VIEWS: 246 PAGES: 96 POSTED ON: 3/11/2010
Respiratory Disorders Jan Bazner-Chandler CPNP, CNS, MSN, RN Respiratory Bifurcation of trachea Change in chest wall shape Upper Airway Characteristics Narrow tracheo-bronchial lumen until age 5 Tonsils, adenoids, epiglottis proportionately larger in children Tracheo-bronchial cartilaginous rings collapse easily Lower Airway Characteristics Fewer alveoli in the neonate Poor quality of alveoli until age 8 Lack of surfactant that lines the alveoli in the premature infant Inhibits alveolar collapse at end of expiration Respiratory Characteristics Basal metabolic rate is greater thus greater oxygen consumption Immunoglobulin G (IgG) levels reach low point around 5 months of age Focused Physical Assessment Types of breathing: Less than 7 years abdominal breathing Greater than 7 years abdominal breathing can indicate problems Respiratory Rate Inspiratory phase slightly longer or equal to expiratory phase Prolonged expiratory phase = asthma Prolonged inspiratory phase = upper airway obstruction Croup Foreign body Color Observe color of face, trunk, and nail beds Cyanosis = inadequate oxygenation Clubbing of nails = chronic hypoxemia Respiratory Distress Grunting = impending respiratory failure Severe retractions Diminished or absent breath sounds Apnea or gasping respirations Poor systemic perfusion / mottling Tachycardia to bradycardia = late sign Decrease oxygen saturations Chest Muscle Retraction Chest Retractions Retractions suggest an obstruction to inspiration at any point in the respiratory tract. As intrapleural pressure becomes increasingly negative, the musculature “pulls back” in an effort to overcome the blockage. The degree and level of retraction depend on the extent and level of the obstruction. Diagnostic Tests Detects abnormalities of chest or lungs Chest x-ray Sweat chloride Test MRI Laryngoscope / bronchoscopy CT Scan White Patchy Infiltrates X-ray Hyperinflation of Lung Vh.org Pleural Effusion Pleural Effusion X-Ray vh.org Sweat Chloride Test •Analysis of sodium and chloride •Contents in sweat •Gold Standard for diagnosis •May do genetic screening earlier if positive family history Ball & Bindler Foreign Body Aspiration A foreign body in one or the other of the bronchi causes unilateral retractions. *usually the right due to broader bore and more vertical placement. Oxygen Therapy: Nursing Interventions Proper concentration Adequate humidity: make sure there is fluid in the bottle Make sure prongs are in nose and that the nares are patent – suction out nares to increase oxygen flow Monitor oxygen SATS: if alarm keeps on going off but the infant / child looks good, check the device Monitor activity level or infant / child Aerosol Therapy Respiratory Therapist will do the treatment Communicate with therapist – eliminated needless paging for treatments Treatment should be done before the infant eats When you make your morning rounds assess if there is any infant / child that needs an immediate treatment Home Teaching Inhaled Medications Correct dosage Prescribed time Proper use of inhaler No OTC drugs Encourage fluids When to call physician Aerosol Therapy Medication administered by oxygen or compressed air. Ball & Bindler Nebulizer - infant Outpatient Aerosol Treatment CPT CPT In the small child you can position on your lap Do first thing in the AM Do before meals or one hour after Do after the aerosol treatment since the treatment will help open the airways and loosen the mucous Suction the infant after treatment – teach parents to do bulb suction – RN, LVN or RT to deep suction prn Mechanical Ventilation Alterations in Respiratory Function Severe Respiratory Distress • Nasal flaring and grunting • Severe retractions • Diminished breath sounds • Hypotonia • Decreased oxygen saturations What to do if infant / child in respiratory distress! Stimulate the infant / child - remember crying or activity will help mobilize secretions and expand lungs Have the older child sit up take deep breaths and cough CPT to loosen secretions and suction! suction! suction! Give oxygen Assess if interventions work Call for help if you need it – pull the emergency cord – yell for help Allergic Rhinitis Symptoms Itching of nose, eyes, and throat Sneezing and stuffiness Watery nasal discharge / post nasal drip Watery eyes Swelling around the eyes Rhinitis Treatment Antihistamines Competitive inhibitors for histamine at the mast cell receptor sites Benadryl – OTC medication Prescription –Cromolyn or steroid nasal spray Environmental changes - avoidance of allergens Do not use combination OTC medications especially those that contain pseudoephedrine Sinusitis Sinuses not fully developed until age 12. Adam.com Sinuses are hollow cavities within the facial bones. Sinusitis Symptoms Fever Purulent rhinorrhea Pain in facial area Malodorous breath Chronic night-time cough Children more prone to sinusitis: children