NCLEX-RN: Pediatric Nursing

Pediatric Nursing: Cardiovascular System

Focus topic: Pediatric Nursing

The heart is the center of the cardiovascular system, which, by contracting rhythmically, pumps blood through the body to nourish all of the body tissues and cells. This is one of the most essential body systems because failure to function results in death of the client.

Pediatric Nursing:System Assessment

Focus topic: Pediatric Nursing

A. History.
  • Family history of congenital or acquired heart disease.
  • Perinatal and antenatal course.
  • Gestational age (at birth).
  • Birth weight, length of hospital stay at birth.
  • Significant illnesses, frequent respiratory infections, family history, rheumatic fever.

B. Inspection.

  • Evaluate skin color (pink, pale, mottled, cyanosis).
  • Evaluate LOC and interaction with caregivers and environment.
  • Observe for signs of respiratory distress head bobbing, nasal flaring, cough, retracting. Note oxygen  saturation.
  • Assess periorbital area, sacrum, scrotum, hands, and feet for edema.
  • Observe for clubbing of fingers and toes.

C. Palpation.

  •  Palpate peripheral pulses for rate and quality fullness; be sure to check brachial, femoral, and pedal pulses.
  •  Assess skin temperature, moisture (diaphoresis), and capillary refill time.
  •  Palpate liver (should be 1–2 cm below right costal margin).
  •  Evaluative precordium for lifts, thrills, or heaves; position of point of maximal impulse.
  •  Assess blood pressure (all four extremities if femoral and pedal pulses weak).

D. Percussion.

  • Percuss hepatic margins; spleen if possible.
  •  Percuss lung fields if suspect fluid or consolidation.

E. Auscultation.

  •  Auscultate heart at aortic, pulmonic, mitral, and tricuspid positions.
  •  Assess heart rate for rhythm and regularity, if apical–radial deficit.
  •  Evaluate S1 and S2, note if splitting of S2 on inspiration. Assess for additional heart sounds (S3, S4).
  •  Evaluate murmur detected for intensity grade I–VI, pitch, timing in cardiac cycle, and changes detected with  positional change.
  •  Evaluate for friction rub, venous hum, clicks in relation to cardiac cycle.
  •  Auscultate lung fields for crackles and wheezes.

F. Assess growth and development.

  •  Feeding patterns or difficulties (tiring easily, sweating, tachypnea).
  • Assess growth patterns plotted on growth charts—note failure to thrive or obesity.
  •  Normal development milestones achieved.

G. Evaluate any other symptoms or history.

  • Chest pain muscular vs. gastrointestinal versus respiratory, and occurrence at rest or with exercise.
  • Syncope requires further investigation,family history of sudden death, electrocardiogram (ECG) evaluation,  relationship to exercise and illness.
  • Infections recent streptococcal or rashes on hands and mouth.
  • Blood pressure screening for hypertension.

Pediatric Nursing: Diagnostic Procedures

Focus topic: Pediatric Nursing

Fetal Ultrasonography

A. “Routine” scan performed at 18–22 weeks’ gestation, if a quality scan and personnel are available. Cardiac, spinal, intracranial, and facial abnormalities can be diagnosed during this time.
B. A Level II ultrasound may be performed, targeting specific anomalies seen on the screening (Level I exam).
C. Proper referral to tertiary medical facility is necessary if further antepartum diagnosis and treatment are advised.

Echocardiography

A. A noninvasive cardiac procedure that records high frequency sound vibrations and reflects mechanical cardiac activity.
B. Usually used to diagnose valvular and other structural anomalies, thickness of septum and ventricular walls, intracardiac defects.
C. May require sedation in young clients—follow institutional protocol.
D. May also be performed via transesophageal route; requires sedation.
E. Nursing responsibilities.

  •  Before procedure, assure child that procedure is painless, and prepare child for procedure to help ensure cooperation. Show child and family equipment.
  •  After procedure, provide general reassurance; recover from sedation per protocol.

Electrocardiography

A. 12-lead ECG used to diagnose arrhythmias as in adults.
B. May need to time with nap schedule in small children unable to hold still for ECG.

Tilt-Table Testing

A. Used in definitive diagnosis of syncope in young clients (or adults) after careful history and physical examination in clients experiencing a syncopal event suspected to be of cardiac origin.

