Module 2 - Pediatric Respiratory Disorders Flashcards
What are the critical differences between adults and children in regard to repsiration?
- Nares (infant take 4-6 weeks before breathing via the mouth)
- Mouth (smaller mouth and larger tongue/tonsils - so a smaller oral cavity proportion makes it more difficult to swallow)
- Faster Respiratory Rate
- Bronchioles and Intercoastal Muscles are Immature (Upper airway shorter and narrower in diameter)
- Short, Horizontal Eustachian Tubes (so if there is a sinus issue some infection can move and cause ear infection)
Why is ear infection so common in PEDS?
their shorter an horizontal eustachian tube makes it easier for infection to move into the ear
Pediatric Assessment Triangle (P.A.T.)
A doorway assessment that can be done before even touching the patient w/ 3 things
- Appearance
- Circulation
- Work of Breathing
What things for Appearance need to be looked at in the PAT?
TICLS
Tone
Interactiveness
Consolability
Look/Gaze
Speech/Cry
What things for Work of Breathing (WoB) need to be looked at in PAT?
Rate of Breathing
Position (are they tripoding?)
Retractions (intercostals, etc)
Anxiety (Hypoxia?)
What things for Circulation need to be looked at in PAT
Color (pale cyanosis, ashen, modeled)
Capillary Refill
What things can we look for (Assess) in a Pediatric Respiratory Assessment?
Color
Capillary Refill
Irregular or Difficulty Breathing
Feeding/Swallowing Problems
Nasal Congestion
Runny Nose
Cough/Stridor (Insp pull/gasp)
Behavior Changes
Irritability Lethargy
Is the cough wet, productive, dry, etc
Tests that can be done for a Pediatric Respiratory Assessment?
CXR
Pulse Ox
Cultures
Example Nursing Diagnosis for Pediatric Respiratory Assessments?
Ineffective Breathing Pattern
Ineffective Airway Clearance
Activity Intolerance
Fear and Anxiety
Knowledge Deficit (Re: Condition, Treatment Plan, Self Care, and Discharge Plan)
Nursing Management for Potential Respiratory Distress?
*If O2 Sats are less than 94%…
- Confirm if the reading is believable (it correlates to heart beat)
- Make sure O2 Sat Probe is Fxning (if anxious and moving could get a false reading)
- Raise HOB or sit child up –> Open Airway (i.e suctioning if needed and ordered) –> Administer O2 (blow by, n/c or face mask) - [This is the order of stuff IF NEEDED]
- Assess for changes in tone, color, VS, etc
- Alert to the appropriate person to communicate changes in O2 and responses to treatment, obtain order for O2 and further actions
Signs of Respiratory Distress needs …
action and reporting to instructor, RN and MD!
Can we administer O2 on our own?
We can, BUT we will eventually need an order on what we had to do and what may need to be done further
What changes should we assess for in children if there is Respiratory Distress?
VS - Especially HR, RR, BP
Mentation/Responsiveness
Tone
Color
Who is at risk for Foreign Body Aspiration?
Infants, Toddlers, Preschoolers - d/t exploration and imitation (check for them putting things in their mouth)
Older Children and Teens - d/t activities while eating like laughing, going to fast, eating too much, high risk activities (esp if intoxicated)
Severity of Foreign Body Aspiration depends on…
Location and Type of Object (ex: popcorn, peanuts, carrots, peanut butter, coins, nails, toys)
Clinical Presentations and Diagnostic Findings of Foreign Body Aspiration
Clinical: Chocking, Cough, Gagging, Hoarseness, Wheezing, Stridor, Drooling and/or Asymmetric Breath Sounds
Diagnostic: CXR, Bronchoscopy
Main methods of Clinical Management for Foreign Body Aspiration
Assessing S/S, Location and Degree of Obstruction
Chest Thrusts and Back Blows for Infants, Abdominal Thrusts, etc
Bronchoscopy
Passage through the GI Tract
PREVENTION!!
Bronchoscopy
Sedation/surgery to remove a foreign body obstruction object
Make sure to monitor vitals after and check gag reflex after they wake up
What should be done for object passage through the GI tract for a foreign object?
Just giving a normal diet with no laxatives for speeding it up
Abdominal Thrusts are often done on choking adults, what should be done though for infants?
Chest thrusts and Back Blows
What is the best clinical management for foreign body aspiration?
PREVENTION
ex: clean up small objects/toys, use Mylar Balloons not latex, positive role model, supervised meals, appropriate size bites ….
