Respiratory Dysfunction Flashcards
What is the most critical and immediate physiologic change required of newborns?
onset of breathing
Chemical factors that stimulate breathing is
low O2
high CO2
low pH
Chemical and thermal factors in the blood initiate impulses exciting the
respiratory center in the medulla
Thermal stimulus for the onset of breathing in newborns is
sudden chilling of the infant (leaving the warm environment of the mother’s womb)
What are acceptable methods of tactile stimulation for stimulating breathing?
tapping or flicking the soles of the feet
gently rubbing the newborn’s back, trunk, or extremities
Should the nurse slap the newborn’s butt or back to stimulate breathing?
no, harmful technique and should not be used
What does prolonged tactile stimulation consist of?
2+ taps or flicks
Why should you not be able to use prolonged tactile stimulation on a newborn?
waste precious time in the event of respiratory difficulty
+ Become hypoxemic in the birth process
The initial entry of air into the lungs is opposed by
surface tension of the fluid-filled inside the lungs and alveoli
What happens to the remaining lung fluid instead of being pushed out during birth?
absorbed by the capillaries and lymphatic vessels
S/S of Respiratory Distress Syndrome
Tachypnea (80-120) initially (could be respiratory failure and shock due to prematurity)
Dyspnea
Retractions (intercostal and substernal)
Fine inspiratory crackles
Audible expiratory grunt
Flaring nares
Cyanosis or pallor
Respiratory Distress Syndrome of nonrespiratory origin is caused by
sepsis
cardiac defects
exposure to cold (Pneumonia - bacterial or viral)
airway obstruction (atresia)
intraventricular hemorrhage
hypoglycemia
metabolic acidosis
acute blood loss
drugs (rare in drug-exposed infants)
Respiratory Distress Syndrome carries the highest risk what type of complications
respiratory and neuro complications
- preterm infants
Patho of RDS
preterm infants born with premature lungs
- more cartilage in the chest wall (collapses inward to stiff tissues)
- Underdeveloped and under-inflatable alveoli
Blood flow is limited due to collapse and shunted from the lungs to ductus arteriosus and foramen ovale
Lack of surfactant and unable to adjust to lack of blood flow and inability to take in O2 and close the cardiac shunts
Surfactant
surface-active phospholipid secreted by alveolar epithelium
- reduces the surface tension of fluids that line the alveoli and respiratory passage
- uniform expansion and maintenance of lung expansion at low interalveolar pressure
Low surfactant production causes
unequal inflation of alveoli on inspiration and the collapse of alveoli on expiration
- Alveoli collapse
- not able to inflate lungs
- need to exert more effort to reexpand
This inability to maintain lung expansion produces
atelectasis
How does the O2 concentration normally increase after birth?
ductus arteriosus constricts and the pulmonary vessels dilate to decrease PVR
Atelectasis and the absence of alveolar stability relations to blood flow to the lungs
PVR increases with resistance to blood flow
increase of hypoperfusion to lung tissue
Increase of PVR = fetal shunts stay open = prevents blood flow oxygenation of the lungs
Inadequate pulmonary perfusion and ventilation produce
hypoxemia (pulmonary arterioles constriction)
hypercapnia
RDS is the deficiency of
surfactant
Dx of RDS
Chest Xray studies
Managing of RDS
immediate supplemental O2 and ventilation
IVF
TPN
Prevent hypotension
thermal environment
What type of feedings are contraindicated for an RSD pt?
nipple feedings
increases RR, aspirations
When do you suction the patient after administering surfactant?
an hour to allow maximum effects
Surfactant therapy is used in
RSD, meconium aspiration, pneumonia, sepsis, constant pulmon. HTN
- prophylactic or later after birth
Nursing management of surfactant administration
- monitor blood gas
- monitor Pulse Ox
- assess tolerance
- adjustment of vent and prevent overinflation
Treatment of RSD
exogenous surfactant to preterm (porcine, bovine)
Complications of surfactant administration through Endotracheal tube
pulmonary hemorrhage
mucous plug
Studies have shown the benefits of administering surfactant early (prophylactic) in infants at risk for developing RDS, then
extubating and place on CPAP
- decrease need for mech vent
O2 for newborns need to be
humidified and warmed up
Meconium Aspiration Syndrome
Therapeutic Management
Suction hypopharynx after delivery
- close monitoring of low APGAR
- resuscitation after suction
Monitor for respiratory distress with supplemental O2
Exogenous surfactant
Prevention of RDS
prevent preterm delivery esp elective early and C section
amniocentesis = assess fetal lung maturity
maternal steroid injection and surfactant after birth
Prognosis of RSD
SELF-LIMITING
improved by 72 hours
onset of diuresis shows improvement
decrease the need for vent support
Nursing Care Management of RDS
observe and assess the infant’s response to therapy
- O2 should improve
- hourly rounding
suctioning PRN (auscultation of the chest, low O2, excess moisture, irritability)
Best positioning for an infant’s open airway
side of the head supported by a folded blanket to keep the neck slightly extended
ETtube suctioning should only be used for no more than
10-15 seconds to maintain negative passage
When administering O2, what needs to be performed daily?
