Co-Director, University of Iowa Roy J. and Lucille A. Carver College of Medicine
Today symptoms when pregnant praziquantel 600 mg on line, cardiovascular nurses facilitate A strong collaborative relationship between cardiovascu- access for patients through nurse-managed clinics treatment xanthelasma eyelid purchase 600 mg praziquantel amex, perform lar physicians and nurses is a key factor in successful patient complex procedures medications elavil side effects purchase praziquantel 600 mg, educate patients and families, and outcomes. Nurse–physician collaboration, a positive organi- ensure safe passage across the complex continuum of care. Program, and the Joint Commission have challenged provid- Each professional discipline requires a scientifc founda- ers to develop safe, timely, effective, effcient, equitable, and tion for its clinical practice. This chapter highlights aspects of patient-centered care systems and environments. Essential elements include authentic lead- laborated on initiatives to improve the work environment ership, the nurse–patient relationship, family-centered care, in acute care settings and established standards for sustain- ing a healthy work environment. The American Association knowledge and skills fundamental to cardiovascular nursing of Critical Care Nurses recognized the inextricable links practice, process and outcome measures for the improvement among the quality of the work environment, excellent nurs- of cardiovascular nursing practice, and nursing innovations ing practice, and patient care outcomes. Selected examples of contem- work environment standards include authentic leader- porary cardiovascular nursing research and improvement ship, skilled communication, true collaboration, effective science initiatives from Children’s Hospital Boston are dis- decision-making, appropriate staffng, and meaningful cussed within each domain. The importance of a con- fdential, nonpunitive, evidence-based, objective appraisal is Authentic cardiovascular leadership requires leaders to emphasized. For nurse–physician a developing child, parents are their child’s greatest resource leadership teams, there must be clarity and agreement about and source of support and comfort. Parents of cardiovascular where there is shared accountability and also where account- patients often spend a signifcant amount of time at the bed- ability rests within one discipline. Depending upon the orga- side, especially when the child requires multiple procedures nization, nurse–physician leadership alliances come in many and inpatient admissions. Because many pediatric cardiovascular centers exist nursing care focus on continuity of nursing care over time in academic institutions, chiefs of the departments have an for each patient so parents may come ‘to know’ their nurse opportunity to effectively model co-leadership between the and feel comfortable that their nurse is familiar with all their disciplines. Likewise, the nurse comes ‘to know’ the Effective leadership requires that leaders value the per- patient’s unique medical, emotional, developmental, and social spective and input of each discipline. Cardiovascular nurses are well positioned to partner challenges in demonstrating a commitment to a shared per- with parents and support them in the care of their child. Parents are not visitors at the bedside; they Important attributes of excellent cardiovascular nurs- are equal partners in providing care to their children. Two ing programs include shared governance decision-making recent cardiovascular nursing research studies provide inter- models, control over nursing practice through nurse empow- esting evidence on this. To better understand and quantify erment, and professional advancement and support for the the needs of parents of pediatric cardiovascular patients, ‘voice’ of staff nurses to be heard at every level of the orga- Natale, Hickey, and Curley conducted a multiphase 4-year nization through a supportive council structure. Staff nurse participation in ered when provided with the choice to be present with a nurse the event review process is one step to ensuring the delivery facilitator during invasive procedures and resuscitation, that of quality nursing care and patient safety. Each family-centered care, but if staff are not trained to support panel member serves for a period of 3 years and receives and partner with parents, that practice may not be fully actu- training in peer review of adverse events. Equally important are the enthusiasm that staff nurses care for cardiovascular patients and families. Five major themes emerged from parental birth, many families new to the cardiovascular care system responses: are those of newborns and infants. Parents have described the nurses’ most signifcant role as the interpreter of their child’s response to the care environment. The nurse–patient relationship continues beyond the bedside in longitudinal follow-up into adulthood for many patients. In each of these categories, nurse behaviors were viewed When caring for adults with congenital heart disease, it is positively. Parents indicated that medical and technical pro- important to honor individual patient preferences and include fciency was a baseline expectation and defned as the ability the extended family of the older child or young adult. Caring described the portion of nursing that is emotion- Providing Comfort ally connected to the patient and referred to as the trait of sin- Parents of children diagnosed with heart disease are under- cerity, and that nurses meet the patient and family where they standably stressed. Parents felt secure believing the nurses threatening condition is often at the front of their minds.
