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PEDIATRIC CARDIOVASCULAR
DISORDERS
Mr. Erwin U. Imperio
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VARIATIONS FROM THE ADULT
Fetal Circulation
Characteristics:
Placenta is the source of oxygen for the fetus
Fetal lungs receive
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NORMAL CIRCULATORY CHANGES AT
BIRTH
When the umbilical cord is clamped or
severed, the blood supply from the placenta is
cut-off, and oxygenation must then take place
in the newborns lungs
As the lungs expand with the air, the
pulmonary artery pressure decreases and
circulation lungs increases
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STRUCTURAL CHANGES
DUCTUS VENOSUS
After the umbilical cord is severed, flow to the
ductus venosus decreases, and eventually ceases
Constricts within 3-7 days after birth
Becomes ligamentum venosum
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STRUCTURAL CHANGES
FORAMEN OVALE
Functional closure occurs when:
Pressure in the LA exceeds pressure in the right
Expansion of PA causes a drop in PA pressure and RA
and RV pressure
Increased pulmonary blood flow to the LA and aortic
pressure = increased LA and LV pressure
Anatomical closure occurs:
Within 1st week after birth with the deposit of fibrin
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STRUCTURAL CHANGES
DUCTUS ARTERIOSUS
Increase aortic blood flow = increase aortic pressure =decrease right-to-left shunt
Increase pulmonary blood flow = increase arterialoxygen = vasoconstriction within hours of birth
Functional closure occurs:
24 hours after birth when vasoconstriction causes cessationof blood flow
Anatomical closure: 1-3 weeks when there is growth of fibrous tissue in the
lumen of ductus arteriosus
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ABNORMAL CIRCULATORY PATTERNS
AFTER BIRTH
This may happen as a result of abnormal
openings between pulmonary and systemic
circulations
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ASSESSMENT
Family History : genetic problems
Pregnancy History:
Rubella
Viral infections
Medications
X-ray exposure
Alcohol ingestion
Cigarette smoking
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ASSESSMENT
Childs health history
Presenting problem
Feeding problems
Failure to thrive
Respiratory difficulties
Color changes
Activity intolerance
Past medical history
Rheumatic fever
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ASSESSMENT
Physical Examination
Plot height and weight
Measure VS (especially BP and RR)
Inspect for chest enlargement Inspect for presence of cyanosis
Inspect for clubbing of finger
Observe for distended neck veins Palpate/percuss quality and symmetry of pulses,
size of liver and spleen, presence of thrill
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ASSESSMENT
Physical Examination
Auscultate for abnormal heart sounds / murmurs
Innocent: no anatomic or physiologic abnormality
Functional: no anatomic defect, but may be caused by a
physiologic abnormality
Organic: caused by structural abnormality
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LABORATORY / DIAGNOSTIC TESTS
CXR
MRI
ECG Hematologic testing
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LABORATORY / DIAGNOSTIC TESTS
Cardiac Catheterization
Access: femoral vein
Nursing Care: Pre-test
Prepare child based on developmental level Administer medications as ordered
Nursing Care: Post-test
Check extremity distal to the catheterization site for:
Color Temperature
Pulse
Capillary refill
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LABORATORY / DIAGNOSTIC TESTS
Cardiac Catheterization
Nursing Care: Post-test
Keep extremity distal to the catheterization site
extended for 6 hours
Check pressure dressing over catheterization site for
bleeding
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NURSING DIAGNOSIS
Altered growth and development: failure tothrive
High risk for injury: physiologic
Activity intolerance Altered nutrition: less than body
requirements Fear/anxiety: child and family
Risk for infection Decreased cardiac output Fluid volume excess
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PLANNING AND IMPLEMENTATION
Tissue will be adequately oxygenated
Child will achieve normal growth and
development milestones
Child will be free from symptoms of
complications of heart disease
Parents will understand childs condition
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CARE OF A PEDIATRIC CLIENT WITH
CONGENITAL HEART DISEASE
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BLOOD CIRCULATION
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FIRST CLASSIFICATION
ACYANOTIC
Left-to-right shunts
Oxygenated tounoxygenated blood
CYANOTIC
Right-to-left shunts
Deoxygenated tooxygenated blood
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SECOND CLASSIFICATION
Increased pulmonary blood flow
Ventricular Septal Defect
(VSD)
Atrial Septal Defect (ASD)
Atrioventricular canal defect
Patent Ductus Arteriosus
(PDA)
Decreased pulmonary blood flow
Tricuspid Atresia
Tetralogy of Fallot