Mouth care
Meconium Aspiration Syndrome is
Aspiration of amniotic fluid containing meconium into fetal or newborn trachea in utero or at first breath
Prematurity Apnea
lapse of spontaneous breathing for greater than 20 seconds, may be followed by bradycardia, O2 low, and color chnage
Prematurity Apnea
Therapeutic Management
Thermal stability and Blood sugar for hypoglycemia
Admin caffeine and CPAP
tactile stimuli and check for breakdown
Signs of caffeine toxicity
Tachycardia (>180)
vomit, restless, irritable
Pneumothorax
presence of extraneous air in pleural space as a result of alveolar rupture
Pneumothorax
Therapeutic Management
evacuate trapped air in pleural space through needle aspiration or chest tube
care of drainage
emergency needle aspiration setup
S/S of pneumothorax
tachypnea or apnea
hypotension
nasal flaring
retractions
bradycardia, cyanosis
low to no breath sounds
Bronchopulmonary Dysplasia
alveolar damage from lung disease, prolonged exposure to mechanical ventilation, high peak inspiratory pressures and oxygen, and immature
alveoli and respiratory tract
Bronchopulmonary Dysplasia
Prevention
steroids and surfactant to avoid intubation
PFT
no air leaks or infections
minimize high O2 concentration and implement resus. if low o2
Bronchopulmonary Dysplasia
Nursing Care Mgmt
Monitor O2 sat
additional rest during feedings
signs of overload
Increased calorie feedings
Persistent Pulmonary HTN of the Newborn
severe pulmonary HTN and large right to left shunt through foramen ovale and ductus arteriosus
Persistent Pulmonary HTN of the Newborn
s/s
hypoxia
cyanosis
tachypnea with grunting and retractions
decreased pulses and poor perfusion
Shock
Persistent Pulmonary HTN of the Newborn
Therapeutic Mgmt
supplemental O2 and vent
vasodilators
prevent Hypoxemia
Persistent Pulmonary HTN of the Newborn
Nursing Actions
reduce stress
do not move or disturb
S/S with Respiratory Infections in infants
Fever (103-105) 1st sign
- listless/irritable
- precipitate febrile seizures
Poor feeding/anorexia
V/D
- dehydration
Abd Pain
Nasal Block/Discharge (Otitis Media)
Cough (persist)
Sore throat (older children)
- refuse oral meds
Meningismus
- HA, pain and stiff neck
- Kernig and Brudzinski signs +
Respiratory Sounds of Respir. Illness
Hoarse
grunt
stridor
wheeze
crackles
no sounds
Croup is characterized by
hoarseness, a resonant cough like “Barking or brassy”, inspiratory stridor
swelling or obstruction
Why is respiratory swelling worse for infants?
the airway is already narrow the inflammation makes it tiny
- prevents feedings and aspirations
Croup syndromes affect what anatomical structures
larynx - voice and breathing harshness
trachea
bronchi
Acute Epiglottitis
-age
-cause
-onset
-s/s
- tx
- 2-5 y/o
- bacteria
- rapid progressive
- dysphagia, stridor, drool, high fever, toxic appearance, rapid pulse and respirations
- airway, corticosteroids, fluids, antibiotics, reassurance
Acute Larygotracheobrochitis
-age
-cause
-onset
-s/s
- tx
- < 5/o
- viral
- slow progressive
- stridor, brassy, hoarse, low fever, nontoxic
- humidify O2, corticosteroids, fluids, reassurance
Acute Spasmodic Laryngitis
-age
-cause
-onset
-s/s
- tx
- 1-3 y/o
- viral with an allergic component
- sudden; night
- croupy, stridor, symptoms awakening the child but disappearing during the day
- cool mist, reassure
Acute Tracheitis
-age
-cause
-onset
-s/s
- tx
- 1mn to 6 y/o
- viral/bacterial with allergic component
- moderate progressive
- purulent secretions, high fever, no response to LTB therapy
- antibiotics, fluids
S/S of Respiratory Failure
Cardinal
restless
tachypnea
tachycardia
Sweating
S/S of Respiratory Failure
Early but subtle
mood swings (euphoria or depression)
HA
Altered depth and respir. pattern
HTN
exertional dyspnea
anorexia
increased output
CNS with impaired LOC
FLARES NOSTRILS
retractions
grunt expiratory
wheezing or prolonged expiration
S/S of Respiratory Failure
Severe Hypoxia
Hypo/Hypertension
altered vision
somnolence
stupor to coma
dyspnea
depressed respirations
low HR
cyanosis
Asthma Severity in Children
Severe = night (1+ (birth to 4 y/o) and 7+ (>5 y/o) per week) and day, extremely limited in activity, use short-acting Beta agonist several times
Moderate = daily, 3-4x nighttime s/s, some limitation, daily use of beta shot-acting
Mild = 2+ times a week, nighttime s/s once a month, minor limitations, twice a week of inhaler
INT = less than 2 days a week, no nighttime awakening, no limitation, use inhaler less than twice a week
Triggers of Asthma Exacerbations
allergens
- trees, shrubs, weeds, grass, pollution
- dust, mold, cockroach antigen
smoke, spray, odors
exercise
cold air
new environment
animals
strong emotions
Asthma components
Inflammation
Bronchospasm
Airflow obstruction
Spirometry can be performed on children as young as
5-6 y/o and assessed yearly
Because inflammation is considered an early and persistent feature of asthma, HCP use what drug
long term corticosteroids (Beta agonists)
- control
short term (rescue)
Corticosteroids in Asthma drug therapy
tx reversible airway obstruction. control s/s, reduce hypersensitivity of the bronchi
1st line in children over 5
Beta-Aderergic Agonists in Asthma therapy
prevent exercise-induced exacerbation
Anticholinergics in asthma therapy
relieve acute bronchospasms
- dries out everything (eyes, throat)
no CNS effect
Should an asthma child stop exercising due to provoking an exacerbation?
no, exercise is beneficial for physical health
The Child with Asthma Case Study
Jeremy is a 17-year-old male with a history of asthma. His asthma symptoms have been controlled
with use of a long-acting inhaler twice daily but an increase in seasonal allergies and a recent
upper respiratory infection (URI) has caused an exacerbation of his symptoms. Jeremy rarely uses
his peak expiratory flow meter (PEFM), instead he waits until his symptoms become severe before
starting to use his rescue medications. He now presents to his primary care provider with his
mother to seek further treatment as his symptoms are not resolving with his current treatment.
