exam 2: (ch 45) the child with a respiratory alteration

cystic fibrosis

an inherited multisystem disorder characterized by widespread dysfunction of the exocrine glands - abnormal secretions of thick, tenacious mucus - obstruction and dysfunction of the pancreas, lungs, salivary glands, sweat glands, reproductive organs - transmitted as an autosomal recessive trait

caring for a child with a tonsillectomy

*assess for postoperative bleeding → #1 side effect** - excessive swallowing - elevated pulse; decreasing blood pressure - signs of fresh bleeding in the back of throat - vomiting bright red blood - restlessness not associated with pain

bacterial pharyngitis

*kids usually sicker, higher fever, hurts more, more general illness - abrupt onset (may be gradual in children younger than 2) - sore throat (usually severe) - erythema, inflammation of pharynx and tonsils - fever usually high (39.4-40 C) - abdominal pain, headache, vomiting - cervical lymph nodes may be enlarged, tender - usually lasts 3-5 days

epiglottis (supra glottis)

- **acute inflammation and swelling of the epiglottis - life threatening - rapidly progressive - almost always caused by H. influenzae

otitis media with effusion (OME)

- *the presence of fluid behind the tympanic membrane without signs of infection; often follows an episode of AOM and usually resolves in 1-3 months - *assess for hearing loss!

cystic fibrosis manifestations → meconium ileus (due to lack of pancreatic enzymes)

- abdominal distention - vomiting - failure to pass stools - rapid development of dehydration

croup treatment

- allow the child to remain in a position of comfort - pulse oximetry - blow by humidified oxygen - racemic epinephrine - dexamethasone - neck films - lateral - keep child quiet **home treatment*** → humidity (cool or warm air) → no extra O2 (diff btwn hospitalization)

diagnostic tests

- blood gas analysis - pulmonary function tests - pulse oximetry - transcutaneous monitoring - end-tidal carbon dioxide monitoring

increase in work of breathing and respiratory effort demonstrated by

- body position - mental status - vital signs - breath sounds - work of breathing - skin color

apnea

- cessation of breathing for 20 seconds or longer - BRUE brief resolved unexplained event during an episode of apnea, it is important to note the following - time and duration of the episode - color change - bradycardia - oxygen saturation - action that stimulated breathing - **teach parents CPR!!

tonsillectomy

- controversial - used conservatively for cases of upper airway obstruction, peritonsillar abscess, obstructive sleep apnea, or other serious problems

four cardinal s/s of epiglottis

- drooling - dysphagia - dysphonia (difficulty talking) - distressed respiratory efforts

asthma manifestations

- dry cough - wheezing - SOB, dyspnea on exertion - retractions, nasal flaring - tachypnea, orthopnea - restlessness, apprehension, diaphoresis

cystic fibrosis diagnosis

- genetic testing - sweat test

bacterial pharyngitis

- gradual onset with sore throat - erythema, inflammation of pharynx and tonsils - vesicles or ulcers on tonsils - fever (usually low grade, may be high) - hoarseness, cough, rhinitis, conjunctivitis, malaise, anorexia (early) - cervical lymph nodes may be enlarged, tender - usually lasts 3-4 days

personal risk factors for respiratory distress

- history of meconium aspiration, prematurity, mechanical ventilation at birth, history of respiratory illnesses - history of respiratory illnesses such as cystic fibrosis, asthma, cardiac disorder, or HIV/AIDS - exposure to passive tobacco smoke of environmental irritants

asthma is a reversible obstructive airway disease characterized by

- increased airway responsiveness to a variety of stimuli - bronchospasm resulting from construction of bronchial smooth muscle - inflammation and edema* of the mucous membranes that line the small airways and the subsequent accumulation of thick secretions in the airways

