Transcript Pediatric Patient 202

Nursing 202
Nursing Through the Lifespan II
The Pediatric Patient in the Adult
Critical Unit
Diane McLean RN BSN MSN
Objectives
O Describe the differences between pediatric and
adult anatomy and physiology.
O Discuss the pathophysiology of selected
pulmonary, cardiac, neurologic, and
gastrointestinal pediatric disorders.
O Explain the medical and nursing management
of selected pulmonary,
cardiac, neurologic, and gastrointestinal
pediatric disorders.
Objectives…
O Describe how critically ill children differ from
adults with regard to:
O Laboratory values
O Medications
O Blood product dosages and methods of administration
O Other therapeutic modalities
Respiratory System
Upper Airway
• Epiglottis is higher, large, and may obstruct the
palate on inspiration
soft
• Infant’s tongue is large relative to the head
http://www.library.vcu.edu/cfapps/tml/oralpathology
O
Respiratory System…
• Larynx is easier to collapse, even
when crying
• Laryngeal mucosa more prone to
swelling toward the center of the
airway with subsequent increased
resistance
• Soft palate and hypopharynx may
narrow with inspiration during sleep
with drop in SaO2 to 80
•
•
Respiratory System…
Lower Airway
• Alveoli smaller in number and size at birth and as
child – predisposition to alveolar collapse and
atelectasis
• Less alveolar connections predispose to ventilation
perfusion mismatch
O
Respiratory System…
• Less oxygen-diffusing capacity than in adults
• Hypoxemia develops more rapidly when
respiration is compromised
Respiratory System…
Chest Mechanics
• Chest wall is more compliant, ribs are more
horizontal, and accessory muscles are less
developed
• Diaphragm more horizontal and pulls lower
ribs inward
• Impaired diaphragm function causes intercostal
and substernal retractions
• Periodic apnea and decreased lung volumes may
cause decrease in SaO2 to 80% in sleep
Respiratory System…
Respiratory Failure
• Tachypnea – usually first sign of distress
• Grunting – creates “auto PEEP” to keep alveoli
open during expiration
• Stridor – upper airway obstruction
• Wheezing – lower airway obstruction
Respiratory System…
Supplemental Oxygen Devices
• Nasal cannula
• Oxygen hood
• Oxygen blow-by
• Self-inflating resuscitation bag
• Anesthesia bag
• PIP
• Ventilatory Mask
Respiratory Devices
O
Respiratory System…
Endotracheal Intubation
• Tube size
• Endotracheal intubation
• ETT cuff pressure
O
Respiratory …
Endotracheal intubation
• Placement
O 1 to 2 cm above the carina
O No higher than the first rib
O Assess breath sounds high in the axillae
• Securing endotracheal/nasotrachael tubes
Respiratory System…
Mechanical Ventilation
• Child’s size
• Minute ventilation requirements
• Lung compliance
Respiratory…
O
Respiratory…
O Causes of acute deterioration in the
intubated pediatric patient:
O D: for Displacement of tube
O O: for Obstruction of tube
O P: for Pneumothorax (or other air lead)
O E: for Equipment failure
Respiratory System…
Weaning/Extubation Guidelines
• Intermittent mandatory ventilation
• Pressure support ventilation
• Must also wean FiO2 and PEEP before
weaning to extubation
• Maintain PaO2 > 70mm Hg or SaO2 > 93%
Respiratory System…
Extubation Complications
• Post extubation croup (usually in 1-4 yrs. age)
• Tracheostomies
•
www.chm.bris.ac.uk/pt/harvey/charles/latest.htm
Respiratory System…
O Bronchiolitis
• Acute viral bronchiolitis most common
condition caused by respiratory viruses in
infants and children
• Term used to describe a condition that affects
the lower respiratory tract resulting in
obstruction of small airways
• Characterized by
O Tachypnea, hyperinflation of the chest, and
widespread fine end-inspiratory crackles
O May also have expiratory wheeze
• Respiratory syncytial virus major cause (RSV)
• Highly contagious; spread by droplets
Respiratory System…
Bronchiolitis: pathophysiology
• Caused by inflammation of respiratory epithelium
with necrosis, submucosal edema with lymphocytic
