Unit 2 Pediatrics
Tetralogy of Fallot s/s
"tet" spells - spells of cyanosis - treated by flexing knees forward and upward Severe irritability due to low oxygen level s Polycythemia Poor growth
nasal cannula
(24% to 35% oxygen; 5-10 L/min).
simple oxygen mask
(35% to 50% oxygen; 5-10 L/min).
Non-rebreather mask
(70% to 100% oxygen; 10-15 L/min). don't rebreathe their CO2
Asthma pathophysiology
(trigger factor leads to airway inflammation which leads to hypersecretion of mucus, airway muscle constriction, and swelling of bronchial membranes. All three lead to narrow breathing passages which leads to wheezing, cough, SOB, and tightness in the chest). -the degree of airway hyperresponsiveness correlates with the severity of symptoms. -Symptoms come from complex interactions among inflammatory cells, mediators, airways, cells, and tissues.
Pulmonary atresia
- Undeveloped pulmonic valve, hypoplastic right ventricle. - Severe hypoxia if not managed. - PDA must remain open; prostaglandins. - Surgical repairs; palliative repair first
pediatric airway
-A smaller nasopharynx and can be obstructed during infection -smaller nares are easily occluded, inhibiting ventilation -tongue, tonsils, and adenoids are large relative to their small size of the oral cavity -a long floppy epiglottis is vulnerable to swelling and obstruction -Larynx is superior/anterior in the neck increasing risk of aspiration -thyroid, cricoid, and tracheal cartilages are narrow and flexible, and may easily collapse when neck is flexed.
Acute Respiratory Distress Syndrome
-Acute, diffuse, and inflammatory lung injury -Hypoxemia and noncompliant lungs -Direct or indirect injury -Bilateral opacities on chest x-ray -Supportive care in ICU: Intubation, Positive pressure mechanical ventilation, Antibiotics, diuretics, and vasodilators, Decrease pulmonary vascular resistance, Gastric ulcer prophylaxis
Kawasaki Disease
-Acute, idiopathic systemic vascular inflammatory disorder. -Usually occurs in children younger than 5 years old. -Most common cause of acquired heart disease. -Three phases: acute (abrupt fever), subacute (fever resolution), and convalescent (complete resolution). -Manifestations: fever, strawberry tongue, polymorphous rash, conjunctivitis, erythema of hands and feet, cervical lymphadenopathy, and desquamation of fingers and toes. -Lasts several weeks, but convalescent phase can take 3 months. -Coronary aneurysms may occur. -Treat with intravenous immunoglobulin G therapy and aspirin.
Respiratory assessment of the pediatric client
-Adventitious sounds: wheeze, stridor (swelling in upper airway; hard for child to get air on inspiration), crackles. -Odors: breath and mucus -Mucus: color and consistency -Positioning: comfort, effect of position on dyspnea -Cough: characteristics, effort, and timing -Color: location and shade, effect of crying, presence of cyanosis -Pain: location and origin, severity
Asthma medications and considerations
-Albuterol: short acting bronchodilator, decreases airway resistance, dilates airways, monitor HR as it may cause tremors. -Methylprednisolone: corticosteroid, reduces inflammation, decreases obstruction, monitor BP, electrolytes and glucose. -Montelukast: Leukotriene receptor antagonist, reduces inflammation and improves lung function. -Theophylline (not commonly used anymore): relaxes muscles and dilates airways, give at the same time each day and avoid caffeine.
Diagnosing Cystic Fibrosis
-All 50 states in the US have mandatory newborn screening -2015: 59.6% of patients were diagnosed by newborn screenings -Diagnosis confirmation: -Sweat chloride test: Standard approach to diagnosis. Collecting sweat and performing chemical analysis (>60mEq/L = positive) -Exocrine pancreatic dysfunction: Measurements of fat balances in 3-day stool collection. Quantification of elastase-1 activity in fresh stool
Transposition of the great arteries
-Arteries connected to wrong ventricles. -Must have another defect for blood flow/O2 mixing. -Prostaglandins to keep PDA open until surgical repair.
Emergency Assessment
-Assess ventilation, oxygenation, and perfusion first. -Establish patent airway and ensure adequate breathing. -Rapid cardiopulmonary assessments. -Initial assessment (safety, airway, breathing, circulation, disability): -Assess scene for safety. -Assess need for cardiopulmonary resuscitation (CPR). -Spend less than 10 seconds assessing for central pulse. -Head-tilt/chin-lift or jaw thrust to assess airway. -Monitor chest rise and respirations. -Capillary refill, bleeding and blood loss, peripheral pulses, and blood pressure assessment. -Neurological assessment and Glasgow Coma Scale score.
