Lecture 3 Disturbances in respiratory function

Question 1

Behavioral changes in young children that may indicate level of consciousness

Answer 1

1. Ability to tolerate oxygen therapy - most young children will try to pull off the mask if they are alert.
2. Separation anxiety - begins around 6 months, will be observed if the child is alert.

Question 2

When a child in respiratory distress has had increased respiratory effort over a prolonged period, a _ is a critical sign of impending respiratory arrest.

Answer 2

Decrease in respiratory rate.

Question 3

Signs and symptoms of impending respiratory failure

Answer 3

1. Increased restlessness/irritability.
2. Lethargy.
3. Mottled color.
4. Cyanosis.
5. Increased respiratory effort (dyspnea, tachypnea, nasal flaring, intercostal retractions).

Question 4

The sweat chloride test is used to screen for _

Answer 4

Cystic fibrosis.

Question 5

Arterial blood gases

Answer 5

Drawn from the *radial artery*. Ranges:
pH: 7.35-7.45
PaCO₂: 35-45 mm Hg
PaO₂: 80-100 mm Hg
HCO₃: 22-26 mEq/L

Question 6

Oxygen delivery

Answer 6

1. Nasal cannula: Usually well tolerated, but make sure to secure lines. Should not be set higher than 6 L and 44% oxygen.
2. Simple face mask: 35%-60% O₂.
3. Nonrebreather mask: 60%-90% O₂.

Question 7

“Croup”

Answer 7

1. Broad classification for upper airway obstruction, results from inflammation/swelling of the epiglottis and larynx.
2. Inspiratory stridor, “seal-like” barking cough, hoarseness.

Question 8

Acute epiglottitis

Answer 8

1. Medical emergency condition; decreasing due to the use of vaccines - Haemophilus influenzae type b (Hib).
2. Bacterial invasion of the epiglottis marked by high fever, dysphagia and intense throat pain. Child may lean forward in the tripod position.
3. Do not inspect the throat, keep the child calm to prevent the epiglottis from closing, prepare for intubation, use humidified oxygen.
4. Intubation is treatment of choice; tracheotomy if intubation is not possible.

Question 9

Acute laryngotracheobronchitis (LTB)

Answer 9

1. Viral invasion of the upper airways.

2. If stridor is present at rest, the child will be hospitalized. Home management if the child has no stridor at rest.

Question 10

Tonsillitis

Answer 10

1. The tonsils are lymphoid structures that grow until age 12, after which they begin to atrophy.
2. Tonsillectomy - Hemorrhaging may occur for up to 10 days afterward - frequent swallowing, increased heart rate, decreased BP (late sign).
3. No red or brown food or drinks - difficult to distinguish from blood. No drinking from straws.

Question 11

A 4-year-old girl is brought to the emergency department. She has a “froglike” croaking sound on inspiration, is agitated, and is drooling. She insists on sitting upright. The nurse should intervene in which manner?

Answer 11

Notify the physician immediately and be prepared to assist with a tracheostomy or intubation. [This child is exhibiting signs of respiratory distress and possible epiglottitis. Epiglottitis is always a medical emergency requiring antibiotics and airway support for treatment. Sitting up is the position that facilitates breathing in respiratory disease. The oral pharynx should not be visualized. If the epiglottis is inflamed, there is the potential for complete obstruction if it is irritated further.]

Question 12

It is important that a child with acute streptococcal pharyngitis be treated with antibiotics to prevent which condition?

Answer 12

Acute rheumatic fever. [Group A hemolytic streptococcal infection is a brief illness with varying symptoms. It is essential that pharyngitis caused by this organism be treated with appropriate antibiotics to avoid the sequelae of acute rheumatic fever and acute glomerulonephritis.]

Question 13

Respiratory syncytial virus (RSV)

Answer 13

1. The most frequent cause of hospitalization in infants.
2. Immunity to RSV is of short duration, and repeated infections may occur throughout life - no permanent immunity.
3. Diagnosis - nasal/nasopharyngeal secretion sampling.

Question 14

When would you use pulmonary toileting (mechanical clearance)?

Answer 14

After administering a bronchodilator and before feedings.

Question 15

Foreign body aspiration

Answer 15

1. Child younger than 1 year: Back blows/chest thrusts.

2. Child older than 1 year: Abdominal thrusts.

Question 16

Asthma

Answer 16

Most common chronic condition of early childhood.

Question 17

Status asthmaticus

Answer 17

1. When an asthmatic child remains in distress despite aggressive therapy - medical emergency
2. Manifestations: Sweating, sits upright, sudden agitation or sudden quietness, unable to rest.

Question 18

Cystic fibrosis

Answer 18

1. Exocrine gland dysfunction leading to abnormal mucus secretion and obstruction.
2. Autosomal recessive; The most lethal genetic illness among Caucasian children. Both parents must be carriers with a 1:4 chance of having a child with CF.
3. Child will need increased caloric intake (150% of RDA), pancreatic enzyme replacement.
4. Complications: Small intestine problems (mucus), diabetes.

