Respiratory Flashcards
Anatomical differences in Pedi
Narrow and short airway (increased risk of obstruction with mucus and edema)
Alveoli is small in size and number (small surface area for gas exchange)
Infants are nose breathers (until 2-4mo)
Shorter, open, and more horizontal eustachian tubes
Abdominal or diaphragmatic breathers until 6yr/o
Weak muscles that keep the airway open
Bigger tongues than adults (risk for obstruction)
1-11 months respirations
30
2 year old respirations
25
4 year old respirations
23
6 year old respirations
21
8 year old respirations
20
10 year old respirations
19
12 year old respirations
19
14 year old respirations
18
16 year old respirations
17
18 year old respirations
16-18
Urgent Respiratory threats
Apnea
Apnea of Prematurity (AOP)
Apnea of infancy or ALTE (Apparent life threatening event)
SIDS (Sudden infant death syndrome)
Normal respiration Rates
The younger the children are the faster they breathe
Thorax and the lungs are the same size, infants must breathe 2-3x more often than an adult for adequate respirations
Characteristics of Respirations
Newborns and infants have episodes of periodic breathing
Normally breathe with an irregular rhythm and may have pauses up to 20 seconds between breaths
Normal unless they show signs of hypoxemia or bradycardia (if they become hypoxic or bradycardic thy have apnea)
Urgent Respiratory threats
Apnea
Apnea of Prematurity (AOP)
BRUE
SIDS (Sudden infant death syndrome)
Apnea
Cessation of breathing for longer than 20 seconds OR for a shorter period of time when associated with hypoxemia or bradycardia (generally occurs in premature infants and newborns that are classified in different categories depending on the age of onset)
Apnea of Prematurity (AOP)
Developmental disorder in premature infants
Occurs as. direct consequence of immature respiratory control
Infants <36wk gestational age: apnea may become evident in the first 2-3 day after birth
Considered clinically significant if the episodes are > 20 seconds in duration or shorter with hypoxia and/or bradycardia
Frequently and severity of symptoms is inversely proportional to gestational age and almost all extremely low birth weight infants (<1000 grams) are effected
Apnea of Prematurity (AOP): Diagnosis of Exclusion
Hypoxemia
Anemia
Infection (sepsis)
Metabolic disorders
Unstable thermal environment
Antepartum administration of Magnesium sulfate or opiates to the mother
Neurologic disorders, including intracranial hemorrhage and neonatal encephalopathy
Necrotizing enterocolitis
Congenital abnormalities of the upper airway
Seizures
Apnea of Prematurity (AOP): Nursing Priorities
Frequent visual/physical assessment and continuous cardiopulmonary monitoring
Continuously monitor patient for changes in color and tome
Make sure they are pink and active or are they cyanotic and flaccid?
Continuous monitoring VS: especially respirations, HR, SPO2 and have room prepared for emergency
Apnea of Prematurity (AOP): Warning alarms
Lower threshold (MD orders specific settings)
Apnea: ≥ 15 or 20 seconds
HR: ≤70 or 80 bpm
SPO2: < 80 or 85%
Apnea of Prematurity (AOP): Treatment
Apneic spells are frequent, prolonged, or associated with bradycardia or frequent decreased SPO2
OR the infant requires intervention with ambu bag, or multiple episodes of tactile stimulation
Often needed for several weeks in AOP until the apnea resolves as the respiratory control of infant matures
Apnea of Prematurity (AOP): Non-pharmacological Treatment
Provide gentle, tactile stimulation (rubbing their chest, stroking the bottom of their feet) if the child becomes apneic
Continuous cardiopulmonary monitoring with apnea settings
Ambu bag, environmental temp control, head and neck position, maintain nasal patency, O2 supplementation to maintain SPO2 90-95%
NCPAP
Apnea of Prematurity (AOP): Pharmacological Treatment
Most commonly used: Methylxanthines (phyllines and Caffeine) stimulates respiratory neural output by inhibiting adenosine receptors
Caffeine is preferred because of its longer half-life, wider margin of safety and lower frequency of A/E
Caffeine A/E: feeding intolerance, tachycardia, tremors, irritability
Apnea of Prematurity (AOP): D/C planning
Increased risk for SIDS but will outgrow it
Parents need to become CPR certified
Teach parents: what to do if child shows apnea at home, provide tactile stimulation, how and when to give medication, home monitor use a safety
BRUE
Refers to idiopathic or pathologic apnea occuring in infants >37 week gestation
Involves significant intervention such as CPR
BRUE: Infant exhibits
Apnea
Change in color
Change in muscle tone
Choking, gagging or coughing
Definition of BRUE
May include apnea, but can occur without apnea
Short periods of apnea <15 seconds can be normal at any age
BRUE: Diagnosis
May different tests, by exclusion: labs, upper GI, Ph probe, EEG, CT, EKG,CXR, skeletal muscle survey, PCG (pneumocardiogram to monitor respirations, HR, nasal airflow, O2), Polysomnography (sleep study, records brain waves)
BRUE): Treatment
If underlying problem is found: treat it
No cause: sent home for monitoring
BRUE: Nursing care
Close and continuous monitoring
Provide gentle tactile stimulation
Educate and support the family
BRUE: D/C planning
Teach home care: apnea monitoring, med admin, monitoring for A/E, CPR class for family members
SIDS (Sudden infant death syndrome)
The sudden death of an infant which remains unexplained after all known and
possible causes have been carefully ruled out through autopsy, death scene investigation, and review of the
medical history. Time of death occurs during sleep.
SIDS (Sudden infant death syndrome): Cause
unknown
Problems with the baby’s ability to wake up (sleep arousal)
Inability for the baby’s body to detect a build-up of carbon dioxide in the blood
SIDS (Sudden infant death syndrome): Peak time
2-4 months of life
SIDS (Sudden infant death syndrome): Incidence
Takes 2250 lives each year, making it the leading cause of death from ages 1 month to 1 year.
