Sunday, December 17, 2006

The start of Final Review.

  • Tricuspid Atresia
    This is a failure of the tricuspid valve development. There is no communication between the RA and the RV. There is no opening where the tricuspid should be. The blood is going to flow…into the Vena Cava then through an ASD or PDA to the left side of the heart. Then goes through a VSD to the RV to the lungs. You will see cyanosis. Palliative Sx is the same for TETs. Corrective Sx= Convert the RA into an outlet for the pulmonary artery called Fontan procedure. Survival stats= 80-90% w/ complications.
  • Tetralogy of Fallot TOF. Remember the aorta is riding the septum. Cyanotic.
    4 defects=
    Ventricular Septal Defect. Pulmonic Stenosis. Overriding aorta. Right ventricular hypertrophy.

Unoxygenated blood enters the aorta.
The shunting in TOF varies.
Right to Left shunt….unoxygenated blood enters the aorta when the pulmonary vascular resistance is higher than the vascular resistance.
Left to right shunt….if systemic resistance is higher than the pulmonary vascular resistance.
S/S= Blue, cyanotic, squatting, clubbing, syncope.
Blue Spells, hyper cyanotic spells, TET spells. The O2 needs are not med by the blood supply usually during crying, feeding or defecation. The cause is an infundibular spasm which decreases the pulm blood flow and increases R to L shunt. The risks from these spells are brain damage, death, neuro complications, polycythemia and increased blood viscosity which increases the risk for CVA. To treat these spells the infant is placed in the knee chest position. Stay calm. 100% O2 via mask. Morphine SQ or IV to reduce the spasm. IV fluids and expanders to decrease the viscosity. More morphine.
Sx= Palliative= Blalock Taussig shunt. But not preferred treatment.
Complete repair= First year of life. Closes the VSD…resection of the infundibular stenosis with pericardial patch to enlarge the right ventricular outflow tract. This is open heart and post op complications include dysrhythmia and CHF. Survival stats are at 95%.

  • CHF in children.
    The heart is not meeting the demand of the body. Seen a lot when there is increased blood flow to the lungs or problems w/ the left side of the heart .
    The subtle signs= poor feeding, irritable, tired when feeding and lethargy.
    2 things happen
    I. Impaired myocardial function
    …Seeing tachycardia, weak pulses, decreased BP and a gallop rhytm. Fatigue restless, anorexia, pale cool mottled extremites. Diaphoresisi. Cardiomegaly. Decreased urinary output.
    II. Systemic Venous congestions…seeing weight gain. Hepatomegaly. Peripheral edema, per orbital edema. Ascites. Neck vein distention. Rales, resp distress…retractions, nasal flaring.
    Therapeutic Management Goals
  • Improve cardiac function by increasing the contractility and decreasing the after load. Decrease the preload…remove accumulated fluid and sodium retention.
  • Decrease the cardiac demands…control the work of the pt.prevent cold stress. Treat infections. Semi fowlers position. Sedation. Rest.
  • Decrease O2 consumption to improve tissue oxygenation.
    Digitalis is a Cardiac glycoside--improves contractility. Increases the force of contraction--positive inotropic. Decreases the heart rate--negative chronotropic. Slows the conduction of impulses through the AV node--negative dromotropic. Enhances duresis indirectly by increases renal perfusion…..
    Concerning Digoxin and Pediatrics.
    Elixer
    IV
    The dose is calculated in micrograms. 1000ug=1 mg. The digitalizing dose is given to bring the serum dig into a therapeutic range. The maintenance dose is 1/8 of the digitalizing dose.
    The therapeutic range is from 0.8-2ug/L
    Check the apical pulse for one full min is a must. For infants hold the med for pulse below 90-110 bpm. For older children do not give if apical is less than 70 bpm.
    Signs of Dig Toxicity
    = bradycardia. Anorexia. Nausea. Vomit often unrelated to feedings. No interest in eating. Decreased oral intake.
    Other meds and treatments.
    ACE inhibitors Vasotec and Capoten to reduce the after load on the heart which makes it easier to pump.
    For severe CHF other inotropic meds given IV in the ICU = dopamine, dobutamine, Amrinone to improve contractility.
    Diuretics= to remove fluid and sodium…but CAUTION a fall in the serum K+ can potentiate the effects of digoxin and there is then an inceased risk of toxicity.

