1. Nursing Care of the Pediatric Individual with a Respiratory Disorder
Pediatric respiratory conditions may occur as a primary problem or as a complication of nonrespiratory conditions and may be life threatening or have long-term implications. Nurses must learn to assess the child’s current respiratory status quickly, monitor progress, and anticipate potential complications. Neurologic and immune processes may be linked to respiratory conditions as well.

2. Describing the differences between adult and pedi client
Differences between the very young child and the older child
Resistance can depend on many factors
Clinical manifestations: those from 6 months to 3 years of age react more severely to acute resp tract infections
Resistance: may depend on the state of the immune system, malnutrition, anemia, fatigiue and chilling of the body. Conditions that weaken defenses of the respiratory tract may also include allergies, asthma (eg asthmatic bronchitis), which occurs more frequently during cold weathers whereas winter and spring are typically the “RSV seasons”

3. Differences in Adult and Child
Tongue is larger in proportion to mouth
Airway has larger amt of soft tissue than adult
Cricoid cartilage encircles airway until middle school age
Larynx is 2-3 cervical vertebrae higher
Lungs have fewer alveoli at birth than at one year
Mucous membranes lining are more loosely attached
Chest wall is less rigid and more soft

4. Let’s understand OM A diagnosis of OM requires all of the following:
Recent, usually abrupt onset of illness
The presence of middle ear fluid, or “effusion” (OME)
Signs or symptoms of middle ear inflammation
OME: hearing loss, tinnitus, vertigo
Differences between young and older child OM:
Young child (infants) fussy, pulls at ear, anorexia, crying, rolling head from side to side
Older child crying, verbalizes discomfort
Distinguish between OM and serous OM (learning guide)

5. Understanding OM
The underlying cause of OM is the malfunctiioning eustachian tubes. This tube, which connects the middle ear to the nasopharynx is normally closed and flat, preventing organisms in the pharyngeal cavity from entering the middle ear. This tube opens to allow drainage of secretions produced by the middle ear mucosa and to equalize air pressure between the middle ear and the outside environment. Impaired drainage of the eustachian tube causes retention of secretions in the middle ear. Air is unable to escape through the obstructed tubes, is absorbed into the circulation, and causes negative pressure within the middle ear. If the tube opens, a difference in pressure causes bacteria to be swept into the middle ear where the organisms quickly prolifereate and invade the mucosa.

6. Clinical Manifestations
What objective sign is this child displaying?
What does it indicate?
This young child is pulling at the ear and acting fussy, two important signs of otitis media. Ask the parents about the presence of fever and night awakenings. Additional signs often observed in children with this condition include:
1. Severe pain in the ear caused by pressure of fluid
2. Fever – hyperthermia is possible
3. Irritability
4. Anorexia
5. Continued symptoms of infections
6. Decreased light reflex of tympanic membrane
7. Red bulging tympanic membrane upon otoscopy 6

7. Otitis media (OM)
Note the ear on the left with clear tympanic membrane (drum); ear on the R the drum is bulging and filled with pus
One of the most prevalent diseases of early childhood; highest in winter bec. Many cases of bacterial OM are preceded by a viral respiratory infection. The most common virus infections are RSV and influenza
Most occur in the first 24 months of life but it may occur up to 7 years of age
Children living in households with smokers have increased risk to have OM. Also those living in households with many members are more likely to have OM.

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. Evaluation and therapy
Tx has always been directed toward abx; however, recently concerns about drug-resistant streptococcus pneumoniae have caused medical professionals to re-evaluate therapy (APA, 2004)
No clear evidence that abx improve OM
Waiting up to 72 hrs for spontaneous resolution is now recommended in healthy infants
When abx warranted, oral amoxicillin in high dosage TOC
When recurrent OM episodes are present, myringotomy, a surgical incision of the eardrum may be necessary to alleviate the severe pain. Recently, a minimally invasive, laser-assisted myringotomy procedure has been performed in outpatient settings
Tympanostomy tube placement and adenoidectomy are also surgical procedures that may be done to treat recurrent OM. Typanosotomy tubes are pressure-equalized (PE) tubes or grommets that facilitate continued drainage of fluid and allow ventilation of the middle ear. Myringotomy with or without insertion of PE tubes should NOT be performed
For the initial management of OM.

