Epiglottis, Cystic Fibrosis, Tuberculosis, RSV, Croup
Crackles
(rales) abnormal, discontinuous, adventitious lung sounds heard on inspiration
Interventions for RSV
1. For a child with bronchiolitis, interventions are aimed at treating symptoms and include airway maintenance, cool humidified air and oxygen, adequate fluid intake, and medications. 2. For a hospitalized child with RSV, isolate the child in a single room or place in a room with another child with RSV. 3. Ensure that nurses caring for a child with RSV do not care for other high-risk children. 4. Use contact and standard precautions during care; using good handwashing techniques and wearing gloves and gowns are necessary. 5. Monitor airway status and maintain a patent airway. 6. For most effective airway maintenance, position the child at a 30- to 40-degree angle with the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm. 7. Provide cool, humidified oxygen as prescribed. 8. Monitor pulse oximetry levels. 9. Encourage fluids; fluids administered intravenously may be necessary until the acute stage has passed. 10. Periodic suctioning may be necessary if nasal secretions are copious; use of a bulb syringe for suctioning may be effective. Suctioning should be done before feeding to promote comfort and adequate intake. 11. Administer ribavirin (Virazole), an antiviral medication, if prescribed (administered via the inhalation route). **Cough suppressants are administered with caution because they can interfere with the clearance of respiratory secretions.
Signs and symptoms of epiglottitis
1. High fever 2. Sore, red, and inflamed throat (large, cherry red, edematous epiglottis) and pain on swallowing 3. Absence of spontaneous cough 4. Drooling, dysphagia, dyspnea 5. Agitation 6. Muffled voice (dysphonia) 7. Retractions as child struggles to breathe 8. Inspiratory stridor aggravated by the supine position 9. Tachycardia 10. Tachypnea progressing to more severe respiratory distress (hypoxia, hypercapnia, respiratory acidosis, decreased level of consciousness) 11. Tripod positioning: While supporting the body with the hands, the child leans forward , thrusts the chin forward and opens the mouth in an attempt to widen the airway
Interventions for epiglottitis
1. Maintain a patent airway. 2. Assess respiratory status and breath sounds , noting nasal flaring, the use of accessory muscles, retractions, and the presence of stridor. 3. Assess temperature by the axillary route, not the oral route. 4. Monitor pulse oximetry. 5. Prepare the child for lateral neck films to confirm the diagnosis (accompany the child to the radiology department). 6. Maintain NPO status. 7. Do not leave the child unattended. 8. Avoid placing the child in a supine position because this position would affect the respiratory status further. 9. Do not restrain the child or take any other measure that may agitate the child. 10. Administer intravenous fluids as prescribed; insertion of an intravenous line may need to be delayed until an adequate airway is established because this procedure may agitate the child. 11. Administer intravenous antibiotics as prescribed; these are usually followed by oral antibiotics. 12. Administer analgesics and antipyretics (acetaminophen [Tylenol] or ibuprofen [Motrin]) to reduce fever and throat pain as prescribed. 13. Administer corticosteroids to decrease inflammation and reduce throat edema as prescribed. 14. Nebulized epinephrine (racemic epinephrine) may be prescribed for severe cases (causes mucosal vasoconstriction and reduces edema); heliox (mixture of helium and oxygen) may also be prescribed to reduce mucosal edema. 15. Provide cool mist oxygen therapy as prescribed; high humidification cools the airway and decreases swelling. 16. Have resuscitation equipment available, and prepare for endotracheal intubation or tracheotomy for severe respiratory distress. 17. Ensure that the child is up to date with immunizations, including Hib conjugate vaccine **If epiglottitis is suspected, no attempts should be made to visualize the posterior pharynx, obtain a throat culture, or take an oral temperature. Otherwise, spasm of the epiglottis can occur leading to complete airway occlusion
Besides RSV other causes of bronchiolitis
1. adenoviruses 2. parainfluenza viruses 3. human metapneumovirus
Acute respiratory distress syndrome can be precipitated by:
1. aspiration 2. trauma 3. drug ingestion 4. shockk 5. massive transfusions
Signs and symptoms of stage 3 of laryngotracheobronchitis
1. continued restlessness 2. anxiety 3. pallor 4. diaphoresis 5. tachypnea 6. signs of anoxia and hypercapnia
Signs and symptoms of stage 2 of laryngotracheobronchitis
