PEDIATRIC NURSING II: PHYSICAL CIRCULATORY SYSTEM

EXAMINATION

COMPONENTS OF PHYSICAL EXAMINATION

-EXCRETORY SYSTEM
-CIRCULATORY SYSTEM
-RESPIRATORY SYSTEM

CONGENITAL HEART DISEASE

Physical examination
*Vital Signs
1. Temperature-Infants are at risk for
hypothermia.
Take the temperature rectally while checking
the PATENCY OF ANUS.
Imperforate anus
Types of imperforate anus
1. Anal stenosis- very small rectal opening
2. Anorectal agenesis- defective development of
the anus with the rectal pouch ending blindly
above the perineal surface.
3. Rectoperineal fistula- rectum opening out at
perineum rather than at anus.
4. Rectovaginal fistula – rectum opening up in the
vagina.
5. Rectourethral fistula- rectum opening up in the
urethra or bladder.
6. Cloaca- all three (rectum, vagina and urethra)
form a single opening.
Eg. Anal Stenosis
Two Major Types:
1. ACYANOTIC HEART DISEASE- where the
blood contains enough oxygen but it's pumped
abnormally around the body.
-common in girls
2. CYANOTIC HEART DISEASE- where
problems with the heart mean there isn't enough
oxygen present in the blood.
- common in boys
Causes:
-Familial
-Maternal exposure to German Measles
-Failure of heart structures to progress.
ACYANOTIC HEART DISEASE
Left to Right shunting
1. Ventricular Septal Defect- is an opening
between the two ventricles.
Signs and Symptoms:
 - systolic murmur at the lower border of the
sternum
 -cardiac catheterization reveals increased
PO2 saturation at right side of the heart
 -ECG reveals right sided
hypertrophy
MGT:
*Open Heart surgery
*Cardiac Catheterization
Nursing Care:
-NPO 6 hours before the procedure
- Check for allergy to dye
-Protect the site of catheter insertion-Right
femoral vein

Signs and symptoms

1. failure to pass meconium

2. Abdominal distention
3. Foul odor of breath
4. Vomitus of fecal CARDIAC CATHETERIZATION
materials Right Femoral Vein
5. Respiratory is the most common site
problems
for cardiac catheterization,
avoid flexion of joints
MGT: surgeryColostomy-anoplast
proximal to the site.
Nursing Care -Observe for common side effects:
 Keep perineal area clean post anoplasty  Infection and thrombus formation

 Use heat lamp to promote healing
 Position child on side or supine
 Maintain NGT and IV fluids as ordered
 Check for distal pulses to determine
collateral circulation
 Observe for signs of cardiac dysrhythmias.
2. Atrial Septal Defect- is the presence of
opening between the two atria.
6. Aortic Stenosis- is the narrowing of
Signs and Symptoms:
the aorta.
 Systolic murmur at the upper border of the Signs and Symptoms:
sternum  ECG reveals left ventricular
hypertrophy
 Cardiac catheterization reveals increased
 may exhibit symptoms similar to
PO2 saturation at right side of the heart
angina.
 ECG reveals hypertrophy of the right side MGT: Balloon sternotomy and Valvotomy/
of the heart Balloon Valvoplasty
MGT: Open Heart Surgery
7. Duplication of Aortic Arch- is doubling of the
arch of aorta causing compression to the trachea
and esophagus.
Signs and Symptom
 Dysphagia
 Dyspnea
 ECG reveals left
ventricular hypertrophy
MNGT: Closed heart surgery

Coarctation of Aorta- is the narrowing of the

aortic arch.

Signs and Symptoms:

3. Endocardial Cushion Defects-
Atrioventricular (AV) canal affecting closed
tricuspid and mitral valves.
Signs and Symptoms:
 Only confirmed by cardiac
catheterization.
MGT: Open Heart surgery
-Absent femoral pulse
 -BP higher in upper extremities and
lower extremities
 -ECG reveals left ventricular
hypertrophy.
MGT: Closed heart surgery-surgical
resection of the narrowed portion and
end-to-end anastomosis of the aorta or
enlargement of the aorta with a graft.

