Transcript Respiratory Alterations - NURSING FDTC Batch Spring 2011

Respiratory Alterations
NUR 264
Pediatrics
Angela J. Jackson, RN, MSN
Respiratory Alterations:
Developmental Differences
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Lungs require longer gestation time to form than any
other body system
Children have a smaller nasopharynx – easily
occluded during infections
Lymph tissue (tonsils, adenoids) grows rapidly in
early childhood, atrophies after age 12
Smaller nares – easily occluded during infection.
Infants are nose breathers
Eustachian tubes are shorter and more horizontal,
facilitating transfer of pathogens into the middle ear
Respiratory Alterations:
Developmental Differences
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Long, floppy epiglottis – vulnerable to swelling and
obstruction
Thyroid, cricoid, tracheal cartilages are immature and
collapse when neck is flexed
Diaphragmatic-abdominal breathing normal in
neonate until approximately 5y/o due to position of
ribs which affect chest wall expansion
Chest wall is supple and very compliant
Irregular patterns of breathing in newborns and
infants
Pediatric arrests usually occur from respiratory arrest
or shock, not cardiac arrest
Choanal Atresia
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Congenital
membranous or
bony obstruction
between the nose
and nasopharynx
Choanal Atresia
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Can obstruct one or
both posterior nasal
openings
Unilateral can be
overlooked until open
nasal passage becomes
obstructed
Bilateral – severe signs
of distress in newborn
More common in girls
Treatment: surgery
Congenital Laryngeal Stridor:
Laryngomalacia
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Laryngeal cartilage
is soft and flaccid,
causing the
supraglottic
structures to
collapse into the
airway, resulting in
partial obstruction
and stridor
Laryngomalacia
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Stridor with retractions
Infant’s cry is normal
Cyanosis is uncommon
Place in prone position to decrease
obstruction
Occurs more frequently in boys
Treatment: Tracheostomy
Acute Viral Nasopharyngitis
(Common Cold)
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Inflammation of the nasopharynx
Self-limiting viral infection
The inflammatory process is associated
with tissue swelling and the formation
of exudate.
Nasal congestion caused by edema and
secretions impede airflow through the
nasal passages
Acute Viral Nasopharyngitis:
Clinical Manifestations
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Nasal stuffiness
Rhinitis
Sneezing
Nasal discharge
Coughing
Sore throat
Fever
Irritability
Malaise
Poor feeding
Acute Viral Nasopharyngitis:
Diagnosis and Treatment
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Diagnosis is based on client history and
physical exam
Supportive care
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Decongestants
Saline nasal spray
Fluids
Vaporizer
Antipyretics
Cough suppressants
Acute Streptococcal
Pharyngitis (Strep Throat)
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Bacterial pharyngitis
Caused by Group A
beta-hemolytic
streptococcus
Red throat, petechia on
palate
Throat pain
Fever
Abdominal pain
Fine raised rash
Anterior cervical
adenopathy
Strep Throat
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Diagnosed with throat cultures, rapid
strep screen
Treated with one dose IM penicillin or
10 day course of antibiotics
Replace toothbrush
Test and treat other members of family
Complications: acute
glomerulonephritis, Rheumatic Fever
Tonsillitis - Adenoiditis
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Viral or bacterial infection of the
palatine and or pharyngeal tonsils
(adenoids)
Children are more prone to tonsillitis
because of the large amount of
lymphoid tissue and frequent
respiratory infections
Tonsillitis – Adenoiditis:
Clinical Manifestations
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Sore throat
Difficulty swallowing
Fever
Nasal congestion
Tonsillitis – Adenoiditis:
Diagnosis
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Based primarily on
symptoms and
visual inspection of
the throat
Throat cultures and
rapid strep
screening are used
to determine
etiologic agents
Tonsillitis – Adenoiditis:
Treatment
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Tonsillectomy may be indicated for
recurrent infection, or when enlarged
tonsils interfere with eating or breathing
Viral infection: supportive care
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Warm saline gargles
Antipyretics
Otitis Media
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Inflammation of the
middle ear
One of the most
common infectious
diseased in
