1. N317 Nursing Care of Children
Altered Respiratory Status
Acute Upper & Lower Infections

2. General Principles URI caused by viruses Most Common Bacteria
Rhinovirus, RSV
Most Common Bacteria
B-Hemolytic Strep
Staph. Aureus
H. Influenza
Pneumococcus

3. General Principles Type of Organism
“Dose” or amt. Of Exposure
Age of Child--Young children—>Sicker
Child’s Immune System
Seasonal variations
RSVDec.Mar., Peak in February

4. Nasopharyngitis “Common Cold”
Etiology Viral-Rhinovirus
S/S
Dry, hacking cough
↑nasal discharge (mucous)
↓appetite & activity
Sneezing, chills, irritability Tx
Supportive – no ASA
Rest, Fluids
Self limiting 4-10 days
Do NOT give expectorants or cough meds to infants and young children due to risk of S.E.
Complications: O.M.

5. S/S Pharyngitis “Sore Throat”
Viral
Bacterial
Cause
Virus
Group-A ß-hemolytic Strep (GABHS)
Onset
Gradual
Sudden
Fever
Low grade
Over 100°
Throat
Red – slight to no exudate
Cherry –red, white exudates
Symptoms
Cough, hoarse
H/A, abd. Pain, enlarged lymph nodes

6. Management of Strep Throat
MUST get throat culture or Rapid Strep Screen to make Dx
Usual drug of choice: Penicillin---10 days
IF ALLERGIC TO PENICILLIN:
Erythromycin, azithromycin (Zithromax), clarithromycin (Biaxin), cephalosporins
PCN + Rifampin is more effective than PCN alone in carriers & those with resistant strains
24° quarantine after begin antibiotics
Symptomatic Tx
Teach imp. of taking all antibiotics & to get new toothbrush after 24° on meds
Risk for: rheumatic fever, acute glomerulonephritis

7. Otitis Media Common causative agents—Strep pneumoniae, H. influenzae
Patho / Etiology
Short-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 tissue
Pooling of fluids (milk from bottle) in pharynx
At risk: cleft palate, Down syndrome, day care, propping bottle, living with smoker(s)
Peak age: 6-36 mons; winter

8. Otitis Media S/S Eardrum may Rupture → Tympanic membrane Earache
Red Bulging → Obstructed Light reflex
No visible bony landmarks
Earache
Temp F common
Swollen Glands
Cold Sx
Crying/irritable when supine
Eardrum may Rupture →
Decrease in pain
Increase in ear drainage (on pillow)

9. Management of Otitis Media
AntibioticsP.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 possible
Chronic OM: prophylactic antibiotics for 6 mos or
Surgery Myringotomy to insert tympanostomy tubes
Complications
Hearing Loss, eardrum scarring, adhesive otitis media, chronic OM, mastoiditis

10. Note lack of light reflex, no bony prominences, bright red, bulging appearance of tympanic membrane
Acute Otitis Media
Ear Tube

11. Otitis Externa
Normal 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 discharge
Tx: antibiotic drops, 3-4x/day til pain & swelling gone, then more days
Prevention:
50:50 sol. of ETOH/white vinegar gtts after swim or bath; 5” each ear
Nothing in ear smaller than “elbow”
Limit stay in water & dry ears after (with towel)

12. Tonsillitis Usually self limiting if viral – must do throat culture
Lymphoid tissue located in pharyngeal cavity becomes infected by viral or bacterial agent
Symptoms
Palatine tonsils edematous (3-4+) – blocks food/air
Adenoids (pharyngeal tonsils) block air from nose to throat
Obstructed nasal breathing → bad breath from mouth breathing & nasal voice
Persistent cough
May block eustachian tubes→OM
Usually self limiting if viral – must do throat culture

