Transcript 2016_Cardiovascular_Assessment 4.0 MB

Cardiovascular Assessment
for School Nurses
-Susan Dalton MSN, RN, CSN
Learning Objectives
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Comprehend the anatomy and physiology of
the cardiovascular system of the school age
child and adolescent
Perform a basic cardiovascular assessment
Differentiate abnormal heart sounds
Apply this knowledge to school nurse clinical
practice
Basic Flow
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https://www.youtube.com/watch?v=TMdKp2z
Hgog
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https://www.youtube.com/watch?v=JA0Wb3g
c4mE
Normal Heart Review
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The heart has four separate chambers. The
two upper chambers are called the right and
left atria.
The atria are receiving chambers for blood
returning from the body and the lungs.
The wall dividing the two atria is called the
atrial septum.
Normal Heart Review
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The lower two chambers are the right and left
ventricles.
The ventricles are muscular chambers
responsible for pumping blood to the body
and lungs.
The wall dividing the two ventricles is called
the ventricular septum.
Normal Heart Review
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There are four separate valves in the heart:
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Tricuspid valve
Pulmonary valve
Mitral valve
Aortic valve.
The valves open to allow blood flow forward
and close prevent any backflow
Normal Heart Review
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Superior and inferior vena cava drain blood
back from the heart to the right atrium
Pulmonary veins drain blood back from the
lungs to the left atrium.
Pulmonary artery connects to the right
ventricle and directs blood out to the lungs.
Aorta connects to the left ventricle and
directs blood out to the body.
Normal Heart Review
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Broad upper portion of the heart is called the
base
Narrower tip is called the apex
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Aortic area is at the right of the 2nd intercostal
space
Pulmonic valve is at the left 2nd intercostal space
Tricuspid area is at the left intercostal space
Mitral area is the 5th intercostal space just medical
to the mid-clavicular line
Point of Maximum Impulse (PMI)
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The PMI is the area of the chest where the
heart beat is palpated most clearly
Students > 7 years of age 5th intercostal
space midclavicular line
If the heart is enlarged the PMI will be felt
laterally
Students < 7 years of age the PMI is located
4th intercostal space midclavicular line
Use your fingertips to detect PMI
Heart Sounds
Focused Health History
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Family history of defects / early cardiac
disease / siblings with defects
Maternal history of stillborn or miscarriages
Congenital anomalies / genetic anomalies /
fetal alcohol spectrum disorder / Down
Syndrome and Turner Syndrome
Maternal exposure to rubella
Focused Health History
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Heart murmur
Tires while eating
Low weight for height
Sweats while eating (diaphoretic)
Cyanosis, worsens with feeding or activity
level
Focused Health History
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In the older child additional symptoms may
include:
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Chest pain
Decreased activity level
Syncope
Slight of build
Cardiovascular Assessment
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Before assessment of the cardiovascular system note the student’s
overall condition
Overall skin condition
 Pale
 Warm or cool
 Moist or dry
Look for the presence and progression of petechiae and purpura
 Petechiae appear as tiny dots and suggest a low platelet count
 Purpura appear as larger non-blanching purple discolorations
and may indicate septic shock
Cardiovascular Assessment
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Lower eyelids
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Inspect the palpebral conjunctivae should be pink
and moist but with poor cardiac perfusion they
may be pale
Check respiratory status
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Count the respiratory rate for a full minute and the
use of accessory muscles
Listen for decreased breath sounds or
adventitious breath sounds such as wheezing
Cardiovascular Assessment
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Palpate the chest wall in a systematic manner with the palmar surface of
your hand
Abnormalities
 Heaves
 Palpate using the palm or heel of your hand along the left sternal border
for signs of heaves.
 The presence of heaves is not normal.
 Thrills
 Thrill is likely to be in the right or left 2nd intercostal space
 Palpate in each of the valve areas for thrills. Thrills are often described
as similar to what one would feel when a hand is placed on a purring
cat.
 The presence of a thrill is not normal
 Caused by leaky valves, stenosed valves or abnormal blood flow
Cardiovascular Assessment
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Capillary Refill reflects skin perfusion and if delayed may indicate
abnormalities in cardiac output
Hold the student’s arm above the level of the heart, occlude the
blood flow by applying pressure to the fingertip and release the
pressure
Count the time it takes for a full return of blood to the blanched
tissue
Normal capillary refill is less than 2 seconds
Compare central and peripheral pulses and check the quality and
the equality of the pulses
Auscultation
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Assessment of heart sounds
Listen at the five precordial landmarks
Listen with the student in both a sitting and
reclining position.
