Transcript Respiratory - Pediatric Nursing

Respiratory Disorders
Jan Bazner-Chandler
CPNP, CNS, MSN, RN
Respiratory
Bifurcation of trachea
Change in chest wall shape
Upper Airway Characteristics
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Narrow tracheo-bronchial lumen until age 5
Tonsils, adenoids, epiglottis proportionately
larger in children
Tracheo-bronchial cartilaginous rings
collapse easily
Lower Airway Characteristics
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Fewer alveoli in the neonate
Poor quality of alveoli until age 8
Lack of surfactant that lines the alveoli in the
premature infant
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Inhibits alveolar collapse at end of expiration
Respiratory Characteristics
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Basal metabolic rate is greater thus greater
oxygen consumption
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Immunoglobulin G (IgG) levels reach low
point around 5 months of age
Focused Physical Assessment
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Types of breathing:
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Less than 7 years abdominal breathing
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Greater than 7 years abdominal breathing can
indicate problems
Respiratory Rate
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Inspiratory phase slightly longer or equal to
expiratory phase
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Prolonged expiratory phase = asthma
Prolonged inspiratory phase = upper airway
obstruction
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Croup
Foreign body
Color
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Observe color of face, trunk, and nail beds
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Cyanosis = inadequate oxygenation
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Clubbing of nails = chronic hypoxemia
Respiratory Distress
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Grunting = impending respiratory failure
Severe retractions
Diminished or absent breath sounds
Apnea or gasping respirations
Poor systemic perfusion / mottling
Tachycardia to bradycardia = late sign
Decrease oxygen saturations
Chest Muscle Retraction
Chest Retractions
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Retractions suggest an obstruction to
inspiration at any point in the respiratory tract.
As intrapleural pressure becomes
increasingly negative, the musculature “pulls
back” in an effort to overcome the blockage.
The degree and level of retraction depend on
the extent and level of the obstruction.
Diagnostic Tests
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Detects abnormalities of chest or lungs
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Chest x-ray
Sweat chloride Test
MRI
Laryngoscope / bronchoscopy
CT Scan
White Patchy Infiltrates
X-ray Hyperinflation of Lung
Vh.org
Pleural Effusion
Pleural Effusion X-Ray
vh.org
Sweat Chloride Test
•Analysis of sodium and chloride
•Contents in sweat
•Gold Standard for diagnosis
•May do genetic screening earlier
if positive family history
Ball & Bindler
Foreign Body Aspiration
A foreign body in one
or the other of the bronchi
causes unilateral
retractions.
*usually the right due to
broader bore and more
vertical placement.
Oxygen Therapy: Nursing Interventions
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Proper concentration
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Adequate humidity: make sure there is fluid in the bottle
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Make sure prongs are in nose and that the nares are patent –
suction out nares to increase oxygen flow
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Monitor oxygen SATS: if alarm keeps on going off but the infant /
child looks good, check the device
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Monitor activity level or infant / child
Aerosol Therapy
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Respiratory Therapist will do the treatment
Communicate with therapist – eliminated
needless paging for treatments
Treatment should be done before the infant
eats
When you make your morning rounds assess
if there is any infant / child that needs an
immediate treatment
Home Teaching Inhaled Medications
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Correct dosage
Prescribed time
Proper use of inhaler
No OTC drugs
Encourage fluids
When to call physician
Aerosol Therapy
Medication
administered
by oxygen or
compressed
air.
Ball & Bindler
Nebulizer - infant
Outpatient Aerosol Treatment
CPT
CPT
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In the small child you can position on your lap
Do first thing in the AM
Do before meals or one hour after
Do after the aerosol treatment since the
treatment will help open the airways and
loosen the mucous
Suction the infant after treatment – teach
parents to do bulb suction – RN, LVN or RT to
deep suction prn
Mechanical Ventilation
Alterations in Respiratory Function
Severe Respiratory Distress
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Nasal flaring and grunting
Severe retractions
Diminished breath sounds
Hypotonia
Decreased oxygen saturations
What to do if infant / child in respiratory
distress!
