respiratory. key pediatric differences in the respiratory system lack of or insufficient surfactant...
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RespiratoryRespiratory
Key Pediatric Key Pediatric Differences in the Differences in the
Respiratory SystemRespiratory System• Lack of or insufficient surfactant (premature
infant) • Smaller airways and underdeveloped cartilage• Tonsilar tissue enlarged• More flexible larynx• Obligatory nose breather (infant)• Less well developed intercostal muscles• Brief periods of apnea common (newborn)• Faster respiratory rate• Increased metabolic needs• Eustachian tubes relatively horizontal
Respiratory Diseases and Respiratory Diseases and Disorders of ChildhoodDisorders of Childhood
• Otitis Media• Pharyngitis• Epiglotitis• Broncholitis• Pneumonia• Asthma exacerbation• Cystic Fibrosis• Tuberculosis
Upper Upper Respiratory Respiratory
Tract Tract DisordersDisorders
Otitis Media (OM)Otitis Media (OM)• One of the most common illnesses in infancy and
childhood• Peak incidence: 6 months to 6 years• Infection or blockage of the middle ear• Acute, Chronic or Serous OM
Risks for Development Risks for Development of Acute Otitis Mediaof Acute Otitis Media
• Exposure to second hand smoke• Allergies• Bottle fed infants
(AOM) Acute Otitis (AOM) Acute Otitis MediaMedia
• Sudden temperature increases
• Sharp pain • Otalgia (earache); pull
on ear, rubbing face • Irritability• Sleep disturbance• Persistent crying• Fever, vomiting,
diarrhea, anorexia• Sudden relief and
drainage=rupture TM
TreatmentTreatment• AOM could be viral or bacterial• Acetaminophen (pain, fever)• Amoxicillin for 7-10 days if bacterial• ALTERNATIVE- wait 72 hours then treat
Serous Otitis Media or Serous Otitis Media or
Otitis Media with Effusion Otitis Media with Effusion
(SOM/OME)(SOM/OME)• Result of chronic otitis
media (3 AOM in 6 months or 4 AOM in 1 year)
• Epithelial cells of middle ear begin producing secretions instead of absorbing them
Surgical Surgical InterventionsInterventions
Myringotomy• Surgical incision or laser of the tympanic membrane• Allows mucoid material to be removed from middle
earTympanostomy tubes• Placed to equalize pressure on both sides of the
tympanic membrane, keeps ear aerated• Allows middle ear mucosa to return to normal and
growth of the eustachian tube to continue
Patient Teaching-Patient Teaching-Post OpPost Op
• Monitor for ear drainage
• Report any fever or increased pain
• Avoid blowing nose for 7-10 days
• Swimming, showers allowed only with earplugs
• Diving and swimming in deep water is prohibited
Pharyngitis (Tonsillitis)Pharyngitis (Tonsillitis)
• Inflammation and infection of the palatine tonsils
• Viral vs. Bacterial • Peak age 4-7 years
Viral PharyngitisViral Pharyngitis• Gradual Sore throat• Erythema, inflammation
of pharynx and tonsils (may be slight)
• Vesicles or ulcers on tonsils
• Fever (usually low grade)
• Hoarseness, cough, rhinitis, conjunctivitis, malaise, anorexia
• Cervical lymph nodes may be enlarged, tender
• Usually lasts 3-4 days then resolves spontaneously
Bacterial Pharyngitis Bacterial Pharyngitis • Abrupt onset (may be
gradual in children younger than 2 years)
• Sore throat (usually severe)
• Erythema, inflammation of pharynx and tonsils
• Fever usually high (103-104F) but may be moderate
• Abdominal pain, headache, vomiting
• Cervical lymph nodes may be enlarged, tender
• Requires antibiotics
ManagementManagement
• Pain relief
• Rest
• Bland, soft diet
• Amoxicillin if bacterial
• Tonsillectomy is controversial
Nursing Care (Pre-Nursing Care (Pre-op)op)
• Assess for current infection and bleeding history
• Check for loose teeth• Teach child and parent what to expect
post-opoMay see dried blood in mouth and
teethoWill still be able to talkoPain management for optimal
recovery
Nursing Care (Post-Nursing Care (Post-op)op)
• Assess for bleedingoElevated pulseoDecreased BPoRestlessnessoFrequent swallowingoVomiting bright red blood• Clear, cool liquids, no red juices!
