pt centered care families exam 3 week 2

externalizing disorders

outward directed, disrupting behaviors that may affect executive functioning and social functioning

• oppositional defiant disorder (ODD)

• conduct disorder

• neurodevelopmental disorders ex: ADHD, autism spectrum disorder (ASD)

internalizing disorders

emotional, mood-related (sefl)

• depression and mood disorders

• anxiety disorders

• feeding and eating disorders

• trauma and stressor related disorders ex: PTSD, reactive attachment disorder

etiology and risk factors for externalizing disorders?

• genetic vulnerability

• child abuse hx

• environmental adversity

• poor family functioning

• parent w/anti-social personality, substance abuse, mood disorder, thought disorder, ADHD

• socioeconomic disadvantages may also be a factor

temperament

externalizing disorders with behaviors like…

• high anxiety

• distractibility

• high intensity

• poor reaction to new stimuli

• poor adaptability

• strong willed - negative persistence

• low sensory threshold

• negative mood

oppositional defiant disorder (ODD)

• persistent pattern (negative way!)

• resists authority - disobeys, breaks rules

• argues

• has anger outbursts

• blames others never their own fault

• behaviors may be more evident in one setting and not another

conduct disorder

• persistent pattern (negative way!)

• BREAKS LAWS - antisocial behavior

• aggressive towards people and/or animals

• destroys property

• steals

• deceives others

• may be present in adolescents w/ADHD. 

breaks laws, doesn’t just bend rules…

attention deficit disorder (ADD)

often lifelong, affects 5 million children ages 3-17, subtypes are inattentive, hyperactive/impulsive, combined

criteria for diagnosis

inattentive: to details, cannot stay on task, trouble organizing

hyperactivity: excessive compared to age expectations

impulsivity: “blurts" out answers and “interrupts”

ADD risk factors

exposure to lead or pesticides, low birth weight, premature birth, brain injury

risk of serious consequences like accidents, school or job failure, substance abuse, depression, anxiety, relationship/family stress and disruption, delinquency, etc…

autism spectrum disorder 

boys 4x more likely to be diagnosed (all ethnic groups, all socio between age 2-6 yrs, by age 3-4 for sure diagnosed)

• persistent deficits in social communication and interaction

• restricted, repetitive patterns of behavior, interests, or activities

• must be present in early developmental period

• may cause significant impairment in functioning

risk factors: older parents, genetics, environmental exposure

nursing considerations for mental health in general

• ensure safety

• provide structure

• work on coping skills and self esteem

• model social skills

nursing considerations for ADD/autism

• short clear instructions

• daily routine

• break tasks into small portions

• get child’s attention

• cue transitions

• manage stimulation (ex: fidgets, slime, glasses…)

nursing considerations ODD/CD

• teach collaborative problem-solving (can do well if supported early on!)

• set clear rules and consequences

• be nonjudgemental

• work on talking vs acting out

• de-escalation

• separate child from behaviors…

reactive attachment disorder (RAD)

affects less than 2% of children

risk factors: early trauma, removed from caregivers, multiple parent figures, neglect, institutional care

symptoms: lack of positive emotions, avoidant of eye contact/touch, tantrums/anger, limited social interactions, withdrawn…

symptoms (DSED): break rules, attention seeking, overly affectionate, poor boundaries, inappropriate social behavior

nursing considerations for RAD

at risk for…

• developmental delays

• mood disorders (anxiety, depression, PTSD, eating disorders, substance use disorder)

• school isues

• relationship issues

• risk taking

nursing approach: consistent limits, consistent approach

treatment: psychology, family therapy, social skills, educational supports, parenting skills

anxiety

most common mental health condition (more common females than males) (25.1% of children age 13-18)

• strong co-existence of depression and anxiety disorders

• physical comorbidities ie. heart disease, etc…

• 3-5 times more likely to visit the doctor and 6 times more likely to be hospitalized

anxiety and mood disorders involve what changes?

physiological, emotional changes, cognitive changes…

physiological changes in anxiety and mood disorders

• increased HR

• increased RR

• increased brain alertness

• increased muscle tone

• increased blood glucose

• increased perspiration

• increased blood volume

• increased epinephrine, NE, cortisol

• decreased GI/GU functioning

• decreased speaking

• decreased sleeping

• decreased immune functioning

• pupil dilation

emotional changes in anxiety and mood disorders

• feelings of worthlessness/helplessness/depression

• suspiciousness/jealousy

• withdrawal/decreased personal involvement

• crying/sobbing

• blaming self/others

• lack of interest

• “not themselves”

cognitive changes in anxiety and mood disorders?

