Chapter 40: Nursing Care of the Child with an Alteration in Gas Exchange/Respiratory Disorder Flashcards
Exam 2
What must be done to prevent life threatening complications?
Must detect problems and intervene early to prevent life-threatening complications
The most common causes of illness and hospitalization in children
Alterations in gas exchange (respiratory disorders) are the most common causes of illness and hospitalization in children
What accounts for the majority of acute illnesses in children
Respiratory infections account for the majority of acute illnesses in children
What can influence both the development of respiratory disorders and the course of the illness?
Age, socioeconomic status, and general health status can influence both the development of respiratory disorders and the course of the illness
Age, socioeconomic status, and general health status can influence both the development of respiratory disorders and the course of the illness
What is an example?
E.g. low-income children have a higher risk for increased severity or increased frequency of respiratory disease
What is key to solving respiratory problems?
Expert assessment skills and early intervention are key
Anatomy and Physiology of the Child’s Nose and Throat:
Infant Nose:
How do infants breath?
How much mucus made?
What are they susceptible to?
What are not developed?
Obligate/preferential nose breathers
Produce very little mucus
More susceptible to infections
Sinuses are not developed
Anatomy and Physiology of the Child’s Nose and Throat:
Newborn Nose:
Very small nasal passages
More prone to obstruction
Anatomy and Physiology of the Child’s Nose and Throat
Throat- What are children at increased risk for?
Increased risk for airway obstruction
Anatomy and Physiology of the Child’s Nose and Throat
Throat- Why are children at increased risk for obstruction?
Infants’ tongues larger in relation to oropharnyx
Children have enlarged tonsilar and adenoid tissue
Lower Respiratory Structures include
Bifurcation of trachea
Narrower bronchi and bronchioles
Smaller numbers of alveoli
Airway much more compliant
Lower Respiratory Structures:
Bifurcation of trachea
Bifurcation of trachea at level of the third thoracic vertebra compared to 6th in adults: important when suctioning or intubating children
Lower Respiratory Structures:
Narrower bronchi and bronchioles increased risk for?
Narrower bronchi and bronchioles of infants and children: increased risk for lower airway obstruction
Lower Respiratory Structures:
Smaller numbers of alveoli: puts children at increased risk for ?
Smaller numbers of alveoli: higher risk of hypoxemia
Lower Respiratory Structures:
Airway much more compliant- puts children at increased risk for ?
Airway much more compliant- making it more susceptible to collapse in presence of airway obstruction.
Chest Wall:
How are infant chest walls? How do they support the lungs?
Infants’ chest walls are highly compliant (pliable) and fail to support the lungs adequately.
Chest Wall:
How is functional residual capacity?
Functional residual capacity can be greatly reduced if respiratory effort is diminished
Chest Wall:
What does lack of lung support lead to?
This lack of lung support also makes the tidal volume of infants and toddlers almost completely dependent upon movement of the diaphragm.
Metabolic Rate and Oxygen Need:
How does children metabolic rate compare to adult?
Children have a significantly higher metabolic rate than adults
Chest wall
If diaphragm movement is impaired what happens?
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.
Metabolic Rate and Oxygen Need:
How RR of children than adult?
Resting respiratory rates are faster and their demand for oxygen is higher.
Metabolic Rate and Oxygen Need:
How does child oxygen consumption compare to adult?
Adult oxygen consumption is 3 to 4 L/min, while infants consume 6 to 8 L/min.
Metabolic Rate and Oxygen Need:
In respiratory distress how are children compared to adults?
In any situation of respiratory distress, infants and children will develop hypoxemia more rapidly than adults
Risk Factors for Respiratory Disorders:
Prematurity
Chronic illness (diabetes, sickle cell anemia, cystic fibrosis, congenital heart disease, chronic lung disease)
Developmental disorders (cerebral palsy)
Passive exposure to cigarette smoke
Immune deficiency
Crowded living conditions or lower socioeconomic status
Daycare attendance
Nursing Assessment for Child with Respiratory Distress:
Health history
Physical exam
Nursing Assessment for Child with Respiratory Distress:
Health history includes:
PMH, FH, Hx present illness, immunization hx, exposure to smoke
Atopy
Atopy
genetic tendency to:
Asthma
Allergic rhinitis
Atopic dermatitis
Nursing Assessment for Child with Respiratory Distress
Physical exam
Inspection and observation
Palpation
Percussion
Auscultation
Inspection and Observation
Anxiety and restlessness
Color: pallor, cyanosis
Hydration status
Clubbing
Breath sounds
Rate and depth of respirations: tachypnea
Respiratory effort
Nose and oral cavity
Cough and other airway noises: stridor
Adventitious Breath Sounds include:
Wheezing
Rales
Adventitious Breath Sounds:
Wheezing
High-pitched sound usually heard on inspiration; sometimes on expiration
Adventitious Breath Sounds:
Wheezing
What does it occur with?
