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Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
Respiratory lecture nurs 3340 fall 2014
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Respiratory lecture nurs 3340 fall 2014

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  • 1. 1 Joy A. Shepard, PhD(c), RN-C, CNE Joyce Buck, MSN, RN-C, CNE Alterations in Respiratory Function 1
  • 2. Learning Outcomes 1.Describe unique characteristics of pediatric respiratory system anatomy and physiology 2.Contrast respiratory conditions and injuries that cause respiratory distress in children 3.Distinguish between mild, moderate, and severe respiratory distress and plan nursing care for each level of distress severity 4.Assess the child’s respiratory status and analyze the need for oxygen supplementation 2
  • 3. Learning Outcomes (cont’d) 5. Differentiate between signs and symptoms of upper and lower airway conditions 6. Create nursing care plan for child with common acute respiratory condition 7. Plan nursing care for child with chronic respiratory condition 3
  • 4. Review: A & P Respiratory System 4
  • 5. Children are not just small adults…. 5
  • 6. Pediatric Respiratory System  Changes until age 12  Child respiratory-illness risk greater than adult  Upper airway more prone to obstruction  Smaller airway = greater resistance  Less alveolar surface area  Reduced area for gas exchange  More diaphragmatic breathing  Flexible chest reduces air intake 6
  • 7. Respiratory Development  Respiratory structures grow in size and distance from each other  Immature infant respiratory and neurologic system offers less efficient response to hypoxia and elevated PCO2  Chest wall stiffens with age  Less retraction with distress 7
  • 8. Differences between Children and Adults  Chest/ Respiratory System  Obligate nasal breathers until 4 – 6 wks  Short neck  Smaller, shorter, narrower airways  = more susceptible to airway obstruction and resp. distress  Tongue is larger in proportion to the mouth  = more likely to obstruct airway in unconscious child 8
  • 9. Differences between Children and Adults Bifurcation of trachea Change in chest wall shape9
  • 10. Differences between Children and Adults Cont’d…  Chest/ Respiratory System  Smaller lung capacity and underdeveloped intercostal muscles, poor chest musculature  = less pulmonary reserve, lung damage w/o fx  Children rely on diaphragm breathing  = high risk for resp. failure if the diaphragm unable to contract 10
  • 11. Upper Airway More Prone to Obstruction Smaller Airway = Increased Airway Resistance 11
  • 12. Review Question  Abdominal breathing is usually present in a child until what age?  A. 2  B. 4  C. 6  D. 8 12
  • 13. 13
  • 14. Respiratory Assessment (p. 554)  Inspection  Chest  Size, symmetry movement  Infancy shape is almost circular  < 6-7 years respiratory movement primarily abdominal or diaphragmatic  Respirations  Rate, rhythm, depth, quality, effort  > 60 /min in small children = significant respiratory distress 14 See video “Pediatric Assessment” 22:03 – 23:18
  • 15.  Auscultation  Listen comparing one areas to the other  Equality of breath sounds  Diminished  Poor air exchange  Abnormal breath sounds  Fine crackles  Wheezes (sibilant rhonchi)  Rhonchi (sonorous, coarse crackles)  Stridor  Cough * Prolonged inspiratory phase = upper airway obstruction (croup, foreign body) * Prolonged expiratory phase = asthma 15 Respiratory Assessment (p. 554)
  • 16. 16
  • 17. 17
  • 18. Adjunct Assessments  Color  Mucous membranes  Nailbeds  Skin  Cyanosis  Temperature  Febrile state increases oxygen consumption  Fluid Needs  Vomiting/diarrhea are commonly associated with respiratory illness  Increase respiratory efforts, increased fluid losses with decreased PO intake requires an increase in fluid needs 18
  • 19. Respiratory Nursing Diagnoses  Impaired gas exchange  Ineffective airway clearance  Ineffective breathing pattern  Risk for aspiration  Risk for imbalanced fluid volume  Risk for ineffective tissue perfusion  Anxiety  Fatigue  Activity intolerance  Imbalanced nutrition: less than body requirements  Delayed growth/development  Deficient knowledge 19
  • 20. Respiratory Distress 20
  • 21. Respiratory Distress  Can Lead to Respiratory Failure, then Cardiopulmonary Arrest  Early recognition and intervention vital  Mild  Tachypnea, tachycardia, diaphoresis  Moderate  Flaring, retractions, grunting, wheezing  Anxiety, irritability, confusion, mood changes  Headaches, hypertension 21 See video “Assessment of Respiratory Distress in the Pediatric Patient”
  • 22. Respiratory Distress Cont’d…. Severe  Cyanosis = late sign  Bradypnea  Apnea or gasping respirations  Tachycardia  Bradycardia  Decreased or absent breath sounds  Decreased oxygen saturations  Decreased LOC; stupor, coma 22
