95 terms

Ch. 28: Upper Respiratory Issues

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Cause of majority of acute illnesses in children
Respiratory Infections
Upper Respiratory Tract
Oronasopharynx, pharynx, larynx, and trachea
Lower Respiratory Tract
Bronchi, bronchioles, and alveoli
Infectious agents - viruses
RSV,
Parainfluenza
Infectious agents - other
Group A β-hemolytic streptococci,
Staphylococci,
Chlamydia trachomatis, Mycoplasma, pneumococci,
Haemophilus influenzae
Infants younger than 3 months
maternal antibodies except GBS
3-6 months
Infection rate increases
Older than 5 years old
increase in Mycoplasma pneumonia and β-strep infections
age
Immunity increases with?
Size
Diameter of airways plays significant role in respiratory illnesses airways smaller, more edema in mucus membranes, increased secretion production.
Distance between structures is shorter, allowing organisms to rapidly move down.
Short eustachian tubes also straighter, allows easier success to inner ear, more horizontal.
Resistance
Immune system,
Allergies, asthma,
Cardiac anomalies,
Cystic fibrosis,
Daycare more exposure.
Seasonal Variations
Most common during winter and spring. Mycoplasmal infections. Asthmatic bronchitis. RSV.
Mycoplasmal infections
Common in fall and winter
Asthmatic bronchitis
More frequent in cold weather
RSV
Winter and Spring
Clinical Manifestations of Seasonal Variations
Fever, Anorexia, vomiting, diarrhea, abdominal pain secondary to mucus, watch for dehydration from vomiting,
Cough, sore throat, nasal blockage or discharge,
Respiratory sounds: Cough, hoarseness, grunting, stridor, wheezing, crackles, uneven BS, decreased BS.
Nursing Interventions for Seasonal Variations
Ease respiratory effort: humidifier, why cool mist, mist tents, quiet activity, steam shower (not evidenced based), bulb syringe and saline gtts, neo-synephrine gtts or spray x 3 days (discard after use on one child), ice bag, heating pad.
Fever management (no aspirin).
Promote rest and comfort.
Infection control: wash hands, cover mouth, don't share cups, etc.
Promote hydration and nutrition.
Family support and teaching.
Prevent spread of infection.
Provide support and plan for home care.
Nasopharyngitis
common cold
URT Infections (URTI)
caused by numerous viruses: RSV, rhinovirus, adenovirus, influenza, and parainfluenza viruses
Clinical Manifestations of URTI
Fever—varies with age of child.
Irritability, restlessness,
Decreased appetite and fluid intake, Nasal inflammation,
Vomiting and diarrhea.
Pharmacological Tx for URTI
Antihistamines ineffective in most cases.
Antipyretics for comfort from fever.
Cough suppressants for dry cough
(Caution alcohol content dextromophoran).
Decongestant to shrink swollen nasal passages (Nose drops more effective than oral administration.
Store meds safely.)
OTC pediatric cold remedies
What is NOT recommended for treating the common cold?
Acute Streptococcal Pharyngitis
Group A β-hemolytic streptococci (GABHS).
Diagnostic Eval for Acute Streptococcal Pharyngitis
Rapid antigen testing, culture
Acute Streptococcal Pharyngitis Sxs
HA, fever, abd pain, Tonsils and pharynx inflammed and covered with exudate by day 2,
Swollen/ tender lymph nodes, difficulty to swallow,
"kissing tonsils", obstruct nares and partially obstruct trachea and esphagus, hard to breathe, talk with nasal voice,
Mouth breathe, dry mucus membranes, mouth odor.
Risk for Serious Sequelae
Acute rheumatic fever.
Acute glomerulonephritis.
Scarlet fever (though rarely seen in United States).
Pharyntitis. sandpaper rash in scarlet fever.
Oral Penicillin for Strep
Needs 10-day treatment to decrease risk of rheumatic fever and glomerulonephritis post illness.
Issues with medication compliance.
IM Penicillin for Strep
G DEEP IM.
Resolves compliance issue (one injection).
Painful injection .
Procaine is less painful injection.
Penicillin G
CANNOT give by IV route
Erythromycin
What to give if allergic to Penicillin?
Other antibiotics for strep
Other antibiotics mycins, zithro, clinda, cephalosporins
Teaching for strep
Culture other family members.
New toothbrush. Back to school after 24 hr abx. Important to complete meds.
Tonsills
lymphoid tissure in pharyngeal cavity. filter pathogenic organisms. normally larger in children. Waldeyer ring- pharyngeal (adenoid), tubal and palatine (removed).
Tonsillitis
Is viral or bacterial May be recurrent strep or peritonsillar abscess. can lead to sleep apnea and otitis media.
