Cardiovascular Assessment by Brianne Johnson.
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Hi, my name is Brie Johnson and I’m a nurse here at the Pediatric Medical Surgical Intensive
Care Unit at Boston Children’s Hospital. I’m here today to talk to you about how
to perform a nursing assessment of the cardiovascular system and how to provide safe and effective
monitoring of the cardiovascular system.
There is a critical importance to your cardiovascular assessment, this will help you identify just
how critically ill your child is. It will help you to identify if a patient is in shock
or if a patient has a congenital or a new onset cardiac or congenital heart disease
issue. We’ll discuss the cardiovascular system in four different sections. First we’ll
talk about a general assessment or appearance. Next we’ll talk about how to accurately
assess their vital signs related to their cardiovascular system; such as their heart
rate and blood pressure. Next we’ll perform a physical assessment in full depth, and lastly
we’ll talk about how you can use technology to continuously monitor your patient.
First you want to take a look at the overall appearance of your patient. How does their
color look? Are they pale? Pink? Mild? Blue? Do they look like they are awake? Alert? Calm?
Comfortable, or are they agitated, or lethargic? Next do they appear to be malnourished or
well nourished? Does the parent report that the child is not taking their normal amount
of PO intake?
Next you’ll want to gain a baseline set of vital signs. They should include, first
and foremost, a heart rate on your patient. You can gain this by both listening to their
heart and counting, feeling for a pulse and counting the heart rate. No matter how you
obtain that number you should be familiar with the normal ranges depending on age and
be able to identify if the patient has a normal fast or slow heart rate. We talk about a slow
heart rate as being Bradycardia, fast heart rate as Tachycardia, and a normal heart rate
as normal. Usually your heart rate is one of the first indicators that your child is
becoming ill.
Next we’ll want to move on to blood pressure. This is going to give you information related
to the cardiac output for your patient. It’s comprised of three different numbers. The
first number is known as the Systolic Blood Pressure over the Diastolic Blood Pressure,
and finally the Mean Arterial blood Pressure, which is also referred to as the “Map.”
The Systolic Blood Pressure measures the pressure during the pumping phase of the heart. Diastole,
or the Diastolic Blood Pressure measures the pressure in the patient’s vasculature during
the refilling portion of the pumping of the heart. Finally the Mean Arterial Pressure,
or the “MAP” is an average using a special calculation of the pressure throughout the
cycle of the pumping of the heart.
Point of Clarification.
The mean arterial pressure can be calculated by taking the systolic blood pressure
in mmHG adding 2 times the diastolic blood pressure and dividing this number by 3.
For example, if your patient has a systolic blood pressure of 100 mmHg and a
diastolic blood pressure of 70 mmHg their mean arterial pressure would be 80 mmHg.
We’ll discuss this a little bit later in some more detail.
To gain an accurate blood pressure there are a few things that should be paid attention
to. The first is the size and placement of the cuff. Here we have our cuff on the patient’s
left upper extremity. Any extremity can be used to obtain an accurate blood pressure.
However, we often say that the right upper extremity may give you the most accurate.
In newborn infants it is best to obtain a four point blood pressure, in other words
you’ll want to gain a blood pressure on each extremity; the upper on both sides and
each side on the lower. The things you’ll want to pay attention to are the size of the
blood pressure cuff. Here you can see that this blood pressure cuff fits just on the
upper portion of the arm. Next, you’ll want to look for the place where it indicates the
artery, you’ll want this arrow to line up where the patient’s artery should be. You
should be able to easily enclose the patient’s arm in the cuff. If the cuff is too big you
may end up with a false blood pressure reading, being falsely low. If the cuff is too small
you may end up with a falsely elevated blood pressure reading.
Point of Clarification.
With an appropriate-sized blood pressure cuff,
the cuff bladder should cover 80% of the circumference and 80%
of the length of the patient's upper extremity.
If you have to manually perform your patient’s blood pressure you should be aware
of what sounds you’ll be listening for.
As you inflate the cuff you’ll want to listen for what we call the Korotkoff sounds.
Once you’ve inflated the cuff you should hear nothing and you should inflate the cuff
until you hear nothing. Once you begin to slowly deflate the cuff you’ll listen for
the first time that you hear a ticking sound. This will be your Systolic Blood Pressure
number. So make sure to make note of where you see that on the meter. When you can no
longer hear any sound that will give you your Diastolic Blood Pressure number.
