Download NURS 2410 Unit 8 and 9 plus cardiac

NURS 2410 Unit 8 and 9 plus
cardiac
Nancy Pares, RN, MSN
Metro Community College
Pediatric Respiratory System Anatomy and
Physiology Variances from the Adult
• Anatomy of airway
• Comparison of airway structures
Figure 25-1 It is easy to see that a child’s airway is smaller and less developed than an adult’s airway, but why is this important?
The infant and child are more vulnerable to the consequences of an upper respiratory tract infection, enlarged tonsils and
adenoids, an allergic reaction, positioning of the head and neck during sleep, and small objects that can be aspirated. All can
cause an airway obstruction that results in respiratory distress.
Pediatric Respiratory System Anatomy and
Physiology Variances from the Adult
• Upper airway differences
– Airway diameter
Figure 25-3 The diameter of an infant’s airway is approximately 4 mm, in contrast to an adult’s airway diameter of 20 mm. An
inflammatory process in the airway causes swelling that narrows the airway, and airway resistance increases. Note that swelling
of 1 mm reduces the infant’s airway diameter to 2 mm, but the adult’s airway diameter is only narrowed to 18 mm. Air must move
more quickly in the infant’s narrowed airway to get the same amount of air to the lungs. The friction of the quickly moving air
against the side of the airway increases airway resistance. The infant must use more effort to breathe and breathe faster to get
adequate oxygen.
Pediatric Respiratory System Anatomy and
Physiology Variances from the Adult
• Upper airway differences
– Position of trachea
Figure 25-2 In children, the trachea is shorter and the angle of the right bronchus at bifurcation is more acute than in the adult.
Where is an aspirated foreign body likely to land? When you are resuscitating or suctioning, you must allow for the differences in
the length of the trachea because it is easier to slip into the right bronchus with an endotracheal tube or suction catheter.
Pediatric Respiratory System Anatomy and
Physiology Variances from the Adult
• Upper airway differences
– Position of right mainstem bronchus
– Airway resistance
Pediatric Respiratory System Anatomy and
Physiology Variances from the Adult
• Lower airway differences
– Growth of alveoli
• Diaphragm use for respirations
– Use of accessory muscles
• Immaturity of respiratory system
Respiratory Conditions and Injuries That Can
Cause Respiratory Distress in Infants and Children
• Airway obstruction
• Blockage of airway passages by different
causes
– Foreign-body aspiration
Figure 25-5 An aspirated foreign body (coin) is clearly visible in the child’s trachea on this chest radiograph.
Source: Courtesy of Rockwood Clinic, Spokane, WA.
Respiratory Conditions and Injuries That Can
Cause Respiratory Distress in Infants and Children
• Acute respiratory distress syndrome (ARDS)
Figure 25-7 A ventilation-perfusion mismatch can occur when an infant or child has an abnormal distribution of ventilation or
perfusion. A, Children with normal lung function and circulation have a ventilation-perfusion ratio of 0.8 to 0.9 because perfusion is
greater than ventilation (air exchange) in the lung bases. B, When ventilation is inadequate to well-perfused areas of the lungs, the
ventilation-perfusion ratio is low or mismatched, resulting in shunting. Blood passing through the pulmonary capillaries gets less
oxygen exchange than normal, and hypoxemia occurs. This is the case in asthma due to bronchoconstriction and in pneumonia
because alveoli are filled with fluid. C, In the case of neonatal hyaline membrane disease the alveoli are collapsed, so blood
passes through the alveolar capillaries and no oxygenation occurs. The ventilation-perfusion ratio is very low with significant
shunting that does not respond to oxygen therapy because the capillary bed never gets exposed to the supplemental oxygen.
