Ch. 26 Flashcards
what muscles should be used when breathing?
- diaphragm (<7 years)
- abdominal muscles
- intercostals
- thoracic muscles (>7 years)
what should you see and hear during a lung assessment?
- sounds
- anterior, posterior, and sides L&R
- symmetrical expansion
what is increased WOB?
increased work of breathing
- nasal flaring
- wheezing (audible is very bad)
- tripod position
- head bobbing (younger babies)
- not talking
- retractions
- increased RR, HR
what is accessory muscle use?
anything besides the diaphragm and intercostals
- neck
- spinal cord muscles
severe distress
what do you hear if a child is having trouble breathing?
- wheezing
- stridor (upper airway obstruction)
- diminished air sounds
- crackles
what are the common retraction sites and names?
- supraclavicular
- suprasternum
- subclavicular
- substernal
- intercostal
what are mild vs. moderate vs. severe (retractions)?
mild: barely visible
moderate: various muscle groups working, child knows that they are in distress: eating/sleeping affected, visible retractions apnea, bradycardia spells
severe: if all accessary muscles are in use, prolonged expiratory phase, changes in levels of consciousness
where should you auscultate for lung sounds?
start right about clavicles, R-L
move down about 4 points on each side
should you perform percussion in children?
- no, not with asthma or bronchiolitis, don’t want to induce bronchospasm
- yes with CF, anything with mucus plugs
supraclavicular
retraction above the clavicle
suprasternum
retraction above the sternum
substernal
retraction below the sternum
subcostal
retraction of the ribs
intercostal
retraction between the ribs
home management (medications) of respiratory illnesses includes
- antipyretics (tylenol)
- antihistamines (Benadryl)- cautious under 6years very tired and sleepy
- cough suppressants
- decongestants
other remedies (respiratory disorders)
- nasal suction
- saline solution
- warm compress on sinus cavities
- fluids to prevent dehydration
- coolness vaporizers
- elevate head when sleeping
- shower steam
- warm food
- rest
medications for colds/respiratory infection are used for
just for symptomatic control
nursing outcomes- respiratory focus
- promote comfort
- promote hydration and nutrition
- reduce body temperature
- prevent spread
- ease respiratory effort
moisture: hot vs. cold?
- no right answer
- heat or cold, whatever works for child
assessment of nursing outcomes
box 26.1 and 26. 2
promoting comfort
- unclog and consider non-pharm and pharm
preventing spread
HW and isolation PRN
reducing body temperature
educate right meds for age and fluid choices
promoting hydration and nutrition
- small frequent feeds
- I/O
- feeding tips ## p. 682
acute streptococcal pharyngitis (GABHS) s/sx
varying presentation:
- sore throat
- fever
- stomach ache/abdominal pain, vomiting
- headache
- dysphagia: difficulty swallowing
- anterior cervical lymphadenopathy (tender)
- inflamed tonsils and pharynx (may have exudate)
strep carrier vs. strep positive
scarlett fever
- strep throat with sand paper rash
- towards end of illness: massive peeling of fingers, hands, feet
s/sx of tonsilitis
- pharyngitis (may be present)
- enlarged tonsils (may have exudate)
- hoarseness
- nasal/muffled voice
- difficulty breathing/sleep apnea
- dysphagia
- foul halitosis
- mouth breathing (adenoids)
- snoring
- persistent cough
- OM/difficult hearing (possible)
pharyngitis: diagnostic
- rapid strep
- if negative, send out for culture
tonsilitis: diagnostic
- rapid strep culture
pharyngitis: therapautic management
pharyngitis: nursing care
- ice pops, ice color around the throat
- hot liquids
- fluids/hydration
