RespiratoryRespiratory

Key Pediatric Key Pediatric Differences in the Differences in the

Respiratory SystemRespiratory System• Lack of or insufficient surfactant (premature

infant) • Smaller airways and underdeveloped cartilage• Tonsilar tissue enlarged• More flexible larynx• Obligatory nose breather (infant)• Less well developed intercostal muscles• Brief periods of apnea common (newborn)• Faster respiratory rate• Increased metabolic needs• Eustachian tubes relatively horizontal

Respiratory Diseases and Respiratory Diseases and Disorders of ChildhoodDisorders of Childhood

• Otitis Media• Pharyngitis• Epiglotitis• Broncholitis• Pneumonia• Asthma exacerbation• Cystic Fibrosis• Tuberculosis

Upper Upper Respiratory Respiratory

Tract Tract DisordersDisorders

Otitis Media (OM)Otitis Media (OM)• One of the most common illnesses in infancy and

childhood• Peak incidence: 6 months to 6 years• Infection or blockage of the middle ear• Acute, Chronic or Serous OM

Risks for Development Risks for Development of Acute Otitis Mediaof Acute Otitis Media

• Exposure to second hand smoke• Allergies• Bottle fed infants

(AOM) Acute Otitis (AOM) Acute Otitis MediaMedia

• Sudden temperature increases

• Sharp pain • Otalgia (earache); pull

on ear, rubbing face • Irritability• Sleep disturbance• Persistent crying• Fever, vomiting,

diarrhea, anorexia• Sudden relief and

drainage=rupture TM

TreatmentTreatment• AOM could be viral or bacterial• Acetaminophen (pain, fever)• Amoxicillin for 7-10 days if bacterial• ALTERNATIVE- wait 72 hours then treat

Serous Otitis Media or Serous Otitis Media or

Otitis Media with Effusion Otitis Media with Effusion

(SOM/OME)(SOM/OME)• Result of chronic otitis

media (3 AOM in 6 months or 4 AOM in 1 year)

• Epithelial cells of middle ear begin producing secretions instead of absorbing them

Surgical Surgical InterventionsInterventions

Myringotomy• Surgical incision or laser of the tympanic membrane• Allows mucoid material to be removed from middle

earTympanostomy tubes• Placed to equalize pressure on both sides of the

tympanic membrane, keeps ear aerated• Allows middle ear mucosa to return to normal and

growth of the eustachian tube to continue

Patient Teaching-Patient Teaching-Post OpPost Op

• Monitor for ear drainage

• Report any fever or increased pain

• Avoid blowing nose for 7-10 days

• Swimming, showers allowed only with earplugs

• Diving and swimming in deep water is prohibited

Pharyngitis (Tonsillitis)Pharyngitis (Tonsillitis)

• Inflammation and infection of the palatine tonsils

• Viral vs. Bacterial • Peak age 4-7 years

Viral PharyngitisViral Pharyngitis• Gradual Sore throat• Erythema, inflammation

of pharynx and tonsils (may be slight)

• Vesicles or ulcers on tonsils

• Fever (usually low grade)

• Hoarseness, cough, rhinitis, conjunctivitis, malaise, anorexia

• Cervical lymph nodes may be enlarged, tender

• Usually lasts 3-4 days then resolves spontaneously

Bacterial Pharyngitis Bacterial Pharyngitis • Abrupt onset (may be

gradual in children younger than 2 years)

• Sore throat (usually severe)

• Erythema, inflammation of pharynx and tonsils

• Fever usually high (103-104F) but may be moderate

• Abdominal pain, headache, vomiting

• Cervical lymph nodes may be enlarged, tender

• Requires antibiotics

ManagementManagement

• Pain relief

• Rest

• Bland, soft diet

• Amoxicillin if bacterial

• Tonsillectomy is controversial

Nursing Care (Pre-Nursing Care (Pre-op)op)

• Assess for current infection and bleeding history

• Check for loose teeth• Teach child and parent what to expect

post-opoMay see dried blood in mouth and

teethoWill still be able to talkoPain management for optimal

recovery

Nursing Care (Post-Nursing Care (Post-op)op)

• Assess for bleedingoElevated pulseoDecreased BPoRestlessnessoFrequent swallowingoVomiting bright red blood• Clear, cool liquids, no red juices!