  • 23. Respiratory Distress Cont’d…  Retractions  Substernal  Subcostal  Intercostal  Suprasternal  Supraclavicular  Effort  Grunting  Nasal flaring  Seesaw respirations/ paradoxical breathing  Head bobbing23
  • 24. 24
  • 25. Retractions: Which types indicate the most distress? 25
  • 26. 26
  • 27. Respiratory Distress Treatment  Oxygenation  Positioning  Fluids  Medications Bronchodilator Anti-inflammatory Corticosteroid 27
  • 28. Cardiorespiratory Monitoring Pulse oximetry Want reading ≥ 95% 28
  • 29. Indications for Mechanical Ventilation  Airway Compromise – airway patency is in doubt or patient may be at risk of losing patency  Ability to sneeze, gag, or cough compromised; aspiration is possible  Respiratory Failure – 2 Types  Hypoxemic Respiratory Failure  PaO2 < 60 mmHg in an otherwise healthy individual  Insufficient O2 transfer into the blood  Hypercapnic Respiratory Failure  PaCO2 > 50 mmHg in an otherwise healthy individual  AKA “Ventilatory Failure” (insufficient CO2 removal)  Increased WOB, ↓ventilatory drive, or muscle fatigue 29
  • 30. Review Question  A child in respiratory distress requires intubation. The nurse would estimate the endotracheal tube size based on: A. The child’s little finger. B. Whether the child is mouth or nose breathing. C. The height of the child. D. Whether the child has nasal flaring or retractions. 30
  • 31. Acute Respiratory Conditions 31
  • 32. Acute Respiratory Conditions  Otitis Media  Tonsillitis & Adenoiditis  Streptococcal Pharyngitis  Aspirations  Foreign body  Croup Syndromes  Laryngotracheobronchitis & epiglottitis  Bronchiole Inflammation  Bronchiolitis  Diphtheria/ Pertussis 32
  • 33. Otitis Media (OM)  Inflammation of middle ear, sometimes accompanied by infection  Common illness: 6 – 24 mos  Eustachian tube – shorter, wider, more horizontal  At risk: boys, daycare, allergies, second-hand smoke, cleft-lip/ palate, enlarged adenoids, Down syndrome, formula-fed  Preceded by upper respiratory/ throat infection  Generally bacterial (causative agents)  Winter months  Chronic OM: > 3 mos; associated with hearing loss33
  • 34. 34
  • 35. Three Anatomical Differences in Eustachian Tubes (Adults & Small Children): Shorter, Wider, More Horizontal 35
  • 36. Otitis Media: Clinical Manifestations • Sudden piercing pain; irritability • Fever (as high as 104°F [40°C]) • Vomiting, diarrhea • Rubbing or pulling at ear • Rolling head from side to side • Night awakenings • Muffled hearing; permanent hearing loss • Speech development problems • Reddened, bulging membrane 36
  • 37. Otitis Media: Clinical Manifestations  What objective sign is this child displaying?  What does it indicate? 37
  • 38. Otitis Media: Diagnosis & Collaborative Care  Otoscopic exam  Reddened, bulging membrane  Culture: Streptococcus pneumoniae, Haemophilus influenzae, & Moraxella catarrhalis  Antibiotics: amoxicillin, Augmentin, ceftriaxone, Zithromax  Surgical: myringotomy, tympanostomy tubes  Analgesics/ antipyretics: acetaminophen, ibuprofen by mouth; Auralgan otic drops (not after myringotomy!)  Chronic infection: hearing & language testing38
  • 39. A Normal TM pars flaccida umbo malleus light reflex pars tensa eustachian tube opening
  • 40. Acute Otitis Media - Characterized by abrupt onset, pain, middle ear effusion, and inflammation Note the injected vessels and altered shape of cone of light 40
  • 41. Serous Otitis Media Note effusion on otoscopy by fluid line and air bubbles Note that the light reflex is not in the expected position due to a change in tympanic membrane shape from air bubbles 41
  • 42. 42
  • 43. Otitis Media: Nursing Interventions  Prevention strategies (educate caregivers) Recognize URI, encourage early treatment Identify & treat allergies Avoid second-hand smoke Do not put the baby to bed with bottle Immunizations up-to-date (especially PCV) Valsalva maneuver: chew gum; blow on a pinwheel See video Otitis Media & Nursing Interventions 43
  • 44. 44
  • 45. Otitis Media: Nursing Interventions  General education:  Explain all diagnostic tests & procedures  Take full course of antibiotics  Warm compress, analgesics/ antipyretics  Positioning  Skin care  No cotton swabs  Comfort: relieve pain; facilitate drainage when possible; provide emotional support to child & family  After surgery: “Care of the Child with Tympanostomy Tube” (p. 532) 45
  • 46. 46
  • 47. Streptococcal Pharyngitis  Inflammation of structures in throat  School-aged children & teens  Symptoms strep throat: abrupt onset; severe sore throat; painful cervical lymph nodes; fever > 101° F (38.3° C); tonsillar exudate; anorexia, nausea, vomiting, abdominal pain; headache, malaise; petechial mottling of soft palate; possible scarlet rash (p. 543)  Contrast: viral pharyngitis (p. 543)  Dx: Rapid strep test, throat culture  Tx: 10-day course penicillin  Complications: rheumatic fever, rheumatic heart disease, and post-streptococcal glomerulonephritis  Nursing interventions: plenty of rest & fluids; sore throat symptom management, prevent spread of infection (same as for tonsillitis) 47