Increased incidence in winter. Increased occurrence in lower socio-economical class.
Back to sleep campaign
Reinforce with the parents that
evidence based research has shown and proven that infants that are placed on their belly to sleep are at greater risk for SIDS.
Prone sleeping may cause oropharyngeal obstruction or affect the thermal balance or the arousal state. Also rebreathing of CO2 while in the prone position may be a possible cause for SIDS
Sleeping on soft mattresses or bedding may not be able to move their heads from side to side, and this increases their risk for suffocation and lethal rebreathing. Even lying baby on their side isn’t appropriate anymore.
Infants at Risk for SIDS
Preterm infants Multiple births- where mother has been pregnant several times Low birth weight Low ABGAR scores Recent viral illness Hx of ALTE or AOP Siblings of SIDS victims Males African Americans, Native Americans, Hispanics all have a greater risk for SIDS
Lower Incidence of SIDS in Infants who:
are placed in supine position to sleep sleep in their own crib sleep on firm mattresses are breast fed are put to sleep with pacifier • are immunized
Education for Parents to Reduce Risk for SIDS
A (alone), B (back), C (crib), S (smoking)
Healthy infants on back to sleep
No soft bedding, baby crib bumpers, blankets, quilts or pillows anywhere in your baby’s sleep area. Use a firm
sleep surface, such as a mattress in a safety-approved crib, covered by a fitted sheet.
No stuffed animals or towels while sleeping. Keep soft objects, toys, and loose beefing out of baby’s sleep area.
Infant to sleep in same room as caregiver. No co-sleeping though. Baby should NOT sleep in an adult bed, on a
couch, or on a chair alone, with you, or with anyone else. Infant should sleep in own bed/crib
Do not let baby get too hot; dress infant in light clothing. Make sure nothing covers the baby’s head. Dress baby in
sleep clothing, such as a one-piece sleeper, and don’t use a blanket.
Change the position of the baby’s head to prevent flattening of the baby’s skull (called positional plagiocephaly)
Offer pacifier during naps and at bedtime, the research has shown that it decreases the risk for SIDS
Encourage breastfeeding for as long as possible
Schedule and go to all WCC
Have child immunized
Don’t smoke or let anyone smoke around your baby.
SIDS: After Occurance… :(
Generally no attempt at resuscitation due to signs of prolonged death: rigor mortis, corneal clouding
Once EMS arrives, they notify coroner of time of death.
Arrival at the ER
Questioned by MD and police officers- must perform an autopsy
Returning home without the child
Provide compassionate care- grieving lasts a year
Support Parents- make sure they get involved in a support group
Acute Nasopharyngitis
“common cold”, and like most viruses it usually lasts 7-10 days
Acute Nasopharyngitis: Cause
Rhinovirus RSV Adenovirus Influenzavirus Parainfluenzavirus
Acute Nasopharyngitis: Clinical manifestations in Young children
Fever Irritability Restlessness Sneezing Post nasal drip Cough Diarrhea Runny or dry nose- make sure to keep their nose clean and dry. Decreased appetite
Acute Nasopharyngitis: Clinical manifestations in Older children
Sneezing Chills Muscular aches Post nasal drip Cough Dry throat Runny or dry nose Decreased appetite
Acute Nasopharyngitis: Nursing assessment
Eyes- red, puffy
Nose- red, swollen, make sure their not flaring
Mouth- cough
Throat- red, sore
Respiratory effort- make sure breathing effectively, rising and falling appropriately, and not retracting
Lung sounds- check for adventitious sounds
V/S- especially her RR
SPO2: make sure its at least 92% on room air, if not give supplemental O2
Acute Nasopharyngitis: Nursing diagnosis
Impaired breathing pattern related to presence of semi- thick nasal discharge
Acute pain related to inflammation of the throat
Ineffective airway clearance related to thick secretions characterized by difficulty in breathing
Imbalance nutrition less than body requirements related to respiratory distress AEB…..
Knowledge deficit related to not familiar with the sources of information
Acute Nasopharyngitis: Nursing interventions
Elevate HOB at least 30 degrees
Maintain adequate fluids- because they’re at risk for dehydration
Suction nares PRN, especially before she goes to bed and before she eats
Saline nose drops before feeding and sleep, and before suctioning
Humidification- will help thin secretions
Tylenol/Ibuprofen- if still running a fever
Promote rest- something is very wrong if a child doesn’t want to play
Acute Nasopharyngitis: Goals
Decrease work of breathing Increase Spo2 Less or no pain Decrease temperature Maintain fluid balance Increase PO intake Sleep through the night
Acute Nasopharyngitis: Evaluation
Effectiveness? Did suctioning help? Nose clear? Breathing easier? Flaring or retracting? SPO2? HOB elevated? Were goals achieved?
Acute Nasopharyngitis: Patient teaching
Treating symptoms at home (how to use medications)
Importance of hand washing
When to go to the ER
Warm against OTC cough medications for less than 6yr/o (proven to be ineffective and can be harmful; causing heart palpitations, hyperactivity, and even death, and worsen asthma)
Pharyngitis
Inflammation of the throat with exudate that can cause pain when swallowing
Can occur at any age. Average age of occurrence 5-10 years
Viral or bacterial (Group AB Hemolytic Streptococcus/GABHS)
Pharyngitis: Clinical manifestations
Inflamed throat Strawberry tongue Exudate Pain when swallowing Headache Fever Abdominal pain Cervical lymphadenopathy Sandpaper rash: face,trunk, axillary perineal/ Scarlet fever
Pharyngitis: Nursing assessment
Throat Respiratory effort Lung sounds V/S: Temp., HR, RR, B/P SpO2 Skin Pain
Pharyngitis: Viral or Bacterial
Must do throat swab!!
