Two Types of Cardiac Defects - Baptist Health Collegeuserfiles/pdfs/course-materials...Congenital Heart Disease (CHD) ... Congenital Heart Defects Acyanotic ... Nursing Management.
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Cardiovascular DysfunctionCardiovascular Dysfunction
Maternal Child Nursing Care Maternal Child Nursing Care Chapter 48, pp. 1553Chapter 48, pp. 1553--16001600
Baptist Health School of NursingBaptist Health School of NursingNSG 3026A: ChildrenNSG 3026A: Children’’s Healths Health
Carole Mackey, Carole Mackey, MNScMNSc, RN, APN, RN, APNDebbie Mercer, BSN, RN, RRTDebbie Mercer, BSN, RN, RRT
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Two Types of Cardiac DefectsTwo Types of Cardiac Defects
CongenitalCongenitalAnatomic>abnormal Anatomic>abnormal functionfunction
AcquiredAcquiredDisease process Disease process
InfectionInfectionAutoimmune responseAutoimmune responseEnvironmental factorsEnvironmental factorsFamilial tendenciesFamilial tendencies
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Assessment of Cardiac FunctionAssessment of Cardiac Function
Health HistoryHealth HistoryPoor FeedingPoor FeedingTachypneaTachypneaMotherMother’’s s HistoryHistory
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Assessment of Cardiac FunctionAssessment of Cardiac Function
InspectionInspectionFailure to thrive Failure to thrive ColorColorChest DeformitiesChest DeformitiesPulsationsPulsationsRespiratory ExcursionRespiratory ExcursionClubbingClubbingAbdomenAbdomenHeart Rate/RhythmHeart Rate/RhythmHeart SoundsHeart Sounds
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Character of Heart Sounds: Character of Heart Sounds: MurmursMurmurs
Classification of MurmursClassification of MurmursI I –– Very faint, heard only after listener has "tuned Very faint, heard only after listener has "tuned in"; may not be heard in all positions. in"; may not be heard in all positions. II II -- Quiet, but heard immediately after placing the Quiet, but heard immediately after placing the stethoscope on the chest stethoscope on the chest III III –– Moderately loud. Moderately loud. IV IV -- Loud, with palpable Loud, with palpable thrillthrill. . V V -- Very loud, with thrill. May be heard when Very loud, with thrill. May be heard when stethoscope is partly off the chest stethoscope is partly off the chest VI VI -- Very loud, with thrill. May be heard with Very loud, with thrill. May be heard with stethoscope entirely off the chest. stethoscope entirely off the chest.
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Diagnostic EvaluationDiagnostic Evaluation
Chest XChest X--rayrayElectrocardiographyElectrocardiographyEchocardiographyEchocardiographyCardiac Cardiac CatherizationCatherizationInterventional Cardiac Interventional Cardiac CatherizationCatherization
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EchocardiographyEchocardiography
TechniquesTechniquesNoninvasiveNoninvasivePainlessPainlessStressfulStressful
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Interventional Cardiac Catheter Interventional Cardiac Catheter Procedures in ChildrenProcedures in Children
Transposition of Transposition of great vesselsgreat vesselsSome complex Some complex singlesingle--ventricle ventricle defectsdefectsASDASDPulmonary artery Pulmonary artery stenosisstenosis
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PrePre--procedural Careprocedural Care
Nursing AssessmentNursing AssessmentHeight/WeightHeight/WeightAllergiesAllergiesS/S InfectionS/S InfectionMethods of SedationMethods of Sedation
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PostPost--procedural Careprocedural Care
Cardiac MonitorCardiac MonitorTemperature and Temperature and Color of extremityColor of extremityVital SignsVital SignsMonitor DressingMonitor DressingDirect pressure if Direct pressure if bleeding occursbleeding occurs
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Critical Thinking ExerciseCritical Thinking Exercise
4 year old with 4 year old with tetralogytetralogyof of FallotFallot recovering from recovering from cardiac catheterization cardiac catheterization begins vomiting and begins vomiting and bleeding (p. 1557). bleeding (p. 1557). Priorities of Nursing CarePriorities of Nursing CareNursing InterventionsNursing Interventions
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Congenital Heart DiseaseCongenital Heart Disease(CHD)(CHD)
Incidence: 5 to 8 per 1000 live births Incidence: 5 to 8 per 1000 live births About 2 or 3 of these are symptomatic in first About 2 or 3 of these are symptomatic in first year of lifeyear of lifeMajor cause of death in first year of life (after Major cause of death in first year of life (after prematurity)prematurity)Most common anomaly is VSDMost common anomaly is VSD28% of children with CHD have another 28% of children with CHD have another recognized anomaly (trisomy 21, 13, 18, )recognized anomaly (trisomy 21, 13, 18, )
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Causes of CHDCauses of CHDChromosomal/genetic = 10%Chromosomal/genetic = 10%--12%12%Maternal or environmental = 1%Maternal or environmental = 1%--2%2%
Maternal drug useMaternal drug useFetal alcohol syndrome Fetal alcohol syndrome risk of CHDrisk of CHD
