9. The Child With a Respiratory Alteration Flashcards
Review of the Respiratory System
* Upper airway
> Nares (or nostrils), pharynx (throat - nasopharynx & oropharynx)
> Larynx is located between the pharynx and trachea and houses the vocal cords
> Epiglottis (covers larynx during swallowing)
> Ciliated mucous membranes
> Tonsils (lymphoid tissue)
* Lower airway
> Trachea, bronchi (right & left), lungs (right ___ lobes & left ___ lobes)
> ___ where gas exchange occurs
3; 2
Alveoli
Differences in the Respiratory System
* Lack of or insufficient ___ in premature infants
* Smaller airways and underdeveloped cartilage increases the risk for obstruction by mucous, edema, and foreign objects
> Neonates’ airway is 50% smaller than an adult
surfactant
* ___ ___ ___ (infant) so when nasal congestion occurs, they have difficulty breathing through the mouth
* Less well-developed intercostal muscles
> Diaphragm is neonates’ major respiratory muscle
> Retractions are common in the infant
* Brief periods of apnea (10-15 seconds) common (newborn)
> Respiratory pattern may be irregular
Obligatory nose breather
* Faster respiratory rate; increased metabolic needs
* Eustachian tubes relatively horizontal
> ↑ risk of bacteria entering ear
* Tonsillar tissue enlarged
* More flexible larynx, susceptible to spasm
* Abdominal breathers
Laboratory & Diagnostic Tests
* Blood gas analysis
> Partial arterial oxygen pressure (PaO2), partial pressure (PaCO2), acid-base balance (pH), and bicarbonate (HCO3-)
* Pulmonary function tests
> Vital capacity and expiratory flow rate
* Pulse oximetry
→ >95% goal of treatment
* Transcutaneous monitoring
> Electrodes on skin that continuously check O2 & CO2 concentrations in the body - electrode sites must be changed every 3-4 hours
* End-tidal CO2 monitoring
* Chest radiograph with posterior, anterior, and lateral views
* Computed tomography (CT)
> Hold feedings 3-4 hours prior
* Bronchoscopy & laryngoscopy
> Hold fluids & food until effects of local sedation have worn off and gag reflex has returned
* Cultures
* Allergen-specific (IgE) immunoassay
* Pilocarpine iontophoresis (Sweat test)
> Used to diagnose __ __
* Mantoux test
> Screens for __
cystic fibrosis (CF)
tuberculosis (TB)
?
* Inflammatory disorder of the nasal mucosa
> Seasonal, recurrent, and triggered by specific allergies
> Usually a family history but usually seen in children with atopic dermatitis and asthma
> Some children have symptoms year-round
* Caused by dust mites, feathers, animal dander, mold spores, and pollen
Allergic rhinitis
Allergic Rhinitis - Manifestations
* Clear rhinorrhea, itching of nose, eyes, ears, and palate, and paroxysmal sneezing
“___ ___” - upward rubbing of nose may lead to nasal crease
” ___ ___” - dark circles under the eyes from congestion and edema
> Dry lips (mouth-breathing)
> Pale boggy mucous membranes
> Nasal obstruction
“Allergic salute”
“Allergic shiners”
Allergic Rhinitis
Diagnostic evaluation
> Elevated IgE antibodies & positive allergy skin tests
Therapeutic Management
* Eliminate the allergen
* Antihistamines (loratidine)
> Due to drowsiness - should be taken at night
* Decongestants
* Short-term topical intranasal corticosteroids (fluticasone)
* Leukotriene inhibitors (Singulair)
* Immunotherapy (allergy shots)
* Warm water or saline solution irrigations of the nasal passages
* Environmental modifications
Implementing Environmental Modifications
* Pollen and dust
> Wash sheets weekly in hot water
> No wool or down blankets
> Dust-proof covers on pillows and mattresses
> Replace carpet with wood or tile
> No drapes or blinds; use curtains or shades
> Air filters and cleaners, use air conditioner
> Household humidity at 40-50%
> Multilayer vacuum bags
> Clean with dust-attracting rags/towels
Mold
> Clean with mold inhibitor
> Dry shoes thoroughly
> Moisture remover in closets
> Avoid basements
> No rubber or inner-spring mattresses
> Use air conditioner
> Humidity below 35%, use a dehumidifier
> House ventilation
> Limit number of indoor plants
Dander
* Keep pets outside, if possible
* House ventilation
* Air cleaners
* Dust covers on mattresses and pillowcases
* Frequent vacuuming
* Air purifier
?
