Transcript Nursing Care of the Pediatric Individual with a Respiratory Disorder

Nursing Care of the Pediatric
Individual with a Respiratory Disorder
General Aspects of Respiratory
Infections (upper and lower)
Described according to the anatomic area
However, respiratory infections rarely fall into just one
anatomic area
Spread is due to the mucous membranes lining the
entire tract
Account for the majority of acute illnesses in children
Infectious agents: Viruses, and bacterial: strep, staph,
influenzae, chlamydia pneumococci
Upper Respiratory Tract Infections
Nasopharyngitis
– Young child: fever, sneezing, vomiting or diarrhea
– Older child: dryness and irritation of nose/throat, sneezing,
aches, cough
Pharyngitis
– Young child: fever, malaise, anorexia, headaches
– Older child: fever, headache, dysphagia, abd pain
Tonsillitis
– Masses of lymphoid tissue in pairs
– Often occurs with pharyngitis
– Characterized by fever, dysphagia, or resp problems forcing
breathing to take place through nose
Nursing Care for respiratory conditions
Assess respiratory status
May need to position upright, esp. for feedings
O2 monitoring
Fluid balance
Temp control
Organize and prioritize care!
Be watchful for complications
Apnea monitors may be needed
Describing the differences between
adult and pedi client
Differences between the very young child and
the older child
Resistance can depend on many factors
Clinical manifestations: those from 6 months to 3
years of age react more severely to acute resp
tract infections
Differences in Adult and Child
Adult
Child
Let’s understand OM
A diagnosis of OM requires all of the following:
– Recent, usually abrupt onset of illness
– The presence of middle ear fluid, or “effusion”
– Signs or symptoms of middle ear inflammation
Chronic OM: hearing loss, tinnitus, vertigo
Differences between young and older child OM:
– Young child (infants) fussy, pulls at ear, anorexia, crying,
rolling head from side to side
– Older child crying, verbalizes discomfort
Understanding OM
Clinical Manifestations
What objective sign
is this child
displaying?
What does it
indicate?
Otitis media (OM)
Note the ear on the left with clear
tympanic membrane (drum); ear on the
R the drum is bulging and filled with pus
Acute Otitis Media
characterized by abrupt onset, pain, middle ear effusion, and inflammation.
Note the injected
vessels and
altered shape of
cone of light.
Evaluation and therapy
Tx has always been directed toward abx; however,
recently concerns about drug-resistant streptococcus
pneumoniae have caused medical professionals to reevaluate therapy (APA, 2004)
No clear evidence that abx improve OM
Waiting up to 72 hrs for spontaneous resolution is now
recommended in healthy infants
When abx warranted, oral amoxicillin in high dosage
TOC
Nursing Care Management for OM
Nursing objectives:
–
–
–
–
–
Relieving pain
Facilitating drainage when possible
Preventing complications or recurrence
Educating the family in care of the child
Providing emotional support to the child and
family
Preparing the child for surgery
A myringotomy or pin hole is made in the ear drum to allow fluid
removal. Air can now enter the middle ear through the ear
drum, by-passing the Eustachian tube. The myringotomy tube
prevents the pin hole from closing over. With the tubes in place,
hearing should be normal and ear infections should be greatly
reduced.
Mastoiditis
Morbidity/mortality
– Hearing loss
– Extension of the
infectious process
beyond the mastoid
system, resulting in either
intracranial complications
or extracranial
complications
Ages affected
– The incidence of
mastoiditis parallels that
of otitis media, affecting
mostly young children
and peaking in those
aged 6-13 months.
– May occur in healthy
adults as well
Nursing care for the child with mastoiditis
Monitor vital signs
Assess for changes in lab values (esp. bacterial
shifts)
Medicate aggressively with abx as ordered
(usually IV if bacterial spread to mastoid)
Drugs of choice: Timentin and Gentamicin
Assess for complications (hearing loss, tinnitus,
etc.)
Tonsillitis
Nursing Care for the Tonsillectomy
and Adenoidectomy Patient
Nursing Care for the Tonsillectomy
and Adenoidectomy Patient
Pre-operative preparation
Providing comfort and minimizing activities or
interventions that precipitate bleeding
–
–
–
–
–
–
Place on abd until fully awake
Manage airway
Monitor bleeding, esp. new bleeding
Ice collar, pain meds
Avoiding po fluids until fully awake..then liquids, soft
Post-op hemorrhage can occur
Nurse Alert for Post-Op T/A surgery
Most obvious sign of early bleeding
is the child’s continuous
swallowing of trickling blood.
