2. Lecture notes for MSc
in cardiovascular
nursing SPHMMC July
2023GC.
Mestawot
Wondimu(MSc
CVN,cath lab N.)
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3. Learning objective
At the end of this section student we be able to
understand:-
Pediatric CVS history taking
Pediatric CVS physical examination
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4. Pediatric Cardiovascular Assessment
Every pediatric cardiology evaluation starts with a
thorough medical history and clinical examination.
The cardiovascular system provides oxygen and
essential nutrients to cells and removes waste
products.
It is closely linked with other systems in the body.
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5. Con…
For this reason, a pediatric cardiovascular assessment
includes
1.assessing both a primary cardiac assessment
-(heart rate , rhythm, blood pressure) &
2.secondary multi-organ assessment
-neurological assessment, urine output &skin color and
perfusion).
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6. History taking
In pediatric cardiology, the medical history
consists of :
-current complaints, gestational, perinatal, family
medical history, and the child's physical development
& current medication.
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7. History taking
Patient’s profile
Name, age (date of birth),Address of parents
Date of admission
Presenting complain
Use parents own words
Ask as to when patient was last entirely well?
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8. History and suggestive s/s of CVS involvement
Newborn and infants
Fast breathing
Difficulty breathing
Poor feeding , poor wait gain
Sweating-suck-Rest-suck –cycle
Reduce activity
Cyanosis- central
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10. Con…
Older children and adolescents
All previous + extra
Chest pain, Syncope
Dizziness
Paroxysmal nocturnal dyspnea
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11. Con..
Other important aspect of history
H/O Hospital admission
H/O Previous surgery
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12. Gestational History
Includes the following specific question:- any
indications of a congenital heart defect in the fetal
ultrasound examinations?
- A large percentage of congenital heart defects can
now be diagnosed prenatally using fetal
echocardiography.
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13. Con…
Were any chromosome anomalies or genetic
diseases suspected or diagnosed prenatally?
-A number of genetic syndromes are associated with
congenital heart defects.
Eg . Trisomy 21,13,18
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14. Con…
Did the mother take any medication / drugs /drink
alcohol during pregnancy?
-Many medications are considered to be teratogenic.
Taking any of the following products during
pregnancy has been associated with congenital heart
defects:-
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16. Con…
Did or does the mother have diabetes mellitus or
gestational diabetes mellitus?
- the child is at an increased risk of hypertrophic
cardiomyopathy (reversible),VSD.
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17. Con…
Did the mother contract a viral infection during
pregnancy? Rubella , cytomegalovirus are
teratogenic.
In late pregnancy, viral infections can cause
congenital myocarditis.
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18. Con…
Health and nutritional status of mom during pregnancy
Drugs( iron,mult vitamin, other drug with dose, duration and
at which time of gestation).
Radiation exposure in first trimester.
maternal autoimmune disease.eg.Immune thrombocytopenia
(ITP) causes a decrease platelets in the blood, can lead to
excessive bleeding in the mother & fetus.
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19. Con…
H/O Birth
Birth weight, gestational age? The birth weight is the
basis for monitoring progress.
postnatal adaptation (Apgar score, pH)Cyanotic heart
defects are a risk factor for perinatal asphyxia.
If cyanosis occurred, was there improvement after
oxygen was administered?
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20. Con…
an increase oxygen saturation after the
administration of oxygen is more indicative of a
pulmonary problem than of a cardiac problem.
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21. Con…
Family history:- can determine whether there is a family
disposition for cardiac disease .
any congenital heart defects among close relatives?
Have there been frequent deaths or syncope of
unknown origin in the family?
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22. Con…
Has any family member had a heart attack at a
young age ?
-In this case, possible coronary anomalies and risk
factors for coronary heart disease such as hereditary
thrombophilia or hypertension must be explored.
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23. Con…
Developmental history
Achieving age of various milestones,
Smile, sit,crawl,stand ,walk ,talk, control of
bladder and bowel.
Compared with normal this age.
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24. Physical Examination
Child most confortable in mother’s lap or while
playing around in OPD area or Child may be at
sleep while brought to OPD.
Change the sequence based on the child’s comfort.
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25. Con…
Wash your hands and don PPE if appropriate
Introduce yourself to the parents and the child,
including your name and role.
Confirm the child’s name and date of birth.
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26. Con…
Briefly explain what the examination will involve
using patient-friendly language.
Gain consent from the parents/ carers and/or child
before proceeding.
