Transcript Nursing care (Post-op)

Respiratory
Key Pediatric Differences
in the Respiratory System
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Lack of or insufficient surfactant (premature infant)
Smaller airways and underdeveloped cartilage
Tonsilar tissue enlarged
More flexible larynx
Obligatory nose breather (infant)
Less well developed intercostal muscles
Brief periods of apnea common (newborn)
Faster respiratory rate
Increased metabolic needs
Eustachian tubes relatively horizontal
Respiratory Diseases and
Disorders of Childhood
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Otitis Media
Pharyngitis
Epiglotitis
Broncholitis
Pneumonia
Asthma exacerbation
Cystic Fibrosis
Tuberculosis
Upper
Respiratory
Tract Disorders
Otitis Media (OM)
• One of the most common illnesses in infancy and
childhood
• Peak incidence: 6 months to 6 years
• Infection or blockage of the middle ear
• Acute, Chronic or Serous OM
Risks for Development of
Acute Otitis Media
• Exposure to second hand smoke
• Allergies
• Bottle fed infants
(AOM) Acute Otitis Media
• Sudden temperature
increases
• Sharp pain
• Otalgia (earache); pull
on ear, rubbing face
• Irritability
• Sleep disturbance
• Persistent crying
• Fever, vomiting,
diarrhea, anorexia
• Sudden relief and
drainage=rupture TM
Treatment
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AOM could be viral or bacterial
Acetaminophen (pain, fever)
Amoxicillin for 7-10 days if bacterial
ALTERNATIVE- wait 72 hours then treat
Serous Otitis Media or Otitis
Media with Effusion (SOM/OME)
• Result of chronic otitis
media (3 AOM in 6
months or 4 AOM in 1
year)
• Epithelial cells of
middle ear begin
producing secretions
instead of absorbing
them
Surgical Interventions
Myringotomy
• Surgical incision or laser of the tympanic membrane
• Allows mucoid material to be removed from middle
ear
Tympanostomy tubes
• Placed to equalize pressure on both sides of the
tympanic membrane, keeps ear aerated
• Allows middle ear mucosa to return to normal and
growth of the eustachian tube to continue
Patient Teaching-Post Op
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Monitor for ear drainage
Report any fever or increased pain
Avoid blowing nose for 7-10 days
Swimming, showers allowed only
with earplugs
• Diving and swimming in deep
water is prohibited
Pharyngitis (Tonsillitis)
• Inflammation and infection of the palatine tonsils
• Viral vs. Bacterial
• Peak age 4-7 years
Viral Pharyngitis
• Gradual Sore throat
• Erythema, inflammation
of pharynx and tonsils
(may be slight)
• Vesicles or ulcers on
tonsils
• Fever (usually low grade)
• Hoarseness, cough,
rhinitis, conjunctivitis,
malaise, anorexia
• Cervical lymph nodes
may be enlarged, tender
• Usually lasts 3-4 days
then resolves
spontaneously
Bacterial Pharyngitis
• Abrupt onset (may be
gradual in children
younger than 2 years)
• Sore throat (usually
severe)
• Erythema, inflammation
of pharynx and tonsils
• Fever usually high (103104F) but may be
moderate
• Abdominal pain,
headache, vomiting
• Cervical lymph nodes
may be enlarged, tender
• Requires antibiotics
Management
• Pain relief
• Rest
• Bland, soft diet
• Amoxicillin if bacterial
• Tonsillectomy is controversial
Nursing Care (Pre-op)
• Assess for current infection and bleeding
history
• Check for loose teeth
• Teach child and parent what to expect postop
o May see dried blood in mouth and teeth
o Will still be able to talk
o Pain management for optimal recovery
Nursing Care (Post-op)
• Assess for bleeding
o Elevated pulse
o Decreased BP
o Restlessness
o Frequent swallowing
o Vomiting bright red blood
• Clear, cool liquids, no red juices!
