Chapter 40

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

CD PATIENT SCENARIO

CARE STUDY: AN ADOLESCENT WITH CYSTIC FIBROSIS

Billy Denman is a 16-year-old with cystic fibrosis admitted to your hospital unit.

CHIEF CONCERN:

“The usual; pneumonia for sure.”

HISTORY OF CHIEF CONCERN:

Billy was diagnosed as having cystic fibrosis at 8 months of age. Has been hospitalized

68 previous times for pneumonia. The present complication began 3 days ago with

elevated temperature (102°F), loss of energy, and persistent green-colored sputum on

postural drainage. Delayed reporting symptoms to mother because he wanted to attend a

school dance this evening; by midmorning this day he realized he was too sick to delay

reporting symptoms any longer. Temperature is now 104°F; respiratory rate is 28 breaths

per minute; pulse is 132 beats per minute. Adolescent is coughing frequently but

nonproductively.

FAMILY PROFILE:

Billy lives with mother. Parents were divorced when he was 4 years old because “father

couldn't stand knowing he had a kid with CF.” Father has never contributed to Billy's

care despite the fact he lives in the city and knows of Billy's large medical bills. Mother is

a nurse; history was obtained from Billy as she had not arrived at hospital as yet. Billy

rated their finances as “hanging in there.” Family lives in a three-bedroom house; “one

bedroom for mom, one for me, and one for a slant board.” Billy does own postural

drainage on anterior lobes with automatic vibrator; mother does posterior surface; a home

care aid visits two times a week to supplement therapy.

HISTORY OF PAST ILLNESSES:

Chickenpox at 4 years (contracted while in hospital). Aspirated on a peanut when he was

4; removed by bronchoscopy with conscious sedation. Tonsillectomy of pallentine tonsils

at 6 years. No complications. Hospital admissions for CF average four times a year since

diagnosis; “severe” congestion with heart failure two times in last 2 years. One ER

admission for swallowing “too many aspirin” last May. Treated with stomach lavage, 24-

hour observation and discharged. Adolescent states episode occurred from “trying to stop

a headache, nothing else.” Immunizations: up to date: received meningococcal vaccine 6

months ago.

PREGNANCY HISTORY:

Planned pregnancy; first pregnancy for mother; no complications. Difficulty with

respirations at birth; resuscitated successfully. No bowel movement for 30 hours post

birth; then meconium plug was expelled. Billy was kept in hospital 3 extra days for

failure to regain birth weight and excessive jaundice.

DAY HISTORY:

Nutrition: 24-hour recall:

Breakfast: two eggs, four pieces sausage, two slices toast, one glass orange juice

Lunch: one hamburger with cheese, one serving French fries, one glass soda, one green

salad with Ranch dressing

Dinner: one serving veal, one serving mashed potatoes, one serving eggplant, one piece

carrot cake with ice cream, one glass milk

Snack: one ham and cheese sandwich, one bowl tomato soup with crackers, one piece

carrot cake, three glasses milk

Sleep: Sleeps 8 hours nightly. Occasionally wakes at night short of breath; relieved by

sitting up.

Recreation: Participates in the school science and computer clubs; participates in no

school sports. Maintains an active walking program; uses treadmill in home on rainy or

cold days. States he is normally able to “do things he wants to do”; admits to using illness

to not do things he does not want to do on occasion.

Growth and Development: Was breastfed as an infant; weight gain continued to be slow;

bowel movements large and foul smelling. Was changed to formula at 3 months in an

attempt to increase weight gain. Weight and height both continued to follow 10th

percentile. Infant and preschool motor milestones achieved late; didn't walk until 24

months. Language: normal: spoke in sentences by 2 years.

Currently attends high school in sophomore year (1 year behind); has had extra

hours tutoring to maintain school placement. Has regular household chores; cleans own

room and does own laundry; mows lawn with power mower.