Apnea
cessation of respiration for longer than 10 seconds
not always about color changes or limpness or choking
What may be the first sign of resp distress in infants (ex: for respi. dysfunction, illness, sepsis, etc)?
Apnea
What may OR MAY NOT be accompanying Apnea?
Cyanosis
Pallor
Hypotonia
Bradycardia
Apnea of Prematurity
occurs in preterm infants d/t lack of maturity of neuro/respiratory systems
Apparent Life Threatening Event (ATLE)
Episode of apnea accompanied by color change, hypotonia, choking, gagging in infants born >37 weeks and aged >60 days
Occurs more so in full term babies rather than preme
Occurs often
When May ATLE occur?
During sleep, wakefulness, feeding - many different times
What is important to do when an ATLE occurs?
You NEED TO FIND OUT WHAT HAPPENED
Find the situation it occurred and try to watch a recreation of the moment so we can monitor for later episodes
After admission and monitoring, what do parents often go home with for ATLE?
Home Apnea Monitor
CPR Teaching/Training
What is the most common cause of ATLE?
GE Reflux (but it could be anything)
It can come up and then take away breath and lead to aspiration
What is a potential abuse cause of ATLE?
Shaken Baby Syndrome
They may have been shaken or it may be a neurological problem
Sudden Infant Death Syndrome (SIDS)
Sudden death of an infant less than 1 year of age that remained UNEXPLAINED after a complete autopsy, death scene investigation and review of history.
When does SIDS most commonly occur?
Death usually occurs during sleep
Etiology of SIDS
Unknown
it is an unpredictable and unpreventable thing
Risks for SIDS
Prematurity
Drug Exposure
Siblings who have died from SIDS
Prenatal/Postnatal Maternal Smoking
Sleeping prone (be on back not belly)
Nursing Management Technique for SIDS
- Eval coping and grieving
- Provide anticipatory guidance for typical feedings
- Allow parents to verbalize; listen and validate feelings
- Refer family for counseling if needed
- Refer to appropriate community self help groups
- Monitor infants for apnea risk
- Teach parents how to minimize risk of SIDS!!!!
Things to teach parents to minimize the risk of SIDS?
Avoid smoking during and after pregnancy
Encourage putting infants to sleep in supine position unless contraindicated
Avoid soft, moldable mattresses and overheating
Avoid use of pillows
Avoid bed sharing
Obstructive Sleep Apnea
Excessive snoring followed by apnea
They are asleep –> airway muscles relax –> decreased tone and obstruction of the lungs occur –> Decreased ventilation, hypoxia, increased CO2
Can only a Heavyset or Older person get Obstructive Sleep Apnea
No, children can have decreased tone and airway relaxing leading to apnea at night as well, and it can occur all night too
Causes for Obstructive Sleep Apnea
Craniofacial Abnormalities
Obesity
Large Tonsils/Adenoids
Complications that can occur from Obstructive Sleep Apnea
FFT
Cognitive Impairment
Diagnostic/Treatments for Obstructive Sleep Apnea
Sleep Study - Diagnostic
Tonsillectomy - Treatment
Craniofacial Repair - Treatment
CPAP Machine - Treatment
FTT
Failure to Thrive
Not growing well – this makes you fall behind (you do not eat, then do not grow, dont sleep, etc)
Croup Syndromes
Upper Airway Syndromes with multiple possible etiologies
It is like going from breathing through a garden hose to breathing through a coffee straw
Common s/s of Croup Syndromes
Swelling of Epiglottis, Trachea, Larynx, and/or Bronchi
Potential Causes of Croup Syndromes?
Viral or Bacterial Causes: (more likely to be viral)
Acute Spasmodic Laryngitis
Acute Laryngotracheobronchitis (LTB)
Epiglottitis
The more mild type of Croup Syndrome
Acute Spasmodic Laryngitis
The more severe type of Croup Syndrome
Epiglottitis
Acute Spasmodic Laryngitis (Croup Syndrome)
Viral/Allergic Origin
Sudden Onset
Peaks at night, resolves by morning but often reoccurs - common in the cool fall
Clears with humidity and cool fluids (decrease swelling)
Mild hoarseness and Slight Stridor
More mild symptoms
Laryngotracheo-bronchitis (LTB) (Croup Syndrome)
Viral Origin
Usually occurs in winter with quick onset
Barking Cough, Inspiratory Stridor, Retractions, and Low Fever!!!!
