Nursing Care of a Child with Respiratory Disorder

Prepared by: Bernalyn Orpilla-Pascual RN MAN

ASSESSING RESPIRATORY ILLNESS IN CHILDREN

Components of Assessing Respiratory Function

RESPIRATIONS:

RATE:DEPTH: EASE:LABORED BREATHING:RHYTHM:

OTHER OBSERVATIONS:

EVIDENCE OF INFECTION:COUGH:WHEEZE:CYANOSIS:CHEST PAIN:.SPUTUM:BAD BREATH:

Signs and Symptoms Associated with Respiratory Infections FEVER: MENINGISMUS:ANOREXIA: VOMITING:DIARRHEA:ABDOMINAL PAIN:NASAL BLOCKAGE:NASAL DISCHARGE:COUGH:RESPIRATORY SOUNDS: Sounds associated with respiratory disease:

CoughHoarseness GruntingStridorWheezing

Auscultation:Wheezing CracklesAbsence of sound

SORE THROAT:

NURSING DIAGNOSIS1 Ineffective Airway Clearance r/t inflammation,obstruction,secretions, or pain2 Ineffective Breathing Pattern r/t inflammatory process or pain3 Tissue Perfusion altered r/t decreased oxygen delivery4 Deficient Fluid Volume r/t fever,decreased appetite, and vomiting5 Fatigue r/t increased work of breathing6 Anxiety r/t respiratory distress and hospitalization7 Parental Role Conflict r/t hospitalization of child

(Others may be apparent in individual cases)

PLANNING1. Child will exhibit normal respiratory efforts2. Child will receive adequate rest3. Child will remain comfortable4. Child will not spread primary infection to others5. Child’s temperature will remain within normal limits6. Child will maintain normal hydration and adequate nutrition7. Child will experience no complications8. Child and family will receive information especially for home care and support

THERAPEUTIC TECHNIQUES USED IN THE TREATMENT OF RESPIRATORY ILLNESS

A. Expectorant TherapyB. Liquefying AgentsC. HumidificationD. CoughingE. Chest PhysiotherapyF. Postural DrainageG. THERAPY TO IMPROVE OXYGENATION1. Oxygen Administration

2. Pharmacologic Therapy3. Incentive Spirometry4. Breathing Techniques5. Tracheostomy6. Suctioning7. Endotracheal Intubation8. Assisted Ventilation

LABORATORY TESTSA. BLOOD GAS ANALYSIS

PULSE OXIMETRYTRANSCUTANEOUS OXYGEN MONITORING

B. NASOPHARYNGEAL CULTURE

C. RSV NASAL WASHINGSD. SPUTUM ANALYSIS

DIAGNOSTIC PROCEDURESA. Chest X-rayB. BronchographyC. Pulmonary Function Studies

UPPER RESPIRATORY INFECTIONS

NASOPHARYNGITISASSESSMENT1. nasal congestion2. watery rhinitis3. low grade fever

THERAPEUTIC MANAGEMENT1. no specific treatment2. saline nose drops or nasal spray3. remove nasal mucus via bulb syringe4. cool mist vaporizer

PHARYNGITISViral PharyngitisTHERAPEUTIC MANAGEMENT:1. Warm heat applied to the external neck area using warm towel or heating pad2. Children: gargling with warm water3. Sufficient fluid to prevent dehydration

for infants

STREPTOCOCCA PHARYNGITIS . Assessment:1. Back of the throat and palatine tonsils are usually markedly erytematous (bright red).2. Tonsils are enlarged and there may be white exudates in the tonsillar crypts.3. Petechiae may be present in the palate4. High fever with extremely sore throat5. Difficulty swallowing and overall lethargy6. Headache with swollen abdominal lymph nodes7. Presence of streptococcus bacteria on throat culture

THERAPEUTIC MANAGEMENT:1. Full 10 day course of oral antibiotic such as penicillin G or clindamycin2. Measures for rest, throat pain and maintenance f hydration.3. cold or warm compress to the neck4. warm saline gargles5. cool liquids or ice chips