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Stimulate the infant / child - remember crying or
activity will help mobilize secretions and expand
lungs
Have the older child sit up take deep breaths and
cough
CPT to loosen secretions and suction! suction!
suction!
Give oxygen
Assess if interventions work
Call for help if you need it – pull the emergency cord
– yell for help
Allergic Rhinitis
Symptoms
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Itching of nose, eyes, and throat
Sneezing and stuffiness
Watery nasal discharge / post nasal drip
Watery eyes
Swelling around the eyes
Rhinitis Treatment
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Antihistamines
Competitive inhibitors for histamine at the
mast cell receptor sites
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Benadryl – OTC medication
Prescription –Cromolyn or steroid nasal spray
Environmental changes - avoidance of allergens
Do not use combination OTC medications
especially those that contain pseudoephedrine
Sinusitis
Sinuses not fully developed
until age 12.
Adam.com
Sinuses are hollow cavities within the facial bones.
Sinusitis Symptoms
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Fever
Purulent rhinorrhea
Pain in facial area
Malodorous breath
Chronic night-time cough
Children more prone to sinusitis: children with asthma
and cystic fibrosis.
Treatment
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Normal saline nose drops
Warm pack to face
Acetaminophen for pain
Increase po fluid intake
Antibiotics
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Recent studies question their effectiveness
Tonsillitis
“Kissing tonsils” occur when the tonsils
are so enlarged they touch each other.
Tonsillitis
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Inflammation of the tonsils.
Part of the immune system to trap and kill
bacteria and viruses traveling through the
body.
Tonsillitis
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Child may refuse to drink
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Night snoring = enlarged tonsils or adenoids
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Size of tonsils are obstructing airway
Treatment
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Antibiotics x ten days if positive for beta strep
Acetaminophen for pain
Cool fluids
Saline gargles
Antiseptic sprays
Viral throat infections will not get better faster
with antibiotics.
Tonsillectomy
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Done if child’s respiratory status is
compromised
Post operative care:
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Side lying position
Ice collar
Watch for swallowing
Cool fluids / soft diet
Croup
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Laryngotracheobronchitis or Acute spasmotic
croup
Infants from 3 months to about 3 years
Respiratory symptoms are caused by
inflammation of the larynx and upper airway,
with resultant narrowing of the airway.
Symptoms
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Symptoms:
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Hoarseness
Inspiratory stridor
Barking cough
Afebrile
Often worsens at night
Management
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Home care:
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Cool mist
Fluids
Hospital care:
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Racemic epinephrine inhalant
Mist tent – not used much anymore
Dexamethasone: IV over 1 to several minutes
Pertussis or whooping cough
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Agent: Bordetella Pertussis
Source: respiratory
Transmission: droplet
Incubation: 10 days
Period of communicability: before onset of
paroxysms to 4 weeks after onset
Management
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Respiratory support as needed
Suctioning
Oxygen to keep oxygen saturation at > 98 %
Nutritional support
IV fluids
Erythromycin, Zithromax or Biaxin for child
and all exposed family members
Isolation Precautions
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Transmission through direct contact with
discharges from respiratory mucous of
infected persons.
Highly contagious with up to 90% of
household contacts developing disease after
contact.
Respiratory and contact isolation for 3-4 days
after the initiation of antibiotic therapy.
Epiglottitis
Bowden & Greenberg
Tripod position
Epiglottitis Symptoms
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Acute inflammation of supra-glottic
structures.
Medical Emergency
Sudden onset
High fever
Dysphasia and drooling
Epiglottis is cherry red and swollen
Epiglottitis
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Has decreased dramatically since
introduction of the Haemophilus influenzae
type b or Hib vaccine in 1985.
Incidence as of 2003: 32 cases in children
under 5 years of age.
