NURS 2410 Unit 8 and 9 plus cardiac

1. NURS 2410 Unit 8 and 9 plus cardiac Nancy Pares, RN, MSN Metro Community College

2. Pediatric Respiratory System Anatomy and Physiology Variances from the Adult • Anatomy of airway • Comparison of airway structures

3. Figure 25-1 It is easy to see that a child’s airway is smaller and less developed than an adult’s airway, but why is this important? The infant and child are more vulnerable to the consequences of an upper respiratory tract infection, enlarged tonsils and adenoids, an allergic reaction, positioning of the head and neck during sleep, and small objects that can be aspirated. All can cause an airway obstruction that results in respiratory distress.

4. Pediatric Respiratory System Anatomy and Physiology Variances from the Adult • Upper airway differences • Airway diameter

5. Figure 25-3 The diameter of an infant’s airway is approximately 4 mm, in contrast to an adult’s airway diameter of 20 mm. An inflammatory process in the airway causes swelling that narrows the airway, and airway resistance increases. Note that swelling of 1 mm reduces the infant’s airway diameter to 2 mm, but the adult’s airway diameter is only narrowed to 18 mm. Air must move more quickly in the infant’s narrowed airway to get the same amount of air to the lungs. The friction of the quickly moving air against the side of the airway increases airway resistance. The infant must use more effort to breathe and breathe faster to get adequate oxygen.

6. Pediatric Respiratory System Anatomy and Physiology Variances from the Adult • Upper airway differences • Position of trachea

7. Figure 25-2 In children, the trachea is shorter and the angle of the right bronchus at bifurcation is more acute than in the adult. Where is an aspirated foreign body likely to land? When you are resuscitating or suctioning, you must allow for the differences in the length of the trachea because it is easier to slip into the right bronchus with an endotracheal tube or suction catheter.

8. Pediatric Respiratory System Anatomy and Physiology Variances from the Adult • Upper airway differences • Position of right mainstem bronchus • Airway resistance

9. Pediatric Respiratory System Anatomy and Physiology Variances from the Adult • Lower airway differences • Growth of alveoli • Diaphragm use for respirations • Use of accessory muscles • Immaturity of respiratory system

10. Respiratory Conditions and Injuries That Can Cause Respiratory Distress in Infants and Children • Airway obstruction • Blockage of airway passages by different causes • Foreign-body aspiration

11. Figure 25-5 An aspirated foreign body (coin) is clearly visible in the child’s trachea on this chest radiograph.Source: Courtesy of Rockwood Clinic, Spokane, WA.

12. Respiratory Conditions and Injuries That Can Cause Respiratory Distress in Infants and Children • Acute respiratory distress syndrome (ARDS)

13. Figure 25-7 A ventilation-perfusion mismatch can occur when an infant or child has an abnormal distribution of ventilation or perfusion. A, Children with normal lung function and circulation have a ventilation-perfusion ratio of 0.8 to 0.9 because perfusion is greater than ventilation (air exchange) in the lung bases. B, When ventilation is inadequate to well-perfused areas of the lungs, the ventilation-perfusion ratio is low or mismatched, resulting in shunting. Blood passing through the pulmonary capillaries gets less oxygen exchange than normal, and hypoxemia occurs. This is the case in asthma due to bronchoconstriction and in pneumonia because alveoli are filled with fluid. C, In the case of neonatal hyaline membrane disease the alveoli are collapsed, so blood passes through the alveolar capillaries and no oxygenation occurs. The ventilation-perfusion ratio is very low with significant shunting that does not respond to oxygen therapy because the capillary bed never gets exposed to the supplemental oxygen.

14. Respiratory Conditions and Injuries That Can Cause Respiratory Distress in Infants and Children • Multiple factors may cause ARDS • Sepsis • Pneumonia • Meconium aspiration • Gastric content aspiration • Smoke inhalation • Near drowing

16. Clinical Manifestations of Respiratory Distress • Dyspnea • Tachypnea • Grunting • Nasal flaring • Retractions

17. Figure 25-4 The chest wall is flexible in infants and young children because the chest muscles are immature and the ribs are cartilaginous. With respiratory distress, the negative pressure created by the downward movement of the diaphragm to draw in air is increased, and the chest wall is pulled inward causing retractions. Intercostal retractions are seen in mild respiratory distress. As the severity of respiratory distress increases, retractions can be seen in the substernal and subcostal areas. In cases of severe distress, accessory muscles (sternocleidomastoid and trapezius muscles) are used, and retractions are seen in the supraclavicular and suprasternal areas.