  • 48. Nurse Alert! The nurse should remind the child with a positive throat culture for strep to discard their toothbrush and replace it with a new one after they have been taking antibiotics for 24 hrs 48
  • 49. Tonsillitis & Adenoiditis  Tonsils & adenoids: Important part of body’s defense against infection  Definition: Infection or inflammation (enlargement)  Pharyngitis (most often)  Enlarged tonsils and adenoids: mouth breathing, obstructive sleep apnea, ear infections  Preschool to mid-teenage years  Caused by virus or bacterium  Group A Beta-hemolytic streptococcal infection – particularly dangerous49
  • 50. Tonsillitis & Adenoiditis: Assessment Findings • Red swollen tonsils • White or yellow patches • Swollen lymph nodes • Sore throat • Decreased food or fluid intake • Difficulty swallowing • Difficulty breathing • Disrupted breathing during sleep • Fever & chills  Diagnostic Criteria:  Rapid strep, throat culture  Inspection, clinical manifestations, X-rays, check for rash & spleen enlargement, CBC50
  • 51. Tonsillitis “Kissing tonsils” occur when the tonsils are so enlarged they touch each other.51
  • 52. Tonsillitis & Adenoiditis: Collaborative & Supportive Care  PCN (full 10-day course) for Group A beta-hemolytic streptococcus infection  Viral infection – supportive care: rest, fluids, comforting foods, saltwater gargles, cool-air humidifier, lozenges, treat pain & fever  Surgery: removal of tonsils & adenoids (T & A)  Respiratory/ swallowing status compromised or for difficult-to- treat conditions 52
  • 53. Tonsillitis & Adenoiditis: Nursing Interventions (Preoperative) • Education vitally important! • Routine preoperative care • Reinforce food & fluid restrictions • No medications that can cause bleeding starting10 days before surgery • Age-appropriate explanations • Encourage parents to stay with child • Prepare child for sights & sounds of surgery • Allow child to play with equipment • Provide reassurance • Put transitional object in recovery room • Prepare child for post- operative experience (sore throat) 53
  • 54. Tonsillitis & Adenoiditis: Nursing Interventions (Postoperative)  Place child in tonsillar position (semi-prone with head to side)  Monitor airway, cardiopulmonary status, vital signs  Cool humidified air via face mask  Once the child is awake: semi- Fowler’s, head turned to side  Check for signs of hemorrhage (such as frequent swallowing)  Provide ice collar  Avoid oral fluids until fully awake; then clear, cool, non-citrus fluids (nothing red)  Administer acetaminophen PRN  Discharge Planning: “Families Want to Know,” p. 545  Avoid throat clearing & coughing  Sore throat interventions  Acetaminophen elixir  Soft diet, push fluids  Bleeding: 1st 24 hrs; 7 – 10 days post surgery; frequent swallowing sign  Report temps > 38.8°C (102°F) 54
  • 55. Nurse Alert for Post-Op T & A Surgery Most obvious sign of early bleeding is the child’s continuous swallowing of trickling blood  Note the frequency of swallowing and notify the surgeon immediately 55
  • 56. Complications to “Routine” T & A Surgeries Can Occur! 56
  • 57. Nursing Care for the T & A Patient 57
  • 58. Foreign Body Aspiration  Inhalation of any object into respiratory tract (usually rt lung)  7% of deaths (children < 4)  Manifestations: Coughing, choking, gagging, hoarse or muffled voice sounds, difficulty breathing, severe inspiratory stridor, wheezing, tachypnea, nasal flaring, retractions, irritability, decreased responsiveness  Nursing Management: Assessment, cardiopulmonary monitoring, remove foreign body 58
  • 59. Figure 20-5 An aspirated foreign body (coin) is clearly visible in the child’s trachea on this chest radiograph. Courtesy of Rockwood Clinic, Spokane, WA. 59
  • 60. Foreign Body Aspiration: Teaching & Prevention  No small hard candies, hot dogs, raisins, popcorn or nuts until age 3 or 4 yrs  No latex balloons  Cut food into small pieces  No running, jumping, or talking with food in mouth  Inspect toys for small parts  Keep coins, earrings, marbles out of reach  Choking Hazard Foods Need Warning Labels 60
  • 61. Croup Syndromes - Laryngotracheobronchitis  Croup – severe inflammation & obstruction of upper airway  Laryngotracheobronchitis – Viral croup syndrome  Viral invasion of upper airway: causes swelling (constriction) around the larynx, trachea, & bronchial passageways  Inflammation of larynx  Hoarseness, inspiratory stridor, barking cough, often worse at night, low-grade fever, respiratory distress, orthopnea 61
  • 62. Figure 20-7 There are two important changes in the upper airway in croup: The epiglottis swells, thereby occluding the airway, and the trachea swells against the cricoid cartilage, causing restriction and narrowing the airway. 62
