NURS 1950 Pharmacology Nancy Pares, RN, MSN Metro Community College 1.
Nancy Pares, RN, MSN Metro Community College. Discuss/review pathophysiology and nursing management...
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Nancy Pares, RN, MSNMetro Community College
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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
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Anatomy of airway Comparison of airway structures
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Upper airway differences◦ Airway diameter
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Upper airway differences◦ Position of trachea
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Upper airway differences◦ Position of right mainstem bronchus◦ Airway resistance
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Lower airway differences◦ Growth of alveoli
Diaphragm use for respirations◦ Use of accessory muscles
Immaturity of respiratory system
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Airway obstruction Blockage of airway passages by different
causes◦ Foreign-body aspiration
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Acute respiratory distress syndrome (ARDS)
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Multiple factors may cause ARDS◦ Sepsis◦ Pneumonia◦ Meconium aspiration◦ Gastric content aspiration◦ Smoke inhalation◦ Near drowing
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Dyspnea Tachypnea Grunting Nasal flaring Retractions
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Quality of pulse Quality of respirations Color Cough Behavior changes Signs of dehydration
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ABC—airway, breathing, circulation Determine if cause can be alleviated
◦ Foreign body Supportive care
◦ Supplemental oxygen
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Pulse oximetry Arterial blood gases
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Force vital capacity (FVC) Peak expiratory flow rate (PEFR)
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Forced expiratory volume in 1 second (FEVI)
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Cessation of respirations for longer than 20 seconds
Obstructive apnea Central apnea Mixed apnea Apnea of prematurity Apparent life-threatening events
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Polysomnography
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Determine baseline status of child Provide pulmonary therapies as needed Maintain oxygenation
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Increased need for calories/nutrition Increased need for fluid
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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
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Oxygenation Activity intolerance Nutrition Growth and development Treatment management Social interactions
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Most important consideration◦ Assess and reassess◦ Hypoxia leads to chronic changes◦ Permanent changes in body systems
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Activity intolerance
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Nutritional concerns◦ Need increased calories to meet body
requirements Developmental
◦ Appropriate activities and interactions
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Lack of peers for some Decreased activity tolerance Decreased age activities
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Family collaboration required◦ Plan around family, if possible
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Inherited autosomal recessive
S/S: salty taste to skin; thick, sticky mucous, stool abnormalities; huge appetite, wt maintenance
Dx: lab value of IRT
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Treatment:◦ Focus on airway maintenance, infection
prevention; GI tract therapy, nutrition
◦ Meds: pg 898◦ Story pg 901
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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
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Recall pathophysiology and nursing process of congential heart defects◦ Defects with increased pulmonary flow◦ Obstructive defects◦ Defects with decreased pulmonary flow◦ Mixed defects
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Atria Ventricles Vena cava Pulmonary artery and vein
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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
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Occurs within few hours after birth Completes at approximately days 10 to 21
with permanent closure of ductus arteriosus
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Hemodynamics change◦ Increased pulmonary blood flow◦ Decreased pulmonary vascular resistance◦ Left atrium increased blood flow
From lungs through pulmonary veins
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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
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Cardiac function Pressure gradients
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Proportionately larger in children
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Continues until puberty
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Defects that cause
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Incidence and etiology
Patho: Left to right shunting
Clinical manifestations:◦ Asymptomatic◦ CHF
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Dx◦ Continuous murmur below left clavicle◦ X ray
Treatment◦ Indomethocin for preterm only◦ Surgery◦ Non surgical closure
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Etiology
Patho: Dx: Treatment:
◦ Diuretics◦ Surgical repair
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Patho:◦ Left to right shunting◦ Heart enlargement◦ Pulmonary vessel congestion
Dx: loud holosytolic murmur Tx: may close by 2 years of age; surgery
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Common manifestations◦ Tachypnea◦ Tachycardia◦ Congestive heart failure
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Defects that cause
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Path: ◦ Obstruction of flow from RV to PA; increase RV
pressure S/S: dyspnea on exertion
Tx: surgical; balloon valvuloplasty
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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
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Common manifestations◦ Cyanosis◦ Hypercyanotic spells◦ Poor weight gain◦ Polycythemia◦ Tricuspid atresia
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Defects that cause
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Common manifestations◦ Diminished pulses◦ Pale color◦ Delayed capillary refill◦ Decreased urinary output◦ Signs of congestive heart failure
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Family-centered plan Home care and planning Assessment for complications Assessment for worsening condition Oxygenation requirements Metabolic and nutritional needs Fluid-volume balance
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Skin integrity Management of illness Medications Other therapeutic interventions Prevention of complications Family interactions Family adjustment and issues
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Immediate care◦ Intensive care unit until stable
One or more days
