A nurse is assessing an infant who has tetralogy of Fallot

GENERAL APPEARANCE ASSESSMENT

After the prenatal history has been obtained, the placenta has been evaluated, immediate postbirth care has been provided, and Apgar scores assigned, one can proceed with the physical examination. As with other facets of nursing care, the physical assessment always begins with the general appearance.

One important assessment strategy is to discuss the upcoming assessment with the infant's parents. Including the parents during the assessment allows the healthcare provider to point out both normal and abnormal findings. Optimizing this time with the parents assists them in understanding their infant and allows them to ask questions [46].

The following findings are considered warning signs that may be seen during the general assessment [35]:

• Axillary temperature less than 36.1°C or greater than 37.2°C

• Heart rate less than 100 bpm or greater than 160 bpm

• Respiratory rate less than 30 or greater than 60 breaths per minute

• Cyanosis

• Jaundice

• Periods of apnea lasting more than 15 seconds

• Lack of movement or responsiveness

• Hypotonic or hypertonic position

• Lack of interest in environment

Should these findings be noted, they would warrant immediate further investigation and treatment.

As noted, maintaining a thermoneutral environment is an important consideration. The assessment of any newborn should be conducted in a warm, well-lit environment. Cooler environments stress the newborn and may lead to inaccuracies in assessment. For example, incorrect findings may be made if the patient is found to look blue, experience bradycardia, or have cold hands and feet due to a hypothermic environment.

The assessment of the infant can be conducted through inspection, auscultation, and palpation. Inspection should occur before physical contact is made with the infant, though the need may arise to remove blankets, diapers, or clothing in order to complete a thorough inspection. Whenever possible, complete the observation portion of the assessment before touching the newborn. Observe the infant's position, temperament, sleep or wake cycle, color, movement, and respiratory pattern before disturbing the infant. Once the newborn has been disturbed, he or she may become agitated, resulting in a guarded posture, increased respiratory rate, and temperament changes. During the assessment, an inspection of the infant's activity level, color, respiratory effort, ease of movement, and posture should be noted [3]. During inspection, one should also note the appearance of any dysmorphic features. The finding of three or more dysmorphic features may warrant chromosome analysis [29,47].

During inspection, the activity level should be noted for sleep states progressing to irritability during the more intrusive parts of the exam [48]. There are six identified sleep states: deep sleep; active sleep; drowsy, in-between state; awake alert; alert and fussy; and crying [33,48,49]. The infant should be assessed in an awake alert state, which has been identified as the infant being bright, focused, and minimally active [29,33,48,49]. Motor activity, such as tremulousness, irritability, and defensiveness, should be noted both before and during the assessment [48].

Proper lighting is important as the accurate assessment of a newborn's skin can be useful in determining problems. Even if a newborn is slightly icteric at birth, making this determination can be useful in following the infant for potential problems related to jaundice. If the lighting of the examination room is inadequate, the slight appearance of jaundice may be overlooked. Color is important in determining pulmonary and cardiac involvement and thermoregulation, as well as other organ function in the newborn. Changes in the infant's color may occur throughout the exam when the infant cries, becomes cool, or is irritable. Assessment should be made for jaundice, cyanosis, pallor, and plethora [3]. It is important to note that acrocyanosis, the blue or dusky hands and feet with a pink trunk and mucous membranes, is frequently found and does not indicate a major problem.

Respiratory effort should be assessed by noting the rate and quality of breaths. Depth of breathing, retracting, grunting, nasal flaring, head bobbing, and posture changes associated with inadequate effort should be noted. Periodic breathing by the newborn (i.e., taking several breaths in a row then pausing for up to 15 seconds) is a normal finding. However, grunting, flaring, retractions, and head bobbing warrant further investigation [29]. A full discussion of respiratory assessment follows later in this course.

During inspection, resting posture offers many clues to the health of a newborn. In a healthy, full-term newborn, the posture should be that of flexion [1,29]. Muscle tone, including the amount of flexion or extension, should be assessed. Asymmetry of extremities, comparison of upper and lower extremities, and flaccid posture or contraction should be noted and further evaluated during the exam. The newborn's ease of movement should be noted throughout the assessment. The levels of fluidity and spasticity should be observed.

