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Nancy Pares, RN, MSN Metro Community College Discuss/review pathophysiology and nursing management of the pediatric client with specified pulmonary conditions, including, but not limited to: ◦ Upper and lower airway obstruction (1400 review) ◦ Pneumonias ( 1400 review) ◦ Respiratory synctial virus, asthma, cystic fibrosis, bronchopulmonary dysplasias Discuss nutritional concepts applicable to pulmonary pediatric disorders Anatomy of airway Comparison of airway structures Upper airway differences ◦ Airway diameter Upper airway differences ◦ Position of trachea Upper airway differences ◦ Position of right mainstem bronchus ◦ Airway resistance Lower airway differences ◦ Growth of alveoli Diaphragm use for respirations ◦ Use of accessory muscles Immaturity of respiratory system Airway obstruction Blockage of airway passages by different causes ◦ Foreign-body aspiration Acute respiratory distress syndrome (ARDS) Multiple factors may cause ARDS ◦ ◦ ◦ ◦ ◦ ◦ Sepsis Pneumonia Meconium aspiration Gastric content aspiration Smoke inhalation Near drowing Dyspnea Tachypnea Grunting Nasal flaring Retractions Quality of pulse Quality of respirations Color Cough Behavior changes Signs of dehydration ABC—airway, breathing, circulation Determine if cause can be alleviated ◦ Foreign body Supportive care ◦ Supplemental oxygen Pulse oximetry Arterial blood gases Force vital capacity (FVC) Peak expiratory flow rate (PEFR) Forced expiratory volume in 1 second (FEVI) Cessation of respirations for longer than 20 seconds Obstructive apnea Central apnea Mixed apnea Apnea of prematurity Apparent life-threatening events Polysomnography Determine baseline status of child Provide pulmonary therapies as needed Maintain oxygenation Increased need for calories/nutrition Increased need for fluid Psychosocial support for parent Psychosocial support for child Discharge Planning ◦ Education about duration of illness ◦ Need for follow up ◦ When to seek emergency care Home care planning ◦ Education to parents Oxygenation Activity intolerance Nutrition Growth and development Treatment management Social interactions Most important consideration ◦ Assess and reassess ◦ Hypoxia leads to chronic changes ◦ Permanent changes in body systems Activity intolerance Nutritional concerns ◦ Need increased calories to meet body requirements Developmental ◦ Appropriate activities and interactions Lack of peers for some Decreased activity tolerance Decreased age activities Family collaboration required ◦ Plan around family, if possible Inherited autosomal recessive S/S: salty taste to skin; thick, sticky mucous, stool abnormalities; huge appetite, wt maintenance Dx: lab value of IRT Treatment: ◦ Focus on airway maintenance, infection prevention; GI tract therapy, nutrition ◦ Meds: pg 898 ◦ Story pg 901 Persistence of premature lungs; usually in neonates on oxygen-esp ventilators S/S: increased resp effort, grunting, retractions, intermittent bronchospasms Dx: x ray; barrel shaped chest Tx: focused on prevention by close monitoring in ICU; meds pg 876; health promotion pg 878 Recall pathophysiology and nursing process of congential heart defects ◦ ◦ ◦ ◦ Defects with increased pulmonary flow Obstructive defects Defects with decreased pulmonary flow Mixed defects Atria Ventricles Vena cava Pulmonary artery and vein Heart pumps blood ◦ Pulmonary system Receives oxygen ◦ Return to heart ◦ To systemic system Provides oxygen to organs and tissues Depletes oxygen stores ◦ Return to heart Occurs within few hours after birth Completes at approximately days 10 to 21 with permanent closure of ductus arteriosus Hemodynamics change ◦ Increased pulmonary blood flow ◦ Decreased pulmonary vascular resistance ◦ Left atrium increased blood flow From lungs through pulmonary veins Hemodynamics change ◦ Right atrial pressure falls ◦ Increased pressure in left atrium Stimulates closure of foramen ovale ◦ Higher oxygen saturation, then fetal circulation Stimulates closure of ductus arteriosus Cardiac function Pressure gradients Proportionately larger in children Continues until puberty Defects that cause Incidence and etiology Patho: Left to right shunting Clinical manifestations: ◦ Asymptomatic ◦ CHF Dx ◦ Continuous murmur below left clavicle ◦ X ray Treatment ◦ Indomethocin for preterm only ◦ Surgery ◦ Non surgical closure Etiology Patho: Dx: Treatment: ◦ Diuretics ◦ Surgical repair Patho: ◦ Left to right shunting ◦ Heart enlargement ◦ Pulmonary vessel congestion Dx: loud holosytolic murmur Tx: may close by 2 years of age; surgery Common manifestations ◦ Tachypnea ◦ Tachycardia ◦ Congestive heart failure Defects that cause Path: ◦ Obstruction of flow from RV to PA; increase RV pressure S/S: dyspnea on exertion Tx: surgical; balloon valvuloplasty Ventricular septal defect; pulmonary stenosis; right ventricular hypertrophy; overriding aorta; S/S: cyanotic vs. non cyanotic Tx: surgical correction: pre op management; modified Blalock-Taussig shunt Common manifestations ◦ ◦ ◦ ◦ ◦ Cyanosis Hypercyanotic spells Poor weight gain Polycythemia Tricuspid atresia Defects that cause Common manifestations ◦ ◦ ◦ ◦ ◦ Diminished pulses Pale color Delayed capillary refill Decreased urinary output Signs of congestive heart failure Family-centered plan Home care and planning Assessment for complications Assessment for worsening condition Oxygenation requirements Metabolic and nutritional needs Fluid-volume balance Skin integrity Management of illness Medications Other therapeutic interventions Prevention of complications Family interactions Family adjustment and issues Immediate care ◦ Intensive care unit until stable One or more days Hospital management focus ◦ Pain Medications Nonmedicated management of pain ◦ Rest ◦ Respiratory functions ◦ Fluid balance Hospital management focus ◦ ◦ ◦ ◦ ◦ Nutrition status Discharge planning Home care teaching Home care follow-up Long-term care and follow-up Etiology Respiratory Pulse Blood pressure Color Heart Fluid status Activity Behavior General Subtle signs ◦ Early stage CHF Advanced signs ◦ Late stage CHF Assessment of child and family Promote oxygenation Cardiovascular function Administration of medications Growth and development Family planning Family education for home care Definition—born with defect Definition—defect related to illness ◦ Infective endocarditis ◦ Rheumatic fever ◦ Kawasaki syndrome Definition—acute complex state of circulatory dysfunction Results in failure to deliver sufficient oxygen to meet demands Hemorrhage Dehydration Sepsis Obstruction of blood flow Cardiac pump failure Early intervention to treat etiology Interventions aimed to prevent falling blood pressure Digestion takes place in duodenum Enzymes aid in the digestion process Liver function immature at birth Enzymes deficient until 4 to 6 months old Abdominal distention from gas common with infants Stomach capacity smaller Define congenital defects Define acquired defects Define infectious defects Describe pathophysiology and nursing management of the pediatric client with anatomic defects of the GI system ◦ Cleft lip/palate, esophageal atresia, hernia, hypertonic pyloric stenosis, intusseption Cleft lip and cleft palate ◦ Definition ◦ Failure of the maxillary processes to fuse between 5 and 12 weeks’ gestation ◦ Failure of the tongue to move down at the correct time prevents the palatine processes from fusing ◦ Multifactorial causes Nursing care Pre- and postoperative care Esophageal atresia and tracheoesophageal fistula ◦ Definition ◦ Foregut fails to lengthen, separate, and fuse into two parallel tubes (esophagus and trachea) at 4 to 5 weeks’ gestation Associated with maternal polyhydramnios Nursing care ◦ Identifying signs and symptoms of these infants Pre- and postoperative care ◦ Suction is important preoperatively ◦ Care of the gastrostomy tube postoperatively Explain pathophysiology and nursing process for the pediatric client with physiologic disorders of the GI tract: ◦ Reflux, hypertrophic pyloric stenosis, lactose intolerance, Hirshbrungs disease Pyloric Stenosis ◦ ◦ ◦ ◦ Definition Etiology unknown Hypertrophy of the circular pylorus muscle Stenosis occurs between stomach and duodenum Nursing care Pre- and postoperative care Gastroesophageal reflux ◦ Definition ◦ Three mechanisms allow reflux to occur Lower esophageal relaxations Incompetent lower esophageal sphincter Anatomic disruption of esophagogastric junction ◦ Reflux acidity damages the esophageal mucosa ◦ Causes Nursing care Important education Gastroschisis and omphalocele ◦ Definition ◦ Gastroschisis usually occurs to the right of the umbilicus and omphalocele occurs through the umbilical cord ◦ Occurs in week 11 of gestation when abdominal contents fail to return to the abdomen ◦ Multifactorial causes Intussusception ◦ Intestine invaginates into another ◦ Mesentery becomes inflamed and obstruction can occur ◦ Multifactorial causes Volvulus ◦ Occurs in 7th to 12th week of gestation ◦ 1 in 6,000 live births ◦ Malrotation of bowel interrupts blood flow and causes bowel necrosis ◦ Surgical emergency Hirschsprung disease ◦ Definition ◦ Congenital absence of ganglion cells in the rectum and colon ◦ Genetically acquired and occurs when there is failure of the migration of neural crest cells in utero ◦ Colon becomes a “megacolon” Anorectal malformations ◦ Anal stenosis and anal atresia ◦ Failure of growth of urorectal septum, lateral mesoderm structures, and ectodermal structures ◦ Associated anomalies up to 70% of the time Congenital diaphragmatic hernia ◦ Protrusion of abdominal contents into thoracic cavity ◦ Occurs in 4th week of gestation ◦ Failure of pleuroperitoneal musculature to close Umbilical hernia ◦ Definition ◦ Etiology unknown ◦ Around week 11 of gestation, the obliterated umbilical vessels occupy the space in the umbilical ring Necrotizing enterocolitis ◦ Inflammatory disease producing vascular compromise of bowel mucosa ◦ More common in premature infants ◦ Caused by intestinal ischemia, bacterial or viral infection, and immature gastrointestinal mucosa Meckel’s diverticulum ◦ Omphalomesenteric duct fails to atrophy ◦ Outpouching of the ileum remains and contains gastric contents, causing ulceration ◦ Bowel obstruction, perforation, or peritonitis can occur Inflammatory bowel disease (Crohn’s disease and ulcerative colitis) ◦ Faulty regulation of the immune response of the intestinal mucosa ◦ Usually genetically triggered ◦ Crohn’s disease can cause inflammation and ulcers anywhere throughout the GI tract ◦ Ulcerative colitis affects large intestine and rectal mucosa Pathophysiology of motility disorders Gastroenteritis ◦ Definition ◦ Acute vs. chronic diarrhea caused by viruses, bacteria, or parasites ◦ Causes of diarrhea in children Celiac disease ◦ Immunologic disorder; characterized by intolerance for gluten ◦ Impairs absorptive process in the small intestine ◦ Affects fat absorption Lactose intolerance ◦ Inability to digest lactose ◦ Lactose enzyme deficiency ◦ Usually acquired, but can be congenital Short bowel syndrome ◦ Shortened intestine resulting from bowel resection ◦ Extent of bowel loss determines severity of disorder ◦ Location of bowel resection determines type of malabsorption Identify pathophysiology and nursing process for the pediatric client with hepatic disorders Analyze nutritional concepts applicable to the pediatric client with GI disorders Jaundice Easy bruising, intense itching White or clay-colored stools Tea-colored urine Hepatic disorders ◦ Biliary atresia ◦ Viral hepatitis ◦ Cirrhosis Abdominal trauma ◦ Blunt or penetrating trauma to the abdomen ◦ Common causes Falls Motor vehicle accidents Automobile vs. pedestrian accidents Child abuse Gunshot wounds Abdominal trauma ◦ Organs commonly involved Liver Spleen Provide emotional support Follow care orders Prevention teaching once stabilized Vomiting or abdominal pain Failure to thrive Stool changes Excessive salivation with cyanosis, coughing, and choking in newborn ◦ Esophageal atresia and tracheoesophageal fistula Abdominal viscera outside the abdominal cavity when born ◦ Gastroschisis and omphalocele Anorectal malformations Abdominal pain Changes in appearance of stool Vomiting and/or anorexia Changes in activity Changes in level of consciousness Congenital defects Gastroesophageal reflux in infant vs. older child Gastrointestinal disorders specific to this age group Meckel’s diverticulum Offer age-appropriate toys Childproof the room Use pictures for education of older toddler Body image starts becoming important after 5 years old Offer age-appropriate toys Use pictures for education of younger child Umbilical hernia repaired Appendicitis (10 to 19 years old) Body image extremely important Allow use of phone to satisfy peer needs Give them handouts about peers with conditions and experiences
