Key Pediatric Differences in the Respiratory System

• Lack of /insufficient surfactant• Alveoli developing• Smaller airways• Underdeveloped cartilage

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Key Differences (cont)

• Obligatory nose breather (infant)• Intercostal muscles less developed• Faster respiratory rate• Eustachian tubes relatively horizontal

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Respiratory Assessment

• RR first - full minute• Breath sounds• Quality

– Retractions– Nasal flaring

• Color• Cough

3

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Signs Respiratory Distress

• Cough• Hoarseness• Grunting• Stridor• Wheezing• Nasal flaring• Retractions

• Vomiting • Diarrhea• Anorexia• Tachypnea• Tachycardia• Restlessness• Cyanosis

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Potential Nursing Diagnoses• Ineffective Airway Clearance• Ineffective Breathing Patterns• Impaired Gas Exchange• Anxiety• Activity Intolerance• Risk for FVD• Altered nutrition• Altered comfort• Knowledge deficit• Ineffective coping – individual or family

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Apnea

• Periodic breathing of newborn• True apnea• ALTE• Parental teaching

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Sudden Infant Death Syndrome

• The sudden and unexplained death of an infant less than 1 yr old.

• Usually occurs during sleep.• “Back to Sleep” campaign• AAP revised SIDS guidelines (Pediatrics,

Vol. 116, No. 5, Nov. 2005)

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Sepsis• Def: a systemic bacterial infection spread

through bloodstream• Neonates high risk: unable to localize

infection• High Risk:

– Immunocompromised– Skin defects/injuries– Invasive devices

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Assessment: Sepsis• Know high risk children & monitor

– Hypo or hyperthermia– Lethargy; poor feeding– Jaundice, hepatosplenomegaly– Respiratory distress– Vomiting– Hyper or hypoglycemia

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Otitis Media

Description: inflammation middle ear– Acute otitis media– Otitis media w/effusion

• Bacterial

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Risk Factors

• < 3 years• Bottle-fed babies• Passive smoke• Group child care

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Acute Otitis Media• Definition

– Inflammation of middle ear–Rapid onset–Fever–Otalgia

• Other Clinical Manifestations:

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Treatment: AOM• Primary Prevention

–pneumococcal vaccine–No passive smoke–Hold bottle fed babies upright–handwashing

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AOM: Secondary Prevention• Pain relief• Rest• Antibiotics after 48-72 hrs in selected

patients 6 mo to 2 yrs.

PEDIATRICS Vol. 113 No. 5 May 2004, pp. 1451-1465

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Nursing Dx: AOM

• Altered comfort r/t inflammation & pressure

• Knowledge deficit r/t incomplete understanding of disease

• Risk for Fluid Volume Deficit

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Otitis Media w/Effusion• Definition

–Fluid in middle ear–No s/s acute infection

• Clinical Manifestations:

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Treatment: OME

• Antibiotics if > 3 mo.• Assess for hearing loss ***• Myringotomy w/placement

tympanostomy tubes

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Pharyngitis

• 80-90% sore throats viral in origin–Gradual onset

• Bacterial–Group A beta-hemolytic strep

greatest concern.

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Therapeutic Management• Primarily symptomatic• Pain relief• Rest • Abx only if positive bacterial culture

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Tonsillectomy/adenoidectomy

• Most common reason: OSA• Monitor for post-op bleeding

– ***Excessive swallowing– Elevated pulse, decreased BP– Evidence of fresh bleeding– Restlessness

• Pain meds – teach parents• Fluids

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Fig. 45-UF03, p. 1209F

Croup

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Croup

• Broad classification of upper airway illness• Group of conditions with:

– Inspiratory stridor– Harsh cough– Hoarseness– Degrees of respiratory distress

• 4 different types

Laryngotracheobronchitis

• Def: inflammatory condition of larynx, trachea, bronchi

• viral• Gradual onset • harsh cough & insp. stridor• Very important to differentiate from

epiglottitis

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LTB - treatment

• Racemic epinephrine via neb• Corticosteroids • Tylenol• Cool mist• Oxygen • Observe for sudden silent respiration

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Four D's of Epiglottitis•Drooling•Dysphagia•Dysphonia•Distressed respiratory efforts

•Tripod position•Do not: examine •throat or do throat culture!•Do: reassure, keep calm, anticipate intubation

25F

Brochiolitis

• Lower airway• 50% RSV (respiratory syncytial virus)

– Contact and droplet precautions– Mycoplasma, parainfluenza, adenovirus

• Usually young infants who need hospitalization.

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Patho of Bronchiolitis• Virus invades

mucosal cells• Cells die: debris• Irritation

increased mucus & bronchospasm

• Air trapping

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BronchiolitisClinical Manifestation

• Tachypnea• Wheezing, crackles, or rhonchi• Retractions• Fever- maybe• Difficulty feeding• Cyanosis

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Changes to Bronchiolitis Management

• Decrease in the amount of nasal swabs being ordered

• Decrease in orders for CPT by RT

• Decrease in continuous O2 saturation monitoring

• Decrease in use of albuterol treatments

• Discharge orders for patients with > 90% O2 saturations while asleep

• When cohorting patients, infection control may be consulted

• Teach parents CPT for comfort measures

• Increase amount of intermittent O2 sat checks (ex. Q4h)

• Increase use of Racemic Epi

• Accept O2 saturations as low as 88% when a patient is sleeping

• Continue suctioning as usual

What You Will See What You Will Do

For patients placed on Isolation Precautions: Gowns, Gloves, & MASKS are encouraged

Bronchiolitis Nursing Interventions

• Facilitate gas exchange

• Monitor I & O (for DFV)• IV prn• Reduce fever• Reduce anxiety

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Asthma

• Reactive airway disease –Bronchospasm–Edema– Increased mucus production

• Triggers– Dusts, pollen, food, strenuous exercise,

weather changes, smoke, viral infections

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AsthmaClinical Manifestations

• Wheezing• Dyspnea w/prolonged expiration • Nonproductive cough• Tachypnea, orthopnea• Tripod position• Fatigue

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Asthma treatment• Short-acting bronchodilator• Mast cell inhibitor • Systemic corticosteroids• Inhaled steroids• Leukotriene receptor antagonist• Peak expiratory flow rate• Immunizations

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Cystic Fibrosis

• Mechanical obstruction r/t increased viscosity of mucous secretions.

• Autosomal recessive disorder

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Cystic Fibrosis: A Multisystem Disorder

• Respiratory system• Digestive system• Integumentary system• Reproductive system• Growth and development

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Assessment findings - CF

• Salty-tasting skin• Profuse sweating• Frequent infections• Dry, non-productive cough• Increased amt, thickness of secretions• Wheezing• Cyanosis

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Assessment findings – CF (cont)

• Digital clubbing• Increased A-P diameter of chest• Steatorrhea• Thin extremities• Muscle wasting• Failure to thrive• Meconium ileus

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Cystic Fibrosis: Interventionsstrengthen lines of resistance

• Facilitate airway clearance and gas exchange.– CPT– Pulmozyme

• Prevent infection– Immunizations– TOBI– Azithromycin

• Promote increased exercise tolerance.38

CF: Interventions

Provide optimal nutrition for growth.• High-calorie, high protein• Pancreatic enzymes with every meal

– Creon, Pancrase– Dosage adjusted to stool formation

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CF interventions (cont)

Strengthen FLD/extrapersonal environment–Child's and family's emotional needs –Prepare the family for home care

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