If your hear differences listen with the student
in a left lateral recumbent position
Auscultation
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Begin using the diaphragm of your
stethoscope
Listen for the first and second heart sounds
The first sound is the lub and occurs when
the triscupid and mitral valve snap shut at the
beginning of systole
S1 is best heard at the apex of the heart over
the tricupsid and mitral valve
Auscultation
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The second heart sound which is the dub occurs when
the aortic and pulmonic heart valves close
S2 is best heard at the base of the heart at the aortic and
pulmonic sites
Erb’s point S1 and S2 are typically equal in sound and
volume
Common in children to hear an irregular rhythm that is
associated with the respiratory cycle
Rhythm called a sinus dysrhythmia and involves the
heart rate increasing with inspiration and decreasing with
expiration
Five Precordial Landmarks
Auscultation
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Aortic Valve Site.
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Pulmonic Valve Site
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Located halfway between the base and the apex of the heart
Tricupsid Valve
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Located at the 2nd intercostal space to the left of the sternum
Erb’s Point
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Located at the 2nd intercostal space to the right of the sternum.
Located at the 4th intercostal space along the left sternal border
Mitral Valve (PMI site)
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Located at the 5th intercostal space midclavicular line in students
7 years of age and older and 4th intercostal space midclavicular
line in students under 7 years of age. PMI site so listen at full
minute at this site
Auscultation
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Listening to heart sounds at each point “inch” your
stethoscope from one point to the next
Identify S1 and S2
If valves do not close simultaneously the heart sounds
may be split
Split heart sound sounds like a “stutter”
S3 following S2 may be heard in congestive heart failure
S4 is associated with hypertension, coronary heart
disease and myocardial infarction
S3 and S4 are low-pitched and may be easier to hear
with the bell of your stethoscope
Heart Murmurs
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After listening with the diaphragm listen again
with the bell
Listen to the spaces between S1 and S2
Blood should be moving smoothly and you
should hear nothing
Valve is stenotic or does not open completely
may cause a swishing or whooshing sound or
valve is regurgitant or incompetent causing
blood to leak backward through it, also causing
a murmur
Heart Murmurs
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These sounds are produced by blood passing
through a defective valve, great vessel, or
other heart structure.
Murmurs are classified by: intensity, location,
radiation, timing, and quality.
http://www.easyauscultation.com/heartsounds
Systolic murmur grading
-diastolic always ABNL
Pulses
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Weaker pulses or lower blood pressure in the
lower extremities may indicate coarctation of the
aorta (COA)
Bounding pulses can indicate a patent ductus
arteriosus (PDA) or aortic insufficiency.
Vital Signs
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Heart rate: tachycardia in the absence of
fever, crying, or stress may indicate cardiac
pathology.
Tachypnea, even with rest, chest retractions
indicate respiratory distress, possibly
resulting from congestive heart failure
Diagnostic Tests
Non-invasive
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Chest x-ray to define silhouette of the heart.
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Heart size, shape, pulmonary markings, and
cardiomegaly.
Electrocardiogram ECG or EKG to define
electrical activity of the heart.
Echocardiogram to visualize anatomic
structures.
Echocardiogram
Cardiac Catheterization
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An invasive test to diagnose or treat cardiac
defects.
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Visualizes heart and vessels.
Measures oxygen saturation of chambers.
Measures intra-cardiac pressures.
Determines muscle function and pumping action
of the heart.
Congenital Heart Disease
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Acyanotic disorders
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Increased Pulmonary Blood Flow
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Atrial Septal Defect
Ventricular Septal Defect
Patent Ductus Arteriosus
Atrioventricular Canal defect
Obstructive disorders
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Coarctation of the Aorta
Aortic Stenosis
Pulmonic Stenosis
Congenital Heart Disease
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Cyanotic disorders
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Decreased Pulmonary Blood Flow + shunt
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Tetralogy of Fallot
Tricuspid Atresia
Mixed Defects
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Transposition of the Great Arteries
Total Anomalous Pulmonary Venous Return
Truncus Arteriosus
Hypoplastic Left Heart Syndrome
Atrial Septal Defect (ASD)
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10% of defects
Blood in left atrium flows into right atrium
Pulmonary hypertension
Reduced blood volume in systemic circulation
If left untreated may lead to pulmonary
hypertension, congestive heart failure or
stroke as an adult.