• Advance to full liquids and soft foods
on 2nd day if no sign of hemorrhage
• Pain relief (throat very sore)
Nursing care (Post-op)
• Encourage child to chew and swallow
• No straws, forks or sharp, pointed toys
• Discourage irritating the operative site
o coughing frequently
o clearing the throat
o blowing the nose
Croup
Manifestations of Croup
• Begins at night; may be preceded by
several days of symptoms of upper
respiratory tract infection
• Sudden onset of harsh, barky cough; sore
throat; inspiratory stridor; hoarseness
• Could progress into use of accessory
muscles to breathe
• Frightened appearance; agitation
• Cyanosis
• Mostly viral in nature, resolves
spontaneously
• Humidification and cold air resolves attacks
Epiglottitis
• Bacterial form of croup (H influenza) with unique
symptoms and treatment
• Bacterial infection invades tissues surrounding the
epiglottis
• Epiglottis becomes edematous, cherry red and may
completed obstruct airway
• Progresses rapidly, child is unable to swallow,
drooling
Symptoms
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May have had mild URI few days prior
Drooling
Dysphasia
Dysphonia
Distressed respiratory efforts
Tripod position: supported by arms, chin
thrust out, mouth open
ER Management
• NEVER leave child unattended
• Don’t examine or culture throat or start IV/Blood
samples
• Continuous pulse ox
• Humidified O2
• Antipyretics suppository-nothing PO
• Calm the parent! Explain what is going on…a calm
parent=calmer child!
• OR- intubation
• Throat & blood cultures done after intubation
• Usually extubated after 48h
• Antibiotics for 7-10 days
• Discharge
Nursing Interventions on unit
once stable
• Continually assess for s/s of respiratory distress
• Maintain pulse ox above 95% with PaO2 between 80100mmHg
• Maintain patent airway
• Position for comfort (never force to lie down)
• Relieve anxiety
• Monitor temp
• Administer antibiotics
Lower
Respiratory
Tract Disorders
Broncholitis
• Inflammation of the
fine bronchioles and
small bronchi
• Occurs in children
birth to 2 years
• peak age 6 months
• Highest in winter
and spring
• RSV is most
responsible
pathogen
Signs and Symptoms
• 1-2 days of URI, then suddenly symptoms become
worse
• nasal flaring
• intercostal and subcostal retractions
• wheezes, crackles or rhonchi
• increased respiratory rate
• low pulse oximetry
• tachycardia and cyanosis
Nursing Management
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Antipyretics
Semi-fowlers position
Hydration- IVF
Humidification
Oxygenation- use Blow By
Bronchdilator therapy
No antibiotics…Viral infection!
Acute phase usually lasts for 2-3 days
Watch for increased severity-can progress to airway
obstruction
Pneunomia (PN)
• Inflammation of the
alveoli usually
following an URI
• Late winter/early
spring
• Viral vs. Bacterial
Signs and Symptoms
Viral- may have mild cold symptoms
Bacterial- distinctly ill
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High fever, may be diaphoretic
Cough (productive or non productive)
Tachypnea
Abnormal BS (fine crackles, rhonchi)
Dull percussion
Chest pain
Increased respiratory effort
CXR changes
Lab findings (increased WBC)
Irritable, restless
Occasional N/V/D
Low PO intake
Ineffective Breathing Pattern:
Interventions
• Assess breath sounds, VS, respiratory status
q1-2h and PRN
• Administer humidified O2 via face mask,
obtain ABG’s, monitor pulse ox
• Administer antibiotics and antipyretics
• Perform chest physiotherapy as ordered
• Engage child in play activities
o Cough, turn, deep breathe
o Incentive spirometer
Activity Intolerance: Interventions
• Balance activity with rest periods,
cluster nursing care
• Provide small frequent meals
• Increase activity gradually
Risk for Deficient Fluid Volume:
Interventions
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Obtain baseline weight, monitor daily
Administer IV fluids as ordered
Offer fluids frequently (jello, ices, etc.)
