1. Module 5 Cardiac

2. CARDIAC ANATOMY

3. CARDIAC CYCLE

4. TRANSITION FROM FETAL CIRC.
Blood flow from placenta to fetus through the umbilical vein to the ductus venosus and into the right atrium of the heart
No need for blood to travel to the lungs, though some does just by way of pressure gradients
Majority of blood passes through patent ductus arteriosus, the vascular channel between the pulmonary artery and the aorta

5. Newborn must adapt to receiving oxygen from the lungs
Transition from fetal to pulmonary circulation occurs in just a few hours
Increase in pressure in the left atrium stimulates closure of the foramen ovale
In response to higher oxygenation satruations ductous arteriosus closes within hours after birth
Permanent closure occurs by days after birth unless sats remain low

6. PEDIATRIC DIFFERENCES
More sensitive to fluid volume changes
Less cardiac muscle compliance
Inability to regulate stroke volume until muscle fibers fully developed at around 5 years of age
Increased metabolic rate and increased oxygen demand
Little cardiac output reserve
H & H concentrations are higher as appropriate for age necessary for oxygen transport
Persistent desaturation/hypoxia can lead to increased H & H from bone marrow response

7. CARDIAC ASSESSMENT Comprehensive History
Has your child ever had a change in skin color during feeding or crying?
Does your child tire easily during physical activities?
Has anyone ever told you that your child has a heart murmur?
Does your child seem to assume a squatting position frequently?

8. PHYSICAL ASSESSMENT Inspection Palpation Auscultation Vital signs
What you can see, feel, and hear will give you all the clues to the state of your patient’s cardiac function.
The nurse needs to develop an organized method for evaluating the chest, heart, and lungs.
The nurse must know baseline functioning ranges of normal vital signs for various age groups. This information should be readily accessible in the clinical setting.
Because children are not always cooperative during a cardiovascular examination, the nurse needs to have a flexible approach.

9. INSPECTION General appearance Note size for age Activity
Level of consciousness
Skin color
Muscle tone
Nail beds
Edema

10. Skin and mucous membranes Color and skin temperature
Pink
Pale
Mottled
Dusky
Moist or dry
Edema
Inspect the skin for turgor. Is it intact, warm, or cool to the touch? Take note if the skin temperature is warmer in the upper body then legs and feet.
Look for signs of edema and note what type it is (e.g., mild, severe, pitting, generalized, or dependent.) This can be a sign of fluid overload. Babies develop periorbital edema before it reaches their extremities.
Diaphoresis is never normal in resting children or from activities of daily living.
Color can be a challenge to assess with confidence when it is abnormal. Our interpretation is subjective.

11. Dusky skin tones COLOR CHANGES
The child in the picture has a right-sided heart defect that obstructs blood flow to her lungs and her oxygenation has suffered. She also has chronic pulmonary hypertension.
COLOR CHANGES
Dusky skin tones

12. Mottled Skin COLOR CHANGES
A little bit of mottling, such as on the legs of a sick child, can be expected, but this baby has it everywhere. Infants, especially a sick infant, can lose body heat rapidly and can become mottled from cold or exposure. Care
COLOR CHANGES
Mottled Skin

13. Note the pallor of extremities compared to trunk
COLOR CHANGES
Note the pallor of extremities compared to trunk

14. Skin color; watch for changes in perfusion when crying or agitated
This is a good example of why you want to inspect children by touching them as little as possible. An agitated child can have changes in skin color and perfusion. The fact that this patient’s color changed so much while crying is also an indication of the cardiovascular challenges this baby is experiencing.
COLOR CHANGES
Skin color; watch for changes in perfusion when crying or agitated

15. Pale or dusky undertones
This baby is sedated, with a noticeable dusky color. The periorbital edema is prominent here. This baby’s SaO2 is about 80%.
COLOR CHANGES
Pale or dusky undertones

16. INSPECTION Pink mucous membranes Nutritional status
Excessive perspiration
Neck vein distention
Retractions
This child is still sick but on the top of her recovery phase. She is breathing easily, is calm, has no retraction, no neck vein distention, appears hydrated, and her mucous membranes are a moist pink color. Her skin color is good and there are no excessive perspirations.

17. PALPATION Assess pulses for rate, rhythm, and volume Apical Radial
Brachial
Femoral

18. 0 = absent Grading of pulses 1 = weak, thready 2 = normal 3 = full
4 = bounding
Pulse quality is a good indicator of perfusion and cardiovascular status. The rhythm of the pulse, if irregular, needs to be further evaluated.