• forgetful/distracted

• ruminative thoughts

• anticipatory worries

• intrusive memories

• cognitive distortions (“awfulizing”)

• lack of attention, decreased concentration

• focus on past, rather than present or future

• reduced productivity/interest/creativity

nursing considerations for mental health

biological interventions: improve sleep, reduce stimulating substances, maintain adequate diet and eating patterns

behavioral interventions: muscle relaxation and breathing, imagery/meditation, behavioral modification, behavioral activation

cognitive interventions: distraction, positive self-talk, cognitive behavioral therapy, psychoeducation

social interventions: stress and time management, family psychoeducation and/or therapy, increased social contact, group therapy…

nursing care in mental health

• ensure safety

• help pt to identify and express stressful feelings

• identify to strengthen coping and strategies

• work on self-esteem

• medication and side effect teaching

• screen for suicide (routine in many EDs and clinics from ages 8-10+ yrs. if at risk refer to social work, ensure safety, 1:1 care, and create safe room if on suicide protocol)

trauma informed care

prevention is the best form of de-escalation…

• shift judgement to “I wonder…”

• have a universal approach (trauma is hidden and prevalent)

• create safety through words and body language

• create trust/transparency

• create space

• ensure choice/voice

• strength based approach to build resilience

• be aware of warning signs (pacing, agitation, forced speech)

coronary arteries

bring oxygen-rich blood to the heart

coronary veins

return oxygen-depleted blood from the heart muscle back to the heart to be sent to the lungs

collaterals

allows blood flow from a blocked artery, protecting the heart tissue from injury

at what phase of the cardiac cycle are the coronary arteries perfused?

diastole

what is the most common congenital heart disorder?

ventricular septal defect

general post-op recommendations

airway
- ETT - where is it? secure? suction?

breathing

• ventilator settings, ABG results

circulation

• vasoactive drips

• heart rate and rhythm

• pulses, perfusion

disability

• bleeding, pain/sedation

exposure

• temperature

how are cardiac defects classified?

1. pulmonary vascularity: increased, normal, none

2. acyanotic: left to right shunts (VSD, PDA, ASD, AVSD), obstructive lesions (AS, PS, COA, cardiomyopathy), or none

3. cyanotic: admixture lesions (D-TGV, TAPVR, truncus, single ventricle lesions, none, obstruction to pulmonary blood flow + septal defects TOF, tricuspid atresia, ebstein’s malformation

what are acyanotic defects with increased pulmonary blood flow?

(left → right shunts)

• patent ductus arteriosus (PDA)

• atrial septal defect (ASD)

• ventricular septal defect (VSD)

• AVSD

patent ductus arteriosis (PDA)

• begins to constrict 10 to 15 hours after birth

• born, placenta removed, onset of respiration, PVR drops, rise in PaO2 and a fall in prostaglandin → ductus constricts

• FULLY CLOSES AT 2-4 WEEKS

doesn’t fully close because of prematurity or hypoxia…

PDA nursing considerations pre-op

• normal newborn cares

• decide on treatment plan (premature infant, larger kids)

• monitor respiratory symptoms (tachypnea, increased work of breathing…)

• failure to thrive

PDA nursing considerations post-op

• phrenic or recurrent larengeal nerve injury

• hemorrhage

• pain management

PDA cath lab care

pre: NPO time, antibacterial bath, meds taken

intra: positioning, VS monitoring, labs

post: pt MUST lay flat for 4-6 hours, pain controlled, eating/voiding

atrial septal defect (ASD)

hole in the wall separating the atrium

• creates a left to right shunt

• results in increased workload on the right heart

• small shunts do not require therapy!

ASD nursing considerations pre-op

• admission from home

• antibacterial bath

• NPO time

ASD nursing considerations post-op

• right ventricular dysfunction (arrhythmias)

• prolonged pulmonary overcirculation (pulmonary disease)

• pain

• bleeding

ventricular septal defect (VSD)

hole between the ventricles

• blood flow pathway

• increased workload on the RIGHT side of the heart

• size of defect and pressures in the lungs and body determine magnitude of symptoms

• different types of VSD based on WHERE THEY ARE IN THE VENTRICLE

VSD nursing considerations pre-op

• CHF

• pulmonary hypertension

VSD nursing considerations post-op

• arrhythmias

• pulmonary hypertension

• low cardiac output syndrome

• residual VSD

acyanotic defects that obstruct blood flow?