4. Patent Ductus Arteriosus- is the failure of CYANOTIC HEART DEFECTS/DISEASE

Ductus Arteriosus to close.
Signs and Symptoms: Right to Left shunting.
1. Transposition of Great Arteries
 continuous machinery-like murmur
(TOGA)- is a situation wherein pulmonary
 present or prominent radial pulse artery arises from left ventricle and aorta
 ECG reveals left ventricular from right ventricle.
hypertrophy. Normally the pulmonary artery arises from
right ventricle and aorta from left ventricle.
Management:
 Indomethacin- prostaglandin inhibitor Signs and Symptoms:
that facilitates closure of the ductus  -Cyanosis after first cry.
arteriosus.  -Polycythemia-increased RBC
production as a compensatory
 Surgery: ligation of PDA by 3 to 4 years old mechanism of the body due to
decreased oxygen
supply—Thrombus
formation—embolus---CVA or stroke.
 -ECG reveals cardiomegaly.
MGT:
 *Palliative repair- Rashkind
procedure
5. Pulmonary Stenosis- refers to the narrowing  *Complete repair- Mustard
of the pulmonary artery. procedure
Signs and Symptoms:
 Typical systolic ejection murmur
 A thrill may be present 2. Total Anomalous Pulmonary Venous
 ECG reveals right ventricular hypertrophy Return-is a situation wherein the pulmonary vein
instead of entering the left atrium, it enters the
MGT: Balloon Valvoplasty or right atrium or superior vena cava.
Balloon sternotomy and Valvotomy
Signs and Symptoms:
 -Open foramen ovale
 -right to left shunt
 -mild to moderate cyanosis
 -aspleenia-absent spleen

MGT: Reconstructing the heart


3. Truncus Arteriosus- refers to a situation
wherein the aorta and pulmonary artery arise
from one common vessel with VSD.
Sign and Symptoms:
 -Cyanosis and Polycythemia
MGT: Modified Rastelli procedure
Management:
 -Oxygen therapy after 1 month old
 -Morphine sulfate
 - Propranolol (Inderal)
 - Palliative repair: Blalock-Taussig
procedure (BLT)
 - Complete repair: Brock procedure

3. Hypoplastic left heart syndrome-

is a non-functioning left ventricles.
Sign:
 Cyanosis
Mgt:
 Administration of prostaglandin E
 Norwood procedure
 Heart transplant

Tricuspid Atresia
Is the failure of the tricuspid valve to open.
Signs and symptoms
 -open foramen ovale
 -right to left shunting
Acquired Heart Disease
Mgt: Fontan procedure
RHEUMATIC HEART DISEASE

An inflammatory disease after two weeks of Group A Beta Hemolytic

Streptococcal infection.

Sweet candies No oral care sore throat/tonsilitis 2 weeks ago

invaded by the strep A secretes toxins to the circulation
inferior or superior vena cava of the heart Right atrium
tricuspid valve right ventricle Lungs pulmonary vein
mitral valve aerobic bacteria to form aschoff bodies.

Aschoff bodies: rounded nodules in the mitral valve containing

multinucleated cells and fibroblasts.
Tetralogy of Fallot

4 Anomalies:
 Pulmonary stenosis
 Ventricular septal defect
 Overriding of aorta
 Right ventricular hypertrophy
Affected body parts:
Signs and symptoms:  - most common: throat and tonsils
 -high degree of cyanosis  -Musculo-skeletal
 -polycythemia  -Cardiac muscles and valves
 -severe dyspnea  -Integumentary
 -syncope  -CNS
 -tet spells or blue spells
 -growth and mental retardation
 -clubbing of finger nails
MAJOR MINOR

A. Polyarthritis- multi-joint pain A. Arthralgia- joint pain

B. Carditis -inflammation of the heart muscle which
can manifest as congestive heart failure with
shortness of breath,pericarditis with a rub,tachycardia
or a new heart murmur.
C. Erythema marginatum – macular rashes
D. Subcutaneous nodules- a form of Aschoff bodies
E. Syndenhan’s Chorea or Saint Vitu’s Dance –
purposeless, involuntary movement of hands and
shoulders.
B. Low grade fever
C. Diagnostic tests:
1. Increased erythrocyte sedimentation rate (ESR)
2. Increased C- reactive protein
3. Increased antibody
4. Positive culture for group A streptococcus
5. Electrocardiogram abnormalities a prolonged PR interval
Note: Jones criteria presence of 2 major signs with history of sore
throat or 1 major and 2 minor and history of sore throat will confirm
the diagnosis.

Treatment: Nursing Care:

-Penicillins -complete bed rest
-Salicylates -avoid contact sports
-prepare for culture and sensitivity through throat swab
-administer antibiotics to prevent recurrence
-give aspirin as anti-inflammatory.

