Pediatric Nursing Module 2 Caring for Children with Alterations in Oxygenation Chapters 19, 20

Pediatric Pediatric NursingNursing

Module 2 Caring for Children Module 2 Caring for Children with Alterations in Oxygenationwith Alterations in Oxygenation

Chapters 19, 20Chapters 19, 20

Differences between Children and AdultsDifferences between Children and Adults

Chest/Respiratory SystemChest/Respiratory System

– Obligate nasal breathers >6wksObligate nasal breathers >6wks– Short neckShort neck– Smaller, narrower airwaysSmaller, narrower airways

= more susceptible to airway obstruction and resp. distress= more susceptible to airway obstruction and resp. distress

– Tongue is larger in proportion to the mouth Tongue is larger in proportion to the mouth = more likely to obstruct airway in unconscious child= more likely to obstruct airway in unconscious child

Differences between Children and AdultsDifferences between Children and Adults

Chest/Respiratory SystemChest/Respiratory System– Smaller lung capacity and underdeveloped intercostal Smaller lung capacity and underdeveloped intercostal

muscles, poor chest musculature muscles, poor chest musculature = less pulmonary reserve, lung damage w/o fx= less pulmonary reserve, lung damage w/o fx

– Children rely on diaphragm breathingChildren rely on diaphragm breathing = high risk for resp. failure if the diaphragm unable to contract= high risk for resp. failure if the diaphragm unable to contract

Adjunct AssessmentsAdjunct Assessments

TemperatureTemperature– Febrile state increases oxygen consumptionFebrile state increases oxygen consumption

Fluid NeedsFluid Needs– Vomiting/diarrhea are commonly associated Vomiting/diarrhea are commonly associated

with respiratory illnesswith respiratory illness– Increase respiratory efforts, increased fluid Increase respiratory efforts, increased fluid

losses with decreased po intake requires an losses with decreased po intake requires an increase in fluid needsincrease in fluid needs

Respiratory SystemRespiratory System

InspectionInspection– ChestChest

Size, symmetry movementSize, symmetry movement Infancy shape is almost circularInfancy shape is almost circular < 6-7 years respiratory movement primarily < 6-7 years respiratory movement primarily

abdominal or diaphragmaticabdominal or diaphragmatic

– RespirationsRespirations Rate, rhythm, depth, quality, effortRate, rhythm, depth, quality, effort >60 /min in small children = significant respiratory >60 /min in small children = significant respiratory

distressdistress

Respiratory AssessmentRespiratory Assessment

RetractionsRetractions– SubsternalSubsternal– SubcostalSubcostal– IntercostalIntercostal– SuprasternalSuprasternal– SupraclavicularSupraclavicular

EffortEffort– GruntingGrunting– Nasal flaringNasal flaring


ColorColor– Mucous membranesMucous membranes– NailbedsNailbeds– SkinSkin– CyanosisCyanosis


AuscultationAuscultation– Listen comparing one areas to the otherListen comparing one areas to the other

Equality of breath soundsEquality of breath sounds DiminishedDiminished Poor air exchangePoor air exchange

– Abnormal breath soundsAbnormal breath sounds RalesRales RhonchiRhonchi WheezingWheezing GruntingGrunting

– Present on inspiration or expirationPresent on inspiration or expiration

Upper Respiratory Tract Infections Upper Respiratory Tract Infections TonsillitisTonsillitis

TonsilsTonsils– Lymphoid tissuesLymphoid tissues– Abundance in children Abundance in children

especially tonsilsespecially tonsils

TonsillectomyTonsillectomy– Pre-opPre-op

Bleeding timeBleeding time Loose teethLoose teeth

TonsillectomyTonsillectomy

Post-opPost-op– T & A positionT & A position

Semi prone with head turned to the sideSemi prone with head turned to the side

– Monitor for bleedingMonitor for bleeding Frequent swallowingFrequent swallowing Persistent pulse of 120 or greater at restPersistent pulse of 120 or greater at rest RestlessnessRestlessness PallorPallor Vomiting bright red bloodVomiting bright red blood May bleed for 5-10 days post-opMay bleed for 5-10 days post-op

– Home care Home care DietDiet

Otitis MediaOtitis Media

Generally bacterialGenerally bacterial– H. influenzaH. influenza– S. pneumoniaeS. pneumoniae

