Patient Review: Kids in the ED
Angela resists as you attempt to apply a finger probe to obtain an SpO2 reading. Her color becomes dusky, and her breathing sounds brassy and seems more labored. On admission to the Emergency Department (ED), Angela's SpO2 was 95%. What should you do? - Call for a physician - Secure the pulse oximetry probe in place with a restraint device - Apply oxygen - Call a code
-Call for a physician -Apply oxygen Earlier in the evening, Angela's SpO2 was 95% (normal). Currently, her clinical presentation (dusky skin color, more labored breathing, brassy stridor) indicates poor oxygenation and a need for oxygen. Oxygen should be applied promptly. A physician's order for oxygen should be obtained. Angela's condition may be deteriorating, but she is still breathing without assistance and has a rapid pulse. A code (emergency resuscitation) is not indicated at this time.
Abby must be critically observed for signs of respiratory decompensation and impending respiratory failure. Which of the following changes in Abby's condition, if noted, might indicate impending respiratory failure? - Change in apical pulse rate from 170 to 80 beats per minute - Change in apical pulse rate from 170 to 190 beats per minute - Change in respiratory rate from 50 to 20 breaths per minute - Change in respiratory rate from 50 to 60 breaths per minute
-Change in apical pulse rate from 170 to 80 beats per minute When gas exchange is impaired and tissues are deprived of oxygen, heart rate increases to bring blood and oxygen to tissues at a faster rate. Abby's heart rate of 170 beats per minute reflects compensation (a normal heart rate for a resting infant, 3-months to 2 years, is 80-150 beats per minute. If gas exchange and tissue oxygenation improve, compensatory tachycardia gradually decrease to a normal heart rate. If gas exchange and tissue oxygenation do not improve, and compensation efforts fail, heart rate decreases dramatically to below normal range. For Abby, a decrease in heart rate from 170 beats per minute to 80 beats per minute would be significant and cause for concern and immediate intervention. -Change in respiratory rate from 50 to 20 breaths per minute Abby is tachypneic with a respiratory rate of 50 breaths per minute. A normal respiratory rate for a resting infant of three months is 30 breaths per minute. Infants and children with respiratory problems compensate by increasing respiratory rate when tissues are deprived of oxygen. However, if gas exchange and hypoxia do not improve, fatigue can set in and breathing effort can diminish, leading to respiratory failure and arrest. Slowing of respirations is generally an ominous sign. For Abby, a change in respiratory rate from 50 to 20 breaths per minute would be cause for concern and immediate intervention. When gas exchange is impaired and tissues are deprived of oxygen, heart rate increases to bring blood and oxygen to tissues at a faster rate. An increase in heart rate from 170 beats per minute to 190 beats per minute would probably be a sign of increasing compensation, not decompensation. A normal heart rate for a resting infant, 3-months to 2 years, is 80-150 beats per minute. However, infants and children with persistent high heart rates should be closely monitored. Prolonged compensation efforts can eventually fail. Abby is tachypneic with a respiratory rate of 50 breaths per minute. A normal respiratory rate for a resting infant of three months is 30 breaths per minute. Infants and children with respiratory problems compensate when gas exchange is impaired and tissues are deprived of oxygen by increasing respiratory rate. For Abby, an increase in respiratory rate from 50 to 60 breaths per minute would probably reflect increased compensatory effort and would not be unexpected. However, prolonged compensation efforts can eventually fail. An infant or child with persistent tachypnea should be closely monitored.
It is important that child caregivers know how to respond when a child has an obstructed airway from foreign body aspiration. Which of the following interventions would be appropriate if a young child choked on a coin and was wheezing, but was able to breathe and talk? - Continue to observe breathing - Deliver sharp back blows between the child's shoulder blades in an attempt to dislodge the coin - Perform the Heimlich maneuver in an attempt to dislodge the coin - Comfort the child and keep him as quiet as possible in a position of comfort
-Continue to observe breathing In the event of foreign body aspiration, emergency services should be called, and respiratory status should be closely observed. Complete airway obstruction could happen quickly. Interventions for foreign body aspiration differ depending on whether or not the child is breathing or not breathing, and able to talk. -Comfort the child and keep him as quiet as possible in a position of comfort In the event of foreign body aspiration, emergency services should be called, and the child should be kept calm in a position of comfort. As long as the child is breathing and talking, no effort should be made to dislodge the foreign body.