10. 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
Providing emotional support to the child and family
Analgesic drugs such as acetaminophen and ibuprofen treat mild pain. Codeine is now recommended for more severe pain. Ice compresses placed over the affected ear may also provide comfort, reduce edema and pressure.
If the ear is draining, the external canal may be cleaned with sterile cotton swabs. These should be loose enough to allow drainage out of the ear. Occasionally drainage is so profuse that the suricle and the skin surrounding the ear become excoriated from the exudate. This is usually prevented by frequent cleansing and application of various moisture barriers or Vaseline.
Prevention of recurrence requires adequate education regarding abx therapy. The sx of pain and fever usually subside within hrs., but nurses must emphasize that the infection is not completely eradicated until all of the prescribed medication is taken.
Parents need to be taught ways to be taught ways to prevent OM, such as sitting or holding an infant upright during bottle-feeding and breatsfeeding. Propping bottles is discouraged to avoid the supine position and to encourage human contact during feeding. Parents must also recognize the initial signs of OM such as irritability and ear puling. Eliminating tobacco smoke and known allergens from the environment is essential

11. Preparing the child for surgery
Not a lot of preparation: this is an outpatient procedure and the child is usually out of recovery and discharged within a couple of hours.
The preoperative Program at Dell: children may come prior to surgery to view the OR and ask questions….very useful for the school aged child
Cancellations: an ordinary cold will not cancel surgery
Your child's medical history esp immunizations; been on abx for OM?
Lab testing CBC, PTT
Parents are part of our team may join up with child in recovery
Be honest with your child answer honestly the questions they may have
The night before surgery
NPO guidelines only liquids for supper the night before
The day of surgery
Caring for your child
Your child is in good hands
Parent and child in recovery

12. 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. 
Here you can see serous fluid from the drum, although it might be purulent or clear as well

13. Tonsillitis Note the pus pockets and exudate
Tonsils are lymph tissue that guards the entrance to the rezpiratory and GI systems
Tonsils should not be removed unless they occlude the airway
Can be treated with abx at home

14. Nursing Care for the Tonsillectomy and Adenoidectomy Patient
Why is collection of blood for assessment of bleeding and clotting times so important?
Assessment of bleeding and clotting times is very important because the tonsils are very vascular and have an increase tendency to bleed.
Labs: CBC, PTT, and throat culture rapid strep test
If strep comes back positive, hold surgery until on abx
If PTT is greater than seconds then hold surgery---has child been on ASA or ibuprofen at home? 14

15. Nursing Care for the Tonsillectomy and Adenoidectomy Patient
Pre-operative preparation
Providing comfort and minimizing activities or interventions that precipitate bleeding
Place on abd until fully awake
Manage airway
Monitor bleeding, esp. new bleeding
Ice collar, pain meds
Avoiding po fluids until fully awake..then liquids, soft
Post-op hemorrhage can occur
Maintain in prone of Sims’ position until fully awake to facilitate drainage of secretions and prevent aspiration
Avoid suctioning and coughing to prevent hemorrhage
Encourage cool fluids---too cold can cause spasms
Avoid use of citrus juices, milk, hot liquids; do NOT use straws

16. Nurse Alert for Post-Op T/A surgery
Most obvious sign of early bleeding
is the child’s continuous
swallowing of trickling blood.
While the child is sleeping,
note the frequency of
swallowing and notify
the surgeon immediately
Another indication of hemorrhage is restlessness, changes in vital signs, frequent clearing of the throat or vomiting of bright red blood. Decreasing blood pressure is a late sign of shock.
RISK FOR BLEEDING in the 1st 24 hrs and again 7-10 days; again noting frequent swallowing and vomiting of blood.

17. 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

18. Apnea Defined as delay of breathing over 20 seconds Manifestations
Diagnostic tests
Therapeutic Interventions and Nursing Care
Clinical manifestations: cessation of breathing; cyanosis, marked pallor, hypotonia, bradycardia
Diagnostic tests: r/o seizures with Eeg, r/o GERD, R/O RSV
Therapeutic interventions and Nursing Care: apnea monitor if documented apnea, teaching CPR to parents prior to discharge

19. Apnea vs Periodic Breathing
Cessation > 20 seconds
S/S to assess:
Cyanosis
Marked pallor
Hypotonia
bradycardia
Periodic breathing
Normal breathing pattern of NB but never > seconds
Even though normal, all parents are taught CPR for their NB