childhood
Primary causative
factor: abnormal
functioning of
eustachian tube
Otitis Media: Clinical
Manifestations
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Pain
Fever
Irritability
Diarrhea and vomiting
May have decreased hearing
Otitis Media: Diagnosis
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Otoscopic examination
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Red, bulging tympanic membrane
Diminished movement with pneumatic
otoscopic assessment
Otitis Media: Treatment
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Antibiotics for 10 days
Tympanostomy tubes for recurrent or
unresolving OM and/or hearing loss
Acute Epiglottitis
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Serious obstructive
inflammatory process of
epiglottis
Occurs principally in
children between 2 and
5 years of age
Caused by infection
with Haemophilus
influenzae
Requires immediate
treatment
Epiglottitis: Clinical
Manifestations
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Abrupt onset
Child complains of sore throat and pain on
swallowing
Fever
Child appears sicker than clinical findings suggest
Insists on sitting upright and leaning forward, with
the chin thrust out, mouth open and tongue
protruding (tripod position)
Drooling is common
Child is irritable and extremely restless, has an
anxious, apprehensive and frightened expression
Voice is thick and muffled
Inspiratory stridor
Acute Epiglottitis: Treatment
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Intubation or tracheostomy
may be necessary for the
child with respiratory distress
Antibiotics, initially given IV
followed by PO
administration, for 10 days
IV fluids, antipyretics,
corticosteroids, keep child
calm
The epiglottal swelling
usually decreases after 24
hours of antibiotic therapy,
and is near normal by the
third day
Laryngotracheobronchitis
(Croup)
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Viral syndrome manifested by a croupy
or “barking” cough, inspiratory stridor,
and respiratory distress
Inflammation of the larynx, trachea,
and bronchi causes narrowing of the
airways
Seen predominately in children between
6months and 3 years of age
Croup: Clinical Manifestations
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Hoarse or “barking” cough
Nasal drainage
Sore throat
Low-grade fever
Tachycardia
Tachypnea
Inspiratory stridor
Croup: Treatment
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Nebulized racemic epinephrine
Corticosteroids
Fluids
Rest
Humidity
Bronchiolitis
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Acute viral infection of the bronchioles,
occurring most often in young children
RSV is the most common causative
agent
95% of children have had bronchiolitis
by the age of 3
Bronchiolitis: Pathophysiology
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Inflammation causes airway edema
The bronchioles are narrowed and
occluded
Occlusion causes air trapping, which
leads to hyperinflation of some alveoli
and atelectasis in others
Overall effect is hypoventilation
Bronchiolitis: Clinical
Manifestations
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Rhinorrhea
Sneezing
Decreased appetite
Low-grade fever
Coughing
Wheezing, nasal flaring, retractions
Crackles
Tachypnea
Bronchiolitis: Diagnosis
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History and physical exam
Nasopharyngeal washings
Chest x-ray
Bronchiolitis: Treatment
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Humidified O2
Bronchodilators
Suctioning
Oxygen saturation monitoring
IV fluids
Strict handwashing and contact precautions
Prophylaxis: Synergis IM once a month
Pneumonia
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Acute inflammation of the pulmonary
parenchyma
Seen frequently in childhood, occurring
most often in infancy and early
childhood
Viruses are the primary causative agent
except in neonatal cases of pneumonia
Pneumonia: Clinical
Manifestations
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Cough
Malaise
Chest pain
Fever
Anorexia
Headache
Tachypnea
Wheezing
Pneumonia: Treatment
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Cough, deep breath, change position
often
CPT, O2, IS
IV fluids
Antibiotics, antipyretics
Cool mist, suctioning
Rest
Asthma
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Chronic inflammatory disorder of
airways with bronchoconstriction and
bronchial hyperresponsiveness
Most common pediatric chronic illness
Asthma: Pathophysiology
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Exposure to irritant causes constriction of
bronchial smooth muscles, edema, increased
mucus production, airway narrowing
Bronchial muscles go into spasm, resulting in
increased respiratory effort, increased airway