• Advance to full liquids and soft foods on 2nd day if no sign of hemorrhage

• Pain relief (throat very sore)

Nursing care (Post-op)Nursing care (Post-op)• Encourage child to chew and swallow

• No straws, forks or sharp, pointed toys

• Discourage irritating the operative site

o coughing frequentlyo clearing the throato blowing the nose

CroupCroup

Manifestations of Manifestations of CroupCroup

• Begins at night; may be preceded by several days of symptoms of upper respiratory tract infection

• Sudden onset of harsh, barky cough; sore throat; inspiratory stridor; hoarseness

• Could progress into use of accessory muscles to breathe

• Frightened appearance; agitation• Cyanosis

• Mostly viral in nature, resolves spontaneously

• Humidification and cold air resolves attacks

EpiglottitisEpiglottitis• Bacterial form of croup (H influenza) with unique

symptoms and treatment• Bacterial infection invades tissues surrounding the

epiglottis• Epiglottis becomes edematous, cherry red and may

completed obstruct airway• Progresses rapidly, child is unable to swallow,

drooling

SymptomsSymptoms

• May have had mild URI few days prior• Drooling• Dysphasia • Dysphonia • Distressed respiratory efforts• Tripod position: supported by arms, chin

thrust out, mouth open

ER ManagementER Management• NEVER leave child unattended• Don’t examine or culture throat or start IV/Blood

samples• Continuous pulse ox • Humidified O2• Antipyretics suppository-nothing PO• Calm the parent! Explain what is going on…a calm

parent=calmer child!• OR- intubation• Throat & blood cultures done after intubation• Usually extubated after 48h• Antibiotics for 7-10 days• Discharge

Nursing Interventions on Nursing Interventions on

unit once stableunit once stable• Continually assess for s/s of respiratory distress• Maintain pulse ox above 95% with PaO2 between 80-

100mmHg• Maintain patent airway• Position for comfort (never force to lie down)• Relieve anxiety• Monitor temp• Administer antibiotics

Lower Lower Respiratory Respiratory

Tract Tract DisordersDisorders

BroncholitisBroncholitis• Inflammation of the

fine bronchioles and small bronchi

• Occurs in children birth to 2 years

• peak age 6 months• Highest in winter and

spring• RSV is most

responsible pathogen

Signs and SymptomsSigns and Symptoms• 1-2 days of URI, then suddenly symptoms become

worse• nasal flaring• intercostal and subcostal retractions • wheezes, crackles or rhonchi• increased respiratory rate• low pulse oximetry• tachycardia and cyanosis

Nursing Nursing ManagementManagement

• Antipyretics• Semi-fowlers position• Hydration- IVF• Humidification• Oxygenation- use Blow By• Bronchdilator therapy• No antibiotics…Viral infection!• Acute phase usually lasts for 2-3 days• Watch for increased severity-can progress to airway

obstruction

Pneunomia (PN)Pneunomia (PN)• Inflammation of the

alveoli usually following an URI

• Late winter/early spring

• Viral vs. Bacterial

Signs and SymptomsSigns and SymptomsViral- may have mild cold symptomsBacterial- distinctly ill

o High fever, may be diaphoretico Cough (productive or non productive)o Tachypneao Abnormal BS (fine crackles, rhonchi)o Dull percussiono Chest paino Increased respiratory efforto CXR changeso Lab findings (increased WBC)o Irritable, restlesso Occasional N/V/D o Low PO intake

Ineffective Breathing Ineffective Breathing

Pattern: InterventionsPattern: Interventions• Assess breath sounds, VS, respiratory status

q1-2h and PRN• Administer humidified O2 via face mask,

obtain ABG’s, monitor pulse ox• Administer antibiotics and antipyretics• Perform chest physiotherapy as ordered• Engage child in play activities

o Cough, turn, deep breatheo Incentive spirometer

Activity Intolerance: Activity Intolerance:

InterventionsInterventions• Balance activity with rest periods,

cluster nursing care• Provide small frequent meals• Increase activity gradually

Risk for Deficient Fluid Risk for Deficient Fluid

Volume: InterventionsVolume: Interventions• Obtain baseline weight, monitor daily• Administer IV fluids as ordered• Offer fluids frequently (jello, ices, etc.)• Administer antipyretics• Monitor I&O, urine for specific gravity

increases

TuberculosisTuberculosis• Bacterial infection that multiplies in the

lung tissue, alveoli and lymph nodes• Initially asymptomatic• Incubation period 2-12 weeks, will test +

