NURS 3311 Unit 3 Lecture Slides PDF

NURS 3311 Nursing Art and Science: Family-centered Care Pediatrics - Unit 4 Land Acknowledgement ▪Douglas College respectfully acknowledges that our campuses are located on the unceded traditional and ancestral lands of the Coast Salish Peoples, including the territories of the q̓íc̓əy̓ (Katzi...

NURS 3311 Nursing Art and Science: Family-centered Care Pediatrics - Unit 4 Land Acknowledgement ▪Douglas College respectfully acknowledges that our campuses are located on the unceded traditional and ancestral lands of the Coast Salish Peoples, including the territories of the q̓íc̓əy̓ (Katzie), qʼʷa:n̓ƛʼən̓ (Kwantlen), kʷikʷəƛ̓əm (Kwikwetlem), xʷməθkʷəy̓əm (Musqueam) and qiqéyt (Qayqayt) First Nations. 2  Unit 4 – Sepsis and Cardiovascular Variations 2024-09-17 3  Learning Objectives ▪ Differentiate between systemic inflammatory response syndrome (SIRS), sepsis, and septic shock in the pediatric population ▪ Identify signs of sepsis and septic shock in the pediatric population ▪ Review diagnostic measures for sepsis ▪ List priority foci for sepsis management ▪ Demonstrate an understanding of the hemodynamic changes that occur after birth ▪ Identify the circulation pathway of a normal heart ▪ Describe the expected consequences of increased pulmonary blood flow, decreased pulmonary blood flow, and obstruction to flow ▪ Apply pathophysiology to create an understanding of the impact of various heart defects on cardiac circulation ▪ List treatment goals for heart failure 2024-09-17 4  Neonatal Infections - Sepsis Sepsis is one of the most significant causes of neonatal morbidity and mortality. ▪Neonates have immature immune systems ▪IgM does not cross placenta ▪IgG is the only antibody to cross the placenta and in term infants is equivalent to maternal levels ▪IgG levels in preterm infants correlates with gestational age ▪Therefore neonates have limited infection fighting ability Source: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., Keenan-Lindsay, L. (2013). Maternal child nursing care in Canada. (1st ed.). Mosby: Canada.  Sepsis Sepsis Bacterial, viral, fungal Patterns Early onset (prenatal) or late onset (post- natal) Nosocomial infection—late onset ▪ Early onset sepsis (24-48hrs) rapid progression and 50% mortality rate ▪ Late onset 7-30 days ▪ Septicemia ▪ Pneumonia – one of the leading causes of perinatal death ▪ Bacterial meningitis ▪ Gastroenteritis is sporadic. Source: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., Keenan-Lindsay, L. (2013). Maternal child nursing care in Canada. (1st ed.). Mosby: Canada. 6  Sepsis ▪ Neonatal sepsis maternal risk factors -See table 29- 3 ▪ Low socioeconomic status ▪ Poor prenatal care ▪ Poor nutrition ▪ Substance use ▪ Sexually transmitted infections *Note the connection with social determinants of health Source: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., Keenan-Lindsay, L. (2013). Maternal child nursing care in Canada. (1st ed.). Mosby: Canada. 7 Sepsis ▪ Sepsis and in Neonates and Infants: ▪ Armando Hasudungan: end at 2:45 https://www.youtube.com/watch?v=S97M48mN_eA&li st=PLqTetbgey0adM_p8Xi1cJ13ICWI3Ob7MK 8 Sepsis - Definitions ▪ Sepsis – the body’s inflammatory reaction to a severe infection, a.k.a. “blood poisoning” ▪ Septecemia/Bacteremia – the infection itself (i.e. the bacteria in the blood that causes sepsis, a.k.a. bacteremia) ▪ Septic Shock - subclass of distributive shock. Abnormal distribution of blood flow in the smallest blood vessels results in inadequate blood supply to the body tissues, resulting in ischemia and organ dysfunction ▪ SIRS – systemic inflammatory response syndrome ▪ Body’s clinical response to infectious agent ▪ Non-specific (i.e. not only due to infections) can be caused by trauma or ischemia ▪ Inflammation, organ failure and/or organ dysfunction  Sepsis - Definitions Source; https://www.google.ca/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiu24uP- arOAhUBwWMKHcoOCggQjhwIBQ&url=http%3A%2F%2Fslideplayer.com%2Fslide%2F6205496%2F&bvm=bv.129391328 2024-09-17 ,d.cGc&psig=AFQjCNFk_3IQky0kocIfY-WlBUVDuOS_-g&ust=1470509544338156 10 Sepsis - Definitions ▪ Sepsis: SIRS in the presence of or as a result of suspected or proven infection ▪ Severe Sepsis: Sepsis with failure or dysfunction of at least one organ ▪ Septic Shock: Can present as either warm, cool, or cold shock: Compensation with tachycardia in an effort to increase perfusion to vital organs leads to declining compensation as evidenced by limited perfusion, altered mental status, and