Incidence in the adult population has
increased from 0.8 to 3.1 per 100,000 adults
Management
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Diagnosis made on presenting symptoms
No tongue blade in mouth
Emergency tracheostomy set
No procedures until in the operating room
Keep quiet
Ceftriaxone – third-generation cephalosporin
for 7 to 10 days.
Apnea
Apnea is cessation of respiration lasting longer
than 20 seconds.
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Monitor in hospital for 48 hours for underlying
problems.
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Discharge home with monitor
Apnea Monitoring
Foreign Body
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Severe inspiratory
stridor
Symptoms depend on
location
Unilateral chest
movement
Chest x-ray
Bronchoscope to
remove object
Coin in Trachea
Teaching
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No small hard candies, raisins, popcorn or
nuts until age 3 or 4 years
Cut food into small pieces
No running, jumping, or talking with food in
mouth
Inspect toys for small parts
Keep coins, earring, balloons out of reach
Influenza
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Associated with community epidemic
Febrile, URI, achy joints,
Management:
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Acetaminophen for fever
Fluids
Keep away from others
Watch for signs of pneumonia
Bronchiolitis
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Acute obstruction and inflammation of the
bronchioles.
Most common causative agent: RSV
Respiratory syncytial virus
Bronchioles become narrowed or occluded
as a result of inflammatory process, edema,
mucus and cellular debris clog alveoli
Symptoms
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Harsh dry cough
Low grade fever
Feeding difficulties
Wheezing
Respiratory distress with apnea
Thick mucus
Management
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Oxygen to maintain oxygen saturation >than
95%
Pulse oximeter
Normal saline nose drops before suctioning
Deep suction especially before feeding
CPT to mobilize secretions
Inhalation therapy – not sure it is beneficial
Mechanical ventilation as needed
RSV Positive - Isolation
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RSV is spread from respiratory secretions
through close contact with infected persons
or contact with contaminated surfaces or
objects.
Patient should be on contact and respiratory
isolation
Can be placed with other RSV + patients
Pneumonia
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An inflammatory condition of the lungs
in which alveoli fill with fluid or blood
resulting in poor oxygenation and air
exchange.
Typical X-ray
Symptoms
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High fever
Thick green, yellow, or blood tinged
secretions
Grunting respirations
Rales, crackles, diminished breath sounds
Cough and cyanosis
Infiltrate seen on x-ray
Management
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Assess for respiratory distress
NPO (rr > 60 = high risk for aspiration)
IV fluids
Oxygen as need to keep oxygen saturation
above 95%
CPT
Deep suctioning
Acetaminophen for fever / antibiotics
Pneumonia Isolation
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Respiratory isolation
May be taken off isolation if RSV negative
and on antibiotics for 24 hours.
Cystic Fibrosis
Inherited autosomal recessive disorder of the exocrine glands.
Pathophysiology: Cystic Fibrosis
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A chronic, progressive, genetic illness
involving the digestive system and lungs.
Abnormality of the exocrine glands
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Sweat and mucous glands
Mucus of CF is thick and viscous
Causes scar tissue
Leads to irreversible lung damage
Exocrine Gland Dysfunction
Mucous secretions are thick and tenacious
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Dysfunction of mucous producing glands leads to
multiple gastrointestinal absorption problems.
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Blocked pancreatic ducts
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No secretion of digestive enzymes
Cystic Fibrosis
Cystic Fibrosis
Symptoms
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Meconium ileus at birth
Failure to thrive
Steatorrhea stools / constipation
Voracious appetite with poor weight gain
Recurrent respiratory infections
Chronic cough
Malabsorption of intestines
Diagnosis
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Positive sweat test
Genetic marker
Life long management
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Enzyme replacement with eating
Daily CPT postural drainage
Inhaled bronchodilators
Control of lung infections
Nutritional supplements as needed
Medications
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Enzymes to help digest food
Antibiotics to control infection
Bronchodilators to open airways
Vitamin C to improve absorption of other
meds
Vitamins E, A, D, K / fat soluble vitamins
Long Term Complications
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Nasal polyps
Sinusitis
Rectal polyps / prolapse
Hyperglycemia / diabetes
infertility
* Life span approximately 30 years of age
Asthma
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Asthma is a chronic, inflammatory lung disease
involving recurrent breathing problems.
