I. Assessment of respiratory function II. 兒童常見呼吸系統疾病

1. Nursing care of children with respiratory dysfunction I.Assessment of respiratory function II. 兒童常見呼吸系統疾病

2. Assessment of respiratory function • Health history • Physical assessment p418 Table 13-1 • Quality of respirations • Quality of pulse • Color • Cough • Behavior change • Signs of dehydration • Diagnostic assessment • 胸部X光檢查 • 痰液檢查 • 血液氣體分析 • 支氣管鏡檢查 • 肺功能檢查(Pulmonary function test)

3. 兒童常見呼吸系統疾病 • Urgent respiratory threats • Sudden infant death syndrome P423 • Upper respiratory tract infection • Otitis Media P703 • TonsilitisP718 • Common cold • Epidemic Influenza • Acute pharyngitis • Reactive airway disorders • CroupP427 • Asthma • Lower respiratory tract infection • Bronchitis • BronchiolitisP447 • PneumoniaP451 • Long-term respiratory dysfunction • Cystic fibrosis

4. Otitis medialP703 • Inflammation of the middle ear. • At least one episode by 6 years of age , with peak incidence at 2 years • Boys • Winter months.

5. Etiology and pathophysiology (1) • Eustachian tube equalizes air pressure between the middle ear and the outside environment and allows for drainage of secretions from middle ear mucosa.P691圖19-1 • Anatomical differences in the Eustachian tube between adult and small children（short, wider, more horizontal）. P691圖19-1 • Cause：unknown, but it appears to be related to Eustachian tube dysfunctionP703倒數第3行 • Often an upper respiratory infection precedes the development of otitis medial.P703倒數第2行

6. Etiology and pathophysiology (2) • Infection →the mucous membranes of the Eustachian tube to become edematous→Eustachian tube blocked →air in the middle ear is reabsorbed into the bloodstream→fluid is pulled from the mucosal lining into the former air space→infected.P703最後1行. • Causative organisms：streptococcus pneumoniae, Haemophilus influenzae .P704第1段第4行 • Allergic rhinitis, cleft palate, Down syndrome.P704第2段 • Higher risk：crowded conditions, exposed to cigarette smoke, attend child care with multiple children. • Breastfeeding provides protection.

7. Clinical manifestations • Pulling at the ear 第2行 • Diarrhea, vomiting, and fever • Irritability and “acting out” may be signs of a related hearing impairment • Asymptomatic（some）p705第1行

8. Diagnostic tests • Otoscopic examination.第1段第1行 • Otitis medial: red, bulging, nonmobile tympanic membrane圖19-7 • Otitis medial with effusion : fluid line or air bubbles圖19-8 • Pneumatic otoscopy (氣式耳鏡) 第3行 • Special gradient acoustic reflectometry（SGAR） (聽覺反射傾斜度) • Tympanogram (鼓室壓力圖)第2段

9. Medical management • Acute and recurrent otitis media 第3段 • Antibiotic therapy－wide spectrum antibiotics • Amoxicllin → Amoxicllin with clavulanate or cefuroxime axetil→ ceftriaxome • Chronic otitis media with effusion 第5段→result in sensorineural or conductive hearing loss and cochlear damage • Audiology • If infection recurs → Myringotomy and tympanostomy tube 最後1段第2行 • Neither decongestants nor antihistamines最後1段第1行

10. Nursing assessment p706 • Assess tympanic membrane－color, transparency, mobility, presence of landmarks, and light reflex. • Ask the parents if the child has had a fever, been fussy, or been pulling at the ears. • Observe for signs of impaired hearing.