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27. General inspection
Appearance and behavior
Observe the child in their environment (waiting room, hospital
bed) for his/her:-
-Activity/alertness (alert and engaged, or quiet and lethargic)
-Cyanosis
-Shortness of breath
-Pallor, Edema , Rashes, Weight
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28. Con…
Cyanosis
bluish discoloration of the skin due to poor
circulation (e.g. peripheral vasoconstriction
secondary to hypovolaemia) or inadequate
oxygenation of the blood (e.g. right-to-left cardiac
shunting).
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29. Con…
Shortness of breath:
may indicate underlying cardiovascular (e.g.
congenital heart disease) or respiratory disease
(e.g. asthma).
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30. Con…
Pallor
a pale color of the skin that can suggest underlying
anemia due to poor perfusion (e.g. congestive
cardiac failure).
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31. Con
Edema
typically presents with swelling of the limbs (e.g.
pedal edema or abdomen (i.e. ascites).
There are many causes of edema including cardiac
failure and nephrotic syndrome.
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32. Con…
Rashes: note the characteristics and distribution of
any skin rashes (e.g. petechiae suggesting clotting
disorder).
Weight: note if the child appears a healthy weight for
their age and height
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33. Con…
Syndromic features
Pay attention to features that may indicate the
presence of an underlying genetic condition
-Stature (e.g. tall/short)
-Syndromic facial features
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34. Con…
Equipment: Observe for any equipment in the
child’s immediate surroundings and consider why this
might be relevant to the CVS.
Eg, Oxygen, saturation probe, mask, nasal prongs,
oxygen tank and other breathing support.
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35. Con…
Medications: Note any medications by the bedside
consider what underlying diagnoses they may indicate:
Anticoagulants (e.g. warfarin/heparin): commonly
prescribed for children with artificial heart valves.
Diuretics (e.g. Lasix): often used in the
management of heart failure.
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36. Con…
Inspection of hands
The hands can provide lots of clinically relevant
information & therefore a focused, structured
assessment is essential.
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37. Con…
Inspect the hands for clinical signs relevant to CVS:-
Color
Xanthomata
Arachnodactyly (‘spider fingers’)
Absent thumbs
Finger clubbing
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39. Con…
Xanthomata : raised yellow cholesterol-rich
deposits that are often noted on the palm, tendons of
the wrist and elbow.
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41. Con…
Arachnodactyly (‘spider fingers’):-
fingers and toes are abnormally long and slender.
Is a feature of Marfan’s syndrome,
which is associated with mitral/aortic valve
prolapse and aortic dissection.
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43. Con…
Absent thumbs: associated with Holt- Oram
syndrome,
-an autosomal dominant genetic condition which
causes abnormalities in the bones of the arms and
hands as well as the heart (atrial septal defect, heart
block).
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44. Con…
Finger clubbing: involves uniform soft tissue
swelling of the terminal phalanx of a digit&
loss of the normal angle between the nail and
the nail bed. (congenital cyanotic heart disease
and infective endocarditis).
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45. Con…
To assess for finger clubbing:
Ask the child to copy you in placing the nails of
their index fingers back to back.
In a healthy individual, observe a small diamond-
shaped window (known as Schamroth’s window).
In finger clubbing develops, this window is lost.
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46. Con…
If the child is too young for this to be possible, you
can simply inspect the fingers, looking for soft
tissue swelling of the terminal phalanx of the digit.
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48. Signs in the hands associated with
endocarditis
Splinter hemorrhage: a longitudinal, red-brown
hemorrhage under a nail that looks like a wood
splinter.
Janeway lesions: non-tender, haemorrhagic
lesions that occur on the thenar and hypothenar
eminences of the palms & soles.
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50. Face
Observe the child’s facial complexion and features,
including their eyes, ears, nose, mouth and throat.
Inspect the general appearance of the child’s face
for signs relevant to the CVS:
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52. Con…
Nasal flaring/grunting: may be associated with
congenital cyanotic heart disease or heart failure.
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53. Eye
Inspect the eyes for signs relevant to CVS
Conjunctiva pallor
Xanthelasma :- yellow, raised cholesterol-rich
deposits around the eyes associated with
hypercholesterolemia.
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55. Mouth
Inspect the mouth for signs relevant to the CVS
tip – ask the child to see how long their tongue is
or how big their mouth to see:-
-Central cyanosis
-Dental hygiene:- is a risk factor for infective
endocarditis.
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60. Con…
Breathing pattern-cyanosis-non labored
-tachypnea
- tachypnea with distress
-grunting (noisy breathing sound)
-scar over the precordium
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61. Palpation
Confirm inspection finding on palpation
Palpation for
Temperature, Pulses
Precordium palpation
Oedema
Capillary Refill
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62. Con…
Palpate for Temperature
-Place the dorsal aspect of your hand on to the
child’s.
