NCLEX: Health Promotion and Maintenance

Health Promotion and Maintenance: CARDIOVASCULAR SYSTEM

Focus topic: Health Promotion and Maintenance


Focus topic: Health Promotion and Maintenance

A. Introduction: There are more than 35 documented types of congenital heart defects, which occur in 5 to 8 per 1000 live births. For the purpose of this review, only five major defects are given.content has been synthesized for ease in review and recall; for additional study aids, the student may wish to refer to Comparison of Acyanotic and Cyanotic Heart Disease and Overview of the Most Common Types of Congenital Heart Disease Chapter 6 also contains information on congestive heart failure, and Chapter 8 covers the most commonly used drugs, including digoxin and furosemide (Lasix).

Health Promotion and Maintenance

Health Promotion and Maintenance

Health Promotion and Maintenance

Health Promotion and Maintenance

Health Promotion and Maintenance

B. Assessment:

Focus topic: Health Promotion and Maintenance

B. Assessment:
1. Exact cause unknown, but related factors include:

a. Familial history of CHD, especially in siblings, parents.
b. Presence of other genetic defects in infant (e.g., Down syndrome, trisomy 13 or 18).                                                                                                                              c. History of maternal prenatal infection with rubella, cytomegalovirus, etc.
d. High-risk maternal factors:

  • Age: under 18 years, over 40 years.
  • Weight: under 100 lb, over 200 lb.
  • Maternal type 1 (insulin-dependent) diabetes.

e. Maternal history of drinking during pregnancy, with resultant “fetal alcohol syndrome.”
f. Extracardiac defects, including tracheoesophageal fistula, renal agenesis, and diaphragmatic hernia.

Health Promotion and Maintenance

Health Promotion and Maintenance

2. Most frequent parental complaint: difficulty feeding.

  • Infant must be awakened to feed.
  • Has weak suck.
  • May turn blue when eating, especially with cyanotic defects.
  • Infant takes overly long time to feed.
  • Falls asleep during feeding, without finishing.

3. Nursing observations

a. Most frequent symptom—tachycardia, as body attempts to compensate for lack of oxygen (hypoxia): heart rate over 160 beats/min.
b. Tachypnea, corresponding to heart rate: respirations over 60 breaths/min.
c. Cyanosis due to hypoxia:

  • Not with acyanotic defects (unless CHF is present).
  • Always with cyanotic defects (“blue infants”).

d. Failure to grow at a normal rate: slow weight gain, height and weight below the norm due to difficulty feeding and hypoxia.
e. Developmental delays related to weakened vphysical condition.
f. Frequent respiratory infections associated with increased pulmonary blood flow or aspiration.
g. Dyspnea on exertion due to hypoxia, shunting of blood.
h. Murmurs may or may not be present (e.g., patent ductus arteriosus [PDA] machinery murmur).
i. Changes in blood pressure (e.g., coarctation— increased blood pressure in arms; decreased blood pressure in legs).
j. Possible congestive heart failure—refer to Chapter 6. Note: Infants may not demonstrate distended neck veins and may have difficult-to-detect generalized edema if not yet walking—check for facial, scrotal edema.
k. Cyanotic heart defects:

  • Tet spells”—choking spells with paroxysmal dyspnea: severe hypoxia, deepening cyanosis; relieved by placing infant in knee-chest position, which alters cardiopulmonary dynamics, thus increasing the flow of blood to the lungs.
  • Clubbing of fingers and toes—due to chronic hypoxia.
  • Polycythemia (increased red blood cells [RBCs]) with possible thrombi/emboli formation.

C. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Ineffective breathing pattern related to tachypnea and respiratory infection.
  • Activity intolerance related to tachycardia and hypoxia.
  • Altered nutrition, less than body requirements, related to difficulty in feeding.
  • Risk for infection related to poor nutritional status.
  • Knowledge deficit related to diagnostic procedures, condition, surgical/medical treatments, prognosis.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: promote adequate oxygenation.

  • Administer oxygen per physician’s order/prn.
  • Use loose-fitting clothing; tape diapers loosely to avoid pressure on abdominal organs, which could impinge on diaphragm and impede respiration.
  • Position: neck slightly hyperextended to keep airway patent; place in knee-chest position to relieve “tet spell” (choking spell).
  • Suction prn to clear the airway.
  • Administer digoxin, per physician’s order, to slow and strengthen heart’s pumping action (refer to Chapter 8 and pediatric pulse rate norms).
  • Monitor pulse oximetry, as ordered.

