Respiratory and cardiac pediatric Week 5

A 5-year-old child is admitted to the pediatric intensive care unit with a diagnosis of acute asthma. A blood sample is obtained to measure the child's arterial blood gases. What finding does the nurse expect?

Increased carbon dioxide level Gas exchange is limited because of narrowing and swelling of the bronchi; the carbon dioxide level increases. The oxygen level will be decreased, not increased. The pH will decrease; the child is in respiratory acidosis, not alkalosis. The bicarbonate level will be increased to compensate for acidosis.

What action should the nurse take when using pulse oximetry to determine a toddler's oxygen saturation?

Placing the sensor probe on the finger The sensor probe for pulse oximetry may be placed on the finger or earlobe. Because toddlers have fragile skin, it is preferable to place the sensor probe on a finger. A single-use (tape-on) probe may be used if the patient is obese and a clip-on probe does not fit properly. However, it is not routinely needed. Because a toddler's skin is so fragile, the sensor should not be placed on the bridge of the nose. The sensor should be placed properly, after which the oximeter should be turned on.

A 17-year-old adolescent with a history of asthma is brought to the emergency department in respiratory distress. A nurse immediately places the client in a bed with the head of the bed elevated and administers oxygen with a facemask. The primary healthcare provider performs a physical assessment and admits the adolescent to the pediatric unit. What is the priority nursing intervention in regard to the primary healthcare provider's prescriptions?

Administering the nebulizer treatment to facilitate breathing Albuterol relaxes smooth muscles in the respiratory tract, resulting in bronchodilation. The priority is the facilitation of respiration. Administering albuterol follows the ABCs of emergency care: airway, breathing, and circulation. Obtaining a blood specimen to send to the laboratory for tests is not the priority. The results will not influence the priority intervention. Asking the respiratory therapist to perform chest physiotherapy is not the priority. Chest physiotherapy is performed after the respiratory airways are opened. In many facilities chest physiotherapy is the responsibility of the nurse, not a respiratory therapist. The use of an incentive spirometer can be taught after the acute episode of respiratory distress. It will take time to obtain the device and teach the adolescent.

Two hours after a 1-year-old child with acute laryngitis is admitted to the hospital, the nurse observes increases in the child's respiratory and cardiac rates, increased restlessness, and substernal and intercostal retractions. What action should the nurse take immediately?

Calling the healthcare provider to report the child's respiratory status A tracheostomy may be necessary to maintain an open airway; therefore the healthcare provider needs to be notified immediately. The child's change in status is not indicative of increased secretions. Suctioning could precipitate laryngospasm and should be avoided in this case. Increased oxygen therapy will be ineffective with a severe spasm of the airway. Striking the child on the back is ineffective against laryngeal spasm.

A nurse is conducting a health class for adolescents. What modifiable risk factor, most closely associated with the development of coronary heart disease (CHD) in both men and women, should the nurse discuss?

Cigarette smoking Nicotine in cigarette smoke constricts blood vessels, including coronary arteries, which contributes to the occurrence of angina and CHD. Opioid use is not a risk factor for CHD. Judicious alcohol intake may promote relaxation, decreasing stress and limiting the development of CHD. Inactivity, not moderate exercise, is a risk factor for CHD. Exercise decreases hypertension, blood clotting, and heart rate. Exercise also increases metabolism, the plasma level of high-density lipoprotein cholesterol, and cardiac capillary blood flow.

What is the nurse's priority action when caring for a child with acute laryngotracheobronchitis?

Continually assessing the respiratory status Laryngeal spasms can occur abruptly; patency of the airway is ensured with constant assessments for signs of respiratory distress. Reducing fever, delivering humidified oxygen, and providing emotional support to the child are all important, but none is the priority.

A 2-year-old child who is hospitalized for repair of tetralogy of Fallot is seen squatting in the playroom. In response to this behavior, what should the nurse do?

Continue to observe the child if there are no other signs of distress. Squatting is a physiologic adaptation for children with tetralogy of Fallot. By squatting, the child decreases the amount of arterial blood that is flowing to the extremities, which in turn decreases venous return to the heart and reduces preload. Oxygen is not indicated. The child has a heart, not a respiratory, problem, so a nebulizer treatment is not indicated. The child's condition has not deteriorated; squatting is a physiologic adaptation.

