NCM 109 PEDIA
PEDIATRICS
LEC / PROF. UBANA
______________________________________________________________________________________________________________
PRELIMS
Week 1: High-Risk Newborn, SGA, AGA,
Prematurity
OUTLINE
Identification of at-risk newborn
A. High Risk Neonate
B. Risk Period
II.
Classification of High-Risk infants based on
Gestational Age
A. AGA
B. SFD / SGA
III.
Problems related to Prematurity
IV.
Causes of prematurity
V.
Characteristics of prematurity
VI.
interventions of prematurity
VII.
Diagnostic interventions
VIII.
Problems related to Gestational weight
TIFICATION OF AT-RISK NEWBORN
I.
I. IDENTIFICATION OF AT-RISK NEWBORN
●
High- risk neonate is a newborn, regardless of
gestational age or birth weight, who has a greaterthan-average chance of morbidity or mortality because of
conditions or circumstances superimposed on the normal
course of events associated with birth and the
adjustments to extrauterine existence.
B. Small for date (SFD) or Small for Gestational Age (SGA)
o
o
regardless - SGA, LGA, premature, postmature
Conditions and circumstances: if AGA inside and
swallowed meconium - possible meconium
o superimposed / adjustment to extrauterine something happened during the delivery process
RECAP:
o Normal weight – 2.5 kg - 3.5 kg
o Term – 38 - 42 weeks
o Premature – 23 - 37 weeks
●
A. Appropriate for gestational age (AGA) infant
●
●
●
The – risk period encompasses human growth &
development from the time of viability, the gestational age
at which survival outside the uterus is believed to be
possible, or as early as 23 weeks of gestation up to 28
weeks following threats to life & health that occur.
o premature may have jaundice.
o Solution: phototherapy / exposure to sunlight
II. CLASSIFICATION OF HIGH-RISK INFANTS BASED
ON GESTATIONAL AGE
●
●
if the birth weight is BELOW the 10th percentile on
intrauterine growth curve for that age or birth weight
less than expected for the specific gestational age.
The infant maybe born preterm (before38th week
gestation), term (between weeks 38 & 42), or post
term (past 42 weeks).
Ex. 38 weeks’ gestation who weighs 5 lbs.
SGA infants are small for their age because they have
experienced INTRAUTERINE GROWTH
RETARDATION (IUGR) - or restriction or failed to
grow at the expected rate in utero.
o
o
o
o
Post term
Term
Preterm
Abortion
(past 42 weeks)
(38 – 42 weeks)
(20 – 37 weeks)
(less than 20 weeks)
CAUSES:
1.
an infant whose weight falls BETWEEN the 10th& 90th
percentile on intrauterine growth curves or birth weight
expected for the gestational age.
Ex. 34th week
o Weight should be proportion sa gestational age
o 2 years old ang ?2
2.
Mothers nutrition during pregnancy plays a major role in
fetal growth outcome & lack of adequate nutrition
maybe a major contributor to IUGR & most common
cause of IUGR is placental anomaly, either:
● the placenta did not obtain sufficient nutrients
from the uterine arteries
● it was insufficient at transporting nutrients to
the fetus.
Placental damage such as partial placental separation
with bleeding limits placental function.
● painful bleeding (abruptia placenta)
1
●
3.
4.
5.
placenta previa - painless bleeding; can’t be
felt by the mother
● not functioning at full capacity
Women with systemic diseases that decrease blood flow
to the placenta as severe diabetes mellitus or pregnancy
– induced hypertension.
Mothers who smoke heavily or use narcotics. Affects the
growth of the baby.
● important to ask in history taking
Placental supply of nutrients is adequate, but the infant
can’t use them - intrauterine infections of rubella or
toxoplasmosis.
ASSESSMENT
● Prenatal Assessment- maybe detected in the utero by
taking the fundal height (Leopold’s Maneuver) during
pregnancy.
● How to take fundic height: from pubic bone to
the top of the uterus (specifically: fundus)
● Do NOT take with contractions (because it
increases measurement)
●
Sonogram can demonstrate the decreased size,
biophysical profile including a non-stress test, placental
grading ultrasound examination can provide placental
function.
APPEARANCE
1) Below average in weight, length, & head
circumference.
2) Skin is dry, little fat
● Wasted appearance
3) Small liver, which may cause difficulty regulating
glucose, protein, & bilirubin levels.
4) Poor skin turgor & generally appears to have a large
head because the rest of the body is so small.
5) Skull sutures may be widely separated from lack of
normal bone growth.
6) Hair is dull & lusterless
7) Abdomen may be sunken.
● (ideal: globullar)
8) The cord often appears dry & maybe stained yellow.
9) Better neurologic responses, sole creases, & ear
cartilage expected for a baby of that weight.
10) Skull may be firmer & the infant may seem unusually
alert & active for that weight.
● check active: apgar, loud vigorous cry
LABORATORY FINDINGS
● High hematocrit level – due to lack of fluid in the utero.
● Polycythemia – increase in RBC due to a state of anoxia
during intrauterine life. NO OXYGEN
● Acrocyanosis – results due to blood viscosity & is difficult
to circulate thick blood. (HEEL PRICK = VERY THICK)
COMMON PROBLEM
●
●
●
1. HYPOGLYCEMIA
decreased glycogen stores - decreased blood glucose or
level below 40mg/dL- IVF to sustain blood sugar until able
to suck vigorously enough to take oral feedings.
Normal: 40 mg/dL above diabetic mothers -> first order is
to take blood sugar by heel pricking to check blood sugar
2. BIRTH ASPHYXIA
due to under-developed chest muscles & risk for
developing meconium aspiration syndrome due to anoxia
during labor.
o (no oxygen going to the baby because entrapped
by meconium, baby blue APGAR: 0-3)
●
Fetal hypoxia causes reflex relaxation of the anal
sphincter & increased intestinal movement.
●
With gasping the fetus draws meconium discharged into
the amniotic fluid into the Tracheobronchial tree. As a
foreign substance it blocks airflow into the alveoli leading
to hypoxemia, acidosis & hypercapnia. ALVEOLI DOES
NOT EXPAND
Nursing Diagnosis
● Ineffective breathing pattern related to
underdeveloped body systems at birth.
Outcome Identification
● NB will initiate & maintain respirations at birth.
Outcome Evaluation
● NB maintains normal respirations at a rate of 30 -60
breaths/ min. after resuscitation at birth.
3. Less able to control body temperature than a normal
newborn because they lack subcutaneous fat. Controlled
environment is essential to keep the infant’s body
temperature in neutral zone.
● immature hypothalamus and lack of brown fat
①
Nursing Diagnosis
● Risk for ineffective thermoregulation related to lack of
subcutaneous fat.
Outcome Identification
● NB will maintain body temperature within normal
limits.
Outcome Evaluation
● Infant’s temp is maintained at 36.5C of 97.8F
②
Nursing Diagnosis
● Risk for impaired parenting related to child’s high-risk
status & possible cognitive impairment from lack of
nutrients in utero. (may be due to CS and stitches)
Outcome Identification
● Parents will demonstrate beginning bonding behavior
with infant while in the hospital
Outcome Evaluation
● Parents express interest in infants & ask questions
about what the child’s care needs will be at home.
Intervention
● Adequate stimulation
● Provide toys suitable for their chronological age
2
●
Nursing Interventions
1. Care of SGA infant is similar in many instances to
care of preterm infant.
2. Tailor high-level nursing care to meet specific needs
of infant with regard to functioning of all body
systems, psychologic growth & development, parental
support & teaching, & prevention of complications.
C. Large for gestational age (LGA termed macrosomia)
●
●
an infant whose birth weight falls ABOVE the 90th
percentile or birth weight more than expected on an
intrauterine growth chart for the specific gestational age.
Ex. Baby born on the 30th week of gestation weighing 5
lbs. on intrauterine growth charts.
CS may be necessary because of CPD (the biparietal
diameter is closer to 10 cm than usual 9 cm) or
shoulder dystocia (wide shoulders are unable to pass
through the outlet of the pelvis.
ASSESSMENT CRITERIA FOR AN LGA INFANT
1) Skin color for ecchymosis, jaundice, & erythema.
2) Motion of extremities on spontaneous movement & in
response to a Moro’s reflex to detect fracture.
3) Symmetry of the anterior chest or unilateral lack of
movement to detect diaphragmatic
4) paralysis from edema of the phrenic nerve.
5) Eyes for evidence of unresponsive or dilated pupils,
vomiting, bulging fontanelles, & high-pitched cry
suggestive of increased intracranial pressure.
6) Activities such as jitteriness, lethargy, & uncoordinated
eye movement that suggest seizure activity.
ASSESSMENT / DIAGNOSTIC TEST
1. A sonogram to confirm the suspicion
2. Non stress test to assess the placenta’s ability to
sustain the large fetus during labor
3. Lung maturity may be assessed by amniocentesis.
4. Recognized during labor when infant can pass
through the pelvic brim.
APPEARANCE:
1. At birth show immature reflexes & low scores on
gestational age examinations in relation to his size.
2. May have extensive bruising or a birth injury such as
broken clavicle or Erb Duchenne paralysis from
trauma to the cervical nerves if born vaginally.
3. Head is large due to pressure at birth prone to caput
succedaneum, cephal- hematoma, or molding.
CAUSES:
1.
2.
3.
4.
5.
Overproduction of growth hormone in utero in diabetic
mothers with poorly controlled glucose levels.
Multiparous women because with each succeeding
pregnancy, babies tend to grow larger.
o every pagbubuntis lumalaki yung weight ng baby
Other conditions: Transposition of the great vessels
o group of congenital heart defects
Beckwith Syndrome - overgrowth disorder usually
present at birth, characterized by increased risk of
childhood cancer & certain congenital features.
Congenital anomalies – omphalocele - Abnormal
contents small & large intestines, stomach & liver,
protrude through a hole in the abdominal wall.
o Do not put the baby in the prone position,
dryness causes rupture
o by 4 gauze soaked with saline to moisten
o if located at the back, prevent supine position
ASSESSMENT
Fetus is suspected LGA when the uterus is unusually large for
the date of pregnancy.
● possible polyhydramnios: too much amniotic fluid
Molding of the head
3
Cardiovascular Dysfunction
●
●
o
Heart rate should be observed.
Cyanosis may be a sign of transposition of the great
vessels, a serious heart anomaly.
POLYCYTHEMIA –
is caused by the infant’s systems
attempting to fully oxygenate all the body tissues.
HYPERBILIRUBINEMIA – increased bilirubin level which may
result from absorption of blood from bruising & polycythemia.
HYPOGLYCEMIA – in the early hours of life because the infant
uses up nutritional
Stores readily to sustain his weight. If the mother has diabetes
that is poorly controlled, the infant will have an increased blood
glucose level in the utero, which causes the infant to produce
elevated levels of insulin. At birth, the increased insulin will
continue for up to 24 hours of life, causing rebound
hypoglycemia.
①
Nursing Diagnosis
● Ineffective breathing pattern related to possible birth
trauma in large for-gestational age NB.
Outcome Identification
● NB will initiate & maintain respirations at birth.
Evaluation
— NB initiates breathing at birth; maintains normal NB
respiratory rate of 30-60 breaths / minute.
● Difficulty establishing respiration because of birth
trauma.
● Increased intracranial pressure from birth of the
larger-than usual head may lead to pressure on the
respiratory center causing a decrease in respiratory
function.
②
Nursing Diagnosis
● Risk for imbalanced nutrition, less than body
requirements related to additional nutrients needed to
maintain weight & prevent hypoglycemia
Outcome Identification
● Infants will ingest adequate fluid for growth during the
neonatal period.
Outcome Evaluation
● Infant’s weight follows percentile growth curve; skin
turgor is good; specific gravity of urine is 1.003 to
1.030; serum glucose is above 40mg/dL. by heel
prick
● As a rule, LGA infants need to be breastfed
immediately to prevent hypoglycemia. (If cannot
breastfeed Supplemental formula feedings after
breast feeding to supply enough fluid & glucose for
the larger than normal for the first few days.
o Mother can also use breast pump,
supplemental feedings must be prescribed
because it is still not allowed for NB
③
Nursing Diagnosis
● Risk for impaired parenting related to high -risk status
of large for gestational age infant.
they can touch and talk as long as they
follow the policy
Outcome Identification
● Parents demonstrate adequate bonding behavior
during the neonatal period.
Outcome Evaluation
● Parents hold infant; speak of the child in positive
terms, state accurately why infant needs to be
observed closely during postnatal period.
PROBLEMS RELATED TO MATURITY
A. PREMATURE (PRETERM) INFANT
an infant born before the end of 37 weeks of gestation,
regardless of birth weight or born before the 38 week.
