Chapter 40 Nursing Care of the Child with an Alteration in Gas Exchange/Respiratory Disorder Flashcards
Gas Exchange
Refers to the process by which oxygen is transported to cells and carbon dioxide is transported from cells
What is the most common cause of illness & hospitalization in children?
Alterations in gas exchange (Respiratory Disorders)
Contributing Factors to Respiratory Disorders
Child’s Age: Immature immune system
- Smaller airways
Socioeconomic status: Access to healthcare and good nutrition
- Poor living conditions
General Health Status: Pre-existing conditions
Season: Fall and Winter most prominent
Variations in Pediatric Anatomy & Physiology: Nose
Newborns are preferential nose breathers until at least 4 weeks of age.
- Cannot automatically open his or her mouth to breathe if the nose is obstructed.
- The nares must be patent for breathing to be successful while feeding.
- Newborns breathe through their mouths ONLY while crying.
The upper respiratory mucus serves as a cleansing agent, yet newborns produce very little mucus, making them more susceptible to infection.
Newborns and young infant have very small nasal passages, so when excess mucus is present, airway obstruction is more likely.
Infants are born with maxillary and ethmoid sinuses present.
The frontal sinuses (most often associated with sinus infection) and the sphenoid sinuses develop by age 6 to 8 years.
- Therefore, younger children are less apt to acquire sinus infections compared to adults.
Variations In Pediatric Anatomy & Physiology: Throat
The tongue of the infant relative to the oropharynx is larger than in adults
- Posterior displacement of the tongue can quickly lead to severe airway obstruction.
Through early school age, children tend to have enlarged tonsillar and adenoidal tissue even in the absence of illness. T
- Can contribute to an increased incidence of airway obstruction.
Variations In Pediatric Anatomy & Physiology: Trachea
Airway lumen is smaller in infants and children than in adults
- When edema, mucus, or bronchospasm is present, the capacity for air passage is greatly diminished.
A small reduction in the diameter of a child’s airway (resulting from the presence of edema or mucus) will result in an exponential increase in resistance to airflow
- Increased work of breathing (effort or labor associated with respiration) then occurs
Variations in Pediatric Anatomy & Physiology: Larynx
In teenagers and adults, the larynx is cylindrical and fairly uniform in width.
In infants and children younger than 10 years old, the cricoid cartilage is underdeveloped -> laryngeal narrowing
- Thus, in infants and children, the larynx is funnel shaped. In addition, the larynx and glottis are located higher in the neck, increasing the chance of aspiration of foreign material into the lower airways
Variations In Pediatric Anatomy & Physiology: Lower Respiratory Structures
The bifurcation of the trachea occurs at the level of the third thoracic vertebra in children, compared to the level of the sixth thoracic vertebra in adults
- Contributes to risk for foreign material aspiration.
The bronchi and bronchioles of infants and children are narrower in diameter than the adult’s, placing them at increased risk for lower airway obstruction
- Lower airway obstruction during exhalation often results from bronchiolitis or asthma or is caused by foreign body aspiration into the lower airway.
Alveoli are developed at approximately 24 weeks’ gestation
- Term infants are born with ~ 150 million alveoli.
- At some point between the age of 3 and 8 years, the child has developed the adult number of alveoli of around 300 million
Alveoli make up most of the lung tissue and are the major sites for gas exchange.
- Oxygen moves from the alveolar air to the blood, while carbon dioxide moves from the blood into the alveolar air.
- Smaller numbers of alveoli, particularly in the premature and/or young infant, place the child at a higher risk of hypoxemia & CO2 retention
Hypoxemia
Deficiency in the concentration of oxygen in arterial blood
Variations In Pediatric Anatomy & Physiology: Chest Wall
Infants’ chest walls are highly compliant (pliable) and fail to support the lungs adequately.
Functional residual capacity can be greatly reduced if respiratory effort is diminished.
- Makes the tidal volume of infants and toddlers almost completely dependent upon movement of the diaphragm
If diaphragm movement is impaired (as in states of hyperinflation, such as asthma), the intercostal muscles cannot lift the chest wall and respiration is further compromised
Pediatric Respiratory Assessment
Inspect and observe
- Color: Pale or cyanotic?
Mental Status: Anxious, restless, lethargic
Nose and Oral Cavity:
- Clear or obstructed? Managing secretions?
- Muffled voice?