  • Syncope associated with exercise is associated with sudden death.
  •  Most syncope is neurogenic or vasodepressor in origin, and is benign; tilt-table test and monitoring help discern those with potentially lethal cardiac conditions.

B. Tilt test simulates orthostatic stress to provoke a syncopal event while clients are closely monitored with 15-lead ECG monitoring and frequent automatic blood pressure evaluation.
C. Protocols may vary among institutions, but most clients start in supine position, then are tilted up 70–80 degrees for up to 30 minutes to duplicate symptoms, while observing for cardiac changes.

Cardiac Catheterization

A. A procedure in which a catheter is passed into the heart and its major vessels for examination of blood flow, pressures in all chambers and vessels, and oxygen content and saturation. The catheter may be passed through the arterial system into the left side of the heart or through the venous system into the right side of the heart, usually via the femoral artery or vein.
B. Nursing responsibilities before procedure.

  •  Prepare client and/or parents and child for procedure by showing equipment, room, monitors, and pictures.
  •  Establish baseline vital signs.
  •  Assess for evidence of illness. Assure NPO status maintained.
  •  Ensure that consent is obtained.

C. Nursing responsibilities during procedure.

  •  Carefully observe vital signs.
  •  Observe for cyanosis or pallor, bradycardia, arrhythmias, and apnea.
  •  Follow sedation protocol.
  •  Assist in comforting the child.

D. Nursing responsibilities following procedure.

  •  Check for peripheral pulses, distal to the site in the extremity used for catheter.
  •  Check for bleeding at the site of the extremity used for catheter.
  •  Take and record vital signs every 15 minutes; observe for subnormal temperature.
  •  Observe for thrombosis: warmth of extremities, weak arterial pulses, cyanosis, blanching of extremity, skin color.
  •  Check for progressive return to normal.
  •  Observe for hypotension (internal bleeding) and signs of infection.
  •  Check incision site for bleeding or hematoma, maintain pressure dressing as ordered.
  •  Observe for reactions to dye used in procedure.
  •  Recover from sedation according to protocol (when done via transthoracic route).

Pediatric Nursing: System Implementation General Principles

Focus topic: Pediatric Nursing

A. Monitor supplemental oxygen concentration to ensure appropriate levels, monitor oxygen saturations (continuously or intermittently).
B. Obtain vital signs at least every 4 hours or more frequently if warranted.
C. Monitor strict I&O and daily weights for changes that may indicate fluid overload.
D. Observe for signs of impending heart failure.

  •  Increase in weight, edema, positive (excess) fluid balance.
  •  Increased pulse and respirations.
  •  Presence of adventitious breath sounds, respiratory distress.
  •  Increase in cyanosis.
  • Liver margin palpable more than 1–2 cm below costal margin.
  •  Tires easily with activity and/or feeding, difficulty sucking nipple (use soft nipples).
  •  Monitor for increased tachypnea, diaphoresis, or feeding intolerance (vomiting).
  •  Feed the infant or child in a quiet and relaxed environment.
  • Provide frequent, small feedings as they may be less tiring.
  •  Hold infant in upright position; may provide less stomach compression and improve respiratory effort.
  •  If child unable to consume appropriate amount of formula during 30-minute feeding q3h, consider nasogastric feeding.
  •  Concentrating formula to 27 kcal/oz will increase caloric intake without increasing infant’s workload.

E. Monitor for signs of polycythemia. Oxygen saturation of arterial blood that is less than 92% on 100% oxygen may indicate cyanotic heart disease. Hematocrit higher than 52% may be a sign of polycythemia.

F. Position cyanotic infants in the knee–chest position during hypercyanotic episodes. The toddler may assume the squatting position by himself.

Pediatric Nursing: Fetal to Infant Circulation

Focus topic: Pediatric Nursing

Pediatric Nursing

G. Organize care and feedings to provide sufficient periods of rest.

H. Feed the child by nipple or nasogastric tube. Formula should contain appropriate caloric concentration and fluid volume.

I. Encourage family to participate in infant’s care provide nurturing environment, promote bonding/ support child’s development.