  • 63. Steeple Sign on X-Ray 63
  • 64. Croup Syndromes - Laryngotracheobronchitis  Treatment & Nursing Care:  Cluster care, keep child calm  Cool mist humidification  Cardiopulmonary/ vital signs monitoring  Oxygen, if SpO2 < 92%  Sedatives contraindicated  Antipyretics, racemic epinephrine, corticosteroids  Intravenous fluids64
  • 65. Review Question An 18-month-old child is seen in the emergency department with a “seal bark” cough, loud, raspy breathing, and chest wall retractions with use of accessory muscles. He is admitted with a diagnosis of laryngotracheobronchitis. Following the initial workup, the toddler is still short of breath but is rubbing his eyes as if he is sleepy. The mother wants to lay the toddler down for his nap. The child refuses to lie down. The nurse would suggest: A. Rocking the child until he is asleep and then lay him down. B. The mother swaddle the child and lay him in her lap. C. The mother allow the child to sleep in an upright position. D. A sleeping pill to help the child rest. 65
  • 66. 66
  • 67. Croup Syndromes - Epiglottitis  True Pediatric Emergency!  Inflammation & edema of the epiglottis  Bacterial, high fever  Rapidly progressive course  Classic symptoms: tripod position; dysphagia; drooling; dysphonia; distressed inspiratory efforts; stridor/ froglike croaking sound;  Antibiotics needed 67
  • 68. Croup Syndromes – Epiglottitis Tripod position68
  • 69. Croup Syndromes - Epiglottitis  Don’t inspect the throat with tongue blade!  May require immediate tracheotomy/ endotracheal intubation  Nursing interventions: reduce anxiety, cardiopulmonary monitoring, O2, no oral fluids, IV, antibiotics  Prevention: H. influenzae type B conjugate vaccine69
  • 70. 70
  • 71. Critical Thinking Exercise  Kim, a 4 year old, is admitted to the emergency department with a sore throat, pain on swallowing, drooling, and a fever of 102.2°. She looks ill, agitated and prefers to sit up and lean over.  What nursing interventions should the nurse implement in this situation? 71
  • 72. 72
  • 73. Review Question A child is brought to the emergency department with suspected epiglottitis. Which nursing intervention would be considered unsafe? A. Allowing the child to remain in the position of choice. B. Placing intubation equipment at the bedside. C. Encouraging parents to comfort the child. D. Examining the throat. 73
  • 74. Bronchiolitis (RSV): Etiology, Pathophysiology, & Complications  Lower respiratory infection: acute obstruction & inflammation of the bronchioles  Can cause viral pneumonia  Leading cause of hospital admission (infants <12 mos)  Preterm, chronic disease states, immunocompromised  Obstructed airways, impaired gas exchange, hypoxemia, hypercarbia, atelectasis, respiratory failure  Long-term effects: wheezing, asthma, COPD Bronchioles become narrowed or occluded as a result of inflammatory process, edema, mucous, and cellular debris clog alveoli 74
  • 75. Bronchiolitis (RSV): Epidemiology, Transmission, & Diagnosis  RSV (a virus) most common cause  Most children infected; 2% require hospitalization  October – April  Transmission: contact & droplet  Sx: 4 – 6 days; most recover in 1 – 2 weeks  Dx: Rapid RSV antigen, viral culture, chest X-ray 75
  • 76. Bronchiolitis (RSV): Clinical Manifestations • Tachypnea • Thick nasal discharge • Respiratory distress: grunting, wheezing, crackles, retractions, nasal flaring • Irritability & lethargy • Air trapping & atelectasis • Distended abdomen • Poor fluid/ food intake • Severe coughing • Vomiting 76
  • 77. Bronchiolitis (RSV): Medical Management  Supportive tx  Medical Management:  Humidified oxygen  IV fluids  Contact & droplet isolation  NG tube feeding  Nasal suctioning  Chest percussion  Mechanical ventilation  Medications:  Nebulizer solutions  Antipyretics  Ribavirin (Virazole)  Palivizumab (Synagis) 77
  • 78. Bronchiolitis (RSV): Nursing Care • Cardiopulmonary monitoring • Monitor respiratory/ cardiovascular status • Cluster care • ↑ HOB/ crib • Contact/ droplet isolation; meticulous hand hygiene • Chest percussion • Promote hydration • Support family • Discharge planning 78
  • 79. Review Question The mother of an infant diagnosed with bronchiolitis asks the nurse what causes this disease. The nurse’s response would be based on the knowledge that the majority of infections that cause bronchiolitis are a result of: A. Ribavirin. B. Mycoplasma pneumoniae (MP). C. Respiratory syncytial virus (RSV). D. Hemophilus influenzae. 79
  • 80. Diphtheria/ Pertussis  Also known as whooping cough, highly contagious and preventable with the immunization DTaP  Major cause of mortality/ morbidity in children throughout the world  Signs and symptoms Initially presents like URI then progresses to paroxysmal cough and ends in a "whooping" sound when the person breathes in
