Pediatric Nursing: Respiratory Disorders

Pediatric Nursing: Respiratory Lecture notes


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 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


Sweat Chloride Test
•Analysis of sodium and chloride
•Contents in sweat
•Gold Standard for diagnosis
•May do genetic screening earlier
if positive family history

Foreign Body
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
Nebulizer - infant
Outpatient Aerosol Treatment
Mechanical Ventilation

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


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 Symptoms
Fever
Purulent rhinorrhea
Pain in facial area
Malodorous breath
Chronic night-time cough


Treatment
Normal saline nose drops
Warm pack to face
Acetaminophen for pain
Increase po fluid intake
Antibiotics
Recent studies question their effectiveness


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 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


Foreign Body
Severe inspiratory stridor
Symptoms depend on location
Unilateral chest movement
Chest x-ray
Bronchoscope to remove object

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