- salt water gargle
- fever: Tylenol
- antibiotic: cephalosporin
tonsilitis: nursing management
- ice pops, ice color around the throat
- hot liquids
- fluids/hydration
- salt water gargle
- fever: tylenol
*no antibiotic unless bacterial
grade 0 tonsil
absent
grade 1 tonsil
subtle
see a little
grade 2 tonsils
tonsils are half way to uvula
grade 3 tonsils
tonsils covering 3/4 back of throat
grade 4 tonsils
kissing tonsils
diagnostic criteria to have tonsils removed
7 episodes in 1 year
5 episodes in 2 years
3 episodes in 3 years
*episode: tonsilitis or pharyngitis (strep throat)
s/p tonsil removal: #1 complication (and what to monitor for)
hemorrhage
- HR increases
- RR increases
- BP increases initially, then drops
- pale skin
- frequent swallowing
- bright red blood
post-op management: tonsil removal
- monitor for hemorrhage
- facilitate drainage of secretions/promote airway clearance
- reduce discomfort
- maintain fluid volume
post-op mngmnt: tonsil removal- hemorrhage
intervention:
- assess risk for bleeding
- baseline VS
examples:
- Discourage frequent coughing, throat clearing, gargling, or nose blowing, straws, sippy cup, no PO objects
s/p tonsil removal: scabs
nothing that will irritate the surgical site
- nose gargling
- straws
- nothing in the throat to irritate it
nutrition after tonsil surgery
- popsicles: no purple or red color (too much like blood)
- bland diet, easy to swallow
child eustachian tube
- very short
- straight
- thin
- this contributes to a higher rate of ear infections
OME
otitis media with effusion (fluid behind the eardrum)
AOM
acute otitis media
OME and AOM are caused by
dysfunctional eustachian tube
AOM: s/sx
- impaired hearing: mild to moderate
- otalgia: ear pain
- otorrhea if tympanic membrane is perforated
- infection: viral or bacterial
- systemic s/sx: fever, malaise
- behavior: crying/irritable, ear batting, poor PO and sleep
AOM: examination
- bulging TM
- redness
- displaced light reflex
- immobile
- use otoscopy
OME: s/sx
- impaired hearing: mild to moderate
- behavior: difficulty hearing or responding to sounds
OME: examination
- TM retracted
- immobile
- yellow or opaque
- use pneumatic otoscopy
otalgia is __
ear pain
chronic AOM is not getting better: child is at risk for
- loss of hearing
chronic OME is not getting better: child is at risk for
- impaired speech development
AOM: treatment
Non-severe unilateral involvement:
- Observation-wait 48-72 hrs.
- If improved = no treatment
- If same/worse = treatment
Severe or bilateral disease:
- Antimicrobial therapy
- Antipyretics for fever & pain
OME: treatment
- Watchful waiting x 3 mos.
- No decongestants
- No antihistamines
- ABT if persistent OME (> 3 mos.)
- No corticosteroids
- No recommendation for an allergist (by AAP)
diagnostic criteria for getting (ear) tubes put in
3 AOM in 6 months
4 AOM in 1 year
OR
OME is not getting better and failed with medications
why is bottle propping not condoned?
some of the bottle will get into nasal passage, into eustachian tube, cause an infection
AOM: when to assess (recheck)
Ear recheck after 48-72 hrs. if watchful waiting
Ear recheck after ABT completed
OME: when to reassess
Reassess q 3-6 months and continue to watch unless hearing loss or structural issues develop
AOM referrals
Hearing testing (if loss suspected)
Language evaluation (delayed speech)
OME referral
If OME follows (see OME guidelines)
AOM: if conjuncitivitis is present,(type of antibiotic used)
use 2nd line ABT
OME surgeries
- consider tymanoplastomy tubes if warranted
- myringotomy (with or without tubes)
AOM and OME prevention
Breastfeeding for at least 6 mos.
- Pacifier discontinuance around 6 mos.
