Ch. 39 – Nursing Care of the Child with a Respiratory Disorder – Flashcards

- Respiratory conditions are most common cause of illness and hospitalization in children - WHAT MAKES CHILDREN DIFFERENT? - See figure 39.1 pg 1257

- Infants 5 years: increase in mycoplasma pneumonia and group β-streptococcal infections - But then increased immunity with age

Immune system: Conditions that weaken defenses: - Allergies, asthma - Cardiac anomalies - Cystic fibrosis - Malnutrition, fatigue, chilling of the body - Daycare (at least initially) - Exposure to cigarette smoke

- Most common infectious agents? - Viruses: - Respiratory syncytial virus (RSV) - Bacterial: - Group A β-hemolytic streptococci - Staphylococci - Staphylococcus - Pneumococcus - Haemophilus Influenzae - Mycoplasma organisms

- Most common during winter and spring - Mycoplasmal infections more common in fall and winter - Asthmatic bronchitis more frequent in cold weather - RSV season considered winter and spring

- What are the signs and symptoms in children? - See pg. 1260, 1264-66 - Colour, cough and noises, respiratory effort, anxiety and restlessness, clubbing, hydration status - Also review on pg. 761 *Lung Sounds* - http://www.youtube.com/watch?v=kP1nwEOCO14

- *Colour* - Note that a child with low RBC count may not show cyanosis for a long time so would not be an indication of the severity of the respiratory condition - *Cough and Sounds* - Slow or irregular is OMINOUS... - *Grunting on expiration* is ominous as it shows the body is trying to preserve or increase functional residual capacity. It may be a sign of alveolar collapse, loss of lung volume, atelectasis, pneumonia, pulmonary edema... - *Stridor* - Upper airway narrowing - *Respiratory effort* - Nasal flaring, retractions, (substernal, suraclvicular, intercostal, etc.) - *Anxiety and Restlessness* - When unable to get enough O2. May change to listlessness and parent just think he is tired, but is in fact, getting worse due to CO2 buildup - *Clubbing* - May occur with chronic, long-term respiratory conditions - *Hydration status* - think about their fluid status

*What can we do as nurses?* - Ease respiratory effort - Fever management - Promote rest and comfort - Small frequent meals - Infection control - Promote hydration and nutrition - Family support and teaching

*Nasopharyngitis*—"common cold" - RSV, rhinovirus, adenovirus, influenza and parainfluenza viruses - Fever - varies with the child's age - Home management - varies with age - OTC combination cold remedies not recommended for younger children (dosing is not for children) - *Note*: Antihistamines are largely ineffective....often makes children hyperactive - Humidity, normal saline spray, comfort, education, hygiene - What about VICKS in the humidity - petroleum based, best not to put in humidifier. - Avoid aspirin (Reye Syndrome) - Use of Tylenol - may mask more serious fever that indicates that it has turned into bacterial infection.

- See Pg. 1275 - Prolonged fever - Increased throat pain, or enlarged painful lymph nodes - Worsening cough, or cough lasting longer than 10 days - Chest pain, difficulty breathing - Earache, headache, tooth or sinus pain - Unusual irritability or lethargy - Skin rash

*Causes and risks* - 80-90% are viral - GABHS (Group A β-hemolytic streptococci ) can be serious rheumatic fever, glomerulonephritis may result. - Clinical manifestations : Sore throat, headache, fever, abdominal pain, often exudate but not always *Diagnostics*: - Throat swab for C&S, Rapid tests *Therapeutic management*: - Oral penicillin (doesn't affect acquiring AGN). - Considered non-communicable after 24 hr of treatment - Popsicles, ibuprofen/tylenol, lozenges, NOT ice cream (can cause increased mucus). - See Figs. 39.10, 39.11, 39.12 (pg. 1278-1279)

- Types A and B cause epidemics *Clinical Manifestations*: - Most severe in infants - Incubation 1-3 days - Cough, photophobia, myalgia, lethargy, fever, chills, coryza - Complications: pneumonia, encephalitis, bacterial infections *Therapeutic management*: nothing can be given to cure it, just manage symptoms - Prevention? Immunization - Concerns: Re: Avian Flu?

- 4 sets of tonsils; palatine tonsils are visible & the ones taken out in tonsillectomy *Pathophysiology and etiology* - Often occurs with pharyngitis *Clinical manifestations* - Difficulty swallowing, breathing *Therapeutic management* - Like pharyngitis, should swab for GABHS - If surgery - no milk products post surgery, and watch for bleed 10 days post when sloughing occurs

- Caused by Epstein-Barr - Fever, malaise, sore throat, lymphadenopathy (especially behind the neck) - Complications: - Splenic rupture - Guillain-Barre syndrome (paralysis starting at fingers that can spread inward to full body, but it does gradually go away - Aseptic meningitis (no pus) - Won't show positive to monospot test until after 7-10 days of illness - Mono and ampicillin may trigger a rash

- Characterized by hoarseness, "barking" cough, inspiratory stridor, and varying degrees of respiratory distress - Usually viral since institution of Hib vaccine - Croup syndromes affect larynx, trachea, and bronchi - HOW?

