Transcript Nursing Care of the Pediatric Individual with a Respiratory Disorder

Nursing Care of the Pediatric
Individual with a Respiratory
Disorder
Differences in Adult and Child
Adult
Child
The diameter of an infant’s airway is approximately 4 mm, in contrast to an
adult’s airway diameter of 20 mm.
Of the three anatomical differences in the
eustachian tube between adults and small
children (shorter, wider, more horizontal),
which do you think could cause more
problems for the child and why?
Otitis Media
Inflammation of the middle ear
sometimes accompanied by infection
Common Causes
• Eustachian tube dysfunction
– Previous URI causes mucous membranes of the
eustachian tube to become edematous and blocks
tube.
– Enlarged adenoids
– Allergic rhinitis
• Pacifier use raises soft palate and alters
dynamics in the eustachian tube
Acute Otitis Media
characterized by abrupt onset, pain, middle ear effusion, and inflammation.
Note the
injected
vessels and
altered shape
of cone of
light.
Serous Otitis Media
Note that the
light reflex is
not in the
expected
position due
to a change in
tympanic
membrane
shape from air
bubbles.
Note effusion
on otoscopy
by fluid line
and air
bubbles
Clinical Manifestations
What objective sign is
this child displaying?
What does it indicate?
Evaluation and therapy
• Treatment has always been directed toward antibiotic
therapy; however, recently concerns about drugresistant streptococcus pneumoniae have caused
medical professionals to re-evaluate therapy (APA,
2004)
• No clear evidence that antibiotics improve OM
• Waiting up to 72 hrs for spontaneous resolution is
now recommended in healthy infants
• When antibiotics are warranted, oral amoxicillin in
high dosage is given
Myringotomy
• 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.
Nursing Care Management for OM
• Nursing objectives:
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Relieving pain
Facilitating drainage when possible
Preventing complications or recurrence
Educating the family in care of the child
Educate regarding prevention
Providing emotional support to the child and
family
Mastoiditis
Mastoiditis
• Morbidity/mortality
– Hearing loss
– Extension of the infectious process beyond the
mastoid system, resulting in intracranial
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
• 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)
Tonsillitis and Adenoiditis
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, abdominal pain
• Tonsillitis
– Masses of lymphoid tissue in pairs
– Often occurs with pharyngitis
– Characterized by fever, dysphagia, or respiratory problems
forcing breathing to take place through nose
Nurse Alert!
Key to understanding
prevention of URI is
meticulous handwashing
and avoiding exposure
to infected persons
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
Clinical Manifestations
• Tonsillitis
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Fever
Persistent or recurrent sore throat
Anorexia
General malaise
Difficulty in swallowing, mouth breather, foul odor breath
Enlarged tonsils, bright red, covered with exudate
• Adenoiditis
– Stertorous breathing - snoring, nasal quality speech
– Pain in ear, recurring otitis media
Nursing Care for the Tonsillectomy
and Adenoidectomy Patient
Post-operative Care
• Providing comfort and minimizing activities or
interventions that precipitate bleeding
– Place on abdomen or side until fully awake
– Manage airway
– Monitor bleeding, esp. new bleeding
– Ice collar, pain meds
– Avoiding p.o. fluids until fully awake --then liquids
and soft cold foods. Avoid citrus juices, milk
– Do not use straws or put tongue blade in mouth,
no smoking (in teenagers).
Nurse Alert for Post-Op T/A surgery
• Most obvious sign of early bleeding
is the child’s continuous
swallowing of trickling blood.
• Note the frequency of
swallowing and notify
the surgeon immediately
Assessment
of
Respiratory Status
Indications of Respiratory Distress
1.
2.
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Nasal Flaring
Circumoral cyanosis
Expiratory grunting
Retractions
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Substernal, lower intercostal,
5. Tachypnea
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Repirations greater than 60
Apnea
• Defined as: Delay of breathing over 20
seconds
• Additional Signs and Symptoms:
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Cyanosis
Marked pallor
Hypotonia
Bradycardia
Treatment and Nursing Care
• Admit to hospital for cardiorespiratory
monitoring
• Teach parents home care instructions in the
use of an apnea monitor
• Encourage parents to learn CPR.