20. SIDS Defined: sudden death of an infant during sleep Etiology
Assessment
Therapeutic Interventions and Nursing Care
Etiology: There is an association between SIDS and the following risk factors: race (most common in native American infants); gender (more common in males; prone sleeping, exposure to tobacco/passive smoke; soft sleeping surfaces; use of pillows and quilts with bedding, bed sharing with others, overheating due to excessive blankets, clothing on infants, room temperature.
Assessment: largest single cause of death after neonatal period; the peak incidence occurs 2-4 months
Nsg Interventions: teaching, prevention by teaching parents to place infa t on back to sleep, support of parents by helping them work through feelings of guilt and loss; refer to National Foundation for SIDS

21. Croup Croup vs epiglottitis Epiglottitis
Croup: 3months-8yr; slowly progressive; attacks at night, barking cough mild elevation of temp; VIRAL; inspiratory stridor
Epiglottitis: Onset 2yrs-8yrs; stridor, cough, BACTERIAL

22. Croup vs. Epiglottitis Croup Epiglottitis viral Hoarseness
Resonant cough
Stridor (inspiratory)
Risk for significant narrowing airway with inflammation
Humidity for treatment
Epiglottitis
Bacterial
Rapidly progressive course
Dysphagia
Stridor aggravated when supine
Drooling, high fever
Antibiotics needed
Croup is a general term applied to a complex syndrome that ranges from infections of the larynx ranging to episodes of acute epiglottitis. This is a serious obstructive inflammatory process that occurs predominantly in children 2-5 yrs of age and requires immediate attention. The responsible organisms is usually Hemophilus influenza. And the HIB vaccine is recommended for young children.
The course of epiglottitis may be fulminant, with respiratory obstruction appearing suddenly. Progressive obstruction leads to hypoxia, hypercapnia, and acidosis followed by reduced level of consciousness. When obstruction becomes more or less complete, a rather sudden death may occur.Exam of the throat with a tongue depressor is contraindicated. Tracheostomy may be indicated. A lateral neck fil may be indicated to demonstrate soft tissue swelling. Most hospitals do not want to transport the child from the ED, but rather have the parents hold and a portable xray done. Intubatin, tracheostomy, and any invasive procedure such as starting an IV should be performed in the operating. These children are given abx IV and the use of steroids for reducing edema may be beneficial during the early hrs of treatment.
Epiglottitis is a serious and frightening disease for the child and family. It is important to act quicky but calmly and ot provide support without increasing anxiety. The child is allowed to remain the the position that provides the most comfort and security, and parents are reassured that everything possible is being done to obtain relief for their child.

23. Four D’s r/t epiglottitis
Drooling
Dysphagia
Dysphonia (difficulty talking)
Distress with respiratory effort
NEVER put anything in the mouth NO throat cultures or visual inspection using a tongue blade!!!

24. Medications used in the treatment of croup and epiglottitis
Beta agonists and beta-adrenergics (albuterol, racemic epinepherine through face mask)
Corticosteroids: not for acute attack
Antibiotics for epiglottitis
Croup tent with mist, Pulse Ox
Endotracheal tube, trach
@ bedside for epiglottitis

25. Nursing care for the child with croup and epiglottitis
Observe for s/s respiratory distress
Assess respiratory rates: >60
Elevated temp ) 101º
The child must NEVER be left alone
NOTHING should be placed in the mouth (laryngeal spasms could result)

26. Bronchitis vs Bronchiolitis
Bronchitis: Inflammation of the trachea and major bronchi. Rarely exists by itself; occurs together with other conditions of the upper and lower respiratory tracts. Characterized by a cough and may take up to 2 weeks to resolve.It is VIRAL. May be confused with asthma. Non productive cough but changes to loose cough with increased mucus production. TX is symptomatic; don’t recommend cough suppressants. Abx given only if a bacterial infection is confirmed by culture.
Bronchiolitis: accumulation of mucus and cellular debris which obstruct the bronchioles. Airway resistance is increased during the inspiratory and expiration phases of respiration because of the small air passages. Caused by RSV (rhino syncytial virus) Air trapping results from hyperinflation of the lungs because the bronchioles construct during expiration. Atelectasis can occur. Manifested by tachypnea (up to a minute); wheezing, retractions, cyanosis. FEEDING MAY BE DIFFICULT because of the infant’s inability to breathe while sucking. Fevers may go up to 105. ABX are not given unless there is a secondary bacterial infection.Head must remain slightly extended to maintain an open airway. Nebulizations has been shown to significatly effect the reduction of oxygen requirements and reduction in respiratory rate. may be a significant cause of hospitalization in infants younger than 1 yr. Respiratory syncytial virus (RSV) Usually acquired from an older child, particularly family members, daycare, etc. RSV communicable and can live on skin or paper for up to 1 hour. It is not airborne, it is highly communicalbe meticulous handwashing is necessary. Highest infection times are winter and early spring

