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7/29/2019 Chronic respiratory illnesses
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Nursing Care of theChild with a
Respiratory Illness
Chronic illnesses
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Asthma Chronic inflammatory disorder of the lungs Subject to acute flare-ups
Cause is multiple
Genetic predisposition Environmental exposures Viral infections
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Even when asymptomatic bronchialbiopsies show
Thickening of bronchial basementmembrane Eosinophilic infiltration
Airway hyper-responsiveness
Airway obstruction
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Asthma and allergy Allergy influences the persistenceand the severity of the disease
Causes immediate reaction Or precipitates a late reaction
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Classification of Asthma Stepwise approach to managingasthma
Based on Frequency of symptoms
Frequency/severity of exacerbations
Lung function P. 881-882 in text
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Patho
Inflammation leads to airwayhyperresponsiveness which results inphysiologic
manifestations
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Respiratory Tree
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Triggers Stimulus which initiates theasthmatic episode
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More patho Antigen deposited on respiratorymucosa
Lysozymes digest outer coating Foreign protein is released
Immune sequence initiated IgE
Release of chemical mediators Increased permeability of blood
vessels
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Contraction of smooth muscle
Stimulation of mucus secretions
Mucosal edema Airway remodeling leads to
decreased lung function
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Clinical manifestations of
asthma Cough, SOB
Increased WOB Chest tightness
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Prolonged expiratory phase withwheezing, restlessness, anxiety
Tripod position Speaks in short, panting phrases
Secretions increase and cough
becomes rattling
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Clinical management of
asthma Meds p. 886 Rescue vs. controller
oxygen systemic steroids
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Drug therapy
SABA quick relief ICS
Long-term control must be used withICS Anti-inflammatory
Cromolyn, ICS, leukotriene modifiers
LABA associated with increased death inadults so Salmeterol (serevent) and
Formoterol are no longer approved inchildren (Only approved for COPD). Advair& Symbicort are still OK
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Hydration IV fluids
?NPO Plan
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Nursing Care of child
with asthma Close observation CAM/POX
monitor O2 I & O
Why is this important?
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side effects of meds Steroids
bronchodilators teaching
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Xolair
Monoclonal antibody (Omalizumab)
Reserved for refractory asthma,
must be over 12 years old. Lowers free IgE so only helpful if
allergy is the trigger.(Check Serum
IgE first). Expensive; risk of anaphylaxis
(given subcu)
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Murine monoclonal AB
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Home management Peak flow meter or symptommonitoring
Determine need for intervention Confirms effectiveness of tx
Allergen control
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GREEN
80-100% of best
Signals all is clear. Asthma is
under good control No symptoms are present and
routine treatment plan for
maintaining control can be followed
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Yellow
50-79% of best
Signals caution
Asthma is not well controlled. Anacute exacerbation may be present.Maintenance therapy may need to be
increased. Call physician if the childstays in this zone
Red
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Red
Below 50% of best
Signals medical alert.
Severe airway narrowing may beoccurring. A short-actingbronchodilator should beadministered. Notify physician iflevel does not return immediately andstay in the yellow or green zone.
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How do we know when
asthma is in control?
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Nursing Diagnoses
Ineffective airway clearance relatedto bronchoconstriction and edema
AEB cough or wheeze. Impaired gas exchange related to
airway obstruction and CO2
retention. Risk for Deficient Fluid Volumerelated to difficulty in drinking.
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Anxiety/Fear (child and parental) r/tdifficulty breathing and change in
health status. Ineffective therapeutic regimen
management (family) r/t lack of
understanding about and need fordaily mgt of a chronic disease.
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Hygiene Hypothesis
There is a school of thought that inthe USA we fail to challenge thenewborns immune system with normal
bacteria (Obsession with sterilizing,etc).
Third world countries have almost no
asthma Farm and rural environments have
minimal asthma
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Exposure to farm animals (even dogs)
to a newborn seem to lessen thechance of asthma
Soare we too clean?
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Cystic Fibrosis Chronic, genetic disorder affectingthe exocrine glands
Autosomal recessive Located on chromosome 7 Sodium transport problems
Thick, sticky mucous
Median survival 38.6 years (4/2006)
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Genetics 1 in 29 caucasians
carry the gene (in USA)
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Diagnosis of CF Positive sweat test with + family history /or
Clinical signs Not reliable in children < 3 weeks
DNA
Genetic carrier Prenatally
siblings
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Clinical manifestations of
CF Meconium ileus (7-10%), latemeconium passage.
