CARDIAC ASESSMENT

Patient assessment is one of the most important skills that you perform as a healthcare
professional. An organized approach to patient assessment will help you differentiate
between patients who require immediate emergency care and those who do not and will help
ensure that no significant findings or problems are missed. Make sure that the scene is safe
before approaching the patient, and always use appropriate personal protective equipment

Assessment of an ill or injured child requires a systematic approach, knowledge of normal

growth and development, and knowledge of the anatomic and physiologic differences
between children and adults. Approaches to obtaining historical information and physical
examination vary depending on the child’s age and presentation. Regardless of the healthcare
environment in which you work, patient care is delivered by a team of professionals. A team
has been defined as “two or more individuals who perform some work-related task, interact
with one another dynamically, have a shared past anda foreseeable shared future, and share
acommon fate”
Appearance

Assessment of the child’s appearance includes your observationsof the child’s mental status,
muscle tone, and body position
Appearance is a reflection of the adequacy ofoxygenation, ventilation, brain perfusion, and
central nervoussystem function (. Themnemonic TICLS, pronounced tickles, was developed
by theAmerican Academy of Pediatrics and is used to recall the areasto be assessed as they
are related to the child’s overall appearance When forming a general impression, the
American Academy of Pediatrics considers identification of achild’s abnormal appearance to
be more effective in spotting subtle behavioral abnormalities than the use of the Alert,
Verbal,Pain, Unresponsive (AVPU) scale or the pediatric Glasgow
Coma Scale (GCS)
Breathing
The second component of the PAT is assessment of the work of breathing (i.e., ventilatory
effort), which reflects the adequacyof the patient’s oxygenation and ventilation (American
Academy of Pediatrics, 2014). Assessment areas include the child’s body position, visible
movement of the chest and abdomen, ventilatory rate, ventilator effort, and audible airway
sounds. Normal breathing is quiet with equal chest rise and fall, without excessive respiratory
muscle effort, and with a ventilatory rate within normal range. Respiratory distress is
characterized by increased work of breathing and a rate of breathing outside the normal range
for the patient’s age. Respiratory distress may result from a
problem in the tracheobronchial tree, lungs, pleura, or chest wall.• Respiratory failure is a
clinical condition in which there is inadequate oxygenation, ventilation, or both to meet the
metabolic demands of body tissues. suprasternal, clavicular, intercostal, subcostal, or
substernalretractions and accessory muscle use (i.e., muscles of the neck,chest, and abdomen
that become active during labored breathing) .
 Head bobbing is an indicator of increased work of breathing in infants. The head
falls forward on exhalation,and comes up when the infant breathes in and its chest
expands.Because a child’s nasal passages are very small, short, and narrow, these
areas are easily obstructed with mucus or foreign objects.
Nasal flaring, which is widening of the nostrils while the
 patient breathes in, is the body’s attempt to increase the
 size of the nasal passages for air to enter during inhalation.
  Nasal flaring may be intermittent or continuous

Seesaw breathing, an ineffective breathing pattern in which

 the abdominal muscles move outward during inhalation
 while the chest moves inward, is a sign of impending respiratory failure

