NURSING CARE OF THE CHILD WITH A RESPIRATORY ALTERATION CHAPTER 45

ASSESSING RESPIRATORY ILLNESS IN CHILDREN Physical assessment cough rate & depth of respirations retractions restlessness cyanosis clubbing of fingers adventitious sounds chest diameters

ASSESSING RESPIRATORY ILLNESS IN CHILDREN Laboratory tests blood gas studies pulse oximetry transcutaneous oxygen monitoring nasopharyngeal culture respiratory syncytial virus nasal washings sputum analysis

ASSESSING RESPIRATORY ILLNESS IN CHILDREN Diagnostic procedures chest x-ray bronchography pulmonary function studies

THERAPEUTIC TECHNIQUES USED IN THE TREATMENT OF RESPIRATORY ILLNESS IN CHILDREN Expectorant therapy oral fluid liquefying agents humidification coughing chest physiotherapy mucus-clearing device

Therapy to improve oxygenation THERAPEUTIC TECHNIQUES USED IN THE TREATMENT OF RESPIRATORY ILLNESS IN CHILDREN Therapy to improve oxygenation oxygen administration pharmacologic therapy incentive spirometry breathing techniques tracheostomy endotracheal intubation assisted ventilation

DISORDERS OF THE UPPER RESPIRATORY TRACT Acute nasopharyngitis ( common cold) Viral and DOES NOT need an antibiotic Fever and green mucus do not necessarily mean bacterial infection Treat the symptoms but suppressing a productive cough is not good Using a humidifier is good but a vaporizer can be dangerous Overuse of antibiotics is associated with resistance and now breast cancer

Allergic Rhinitis S/S Sneezing, nasal engorgement, watery nasal d/c Allergic salute leading to an allergic crease Allergic shiners Headaches Therapeutic management Avoidance of allergens Antihistamines, leukotriene inhibitors, intranasal corticosteroids immunotherapy

DISORDERS OF THE UPPER RESPIRATORY TRACT Pharyngitis viral pharyngitis Usually milder with “cold” symptoms Treat the symptoms streptococcal pharyngitis Assessed with a throat culture or a rapid strept May be accompanied by a sandpaper rash, petechiae, abdominal pain, vomiting Rarely accompanied by “cold” symptoms If untreated, may result in Rheumatic fever Treated or not, some children will develop acute glomerulonephritis See tonsillitis for treatment

DISORDERS OF THE UPPER RESPIRATORY TRACT Tonsillitis Infection and inflammation of the palatine tonsils S/S Sore throat Drooling Fever Management Most common cause is group A beta-hemolytic streptoccus, treated with Amoxil If strept negative, assumed to be viral and treated with comfort measures Tonsillectomy Less common today Usually done for three or more cases of Strept throat in six months, mouth breathing, sleep apnea Risk for hemorrhage is greater because site is cauterized and not sutured Observe closely for frequent swallowing, changes in BP Don’t allow red foods, drinks to be consumed Bleeding times should be assessed if there is a question before this surgery. Child should have head lower than chest (like pillow under chest when on abd) to prevent blood from draining back into pharynx

DISORDERS OF THE UPPER RESPIRATORY TRACT Epistaxis Usually comes from “picking” but may come from lack of humidity, resp. illness, or systemic illness Keep children in an upright position with head tilted forward applying pressure to the sides of the nose Croup (Laryngotracheobronchitis) Characterized by “barking” cough, stridor, and retractions Danger from laryngeal inflammation closing off airway Emergency measures include putting child in a hot, steamy bathroom or receiving racemic epi via nebulizer in the ER Worsening cough could mean that airway is closing off

DISORDERS OF THE UPPER RESPIRATORY TRACT Epiglottitis Airway emergency S/S Severe inspiratory stridor with a very sore throat High fever, hoarseness If this is suspected, never attempt to visualize epiglottis with a tongue blade or obtain a throat culture Management Possible tacheostomy, antibiotics

