Transcript Lecture 8+ 9+10+11x

Clinical Aspect of Maternal and Child Nursing
NUR 363
Lecture 8
NURSING CARE OF THE CHILD WITH A
CARDIOVASCULAR DISEASE
ASSESSMENT OF HEART DISORDERS
IN CHILDREN
• History
• Physical
assessment
– general
appearance
– pulse, blood
pressure, &
respirations
ASSESSMENT OF HEART DISORDERS
IN CHILDREN
• Diagnostic tests
– Electrocardiogram
– Radiography
– Echocardiography
– Magnetic resonance imaging
– Exercise testing
– Laboratory tests
CLASIFICATION OF CHD
A Cyanotic Heart Defect
Move blood from arterial …to…venous system
A Cyanotic
Increased in pulmonary
blood flow
1. VSD
2. ASD
Obstruction of blood flow from
ventricle
1. Pulmonary stenosis
2. Aortic stenosis
3.Coarctation of the Aorta
CONGENITAL HEART DISEASE
• Defects with increased
pulmonary blood flow
– Ventricular Septal Defect
• Opening between
ventricles
• S/S
– 4-8 weeks, fatigue and
harsh murmur
• Therapeutic management
– Most close spontaneously
(small ones). Other larger
VSDs may require open
heart surgery
• Defects with
increased
pulmonary blood
flow
– Atrial Septal Defect
• Opening between
the atria
• S/S
– Murmur
• Management
– Surgery
A trial Sepal Defect (ASD)
**Obstruction of blood flow from
ventricle
1.Pulmonary stenosis
2.Aortic stenosis
3.Coarctation of the Aorta
– Pulmonic Stenosis
• Narrowing of the
pulmonary valve or
artery causing the right
ventricle to hypertrophy
• S/S
– Mild right sided heart
failure
• Therapeutic
Management
– Balloon angioplasty
to relieve the stenosis
-Aortic Stenosis
• Stenosis of the aortic
valve prevents blood from
passing from the left
ventricle into the aorta,
leading to hypertrophy of
the left ventricle
• S/S
– Usually asymptomatic but
with murmur
– May have chest pain and
even sudden death
• Therapeutic Management
– Stabilization with a Beta
Blocker or Calcium
Channel Blocker
– Balloon valvuloplasty
– Valve replacement
– Coarctation of the
Aorta
• Narrowing of the
lumen of the
aorta
• S/S
– Absence of
palpable femoral
&/or brachial
pulses;
headache,
vertigo,
nosebleeds, leg
pain
• Therapeutic
Management
– Surgery or
angiography
Coarctation of the Aorta
Cyanotic Heart Defect
Cyanotic
Decreased pulmonary
blood flow
Mixed blood flow
**Defect with Decreased pulmonary blood flow
1. Tricuspid Atresia
2. Tetrology of Fallot
– Tricuspid Atresia
• The tricuspid valve is
completely closed,
allowing no blood to
flow from the right
atrium to the right
ventricle.
• When these structures
close, cyanosis,
tachycardia, and
dyspnea occur.
• Treatment consists of
an IV infusion of PGE
(prostaglandin) to keep
the ductus open until
surgery can be
performed.