differences in the respiratory system

- lack of or insufficient surfactant (especially in preterm infants; made in last trimester of pregnancy) - smaller airways and underdeveloped cartilage - obligatory nose breather (infant) - less well developed intercostal muscles - brief periods of apnea common (newborn) - faster respiratory rate; increased metabolic needs - eustachian tubes relatively horizontal (**starting off more in children not infants) - tonsillar tissue is normally enlarged - more flexible larynx, susceptible to spasm - abdominal breathers - child's flexible larynx is susceptible to spasm

cystic fibrosis manifestations → GI manifestations

- large, bulky, loose, frothy, foul smelling stools → malabsorption - voracious appetite (early on) with no weight gain - loss of appetite (later) - weight loss - failure to grow - anemia - distended abdomen

asthma

- leading cause of acute and chronic illness in children - increased with poverty and urban settings - most frequent hospital admission diagnosis in kids - interaction between genetic and environmental factors - triggered by a variety of stimuli (cold air, smoke, allergens, infections, stress, exercise, odors, and pollutants)

epiglottitis: DO NOT

- leave child unattended if suspected - examine or attempt to obtain culture; any stimulation by tongue depressor or culture swab could trigger complete airway obstruction

upper airway

- nares, pharynx - larynx is located between the pharynx and trachea and houses vocal cords - *ciliated mucous membranes - tonsils

croup

- often begins at night; may be preceded by several days of symptoms of upper respiratory infection - sudden onset of harsh, metallic, barky cough; sore throat; inspiratory stridor; hoarseness - use of accessory muscles to breathe - frightened appearance - agitation - cyanosis

therapeutic management of an acute asthmatic episode

- physician's office or ER - bronchodilator, usually short acting beta adrenergic agonist (SABA) such as albuterol administered via powered nebulizer - improved → return home with SABA prescription and other routine medications

RSV prevention

- prevention of utmost importance for at risk intramuscular palivizumab (Synagis) administered monthly IM (virus fighting antibodies) - infants < 32 weeks gestation - < 2 years with BPD who have received treatment within 6 months of RSV season - severe BPD treat for 2 RSV seasons - teach the importance of meticulous hand washing to prevent spread!!

cystic fibrosis nursing management

- respiratory and GI assessment - assess newborn for feeding and stooling patterns administer medications - treat infections aggressively (increase lung damage) - nutritional support - **CPT → pulmonary hygiene 2-4 times a day - **assist with mechanical device - oxygen administration - physical activity alternating with rest

status asthmaticus

- severe asthma that is unresponsive to vigorous treatment - medical emergency that can cause respiratory failure and death - ICU care - intubation, IV steroids

respiratory distress s/s

- tachypnea - hypoxemia - accessory muscle use - retractions (ribs & neck) - nasal flaring* - hypoventilation - apnea - head bobbing* - respiratory failure

nursing management

- thorough respiratory assessment and health history - physical characteristics related to chronic respiratory illness - medication administration teaching - support child and family asthma care plan/teaching - educate child and family in use of inhaled medication - educate child and family to avoid triggers and allergens - develop written action plan for asthma management

lower airway

- trachea, lungs, and bronchi - alveoli where *gas exchange occurs

emergency asthma management

- worsening wheeze, cough, or shortness of breath - no improvement after bronchodilator use - difficulty breathing - trouble with walking or talking - discontinuation of play - listlessness or weak cry - gray or blue skin coloring

cystic fibrosis therapeutic management

chest physical therapy*** - flutter mucus clearance device → hand held pipe that facilitates removal of mucus - every day, several times a day when child is young, then child can wear devices - exercise and physical fitness - antibiotic therapy (oral, IV, inhaled); intermittent or continuous - immunizations - treatment of complications - lung transplantation

respiratory assessment

compare one side to the other - equal breath sounds - diminished breath sounds - poor *air exchange - abnormal breath sounds - cough - observation

acute otitis media manifestations

earache (otalgia); infants may pull their ears or roll their heads - assess for recent URI and runny nose - bulging, opaque tympanic membrane that usually looks red, with decreased mobility; diffuse light reflex; and obscured landmarks - drainage, usually yellowish green, purulent, and foul smelling (indicates perforation of the tympanic membrane)