eventual circulatory/organ failure. Source: BCCH Guidelines for Pediatric Sepsis/Severe Sepsis Screening and Treatment  ▪ Medscape - Shock Clinical Presentation ▪ UpToDate - Children with early and life-threatening sepsis: Definitions, clinical manifestations, and diagnosis ▪ UpToDate - Pathophysiology of sepsis 2024-09-17 12  Sepsis - Assessment SEPTIC SHOCK SEPSIS SEVERE SEPSIS Severe sepsis SIRS + SIRS Sepsis Cold shock + Temp –>38.5°C or Warm shock + Acute organ 10% bands Confirmed or dysfunction HR - abnormal suspected RR - abnormal infection Source: BCCH Guidelines for Pediatric Sepsis/Severe Sepsis Screening and Treatment 2024-09-17 13 Sepsis - Assessment ▪ Sepsis Screening Source: BCCH Patient Screening for Sepsis Sepsis - Assessment Source: BCCH Patient Screening for Sepsis Sepsis - Assessment Source: BCCH Patient Screening for Sepsis BCCH Sepsis Resuscitation Bundle ▪ BC Children’s Hospital and Child Health BC (CHBC) have developed sepsis screening tools, and management algorithms to help care providers with early recognition and management to prevent mortality. ▪ Child Health BC Pediatric Sepsis Resources: ▪ CHBC Provincial Pediatric Sepsis Recognition and Management Guideline ▪ CHBC Provincial Pediatric Sepsis Screening Tool ▪ Child Health BC Pediatric Sepsis Clinical Care Algorithm ▪ Parent/Caregiver Information Booklet: When your Child has Sepsis: Information about Sepsis, Care and Recovery (English) ▪ BC CHILDREN’S HOSPITAL EMPIRIC ANTIMICROBIAL GUIDE 12TH ED ▪ Neonatal Shock Algorithm 17 Shock Shock is a syndrome that results from inadequate oxygen delivery to meet metabolic demands POOR OXYGEN DELIVERY!!!!!! Younger children primarily exhibit diminished perfusion while maintaining normal blood pressure = delayed cap refill, weak peripheral pulses, cool extremities  Three Stages Septic Shock First stage = hyperdynamic (warm) - COMPENSATED ▪ Clinical manifestations: ▪ Chills / fever ▪ vasodilation (incr CO) = warm, flushed skin ▪ TACHYCARDIA ▪ Bounding pulse ▪ BP normal ▪ U/O normal Source: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., Keenan-Lindsay, L. (2013). Maternal child nursing care in Canada. (1st ed.). Mosby: Canada.  Three Stages Septic Shock Second stage = normodynamic (cool) – DECOMPENSATION (lasts only a few hours) ▪ Clinical manifestations: ▪ Skin is cool ▪ mental state ↓ ▪ S&S of circulatory decompensation → circulatory collapse ▪ Pulses and BP are N ▪ u/o ↓ Source: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., Keenan-Lindsay, L. (2013). Maternal child nursing care in Canada. (1st ed.). Mosby: Canada.  Three Stages Septic Shock Third stage = hypodynamic (cold) - UNCOMPENSATED ▪ Clinical manifestations: ▪ hypothermia ▪ cold extremities ▪ Severe lethargy / coma ▪ weak pulses ▪ hypotension ▪ oliguria or anuria ***Multi-organ failure*** Source: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., Keenan-Lindsay, L. (2013). Maternal child nursing care in Canada. (1st ed.). Mosby: Canada. Sepsis Pathway Infection SIRS Sepsis Severe Sepsis Septic Shock (circulatory failure) MODS (Multi-organ dysfunction syndrome) Death Sepsis - Diagnosis Blood work: ▪ Cultures (should not delay abx trtmt if cannot obtain) ▪ Venous blood gas ▪ Lactate ▪ Coagulation ▪ CBC differential ▪ Electrolytes ▪ BUN ▪ Cr ▪ Glucose Other possible tests if source of infection unknown: ▪ Urine analysis, NPW for viral panel, CXR, etc Sepsis - Management Goal: ▪ Maintain or restore airway, oxygenation, ventilation, and circulation Treatment acute phase: ▪ Administer oxygen PRN ▪ Obtain venous access ▪ Fluid resuscitation - bolus ▪ Administer antibiotics Sepsis - Management Monitoring: ▪ Follow PEWS protocol ▪ Frequently monitor vital signs including temperature ▪ Monitor strict intake and output ▪ Obtain ECG or CXR as per MD orders Sepsis - Management Good oxygen delivery = good end organ perfusion Sepsis Summary ▪ Sepsis is a disease spectrum and patients can present anywhere in the process ▪ Inflammation and inflammatory mediators, for the most part, are responsible for the tissue injury seen in sepsis ▪ Management involves increasing oxygen delivery and minimizing oxygen demand ▪ Management is basic: ABC, antibiotics, fluids, and supportive measures to maintain adequate perfusion  Unit 4 – Cardiovascular Variations 2024-09-17 28 Cardiovascular ▪Heart rate decreases with age while BP increases. ▪In contrast to adults, cardiac arrest in children is rarely sudden and is usually due to a progression of respiratory distress or shock. Cardiovascular ▪The circulating blood