptoms. Moderate or large VSDs may be associated with CHF, poor growth, decreased exercise tolerance, an increased number of pulmonary infections, and pulmonary hypertension. A systolic murmur is auscultated at the third or fourth left intercostal space at the sternal border. A thrill may be present. VSD DIAGNOSTIC -Correct Answers: A chest radiograph and ECG reveal little when VSDs are small. An enlarged heart and pulmonary vascular markings on chest radiograph occur in cases of large VSDs with shunting. Right and left ventricular hypertrophy may be seen on ECG. Echocardiogram identifies the size and location of the defect. VSD clinical therapy prognosis -Correct Answers: Most small VSDs close spontaneously within the first 6 months of life. Treatment is conservative when no signs of CHF or pulmonary artery hypertension are present. VSD surgical closure is performed after 1 year of age unless CHF cannot be managed medically. Surgery for these infants is performed within the first 6 months of life. Device closure of VSD during cardiac catheterization may be attempted for some VSDs that are not too close to the heart valves. Prognosis Highest risk associated with surgical repair is in the first 2 months of life. Children respond well to surgery and experience substantial catch-up growth. Arrhythmias, right bundle branch block, and complete heart block are possible complications. Some children need a pacemaker. Patent Ductus Arteriosus (PDA) patho -Correct Answers: Pathophysiology A common congenital defect caused by persistent fetal circulation that accounts for 5% to 10% of all infants with congenital heart disease (Park, 2014). When pulmonary circulation is established and systemic vascular resistance increases at birth, pressures in the aorta become greater than in the pulmonary arteries. Blood is then shunted from the aorta to the pulmonary arteries, increasing circulation to the pulmonary system. It is a common problem of preterm infants who have respiratory distress syndrome or hypoxemia that work to keep the ductus arteriosus open (Park, 2014). PDA manifestations -Correct Answers: Dyspnea Tachypnea Tachycardia Full, bounding pulses Widened pulse pressure High systolic, normal diastolic PDA - Clinical manifestations -Correct Answers: Hypotension may be noted when cardiac output is low. May be asymptomatic. CHF, intercostal retractions, hepatomegaly, and poor growth when a large PDA exists. A continuous "machinery" murmur during systole and diastole, and a thrill in the pulmonic area. High risk for frequent respiratory infections and pneumonia. PDA - Diagnostic tests -Correct Answers: The chest radiograph and ECG show left ventricular hypertrophy. The PDA can be visualized, and PDA blood flow can be measured on echocardiogram. PDA -Clinical therapy -Correct Answers: Transcatheter closure by obstructive device is the standard therapy in most centers. Video-assisted thoracoscopic surgery with clip ligation of the PDA may be performed. Intravenous ibuprofen or indomethacin often stimulates closure of the ductus arteriosus in preterm infants, but cannot be used if CHF is present; it is not used in term infants. Which vessel is the higher pressure vessel? Aorta. If there is a connection between the aorta and the pulmonary artery, which way will blood flow? Aorta to pulmonary artery Extra blood flows to the pulmonary artery and into the lungs... what symptoms would you expect to see in this child? CHF Patent ductus arteriosus is often seen in premature infants. Medications= indomethacin has proven to be effective in closure of PDAs in preemies and newborn. Risk of renal failure...be careful Surgical intervention- thoracotomy with division or ligation of ductus thorascopic surgery is used in some institutions = three small incisions, thorascope and a clip is placed on ductus Nonsurgical- coils placed in cath lab. Very small infants and those with large PDAs require surgical intervention Defects with Obstructive Pulmonary Blood Flow -Correct Answ