Peds Respiratory Flashcards
General concepts
Look first; what do you see?
Is the breathing labored? Is there grunting? Are there retractions? Is there wheezing? Is there stridor? Do you have lung sounds bilaterally? What does it mean if you don’t?
Is there oxygen present? Style of device? How are they breathing through nose, mouth, chest, abdominal? Is there a need for assist control by a ventilator? Is there a set rate?
Where do you take a pulse ox? In infants vs adults? What would you do if you had a reading less than 90?
Is there diaphoretic skin?
Is there a need to be upright?
Is there inability to swallow? Is there drooling?
What is the tone of the skin?
What do you hear when you auscultate for lung sounds?
Do the physician orders correlate to the symptoms?
Is there an IV running? What is the rate? How does this relate to lung sounds?
What is the urine output? Is there retention? How do you know that? How does this relate to lung sounds?
Is there swelling ie pitting edema in the extremities? How does this relate to the heart?
If you hear “wet lungs” what is it helpful to do? Would sitting upright help this situation?
Would Albuterol aerosol be helpful?
If there is drooling present what does that mean to you? What should you not do? What action does this imply?
Respiratory disorders general
Respiratory disorders are the most common cause of illness and death in infants and children.
Distress is due to
Immature immune systems
Smaller upper and lower airways
Underdeveloped supporting cartilage
Usually self-limiting, but distress due to mucus & edema obstructing the airways
Peds respiratory differences General
Smaller upper and lower airways
Underdeveloped supporting cartilage
Less well-developed intercostal muscles
Alveoli have less elasticity
Tongue is large in proportion to oropharynx
Eustachian tubes relatively horizontal
Tonsilar tissue enlarged
Larynx is more anterior, more flexible
Smaller septum; nasal bridge is flat and flexible
Vocal cords located at C3-4 versus C5-6 in adults (Contributes to aspiration if neck is hyperextended)
Smaller airway
Airway narrowest at cricoid ring instead of at vocal cords
Airway diameter is 4 mm (20 mm in adult)
Peds differences - upper
Obligatory nose breather (< 4 months)
Tongue is large in proportion to oropharynx
Larynx is more anterior, more flexible
Eustachian tubes shorter and more horizontal
Epiglottis is large and floppy
Tonsillar tissue enlarged
Trachea shorter, bifurcation higher up
Tracheal diameter size of straw, cartilage rings easily compressed
More smooth muscle makes airway more reactive or sensitive to foreign substances
Peds differences - lower and general
Lack of or insufficient surfactant (preemie) Less well-developed intercostal muscles Alveoli have less elasticity Faster respiratory rate Apnea periods common with newborn
Hyaline membrane disease/BPD Broncho pulmonary dysplasia
Causes of respiratory compromise
Upper or lower respiratory infections Sedative medications CNS disorders Musculoskeletal deformities Congenital anomalies Aspiration
CNS disorders such as muscular dystrophy or cerebral palsy
Genetic defects with curvature of the spine
Diaphramatic hernias
Infection Preventive Teaching measures
Adequate rest
Good nutrition
Good hygiene
Especially HANDWASHING
Nurses must remember to wash hands and not touch eyes/nose (teach patients also)
Change toothbrush esp with bacterial infections (24 hr after starting antibiotics
History, questions to ask
Time of onset of problem ? Rapid or gradual ?
Previous episodes of respiratory distress ?
Presence of a cough ?
Shortness of breath ?
Nasal flaring ?
Nasal congestion ?
Noisy respirations ?
Decreased level of awareness or response ?
Anxiety, confusion, ability to be consoled ?
Difficulty feeding ?
Any episodes of apnea ?
Questions should also include
- medication history - living environment - exposure to respiratory infection
Significant past history
Low birth weight/SGA
Prematurity/Early and Late
Chronic illnesses, including asthma
Previous hospitalization for respiratory illness
International travel
Asthma stemming from BPD and venting
Physical assessment general
Consider the child’s chronological age and developmental level
Be creative in gaining cooperation
Always use appropriate size equipment
Phys assess- inspection
Evaluate color, rate, ease of breathing
Children< 6-7 years of age: abdominal breathing
Children> 6-7 years of age: thoracic breathing
Note shape and size of chest
Note nasal flaring, SOB, retractions, grunting, stridor*
Nasal flaring: a serious sign of air hunger, widening of nares for more oxygen
Retractions: abnormal chest wall movement at inspiration; intercostally and substernally
Grunting: noise audible with or without a stethoscope
Stridor: shrill, harsh sound during inspiration or expiration or both. Air flow through a narrowed segment
Coloring: more in trunk and less to extremities
Phys inspection - auscultation
Follow a systematic pattern
Check for presence or absence of breath sounds
Check for adventitious breath sounds
Listen for intensity, pitch, and duration
Adventitious breath sounds:
Crackles: heard on inspiration
result as air moves through fluid filled alveoli as in pneumonia
may not change after coughing
sound can be simulated by rolling hair between your fingers
Rhonchi: low pitched sounds heard throughout respiration
air passing through thick secretions
may clear after coughing
Stridor high pitched sound heard on inspiration as in croup
Wheezing: heard throughout respirations high pitched musical sound result of air passing thru constricted bronchioles as in asthma
Upper airway problems
Sinusitis Allergic rhinitis Epistaxis Otitis media* Pharyngitis Tonsillitis* Croup* Epiglottitis* Laryngitis Foreign body
Upper respiratory infection – (URI) – common cold
Otitis Media
Middle ear infection
Otitis Media Acute
Otitis Media with Effusion
Peak ages between 6 months and 3 years
Two types
May cause hearing loss or eardrum puncture
Often caused by bacteria: Streptococcus pneumonae or haemophilus influenzae
Can be caused by virus: RSV respiratory syncytial virus
Of all children 84% will have at least one episode before age 3
Otitis media causes/factors
The Eustachian tube is more horizontal, shorter and wider, so secretions do not drain efficiently.