A nurse is reviewing the prescriptions for a 2-year-old child who has been admitted to the pediatric unit with acute laryngotracheobronchitis (croup). What is the rationale for the prescription to administer oxygen by way of a nasal cannula?

Decreases the effort required for breathing and permits rest Administering oxygen by way of nasal cannula limits the energy required for breathing; this allows the child to conserve energy that can be used for fluid and nutrient intake. Congealed mucus will obstruct air passageways and increase respiratory distress. Oxygen administration does not trigger the cough reflex. Oxygen administration through a nasal cannula will have a drying effect.

A nurse knows that when routine oxygen therapy is being administered to a 7-year-old child, which safety measure should be taken in terms of handling the oxygen?

It is closely monitored for the correct concentration. The oxygen concentration must be closely monitored to minimize side effects. Oxygen does not ignite and is not flammable, but it supports fire. Oxygen is not warmed before administration; it is cool when routinely administered. Oxygen is considered a medication and therefore must be prescribed when administered routinely.

A 3-month-old infant with tetralogy of Fallot is admitted for a diagnostic workup in preparation for corrective surgery. The morning after cardiac catheterization the infant suddenly becomes cyanotic and begins breathing rapidly. In what position should the nurse immediately place the infant?

Knee-chest The infant is experiencing a hypercyanotic ("tet" spell) episode caused by a sudden decrease in pulmonary blood flow and an increase in right-to-left shunting. It usually occurs after increased activity. The knee-chest position decreases venous return from the legs, which increases systemic vascular resistance, thereby increasing pulmonary blood flow. The supine and lateral positions increase venous return, which exacerbates the problem. Although the semi-Fowler position is recommended for infants with cardiac disease, it is not adequate for an infant experiencing a tet spell.

An infant with a congenital heart defect is returned to the unit after cardiac catheterization. The nurse manager is observing a nurse newly assigned to the unit. Which nursing intervention should the nurse manager interrupt?

Perform range-of-motion exercises. Range-of-motion exercises of the limb bearing the catheterization site might cause the dislodgement of a clot and result in hemorrhage. Intake should start with fluids and progress as tolerated. The apical pulse is monitored because a common complication after cardiac catheterization involves disturbances of cardiac rate and rhythm. The peripheral pulses are assessed because formation of thrombi is a complication of cardiac catheterization.

A nurse is reviewing the clinical records of infants and children with cardiac disorders in whom heart failure developed. What does the nurse identify as the last sign of heart failure?

Peripheral edema Heart failure is characterized by a decrease in blood flow to the kidneys, causing sodium and water reabsorption and resulting in peripheral edema. The peripheral edema indicates severe cardiac decompensation. Tachypnea and tachycardia constitute an early attempt by the body to compensate for decreased cardiac output. Periorbital edema occurs most noticeably in children with acute poststreptococcal glomerulonephritis, not heart failure.

An adolescent is admitted to the hospital in respiratory distress, and the primary healthcare provider prescribes oxygen at 40% by way of a Venturi mask. The instructions for the Venturi mask indicate that delivery of 4 L/min equals 24% to 28% oxygen, delivery of 8 L/min equals 35% to 40% oxygen, and 12 L/min equals 50% to 60% oxygen. Where should the ball of the flow meter should be raised to deliver the percentage of oxygen prescribed by the primary healthcare provider?

The ball of the oxygen flowmeter should be set at 8 L/min, shown in Option C, to deliver 40% oxygen through the Venturi mask.

The nurse is caring for a 4-year-old child who has been hospitalized with an acute asthma exacerbation. Which assessment finding requires action by the nurse?

Diminished breath sounds At the beginning of an asthma episode, wheezing may be heard only with a stethoscope. As the severity of the episode increases, wheezing may become audible to the unaided ear. Children in severe respiratory distress may not demonstrate wheezing because of decreased air movement; diminished breath sounds in a child may signal an inability to move air, so this finding requires action. The normal pulse range for a 4-year-old is 80 to 125 beats/min; a pulse of 110 beats/min does not require action. The normal respiratory range for a 4-year-old is 20 to 30 breaths/min, so a respiratory rate of 24 breaths/min does not require action. A pulse oximetry reading of 95% is acceptable. Once the child has been hospitalized with an acute asthma attack, oxygen saturation should be kept at 95% or higher.

