cha1-test 3 study guide
TRANSCRIPT
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SIDS (London, Ladweig, Ball, & Bindler, pp. 1398-1400)
Definition-the sudden unexpected death of an infant under 1 year of age with onset of the fatal episode
during sleep that remains unexplained after a thorough investigation, including an autopsy, a review of the
circumstances of death and leading cause of death in infants between 1 month and 1 year of age, with
90% of cases occurring before 6 months.
A. Risk Factors
a. Race
i. Most common in Native American infants
ii. Followed by Black, Hispanic, white and Asian infants
b. Gender
i. More common in males
c. Age: most common in infants between 2 and 4 months of age
d. Time of year: more prevalent in WINTER months
e. Exposure to passive smoke
f. Sleeping arrangement
i. prone or side-lying position and turning to prone, sharing bed with others, use of pillows
and quilts with bedding
g. Overheating due to excessive blankets, clothing on infant, room temperature
B. Maternal Risk factors
a. Maternal age less than 20yrs at 1st pregnancy and a short interval between pregnancies
b. Prenatal smoking, binge alcohol, and illicit drug use
c. Anemia
d. Poor prenatal care, low weight gain during pregnancy
e. History of STDs or UTIs
C. Causes
a. No known causes, all other disease processes ruled out
D. Signs and Symptoms
a. 1st symptom= Cardiac arrest
b. Evidence of a struggle or change in position during sleep
c. Presence of frothy, blood-tinged secretions from the mouth and nares
d. Found dead in crib in am or after nap
e. Parents report no cries or disturbances during the night
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E. Prevention
a. Educate on sleep positions
i. Recommended sleep position-ON THE BACK (supine)
ii. Make sure this position is used when the infant is cared for by others
b. Use a firm mattress
c. Avoid the use of loose bedding, toys and pillows
d. Pacifier at night (per PPT)
F. Counseling (from Table 47-3 on pg 1399)
a. The nurses role is to be empathetic and provide support during one of the greatest crises a
family must face.
b. Provide parents with a private area and a support person who reinforces that the
infants death was not their fault.Parents need to be able to express their grief in their own
way and hear that they are not being blamed for the infants death.
c. Prepare the family for the viewing of the infant. Describe how the infant will look and
feel.You can say, Pauls (use the infants name) skin will feel cool. He will be very
still and his eyes will be closed. They probably know this, but a gentle explanation
demonstrates empathy. Explain that pooling of blood on the dependent areas will
look like bruises.
d. Allow parents to hold, touch, and rock the infant if desired. Viewing the infant allows
parents a chance to say good-bye. Before bringing the infant to parents, wrap in a
clean blanket, comb the hair, wash the face, swab the mouth clean, and apply
Vaseline to lips.
e. Reinforce the physicians explanation about the need for an autopsy. An autopsy is
required for all unexplained deaths. You can say to parents, It is the only way we can be sure
of what caused your babys death.
f. Answer parents questions and provide them with sources for further information.
Provide literature and a name of the local contact for a SIDS support group, as well as for the
national foundation. Parents may not be able to take in all of your answers. Many emergency
department and pediatric units have a social worker who provides ongoing contact with the
family. Provide names of resource people and phone numbers for SIDS support groups.
g. Advise parents that surviving sibling may benefit from psychologic support. Siblings
often require emotional support in the weeks and months after the death. Older
children may need reassurance that SIDS will not happen to them. They may also
believe that bad thoughts or wishes about their baby brother or sister caused the
death.
h. Provide parents with a lock of hair, footprints, and handprints, if they desire.
Personal items can be placed in a memory book. This reaffirms the childs existence
for many parents.
CROUP-LARYNGOTRACHEOBRONCHITIS (London, Ladweig, Ball, & Bindler, 2007, pp. 1400-1403)
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Definition: a broad classification of upper airway illness that result from swelling of the epiglottis and
larynx. Swelling usually extends into the trachea and bronchi.