A negative pressure occurs in the middle space , and fluid creates a medium for bacterial growth.
Babies who drink bottles laying flat in a crib rather than a baby seat
Acute otitis media Sx
Febrile High Grade/febrile seizures
Earache, toddlers may pull on ear, infants may rub ear on things
Vomiting, anorexia
Irritability, sleep disturbance, persistent crying
Otoscope findings: tympanic membrane red and bulging.
Otitis media interventions
Administer analgesics Administer antibiotics if ordered* Promote drainage Promote comfort Encourage fluids Instruct parent about the importance of completing the prescribed medications
30 degree elevation, warm or cold compresses, encouraging fluids to liquify secretions
Otitis media with effusion Sx
Tinnitus
Conductive hearing loss may occur
Afebrile
Otoscope findings: tympanic membrane dull gray, orange, immobile
Fluid in the middle ear space without symptoms of an acute ear infection
Children with OME do not act sick*.
Common after acute ear infection
Eustachian tube, which connects the inside of the ear to the back of the throat, becomes blocked
Usually drains secretions from the tube and are swallowed.
When Eustachian tube is partially blocked, fluid accumulates in the middle ear. Bacteria already inside the ear becomes trapped and begins to multiply.
Tonsilitis
Frequent colds and throat infections
Irritation in throat w/ pain, radiating to ears, difficulty eating and drinking, occasional fever, inflamed tonsils
All about tonsilitis
What are tonsils?
mass of lymphoid tissue encircling nasal and oral pharynx
Purpose of tonsils?
prevent bacteria, virus, allergens, etc attempting to attack the human body. As lymphoid tissues, they produce Lymphocytes. which form an immunological network of self-defense.
Symptoms of tonsillitis?
Sore throat (gradual with viral);
DIFFICULTY SWALLOWING (DYSPHAGIA) from pain or large size due to inflammation
Erythema and inflammation of pharynx and tonsils (vesicles on tonsils with viral)
Fever
Apnea during sleep with obstruction of air passage
Snoring due to obstructed air passage
Malaise, loss of appetite, headache, body ache
Examination:
inflamed, red, congested tonsils.
visible small pus pockets
enlarged and mildly painful neck glands palpable
:
Intervention
Differentiate between viral and bacterial with culture
Comfort with rest, soft/liquid diet, cool mist vaporizer, warm gargles, lozenges, Tylenol (codeine)
Antibiotics if bacterial
Surgery after 3-4 infections/year not responding to medical therapy
Analgesics
No red food or liquida)
Discourage coughing or clearing throat
Croup / Acute Laryngotracheobronchitis LTB
Assessment/History What treatment or meds have been given? How effective were meds? Any difficulty swallowing? Drooling present? Has the child been ill? What symptoms noted & what changes?
Differentiate by LOCATION and causative ORGANISM – VIRUS OR BACTERIA
Usually caused by a virus, preceded by a URI
Low grade fever, barking, seal like harsh coughworse at night usually absent by day
Narrowing of the larynx, trachea, bronchi….if severe, stridor may be seen and other signs of resp distress…less likely to cause obstruction than epiglottis,
Croup mgmt at home
Place child in bathroom with hot shower running, followed by blast of cool air.
Humidifiers
Fluids
Ibuprofen
Croup management in hospital
Assess & monitor ABC’s
High flow humidified O2
Limit exam/handling to avoid agitation
Be prepared for respiratory arrest & CPR
Do not place instruments in mouth or throat
Supportive nursing care; administer steroids as ordered.
Corticosteroids such as Dexamethasone with side effects of hypertension and elevated glucose levels
Beta adrenergics such as epinephrine are rapid acting aerosols which decrease inflamation and mucus production Beta adrenergics can lead to tachycardia, hypertension, headache and anxiety
Milk products increase mucus production….
