The child w/ respiratory dysfxn Flashcards
Assessment
-Respiration: Tachypnea, Hyperpnea/hypopnea
-Associated Observations: Retractions, Nasal flaring, Head bobbing, Noisy breathing, Stridor, Grunting, Wheezing, Color changes of the skin, Chest pain, Clubbing, Cough
Dx tests
-Pulmonary Function Tests: Radiology & Other Diagnostic Procedures, Blood Gas Determination, Noninvasive monitoring: Pulse oximetry, Transcutaneous monitoring, End-tidal carbon dioxide monitoring (ETCO2)
Pulse ox
-Most helpful in determining extent of hypoxia
-Ensuring the sensor probe is properly placed is the
priority nursing action. (ATI)
-Good contact with skin, remove nail polish, ink on feet
-Pulse ox number should have an ocean-like wave next to it
RTIs
-Described according to area of involvement
-Spread due to contiguous nature of the mucous membrane
lining the entire tract
-Respiratory infections are cause of majority of acute illnesses in
children
-Upper respiratory tract
-Oronasopharynx, pharynx, larynx, and trachea
-Lower respiratory tract
-Bronchi, bronchioles, and alveoli
-Croup syndromes
-Infections of the epiglottis or larynx
Etiology of dysfxn
-Viruses: RSV, Parainfluenza
-Others: Group A beta-hemolytic streptococci, Staphylococci, Chlamydia trachomatis, Mycoplasma, pneumococci, Haemophilus influenzae
Age
● Infants younger than 3 months—maternal antibodies
● 3 to 6 months—infection rate increases
● Toddler and preschool-ages—high rate of viral infections
● Older than 5 years—increase in Mycoplasma pneumonia
and beta-strep infections
● Increased immunity with age
Size
● Diameter of airways is smaller: When edema, mucus, or bronchospasm is present, the capacity for
air passage is greatly diminished; Small reduction in the diameter of a child’s airway will result in an
exponential increase in resistance to airflow, causing increased
work or breathing
● Distance between structures is shorter, allowing organisms
to rapidly move down
● Short and open eustachian tubes
Resistance
● Immune system deficiencies
● Allergies, asthma
● Cardiac anomalies
● Cystic fibrosis
● Exposure to infections in daycare
● Exposure to second-hand smoke
Seasonal variations
● Most common during winter and spring
● Mycoplasmal infections more common in fall and winter
● Asthmatic bronchitis more frequent in cold weather
● RSV season considered winter and spring
Clinical s/s
○ Fever
○ Anorexia, vomiting, diarrhea, abdominal pain
○ Cough, sore throat, nasal blockage, or discharge
○ Respiratory sounds
Nursing interventions
● Ease respiratory effort: Effecting breathing patterns, Promote airway clearance and maintenance, Adequate gas exchange
● Fever management
● Promote rest and comfort
● Infection control
● Promote hydration and nutrition
● Family support and teaching
● Prevent spread of infection
● Provide support and plan for home care
URIs
● Acute viral Nasopharyngitis—“common cold” More frequent in the winter
● Caused by numerous viruses: RSV, rhinovirus, adenovirus, influenza, and parainfluenza viruses
● Clinical manifestations: Fever—varies with age of child, Irritability, restlessness, Decreased appetite and fluid intake, Nasal inflammation, Vomiting and diarrhea
● Therapeutic Management –> OTC Cold Preparations/Prevention
URI meds
● OTC pediatric cold remedies are not recommended for treating “common cold”
● Antihistamines ineffective in most cases
● Antipyretics for comfort from fever
● Cough suppressants for dry cough: Caution alcohol content
● Decongestant to shrink swollen nasal passages: Nose drops more effective than oral administration
Acute infectious pharyngitis
● AKA “acute streptococcal pharyngitis”
● Etiology and risks in children: Group A β-hemolytic streptococci (GABHS) infection of the upper airway (strep throat)
● Clinical Manifestations: Pharyngotonsillitis, headache, fever & abdominal pain, Inflamed tonsils and pharynx that are covered by exudate, Anterior cervical lymphadenopathy
