Transcript Oxygenation Ventilation Tissue Perfusion

OXYGENATION
VENTILATION
TISSUE PERFUSION
K. Choppi MSN Ed, RN, CPEN - 2013
Overview
• Anatomy & Physiology Differences
• Respiratory Distress vs. Failure
• Airway Issues
• Interventions
• Acute Respiratory Conditions
• Chronic Respiratory Conditions
Objectives
• Describe unique characteristics of pediatric
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respiratory system
Describe development of child’s respiratory system
List respiratory conditions and injuries that cause
respiratory distress in children
Distinguish between mild , moderate, and severe
respiratory distress
Differentiate between signs and symptoms of
upper and lower airway conditions
Develop nursing care plans for children with acute
and chronic respiratory conditions
Anatomy & Physiology of Pediatric
Differences
• Upper Airway
• Shorter & Narrower
• Greater potential for obstruction
• Trachea higher & different angle
• Newborns obligatory nose breathers
• Lower Airway
• Less alveoli
• Bronchi & bronchioles are lined with smooth muscle
• Diaphragm breathers
Airway Comparison
Airway Comparison
Respiratory Distress
• Mild
• Tachypnea
• Tachycardia
• Diaphoresis
• Moderate
• Flaring
• Retractions
• Grunting
• Anxiety
• Headaches
Normal
appearance
Increase work of
breathing
Normal circulation to the skin
Respiratory Failure
• Dyspnea
• Bradycardia
• Altered level of consciousness
• Lethargy
• Cyanosis
Abnormal
appearance
Increased or
Decreased work
of breathing
Pale cyanotic skin color
Respiratory Distress/Failure Interventions
• Oxygenation
• Positioning
• Fluids
• Medications
• Bronchodilator
• Anti-inflammatory
• Corticosteroid
Upper Airway Disorders
• Signs & Symptoms
• Tachypnea
• Increased inspiratory effort
• Changes in voice (snoring or High pitched stridor)
• Poor chest rise
• Poor air entry on auscultation
• Intervention
• Maintain position of comfort
• Oxygen as tolerated
• Suction as needed
Lower Airway Disorder
• Signs & Symptoms
• Tachypnea
• Wheezing
• Expiratory more common, can have inspiratory wheezing
• Prolonged expiratory phase
• Cough
• Intervention
• Reverse bronchospasm
• Improve hypoxia
• Correct dehydration
Disease/Fluid of the Lungs
• Signs & Symptoms
• Tachypnea
• Tachycardia
• Increased respiratory effort
• Grunting
• Hypoxemia
• Crackles
• Diminished breath sounds
• Interventions
• Antimicrobial therapy
• Nebulized bronchodilator
• CPAP/BiPAP
• O2
Disordered Control of Breathing
• Signs & Symptoms
• Inadequate respiratory rate
• Inadequate effort of breathing
• Inadequate rate and effort
• Interventions
• Positive pressure ventilations
• Definitive airway
Airway Interventions
• Basic
• Allow the child to stay in a position of comfort
• Use head tilt chin lift or jaw thrust to open the airway
• Avoid over extending the head/neck in infants
• Advanced
• Intubation
• CPAP
• Cricothyrotomy
Peds Pearl
Anatomic Problem
Physical Sign
• Upper airway obstruction
• Stridor
• Lower airway obstruction
• Wheezing
• Disease/Fluid of the lungs
• Crackles
• Disordered control of
• Inadequate RR, effort or
breathing
both
Acute Respiratory Conditions
• Aspirations
• Foreign body
• Croup Syndromes
• Laryngotracheobronchitis
• Epiglottitis
• Bacterial tracheitis
• Bronchiole/Alveolar Infection/Inflammation
• Bronchitis
• Bronchiolitis
• Pneumonia
Acute Respiratory Conditions
• Conditions of Infancy
• Apnea
• Apparent Live Threatening Event (ALTE)
• Sudden Infant Death Syndrome (SIDS)
Airway Obstruction
• Foreign body
• Infants over 6 months of age
• Aspiration
• Food (solid or liquid),
• Non food (toy)
• Interventions
• Maintain airway
• Maintain position of comfort
• Reduce anxiety of child and parent
• Nursing Care
• Childproofing home
• CPR
Croup Syndromes
• Upper airway
• Viral
• Spasmodic laryngitis
• Larygotracheitis
• Laryngotracheobronchitis (LTB)
• Bacterial
• Bacterial Tacheitis
• Epiglottis
• Nursing Care
