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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
Child’s Respiratory Tract
Children are prone to:
–Respiratory tract infection
–Respiratory failure
–Airway collapse
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 AOM
• Exposure to second hand smoke
• Allergies
• Bottle fed infants
(AOM) Acute Otitis Media
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Sudden temperature increases
Sharp pain
Otalgia (earache); pull on ear, rubbing face
Bulging, opaque red tympanic membrane
Irritability
Sleep disturbance
Persistent crying
Fever, vomiting, diarrhea, anorexia
Sudden relief and drainage=rupture TM
AOM
Treatment:
• AOM could be viral or bacterial
• Acetaminophen (pain, fever)
• ABX (Amoxicillin) if bacterial
• ALTERNATIVE- wait 72 hours then treat
Serous Otitis Media or Otitis Media
with Effusion (SOM/OME)
• Result of chronic otitis media (3 in 6
mos, 4 in 1 year)
• Epithelial cells of middle ear begin
producing secretions instead of
absorbing them
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
Surgical Interventions
Myringotomy
• surgical incision of the tympanic
membrane (mucoid material 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
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 (103-104F) but may be moderate
• Abdominal pain, headache, vomiting
• Cervical lymph nodes may be enlarged, tender
• Requires antibiotics
Pharyngitis
Management:
Pain relief; rest; bland, soft
diet
PCN if bacterial
Tonsillectomy is controversial
Tonsillectomy
Nursing Care (Pre-op)
• Assess for current infection and bleeding
history
• Check for loose teeth
• Teach child and parent what to expect postop
– May see dried blood in mouth and teeth
– Will still be able to talk
– Pain management for optimal recovery
Tonsillectomy
Nursing care (post-op)
• Assess for bleeding number one
priority!!!!
– Elevated P, decreased BP,
restlessness, frequent swallowing,
vomiting bright red blood, fresh
blood in throat
• Clear, cool liquids, no red juices!
• Advance to full liquids and soft foods
on 2nd day if no sign of hemorrhage
• Pain relief 2nd priority-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
– coughing frequently
– clearing the throat
– blowing the nose
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
Cardinal signs and symptoms
• May have had mild URI few days
prior
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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
• Patent airway ASAP
• Monitor oxygenation status, (continuous pulse ox, humidified
O2)
• Antipyretics suppository
• 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 80-100mmHg
• Maintain patent airway
• Position for comfort (never force to lie
down)
• Relieve anxiety
• Monitor temp (antipyretics, ABX)
Lower Respiratory Tract Disorders
Broncholitis
Inflammation of the fine bronchioles and
small bronchi.
• Occurs in children < 2yo; peak age 6mos
• Highest in winter and spring
• Most responsible pathogen: RSV
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
Management
Severe Symptoms
• Hospitalization
• Monitor: respiratory
status, pulse ox,
blood gases
• Bronchdilator
therapy
No antibiotics…Viral
infection!
Mild-Mod symptoms
• Antipyretics
• Hydration
• Humidification
• Watch for increased
severity
Acute phase usually
lasts for 2-3 days.
Nursing Interventions
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Position: for comfort, semi-fowlers
Decrease anxiety
Administration of IV fluids
Provide humidified O2 (40% then
wean) use BB
• Determine in child is candidate for
Ribavirin therapy (antiviral agent
used with severe RSV cases)
Pneunomia (PN)
• Inflammation of the alveoli usually
following an URI
• Occurrence:
late winter/early spring
• Pneumococcal (bacterial) vs. Viral
Pneumonia
(ABX vs. no ABX)
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, pulse ox
• Administer ABX (Ampicillin, Cephalosporin),
antipyretics
• Perform chest physiotherapy as ordered
• Engage child in play activities (TCDB, IS)
Activity Intolerance: Interventions
• Balance activity with rest
periods, cluster nursing care
• Provide small frequent
meals
• Increase activity gradually
Risk for Deficient Fluid Volume:
Interventions
• 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
Asymptomatic children
• INH x 9 months
• 12 months if HIV+
• Household contacts
treat for 12 weeks
Symptomatic children
• INH, rifampin and
pyrazinamide x 2
months
• Followed by INH and
rifampin x 4 months
Side effects: GI, orange
tears, urine=
noncompliance
Chronic Lung Diseases
Asthma
A reversible obstructive airway
disease characterized by
• 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
Acute Asthma 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
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
Management of Acute 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
Acute Asthma Exacerbation
• Administer short acting beta2 agonist
bronchodilators
– Ventolin, Proventil, Albuterol
• Administer corticosteroids
– Predinsone, Prednisolone, Solumedrol
• Monitor effectiveness of meds
• Easily fatigable
• Frequent position changes
Acute Asthma Exacerbation
• Observe for Status Asthmaticus
• Occurs when child fails to respond
to treatment (severe emergency)
• Often caused by pulmonary
infection
• Call MD!
