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Nursing Care of the Pediatric Individual with a Respiratory Disorder Differences in Adult and Child Adult Child The diameter of an infant’s airway is approximately 4 mm, in contrast to an adult’s airway diameter of 20 mm. Of the three anatomical differences in the eustachian tube between adults and small children (shorter, wider, more horizontal), which do you think could cause more problems for the child and why? Otitis Media Inflammation of the middle ear sometimes accompanied by infection Common Causes • Eustachian tube dysfunction – Previous URI causes mucous membranes of the eustachian tube to become edematous and blocks tube. – Enlarged adenoids – Allergic rhinitis • Pacifier use raises soft palate and alters dynamics in the eustachian tube Acute Otitis Media characterized by abrupt onset, pain, middle ear effusion, and inflammation. Note the injected vessels and altered shape of cone of light. Serous Otitis Media Note that the light reflex is not in the expected position due to a change in tympanic membrane shape from air bubbles. Note effusion on otoscopy by fluid line and air bubbles Clinical Manifestations What objective sign is this child displaying? What does it indicate? Evaluation and therapy • Treatment has always been directed toward antibiotic therapy; however, recently concerns about drugresistant streptococcus pneumoniae have caused medical professionals to re-evaluate therapy (APA, 2004) • No clear evidence that antibiotics improve OM • Waiting up to 72 hrs for spontaneous resolution is now recommended in healthy infants • When antibiotics are warranted, oral amoxicillin in high dosage is given Myringotomy • A myringotomy or pin hole is made in the ear drum to allow fluid removal. Air can now enter the middle ear through the ear drum, by-passing the Eustachian tube. The myringotomy tube prevents the pin hole from closing over. With the tubes in place, hearing should be normal and ear infections should be greatly reduced. Nursing Care Management for OM • Nursing objectives: – – – – – – Relieving pain Facilitating drainage when possible Preventing complications or recurrence Educating the family in care of the child Educate regarding prevention Providing emotional support to the child and family Mastoiditis Mastoiditis • Morbidity/mortality – Hearing loss – Extension of the infectious process beyond the mastoid system, resulting in intracranial complications • Ages affected – The incidence of mastoiditis parallels that of otitis media, affecting mostly young children and peaking in those aged 6-13 months. – May occur in healthy adults as well Nursing care for the child with mastoiditis • Monitor vital signs • Assess for changes in lab values • Medicate aggressively with abx as ordered (usually IV if bacterial spread to mastoid) • Drugs of choice: Timentin and Gentamicin • Assess for complications (hearing loss, tinnitus) Tonsillitis and Adenoiditis Upper Respiratory Tract Infections • Nasopharyngitis – Young child: fever, sneezing, vomiting or diarrhea – Older child: dryness and irritation of nose/throat, sneezing, aches, cough • Pharyngitis – Young child: fever, malaise, anorexia, headaches – Older child: fever, headache, dysphagia, abdominal pain • Tonsillitis – Masses of lymphoid tissue in pairs – Often occurs with pharyngitis – Characterized by fever, dysphagia, or respiratory problems forcing breathing to take place through nose Nurse Alert! Key to understanding prevention of URI is meticulous handwashing and avoiding exposure to infected persons Nurse Alert! The nurse should remind the child with a positive throat culture for strep to discard their toothbrush and replace it with a new one after they have been taking antibiotics for 24 hours Clinical Manifestations • Tonsillitis – – – – – – Fever Persistent or recurrent sore throat Anorexia General malaise Difficulty in swallowing, mouth breather, foul odor breath Enlarged tonsils, bright red, covered with exudate • Adenoiditis – Stertorous breathing - snoring, nasal quality speech – Pain in ear, recurring otitis media Nursing Care for the Tonsillectomy and Adenoidectomy Patient Post-operative Care • Providing comfort and minimizing activities or interventions that precipitate bleeding – Place on abdomen or side until fully awake – Manage airway – Monitor bleeding, esp. new bleeding – Ice collar, pain meds – Avoiding p.o. fluids until fully awake --then liquids and soft cold foods. Avoid citrus juices, milk – Do not use straws or put tongue blade in mouth, no smoking (in teenagers). Nurse Alert for Post-Op T/A surgery • Most obvious sign of early bleeding is the child’s continuous swallowing of trickling blood. • Note the frequency of swallowing and notify the surgeon immediately Assessment of Respiratory Status Indications of Respiratory Distress 1. 2. 3. 4. Nasal Flaring Circumoral cyanosis Expiratory grunting Retractions – Substernal, lower intercostal, 5. Tachypnea – Repirations greater than 60 Apnea • Defined as: Delay of breathing over 20 seconds • Additional Signs and Symptoms: – – – – Cyanosis Marked pallor Hypotonia Bradycardia Treatment and Nursing Care • Admit to hospital for cardiorespiratory monitoring • Teach parents home care instructions in the use of an apnea monitor • Encourage parents to learn CPR. Cardiorespiratory Monitoring pulse oximetry Want reading > 95% SIDS • Defined: sudden death of an infant during sleep • Risk Factors – – – – Prematurity, low birth weight Most common in infants 2-4 months old More prevalent in winter months Sleeping in bed with others, sleeping prone, use of pillows and quilts – Exposure to passive smoke SIDS – Nursing Interventions • Parent teaching: – – – – – place infant on back to sleep Place on firm mattress Do not use loose bedding, toys, pillows Avoid overheating with too many clothes Parents should stop smoking • Provide support of parents