cystic fibrosis manifestations → respiratory system

early s/s - wheezing/dry cough, bronchiolitis, pneumonia, purulent/copious sputum worsening s/s - crackles, wheezes, decreased breath sounds, retractions, hypoxia - nasal polyps, sinusitis, digital clubbing, barrel chest

otitis media

effusion and infection or blockage of the middle ear

acute otitis media (AOM)

effusion in the middle ear that occurs suddenly and is associated with other signs of illness

long term management of asthma

environmental control - irritants and allergens exercise - warm the air (breathing through nose or covering mouth) sports without sustained effort are ideal → **swimming* - infections - emotions **monitor symptoms - early treatment is best - peak flow meter

nursing care for respiratory alterations

facilitate gas exchange - maintain oxygen sats > 95% on room air - humidified oxygen (35-45%) via hood, mask, nasal - respiratory therapy - positioning → head at 30-40 degrees - suction PRN prevent transmission - respiratory and contact precautions PRN maintain fluid balance - orally (clear liquids) or IV prn - saline nose drops - promote rest, reduce fever, decrease anxiety - reduce patient and family anxiety

family risk factors for respiratory distress

family history of allergies, asthma, TB, or cystic fibrosis

pancreatic enzymes in cystic fibrosis

give with every meal and snack**** (in order to digest food, or else they'll die of starvation

adenoiditis

infection and inflammation of the pharyngeal tonsils or adenoids

tonsilitis

inflammation and injection of the two palatine tonsils

bronchiolitis

inflammation of bronchioles - respiratory syncytial virus (RSV) is the causative agent in 50% of cases in bronchiolitis - RSV is a significant cause of hospitalization in children under 1 year of age - ** highly communicable - contact isolation and scrupulous hand hygiene!!*** - can live on non-porous surfaces for up to 6 hours

pneumonia

inflammation of the lung parenchyma - primary or secondary disease - viral or bacterial - community acquired - marked decrease since the introduction of routine vaccinations

allergic rhinitis

inflammatory disorder of the nasal mucosa - seasonal, recurrent, and triggered by specific allergies - usually there is a family history - some children have symptoms year round - rhinorrhea, itching, and sneezing - allergic salute & allergic shiners **table from pg 1034** in mckinney book in powerpoint

expect ___________ and ICU admission with epiglottitis

intubation

diagnostic evaluation of pharyngitis

is usually self limiting and relatively minor, however streptococcal infections can have serious complications - rheumatic fever - acute glomerulonephritis throat culture - the only reliable means of determining if bacterial or viral -- *rapid strep test

which action would the nurse include in the plan of care for a 6 month old infant with RSV who is in respiratory distress? - begin a clear fluid diet - maintain droplet and contact precautions - administer prescribed antibiotic immediately - allow parents and siblings to room in with the infant

maintain droplet and contact precautions

prenatal risk factors for respiratory distress

maternal infections, maternal smoking, maternal drug use

incidence of pharyngitis and tonsillitis peaks during

middle childhood

can be hard to tell the difference between viral and bacterial ___________

pharyngitis

a client is experiencing an acute episode of bronchial asthma. the nurse would focus on which goal when creating the client's plan of care? - curing the condition permanently - removing mucous secretions from the chest - limiting pulmonary secretions by decreasing fluid intake - helping the client recognize that the condition is emotionally based

removing mucous secretions from the chest

sudden infant death syndrome

sudden and unexplained death of an infant younger than 1 year old - exact cause is unknown - referred to as crib death by the public - usually occurs during sleep - more common in boys - low birth weight infants - racial disparity - most common in winter months

respiratory failure

unrecognized or untreated respiratory distress - children failing to improve with treatment or who deteriorate despite treatment are likely to suffer most common cause of cardiopulmonary arrest in children