EVALUATING THE CARDIOVASCULAR SYSTEM

The fetal cardiovascular system is markedly different from that of the newborn. Because the fetus does not rely upon its lungs for oxygenation, very little blood flows through the pulmonary vasculature. Fetal circulation begins with oxygenated blood traveling to the fetus through the umbilical vein. Note the unusual circumstance of a vein carrying richly oxygenated blood. The blood enters the fetus at the site of the umbilicus and divides into two branches. One branch carries blood to the fetal liver, while the other, larger branch carries blood through the ductus venosus into the fetal vena cava [33]. The oxygen-rich blood then travels to the fetal heart through the right atrium. In an adult, the blood passes into the right ventricle for distribution into the pulmonary vasculature, which would then oxygenate the blood. Because the blood in the fetus is already oxygenated, the majority then passes through the foramen ovale to the left atrium. A small amount of blood does pass into the right ventricle, which pumps the blood into the pulmonary artery to oxygenate the lung tissue. However, the majority of this blood also passes through another duct, the ductus arteriosus, into the aorta for distribution to the body [33]. The deoxygenated blood then leaves the fetus via two umbilical arteries for nutrient and gas exchange in the intervillous spaces of the placenta.

Once the newborn is breathing and maternal blood flow from the umbilicus stops, changes in blood flow, pressures, and volume occur within the heart, causing structural changes. The foramen ovale, which is a naturally occurring atrial septal defect, closes, as does the ductus venosus, due to the changes in pressure and flow [37]. The increase in arterial oxygen tension causes the ductus arteriosus to begin to close at a later time, approximately 12 hours after birth. It is completely closed no later than 21 days after birth [37,130]. The size and shape of the heart changes over a period of time as the left ventricle assumes the primary pumping role.

After the newborn's structural cardiovascular changes occur and the infant is breathing, the pressures in the heart and the volume of blood during flow also shift because of the new route. When the lungs begin receiving a higher concentration of oxygen, the pulmonary vascular bed relaxes, allowing blood to flow through the lungs [130]. Blood through the ductus venosus is halted following the clamping of the umbilical cord. The ductus venosus usually completely closes seven days after birth, though there is no flow through it after the umbilical cord is clamped. When the cord is clamped, it separates the newborn from maternal blood flow, causing systemic vascular resistance to rise. This is due to the increase in pressure of the newborn's circulatory system as opposed to the low pressures in the placenta [130].

It takes time for the fetal right ventricular muscle to remodel itself into the lesser pump side and decrease work [114]. Though the left side of the heart is functioning as in an adult, the muscle mass may not achieve complete dominance over the right ventricle until the sixth month of life [114].

The cardiovascular assessment is composed of auscultation, electrocardiogram (ECG) analysis, blood pressure monitoring, pulse quality, and capillary refill time. However, in the healthy term infant, many practitioners will do little more than auscultation if there are no other signs of problems. Cardiac abnormalities generally present themselves quite obtrusively.

One should note the regularity or irregularity of the rhythm when assessing heart sounds. Noting changes as they associate with breathing patterns will be helpful in identifying the need for further evaluation. Normal heart tones are a result of the heart's valves opening and closing.

Auscultation of heart sounds may be performed in the following sequence [50,131]:

1. The aortic area, which is defined as the second intercostal space at the right of the sternum

2. The pulmonic area, which is located at the second intercostal space to the left of the sternum

3. Erb's point, which is located at the third intercostal space to the left of the sternum

4. The tricuspid area, which is located in the fifth intercostal space to both the left and right of the sternum

5. The apical area, which is found at the fourth intercostal space at the left of the left midclavicular line

The normal heart rate range of an awakened newborn is between 100 to 150 bpm [132]. Bradyarrhythmias occur when the heart rate is less than 60 bpm [133]. If the slow rate is associated with poor systemic perfusion, it should be treated [63]. Tachycardias vary in origin; they may originate from the sinus, supraventricular, or ventricular areas. In infants with tachycardia, the rate is greater than normal for age and is typically greater than 220 bpm [133]. Both bradycardia and tachycardia should be considered as signs of cardiac compromise, noted, and referred for appropriate treatment.

Monitoring the infant's ECG can provide valuable assessment information. The basic ECG cycle consists of a P wave, a QRS, and a T wave. The P wave represents depolarization of both atria. The QRS represents depolarization of the ventricles, and the T wave represents repolarization of the ventricles. Abnormal rhythms may be classified as fast, slow, or pulseless [133]. Rhythm disturbances should be treated if they compromise cardiac output or have the potential to degenerate to a lethal rhythm [133].

