Ch 38 Peds Respiratory Flashcards
Epiglottitis
bacterial form of croup
may be caused by H. influenzae type b or Strep pneumoniae
children immunized with Hib less risk
occurs most freq in children 2 - 8 yrs
onset abrupt, typically in winter
*emergency –> can rapidly progress to severe resp distress
Epiglottitis assessment
fever large, cherry red, edematous epiglottis no spontaneous cough drooling swallowing pain muffled voice retractions inspiratory stridor, worse in supine tripod positioning
Epiglottitis interventions
assess temp via axillary
pulse ox
lateral neck films to confirm dx
NPO
do not leave child unattended
do not place in supine position
do not agitate child
may need to delay IV line to not agitate child
administer abx (IV then oral)
admin corticosteroids to decrease inflammation and reduce throat edema
nebulized epinephrine may be rx for severe cases
heliox (helium and oxygen mix) may be rx to reduce mucosal edema
cool mix o2
prepare for endotracheal intubation or tracheotomy for severe resp distress
ensure immunizations up to date
if epiglottitis suspected
NO attempt should be made to visualize the post pharynx, obtain a throat culture, or take an oral temp.
spasm of the epiglottis can occur and lead to complete airway obstruction.
Laryngotracheobronchitis
inflammation of the larynx, trachea, and bronchi most common type of croup may be viral or bacterial most frequently in children < 5 yrs parainfluenzae virus types 1 & 2 respiratory syncytial virus (RSV) Mycoplasma pneumoniae influenza gradual onset that may be preceded by an upper respiratory infection
Laryngotracheobronchitis symptom progression
Stage 1: fever, hoarseness, SEAL bark and brassy cough, insp stridor, fear, irritability
Stage 2: continuous resp stridor, retractions, use of accessory muscles, crackles, labored respirations
Stage 3: continued restlessness, anxiety, pallor, diaphoresis, tachypnea, signs of anoxia and hypercapnia
Stage 4: intermittent cyanosis progressing to permanent cyanosis, apneic episodes progressing to cessation of breathing
Laryngotracheobronchitis interventions
elevate head of bed and provide rest
humidified o2 via cool air / mist tent as rx
cool air vaporizer at home
no cough syrups or cold medicines –> may dry and thicken secretions
corticosteroids may be rx
nebulized epinephrine (for children w severe disease - stridor at rest, retractions, or difficulty breathing)
heliox
upper resp infection - hospital
isolation precautions should be implemented for a hospitalized child until cause of infection is known
Bronchitis
inflammation of trachea and bronchi (tracheobronchitis)
usually occurs w upper resp infection
usually mild disorder, usually viral
bronchitis assessment
fever
dry, hacking, nonproductive cough that is worse at night
cough becomes productive in 2 - 3 dys
bronchitis interventions
tx sxs as necessary
cool, humidified air to child
cough suppressants may be rx
oxygen delivery systems
oxygen mask
nasal cannula
oxygen tent
oxygen hood, face tent
oxygen mask
advantages: various sizes, higher O2 than cannula, predicatable conc. of O2 (Venturi)
disadvantages: skin irritation, fear of suffocation, moisture on face, possible aspiration of vomit, difficulty in controlling )2 conc except w Venturi
Nasal cannula
adv: low - mod O2 conc (22-40%), able to eat / talk while on O2, better able to observe child
disadv: must have patent nasal passages, difficult to control O2 conc if child breathes through mouth, no mist
Oxygen tent
adv: lower O2 conc (FIO2 0.3-0.5), child able to receive desired O2 even while eating
disadv: necessity for tight fit around bed to prevent leakage of O2, cool / wet tent environment, poor access to child
oxygen hood, face tent
adv: provides high O2 conc (FIO2 up to 1.00), free access to child’s chest for assessment
disadv: high humidity environment, need to remove child for feeding and care
Bronchiolitis and RSV (respiratory synctial virus)
bronchiolitis: inflammation of the bronchioles that cauess production of thick mucus that occludes bronchiole tubes and small bronchi.