Respiratory Conditions and Injuries That Can
Cause Respiratory Distress in Infants and Children
• Multiple factors may cause ARDS
– Sepsis
– Pneumonia
– Meconium aspiration
– Gastric content aspiration
– Smoke inhalation
– Near drowing
Clinical Manifestations of
Respiratory Distress
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Dyspnea
Tachypnea
Grunting
Nasal flaring
Retractions
Figure 25-4 The chest wall is flexible in infants and young children because the chest muscles are immature and the ribs are
cartilaginous. With respiratory distress, the negative pressure created by the downward movement of the diaphragm to draw in air
is increased, and the chest wall is pulled inward causing retractions. Intercostal retractions are seen in mild respiratory distress. As
the severity of respiratory distress increases, retractions can be seen in the substernal and subcostal areas. In cases of severe
distress, accessory muscles (sternocleidomastoid and trapezius muscles) are used, and retractions are seen in the
supraclavicular and suprasternal areas.
Assessment of
Respiratory Status
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Quality of pulse
Quality of respirations
Color
Cough
Behavior changes
Signs of dehydration
Nursing Care
• ABC—airway, breathing, circulation
• Determine if cause can be alleviated
– Foreign body
• Supportive care
– Supplemental oxygen
Diagnostic Tests to Determine
Oxygen Saturation
• Pulse oximetry
• Arterial blood gases
Figure 25-10 The phrase “thumb sign” has been used to describe this enlargement of the epiglottis. Recall the
trachea’s usual “little finger” size. Do you see the stiff, enlarged “thumb” above it in this lateral neck radiograph?
Pulmonary Function for
Chronic Conditions
• Force vital capacity (FVC)
• Peak expiratory flow rate (PEFR)
Pulmonary Function for
Chronic Conditions
• Forced expiratory volume in 1 second (FEVI)
Apnea in Infants and Children
• Cessation of respirations for longer than 20
seconds
• Obstructive apnea
• Central apnea
• Mixed apnea
• Apnea of prematurity
• Apparent life-threatening events
Apnea Monitors
• Polysomnography
Respiratory Assessment
• Determine baseline status of child
• Provide pulmonary therapies as needed
• Maintain oxygenation
Increased Metabolic Activity
• Increased need for calories/nutrition
• Increased need for fluid
Anxiety and Fear Common
• 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
Nursing Considerations for Chronic
Respiratory Conditions
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Oxygenation
Activity intolerance
Nutrition
Growth and development
Treatment management
Social interactions
Oxygenation
• Most important consideration
– Assess and reassess
– Hypoxia leads to chronic changes
– Permanent changes in body systems
Figure 25-18 Digital clubbing.
Oxygenation
• Activity intolerance
Growth and Development
• Nutritional concerns
– Need increased calories to meet body
requirements
• Developmental
– Appropriate activities and interactions
Social Interactions
• Lack of peers for some
• Decreased activity tolerance
• Decreased age activities
Treatment Management
• Family collaboration required
– Plan around family, if possible
Cystic Fibrosis
• 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
Broncho pulmonary dysplasia
• 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
Anatomy of Heart
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•
•
•
Atria
Ventricles
Vena cava
Pulmonary artery and vein
Hemodynamics of Heart
(Circulatory System)
• 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
Transition from Fetal to
Pulmonary Circulation
• Occurs within few hours after birth
• Completes at approximately days 10 to 21
with permanent closure of ductus arteriosus
Transition from Fetal to
Pulmonary Circulation
• Hemodynamics change
– Increased pulmonary blood flow
– Decreased pulmonary vascular resistance
– Left atrium increased blood flow
• From lungs through pulmonary veins
Figure 26-4 The arrows indicate the flow of blood through the heart while the color indicates the level of oxygen
saturation in the blood. A, Fetal (prenatal) circulation. B, Pulmonary (postnatal) circulation. LA, left atrium; LV, left
ventricle; RA, right atrium; RV, right ventricle.