Blood pressure monitoring is usually performed to identify low perfusion states associated with decreased vascular volume or decreased cardiac output and also to identify hypertensive states. In healthy term newborns, blood pressure monitoring is rarely performed unless there is an indication of a problem. In the healthy newborn, blood pressure is maintained at a fairly constant level by inter-related changes in resistance and cardiac output. Regional blood flow is determined by metabolic needs and adjusted by changes in resistance rather than pressure. Cardiac output adjusts flow to maintain a fairly constant blood pressure. In cases of severe asphyxia, septic shock, or blood loss, a decrease in blood pressure is a late sign of compromise [134,135]. In the first week of life, blood pressure may be slightly higher in the lower extremities than in the upper extremities [3]. Pulse pressure is obtained by subtracting the diastolic pressure from the systolic pressure. For the term infant, a wide pulse pressure is 25–30 mm Hg, and in the preterm infant, it is 15–25 mm Hg [3]. Multiple readings should be obtained and averaged for the best results [134].

Murmurs occur as blood moves through a highly turbulent area in the heart. Heart murmurs are very common in newborns as their cardiopulmonary systems adjust to extrauterine life [92,136]. These benign murmurs in newborns are usually transient in nature and caused by the foramen ovale not being closed completely. Murmurs are usually benign and not necessarily indicative of heart disease [85]. They generally resolve spontaneously.

Murmurs are classified by intensity (i.e., loudness) from grades 1 to 6. A grade 1 murmur is barely audible and not heard in all positions with the use of a stethoscope. A grade 6 murmur is audible with the stethoscope off the chest [137,138]. The location of the murmur identifies the type of defect. Apical murmurs are indicative of mitral insufficiency, mitral stenosis, subaortic stenosis, aortic insufficiency, aortic ejection click of aortic stenosis, or click or late systolic murmur of mitral valve prolapse [137]. Tricuspid murmurs are indicative of tricuspid insufficiency or stenosis, pulmonary insufficiency, ventricular septal defect, or aortic insufficiency [137]. Aortic murmurs are indicative of aortic insufficiency or aortic stenosis [137]. Pulmonic murmurs are generally caused by pulmonary stenosis or insufficiency, atrial septal defect, pulmonary ejection click, or patent ductus arteriosus [137].

In the United States, approximately 1%, or 40,000, of infants born annually have congenital heart defects (CHDs), which are considered the most common type of birth defect [139]. Survival rates of infants born with CHDs have improved over the past several decades. Approximately 75% of infants born with CHDs are expected to survive to 1 year of age and 69% are expected to survive to 18 years of age [140,141]. Family history, maternal diabetes, maternal overweight, maternal obesity, maternal smoking during pregnancy, genetic or chromosomal abnormalities, and maternal exposure to certain drugs or organic solvents may all contribute to the development of CHDs [140,141,142]. Genetic defects are also associated with a higher risk of CHDs. For example, 50% of infants born with Down syndrome also have CHDs [139]. Acute CHD symptoms occur within the first few days of life in approximately one-third of infants [141].

Feeding difficulties are often a first sign, and they may be evident as early as 6 to 12 hours prior to symptoms of heart failure [144]. Because feeding difficulty may be attributed to many different causes, it should exceed 30 minutes and be accompanied by tachypnea, sweating, and subcostal retraction to be considered related to a CHD or heart failure [139,141].

CHDs are classified as acyanotic or cyanotic. Acyanotic defects are usually associated with left-to-right shunting and have symptoms similar to congestive heart failure. Cyanotic defects are characterized by a mixing of oxygenated and unoxygenated blood resulting from the various defects. These defects cause low oxygen-saturated blood to be pumped through the circulatory system.

Patent ductus arteriosus (PDA) is an acyanotic cardiac lesion that occurs when the ductus arteriosus that is present in fetal circulation fails to close completely within 12 hours of birth. It allows for a mixing of oxygenated and deoxygenated blood at the level of the aorta, causing the body and brain to receive blood with a lower PO2 [139].

PDA has a higher incidence in premature and low birth weight infants, females, exposure to rubella during the first trimester of gestation, and high-altitude births [139,141]. Signs associated with PDA include a grade 2 or 3 murmur and an increased difference between systolic and diastolic pulse pressure [33]. Untreated, PDA can lead to right ventricular failure and pulmonary congestion. Treatment includes medications such as indomethacin or ibuprofen, transcatheter placement, or surgery [139].

Atrial Septal Defect

Atrial septal defect (ASD), another acyanotic cardiac lesion, occurs when the foramen ovale fails to close, leaving an opening between the right and left atrium. This generally results in a left-to-right shunting of blood and is generally asymptomatic initially.

The signs of ASD include a murmur and, eventually, failure to thrive, poor exercise tolerance, and upper respiratory infections [33]. Approximately 50% of ASDs close spontaneously, and approximately 20% resolve within the first year of life [139,140]. Treatment includes catheter and surgical procedures [139].

