Chapter 18: Nursing Care of the Child With an Alteration in Gas Exchange/ Respiratory Disorder

1. Chapter 18: Nursing Care of the Child With an Alteration in Gas Exchange/Respiratory Disorder

2. Anatomy and Physiology of the Child’s Nose and Throat • Nose • Infants are obligate nose breathers; they cannot open their mouths to breathe, produce very little mucus, which makes them more susceptible to infections. • Newborns have very small nasal passages, making them more prone to obstruction; sinuses are not developed, making them less prone to sinus infection. • Throat • Infants’ tongues relative to oropharynx are larger; placement of tongue can lead to airway obstruction. • Children have enlarged tonsillar and adenoid tissue, which can lead to airway obstruction.

3. Child’s Airway

4. Lower Respiratory Structures • Bifurcation of trachea occurs at level of the third thoracic vertebra in children, compared to the sixth in adults. • Important when suctioning or intubating children. • The bronchi and bronchioles of infants and children are narrower in diameter than the adult’s. • Increased risk for lower airway obstruction. • Smaller numbers of alveoli. • Higher risk of hypoxemia.

5. Inspection and Observation of the Respiratory System • Color: pallor, cyanosis, acrocyanosis • Rate and depth of respirations: tachypnea • Nose and oral cavity • Cough and other airway noises: atelectasis, stridor • Respiratory effort • Anxiety and restlessness • Clubbing • Hydration status

6. Adventitious Breath Sounds • Wheezing • High-pitched sound on inspiration or expiration. • May occur with obstruction in lower trachea or bronchioles. • May occur in asthma or viral infections. • Rales • Crackling sounds heard when alveoli become fluid filled. • May occur with pneumonia.

7. Question The nurse is percussing the chest of a child with a suspected respiratory disorder. What sound might the nurse note that would indicate pneumonia? a. Decreased fremitus b. Dull sound c. Tympany d. Hyperresonance

8. Answer b. Dull sound. A dull or flat sound would be percussed over partially consolidated lung tissue, as occurs with pneumonia. Rationale: Decreased fremitus is found on palpation and may be found with barrel chest, as may occur with cystic fibrosis. Tympany might be percussed with pneumothorax, and hyperresonance might be apparent with asthma.

9. Laboratory and Diagnostic Tests Ordered for Respiratory Disorders • Pulse oximetry: oxygen saturation might be decreased significantly. • Chest radiograph: might reveal hyperinflation and patchy areas of atelectasis or infiltration. • Blood gases: might show carbon dioxide retention and hypoxemia. • Nasal-pharyngeal washings: positive identification of RSV or other viral illness via enzyme-linked immunosorbent assay (ELISA) or immunofluorescent antibody (IFA) testing. • Rapid strep testing via throat swab culture.

10. Other Laboratory and Diagnostic Tests Ordered for Pneumonia • Pulse oximetry: oxygen saturation might be decreased significantly or within normal range. • Chest x-ray: varies according to child age and causative agent. • Sputum culture: may be useful in determining causative bacteria in older children and adolescents. • White blood cell count: might be elevated in the case of bacterial pneumonia.

11. Laboratory and Diagnostic Tests Ordered for Cystic Fibrosis • Sweat chloride test: considered suspicious if the level of chloride in collected sweat is above 50 mEq/L and diagnostic if the level is above 60 mEq/L. • Pulse oximetry: oxygen saturation might be decreased, particularly during a pulmonary exacerbation. • Chest radiograph: might reveal hyperinflation, bronchial wall thickening, atelectasis, or infiltration. • Pulmonary function tests: might reveal a decrease in forced vital capacity and forced expiratory volume, with increases in residual volume.

12. Common Medical Treatments for Respiratory Disorders • Oxygen • High humidity • Suctioning • Chest physiotherapy and postural drainage • Saline gargles or lavage • Mucolytic agents • Chest tubes • Bronchoscopy

13. Question The nurse is caring for a child with cystic fibrosis. Which of the following treatments would be used to promote mucus clearance through percussion or vibration? a. Suctioning b. Chest tube c. Bronchoscopy d. Chest physiotherapy

14. Answer d. Chest physiotherapy. Chest physiotherapy promotes mucus clearance through percussion or vibration. Rationale: Suctioning removes secretions via bulb syringe or suction catheter, chest tubes remove air or fluid though a drain inserted into the pleural cavity, and bronchoscopy is the introduction of a bronchoscope into the bronchial tree for diagnostic purposes.

