Learning Guide
Respiratory Disorders
Chapter 45 The Child With a Respiratory Alteration
1.
How is the child’s respiratory system different from an adult?
Smaller nasopharynx, easily occluded during infection
Lymph tissue (tonsils, Adenoids) grow rapidly in early childhood the atrophies after 12 years old
Immature immune system till > 3 years old
Small oral cavity and large tongue increases rule out obstruction
Thyroid, cricoid and trach cartilage is immature and may collapse when neck is flexed
Fewer functional muscles in airway
More soft tissue and mucous membranes lining the airway increase r/o edema and obstruction
Otitis Media
2. Compare the manifestations of acute otitis media (AOM) and otitis media with effusion (OME).
Acute otitis media (AOM)
Abrupt onset of pian, middle ear effusion and inflammation and IS associated with other signs of illness
Pulls on ear
Otitis Media w/Effusion (OME)
Noninfected fluid in middle ear – often follow AOM and resolves in 1-3 months
3. Describe medication options for the treatment of AOM.
AOM Therapy
Wait 48-72 hours for spontaneous resolution in otherwise healthy infants. Immunocompromised children
get immediately
Because of drug resistant strep pneumonia
When antibiotics warranted → oral amoxicillin
AOM Treatment
Myringotomy with tympanostomy (in persistent AOM)
o Drainage by inserting tube
o Promotes air exchange by passing eustachian tube prevents scaring and hearing loss
4.
How does the nurse prepare the patient/family for a tympanostomy?
Antibiotic therapy
Comfort measures
Teaching for home care
o When to notify HCP
o Follow up visit with PCP
o Preventative measures
5.
What post op education is provided follow tympanostomy?
Assess immediate post op and ongoing
Pre and post op family support
Teaching
o Hygiene
o No swimming/diving without earplugs
If untreated → Mastoiditis
Mastoiditis
Acute infection of mastoid bone surrounding ear → untreated = meningitis/encephalitis
Hearing loss
Can cause intracranial complications
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Affects mostly 6-13 months old
Assess vitals (Temp> 101.0) F)
Medicate with vancomycin aggressively
Assess for complications
Vancomycin care
Allergies sensitivities
Peak/trough → oto/nephrotic most affected
Peak → 1 hour prior to administration
SE → red man syndrome → extended rate of administration
Pharyngitis/Tonsillitis
6. What is the most common organism leading to tonsillitis?
Group A beta-hemolytic streptococcal (GABHS) bacteria are in important and most frequently seen
bacterial cause of pharyngitis.
Streptococcal infection is spread by close droplet transmission
Tonsillitis, like pharyngitis can be bacterial or viral in origin
7.
What are the manifestations for tonsillitis?
Sore throat, which can be persistent or recurrent
Tonsils enlarged and bright red; may be covered with white exudate of cryptic plugs
Difficulty swallowing
Mouth breathing and an unpleasant mouth odor
Enlarged adenoids, which may cause a nasal cavity quality of speech, mouth breathing, hearing difficulty,
otitis media, snoring, or obstructive sleep apnea
Nasopharyngitis
Young child: fever, sneezing, vomiting or diarrhea
Older child: dryness and irritation of nose/throat, sneezing aches, cough
Pharyngitis
Young child: fever, malaise, anorexia, headaches
Older child: fever, headache, dysphagia, abdominal pain
Tonsilitis
Masses of lymphoid tissue in pairs
Often occurs with pharyngitis
Characterized by fever, dysphagia or respiratory problems forcing breathing to take place through the
mouth
With positive strep culture throw away toothbrush after 24 hours of antibiotics
8.
What diagnostic tests are important to obtain and review prior to a tonsillectomy?
Laboratory results
o Prothrombin time
o Partial thromboplastin time
o Platelet count
o Hemoglobin
o Hematocrit
o Urinalysis
9.
What post op complications will the nurse assess for following a tonsillectomy?