13. Resource with drawings on Tonsils & Adenoids http://www. entnet
tonsillitis
Hypertropic tonsils

14. T & A Discharge Instructions
Surgery if documented frequent strep throats
Tonsillectomy not done until after age 3 or 4
Adenoids can be removed if < 3yrs if obstructed nasal breathing
Pre-op
H&P, CBC, Bleeding Time, check for any loose teeth
Post-op
#1 priority---Assess for Bleeding – watch for excessive swallowing!!
Pain Relief
Hydration
No milk products or anything red
Discharge Instructions
No Spicy foods
Avoid Gargles, vigorous brushing
Check for bleeding – up to 10 days post op
Foul breath odor, earache, Temp.↑

15. Infectious Mononucleosis
Def: acute, self-limiting infectious disease, common under age 25. Increase of mononuclear elements of the blood
Etiology:
Epstein Barr Virus(EBV) - direct transmission with oral secretions
Incubation: 4-6 weeks after exposure
Symptoms: Fatigue may last 1-2 mos
malaise, sore throat, fever, HA, lymphadenopathy, spleenomegaly, rash, exudative pharyngitis

16. Infectious Mononucleosis
Diagnosis:
1. Self reported symptoms
2. Monospot (EBV antigen test); WBC - atypical lymphocytes
3. Heterophil antibody test (mono titer-1:160 is diagnostic)
Management:
1. Mild analgesia; antipyretics
2. Bed rest; fluid intake
3. Enlarged spleen - no contact activities
4. Penicillin - if Strep. B is cultured from pharynx; NO ampicillin
Prognosis:
Self-limiting
Avoid contact with live virus vaccines for several months after recovery!!! Depressed cellular immune reactivity.

17. Croup Syndromes (middle airways infections)
Symptom complex:
hoarseness
a resonant “barky” cough
varying degrees of inspiratory stridor
respiratory distress resulting from swelling/obstruction in the region of the larynx.

18. Acute Epiglottitis Def: inflammation and swelling of the epiglottis.
Etiology/Pathophysiology: ages 2-8.
Haemophilus influenza most common
Epiglottis 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 inspiration
Sudden onset; medical emergency

19. Acute Epiglottitis Assessment:
Sudden onset high fever & extreme sore throat
The 4 D’s: dysphonia, dysphagia, drooling, distress
Anxious, restless, tripod position.
Inspiratory stridor, tongue protrusion
Contraindication: exam of throat unless incubation equipment & personnel are available **could result in spasm & complete obstruction of airway.

20. Acute Epiglottitis Assessment cont.: Lateral neck x-ray
Never leave child unattended or without intubation equipment near
Usually intubated for 24 hours; restraints may be necessary
Always stay calm and help child and parent stay comfortable and calm
TX: antibiotics 7-10 days; antipyretics, discharge in abt 3 days from hospital

21. Acute Laryngotracheobronchitis (LTB) - CROUP
Def: viral; inflammation, edema, narrowing of larynx, trachea, and bronchi
Common in infants, toddlers; Boys>girls; most common of croup syndromes*****
Causative agents: parainfluenzae virus, influenzae A and B, RSV & mycoplasma pneumoniae
Inflammation/narrowing airways inspiratory stridor + suprasternal retractions
Thick secretions produced + edema  obstruction of airway  hypoxia + CO2 accumulation  resp acidosis & failure

22. Croup: assessment and tx
Assessment & Tx
Onset gradual, often after URI; low-grade fever, barking cough, acute stridor, accessory muscles, retractions
Pulse-OX, CXR: AP and Lat upper airways
Watch for cyanosis, drooling
Humidified O2, IV fluids
Assist child to position of comfort; keep parents near
Meds: Nebulized Racemic Epinephrine preferred over beta 2 adrenergic agonists, po corticosteroids like prednisone or Orapred
Teaching: viral, worse at night & may recur for several nights, use cool mist humidifier in bedroom
Seek medical help immed. if breathing is labored, child seems exhausted or very agitated, or cool air humidity tx does not improve symptoms

23. Bronchitis (lower airways)
Inflammation of the large airways; viral; usually associated with a URI, abrupt
Symptoms: persistent dry, hacking, nonproductive cough; worse at night; productive by 2nd to 3rd day; low-grade fever
Mild self-limiting; 5-10 days
Symptomatic tx: analgesics, fluids, rest & humidity; cough suppressants only if can’t rest d/t cough

