Presentation on theme: "N317 Nursing Care of Children"— Presentation transcript:
1N317 Nursing Care of Children Altered Respiratory StatusAcute Upper & Lower Infections
2General Principles URI caused by viruses Most Common Bacteria Rhinovirus, RSVMost Common BacteriaB-Hemolytic StrepStaph. AureusH. InfluenzaPneumococcus
3General Principles Type of Organism “Dose” or amt. Of ExposureAge of Child--Young children—>SickerChild’s Immune SystemSeasonal variationsRSVDec.Mar., Peak in February
4Nasopharyngitis “Common Cold” Etiology Viral-RhinovirusS/SDry, hacking cough↑nasal discharge (mucous)↓appetite & activitySneezing, chills, irritabilityTxSupportive – no ASARest, FluidsSelf limiting 4-10 daysDo NOT give expectorants or cough meds to infants and young children due to risk of S.E.Complications: O.M.
5S/S Pharyngitis “Sore Throat” ViralBacterialCauseVirusGroup-A ß-hemolytic Strep (GABHS)OnsetGradualSuddenFeverLow gradeOver 100°ThroatRed – slight to no exudateCherry –red, white exudatesSymptomsCough, hoarseH/A, abd. Pain, enlarged lymph nodes
6Management of Strep Throat MUST get throat culture or Rapid Strep Screen to make DxUsual drug of choice: Penicillin---10 daysIF ALLERGIC TO PENICILLIN:Erythromycin, azithromycin (Zithromax), clarithromycin (Biaxin), cephalosporinsPCN + Rifampin is more effective than PCN alone in carriers & those with resistant strains24° quarantine after begin antibioticsSymptomatic TxTeach imp. of taking all antibiotics & to get new toothbrush after 24° on medsRisk for: rheumatic fever, acute glomerulonephritis
7Otitis Media Common causative agents—Strep pneumoniae, H. influenzae Patho / EtiologyShort-wide eustachian tubes which allows for bacteria to be swept into them when tube opens; also more horizontal so don’t allow for drainage easily.Increased Lymphoid tissuePooling of fluids (milk from bottle) in pharynxAt risk: cleft palate, Down syndrome, day care, propping bottle, living with smoker(s)Peak age: 6-36 mons; winter
8Otitis Media S/S Eardrum may Rupture → Tympanic membrane Earache Red Bulging → Obstructed Light reflexNo visible bony landmarksEaracheTemp F commonSwollen GlandsCold SxCrying/irritable when supineEardrum may Rupture →Decrease in painIncrease in ear drainage (on pillow)
9Management of Otitis Media AntibioticsP.O.:Amoxicillin, Augmentin, Trimethoprim-sulfamethoxazole (Bactrim, Septra), E-mycin-sulfisoxazole (Pediazole), Azithrmycin (Zithromax), Clarithromycin (Biaxin), Cephalosporins. IM Ceftriaxone (Rocephin)Analgesics for pain and temperature; warmth to ears; keep upright as much as possibleChronic OM: prophylactic antibiotics for 6 mos orSurgery Myringotomy to insert tympanostomy tubesComplicationsHearing Loss, eardrum scarring, adhesive otitis media, chronic OM, mastoiditis
10Note lack of light reflex, no bony prominences, bright red, bulging appearance of tympanic membrane Acute Otitis MediaEar Tube
11Otitis ExternaNormal ear flora becomes pathogenic in excessive wet/dry conditions (trauma or “swimmer’s ear”)Pain, edema so can’t visualize TM, hearing loss, cheesy green-blue-gray dischargeTx: antibiotic drops, 3-4x/day til pain & swelling gone, then more daysPrevention:50:50 sol. of ETOH/white vinegar gtts after swim or bath; 5” each earNothing in ear smaller than “elbow”Limit stay in water & dry ears after (with towel)
12Tonsillitis Usually self limiting if viral – must do throat culture Lymphoid tissue located in pharyngeal cavity becomes infected by viral or bacterial agentSymptomsPalatine tonsils edematous (3-4+) – blocks food/airAdenoids (pharyngeal tonsils) block air from nose to throatObstructed nasal breathing → bad breath from mouth breathing & nasal voicePersistent coughMay block eustachian tubes→OMUsually self limiting if viral – must do throat culture
13Resource with drawings on Tonsils & Adenoids http://www. entnet tonsillitisHypertropic tonsils