PPD• Immune system can ward off full

development and become dormant• Children rarely develop active TB, but are

excellent transmitters to others

Risk FactorsRisk Factors• Contact with infected adults • Chronic illness, immunosuppression, HIV

infection, malnutrition• Young age (infancy, adolescence)• Nonwhite racial, ethnic groups,

immigrants from areas with high incidence

• Urban, low-income living conditions• Incarcerated adolescents• Contact with adults from high-risk groups

Active TB SymptomsActive TB Symptoms• +PPD• Malaise• Fever• Night Sweats• Slight cough• Weight loss• Anorexia• Lymphadenopathy• Confirmed by CXR,

sputum sample, or gastric washing

ManagementManagementAsymptomatic

children• INH x 9 months• 12 months if HIV+• Household contacts

treat for 12 weeks

Symptomatic children• INH, rifampin and

pyrazinamide x 2 months

• Followed by INH and rifampin x 4 months

Side effects: GI, orange tears, urine= noncompliance

Chronic Lung Chronic Lung DiseasesDiseases

AsthmaAsthma• A reversible obstructive

airway disease

• Hypersensitivity of many cells (Mast, Eosinophils, T Lymphocytes)

• Increased airway responsiveness to a variety of stimuli

AsthmaAsthma• Bronchospasm resulting from constriction of bronchial

smooth muscle

• Inflammation and edema of the mucous membranes that line the small airways and the subsequent accumulation of thick secretions in the airways

• Initial Symptom is a Cough (w/o illness) usually at night• Wheezing is produced when there is decreased

expiratory airflow

Asthma SeverityAsthma Severity• Classified as

o Mild intermittent• Symptoms < 2 x week

o Mild Persistent• Symptoms > 2 x week, but less than

once a dayo Moderate

• Day symptoms 2 x week, 1 or more night symptoms per week

o Severe• Continual day symptoms, frequent

night symptoms

TriggersTriggers• Cold air exposure• Smoke/fumes• Viral infection• Stress• Exercise• Odors (perfume)• Animal dander• Dust, cockroaches, rodents• Certain drugs (aspirin, NSAID’s)• GI reflux• Food allergens, outdoor allergens

Acute Asthma Acute Asthma Exacerbation SymptomsExacerbation Symptoms

• Chest tightness• Wheezing• Shortness of breath• Nonproductive cough

(with or without wheezing); later becomes productive

• Tachypnea, orthopnea

• Tripod position or straight

Management of Acute Management of Acute

Asthma ExacerbationAsthma Exacerbation• Monitor respiratory rate and effort,

color

• Provide oxygen therapy:

• warmed and humidified

• at 30-40% not 100%

• keep O2 sat > 95%; need CO2 stimulation for inhalation

Management of Acute Management of Acute Asthma ExacerbationAsthma Exacerbation

• Administer short acting beta2 agonist bronchodilatorso Ventolin, Proventil, Albuterol

• Administer corticosteroidso Predinsone, Prednisolone, Solumedrol

• Monitor effectiveness of meds• Easily fatigable• Frequent position changes

Management of Acute Management of Acute Asthma ExacerbationAsthma Exacerbation

• Observe for Status Asthmaticus

• Occurs when child fails to respond to treatment (severe emergency)

• Often caused by pulmonary infection

• Call MD!

Maintenance Maintenance MedicationsMedications

• Mild Intermittent and Persistent Asthma o anti-inflammatory corticosteroids PRN (Flovent

inhaler)

• Moderate Asthmao anti-inflammatory corticosteroids QD (Flovent inhaler)o long-acting bronchodilator at HS(Theophylline,

Serevent)

Maintenance Maintenance MedicationsMedications

• Severeo oral corticosteroid qdo inhaled corticosteroid qd o long-acting bronchodilator HS

Discharge PlanningDischarge Planning• Teaching self-management

o Identify triggerso Avoidance of allergensoMay need skin testing and hyposensitization

NebulizerNebulizer• Assess availability of home meds (proper inhaler

use and storage, nebulizer)

Teach use of Peak Flow Teach use of Peak Flow MeterMeter

• Measures maximum peak expiratory flow rate

• Need to first use when healthy to mark baseline

• Can use to predict acute exacerbation in kids 5-6 years and older

• Take a deep breath, blow out hard and fast

• If peak flow is 30-50% of child’s predicted baseline=ER

Cystic Fibrosis (CF)Cystic Fibrosis (CF)• Mutated gene on chromosome 7 CFTR

• Inherited autosomal recessive trait

• Both parents carry gene

(1/4 chance of conceiving affected child)

