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Module 5 Cardiac
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CARDIAC ANATOMY
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CARDIAC CYCLE
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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
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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
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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
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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?
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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.
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INSPECTION General appearance Note size for age Activity
Level of consciousness Skin color Muscle tone Nail beds Edema
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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.
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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
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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
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Note the pallor of extremities compared to trunk
COLOR CHANGES Note the pallor of extremities compared to trunk
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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
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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
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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.
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PALPATION Assess pulses for rate, rhythm, and volume Apical Radial
Brachial Femoral
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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.
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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.
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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
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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.
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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.
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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).
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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.
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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.
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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.
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CLINICAL MANIFESTATIONS
Tachycardia Muscle failure – poor contractility Marginal B/P Change in pulses Diaphoresis Poor feeding Pale color Hepatomegaly
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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
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HYPOPLASTIC LEFT HEART
LILY NEWBORN PRE OP LILY ONE DAY OLD POST OP
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LILY 4 YEARS OLD LILY 5 YEARS OLD
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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.
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Volume and pressure overload
Backward failure Tachypnea Increased work of breathing Moist rales Signs and symptoms of pulmonary hypertension
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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
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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
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Medication to assist with contractility
Digoxin Dopamine IV Medication to aid perfusion Captopril PO Milrinone IV Treat underlying cause
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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.
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CONGENITAL DEFECTS Atrial Septal Defect Ventricular Septal Defect
Patent Ductus Arteriosus Hypoplastic Left Heart Transposition of the Great Arteries Tetralogy of Fallot
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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
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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.
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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.
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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.
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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.
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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
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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
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MODULE 5 WORKSHEET Complete MODULE 5 WORKSHEET
Know which medications are used for which purpose in children with cardiovascular compromise
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