Nursing Care of the Pediatric Individual with a Respiratory Disorder

1. Nursing Care of the Pediatric Individual with a Respiratory Disorder

2. General Aspects of Respiratory Infections (upper and lower) • Described according to the anatomic area • However, respiratory infections rarely fall into just one anatomic area • Spread is due to the mucous membranes lining the entire tract • Account for the majority of acute illnesses in children • Infectious agents: Viruses, and bacterial: strep, staph, influenzae, chlamydia pneumococci

3. Upper Respiratory Tract Infections • Nasopharyngitis • Young child: fever, sneezing, vomiting or diarrhea • Older child: dryness and irritation of nose/throat, sneezing, aches, cough • Pharyngitis • Young child: fever, malaise, anorexia, headaches • Older child: fever, headache, dysphagia, abd pain • Tonsillitis • Masses of lymphoid tissue in pairs • Often occurs with pharyngitis • Characterized by fever, dysphagia, or resp problems forcing breathing to take place through nose

4. Nursing Care for respiratory conditions • Assess respiratory status • May need to position upright, esp. for feedings • O2 monitoring • Fluid balance • Temp control • Organize and prioritize care! • Be watchful for complications • Apnea monitors may be needed

5. Describing the differences between adult and pedi client • Differences between the very young child and the older child • Resistance can depend on many factors • Clinical manifestations: those from 6 months to 3 years of age react more severely to acute resp tract infections

6. Differences in Adult and Child Adult Child

7. Let’s understand OM • A diagnosis of OM requires all of the following: • Recent, usually abrupt onset of illness • The presence of middle ear fluid, or “effusion” • Signs or symptoms of middle ear inflammation • Chronic OM: hearing loss, tinnitus, vertigo • Differences between young and older child OM: • Young child (infants) fussy, pulls at ear, anorexia, crying, rolling head from side to side • Older child crying, verbalizes discomfort

8. Understanding OM

9. Clinical Manifestations What objective sign is this child displaying? What does it indicate?

10. Otitis media (OM) • Note the ear on the left with clear tympanic membrane (drum); ear on the R the drum is bulging and filled with pus

11. Acute Otitis Media characterized by abrupt onset, pain, middle ear effusion, and inflammation. Note the injected vessels and altered shape of cone of light.

12. Evaluation and therapy • Tx has always been directed toward abx; however, recently concerns about drug-resistant streptococcus pneumoniae have caused medical professionals to re-evaluate therapy (APA, 2004) • No clear evidence that abx improve OM • Waiting up to 72 hrs for spontaneous resolution is now recommended in healthy infants • When abx warranted, oral amoxicillin in high dosage TOC

13. Nursing Care Management for OM • Nursing objectives: • Relieving pain • Facilitating drainage when possible • Preventing complications or recurrence • Educating the family in care of the child • Providing emotional support to the child and family

14. Preparing the child for surgery

15. A myringotomy or pin hole is made in the ear drum to allow fluid removal.  Air can now enter the middle ear through the ear drum, by-passing the Eustachian tube.  The myringotomy tube prevents the pin hole from closing over.  With the tubes in place, hearing should be normal and ear infections should be greatly reduced.

16. Mastoiditis

17. Morbidity/mortality Hearing loss Extension of the infectious process beyond the mastoid system, resulting in either intracranial complications or extracranial complications Ages affected The incidence of mastoiditis parallels that of otitis media, affecting mostly young children and peaking in those aged 6-13 months. May occur in healthy adults as well

18. Nursing care for the child with mastoiditis • Monitor vital signs • Assess for changes in lab values (esp. bacterial shifts) • Medicate aggressively with abx as ordered (usually IV if bacterial spread to mastoid) • Drugs of choice: Timentin and Gentamicin • Assess for complications (hearing loss, tinnitus, etc.)

19. Tonsillitis

20. Nursing Care for the Tonsillectomy and Adenoidectomy Patient Why is collection of blood for assessment of bleeding and clotting times so important?

21. Nursing Care for the Tonsillectomy and Adenoidectomy Patient • Pre-operative preparation • Providing comfort and minimizing activities or interventions that precipitate bleeding • Place on abd until fully awake • Manage airway • Monitor bleeding, esp. new bleeding • Ice collar, pain meds • Avoiding po fluids until fully awake..then liquids, soft • Post-op hemorrhage can occur

22. Nurse Alert for Post-Op T/A surgery • Most obvious sign of early bleeding is the child’s continuous swallowing of trickling blood. While the child is sleeping, note the frequency of swallowing and notify the surgeon immediately

23. 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 hours

24. Fever (may 105° even with mild infections; norm for infant is 99°) Anorexia (may be initial finding) Vomiting (esp small children; usually short-lived) Diarrhea (usually mild; often accompanies viral infections Meningismus Abd pain is common complaint Nasal blockage nasal passages block Nasal discharge starts thin, but changes to color Cough Respiratory sounds(grunting, stridor, wheezes,crackles) Sore throat freq c/o older children Manifestations of respiratory symptoms in infants and small children

25. Assessment findings to indicate respiratory distress • Nasal flaring • Circumoral cyanosis • Expiratory grunting • Retractions: subcostal, substernal, or lower intercostal • Tachypnea: respiratory rate > 60