DISORDERS OF THE EAR Otitis Externa Impacted cerumen Swimmer’s ear Pain upon manipulation of the pinna Treatment…Floxin Otic Gtts Impacted cerumen Wax seldom needs removing, serves to cleanse the outer ear Using Qtips can push wax further into the canal Cerumex will remove hard wax if necessary

DISORDERS OF THE EAR Acute otitis media Common childhood disorder Occurs most often following a “cold” and in homes with smoking S/S Pulling on ears Fever On inspection, TM appears inflamed and light reflex is absent, fluid may be present causing bulging of TM (serous) Probably overtreated

DISORDERS OF THE EAR Otitis Media with Effusion Results from chronic Otitis Media s/s Pressure in the ear Muffled hearing On inspection Level of fluid behind TM distorted light reflex TM immobile Treatment Myringotomy tubes Tubes come out on their own within 6-12 months Water shouldn’t enter the ears while tubes are in place Will have hearing impairment with tubes

DISORDERS OF THE LOWER RESPIRATORY TRACT Bronchiolitis Most common causative agent, RSV Usually in children younger than 2 S/S Resp distress with exp wheezing Management Humidified oxygen, albuterol, steroids Possibly Ribavirin if RSV positive Parents may want a nebulizer during the first occurrence but they are usually saved for an asthma diagnosis due to cost

DISORDERS OF THE LOWER RESPIRATORY TRACT Asthma Hypersensitivity response connected to other atopic conditions (i.e. eczema and allergic rhinitis) Characterized by exp wheezing and coughing Treated according to how many times they must use their rescue inhaler (short acting beta2agonist) weekly and how often they are awakened at night with symptoms All but the mildest stage require an inhaled steroid to minimize chronic lung changes according to the NIH Remember, wheezing that is unilateral points toward foreign body aspiration. This is often diagnosed many times as bronchiolitis before it is deemed “asthma.” Asthma has negative connotations and is not used before a diagnosis is sure.

Pneumonia Many different types Clinical presentations Management Chlamydial…wheezes, hx of conjunctivitis in first 2 weeks of life Viral…rhinorrhea, low-grade fever, non-productive cough Bacterial…acute onset of fever, productive cough, pleural pain, toxic appearance, poor feeding, lethargy Mycoplasma (community acquired)…staccato cough Management Depends on type 3-11 weeks, suspect Chlamydia 3 months to five years, suspect RSV, Strept, HIB (if not vaccinated) Over 5 years, suspect mycoplasma, in all cases,will hear localized, diminished breath sounds and may have signs of resp distress.

Foreign Body Aspiration Children will put anything into their mouth! The usual-hot dogs, grapes The unusual-Barbie shoes, Christmas ornaments Suspect aspiration when… Choking, coughing, wheezing unilaterally occurs Treatment Bronchoscopy, laryngoscopy

Apnea Defined as the cessation of breathing for 20 seconds or longer When combined with color change or a change in muscle tone, is referred to as an apparent life-threatening event Infants are sent home with apnea monitors, parents trained in CPR, and resuscitation equipment.

Sudden Infant Death Syndrome Characterized by the sudden, unexplained death of an infant Etiology is unknown but several theories exist Most victims are boys, under 6 mos, lower socioeconomic status, and in winter months. At present, putting healthy infants to sleep on their back has reduced the SIDS rate in the US drastically.

DISORDERS OF THE LOWER RESPIRATORY TRACT Cystic fibrosis Autosomal recessive inheritance Disorder of the exocrine glands where secretions have difficulty flowing through gland ducts pancreas involvement Inability of child to digest fat, protein, and some sugars cause stools to be large, bulky, greasy, and foul (steatorrhea) Children appear malnourished because of poor absorption Suspect CF with an infant with a meconium plug

DISORDERS OF THE LOWER RESPIRATORY TRACT Cystic fibrosis lung involvement Thick secretions provide a medium for infection Symptoms of emphysema occur sweat gland involvement Skin has salty taste, test is called “sweat test” Management High calorie, high protein, moderate fat diet Synthetic pancreatic enzyme at meals Chest physiotherapy Increased AP diameter, clubbed fingers, atelectasis