View
220
Download
2
Category
Tags:
Preview:
Citation preview
Key Pediatric Differences in the Respiratory 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
Child’s Respiratory Tract
Children are prone to:–Respiratory tract infection
–Respiratory failure
–Airway collapse
Respiratory Diseases and Disorders of Childhood
• Otitis Media• Pharyngitis• Epiglotitis• Broncholitis• Pneumonia• Asthma
exacerbation• Cystic Fibrosis• Tuberculosis
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
(AOM) Acute Otitis Media
• Sudden temperature increases• Sharp pain • Otalgia (earache); pull on ear, rubbing face • Bulging, opaque red tympanic membrane• Irritability• Sleep disturbance• Persistent crying• Fever, vomiting, diarrhea, anorexia• Sudden relief and drainage=rupture TM
AOM
Treatment:• AOM could be viral or bacterial• Acetaminophen (pain, fever)• ABX (Amoxicillin) if bacterial• ALTERNATIVE- wait 72 hours then treat
Serous Otitis Media or Otitis Media with Effusion
(SOM/OME)• Result of chronic otitis media (3 in 6
mos, 4 in 1 year)• Epithelial cells of middle ear begin
producing secretions instead of absorbing them
Patient Teaching-Post 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)
• Inflammation and infection of the palatine tonsils
• Viral vs. Bacterial
• Peak age 4-7 years
Viral 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
Surgical Interventions
Myringotomy• surgical incision of the tympanic
membrane (mucoid material removed from middle ear)
Tympanostomy 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
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
Pharyngitis
Management:Pain relief; rest; bland, soft dietPCN if bacterialTonsillectomy is controversial
Tonsillectomy
Nursing Care (Pre-op)• Assess for current infection and
bleeding history• Check for loose teeth• Teach child and parent what to
expect post-op– May see dried blood in mouth and
teeth– Will still be able to talk– Pain management for optimal recovery
TonsillectomyNursing care (post-op)
• Assess for bleeding number one priority!!!!– Elevated P, decreased BP,
restlessness, frequent swallowing, vomiting bright red blood, fresh blood in throat
• Clear, cool liquids, no red juices!• Advance to full liquids and soft foods on
2nd day if no sign of hemorrhage• Pain relief 2nd priority-throat very sore
Nursing care (post-op)
• Encourage child to chew and swallow
• No straws, forks or sharp, pointed toys
• Discourage irritating the operative site
– coughing frequently– clearing the throat– blowing the nose
Manifestations of Croup• 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
Epiglottitis• 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
Cardinal signs and symptoms
• 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 Management
• NEVER leave child unattended• Don’t examine or culture throat or start
IV/Blood samples• Patent airway ASAP• Monitor oxygenation status, (continuous pulse ox, humidified
O2)• Antipyretics suppository• 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 unit 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 (antipyretics, ABX)
Broncholitis
Inflammation of the fine bronchioles and small bronchi.
• Occurs in children < 2yo; peak age 6mos• Highest in winter and spring• Most responsible pathogen: RSV
Signs 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
Management
Severe Symptoms• Hospitalization• Monitor: respiratory
status, pulse ox, blood gases
• Bronchdilator therapy
No antibiotics…Viral infection!
Mild-Mod symptoms• Antipyretics• Hydration• Humidification• Watch for increased
severity
Acute phase usually lasts for 2-3 days.
Nursing Interventions
• Position: for comfort, semi-fowlers• Decrease anxiety• Administration of IV fluids • Provide humidified O2 (40% then
wean) use BB• Determine in child is candidate for
Ribavirin therapy (antiviral agent used with severe RSV cases)
Pneunomia (PN)
• Inflammation of the alveoli usually following an URI
• Occurrence: late winter/early spring• Pneumococcal (bacterial) vs. Viral
Pneumonia(ABX vs. no ABX)
Signs and Symptoms
Viral- may have mild cold symptomsBacterial- distinctly ill
– High fever, may be diaphoretic– Cough (productive or non productive)– Tachypnea– Abnormal BS (fine crackles, rhonchi)– Dull percussion– Chest pain– Increased respiratory effort– CXR changes– Lab findings (increased WBC)– Irritable, restless, occasional N/V/D, low PO
intake
Ineffective Breathing Pattern: Interventions
• Assess breath sounds, VS, respiratory status q1-2h and PRN
• Administer humidified O2 via face mask, obtain ABG’s, pulse ox
• Administer ABX (Ampicillin, Cephalosporin), antipyretics
• Perform chest physiotherapy as ordered• Engage child in play activities (TCDB, IS)
Activity Intolerance: Interventions
• Balance activity with rest periods, cluster nursing care
• Provide small frequent meals
• Increase activity gradually
Risk for Deficient Fluid Volume: 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
Tuberculosis
• 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 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 Symptoms
• +PPD• Malaise• Fever• Night Sweats• Slight cough• Weight loss• Anorexia• Lymphadenopathy• Confirmed by CXR, sputum sample, or
gastric washing
Management
Asymptomatic 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
Asthma
A reversible obstructive airway disease characterized by
•Hypersensitivity of many cells (Mast, Eosinophils, T Lymphocytes)
•Increased airway responsiveness to a variety of stimuli
Asthma• 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
Acute Asthma Exacerbation Symptoms
• Chest tightness• Wheezing• Shortness of breath• Nonproductive cough (with or without
wheezing); later becomes productive• Tachypnea, orthopnea• Tripod position or straight
Triggers
• 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
Management of Acute Exacerbation
• Monitor respiratory rate and effort, color
• Provide oxygen therapy:warmed and humidifiedat 30-40% not 100%keep O2 sat > 95%; need CO2 stimulation for inhalation
Acute Asthma Exacerbation
• Administer short acting beta2 agonist bronchodilators– Ventolin, Proventil, Albuterol
• Administer corticosteroids– Predinsone, Prednisolone, Solumedrol
• Monitor effectiveness of meds
• Easily fatigable
• Frequent position changes
Acute Asthma Exacerbation
• Observe for Status Asthmaticus
• Occurs when child fails to respond to treatment (severe emergency)
• Often caused by pulmonary infection
• Call MD!