Weight of less than 2500g (5 lb. 8 oz.) at birth.
●
th
B. PRETERM INFANTS
born before term (before the beginning of the 38 week
of pregnancy).
●
th
4.
5.
6.
7.
8.
Low birth weight (LBW)
● an infant whose birth weight is less 2500g,
regardless of gestational age.
Moderately Low Birth Weight infant (MLBW)
● an infant whose birth weight is 1501 to 2500g
Very low birth weight (VLBW)
● an infant whose birth weight is 1000 to 1500g
born before 30 weeks of pregnancy (3 lbs. & 5
oz.)
Extremely Low Birth Weight infant (ELBW)
● an infant whose birth weight is 500 - 1000g (2
lbs. & 3 oz.) born at 27 weeks gestation or
even younger.
Minimum age of viability is 23 weeks gestation
CLASSIFICATION
1. Late preterm - born between 34 & 37 weeks.
2. Early preterm - born between 24 & 34 weeks.
3. Post term - Infants born after the end of 42 weeks of
pregnancy.
CAUSES
1. Maternal factors: age, smoking, poor nutrition,
placental problems, preeclampsia/ eclampsia.
2. Fetal factors: multiple pregnancy, infection, intrauterine
growth retardation (IUGR).
3. Other: low socioeconomic status, early termination of
pregnancies (mangyayari kung may condition ang
nanay for ex: pre-eclampsia or may sakit sa puso),
environmental exposure to harmful substances,
iatrogenic causes, such as elective cesarean birth &
inducement of labor according to dates rather than fetal
maturity.
FACTORS ASSOCIATED WITH PRETERM BIRTH
1. Low socio- economic level - no balanced diet
o no money no care
2. Poor nutritional status
3. Lack of prenatal care
4. Multiple pregnancy
5. Prior previous early birth
6. Race (non- white higher incidence)
4
7.
8.
9.
10.
11.
12.
13.
14.
15.
▪
▪
▪
▪
Cigarette smoking
Age of the mother (highest incidence younger than
age 20)
Order of birth
Closely spaced pregnancies (need of family planning,
especially for CS)
Abnormalities of the mother’s reproductive system,
such as intrauterine septum
Infections (especially UTI)
Obstetric complications such as PROM or premature
separation of placenta (premature rupture of
membrane)
o avoid ambulation, bedrest to prevent cord
prolapsing
Early induction of labor using oxytocin
Elective cesarean birth
o patient suggests, they want to do it on a
specific date.
CHARACTERISTICS
Appearance - small & underdeveloped. The head is
disproportionately large (3cm or more- greater than
chest size). The skin is generally or usually ruddy
because the infant has little subcutaneous fat beneath
it; veins are easily noticeable; & a high degree of
acrocyanosis may be present.
Preterm neonate, 24-36 weeks, typically is covered
with vernix caseosa. In very preterm newborns (less
than 25 weeks’ gestation), vernix is absent because it is
not formed this early in pregnancy. Lanugo is usually
extensive, covering the back, forearms, forehead, &
sides of the face, because this amount is present until
late in pregnancy. Both anterior & posterior fontanelles
are small. Few or no creases on the soles of the feet.
anterior - diamond
posterior - triangle
The eyes are small, with varying degrees of myopia
(nearsightedness) because of lack of eye globe depth.
The cartilage of the ear is immature & allows the pinna
to fall forward. The ears appear large in relation to the
head. The level of the ears should be carefully
inspected to rule out chromosomal abnormalities.
o Pull the pinna backward and upward
Neurologic function
Neurologic function is difficult to evaluate. Sucking &
swallowing is weak & immature, deep tendon reflexes such as
Achilles tendon are markedly diminished. Cry is weak & highpitched.
o To test for chromosomal abnormalities - outer canthus
must be in level with the pinna.
o
mechanical ventilator, umbilical catheterization they
can also put IV on umbilical cord. Head can also be
used.
Pre- term SGA
Intensive Incubator
Radiant Warmer
Radiant Warmer with Mechanical Ventilator
General activity is feebler & weaker; often assume frog-like
position;
Scarf sign - elbow passes the midline of the body.
Square window - wrist at a 90 degrees angle
CNS center for respiration is underdeveloped, which results in
irregular breathing w/ short periods of apnea. O2 administered
should never be more than 40% because it can lead to
blindness due to retrolenthal fibroplasia, an overgrowth of
retinal blood vessels causing blindness.
o center for respiration: medulla oblongata
o center for temperature control: hypothalamus
Mechanical Ventilator
5
COMPONENTS OF NEUROMUSCULAR
ASSESSMENT / BALLAD SCORE
1.
2.
3.
4.
5.
6.
Posture
Square window
Arm recoil
Popliteal angle
Scarf sign
Heel to ear
POSTURE
Assess posture for degree of flexion.
Term - legs & arms are moderately
Flexed at rest.
Preterm - lesser degrees of flexion
POPLITEAL ANGLE
Term NB’S are less flexible, with about 90 degrees angle,
Measure the popliteal angle by moving the foot gently toward
the head until you meet resistance. Then measure the distance
behind the knee in the popliteal area.
Preterm – the leg straightens to 180 degrees angle.
SQUARE WINDOW
Assess square window by grasping the NB’s forearm & gently
flexing the wrist toward the inner arm. Do NOT allow rotation of
the wrist.
Term the hand should touch the wrist resulting to 0-degree
angle.
Preterm - greater angles of flexion. The younger, the less
flexibility of the wrist.
SCARF SIGN
Scarf sign by grasping the NB’s hand & attempting to cross the
arm over the body at the neck.
Arms of the Term NB meet resistance before crossing midline.
Premature NB cross the elbow past midline.
HEEL TO EAR
ARM RECOIL
Assess heel to ear by raising the NB’s heel towards his head in
an attempt to bring the foot to ear. DON’T bring the NB’s
buttocks off the examination surface. Stop when you meet
resistance & measure the degree of extension of the leg.
Preterm you’ll come close to touching the heel to the ear.
Term - you’ll meet resistance almost immediately.
Measure arm recoil by first flexing & holding both forearm for 5
sec. then extending the hands & arms fully at the NB’s side.
Release the hands & allow the arms to recoil (return to flexion)
Term full recoil to a position of flexion.
Preterm less flexion
6
COMPONENTS OF PHYSICAL MATURITY
1.
2.
3.
4.
5.
6.
Skin
Lanugo
Plantar surface
Breast
Eye/ear
Genitals
SKIN
Skin ranges from translucent & friable in preterm.
Post term - leathery, cracked to wrinkled.
GENITALS
Term - testes usually descend near term & rugae are visible on
the scrotum. Palpate testes to determine if they have
descended. & note the rugae.
Premature - flat & smooth
Female NB at term - labia majora are larger than the clitoris &
the labia minora.
Preterm have prominent clitoris & small labia minora.
LANUGO
MALE
FEMALE
Lanugo - very fine body hair.
Extremely premature NB’s have none.
Term NB’s have very little.
Post term - nearly absent.
PLANTAR SURFACE
Term NB’s have creases over the entire plantar surface.
Preterm - from absent to faint red markings.
Hypospadia - below
Epispadia - above
Cryptorchidism - undescended testes
Hypothalamus - center for temperature control
Medulla Oblongata - center for respiration
BREAST
Inspect the breast to assess the size of the breast bud in
millimeters & the development of the areola.
Preterm NB’s lacked developed breast tissue.
Term - have a raised to a full areola with breast buds that are 3
to 10 millimeters in diameter.
EYE/EAR
The eye/ear assessment is an analysis of the ear cartilage &
shape of the pinna.
Preterm – pinna is less curved.
Term – well-curved pinna with firm cartilage. Ear recoil goes
back quickly.
Preterm eyes fused eyelids.
CNS center for respiration is underdeveloped, which results in
irregular breathing w/ short periods of apnea. O2 administered
should never be more than 40% because it can lead to
blindness due to retrolental fibroplasia,- an overgrowth of
retinal blood vessels causing blindness.
due to too much oxygen.
POTENTIAL COMPLICATIONS
(1) Anemia of Prematurity
Cause: low levels of Vitamin E, less iron stores
● Develop normochromic, normocytic anemia. Blood
cells may be fragmented or irregularly shaped.
● The reticulocyte count is low because bone marrow
does not increase its production until approximately
32 weeks.
● Infants appear pale, lethargic & anorectic & fail to
thrive.
● The fault appears to be immaturity of the
hematopoietic system combined with destruction of
RBC due to low levels of vitamin E, which normally
protects RBC against oxidation.
● They have less iron stores (because transfer of iron
stores from the mother to the baby also occurs during
the last weeks of pregnancy) & smaller RBC mass
(since cord was cut immediately after delivery).
7
Intervention:
● Blood transfusion, vitamin E & iron provided by
preterm formula, administration of DNA recombinant
erythropoietin.
(2) Hyperbilirubinemia
Cause: immaturity of the liver
● Kernicterus (staining of brain cells with bilirubin,
causing irreversible brain damage or even death) or
destruction of brain cells by invasion of indirect
bilirubin. This invasion results from excessive
breakdown of RBC.
● More prone because with acidosis that occurs from
poor respiratory exchange, brain cells are susceptible
to the effect of indirect bilirubin than normally.
● They have less serum albumin available to bind
indirect bilirubin & therefore inactivate its effect.
Because of this, kernicterus may occur at lower
levels (as low as 12mg/ 100ml of indirect bilirubin) in
these infants.
Intervention:
● If jaundice occurs, phototherapy or exchange
transfusion can be started to prevent excessively high
indirect bilirubin levels.
○ Phototherapy - cover eyes, whole skin is
exposed
○ exchange transfusion through umbilical
catheterization - insert catheter in the artery
of the baby -> insert 3 way stop-cock -> 5cc
out and 5 cc in, using syringe until the pack
of blood is finished. The blood that is out is
put in the blood warmer. Monitor vital signs.
(3) Persistent Patent Ductus Arteriosus
Cause: Because preterm infants lack surfactant, their lungs
are noncompliant. It is more difficult for them to move blood
from the pulmonary artery into the lungs.
● This
condition
leads
to
pulmonary
artery
hypertension, which may interfere with closure of the
ductus arteriosus.
Intervention:
● Administer IV Therapy cautiously to avoid increasing
blood pressure. Indomethacin may be administered
to initiate closure of the patent ductus arteriosus.
Through endotracheal tube.
Diagnostic intervention: Cranial ultrasound done after the
first few days of life to detect if hemorrhage has occurred.
An infant’s prognosis is guarded until it can show that
development in the infant is normal after an intracranial
bleeding.
PROBLEMS RELATED TO GESTATIONAL WEIGHT
A. Low birth weight (LBW)
● Birth weight: 1500 to 2500 or less 2500g,
regardless of gestational age.
B. Moderately Low Birth Weight infant (MLBW)
● Birth weight : 1501 to 2500g
C. Very low birth weight (VLBW)
● Birth weight : 1000 to 1500g
● born before 30 weeks of pregnancy (3 lbs. & 5
oz.)
D. Extremely Low Birth Weight infant (ELBW)
● Birth weight : 500 - 1000g (2 lbs. & 3 oz.)
● born at 27 weeks gestation or even younger.
E. Minimum age of viability is 23 weeks gestation
Infants born after the 37th week are considered term.
●
●
All such infants need neonatal intensive care from the
moment of birth to give them their best chance of
survival without neurologic effects.
A lack of lung surfactant makes them extremely
vulnerable to respiratory distress syndrome.
OTHER POTENTIAL COMPLICATIONS
1.
2.
3.
4.
RDS
Apnea
Retinopathy of prematurity
Necrotizing enterocolitis
(4) Periventricular/ Intraventricular hemorrhage
Preterm infants are particularly prone to periventricular hemorrhage (bleeding into the tissue
surrounding the ventricles) or intraventricular
hemorrhage (bleeding into the ventricles).
Cause: Preterm infants have fragile capillaries & immature
cerebral vascular development their susceptibility.
● When there is rapid change in cerebral blood
pressure, such as with hypoxia, IV infusion,
ventilation, & pneumothorax, the capillaries rupture.