infiltrates and alveolar debris
• RSV major cause
• Most often in children <2 years and in infants
• Highly contagious, durable virus spread by droplets
Respiratory System…
Clinical Assessment in Bronchiolitis
• Upper respiratory symptoms first
• Respiratory distress: increased respirations, cough,
nasal flaring, chest retractions, wheezing, irritability
and feeding difficulties
• If respiratory failure: usually lasts 48-72 hours but
decreased O2 may last several weeks
• Gradual improvement, recovers in
2 weeks after bronchiolitis recognized
Respiratory System…
Treatment of Bronchiolitis and RSV
• Supportive care
• Oxygen to decrease work of breathing and
oxygen demand
• Maintain euvolemia with judicious use of diuretics
• Possible use of ribavirin with precautions
• Prevention
O Monoclonal antibody palivizumab
Respiratory System…
Status Asthmaticus
• Moderate to severe airway obstruction
• Lung hyperinflation and air trapping
• Increased minute ventilation and V/Q mismatch
• Hypoxemia, hypercapnia, acidosis, cardiac stress from
increased cardiac output in face of increased afterload
• Triad of physiologic process
O Airway inflammation
O Edema
O Airway hyperactivity
Respiratory System…
Clinical Assessment: Status Asthmaticus
• Respiratory rate and breath sounds
• Level of consciousness
• Accessory muscle use
• Color, quality of cry
• Dyspnea, SaO2, and PaCO2
• PEFR (Peak expiratory flow rate)
• Feeding/sucking ability
Respiratory System…
Treatment in ICU
• Humidified oxygen to keep SaO2 > 95%
• Continuous nebulization of 2 agonists
• IV steroids and aminophylline
• IV Terbutaline possible
• Mechanical ventilation may be necessary
• Maintain Euvolemia, minimize anxiety
Respiratory System…
Treatment of Apnea and ALTE
• Reopen airway
• Manual ventilation
• Home monitoring
• Stimulation
ALTE: an apneic event combined
With pallor or cyanosis, a loss of muscle tone requiring
vigorous stimulation all the way to full resuscitation
Apparent life-threatening event
Cardiovascular System
Anatomy and Physiology
• Fetal circulation
Cardiovascular System
• At birth:
– Lungs and liver assume normal function
– Foramen ovale closes
– Ductus arteriosus, ductus venosus and
umbilical vessels become ligaments
Cardiovascular System…
Health History: Complete Birth History
• Poor feeding or fatigue during feeding
• Diaphoresis with feeding
• Weight loss or inability to gain weight
• Respiratory problems, dyspnea, tachypnea
• Frequent respiratory infections
• Cyanosis
• Fatigue during play
Cardiovascular System…
Physical Examination
• Heart rate and blood pressure
• Auscultation of heart sounds
• Monitor tissue perfusion
Cardiovascular System…
Cardiovascular System…
Cardiovascular System…
Pediatric Blood Volumes
•
•
•
•
Neonates
Infants
Children
Adults
•
www.ufhscj.edu/peds/faculty.asp?d=neo&ref=neo
85-90 ml/kg
75-80 ml/kg
70-75 ml/kg
65-70 ml/kg
www.siuh.com/pediatrics
Cardiovascular System…
O Hemodynamic monitoring
O Accurately monitor fluids
O Direct arterial blood pressure monitoring
O Pulmonary artery catheter
O Hemodynamic parameters
Cardiovascular System…
O
Hemodynamic parameters
Congenital Heart Defects
Heart Disease
• Acyanotic
– Increased pulmonary blood flow
– Obstruction to blood flow from ventricles
• Cyanotic
– Decreased pulmonary blood flow
– Mixed blood flow
Cardiovascular System:
O Comparison of acyanotic-cyanotic and
hemodynamic classification systems of CHD
Cardiovascular System…
Congenital heart defect (CHD)
• Defects that allow flow from high pressure
left side of heart to lower pressure right side
(left to right shunt)
O Increase in pulmonary blood flow
O Congestive heart failure (CHF)
• Obstructive defects impede blood flow out of
ventricles
O Left side results in congestive heart failure
O Right side results in cyanosis
• Pediatric patients with mixed lesions have
variable symptoms
Congenital Heart Defects
Potential Complications
O Congestive heart failure
Cardiovascular System…
CHD potential complications