volume of infants is about 10ml/kg greater than adults. ▪In infants and children, hypotension is a very late sign of cardiac failure. They have to lose almost ¼ of their circulating blood volume for hypotension to develop. ▪In infants and children, bradycardia is also a late sign of cardiovascular failure. Cardiovascular Tissue Perfusion Check ▪Peripheral AND central capillary refill checks taken and compared ▪In infants and small children, peripheral capillary refill assessed by pressing on the fleshy parts of the sole of the foot or the palm of the hand – not by pressing on the fingernails. ▪Temperature may affect color (flushing, mottling, pallor) and tissue perfusion (resulting in a falsely slow or falsely brisk cap refill time) ▪Acrocyanosis common in newborns. Cardiovascular Two Types of Cardiac Disorders: Congenital heart disease ▪ Anatomical: abnormal function – this will be our focus Acquired cardiac disorder ▪ Disease process ▪ Infection ▪ Autoimmune response ▪ Environmental factors ▪ Familial tendencies Consequences ▪Heart failure ▪Hypoxemia Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 32 Congenital Heart Disease (CHD) ▪Incidence: 5 to 8 per 1000 live births ▪About 2 or 3 of these are symptomatic in the first year of life ▪CHD is a major cause of death in the first year of life (after prematurity) ▪The most common anomaly is ventricular septal defect (VSD) of 35 recognized defects ▪Often children with CHD have another recognized anomaly (trisomy 21, 13, 18) Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 33 CHD Reid’s Story https://www.youtube.com/watch?v=bQyKdS-N-Co 34 Cardiovascular System The key to learning the various heart defects is to have a strong understanding of the anatomy and physiology of the normal heart. With each defect, if you know which structure is impacted, you can use your knowledge to work through how the blood would flow through the heart, given the anatomical changes, and anticipate the resulting consequences. In other words, don’t try to memorize the defects – figure out what is happening with the blood flow and you will be able to figure out the clinical manifestations you could expect! 35  Cardiovascular System To really understand CHD, we must first look at the circulatory changes that take place at birth: ▪Umbilical vein; umbilical arteries ▪Foramen ovale ▪Ductus arteriosus ▪Ductus venosus Fetal circulation videos for your own review: ▪ https://www.youtube.com/watch?v=-IRkisEtzsk ▪ https://www.youtube.com/watch?v=jFn0dyU5wUw ▪ Nursing Central app – Taber’s Medical Dictionary – Videos – Fetal Circulation Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 36  Fig. 48-1. Changes in circulation at birth. A: Prenatal circulation. B: Postnatal circulation. Arrows indicate direction of blood flow. Although four pulmonary veins enter the LA, for simplicity this diagram shows only two. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle. Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 37 Cardiovascular System Gradients: ▪Blood will always flow across a gradient from high pressure to low pressure ▪The higher the pressure gradient, the greater the rate of flow ▪Conversely, the higher the resistance, the lower the rate of flow ▪In a normal heart, there is less pulmonary resistance and more systemic resistance 38 Cardiovascular System ▪The right side of the heart pumps deoxygenated blood received from the body to the lungs ▪The right ventricles are working against relatively lower resistance ▪Whereas the left atrium receives oxygenated blood from the lungs and the left ventricle pumps it out to the body against greater systemic resistance ▪Therefore, in a normal heart, the left side is under greater pressure than the right 39 CHD Cardiovascular System ▪HEART FAILURE is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the body's metabolic demands ▪Right-sided failure - the right ventricle is unable to pump blood effectively into the pulmonary artery, resulting in increased pressure in the right atrium and systemic venous circulation. Systemic venous hypertension causes hepatosplenomegaly and occasionally edema ▪Left-sided failure - the left ventricle is unable to pump blood into the systemic circulation, resulting in increased pressure in the left atrium and pulmonary veins. The lungs become congested with blood, causing elevated pulmonary pressures and pulmonary edema. 