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SECOND CLASSIFICATION
Mixed blood flow
Transposition of the great
arteries
Total anomalous pulmonary
venous return
Truncus arteriosus
Hypoplastic left heartsyndrome
Obstruction to blood flow
Pulmonary stenosis
Aortic stenosis Coarctation of the aorta
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INCREASED PULMONARY BLOOD
FLOW
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VENTRICULAR SEPTAL DEFECT
ILLUSTRATION description
Opening present in the
septum between two
ventricles
Left-to-right shunt
(acyanotic)
Results into RV hypertrophy
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ATRIAL SEPTAL DEFECT
ILLUSTRATION description
Opening present between
two atria
Left-to-right shunt
(acyanotic)
Results into RV hypertrophy
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ATRIOVENTRICULAR SEPTAL DEFECT
ILLUSTRATION description
Endocardial cushion
defect
Left-to-right shunt
Blood may flow between all
four heart chambers
Seen in 50% of children withDown Syndrome
Leads to RV hypertrophy
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PATENT DUCTUS ARTERIOSUS (PDA)
Patent ductus arteriosus description
Results from failure to close
at birth
Left-to-right shunt
Leads to RV hypertrophy
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ASSESSMENT FINDINGS
CHF:
Tachypnea, tachycardia
Hepatomegaly
Feeding difficulties
FTT
Activity intolerance
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MANAGEMENT
CONGENITAL HEART DEFECTS
VSD
MEDICAL
CHF Management
Digoxin and diuretics
Avoid oxygen
Increase caloric intake
Infective endocarditis
prophylaxis 6 months aftersurgery / ventricular device
occluder
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MANAGEMENT
CONGENITAL HEART DEFECTS
VSD
SURGICAL
Cardiac catheterization for
placement of ventricular
occlusion
Usually repaired after age 1
Approaches:
One-stage
Patch closure
Two-stages
PA banding to restrict
pulmonary blood flow
Patch close of VSD, removal
of PA banding
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MANAGEMENT
CONGENITAL HEART DEFECTS
ASD
MEDICAL
CHF Management
Digoxin and diuretics
Infective endocarditis
prophylaxis 6 months after
surgery / atrial device
occluder
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MANAGEMENT
CONGENITAL HEART DEFECTS
ASD
SURGICAL
Cardiac catheterization for
placement of atrial
occlusion
Primary repair: suture
closure of ASD
Patch repair of ASD
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MANAGEMENT
CONGENITAL HEART DEFECTS
PDA
MEDICAL
CHF Management
Digoxin and diuretics
Infective endocarditis
prophylaxis 6 months after
surgery coil occlusion
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MANAGEMENT
CONGENITAL HEART DEFECTS
PDA
SURGICAL
Cardiac catheterization
Small PDAs; coil occlusion
Large PDAs: closure device
PDA ligation
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DISORDERS WITH OBSTRUCTION TO
BLOOD FLOW
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PULMONARY STENOSIS
ILLUSTRATION description
Inability of RV to evacuate
blood by way of PA
Results into RV hypertrophy
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AORTIC STENOSIS
ILLUSTRATION description
Inability of LV to evacuate
blood by way of aortic valve
Results into LV hypertrophy
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COARCTATION OF THE AORTA
ILLUSTRATION description
Narrowing of the lumen of
the aorta due to a
constricting band
Two locations:
Preductal (bet. subclavian
artery and ductus arteriosus)
Postductal (distal to ductusarteriosus)
Results into increase BP
proximal to coarctation and
decrease distal to it
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ASSESSMENT FINDINGS
Pulmonary Stenosis
Hypoxia
Tachypnea
RV failure
Activity intolerance
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ASSESSMENT FINDINGS
Aortic Stenosis
Severe CHF
Tachypnea
Faint peripheral pulses, poor perfusion, poor
capillary refill, cool skin
Poor feeding
Activity intolerance
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ASSESSMENT FINDINGS
Coarctation of the Aorta
Hypertesion in the upper extremities, with absent
or weak femoral pulses
Nosebleeds
Headaches
Leg cramps
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MANAGEMENT
CONGENITAL HEART DEFECTS
Pulmonary Stenosis
MEDICAL
PGE1 infusion
Intubation and ventilation
Inotropics
Infective endocarditis
prophylaxis
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MANAGEMENT
CONGENITAL HEART DEFECTS
Pulmonary Stenosis
SURGICAL
Balloon pulmonary
valvuloplasty
Valvotomy or valvectomy
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MANAGEMENT
CONGENITAL HEART DEFECTS
Aortic Stenosis
MEDICAL
PGE1 infusion
Intubation and ventilation
Inotropics
Infective endocarditis
prophylaxis
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MANAGEMENT
CONGENITAL HEART DEFECTS
Aortic Stenosis
SURGICAL
Cardiac catheterization
Aortic balloon valvuloplasty
Aortic balloon angioplasty
Valvotomy
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MANAGEMENT