TONSILLITISAssessment:1. children drool2. painful swallowing as if swallowing bits of metal or glass3. high fever , lethargy4. bright red tonsilar tissue and

enlarged5. two areas of palatine tonsilar

tissue meet in the midline6. signs of adenoidal tissue infection:

a. nasal quality of speechb. mouth breathingc. difficulty hearingd. halitosis with sleep apnea

THEAPEUTIC MANAGEMENT1. antipyretic for fever, analgesic for pain2. full 10 day course of antibiotic3. Tonsillectomy and Adenoidectomy

Nursing Care Post Surgery1. soft liquid diet2. cool mist vaporizer3. measures of comfort:4. until fully awake place on their abdomen or side 5. avoid coughing or clearing throat, blowing nose6. ice colar may provide relief7. offer cool water, crushed ice, flavored ice pops, or diluted fruit juice8. fluids with red or brown color are avoided;

citrus juice may cause discomfort9. soft foods particularly gelatin, cooked fruits, soup, mashed potatoes10. avoid milk, ice cream and pudding.11. Assess for signs of hemorrhage:

A. increased pulse rateB. Pallor and frequent clearing of throat or swallowing.C. Restlessness

INFLUENZAAssessment:1. dry throat and nasal mucosa, dry

cough and hoarseness2. flushed face, myalgia, prostration with

sudden onset of fever and chills3. subglottal croup is common especially in infantsTHERAPEUTIC MANAGEMENT1. symptomatic treatment: antipyretics,

analgesic and fluids2. avoid using aspirin as treatment

OTITIS MEDIATHERAPEUTIC MANAGEMENT:1. Antibiotic: oral amoxicillin2. Myringotomy and tympanostomy3. polyvalent pneumococcal polysaccharide vaccine4. Bacterial polysaccharide immune globulin (BPIG)5. relieve pain: acetaminophen, ice compress placed on affected ear6. facilitate drainage7. prevent complication8. educate family:

CHOANAL ATRESIATHERAPEUTIC MANAGEMENT:1. local piercing of the obstructing membrane2. surgical removal of the bony growth3. IV fluids to maintain their glucose and fluid level

EPISTAXISTHERAPEUTIC MANAGEMENT:1. place on upright position with head tilted slightly forward2. apply pressure to the sies of the nose with fingers3. epinephrine (1:1000) may be appied to the bleeding site4. nasal pack may be applied

SINUSITISSigns and symptoms

1. fever2. purulent nasal discharge3. headache4. tenderness over the affected

sinusTherapeutc Management:

1. antipyretics, analgesic for pain and antibiotic

2. Oxymetazolie Hydrochloride (nose drops/nasal spray) for 3 days

3. warm compress to the sinus area

CONGENITAL LARYNGOMALACIA/TRACHEOMALACIAAssessment:1. retraction on infants sternum and intercostal spaces on inspiration2. stridor on inspirationTherapeutic Management:1. feed slowly; provide rest periods as needed2. assess for signs of upper respiratory infection3. condition improves as cartilage in the larynx becomes stronger at about 1 year of age

CROUP SYNDROMES

ACUTE EPIGLOTITISAssessment:

1. sore throat and pain on swallowing2. fever; insists on sitting upright and leaning forward, with chin thrust out,

mouth open, and tongue protruding (Tripod Position)

3. drooling of saliva4. predictive of epiglotitis: absence of spontaneous cough, drooling and

agitation5. voice is thick and muffled, with

froglike croaking sound on inspiration, but child is not hoarse

6. throat is red and inflamed, and a distinctive large, cherry red,

edematous epiglottis

Therapeutic Management: 1. Do not attempt to view throat without properly experienced personnel

is present with emergency equipment like intubation set and tracheostomy.

2. lateral neck films3. Antbiotic therapy: 7 to 10 day course

(second generation cephalosporins:cefuroxime)

4. cortecosteroids5. intravenous fluid therapy

ACUTE LARYNGITIS - viruses are the usual offending agents and principal complaint is hoarseness, which may be accompanied by an upper respiratory infection( coryza, sore throat, nasal congestion) and systemic manifestations.