11. Nursing management P707care plan • Pain • Infection • Risk for caregiver role strain • Knowledge deficit about infection • Altered growth and development

12. Tonsillitis Etiology and pathophysiology • An infection or inflammation（hypertrophy）of the palatine tonsils. P718 • Most children with pharyngitis may have infected tonsils. • May be caused by virus or bacterium.P719

13. Clinical manifestations • Frequent throat infections with breathing and swallowing difficulties. • Persistent redness of the anterior pillars • Enlargement of the cervical lymph nodes • Mucous membranes may become dry and irritated

14. Diagnostic tests • Visual inspection • Clinical manifestations • Throat culture

15. Medical management • Symptomatic treatment • Penicilline for 10 days（or erythromycin） • Tonsillectomy • 3 per year for 3 years • Chronic tonsillitis • Obstructive sleep apnea • Malformations causing nasal speech or a facial growth abnormality • If the pharyngeal tonsils are enlarged • Mouth breathing, cough, impaired taste and smell, a muffled quality to the voice, and chronic otitis media.

16. Assess the throat Observe for tonsils Pain or difficulty swallowing History Nursing assessment

17. Nursing managementP720 • Supportive care（symptomatic relief） • Completion of the full course of treatment.（10-day） • Acetaminophen reduces throat pain and generalized fever. P718 • Cool, nonacidic fluids and soft foods, ice chips or frozen juice pops given frequently in small amounts facilitate swallowing and prevent dehydration. • Humidification, chewing gum, and gargling with warm salt water soothe an irritated throat. • Encourage the child to rest.

18. Nursing management • Before surgery P720第2段 • Free of sore throat, fever, or URI for at least 1 week before surgery. • Not be given aspirin or ibuprofen for 2 weeks before surgery. • Check if any herbal medications are taken • After surgery • 局部用冷 • 觀察嘔吐次數，可能早期出血的徵象 • 避免不必要的擤鼻涕、咳嗽或清喉嚨 • 術後採側臥或俯臥 • 避免酸性飲料或辛辣食物，且避免使用吸管 • 術後1～2週可恢復正常活動 • 合併症—bleeding, infection, painP720

19. Croup syndrom • Swelling of the epiglottis and larynx. p427第1段第2行 • Viral syndromes and bacterial syndromes p429 Table13-5 • Viral syndromes • Acute Spasmodic Laryngitis • Laryngotracheitis • Laryngotracheobronchitis (LTB) • Bacterial syndromes • Epiglottitis • Bacterial Tracheitis • Big three－LTB, epiglottis, and bacterial tracheitisp428第2段 • Stridor, seal-like barking cough, and hoarseness

20. Laryngotracheobronchitis（LTB）p428 Etiology and pathophysiology • Viral invasion • Throughout the larynx, trachea, and bronchi • Age：3 months to 4 years of age • Boys than girls • Cause：Parainfluenze virus（75%）、RS virus、Influenze virus • Airway tissues produce copious, tenacious secretions and swelling. P429第1段圖13-5

21. Clinical manifestations • Tachypnea, inspiratory stridor, seal-like barking cough, and hoarseness • Fever may or may be not present. Diagnostic tests • Clinical signs • Pulse oximetry • Anteroposterior and lateral x-rays－steeple sign

22. Humidification Medications P430 上表 Beta-agonists and beta-adrenergics Aerosolized through face mask Improvement in 30’ & lasts about 2 hours Tachycardia & hypertension Dizziness, headache, and nausea stop medication Corticosteroids IM, PO, Nebulized budesonide CV symptoms Stridor resolves faster Oxygen Medical management

23. Nursing management P431 • Maintain airway patency • Meet fluid and nutritional needs

24. Epiglottitis（Supraglottitis） P431 Etiology and pathophysiology 第1段 • An inflammation of the epiglottis. • Edema can rapidly obstruct the airway by occluding the trachea. • Potentially life-threatening • Cause：bacterial invasion of the soft tissue of the larynx 第2段 • Streptococcus • Staphylococcus • Haemophilus influenzae type B • Inflammation and edema → airway obstruction

25. Clinical manifestations第3段 • Suddenly becomes very ill • High fever（＞39oC） • Sore throat • 4D（Dysphonia、Dysphagia、Drooling、Distressed respiratory effort） • Stridor • Sits up and leans forward

26. Diagnostic tests P432 第4段 • Lateral neck x-ray • Blood culture PS： Laryngospasm and airway obstruction → visual inspection of the mouth and throat is contraindicated 圖13-6

