51 terms

N313- Peds Respiratory

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Immunity
Maternal antibodies diminish in first 3 months of life
Increased immunity with age
Respiratory Infections
account for the majority of acute illness in children
Risk Factors
Small diameter of airways, secretion plug
Small surface area for gas exchange
Short distance between structures, allowing organisms to rapidly move down
Short, wide, horizontal eustachian tubes
Low child resistance with malnutrition, chronic diseases, day care, smoking
Normal Respiratory Rates
Newborn = 35/min
1-11 mo. old = 30/min
2 years to 10 years = 19 to 25/min
12 years to 18 years = 16 to 19/min
Respiratory Distress Video
http://www.youtube.com/watch?v=NBA9iigiDgk&list=PL7EA9354BC2DD8B67
Acute Viral Nasopharyngitis (common cold)
Advise to see MD if earache develops as can indicate further involvement
Acute Streptococcal Pharyngitis (strep throat)
80-90% viral but can be caused by Group A beta hemolytic streptococcus (GABHS) so treatment is antibiotics because
Can lead to RHEUMATIC FEVER in 18 days, inflammation of heart, joints , CNS, and nephritis in 10 days, abscess
Or glomerulonephritis
Acute Streptococcal Pharyngitis Dx & Tx
Dx: Antistreptolysin O antibody (blood test)
Tx: Penicillin for 10 days, IM penicillin G, clarithromycin, cephalosporin, amoxicillin or erythromycin (if allergic to penicillin)
Tonsillitis
Tonsillectomy for chronic palatine tonsillitis with documented recurrent ( 3 or more) GABHS or massive hypertrophy. Adenectomy if causes nasal breathing obstruction
Post-Op Care for Tonsillectomy
Observe for edema which can cause airway obstruction & for continuous swallowing which means bleeding
Otis Media
Otitis media (OM)-An inflammation of the middle ear without reference to etiology or pathogenesis
Acute otitis media (AOM)- An inflammation of the middle ear space with a rapid onset of the signs and symptoms of acute infection, namely, fever and otalgia (ear pain)
Otitis media with effusion (OME)- Fluid in the middle ear space without symptoms of acute infection

Result of dysfunction of eustachian tube
Acute Otitis Media (AOM) vs Otitis Media with Effusion (OME)
AOM ^ purulent fluid accumulates in middle ear causing pain so infants are irritable, pull at ears, fever as ^ 40C (104F), enlarged lymph nodes, rhinorrhea, anorexia, vomiting, concurrent respiratory or pharyngeal infection
OME-no pain but a feeling of fullness in ear
Tx of AOM
Wait 72 hrs. for spontaneous resolution before giving antibiotics children> 6 mos.
Croup Syndromes
Characterized by hoarseness, "barking" cough, inspiratory stridor and varying degrees of respiratory distress:
Acute Epiglottitis
Acute Laryngitis
Acute Laryngotracheobronchitis
Acute Spasmodic Laryngitis
Bacterial Tracheitis
Croup: Acute Epiglottitis
Emergency-requires immediate medical attention
Serious bacterial infection that causes obstructive inflammation in 2-5 yr. olds
Clinical manifestations:
Abrupt onset
High fever, sore throat, drooling, pain, inspiratory stridor, dysphagia, agitation
Tripod positioning-child sits upright, leans forward, opens mouth, protrudes tongue
Froglike croaking sound on inspiration, retraction, mild hypoxia, distress, toxic appearance
Croup: Acute Epiglottitis Tx
Cool mist humidified air
Medications to decrease edema
Antibiotics
Nebulized epinephrine (racemic epinephrine) if not relieved by cool mist
Onset of action rapid; peak effect 2 hrs
Corticosteroids
Improvement in 6- 24 hours
Tracheostomy set kept at bedside for potential emergency
Throat inspection is contraindicated unless for intubation
DO NOT place tongue blade in mouth
Croup: Acute Laryngotracheobronchitis (LTB)
Most common of the croup syndromes
Inflammation of laryngotracheal lining causing narrowing of airway
Parainfluenza virus 1 then 3 and 2, RSV, influenza A and B, and Mycoplasma pneumoniae
Preceded by URI
Symptoms: low grade fever, barky cough, hoarseness, inspiratory strider, retraction, wheezing, nasal flaring, tachypnea
Symptoms worsen at night
Can lead to hypoxia & respiratory failure
Croup: Acute Laryngotracheobronchitis (LTB) Tx
Cool mist humidified air
Medications to decrease edema
Nursing considerations:
Observe for resp. distress, lowered O2 saturation, altered ABGs
No PO if RR>60
Key difference between epiglottitis and LTB
With epiglottitis there is an absence of cough and presence of dysphagia
In epiglottitis children look worse than they sound while with LTB, they sound worse than they look
Croup: Acute Laryngitis Tx
Cool humidified air, fluids, & comfort
Warm vaporizers have potential for safety issues & bacterial growth
Croup: Acute Spasmodic Laryngitis Tx
Cool mist humidified air
Croup: Acute Bacterial Tracheitis
Can cause airway obstruction & respiratory distress
Clinical manifestations similar to those of LTB
Tx: Cool humidified air
Croup Video
http://www.youtube.com/watch?v=Qbn1Zw5CTbA
Foreign Body in Nose
Suspected when there is unilateral nasal discharge that is foul smelling, sneezing discomfort
Lower Respiratory Infections
Involve bronchi and bronchioles in children
Cartilaginous support of the large airways is not fully developed until adolescence
Lobar Pneumonia
All or a large segment of one or more pulmonary lobes involved
When both lungs are affected, it is known as bilateral or double pneumonia
Bronchopneumonia
Begins in terminal bronchioles, which become clogged with mucopurulent exudate to form consolidated patches in nearby lobules
also called lobular pneumonia
Interstitial pneumonia
Inflammatory process more or less confined within the alveolar walls (interstitium) and the peribronchial and interlobular tissues
Viral Pneumonia
Symptoms: Mild to high fever, cough & malaise to severe productive cough & fatigue
TX: Symptomatic to ^ oxygenation & comfort
O2, postural drainage, antipyretics, ^ fluids
Bacterial Pneumonia
Onset abrupt, follows viral infection; diagnosed by Xray & cultures
Symptoms: fever, unproductive cough to whitish sputum, tachypnea, chest pain, retractions, breath sounds; rhonchi or fine crackles, nasal flaring, pallor to cyanosis
Tx: PO Amoxycillin (< 5 yr) PO Erythromycin (older children), or IV cefuroxime cefotaxime, ceftriaxone, IV fluids & O2
Bronchiolitis or Respiratory Syncytial Virus (RSV)
Most frequent cause of hospitalization in children < 1 yr old
Sx: Increased coughing & wheezing, air hunger, tachypnea, retractions, cyanosis, tachypnea, listlessness, apneic spells, poor air exchange
Asthma
Most common chronic lung disease in children due to heightened airway reactivity

