Nancy Pares, RN, MSNMetro Community College

Discuss/review pathophysiology and nursing management of the pediatric client with specified pulmonary conditions, including, but not limited to:◦ Upper and lower airway obstruction (1400 review)◦ Pneumonias ( 1400 review)◦ Respiratory synctial virus, asthma, cystic fibrosis,

bronchopulmonary dysplasias Discuss nutritional concepts applicable to

pulmonary pediatric disorders

Anatomy of airway Comparison of airway structures

Upper airway differences◦ Airway diameter

Upper airway differences◦ Position of trachea

Upper airway differences◦ Position of right mainstem bronchus◦ Airway resistance

Lower airway differences◦ Growth of alveoli

Diaphragm use for respirations◦ Use of accessory muscles

Immaturity of respiratory system

Airway obstruction Blockage of airway passages by different

causes◦ Foreign-body aspiration

Acute respiratory distress syndrome (ARDS)

Multiple factors may cause ARDS◦ Sepsis◦ Pneumonia◦ Meconium aspiration◦ Gastric content aspiration◦ Smoke inhalation◦ Near drowing

Dyspnea Tachypnea Grunting Nasal flaring Retractions

Quality of pulse Quality of respirations Color Cough Behavior changes Signs of dehydration

ABC—airway, breathing, circulation Determine if cause can be alleviated

◦ Foreign body Supportive care

◦ Supplemental oxygen

Pulse oximetry Arterial blood gases

Force vital capacity (FVC) Peak expiratory flow rate (PEFR)

Forced expiratory volume in 1 second (FEVI)

Cessation of respirations for longer than 20 seconds

Obstructive apnea Central apnea Mixed apnea Apnea of prematurity Apparent life-threatening events

Polysomnography

Determine baseline status of child Provide pulmonary therapies as needed Maintain oxygenation

Increased need for calories/nutrition Increased need for fluid

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

Oxygenation Activity intolerance Nutrition Growth and development Treatment management Social interactions

Most important consideration◦ Assess and reassess◦ Hypoxia leads to chronic changes◦ Permanent changes in body systems

Activity intolerance

Nutritional concerns◦ Need increased calories to meet body

requirements Developmental

◦ Appropriate activities and interactions

Lack of peers for some Decreased activity tolerance Decreased age activities

Family collaboration required◦ Plan around family, if possible

Inherited autosomal recessive

S/S: salty taste to skin; thick, sticky mucous, stool abnormalities; huge appetite, wt maintenance

Dx: lab value of IRT

Treatment:◦ Focus on airway maintenance, infection

prevention; GI tract therapy, nutrition

◦ Meds: pg 898◦ Story pg 901

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

Recall pathophysiology and nursing process of congential heart defects◦ Defects with increased pulmonary flow◦ Obstructive defects◦ Defects with decreased pulmonary flow◦ Mixed defects

Atria Ventricles Vena cava Pulmonary artery and vein

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

Occurs within few hours after birth Completes at approximately days 10 to 21

with permanent closure of ductus arteriosus

Hemodynamics change◦ Increased pulmonary blood flow◦ Decreased pulmonary vascular resistance◦ Left atrium increased blood flow

From lungs through pulmonary veins

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

Cardiac function Pressure gradients

Proportionately larger in children

Continues until puberty

Defects that cause

Incidence and etiology

Patho: Left to right shunting

Clinical manifestations:◦ Asymptomatic◦ CHF

Dx◦ Continuous murmur below left clavicle◦ X ray

Treatment◦ Indomethocin for preterm only◦ Surgery◦ Non surgical closure

Etiology

Patho: Dx: Treatment:

◦ Diuretics◦ Surgical repair

Patho:◦ Left to right shunting◦ Heart enlargement◦ Pulmonary vessel congestion

Dx: loud holosytolic murmur Tx: may close by 2 years of age; surgery

Common manifestations◦ Tachypnea◦ Tachycardia◦ Congestive heart failure

Defects that cause

Path: ◦ Obstruction of flow from RV to PA; increase RV

pressure S/S: dyspnea on exertion

Tx: surgical; balloon valvuloplasty

Ventricular septal defect; pulmonary stenosis; right ventricular hypertrophy; overriding aorta;