• Advance to full liquids and soft foods on 2nd day if no sign of hemorrhage
• Pain relief (throat very sore)
Nursing care (Post-op)Nursing care (Post-op)• Encourage child to chew and swallow
• No straws, forks or sharp, pointed toys
• Discourage irritating the operative site
o coughing frequentlyo clearing the throato blowing the nose
CroupCroup
Manifestations of Manifestations of CroupCroup
• Begins at night; may be preceded by several days of symptoms of upper respiratory tract infection
• Sudden onset of harsh, barky cough; sore throat; inspiratory stridor; hoarseness
• Could progress into use of accessory muscles to breathe
• Frightened appearance; agitation• Cyanosis
• Mostly viral in nature, resolves spontaneously
• Humidification and cold air resolves attacks
EpiglottitisEpiglottitis• Bacterial form of croup (H influenza) with unique
symptoms and treatment• Bacterial infection invades tissues surrounding the
epiglottis• Epiglottis becomes edematous, cherry red and may
completed obstruct airway• Progresses rapidly, child is unable to swallow,
drooling
SymptomsSymptoms
• May have had mild URI few days prior• Drooling• Dysphasia • Dysphonia • Distressed respiratory efforts• Tripod position: supported by arms, chin
thrust out, mouth open
ER ManagementER Management• NEVER leave child unattended• Don’t examine or culture throat or start IV/Blood
samples• Continuous pulse ox • Humidified O2• Antipyretics suppository-nothing PO• Calm the parent! Explain what is going on…a calm
parent=calmer child!• OR- intubation• Throat & blood cultures done after intubation• Usually extubated after 48h• Antibiotics for 7-10 days• Discharge
Nursing Interventions on Nursing Interventions on
unit once stableunit once stable• Continually assess for s/s of respiratory distress• Maintain pulse ox above 95% with PaO2 between 80-
100mmHg• Maintain patent airway• Position for comfort (never force to lie down)• Relieve anxiety• Monitor temp• Administer antibiotics
Lower Lower Respiratory Respiratory
Tract Tract DisordersDisorders
BroncholitisBroncholitis• Inflammation of the
fine bronchioles and small bronchi
• Occurs in children birth to 2 years
• peak age 6 months• Highest in winter and
spring• RSV is most
responsible pathogen
Signs and SymptomsSigns and Symptoms• 1-2 days of URI, then suddenly symptoms become
worse• nasal flaring• intercostal and subcostal retractions • wheezes, crackles or rhonchi• increased respiratory rate• low pulse oximetry• tachycardia and cyanosis
Nursing Nursing ManagementManagement
• Antipyretics• Semi-fowlers position• Hydration- IVF• Humidification• Oxygenation- use Blow By• Bronchdilator therapy• No antibiotics…Viral infection!• Acute phase usually lasts for 2-3 days• Watch for increased severity-can progress to airway
obstruction
Pneunomia (PN)Pneunomia (PN)• Inflammation of the
alveoli usually following an URI
• Late winter/early spring
• Viral vs. Bacterial
Signs and SymptomsSigns and SymptomsViral- may have mild cold symptomsBacterial- distinctly ill
o High fever, may be diaphoretico Cough (productive or non productive)o Tachypneao Abnormal BS (fine crackles, rhonchi)o Dull percussiono Chest paino Increased respiratory efforto CXR changeso Lab findings (increased WBC)o Irritable, restlesso Occasional N/V/D o Low PO intake
Ineffective Breathing Ineffective Breathing
Pattern: InterventionsPattern: Interventions• Assess breath sounds, VS, respiratory status
q1-2h and PRN• Administer humidified O2 via face mask,
obtain ABG’s, monitor pulse ox• Administer antibiotics and antipyretics• Perform chest physiotherapy as ordered• Engage child in play activities
o Cough, turn, deep breatheo Incentive spirometer