Asthma Severity
• Classified as– Mild intermittent
•Symptoms < 2 x week– Mild Persistent
•Symptoms > 2 x week, but less than once a day
– Moderate•Day symptoms 2 x week, 1 or more night
symptoms per week– Severe
•Continual day symptoms, frequent night symptoms
Maintenance Medications
• Mild asthma: – PRN anti-inflammatory
corticosteroids (Flovent inhaler QD)
• Moderate: – anti-inflammatory corticosteroids QD – long-acting bronchodilator
(Theophylline, Serevent)HS
Maintenance Medications
• Severe: – oral corticosteroid qd– inhaled corticosteroid qd – long-acting bronchodilator HS – short-acting beta-2-agonist bronchodilator
(Albuterol) if attack beginsAlso:– Mast Cell inhibitors (Intal),– Leukotriene Blocker (Singulair) (prevents severe bronchospasm, not effective if
symptoms present)
Discharge Planning
• teaching self-management– Identify triggers– Avoidance of allergens– May need skin testing and
hyposensitization
Teach use of Peak Flow Meter
• 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)
• Mutated gene on chromosome 7 CFTR
• Inherited autosomal recessive trait
• Both parents carry gene
(1/4 chance of conceiving affected child)
CF
• Chronic multisystem disorder affecting the exocrine glands
• Affects: bronchioles, small intestines, pancreatic & bile ducts
• Incurable• Median life expectancy is 33 yrs• Usually diagnosed before 1st birthday• Symptoms worsen as disease
progresses
CF: Respiratory 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
CF: Digestive System
• 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
CF: Exocrine Glands
• Abnormally high concentrations of sodium and chloride in the sweat
• Sweat Test: determines amount of sodium chloride in sweat > 60 is diagnostic
• Risk for electrolyte imbalance during hot weather
CF: Reproductive System
• 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
Management
• Prevention and treatment of pulmonary infections
• Maintaining optimal nutritional status– High calorie, high protein– Enzyme supplements
• Managed at home most of time– Flutter device– CPT BID– Postural drainage– Exercise
Interventions for Hospitalized CF Child
• Facilitating airway clearance
• Prevent pooling of secretions
• Limit procedures
• CPT every 4 hours (1 hour before or 2 hours after meals, prior to bedtime)
• Forced expiration (“huffing”)
Interventions
• Administer bronchodilators and mucolytics • High-humidity cool-mist tent to mobilize
secretions• If 02 is required, low flow rate• IV ABX• Well balanced diet high in calories, protein,
carbohydrates• Pancreatic enzymes within 30 minutes of eating
all meals and snacks • Extra salt and fluid in hot weather
Long Term Support
• Cystic Fibrosis Foundation
• American Lung Association
• Coordination of care from home to school
• Increase self-esteem
• Foster independence
Dehydration and Fluid Loss
• Large portion of a child’s fluids is located in extracellular fluid (increased BSA)– Infants: 75-80% of the weight– 2 year old: 60% of weight
• First two years of life kidneys are not functionally mature
• Inefficient at excreting waste products
Dehydration and Fluid Loss
• 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
Sensible Fluid Loss
• Can be measured and observed• Urine output• Drains and tubes• Emesis • Diarrhea
Insensible 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 – BMR increases by 20% !
Electrolytes
• NA- major electrolyte in ECF– Needed to establish osmolarity
• K- major electrolyte in ICF– Needed for excitability of neurons and
muscles
Isotonic 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 Dehydration
• 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 Dehydration
• 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 Dehydration
• Mild– Normal VS, moist mucous membranes,
alert, normal urine output, normal turgor, fontanelle, normal cap refill, thirsty
• Moderate– 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 Dehydration
• 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 Dehydration
URINE OUTPUT SHOULD BE AT LEAST 1-2 ml/kg/hr
ALL children are on I+O pay attention to the balance
Monitor labs for:– Increased BUN– Increased serum bicarb– Hyponatermia– Hyperkalemia– Increased urine specific gravity
PREVENT 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 Fluids
• 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
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 antibiotics
b. 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 Dehydration– 2. Hypotonic Dehydration– 3. Hypertonic Dehydration.– 4. Normal, the child is not dehyrated
Recommended