Medications used in pediatric emergencies
-Atropine: Anticholinergic used to increase heart rate and cardiac output. -Dextrose: Increase blood glucose levels. -Dobutamine: Increases heart rate and myocardial contractility. -Dopamine: Increases cardiac output and blood pressure. -Epinephrine (Epi): Increases heart rate and systemic vascular resistance. -Naloxone (Narcan): Reverses respiratory depression and hypotension related to narcotic effects.
rheumatic fever
-Autoimmune, inflammatory reaction to group A streptococcus. -Can be prevented by administering antibiotics for streptococcal pharyngitis. -Manifestations: chorea, arthralgia, fever, carditis, erythema marginatum, subcutaneous nodules, polyarthritis, and elevated C-reactive proteins. -Diagnosed using Jones criteria. -Antibiotics and anti-inflammatory medications. -Prolonged hospitalizations.
Those at Risk for CF
-Autosomal Recessive Disorder -A person must have two copies of the abnormal gene to have the manifestations of CF. -Family history of cystic fibrosis can cause an increased risk -Caucasians of European descent, but also occurs in all groups
Cystic Fibrosis
-Autosomal recessive genetic disorder: abnormalities in body's salt, water, and mucus-making cells -Can asymptomatically carry the gene. -Thick, sticky mucus builds up in lungs, sinuses, liver, pancreas, intestines, and reproductive organs. -Manifestations: steatorrhea, failure to thrive, tachypnea, wheezing, retractions, recurrent pneumonia -Sweat chloride testing -Treat and manage the affected systems: Pancreatic enzyme replacement, Percussion and drainage, Mucolytics, Diet: high protein, high calorie, high fat
Double-outlet right ventricle
-Both great arteries exit from right ventricle. -Always has VSD present (required to survive). -Manage heart failure and surgical repair.
School age physical assessment techniques
-Build rapport with the child by discussing their likes and hobbies. -Assess development through questions about their life. -Direct questions to the child, confirming the information with the caregiver.
Progression of Cystic Fibrosis
-Childhood: many stay in good health until they reach adulthood. Promote a normal life, encourage attending school -Lung disease can worsen to the point where one becomes disabled: Build up of mucus in the lungs, leads to increased lung infections. Lung infections can lead to worsening lung disease. Death most often caused by complications of the lungs. B. cepacian, MRSA, nontuberculosis mycobacteria, P. aeruginosa -Life expectancy depends on age of diagnosis, severity of the disease, and type of CF gene mutation
Bronchopulmonary Dysplasia (BPD)
-Chronic obstructive pulmonary disorder. -Occurs from prolonged use of supplemental oxygen and positive pressure ventilation after premature birth. -Reduced surface area for gas exchange. -Manifestations: tachypnea, tachycardia, nasal flaring, grunting, retractions, wheezing, crackles, failure to thrive, and increased oxygen demands. -Treatments: positioning, humidified supplemental oxygen, chest physiotherapy, bronchodilators, and suction. -Cluster and organize nursing care. -Diuretics to prevent fluid overload. -May require tracheostomy.
Heart Defects: Obstruction to systemic blood flow
-Coarctation of the aorta -hypoplastic left heart syndrome -mitral stenosis -interrupted aortic arch Presentation: diminished pulses, delayed capillary refill, poor color, heart failure, pulmonary edema
Heart failure interventions
-Collaborative approach with multidisciplinary team. -Maintain oxygenation and cardiac output. -Monitor fluid balance and weight. -Administer medications: Cardiac glycosides: positive inotropic effect, avoid giving with meals, and monitor for toxicity. ACE inhibitors: decreases peripheral resistance, afterload, and preload; may cause cough. Loop diuretics: sodium-rich diuresis (hold onto H2O and Na+); monitor urine output and potassium levels. Beta blockers: blocks beta-adrenergic receptors to decrease excitability in heart; check apical pulse and blood pressure before administering.
Immunization safety in Infants
-Common side effects: Fever up to 102°F. Redness or swelling at the injection site. Increased fussiness and sleepiness for 24 hours after immunizations -When to call the healthcare provider: High fever. Seizures. Uncontrollable crying for 3 hours or longer -Antipyretic use: Fever helps the body mount an antibody response against viral and bacterial pathogens. Giving an antipyretic reduces the antigen response. Caregivers should only give antipyretics if high fever or extreme fussiness.
