cha1-test 3 study guide

8/8/2019 CHA1-Test 3 Study Guide

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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.

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