● Diagnostic Evaluation –> 80 to 90% are viral: Rapid antigen testing, Culture
● Risk of rheumatic fever, acute glomerulonephritis
● Bacterial treatment: ABX as ordered, Change toothbrush after 24 hrs on ABX
● Viral treatment: symptom management
Strep meds
● Penicillin: Oral (Needs 10-day treatment to decrease risk of rheumatic fever and glomerulonephritis post strep), Issues with medication compliance
○ IM: Penicillin G: Resolves compliance issue (one injection), Painful injection, Penicillin G procaine is less painful injection, CANNOT give penicillin G by IV route
○ Erythromycin if penicillin allergy
○ Other antibiotics
Tonsillitis
● Enlarged tonsils can block the nose and throat & disrupt the function of the Eustachian tubes: Often occurs with pharyngitis
● Acute or chronic: Acute is self-limiting
● Enlarged tonsils can block the nose & throat, disrupt fxn of the eustachian tubes
● Commonly occurs with pharyngitis
Tonsillitis tx
● Therapeutic Management: Medical, Surgical –> tonsillectomy/adenoidectomy (Controversial, May be indicated with massive hypertrophy)
● Nursing Care Management:
○ Codeine contraindicated postoperatively, Food & Fluids, Monitor for “continuous swallowing” –> bleeding postoperatively
Tonsillectomy/adenoidectomy
● Indicated for recurrent throat infections
● Post-op: Assess for bleeding, Assess airway and VS, Comfort measures, Educate about post-op hemorrhage
Nursing Concerns-Post-Operative Tonsillectomy
● Airway: Positioning
● Bleeding: Observation—frequent swallowing, Prevention of recurrent bleeding, Maintain quiet environment, Minimize agitation/crying, NO suctioning
Infectious Mononucleosis (aka mono)
● Acute, self-limiting infection; common in younger than 25-year-olds
● Etiology & Pathophysiology –> Epstein Barr Virus (EBV)
-s/s: fever, pharyngitis, looks like strep throat (when given abx for strep –> rash)
-May cause spleen rupture (d/t splenomegaly)
● Diagnostic Evaluation: CBC –> atypical leukocytes, Monospot –> nonspecific heterophile antibody test
Influenza
● Flu A, B, & C
● 1-3 day incubation period
● Prevention: vaccine
Influenza meds
● Antivirals for children: Oseltamivir (Tamiflu), Zanamivir (RELENZA)
● Must start within 48 hr of symptom onset
● Avoid aspirin—possible link with Reye syndrome (damages brain and lever)
Prevention of influenza
● Vaccine recommended for children greater than 6mo
● New vaccine annually
● Types: Inactivated influenza vaccine, Live attenuated influenza vaccine which is
administered intranasally.
● United States –> quadrivalent: Contain 2 strains of influenza A & 2 strains of influenza B
● Can be given simultaneously with other vaccines
but at a separate site
Otitis media
● Streptococcus pneumoniae, H. influenzae & Moraxella catarrhalis, The two viruses most likely to precipitate OM are RSV & influenza
● Impact of passive smoke inhalation/crowded living conditions
● Therapeutic Management : Acute AOM/Recurrent AOM/AOM with Effusion (Myringotomy)
Otitis media: infant feeding methods
- Breastfed infants have less OM than bottle-fed infants
- Immunoglobulin A
- Position in breastfeeding may decrease reflex in Eustachian tubes
Otitis media: abx therapy
- If over age 6 month –> “watchful waiting” up to 72 hours for spontaneous resolution
- Antibiotics if less than 2 years with persistent
acute symptoms of fever & severe ear pain - Antibiotics if less than 6 months
- Topical relief heat or cold or benzocaine drops (Rx)
Otitis media w/ effusion (OME)
Prevention: pneumococcal vaccine, breastfeeding, preventing exposure to tobacco smoke
Otitis externa (OE)
- “Swimmer’s ear”
- Infections of the external ear canal
- Etiology: Staphylococcus or
Corynebacterium - Acute Otitis Externa (AOE)
OM meds
● First-line antibiotics: Amoxicillin PO 80 to 90 mg/kg/day, divided twice daily ×10 days