May occur with obstruction in lower trachea or bronchioles
Adventitious Breath Sounds:
Wheezing- What does it occur in?
May occur in asthma or viral infections
Adventitious Breath Sounds
Rales
Crackling sounds heard when alveoli become fluid filled
Adventitious Breath Sounds
Rales- What does it occur with?
May occur with pneumonia
Percussion- What are the things?
Normal/resonant
Flat or dull sounds
Tympany
Hyperresonant
Percussion:
Normal=
Normal= resonant- low pitched, hollow
Percussion:
Flat or dull sounds might be percussed where?
Flat or dull sounds might be percussed over partially consolidated lung tissue, as in pneumonia
Percussion- Tympany
Hollow drum sound- might be percussed with a pneumothorax
Percussion- hyperresonance
What may it be apparent for?
Note the presence of hyperresonance (as might be apparent with asthma).
Laboratory and Diagnostic Tests :
Pulse oximetry:
Chest radiograph
Blood gases:
Nasal-pharyngeal washings:
Rapid strep
Laboratory and Diagnostic Tests :
How is pulse ox?
Pulse oximetry: oxygen saturation might be decreased significantly
Laboratory and Diagnostic Tests :
Chest radiograph:
might reveal hyperinflation and patchy areas of atelectasis or infiltration
Laboratory and Diagnostic Tests :
Blood gases:
might show carbon dioxide retention and hypoxemia
Laboratory and Diagnostic Tests
Nasal-pharyngeal washings:
positive identification of RSV or other viral illness via enzyme-linked immunosorbent assay (ELISA) or immunofluorescent antibody (IFA) testing
Laboratory and Diagnostic Tests
Rapid strep
testing via throat swab
Common Medical Treatments:
Oxygen
High humidity
Suctioning
Chest physiotherapy and postural drainage
Saline gargles or lavage
Mucolytic agents
Chest tubes
Bronchoscopy
Acute Infectious Disorders
Common cold
Sinusitis
Influenza
Pharyngitis, tonsillitis
Laryngitis
Croup syndromes
Pneumonia and bronchitis
Infectious mononucleosis
Acute Infectious Disorders
Common cold
– viral URI or nasopharyngitis; eg, Respiratory syncytial virus (RSV);
Acute Infectious Disorders:
Sinusitis
Sinusitis – bacterial; acute or chronic
Acute Infectious Disorders: Influenza
Influenza – viral infection; ‘the flu’; bacterial infections may follow
Acute Infectious Disorders:
Pharyngitis, tonsillitis–
often viral
Acute Infectious Disorders:
Laryngitis
Laryngitis – inflammation of larynx
Acute Infectious Disorders:
Infectious mononucleosis
–caused by Epstein-Barr virus;
‘kissing disease’, often in adolescence;
spleen rupture, Guillain-Barre syndrome; meningitis
Nursing Management of Epiglottitis:
What is often the cause of Epiglottitis?
How common is it and why?
Most often caused by Haemophilus influenza type b;
become more rare with Hib vaccine
Signs and Symptoms of Bronchiolitis (RSV)
Onset of illness with a clear runny nose (sometimes profuse)
Pharyngitis
Low-grade fever
Development of cough 1 to 3 days into the illness, followed by a wheeze shortly thereafter
Poor feeding
Nursing Management of Epiglottitis:
What should you not do?
Attempt to visualize the throat - larygnospasm
Leave the child unattended
Place the child in a supine position
Nursing Management of Epiglottitis:
What should you do?
Provide 100% oxygen in the least invasive manner
Ensure tracheostomy tray and emergency equipment readily available
Nursing Management of Epiglottitis:
CLINICAL REASONING ALERT!
What is Epiglottitis characterized by?
Epiglottitis is characterized by dysphagia, drooling, anxiety, irritability, and significant respiratory distress.
Nursing Management of Epiglottitis:
CLINICAL REASONING ALERT!
WHat should you prepare for?
Prepare for the event of sudden airway occlusion.
Chronic Respiratory Disorders:
Allergic rhinitis
Asthma
Chronic lung disease
Cystic Fibrosis
Apnea
Chronic Respiratory Disorders:
Allergic rhinitis- What is it associated with?
Associated with asthma and atopic dermatitis
Chronic Respiratory Disorders:
Asthma
Chronic inflammatory airway disorder
Chronic Respiratory Disorders:
Chronic lung diseases aka bronchopulmonary dysplasia
infants who had RSD and require O2 past 28 days
Chronic Respiratory Disorders:
Apnea- and what accompanies it?
absence of breathing for more than 20 seconds; may be accompanied by bradycardia
Chronic Respiratory Disorders:
Apnea-What are the three types
Central
Occurs with other illnesses
Apnea of prematurity
Chronic Respiratory Disorders:
Central Apnea
unrelated to another cause
Chronic Respiratory Disorders:
Apnea of prematurity- What is it a precursor for?