Assessment
Based on these events, what are the most important subjective and objective data that should be
assessed?
Dyspnea
Shortness of breath
Diminished breath sounds and/or adventitious breath sounds (wheezing)
Increased respiratory rate
Use of accessory muscles (retractions)
Dry cough
Chest tightness or chest pain
What are the most appropriate nursing interventions for a child with acute respiratory tract
infection?
monitor ABCs
assume the position of comfort
humidified O2 > 90
rescue inhalers
assist in triggers monitors
Blow-By O2
occasional in newborns
- no control of O2 amount (30%)
- issues with eyes drying out
Nasal Cannula
24-44% on 1-6L
- drys out nose and skin breakdown (esp. with babies
If the nasal cannula is giving 4L+, then what is also provided?
humidity
What is the % of O2 in RA?
21%
Simple Mask
5-8L 40-60% O2
- No holes in the mask
- develop CO2 in the mask when LESS than 5L
NEED TO ENSURE 5L FLOW
Venturi Mask
4-12L 24-60%
Large holes to prevent CO2 build-up
Non-rebreather Mask
10-15L 100%
The reservoir bag needs to be what before use?
filled with pure O2
Respiratory Risk Factors in Infants and Children
Age
Airway diameter small
shorter trachea
Infant (0-3mn) infection rates are _______ due to
lower rate of infection from maternal antibodies
with breastfeeding
What is a common illness for healthy full-term infants (0-3 months)?
Pertussis
- vaccination
3-6 month old infants infection rate is
increased rate of infection due to maternal antibodies going toward the mother
- Baby starts to make her own antibodies
Toddlers and Preschoolers common illness
viral infections from daycare
5+ y/o common illnesses
Kindergarten
- viral decreases
- STREP increases
Infants airway diameter compared to adolescents
smaller
The trachea structure is how long in infants
short distance
- organisms rapidly down the tract
The Eustachian tube in small children is
short, open, and flat
Upper Airway
oral nasopharynx
Pharynx
Larynx
Upper part of the trachea
Lower airway
Lower trachea
Bronchi
Bronchioles
Alveoli
Inadequate ______ can lead to immune deficiencies.
diet/nutrients; no supplements
- heart and asthma conditions to consider
What viral infection is the biggest in Pediatric populations?
RSV lasting longer and more severe
- COVID extended because isolation caused the immune system to pause in children
Seasonal variations of viruses occur around
winter and spring
Preterm newborns have an increased danger of
respiratory obstructions
- small
In the NICU, can you place a baby prone if they are having respiratory issues?
Yes, PUT THEM PRONE AND LEAVE THEM ALONE
- opens up the airway and improves drainage out of the lungs
- SIDS is not a worry due to ABC and continuous monitoring
The bronchi and trachea are so narrow that
mucous can obstruct the airway
What position is okay to have the preterm infant in when allowing for normal respiratory functions regardless of SIDS?
Prone - chest expansion
because of continuous monitoring in the NICU, we are not worried much about SIDS
When does the infant get their gag reflex at?
6 months old
A weak or absent gag reflex increases the chance of
aspiration in the premature
S/S of Respiratory Distress in NEWBORN
subcostal retraction with tachypnea
expiratory grunting
nasal flaring
cyanosis (lips and spread)
- serious when generalized
apneic episodes
diminished air entry
presence of crackles or rhonchi (after 4-6 hour of birth normally bad)
Tachypnea is
sustained rate >60 after 4-6 hours of life
Why does a baby grunt with expirations (not normal)?
trying to create their own positive pressure
push open their alveoli
Cyanosis starts where?
lips and spreads (mucous membranes)
- serious when generalized
Apneic episodes are characterized as
over 15 seconds of not breathing with color changes
What respiratory sounds with RDS do you hear when you auscultate the lungs?
Crackles or rhonchi
- Okay at birth not after 4-6 hours
Apnea of Prematurity refers to
cessation of breathing for 20 + seconds with signs of cyanosis, pallor, and low HR
- day 2 shows extent and problems
What is the 1st sign of a breathing or apneic issue?
cyanotic on the mouth and spreads
Apnea is the most common problem in the preterm infant < ____ weeks starting within day ___-___ days of life
36 weeks
2-7 days of life
Central apnea occurs in
preterm infant’s irregular breathing Patterns
- neuronal immaturity
Apnea is primarily thought to be the result of
neuronal immaturity
- not good at multitasking
- forget to start breathing again
Obstructive apnea occurs in
a preterm infant when there is a cessation of airflow associated with blockage of the upper airway (small airway diameter, increased pharyngeal secretions, improper body alignment, and positioning)
- positioning issue in opening the airway
- reflux after eating
- no suction
Apnea onset is usually
quick and insidious
Apnea occurs during what type of activity
feeding
suctioning
stooling
- no observation activity related
Does all apnea spells have observable activity r/t apnea?
No
How do you document apnea and what should be documented with it?
ALWAYS document as a drop
- time
- length of episode
- treatment required
Interventions of apnea depend on the
severity
Mild and acute apnea interventions by the nurse
Stimulate or rub their chest to create positive pressure
Air then Supplemental O2
Severe apnea interventions
Supplemental O2
Caffeine Citrate (shot of espresso)
What is the medication tx for apnea prematurity?
Caffeine Citrate (methylxanthine)
Caffeine Citrate
Monitor for
HR raising and bounding
- higher range of normal
Continous monitoring with med
IV/PO
Caffeine Citrate
Toxicity
low and safer
Caffeine Citrate is withheld if
HR 170+
Caffeine Citrate given ONLY
in hospital and need to wean baby off
DO NOT SEND BABY HOME WITH IT!!