• Airway support
• Drug therapy
• Emotional support
Bronchiole/Alveolar Infection/Inflammation
• Lower Airway
• Bronchitis
• Viral or bacterial
• Trachea and bronchi
• Bronchiolitis
• Viral or bacterial
• Inflammation & obstruction of the bronchioles
• Peak age 2-6 months
• Pneumonia
• Viral, bacterial, or mycoplasmal
• Inflammation or infection of the bronchioles and alveolar space
• Nursing care
• Maintaining respiratory function
• Decreasing stress/promoting rest
Apnea
• ALTE
• Greater than 37 weeks
• Peak between 1 week and 2 months
• Causes include
• Infection
• Gastroesophageal reflux
• Seizures
• Cardiac arrhythmias
• Metabolic or endocrine problems
• Nursing Care
• Provide emotional support
• Encourage parent participation in care
• CPR for parents
Sudden Infant Death
• Pathophysiology
• Genetic
• Clinical Manifestations
• Cardiopulmonary arrest
• Seasonal
• Nursing Care
• Supportive Care for Family
• Back to sleep
Chronic Respiratory Conditions
• Bronchopulmonary Dysplasia (BPD)
• Asthma
• Cystic Fibrosis
• Systemic exocrine disorder
Bronchial Pulmonary Dysplasia
• Risk factors
• Prematurity
• Symptoms
• Persistent signs of respiratory distress
• Tachypnea
• Wheezing, crackles,
• Irritability
• Nasal flaring, grunting, retractions
• Interventions
• Supportive care
• Diuretics
• Bronchodilators
• Steroids
Asthma
• Factors
• Environmental exposure
• Viral illnesses
• Allergens
• Genetic predisposition
• Symptoms
• Breathing difficulty
• Cough, wheezing, or shortness of breath
• Interventions
• Medications
• Asthma action plan
• Maintaining airway patency
• Fluids
• Rest
Health Promotion
• Triggers
• Changes in weather
• Dust/allergens
• Smoke
• Peak Flows
• Green zone 80% - 100%
• Yellow zone 50% - 80%
• Red zone below 50%
Cystic Fibrosis
• Pathophysiology
• Defective chloride-ion transport & decreased water flows
• Abnormal accumulation of viscous mucous
• Manifestations
• Production of thick sticky mucus
• Meconium ileus
• Chronic moist productive cough
• Frequent respiratory infections
• Diagnosis
• Sweat Chloride test (60 mEq/l)
Cystic Fibrosis
• Assessment
• Physiologic
• Psychosocial
• Developmental
• Respiratory Therapy
• Chest Physiotherapy
• Prophylactic antibiotics
• Nutrition
• Diet
• Fat soluble vitamins
• High protein
• High caloric diet
• Pancreatic Enzymes
• Discharge Planning
Cardiac
Overview
• Pulmonary Circulation
• Cardiovascular Changes
• Anatomical Differences
• Assessment
• Congestive Heart Failure
• Congenital Heart Defects
• Acquired Heart Defects
Objectives
• Discuss Pulmonary Circulation
• Verbalize the Cardiovascular Changes that Occur
• Describe the Anatomical Differences
• Demonstrate a Cardiac Assessment
• Summarize Congestive Heart Failure
• Construct a Nursing Care Plan for a Child in CHF
• Differentiate between Congenital Heart Defects
• Discuss the differences between Acquired Heart Diseases
Pulmonary Circulation
• Oxygenated Blood
• Pulmonary Vein to Left Atrium
Aortic Valve to Aorta
Mitral Valve, to Left Ventricle,
Rest of Body
• Deoxygenated Blood
• Superior Vena Cava, to Right Atrium,
Tricuspid Valve, to
Right Ventricle, then
Pulmonary Valve to Pulmonary
Artery
Lungs
Cardiovascular Changes
• Fetal to Pulmonary Circulation
• Must shift within a few hours after birth
• Increased left arterial pressure
• Closure of foramen ovale
• Higher O2 levels
• Close ductus arteriosus
Anatomical Differences
• Cardiac
• Compliance
• Contractility
• Stroke volume
• Compensatory mechanisms
Cardiac Assessment
• Apex
• 4th ICS left of the MCL
• Apical pulse
• Auscultate
• Murmurs
• S3
• Pulses
• Infant
• Brachial
• Femoral
Congestive Heart Failure (CHF)
• Insufficient Cardiac Output
• Circulatory and metabolic needs unmet
• Due to Heart Problems
• Congenital defects
• Loss of contractility
• Damage due to disease
Pathophysiology
• Blood volume overload
• Obstructive congenital defects
CHF
• Signs & Symptoms
• Infants