Activity Intolerance: Activity Intolerance:
InterventionsInterventions• Balance activity with rest periods,
cluster nursing care• Provide small frequent meals• Increase activity gradually
Risk for Deficient Fluid Risk for Deficient Fluid
Volume: InterventionsVolume: Interventions• Obtain baseline weight, monitor daily• Administer IV fluids as ordered• Offer fluids frequently (jello, ices, etc.)• Administer antipyretics• Monitor I&O, urine for specific gravity
increases
TuberculosisTuberculosis• Bacterial infection that multiplies in the
lung tissue, alveoli and lymph nodes• Initially asymptomatic• Incubation period 2-12 weeks, will test +
PPD• Immune system can ward off full
development and become dormant• Children rarely develop active TB, but are
excellent transmitters to others
Risk FactorsRisk Factors• Contact with infected adults • Chronic illness, immunosuppression, HIV
infection, malnutrition• Young age (infancy, adolescence)• Nonwhite racial, ethnic groups,
immigrants from areas with high incidence
• Urban, low-income living conditions• Incarcerated adolescents• Contact with adults from high-risk groups
Active TB SymptomsActive TB Symptoms• +PPD• Malaise• Fever• Night Sweats• Slight cough• Weight loss• Anorexia• Lymphadenopathy• Confirmed by CXR,
sputum sample, or gastric washing
ManagementManagementAsymptomatic
children• INH x 9 months• 12 months if HIV+• Household contacts
treat for 12 weeks
Symptomatic children• INH, rifampin and
pyrazinamide x 2 months
• Followed by INH and rifampin x 4 months
Side effects: GI, orange tears, urine= noncompliance
Chronic Lung Chronic Lung DiseasesDiseases
AsthmaAsthma• A reversible obstructive
airway disease
• Hypersensitivity of many cells (Mast, Eosinophils, T Lymphocytes)
• Increased airway responsiveness to a variety of stimuli
AsthmaAsthma• Bronchospasm resulting from constriction of bronchial
smooth muscle
• Inflammation and edema of the mucous membranes that line the small airways and the subsequent accumulation of thick secretions in the airways
• Initial Symptom is a Cough (w/o illness) usually at night• Wheezing is produced when there is decreased
expiratory airflow
Asthma SeverityAsthma Severity• Classified as
o Mild intermittent• Symptoms < 2 x week
o Mild Persistent• Symptoms > 2 x week, but less than
once a dayo Moderate
• Day symptoms 2 x week, 1 or more night symptoms per week
o Severe• Continual day symptoms, frequent
night symptoms
TriggersTriggers• Cold air exposure• Smoke/fumes• Viral infection• Stress• Exercise• Odors (perfume)• Animal dander• Dust, cockroaches, rodents• Certain drugs (aspirin, NSAID’s)• GI reflux• Food allergens, outdoor allergens
Acute Asthma Acute Asthma Exacerbation SymptomsExacerbation Symptoms
• Chest tightness• Wheezing• Shortness of breath• Nonproductive cough
(with or without wheezing); later becomes productive
• Tachypnea, orthopnea
• Tripod position or straight
Management of Acute Management of Acute
Asthma ExacerbationAsthma Exacerbation• Monitor respiratory rate and effort,
color
• Provide oxygen therapy:
• warmed and humidified
• at 30-40% not 100%
• keep O2 sat > 95%; need CO2 stimulation for inhalation
Management of Acute Management of Acute Asthma ExacerbationAsthma Exacerbation
• Administer short acting beta2 agonist bronchodilatorso Ventolin, Proventil, Albuterol
• Administer corticosteroidso Predinsone, Prednisolone, Solumedrol
• Monitor effectiveness of meds• Easily fatigable• Frequent position changes
Management of Acute Management of Acute Asthma ExacerbationAsthma Exacerbation
• Observe for Status Asthmaticus
• Occurs when child fails to respond to treatment (severe emergency)
• Often caused by pulmonary infection
• Call MD!