- No bottle propping
- avoid URI exposure
- avoid 2nd and 3rd hand smoke
- UTD immunizations (Prevnar 13 and influenza)
- minimal daycare
- upright feeding position
which seasons are a higher risk for croup?
fall winter spring
- mostly in little kids, under 6
croup is
inflammation and edema of the epiglottis and larynx
- may involve trachea and bronchi
- airway narrowing from trachea swelling against the cricoid cartilage
croup: symtoms
- stridor
- barking cough (seal)
- hoarseness
croup: viral or bacterial?
viral
- spread by droplet and contact, kids cough and the drops fall onto surfaces for several hours
- highly contagious
acute epiglottis: age group affected
- toddlers
- preschoolers
acute epiglottis: tiologic agent
bacterial
acute epiglottis: onset
rapid progression (hours)
acute epiglottis: major symptoms
- high fever (>102.2)
- URI
- intense sore throat
- dysphagia, drooling
- tachycardia and tachypnea
- prefers tripoding position with neck extension
- cherry red epiglottis
- absent barking cough
acute epiglottis: treatment
Immediate airway protection, Intubation, or tracheotomy
Supplemental oxygen
Blood cx and epiglottis cx
IVF
Gram + ABT until C&S known
Reassurance
HIB vaccination if needed
acute LTB laryngotrachelitis: age-group affected
- infant
- young children
acute LTB laryngotrachelitis: tiologic agent
viral
acute LTB laryngotrachelitis: onset
slow progression over 24-48 hours
acute LTB laryngotrachelitis: major symptoms
Early: mild fever (less than 102.2)
Barking-seal, brassy, croupy cough
Rhinorrhea
Sore throat
Inspiratory stridor
Apprehension
Listless or irritable
Can progress to retractions & cyanosis
acute LTB laryngotrachelitis: treatment
Oral dexamethasone
Nebulized epinephrine if severe
Supplemental O2 if hypoxic
Monitor for airway obstruction
acute spasmodic laryngitis: age group affected
toddlers
acute spasmodic laryngitis:tiologic agent
viral with allergic component
acute spasmodic laryngitis: onset
- sudden, nocturnal
- resolves in 24-48 hours
acute spasmodic laryngitis: major symptoms
Afebrile (no fever)
Mild respiratory distress
Barking, seal-like cough
No signs of respiratory infection
Can reoccur due to allergies, another viral infection & GERD
acute spasmodic laryngitis: treatment
Cool mist
Reassurance
Oral dexamethasone
acute tracheitis: age-group affected
- infancy through preschool
acute tracheitis: tiologic agent
viral or bacterial with allergic component
acute tracheitis: onset
moderate progression over 2-5 days
acute tracheitis: major symptoms
High fever (>102.2F)
URI
Initially presents like spasmodic croup
Purulent secretions
Prefers supine
No drooling
No dysphagia
acute tracheitis: treatment
Initially same as LTB then
Blood cultures
IV Antibiotics
Fluids
Possible intubation
westley croup score: <2
mild
westley croup score: 3-7
moderate
westley croup score: 8-11
severe
westley croup score: >/= 12
failure
RSV is
respiratory syncytial virus
bronchiolitis
Most commonly from RSV but also Adenovirus, Parainfluenza Human metapneumovirus
May be accompanied by other viruses & bacteria
RSV etiology
- incubation period: 2-8 days
- viral shedding: 3-8 days
- fall through spring months
- spread through direct and indirect contact, contact and droplet precautions
- increases in severity before resolving
RSV: mild s/sx
rhinitis, cough, low-grade fever, wheezing, tachypnea, poor feeding, emesis, diarrhea
@home
RSV: severe s/sx
RR>70, grunting, wheezing, crackles, retractions, nasal flaring, irritability, lethargy, poor PO, distended abdomen, cyanosis
@hospital
RSV: diagnostic and lab evaluation
- CXR
- viral swab or wash
RSV: nursing care and management
- contact and droplet precautions
- hydration PO/IV (FMR)
- nasal suctioning, saline
- positioning for feeds/sleep: 30* elevation to help with post-nasal drip
- fever: tylenol
- if destating: O2
- cardiopulmonary monitoring (A&B)
- VS, I&O, USG, focused assessments
RSV medications
- humidified oxygen
- antipyretics
- nebulized saline
- antibiotics ONLY if bacterial (UTI, meningitis, OM, PNA)
- prevention: palivizumab (synagis)
who is at risk for RSV?
