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Care of the Pediatric Patient with Respiratory Problems Elizabeth Allen RN, MSN Learning Objectives Describe Unique Characteristics of Pediatric Respiratory System List Respiratory Conditions and Injuries that Cause Respiratory Distress in Children Distinguish between Mild, Moderate, and Severe Respiratory Distress Differentiate between Signs and Symptoms of Upper and Lower Airway Conditions Differences in A&P Newborn- 3 months obligatory nose breathers Child’s airway is shorter and more narrow<6 years breathe with diaphragm- intercostal muscles immature A newborn’s chest is circular until age 6. Decreased muscularity is responsible for the thin chest wall in infants. Differences in A&P Child epiglottis longer, floppier Higher oxygen demand in children Immature Infant Respiratory and Neurologic System Offers Less-Efficient Response to Hypoxia and Elevated PCO2 Pediatric Respiratory Assessment Noises Work of Breathing Stridor Wheeze Cough Grunting Cry Rate Head bobbing Retractions Nasal flaring Pulse Oximetry Auscultate Diagnostic Tests Pulmonary Radiology Function Chest Neck Arterial Blood Gases Capillary Blood Gases Pulse oximetry Respiratory Distress Can Lead to Respiratory Failure Early recognition and intervention vital Mild Tachypnea, tachycardia, diaphoresis, mild retractions Moderate Flaring, moderate retractions, grunting, wheezing Anxiety, irritability, confusion, mood changes Severe Dyspnea, severe retractions Bradycardia, bradypnea Stupor, coma Cyanosis = late sign How Long can the child maintain that level of effort? Respiratory Distress Interventions Assessment Oxygen Airway positioning Tripod Position Medications Racemic Epinephrine Beta 2 Agonists/ Bronchodilators Corticosteroids Antibiotics Apparent Life Threatening Event (ALTE) 1 week to 2 months Identifying diseases and conditions GERD, acute respiratory infections, seizures, Congenital heart defects, metabolic conditions, child abuse (Munchausen by proxy) Lab work Diagnostic testing Monitoring Home Education Sudden Infant Death Syndrome (SIDS) Etiology / Pathophysiology Genetic Clinical Manifestation Cardiopulmonary arrest Season Collaborative Care Back to Sleep Nursing Management Safe Sleep Environment Supportive Care Safe Sleep Environment Respiratory Infection Transmission Airborne Isolation Small particles negative pressure room Droplet Large Isolation particles- drop 3 feet Contact Isolation Upper Airway Problems Strep Throat/ Viral tonsillitis Tonsillitis Supportive care Strep Throat- Streptococcus infection Fevers, gastritis Positive rapid strep test or positive culture Treat with antibiotics No longer contagious 24 hrs. after first antibiotic dose Upper Airway Problems Tonsillectomy and possible Adenoidectomy Post Op Care Pain management Maintain hydration Evaluate for bleeding, swelling or airway compromise Upper Airway Problems Croup Upper airway illness causing inflammation in larynx and epiglottis Viral or bacterial Symptoms: “Barking” cough Stridor Hoarseness Laryngealtracheobronchitis Viral Treatment Keep child calm!!! Cold, humid night air Corticosteroids Racemic epinephrine Albuterol as needed Upper Airway Treatment Cool Mist Tent Upper Airway Problems Epiglottitis Inflammation of the epiglottis – life threatening Symptoms: 3 D’s Bacterial • Dysphagia • Drooling • Dysphonia Hx: Acute fever, sore throat, dysphonia and dysphagia Diagnostic testing Streptococcus Staphylococcus Haemophilus influenzae type B X-ray? Treatment/Interventions Antibiotics Cephalosporin Airway management Evaluation Upper Airway Problems Foreign Body Aspiration Developmental- older infants and Toddlers Usually bronchial obstruction, R bronchial Signs Cough, weak cough Stridor