CONGENITAL HEART DEFECTS
Coarctation of the Aorta
MEDICAL
PGE1 infusion
Intubation and ventilation
Infective endocarditis
prophylaxis
Anticongestive therapy
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MANAGEMENT
CONGENITAL HEART DEFECTS
Coarctation of the Aorta
SURGICAL
Balloon angioplasty
End-to-end anastomosis
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DISORDERS WITH MIXED BLOOD
FLOW
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TRANSPOSITION OF GREAT ARTERIES
ILLUSTRATION description
Aorta rises from the RV
instead of the left
Pulmonary artery arises
from the LV instead of right
TOTAL ANOMALOUS PULMONARY
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TOTAL ANOMALOUS PULMONARY
VENOUS RETURN
ILLUSTRATION description
PV returns to the Ra or the
superior vena cava instead
of the LA
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TRUNCUS ARTERIOSUS
ILLUSTRATION description
ONE major trunk arises
from the LV and RV in place
of separate aorta and
pulmonary artery vessels
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ASSESSMENT FINDINGS
Transposition of Great Arteries
Cyanosis
Tachypnea
CHF
Feeding difficulties
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ASSESSMENT FINDINGS
Total Anomalous Pulmonary Venous Return
Cyanostic
Activity intolerance
Signs of RSHF
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ASSESSMENT FINDINGS
Truncus Arteriosus
Cyanotic
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MANAGEMENT
CONGENITAL HEART DEFECTS
Transposition of great
arteries
MEDICAL
PGE1 infusion
Anticongestive drugs
Intubation and ventilation
Inotropics
Infective endocarditis
prophylaxis
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MANAGEMENT
CONGENITAL HEART DEFECTS
Transposition of great
arteries
SURGICAL
Procedure of choice:
Arterial switch operation
Aorta and PA are switched
back to their anatomically
correct ventricle
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MANAGEMENT
CONGENITAL HEART DEFECTS
Total anomalous pulmonary
venous return
MEDICAL
PGE1 infusion
Anticongestive drugs
Intubation and ventilation
Inotropics
Infective endocarditis
prophylaxis
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MANAGEMENT
CONGENITAL HEART DEFECTS
Total anomalous pulmonary
venous return
SURGICAL
Reimplantation of the
pulmonary veins into the
left atrium
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MANAGEMENT
CONGENITAL HEART DEFECTS
Truncus arteriosus
MEDICAL
PGE1 infusion
Anticongestive drugs
Intubation and ventilation
Inotropics
Infective endocarditis
prophylaxis
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MANAGEMENT
CONGENITAL HEART DEFECTS
Truncus arteriosus
SURGICAL
Grafting to separate aorta
and pulmonary artery
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DISORDERS WITH DECREASED
PULMONARY BLOOD FLOW
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TRICUSPID ATRESIA
ILLUSTRATION description
Tricuspid valve completely
closed = no blood flow from
the RA to the RV
Blood bypasses the lungs
(crosses from foramen ovale
to LA)
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TETRALOGY OF FALLOT
ILLUSTRATION description
FOUR anomalies present
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ASSESSMENT FINDINGS
Tricuspid Atresia
Cyanosis
Tachypnea
Feeding difficulties
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ASSESSMENT FINDINGS
Tetralogy of Fallot
Cyanosis
Polycythemia
Activity intolerance
Squatting
Hypercyanotic spells Tet spells
Occurs in the morning soon after awakening, during orafter: crying, feeding, painful procedures
Characterized by: tachypnea, irritability, increasing
cyanosis, flaccidity and loss of consciousness
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MANAGEMENT
CONGENITAL HEART DEFECTS
Tricuspid Atresia
MEDICAL
PGE1 infusion
Anticongestive drugs
Intubation and ventilation
Inotropics
Infective endocarditis
prophylaxis
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MANAGEMENT
CONGENITAL HEART DEFECTS
Tricuspid atresia
SURGICAL
First surgery: neonate
Blalock-Taussig shunt (shunt
bet. aorta and PA)
Pulmonary artery band
Second surgery: 6-9 months
End-to-end anastomosis
Third surgery: 18 months-3yrs
IVC to PA connection
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MANAGEMENT
CONGENITAL HEART DEFECTS
Tetralogy of Fallot
MEDICAL
Positioning (knee-chest)
Morphine sulfate
Beta-blockers
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MANAGEMENT
CONGENITAL HEART DEFECTS
Tetralogy of Fallot
SURGICAL
Blalock-Taussig procedure
Brock procedure (full repair)
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ACQUIRED HEART DISEASE
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Congestive Heart Failure (CHF)
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DESCRIPTION
Occurs when CO cannot meet metabolic
demands of the body
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ASSOCIATED FACTORS
CHDs
Acquired heart disease: myocarditis,
cadiomyopathy, acute rheumatic fever
Anemia
Iatrogenic fluid overload
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CLASSIFICATIONS
