Nursing Care of the Pediatric Individual with a Respiratory Disorder presented by Marlene Meador RN, MSN, CNE

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Nursing Care of the Pediatric Individual with a
Respiratory Disorderpresented by Marlene
Meador RN, MSN, CNE

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Differences in Adult and Child
Adult
Child
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The diameter of an infants airway is
approximately 4 mm, in contrast to an adults
airway diameter of 20 mm.
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What are the anatomic differences in the
eustachian tube of adults and small children?
(shorter, wider, more horizontal) Which
difference do you think could cause more problems
for the child and why?
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Otitis Media

• Inflammation of the middle ear
• sometimes accompanied by infection

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Common Causes

• Eustachian tube dysfunction
• Previous URI causes mucous membranes of the
  eustachian tube to become edematous and blocks
  tube.
• Enlarged adenoids
• Allergic rhinitis
• Exposure to cigarette smoke (airborne pollutants)
• Pacifier use may raise soft palate and alter
  dynamics in the eustachian tube

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Clinical Judgment Question

• Considering the contributing factors to this
  condition, what age group most commonly
  experiences acute otitis media?

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Acute Otitis Media characterized by abrupt
onset, pain, middle ear effusion, and
inflammation.
Note the injected vessels and altered shape of
cone of light.
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Serous Otitis Media
Note that the light reflex is not in the expected
position due to a change in tympanic membrane
shape from air bubbles.
Note effusion on otoscopy by fluid line and air
bubbles
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Clinical Manifestations
What objective sign is this child
displaying? What does it indicate?
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Evaluation and therapy

• Recent concerns of drug-resistant streptococcus
  pneumoniae have caused medical professionals to
  re-evaluate antibiotic therapy (APA, 2004)
• Many episodes of OM result from viral infections
• Waiting up to 72 hrs for spontaneous resolution
  is now recommended in healthy infants
• When antibiotics are warranted, oral amoxicillin
  in high dosage is the medication of choice.

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Nursing Interventions

• Nursing implications for antibiotic therapy
• Safety
• Teaching
• Comfort measures
• Teaching for home care
• When to notify primary care provider
• Follow up visit with primary care provider
• Preventive measures

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Myringotomy

• Purpose
• Drainage
• Air exchange by-passing Eustachian tube
• Prevent further scaring and hearing loss

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Nursing Care Management following placement of
Myringotomy

• Comfort measures
• Assessments immediately post operatively and
  ongoing
• Pre Post-op support for the family
• Discharge teaching
• Comfort measures
• When to notify primary care provider
• Preventative measures
• Hygiene
• Recreational

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Mastoiditis
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Mastoiditis

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

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Nursing care for the child with mastoiditis

• Assess vital signs (what additional VS do you
  need to assess?)
• Which lab values would indicate additional
  concerns?
• Medicate aggressively with antibiotics as
  ordered (usually IV if bacterial spread to
  mastoid) WHY?
• Antibiotics of choice ticarcillin disodium
  (Timentin) and gentamicin sulfate (Garamycin)
• Assess for complications (hearing loss, tinnitus)
• Comfort measures

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Nursing interventions related to administration
of antibiotics

• Contraindications
• Allergies/sensitivities- what medications have a
  co-morbidity? (aminoglycosides- mycin or micin
  suffix)
• Peak/ Trough- when to draw, how to interpret
• Assessment of adequate filtration from the body
  (what organs are most effected)
• Why is rate of administration vitally important?

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Upper Respiratory Tract Infections (URI)
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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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Nurse Alert!
Key to understanding prevention of URI
is meticulous handwashing and avoiding exposure
to infected persons
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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
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Clinical Manifestations

• 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
• Respirations stridor, snoring, nasal quality
  speech
• Pain in ear, recurring otitis media

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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
• Place on abdomen or side until fully awake
• Manage airway
• Monitor bleeding, esp. new bleeding
• Ice collar, pain meds
• Avoiding p.o. fluids until fully awake --then
  liquids and soft cold foods. Avoid citrus
  juices, milk
• Do not use straws or put tongue blade in mouth,
  no smoking

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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.
• Note the frequency of
• swallowing and notify
• the surgeon immediately

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Assessment of Respiratory Status
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Indications of Respiratory Distress

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

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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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Treatment and Nursing Care

• Admit to hospital for cardio-respiratory
  monitoring
• Teach parents home care instructions in the use
  of an apnea monitor
• Encourage parents to learn CPR.