S/S: cyanotic vs. non cyanotic Tx: surgical correction: pre op

management; modified Blalock-Taussig shunt

Common manifestations◦ Cyanosis◦ Hypercyanotic spells◦ Poor weight gain◦ Polycythemia◦ Tricuspid atresia

Defects that cause

Common manifestations◦ Diminished pulses◦ Pale color◦ Delayed capillary refill◦ Decreased urinary output◦ Signs of congestive heart failure

Family-centered plan Home care and planning Assessment for complications Assessment for worsening condition Oxygenation requirements Metabolic and nutritional needs Fluid-volume balance

Skin integrity Management of illness Medications Other therapeutic interventions Prevention of complications Family interactions Family adjustment and issues

Immediate care◦ Intensive care unit until stable

One or more days

Hospital management focus◦ Pain

Medications Nonmedicated management of pain

◦ Rest◦ Respiratory functions◦ Fluid balance

Hospital management focus◦ Nutrition status◦ Discharge planning◦ Home care teaching◦ Home care follow-up◦ Long-term care and follow-up

Etiology

Respiratory Pulse Blood pressure Color Heart

Fluid status Activity Behavior General

Subtle signs◦ Early stage CHF

Advanced signs◦ Late stage CHF

Assessment of child and family Promote oxygenation Cardiovascular function Administration of medications Growth and development Family planning Family education for home care

Definition—born with defect

Definition—defect related to illness◦ Infective endocarditis◦ Rheumatic fever◦ Kawasaki syndrome

Definition—acute complex state of circulatory dysfunction

Results in failure to deliver sufficient oxygen to meet demands

Hemorrhage Dehydration Sepsis Obstruction of blood flow Cardiac pump failure

Early intervention to treat etiology Interventions aimed to prevent falling blood

pressure

Digestion takes place in duodenum Enzymes aid in the digestion process

Liver function immature at birth Enzymes deficient until 4 to 6 months old Abdominal distention from gas common

with infants Stomach capacity smaller

Define congenital defects Define acquired defects Define infectious defects

Describe pathophysiology and nursing management of the pediatric client with anatomic defects of the GI system◦ Cleft lip/palate, esophageal atresia, hernia,

hypertonic pyloric stenosis, intusseption

Cleft lip and cleft palate◦ Definition◦ Failure of the maxillary processes to fuse between

5 and 12 weeks’ gestation◦ Failure of the tongue to move down at the correct

time prevents the palatine processes from fusing◦ Multifactorial causes

Nursing care Pre- and postoperative care

Esophageal atresia and tracheoesophageal fistula◦ Definition◦ Foregut fails to lengthen, separate, and fuse into

two parallel tubes (esophagus and trachea) at 4 to 5 weeks’ gestation Associated with maternal polyhydramnios

Nursing care◦ Identifying signs and symptoms of these infants

Pre- and postoperative care◦ Suction is important preoperatively◦ Care of the gastrostomy tube postoperatively

Explain pathophysiology and nursing process for the pediatric client with physiologic disorders of the GI tract:◦ Reflux, hypertrophic pyloric stenosis, lactose

intolerance, Hirshbrungs disease

Pyloric Stenosis◦ Definition◦ Etiology unknown◦ Hypertrophy of the circular pylorus muscle◦ Stenosis occurs between stomach and duodenum

Nursing care Pre- and postoperative care

Gastroesophageal reflux◦ Definition◦ Three mechanisms allow reflux to occur

Lower esophageal relaxations Incompetent lower esophageal sphincter Anatomic disruption of esophagogastric junction

◦ Reflux acidity damages the esophageal mucosa◦ Causes

Nursing care Important education

Gastroschisis and omphalocele◦ Definition◦ Gastroschisis usually occurs to the right of the

umbilicus and omphalocele occurs through the umbilical cord

◦ Occurs in week 11 of gestation when abdominal contents fail to return to the abdomen