Poisoning
-Consequences of ingestion depend on child's age and weight, type and toxicity of substance ingested, response time, and treatment provided. -Manifestations (depend on substance ingested): nausea, vomiting, anorexia, pallor, sweating, altered mental status, bradycardia, hypotension, tachypnea, and seizures. -Commonly ingested substances: cosmetics and personal care products, analgesics, pesticide, household cleaners, alcohols, and medications. -Determine what substance was ingested and how much. -Corrosives can quickly cause respiratory compromise and ingestion of opioids can lead to respiratory depression. -Interventions are based on substance ingested; contact poison control center for recommendations.
Fetal Circulation
-Constricted pulmonary blood vessels. Lungs are full of fluid. Not responsible for oxygenation -Dilated systemic blood vessels with low resistance -Patent Ductus arteriosus -Patent foramen ovale -Patent ductus venosus
cystic fibrosis
-Cystic fibrosis is a complex genetic disease that affects many organs in the body -Chronic disease à abnormality in the body's salt, water, and mucus making cells -Autosomal recessive disorder -1 in 31 people in the US are carriers of CF -Median age of life is 41.7 years -Affects the sinuses, lungs, skin, liver, pancreas, intestine, and reproductive organs -Death is most commonly caused by respiratory and cardiorespiratory issues
Manifestations of shock
-Depend on stage of shock. -Compensated: Tachycardia, tachypnea, and warm or cool skin. -Decompensated: Cool skin, decreased peripheral pulses, decreased urinary output, extremely high heart rate, altered neurological status, and hypotension. -Irreversible: Bradycardia, hypotension unresponsive to treatment, and evidence of end-organ damage.
Social/emotional milestones for school age children
-Develops hobbies -Thinks about the future -Wants to be liked and pays attention to friendships -Focuses less on self
Asthma
-Diagnosed with pulmonary function testing (PFTs). -Treatment involves medications, control of triggers, and education. -Common asthma triggers: pollen, mold, pet dander, tobacco smoke, exercise, anxiety, and dust mites -Use step-wise approach for management and treatment. -Interventions based on peak-flow meter results (asthma action plans).
Neonatal (post birth) circulation
-Dilated pulmonary blood vessels -Vascular resistance, arterial pressure, and systemic blood volume increase -Ductus arteriosus closes by 2-5 days after birth -Foramen ovale closes -Ductus venous constricts and closes
Cardiomyopathy
-Disease of the heart muscle resulting in muscle defects. -Dilated and hypertrophic are two most common forms. -Thin heart muscle, dilated left ventricle, loss of squeeze, and reduced cardiac output (dilated). -Myocarditis is the most common cause of dilated cardiomyopathy (viral). -Malformation syndromes are the most common cause of hypertrophic cardiomyopathy. -Left ventricle and septum enlargement; rigid walls (hypertrophic). -Obstructions occurs after hypertrophic cardiomyopathy. -Treatment same as heart failure treatment.
Pathophysiology of CF
-Etiology = defect or dysfunction of the CF transmembrane conductance regulator protein -Most common mutation is on gene delta F508 -More than 1,000 different changes -Gene is active in epithelial cells of the airways, GI tract, sweat glands, and genitourinary systems -Dysfunction: -Chloride ion transport impaired -Sodium absorption reduces water movement across cell membranes -Body secretions become thickened -Pancreas enzyme production inhibited
Tricuspid Atresia
-Incomplete tricuspid valve, right atrium and ventricle unconnected and ASD present -Prostaglandins immediately, heart failure medications -Three-staged surgical repair
Hypertension in pediatrics
-Increase in cardiac output or peripheral vascular resistance leads to increase in blood pressure. -Defined as a Blood pressure > 95th percentile for age. -Usually asymptomatic. -Associated with obesity. -Treatment will start with a low-sodium and low-fat diet, and weight control measures. -Encourage developmentally-appropriate activity. -Treat with antihypertensives (only if non-pharmacological interventions don't work),
Respiratory Distress
-Increased respirations -Pink pale color -Wheezing, retractions, nasal flaring, grunting -Irritable, restless, confused, headache -Tachycardic, diaphoresis, HTN -O2 sat may be normal or slightly lower, mild hypoxia, may require oxygen -pH normal or alkalotic, or mild acidosis
Pneumonia
-Infection or inflammation in lower airways. -Bacterial or viral; community or hospital acquired. -Clinical presentation: fever, tachypnea, cough, n/v, irritable, restless, lethargic, crackles. -Treatment: monitor for respiratory distress, encourage coughing and deep breathing, antibiotics if bacterial
Health Promotion and Prevention of CF
-Infection prevention: Report any signs of respiratory infections as soon as possible. Avoid touching face, wash hands frequently, use hand-sanitizer. Do not share personal items. Avoid crowded areas. Avoid frequent contact with dust and dirt -Immunizations: Influenza vaccine. Pneumococcal vaccine. CDC recommendations -Nutrition: Diet high in calories and protein. Increase intake of Vitamins A, D, E, and K. -Follow medication regimen -CF patients should stay >6 feet away from each other -Exercise
Epiglottitis
-Inflammation and swelling of epiglottis -Medical emergency due to airway constriction -Bacterial infection (Hib was common cause) -Rapid onset; airway obstruction imminent. -Clinical presentation: toxic appearance and tripod positioning, drooling, stridor/ croaking sound, high fever, cherry red epiglottis, steeple sign on x-ray. -Treatment: keep calm and avoid anxiety and crying. Immediate endotracheal tube for airway patency. antibiotic administration.