1. continuous respiratory stridor 2. retractions 3. use of accessory muscles 4. crackles and wheezing 5. labored respirations
Signs and symptoms of bronchitis
1. fever 2. dry, hacking, and nonproductive cough that is worse at night and becomes productive in 2 to 3 days
Signs and Symptoms of RSV (as disease progresses)
1. increased coughing and wheezing 2. signs of air hunger 3. tachypnea and retractions 4. periods of cyanosis
Signs and symptoms of stage 4 of laryngotracheobronchitis
1. intermittent cyanosis progressing to consistent cyanosis 2. apneic episodes progressing to cessation of breathing
Signs and symptoms of stage 1 of laryngotracheobronchitis
1. low grade fever 2. hoarseness 3. seal bark and brassy cough (croup cough) 4. inspiratory stridor 5. fear 6. irritability and restlessness
Interventions for laryngotracheobronchitis
1. maintain patent airway 2. assess respiratory status and monitor pulse oximetry; monitor for nasal flaring, sternal retraction, and inspiratory stridor 3. monitor for adequate respiratory exchange; monitor for pallor or cyanosis 4. elevate the head of the bed and provide rest 5. provide humidified oxygen via a cool air or mist tent as prescribed for a hospitalized child 6. instruct the parents to use a cool air vaporizer at home; other measures include having the child breathe in the cool night air or the air from an open freezer or taking the child to a cool basement or garage 7. provide and encourage fluid intake; IV fluids may be prescribed to maintain hydration status if the child is unable to take fluids orally 8. administer analgesics as prescribed to reduce fever 9. teach the parent to avoid administering cough syrups or cold medications, which may dry and thicken secretions 10. administer corticosteroids if prescribed to reduce inflammation and edema 11. administer antibiotics, noting that they are not indicated unless a bacterial infection is present 12. heliox (mixture of helium and oxygen) may be prescribed 13. have resuscitation equipment available 14. provide appropriate reassurance and education to the parents and caregivers
Six foods that are commonly aspirated by young children
1. nuts 2. grapes 3. hard candy 4. popcorn 5. hot dogs 6. raw carrots 7. large chunks of food
Common causative organisms of laryngotracheobronchitis
1. parainfluenza virus types 2 and 3 2. respiratory syncytial virus (RSV) 3. mycoplasma pneumoniae 4. influenza A and B
Sweat Chloride test (cystic fibrosis)
1. production of sweat is stimulated, sweat is collected, and sweat electrolytes are measured (more than 75 mg of sweat is needed) 2. normally, the sweat chloride concentration is less than 40 mEq/L 3. chloride concentration greater than 60 mEq/L is a positive test result; higher than 40 mEq/L is diagnostic in infants younger than 3 months old 4. chloride concentrations of 40 to 60 mEq/L are highly suggestive of cystic fibrosis and require a repeat test
Signs and Symptoms of RSV (initial manifestation):
1. rhinorrhea 2. eye or ear drainage 3. pharyngitis 4. coughing 5. sneezing 6. wheezing 7. intermittent fever
Signs and Symptoms of RSV (severe illness):
1. tachypnea more than 70 breaths per minute 2. decreased breath sounds and poor air exchange 3. listlessness 4. apneic episodes
Interventions for bronchitis
1. treat symptoms 2. monitor for respiratory distress 3. provide cool, humidified air to the child 4. encourage increased fluid intake; child may drink beverages that he or she likes as long as the respiratory status is stable 5. administer antipyretics for fever 6. a cough suppressant may be prescribed to promote rest
Respiratory syncytial virus (RSV) is the causative agent in bronchiolitis in more than what percentage of cases?
50
The oxygen saturation of a child with pneumonia, who has no underlying chronic pulmonary disease, should be maintained at?
95%
You're assessing a 4 year old with epiglottitis who just arrived to the pediatric clinic. The child is drooling and has a respiratory rate of 45 breaths per minute. In addition, the child is becoming increasingly apprehensive. Which findings below exhibited by the patient represents an acute upper airway obstruction that requires IMMEDIATE treatment? Select all that apply:* A. Stridor B. Cyanosis C. Chest retractions D. Nasal flaring
All the answers are correct. All these findings represent an upper airway obstruction and require immediate treatment.
What can be done to promote pulmonary drainage in a child with pneumonia?
Chest physiotherapy before meals and before bed; change position every 2 hours; elevate head of bed; assist older children to cough and deep breathe
What is the preferred method for screening for TB?