14T & A Discharge Instructions Surgery if documented frequent strep throatsTonsillectomy not done until after age 3 or 4Adenoids can be removed if < 3yrs if obstructed nasal breathingPre-opH&P, CBC, Bleeding Time, check for any loose teethPost-op#1 priority---Assess for Bleeding – watch for excessive swallowing!!Pain ReliefHydrationNo milk products or anything redDischarge InstructionsNo Spicy foodsAvoid Gargles, vigorous brushingCheck for bleeding – up to 10 days post opFoul breath odor, earache, Temp.↑
15Infectious Mononucleosis Def: acute, self-limiting infectious disease, common under age 25. Increase of mononuclear elements of the bloodEtiology:Epstein Barr Virus(EBV) - direct transmission with oral secretionsIncubation: 4-6 weeks after exposureSymptoms: Fatigue may last 1-2 mosmalaise, sore throat, fever, HA, lymphadenopathy, spleenomegaly, rash, exudative pharyngitis
16Infectious Mononucleosis Diagnosis:1. Self reported symptoms2. Monospot (EBV antigen test); WBC - atypical lymphocytes3. Heterophil antibody test (mono titer-1:160 is diagnostic)Management:1. Mild analgesia; antipyretics2. Bed rest; fluid intake3. Enlarged spleen - no contact activities4. Penicillin - if Strep. B is cultured from pharynx; NO ampicillinPrognosis:Self-limitingAvoid contact with live virus vaccines for several months after recovery!!! Depressed cellular immune reactivity.
17Croup Syndromes (middle airways infections) Symptom complex:hoarsenessa resonant “barky” coughvarying degrees of inspiratory stridorrespiratory distress resulting from swelling/obstruction in the region of the larynx.
18Acute Epiglottitis Def: inflammation and swelling of the epiglottis. Etiology/Pathophysiology: ages 2-8.Haemophilus influenza most commonEpiglottis become cherry red, swollen, causing obstruction of airway, secretions pool in the larynx and pharynx, complete obstruction within 2 to 6 hours.Froglike croak on inspirationSudden onset; medical emergency
19Acute Epiglottitis Assessment: Sudden onset high fever & extreme sore throatThe 4 D’s: dysphonia, dysphagia, drooling, distressAnxious, restless, tripod position.Inspiratory stridor, tongue protrusionContraindication: exam of throat unless incubation equipment & personnel are available **could result in spasm & complete obstruction of airway.
20Acute Epiglottitis Assessment cont.: Lateral neck x-ray Never leave child unattended or without intubation equipment nearUsually intubated for 24 hours; restraints may be necessaryAlways stay calm and help child and parent stay comfortable and calmTX: antibiotics 7-10 days; antipyretics, discharge in abt 3 days from hospital
21Acute Laryngotracheobronchitis (LTB) - CROUP Def: viral; inflammation, edema, narrowing of larynx, trachea, and bronchiCommon in infants, toddlers; Boys>girls; most common of croup syndromes*****Causative agents: parainfluenzae virus, influenzae A and B, RSV & mycoplasma pneumoniaeInflammation/narrowing airways inspiratory stridor + suprasternal retractionsThick secretions produced + edema obstruction of airway hypoxia + CO2 accumulation resp acidosis & failure
22Croup: assessment and tx Assessment & TxOnset gradual, often after URI; low-grade fever, barking cough, acute stridor, accessory muscles, retractionsPulse-OX, CXR: AP and Lat upper airwaysWatch for cyanosis, droolingHumidified O2, IV fluidsAssist child to position of comfort; keep parents nearMeds: Nebulized Racemic Epinephrine preferred over beta 2 adrenergic agonists, po corticosteroids like prednisone or OrapredTeaching: viral, worse at night & may recur for several nights, use cool mist humidifier in bedroomSeek medical help immed. if breathing is labored, child seems exhausted or very agitated, or cool air humidity tx does not improve symptoms