If order to D/C the baby from the hospital that has caffeine Citrate, what criteria do they need to meet?
NO apneic episodes within 7 days
- clock resets for another 7 days when apneic episode starts again
Respiratory Distress Syndrome is due to
surfactant deficiency
- underdeveloped alveoli
Surfactant
Liquid around the lungs allows the lungs to open
Are premature babies the only ones affected by RDS?
no, near-term babies too.
RDS peak severity with no complications is
1-3 days
Onset of recovery of RDS
around 3 days
- with diuresis
RDS patients need to be on what type of I&Os
strict (and with O2)
- notice when recovery occurs with diuresis
RDS Risk factors
Low Gestational age (PRETERM < 37 weeks)
Male predominance (NOT FIGHTERS like AA women)
Maternal diabetes
Perinatal depression (mom drugs)
Maternal diabetes causes what in the infant related to RDS
An increase in sugar and insulin causes a decrease of surfactant
S/S of RDS** similar to all
Tachypnea initially
Dyspnea
Intercostal or subcostal retractions
Inspiratory crackles
Audible expiratory grunt
Flaring of the nares
Cyanosis
Pallor
RDS Mgmt
Artificial surfactant replacement
Respiratory support and monitoring
Oxygen supplementation
IVF, TPN, Gavage feedings (Tropic feeds start)
Artificial Surfactant Replacement
is made of what
- ground up pig/cow lungs ($$$$)
What is monitored with an Artificial Surfactant Replacement, and what interventions must be implemented?
Intubate and surfactant placed directly and slowly
- Frequent turning to coat the lungs
- SAT 100% and wean off O2
- Respiratory Therapist
RDS support for respirations
surf and turf = intubate and pull the tube with CPAP
- keep the tube in if O2 sat does not improve with replacement
Why do you not want an infant to Ox Sat at 100% if on supplemental O2?
cause blindness (o2 Toxicity in preemies)
- air and O2 mix
- INT mixed flow
Bronchopulmonary Dysplasia aka
Chronic lung disease
Bronchopulmonary Dysplasia occurs in primarily?
and secondary?
1st: low birth weight preterm infants
2nd: O2 and mech vent tx of RDS
What is the complication of RDS of using O2 and mechanical ventilation?
Bronchopulmonary Dysplasia
- asthma later
- severe RDS with small airway from early on in life
Bronchopulmonary Dysplasia is defined as
dependence on O2 >28 days + of age
- more support early on leads to more o2 for longer periods
- increase risk of reactive airway/respiratory disease
Early signs of respiratory complications in children
Refuse fluids with low urine
- too many dry diapers
earache (respir. infection)
RR>50-60
Fever >101
listless (confused with no energy)
increased irritation
persistent cough
wheeze
restless
If they have early signs of respiratory s/s, then what does the parent need to do?
If blue?
Call HCP
- If blue then ER
Upper Respiratory Disorders
Acute Streptococcal Pharyngitis
Tonsilitis
Otitis Media
Croup (Acute Epiglottitis, Acute Laryngotracheobronchitis)
Lower Respiratory Disorders
RSV
Bronchiolitis
Asthma
Acute Streptococcal Pharyngitis aka
Strep throat
Strep is what type of infection
Bacterial infection of the throat and tonsils
What is the most common types to have Strep?
5-15 y/o
What causative agent/bacteria causes Strep throat?
Group A Beta-Hemolytic Streptococcus (GABHS)
Strep Throat S/S
FINE SANDPAPER RASH
Sore throat
- uvula edematous and red
- inflamed tonsils and lymph nodes
- exudate
HA
Fever
Abd pain (Stomach bug with N/V)
Strep Throat Dx
Rapid Streptococcal Antigen Test/ Throat Culture
- gag reflex
- back of the throat
- results within 15 mins
pos. : antibiotics
neg. with s/s: send in throat culture with antibiotics
If the strep test is negative but they still have s/s, then
send in throat culture
send home on antibiotics
If the strep test is positive, then what interventions should be implemented and teachings involved?
Amoxicillin or Erythromycin
Take fluids
24 hours return after all antibiotics
Discard the toothbrush and replace it after antibiotics
TAKE antibiotics all Rx
- Rheumatic fever or Acute Glomerulonephritis can affect the heart and kidneys
Why should the patient take all their antibiotics for Strep?
Rheumatic fever or Acute Glomerulonephritis will develop and can affect the heart and kidneys
Tonsillitis is the
inflammation of the tonsils
What is the causative agent for Tonsillitis?
viral or bacterial
- frequency of respiratory infections
What is the major difference between strep and tonsillitis?
Tonsillitis is a bacterial and/or viral
Strep is only bacterial
What are your different tonsils from top to bottom?
Pharyngeal (adenoids)
Tubal
Palatine (faucial) (see them)
Linguinal
Tonsils are larger in
children than adolescents
- protective
S/S of Tonsillitis
Sore Throat
Difficulty Swallowing
Fever
Enlarged Tonsils
- “Kissing Tonsils” = touching together
Obstructed Breathing
Exudate, Maybe
snoring at night
talk with a frog croak
Interventions of Tonsillitis
Rapid “Strep” Test And/Or Throat Culture
- If Positive, Antibiotics
Antipyretics - Acetaminophen/Ibuprofen
Ice Chips, Soft Or Liquid Diet
Warm Saline Gargles help irritation
For Frequent Episodes, Consider Surgical Options
If you have frequent episodes of tonsillitis, what interventions should be considered?