• Tires easily when feeding
• Loses weight
• Sweats
• Irritable
• Prone to infections
• Children
• Exercise Intolerance
• Dyspnea
• Abdominal Pain
• Peripheral Edema
• Skin Mottling
• Pallor
Progression
• Tachycardia
• Tachypnea
• Nasal Flaring, Grunting
• Crackle
• Signs of Fluid Retention
• Edema in face
• Jugular vein distension
• Hepatomegaly
• Cardiomegaly
Clinical Manifestations CHF
Cause
Clinical Manifestations
Pulmonary venous
congestion
Tachypnea, wheezing, crackles, retractions, cough,
grunting, nasal flaring, feeding difficulties,
irritability, tire with play
Systemic venous
congestion
Hepatomegaly, ascites, peripheral edema
Impaired cardiac
output
Tachycardia, diminished pulses, hypotension
capillary refill time greater than 2 seconds, pallor,
cool extremities, oliguria
High metabolic rate
Failure to thrive or slow weight gain
Treatment Goals
• Reduce Cardiac Workload
• Treatment: rest, oxygen
• Improve Cardiac Output
• Treatment: digoxin, positioning
• Remove Excess Fluid
• Treatment: diuretics
Drugs
Drug
Action
Digoxin
Increases myocardial contractility improving
systemic circulations
Furosemide
Rapid diuresis
Thiazides
Maintenance diuresis, decreased absorption of
Chorothiazide
sodium, water, potassium, chloride, and
Hydrochorothiaze bicarbonate in renal tubules
Spironolactone
Maintenance diuresis (potassium sparing)
ACE inhibitors
Promotes vascular relaxation and reduced
peripheral vascular resistance
Propranolol
Increased contractility
Nursing Diagnosis
• Decreased Cardiac Output
• Fluid Volume Excess
• Risk for Altered Skin Integrity
• Altered Nutrition: Less than Body Requirements
• Ineffective Family Coping
Nursing Interventions
• Careful Medication Administration
• Digoxin, Diuretics
• Rest
• Plan activities, feeding schedule
• Protect Skin
• Promote High-Calorie Nutrition
Family Teaching
• Medications
• Administration, side effects
• Support
• Child: effects of disease, treatment
• Family: emotional, financial impact
• Optimize Development
• Physical
• Cognitive
Congenital Heart Defects
• More than 35 Known Defects
• Begin during first eight weeks of fetal development
• Survivability greater than 85%
• Classified by Change in Blood Flow
• Increased pulmonary
• Decreased pulmonary
• Obstructed systemic
• Mixed systemic and pulmonary
Increase Pulmonary Blood Flow
• Pathophysiology
• Septal defects (ASD, VSD)
• Great arteries (PDA)
• Atrioventricular Canal (AV canal)
Decreased Pulmonary Blood Flow
• Pathophysiology
• Pulmonic Stenosis
• Tetralogy of Fallot
• Pulmonary or Tricuspid Atresia
Mixed Blood Flow
• Pathophysiology
• Transposition of the Great Arteries
• Truncus Arteriosus
• Total Anomalous Pulmonary Venous Return
Obstructed Blood Flow
• Pathophysiology
• Aortic Stenosis
• Coarctation of the Aorta
• Hypoplastic Left Heart
Congenital Heart Defects
• Signs & Symptoms
• Auscultation
• Murmurs, fluid in lungs, tachypnea
• Inspections
• Cyanosis, pallor, squatting, edema in face, fatigue
• Poor weight gain
• Palpation
• Diminished pulses
• Peripheral edema
Nursing Care
• Nursing Diagnoses
• Delayed growth and development
• Ineffective management of the therapeutic regiment
• Imbalanced nutrition: Less than bodily requirements
• Activity Intolerance
• Caregiver role strain
Nursing Care
• Nursing Interventions
• Optimize cognitive and physical development
• Administer medications
• Know and teach side effects
• Reduce fatigue
• Teach positioning
• Optimize nutrition
• Offer support to parents
Heart Surgery
• Preoperative
• Assess for CHF
• Teach surgical and post operative expectations
• Provide support for uncertain outcome
• Parental role
• Promote good nutrition
• Prevent infection
• Ensure that immunizations are up to date
Heart Surgery
• Teach Child
• Surgical experience and expectations
• Expected sensations
• Postoperative experience
• Postoperative Care
• Pain control
• Prevent complications,
• Infection, arrhythmia, impaired tissue perfusion