Maintenance Maintenance MedicationsMedications
• Mild Intermittent and Persistent Asthma o anti-inflammatory corticosteroids PRN (Flovent
inhaler)
• Moderate Asthmao anti-inflammatory corticosteroids QD (Flovent inhaler)o long-acting bronchodilator at HS(Theophylline,
Serevent)
Maintenance Maintenance MedicationsMedications
• Severeo oral corticosteroid qdo inhaled corticosteroid qd o long-acting bronchodilator HS
Discharge PlanningDischarge Planning• Teaching self-management
o Identify triggerso Avoidance of allergensoMay need skin testing and hyposensitization
NebulizerNebulizer• Assess availability of home meds (proper inhaler
use and storage, nebulizer)
Teach use of Peak Flow Teach use of Peak Flow MeterMeter
• Measures maximum peak expiratory flow rate
• Need to first use when healthy to mark baseline
• Can use to predict acute exacerbation in kids 5-6 years and older
• Take a deep breath, blow out hard and fast
• If peak flow is 30-50% of child’s predicted baseline=ER
Cystic Fibrosis (CF)Cystic Fibrosis (CF)• Mutated gene on chromosome 7 CFTR
• Inherited autosomal recessive trait
• Both parents carry gene
(1/4 chance of conceiving affected child)
Cystic FibrosisCystic Fibrosis• Chronic multisystem disorder affecting the exocrine
glands• Affects bronchioles, small intestines, pancreatic &
bile ducts• Usually diagnosed before 1st birthday• Incurable• Symptoms worsen as disease progresses• Median life expectancy is reduced due to infections
Cystic FibrosisCystic Fibrosis• Respiratory System• Gastrointestinal System• Reproductive System• Exocrine Glands
Respiratory SystemRespiratory System• Wheezing, dry, non-productive cough,
repeated URI’s• Copious, thick sputum• Crackles, wheezes, decreased breath sounds• Increasing signs of respiratory distress =>
emphysema & atelectesis• Clubbing, barrel chest
Nursing ManagementNursing Management• Facilitate airway clearance • Prevent pooling of secretions – postural drainage• CPT every 4 hours (1 hour before or 2 hours after meals,
prior to bedtime)• Forced expiration (“huffing”)• Prevention and treatment of pulmonary infections-
aggressive IV antibiotics• Administer bronchodilators and mucolytics • High-humidity cool-mist tent to mobilize secretions• If 02 is required, use low flow rate
CPTCPT
Gastrointestional Gastrointestional SystemSystem
• Steatorrhea: frothy, foul-smelling stools 2-3 times bulkier than normal
• Malnutrition and failure to thrive despite normal caloric intake
• Protuberant abdomen• Fat soluble vitamin deficiencies: K, A, D, E (caused
by inability to absorb fats)• Meconium illeus in the newborn might be 1st sign
Nursing ManagementNursing Management• Well balanced diet high in calories,
protein, carbohydrates• Pancreatic enzymes within 30 minutes of
eating all meals and snacks
Reproductive Reproductive SystemSystem
• Average of 2 year delay in the development of secondary sex characteristics
• Females have thick cervical mucus (trouble getting pregnant)
• Some male patients sterile due to lack of sperm
Exocrine GlandsExocrine Glands
• Abnormally high concentrations of sodium and chloride in the sweat
• Sweat Test determines amount of sodium chloride in sweat
• Risk for electrolyte imbalance during hot weather
Nursing Nursing ManagementManagement
• Monitor for dehydration• Extra salt and fluid in hot weather
Dehydration Dehydration and Fluid Lossand Fluid Loss
Dehydration and Fluid Dehydration and Fluid LossLoss
• Large portion of a child’s fluids is located in extracellular fluid (increased BSA)o Infants: 75-80% of the weighto 2 year old: 60% of weight
• First two years of life kidneys are not functionally mature
• Inefficient at excreting waste products
Dehydration and Fluid Dehydration and Fluid LossLoss
• Fluid and electrolyte imbalances develop and progress very quickly
• Sick children often have low PO intake and diarrhea and vomiting =
• Infants and young children are highly susceptible to rapid and profound fluid and electrolyte imbalances
Types of Fluid LossTypes of Fluid Loss
• Sensible Fluid Loss• Insensible Fluid Loss
Sensible Fluid LossSensible Fluid Loss• Can be measured and observed• Urine output• Drains and tubes• Emesis • Diarrhea
Insensible Fluid LossInsensible Fluid Loss• Loss of fluid through lungs (2/3) and skin
(1/3)• Influenced by heat and humidity, body
temp, respiratory rate (children have higher RR than adults)
• Basal metabolic rate increases 10% for each degree Celsius above normal body temperature
• Example 39 Celsius = 102.2F o BMR increases by 20% !