-In healthy individuals, the hands should be
symmetrically warm, suggesting adequate perfusion.
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64. Con…
palpate for Capillary refill time (CRT) -
Measuring CRT in the hands is a useful way of
assessing peripheral perfusion.
-Apply 5 seconds of pressure to the distal phalanx of
one of a child’s fingers and then release.
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65. Con…
.In healthy child, pallor of the area you compressed
should return to its normal color in <2 seconds.
. a CRT > 2 seconds suggests poor peripheral
perfusion (e.g. hypovolaemia, congestive heart
failure) and the need to assess central CRT.
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66. Con…
Palpate for Pulses:- Palpate the child’s radial pulse, located at
the radial side of the wrist, with the tips of your index and
middle fingers aligned longitudinally over the course of the
artery.
Once you have located the radial pulse, assess the rate and
rhythm. , volume, character, pulse deficit, R-R delay.
In babies, assess the femoral pulse instead.
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68. Con…
Heart rate: calculate the heart rate in a number of
ways, measuring for 60 sec. , for 30 sec ×, for
15 sec times 4.
For irregular rhythms, you should measure the
pulse for a full 60 sec to improve accuracy.
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71. Con…
What is expected:
Strong regular pulse
Bilateral femoral/radial pulses present.
Abnormal findings:
Absent, weak, thready, bounding or irregular pulse
Abnormalities such as a weak femoral pulse can indicate
a congenital cardiac defect.
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72. Con…
Radio-radial delay : describes a loss of
synchronicity between the radial pulse on each arm,
resulting in the pulses occurring at different times.
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73. Con…
To assess for radio-radial delay:- Palpate both
radial pulses simultaneously.
In healthy , the pulses should occur at the same
time.
If the radial pulses are out of sync, this would be
described as radio-radial delay.
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74. Con…
Causes of radio-radial delay include:-Subclavian
artery stenosis (e.g. compression by a cervical rib)
-Aortic dissection.
-Aortic coarctation.
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75. Con…
Alert
-If you are unable to palpate a pulse & the infant/
child is unresponsive, immediately commence CPR
and call for help.
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77. Con…
Normal position
<7 years old: 4th ICS to the left of the
midclavicular line.
>7 years old: 5th ICS in the midclavicular line
Diameter- < 2cm
Quality- tapping
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78. Con…
Abnormal position:
Left displacement: causes include cardiomegaly,
pectus excavatum (“sunken in” or “funnel chest )
& scoliosis.
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79. Con…
Right displacement:- causes include dextrocardia,
left diaphragmatic hernia, collapsed right lung, left
pleural effusion and left tension pneumothorax.
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80. Con…
Tip: Instead of the heel of your hand, use your
fingertips with babies and younger children.
If heaves are present you should feel the heel of
your hand being lifted with each systole
associated with chamber dilatation.
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81. Con…
Thrills: is a palpable vibration caused by turbulent
blood flow through a heart valve (a thrill is a palpable
murmur).
Is a sign of right ventricular hypertrophy
You should assess for a thrill across each of the
heart valves.
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82. Con…
Palpate for oedema
Palpate both centrally and peripherally for the presence of
oedema.
To assess peripherally remove the child's shoes and socks.
Apply gentle pressure, with your thumbs to the top aspect
of the child's left and right foot, hold for 3-4 sec before
removing.
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84. Con…
What is expected:
- On removing your thumbs no dip or pit should be
present.
Abnormal findings:
-On removing your thumbs if a dip is present, the
child may have peripheral oedema.
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85. Percussion
Percussion is a method of tapping body parts with fingers.
done to determine:-
To see the enlargement dullness of the cardiac region.
- Left border - Right border
- Apex - Right sternal border
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87. Auscultation
Cardiac auscultation refers to listening to the
sounds of the heart with a stethoscope.
listen to the different points of auscultation to
determine if there are any abnormalities present
and if further tests need to be performed .
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91. Con…
Normal heart sound
S1&S2 termed as LUB-DUB
High pinched sounds
best heard with diaphragm
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92. Con…
S1 closing of mitral and tricuspid valves at
transition from diastole to systole.
S2 closing of aortic and pulmonic valves at
transition from systole to diastole.
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93. Con…
Third heart sound(S3)
Protodiastolic sound or ventricular gallop.
Produced by initial passive filling of ventricles
Heard best with bell at the apex.
