Nursing Diagnosis

Welcome to our very last week of blogging! Last week we discussed things that nurses can do to help their patients with pediatric Long QT Syndrome. We called these areas to focus on “nursing interventions.” A nursing intervention is a response to a nursing diagnosis. There is a large difference between a nursing diagnosis and a medical diagnosis. A medical diagnosis is where a provider is trying to identify or treat the condition, whereas a nursing diagnosis focuses on how the body physically and psychologically responds to the disease and treatment.

Five key nursing diagnoses that I will discuss during this blog are:

1) alteration in cardiac output

2) risk for death anxiety

3) risk for ineffective health maintenance

4) risk for ineffective individual coping

5) risk for ineffective community coping

1)    alteration in cardiac output

This nursing diagnosis focuses on how LQTS creates a functional challenge for the heart. Any dysrhythmia (mistimed or uncoordinated heart beats) that occur due to LQTS will often cause a change in how much blood is squeezed effectively from the heart. This is just like a pump that isn’t working appropriately. Adhering to a medication routine and/or following provider recommendations for an implanted defibrillator will help prevent the irregular heart beats from occurring, thus keeping cardiac output consistent (Seattle Children’s Hospital 2015).

           

2) risk for death anxiety

            As I have discussed throughout this blog, LQTS can have very serious and fatal consequences if not properly diagnosed and managed. When a provider explains the seriousness of this condition a risk for death anxiety could occur in both the patient and their family. Counseling may be helpful in teaching coping skills to help manage anxiety.

3) risk for ineffective health maintenance

            There are a lot of changes that occur when a patient is diagnosed with a chronic disease. Especially because I’m primarily focusing on pediatric patients in this blog—health maintenance will require both the patient and family to get on board with these sudden new changes. Examples could include creating a colorful visual medication schedule to help the patient and caregivers know when medications are to be taken. Other factors in this nursing diagnosis include: consistent attendance for medical appointments, access to healthcare providers that understand LQTS, etc.

4) risk for ineffective individual coping

With all of the big changes that come with diagnosis of a chronic disease, we must check in to see how the pediatric patient is coping. Many feelings such as fear and stress can come up as a child begins to understand and take ownership of their condition. Age appropriate interventions such as counseling and support groups can be helpful in assisting a pediatric patient in managing their disease.

5) risk for ineffective community coping

This nursing diagnosis focuses on all of the other members of the patient’s life. For example, symptoms of LQTS exacerbations will often be seen when the child is undergoing physical stress such as during PE in school or at an after school sport. Informing teachers and coaches of signs/symptoms/how to best care for this child will be vital in keeping the patient safe. Similarly, it is helpful for all caregivers and family members to learn how to adjust to changes such as a rigorous medication schedule or exercise limitations that occur when a child is diagnosed with LQTS.

Here’s a table that my professor asked us to create demonstrating a break down of one of the examples that I just listed above in a table format.

Nursing Diagnosis	Related to	As Evidenced By	Nursing Intervention	Goal
Risk for ineffective health maintenance	Pt and family do not fully understand scheduling of medications	Unable to describe care coordination of medication administration	Create visual schedule that parents and child can use to track medication administration	Consistent compliance with taking medication

Source:

Seattle Children's Hospital. (2015, January 1). Long QT Syndrome. Retrieved March 1, 2015, from http://www.seattlechildrens.org/medical-conditions/heart-blood-conditions/long-qt-syndrome/

Nursing Interventions

Welcome back! This week we will focus on nursing interventions for pediatric patients with Long QT Syndrome (LQTS). Nursing interventions generally include everything from readjusting a patient into a certain therapeutic position to administering medication. During the acute treatment of a new child diagnosed with LQTS nurses will follow protocols such as the one below.

This first section discusses immediate assessment of a cardiac patient. The second section discusses administering therapeutic interventions to help a cardiac patient. I've copied and pasted the section from this very helpful educational website: http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick10.html

*The website uses some medical jargon—I'll put some translation in parentheses. *


• Assess mentation (how a person is acting).
  • Restlessness is noted in the early stages; severe anxiety and confusion are seen in later stages.
• Assess heart rate and blood pressure.
• Assess skin color and temperature.
  • Cold, clammy skin is secondary to compensatory increase in sympathetic nervous system stimulation and low cardiac output and desaturation.
• Assess peripheral pulses (feeling pulses in hands/feet/extremities).
  • Pulses are weak with reduced cardiac output.
• Assess fluid balance and weight gain.
  • Compromised regulatory mechanisms may result in fluid and sodium retention. Body weight is a more sensitive indicator of fluid or sodium retention than intake and output.
• Assess heart sounds, noting gallops, S3, S4 (this means listening for any abnormal extra heart sounds).
  • S3 denotes reduced left ventricular ejection and is a classic sign of left ventricular failure. S4 occurs with reduced compliance of the left ventricle, which impairs diastolic filling.
• Assess lung sounds
• Assess Hemodynamic Monitoring (looking at lab work for abnormalities)
• Monitor continuous ECG as appropriate
• Monitor ECG for rate, rhythm, ectopy, and change in PR, QRS, and QT intervals.
• Assess response to increased activity.
  • Physical activity increases the demands placed on the heart; fatigue and exertional dyspnea are common problems with low cardiac output states. Close monitoring of patient's response serves as a guide for optimal progression of activity.
• Assess urine output. Determine how often the patient urinates.
• Assess for chest pain.
  • Indicates an imbalance between oxygen supply and demand.
• Assess contributing factors so appropriate plan of care can be initiated. 
  Examples of treatment interventions include:
  
