Nursing Care of the Pediatric Individual with a Respiratory Disorder

Differences in Adult and Child

Adult Child

The diameter of an infant’s airway is approximately 4 mm, in contrast to an adult’s airway diameter of 20 mm .

Of the three anatomical differences in the eustachian tube between adults and small children (shorter, wider, more horizontal), which do you think could cause more problems for the child and why?

Otitis Media

Inflammation of the middle ear sometimes accompanied by infection

Common Causes

• Eustachian tube dysfunction – Previous URI causes mucous membranes of the eustachian tube to become edematous and blocks tube. – Enlarged adenoids – Allergic rhinitis • Pacifier use raises soft palate and alters dynamics in the eustachian tube

Acute Otitis Media characterized by abrupt onset, pain, middle ear effusion, and inflammation. Note the injected vessels and altered shape of cone of light.

Note that the light reflex is not in the expected position due to a change in tympanic membrane shape from air bubbles.

Serous Otitis Media

Note effusion on otoscopy by fluid line and air bubbles

Clinical Manifestations

What objective sign is this child displaying?

What does it indicate?

Evaluation and therapy

• Treatment has always been directed toward antibiotic therapy; however, recently concerns about drug resistant 2004) streptococcus pneumoniae have caused medical professionals to re-evaluate therapy (APA, • No clear evidence that antibiotics improve OM • Waiting up to 72 hrs for spontaneous resolution is now recommended in healthy infants • When antibiotics are warranted, oral amoxicillin in high dosage is given

Myringotomy

• A myringotomy or pin hole is made in the ear drum to allow fluid removal. Air can now enter the middle ear through the ear drum, by-passing the Eustachian tube. The myringotomy tube prevents the pin hole from closing over. With the tubes in place, hearing should be normal and ear infections should be greatly reduced.

Nursing Care Management for OM

• Nursing objectives: – Relieving pain – Facilitating drainage when possible – Preventing complications or recurrence – Educating the family in care of the child – Educate regarding prevention – Providing emotional support to the child and

family

Mastoiditis

Mastoiditis

• Morbidity/mortality – Hearing loss – Extension of the infectious process beyond the mastoid system, resulting in intracranial complications • Ages affected – The incidence of mastoiditis parallels that of otitis media, affecting mostly young children and peaking in those aged 6-13 months. – May occur in healthy adults as well

Nursing care for the child with mastoiditis

• Monitor vital signs • Assess for changes in lab values • Medicate aggressively with abx as ordered (usually IV if bacterial spread to mastoid) • Drugs of choice: Timentin and Gentamicin • Assess for complications (hearing loss, tinnitus)

Tonsillitis and Adenoiditis

Upper Respiratory Tract Infections

• Nasopharyngitis – Young child: fever, sneezing, vomiting or diarrhea – Older child: dryness and irritation of nose/throat,

sneezing, aches, cough

• Pharyngitis – Young child: fever, malaise, anorexia, headaches – Older child: fever, headache, dysphagia, abdominal pai

n

• Tonsillitis – Masses of lymphoid tissue in pairs – Often occurs with pharyngitis – Characterized by fever, dysphagia, or respiratory problems

forcing breathing to take place through nose

Nurse Alert!

Key to understanding prevention of URI is meticulous handwashing and avoiding exposure to infected persons

Nurse Alert!

The nurse should remind the child with a positive throat culture for strep to discard their toothbrush and replace it with a new one after they have been taking antibiotics for 24 hours

Clinical Manifestations

• Tonsillitis – Fever – Persistent or recurrent sore throat – Anorexia – General malaise – Difficulty in swallowing, mouth breather, foul odor breath – Enlarged tonsils, bright red, covered with exudate • Adenoiditis – Stertorous breathing - snoring, nasal quality speech – Pain in ear, recurring otitis media

Nursing Care for the Tonsillectomy and Adenoidectomy Patient

Post-operative Care

• Providing comfort and minimizing activities or interventions that precipitate bleeding – Place on abdomen or side until fully awake – Manage airway – Monitor bleeding, esp. new bleeding – Ice collar, pain meds – Avoiding p.o. fluids until fully awake --then liquids and soft cold foods. Avoid citrus juices, milk – Do not use straws or put tongue blade in mouth, no smoking (in teenagers).