Pediatric Nursing: Congenital Heart Conditions

Focus topic: Pediatric Nursing

Pediatric Nursing: Fetal Circulation

Focus topic: Pediatric Nursing

A. Major structures of fetal circulation.

  •  Ductus venosus: a structure that shunts blood past the portal circulation.
  •  Foramen ovale: an opening between the right and left atria of the heart that shunts blood past the lungs.
  •  Ductus arteriosus: a structure between the aorta and the pulmonary artery that shunts blood past the lungs in uterine development.

B. Normal changes in circulation at birth.

  • The umbilical arteries and vein and the ductus venosus become nonfunctional.
  • The lungs expand, reducing pulmonary vascular resistance, and greater amounts of blood enter the  pulmonary circulation.
  • Increased blood in the pulmonary circulation
    elevates the return of blood to the left atrium, which initiates the closure of the flap of tissue covering  for a  men ovale.
  • The ductus arteriosus contracts and the blood flow decreases; eventually, the duct closes. Absence of hypoxemia provides the stimulus for ducts to close.

Pediatric Nursing: Congenital Heart Defects

Focus topic: Pediatric Nursing

Pediatric Nursing

C. Indications of heart disease in newborns.

  •  Heart failure.
    a. Biventricular failure most common in infants (signs of left and right heart failure).
    b. Cyanosis (persistent with administration of 100% oxygen).
  • Arrhythmias.

Pediatric Nursing: Cyanotic Defects

Focus topic: Pediatric Nursing

Definition: Cyanotic heart defects are a group of congenital heart defects (CHDs) in which the child may appear cyanotic (blue) due to deoxygenated blood bypassing the lungs and entering the systemic circulation. Cyanotic defects account for approximately 25% of all CHDs. Causes include transposition of the great arteries (TGA) and defects that involve right to left or bidirectional shunting.

Characteristics

A. Causes: No specific cause is known, but may be associated with drug use, chemical exposure, or infections during pregnancy.
B. Types of cyanotic CHD: tetralogy of Fallot, TGA, Ebstein’s anomaly, tricuspid atresia, total anomalous pulmonary venous return, pulmonic stenosis, truncus arteriosus, hypoplastic left heart syndrome (HLHS), critical pulmonary valvular stenosis or atresia, severe coarctation of the aorta, interrupted aortic arch.

Assessment

A. Symptoms: central and peripheral cyanosis, dyspnea (may assume squatting position), hypoxic “spells,” syncope, and chest pain. Child may have clubbed fingers, murmur, crackles.
B. Diagnostic tests: chest x-ray, complete blood counts (CBC), arterial blood gases (ABGs), electrocardiogram, echo-Doppler, transesophageal echocardiography (TEE), cardiac catheterization, and electrophysiologic studies.

Implementation

A. General management: treatment of heart failure, palliative procedures to improve pulmonary blood flow (septostomy, central Gore-Tex shunt, Glenn shunt).
B. Monitor polycythemia (hematocrits that are > 50% put child at risk for stroke, infectious endocarditis, brain abscess, impaired growth, and pulmonary hypertension).

Pediatric Nursing: Tetralogy of Fallot

Focus topic: Pediatric Nursing

Definition: A cardiac malformation characterized by presence of four anatomic abnormalities caused by the underdevelopment of the right ventricular infundibulum.

Characteristics

A. Ventricular septal defect.
B. Dextroposition of aorta so that it overrides the defect.
C. Hypertrophy of the right ventricle.
D. Varying degrees of stenosis of the pulmonary artery.
E. Hemodynamics: A right-to-left shunt arises in this anomaly due to the degree of pulmonary stenosis, position of the aorta, and the hypertrophied right the systemic circulation.
F. Cyanosis may not be immediately evident in the newborn due to patent ductus arteriosus (PDA), and will be determined by the amount of pulmonary stenosis.

Assessment

A. Observe for symptoms of cyanotic conditions: squatting, clubbing of fingers.
B. Assess heart rate; arrhythmias are common.
C. Evaluate fatigue with exercise.
D. Observe for dyspnea and tachypnea.
E. Observe for signs of polycythemia (can lead to clotting problems and cerebral vascular diseases).
F. Assess for hypercyanotic episodes—“TET spells” and potential for seizure activity.
G. Failure to thrive.