- premature or PT infant
- congenital heart disease
- exposed to smoke
- compromised immunity
- daycare, siblings (exposure to germs)
prevention medication for RSV
palivizumab (synagis)
palivizumab (synagis)
short-acting monoclonal antibody vaccine for RSV that is given 1x/month (q30 days) from November-March (RSV season), 5 doses total
for:
- high-risk infants (CHD, CLD w/ prematurity)
- infants born before 29 weeks gestation
- infants in the first year of life with hemodynamically significant heart disease
- infants in the first year of life for preterm infants (<32 weeks) with chronic lung disease who require continued medical intervention
- immunocompromised children under 24 months of age
- children with anatomic lung abnormalities or a neuromuscular disorder
- possible second year of life dosing
nirsevimab
long-acting monoclonal antibody vaccine for RSV, single dose
for:
- full-term or late-term babies
- All infants < 8 months born during or entering their first RSV season, including those recommended by the American Academy of Pediatrics (AAP) to receive palivizumab
- Infants and children aged 8-19 months at increased risk of severe RSV disease and entering their second RSV season, including those recommended by the AAP to receive palivizumab
when do you begin using palivizumab if the baby was born in january?
start in january, end in march
would you recommend palivizumab for children with Trisomy 21 or CF?
no research to support it
should children continue to finish the series if they get RSV?
no, we don’t have to
- unlikely that children would get RSV twice in same season
pertussis is also known as
whooping cough
pertussis: caused by
bordetella pertussis
*in US occurs most often in children who are not immunized
*highest incidence in spring and summer months
pertussis: predominant symptom
highly contagious
- persistent cough x 6-10 weeks
*risk of death in young infants
pertussis: lifelong immunity
with a single episode
pertussis vaccines
- DTaP x5 in childhood
- booster x1 with TDaP between ages of 11-64 years
pertussis: incubation period
5-10 days
pertussis: catarrhal stage
*1st stage of s/sx
cold s/sx x 1-2 weeks
pertussis: paroxysmal stage
nasal swab confirmation
pertussis episode:
series of rapid coughs f/b a forceful inhalation through a narrowed glottis (whoop)
pertussis: infant episode s/sx
- gagging
- gasping
- apnea
- absence of whoop
- can be triggered by feeds
- risk for complications from the forcefulness of cough
pertussis: child episode s/sx
- cyanosis
- post-tussis emesis
- exhaustion
- whoop may be absent
- risk for complications from the forcefulness of cough
pertussis precautions
droplet precautions x 5 days
pertussis: nursing care and management
- small frequent PO feeds
- oxygenation during paroxysms (side-lying position until passes)
- suctioning PRN
- observe for s/sx of airway obstruction (restlessness, increased WOB, cyanosis, A’s and B’s)
- encourage ABT compliance
- encourage immunizations/boosters (include close contacts)
- many complications (PNA= death in infants) may result in pICU with advanced airway management
- observe for s/sx of hemorrhage (pulmonary, nasal, sclera, conjunctiva)
- assess for hernia, prolapsed rectum, syncope, rib fracture, incontinence, weight loss, dehydration, seizures, OM, anorexia, dehydration, PNA or atelectasis
- may need mechanical ventilation
- antipyretics PRN
asthma
- IgE mediated response, reaction within the lung itself
- hereditary
risk factors of asthma
prematurity or LBW, exposure to second-hand smoke
asthma triggers
- environmental factors: allergens: pollen/mold/pet dander/grass, smoke, humidity/cold
- exercise
- infections (respiratory), flu, cold, sinus infection
drug therapy for asthma can be
- quick relief
- long-term control
asthma: quick relief medications
- short-acting beta agonisits
- anticholinergics
- systemic corticosteroids
*rescue meds
asthma: long-term control medications
- inhaled corticosteroids
- cromolyn sodium and nedocromil
- long-acting beta agonists
- methylxanthines
PEFM
peak flow meter
- used in children with asthma to measure how open the airways in the lungs are functioning/opening
- done when child is well (baseline), to compare numbers when sick
family-centered care: how to use a peak flow meter
- before use, make sure the sliding marker/arrow on the peak flow meter is at the bottom of the numbered scale
- stand up straight
- remove gum or food from mouth