Nurse Alert for Post-Op T/A surgery

• Most obvious sign of early bleeding is the child’s continuous swallowing of trickling blood.

• Note the frequency of swallowing and notify the surgeon immediately

Assessment of Respiratory Status

Indications of Respiratory Distress

1. Nasal Flaring 2. Circumoral cyanosis 3. Expiratory grunting 4. Retractions – Substernal, lower intercostal, 5. Tachypnea – Repirations greater than 60

Apnea

• Defined as: Delay of breathing 20 seconds or longer • Additional Signs and Symptoms: – Cyanosis – Marked pallor – Hypotonia – Bradycardia

Treatment and Nursing Care

• Admit to hospital for cardiorespiratory monitoring and diagnostics • Teach parents home care instructions in the use of an apnea monitor • Teach to keep a diary of all episodes • Encourage parents to learn CPR.

• 24 hour medical and technical coverage is manadatory

Cardiorespiratory Monitoring pulse oximetry Want reading > 95%

SIDS

• Defined: sudden and unexplained death of an infant younger than one year during sleep • Risk Factors – Prematurity, low birth weight – Most common in infants 2-4 months old – More prevalent in winter months – Sleeping in bed with others, sleeping prone, use of

pillows and quilts

– Exposure to passive smoke

SIDS – Nursing Interventions

• Parent teaching: – place infant on back to sleep – Place on firm mattress – Do not use loose bedding, toys, pillows – Avoid overheating with too many clothes – Parents should stop smoking • Provide support of parents by helping them work through feelings of guilt and loss; refer to National Foundation for SIDS

Croup

Croup

• Refers to a group of viral and bacterial syndromes • Laryngotracheobronchitis, Bacterial tracheitis and epiglottitis are the “big three” • Initial symptom of all three is stridor, a seal like barking cough and hoarseness

Croup vs. Epiglotitis

• Croup – Viral/Bacterial – Fever – Hoarseness – Resonant cough – Stridor (inspiratory) – Risk for significant narrowing airway with inflammation – Humidity for treatment • Epiglottitis – Bacterial – High fever – Rapidly progressive course – Dysphagia – Drooling – Dysphonia – Distressed inspiratory efforts – Antibiotics needed

Medications

• Beta-agonist /Bronchodilator– Albuterol • Corticosteroids • Which of these medications would the nurse give first? Rationale?

Nursing Care

• Maintain patent airway – Oxygen with humidification – Keep resuscitation equipment at the bedside – Assess VS (T102 or >, and R>60) – Nothing should be placed in the mouth • Meet fluid and nutritional needs – Cool, noncarbonated, non-acid drinks – Assess for difficulty swallowing – may need IV therapy

Child with Epiglottitis

Critical Thinking Exercise

• Kim, a 4 year old, is admitted to the emergency department with a sore throat, pain on swallowing drooling, and a fever of 102.2°. She looks ill, agitated and prefers to sit up and lean over. • What nursing interventions should the nurse implement in this situation?

Bronchitis vs. Bronchiolitis

Bronchiolitis Bronchitis

Bronchitis

• Rarely occurs in childhood as isolated problem • Can be present with other respiratory illness • Most often viral • Can be response to allergen • Symptoms include coarse, hacking cough (increases at night), fatigue, sore ribs, respirations deep and rattling, audible wheezing

Bronchiolitis / RSV

• RSV is respiratory syncytial virus • Affects 2-6 month olds primarily • Infection of bronchial mucosa leading to obstruction • Starts out with Upper Respiratory Infection and progresses to Respiratory Distress. • Diagnosed with a RSV wash

Nursing Care for Child with RSV

• Medication therapy – Bronchodilators – – Steroids – Beta-adrenergic agonist – Antiviral • Virozole (Ribavirin) – Prevention drug – Synagis (palivizumab)

given IM. and RespiGam (RSV immune globulin) given IV.