BIG THREE pediatric respiratory illnesses-affect greatest # of children
LTB (laryngotracheobronchitits)-this is what Croup is most often used to refer too A viral invasion of the upper airway
o Extends throughout larynx, trachea, bronchi
o Barking-seal like cough
o Stridoro Rhinorrhea
o Sore thorat
Epiglottis (most life threatening-medical emergency)o Progresses rapidly-HOURS
o Bacterial cause
o High fever 102.2F
o Intense sore throat
o ^HR and RR
o Dysphagia
o Drooling
o Prefers upright position (tripod position with chin thrust)
Bacterial tracheitiso Progressive from URI
o 1-2days
o High fever -102.2 F
o Stridor
Signs and Symptoms (this refers to LTB only-which I think is all we need to know)
Tachypnea
Inspiratory STRIDOR (a high pitched, musical sound that is created by narrowing of the airway)
Seal-like barking cough
TreatmentMAINTAIN AND IMPROVE AIRWAY
Humidification/Vaporizerso Cool mist
Supplemental Oxygen when Pulse Ox
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LARYNGECTOMY(LeMone & Burke, 2008, pp.. 1255-1256)
Laryngectomy-removal of the larynx
PURPOSE Tumors localized to a portion of the larynx
Cancers that extend beyond the vocal cords
TypesPartial laryngectomy
50% or more of larynx is removed
Voice is preserved, although it may be changed
Normal speaking, breathing, and swallowing are restored
Total laryngectomy
Entire larynx is removed along with epiglottis, thryroid cartilage, several tracheal rings, and hyoidbone
Because trachea and esophagus are permanently separated by surgery- there is no risk foraspiration during swallowing
Normal speech is lost (need device to speak)
Permanent tracheostomy is createdo Tracheostomy may be removed after several weeks leaving a natural stoma or it may be left
in place permanentaly.
Teaching Teach to protect the stoma from particulate matter in the air with a gauze square or other stomaprotector.
Stress the importance of not yelling or screaming
Encourage smoking cessation
Tracheostomy stoma care and preventing respiratory infectiono Using a humidifier or vaporizer add humidity to inspired air
o Increasing fluid intake to maintain mucosal moisture and loosen secretions
o Shielding the stoma with a stoma guard, such as a gauze square on a tie around the neck, to
prevent particulate matter from entering the lower respiratory tract.o Promptly removing secretions from skin surrounding the stoma to prevent irritation and skin
breakdown.o Water sports are contraindicated with a permanent tracheostomy; there is no restriction on
other activities.o Showering and bathing are allowed; protect the stoma with a cupped hand or washcloth
Manifestations of potential complications of laryngectomy to be reported to the physician includeloss of hearing or facial expression due to auditory or facial nerve injury, or shoulder drop due todamage to the spinal accessory nerve.
ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)(LeMone & Burke, 2008, pp. 1365-1371)
Characterized by noncardiac pulmonary edema and progressive refractory hypoxemia
Severe form of Respiratory failure
Mortality rate 30-40%
What happens?
Surfactant producing cells are damaged by the inflammatory process
leading to
o a deficit of surfactant
o increased alveolar surface tension
o alveolar collapse with atelectasis
Lungs become less compliant
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Gas exchange is impaired
As ARDS progresses
Hypoxia becomes significant
Metabolic acidosis develops
Carbon dioxide exchange is impaired as well as oxygen exchange= combined respiratory and
metabolic acidosis
Leading causes of ARDS death
o Sepsiso Multiple organ system dysfunction
Kidneys
Liver
GI tract
CNS
Cardiovascular system
Causes
Shock
Trauma
Inhalation injuries
Infections
Drug overdose
Other
o Disseminated intravascular coagulation
o Pancreatitis
o Uremia
o Amniotic fluid and air emboli
o Multiple transfusions
o Open heart surgery with cardiopulmonary bypass
Near drowning Sepsis
Nervous system injury
Manifestations
Early signs
o Dyspena
o Tachypena
o Anxiety
Progressive signs
o Intercostals retractions
o Use of accessory muscleso Cyanosis
o Crackles (rales) and rhonchi
o Mental status changes
o Agitation
o Confusion
o Lethargy
Infants
o Stridor
o Retractions
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Diagnostic tests
1. Refractory hypoxemia (hypoxemia that does not improve with oxygen administration) is the hall
mark of ARDS
2. ABGs
3. Chest x-ray
4. Pulmonary function testing- shows decreased lung compliance with reduced vital capacity
5. Pulmonary artery pressure monitoring
a. Shows normal pressure in ARDSb. Helping distinguish ARDS from cardiogenic pulmonary edema
Treatment
A. Medications
a. Inhaled nitric oxide
b. Surfactant therapy
c. Corticosteriods-under investigation at this point
B. **Mechanical Ventilation**
a. Management is endotracheal intubation and mechanical ventilation with PEEP
b. Does not cure ARDS
c. Supports respiratory function while the underlying problem is identified andtreated
C. Prone positioning in conjunction with mechanical ventilation reduces the pressure of surrounding
tissue on dependent regions and improves oxygenation.