Congestive heart failure
O Clinical syndrome in which the heart is
unable to pump enough blood to the body to
meet its needs, to dispose of system or
pulmonary venous return adequately, or both
O Most common cause of CHF in infancy is CHD
Cardiovascular System…
CHD potential complications…
Congestive heart failure…
O Symptoms are related to responses of impaired
cardiac function, pulmonary venous congestion,
and systemic venous congestion
O Change in responsiveness, tachypnea with
O
O
O
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feedings, poor weight gain, cold sweat
Tachycardia
Older children may complain of dyspnea,
especially with activity, and early fatigue
Crackles and wheezing may be auscultated in
infants
Cardiomegaly is almost always present
Cardiovascular System…
CHD potential complications…
Congestive heart failure…
Treatment
O Elimination of underlying causes and control of
heart failure
O Pharmacologic approach
O Inotropic agents, diuretics, and afterload
reducers
O Digoxin is drug of choice for CHF in pediatric
patients
Cardiovascular System…
CHD potential complications…
Hypoxemia
O Cyanosis is present in children with certain CHD
O Central cyanosis associated with desaturation of
arterial blood
O Peripheral cyanosis in normal arterial oxygen
saturation
O Differentiation of cause of cyanosis is important
to proper treatment
O Most common CHD causing presentation with
cyanosis: tetralogy of Fallot
Cardiovascular System…
CHD potential complications…
Hypoxemia due to tetralogy of Fallot
O Presentation
O Usually develops in first year of life; manifests
more often in morning
O Child becomes cyanotic, hypoxic, tachypneic, and
may lose consciousness
O Treatment
O Calm child
O Place child in a knee-chest position
O Oxygen, fluid, sedation
Congenital Heart Defects
Potential Complications…
O Hypoxemia
Cardiovascular System…
CHD potential complications (continued)
Arrhythmias
O Clinically significant pediatric arrhythmias
O Bradycardia
O Tachycardia
O Those that produce cardiac collapse or loss
of pulse
Congenital Heart Defects
Potential Complications…
O Dysrhythmias
Congenital Heart Defects
Potential Complications…
O Bradycardias
Cardiovascular System…
O Shock in infants and children
O Shock results from inadequate delivery of
oxygen and nutrients to the tissues to meet
metabolic demand
O Treatment goal is to prevent end-organ injury
and stop progression from cardiopulmonary
failure to cardiac arrest
Cardiovascular System…
O Shock in infants and children (continued)
Classification of shock
O Hypovolemic shock
O Most common cause of shock in children
O Hypovolemia from diarrhea, vomiting, inadequate
fluid intake, osmotic diuresis, third space loss and
burns
O Treatment = fluid resuscitation
O Starting volume 20 mL/kg
O May need more than one bolus
O Starting volume is 10 mL/kg when blood is
needed
Congenital Heart Defects
Potential Complications…
O Shock
O Hypovolemic
Cardiovascular System…
O Shock in infants and children…
Classification of shock…
O Cardiogenic shock
O Impaired myocardial function
O In pediatric patient, most common cause is
pump failure, CHD, or rhythm abnormality
O Presentation
O Decreased cardiac output, marked tachycardia,
and high systemic vascular output
O Decreased urine output
O Changes in mental status
O Crackles and frothy sputum
Cardiovascular System…
O Shock in infants and children…
Classification of shock…
O Cardiogenic shock
O Treatment goals
O Improve cardiac function
O Careful monitoring of cardiac and pulmonary
status
O Oxygen
O Pharmacology
O Diuretics
O Vasodilators
Congenital Heart Defects
Potential Complications…
O Cardiogenic
Cardiovascular System…
O Shock in infants and children…
Classification of shock…
O Distributive shock/septic shock
O Causes
O Infectious agents or their endotoxins
O Stimulated immune system triggers release or
activation of inflammatory mediators
O Presentation
O Manifestations of systemic inflammatory
response syndrome