Which isolation precautions should be observed when working with Angela? - Airborne Precautions - Droplet Precautions - Standard Precautions --Contact Precautions
-Droplet precautions Most cases of epiglottitis are caused by the bacterium Haemophilus influenzae type b (Hib). When epiglottitis is present, Haemophilus influenzae type b (Hib) can be transmitted in large particle droplets of nasopharyngeal/respiratory tract secretions that can be propelled a short distance (less than three feet). According to Centers for Disease Control (CDC) guidelines, Droplet Precautions are indicated for presumed or confirmed epiglottitis due to Haemophilus influenzae type b (Hib). Droplet Precautions reduce the risk of airborne transmission during coughing, sneezing, talking, and respiratory tract procedures. Droplet Precautions require that Angela be in a private room, a mask be worn by healthcare professionals when working within three feet of Angela, and a mask be worn by Angela when she is out of her room. -Standard precautions According to Centers for Disease Control (CDC) guidelines, Standard Precautions apply to the care of all patients in all healthcare settings. Standard Precautions are designed to reduce the risk of transmission of pathogens from known and unknown sources.
As you approach Angela's treatment area, you recall what you know about epiglottitis. You know that: - epiglottitis is usually caused by a virus - epiglottitis is usually caused by a bacterium - epiglottitis usually occurs in young children - epiglottitis is serious and communicable - the incidence of epiglottitis has increased in recent years
-Epiglottitis is usually caused by a bacterium Epiglottitis (supraglottitis) is an infectious process that causes acute inflammation of the epiglottis and surrounding tissues, which become cherry red and edematous. Epiglottitis is almost always caused by the bacterium Haemophilus influenzae type b. -Epiglottitis usually occurs in young children Epiglottitis occurs most commonly in toddlers and young children under five years of age. -Epiglottitis is serious and communicable Epiglottitis is serious, and communicable. Isolation precautions are indicated for children with suspected or diagnosed epiglottitis.
Standard precautions and Contact precautions apply for Abby's care. To correctly implement these precautions, which of the following will be indicated during Abby's hospitalization? - Handwashing - Placement of Abby in a private room - Use of clean gloves by caregivers when providing direct care to Abby - Use of a gown by caregivers when providing direct care to Abby - Use of an isolation mask by caregivers when providing direct care to Abby
-Handwashing -Placement of Abby in a private room -Use of clean gloves by caregivers when providing direct care to Abby -Use of a gown by caregivers when providing direct care to Abby
Based on data presented, nursing diagnoses appropriate for Abby include: - Ineffective Airway Clearance related to increased respiratory secretions - Risk for Deficient Fluid Volume related to decreased fluid intake and insensible water loss - Interrupted Family Processes related to having a child with chronic illness - Interrupted Family Processes related to hospitalization - Activity Intolerance related to increased work of breathing and decreased tissue oxygenation
-Ineffective Airway Clearance related to increased respiratory secretions Ineffective Airway Clearance related to increased secretions is an appropriate nursing diagnosis for Abby at this time. Bronchiolitis is characterized by inflamed, edematous, fluid-filled bronchioles. Clearing the airway becomes difficult because of excess mucous. Abby has audible wheezing and nasal mucous, and frequently coughs. Nursing interventions, such as positioning and suctioning, may be needed to assist with the process of airway clearance. -Risk for Deficient Fluid Volume related to decreased fluid intake and insensible water loss The nursing diagnosis Risk for Deficient Fluid Volume related to decreased fluid intake and insensible water loss applies at the time. Infants and small children with bronchiolitis are often unable to maintain adequate fluid intake, and subsequently may become fluid deprived and dehydrated. Abby's mother has indicated that Abby is not nursing well. Also, fever increases metabolic rate and fluid needs, and rapid respirations increase insensible water loss. Abby has a fever and a rapid respiratory rate. Abby has clinical signs (dry, cracked lips) that indicate she could be fluid volume deficient and dehydrated already, but other data would be needed to confirm this. Abby's skin turgor and capillary refill should be checked. Abby's mother should be asked about Abby's wetting. A well-hydrated infant has 6-8 wet diapers a day. A poorly-hydrated infant has fewer wet diapers. -Interrupted Family Processes related to hospitalization Abby is being admitted to the hospital for supportive care, and this is a significant stressor for her family. Hospital environments can be overwhelming, and normal family routines are disrupted. Abby's parents and family members will need support and reassurance throughout her hospital stay. The nursing diagnosis Interrupted Family Processes related to hospitalization is appropriate for Abby. -Activity Intolerance related to increased work of breathing and decreased tissue oxygenation The nursing diagnosis Activity Intolerance related to increased work of breathing and decreased tissue oxygenation applies for Abby. Nursing interventions will insure that Abby has an appropriate balance of rest and activity, and that she does not expend too much energy while her condition is compromised.