- "Spasmodic croup" or "Midnight croup" - Paroxysmal attacks of laryngeal obstruction, chiefly at night - Usually under age 3 - What to do?

ACUTE LTB - LTB = laryngotracheobronchitis - Most common of the croup syndromes - Generally affects children <5 years *Organisms responsible*: -RSV, parainfluenza virus, Mycoplasma pneumoniae, influenza A and B *Manifestations* - Inspiratory stridor - Suprasternal retractions - Barking or seal-like cough - Increasing respiratory distress and hypoxia What does that look like? - Can progress to respiratory acidosis, respiratory failure, - and death - May develop bacterial tracheitis

- Airway management - Teach parents S & S of resp distress & advise to access hospital care when they worsen - Maintain hydration (PO or IV) - High humidity with cool mist - Nebulizer treatments: - Epinephrine - Steroids

*Clinical manifestations*: - Sore throat, pain, tripod positioning, retractions - Inspiratory stridor, mild hypoxia, distress *Classic*: - No spontaneous cough, *drooling*, agitation - Often sudden onset of high fever - VERY toxic and sick looking

*NO THROAT EXAMINATION!* - Do not lie them down - WHY do we see so little now compared to "old" days - Prevention: Hib Vaccine *Therapeutic management*: - Potential for respiratory obstruction, which can be triggered by invasive procedures such as starting an IV or using tongue depressor. - Have ability to do tracheotomy or intubation on stand-by - Antibiotics (via IV) and corticosteroids

- Usually under age 3 yr - Thick mucous which may obstruct - History of URI, croupy cough, high fever, stridor, *no drooling*

- Bronchi and Bronchioles are the reactive portion (as opposed to the lungs) - What does this mean? They constrict. - Cartilaginous support not fully developed until adolescence -> smooth muscle constriction of airways Manifests as 1. Asthma 2. Bronchitis 3. Bronchiolitis

- Also known as tracheobronchitis *Definitions* - Inflammation of large airways *Causative agents* - Usually viral; but may be m. pneumoniae *Clinical manifestations* - Dry, hacking, non-productive cough, worse at night - Cough medicine may decrease cough to allow sleep but can also interfere with clearance of secretions

- *RSV = Respiratory Syncytial Virus* and is most common cause of Bronchiolitis - Severe RSV > can cause a risk for asthma *Pathophysiology* - Affects epithelial cells; cilia cells swell, protrude into the lumen, lose their cilia - Bronchiolar mucosa swells and the lumina fills with exudate - May appear air hungry, low fever, cough with wheeze, poor feeding, varying degrees of cyanosis and respiratory distress, retractions, grunting, tachypnea = these are often *sick kids* and may deteriorate quickly

VIRAP (nasopharyngeal aspirate) *Therapeutic management* Symptom management: - May need to stay upright and suctioned - Cool humidified air or oxygen, fluids, airway management - Manage at home until respiratory distress or unable to maintain hydration

- Prophylaxis - Synagis IM for preterm infants 1/month for 5 months - HANDWASHING! - Room with others with RSV or alone, contact and standard precautions, limit # hospital personnel, visitors and uninfected children, - Nursing considerations - monitor oxygenation.

Pending

*Bacterial* - S. pneumoniae most common - Usually follows viral infection, very ill, acute onset, referred abdominal pain, neck stiffness, *Viral* - RSV, parainfluenza, adenovirus, influenza - Treat symptomatically *Aspiration* - May be difficult to realize cause, may have s/s for weeks Histomycosis, coccidiomycosis, other fungi *"Atypical pneumonias"* - M. pneumoniae, Chlamydia pneumoniae, SARS, Avian flu

Caused by Bordetella Pertussis - Occurs most often in children who have not been immunized - Highest incidence in spring and summer - Highly contagious - Risk to young infants (unvaccinated) - Vaccines -VERY thick mucous that plugs airways and they essential suffocate in a horrible death

*Risk among children* - What ages are most at risk? *Diagnostic evaluation* Symptoms: - choking, gagging, wheezing, coughing, stridor, hoarseness but up to half have no symptoms - X-ray may show pulmonary "lesion"; endoscopy *Therapeutic management* - Abdominal thrusts if over one year, back blows if under 1 year but usually requires removal via endoscopy - BALLOONS

*What do you know?* - Usually in lungs, but can manifest in lungs, kidneys, meninges *Who is at risk?* - Aboriginals, Lack of light, Cold, Poverty *How is it diagnosed?* - X-ray, Tuberculin Test How can it manifest? Medications? - INH, Rifampin, Pyrazinamide Skip ARDS, smoke inhalation, tobacco

*Specific to neonates* - Used to be called Hyaline membrane disease - Usually premature infants, but may also be in infant of diabetic mother, especially if delivered by section - Lack of surfactant = stiff lungs, inability to alveoli to expand - R to L shunting and many complications - Please note SARS is different!

