Nursing Care of the Pediatric Individual with a Respiratory Disorder

Describing the differences between adult and pedi client

Differences between the very young child and the older childResistance can depend on many factorsClinical manifestations: those from 6 months to 3 years of age react more severely to acute resp tract infections

Differences in Adult and Child Adult

Child

Let’s understand OM

A diagnosis of OM requires all of the following:– Recent, usually abrupt onset of illness– The presence of middle ear fluid, or “effusion” (OME)– Signs or symptoms of middle ear inflammation

OME: hearing loss, tinnitus, vertigo

Differences between young and older child OM:– Young child (infants) fussy, pulls at ear, anorexia, crying,

rolling head from side to side– Older child crying, verbalizes discomfort

Understanding OM

What objective sign is this child displaying?

What does it indicate?

Clinical Manifestations

Otitis media (OM)

Note the ear on the left with clear tympanic membrane (drum); ear on the R the drum is bulging and filled with pus

Acute Otitis Media characterized by abrupt onset, pain, middle ear effusion, and inflammation.

Note the injected vessels and altered shape of cone of light.

Evaluation and therapy

Tx has always been directed toward abx; however, recently concerns about drug-resistant streptococcus pneumoniae have caused medical professionals to re-evaluate therapy (APA, 2004)No clear evidence that abx improve OMWaiting up to 72 hrs for spontaneous resolution is now recommended in healthy infantsWhen abx warranted, oral amoxicillin in high dosage TOC

Nursing Care Management for OM

Nursing objectives:– Relieving pain– Facilitating drainage when possible– Preventing complications or recurrence– Educating the family in care of the child– Providing emotional support to the child and

family

Preparing the child for surgery

A myringotomy or pin hole is made in the ear drum to allow fluid removal.  Air can now enter the middle ear through the ear drum, by-passing the Eustachian tube.  The myringotomy tube prevents the pin hole from closing over.  With the tubes in place, hearing should be normal and ear infections should be greatly reduced. 

Tonsillitis

Nursing Care for the Tonsillectomy and Adenoidectomy Patient

Nursing Care for the Tonsillectomy and Adenoidectomy Patient

Pre-operative preparationProviding comfort and minimizing activities or interventions that precipitate bleeding– Place on abd until fully awake– Manage airway– Monitor bleeding, esp. new bleeding– Ice collar, pain meds– Avoiding po fluids until fully awake..then liquids, soft– Post-op hemorrhage can occur

Nurse Alert for Post-Op T/A surgery

Most obvious sign of early bleeding

is the child’s continuous

swallowing of trickling blood.

While the child is sleeping,

note the frequency of

swallowing and notify

the surgeon immediately

Nurse Alert!

The nurse should remind the child with a positive throat culture for strep to discard their toothbrush and replace it with a new one after they have been taking antibiotics for 24 hours

Apnea

Defined as delay of breathing over 20 secondsManifestationsDiagnostic testsTherapeutic Interventions and Nursing Care

Apnea vs Periodic Breathing

Apnea: – Cessation > 20 seconds– S/S to assess:

• Cyanosis• Marked pallor• Hypotonia• bradycardia

Periodic breathing– Normal breathing pattern

of NB but never > 10-15 seconds

• Even though normal, all parents are taught CPR for their NB

SIDS

Defined: sudden death of an infant during sleepEtiologyAssessmentTherapeutic Interventions and Nursing Care

CroupCroup

Croup vs epiglottitis

Croup vs. Epiglottitis

Croup– viral– Hoarseness– Resonant cough– Stridor (inspiratory)– Risk for significant

narrowing airway with inflammation

– Humidity for treatment

Epiglottitis– Bacterial– Rapidly progressive

course– Dysphagia– Stridor aggravated when

supine– Drooling, high fever– Antibiotics needed

Four D’s r/t epiglottitis

DroolingDysphagiaDysphonia (difficulty talking)Distress with respiratory effort

Medications used in the treatment of croup and epiglottitis

Beta agonists and beta-adrenergics (albuterol, racemic epinepherine through face mask)Corticosteroids: not for acute attackAntibiotics for epiglottitisCroup tent with mist, Pulse OxEndotracheal tube, trach

@ bedside for epiglottitis

Nursing care for the child with croup and epiglottitis

Observe for s/s respiratory distressAssess respiratory rates: >60Elevated temp ) 101ºThe child must NEVER be left aloneNOTHING should be placed in the mouth (laryngeal spasms could result)

Bronchitis vs Bronchiolitis

The diameter of an infant’s airway is approximately 4 mm, in contrast to an adult’s airway diameter of 20 mm.

Preventive measures against RSV

Follow droplet and contact precautions (can live up to 7 hrs on inanimate objects)Nosocomial infections very common; strict hand hygiene must be observedSynagis (palivizumab) given IM only to at risk children

Reactive Airway Disease (asthma)

Chronic inflammatory disorder affecting mast cells, eosinophils, and T lymphocytesInflammation causes increase in bronchial hyper-responsiveness to variety of stimuli (dander, dust, pollen, etc.)Most common chronic disease of childhood; primary cause of school absences

Asthma, cont.