The infant experiences brain anoxia beyond the
rupture. Hydrocephalus may occur from bleeding
into the aqueduct of Sylvius with resulting obstruction
of the aqueduct. pneumothorax - air in the lungs.
take anthropometric measurement, measure HC for
baseline
hydrocephalus may occur from bleeding, bulging
fontanelles
●
8
Week 2: Preterm: Apnea and Nursing
Diagnoses, Assessment, Interventions,
Post-Maturity
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
OUTLINE
Apnea of Prematurity
Impaired Gas Exchange
Risk for Deficient Fluid Volume
Risk for Imbalanced Nutrition: Less than Body
Requirements
A. Feeding Schedule
B. Gavage Feeding
C. Formula Feeding
Ineffective Thermoregulation
Risk for Infection
Assessment
Interventions
Post Maturity
Worsened by variety of factors:
1. Infection
2. Intracranial hemorrhage (within the skull)
3. Patent ductus arteriosus – PDA (abnormal opening
between the aorta and the pulmonary artery)
4.
suffix: mia = blood, xia = tissues
THERAPEUTIC MANAGEMENT
1. Administer
Methylxanthines:
theophylline, or caffeine
●
●
●
I. APNEA OF PREMATURITY
Reason: baby was born prematurely and alveoli does not have
surfactant. Atelectasis occurs.
● Is a common phenomenon in the preterm infant.
Infants less than 33 weeks gestation & healthy infants
less than 30 weeks of gestation. Resolves as the
infant approaches 37 weeks gestation. (lung
surfactant matures and becomes adequate)
● Apnea is a lapse of spontaneous breathing for 20
seconds or more, or shorter pauses accompanied by
hypotonia, bradycardia or color change.
o Hypotonia - lethargic or not alert
o Bradycardia - slow heart rate
o Color change - pale and cyanotic
o Baby is nude/diaper, kept in supine position
to check the breathing pattern.
o NEVER ON PRONE POSITION
1.
CLASSIFICATION ACCORDING TO ORIGIN
Central apnea - an absence of diaphragmatic & other
respiratory muscle function that causes a lack of
respiratory effort & occurs when CNS does not transmit
signals to the respiratory muscle.
2.
Obstructive apnea - when air flow ceases because of
upper airway obstruction, yet chest or abdominal wall
movement is present.
3.
Mixed apnea - a combination of central & obstructive
apnea, & the most common form of apnea seen in
preterm infants.
PATHOPHYSIOLOGY
● Apnea of Prematurity reflects the immature & poorly
refined neurologic & chemical respiratory control
mechanisms in premature infants. These infants are NOT
responsive to hypercarbia & hypoxemia, & their neurons
have fewer dendritic associations than those of more
mature infants. Respiratory reflexes are significantly less
mature.
○ Hypercarbia: high CO2
○ Hypoxemia: decreased O2 in blood
● Overall weakness of the thorax, diaphragm & upper
airway may also contribute to apneic episodes. Apnea is
characteristically observed during the period of REM
sleep.
●
aminophylline,
Act as CNS stimulants to breathing. Observe
symptoms of toxicity.
Serum theophylline levels are determined by the
infection, intracranial hemorrhage, or PDA, infant’s
weight, gestational age, & chronological age &
maintained within a therapeutic range.
Caffeine has fewer side effects, once daily, more
predictable plasma concentrations, slower elimination,
& wider therapeutic range (rough, 5-20 mcg/ml)
○ Caffeine not widely used
○ Serum theophylline levels are measured first
before
administering,
and
consider
gestational age and weight to determine
dosage. It must be within normal levels
before administration of the drug.
Weight & urinary output should be closely
monitored because both have mild diuretics.
○ Normal urine output per hour: 30 mL
2. Nasal CPAP & IMV ventilation – acts to maintain airway
patency, effective for obstructive & mixed apnea.
●
Nasal CPAP - Continuous Positive Airway Pressure
helps prevent apneic episode, has an alarm if baby
has an episode, nurse must count the number of
seconds the baby is experiencing apnea.
●
IMV - Intermittent Mandatory Ventilation.
NURSING CARE
1. Monitoring respiration & heart rate. (bradycardia)
2. Cardiorespiratory monitors alert staff-preset delay
time-15-20 seconds.
● DO NOT turn off alarms
3. If begun early, gentle tactile stimulation (rubbing back
& chest gently, turning infant to supine position)
● baby may become cyanotic
4. If tactile stimulation fails to reinstitute respiration,
flow-by oxygen & suctioning of nose & throat, if
breathing does not begin, the chin is raised gently to
open the airway, & resuscitate by mask & bag to lift
the rib cage. Never shake.
● gentle suctioning - may affect vagus nerve
that is connected to the heart
● Immediately connect to ventilator - CPAP
● resuscitate (light pressure only sa ambu bag
- hyperextend the neck)
5. If breathing is restored, assess the infant for
temperature, abdominal distention.
● abdomen may expand due to the
interventions
6. Use pulse oximetry. to check oxygen saturation
7. Record apneic episodes.
9
8.
If persistent & recurrent apnea, put the baby on
mechanical ventilation / CPAP.
REMEMBER:
●
DO NOT turn off the alarm of the ventilators and monitors.
What to do if the baby is in apneic episodes?
●
Gentle stimulation, rub the chest and rub the back, supine
position and turn to side
●
Take note of its heart rate, color changes to pale or
cyanotic
What if the rubbing does not work?
●
There is an oxygen and suction on the bed side. Connect
the oxygen to the baby. Nasal Prong or mask, gentle
suction the nose and throat. Vagus Nerve
●
IF NOT PA DIN, They will do CPR, gentle only. Connect
the baby to ventilator.
●
●
Preterm is unable to initiate effective respirations as
quickly as the mature infant, he is prone to irreversible
acidosis. To prevent, the infant must be resuscitated
within 2 minutes after birth.
Birthing room should be prepared with: preterm-size
laryngoscope (smallest, check battery), ET, suction
catheters, & synthetic surfactant to be administered
by endotracheal tube.
Rolled diaper at the back and hyperextend the neck
then insert laryngoscope. Ready micropore.
Laryngoscope can be inserted through the nose or
mouth. Usually orotracheal because they are
nose-breathers.
similar to anchoring NGT:
II. IMPAIRED GAS EXCHANGE
Nursing diagnosis
● Impaired gas exchange
pulmonary functioning.
related
to
immature
Outcome Identification
● Newborn will initiate & maintain respirations after
surfactant therapy.
Outcome Evaluation
● Newborn initiates breathing at birth after
resuscitation; maintains normal newborn respirations
of 30 to 60 breaths / minute free of assisted
ventilation; exhibits oxygen saturation levels of at
least 90% as evidenced by arterial blood gases.
● Normal: 96-100%, 90% is acceptable for infants
EXPLANATION
Preterm infants have great difficulty initiating respiration at
birth because the pulmonary capillary bed is immature. Lung
surfactant does not form in adequate amounts until about the
34 to 35 week of pregnancy. maturity is at 37 weeks
th
●
●
The infant must be kept warm during resuscitation
procedure, so he is not expending extra energy to
increase the metabolic rate to maintain body
temperature. Handle infants gently.
Giving 100% oxygen during resuscitation or to
maintain respirations presents the danger of
pulmonary edema & retinopathy of prematurity
(blindness of prematurity) when saturation of the
blood with oxygen (PO2 of more than 100 mm hg
which usually occurs when oxygen is administered at
a concentration over 70%).
With true apnea, the pause of respirations is more than 20
seconds & bradycardia does occur.
III. RISK FOR DEFICIENT VOLUME
th
Thus, it may be inadequate, leading to alveolar collapse with
each expiration.
Breech born infants are apt to expel meconium into the
amniotic fluid. If the fetus aspirates either vaginal secretions or
meconium, the respiratory problem is further compromised.
MEDICAL INTERVENTION:
1. Giving mother oxygen by mask during birth will help
provide the preterm infant with optimal oxygen saturation
at birth (85-90%).
When determined premature, it is needed to give 02
via mask
2. Keeping maternal analgesia & anesthesia to a minimum
offers the infant the best chance of initiating effective
respiration.
anesthesia can compromise the lung respiration by
causing respiratory depression
3. Cesarean birth, although it has the advantage of
reducing pressure on the immature head may lead to
additional respiratory complications because of retained
lung fluid
Better option if premature but has
complications
Nursing diagnosis:
● Risk for deficient fluid volume related to insensible
water loss at birth & small stomach capacity.
● mild diuresis can compromise the many fluids NB has
so urine output needs to be monitored
Outcome Identification
● Newborn will demonstrate intake of adequate fluid &
electrolytes to meet body needs.
Outcome Evaluation:
● Plasma glucose is between 40 & 60 mg per 100ml;
specific gravity of urine is maintained at 1.003 to
1.030; urine output is maintained at a minimum of
1ml/kg/h; electrolyte levels are within normal levels.
EXPLANATION
The preterm newborn has a high insensible water loss due to
large body surface compared with total body weight. The infant
also is unable to concentrate urine well because of immature
kidney function & thus excretes a high proportion of fluid from
the body. higher surface body with fluids
All these factors make it important that the preterm baby
receive up to 160-200ml of fluid / kg of body weight daily
(higher than the term infant).
10
IV fluid administration begins within hours after birth to fulfill
this fluid requirement & provide glucose to prevent
hypoglycemia. Given via continuous infusion pump (digital) to
ensure a constant infusion rate & prevent accidental overload.
o They are prone to infiltration,
IV sites checked conscientiously because if infiltration should
occur, the lack of subcutaneous tissue places the preterm
newborn at risk for damaged tissue. They lack adequately
sized peripheral veins; therefore IV/ umbilical venous
catheter is used.
● prone to infiltration
● Umbilical cord is cut more than 5cm because it is
difficult to insert a catheter.
● Cut longer to allow the doctors for umbilical
catheterization.
NURSING OUTCOMES CLASSIFICATION AND
NURSING INTERVENTION CLASSIFICATIONS
● Monitor baby’s weight, urine output & specific gravity,
& serum electrolytes to ensure adequate fluid
intake.
● Over hydration may lead to non-nutritional weight
gain, pulmonary edema & heart failure.
● Range of urine output for the first few days of life in
preterm babies is high with that of the term baby: 40
to 100ml / 24 hours, compared with 10 to 20 ml/
kg/ 24 hours.
● Specific gravity is low-1.012, normal babies up to
1.030.
● Test urine for ketones & glucose. Hyperglycemia
caused by glucose infusion may lead to glucose
spillage into the urine & an accompanying diuresis. If
too little glucose is supplied & body cells are using
protein for metabolism, ketone bodies will appear in
the urine.
● Blood glucose determinations every 4-6 hours help
determine hypoglycemia or hyperglycemia.
● Blood glucose should range between 40 & 60mg/dl.
● Check for blood in the stools to evaluate for possible
bleeding from intestinal tract.
nutrients are not supplied, the infant will develop
hypocalcemia (decreased serum calcium) or azotemia (low
protein level in blood).
Delayed feeding & a resultant decrease in intestinal
motility may add to hyperbilirubinemia when fetal RBC begin
to be destroyed.
Nutrition problems are compounded by the preterm infant’s
immature reflexes, which make swallowing & sucking difficult.
The stomach’s capacity is small, possibly impeding nutrition.
A distended stomach puts pressure on the diaphragm, which
could lead to respiratory distress. Increased activity
necessitated by ineffective sucking may increase the metabolic
rate & oxygen requirements. Immature cardiac sphincter
(between the stomach & the esophagus allows regurgitation to
occur readily.
The lack of cough reflex may lead the infant to aspirate
regurgitated formula. Avoid regurgitation to avoid aspiration
A. FEEDING SCHEDULE
W/ the early administration of IVF to prevent hypoglycemia &
supply fluid, feedings may be delayed until the infant has
stabilized his respiratory effort from birth.
● Fed by Total Parenteral Nutrition until they are stable.
● Breastfeeding, gavage, or bottle feedings are begun as
soon as the infant is able to tolerate them to prevent
deterioration of the intestinal villi.
● Needs 115-140 calories / kg of body weight / day,
compared with 100-110 needed by term infant.
● Protein requirement are 3 to 3.5 g/kg of body weight,
compared with 2.0 to 2.5 for term newborn.
● Because preterm infant has a smaller stomach capacity,
she should be fed more frequently with smaller amounts
as 1 or 2 ml. every 2 to 3 hours.
B. GAVAGE FEEDING
IV. RISK FOR IMBALANCED NUTRITION: LESS THAN
BODY REQUIREMENTS
Nursing Diagnosis
● Risk for imbalanced nutrition, less than body
requirements related to additional nutrients needed
for maintenance of rapid growth, possible sucking
difficulty, & small stomach.
Outcome Identification
● Infant will receive adequate fluid & nutrients for
growth during hospitalization.
Outcome Evaluation
● Infant’s weight follows percentile growth curve; skin
turgor is good; specific gravity of urine is maintained
between 1.003 & 1.030; infant has no more than 15%
weight loss in first 3 days of life & continuous to gain
weight after.
EXPLANATION:
Nutritional problems arise because the body is attempting to
continue to maintain the rapid rate of intrauterine growth.