While the child is sleeping,
note the frequency of
swallowing and notify
the surgeon immediately
Nurse Alert!
The nurse should remind the
child with a positive throat
culture for strep to discard their
toothbrush and replace it with a
new one after they have been
taking antibiotics for 24 hours
Manifestations of respiratory symptoms in infants and
small children
Fever (may 105° even
with mild infections; norm
for infant is 99°)
Anorexia (may be initial
finding)
Vomiting (esp small
children; usually shortlived)
Diarrhea (usually mild;
often accompanies viral
infections
Meningismus
Abd pain is common
complaint
Nasal blockage nasal
passages block
Nasal discharge starts thin,
but changes to color
Cough
Respiratory
sounds(grunting, stridor,
wheezes,crackles)
Sore throat freq c/o older
children
Assessment findings to indicate
respiratory distress
Nasal flaring
Circumoral cyanosis
Expiratory grunting
Retractions: subcostal, substernal, or lower
intercostal
Tachypnea: respiratory rate > 60
Nursing interventions for respiratory
distress
Antibiotic therapy (after cultures are done)
Respiratory treatments and medications:
albuterol, nebs, azmacort, combivent
Assess ongoing respiratory status
High Fowlers position
Fluid maintenance
Temp control
Apnea
Defined as delay of breathing over 20 seconds
Manifestations
Diagnostic tests
Therapeutic Interventions and Nursing Care
Apnea vs Periodic Breathing
Apnea:
– Cessation > 20 seconds
– S/S to assess:
•
•
•
•
Cyanosis
Marked pallor
Hypotonia
bradycardia
Periodic breathing
– Normal breathing pattern
of NB but never > 10-15
seconds
• Even though normal, all
parents are taught CPR
for their NB
SIDS
Defined: sudden death of an infant during sleep
Etiology
Assessment
Therapeutic Interventions and Nursing Care
Croup vs epiglottitis
Croup
Croup vs. Epiglottitis
Croup
–
–
–
–
–
viral
Hoarseness
Resonant cough
Stridor (inspiratory)
Risk for significant
narrowing airway with
inflammation
– Humidity for treatment
Epiglottitis
– Bacterial
– Rapidly progressive
course
– Dysphagia
– Stridor aggravated when
supine
– Drooling, high fever
– Antibiotics needed
Four D’s r/t epiglottitis
Drooling
Dysphagia
Dysphonia (difficulty talking)
Distress inspiratory effort
Medications used in the treatment of
croup and epiglottitis
Beta agonists and beta-adrenergics (albuterol,
racemic epinepherine through face mask)
Corticosteroids: not for acute attack
Antibiotics for epiglottitis
Croup tent with mist, Pulse Ox
Endotracheal tube, trach
@ bedside for epiglottitis
Nursing care for the child with croup and
epiglottitis
Observe for s/s respiratory distress
Assess respiratory rates: >60
Elevated temp ) 101º
The child must NEVER be left alone
NOTHING should be placed in the mouth
(laryngeal spasms could result)
Bronchitis vs Bronchiolitis
The diameter of an infant’s airway is approximately 4 mm,
in contrast to an adult’s airway diameter of 20 mm.
Preventive measures against RSV
Follow droplet and contact precautions (can live
up to 7 hrs on inanimate objects)
Respigam: IV RSV immune globulin (passive
immunity)
Synagis (palivizumab) given IM
Reactive Airway Disease (asthma)
Chronic inflammatory disorder affecting mast
cells, eosinophils, and T lymphocytes
Inflammation causes increase in bronchial
hyperresponsiveness to variety of stimuli
(dander, dust, pollen, etc.)
Most common chronic disease of childhood;
primary cause of school absences
Asthma, cont.
Pathophysiology
– Increased airway resistance, decreased flow rate
– Increased work of breathing
– Progressive decrease in tidal volume
Arterial pH changes: respiratory alkalosis, metabolic
acidosis
Characterized by
– Mucosal edema
– Wheezing (r/t bronchospasm)
– Mucus plugging
Asthma, cont.