* Inflammation and infection of the sinuses
> Can be chronic or acute
> Although not serious may lead to life-threatening complications if left untreated
* Often follows an upper respiratory tract viral infection
> May also have allergic rhinitis or otitis media with effusion
> Most common causative agents ___ ___ and ___ ___
Sinusitis
Streptococcus pneumoniae; Haemophilus influenzae
Sinusitis - Manifestations
> S/S of a cold with no improvement after 10 days
* Low-grade fever, nasal discharge, halitosis, cough that worsens when child is laying down, headache, and feeling of fullness over sinus area
* Less common symptoms may include facial edema, orbital cellulitis, fatigue, and sense of taste or smell impairment
Sinusitis - Therapeutic Management
> Antibiotics - ___ or ___
> Analgesics, hydration application of moist heat
> Antihistamines
> Saline nasal irrigation
> Steroid nasal sprays
> If orbital cellulitis develops → needs to be hospitalized immediately and receive parenteral antibiotic therapy
Amoxicillin; Augmentin (amoxicillin potassium clavulanate)
Nursing focus is on teaching about antibiotic therapy, comfort measures, how did we monitor for response to the treatment, and how to identify complications
Otitis Media Definitions
?
Effusion and infection or blockage of the middle ear
Otitis media
?
The presence of fluid behind the tympanic membrane without signs of infection; often follows an episode of AOM and usually resolves in 1 to 3 months
Otitis media with effusion (OME)
?
Effusion in the middle ear that occurs suddenly and is associated with other signs of illness
Acute otitis media (AOM)
Acute Otitis Media - Manifestations
> Earache (otalgia); infants may pull their ears or roll their heads
> Bulging, opaque tympanic membrane that usually looks red, with decreased mobility; diffuse light reflex; and obscured landmarks
> Drainage, usually yellowish green, purulent, and foul-smelling (indicates perforation of the tympanic membrane)
> Irritability, sleep disturbances, persistent crying in infants, fever, vomiting, anorexia, or diarrhea especially in infants
Acute Otitis Media - Therapeutic Management
> American Academy of Pediatrics (AAP) recommends
* Accurate diagnosis of AOM before treatment decisions are made
* Treating the symptoms with appropriate analgesics
* Symptomatic treatment and observation for 48 to 72 hours after diagnosis before initiating antibiotic therapy
* Reassessment and treatment initiation for children with positive AOM after the 48-72 hour observation period
* Amoxicillin 80 to 90 mg/kg/day for 5 to 10 days
> or a cephalosporin for children with allergy to penicillin
Otitis Media with Effusion (OME) - Manifestations
* Difference from acute otitis media in that there are __ __ __ __ __
* Tympanic membrane appears retracted and dull gray or yellow
> air fluid level or air bubbles may be visible through the tympanic membrane
> Tinnitus, popping sounds
> Hearing loss (usually conductive) below 35 decibels
> Mild balance disturbances
> Flattened tracing and negative pressure on tympanogram
no signs of acute infection
Otitis Media with Effusion (OME) - Nursing Care
* Teach about the importance of antibiotic therapy
* Encourage the use of acetaminophen to relieve discomfort
* Fluid intake should increase if fever is present
* Teach methods to decrease the risk of recurrent otitis media
> Encourage breastfeeding during infancy
> Discontinuing bottlefeeding as soon as possible
> Feeding the infant in an upright position
> Refraining from giving a bottle to the infant at night
___ Pharyngitis
* Abrupt onset (may be gradual in children younger than 2 years)
* Sore throat (usually severe)
* Erythema, inflammation of the pharynx and tonsils