Quick Strep/Rapid Antigen Test
Throat Culture
Pharyngitis: Treatment plan for GABHS (strep throat)
Must be treated with ABX: Penicillin or Amoxicillin
Allergic to penicillin may use a cephalosporin such as cephalexin (Keflex), Clarithromycin (Biaxin),
Azithromycin (Zithromax, Zmax), or Clindamycin
Pharyngitis: Nursing management
Monitor V/S Monitor I & O’s Monitor Pain Administer IV ABX as ordered Cold/warm compress to neck Warm saline gargles Encourage fluids Recommend soothing /soft foods Humidification Encourage low level activities
Pharyngitis: D/C planning, Teaching
Disease transmission and prevention
High contagiousness of this condition
Importance of hand washing
Make sure the child does not return to school until they have been on ABX for a full 24 hours
Importance of giving the child ABX until finished
No sharing utensils
No eating or drinking after others
Change out toothbrush after 24 hours of being on ABX
Rheumatic fever
Usually occurs 2-6 weeks after pt. infected with GABHS
ASO titers done
Treated with PCN
Prophylactic treatment required and depends on age of child and severity of condition
Acute Glomerulonephritis
Most common post-infectious renal diseases in childhood
ASO titers done
Symptomatic treatment
Tonsillitis
Inflammation/infection of the tonsils
Occurs most often with pharyngitis
May be viral or bacterial
Tonsillitis: Diagnosis
Early rapid strep test/throat culture to determine causative agent
Tonsillitis: Classic S/S
Red, inflamed, enlarged, touching tonsils aka “kissing tonsils”, difficulty swallowing and breathing.
Breathe through mouth because the adenoids enlarge and block the space between the posterior nares
making it difficult or impossible for air to pass from the nose to the throat
Tonsillitis: Treatment
Depends on causative agent
warm, salt water gargles, throat lozenges, Tylenol if patient in pain
Tonsillitis: Surgical Treatment
Severe
Remove the palatine tonsils and it will be nurse’s job to prepare them for surgery and monitor child post-op
Prepare children
Child comes back to surgery: placed on their side or in a prone position with their head to the side to facilitate the drainage of the secretions
Careful suctioning as needed
Avoid coughing and blowing nose
Reddish brown secretions are normal
Bright red blood is not normal and surgeon needs to be be notified immediately
Watch for bleeding for up to 10 days post-operatively
each the family and the patient to avoid red colored liquids and milk based foods (because they increase the production of mucous) initially
Advance from a clear, soft diet to a regular diet. D/C instructions include teaching pt to avoid irritating and spicy foods, avoid gargles and vigorous tooth brushing, avoid coughing or clearing throat, avoid using straws and chewing gum, how to take medication appropriately to control pain/discomfort.
Tonsillitis: Management: Non-pharmacological
Humidification
Warm salt water gargles
Throat lozenges
Tonsillitis: Management: Pharmacological
Tylenol
Antibiotics if bacterial
Tonsillitis: Management: Surgical
Recurrent infections/obstructive sleep apnea
Tonsillectomy/Adenoidectomy: Pre-op Teaching/Consent
Room set up
Tonsillectomy/Adenoidectomy: Post-Op Teaching/Care
Positioning: abdomen/side lying
Monitor for bleeding
Minimize activities that precipitate bleeding
Monitor I & O’s
Otitis Media
Inflammation of the middle ear
Most prevalent diseases of early childhood
Increase incidence between 6 months and 2 years
Breast feed have a lower incidence than those who bottle feed, related to positioning of the baby.
If parents have a history of otitis media, their children will be at greater risk for it. Children who are around passive smoke, in a household with many members, attend day care, cleft lip/palate, have Down’s Syndrome, are at increased risk for it. Most common in winter months
Otitis Media: Risk factors
Environmental
Life style factors
Otitis Media: Triggered by
Bacterial/ viral infection
Allergies
Enlarged tonsils
Otitis Media: Results from:
blocked Eustachian tubes from edema
Acute Otitis Media:
Bacterial infection that causes inflammation of the middle ear space with rapid onset. It is generally caused by
Streptococcus Pneumonia, H.Influenza, and Marxella Cateralis. Usually follows an upper respiratory infection.
Acute Otitis Media: S/S
Painful ear Pulling or rubbing the ears Fever Fussiness or irritability Fluid leaking from the ear Changes in appetite or sleep Trouble hearing
Acute Otitis Media: Diagnosis
Made by a visual inspection with otoscope of tympanic membrane to check for its mobility. Done by MD or Np
Acute Otitis Media: Treatment
Tylenol/Ibuprofen Benzocaine Cold packs ABX- usually Amoxicillin Surgery
Acute Otitis Media: Nursing objectives
Relieving pain either with Tylenol or Tylenol with Codeine, ice pack, or Ibuprofen, or Benzocaine
Facilitate drainage when possible, prevent complications of recurrence
Acute Otitis Media: Teaching
How to hold the baby during feeding, making sure the child is sitting upright, discourage propping of bottle, encourage breastfeeding
Maintain immunization
Decrease exposure to smoke
May need surgical intervention
may also need a tympanostomy, tube placement, and also an adenoidectomy procedure to treat recurrent chronic otitis media.
3 bouts in 6 months, 6 and 12 months, or 6 by 6 years of age.
Otitis Media with Effusion
Generally caused by middle ear infections, may lead to “glue ear”, which is OME, where sticky fluids build up and affect the child’s hearing.
May also lead to unclear speech and behavioral problems.
