1. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 18 Nursing Care of the Child With a Respiratory Disorder

2. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy and Physiology of the Child’s Nose and Throat Nose –Infants are obligate nose breathers; newborns produce very little mucus, making 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. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Child’s Airway

4. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adventitious Breath Sounds Wheezing –High-pitched sound on expiration –May occur with obstruction in lower trachea or bronchioles Rales –Crackling sounds heard when alveoli become fluid filled –May occur with pneumonia

7. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Laboratory and Diagnostic Tests Ordered for Bronchiolitis (RSV) 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 can be made via enzyme-linked immunosorbent assay (ELISA) or immunofluorescent antibody (IFA) testing

10. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Common Medical Treatments for Respiratory Disorders Oxygen High humidity Suctioning Chest physiotherapy and postural drainage Saline gargles Saline lavage Chest tubes Bronchoscopy

13. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Alternatives to Traditional Mechanical Ventilation

16. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Acute Infectious Disorders Common cold, sinusitis Influenza Pharyngitis, tonsillitis, and laryngitis Croup syndromes Respiratory syncytial virus (RSV) Pneumonia and bronchitis

17. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

18. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

19. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Chronic Respiratory Disorders Allergic rhinitis Asthma Chronic lung disease (bronchopulmonary dysplasia) Cystic fibrosis Apnea

21. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Asthma Severity Classification in Children Not Taking Long-Term Control Medications 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. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Pathophysiology of Cystic Fibrosis and Resultant Respiratory and Gastrointestinal Clinical Manifestations 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. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Methods of Oxygen Delivery

26. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

27. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

28. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Acute Noninfectious Respiratory Disorders Epistaxis Foreign body aspiration Respiratory distress syndrome Acute respiratory distress syndrome Pneumothorax

29. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Peak Expiratory Flow Rate 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.

30. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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