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Hospital management focus◦ Pain
Medications Nonmedicated management of pain
◦ Rest◦ Respiratory functions◦ Fluid balance
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Hospital management focus◦ Nutrition status◦ Discharge planning◦ Home care teaching◦ Home care follow-up◦ Long-term care and follow-up
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Etiology
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Respiratory Pulse Blood pressure Color Heart
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Fluid status Activity Behavior General
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Subtle signs◦ Early stage CHF
Advanced signs◦ Late stage CHF
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Assessment of child and family Promote oxygenation Cardiovascular function Administration of medications Growth and development Family planning Family education for home care
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Definition—born with defect
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Definition—defect related to illness◦ Infective endocarditis◦ Rheumatic fever◦ Kawasaki syndrome
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Definition—acute complex state of circulatory dysfunction
Results in failure to deliver sufficient oxygen to meet demands
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Hemorrhage Dehydration Sepsis Obstruction of blood flow Cardiac pump failure
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Early intervention to treat etiology Interventions aimed to prevent falling blood
pressure
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Digestion takes place in duodenum Enzymes aid in the digestion process
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Liver function immature at birth Enzymes deficient until 4 to 6 months old Abdominal distention from gas common
with infants Stomach capacity smaller
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Define congenital defects Define acquired defects Define infectious defects
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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
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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
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Nursing care Pre- and postoperative care
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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
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Nursing care◦ Identifying signs and symptoms of these infants
Pre- and postoperative care◦ Suction is important preoperatively◦ Care of the gastrostomy tube postoperatively
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Explain pathophysiology and nursing process for the pediatric client with physiologic disorders of the GI tract:◦ Reflux, hypertrophic pyloric stenosis, lactose
intolerance, Hirshbrungs disease
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Pyloric Stenosis◦ Definition◦ Etiology unknown◦ Hypertrophy of the circular pylorus muscle◦ Stenosis occurs between stomach and duodenum
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Nursing care Pre- and postoperative care
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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
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Nursing care Important education
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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
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Intussusception◦ Intestine invaginates into another◦ Mesentery becomes inflamed and obstruction can
occur◦ Multifactorial causes
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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
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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”
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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
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Congenital diaphragmatic hernia◦ Protrusion of abdominal contents into thoracic
cavity◦ Occurs in 4th week of gestation◦ Failure of pleuroperitoneal musculature to close
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Umbilical hernia◦ Definition◦ Etiology unknown◦ Around week 11 of gestation, the obliterated
umbilical vessels occupy the space in the umbilical ring
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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
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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
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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
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Pathophysiology of motility disorders Gastroenteritis
◦ Definition◦ Acute vs. chronic diarrhea caused by viruses,
bacteria, or parasites◦ Causes of diarrhea in children
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Celiac disease◦ Immunologic disorder; characterized by
intolerance for gluten◦ Impairs absorptive process in the small intestine◦ Affects fat absorption
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Lactose intolerance◦ Inability to digest lactose◦ Lactose enzyme deficiency◦ Usually acquired, but can be congenital
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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
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Identify pathophysiology and nursing process for the pediatric client with hepatic disorders
Analyze nutritional concepts applicable to the pediatric client with GI disorders
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Jaundice Easy bruising, intense itching White or clay-colored stools Tea-colored urine
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Hepatic disorders◦ Biliary atresia◦ Viral hepatitis◦ Cirrhosis
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Abdominal trauma◦ Blunt or penetrating trauma to the abdomen◦ Common causes
Falls Motor vehicle accidents Automobile vs. pedestrian accidents Child abuse Gunshot wounds
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Abdominal trauma◦ Organs commonly involved
Liver Spleen
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Provide emotional support Follow care orders Prevention teaching once stabilized
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Vomiting or abdominal pain Failure to thrive Stool changes
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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
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Abdominal pain Changes in appearance of stool Vomiting and/or anorexia Changes in activity Changes in level of consciousness
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Congenital defects Gastroesophageal reflux in infant vs. older
child Gastrointestinal disorders specific to this
age group
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Meckel’s diverticulum Offer age-appropriate toys Childproof the room Use pictures for education of older toddler
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Body image starts becoming important after 5 years old
Offer age-appropriate toys Use pictures for education of younger child Umbilical hernia repaired
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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