However symptoms magnesium deficiency generic praziquantel 600mg on-line, as stated above medications osteoarthritis pain buy praziquantel 600 mg on line, these patients are at less risk for sudden drops in systemic cardiac output and blood pressure treatment table order generic praziquantel on-line. This would suggest that if these patients can tolerate somewhat more vigorous physical activity, it may be undertaken with less risk. Careful and frequent monitoring of exercise symptoms and capacity are still essential (177). Competitive Sports Given the high-risk nature of this population, restriction from any competitive sport is probably warranted. Special circumstances may occur when participation in low static and dynamic sports may be considered on an individual basis for Class 1 patients. There are, however, no significant data that would allow accurate assessment of risk for an individual patient. Heart Transplantation Exercise capacity as measured by both aerobic capacity and musculoskeletal strength is significantly decreased in the pediatric population following heart transplantation. These values are not significantly different from those reported in the adult population. The reasons for this finding appear to be due to both central and peripheral factors combining to impair aerobic capacity. This may be due to systolic impairment but more importantly to diastolic dysfunction with high cardiac filling pressures. Abnormalities of autonomic innervation and function also impact on cardiac output during exercise. This significantly decreases chronotropic reserve and blunts the time course of the chronotropic response. There is some evidence for reinnervation and improved chronotropy late after transplant in some patients or as a response to cardiac training (discussed below). In addition to the cardiac effects, autonomic tone is abnormal in the peripheral vasculature. Limitations of the peripheral exercising musculature are likely at least as important as central mechanisms in limiting aerobic capacity. Following heart transplant, skeletal muscle mass is often reduced by 20% of normal. This may reflect the marked deconditioning in these patients that occurs prior to transplantation but may also be the result of immunosuppressant therapy. These changes result in an impaired ability of the exercising muscle to extract oxygen. Muscle strength is significantly impaired, especially in the early transplant period. Use of ongoing immunosuppressant medications may continue to exacerbate the problem of demineralization. Serial studies of exercise performance following pediatric heart transplant are limited. The reason for these discrepant findings are unclear but are probably the combined improvement of systolic and especially diastolic function in the immediate posttransplant period as well as the longer-term improvement in musculoskeletal conditioning, even in the absence of formal rehabilitation. In addition, improved chronotropy suggests at least some patients benefit from autonomic reinnervation of the donor heart. There are no significant data on the risks and benefits of exercise training in pediatric heart transplant recipients. Studies in adults consistently show significant improvement in maximal aerobic capacity. There is also some evidence from small studies that suggest that high-intensity interval training is more effective in this population than prolonged moderate intensity training (187,188,189,190,191,192).
The left hepatic vein joins the ductus venosus near the inferior vena cava medicine 7 day box purchase 600mg praziquantel visa, so that this highly saturated blood is also directed toward the foramen ovale treatment junctional rhythm buy generic praziquantel pills. The limbus of the foramen ovale helps to direct this blood into the left atrium (66) medications 3605 discount praziquantel 600 mg with amex. The remainder of the umbilical venous blood, along with >95% of the poorly saturated portal venous blood, is directed to the right lobe of the liver. Ultrasound-based studies suggest that in the human the relative distribution of umbilical venous flow to the ductus venosus may be lower, although it is altered by fetal distress (67). From the right lobe, this much less saturated blood enters the right hepatic vein and tends to stream with the blood of the distal inferior vena cava to the tricuspid valve. The hepatic artery, which carries blood that is moderately well saturated, constitutes <10% of hepatic blood flow in the fetus, so it does not significantly contribute to oxygen supply. Thus, preferential streaming patterns among the different sources of venous return allow most of the poorly saturated blood from the upper body, myocardium, and lower body to reach the right ventricle, and the more highly saturated umbilical venous return to reach the left ventricle. Although the separation of fetal venous return and ventricular output according to its level of blood oxygenation is not as efficient as the postnatal separation, it is quite remarkable in its ability to allow the right and left ventricles to perform their normal postnatal functions of delivery of blood for O uptake and O supply, respectively (2 2 Fig. Changes in the Central Circulation at Birth The changes in the central circulation at birth are primarily caused by external events rather than by primary changes in the circulation itself. The most important of these are the rapid and large decrease in pulmonary vascular resistance and the disruption of the umbilical–placental circulation. The decrease in pulmonary vascular resistance, the mechanisms responsible for which will be discussed later, has profound effects on the central shunts in the systemic circulation. At birth, the ductus arteriosus changes abruptly from a right-to-left conduit of blood to the descending aorta, to a left-to-right conduit of blood to the lungs, until it closes in the first hours or days of life. This closure is commonly delayed in the premature infant, causing a steal of blood from the regional systemic vascular beds. The physiologic basis of ductal normal closure and problems associated with delayed closure are discussed elsewhere (see Chapter 31). At birth, the umbilical–placental circulation is abolished, causing a marked reduction in flow through the ductus venosus and in flow to the left lobe of the liver. However, portal venous flow through the ductus venosus increases from <5% to >50% by 1 hour of age so that, despite an increase in portal venous flow at birth, blood flow to the liver itself actually decreases substantially (68). This shunt of portal venous blood through the ductus venosus is transient, generally lasting for 1 day to 2 weeks. Closure of the ductus venosus is probably a passive