Acute bronchitis
-Inflammation of the lining of the bronchial tubes -Usually viral -Coarse barking cough, gurgles (rhonchi) on auscultation, chest pain, and thick sputum that is expectorated. -Self-limiting; treat symptomatically (humidification) -May vomit thick mucus during strong coughing episodes
Foreign body aspiration
-Inhalation of object into respiratory tract -Manifestations: cough, dyspnea, stridor, and hoarseness -Severe respiratory distress -Foreign body removal -Prevent with anticipatory guidance
Physical assessment techniques for infants
-Keep infant comfortable on parent's lap -Weigh infant in dry diaper only -First: Inspect and auscultate, while the infant is calm and quiet. -Next: Palpate, saving invasive procedures for last. Palpate the anterior and posterior fontanelle -Last: Assess the ears, nose, and throat last because it irritates babies the most
Gross motor milestones in school age children
-Learns to ride a bicycle -Skilled in running, jumping, skipping, and hopping -Throws objects with accurate aim and increased distance
Tuberculosis
-Lung infection with acid-fast bacilli -Risk factors can be environmental or immune-related -Spreads by airborne droplets -Primary and secondary forms. -Manifestations: Persistent cough, Night sweats, Fevers -Diagnostic testing: Tuberculin skin testing, Chest x-ray, QuantiFERON gold testing (blood test) -Long-term antibiotic treatment
Pediatric lower airway variations
-Mainstem bronchi separates higher (T3 versus T6) -Fewer, immature alveoli -Narrower bronchioles -Diaphragm for inspiration in children younger than 6 years -Smaller lungs -Immature intercostal muscles leads to retractions in respiratory distress (pulling in around the ribcage when child is having difficulty breathing)
Hospitalization in Infants
-Medications and fluid doses: Are calculated using weight-based dosing. It is important to have an accurate weight (in kg). -Assess pain using a developmentally appropriate pain scale (caregiver report, FLACC Scale, etc.) -Infants are in Erikson's stage of trust vs. mistrust: Keep feeding routines the same as much as possible. Allow parents and caregivers to hold and feed the infant whenever possible. If parents and caregivers cannot stay at the hospital, they can leave a recording or item from home. Nurses should respond to infants quickly to encourage psychosocial development.
Medications/Treatments Commonly Prescribed for CF
-Medications that target gene mutations -Antibiotics -Anti-inflammatories -Mucolytics -Bronchodilators -Pancreatic enzymes -Stool Softeners -Acid-reducing agents -Chest percussion with or without high-frequency chest wall oscillation combined with postural therapy
Respiratory distress in school age children
-Mild distress= mildly increased respiratory rate, pink color, slightly increased HR. -Moderate distress: irritability, increased respiratory rate with moderate retractions, nasal flaring. -Severe distress: lethargy, prominent chest retractions, pale and or cyanotic, extreme HR and BP changes.
Disease management in school age children
-Milestones: Can plan, problem-solve, and make decisions regarding chronic diseases. Can understand rationale, effects, and importance of disease management -Caregiver involvement: Caregivers share responsibility with child. Encourage child to take an active role in disease management
Laryngotracheobronchitis LTB (croup disorder)
-Most common croup disorder; occurs in 3 months to 8 years. -Viral infection in the upper airway. -Gradual onset and slow progression. -Signs: brassy cough, dyspnea, stridor, low-grade fever. -Treatment: steroids, fluids, and racemic epinephrine (breathing treatment)
Asthma treatments
-Nebulizers: continuous or intermittent. Place in mouth, seal lips, breathe in through mouth and out through nose. -Inhalers: should be used with a spacer -oral medications -oxygen administration -intravenous medications: used during emergency exacerbations.
