help!
Low NIRs, hypotension, poor perfusion (cold, clammy, weak peripheral pulses), decreased urine output
How is blood flow determined within the heart?
Blood flow is determined by the pressure gradient within the heart and blood will always travel the path of least resistance
List the left to right shunts
Atrial Septal Defect, Ventricular Septal Defect, Patent Ductus Arteriosus, Atrioventricular Septal Defect
You are trying to organize your tasks for the day. You have orders to start cefepime, pull the ETT out by 0.5 cm, get a blood culture, and fortify feeds to 24 cal. You also need to print breast milk labels and feed your other patient. In which order do you complete these tasks?
Pull and retape ETT, blood culture, start cefepime, fortify feeds. You will need 2 people to retape and do the blood culture. You can utilize unit resource, charge, or another RN to complete these tasks. For the labels and feeding the other patient you can utilize a PCT.
What are the three types of hypoplastic left heart? Why do they saturate 75-85%?
Mitral Stenosis/Aortic Stenois
Mitral Stenosis/Aortic Atresia
Mitral Atresia/Aortic Atresia
They saturate lower because oxygen rich and oxygen poor blood mix in the heart.
In the arterial switch procedure, the surgeon manipulates the coronary arteries. What is a potential complication of this intervention?
ST segment changes as a result of decreased cardiac output or myocardial ischemia
Describe the blood flow of a normal heart
SVC/IVC
Right Atrium
Tricuspid Valve
Right ventricle
Pulmonary Valve
Pulmonary Arteries
Lungs
Pulmonary Veins
Left Atrium
Mitral Valve
Left Ventricle
Aortic Valve
Aorta
A PDA dependent patient needs to be on [ ] preoperatively. Side effects of this medication might include [ ].
Prostaglandin/PGE; side effects include apnea, fever, hypotension
Your patient is actively being paced for complete heart block. What should your safety checks include?
Check settings on pacemaker, battery check and extra batteries, backup pacemaker in room, dressing intact, pacemaker wires easily accessible.
What are the three goals of the Norwood procedure?
restricted pulmonary blood flow, unobstructed pulmonary venous return, unobstructed systemic blood flow
Your post op neonatal patient is tachycardic, hypotensive, and has a high CVP. You have had 5 mls of chest tube output in the past 8 hours. What diagnosis do you anticipate? What is an immediate intervention you can perform?
cardiac tamponade; strip your chest tube!
Does increased heart rate ALWAYS mean increased cardiac output?
Not always - tachycardia may decrease filling time, which will decrease cardiac output
What is a TET spell and how do you treat it?
A tet spell is an acute episode of hypoxia from an infundibulum spasm that causes increased RVOTO/PVR and decreased SVR. Treat by putting knees to chest, fluid bolus to increase preload, morphine, phenylephrine
Your patient's chest tube fell out when transferring back to bed. Now they are crying, desaturated, tachycardic, tachypneic, and have asymmetrical chest movement. What diagnosis do you anticipate and what interventions can you do in the meantime? How might you confirm your diagnosis?
pneumothorax; use your petroleum dressing, gauze, and Tegaderm (should be at the bedside & part of safety checks!); we can confirm this with CXR and listening for breath sounds
You were just told that the Glenn you are admitting is coming out intubated. Why is this a concern?
Positive pressure ventilation inhibits the passive blood flow of the Glenn
Your patient is a redo-sternotomy who was in the OR for several hours. They are hypotensive, have required several different blood products, and have abnormal coags. Now they just had a massive dump in their chest tube output. You may anticipate activating the [ ].
massive transfusion protocol - helps decrease risk of electrolyte imbalances and coagulopathy when large amounts of blood product are required; can find protocol in the charge book
What is CVP?
Central venous pressure - a measure of right atrial pressure. Can be used as a measure of the patient's volume status/preload.
After a Norwood procedure the patient with HLHS will receive systemic blood flow via the [ ] and pulmonary flow via the [ ] or [ ]. This patient would be highly dependent on a balanced QP which is [ ] and QS which is [ ].
systemic - neoaorta (formed by combining the patient's pulmonary artery with their hypoplastic aorta)
pulmonary - sano (RV to PA) or BTT shunt (shunt from PA to subclavian artery)
QP - pulmonary blood flow
QS - systemic blood flow
What do you anticipate with a transthoracic line removal? What are the risks you should always anticipate and how do we prepare for them?
Transthoracic lines are inserted directly into the heart. This makes it high risk for bleeding. The provider removing the line will be aware that if there is significant external bleeding with removal it may require a blood transfusion (why we always have a PIV prior to removal of the line). If there is no external bleeding at all the patient could still be bleeding internally. This could lead to cardiac tamponade. If we cannot control the bleeding the patient may need surgical intervention which is why these patients are made NPO. The patient always receives an echo after removing this line to check for effusion. Protect this line with all transfers and turns!!!
What are the signs of a failing fontan?
fatigue, shortness of breath, signs of fluid overload, edema, hepatomegaly, ascites, jaundice, cyanosis
Your patient is post op AVC repair with trisomy 21. What would be some signs that the patient is experiencing a pulmonary hypertensive crisis? How would we treat this?
Signs - tachycardia, narrow pulse pressure, hypoxia, hypercarbia, low etCO2. Treat with oxygen, epo, iNO, treat agitation with sedation, milrinone, support RV function and decrease RV afterload, and give PHTN meds
In neonates, contractility is very dependent on which electrolyte? How might you determine good vs poor contractility?
What are MAPCAS, which type of shunt are they associated with and where/why do they form?
Major Aortopulomonary Collateral Arteries; formed in right to left shunts (pulmonary atresia with VSD; TOF). They form on the descending aorta in order to supply blood flow to the lungs. They compensate for hypoplastic pulmonary arteries.
You were told to pull your ETT out by 1 cm based on the CXR. How do you know this needs to be done and what kind of symptoms might you see if you do not intervene?
The ETT would be deep or near the carina on CXR. The carina is the end of the trachea where it splits into the right and left bronchi. You may hear louder breath sounds on the right side of the lungs. The patient by drop their heart rate with suctioning due to the closeness to the carina. Your patient would be at risk for trauma and bleeding with suctioning.
What patients are "interstage"? What makes an interstage patient "high risk"?
Interstage is the period between the norwood and the glenn. A patient would have the highest risk if they are oxygen dependent and have moderate tricuspid regurgitation.