19. Capillary refill Fontanel Hepatosplenomegaly
Normal time < 2 seconds
Fontanel
Indicates fluid status
Hepatosplenomegaly
Capillary refill reflects skin perfusion and might indicate abnormalities in cardiac output. Capillary refill time is the time it takes for blood to return to tissue blanched with pressure.
The anterior fontanel is used for fluid assessment. It can be palpated throughout the first year of life.
Hepatosplenomegaly is an enlarged liver and spleen. The liver and spleen will enlarge and swell from fluid retention. The nurse should suspect potential heart failure.

20. AUSCULTATION
Heart sounds are the refection of the heart’s functioning, the intensity varies with age, thickness of chest wall and cardiac output.
S1: Closure of mitral and tricuspid valves, producing the first heart sound “lub” of “lub-dub.” This is the beginning of systole
S2: Closure of aortic and pulmonic valves, the second heart sound “dub.” This is the beginning of diastole.
Auscultate with both the diaphragm and the bell of the stethoscope. High-pitched sounds are best heard with the diaphragm of the stethoscope, while low-pitched sounds are best heard with the lightly applied bell of the

21. MURMURS
Innocent murmurs are those that occur in the absence of significant heart disease or structural abnormality of the heart.
Innocent murmurs are rarely heard in newborns and should be evaluated.
Approximately 30% of children beyond the neonatal period are found to have an innocent murmur.
A heart murmur is a noise made by the flow of blood. It can signify a pathological problem or it can be benign.
To develop skill at listening to and describing murmurs, you must develop a systematic approach to chest auscultation so you can describe the sounds you hear.
Innocent murmurs can be classified as follows:
Still’s murmur: A low-pitched, soft murmur occurring in the early to mid-phase of systolic timing and best heard at the apex and left sternal border of the heart when the child is supine.
Basal ejection murmur: A higher-pitched, blowing sound best heard in the pulmonic area while the patient is supine.
Pulmonary outflow murmur: A short systolic murmur heard at the axillary region or back and disappears during infancy as the pulmonary arteries enlarge.
Venous hum: A continuous murmur, described as a humming sound. It is best heard in the infra and supraclavicular areas when the child is lying down, head turned to one side, or when the jugular vessels are occluded.

22. Diastolic murmurs are always pathologic Graded on a scale of 1-6
Clinical assessments must be correlated with murmurs
Murmurs are graded on a scale of 1 to 6.
Grade 1: Barely audible in a quiet room by experienced examiner.
Grade 2: Soft, but easily audible. Limited radiation.
Grade 3: Moderately loud. Moderate to wide radiation.
Grade 4: Loud. Associated with palpable thrill.
Grade 5: Audible with stethoscope chest piece in incomplete contact with skin.
Grade 6: Audible with chest piece 1 cm away from skin.
It is necessary to correlate identified murmurs (sounds and location) with any abnormal clinical assessment, such as poor feeding, tiring easily, color changes, diaphoresis, and respiratory problems.
Loud, coarse systolic murmurs usually suggest an obstructive heart problem.
A high-pitched murmur, heard only in the left axillary area or back, suggests constriction of the aorta and prompt referral to a pediatric a cardiologist should be made.
In an older child, an organic problem should be suspected if there is a thrill and a grade IV-VI heart murmur.

23. CLINICAL ASSESSMENT Monitor vital signs Interpret lab values
Heart rate
Blood pressure
Respirations
Pulse oximetry
Interpret lab values
Maintain strict intake and output
Normal heart rate depends on age. Expect tachycardia with illness. As a child recovers, her heart rate will return to normal.
In people between ages 2 and 10, the systolic pressure can be calculated by the use of the following equation:
90 divided (2 X age in years)
Blood pressure should be within normal limits for age. Even with a very sick child, the blood pressure will be the last vital sign to change to below normal. A child can lose up to 20% of her circulating volume before her blood pressure drops. This is important to keep in mind with children being treated for infection or who are immunosuppressed.
Sick children on a hem/onc floor need to be watched closely. With the state of immune suppression most of them are in, their blood pressure can drop quickly when septic. Before hypotension occurs, careful observation will show a trend of increasing tachycardia.
Respirations need to be evaluated for abnormal breath sounds such as crackles or rales.
Pulse oximetry can be used to evaluate cyanosis. Normal is >90%. If they have a mixing cardiac lesion, then 75% to 85% can be their norm. NICU premies are tolerated with sats in the high 80s.
Common tests include electrolyte panel (the CO in the electrolyte panel is an indicator of acid-base status) Complete Blood Count(CBC): Besides looking for signs of infection, anemia, and high Hct will both stress the heart Calcium: Especially important for heart muscle contraction Magnesium: Also important to heart function.
Any hospitalized should be monitored for I&O: most Med/Surg patients can be followed Q 4–8 hour totals while critical patients are monitored more frequently (Q 1–2 hours would be expected).