Excessive swallowing
Elevated pulse, decreasing blood pressure
Signs of fresh bleeding in the back of the throat
Vomiting bright red blood
Restlessness that does not seem to be associated with pain
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10. List post op nursing care.
Comfort measures and minimize activities or interventions that precipitate bleeding
Place on abdomen] or side to prevent aspiration
Minimize activities
Manage airway
Monitor bleeding, especially new bleeding
Diet
Do not use straws or put tongue depressor in mouth
Ice collar, pain meds
Most obvious sign of early bleeding is continuous swallowing of trickling blood monitor frequency of
swallowing and notify surgeon immediately
Respiratory Distress
11. List the common manifestations of respiratory distress in the child.
Nasal flaring
Circumoral cyanosis
Expiratory grunting
Retractions
o Substernal, suprasternal
o Lower intercostal
o Supraclavicular
Tachypnea (RR >60)
O2 saturations
Manifestations
Respiratory rate, Rhythm and Depth
Accessory muscles
Inspiratory and expiratory effort
Lungs sounds
O2 Sat
O2 administration per device
o NC 1-5L
o Simple face mask 6-10L
o Non-rebreather >10
Other types of oxygen delivery devices
o Venturi
o Aerosol
o Bag mask valve
12. What are nursing interventions for respiratory distress?
Raise HOB
Administer O2
Administer medications as ordered
Monitor O2 sat
Monitor work of breathing
Apnea
13. Define apnea. What is the difference between apnea and periodic breathing?
Apnea = delayed breathing lasting over 20 seconds
Additional signs and symptoms
o Cyanosis
o Marked pallor
o Hypotonia
o Bradycardia
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True apnea differs from periodic breathing, which might be seen in the premature infants. In periodic
breathing, there is a shift form regular rhythmic breathing to brief episodes of Apnea. This type of
breathing consists of three or more respiratory pauses of longer than 3 seconds, with less than 20 seconds
of respiration between pauses.
Rarely, periodic breathing is associated with changes in heart rate or color
14. What pulse oximeter reading is indicative of hypoxemia?
Depending on the child’s condition
15. What is the nursing care related to a child with apnea?
Admit to hospital for cardia and respiratory monitoring
Teach parents home care instructions for the use of apnea monitor
Teach parents CPR
Sudden Infant Death Syndrome (SIDS)
16. How is SIDS defined?
Sudden and unexplained death of infant less than 1 year old
17. What risk factors are associated with SIDS?
Prematurity, low birth weight
Most common in infants 2-4 months old
More prevalent in winter months
Exposure to passive smoke
18. What are nursing interventions related to the care of the family following SIDS?
Parent teaching
o Place infant on back to sleep
o Place on firm mattress
o Remove loose bedding, toys, pillows
o Do not place infants to sleep in car seats or swings
Provide support of parents by helping them work through feelings of guilt and loss
o Refer to National Foundation for SIDS
Croup – Laryngotracheobronchitis and Epiglottitis
19. Differentiate between laryngotracheobronchitis and epiglottitis.
Manifestations
Medications
Laryngotracheobronchitis
Epiglottitis = Bacterial
Drooling
Antibiotic Cephalosporin
form of croup,
Dysphagia (diff swallow)
IV if intubated. 10-day
Sudden onset,
Dysphoria (diff talking)
course post extubation
High fever
Distressed inspiratory
efforts
20. What is the priority intervention for a child with epiglottitis?
Keep kid calm to prevent laryngospasm
Bronchiolitis
21. What is the most common cause of bronchiolitis?
Begins with URI and progresses to respiratory distress
Dx with RSV wash
22. What type of precautions are implemented for a child with bronchiolitis?
Contact isolation, hand washing
Although it is highly communicable it is not airborne
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Nursing Care
Assess respiratory
distress; (nasal flaring,
tachypnea, tachycardia,
retraction drooling, LOC,
cyanosis)
