Transcript 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.
What are the anatomic
differences in the eustachian
tube of adults and small children?
(shorter, wider, more horizontal)
Which difference do you
think could cause more
problems for the child and
why?
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
 Exposure to cigarette smoke (airborne pollutants)
 Pacifier use may raise soft palate and alter dynamics in
the eustachian tube
Clinical Judgment Question:
 Considering the contributing factors to
this condition, what age group most
commonly experiences acute otitis
media?
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
 Recent concerns of drug-resistant streptococcus
pneumoniae have caused medical professionals to reevaluate antibiotic therapy (APA, 2004)
 Many episodes of OM result from viral infections
 Waiting up to 72 hrs for spontaneous resolution is
now recommended in healthy infants
 When antibiotics are warranted, oral amoxicillin in
high dosage is the medication of choice.
Nursing Interventions:
 Nursing implications for antibiotic therapy
 Safety
 Teaching
 Comfort measures
 Teaching for home care:
 When to notify primary care provider
 Follow up visit with primary care provider
 Preventive measures
Myringotomy
 Purpose:
 Drainage
 Air exchange by-passing Eustachian tube
 Prevent further scaring and hearing loss
Nursing Care Management following
placement of Myringotomy:
 Comfort measures
 Assessments immediately post operatively and ongoing
 Pre & Post-op support for the family
 Discharge teaching:
 Comfort measures
 When to notify primary care provider
 Preventative measures


Hygiene
Recreational
Mastoiditis
Mastoiditis
 Morbidity/mortality
 Hearing loss
 Extension of the infectious process beyond the mastoid
system, resulting in intracranial complications
 Ages affected
 Parallels 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:
 Assess vital signs (what additional VS do you need to assess?)
 Which lab values would indicate additional concerns?
 Medicate aggressively with antibiotics as ordered
(usually IV if bacterial spread to mastoid) WHY?
 Antibiotics of choice: ticarcillin disodium (Timentin®) and
gentamicin sulfate (Garamycin®)
 Assess for complications (hearing loss, tinnitus)
 Comfort measures
Nursing interventions related to
administration of antibiotics:
 Contraindications:
 Allergies/sensitivities- what medications have a comorbidity? (aminoglycosides- mycin or micin suffix)
 Peak/ Trough- when to draw, how to interpret
 Assessment of adequate filtration from the body
(what organs are most effected)
 Why is rate of administration vitally important?
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
 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
 Respirations – stridor, 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
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
Indications of Respiratory Distress
1. Nasal Flaring
2. Circumoral cyanosis
3. Expiratory grunting
4. Retractions:
•
•
Substernal,
Lower intercostal,
5. Tachypnea

Repirations greater than 60
Apnea
 Defined as: Delay of breathing over 20 seconds
 Additional Signs and Symptoms:
 Cyanosis
 Marked pallor
 Hypotonia
 Bradycardia
Treatment and Nursing Care
 Admit to hospital for cardio-respiratory
monitoring
 Teach parents home care instructions in the
use of an apnea monitor
 Encourage parents to learn CPR.
Cardiorespiratory
Monitoring
pulse oximeter
desired reading
> 95%
SIDS
 Defined: sudden death of an infant during sleep
 Risk Factors
 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:
 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
Epiglottitis
Croup: viral and bacterial syndromes
 Laryngotracheobronchitis
 Bacterial tracheitis
 Epiglottitis
Initial symptom of all three is stridor, a seal- like
barking cough and hoarseness
Croup vs. Epiglotitis
 Croup
 Epiglottitis
 Viral/Bacterial
 Bacterial
 Fever
 High fever
 Hoarseness
 Rapidly progressive course
 Resonant cough
 Dysphagia
 Stridor (inspiratory)
 Drooling
 Risk for significant
 Dysphonia
narrowing airway with
inflammation
 Humidity for treatment
 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
 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
Clinical Judgment:
 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
first in this situation?
Bronchitis vs. Bronchiolitis
Bronchitis
Bronchiolitis
Bronchitis
 Rarely occurs in childhood as isolated problem
 May occur with other respiratory illness
 Most often viral
 May result from a response to an allergen
 Symptoms include coarse, hacking cough (increases
at night), fatigue, sore ribs, deep and rattling
respirations, audible wheezing
Bronchiolitis /
Rhino Syncytial Virus (causes 50% of cases)
 Primarily affects infants 2-6 months of age
 Infection of bronchial mucosa leading to
obstruction
 Begins as upper respiratory infection (URI) and
progresses to Respiratory Distress.
 Diagnosed with a RSV wash
Nursing Care for Child with RSV
 Medication therapy
 Bronchodilators
 Steroids
 Beta-antagonists
 Antiviral-Virozole (Ribavirin)
 Prevention – Synagis (palivizumab) administered IM.
and RespiGam (RSV immune globulin) administered 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 hyper-
responsiveness 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
Asthma (RAD) continued:
 Increased work of breathing
 Progressive decrease in tidal volume and expiratory
volume
 Arterial pH abnormalities due to:
 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 Fowler’s
position
Pulse
Oximeter
Humidified
Oxygen via
mask
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:
 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
For questions regarding this
presentation please contact:
Marlene Meador RN, MSN, CNE
[email protected]