● Second-line antibiotics: Amoxicillin-clavulanate (Augmentin), azithromycin, Cephalosporins IM (If highly resistant organism or noncompliant with oral doses, IM is painful –> Reconstitute with 1% lidocaine, w/o EPI, to decrease pain of injection)
● Analgesic–antipyretic drugs: Acetaminophen, Ibuprofen (only if > 6 m)
● No steroids, antihistamines, decongestants, antibiotic ear drops
Acute epiglottitis
● Serious obstructive, inflammatory process
● Clinical manifestations: Abrupt onset, Sore throat, pain, tripod positioning, retractions, Inspiratory stridor, mild hypoxia, distress, Fever
● Therapeutic mgmt: Potential for complete respiratory obstruction
● Nursing mgmt: position for comfort, no tongue blade, keep suction at bedside, keep emergency respiratory equipment at bedside, decrease anxiety
● Prevention: Hib vaccine
Croup syndromes
● Characterized by hoarseness, “barking” cough, inspiratory stridor & varying degrees of respiratory distress
● Affect larynx, trachea & bronchi
● Described by anatomic area primarily affected: Epiglottitis (or supraglottitis), laryngitis, laryngotracheobronchitis (LTB) & tracheitis
Acute laryngitis
● More common in older children & adolescents
● Usually caused by virus
● Chief complaint –> hoarseness
● Generally self-limiting & without long-term sequelae
● Acute laryngotracheobronchitis (LTB): Most common type of croup experienced by children admitted for hospitalization, Primarily affects children 6 to 36 months old
Acute Spasmodic Laryngitis
● Also called spasmodic croup, midnight croup
● Paroxysmal attacks of laryngeal obstruction
● Occurs chiefly at night
● Inflammation: mild or absent
● Most often affects children ages 1 through 3
Bacterial tracheitis
● Infection of the mucosa of the upper trachea
● Distinct entity, features of croup & epiglottitis in older children (5 to 7 years)
● s/s: Thick, purulent secretions, Respiratory distress & stridor, May develop life-threatening obstruction or respiratory failure
● Mgmt: Humidified O2, Antipyretics, abx, intubation
LRI
● Considered the “reactive” portion of the lower respiratory tract
● Includes bronchi and bronchioles
● Cartilaginous support not fully developed until adolescence
● Constriction of airways
Bronchitis
● AKA tracheobronchitis
● Inflammation of the large airways, frequently associated
with URIs: Persistent dry, hacking, non-productive cough
● Usually viral
● Mild and self-limiting
Bronchiolitis
● Most often caused by respiratory syncytial virus (RSV)
● Primarily affects the bronchi and bronchioles: Occurs at bronchiolar level, Intraluminal obstruction from swelling leads to hyperinflation,
obstructive emphysema, and areas of atelectasis
● Initially, URI symptoms which progress to increased WOB and hypoxia
● Infants are typically hospitalized
● Prevention of RSV: prophylaxis (palivizumab [Synagis])
RSV
-Copious secretions, tachypnea, apnea, cyanosis
-Monitor O2 and respiratory status
-Dx: PCR nasal swab
-Tx: deep suctioning before eating, fluids, antipyretics
-Droplet precautions
COVID-19
-Airborne precautions
-Tx: veklury (remdesivir),
Multi-system inflammatory syndrome (MIS-C)
-Post-covid syndrome –> hyperinflammatory syndrome
-Fluids, O2, BP meds, abx, blood clot meds
Pneumonia
● Causative organism varies greatly by age category: Young children at risk for aspiration PNA
● The most useful classification is etiologic agent: Viral, Bacterial, Mycoplasmal, foreign substances
● Hospitalization for O2 therapy, IV hydration, and IVAB may be necessary if s/s of respiratory distress: tachypnea, retractions, nasal flaring, low SaO2
● s/s: Fever, malaise, rapid respiration, cough, Chest or abdomen pain, nausea
● Dx: X-ray –> Pulmonary infiltrates, Lobar consolidation, Pleural effusion
● Lab tests: Cultures –> sputum, blood cultures, lung aspiration, & biopsy; WBC
● Prevention: PCV vaccine
Asthma
● Most common chronic respiratory illness of childhood