Elective Surgical
- Tonsillectomy
- Adenoidectomy
Tonsillectomy
removal of palatine tonsils
Adenoidectomy
removal of pharyngeal tonsils
- back of the throat
Contraindications of Tonsillitis Surgery options
- NO cleft palate = tonsils help speak
- NO fever within 24 hrs (inflamed lymph nodes cause more bleeding risk)
- Blood disease or clotting issue
- Anesthesia risk (not wanting to wake up)
What anestesia is used in tonsillectomy?
general (outpt)
Pre-Op for tonsillectomy/adenoidectomy
Assess possible infections, lab values
Check for loose teeth that could dislodge and aspirate
- warn anesthesia won’t be themselves after (confused)
Happy Juice = Versed
Post-Op for tonsillectomy/adenoidectomy
Comfort
- prone or side-lying
- HOB up after alert
- analgesic, ice collar
encourage rest
NO coughing, throat clearing, nose blowing
Post-Op Tonsillectomy and Adenoidectomy
Diet
Ice Chips, Sips Of Water, And Clear Liquids
No Red-Colored Liquids, Citrus, or Milk-Based Foods Initially
What is the biggest post-op problem of tonsillectomy and adenoidectomy?
bleeding
D/C Education of Tonsillectomy/Adenoidectomy
cont. soft, bland food (jello, smoothie with spoon)
- no sharp objects in the mouth (NO straws or forks)
Scheduled Analgesic for 1st 48 hours
- esp. at night for breakthrough pain
Limit activity 2 weeks along with no swimming
Immediate HCP for signs of hemorrhage
- mostly in 1st 24 hours
S/S of Hemorrhage Post-Op Tonsillectomy
Heart is beating fast (tachycardia)
Pallor
Frequent clearing and swallowing (blood builds)
Vomit of bright red blood
Restless
Hypertensive or shocky (not usually noticed)
Post-Tonsillectomy Appearance tell the parents
White scab is normal when healing
7-10 starts to come off – higher pain and sensitivity
Otitis Media
inflammation of the middle ear
Otitis Media is precipitated by
pharyngeal infection and RSD
Why is OM more common in children?
Eustachian tube is smaller and flatter allowing the bacteria to travel easier
Acute Otitis Media (AOM):
An inflammation of the middle ear space with a rapid onset of the signs and symptoms of acute infection (Fever And Ear Pain)
Otitis Media With Effusion (OME):
Fluid in the middle ear space without symptoms of acute infection
Hole all the time annoyed
OM Risk Factors
Age < 2 Years Old - anatomy structure
Recent URI
Family Hx
Socioeconomic Status (exposure to related factors)
- Day Care/Exposure To Other Children
- Allergies
- Crowded Households
- Secondhand Smoke Exposure
Bottle-feeding (no maternal antibodies)
Bottle Propping (milk down eustachian tube)
Winter month
Enlarged Tonsils/Adenoids
Cleft Lip/Cleft Palate
Down Syndrome
Males
Pacifier Use (constant sucking)
Infant S/S of Acute OM
Crying
Fussiness (↑ When Lying Down)
Tendency To Rub, Hold, Or Pull Affected Ear
Rolls Head From Side To Side
Difficult To Comfort
Refuses To Feed
Vomiting, Diarrhea
- Lack of swallowing
Older Children S/S of Acute OM
Crying Or Verbalizes Feelings Of Discomfort
Irritability
Lethargy
Loss Of Appetite
Purulent Drainage S/S of OM is a sign of
tympanic membrane rupturing
- a sense of relief no pain
BAD THING
AOM Dx
Otoscopic Examination Of Tympanic Membrane
Presence Of Purulent Discolored Effusion
Bulging Or Full
Immobile
Red
Opaque
- gray = normal
AOM interventions
Administer Antibiotics – PO and/or ear drops
Administer Analgesic-Antipyretic (acetaminophen, 6 months + = ibuprofen)
Facilitate Drainage If Possible
Position Child On Affected Ear** - towel
Warm Compress Relief on Affected Ear
Otitis media with effusion if drainage longer than
3 months
Otitis media with effusion s/s
May Have Rhinitis, Cough, Diarrhea
Feeling Of Fullness And/Or Motion In-Ear
Popping Sensation When Swallowing
Otitis media recurrent or with effusion Dx through
Otoscopic Examination Of Tympanic Membrane
Orange, Discolored
Immobile
OME usually resolves
on its own
- antibiotics if longer then to Myringotomy
OME precipitated by
upper respiratory infection
OM
Myringotomy
Tympanostomy Tubes
Alleviates Pain
Facilitates Drainage
Allows For Ventilation
- quick 20-45 minutes
Myringotomy Post-Op
Position To Facilitate Drainage with the affected ear down
Keep Ears Dry
Antibiotics – PO and ear drops (drainage thinner)
Analgesics – Tylenol and ibuprofen
Discourage Nose Blowing For 7-10 Days can dislodge
Notify Provider If Tubes Fall Out
Keep Immunizations Up-To-Date**
Decrease OM/AOM Risk Factors
When you can
What happens when the myringotomy tube falls out?
Notify provider
- if falls out within 7-10 days
After not a big deal
Croup Syndromes includes
Acute Epiglottitis
Acute Laryngotracheobronchitis (Croup)
Acute Spasmodic Laryngitis (Spasmodic Croup)
Bacterial Tracheitis
Croup Characteristics
Hoarseness
“Barking” Or “Brassy” Cough- seals
Varying Degrees Of Inspiratory Stridor
Varying Degrees Of Respiratory Distress
Acute Epiglottitis
serious obstructive inflammatory process
- severe and life-threatening infection
The most common causative organism of Acute Epiglottitis
Haemophilus Influenza
Acute Epiglottitis is a medical
EMERGENCY
What age of children is more likely to have acute epiglottitis?
