Exam #2 Respiratory Flashcards
Before born, lungs are not needed.
True
Less than 32-33 weeks of age, baby does not have sufficient amount of surfactant.
True
Biggest change in the NICU is the development of surfactant
If less than 34 weeks 1st dose of surfactant is given at birth
Fake surfactant = decrease incidence of -
RDS - Respiratory Distress Syndrome
and
BPD- Bronchopulmonary Dysplasia
** Respiratory Distress Syndrome =
Lack of Surfactant
Bronchopulmonary Dysplasia
hard alveoli due to constant ventilator causing positive pressure.
lung tissues get pounded until gets tough
Treatment for Apnea of Prematurity
Caffeine
Can give through IV or Orally
Monitor for Toxicity
What is Apnea of Prematurity?
pause longer than 20 seconds
Apnea spells can last so long that they cause bradycardia
Sudden Infant Death Syndrome (SIDS) interventions:
sleep on back
No Bumpers
pacifier after 1 month
A + B Spells =
Apnea and Brady
How premie tells us they are sick
If alarm goes off, ASSESS FIRST
Infants breathe periodically- breathe, Breathe, Pause
—-Happens in Premature babies
Preterm babies =
Bronchiolitis
** S/S of Caffeine Toxicity
vomit
Irritable
Tachycardia
Jittery/ excitability
Tremors
Toddlers and Preschoolers breathe abdominally
True
use of abdominal muscles to breathe until 5 years old
Infants have irregular breathing patterns and are nose breathers.
True
they have smaller, less rigid airways
smaller lung size
horizontal, short eustachian tubes in Infants
Immature immune systems
Surfactant was given in clinical trials and had to stop because was unethical.
True….I guess….
What is a late sign of respiratory distress?
Cyanosis
Assessing Respiratory Status - VISUAL ASSESSMENT =
- work of breathing such as grunting, flaring, retracting
- Rate of breathing
- Chest Movement- is it equal?
- Posture and activity level - Well Flexed alert and awake**
- Sensorium (LOC)
- Level of comfort
- Color- skin and mucus membranes
- pink? sats in the 90’s
- Grey? 80’s or lower
- Worried about mucus membranes
Assessing Respiratory status - AUSCULTATION
Without the stethoscope you can hear grunting, stridor, or wheezing.
With Stethoscope- inspiratory and expiratory- will usually tell us if it is something in the upper or lower airway
Baby- Listen to Axillae and back
Older listen to front and back
While grunting- baby uses abdominal muscles to push air out.
True
What are the cardinal signs of respiratory distress?
Tachypnea
Restlessness (Huge sign) , Confusion, Anxiety, Irritability
Tachycardia
Diaphoresis
What is the earliest sign of respiratory distress?
Tachycardia
What are additional signs of respiratory distress?
Wheezing
grunting, flaring, retracting
What are the signs of Impending Respiratory Failure?
Depressed or slow respirations (Decreased inspiratory breath sounds)
Dyspnea
Bradycardia
Somnolence
Stupor/coma
Cyanosis (Central (Mucus membranes)
Oxygen desat
What are 2 signs that a baby is about to code?
80’s o2 sat
and
Bradycardia
Means about to code…,.
O2 Sats falling are a sign of respiratory failure….
true
dont wait for them to become cyanotic
Why is tachypnea a sign of respiratory distress?
because if you have trouble breathing, you are going to breathe faster to get more air.
Acidosis
pH Less than 7.35
Respiratory Acidosis causes =
ventilation problem
need to be ventilated with oxygen
Metabolic Acidosis causes =
Diarrhea, Kidney failure, DKA
Alkalosis =
pH greater than 7.45
Respiratory Alkalosis causes =
test taking, any rapid respiratory rate
to little co2, hyperventilating
Metabolic Alkalosis causes =
Vomiting
Respiratory Acidosis S/S =
Dyspnea Respiratory Distress Shallow respirations Headache Restlessness Confusion Tachycardia Dysrhythmias
Respiratory Alkalosis S/S =
Tachypnea Light Headedness numbness and tingling confusion/ can't concentrate Blurred Vision Dysrhythmia Palpitations / Diaphoresis Dry Mouth, Tetanic spasms of arms and legs
CPAP-
has prongs gives positive pressure to keep stimulus for breathing….
Piaget — FUNCTIONAL
blow balloons and bubbles in place of Incentive Spirometer.
Oxygen Safety?