• Manage fluids
• Careful I/O
• Carefully increase activity level
Acquired Heart Diseases
• Rheumatic Fever,
• Infective Endocarditis
• Kawasaki Disease
Rheumatic Fever
• Pathophysiology
• Exact cause unknown
• Autoimmune
• Aschoff’s bodies
• Diagnosis
• Antistreptolysin O (ASLO)
• Treatment
• Antibiotics
• Aspirin
Nursing Care
• Vital signs
• Temp
• Control joint pain
• Alternate hot/cold compress
• Limit physical exercise
• Follow up
Infective Endocarditis
• Pathophysiology
• Inflammation
• Bacterial
• Enteroccocci
• Fungal
• Diagnosis
• Blood culture
• Elevated ESR
• Changes in EKG
• Treatment
• Antibiotics
• Surgery to replace heart valves
Kawasaki Disease
• Pathophysiology
• Inflammatory illness
• Unknown etiology
• 3 stages
• Acute
• Subacute
• Convalescent
• Diagnosis
• Clinical signs
• Elevated ESR
• Treatment
• IV Immunoglobulin
• Aspirin
Shock
• Inadequate tissue delivery
• Not dependent of blood pressure
• Types
• Hypovolemic
• Distributive
• Septic
• Anaphylactic
• Neurogenic
• Cardiogenic
• Obstructive
Treatment of Shock
• Goal
• To improve O2 delivery.
• Components of O2 delivery
• Sufficient O2 in the blood
• Adequate blood flow to the tissues (cardiac output)
• Appropriate distribution of blood flow to the tissues
Hypovolemic
• Most common
• Volume loss
• Diarrhea, vomiting, hemorrhage, osmotic diuresis (DKA), third
space losses
• Decreased preload leading to reduced stroke volume and
low cardiac output
• Tachycardia, increased SVR, and increased cardiac contractility
• Increased afterload
Primary Assessment
Clinical signs
Airway
Typically patient unless level of consciousness
is significantly impaired
Breathing
Tachypnea without increased effort
Circulation
• Tachycardia
• Adequate systolic blood pressure, narrow
pulse pressure,
• Weak or absent peripheral pulses
• Delayed cap refill
• Cool to cold, pale, mottled, diaphoretic skin
• Dusky/pale distal extremities
• Oliguria
Disability
Changes in level of consciousness
Environment
Extremities often cooler than trunk
Treatment
• Fluid resuscitation
• 20ml/kg isotonic crystalloid rapidly
• Failure to improve after 3 boluses indicate
• Under estimated of fluid loss
• May need colloid or blood
• Ongoing fluid loss
• Etiology of shock is wrong
• Blood replacement
• PRBC 10ml/kg bolus (warmed)
• Whole blood 20ml/kg
Distributive
•
•
Inappropriate distribution of blood volume with
inadequate organ and tissue perfusion
Types
–
Septic
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•
–
Reduced or increased SVR (vasodilation)
Increased capillary permeability (loss of plasma in vascular space)
Anaphylactic
Vasodilation with pulmonary vasoconstriction
–
Neurogenic
•
Loss of vascular tone (high cervical spine injury)
Primary
Assessment
Clinical signs
Airway
Usually patent unless change in level of consciousness
Breathing
Tachypnea without increased work of breathing
Circulation
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•
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•
Disability
Changes in level of consciousness
Environment
• Fever or hypothermia
• Extremities warm or cool
• Petechial or purpura rash (septic shock)
Tachycardia
Bounding peripheral pulses
Brisk or delayed cap refill
Warm, flushed skin peripherally (warm shock) or
Pale, mottled skin with vasoconstriction (cold shock)
• Hypotension with a wide pulse pressure (warm shock) or
Hypotension with a narrow pulse pressure (cold shock)
• Normotensive
• Oliguria
Septic shock
• Repeated 20ml/kg boluses of isotonic crystalloid
•
•
•
•
•
or more)
Correct hypoglycemia and hypocalcaemia
Administer first dose of antibiotics
Normotensive – begin dopamine
Hypotensive vasodilation (warm) shock – begin
norepinephrine
Hypotensive vasoconstriction (cold) shock – begin
epinephrine
(3-4
Anaphylactic
• IM epinephrine
• Fluid boluses 20ml/kg isotonic crystalloids
• Albuterol
• Antihistamine, corticosteroids