2-5 y/o
Acute Epiglottitis PREDICTIVE S/S
Absence Of Spontaneous Cough
Presence Of Drooling
Agitation
Acute Epiglottitis S/S
Abrupt Onset
**Predictive Signs (Absence Of Spontaneous Cough, Presence Of Drooling, Agitation)
Fever And Appears Very Sick (“Toxic”)
Tripod Positioning
Irritability and Restlessness
Thick, Muffled, Froglike Croaking Voice
Retractions
Red And Inflamed Throat
Large, Cherry Red, Edematous Epiglottis Visible Upon CAREFUL Throat Inspection
Acute Epiglottitis: the throat looks like on careful inspection
Large, Cherry Red, Edematous Epiglottis Visible Upon CAREFUL Throat Inspection
Acute Epiglottitis positioning is known as
Tripod
Acute Epiglottitis Dx
Throat Inspection
Laryngoscopy-With Airway Protected
Lateral Neck X-Ray
“Thumb Sign”
Throat and Blood Cultures
What needs to be avoided when doing a throat inspection for acute epiglottitis?
Oral Temperature
Tongue Depressors
Acute Epiglottitis patho
Epiglottis swells up and closes the airway and won’t pop open
Airway opens then cultures
Intubate if unable then trach
Acute Epiglottitis Mgmt
Protect Airway – Keep Child NPO
NOTHING BY MOUTH OR OBJECTS
Position Of Comfort
– HOB ELEVATED
- Avoid Supine Position
Pulse Oximetry (everything)
Antibiotics - IV
Corticosteroids
Droplet Isolation for at least 24 hours after antibiotics
For acute epiglottitis, what isolation needs to be taken, and for how long?
Droplet for at least 24 hours after antibiotics
Acute Laryngotracheobronchitis is the main version of
Croup
Acute Laryngotracheobronchitis is the
inflammtion of laynx, trachea, and bronchi
Acute Laryngotracheobronchitis is preceded by
URI
causative agent: VIRAL
Acute Laryngotracheobronchitis is seen in what age groups
less than 5 y/o
- head cold then down
Croup S/S
Usually Preceded By Upper Respiratory Infection (URI)
Low-Grade Fever 101 usually
Barky, Brassy (“Seal-Like”) Cough
Hoarseness
Croup S/S AS THE AIRWAY NARROWS
Inspiratory Stridor (HIGH PITCH)
Retractions
Increasing Respiratory Distress And Hypoxia
Can Lead To Respiratory Acidosis And Respiratory Failure if untreated
Upper respiratory infections have what sound
stridor
Lower respiratory infections have what sound
wheezing
Mild Croup Home Care Education
Observe Respiratory Status
- Monitoring For Worsening Symptoms and call
Cool-Air Vaporizer
Or Cool-Air Environment
Oral Hydration And Nourishment
Comfort Measures
- riding in the cold will help airway open
Hospitalized Care of Croup
Cool Mist Humidity And O2 As Needed
Pulse Oximetry
IV Fluids As Needed
Nebulized Epinephrine
Corticosteroids
Do you use antibiotics or antivirals on croup?
no
- oral/IV fluids
Nebulized Epinephrine
hand-held breathing treatment help with edema in the throat
1 =
2 = ED and monitor
3 = pediatric ED and stay over night
RSV and Bronchiolitis are ________ communicable
highly
RSV and Bronchiolitis are what type of infection
acute viral with max effect at the bronchiolar level
What kids can get RSV?
UNDER 2 Y/O (common in Premies)
- Recurrent over the years
- same with RSV
- vaccine coming out
RSV can live on objects for
7 hours 30 mins on hands (hand hygiene)
What is the incubation period of RSV?
2-8 days
- begins replication in the nasal
- epithelial lining to tissue
What months is RSV more prevalent?
November to April
Initial S/S of RSV
History Of URI - RSV
Rhinorrhea – runny nose (constant)
suctioning
Pharyngitis
Coughing, Sneezing
Wheezing
Possible Ear Or Eye Drainage
Intermittent Fever
RefusalFeed
Copious Nasal Secretions
At what point during RSV s/s do you take them to the hospital?
stop eating
In RSV, the younger the infant the greater the
severity
- size of the airway and lungs
W/ Progression S/S of RSV
Increased Coughing And Wheezing
Retractions
Crackles
Dyspnea
Tachypnea
Cyanosis
Diminished breath sounds
- Intubation in PICU
Severe S/S of RSV
Tachypnea > 70 breaths/min.
Listlessness
Apneic Spells
Poor Air Exchange
Poor Breath Sounds
Dx RSV
Nasopharyngeal Secretions ~ RSV Antigen Detection
- Swab nose and mouth with rapid test
Supportive RSV pt care
Contact Isolation
Monitor Airway
Humidified O2 With Pulse Ox
Hydration – IV, If Oral Not Tolerated
Nasal Suctioning esp. with feeding times
Antibiotics, Possibly (coexisting bacterial infections)
Bronchodilators, Possibly with mechanical ventilation
Racemic Epinephrine (antiviral – last effort), Possibly
Ribavirin, Possibly
RT sets up medication, watch them
What is chest percussion used for in RSV pts?
