Nursing Care of the Pediatric Individual with a Respiratory Disorder

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Nursing Care of the Pediatric Individual with a
Respiratory Disorder

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Pediatric Differences In Anatomy and Physiology
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Differences in Adult and Child
Adult
Child
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Trachea Position
In children, trachea is shorter and the angle of
the right bronchus at the bifurcation is more
acute than in the adult.
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The diameter of an infants airway is
approximately 4 mm, in contrast to an adults
airway diameter of 20 mm. An inflammatory process
in the airway causes swelling that narrows the
airway, and airway resistance increases. Note
that swelling of 1 mm reduces the infants airway
diameter to 2 mm, but the adults airway diameter
is only narrowed to 18 mm. Air must move more
quickly in the infants narrowed airway to get
the same amount of air to the lungs. The friction
of the quickly moving air against the side of the
airway increases airway resistance. The infant
must use more effort to breathe and breathe
faster to get adequate oxygen.
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Respiratory Conditions
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Otitis Media Otitis Media with Effusion
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Understanding Otitis Media
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Question Of the three anatomical differences in
the eustachian tube between adults and small
children (shorter, wider, more horizontal), which
do you think could cause more problems for the
child and why? Answer More horizontal. Small
children who are bottle fed in a supine position
have a greater probability of developing otitis
media because the eustachian tube opens when the
child sucks and the horizontal angle provides
easy access to the middle ear. In older children
the greater angle helps keep foreign substances
and germs away from the middle ear.
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Common Causes

• Usually preceded by a viral upper respiratory
  infection
• Fluid and pathogens travel upward from the
• nasopharyngeal area, invading the middle ear.
  Fluid
• behind the eardrum has difficulty draining
  back out
• toward the nasopharyngeal area because of the
  
• horizontal positioning of the Eustachian
  tube.
• Pathogens gain access to the Eustachian tube,
  where
• they proliferate and invade the mucosa.

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Acute Otitis Media

• Fever hyperthermia is possible
• Irritability or fussiness
• Poor feeding to lack of appetite/ anorexia
• Severe pain in the ear caused by pressure of
  fluid
• Lethargy
• Decreased light reflex of tympanic membrane
• Red bulging tympanic membrane upon
• otoscopy

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Clinical Manifestations
What objective sign is this child
displaying? What does it indicate?
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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
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Serous Otitis Media

• Intermittent pain
• Drainage yellow, green, purulent, foul-smelling
• Otoscopic examination reveals
• Dull, opaque tympanic membrane
• Visualization of fluid line and air bubbles
• Light reflex is to the side, not in expected
  position (middle of the ear) due to changes
  caused by air bubbles

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Complications
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Treatment

• Treatment has always been directed toward
  antibiotic therapy however, recently medical
  professionals are allowing for a period of
  observation or watchful waiting to re-evaluate
• Waiting up to 72 hrs for spontaneous resolution
  is now recommended in healthy infants
• When antibiotics are warranted, oral amoxicillin
  in high dosage is given

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Nursing Care Management for OM

• Relieving pain
• Mild analgesics, narcotic analgesics
• Heat or cool compresses to affected side
• Numbing eardrops benzocaine (Auralgan)
• Facilitating drainage when possible
• Preventing complications or recurrence
• Educating the family in care of the child
• Providing emotional support to the child and
  family

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Myringotomy Pressure-equalizing
tubes

• A myringotomy a pin hole opening 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. 
• Insertion of pressure equalizing tubes help
  prevents the pin hole from closing over.  With
  the tubes in place, hearing should be normal and
  ear infections should be greatly reduced. 

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Post-op Teaching

• Administer ear drops as ordered
• Avoid water in the ears
• Use ear plugs in bathtub or when swimming
• Do not allow to swim in lake water- causes
  infection
• Heat to ear
• Assess motor and language development
• Teach parents to give all of antibiotics
  completing the entire course of antibiotics
• Return for follow-up

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When to Call the Doctor

• Call Healthcare Provider (HCP)if
• Decrease hearing
• Increased ear drainage
• Increased pain
• Increased bleeding
• Fever

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Patient/Parent Teaching

• If the ear is draining, the external canal may be
  cleaned with sterile cotton swabs. These should
  be loose enough to allow drainage out of the ear.
  Occasionally drainage is so profuse that the
  auricle and the skin surrounding the ear become
  excoriated from the exudate. This is usually
  prevented by frequent cleansing and application
  of various moisture barriers or Vaseline.