with asthma and cystic fibrosis. Treatment Normal saline nose drops Warm pack to face Acetaminophen for pain Increase po fluid intake Antibiotics Recent studies question their effectiveness Tonsillitis “Kissing tonsils” occur when the tonsils are so enlarged they touch each other. Tonsillitis Inflammation of the tonsils. Part of the immune system to trap and kill bacteria and viruses traveling through the body. Tonsillitis Child may refuse to drink Night snoring = enlarged tonsils or adenoids Size of tonsils are obstructing airway Treatment Antibiotics x ten days if positive for beta strep Acetaminophen for pain Cool fluids Saline gargles Antiseptic sprays Viral throat infections will not get better faster with antibiotics. Tonsillectomy Done if child’s respiratory status is compromised Post operative care: Side lying position Ice collar Watch for swallowing Cool fluids / soft diet Croup Laryngotracheobronchitis or Acute spasmotic croup Infants from 3 months to about 3 years Respiratory symptoms are caused by inflammation of the larynx and upper airway, with resultant narrowing of the airway. Symptoms Symptoms: Hoarseness Inspiratory stridor Barking cough Afebrile Often worsens at night Management Home care: Cool mist Fluids Hospital care: Racemic epinephrine inhalant Mist tent – not used much anymore Dexamethasone: IV over 1 to several minutes Pertussis or whooping cough Agent: Bordetella Pertussis Source: respiratory Transmission: droplet Incubation: 10 days Period of communicability: before onset of paroxysms to 4 weeks after onset Management Respiratory support as needed Suctioning Oxygen to keep oxygen saturation at > 98 % Nutritional support IV fluids Erythromycin, Zithromax or Biaxin for child and all exposed family members Isolation Precautions Transmission through direct contact with discharges from respiratory mucous of infected persons. Highly contagious with up to 90% of household contacts developing disease after contact. Respiratory and contact isolation for 3-4 days after the initiation of antibiotic therapy. Epiglottitis Bowden & Greenberg Tripod position Epiglottitis Symptoms Acute inflammation of supra-glottic structures. Medical Emergency Sudden onset High fever Dysphasia and drooling Epiglottis is cherry red and swollen Epiglottitis Has decreased dramatically since introduction of the Haemophilus influenzae type b or Hib vaccine in 1985. Incidence as of 2003: 32 cases in children under 5 years of age. Incidence in the adult population has increased from 0.8 to 3.1 per 100,000 adults Management Diagnosis made on presenting symptoms No tongue blade in mouth Emergency tracheostomy set No procedures until in the operating room Keep quiet Ceftriaxone – third-generation cephalosporin for 7 to 10 days. Apnea Apnea is cessation of respiration lasting longer than 20 seconds. Monitor in hospital for 48 hours for underlying problems. Discharge home with monitor Apnea Monitoring Foreign Body Severe inspiratory stridor Symptoms depend on location Unilateral chest movement Chest x-ray Bronchoscope to remove object Coin in Trachea Teaching No small hard candies, raisins, popcorn or nuts until age 3 or 4 years Cut food into small pieces No running, jumping, or talking with food in mouth Inspect toys for small parts Keep coins, earring, balloons out of reach Influenza Associated with community epidemic Febrile, URI, achy joints, Management: Acetaminophen for fever Fluids Keep away from others Watch for signs of pneumonia Bronchiolitis Acute obstruction and inflammation of the bronchioles. Most common causative agent: RSV Respiratory syncytial virus Bronchioles become narrowed or occluded as a result of inflammatory process, edema, mucus and cellular debris clog alveoli Symptoms Harsh dry cough Low grade fever Feeding difficulties Wheezing Respiratory distress with apnea Thick mucus Management Oxygen to maintain oxygen saturation >than 95% Pulse oximeter Normal saline nose drops before suctioning Deep suction especially before feeding CPT to mobilize secretions Inhalation therapy – not sure it is beneficial Mechanical ventilation as needed RSV Positive - Isolation RSV is spread from respiratory secretions through close contact with infected persons or contact with contaminated surfaces or objects. Patient should be on contact and respiratory isolation Can be placed with other RSV + patients Pneumonia An inflammatory condition of the lungs in which alveoli fill with fluid or blood resulting in poor oxygenation and air exchange. Typical X-ray Symptoms High fever Thick green, yellow, or blood tinged secretions Grunting respirations Rales, crackles, diminished breath sounds Cough and cyanosis Infiltrate seen on x-ray Management Assess for respiratory distress NPO (rr > 60 = high risk for aspiration) IV fluids Oxygen as need to keep oxygen saturation above 95% CPT Deep suctioning Acetaminophen for fever / antibiotics Pneumonia Isolation