The Child With a Respiratory Alteration - Chapter 45

Postnatal changes in the respiratory system occur as follows:

1. Compression of the thorax during vaginal delivery forces out some of the fetal lung fluid. 2. Respirations are stimulated by hypoxemia, hypercarbia, cold, tactile stimulation, and possibly by the decrease in the plasma concentration of prostaglandin E2. 3. Inflation of the normal lung is complete within a few breaths, and most alveoli have expanded within the first hour of life. 4. Surfactant in the lung liquid lowers surface tension and facilitates lung expansion. 5. Pulmonary blood flow increases. 6. Closure of the foramen ovale and the ductus arteriosus (see Chapter 46) establishes the pulmonary and circulatory systems.

Monitoring Breathing Capacity With a Peak Flow Meter

1. Remove gum or food from the mouth and stand up. 2. Move the pointer on the meter to 0, its lowest point. 3. Hold the meter horizontally, being sure to keep your fingers away from vent holes and the marker. 4. Relax and take a few slow, deep breaths. Then, slowly take the deepest breath you possibly can with your mouth wide open. 5. While holding your breath, place the mouthpiece of the meter on your tongue, and close your lips tightly around the mouthpiece. 6. Blow out as hard and fast as possible. Give a short, sharp blast, like blowing a loud whistle, not a slow blow. (The meter records the fastest blow, not the longest.) Look at the number by the marker on the numbered scale. Write it down. 7. Repeat two more times. Wait at least 10 seconds between attempts. (Be sure to move the pointer to 0 after each try.) 8. Record the highest of the three readings in your daily asthma diary. 9. It is best to take peak flow readings every day, preferably in the morning and before and after you take a bronchodilator.

Acute Asthma Episode Management

A child who is having an episode of wheezing along with other symptoms of asthma is usually seen at a physician's office or an emergency department. First, a bronchodilator, usually a short-acting beta2-adrenergic agonist (SABA) such as albuterol, is administered by a powered nebulizer or metered-dose inhaler (MDI) as often as every 20 minutes for 1 hour or continuously. Oxygen is administered as well.

Asthma Manifestations

A child with an asthma episode may have only a dry cough. Wheezing is a classic sign of asthma, but other signs can be present, including shortness of breath, cough, or dyspnea on exertion. Other manifestations may have a sudden or insidious onset: • Retractions, nasal flaring, or stridor • Nonproductive cough (with or without wheezing) that later becomes productive • Tachypnea, orthopnea • Restlessness, apprehension, diaphoresis • Abdominal pain resulting from the strain placed on the abdominal muscles during labored breathing • A hunched-over sitting position with arms braced (tripod position) • Fatigue and difficulty performing simple tasks such as eating, walking, or even talking, because of shortness of breath • A feeling of chest tightness followed by a dry cough, wheezing, and dyspnea • Worsening of symptoms after the child goes to bed at night because of increased narrowing of the airways at night and pooling of secretions

Tonsillectomy Assessment: Preoperative Period

A complete history is taken, with special attention given to allergy symptoms, difficulty swallowing, or airway obstruction. The child is assessed for signs of active infection (fever, elevated white blood cell [WBC] count) and redness and presence of exudate in the throat

Bronchiolitis Manifestations

A mild upper respiratory tract infection usually precedes the development of bronchiolitis. Serous nasal drainage, sneezing, low-grade fever, and anorexia are present for several days, followed by the onset of acute respiratory distress, manifested by the following signs and symptoms: • Tachypnea—respiratory rates of 60 to 80 breaths/min • Tachycardia—heart rate greater than 140 beats/min • Wheezing, crackles, or rhonchi • Intercostal and subcostal retractions with or without nasal flaring • Cyanosis

The parent of a child with cystic fibrosis calls the clinic nurse and describes signs and symptoms of tachypnea, tachycardia, dyspnea, pallor, and cyanosis. What does the nurse suspect the child is experiencing? A. A pneumothorax B. Bronchodilation C. Carbon dioxide retention D. Extremely thick sputum

A pneumothorax The child is exhibiting signs of increasing respiratory distress suggestive of a pneumothorax. The child needs to be seen as soon as possible. Bronchodilation would not produce the symptoms listed. Carbon dioxide retention would not produce the symptoms listed. An increased viscosity of sputum is characteristic of cystic fibrosis. The described change in respiratory status is potentially due to a pneumothorax.

Asthma

A reversible obstructive airway diseasecharacterized by ØIncreased airway responsiveness to a variety of stimuli ØBronchospasm resulting from constriction of bronchial smooth muscle ØInflammation and edema of the mucous membranes that line the small airways and the subsequent accumulation of thick secretions in the airways

A 4-year-old child needing to use a metered-dose inhaler to treat asthma cannot coordinate her breathing to use it effectively. The appropriate intervention by the nurse is to use which piece of respiratory equipment? A spacer A nebulizer A peak expiratory flowmeter An incentive spirometer

A spacer The medication in a metered-dose inhaler is sprayed into the spacer. The child can then inhale the medication without having to coordinate the spraying and breathing. A nebulizer is a mechanism used to administer medications, but it cannot be used with metered-dose inhalers. This is a measure of pulmonary function not related to medication administration. This item helps patients to increase their lung expansion and to be able to see their progress.

Pharyngitis and Tonsillitis Therapeutic Management

Acetaminophen or ibuprofen is used for pain; older children may find gargling with warm saline solution comforting. Cool, bland liquids are tolerated best because of the discomfort caused by swallowing solids or irritating liquids. The primary reason for treating streptococcal pharyngitis is to prevent acute rheumatic fever and its consequences

Pulmonary Noninfectious Irritation Acute Respiratory Distress Syndrome

ARDS represents severe diffuse lung injury precipitated by a variety of illnesses. The mechanism of lung injury in children is similar to that of adults and usually occurs from 8 to 48 hours after the initial illness, which may be, but is not limited to, aspiration, trauma, drug ingestion, shock, and massive transfusions. ØSevere diffuse lung injury ØPrecipitated by a variety of illnesses ØBreakdown in the alveolar-capillary barrier

Bronchitis Etiology and Incidence

Acute bronchitis is usually viral in origin. Rhinoviruses are the most common causative organisms. Other viruses thought to cause bronchitis include respiratory syncytial virus, influenza virus, parainfluenza virus, and adenovirus. Most bacterial infections occur secondary to a primary viral infection or some other airway problem. They can also occur as a result of foreign body aspiration.

Sinusitis Pathophys

Acute sinusitis occurs when the sinus cavity is invaded by bacteria, causing mucosal inflammation and edema that block narrow sinus channels. The volume of secretions increases, and the affected sinuses fill with purulent material. Inflammation and infection interfere with the protective cleansing action of the cilia covering the sinus mucous membranes. Impaired mucociliary transport leads to stagnation of secretions within the sinuses; the stagnant secretions provide a medium for bacterial growth. Chronic sinusitis is usually a complication of acute sinusitis. Prolonged or repeated infections result in irreversible changes in the mucosal lining of the sinus. Nasal polyps, a deviated septum, and enlarged adenoids inhibit sinus drainage, which can lead to infections. The frontal and sphenoid sinuses are most often involved in children. Infection from sinusitis can spread to the middle ear, causing otitis media. Serious complications occur when infection spreads either directly through the bone or along the venous channels of the skull into adjacent structures, such as the orbit or the central nervous system.