Asthma Severity
• Classified as
– Mild intermittent
• Symptoms < 2 x week
– Mild Persistent
• Symptoms > 2 x week, but less than once a day
– Moderate
• Day symptoms 2 x week, 1 or more night symptoms
per week
– Severe
• Continual day symptoms, frequent night symptoms
Maintenance Medications
• Mild asthma:
– PRN anti-inflammatory
corticosteroids (Flovent inhaler QD)
• Moderate:
– anti-inflammatory corticosteroids QD
– long-acting bronchodilator
(Theophylline, Serevent)HS
Maintenance Medications
• Severe:
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oral corticosteroid qd
inhaled corticosteroid qd
long-acting bronchodilator HS
short-acting beta-2-agonist bronchodilator
(Albuterol) if attack begins
Also:
– Mast Cell inhibitors (Intal),
– Leukotriene Blocker (Singulair)
(prevents severe bronchospasm, not effective if
symptoms present)
Discharge Planning
• teaching self-management
– Identify triggers
– Avoidance of allergens
– 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)
CF
• Chronic multisystem disorder affecting
the exocrine glands
• Affects: bronchioles, small intestines,
pancreatic & bile ducts
• Incurable
• Median life expectancy is 33 yrs
• Usually diagnosed before 1st birthday
• Symptoms worsen as disease
progresses
CF: 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
CF: Digestive 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
CF: Exocrine Glands
• Abnormally high concentrations of
sodium and chloride in the sweat
• Sweat Test: determines amount of
sodium chloride in sweat > 60 is
diagnostic
• Risk for electrolyte imbalance during
hot weather
CF: 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
Management
• Prevention and treatment of pulmonary
infections
• Maintaining optimal nutritional status
– High calorie, high protein
– Enzyme supplements
• Managed at home most of time
– Flutter device
– CPT BID
– Postural drainage
– Exercise
Interventions for Hospitalized CF
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Facilitating airway clearance
Prevent pooling of secretions
Limit procedures
CPT every 4 hours (1 hour before
or 2 hours after meals, prior to
bedtime)
• Forced expiration (“huffing”)
Interventions
• Administer bronchodilators and mucolytics
• High-humidity cool-mist tent to mobilize
secretions
• If 02 is required, low flow rate
• IV ABX
• Well balanced diet high in calories, protein,
carbohydrates
• Pancreatic enzymes within 30 minutes of eating
all meals and snacks
• Extra salt and fluid in hot weather
Long Term Support
• Cystic Fibrosis Foundation
• American Lung Association
• Coordination of care from
home to school
• Increase self-esteem
• Foster independence
Dehydration and Fluid Loss
Dehydration and Fluid Loss
• Large portion of a child’s fluids is located in
extracellular fluid (increased BSA)
– Infants: 75-80% of the weight
– 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
– BMR increases by 20% !
Electrolytes
• NA- major electrolyte in ECF
– Needed to establish osmolarity
• K- major electrolyte in ICF
– 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
• 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
Know the S+S of Dehydration
• Mild
– Normal VS, moist mucous membranes, alert, normal
urine output, normal turgor, fontanelle, normal cap
refill, thirsty
• Moderate
– 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 LEAST
1-2 ml/kg/hr
ALL children are on I+O pay attention to the balance
Monitor labs for:
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Increased BUN
Increased serum bicarb
Hyponatermia
Hyperkalemia
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.
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d.
Swim team
The Band
Pet “show and tell”
An art class
A toddler with cystic fibrosis is placed in a
high-humidity cool-mist tent operated with
compressed air. The nurse knows the primary
reason for this therapy is to:
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b.
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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.
b.
c.
d.
Place a pediatric size tracheostomy tray in the room
Monitor pulse oxygen saturation every 15 minutes
Place in respiratory isolation
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.
b.
c.
d.
Coughing a night in absence of respiratory infection
Coughing throughout the day
Expiratory wheezing
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:
a. Talking and chewing
b. Blowing the nose
c. Eating lemon flavored ice pops
d. Taking pain medication
a.
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:
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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