24. Respiratory Syncytial Virus (bronchiolitis~ lower airway, cont’d)
Viral - produces serious lower respiratory infections, esp. pneumonia or bronchiolitis
Young children/infants (2-24 mo)
1-6 months highest risk; 50% will be infected
Older children: rhinorrhea, sore throat, cold
Close contact: aerosols from coughing or sneezing; also contaminated objects. Not airborne – contact isolation
Incubation: 4 to 8 days
Viral shedding: ~ 2 weeks

25. RSV – Assessment
Begins w/simple URI; fever (102°); can progress to severe Respiratory Distress quickly
Thick nasal secretions, wheezing, fine rales; cough, anorexia, retractions, nasal flaring in infants
Severe: tachypnea, dyspnea, hypoxia, cyanosis, can progress to apnea
Assessment: lung auscultation, oximetry
RSV swab/washings (nasopharynx, throat)—positive result
CXR: overinflation, thickening, infiltrates
CBC w/differential: viral shift usually present
Arterial blood gases—only in severe cases
Respiratory acidosis

26. RSV: Treatment
Droplet and Contact Isolation is critical: with gown, glove, mask, when holding infant
Cool oxygenated mist, hydration, rest, suctioning, careful monitoring of SaO2
Respiratory Treatments via Nebulizer
beta adrenergic agonists~Albuteral, Xopenex, racemic epinephrine--AAP does NOT recommend these anymore.
Relieve bronchospams; EBP does not support efficacy
Corticosteroids—may be given as anti-inflammatory
Riboviran—Nebulizer anti viral agent; precautions
Respigam—IV Immunoglobulin requires 1:1 RN
Synagis—(palivizumab) RSV “Vaccine”
Costly, but very worthwhile to high-risk infants
IM/Monthly during high season
Indicated for preemies + hx of RDS, CHD

27. Pneumonia Causes (can be 1° or 2°) Inflammation of Lung Parenchyma
Bronchioles; alveolar spaces
Causes (can be 1° or 2°)
Viral (RSV)
Bacteria
Pneumoncocci
S. pneumoniae
Staph aureus / Strep
Chlamydia
Primary atypical (community acquired)
Mycoplasma

28. Assessment and Diagnosis of Pneumonia
Viral Etiology
Mild fever, slight cough & malaise OR
High fever, severe cough, & resp. distress (RSV)
Unproductive cough
Rhinitis
Breath sounds~ few wheezes, fine crackles
X-ray~diffuse, patchy infiltration
R/o bacterial or mycoplasma (CBC, bld cultures, microbiology
Bacterial Etiology
High fever & tachypnea
Bacteria in bloodstream travel to lungs and ↑ there
Cough~unproductive→productive w/white sputum; exhausting
Breath sounds~rhonchi or crackles
Retractions, chest pain, nasal flaring
Pallor-cyanosis
X-ray~diffuse or patchy infiltration; ↑fluid as alveoli fill w/fluid & exudates
May involve 1 segment or entire lung
Behavior~ irritable, restless, lethargic
GI~ anorexia, V&D, abdominal pain
 WBC (neutrophils)
ASO titer if Strep

29. Treatment of Pnemonia Viral Bacterial
Supportive care: antipyretics & hydration
Self limiting
Monitor lung sounds, VS, respiratory status of patient; oximetry; bld gases
Humidification; O2 prn
Chest physiotherapy
Antibiotics are not indicated unless for prophylactic use
Teach parents s/s of dehydration & ↑ resp distress
Bacterial
Antibiotics are indicated
Outpatient~ may use po Amoxicillin clavulanate (Augmentin) or 2nd generation cephalosporin
Hospitalized pt~ parenteral antibiotic therapy with Ampicillin sulbactam(Unasyn) and cefuroxime
All interventions for viral etiology are also implemented here
May need to splint chest d/t cough

30. Primary 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.