obstructive lesions (AS, PS, COA, cardiomyopathy)

obstructive acyanotic lesions

coarctation of the aorta

aortic stenosis

pulmonary stenosis

• increase in LV work

• no intracardiac connections

• no shunting

• PBF normal, cyanosis absent

coarctation of aorta

increased resistance to blood flow to body

left ventricle

• elevated pressure to maintain flow

• proximal to narrowing: pressures are high

• disal to narrowing: pressures are low

• collateral pathways

presentation

• cardiac collapse at birth

• as a teenager

overall goal is to prevent end organ damage

coarctation nursing considerations pre-op

infant

• monitoring for PDA to close

• difference in upper and lower extremity pulses and pressure

teenager

• probably asymptomatic

• extremely elevated BP

OR

• admission from home

• antibacterial bath

• NPO time

coarctation nursing considerations post-op

• hypertension

• post-coarctectomy syndrome

• spinal cord hypoperfusion - paralysis

cyanotic defects w/increased pulmonary vascularity

admixture lesions: D-TGV, TAPVR, truncus, single ventricle lesions

d-transposition of the great arteries

• blood flow pathway

• aorta rises from the right ventricle - no opportunity to be oxygenated in lungs

• the pulmonary artery arises from the left ventricle - no opportunity for oxygenated blood to reach the body

• the child requires intracardiac mixing to survive

d transposition pre-op considerations

• prostaglandins (PGE1) to maintain ductal patency

• monitor pre and post-ductal O2 saturations

• intracardiac shunting necessary to survive - will go to cath lab if needed

transposition post-op considerations

• cardiac output

• BP control

• pain/sedation

• monitor for myocardial infarction (MI)

• telemetry monitor

• anticoagulation

• provide coronary artery patency

total anomalous pulmonary venous return (TAPVR)

• pulmonary veins have no connection to the left side of the heart

• blood flow pathway

• results in over circulation of right side of heart and lungs and inadequate blood flow to the body

TAPVR nursing considerations pre-op

• patients are dependent on an ASD

• assess the structure of pulmonary veins - dictate timing of repair

TAPVR nursing considerations post-op

• at risk for pulmonary hypertension

• pain/sedation

• oxygenation

• at risk for low cardiac output

• bleeding

• vasoactive infusions

truncus arteriosus

• results from inadequate division of the common great vessel during fetal development

• blood flow pathway

• a single arterial trunk gives rise to pulmonary, systemic, and coronary circulations

• usually a single large truncal valve with 2-6 cusps

truncus nursing considerations pre-op

• maintain adequate but not excessive pulmonary blood flow

• room air-no increased FiO2

• lasix

• vasoactive

post-op considerations

• truncal valve insufficiency

• pulmonary hypertension

• arrhythmias

• low cardiac output syndrome

• residual pulmonary stenosis

fontan stage III

• all blood returning to the heart bypasses the heart and goes DIRECTLY TO TGE LUNGS (connects the IVC to the PA)

• the right ventricle becomes the pumping ventricle

• no pump propelling blood forward

• normal ish sats after this operation

• accomplished at 3 yrs of age

• exubate ASAP

VAD/transplant

• bridge to healing, transplant, or destination

• berlin VAD is the only pediatric approved VAD (others on teenagers)

nursing considerations: VAD safety (no cracks or clots), cardiac output, neurodevelopment

cyanotic defects w/decreased pulmonary blood flow and septal defects?

TOF, tricuspid atresia, ebstein’s malformation

tetralogy of fallot (TOF)

1. pulmonary valve stenosis or atresia and RVOT obstruction

2. right ventricular hypertrophy

3. overriding aorta

4. VSD

“PROVe” you have tetralogy

hypercyanotic or “tet” spells

increased RVOT resistance coupled w/decreased SVR:

• significantly increased R to L shunting via VSD

• precipitates hypoxemia

causes

• increased RVOT resistance: crying, stooling, feeding, noxious stimulus such as lab draws, IV starts, any stressors

decreased SVR: fever, dehydration

TOF nursing considerations 

pre op: elevate HOB, squatting knee-chest during tet spells, O2 via best tolerated means, goal sats >85%

post op: monitor for arrhythmias, temp goal of 36-36.5, bleeding, low cardiac output

heart failure

the heart muscle can’t pump enough blood to meet the body’s needs for blood and oxygen

diagnosis: CXR-enlarged heart, ECHO - normal ejection fraction is 50-70%