Potential for Airway Obstruction
Medium Intensity
Treatment for Laryngotracheo-bronchitis (LTB)
Humidity
Steroids
Racemic Epinephrine via Nebulizer
Stridor
inspiratory high pitch noise common of upper airway swelling
Laryngotracheo-bronchitis can lead to …
hospitalization in the ER with a need for steroids to decrease inflammation
Steroids decrease ____
inflammation
With research, which is found more helpful for bronchiolitis: Nebulized Epinephrine or Albuterol
Nebulized Epinephrine
Epiglottitis (Croup Syndrome)
Bacterial origin (Haemophilus influenzae B)
The worst croup syndrome
Incidence decreases with higher immunization of HIB vaccine
Severe, rapid onset, high fever - very sick
Inflammation of epiglottis causing airway obstruction within minutes to hours
Treatment for Epiglottitis
Maintain the airway - ex: intubate, tracheotomy set at bedside (do not want to lose any minutes)
O2
IV fluids and antibiotics
Special Considerations for Epiglottitis
It is a rapid, progressive, and life threatening issue
Keep the child calm! - they may want to sit forward, drool, mouth open, leaning all because of difficulty breathing
Absent cough d/t swelling - so swollen that you do not get into the throat easy because of risk of spasms
AVOID throat culture, tongue depressor or palpation of throat area - could cause severe laryngospasms progressing to resp. arrest potentially
What is absent in Epiglottitis
COUGH
Steeple Sign
Sign for epiglottitis
In an X Ray the larynx is so tight that it is almost closed and it looks like a steeple/triangle in the throat
Nasopharyngitis
A “Cold”
One of the most common infections of the respiratory tract
What is the principle cause of Nasopharyngitis
Rhinovirus
This is spread from person to person by sneezing, coughing or direct contact
S/S of Nasopharyngitis
Nasal Discharge
Irritability
Sore Throat
Cough
General Discomfort
Treatment for Nasopharyngitis
Clear Airways (esp BEFORE feedings; ex: suction)
Saline Drops (bulb syringe for infants), Humidifier
Adequate Fluid Intake
Prevention of Fever (ex: Tylenol)
Teach parents how to manage
Pharyngitis
could be Viral OR bacterial - we need to know which one!
Essentially Strep
MUST be treated because untreated can lead to inflammation attacking the heart, joint, and maybe even the brain
Why is it important to differentiate if Pharyngitis is Viral or Bacterial?
If it is viral and strep then we must prevent rheumatic fever and peritonsillar abscess
If someone continuously is getting strep (Viral Pharyngitis) then what might need to be done?
Recommendations of Tonsillectomy and Adenoidectomy (T&A)
Post Op Care for T&A
Observe for bleeding
Prevent bleeding by discouraging coughing and throat clearing
Relieve Pain to get them to drink and encourage fluids (no straws because the sucking pulls on the throat)
Position on the side to facilitate drainage
Patient Teaching
What is frequent swallowing an early sign for following T&A?
Bleeding
Things to Teach Patients following T&A
Soft, cold diet: no milk, hot fluids or citrus liquids
Monitor for bleeding, especially 5-10 days post op
Relieve pain, encourage fluids consistently at home
A toddler is being admitted to the pediatric unit with epiglottitis. Which intervention would be the most important for the nurse?
Notify the respiratory therapist of the admission.
Have a tracheotomy set available at bedside.
Have antibiotics prepared when the child arrives on the unit.
Make the child NPO.
Have a tracheotomy set available at bedside
Acute Otitis Media (AOM)
Inflammation / Infection of the Middle Ear
Very common in children and can recur often
Why are some children anatomically prone to AOM?
They have poor Eustachian tube dysfunction with or without a URI (upper resp infection)
What causes Acute Otitis Media?
Hemophilus influenzae
Streptococcus pneumoniae
Feeding infant in supine position (could get fluid moved on accident)
Passive Smoking (causes resp and ear infections)
What two infections often go together?