Clinical manifestations of bronchiolitis can include: - vomiting - tachypnea - tachycardia - adventitious breath sounds - retractions - diarrhea - apneic episodes
-Tachypnea Tachypnea is commonly seen in children with severe bronchiolitis. Tachypnea occurs as a compensatory mechanism to bring in more oxygen when tissue oxygenation is impaired. Abby is tachypneic, with a respiratory rate of 50 breaths per minute. A normal respiratory rate for an infant 1-11 months old is 30 breaths per minute. -Tachycardia Tachycardia may occur in children with severe bronchiolitis. Tachycardia is a compensatory mechanism that occurs when tissue oxygenation is impaired. Tachycardia is an effort to circulate more blood and oxygen. Abby's apical heart rate is 170 beats per minute, resting awake in her mother's arms. A normal heart rate for an awake resting infant 3 months to 2 years of age is 80-150 beats per minute, therefore Abby has tachycardia. -Adventitious breath sounds Abnormal lung sounds are often present in infants and children with bronchiolitis, because of excess mucous. Wheezing, crackles, pops, and squeaks are not uncommon sounds to hear when auscultating the lungs of an infant or child with bronchiolitis. Excess mucous may precipitate coughing. Abby's breath sounds are diminished, and crackles are noted. She frequently coughs. -Retractions Because of decreased lung compliance and increased work of breathing, retractions may be noted in infants and children with bronchiolitis. Nasal flaring also occurs. Abby does not have retractions or nasal flaring. -Apneic episodes Episodes of apnea may occur in children with severe bronchiolitis. Parents may not realize how sick a child is until they witness an apneic event. Abby's mother reports that she has not seen any episodes of apnea. Vomiting is not considered a clinical manifestation of bronchiolitis. However, post-tussive emesis (vomiting induced by coughing) may occur when bronchiolitis is severe. Diarrhea is not a clinical manifestation of bronchiolitis.
You recall what you know about bronchiolitis. You know that bronchiolitis: - usually occurs in infants and young children - involves inflammation of the upper airways - is often caused by a virus - is characterized by inspiratory stridor
-Usually occurs in infants and young children Bronchiolitis is most common in infants and toddlers under two years of age. Premature infants, and those with chronic lung disease, cardiac disease, or other congenital disorders, are at increased risk. Infants with severe bronchiolitis need to be hospitalized. -Is often caused by a virus Bronchiolitis is an acute viral infection, frequently caused by respiratory syncytial virus (RSV). Hospitalizations for bronchiolitis due to RSV infection peak from mid-winter to early spring. RSV is a frequent cause of other illness in children, including colds, otitis media, and pneumonias. Most lower respiratory tract infections in children are a result of RSV.
Signs and symptoms that are common in croup conditions include which of the following? - Gurgling breath sounds - Expiratory stridor - Wheezing - Hoarseness - Harsh cough - Dyspnea
-Wheezing In croup, upper airway structures and mucosa are inflamed and edematous, resulting in narrowed air passages. Narrowed air passages results in wheezing as air is inhaled through narrowed passages. -Hoarseness -Harsh cough The classic symptom of croup is a harsh cough, frequently described as "seal-like," "barking," "brassy," or "metallic." -Dyspnea Varying degrees of respiratory distress may be present with croup, depending on the amount of airway narrowing. Because of increased airway resistance, there is increased respiratory effort. Accessory muscles may be used to aid respiratory effort, and retractions may be present. Children with respiratory distress are usually anxious, frightened, and sometimes agitated. Gurgling sounds typically arise from lower airway structures, such as the lungs. Gurgling sounds do not characterize croup conditions. Narrowed air passages result in inspiratory stridor (harsh, rough sound) as air is inhaled through narrowed passages.
You know that Angela will be started on antibiotics. After ____ on antibiotics, epiglottitis due to Haemophilus influenzae b (Hib) will no longer be communicable. - 12 hours - 24 hours - 36 hours - 48 hours
24 hours After 24 hours on antibiotics, epiglottitis due to Haemophilus influenzae type b (Hib) will no longer be communicable.