41 CHD - Increased Pulmonary Flow Increased Pulmonary Blood Flow ▪If there is an abnormal opening between the left and right chambers (in the absence of other abnormalities) blood will flow from high to low pressure across the gradient = LEFT to RIGHT SHUNT ▪Since the right ventricle pumps blood to the lungs via the pulmonary artery, an increased volume received by this chamber results in greater blood flow to the pulmonary artery and lungs at an increased rate ▪This excess fluid going to the lungs can ultimately result in heart failure because it cannot be removed as quickly as it accumulates 42 CHD - Increased Pulmonary Flow Increased Pulmonary Flow ▪ ASD ▪ VSD ▪ PDA ASD  ASD ▪Atrial septal defect causes, symptoms, diagnosis, treatment, pathology - YouTube 2024-09-17 45 VSD VSD Ventricular septal defect (VSD) - repair, causes, symptoms & pathology - YouTube  Cardiovascular System ▪Patent Ductus Arteriosus ▪After birth, as aortic pressure increases and pulmonary pressure decreases, blood flow through a PDA in a L to R shunt ▪Oxygenated blood is recirculated to the lungs ▪This results in increased L sided workload and pulmonary vascular congestion/resistance leading to heart failure ▪In association with PS can allow blood to shunt from aorta to lungs to become oxygenated ▪In patients with certain defects a patent DA is essential in allowing blood to partially oxygenate and may be kept open using prostaglandin E until surgery in order to sustain life Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 48 PDA CHD – Obstructive Defects Obstructive Defects ▪ Coarctation of the Aorta ▪ Pulmonic Stenosis CHD – Obstructive Defects ▪Blood exiting the heart meets an area that is narrowed (stenosis) ▪Pressure is increased before the obstruction and decreased beyond ▪Increase workload on ventricle and decreased CO ▪Typically severe stenosis leads to heart failure and can result in hypoxemia / cyanosis 51 Coarctation of the Aorta Coarctation of the Aorta COARCTATION OF AORTA | Pediatrics | Causes | Pathophysiology | Symptoms | The Nures Station - YouTube Pulmonic Stenosis https://www.cincinnatichildrens.org/patients/child/ encyclopedia/defects/graphicsummaries/pvstengs Cardiovascular System ▪Any chamber that must pump against resistance can become hypertrophic over time ▪Think of it like weight-lifting; with time, your muscles get bigger ▪The walls of the heart are muscles, and with more resistance, pump harder and get thicker ▪In this case, it’s not a good thing because thicker smooth muscle is less effective at pumping blood around the circulatory system 55 Cardiovascular System Let’s simplify this ▪Decreased pulmonary blood flow = less blood gets oxygenated = potential cyanosis (depends on how much blood gets oxygenated) ▪Increased pulmonary blood flow = L →R shunt = fluid overload = heart failure ▪Obstructive impediment to blood flow from the ventricles: ▪ Left side = backs up into lungs = fluid overload = heart failure ▪ Right side = less blood gets oxygenated = heart failure, cyanosis 56 CHD Cincinnati Children’s Hospital Heart Encyclopedia has excellent resources, images and videos, including videos and 3D images of surgical repairs Browse by Category (cincinnatichildrens.org) A graphic representation of some common defects https://www.youtube.com/watch?v=tKFjmbKRuuY CHD Children’s Heart Institute Heart House has an amazing website with excellent visuals. http://thechildrensheartclinic.com/education/ Cove Point Foundation http://www.pted.org/?id=list  Cardiovascular System - Management Treatment Goals for HF: ▪Improve cardiac function ▪Remove accumulated fluid and sodium ▪Decrease cardiac demands (cluster care, limit activity, limit stress, encourage rest) ▪Improve tissue oxygenation and decrease oxygen consumption ▪Meds: ACE inhibitors, B-blockers, diuretics, digoxin, Viagra ▪Maintain nutritional status ▪Assist in measures to promote fluid loss Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 59  Cardiovascular System - Management Management of Hypoxia: ▪Increase O2 supply to tissues ▪Correct metabolic imbalances due to poor gas exchange and acid base imbalances ▪Balloon angioplasty of Valvar Pulmonary Stenosis ▪Balloon Atrial Septostomy if restrictive PFO/ASD in Tricuspid Atresia Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 60  Cardiovascular System - Management Help the family cope with stress: ▪Help the family adjust to the disorder ▪Educate the family about the disorder ▪Help the family manage the illness at home ▪Prepare the child and family for invasive procedures ▪Provide postoperative care ▪Plan for discharge and home care Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 61 Thank you douglascollege.ca