Ear and Respiratory infections
Nursing Management for Acute Otitis Media (AOM)
Assess Child for Fever and Pain Level
Administer Prescribed Meds (Antibiotics, Antipyretics)
Frequency of AOM may warrant surgery (prepare)
Myringotomy
Assistance with speech and hearing problems if they occurred
Myringotomy
Small incision in the tympanic membrane where “tubes” placed which allows for proper drainage of fluid
It will relieve symptoms of AOM and restore hearing
Things to teach regarding to Myringotomy
Sometimes they fall out, or must be removed
Headsets or Wax need to be used to keep the ear dry
Bronchiolitis
Lower Airway Disorders
inflammation and obstruction of bronchioles
Viral (RSV, influenzas type A and B, etc), Bacteria, or Allergen Cause
S/S of Bronchiolitis
Rhinorrhea
Pharyngitis
Obstruction and Phlegm
Coughing
Sneezing
Wheezing
Intermittent Fever
Severe: Tachypnea (RR>70) (may stop eating), Listless, Diminished Breath Sounds, Apneic Spells
Treatment for Bronchiolitis
Supportive Humidified O2
Rest
Push PO Fluids
IVF’s if tachypneic to prevent aspiration
Respiratory Syncytial Virus (RSV)
Lower airway disorder
RSV is a common cold like virus causing bronchiolitis
transmitted through close or direct contact (day care, shelters, high density group living, older siblings)
S/S for Respiratory Syncytial Virus (RSV)
Airways swell
Produce excess secretions causing obstruction and bronchospasm
URI
fever
rhinitis
progressing to wheeze and course breath sounds
loss PO intake
less energy
increased sleepiness
How to Diagnose RSV
viral cultures from nasal secretions
put children on contact precautions
Therapy/Managements of RSV
Humidified O2, CPT, Isolation Precautions, Handwashing, IVF’s, SUCTION!!!, Family Support
Meds: Bronchodilators (Albuterol, Xopenex)
Synagis and Respigam
Medications to treat RSV
Synagis is IM and is for Premies and Children with underlying conditioons - provides passive immunity
Respigam gives the same passive immunity but is via IV
Pneumonia
Viral or Bacterial Causes
Inflammation or infection of the bronchioles and alveolar spaces of lungs
S/S of Pneumonia
end result is Exudate, creating areas of plugging and consolidation that interferes with gas exchange
Increase cough
SOB with exertion
Nursing Management for Pneumonia
Frequent, persistent coughing can cause muscle strain and interrupted sleep for both child and parent
Tylenol or Ibuprogen for Fever/Pain control
Cough Suppressants not for children, older children for sleep
Supportive therapy like fluids, nutrition, O2 prn
For who with pneumonia is Cough Suppressants for?
Older children to sleep at night, not routinely advised for children - Robitussin with Codeine
Asthma
Chronic inflammatory, obstructive airway disease CHARACTERIZED BY WHEEZING
It impacts the large and small airways with increased mucous, swelling and bronchospasm
Inflammation rises up and it is a deeper inflammation than Croup Syndrome
Triggers for Astham
Exercise
Infection
Allergies and Environmental Irritants (Smoke, weather changes)
Most common chronic disease in children is ___
asthma
Assessment and Management for Asthma in Hospital
Assess for degree of Resp Distress (RR, HR, Color/O2 Sat, Cap Refill)
Breath Sounds, Air Movement, Peak Flow
Assess Fluid Status
Monitor Output - Strict I and O (Weight diapers)
Promote Rest to conserve Energy so there is less O2 need
Medicines like MDI and nebulizer inhalation
Teach about prevention and management at home like Peak Flow Machine
Why is it important to assess fluid status for Asthma
increased RR leads to insensible loss of water, dries out mucous airways and risk of aspiration
Nebulizer Inhalation
Mask for children that administers B adrenergic agonists, long acting B adrenergic agonists, and Corticosteroids in order to treat asthma by reducing inflammation or bronchodilation for easy breathing
MDI
metered dose inhaler (with space)
Peak Flow Meter
a device for asthma management
breath in hard and the tab goes high or low and wherever it lands is your base, and then do again when feeling bad to see difference
Difference determines what action to do next for your asthma plan
Helps find a more objective tidal volume
What is the primary at home goal of Asthma Management?
PREVENTION of issues!!!
use nebulizers, peak flow meters, keeping a log of tx and events
avoid triggers
determine need for MDi and nebulizer and steroids for maintenance and prevention and emergencies
have a clear follow up plan
Triggers for Asthma
ice cold drinks
encase pillow/mattresses
no dust collectors in room
no pets
change clothes after being outside
no cockroaches
Status Asthmaticus
severe, unrelenting respiratory distress with bronchospasm
persists despite medication and supportive interventions
It is a MEDICAL EMERGENCY needing endotracheal intubation with assisted ventilation (may be difficult to intubate since its so tight hard to reverse)
DEATH can be a direct result of poor teaching and mismanagement of medications
Fluids offered to the child with asthma should
not be too cold because they may
- Increase the chance of dehydration
- Trigger reflex bronchospasm
- Cause nausea and vomiting
- Increase mucus
trigger reflex bronchospasm
Bronchipulmonary Dysplasia (BPD)
Fibrous or thickening of the lung (leathery) caused by persistent oxygen need (O2 toxicity) and ventilation given to newborns for a prolonged period of time
What is the main cause of O2 and Vent use leading to BPD?