Sinusitis

Acute sinusitis often follows an upper respiratory tract viral infection. Children with chronic sinusitis often have allergic rhinitis or otitis media with effusion (OME) as well. Children with cystic fibrosis have a high incidence of sinusitis because of highly viscous mucus secretions and nasal polyps. Sinusitis, although not itself a serious disorder, can lead to life-threatening complications. Inflammation and infection of the sinuses can be acute or chronic. Hypertrophied adenoids, immune deficiencies, and foreign body obstruction of the nose also predispose one to sinusitis.

ARDs Manifestations

Acute, subacute, and chronic phases Pulmonary manifestations may be minimal during acute phase but will move toward respiratory distress (dyspnea, tachypnea, retractions, grunting, cyanosis). Severe hypoxemia and, occasionally, hypercapnia may develop. Note that there is a primary disease, and manifestations of that disease process will also be present.

allergic rhinitis (hay fever) Etiology and Incidence

Agents that commonly cause allergic rhinitis include dust mites, feathers, animal dander, mold spores, and pollens of trees, grasses, and weeds. There is usually a family history, as seen in individuals with atopic dermatitis and asthma.

allergic rhinitis (hay fever) Pathophys

Allergens (pollens, molds, spores, dust mites, animal dander) are deposited on the nasal mucosa, causing local inflammation and increased capillary permeability. Local immunoglobulin E (IgE) is produced, and sensitization of the respiratory tissues occurs. Mast cell mediators are released, producing vasodilation, mucosal edema, mucus secretions, stimulation of itch receptors, and a reduced threshold for sneezing.

Cystic Fibrosis

An inherited multisystem disorder characterized by widespread dysfunction of the exocrine glands ØAbnormal secretions of thick, tenacious mucus ØObstruction and dysfunction of the pancreas, lungs, salivary glands, sweat glands, and reproductive organs ØTransmitted as an autosomal recessive trait

Tonsillectomy Safety Alert

Assessing the child for postoperative bleeding is most important. Because the operative site is not as readily visible as other sites, the nurse needs to look for the following: • Excessive swallowing • Elevated pulse; decreasing blood pressure • Signs of fresh bleeding in the back of the throat • Vomiting bright-red blood • Restlessness that does not seem to be associated with pain

Pulmonary Noninfectious Irritation Smoke Inhalation

As many as 50% of all fire-related deaths are caused by smoke injuries. Singed nasal hair Cough Hoarseness Hemoptysis Soot in sputum Cyanosis Wheezing Carbon monoxide effects: Mild: Headaches, mild dyspnea, visual changes, confusion Moderate: Irritability, diminished judgment, dim vision, nausea Severe: Hallucinations, confusion, ataxia, collapse, coma Can contribute to ARDS

Croup Assessment

Assess the child for inspiratory stridor, barking cough, hoarseness, and increased heart and respiratory rates Record any signs of respiratory distress, such as the use of accessory muscles; substernal, intercostal, and suprasternal retractions; nasal flaring; restlessness and irritability; and pallor or cyanosis. Cyanosis, increased heart rate and respiratory rate, extreme restlessness, or evidence of fatigue or listlessness are signs of hypoxia and should be reported to the physician immediately The lungs should be auscultated for adventitious breath sounds or areas of decreased breath sounds. Temperature and hydration status should also be assessed.

Bronchiolitis

Bronchiolitis, or inflammation of the bronchioles, is a significant cause of hospitalization in infants younger than 1 year. Respiratory syncytial virus (RSV) is the causative agent in more than half of cases It is usually transferred by inadequately washed hands. Meticulous hand hygiene decreases the spread of organisms.

Bronchitis

Bronchitis is a disease that rarely exists by itself but occurs together with other conditions of the upper and lower respiratory tracts. It can be confused with asthma. A cough is the major sign; it usually resolves without therapy in approximately 2 weeks.

Bronchitis Manifestations and Diagnostic Evaluation

Bronchitis is characterized by the gradual onset of rhinitis and a cough that is initially nonproductive but may change to a loose cough with increased mucus production. Auscultation can reveal coarse and fine, moist crackles and high-pitched rhonchi (resembling the wheezing of asthma). Associated symptoms include malaise, low-grade fever, and increased mucus, which can be purulent. Chest radiographs are usually normal. The diagnosis is based on the clinical findings.

Apnea

Cessation of breathing for 20 seconds or longer During an episode of apnea it is important to note the following: ØTime and duration of the episode ØColor change ØBradycardia ØO2 saturation ØAction that stimulated breathing

Tuberculosis Manifestations

Children aged 3 to 15 years are usually asymptomatic, have normal chest radiographs, and can be identified only through a positive skin 1073test. Some children have malaise, fever, night sweats, a slight cough, weight loss, anorexia, lymphadenopathy, or more specific symptoms related to the site of extrapulmonary infection (e.g., kidneys, brain, bone).

Pulmonary Noninfectious Irritation Passive Smoking

Children with a history of exposure to cigarette smoke, both prenatally and postnatally, have more frequent upper and lower respiratory complications, more hospitalizations for those complications, and a greater tendency to develop wheezing than do nonexposed children. Increased respiratory infections An effect on respiratory function and growth in infants and small but significant reduction in airway function in older children Possible negative effect on linear growth of children with CF

Bronchopulmonary Dysplasia

Chronic obstructive pulmonary disease Result of acute lung injury in some infants who have received supplemental O2 and mechanical ventilation Thickening of the alveolar walls and bronchiolar epithelium Occurs primarily in low-birth-weight and premature infants Chronic lung disease of infancy

Sinusitis Diagnostic Evaluation

Criteria: Persistent - symptoms for more than ten days without improvement; Worsening - symptoms that become worse after initial improvement, or symptoms along with a late-appearing fever; or Severe - purulent discharge along with fever for three consecutive days Imaging studies are not recommended for diagnosing sinusitis

Croup Pathophysiology

Croup is a viral infection of the upper airway. Although the entire upper, or nonreactive, airway is involved to some extent in all forms of croup, each type is named according to the anatomic area most severely involved. For example, laryngotracheobronchitis affects the larynx, trachea, and bronchi. In acute spasmodic croup, the larynx is the area of most severe inflammation. In all forms of croup, mucosal inflammation and edema cause narrowing of the airway. This narrowing is more dangerous in infants and young children than in adults because of their small airway diameter and flexible larynx, which is more susceptible to spasm. Symptoms are usually worse at night and better in the day; they may recur for several nights. Croup usually lasts 3 to 4 days.

Croup Manifestations

Croup often begins at night and may be preceded by several days of symptoms of upper respiratory tract infection. The child with laryngotracheobronchitis may have a gradual onset and a fever along with other signs and symptoms; occasionally the fever is as high as 40° C (104° F). Children with spasmodic croup do not have a fever. Other manifestations include the following: • The sudden onset of a harsh, metallic barky cough; sore throat; inspiratory stridor; and hoarseness 1043 • The use of accessory muscles (substernal, intercostal, suprasternal retractions) to breathe • Frightened appearance • Agitation • Cyanosis

Croup

Croup refers to a group of conditions characterized by inspiratory stridor, a harsh (brassy or croupy) cough, hoarseness, and varying degrees of respiratory distress The major types of croup are acute spasmodic croup, laryngotracheobronchitis, bacterial tracheitis, and epiglottitis. Although epiglottitis is a type of croup, it is discussed separately because it is a bacterial infection with unique symptoms and treatment.