RSV: causes an acute viral infection and is an common cause of bronchiolitis
other organisms that cause bronchiolitis:
adenoviruses
parainfluenza viruses
human metapneumovirus
RSV
not airborne
highly communicable
transferred by direct contact w resp secretions
occurs primarily in winter / spring
rare in children > 2 yrs, peak incidence = 6mo
at risk children: children > 1 yr w chronic / disabling condition
dx: testing of nasal / nasophar secretions
RSV preventions
encouraging breast feeding
avoiding tobacco smoke exposure
good handwashing technique
admin of palivisumab (Synagis) (monoclonal antibody, for high risk infants, via IM - monthly injection)
palivisumab (Synagis)
RSV prevention IM injection monoclonal antibody monthly over a 5 mo period (nov - march) for high risk infants
bronchiolitis / RSV interventions
airway maintenance, cool humifiied air, O2
hospital - isolation (private room or w RSV pt)
no nursing care for RSV AND high risk pt
contact precautions
airway maintenance, 30-40 degree bed angle, neck slightly extended
periodic suctioning (before feeding)
ribavirin (Virazole) - antiviral med (via inhalation)
Pneumonia
inflammation of the pulmonary parenchyma or alveoli or both.
caused by a virus, mycoplasmal agents, bacteria, or aspiration of foreign subs
agent introduced via lungs or bloodstream
viral pneumonia
seen more often than bacterial pneumonia
seen in children of all ages
often asso. w viral upper resp infection
primary atypical pneumonia
mycoplasma pneumoniae or chlymydia pneumoniae
most often in the fall / winter
more common in crowded living conditions
children - 5 - 12 yrs old (most often)
bacterial pneumonia
often a serious infection req hospitalization when pleural effusion or empyema accompanies the disease
hospitalization also for children with staphylococcal pneumonia
aspiration pneumonia
when material enters the lung and causes inflammation and a chemical pneumonitis
sx: increasing cough or fever w fould smelling sputum, deteriorating results on cxrs
pneumonia prevention
vaccination of infants and children w pneumococcal vaccine
viral pneumonia assessment
acute onset
sx: fever, cough, diaphoresis, nonproductive or productive cough of small amts of whitish sputum
wheezes or fine crackles
viral pneumonia interventions
tx is symptomatic
o2 w cool humidified air as prescribed
primary atypical pneumonia assessment
acute
sx: fever, chills, anorexia, ha, malaise, myalgia, rhinitis, sore throat, dry, hacking cough
nonproductive cough –> production of seromucoid sputum –> mucopurulent / blood streaked sputum
primary atypical pneumonia interventions
tx is symptomatic
recovery in 7 - 10 dys
bacterial pneumonia assessment
acute
sx:
infant - irritability, lethargy, poor feeding, abrupt fever (poss. szs), resp distress.
child - ha, chills, ab pain, cp, meningeal sxs
hacking, productive cough
dim breath sounds / crackles
non productive –> productive (purulent sputum) w coarse crackles / wheezing
bacterial pneumonia interventions
abx therapy as soon as dx suspected
IV abx in hospital
o2 for resp distress
cool mist tent as rx
admin chest physiotherapy and postural drainage q4h
bed rest
encourage to lie on affected side to splint the chest and reduce pleural rubbing discomfort
monitor temp r/t risk for febrile szs
isolation precautions w pneumococcal / stephylococcal pneumonia
cont. closed chest drainage may be instituted if purulent fluid is present
fluid accumulation in pleural cavity –> thoracentesis (also used for culture and abx)
asthma
chronic inflammatory disease of the airways
classified based on disease severity
rxn can be immediate or delayed several hrs
mast cell release of histamine –> bronchoconstrictive process / bronchospasm / obstruction
status asthmaticus
acute asthma attack
child displays resp distress despite vigorous tx measures
*medical emergency
can lead to resp failure / death
asthma assessment
sx particularly in the early morning or at night
acute asthma attacks
air is trapped behind occluded or narrow airways
just before attack child may present w itching localized at the front of neck or over the upper back
resp sxs: hacking, irritable, nonproductive cough (d/t bronchial edema)
secretion accumulates –> stims cough, cough becomes rattling, sputum = frothy, clear, gelatinous sputum
retractions
hyperresonance
crackles, coarse rhonchi, insp / exp wheezing