Implementation

A. Provide appropriate nursing interventions discussed under general implementation section.
B. Provide postoperative care for child having palliative shunting procedure, increasing blood flow to the lungs.
C. Provide postoperative care for corrective treatment of pulmonary stenosis and ventricular septal defect.
D. Provide support and education to family.

Pediatric Nursing:Transposition of the Great Vessels

Focus topic: Pediatric Nursing

Definition: In this condition, the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle, leading to blood flowing in two parallel circuits. This defect is not compatible with survival unless there is a large defect present in the ventricular or atrial septum, allowing for mixing of oxygenated and unoxygenated blood.

Characteristics

A. Babies are blue at birth, not responsive to oxygen.
B. Aorta is anterior to pulmonary artery.
C. Pulmonary artery ascends parallel to aorta rather than crosses it.
D. Ventricular septal defect may or may not be present.
E. Atrial septal defect must be treated by balloon septostomy (Rashkind procedure) to create mixing of oxygenated and unoxygenated blood.
F. Patent ductus arteriosus is life preserving in the neonate; allows some oxygenated blood to enter the systemic circulation.
G. Alprostadil (prostaglandin E1) may be given to prevent PDA from closing until baby can be transferred to a cardiac center.

Assessment

A. Evaluate for development of subvalvular pulmonic stenosis, decreased pulmonary blood flow, hypoxia, and polycythemia.
B. Observe for profound cyanosis.
C. Assess for signs of heart failure.

Implementation
A. Provide appropriate nursing interventions as listed under general implementation section.
B. Alprostadil infusion (0.005–0.1 micrograms/ kg/minute) may be used in cyanotic newborns to maintain patency of the ductus arterosus and improve pulmonary blood flow. Monitor for respiratory distress, seizures, apnea, hypotension, bradycardia, and hypoglycemia.
C. Provide postoperative care for palliative surgery (creation or enlargement of a large septal defect, allowing for greater mix of oxygenated and unoxygenated blood).
D. Provide postoperative care for palliative surgery (creation of a patent ductus arteriosus or pulmonary artery banding to decrease blood flow through lungs).
E. Provide postoperative care for corrective surgery: arterial switch procedure.

  •  In arterial switch procedures, the great arteries are transected and reanastomosed so that the distal aorta arises from the left ventricle and distal pulmonary aorta arises from the right ventricle. Coronary arteries must be reimplanted to the functional aorta and is crucial to survival.
  •  This procedure is ideally done in the first few weeks of life.

F. Family support and teaching about possible treatments, follow-up, prognosis. Refer to appropriate agencies and support groups.

Pediatric Nursing: Truncus Arteriosus

Focus topic: Pediatric Nursing

Definition: Persistence of a single arterial trunk arising from both ventricles that supplies the systemic, pulmonary, and coronary circulations. Normally, the truncus arteriosus divides at about 34 days of gestation. A ventricular septal defect is usually present, as is a single, defective, semilunar valve.

Assessment

A. Assess for mottled skin and ashen color; signs of poor cardiac output or hypoxemia.
B. Evaluate for cyanotic symptoms; if present, provide measures to reduce oxygen demand and increase oxygen supply.
C. Determine if murmur is present.

Implementation

A. Provide nursing care as outlined in general intervention section.
B. Provide postoperative care for palliative treatment or complete repair.

Pediatric Nursing: Tricuspid Atresia

Focus topic: Pediatric Nursing

Definition: Complete obstruction of the tricuspid valve associated with hypoplastic right ventricle, accompanied by atrial septal defect; necessary for survival.

Assessment
A. Evaluate for a right-to-left shunt through the atrial septal defect. Should hear gurgle S2 on auscultation; may be variable murmur—often no murmur. Blood mixes with pulmonary venous blood and enters the left ventricle. From the left ventricle, some blood is shunted to the right ventricle and then to the pulmonary artery. The rest passes into the aorta.
B. Assess for symptoms of cyanotic conditions.
C. Observe for cyanosis at birth.

Implementation
A. Provide nursing care as outlined in general intervention section.
B. Provide postoperative care for palliative surgery designed to increase pulmonary blood flow until corrective surgery may be performed.