Administer antipyretics
Monitor I&O, urine for specific gravity
increases
Tuberculosis
• Bacterial infection that multiplies in the lung tissue,
alveoli and lymph nodes
• Initially asymptomatic
• Incubation period 2-12 weeks, will test + PPD
• Immune system can ward off full development and
become dormant
• Children rarely develop active TB, but are excellent
transmitters to others
Risk Factors
• Contact with infected adults
• Chronic illness, immunosuppression, HIV
infection, malnutrition
• Young age (infancy, adolescence)
• Nonwhite racial, ethnic groups, immigrants
from areas with high incidence
• Urban, low-income living conditions
• Incarcerated adolescents
• Contact with adults from high-risk groups
Active TB Symptoms
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+PPD
Malaise
Fever
Night Sweats
Slight cough
Weight loss
Anorexia
Lymphadenopathy
Confirmed by CXR,
sputum sample, or
gastric washing
Management
Symptomatic children
• INH, rifampin and
pyrazinamide x 2
months
• Followed by INH and
rifampin x 4 months
Side effects: GI, orange
tears, urine=
noncompliance
Asymptomatic children
• INH x 9 months
• 12 months if HIV+
• Household contacts
treat for 12 weeks
Chronic Lung
Diseases
Asthma
• A reversible obstructive airway
disease
• Hypersensitivity of many cells
(Mast, Eosinophils, T Lymphocytes)
• Increased airway responsiveness
to a variety of stimuli
Asthma
• Bronchospasm resulting from constriction of bronchial
smooth muscle
• Inflammation and edema of the mucous membranes that
line the small airways and the subsequent accumulation
of thick secretions in the airways
• Initial Symptom is a Cough (w/o illness) usually at night
• Wheezing is produced when there is decreased
expiratory airflow
Asthma Severity
• Classified as
o Mild intermittent
• Symptoms < 2 x week
o Mild Persistent
• Symptoms > 2 x week, but less than once a
day
o Moderate
• Day symptoms 2 x week, 1 or more night
symptoms per week
o Severe
• Continual day symptoms, frequent night
symptoms
Triggers
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Cold air exposure
Smoke/fumes
Viral infection
Stress
Exercise
Odors (perfume)
Animal dander
Dust, cockroaches, rodents
Certain drugs (aspirin, NSAID’s)
GI reflux
Food allergens, outdoor allergens
Exacerbation Symptoms
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Chest tightness
Wheezing
Shortness of breath
Nonproductive
cough (with or
without wheezing);
later becomes
productive
• Tachypnea,
orthopnea
• Tripod position or
straight
Management of Acute Asthma
Exacerbation
• Monitor respiratory rate and effort,
color
• Provide oxygen therapy:
• warmed and humidified
• at 30-40% not 100%
• keep O2 sat > 95%; need CO2
stimulation for inhalation
Management of Acute
Asthma Exacerbation
• Administer short acting beta2 agonist
bronchodilators
o Ventolin, Proventil, Albuterol
• Administer corticosteroids
o Predinsone, Prednisolone, Solumedrol
• Monitor effectiveness of meds
• Easily fatigable
• Frequent position changes
Management of Acute
Asthma Exacerbation
• Observe for Status Asthmaticus
• Occurs when child fails to respond
to treatment (severe emergency)
• Often caused by pulmonary
infection
• Call MD!
Maintenance
Medications
• Mild Intermittent and Persistent Asthma
o anti-inflammatory corticosteroids PRN (Flovent
inhaler)
• Moderate Asthma
o anti-inflammatory corticosteroids QD (Flovent
inhaler)
o long-acting bronchodilator at HS(Theophylline,
Serevent)
Maintenance
Medications
• Severe
o oral corticosteroid qd
o inhaled corticosteroid qd
o long-acting bronchodilator HS
Discharge Planning
• Teaching self-management
o Identify triggers
o Avoidance of allergens
o May need skin testing and hyposensitization
Nebulizer