RESPIRATION
NEWBORN 30-60 bpm irregular, abdominal or diaphragmatic with short period
of apnea without cyanosis
-40-90 bpm when struggling to adapt to the environment

1 year 20-40 bpm

2-3 years 20-30 bpm
5 years 20-25 bpm
10 years 17-22 bpm
15 & above 12-20bpm

NORMAL BREATH SOUNDS

VESICULAR Soft low pitched sound over the lateral aspect of the chest with
longer Inspiration than expiration (auscultation)
BRONCHOVESICULAR Soft medium-pitched sound over the parasternal area
corresponding to the area of major bronchi, inspiration is as long as
expiration. (auscultation)
BRONCHIAL Loud high-pitched sound over the area of trachea longer expiration
than inspiration.(auscultation)
RHONCHI Snoring sound made when air passes through mucus in the bronchi.
(auscultation)
RESONANCE Loud, low tone, heard in normal lungs.(percussion)

ABNORMAL BREATH SOUNDS

RALES Cellophane-like crackles made when air passes through fluid in
alveoli.
WHEEZING Whistle-like sound as air is forced through a narrow bronchi.
STRIDOR Air sucked through a narrowed laryngeal opening produce a
crowing/rooster-like sound.
HYPERRESONANCE Louder, lower sound than resonance, the sound over hyperinflated
lung tissue. (percussion)

Signs and Symptoms

RESPIRATORY DISORDERS
LARYNGOTRACHEOBRONCHITIS- CROUP
- is the inflammation of the larynx, trachea and bronchi.
-respiratory disease which afflicts infants and young
children typically aged between 3 months and 3 years.
-the larynx and upper airways get inflamed resulting to
the narrowing of the airways.
-inspiratory stridor
clustered for assessment purposes
1. Stage 1- fever, nausea and vomiting, nasal
flaring, hoarseness, inspiratory stridor when
disturbed croupy or barky cough
2. Stage 2- continuous inspiratory stridor,
intercostal retractions, lower rib retractions, use
of accessory muscles
3. Stage 3- acidosis and CO2 retention,
restlessness, pallor, anxiety, sweating and rapid
respirations, airway obstruction and signs of
anoxia.
4. Stage 4- Intermittent respirations, permanent
cyanosis, cessation of breathing.
CAUSES: ASTHMA
 -Parainfluenza virus
 -Other bacterial infections -Is a chronic lung disease caused by inflammation
 -respiratory distress and bronchospasm.
DIAGNOSTIC TEST Three components of an asthma attack.
 - Throat swab  1. Bronchospasm
 -Chest and neck x-ray  2. Mucus production
 -CBC  3. airway edema
MANAGEMENT: Signs and symptoms:
 Oxygen administration  recurrent cough
 Oral or injected steroids  expiratory wheezing
 Nebulization  shortness of breath
 Prepare for emergency management  reduced expiratory flow
 Intubation is rarely needed  exercise intolerance
 Croup tent- check if the edges are  respiratory distress
properly tucked. Provide washable
plastic toys. Avoid furry and friction toys. Classification of Asthma:
Encloses the patient in thin flexible
plastic and oxygen or regular air is blown 1. Mild Intermittent – is a condition where
in the tent. Used to treat breathing asthma symptoms occur no more than two
problems. days a week with nighttime asthma flare ups
occurring no more than twice a month. No
BRONCHIOLITIS breathing difficulties.
Causes: exposure to very cold air, exposure to
 Inflammation of the bronchioles, the noxious fumes or chemical irritants.
smaller air passages of the lungs,
caused by respiratory syncytial virus. 2. Mild Persistent- symptoms occur more than
 Occurs in children younger than 2 twice a week but less than once a day, and
years of age with peak incidence of flare-ups may affect activity. Nighttime flare up
about 6 months of age. occur more often than twice a month but less
 RSV invades bronchioles causing than once a week.
increased production of mucus and -Signs and symptoms: shortness of breath,
airway edema. whistling when you breath, coughing and chest
tightness, pain
Signs and Symptoms:
 hacking cough 3. Moderate Persistent Asthma - is an
 cold-like or flu-like symptoms advanced stage of asthma. People who have
 Tenacious mucus secretions this condition experience asthma symptoms
 Tachypnea every day.
 wheezing and intercostal retractions they may also experience symptoms at least
 fever one night per week.
 Restlessness and irritability from air hunger flare-ups can last several days.
Sign and symptoms: Cough and shortness of
Drug of Choice: Ribavirin(Virazole)- antiviral drug. breath Still responds to medical treatment
-bronchodilators may be used
-aerosolized epinephrine 4. Severe Persistent Asthma- symptoms occur
-Oxygen mask daily and often.
-corticosteroids and antibiotics are not used They also frequently curtail the child’s
activities or disrupt his sleep.
EPIGLOTTITIS- emergency condition of URTI. It is the least common asthma
-acute inflammation of the epiglottis causing it is uncontrolled despite proper use of
respiratory distress from airway obstruction. medications.
 Asthma is the most common chronic disease
Signs and Symptoms: among children.
 sudden onset
 drooling of saliva or difficulty CAUSES: (Triggers):
 of swallowing  Indoor Allergens
 hoarseness  dust mites
 cherry-red epiglottis  stuffed furniture
 Tripod position  Pollution and Pet dander
 High fever  Outdoor Allergens
 wheezing inspiratory stridor and snoring  Pollens, Molds
expiratory sound  Food Allergens
 nasal flaring  Chocolates and Fudge Brownies
 rapid pulse and respirations  Tobacco smoke
 retractions of the suprasternal notch and  Chemical irritants
subclavicular and intercostal spaces.  Cold air
Management:  extreme emotional arousal Medications such
 intubation or tracheostomy set as NSAIDS
 avoid use of tongue depressors TREATMENT
 allow child to remain in position of comfort  avoidance of triggers is the best therapy.
 regulate IV fluids as ordered  anticholinergics-decrease bronchospasm and
 administer antibiotics secretion of mucus airways. Eg. Ipratropiun
 patient will be placed in mist tent/croupette or bromide (Atrovent)
croup tent  Short acting beta2-adrenergic e.g. Terbutaline
 - Hib (Haemophilus influenza type B) Vaccine (Bricanyl)
is the vaccine that will prevent the occurrence  Corticosteroids- decrease inflammation within
of epiglottitis. airways e.g. Prednisone,
hydrocortisone( Solu- cortef)
NURSING management:
 Auscultate breath sounds
 Administer due bronchodilators and
nebulizations
 gentle chest clapping after nebulizations
 encourage increased oral fluid intake
 position comfortably on bed
CLASSIFICATION OF PNEUMONIA
1. Pneumonitis – inflammation of the walls of the
alveoli, alveolar sacs and ducts or bronchioles.
2. Lobar pneumonia-inflammation of one or more
lobes of lungs with complete consolidation.