Maternal illnessMaternal illnessRubella in 1st 7 wk of pregnancyRubella in 1st 7 wk of pregnancyCMV, toxoplasmosis, other viral illnesses CMV, toxoplasmosis, other viral illnesses IDMsIDMs = 10% risk of CHD (VSD, cardiomyopathy, = 10% risk of CHD (VSD, cardiomyopathy, TGA most common)TGA most common)
Multifactorial = 85%Multifactorial = 85%
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OverviewOverview
Normal Fetal CirculationNormal Fetal CirculationPatent Ductus ArteriosusPatent Ductus ArteriosusForamen OvaleForamen Ovale
PostPost--Natal CirculationNatal CirculationPhysiologic Events:Physiologic Events:
Increase in Systemic Circulation PressuresIncrease in Systemic Circulation PressuresDecrease in Lung ResistanceDecrease in Lung Resistance
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Fetal Circulation Structures Fetal Circulation Structures
Umbilical vein; umbilical Umbilical vein; umbilical arteriesarteriesForamen ovaleForamen ovaleDuctus arteriosusDuctus arteriosusDuctus venosusDuctus venosus
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Heart = PumpHeart = Pump
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How the Heart WorksHow the Heart Works
Right SideRight Sideto Lungsto Lungs
Left Side Left Side to Bodyto Body
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Normally low oxygen Normally low oxygen blood entering the blood entering the right side of the heart right side of the heart stays on the right sidestays on the right sideOxygen rich blood Oxygen rich blood stays on the left side stays on the left side of the heart where it of the heart where it is pumped to the is pumped to the bodybody
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Traditional Categories of CHDTraditional Categories of CHD
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Congenital Heart DefectsCongenital Heart Defects
AcyanoticAcyanoticAtrial Septal DefectAtrial Septal DefectVentricular Septal Ventricular Septal DefectDefectPatent Ductus Patent Ductus ArteriosusArteriosusCoarctation of the Coarctation of the AortaAortaAortic StenosisAortic StenosisPulmonic StenosisPulmonic Stenosis
Cyanotic Cyanotic TetrologyTetrology of of FallotFallotPulmonary Pulmonary AtresiaAtresiaTransposition of Great Transposition of Great VesselsVesselsHypoplasticHypoplastic left heartleft heart
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Newer Classification of CHDNewer Classification of CHD
Hemodynamic characteristicsHemodynamic characteristicsIncreased pulmonary blood flowIncreased pulmonary blood flowDecreased pulmonary blood flowDecreased pulmonary blood flowObstruction of blood flow out of the Obstruction of blood flow out of the heartheartMixed blood flowMixed blood flow
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Increased Pulmonary Blood Flow Increased Pulmonary Blood Flow DefectsDefects
Abnormal connection between two sides of Abnormal connection between two sides of heart heart -- either the septum or the great vesselseither the septum or the great vesselsIncreased blood volume on right side of heartIncreased blood volume on right side of heartIncreased or decreased pulmonary blood flowIncreased or decreased pulmonary blood flowDefects include:Defects include:
•• AtrialAtrial septalseptal defectdefect•• Ventricular Ventricular septalseptal defectdefect•• Patent Patent ductusductus arteriosusarteriosus
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HemodynamicsHemodynamics with Increased with Increased Pulmonary Blood FlowPulmonary Blood Flow
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Defects with Increased Pulmonary Defects with Increased Pulmonary Blood FlowBlood Flow
AtrialAtrial Septal DefectSeptal DefectVentricular Septal DefectVentricular Septal DefectPatent Ductus ArteriosusPatent Ductus Arteriosus
Patients present with signs and symptoms Patients present with signs and symptoms of Congestive Heart Failureof Congestive Heart Failure
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AtrialAtrial SeptalSeptal Defect (ASD)Defect (ASD)
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Ventricular Ventricular SeptalSeptal Defect (VSD)Defect (VSD)
Abnormal pathway Abnormal pathway b/tb/t right and left right and left ventricles causing shunting and fluid ventricles causing shunting and fluid excess (volume overload)excess (volume overload)Can result in CHF Can result in CHF Loud Loud holosystolicholosystolic murmurmurmurTypically Typically asymtomaticasymtomaticuntil CHF developsuntil CHF develops
Risk for Risk for endocarditisendocarditis and PV obstructionand PV obstruction
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VSDVSD
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Patent Patent DuctusDuctus ArteriosusArteriosus (PDA)(PDA)
Failure of the fetal artery Failure of the fetal artery connecting the aorta and connecting the aorta and pulmonary artery to close pulmonary artery to close within the first few weeks within the first few weeks of lifeof lifeAllows blood to flow from Allows blood to flow from the higherthe higher--pressure aorta pressure aorta to the lower pressure to the lower pressure pulmonary artery, pulmonary artery, causing leftcausing left--toto--right right shuntingshunting
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PDAPDA
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PDA cont.PDA cont.