O Low temperature or temperature instability
O Level of consciousness changes: irritability,
restlessness, or lethargy
O Poor feeding; decreased fluid intake
Cardiovascular System…
O Shock in infants and children…
Classification of shock…
O Distributive shock/septic shock…
O Treatment
O Oxygen
O Fluids
O Antibiotics
Congenital Heart Defects
Potential Complications…
O Distributive
O Septic shock
Cardiovascular system…
O Shock in infants and children…
Classification of shock…
O Obstructive shock
O Impaired cardiac output caused by obstruction
of blood flow
O Causes
O Cardiac tamponade
O Tension pneumothorax
O Massive pulmonary embolism
O Ductal-dependent congenital heart defect
O Treatment based on presentation
Cardiovascular system…
O Cardiopulmonary arrest
O Airway
O Circulation
O Intravenous access
O Dysrhythmia treatment
O Defibrillation
O Initial dose of electricity is 2 J/kg
O Repeat dose is 4 J/kg
O Medications
O Epinephrine: first dose 0.01 mg/kg; repeat every 5
minutes
Cardiovascular System…
O Cardiopulmonary arrest (continued)
O Primary goals for postresuscitation
management
O Optimize cardiopulmonary function
O Prevent secondary organ injury
O Identify and treat causes
O Initiate measures to help improve long-term,
neurologically intact survival
Nervous System
Anatomy
• One half of brain growth achieved by 1 year
• 75% by 3 years
• 90% by age 6 or 7
• Fontanelles provide flexibility of skull bones
Nervous System…
Physiology
• Cerebral blood flow and oxygen consumption
• Cerebral perfusion pressure
Nervous System…
Assessment
• Level of consciousness
• Movement
• Pupil size, equality, and reactivity
• Reflexes
O Babinski
• Glasgow Coma Scale (GCS)
Nervous System…
Assessment
• Level of consciousness
• Movement
• Pupil size, equality
and reactivity
• Reflexes
Nervous System…
Thermoregulation
• Avoid cold stress which causes hypoxia, metabolic
acidosis, hypoglycemia
• Infants cannot shiver effectively
• Sudden infant temperature changes may lead to apneic
spells, especially in rewarming
Nervous System…
Common Causes of Seizures
in Infants/Children
• Brain damage if in first few months of life
• Infections are common cause in older infants
and toddlers
• Epilepsy in preschoolers and older children
• Jitteriness and seizures may be caused by asphyxia,
hypoglycemia or hypocalcemia
Nervous System…
O
Nervous System…
Three major groups of seizures
O Partial seizures
O Local onset, involve relatively small part of
brain
O Generalized seizures
O Involve both hemispheres
O Unclassified epileptic seizures
O No sufficient information present to classify the
seizure
Nervous System…
Subtle Signs/Symptoms of Seizures
• Tonic horizontal deviations of the eyes with or without
nystagmic jerking
• Repetitive blinking/fluttering eyelashes
• Drooling, sucking, and/or tongue thrusting
• Swimming/rowing movements of arms with occasional
bicycling of legs
Nervous System…
Status epilepticus treatment
• Medical emergency
• Characterized by two or more unprovoked
seizures
• Caused by a variety of pathologic processes in
brain
O High fever
O Meningitis
O Encephalitis
O Metabolic disorders
O Abrupt stoppage of anticonvulsant drugs
Nervous System…
Status Epilepticus Treatment…
• Anticonvulsants
• Airway maintenance and oxygenation
• Barbiturate coma
• General anesthesia
• Monitor airway, perfusion, vital signs and
neurologic status
Nervous System…
Bacterial Meningitis Etiology
• Acute inflammation of meninges with purulent exudate in
cerebrospinal fluid (CSF)
• Pathogens enter the bloodstream, producing sepsis, and
then invade the meninges
• Highest incidence in children younger than 1 year
• Meningococcal meningitis readily transmitted by droplet
Nervous System…
Bacterial Meningitis: Signs/Symptoms
• Fever, chills
• Headache, photophobia
• Vomiting
• Irritability or lethargy
• Nuchal rigidity
• Positive Kernig’s or Brudzinski’s sign
• In meningococcemia: petechiae and purpura may be
present
Nervous System…
OBacterial meningitis:
