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Nursing Care of the Pediatric Individual with a Respiratory Disorder


... oral amoxicillin in high dosage TOC Nursing Care Management for ... until fully awake Manage airway ... Fever may be absent in newborn infants; ... – PowerPoint PPT presentation

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Title: Nursing Care of the Pediatric Individual with a Respiratory Disorder

Nursing Care of the Pediatric Individual with a
Respiratory Disorder

General Aspects of Respiratory Infections (upper
and lower)
  • Described according to the anatomic area
  • However, respiratory infections rarely fall into
    just one anatomic area
  • Spread is due to the mucous membranes lining the
    entire tract
  • Account for the majority of acute illnesses in
  • Infectious agents Viruses, and bacterial strep,
    staph, influenzae, chlamydia pneumococci

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

Nursing Care for respiratory conditions
  • Assess respiratory status
  • May need to position upright, esp. for feedings
  • O2 monitoring
  • Fluid balance
  • Temp control
  • Organize and prioritize care!
  • Be watchful for complications
  • Apnea monitors may be needed

Describing the differences between adult and pedi
  • Differences between the very young child and the
    older child
  • Resistance can depend on many factors
  • Clinical manifestations those from 6 months to 3
    years of age react more severely to acute resp
    tract infections

Differences in Adult and Child
Lets 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
  • Signs or symptoms of middle ear inflammation
  • Chronic OM 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

Clinical Manifestations
What objective sign is this child
displaying? What does it indicate?
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
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 OM
  • Waiting up to 72 hrs for spontaneous resolution
    is now recommended in healthy infants
  • When 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

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. 

  • Morbidity/mortality
  • Hearing loss
  • Extension of the infectious process beyond the
    mastoid system, resulting in either intracranial
    complications or extracranial complications
  • Ages affected
  • The incidence of mastoiditis parallels that of
    otitis media, affecting mostly young children and
    peaking in those aged 6-13 months.
  • May occur in healthy adults as well

Nursing care for the child with mastoiditis
  • Monitor vital signs
  • Assess for changes in lab values (esp. bacterial
  • Medicate aggressively with abx as ordered
    (usually IV if bacterial spread to mastoid)
  • Drugs of choice Timentin and Gentamicin
  • Assess for complications (hearing loss, tinnitus,

Nursing Care for the Tonsillectomy and
Adenoidectomy Patient
Why is collection of blood for assessment of
bleeding and clotting times so important?
Nursing Care for the Tonsillectomy and
Adenoidectomy Patient
  • Pre-operative preparation
  • Providing 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 childs 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
Manifestations of respiratory symptoms in infants
and small children
  • Fever (may ?105 even with mild infections norm
    for infant is 99)
  • Anorexia (may be initial finding)
  • Vomiting (esp small children usually
  • Diarrhea (usually mild often accompanies viral
  • Meningismus
  • Abd pain is common complaint
  • Nasal blockage nasal passages block
  • Nasal discharge starts thin, but changes to color
  • Cough
  • Respiratory sounds(grunting, stridor,
  • Sore throat freq c/o older children

Assessment findings to indicate respiratory
  • Nasal flaring
  • Circumoral cyanosis
  • Expiratory grunting
  • Retractions subcostal, substernal, or lower
  • Tachypnea respiratory rate gt 60

Nursing interventions for respiratory distress
  • Antibiotic therapy (after cultures are done)
  • Respiratory treatments and medications
    albuterol, nebs, azmacort, combivent
  • Assess ongoing respiratory status
  • High Fowlers position
  • Fluid maintenance
  • Temp control

  • Defined as delay of breathing over 20 seconds
  • Manifestations
  • Diagnostic tests
  • Therapeutic Interventions and Nursing Care

Apnea vs Periodic Breathing
  • Apnea
  • Cessation gt 20 seconds
  • S/S to assess
  • Cyanosis
  • Marked pallor
  • Hypotonia
  • bradycardia
  • Periodic breathing
  • Normal breathing pattern of NB but never gt 10-15
  • Even though normal, all parents are taught CPR
    for their NB

  • Defined sudden death of an infant during sleep
  • Etiology
  • Assessment
  • Therapeutic Interventions and Nursing Care