Therefore, the preterm newborn requires a larger amount of
nutrients in the diet than the mature infant does. If these
WHY GAVAGE FEEDING IS IMPLEMENTED?
The gag reflex is not intact until an infant is 32 weeks
gestation. The ability to coordinate sucking & swallowing is
inconsistent until approximately 34 weeks’ gestation.
● Thus, infants born 32 to 34 weeks gestation & those
who are ill or experiencing respiratory distress are
usually started on gavage feedings because preemies
have ineffective sucking which is not coordinated with
swallowing & therefore, may aspirate.
MEASUREMENT AND INSERTION
11
Measurement: When inserting NGT measure from the earlobe
to the tip of the nose to the distal end of the sternum. xiphoid
process
They may be fed by continuous drip feedings at about 1 ml/h.
Helpful for infants on ventilators or those who experience
oxygen deprivation with handling.
Insertion: Hyperextend the neck of the baby, pulupot ang tali
and then going down not straight, because it can cause
trauma.
STOMACH CONTENT
Position: large babies - sitting, pre-term - supine
Materials: 20 or 60 cc syringe, micropore, stethoscope (for
assessment of gurgling sounds), gloves
As long as the infant is being gavage-fed, stomach secretions
are usually aspirated, measured, & replaced before the
feeding. An infant who has a stomach content of more than
2ml just before a feeding is receiving more formula than he can
digest in the time allowed. Feedings should not be increased
but possibly even cut back to ensure better digestion &
decrease the possibility of regurgitation & aspiration.
An infant who has a stomach content of more than 2ml,
refer to doctor and suspend feeding
●
CHECK CORRECT PLACEMENT OF THE TUBE BY:
a. Aspirate gastric contents, Acidic - NGT in place
tube must be in stomach
Check if you are in the right place. Get the syringe
and attach it to the end of the tube and aspirate the
gastric content/gastric secretions/residual.
b. Inject 5 cc of air then auscultate. If no gurgling sound
is heard as air is injected, it means NGT is not in the
stomach.
When you aspirate 5cc of air, it means you are in the
right way. Get stethoscope and put in xyphoid
process. aspirate 5 cc of air then insert the it into the
end of the tube to the stomach and push and hear a
GURGLE SOUND.
c. Measure the amount of residual, Subtract the same
amount from the next feeding because this means
that the baby is not able to digest all the milk that has
been given to him.
eg: doctor’s order is 2cc but there is 1cc residual,
introduce additional 1cc only
d. Put back the residual since it contains acids & the
baby can develop metabolic alkalosis/
e. Keep NGT always closed to avoid abdominal
distention.
f. Fill syringe with formula before opening NGT, let it
flow by gravity.
g. Flush NGT w/ sterile water after giving formula in
order to prevent clogging the NGT
h. Minimal handling is necessary in order to conserve
energy.
Gavage - feeding
Lavage - gastric washing, done when the baby is bleeding in
NGT, use saline solution
Assessments:
Measure abdominal girth after feeding, high
measurement means the feeding was not tolerated.
If Tachypneic -> do not offer food, it may lead to
aspiration
FEEDING SCHEDULE
May be given intermittently every few hours or
continuously via tubes passed through the mouth or nose.
●
●
●
●
●
C. FORMULA
The caloric concentration of formulas used for preterm
infants is usually 24 cal/oz, compared with 20 cal/oz for
term infants. Supplementing minerals such as iron,
calcium, & phosphorus chloride as necessary
minerals are included in IV
Vitamin K 0.5 is administered instead of 1 ml to term
baby because of the infant’s small size.
ready cotton ball before removing syringe
Vitamin A is important in improving healing &
possibly reducing the incidence of lung disease.
Vitamin E important in preventing hemolytic anemia
in preterm.
Electrolytes such as sodium, potassium & chloride may
be necessary.
Breast milk is the best milk for preterm because of the
immunologic properties play a major role in preventing
neonatal necrotizing enterocolitis, a destructive
intestinal disorder that often occurs in preterm babies.
The mother can manually express breast milk for
gavage feeding.
V. INEFFECTIVE THERMOREGULATION
NURSING DIAGNOSIS: Ineffective thermoregulation related to
immaturity.
Outcome Identification
● Infant will maintain body temperature within normal
limits until term age.
Outcome Evaluation
● Infant’s temperature is 97.6 degrees F (36.5degrees C)
EXPLANATION
Preterm has little subcutaneous fat for insulation & poor
muscular development does not allow the child to move as
actively as the older infant.
Has a limited amount of brown fat, the special tissue present
in the newborns to maintain body temperature.
The infant is unable to shiver, a useful mechanism to increase
body temperature; on the other hand, the child is unable to
sweat & thereby reduce body temperature because of an
immature central nervous system & hypothalamic control.
Thus, the infant depends on the environmental temperature
provided.
In the delivery room, temperature is kept at 62 to 68 degrees
F (16.6 to 20degrees C), the infant must be kept in a radiant
12
heat warmer. A 1500g infant exposed to this low, a
temperature loses 1 degree C of body heat every 3 minutes if
left unprotected.
8.
9.
10.
11.
VI. RISK FOR INFECTION
NURSING DIAGNOSIS: Risk for infection related to immature
immune defenses in preterm infant
Outcome Identification
● Infant will remain free of infection during hospital stay.
Outcome Evaluation
● Temperature instability decreasing, being maintained at
97.6 degrees F (36. 5degrees C) axillary; absence of
further s/s of infection such as poor growth or a reduced
temperature
12.
13.
14.
15.
16.
MAJOR COMPLICATING CONDITIONS:
Severity of problems related to level of maturity: the earlier the
infant is born, the greater the chance of complications.
Major complicating conditions:
a. Respiratory distress syndrome
b. Thermoregulatory problems
c. Conservation of energy
d. Infection
e. Hemorrhage
VII. ASSESSMENT FINDINGS:
1.
2.
3.
4.
5.
6.
7.
Respiratory system
a. insufficient surfactant
b. Apneic episodes
c. Retractions, nasal flaring, grunting, seesaw
pattern of breathing, cyanosis
d. Increased respiratory rate
Thermoregulation
a. body
temperature
fluctuates
easily
(premature newborn has less subcutaneous
fat & muscle mass)
Nutritional status
a. Poor sucking & swallowing reflexes
b. Poor gag & cough reflexes
Skin
a. lack of subcutaneous fat; reddened;
translucent
Drainage from umbilicus/ eyes
Cardiovascular
a. Petechiae caused by fragile capillaries &
prolonged prothrombin time
b. Increased bleeding at injection sites
Neuromuscular
a. Poor muscle tone
b. Weak reflexes
c. Weak, feeble cry
VIII. NURSING INTERVENTIONS:
1.
2.
3.
4.
5.
6.
7.
Maintain respirations at less than 60/ minute, check
every 1-2 hours
Administer oxygen as ordered; check concentration
every 2 hours to avoid retrolental fibroplasia (blindness)
while providing adequate oxygenation.
Auscultate breath sounds to assess lung expansion.
Encourage breathing with gentle rubbing of back & feet.
Suction as needed.
Reposition every 1-2 hours for maximum lung
expansion & prevention of exhaustion.
Monitor for signs of infection; these infants have little
antibody production & decreased resistance.
17.
18.
19.
20.
21.
22.
23.
24.
Monitor blood gases & electrolytes.
Maintain appropriate humidity level.
Feed according to abilities.
Monitor sucking reflex; if poor, gavage feeding
indicated. Most preterm infants require at least some
gavage feeding as it diminishes the effort required for
sucking while improving the caloric intake.
Use “premie” nipple if bottle- feeding.
Monitor intake & output, weight gain or loss; these
infants are easily dehydrated, with poor electrolyte
balance.
Monitor for hypoglycemia & hyper-bilirubinemia.
Handle carefully, organize care to minimize
disturbances. Do everything in one setting to prevent
added stress.
Provide skin care with special attention to cleanliness &
careful positioning to prevent breakdown.
Monitor heart rate & pattern at least every 1-2 hours;
listen apically for 1 full minute.
Monitor potential bleeding sites (umbilicus, injection
sites, skin); these infants have lowered clotting factors.
Monitor growth & development of the infant; check
weight, length, head circumference.
Provide tactile stimulation when caring for or feeding
infants.
Provide complete explanations for parents.
Encourage parental involvement in infant’s care.
Provide support for parents; refer to self-help group or
other parents if necessary.
Promote parental confidence with infant care before
discharge.
teach the caring to prevent aspiration especially if the
baby stayed long in respirator
The maturity of the newborn is determined by physical
findings such as sole creases, skull firmness, ear cartilage, &
neurologic findings that reveal gestational age, as well as the
mother’s report of the date of her last menstrual period &
sonographic estimations of gestational age.
Amniocentesis or ultrasound– is a test for fetal maturity to
avoid inducing labor prematurely.
invasive, mandatory in USA
IX. POST MATURITY
Post-Maturity or Post Term Infants - born after the
completion of 42 weeks of pregnancy or gestation.
Problems of the post-term infant are associated with the
progressively less efficient actions or capacity of placenta to
sustain intrauterine life. The fetus who remains in utero w/ a
failing placenta may die or develop post term syndrome.
dehydrated
ASSESSMENT FINDINGS
1. Skin
● Vernix & lanugo completely disappeared or absent
● Dry, cracked, parchment like appearance of skin or
leather- like skin from lack of fluid & absence of
vernix
● Color: yellow to green skin, nails & cord from
meconium staining
2. Depleted or little subcutaneous fat with newborn old
looking
3. Hard nails or long nails extending beyond fingertips.
yellow nails due to passed meconium
13
4.
5.
6.
Old man wrinkled appearance or “old man face” - due to
intrauterine weight loss, dehydration, & chronic hypoxia.
Signs of birth injury or poor tolerance of birth process
Wide- eye alertness of a 1 -month -old baby, firm skull
DIAGNOSTIC PROCEDURE
1. Ultrasound to measure the biparietal diameter of the
fetus.
2. Non-stress test or complete biophysical profile to
establish whether the placenta is still functioning.
3. Cesarean birth
MANAGEMENT
1. Monitor vital signs
2. IV as ordered
PROBLEMS
1. Difficulty establishing respirations especially if
meconium stained or perinatal asphyxia.
2. Hypoxia due to asphyxia & cause increased in
production of RBC
3. Meconium aspiration
4. Hypoglycemia owing to insufficient stores of glycogen
which were used for nourishment in the last weeks of
intrauterine life.
5. Subcutaneous fat levels may be low having been used
up in the utero.
6. Tolerate stress of labor poorly
7. Temperature regulation difficult- cold stress, protect
from chilling
Management – Provide warm blanket, exposed to
drop light or keep in isolette
8. Polycythemia from decreased oxygenation in the final
weeks.
Management - Partial exchange transfusion
Heel prick - viscous
9. Elevated hematocrit because of polycythemia &
dehydration which lowers the circulating plasma level.
10. Long term Problem
1. Poor weight gain
2. Low IQ scores
NURSING INTERVENTIONS
1. Nursing care of the post mature infant has many
characteristics in common with the care given to the
premature infant
2. Design high-level nursing care to identify the infant’s
specific physical & psychologic needs or parental
teaching of newborn care.
3. Monitor functioning of all body systems, growth &
development, parental support & teaching, & prevention
of complications.
4.
Parents hold infant, speak of the child in positive terms;
state accurately why the infant needs to be closely
observed in postnatal period.
INTERVENTIONS (additional)
● Have the same developmental care that all other infants
need.
● Singing or talking to the baby, stroking the child’s back
& rocking the baby.
● Encourage parents to treat their baby as a fragile NB
who needs warm nurturing, not as a tough big infant
who has grown past that stage.
● Remind parents that the infant’s birth weight is not
correlation of the child’s projected adult size.
14
Week 3: Acute Conditions of the Neonates
I.
OUTLINE
Acute Conditions of the Neonates
A. Respiratory Distress Syndrome
B. Transient Tachypnea of NB
C. Meconium Aspiration Syndrome
D. Apnea
E. Sudden Infant Death Syndrome
F. Hyperbilirubinemia
G. Hemolytic Disease of the NB
H. ABO Incompatibility
A. RESPIRATORY DISTRESS SYNDROME (RDS) OR
HYALINE MEMBRANE DISEASE
Cause: inadequate lung surfactant
Occurs in preterm infant, infants of diabetic mother, infants
born by CS or those with decreased blood perfusion of the
lungs. The pathologic feature of RDS is a hyaline-like (fibrous)
membrane comprising products formed from exudate of the
infant’s blood that lines the terminal bronchioles, alveolar
ducts, & alveoli. This membrane prevents exchange of oxygen
& carbon dioxide at the alveolar –capillary membrane. The
cause is a low level or absence of surfactant, the phospholipid
that normally lines the alveoli & reduces surface tension on
expiration to keep the alveoli from collapsing on expiration.
