Alteration in Respiratory Function
Jan Bazner-Chandler RN, MSN, CNS, CPNP
Allergic Rhinitis
Assessment Itching of nose, eyes, and throat Sneezing and stuffiness Watery nasal discharge / post nasal drip Watery eyes Swelling around the eyes
Assessment
Allergic Shiner Allergic Salute
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Rhinitis Interdisciplinary Interventions Avoid offending allergen – smoke / pets Pharmacologic management:
Oral or nasal antihistamines - Benadryl Leukotriene modifiers - Singulair Mast cell stabilizers – cromylin – nasal /
ophthalmic / inhaled Allergen-specific immunotherapy
Do not use combination OTC medications especially those that contain pseudoephedrine
No OTC Antihistamines for children under 6 years of age.
Sinusitis
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Assessment Fever Purulent rhinorrhea Nasal congestion Pain in facial area Malodorous breath Chronic night-time cough
Children more prone to sinusitis: children with asthmaand cystic fibrosis.
Interdisciplinary Interventions Normal saline nose drops Warm pack to face Acetaminophen for pain Increase po fluid intake Antibiotics
Recent studies question their effectiveness
Tonsillitis Tonsils and adenoids are important to the
normal development of the body’s immune system.
Serve as part of the body’s defense against infection
Can become the site of acute or chronic infection
Repeated acute infections cause the tonsil tissue to swell
Enlarged tonsils and adenoids impinge on the pharyngeal opening of the eustachian tube
Assessment Child may refuse to drink Fever Reddened pharynx and tonsils Most common causative agent = group A
beta-hemolytic stretococci Chronic tonsillitis may result in snoring due to
enlarged tonsils and adenoids
Tonsilitis
“Kissing tonsils” occur when the tonsils are so enlarged they touch each other.
Interdisciplinary Interventions Throat culture to determine causative agent Antibiotics for ten days if throat
culturepositive for beta strep Acetaminophen for pain Cool fluids Saline gargles Antiseptic sprays Viral throat infections will not get better faster
with antibiotics.
Tonsillectomy Done if child’s respiratory status is
compromised Post operative care:
Side lying position Ice collar Watch for swallowing Cool fluids / soft diet
Croup Most common acute respiratory condition
seen in early childhood. Highest incidence from 6 months to about 3
years Respiratory symptoms are caused by
inflammation of the larynx and upper airway, with resultant narrowing of the airway.
Severity depends on the area of the upper airway that is inflamed and narrowed.
Most often viral – antibiotics are not needed
Assessment
Symptoms: Hoarseness Inspiratory stridor Barking cough Afebrile Often worsens at night
Interdisciplinary Interventions Home care:
Cool mist Fluids
Hospital care: Racemic epinephrine inhalant Mist tent – not used much anymore Dexamethasone IV fluids if not taking po fluids
Epiglottitis
Tripod position
Bowden & Greenberg
Acute Epiglottitis Acute inflammation of supraglottic structures,
the epiglottis and aryepiglottic folds. True pediatric emergency Delayed treatment may result in complete
airway obstruction Most often seen in children 2 to 7 years Most common causative agent – H. influenzae
type B
Assessment Sudden onset High fever – 102.2 or greater Dysphasia and drooling Agitation, irritability and restlessness Epiglottis is cherry red and swollen Note: Do not look into the mouth – diagnosis
often made by presenting symptoms or lateral neck x-ray
Interdisciplinary Interventions Keep child quiet in a controlled medical
environment with emergency airway equipment readily available.
Do not put tongue blade in mouth to look in the throat – may cause epiglottis to spasm and shut
Assess respiratory status Give humidified oxygen by mask and keep
HOB elevated. Mild sedation may help the child relax
Apnea Apnea is cessation of respirations lasting
longer than 20 seconds.