Cardiorespiratory
Monitoring
pulse oximetry
Want reading > 95%
SIDS
• Defined: sudden death of an infant during
sleep
• Risk Factors
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Prematurity, low birth weight
Most common in infants 2-4 months old
More prevalent in winter months
Sleeping in bed with others, sleeping prone, use of
pillows and quilts
– Exposure to passive smoke
SIDS – Nursing Interventions
• Parent teaching:
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place infant on back to sleep
Place on firm mattress
Do not use loose bedding, toys, pillows
Avoid overheating with too many clothes
Parents should stop smoking
• Provide support of parents by helping them
work through feelings of guilt and loss; refer
to National Foundation for SIDS
Croup
Croup
• Refers to a group of viral and bacterial
syndromes
• Laryngotracheobronchitis, Bacterial tracheitis
and epiglottitis are the “big three”
• Initial symptom of all three is stridor, a seallike barking cough and hoarseness
Croup vs. Epiglotitis
• Croup
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Viral/Bacterial
Fever
Hoarseness
Resonant cough
Stridor (inspiratory)
Risk for significant
narrowing airway with
inflammation
– Humidity for treatment
• Epiglottitis
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Bacterial
High fever
Rapidly progressive course
Dysphagia
Drooling
Dysphonia
Distressed inspiratory
efforts
– Antibiotics needed
Medications
• Beta-agonist /Bronchodilator– Albuterol
• Corticosteroids
• Which of these medications would the nurse
give first? Rationale?
Nursing Care
• Maintain patent airway
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Oxygen with humidification
Keep resuscitation equipment at the bedside
Assess VS (T102 or >, and R>60)
Nothing should be placed in the mouth
• Meet fluid and nutritional needs
– Cool, noncarbonated, non-acid drinks
– Assess for difficulty swallowing – may need IV
therapy
Child with Epiglottitis
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?
Bronchitis vs. Bronchiolitis
Bronchitis
Bronchiolitis
Bronchitis
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Rarely occurs in childhood as isolated problem
Can be present with other respiratory illness
Most often viral
Can be response to allergen
Symptoms include coarse, hacking cough
(increases at night), fatigue, sore ribs,
respirations deep and rattling, audible
wheezing
Bronchiolitis / RSV
• RSV is rhino syncytial virus
• Affects 2-6 month olds primarily
• Infection of bronchial mucosa leading to
obstruction
• Starts out with Upper Respiratory Infection
and progresses to Respiratory Distress.
• Diagnosed with a RSV wash
Nursing Care for Child with RSV
• Medication therapy
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Bronchodilators –
Steroids
Beta-antagonists
Antiviral
• Virozole (Ribavirin)
– Prevention drug – Synagis (palivizumab)
given IM. and RespiGam (RSV immune
globulin) given IV.
• Droplet and contact isolation
Nebulized epinephrine administered for
Bronchiolitis
Parents can hold nebulizer to decrease infant’s fear
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,smoke)
• Most common chronic disease of childhood;
primary cause of school absences
Asthma
Etiology/Pathophysiology of Asthma
• Obstructive airflow limitation due to:
– Mucosal edema - membranes that line airways
– Bronchospasm (bronchoconstriction)
– Mucus plugging (thicker) causes:
• Increased airway resistance
• Decreased flow rates
Etiology/Pathophysiology
• Increased work of breathing
• Progressive decrease in tidal volume and expiratory
volume
• Arterial pH abnormalities due to:
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Increase in number of poorly ventilated alveoli
Increase in hypoxemia
Carbon dioxide retention
Respiratory acidosis
Asthma Triggers
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
Medications to treat Asthma
• Reliever or Rescue Meds
– Short acting beta-agonists - Albuterol
– Corticosteroids- Prednisone,
Beclomethasone for short term therapy
– Anticholinergic agents: Atrovent
• Preventer / Controller Medications
• Mast-cell inhibitors (Cromolyn)
• Leukotriene modifiers – (Singulair)
• Inhaled steroids ( Advair, Pulmocort, Azmacort)
Child receiving nebulizer treatment
What is important patient teaching ?
Treatment and Nursing Care
High fowlers
position
Humidified
Oxygen via
mask
Pulse
Oximetry
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
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 them
• Passages in organs such as the pancreas
become obstructed
• First manifestation is meconium ileus in
newborn
Cystic Fibrosis
Physical findings of the CF patient
• Clubbing of the fingers
• Increased respirations,
cyanosis
• Productive, moist cough
• Barrel chest
Assessment
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FTT despite high caloric intake.
Frequent respiratory infections.
Malabsorption of fats and proteins
Mild diarrhea with malodorous stools,
steatorrhea.
• Abnormally high levels of sodium chloride in
sweat.
Diagnosis
• Sweat test:
Chloride – Normal < 40 mEq/L.
Highly suggestive of CF 40-60 mEq/L
Diagnostic > 60 mEq/L.
(see bags over hands and arms)
• Pancreatic enzymes:
Collection of stool specimen to
assess Trypsin and lipase. Trypsin
absent in 80% of children with CF
CF Management
• Treatment
– Prevention and treatment of pulmonary
infections with antibiotics
– Chest Physiotherapy at least twice a day to
increase sputum expectoration
– Physical exercise important adjunct
– Management of dietary supplements
(enzymes with meals and snacks)
Chest Physiotherapy
cupping and clapping
The End