2. Goal: reduce workload of heart to conserve energy.

  • Position: infant seat, semi-Fowler’s to promote maximum expansion of the lungs.
  • Provide pacifier to promote psychological rest.
  • Organize nursing care to provide periods of uninterrupted rest.
  • Adjust physical activity according to child’s condition, capabilities to conserve energy.
  • Provide diversion, as tolerated, to meet developmental needs yet conserve energy.
  • Avoid extremes of temperature to avoid the stress of hypothermia/hyperthermia, which will increase the body’s demand for oxygen.
  • Administer diuretics (Lasix), per physician’s order, to eliminate excess fluids, which increase the heart’s workload. Note: Refer to Chapter 8.

3. Goal: provide for adequate nutrition.

  • May need standard infant formula with ↑ caloric density to minimize fluid retention and meet nutritional needs.
  • Discourage foods with high or added sodium to minimize fluid retention.
  • I&O, daily/weekly weights, and monitor for rate of growth.
  • Limit PO feedings to 20 minutes to avoid overtiring infant. Supplement PO feeding with gavage feeding (prn with physician’s order) to meet fluid and caloric needs.
  • Encourage foods high in potassium (prevent hypokalemia) and high in iron (prevent anemia). Note: Refer to Chapter 9.

4. Goal: prevent infection.

  • Standard precautions to prevent infection.
  • Use good hand-washing technique.
  • Limit contact with staff/visitors (especially children) with infections.
  • Monitor for early symptoms and signs of infection; report STAT.

5. Goal: meet teaching needs of client, family.

  • Explain diagnostic procedures: blood tests, x-rays, urine, ECG, echocardiogram, cardiac catheterization.
  • Explain condition/treatment/prognosis.
  • Review nutrition and medications.
  • Discuss how to adjust realistically to life with congenital heart disease, activity restrictions, etc.

E. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • Child’s level of oxygenation is maintained, as evidenced by pink color in nail beds and mucous membranes (for both light- and dark-skinned children) and ease in respiratory effort.
  • Energy is conserved, thus reducing the heart’s workload as evidenced by vital signs within normal limits.
  • The child’s fluid and caloric requirements are met, allowing for physical growth to occur at normal or near-normal rate.
  • The family (and child, when old enough) verbalize their understanding of the type of CHD, its treatment, and prognosis.
  • The family and child demonstrate adequate coping mechanisms to deal with CHD.


Focus topic: Health Promotion and Maintenance

A. Introduction: Rheumatic fever is an acute, systemic, inflammatory disease affecting multiple organs and systems: heart, joints, CNS, collagenous tissue, etc. Thought to be autoimmune in nature, it most commonly follows a streptococcus infection (Fig. 5.8) and occurs primarily in school-age children. In addition, it tends to recur, and the risk of permanent heart damage increases with each subsequent attack of rheumatic fever.

B. Assessment:

Focus topic: Health Promotion and Maintenance

1. Major manifestations (modified Jones criteria)

  • Carditis: tachycardia, cardiomegaly, murmur, congestive heart failure (CHF).
  • Migratory polyarthritis: swollen, hot, red, and excruciatingly painful large joints; migratory and reversible.
  • Sydenham’s chorea (St. Vitus’ dance): sudden, aimless, irregular movements of the extremities; involuntary facial grimaces, speech disturbances, emotional lability, muscle weakness; completely reversible.
  • Erythema marginatum: reddish pink rash most commonly found on the trunk; nonpruritic, macular, clear center, wavy but clearly marked border; transient.
  • Subcutaneous nodules: small, round, freely movable, and painless swellings usually found over the extensor surfaces of the hands/feet or bony prominences; resolve without any permanent damage.

Health Promotion and Maintenance

2. Minor manifestations

a. Clinical

  • Previous history of rheumatic fever.
  • Arthralgia.
  • Fever—normal in morning, rises in midafternoon, normal at night.

b. Laboratory

  • Increased erythrocyte sedimentation rate (ESR).
  • Positive C-reactive protein.
  • Leukocytosis.
  • Anemia.
  • Prolonged P-R/Q-T intervals on ECG.

