Caring for Hospitalized Adolescents with Heart Murmur

Hospitalised adolescents with a heart murmur generally fall into two major groups, those who are there for investigation of a heart murmur that has been recently found or those that have had a positive diagnosis and are amenable and suitable for treatment. (Mahnke, C. B et al 2004).

The heart murmur is a subject that has had countless volumes of literature written about it and a brief appraisal of this evidence base suggests that the single most important consideration is to sort those that are clinically significant from those that are of no clinical significance at all. (Farrer, K F M et al 2003)

In broad terms, a heart murmur is an audible indication that there is turbulence in the normally laminar blood flow through the heart. It is often discovered during a routine examination and is more often than not completely asymptomatic when found. (Biancaniello, T. 2005).  Caring for Hospitalized Adolescents with Heart Murmur.

In any discussion relating to the actual physical needs of the disorder one must first take account of the likelihood of any given heart murmur being associated with a degree of pathology. The evidence base (Green & Britten  1998) suggests that even in the first group ( those admitted for investigation) over half will be found to have no disease present (Newburger JW et al 1993).

It is therefore clear that in this group (from a medical point of view) nothing more than simple reassurance will be required. This comment should not be taken lightly nor undervalued as the majority of adolescents (and presumably their parents)  will probably have been mortified by the discovery of a heart murmur. The majority of lay people will immediately associate the diagnosis with serious pathology, particularly if this is also associated with the necessity to be admitted into hospital for further investigation. (Gaskin, P. R. A et al 2000).

A simple comment that “nothing has been found” is entirely inappropriate in this group. The professional nurse will consider it is part of their remit to spend some time with both the patient and their family and explain the true significance of an asymptomatic heart murmur and the fact that there need be no restrictions on activity, as it probably will not be otherwise understood. (Hogston &. Simpson,  2002)

With regard to the second group of patients who are in hospital for assessment and possible treatment, they will almost universally be concerned and scared of the high technology environment into which they suddenly find themselves propelled. (Birkebæk, N. H et al 1999).

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The empathetic nurse will clearly recognise this in both the patient and their parents and will find the time to discuss the particular case with them, to sensitively explore their particular worries and to adopt an approach of empowerment and education by means of thorough explanation of the areas that they raise (Howe & Anderson  2003)

Clearly the management of the particular patient with a heart murmur will depend primarily on the actual pathology found. In an essay such as this it is neither practical nor appropriate to cover every eventuality,  but in broad terms, the majority of heart murmurs that are found to be associated with pathology will have a diagnosis of either a valvular disorder or some form of septal defect. Caring for Hospitalized Adolescents with Heart Murmur.In modern practice, both eventualities are considered almost universally treatable and almost routine. (McDonald, I G et al 1999),

The nursing input in these cases must be not only to educate the patient and their parents but possibly also act as their advocate with the medical or surgical teams. (Marks-Moran & Rose  1996)

It follows form the discussions presented here that perhaps the most important general skill that is applicable to virtually all cases of the hospitalised adolescent with a heart murmur is the skill of communication. It follows that this requires the nurse to have a firm grasp of the pathophysiology of the situation in order to be able to communicate clearly and authoritatively with the patient. It also requires a positive realisation that the patient, and their parents, will have a large number of (probably) unspoken concerns which they would ideally like a healthcare professional to address. It therefore requires some sympathetic and empathetic enquiries to address this need in the patient in order to achieve the best outcome for them. (Newell and Simon. 1992) Caring for Hospitalized Adolescents with Heart Murmur.

References

Biancaniello, T. (2005).

Innocent Murmurs.
Circulation 111: e20-e22

Birkebæk, N. H., Hansen, L. K., Elle, B., Andersen, P. E., Friis, M., Egeblad, M., Damgaard-Pedersen, K., Nielsen, N. T., Oxhøj, H. (1999).
Chest Roentgenogram in the Evaluation of Heart Defects in Asymptomatic Infants and Children With a Cardiac Murmur: Reproducibility and Accuracy. Pediatrics 103: 15e-15

Farrer, K F M, Rennie, J M (2003).
Neonatal murmurs: are senior house officers good enough?.
Arch. Dis. Child. Fetal Neonatal Ed. 88: F147-151

Gaskin, P. R. A., Owens, S. E., Talner, N. S., Sanders, S. P., Li, J. S. (2000). Clinical Auscultation Skills in Pediatric Residents.
Pediatrics 105: 1184-1187

Green J, Britten N. 1998
Qualitative research and evidence based medicine.
BMJ 1998; 316: 1230-1233

Hogston, R. Simpson, P. M. (2002)
Foundations in nursing practice 2nd Edition,
London: Palgrave & Macmillian. Caring for Hospitalized Adolescents with Heart Murmur.

Howe and  Anderson  2003
Involving patients in medical education
BMJ, Aug 2003; 327: 326 – 328.

Mahnke, C. B., Nowalk, A., Hofkosh, D., Zuberbuhler, J. R., Law, Y. M. (2004).
Comparison of Two Educational Interventions on Pediatric Resident Auscultation Skills.
Pediatrics 113: 1331-1335

Marks-Moran & Rose  1996
Reconstructing Nursing: Beyond Art and Science
London: Balliere Tindall October, 1996

McDonald, I G, Daly, J, Jelinek, V M, Panetta, F, Gutman, J M (1996). Opening Pandora’s box: the unpredictability of reassurance by a normal test result. BMJ 313: 329-332

Newburger JW, A Rosenthal, RG Williams, K Fellows, and OS Miettinen 1993
Noninvasive tests in the initial evaluation of heart murmurs in children
New England Journal of Medicine Volume 308:61-64  January 13, 1993  Number 2

Newell and Simon. 1992
Human Problem Solving. Caring for Hospitalized Adolescents with Heart Murmur.