↓surfactant → ↓alveolar expansion & ↑ Pulmonary Vascular Resistance → R to L shunting → ↓O2 → ↓Ph→ Vasoconstriction → ↑PVR → ↓O2→ Lactic Acid → metabolic acidosis PLUS CO2 → Respiratory Acidosis → ↑vasoconstriction ...and the vicious cycle continues

ARDS occurs after a severe primary injury or infection to the lung such as: - Near drowning, smoke inhalation, sepsis, viral pneumonia, assault to lungs - Pulmonary edema occurs - May be decreased surfactant production and hyaline membrane may also form as in RDS - Lung "stiffness" - Mucosal swelling - Impaired gas diffusion - respiratory failure, death *TREATMENT*: Oxygen and ventilation

SOB with air movement in the chest restricted to the point of absent breath sounds accompanied by a sudden rise in respiratory rate is an ominous sign indicating ventilatory failure and imminent respiratory arrest.

*Chronic inflammatory disorder of airways* - Bronchial hyper-responsiveness - Airway edema - Mucous production - Episodic - Limited airflow or obstruction that reverses spontaneously or with treatment *Etiology* - Allergies, often as a result of a genetic predisposition

*Complex inflammatory process* - Muscle contraction, inflammation and edema, mucus secretion, - Increased resistance in the airway causes force expiration through the narrowed lumen - Air gets trapped in lungs forcing the child to breathe at higher and higher lung volumes. They fight to inspire sufficient air. *Result*: - Fatigue, increased O2 consumption, hyperinflation of alveolar making coughing less efficient, - Eventually can have CO2 retention, hypoxemia, respiratory acidosis and eventually respiratory failure - May be more susceptible to serious bacterial and viral respiratory infections

Process is considered reversible but can also cause airway remodeling *AIRWAY REMODELLING*: - Permanent structural changes as a result of long term inflammatory process - Increased airway wall thickness that involves both smooth muscle and collagen tissue. - Increased mucous glands and mucus production - Increased vascularity, or blood supply, in the airways

- Avoid exacerbation - Avoid allergens - Relieve asthmatic episodes promptly - Relieve bronchospasm - Monitor function with peak flow meter - Self-management of inhalers, devices, and activity regulation

- Clinical manifestations, history - Chronic cough, *expiratory wheeze* - Pulmonary function tests (spirometry), Peak Expiratory Flow Rate

*Exercise* - May need medication prior - Swimming, non-endurance sports tolerated best *Chest physical therapy (CPT)* - Breathing exercises to strengthen musclulature *Hyposensitization* - House dust mites, cockroach, mouse, dog (may be protective), cat, tobacco, pollution, wood burning, *Prognosis* - 2/3 of children continue to have symptoms into adulthood

- 2 classes (Long-term and Quick-relief) - *Long-term control* (preventive medication) to achieve and maintain control of inflammation - Inhaled corticosteroids reduce hyper-responsiveness non-steroidal anti-inflammatory that inhibits airway narrowing - *Quick relief* (rescue) medication to treat symptoms and exacerbations Short-acting B2-agonists for acute exacerbation and for exercise induced asthma Systemic corticosteroids Methylxanthines (stimulants) Anticholinergics for acute bronchospasm Have many adverse side effects such as drying of secretions, blurred vision, cardiac and CNS stimulation Many medications are given by inhalation with nebulizer or a metered-dose inhaler. A spacer helps limit yeast infections with corticosteroid medication. See page 1298

- Can be 6 hours before - Rhinorrhea, cough, low-grade fever, irritability - Itching especially in front of neck and chest - Apathy, Anxiety, Sleep Disturbance, Loss of Appetite, Stress, Excitement

- Respiratory distress continues despite vigorous therapeutic measures - Emergency treatment: epinephrine 0.01 ml/kg SC (maximum dose 0.3 ml) - Concurrent infection in some cases - Therapeutic intervention

- Disorder of *exocrine* gland dysfunction that produces multi system involvement (these glands produce mucus) and also involves pancreas - Most common lethal genetic illness among *Caucasian* children - Autosomal recessive trait (mom and dad need to both be carriers) - Inherits defective gene from both parents, with an overall incidence of *1:4* in their offspring

Characterized by several clinical features: - Increased viscosity of *mucous* gland secretions -> Results in *mechanical* obstruction -> Thick mucoprotein accumulates, dilates and precipitates to form congregations in respiratory tract and pancreas - Increased *sweat* electrolytes - Increased organic-enzymatic constituents of *saliva*

- Present in almost all CF patients but onset and extent are variable - Stagnation of mucus and bacterial colonization result in *destruction of lung tissue* - Tenacious secretions are difficult to expectorate, obstruct bronchi and bronchioles - *Frequent respiratory infections*: Pseudomonas, staph aureus, HIB, Klebsiella and increasingly is MRSA and other resistant organisms

- Gradual progression follows chronic infection - Bronchial epithelium is destroyed - Infection spreads to peribronchial tissues weakening bronchial walls and causing fibrosis - Decreased O2-CO2 exchange - Chronic hypoxemia causes contraction and hypertrophy of muscle fibers in pulmonary arteries and arterioles - Pulmonary hypertension - Cor pulmonale (right-sided heart failure) - Pneumothorax - Hemoptysis