3. Supportive evidence

a. Recent history of streptococcus infection:

  • Strep throat/tonsillitis.
  • Otitis media.
  • Impetigo.
  • Scarlet fever.

b. Positive throat culture for streptococcus.
c. Increased antistreptolysin-O (ASO) titer: indicates presence of streptococcus antibodies; begins to rise in 7 days, reaches maximum level in 4 to 6 weeks.

C. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Decreased cardiac output related to carditis.
  • Pain related to migratory polyarthritis.
  • Risk for injury related to chorea.
  • Diversional activity deficit related to lengthy hospitalization and recuperation.
  • Knowledge deficit related to preventing cardiac damage, relieving discomfort, and preventing injury.
  • Ineffective management of therapeutic regimen with long-term antibiotic therapy and followup care.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: prevent cardiac damage.

  • Hospitalization, with strict bedrest.
  • Monitor apical pulse for changes in rate, rhythm, murmurs.
  • Evaluate tolerance of increased activity by apical rate: if heart rate increases by more than 20 beats/min over resting rate, child should return to bed.
  • Offer low-sodium diet to prevent fluid retention.
  • Administer oxygen, digoxin/Lasix as ordered (if CHF develops). Note: Refer to Chapter 6 for additional information on CHF.

2. Goal: relieve discomfort.

  • Use bed cradle to keep linens from resting on painful joints.
  • Administer aspirin as ordered to relieve pain.
  • Move child carefully, minimally—support joints.
  • Do not massage; do not perform range-ofmotion (ROM) exercises; do not apply splints; do not apply heat/cold. All these treatments will cause increased pain and are not needed, because no permanent deformities will result from this type of arthritis.

3. Goal: promote safety and prevent injury related to chorea.

  • Use side rails: elevated, padded.
  • Restrain in bed if necessary.
  • No oral temperatures—child may bite thermometer.
  • Spoon-feed—no forks or knives, to prevent injury to oral cavity.
  • Assist with all aspects of ADLs until child can care for own needs.

4. Goal: provide diversion as tolerated.

  • Encourage quiet diversional activities: hobbies, reading, puzzles.
  • Get homework, books; provide tutor as condition permits.
  • Encourage contact with peers: telephone calls, letters, cards.

5. Goal: encourage child and family to comply with long-term antibiotic therapy.

  • Begin antibiotics immediately, to eradicate any lingering streptococcus infection.
  • Duration of prophylaxis varies (5 years → lifelong) and depends on cardiac involvement.
  • Stress need to adhere to prescribed prophylaxis schedule.
  • Enlist child’s cooperation with therapy (e.g., “hero” badge).

6. Goal: health teaching.

  • To encourage compliance with prolonged bed rest—stress that ultimate prognosis depends on amount of cardiac damage.
  • Teach necessity for long-term prophylactic therapy, for example, during dental work, childbirth, surgery (to prevent subacute bacterial endocarditis [SBE]). Instruct adolescents to avoid body piercing and tattooing for same rationale.
  • Teach rationale: permanent cardiac damage (mitral valve) is more likely to occur with subsequent attacks of rheumatic fever.

E. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • No permanent cardiac damage occurs.
  • Child is free from discomfort or is able to tolerate discomfort.
  • Injuries are avoided.
  • Child’s need for diversional activity is met.
  • Child/family comply with long-term antibiotic therapy/prophylactic therapy.


Focus topic: Health Promotion and Maintenance

A. Introduction: Kawasaki disease (mucocutaneous lymph node syndrome) is an acute, febrile, multisystem disorder believed to be autoimmune in nature. Affecting primarily the skin and mucous membranes of the respiratory tract, lymph nodes, and heart, Kawasaki disease has a low fatality rate (<2%), although vasculitis and cardiac involvement
(coronary artery changes) may result in major complications in as many as 20% to 25% of children with this disease. The disease is not believed to be communicable, and the exact cause remains unknown; geographic (living near fresh water) and seasonal (late winter, early spring) outbreaks do occur. Kawasaki disease occurs in both boys and
girls between 1 and 14 years of age; 80% of cases occur in children under age 5 years. It is more common among children of Japanese or Korean descent, although children from any ethnic background may be affected. It may be preceded by URI or exposure to a freshly cleaned carpet. A complete and apparently spontaneous recovery occurs within 3 to 4 weeks in the majority of cases. Treatment, which is primarily symptomatic, does not appear to either enhance recovery or prevent complications, although recent research indicates that life-threatening complications and long-term disability may be avoided or minimized with early treatment (i.e., gamma globulin) to reduce cardiovascular damage.