Epiglottitis (Supraglottitis) Cardinal S/S - Safety Alert

Drooling Dysphagia (difficulty swallowing) Dysphonia (difficulty talking) Distressed inspiratory efforts Do not examine or obtain material for culture from a child's throat if epiglottitis is suspected because any stimulation with a tongue depressor or culture swab could trigger complete airway obstruction. Do not leave a child with epiglottitis unattended.

Antihistamine s/e

Drowsiness, the most common side effect of antihistamines, can usually be alleviated if the child takes the medication at night. Some children have dry mucous membranes or excitability. Warm water or saline solution irrigations of the nasal passages can be used to moisten mucous membranes, soften crusted secretions, and wash out irritants

Epiglottitis (Supraglottitis) Pathophysiology

Epiglottitis is a bacterial form of croup. The epiglottis and surrounding structures become inflamed as bacterial infection invades the soft tissue. The epiglottis becomes edematous and cherry red and may become so swollen that it completely covers the glottis and obstructs the airway. Secretions pool in the hypopharynx and larynx. As the disease rapidly progresses, swelling becomes so severe that the child is unable to swallow and begins to drool. The child's voice is muffled, and the throat is very sore. Inspiratory stridor, cough, and irritability are present. Complete airway obstruction can occur rapidly, resulting in hypoxia, acidosis, and death. The onset of epiglottitis is usually sudden. The child may have had symptoms of a mild upper respiratory tract infection for a few days before symptoms began. Children with epiglottitis can progress from wellness to complete airway obstruction within 2 to 6 hours.

Epiglottitis (Supraglottitis)

Epiglottitis, the acute inflammation and swelling of the epiglottis and surrounding tissue, is a life-threatening, rapidly progressive condition that can cause complete airway obstruction within a few hours of onset.

Laryngomalacia (Congenital Laryngeal Stridor)

Flaccidity of the epiglottis and supraglottic aperture and weakness of the airway walls contribute to laryngomalacia, the most common cause of inspiratory stridor in the neonatal period Laryngomalacia may be caused by immature neuromuscular development in the airway.

Asthma Diagnostic Evaluation

For children older than 5 years, an objective measure of airflow by spirometry is necessary for diagnosis. Improvement of symptoms in response to nebulized bronchodilators is strongly suggestive of asthma as opposed to other pulmonary disease

Foreign Body Aspiration

Foreign body aspiration is seen most frequently in children ages 6 months to 5 years. Children who play, run, or laugh with objects in their mouths are at risk. Certain items have an increased incidence of aspiration by infants and children

Tonsillectomy Assessment: Postoperative Period

Immediately after surgery, the child should be assessed for bleeding and ability to swallow secretions. Postoperative hemorrhage is a dangerous complication that will need immediate attention. If bleeding occurs, the child is returned to surgery for recauterization. Suction equipment should be available, but do not suction unless there is airway obstruction. The child is assessed for bleeding (frequent swallowing; restlessness; a fast, thready pulse; or vomiting bright red blood). When visually assessing the site for clots or bleeding, use a flashlight for illumination and avoid using a tongue depressor if at all possible.

Croup Interventions

If epiglottitis is suspected, the physician should be contacted and the throat should not be inspected because such examination can result in laryngospasm and airway obstruction. The nurse should administer humidified oxygen at the ordered flow rate. Record vital signs and pulse oximetry readings frequently. There should be emergency intubation equipment (e.g., intubation tray, oxygen, suction, manual resuscitation bag-valve-mask) closely available should the child's condition change rapidly. Aerosolized racemic epinephrine is often administered to decrease laryngeal 1045edema, and dexamethasone is given as an antiinflammatory agent. The child should be observed for recurrence of obstruction, which may occur within a few hours after administration of racemic epinephrine. The child should be kept as quiet as possible because crying can aggravate laryngospasm and increase hypoxia. Encourage parents to stay nearby. Maintain a calm, quiet environment. Observe the child closely but disturb as little as possible. Support the child in an upright position with the head of the bed elevated to facilitate respiration. Tachypnea causes insensible water loss, and difficulty swallowing leads to decreased intake. Observe the child's ability to swallow because tachypnea and laryngospasm often cause dysphagia.

Bronchiolitis Pathophysiology

In bronchiolitis, edema and the accumulation of mucus and cellular debris cause obstruction of the bronchioles. Airway resistance is increased during the inspiratory and expiratory phases of respiration because of the small air passages. Hyperinflation of the lungs results from air trapping because the bronchioles constrict during expiration. Atelectasis can occur if obstruction becomes complete and trapped air is absorbed. Normal gas exchange is impaired, and the infant becomes hypoxic. Some infants have mild respiratory alkalosis; more frequently, metabolic acidosis is observed. The child with bronchiolitis is most acutely ill during the first 48 to 72 hours after the onset of the disease. Improvement usually occurs in a few days. Symptoms may last for 10 to 14 days. Mortality rate is less than 1%.

Bronchitis Pathophysiology

Inflammation of the trachea and major bronchi is present in bronchitis. Mucus production is increased, and the mucosa is congested. Because of nonspecific leukocytic migration, purulent secretions can occur even in the absence of a bacterial infection. Acute bronchitis is a self-limiting disease. Chronic bronchitis in children may indicate an underlying chronic respiratory dysfunction.

Viral Pneumonia Manifestations

Low to high fever, cough, crackles, wheezing (more common with RSV), headache, malaise, myalgia, abdominal pain. Infiltrates seen on chest radiography. WBC count <20,000/mm3. Usually lasts 5-7 days.

Sinusitis Therapeutic Management

Most cases of acute sinusitis are self-resolving and do not require antibiotics When a prescription is required, amoxicillin or amoxicillin-potassium clavulanate (Augmentin) is used most frequently. In addition to antibiotics, treatment includes analgesics, hydration, and the application of moist heat. Antihistamines may be used to treat allergy symptoms associated with chronic sinusitis, but they tend to impair sinus drainage by thickening secretions

Tuberculosis

Mycobacterium tuberculosis, an acid-fast bacillus, causes TB. Contamination occurs chiefly through inhalation of droplets from a person with active TB. Droplets produced by coughing and sneezing remain suspended in the air. When inhaled, they can reach the bronchioles and alveoli. The risk of infection by the organism is thought to depend on several physiologic and socioeconomic factors. Most children are infected by a family member, babysitter, or other person with whom they have frequent contact

Laryngomalacia (Congenital Laryngeal Stridor) Manifestations

Noisy, crowing inspiratory respiratory sounds (stridor) are present, with or without retractions. The infant usually remains acyanotic despite the stridor. Stridor is usually present at birth but may begin as late as age 2 months. Symptoms increase when the infant is supine or when the infant is crying. There may be associated reflux or dysphagia. The diagnosis is based on a thorough history and on findings on direct laryngoscopy.

