Transcript NURS 2410 unit 8 and 9

Nancy Pares, RN, MSN
Metro Community College
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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
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Discuss nutritional concepts applicable to
pulmonary pediatric disorders
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Anatomy of airway
Comparison of airway structures
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Upper airway differences
◦ Airway diameter
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Upper airway differences
◦ Position of trachea
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Upper airway differences
◦ Position of right mainstem bronchus
◦ Airway resistance
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Lower airway differences
◦ Growth of alveoli
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Diaphragm use for respirations
◦ Use of accessory muscles
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Immaturity of respiratory system
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Airway obstruction
Blockage of airway passages by different
causes
◦ Foreign-body aspiration
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Acute respiratory distress syndrome (ARDS)
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Multiple factors may cause ARDS
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Sepsis
Pneumonia
Meconium aspiration
Gastric content aspiration
Smoke inhalation
Near drowing
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Dyspnea
Tachypnea
Grunting
Nasal flaring
Retractions
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Quality of pulse
Quality of respirations
Color
Cough
Behavior changes
Signs of dehydration
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ABC—airway, breathing, circulation
Determine if cause can be alleviated
◦ Foreign body
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Supportive care
◦ Supplemental oxygen
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Pulse oximetry
Arterial blood gases
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Force vital capacity (FVC)
Peak expiratory flow rate (PEFR)
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Forced expiratory volume in 1 second (FEVI)
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Cessation of respirations for longer than 20
seconds
Obstructive apnea
Central apnea
Mixed apnea
Apnea of prematurity
Apparent life-threatening events
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Polysomnography
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Determine baseline status of child
Provide pulmonary therapies as needed
Maintain oxygenation
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Increased need for calories/nutrition
Increased need for fluid
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Psychosocial support for parent
Psychosocial support for child
Discharge Planning
◦ Education about duration of illness
◦ Need for follow up
◦ When to seek emergency care
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Home care planning
◦ Education to parents
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Oxygenation
Activity intolerance
Nutrition
Growth and development
Treatment management
Social interactions
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Most important consideration
◦ Assess and reassess
◦ Hypoxia leads to chronic changes
◦ Permanent changes in body systems
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Activity intolerance
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Nutritional concerns
◦ Need increased calories to meet body requirements
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Developmental
◦ Appropriate activities and interactions
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Lack of peers for some
Decreased activity tolerance
Decreased age activities
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Family collaboration required
◦ Plan around family, if possible
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Inherited autosomal recessive
S/S: salty taste to skin; thick, sticky mucous,
stool abnormalities; huge appetite, wt
maintenance
Dx: lab value of IRT
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Treatment:
◦ Focus on airway maintenance, infection prevention;
GI tract therapy, nutrition
◦ Meds: pg 898
◦ Story pg 901
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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
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Recall pathophysiology and nursing process
of congential heart defects
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Defects with increased pulmonary flow
Obstructive defects
Defects with decreased pulmonary flow
Mixed defects
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Atria
Ventricles
Vena cava
Pulmonary artery and vein
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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
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Occurs within few hours after birth
Completes at approximately days 10 to 21
with permanent closure of ductus arteriosus
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Hemodynamics change
◦ Increased pulmonary blood flow
◦ Decreased pulmonary vascular resistance
◦ Left atrium increased blood flow
 From lungs through pulmonary veins
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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
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Cardiac function
Pressure gradients
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Proportionately larger in children
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Continues until puberty
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Defects that cause
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Incidence and etiology
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Patho: Left to right shunting
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Clinical manifestations:
◦ Asymptomatic
◦ CHF
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Dx
◦ Continuous murmur below left clavicle
◦ X ray
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Treatment
◦ Indomethocin for preterm only
◦ Surgery
◦ Non surgical closure
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Etiology
Patho:
Dx:
Treatment:
◦ Diuretics
◦ Surgical repair
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Patho:
◦ Left to right shunting
◦ Heart enlargement
◦ Pulmonary vessel congestion
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Dx: loud holosytolic murmur
Tx: may close by 2 years of age; surgery
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Common manifestations
◦ Tachypnea
◦ Tachycardia
◦ Congestive heart failure
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Defects that cause
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Path:
◦ Obstruction of flow from RV to PA; increase RV
pressure
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S/S: dyspnea on exertion
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Tx: surgical; balloon valvuloplasty
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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
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Common manifestations
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Cyanosis
Hypercyanotic spells
Poor weight gain
Polycythemia
Tricuspid atresia
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Defects that cause
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Common manifestations
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Diminished pulses
Pale color
Delayed capillary refill
Decreased urinary output
Signs of congestive heart failure
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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
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Skin integrity
Management of illness
Medications
Other therapeutic interventions
Prevention of complications
