Peds Unit 3 Resp
mild resp distress attempting to compromise s/s
-Restlessness -Tachypnea -Tachycardia -Diaphoresis
How to distinguish allergic rhinitis from common cold on physical examination
-allergic shiners: bluish discoloration of the infraorbital area. caused by increased venous flow related to local allergic vigor -allergic salute: transverse crease across the lower third of the nose caused by rubbing of the nose, -examination of the nasal cavity may reveal edematous mucosa , with swollen boggy , and pale pink to blue-gray turbinates. -nasal secretions are clear, watery, or white -itching of the nose, fatigue, irritability
Viral Pharyngitis
Gradual onset Sore throat (peaks day 2-3) Erythema and inflammation of tonsil- ulcers present Fever Hoarseness, cough, rhinitis Enlarged lymph nodes Duration 3-4 days
Medical management of allergic rhinitis
-Eliminate allergen Medications: -Antihistamines -Decongestant -Intranasal corticosteroids -leukotriene modifiers , mast cell stabilizers -Allergy injections
Grunting
noise made in infant when he or she attempts to provide induced positive end-expiratory pressure. *usually an ominous sign and may indicate impending respiratory failure in the infant or young child*
Pharyngitis s/s
-Extreme throat discomfort Young child: fever, malaise, anorexia, headaches Older child: fever, headache, dysphagia, abdominal pain -Group A Strep (GABHS) -White exudate, petachiae, high fever, scarlet fever rash, -cervical lymphadenopathy, dyphasia, hoarseness, laryngitis
Moderate Respiratory Distress: Early Decompensation s/s
-Nasal flaring -Retractions -Grunting, wheezing -Anxiety, irritability, mood changes, confusion -Hypertension
Simplified pediatric differences
-Premature infants lack surfactant -Smaller lower airway -Lack of support from cartilage -Infant Obligatory nose breathers -Diaphragm major respiratory muscle for neonates Higher respiratory rate -↑ Metabolic rate= ↑ O2 needs -Respiratory tract continues to grow until about age 12 -Eustachian tubes flat -the diameter of an infant's airway is 4mm, in contrast to an adult's airway 20mm
Pediatric differences in respiratory system
- Respiratory problems are the most common cause of acute illness in infants and children and the leading cause of morbidity in children. (Influenza) -Surfactant lacking in premature infants. - High risk of RDS in those born prior to 34 weeks gestation. -Due to immature system children <3 years at higher risk for developing respiratory infections. (Size-structure-function) -Preventive measures teach caregivers: Rest Good Nutrition Hygiene- especially handwashing -Child physically smaller less reserve capacity risk for respiratory failure more readily -Airway short and narrow -Smaller airway and underdeveloped cartilage predisposes to obstruction by mucus, edema and foreign bodies. -Diaphragm is infants major respiratory muscle. -Intercostal muscles not developed therefore retractions are common in infants than in older children. Anything causing abdominal distention can lead to respiratory distress. -Brief apnea periods (10 to 15 seconds) are common as well as irregular respiratory pattern. -Infants are obligatory nasal breathers. -Nasal congestion leads to breathing difficulty. -Chest wall is twice as compliant and flexible compared to adult so retractions are more visible. - Nurse teach parents what to look for and when to call health care provider -Oral decongestants work systemically to shrink mucous membranes but may be a problem for those with diabetes, or high blood pressure. -The respiratory tract of the child grows until they are about 12 years of age in length and diameter. -Children younger than 8 do not need cuffed ET tubes because cricoid is so narrow it provides a natural physiologic cuff.
diagnosis for sinusitis
-CT scan (over age of 6) -cultures -other radiographic studies to rule out complications such as orbital cellulitis (med emergency)
Severe Respiratory Distress: Respiratory Failure/Imminent Arrest s/s
-Dyspnea -Bradycardia -Cyanosis (note that cyanosis is a late sign) Stupor, coma
Assessment of children with sinusitis
-ask ?s nasal congestion, rhinorrhea, cough,HA, toothache, and worsening of symptoms . -positive hx for sinusitis would be symptoms that last for more than 10 days w/o evidence of improvement. -Acute / Chronic Viral or bacterial Follow URT viral infections s/s of cold that does not improve after 14 days Low grade fever Nasal congestion with purulent drainage Sinuses pressure/fullness Headache or toothache
The nurse is providing care to several children who have been brought to the clinic by the parents reporting cold-like symptoms. The nurse would most likely suspect sinusitis in which child? a) A 5-year-old with nasal congestion and sore throat b) A 3-year-old with sneezing and coughing c) A 7-year-old with halitosis and thick, yellow nasal discharge d) A 2-year-old with thin watery nasal discharge
A 7-year-old with halitosis and thick, yellow nasal discharge Explanation: The frontal sinuses, those most commonly associated with sinus infection, develop by age 6 to 8 years. Therefore, the 7-year-old would most likely experience sinusitis. In addition, this child also exhibits halitosis and a thick, yellow nasal discharge, other findings associated with sinusitis. Thin watery discharge in a 2-year-old is more likely to indicate allergic rhinitis. A 3-year-old with coughing and sneezing or a 5-year-old with nasal congestion and sore throat suggests the common cold
Bacterial pharyngitis
Abrupt onset Sore throat (severe) Erythema and inflammation of tonsils Fever (↑ 103°) lasts 1-4 days Abd pain, vomiting, h/a Enlarged cervical lymph nodes Duration 3-5 days
Infants and children develop impaired __________ and ________ much faster than adults.