15. Acute Infectious Disorders • Common cold, sinusitis • Influenza • Pharyngitis, tonsillitis, and laryngitis • Croup syndromes • Respiratory syncytial virus (RSV) • Pneumonia and bronchitis

16. Risk Factors for Respiratory Disorders • Prematurity • Chronic illness (diabetes, sickle cell anemia, cystic fibrosis, congenital heart disease, chronic lung disease) • Developmental disorders (cerebral palsy) • Passive exposure to cigarette smoke • Immune deficiency • Crowded living conditions or lower socioeconomic status • Daycare attendance

17. Signs and Symptoms of Bronchiolitis (RSV) • Onset of illness with a clear runny nose (sometimes profuse). • Pharyngitis. • Low-grade fever. • Development of cough 1 to 3 days into the illness, followed by a wheeze shortly thereafter. • Poor feeding. • Vaccination is available for at-risk populations.

18. Risk Factors for Tuberculosis • HIV infection. • Incarceration or institutionalization. • Positive recent history of latent TB infection. • Immigration or travel to endemic countries. • Exposure at home to HIV-infected or homeless persons, illicit drug users, persons recently incarcerated, migrant farm workers, or nursing home residents.

19. Signs and Symptoms and Risk Factors for a Pneumothorax • Signs and symptoms • Chest pain might be present as well as signs of respiratory distress such as tachypnea, retractions, nasal flaring, or grunting. • Risk factors • Chest trauma or surgery, intubation and mechanical ventilation, or a history of chronic lung disease such as cystic fibrosis.

20. Chronic Respiratory Disorders • Allergic rhinitis • Asthma • Chronic lung disease (bronchopulmonary dysplasia) • Cystic fibrosis • Apnea

21. Tiered system of therapy with fast acting short-acting β2 agonist (SABA) lateradding by longer-acting β2 agonist (LABA) if symptoms persist. • Classified by severity: • mild (no or minor interference in normal activity, FEV >80% of predicted). • moderate (some limitation of activity, FEV 60% to 80% of predicted). • severe (extremely limited, FEV <60% of predicted). • Frequency of symptoms. • intermittent or persistent. Asthma Severity Classification Adapted from National Asthma Education and Prevention Program. (2007). Expert panel report 3: Guidelines for the diagnosis and management of asthma (NIH Publication No. 07-4051). Bethesda, MD: National Institutes of Health, National Heart, Lung and Blood Institute.

22. Question Is the following statement true or false? The nurse caring for a child with asthma documents lung function as forced expiratory volume (FEV) 60% to 80% of predicted. This child is classified as having intermittent asthma.

23. Answer False. A child with lung function documented as forced expiratory volume (FEV) 60% to 80% predicted is classified as having moderate persistent asthma. Rationale: Intermittent and mild persistent asthma is FEV 80% or more and severe persistent asthma is FEV less than 60% of predicted.

24. Complex genetic disease affecting both the respiratory and gastrointestinal (GI) systems. • Characterized by excess thick, tenacious mucus lining airways causing decreased resistance to infection and air trapping. • Eventually can destroy pulmonary parenchyma. • GI symptoms include decreased pancreatic enzymes and hypersecretion of gastric acids. • Diagnostic testing includes chloride sweat testing. Cystic Fibrosis Adapted from Federico, M. J. (2011). Respiratory tract & mediastinum. In W. W. Hay, M. J. Levin, J. M. Sondheimer, & R. R. Deterding (Eds.), Current pediatric diagnosis and treatment (20th ed.). New York: McGraw-Hill; and Hazle, L. A. (2010). Cystic fibrosis. In P. J. Allen, J. A. Vessey, & N. A. Schapiro (Eds.), Primary care of the child with a chronic condition (5th ed.). St. Louis: Mosby.

25. Methods of Oxygen Delivery

26. Alternatives to Traditional Mechanical Ventilation

27. Nursing Management of Epiglottis • Do not attempt to visualize the throat. • Do not leave the child unattended. • Do not place the child in a supine position. • Provide 100% oxygen in the least invasive manner. • If complete airway occlusion occurs, tracheostomy may be necessary. • Ensure emergency equipment is available.

28. Nursing Care Posttonsillectomy • Promoting airway clearance • Place child in side-lying or prone position. • Maintaining fluid volume • Discourage coughing. • Encourage fluids; avoid citrus, brown, or red fluids. • Relieving pain • Ice collar and analgesics with or without narcotics.

29. Acute Noninfectious Respiratory Disorders • Epistaxis • Foreign body aspiration • Respiratory distress syndrome • Acute respiratory distress syndrome • Pneumothorax

30. Interventions to Minimize Psychosocial Impact of Chronic Respiratory Conditions • Promoting child’s self-esteem through education and support. • Allowing school-age child to take control of management of the disease. • Promoting family coping through education and encouragement. • Providing culturally sensitive education and interventions.