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