Monitor in hospital for underlying problems
Discharge home with monitor
Foreign Body
Severe inspiratory stridor
Symptoms depend on location
Unilateral chest movement
Chest x-ray Bronchoscope to
remove object
Coin in Trachea
Teaching No small hard candies, raisins, popcorn or
nuts until age 3 or 4 years Cut food into small pieces No running, jumping, or talking with food in
mouth Inspect toys for small parts Keep coins, earring, balloons out of reach
Influenza Associated with community epidemic Febrile, URI, achy joints Management:
Acetaminophen for fever Fluids Keep away from others Watch for signs of pneumonia
Bronchiolitis Acute obstruction and inflammation of the
bronchioles. Most common causative agent: Respiratory
Syncytial Virus (RSV) Bronchioles become narrowed or occluded as
a result of inflammatory process, edema, mucus and cellular debris clog alveoli
Assessment Harsh dry cough Low grade fever Feeding difficulties Wheezing Respiratory distress with apnea Thick mucus
Interdisciplinary Interventions Oxygen to maintain oxygen saturation >than
95% Pulse oximeter Nasal suction as needed Chest percussion to mobilize secretions Inhalation therapy – not sure if it is beneficial Mechanical ventilation as needed if increased
work of breathing is seen Increased heart rate, poor peripheral perfusion,
apnea, bradycardia and hypercarbia
RSV Positive - Isolation Respiratory Syncytial Virus is spread from
respiratory secretions through close contact with infected persons or contact with contaminated surfaces or objects.
Patient should be on contact and respiratory isolation
Can be placed with other RSV + patients
Pneumonia An inflammatory condition of the lungs in
which alveoli fill with fluid or blood resulting in poor oxygenation and air exchange.
Can be primary illness or develop as a complication of another illness.
Incidence: 34 to 40 cases per 1000 children younger than 5 years
Most likely to develop when the body is unable to defend against infectious agents.
Typical X-ray
Assessment High fever Thick green, yellow, or blood tinged secretions Grunting respirations Rales, crackles, diminished breath sounds Cough and cyanosis Diagnostic tests: Infiltrate seen on x-ray
Interdisciplinary Interventions• Assess for respiratory distress• NPO (respiratory rate > 60 = high risk for
aspiration)• IV fluids for hydration • Supplemental Oxygen to keep oxygen
saturation equal to or > 92%• Chest percussion• Nasal suctioning as needed• Acetaminophen for fever • Antibiotics – ampicillin and an aminoglycoside
(Gentamicin)
Pneumonia Isolation Respiratory isolation May be taken off isolation if RSV negative and
on antibiotics for 24 hours.
Cystic Fibrosis Inherited autosomal recessive disorder of the
exocrine glands Gene responsible for CF is located on
chromosome 7 Life span is about 37 years Complex disease requiring a holistic approach
CFTR Gene Mutation of the CFTR gene disrupts the
function of the chloride channels, preventing them from regulating the flow of chloride ions and water across cell membranes. As a result cells that line the passage ways of the lungs, pancreas and other organs produce mucus that is thick and sticky
Cystic Fibrosis
Cystic Fibrosis
Assessment History of Meconium ileus at birth Foul smelling, greasy, bulky stools /
constipation Voracious appetite with poor weight gain Recurrent respiratory infections Persistent chronic cough Salty tasting skin
Diagnosis Positive sweat test – Gold standard Genetic marker
Medications Pancreatic enzymes to help digest food Inhaled antibiotics – antimicrobial for lung treatment Aerosol bronchodilators to open airways Mucolytic enzyme – to thin mucus H2 blocker – alters gastrointestinal acidic environment
Tagamet Prokinetic agents – enhances gastrointestinal motility
Reglan Vitamin C to improve absorption of other meds Vitamins E, A, D, K / fat soluble vitamins Oral and IV antibiotics – S. aureus, H. influenzae, P aeruginosa
Long Term Complications Nasal polyps Sinusitis Rectal polyps / rectal prolapse Hyperglycemia / diabetes Infertility - male
Asthma Asthma is a chronic, inflammatory lung disease
involving recurrent breathing problems. Third leading cause of hospitalization among
children younger than 15 years. Most common, chronic health problem in children
Pathophysiology Reversible changes in airway that lead to
bronchoconstriction, airway hyper-responsiveness and airway edema.
