Chapter 40 Nursing Care of a Family When a Child Has a Respiratory Disorder

The nurse is caring for a 5-year-old client and notes respiratory rate of 45 breaths per minute, blood pressure 100/70 mm Hg, heart rate 115, temperature 101°F (38.3°C), and oxygen saturation 86%. Which diagnostic test is priority for the nurse to complete? A. Arterial blood gas (ABG) B. Complete blood count (CBC) C. Electroencephalogram (EEG) D. Pulmonary function test

A. Arterial blood gas (ABG) (The most useful diagnostic test in respiratory distress is an ABG. Knowing normal blood gas values for children is very important for evaluation and proper treatment. A CBC is a blood test used to test for disorders including anemia, infection, and leukemia. An EEG is a test used to find problems related to electrical activity of the brain. A pulmonary function test is performed to evaluate the respiratory system. Based on the findings, the child is experiencing respiratory distress and has an elevated temperature. Airway and breathing are priority over an elevated temperature. The child's blood pressure is within normal range for this age.)

The nurse is administering 2 puffs of an albuterol sulfate inhaler to a 4-year-old. Which side effect would the nurse instruct the parent to most likely expect? A. Increased heart rate and restlessness B. Increased mucus expectoration C. Increased nonproductive cough D. Drowsiness causing a nap

A. Increased heart rate and restlessness (The nurse instructs the parents on the side effects of the bronchodilator, albuterol sulfate. The side effect of this medication is restlessness, anxiety, fear, palpitations, and tremors. It is important for the parents to realize this so they understand the actions of the 4-year-old. Once the bronchial tree is open, cough is decreased but mucus expectoration could increase. The medication does not cause drowsiness.)

Assessment of status asthmaticus

Acute respiratory distress that has failed to respond to first-line therapy. Symptoms: HR & RR elevated, altered alertness & responsiveness, anxious, O sat & PO2 low, PCO2 elevated (CO2 trapped)= acidosis, limited breath sounds

The nurse makes the statement that if an older child inhales a foreign body, the inhaled object is more likely to be drawn into the right bronchus rather than the left. What is the basis for this statement? A. The left bronchus is shorter and wider than the right. B. The right bronchus is shorter and wider than the left. C. Both bronchi are the same size, but the left is more vertical than the right. D. The left bronchus is more vertical than the right.

B. The right bronchus is shorter and wider than the left. (In children older than 2 years, the right bronchus is shorter, wider, and more vertical than the left. If the child inhales a foreign body, it is more likely to be drawn into the right bronchus rather than the left.)

The nurse is working with a group of caregivers of small children discussing various disorders seen in children. One of the caregivers makes the statement that her children always seem to have a common cold. After discussing this condition, the caregivers make the following statements. Which statement indicates the most accurate understanding of a complication related to the common cold? A. "When my 6-month-old gets a cold, I know her temperature will be high." B. "At least with a cold they only have diarrhea for a few days." C. "Next time he has a cold, I will watch closely to see if my 1-year-old pulls at his ears." D. "Last week my son came home from school with a cold and I gave him Tylenol for the pain."

C. "Next time he has a cold, I will watch closely to see if my 1-year-old pulls at his ears." (The most common complication of a common cold is otitis media. If the symptoms persist for several days, the child must be seen by a physician to rule out complications such as otitis media. Most young children do not have a fever with a common cold. The child may have mild diarrhea caused by mucus drainage into the digestive system, but this is not a major complication seen with the condition. The school-age child can be given acetaminophen, but pain is not a complication associated with the common cold.)

Pulmonary function tests

Evaluates asthma. Depends on good ventilation, good gas transfer, & good volume & distribution of blood flow. Vital capacity may be low or normal but expiratory rate will be too long (>10 seconds). Ages 8 & older.

Sinusitis

Infection & inflammation of the sinus cavities. Usually in children 6 & up because sinus do not develop fully until then. Symptoms: fever, nasal drainage, & cough lasting >7-10 days. Treatment: analgesic for pain & antibiotic.

Influenza

Inflammation & infection of the major airways. Symptoms: cough & fever, fatigue, body aches, sore throat, GI symptoms (vomiting & diarrhea). Treatment: Osltamivir started within 48 hours of onset, children > 6 months gets a flu shot (yearly).

Croup (laryngotracheobronchitis)

Inflammation of the larynx, trachea, & major bronchi. From a viral infection

Laryngitis

Inflammation of the larynx. Complication of pharyngitis or excessive use of voice. Symptoms: hoarse voice or loss of voice. Treatment: sips of fluid.

Bronchitis

Inflammation of the major bronchi & trachea

Bronchial obstruction

Obstruction of a part or all of the lung. Alveoli will collapse as the air becomes absorbed (atelectasis).

Tonsillectomy

Removal of the palatine tonsils. Tonsilar tissue is removed by laser surgery or ligation. Risk for hemorrhage & aspiration of blood.