Otitis Media Therapeutic Management

Optimal pain relief with an appropriate analgesic for children with AOM Symptomatic treatment and observation for 48 to 72 hours after diagnosis as an alternative to initiating antibiotic therapy for selected children Use of amoxicillin at a dose of 80 to 90 mg/kg/day for 5 to 10 days when treatment is indicated, or a cephalosporin for children allergic to penicillin

Otitis Media Manifestations AOM

Otalgia (earache); infants may pull their ears or roll their heads. A bulging, opaque tympanic membrane that usually looks red, with decreased mobility; diffuse light reflex; and obscured landmarks recurrent if the child experiences more than three episodes over a 6-month period or four episodes in a year

Croup Etiology and Incidence

Parainfluenza viruses cause most cases of viral croup. The cause of acute spasmodic croup is unknown. Laryngotracheobronchitis, the most common form of croup, usually affects infants and toddlers; it is one cause of airway obstruction in children ages 6 months to 6 years. Acute spasmodic croup occurs most often in children ages 1 to 3 years. Spasmodic croup occurs more often in anxious and excitable children. There seems to be hereditary predisposition to spasmodic croup

Pharyngitis Pathophysiology

Pharyngitis often accompanies the common cold. Tonsillitis is usually present with pharyngitis. Infection and inflammation of the tonsils cause them to enlarge. The palatine tonsils may meet in the midline ("kissing tonsils") and cause difficulty swallowing and breathing. If adenoids enlarge, they can obstruct the eustachian tubes, resulting in otitis media and hearing impairment. Hypertrophy of the adenoids can also block the passageway between the nose and the throat, causing mouth breathing or obstructive sleep apnea.

Pharyngitis

Pharyngitis, inflammation of the pharynx and surrounding lymphoid tissue, can be viral or bacterial in origin. Although pharyngitis is a self-limiting and relatively minor disorder, streptococcal infections can have serious complications—among them, rheumatic fever and acute glomerulonephritis.

Bacterial Pneumonia Manifestations

Preceded by upper respiratory infection. Abrupt onset of high fever, chills, cough, chest pain, decreased breath sounds, signs of respiratory distress (retractions, nasal flaring, tachypnea), restlessness, and apprehension. Symptoms may be vague in infants; older children can have gastrointestinal symptoms, chest pain, and abnormal breath sounds. Onset of the bacterial-like pneumonias can be more insidious. Radiography reveals consolidation; WBC count is elevated.

Respiratory Illness in Children

Respiratory alterations are the most common causes of illness in the infant and child. Upper respiratory disorders affect the ears, nose, pharynx, and larynx; lower respiratory disorders include those that involve the trachea, bronchi, and lungs. Infants and children younger than 3 years are at greater risk than older children and adults for developing respiratory infections because of their immature immune systems, smaller upper and lower airways, and underdeveloped supporting cartilage. Although most respiratory infections are self-limiting, respiratory distress can occur quickly in infants and young children, as mucus and edema obstruct their small airways.

Safe Use of Oxygen at Home

Secure the oxygen tank in an upright position. Keep oxygen tanks at least 5 feet from heat sources and electrical devices (e.g., space heaters, heating vents, fireplaces, radios, vaporizers). Ensure that no one smokes in the room or in the area of the oxygen tank. Avoid using alcohol-based substances or oil to relieve dryness around your child's mouth (e.g., petroleum jelly, vitamin A & D ointment, baby oil). Turn off both the volume regulator and the flow regulator when oxygen is not in use.

Tonsillitis Manifestations

Sore throat, which can be persistent or recurrent Tonsils enlarged and bright red; may be covered with white exudate or cryptic plugs Difficulty swallowing Mouth breathing and an unpleasant mouth odor Enlarged adenoids, which may cause a nasal quality of speech, mouth breathing, hearing difficulty, otitis media, snoring, or obstructive sleep apnea There is a risk of airway obstruction and dehydration with this condition.

Sudden Infant Death Syndrome

Sudden and unexplained death of an infant younger than 1 year ØExact cause is unknown. ØReferred to as crib death by the public ØUsually occurs during sleep ØMore common in boys ØLow-birth-weight infants ØRacial disparity ØMost common in winter months

Laryngomalacia (Congenital Laryngeal Stridor) Therapeutic Management

Symptoms usually resolve without treatment by age 18 to 24 months. In rare instances, endotracheal intubation or tracheostomy may be required.

Croup Parent Education

Teach parents the signs and symptoms of respiratory distress and symptoms that should prompt a call to the physician: • Increased difficulty breathing or worsening of symptoms • Retractions (tugging in of the skin between, above, or below the ribs with inspiration) • Lips turn bluish or dusky • Breathing cool or warm mist does not improve symptoms in 20 minutes • Inability to drink much over the past 24 hours • Drooling or difficulty swallowing • Fever (greater than 39.4° C [103° F]) • Lethargy, listlessness, or severe agitation Parents are taught that acetaminophen or ibuprofen is effective in reducing fever and will help the child feel more comfortable. Cough syrups and cold medicines are avoided because they can dry and thicken secretions.

Tonsillectomy Interventions: Postoperative

The child should be placed in a prone or side-lying position to facilitate drainage. If bleeding occurs, the child is turned to the side and the physician notified. Vomiting of old blood ("coffee grounds" emesis) is common. Antiemetics are given as ordered to decrease throat pain caused by retching. If vomiting occurs, keep the child on NPO status for 30 minutes and then resume clear liquids. Provide clear, cool liquids when the child is fully awake. Avoid citrus drinks, carbonated drinks, and extremely hot or cold liquids because they may irritate the throat. Milk and milk products (puddings, ice cream) can coat the throat, causing a need to clear the throat, and thus, increasing the risk for bleeding.

allergic rhinitis (hay fever) Manifestations

The classic symptoms of allergic rhinitis are clear rhinorrhea with itching of the nose, eyes, ears, and palate, and paroxysmal sneezing not associated with an upper respiratory infection. Additional signs and symptoms include the "allergic salute"—an upward rubbing of the nose with the palm of the hand, which can leave a crease below the bridge(Fig. 45.1); allergic shiners—dark circles under the eyes from congestion and edema; dry lips from mouth breathing; pale, boggy nasal mucous membranes; and nasal obstruction

Croup Diagnostic Evaluation

The diagnosis is made mainly from observation of clinical symptoms. Differentiation between viral croup and bacterial epiglottitis is very important because treatment differs. However, the use of the H. influenzae type B (Hib) vaccine has reduced the incidence of epiglottitis. A croup score is often used to describe the severity of respiratory distress. Arterial blood gas values or pulse oximetry readings may be monitored to detect decreased PaO2 levels.

Emergency Asthma Management Safety Alert

The following symptoms indicate the need for emergency treatment of asthma: • Worsening wheeze, cough, or shortness of breath • No improvement after bronchodilator use • A peak flow rate that decreases or does not change (even after use of an inhaled beta2-adrenergic agonist) or that is less than 60% of the child's predicted baseline level or personal best • Difficulty breathing (the child's chest and neck are pulled in with each breath, or the child hunches over or struggles to breathe) • Trouble with walking or talking • Discontinuation of play without the ability to resume activity • Listlessness and weak cry in an infant; refusal to suck bottle or breast • Gray or blue lips or fingernails (in which case the child needs emergency treatment immediately!)

