Congenital Heart Defects in Children

Pediatric Assessment

• Gather as much information as possible by observation, being systematic yet flexible.
• Start assessment with the least invasive procedures.
• Begin with heart and lung sounds, followed by hands, arms, and feet.
• Address painful areas like ears, nose, and mouth last.

Growth Facts

• Birth weight doubles by 6 months.
• Birth weight triples by 1 year and quadruples by 2 years.
• A temperature over 38.6°C or 101.5°F is considered febrile.
• Lethargy is a major red flag in children.
• Neurological assessment of infants includes checking primitive reflexes, head raising, object tracking, turning, sitting, and standing, plus fontanelles.
• Toddler neurological assessment involves observing crawling, walking, and 2-3 word sentences.
• Preschoolers see increased development in motor skills and language.
• School-age children and adolescents show increasing communication skills.

Integumentary & Respiratory Assessment

• For infants, check skin turgor in the abdomen or groin.
• Infants are obligate nose breathers, with abdominal breathing.
• Count respiratory rate for a full minute because respirations are irregular, including cessation up to 20 seconds in infants.
• Limited ability to increase the depth of respirations.
• Count respiration by watching abdominal movement and listening for airflow.
• Auscultate and observe breathing work under clothing.

Heart Sounds & Pulses

• Aortic heart sounds are best heard at the 2nd intercostal space (ICS) on the right.
• Pulmonic heart sounds at the 2nd ICS on the left.
• Tricuspid heart sounds at the 5th ICS on the left.
• Mitral heart sounds at the apex, which is the 3rd/4th ICS left midclavicular on infants and the 5th ICS left midclavicular on older children.
• Count apical pulse for a full minute.
• In pediatric hearts, an increased heart rate is the primary mechanism for increasing cardiac output as opposed to stroke volume or contraction strength.
• Assess central pulses at the carotid, apical, and femoral arteries.
• Check peripheral pulses at the radial and pedal arteries.
• Tachycardia may be serious if it starts at 160 bpm or higher.

Other Assessments

• Capillary refill assessment should be performed on the hands, feet, and trunk, but not the fingernails.
• Prolonged capillary refill is over 3 seconds for color to return.
• A round, distended abdomen is normal.
• Assess secondary sex characteristics in adolescents using Tanner stages; early development before 8 years in girls or 9 years in boys needs further evaluation for precocious puberty.
• Assess the patient prior to using equipment
• Infants with different knee heights when hips and knees are flexed should be assessed for hip dislocation with assessment of muscular tone in the muscles
• Bow legs are normal for toddlers, and knock knees are normal until school age.

Communication: Infants (Birth to 1 Year)

• Erikson's Psychosocial Development focuses on Trust vs Mistrust.
• Trust arises from caregivers responding to basic needs.
• Comfort is key for children who are exposed to painful procedures, and hygiene
• Communication strategies include a calm body language (calm), a soothing voice, and facial expressions.
• Toys and bright colors offer distraction.
• Involve parents, hold the baby, provide comfortable environment and have adequate lighting.
• Separation from parents (separation or strangers anxiety) and impaired trust are major stressors for infants.
• Avoid abrupt movements, advance slowly, provide comfort, always let the parents provide support.
• Respond to basic needs as the best stategy to facilitate trust in the infant,
• Limit stranger presence

Communication: Toddlers (1–3 Years)

• Erikson's Psychosocial Development: Autonomy vs Shame; toddler wants to do things themselves.
• Offering choices promotes autonomy.
• Develop independence and self-control and increase independence in many spheres of life
• Include the use of repetition, get on the childs eye-level, and offering praise.

Communication: Preschoolers (3-6 Years)

• Likes initiating activities, eager to learn, also likes pleasing others by doing what they are told.
• Encourage kids how to cooperate.
• Letting child handle medical equipment is a good way to lesson the child's anxiety.

Piaget's Cognitive Development

• Piaget's Cognitive Development for infants focus on the Sensorimotor stage (birth-2 years).
• Infants learn through sensory, movement, and motor perceptions.
• Piaget's Cognitive Development: for Preoperational children (2-7 years), they differentiate self from others and objects, and they experiment with behaviors
• Piaget's Cognitive Development: Toddler (1-3 yrs): Shows inc curiosity & explorative behavior; language skills improve so ensure safe surroundings to allow opportunities to manipulate objects; name objects & give explanations.
  • Animism: Objects have characteristics, they can imitate and substitute in play and also use repetition, short concrete terms, but are unable tp reason at this age
• Separation from family, restriction of movement, loss of control are the major Major Toddler Stressors:
• Preschool Magical Thinking: They cause events to happen

Communication & Thought Processes

• Key Toddler points: Signature phrase is “No!”
• Offer viable choices not do you wanna take medication now?
• Rituals are very important.
• Use 5 senses to explain. Preschoolers are very literal so watch your words!!
• Preschoolers (yr 4-7) have limitations in thought processes, causality often confused so they may feel responsible for causing an illness
• Preschoolers (yr 4-7) use Egocentrism (Toddlers & preschoolers have self-centered understanding of world; can only see from their perspective
• Preschooler: Transductive Reasoning: Create connection btwn 2 events that occur at same time even tho there's nothing in common
• School aged children are Modest is important an Signature phrase is “Why?”