  • 81. Diphtheria/ Pertussis: Nursing Care  Limit paroxysms (observe severity of cough, nutrition, rest, and recovery)  Give antibiotic therapy  Promote adequate nutrition  Discuss vaccination (DTaP)  Teach parents about hospitalization Droplet precaution Vital signs and oxygen saturation Hydration, nutrition, and fluids 81
  • 82. Chronic Respiratory Conditions 82
  • 83. Chronic Respiratory Conditions  Bronchopulmonary Dysplasia (BPD)  Asthma  Cystic Fibrosis Systemic exocrine disorder 83
  • 84. Bronchopulmonary Dysplasia (BPD)  Most common chronic lung dz of infancy  Lower airway: inflamed & scarred lungs  Premature lungs (≤ 30 wks; < 2 lbs)  RDS at birth  Supplemental O2, mechanical ventilation  Need long-term breathing support & O2  Defined & classified by gestational age & O2 requirement: mild, moderate, severe 84
  • 85. Review Question  The father of a premature infant asks why oxygen concentrations are not higher to help his son breathe better. The nurse’s best response is based on an understanding of: A. Cystic fibrosis. B. Asthma. C. Bronchiolitis. D. Bronchopulmonary dysplasia. 85
  • 86. BPD: Clinical Manifestations  Irritability  Tachypnea, retractions, coughing  Crackles, rhonchi, wheezing  Decreased breath sounds  Grunting, nasal flaring  Circumoral cyanosis  Clubbing of fingers  Failure to thrive; delayed growth & development  Barrel chest  Pulmonary HTN; manifestations of right- sided heart failure86
  • 87. BPD: Collaborative Care  Supplemental O2  Chest percussion  Bronchodilators  Diuretics (pulmonary hypertension)  Planned rest periods to decrease respiratory effort & conserve energy  Small frequent meals to prevent over-distention of stomach  Nutritional support: po formula + NG supplement87
  • 88. Review Question An 11-month-old child is being discharged home for the first time after being diagnosed with bronchopulmonary dysplasia (BPD). She will require home oxygen therapy. Which statement by the mother indicates that discharge teaching is incomplete? A. “We will not allow any smoking at our home.” B. “We have several fire extinguishers, and we know how to use them.” C. “Her brother will blow out the birthday candles at her party.” D. “We will return to the hospital if she seems irritable and won’t play.” 88
  • 89. Asthma: Introduction  Most common chronic disease of childhood  Chronic inflammatory condition of lower airways  Recurrent, reversible airway obstruction  Inflammation, bronchospasm, & mucous  Air trapped in alveoli, hyperinflation  Complex interplay of genetic (predisposition) & environmental factors (triggers)  Triggers: tobacco smoke, dust mites, pets, mold, allergens, strong odors, food additives, physical exercise, weather changes, strong emotions, certain medications  At risk: family hx, allergies, eczema, black race  Poor control: permanent airway remodeling 89
  • 90. How asthma obstructs airflow through constriction and narrowing of the airway, along with increased production of mucus 90
  • 91. Review Question An adolescent with asthma says she heard her doctor say smoking was her trigger. The adolescent asks the nurse what that means. The nurse explains to the adolescent that a trigger is: A. A substance or condition that brings on an asthmatic episode. B. The term for narrowing of the airways during an asthmatic episode. C. Another way to describe asthma. D. The rapid breathing associated with an asthma attack. 91
  • 92. 92
  • 93. 93
  • 94. Review Question  Which of the following might a child with asthma be advised to avoid? A. Swimming. B. Gymnastics. C. Snow skiing. D. Playgrounds. 94
  • 95.  Frequent coughing (especially at night)  Coughing that gets worse after active play or changes in the weather  Prolonged expiration  Expiratory wheezing  Shortness of breath (short panting phrases)  Increased work of breathing (tachypnea, nasal flaring, retractions, use of accessory muscles)  Chest tightness  Poor exercise tolerance Asthma: Clinical Manifestations 95
  • 96. Figure 20-8 Children with severe respiratory distress and a narrowed airway often sit in a tripod position with arms on the legs leaning forward. The head and neck are extended with the jaw thrust forward to help keep the airway open. This position may also be seen in a child with a severe asthma flare. 96
  • 97. Asthma Attack 97
  • 98. Asthma: Diagnostic Testing  Clinical diagnosis: H & P, symptoms, symptom patterns, severity, observations  Recurrent coughing spells (especially at night)  Family hx of asthma/ allergies  Difficulty breathing  Frequent respiratory infections  Spirometry  Pulse oximetry  ABG: ↓ PaO2, ↑ PaCO2  Elevated eosinophils  Chest radiograph  Allergy skin testing 98