Croup vs epiglottitis
Croup vs. Epiglottitis
  • Croup
  • viral
  • Hoarseness
  • Resonant cough
  • Stridor (inspiratory)
  • Risk for significant narrowing airway with
  • Humidity for treatment
  • Epiglottitis
  • Bacterial
  • Rapidly progressive course
  • Dysphagia
  • Stridor aggravated when supine
  • Drooling, high fever
  • Antibiotics needed

Four Ds r/t epiglottitis
  • Drooling
  • Dysphagia
  • Dysphonia (difficulty talking)
  • Distress inspiratory effort

Medications used in the treatment of croup and
  • Beta agonists and beta-adrenergics (albuterol,
    racemic epinepherine through face mask)
  • Corticosteroids not for acute attack
  • Antibiotics for epiglottitis
  • Croup tent with mist, Pulse Ox
  • Endotracheal tube, trach
  • _at_ bedside for epiglottitis

Nursing care for the child with croup and
  • Observe for s/s respiratory distress
  • Assess respiratory rates gt60
  • Elevated temp ) 101º
  • The child must NEVER be left alone
  • NOTHING should be placed in the mouth (laryngeal
    spasms could result)

Bronchitis vs Bronchiolitis

The diameter of an infants airway is
approximately 4 mm, in contrast to an adults
airway diameter of 20 mm.
Preventive measures against RSV
  • Follow droplet and contact precautions (can live
    up to 7 hrs on inanimate objects)
  • Respigam IV RSV immune globulin (passive
  • Synagis (palivizumab) given IM

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

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
  • Preventer Medications
  • 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
    hypoxicimmediate intervention needed

Etiology of Acute Wheezing in an ED setting
  • Patients lt 2 yrs of age
  • Evidence of smoke exposure
  • Significant role of viral infections (RSV)
  • Patients gt 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 symptoms
  • Monitor peak expiratory flow (Peak Flow)
  • Prevent exacerbations
  • Maximize compliance to therapeutic regime
  • Recognize triggers
  • Exercise
  • allergens

Types of medications for asthma
  • Rescue short acting beta agonists (albuterol)
    main rescue classification
  • Controller medications mast-cell inhibitors
    (Intal), Luekotriene modifiers (Singulair),
    inhaled steroids (Advair, Flonase)
  • Preventer/controller drugs combination of
    controller meds plus some inhaled steroids (nasal)

Purpose of the MDI
  • Shake vigorously prior to use
  • Exhale slowly and completely
  • Place mouthpiece in mouth, closing lips around it
  • Press and release the med while inhaling deeply
    and slowly
  • Hold breath for 10 seconds and exhale
  • Repeat x1

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

Why dont we give bicarbonate for respiratory
  • Child not able to blow off CO2 and acidosis will
    get worse
  • Correct the cause of the acidosis
  • Patient 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 secretions
  • Mucous glands produce a thick protein that
    accumulates and dilates the glands
  • Passages in organs such as the PANCREAS become
  • First manifestation is meconium ileus in NB
  • Sweat 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
  • Clubbing of the fingers
  • Barrel chest
  • Increased respirations, cyanosis
  • Productive cough

Diagnostics for CF
  • Sweat test increased levels of chloride
  • Normal is lt40 in CF gt40-60 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 mucus
  • Nutritional inc. weight, enzymes with all food
    (Viokase or Ultrace) dosage is regulated by
    evaluation of the stool
  • Fat soluble vitamins ADKE
  • High calorie, high protein, low fat
  • Maintain Na balance (when sweating and ill)

Nursing Care of the CF patient
  • Assessing both GI and pulmonary status
  • Assisting with diagnostic testing
  • Collections of stool specimens for trypsin and
    lipase (fat analyses)
  • Administer oxygen with great caution because of
    the threat of oxygen narcosis
  • Implement 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?

Case 6 year old boy
  • Admitted to PICU from ED
  • Sudden onset of high fever, sore throat, and
  • Toxic appearing
  • VS HR 140, RR 30, O2 sat 96 Temp 101.4
  • Whats going on here?