  Administer medication as prescribed, noting response and watching for side effects and toxicity. Clarify with physician parameters for withholding medications.
  
• Maintain optimal fluid balance (don't want too much fluid or too little fluid)
• Maintain hemodynamic parameters at prescribed levels.
• Maintain adequate ventilation and perfusion (maintain breathing and blood circulation by repositioning patient in bed):
  • Place patient in semi- to high-Fowler's position
    • To reduce preload and ventricular filling.
  • Place in supine position
    • To increase venous return, promote diuresis.
  • Administer humidified O2 as ordered.
    • The failing heart may not be able to respond to increased O2 demands.
      
• Maintain physical and emotional rest, as in the following:
  • Restrict activity
    • To reduce O2 demands.
  • Provide quiet, relaxed environment.
    • Emotional stress increases cardiac demands.
  • Organize nursing and medical care
    • To allow rest periods.
  • Monitor progressive activity within limits of cardiac function.
• Administer stool softeners as needed.
  • Straining for a bowel movement further impairs cardiac output.
• Monitor sleep patterns; administer sedative.
  • Rest is important for conserving energy.
• If arrhythmia occurs, determine patient response, document, and report if significant or symptomatic.
  • Both tachyarrhythmias (heart beating too fast) and bradyarrhythmias (heart beating too slow) can reduce cardiac output and myocardial tissue perfusion.
  • Have antiarrhythmic drugs readily available.
  • Treat arrhythmias according to medical orders or protocol and evaluate response.
• If invasive adjunct therapies are indicated (e.g., intra-aortic balloon pump, pacemaker), maintain within prescribed protocol.

In conclusion, there are many manuals that help organize the flow of responsibilities for a nurse. However, one of the most important jobs for the nurse to accomplish is establishing rapport and trust with the patient and family/caregivers. Through describing interventions at an age appropriate level, nurses can help make the patient and family feel more included in their care.

Sources:

Gulanick, M. (2012, January 1). EHS: Nursing Diagnosis Care Plans, 4/e - Cardiac Output, Decreased. Retrieved February 22, 2015, from http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick10.html

Signs/Symptoms

Signs and Symptoms

The signs/symptoms of many diseases are slow, persistent cues that help to tell caregivers that there is something wrong and then help a provider diagnose the patient. But in pediatric Long QT Syndrome (LQTS) the signs that lead to initial diagnosis tend to come on as rapid cardiac symptoms such as irregular heart beats, fainting, loss of consciousness, and seizures (Mayo Clinic 2012). If these symptoms of irregular heart rhythms from LQTS are not immediately addressed with an AED (automatic external defibrillator) then sudden cardiac death can occur. These symptoms usually present between birth and adolescence as the child exercises and experiences cardiac irregularity.

The above symptoms are quite concerning to both the patient as well as the family/caregivers. After initial cardiac work up and stabilization is complete, it is often helpful for all family members to talk through and process their experiences in seeing their child experience these symptoms. Mental health professionals can be helpful in discussing age appropriate explanations for the pediatric patient/siblings.

An AED saves lives. They can be found in many public places such as schools, businesses, community centers, and pools. AED’s are very easy to use as they have step-by-step instructions that tell the user exactly what to do. Here’s a diagram that demonstrates using an AED.

http://www.nhlbi.nih.gov/health/health-topics/topics/aed/howtouse

Here is a helpful video that demonstrates CPR and using an AED on a child. https://www.youtube.com/watch?v=xP_uyuUnzQg

These skills can help save a child’s life…so watch the video!

Here’s a great video from a nurse who demonstrates how to help a person who is fainting safely get to the ground:  https://www.youtube.com/watch?v=LIiuqzvX4vs

Here’s a video from a nurse who demonstrates how to help a person who is having a seizure. https://www.youtube.com/watch?v=4qWPFCFmRlI  FYI: this video is geared more towards assisting a person with epilepsy (a seizure disorder), whereas seizures with LQTS are a symptom of cardiac issues. Here's a diagram summarizing basic ways to help keep a person who is having a seizure safe.

http://www.efepa.org/living-with-epilepsy/

That's all folks! Next week we'll discuss immediate action that occurs when a patient comes into the hospital for a cardiac work up as well as long term treatment for a patient with pediatric Long QT Syndrome.