24. DIAGNOSTIC STUDIES Chest X-ray Electrocardiogram (ECG/EKG)
Echocardiogram
Cardiac catheterization
Arterial blood gases
The chest X-ray provides cardiac size and size of specific chambers and great vessels, cardiac contour, status of pulmonary blood flow, and status of lungs and other surrounding tissue. When the cardiac silhouette is >55% of the width of the thoracic cage, it is considered cardiomegaly.
The ECG/EKG monitors the electrical activity of the heart from different locations and in different planes of the body. Among teenagers, the symptom of most concern is syncope, which can represent a complete heart block, prolonged QT interval syndrome, hypertophic myopathies, sick sinus syndrome, or pulmonary hypertension.
PVCs are common in sick children with a stressed heart. Other abnormal rhythms are screened with the ECG. The most ominous rhythm in pediatrics is bradycardia.

25. CONGESTIVE HEART FAILURE
Is the pathophysiologic state in which the heart is unable to pump sufficient blood to meet the metabolic demand of the body.
Volume overload
Pressure overload
Myocardial dysfunction: Problems with contractility
High cardiac output demand
Etiology
Excessive workload (volume, pressure or both) secondary to congenital heart disease or acquired heart disease in the presence of normal myocardial function.
Normal workload in the presence of myocardial dysfunction.
Congestive heart failure is the most common presentation of heart disease. It often is the result of significant structural abnormality of the heart but is also caused by anemia, arrhythmias, hypertension, myocarditis, and sepsis.

26. RIGHT SIDED FAILURE Effects of increased ventricular pressure
- Wall stress and attempts by heart to pump better
Effects of increased volume
- Dilation of the chamber
- Regurgitation back into the atrium
The increased workload on the right ventricle will lead to hypertrophy of the right ventricular muscle. The dilation is an attempt to accommodate the increase in volume that the ventricle is unable to empty.

27. CLINICAL MANIFESTATIONS
Tachycardia
Muscle failure – poor contractility
Marginal B/P
Change in pulses
Diaphoresis
Poor feeding
Pale color
Hepatomegaly

28. LEFT SIDED FAILURE Increased pressure in left ventricle
Increased volume in left ventricle
Increased pressure in pulmonary veins
High pulmonary artery wedge pressure
Similar effects on the heart but different systems directly affected

29. HYPOPLASTIC LEFT HEART
LILY NEWBORN PRE OP
LILY ONE DAY OLD POST OP

30. LILY 4 YEARS OLD
LILY 5 YEARS OLD

31. CLINICAL MANIFESTATIONS
Effects of increased pressure
Muscle failure as on the right
Effects of increased volume
Ventricular dilation and worsening of muscle failure
Poor contractility
Marginal blood pressure
Tachycardia
Dilation and hypertrophy of the left side of the heart will happen as on the right side.

32. Volume and pressure overload
Backward failure
Tachypnea
Increased work of breathing
Moist rales
Signs and symptoms of pulmonary hypertension

33. Failure on either side Poor perfusion Gallop heart sound Tachycardia
Capillary refill is delayed
Extremities are cool
Gallop heart sound
Tachycardia
Peripheral edema
Diaphoresis
Loss of appetite

34. CLINICAL MANAGEMENT Fluid restriction to help with congestion
Diuretic therapy to help manage excess body water
Nutritional support, either NGT or IV therapy
Oxygen for the heart muscle
General measures include:
Restriction of physical activity
Oxygen
Tube feedings
Limit of salt intake
Daily weights
Treatment of underlying cause:
Surgical palliation or correction of structural abnormality
Medical treatment of endocarditis, myocarditis, anemia or hypertension

35. Medication to assist with contractility
Digoxin
Dopamine IV
Medication to aid perfusion
Captopril PO
Milrinone IV
Treat underlying cause

36. MEDICATIONS-what and why?
Diuretics
Cardiac glycosides
ACE
Inhibitors/Antihypertensive agents
Antibiotics
Analgesics
Salicylates
Oxygen
Gamma Globulin
The medications given are directed toward managing the symptoms. Treating the cause is the only chance for a full recovery. Digoxin will help support contractility and might be the treatment of choice for some arrhythmias associated with CHF. Kids can be discharged on digoxin. Dopamine is an IV medication that helps contractility and supports blood flow to the kidneys in low doses or can support blood pressure with higher dosing. Dopamine is for hospital use only.
Captopril is a vasodilator as is milrinone. They both decrease afterload. Captopril is also potassium sparing, so it works well with Lasix, which is a common, effective diuretic used in children.