18. Assessment of Respiratory Status • Quality of pulse • Quality of respirations • Color • Cough • Behavior changes • Signs of dehydration

19. Nursing Care • ABC—airway, breathing, circulation • Determine if cause can be alleviated • Foreign body • Supportive care • Supplemental oxygen

20. Diagnostic Tests to Determine Oxygen Saturation • Pulse oximetry • Arterial blood gases

22. Figure 25-10 The phrase “thumb sign” has been used to describe this enlargement of the epiglottis. Recall the trachea’s usual “little finger” size. Do you see the stiff, enlarged “thumb” above it in this lateral neck radiograph?

23. Pulmonary Function for Chronic Conditions • Force vital capacity (FVC) • Peak expiratory flow rate (PEFR)

25. Pulmonary Function for Chronic Conditions • Forced expiratory volume in 1 second (FEVI)

26. Apnea in Infants and Children • Cessation of respirations for longer than 20 seconds • Obstructive apnea • Central apnea • Mixed apnea • Apnea of prematurity • Apparent life-threatening events

27. Apnea Monitors • Polysomnography

28. Respiratory Assessment • Determine baseline status of child • Provide pulmonary therapies as needed • Maintain oxygenation

29. Increased Metabolic Activity • Increased need for calories/nutrition • Increased need for fluid

30. Anxiety and Fear Common • Psychosocial support for parent • Psychosocial support for child • Discharge Planning • Education about duration of illness • Need for follow up • When to seek emergency care • Home care planning • Education to parents

31. Nursing Considerations for Chronic Respiratory Conditions • Oxygenation • Activity intolerance • Nutrition • Growth and development • Treatment management • Social interactions

32. Oxygenation • Most important consideration • Assess and reassess • Hypoxia leads to chronic changes • Permanent changes in body systems

33. Figure 25-18 Digital clubbing.

34. Oxygenation • Activity intolerance

35. Growth and Development • Nutritional concerns • Need increased calories to meet body requirements • Developmental • Appropriate activities and interactions

36. Social Interactions • Lack of peers for some • Decreased activity tolerance • Decreased age activities

37. Treatment Management • Family collaboration required • Plan around family, if possible

38. Cystic Fibrosis • Inherited autosomal recessive • S/S: salty taste to skin; thick, sticky mucous, stool abnormalities; huge appetite, wt maintenance • Dx: lab value of IRT

39. Treatment: • Focus on airway maintenance, infection prevention; GI tract therapy, nutrition • Meds: pg 898 • Story pg 901

40. Broncho pulmonary dysplasia • 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

41. Anatomy of Heart • Atria • Ventricles • Vena cava • Pulmonary artery and vein

42. Hemodynamics of Heart (Circulatory System) • 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

43. Transition from Fetal to Pulmonary Circulation • Occurs within few hours after birth • Completes at approximately days 10 to 21 with permanent closure of ductus arteriosus

45. Transition from Fetal to Pulmonary Circulation • Hemodynamics change • Increased pulmonary blood flow • Decreased pulmonary vascular resistance • Left atrium increased blood flow • From lungs through pulmonary veins

46. Figure 26-4 The arrows indicate the flow of blood through the heart while the color indicates the level of oxygen saturation in the blood. A, Fetal (prenatal) circulation. B, Pulmonary (postnatal) circulation. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

47. Transition from Fetal to Pulmonary Circulation • 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

48. Normal Hemodynamics of Heart • Cardiac function • Pressure gradients

49. Figure 26-1 Normal pressure gradients and oxygen saturation levels in the heart chambers and great arteries. The ventricle on the right side of the heart has a lower pressure during systole than the left ventricle because less pressure is needed to pump blood to the lungs through the rest of the body.

50. Heart Size • Proportionately larger in children