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Prevention

• Parents need to be taught ways to prevent OM
• sitting or holding an infant upright during
  bottle-feeding and breastfeeding. Propping
  bottles is discouraged to avoid the supine
  position and to encourage human contact during
  feeding.
• Avoid use of pacifiers
• Parents must also recognize the initial signs of
  OM such as irritability and ear puling.
• Eliminating tobacco smoke and known allergens
  from the environment is essential

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Tonsillitis
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Upper Respiratory Tract Infections

• Nasopharyngitis
• Young child fever, sneezing, vomiting or
  diarrhea
• Older child dryness and irritation of
  nose/throat, sneezing, aches, cough
• Pharyngitis
• Young child fever, malaise, anorexia, headaches
• Older child fever, headache, dysphagia,
  abdominal pain
• Tonsillitis
• Masses of lymphoid tissue in pairs
• Often occurs with pharyngitis
• Characterized by fever, dysphagia, or respiratory
  problems forcing breathing to take place through
  nose

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Clinical Manifestations

• Pharyngitis and Tonsillitis
• Fever
• Persistent or recurrent sore throat
• Anorexia
• General malaise
• Difficulty in swallowing, mouth breather, foul
  odor breath
• Enlarged tonsils, bright red, covered with
  exudate
• Adenoiditis
• Stertorous breathing - snoring, nasal quality
  speech
• Pain in ear, recurring otitis media

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Treatment and Nursing Care

• Saline gargles
• Analgesics
• Throat lozenges or hard candy
• Cool mist humidifier
• Hydration with cool liquids

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Nurse Alert!
Key to understanding prevention of URI
is meticulous handwashing and avoiding exposure
to infected persons
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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
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Nursing Care for the Tonsillectomy and
Adenoidectomy Patient
Why is collection of blood for assessment of
bleeding and clotting times so important?
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Post-operative Care

• Providing comfort and minimizing activities or
  interventions that precipitate bleeding
• Maintain airway - Place in prone or side-lying
  position to avoid aspiration until fully awake
• Monitor bleeding, esp. new bleeding
• Nonaspirin analgesics avoid administering red
  colored medications
• Ice collar
• Avoiding p.o. fluids until fully awake --then
  liquids and soft cool foods.

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Nurse Alert for Post-Op T/A surgery

• Most obvious sign of early bleeding
• is the childs continuous
• swallowing of trickling blood.
• While the child is sleeping,
• note the frequency of
• swallowing and notify
• the surgeon immediately

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Discharge Teaching

• Avoid citrus juices, milk, carbonated drinks, and
  extremely hot or cold liquids
• Do not use straws or put tongue blade in mouth,
  no smoking (in teenagers).
• Can add cream soups, gelatin, on second day an
  soft foods as the child tolerates
• Discourage from coughing, clearing throat, or
  gargling.
• See Parents Want to Know p. 1184.

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Croup
Epiglottitis
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Croup vs. Epiglotitis

• Croup
• Viral
• Fever
• Hoarseness
• Resonant cough
• Stridor (inspiratory)
• Risk for significant narrowing airway with
  inflammation
• Humidity for treatment

• Epiglotitis
• Bacterial
• High fever
• Rapidly progressive course
• Dysphagia
• Drooling
• Dysphonia
• Distressed inspiratory efforts
• Antibiotics needed

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Child with Epiglottitis
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Nursing Care

• Maintain patent airway
• Oxygen with humidification
• Keep resuscitation equipment at the bedside
• Provide mist - Cool mist humidifier or running
  hot water in closed bathroom
• Take out into cool, humid night air
• Meet fluid and nutritional needs
• Cool, noncarbonated, non-acid drinks
• Assess for difficulty swallowing may need IV
  therapy
• Keep quiet as possible

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Medications

• Beta-agonist racemic epinephrine, Albuterol
• Corticosteroids
• Which of these medications would the nurse give
  first? Rationale?

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If condition worsens

• Take to emergency room
• Humidified oxygen
• IV fluids
• Sedatives are contraindicated mask symptoms
• Monitor vital signs and pulse oximetry
• Have intubation equipment available should the
  childs condition change rapidly.