Transition from Fetal to
Pulmonary Circulation
• 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
Normal Hemodynamics of Heart
• Cardiac function
• Pressure gradients
Figure 26-1 Normal pressure gradients and oxygen saturation levels in the heart chambers and great arteries. The
ventricle on the right side of the heart has a lower pressure during systole than the left ventricle because less pressure
is needed to pump blood to the lungs through the rest of the body.
Heart Size
• Proportionately larger in children
Cardiovascular System Growth
• Continues until puberty
Increased Pulmonary Blood Flow
• Defects that cause
Patent Ductus Arterious
• 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
ASD
• Etiology
• Patho:
• Dx:
• Treatment:
– Diuretics
– Surgical repair
Table 26-7 (continued) Pathophysiology, Clinical Manifestations, and Clinical Therapy for Heart Defects
That Increase Pulmonary Blood Flow
VSD
• Patho:
– Left to right shunting
– Heart enlargement
– Pulmonary vessel congestion
• Dx: loud holosytolic murmur
• Tx: may close by 2 years of age; surgery
Table 26-7 (continued) Pathophysiology, Clinical Manifestations, and Clinical Therapy for Heart Defects
That Increase Pulmonary Blood Flow
Increased Pulmonary Blood Flow
• Common manifestations
– Tachypnea
– Tachycardia
– Congestive heart failure
Decreased Pulmonary
Blood Flow
• Defects that cause
Pulmonary stenosis
• Path:
– Obstruction of flow from RV to PA; increase RV
pressure
• S/S: dyspnea on exertion
• Tx: surgical; balloon valvuloplasty
Tetrology of Fallot
• 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
Table 26-8 (continued) Pathophysiology, Clinical Manifestations, and Clinical Therapy for Heart Defects
with Decreased Pulmonary Blood Flow
Decreased Pulmonary
Blood Flow
• Common manifestations
– Cyanosis
– Hypercyanotic spells
– Poor weight gain
– Polycythemia
– Tricuspid atresia
Obstructed Systemic Blood Flow
• Defects that cause
Table 26-10 (continued) Pathophysiology, Clinical Manifestations, and Clinical Therapy for Heart Defects
That Obstruct the Systemic Blood Flow
Table 26-10 (continued) Pathophysiology, Clinical Manifestations, and Clinical Therapy for Heart Defects
That Obstruct the Systemic Blood Flow
Obstructed Systemic Blood Flow
• Common manifestations
– Diminished pulses
– Pale color
– Delayed capillary refill
– Decreased urinary output
– Signs of congestive heart failure
Education of Family
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Family-centered plan
Home care and planning
Assessment for complications
Assessment for worsening condition
Oxygenation requirements
Metabolic and nutritional needs
Fluid-volume balance
Education of Family
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Skin integrity
Management of illness
Medications
Other therapeutic interventions
Prevention of complications
Family interactions
Family adjustment and issues
Postoperative Care of
Heart Surgery
• Immediate care
– Intensive care unit until stable
• One or more days
Postoperative Care of
Heart Surgery
• Hospital management focus
– Pain
• Medications
• Nonmedicated management of pain
– Rest
– Respiratory functions
– Fluid balance
Postoperative Care of
Heart Surgery
• Hospital management focus
– Nutrition status
– Discharge planning
– Home care teaching
– Home care follow-up
– Long-term care and follow-up
Congestive Heart Failure (CHF)
• Etiology
Assessment of CHF
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Respiratory
Pulse
Blood pressure
Color
Heart
Assessment of CHF
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Fluid status
Activity
Behavior
General
Clinical Manifestations
• Subtle signs
– Early stage CHF
• Advanced signs
– Late stage CHF
Nursing Management of CHF
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Assessment of child and family
Promote oxygenation
Cardiovascular function
Administration of medications
Growth and development
Family planning
Family education for home care
Congenital Heart Disease
• Definition—born with defect
Acquired Heart Disease
• Definition—defect related to illness
– Infective endocarditis
– Rheumatic fever
– Kawasaki syndrome
Figure 26-15 This child has returned for one of her frequent follow-up visits to assess her cardiac status after
treatment for Kawasaki syndrome. Notice the lips that show the inflammation and cracking.
