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