Oxygenation
-Newborns are obligatory nose breathers: mouth breathing starts at 4 months of age, use nasal cannula due to nose breathing. -Select the device based on age, situation, and required flow rate. -Monitor O2 saturation while on supplemental oxygen. -Position to increase oxygenation. -Nasal cannula (24% to 35% oxygen; 5-10 L/min). -Simple oxygen mask (35% to 50% oxygen; 5-10 L/min). -Non-rebreather mask (70% to 100% oxygen; 10-15 L/min). -Bilevel positive airway pressure (BiPAP), continuous positive airway pressure (CPAP), or ventilator if positive airway pressure needed.
Current Treatment for CF
-No cure, but treatment helps decrease symptoms, reduce complications, and improve quality of life -Plan of care focuses on respiratory, gastrointestinal, and endocrine systems. Varies from patient to patient -Goals: Preventing and controlling infections that occur in the lungs. Removing and loosening mucus from the lungs. Treating and preventing intestinal blocks. Providing nutrition that's adequate for the patient. Lung transplant may be an option
spasmodic laryngitis (croup disorder)
-Occurs in children 3 months to 3 years. -Occurs suddenly; often at night. -Unknown cause; maybe viral. -Signs: barking cough, afebrile, mild respiratory distress. -Treatment: cool mist; self-limiting and transient.
Hospitalization in School-Aged Children
-Offer choices related to hospital treatments when possible. -Use child-friendly, developmentally-appropriate hospital equipment. -Explain procedures in simple, clear terms. -Offer age-appropriate activities and toys, such as: Crafts, Coloring, Movies, Puzzles, Games.
Treatment of Respiratory Arrest
-Open the airway and assist with breathing to maintain oxygenation. -Use a bag-valve mask to deliver breaths until an advanced airway can be established through endotracheal intubation. -Ensure a proper mask fit; size is based on child's size. -Encourage parent presence during resuscitation. -Mechanical ventilation to replace spontaneous breathing after intubation.
General Nursing Interventions for Pediatric Emergencies
-Provide CPR: Infant CPR, Child CPR -Administer medications and fluids: Broslow Tape: Weight-based dosing. Normal saline or lactated ringers used for volume expansion. Push-pull technique to quickly administer fluid boluses. -Provide emotional and psychological support: Caregivers may feel sadness, fear, guilt, or anger. Provide up-to-date information and open, honest communication.Offer empathy and ongoing emotional support. Utilize social workers, chaplains, and DEBRIEF!
Nursing Care for Cardiovascular Disorders
-Provide appropriate pain interventions, especially post-operatively. -Adequate oxygenation: Decreased cardiac output leads to inadequate oxygenation. Administer supplemental oxygen and monitor saturation. -Hydration and nutrition: Monitor protein and vitamin intake and use small, frequent meals. -Promote growth and development: Use occupation therapy and physical therapy to meet motor milestones. Encourage play and socialization with peers to promote psychosocial development. -Provide emotional and psychosocial support, using support groups and social workers as needed.
Heart failure manifestations
-Pulmonary venous congestion: Tachypnea, labored breathing during feeding, cough, crackles, grunting, cyanosis, diaphoresis during feeding -Systemic venous congestion: Peripheral edema, fluid retention, ascites, enlarged liver, jugular venous distension -Impaired cardiac output: Tachycardia, pallor, tiring with play, cool extremities, weak pulses, hypotension, oliguria, irritability, delayed capillary refill -Increased metabolic demand: Diaphoresis, slow weight gain, failure to thrive, weight loss
Tetralogy of Fallot
-Pulmonic stenosis, right ventricular hypertrophy, overriding aorta, and VSD. -May also have open foramen ovale or ASD. -Most common cyanotic defect; hypercyanotic episodes. -Manifestations depend on severity. -Decrease systemic venous flow during spells. -Surgical repair of defect.
Submersion injury treatments
-Rapid rescue from the water. -Basic life support to stabilize cardiopulmonary status. -Treatments focused on optimizing oxygenation and cardiac output and controlling temperature. -Administer and monitor oxygen. -Noninvasive or invasive ventilatory support to decrease carbon dioxide levels. -Monitor for temperature changes and intervene appropriately. -Fluid resuscitation and inotropic support to restore intravascular volume. -Monitor for pulmonary edema. -Education for prevention: physical barriers around pools and swimming lessons.
Shock
-Reduction in tissue perfusion resulting in decreased oxygen delivery to tissues and decrease removal of harmful by-products of metabolism. -Prolonged oxygen deprivation leads to cellular hypoxia and death. -Categorized as hypovolemic, distributive, obstructive, or cardiogenic based on cause. -Distributive shock can be further categorized as neurogenic, septic, or anaphylactic. -Classified as compensated (homeostatic mechanisms), decompensated (hypotension and rapid deterioration), and irreversible (death is imminent).