Hypovolemic Shock
• Definition—acute complex state of circulatory
dysfunction
• Results in failure to deliver sufficient oxygen to
meet demands
Figure 26-17 If hemorrhage reduces the circulating blood volume sufficiently then vasoconstriction occurs, shifting
blood to larger blood vessels that maintain the perfusion of vital organs. When the blood loss exceeds 20% to 25%, the
child’s body can no longer compensate and hypovolemic shock ensues.
Etiology of Shock
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Hemorrhage
Dehydration
Sepsis
Obstruction of blood flow
Cardiac pump failure
Nursing Management
• Early intervention to treat etiology
• Interventions aimed to prevent falling blood
pressure
Gastrointestinal System
• Digestion takes place in duodenum
• Enzymes aid in the digestion process
Figure 30-1 The internal anatomic structures of the stomach, including the pancreatic, cystic, and hepatic ducts; the
pancreas; and the gallbladder.
Child vs. Adult
Gastrointestinal System
• Liver function immature at birth
• Enzymes deficient until 4 to 6 months old
• Abdominal distention from gas common with
infants
• Stomach capacity smaller
Disorders of
Gastrointestinal System
• Define congenital defects
• Define acquired defects
• Define infectious defects
Types of Pathophysiology Associated with
Structural Defects of the Gastrointestinal System
• 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
Figure 30.3 A, Unilateral cleft lip.
Figure 30.3 (continued) B, Bilateral cleft lip. Source: Courtesy of Dr. Elizabeth Peterson, Spokane, WA.
Types of Pathophysiology Associated with
Structural Defects of the Gastrointestinal System
• 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
Figure 30-7 In the most common type of esophageal atresia and tracheoesophageal fistula, the upper segment of the
esophagus ends in a blind pouch connected to the trachea; the fistula connects the lower segment to the trachea.
Types of Pathophysiology Associated with
Structural Defects of the Gastrointestinal System
• Pyloric Stenosis
– Definition
– Etiology unknown
– Hypertrophy of the circular pylorus muscle
– Stenosis occurs between stomach and duodenum
Figure 30-9 In pyloric stenosis, the hypertrophied pyloric muscle causes symptoms of projectile vomiting and visible
peristalsis.
Types of Pathophysiology Associated with
Structural Defects of the Gastrointestinal System
• 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
Types of Pathophysiology Associated with
Structural Defects of the Gastrointestinal System
• 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
Figure 30-10 In omphalocele, the size of the sack depends on the extent of the protrusion of abdominal contents
through the umbilical cord. Source: From Rudolph, A. M., Hoffman, J. I. E., & Rudolph, C. D. (Eds). (1991). Rudolph’s
pediatrics (19th ed., p. 1040). Stamford, CT: Appleton & Lange.
Figure 30-11 The newborn with gastroschisis has abdominal contents located outside the abdominal wall. Source:
Used with permission of the authors and the University of Iowa’s Virtual Hospital®, www.vh.org
Types of Pathophysiology Associated with
Structural Defects of the Gastrointestinal System
• Intussusception
– Intestine invaginates into another
– Mesentery becomes inflamed and obstruction can
occur
– Multifactorial causes
Figure 30-12 In infants, intussusception is commonly associated with viral illnesses and gastroenteritis.