• Epinephrine infusion
Neurogenic
• 20ml/kg isotonic crystalloids (repeat as needed)
• Vasopressor
• Norepinephrine
• Epinephrine
• Position the child flat or head down to improve venous
return
• Provide warming or cooling as needed
Obstructive
Cardiac output is impaired by a physical
obstruction of blood flow
• Causes
•
– Cardiac tamponade
– Tension pneumothorax
– Ductal dependent congenital heart lesions
– Massive pulmonary embolism
•
Clinical signs vary according to the causes
of the obstruction
Cardiac Tamponade
Primary
Assessment
Clinical signs
Airway
Usually patent
Breathing
Respiratory distress with increased respiratory rate and
effort
Circulation
• Tachycardia
• Poor peripheral perfusion (weak distal pulses, cool
extremities, delayed cap refill)
• Muffled or diminished heart sounds
• Narrow pulse pressure
• Pulses paradoxus (decrease in systolic blood pressure
by >10mm Hg during inspiration)
• Distended neck veins (may be difficult to see in infants,
especially with severe hypotension)
Disability
Changes in level of consciousness
Environment
Extremities often cooler than trunk
Intervention
• Pericardiocentesis
• 20ml/kg isotonic crystalloids
Tension Pneumothorax
Primary
Assessment
Clinical signs
Airway
• Varies (primary cause respiratory distress)
• Tracheal deviation towards contralateral side (difficult to
see in infants)
Breathing
• Respiratory distress with increased respiratory rate and
effort
• Hyperresonance of affected side; hyperexpansion of
affected side
• Diminished breath sounds on affected side
Circulation
• Distended neck veins
• Pulsus paradoxus
• Rapid deterioration in perfusion
Disability
Changes in level of consciousness
Environment
Extremities often cooler than trunk
Intervention
• Needle decompression
• Thoracotomy
Ductal Dependent Lesions
Primary
Assessment
Clinical signs
Airway
Usually patent
Breathing
Respiratory failure with signs of pulmonary edema or
inadequate respiratory effort
Circulation
•
•
•
•
Disability
Rapid deterioration in level of consciousness
Environment
Cool skin
Rapid progressive deterioration in systemic perfusion
Congestive heart failure
Higher preductal versus postductal blood pressure
Higher (greater than 3% to 4% preductal versus
postductalarterial O2 saturation
• Absence of femoral pulses
• Metabolic acidosis
Intervention
• Prostaglandin E1
• Consultation
Pulmonary Embolism
Primary
Assessment
Clinical signs
Airway
Usually patent
Breathing
Respiratory distress with increased rate and effort
Circulation
•
•
•
•
•
Disability
Changes in level of consciousness
Environment
Extremities may be cooler than trunk
Tachycardia
Cyanosis
Hypotension
Systemic venous congestion and right heart failure
Chest pain
Intervention
• 20ml/kg isotonic crystalloids (repeat prn)
• Consider thrombolytic anticoagulants
• Consultation
Cardiogenic
• Inadequate tissue perfusion secondary to myocardial
dysfunction
• Causes include
• Congenital heart disease, myocarditis, cardiomyopathy,
arrhythmias, sepsis, poisoning or drug toxicity,
myocardial injury
• Severe or sustained shock of any type eventually causes
impaired myocardial function
Cardiogenic
Airway
Patient, unless level of consciousness is significantly
impaired
Breathing
• Tachypnea
• Increased respiratory effort (retractions, nasal flaring,
grunting) resulting from pulmonary edema
Circulation
• Tachycardia
• Normal or low blood pressure with a narrow pulse
pressure
• Weak or absent peripheral pulses
• Normal and then weak central pulses
• Delayed cap refill
• Signs of congestive heart failure
• Cyanosis
Disability
Changes in level of consciousness
Environment
Extremities often cooler than trunk
Intervention
 Bradyarrhythmia/Tachyarrhythmia
◦ Follow algorithms
 CHD, Myocarditis, Cardiomyopathy, Poisoning
◦ 5 – 10ml/kg isotonic crystalloids (repeat prn)
◦ Diuretics & vasodilators
◦ Increase cardiac output by improving contractility
 Milrinone
◦ Cardiology consultation