A 15-year-old with cystic fibrosis (CF) is admitted with a respiratory infection. The nurse determines that the adolescent is cyanotic, has a barrel-shaped chest, and is in the 10th percentile for both height and weight. What is the priority nursing intervention?

Performing postural drainage Postural drainage, including percussion and vibration, aids removal of respiratory secretions that provide a medium for further bacterial growth. Children with CF must cope with impaired gas exchange that results in intolerance to activity. Increasing activity at this time may be too taxing. There must be a balance between activity and rest within the child's limitations. There are no dietary restrictions. Children with CF should have a balanced nutritional intake that is high in calories. Although important, administration of prescribed pancreatic enzymes is not the priority.

Antibiotic prophylaxis is prescribed for a 2-year-old child with a cardiac malformation who is awaiting corrective surgery. The nurse explains to the child's parents that the antibiotic will prevent what?

Subacute bacterial endocarditis Prophylaxis before surgery can prevent bacterial endocarditis, which often occurs in children and adults with heart structure anomalies. Prophylactic antibiotics are not used to prevent bacterial pneumonia in a child with cardiac problems. Laryngotracheobronchitis is a viral infection; if this infection develops, corrective surgery will be postponed. Avoidance of crowds, not taking antibiotics, is recommended to prevent upper respiratory infection in children with cardiac problems.

A 3-year-old child with the diagnosis of tetralogy of Fallot is brought to the United States by a charitable organization for cardiac surgery. What should the nurse expect when conducting an admission assessment of the child?

Clubbing of Fingers Hypoxia leads to poor peripheral circulation; clubbing occurs as a result of additional capillary development and tissue hypertrophy of the fingertips. A fever is not expected unless the child has an infection or is dehydrated; the data do not indicate this. The child's respiratory rate will be increased, not decreased. The child's problems are related to decreased oxygenation, not to a clotting deficiency.

An infant is admitted to the pediatric unit with bronchiolitis caused by respiratory syncytial virus (RSV). What interventions are appropriate nursing care for the infant?

Instilling saline nose drops Maintaining contact precautions Suctioning mucus with a bulb syringe Saline nose drops help clear the nasal passage, which improves breathing and aids the intake of fluids. RSV is contagious; infants with RSV should be isolated from other children, and the number of people visiting or caring for the infant should be limited. Infants with RSV produce copious amounts of mucus, which hinders breathing and feeding; suctioning before meals and at naptime and bedtime provides relief. Fluid intake should be increased; adequate hydration is essential to counter fluid loss. These infants have difficulty nursing and often vomit their feedings. If measures such as suctioning before feeding and instilling saline nose drops are ineffective, intravenous fluid replacement is instituted. The humidified oxygen should be cool. It relieves the dyspnea and hypoxia that is prevalent in infants with RSV.

A school-aged child with cystic fibrosis has recurrent episodes of bronchitis, and the parents ask the nurse why this happens. What reason should the nurse include in the reply?

Tenacious secretions that obstruct the respiratory tract provide a favorable medium for growth of bacteria. Cystic fibrosis is characterized by an overproduction of viscous mucus by exocrine glands in the lungs. The mucus traps bacteria and foreign debris that adhere to the lining and cannot be expelled by the cilia, resulting in obstruction of the airway and the development of a favorable environment for the growth of microorganisms, leading to infection. Cardiac defects are not associated with cystic fibrosis. Neuromuscular irritability of the bronchi does not occur in cystic fibrosis. Although there is increased sodium and chloride in the saliva, they do not irritate or inflame the mucous membranes.

A 6-month-old infant has a congenital right-to-left shunt defect of the heart. What clinical findings are expected when the nurse completes a history and physical assessment and reviews the child's laboratory reports?

Tissue hypoxia Increased hematocrit When right-to-left shunting of blood occurs in a congenital heart defect, nonoxygenated blood is being circulated to the extremities, resulting in tissue hypoxia. With the hypoxic conditions in the capillaries, erythropoietin is released to signal increased production of red blood cells (RBCs). The increased production of RBCs results in an increased hematocrit. There is no orthopnea with right-to-left shunting. Respiratory infection is common in the setting of left-to-right shunt. There are no peripheral pulse changes with this type of cardiac shunt.