It is important to again, know your values for normal blood pressure ranges. According
to the PALS, or Pediatric Life Support System, we have a few helpful calculations that can
determine if your patient is becoming hypotensive, in others words has a low blood pressure.
In neonates ages zero to about twenty-eight days, you’ll want a systolic that’s greater
than sixty, anything lower than that would be deemed hypotensive. In an infant who is
one to twelve months or a year old, you’re going to want a systolic blood pressure that’s
at least seventy milliliters of Mercury. In any other child between the ages of about
one and ten you can calculate what we would consider the lowest threshold for a systolic
blood pressure. By taking the number seventy and adding it to the patient’s age in years
times two. In other words, if your patient was five years old you would have the number
seventy and then multiply five times two, to give you ten, add that to seventy and you
have a systolic of eighty as your lowest threshold[AO2] .
For a child older than ten years old anything less than ninety milliliters of Mercury for
a systolic blood pressure would be considered hypotensive. Again, always take into account
that every child will be different and it is important to discuss with your team as
a whole if you get a number lower than any of these to determine whether this truly is
hypotension in your patient. It is also important to know that shock can be helpful to use their
blood pressure to determine the severity. Hypotension is a very late sign in shock however
and it is important to note that. Needless to say it is important then to also be able
to use the other parts of your cardiovascular assessment to determine your patient’s clinical
condition.
Now we’ll move on to a comprehensive physical exam, or assessment of the cardiovascular
system. Once again we’ll move on to a look, listen, and feel model. First you’ll just
want to look for any signs or symptoms of diminished cardiac output or poor cardiac
function. You’ll be able to tell this by color, perfusion, and general overall appearance
of your patient. The color of your patient should be pink and well perfused, if the child
looks incredibly pale this could indicate a number of things from Anemia to poor cardiac
output, or some clamping down or narrowing of your patient’s blood vessels in response
to shock.
Next, you’ll want to look to see if the patient has the presence of something called
“clubbing.” Which is the expansion of the patient’s fingernail or fingertips,
this is often caused by a prolonged and long-term hypoxemia or low oxygen levels in the blood
and is typically seen in children with congenital heart defects. Next you’ll want to look
for edema, or swelling. Edema can be either in a generalized capacity, meaning that the
patient as a whole looks a little bit puffy and fluid overloaded, or perhaps it is more
localized to a certain region such as their lower extremities. Lower extremity edema is
often associated with congestive heart failure. It’s also important to note whether the
edema is something we call pitting, in which if you pushed on the edema you would see an
indentation that may remain for some time. This can get graded on a scale of zero to
plus four and it is important to note just how severe that is.
Next, you’ll want to look for any visible pulsations. One of the most important ones
we look for is in the neck. You’ll look for jugular vein distention, which you’ll
see here. In some babies this is normal but in a patient who is laying at about a thirty
to forty-five degree angle, you should see no extra pulsations happening in their neck.
If you see this, this could be indicative of some sort of a blockage obstruction or
heart problem.
Next you want to look at their chest. It is normal and can be in small children to see
their precordium move up and down with their heartbeat. However if you are seeing extreme
changes or something abnormal you’ll want to notify the team.
Next we’ll want to actually start to touch our patient, this would be the feel portion
of your assessment. First you’ll want to assess the pulses, the first thing you’ll
want to do is to assess the central pulses. In infants [AO3] be sure to note that the
best place to assess the central pulse is their brachial artery. That is in their upper
more medial part of their arm. You can also palpate for a femoral pulse, which is located
in their groin. In older children you will want to feel for a carotid pulse that is in
their neck and you’ll take two fingers starting at their trachea and move down just a touch
to the side. It is imperative here to note that the absence of central pulses indicates
the need for immediate CPR and you should call for emergency response. Aside from assessing
for the central pulses you’ll also want to feel for the child’s peripheral pulses.
You can palpate these in their radial artery, which can be found in their wrists, and again
you’ll want to compare both sides. You can also feel their feet. You can feel the dorsalis
pedis and also the posterior tibial pulses. It is important to note whether these pulses
are strong, normal, weak or threading. Again, they’re graded on a zero to plus four basis,
zero would obviously be the absence of the pulse and three to four we consider bounding.