27. The diameter of an infant’s airway is approximately 4 mm,
An inflammatory process in the airway causes swelling that narrows the airway, and airway resistance increases. Note that swelling of 1 mm reduces the infant’s airway diameter to 2 mm, but the adult’s airway diameter is only narrowed to 18 mm. Air must move more quickly in the infant’s narrowed airway to get the same amount of air to the lungs. The friction of the quickly moving air against the side of the airway increases airway resistance. The infant must use more effort to breathe and breathe faster to get adequate oxygen.
The diameter of an infant’s airway is approximately 4 mm,
in contrast to an adult’s airway diameter of 20 mm.

28. Preventive measures against RSV
Follow droplet and contact precautions (can live up to 7 hrs on inanimate objects)
Nosocomial infections very common; strict hand hygiene must be observed
Synagis (palivizumab) given IM only to at risk children
These treatments are expensive so it s given mainly to high-risk children for 5 consecutive months during the winter to prevent RSV

29. Reactive Airway Disease (asthma)
Chronic inflammatory disorder affecting mast cells, eosinophils, and T lymphocytes
Inflammation causes increase in bronchial hyper-responsiveness to variety of stimuli (dander, dust, pollen, etc.)
Most common chronic disease of childhood; primary cause of school absences
Mucosal edema, increased airway irritation, mast cells release substances that act upon airways, bronchospasm, mucus plugging, increased work of breathing, gas exchange and tissue oxygenation is diminished,

30. Asthma, cont. Pathophysiology
Increased airway resistance, decreased flow rate
Increased work of breathing
Progressive decrease in tidal volume
Arterial pH changes: respiratory alkalosis, metabolic acidosis
Characterized by
Mucosal edema
Wheezing (r/t bronchospasm)
Mucus plugging
Arterial pH abnormalities include respiratory alkalosis (early) or acidosis (late); metabolic acidosis (from hypoxemia, and the work of breathing. Airway inflammation causes smooth muscle construction in large airways. This occurs rapidly and improves significantly with bronchodilators. There is mucus plugging and mucosal edema that does respond to steroid. Young children are more likely to have hospitalization for asthma attacks since they have such small airways.
PREVENTERS: allergy injections, decrease the allergens (carpets, pillows)
CONTROLLERS: Cromolyn, steroids (inhaled), leukotrienes (Singular)
RESCUERS: bronchodilators (beta agonists), steroids IV, IV fluids

31. Asthma, cont. Therapies:
Medi-halers (not more than one canister/month)
Beta-agonists: relax smooth muscle in airway
Corticosteroids: for short term therapy
Anticholinergic agents: Atrovent
Mast-cell inhibitors (Cromolyn)
Singulair
Inhaled steroids ( Advair, Pulmocort, Azmacort) (always rinse mouth following administration)

32. Emergency situations of asthma
Acute episode of reactive disease: bronchioles may close rapidly, causing severe airway obstruction, anxiety, restlessness, and fear. Will need to be seen in ER if not relieved by med
Status asthmaticus: medical emergency with severe edema, profuse sweating, respiratory failure and death if untreated. Becomes seriously hypoxic…immediate intervention needed

33. Etiology of Acute Wheezing in an ED setting
Patients < 2 yrs of age
Evidence of smoke exposure
Significant role of viral infections (RSV)
Patients > 2 yrs of age
High incidence of allergies to dust mite, cock roach and other inhaled allergens
High incidence of viral respiratory infections

34. Goals for child with asthma
Prevention of chronic symptoms
Monitor peak expiratory flow (Peak Flow)
Prevent exacerbations
Maximize compliance to therapeutic regime
Recognize “triggers”
Exercise -stress
Allergens -infections

35. Types of medications for asthma
“Rescue”: short acting beta agonists (albuterol) main rescue classification
“Controller” or routine medications: mast-cell inhibitors (Intal), Luekotriene modifiers (Singulair), inhaled steroids (Advair, Flonase)
Preventer drugs: combination of controller meds plus some inhaled steroids (nasal)