In preparation for insertion of an IV catheter, EMLA anesthetic cream (lidocaine 2.5% and prilocaine 2.5%) was applied to Abby's skin earlier, at the intended catheter insertion site. The area is covered with Tegaderm. The anesthetic effect of EMLA takes effect, and the IV catheter can be inserted: - 5 minutes after EMLA application - 15 minutes after EMLA application - 30 minutes after EMLA application - 60 minutes after EMLA application
60 minutes after EMLA application To be effective for pain control, EMLA anesthetic cream (lidocaine 2.5% and prilocaine 2.5%) requires approximately one hour of contact with the skin. Optimal anesthetic effect occurs at 2-3 hours. Use of EMLA should reduce or eliminate the pain associated with IV catheter insertion. This should avoid agitation and crying that could potentially exacerbate Abby's already compromised respiratory status.
Which patient should you assess first? - Abby, the three-month-old infant with bronchiolitis - Angela, the three-year-old child with possible epiglottitis
Angela, the three-year-old child with possible epiglottitis It would be prudent to first check on Angela, the child who may have epiglottitis. Angela just arrived in the Emergency Department (ED), assessment data is limited, and her condition may not be stable. With epiglottitis, the epiglottis and surrounding tissues are very edematous. The disease process can cause a well child to rapidly deteriorate to complete airway obstruction. Continuous monitoring is indicated to detect life-threatening airway obstruction and insure prompt intervention. Infants with bronchiolitis can be very sick and require supportive care. Generally, however, they are not at immediate risk for life-threatening airway obstruction that requires more frequent monitoring and possibly aggressive treatment.
After quietly introducing yourself, which subsequent actions on your part are indicated? - Take Angela from her mother, place her in a sitting position on a chair, and take her vital signs - Ask Angela's mother to support Angela in her preferred position, and take her vital signs
Ask Angela's mother to support Angela in her preferred position, and take her vital signs It would be best to have Angela's mother continue to hold her, in her preferred position. The security offered by her mother's arms should be calming for Angela, and minimize anxiety and respiratory effort. Children with breathing difficulty generally attempt to assume a position of comfort that is referred to as the tripod position. In this sitting position, the child leans forward on both arms, with her mouth open and chin protruded. This position allows for easier breathing, is most comfortable for the child, and should be allowed.
With some difficulty, you are able to determine Angela's respiratory and pulse rates. By which route should Angela's temperature be taken? - Rectal route - Oral route - Axillary route
Axillary route The axillary route is the best route for taking Angela's temperature, because it is the least likely to make her anxious. Having her temperature taken rectally would probably make Angela anxious and increase her work of breathing. The oral route must be avoided, since anything placed in the mouth of a child with epiglottitis could precipitate sudden airway obstruction. The tympanic route (ear canal) could also be used with Angela.
How should oxygen be delivered to Angela? - Face mask - Nasal cannula - Bag-valve-mask (ambu bag) assisted - Blow-by
Blow-by Blow-by oxygen is the best method for delivering oxygen to Angela at this time. This method is the least intrusive and the least likely to agitate Angela any further. Blow-by oxygen can be delivered by having Angela's mother hold blow-by tubing close to Angela's face. At least some oxygen will be inhaled. A crib tent or nasal cannula can be used for delivering oxygen to cooperative older infants and small children. An oxygen head hood is the preferred method for delivering oxygen to small, relatively immobile infants. Infants and children do not like having masks placed over their faces.
You know that the Mantoux/PPD test is used to determine if a person: - is infected with the tuberculosis bacillus - has active tuberculosis disease
Is infected with the tuberculosis bacillus The results of a Mantoux/PPD test are reported as positive or negative. A positive reaction indicates that the individual has been infected with and developed a sensitivity to the protein of the tuberculosis bacillus. When the results are positive, a chest x-ray is done to determine if active tuberculosis disease is present.
Most cases of epiglottitis are caused by the bacterium Heamophilus influenae tybe b (Hib). You know that epiglottitis due to Haemophilus influenzae tybe b (Hib) is transmittable through contact with: - blood - nasopharyngeal/respiratory secretions - discharge from skin lesions - urine - stool
Nasopharyngeal/respiratory secreations Haemophilus influenzae type b (Hib) causing epiglottitis can be transmitted to others through direct contact with nasopharyngeal/respiratory secretions.