Mantoux test
What product is intramuscularly administered monthly during RSV season as an RSV prophylaxis in preterm infants?
Respiratory syncytial virus monoclonal antibody (Synagis)
Manifestations of epiglottitis include:
Sudden onset: high fever, sitting in tripod position, nasal flaring, retractions, tachycardia, drooling, dysphagia, and dysphonia
A 3 year old arrives to the ER. The child has a temperature of 102.4 'F, respiratory rate of 45, and is agitated. The child is diagnosed with epiglottitis. You note the child is sitting up, positioned forward with chin in the air and the tongue is protruding with the mouth open. Which nursing intervention below is NOT appropriate for this patient?* A. Assist the patient in a supine position. B. Keep the child on the parent's lap during treatments. C. Keep the child nothing by mouth. D. Avoid taking a temperature on the patient orally.
The answer is A. Allow the child to be in a position that allows them to breathe and be comfortable. The child is in the tripod position, which is a common finding with epiglottis. Placing the child in the supine position is contraindicated because it impedes respiratory effort. A nursing goal is to keep the child calm (avoid things that cause the child to cry because this can affect the airway since the epiglottis is inflamed). So, keeping the child in the parent's lap during treatments is appropriate. In addition, NEVER place anything in the patient's mouth due to the risk of causing spasms which will further constrict the airway.
An infant is hospitalized following an apparent life threatening event. The apnea monitor suddenly alarms. The nurse should first: a. assess the infant b. questions witnesses about the triggering event c. initiate cardiopulmonary resuscitation d. reset the monitor
The answer is A: assess the infant
In preparing a 6 year old child for a tonsillectomy, the nurse should not: a. direct the teaching at the child's parents b. reassure the child that she will be able to talk following the surgery c. explain that her throat will be sore after surgery d. explain that she will have to drink a lot after surgery
The answer is A: direct the teaching at the child's parents
Regarding question 2, what is the recommended preventive administration schedule for this medication in preventing epiglottitis?* A. 4, 6, 12-15 months and 4-6 years B. 2, 4, 6, 12-15 months C. 4, 6 months and 4-6 years D. 2 and 6 months
The answer is B. The Hib vaccine can prevent most cases of epiglottitis. Three or four doses are given, depending on the brand used. It is given at 2, 4, 6, and 12-15 months.
Parents bring their 8 month old son to the emergency department because "He's breathing so fast that he can't even eat, and he's so hot." Physical examination reveals nasal flaring, intercostal retraction, and moderate expiratory wheezing. The nurse suspects that the infant has: a. acute spasmodic croup b. bronchiolitis c. epiglottitis d. aspirated a foreign body
The answer is B: bronchiolitis
Active bleeding in a child following a tonsillectomy is indicated by: a. refusal to drink fluids b. frequent swallowing c. coffee grounds emesis d. all of the above
The answer is B: frequent swallowing
A toddler is admitted to the hospital with croup. He is tachypneic with substernal retractions and nasal flaring. He has a harsh, bark-like cough. His pulse oximetry reading on room air is 98%. The most accurate nursing diagnosis for him is: a. ineffective breathing pattern b. ineffective airway clearance c. impaired gas exchange d. all of the above
The answer is B: ineffective airway clearance
A preschooler arrives in the emergency department. She is very anxious and irritable and refuses to lie down to be examined. She is sitting up, leaning forward on her hands, and drooling saliva. She is warm to the touch and her color is pale. The nurse should: a. take the child's vital signs b. immediately notify the physician c. ask the parents to wait outside the examining room d. start an intravenous line
The answer is B: notify the physician
A test used in the diagnosis of cystic fibrosis is: a. radioallergosorbent test (RAST) b. sweat chloride c. culture for Pseudomonas d. Mantoux
The answer is B: sweat chloride
During a 2 month well visit with a patient and her mother you educate the parent on the most common cause of epiglottitis. You explain to the mother the most common cause of this condition is the _______________. In addition, you explain _________ can help prevent most cases of this condition?* A. respiratory syncytial virus, palivizumab B. influenza virus, annual flu shot C. haemophilus influenzae type b, Hib vaccine D. rotavirus, RV vaccine
The answer is C. Most common cases of epiglottitis are caused by a bacteria that attacks the epiglottis called haemophilus influenza type B. The Hib vaccine can be given as prevention. Three to four doses are given (depending on the brand used) at 2, 4, 6 months, and 12-15 months.