Pathophysiology– Increased airway resistance, decreased flow rate– Increased work of breathing– Progressive decrease in tidal volume

Arterial pH changes: respiratory alkalosis, metabolic acidosis Characterized by– Mucosal edema– Wheezing (r/t bronchospasm)– Mucus plugging

Asthma, cont.

Therapies:– Medi-halers (not more than one canister/month)– Beta-agonists: relax smooth muscle in airway– Corticosteroids: for short term therapy

– Anticholinergic agents: Atrovent • Mast-cell inhibitors (Cromolyn)• Singulair• Inhaled steroids ( Advair, Pulmocort, Azmacort) (always

rinse mouth following administration)

Emergency situations of asthma

Acute episode of reactive disease: bronchioles may close rapidly, causing severe airway obstruction, anxiety, restlessness, and fear. Will need to be seen in ER if not relieved by med

Status asthmaticus: medical emergency with severe edema, profuse sweating, respiratory failure and death if untreated. Becomes seriously hypoxic…immediate intervention needed

Etiology of Acute Wheezing in an ED setting

Patients < 2 yrs of age– Evidence of smoke exposure– Significant role of viral infections (RSV)

Patients > 2 yrs of age– High incidence of allergies to dust mite, cock roach

and other inhaled allergens– High incidence of viral respiratory infections

Goals for child with asthma

Prevention of chronic symptomsMonitor peak expiratory flow (Peak Flow)Prevent exacerbationsMaximize compliance to therapeutic regimeRecognize “triggers”– Exercise -stress– Allergens -infections

Types of medications for asthma

“Rescue”: short acting beta agonists (albuterol) main rescue classification“Controller” or routine medications: mast-cell inhibitors (Intal), Luekotriene modifiers (Singulair), inhaled steroids (Advair, Flonase)Preventer drugs: combination of controller meds plus some inhaled steroids (nasal)

Purpose of the MDI

Shake vigorously prior to useExhale slowly and completelyPlace mouthpiece in mouth, closing lips around itPress and release the med while inhaling deeply and slowlyHold breath for 10 seconds and exhaleRepeat x1

Interpreting Peak Expiratory Flow Rates

Green: (80-100% of personal best) signals all clear and asthma is under reasonably good controlYellow (50-79% of personal best) signals caution; asthma not well controlled; call dr. if child stays in this zoneRed (below 50% of personal best) signals a medical alert. Severe airway narrowing is occurring; short acting bronchodilator is indicated

Why don’t we give bicarbonate for respiratory acidosis?

Child not able to blow off CO2 and acidosis will get worseCorrect the cause of the acidosisPatient may need to be intubated

Cystic Fibrosis

Cystic Fibrosis

Cystic Fibrosis (CF)

Factor responsible for manifestations of the disease is mechanical obstruction caused by increased viscosity of mucous gland secretionsMucous glands produce a thick protein that accumulates and dilates the glandsPassages in organs such as the PANCREAS become obstructedFirst manifestation is meconium ileus in NBSweat chloride test

Cystic Fibrosis, cont.

Systems affected:– Respiratory: thick mucus, inflammation, inc.

infections, atelectasis and pneumothorax– Pancreas: obstructed pancreatic ducts by mucus

and pancreatic enzymes (trypsin lipase, amylase) to duodenum

– GI: decrease in absorption of nutrients, fatty stools (steatorrhea)

– Reproductive: 99% of males are sterile

Physical findings of the CF patient

Frequently admitted with FTTClubbing of the fingersBarrel chestIncreased respirations, cyanosisProductive cough

Diagnostics for CF

Sweat test: increased levels of chloride– Normal is <40; in CF >40-60 is positive; may be 3-5X

higher

Pancreatic enzymes via stool cultures: trypsin absent in 80% of children with CF; lipase and amylase also absent

Planning the care for a CF child

Respiratory goal: removal of secretions (chest physiotherapy with Thairapy vest) by vibrations loosen mucusNutritional: inc. weight, enzymes with all food (Viokase or Ultrace) dosage is regulated by evaluation of the stoolFat soluble vitamins ADKEHigh calorie, high protein, low fatMaintain Na balance (when sweating and ill)

Nursing Care of the CF patient

Assessing both GI and pulmonary statusAssisting with diagnostic testingCollections of stool specimens for trypsin and lipase (fat analyses)Administer oxygen with great caution because of the threat of oxygen narcosisImplement dietary management; many have a good appetite and some will eat excessively

Critical Thinking Exercise

Kim, a 4 year old, is admitted to the emergency department with a sore throat, pain on swallowing drooling, and a fever of 102.2°. She looks ill, agitated and prefers to sit up and lean over. What nursing interventions should the nurse implement in this situation?