Resp distress and failure
Meds for epiglottis and interventions
Beta-agonist /Bronchodilator- Albuterol Corticosteroids 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
A group of nursing students are reviewing information about the variations in respiratory anatomy and physiology in children in comparison to adults. The students demonstrate understanding of the information when they identify which finding? a) An increase in oxygen saturation leads to a much larger decrease in pO2. b) Children's demand for oxygen is lower than that of adults. c) Children develop hypoxemia more rapidly than adults do. d) Children's bronchi are wider in diameter than those of an adult.
Children develop hypoxemia more rapidly than adults do. Correct Children develop hypoxemia more rapidly than adults do because they have a significantly higher metabolic rate and faster resting respiratory rates than adults do, which leads to a higher demand for oxygen. A smaller decrease in oxygen saturation reflects a disproportionately much larger decrease in pO2. The bronchi in children are narrower than in adults, placing them at higher risk for lower airway obstructio
Croup
Commonly begins at night; May be preceded by several days of symptoms of URI Sudden onset of harsh, barky cough Sore throat Use of accessory muscles to breathe Frightened appearance Agitation Commonly begins at night; May be preceded by several days of symptoms of URI Sudden onset of harsh, barky cough Sore throat Use of accessory muscles to breathe Frightened appearance Agitation Cyanosis
Croup vs. epiglottis
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
Interventions for epiglottis
DO NOT: Leave child unattended if epiglottitis suspected Examine or attempt to obtain culture; any stimulation by tongue depressor or culture swab could trigger complete airway obstruction DO: Allow child to maintain position of comfort
Cardinal signs and symptoms of epiglottis
Drooling Dysphagia Dysphonia Distressed inspiratory efforts
A caregiver calls the pediatrician's office and reports to the nurse that her 4-year-old, who was fine the previous day, complained of a sore throat early in the morning and now has a temperature of 102.6° F (39.2° C). The caregiver has tried to get the child to nap but the child gets panicky, immediately sits back up, and leans forward with her mouth open and tongue out when the caregiver encourages her to lie down. The nurse suspects the child has which condition? a) Acute laryngotracheobronchitis b) Spasmodic laryngitis c) Epiglottitis d) Mild asthma
Epiglottitis Correct Explanation: Epiglottitis is acute inflammation of the epiglottis that most often affects children ages 2 to 7 years. The child may have been well or may have had a mild upper respiratory infection before the development of a sore throat (difficulty swallowing) and a high fever of 102.2 to 104 degrees Fahrenheit. The child is very anxious and prefers to breathe by to sitting up and leaning forward with the mouth open and the tongue out. This is called the "tripod" position. Immediate emergency attention is necessary
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
The nurse is assessing an adolescent complaining of a sore throat. The nurse anticipates the need for antibiotic therapy as treatment because the adolescent most likely has bacterial pharyngitis. Which of the following would the nurse identify to support this determination? a) White blood cell count within normal range b) Gradual onset c) Fever of 103 degrees F d) Rhinitis
Fever of 103 degrees F Correct Explanation: The signs and symptoms of bacterial pharyngitis include an elevated white blood cell count, an abrupt onset, headache and fever as high as 104 degrees F, sore throat, abdominal discomfort, tonsillar enlargement and firm cervical lymph nodes
A child is brought to the emergency department by his parents because he suddenly developed a barking cough. Further assessment leads the nurse to suspect that the child is experiencing croup. What would the nurse have most likely assessed? a) Inspiratory stridor b) High fever c) Dysphagia d) Toxic appearance
Inspiratory stridor Correct Explanation: A child with croup typically develops a bark-like cough often at night. This may be accompanied by inspiratory stridor and suprasternal retractions. Temperature may be normal or slightly elevated. A high fever, dysphagia, and toxic appearance are associated with epiglottitis
Management of Croup