Types of Pathophysiology Associated with
Structural Defects of the Gastrointestinal System
• 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
Types of Pathophysiology Associated with
Structural Defects of the Gastrointestinal System
• 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”
Types of Pathophysiology Associated with
Structural Defects of the Gastrointestinal System
• 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
Types of Pathophysiology Associated with
Structural Defects of the Gastrointestinal System
• Congenital diaphragmatic hernia
– Protrusion of abdominal contents into thoracic
cavity
– Occurs in 4th week of gestation
– Failure of pleuroperitoneal musculature to close
Types of Pathophysiology Associated with
Structural Defects of the Gastrointestinal System
• Umbilical hernia
– Definition
– Etiology unknown
– Around week 11 of gestation, the obliterated
umbilical vessels occupy the space in the umbilical
ring
Figure 30-13 The umbilical hernia of the newborn usually closes as the muscles strengthen in later infancy and
childhood. Source: From Zitelli, B., & Davis, H. (Eds.). (2007). Atlas of pediatric physical diagnosis. (5th ed., p. 48).
St. Louis, MO: Mosby.
Pathophysiology Associated
with Inflammatory Disease
• 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
Pathophysiology Associated
with Inflammatory Disease
• 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
Pathophysiology Associated
with Inflammatory Disease
• 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 Associated
with Inflammatory Disease
• Pathophysiology of motility disorders
• Gastroenteritis
– Definition
– Acute vs. chronic diarrhea caused by viruses,
bacteria, or parasites
– Causes of diarrhea in children
Pathophysiology of Disorders
of Malabsorption
• Celiac disease
– Immunologic disorder; characterized by
intolerance for gluten
– Impairs absorptive process in the small intestine
– Affects fat absorption
Pathophysiology of Disorders
of Malabsorption
• Lactose intolerance
– Inability to digest lactose
– Lactose enzyme deficiency
– Usually acquired, but can be congenital
Pathophysiology of Disorders
of Malabsorption
• 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
Pathophysiology of
Hepatic Disease
• Hepatic disorders
– Biliary atresia
– Viral hepatitis
– Cirrhosis
Pathophysiology of Injuries to
the Gastrointestinal System
• Abdominal trauma
– Blunt or penetrating trauma to the abdomen
– Common causes
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•
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Falls
Motor vehicle accidents
Automobile vs. pedestrian accidents
Child abuse
Gunshot wounds
Pathophysiology of Injuries to
the Gastrointestinal System
• Abdominal trauma
– Organs commonly involved
• Liver
• Spleen
Signs of Hepatic Disorders
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•
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•
Jaundice
Easy bruising, intense itching
White or clay-colored stools
Tea-colored urine
Clues to Gastrointestinal
Disorders in Children
• Vomiting or abdominal pain
• Failure to thrive
• Stool changes
Potential Signs of Gastrointestinal
Emergencies in Infants
• 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
Potential Signs of Gastrointestinal
Emergencies in Children
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Abdominal pain
Changes in appearance of stool
Vomiting and/or anorexia
Changes in activity
Changes in level of consciousness
Cleft Lip and Cleft Palate
• Nursing care
• Pre- and postoperative care
Esophageal Atresia and
Tracheoesophageal Fistula
• Nursing care
– Identifying signs and symptoms of these infants
• Pre- and postoperative care
– Suction is important preoperatively
– Care of the gastrostomy tube postoperatively
Pyloric Stenosis
• Nursing care
• Pre- and postoperative care
Gastroesophageal Reflux
• Nursing care
• Important education
Infant (Birth to 1 Year Old)
• Congenital defects
• Gastroesophageal reflux in infant vs. older
child
• Gastrointestinal disorders specific to this age
group
Toddlers (1 Year Old to
3 Years Old)
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•
•
•
Meckel’s diverticulum
Offer age-appropriate toys
Childproof the room
Use pictures for education of older toddler
Children (3 Years Old to
12 Years Old)
• Body image starts becoming important after 5
years old
• Offer age-appropriate toys
• Use pictures for education of younger child
• Umbilical hernia repaired
Adolescents (13 Years Old to
17 Years Old)
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•
•
•
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
LEARNING OUTCOME 6
• Discuss nursing management of the child with
an injury to the abdomen.
Abdominal Trauma
• Provide emotional support
• Follow care orders
• Prevention teaching once stabilized