SIDs;
caffeine- theophylline
Pneumonia—Laboratory and Diagnostic Tests
Pulse oximetry:
Pulse oximetry: oxygen saturation might be decreased significantly or within normal range
Pneumonia—Laboratory and Diagnostic Tests
Chest x-ray
Chest x-ray: varies according to child age and causative agent
Pneumonia—Laboratory and Diagnostic Tests
WBC count
White blood cell count: might be elevated in the case of bacterial pneumonia
Pneumonia—Laboratory and Diagnostic Tests
Sputum culture:
may be useful in determining causative bacteria in older children and adolescents
Cystic Fibrosis—Laboratory and Diagnostic Tests
Sweat chloride test:
considered suspicious if the level of chloride in collected sweat is above 50 mEq/L and diagnostic if the level is above 60 mEq/L
Cystic Fibrosis—Laboratory and Diagnostic Tests
Pulse oximetry:
oxygen saturation might be decreased, particularly during a pulmonary exacerbation
Cystic Fibrosis—Laboratory and Diagnostic Tests
Chest Radiograph
Chest radiograph: might reveal hyperinflation, bronchial wall thickening, atelectasis, or infiltration
Cystic Fibrosis—Laboratory and Diagnostic Tests
Pulmonary function tests:
might reveal a decrease in forced vital capacity and forced expiratory volume, with increases in residual volume
Risk Factors for Tuberculosis
TB
HIV infection
Incarceration
Positive recent history of latent TB infection
Immigration or travel to endemic countries
Exposure at home to HIV infected or homeless persons, illicit drug users, persons recently incarcerated, migrant farm workers, or nursing home resident
Asthma
Chronic inflammatory airway disorder- most common chronic illness of childhood
What is the most common chronic illness of childhood?
Asthma
Asthma - symptoms
Airway hyperresponsiveness
Airway edema
Mucus production
Results in airway obstruction that might be partially or completely reversed
Asthma- how do symptoms occur in people?
Some have long periods of control with infrequent exacerbations others have presence of persistent daily symptoms
Asthma Incidence & severity increasing -is caused by
environment
Asthma: Therapeutic Management
Allergens or triggers
Comorbid conditions
“Stepwise” approach –increasing meds as they worsen, backing offtx as they improve
Medications
BOX40.3Stepwise Approach to Asthma Management
How many steps?
6 steps
BOX40.3Stepwise Approach to Asthma Management
What occurs at every step?
All children: child education, environmental control, and management of comorbidities at each step.
BOX40.3Stepwise Approach to Asthma Management
When should you consider referral for asthma specialist?
Consider referral to asthma specialist at step 3.
BOX40.3Stepwise Approach to Asthma Management
Step 2 and above are considered what?
(Step 2 and above are persistent asthma.
Slide 24 read if time?
Probs no time
Asthma Management: How is management decided?
Tiered system of therapy: based on Asthma Severity Classification
Asthma Management
What are rescue meds?
Rescue medicine: short-acting bronchodilators
Asthma Management
What are maintenance meds?
Leukotriene modifiers
Inhaled corticosteroids
Long-acting bronchodilators
Lab and Diagnostic Tests for Asthma
Pulse oximetry:
oxygen saturation may be decreased significantly or normal during a mild exacerbation.
Lab and Diagnostic Tests for Asthma:
Chest radiograph:
Chest radiograph: usually reveals hyperinflation.
\
Lab and Diagnostic Tests for Asthma
Blood gases:
Blood gases: might show carbon dioxide retention and hypoxemia.
Lab and Diagnostic Tests for Asthma:
Pulmonary function tests (PFTs):
Pulmonary function tests (PFTs): can be very useful in determining the degree of disease but are not useful during an acute attack. Children as young as 5 or 6 years might be able to comply with spirometry.
Lab and Diagnostic Tests for Asthma:
Peak expiratory flow rate (PEFR):
Peak expiratory flow rate (PEFR): is decreased during an exacerbation.
Lab and Diagnostic Tests for Asthma:
Allergy testing:
skin test or RAST can determine allergic triggers for the asthmatic child.
What is Asthma Action Plan? What does it do?
Education of child and family
Management plan
Maintenance medications
Age-appropriate spacer or holding chamber with meter-dose inhalers
It also provides guidance on when to call healthcare provider or when to go to the emergency room
Asthma Action Plan:
What does it show?
Written, individualized worksheet that shows you the steps to take to keep asthma from getting worse.
Cystic Fibrosis: What kind of disorder is it?