NPO status
Anti-Pyrectics
23. Which patients are candidates for preventative medication options?
IM palivizumab (Synagis) administered monthly through the RSV season has reduced hospitalization for
premature infants (less than 35 weeks), younger than 6 months, and children under 24 months with
chronic lung disease or congenital cardiac disease
Asthma
24. Describe the pathophysiology of asthma.
Chronic inflammatory disorder affecting mast cells, eosinophils and T lymphocytes
Inflammation causes increased in bronchial hypersensitivity to a variety of stimuli (dander, cockroach
droppings, dust, pollen, smoke)
Inflammation and edema of he mucous membranes that line the small airways and the subsequent
accumulation of thick secretion in the airways
Most common chronic disease in childhood
Obstructive airflow limitation due to
o Mucosal edema
o Bronchospasm (constriction)
o Mucous plugging
 Increased airway resistance
 Decreased flow rates
Manifestations
o Increase work of breathing due to resistance
o Progressive decrease in tidal and expiratory volume
Arterial pH abnormalities because
o Increase in number of poorly ventilated alveoli
o Increase in hypoxemia
o CO2 retention
o Respiratory retention
o Respiratory acidosis
Acute episodes
o bronchioles may close rapidly, causing sever airway obstruction, anxiety, restlessness and fear
o Need to be seen in ER if not relieved by medication
Status asthmaticas
o Medical emergency with edema profuse sweating, respiratory failure and death
o Seriously hypoxic
o Treatment with Albuterol
25. What is the priority for a child diagnosed with asthma?
Long-term asthma treatment should minimize the control symptoms, prevent acute asthma episodes,
avoid the side effects of therapy, and help the child maintain a normal lifestyle
26. List common triggers of asthma in children.
Acute
o dander, cockroach droppings, dust, pollen, smoke
Long-term management
o Irritants and allergens
o Exercise
o Infection
o Emotions
27. Complete the table of rescue or reliver medications used for treatment of asthma.
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Albuterol
prednisone (Prelone)
ipratropin (Atrovent)
Classification/Action
Short acting beta-agonists
-Relax bronchial smooth
muscle and inhibit the
release of mediators from
mast cells.
Corticosteroids
-Decrease airway
inflamation
ACH
Route
MDI or
Nebulizer
Inhalers
Nursing Considerations
Can be given for
symptomatic or before
exercise
Inhaler
Given in a short course 57 days
inhaler
28. Complete the table of controller medications for asthma.
Long-term
Mechanism of
Common Names
Control
Action
Cromoly sodium
Prevents asthma
(Intal)
sx’s by blocking
Mast Cell
the release of
Inhibitors
mast cell
meditators
Montelukast
Diminishes the
Leukotriene
mediator action
modifiers
of leukotrienes
Inhaled
Corticosteroids
Long Acting
Beta2
Adrenergic
Agonist (LABA)
Becholmethason,
budesonide,
fluticasone,
flunisolide, and
triamcinolone
acetonide
Salmetrol (Serevent)
and formoterol
(Foradil)
Route
Nursing
Considerations
Inhaled non-steroid
anti-inflammatory
Sprinkles and
chewable tablets
BEFORE TRIGGER
Can be given to
children as young as 1
year old
inhaled
Promotes
vasodilation
Budesonide and
formoterol
(Symbicort a
combination inhaled
corticosteroid and
Combination
LAMA), fluticasone
Medications
and salmeterol
(Advair, a
combination inhaled
corticosteroid and
LABA)
29. How does the nurse explain proper use and care of an inhaler with spacer to the child/family?
A spacer attached to an MDI may make it easier for younger children to use the MDI. It also provides a
more even distribution of medication
Is using a spacer, the child attaches the spacer to the outlet of the MDI, closes the lips around the spacer
mouthpiece, activates the canister, and inhales
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Dry power inhalers (DPIs) are now available as well. They are easier to use than MDIs because the
medication only dispenses when the child inhales. In addition to the single-dose. DPI, a multidose inhaler
(for budesonide) and a multidose disk shaped inhaler (for fluticasone and salmeterol) are available