  • 99. Asthma: Collaborative Care  Clinical therapy: medications, hydration, education, support of family/ child  Main goal: Maintain good long-term asthma control using the least amount of medications; reduce risk of adverse effects  Stepwise approach to medication management  Status asthmaticus: acute exacerbation of asthma, unresponsive to rescue medications; medical emergency!  Position upright; O2; cardiopulmonary monitoring; continuous nebulizers; establish IV access; IV meds/ fluids (corticosteroids, magnesium, theophylline, normal saline); monitor electrolytes (especially K+ & Mg++) 99
  • 100. Asthma: Rescue (Short-Term) Asthma Control Medications (p.578)  Rescue medications  Short-acting beta agonists (SABA) (bronchodilation, clear mucous): albuterol (Ventolin); levalbuterol (Xopenex); pirbuterol (Maxair)  Anticholinergic (bronchodilation, clear mucous): Ipratropium (Atrovent)  Corticosteroids (anti- inflammatory): prednisone; prednisolone; methylprednisolone 100
  • 101. Asthma: Long-term Asthma Control Medications (pp.578-9)  Long-acting beta-agonists (LABA) (bronchodilation): salmeterol (Serevent); formoterol (Foradil, Perforomist)  Inhaled corticosteroids (ICS) (anti-inflammatory): beclomethasone (Qvar); budesonide (Pulmicort); flunisolide (Aerobid); fluticasone (Flovent); mometasone (Asmanex); triamcinolone (Azmacort)  Leukotriene receptor antagonist (LTRA) (bronchodilation, anti-inflammatory): montelukast (Singulair); zafirlukast (Accolate); zileuton (Zyflo)  Mast-cell inhibitors (anti-inflammatory): cromolyn sodium (Intal); nedocromil (Tilade)  Theophylline (bronchodilation)  Combination inhalers (bronchodilation, anti-inflammatory): fluticasone- salmeterol (Advair Diskus), budesonide-formoterol (Symbicort) and mometasone-formoterol (Dulera) 101 See video Respiratory Meds
  • 102. Review Question  A child presents to the emergency department in acute respiratory distress caused by an asthmatic episode. Which of the following drugs would the nurse plan to administer first? A. Prednisone. B. Albuterol. C. Theophylline. D. Cromolyn sodium. 102
  • 103. 103
  • 104. Medications to Treat Asthma: How to Use a Spray Inhaler The health-care provider should evaluate inhaler technique at each visit 104
  • 105. Medications to Treat Asthma: Inhalers and Spacers Spacers can help patients who have difficulty with inhaler use and can reduce potential for adverse effects from medication 105
  • 106. Medications to Treat Asthma: Nebulizer  Machine produces a mist of the medication  Used for small children or for severe asthma episodes  No evidence that it is more effective than an inhaler used with a spacer 106
  • 107. Child receiving nebulizer treatment What is important patient teaching? 107
  • 108. Managing Asthma: Asthma Action Plan  Develop with primary care provider  Tailor to meet individual needs  Educate patients and families about all aspects of plan  Recognizing symptoms  Medication benefits and side effects  Proper use of inhalers and Peak Expiratory Flow (PEF) meters 108
  • 109. Managing Asthma: Sample Asthma Action Plan Describes medicines to use & actions to take National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. NIH Publication no. 08-4051, 2007. 109
  • 110. 110
  • 111. Managing Asthma: Peak Expiratory Flow (PEF) Meters  Allows patient to assess status of his/ her asthma  Recommended standard of care for management of asthma 111
  • 112. Interpreting Peak Expiratory Flow Rates  Green: (80-100% of personal best) signals all clear and asthma is under reasonably good control  Yellow (50-79% of personal best) signals caution; asthma not well controlled; call dr. if child stays in this zone  Red (below 50% of personal best) signals a medical alert. Severe airway narrowing is occurring; short acting bronchodilator is indicated 112
  • 113. How to use a peak flow meter  Slide indicator tab to bottom (zero)  Stand up straight  Take a deep breath  Close your lips tightly around mouthpiece  Blow out as hard as you can  Write down number where stopped  Repeat 2 more times  Record highest of 3 numbers  Measure peak flow rate twice a day (morning & evening) 113
  • 114. Managing Asthma: Peak Flow Chart People with moderate or severe asthma should take readings:  Every morning  Every evening  After an exacerbation  Before inhaling certain medications Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma Created and funded by NIH/NHLBI 114
  • 115. Review Question Which statement by an 8-year-old child with asthma indicates that she understands the use of a peak expiratory flow meter? A. “My peak flow meter can tell me if an asthma episode might be coming, even though I might still be feeling okay.” B. “When I do my peak flow, it works best if I do three breaths without pausing in between breaths.” C. “I always start with the meter reading about halfway up. That way I don’t waste any breath.” D. “If I use my peak flow meter every day, I will not have an asthma attack.” 115