 Observing the position of the child can provide important clues with regard to the
patient’s level of distress and work of breathing.
 For example, a child may assume a sniffing position to
 decrease his or her work of breathing. In this position, the child
 sits upright and leans forward with the chin slightly raised,
 aligning the axes of the mouth, pharynx, and trachea to open
 the airway and increase airflow. When a child assumes a tripod
 position, also called tripoding, the child attempts to maintain
Circulation
The final component of the PAT is assessment of the circulation to the skin, which is a
reflection of the adequacy of cardiac output and the perfusion of vital organs . The child’s
skin color should appear normal for his or her ethnic group. Possible causes of flushed The
presence of pale, cyanotic, or mottled skin suggests inadequate oxygenation,poor perfusion).
If the child exhibits abnormal findings with regard to his or her skin color, immediately
proceed to the primary assessment.
Breath Sounds
 Audible signs of breathing difficulty include stridor, gurgling, grunting, wheezing,
and crackles. Stridor and gurgling have been discussed.
• Grunting is a short, low-pitched sound heard as the patient
 exhales against a partially closed glottis. It is a compensatory mechanism to help
maintain the patency of the alveoli and prolong the period of gas exchange.
• Wheezes are high- or low-pitched sounds produced as air passes through
airways that have narrowed because of swelling, spasm, inflammation,
secretions, or the presence of a foreign body. If air movement is inadequate,
wheezing may not be heard.
• Crackles, formerly called rales, are crackling sounds produced as air passes
through airways containing fluid or moisture.
Oxygen Saturation

Pulse oximetry is a noninvasive method of monitoring the percentage of hemoglobin (Hb)