Therapeutic Management:1. fluids2. humidified air

ACUTE LARYNGOTRACHEOBRONCHITISCharacterized by gradual onset of low grade fever.Assessment:

1. the child struggles to inhale air past the obstruction and into the lungs producing: inspiratory stridor and supratsternal retractions2. classic barking or seal-like cough and acute stridor after several days of coryza.

Stages:Stage I: fear, hoarseness, croupy cough, inspiratory

stridorStage II: continuous respiratory stridor, lower rib

retraction, retraction of soft tissue of the neck, use of accessory muscles of respiration, labored respiration

Stage III: signs of anoxia and carbon dioxide retention, restlessness, anxiety, pallor, sweating, rapid respirations

Stage IV: intermittent cyanosis, permanent cyanosis, cessation of breathing

Therapeutic Management:1. mild croup: home care (fluids and comfort

measures with cool-air vaporizer)2. high humidity with cool mist3. cool-air vaporizer4. hoods for infants/tents for toddlers5. racemic epinephrine administration (severe)6. Cortecosteroid7. IV therapy8. Watch for early signs of impending airway

obstruction: increased pulse and respiratory rate; substernal, suprasternal, and

intercostals retractions; flaring nares; increased restlessness

ACUTE SPASMODIC LARYNGITIS

Assessment:1. child goes to be well /mild resp symptoms and awakes suddenly with:

1. Barking, metallic cough2. hoarseness3. noisy respirations4. restlessness, anxious, frightened

and prostrated5. dyspnea is noted with excitement

with no fever

Therapeutic Management and Nursing Considerations

1. cool mist2. warm mist provided by steam from hot

running water in a closed bathroom

3. spasm is relieved by sudden exposure to cool air(as when the child is

taken out at night)4. sleeping in a humidified air5. severe: racemic epinephrine; cool mist

and corticosteroid therapy

BACTERIAL TRACHEITISAssessment:

1. similar to LTB but unresponsive to LTB therapy2. history of previous URI with croupy cough,

stridor unaffected by position, toxicity and high fever

3. production of thick, purulent tracheal secretions

Therapeutic Management and Nursing Considerations1. humidified oxygen2. antipyretics3. antibiotics4. severe: endotracheal suctioning

INFECTIONS OF THE LOWER AIRWAYS

BRONCHITISAssessment:

1. dry hacking cough, nonproductive that wosens at night

2. cough becomes productive in 2 to 3 days

Therapeutic Management:1. antipyretics, analgesics and

humidity2. cough suppressants

RESPIRATORY SYNCYTIAL VIRUS AND BRONCHIOLITISAssesment:

1. rhinorrhea and low grade fever2. otitis media and conjunctivitis3. cough develops:4. chest radiographs: hyperaeration and areas

of consolidation which is difficult to differentiate from bacterial pneumonia

5. apnea6. Severe: rise in arterial carbon dioxide tension

(hypercapnia)-respiratory acidosis and hypoxemia

Signs and Symptoms1. INITIAL: rhinorrhea, pharyngitis,

coughing/sneezing, wheezing, possible ear or eye drainage, intermittent fever

2. WITH PROGRESSION OF ILLNESS: increased coughing and

wheezing, air hunger, tachypnea and retractions, cyanosis

3. SEVERE ILLNESS : tachypnea greater than 70 breaths per minute, listlessness, apneic spells, poor air exchange; poor breath sounds

Dianostic Evaluation: Enzyme-linked immunosorbent Assay (ELISA)/rapid immunoflourescent antibody (IFA)

Therapeutic Management and Nursing Consideration1. high humidity, adequate fluid intake, oxygen mist and

rest2. Ribavirin3. Prevention

RSV immune globulin (RSV-IGIV) Monoclonal Antibody, Palivizumab

4. Prophylaxis recommendations: a. Infants born 32 and 35 weeks gestation if they are

younger than 6 months of ageb. infants who have two or more additional risk factors:

b.1 school-age siblings b.2 crowding in the home b.3 day care attendance b.4 exposure to tbacco smoke in the homec. children who are 24 months of age or younger

