05-15 Pediatric Nursing

Rheumatic Fever

An infection involving the heart, CNS, joints, subcutaneous tissue, and the skin caused by Group A Beta-hemolytic Streptococcus.

• Risk Factors: children with dental caries (check-up once every 6 months), those who have had recent or recurrent strep throat, immunocompromisation

JONES Criteria

In Rheumatic Fever, the child presents with two major manifestations or one major with two minor manifestations.

1. Major: heart carditis, CNS chorea, joint polyarthritis, subcutaneous nodules, skin erythema marginatum.
2. Minor: fever, history of strep. infection (ask for sore throat), elevated laboratory findings (anti-streptolysin O titer [ASOT]), arthralgia
   • ASOT Lab Findings:
     • 150 to 250: (inc.)

     • 250 to <500: Dormant RF

     • 500 to <5000: Active RF

     • 5000: Rheumatic Heart Disease

   • ESR, increased during hyperemia.
   • CRP, produced by the liver in response to inflammation and tissue damage. This is used to determine both the presence of inflammation and response to treatment.

Pathophysiology

1. Spread of GABHS to the pulmonary system, through pulmonary circulation, to the mitral valve (proliferation) of the heart results in the major manifestations:
   • Carditis
   • CNS Chorea
   • Polyarthritis: inflammation
   • Subcutaneous Nodules
   • Erythematous Marginatum
2. Mitral Valve Stenosis: damage to the mitral valve from GAHBS. Left ventricular hypertrophy occurs for compensation. This backs up to the left atrium and pulmonary circulation, resulting in LSCHF. Crackles and moist coughing occurs from pulmonary edema.
   • Lanoxin (Digitalis) increases heart contraction, while decreasing heart rate. This results in bradycardia. Do not administer Lanoxin if heart rate is less than (adult) 100 (infant), 90 (toddler, 80 (preschooler), 70 (school-age), 60 bpm (adolescent/adult). Decreased cerebral perfusion alters LOC.

Nursing Management

1. Fever, Pain (polyarthritis), Inflammation, Thrombotic Formation
   • Aspirin fulfills all of these problems within a child (antipyretic, analgesic, antiinflammatory effect, thrombolytic effect). The main purpose is for its antiinflammatory effect on polyarthritis.
2. Diet: high calorie, high fiber, low sodium, and soft diet. If polyarthritis affects the temporomandibular joint, NGT/OF may be required.
3. Polyarthritis: pain may be produced even by thin linens. A bed cradle is created and formed as a tent, to maintain thermoregulation without placing weight on the patient directly.
   • Fractured TSB may be required to reduce discomfort. Avoid the joints, and only pat the patient. Place a moist towel on the forehead, torso, and axillary areas.

Treatment

Penicillin is the drug of choice, combined with erythromycin and benzanthin penicillin. 2. Oral: Erythromycin with Penicillin 3. Monthly injection of 1 gram benzathine penicillin (twice a month, 500 mg per dose).

---

Congenital Heart Defects

Rubella is the most common cause of CHD, in the first trimester of pregnancy. The most common complication is CHF. The most common cause of CHF in children is CHD.

Acyanotic CHD

1. Obstructive Lesions: narrowing or obstructions in the blood vessels or valves.
   • Pulmonic Valve Stenosis: decreased flow causes right ventricular hypertrophy (compensation), eventually resulting in backflow towards the right atrium, IVC, lower extremities, then hepatosplenomegaly ensues. Management is .
   • Aortic Valve Stenosis: decreased flow causes left ventricular hypertrophy, eventually resulting in backflow towards the left atrium, pulmonary circulation (pulmonary edema). Management is valve placement.
   • Coarctation of the Aorta: narrowing often found in the descending aorta. This diverts blood to the ascending arteries, increasing blood pressure in the upper extremities. Characteristic of COA is Upper Extremity Hypertension. Manifestations of low perfusion.
2. Left-to-Right Shunting: oxygenated blood enters the deoxygenated blood compartments.
   • Atrial Septal Defect: increased blood volume in the right atrium, which results in increasing rate of contraction, then back to systemic circulation. Management is a dacron or teflon patch in an open heart surgery.
   • Ventricular Septal Defect (most common): eventually results in right ventricular hypertrophy, which reverses the shunt (rarely). Management is patching in an open heart surgery.
   • Atrioventral Septal Defect/Atrioventricular Canal Defect: Management is patching (VSD first, then ASD).
   • Patent Ductus Arteriosus (among the most common): a connection between the aorta and pulmonary artery, classified as a left-to-right shunt despite having no septal defects. Machinery murmurs can be heard as this is outside of the heart.
     • Indomethacin stimulates closure of the PDA. Prostaglandin keeps it open (used in ToGV to compensate). If unresolved, closed heart surgery is done.

Cyanotic CHD

1. Right-to-Left Shunt: deoxygenated blood enters the oxygenated blood compartments.
   • Tetralogy of Fallot: A combination of (mn. PROV) pulmonic ventricular stenosis, right ventricular hypertrophy (boot shaped heart), overriding of aorta, and ventricular septal defect.
   • ToGV: transposition of great vessels; swapping of the pulmonary artery and aorta routes. Systemic and pulmonary circulation becomes isolated from one another. A patent ductus arteriosus (maintained open with prostaglandin) and a patent foramen ovale allow for circulation to persist, even if minimally.
   • Tricuspid Atresia: malformation; no tricuspid valve is present. The intake route for the right ventricle is closed. This exists with a patent foramen ovale and a ventricular septal defect, otherwise circulation would fail. Management is addition of an artificial valve (which closes the PFO), then VSD patching.