Respirations:
- Rate and depth: Tachypnea often first sign of respiratory illness
Effort
- Retractions?
- Grunting?
- Stridor?
- Clubbing of nails
- Hydration Status
Variations in Pediatric Anatomy & Physiology: Metabolic Rate & O2 Need
Children have a significantly higher metabolic rate than adults. T
- Resting respiratory rates are faster and their demand for oxygen is higher.
Adult O2 consumption is 3 to 4 L/min, while infants consume 6 to 8 L/min.
In any situation of respiratory distress, infants and children will develop hypoxemia more rapidly than adults
Pallor
Pale appearance that occurs as a result of peripheral vasoconstriction in an effort to conserve oxygen for vital functions
Cyanosis
A bluish tinge to the skin & mucous membranes occurs as a result of hypoxia
Might 1st present circumorally & progress to central cyanosis
- Begins around the mouth
Infant might have pale hands and feet when cold or when ill, as peripheral circulation is not well developed in early infancy.
- Note if the cyanosis is central (involving the midline), as this is a true sign of hypoxia.
Children w/ low RBCs might not demonstrate cyanosis as early in the course of hypoxemia as children with normal hemoglobin levels.
- Absence of cyanosis or the degree of cyanosis present is not always an accurate indication of the severity of respiratory involvement.
Note the rate and depth of respiration as well as work of breathing
What is often the 1st sign of respiratory illness in infants & children?
Tachypnea
Tachypnea
Increased respiratory rate for age
Nursing Assessment: Cough & Other Airway Noises
Note the sound of the cough (Is it wet or productive, dry and hacking, tight?
When does the cough occur? Is it only or mainly at night?).
Also note if noises associated with breathing are present (e.g., grunting, stridor, or audible wheeze).
Grunting occurs on expiration and is produced by premature glottic closure.
- It is an attempt to preserve or increase functional residual capacity.
- Might occur with alveolar collapse or loss of lung volume, such as in atelectasis (a collapsed or airless portion of the lung), pneumonia, and pulmonary edema
Atelectasis
Collapsed/airless portion of the lung
Stridor
A high-pitched, readily audible inspiratory noise that is often a sign of upper airway obstruction
Audible Wheezes
Wheezes that can be heard by the naked ear
Wheezing
A high-pitched sound that usually occurs on expiration, results from obstruction in the lower trachea or bronchioles.
Wheezing that clears w/ coughing is most likely a result of secretions in the lower trachea.
Wheezing resulting from obstruction of the bronchioles, as in bronchiolitis, asthma, chronic lung disease, or cystic fibrosis, does not clear with coughing
Retractions
Inward pulling of soft tissues with respiration
Can occur in the intercostal, subcostal, substernal, supraclavicular, or suprasternal regions
Document the severity of the retractions: mild, moderate, or severe.
Also note the use of accessory neck muscles.
Note the presence of paradoxical breathing
Paradoxical Breathing
Lack of simultaneous chest and abdominal rise with the inspiratory phase).
Restlessness & anxiety accompanied w/tachypnea is associated w/…
…early signs of respiratory distress
Restlessness might progress to listlessness & lethargy if respiratory dysfunction is not addressed
Clubbing
An enlargement of the terminal phalanx of the finger, resulting in a change in the angle of the nail to the fingertip
Usually occurs in those w/chronic respiratory illness
- Result of increased capillary growth as the body attempts to supply more oxygen to distal body cells
Nursing Assessment: Hydration Status
Palpate the infant’s fontanels to determine if sunken
Assess the oral mucosa for color and moisture
Note skin turgor, presence of tears, and adequacy of urine output
Child w/ a respiratory illness is at risk for dehydration.
- Pain related to sore throat or mouth lesions may prevent the child from drinking properly.
- Nasal congestion interferes with the infant’s ability to suck effectively at the breast or bottle
Tachypnea and increased work of breathing interfere with the ability to safely ingest fluids
Nursing Assessment: Palpation
Palpate the sinuses for tenderness in the older child.
Assess for enlargement or tenderness of the lymph nodes of the head and neck
Document alterations in tactile fremitus detected on palpation
- Increased tactile fremitus might occur in the case of pneumonia or pleural effusion.
- Fremitus might be decreased in the case of barrel chest, as with cystic fibrosis.
- Absent fremitus might be noted with pneumothorax or atelectasis.