HISTORY OF FAMILY ILLNESSES:

A maternal uncle has “much less severe cystic fibrosis”; maternal grandmother who lives

in Switzerland had two infants die at birth for “unknown reasons.” Mother: hysterectomy

3 years ago for dermoid cysts of ovaries. Father's family history: not known. A cousin has

severe asthma: treated with Cromolyn sodium and Zafirlukast (Accolate).

REVIEW OF SYSTEMS:

Head: occasional headaches when using computer too long.

Eyes: vision 20/50 L, 20/70 R; wears corrective glasses.

Ears: No otitis media; hearing tested in school in 8th grade and found to be adequate.

Nose: Occasional nosebleeds if in air-conditioned room.

GI: Takes pancreatin with meals; no rectal prolapse

Integument: had heat prostration in 6th grade from running in a foot race in hot sun.

Treated with intravenous fluid in emergency room. Now more careful to reduce activities

in hot weather.

Neuro/psych: “Resigned” to having chronic illness although does experience occasional

episodes of depression thinking about future; mother concerned that poisoning episode

last year was not a pure accident.

PHYSICAL EXAMINATION

Height: 5 feet 4 inches (x%). Weight: 92 pounds (x%). (MRI: xx)

Blood pressure: 90/50.

General Appearance: Underweight pale appearing adolescent male; sad facial expression.

Head: Normocephalic; 2 blackened comedones present on forehead.

Eyes: Red reflex present; follows to all fields of vision; no erythema or discharge present.

Ears: TMs reddened bilaterally; landmarks not distinct; hearing equal to examiner’s.

Nose: Midline septum; mucous membrane reddened; yellow pustular discharge present.

Mouth and Throat: Prominent anterior overbite; no cavities; geographic tongue. Yellow

drainage present on posterior throat; posterior palate slightly erythematous.

Neck: Supple, no pain on forward flexion; midline trachea; no nodes palpable in thyroid;

three palpable lymph nodes on left; two on right in posterior cervical chains.

Lungs: Scattered rhonchi in all lobes; decreased breath sounds in right lower lobes; moist

crackling in both lower lobes.

Heart: Rate: 80 beats per minute; third heart sound audible. Marked sinus arrhythmia.

Abdomen: Liver palpable 2 cm below right costal margin; no masses; bowel sounds at 2

to 3 per minute in all quadrants.

Genitalia: Adolescent male; Tanner 5; testes descended; midline meatus

Extremities: Full ROM, poor muscle tone in upper extremities.

Neuro: Patellar and brachial reflexes 2+. Sensory and motor nerves grossly intact.

Billy is diagnosed as having pneumonia. He is hospitalized for intravenous antibiotic

therapy.

CARE STUDY QUESTIONS:

1. Billy had difficulty breathing at birth. Premature newborns may have difficulty with

lung function because they lack surfactant. What is the role of this in lung function?

a. It propels inhaled particles up the bronchi.

b. It phagocizes viral invaders that enter the alveoli.

c. It prevents complete collapse of alveoli on expiration.

d. It allows alveoli to expand to their full limit on inspiration.

Answer: c. Surfactant, a lipid protein produced by lung cells decreases surface tension so

it prevents alveoli from completely collapsing on expiration; this makes inflating alveoli

easier with the next inspiration.

2. Billy aspirated a peanut when he was 3. Where on a chest sonogram would you have

expected to have seen this lodged?

a. In his right chest

b. Behind the sternum

c. In his left chest

d. Just above the stomach bubble

Answer: a. The right bronchus is larger and straighter than the left so most aspirated

objects lodge in the right lower lung.

3. Why is aspiration of a peanut a particular dangerous type of aspiration?

a. Peanuts cause the lungs to rust

b. A lipid pneumonia can develop

c. Health insurance doesn’t cover this

d. He will develop an allergy to peanuts

Answer: b. Because peanuts are coated by oil, they cause extreme inflammation of lung

tissue, which then becomes secondarily infected.

4. What is a risk factor Billy has for cystic fibrosis?

a. He rides a school bus every day.

b. He lives in the United States.

c. His family is allergy prone.

d. He has an uncle with the disease.