Caused by complex, multicellular reaction in the
airway characterized by:
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Airway inflammation
Airway hyper-responsiveness to a variety of triggers
* Asthma is the most common, chronic health problem among children.
Symptoms
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Wheezing
Cough
Tightness of chest
Prolonged expiratory phase
Hypoxemia
X-ray = hyper-expansion of lungs
Medical Management
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High fowlers position / bed rest
Pulse oximetry
Nebulized albuterol
CPT
Methylprednisone / Solu-medrol IV
IV fluids
Oxygen to keep oxygen sats > 95%
Home Management
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Peak flow spirometer
Identify triggers
Maximize lung function
Optimal physical growth
Optimal psycho-social state
Maximum participation
Peak Flow Monitoring
Spirometry measures how
much and how fast air is
forcefully expelled from fully
inflated lungs.
Recommended standard of care
for management of asthma.
Home Medications
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Rescue drugs: short acting albuterol beta 2
agonist – used as a quick-relief agent for
acute bronchospasm and for prevention of
exercise induced bronchospasm.
Anti-inflammatory or preventative: low-dose
inhaled corticosteroid: inhaled or oral
prednisone
Allergy: Singulair
Bronchodilators
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Bronchodilators rapidly relax the airway
smooth muscle cells, thus reversing the
bronchospasm until anti-inflammatory effect
of steroids is attained.
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Aerosols
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Via mouth piece 3 years and older
Via facial mask for less than 3 years
Corticosteroids
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Steroids reduce the inflammatory component of
bronchial obstruction, decrease mucus production
and mediator release, as well as the late phase
(cellular) inflammatory process.
Methyl prednisone IV in severe cases
May need histamine H2 receptor antagonists
(cimetadine or ranitidine) if experiencing GI upset
PO prednisone – always give with food to decrease
GI upset
Anti-inflammatories
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Oral prednisone (Pedia-pred, Prelone, Liquid
pred) recommended for short course in
moderate or severe exacerbation
Inhaled: Pulmicort, AeroBid, Flovent
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Infant: mask should fit firmly: cataracts
Older child: rinse and spit after treatment to
prevent thrush
Family Teaching:
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Teach how to use medication
When to use and how often
No OTC drugs
Increase fluid intake
Signs and symptoms of respiratory distress
Normal Lungs
http://galen.med.virginia.edu/~smb4v/tutorials/asthma/asthma1.html
Asthma Attack
Bronchopulmonary Dysplasia
Pediatric Nursing January/February 1999
History
It occurs in newborns who are born prematurely
and or have a variety of pulmonary disorders
and who require ventilatory support with high
pressure and oxygen in the first 2 weeks of
life.
Pathophysiology
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Fibrosis of airways and marked hyperplasia of the
bronchial epithelium
Increased fluid in the lungs, as a result of disruption
of the alveolar-capillary membrane
Over distention due to damage to alveolar
supporting structures resulting in air trapping
Fibrosis, airway edema, and broncho-constriction
BPD Symptoms
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Persistent respiratory distress
Dependent on supplemental oxygen
Failure to thrive
Gastro-esophageal reflux
Pulmonary hypertension
Long Term Management
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Supplemental oxygen
CPT
Bronchodilators
Diuretics (pulmonary hypertension)
Anti-inflammatory medication
Nutritional support: po formula + NG supplement
Gastrostomy tube (GER)
Bicarbonate in formula due to chronic state of
acidosis
Long-term Outcomes
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Oxygen dependent
Visual problems
Feeding difficulties
Developmental delay
Learning difficulties