  • 116. Asthma: Nursing Management  High Fowler’s, O2  Monitor: respiratory & cardiovascular status; cough; vital signs; effectiveness of drug therapy; peak flow rates  Chest percussion  Push fluids  Cluster care  Support family 116
  • 117. Treatment and Nursing Care Pulse Oximetry High Fowlers position Humidified Oxygen via mask 117
  • 118. Asthma: Nursing Management  Educate family & child: Allergen & irritant exposure control Avoid secondhand smoke Signs of early respiratory distress  Review asthma action plan Maximum participation Communicate plan to school nurse  Discharge planning 118
  • 119. Review Question The nurse is giving discharge instructions to the parents of a toddler with asthma. What information is essential to include? A. Take prescribed medications weekly to control asthma symptoms. B. Remove mold, animal dander, dust, and cockroach particles from the child’s surroundings. C. Use commercial air fresheners to neutralize the smell of cigarette smoke in the home. D. For adequate nutrition, include cow’s milk, eggs, peanuts, and wheat products in the diet. 119
  • 120. 120
  • 121. 121
  • 122. Cystic Fibrosis  Genetic illness, dysfunction of exocrine glands  Obstruction caused by thick, viscous mucous  Leads to irreversible lung damage  Autosomal recessive trait: more common in Caucasians  One of the most common causes of childhood death  Complex disorder: affects multiple organ systems, especially respiratory & GI Factor responsible for manifestations of the disease is mechanical obstruction caused by increased viscosity of mucous gland secretions122
  • 123. Autosomal Recessive Inheritance: 1 in 4 Chance of Cystic Fibrosis 123
  • 124. Defective CFTR leads to an imbalance between fluid absorption and secretion in the lungs of cystic fibrosis patients, resulting in dehydrated mucus on the airways 124
  • 125. Cystic Fibrosis: Complications  Cardiorespiratory System  Respiratory: Chronic sinusitis; chronic moist productive cough; frequent respiratory infections; dyspnea; tachypnea; wheezing, decreased breath sounds, fine crackles on auscultation; clubbing of fingers and toes; barrel chest; cyanosis  Pulmonary hypertension, over inflation of the lungs  Cardiovascular: Rt-sided heart enlargement (cor pulmonale); heart failure; hyponatremia; circulatory collapse 125
  • 126. Clubbing of Fingers 126
  • 127. Review Question The highest priority nursing intervention for a child hospitalized with respiratory infection and cystic fibrosis would be: A. Maintaining strict intake and output. B. Administering intravenous antibiotics. C. Recording vital signs every four hours. D. Arranging for sweat chloride testing. 127
  • 128. Cystic Fibrosis: Complications  Gastrointestinal System  Clinical manifestations may appear at birth or may take years; vary in severity  Blocked pancreatic ducts; no secretion of digestive enzymes  Meconium ileus in a neonate (1st manifestation); large, frothy, bulky, greasy, foul-smelling stools; distended abdomen; abdominal cramping; weight loss; FTT, malnourishment, vitamin deficiency; liver cirrhosis  Pot belly with wasted buttocks128
  • 129. 129
  • 130. Review Question When taking the nursing history of a child with cystic fibrosis, what piece of information about the child’s newborn period would the nurse expect the mother to report? A. The child required resuscitation in the delivery room. B. Labor was longer than 24 hours. C. The child had a meconium ileus. D. Labor was less than 4 hours. 130
  • 131. Review Question A 6-year-old client with cystic fibrosis (CF) is preparing to eat breakfast. What is the most important piece of information the nurse would want before the child eats? A. Whether the meal is exactly what he ordered. B. If he plans to eat all of it. C. When he ate last. D. If he has taken his enzymes. 131
  • 132. Review Question A child with cystic fibrosis is hospitalized for a respiratory infection. Which documentation in the chart would indicate the need for counseling regarding nutrition and gastrointestinal complications? A. Frothy, foul-smelling stools. B. Weight unchanged from yesterday. C. Consumption of high-sodium foods. D. Eats three snacks every day. 132
  • 133. Cystic Fibrosis: Complications  Skin:  Salty taste to the skin  Secretions excessive salt  Basis for the “sweat test”  Loss of electrolytes: electrolyte imbalances  Reproductive system:  In males: ↓ sperm motility  Blocked vas deferens  In females:  Thick cervical mucous  Difficulty conceiving  Pregnancy complications 133
  • 134. Review Question An adolescent was diagnosed with cystic fibrosis as an infant. At this time, the adolescent will need additional teaching related to: A. Obtaining a sweat chloride test. B. The effect of pancreatic enzymes on the sex hormones. C. Weight reduction diet. D. Reproductive ability. 134
  • 135. 135