Respiratory Distress Muffled or hoarse voice Drooling Anxiety, irritability Unilateral diminished breath sounds Aspiration Treatment Keep child calm Position of comfort Monitor cardiorespiratory status Airway intervention if necessary CXR Endoscopy OR Upper Airway Problems Otitis Media Inflammation of middle ear 84% infants have at least 1 case before age 3 years More common in: Kids with allergies Families who smoke Pacifiers American Indian Symptoms Ear pain/ pulling at ear Fever Vomiting/diarrhea Irritability Treatment Guidelines AAP Avoid over treatment with antibiotics Educate families to complete courseavoid drug resistance Figure 19–9 This young child is pulling at the ear and acting fussy, two important signs of otitis media. Ask the parents about the presence of fever and night awakenings, additional signs that are often observed in children with this condition. Upper Airway Problems Otitis Media Repeated Otitis Media Hearing Loss Speech delay Tympanostomy Tubes Fall out on own Drainage Lower Airway Problems Bronchitis/ Bronchiolitis Viral or bacterial Underlying chronic illness Bronchiolitis (bronchioles) RSV, parainfluenza, adenovirus Edema, debris clog and narrow airway Clinical Therapy Maintain Respiratory Function Close monitoring Keep airways clear! Oxygen Humidity Hydration Nutrition Rest Anxiety Discharge Planning Lower Airway Problems Nursing Diagnoses for bronchiolitis? What’s your priority? Breathing pattern, ineffective Ineffective airway clearance Fluid volume deficit, risk for Anxiety Lower Airway Problems Asthma Etiology/Pathophysiology Clinical Therapy Assessment Peak Expiratory Flow Rate Respiratory Distress Triggers Interventions Medications Maintain Airway Patency Meet Fluid Needs Pediatric Considerations Discharge Planning Evaluation Resource http://www.nhlbi.nih.gov/fil es/docs/public/lung/asthm a_actplan.pdf Lower Airway Problems Asthma Exacerbation: Across the Room Assessment LOC Asthma Exacerbation Video- follow link Respiratory rate https://www.youtube.com/watch?v=EK8nzKzdnIM Retractions Audible wheezing Head bobbing Grunting Speaking Then listen for wheezing, diminished breath sounds Lower Airway Problems Know your Peak Flow Green zone: 80%- 100% Yellow zone: 50%80% Red zone: below 50% Lower Airway Problems Asthma Severity Scale Medications http://www.nhlbi.nih.gov/files/docs/guidelines/asthma_ qrg.pdf Intermittent asthma to Persistent Asthma requiring daily medications Short acting Beta2 agonist Inhaled corticosteroid Montelukast Evaluate control with medications PFT Symptom tracking Lower Airway Problems (London et. al., 2014) Lower Airway Problems (London et. al., 2014) Lower Airway Problems (London et. al., 2014) Lower Airway Problems (London et. al., 2014) Lower Airway Problems Cystic Fibrosis Autosomal recessive disorder Incidence Pathophysiology Defective chloride secretion and increased sodium absorption. Rate of progression varies among children Clinical manifestations Diagnostic Procedures- Sweat Chloride Test Resource http://www.cff.org/ Defective chloride-ion transport and decreased water flow across cell membranes – excessive electrolyte loss. Lower Airway Problems Cystic Assessment Chest Physiotherapy Prophylactic antibiotics? Nutrition Physiologic Psychosocial Developmental Respiratory Therapy (including) Fibrosis Pancreatic Enzymes Discharge Planning Lower Airway Problems Cystic Fibrosis Clinical Therapy Maintain respiratory function Manage infection Optimize nutrition Prevent gastrointestinal blocking Nursing Diagnoses Medications Pancreatic enzymes Antibiotics- oral and inhaled Osmotic medicationpolyethylene glycol High calorie formula, MCT H2 blocker, PPI Tracheostomy Tracheostomy Care Suctioning Routine Care Emergency care Tracheostomy