-Chronic inflammatory disorder of the airways: Can lead to airway remodeling
● Recurring episodic symptoms: Wheezing, Breathlessness,Chest tightness, Cough (especially at night), Limited air flow or obstruction that reverses spontaneously or w/ tx, Bronchial hyperresponsiveness
Neonatal pneumonia (not on test)
● Occurs in the immediate neonatal period
● Infected mother transmits to fetus via ascending infection or during delivery
● Multiple organisms
● Infant is afebrile with cough, tachypnea, rales
● X-ray
● Abx
Aspiration pneumonia
● Risk for child with feeding difficulties
● Types: lipoid, inhalation, hydrocarbon
● Mgmt: Prevention of aspiration, Feeding techniques, positioning
● Avoid these aspiration risks: Oily nose drops, petroleum distillates, Solvents, Talcum powder
Pneumonia pathogenesis
● Severity of lung injury depends on ingested substance
● Hydrocarbons: Petroleum distillates often contain heavy metals or other toxic chemicals, Often found in home or garage, Severe effect even with small amount ingested, Spread over surface of tissues & interfere with gas exchange
Hydrocarbon pneumonia s/s
● Coughing, vomiting, aspiration
● CNS: agitation, restlessness, confusion, drowsiness, and coma
● Elevated body temperature (37.8° to 40° C)
● Dyspnea, cyanosis, tachycardia, tachypnea, nasal flaring, retractions
● Hemoptysis, pulmonary edema, severe cyanosis & death within 24 hrs of aspiration
Pulmonary edema (PE)
-Types: cardiogenic (hydrostatic hemodynamic), noncardiogenic (factors that increase pulmonary capillary permeability)
-Tx: PEEP, pulse ox, ventilation, intubation
Acute lung injury (ACL)/Acute respiratory distress syndrome (ARDS)
● Continuum of symptoms of ALI, with ARDS the most severe form
● Characterized as respiratory distress and hypoxia within 72 hours after serious injury or surgery in person w/ previously normal lungs
-ICU, high mortality
● Animation: Bag Ventilation, dx criteria are based on the Berlin definition of ARDS
● Mgmt: oxygenation, pulmonary perfusion, tx of infection, adequate cardiac output, intubation
Suspicion for Inhalation Injuries
● History of exposure to flames whether burns are present
● Soot around nose or in sputum, singed nasal hairs, or mucosal burns of the nose, lips, mouth, or throat
● Hoarse voice & cough
-Swollen neck, burned hair
-FLASH (facial skin, lips, airway, sputum, hair
● Increased inspiratory & expiratory stridor
● Tachypnea, tachycardia, abnormal breath sounds
Inhalation Injuries:
Pulmonary Complications
● Early carbon monoxide poisoning, airway obstruction & pulmonary edema
● ARDS 24 to 48 hours after injury
● Late complications: bronchopneumonia & pulmonary emboli
● Airway compromise from eschar after a severe burn
Smoke Inhalation Injuries
● Heat injury: Thermal injury to upper respiratory tract, Reflex glottis closure
● Local chemical Injury: Insoluble gases in the lower respiratory tract
● Systemic injury: CO causing tissue hypoxia
● Mgmt: 100% O2, bronchodilators
Environmental tobacco exposure
● Children exposed to passive or environmental smoke
● Legislation to prevent smoking in public places
● Use of e-cigs
Allergies vs cold: allergies
-Occur repeatedly
-Seasonal
-No fever
-Itching in eyes and nose
-Trigger constant sneezing
-Accompanied by eye and ear problems
Asthma
● Chronic inflammatory disorder of airways
● Bronchial hyperresponsiveness
● Episodic
● Limited airflow or obstruction that reverses spontaneously or w/
treatment
● Atopy (genetic)
● s/s: Dyspnea, Wheeze, Cough
● Dx: PFTs most accurate, peak expiratory flow meter
● Nursing mgmt: education plan, severity classification, acute asthma care, avoid allergens, relieve bronchospasm, inhalers
● Risks: mother < 20 y, smoking on maternal side, African American ethnicity, allergic genes on chromosome 5, lack of access to medical care, prior life-threatening attacks