AVOID NYLON AND WOOL
- Avoids materials that generate static electricity, such as wool blankets and synthetic fabrics, Cotton Fabrics and blankets.
- Avoid the use of volatile, flammable materials such as oils, greases, alcohol, ether, and acetone (Nail polish remover) near clients receiving oxygen
- make sure that electric devices (such as razors, hearing aids, radios, TV, and heating pads) are in good working order to prevent the occurrence of short circuit sparks.
- For home oxygen use teach family members to smoke outside away from the client.
Respiratory Scoring Sheet
Gives an Idea and can help determine if kids can leave the PICU
Inspiratory sounds-
Inspiratory Stridor = Upper airway obstruction (Trachea)
Wheezing- Exhalation =
Lower airway obstruction (Asthma, Bronchiolitis)
Bronchioles and alveoli
Upper Airway Obstruction causes :
Foreign body aspiration
Swelling of tissues (Croup, tonsils, Epiglotis)
Congenital Narrowing of upper airway
Clinical Signs of Upper airway Obstruction :
Tachypnea
Increased Respiratory Effort
Hoarse voice or Cry (seal like cough)
Stridor
Croup = 4 types of croup
- larygotracheobronchitis
- Acute spasmotic croup
- Epiglotis
- Bacterial tracheitis
Croup General Info-
late autumn / early winter
6 months to 3 years
Barking cough, hoarseness, inspiratory stridor
respiratory distress
What is the most common type of croup?
- larygotracheobronchitis
larygotracheobronchitis LTB
or laryngotracheitis
Most common of the croup syndromes.
- Sound worse than they look
- Abrupt Onset, usually at night
Generally Effects children LESS THAN 3 years
Organisms responsible : Viral
- RSV, Parainfluenza virus, Mycoplasma pneumoniae, Influenza A and B
Treatment of Croup LTB - (larygotracheobronchitis)
Dexamethasone - Oral or IM
- 0.6 mg/kg - Duration of action is 48 - 96 hours***
Nebulized Epinepherine - Racemic Epinepherine
- Used to dilate the airway
- Alpha adrenergic Effects = Mucosal Vasoconstriction
- Duration 1 - 2 hours ***
- Observe the patient for 2 - 4 hours (to make sure
airway doesnt collapse again.)
Dexamethasone - Oral or IM
- 0.6 mg/kg
- Duration of action is 48 - 96 hours***
Nebulized Epinepherine - Racemic Epinepherine
- Used to dilate the airway
- Alpha adrenergic Effects = Mucosal Vasoconstriction
- Duration 1 - 2 hours ***
- Observe the patient for 2 - 4 hours (to make sure
airway doesnt collapse again.)
Croup LTB Info-
Cough medications and decongestant meds are contranindicated because want baby to cry and cough to keep airway patent.
Over the counter medications, esp cough and cold meds should not be administered to CHILDREN UNDER 2 YEARS OF AGE *******
Controversy over whether cool humidified air works. Still may recommend cold water vaporizers, shower vapor, cool night air.
Suction out the child
Over the counter medications, esp cough and cold meds should not be administered to CHILDREN UNDER 2 YEARS OF AGE *******
true
Epiglottitis -
MEDICAL EMERGENCY
Sudden swelling and about to swell shut
Can’t talk
Elective intubation
Dysphagia cannot swallow
Epiglottitis Clinical Manifestations:
- Sudden Onset, Fever and sore throat
- Usually in patients 2 - 8 years old
****Drooling, Dysphonia, Dysphagia
- Tripod positioning with retractions and flaring
- Inspiratory Stridor, mild hypoxia, distress
**** Not hoarse, NO COUGH
Epiglottitis Diagnostic Testing :
Lateral neck x-ray
Thumb print on x-ray is indicative of swollen epiglottis
Epiglottitis positioning =
stay with child and parent can keep child calm. Ask for the people to come to them. Let them stay in whichever position they are in.
Therapeutic Management of Epiglottitis
Potential for respiratory obstruction
Nursing Considerations:
- No Tongue Blades
- Maintain calm
- Emergency Intubation Equipment on hand
- No cultures
Do a conscious sedation and intubate them….