resistance, air trapping, hyperinflammation of
airway
Risk factors: hereditary, environmental
stimuli, stress, weather changes, exercise,
viral or bacterial agents, food additives
Asthma: Clinical
Manifestations
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Recurrent episodes of wheezing
Breathlessness
Nasal flaring, retractions, head bobbing
Chest tightness
Cough
Prolonged expiration
Dyspnea
Tachypnea, tachycardia, barrel chest
develops
Asthma: Diagnosis
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Chest x-ray shows hyperinflation of the
airways
PFT’s show decreased peak expiratory
flow rate
Asthma: Treatment
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Avoidance of triggers
Regular peak flow monitoring
Medications
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Short-acting beta-2 agonists (albuterol)
Inhaled corticosteroids (beclomethasone)
Systemic corticosteroids
Antileukotrienes (Singulair)
Long-acting bronchodilators (Serevent)
Anticholinergics (atrovent)
Cystic Fibrosis
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Autosomal recessive disorder that
affects the exocrine glands
Causes the body to produce thick,
sticky mucus that clogs the lungs, the
GI tract and the GU tract
Affects approximately 30,000 children
and adults in the United States
Median age of survival is 33.4 years
Cystic Fibrosis: Clinical
Manifestations
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Salty taste to the skin
Foul smelling, greasy stools
Delayed growth
Thick sputum
Chronic coughing or wheezing
Frequent chest and sinus infections with recurring
pneumonia or bronchitis
Clubbing of fingers and toes
Intussusception
Rectal prolapse
Meconium ileus
Cystic Fibrosis: Diagnosis
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History and physical exam
Sweat test
DNA analysis
Cystic Fibrosis: Treatment
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Antibiotics
Mucus-thinning drugs (Pulmozyme)
Bronchodilators
Bronchial airway drainage
Oral enzymes
High calorie diets
Lung transplant
Cystic Fibrosis: Complications
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Chronic respiratory infections
Bronchiectasis (irreversible dilation and destruction of
the bronchial walls)
Pneumothorax
Cor pulmonale (failure of the right ventricle of the
heart)
Chronic diarrhea
Severe nutritional deficiencies
Type 1 diabetes
Liver damage
Infertility
Cystic Fibrosis: Nursing
Considerations
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Infection control
Maintain adequate nutrition
Medication administration
P&PD
Family teaching
Support groups
Bronchopulmonary Dysplasia
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Chronic lung disease that primarily affects
premature infants who have respiratory
distress syndrome
9 out of 10 babies with BPD weighed 1500
grams or less at birth
1 out of 3 babies born weighing less than
1000 grams gets BPD
5,000 to 10,000 babies in the U.S. get BPD
each year
BD: Pathophysiology
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Poor lung compliance requires mechanical
ventilation
Trauma to the pulmonary structures occurs,
leading to interstitial edema and epithelial
destruction
Inflammatory response causes airway
obstruction
Tissue and pulmonary vasculature damage
results in a ventilation/perfusion imbalance
that leads to hypercapnia and hypoxemia
BP: Clinical Manifestations
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Rapid, shallow breathing
Retractions
Cough
Wheezing
Cor pulmonale
Pulmonary edema
Dependence on supplemental O2 for
more than 28 days
Respiratory acidosis
BP: Diagnosis
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History and physical exam
RDS that does not improve within two
weeks
Prolonged mechanical ventilation
Prolonged need for supplemental O2
Chest x-ray
BP: Treatment
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Prevention is the primary focus
Prenatal steroids to promote the
maturation of fetal lungs
Administration of surfactant
Diuretics, steroids, bronchodilators
Supplemental O2
BP: Potential Complications
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Learning difficulties
Poor coordination and muscle tone
Trouble walking
Activity intolerance
Eye and ear problems
Increased susceptibility to URI’s and
other infections
BP: Nursing Considerations
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Maintain mechanical ventilation
Administration of medications (steroids, diuretics,
bronchodilators, antibiotics)
Monitor I&O
Provide adequate nutrition
Family teaching:
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Signs and symptoms of respiratory infection
Importance of immunizations
Medications
O2 therapy
CPR
Follow-up
Any Questions?