37. CONGENITAL DEFECTS Atrial Septal Defect Ventricular Septal Defect
Patent Ductus Arteriosus
Hypoplastic Left Heart
Transposition of the Great Arteries
Tetralogy of Fallot

38. ACQUIRED DEFECTS Kawasaki Disease Rheumatic Heart Disease
Acute systemic inflammatory illness
Leading cause of acquired heart disease in children
Usually preceded by URI
Rheumatic Heart Disease
Damage occurs, usually to valves, following rheumatic fever
More prevalent in 3rd world countries
Inflammatory disease affecting heart, joints, CNS
Inflammatory disease that occurs after infection with beta hemolytic strep pharyngitis

39. CASE STUDY
Sara is an 18-year-old first-time mom. She brings her 3-week-old baby Adam into the ER for a check because his color did not look right today. She tells you that he is a good baby, he sleeps all the time, he never wakes up to eat, she wakes him up
What else do you want to ask?
What else do you want to ask?
What was Adam’s birth weight? Mom reports 7 lbs., 9 oz.
What is his current weight? You weigh him today at 7 lbs., 1 oz.
How much is he eating? He eats about 3 oz. every four to six hours.
Number of wet diapers a day? He has a wet diaper about every six hours.
Ask mom to describe the scenario about the color changes. Mom states he was feeding today and he looked a little blue.

40. What else do you want to ask?
What was Adam’s birth weight? Mom reports 7 lbs., 9 oz.
What is his current weight? You weigh him today at 7 lbs., 1 oz.
How much is he eating? He eats about 3 oz. every four to six hours.
Number of wet diapers a day? He has a wet diaper about every six hours.
Ask mom to describe the scenario about the color changes. Mom states he was feeding today and he looked a little blue.

41. You ask the mom whether Adam had a murmur at birth and mom says no
You ask the mom whether Adam had a murmur at birth and mom says no. The ER doctor examines him and tells Sara he believes that Adam has a VSD Why would his murmur be heard now at 3 weeks of age?
Why would his murmur be heard now at 3 weeks of age?
A VSD is a hole between the ventricles. At birth the pressure in both sides of the heart is equal. As the baby grows, the pressure in the left side of the heart increases, forcing blood back into the right side of the heart and backing up into the lungs, which causes respiratory distress and poor feeding. It also results in an audible murmur.

42. Why would his murmur be heard now at 3 weeks of age?
A VSD is a hole between the ventricles. At birth the pressure in both sides of the heart is equal. As the baby grows, the pressure in the left side of the heart increases, forcing blood back into the right side of the heart and backing up into the lungs, which causes respiratory distress and poor feeding. It also results in an audible murmur.

43. What tests would be ordered and what would be in Adam’s plan of care?
Chest X-ray to look for cardiomegaly, pulmonary edema.
ECG for rhythm disturbances.
Echocardiogram to confirm the VSD and look for other structural abnormalities and to determine the size of the VSD.
Adam’s plan of care will include oxygen, feeding support with smaller, more frequent feeds with a special nipple, and higher calorie formula. The food might be delivered via nasogastric feeds. Treatment will be based on the size and location of the VSD. It can be surgical or conservative

44. What tests would be ordered and what would be in Adam’s plan of care?
Chest X-ray to look for cardiomegaly, pulmonary edema.
ECG for rhythm disturbances.
Echocardiogram to confirm the VSD and look for other structural abnormalities and to determine the size of the VSD.
Adam’s plan of care will include oxygen, feeding support with smaller, more frequent feeds with a special nipple, and higher calorie formula. The food might be delivered via nasogastric feeds. Treatment will be based on the size and location of the VSD. It can be surgical or conservative

45. MODULE 5 WORKSHEET Complete MODULE 5 WORKSHEET
Know which medications are used for which purpose in children with cardiovascular compromise