Cystic FibrosisCystic Fibrosis• Chronic multisystem disorder affecting the exocrine

glands• Affects bronchioles, small intestines, pancreatic &

bile ducts• Usually diagnosed before 1st birthday• Incurable• Symptoms worsen as disease progresses• Median life expectancy is reduced due to infections

Cystic FibrosisCystic Fibrosis• Respiratory System• Gastrointestinal System• Reproductive System• Exocrine Glands

Respiratory SystemRespiratory System• Wheezing, dry, non-productive cough,

repeated URI’s• Copious, thick sputum• Crackles, wheezes, decreased breath sounds• Increasing signs of respiratory distress =>

emphysema & atelectesis• Clubbing, barrel chest

Nursing ManagementNursing Management• Facilitate airway clearance • Prevent pooling of secretions – postural drainage• CPT every 4 hours (1 hour before or 2 hours after meals,

prior to bedtime)• Forced expiration (“huffing”)• Prevention and treatment of pulmonary infections-

aggressive IV antibiotics• Administer bronchodilators and mucolytics • High-humidity cool-mist tent to mobilize secretions• If 02 is required, use low flow rate

CPTCPT

Gastrointestional Gastrointestional SystemSystem

• Steatorrhea: frothy, foul-smelling stools 2-3 times bulkier than normal

• Malnutrition and failure to thrive despite normal caloric intake

• Protuberant abdomen• Fat soluble vitamin deficiencies: K, A, D, E (caused

by inability to absorb fats)• Meconium illeus in the newborn might be 1st sign

Nursing ManagementNursing Management• Well balanced diet high in calories,

protein, carbohydrates• Pancreatic enzymes within 30 minutes of

eating all meals and snacks

Reproductive Reproductive SystemSystem

• Average of 2 year delay in the development of secondary sex characteristics

• Females have thick cervical mucus (trouble getting pregnant)

• Some male patients sterile due to lack of sperm

Exocrine GlandsExocrine Glands

• Abnormally high concentrations of sodium and chloride in the sweat

• Sweat Test determines amount of sodium chloride in sweat

• Risk for electrolyte imbalance during hot weather

Nursing Nursing ManagementManagement

• Monitor for dehydration• Extra salt and fluid in hot weather

Dehydration Dehydration and Fluid Lossand Fluid Loss

Dehydration and Fluid Dehydration and Fluid LossLoss

• Large portion of a child’s fluids is located in extracellular fluid (increased BSA)o Infants: 75-80% of the weighto 2 year old: 60% of weight

• First two years of life kidneys are not functionally mature

• Inefficient at excreting waste products

Dehydration and Fluid Dehydration and Fluid LossLoss

• Fluid and electrolyte imbalances develop and progress very quickly

• Sick children often have low PO intake and diarrhea and vomiting =

• Infants and young children are highly susceptible to rapid and profound fluid and electrolyte imbalances

Types of Fluid LossTypes of Fluid Loss

• Sensible Fluid Loss• Insensible Fluid Loss

Sensible Fluid LossSensible Fluid Loss• Can be measured and observed• Urine output• Drains and tubes• Emesis • Diarrhea

Insensible Fluid LossInsensible Fluid Loss• Loss of fluid through lungs (2/3) and skin

(1/3)• Influenced by heat and humidity, body

temp, respiratory rate (children have higher RR than adults)

• Basal metabolic rate increases 10% for each degree Celsius above normal body temperature

• Example 39 Celsius = 102.2F o BMR increases by 20% !

ElectrolytesElectrolytes• NA- major electrolyte in ECF

o Needed to establish osmolarity

• K- major electrolyte in ICFo Needed for excitability of neurons and muscles

Three Types of Three Types of DehydrationDehydration

• Isotonic• Hypotonic• Hypertonic

Isotonic DehydrationIsotonic Dehydration• Sodium and water deficits are the same

(salt and water are lost in equal amounts in ICF and ECF)

• NA+ 130-150meq/L (normal)• Most common type in children from low PO

intake• Can result in hypovolemic shock

Hypotonic Hypotonic DehydrationDehydration

• Sodium deficit is greater than the water deficit

• Water moves from ECF to ICF• NA+ < 130meq/L• Results from GI losses (vomit, diarrhea)

