Nursing Care of the Pediatric Individual with a Respiratory Disorder

1. Nursing Care of the Pediatric Individual with a Respiratory Disorder

2. Differences in Adult and Child Adult Child

3. The diameter of an infant’s airway is approximately 4 mm, in contrast to an adult’s airway diameter of 20 mm.

4. Of the three anatomical differences in the eustachian tube between adults and small children (shorter, wider, more horizontal), which do you think could cause more problems for the child and why?

6. Otitis Media Inflammation of the middle ear sometimes accompanied by infection

7. Common Causes • Eustachian tube dysfunction • Previous URI causes mucous membranes of the eustachian tube to become edematous and blocks tube. • Enlarged adenoids • Allergic rhinitis • Pacifier use raises soft palate and alters dynamics in the eustachian tube

8. Acute Otitis Media characterized by abrupt onset, pain, middle ear effusion, and inflammation. Note the injected vessels and altered shape of cone of light.

9. Serous Otitis Media Note that the light reflex is not in the expected position due to a change in tympanic membrane shape from air bubbles. Note effusion on otoscopy by fluid line and air bubbles

10. Clinical Manifestations What objective sign is this child displaying? What does it indicate?

11. Evaluation and therapy • Treatment has always been directed toward antibiotic therapy; however, recently concerns about drug-resistant streptococcus pneumoniae have caused medical professionals to re-evaluate therapy (APA, 2004) • No clear evidence that antibiotics improve OM • Waiting up to 72 hrs for spontaneous resolution is now recommended in healthy infants • When antibiotics are warranted, oral amoxicillin in high dosage is given

12. Myringotomy • A myringotomy or pin hole is made in the ear drum to allow fluid removal.  Air can now enter the middle ear through the ear drum, by-passing the Eustachian tube.  The myringotomy tube prevents the pin hole from closing over.  With the tubes in place, hearing should be normal and ear infections should be greatly reduced.

13. Nursing Care Management for OM • Nursing objectives: • Relieving pain • Facilitating drainage when possible • Preventing complications or recurrence • Educating the family in care of the child • Educate regarding prevention • Providing emotional support to the child and family

14. Mastoiditis

15. Mastoiditis • Morbidity/mortality • Hearing loss • Extension of the infectious process beyond the mastoid system, resulting in intracranial complications • Ages affected • The incidence of mastoiditis parallels that of otitis media, affecting mostly young children and peaking in those aged 6-13 months. • May occur in healthy adults as well

16. Nursing care for the child with mastoiditis • Monitor vital signs • Assess for changes in lab values • Medicate aggressively with abx as ordered (usually IV if bacterial spread to mastoid) • Drugs of choice: Timentin and Gentamicin • Assess for complications (hearing loss, tinnitus)

17. Tonsillitis and Adenoiditis

18. Upper Respiratory Tract Infections • Nasopharyngitis • Young child: fever, sneezing, vomiting or diarrhea • Older child: dryness and irritation of nose/throat, sneezing, aches, cough • Pharyngitis • Young child: fever, malaise, anorexia, headaches • Older child: fever, headache, dysphagia, abdominal pain • Tonsillitis • Masses of lymphoid tissue in pairs • Often occurs with pharyngitis • Characterized by fever, dysphagia, or respiratory problems forcing breathing to take place through nose

19. Nurse Alert! Key to understanding prevention of URI is meticulous handwashing and avoiding exposure to infected persons

20. Nurse Alert! The nurse should remind the child with a positive throat culture for strep to discard their toothbrush and replace it with a new one after they have been taking antibiotics for 24 hours

21. Clinical Manifestations • Tonsillitis • Fever • Persistent or recurrent sore throat • Anorexia • General malaise • Difficulty in swallowing, mouth breather, foul odor breath • Enlarged tonsils, bright red, covered with exudate • Adenoiditis • Stertorous breathing - snoring, nasal quality speech • Pain in ear, recurring otitis media

22. Nursing Care for the Tonsillectomy and Adenoidectomy Patient Why is collection of blood for assessment of bleeding and clotting times so important?

23. Post-operative Care • Providing comfort and minimizing activities or interventions that precipitate bleeding • Place on abdomen or side until fully awake • Manage airway • Monitor bleeding, esp. new bleeding • Ice collar, pain meds • Avoiding p.o. fluids until fully awake --then liquids and soft cold foods. Avoid citrus juices, milk • Do not use straws or put tongue blade in mouth, no smoking (in teenagers).