Normally present in children and athletes
Pathological causes:-high out put state.
-Congenital heart disease
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94. Con…
Aortic
The aortic point is located on the right side of the
sternum in the 2nd ICS.
the heart creates a “lub-dub” sound, which occurs when
blood is being pumped and flowed to and from the
heart.
These are also referred to as S1 & S2 sounds.
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95. Con…
Pulmonic
Is located left to the sternum in the 2nd ICS.
The typical S2 sound, referred to as the “dub”
sound.
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96. Con…
Erb’s Point
Located to the left of the sternum in the 3rd ICS &
approximate center of the heart.
At this point, listen for both the S1 and S2 sounds.
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97. Con…
Tricuspid
Is located left of the sternum in the 4thICS.
Here you can listen to the S1, or “lub”sound.
also check for an opening snap, which is a high-frequency
sound caused by the opening of the mitral or tricuspid valves,
which may indicate a narrowing of the valves.
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98. Con…
Mitral
located at the left side of the sternum in the 5th
ICS.
Here, you will get the clearest resonance of the S1
sound.
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99. Con…
Heart murmur
simply an extra sound heard when listening to the
heart
Blood is flowing abnormally across your heart
valves.
may mean there's a problem with your heart.
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100. Con…
But heart murmurs are also present in healthy
people who don't have a heart problem (called
“innocent” heart murmurs)
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102. Con…
Types of Murmurs
Systolic:- occurs during a heart muscle
contraction.
Diastolic:- occurs during heart muscle relaxation
between beats.
Continuous:- occurs throughout the cardiac cycle.
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103. Con…
heart murmurs are not serious & not affect a child's
health, but in rare cases, sign of a serious condition
(congenital heart disease ).
at least half of all children have it.
sometimes happen because of fever or infection, &
they usually disappear when your child is well again.
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104. Con…
A pericardial friction rub
sound that generated as a result of an inflamed pericardium.
It has a scratchy or creaking sound similar to leather rubbing
against leather.
Best auscultated with the diaphragm at left lower sternal
border in end expiration with the patient leaning forward.
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105. Con…
In children, most likely to occur following
surgery, repair congenital heart defects or acquired
heart disease.
Rheumatic fever (viral and bacterial infection) is
often the cause of pericardial friction rub.
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106. Auscultate the lungs
Auscultate the lung fields on the anterior and posterior
aspect of the chest:
Ask the child to take ‘big breaths’ – some abnormal
sounds may be inaudible if the child is taking shallow
breaths.
Auscultate each side of the chest in a symmetrical
pattern, comparing side to side.
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107. Con…
Pay attention to the inspiratory and expiratory
sounds at each placement.
Note the quality and volume of breath sounds and
note any additional sounds.
crackles may be a late sign of pulmonary
congestion secondary to congestive heart failure.
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109. Con…
Examination also includes
taking vital signs (pulse, respiratory rate, oxygen
saturation, blood pressure height and
weight,),nutritional assessment & urine out put.
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110. Con…
Vital Signs
Obtain and document a full set of observations on the age
appropriate Children’s.
Any abnormal findings should be action &guide to Normal
Parameters.
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111. Con…
Blood Pressure
should preferably be obtained when the infant or
child is not distressed, and the limb should remain
immobile bare & during measurement.
the infant or child should be seated or supine with
the limb at heart level.
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112. Con…
Sites for blood pressure cuff placement.
Under 12 months: upper arms or calf.
1-5 years of age: upper arms or calf (if arms are
unavailable).
Over 5 years: upper arms.
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113. Con…
Guide to Picking the Correct Blood Pressure Cuff:
The cuff should be approximately 40% of the
infant or child’s arm/leg circumference.
The cuff bladder length should be 80-100% of the
circumference of the arm/leg.
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116. Con
Tips in children
Some infants and young children become upset by the
blood pressure cuff especially when it tightens.
some ideas to overcome this:
Infants -Ask caregivers to talk and reassure their baby.
- Use toys and distractions tempt ,while feeding,
asleep or calm.
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117. Con…
Toddlers- Provide a simple explanation and make it a
game. For example, “This is going to give your arm a
little squeeze and it will tell us how big your muscles
are.”
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118. Con…
Older children:- Provide an explanation and involve
the child and their caregiver where possible.
You can ask them to help place the cuff on their
arm or push the start button.
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119. Con…
Alert
Hypotension is a late indicator of cardiovascular
compromise or collapse. If you have an infant or
child found to be hypotensive seek an immediate
medical review.
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120. Con…
Pulse rate
• Count for full 1 min by palpating radial artery
• preferably when the infant or child is not
distressed.