• May result in shock

Hypertonic Hypertonic DehydrationDehydration

• Water loss exceeds sodium loss• Body compensates with fluid shifts from ICF

to ECF• NA+ > 150meq/L• May be caused by severe vomiting, too

much IV NA• Can result in seizures

Know the S+S of Know the S+S of DehydrationDehydration

• MildoNormal VS, moist mucous membranes,

alert, normal urine output, normal turgor, fontanelle, normal cap refill, thirsty

• Moderateo Rapid pulse and RR, normal BP, dry

mucous membranes, irritable, dark urine and decreased output, poor turgor, sunken fontanelle, delayed cap refill, moderately thirsty

Know the S+S of Know the S+S of DehydrationDehydration

• Severe• Changes in respirations depth and pattern, rapid weak pulse, low BP, mucous membranes parched, can be comatose, absent urine output, very poor turgor, sunken fontanelle, cool skin

Monitor for Monitor for DehydrationDehydration

URINE OUTPUT SHOULD BE AT MINIMUM1 ml/kg/hr

ALL children are on I+O

Monitor labs for:o Increased BUNo Increased serum bicarboHyponatermiaoHyperkalemiao Increased urine specific gravity

PREVENT dehydrationPREVENT dehydration• Monitor temperature, prevent overheating• Give frequent fluids, may need oral rehydration

(pedialyte) 50 ml/kg/ in 4 hours when febrile and GI losses

• Use small medicine cups, syringe without needed to administer fluids…even 1 tsp every few minutes

• Monitor IV fluid administration, ensure patent IV site

Administering IV Administering IV FluidsFluids

• Always use an infusion pump with a volume control device

• Prevents a sudden extracellular fluid volume overload

• Never use more than a 500 ml bag

• Mechanical pumps can have faulty performance, so check the intravenous line, bag, and rate often

Practice Practice Questions!Questions!

A teenager with chronic asthma asks the nurse, “How come I make so much noise when I breathe?” The nurse’s best response is:

a. It is the sound of air passing through fluid in your alveoli

b. It is the sound of air passing through fluid in your bronchus

c. It is the sound of air being pushed through narrowed bronchi on expiration

d. It is the sound of air being pushed through narrowed bronchi on inspiration

Which school related activity might the school nurse prohibit for a child with asthma?

a. Swim teamb. The Bandc. Pet “show and tell”d. An art class

A toddler with cystic fibrosis is placed in a high-humidity cool-mist tent operated with compressed air. The nurse knows the primary reason for this therapy is to:

a. Provide oxygenb. Lower the child’s temperaturec. Moisten the airway and mobilize secretionsd. Provide additional fluids

A preschooler with a diagnosis of epiglottitis is admitted to the hospital. Which MD order should the nurse question for this child?

a. Place a pediatric size tracheostomy tray in the room

b. Monitor pulse oxygen saturation every 15 minutes

c. Place in respiratory isolationd. Obtain CBC and Throat Culture

When assessing a child who is suspected of having asthma, the nurse should specifically ask the parents about which initial symptom that they may have noted?

a. Coughing a night in absence of respiratory infection

b. Coughing throughout the dayc. Expiratory wheezingd. Shortness of breath

When caring for a child who has recently undergone a tonsillectomy, the nurse should be aware that the child is discouraged from:

a. Talking and chewingb. Blowing the nosec. Eating lemon flavored ice popsd. Taking pain medication

When caring for a child who has had a tonsillectomy the nurse’s priority observation should be for:

a. Coffee ground emesisb. Frequent swallowingc. Complaints of a sore throatd. A slight increase in temperature

When assessing a child who is preverbal for otitis media, the nurse should anticipate that the child will:

a. Have difficulty swallowingb. Rub the affected side of head on the mattressc. Have a runny nosed. Have vomiting and diarrhea

The nurse’s health care teaching to assist parents in preventing otitis media should include instructions to:

a. Finish the entire prescription of antibioticsb. Administer acetaminophen to reduce painc. Apply warm compresses to affected eard. Refrain from putting the child to bed with a

bottle

The nurse has admitted a child with diarrhea for 3 days. The child’s laboratory results reveal sodium of 126. The nurse understands this is:

1. Isotonic Dehydration2. Hypotonic Dehydration3. Hypertonic Dehydration.4. Normal, the child is not dehyrated

The physician ordered pedialyte administration 50 ml/kg/ in 4 hours for a child weighing 33 lbs. Upon awakening, the child consumed 200ml of pedialyte at 9:00 am for breakfast. How many more ml does the child need to drink by 1 pm?1. 1650 ml2. 1450 ml3. 750 ml4. 550 ml