Tetrology of Fallot (TOF)
– Tetralogy of Fallot
• Four anomalies
– Pulmonary stenosis
– VSD
– Dextroposition of the
aorta
– Hypertrophy of right
ventricle
• S/S
– Cyanosis
– Polycythemia (increase
in number of RBC)
– Dyspnea, growth
restriction, clubbing of
fingers
• Therapeutic Management
– Surgery
Lecture 9
Gastrointestinal System
• Many GI issues require surgical
intervention
• Nursing interventions will often
include general pre and post-op
care
• Assess stools
• Assess hydration status
Gastrointestinal System
Pediatric Variances
•Mechanical functions of digestion are
immature at birth
•Infants have decreased saliva
•Peristalsis is faster in infants
•Digestive processes are mature as a toddler
•Gastric acidity is low at birth
The Gastrointestinal System
8 Altered Connections
3 Esophageal Atresia/Tracheoesophageal Fistula
3 Cleft Lip and Palate
8 Gastrointestinal Disorders
3 Gastroesophageal Reflux
3 Pyloric Stenosis
8
Acquired Gastrointestinal Disorders
3 Appendicitis
ESOPHAGEAL ATRESIA &
TRACHEOESOPHAGEAL FISTULA
•
•
•
•
Congenital defects of esophagus
EA is an incomplete formation of esophagus
TEF is a fistula between the trachea and esophagus
Classic 3 “C’s” - coughing, choking, cyanosis
ESOPHAGEAL ATRESIA &
TRACHEOESOPHAGEAL FISTULA
TREATMENT
• Surgery: either a one- or two-stage repair
• Pre-op care focuses on preventing aspiration and
hydration
• Post-op care focus is a patent airway, prevent incisional
trauma
Cleft Lip/Palate
 May present as single defect or combined
 Non-union of tissue and bone of upper lip and
hard/soft palate during fetal development
 Cleft interferes with normal anatomic structure of
lips, nose, palate, muscles – depending on severity
and placement
 Open communication between mouth and nose with
cleft palate
Nutrition is a challenge in infancy
Risk for aspiration
Respiratory distress
Cleft Lip/Palate
Operative Care
 Monitor for infection
 Clean Cleft Lip incision
 Pain Management
GASTROESOPHAGEAL REFLUX
 Regurgitation of gastric
contents back into esophagus
 GER may predispose patient
to aspiration and pneumonia
 Apnea has been associated
with GER
  chance of GER after 12-18
months old related to growth
due to elongation of
esophagus
GASTROESOPHAGEAL REFLUX
SIGNS/SYMPTOMS
•
•
•
•
•
Vomiting
Gagging during feedings
Irritability
Anemia
Bloody stools
DIAGNOSTIC EVAL
• History of feedings/Physical
Exam
• Upper GI endoscopy to
visualize esophageal mucosa
GASTROESOPHAGEAL REFLUX:
Therapeutic Management
• Positioning
• Prone HOB  30°
• Right side
• Dietary modifications
• Medications
• Prokinetic agents
• Histamine H-2
• Small, frequent
• Proton Pump Inhibitors
feedings
• Possibly thicken
• Mucosal Protectants
formula
• Avoid fatty, spicy foods
caffeine, & citrus
• Surgery: fundoplication
• Teach
Fundoplication (anti-reflux surgery): A surgical technique that strengthens the barrier to
acid reflux when the lower esophageal sphincter does not work normally and there is
gastro-esophageal reflux.
PYLORIC STENOSIS
 Hypertrophy of pyloric sphincter, causing a narrowing/ obstruction
 Infant presents “always hungry”
 Weight loss
PYLORIC STENOSIS
DIAGNOSTIC EVAL
INTERVENTIONS
• History/Physical Exam
• Pre-op: NPO, NGT to
hydration, I/O, monitor
electrolytes
• Abdominal Ultrasound
TREATMENT
• Surgical Intervention:
Pyloromyotomy
• Post-op: Start feedings
in 4-6 hrs. Progressive
feeding schedule
APPENDICITIS
• Inflammation and infection
of vermiform appendix,
usually related to an
obstruction
• Surgery is necessary
• Cause may be bacteria,
virus, trauma
• Post-op Care: routine
post-op care,
IVF/antibiotics,
NPO ambulation,
positioning, pain
management, wound
care, possible drains.
• S/S: periumbilical pain,
fever, vomiting, diarrhea,
irritability,  WBC’s
• Pre-op Care: NPO, pain
management,
hydration, consent
Lecture 10+11
Respiratory System
Pediatric Variances
 The airway is smaller.
 The larynx is more flexible and more susceptible to spasm.
 The tongue is large.