Pediatric Nursing: Increased Pulmonary Flow (Acyanotic) Defects

Focus topic: Pediatric Nursing

Pediatric Nursing:Patent Ductus Arteriosus

Focus topic: Pediatric Nursing

Definition: A patent ductus arteriosus is present when closure of the fetal shunt after birth fails to occur. The potential for difficulty with this defect is dependent on the amount of blood passing through the defect. PDA occurs often in association with other cardiac defects.

Assessment
A. Assess for loud, continuous machinery-type murmur at left upper sternal border.
B. Palpate for possible thrill.
C. Check for low diastolic blood pressure and for widened pulse pressure.
D. Evaluate for poor feeding habits, diaphoresis, and easy tiring.
E. Check for frequent respiratory infections and distress.
F. Palpate for bounding peripheral pulses.

Implementation
A. Provide appropriate nursing care as listed under general implementation.
B. Closure may be achieved in neonates (especially preemies) with Indocin (indomethacin; IV or orally), which inhibits prostaglandins.
C. Provide appropriate nursing care following occlusion procedure in cardiac catheter lab.
D. Provide postoperative care for surgical ligation of ductus and postoperative thoracotomy care.

Pediatric Nursing: Atrial Septal Defect

Focus topic: Pediatric Nursing

Definition: A communication between the left and right atria persisting after birth.

Characteristics
A. Patent foramen ovale.

  • In 20% of all births, a slit-like opening remains in the atrial septum.
  •  This defect usually presents as a functional murmur and requires no surgical intervention, unless symptoms are present.

B. Ostium secundum defects.

  •  A defect high in the atrial septum (ostium secundum) in which the foramen ovale fails to close, or the septum fails to fuse.
    a. Frequently asymptomatic.
    b. Murmur in area of pulmonary artery.
    c. May be well tolerated in childhood, as the shunting of blood from the left atrium to the right atrium is under relatively low pressure.
  •  A defect low in the atrial septum (ostium primum) in which there is inadequate development of endocardial cushions. The atrial septum allows a flow of blood from the left high pressure chamber to the right atrial chamber.
    a. May be accompanied by mitral insufficiency.
    b. Asymptomatic if there are no valvular abnormalities.

Assessment
A. Assess for widely split and fixed S2 heart sound.
B. Auscultate for systolic ejection murmur.
C. Monitor for signs of heart failure (initially no signs of heart failure in infants and children unless there is pulmonary artery hypertension).

Implementation
A. Provide symptomatic care preoperatively.
B. Provide postoperative care  following occlusion procedure or following surgical closure (requiring cardiopulmonary bypass).

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Pediatric Nursing: Ventricular Septal Defect

Focus topic: Pediatric Nursing

Definition: A communication occurring between the left (higher pressure) and right (lower pressure) ventricles allowing oxygenated blood to shunt back into the pulmonary circulation, causing pulmonary volume and/or pressure overload. Ventricular septal defects (VSDs) account for more than 20% of all congenital heart defects and are the most common defect.

Assessment
A. Signs and symptoms depend on size of defect and amount of shunting. Position of defect also impacts severity. Usually children with large defects present with symptomatology.

  • Cardiac enlargement.
  • Pulmonary engorgement.
  • Dyspnea.
  • Frequent respiratory infections.
  • Loud systolic murmur, thrill.
  • Signs may not present until after 4–6 weeks of age and pulmonary vascular resistance falls (creating a pressure gradient across the defect, and shunting of blood through the VSD from right to left. Then the unoxygenated blood mixes with oxygenated blood and travels to the systemic circulation via the aorta). Presentation of symptoms depends on size of defect and gestational age of child.

C. Observe for tendency to tire easily.
D. Assess for frequent respiratory infections.
E. Check for poor weight gain, failure to thrive.
F. Evaluate for murmur, may radiate over entire left chest.

Implementation
A. Usually no nursing care needs for child with small asymptomatic defects; up to 50% may close spontaneously.
B. Provide symptomatic nursing care for child with large defects as shunting of blood can produce pulmonary vascular resistance over time.
C. Provide preoperative and postoperative care for repair of VSD. Closure of defect is accomplished using a patch or direct suturing. Requires cardiopulmonary bypass.

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