Assessment of Pneumothorax

Symptoms: respiratory distress, absent or decreased breath sounds, hyperresonant, medial shift of the apical pulse. Tests: chest radiography= darkened area.

Treatment of Bronchitis

Relieving respiratory symptoms, reduce fever, hydration, antibiotic

Rifampin

Causes body fluids such as urine, sweat, tears, and feces to turn orange-red. Continued for 9 to 18 months. Tuberculosis.

Treatment of Pneumococcal pneumonia

IV fluids, antibiotics, antipyretics, O sat levels, humidified oxygen (prevent hypoxemia), repositioning

What is a symptom of bacterial pharyngitis? A. fever B. rhinitis C. symptoms have gradual onset D. white blood cell (WBC) count in normal range

A. fever

Pneumococcal pneumonia

Abrupt. Infants: bronchopneumonia with poor consolidation. Older children: localizes in one lobe with full consolidation.

Treatment of Congenital laryngomalacia/tracheomalacia

Feed infants slowly & give rest periods. Common in preterm infants. Will improve with maturity as the larynx becomes stronger at about 1 year. Teach about signs of upper respiratory infections (because can cause obstruction of the trachea).

Atelectasis

Collapse of lung alveoli

Assessment of Bronchiolitis

Congestion, rhinorrhea, fever, & pogress to cough, wheezing, & retractions. Infants: Respiratory distress.

Chlamydial pneumonia

Contact with chlamydia during a vaginal delivery. Symptoms: nasal congestion, sharp cough, poor weight gain, tachypnea, wheezing, rales. Tests: elevated IgG & IgM antibodies, peripheral eosinophilia, & antibodies to C. trachomatis.

Congenital laryngomalacia/tracheomalacia

Infant's laryngeal structure is weaker than normal & cartilage rings collapse more than usual on inspiration= laryngeal stridor. Present from birth & intensifies when supine or sucking.

Pneumonia

Infection & inflammation of alveoli

Treatment of Bronchopulmonary dyspnea

Mild: increased O2. Severe: tracheotomy & mechanical ventilation during the 1st few years of life. Corticosteroids & bronchodilator by nebulizer. Monitor nutrition & fluid intake.

Assessment of Croup (laryngotracheobronchitis)

Minimal signs at bedtime. Barking cough, inspiratory stridor, retractions from inflammation of the larynx, trachea, & major bronchi.

Treatment of Acute nasopharyngitis (common cold)

NO specific treatment. Fever: antipyretic (acetaminophen/ ibuprofen) but does not reduce congestion. Infants: difficulty breastfeeding= saline nasal drops or spray, removing mucus with bulb syringe. Cold moist vaporizer (caution: medium for bacteria).

Epistaxis

Nosebleeds. Causes: trauma or irritation, dry air, strenuous exercise (with hemolytic disorders), nasal polyps, sinusitis, & allergic rhinitis. Treatment: Upright with head tilted slightly forward (minimize BP & keep blood moving forward not into nose) & apply pressure to cartilage for 10 minutes.

Treatment of Atelectasis

Object removed by bronchoscopy, mucus plug decreases, free from pressure, semi-Fowlers position, suction, CPT, humidity

Pneumothorax

Presence of atmospheric air in the pleural space, causing atelectasis. Caused by external wounds allowing air to enter the chest.

Secondary Atelectasis

Resp. obstruction prevents air from entering portion of the lung= alveoli collapse. Causes: mucus plugs, object, pressure on lung tissue, scoliosis, enlarged lymph nodes. Symptoms: Asymmetry of the chest, diminished breath sounds, tachypnea, cyanosis. Tests: chest radiography= visualize. Prone to secondary infection from stagnant mucus.

Retropharyngeal abscess

Retropharyngeal lymph nodes can form an abscess that may cause a medical emergency since it can impact the airway. Symptoms: fever, refusal to eat, drooling, snore, hyperextend their head (more breathing space). Treatment: IV antibiotic & hospitalization (to monitor hydration & respiratory status), some will need surgical drainage.

Assessment of Epiglottitis

Severe respiratory stridor, high fever, hoarseness, very sore throat, Swollen & inflamed epiglottis is cherry-red. Never attempt to visualize the epiglottis directly with a tongue blade or obtain a throat culture.

Assessment of Congenital laryngomalacia/tracheomalacia

Sternum & intercostal spaces may retract on inspiration from increased effort to pull air into trachea. Will stop sucking frequently to maintain adequate ventilation.

Assessment of Pneumococcal pneumonia

Symptoms: Blood-tinged/ purulent thick sputum, fever, tachycardia, chest/abdominal pain, chills, respiratory distress, crackles, dullness on percussion. Tests: chest radiography= consolidation, lab tests how leukocytosis.

