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Anatomy of the respiratory system
• The respiratory system is divided into two divisions; upper & lower airways.
• The uppers is consisting from: nose, pharynx, larynx & epiglottis.
• The larynx divides the upper from the lower airways.
• The lower airways consist of trachea, bronchi, bronchioles & alveoli.
• During respiration: respiratory system delivers warmed, moistened air to alveoli; gas exchange occur; then carbon dioxide filled air is transferred outside the lungs.
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Pediatric differences • The child’s respiratory system grows constantly &
changes until 12 years of age.
1- Upper & lower airway differences:
• Children have smaller nasopharynx which would occluded easily during infections.
• Children have small oral cavity & large tongue that would increase the risk of obstruction.
• Children have small nares that would be easily occluded.
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• Children have immature thyroid, cricoid and tracheal cartilages, which would be easily collapsed when neck is flexed.
• Children have fewer muscle functioning, which will leads lungs to not being able to compensate for edema, spasm & trauma.
• Newborns and infants until 2-3 month are nose breathers.
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• The child’s airway is shorter & narrower than an adults.
• The trachea diameter can be estimated by the child’s little finger; it increase in length rather than diameter in the first 5 years of life.
Child --- 4mm
Adult --- 8mm
• The bifurcation of the trachea is at T3 while in adults is at T6.
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Assessing respiratory illness in children
Position of comfort
Tripod position (sitting forward with arms on knee for support & extending the neck.
Lung auscultation
Diminished or absent breath sounds.
Presence of adventitious sounds ( wheezing, crackles).
Color Color of the mucus membrane (pink, cyanotic) with & without crying.
Clubbing nail Presence of clubbing nail.
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Retractions • Presence of visible appearance of the chest being drawn on inspiration.
• Retractions in the supraclavicle suggest upper airway obstruction.
• Retractions in intercostal’s musclesuggest lower airway obstruction.
Respiratory efforts
Presence of nasal flaring.
Presence of tachycardia.
Presence of paradoxical breathing
( chest & abdomen do not raise at the same time).
Cough Presence of cough; dry, productive, brassy (musical, noisy).
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Measure Normal value Clinical significance
P02 80-100 mmHg Decrease when child cannot inspire adequately
PCO2 35-45 mmHg Increase when the child cannot expire adequately
O2 saturation 95-100 % Decrease if O2 cannot reach RBC
pH 7.35-7.45 Decrease if CO2 is being retained as carbonic acid in blood
HCO3 22-26 mEq/L Increase in respiratory alkalosis; decreased in respiratory acidosis.
Base excess -2.5 or + 2.5
mEq/L
(+) = alkaline excess
(-) = alkaline deficit
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Disorders of the nose & throat
• Nose bleed is common in school-age child, commonly caused by irritation from nose picking, foreign bodies, low humidity, forceful coughing, allergies.
• Or it could be related to systemic disease(bleeding disorder).
• To stop the nosebleed the child must be sit upright with head tilted forward to prevent blood drip down the throat cause vomiting.
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• The nares should be squeezed just below the nasal bone & held for 10-15 minute, while the child breath from his mouth.
• If bleeding does not stop, cotton ball soaked with epinephrine or lidocaine may be inserted to the affected nares to provide topical vasoconstriction or anesthesia.
• Post the bleeding, the child may be vulnerable to other episodes, so child must avoid hot bathes, hot drinks, vigorous exercise, bending over for the next 2-3 days.
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To prevent epistaxis:
Educate parents to:
• Provide humidity in the child’s room.• Discourage the child from picking or rubbing the
nose or inserting foreign objects into nose.
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• Known as the common cold, it causes inflammation of the nose & throat.
• The most common viruses that cause the infection includes rhinovirus & coronavirus; and from bacteria is group A streptococcus.
• The organism incubate for 1-3 days and the infection is communicable for several hours before the symptoms occur for 1-2 days. Symptoms last for 10-14 days.
• Disease spread through direct or indirect contactwith the patient (air droplets).
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Clinical manifestations Infant < 3 months
Infant > 3 months
Older children
Lethargy
Irritability
Poor Feeding
Fever
Fever
Vomiting
Diarrhea
Sneezing
Restlessness
Dry, irritated nose.