• Assess availability of home meds (proper inhaler
use and storage, nebulizer)
Teach use of Peak Flow
Meter
• Measures maximum peak
expiratory flow rate
• Need to first use when
healthy to mark baseline
• Can use to predict acute
exacerbation in kids 5-6
years and older
• Take a deep breath, blow
out hard and fast
• If peak flow is 30-50% of
child’s predicted
baseline=ER
Cystic Fibrosis (CF)
• Mutated gene on chromosome 7 CFTR
• Inherited autosomal recessive trait
• Both parents carry gene
(1/4 chance of conceiving affected child)
Cystic Fibrosis
• Chronic multisystem disorder affecting the exocrine
glands
• Affects bronchioles, small intestines, pancreatic &
bile ducts
• Usually diagnosed before 1st birthday
• Incurable
• Symptoms worsen as disease progresses
• Median life expectancy is reduced due to infections
Cystic Fibrosis
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Respiratory System
Gastrointestinal System
Reproductive System
Exocrine Glands
Respiratory System
• Wheezing, dry, non-productive cough,
repeated URI’s
• Copious, thick sputum
• Crackles, wheezes, decreased breath sounds
• Increasing signs of respiratory distress =>
emphysema & atelectesis
• Clubbing, barrel chest
Nursing Management
• Facilitate airway clearance
• Prevent pooling of secretions – postural drainage
• CPT every 4 hours (1 hour before or 2 hours after meals,
prior to bedtime)
• Forced expiration (“huffing”)
• Prevention and treatment of pulmonary infectionsaggressive IV antibiotics
• Administer bronchodilators and mucolytics
• High-humidity cool-mist tent to mobilize secretions
• If 02 is required, use low flow rate
CPT
Gastrointestional System
• Steatorrhea: frothy, foul-smelling stools 2-3 times
bulkier than normal
• Malnutrition and failure to thrive despite normal
caloric intake
• Protuberant abdomen
• Fat soluble vitamin deficiencies: K, A, D, E (caused
by inability to absorb fats)
• Meconium illeus in the newborn might be 1st sign
Nursing Management
• Well balanced diet high in calories,
protein, carbohydrates
• Pancreatic enzymes within 30 minutes of
eating all meals and snacks
Reproductive System
• Average of 2 year delay in the
development of secondary sex
characteristics
• Females have thick cervical mucus
(trouble getting pregnant)
• Some male patients sterile due to
lack of sperm
Exocrine Glands
• Abnormally high
concentrations of
sodium and chloride in
the sweat
• Sweat Test determines
amount of sodium
chloride in sweat
• Risk for electrolyte
imbalance during hot
weather
Nursing Management
• Monitor for dehydration
• Extra salt and fluid in hot weather
Dehydration
and Fluid Loss
Dehydration and Fluid
Loss
• Large portion of a child’s fluids is located in
extracellular fluid (increased BSA)
o Infants: 75-80% of the weight
o 2 year old: 60% of weight
• First two years of life kidneys are not functionally
mature
• Inefficient at excreting waste products
Dehydration and Fluid
Loss
• Fluid and electrolyte imbalances develop and
progress very quickly
• Sick children often have low PO intake and diarrhea
and vomiting =
• Infants and young children are highly susceptible to
rapid and profound fluid and electrolyte
imbalances
Types of Fluid Loss
• Sensible Fluid Loss
• Insensible Fluid Loss
Sensible Fluid Loss
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Can be measured and observed
Urine output
Drains and tubes
Emesis
Diarrhea
Insensible Fluid Loss
• Loss of fluid through lungs (2/3) and skin (1/3)
• Influenced by heat and humidity, body
temp, respiratory rate (children have higher
RR than adults)
• Basal metabolic rate increases 10% for each
degree Celsius above normal body
temperature
• Example 39 Celsius = 102.2F
o BMR increases by 20% !
