Pediatric Nursing Module 2 Caring for Children with Alterations in Oxygenation Chapters 19, 20

Differences between Children and Adults  Chest/Respiratory System –Obligate nasal breathers >6wks –Short neck –Smaller, narrower airways  = more susceptible to airway obstruction and resp. distress –Tongue is larger in proportion to the mouth  = more likely to obstruct airway in unconscious child

Differences between Children and Adults  Chest/Respiratory System –Smaller lung capacity and underdeveloped intercostal muscles, poor chest musculature  = less pulmonary reserve, lung damage w/o fx –Children rely on diaphragm breathing  = high risk for resp. failure if the diaphragm unable to contract

Adjunct Assessments  Temperature –Febrile state increases oxygen consumption  Fluid Needs –Vomiting/diarrhea are commonly associated with respiratory illness –Increase respiratory efforts, increased fluid losses with decreased po intake requires an increase in fluid needs

Respiratory System  Inspection –Chest  Size, symmetry movement  Infancy shape is almost circular  < 6-7 years respiratory movement primarily abdominal or diaphragmatic –Respirations  Rate, rhythm, depth, quality, effort  >60 /min in small children = significant respiratory distress

Respiratory Assessment  Retractions –Substernal –Subcostal –Intercostal –Suprasternal –Supraclavicular  Effort –Grunting –Nasal flaring

Respiratory Assessment  Color –Mucous membranes –Nailbeds –Skin –Cyanosis

Respiratory Assessment  Auscultation –Listen comparing one areas to the other  Equality of breath sounds  Diminished  Poor air exchange –Abnormal breath sounds  Rales  Rhonchi  Wheezing  Grunting –Present on inspiration or expiration

Upper Respiratory Tract Infections Tonsillitis  Tonsils –Lymphoid tissues –Abundance in children especially tonsils  Tonsillectomy –Pre-op  Bleeding time  Loose teeth

Tonsillectomy  Post-op –T & A position  Semi prone with head turned to the side –Monitor for bleeding  Frequent swallowing  Persistent pulse of 120 or greater at rest  Restlessness  Pallor  Vomiting bright red blood  May bleed for 5-10 days post-op –Home care  Diet

Otitis Media  Generally bacterial –H. influenza –S. pneumoniae  Signs/Symptoms –Fever (maybe) –Pulling, tugging on ears –GI upset – vomit/diarrhea, poor appetite Acute infection of the middle ear

Otitis Media –Irritability –URTI  Treatment –Antibiotics Ampicillin, amoxicillin Nursing Concerns - compliance - chronic or recurrent otitis media - hearing loss can lead to speech impediments

Croup - Acute Laryngotracheal Bronchitis  Upper airway problem –Edema, swelling of the larynx –Viral 3 months to 3 years –Bacterial 3 to 7 years  Signs/Symptoms –Croupy cough –Inspiratory stridor –Hoarseness –Fever –Drool

Croup  Primary concern –Obstruction of the airway –Sedatives are contraindicated –Treatment – racemic epinephrine, cool mist

Infections of the Lower Airways Broncholitis / RSV -Respiratory Syncytial Virus  Common cause of bronchiolitis or the common cold in infants  Signs/Symptoms –Pharyngitis –Fever –Otitis media –Tachypnea –Apnea spells –Poor air exchange –Secretions

RSV  Treatment –Aerosol respiratory treatments –Supplemental 02 –Vaccine for high risk infants

Pneumonia  Classified according to etiology –viral, bacterial, fungal, aspiration  Signs and Symptoms –Respiratory  rhonchi, rales  dull to percussion  retractions, nasal flaring  cough

Pneumonia –Systemic  high fever –Neurological  irritable, restless, lethargic  pain –Gastrointestinal  a/v/d  abdominal pain

Chest X-ray Pneumonia

Long Term Respiratory Dysfunction Asthma  Chronic inflammatory disease of airways –airway inflammation –bronchospasm –obstruction  Triggers –environmental, chemical, tobacco, exercise, cold air, infection, medication, foods, emotions

Asthma  Signs and Symptoms –Respiratory  cough  auscultation - prolonged expiration, wheeze, diminished breath sound  shortness of breath –short panting phrases –Other  restlessness, apprehension, cyanosis, sweating

Cystic Fibrosis

 Hereditary disease of the exocrine glands thick, tenacious secretions of the mucous- producing glands especially of the bronchi and pancreatic ducts  Lungs –Chronic lung disease  Bronchial obstruction – pulmonary hypertension  Over inflation of the lungs  Repeated lung infections

Cystic Fibrosis  G.I System –Pancreatic ducts –Blockage of enzymes needed for digestion  Sweat glands –Secretions contain excessive amount of salt

Cystic Fibrosis  Signs/symptoms –Newborn meconium ileus –Tastes salty when kissed –Recurrent respiratory illnesses –Failure to gain weight with a good appetite –Malasbsorption of fats and proteins  Stools are foul smelling, frothy and bulky  Pot belly with wasted buttocks

Cystic Fibrosis  Diagnosis –Family history of CF –Repeated illnesses/hospitalization with respiratory problems or failure to thrive –Absence of pancreatic enzyme or stool studies –+ sweat chloride tests  Concentration of Cl > 60mEq/L

Cystic Fibrosis  Treatment –Nutritional  Pancreatic enzymes with meals and snacks  Vitamin replacement – A,D,E,K  High protein, high calorie diet –Pulmonary  Thin the secretions, keep them mobile –CPT –Aerosol Treatment  bronchodilators, D-nase

Cystic Fibrosis  02 when needed  Antibiotics for resp. infections  Pulmonary complications –Atelectasis –Lung abscesses –Pneumothorax –Emphysema  Prognosis –Life expectancy teen years to early 20s

Respiratory – Nursing Diagnosis  Impaired gas exchange  Ineffective airway clearance  Ineffective breathing pattern  High risk fluid volume deficit  Altered tissue perfusion  Anxiety  Activity Intolerance  Altered growth/development  Knowledge deficit

Respiratory – Nursing Diagnosis  PC: Atelectasis/Pneumonia  PC: Electrolyte Imbalance  PC: Hemorrhage  PC: Hypoxia

Nursing Interventions  Assess respiratory status –Tachypnea, labored breathing, shallow breathing –Effort  Retractions  Nasal flaring  Head bobbing –Grunting –Apnea –Poor air exchange –02 saturation

Nursing Interventions  Oxygenation/ventilation needs –Administer O2  Incubator/oxygen hood  Nasal prongs  Mist tent –Tracheotomy – croup  Decrease respiratory efforts  Infant car seat  Knee-chest position

Nursing Interventions  Maintain airway –Head tilt – do not hyper extend neck –Aerosol treatment –CPT –Suction bulb syringe, BBG or tracheal bronchial  Fluids –IV or po

Nursing Interventions  Labs  Medications  Conserve energy –Organize care  Monitor vital signs  Teaching