Pathophysiology
High Pressure is required to fill the lungs with air for the first
time & overcome the pressure of lung fluid. It takes a pressure
between 40 & 70 cm H2O to inspire a first breath but only 15 to
20 cm H2O to maintain quite, continued breathing. If alveoli
collapse with each expiration, as happens when surfactant is
deficient & continues to take forceful inspiration to inflate
them.
A very immature infants release a bolus of surfactant at birth
into their lungs from the stress of birth. However, w/ deficient
surfactant areas of hypo-inflation occur & pulmonary resistance
increased.
Blood then shunts through the foramen ovale & the ductus
arteriosus as it did during fetal life. The lungs are poorly
perfused, affecting gas exchange. As a result, the production of
surfactant decreases even further. The poor O2 exchange
leads to tissue hypoxia which causes the release of lactic acid.
This combined with the increasing carbon dioxide level
resulting from the formation of the hyaline membrane on the
alveolar surface, leads to severe acidosis. Acidosis causes
vasoconstriction, & decreased pulmonary perfusion from
vasoconstriction further limits surfactant production.
With decreased surfactant production, the ability to stop alveoli
from collapsing with each expiration becomes impaired. This
vicious cycle continues until the oxygen carbon dioxide
exchange in the alveoli is no longer adequate to sustain life
without ventilator support.
Summarized ver. of Pathophysiology
Decreased pulmonary surfactant – increased surface tensionalveolar walls will not separate- lack of expansion of affected
alveoli – decreased alveolar ventilation – inadequate exchange
of O2 & carbon dioxide – hypoxia increased capillary
permeability which causes effusion from the pulmonary
capillaries into the alveoli & terminal – bronchioles- hyaline
–like membrane found in the alveoli & bronchioles composed
of mainly of fibrin – atelectasis.
Additional Factors:
a. Hypoxia,
b. Patent ductus arteriosus
c. Hyperbilirubinemia
d. Retrolental fibroplasia
e. Bronchopulmonary dysplasia (BPD)-damaged to the
alveolar epithelium of the lungs related to high O2
concentration & + pressure ventilation
f. Necrotizing enterocolitis
Diagrammatic Presentation of RDS
Assessment/ Signs & Symptoms
1. Low body temperature
2. Nasal flaring
3. Sternal & subcostal retractions
4. Tachypnea or Increased RR- more than 60/ m
5. Expiratory grunting- major symptom
6. Cyanotic mucous membranes
7. Rales
8. Respiratory acidosis
a. Low Ph level (normal- 7.35- 7.45)
b. Low PO2 level (normal -40-60 mm Hg)
c. High PCO2 level (normal- 35-45)
As distress increases:
1. Seesaw respirations-diaphragm descends causing
the abdomen. to lift & the chest to sink
2. Heart failure evidenced by decreased urine output &
edema of the extremities
3. Pale gray skin
4. Periods of apnea
5. Bradycardia
6. Pneumothorax
Diagnostic Evaluation
1. Blood glucose- test hypoglycemia
2. Serum Calcium- test hypocalcemia
3. Blood gas- respiratory acidosis, PaO2- for hypoxia
4. Chest X-Ray (haziness)
Beta –hemolytic B Streptococcus mimic RDS.
Therapeutic Management
1. Administer Surfactant- through ET tube
2. Oxygen therapy, high humidity, warmth, -to provide
adequate oxygen to tissues, to prevent lactic
accumulation resulting from hypoxia & prevent the
negative effects of oxygen therapy.
CPAP - Continuous Positive Airway Pressure – Continues
application of 3 to 8 cm H2O (positive) pressure to the airway,
uses the infant’s spontaneous respiration to improve O2 by
helping prevent alveolar collapse.
Greatly improves oxygen exchange.
IMV is used with Positive End-Expiratory Pressure (PEEP)
allows to breath at their own rate but provides + pressure w/
15
end-expiratory pressure to prevent alveolar collapse &
overcome airway resistance.
The PIP (Positive Inspiratory Pressure) is the maximum
amount of + pressure applied to infant on inspiration. The total
amount of pressure transmitted to the airway throughout an
entire respiratory cycle is called mean airway pressure
(MAP), improve oxygenation by maintaining functional residual
capacity & overcoming the resistive forces of the atelectatic
lung.
SIMV - Synchronized Intermittent Mandatory Ventilationbreaths delivered by the ventilator are synchronized to the
onset of spontaneous infant’s breaths.
Complication of Positive Pressure Ventilation:
Pneumothorax,
pulmonary
interstitial
emphysema,
pneumomediastinum
3.
4.
5.
6.
7.
8.
9.
Monitor vital signs, arterial blood gases, skin color
muscle tone
Proper positioning; NPO; IV, NGT care
Suction PRN
Prevent complications
Sodium bicarbonate – for acidosis (60 mL in glass)
Changing infant’s position frequently
Indomethacin – to cause closure of the patent ductus
arteriosus
Additional Therapy
1. Pancuronium (Pavulon) IV - muscle relaxant.
2. Extracorporeal Membrane oxygenation (ECMO)
Management for chronic hypoxemia.
3. Nitric Oxide - causes pulmonary vasodilatation to help
increase blood flow to the alveoli when persistent
pulmonary hypertension is present.
4. Liquid Ventilation - Perfluorocarbons- effective in
delivering O2 & surfactant.
5. Supportive Care- kept warm reduces metabolic oxygen
demand.
Prevention
1. Check the level of Lecithin/ Sphingo-myelin ratio in
amniotic fluid by 2:1
2. Use tocolytic agents- terbutaline-prevents preterm birth
by 2 injections of Glucocorticosteroid
● Ex. Betamethasone at 12 & 24 hours before
birth at 24to 34 weeks pregnancy. Given to
mother before birth if premature
● Signs of respiratory distress usually begins
within 2 hours after birth:
● Grunting on expiration,
● Flaring of nostrils
● Tachypnea
● Chest retractions
● Generalized cyanosis
● Pallor
● Decreased breath sounds on auscultation of the
lungs as lesser areas are functional
● Cough due to excessive lung secretions
● Chin lug
● Hypotension & shock
The important surfactant that must be present at birth:
a. Lecithin/ Sphingomyelin – 2:1
b. Phosphatidylcholine
c. Phosphatidylglycerol
Nursing Interventions:
1.
Maintain an infant's body temperature at 97.6degrees
F (36.5 degreesC).
2. Provide sufficient caloric intake for size, age, &
prevention of catabolism (usually IV glucose with
gradual increase in feedings). Nasogastric tube may be
used.
3. Organize care for minimal handling of infant.
4. Administer oxygen therapy as ordered.
a. Monitor oxygen concentration every 2-4 hours;
maintain less than 40% concentration if
possible.
b. Oxygen may be administered by hood, nasal
prongs, intubation, or mask.
c. Oxygen may be atmospheric or increased
pressure.
d. Continuous positive air pressure (CPAP) or
positive end-expiratory pressure
e. (PEEP) may be used to prevent collapse & to
keep alveoli expanded.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Therapeutic range is 10-12 cm of water
pressure.
● First 72 hours – increase pressure to
keep airway open
● After 72 hours – decrease pressure for
airways are already open
Oxygen should be warmed & humidified
Monitor infant’s blood gases
Eg: If intubated, suction (for less than 5
seconds) prn using sterile catheter.
● Bag the baby first: ambu-bag and
ET-tube to prevent anoxia. Deliver
oxygen first so that when ventilator
is disconnected, has oxygen.
● Prolonging more than 5 seconds
lead to anoxia
● Use sterile water in sterile cup if
there are secretions
Glucocorticoid (Celestone) – Artificial surfactant given
at birth before the first breath or after diagnosis of
RDS which is effective for up to 72 hours.
● Put in endotracheal tube
● Prevents lung collapse/atelectasis
● Surfactant can be administered by
aerosol spray or ET tube. This
surfactant will help to hasten lung
maturity.
BT to replace extracted blood used for tests.
● Another option - puncturing of heel
● Umbilical cut may be a source of
infection.
Give milk by gavage if NB has mild tachypnea
Auscultate breath sounds. specially when baby is
intubated
● check bilateral lung entry - same
breath sounds on both right and left
Provide chest physiotherapy, postural drainage, &
percussion if ordered.
● cupping: using artificial nipple
● Nebulization: not attached on ET
tube when to nebulize: should be
before or after feeding WITH GAP.
Encourage parental involvement in care (visiting,
stroking infant, talking).
● if there is no contraindications
Administer surfactant via endotracheal tube & other
medications as ordered.
16
14. Place the newborn on the back or in a side lying
position with the neck slightly extended.
15. Hold breastfeeding to conserve energy. Newborn may
be on NPO & given IVF
● to avoid fatigue
● depending on residual - deduct
feeding
● NPO - tachypnea, bradycardia,
abdominal distension
Normal Arterial Blood gases
Temperature
: 36.5- 37.5
pH
: 7.35 -7.45
pCO2
: 35 – 45
pO2
: 80- 100
HCO3
: 22- 26
O2 saturation
: 94-100%
Base excess
:+-2
C. MECONIUM ASPIRATION SYNDROME
Meconium is present in the fetal bowel as early as 10 weeks
gestation. An infant with hypoxia in utero experiences a vagal
reflex relaxation of the rectal sphincter, which releases
meconium into the amniotic fluid from pressure on the
buttocks. Appears green to greenish black.
Normal: breech presentation, abnormal: cephalic
Cause: vagal reflex relaxation
capillary: not on ABG
Neonatal
Newborn
Distress
Syndrome
https://www.youtube.com/watch?v=xWe7Xwh7O1Y
(video):
Respiratory
Distress
in
the
Newborn
https://www.youtube.com/watch?v=j3ypUlLMRLs
(video):
B. TRANSIENT TACHYPNEA OF THE NEWBORN
●
●
●
NURSING CARE
1. Close observation of the NB is the priority.
2. Watch carefully that increased effort is not tiring.
3. Watch for beginning signs of a more serious disorder
because rapid RR is the first sign of respiratory
obstruction. One full minute RR.
4. Oxygen administration
5. Transient Tachypnea of the NB peaks at approximately
36 hours of life & slowly begins to fade at 72 hours as
lung fluid is absorbed & respiratory activity becomes
effective.
At birth, a newborn may have a rapid rate of
respiration, up to 80 breaths / minute when crying.
Within 1 hour, this rapid rate slows between 30-60
breaths / minute.
The respiratory rate remains at a high level,
between 80-120 breaths/ minute.
Signs & Symptoms
1. The infant does not appear to be in a great deal of
distress, aside from the tiring effort of breathing so
rapidly.
2. Has mild retractions but not marked cyanosis.
3. Mild hypoxia & hypercapnia
4. Feeding is difficult because the child cannot suck &
breathe deeply at the same time.
5. Chest X-ray reveals some fluid in the central lung, but
aeration is adequate. Chest did not expand that much
Causes
● Result from slow absorption of lung fluid.
● Reflect a slight decrease in production of phosphatidyl
glycerol or mature surfactant.
These factors limit the amount of alveolar surface area
available to the infant for gas exchange. Thus, the infant must
increase the respiratory rate & depth to better use the surface
available.
Occurs more often in infants who are:
1. Born by cesarean section- because the thoracic cavity
is not compressed by the force of vaginal birth, less
lung fluid is expelled than normally.
2. Infants whose mothers received extensive fluid
administration during labor
3. In preterm infants
●
●
Asphyxia or other stress can cause passage of
meconium before the fetus is born.
Meconium aspiration syndrome occurs when the
meconium-stained amniotic fluid is aspirated by the
fetus before or after delivery. Aspiration of meconium
in utero can cause chemical pneumonitis
Asphyxia due to blockage of oxygen pathway
two ways of meconium aspiration:
1. while in utero
2. after labor - Be cautious to prevent meconium
swallowing. When diagnosed with meconium
stain/amniotic fluid is swallowed, do not suction.
Gasping reflex -> swallow. Suction after insertion of
ET Tube, use a bulb syringe.
Meconium can cause severe respiratory distress in 3 ways:
1. It can bring about inflammation of bronchioles
because it is a foreign substance
2. It can block small bronchioles by mechanical
plugging.
3. It can cause a decrease in surfactant production
through lung cell trauma.
Hypoxemia,
carbon
dioxide
retention,
&
intrapulmonary & extrapulmonary shunting occur.
A secondary infection of injured tissue may lead to
pneumonia.