Obstruction occurs either by inflammation or airway hyper-responsiveness to a variety of stimuli

Anti-inflammatory inhaled steroid is vital
Asthma: Clinical Manifestations
Dyspnea
Cough
Diffuse wheezing during expiration
Asthma: Diagnostic Evaluation
Xray is used to rule out other diseases
Pulmonary function tests: Objective method of evaluating severity of asthma/lung disease and response to medication therapy
Asthma: Drug Therapy
Stepwise approach based on severity

Long term control: Many different possible combinations of bronchodialators. May have leukotriene modifiers to block inflammation and bronchospasm (Singulair)

Quick relief: short acting beta2 agonists (Albuterol)

Corticosteriods
Asthma: Nursing Care
maintain child's normal functioning

Reinforce long term care of bronchospasm & reduce underlying inflammation within the lungs

Monitor q 3-6 months for delayed or slowed growth if taking long term steroids
Signs of Respiratory Distress
Shortness of breath
Stridor, grunting, flaring, retractions
Sweats profusely
Remains upright, tripod position
Refuses to lie down
Restless and apprehensive
Speaks in short broken phases
Breath sounds can be coarse or barely audible
Cystic Fibrosis
Characterized by exocrine gland (mucus producing) dysfunction that produces multisystem involvement
CF: Clinical Features (unrelated)
A striking elevation of sweat electrolytes
An increase in several organic & enzymatic constituents of saliva
Abnormalities in autonomic nervous system function
Increased viscosity of mucous gland secretions
CF Mortality
Average survival 38 years old
CF: Mucous Accumulation
Increased viscosity of mucous gland secretion
Results in mechanical obstruction
CF: Dx
Most reliable test is increased sweat chloride
Averages less than 40 meq/l
Diagnosed at > 60 meq/l

Chest Xray

Stool fat analysis
CF: Respiratory Manifestations
Tenacious secretions are difficult to expectorate—obstruct bronchi/bronchioles

Compression of the pulmonary blood vessels and progressive lung dysfunction lead to pulmonary hypertension, respiratory failure, and death
CF: Clinical Features
Wheezing respiration, dry nonproductive cough

Clubbing of fingers and toes

Pancreatic enzyme deficiency
CF: Respiratory Management
Chest Physical Therapy (CPT)

Aerosolized bronchodilator medication
Always given prior to CPT
CF: GI Management
Replacement of pancreatic enzymes, 1-5 coated tablets or sprinkled on food with meals
Why are cool-mist vaporizers rather than steam vaporizers recommended in the home treatment of respiratory infections?
Cool-mist vaporizers are safer than steam vaporizers, and little evidence exists to show any advantages to steam. The cost of cool-mist and steam vaporizers is comparable
The parent of an infant with nasopharyngitis should be instructed to notify the health professional if the infant:
If an infant with nasopharyngitis shows signs of an earache, it may indicate respiratory complications and possibly secondary bacterial infection

The health professional should be contacted to evaluate the infant
It is important that a child with acute streptococcal pharyngitis be treated with antibiotics to prevent:
RHEUMATIC FEVER

Group A -hemolytic streptococcal infection is a brief illness with varying symptoms. It is essential that pharyngitis caused by this organism be treated with appropriate antibiotics to avoid the sequelae of acute rheumatic fever and acute glomerulonephritis.
Chronic otitis media with effusion (OME) differs from acute otitis media (AOM) because it is usually characterized by which of the following?
OME is characterized by feeling of fullness in the ear or other nonspecific complaints. OME does not cause severe pain. `
An infant has been diagnosed with staphylococcal pneumonia. Nursing care of the child with pneumonia includes which of the following?
Antibiotics are indicated for bacterial pneumonia.

Often the child has decreased pulmonary reserve, and clustering of care is essential.

The child's respiratory rate and status and general disposition are monitored closely, but frequent complete physical assessments are not indicated.

Antitussive agents are used sparingly. It is desirable for the child to cough up some of the secretions.

Fluids are essential to kept secretions as liquefied as possible.