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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?

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Bronchitis vs. Bronchiolitis
Bronchiolitis
Bronchitis
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Bronchiolitis / RSV

• RSV is rhino syncytial virus
• Affects 2-6 month olds primarily
• Infection of bronchial mucosa leading to
  obstruction
• Starts out with Upper Respiratory Infection and
  progresses to Respiratory Distress.
• Diagnosed with a RSV wash

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Clinical Manifestations

• Tachypnea
• Tachycardia
• Wheezing, crackles, or rhonchi
• Intercostal and subcostal retractions
• Cyanosis
• Difficulty feeding

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Nursing Care for Child with RSV
Contact Isolation Wearing gown and gloves
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Treatment and Nursing Care

• Medication therapy
• Bronchodilators
• Steroids
• Beta-antagonists
• Antiviral
• Virozole (Ribavirin)
• Prevention drug Synagis (pavilzumab) given IM.
  and RespiGam (RSV immune globulin) given IV.

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Nebulized epinephrine administered for
Bronchiolitis
Parents can hold nebulizer to decrease infants
fear
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Respiratory Distress
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Indications of Respiratory Distress

• Nasal Flaring
• Circumoral cyanosis
• Expiratory grunting
• Retractions
• Substernal, lower intercostal,
• Tachypnea
• Repirations greater than 60 bpm

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Nursing Care

• Maintain open airway
• Position with airway open
• Humidify oxygen
• Give IV fluids to help liquefy secretions for
  ease in clearance
• Perform chest physiotherapy
• Ensure emergency equipment is readily available

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APNEA
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Apnea

• Defined as Delay of breathing over 20 seconds
• Additional Signs and Symptoms
• Cyanosis
• Marked pallor
• Hypotonia
• Bradycardia

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Diagnosis

• Pneumocardiography
• Tests for apnea
• Records the heart rate and chest wall movements

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Treatment and Nursing Care

• Admit to hospital for cardiorespiratory
  monitoring and maintain pulse oximetry above 95
• Teach parents home care instructions in the use
  of an apnea monitor
• Encourage parents to learn CPR.

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Cardiorespiratory Monitoring pulse oximetry
Want reading gt 95
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SIDS

• Sudden death of a previously healthy infant
  during sleep. Usually lt1 year of age.
• Risk Factors
• Prematurity, low birth weight
• Most common in infants 2-4 months old
• More prevalent in winter months
• Sleeping in bed with others, sleeping prone, use
  of pillows and quilts
• Exposure to passive smoke

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SIDS Nursing Interventions

• Parent teaching
• place infant on back to sleep
• Place on firm mattress
• Do not use loose bedding, toys, pillows
• Avoid overheating with too many clothes
• Parents should stop smoking
• Provide support of parents by helping them work
  through feelings of guilt and loss refer to
  National Foundation for SIDS

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Reactive Airway Disease Asthma
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Reactive Airway Disease (asthma)

• Chronic inflammatory disorder affecting mast
  cells, eosinophils, and T lymphocytes
• Inflammation causes increase in bronchial
  hyperresponsiveness to variety of stimuli
  (dander, dust, pollen, etc.)
• Most common chronic disease of childhood primary
  cause of school absences

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Asthma
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Etiology/Pathophysiology of Asthma

• Obstructive airflow limitation due to
• Mucosal edema - membranes that line airways
• Bronchospasm (bronchoconstriction)
• Mucus plugging (thicker) causes
• Increased airway resistance
• Decreased flow rates
• Increased work of breathing
• Progressive decrease in tidal volume
• Arterial pH abnormalities include
• Respiratory alkalosis (early) or acidosis (late)
• Metabolic acidosis - from hypoxemia, work of
  breathing

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Asthma Triggers
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Medications to treat Asthma

• Reliever or Rescue Meds
• Short acting beta-agonists
• albuterol
• terbutaline
• Anticholinergic agents Atrovent
• Corticosteroids- prednisone (Prelone), for short
  term therapy

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Medication Therapy

• Preventer / Controller Medications
• Mast-cell inhibitors (Cromolyn)
• Inhaled steroids ( Advair, Pulmocort, Azmacort)
  (always rinse mouth following administration)
• Leukotriene modifiers - (Singulair)

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Children can receive nebulizer treatment /
Metered Dose Inhaler
What is important patient teaching ?
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Metered-Dose Inhaler with spacer

• A spacer is a chamber that can be attached to a
  metered-dose inhaler (MDI). The spacer chamber
  allows the medication to be held in the chamber
  before it is inhaled so the child can inhale the
  medicine in one or many breaths, depending on
  ability.
• A spacer
• Helps prevent getting a yeast infection in the
  mouth (candidiasis)
• Increases the amount of medicine delivered
  directly to airways
• Reduces the amount of medicine swallowed, which
  minimizes side
• effects.

