Alterations in Alterations in Oxygen TransportOxygen Transport

Chapters 24-26

By Dr. Nataliya Haliyash, MD, BSN

Oxygen TransportOxygen Transport

Lecture ObjectivesUpon completion of this lecture, you will be better

able to: Explain differences in the anatomy, physiology, and

functioning of the respiratory system of children and adults.

Describe the pathophysiology, clinical manifestations, treatment, and nursing management of:* common acute respiratory alterations:

nasopharyngitis, pharyngitis, tonsillitis, otitis media, croup, bronchiolitis, and pneumonia.

* common chronic respiratory alterations: allergic rhinitis and asthma.

* less common respiratory alterations: cystic fibrosis, bronchopulmonary dysplasia, tuberculosis, and sinusitis.

* additional respiratory alterations: foreign body aspiration, smoke inhalation injury, acute respiratory distress syndrome, and apnea.

Lecture Objectives Explain differences in anatomy and physiology of

child's cardiovascular system as compared to adults. Perform an assessment of the child with heart

disease. Describe the clinical symptoms of congestive heart

failure and identify appropriate interventions. Identify two congenital heart lesions that increase

pulmonary blood flow. Identify two congenital heart lesions that decrease

pulmonary blood flow resulting in cyanosis. Describe the disorder and treatment for acute

rheumatic fever, Kawasaki disease, and infectious endocarditis.

Identify the three forms of shock.

Shock in ChildrenShock in Children

A clinical syndrome characterized by prostration and insufficient perfusion to meet the metabolic demands of tissues

Hypotension is not part of the definition in children

Shock vs. Hypotension

Shock – State of insufficient perfusion to meet the

metabolic demands of tissues Hypotension

– Physical sign characterized by a fall in systolic blood pressure (BP below normal values)

– Hypotension is a late sign of shock in children and it’s presence in children implies profound cardiovascular compromise

Pathophysiology Hypovolemic shock

– Hemorrhage– Dehydration

Distributive shock– Neurogenic / Spinal– SIRS / Sepsis– Anaphylaxis

Cardiogenic– Pump failure– Obstructive

Help!

Excuse me, I believe that my child is in a state of inadequate tissue perfusion!

Recognition of shock Early recognition is key

– The longer you wait, the higher the mortality!!!!

Key parameters to assess:– L.O.C.– Respiratory rate– Heart rate– Peripheral perfusion

• Skin color and temp.• Capillary refill

Heart Rate Tachycardia

– Above higher normal limit• (age x 5 minus 150)

– 4yr X 5 = 20 – 150 = 130• Too fast

– Infant > 220– Child > 180

• Too slow– < 60

– Sustained– Decompensated shock

• Slowing or Bradycardia

Level of Consciousness (L.O.C.) (Key)

Changes in L.O.C. occur early– Irritable– Does not interact with parents– Stares vacantly into space– Poor response to pain– Asleep/sleeping a lot

• Difficult to arouse

– Unresponsive

Peripheral Perfusion (Key)

Decreased or bounding pulses

Volume discrepancy– Central vs peripheral

pulses• Poor or brisk capillary

refill• Cool or mottled or red

and warm extremities• Decreased urine

output

Respiratory Rate

Compensated shock– Tachypnea

• Elevated for age• “Quiet respirations”

– Think of DKA or Hypovolemia

• Retractions

– Sepsis• Decompensated shock

– Bradypnea or apnea

Compensated (Early) Shock

Vital organ function is maintained by intrinsic compensatory mechanisms; blood flow is usually normal or increased but generally uneven or maldistributed in the microcirculation.

Compensated (Early) Shock

Normal level of consciousness– Agitated

Quiet tachypnea Tachycardia

– Sustained– Difference between central and peripheral pulses

Normal or delayed capillary refill Normal or elevated B/P

Decompensated Shock (with hypotension)

Efficiency of the CVS gradually diminishes, until perfusion in the microcirculation becomes marginal despite compensatory adjustments.

Decompensated Shock (with hypotension)

Altered level of consciousness– Painful stimulation or unresponsive

Delayed capillary refill– > 5 seconds

Hypotension Weak central pulses, absent peripheral

pulses Bradycardia

Hypotension

Blood Pressure– Lowest acceptable systolic blood pressure

• Birth – 1 month: 60 mmhg• 1 month – 1 year: 70 mmhg• 1 year – 10 year: 70 + (2 X age in years)• >10 years : 90 mmhg

Normal systolic– 80 + (2 x age in years) – or fiftieth percentile

Irreversible (terminal) shock

Damage to vital organs such as the heart or brain of such magnitude that the entire organism will be disrupted regardless of therapeutic intervention. Death occurs even if CV measurements return to normal levels with therapy.

Hypovolemic shock

Hypovolemia is the usual cause of shock in the out of hospital setting– Most common cause is blood loss

secondary to blunt force trauma– Vomiting and diarrhea is a second leading

cause

Septic Shock

Most common form of distributive shock

Infectious organism or their byproducts (endotoxins)

Triggers an immune response– Vasodilation– Increase capillary

permeability– Maldistribution of blood

Early stage– High cardiac output, low

vascular resistance• Tachycardia

– Bounding pulses• Flash capillary refill• Flush, warm skin

Later stage– Just like hypovolemic shock

Neurogenic

Usually the result of either head or high spinal cord injury (T6)– Disrupts sympathetic

nervous system innervention with blood vessels and heart

– Uncontrolled vasodilation

Signs and symptoms– Hypotension with

wide pulse pressure– Normal heart rate or

bradycardia– Increased respiratory

rate– Diaphragmatic

breathing

Cardiogenic Shock

Usually a problem with stroke volume– Rate is either:

• Too fast– Inadequate time for

ventricle filling– SVT, Atrial Fib

• Too slow– Bradycardia

• Or not at all– Asystole– PEA

Manifestations– Alteration in L.O.C.– Trouble breathing

• Crackles/rales

– Trouble feeding or not feeding well

– Large liver– S3 gallop

Anaphylactic

Acute multisystem allergic response

Can occur in seconds or minutes– Usually within 5 – 10

minutes of exposure

• Venodilation • Systemic vasodilation • Pulmonary

vasoconstriction

Signs & symptoms – Anxiety/agitation – Nausea and vomiting – Urticaria (hives) – Angioedema – Respiratory distress – Hypotension – Tachycardia

Nursing management

Dxs: – Ineffective breathing pattern R/T

diminished oxygen needed for impaired tissue perfusion

– Altered tissue perfusion R/T reduced blood flow, decreased blood volume, reduced vascular tone

– Altered family process R/T a child in a life-threatening condition

Nursing management

Goals: Inc O2 to lungs

– Adm O2 as prescribed, position to maintain open airway, monitor artificial airway

Promote venous return and cardiac output– Position flat with legs elevated– Adm. IV fluids and plasma expander, vasopressor

and cardiotonics– Maintain opt body tempr.

Neck in neutral Neck in neutral or “sniffing” or “sniffing”

positionposition

The end.The end.

Q & A ?Q & A ?