 Chest muscles are not well developed
 Irregular breathing pattern and brief periods of apnea (10 -
15 secs) are common
 Abdominal muscles are used for inhalation until age 5-6 yrs.
 Respiratory rate is higher
The Respiratory System
Upper Airway Disorders
Tonsillitis
Croup/Epiglottis
Foreign Body Aspiration
Lower Airway Disorders
Bronchiolitis
Asthma
Otitis Media
Tonsillitis
CLINICAL MANIFESTATIONS
 Sore throat
 Mouth breathing
 Sleep Apnea
 Difficulty swallowing
 Fever
IMPLEMENTATIONS
Provide Comfort
Warm saline gargles
Reduce Fever
 Promote Hydration
 Administer Antibiotics
 Provide Rest
 Patient Teaching
 Tonsillectomy may be
necessary
Tonsillectomy
Pre-operative Nursing Care
– Monitor Labs (CBC, PT, PTT)
– Age-appropriate Preparation/Teaching
– Surgical Consent
Post-operative Nursing Care
–
–
–
–
–
Frequent site assessment
Monitor for S/S of Complications
Pain Management
Diet
Patient Teaching
Croup/Epiglottitis
• Infection and swelling of larynx,
trachea, epiglottis, bronchi
• Causative agent: Viral
• Characterized by hoarseness, barky
cough, inspiratory stridor, and
respiratory distress
• LIFE-THREATENING
EMERGENCY
• Often the child is intubated
Croup/Epiglottitis
Nursing Interventions
 Maintain Patent Airway
 Assess and Monitor
Nursing Interventions
 Administer Meds
 Corticosteroids
 Promote Hydration
 Reduce Fever
 Calm Environment
 Promote Rest
 Nebulizer treatment
 Antibiotic for epiglottitis
Foreign Body Aspiration
• Occurs most often in small children
• Choking, coughing, wheezing, respiratory difficulty
• Often it is round food, such as grapes, nuts,
popcorn
• Bronchoscopy often needed for removal
• Prevention and parent education is very important
Bronchiolitis
• Acute viral infection of the bronchioles causing an
inflammatory/obstructive process to occur
• CXR shows hyperinflation and consolidation if
atelectasis present
• Primarily seen in children under 2 years of age
Bronchiolitis
CLINICAL MANIFESTATIONS
 Nasal Congestion
 Cough
 Crackles, Wheezes
 Increased RR & SOB
 Respiratory Distress
 Fever
 Poor Feeding
IMPLEMENTATIONS
 Suction – priority
 Bronchodilator
 CPT
 Promote fluids
 Monitor VS , SaO2, lung
sounds & respiratory effort
 Supplemental oxygen
 Reduce fever
 Promote rest
Asthma
Asthma is a common chronic inflammatory disease
of the airways






CLINICAL MANIFESTATIONS
Tachypnea
SaO2 below 95%
Wheezes, crackles
Non-productive cough
Restlessness, fatigue
Abdominal pain
Asthma
INTERVENTIONS
 Monitor VS (HR, RR)
 Monitor SaO2
 Auscultate lung sounds
 Monitor respiratory effort
 Humified oxygen
 Calm environment
 Promote hydration
 Promote rest
 Monitor labs/x-rays
 Patient teaching
Administer Medications
 Bronchodilator
 Corticosteroid IV or PO
 Antibiotic if precipitated from a respiratory infection
Otitis Media
 Most common childhood illness
 Inflammation of middle ear
 Acute otitis media (AOM)
 S/S: pain, fever, irritability, vomiting, diarrhea, ear
drainage, full/bulging tympanic membrane
 Otitis media with effusion (OME)
 Inflammation of middle ear with fluid behind tympanic
membrane-no infection
 Chronic otitis media
 Can lead to hearing loss/delayed speech
Otitis Media
TREATMENT
 Antibiotics
INTERVENTIONS
 Teaching
 Feeding techniques
 Medication regimen
PAIN MANAGEMENT
 Fever management
 Surgery prep if needed