Epiglottitis Prevention -
HIB Vaccine
Influenza Type B
Bacterial Tracheitis-
Attacks the Trachea
Occurs in the fall and winter months
ages 6 months to 6 years
URI for several days or classic viral croup
Staph aureus, H. Influenzae, Strep
Decompensates: high fever, productive cough, respiratory distress
Endotracheal intubation, mechanical ventilation, IV antibiotics
***Same problem as epiglottitis but not 3 D’s
(Dysphagia, Drooling, Dysphonia)
Treat with elective intubation
Lower Airway Obstruction causes:
asthma
Bronchiolitis
Lower Airway Obstruction clinical Signs:
Typically heard on expiration
Wheezing - airway narrows (Rales- crackles)
Rhonchi in larger airway
Tachypnea
Retractions, and nasal flaring
Prolonged expiration phase combined with expiratory effort
Cough
Bronchiolitis
RSV= Respiratory Syncytial Virus- affects small airways
NO ANTIBIOTICS
#1 Nursing Intervention: Contact Isolation #2 Assess Respiratory Status #3 IV Placement #4 I & O's
Bronchiolitis Diagnostics ;
Culture secretions
Bronchiolitis Therapeutic Management :
Hydration
Rest
Humidification
Increased fluid Intake
need pulse ox
bag mask
BP cuff
Bulb Syringe
Bronchiolitis and RR Greater than 60, baby is at risk for
Aspiration
RSV Respiratory Syncytial Virus
Born before 33 weeks give synergist -
Prevention of RSV: Prophylaxis- Palivizumab-
Need once a month during RSV period if under 35 weeks gestation… until 2
Ribavirun - antiretroviral med rarely used. Used for life or death situations only….Not typical treatment for RSV anymore.
When is RSV Season In TN
October - March is RSV season in Tennessee
Asthma -
Chronic Inflammatory disorder of the airways
limited airflow or obstruction that reverses spontaneously or with treatment
bronchial hyperresponsiveness
Episodic tightening of smooth muscle
Trach Care-
- if you go past tip, you are suctioning bronchial tissue
- Normal saline can wash microbes that are around the mouth area into the lungs. Suction the back of the mouth to get the secretions out.
- Non- Sterile cath used to suction mouth first then get sterile cath to suction ET Tube.
- Suction for 3-5 seconds
- 2 Trachs at bedside.. One same size and one smaller.
- Mouth care is as important as trach care.
Anti Inflammatory Drugs-
Inhaled corticosteroids
Oral or Parenteral Corticosteroids
Leukotriene Receptor Antagonists
Inhaled corticosteroids Examples
Flucticasone proprionate ( Flonase, Flovent) Budesonide - (Pulmicort)
Steroids can cause thrush in mouth, use spacer and rinse out mouth with water or brush teeth after use.
Leukotriene Receptor Antagonists
Montelukast (Singulair)
Corticosteroids-
In low doses for asthma
Side effects: Cough, dysphonia, ORAL THRUSH**,
Monitoring: Every 3-6 months- growth parameters
- Can cause diminished growth
Leukotriene Modifiers
Blocks inflammatory and bronchospasm effects of leukotrienes
Zafirlucast (Accolate)- for children 7 years and up
Montelukast sodium (Singulair) for children 1 year and older
***Can cause aggression and anxiety
Montelukast (Singulair) Side Effects:
Headache
Can cause increase in SGOT/SGPT- use cautiously in patients with impaired liver function
Patients with PKU- Montelukast contains phenyalanine
Linked with odd psycho effects such as strange mood changes.
Beta 2 Adrenergic Agonists-
allow smooth muscle to relax
inhaled form hasa a more rapid onset of action than the oral form
side effects: seen mostly in oral form. irritability, tremor, nervousness, and insomnia
Beta 2 Adrenergic Agonists- examples
Albuterol, levabuterol, (Short acting)
Salmeterol - Long acting
Action: Relaxes airway smooth muscle
Indication: Acute and Chronic treatment of Wheezing
Adverse Reactions: Nervousness, tachycardia, jitteriness
Nursing Considerations: Inhalation route has fewer side effects
Albuterol
Sympathomimetic Drug
Stimulates beta 2 adrenergic receptors in lungs causing bronchial smooth muscle relaxation
CAUTION: May increase risk of arrhythmias in Digoxin patients
Side Effects: HA, Nausea, Restlessness, Nervousness, Trembling
Albuterol Overuse
- Loss of bronchodilation effects
2. SEVERE paradoxical Bronchoconstriction
Nursing Considerations for Albuterol
client family teaching
Wait 2 min before inhaling 2nd puff
Salmeterol Servent
long acting - salmeterol (servent)-
Used no more than every 12 hours.
