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					Nursing Care of the Pediatric
Individual with a Respiratory
           Disorder
Differences in Adult and Child
Adult
                          Child
Trachea Position
               In children, trachea
               is shorter and the
               angle of the right
               bronchus at the
               bifurcation is more
               acute than in the
               adult.
The diameter of an infant’s airway is approximately 4 mm, in contrast to an adult’s 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 infant’s airway diameter to 2 mm, but
  the adult’s airway diameter is only narrowed to 18 mm. Air must move more quickly in the infant’s
  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.
Understanding Otitis Media
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.
                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.
             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
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
              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
          Complications


Hearing Loss

  Delayed language development


     Behavior Problems
                     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
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
                  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.
                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
        When to Call the Doctor

   Call Healthcare Provider (HCP)if:
     – Decrease hearing
     – Increased ear drainage
     – Increased pain
     – Increased bleeding
     – Fever
         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.
                     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
Tonsillitis
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
             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
     Treatment and Nursing Care
   Saline gargles

    Analgesics

       Throat lozenges or hard candy

          Cool mist humidifier

             Hydration with cool liquids
    Nurse Alert!


 Key to understanding
  prevention of URI is
meticulous handwashing
 and avoiding exposure
   to infected persons
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
Nursing Care for the Tonsillectomy
   and Adenoidectomy Patient
             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.
Nurse Alert for Post-Op T/A surgery

       Most obvious sign of early bleeding
              is the child’s continuous
          swallowing of trickling blood.
           While the child is sleeping,
                note the frequency of
               swallowing and notify
             the surgeon immediately
            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.
Croup
            Croup vs. Epiglotitis

Croup                      Epiglotitis
 – Viral                      – Bacterial
 – Fever                      – High fever
 – Hoarseness                 – Rapidly progressive course
 – Resonant cough             – Dysphagia
 – Stridor (inspiratory)      – Drooling
 – Risk for significant       – Dysphonia
   narrowing airway with      – Distressed inspiratory
   inflammation                 efforts
 – Humidity for treatment     – Antibiotics needed
Child with Epiglottitis
                   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
                      Medications

   Beta-agonist – racemic epinephrine, Albuterol

   Corticosteroids

   Which of these medications would the nurse give
    first? Rationale?
            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.
         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?
  Bronchitis vs. Bronchiolitis
                 Bronchiolitis
Bronchitis
              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
      Clinical Manifestations

   Tachypnea
   Tachycardia
   Wheezing, crackles, or rhonchi
   Intercostal and subcostal retractions
   Cyanosis
   Difficulty feeding
Nursing Care for Child with RSV
     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.
Nebulized epinephrine administered for
             Bronchiolitis




  Parents can hold nebulizer to decrease infant’s fear
Indications of Respiratory Distress

     1.    Nasal Flaring
     2.    Circumoral cyanosis
     3.    Expiratory grunting
     4.    Retractions
          – Substernal, lower intercostal,
     5.    Tachypnea
          – Repirations greater than 60 bpm
                   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
                       Apnea

   Defined as: Delay of breathing over 20 seconds
   Additional Signs and Symptoms:
     – Cyanosis
     – Marked pallor
     – Hypotonia
     – Bradycardia
              Diagnosis

 Pneumocardiography


  – Tests for apnea

  – Records the heart rate and chest wall
    movements
      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.
Cardiorespiratory
   Monitoring

 pulse oximetry
Want reading > 95%
                         SIDS

   Sudden death of a previously healthy infant during
    sleep. Usually <1 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
     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
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
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
Asthma Triggers
      Medications to treat Asthma
   Reliever or Rescue Meds
     – Short acting beta-agonists
        • albuterol
        • terbutaline

    – Anticholinergic agents: Atrovent

    – Corticosteroids- prednisone (Prelone), for
      short term therapy
            Medication Therapy
   Preventer / Controller Medications
     – Mast-cell inhibitors (Cromolyn)

    – Inhaled steroids ( Advair, Pulmocort, Azmacort)
      (always rinse mouth following administration)

    – Leukotriene modifiers - (Singulair)
Children can receive nebulizer
treatment / Metered Dose Inhaler




   What is important patient teaching ?
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.
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
    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
           Treatment and Nursing Care


                                 High fowlers
                                   position



                                    Humidified
                                    Oxygen via
                                      mask

Pulse
Oxymetry
    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 hypoxic…immediate intervention
    needed
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 them

   Passages in organs such as the pancreas become
    obstructed

   First manifestation is meconium ileus in newborn
               Pathophysiology

   Respiratory System
     – Chronic changes, due to accumulation and
       retention of mucus in the airways, air trapping
     – Cycle of infection > increased mucus >
       inflammation > further obstruction
   Pancreas
     – Mucus inhibits the flow of trypsin, lipase, and
       amylase to the duodenum. Thus malabsorption of
       fats.
                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.
Cystic Fibrosis
           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.
           Continued Assessment

   FTH despite high caloric intake.

   Frequent respiratory infections.

   Malabsorption of fats and proteins
Diagnosis

• Sweat test:
   Chloride – Normal < 40 mEq/L.
   Highly suggestive of CF 40-60 mEq/L
   Diagnostic > 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
   Cystic Fibrosis Confirmation

 Diagnosis is confirmed with:
  – absence of pancreatic enzymes
  – increase in electrolyte concentration
    in sweat
  – pulmonary symptoms
     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
     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 child’s
         bowel elimination patterns.
Chest Physiotherapy
   cupping and clapping
The End

				
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posted:10/16/2011
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