Croup Therapeutic Management

The goal of treatment is to maintain a patent airway. Crying aggravates the airway obstruction. Children who develop stridor at rest, cyanosis, severe agitation, fatigue, moderate to severe retractions, or are unable to take oral fluids should be seen in the emergency department. For mild croup, oral dexamethasone in a single dose of 0.15 to 0.6 mg/kg or inhaled budesonide decreases airway inflammation and reduces the necessity for hospitalization for many children Children with laryngotracheobronchitis, usually a more severe type of croup, are more often hospitalized than are those with acute spasmodic croup. Racemic epinephrine nebulized with oxygen can be given to decrease the laryngeal edema and bronchospasm. The child must be observed closely for changes in respiratory status and should not be treated with epinephrine on an outpatient basis because the effects of epinephrine are temporary. Croup symptoms can reoccur after approximately 2 hours, so children who receive epinephrine should be observed in the emergency department for at least 3 hours after treatment and should not be discharged if stridor or retractions are present. Antibiotics are not indicated unless a bacterial infection is present. Acetaminophen is given to reduce fever. For children with more severe symptoms (progressively worsening stridor, cyanosis, decreased oxygen saturation, retractions), hospitalization is necessary. Humidified oxygen and intravenous (IV) fluids are given until respiratory distress subsides and the child can take adequate fluids by mouth. Sedatives are contraindicated because they depress respirations and could mask restlessness, an early sign of hypoxia. If signs of moderate or severe hypoxia develop, the child is intubated immediately and is transferred to an intensive care unit. Usually, the tube remains in place for 3 to 5 days and is removed when the child can breathe around the tube and the inflammation subsides.

Epiglottitis (Supraglottitis) Diagnostic Evaluation

The most reliable diagnostic sign of epiglottitis is an edematous, cherry-red epiglottis. However, examination and visual observation of 1046the epiglottis are contraindicated until emergency intubation equipment and qualified personnel are available to support the child in case of sudden airway obstruction. The child's WBC count is usually elevated (20,000 to 30,000/mm3).

Sinusitis Nursing Considerations

The nurse assesses the location of pain or fullness. Pain can occur in the forehead or over the cheek bones or upper teeth, or it may radiate to the top of the head. Inspect and palpate the face for edema, document any fever, and inspect the nose and throat for purulent discharge. The nasal mucous membranes are inspected for erythema and edema. Sinus drainage is facilitated by increasing the child's intake of clear fluids and by using a bedside humidifier.

Laryngomalacia (Congenital Laryngeal Stridor) Nursing Considerations

The nurse observes the neonate for stridor, retractions, and dyspnea, noting any signs of acute respiratory distress. Because some infants have feeding problems, the infant should be observed for feeding difficulties and appropriate growth and development patterns. Obstruction may increase during crying or when the child has a respiratory infection. Stridor may increase when the child is supine with the neck flexed. Positioning with the neck hyperextended improves the child's breathing by reducing the obstruction, and thus, improves the stridor. If the bottle-fed infant has feeding difficulties, the parents can try using a smaller nipple. Smaller, more frequent feedings are sometimes better tolerated by infants with respiratory difficulties.

Bronchitis Nursing Considerations

The nurse should assess temperature, appearance of secretions, and respiratory effort every 2 to 4 hours. The child's intake should be monitored, and the nurse should observe for signs of sleep deprivation related to the persistent cough. Advise the parents to encourage fluids by frequently offering small amounts of the child's favorite liquids and to humidify the child's room. The child should be assessed for signs of dehydration; this includes taking daily weights if the child is hospitalized. Acetaminophen is administered for an elevated temperature (usually above 38.3° C [101° F]). Quiet activities should be provided for diversion.

Epiglottitis (Supraglottitis) Nursing Considerations

The nurse should continuously assess for signs of respiratory distress (stridor, nasal flaring, tachypnea, tachycardia, retractions, drooling, changes in level of consciousness, cyanosis). A sudden decrease in respiratory effort may be a sign of exhaustion and impending respiratory arrest. Arterial blood gas values and pulse oximetry findings are monitored. On pulse oximetry, the oxygen saturation should remain above 95%, with the PaO2 between 80 and 100 mm Hg. If temperature is taken, it 1047should be by the axillary or tympanic route rather than the oral route. The child should be supported in a position of comfort, usually sitting straight up (orthopneic); never force the child to lie down. Humidified oxygen is delivered in high concentrations Emergency intubation equipment (i.e., oxygen, laryngoscope, endotracheal tube, suction equipment) should be immediately available in case of complete airway obstruction. Worsening of the child's condition should be reported to the physician immediately. Antipyretics are given rectally for fever. Because of the risk for aspiration, the child is kept on NPO status, and fluids are given intravenously. The nurse must closely monitor the ordered IV rate and the urine specific gravity and other indicators of hydration. IV antibiotics are administered as ordered. If the child has an artificial airway, with either an endotracheal tube or a tracheostomy, the nurse must observe the child closely for respiratory distress and suction the airway as needed. The endotracheal tube must be securely taped to decrease movement of the tube and to minimize the chance of accidental extubation. Once intubated, the child needs to be restrained and sedated to prevent accidental extubation. It may be impossible to reintubate the child because of the severe swelling of the epiglottis. The endotracheal tube is usually kept in place for approximately 24 to 48 hours. After extubation, the child must be watched carefully and may be placed in a mist tent for 24 hours before being transferred to a pediatric unit. Normal respiratory rate and rhythm and normal color serve as evaluation criteria.

Bronchopulmonary Dysplasia Pathophysiology

The pressure of mechanical ventilation damages the bronchial epithelium. Macrophages and polymorphonuclear inflammatory cells invade the airways, causing airway edema. Alveolar walls become thickened, and fibrotic changes occur in the airways and alveoli. The continued use of oxygen affects the growth and development of lung structures, significantly reducing the number of developing alveoli. Cystic and atelectatic areas develop in the lungs, predisposing the infant to pulmonary hypertension. Loss of ciliated cells also can occur, which decreases the lungs' ability to remove mucus and leads to mucous plugs, atelectasis, and pneumonia.

allergic rhinitis (hay fever) Therapeutic Management

The treatment of choice is to eliminate the allergen from the child's environment. When this goal is impossible, as in the case of pollen in the air, medication can control symptoms. Antihistamines and/or intranasal corticosteroids can be effective in treating allergic rhinitis Antihistamines are most effective when given before or very early in an allergic episode. Because they can cause drowsiness, they should be given at night. Some of the newer antihistamines (e.g., loratadine, cetirizine, fexofenadine) are long acting, have fewer side effects, and require only one or two doses daily. They are prescribed according to the child's age. Decongestants can be effective in relieving nasal congestion but are not recommended in young children. Decongestants have side-effect profiles that include insomnia, behavior problems, and even cardiac events Short-term topical intranasal corticosteroids (e.g., fluticasone, mometasone, and budesonide) are highly effective and can be used as first-line therapy for children with allergic rhinitis. Several days of treatment are required before the child feels the effects of topical corticosteroids. Leukotriene inhibitors (e.g., montelukast [Singulair])

Tonsillitis

Tonsillitis is the term commonly used to describe inflammation and infection of the two palatine tonsils. Adenoiditis refers to infection and inflammation of the pharyngeal tonsils, or adenoids, which are located above the palatine tonsils on the posterior wall of the nasopharynx. The purpose of these lymphoid tissues is to filter and protect the respiratory and digestive tracts from invasion by pathogens, but often the tonsils become a site for infection.