Causes
1. Relaxation of anal sphincter
2. Accelerated intestinal peristalsis & passage of
meconium
3. Reflex gasping & aspiration of meconium mixed in
amniotic fluid (cause after delivery, even if baby is
outside)
Complications
1. Air leak
2. Pulmonary hemorrhage
3. Pulmonary interstitial emphysema
4. Pulmonary hypertension
5. Pneumonia
6. Infection
7. Thrombocytopenia- deficiency of platelet
8. Asphyxia
17
Assessment
1. Difficulty establishing respirations at birth- meconiumstained amniotic fluid.
Not born breech- hypoxia
2. Apgar score low (poor)
3. Tachypnea, retractions & cyanosis
4. Poor gas exchange- decreased PO2 & increased
PCO2
5. Continue to have retractions due to inflammation of
bronchi tends to trap air in the alveoli causing
enlargement of the antero-posterior diameter of the
chest (barrel chest).
Diagnostic Tests
1. Chest X-ray will show bilateral coarse infiltrates in the
lungs, w/ spaces of hyperaeration, (honeycomb
effect), diaphragm will be pushed downward.
2. Complete blood count
to check if WBC count is high -> baby has infection
3. C-reactive protein -> infection
4. Blood cultures -> to check what organism is sensitive
to the baby. Wait for result before antibiotic (36-72
hours).
This prevents taking antibiotics that are resistant to
the organism.
Therapeutic Management
1. Intrapartally, amnio transfusion may be used to dilute
the amount of meconium in amniotic fluid to reduce
the risk of aspiration. To prevent aspirating thick
meconium.
2. Suctioning after the head is delivered with a bulb
syringe, or a catheter after the endotracheal tube is
inserted while at the perineum.
3. After tracheal suction, oxygen administration &
assisted ventilation.
4. Administer prescribed:
○
Antibiotic therapy - prevent pneumonia
○
Bicarbonate for acidosis
5. Monitoring of blood gases *as ordered
6. Watch out for seizures, GIT bleeding & renal failure
7. Observe closely for pneumothorax - due to trapping of
air in the alveoli. through auscultation
8. Observe for signs of heart failure (increased RR &
signs of respiratory distress)
9. Maintain a temperature-neutral environment to
prevent increasing the metabolic oxygen demands.
10. Chest physiotherapy with clapping & vibrationremove remnants of meconium. look in X-ray what
part of the lung needs it so you can concentrate on
that part (eg: right, left, lower or upper lung).
Done by RT, or Nurses during position change and
after suctioning
D. APNEA
Apnea is a pause in respirations longer than 20 seconds with
accompanying bradycardia
Beginning Cyanosis may be present.
Preterm infants have periods of apnea due to fatigue or the
immaturity of their respiratory mechanism.
Babies with secondary stresses such as infection,
hyperbilirubinemia, hypoglycemia, or hypothermia have high
incidence of apnea.
Management
1. Gently shaking the baby or flicking the sole of the
foot stimulates the baby to breathe.
2. If infant does not respond, resuscitation is necessary.
3. Apnea monitors that record respiratory movement.
4. Ventilator - for infants with frequent or difficult to
correct episodes.
5. Maintain a neutral thermal environment & gentle
handling to avoid excessive fatigue.
6. Suction gently to minimize nasopharyngeal irritation,
which can cause bradycardia due to vagal stimulation.
7. Use indwelling NGT rather than intermittent
reduce the amount of vagal stimulation.
Difference: indwelling - as is (up to 3 days only for
infection control), letting it stay there. Intermittent frequent changing, inserting and removing every
feeding.
8. After feeding, observe the infant carefully because the
full stomach can put pressure on the diaphragm. Burp
to reduce the effect.
9. Never take rectal temperatures
10. Theophylline
or
caffeine
sodium
benzoate
administered to stimulate respirations - increase an
infant’s sensitivity to carbon dioxide, ensuring better
respiratory function.
E. SUDDEN INFANT DEATH SYNDROME
Sudden Infant Death Syndrome (SIDS) is the sudden,
unexplained death in infancy or unexpected death of an
apparently healthy infant under 1 year of age in which a
thorough autopsy fails to demonstrate an adequate cause of
death.
unknown cause but common below 1 year of age
Factors and Causes:
It tends to occur at a higher rate in the infants of:
1. Adolescent mothers
2. Infants of closely spaced pregnancies
3. Underweight infants
4. Preterm infants
5. Bronchopulmonary dysplasia
6. Twins
7. Siblings of another child with SIDs
caution the mother, must be well monitored
8. Native American & Alaskan infants
9. Economically disadvantaged black infants
10. Infants of narcotic-dependent mothers
Other possible contributing factors:
1. Viral respiratory or botulism infection
2. Pulmonary edema
3. Brain stem abnormalities
4. Neurotransmitter deficiencies
5. Heart rate abnormalities
6. Distorted familial breathing patterns
7. Decreased arousal
8. Possible lack of surfactant in alveoli
9. Sleeping prone - resp. muscles restricted)
Age: Peak incidence is between 2-4 months of age
Time of Year: esp. during winter months.
Time of Death: During Sleep
Cause - unknown
18
Sleep Risk Habits:
A. prone sleeping position
B. Overheating (thermal stress)
C. Use of soft bedding
D. Possibly sleeping with an adult
E. Respiratory disorders,
F. History of life- threatening event,
Maternal risk factors:
A. Maternal smoking
B. Young mothers age
C. High risk pregnancy
D. Substance abuse
Specific cause of SIDS cannot be explained, placing the infant
in a supine position or side has been shown to decrease the
incidence of the syndrome.
Assessment
Death typically occurs during sleep.
Appearance when found:
1. Apneic, blue, lifeless
2. Frothy blood-tinged fluid in the nose & mouth
3. May be found in any position
4. May be clutching bedding
5. Diaper is wet & full of stool
Diagnostic
● No test can predict risk
● Cardiopneumogram or pneumocardiogram
Nursing Intervention / Prevention
1. Apparent life- threatening event
a. Home cardiorespiratory event monitor - discontinue
monitor 2-3 months without episodes.
b. Administer respiratory stimulant medications theophylline or caffeine as prescribed
Emergency
1. Review scenario
2. Healthy infants should be placed in supine
position for sleep. supine-lying position
3. Infants with gastroesophageal reflux or other
airway anomalies that predispose to airway
obstruction may be placed in a prone
position.
to prevent aspiration of gastric reflux. It will
flow by gravitational pull
2. Soft moldable mattress & bedding, such as pillows
should not be used.
To prevent falling down on the face. It can suffocate
the baby.
3. Stuffed animals should be removed from the crib
while sleeping.
To also prevent the baby from suffocation.
4. Allow the parents & family to say good-bye to their
infant
5. Clean the infant before allowing the family to see him.
6. Make an appropriate referral for follow-up with the
family.
Public Health Nursing
● Encourage the expression of feelings
● Explore coping mechanisms & evaluate effectiveness
● Assess parental intellectual knowledge
● Provide written information about SIDS
F. HYPERBILIRUBINEMIA
Hyperbilirubinemia (an elevated level of bilirubin in the blood)
results from destruction of red blood cells by either a normal
physiologic process or the abnormal destruction of red blood
cells.
Refers to an excessive level of accumulated bilirubin in the
blood & is characterized by jaundice, or icterus, a yellowish
discoloration of the skin, sclera, & nails.
Best assessment: natural light, light pressing of nose or chest
bone: yellow. If it progresses, sclera is yellow.
Hyperbilirubinemia may result from increased unconjugated or
conjugated bilirubin. Most common is unconjugated bilirubin.
Pathophysiology
Bilirubin is one of the breakdown products of the hemoglobin
that results from red blood cell (RBC) destruction. When RBCs
are destroyed the breakdown products are released into the
circulation, where the hemoglobin splits into two fractions
heme & globin.
● The globin (protein) portion is used by the body,
● The heme portion is converted to unconjugated
bilirubin; an insoluble substance bound to albumin.
In the liver the bilirubin is detached from the albumin molecule
&, in the presence of the enzyme glucuronyl transferase, is
conjugated with glucuronic acid to produce a highly soluble
substance, conjugated bilirubin glucuronide, which is then
excreted into the bile.
In the intestine, bacterial action reduces the conjugated
bilirubin to urobilinogen, the pigment that gives stool its
characteristic color. Most of the reduced bilirubin is excreted
through the feces, a small amount is excreted in the urine.
Normally the body is able to maintain a balance between the
destruction of RBCs & the use of excretion of by-products.
However, when developmental limitations or a pathologic
process interferes with this balance, bilirubin accumulates in
the tissues to produce jaundice.
Possible Causes of Hyperbilirubinemia
1. Physiologic (developmental) factors (prematurity)
2. An association with breastfeeding or breast milk
due to substances in the maternal milk such as”
● B-glucuronidase & non-esterified fatty acids which
may inhibit normal bilirubin metabolism
● or
pregnanediol (a breakdown product of
progesterone) in breastmilk depresses the action of
glucuronyl transferase, the enzyme that converts
indirect bilirubin to the direct form, which is readily
excreted in bile.
indirect bilirubin must be converted to direct to excrete
it.
3. Excess production of bilirubin (hemolytic disease,
biochemical defects, bruises)
cephalohematoma - normal jaundice but disappears
from 2-6weeks.
4. Disturbed capacity of the liver to secrete
conjugated bilirubin (enzyme deficiency, bile duct
obstruction-> plugging of biliary secretions - when
obstructed bile is unable to enter the intestinal tract,
accumulates in the liver. Bile pigments (direct
19
5.
6.
7.
bilirubin) enter the bloodstream & jaundice
(physiologic) occurs.)
Combined overproduction & under secretion
(sepsis)
Some disease states (hypothyroidism, galactosemiagenetic metabolic disorder that affects an individual’s
ability to metabolize the sugar galactose properly,
infant of diabetic mother) Diseases part of Newborn
Screening
Genetic predisposition to increased production
(Native Americans, Asians)
permanent cell damage & scarring of the basal
ganglia & brain stem called kernicterus.
Nursing intervention
Nursing Intervention for physiologic jaundice in NB is rarely
necessary except for:
1.
2.
2 Types of Jaundice
depends on the day it appears. Physio - 2nd-3rd, Patho - first
24 hrs or 1st day
1. Physiologic jaundice or icterus – term infants, starts on
the 2 day or 3rd day of life in about 50% of all newborns as a
result of the breakdown of fetal RBC.
● Bilirubin levels gradually increase to approximately
6mg/dl on the 3 day of life or 72 hours, then
decrease to a plateau of 2 to 3 mg/dl by the 5 day.
● Preterm infants – serum bilirubin levels may peak as
high as 10 to 12 mg/dl at 4 to 5 days and decrease
slowly over a period of 2 to 4 weeks.
more common and normal to them due to immaturity
of the liver.
nd
rd
th
2. Pathologic jaundice - usually appears early, up to 24 hours
after birth; represents a process ongoing before birth. Pattern
of progression is from head to feet.
● Blanch the skin over the bony area or look at
conjunctiva & buccal membranes in dark skinned
infants. With disease process
3.
4.
5.
6.
7.
8.
Early feeding to speed passage of feces through the
intestine & prevent reabsorption of bilirubin from the
bowel
Phototherapy (exposure to infant to light) to initiate
maturation of liver enzymes may be used, used to
help convert unconjugated (insoluble) bilirubin to
conjugated (soluble) & move from the skin to the
blood plasma & then excreted.
● Baby must be naked
● Turn every 2 hours to expose all parts.
Completely undress the infant except for the diaper
with eye patches to protect the eyes from the high
intensity fluorescent lights.
Remove eye patches during assessment & feeding.
Maintain temperature regulation due to large surface
area being exposed to environmental temperatures
● high temperature may cause hyperthermia
Maintain adequate hydration due to increased
excretion of conjugated bilirubin through the bowel &
urinary system.
● IV fluids: for them to be hydrated to aid the
excretion of bilirubin levels
● If good sucking power: additional water and
fluids
● may also cause excretion in sweat, urine
(yellowish)
Monitor serial fractionated bilirubin levels to evaluate
the infant’s condition.
Instruct the parents on the disease & the expected
care of the infant.
Diagnostic evaluation
The degree of jaundice is determined by serum bilirubin
measurements.
● order may occur every hour if the levels are too high
Phototherapy is not always the intervention for jaundice (case
to case basis)
Normal values of unconjugated bilirubin are 0.2 to 1.4 mg/dl.
In the newborn, levels must exceed 5mg/dl before jaundice is
observable.
