1. NURSING CARE OF THE CHILD WITH A RESPIRATORY ALTERATION CHAPTER 45

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

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

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

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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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.

18. 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.

19. 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

20. 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.

21. 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.

22. 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

23. 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