Compare central and peripheral pulses.
- Note the quality of the pulse as well as the rate. With significant respiratory distress, perfusion often becomes compromised.
- Poor perfusion might be reflected in weaker peripheral pulses (radial, pedal) when compared to central pulses
Nursing Assessment: Percussion
When percussing, note sounds that are not resonant in nature
Flat or dull sounds might be percussed over partially consolidated lung tissue, as in pneumonia.
Tympany might be percussed with a pneumothorax.
Note the presence of hyperresonance (as might be apparent with asthma
Nursing Assessment: Auscultation
Breath sounds should be equal bilaterally. The intensity and pitch should be equal throughout the lungs
- Document diminished breath sounds.
In the absence of concurrent lower respiratory illness, the breath sounds should be clear throughout all lung fields.
During normal respiration, the inspiratory phase is usually softer and longer than the expiratory phase.
- Prolonged expiration is a sign of bronchial or bronchiolar obstruction.
- Bronchiolitis, asthma, pulmonary edema, and an intrathoracic foreign body can cause prolonged expiratory phases.
Infants and young children have thin chest walls.
- When the upper airway is congested (as in a severe cold), the noise produced in the upper airway might be transmitted throughout the lung fields.
- When upper airway congestion is transmitted to the lung fields, the congested sounding noise heard over the trachea is the same type of noise heard over the lungs, but is much louder and more intense.
To ascertain if these sounds are truly adventitious lung sounds or if they are transmitted from the upper airway, auscultate again after the child coughs or his or her nose has been suctioned.
- Another way to discern the difference is to compare auscultatory findings over the trachea to the lung fields to determine if the abnormal sound is truly from within the lung or is actually a sound transmitted from the upper airway
Rales
Crackling sounds result when the alveoli become fluid filled, such as in pneumonia
Common Tests Used for Children with Respiratory Disorders: Allergy Skin Testing
Suggested allergen is applied to skin via scratch, pin, or prick.
Result: A wheal response indicates allergy to the substance.
Indications: Allergic rhinitis, asthma.
Special Considerations: Antihistamines must be discontinued before testing, as they inhibit the test
- Close observation for anaphylaxis is necessary. Epinephrine and emergency equipment should be readily available.
- Some children react to the skin test almost immediately; others take several minutes
Common Tests Used for Children with Respiratory Disorders: Arterial blood gas (ABG)
Invasive method (requires blood sampling) of measuring arterial pH, partial pressure of oxygen and carbon dioxide, and base excess in blood
Indications: Reserved for severe illness, the intubated child, or suspected carbon dioxide retention
Special Considerations: Hold pressure for several minutes after a peripheral arterial stick to avoid bleeding.
- Radial arterial sticks are common and can be very painful.
- Note if the child is crying excessively during the blood draw, as this affects the carbon dioxide level
Common Tests Used for Children with Respiratory Disorders: Chest Radiograph (Chest X-ray)
Radiographic image of the expanded lungs: can show hyperinflation, atelectasis, pneumonia, foreign body, pleural effusion, abnormal heart or lung size
Indications: Bronchiolitis, pneumonia, tuberculosis, asthma, cystic fibrosis, bronchopulmonary dysplasia
Special Considerations: Children may be afraid of the x-ray equipment. If a parent or familiar adult can accompany the child, often the child is less afraid.
- If the child is unable or unwilling to hold still for the x-ray, restraint may be necessary.
- Restraint should be limited to the amount of time needed for the x-ray.
Common Tests Used for Children with Respiratory Disorders: Fluorescent Antibody Testing
Determines presence of respiratory syncytial virus (RSV), adenovirus, influenza, parainfluenza, or Chlamydia in nasopharyngeal secretion
Indications: Bronchiolitis, pneumonia
Special Considerations: To obtain a nasopharyngeal specimen, instill 1–3 mL of sterile normal saline into one nostril, aspirate the contents using a small sterile bulb syringe, place the contents in sterile container, and immediately send them to the lab
Common Tests Used for Children with Respiratory Disorders: Gastric Washing for AFB
Determines presence of AFB (acid-fast bacilli) in stomach (children often swallow sputum)
Indications: TB
Special Considerations: NG tube is inserted, and saline is instilled and suctioned out of the stomach to obtain the specimen
Common Tests Used for Children with Respiratory Disorders: Peak Expiratory Flow
Measures the maximum flow of air (in L/s) that can be forcefully exhaled in 1 second
Indications: Daily use can indicate adequacy of asthma control
Special Considerations: It is important to establish the child’s “personal best” by taking twice-daily readings over a 2-week period while well.