◦ Multifactorial causes

Intussusception◦ Intestine invaginates into another◦ Mesentery becomes inflamed and obstruction can

occur◦ Multifactorial causes

Volvulus◦ Occurs in 7th to 12th week of gestation◦ 1 in 6,000 live births◦ Malrotation of bowel interrupts blood flow and

causes bowel necrosis◦ Surgical emergency

Hirschsprung disease◦ Definition◦ Congenital absence of ganglion cells in the

rectum and colon◦ Genetically acquired and occurs when there is

failure of the migration of neural crest cells in utero

◦ Colon becomes a “megacolon”

Anorectal malformations◦ Anal stenosis and anal atresia◦ Failure of growth of urorectal septum, lateral

mesoderm structures, and ectodermal structures◦ Associated anomalies up to 70% of the time

Congenital diaphragmatic hernia◦ Protrusion of abdominal contents into thoracic

cavity◦ Occurs in 4th week of gestation◦ Failure of pleuroperitoneal musculature to close

Umbilical hernia◦ Definition◦ Etiology unknown◦ Around week 11 of gestation, the obliterated

umbilical vessels occupy the space in the umbilical ring

Necrotizing enterocolitis◦ Inflammatory disease producing vascular

compromise of bowel mucosa◦ More common in premature infants◦ Caused by intestinal ischemia, bacterial or viral

infection, and immature gastrointestinal mucosa

Meckel’s diverticulum◦ Omphalomesenteric duct fails to atrophy◦ Outpouching of the ileum remains and contains

gastric contents, causing ulceration◦ Bowel obstruction, perforation, or peritonitis can

occur

Inflammatory bowel disease (Crohn’s disease and ulcerative colitis)◦ Faulty regulation of the immune response of the

intestinal mucosa◦ Usually genetically triggered◦ Crohn’s disease can cause inflammation and

ulcers anywhere throughout the GI tract◦ Ulcerative colitis affects large intestine and rectal

mucosa

Pathophysiology of motility disorders Gastroenteritis

◦ Definition◦ Acute vs. chronic diarrhea caused by viruses,

bacteria, or parasites◦ Causes of diarrhea in children

Celiac disease◦ Immunologic disorder; characterized by

intolerance for gluten◦ Impairs absorptive process in the small intestine◦ Affects fat absorption

Lactose intolerance◦ Inability to digest lactose◦ Lactose enzyme deficiency◦ Usually acquired, but can be congenital

Short bowel syndrome◦ Shortened intestine resulting from bowel

resection◦ Extent of bowel loss determines severity of

disorder◦ Location of bowel resection determines type of

malabsorption

Identify pathophysiology and nursing process for the pediatric client with hepatic disorders

Analyze nutritional concepts applicable to the pediatric client with GI disorders

Jaundice Easy bruising, intense itching White or clay-colored stools Tea-colored urine

Hepatic disorders◦ Biliary atresia◦ Viral hepatitis◦ Cirrhosis

Abdominal trauma◦ Blunt or penetrating trauma to the abdomen◦ Common causes

Falls Motor vehicle accidents Automobile vs. pedestrian accidents Child abuse Gunshot wounds

Abdominal trauma◦ Organs commonly involved

Liver Spleen

Provide emotional support Follow care orders Prevention teaching once stabilized

Vomiting or abdominal pain Failure to thrive Stool changes

Excessive salivation with cyanosis, coughing, and choking in newborn◦ Esophageal atresia and tracheoesophageal fistula

Abdominal viscera outside the abdominal cavity when born◦ Gastroschisis and omphalocele

Anorectal malformations

Abdominal pain Changes in appearance of stool Vomiting and/or anorexia Changes in activity Changes in level of consciousness

Congenital defects Gastroesophageal reflux in infant vs. older

child Gastrointestinal disorders specific to this

age group

Meckel’s diverticulum Offer age-appropriate toys Childproof the room Use pictures for education of older toddler

Body image starts becoming important after 5 years old

Offer age-appropriate toys Use pictures for education of younger child Umbilical hernia repaired

Appendicitis (10 to 19 years old) Body image extremely important Allow use of phone to satisfy peer needs Give them handouts about peers with

conditions and experiences