After age 3-4, decreased bleeding and regrowth.
Clinical Manifestations of Tonsillitis
sore throat, swollen glands, snoring, may occlude airway
Surgical Tx of Tonsillitis
Controversial.
May be indicated with massive hypertrophy.
Post Op Tonsillectomy Nursing Concerns
-Airway: Positioning
-Bleeding:
Observation—frequent swallowing? if you swallow blood, what do you do?.
Prevention of recurrent bleeding.
Maintain quiet environment.
Minimize agitation/crying.
NO suctioning.
Signs of bleeding- tachycardia, pallor.
-Comfort avoid seasonings, no gargling.
-Pain meds, ice collar.
Infectious Mononucleosis
Kissing disease. Acute, self-limiting infection. Common in younger than 25-year-olds.
Etiology of Infectious Mononucleosis
EBV principal cause blood transfusions, transplantation, oral secretions, mildly contageous, 30-50day incubation
Clinical Manifestations of Infectious Mononucleosis
manifestations malaise, sore throat, fever, HA, inlarged lymph nodes and spleen, inc leukocytes and atypical leukocytes
Diagnosis of Infectious Mononucleosis
heterophil antibody test tells extent pt serum witll agglutinate in sheep RBCs. 1:160. Monospot- specially treated paper- blood agglutinated.
Therapeutic Management of Infectious Mononucleosis
Rest, fluids, treat symptoms,
safety.
Influenza (Flu)
three typesA (H1N1), b, C. Large droplet and secretion spread. More severe in young children, older adults, immunocompromised patients.
Clinical Manifestations of Influenza (Flu)
1-4 day incubation, infectious 24 hours before and after onset of symptoms.
Therapeutic Management of Influenza (Flu)
fever control, comfort, hydration, rest
Pharmacology for Influenza in Children
Antivirals for children:
Oseltamivir (Tamiflu, greater than 2 weeks age),
Zanamivir (RELENZA).
Must start within 48 hours of symptom onset.
AVOID aspirin—possible link with Reye syndrome.
Every 5-6 years
antigentic shift
Prevention of Influenza
Now recommended for children > 6mo.
New vaccine annually.
Injected and inhaled vaccines.
Contraindications to influenza vaccines allergy, age.
Epidemiologic value of influenza vaccines in pediatric population.
For pregnant women, children 6 mo - 24 mo, health care workers, EMS, caretakesr for < 6 mo age, 25-64 with medical conditions.
Reye's Syndrome
follows viral illness. linked with aspirin use. Cerebral edema and fatty changes in liver. Vomiting and neurological impairment.
Mitrochondrial insult. Lethargy progresses to coma.
Otitis Media (OM)
result of dysfuntioning eustachian tube: protects middle ear from np secretions, drains secretions into np, equalizes air pressure.
More common in winter. Impact of passive smoke inhalation/crowded living conditions.
Precursor to OM
RSV, flu,adenovirus, rhinovirus
OM Age Range
Usually < 24 mo, then decreases until preschool age to 7 years.
Sxs of OM
irritable, pull at ears, dec appetite, rinorrhea, fever, pain from pressure of fluid. Visual inspection, yellow, red, fixed bulging membrane
Otitis Media
infection of middle ear
Acute OM
rapid onset with fever and pain
OM with Effusion
fluid in ear but no symptoms
Prolonged OM
funtional hearing loss, speech, language and congition problems
Structural Damage of OM
contacton and scarring of ear drum (tympanic membrane)
OM and Infant Feeding Methods
Breast-fed infants have less OM than bottle-fed infants due to Immunoglobulin A. Position in breast-feeding may decrease reflex in eustachian tubes.
> 6 months, OM antibiotic therapy
"watchful waiting" up to 72 hours for spontaneous resolution
<2 years old, OM antibiotic therapy
Antibiotics with persistent acute symptoms of fever and severe ear pain.
< 6 months, OM antibiotic therapy
always give antibiotics
Topical Relief for OM
heat or cold or benzocaine drops (Rx)
First Line Antibiotics for OM
Amoxicillin PO 80 to 90 mg/kg/day, divided twice daily ×10 days. may give 5-7 days if milder case.
Second line antibiotics for OM
Amoxicillin-clavulanate (Augmentin), azithromycin,
Cephalosporins IM (If highly resistant organism or noncompliant with oral doses.
IM is painful.
Reconstitute with 1% lidocaine (without epinephrine) to decrease pain of injection).
Analgesic-antipyretic drugs for OM
Acetaminophen.
Ibuprofen (only if >6 months of age).
Tx of OM
NO steroids, antihistamines, decongestants, antibiotic ear drops.