24. Nurse Alert for Post-Op T/A surgery • Most obvious sign of early bleeding is the child’s continuous swallowing of trickling blood. • Note the frequency of swallowing and notify the surgeon immediately

25. Assessment of Respiratory Status

26. Indications of Respiratory Distress • Nasal Flaring • Circumoral cyanosis • Expiratory grunting • Retractions • Substernal, lower intercostal, • Tachypnea • Repirations greater than 60

27. APNEA

28. Apnea • Defined as: Delay of breathing over 20 seconds • Additional Signs and Symptoms: • Cyanosis • Marked pallor • Hypotonia • Bradycardia

29. Treatment and Nursing Care • Admit to hospital for cardiorespiratory monitoring • Teach parents home care instructions in the use of an apnea monitor • Encourage parents to learn CPR.

30. Cardiorespiratory Monitoring pulse oximetry Want reading > 95%

31. SIDS • Defined: sudden death of an infant during sleep • Risk Factors • Prematurity, low birth weight • Most common in infants 2-4 months old • More prevalent in winter months • Sleeping in bed with others, sleeping prone, use of pillows and quilts • Exposure to passive smoke

32. SIDS – Nursing Interventions • Parent teaching: • place infant on back to sleep • Place on firm mattress • Do not use loose bedding, toys, pillows • Avoid overheating with too many clothes • Parents should stop smoking • Provide support of parents by helping them work through feelings of guilt and loss; refer to National Foundation for SIDS

33. Croup Epiglottitis

34. Croup • Refers to a group of viral and bacterial syndromes • Laryngotracheobronchitis, Bacterial tracheitis and epiglottitis are the “big three” • Initial symptom of all three is stridor, a seal- like barking cough and hoarseness

35. Croup vs. Epiglotitis • Croup • Viral/Bacterial • Fever • Hoarseness • Resonant cough • Stridor (inspiratory) • Risk for significant narrowing airway with inflammation • Humidity for treatment • Epiglottitis • Bacterial • High fever • Rapidly progressive course • Dysphagia • Drooling • Dysphonia • Distressed inspiratory efforts • Antibiotics needed

36. Medications • Beta-agonist /Bronchodilator– Albuterol • Corticosteroids • Which of these medications would the nurse give first? Rationale?

37. Nursing Care • Maintain patent airway • Oxygen with humidification • Keep resuscitation equipment at the bedside • Assess VS (T102 or >, and R>60) • Nothing should be placed in the mouth • Meet fluid and nutritional needs • Cool, noncarbonated, non-acid drinks • Assess for difficulty swallowing – may need IV therapy

38. Child with Epiglottitis

39. Critical Thinking Exercise • Kim, a 4 year old, is admitted to the emergency department with a sore throat, pain on swallowing drooling, and a fever of 102.2°. She looks ill, agitated and prefers to sit up and lean over. • What nursing interventions should the nurse implement in this situation?

40. Bronchitis vs. Bronchiolitis Bronchiolitis Bronchitis

41. Bronchitis • Rarely occurs in childhood as isolated problem • Can be present with other respiratory illness • Most often viral • Can be response to allergen • Symptoms include coarse, hacking cough (increases at night), fatigue, sore ribs, respirations deep and rattling, audible wheezing

42. Bronchiolitis / RSV • RSV is rhino syncytial virus • Affects 2-6 month olds primarily • Infection of bronchial mucosa leading to obstruction • Starts out with Upper Respiratory Infection and progresses to Respiratory Distress. • Diagnosed with a RSV wash

43. Nursing Care for Child with RSV • Medication therapy • Bronchodilators – • Steroids • Beta-antagonists • Antiviral • Virozole (Ribavirin) • Prevention drug – Synagis (palivizumab) given IM. and RespiGam (RSV immune globulin) given IV. • Droplet and contact isolation

44. Nebulized epinephrine administered for Bronchiolitis Parents can hold nebulizer to decrease infant’s fear

45. Reactive Airway Disease Asthma

46. Reactive Airway Disease (asthma) • Chronic inflammatory disorder affecting mast cells, eosinophils, and T lymphocytes • Inflammation causes increase in bronchial hyperresponsiveness to variety of stimuli (dander, dust, pollen,smoke) • Most common chronic disease of childhood; primary cause of school absences

47. Asthma

48. Etiology/Pathophysiology of Asthma • Obstructive airflow limitation due to: • Mucosal edema - membranes that line airways • Bronchospasm (bronchoconstriction) • Mucus plugging (thicker) causes: • Increased airway resistance • Decreased flow rates

49. Etiology/Pathophysiology • Increased work of breathing • Progressive decrease in tidal volume and expiratory volume • Arterial pH abnormalities due to: • Increase in number of poorly ventilated alveoli • Increase in hypoxemia • Carbon dioxide retention • Respiratory acidosis

50. Asthma Triggers