80% resolve by 18 months
ASD
ASD
Diagnosis and Treatment
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Diagnosis: heart murmur may be heard in the
pulmonary valve area because the heart is
forcing an unusually large amount of blood
through a normal sized valve.
Echocardiogram is the primary method used
to diagnose the defect – it can show the hole
and its size and any enlargement of the right
atrium and ventricle in response to the extra
work they are doing.
Treatment of ASD
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Surgical closure of the atrial septal defect if
no closure by age 3
After closure in childhood the heart size will
return to normal over a period of four to six
months.
No restrictions to physical activity
post- closure
Ventricular Septal Defect
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VSD
30% of defects
Opening in the ventricular septum
Left-to-right shunt
Right ventricular hypertrophy
Deficient systemic blood flow
VSD
VSD
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Small holes generally are asymptomatic
Medium to moderate holes will cause
problems when the pressure in the right side
of the heart decreases and blood will start to
flow to the path of least resistance (from the
left ventricle through the VSD to the right
ventricle and into the lungs)
This will generally lead to CHF
Diagnosis and Treatment
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Diagnosis – heart murmur – a louder murmur
may indicate a smaller hole due to the force
that is needed for the blood to get through the
hole.
Electrocardiogram – to see if there is a strain
on the heart
Chest x-ray – size of heart
Echocardiogram – shows size of the hole and
size of heart chambers
Treatment VSD
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CHF: diuretics of help get rid of extra fluid in
the lungs
Digoxin if additional force needed to squeeze
the heart
FTT or failure to grow may need higher
calorie concentration
Will need prophylactic antibiotics before
dental procedures if defect is not repaired
Spont. Closure by 2 years in 50%
Larger defects need surgery
Surgical Repair
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Over a period of years the vessels in the
lungs will develop thicker walls – the pressure
in the lungs will increase and pulmonary
vascular disease
If pressure in the lungs becomes too high the
un-oxygenated blood with cross over to the
left side of the heart and un-oxygenated
blood with enter the circulatory system.
If the large VSD is repaired these changes
will not occur.
Coarctation of Aorta
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COA
7 % of defects
Congenital narrowing of the descending aorta
80% have aortic-valve anomalies
Difference in BP in arms and legs (severe
obstruction 20 mmHg upper)
COA
Diagnosis and Treatment
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In 50% the narrowing is not severe enough to
cause symptoms in the first days of life.
When the PDA closes a higher resistance
develops and heart failure can develop.
Pulses in the groin and leg will be diminished
Echocardiogram will show the defect in the
aorta
Epistaxis, dizziness, leg pain, H/A
Treatment
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Prostaglandin may given to keep the PDA open to
reduce the pressure changes
The most common repair is resection of the
narrowed area with re-anastomosis of the two ends
Surgical complications – kidney damage due to
clamping off of blood flow during surgery
High blood pressure post surgery – may need to be
on antihypertensives
Antibiotic prophylactic need due to possible aortic
valve abnormalities.
Aortic Stenosis
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6% of defects
Aortic valve: has two rather than three
leaflets. Leaflets are thickened or fused.
Obstruction of blood flow from left ventricle
Mild symptoms: dizziness, syncope, angina,
fatigue
30% incidence of sudden death
Aortic Stenosis
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Causes obstruction to blood flow between the
left ventricle and aorta.
Most common form is obstruction of the valve
itself
When the aortic valve does not open properly
the left ventricle must work harder to eject
blood into the aorta.
Left ventricular muscle becomes
hypertrophied.
AS
Diagnosis
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Heart murmur or AS is a turbulent noise
caused by ejection of blood through the
obstructed valve.
Electrocardiogram is usually normal
Echocardiogram will show the obstruction
and rule out other heart anomalies
Exercise stress test – provides information on
impact of the stenosis on heart function
Treatment
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Cardiac catheterization – balloon dilation of the
narrowed valve.
Surgical valvotomy if the closed procedure does not
work – often done when patient is older when
severe calcium deposits further obstruct the valve.
Recurrent valve obstruction is a complication and if
valve replacement is done too early the child may
outgrow the valve.
Antibiotic prophylaxis especially if valve replacement
Hypoplastic Left Heart Syndrome
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One of the most complex defects seen in the
newborn and the most challenging of all the
congenital defects
All the structures on the left side of the heart
are severely underdeveloped.