that is saturated with oxygen
(SpO2) by using selected wavelengths of light. Continuous monitoring of oxygen saturation
by means of pulse oximetry is considered the standard of care in any circumstance in which
detection of hypoxemia is important. A pulse oximeter is an adjunct to, not a replacement for,
vigilant patient assessment.It is essential to correlate your assessment findings with pulse
oximeter readings to determine appropriate treatment interventions
for your patient.
Heart Rate and Regularity
Determine if the patient’s heart rate is within normal limitsfor the child’s age and if the
rhythm is regular
Heart rate is influenced by the child’s age and level of activity. Avery slow or rapid rate may
indicate or may be the cause of cardiovascularcompromise. The terms arrhythmia and
dysrhythmiaare used interchangeably to refer to an abnormal heart rhythm.In the pediatric
patient, dysrhythmias are divided into four broadcategories based on heart rate: (1) normal for
age, (2) slowerthan normal for age (bradycardia), (3) faster than normal forage (tachycardia),
or (4) absent (cardiac arrest). In children, dysrhythmiasare treated only if they compromise
cardiac output orif they have the potential for deteriorating into a lethal rhythm.For example,
fever, pain, and fear are common causes of a temporaryincrease in heart rate. The heart rate
typically returns tonormal as the underlying cause is treated. In contrast,
ventricularfibrillation is a lethal rhythm that requires prompt treatmentwith chest
compressions and defibrillation.
Pulse Quality
Pulse quality, which reflects the adequacy of peripheral perfusion,refers to the strength of the
heartbeat felt when taking a pulse. Pulse quality is assessed by feeling central and
peripheralpulses and comparing their strengths. It is also important to compare differences
between the upper and lower extremities.Lower extremity pulses that are absent or weak
when comparedwith the upper extremities suggest coarctation of the aorta (Duderstadt,
2014).A central pulse is a pulse found close to the trunk of the body.Central pulse locations
that are generally easily accessible include the brachial artery (in infants), the carotid artery
(in older children),the femoral artery, and the axillary artery. Determiningthe presence and
strength of a femoral pulse can be challenging in overweight and obese children because of
the necessity to palpatethrough adipose tissue
Peripheral pulse locations include the radial, dorsalis pedis, andposterior tibial arteries.
Assess a peripheral pulsewhile keeping one hand on the central pulse location to
comparetheir strengths. For example, feel a femoral (central) and dorsalispedis (peripheral)
pulse.
A strong pulse is one that is easily felt and that is not easily obliterated with pressure. A
bounding pulse is not obliterated with
pressure. A weak pulse is difficult to feel and a thready pulse is one that is weak and fast. A
weak, thready, or absent pulse is an indication for fluid resuscitation, chest compressions, or
both
Skin Color and Temperature
Skin color is most reliably evaluated in the sclera, conjunctiva,nail beds, tongue, oral mucosa,
palms, and soles
Possible causes of flushed (red) skin include fever, infection,toxic exposure, exposure to
warm ambient temperatures, and heat-related emergencies.Pallor may be the result of
respiratory failure, anemia, shock, or chronic disease. Cool, pale extremities are associated
withdecreased cardiac output, as seen in shock and hypothermia. Inchildren with dark skin,
pallor may be observed as ashen gray skin. Pallor in brown-skinned individuals may appear
as a yellow color. Blue (cyanosis) coloration of the nails, palms, and soles suggests
hypoxemia or inadequate perfusion. In dark skin, cyanosis may be observed as ashen gray
lips, gums, or tongue. Possible causes of peripheral cyanosis, which is a blue discoloration of
the hands and feet, include anxiety, cold, shock, peripheral vascular disease, and heart
failure. Central cyanosis, which is a blue discoloration of the trunk or mucous membranes of
the eyes, nose, and mouth, reflects a marked decrease in the oxygen carrying capacity of the
blood. Possible causes of central cyanosis are shown in.The presence of central cyanosis is an
indication for the administration of supplemental oxygen and ventilatory support Mottling is
an irregular or patchy skin discoloration that is usuallya mixture of blue and white. The
presence of mottling suggestsdecreased cardiac output, ischemia, or hypoxia, but it can be
normal in an infant that has been exposed to a cool environment. Mottled skin is usually seen
in patients in shock, with hypothermia, or in cardiac arrest.Jaundice is a yellow color seen in
the skin, the sclera of the eyes,and the mucus membranes of the mouth. It is caused by
elevated levels of bilirubin in the blood resulting from an increased breakdown of
hemoglobin. The skin is normally warm and dry with good turgor. Use the dorsal surfaces of
your hands and fingers to assess skin The presence of strong central and peripheral pulses
suggeststhat the child has an adequate blood pressure. A weak centralpulse may indicate
hypotensive shock. A peripheral pulse that isdifficult to find, weak, or irregular suggests poor
peripheral perfusion and may be a sign of shock or hemorrhage. If no centralpulse is present,
chest compressions should be started using rates and techniques (e.g., compression depth,
finger or hand placement)in accordance with current resuscitation guidelines.
Capillary Refill Time
Capillary refill, also called the blanching test, is assessed by applyingpressure to tissue until it
blanches and then rapidly releasing pressure and observing the time it takes for the tissue to
return toits original color. Sites that may be used to assess capillary refill include the nail
beds, forearm, forehead, chest, abdomen, kneecap, and fleshy part of the palm. If the ambient
temperature is warm, color should return within 2 to 3 seconds. A capillary refill time of 3 to
5 seconds is said to be delayed. This may indicate poor perfusion or exposure to cool
temperatures. A capillary refill time of more than 5 seconds is
said to be markedly delayed and suggests shock. If capillary refill is initially assessed in the
hand or fingers and it
is delayed, recheck it in a more central location such as the chest. temperature. As cardiac
output decreases, coolness will begin in the hands and feet and ascend toward the trunk.
• Turgor refers to the elasticity of the skin. To assess skin turgor, grasp the skin on the upper
arm or abdomen between your thumb and index finger. Pull the skin taut and then quickly
release. Observe the speed with which the skin returns to its original contour once released.
The skin should immediately resume its shape with no tenting or
wrinkling.
Blood Pressure
A child’s blood pressure varies with age . It may beaffected by emotion, the child’s degree of
activity, the presence of pain, and medications. In children younger than 3 years, a strong
central pulse is considered an acceptable sign of adequate
blood pressure.
When measuring blood pressure, use a cuff that completely encircles the extremity and
ensure that the width of the cuff is two-thirds the length of the long bone used (such as the
upper arm or thigh). Use of a cuff that is too large will result in a falsely low reading; use of a
cuff that is too small will result in a falsely high reading. Pulse pressure, which is the
difference between the systolic and diastolic blood pressure, provides important information
about a patient’s stroke volume. A narrowed pulse pressure is an indicator of circulatory
compromise.