The amount of leftThe amount of left--toto--right shunting right shunting depends upon the size of the PDA and the depends upon the size of the PDA and the relative resistances of the systemic and relative resistances of the systemic and pulmonary circulationspulmonary circulationsResults in increased pulmonary artery Results in increased pulmonary artery blood flow as well as left blood flow as well as left atrialatrial and left and left ventricular overloadventricular overloadA large PDA can result in systemic organ A large PDA can result in systemic organ hypoperfusionhypoperfusion
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AtrioventricularAtrioventricular Canal Defect (AVC)Canal Defect (AVC)
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Obstructive DefectsObstructive Defects
Anatomic Narrowing Anatomic Narrowing ((StenosisStenosis))
ValvularValvular
SubvalvularSubvalvular
SupravalvularSupravalvular
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Obstructive DefectsObstructive Defects
CoarctationCoarctation of the aortaof the aortaAortic stenosisAortic stenosisPulmonic stenosisPulmonic stenosis
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COACOA
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Aorta Aorta -- Largest artery Largest artery
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CoarctationCoarctation of the aortaof the aorta
Increased pressure Increased pressure proximal to the defect proximal to the defect (head and upper (head and upper extremities) extremities) Decreased pressure Decreased pressure distal to the distal to the obstruction (body and obstruction (body and lower extremities)lower extremities)
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CoarctationCoarctation RepairRepair
Normal Normal CoarctationCoarctation
Repair Step #1Repair Step #1 Completed RepairCompleted Repair
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Aortic StenosisAortic Stenosis
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Pulmonic Stenosis Pulmonic Stenosis
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Decreased Pulmonary Decreased Pulmonary Blood Flow DefectsBlood Flow Defects
Obstruction of pulmonary Obstruction of pulmonary flow + Anatomic Defectflow + Anatomic DefectASD or VSDASD or VSDHypoxicHypoxicCyanoticCyanotic
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HemodynamicsHemodynamics with Decreased with Decreased Pulmonary Blood Flow DefectsPulmonary Blood Flow Defects
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Most Common Decreased Most Common Decreased Pulmonary Pulmonary
Blood Flow DefectsBlood Flow Defects
Tetralogy of FallotTetralogy of FallotTricuspid atresiaTricuspid atresia
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Tetralogy of FallotTetralogy of Fallot
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TetralogyTetralogy of of FallotFallot
Includes 4 defects: Includes 4 defects: ventricular ventricular septalseptal defect, defect, pulmonic pulmonic stenosisstenosis, , overriding aorta, and overriding aorta, and right ventricular right ventricular hypertrophyhypertrophyAs the severity of right As the severity of right ventricular outflow tract ventricular outflow tract obstruction increases, obstruction increases, right to left shunting of right to left shunting of blood occurs through the blood occurs through the VSD resulting in cyanosisVSD resulting in cyanosis
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TetrologyTetrology of of FallotFallot (TOF)(TOF)
Four separate yet intertwined problemsFour separate yet intertwined problemsPulmonary Pulmonary StenosisStenosisVentricular Ventricular septalseptal defect (VSD)defect (VSD)Overriding aortaOverriding aortaRight ventricular hypertrophy Right ventricular hypertrophy This is a CYANOTIC CHDThis is a CYANOTIC CHDTypically seen with Downs childrenTypically seen with Downs childrenASD can also occur (must have the ASD to encourage ASD can also occur (must have the ASD to encourage circulation and oxygenation)circulation and oxygenation)
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TetralogyTetralogy cont.cont.