Epiglottitis (Supraglottitis) Therapeutic Management

Treatment for epiglottitis should achieve a patent airway as quickly as possible. The child with epiglottitis has an edematous epiglottis that can completely obstruct the airway at any time. Radiographs are best obtained at the bedside, where the child can be constantly monitored and emergency equipment is readily available. The danger of airway obstruction is so great that usually all invasive procedures, such as venipuncture, are postponed until the child is intubated. Once the airway is secured, the child is transferred to the intensive care unit. Oxygenation status is closely monitored with arterial blood gas values or pulse oximetry, and humidified oxygen is administered. Mechanical ventilation is sometimes instituted. Throat and blood specimens are obtained for culture after the child is intubated. Antipyretics are given for fever. Antibiotics, usually a cephalosporin, are administered IV until the child is extubated, then continued orally for a 10-day course Usually the child improves dramatically after 48 hours of antibiotic therapy and can be extubated at this time. Discharge occurs in approximately 3 to 7 days.

Bronchitis Therapeutic Management

Treatment is mainly symptomatic and includes rest, humidification, and increased fluid intake. Exposure to cigarette smoke should be avoided. Cough suppressants are not recommended unless the cough interferes with the child's ability to rest. Antihistamines should be avoided because of their drying effect on secretions. Antibiotics should be given only if a bacterial infection is confirmed by culture or if the clinical findings support the diagnosis.

The mother of a 20-month-old child tells the nurse that the child has a barking cough at night and has a temperature of 37° C (98.6° F). Suspecting the child has croup, what should the nurse instruct the mother to do? Control the fever with acetaminophen, and call if the cough gets worse tonight. Try a cool-mist vaporizer at night and watch for signs of difficulty breathing. Try over-the-counter cough medicine, and come to the clinic tomorrow if there is no improvement. Take the child to the hospital in case epiglottitis occurs.

Try a cool-mist vaporizer at night and watch for signs of difficulty breathing. Because the child is not having difficulty breathing, the nurse should teach the parents the signs of respiratory distress and tell them to come to the emergency department if they develop. Cool mist is recommended to provide relief. Cough suppressants are not indicated. A barking cough and temperature of 37° C are characteristic of laryngotracheobronchitis (croup) and not epiglottitis. The child does not have a fever that needs to be managed.

Viral Pharyngitis v Bacterial Pharyngitis

Viral: Gradual onset Sore throat (reaches a peak on the second or third day) Erythema and inflammation of the pharynx and tonsils (may be slight), vesicles or ulcers on tonsils Fever (usually low grade but may be high) Hoarseness, cough, rhinitis, conjunctivitis, malaise, anorexia (early) Cervical lymph nodes may be enlarged and tender Usually lasts 3-4 days Bacterial: Abrupt onset (may be gradual in children <2 yr old) Sore throat (usually severe) Erythema and inflammation of the pharynx and tonsils Fever (usually high, 39.4-40° C [103-104° F], but may be moderate), begins early in illness and usually lasts 1-4 days Abdominal pain, vomiting, headache Cervical lymph nodes may be enlarged and tender Usually lasts 3-5 days **diagnose with a throat culture - only way to differentiate

Pulmonary Noninfectious Irritation

acute respiratory distress syndrome (ARDS), passive smoking, and smoke inhalation.

allergic rhinitis (hay fever)

an inflammatory disorder of the nasal mucosa that is usually seasonal, recurrent, and triggered by specific allergens Some children have symptoms year round

Otitis Media Etiology

bacteria Although viruses do not cause otitis media, they are thought to predispose the child to ear infection by altering host defenses and contributing to eustachian tube dysfunction. Allergies are also thought to precipitate otitis media. Bottle feeding can contribute to ear infection because of the position of the infant during feeding.

Otitis Media

effusion (fluid) and infection or blockage of the middle ear. Acute otitis media (AOM) is effusion and inflammation in the middle ear that occurs suddenly and is associated with other signs of illness. Otitis media with effusion (OME) refers to the presence of fluid behind the tympanic membrane without signs of infection. When the eustachian tube is obstructed, as frequently occurs with enlarged adenoids or mucosal edema from an upper respiratory tract infection, effective drainage and ventilation of the middle ear cannot occur.

Epiglottitis (Supraglottitis) Manifestations

epiglottitis has an abrupt onset with rapid progression of symptoms. Often parents report that the child was put to bed well and awakened with a severe sore throat and difficulty swallowing. The child demonstrates a high fever (39° C to 40° C [102.2° F to 104° F]) and appears to be in a toxic condition and very ill. The accompanying sore throat can progress to acute respiratory distress in a few hours. The child appears anxious and frightened and may be irritable or lethargic. One of the classic signs of epiglottitis is that the child insists on sitting upright, often in a tripod position (leaning forward supported on the arms), with the chin thrust out and the mouth open. Respiratory symptoms include nasal flaring; suprasternal, substernal, and intercostal retractions; pale skin color to cyanosis (depending on the degree of airway obstruction); and tachycardia. The epiglottis appears edematous and cherry red.

Pneumonia

inflammation of the lung parenchyma that can occur as a primary or a secondary disease. The two most common types of infectious pneumonia are viral and bacterial

Otitis Media Manifestations OME

no signs of acute infection. The tympanic membrane appears retracted and either dull gray or yellow, and an air-fluid level or air bubbles may be visible through the tympanic membrane. Tinnitus, popping sounds Hearing loss (usually conductive) below 35 decibels; in the older child, hearing loss may manifest as behavior problems, poor school performance, disturbed sleep, irritability, and decreased responsiveness Mild balance disturbances that may result in delays in motor skills A flattened tracing and negative pressure on the tympanogram (a graphic representation of tympanic mobility and middle ear pressure)

Otitis Media Incidence

peaks between ages 6 months and 2 years Early onset of AOM (during infancy) increases the risk for recurrent episodes

Sinusitis Manifestations

signs and symptoms of a cold that do not improve after 10 days, low-grade fever, nasal congestion with purulent nasal discharge, halitosis, cough (which usually increases when the child is lying down), headache, and tenderness and a feeling of fullness over the affected sinuses. Young children may become irritable. Occasionally, children have facial edema or complications such as orbital cellulitis or central nervous system symptoms.

Bronchopulmonary Dysplasia Manifestations

tachycardia and tachypnea related to decreased oxygenation; an increased work of breathing, retractions, and prolonged exhalation with the increased use of abdominal and accessory muscles; pallor associated with chronic hypoxia; and cyanosis and activity intolerance (feeding, handling). Affected infants also exhibit weight loss or poor weight gain related to the increased metabolic workload, hypoxia, and poor feeding; restlessness and irritability related to hypoxia; wheezing (intermittent or chronic) associated with a hyperresponsive airway; and puckering or pursing of the mouth with flaring of the nares (early signs of impending respiratory distress).

Tonsillectomy Interventions: Preoperative Period

talking will not be a problem after surgery. it is important to drink liquids after surgery, although the child's throat will be sore many parents undermedicate their children. Undermedication can interfere with optimal postoperative recovery.