Respiratory isolation May be taken off isolation if RSV negative and on antibiotics for 24 hours. Cystic Fibrosis Inherited autosomal recessive disorder of the exocrine glands. Pathophysiology: Cystic Fibrosis A chronic, progressive, genetic illness involving the digestive system and lungs. Abnormality of the exocrine glands Sweat and mucous glands Mucus of CF is thick and viscous Causes scar tissue Leads to irreversible lung damage Exocrine Gland Dysfunction Mucous secretions are thick and tenacious • Dysfunction of mucous producing glands leads to multiple gastrointestinal absorption problems. • Blocked pancreatic ducts • No secretion of digestive enzymes Cystic Fibrosis Cystic Fibrosis Symptoms Meconium ileus at birth Failure to thrive Steatorrhea stools / constipation Voracious appetite with poor weight gain Recurrent respiratory infections Chronic cough Malabsorption of intestines Diagnosis Positive sweat test Genetic marker Life long management Enzyme replacement with eating Daily CPT postural drainage Inhaled bronchodilators Control of lung infections Nutritional supplements as needed Medications Enzymes to help digest food Antibiotics to control infection Bronchodilators to open airways Vitamin C to improve absorption of other meds Vitamins E, A, D, K / fat soluble vitamins Long Term Complications Nasal polyps Sinusitis Rectal polyps / prolapse Hyperglycemia / diabetes infertility * Life span approximately 30 years of age Asthma Asthma is a chronic, inflammatory lung disease involving recurrent breathing problems. Caused by complex, multicellular reaction in the airway characterized by: Airway inflammation Airway hyper-responsiveness to a variety of triggers * Asthma is the most common, chronic health problem among children. Symptoms Wheezing Cough Tightness of chest Prolonged expiratory phase Hypoxemia X-ray = hyper-expansion of lungs Medical Management High fowlers position / bed rest Pulse oximetry Nebulized albuterol CPT Methylprednisone / Solu-medrol IV IV fluids Oxygen to keep oxygen sats > 95% Home Management Peak flow spirometer Identify triggers Maximize lung function Optimal physical growth Optimal psycho-social state Maximum participation Peak Flow Monitoring Spirometry measures how much and how fast air is forcefully expelled from fully inflated lungs. Recommended standard of care for management of asthma. Home Medications Rescue drugs: short acting albuterol beta 2 agonist – used as a quick-relief agent for acute bronchospasm and for prevention of exercise induced bronchospasm. Anti-inflammatory or preventative: low-dose inhaled corticosteroid: inhaled or oral prednisone Allergy: Singulair Bronchodilators Bronchodilators rapidly relax the airway smooth muscle cells, thus reversing the bronchospasm until anti-inflammatory effect of steroids is attained. Aerosols Via mouth piece 3 years and older Via facial mask for less than 3 years Corticosteroids Steroids reduce the inflammatory component of bronchial obstruction, decrease mucus production and mediator release, as well as the late phase (cellular) inflammatory process. Methyl prednisone IV in severe cases May need histamine H2 receptor antagonists (cimetadine or ranitidine) if experiencing GI upset PO prednisone – always give with food to decrease GI upset Anti-inflammatories Oral prednisone (Pedia-pred, Prelone, Liquid pred) recommended for short course in moderate or severe exacerbation Inhaled: Pulmicort, AeroBid, Flovent Infant: mask should fit firmly: cataracts Older child: rinse and spit after treatment to prevent thrush Family Teaching: Teach how to use medication When to use and how often No OTC drugs Increase fluid intake Signs and symptoms of respiratory distress Normal Lungs http://galen.med.virginia.edu/~smb4v/tutorials/asthma/asthma1.html Asthma Attack Bronchopulmonary Dysplasia Pediatric Nursing January/February 1999 History It occurs in newborns who are born prematurely and or have a variety of pulmonary disorders and who require ventilatory support with high pressure and oxygen in the first 2 weeks of life. Pathophysiology Fibrosis of airways and marked hyperplasia of the bronchial epithelium Increased fluid in the lungs, as a result of disruption of the alveolar-capillary membrane Over distention due to damage to alveolar supporting structures resulting in air trapping Fibrosis, airway edema, and broncho-constriction BPD Symptoms Persistent respiratory distress Dependent on supplemental oxygen Failure to thrive Gastro-esophageal reflux Pulmonary hypertension Long Term Management Supplemental oxygen CPT Bronchodilators Diuretics (pulmonary hypertension) Anti-inflammatory medication Nutritional support: po formula + NG supplement Gastrostomy tube (GER) Bicarbonate in formula due to chronic state of acidosis Long-term Outcomes Oxygen dependent Visual problems Feeding difficulties Developmental delay Learning difficulties
"Respiratory - PowerPoint"