phenomenon, although it has been demonstrated that the isolated ductus venosus can respond to adrenergic stimulation and prostanoids. Thus, its closure may be partly induced by the same hormonal changes that are implicated in the closure of the ductus arteriosus. Closure of the foramen ovale at birth is entirely passive, secondary to alterations in the relative return of blood to the right and left atria. Prior to birth, direct left atrial return via the pulmonary veins is only modest, ≤25% of combined venous return. Thus, the pressure gradient from the right atrium to the left atrium maintains a large flow of blood through the foramen ovale, which appears as a “wind sock” bulging into the left atrium. With the onset of air ventilation, the proportion of combined venous return that directly enters the left atrium via the pulmonary veins increases dramatically, to >50%. This is because of the marked increase in pulmonary blood flow, which includes a transient left-to-right shunt through the ductus arteriosus. Left atrial pressure thus exceeds right, and the redundant flap of tissue of the foramen ovale that previously bowed into the left atrium is now pressed against the septum. Although patency of the foramen ovale may be present for several years, shunts of any significance occur only when the primum septum is deficient, thus forming a secundum atrial septal defect (see Chapter 28). Developmental Changes in the Systemic Circulation The mechanisms which determine flow in the systemic vascular bed and the regulation of flow to specific organ systems have been described earlier in this chapter.
Given that the conditions are extremely dry symptoms to pregnancy buy praziquantel 600 mg fast delivery, a good precaution would be to have interagency agreements that could bring in frst responders to fght fres if any fres begin to start in the rural areas medicine cabinet with lights cheapest praziquantel. Having the proper equipment to combat large-scale fres is important since the conditions would appear to be optimal for a fre to spread quickly owing to the extent of dry vegetation available to keep the fre fueled symptoms uric acid buy generic praziquantel line. Tere should also be a series of Geographic Information Systems maps that should be constructed that would indicate how to fght fres if they started in the rural areas, as well as showing possible evacuation routes from diferent cities and towns if fres were to occur in those areas. What resources do you need if a potential fre were to break out in the country- side? If available, frefghter vehicles and planes could provide a good means to put out any fre quickly, if the fre is sighted soon enough before it begins to spread throughout the surrounding countryside. Water and chemicals that are used to fght fres can be stockpiled and pre-positioned in areas where fres could potentially cause harm to larger populations of residents. You should communicate with the citizens of the state of Victoria with a recommenda- tion not to burn any type of waste, be extremely careful if they go camping by making sure that all campfres are extinguished, and that cigars and ciga- rettes can be deadly if improperly disposed of in dry vegetation. Additionally, there could be a very forceful campaign to prevent any type of arson from occurring by reminding the populous that stif criminal charges can be fled if one is caught perpetrating arson. Stage 2 of the Disaster On Saturday February 7, 2009, you receive word that over 100 fres have been sighted (The Day the Sky Turned Black, 2012). With winds gusting over 60 miles per hour and temperatures that are over 100°, you know that the fre will spread quickly if action is not taken immediately (Siddaway and Petelina, 2009). At this point you should gather all resources avail- able given the number of fres, and that you have to protect not only the land that has not caught fre yet, but also and primarily the citizens. Terefore, you will need to mobilize your frst responders to combat fres around populated centers frst, and then go after the fres that are primarily in rural areas as a secondary priority. Any person that is a frefghter or frst responder needs to be mobilized immediately, along with any type of vehicle that can support those eforts. Any frefghting plane that can be obtained to combat the fres should be utilized as soon as possible. You should also begin to think about what types of resources will be needed to help evacuate and temporarily shelter displaced residents if the fres begin to threaten populated areas of the state. Agencies at the local and central government levels need to be contacted to request assistance with additional manpower, vehicles, logistics, or medical resources. You should be very dili- gent about communicating with your frst responders to make sure that frefghting eforts are fully coordinated. Stage 3 of the Disaster You have now learned that there are 400 separate fres, accompanied by strong winds that are over 70 miles per hour, and they are not only occurring but chang- ing direction, causing all of the fres to increase dramatically in size and ferocity (Siddaway and Petelina, 2009; The Day the Sky Turned Black, 2012). In addition, you now have fve towns that have been obliterated in addition to the 173 people Case Studies: Disasters from Natural Forces—Fires ◾ 41 that have been killed, over 5,000 people have been injured, and 2,029 homes have been destroyed (Australian Broadcast Corporation, 2012). The aftermath of the disaster still poses many problems for your management skills. The displaced individuals will need to be assisted, which will create quite a logistical challenge with 2,029 homes destroyed, and people that will need housing, food, water, medicine, sanitation infrastruc- ture, and medicine. The next challenge that will be posed to public adminis- trators is how to rebuild the communities in the state and where the money will come from. Medical resources will be in high demand in the short term until the majority of injured are treated. Temporary housing and communities to host those temporary shelters will need to be found quickly and then stockpiled with supplies to support those individuals. You need to communicate with the local and central governments about what has been done to date, what needs to be done, and what resources you need to support all of the displaced persons. The displaced persons will need to be contacted to let them know that they are being provided for and what the plans are to get them in a more perma- nent state of housing. Key Issues Raised from the Case Study Tere were defnitely signs that a wildfre could occur in the area before the fres broke out in Victoria given the drought conditions and dry vegetation.