Cystic Fibrosis Manifestations

wheezing and a dry, nonproductive cough (earliest pulmonary manifestations), As the disease progresses, symptoms include crackles, wheezes, diminished breath sounds, accessory muscle use, retractions, hypoxia, and cyanosis. Cough increases and, dyspnea and tachypnea occur Digital clubbing can be an indication of hypoxia, which often occurs in cystic fibrosis and other respiratory disorders. steatorrhea (frothy, foul-smelling stools two to three times bulkier than normal) and flatus. Malnutrition and growth failure may be evident despite normal caloric intake; deficiencies in the fat-soluble vitamins A, D, E, and K are caused by an inability to absorb fats. Respiratory System Abnormally thick, sticky secretions cause obstruction of both the small and large airways. Stasis of secretions from bronchial obstruction provides a medium for bacterial growth. Hyperinflation is one of the first findings on chest radiographs of a child with CF. Chronic infection leads to atelectasis and eventual fibrosis and destruction of pulmonary tissue. Chronic respiratory tract infection and impaired oxygen and carbon dioxide exchange cause varying degrees of hypoxia, hypercapnia, and acidosis. Alveolar hypoxia leads to pulmonary vasoconstriction, increasing pulmonary vascular resistance. Increased pulmonary vascular resistance causes the right side of the heart to work harder to pump blood into the lungs. Enlargement of the right ventricle in response to increased pulmonary resistance (cor pulmonale) results. Heart failure may develop. Pulmonary complications include sinusitis, spontaneous pneumothorax, and hemoptysis. Death in individuals with CF is almost always the result of respiratory failure. Digestive System Blocked by thick mucus, the pancreatic ducts are unable to secrete trypsin, amylase, and lipase into the small intestine. Without these digestive enzymes, proteins, carbohydrates, and fats are poorly absorbed. Bowel obstruction from thickened intestinal mucus and pancreatic insufficiency may be present at birth (meconium ileus). The islets of Langerhans in the pancreas are normal in patients with CF, but they may decrease in number as the disease progresses and the pancreas undergoes fibrotic changes. Type 1 diabetes sometimes develops in older children with CF. Abnormalities of the gallbladder are common. Integumentary System The sweat glands of children with CF secrete normal amounts of sweat. However, the levels of sodium and chloride in the sweat are two to five times the normal range. Reproductive System Ninety-five percent of males with CF are sterile because of obstruction of the deferent ducts and seminal vesicles. Females have reduced fertility because of abnormally thick cervical mucus, which impedes sperm penetration of the cervical canal.

Sudden Infant Death Syndrome Recommendations

• Avoid bed-sharing; put the infant in a safe bassinet or crib in the parent's room for sleeping. The infant should be kept in the parents' room a minimum of six months and ideally up to one year of age. • Use only a firm mattress fitted specifically to the crib frame; do not place any soft bedding (e.g., blankets, pillows, crib bumpers) in the crib or bassinet; sleep wear designed to keep the infant warm can be used. • Provide a pacifier for sleep; wait a few weeks for breastfeeding to be established before introducing a pacifier. • Do not put the infant to sleep in a car seat, infant carrier or swing; be sure infants who are being carried in a sling have their faces exposed and that no fabric is blocking the infant's mouth or nose.

Risk Factors for the Development of Tuberculosis

• Contact with adults with infectious tuberculosis (TB) • Chronic illness, immunosuppression, human immunodeficiency virus (HIV) infection • Malnutrition • Age (infancy, adolescence) • Nonwhite racial and ethnic groups; immigration from areas with a high incidence of TB • Urban, low-income living conditions • Incarcerated adolescents • Children in close contact with any of the following groups of adults: HIV-infected persons, users of intravenous (IV) or other street drugs, poor or medically indigent city dwellers, residents of nursing homes, migrant farm workers

Cystic Fibrosis Evaluation

• Does the child exhibit improved breath sounds, oxygen saturation greater than 95% on room air, and stable respiratory status? • Are the child's body temperature and WBC count within normal limits? Has the sputum amount decreased? • Is the child growing in height and weight along the normal growth curve? • Are the child's stools of normal consistency, frequency, and color? • Is the child able to engage in appropriate physical activity? • Does the child appear to be developing age-appropriate cognitive, emotional, and social skills and an appropriate level of self-care? • Does the child demonstrate an attitude of acceptance of self and of the illness? • Does the family demonstrate appropriate coping strategies, adherence to the child's treatment plan, and the ability to access needed resources? • Can the parents demonstrate CPT, inhalation therapy, and other treatments to be performed at home? • Are the child and family able to appropriately express feelings of anger, sadness, and fear without guilt?

Key Concepts

• Infants and children younger than 3 years are at increased risk for development of respiratory tract infections because of their immature immune system, smaller airways, and underdeveloped supporting cartilage. • At birth, the neonate must inflate the lungs, establish continuous breathing, and transfer the gases needed to meet metabolic needs. • The severity of allergic rhinitis can be decreased through the early identification and treatment of manifestations. • The only reliable way to determine whether pharyngitis is viral or bacterial in origin is with a throat culture. • Manifestations of bleeding after a tonsillectomy include frequent swallowing; restlessness; a fast, thready pulse; and the vomiting of bright-red blood. • The mucosal edema associated with croup can sometimes be decreased by taking the child out into the cool, humid night air. • Children with croup who have stridor at rest, cyanosis, severe agitation or fatigue, moderate to severe retractions, or are unable to take oral fluids should be seen in the emergency room. • The four Ds of epiglottitis are drooling, dysphagia, dysphoria, and distressed inspiratory efforts. • Visual examination of the epiglottis is contraindicated if epiglottitis is suspected because the examination tools can provoke laryngospasm and airway obstruction. • Because RSV infection is highly communicable, during RSV season hospitalized infected children should be placed on Contact Precautions. Good hand hygiene should be emphasized and gowns worn when there is a chance that clothing might be soiled. • Oxygen needs can be decreased in the child in respiratory distress by scheduling nursing care to allow the child periods of rest. • If a child is aphonic and not breathing, the guidelines for management of an obstructed airway should be followed. • During an apneic episode, the time and duration of the episode, color change, bradycardia, oxygen saturation, what the infant was doing before the apneic period, and any actions that stimulated breathing should be recorded. • Healthy infants should be placed on their backs for sleeping to reduce the risk of SIDS. • When interviewing parents of an infant suspected of dying of SIDS, the nurse should avoid any implication of fault on the part of the parents. • Asthma is the most common chronic disease of childhood. Asthma is characterized by bronchospasm, edema of the bronchiolar mucous membranes, and increased secretion of mucus in the airways. • Asthmatic symptoms signaling spasm of the smooth muscle of the bronchi and bronchioles may be triggered by a variety of stimuli, including allergens, cold air, weather changes, infection, exercise, fatigue, and emotional distress. • Status asthmaticus (continued severe respiratory distress despite medical treatment) places the child in imminent danger of respiratory arrest and requires immediate hospitalization. • Nursing care of the child with a severe asthma episode includes administration of inhaled bronchodilators and IV or oral corticosteroids, as ordered; providing oxygen therapy; providing IV fluids; and assisting with intubation and mechanical ventilation. • Nursing care of the child with chronic asthma includes administration of prescribed medications and treatments and education of the child and family about medications, how to avoid triggers of asthma symptoms, how to recognize early warning signs of an asthma episode, and measures that can be taken to prevent severe asthma episodes. • BPD is a chronic lung disease characterized by thickening of the alveolar walls and bronchiolar epithelium. BPD occurs primarily in premature and low-birth-weight infants who have been mechanically ventilated for prolonged periods. • Nursing care of the infant with BPD includes supportive interventions to maintain adequate oxygenation and the provision of appropriate stimulation to promote normal growth and development. • CF is an inherited (autosomal recessive), multisystem disorder characterized by widespread dysfunction of the exocrine glands. Abnormal secretion of thick, tenacious mucus causes obstruction and dysfunction of the pancreas, lungs, salivary glands, sweat glands, and reproductive organs. • Nursing care of the child with CF includes maintaining a patent airway by administering bronchodilators and performing or supervising respiratory treatments, administering antibiotics and pancreatic enzymes, and teaching the child and family about CF and its treatment. • Nursing care of the child with TB includes administering and evaluating TB skin tests and administering anti-TB medications as ordered. The nurse also instructs the child and family about the importance of adequate rest, a nutritionally adequate diet, adherence to the medication regimen, and ways to prevent the transmission of TB infection.