B. Assessment:

Focus topic: Health Promotion and Maintenance

1. Abrupt onset with high fever (102° to 106°F) lasting more than 5 days that does not remit with the administration of antibiotics and antipyretics.
2. Conjunctivitis—bilateral, nonpurulent.
3. Oropharyngeal manifestations:

  • Dry, red, cracked lips.
  • Oropharyngeal reddening and a “strawberry” tongue.

4. Peeling (desquamation) of the palms of the hands and the soles of the feet; begins at the fingertips and the tips of the toes; as peeling progresses, hands and feet become very red, sore, and swollen.

5. Cervical lymphadenopathy.

6. Generalized erythematous rash on trunk and extremities, without vesicles or crusts.

7. Irritability, anorexia.

8. Arthralgia and arthritis.

9. Panvasculitis of coronary arteries: formation of aneurysms and thrombi; CHF, myocarditis, pericardial effusion, arrhythmias, mitral insufficiency, myocardial infarction (MI).

10. Three phases: acute (onset of fever) → subacute (resolution of fever and all outward clinical signs) → convalescent (without clinical signs but laboratory values remain abnormal).

11. Laboratory tests:

  • Elevated: ESR.
  • Elevated: white blood cell (WBC) count.
  • Elevated: platelet count.

C. Analysis/nursing diagnosis:

  • Hyperthermia related to high, unremitting fever.
  • Altered oral mucous membrane and impaired swallowing related to oropharyngeal manifestations.
  • Impaired skin integrity related to desquamation.
  • Fluid volume deficit related to high fever and poor oral intake.
  • Altered tissue perfusion (cardiovascular, potential/actual) related to vasculitis or thrombi.
  • Knowledge deficit related to disease course, treatment, prognosis.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: reduce fever.

  • Monitor temperature every 2 hours or prn.
  • Administer aspirin (not acetaminophen [Tylenol]) per physician’s order. (Note: aspirin is the drug of choice to reduce fever; also has anti-inflammatory effect and antiplatelet effect. Dose is 100 mg/kg/day in divided doses q6h. Monitor for signs of salicylate toxicity.)
  • Tepid sponge baths or hypothermia blanket per physician’s order.
  • Offer frequent cool fluids.
  • Apply cool, loose-fitting clothes; use cotton bed linens only (no heavy blankets).
  • Seizure precautions.

2. Goal: provide comfort measures to oral cavity to ease the discomfort of swallowing.

  • Good oral hygiene with soft sponge and diluted hydrogen peroxide.
  • Apply petroleum jelly to lips.
  • Bland foods in small amounts at frequent intervals.
  • Avoid hot, spicy foods.
  • Offer favorite foods from home or preferred foods from hospital selection.

3. Goal: prevent infections and promote healing of skin.

  • Monitor skin for desquamation, edema, rash.
  • Keep skin clean, dry, well lubricated.
  • Avoid soap to prevent drying.
  • Gentle handling of skin to minimize discomfort.
  • Provide sheepskin to lie on.
  • Prevent scratching and itching—apply cotton mittens if necessary.
  • Bed rest; elevate edematous extremities.

4. Goal: prevent dehydration and restore normal fluid balance.

  • Strict I&O.
  • Monitor urine specific gravity q8h for increase (dehydration) or decrease (hydration).
  • Monitor vital signs for fevers, tachycardia, arrhythmia.
  • Monitor skin turgor, mucous membranes, anterior fontanel for dehydration.
  • Force fluids.
  • IV fluids per physician’s order.

5. Goal: prevent cardiovascular complications.

  • ECG monitor—report arrhythmias or tachycardia.
  • Administer aspirin (see Goal 1) and high-dose IV gamma globulin.
  • Monitor for signs and symptoms of CHF: tachycardia, tachypnea, dyspnea, crackles, orthopnea, distended neck veins, dependent edema.
  • Monitor circulatory status of extremities— check for possible development of thrombi.
  • Stress need for long-term follow-up, including ECGs and echocardiograms, possible cardiac catheterization (if coronary artery abnormalities exist at 1 year after disease).

E. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • Fever returns to normal.
  • Oral cavity heals, and child is able to swallow.
  • Skin heals, and no infection occurs.
  • Normal fluid balance is restored.
  • Normal cardiovascular functioning is reestablished, and no complications occur.
  • Parents/child verbalize their understanding of kawasaki disease.



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