Otitis Media with Effusion: S/S
OME may have no symptoms at all
Most frequent presentation is covert and overt hearing loss, which mostly fluctuates with season and may be affected in changing position
Plugged ear or a stuffy or wooly feeling in the air
Child is talking loudly or not responding to verbal commands
Have their music/tv turned up really loud.
No c/o pain. No fever.
Speech delay.
Sometimes it can be detected on routine audiometry.
Otitis Media with Effusion: Diagnosis
Visualization of tympanic membrane and use of an otoscope to test for mobility of the tympanic membrane
Otitis Media with Effusion: Treatment
Bilateral myringotomy/PE (pressure equalizing) tubes, surgical placement of tympanostomy tubes (takes only 15 minutes and usually the tubes come out on their own in 6-12 months)
Croup Syndrome
General term applied to a symptom complex characterized by hoarseness, a resonant cough, described as “barking” or “brassy” (croupy), varying degrees of inspiratory stridor, and varying degrees of respiratory distress resulting from swelling or obstruction in the region of the larynx and trachea
Affect the larynx, bronchi, and trachea.
Croup syndromes are described according to the primary anatomical area affected
Acute epiglottitis or Acute supraglottitis:
Serious obstructive inflammatory condition
Predominately in children ages 2 years to 5 years old- but can occur from infancy through adulthood.
H. Influenza B is the main culprit- bacteria
Considered a medical emergency due to fast onset
Epiglottitis looks worse than they sound, there’s a high degree of toxicity, no cough, and dysphagia
Acute epiglottitis or Acute supraglottitis: Clinical manifestations
Sudden abrupt onset of: heigh fever >39 C, Sore, red, swollen throat, Absence of cough
The 4 D’s
▪ Dysphonia- a muffled, hoarse, or absent voice.
▪ Dysphagia- difficulty swallowing due to the pain
▪ Drooling- also due to the pain
▪ Distressed respiratory effort- inspiratory stridor as the larynx becomes obstructed
Agitation/Irritablity
Tripod position- the child may insist on sitting upright and leaning forward, with the chin thrusted out, mouth
open, and the tongue protruding
Expiratory Stridor
Acute epiglottitis or Acute supraglottitis: Diagnosis
Clinical manifestations
Radiography- a lateral neck x-ray, which will show a thumb sign from an enlarged epiglottis
Blood cultures- to show what antibiotic to use
Acute epiglottitis or Acute supraglottitis: Therapeutic Management
Avoid looking in mouth without emergency equipment readily available Calm environment Encourage position of comfort Let caregiver stay with child Emergency intubation/tracheostomy if child is in severe respiratory distress Humidified oxygen Antibiotic therapy Corticosteroids
Acute epiglottitis or Acute supraglottitis: Nursing management
Frequent assessments Continuous cardiopulmonary monitoring Maintain airway patency NPO IV fluid administration as prescribed ABX Provide emotional support Discharge planning- home teaching includes completing a 7-10 day course of antibiotics. For children under the age of 4 years, Rifampin is used for treatment for 4 days.
Laryngotracheobronchitis (LTB)
Most common of croup syndromes affecting children < 5 years of age
Mostly caused by para-influenza virus types 1 & 2, RSV, influenza A & B*
Usually starts as an upper respiratory tract infection that descends to adjacent structures
Inflammation and swelling of the mucosa lining, the larynx, and trachea causes a narrowing of the airway that result in the onset of the classic symptoms like the croupy, barking cough
They sound worse than they look, have a seal-like cough*
Laryngotracheobronchitis (LTB): Clinical manifestations
Gradual onset of low grade-fever- ***
Ill with URI for several days- see a runny nose or cough that’s escalated into a severe cough with hoarseness
(because the inflammation of the trachea and larynx is causing severe swelling)
Inspiratory stridor
Seal like barking cough and hoarseness
Tachypnea
Laryngotracheobronchitis (LTB): Diagnostic tests
Clinical signs and history
Cardiopulmonary monitoring and SPO2 for hypoxemia
Chest x-ray
Laryngotracheobronchitis (LTB): Nursing management of Mild-Moderate symptoms
Humidification, Medications- (IV therapy for hydration and steroids for inflammation), O2 therapy
Observation in ER, sent home if showing good
response to treatment.
Encourage fluids if mild symptoms to prevent dehydration
Uncommonly – children will need intubation and be sent to ICU.
Admitted if moderate to severe symptoms.
If LTB is severe, nebulized Epi is often used in children with severe disease, stridor at rest, retractions, or difficulty breathing, administration of Heliox is used to decrease the work of breathing and relieve airway obstruction.
Laryngotracheobronchitis (LTB): Nursing management of Severe symptoms
Oxygen therapy & Closely monitor pulse oximetry- to monitor O2 status
Nebulized epinephrine- to help with stridor
Corticosteroids
IV therapy
Placing patient on NPO status for RR > 60/ minute, because this puts them at risk for aspiration
ABG/VBG monitoring for acidosis
Accurate & frequent assessments- continuous vigilant observation & accurate assess of respiratory status
because changes in therapy are performed based on your observation as a nurse, child’s response to the therapy, and tolerance of the procedure.