Asthma Routine medications

• Inhaled corticosteroids: Beclomethasone, budesonide, fluticasone, flunisolide, and triamcinolone acetonide deliver topical antiinflammatory action directly to the airway. • Long-acting beta2-adrenergic agonists (LABAs): Salmeterol (Serevent) and formoterol (Foradil). • Combination medications: budesonide and formoterol (Symbicort, a combination inhaled corticosteroid and LABA), fluticasone and salmeterol (Advair, a combination inhaled corticosteroid and LABA) • Leukotriene blockers: Montelukast diminishes the mediator action of leukotrienes. Montelukast is available in sprinkles and chewable tablets and can be given to children as young as 1 year old. • Anti-immunoglobulin E (anti-IgE) antibody: Omalizumab (Xolair) for allergic-type moderate to persistent asthma is approved for use in children older than 12 years. It is administered subcutaneously every 2 to 4 weeks.

Foreign Body Aspiration Common Items of Aspiration

• Nuts • Pins • Screws • Coins • Seeds • Grapes • Bones • Earrings • Small toys • Chunks of food • Parts of toys • Hard candy • Latex balloons • Popcorn • Hot dogs • Carrots

Tonsillectomy Patient-Centered Teaching

• Pain should not persist past the first week. Notify your physician if pain persists. • Add full liquids (cream soups, gelatin, puddings, and other soups) on the second day and soft foods (mashed potatoes, soft cereals, eggs) as your child tolerates them. Avoid rough or scratchy foods (bacon, chips, popcorn), citrus foods, or spicy foods for 3 weeks. • Discourage your child from coughing, clearing the throat, or gargling. • Bad mouth odor is normal and may be relieved by drinking more liquids (Avoid citrus juices, which irritate the throat, for 10 days.) • Bleeding caused by tissue sloughing during the healing process can occur 7 to 10 days after surgery. Such bleeding requires immediate medical attention. • Keep your child away from crowds for 2 weeks to avoid catching a cold. • Your child may return to school when directed by the physician, usually in approximately 10 days.

Pneumonia Patient-Centered Teaching

• Provide rest. • Increase your child's fluid intake. Offer favorite fluids more frequently than usual, and be sure your child is urinating appropriate amounts. Warm liquids (lemonade, apple juice, Pedialyte, Ricelyte) help loosen secretions. Call your healthcare provider if the child's mucous membranes appear dry or if urination decreases. • Administer acetaminophen for fever and discomfort. • Administer antibiotics as ordered; give the correct dose and the entire prescribed amount. • Avoid exposing your child to cigarette smoke

Asthma Rescue medications

• SABAs: albuterol (Ventolin, Proventil), levalbuterol (Xopenex), and terbutaline (Brethine, Brethaire) relax bronchial smooth muscle and inhibit the release of mediators from mast cells. They are delivered by MDIs (metered dose inhalers) or by nebulizer three or four times daily if the child is symptomatic or before exercise. • Anticholinergic: Ipratropium bromide (Atrovent) is used in combination with beta2-adrenergic agonists in older children (older than 12 years) with severe asthma. • Mast cell inhibitors: Cromolyn sodium (Intal), an inhaled nonsteroidal antiinflammatory drug, prevents asthma symptoms by blocking the release of mast cell mediators. It can be given 30 minutes before exposure to triggers. Another antiinflammatory asthma medication, nedocromil sodium (Tilade), is available for use in children age 12 years or older. 1062 • Systemic corticosteroids: Prednisone and prednisolone decrease airway inflammation. They are preferably given in short-burst courses of 5 to 7 days.

Pediatric Differences in the Respiratory System

• Surfactant is lacking in premature infants. Infants born before 34 weeks of gestation have a higher risk of respiratory distress syndrome (RDS). • Smaller lower airways and undeveloped supporting cartilage predispose the child to an increased risk for obstruction by mucus, edema, and foreign bodies. The neonate's airway is 50% smaller than that of adults. A premature infant has a more compliant chest wall and weaker respiratory muscles than a term infant. • Lung size is proportional to body height. Therefore, lung volumes and capacities do not vary from age to age. • Infants are obligatory nose breathers; they have difficulty breathing through the mouth. If the infant has nasal congestion, breathing becomes more difficult. • The diaphragm is the neonate's major respiratory muscle. Intercostal muscles are not well developed. Retractions are more common in the infant than in older children and adults. • Brief periods of apnea (10 to 15 seconds) are common in the neonate. The respiratory pattern may be irregular. • Children's normal respiratory rate is higher than that of adults. • An increased metabolic rate increases oxygen needs. • Alveoli develop from approximately 20 million to 200 million by age 3 years. Alveolar development gradually decreases after age 3 years; few develop after age 8 years. • The lung surface increases until age 5 to 8 years. Actual lung growth continues into the adolescent years. • Eustachian tubes are relatively horizontal, which increases the risk for bacteria entering the middle ear. • Tracheal size approximately triples by adulthood. • Tonsillar tissue is normally enlarged in early school-age children. • Infants and children use abdominal muscles to inhale until approximately 5 to 6 years of age. • The child's flexible larynx is more susceptible to spasm.

Tips on Using a Nebulizer

• Wash your hands before setting up the nebulizer equipment. You should have available the nebulizer machine, clean tubing (attached to the nebulizer), and the reservoir for medication with dome cover attached to the t-shaped mouthpiece, or mask, if preferred. • Unscrew the reservoir from the dome and place the ordered amount of liquid medication in the reservoir; most medications will have additional normal saline solution added. • Reattach the dome cap tightly, attach to the tubing, and turn on the machine. You will see mist begin to come out of the mouthpiece. • Ask the child to put the mouthpiece in the mouth with the lips forming a seal around the mouthpiece. The child should be sitting upright, if possible, or on your lap. • Your child should breathe at a normal rate, but deeply. As the treatment progresses, condensation may build up on the sides of the reservoir. Gently tap the reservoir so the liquid drops to the bottom. • Most nebulizer treatments take approximately 15 to 20 minutes. • When the treatment is complete, be sure to clean the equipment carefully according to manufacturer recommendations and store it in a clean, dry place.