Viral pneumonia

Symptoms: Diminished breath sounds, fine rales, & fatigue. Treatment: rest & antipyretics (no antibiotics).

Assessment of a Bronchial obstruction

Symptoms: cough violently, dyspneic, hemoptysis, fever, purulent sputum, leukocytosis, localized wheezing. Tests: chest x-ray (will reveal presence).

Mycoplasmal pneumonia

Symptoms: fever, cough, cervical lymphadenopathy, & rhinitis. Treatment: erythromycin & tetracycline.

Viral Pharyngitis

Symptoms: sore throat, fever, rhinorrhea, cough, general malaise, dysphagia, headache, enlarged regional lymph nodes, erythema on pharynx & palatine. Treatment: oral analgesic like acetaminophen or ibuprofen, gurgling warm water solution (by school-age). Assess for oral hydration (intake diminished).

Assessment of Bronchopulmonary dyspnea

Symptoms: tachypnea, retractions, nasal flaring, tachycardia, oxygen dependance, decreased oxygen movement, & left with fibrotic scaring as it heals. Tests: chest radiography= overinflation, inflammation, & atelectasis.

Assessment of Asthma

Wheezing, breathlessness, chest tightness, cough, dry cough, increasing difficulty exhaling, dyspnea on expiration, retractions. Expiration becomes longer than inspiration. More comfortable in a sitting leaning forward & raising shoulders (more breathing room).

Primary Atelectasis

With preterm infants who have limited surfactant & poor resp. strength or mucous/meconium plug in trachea. Symptoms: resp. irregular, nasal flaring, apnea, grunting (keeps alveoli from collapsing), hypoxemia, hypotonicity, & flaccidity. Treatment: cause of atelectasis.

Treatment of a Bronchial obstruction

Bronchoscopy to remove. Assess for bronchial edema & airway obstruction after. Frequent vitals. NPO for at least 1 hour then introduce cold fluids. Breathing cool moist air, ice collar.

Treatment of status asthmaticus

Continuous nebulization with inhaled beta 2 agonist & IV corticosteroids, smooth muscle relaxants. Severe: endotracheal intubation & mechanical ventilation.

When assessing a child for the probable cause of acute bronchiolitis, the nurse focuses on which factor? A. Bacterial infections B. Environmental allergies C. Prenatal complications D. Viral infections

D. Viral infections (Acute bronchiolitis is caused by a viral not bacterial infection. Neither allergies nor prenatal complications contribute to the development of this disorder.)

Treatment of Bronchiolitis

Diagnosis based of history & clinical symptoms. Less severe: antipyretics, adequate hydration, nasal construction, nasal saline, avoidance of tobacco exposure. Hospitalization: apnea, hypoxia, dehydration (from difficulty feeding). Palivizumab as a prophylactic injection.

Cystic fibrosis

Encourage everyone in the family to use good handwashing techniques.

Streptococcal Pharyngitis

Group A. Symptoms: throat & palatine erythematous, tonsils enlarged, white exudate on tonsils, petechiae on palate, fever, sore throat, headache, stomach ache, difficulty swallowing, sandpaper-like rash (scarlatiniform rash). Tests: rapid antigen test & throat culture. Treatment: antibiotics (penicillin or cephalosporin).

Pharyngitis

Infection & inflam. of the throat. Bacterial or viral. Constant postnasal drainage= throat irritation. First action should be to obtain a throat culture to determine if the child has a bacterial or viral infection.

Bronchiolitis

Inflammation & edema of the fine bronchioles & smaller bronchi

Treatment of Pneumothorax

Oxygen therapy. Thoracotomy catheter or needle to remove air. symptoms relieved after 24 hours of suction. Stab wound: cover chest wound immediately to prevent more air entering.

Assessment of Bronchitis

Symptoms: fever, dry hacking cough, hoarse, mildly productive cough that awakens child from sleep, & coarse crackles. Lasts as long a 2 weeks. Tests: chest x-ray= diffuse alveolar hyperventilation.

Assessment of Acute nasopharyngitis (common cold)

Symptoms: nasal congestion, watery rhinitis, low grade fever. mm of nose edemas & inflamed. Posterior rhinitis + local irritation= pharyngitis (sore throat). Secretions drain into trachea= cough Cervical lymph nodes may be swollen. Lasts for about a week.

The nurse is correct to identify which group of symptoms as present with acute laryngotracheobronchitis? A. Wheezing and a moist cough B. Fever and labored respirations C. Crackles in lung fields with cyanosis D. Hypoxia with shallow respirations

B. Fever and labored respirations (Acute laryngotracheobronchitis presents with hoarseness and a barking cough with fever reaching 104°F to 105°F (40°C to 40.6°C) As the disease progresses, marked laryngeal edema occurs with dyspnea, a rapid pulse and cyanosis. Stridor is heard in the lung fields.)