Electrolytes
• NA- major electrolyte in ECF
o Needed to establish osmolarity
• K- major electrolyte in ICF
o Needed for excitability of neurons and muscles
Three Types of
Dehydration
• Isotonic
• Hypotonic
• Hypertonic
Isotonic Dehydration
• Sodium and water deficits are the same (salt and
water are lost in equal amounts in ICF and ECF)
• NA+ 130-150meq/L (normal)
• Most common type in children from low PO intake
• Can result in hypovolemic shock
Hypotonic Dehydration
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Sodium deficit is greater than the water deficit
Water moves from ECF to ICF
NA+ < 130meq/L
Results from GI losses (vomit, diarrhea)
• May result in shock
Hypertonic Dehydration
Water loss exceeds sodium loss
Body compensates with fluid shifts from ICF to ECF
NA+ > 150meq/L
May be caused by severe vomiting, too much IV
NA
• Can result in seizures
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Know the S+S of
Dehydration
• Mild
o Normal VS, moist mucous membranes,
alert, normal urine output, normal turgor,
fontanelle, normal cap refill, thirsty
• Moderate
o Rapid pulse and RR, normal BP, dry
mucous membranes, irritable, dark urine
and decreased output, poor turgor,
sunken fontanelle, delayed cap refill,
moderately thirsty
Know the S+S of
Dehydration
• Severe
• Changes in respirations depth and
pattern, rapid weak pulse, low BP,
mucous membranes parched,
can be comatose, absent urine
output, very poor turgor, sunken
fontanelle, cool skin
Monitor for Dehydration
URINE OUTPUT SHOULD BE AT MINIMUM
1 ml/kg/hr
ALL children are on I+O
Monitor labs for:
o Increased BUN
o Increased serum bicarb
o Hyponatermia
o Hyperkalemia
o Increased urine specific gravity
PREVENT dehydration
• Monitor temperature, prevent overheating
• Give frequent fluids, may need oral rehydration
(pedialyte) 50 ml/kg/ in 4 hours when febrile and GI
losses
• Use small medicine cups, syringe without needed to
administer fluids…even 1 tsp every few minutes
• Monitor IV fluid administration, ensure patent IV site
Administering IV Fluids
• Always use an infusion
pump with a volume
control device
• Prevents a sudden
extracellular fluid
volume overload
• Never use more than a
500 ml bag
• Mechanical pumps
can have faulty
performance, so check
the intravenous line,
bag, and rate often
Practice
Questions!
A teenager with chronic asthma asks the
nurse, “How come I make so much noise
when I breathe?” The nurse’s best
response is:
a. It is the sound of air passing through fluid in
your alveoli
b. It is the sound of air passing through fluid in
your bronchus
c. It is the sound of air being pushed through
narrowed bronchi on expiration
d. It is the sound of air being pushed through
narrowed bronchi on inspiration
Which school related activity might the school nurse
prohibit for a child with asthma?
a.
b.
c.
d.
Swim team
The Band
Pet “show and tell”
An art class
A toddler with cystic fibrosis is placed in a highhumidity cool-mist tent operated with
compressed air. The nurse knows the primary
reason for this therapy is to:
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d.
Provide oxygen
Lower the child’s temperature
Moisten the airway and mobilize secretions
Provide additional fluids
A preschooler with a diagnosis of
epiglottitis is admitted to the hospital.
Which MD order should the nurse question
for this child?
a. Place a pediatric size tracheostomy tray in
the room
b. Monitor pulse oxygen saturation every 15
minutes
c. Place in respiratory isolation
d. Obtain CBC and Throat Culture
When assessing a child who is suspected of
having asthma, the nurse should
specifically ask the parents about which
initial symptom that they may have noted?
a. Coughing a night in absence of respiratory
infection
b. Coughing throughout the day
c. Expiratory wheezing
d. Shortness of breath
When caring for a child who has recently
undergone a tonsillectomy, the nurse should be
aware that the child is discouraged from:
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b.
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d.
Talking and chewing
Blowing the nose
Eating lemon flavored ice pops
Taking pain medication
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b.
c.
d.
When caring for a child who has had a
tonsillectomy the nurse’s priority observation
should be for:
Coffee ground emesis
Frequent swallowing
Complaints of a sore throat
A slight increase in temperature
a.
b.
c.
d.
When assessing a child who is preverbal for otitis
media, the nurse should anticipate that the child
will:
Have difficulty swallowing
Rub the affected side of head on the mattress
Have a runny nose
Have vomiting and diarrhea
The nurse’s health care teaching to assist parents in
preventing otitis media should include instructions
to:
a. Finish the entire prescription of antibiotics
b. Administer acetaminophen to reduce pain
c. Apply warm compresses to affected ear
d. Refrain from putting the child to bed with a bottle
The nurse has admitted a child with diarrhea
for 3 days. The child’s laboratory results reveal
sodium of 126. The nurse understands this is:
1. Isotonic Dehydration
2. Hypotonic Dehydration
3. Hypertonic Dehydration.
4. Normal, the child is not dehyrated
The physician ordered pedialyte administration 50
ml/kg/ in 4 hours for a child weighing 33 lbs. Upon
awakening, the child consumed 200ml of pedialyte at
9:00 am for breakfast. How many more ml does the
child need to drink by 1 pm?
1. 1650 ml
2. 1450 ml
3. 750 ml
4. 550 ml