These 4 defects lead to a reduced blood These 4 defects lead to a reduced blood flow to the lungs and the mixing of flow to the lungs and the mixing of oxygenoxygen--rich and oxygenrich and oxygen--poor blood in the poor blood in the heart. This causes the babies to appear heart. This causes the babies to appear cyanotic, especially during exertion cyanotic, especially during exertion (feeding)(feeding)If left untreated will usually cause death If left untreated will usually cause death by age 20by age 20Must be repaired surgically, usually in 2 Must be repaired surgically, usually in 2 stages, when the child is very youngstages, when the child is very young
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Nursing and medical management Nursing and medical management (TOF)(TOF)
Diagnosis: CXR shows boot shaped heart (RV Diagnosis: CXR shows boot shaped heart (RV large), EKG shows RVH, ECHO large), EKG shows RVH, ECHO If If DuctusDuctus arteriosisarteriosis closes cyanosis develops IV closes cyanosis develops IV Prostaglandin in infancy (keep Prostaglandin in infancy (keep ductusductus open)open)Monitor labs CBC (blood can thicken)Monitor labs CBC (blood can thicken)Initial surgery in infancy then progressive Initial surgery in infancy then progressive surgeries depending on hypoxic eventssurgeries depending on hypoxic eventsCan have Can have hypercyanotichypercyanotic spellsspells
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Tricuspid AtresiaTricuspid Atresia
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Palliative Tricuspid Palliative Tricuspid AtresiaAtresia RepairRepair
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Mixed DefectsMixed Defects
Transposition of great vesselsTransposition of great vesselsTotal anomalous pulmonary venous Total anomalous pulmonary venous connectionconnectionHypoplastic heart syndrome Hypoplastic heart syndrome
RightRightLeftLeft
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Transposition of Great VesselsTransposition of Great Vessels
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Total Anomalous Pulmonary Venous Total Anomalous Pulmonary Venous ConnectionConnection
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TruncusTruncus ArteriosusArteriosus (TA)(TA)
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Hypoplastic Left HeartHypoplastic Left Heart
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Congestive Heart FailureCongestive Heart FailureDefinition: Congestive heart failure Definition: Congestive heart failure (CHF) is a condition in which the heart (CHF) is a condition in which the heart cannot pump enough oxygenated blood cannot pump enough oxygenated blood to meet the needs of the body's other to meet the needs of the body's other organs organs
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Congestive Heart FailureCongestive Heart Failure
Pathophysiology of CHFPathophysiology of CHFRightRight--Sided FailureSided FailureLeftLeft--Sided FailureSided Failure
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Congestive Heart FailureCongestive Heart Failure
Therapeutic GoalsTherapeutic GoalsImprove Cardiac FunctionImprove Cardiac FunctionRemove Excess FluidsRemove Excess FluidsDecrease Cardiac DemandsDecrease Cardiac DemandsImprove OxygenationImprove Oxygenation
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Improve Cardiac FunctionImprove Cardiac Function
Increase Increase contractility contractility Decrease Decrease AfterloadAfterloadDigitalis GlycosidesDigitalis Glycosides
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Remove Excess FluidRemove Excess Fluid
DiureticsDiureticsFluid RestrictionFluid RestrictionSodium Sodium RestrictionRestrictionPotassium Potassium SupplementsSupplements
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Decrease Cardiac DemandsDecrease Cardiac Demands
Bed RestBed RestReduce Effort of Reduce Effort of BreathingBreathingSedationSedationTreat InfectionsTreat Infections
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Improve Tissue OxygenationImprove Tissue Oxygenation
Humidified Humidified OxygenOxygenOxygen HoodOxygen HoodNasal Nasal CannulaCannula
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Nursing Care Management of CHFNursing Care Management of CHF
Nursing Care Plan Nursing Care Plan (p. 1576)(p. 1576)Goals (p. 1571)Goals (p. 1571)
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Improve Cardiac Function: Improve Cardiac Function: DigoxinDigoxinAdministrationAdministration