Answer: d. Cystic fibrosis is an autosomal recessively inherited disease.

5. Billy’s family is planning a vacation. Which location for this would you suggest?

a. Jamaica, because the beaches are so warm and sunny

b. A Los Angeles beach because they are always crowded with people

c. Alaska, because the cold air will be invigorating

d. Ohio with its moderately warm climate

Answer: d. Children with cystic fibrosis need to be careful not to expose themselves to

hot sun because they lose excess perspiration in sweat; they also need to avoid contacting

upper respiratory infections from cold.

6. Suppose Billy’s pH was 7.30, his PaCO2 was 52 mm Hg, and his HCO3 was 32

mEq/L. This would lead you to believe that Billy has a

a. respiratory acidosis from oxygen pooling.

b. respiratory alkalosis with oxygen want.

c. partially compensated respiratory acidosis.

d. fully compensated metabolic acidosis.

Answer: c. Children with cystic fibrosis “pocket” carbon dioxide as thick mucus traps it

in alveoli, leading to respiratory acidosis.

7. Billy is diagnosed as having right lower lobe pneumonia in addition to cystic fibrosis.

This is

a. acute infection of the alveoli of the lung.

b. infection of the major bronchi with exudate.

c. a contagious disease that affects the trachea.

d. alveoli coated with a fibrous membrane.

Answer: a. Pneumonia is inflammation and infection of lung alveoli. No fibrous

membrane is present.

8. Billy has blood-tinged sputum. This occurs with pneumonia because

a. his nose must be bleeding from coughing.

b. his inflamed tonsils are irritated and bleeding.

c. red blood cells have invaded his alveoli.

d. lymphocytes have turned WBCs rust colored.

Answer: c. With pneumonia, red blood cells enter the alveoli and are coughed up with

sputum.

9. Billy had no breath sounds in his right lower lobe. The reason this has occurred is that

a. his wheezing was so loud, it blocked out other sounds.

b. his chest wall is too thick at that point to hear through.

c. he must have been holding his breath to that one lobe.

d. the lobe is filled with so much exudate that air can’t enter.

Answer: d. No breath sounds indicate no air is entering that portion of the lung; with

pneumonia, air is blocked from entering by collected fluid.

10. Billy has rales in his upper left lobe. Rales indicate

a. an innocent collection of normal fluid.

b. fluid is present in his lung alveoli.

c. he must have a postnasal discharge.

d. his respiratory rate is abnormally rapid.

Answer: b. The sound of rales (crackles) is made by air passing through fluid in alveoli.

11. Billy’s SaO2 is 93%. His PaO2 is 75 mm Hg. You would evaluate this as

a. hypoxemia with lessened oxygen saturation.

b. adequate oxygenation but poor O2 saturation.

c. ineffective oxygenation from a blocked airway.

d. both poor oxygen saturation and hypoxia.

Answer: a. Oxygen saturation (SaO2) should be 95% to 100%; PaO2 should be 80 to 100

mm Hg.

12. Billy has never had a pneumococcal vaccine. You would advise him that

a. he doesn’t need it now as he is recovering from pneumonia.

b. the vaccine is contraindicated for children with cystic fibrosis.

c. at 16, he is too old to be a candidate for the vaccine.

d. he should receive this as soon as he recovers from his illness.

Answer: d. Billy should have the pneumococcal vaccine to help reduce the possibility

that he will acquire another episode of pneumonia.

13. Billy had bronchiolitis as an infant. This is

a. another name for pneumonia.

b. a type of bacterial influenza.

c. inflammation of the small bronchi.

d. a first response to breathing room air.

Answer: c. When alveoli are infected, it is pneumonia. When small bronchi are involved,

it is bronchiolitis.

14. The most frequent organism that causes bronchiolitis in infants is

a. streptococcus A.

b. chlamydia.

c. pneumococcus bacteria.

d. respiratory syncytial virus.