Chills, fever
Headache, malaise,sneezing
• Nasopharyngitis does not need hospitalization or any medical interventions, just support therapy.
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Symptomatic Therapy • For children who cannot breath from mouth, nasal
drop of normal saline should administer every 3-4 hours especially before feeding.
• Administration of Antihistamines would be helpful (as doctor order).
• Administer Antipyretic to decrease the fever. • Aspirin is not recommended for children below 5
years, due its association with Reyes’ syndrome. • Hot fluide and vitamine C .• Room humidification would help in preventing
drying nasal secretions. • Encourage rehydration (increase oral intake).
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• Infection that affects the pharynx, including the tonsils. 80% of these infections are caused by viruses (most commonly enteroviruses).
• Bacterial pharyngitis is known as strep throat; because 20-40 % of bacteria is caused b group A beta-hemolytic streptococcus
• Throat culture is needed to identify the causative agent.
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Clinical manifestations Viral Bacterial
Nasal congestion
Mild sore throat
Cough
Hoarseness
Fever < 38 C
Minimal tonsillar exudates
Mild pharyngeal redness
Abrupt onset
Tonsillar exudates
Anorexia, nausea,vomiting.
Sever sore throat
Headache, malaise.
Fever > 38 C
Dysphagia
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• Pharyngitis is treated by giving oral Penicillin or injection if the child have no allergy to Penicillin.
• If he have allergy, Erythromycin is the second drug of choice.
• For viral infection, symptomatic treatment alone is used.
Nursing interventions:
• reduce the child pain & discomfort.
• Decrease fever.
• Increase oral intake.
• Gargling with warm salt water (1 tsp in 250 ml).
• Encourage bed rest.
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Complications of Pharyngitis:
• Otitis media.
• Cervical adenitis.
• Lower respiratory tract infection.
• Rheumatic fever.
• Glomerulonephritis.
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Tonsillitis & Adenoiditis • Tonsillitis is an infection of the palatine tonsils;
while adenitis refer to infection of the adenoid pharyngeal tonsils.
Different types of tonsils: • The palatine tonsils: are located on both sides of
the pharynx. • Adenoid: are in the nasopharynx. • Tubal tonsils: are located at the entrance to the
Eustachian tubes. • Lingual tonsils: are located at the base of the
tongue.
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Clinical manifestations All symptoms of sever pharyngitis:
• Sore throat• Difficult & painful swallowing. • High fever. • Lethargic. • Pharyngeal pain & edema. • Mouth breathing. • Sleep apnea that results from pharyngeal
obstruction ## throat culture will reveal viral cause in children <
3 and bacterial cause in children > 3 years.
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Treatment • Antipyretic for fever.
• An analgesia for pain.
• Full 10 days course for antibiotic, such as Penicillin.
• If the cause is virus, no therapy other than comfort measures or fever reduction are needed
Surgical treatment:
Which includes removal of the palatine tonsils. IF
-Tonsillitis is recurrent -3 or more times in one year- removal must mot be before 3-4 years.
- IF there is sleep apnia
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Why we should not remove tonsils before 3-4 years of age?
• Excessive blood loss in small children.
• The possibility of regrowth.
• Hypertrophy of lymphoid tissue.
Tonsillectomy: refer to removal of palatine tonsils.
Adenoidectomy: refer to removal of the pharyngeal tonsils.
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Nursing management for tonsillectomy
Preoperative preparations includes:
• Complete history.
• Physical examination.
• Pt, PTT.
• Complete blood counts.
• Urine analysis.
• Assessment if the child have loose teeth.
## Tonsillectomy must not be done if the organs are infected.
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Post operative interventions includes:
• place the child on prone position with the head on the side to reduce the pressure on the operative site & prevent obstruction. (the head must be lower than the body). Why??
• Monitor for bleeding, if bleeding is heavy, return the child to the operation room to make suture to halt bleeding.
• The most dangerous period is 24 hrs after operation, so observe V/S carefully.