Mitral and aortic valves are either completely
closed or are very small – left ventricle is tiny
– aorta is small and often only a few
millimeters in diameter
Treatment
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Three staged procedure to reconfigure the
cardiovascular system
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Norwood – right ventricle becomes the systemic
ventricle pumping blood to the body
Glenn done at 3-6 months
Fontan done at 2 -3 years of age
Long Term Complications
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Easily tiring when participating in sports or
other exercises
Formation of blood clots – heparin or
Coumadin use
Heart arrhythmias – pacemaker
Cardiac failure
Interventions
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Fluid restriction
Diuretics – Lasix (potassium wasting) or
Aldactone (potassium sparing)
Bed rest
Oxygen
Small frequent feedings – soft nipple with
supplemental NG for adequate calorie intake
Pulse oximeter
Sedatives if needed
Digoxin Therapy
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Digoxin increases the force of the myocardial
contraction.
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Take an apical pulse with a stethoscope for 1 full
minute before every dose of digoxin. If
bradycardia is detected.
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< 100 beats / min for infant and toddler
< 80 beats in the older child
< 60 beats in the adolescent
Blood levels
Signs of Digoxin Toxicity
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Bradycardia
Arrhythmia
Nausea, vomiting, anorexia
Dizziness, headache
Weakness and fatigue
Halos
Lasix (Furosemide)
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ACTIONS:
Potent Diuretic
Used for severe CHF
Causes excretion of Cl- and K+
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SIDE EFFECTS:
Nausea and vomiting
Diarrhea
Ototoxcity
Decreased K+
Dermatitis
Postural hypotension
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ASSESSMENT AND INTERVENTIONS:
Intake and output
Observe for dehydration
Observe for signs and symptoms of digoxin toxicity
Encourage increased potassium intake
Captopril
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Vasodilation = decreased pulmonary and systemic vascular resistance
(decreased B/P),
decreased afterload,
decreased right and left atrial pressures
decrease aldosterone (decreased preload),
increase renal perfusion
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SIDE-EFFECTS:
Decrease blood pressure
Renal dysfunction
cough
fever
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May change to Vasotec when older due to less side effects and BID dosing
Chlorothiazide (Diuril)
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ACTIONS:
Diuretic
Causes excretion of K+
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SIDE EFFECTS:
Nausea
Dizziness
Skin eruptions
Weakness
Muscle Cramps
Decreased K+
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SPECIAL CONSIDERATIONS:
Inexpensive
Frequently used
May be used on an intermittent basis
Encourage increased K+ intake
Sprinolactone (Aldactone)
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ACTIONS:
Potassium sparing diuretic
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SIDE EFFECTS:
Skin rash
Drowsiness
Ataxia
Increased K+
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SPECIAL CONSIDERATIONS:
Poorly absorbed from the GI tract
Do not give potassium supplements
Bacterial Endocarditis
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Infection of endocardial surface of the heart
History of CHD, Kawasaki Disease,
Rheumatic Fever, or prosthetic valves are
more susceptible to infection
Prophylactic antibiotics with dental care,
throat, intestinal, urinary or vaginal infections
or surgery.
SBE Sub-acute Bacterial endocarditis
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Assessment:
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Fever
Fatigue
Muscle and joint pain
Headache
Nausea and vomiting
CHF
Splenomegaly
Diagnosis:
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Blood cultures
Echocardiogram
Antibiotic Prophylaxis for Children at Risk for
Infective Endocarditis
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Dental procedures, including cleaning, that may induce
gingival or mucosal bleeding
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Tonsillectomy and/or adenoidectomy
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Surgery and/or biopsy involving respiratory or intestinal
mucosa
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Incision and drainage of infected tissue
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Invasive GU and GI procedures
Kawasaki Disease
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Acute-self limiting disease
Generalized vasculitis; risk of aneurysm
Peak incidence 6 months to 2 years
More common in males and Japanese
Elevated WBC,ESR, platelets
Clinical Manifestations
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High fever
Conjunctivitis – no drainage
Strawberry tongue
Edema of hands and feed
Reddening of palms and soles
Lymph node swelling
Edema – Hands and Feet
Peeling Finger Tips
Interdisciplinary Interventions
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Intravenous gamma globulin (avoid MMR and
Varivax for up to 11 months after admin)
High dose of ASA while in hospital
Low dose ASA upon discharge-S/S Reye’s
ECHO to assess coronary artery status
ROM to joints if stiffness
References
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Hockenberry, M. and Wilson, D. (2015).
Wong’s nursing care of infants and children
(10th ed). St. Louis, MO. Elsevier Mosby
Selekman,J. (2013). School nursing a
comprehensive text (2nd ed.). Philadelphia,
PA. F.A. Davis.