Early signs of airway obstruction include increased pulse, RR, sub-sternal, supra-sternal, and intercostal retractions, nasal flaring, and increased restlessness
Intubation equipment readily available & patient’s code drugs listed on a sheet and readily available
Croup syndromes: Nursing care Goals
Maintain airway patency, meet fluid & nutritional needs, discharge planning, home care teaching
Home care includes monitoring for worsening of symptoms, continued humidity, adequate nutrition/nourishment
Croup syndromes: Nursing Diagnosis
Ineffective breathing pattern related to tracheobronchial obstruction, decreased energy and fatigue
Impaired gas exchange related to altered O2 supply
Altered nutrition: less than body requirements related to expenditure of glycogen stores and inadequate food
and fluid intake prior to admission
Fear/anxiety in parents or child related to acute illness, uncertainty of prognosis, unfamiliar surrounds and
procedures
Knowledge deficits in parent- related to diagnosis, prognosis, treatment, and home care needs
Bronchitis
Inflammation of the large airways
Usually follows an URI in children < 4 years of age
Usually caused from virus
Self-liming, child recovers with symptomatic treatment within 5-10 days
Bronchitis: Clinical manifestations
Course, hacking, dry/non-productive cough with increased severity at night, may turn productive in 2-3 days
Audible wheezing
Bronchitis: Treatment
Antipyretics- if they do run a fever
Analgesics- such as Tylenol and Ibuprofen
Humidity- help with inflammation
Hydration
Cough suppressants (caution: can interfere with clearing secretions, don’t used under 6yr)
Bronchiolitis
An acute viral infection, mostly caused by Respiratory Syncytial Virus (RSV)
Primarily affects the bronchi and bronchioles
Rare in children > 2 years of age
Occurs most often in winter and early spring
Affects boys more than girls
Bronchiolitis: Clinical manifestations
URI (upper respiratory symptoms such as rhinorrhea, pharyngitis, cough, and fever)
Progress to lower tract, more cough, labored breathing, shallow respiration, nasal flaring, retractions, cyanosis Child acting more ill, may refuse to eat, spits up more
May also have emphysema, increased nasal mucous, wheezing, fever
Apnea may be the first recognized indicator of RSV infection in infants < 1 month of age
RSV (Respiratory Syncytial Virus)
Most frequent cause of hospitalization in children less than 1 year old
Peak infection season is November – April
Transmitted through direct person-person contact & by droplet inhalation
RSV (Respiratory Syncytial Virus): Treatment
Primarily supportive, unless high risk give Synagis prophylactically
RSV (Respiratory Syncytial Virus): High risk groups
Infants born before 35 weeks of gestation, infants with chronic lung disease, and infants born with hemodynamically significant congenital heart disease
RSV (Respiratory Syncytial Virus): Synagis
Only product available in the US used for the prevention of RSV infection
It’s a monoclonal antibody and is given monthly in an IM injection to prevent hospitalization of patients who are at high risk for developing RSV
It can be given in 3 or 5 doses depending on patient and severity
RSV (Respiratory Syncytial Virus): Pathophysiology
Edema of bronchioles and thick secretions
Obstruction and hyperinflation
Increased respiratory effort=respiratory distress Respiratory Failure
RSV (Respiratory Syncytial Virus): Clinical manifestations
Fever Cough Tachycardia Cyanosis Tachypnea Retractions Wheezing Sepsis like appearance Apneic episodes (in the very young) Dehydration
RSV (Respiratory Syncytial Virus): Diagnosis
Rapid RSV antigen testing done via nasal aspirate or nasal wash or nasopharyngeal swab
Chest X-Ray
RSV (Respiratory Syncytial Virus)/ Bronchiolitis: Nursing Diagnosis
Ineffective airway clearance related to increased airway secretions, fatigue from coughing, dyspnea, air trapping
Ineffective breathing patterns related to inflamed tracheobronchial tree and progression of bronchiolitis,
increased work of breathing and decreased energy
Fluid volume deficit r/t inability to meet fluid needs and increased metabolic demands
Altered tissue perfusion r/t partially obstructed airways
RSV (Respiratory Syncytial Virus): Nursing management
Separate rooms or grouped with other RSV infected children
Contact and standard precautions
Maintaining respiratory function
Supporting overall physiologic function
Hydration
Reducing child’s and family’s anxiety
Preparing child and family for home- teaching them about med administration, symptoms of RSV, and when to call doctor
Pneumonia
Inflammation of the pulmonary parenchyma or infection in one or both lungs is common in childhood but occurs more frequently in early childhood
May occur as a primary disease or as a complication of another illness
Caused from virus, bacteria, fungus or aspiration
Pneumonia: Clinical manifestations
Fever-Usually high > 39.5 C (103 F) Respiratory: • Cough • Tachypnea • Rhonchi • Crackles • Chest/abdominal pain • Retractions • Flaring • Pallor Behavior: • Irritable • Restless • Lethargic Gastrointestinal: • Anorexia- doesn’t want to eat • Vomiting • Diarrhea
Pneumonia: Nursing care
Respiratory assessment, and a continuous assessment
Monitoring: VS and pulse oximetry
Administration of supplemental oxygen as ordered
IV fluids- to prevent dehydration
Antibiotics- depending
Pharmacological/non-pharmacological pain relieve measures
Elevate HOB to get good chest expansion
Possible Chest tube placement- to remove fluid or air that’s accumulated in the lung
Daily chest x-rays
Provide calm environment- allow for presence of caregivers as they provide a source of comfort for patient
Teach and support patient/family, prepare for d/c- teach regarding O2 needs, medication needs, positioning
Asthma
Chronic inflammatory disorder of the airways characterized by:
Recurring symptoms
Airway obstruction
Bronchial hyper-responsiveness
Asthma: Causes
Exact cause is unknown
Allergies
Frequent viral respiratory infections
Asthma: Early warning signs
Eczema starting in the early months
Frequent lower respiratory symptoms
Respiratory problems appearing before the first birthday
Having a family history of asthma
Asthma: Diagnostics
Classic manifestations: Dyspnea, Wheezing, Coughing
History/Physical Exam:
➢History of chronic cough with absence of infection
➢Diffuse expiratory wheezing
PFT
Incentive spirometry
PEFR
Bronchoprovocation testing
Skin prick testing and immunological testing
Laboratory tests
Frontal and lateral view chest X-ray
Asthma: Diagnostics: Pulmonary function test
Provide an adjective measure of evaluating the presence and degree of lung disease as well as the response to therapy
Asthma: Diagnostics: Incentive spirometry
Performed reliably on children 5-6 years of age
Asthma: Diagnostics: Peak expiratory flow rate
Measures maximum flow of air that can be forcefully exhaled/second
Asthma: Diagnostics: Skin prick testing and immunological testing
For allergen specific IgE, used to ID environmental triggers
Asthma: Diagnostics: Lab tests
CBC
Asthma: Clinical manifestations
Cough Shortness of breath Audible wheeze Malar flush, red ears Cyanosis of nail beds Circumoral cyanosis Dyspnea Nasal flaring Retractions Hyperresonance on chest percussion Coarse and/or crackles and wheezes throughout all the lung fields Sweating Posture/ tripod position Changes in speech Restlessness Anxiety Fatigue
Asthma: Nurse assessment
Airway potency, RR, symmetry, effort, and use of accessory muscles, breath sounds in all
lung fields
Asthma: Nursing alert!