Correct DosageCorrect DosageApical PulseApical PulseInfants (>90Infants (>90--110 110 bpmbpm))Young Children (>70 Young Children (>70 bpmbpm))Older Children (>60 Older Children (>60 bpmbpm))Signs of ToxicitySigns of ToxicityParental TeachingParental Teaching
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AfterloadAfterload Reduction: ACE Inhibitors Reduction: ACE Inhibitors
Monitor Blood Monitor Blood PressurePressureSerum Serum Electrolytes Electrolytes Renal FunctionRenal Function
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Decrease Cardiac Demands Decrease Cardiac Demands
RestRestFeedingFeedingMinimize StressMinimize Stress
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Reduce Respiratory Distress Reduce Respiratory Distress
AssessmentAssessmentPositioningPositioningOxygen Oxygen AdministrationAdministration
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Maintain Nutritional Status Maintain Nutritional Status
Caloric NeedsCaloric NeedsFatigue with Fatigue with FeedingFeedingGavageGavage FeedingFeedingAdded CaloriesAdded Calories
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Promote Fluid Loss Promote Fluid Loss
Record I & ORecord I & O’’ssWeightsWeightsSerum Potassium Serum Potassium LevelsLevelsFluid RestrictionFluid RestrictionSodium RestrictionSodium Restriction
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Support Child and Family Support Child and Family
Reduce AnxietyReduce AnxietyFrequent Frequent CommunicationCommunicationReassuranceReassuranceFamily TeachingFamily TeachingEnd Stage CHFEnd Stage CHF
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CHF: Evaluate Interventions CHF: Evaluate Interventions
Monitor Heart Monitor Heart RateRateMonitor NutritionMonitor NutritionMonitor I/OMonitor I/OMonitor WeightMonitor WeightFamily ConcernsFamily Concerns
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Hypoxemia Hypoxemia HypoxemiaHypoxemiaHypoxia Hypoxia CyanosisCyanosisEisenmengerEisenmengerComplex Complex (syndrome)(syndrome)
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Hypoxemia: Therapeutic Hypoxemia: Therapeutic Management Management
PolycythemiaPolycythemiaClubbingClubbingSquattingSquattingHypercyanoticHypercyanoticSpellsSpellsNeurologicNeurologicComplicationsComplications
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Hypoxemia: Nursing Care Hypoxemia: Nursing Care Management Management
Treatment of Treatment of HypercyanoticHypercyanotic SpellsSpells
OxygenOxygenMorphineMorphineHydrationHydrationNurse AssessmentNurse Assessment
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Care of Family and Child with Care of Family and Child with CHDCHD
Care before RepairCare before RepairCare after RepairCare after RepairFamily AdjustmentFamily AdjustmentEducate FamilyEducate FamilyFamily CopingFamily CopingPrepare for SurgeryPrepare for Surgery
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Preparations for SurgeryPreparations for Surgery
EnvironmentEnvironmentProceduresProceduresPostoperative Postoperative CareCare
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Postoperative CarePostoperative Care
Observe Vital SignsObserve Vital SignsMaintain Maintain Respiratory StatusRespiratory StatusMonitor FluidsMonitor FluidsRest and ActivityRest and ActivityComfort and Comfort and Emotional SupportEmotional Support
Acquired CardiovascularAcquired CardiovascularDisordersDisorders
Infectious and Inflammatory Infectious and Inflammatory Cardiac DisordersCardiac Disorders
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Bacterial (Bacterial (Infective)EndocarditisInfective)Endocarditis
PathophysiologyPathophysiologyDiagnostic EvaluationDiagnostic EvaluationTherapeutic ManagementTherapeutic ManagementNursing Care Nursing Care ManagementManagement
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Rheumatic FeverRheumatic Fever
RFRFInflammatory disease occurs after Group A Inflammatory disease occurs after Group A ßß--hemolytic streptococcal pharyngitishemolytic streptococcal pharyngitisInfrequently seen in U.S.; big problem in Third Infrequently seen in U.S.; big problem in Third World World SelfSelf--limitinglimiting
Affects joints, skin, brain, serous surfaces, and Affects joints, skin, brain, serous surfaces, and heartheart
Rheumatic heart diseaseRheumatic heart diseaseMost common complication of RFMost common complication of RFDamage to valves as result of RFDamage to valves as result of RF
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Clinical Manifestations of RFClinical Manifestations of RF
CarditisCarditisPolyarthritisPolyarthritisErythema marginatumErythema marginatumSubcutaneous nodulesSubcutaneous nodules