- close lips tightly around the mouthpiece. be sure to keep tongue away from mouthpiece
- blow out as hard and as fast as you can, a “fast, hard puff”
- note the number by the marker on the numbered scale
- repeat entire routine 2 more times but wait at least 30 seconds between each routine
- record the highest of the three readings, not the average
- measure your peak expiratory flow rate (PEFR) close to the same time and same way every day (ie morning and evening; before and 15 minutes after taking medication)
- keep record of your PEFRs
asthma severity: green zone
80-100% function, intermittent- persistent
s/sx occur:
(intermittent green)
- day: 0-1 day/week
- night: 0-1x/month
(persistent green)
day: >2 days/week; not QD
night: 1-4x/month
going to school
eating & sleeping well
participating in sports, parties
no limitations (intermittent); minor limitations to activity (persistent)
asthma severity: yellow zone
50-80% function, moderate persistent
s/sx occur:
day: daily
night: >1x/week, but not nightly
compromised, head cold
some limitations to activity
bronchodialotor
asthma severity: red zone
<50% function, severe persistent
if adding steroid is not helping, going to hospital
s/sx occur:
- day: continuous
- night: frequently
extremely limited activity
asthma scale
lower number- milder symptoms
higher number- more severe symptoms
asthma action plan: green zone
- no cough, wheeze, chest tightness, trouble breathing at any time
- can do all things usually done (acitivities)
- when using peak flow meter, peak flow is >80%
action: continue taking long-term control medicine
asthma action plan: yellow zone
- some cough, wheezing, chest tightness, trouble breathing
- waking up at night because of asthma
- can’t do some of the things usually done (acitivities)
- when using peak flow meter, peak flow is 1/2 to 3/4 of best peak flow
control: add quick-relief medicine and continue long-term control medicine
- if sx get better after an hour, keep checking them and continue long-term control medicine
asthma action plan: red zone
- have a lot of trouble breathing
- quick-relief meds aren’t helping
- can’t do any of the things usually done (activities)
- was in yellow zone for 24 hours and did not get better
- when using peak flow meter, peak flow is less than 1/2 best peak flow
action: add other medicines MD prescribed and call MD
- if symptoms don’t get better and can’t reach MD, go to the hospital
asthma score: mild
peak expiratory flow rate %: >70%
scale score: 5-7
asthma score: moderate
peak expiratory flow rate %: 50-70%
scale score: 8-11
asthma score: severe
peak expiratory flow rate %: <50%
scale score: 12-15
management of asthmaticus status
- maintain airway patency
- fluid maintenance/hydration
- promote rest and stress reduction
- family support
asthmaticus management: maintaining airway patency
- NPO
- oxygen (high flow)
- positioning
- cardiopulmonary monitoring and VS
- systemic medications
asthmaticus management: fluid maintenance/hydration
- IVF at FMR
- I&O and USG
- possible nutritional support
- monitor for overhydration
asthmaticus management: promote rest and stress reduction
- quiet room
- cluster care
asthmaticus management: family support
- frequent updates on the child’s condition
- participation at will
- respite breaks PRN
- cultural and spiritual assessments
- discharge planning when appropriate
cystic fibrosis
- more common in caucasians, no gender dominance
- survival rate: late 30s/early 40s
- hereditary, inherited autosomal recessive disorder: both parents have to be carriers for child to get the disease
- endocrine and exocrine glands disorder
- causes physiological alterations to body systems: Resp, GI, Reproductive
endocrine glands
pancreas
pituitary gland
thyroid
parathyroid
hypothalamus
exocrine gland
any secreting gland
concerns/sx warranting testing for CF
- baby fails to pass meconium stool
- salty-tasting babies
- s/sx associated with thick mucus
- growth failure
what tests are used for CF screening
PKU
newborn screening: IRT (elevated pancreatic enzymes)
DNA test (gene for CF: CFTR)
- sweat chloride test (quantitative: >40 suggests, >60 indicates)
IRT test
IRT is tested in the newborn screening blood sample. If +, it is repeated 1-2 weeks later. If elevated again, DNA testing is performed. The newborn screening is positive if the birth sample and the repeat test are positive AND the DNA test identifies one or more CFTR mutations are present.