OCSF studies per lumbar puncture
O Elevated WBC’s
O Increased protein
O Decreased glucose
OTreatment
O Antibiotics
O Tylenol for temperature elevation/control seizures
O Hydration
Nervous System…
Nursing Management
• Universal and isolation precautions
• Quiet environment
• Monitor neurological, respiratory and cardiac status
O Maintain ventilation/hydration
O Reduction of increased intracranial pressure (ICP)
O Management of systemic shock
• Measure and document head circumference
if < 2 years of age
• Administer antibiotics and analgesics
• Provide education and family support
Nervous System…
Common Causes of Head Trauma
• More common in males
• Motor vehicle accidents
• Falls
• Violence
• Abuse (most common cause of head injury if <
1 year of age)
Nervous System…
Head trauma in children…
• Most common types of cerebral injuries in
children
O Concussions
O Contusions
O Skull fractures
O Vascular injuries
• Treatment goals
O Ensure adequate cerebral oxygenation
O Prevention of secondary brain injury
Nervous System…
Complications of Head Trauma
• Hemorrhage: subdural and epidural hematoma
• Infection
• Cerebral bleeding
• Cerebral edema,
and increased ICP
• Seizures
• Brain herniation
Nervous System…
O Nursing care of a head trauma patient
O Precise neurologic assessment
O Monitoring for signs of increased ICP
O Psychosocial and emotional care of child and
family
O Advocate honest approach if child is not
expected to live
Gastrointestinal
System/Fluids/Nutrition
Gastric Volume
Newborn
3 mos.
1 year
Adult
www.nuh.com.sg/healthinfo/
30 ml
150-180 ml
240 ml
1500 ml
Gastrointestinal System…
Physiology
O Differences in gut immunity; greater
mucosal binding for bacterial toxins
O Greater potential for fluid loss
Gastrointestinal System…
Assessment and treatment
O Fluid requirements
O Replace outputs and insensible losses
O Extra fluid for new intracellular and
extracellular fluid during growth
Gastrointestinal System…
O Assessment of dehydration
O Mild
O Moderate
O Severe
O Fluid replacement
Gastrointestinal System…
Gastrointestinal
System/Fluids/Nutrition…
O Total parenteral nutrition
O Caloric level
O Continuous vs. cycled
O Enteral vs. parenteral intake
O Gavage feeding
O Amount
Continuous vs. intermittent
O Feeding tubes
O Nonnutritive sucking
O Positioning
Gastrointestinal
System/Fluids/Nutrition…
Pain Management
Physiology and pharmacokinetics
O Neurotransmitters and peripheral/central neural
pathways for pain transmission are functional before
birth and continue to mature during first 2 years of life
O Each child must be monitored for individual response to
drug therapy
Pain…
Physiology and pharmacokinetics (continued)
O Physiologic effects of untreated pain in the child
O Hyperglycemia
O Metabolic acidosis
O Increased corticosteroids, growth hormone, and
catecholamines
O Increased pulmonary vascular resistance
O Hypoxemia
Pain Management…
Assessment
• Influence of parental response and behavior
• Determination of pain and severity of pain
• Limitations of cognitive ability
• Limitations of assessment instruments
Pain Management…
O Treatment of pain
O General principles
O Prevention of pain
O Adequate assessment
O Multimodal approach
O Parental involvement
O Nonnoxious routes of administration
O Pain control during procedures
Pain…
O Treatment of pain…
O NSAIDs
O Effective for mild to moderate pain
O Can be combined with opioids
O Opioid analgesics
O Moderate to severe pain
O Topical anesthetics
O Local pain relief
O Reduces child’s anticipated pain and anxiety
Pain…
Psychosocial Issues
of the Child and Family
The Ill Child’s Experience of Critical Illness
• Emotional reactions
• Support from parents or primary caregiver
• Anxiety and fear
• Withdrawal vs. fatigue
• Reducing anxiety
• Age related responses
Psychosocial Issues
of the Child and Family…
Parents’ Experience of a child’s critical illness
• Stress, anxiety, fear, feelings of helplessness
• Reassurance, need to see child
• Support groups