Autosomal recessive disorder
Cystic Fibrosis: What is the mutation that causes disease?
Cystic fibrosis transmembrane conductance regulator (CFTR) mutation results in problems in exocrine glands
Cystic Fibrosis- What occurs during it?
What decreases with it?
Excess thick, tenacious mucus lining airways causing decreased resistance to infection and air trapping
Decreased pancreatic enzymes and hypersecretion of gastric acids
Cystic Fibrosis Treatment
Chest physiotherapy (multiple times daily)
Inhaled dornase alfa (pulmonary enzyme)
Inhaled antibiotics for exacerbation
Pancreatic enzyme supplementation
ADEK vitamin supplementation
Well-balanced, high-calorie, high-protein diet
Providing Oxygen Supplementation:
What does it require?
Types of ways oxygen is given?
Requires MD or NP order, exception for emergencies – follow policy
Simple mask
NC
Oxygen tent
Providing Oxygen Supplementation:
CLINICAL REASONING ALERT!
Monitor vital signs, color, respiratory effort, pulse oximetry, and level of consciousness before, during, and after oxygen therapy to evaluate its effectiveness.
Alternatives to Traditional Mechanical Ventilation
High frequency oscillators
Nitric oxide inhalation
Perfluorocarbon liquid
Extracorporeal membrane oxygenation (ECMO)
Alternatives to Traditional Mechanical Ventilation
High frequency oscillators
Provide respiratory rates up to 1200 bpm with low tidal volume
Alternatives to Traditional Mechanical Ventilation: Nitric oxide inhalation
Inhaled nitric oxide gas, causes vasodilation to increase blood flow to alveoli
Alternatives to Traditional Mechanical Ventilation: Per fluorocarbon liquid
Acts like a surfactant;
Provides improved gas exchange
Alternatives to Traditional Mechanical Ventilation:
Extracorporeal membrane oxygenation (ECHO)
Blood is removed from the body, warmed, oxygenated and returned to the patient via pump.
Nursing Care Posttonsillectomy
What should you do?
Promoting airway clearance:
Maintaining fluid volume
Relieving pain:
Nursing Care Posttonsillectomy
How to promote airway clearance?
Promoting airway clearance: place child in side-lying or prone position
Nursing Care Posttonsillectomy
How to maintain fluid volume
Discourage coughing
Encourage fluids; avoid citrus, brown, or red fluids
Nursing Care Posttonsillectomy
How to relieve pain?
Relieving pain: ice collar and analgesics with or without narcotics
Nursing Care Posttonsillectomy:
What may indicated bleeding
*Frequent swallowing may indicate bleeding.
Acute Noninfectious Respiratory Disorders include:
Epistaxis
Foreign body aspiration
Acute respiratory distress syndrome
Pneumothorax
Acute Noninfectious Respiratory Disorders: Epistaxis
Bloody nose
Acute Noninfectious Respiratory Disorders: Epistaxis
Where does it usually occur? How does it occur?
Often in the anterior portion of the septum
Can be recurrent and idiopathic
Acute Noninfectious Respiratory Disorders: Foreign body aspiration
solid or liquid substance inhaled in reparatory tract
Small objects smaller than diameter of their airway
Items smaller than 1.25 inch -Toilet paper roll
Acute Noninfectious Respiratory Disorders: Acute Respiratory distress
When can it occur?
May follow another illness or insult
Acute Noninfectious Respiratory Disorders: Acute Respiratory distress
HOw?
Pulmonary edema–> mucosal swelling–> atelectasis –> impaired gas exchange
Acute Noninfectious Respiratory Disorders: Pneumothorax
Collection of air in the pleural space
Acute Noninfectious Respiratory Disorders: Pneumothorax
What occurs in this disorder? What is treatment
Trapped air consumes space in pleural cavity and affected lung may suffer partial or total collapse
Needle aspiration or chest tube
Pneumothorax: Risk factors:
Chest trauma or surgery
Intubation and mechanical ventilation
History of chronic lung disease such as cystic fibrosis
Pneumothorax: Signs and symptoms
Chest pain
Signs of respiratory distress:
Tachypnea
Retractions
Nasal flaring
Grunting
Pneumothorax: Signs and symptoms of respiratory distress
Signs of respiratory distress:
Tachypnea
Retractions
Nasal flaring
Grunting
Tracheostomy
Artificial opening in the airway
What are tracheostomies performed for?
Tracheostomies are performed to relieve airway obstruction, such as with subglottic stenosis (narrowing of the airway sometimes resulting from long-term intubation)
Who are tracheostomies used in?
Used in child who requires chronic mechanical ventilation
Tracheostomy: What does it facilitate?
The tracheostomy facilitates secretion removal, reduces work of breathing, and increases the child’s comfort.