Question 19

Bronchopulmonary dysplasia (BPD)

Answer 19

A chronic inflammatory disorder leading to fibrotic tissue in the lungs that results in decreased surfactant production. Child may require surfactant replacement.

Question 20

Palivizumb (Synagis)

Answer 20

Given to BPD patients for RSV prophylaxis.

Question 21

A child with asthma is having pulmonary function tests. What rationale explains the purpose of the peak expiratory flow rate?

Answer 21

To assess the severity of asthma. [Peak expiratory flow rate monitoring is used to monitor the child’s current pulmonary function. It can be used to manage exacerbations and for daily long-term management.]

Question 22

A child with cystic fibrosis (CF) receives aerosolized bronchodilator medication. When should this medication be administered?

Answer 22

Before chest physiotherapy (CPT). [Bronchodilators should be given before CPT to open bronchi and make expectoration easier. These medications are not helpful when used after CPT. Oxygen is administered only in acute episodes, with caution, because of chronic carbon dioxide retention.]

Question 23

The parent of a child with cystic fibrosis (CF) calls the clinic nurse to report that the child has developed tachypnea, tachycardia, dyspnea, pallor, and cyanosis. The nurse should tell the parent to bring the child to the clinic because these signs and symptoms are suggestive of what condition?

Answer 23

Pneumothorax. [Usually the signs of pneumothorax are nonspecific. Tachypnea, tachycardia, dyspnea, pallor, and cyanosis are significant signs and symptoms and are indicative of respiratory distress caused by pneumothorax.]

Question 24

When is bronchial (postural) drainage generally performed?

Answer 24

Before meals and at bedtime. [The therapy should be done at bedtime and before meals or 1 to 1.5 hours after meals to avoid stomach upset. Postural drainage is most effective when it is performed after other respiratory therapy interventions, including bronchodilator and nebulizer treatments.]

Question 25

What intervention is necessary when weaning a child from the ventilator?

Answer 25

Cool mist begun immediately after extubation. [A cool mist or noninvasive oxygen therapy is initiated immediately after extubation. Steroids may be administered to minimize any laryngeal edema.]

Question 26

A 3-year-old child with a tracheostomy will soon be discharged. What recommendation should the nurse share with the family?

Answer 26

Avoid exposure to noxious fumes such as paint or varnish.

Question 27

The nurse is reviewing factors that affect lung development. What factor delays surfactant production and maturation of alveolar cells?

Answer 27

Excess of endogenous insulin.

Question 28

_ is an acute condition caused by respiratory syncytial virus

Answer 28

Bronchiolitis.

Question 29

Children who are taking long-term inhaled steroids should be assessed frequently for what potential complication?

Answer 29

Slowed growth. [The growth of children on long-term inhaled steroids should be assessed frequently to evaluate systemic effects of these drugs.]

Question 30

A child is admitted with acute laryngotracheobronchitis (LTB). The child will most likely be treated with which?

Answer 30

Racemic epinephrine and corticosteroids. [Nebulized epinephrine (racemic epinephrine) is now used in children with LTB that is not alleviated with cool mist. The beta-adrenergic effects cause mucosal vasoconstriction and subsequent decreased subglottic edema. The use of corticosteroids is beneficial because the anti-inflammatory effects decrease subglottic edema.]

Question 31

A 3-year-old is brought to the emergency department with symptoms of stridor, fever, restlessness, and drooling. No coughing is observed. Based on these findings, the nurse should be prepared to assist with what action?

Answer 31

Emergency intubation. [Three clinical observations that are predictive of epiglottitis are absence of spontaneous cough, presence of drooling, and agitation. Nasotracheal intubation or tracheostomy is usually considered for a child with epiglottitis with severe respiratory distress. The throat should not be inspected because airway obstruction can occur, and steroids would not be done first when the child is in severe respiratory distress.]

Question 32

A 3-month-old infant is admitted to the pediatric unit for treatment of bronchiolitis. The infant’s vital signs are T, 101.6° F; P, 106 beats/min apical; and R, 70 breaths/min. The infant is irritable and fussy and coughs frequently. IV fluids are given via a peripheral venipuncture. Fluids by mouth were initially contraindicated for what reason?

Answer 32

Tachypnea. [Fluids by mouth may be contraindicated because of tachypnea, weakness, and fatigue. Therefore, IV fluids are preferred until the acute stage of bronchiolitis has passed.]

Question 33

What medication is contraindicated in children post tonsillectomy and adenoidectomy?

Answer 33

Codeine. [Codeine use in certain children after tonsillectomy or adenoidectomy may lead to rare but life-threatening adverse events or death.]