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Interpreting Peak Expiratory Flow Rates

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

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How to Use Peak Flow Meter

• A peak flow meter is simple to use for
• tracking asthma.
• Here's what to teach
• Stand up or sit up straight.
• Make sure the indicator is at the bottom of the
  meter (zero).
• Take a deep breath in, filling the lungs
  completely.
• Place the mouthpiece in the mouth and blast the
  air out as
• hard and as fast as possible in a single blow.
  
• Remove the meter from the mouth and record the
  number
• that appears on the meter.
• Repeat three times

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Treatment and Nursing Care
High fowlers position
Humidified Oxygen via mask
Pulse Oxymetry
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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
  hypoxicimmediate intervention needed

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Cystic Fibrosis
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Cystic Fibrosis
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Cystic Fibrosis (CF)

• Factor responsible for manifestations of the
  disease is mechanical obstruction caused by
  increased viscosity of mucous gland secretions
• Mucous glands produce a thick protein that
  accumulates and dilates them
• Passages in organs such as the pancreas become
  obstructed
• First manifestation is meconium ileus in newborn

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Pathophysiology

• Respiratory System
• Chronic changes, due to accumulation and
  retention of mucus in the airways, air trapping
• Cycle of infection gt increased mucus gt
  inflammation gt further obstruction
• Pancreas
• Mucus inhibits the flow of trypsin, lipase, and
  amylase to the duodenum. Thus malabsorption of
  fats.

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Pathophysiology

• Intestine
• Mucus accumulation may lead to bowel obstruction
• Meconium ileus happens in 10-15
• Sludging of intestinal contents leads to rectal
  prolapse, fecal impaction, bowel obstruction and
  intussusception
• Altered absorption of fat soluble vitamins
•  Reproductive System
• 99 of males sterile due to mucus obstruction
  females have decrease fertility due to thick
  cervical secretions.

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Cystic Fibrosis
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Clinical Manifestations

• Salty taste to child's skin
• Meconium ileus
• Abdominal pain or difficulty passing stool
• Clubbing of the fingers
• Barrel chest
• Increased respirations, cyanosis
• Productive cough
• Mild diarrhea with malodorous stools,
  steatorrhea.

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Continued Assessment

• FTH despite high caloric intake.
• Frequent respiratory infections.
• Malabsorption of fats and proteins

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Diagnosis

• Sweat test
• Chloride Normal lt 40 mEq/L.
• Highly suggestive of CF 40-60 mEq/L
• Diagnostic gt 60 mEq/L.
• (see bags over hands and arms)
•  
• Pancreatic enzymes
• Collection of stool specimen to
• assess Trypsin and lipase. Trypsin
• absent in 80 of children with CF.
• r/t Failure to absorb nutrients
•  

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Cystic Fibrosis Confirmation

• Diagnosis is confirmed with
• absence of pancreatic enzymes
• increase in electrolyte concentration in sweat
• pulmonary symptoms

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Treatment and Nursing Care

• Relieve airway obstruction
• Chest Physiotherapy at least twice a day to
  increase sputum expectoration
• Physical exercise important adjunct
• Administration of mucolytic agents
• Prevention and treatment of pulmonary infections
• Administer antibiotics

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Treatment and Nursing Care

• Provide optimal nutrition for growth
• Provide well balanced diet which is high in
  calories, protein, CHO. Increase salt in hot
  weatjer.
• Administer fat soluble vitamins in water soluble
  form
• Administration of pancreatic enzymes prior to all
  meals and snacks
• Comes in enteric coated capsule may swallow
  capsule or open and sprinkle beads over food
• Note color, consistency, frequency of stools
  because enzyme dosing is correlated with childs
  bowel elimination patterns.

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Chest Physiotherapycupping and clapping
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The End
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