- The average of these is termed “personal best.”
- Charts based on height and age are also available to determine expected peak expiratory flow.
Common Tests Used for Children with Respiratory Disorders: Pulmonary Function Test (PFT)
Measure respiratory flow and lung volumes
Indications: Asthma, cystic fibrosis, chronic lung disease
Special Considerations: Usually performed by a respiratory therapist trained to do the full spectrum of tests.
- Spirometry can be obtained by the trained nurse in the outpatient setting
Common Tests Used for Children with Respiratory Disorders: Pulse Oximetry
Noninvasive method of continuously (or intermittently) measuring oxygen saturation
Indications: Can be useful in any situation in which a child is experiencing respiratory distress
Special Considerations: Probe must be applied correctly to finger, toe, foot, hand, forehead, or ear in order for the machine to appropriately pick up the pulse and oxygen saturation
Common Tests Used for Children with Respiratory Disorders: Rapid Flu Test
Rapid test for detection of influenza A or B
Indications: Influenza
Special Considerations: Should be done in first 24 hours of illness so that medication administration can begin
- Have the child gargle with sterile normal saline and then spit into a sterile container
- Send immediately to the lab
Common Tests Used for Children with Respiratory Disorders: Rapid Strep Test
Instant test for presence of streptococcus A antibody in pharyngeal secretions
Indications: Pharyngitis, tonsillitis
Special Considerations: Results in 5–10 minutes. Negative tests should be backed up with throat culture
Common Tests Used for Children with Respiratory Disorders: RAST (radioallergosorbent test)
Measures minute quantities of immunoglobulin E in the blood
- Carries no risk of anaphylaxis but is not as sensitive as skin testing
Indications: Asthma (food allergies)
Special Considerations: Blood test that is usually sent out to a reference laboratory
Common Tests Used for Children with Respiratory Disorders: Sputum Culture
Bacterial culture of invasive organisms in the sputum
Indications: Pneumonia, cystic fibrosis, TB
Special Considerations: Must be true sputum, not mucus from the mouth or nose.
- Child can deep breathe, cough, and spit, or specimen may be obtained via suctioning of the artificial airway
Common Tests Used for Children with Respiratory Disorders: Sweat Chloride Test
Collection of sweat on filter paper after stimulation of skin with pilocarpine
- Measures concentration of chloride in the sweat
Indications: Cystic Fibrosis
Special Considerations: May be difficult to obtain sweat in a young infant
Common Tests Used for Children with Respiratory Disorders: Tuberculin skin test
Mantoux test (intradermal injection of purified protein derivative)
Indications: TB, chronic cough
Special Considerations: Must be given intradermally; not a valid test if injected incorrectly
Common Medical Treatments: Oxygen
Supplemented via mask, nasal cannula, hood, or tent or via endotracheal or nasotracheal tube
Indications: Hypoxemia, respiratory distress
Special Considerations: Monitor response via work of breathing and pulse oximetry.
Simple Mask
Provides 35%–60% oxygen with a flow rate of 6–10 L/min. Oxygen delivery percentage is affected by respiratory rate, inspiratory flow, and adequacy of mask fit
Nursing Implications:
- Must maintain oxygen flow rate of at least 6 L/min to maintain inspired oxygen concentration and prevent rebreathing of carbon dioxide
- Mask must fit snugly to be effective but should not be so tight as to irritate the face
Venturi Mask
Provides 24%–50% oxygen by using a special gauge at the base of the mask that allows mixing of room air with oxygen flow
Nursing Implications:
- Set oxygen flow rate according to percentage of oxygen desired as indicated on the gauge/dial.
- As with simple mask, must fit snugly
Nasal cannula
Provides LOW oxygen concentration (22%–44%)
Nursing Considerations:
- Must be used with humidification to prevent drying and irritation of airways
- Can provide very small amounts of oxygen (as low as 25 mL/min)
- Maximum recommended liter flow in children is 4 L/min.
- Children can eat or talk while on oxygen.
- Inspired oxygen concentration affected by mouth breathing
- Requires patent nasal passages
Oxygen tent
Provides high-humidity environment with up to 50% oxygen concentration
Nursing Implications:
- Oxygen level drops when tent is opened.