Right-sided
Left-sided
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ASSESSMENT FINDINGS
LEFT-SIDED
Pulmonary congestion
Tachypnea
Cyanosis
Cough
Crackles
RIGHT-SIDED
Systemic venous congestion
Hepatomegaly
Peripheral edema: scrotal and
orbital
Weight gain
Decreased urine output
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MANAGEMENT
Diuretics
Digoxin
ACE inhibitors
Beta-adrenergic blockers
Inotropics
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NURSING DIAGNOSES
Decreased Cardiac Output related to myocardialdysfunction
Excess fluid volume related to decreased cardiac
contractility and decreased excretion from the kidney Impaired gas exchange related to pulmonary venous
congestion
Activity intolerance
Risk for infection related to pulmonary congestion
Imbalanced Nutrition: Less Than Body Requirements
related to increased metabolic demands with
decreased caloric intake
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NURSING INTERVENTIONS
Improving Myocardial Efficiency
Administer Digoxin as prescribed
Measure HR, hold if HR < 90 bpm
Check MOST RECENT potassium level, hold if < 3.5 Report signs of digoxin toxicity:
Vomiting
Nausea
Visual changes Bradycardia
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NURSING INTERVENTIONS
Improving Myocardial Efficiency
Administer afterload reduction medications as
prescribed
Measure BP before and after giving meds, hold if lowBP and notify the physician
Observe for signs of hypotension:
Dizziness
Light-headedness Sncope
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NURSING INTERVENTIONS
Maintaining Fluid and Electrolyte Balance
Administer diuretics as prescribed
Obtain daily weights
Keep strict I&O monitoring Monitor serum potassium (potassium supplements as
needed)
Sodium restriction
Fluid restriction
S G O S
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NURSING INTERVENTIONS
Relieving Respiratory Distress
Administer oxygen as prescribed
Elevate HOB
NURSING INTERVENTIONS
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NURSING INTERVENTIONS
Promoting Activity Tolerance
Organize nursing care
Respond efficiently to a crying infant
Provide small, frequent feedings
NURSING INTERVENTIONS
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NURSING INTERVENTIONS
Decreasing Risk of Infection
Ensure good hand washing by everyone
Avoid exposure to all children or caretakers
Monitor signs of infection: fever, cough, runnynose, diarrhea, vomiting
NURSING INTERVENTIONS
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NURSING INTERVENTIONS
Providing Adequate Nutrition
Provide nutritious foods that the child likes
High calorie snack
EVALUATION
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EVALUATION
HR within normal range
No unexpected weight gain
Clear lungs
Participates in quiet diversional activities
No signs and symptoms of infection
Adequate intake of small, frequent feedings
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Acute Rheumatic Fever
DESCRIPTION
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DESCRIPTION
Acute autoimmune disease that occurs as asequeale of GABHS infection
ASSESSMENT
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ASSESSMENT
Major
Carditis
Polyarhtritis
Chorea
Erythema marginatum
Subcutaneous nodules
ASSESSMENT
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ASSESSMENT
Minor
Arthralgia
Fever
Laboratory abnormalities: elevated ESR, WBC, C-reactive protein positive
ECG changes prolonged PR interval
MANAGEMENT
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MANAGEMENT
Antibiotics (penicillin/erythromycin)
Oral salicylates (aspirin)
Corticosteroids
Diazepam or other neurologic agents
Bed rest
NURSING DIAGNOSIS
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NURSING DIAGNOSIS
Decreased Cardiac Output related to carditis
Acute and Chronic Pain related to arthritis
Risk for injury related to chorea
NURSING INTERVENTIONS
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NURSING INTERVENTIONS
Improving Cardiac Output
Explain to the child and family the need for bed
rest
Organize nursing care Administer course of antibiotics as prescribed
Administer meds for CHF as directed
NURSING INTERVENTIONS
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NURSING INTERVENTIONS
Relieving Pain
Administer anti-inflammatory medication,
analgesics, and antipyretics
Monitor for signs of aspirin toxicity Tinnitus, nausea and vomiting, headache
Monitor for signs of corticosteroid use
Weight gain, rounded face, decrease resistance to infection
Administer with food
NURSING INTERVENTIONS
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NURSING INTERVENTIONS
Protecting the Child with Chorea
Use padded side rails
Assist with feeding
Avoid the use of straw and sharp utensils
Administer phenobarbital or other neurologic
agents as prescribed
EVALUATION
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EVALUATION
HR within normal range
Compliant with anti-inflammatory therapy
Feeds self, washes face and hands, and
ambulates without injury