• Contact isolation strictly enforced with

staff and family

Nebulized epinephrine administered for Bronchiolitis

Parents can hold nebulizer to decrease infant’s fear

Reactive Airway Disease (asthma)

• Chronic inflammatory disorder affecting mast cells, eosinophils, and T lymphocytes • Inflammation causes increase in bronchial hyperresponsiveness to variety of stimuli (dander, dust, pollen,smoke) • Most common chronic disease of childhood; primary cause of school absences

Asthma

Etiology/Pathophysiology of Asthma

• Obstructive airflow limitation due to: – Mucosal edema - membranes that line airways – Bronchospasm (bronchoconstriction) – Mucus plugging (thicker) causes : • Increased airway resistance • Decreased flow rates

Etiology/Pathophysiology

• Increased work of breathing • Progressive decrease in tidal volume and expiratory volume • Arterial pH abnormalities due to: – Increase in number of poorly ventilated alveoli – Increase in hypoxemia – Carbon dioxide retention – Respiratory acidosis

Asthma Triggers

Interpreting Peak Expiratory Flow Rates

• Green: (80-100% of personal best) signals all clear; asthma is under reasonably good control • Yellow (50-79% of personal best) signals caution; asthma not well controlled; call health care provider if child stays in this zone • Red (below 50% of personal best) signals a medical alert. Severe airway narrowing and short acting bronchodilator indicated

Medications to treat Asthma

• Reliever or Rescue Meds – Short acting beta2-adrenergic agonists

(SABAs) – albuterol, Xopenex (levalbuterol), terbutaline (Brethine, Brethaire)

– Anticholinergic –Ipratropium bromide

(Atovent) children 12 yrs or older

– Mast Cell Inhibitors – Cromolyn Sodium

(Intal) inhaled NSAID, blocks release of mast cell mediators, give before exposure; Nedrocromil sodium (Tilade) 12 yrs or older

– Corticosteroids- Prednisone,

Beclomethasone for short term therapy

Medications

• Routine Medications for long term

control

• Inhaled steroids - Beclamethasone,

budesonide, fluticasone, flunisolide and triamcinolone acetonide

• Long acting beta adrenergic agonists

(LABAs) – Salmeterol (Serevent) and formoterol (Foradil)

• Leukotriene blockers – Montelukast

(sprinkles or chewable) and zafirlucast. Zileuton for children 12 or older

Child receiving nebulizer treatment What is important patient teaching ?

Pulse Oximetry Treatment and Nursing Care High fowlers position Humidified Oxygen via mask

Emergency situations of asthma

• Acute episode of reactive disease:

med bronchioles may close rapidly, causing severe airway obstruction, anxiety, restlessness, and fear. Will need to be seen in ER if not relieved by

• Status asthmaticus:

needed medical emergency with severe edema, profuse sweating, respiratory failure and death if untreated. Becomes seriously hypoxic…immediate intervention

Cystic Fibrosis

Cystic Fibrosis (CF)

• Factor responsible for manifestations of the disease is mechanical obstruction caused by increased viscosity of mucous gland secretions • Mucous glands produce a thick protein that accumulates and dilates them • Passages in organs such as the pancreas become obstructed • First manifestation is meconium ileus in newborn

Cystic Fibrosis

Physical findings of the CF patient

• Clubbing of the fingers • Increased respirations, cyanosis • Productive, moist cough • Barrel chest

Assessment

• FTT despite high caloric intake. • Frequent respiratory infections. • Malabsorption of fats and proteins • Mild diarrhea with malodorous stools, steatorrhea. • Abnormally high levels of sodium chloride in sweat.

Diagnosis

•

Sweat test: Chloride – Normal < 40 mEq/L. Highly suggestive of CF 40-60 mEq/L Diagnostic > 60 mEq/L. (see bags over hands and arms)

•

Pancreatic enzymes: Collection of stool specimen to assess Trypsin and lipase. Trypsin absent in 80% of children with CF

CF Management

• Treatment – Prevention and treatment of pulmonary

infections with antibiotics

– Chest Physiotherapy at least twice a day to

increase sputum expectoration

– Physical exercise important adjunct – Management of dietary supplements

(enzymes with meals and snacks)

Chest Physiotherapy

cupping and clapping

The End