Care of the Baby with Cyanotic CHD

These babies experience cyanosis, clubbing of the fingers, polycythemia, tet. spell, delayed physical growth (also in Acyanotic CHD), murmurs (also in Acyanotic CHD)

Tetralogy of Fallot

1. Chronic Hypoxemia: tachycardia, tachypnea (poses risk for aspiration during breastfeeding; prevent with head elevation).
   • Clubbing of fingers are checked with the camroth window test, bringing the two backs of the nails together, which should form a diamond window.
   • Immature RBC will be produced by a stimulated bone marrow, acting as compensation. This increases blood viscosity, increasing platelet clotting. Management: aspirin as a thrombolytic.
2. Hypercyanotic Spell: sudden cyanosis of the lips or fingernail beds; AKA Tet. Spell, Choking Spell. Management is a squatting (ideal) or knee-chest position that facilitates impeded IVC flow, which enables oxygenated blood to enter the overriding aorta.
3. Risk for infection: frequent hand washing, avoid crowded places, avoid contact with persons with (respiratory) infection, masking when necessary. Prophylactic antibiotic therapy may be prescribed.
4. Delayed physical growth and development: high caloric requirements, high fiber (prevent constipation), low sodium (decrease fluid volume; lonalac formula). To promote development, allow the child to regulate their own activities.

---

Example Questions

1.) Which of the following confirms the presence of streptococcal infection? A. Increased WBC B. Increased CRP C. Increased Antibody Level D. None of the Above

2.) If the child will undergo a tonsillectomy, what is the number one rule? A.) The child must be afebrile for 1 week before the surgery B.) Bleeding and clotting (PT, PTT) should be normal. C.) Obtain consent from the patient D.) RBC count should be normal.

3.) What is the sign of postoperative bleeding from tonsillectomy? A. Frequent swallowing B. Difficulty of breathing

4.) What is the normal body temperature in fahrenheit? A.) 98.6 B.) 100.6 C.) 97.6 D.) 99.6

5.) A child is scheduled for a tonsillectomy and has a temperature of 100.8F. What is the nursing action? A.) Inform the physician B.) Tepid Sponge Bath C.) Administer Paracetamol D.) Call the OR to cancel the surgery.

6.) After tonsillectomy, the child is experiencing pain. What is the best nursing action? A.) Vanilla Ice Cream B.) Ice Chips C.) Cold Orange Juice D.) None of the Above

7.) At what level does a preschooler become bradycardic? A.) 60 BPM B.) 80 BPM C.) 90 BPM D.) 100 BPM

8.) What is indicative of therapeutic digitalis treatment? A.) Increased BP B.) Increased HR C.) Increased UO D.) None of the Above

9.) Various ways to determine NGT placement? X-ray, Aspiration of Gastric Content, Auscultation of Air Instillation, and Immersion (placement of outlet into a water basin to check if the tube is in the airway instead of the stomach) 10.) The most prevalent cyanotic heart defect: Tetralogy of Fallot 11.) The most prevalent acyanotic heart defect: Ventricular Septal Defect

12.) What is the most common cause of congenital heart disease? A.) Rubella B.) Maternal infection C.) Premature birth D.) Drug use during pregnancy

13.) Where does the pulmonary artery originate from? A.) Right Atrium B.) Right Ventricle C.) The Lungs D.) Left Ventricle

14.) Where does the aorta originate from? A.) Left Atrium B.) Left Ventricle C.) Pulmonary Circulation D.) Right Ventricle

15.) What occurs in left-to-right shunting? A.) Increased pulmonary blood flow B.) Decreased pulmonary blood flow

16.) What occurs in right-to-left shunting? A.) Increased pulmonary blood flow B.) Decreased pulmonary blood flow

17.) What postoperative activity should be avoided after COA repair? A.) Crying B.) Coughing C.) Sleeping D.) Constipation

18.) Which of the following is commonly seen among children with CHD? A.) Delayed physical growth B.) Cyanosis C.) Clubbing of fingers D.) None of the above

19.) Which of the following is not commonly seen among babies with left-to-right shunt CHD? A.) Delayed physical growth B.) Murmurs C.) Clubbing of fingers D.) None of the above

20.) What type of formula will be giveno a baby with CHD? A.) Lonalac, a low sodium formula B.) Lofenalac, a low phenylalanine formula

21.) A 10-year-old child with mild TOF is experiencing a Tet. Spell. She is found in a squatting position. What will be the nurse’s initial course of action? A.) Bring the child to the nearest hospital B.) Observe the child C.) Call the doctor of the child as soon as possible D.) Administer O2 therapy

22.) A 10-year-old child with mild TOF has issues with growth and development. Which teaching for parents is appropriate? A.) Allow the child to regulate their own activities. B.) Prohibit the child from participating in any physical activities. C.) Limit the child’s activities to within the home. D.) Allow the child to perform any activities they want.