26. Nursing interventions for respiratory distress • Antibiotic therapy (after cultures are done) • Respiratory treatments and medications: albuterol, nebs, azmacort, combivent • Assess ongoing respiratory status • High Fowlers position • Fluid maintenance • Temp control

27. Apnea • Defined as delay of breathing over 20 seconds • Manifestations • Diagnostic tests • Therapeutic Interventions and Nursing Care

28. Apnea: Cessation > 20 seconds S/S to assess: Cyanosis Marked pallor Hypotonia bradycardia Periodic breathing Normal breathing pattern of NB but never > 10-15 seconds Even though normal, all parents are taught CPR for their NB Apnea vs Periodic Breathing

29. SIDS • Defined: sudden death of an infant during sleep • Etiology • Assessment • Therapeutic Interventions and Nursing Care

30. Croup vs epiglottitis Croup Epiglottis

31. Croup viral Hoarseness Resonant cough Stridor (inspiratory) Risk for significant narrowing airway with inflammation Humidity for treatment Epiglottitis Bacterial Rapidly progressive course Dysphagia Stridor aggravated when supine Drooling, high fever Antibiotics needed Croup vs. Epiglottitis

32. Four D’s r/t epiglottitis • Drooling • Dysphagia • Dysphonia (difficulty talking) • Distress inspiratory effort

33. Medications used in the treatment of croup and epiglottitis • Beta agonists and beta-adrenergics (albuterol, racemic epinepherine through face mask) • Corticosteroids: not for acute attack • Antibiotics for epiglottitis • Croup tent with mist, Pulse Ox • Endotracheal tube, trach @ bedside for epiglottitis

34. Nursing care for the child with croup and epiglottitis • Observe for s/s respiratory distress • Assess respiratory rates: >60 • Elevated temp ) 101º • The child must NEVER be left alone • NOTHING should be placed in the mouth (laryngeal spasms could result)

35. Bronchitis vs Bronchiolitis

36. The diameter of an infant’s airway is approximately 4 mm, in contrast to an adult’s airway diameter of 20 mm.

37. Preventive measures against RSV • Follow droplet and contact precautions (can live up to 7 hrs on inanimate objects) • Respigam: IV RSV immune globulin (passive immunity) • Synagis (palivizumab) given IM

38. Reactive Airway Disease (asthma) • Chronic inflammatory disorder affecting mast cells, eosinophils, and T lymphocytes • Inflammation causes increase in bronchial hyperresponsiveness to variety of stimuli (dander, dust, pollen, etc.) • Most common chronic disease of childhood; primary cause of school absences

39. Asthma, cont. • Pathophysiology • Increased airway resistance, decreased flow rate • Increased work of breathing • Progressive decrease in tidal volume • Arterial pH changes: respiratory alkalosis, metabolic acidosis • Characterized by • Mucosal edema • Wheezing (r/t bronchospasm) • Mucus plugging

40. Asthma, cont. • Therapies: • Medi-halers (not more than one canister/month) • Beta-agonists: relax smooth muscle in airway • Corticosteroids: for short term therapy • Anticholinergic agents: Atrovent • Preventer Medications • Mast-cell inhibitors (Cromolyn) • Singulair • Inhaled steroids ( Advair, Pulmocort, Azmacort) (always rinse mouth following administration)

41. Emergency situations of asthma • Acute episode of reactive disease: bronchioles may close rapidly, causing severe airway obstruction, anxiety, restlessness, and fear. Will need to be seen in ER if not relieved by med • Status asthmaticus: medical emergency with severe edema, profuse sweating, respiratory failure and death if untreated. Becomes seriously hypoxic…immediate intervention needed

42. Etiology of Acute Wheezing in an ED setting • Patients < 2 yrs of age • Evidence of smoke exposure • Significant role of viral infections (RSV) • Patients > 2 yrs of age • High incidence of allergies to dust mite, cock roach and other inhaled allergens • High incidence of viral respiratory infections

43. Goals for child with asthma • Prevention of chronic symptoms • Monitor peak expiratory flow (Peak Flow) • Prevent exacerbations • Maximize compliance to therapeutic regime • Recognize “triggers” • Exercise • allergens

44. Types of medications for asthma • “Rescue”: short acting beta agonists (albuterol) main rescue classification • “Controller” medications: mast-cell inhibitors (Intal), Luekotriene modifiers (Singulair), inhaled steroids (Advair, Flonase) • “Preventer/controller” drugs: combination of controller meds plus some inhaled steroids (nasal)

45. Purpose of the MDI • Shake vigorously prior to use • Exhale slowly and completely • Place mouthpiece in mouth, closing lips around it • Press and release the med while inhaling deeply and slowly • Hold breath for 10 seconds and exhale • Repeat x1

46. 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

47. Why don’t we give bicarbonate for respiratory acidosis? • Child not able to blow off CO2 and acidosis will get worse • Correct the cause of the acidosis • Patient may need to be intubated

48. Cystic Fibrosis

49. Cystic Fibrosis

50. Cystic Fibrosis (CF) • Factor responsible for manifestations of the disease is mechanical obstruction caused by increased viscosity of mucous gland secretions • Mucous glands produce a thick protein that accumulates and dilates the glands • Passages in organs such as the PANCREAS become obstructed • First manifestation is meconium ileus in NB • Sweat chloride test