Peds, part 25: Cardiovascular Disorders - Heart Failure and Hypoxemia
by Cathy Parkes December 29, 2021 Updated: March 20, 2022 5 min read
Hi. I'm Cathy with Level Up RN. In this video, we are going to talk about heart failure and hypoxemia, which are two big things that occur when a patient has a congenital heart defect. At the end of the video, I'm going to give you guys a little quiz to test your knowledge of some of the key points I'll be covering in this video, so definitely stay tuned for that. And if you have our Level Up RN pediatric nursing flashcards, definitely pull those out so you can follow along with me.
Heart failure is the inability of the heart to adequately supply blood to meet the body's needs. And this may be due to a congenital heart defect. It could be due to cardiomyopathy, which is a disease of the heart muscle, or some other cardiac abnormality. So with heart failure, we end up with volume overload on the heart muscle and/or pump failure. So general signs and symptoms of heart failure can include poor feeding, tachycardia, activity intolerance, pallor, weak pulses, as well as cardiomegaly, so enlargement of the heart. We can also end up with pulmonary congestion with left-sided heart failure. So symptoms of left-sided heart failure include tachypnea, dyspnea, as well as nasal flaring, retractions, and wheezing, so issues with breathing. If we are dealing with right-sided heart failure, that will cause systemic congestion, and it will cause symptoms such as peripheral edema, ascites, as well as hepatomegaly - so enlargement of the liver - and jugular vein distension.
So we have some Cool Chicken hints on the card here to help you remember what symptoms are associated with left-sided heart failure and right-sided heart failure. So with left-sided heart failure, that primarily affects the lungs, and with right-sided heart failure, that affects the rest of the body. And if you think about the blood flow through the heart, it really makes sense. So we have blood that is coming in to the right side of the heart, then going to the lungs, and then to the left side of the heart, and then out to the body. So if the left side of the heart is not functioning correctly, that blood is going to back into the lungs. What about the right side? So the blood's coming into the right side of the heart, and if the right side of the heart is not functioning correctly, that blood is going to back up into the body and cause that systemic congestion. So I hope that Cool Chicken hint, as well as that explanation, helps you to remember what you can expect with left- versus right-sided heart failure.
Diagnostic tools that are helpful in the diagnosis of heart failure include an echocardiogram, EKG, as well as a chest X-ray. In addition, when we obtain labs, the HBMP level will be elevated. So HBMP is a hormone that is released by the heart in response to stretching of that heart muscle, which we definitely have with heart failure because we have this fluid volume overload on the heart, and that will result in stretching, which results in the release of HBMP. In terms of treatment, digoxin is going to be a key medication used to help improve contractility of the heart. So it will slow down the heart rate and help those contractions be more effective and efficient. In addition, we would provide diuretics such as furosemide to help get rid of that excess fluid. And then other medications that are used to treat heart failure include beta blockers and ACE inhibitors.
In terms of nursing care, because our patients with heart failure have poor feeding, we're going to make sure our child is sitting upright while they're eating, and we want to use a nipple with an enlarged opening to help decrease the amount of energy required by the child while they are feeding. In addition, we may need to use high-calorie formula to help supplement their calorie intake, and then we want to make sure we are providing frequent rest periods because the child's going to have activity intolerance. And then when we are administering digoxin, we absolutely want to take the child's pulse before administration. And we would hold the digoxin - so do not administer it - for a pulse rate under 90 beats per minute for infants or under 70 beats per minute for older children, or per orders. And then we want to monitor for signs and symptoms of digoxin toxicity, which can include nausea and vomiting, bradycardia, as well as dysrhythmias. And then we're going to want to closely monitor the patient's serum digoxin levels. So the therapeutic range for that typically is between 0.8 and 2.
Next, let's talk about hypoxemia, which is where we have inadequate oxygenation of the blood. This in turn can cause hypoxia, which is where we have inadequate oxygenation of the body's tissues. And congenital heart defects are a key thing that can cause hypoxemia. Other causes include respiratory disorders, as well as anemia. In the case of congenital heart defects, many of those defects cause unoxygenated blood to enter systemic circulation. So that's how congenital heart defects cause hypoxemia. Signs and symptoms of hypoxemia include cyanosis, tachypnea, dyspnea, clubbing - which is where we have those upside-down, spoon-shaped nails - as well as polycythemia. So with polycythemia, the body is compensating for that lack of oxygenation in the blood by increasing the amount of red blood cells it produces. So the body is like, "Oh no, we don't have enough oxygen. Let's crank out some more red blood cells." So polycythemia is an elevation in red blood cells in response to the hypoxemia. In terms of diagnosis, ABGs will show a decrease in the partial pressure of oxygen. We will also see decreased oxygen saturation with pulse oximetry. In terms of treatment, we can provide oxygen, morphine, as well as IV fluids to the child. And then for cyanotic episodes, we would want to place the child in a knee-chest position to help improve blood flow to the lungs.
All right, it's time for a quiz. I've got three questions for you. First question. What medication is used to improve heart contractility in a child with heart failure? The answer is digoxin. Question number two. When feeding a child with heart failure, why is a nipple with an enlarged opening used? The answer is to decrease the amount of energy required during feeding. Question number three. Blank is an increase in red blood cells to compensate for hypoxemia in a child with a congenital heart defect. The answer is polycythemia. All right. That's it for this video. I hope it was helpful. Take care and I'll see you soon.
In terms of other diagnostic tools we can use to diagnose hypoxemia, if-- I wasn't ready. [Ugh?]. Signs and symptoms of hypoxemia includes cyanosis, tachycardia, [inaudible]. I can't talk today. [inaudible] or some other cardiac abnormality. And it causes [inaudible].
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