1. Pediatric Cardiac Assessment Cynthia Crews RN, MSN, CNE Lisa Minor, RN, MSN, Ed.D Longwood University Nursing Faculty

2.  Participants will be able to identify essential components of a pediatric cardiac assessment.  Participants will be able to demonstrate a cardiac assessment recognizing normal and abnormal assessment findings.  Participants will be able to identify common childhood conditions affecting the heart Objectives

3. What tools are needed?

4. Overview of Heart  There are 4 chambers of the heart  2 Atria (Right & Left)  2 Ventricles (Right & Left)

5.  There are two sets of valves  Atrioventricular  Mitral valve between the left atria & ventricle  Tricuspid valve between the right atria & ventricle  Semilunar  Pulmonic valve (Rt ventricle and pulmonary artery)  Aortic valve (Lt. ventricle and aorta) Overview of Heart

6.  Assess:  Level of alertness, activity, tone  Vital Signs  Pulses  Respiratory effort  Chest symmetry  Cap refill (should be less than 3 secs)- prolonged indicates poor cardiac output  Clubbing  Peripheral edema  Color and temperature of extremities Cardiac Assessment

7.  Normal vital signs Cardiac Assessment Age (yr) Respiratory Rate (breaths/min) Heart Rate (beats/min) <130-60100-160 SBP: 65-100 DBP: 45-65 1-224-4090-150 SBP: 90-105 DBP: 55-70 2-522-3480-140 SBP: 95-110 DBP: 60-75 6-1218-3070-120 SBP: 100-120 DBP: 60-75 >1212-1660-100 SBP: 110-135 DBP: 65 - 85

8.  The diaphragm of the stethoscope is best used for hearing higher pitched sounds such as S1 and S2 and some murmurs  The bell is best used for hearing lower pitched sounds such as S3 and S4 What is the best way to auscultate?

9. Objective Assessment  Auscultation:  Auscultate all areas with patient sitting, leaning forward, supine, and on left side.  Begin with the diaphragm and then the bell in all 5 areas  Describe rate, rhythm, duration of cycle, timing, intensity, frequency, splitting or murmurs, and quality

10.  Auscultation of the heart includes two main things:  Rate:  Rhythm ( S1 and S2) and listening for abnormal rhythms Listening to Heart Sounds Age (yr)Heart Rate (beats/min) <1100-160 1-290-150 2-580-140 6-1270-120 >1260-100

11. Listening to Heart Sounds

14. Extra Heart Sounds  S 3 - Ventricular filling sound that occurs in early  diastole  soft, low pitched  Ken----tuc---ky (Lub – duppa)  May be an early sign of heart failure  S 4 Atrial gallop atria contraction in late diastole  Soft, low pitched sound  Tenn ---- es—see (daLub –dup)  Seen w/ CAD or cardiomyopathy

15.  Heart Murmurs:  A heart murmur describes an extra sound in addition to the "lub-dub." Sometimes these extra sounds are simply the sound of normal blood flow moving through a normal heart. Other times, a murmur may be a sign of a heart problem. Extra Heart Sounds

16.  Murmurs:  R/t disruption of flow  Commonly caused by diseased valves  Characteristics:  Timing: systolic or diastolic  Intensity/Loudness: grades 1-6  Pitch: High, medium, or low  Pattern : crescendo; decrescendo, or square  Quaility: harsh, blowing, musical  Location: anatomical lanmarks  Radiation: sound transmitted in direction of blood flow

17. Murmurs  Systolic  Mid-systolic – pulmonary or aortic stenosis  Pansystolic – mitral or tricuspid regurgitation  Late systolic – mitral prolapse  Diastolic  Early diastolic – aortic regurgitation  Mid diastolic – mitral stenosis  Late diastolic – mitral stenosis  Many children may have an innocent murmur that will resolve during school age years.

18. Murmurs Grading  Grade I- barely audible  Grade II – quiet but clearly audible  Grade III – moderately loud  Grade IV – loud  Grade V – Very loud, thrill easily palpable  Grade VI – Very loud heard w/o stethoscope, + thrill

19.  An arrhythmia is an abnormal heart rhythm. It may feel like fluttering or a brief pause. It may be so brief that it doesn’t change your overall heart rate. Or it can cause the heart rate to be too slow or too fast. Some arrhythmias don’t cause any symptoms. Others can make you feel lightheaded or dizzy. There are two basic kinds of arrhythmias.  Bradycardia is when the heart rate is too slow — less than 60 beats per minute.  Tachycardia is when the heart rate is too fast — more than 100 beats per minute. Cardiac Arrhythmias

20.  dizziness  fatigue  lightheadedness  weakness  palpitations (a feeling of fluttering or pounding in the chest)  shortness of breath  chest pain  fainting Arrhythmia Signs and Symptoms

21.  Age Normal Range (Average) (bpm)  3-4 years73-137 (108)  5-7 years65-133 (100)  8-11 years62-130 (91)  12-15 years80-119 (85)  > 16 years60-100 Tachycardia and Bradycardia

22.  Most common cardiac conditions that affect children are congenital heart defects which usually are detected in infancy therefore surgical or medical interventions will have usually resolved by the time the child enters school.  The two major types of acquired heart disease in children are rheumatic heart disease and Kawasaki disease (World Heart Federation) Common childhood conditions affecting the heart

23.  Rheumatic Heart Disease: condition where heart muscle and valves are damaged due to rheumatic fever.  Signs/Symptoms:  Aortic or mitral valve abnormalities (murmurs)  Shortness of breath with activity or at rest  Joint pain and inflammation (migrates)  Small, painless nodules beneath the skin  Chest pain  fatigue Common childhood conditions affecting the heart

24.  Kawasaki disease: fever, rash, swollen hands and feet, bloodshot eyes, swollen lymph nodes, strawberry appearance to tongue, acute inflammation of blood vessels. Cause unknown thought to be r/t infection. Higher incidence less than 5 and more common in boys. Common childhood conditions affecting the heart

25.  Acquired heart diseases are most often due to:  Cardiomyopathy  Infections (Rheumatic Fever)  Autoimmune factors  Genetic Factors  Teratogens –  Chest pain is rare in pediatrics: if a child experiences chest pain it is usually related to other conditions such as costacondritis; musculoskeletal discomforts; skin conditions, or pleural pain. Common childhood conditions affecting the heart

26. Video and then Practice Time

27. Discussion and Questions