Interventions for Bronchiolitis in Infants
-Regular assessments for respiratory distress should be conducted. -Medications: Do not decrease the length of hospital stay. Do not improve the outcome. -The mainstay of bronchiolitis treatment is supportive. -Treatment standards: Hydration with isotonic intravenous fluids. Feeding as tolerated with suction prior to feeds. Oxygen administration to keep saturation above 90%
Respiratory failure
-Respirations progressing to bradypnea -Cyanotic or gray color -Minimal chest expansion with severe retractions and apnea -Difficult to arouse, limp, stupor, coma -Extreme tachycardia and bradycardia when hypoxia is present, hypotension -Hypoxia worsens; cerebral oxygenation severely affected -pH acidotic -occurs suddenly when compensatory mechanisms fail
Classic Signs and Symptoms of CF
-Respiratory: Cough, purulent mucus, bronchiolitis with wheezing, tachypnea, Increased work of breathing, exercise intolerance, SOB -Gastrointestinal: Bulky, greasy stools, failure to gain weight, constipation, abdominal distention -Endocrine: Stools with droplets of fat, excessive gas. Hyperglycemia (CF diabetes), polyuria -Reproductive: Females = difficulty conceiving. Males = infertility -Sweat glands: Salty sweat, hyponatremia, hypochloremic alkalosis
Asthma discharge education
-Review triggers and the asthma action plan. -Review medications and have the child demonstrate proper use of inhaler and spacer. -Review the peak flow meter and have the child demonstrate its use. -Review when to call the physician or go to the emergency room. -Provide instructions for returning to school.
Pulmonic stenosis
-Right ventricular outflow obstruction. -Subvalvular, valvular, or supravalvular. -Lifelong endocarditis prophylaxis. -Surgical interventions and heart failure management.
Anticipatory Guidance for Caregivers of School-Agers
-Safety: Ensure children wear protective gear when playing sports, biking, and skating. Discuss the family fire safety plan. Lock up guns and firearms. Supervise when swimming or near water. Teach children to look both ways before crossing the street. -Social: Meet and get to know the child's friends. Teach children how to answer the phone and door. Monitor for signs of bullying. Talk with children about their friends and peers. Teach children about safety and peer pressure.
Fine motor milestones for school age children
-Shows increased coordination
Truncus arteriosus
-Single great artery with large VSD. -Activity limitations. -Manage heart failure and surgical repair.
Respiratory Arrest
-State of cessation of breathing or severe respiratory dysfunction that leads to inadequate ventilation and oxygenation. -Usually proceeded by respiratory distress. Take action at this stage to prevent progression! -Leads to cardiopulmonary arrest if untreated. Most common cause of cardiac arrest in pediatric clients is respiratory arrest! -Quickly determine cause to choose appropriate interventions. -Impending signs: respiratory rate changes (tachypnea, bradypnea, or apnea), shallow chest rise, altered mental status, and cyanosis.
Heart failure
-Structural or functional impairment of ventricles. -Ventricular dysfunction, volume overload, or pressure overload categories. -Ventricular dysfunction can have structural abnormalities. -Volume overload can be cardiac or noncardiac. -Pressure overload typically from obstruction. -Manifestations vary based on age, cause, and severity. -Monitor mental status, pulmonary function, and kidney function.
Speech and cognitive milestones in school age children
-Talks through thoughts and feelings -Reads -Rapidly develops judgment and mental skills -Concentrates for increasingly longer periods of time -Can comprehend time -Develops logical thinking skills
Incidence, Mortality, and Morbidity of CF
-The median age of diagnosis of CF is 6-8 months -Majority are diagnosed before the first year of life -Most frequent populations: Caucasians in North America, Northern Europe, Australia, and New Zealand -Prevalence: -1 in 3500 Caucasians -1 in 9200 Spanish decent -1 in 15000 African American decent -More than 30,000 people have CF in the US -Approximately 1,000 new cases are diagnosed each year
Environmental Tobacco Smoke (ETS) Exposure
-Tobacco exposure increases the risk for: Respiratory diseases, Otitis media, Overall decreased lung function, Decreased gross motor and fine motor function, Development of attention deficit hyperactivity disorder, Development of lower respiratory tract infections. -Secondhand smoke: Is smoke that is inhaled directly from smokers -Thirdhand smoke: Is exposure to nicotine-like contaminants that settle into clothing, food, and other household items. -The best way to protect children is to avoid any exposure to ETS.