Which statement is correct regarding the role of the epiglottis?* A. This structure prevents food from entering the nasopharynx. B. The epiglottis helps with vocal cord vibration. C. After swallowing this structure moves downward to prevent swallowed contents from entering the trachea. D. The epiglottis is found in between the vocal folds.
The answer is C. Option A is wrong because this is the role of the uvula (NOT epiglottis). Option B is wrong because this is the role of the GLOTTIS (not epiglottis). Option D is where the glottis is found (not epiglottis). The epiglottis is found on the inside of the thyroid cartilage and is at the back of the tongue.
The nurse is preparing a child for bronchoscopy. The child most likely has: a. apnea b. bronchiolitis c. aspirated a foreign body d. pneumonia
The answer is C: aspirated a foreign body
Which drug is a respiratory stimulant? a. isoniazid b. albuterol c. caffeine d. ribavirin
The answer is C: caffeine
Which therapy is least likely to be used for a child with cystic fibrosis who is hospitalized with a respiratory infection? a. chest physiotherapy every 3 hours b. intravenous antibiotics c. cough-suppressant medications d. postural drainage
The answer is C: cough suppressant medications
A child experiences bronchoconstriction 5 hours after an acute asthma attack. This is an example of which kind of inflammatory response? a. immediate b. intermediate c. delayed
The answer is C: delayed
A nurse teaching a family about the use of pancreatic enzymes for the treatment of cystic fibrosis should include: a. administer the preparation thrice a day and before bedtime b. dissolve the enzyme in warm whole milk c. increase the dosage if the child has loose, fatty stools d. chewing the enzymes will increase their efficacy
The answer is C: increase the dosage if the child has loose, fatty stools.
Select all the signs and symptoms that can present with epiglottitis?* A. Slow onset B. Difficulty swallowing C. Drooling D. High Fever E. Barking cough F. Stridor G. Exudate on Tonsils H. Crackles
The answers are B, C, D, and F.
The parents of a 3 year old bring their child to the ER. The parents report the child suddenly developed a fever overnight and has had issues swallowing, which has led to excessive drooling. In addition, the parents explain that the child complains of sore throat, and it is hard to understand the child's speech because her voice is muffled. Based on this information, your next nursing actions will be? Select all that apply:* A. Assess the child's temperature orally B. Obtain a throat culture C. Count the patient's respirations D. Assess the child's throat for tonsillar exudate E. Keep the child NPO
The answers are C and E. Based on the patient's signs and symptoms this may be a case of epiglottitis. Therefore, the nurse should NOT stick anything in the patient's mouth that could can a spasm (example: taking oral temperature, throat culture, using a tongue depressor etc.) and further block the airway.
A 5 year old with acute epiglottitis is intubated for airway management. As the nurse you know that all of the following can be prescribed as treatment for this condition EXCEPT?* A. Intravenous fluids B. Antipyretics C. Corticosteroids D. Cough suppressants
The only answer is D. A cough is usually absent in this condition, which on the contrary is present in croup (laryngotracheobronchitis). Therefore, cough suppressants are not usually ordered for this condition because there is no cough.
Cystic fibrosis
a chronic multisystem disorder (autosomal recessive trait disorder) characterized by exocrine gland dysfunction
retractions
abnormal movement of the chest wall during inspiration
Mucus produced by the exocrine gland in cystic fibrosis
abnormally thick, tenacious, and copious, causing obstruction of the small passageways of the affected organs, particularly in the respiratory, gastrointestinal, and reproductive systems
The onset of epiglottitis is
abrupt and occurs most often in winter
What may be as effective as chest physiotherapy in relieving pulmonary obstruction in cystic fibrosis?
aerobic exercise
What can be used in place of intravenous antibiotics for cystic fibrosis?
aerosolized antibiotics
children with laryngotracheobronchitis are typically?
afebrile
Manifestations of an obstructed airway in a child who has aspirated are:
aphonia and apnea
Common symptoms of cystic fibrosis
are associated with pancreatic enzyme deficiency and pancreatic fibrosis caused by duct blockage, progressive chronic lung disease as a result of infection, and sweat gland dysfunction resulting in increased sodium and chloride sweat concentrations
Children who receive racemic epinephrine in the emergency department should be observed for?
at least 3 hours after treatment
epiglotitis
bacterial form of croup
Abdominal pain and vomiting are manifestations of?
bacterial pharyngitis
Two breathing exercises to slow the respiratory rate are?
