Alterations in Oxygen
Transport
Chapters 24-26
By Dr. Nataliya Haliyash, MD, BSN
Oxygen Transport
Lecture Objectives
Upon completion of this lecture, you will be better
able to:
 Explain differences in the anatomy, physiology, and
functioning of the respiratory system of children and
adults.
 Describe the pathophysiology, clinical manifestations,
treatment, and nursing management of:
* common acute respiratory alterations:
nasopharyngitis, pharyngitis, tonsillitis, otitis media,
croup, bronchiolitis, and pneumonia.
* common chronic respiratory alterations: allergic
rhinitis and asthma.
* less common respiratory alterations: cystic fibrosis,
bronchopulmonary dysplasia, tuberculosis, and
sinusitis.
* additional respiratory alterations: foreign body
aspiration, smoke inhalation injury, acute respiratory
distress syndrome, and apnea.
Lecture Objectives








Explain differences in anatomy and physiology of
child's
cardiovascular system as compared to adults.
Perform an assessment of the child with heart
disease.
Describe the clinical symptoms of congestive heart
failure and identify appropriate interventions.
Identify two congenital heart lesions that increase
pulmonary blood flow.
Identify two congenital heart lesions that decrease
pulmonary blood flow resulting in cyanosis.
Describe the disorder and treatment for acute
rheumatic fever, Kawasaki disease, and infectious
endocarditis.
Identify the three forms of shock.
Shock in Children

A clinical syndrome characterized by
prostration and insufficient perfusion to
meet the metabolic demands of tissues

Hypotension is not part of the definition
in children
Shock vs. Hypotension

Shock
– State of insufficient perfusion to meet the
metabolic demands of tissues

Hypotension
– Physical sign characterized by a fall in systolic
blood pressure (BP below normal values)
– Hypotension is a late sign of shock in children and
it’s presence in children implies profound
cardiovascular compromise
Pathophysiology

Hypovolemic shock
– Hemorrhage
– Dehydration

Distributive shock
– Neurogenic / Spinal
– SIRS / Sepsis
– Anaphylaxis

Cardiogenic
– Pump failure
– Obstructive
Help!

Excuse me, I
believe that my
child is in a state
of inadequate
tissue perfusion!
Recognition of shock

Early recognition is key
– The longer you wait, the higher the
mortality!!!!

Key parameters to assess:
– L.O.C.
– Respiratory rate
– Heart rate
– Peripheral perfusion
• Skin color and temp.
• Capillary refill
Heart Rate

Tachycardia
– Above higher normal limit
• (age x 5 minus 150)
– 4yr X 5 = 20 – 150 = 130
• Too fast
– Infant > 220
– Child > 180
• Too slow
– < 60
– Sustained
– Decompensated shock
• Slowing or Bradycardia
Level of Consciousness (L.O.C.)
(Key)

Changes in L.O.C. occur early
– Irritable
– Does not interact with parents
– Stares vacantly into space
– Poor response to pain
– Asleep/sleeping a lot
• Difficult to arouse
– Unresponsive
Peripheral Perfusion (Key)


Decreased or
bounding pulses
Volume discrepancy
– Central vs peripheral
pulses
• Poor or brisk capillary
refill
• Cool or mottled or red
and warm extremities
• Decreased urine
output
Respiratory Rate

Compensated shock
– Tachypnea
• Elevated for age
• “Quiet respirations”
– Think of DKA or Hypovolemia
• Retractions
– Sepsis
• Decompensated shock
– Bradypnea or apnea
Compensated (Early) Shock

Vital organ function is maintained by
intrinsic compensatory mechanisms;
blood flow is usually normal or
increased but generally uneven or
maldistributed in the microcirculation.
Compensated (Early) Shock

Normal level of consciousness
– Agitated


Quiet tachypnea
Tachycardia
– Sustained
– Difference between central and peripheral pulses


Normal or delayed capillary refill
Normal or elevated B/P
Decompensated Shock
(with hypotension)

Efficiency of the CVS gradually
diminishes, until perfusion in the
microcirculation becomes marginal
despite compensatory adjustments.
Decompensated Shock
(with hypotension)

Altered level of consciousness
– Painful stimulation or unresponsive

Delayed capillary refill
– > 5 seconds



Hypotension
Weak central pulses, absent peripheral
pulses
Bradycardia
Hypotension

Blood Pressure
– Lowest acceptable systolic blood pressure
•
•
•
•

Birth – 1 month: 60 mmhg
1 month – 1 year: 70 mmhg
1 year – 10 year: 70 + (2 X age in years)
>10 years : 90 mmhg
Normal systolic
– 80 + (2 x age in years)
– or fiftieth percentile
Irreversible (terminal) shock

Damage to vital organs such as the
heart or brain of such magnitude that
the entire organism will be disrupted
regardless of therapeutic intervention.
Death occurs even if CV measurements
return to normal levels with therapy.
Hypovolemic shock

Hypovolemia is the usual cause of
shock in the out of hospital setting
– Most common cause is blood loss
secondary to blunt force trauma
– Vomiting and diarrhea is a second leading
cause
Septic Shock



Most common form of
distributive shock
Infectious organism or
their byproducts
(endotoxins)
Triggers an immune
response
– Vasodilation
– Increase capillary
permeability
– Maldistribution of blood

Early stage
– High cardiac output, low
vascular resistance
• Tachycardia
– Bounding pulses
• Flash capillary refill
• Flush, warm skin

Later stage
– Just like hypovolemic shock
Neurogenic

Usually the result of
either head or high
spinal cord injury
(T6)
– Disrupts sympathetic
nervous system
innervention with
blood vessels and
heart
– Uncontrolled
vasodilation

Signs and
symptoms
– Hypotension with
wide pulse pressure
– Normal heart rate or
bradycardia
– Increased respiratory
rate
– Diaphragmatic
breathing
Cardiogenic Shock

Usually a problem
with stroke volume

Manifestations
– Rate is either:
– Alteration in L.O.C.
– Trouble breathing
• Too fast
• Crackles/rales
– Inadequate time for
ventricle filling
– SVT, Atrial Fib
• Too slow
– Bradycardia
• Or not at all
– Asystole
– PEA
– Trouble feeding or
not feeding well
– Large liver
– S3 gallop
Anaphylactic
Acute multisystem
allergic response
 Can occur in seconds
or minutes
– Usually within 5 – 10
minutes of exposure



• Venodilation
• Systemic vasodilation
• Pulmonary
vasoconstriction
Signs & symptoms
 – Anxiety/agitation
 – Nausea and vomiting
 – Urticaria (hives)
 – Angioedema
 – Respiratory distress
 – Hypotension
 – Tachycardia
Nursing management

Dxs:
– Ineffective breathing pattern R/T
diminished oxygen needed for impaired
tissue perfusion
– Altered tissue perfusion R/T reduced blood
flow, decreased blood volume, reduced
vascular tone
– Altered family process R/T a child in a lifethreatening condition
Nursing management


Goals:
Inc O2 to lungs
Neck in neutral
or “sniffing”
position
– Adm O2 as prescribed, position to maintain open
airway, monitor artificial airway

Promote venous return and cardiac output
– Position flat with legs elevated
– Adm. IV fluids and plasma expander, vasopressor
and cardiotonics
– Maintain opt body tempr.
The end.
Q&A?