Transcript Child`s Respiratory Tract Children are prone to

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Respiratory Stressors and
Adaptation
Child’s Respiratory Tract
Children are prone to:
• Respiratory tract infection
• Respiratory failure
• Airway collapse
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
Respiratory Diseases and
Disorders of Childhood
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Otitis Media
Pharyngitis
Epiglotitis
Broncholitis
Pneumonia
Asthma exacerbation
Cystic Fibrosis
Tuberculosis
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
(AOM) Acute Otitis Media
• Sudden temperature
increases
• Sharp pain
• Otalgia (earache); pull
on ear
• Bulging, opaque red
tympanic membrane
• Irritability
• Sleep disturbance
• Persistent crying
• Fever, vomiting,
diarrhea, anorexia
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
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
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
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 (103104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
• Encourage child to chew and swallow
• No straws, forks or sharp, pointed toys
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)
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
Asthma
A reversible obstructive airway disease
characterized by
• Hypersensitivity of many cells (Mast,
Eosinophils, T Lymphocytes)
• Increased airway responsiveness to a variety
of stimuli
• 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
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Acute Asthma Exacerbation
Symptoms
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 selfmanagement
– Identify triggers
– Avoidance of
allergens
– May need skin
testing and
hyposensitization
– 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)
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Carrier
mom
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Carrier
Dad
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Carrier
female
Affected
Female
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XY
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Normal Carrier
male
female
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
• Humidified oxygen, low flow
• 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
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 for Development of
Tuberculosis
• 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
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
• 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
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.
c.
d.
Swim team
The Band
Pet “show and tell”
An art class
A toddler with cystic fibrosis is placed in a highhumidity cool-mist tent operated with
compressed air. The nurse knows the primary
reason for this therapy is to:
a.
b.
c.
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
IV D5W at 42 ml/hr
Obtain CBC and Throat Culture
When assessing a child who is suspected of having
asthma, the nurse should specifically ask the parents
about which 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
b. Blowing the nose
c. Eating flavored ice pops
d. Taking pain medication
When caring for a child who has had a
tonsillectomy the nurse’s priority observation
should be for:
a. Coffee ground emesis
b. Frequent swallowing
c. Complaints of a sore throat
d. A slight increase in temperature
When assessing a child who is preverbal for otitis
media, the nurse should anticipate that the
child will:
a. Have difficulty swallowing
b. Rub the affected side of head on the mattress
c. Have a runny nose
d. 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