    Cancer of the Larynx
    At risk= smoking and ETOH. Pollution. Nutritional deficiency. Family predisposition. Vocal straining.
    Early signs= hoarseness. lump in neck, pain in throat when drinking hot fluids or juice.
    Late Signs= Dysphagia, Dyspnea, Foul breath. Chronic cough. Hemoptysis. Sore throat or sores in throat.
    Signs of Metastasis= Enlarged cervical lymph nodes. Weight loss. General debility. Otalgia.
    Most are squamous cell.
    Laryngectomy 3
    Partial--½ or more of the larynx removed. High cure rate stats. It is a vertical midline incision. Trached first few days. VOICE HOARSE. No dysphagia.
    Supraglottic--removes hyoid bone. Epiglottis and false cords. It is radical neck dissection. Tracheotomy. NG tube for 2 weeks. Voice is preserved. Post op dysphagia because some muscles removed.
    Total--removes hyoid bone. Epiglottis, cricoid cartilage and 2-3 rings of the trachea. Permanent tracheal stoma. NO VOICE. It is radical neck dissection.
    Complications= resp distress. Hemorrhage. Infection.
    Post op--be alert for serious complication of rupture of carotid artery. If it happens apply direct pressure. Call for help. And provide emotional support until it can be ligated.
  • Spinal Cord injuries
    4 types of injury. Hyperflexion&Hyperextension (think car wreck). Axial Loading (think fall from ladder). Excessive Rotation.
    Complete (total cord transection) or Incomplete (partial cord transection).
    Injuries affect motor & sensory fx at and below the level of the injury.
    Spinal shock= areflexia (loss of reflex fx). Decrease in BP & bradycardia. Below the injury paralysis and no sensation and no diaphoresis. Check for distended bladder. Lasts days or months.
    Paraplegia= paralysis of lower body. Injury level in the thoracic spine or lower.
    Tetraplegia= Quad= injury in the cervical spine=arms, legs, trunk and pelvic paralysis.
    Maintain patent airway. Cervical injury edema.
    Meds
    High does Corticosteroids within 8 hours.
    Mannitol to decrease edema around the spinal cord
    Baclofen=muslce relaxer to reduce plasticity
    Dextran= prevents BP from dropping and improves the capillary blood flow.
    Traction= tongs such as the Gardner Wells or Crutchfield. Halo.
    Weights hang free.
    Do not remove.
    Clean tongs with betadine
    Assess for infection.
    Sx
    Surgical immobilization….via anterior/posterior decompression and fusion w/ bone grafts. Decompression w/ laminectomy will remove bony fragments that cause compression…remove the foreign body causing compression. Fusion-anterior/posterior using Harrington rods.
    Orthotics
    SOMI=sterno occipital mandibular immobilizer
    CTLSO= cervical thoracic lumbar sacral orthotic.
    Complications may include= DVT. Orthostatic hypotension. Autonomic Dysreflexia.
    Nursing Interventions
  • Promote Adequate Breathing and airway clearance--I am not going into this as we should know this by now! But I will say that if suctioning is needed--be careful because this can stimulate the vagus nerve which can lead to bradycardia and cardiac arrest.
  • Improving mobility--maitain proper body alignment at all times. Feet are prone to foot drop. Use splints removing and reapplied q 2 hours. Trochanter rolls to prevent external rotation of the hip. If the pt is not on a rotating bed do not turn unless the spine is stable and the MD must order. PROM to avoid contractures.
  • Promote adaptation to sensory and perceptual alterations.
  • Maintain skin integrity--Prevent pressure ulcers. They can happen very quickly.
  • Maintain Urinary Elimination--intermittent cath. Teach family. Neurgenic bladder. Prevent UTI--increase fluid, high acid fluids, no ETOH, avoid alkaline fluids.
  • Improve Bowel function--paralytic ileus from Neutrogena paralysis of the bowel. NG tube to relieve distention and prevent aspiration. Bowel activity usually returns in a week. After BS are heard pt given high calorie, high protein, high fiber diet.
    Remember Again that the Emergency Autonomic Dysreflexia
    1. Immediately the head of bed up and BP q 5 min,
    2. Rapid Assess to find the cause and alleviate
    3.Urinary Cath but never drain more than 700cc--can lead to Hypovolemic shock.
    4. Check for fecal mass. Topical anesthetic for 10-15 min…then remove.
    5. Check skin for pressure
    6. Remove all stimulus.
    7. Report to MD immediately if BP does not drop.
    Meds for Autonomic Dysreflexia.
    Nitropaste-vasodilator
    Arfonad IV / Apresoline IV--ganglionic blocker to lower BP fast. relaxes arteriolar smooth muscle.
    Low spinal anesthetic at L4 in nothing works.
    Prevention=antihypertensives.
  • Burns- Some nursing Care. NG tube to decompress. Foley Cath for I&O--HOURLY! Putting a lot of fluids in so we need to see what is coming out. Urine glucose levels. Pain relief. Continuous assessment of extremity pulses and ventilation. Emotional support. Check for GI bleed--stool for OB, coffee ground emesis.
    Nursing care for pt w/ grafts
    Occlusive dressing. Check for infection and foul smell. If the graft is dislodged cover w/ sterile saline dressing. Keep the pressure off and elevate. The donor site is more painful than the burn site!
    Pain is severe and may need PCA pump w. morphine.
    For Rehab…..help the pt set realistic goals and include the pt in decision making…give them some control.
    S/S of smoke inhalation damage from burns
    Focus on signs of resp and cardiac involvement. Burned nasal hair. Cyanotic lips. Hard time talking, facial burns, Dyspnea, Tachypnea, Cough, Stridor, Hoarseness, Sooty sputum. Rales, Wheezes, Rhonchi.

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