Download Module 5 Cardiac

MODULE 5 CARDIAC
CARDIAC ANATOMY
CARDIAC CYCLE
TRANSITION FROM FETAL CIRC.
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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 10-15 hours after birth
Permanent closure occurs by 10-21 days after birth
unless sats remain low
PEDIATRIC DIFFERENCES
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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
CARDIAC ASSESSMENT
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Comprehensive History
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Has your child ever had a change in skin color during
feeding or crying?
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Does your child tire easily during physical activities?
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Has anyone ever told you that your child has a heart
murmur?
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Does your child seem to assume a squatting position
frequently?
PHYSICAL ASSESSMENT
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Inspection
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Palpation
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Auscultation
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Vital signs
INSPECTION
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General appearance
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Note size for age
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Activity
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Level of consciousness
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Skin color
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Muscle tone
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Nail beds
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Edema
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Skin and mucous membranes
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Color and skin temperature
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Pink
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Pale
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Mottled
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Dusky
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Moist or dry
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Edema
COLOR CHANGES
Dusky skin tones
COLOR CHANGES
Mottled Skin
COLOR CHANGES
Note the pallor of extremities
compared to trunk
COLOR CHANGES
Skin color; watch for changes in perfusion when
crying or agitated
COLOR CHANGES
Pale or dusky undertones
INSPECTION
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Pink mucous
membranes
Nutritional status
Excessive
perspiration
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Neck vein distention
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Retractions
PALPATION
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Assess pulses for rate, rhythm, and volume
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Apical
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Radial
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Brachial
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Femoral
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Grading of pulses
0 = absent
1 = weak, thready
2 = normal
3 = full
4 = bounding
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Capillary refill
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Fontanel
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Normal time < 2 seconds
Indicates fluid status
Hepatosplenomegaly
AUSCULTATION
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Heart sounds are the refection of the heart’s
functioning, the intensity varies with age, thickness of
chest wall and cardiac output.
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S1: Closure of mitral and tricuspid valves,
producing the first heart sound “lub” of “lub-dub.”
This is the beginning of systole
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S2: Closure of aortic and pulmonic valves, the
second heart sound “dub.” This is the beginning of
diastole.
MURMURS
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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.
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Diastolic murmurs are always pathologic
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Graded on a scale of 1-6
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Clinical assessments must be correlated with
murmurs
CLINICAL ASSESSMENT
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Monitor vital signs
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Heart rate
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Blood pressure
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Respirations
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Pulse oximetry
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Interpret lab values
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Maintain strict intake and output
DIAGNOSTIC STUDIES
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Chest X-ray
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Electrocardiogram (ECG/EKG)
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Echocardiogram
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Cardiac catheterization
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Arterial blood gases
CONGESTIVE HEART FAILURE
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Is the pathophysiologic state in which the heart
is unable to pump sufficient blood to meet the
metabolic demand of the body.
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Volume overload
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Pressure overload
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Myocardial dysfunction: Problems with contractility
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High cardiac output demand
RIGHT SIDED FAILURE
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Effects of increased ventricular pressure
- Wall stress and attempts by heart to pump better
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Effects of increased volume
- Dilation of the chamber
- Regurgitation back into the atrium
CLINICAL MANIFESTATIONS
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Tachycardia
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Muscle failure – poor contractility
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Marginal B/P
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Change in pulses
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Diaphoresis
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Poor feeding
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Pale color
Hepatomegaly
LEFT SIDED FAILURE
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Increased pressure in left ventricle
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Increased volume in left ventricle
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Increased pressure in pulmonary veins
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High pulmonary artery wedge pressure
HYPOPLASTIC LEFT HEART
LILY NEWBORN PRE OP
LILY ONE DAY OLD POST OP
LILY 4 YEARS OLD
LILY 5 YEARS OLD
CLINICAL MANIFESTATIONS
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Effects of increased pressure
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Effects of increased volume
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Muscle failure as on the right
Ventricular dilation and worsening of muscle failure
Poor contractility
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Marginal blood pressure
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Tachycardia
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Volume and pressure overload
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Backward failure
 Tachypnea
 Increased
work of breathing
 Moist
rales
 Signs
and symptoms of pulmonary hypertension
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Failure on either side
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Poor perfusion
 Capillary refill is delayed
 Extremities are cool
Gallop heart sound
Tachycardia
Failure on either side
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Peripheral edema
Diaphoresis
Loss of appetite
CLINICAL MANAGEMENT
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Fluid restriction to help with congestion
Diuretic therapy to help manage excess body
water
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Nutritional support, either NGT or IV therapy
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Oxygen for the heart muscle
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Medication to assist with contractility
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Digoxin
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Dopamine IV
Medication to aid perfusion
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Captopril PO
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Milrinone IV
Treat underlying cause
MEDICATIONS-what and why?
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Diuretics
Cardiac glycosides
ACE
Inhibitors/Antihypertensive agents
Antibiotics
Analgesics
Salicylates
Oxygen
Gamma Globulin
CONGENITAL DEFECTS
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Atrial Septal Defect
Ventricular Septal Defect
Patent Ductus Arteriosus
Hypoplastic Left Heart
Transposition of the Great Arteries
Tetralogy of Fallot
ACQUIRED DEFECTS
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Kawasaki Disease
Acute systemic inflammatory illness
 Leading cause of acquired heart disease in children
 Usually preceded by URI
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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
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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?
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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.
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?
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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?
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What tests would be ordered and what would be in Adam’s plan of
care?
Tests:
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
MODULE 5 WORKSHEET
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Complete MODULE 5 WORKSHEET
Know which medications are used for which purpose
in children with cardiovascular compromise