Submersion Injuries
-Trauma caused by near drowning or survival after suffocation and respiratory impairment by submersion in a liquid medium. -Also known as drowning. -Risk factors: lack of swimming ability, lack of physical barriers to water sources, and lack of close supervision. -After submerging in water, breath holding, panic, swallowing of water, aspiration, and laryngospasm follow. -Hypoxia and hypercapnia leads to unconsciousness. -If resuscitation, still long-term consequences associated with brain damage from prolonged hypoxia, acute respiratory distress syndrome, and lung infection. -Manifestations: tachypnea, labored breathing, wheezing, shortness of breath, and hypoxemia.
airway components
-Upper airway (Allows for ventilation): Nasopharynx and oropharynx, Epiglottis -Larynx separates the upper and lower airways. -Lower airway (Allows for oxygenation/gas exchange): Trachea, Bronchi and Bronchioles, Lungs, Alveoli
Common Causes of Respiratory Arrest
-Upper airway disorders: Croup, epiglottitis, strangulation, tracheal stenosis -Lower airway disorders: Asthma, bronchitis, pertussis, pneumothorax, pneumonia -Neurological disorders: Seizures, spinal cord trauma, sudden infant death syndrome -Cardiac disorders: Arrhythmias, acquired heart problems, congenital defects -Traumatic injuries: Burns, foreign body aspiration, child abuse, drowning, electrocution, gunshot wound, motor vehicle accidents, poisoning -Other: Shock, cystic fibrosis, diabetic ketoacidosis, reflux
Asthma action plans
-Used to provide patient and caregivers with a plan for decision making regarding asthma interventions. -A stoplight approach to identify green, yellow, or red zones based on peak flow meter results: Green zone: no exacerbation. Yellow zone: asthma progression. Red zone: emergency exacerbation -Must be combined with verbal and written education on symptoms, medications, disease management, and inhaler use.
Cardiac medications: Inotropes
-alters force or strength of heart muscle contractions to improve cardiac output -used for heart failure management
Monitoring asthma exacerbations
-assess the following frequently to monitor progression of distress: feelings of chest tightness, air hunger, increased wheezing/ coughing, decreased ventilation, increased lethargy, tachypnea with shallow breathing, tripod positioning, prolonged expiratory phase, oxygen needs and pulse ox saturation values.
3 things that occur in asthma
-bronchoconstriction, -increased mucus production -airway inflammation
heart defects: increased pulmonary blood flow
-deoxygenateed blood mixes with oxygenated blood -left to right shuntiing (high to low pressure) -Patent ductus arteriosus -Atrial septal defect -ventricular septal defect -atrioventricular canal Presentation: tachypnea, frequent respiratory infections, tachycardia, murmur, diaphoresis, poor weight gain, heart failure
Asthma symptoms
-fatigue -tachypnea -heaviness in the chest -prolonged expiratory phase -retractions -wheezing or decreased breath sounds -dyspnea
Cardiac output in pediatrics
-high HR low BP at birth -HR decreases and blood pressure increases with age -newborn HR 100-150 BP 65-85/45-55 -ages 3-6: HR 65-110 BP 95-110/60-75
Infective Endocarditis
-infection of endocardium (inner lining of heart) -Vegetations grow in valves and lining, causing dysfunction of valves -most caused by bacterial pathogens -manifestations vary greatly depending on severity -administer antibiotics, manage cardiac output, and possible heart failure -prophylactic antibiotics before procedures and surgeries in the future.
atrial septal defect (ASD)
-manifestations depend on size of defect -small ASDs may close spontaneously -surgical patch
Aortic stenosis
-narrowing of aortic valve -surgical repair or balloon valvuloplasty
coarctation of the aorta
-narrowing of the aorta -high BP in upper extremities and low blood pressure in lower extremities -impaired perfusion when PDA closes -surgical repair
Heart Defects: Decreased pulmonary blood flow
-obstruction of blood flow to the lungs -right to left shunting -pulmonic stenosis -tetralogy of Fallot -Pulmonary atresia -Tricuspid atresia Presentation: cyanosis, poor weight gain, hypercyanotic episodes, polycythemia
ventricular septal defect (VSD)
-patch placed at 3-12 months of age -monitor for heart failure -medications for heart failure -manifestations depend on size -if small, may close on their own within the first year of life
Cardiac medication: Prostaglandin E
-relaxes smooth muscle to prevent patent ductus arteriosus (PDA) closure -used in conditions that require an open PDA for blood mixing
Asthma Triggers
-respiratory infections: pneumonia, common cold, bronchiolitis. -Allergens: dust, pollen, pet dander, weeds. Remove plants from the home and avoid toys that collect dust. -Irritants: tobacco smoke, cleaning products, perfume. Avoid tobacco exposure. -Exercise: continue to encourage regular exercise, implement prophylactic medications before exercise.