Maintain patent airway Cool mist Epinephrine Observe in ER Oral dexamethosone Antipyretic Hydration
Post-op care for tonsillectomy
Monitor for bleeding Excessive swallowing ↑ Pulse Vomiting bright red emesis Restlessness not associated with pain Educate Encourage liquids (avoid red) Avoid scratchy food No straw, fork or sharp object in mouth Nursing dx Risk for injury (hemorrhage) r/t surgery Acute pain r/t surgical procedure
Desired results when using Oxygen
PaO2 >60-80 mmHg O2 sat > 93%
The nurse is examining an 8-year-old boy with tachycardia and tachypnea. The nurse anticipates which test as most helpful in determining the extent of the child's hypoxia? a) Chest radiograph b) Pulmonary function test c) Peak expiratory flow d) Pulse oximetry
Pulse oximetry Correct Explanation: Pulse oximetry is a useful tool for determining the extent of hypoxia. It can be used by the nurse for continuous or intermittent monitoring. Pulmonary function testing measures respiratory flow and lung volumes and is indicated for asthma, cystic fibrosis, and chronic lung disease. Peak expiratory flow testing is used to monitor the adequacy of asthma control. Chest radiographs can show hyperinflation, atelectasis, pneumonia, foreign bodies, pleural effusion, and abnormal heart or lung size
Diagnostic tests for Allergic rhinitis
RAST - radioallergosorbent test Blood test measuring immunoglobulin E Not as sensitive as skin testing
Adenoiditis
Stertorous breathing - snoring, nasal quality speech Pain in ear, recurring otitis media
ALTE
Sudden event Combination of events: Apnea Change in color (pallor, cyanosis, redness) Change in muscle tone Choking, gagging, coughing Requires significant intervention & or CPR by caregiver witnessing event ALTE can occur without apnea *
ALTE tx
Treatment of underlying condition Recurrent Apnea without organic condition Home CR monitoring Respiratory Stimulant Drugs (Theophylline or Caffeine) Monitoring discontinued when no significant episodes for 2-3 months Download data directly to PEDS office Home monitoring will not Predict or Prevent SIDS
Peak flow measurement
Used to measure the greatest flow velocity during a forced expiration. Child exhales forcefully and quickly into the meter while taking maximal deep inhalation.
Nasopharyngitis s/s
clear rhinorrhea, nasal stuffiness, cough Young child: fever, sneezing, vomiting or diarrhea Older child: dryness and irritation of nose/throat, sneezing, aches, cough
Stridor
high-pitched,harsh, whistling sound heard on inspiration and is produced by turbulent airflow through laryngeal or tracheal obstruction. Usually more pronounced when child is crying or agitated.
Newborns who are born more than 24 hours after rupture of the amniotic membranes are particularly prone to developing pneumonia in their first few days of life. a) False b) True
true
Choice Multiple question - Select all answer choices that apply. A child is diagnosed with bronchiolitis. Which of the following would the nurse expect to include in the child's plan of care? Select all that apply. a) Oxygen therapy b) Bronchodilator therapy c) Chest physiotherapy d) Fluid and electrolyte replacement e) Pulse oximetry monitoring
• Oxygen therapy • Pulse oximetry monitoring • Fluid and electrolyte replacement Explanation: Humidified oxygen is used for infants who demonstrate oxygen desaturation of less than 90% (Schuh, 2011). Continuous pulse oximetry is recommended for infants in acute distress. Nutritional care for the infant with bronchiolitis includes supportive fluid and electrolyte replacement. Chest physiotherapy has not be found to be helpful. Bronchodilators and corticosteroids have limited effects on a child with bronchiolitis.
A 5-year-old child is brought to the clinic by his father because the child developed a high fever over the past 2 to 3 hours. The nurse suspects epiglottitis based on which signs and symptoms? Select all that apply. a) Drooling b) Cough c) Difficulty speaking d) Frightened appearance e) Sitting with neck extended
• Sitting with neck extended • Drooling • Frightened appearance • Difficulty speaking Correct Explanation: Epiglottitis is manifested by a sudden onset of symptoms and high fever. The child has an overall toxic appearance and may refuse to speak or speak only in a very soft voice. The child may assume the characteristic position of sitting forward with the neck extended. Drooling may be present but a cough is usually absent. The child may appear frightened or anxious. (less)