Family interactions
Family adjustment and issues
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Immediate care
◦ Intensive care unit until stable
 One or more days
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Hospital management focus
◦ Pain
 Medications
 Nonmedicated management of pain
◦ Rest
◦ Respiratory functions
◦ Fluid balance
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Hospital management focus
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Nutrition status
Discharge planning
Home care teaching
Home care follow-up
Long-term care and follow-up
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Etiology
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Respiratory
Pulse
Blood pressure
Color
Heart
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Fluid status
Activity
Behavior
General
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Subtle signs
◦ Early stage CHF
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Advanced signs
◦ Late stage 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
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Definition—born with defect
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Definition—defect related to illness
◦ Infective endocarditis
◦ Rheumatic fever
◦ Kawasaki syndrome
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Definition—acute complex state of circulatory
dysfunction
Results in failure to deliver sufficient oxygen
to meet demands
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Hemorrhage
Dehydration
Sepsis
Obstruction of blood flow
Cardiac pump failure
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Early intervention to treat etiology
Interventions aimed to prevent falling blood
pressure
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Digestion takes place in duodenum
Enzymes aid in the digestion process
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Liver function immature at birth
Enzymes deficient until 4 to 6 months old
Abdominal distention from gas common with
infants
Stomach capacity smaller
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Define congenital defects
Define acquired defects
Define infectious defects
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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
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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
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Nursing care
Pre- and postoperative care
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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
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Nursing care
◦ Identifying signs and symptoms of these infants
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Pre- and postoperative care
◦ Suction is important preoperatively
◦ Care of the gastrostomy tube postoperatively
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Explain pathophysiology and nursing process
for the pediatric client with physiologic
disorders of the GI tract:
◦ Reflux, hypertrophic pyloric stenosis, lactose
intolerance, Hirshbrungs disease
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Pyloric Stenosis
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Definition
Etiology unknown
Hypertrophy of the circular pylorus muscle
Stenosis occurs between stomach and duodenum
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Nursing care
Pre- and postoperative care
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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
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Nursing care
Important education
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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
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Intussusception
◦ Intestine invaginates into another
◦ Mesentery becomes inflamed and obstruction can
occur
◦ Multifactorial causes
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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
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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”
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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
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Congenital diaphragmatic hernia
◦ Protrusion of abdominal contents into thoracic
cavity
◦ Occurs in 4th week of gestation
◦ Failure of pleuroperitoneal musculature to close
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Umbilical hernia
◦ Definition
◦ Etiology unknown
◦ Around week 11 of gestation, the obliterated
umbilical vessels occupy the space in the umbilical
ring
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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
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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
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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
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Pathophysiology of motility disorders
Gastroenteritis
◦ Definition
◦ Acute vs. chronic diarrhea caused by viruses,
bacteria, or parasites
◦ Causes of diarrhea in children
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Celiac disease
◦ Immunologic disorder; characterized by intolerance
for gluten
◦ Impairs absorptive process in the small intestine
◦ Affects fat absorption
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Lactose intolerance
◦ Inability to digest lactose
◦ Lactose enzyme deficiency
◦ Usually acquired, but can be congenital
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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
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Identify pathophysiology and nursing process
for the pediatric client with hepatic disorders
Analyze nutritional concepts applicable to the
pediatric client with GI disorders
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Jaundice
Easy bruising, intense itching
White or clay-colored stools
Tea-colored urine
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Hepatic disorders
◦ Biliary atresia
◦ Viral hepatitis
◦ Cirrhosis
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Abdominal trauma
◦ Blunt or penetrating trauma to the abdomen
◦ Common causes
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Falls
Motor vehicle accidents
Automobile vs. pedestrian accidents
Child abuse
Gunshot wounds
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Abdominal trauma
◦ Organs commonly involved
 Liver
 Spleen
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Provide emotional support
Follow care orders
Prevention teaching once stabilized
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Vomiting or abdominal pain
Failure to thrive
Stool changes
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Excessive salivation with cyanosis, coughing,
and choking in newborn
◦ Esophageal atresia and tracheoesophageal fistula
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Abdominal viscera outside the abdominal
cavity when born
◦ Gastroschisis and omphalocele
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Anorectal malformations
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Abdominal pain
Changes in appearance of stool
Vomiting and/or anorexia
Changes in activity
Changes in level of consciousness
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Congenital defects
Gastroesophageal reflux in infant vs. older
child
Gastrointestinal disorders specific to this age
group
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Meckel’s diverticulum
Offer age-appropriate toys
Childproof the room
Use pictures for education of older toddler
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Body image starts becoming important after 5
years old
Offer age-appropriate toys
Use pictures for education of younger child
Umbilical hernia repaired
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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