Hear defects: mixed flow (most severe)
-transposition of the great arteries -Truncus arteriosus -Double-outlet right ventricle Presentation: cyanosis, poor weight gain, pulmonary congestion, heart failure
Hypoplastic Left Heart Syndrome
-underdeveloped left side of the heart -must have open PDA -surgical repair -usually fatal within first year of life
Cardiac medications: Indomethacin
-used to close PDA -inhibits prostaglandin, which allows smooth muscle contraction to close openings
Tracheitis
-viral or bacterial -more common in males than females -clinical manifestations: toxic appearance, croupy cough, dysphonia, hoarseness, high fever, no drooling, stridor that does not improve with positioning, thick purulent secretions. -Treatments: antibiotic administration, fluids for rehydration, maintain patent airway and oxygenation, mucolytics (medications that lyse the mucus- Mucinex)
patent ductus arteriosus (PDA)
-when ductus arteriosus fails to close -may be asymptomatic -Tx= Indomethacin, NSAIDS, surgical ligation sometimes needed.
17 year old respiratory rate
12-20
10 year old respiratory rate
16-20
7 year old respiratory rate
16-22
3 year old respiratory rate
20-30
1 year old respiratory rate
25-40
Newborn respirations
30-55 breaths/min
What needs to be present in hypoplastic left heart syndrome
ASD or patent foramen ovale needs to be present for oxygenation of the blood.
Common items associated with foreign body aspiration
Foods: nuts, seeds, popcorn, raw vegetables, hot dogs, grapes, hard candy. Household items: coins, safety pins, buttons, pieces of balloons, beads, disk batteries. Toys: wheels, magnets, balls, marbles, caps off of markers or pens.
Truncus arteriosus s/s
HF, murmur, variable cyanosis, delayed growth, lethargy, fatigue, poor feeding habits
Tricuspid atresia s/s
Infants: cyanosis, dyspnea, tachycardia Older kids: hypoxemia, clubbing of the fingers
Hypovolemic shock
Loss of plasma or blood from intravascular space. Etiologies: acute diarrhea or vomiting, dehydration, hemorrhage from significant injury or surgery, diabetic ketoacidosis, burns, nephrotic syndrome, and sepsis. Administer IV fluid replacement to restore circulating volume. Use isotonic crystalloids (normal saline, lactated ringers). Rapid fluid boluses using push-pull method. Assess for signs of fluid overload before each fluid bolus. Inotropic support if unresponsive to fluid replacement.
Hypoplastic Left Heart Syndrome s/s
Mild cyanosis Heart failure Lethargy Cold hands and feet Once PDA closes, progression of cyanosis and decreased cardiac output result in eventual cardiac collapse
Cardiovascular assessment
Peripheral Vascular: color, pulse, capillary refill, skin, activity, fluid status. Cardiac: heart rhythm, adventitious breath sounds, heart sounds, chest
Bronchiolitis and Respiratory Syncytial Virus (RSV)
RSV (virus) causes bronchiolitis which is the inflammation of the bronchioles. Begins with mild cough, rhinorrhea, and congestion. Worsening symptoms after 2 days: wheezing, decreased oxygenation. Symptomatic treatment: O2 administration, suctioning, hydration, antibiotics for secondary infections.
what needs to be present in transposition of the great arteries
Septal defect or PDA must exist to oxygenate the blood
What needs to be present in Tricuspid Atresia
atrial septal opening needs to be present to allow blood to enter left atrium
pulmonary stenosis s/s
cardgiomegaly, HF, cyanosis varying on severity
Aortic stenosis s/s
hypotension, tachycardia, poor feeding, chest pain, dizziness
coarctation of the aorta s/s
increased BP and O2 saturation in upper extremities compared to lower extremities, nosebleeds, headaches, vertigo, leg pain, weak or absent lower extremity pulses notching of the ribs caused by vessels developed by collateral circulation, fainting
anytime a child's respirations are greater than 60
it is a concern; they are at a high risk for aspiration and would not be fed orally
ventricular septal defect s/s
loud harsh murmur auscultated at the left sternal border, HF
Atrial septal defect s/s
loud harsh murmur with a fixed split second heart sound heart failure, asymptomatic sometimes
Asthma is the
most common chronic condition in pediatrics
Transposition of the great arteries s/s
murmur, severe to less cyanosis, cardiomegaly, HF
#1 reason for cardiac arrest in pediatrics
respiratory arrest
Patent ductus arteriosus s/s
systolic murmur, wide pulse pressure, bounding pulses, possibly asymptomatic, HF, rales
RSV can last
up to 6 hours on hard surfaces