ElectrolytesElectrolytes• NA- major electrolyte in ECF
o Needed to establish osmolarity
• K- major electrolyte in ICFo Needed for excitability of neurons and muscles
Three Types of Three Types of DehydrationDehydration
• Isotonic• Hypotonic• Hypertonic
Isotonic DehydrationIsotonic Dehydration• Sodium and water deficits are the same
(salt and water are lost in equal amounts in ICF and ECF)
• NA+ 130-150meq/L (normal)• Most common type in children from low PO
intake• Can result in hypovolemic shock
Hypotonic Hypotonic DehydrationDehydration
• Sodium deficit is greater than the water deficit
• Water moves from ECF to ICF• NA+ < 130meq/L• Results from GI losses (vomit, diarrhea)
• May result in shock
Hypertonic Hypertonic DehydrationDehydration
• Water loss exceeds sodium loss• Body compensates with fluid shifts from ICF
to ECF• NA+ > 150meq/L• May be caused by severe vomiting, too
much IV NA• Can result in seizures
Know the S+S of Know the S+S of DehydrationDehydration
• MildoNormal VS, moist mucous membranes,
alert, normal urine output, normal turgor, fontanelle, normal cap refill, thirsty
• Moderateo Rapid pulse and RR, normal BP, dry
mucous membranes, irritable, dark urine and decreased output, poor turgor, sunken fontanelle, delayed cap refill, moderately thirsty
Know the S+S of Know the S+S of DehydrationDehydration
• Severe• Changes in respirations depth and pattern, rapid weak pulse, low BP, mucous membranes parched, can be comatose, absent urine output, very poor turgor, sunken fontanelle, cool skin
Monitor for Monitor for DehydrationDehydration
URINE OUTPUT SHOULD BE AT MINIMUM1 ml/kg/hr
ALL children are on I+O
Monitor labs for:o Increased BUNo Increased serum bicarboHyponatermiaoHyperkalemiao Increased urine specific gravity
PREVENT dehydrationPREVENT dehydration• Monitor temperature, prevent overheating• Give frequent fluids, may need oral rehydration
(pedialyte) 50 ml/kg/ in 4 hours when febrile and GI losses
• Use small medicine cups, syringe without needed to administer fluids…even 1 tsp every few minutes
• Monitor IV fluid administration, ensure patent IV site
Administering IV Administering IV FluidsFluids
• Always use an infusion pump with a volume control device
• Prevents a sudden extracellular fluid volume overload
• Never use more than a 500 ml bag
• Mechanical pumps can have faulty performance, so check the intravenous line, bag, and rate often
Practice Practice Questions!Questions!
A teenager with chronic asthma asks the nurse, “How come I make so much noise when I breathe?” The nurse’s best response is:
a. It is the sound of air passing through fluid in your alveoli
b. It is the sound of air passing through fluid in your bronchus
c. It is the sound of air being pushed through narrowed bronchi on expiration
d. It is the sound of air being pushed through narrowed bronchi on inspiration
Which school related activity might the school nurse prohibit for a child with asthma?
a. Swim teamb. The Bandc. Pet “show and tell”d. An art class
A toddler with cystic fibrosis is placed in a high-humidity cool-mist tent operated with compressed air. The nurse knows the primary reason for this therapy is to:
a. Provide oxygenb. Lower the child’s temperaturec. Moisten the airway and mobilize secretionsd. Provide additional fluids
A preschooler with a diagnosis of epiglottitis is admitted to the hospital. Which MD order should the nurse question for this child?
a. Place a pediatric size tracheostomy tray in the room
b. Monitor pulse oxygen saturation every 15 minutes
c. Place in respiratory isolationd. Obtain CBC and Throat Culture
When assessing a child who is suspected of having asthma, the nurse should specifically ask the parents about which initial symptom that they may have noted?
a. Coughing a night in absence of respiratory infection
b. Coughing throughout the dayc. Expiratory wheezingd. Shortness of breath
When caring for a child who has recently undergone a tonsillectomy, the nurse should be aware that the child is discouraged from:
a. Talking and chewingb. Blowing the nosec. Eating lemon flavored ice popsd. Taking pain medication
When caring for a child who has had a tonsillectomy the nurse’s priority observation should be for:
a. Coffee ground emesisb. Frequent swallowingc. Complaints of a sore throatd. A slight increase in temperature
When assessing a child who is preverbal for otitis media, the nurse should anticipate that the child will:
a. Have difficulty swallowingb. Rub the affected side of head on the mattressc. Have a runny nosed. Have vomiting and diarrhea
The nurse’s health care teaching to assist parents in preventing otitis media should include instructions to:
a. Finish the entire prescription of antibioticsb. Administer acetaminophen to reduce painc. Apply warm compresses to affected eard. Refrain from putting the child to bed with a
bottle
The nurse has admitted a child with diarrhea for 3 days. The child’s laboratory results reveal sodium of 126. The nurse understands this is:
1. Isotonic Dehydration2. Hypotonic Dehydration3. Hypertonic Dehydration.4. Normal, the child is not dehyrated
The physician ordered pedialyte administration 50 ml/kg/ in 4 hours for a child weighing 33 lbs. Upon awakening, the child consumed 200ml of pedialyte at 9:00 am for breakfast. How many more ml does the child need to drink by 1 pm?1. 1650 ml2. 1450 ml3. 750 ml4. 550 ml