It’s important to note because while, maybe, you might think that a bounding pulse seems
like a good thing this actually could be indicating sort of a hyper-dynamic state in your patient
which may be indicative of something called warm shock.
Next you’ll want to feel the overall temperature of you patient. Do they feel hot? Cold? Warm?
Is their temperature different depending on what part of their body you touch? Warm and
dry usually is normal, if they are cool and clammy this may indicate that something is
going on with their vasculature and warrants further investigation. Something else you
will want to be aware of is does their core, such as their trunk and their abdomen feel
warm, but when you touch their hands or their feet you notice that they are cool or even
cold. This could indicate again, the beginning of the development of shock. It’s important
to note the line of delineation where the patient no longer feels warm and transitions
to feeling cold. You’ll also want to feel the pulses and the coloring and the temperature
of the fingertips and the toes.
Next you’ll want to test the patient’s capillary refill time. This can be judged
by pressing on either a finger or a toe until it turns white or blanche and then you’ll
want to watch for the spontaneous return of the color. Normal is typically less than two
seconds for that color to return, if you start to get into three to four we would describe
that as delayed capillary refill time. Anything greater than five seconds for capillary refill
is indicative of a very serious problem and most likely requires immediate intervention[AO4]
.
Now it’s time to listen to the heart. Again, you’ll need to go back to your stethoscope
to do so. You’ll want to be able to identify the basic heart sounds in normal people and
normal children you’ll hear an S1 and S2, or the typical “lub dub” that we talk
about in the heart. S1 indicates the closing of the AV valve, whereas S2 is the closing
of the semi-lunar valves. Here you’ll want to take a listen to the patient’s chest.
To accurately count a heart rate you’ll want to listen for a good fifteen to thirty
seconds and then multiply that by the increment in which you counted, in other words if you
counted for thirty seconds multiply by two to get their heart rates per minute. Listening
to the heart takes a lot of practice and the most important thing for you to be able to
do is identify abnormalities in which you can bring to the attention of the team for
further investigation.
As stated, the S1 and S2 are the two normal heart sounds and we want to be able to be
sure that we hear those noises. However, as you move forward you might hear an S3 or an
S4. S3 can be normal and is sometimes heard in small, small children. This is usually
heard at the apex of the heart and it can be also identified as a gallop you may hear
some people refer to it. This can be normal but again, always, always bring this to the
attention of a provider if it is a new finding. S4 is a concerning finding and it is usually
identified at the atrial contraction portion of the heart pumping cycle. It is a low frequency
sound and can often indicate severe hypertension or a potential cardiomyopathy. [AO5]
Some other abnormal heart sounds you may want to be aware of is a pericardial friction rub.
This may sound sort of like if you took a piece of hair and rubbed it between two fingers
and listened to it. This is concerning as well as it could indicate that there’s a
pericardial fusion, or it could develop after a pericardiotomy. The final thing you’ll
want to be aware of is a murmur. This often indicates there is some sort of an opening
or connection between two of the chambers in the heart, that or it can indicate abnormal
valve function. Again either way a murmur should be brought to the attention of the
care team in order to best diagnose and treat the problem.
Some things you should know and when you should be worried and concerned for your patient.
Tachycardia, or a high heart rate is typically going to be one of the first indicators that
your child is becoming more ill. Secondly, you’ll want to watch for decreased perfusion,
as we talked about the signs of decreased perfusion are going to be poor color, paler,
you may notice some modeling where there is some pale white spots developing around the
patient’s body, you’ll want to look for decreased capillary refill time, you’ll
also want to note has your patient become more lethargic or sleepy.
A child who is unresponsive to pain should be evaluated immediately and is most likely
in an impending situation. In addition you’ll want to watch their urine output. When a child
is in a situation where there cardiac output is compromised your body will shut down the
blood flow to the kidneys and you may see a complete or partial decrease in their urine
output or production. This should immediately also be brought to the attention of the care
team.
Some of the late signs that your child is in an impending cardiovascular collapse may
be, again, the decreased pain response or total lack of response, they’ve become flaccid
and their tone is low, and finally they’re experiencing hypotension, or low blood pressure
and or a low heart rate, or Bradycardia. These are typically impending signs of doom. Again
it is important to note a lack of a central pulse indicates immediate need for CPR and
chest compressions and the emergency system should be activated.
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