Asthma types and categories
● Types: Recurrent wheezing usually precipitated by a viral respiratory tract infection (e.g. RSV), Chronic asthma associated with allergy persisting into later childhood and often adulthood, Associated w/ girls who develop obesity and early-onset puberty by 11 y, Cough-variant asthma
● Categories: Intermittent, mild persistent, moderate persistent, and severe persistent
Asthma severity classification in children 5+ (not on test)
● Stage I—mild, intermittent asthma
● Stage II—mild, persistent asthma
● Stage III—moderate, persistent asthma
● Stage IV—severe, persistent asthma
Asthma meds
● Long-term control meds: Inhaled corticosteroids, cromolyn sodium and nedocromil, long-acting β2-agonists,
methylxanthines, leukotriene modifiers (Advair or Pulmicort), theophylline, leukotriene modifiers, Mg sulfate, oral steroids
● Quick-relief (“rescue”) medications: Short-acting β2-agonists, anticholinergics, systemic corticosteroids AKA bronchodilators, EPI-pen
Asthma drug routes
● Inhaled for most medications: MDI with spacer, Nebulizer (Albuterol tx)
● Generally less effective in treating asthma: Oral, IV
Asthma interventions
-Breathing exercises and physical therapy
-Chest physiotherapy (CPT)
-Hyposensitization
Acute asthma care
● Calm nursing presence
● Monitor with pulse oximetry
● Assess breath sounds
● Allow older children to sit up if they are more comfortable in that position
● Safety precautions
● Allow parents to remain with children: Try to decrease parental stress
Signs of severe Respiratory Distress in
Children with Asthma
● Remains sitting upright, refuses to lie down
● Sudden agitation
● Agitated child who suddenly becomes quiet
● Diaphoresis
● Pale
Status asthmaticus
● Life threatening episode of airway obstruction that is often unresponsive to common treatments: Can result in respiratory failure and death
● Medical Emergency!: Lack of air movement in lungs, Be prepared for intubation, Monitor SaO2 and ABGs carefully
● Humidified O2, continuous bronchodilator nebulizer tx, corticosteroid, Mg sulfate, sit the child up
● Emergency tx: EPI 0.01 mL/kg subq (max is 0.3 mL), IV Mg sulfate, IV ketamine, IV corticosteroids, heliox (breathing gas mix of He and O2)
Cystic fibrosis (CF)
● Autosomal recessive genetic disease
● Abnormal gene is located on the long arm of chromosome 7
● 95% known cases occur in Caucasians
● Most common lethal genetic illness among Caucasian children
● Approximately 3% of US Caucasian population are symptom-free carriers
CF patho
● Characterized by several unrelated clinical features: Respiratory system, GI system
(small intestine, pancreas, bile ducts, Growth patterns), Reproductive system and skin
● Increased viscosity of mucous gland secretion: Results in mechanical obstruction, Thick, inspissated mucoprotein accumulates, dilates, precipitates,
coagulates to form concretions in glands and ducts, Respiratory tract and pancreas are predominantly affected
CF dx
● Early infancy screening
● DNA testing (autosomal recessive)
● Sweat chloride test (garbage bag sweatsuit, test level of Cl in sweat, 3x normal child)
● Chest radiography
● Pulmonary function tests (PFTs)
● Stool fat (fatty, stinky stools) and/or enzyme analysis
● History and physical exam
CF s/s
● Meconium ileus at birth
● Prolapse of the rectum
● Distal intestinal obstruction syndrome
● Pancreatic enzyme deficiency (d/t pancreatic fibrosis) steatorrhea
● Excretion of undigested food in stool: Stool is bulky, frothy, and foul smelling
● Failure to thrive/growth failure/wasting of tissues, hx of repeated respiratory infections
● Sweat gland dysfunction
● Increased weight loss despite increased appetite
● Gradual respiratory deterioration
● Wheezing respiration; dry, nonproductive cough
● Generalized obstructive emphysema
● Patchy atelectasis
● Cyanosis
● Clubbing of fingers and toes