Prosthetic Valves Prosthetic valves are used in both the atrioventricular and semilunar valve positions in children and adolescents with both congenital and less commonly acquired heart disease medicine 877 generic praziquantel 600 mg fast delivery. Bioprosthetic valves medicine urology discount 600 mg praziquantel otc, also referred to as “tissue valves symptoms 24 hours before death discount 600 mg praziquantel with amex,” are allografts or xenografts (bovine or porcine). Mechanical valves have a higher durability but require systemic anticoagulation, with a higher degree of anticoagulation theoretically required on the right side of the heart secondary to the lower pressures and the lower-flow velocities. Long-term systemic anticoagulation is usually not required with bioprosthetic valves although they are less durable than mechanical valves with rapid deterioration in children especially in the aortic and mitral positions. Bioprosthetic valves, however, are more durable on the right side compared with the left side of the heart. Based on the above observations, mechanical valves are usually used in the mitral position and bioprosthetic valves on the pulmonary side. Despite prescribed anticoagulation with warfarin, patients with mechanical valves are still at increased risk for both bleeding and clotting. A single, prospective, multicenter study of children <5 years of age at mitral valve replacement with a mechanical prosthesis (average follow-up 6. Several retrospective studies in pediatric patients report the risk of thrombotic complications as 0% to 1. Tricuspid valve replacement is rare with Ebstein anomaly the most common indication and bioprosthetic valves most commonly employed. Mechanical valves are rarely used in the tricuspid position of a biventricular heart, and when they are used, an increased level of anticoagulation has been recommended because of the decreased flow velocity across the tricuspid valve. Although reports are limited and mainly in adults, the risk of thrombosis appears to be high despite anticoagulation. Surgically placed bioprosthetic valves in the pulmonary position have a low risk for thrombosis and essentially no risk for systemic embolization. There are no data to support systemic anticoagulation for a surgically placed bioprosthetic valve in the pulmonary position. Recently there has been increased use of the Melody transcatheter pulmonary valve to address conduit obstruction/incompetence in the right ventricular outflow tract position. Although endocarditis and Melody stent fracture with re-stenosis are known complications, thrombosis in the absence of endocarditis has not been reported to date either in vivo or from explanted Melody pulmonary valves (233,234). As discussed above, tricuspid valve replacement is rare, with Ebstein anomaly being the most common indication. Thrombosis has been reported in a Melody valve placed in a stenotic bioprosthetic tricuspid valve (238). Since there is a paucity of data on the efficacy and safety of anticoagulation strategies for prosthetic valves in children and adolescents, most centers and experts in the field follow the guidelines established for adults by the American College of Cardiology and the American Heart Association revised in 2014 (142) and those of the American College of Chest Physicians published in 2008 (239). Warfarin is currently the mainstay of prophylactic therapy for mechanical valves, although stable, long-term anticoagulation is difficult especially in infants and young children because of developmental hemostasis as well as concomitant medications and certain foods and formulas which may enhance or diminish the anticoagulant effect. Infants are generally at higher risk of prosthetic valve thrombosis because of the smaller size of the prosthesis and difficulties in achieving stable anticoagulation with warfarin therapy. Partial valve occlusion should be suspected in children with signs of low cardiac output, respiratory distress, hepatomegaly, pleural effusions, and/or pulmonary edema. Transthoracic echocardiography may reveal an increased inflow gradient across the valve and decreased leaflet mobility.
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