Not used in children under 12 years old
NEVER USED FOR ACUTE SYMPTOMS
What are triggers for asthma :
allergens- dust, animal dander, smoke
Cold air
Weather changes
Infection
Exercise
Fatigue
Emotional Distress
Environmental changes like starting a new school
(ASK ABOUT WHAT THE PATIENTS INDIVIDUAL TRIGGERS ARE)
Atopy
genetic predisposition for the development of an IgE mediated response to common aeroallergens
Strongest predisposing factor for developing asthma
Born with more IgE
All Children have atopy
Hyperresponsiveness to triggers
Antihistimines
Loratadine (Claritin) &Cetirizine (Zyrtec)
Fexofenadine (Allegra)
Loratadine (Claritin) &Cetirizine (Zyrtec) MOA=
competes with histamine on H1 receptor sites
Fexofenadine (Allegra) MOA=
antagonizes histamine effects
What are the side effects of antihistamines?
Side effects: headache, dry mouth, drowsiness
(Opposite of muscarinic man)
Children may experience a paradoxical reaction of restlessness, insomnia, nervousness
Aspirin Triad
A subpopulation of asthmatic patients who react with acute dyspnea within 2 hours after ingestion of aspirin.
Triad: Chronic rhinosinusitis including polyps, severe bronchial asthma, and intolerance to aspirin and other NSAIDs
Client/family education: use acetaminophen
Drug Therapy for Asthma
Long-term meds/ Preventive
Corticosteroids Cromolyn sodium Albuterol Salmeterol Leukotriene modifiers
Drug Therapy for Asthma
Quick relief/Rescue meds
Albuterol
Ipratropium (anticholinergic)
Magnesium sulfate IV
Asthma action plan
…..
Peak Expiratory Flow Rate
80-100% Green
50 – 80 % Yellow
< 50% Red
What is red on peak expiratory flow rate?
less than 50%
What is green on peak expiratory flow rate?
80 - 100%
What is yellow on peak expiratory flow rate?
50 - 80 %
What is the patient teaching for a peak expiratory flow rate?
Done in morning. Standing.
Have child “huff and cough” 2 or 3 times to clear airway and set meter gauge on zero before beginning test.
Asthma meds and nursing management
Baseline assessment of depth, rate, rhythm, and type of patient respirations
Post-treatment assessment of same
Monitor the quality and rate of patient’s pulse
Assess the patient’s lung sound for crackles, rhonchi, and wheezing
Observe fingernails and lips for signs of cyanosis
Client/Family Teaching For Asthma
Instruct patient and family to increase fluid intake to decrease viscosity of lung secretions
Never abruptly discontinue asthma meds
Practice good, oral hygiene
House at 50 – 60 % humidity
No carpet, but if carpet vacuum daily
Status Asthmaticus
Respiratory distress continues despite vigorous therapeutic measures
Medical emergency
Humidified oxygen
Aerosolized short-acting Beta 2 –agonist
IV access
Emergency treatment: epinephrine 0.01 ml/kg SC (maximum dose 0.3 ml)
At risk of asphyxia and respiratory arrest
Goals of Asthma Management
Avoid exacerbation
Avoid allergens
Relieve asthmatic episodes promptly
Relieve bronchospasm
Monitor function with peak flow meter
Self-management of inhalers, devices, and activity regulation
Participate in sports/exercise when asthma controlled
Cystic Fibrosis
Exocrine gland dysfunction that produces multisystem involvement
Most common lethal genetic illness among Caucasian children
Approximately 3% U.S. Caucasian population are symptom-free carriers
Autosomal recessive trait
What is the most reliable diagnostic procedure for cystic fibrosis?
Basis of the most reliable diagnostic procedure: sweat chloride test (pilocarpine iontophoresis)
Normal sweat chloride is < 40 mEq/L
A sweat chloride > than 60 mEq/L is diagnostic
Extra salt and fluid required during hot weather
What is a normal sweat chloride ?
Normal sweat chloride is < 40 mEq/L
What does the level of sweat chloride have to reach in order to be diagnostic for cystic fibrosis?