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Prevention of RHD Prevention of RHD Treatment of streptococcal Treatment of streptococcal tonsillitis/pharyngitistonsillitis/pharyngitis
Penicillin GPenicillin G——IM x 1IM x 1Penicillin VPenicillin V——oral x 10 daysoral x 10 daysSulfaSulfa——oral x 10 daysoral x 10 daysErythromycin (if allergic to above)Erythromycin (if allergic to above)——oral x 10 oral x 10 daysdays
Treatment of recurrent RFTreatment of recurrent RFSame as aboveSame as above
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HyperlipidemiaHyperlipidemia
Identify kids at risk and treat Identify kids at risk and treat earlyearlyTreatment: dietaryTreatment: dietary
Restrict intake of cholesterol and Restrict intake of cholesterol and fatsfats
If no response to dietIf no response to diet→→RxRxColestipol (Colestid)Colestipol (Colestid)Cholestyramine (Questran)Cholestyramine (Questran)
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Cardiac Cardiac DysrythmiasDysrythmias
Variable heart rateVariable heart rateDiagnostic Diagnostic EvaluationEvaluationBradycardiaBradycardiaTachycardiaTachycardiaConduction Conduction disturbancesdisturbances
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Pulmonary Artery HypertensionPulmonary Artery Hypertension
PAD definedPAD definedSupportive CareSupportive CareCausesCausesClinical Clinical ManifestationsManifestationsTherapeutic Therapeutic ManagementManagement
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CardiomopathyCardiomopathy
EtiologyEtiologyDilated Dilated HypertrophicHypertrophicRestrictive Restrictive ManagementManagement
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Heart TransplantationHeart Transplantation
Orthotopic transplantOrthotopic transplantHeterotopic transplant (piggyback)Heterotopic transplant (piggyback)Organ donation issuesOrgan donation issuesNursing ManagementNursing Management
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Hypertension in childrenHypertension in children
Essential Essential HypertensionHypertensionSecondary Secondary HypertensionHypertensionEtiologyEtiologyClinical Clinical ManifestationsManifestations
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Hypertension in ChildrenHypertension in Children
DiagnosisDiagnosisTherapeutic Therapeutic ManagementManagementDiagnostic Diagnostic ManagementManagement
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Kawasaki diseaseKawasaki disease
DefinitionDefinitionEtiologyEtiologyPathphysiologyPathphysiology
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Kawasaki Clinical ManifestationsKawasaki Clinical Manifestations
Diagnostic Diagnostic Criteria (Box 48Criteria (Box 48--11, p. 1593)11, p. 1593)Acute PhaseAcute PhaseSubacuteSubacute PhasePhaseConvalescent Convalescent PhasePhase
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Kawasaki: Cardiac InvolvementKawasaki: Cardiac Involvement
ComplicationsComplicationsTherapeutic Therapeutic ManagementManagementPrognosisPrognosisNursing CareNursing Care
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Kawasaki Disease TreatmentKawasaki Disease Treatment
Then 3Then 3--5 mg/kg/day5 mg/kg/day——antiplateletantiplatelet
IVIGIVIG ASA 80ASA 80--100 mg/kg/day100 mg/kg/day——feverfever
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ShockShock
HypovolemicHypovolemicDistributiveDistributiveCardiogenicCardiogenicClinical Clinical manifestationsmanifestationsTherapeutic Therapeutic ManagementManagementNursing Nursing ManagementManagement
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Emergency Treatment: ShockEmergency Treatment: Shock
VentilationVentilationFluid Fluid AdministrationAdministrationCardiovascular Cardiovascular SupportSupportGeneral General SupportSupport
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AnaphylaxisAnaphylaxis
DefinitionDefinitionClinical Clinical manifestationsmanifestationsTherapeutic Therapeutic ManagementManagementNursing Nursing ManagementManagement
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Toxic Shock Syndrome (TSS)Toxic Shock Syndrome (TSS)
Diagnostic evaluationDiagnostic evaluationCriteria (Box 48Criteria (Box 48--14, p. 14, p. 1598)1598)
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Toxic Shock Syndrome (TSS)Toxic Shock Syndrome (TSS)
Diagnostic evaluationDiagnostic evaluationTherapeutic managementTherapeutic managementNursing considerationsNursing considerationsCriteria for definition of TSSCriteria for definition of TSS
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