s/sx of CF: upper respiratory
clogged sinuses
- nasal polyps
- chronic sinustis, frontal HA, rhinitis, post-nasal drip
s/sx of CF: lower respiratory
decreased ciliary clearance, obstructed airways, air trapping and hyperinflation, bacterial colonization, chronic fibrotic lung changes
- Chronic moist productive cough
- wheezing
- course crackles
- frequent infections
- SOB
- ↓ exercise tolerance
- barrel chest
- digit clubbing
s/sx of CF: pancreas
damaged pancreatic ducts obstruct digestive enzynmes; enzymes damage the pancreas leading to inadequate insulin secretion
- Poorly digested food
- Vitamin ADEK deficiencies
- poor wt. gain
- FTT
- delayed puberty
- CF-IDDM
s/sx of CF: GI
thickened intestinal secretions and decreased motility obstructed bile ducts
- Meconium ileus
- abdominal distention
- steatorrhea (frothy, foul, floating)
- constipation
- obstruction
- prolapse
- cirrhosis
s/sx of CF: reproductive
male: absence of vas deferens, decreased sperm count
- infertility
female: thick vaginal discharge, decreased cervical secretions
- difficulty conceiving
s/sx of CF: sweat glands
excessive CL and NA electrolyte loss in sweat
- salty sweat
- salt depletion, hyponatremia
CF: nursing management
Focused respiratory and GI assessments
Anthropometric measurements
Respiratory therapy
- VS and spirometry
- CPT/pulmonary toilet
- Airway clearance techniques (video)
- Meds
Nutrition
Meds
High fat, high protein, high calories, unrestricted salt
Psychosocial support
Home care mgmt.
CF medications: SABA meds
- bronchospasm prevention
CF medications: dornase alpha nebulizer
- loosens and thins secretions
CF medications: hypertonic saline nebulizer
- hydrates airway mucus and stimulates cough
CF medications: ibuprofen PO
- slow progression of pulmonary function decline
CF medications: antibiotics nebulizer, oral, or IV
- treat or prevent infection
CF medications: pancreatic enzyme supplements
- with every meal!
- assists in digestion of nutrients
CF medications: vitamins ADEK and antioxidants (zinc, selenium, ascorbate)
- supplements and vitamins not produced
CF: treatments to promote airway clearance
- high frequency chest wall oscillation vest (usually paired with with nebulized medication)
- flutter mucus clearance device
can expectorants be used on children to aid in respiratory illness relief?
no, don’t use with children
tonsilitis: therapeutic management
- treatment is symptomatic b/c viral
- tonsillectomy: surgical removal of tonsils
- adenoidectomy: surgical removal of adenoids
post-op mngmnt: tonsil removal- drainage of secretions/promote airway clearance
Interventions:
- positioning
- suctioning PRN
Examples:
- side lying position/prone then sitting
post-op mngmnt: tonsil removal- reducing discomfort
Interventions:
- Pain assessment
- Pharm vs. non-pharm
- Cluster care
Examples:
- ATC med dosing
- Consider IV, IM, PO
- Ice collar
- Local anesthetics
- antiemetics
post-op mngmnt: tonsil removal- maintain fluid volume
Interventions:
- assess I/O
- offer fluids as tolerated
Examples:
- Avoid citrus and red/brown fluids; avoid scratchy foods
is it advisable to give both Nirsevimab and Palivizumab for RSV vaccines in the same year?
no it is not
when should nirsevimab be administered to an infant?
moms status unknown: 1 dose before RSV season/within 1 week (if born in RSV season: October-March)
mom’s dose <14 days: 1 dose before RSV season/within 1 week (if born in RSV season: October-March)
mom’s dose >14 days: not needed
