Pediatric O2 Norms

Fetal Circulation

There are three structures which allow most blood from the placenta to bypass the fetal lungs and liver:

Ductus venosus

Ductus Arteriosus

Foramen Ovale

At birth the organ responsible for oxygenation changes from the placenta to the lungs

Three circulatory shunts close in response to the pressure changes in the major vessels, the lungs and the heart

Functional closure occurs when the infant breathes

Ductus Venosus

A shunt that does not involve the lungs; from liver to shunt

Ductus Arteriosus

Pulmonary artery to aorta

Foramen Ovale

Opening between the right and left atrium

Ductus Ateriorosus Closure

Closes within 10-15 hours after birth and then permanently at 3 weeks

Foramen Ovale Closure

Permanently closes at 3 months

Ductus Venosus Closure

Permanently closes at 1 week

Failure of the Ductus Arteriosus and/or the Foramen Ovale to close

Will result in congenital heart defects

Growth & Development in Utero

The lungs don’t work as a fetus so only a small amount of blood is used for this 

Newborn’s first breath

The lungs should start to work

Murmur

Congenital cardiac defect as these structures have not closed as they should.

Components of Newborn Blood

Born with increased levels of red blood cells and hemoglobin

Fetal hemoglobin cells have a shorter life span than adult hemoglobin cells

The liver is the most immature GI organ

The enzyme glucuronyltransferase affects the conjugation of bilirubin by decreasing its activity, which contributes to physiologic jaundice

Jaundice

Also known as icterus, this is the yellowing of the skin, sclerae, and nails.

Physiological Hyperbilirubinemia

Occurs during the 2nd-3rd day of life, peaks on the 2nd-4th day of life and decreases beginning the 5th-7th day of life

Occurs in about 50% of full-term infants and about 80% of preemies

Bilirubin is a byproduct of Hgb breakdown and is released into the circulation, it leaves the circulation and migrates to the skin and sclera causing jaundice

Fair Skinned Infants

Pinch nose: will look orange indicating jaundice

Dark/Olive Skinned Infants

Must view the sclera of the eyes to see jaundice

Hyperbilirubinemia

Pathological jaundice – occurs within the first 24 hours and indicates a serious problem (e.g., blood incompatibility, sepsis)

Bilirubin binds to albumin, is broken down by liver enzymes and is excreted in urine and stool

High levels of bilirubin are toxic to neurons

Kernicterus – increased bilirubin levels in brain cells which leads to brain damage

Diagnostic Tests for Hyperbilirubinemia

Indirect serum bilirubin

• Elevated levels are > 12 in formula-fed infants or > 15 in breast-fed infants

• Normal 0.2-1.4mg/dl

• Increase > 5mg/dl/day

• *Evaluation is also based on: timing of appearance of jaundice, gestational age at birth, maternal Rh factor, evidence of hemolysis, feeding method and progression of serial serum levels

• Draw blood from the heel of the infant with the lights off

Nursing Interventions for Hyperbilirubinemia

Monitor color of skin, sclera and mucous membranes

Prevention:

• Early feeding promotes excretion of bilirubin

Increase formula/breastmilk intake every 2-3 hours

Provide phototherapy – infant is exposed to fluorescent light

Nursing Interventions for Phototherapy

Place infant in an isolette

Lights should be about 18” above the infant

Use a phototherapy blanket under the baby

These infants may need up to 200% additional fluid volume to compensate for any insensible and intestinal fluid loss

Only eye shields and a diaper to protect the gonads are worn

Monitor the temperature of the isolette and the infant

Prevent skin breakdown around their eyes by:

• Removing the shield frequently (when feeding/lights off) to assess for irritation, discharge and/or pressure on their lids

Monitor skin for dehydration and drying

Assess stools – expect them to be loose and greenish

Do not apply oil or lotion

Take blood samples from the heel to assess bilirubin with the lights off

Upon discharge suggest indirect sunlight

Discharged infants who left the newborn unit

They can’t return due to the possibility of hygiene safety being breached. Hygiene safety must be maintained for the other newborns arriving at the unit for the first time and for those who have not left the unit yet.

Side Effects of Phototherapy

Loose, greenish stools, transient skin rashes, mild hyperthermia, and increased metabolic rate. Dehydration and electrolyte disturbances, such as hypocalcemia, are uncommon but may still occur.

Bronze-baby syndrome: the serum, urine, and skin turn grayish-brown several hours after the infant is placed under the light. Probably caused by retention of a bilirubin breakdown product of phototherapy, possibly copper porphyrin

Double Phototherapy

A Bili blanket helps them get the treatment on their back, and they are receiving the therapy on their anterior side too.

Triple Phototherapy

A Bili blanket helps them get the therapy on their back, and they are receiving the treatment on their anterior side too, and on one of their lateral side.

Parenteral Consideration with Phototherapy

Sometimes the newborn will have to be left in the hospital, which can leave the parent/s upset

Respiratory System of the Child

They are more vulnerable to respiratory problems

Physical size and reserve capacity

Infants and children up to 2 yrs have small airway diameters — eustachian tube is straight: subject to otitis media, while adults have a curved eustachian tube

Tongue size — larger in infants/pediatric

Infants – relationship of respiratory structures

The trachea is shorter in children up to 8 years of age versus an adults trachea

Infants have cartilage around the larynx that is easily compressed

Infants are nose breathers until 4-6 weeks old, they use abdominal muscles and have irregular respirations with periods of apnea— unlike adults there is no chest rise

Thoracic breathing begins at 2-3 years of age and is complete by 7 years of age

Lack of bony structure of the ribs and chest

Underdeveloped muscles in the chest area

Infants have increased oxygen needs related to an increased metabolic rate

Pediatric patients have increased incidences of URI’s

Infants and Young Children Respiratory System

Alveoli are decreased in number and are immature

There is a decreased alveolar surface which can cause obstruction of narrow airways

Lack of collateral pathways leads to decreased ventilation beyond obstructed airways which can cause obstruction and atelectasis

Infants have an elevated respiratory rate that decreases with age

They have a decreased pulmonary reserve

Common Nursing Problems

Impaired Gas Exchange

Ineffective Breathing Pattern

Ineffective Airway Clearance

Altered Nutrition: less than body requirements

Actual/Potential Risk for Infection

Fear and/or Anxiety R/T difficulty breathing

Activity Intolerance R/T decreased oxygenation