Answer: d. Respiratory syncytial virus is a major organism that causes bronchiolitis in

infants.

15. Billy had a tonsillectomy when he was 6. The best fluid to offer following a

tonsillectomy would be

a. water.

b. a cola drink.

c. orange juice.

d. red gelatin.

Answer: a. Carbonated or acidic fluids sting; red fluids could be mistaken for blood if

they are vomited.

16. Billy had a tracheostomy when he was younger. Safety precautions to take with a

child with a tracheotomy are

a. don’t let the child use a straw to drink.

b. don’t allow him to sleep on his back.

c. inspect toys for small breakable parts.

d. encourage the child to play indoors.

Answer: c. If small parts break, they could fly into the tracheotomy opening.

17. Billy has frequent nosebleeds (epistaxis). Which intervention would be best for this?

a. Elevate his head slightly and apply pressure to the forehead

b. Sit him upright and apply pressure to the sides of the nose

c. Turn his head to the side and press on his nasal ridge

d. Keep him flat and apply pressure to the bridge of the nose

Answer: b. Sitting upright relieves intravascular pressure; applying pressure to the sides

of the nose constricts blood vessels.

18. Billy had croup (laryngotracheobronchitis) as a preschooler. Which observation

would have been most important to demonstrate that his airway occlusion was

occurring?

a. Billy stated he was tired and wanted to sleep.

b. Respiratory rate was gradually increasing.

c. His cough was becoming louder and harsher.

d. His nasal discharge was increasing in amount.

Answer: b. An increasing respiratory rate suggests difficulty with breathing.

19. Which measure would have been most effective to aide bronchodilation with croup?

a. Urge Billy to continue to take oral fluids.

b. Administer an oral corticosteroid.

c. Teach Billy to take long slow breaths.

d. Assist with racemic epinephrine by nebulizer.

Answer: d. Racemic epinephrine by nebulizer is the drug of choice for bronchodilation

for children with laryngotracheobronchitis.

20. Billy needs postural drainage four times a day. To perform this you would

a. schedule it immediately after a meal so Billy has optimal energy.

b. caution Billy not to cough during the procedure to avoid lung damage.

c. position Billy sitting upright and use vibration to drain his upper alveoli.

d. caution Billy that he is too old to be using a slantboard; at his age it is dangerous.

Answer: c. Billy should cough to clear away secretions. Scheduling the procedure after a

meal could lead to vomiting with coughing. Sitting upright best drains upper lobes.

21. Billy has a cousin who has asthma. Is asthma mainly a problem of inspiration or

exhalation?

a. Inspiration because of narrowed alveoli

b. Expiration because of narrowed bronchi

c. Inspiration because alveoli are already full

d. Expiration because rhonchi are present

Answer: b. Because bronchi are more narrow on expiration than inspiration, respiratory

distress in asthma begins as expiratory distress.

22. Billy’s cousin takes Cromolyn sodium (Intal) for his asthma. The purpose of this is to

a. prevent serious infections.

b. keep secretions moist.

c. produce bronchial dilation.

d. inhibit release of histamine.

Answer: d. Cromolyn sodium is a mast cell stabilizer that prevents release of histamine.

23. Which statement by Billy’s cousin would assure you he understands how to use

Cromolyn sodium best?

a. “I should take it as soon as an asthma attack starts.”

b. “I can’t take it if I have a fever over 101°.”

c. “I should take it to prevent triggering an attack.”

d. “I should use it for only 24 hours after an attack.”

Answer: c. Cromolyn sodium prevents asthma attacks. It is not effective after an acute

attack begins.

24. Billy demonstrates use of a peak flow meter for you. To use this properly, he should

a. inhale into it as deeply as possible and then exhale slowly.

b. take a deep inhalation and exhale deeply into it.

c. breathe normally into it for a count of at least ten.

d. inhale deeply and hold his breath until it registers.

Answer: b. Peak flow measures the maximum amount of air that can be expelled in one

breath.