5. infection control measures:

PNEUMONIASTypes of Pneumonia:

1. Lobar Pneumonia2. Bronchopneumonia3. Interstititial

BACTERIAL PNEUMONIAA.1 PNEUMOCOCCALAssessment:1. high fever,nasal retractions, chest pain, chills and dyspnea2. some: abdominal pain, febrile seizures3. tachypnea and tachycardia4. breath sounds become bronchial 5. crackles or rales as a result of the fluid, dullness on percussion on lobe indicates consolidation

A.2 STREPTOCOCCAL A.3 STAPHYOCOCCAL A.4 HAEMOPHILUS A.5 CHLAMYDIAL

VIRAL PNEUMONIAMYCOPASMAL PNEUMONIA -LIPID PNEUMONIA - HYDROCARBON PNEUMONIA -

ATELECTASISPrimary Atelectasis:

Assessment: respirations are irregular with nasal flaring and apnea; Respiratory grunt and cyanosis (sound of respiratory grunt is caused by the newborns glottis closing on expiration)

Secondary Atelectasis:Causes: mucus plugs, aspiration of foreign objects, trauma or pressure on lung tissueAssessment: asymmetry of the chest; breath sounds on affected chest is diminished; tachypnea and cyanosis; CXR: a white out a collapsed alveoli

Therapeutic Management:1. Foriegn object: bronchoscopy2. Mucus plugs: expectorated3. place on semi fowlers position4. increase humidity in the childs environment5. suctioning and CPT

OTHER INFECTIONS OF THE RESPIRATORY TRACT

PERTUSSIS (WHOOPING COUGH)Assessment:

STAGE I : (Catarrhal Stage)STAGE II : ( Paroxysmal Stage)STAGE III : ( Convalescent Stage)

Therapeutic management:1. erythromycin estolate,

azithromycin, clarithromycin2. supportive: antipyretics, bed

rest, quiet environment,gentle suctioning, increase fluid

intake, oxygen3. prevention: pertussis vaccine

TUBERCULOSIS -Diagnosis: TST (Mantoux Test, PPD): dose: 5

tuberculin units, 27 gauge needle and a 1 ml syringe. ID. Read by 48-72 hours.Postive reaction: individual has been infected

1. Latent TB infection (LTBI):2. TB disease:.

Gastric washing-aspiration of the lavaged contents into a fasting stomach

Clinical Manifestations1. fever, malaise, anorexia, weight loss, Cough may or may not be present ( progresses slowly over weeks to months), aching pain and tightness in the chest2. with progression: RR increases, poor

expansion of lung on the affected side, diminished breath sounds and

crackles; dullness to percussion, fever persists

3. generalized symptoms are manifested, pallor, anemia weakness and weight loss

Therapeutic management:1. nutrition and general supportive measures2. prevention of unnecessary exposure3. chemotherapy: combinations of isoniazid (INH), rifampin, and pyrazinamide (PZA)

a. 6 months regimen: INH, rifampin and PZA given daily for the first 2 months; followed by INH and Rifampin given 2 to 3 times per week for the remaining 4 months.b. when drug resistance is suspected: ethambutol or aminoglycoside is added to the therapeutic regimen

4. Prevention: avoid contact and maintain an optimal state of nutrition

Bacille Calmette-Guerrin (BCG)

PULMONARY DYSFUNCTION CAUSED BY NONINFECTIOUS IRRITANTS

FOREIGN BODY ASPIRATION -Assessment:

1. choking, gagging, wheezing, or coughing2. laryngotracheal obstruction: dyspnea,

cough, stridor, and hoarseness because of decreased air entry.

3. cyanosis if obstruction becomes worse4. Bronchial obstruction: cough(frequently

paroxysmal), wheezing, asymmetric breath sounds, decreased airway entry, and

dyspnea.5. Larynx: unable to speak or breathe

Therapeutic management and Nursing Considerations

1. Bronchoscopy: larynx and trachea2. Flouroscopic Exam: bronchi3. Back blows or the Hemleich Maneuver4. The child in distress: 1.cannot speak, 2. Becomes cyanotic,3. Collapses. These signs indicate that the child is

truly choking and requires immediate action. The child can die within 4 minutes.