RT with cupping to prevent progress to pneumonia
Would you use antibiotics?
possibly to help the coexisting illness
Racemic Epinephrine
high cost, toxic to healthcare providers
- opens airway
administering it aerosol, efficacy questioned, need N95 to protect yourself
If the nurse has an RSV pt then the charge nurse will not assign them
immunodeficient
RSV Prevention
Encourage Breastfeeding (IgA)
Avoid Tobacco Smoke Exposure
Good Handwashing
Palivizumab (Synagis)
- Monthly IM Injections for High-Risk Infants
–November – March/April
–Preemies
–Decrease severity and fewer hospitalizations
Asthma
Chronic Inflammatory Reactive Airway Disease
- 3rd leading cause of hospitalizations
80-90% 1st s/s <4-5 y/o
INT Ashtma
– symptoms less than twice a week
not pharmo
Mild ashtma
s/s more than 2 a week but not daily
Moderate asthma
daily s/s occur with exacerbations 2x a week
Severe asthma
affects the quality of life
s/s persistent along with frequent exacerbations
Airway Obstruction caused by asthma
Thick mucus, mucosal edema, and smooth muscle spasms obstruct small airways; breathing becomes labored, and expiration is difficult
- triggers inflammation and edema
- mucous builds
- narrow airway and wheezing
expiratory traps CO2 in alveoli
Asthma Risk Factors
Family Hx
Hx Allergies (inflammation and mucous buildup)
Gender (males younger than girls in older)
Smoking Or Exposure To Secondhand Smoke
Maternal Smoking During Pregnancy
Ethnicity – AA at greatest risk
Low Birth Weight – underdeveloped lungs and BPD)
Being Overweight
Which ethnicity has the greatest risk of asthma?
AA
Triggers of ASTHMA
Allergens (Outdoor/Indoor/Irritants) - smoking
Exercise (mouth breathing and temperature outside)
Cold Air Or Changes In Weather Or Temperature
Environmental Change
Colds And Infections
Animals
Medications – aspirin, NSAIDs, beta blockers
Strong Emotions (scared, anger, crying)
Foods And Food Additives
And So On…
“CLASSIC” S/S of asthma
Shortness Of Breath
Wheezing
Non-Productive Coughing
(Worsens During Nighttime)
Chest Tightness/Pain
- Rash red on the chest
Increased Restlessness/Anxiousness
DX of Ashtma
Clinical Manifestations
H&P (rash, ears and nails blue, sweat, tripod, short phrasesVS, wheezing/crackles, and accessory muscle use)
-CBC with differential; (WBC elevated)
-CXR (infiltrates and hyper expansion of the airway
-Pulmonary Function Tests (PFTs)
-Peak Expiratory Flow Rate (PEFR)
(How much air they can push out)
Skin Prick Testing (SPT) – allergy
- Get itchy but don’t itch
- Gel afterward
Long-Term Control (Preventive) Medications
To Achieve And Maintain Control of Inflammation
Every day
Quick-Relief (Rescue) Medications
To Treat Symptoms And Exacerbations
When in an attack for relief
What meds are used for Asthma pts every day?
Long-Term Control (Preventive) Medications
Quick-Relief (Rescue) Medications
Long Term Control of Asthma
Corticosteroids (Anti-Inflammatory)
Fluticasone (Flovent) – INH
Budesonide (Pulmicort) – INH
Mast Cell Stabilizers (Anti-Histamine)
Cromolyn Sodium (Intal) – INH
Nedocromil (Tilade) – INH (Not Used In Children < 5 Yrs)
Long-Acting β2 Agonists “LABA” (Bronchodilator)
Salmeterol (Serevent) – INH
Formoterol (Foradil) – INH
Leukotriene Modifiers (Blocks Inflammatory And Bronchospasm)
Montelukast (Singulair) – PO (Not Used in Children < 12 Mo.)
Zafirlukast (Accolate) – PO (Not Used in Children < 7 Yrs.)
Monoclonal Antibodies (Blocks Binding Of Immunoglobulin E To Mast Cells To Inhibit Inflammation)
Omalizumab (Xolair) – SQ (Not Used in Children < 12Yrs.)
Methylxanthine (Bronchodilator)
Theophylline – PO
Aminophylline – IV
- Used Primarily In The ED When The Child Is Not Responding To Maximal Therapy
Quick Relief Medications for Asthma
Short-Acting β2-Agonists “SABA” (Bronchodilator)
Albuterol (Ventolin) – PO, INH
Levalbuterol (Xopenex) – INH
Terbutaline – PO, INH, SQ, IV
Anticholinergics (Bronchodilator)
Ipratropium Bromide (Atrovent) – INH
Corticosteroids (Anti-Inflammatory)
Methylprednisolone (Solu-Medrol, Prednisone) – IV, PO
Rescue relief is used for
exacerbation in with the long term preventative
- inhaler or nebulizar with face mask
Exercise-Induced Bronchospasm
Acute, Reversible Airway Obstruction
During Or After Vigorous Exercise
Rare In Activities That Require Short Bursts Of Energy - basketball, soccer
Cough, SOB, Chest Pain Or Tightness, Wheezing, Endurance Problems
Endurace-based Bronchospams can taken what before PE or athletics to help prevent EIB?
Prophylactic Quick-Relief (Rescue) Medication Before Exercise – albuterol or SABA
Before PE or athletics
What exercises are considered vigorous for asthma pts
Sprint, skiing, gymnastics, baseball
What exercises should asthma pts do?