  • 136. Cystic Fibrosis: Diagnosis  Presentation: meconium ileus; FTT; respiratory infections; intussusception  Newborn screening, genetic marker  Positive sweat test – Gold standard  Chloride – Normal < 40 mEq/L  Highly suggestive of CF 50-60 mEq/L  Diagnostic > 60 mEq/L  Pancreatic enzymes  Collection of stool specimen to assess trypsin & lipase  Trypsin absent in 80% of children with CF 136 Newborn Screening in North Carolina
  • 137. Review Question A child with a respiratory infection is scheduled to have a sweat test. The mother asks the purpose of this diagnostic test. The nurse’s response would be based on the knowledge that the test: A. Determines if the child is dehydrated. B. Assesses if the sweat glands are functioning. C. Identifies the infectious organism. D. Establishes a diagnosis of cystic fibrosis. 137
  • 138. Cystic Fibrosis: Maintaining Respiratory Function  Aerosol treatments – thin secretions, keep them mobile  Bronchodilators  Dornase alfa (DNase)  Hypertonic saline  Never give cough syrups or codeine (why?)  Aggressive chest physiotherapy/ oscillating vest 3-4 times/day (before meals & at bedtime) to increase sputum expectoration  Breathing exercises  Physical exercise important adjunct  Lung transplantation138
  • 139. Cystic Fibrosis: Managing Infection  Meticulous hand hygiene  Immunizations  Good pulmonary hygiene  Prevention and treatment of pulmonary infections with antibiotics  TOBI Podhaler 139
  • 140. Cystic Fibrosis: Promoting Optimal Nutrition  I & O, daily weights  High: protein, fat, calorie diet  Medium-chain triglycerides (MCT) oil  Vitamin replacement – A, D, E, K  Push fluids  Salty foods  Pancreatic enzymes with meals and snacks  Goal: achieve near-normal, well-formed stools & adequate weight gain 140
  • 141. Cystic Fibrosis: Preventing Gastrointestinal Blockage  Distal intestinal obstruction syndrome (DIOS) – ileum/ colon in right lower quadrant  Abdominal pain, distention, vomiting, failure to pass stools; right lower quadrant mass  Chronic constipation  Rectal prolapse  Prevention/ Treatment:  Fiber and fluid  Early aggressive laxative treatment with polyethylene glycol (Miralax) – either oral or intestinal lavage  Prokinetic agents (Reglan) – enhance gastrointestinal motility  Enemas 141
  • 142. Chest Physiotherapy: Cupping & Clapping 142
  • 143. Chest Physiotherapy 143
  • 144. 144
  • 145. Postural Drainage – Six Manual Chest Physiotherapy Positions 145
  • 146. Figure 20-16 (continued) A, Postural drainage can be achieved by clapping with a cupped hand on the chest wall over the segment to be drained to create vibrations that are transmitted to the bronchi to dislodge secretions. B, Oscillating vibration vest that this child can independently set up to perform chest physiotherapy. B 146
  • 147. Cystic Fibrosis: Medications (p. 591)  Aerosol bronchodilators to open airways  Mucolytic enzyme (Dornase alfa [Pulmozyne]) – to thin mucous to cough it out easier  Mist of hypertonic saline – to clear thick mucous from lungs  Ibuprofen – slows lung function decline  Inhaled antibiotics (tobramycin) – antimicrobial for chronic lung infections (Pseudomonas aeruginosa)  Oral and IV antibiotics – treat and suppress infections  Pancreatic enzymes to help digest food  Vitamins A, D, E, K / fat soluble vitamins 147
  • 148. Cystic Fibrosis: Nursing Interventions  Pulmonary hygiene  Nutrition  Medications  Conserve energy  Organize care  Monitor respiratory status, vital signs, infection  Teaching/ support 148
  • 149. Review Question An appropriate nursing recommendation for parents to assist in preventing recurrent respiratory infection would be to: A. Keep child away from other children. B. See the pediatrician weekly. C. Maintain strict handwashing. D. Avoid all animals. 149
  • 150. Review Question The parents of a child with cystic fibrosis inform the nurse that they will be unable to perform postural drainage at home because their bed does not recline like the hospital bed. The nurse’s response is based on an understanding that: A. Postural drainage is essential to mobilize secretions in the airways so they can be coughed out. B. Postural drainage is not necessary as long as the child takes his pulmozyme to decrease the viscosity of the mucus. C. Postural drainage does not influence the pulmonary status of a child with cystic fibrosis. D. The parents can be referred to The Cystic Fibrosis Foundation for a flexible bed. 150
  • 151. Review Question The mother has been taught to perform chest physiotherapy on her child. Which observation by the nurse indicates the need for additional teaching? A. The child has on only a T-shirt. B. The mother delayed the treatment until the child had finished breakfast. C. The mother is making a popping sound when doing percussion. D. The child is positioned in various head-down positions. 151
  • 152. 152

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