Ventricular Septal Defect

Ventricular septal defect (VSD) is an acyanotic lesion that occurs due to an abnormal opening between the left and right ventricles. It is more common in male infants than female infants. VSDs vary in size and can lead to left-to-right shunting of blood. These defects are often asymptomatic initially, followed by a degenerative course over the first several weeks to months.

The signs of VSD include a loud murmur, tachypnea, growth failure, feeding difficulties, and eventual heart failure [33]. VSDs can exist without symptoms of heart failure, and as with ASDs, more than 50% close spontaneously. If no signs of heart failure are evident, surgical intervention may be delayed with close follow-up [146]. Because infants with VSDs are often premature and/or tire easily during feedings, nutrition therapy is recommended. Nutrition therapy is considered temporary treatment and may be administered in the form of high-calorie formula, breast milk supplements, and in some cases, tube feeding. If VSD symptoms persist or worsen, surgical intervention is required [146].

Coarctation of the Aorta

Coarctation of the aorta is an acyanotic cardiac lesion that occurs when there is a narrowing of the aorta. It accounts for 5% to 8% of all CHDs [147]. This stricture may cause an obstruction to the blood flow, resulting in increased left ventricular pressure [33]. Signs of coarctation include absent or diminished femoral pulses, murmur, and degeneration into heart failure within the first 7 to 21 days of life [33]. Treatment is surgical [148,149].

Transposition of the great arteries (TGA) affects approximately 1 in 3,400 newborns annually and is often accompanied by heart failure [141,150,151]. The aorta and pulmonary artery are switched when they are formed in the embryonic stage. Signs of transposition include cyanosis, hyperpnea, difficulty feeding, and clubbing of the fingers or toes [150,151].

Transposition has been associated with exposure to rubella or other viral illnesses, poor prenatal nutrition, alcoholism, maternal diabetes, and advanced maternal age (i.e., older than 40 years of age) [150,151]. Prostaglandin E is administered intravenously, which maintains a patent ductus arteriosus until transposition is repaired via surgery [150].

Tetralogy of Fallot

The tetralogy of Fallot is the most common cyanotic CHD, occurring in approximately 1 in every 2,500 newborns, although it may not be evident as early as other defects [152,153]. It is characterized by four components: pulmonary stenosis, overriding aorta, right ventricular hypertrophy, and VSD [152,153]. Tetralogy of Fallot has been associated with the same conditions as TGA; however, chromosomal disorders are also common in this population [152].

Infants with tetralogy of Fallot eventually develop what are commonly known as "tet spells," which include hyperpnea, irritability, decreased murmur intensity, and extreme cyanosis in the extremities and mouth during crying, feeding, or exertion [141,152,153]. Infants may also have feeding difficulties, failure to thrive, syncope, clubbing of fingers, or sudden death [152]. Some immediate relief during a spell may be achieved by squatting. For newborns, this maneuver may be accomplished by placing infants on their sides and putting their knees up to their chests. Other interventions that are helpful are slower feedings, smaller and more frequent meals, and comfort measures to minimize anxiety [152].

The tetralogy of Fallot is the most likely CHD to remain untreated past infancy [139,141]. In the past, a palliative surgery was completed to improve blood flow, with complete corrective surgery often postponed until the child reached 3 years of age [141]. Complete surgical repair is now performed during infancy, and infants who have surgery usually do well [139,153]. However, infants too weak or too small to have full surgical repair may still receive the palliative surgery first and the complete surgical repair later [139]. Without surgery, death usually occurs before 20 years of age [153].

ASSESSING THE PULSE AND CAPILLARY REFILL TIME

Peripheral pulses should be assessed for quality and equality. The pulse rate and rhythm should match that of the apical rate and rhythm. Assessing these at the same time can assure mechanical conduction.

Capillary refill time determination is usually performed by applying enough pressure to cause blanching to the dorsum of the foot or palm for approximately five seconds and then tracking the length of time until color uniformity returns. This technique is sometimes used to help assess the newborn cardiovascular status. However, it is considered controversial due to the large variation in the results of studies. Many factors affect refill time, including skin temperature of the examiner's hand; axillary temperature of the newborn; environmental temperature; length of time the examiner applies pressure (i.e., accuracy/ability of the examiner to precisely measure five seconds); body site used; and the firmness of applied pressure [155]. Studies indicate that more research is necessary regarding parameters and diagnostic efficacy before capillary refill time can be recommended as a clinical tool; however, one systematic review suggests that a finger capillary refill time greater than three seconds should be considered abnormal if the test was performed correctly [155,156,157].

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