D. Careful fluid replacement
a. Carefully tailored to avoid fluid imbalances
E. Attention to nutrition
a. Enteral or parenteral feeding is necessary to maintain nutritional status and prevent tissue
catabolism
F. Treatment of any infection
a. With IV antibiotic therapy
G. Correction of the underlying condition
H. Swan-Ganz catheter line
a. Placed to monitor pulmonary artery pressures and cardiac output
I. Low-molecular-weight heparin
a. May be ordered to prevent thrombophlebitis and possible pulmonary embolus or
disseminated intravascular coagulation, a possible complication of ARDS
Nursing Dx and Interventions
Decreased Cardiac Output
Monitor and record vital signs, including apical pulse, at least every 2 hours; more frequently
immediately following initiation of mechanical ventilation or addition of PEEP.
Record urine output hourly. Because a significant portion of the cardiac output goes directly to the
kidneys, a fall in urine output to less than 30mL per hour is the first sign of decreased cardiac
output.
Assess LOC at least q4h.Altered LOC, confusion, and restlessness are early signs of cerebral
hypoxia due to decreased C/O.
Monitor pulmonary artery pressures, central venous pressures, and cardiac output reading q 1-4h.
Assess heart and lung sound frequently. Increasing crackles or abnormal heart sounds may
indicate heart failure.
Weight daily at the same time.Accurate daily weights are the best indicator of fluid volume status.
Frequently prvide good skin care.
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Maintain IV fluids as ordered. IV fluids are given to maintain vascular volume and prevent
dehydration.
Administer analgesics, sedatives, and neuromuscular blockers as needed. These medications may
be prescribed to decrease cardiac workload.
Dysfunctional Ventilatory Weaning Response
The client with dysfunctional ventilatory weaning response has difficulty adjusting to reduced mechanical
ventilator support, prolonging the weaning process.
Assessment findings indicative of dysfunctional weaning include: Dyspena, apprehension, or agitation
Decreased oxygen saturation level
Cyanosis or pallor, diaphoresis
^BP, HR, and RR
Diminished or adventitious breath sounds, use of accessory muscles
Decreased LOC
Deteriorating ABG values
Shallow, gasping breaths or paradoxic abdominal breathing.
Interventions
Assess vital signs q 15-30 minutes.
Place in Fowlers or high-Fowlers position.
Fully explain all weaning procedures, along with expected changes in breathing.Adequate
explanations help reduce anxiety and improve the ability to cooperate.
Remain with the client during initial periods following changes of ventilator setting or T-piece trials.
Limit procedures and activities during weaning periods.
Provide diversion, such as television or radio. Diversion helps distract the focus from breathing.
Begin weaning procedures in the morning, when the client is well rested and alert; weaning may be
discontinued overnight to provide rest.
Avoid administering drugs that may depress respirations during the weaning process (except as
ordered at night to facilitate rest when ventilator support is provided). Sedatives or analgesics that
depress respirations can impair the weaning process. Keep oxygen at the bedside following weaning and extubations.
Provide pulmonary hygiene with percussion and postural drainage. Maintaining patent airways and
adequate alveolar ventilation is vital during the weaning process.