Child who sweats profusely, remains sitting upright, and refuses to lie down is in severe respiratory
distress!!! Pay close attention to this child and have emergency equipment readily available
A child who suddenly becomes agitated or an agitated child who suddenly becomes quiet may have serious
hypoxia and require immediate intervention
Asthma: Triggers
Allergens: indoor (dust mites, mold, etc.) and outdoor (trees, pollen, pollution, etc.)
Irritants (tobacco or wood burning smoke, odors, sprays)
Exercise
Sudden weather or temperature changes (extreme cold or hot)
Seasonal allergens (grass, trees, weed pollen)
Animal dander
Strong emotions
Food
Medications
Asthma: Treatment plan
Step 1. Mild intermittent- Symptoms occur < twice a week
Step 2. Mild persistent- Symptoms occur more than twice a week, but not daily
Step 3 or 4: Moderate persistent- Daily symptoms occur in conjunction with exacerbations twice a week
Step 5 or 6: Severe persistent- Symptoms occur continually, along with frequent exacerbations twice a week
Asthma: Treatment: Non-Pharmacological
Prevention and reduction of exposure to airborne allergens and irritants
Nurses Role: Family and patient teaching on “Allergy proofing the home and community”
Asthma: Treatment: Pharmacological Goals
Preventing and controlling asthma symptoms
Reducing the frequency and severity of the child’s asthma
Reversing airflow obstruction
Providing long term suppression of inflammation
Asthma: Treatment: Short acting meds (Quick action)
Bronchodilators used to treat symptoms and exacerbations. Include SABA Prevent exercise induced asthma Only taken PRN Albuterol Xopenex Terbutaline Metaproterenol
Asthma: Treatment: Long term control
Achieve and maintain control of inflammation
Used daily to control and reduce the number of day or night symptoms
Not used for relief
Symptoms more than 2x/week or who wake > 2x/month should be on a controller medication.
Inhaled corticosteroids: QVAR, Pulmicort, Flovent
Long acting bronchodilators (LABA): Salmeterol Leukotriene Receptor Agonists
Methylxanthines: Theophylline
Asthma: Treatment: Medications types
Metered-dose inhalers, Dry powder inhalers, Liquids that can be used in nebulizers, Pills
Asthma: Treatment: Choosing the right medication
Severity and frequency of symptoms
Child’s age
Child’s developmental level
Child’s coordination- must be able to push down on inhaler and breathe in at same time
Asthma: Treatment: Most common MDIs
Corticosteroids Cromolyn sodium Nedocromil sodium Xopenex Albuterol Metaproterenol Terbutaline Salmeterol (Serevent) Methylxanthines (theophylline)
Asthma: Treatment: Albuterol A/E
shakiness, tremors, tachycardia, hyperactivity
Asthma: Treatment: Glucocorticoids A/E
thrush, modest reduction in height
Asthma: Nurses role
Observe for signs of trouble breathing Teach family on how to avoid allergens Take medications appropriately and caution with A/E and dangers of over use of SABA/LABA Monitor for medication toxicity while in hospital (shakiness, irritability, jitteriness, increased HR) Show how to use PEFM in child >5yr Provide supportive environment At home action plan Have Epipen for severe allergic reaction
Asthma: Nurse warning (status asthmaticus)
Shortness of breath with air movement in the chest restricted to the point of absent breath sounds accompanied by a sudden rise in respiratory rate is an ominous sign indicating ventilatory failure and imminent respiratory arrest
Not hearing any air movement
Continue to display respiratory distress despite vigorous therapeutic treatment with bronchodilators such as Albuterol and Epinephrine are considered to be in Status Asthmaticus.
Status Asthmaticus
A life threatening episode of airway obstruction, unresponsive to common treatment
Medical Emergency
Can result in respiratory failure and death if untreated
It may develop gradually or rapidly
Status Asthmaticus: Therapy
Improving ventilation Decreasing airway resistance Relieving bronchospasms Correcting dehydration and acidosis Allaying child and parent fears/anxieties by providing a quiet, calm, family-centered environment
Status Asthmaticus: Nurses role
Maintain patent airway
Administer humidified O2
Administer 3 neb tx of a beta2-agonist, 20-30 apart (usually Albuterol)
Obtain IV access: hydration and to correct acidosis, IV Epi/Magnesium Sulfate
Monitor ABGs and serum electrolytes
Administer corticosteroids, either PO, IV, or IM to help with inflammation
Prepare for emergency intubation if patient goes into respiratory distress
Have crash cart, code sheet and code drugs readily available
Establish calm environment, allowing parent presence at all times
Cystic Fibrosis
Chronic autosomal recessive disorder of the exocrine glands. It is the most common inherited metabolic disorder
Thick and copious mucous obstructs the small passageways of the affected organs
Cystic Fibrosis: Cause
Inherited as an autosomal recessive trait
Mutated gene for CF is located on the long arm of chromosome 7.