younger children - tripod sitting position
older children - upright w shoulders hunched (refuses to lie down)
ventilatory failure and asphysia
acute asthma attacks
SOB, air mvmt in chest restricted to the pt of absent breath sounds
sudden increase in respiratory rate
Priority Nursing Actions ACUTE ASTHMA ATTACK
- assess airway patency and resp status
- admin humidified o2 by nc or face mask
- admine rescue meds
- initiate an IV line
- prepare child for chest radiograph if rx
- prepare to obtain blood sample for arterial blood gas levels if rx
Acute asthma meds
- quick relief (rescue) meds
- long term control meds
- nebulizer, MDI
(MDI for corticosteroids = spacer)
(growth patterns monitored for cort steroids)
chest physiotherapy
breathing exercises, clapping, vibration procedures with postural drainage and suctioning
strengthens breathing muscles
not recommended during acute
asthma teaching
instruct child and family about monitoring peak expiratory flow rate
decrease in expiratory flow rate may indicated inpending infection or exacerbation
asthma precipitants
meds: aspirin, NSAIDS, abx, beta blockers
strong emotions
conditions: gerd, tracheoesophageal fistula
food additives: sulfite preservatives
foods: nuts, milk and other dairy produces
endocrine fx: menses, pregnancy, thyroid disease
peak expiratory flow rate
measures max flow of air forcefullly exhaled in 1 second
“personal best value” used for comparison at other times
radioallergosorbent test
blood test used to identify a specific allergen
Quick relief asthma meds (rescue)
short acting B2 agonists (bronchodilation) anticholinergics (relief of acute bronchosp) systemic corticosteroids (anti-inflam to tx reversible airflow obstruction)
Long Term Asthma control (preventative)
corticosteroids (anti-inflam)
antiallergic meds
NSAIDS (anti-inflam)
long acting B2 agonists (long act bronchod)
leukotriene modifiers (prevent bronchosp and inflammatory cell infiltration)
monoclonal antibody (blocks binding of IgE to mast cells to inhibit inflammation)
cystic fibrosis
chronic multisystem disorder (autosomal recessive) characterized by exocrine gland dysfxn
mucus from exocrine glands = thick, tenacious, and copious –> particularly affects resp, GI, and reproductive systems
*progressive and incurable disorder - resp failure is a common cause of death
organ transplantation may be an option
cystic fibrosis common sxs
asso. w pancreatic enzyme deficiency and pancreatic fibrosis (caused by duct blockage, progressive chronic lung disease r/t infection, and sweat gland dysfxn –> increases sodium and chloride sweat conc)
sweat chloride test
CF increases Na and Cl in sweat and saliva
1. production of sweat is stim., sweat is collected, sweat electrolytes are measures (> 75 mg sweat needed)
normal = < 40 mEq/L sweat chloride conc.
positive test = > 60 mEq/L
>40mEq/L = dx in infants <3mo
chloride conc. 40 - 60 mEq/L are highly suggestive of CF, req repeat test
CF resp system
stagnant mucus in airway –> bac colonies / destruction of lung tissue
emphysema + atelectasis
chronic hypoxemia –> conc. and hypertrophy of muscle fibers in pulm arteries and arterioles –> pulm HTN –> cor pulmonale
pneumothorax: d/t ruptured bullae and hemoptysis d/t erosion of bronchial wall
sxs: wheezing / cough, dyspnea, cyanosis, clubbing of figners/toes, barrel chest, bronchitis/ pna
CF GI system
meconium ileus in newborn = early manif. intestinal obstruction d/t thick intestinal secretions can occur (s: pain, ab distention, N&V) stools = frothy and foul smelling ADEK deficient --> easy bruising / anemia malnutrition / FTT concern hypoalbuminemia can occur (d/t dim. absorb of protein) --> general edema rectal prolapse (d/t large, bulky stools) pancreatic fibrosis (ups risk of DM)
CF integumentary system
high conc. of Na and Cl in sweat
infant tastes “salty”
dehydration + electrolyte imbalanes (esp when hyperthermic)
CF reproductive system
can delay puberty in girls
fertility inhibited by highly viscous cervical secretions (act as plug –> block sperm)
males: usually sterile (d/t blocked vas deferens by abnormal secretions or abnormal dev of duct structures)
CF dx tests
- quantitative sweat chloride test positive
- newborn screening: immunoreactive trypsinogen analysis and direct DNA analysis for mutant genes
- cxr = atelectasis and obstructive emph.