ASPIRATION PNEUMONIA -Nursing Considerations:

1. same as pneumonia2. Prevention: proper feeding techniques;

use of talcum powder should be avoided; infants and debilitated

children should be positioned on their right side after feedings to

minimize aspiration.

SMOKE INHALATION - Three types of Injury:1. Heat Injury – 2. Chemical Injury – 3. Systemic Injury –

Therapeutic management:1. humidified oxygen as quickly as possible2. baseline arterial blood gases and COHb levels3. If CO poisoning s confirmed: 100% oxygen is continued until COHb level falls below

10%4. Intubation /tracheostomy available at bedside for transient edemaIndications: severe burns in the nose

mouth and face; Vocal cord edema; Progressive respiratory distress

5. cortecosteroid

PASSIVE SMOKING - children exposed to passive smoking increases the number f respiratory illness and reduced performance to pulmonary function test.

Exposure has been linked to the prevalence of asthma in the family.

LONG TERM RESPIRATORY DYSFUNCTION

ASTHMA The mechanism responsible for the obstructive symptomsinclude:

1. inflammation and edema of the mucuous membrane2. accumulation of tenacio

secretions from the mucous glands

3. spasm of the smooth muscle of the bronchi and bronchioles,

which decreases the caliber of the bronchioles

ASTHMA SEVERITY CLASSIFICATION1. STEP 4: Severe Persistent Asthma

1. continual symptoms, frequent nighttime symptoms2. PEF or Forced expiratory volume in second is less than 60% of the predicted value;

2. STEP 3 : Moderate Persistent Asthma1. daily symptoms, nighttime symptoms more than 1

night/week2. PEF or FEV is more than 60% to below 80% of predicted

value; 3. STEP 2: Mild Persistent Asthma

1. Symptoms more than 2 times /week, but less than 1 time a day,nighttime symptoms more than 2 times a

month2. PEF or FEV is greater than or equal 80% of predicted

value, 4. STEP 1 : Mild Intermittent Asthma

1. symptoms less than 2 times / week, nighttime symptoms less than 2 times a month

2. PEF or FEV is greater than or equal to 80% of predicted value,

Diagnostic Evaluation:

1. Pulmonary Function Test (PFT) : spirometry2. Peak expiratory flow rate: 3. skin testing4. provocative testing

Therapeutic management1. Allergen Control: housedust mites and cockroaches2. Drug Therapy:

a. long term control medications (preventor medicines)b. Quick relief medications (rescue medications)c. Metered dose inhaler with spacerd. Cortecosteroids: oral / inhaled (low dose inhaled corticosteroid)e. Cromolyn Sodiumf. B-adrenergic agonist-g. Leukotirene modifiers:

Leukotriene modifiers(Montelukast) Omalizumab (Xolair)

3. Exercise: EIB (exercise induce bronchspasm)Swimming and exhaling under water

4. Chest Physiotherapy5. Status Asthmaticus:Therapy: Bronchospasm( inhaled aerosolized shrt acting b2 agonsts along with cortecosteroids: oral/parenteral)If unresponsive to above therapy, subcutaneous epinephrine

or subcutaneous terbutaline is administered

CYSTIC FIBROSIS -

Assessment:1. meconim ileus: earliest 2. panceatic fibrosis3. steatorrhea nd azotorrhea4. prolapsed rectum5. pulmonary complications: most serious, bronchial and bronchiolar obstruction by the abnormally thick tenacious mucus causing patchy atelectasis with hyperinflainflation; child is unable to

expectorate mucus

Diagnosis:1. history of the dsease in te family2. absence of pancreatic enzymes3. increase in electrolyte conc of sweat4. chronic pulmonary involvement5. sweat chloride test (pilocarpine)

Normal sweat chloride= 40 mEq/LGreater than 60 mEq/L= CF

Therapeutic Management1. management of pulmonary problems:2. management of gastrointestinal problem