Which of the following expected effects of epinephrine treatment should help alleviate Melissa's respiratory distress? - Increase in cardiac output - Vasoconstriction - Bronchodilation
Vasoconstriction The potent vasoconstrictive effect of epinephrine is expected to cause a decrease in blood flow to the highly vascular larynx and surrounding respiratory tissues. This should reduce bronchial and tracheal secretions and alleviate mucosal edema, and make breathing easier. Decreased respiratory effort is usually observed within 30 minutes of racemic epinephrine administration.
Supplemental oxygen may be ordered for Abby, if her oxygen saturation (SpO2) level falls below 92% on room air. Abby's SpO2 has been 93-95% on room air. If oxygen is needed, which of the following oxygen delivery devices will be best for Abby, given her age of three months? - Nasal cannula - Oxygen hood - Simple oxygen mask - Venturi mask
Oxygen hood An oxygen head hood is usually well-tolerated by infants. A head hood delivers oxygen in a concentration that cannot be precisely controlled. Care can usually be provided without having to remove the hood and interrupt oxygen delivery.
Melissa is running around the ED bed. Which of the following comments to Melissa's parents is best? - "It's good that Melissa is so active. Physical activity should help her breathing." - "Please try to calm Melissa down. Her behavior may be disturbing to other patients." - "Please try to calm Melissa down. Running around can make her cough worse." - "Is there a board game Melissa might like to play with right now?"
Please try to calm Melissa down. Running around can make her cough worse Physical activity increases the work of breathing, aggravates croup symptoms, and results in increased coughing. It would be best if Melissa was calmed down and less active
To evaluate the effectiveness of racemic epinephrine treatment, which of the following assessments is most pertinent? - Respiratory rate - Heart rate
Respiratory rate Racemic epinephrine is prescribed to alleviate Melissa's respiratory distress. Epinephrine has a rapid onset and evidence of clinical improvement should be apparent quickly. Melissa's respiratory rate is expected to decrease if treatment is effective. In addition, cough and stridor should decrease. Retractions should become less evident.
Adam's father wants to know if Adam can have a bottle. You tell him that Adam: - should have nothing by mouth - may have clear juice by bottle - may have formula by bottle - may have baby food but no bottles
Should have nothing by mouth Adam's condition could quickly deteriorate to life-threatening airway obstruction. He should have nothing by mouth. In the event that increased respiratory distress or airway obstruction were to occur, emergency intubation might be required. Emergency treatment could be complicated by the presence of food in Adam's gastrointestinal tract. Risk of further aspiration would be increased. Adam is receiving IV fluids.
You know that foreign body aspiration is most common in which age group? - Newborn to three months - Six months to five years - 6-12 years - 12-16 years
Six months to five years Foreign body aspiration is most common in young children ages six months through five years. During infancy and early childhood, children are curious and use their mouths to explore the environment. Also, infants and young children tend to not chew foods well, and because of smaller lung volumes and less forceful coughs, they are not able to expel items from the throat and trachea as efficiently as older children. In addition, young children often play, laugh, or run with things in their mouths.
When should teaching regarding prevention of foreign body aspiration be done with Adam's father? - Immediately - Tomorrow, while Adam is having the bronchoscopy performed - When Adam nears discharge
When Adam nears discharge Learning occurs more readily and knowledge retention is increased when a person's anxiety level is low or moderate. It is likely that Adam's father will be more relaxed when Adam recovers from his procedure and discharge is imminent.
It is presumed that Abby has bronchiolitis due to respiratory syncytial virus (RSV). RSV infections of the respiratory tract are highly contagious and easily spread. - True/ False
True Respiratory syncytial virus (RSV) infections of the respiratory tract are highly contagious. RSV is spread through close contact with an infected person or contaminated surfaces. RSV can live on porous surfaces (skin, paper) for up to one hour, and can survive on nonporous surfaces for up to six hours. Transmission is primarily by nasopharyngeal/respiratory tract secretions. Centers for Disease Control (CDC) guidelines call for implementation of Standard Precautions and Contact Precautions (for the duration of the illness) when respiratory syncytial virus (RSV) infection is presumed or confirmed in a healthcare setting. Contact Precautions are indicated when an illness is highly transmissable by direct or indirect contact.