~Until the next beat~
Sarah

Sources:

Mayo Clinic Staff. (2012, April 20). Long QT syndrome. Retrieved February 8, 2015, from http://www.mayoclinic.org/diseases-conditions/long-qt-syndrome/basics/symptoms/con-20025388

Diagnosis

This week we will discuss how Long QT Syndrome (abbreviated LQTS) in our pediatric population is diagnosed. As I have mentioned in the previous blog posts, this condition is often unknown until a child experiences very serious cardiac symptoms such as loss of consciousness and cardiac arrest (Gajewski & Saul 2010).  In an optimal situation a first responder would begin CPR and utilize a nearby defibrillator to revive the child to limit potential long-term consequences of this event. Once the child is transported to the hospital the workup for the cause and further treatment of the cardiac arrest begins. Laboratory tests may be completed in order to rule out any electrolyte abnormalities or other causes of symptoms. While no blood draw is fun for anyone, here’s a great example of how setting up a positive environment and teamwork with providers and caregivers can make a non-traumatic experience for the child:  https://www.youtube.com/watch?v=5UNP0Gjx2F4

Most importantly to diagnose Long QT Syndrome, an EKG or ECG (same test, different name) is completed to study the conduction of the heart. In this test sticky monitors are placed on the child’s body to create a picture of how the heart is functioning. These electrodes do not cause any pain/discomfort.

Here’s a kid-friendly video that shows what an EKG/ECG is like: https://www.youtube.com/watch?v=MSc0Trc_d88

Most importantly a pediatric cardiologist will be involved in the immediate and long-term management of this child’s cardiac condition. Many hospitals are offering prophylactic screening with EKG’s during annual sports physicals of young athletes to try to identify a problem such as LQTS before it becomes a life-threatening issue in that child. Here’s a video from Miami Children’s Hospital describing how helpful these screenings can be to a child’s overall health:  https://www.youtube.com/watch?v=dVX37frwDMA

Source:

Gajewski, K., & Saul, J. (2010). Sudden cardiac death in children and adolescents (excluding Sudden Infant Death Syndrome). Annual Pediatric Cardiology, 3(2), 107-112. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3017912/

.

Pathophysiology (The HOW?)

Pathophysiology (The HOW?)

This week we will discuss how Pediatric Long QT Syndrome (abbreviated LQTS) occurs. I briefly discussed this already in my first introductory blog post.  LQTS is a genetically inherited condition. This means that there weren’t any lifestyle changes or modifiable behaviors that could have been done to prevent this problem. Patients are born with this abnormality already written into their genetic code (Raghavan 2014). It also means that if an adult diagnosed with LQTS is interested in having children they should consult a physician to make a game plan that discusses screening future offspring for this syndrome.

As we talked about in the first blog post, your heart is a muscle. This muscle pumps blood throughout your system by squeezing and contracting. Electrical signals tell your heart when to squeeze and when to contract. These electrical signals are made as ions such as potassium and sodium flow in precise amounts in and out of cells (SADS 2008). In LQTS the channels that these ions move through are not regulated correctly. This causes the dangerous irregularity in the heart’s rhythm that we see with LQTS.

As a picture is worth a thousand words I thought that some videos would be even better.

Here’s a great short video that describes the cause of LQTS in case you are more of a visual person:  https://www.youtube.com/watch?v=3n3So15GY34

Here’s a slightly longer video of Dr. Sanjay Sharma giving a very well spoken description of general LQTS:  https://www.youtube.com/watch?v=Fk-YVgYFUtY

My personal favorite video is this patient and family’s perspective of their experience with diagnosis of Pediatric Long QT Syndrome:  https://www.youtube.com/watch?v=_9eMJv669dM

Remember when we talked the first week about EKG’s? I explained how EKG’s give us a visual picture of the electrical signals powering the different parts of the heart to squeeze and release (SADS 2008). Well here’s a great picture that shows the difference between a normal EKG and that of a patient with LQTS:

EKG difference between normal heart and LQTS heart

 See the smoothly rounded hump in the picture above? The important part of the picture is that the normal (top) EKG strip has a small rounded bump for the QT interval whereas the LQTS (bottom) EKG strip has an elongated hump for the QT interval. It is this electrical change that can cause problems with the pace and rhythm of the heart in LQTS.

I hoped that this blog post helped us review some earlier information and learn new information on how Pediatric Long QT Syndrome occurs. Next week we will talk about how a formal diagnosis of LQTS is made in our pediatric population.

~Until the next beat~

Sarah

Sources:

Long QT Syndrome. (2008, June 1). Retrieved January 25, 2015, from http://www.sads.org/library/long-qt-syndrome#.VMSbrXDF87g

Raghavan, S. (2014, June 26). Pediatric Long QT Syndrome . Retrieved January 25, 2015, from http://emedicine.medscape.com/article/891571-overview