swimming
endurance
soccer
basketball’football
work out with SABA
Ashtma for inpts
Position Of Comfort
**Supplemental O2 – Keep O2 Sats > 90%
Short-Acting β2-Agonists (Quick-Relief Medications) – metered or nebulizer
Anticholinergic, May Be Added
Corticosteroids – inflammation in the airway
Hydration – IV if not PO
Reassurance, Support, Education
Calm environment with no anxiety, sounds or songs, or video to relax
Let them find their comfort position - Tripod
Status Asthmaticus
Respiratory Distress Despite Vigorous Therapeutic Measures
Inhaled Nebulized Short Acting β2-Agonists
- 3 Treatments: 20-30 Minutes Apart
Status Asthmaticus tx
O2 Above 90%
Mag sulfate – muscle relaxant, IV
Heliox – helium and O2, inhalation, keep decrease airway to help with breathing
Anticholinergics
Corticosteroids
Keta –
= ready CODE in case
Sit upright and sweating
Hypoxic and intubate if no talking and quiet
Medication Delivery Devices for Ashtma medication
Metered Dose Inhaler (MDI)
with Spacer (more time and breath slowly for 10-15 seconds)
Nebulizer (customized)
Time to complete with show or game
Peak Expiratory Flow Meter (PEFM) is used in children
greater or 5 y/o
Peak Expiratory Flow Meter (PEFM)
Child’s Personal Best
“Zones” For Asthma Management
Green Zone (Mild) - 80-100%
Yellow Zone (Moderate) 50-80%
Red Zone (Severe) <50%
Steps of Peak Expiratory Flow Meter
Stand or sit straight with chin lifted
Breath out completely
Set to 0
Breath in
Lips around
Blow out hard and fast
Look at meter and mark
Repeat and measure 3 times
Highest number is PEAK
Repeat
Document for 2 weeks
Prevention of Asthma
Recognition And Avoidance Of Triggers
Recognize Signs And Symptoms Of Exacerbation
Compliance With Asthma Action Plan
Medications And Use Of Delivery Devices
Good Handwashing
Up-To-Date Immunizations
Exercise
- teach deep breathing and relaxation techniques
Cystitic Fibrosis
Autosomal Recessive Disease That Causes Exocrine Gland (Mucus Producing Glands) Dysfunction
- thick and sticky
Cystitic Fibrosis is caused by
Mutation In The Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Gene
Results In Exocrine Gland Secreting Mucus That Is Thick And Sticky
Cystic Fibrosis results in
Exocrine Gland Secreting Mucus That Is Thick And Sticky
Is CF curable?
no
- more common in causacians
CF is screened on the
newborn
What trait causes CF
RECESSIVE
- both parents need the gene
CF Patho
- Exocrine Glands Produce Thick And Sticky Mucus
- mechanical Obstruction Of The Affected Organs - Altering Their Function
Primarily Affects Skin, Respiratory, Gastrointestinal, And Reproductive Systems
What body systems are normally affected by CF
SKIN
respiratory
GI
reproductive
CF skin s/s
elevated of sweat electrolytes (Na AND Cl)
Salty skin
CF respiratory s/s
progressive lung failure result from infection
CF GI s/s
pancreatic enzyme deficit and pancreatic kyphosis
CF reproductive s/s
= delay puberty and infertility (men sterile)
What body system is not affected by CF?
brain and nervous system
- learning is not affected
CF Dx
Family History
Genetic Testing
Newborn Screening
Sweat Chloride Test
Chest X-Ray
Pulmonary Function Tests
Stool Analysis = fat in stool - no pancreatic enzymes
Sweat Chloride Test results
< 40 normal
> 60 CF
usually takes an hour, noninvasive
CF Respiratory Assessment
Symptoms Produced By Stagnation Of Mucus Infection
Airway
Persistent Coughing
May Be Productive
Recurrent Respiratory Tract Infections
Pneumonia And Bronchitis
Wheezing
Shortness Of Breath
In CF pts, the mucous sits in the lungs causing
Infections:
Bacteria attracted to the mucous
Greater damage to airway
Lungs become destroyed and death
Respiratory Interventions for CF
Prevent Or Minimize Pulmonary Complications
Airway Clearance Therapies
- Inhaled Medications
- Bronchodilators
- dornase alfa (Pulmozyme)
- Nebulization with percussion
Exercise –stimulate clearing out
Antibiotics As Needed
-Vest for vibrations to clear mucous out**
What medication for CF pts is used daily with percussion vest in the nebulizer?
dormase alfa (Pulmozyme)
- decreases viscosity of the mucous
GI Assessment for CF
1ST = Meconium Ileus At Birth - blocked by thick poop (20-30%)
Pancreatic Fibrosis:
Impaired Digestion And Absorption Of Nutrients
Fat-soluble vitamins (A, D, E, K)
Steatorrhea (Excessive Fat, Greasy Stools)
Foul-Smelling Bulky Stools
Failure To Gain Weight And Delayed Growth Patterns
Look like FTT pt
Diabetes Mellitus - need insulin
Rectal Prolapse
Panceratic Fibrosis
Impaired Digestion And Absorption Of Nutrients
Fat-soluble vitamins (A, D, E, K)
In CF, what vitamins are not absorbed in the body?
fat-soluble (A,D,E,K)
GI Interventions for CF pts
Replace Pancreatic Enzymes
High-Calorie, High-Protein, High-Fat Diet
- malnutrition from partial absorption
Vitamins A,D, E, K And Multivitamins (water soluble)
150% MORE DAILY ALLOWANCE
Laxatives Or Stool Softeners
What type of diet does a CF patient eat?
HIGH calorie, protein , and fat diet
with water soluble vitamins
Pancreatic Enzymes should be taken with
fatty foods to absorb
Education of CF
Multidisciplinary Approach
MD, Nurse, Respiratory Therapist, Nutritionist, Social Services
Infection Prevention
- Discouraging Close Contact With Other CF Children
- Up-To-Date Immunizations
- Notify Provider For Signs And Symptoms Of Infection
Encourage Compliance With Care Plan
Encourage Physical Activity
VEST, NEB, MEAL PLAN
- support due to separation
CF pts each have a unique bacteria colonized so CF patients need to
stay away from one another
Should you recommend an adolescents CF pt. to go to a camp for CF pts?
No