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121. Con…
Normal heart rate
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age Heart rate(beat/min)
Infant 120-160
Toddlers 90-140
Preschooler 80-110
School agers 75-100
Adolescent 60-90
Adult 60-100
122. Con…
Respiratory Rate in Infants & Children
The respiratory rate should be counted for a full 60 sec.
Is preferably conducted when the child is sleeping or
quietly awake.
Observe for work of breathing (mild, moderate or
severe) and for accessory muscle use.
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123. Con…
Tips in children
Under 12 months: When counting an infant’s respiratory rate,
gently rest your hand over their chest and abdomen.
Over 12 months: Sit the child in the caregivers lap or have
them sit close by to their child in bed for comfort.
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124. Con…
Ask the caregiver to unbutton or lift their child’s shirt
to expose the chest enabling you to count from the end
of the bed.
Some younger children may require a toy or some
bubbles to keep them distracted while you count.
Remove appropriate clothing to visually assess work of
breathing.
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126. Con…
Skin temperature
Using a bare hand feel the infant’s skin centrally
(torso) and peripherally (hands and feet).
What is expected:
Warm to touch, Dry
No or minimal discrepancy when comparing central
and peripheral warmth.
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127. Con…
Abnormal findings:
Cool to touch
Temperature discrepancy between central and
peripheral skin temperature (warm centrally
however cool peripherally)
Clammy skin (wet skin from sweating).
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128. Con…
The preferred site of the temperature check varies
according to the size of the child:
- Under 6 months: Axillary.
- 6 months and above: Tympanic.
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129. Con…
The temperature probe must fit the ear canal
comfortably to ensure accuracy.
If in doubt use the axillary site.
Oral temperatures are not routinely recommended.
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131. Con…
Oxygen Saturations (SpO2)
Many different types of oxygen saturation probes.
Check the probe you are using to ensure the
weight range is appropriate for the size infant or
child you are using it on.
Best site infants are around the palm & foot.
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134. Con…
Adult ‘peg’ probes are not appropriate for infants.
The probe site should be changed hourly in infants
and second hourly in young children, due to the
risk of pressure injuries.
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135. Con…
SpO2 Probe Placement:
Under 12 months: Probe placement works best on
the hand, foot or big toe.
1-3 years: Probe placement works best on the big
toe & thumb.
Over 3 years: Probe placement works best on the
thumb & fingers. You may also use the ear lobe.
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136. Con…
Hand:
Place emitter on the palm at the base of the little
finger with the detector directly opposite on the
outer aspect of the hand and secured with a self-
adhering foam tape.
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137. Con…
Foot:
Place emitter on the foot at the base of the little toe
with the detector directly opposite on the outer
aspect of the foot and secured with a self-adhering
foam tape.
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138. Con…
Fingers, thumbs and big toes:
Place emitter on the nail & the detector directly opposite on
the pad to the finger.
Tips in children
Some young children become upset by the Sp02 probe &
Show them the probe is not scary by placing it on their
doll/teddy or caregiver.
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139. Con…
Place the probe on their big toe and cover it with a
sock or shoe.
Use distractions such as toys or bubbles to shift
their attention away from the probe.
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140. Con…
• Always check the probe is in the correct position,
• secure & pleth wave is even before accepting the reading you
are given on the monitor.
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141. Con…
Anthropometry
Anthropometric measures are frequently used
worldwide to assess the risk of CVD. Body mass
index (BMI) by calculating Weight and Height.
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143. Con…
Nutrition Assessment:-
With the involvement of care givers carry out a
nutrition assessment.
assessing mucous membranes,
oral intake and urine output.
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144. Con…
What is expected?
Feeding well (greater than 50% of their usual oral intake)
Moist mucous membranes
No changes in urine output.
22 September 2023
MESTAWOT
144
145. Con…
A normal urine output
in a child under 2 years of age is between 2-3ml/
kg/hr.
Children over the age of 2 have a normal
urine output between 0.5-1ml/kg/hr.
22 September 2023
MESTAWOT
145
146. Con…
Abnormal findings:
Decreased feeding (less than 50% of their usual
oral intake)
Dry mucous membranes
Reduced urine output (yellow/orange colour ) or
minimal/an uric.
22 September 2023
MESTAWOT
146
147. Con…
-Reduced number of wet nappies in 24hrs or
-nappies feel lighter
- Diarrhea - hard to assess how much urine
produced.
- Sunken eyes, dark rings around eyes, eyes
22 September 2023
MESTAWOT
147