• Assess for signs of bleeding ( increase in pulse or respiratory rate, frequent swallowing, feeling of anxiety)
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• If bleeding occur, elevate the head & turn the child to his side.
• Avoid red fluid or red Jell-O, that could vomiting being mistaken with bleeding.
• Offer frequent sips of clear cold liquid, popsicles (liquid ice cream).
• Start soft diet 9 mashed potatoes, soups, cooked fruits after 24-48 hrs, and soft food for the first weeks to prevent pharyngeal irritation.
• Apply an ice cooler around the neck.
• Having the child gargle with solution of baking soda & salt (0.5 tsp in 250 ml).
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Nursing Diagnosis
Related tonsillitis: • Acute pain related to inflammation of the pharynx. • Risk for ineffective breathing patterns related to
obstruction by enlarged tonsils.• Risk for deficit fluid volume related to inadequate
intake. • Impaired swallowing related to inflammation &
pain. • Deficit knowledge (parents) related to home care
following discharge.
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Otitis Media
• Is an inflammation of middle ear, it is one of the most prevalent disease of early childhood .
• 70% of child have one episode in the first year of life and 50% of them have 2-3 episode by 3 years of age .
• The highest incident at 6 months to 2 years .
• It caused by streptococcus pneumonia, hemophilia influenza, staphylococcus.
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Factors that increase risk
• Child with smoker person more risk for develop OM than those who live with no smoking , because tobacco smoke inhalation increase the risk of blocked Eustachian tube and congestion of soft nasopharyngeal tissue lead to OM.
• Bottle feeding during sleep
• Children who use pacifiers for several hours daily.
• More common in winter.
• Children with cleft lip or palate, Down syndrome.
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Causes of non infectious type is unknown , but many risk factors :-
• Blocked Eustachian tube. • Edema or infections of URT.• Allergic rhinitis .• Hypertropic adenoids .
• Methods of feeding ( breast feeding infant less like to develop OM because the breast milk have IgA that limits the exposure of the Eustachian tubes to microbial pathogens ) .
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Pathophysiology • All of the previous risk factors could lead to
obstruction of the eustachian tube, which will leads eustachian tube’s mucus membrane to become edematous.
• As result the normal air flow to middle ear is blocked. & the air in the middle air absorbed into the blood stream.
• Which will leads fluid to shifts into middle ear, and provides good area for rapid growth of pathogens.
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Definitionterms
General term for inflammation of the middle ear
OM
An acute onset of ear pain, redness of tympanic membrane lasting approximately 3 weeks .
Acute OM
Inflammation of the middle ear in which a collection of fluid is present in the middle ear space .
OM with Effusion
(OME)
OME persist beyond 3 months .Chronic (OME)
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Clinical manifestations In acute OM:
• Ear pain (Otalgia, earache), rapid onset, irritability, poor feeding, malaise, bulging tympanic membrane, poorly mobile tympanic membrane. Rolling the head from side to side
In OM effusion:
• Difficulty of hearing, signs of acute inflammation are not present, tympanic membrane is retracted,
• Feeling of fullness in ear, popping sensation during swallowing and feeling of motion in the ear if air present above level of fluid.
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Medical Treatment For acute otitis media: • Treatment with antibiotic for 10 days in children
under 6 years of age and for 5-7 days in children above 6 years.
• First line therapy is Amoxicillin at a dose of 80 -90 mg/kg/day. Second drug is Cefuroxime (second generation of cephalosporin), at dose of 10 mg/kg/day.
For OM with effusion: • Myringotomy (surgical incision of the tympanic
membrane) may be performed. • Tympoanostomy may be inserted to drain fluid
from the middle ear (pressure equalizing tube).
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Nursing interventions
• Application of heating pad may reduce the discomfort (over the ear).
• Put the child on lying down position will facilitate drainage.
• Give analgesia & antipyretic as order to reduce pain & fever.
• An ice bag placed over the affected ear may be helpful to reduce edema & pressure
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Nursing Diagnosis
• Risk for imbalanced body temperature, hyperthermia related to infectious process.
• Fatigue (child & parents) related to sleep deprivation.
• Disturbed Sensory Perception (auditory) related to chronic ear infections and altered hearing perception.