by helping them work through feelings of guilt and loss; refer to National Foundation for SIDS Croup Croup • Refers to a group of viral and bacterial syndromes • Laryngotracheobronchitis, Bacterial tracheitis and epiglottitis are the “big three” • Initial symptom of all three is stridor, a seallike barking cough and hoarseness Croup vs. Epiglotitis • Croup – – – – – – Viral/Bacterial Fever Hoarseness Resonant cough Stridor (inspiratory) Risk for significant narrowing airway with inflammation – Humidity for treatment • Epiglottitis – – – – – – – Bacterial High fever Rapidly progressive course Dysphagia Drooling Dysphonia Distressed inspiratory efforts – Antibiotics needed Medications • Beta-agonist /Bronchodilator– Albuterol • Corticosteroids • Which of these medications would the nurse give first? Rationale? Nursing Care • Maintain patent airway – – – – Oxygen with humidification Keep resuscitation equipment at the bedside Assess VS (T102 or >, and R>60) Nothing should be placed in the mouth • Meet fluid and nutritional needs – Cool, noncarbonated, non-acid drinks – Assess for difficulty swallowing – may need IV therapy Child with Epiglottitis Critical Thinking Exercise • Kim, a 4 year old, is admitted to the emergency department with a sore throat, pain on swallowing drooling, and a fever of 102.2°. She looks ill, agitated and prefers to sit up and lean over. • What nursing interventions should the nurse implement in this situation? Bronchitis vs. Bronchiolitis Bronchitis Bronchiolitis Bronchitis • • • • • Rarely occurs in childhood as isolated problem Can be present with other respiratory illness Most often viral Can be response to allergen Symptoms include coarse, hacking cough (increases at night), fatigue, sore ribs, respirations deep and rattling, audible wheezing Bronchiolitis / RSV • RSV is rhino syncytial virus • Affects 2-6 month olds primarily • Infection of bronchial mucosa leading to obstruction • Starts out with Upper Respiratory Infection and progresses to Respiratory Distress. • Diagnosed with a RSV wash Nursing Care for Child with RSV • Medication therapy – – – – Bronchodilators – Steroids Beta-antagonists Antiviral • Virozole (Ribavirin) – Prevention drug – Synagis (palivizumab) given IM. and RespiGam (RSV immune globulin) given IV. • Droplet and contact isolation Nebulized epinephrine administered for Bronchiolitis Parents can hold nebulizer to decrease infant’s fear Reactive Airway Disease (asthma) • Chronic inflammatory disorder affecting mast cells, eosinophils, and T lymphocytes • Inflammation causes increase in bronchial hyperresponsiveness to variety of stimuli (dander, dust, pollen,smoke) • Most common chronic disease of childhood; primary cause of school absences Asthma Etiology/Pathophysiology of Asthma • Obstructive airflow limitation due to: – Mucosal edema - membranes that line airways – Bronchospasm (bronchoconstriction) – Mucus plugging (thicker) causes: • Increased airway resistance • Decreased flow rates Etiology/Pathophysiology • Increased work of breathing • Progressive decrease in tidal volume and expiratory volume • Arterial pH abnormalities due to: – – – – Increase in number of poorly ventilated alveoli Increase in hypoxemia Carbon dioxide retention Respiratory acidosis Asthma Triggers Interpreting Peak Expiratory Flow Rates • Green: (80-100% of personal best) signals all clear and asthma is under reasonably good control • Yellow (50-79% of personal best) signals caution; asthma not well controlled; call dr. if child stays in this zone • Red (below 50% of personal best) signals a medical alert. Severe airway narrowing is occurring; short acting bronchodilator is indicated Medications to treat Asthma • Reliever or Rescue Meds – Short acting beta-agonists - Albuterol – Corticosteroids- Prednisone, Beclomethasone for short term therapy – Anticholinergic agents: Atrovent • Preventer / Controller Medications • Mast-cell inhibitors (Cromolyn) • Leukotriene modifiers – (Singulair) • Inhaled steroids ( Advair, Pulmocort, Azmacort) Child receiving nebulizer treatment What is important patient teaching ? Treatment and Nursing Care High fowlers position Humidified Oxygen via mask Pulse Oximetry Emergency situations of asthma • Acute episode of reactive disease: bronchioles may close rapidly, causing severe airway obstruction, anxiety, restlessness, and fear. Will need to be seen in ER if not relieved by med • Status asthmaticus: medical emergency with severe edema, profuse sweating, respiratory failure and death if untreated. Becomes seriously hypoxic…immediate intervention needed Cystic Fibrosis Cystic Fibrosis (CF) • Factor responsible for manifestations of the disease is mechanical obstruction caused by increased viscosity of mucous gland secretions • Mucous glands produce a thick protein that accumulates and dilates them • Passages in organs such as the pancreas become obstructed • First manifestation is meconium ileus in newborn Cystic Fibrosis Physical findings of the CF patient • Clubbing of the fingers • Increased respirations, cyanosis • Productive, moist cough • Barrel chest Assessment • • • • FTT despite high caloric intake. Frequent respiratory infections. Malabsorption of fats and proteins Mild diarrhea with malodorous stools, steatorrhea. • Abnormally high levels of sodium chloride in sweat. Diagnosis • Sweat test: Chloride – Normal < 40 mEq/L. Highly suggestive of CF 40-60 mEq/L Diagnostic > 60 mEq/L. (see bags over hands and arms) • Pancreatic enzymes: Collection of stool specimen to assess Trypsin and lipase. Trypsin absent in 80% of children with CF CF Management • Treatment – Prevention and treatment of pulmonary infections with antibiotics – Chest Physiotherapy at least twice a day to increase sputum expectoration – Physical exercise important adjunct – Management of dietary supplements (enzymes with meals and snacks) Chest Physiotherapy cupping and clapping The End