Growth failure Frothy, foul-smelling stools
(steatorrhea)
Salty taste Recurrent respiratory symptoms
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Later manifestations of
CF Clubbing barrel-shaped chest
portal hypertension frequent respiratory infections
cough
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esophageal varicies
pancreatic fibrosis DM
Distal intestinal obstructionsyndrome
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http://en.wikipedia.org/wiki/File:ClubbingCF.JPG7/29/2019 Chronic respiratory illnesses
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Management of CF
Facilitate airway clearance and gasexchange nebs
Exercise/CPT Prevent/treat infection
Antibiotics Prophylactic
Treatment Inhaled TOBI
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Provide optimum nutrition Enzymes Salt Increased calories
Emotional support lung transplant gene therapy
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Meds for CF
Nebs Bronchodilators
Pulmozyme (dornase alfa)
Hypertonic saline, TOBI
Enzymes (Ultrase, pancrease)
vitamins
Antibiotics
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Nursing Care Supportive and encouraging Meds Nutrition
High cal/high protein Supplemental feedings
Diabetes management Coordinate with RT
Education isolation
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Bronchopulmonary
dysplasia Chronic lung disease (CLD) Primarily ELBW and VLBW
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Patho of BPD Immature lung is injured anddevelops chronic inflammation Mechanical ventilation Prenatal/postnatal infection Oxygen therapy Increased pulmonary blood flow
Results in hypercarbia and hypoxemia
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Prevention of BPD Surfactant Prenatal steroids
Lowest possible pressures Lowest possible O2 concentration
Bubble CPAP
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Signs and symptoms of
BPD Sx of resp distress What are they?
Intermittent bronchospasms andmucous plugging
Barrel shaped chest
FTT O2 dependence; chronic CO2
retention
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Management of BPD Maintain oxygenation Control interstitial fluid
Adequate nutrition Avoid infection
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Nursing care for BPD Oxygenation O2 Pulse ox Normothermia Adequate rest
Strict I & O
diuretics
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Nutrition Ensure adequate calories
Oral-motor stimulation Avoid infection (RSV, flu)
Education
Support
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Nursing Diagnoses
Alteration in respiratory function
Alteration in nutrition
Anxiety Fluid volume deficit
Activity intolerance
Knowledge deficit Alteration in thermoregulation
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Alteration in respiratory
function HOB up Monitor sats, oxygen if needed
Suction Fluids
Promote rest
Meds Side effects
Teaching
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Alteration in Nutrition Calculate calorie needs Provide adequate calories
Accurate I and O Daily weight
Measure to encourage intake
E ( h k )
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MEDS (think COPD)
Albuterol or Xopenex nebs (oftenwith ipratropium/atrovent, etc)
Inhaled steroids (azmacort)
Diuretics (if so, may need KCL also) Antibiotics prn (or prophylaxis)
Vitamin A (plays a role in lung
function) Synagis
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Fourteen year old John is admittedwith LRI and CF. This is his 20thadmission.
What abnormal physical assessmentfindings would you expect to see?
What orders would you expect?
What are developmental issues atthis age?
How would you adapt your nursinginterventions to an adolescent
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A child with CF is receiving
Tobramycin 75 mg IV q 8 h. Safe dose is 2.5-3.3 mg/kg/dose
Patient weighs 50 lb
Is this a safe dose?
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A baby with CF weighs
20 lb 3 oz
Calorie needs are 120 cal/kg/day
How many ounces of 27 cal formula
would the child need per day?
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A 6 year old child is being admitted
from the MDs office with asthma.When he gets to the floor, what will
you do first?
VS weight
O2 sat
oxygen start IV
neb treatment
Hi it l i
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His vital signs are: HR 124
RR 28 T 39 C
What do you think about these?
What do you think his breath sounds
are like? How is he acting?
What other systems do you want to
assess closely?
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Which statement indicates that
parents have understood teachingabout prevention of asthma attacks?
We will replace the carpet in ourchilds bedroom with tile
Were glad the dog can still sleep inour childs room
Well be sure to use the fireplace tokeep the house warm.
Well keep the plants in our childs