Bronchopulmonary dyspnea

Chronic lung condition that occurs in preterm infants that received mechanical ventilation. Combination of surfactant deficiency, barotrauma, oxygen toxicity, & inflammation.

Epiglottitis

Inflammation of the epiglottis. Inflammation can cause the inability of the airway to stay open. Bacterial or viral.

Treatment of Croup (laryngotracheobronchitis)

Corticosteroids like dexamethasone or racemic epinephrine given by nebulizer= bronchodilation

Treatment of Epiglottitis

Cyanosis/respiratory distress: Oxygen, IV fluids, pharm. therapy, & endotracheal airway (to maintain airway)

Diet with cystic fibrosis

High-calorie, high-protein, & moderate-fat. Supplemental vitamins A, D, & E. Hot months: extra salt to make up for loss. Synthetic pancreatic enzyme: pancreatic lipase added to small meals.

Treatment of Asthma

Measure of asthma assessment & monitoring. Education about self-management. Control environment factors. Pharm. therapy. Goal: prevention of airway inflammation. Mild intermittent: inhaled short acting beta-agonist (albuterol). Severe: inhaled corticosteroid daily.

The nurse is caring for a child diagnosed with tonsillitis. Which nursing action is most helpful prior to the tonsillectomy? A. Instruct on salt water gargling. B. Obtain blood cultures to determine the causative organism. C. Begin a 10-day course of antivirals to treat the infection. D. Use a warm-mist vaporizer as a comfort measure to relieve symptoms.

A. Instruct on salt water gargling. (Depending upon recurrence of tonsillitis, surgical removal of the tonsils may be recommended. Prior to surgery, salt water gargling is an easy and homeopathic way to limit or eliminate swelling and infection. Tonsillectomies are not performed if an infection is present. Antibiotics, not antivirals, are also used to treat infections prior to tonsillectomies.)

In caring for the child with asthma, the nurse recognizes that bronchodilator medications are administered to children with asthma for which reason? A. Relief of acute symptoms B. Management of chronic pain C. To stabilize the cell membranes D. Prevention of mild symptoms

A. Relief of acute symptoms (Bronchodilators are used for quick relief of acute exacerbations of asthma symptoms. Mast cell stabilizers help to stabilize the cell membrane by preventing mast cells from releasing the chemical mediators that cause bronchospasm and mucous membrane inflammation. Leukotriene inhibitors are given by mouth along with other asthma medications for long-term control and prevention of mild, persistent asthma. Bronchodilators are not effective for pain.)

A child is hospitalized with pneumonia. The nurse assesses an increase in the work of breathing and in the respiratory rate. What intervention should the nurse do first to help this child? A. elevate the head of the bed B. administer oxygen C. notify the health care provider D. obtain oxygen saturation levels

A. elevate the head of the bed (The child who is experiencing increased work of breathing should be placed in a position to better open the airway and provide more room for lung expansion. Generally this is accomplished by elevating the head of the bed. If this does not improve the work of breathing, then administering oxygen should be done. The oxygen saturation should be measured because it will provide information as to the severity of the respiratory problem, but this measurement will not directly help the child. The health care provider should be notified if the child continues to deteriorate.)

A 4-week-old infant is diagnosed with acute bronchiolitis. The parent states, "I do not know how the baby got this!" How should the nurse respond? A. "Do you have allergies in the family?" B. "Do any family members have history of asthma?" C. "Do you have air conditioning in your house?" D. "Has your infant been around any crowds?"

D. "Has your infant been around any crowds?" (Acute bronchiolitis is caused by a viral infection, most often, respiratory syncytial virus. Viruses are often spread between groups of people in close contact. Hereditary and environmental complications do not relate to this disorder.)

The nurse is assisting in an emergency situation at a store. The child appears pale, has small quick respirations, exhibits stridor and is sitting in a tripod position. What action will the nurse take first? A. Obtain a heart and respiratory rate. B. Instruct the child to cough. C. Begin abdominal thrusts. D. Instruct someone to call 911 for emergency assistance.

D. Instruct someone to call 911 for emergency assistance. (Upon finding a child in respiratory distress (most likely from a foreign body obstruction) and alert and breathing independently, the nurse will instruct a bystander to call 911 for emergency assistance. Any nursing intervention such as attempting to dislodge the obstruction or having the child cough could inadvertently cause a complete obstruction. Once emergency personnel with advanced life support equipment are present, further methods for removal may be attempted. Obtaining vital signs for heart rate and respiratory rate does not provide pertinent information at this time.)

Peak expiratory flow rate monitoring

Daily to measure gross changes in peak expiratory flow. Blow out as hard & fast as possible then repeats 2-3 more times & record highest number.

Aspiration

Inhalation of a foreign object into the airway. Symptoms: hard, forceful coughing. Treatment: abdominal thrusts or back blows.