Intervention for pathologic: depending on the degree:
exchange transfusion, because rH/ABO incompatibility
increases bilirubin levels
Evaluation of jaundice is based on:
1. Serum bilirubin levels
2. Timing of the appearance of clinical jaundice
3. Gestational age at birth premature are prone
4. Family history including maternal Rh factors
maternal rH incompatibilities
5. Age in days since birth patho or physio
6. Feeding method if physio, continue BF
7. Infant’s physiologic status
8. The progression of serial serum bilirubin levels
Diagnostic Tests
a. Physical examination to check for cephalocaudal
progression of dermal icterus
b. Serum bilirubin determination *upon doctor’s order
Criteria of Pathologic Jaundice
● Appearance of jaundice within 24 hours
● Persistent jaundice after 1 (term neonate) or 2
preterm weeks
At 10–12 mg/100 mL: If the level of indirect serum
bilirubin rises above 10 to 12 mg./ 100ml. Treatment
will be considered although age, maturity &
breastfeeding affect this.
At about 20mg/ 100ml: Enough indirect bilirubin has
left the bloodstream that it could interfere with the
chemical synthesis of brain cells, resulting in
G. HEMOLYTIC DISEASE OF THE NEWBORN
(Erythroblastosis fetalis)
Hemolytic - characterized by destruction(lysis) of red blood
cells
Caused by:
1. ABO incompatibility
2. Rh factor
3. Maternal antibodies
4. Complications
include
(neurological damage)
anemia,
kernicterus
Assessment:
a. Jaundice due to hyperbilirubinemia
b. Pallor due to hemolytic anemia
20
Diagnostic Test
a. Cord blood studies
puncture and get blood sample in the cord
use the blood sample from the cord in the following test too:
b. Complete blood count
c. Reticulocyte count
d. Bilirubin
red blood cells early in pregnancy if the fetus is Rh
positive. By the end of the second pregnancy, a fetus
can be severely compromised by the action of these
antibodies crossing the placenta and destroying RBC.
1.
2.
Mechanism of Rh Incompatibility:
a.
b.
c.
d.
e.
f.
Sensitization of Rh-negative women by transfusion of
Rh-positive blood.
Sensitization of Rh-negative woman by presence of
Rh Positive RBCs from her fetus conceived with
Rh-positive man
65% of infants conceived by this combination of
parents will be Rh +.
Mother is sensitized by passage of fetal Rh-positive
RBC’s through placenta, either:
● INSIDE: during pregnancy (break /leak in
membrane)
● OUTSIDE: or at the time of separation of the
placenta after delivery.
This stimulates the mother’s immune response
system to produce anti-Rh-positive antibodies that
attack fetal RBC’s & cause hemolysis.
If this sensitization occurs
● during pregnancy: the fetus is affected in
utero
● at the time of delivery: subsequent
pregnancies may be affected. Next babies
will have positive rH too.
H. ABO AND RH INCOMPATIBILITY
ABO incompatibility:
a. Same underlying mechanism
b. Mother is blood type O; infant is A, B, or AB
c. Reaction in ABO incompatibility is less severe.
rH is more severe with higher bilirubin levels
Nursing Interventions:
a. Provide phototherapy
done while doing exchange transfusion
b. Monitor laboratories
c. Assist with exchange transfusion
Through umbilical cord catheterization: 5cc out and in,
with specific amount of blood depending on the
severity of the bilirubin blood level.
Rh incompatibility:
No direct connection exists between the fetal & maternal
circulation, & no fetal blood cells enter the maternal
circulation.
If the mother’s blood type is Rh (D) negative & the fetal blood
type is Rh positive (contains the D antigen):
● The introduction of fetal blood causes sensitization to
occur, & the mother begins to form antibodies against
the D antigen.
● Most form in the mother’s blood stream in the first 72
hours after birth because there is an active exchange
of fetal – maternal blood as placental villi loosen & the
placenta is delivered.
● After this sensitization, in a second pregnancy, there
will be a high level of antibody D circulating in the
mother’s bloodstream, which acts to destroy the fetal
●
●
3.
4.
5.
●
6.
7.
8.
First pregnancy: mother may become sensitized,
baby rarely affected
Indirect Coombs test (tests for anti-Rh-positive
antibodies in mother’s circulation) performed during
pregnancy at first visit & again about 28 weeks’
gestation.
If indirect Coombs test is negative at 28 weeks, a
small dose of (MicRhogam) is given prophylactically
to prevent sensitization in the third trimester.
Rhogam may also be given after the second trimester
amniocentesis.
If positive, levels are titrated to determine extent of
maternal sensitization & potential effect on fetus.
Direct Coombs test done on cord blood at delivery to
determine presence of anti-Rh –positive antibodies on
fetal RBCs.
If both indirect & direct Coombs tests are:
negative (no formation of anti-Rh-positive antibodies)
& infant is Rh positive, then Rh-negative mother can
be given RhoGam (RhoD) human immune globulin) to
prevent development of anti-RH-positive antibodies
as a result of sensitization from present (just
terminated) pregnancy.
In each pregnancy, an Rh-negative mother who
carries an Rh-positive fetus can receive RhoGam to
protect future pregnancies if the mother has had
negative indirect Coombs tests & the infant has had
positive direct Coombs tests.
- mother, + fetus = rhogam
If the mother has been sensitized (produced anti-Rhpositive antibodies), RhoGam is not indicated.
RhoGAM must be injected into an unsensitized
mother’s system within the first 24 hours if possible,
by 72 hours at the latest.
ABO Incompatibility:
1. The maternal blood type is O & the fetal blood type is
A
2. Occur when the fetus has type B or AB blood
3. A reaction in an infant with type B blood is often
serious.
4. Hemolysis can become a problem with a first
pregnancy in which there is ABO incompatibility.
● Reaction less severe than with Rh incompatibility.
● First born may be affected because Type O mother
may have anti-B antibodies even before pregnancy.
● Fetal RBCs with A, B, or AB antigens evoke less
severe reactions on part of the mother, thus fewer
anti- A, anti-B, or anti-AB –antibodies are produced.
● 4. Clinical manifestations of ABO Incompatibility are
milder & shorter duration than those of Rh
incompatibility.
● Care must be taken to observe for hemolysis &
jaundice.
Assessment
● Rh incompatibility of the NB can be predicted by rising
anti-Rh titer or a rising level of antiBodies (indirect Coombs test) in the mother during
pregnancy. Confirmed by detecting antibodies on the
fetal erythrocytes in cord blood (positive direct
Coombs test) by umbilical cord sampling. The mother
21
have Rh-negative blood (dd), & the baby will be Rh
positive) or Dd). cord blood confirms
HYDROPS FETALIS
- pathologic accumulation of at least 2 or more cavities w/ a
collection of fluid in the fetus.
● Indirect bilirubin is fat-soluble & can’t be excreted
from the body. The liver enzyme glucuronyl
transferase converts indirect bilirubin to direct
bilirubin. baby will also be jaundice
● Direct bilirubin is water-soluble & combines with bile
for excretion from the body with feces. In preterm, the
liver is unable to convert bilirubin thus jaundice is
extreme. feces, sweating, urine
● Normally cord blood has an indirect bilirubin level of 0
to 3 mg/100ml.
● An increasing indirect bilirubin level is dangerous if
the level rises above 20mg/dl in term infant or
12mg/dl in a preterm infant - brain damage from
kernicterus (invasion of bilirubin in brain cells) occur.
Therapeutic Management:
● Early feeding
● Phototherapy- 12- 30 in’ above NB’s bassinet
● Exchange blood transfusion- Monitor HR, RR, & BP
o 5mg/ 100 ml at birth
o 10mg/ 100ml at age 8 hours
o 12 mg/100ml at age 16 hours
o 15 mg/100ml at 24 hours
depends on time of birth
Assessment:
1. Jaundice
BOTH ABO and rH causes pathologic jaundice
ABO has less severity of jaundice
2. Anemia
3. Erythropoiesis- production of RBC
4. Enlarged placenta
5. Edema & ascites
Nursing Interventiont:
1. Determine blood type & Rh early in pregnancy.
2. Determine results of indirect Coombs test early in
pregnancy & again at 28-32 weeks. ordered by the doctor
3. Determine results of direct Coombs test on cord blood
(type & Rh, hemoglobin & hematocrit).
4. Administer RhoGam IM to mother as ordered.
5. Monitor carefully infants of Rh-negative & type O mothers
for jaundice.
6. Set up phototherapy as ordered & monitor infants during
therapy.
7. Support parents with explanations & information.
22
Week 4: Upper Respiratory Tract Disorders
I.
OUTLINE
UPPER RESPIRATORY TRACT
A. Choanal Atresia
B. Acute Nasopharyngitis
C. Pharyngitis
C.1. Viral Pharyngitis
C.2. Streptococcal Pharyngitis
D. Tonsillitis
E. Epistaxis
F. Laryngitis
G. Croup
H. Epiglottis
Care of Client with Upper Respiratory Disorder
Learning Objectives
After lecture /discussion, the students will be able to:
1. Review the anatomy & physiology of the upper & lower
respiratory disorders.
2. Identify the different disorders of the upper & lower
respiratory disorders
3. Define related terms.
4. Discuss the signs & symptoms of each problem.
5. Explain the Nursing Implications of each disorder
right lobe = 3, left lobe = 2
UPPER RESPIRATORY TRACT
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A. CHOANAL ATRESIA
Choanal Atresia; Pink on crying, blue on breastf…
Refers to an obstruction, either unilateral or bilateral,
of the posterior nares.
Prevents newborns (who up to age 3 months are
natural nose breathers) from drawing air through the
nose & down into the nasopharynx.
The condition may be congenital or may be caused by
an obstructing membrane or bony growth.
Thre’s a leakage of air
Treatment for bilateral atresia involves:
● Piercing of the obstructing membrane.
● Surgical removal of the bony growth.
as the child grows, needs more air to breathe, may have
another surgery as he/she grows older
Assessment Findings:
● Respiratory distress at birth or immediately after the
infant quiets & tries to breathe through the nose.
23
●
●
Air hunger when the mouth is closed.
Air hunger & cyanosis at feeding.
pink when crying, bluish when cyanotic = obligatory
nasal breathers, leak of air in the mouth when crying
causes pink color
Nursing Implications:
● Assess for choanal atresia, by gently compressing
first one nostril & then the second; if present,
struggling secondary to air hunger occurs.
assessment 1): occlude one nostril and observe
inhalation, repeat on the next side to check if
unilateral or bilateral.
assessment 2): cover the mouth of the baby then
observe for any presence of cyanotic
● Pass a soft no. (Fr)ench 8, 10 catheters through the
posterior nares to the stomach in the delivery room. If
such catheter does not pass bilaterally, diagnosis of
choanal atresia is confirmed.
Confirm: insert a nasal suction catheter or NGT tube
and check if it will go down. There will be blockage.
● Ensure adequate hydration & glucose levels by
administering intravenous fluids for infants with
difficulty feeding.
● Help the parents to understand the anatomic problem
& how surgical intervention may be required.
● Insert an oral airway, if necessary. to avoid
Respiratory Distress
● Provide the parents with emotional support &
information.
● Allow the parents to see their child as soon as the
procedure is over.
● Prepare the parents & the infant for discharge &
answer any questions the parents may have.
● Because of difficulty with feeding, they may receive
IVF to maintain their glucose & fluid level until surgery
can be performed.
B. ACUTE NASOPHARYNGITIS
Acute Nasopharyngitis referred to as - (Common Cold)
● The most frequent infectious disease in children, is
caused by one of several viruses.
● The most common causative organism are:
rhinovirus, coxsackie virus, respiratory syncytial
virus adeno virus, parainfluenza viruses.
●
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Children are commonly exposed to colds at school
from other children; toddlers average 10-12 colds a
year; school –age children & adolescents have 8 to
10 colds a year.
The incubation period for a cold is 2-3 days.
Children who are in ill health from some other cause
are more susceptible to the cold viruses than are
well children.
Stress factors appear to play a role in developing a
cold.
●
●
Other possible factors associated with increasing the
susceptibility to colds include exposure to drafts,
cold feet, & chilling.
if bed is adjacent to window during cold seasons
Immune system compromised
Assessment/Symptoms:
A. begin with nasal congestion,
B. a watery rhinitis
prevent rough handkerchief, it can irritate
C. a low- grade fever- 102F to 104F (38.8- 40C)
D. Dehydration- refuse feedings
why? because baby cannot eat
E. Reddened, swollen nasal mucous membrane
F. Difficulty in breathing secondary to nasal edema &
congestion
G. Pharyngitis secondary to posterior rhinitis & local
irritation
H. Cough secondary to draining pharyngeal secretions
post-nasal drip
I. Swollen & palpable cervical lymph nodes last about a
week & then symptoms fade.
Is it bad to have palpable lymph nodes? No, it acts as
a defense mechanism or “soldier” and part of the
immune system.