36. Purpose of the MDI Shake vigorously prior to use
Exhale slowly and completely
Place mouthpiece in mouth, closing lips around it
Press and release the med while inhaling deeply and slowly
Hold breath for 10 seconds and exhale
Repeat x1
A spacer may be used to help children who cannot coordinate inspiration with medication release. The space captures the medicine in a reservoir for the child to breathe in over a couple of minutes

37. Interpreting Peak Expiratory Flow Rates
Green: (80-100% of personal best) signals all clear and asthma is under reasonably good control
Yellow (50-79% of personal best) signals caution; asthma not well controlled; call dr. if child stays in this zone
Red (below 50% of personal best) signals a medical alert. Severe airway narrowing is occurring; short acting bronchodilator is indicated

38. Why don’t we give bicarbonate for respiratory acidosis?
Child not able to blow off CO2 and acidosis will get worse
Correct the cause of the acidosis
Patient may need to be intubated

39. Cystic Fibrosis
Inherited as an autosomal recessive trait; the affected child inherits the defective gene from both aprents, with an overal incidence of 1:4. The mutated gene responsible for CF is located on the long arm of chromosome 7, along with its protein product, cystic fibrosis transmembrane regulator.
Characterized by several clinical features; increased viscosity of mucous gland secretions, a striking elevation of sweat electrolytes, an increase in several organic and enzymatic consitituents of saliva, and abnormalities in ANS function. Although both sodium and chloride are affected, the defect appears to be primarily a result of abnormal chloride movements. Children with DF demonstrate decreased pancreatic secretion of bicarbonate and chloride and an increase in sodium and chloride in both saliva and sweat. This characteristic is the basis for the sweat chloride diagnostic test.

40. Cystic Fibrosis
Here is the genetic ratio of parents with the gene

41. Cystic Fibrosis (CF)
Factor responsible for manifestations of the disease is mechanical obstruction caused by increased viscosity of mucous gland secretions
Mucous glands produce a thick protein that accumulates and dilates the glands
Passages in organs such as the PANCREAS become obstructed
First manifestation is meconium ileus in NB
Sweat chloride test
Sweat test done for accurate diagnosis: measure amt of Cl after patch is applied. A negative test, however, does not necessarily eliminate the possibility of being affected by the disease.
Genetic testing needs to be done if suspicious of CF with negative sweat test. Some babies with FTT may have the disease.
Level < 40 for both Na and Cl; patients with CF have > 60 for both Na and Cl

42. Cystic Fibrosis, cont. Systems affected:
Respiratory: thick mucus, inflammation, inc. infections, atelectasis and pneumothorax
Pancreas: obstructed pancreatic ducts by mucus and pancreatic enzymes (trypsin lipase, amylase) to duodenum
GI: decrease in absorption of nutrients, fatty stools (steatorrhea)
Reproductive: 99% of males are sterile

43. Physical findings of the CF patient
Frequently admitted with FTT
Clubbing of the fingers
Barrel chest
Increased respirations, cyanosis
Productive cough

44. Diagnostics for CF Sweat test: increased levels of chloride
Normal is <40; in CF >40-60 is positive; may be 3-5X higher
Pancreatic enzymes via stool cultures: trypsin absent in 80% of children with CF; lipase and amylase also absent

45. Planning the care for a CF child
Respiratory goal: removal of secretions (chest physiotherapy with Thairapy vest) by vibrations loosen mucus
Nutritional: inc. weight, enzymes with all food (Viokase or Ultrace) dosage is regulated by evaluation of the stool
Fat soluble vitamins ADKE
High calorie, high protein, low fat
Maintain Na balance (when sweating and ill)

46. Nursing Care of the CF patient
Assessing both GI and pulmonary status
Assisting with diagnostic testing
Collections of stool specimens for trypsin and lipase (fat analyses)
Administer oxygen with great caution because of the threat of oxygen narcosis
Implement dietary management; many have a good appetite and some will eat excessively

47. 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?
Epiglottis
Is there sufficient evidence to draw any conclusions about Kim’s condition at this time?
Describe some underlying assumptions about each of the following: epiglottitis in children, sx of epiglottitis, precautions to be taken when a child as suspected epiglottis, immediate nsg interventions when caring for a child with epiglottitis
What priorities for nsg care can be drawn at this time?
Does the evidence objectively support your argument (conclusion)?