The Place of Paediatric Nurses in Cardiology

Iluebbey Frances

OBJECTIVES

To enlighten and re-orientate nurses to their roles in the management of patients with heart disease. To increase their alertness in identifying children with heart disease. To emphasise the importance of their roles in ensuring optimal health for children with cardiac dysfunction.

CLINICAL ASSESSMENT OF CARDIOVASCULAR FUNCTION.

Much information can be gained via the following routes:

History taking
Physical examination

HISTORY TAKING

Prenatal period i.e maternal illness and drug intake (e.g amphetamines) Present illness: Its presenting complaints, severity, evidence of respiratory iii. distress, growth pattern, feeding difficulties, activity intolerance. Etc. Family History: To ascertain familiar tendencies of hereditary cardiac diseases

PHYSICAL EXAMINATION
Conventionally, physical exam should be done with the standard format of
Inspection/observation
Palpation Percussion Auscultation

Inspection

Begins from the head Normally during history taking Points to note include. General appearance for cyanosis, pallor.

Circulatory problems i.e clubbing of fingers.

Respiratory efforts i.e any difficulty, shallow, increase in respiratory rate etc.

Feeding pattern: Restless/Fussiness during feeding, easily tires out etc. Vital Signs to be observed as follows:

Heart rate may be high (tachycardia) or low (bradycardia).

Respiratory rate may be increased (tachypnoea)

Inspection of chest may reveal asymmetry suggesting chronic heart enlargement.

Palpation

Palpate pulses: to assess for rate, regularity, intensity, timing etc. Palpating the abdomen may reveal an enlarged liver (hepatomegaly)

Auscultation

Is the most important part of cardiovascular exam. Assesses each portion of the cardiac cycle i.e listens to heart rate, regularity, the heart sounds, murmurs.

DEFINITION OF CONGESTIVE HEART FAILURE

It is the inability of the heart to pump adequate amount of blood at a rate commensurate to meet the bodys metabolic demands.

ETIOLOGY

Congestive Heart failure may result due to:

Congenital

heart disease Acquired heart disease e.g rheumatic fever, rheumatic heart disease, myocarditis etc Non-cardiovascular diseases e.g pulmonary disease, fluid overload, respiratory infections.

CLINICAL SIGNS AND SYMPTOMS

These are divided into 3 groups

Impaired myocardial function

Increased heart rate (tachycardia) Inappropriate Sweating Fatigue especially during feeds Weakness Restlessness Pale, Cold extremities Cardiomegaly (enlarged heart). Decreased blood pressure

 PULMONARY

CONGESTION

Increased respiratory rate (tachypnoea) Difficulty in breathing (Dypsnoea) Sternal retractions Nasal flaring Activity intolerance Cough/Hoarseness (later due to laryngeal compression) Cyanosis (Bluish discolouration of the skin and mucous lining). Crepitations/reduced breath sounds.

 SYSTEMIC
Weight

VENOUS CONGESTION

gain Hepatomegaly (enlarged liver ) Peripheral oedema/ascites

DIAGNOSTIC STUDIES

are done not so much to confirm the diagnosis but more importantly to ascertain the cause, severity and monitor response to treatment.

Chest X-ray Assessment of extracardiac structures, the size and shape of the heart and size and position of the pulmonary artery and aorta. Electrocardiogram (ECG) valuable, non-invasive screening tool. Provides information about the rate, rhythm, depolarization and repolarization of cardiac cells. Also size and wall thickness of the heat chambers.

Arterial Blood Gases (ABG)

Echocardiography has become the most important non-invasive tool in the diagnosis and management of cardiac disease.

Cardiac Catherization: performed on patients who need additional anatomic information. - A catheter is introduced into the heart then oxygen saturation, blood pressure are measured in each heart chamber. Pulse oxymetry painless, inexpensive but valuable tool to assess oxygen saturation.

Other diagnostic studies include

Full Blood Count (FBC) sedimentation rate (ESR)

Erythrocyte

Blood

Cultures /Electrolyte and Urea Levels etc.

S/N

NURSING DIAGNOSIS

EXPECTED PATIENTS OUTCOME

Decreased cardiac output related to cardiac dysfunction

1. Child will have adequate output as evidenced by a. Heart rates within acceptable limits b. Respiratory rate within acceptable range c. Blood pressure normal for age d. Lack of oedema e. Adequate urine output (12mls/kg/hr

S/N 2

NURSING DIAGNOSIS Ineffective breathing pattern related to pulmonary congestion

EXPECTED PATIENTS OUTCOME 1. Child will have effective breathing pattern as evidenced by: a. Respiratory rate within acceptable range b. Clear and equal breath sounds c. Pink colour d. Absence of nasal flaring/retractions e. Unlaboured breathing

Fluid volume excess related to oedema

No evidence of fluid excess.

Therapeutic Management

The goals of treatment are to:

Improve

cardiac function Remove accumulated fluid and sodium Decrease cardiac demands Improve tissue oxygenation and decrease oxygen consumption Children with congestive heart failure may require intensive care until symptoms improve

Essential nursing management will include the following:

Assist in measures to improve cardiac function Decrease cardiac demands Reduce respiratory distress Maintain Nutritional Status Assist in Measures to Promote fluid loss Support the Child and Parents

Assist in measures to improve cardiac function

calculating and administering prescribed drugs especially digoxin Monitor signs of side effects Do not give, if heart rate is below 70 for older children, 90110 for infants.

Decrease cardiac demands:

to be organized and planned bathing, medications, procedures Minimize disturbance Provide adequate rest periods. Encourage parents to cuddle/rock babies per required
Cares

 Reduce

respiratory distress:

Gently assess babies Ensure good positioning Prompt oxygen administration Report / record any abnormality in respiration Do clothing and diapers loosely.

Maintain Nutritional Status: This is a serious nursing

challenge.

Individualize feeding needs. A 3 hour feeding schedule works well for most infants.

Feed in an upright position well-supported.

Diet plan specific to the individual calculated to meet caloric needs. Expressed Breast Milk (EBM) may be given in some case. Feed as child can tolerate for a period of 30 minutes. Nasogastric feeding can be done in severe and acute cases.

Assist in Measures to Promote fluid loss

Record

fluid intake and output Monitor body weight Monitor for signs of electrolyte imbalance Give intravenous fluids as prescribed

Support the Child and Parents:

Communicate

frequently with parent regarding childs progress Encourage active participation in childs care.

Thanks for Listening