belly breathing: pursed lip breathing
rhonchi
breath sounds caused by passage of air through thick secretions
Respiratory Syncytial Virus (RSV)
causes an acute viral infection and is a common cause of bronchiolitis; highly communicable and is usually transferred via droplets or by direct contact with respiratory secretions
Epiglottitis occurs most frequently in:
children 2 to 8 years old
At risk children for RSV
children who have a chronic or disabling condition and those who are immunocompromised
The tonsils help filter?
circulating lymph fluid
Atelectasis
collapsed or airless part of the lung
Corticosteroids are used during an acute asthma attack to
decrease inflammation
hypocapnia
decreased levels of carbon dioxide in the blood
hypoxia
decreased levels of oxygen in the blood
dyspnea
difficulty breathing
orthopnea
difficulty breathing except in an upright position
dysphagia
difficulty swallowing
Beta2 adrenergic agonists are used to
dilate airway and/or relieve bronchospasm
Diagnosis of RSV
done via testing of nasal or nasopharyngeal secretions
Prevention of RSV
encouraging breastfeeding; avoiding tobacco smoke exposure; using good hand hygiene
Cystic fibrosis affects the functioning of what glands?
exocrine
Wheezing is typically heard on
expiration
Mast cell inhibitors are administered 30 minutes before
exposure to triggers
Laryngotracheobronchitis is characterized by
gradual onset that may be preceded by an upper respiratory infection
wheezing
high-pitched musical whistles heard with or without a stethoscope
In recent years, the incidence and mortality rates for asthma have both
increased
hypercapnia
increased levels of carbon dioxide in the blood
tachypnea
increased respiratory rate
Epiglottitis occurs when
inflammation caused by Haemophilus influenzae type B or Streptococcus pneumoniae infects the child.
Bronchiolitis
inflammation of the bronchioles that causes production of thick mucus that occludes bronchiole tubes and small bronchi
Laryngotracheobronchitis (Croup)
inflammation of the larynx, trachea, and bronchi
Bronchitis
inflammation of the trachea and bronchi; may be referred to as tracheobronchitis
The hallmark of laryngomalacia is
inspiratory stridor with or without retractions
Why is RSV so easily communicable?
it can live on the skin for up to 1 hour and on nonporous surfaces for up to 6 hours
Why is epiglottitis considered an emergency situation?
it can progress rapidly to severe respiratory distress
Most common type of croup
laryngotracheobronchitis may be bacterial or viral occurs most frequently in children younger than 5 years
Tachypnea __________________________ carbon dioxide levels in blood
lowers
What is the first indicator of cystic fibrosis?
meconium ileus
laryngotracheobronchitis
most common form of croup
Acute spasmodic croup
occurs more often in anxious, excitable children
What is associated with bronchial hyperresponsiveness in children?
passive smoking
Children with asthma monitor their condition at home using
peak flow meters
TB infection
positive skin test with no signs and symptoms
TB disease
positive skin test with signs and symptoms of TB
Children with TB are:
rarely contagious
RSV occurs
rarely in children older than 2 years, with a peak incidence at approximately 6 months of age
TB exposure
recent contact with a person who has contagious TB
Lack of surfactant places a preterm infant at risk for?
respiratory distress syndrome
Treatment for bronchitis includes:
rest; humidification; increased fluid intake
A child with cystic fibrosis requires extra _________ and ___________ when the weather is hot
salt and fluids
nasal polyps
semi transparent herniations of respiratory epithelium
stridor
shrill, harsh sound heard during inspiration, expiration, or both
grunting
sound similar to a grunting noise, that can be heard with or without a stethoscope
Increasingly severe asthma that does not respond to vigorous treatment is called
status asthmaticus
What is an ideal sport for children with asthma?
swimming
Why do healthcare professionals maintain contact precautions when caring for infants with RSV?
to prevent nosocomial transmission of the virus to other patients
When epiglottitis is suspected, never use ______________ to inspect the child's throat?
tongue depressor
The onset of allergic rhinitis rarely occurs before the age of
two years
tracheitis
usually follows an upper respiratory infection
Causative agent of bronchitis
usually viral and occurs in association with an upper respiratory infection
H. influenzae type b (Hib vaccine)
vaccine against Haemophilus influenzae type B helps lower the child's risk of getting epiglottitis
Bronchitis is usually caused by a
virus
nasal flaring
widening of the nares that indicate air hunger