Signs/SymptomsSigns/Symptoms– Fever (maybe)Fever (maybe)– Pulling, tugging on earsPulling, tugging on ears– GI upset – vomit/diarrhea, poor appetiteGI upset – vomit/diarrhea, poor appetite

Acute infection of the middle ear

Otitis MediaOtitis Media

– IrritabilityIrritability– URTIURTI

TreatmentTreatment– AntibioticsAntibiotics

Ampicillin, amoxicillinAmpicillin, amoxicillin

Nursing ConcernsNursing Concerns

- compliance- compliance

- chronic or recurrent otitis media- chronic or recurrent otitis media

- hearing loss can lead to speech impediments- hearing loss can lead to speech impediments

Croup -Croup - Acute Laryngotracheal Acute Laryngotracheal BronchitisBronchitis

Upper airway problemUpper airway problem– Edema, swelling of the larynxEdema, swelling of the larynx– Viral 3 months to 3 yearsViral 3 months to 3 years– Bacterial 3 to 7 yearsBacterial 3 to 7 years

Signs/SymptomsSigns/Symptoms– Croupy coughCroupy cough– Inspiratory stridorInspiratory stridor– HoarsenessHoarseness– Fever Fever – DroolDrool

CroupCroup

Primary concernPrimary concern– Obstruction of the airwayObstruction of the airway– Sedatives are contraindicated Sedatives are contraindicated – Treatment – racemic epinephrine, cool mistTreatment – racemic epinephrine, cool mist

Infections of the Lower AirwaysInfections of the Lower AirwaysBroncholitis / RSV -Respiratory Syncytial VirusBroncholitis / RSV -Respiratory Syncytial Virus Common cause of bronchiolitis or the common cold in Common cause of bronchiolitis or the common cold in

infantsinfants Signs/SymptomsSigns/Symptoms

– PharyngitisPharyngitis– FeverFever– Otitis mediaOtitis media– TachypneaTachypnea– Apnea spellsApnea spells– Poor air exchange Poor air exchange – Secretions Secretions

RSVRSV

TreatmentTreatment– Aerosol respiratory treatmentsAerosol respiratory treatments

– Supplemental 02Supplemental 02

– Vaccine for high risk infantsVaccine for high risk infants

PneumoniaPneumonia

Classified according to etiologyClassified according to etiology– viral, bacterial, fungal, aspirationviral, bacterial, fungal, aspiration

Signs and SymptomsSigns and Symptoms– RespiratoryRespiratory

rhonchi, ralesrhonchi, rales dull to percussiondull to percussion retractions, nasal flaringretractions, nasal flaring coughcough

PneumoniaPneumonia

– SystemicSystemic high fever high fever

– NeurologicalNeurological irritable, restless, lethargicirritable, restless, lethargic painpain

– GastrointestinalGastrointestinal a/v/da/v/d abdominal painabdominal pain

Chest X-ray PneumoniaChest X-ray Pneumonia

Long Term Respiratory DysfunctionLong Term Respiratory DysfunctionAsthmaAsthma

Chronic inflammatory disease of Chronic inflammatory disease of airwaysairways– airway inflammationairway inflammation– bronchospasmbronchospasm– obstructionobstruction

TriggersTriggers– environmental, chemical, tobacco, environmental, chemical, tobacco,

exercise, cold air, infection, exercise, cold air, infection, medication, foods, emotions medication, foods, emotions

AsthmaAsthma

Signs and SymptomsSigns and Symptoms– RespiratoryRespiratory

coughcough auscultation - prolonged expiration, wheeze, auscultation - prolonged expiration, wheeze,

diminished breath sounddiminished breath sound shortness of breathshortness of breath

– short panting phrasesshort panting phrases

– OtherOther restlessness, apprehension, cyanosis, sweatingrestlessness, apprehension, cyanosis, sweating

Cystic FibrosisCystic Fibrosis


Hereditary disease of the exocrine glands Hereditary disease of the exocrine glands thick, tenacious secretions of the mucous-thick, tenacious secretions of the mucous-producing glands especially of the bronchi producing glands especially of the bronchi and pancreatic ductsand pancreatic ducts

LungsLungs– Chronic lung diseaseChronic lung disease

Bronchial obstruction Bronchial obstruction – pulmonary hypertensionpulmonary hypertension

Over inflation of the lungsOver inflation of the lungs Repeated lung infectionsRepeated lung infections