* Fever usually high (39.4 - 40°C)
* Abdominal pain, headache, vomiting
* Cervical lymph nodes may be enlarged, tender
* Usually lasts 3 to 5 days
Bacterial
___ Pharyngitis
* Gradual onset with sore throat
* Erythema, inflammation of pharynx and tonsils
* Vesicles or ulcers on tonsils
* Fever (usually low-grade, may be high)
* Hoarseness, cough, rhinitis, conjunctivitis, malaise, anorexia (early)
* Cervical lymph nodes may be enlarged, tender
* Usually lasts 3-4 days
Viral
Pharyngitis and Tonsillitis
Tonsillitis
* Inflammation and infection of the two palatine tonsils
* Manifestations
> Sore throat persistent or recurrent
> enlarged tonsils bright red may be covered with white exudate or cryptic plugs
> difficulty swallowing
> mouth breathing and an unpleasant mouth odor
> enlarged adenoids which may cause a nasal quality of speech, mouth breathing, hearing difficulty, otitis media, snoring, or obstructive sleep apnea
___
* Infection and inflammation of the pharyngeal tonsils or ___
* Incidence peaks during middle childhood
Adenoiditis
adenoids
___
* Flaccid epiglottis and supraglottic aperture with weakness of the airway walls
* Caused by immature neuromuscular development in the airway
* Congenital laryngeal stridor
> Noisy, crowing (stridor), respiratory sounds with or without retractions in the neonatal period
> Symptoms increase when the infant is supine or crying
> Associated reflux or dysphasia
> Symptoms resolve by 18 to 24 months
Laryngomalacia
?
* Often begins at night; may be preceded by several days of symptoms of upper respiratory tract infection
* Sudden onset of harsh, metallic, barky cough; sore throat; inspiratory stridor; hoarseness
* Use of accessory muscles to breathe (substernal, intercostal, suprasternal retractions)
* Frightened appearance
* Agitation
* Cyanosis
Croup
___ (Supraglottitis)
* Acute inflammation and swelling of the epiglottis and surrounding tissues
* Life-threatening - progresses rapidly
* Bacterial infection (Haemophilus influenzae) epiglottis becomes edematous and cherry red with high fever - edema is severe and painful and obstructs the airway and the trachea - complete airway obstruction → hypoxia → acidosis → death
Epiglottitis
Classic signs of epiglottitis
* Child insists on sitting in an upright ___ position leaning forward supported on the arms with their chin thrust out and mouth open
tripod (position)
Bronchiolitis
__ __ __ (___)
* Inflammation of the bronchioles
* ___ is the causative agent in 50% of cases of bronchiolitis
* ___ is a significant cause of hospitalization in children under 1 year of age
* Highly communicable → acquired through contact with contaminated surfaces and hand to hand transmission
* Contact isolation and scrupulous hand hygiene
Respiratory syncytial virus (RSV)
RSV
RSV
Asthma
* A reversible obstructive airway disease characterized by
> 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
Asthma - Etiology
* Caused by an interaction between genetic and environmental factors
* Triggered by cold air, smoke, allergens, viral infections, stress, exercise, odors, and environmental pollutants
* Immature anatomy of infants in small children predisposes them to increased risk of asthma
Bronchopulmonary Dysplasia
__ __ __ __ (___)
> Result of acute lung injury in some infants who have received supplemental O2 and mechanical ventilation
> Thickening of the alveolar walls and bronchiolar epithelium
* Occurs primarily in low-birth weight infants and premature infants
> Chronic lung disease of infancy
Chronic obstructive pulmonary disease (COPD)
> Exocrine glands
* High concentration of sodium and chloride in sweat (mom usually reports baby tastes salty when kissed)
> Reproductive system
* Delay in sexual development
* Fertility issues