School age and Adolescents:

• School age children show interests in how things work and continue to make new activities and complete old ones
• School age children need Compentence and mastery due to seeing increased involvement activities
• School age children should focus on Competence/mastery = Goal where the kid gains sense of self-worth from involvement in activities
• School age children should understand Encourage to continue schoolwork while hospitalized, bring favorite pastimes to hospital; help them adjust to limitations on favorite activities
• School age children get more comfortable talking with peers where school aged children should understand reassure and treat as a person.
• School age children are able to give an able to view world from another point of view but still need abstract thinking and begin to build abstract thoughts
• Signature phrase is "How does this work?"
• Adolescents are people from 12-18 years Erikson's Psychosocial Development for Adolesecents is focused around their indentity vs confusion Adolescents Believes other ppl are closely listening to and watching them, explore with new people and get to know them.
• Provide separate recreation room for teens hospitalized; take health hx and perform exams w/o parents present; introduce teen to other teens w/ same health problem
• Adolescents need abstract, mature, logical, organized thinking.
• Signature phrase is “I know.”

G & D Notes Examples of Play

• Solitary: Engrossed in play; no interaction w/ others (ex: playing w/ toys alone) (birth-12 months) Parallel: Mimics other kids play but doesn't engage other kids (ex: playing in sandbox next to each other) Toddler (12 months- 3 years) Associative: Very social w/ no rules (ex: playing "house” tg but not organized manne Preschool (3-5 years old) Cooperative: Concrete organization, some rules, and a goal, but child is out to win for themselves (ex: “I win”, board games, candyland) (School age and adolescents (6-18 years old) Collaborative: Kid's work toward common goal through sharing (ex: "I win as a team", competitive team sports, soccer, debate team) (School age and adolescents (6-18 years old) Medical: False medical equipment kids play w/ to alleviate fears about procedures (ex: child life "dolls") toddlers and up

Respiratory Disorders

• Nasopharynx & nares smaller which has led to more prone to occlusion and harder to breathe esp. infants b/c they're nose breathers
• Larynx & glottis higher in airway which makes it easier to have airway occluded/easier to choke
• Ribs & diaphragm more horizontal; abdominal breathing until 5-7 y/o & then thoracic breathing
• B/c kids have smaller airways they already have inc airway resistance combined w/ dec chest excursion, therefore have higher RR -> inc risk of swelling & infection, less likely to compensate

What Abnormal Breath Sounds Could Indicate

• Stridor is when Continuous high-pitch crowing sound in inspiration happens d/t partial obstruction of larynx or trachea from Foreign body, croup, swelling in throat, abscess, or tumor,
• Wheezing happens where High pitch continuous musical sound is had d/t air passing thru an obstructed, narrow airway; heard during expiration because of Asthma, chronic bronchitis, emphysema, pneumonia, allergic
• Crackles happens when Alveolar rails; fine, short high pitched intermittent occurs d/t air passing thru fluid, pus or mucus heard in bases of lung lobes
• Rhonchi sounds from a Large airway with with continuous gurgling/bubbling heard in inspiration and exhalation because of Pneumonia, cystic fibrosis and chronic bronchitis Epinephrine as Medication

Respiratory Distress

• In the respiratory distress the Inc work of breathing WITH adequate gas exchange that compensate.
• Airway is open with normal respiratory sounds possible or abnormal
• Retractions and Diaphoresis can cause the Use of accessory muscles
• Position of comfort like tripod or wanting to sit up rather than laying down shows Moderate Resp Distress where the The Sever Respiratroy Distress: Nasal flaring and mouth will be open In the Inc rate (tachypnea) there will be Inc work (inc resp effort)

Respiratory Failure

• In Respiratory Failure there is an Inability to maintain adequate oxygenation which leads to compensatory mechanisms failing.
• Gaspng and Strdor can lead to dec LOC or change in mental status where the Resp Failure will lead to the Most common pathway to cardiopulmonary arrest

Upper and Lower Airway issues

• Croup is caused from viral resp infections with Treatmen of Dexamethasone
• Epiglottis : Life threatening emergency!
• Lower Airway issues Bronchiolitis (RSV) are caused by viral rsp infx.
• Clinical manifestation of Kawasaki : Typical child under 5 yr, asian, sudden onset of high fever
• Goals of CHF Mgmt & Nursing Considerations: The same as an Adult where medication are used