- Must change linen FREQUENTLY as it becomes damp from the humidity.
- Secure edges of tent with blankets or by tucking edges under mattress.
- Young children may be fearful and resistant.
- Mist may interfere with visualization of child inside tent.
Oxygen hood
Provides high concentration (up to 80%–90%) for INFANTS ONLY
- Allows easy access to chest and lower body
Nursing Implications:
- Liter flow must be set at 10–15 L/min.
- Good method for infant but need to remove for feeding
- Can and should be humidified
Partial rebreathing mask
Simple facemask with an oxygen reservoir bag. Provides 50%–60% oxygen concentration
Nursing Implications:
- Must set liter flow rate at 10–12 L/min to prevent rebreathing of carbon dioxide.
- The reservoir bag does not completely empty when child inspires if flow rate is set properly
Nonrebreathing mask
Simple facemask w/ valves at the exhalation ports and an oxygen reservoir bag w/ a valve to prevent exhaled air from entering the reservoir
- Provides 95% oxygen concentration
Nursing Implications:
- Must set liter flow rate at 10–12 L/min to prevent rebreathing of carbon dioxide.
- The reservoir bag does not completely empty when child inspires if flow rate is set properly
Common Medical Treatments: High Humidity
Addition of moisture to inspired air
Indications: Common cold, croup, tonsillectomy
Special Considerations: Infant may require extra blankets with cool mist, and frequent changes of bedclothes under oxygen hood or tent as they become damp.
Common Medical Treatments: Suctioning
Removal of secretions via bulb syringe or suction catheter
Indications: Excessive airway secretions (common cold, flu, bronchiolitis, pertussis)
Special Considerations: Should be done carefully and only as far as recommended for age or tracheostomy tube size, or until cough or gag occurs
Common Medical Treatments: Chest physiotherapy (CPT) & postural drainage
Promotes mucus clearance by mobilizing secretions with the assistance of percussion or vibration accompanied by postural drainage
Indications: Bronchiolitis, pneumonia, cystic fibrosis, or other conditions resulting in increased mucus production
- NOT EFFECTIVE in inflammatory conditions without increased mucus
Special Considerations: May be performed by respiratory therapist in some institutions, by nurses in others.
- In either case, nurses must be familiar with the technique and able to educate families on its use
Common Medical Treatments: Saline Gargles
Relieves throat pain via salt water gargle
Indications: Pharyngitis, tonsillitis
Special Considerations: Recommended for children old enough to understand the concept of gargling (to avoid choking)
Common Medical Treatments: Saline Lavage
NS introduced into the airway, followed by suctioning
Indications: Common cold, flu, bronchiolitis, any condition resulting in increased mucus production in the upper airway
Special Considerations: Very helpful for loosening thick mucus
- Child may need to be in semi-upright position to avoid aspiration
Common Medical Treatments: Chest Tube
Insertion of a drainage tube into the pleural cavity to facilitate removal of air or fluid and allow full lung expansion
Indications: Pneumothorax, empyema
Special Considerations: Should tube become dislodged from container, the chest tube must be clamped immediately, or the open end placed into a container of sterile water to avoid further air entry into the chest cavity
Common Medical Treatments: Bronchoscopy
Introduction of a bronchoscope into the bronchial tree for diagnostic purposes. Also allows for bronchiolar lavage
Indications: Removal of foreign body, cleansing of bronchial tree
Special Considerations: Watch for post-procedure airway swelling, complaints of sore throat.
Upper Respiratory Infections: Acute Nasopharyngitis
AKA “Common Cold”
Causes: Rhinoviruses, parainfluenza, RSV, enteroviruses, adenoviruses, and human metapneumovirus
Clinical Manifestations: (More severe in infants & children than adults)
- Nasal discharge: Thick, white, yellow, or green (can be thin)
- Nasal congestion: Causes mouth breathing
- Sneezing
- Cough
- Headache (varies)
- Fever is common in young and older children
- Irritability/restlessness
Duration: 10 days or less
Potential Complications: Secondary bacterial infections of the ears, throat, sinuses, or lung
Therapeutic Management of Acute Nasopharyngitis
Therapeutic management is directed towards symptom relief
Acute Otitis Media
Therapeutic Management of Otitis Media