Respiratory Distress Syndrome (RDS) in newborns
Main cause of RDS in the newborn is ___
prematurity
Clinical Symptoms of BPD
respiratory distress
tachypnea
wheezing
retractions
cyanosis on exertion
grunting
irritability
long term dyspnea can lead to a barrel chest and clubbing (like COPD)
looks a lot like respiratory distress - so eating becomes difficult and they may need small frequent meals instead - feeding, playing or mild URI, and other things become difficult - so they may become skinny
Medical Managements for BPD
Respiratory Support - humid O2, mechanical ventilation, suction, CPT 3-4x a day
Med support - bronchodilators, diuretics, anti inflammatory, antibiotics if needed - want to prevent so use respigam or synagis
Nutritional support - NG tube feedings to conserve energy (calorie time)
Nursing Management for BPD
support safe weaning from oxygen
promote normal growth and development
prepare family for home care needs
teach close monitoring of RR, HR, color and behavioral changes, and how the family unit is coping with caring for this child with special needs
discuss clear parameters for follow up in an acute illness - re admission to the hospital is common and they become ill very quickly
Want to wean them off management and teaching is important for home care needs
Cystic Fibrosis
Exocrine gland releasing thick fluid that affects functioning of the respiratory, GI, endocrine, skin and reproductive systems
Cystic Fibrosis is a major cause of what?
serious chronic lung disease in children, inherited from both parents carrying a gene for the disease (autosomal recessive)
What population is cystic fibrosis most found in?
White Population
Equal Distribution among gender
Median Life Span for Cystic Fibrosis is __ ___
30 years
What glands are important to cystic fibrosis occurring?
Exocrine Glands
How is the Resp System impacted by Cystic Fibrosis
lungs plugged with thick mucous that cannot be easily expectorated, causing atelectasis, air trapping, fibrosis and frequent infections
Respiratory S/S of Cystic Fibrosis
wheezing
dyspnea
cough
cyanosis
Thick mucus in lungs
generalized obstructive emphysema produces characteristic features like barrel chest and finger clubbing – from lack of oxygen
How is the Digestive System impacted by Cystic Fibrosis
secretions prevent digestive from flowing to GI tracts, thus resulting in poor absorption of food
Digestive S/S of Cystic Fibrosis
great appetite
weight loss
FTT
bulky and foul smelling stools are frothy d/t undigested food
rectal prolapse
pancreatic ducts blocked so insulin dependent diabetes may occur
How is the Reproductive System impacted by Cystic Fibrosis
Female will have delayed puberty and decreased fertility (thick cervical mucus)
Males also have decreased fertility (decreased sperm motility, blockage of vas deferens)
How is the Cardiovascular System impacted by Cystic Fibrosis?
right sided heart enlargement and CHF from obstruction of pulmonary blood flow
How is the Integumentary System impacted by Cystic Fibrosis?
Increased concentrations of sodium and chloride in sweat: salty skin surface, tears, and saliva
Primary Presentation of Cystic fibrosis
Meconium ileus in the new born (small bowel obstruction occurs after - not just in elderly this means)
Meconium leads to small bowel obstruction as a young infant
fecal impaction and/or intussusception
steatorrhea (bulky fatty stools)
productive cough, frequent URI, weight loss
Diagnosis of Cystic Fibrosis
Elevated chloride on a sweat test (>50-60)
Steatorrhea
bulky fatty stools
Intussusception
where the intestine folds in on itself because stuck and bulky stool
Nursing Management for Cystic Fibrosis
Therapy - oxygen prn, antibiotics, aerosols and MDIs, postural draining, breathing exercise, prevention of infection
Dietary
Other - general hygiene, dentition may be in poor condition d/t dietary deficiencies, promote growth and development, assist family to adjust to chronic disease and long term implications
What sort of dietary supplements are needed with cystic fibrosis?
Supplemental Pancreatic Enzymes (to help food absorption)
Postural Drainage
chest PT (pound) but in different positions
moves the mucus to make them cough it up or potentially vomit the mucus up
you do it at certain times each day, not when they are full, and it is done BEFORE EACH MEAL
breathing exercises then help aerate as well
Suzie Q., a 3 month old, has cystic fibrosis(CF). The parents want to know how their child got the disease, because no one in the family has CF. The nurse understands that with CF
1. Only one parent carries the CF gene 2. Both parents are carriers of the CF gene 3. The inheritance pattern is multifactoral 4. Was probably the result of a genetic mutation
- both parents are carriers of the CF gene