- pulmonary fxn tests = abnormal small airway fxn
- stool, fat, enzyme analysis: 72 hr stool sample to check fat or enzyme (trypsin) content –> food intake recorded
CF interventions: resp system
prevent/tx pulmonary infection, monitor resp status, chest physiotherapy on awakening / evening (should not be before/soon after meal), flutter mucus clearance device, hand held percussors to loosen secretions, positive expiratory pressure mask (forces secretion to the upper airway for cough out), forced expiratory tech (huffing), bronchodilator med by aerosol, physical exercise program, aerosol / IV abx, o2 during acute episodes, monitor for hemoptysis (should be < 250 mL / dy)
Flutter Mucus Clearance device
small, hand held plastic pipe w stainless steel ball on inside
facilitates removal of mucus
store away from small children bc steel ball poses choking hazard
CF oxygen admin
monitor closely for o2 narcosis
s: N&V, malaise, fatigue, numbness and tingling of exremities, substernal distress
* children w cystic fibrosis may have chronic co2 retention
CF interventions: GI
high cal, high protein, well balanced diet, multivit + vit ADEK, moitor weight and FTT, monitor stool patterns and for signs of intestinal obstruction, replace pancreatic enzymes (admin w/in 30 min of eating and admin w all snacks, should not be given if NPO), pancreatic enzyme amt = 2-3 stools / dy, pancreatic enzyme capsules can be sprinkled on small amt of food, monitor for constipation, intestinal obstruction, and rectal prolapse, monitor for signs of gerd (sit upright after eating)
CF interventions
monitor BG levels and for signs of DM, adequate salt intake, and fluids w electrolytes in hot weather, monitor bone growth, monitor for signs of retinopathy or nephropathy
SIDS
unexpected death of an apparently healthy infant < 1 yr - autopsy fails to show adequate cause of death
most frequent in winter months
usually during sleep periods
typically 2-3 month olds
higher in boys
higher in Native Americans, african americans, hispanics, lower socioeconomic
lower in breastfed infants and those sleeping w pacifier
SIDS high risk conditions
prone position
use of soft bedding, sleep in a noninfant bed
overheating
cosleeping
mother who smoked / abused substances during pregnancy
exposure to tobacco smoke after birth
SIDS assessment
apneic, blue, lifeless
frothy, blood tinged fluid in nose / mouth
typically in disheveled bed w blankets over head, huddled in corner
clutching bedding
diaper may be wet / full of stool
SIDS prevention / interventions
supine position for sleep
monitor for positional plagiocephaly (flat head) caused by supine sleeping position
Foreign body aspiration
most inhaled foreign bodies lodge in the main stem or lobar bronchus
most common: round food - hot dogs, candy, peanuts, popcorn, grapes
FBA assessment
choking, gaggin, coughing, retractions
laryngotracheal obstruction
leads to dyspnea, stridor, cough, hoarseness
bronchial obstruction
paroxysmal cough, wheezing, asymmetrical breath sounds, dyspnea
FBA interventions
nonemergency care:
removal by endoscopy - post: child receives high humidity air, observe for s/sx of edema
Tuberculosis
contagious disease caused by Myocobacterium tuberculosis (acid fast bacillus)
multidrug resistant strains of M. tuberculosis occur bc of child/fam noncompliance w therapeutic regime
route of trans: inhalation of droplets from indv w active TB
increased incidence in urban low income area, nonwhite racial/ethnic group, 1st gen immigrants from endemic countries
*most children infected from a fam member or by an indv w whom they have freq contact
TB assessment
may be asymptomatic
sx: malaise, fever, cough, weight loss, anorexia, lymphadenopathy
specific sx r/t site of infection (lungs, brain, bone)
increased time –> asym expansion of lungs, dec breath sounds, crackles/dullness to percussion
Mantoux test
produces a postive rxn 2 - 10 wks after initial infection
determines if a child has been infected and dev. a sensitivity to the protein of the tubercle bacillus –> positive rxn does not confirm presence of active disease (exposure v. presence)
after a positive rxn –> always positive
tb test should not be at same time as measles immunization (viral interference may cause false negative result)
induration > 15 mm is positive rxn in children > 4yrs w/o high risk fxs
induration > 10 mm is positive rxn in children < 4 yrs and high risk children
induration > 5 mm is positive for highest risk groups (ex. HIV)
TB sputum culture
definitive dx is made by showing the presence of mycobacteria in a culture
cxr supplemental to sputum culture / not definitive alone
gastic washing may be done to obtain specimen
gastric washing
bc infant / young child often swallows sputum instead of expectorating it gastric washing may be used to obtain sputum sample
this is an aspiration of lavaged contents from the fasting stomach
done in the early morning before breakfast
TB interventions
9 month course of isoniazid (INH) may be rx to prevent a latent infection from progressing to clinically active TB, or to prevent infection in high risk children
12 mo course may be prescribed for HIV child
clinically active TB –> combo admin of isoniazid, rifampin (Rifadin), and pyrazinamide daily for 2 mo, then isoniazid and rifampin only 2x weekly for 4 mo
body fluids / urine may turn orange-red w tx
TB hospital
respiratory isolation until meds initiate, sputum cultures show diminishing of organisms, and cough is improved
use personal air purifying gN95 or N100 respirator when caring for child
hemoptysis
coughing up blood
