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