It codes for a protein of 1480 AA called CF-Transmembrane Regulator
Cystic Fibrosis: Areas of abnormal secretions
Bronchial – chronic bronchial pneumonia, emphysema
Small intestine – meconium impaction, bowel obstruction
Pancreatic duct – malabsorption syndrome
Bile duct – biliary fibrosis, portal hypertension
Cystic Fibrosis: Diagnosis
Average age of dx is 14 months
2 Positive sweat chloride tests: a consistent finding of abnormally high NaCl
concentrations in the sweat is a unique characteristic of CF:
Normal < 40 Meq/L
Positive > 60 Meq/L in children
>40 Meq/L in infants
Chest Radiography: patchy atelectasis, obstructive emphysema
Positive family history
72 hour stool sample- steatorrhea (undigested fats), azotorrhea (foul-smelling stools)
Enzyme Analysis- Absence of pancreatic enzymes
Cystic Fibrosis: Clinical Manifestations
Thick, sticky mucous Bowel obstruction (newborn) Intussusception (telescoping bowel) Impaction in infants and toddlers Chronic cough Difficulty in gaining weight FTT-failure to thrive Skin is salty
Cystic Fibrosis: Stool characteristics
Steatorrhea (fatty), frothy, foul smelling, floats. This is because in the pancreas, the thick
secretions block the ducts, which eventually causes pancreatic fibrosis. This blockage prevents essential pancreatic enzymes from reaching the duodenum, which causes marked impairment in the digestion and impairment of nutrients.
Cystic Fibrosis: Goals
- Prevent or minimize pulmonary complications
- Ensure adequate nutrition for growth
- Encourage appropriate physical activity
- Promote a reasonable quality of life for the child and family, which will require a multi-disciplinary approach
Cystic Fibrosis: Management: ABX
to treat pulmonary infections
Cystic Fibrosis: Management: Physical exercise
Very important and is a good adjust to daily ACT. Remember exercise stimulates mucous excretion and provides a sense of well-being and increased sense of self-esteem.
Cystic Fibrosis: Management: Bronchodilators
Improve ventilation.
These may be given in an aerosolized form to open up the bronchi foreasier expectoration. These are administered before percussion and postural drainage, especially when
patient is exhibiting signs of active airway disease or wheezing.
Cystic Fibrosis: Management: Mucolytics
Remove mucopurulent secretions. Another aerosolized medication that’s popular is DNase or
Cystic Fibrosis: Management: Orkambi
New drug
First drug for cystic fibrosis directed at treating the cause of the disease in people who have two copies of a specific mutation
For 12yr/o + who have F508del mutation, which causes the production of an abnormal protein that disrupts thow water and chloride ar transported in the body
Cystic Fibrosis: Management: Airway clearance therapies
Improve ventilation and remove mucopurulent secretions
Performed 2x a day: upon rising and in the evening, more frequently when they have an infection
Perform at least 30 minutes after meal to prevent N/V
➢Chest Percussion Therapy
➢ Postural drainage- kids like wheel barrow pose, walk on their hands & you hold their feet, works great!
➢ Flutter mucous clearance device
➢ Positive expiratory pressure or PEP devices
➢ Active-cycle-of-breathing techniques
➢ High frequency chest compression
Cystic Fibrosis: Management of Gastrointestinal Problems
Pancreatic Enzymes- should be taken at the beginning of the meal and should be taken WITH IN 30 minutes
of eating. These can be swallowed whole or sprinkled on food.
Encourage well-balanced, high protein, high calorie diet due to their impaired intestinal absorption
Fat soluble vitamins: A, D, E, K given in water soluble form for easy digestion
Prevent/treat constipation- treat with laxatives or stool softener
Cystic Fibrosis: Management of Endocrine Problems
Diabetes mellitus (DM) or Cystic fibrosis related diabetes (CFRD) is greater in children with
CF than in general population. CFRD is the most common complication associated with CF.
By age 30 years, approx. 50% of people with CF will develop diabetes
Close monitoring of blood glucose levels is imperative
Cystic Fibrosis: Nursing care/goals
Main goal also is to prevent respiratory infection
Continuous assessment of Respiratory, GI and Endocrine system
Provide supplemental oxygen as needed
Provide ACT therapy/ but not before meals or immediately after meals, to avoid inducing N/V
Administer pancreatic enzymes with all meals and snacks
Teaching regarding consuming a high calorie, high protein diet, medications, therapy
Encourage compliance with therapeutic medication and diet regimen
Cystic Fibrosis: Family support
Long disease process
Persistent need for treatment
Child and family activities are built around treatments- so always involve family around treatment plans
Life long medications expensive
Poor prognosis: increased survival rates due to lung, heart, pancreas, and liver transplantation, mean age of life: 38yr, progressive and incurable
Encourage support groups
Anticipatory grieving- it’s a long disease process and life-long medications become very expensive
BPD (Bronchopulmonary Dysplasia)
BPD can be mild, moderate, or severe. Diagnosis depends on how much extra oxygen a baby needs at the time of his or her original due date. It also depends on how long the baby needs oxygen therapy.
BPD (Bronchopulmonary Dysplasia): Effects…
Affects infants who are born early- usually more than 10 weeks before their due dates- and still need oxygen therapy by the time they reach their original due dates are diagnosed with broncho-pulmonary dysplasia (BPD).
BPD (Bronchopulmonary Dysplasia): Diagnosis
Chest x ray- shows: alveolar damage, inflammation lungs, and scarring of lungs
Blood work- to rule out infection
Echocardiogram- to rule out pulmonary HTN
BPD (Bronchopulmonary Dysplasia) or Chronic Lung Disease: Description
Pathologic process related to alveolar damage from lung disease, prolonged exposure to high peak
inspiratory pressures, antimatter alveoli and respiratory tract.