3. Bronchopneumonia- inflammation of the

CYSTIC FIBROSIS (MUCOVISCIDOSIS)
A chronic disorder involving the
exocrine glands resulting in the
production of thick, viscous mucus in the
lungs, pancreas and other body organs.
-a multisystem autosomal recessive
disease that is characterized by chronic
airway obstruction and infection,
malabsorption and failure to thrive.
Signs and Symptoms:
 failure to pass meconium for newborns
 difficulty breathing
 thick mucous production
 increased appetite
 cyanosis and clubbing
 poor growth and failure to thrive
 greasy, bulky stools (Steatorrhea).
 frosting of the skin or a salty taste sweat.
 It is the most common life-shortening,
childhood onset inherited diseases.
 Can be diagnosed prior to birth by genetic
testing or early childhood by a Sweat Chloride
Test – for diagnosis, the patient must have a
sweat chloride > 60mEq/L.
bronchioles with exudates.
Signs and symptoms:
- Cough, wheezing and stridor
-rusty sputum
-high fever and shortness of breath
-decreased breath sounds and cyanosis
Diagnostics:
-Chest X-ray and CBC, Blood culture,
nasopharyngeal swab
Nursing management
1. Assess patient for difficulty of breathing,
intercostal retractions, cyanosis and abnormal
breath sounds
-tepid sponge bath for fever
-administer antipyretics and antibiotics as ordered
-administer bronchodilators/nebulizations
-encourage small frequent feedings
-hold feeding of infants and small children if
tachypneic

Treatment:
1. Clear secretions and control respiratory
infections
 inhalation therapy
 chest physiotherapy
 antibiotics-anti-inflammatories
2. Nutritional therapy
 vitamin supplementation
 electrolyte correction
 high protein, high calorie, moderate fats and
high sodium

Nursing Interventions:
1. teach parents how to care for child
 chest physiotherapy
 medications and nutrition
 signs and symptoms of complications
2. monitor child’s respiratory status frequently and
observe for signs of infection
3. schedule child’s activities with frequent rest
periods and activities that encourages optimal
development
4. emphasize important of follow-up care.

PNEUMONIA

-inflammation of pulmonary tissue, associated with

consolidation of the alveolar spaces.