A sweat chloride > than 60 mEq/L is diagnostic
Respiratory Manifestations of CF
Present in almost all CF patients but onset and extent are variable
Stagnation of mucus and bacterial colonization result in destruction of lung tissue
Tenacious secretions are difficult to expectorate, obstruct bronchi and bronchioles
Decreased O2-CO2 exchange
Results in hypoxia, hypercapnia, acidosis
Compression of pulmonary blood vessels and progressive lung dysfunction lead to pulmonary hypertension, cor pulmonale, respiratory failure, and death
Management of CF
Percussion and postural drainage
Mucolytic agents
Antibiotics – Vancomycin, Tobramycin
Pancreatic enzymes
Supplement fat soluble vitamins
Pulmozyme (dornase alfa)
Action: Enzyme that hydrolyzes the DNA in sputum
Indications: Cystic fibrosis
Nursing indications:
–Given by nebulizer
–Monitor for dysphonis and pharyngitis
CF Diet
Children with CF have an energy intake of 100% to 200% of standards for healthy persons
High protein, high caloric, with unrestricted fat
Azotorrhea =
increased protein in stool
Steatorrhea =
increased fat in stool – greasy stools
Otitis Media
Otitis Media is primarily a result of a dysfunctioning eustachian tube.
AOM
Acute otitis media
OME
Otitis media with effusion
CSOM
Chronic suppurative otitis media
Mastoiditis
…
Risk factors for developing AOM or OME
Less than 2 years of age – peak incidence between 6 and 18 mo
Atopy
Bottle propping
Chronic sinusitis
Cleft palate
Child care attendance
Down syndrome
Immunocompromising conditions
Risk factors for developing AOM or OME
“Passive smoking increases the risk of persistent middle ear effusion by enhancing attachment of the pathogens that cause otitis to the respiratory epithelium in the middle ear space, prolonging the inflammatory response, and impeding drainage through the eustachian tube.”
True or false?
True
Signs and symptoms of AOM
Holding or pulling at ears
Rolling head side to side
Pain
Fever
Enlarged postauricular, cervical lymph glands
Diagnosis of AOM
Acute onset of symptoms
Evidence of middle ear effusion
Signs and symptoms of middle ear inflammation
Treatment of AOM
Spontaneous resolution in 80% children
Wait up to 72 hours for spontaneous resolution while providing pain control
Amoxicillin 90 mg/kg/day divided bid for 10 days
Second-line antibiotic: Augmentin (amoxicillin/clavulanate)
Third-line: ceftriaxone (Rocephin)
What is the second line treatment for AOM?
Second-line antibiotic: Augmentin (amoxicillin/clavulanate)
What is the 1st line treatment for AOM?
Amoxicillin 90 mg/kg/day divided bid for 10 days
What is the 3rd line treatment for AOM?
Third-line: ceftriaxone (Rocephin)
True or False?
Steroids, decongestants, and antihistamines are not recommended for treatment of AOM
True
True or False?
Tonsillectomy does NOT reduce incidence of otitis
true
Nursing Care of AOM
Relief of pain
—-Acetaminophen, Ibuprofen, acetaminophen with codeine
—-Topical –topical benzocaine
—-Local heat over ear while child lies on affected side
Management of OME
75% of cases resolved within 3 months
Temporary hearing deficit
Persistent OME past 3 months with hearing or language delays may benefit from tympanostomy tubes
Myringotomy and tubes
“Placement of tympanostomy tubes is recommended after a total of 4 – 6 months of bilateral effusion with a bilateral hearing deficit.”
True or False
True
Nursing Care For draining ears:
Sterile cotton in ears, still allowing drainage
Moisture barrier on skin
Speech and hearing evaluation
Nursing Care For tubes–
keep bath water and shampoo out of ears – ear plugs
Speech and hearing evaluation
Pneumococcal immunization
Pneumococcal conjugate vaccine –PCV7– and currently PCV 13
Reduced the number of otitis media cases dramatically
S pneumoniae in 50% of children in daycare
Tonsillectomy
Post-op Nursing care:
Observe for bleeding (7 – 10 da)
Position side-lying
Strict intake and output
Oral fluids, or popcicles
Nothing scratchy or salty
Pharyngitis
Gargle with warm saline three times a day
Ice chips/popcicles
Tylenol q 4 – 6 hours
Strep throat
Gargle with warm saline three times a day
Ice chips/popcicles
Tylenol q 4 – 6 hours
Penicillin for 10 days
What is the difference in treatment for strep throat vs pharyngitis?
treatment is the same for both but strep throat requires Penicillin for 10 days.
Acute Streptococcal Pharyngitis
Treat with Penicillin – usually oral for 10 days
—–Erythromycin is allergic to
PCN
May return to school or day care after have been taking antibiotics for a full 24 hour period
Need to discard toothbrush and replace with new one after being on antibiotics for 24 hours