Therapies:
– Medi-halers (not more than one canister/month)
– Beta-agonists: relax smooth muscle in airway
– Corticosteroids: for short term therapy
– Anticholinergic agents: Atrovent
– Preventer Medications
• Mast-cell inhibitors (Cromolyn)
• Singulair
• Inhaled steroids ( Advair, Pulmocort, Azmacort) (always rinse
mouth following administration)
Emergency situations of asthma
Acute episode of reactive disease: bronchioles may
close rapidly, causing severe airway obstruction,
anxiety, restlessness, and fear. Will need to be seen
in ER if not relieved by med
Status asthmaticus: medical emergency with severe
edema, profuse sweating, respiratory failure and
death if untreated. Becomes seriously
hypoxic…immediate intervention needed
Etiology of Acute Wheezing in an ED
setting
Patients < 2 yrs of age
– Evidence of smoke exposure
– Significant role of viral infections (RSV)
Patients > 2 yrs of age
– High incidence of allergies to dust mite, cock roach
and other inhaled allergens
– High incidence of viral respiratory infections
Goals for child with asthma
Prevention of chronic symptoms
Monitor peak expiratory flow (Peak Flow)
Prevent exacerbations
Maximize compliance to therapeutic regime
Recognize “triggers”
– Exercise
– allergens
Types of medications for asthma
“Rescue”: short acting beta agonists (albuterol)
main rescue classification
“Controller” medications: mast-cell inhibitors
(Intal), Luekotriene modifiers (Singulair), inhaled
steroids (Advair, Flonase)
“Preventer/controller” drugs: combination of
controller meds plus some inhaled steroids
(nasal)
Purpose of the MDI
Shake vigorously prior to use
Exhale slowly and completely
Place mouthpiece in mouth, closing lips around it
Press and release the med while inhaling deeply
and slowly
Hold breath for 10 seconds and exhale
Repeat x1
Interpreting Peak Expiratory Flow
Rates
Green: (80-100% of personal best) signals all clear and
asthma is under reasonably good control
Yellow (50-79% of personal best) signals caution;
asthma not well controlled; call dr. if child stays in this
zone
Red (below 50% of personal best) signals a medical
alert. Severe airway narrowing is occurring; short acting
bronchodilator is indicated
Why don’t we give bicarbonate for
respiratory acidosis?
Child not able to blow off CO2 and acidosis will
get worse
Correct the cause of the acidosis
Patient may need to be intubated
Cystic Fibrosis
Cystic Fibrosis
Cystic Fibrosis (CF)
Factor responsible for manifestations of the disease is
mechanical obstruction caused by increased viscosity of
mucous gland secretions
Mucous glands produce a thick protein that
accumulates and dilates the glands
Passages in organs such as the PANCREAS become
obstructed
First manifestation is meconium ileus in NB
Sweat chloride test
Cystic Fibrosis, cont.
Systems affected:
– Respiratory: thick mucus, inflammation, inc.
infections, atelectasis and pneumothorax
– Pancreas: obstructed pancreatic ducts by mucus
and pancreatic enzymes (trypsin lipase, amylase)
to duodenum
– GI: decrease in absorption of nutrients, fatty stools
(steatorrhea)
– Reproductive: 99% of males are sterile
Physical findings of the CF patient
Clubbing of the fingers
Barrel chest
Increased respirations, cyanosis
Productive cough
Diagnostics for CF
Sweat test: increased levels of chloride
– Normal is <40; in CF >40-60 is positive; may be 3-5X
higher
Pancreatic enzymes via stool cultures: trypsin absent
in 80% of children with CF; lipase and amylase also
absent
Planning the care for a CF child
Respiratory goal: removal of secretions (chest
physiotherapy with Thairapy vest) by vibrations loosen
mucus
Nutritional: inc. weight, enzymes with all food (Viokase
or Ultrace) dosage is regulated by evaluation of the
stool
Fat soluble vitamins ADKE
High calorie, high protein, low fat
Maintain Na balance (when sweating and ill)
Nursing Care of the CF patient
Assessing both GI and pulmonary status
Assisting with diagnostic testing
Collections of stool specimens for trypsin and
lipase (fat analyses)
Administer oxygen with great caution because of
the threat of oxygen narcosis
Implement dietary management; many have a
good appetite and some will eat excessively
Critical Thinking Exercise
Kim, a 4 year old, is admitted to the emergency
department with a sore throat, pain on
swallowing drooling, and a fever of 102.2°. She
looks ill, agitated and prefers to sit up and lean
over. What nursing interventions should the
nurse implement in this situation?
Case: 6 year old boy
Admitted to PICU from ED
Sudden onset of high fever, sore throat, and
drooling
Toxic appearing
VS: HR 140, RR 30, O2 sat 96% Temp 101.4
What’s going on here?