Surgical Intervention for OM -Myringotomy
Incision of ear drum, tubes (tympanostomy tubes) stay in till they fall out.
Prevention of OM with Effusion
PCV 7 vaccine.
Breastfeeding.
Preventing exposure to tobacco smoke.
Otitis Externa (OE)
Swimmer's ear. Infections of the external ear canal. normal flora goes rogue. Inflammation. maceration. May have secondary infection.
Etiology of OE
Staphylococcus or Corynebacterium.
Prevention of OE
white vinegar and alcohol to prevent
Clinical Manifestations of OE
edema, pain, fever
Tx of OE
Neomycin, steroids, ear wick
Croup Syndromes
Characterized by hoarseness, "barking" cough, inspiratory stridor, and varying degrees of respiratory distress.
Croup Syndromes Age Ranges
More in boys, autumn and winter, 6 mo-3 yr
What croup syndrome affects
Affect larynx, trachea, and bronchi. more serious in infants and small children due to smaller airway diameter. HinfB, adenovirus, flu RSV.
Anatomical area affected in Croup Syndromes
Epiglottitis [or supraglottitis], laryngitis, laryngotracheobronchitis [LTB], and tracheitis
Acute Epiglottitis
Serious obstructive, inflammatory process.
Clinical Manifestations of Acute Epiglottitis
Abrupt onset. Sore throat may be first sign pain. tripod positioning. retractions. drooling. agitation. NO cough.
Inspiratory stridor. mild hypoxia. distress. Fever.
Therapeutic Management of Acute Epiglottitis
Potential for complete respiratory obstruction. Edematous epiglottis- plaeor cyanotic. Check carefully because tongue blade may cause spasm and obstruction. Be prepared to use artificial airway. Humidified O2, air, abx 7-10 days, steroids.
Prevention of Acute Epiglottitis
Hib vaccine
Nursing Considerations Acute Epiglottitis
Position for comfort.
Decrease anxiety.
No tongue blade.
Keep suction at bedside.
Keep emergency respiratory equipment at bedside.
Epiglottitis looks worse, LTB sounds worse.
Acute Laryngitis
More common in older children and adolescents.
Usually caused by virus. Generally self-limiting and without long-term sequelae.
Sxs of Acute Laryngitis
Chief complaint: hoarseness.
Also congestion, sore throat, fever, HA.
Therapeutic Management of Acute Laryngitis
symptomatic
Acute Laryngotracheobronchitis (LTB)
Most common of the croup syndromes. Generally affects children younger than 5 years.
Organisms that cause LTB
RSV, parainfluenza virus, Mycoplasma pneumoniae, influenza A and B.
Typically preceded by URI that descends to lower structures.
Manifestations of LTB
Inspiratory stridor.
Suprasternal retractions.
Barking or "seal-like" cough.
Low-grade fever, worse at night, cough, airway inflammation.
Increasing respiratory distress and hypoxia.
Can progress to respiratory acidosis, respiratory failure, and death.
Therapeutic Management of LTB
Airway management.
Maintain hydration—PO or IV.
High humidity with cool mist vaporizer, mask if in hospital, cool night air, freezer.
Nebulizer treatments mucosal vasoconstriction and decrease edema. Q 20-30 min,peaks at 2 hours.
Side- tachycardia, hypertension, shaky, wild child (Racemic epinephrine, Steroids).
Heliox if unresponsive to other treatments.
Oral steroids, oral fluids, comfort measures.
Signs of Increasing Respiratory Distress in Children
RESTLESSNESS
Tachycardia
Tachypnea
Retractions (Substernal, Suprasternal, Intracostal. Look at effort, rate, retraction, flaring, oxygenation (color, pulse ox), temp, activity, comfort level)
Acute Spasmodic Laryngitis
spasmodic croup, midnight croup.
Paroxysmal attacks of laryngeal obstruction.
Occurs chiefly at night.
Inflammation—mild or absent.
Most often affects children ages 1 through 3.
Therapeutic management:
Cool mist, cold air, racemic epi.
Bacterial Tracheitis
Infection of the mucosa of the upper trachea. Distinct entity, features of croup and epiglottitis in older children (5-7 yrs).
Bacterial Tracheitis Clinical Manifestations
Thick, purulent secretions.
Respiratory distress.
Stridor, cough.
May develop life-threatening obstruction or respiratory failure, ARDS, multiple organ dysfunction (ask why).
Therapeutic Management of Bacterial Tracheitis
Humidified oxygen. Antipyretics
Antibiotics. May require intubationand ventilator support. Nursing: comfort, positioning, suctioning, turning.
Nutrition, hydration.