27. Medical management • On endotracheal tube • Antibiotics • Antipyretics • Hydration • Humidifies oxygen

28. Nursing management • Airway management 第2段 • Sit upright or assume a position of comfort to maintain the airway • Humidifies oxygen • Provide a quiet environment • Treat the infection and provide fluid to provide hydration 第3段 • Provide emotional support 第4段

29. Bacterial Tracheitis P433 Etiology and pathophysiology 第1段 • Senondary infection of the upper trachea after viral laryngotracheitis. • Most caused by group A streptococcus or Haemophilus influenzae Clinical manifestations • Starts with croupy cough and stridor • High fever greater than 390C，persists for several days. • Prefer lying flat to sitting up

30. Diagnostic tests • Blood culture • Medical management • Antibiotics are given for a full 10-day course • Artificial airway and ventilatory support.

31. Nursing management • Airway assessment and support • Airway maintenance • Suctioning as needed • Humidified oxygen • Antibiotics • Preparation for resuscitation

32. Bronchiolitis P447 An infecting agent（virus or bacterium）causes inflammation and obstruction of the small airway, the bronchioles. Infection occurs most frequently in toddlers and preschooers.

33. Etiology and pathophysiology • RSV is the most common cause. • Direct or close contact with respiratory secretions of infected individuals. • Viruses invade the mucosal cell→cell debris clogs and obstruct the bronchioles and irritates the airway. • Partial airway obstruction and bronchospasms. →Wheezing & Crackles→respiration failure（O2 ↓, CO2 ↑）→Apnea and pulmonary edema • The noisier the lungs, the better.第3段

34. Clinical manifestations • URI symptoms－Nasal stuffiness, cough, and fever for a few days（＜39oC） → LRI symptoms－wheezing; a deeper, more frequent cough; more labored breathing • Respirations are rapid, shallow, and accompanied by nasal flaring and retraction. • Acting more ill－appearing sicker, less playful, and less interested in eating

35. Diagnostic tests • History • PE • X-ray • Nasal swab or nasopharyngeal wash第2段第2行

36. Nursing assessment • Physiologic assessment • Psychosocial assessment 參考P439 Table13-10 • Developmental assessment

37. Nursing implementationP449, 450-451care plan • Maintain respiratory function • Support physiologic function • Reduce anxiety • Discharge planning • Use of the bulb syringe to suction the nares • Fluid intake • Rest • P452 Families want to know

38. Pneumonia p451 Etiology and pathophysiology • An inflammation or infection of the bronchioles and alveolar spaces. • Most often in infants and young children • Viral, mycoplasmal, or bacterial in origin 第2段

39. Clinical manifestations • Fever, rhonchi, crackles, wheezes, cough, dyspnea, tachypnea, restlessness, and decreased breath sound • Bacteria：one or more lobes of a single lung; unilateral lobar pneumonia • Viruses：infiltrating the alveoli nearest the bronchi of one or both lungs.

40. Diagnostic testsP452第4段 • PE • X-ray • Sputum culture（blood culturelung puncture）

41. Symptomatic therapy Supportive care（airway management, fluids, and rest） Organism-sensitive antibiotics Oxygen and anti-inflammatory medications Pulmonary care Antibiotics Hydration Pain management 持續性密閉式胸腔引流 Discharge planning Administration of drugs and any side effects F/U chest X-ray Nursing management Medical management

42. Nursing care plan for the children with respiratory dysfunction • Ineffective breathing pattern related to increased work of breathing and decreased energy（fatigue）. • Altered tissue perfusion（cardiopulmonary）related to partially obstructed airway. • Risk for fluid volume deficit related to inability to meet body requirements and increased metabolic demand • Fear/Anxiety（child and parent）related to acute illness, hospitalization, and uncertain course of illness and treatment . • Knowledge deficit（child and parent）related to diagnosis, treatment, prognosis, and home care needs . • High risk infection • Pain • 活動無耐力 • 營養狀況少於身體需求 • 睡眠型態混亂