G.I SystemG.I System– Pancreatic ductsPancreatic ducts– Blockage of enzymes Blockage of enzymes

needed for digestionneeded for digestion

Sweat glandsSweat glands– Secretions contain Secretions contain

excessive amount of excessive amount of saltsalt


Signs/symptomsSigns/symptoms– Newborn meconium ileusNewborn meconium ileus– Tastes salty when kissedTastes salty when kissed– Recurrent respiratory illnessesRecurrent respiratory illnesses– Failure to gain weight with a good Failure to gain weight with a good

appetiteappetite– Malasbsorption of fats and proteinsMalasbsorption of fats and proteins

Stools are foul smelling, frothy and Stools are foul smelling, frothy and bulkybulky

Pot belly with wasted buttocksPot belly with wasted buttocks


DiagnosisDiagnosis– Family history of CFFamily history of CF– Repeated illnesses/hospitalization with Repeated illnesses/hospitalization with

respiratory problems or failure to thriverespiratory problems or failure to thrive– Absence of pancreatic enzyme or stool studiesAbsence of pancreatic enzyme or stool studies– + sweat chloride tests+ sweat chloride tests

Concentration of Cl > 60mEq/LConcentration of Cl > 60mEq/L


TreatmentTreatment– NutritionalNutritional

Pancreatic enzymes with meals and snacksPancreatic enzymes with meals and snacks Vitamin replacement – A,D,E,KVitamin replacement – A,D,E,K High protein, high calorie dietHigh protein, high calorie diet

– PulmonaryPulmonary Thin the secretions, keep them mobileThin the secretions, keep them mobile

– CPTCPT– Aerosol TreatmentAerosol Treatment

bronchodilators, D-nasebronchodilators, D-nase


02 when needed02 when needed Antibiotics for resp. infectionsAntibiotics for resp. infections

Pulmonary complicationsPulmonary complications– AtelectasisAtelectasis– Lung abscessesLung abscesses– PneumothoraxPneumothorax– EmphysemaEmphysema

PrognosisPrognosis– Life expectancy teen years to early 20sLife expectancy teen years to early 20s

Respiratory – Nursing DiagnosisRespiratory – Nursing Diagnosis

Impaired gas exchangeImpaired gas exchange Ineffective airway clearanceIneffective airway clearance Ineffective breathing patternIneffective breathing pattern High risk fluid volume deficit High risk fluid volume deficit Altered tissue perfusionAltered tissue perfusion AnxietyAnxiety Activity IntoleranceActivity Intolerance Altered growth/developmentAltered growth/development Knowledge deficitKnowledge deficit

Respiratory – Nursing DiagnosisRespiratory – Nursing Diagnosis

PC: Atelectasis/PneumoniaPC: Atelectasis/Pneumonia PC: Electrolyte ImbalancePC: Electrolyte Imbalance PC: HemorrhagePC: Hemorrhage PC: HypoxiaPC: Hypoxia

Nursing InterventionsNursing Interventions

Assess respiratory statusAssess respiratory status– Tachypnea, labored breathing, shallow breathingTachypnea, labored breathing, shallow breathing– EffortEffort

RetractionsRetractions Nasal flaringNasal flaring Head bobbingHead bobbing

– GruntingGrunting– ApneaApnea– Poor air exchangePoor air exchange– 02 saturation02 saturation


Oxygenation/ventilation needsOxygenation/ventilation needs– Administer O2Administer O2

Incubator/oxygen hoodIncubator/oxygen hood Nasal prongsNasal prongs Mist tentMist tent

– Tracheotomy – croupTracheotomy – croup

Decrease respiratory effortsDecrease respiratory efforts Infant car seatInfant car seat Knee-chest positionKnee-chest position


Maintain airwayMaintain airway– Head tilt – do not hyper Head tilt – do not hyper

extend neckextend neck– Aerosol treatmentAerosol treatment– CPTCPT– Suction bulb syringe, BBG Suction bulb syringe, BBG

or tracheal bronchialor tracheal bronchial

Fluids Fluids – IV or poIV or po


LabsLabs MedicationsMedications Conserve energyConserve energy

– Organize careOrganize care

Monitor vital signsMonitor vital signs TeachingTeaching

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Pediatric Nursing Module 2 Caring for Children with Alterations in Oxygenation Chapters 19, 20