23Bronchitis (lower airways) Inflammation of the large airways; viral; usually associated with a URI, abruptSymptoms: persistent dry, hacking, nonproductive cough; worse at night; productive by 2nd to 3rd day; low-grade feverMild self-limiting; 5-10 daysSymptomatic tx: analgesics, fluids, rest & humidity; cough suppressants only if can’t rest d/t cough
24Respiratory Syncytial Virus (bronchiolitis~ lower airway, cont’d) Viral - produces serious lower respiratory infections, esp. pneumonia or bronchiolitisYoung children/infants (2-24 mo)1-6 months highest risk; 50% will be infectedOlder children: rhinorrhea, sore throat, coldClose contact: aerosols from coughing or sneezing; also contaminated objects. Not airborne – contact isolationIncubation: 4 to 8 daysViral shedding: ~ 2 weeks
25RSV – AssessmentBegins w/simple URI; fever (102°); can progress to severe Respiratory Distress quicklyThick nasal secretions, wheezing, fine rales; cough, anorexia, retractions, nasal flaring in infantsSevere: tachypnea, dyspnea, hypoxia, cyanosis, can progress to apneaAssessment: lung auscultation, oximetryRSV swab/washings (nasopharynx, throat)—positive resultCXR: overinflation, thickening, infiltratesCBC w/differential: viral shift usually presentArterial blood gases—only in severe casesRespiratory acidosis
26RSV: TreatmentDroplet and Contact Isolation is critical: with gown, glove, mask, when holding infantCool oxygenated mist, hydration, rest, suctioning, careful monitoring of SaO2Respiratory Treatments via Nebulizerbeta adrenergic agonists~Albuteral, Xopenex, racemic epinephrine--AAP does NOT recommend these anymore.Relieve bronchospams; EBP does not support efficacyCorticosteroids—may be given as anti-inflammatoryRiboviran—Nebulizer anti viral agent; precautionsRespigam—IV Immunoglobulin requires 1:1 RNSynagis—(palivizumab) RSV “Vaccine”Costly, but very worthwhile to high-risk infantsIM/Monthly during high seasonIndicated for preemies + hx of RDS, CHD
27Pneumonia Causes (can be 1° or 2°) Inflammation of Lung Parenchyma Bronchioles; alveolar spacesCauses (can be 1° or 2°)Viral (RSV)BacteriaPneumoncocciS. pneumoniaeStaph aureus / StrepChlamydiaPrimary atypical (community acquired)Mycoplasma
28Assessment and Diagnosis of Pneumonia Viral EtiologyMild fever, slight cough & malaise ORHigh fever, severe cough, & resp. distress (RSV)Unproductive coughRhinitisBreath sounds~ few wheezes, fine cracklesX-ray~diffuse, patchy infiltrationR/o bacterial or mycoplasma (CBC, bld cultures, microbiologyBacterial EtiologyHigh fever & tachypneaBacteria in bloodstream travel to lungs and ↑ thereCough~unproductive→productive w/white sputum; exhaustingBreath sounds~rhonchi or cracklesRetractions, chest pain, nasal flaringPallor-cyanosisX-ray~diffuse or patchy infiltration; ↑fluid as alveoli fill w/fluid & exudatesMay involve 1 segment or entire lungBehavior~ irritable, restless, lethargicGI~ anorexia, V&D, abdominal pain WBC (neutrophils)ASO titer if Strep
29Treatment of Pnemonia Viral Bacterial Supportive care: antipyretics & hydrationSelf limitingMonitor lung sounds, VS, respiratory status of patient; oximetry; bld gasesHumidification; O2 prnChest physiotherapyAntibiotics are not indicated unless for prophylactic useTeach parents s/s of dehydration & ↑ resp distressBacterialAntibiotics are indicatedOutpatient~ may use po Amoxicillin clavulanate (Augmentin) or 2nd generation cephalosporinHospitalized pt~ parenteral antibiotic therapy with Ampicillin sulbactam(Unasyn) and cefuroximeAll interventions for viral etiology are also implemented hereMay need to splint chest d/t cough
30Primary Atypical Pneumonia Etiology: mycoplasma pneumoniae, fall/winter; crowded living conditions. Peak ages 5-12yrs.Symptoms: sudden/insidious onset. Fever, HA, malaise, anorexia, myalgia, rhinitis, sore throat, cough; fine crackles over lung fields. May last up to 2 wks.Management:Most recover in 7-10days with symptomatic treatment. Hospitalization not usually necessary. Erythromycin drug of choice.