30. Describe how the peak flow meter works and why it is important for the child with asthma.
The peak flow meter is a device to help children monitor their asthma on a daily basis. Results gained
from daily monitoring are related to an overall action plan
o Remove gum or food from the mouth and stand up
o Move the pointer on the meter to 0, its lowest point
o Hold the meter horizontally, being sure to keep your fingers away from the vent holes and the
marker
o Relax and take a few slow deep breaths. Then, slowly take the deepest breath you possibly can
with your mouth wide open
o While holding our breath, place the mouthpiece of the meter on your tongue, and close our lips
tightly around the mouthpiece
o Blow out as hard and fast as possible. Give a short, sharp blast, like blowing out while, not a slow
blow. (The meter records the fastest blow, not the longest). Look at the number by the marker
on the numbered scale.
o Repeat two more times. Wait at least 10 seconds between attempts. Be sure to move pointer
back to zero each time
o Record the highest of the three reading in your daily asthma diary
o It is best to take peak flow readings every day, preferably in the morning and before after you
take a bronchodilator
31. Describe how the asthma action plan is used.
Obtain baseline for peak flow or >80%
Green zone (80% - 100% of best)
Yellow (50-79%) → caution/notify HCP if no change
Red (<50%) → medical alert → bronchodilator needed
Cystic Fibrosis (CF)
32. What is the pathophysiology of CF?
Genetic defect causes mechanical obstruction caused by increased viscosity of mucous gland secretions
Mucous glands produce a thick protein that accumulates and dilates them
Passage in organs like pancreas can be obstructed
First manifestation is meconium ileus (stuck in ileus)
Manifestations
o Clubbing of fingers
o Increased RR, cyanosis
o Productive cough with thick secretions
o Barrell chest
o Failure to thrive despite caloric intake
o Frequent respiratory infection
o Malabsorption of fats and proteins
o Mild diarrhea with malodorous stools, steatorrhea
o Increased Na+ in sweat
33. How is CF diagnosed?
Sweat test
o Chloride → normal > 40-60 mEq/L
o Diagnostic > 60 mEq/L
Pancreatic enzymes
o Collection of stool specimen to assess trypsin and lipase. Trypsin absent in 80% of kids with CF
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o Liver function test (alanine aminotransferase and aspartate aminotransferase)
o Lasting blood glucose test
o Chest x-ray
o Sputum culture
o Pulmonary function test
Organs affected are GI, respiratory, reproductive (anywhere mucous is)
34. Why are pancreatic enzymes administered to the patient with CF?
Enteric-coated microencapsulated pancreatic enzyme preparations are administered with every meal and
snack.
35. How can the patient determine appropriate dosage of enzymes?
Enzyme dosage is adjusted according to stool formation: fewer enzymes with constipation; more enzymes
with loose, fatty stools. Still the enzymes should be individualized for each child and kept as low as
possible while still maintaining the child’s nutritional status.
Often, histamine-2 receptor blockers (ranitidine) or proton pump inhibitors are prescribed to decrease the
overly acidic intestines, because enzymes will only work n alkaline environment. Extra salt is added to the
diet in extremely hot weather or when the child exercise vigorously
36. Develop a teaching plan for the patient with CF.
Preparation for home care involves teaching family members how to carry out CPT, how to provide
breathing treatments, and how to give medications at home.
Treatment
o Antibiotics
o Chest physiotherapy at least 2x a day to increase sputum expectoration
o Exercise important adjunct
o Management of dietary supplements
o Increase caloric diet, increase carbs, proteins, and Na+
o Replace enzymes
Chapter 41 The Child With an Infectious Disease
Pertussis
37. What education does the nurse provide to prevent pertussis?
Prevent with vaccine during pregnancy
Antibiotics including potential family history
Hospitalization
38. What are nursing considerations for the patient hospitalized with pertussis?
Isolation considerations
o Isolation DROPLET AND CONTACT
o Monitor vital signs, Especially O2
o Monitor Input and output
o Closely monitor cyanotic episodes
o Quiet, calm environment
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