● Repeated bouts of bronchitis and pneumonia
● Stasis of mucus increases the risk for life-threatening
respiratory infections
● Delayed puberty in females
● Sterility in males
● Parents report that children taste “salty”
● Dehydration
● Hyponatremic or hypochloremic alkalosis
CF respiratory s/s
● Viscous secretions are difficult to expectorate and obstruct bronchi and bronchioles: Cause atelectasis and hyperinflation, Stagnant mucus leads to destruction of lung tissue, Stagnant mucus provides a favorable environment for bacteria growth
● Mgmt: Improving ventilation, removing mucopurulent secretions, and administering
antimicrobial agents
CF respiratory progression
● Gradual progression follows chronic infection
● Bronchial epithelium is destroyed
● Infection spreads to peribronchial tissues, weakening bronchial walls
● Peribronchial fibrosis
● Decreased O2/CO2 exchange
● Chronic hypoxemia causes contraction and hypertrophy of muscle fibers in pulmonary arteries and arterioles
● Pulmonary hypertension
● Cor pulmonale (RHF, enlarged RV d/t high BP in lungs)
● Pneumothorax
● Hemoptysis
CF and GI tract
● Thick secretions block ducts → cystic dilation → degeneration → diffuse fibrosis
● Prevents pancreatic enzymes from reaching duodenum
-Meconium ileus –> meconium is abnormally thick and sticky
● Impaired digestion/absorption of fat → steatorrhea
● Impaired digestion/absorption of protein → azotorrhea
● Endocrine function of pancreas initially stays unchanged
● Eventually pancreatic fibrosis occurs; may result in diabetes mellitus
● Focal biliary obstruction results in multilobular biliary cirrhosis
● Impaired salivation
CF respiratory mgmt
● Airway clearance therapies (ACTs): Chest PT, PEP, Active-cycle-of-breathing, forced expiration, mechanical vest
● Bronchodilator medication prior to ACT
● Dornase alfa (Pulmozyme): Decreases mucus viscosity
● Aggressive treatment of pulmonary infections: Home IV abx therapy, Aerosolized abx
● Pneumothorax
● Hemoptysis
● Transplantation: heart, lung, pancreas, and liver for adolescents who have advanced disease
CF GI mgmt
● Administration of pancreatic enzymes & ADEK
● High-protein, high-calorie diet, as much as 150% rDA
increase fluids
● Reduction of rectal prolapse
● Salt supplementation
● Oral glucose-lowering agents or insulin injections as needed
● Treat gastroesophageal reflux: Place the patient in the upright position after meals, H2 Blockers
CF Endocrine mgmt
● CFRD (cystic fibrosis-related diabetes): Characteristics of both Type 1 & Type 2 DM, Increased risk for glucose mgmt problems
● Screening: oral glucose tolerance test at 10 years of age
● Monitor blood glucose levels: 3x/day, Insulin
● Diet
● Exercise
● A1C measurements
● Regular eye examinations: Retinopathy
CF prognosis
● Estimated life expectancy for a child born with CF is 40 yrs
● CF continues to be a progressive, incurable disease
● Organ transplantation has increased the survival rate: Heart–lung and bilateral lung transplantation, Liver and pancreas transplantation
● Maximize health potential: Nutrition, Prevention and early aggressive treatment of infection, Pulmonary hygiene
CF family support
● New research hope: Transplantation, Gene therapy, Bilateral lung transplants, Improved meds
● Child requires treatments multiple times each day: child may rebel, Depression & anxiety common
● Frequent hospitalizations: Nosocomial infections (pt may be on contact precautions)
Respiratory failure (RF)
● Respiratory insufficiency: Increased work of breathing (WOB), Hypoxemia and acidosis
● Respiratory arrest: Complete cessation of respiration
● Apnea: Cessation of breathing for > 20 sec
● Restlessness, tachypnea, tachycardia, diaphoresis
● Retractions, grunting, changes in resp pattern, CNS symptoms
● Supplemental O2, positioning, suctioning, CPAP/BiPAP, consider early intubation
● Resuscitative measures if respiratory arrest