At the cellular level mast cells release histamine causing smooth muscle contraction and bronchoconstriction.
Increased mucous secretion by goblet cells causes epithelial damage
Increased mucus secretion results in airway edema, mucus hypersecretion and plugging, airway narrowing, leading to airway obstruction
Assessment Wheezing Cough Tightness of chest Prolonged expiratory phase
Assessment Hypoxemia – universal in child with moderate
to severe symptoms Hypercarbia – carbon dioxide retention from
air trapping in the alveoli and ventilation – perfusion mismatch
Monitor blood gases – PaCO2 level more than 50 mm Hg indicated ventilatory failure
Diagnostics: chest x-ray = hyper-expansion of lungs
Asthma Attack
Interdisciplinary Interventions High fowlers position / bed rest Pulse oximetry Nebulized albuterol – beta 2 agonist Chest percussion to mobilize secretions Methylprednisone / Solu-medrol IV IV fluids Oxygen to keep oxygen sats > 95%
Home Management Peak flow spirometer Identify triggers Maximize lung function Optimal physical growth Optimal psycho-social state Maximum participation
Peak Flow Meter
Peak flow meters are used to measurePEFR and are designed for monitoring purposes rather than diagnosis of asthma.
Home Medications Rescue drugs: short acting albuterol beta 2
agonist – used as a quick-relief agent for acute bronchospasm and for prevention of exercise induced bronchospasm.
Anti-inflammatory or preventative: low-dose inhaled corticosteroid: inhaled or oral prednisone
Allergy: leukotrines such as Singulair
Bronchodilators Bronchodilators rapidly relax the airway
smooth muscle cells, thus reversing the bronchospasm until anti-inflammatory effect of steroids is attained. Aerosols
Via mouth piece 3 years and older Via facial mask for less than 3 years
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Nebulizer
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Corticosteroids Steroids reduce the inflammatory component
of bronchial obstruction, decrease mucus production and mediator release, as well as the late phase (cellular) inflammatory process.
Methyl prednisone IV in severe cases May need histamine H2 receptor antagonists
(cimetadine or ranitidine) if experiencing GI upset
PO prednisone – always give with food to decrease GI upset
Inhaled Corticosteroids Inhaled corticosteroids: Pulmicort, AeroBid,
Flovent Infant: mask should fit firmly to prevent cataracts Older child: rinse and spit after treatment to
prevent thrush
Family Teaching Teach how to use medication When to use and how often No OTC drugs Increase fluid intake Signs and symptoms of respiratory distress
Neonate Disorders
Pediatric Nursing January/February 1999
Bronchopulmonary Dysplasia
HistoryIt occurs in newborns who are born prematurely
and or have a variety of pulmonary disorders and who require ventilatory support with high pressure and oxygen in the first 2 weeks of life.
Pathophysiology Fibrosis of airways and marked hyperplasia of
the bronchial epithelium Increased fluid in the lungs, as a result of
disruption of the alveolar-capillary membrane Over distention due to damage to alveolar
supporting structures resulting in air trapping Fibrosis, airway edema, and broncho-
constriction
BPD Assessment Persistent respiratory distress Dependent on supplemental oxygen Failure to thrive Gastro-esophageal reflux Pulmonary hypertension
Long-term Outcomes Oxygen dependent Visual problems Feeding difficulties Developmental delay Learning difficulties
Long Term Management Supplemental oxygen CPT Bronchodilators Diuretics (pulmonary hypertension) Anti-inflammatory medication Nutritional support: po formula + NG
supplement Gastrostomy tube (GER) Bicarbonate in formula due to chronic state of
acidosis