BPD (Bronchopulmonary Dysplasia) or Chronic Lung Disease: Prognosis
Mortality is 10-25%
BPD (Bronchopulmonary Dysplasia) or Chronic Lung Disease: Clinical manifestations
Dyspnea Barrel chest Inability to wean from ventilator following a course of respiratory distress syndrome Wheezing Cyanosis Irritability Nasal flaring Retractions
BPD (Bronchopulmonary Dysplasia) or Chronic Lung Disease: Therapeutic management
Administer maternal steroids Administer exogenous surfactant post-natal ● Use nasal CPAP Prevent air leaks Use high frequency ventilation Maintain adequate oxygenation Administer bronchodilators Administer diuretics Administer immunizations
BPD (Bronchopulmonary Dysplasia) or Chronic Lung Disease: Care management
Monitor oxygen saturations and VS closely
Avoid hypo/hyperoxemia. So anticipate ABG or VBGs to be done routinely.
Cluster care, provide infant additional time to rest
Observe for signs of fluid overload or pulmonary edema
Assist in preventing upper respiratory infections- includes judicious hand washing and PPE when indicated
Provide increased calorie feedings with human milk fortifiers or protein supplements
BPD (Bronchopulmonary Dysplasia) or Chronic Lung Disease: D/C teaching
Home ventilatory need
Medications, and their AE
Immunizations- go to all well child check ups
Preventing respiratory infections and frequent hospitalizations
Neonatal Respiratory Distress Syndrome (RDS)
Almost exclusively in preterm infants.
Most common lung problem in a premature baby.
The name is applied to respiratory dysfunction in the neonate and is primarily a disease related to developmental delay in lung maturation.
Deficiency in pulmonary surfactant in the infants immature lungs.
Surfactant is a substance that keeps the tiny air sacs in the lungs open.
Responsible for more infant deaths than any other disease.
Carries the highest risk in terms of long term respiratory and neurologic complications.
Neonatal Respiratory Distress Syndrome (RDS): Diagnosis/Clinical manifestations
Tachypnea (> 60 breaths/min) Dyspnea Nasal flaring Retractions Grunting Fine inspiratory crackles Cyanosis and/or pallor Chest X-ray which shows common characteristics (diffuse granular pattern over both lung fields, resembles ground glass and represents alveolar atelectasis, Dark streaks representing dilated air-filled bronchioles)
Neonatal Respiratory Distress Syndrome (RDS): Nursing management
Use of warmer Close monitoring Pulse oximetry and blood gas monitoring O2 therapy with CPAP Surfactant Administration Minimize unnecessary physical stimulation Positioning to facilitate breathing Teach parents CPR and home monitoring
Neonatal Respiratory Distress Syndrome (RDS): Supportive Measures
Maintain adequate ventilation and oxygenation
Maintain acid-base balance
Maintain a neutral thermal environment
Maintain adequate tissue perfusion and oxygenation
Prevent hypotension
Maintain adequate hydration and electrolyte status
Neonatal Respiratory Distress Syndrome (RDS): Nursing responsibilities with Surfactant administration
Assisting in the delivery of the product
Collecting and monitoring of arterial blood gases
Continuous monitoring of oxygenation with pulse oximetry
Assessment and documentation of the infants tolerance of the procedure
Neonatal Respiratory Distress Syndrome (RDS): Surfactant
May be administered at birth as a preventative or prophylactic treatment of RDS or later in the course of RDS as a rescue treatment. Studies have shown that early administration of surfactant decreased the overall incidence of BPD, need for mechanical ventilation, and fewer air leaks.
Neonatal Respiratory Distress Syndrome (RDS): Nursing responsibilities Before/After Surfactant administration
Assisting in the delivery: infant is temporarily intubated, surfactant is administered down the endo-tube, give supportive O2
Turn baby from one side to other for the medication to get farther down into the alveoli, then extubated, then on supplemental O2
Collect ABG, continuous monitoring of O2
Assessment and documentation of infants tolerance of the procedure
Foreign body obstruction: Cause
Swallowing of small items getting lodged in the bronchi
Foreign body obstruction: S/S
Sudden, violent coughing, gagging, wheezing, vomiting, brief episode of apnea, cyanosis
Not talking
Can die with in 4 minutes if nothing is done
Foreign body obstruction: Diagnosis
Good history
Physical Exam
X-ray
Endoscopy can be diagnostic and therapeutic if ever there was a doubt about foreign body obstruction.
Foreign bodies are rarely coughed up and must be removed by endoscopy
Foreign body obstruction: Treatment
Removal of object via back blows and chest thrusts in infants, abdominal thrusts in children, or endoscopy
Keep environment and child quiet until object removed
Aspiration Pneumonia
Foods, secretions, or liquids enter the lung and cause inflammation and chemical pneumonitis.
Difficulty swallowing, unable to swallow because of paralysis, weakness, or congenital anomalies, or an absent cough reflex, or in a child who is force fed especially if they’re crying or breathing rapidly, and tracheoesophageal fistula are at high risk for aspiration.
Aspiration Pneumonia: Classic S/S
Increasing cough, fever, foul-smelling sputum, decrease in oxygenation, and evidence of chest
infiltrates on a chest x-ray.
Aspiration Pneumonia: Treatment
O2 administration as needed
Elevate HOB at least 30-45. If they are at risk for vomiting or can’t protect their airway, then put them in side lying position
Encourage slow, frequent feeding
Positioning
Antibiotics if infection present
Safety teaching- teach parents how to prevent aspiration pneumonia
Asthma: Diagnostics: Bronchoprovocation testing
Direct exposure of mucous membranes to a suspected antigen at increasing
concentrations. This helps identify allergens.