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Cardiorespiratory Monitoring pulse oximeter
desired reading gt 95
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SIDS

• Defined sudden death of an infant during sleep
• 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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Croup
Epiglottitis
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Croup viral and bacterial syndromes

• Laryngotracheobronchitis
• Bacterial tracheitis
• Epiglottitis
• Initial symptom of all three is stridor, a seal-
  like barking cough and hoarseness

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Croup vs. Epiglotitis

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

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

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Medications

• Beta-agonist /Bronchodilator Albuterol
• Corticosteroids
• Which of these medications would the nurse give
  first? Rationale?

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Nursing Care

• Maintain patent airway
• Oxygen with humidification
• Keep resuscitation equipment at the bedside
• Assess VS (T102 or gt, and Rgt60)
• Nothing should be placed in the mouth
• Meet fluid and nutritional needs
• Cool, noncarbonated, non-acid drinks
• Assess for difficulty swallowing may need IV
  therapy

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Child with Epiglottitis
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Clinical Judgment

• 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 first in this situation?

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Bronchitis vs. Bronchiolitis
Bronchiolitis
Bronchitis
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Bronchitis

• Rarely occurs in childhood as isolated problem
• May occur with other respiratory illness
• Most often viral
• May result from a response to an allergen
• Symptoms include coarse, hacking cough (increases
  at night), fatigue, sore ribs, deep and rattling
  respirations, audible wheezing

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Bronchiolitis / Rhino Syncytial Virus (causes
50 of cases)

• Primarily affects infants 2-6 months of age
• Infection of bronchial mucosa leading to
  obstruction
• Begins as upper respiratory infection (URI) and
  progresses to Respiratory Distress.
• Diagnosed with a RSV wash

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Nursing Care for Child with RSV

• Medication therapy
• Bronchodilators
• Steroids
• Beta-antagonists
• Antiviral-Virozole (Ribavirin)
• Prevention Synagis (palivizumab) administered
  IM. and RespiGam (RSV immune globulin)
  administered IV.
• Droplet and contact isolation

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Nebulized epinephrine administered for
Bronchiolitis
Parents can hold nebulizer to decrease infants
fear
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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
  hyper-responsiveness to variety of stimuli
  (dander, dust, pollen, smoke)
• 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

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Asthma (RAD) continued

• Increased work of breathing
• Progressive decrease in tidal volume and
  expiratory volume
• Arterial pH abnormalities due to
• Increase in number of poorly ventilated alveoli
• Increase in hypoxemia
• Carbon dioxide retention
• Respiratory acidosis

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Asthma Triggers
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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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Medications to treat Asthma

• Reliever or Rescue Meds
• Short acting beta-agonists - Albuterol
• Corticosteroids- Prednisone, Beclomethasone for
  short term therapy
• Anticholinergic agents Atrovent
• Preventer / Controller Medications
• Mast-cell inhibitors (Cromolyn)
• Leukotriene modifiers (Singulair)
• Inhaled steroids ( Advair, Pulmocort, Azmacort)
  

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Child receiving nebulizer treatment
What is important patient teaching ?
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Treatment and Nursing Care
High Fowlers position
Humidified Oxygen via mask
Pulse Oximeter
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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 (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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Cystic Fibrosis
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Physical findings of the CF patient

• Clubbing of the fingers
• Increased respirations,
• cyanosis
• Productive, moist cough
• Barrel chest

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Assessment

• FTT despite high caloric intake.
• Frequent respiratory infections.
• Malabsorption of fats and proteins
• Mild diarrhea with malodorous stools,
  steatorrhea.
• Abnormally high levels of sodium chloride in
  sweat.

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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)
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• Pancreatic enzymes
• Collection of stool specimen to
• assess Trypsin and lipase. Trypsin
• absent in 80 of children with CF
•  

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CF Management

• Treatment
• Prevention and treatment of pulmonary infections
  with antibiotics
• Chest Physiotherapy at least twice a day to
  increase sputum expectoration
• Physical exercise important adjunct
• Management of dietary supplements (enzymes with
  meals and snacks)

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Chest Physiotherapycupping and clapping
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For questions regarding this presentation please
contact Marlene Meador RN, MSN,
CNEmmeador_at_austincc.edu