J. Thick, purulent nasal discharge secondary to bacteria
such as streptococci causing secondary infection
virus - clear
bacteria - green / yellow
K. May develop secondary symptoms, such as vomiting,
& diarrhea.
Nursing Implications:
1. There is no specific treatment because it is caused by
a virus, unless secondary bacterial infection has
occurred- antibiotics.
2. Monitor vital signs 3. Control fever - oral temperature 38.4C or 101F
antipyretics - Acetaminophen (Tylenol) be given.
no antibiotic if viral
cough - expectorant
4. Monitor fluids & electrolytes in infants & toddlers.
hydration is needed
action of fluid in the baby - liquifies the phlegm for
easy expectoration
5. Keep in mind that symptoms persist for approximately
1 week & then subside.
6. Teach the parents how to monitor young children for
dehydration.
7. Teach the parents that acetaminophen is for fever
reduction & does not reduce cold symptoms.
8. Teach the parents to instill saline nose drops or spray
for nasal congestion- to liquefy nasal secretions &
help them drain.
9. Teach the parents correct use of bulb suction to clear
nasal mucous by compressing the bulb before
insertion into the child's nostril - allows them to
breathe more efficiently.
some mothers do this manual sucking
10. Guaifenesin - loosens secretions but does not
suppress cough.
some buys OTC, pharmacist should ask if cough is
productive (with phlegm) or non-productive (no
phlegm)
suppressant = for sleep
11. Encourage the parents to use cool mist vaporizer to
help loosen nasal secretions.
24
nebulizer
12. Administer phenylephrine nose drops to tree the
airway by constricting the mucous membrane.
To minimize congestion
13. Encourage fluids & maintain hydration.
14. Encourage good hand washing to prevent the spread
of colds.
15. Explain to parents that antihistamine, antibiotics, &
expectorants are not generally recommended.
drink liberal amounts of water
sucking difficulty for baby - IV
16. Teach the parent that it is not necessary to suppress
the cough because this mobilizes secretions &
prevents pooling & subsequent infection unless
ordered.
17. Teach the parents about the safe use of vaporizers
such as cleaning, & safe placement to prevent burn
injury to the child from the steam.
steam home remedy -> rolled cardboard then the
baby inhales on the other side so the vapor will be
inhaled.
loosens congestion -> minimizes congested nares ->
more comfortable breathing → 1 foot distance
Home remedy: “Suob”
●
●
cold first
Peak incidence occurs between 5 & 15 years old,
incubation period-2-5 days.
Occur as a result of chronic allergy in which there is
constant postnasal discharge that results in
secondary irritation.
post nasal discharge can be swallowed when lying
down
C.1. VIRAL PHARYNGITIS
Causative agent is virus, symptoms are:
Generally mild:
● Sore throat
● Fever
● General malaise
● Enlarged lymph nodes
● Erythema present at the back of the pharynx & the
palatine arch
18. Teach the parents the signs of otitis media (middle
ear infection), elevated temperature, & ear pain
because this can be a complication of the common
cold & requires treatment.
holding the portion of the ear may indicate the
child/baby is in pain
secretion (luga) that is foul smelling
treated using ear drop, cleanse secretion.
Nursing Diagnosis:
● Parental health seeking behavior related to
management of child’s cold.
Outcome Identification
● Parents will demonstrate knowledge of what is & what
is not helpful in the treatment of a cold by end of
health visit.
Outcome Evaluation
● Parents state intention to use cool mist vaporizer to
loosen secretions, to encourage oral fluid, to
administer an antipyretic to reduce fever, & to avoid
cough medicine.
● Care of a child with cold is primarily supportive- loss
of appetite – give liquid to solid foods.
●
●
C. PHARYNGITIS
It is an infection & inflammation of the throat, bacterial
or viral in origin.
Frequently accompanies the common cold.
Treatment for viral pharyngitis is directed to comfort
interventions, such as acetaminophen for pain & fever or
gargling with warm water.
acetaminophen is analgesic and antipyretic
● Group A beta-hemolytic streptococcus is the
organism most frequently involved in bacterial
pharyngitis, usually affecting children age 6 & older.
● Treatment for streptococcal pharyngitis is a
full-day course of antibiotics, such as Clindamycin or
amoxicillin.
● Children not fully treated can develop a
hypersensitivity reaction resulting in rheumatic fever
(rare).
some have financial incapacity and stops treatment, it
may cause reaction
rheumatic fever affects the heart - Penicillin G (Pen
G). Hard to inject, very viscous.
● Symptoms of acute glomerulonephritis may appear in
1 to 2 weeks after streptococcal pharyngitis
regardless of a full course of antibiotics.
● If the bacterial strain was a nephrogenic one, the
chances are as high as 50% that the kidney disease
will develop.
Laboratory studies:
–increase WBC count.
●
●
If inflammation is mild, children rarely need more than
an oral analgesic such as acetaminophen or
ibuprofen for comfort.
Warm heat applied to external neck area using a
warm towel or heating pad can be soothing.
not to hot it may scald the head
25
●
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Sore throat - give liquid to solid food.
Observed closely infants until inflammation &
tenderness diminish to be certain they take in
sufficient fluid to prevent dehydration.
C.2 STREPTOCOCCAL PHARYNGITIS
Between ages- 5-15 years.
Organism: Group A beta-hemolytic streptococcus- bacterial
pharyngitis in children. Must be taken seriously because they
can lead to cardiac & kidney damage from an auto immune
process.
Assessment Findings:
● Erythematous & enlarged palatine & tonsils (bright
red)
● White exudate in the tonsillar crypts/pus
● Petechiae present on the palate.
● High fever
● An extremely sore throat
● Difficulty swallowing,
● Lethargy
● Temperature usually elevated to as high as
104F(40C)
● Headache
● Swollen abdominal lymph nodes may cause
abdominal pain
● Throat
cultures
confirm
the
presence
of
Streptococcus bacteria - virulent causing necrosis
of tissue & extensive damage.
Nursing implications:
● Encourage parents always to have the child with
pharyngitis seen at a health care facility.
● Tell parents that the child needs to have a throat
culture because it is impossible to discriminate
between pharyngitis, from a virus or streptococcal
pharyngitis, which requires treatment to prevent
life-threatening illness.
● Educate parents on the importance of administering a
full 10-day course of an oral antibiotic - Penicillin G or
single injection of benzathine penicillin G to ensure
that streptococci are completely eradicated.
● Cephalosporins or broad-spectrum macrolides –
Erythromycin- if resistant organisms are known in the
community
● Hypersensitivity or autoimmune reaction to group
A streptococci that results in rheumatic fever &
glomerulonephritis.
● Symptoms of acute glomerulonephritis:
o
Blood & protein in urine appear in 1 to 2
weeks after pharyngitis.
not normal in urine
o 2 weeks after treatment - check urine
specimen for protein to check for developing
glomerulonephritis.
urinalysis
● Instruct parents about measures for rest,
●
Relief of throat pain
●
Maintain hydration
●
Examined by a health care personnel
● Instruct the parents on appropriate comfort measures
for the child.
● Inform the parents that the child with streptococcal
pharyngitis is infectious until the 24 hours after
antibiotics have begun.
after 24 hours of antibiotic, free from infecting others
●
Ensure that the child returns to the health care facility
2 weeks after treatment to obtain a urine specimen
(urinalysis) & evaluate for poststreptococcal
glomerulonephritis
D. TONSILLITIS
Refer to infection & inflammation of the adenoid(pharyngeal)
tonsils.
Adenitis – infection & inflammation of the adenoid
(pharyngeal) tonsils.
Tonsillar tissue is lymphoid tissue that filters pathogenic
organisms from the head & neck area.
palatine tonsil meets at midline, with exudates, almost touching
the uvula
Tonsil grading
1.
The palatine tonsils are located on both sides of the
pharynx
2. The adenoids are in the nasopharynx
3. Tubal tonsils are located at the entrance to the
eustachian tubes
4. Lingual tonsils are located at the base of the tongue.
All of these tonsils are referred as Waldeyer’s ring, are easily
infected because of the bacteria that pass through or through
them with lymph.
Treatment of Choice:
Currently, tonsillectomy, removal of the palatine tonsils, is not
recommended unless all other measures prove ineffective.
26
to avoid rheumatic fever: tonsil engulfs the microorganisms
before it enters the tract. If there are frequent attacks (6 times
a year) it is removed.
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Adenoidectomy- removal of the pharyngeal tonsils.
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Assessment Findings:
● Drooling because their throat is too sore for them to
swallow saliva. Swallowing is so painful that it feels as
if they are swallowing bits of metal or glass.
● High fever
● Lethargic
● Sore throat
● Tonsillar tissue appears bright red & enlarged that 2
areas of palatine tonsillar tissue meet in the midline.
● Pus on or expelled from the crypts of the tonsils
● Group A beta-hemolytic streptococcus common on
throat culture
● Pharyngeal pain & edema
Symptoms of Adenoidal tissue infection:
1. Nasal quality of speech
2. Mouth breathing
3. Difficulty hearing
4. Halitosis
5. Sleep apnea
Nursing Implications:
● Instruct the parents about prescribed antipyretics and
analgesics.
● Explain the need to complete the full 10-day course of
antibiotic therapy, despite improved symptoms.
●
●
If tonsillectomy is planned, provide necessary
teaching, including the reason why surgery cannot be
performed while tonsils are infected.
Before surgery, check to be certain that bleeding &
clotting times, complete blood count, & urinalysis
have been done & that the child does not have loose
teeth.
check for clotting time - prothrombin time
CBC and Urinalysis - to check for infection
Following tonsillectomy, position the child on the
abdomen with a pillow under the chest to promote
drainage from the child’s mouth.
prevent aspiration
Monitor vital signs frequently to check for signs of
hemorrhage, & observe for other subtle signs, such
as frequent swallowing, throat clearing, & a feeling of
anxiety.
given ice cream after anesthesia wears off vasoconstrictor
If bleeding does occur, elevate the child’s head & turn
him or her on side, & notify the physician.
Anticipate a return to surgery if hemorrhage is
extreme.
If inspiratory stridor, increased respiratory rate, &
cyanosis occur, suspect pharyngeal obstruction
caused by local bleeding & clot formation, & notify the
surgeon immediately.
If appropriate, extend the child’s head & neck over the
edge of the bed & strike the back sharply to help
dislodge the obstruction.
same approach with pregnant women (heimlich
maneuver)
Have suctioning equipment available to clear an
obstruction but keep in mind that this procedure may
initiate fresh bleeding.
suction not on the tonsil removed, sa bungad lang
Offer frequent sips of clear liquid or ice chips as soon
as the child has completely awakened from the
anesthesia.
Do not offer dairy products, carbonated beverages, or
acid juices.
acid is contraindicated
Tell the parents to progress to a soft diet in 24 to 48
hours & a selective diet by the second week.
depends on the doctor’s order
Provide teaching to the parents, including danger
signs to watch for, need for activity restriction until
after the 7 postoperative
danger signs: check subtle signs of hemorrhage
above
Telephone number to use if they have a question &
need to keep a follow-up appointment in
approximately 2 weeks.
th
●
Nursing Diagnosis:
● Risk for deficit fluid volume related to blood loss from
surgery.
Outcome Evaluation
● Child will maintain adequate fluid volume balance
postoperatively.
● Child’s pulse & blood pressure are normal for age
group; there is absence of extensive bleeding; intake
& output are within acceptable parameters.
● Pain related to surgical procedure.
specify pain scale
Outcome identification
● Child’s discomfort will be limited to a tolerable level.
27
Outcome evaluation
● Child states that level of pain is tolerable.
E. EPISTAXIS
Description
● Epistaxis (nosebleed) is extremely common in
children.
balingoyngoy in tagalog
● It can occur from trauma; lack of humidification;
respiratory infection; after strenuous exercise; & in
association with a number of systemic diseases; such
as rheumatic fever & measles.
● Epistaxis can occur with nasal polyps, sinusitis, &
allergic rhinitis.
● There is a familial predisposition to epistaxis.
other members of the family experiences it too
Assessment Findings:
● Visible bleeding
● Blood in nasopharynx
● Slight choking sensation
Nursing Implications:
● POSITION: Keep the child with nosebleed in an
upright position w/ their head slightly tilted forward to
minimize the amount of blood pressure in nasal
vessels & to keep blood moving forward not back into
the nasopharynx.
● Apply pressure to the sides of the upper nose with
your fingers for about 10 minutes. Ice on Forehead 15
minutes
pinch the bony area at the bridge of the nose
apply ice cap in forehead as vasoconstrictor
● Calm the child because crying increases pressure in
the blood vessels of the head & prolongs bleeding.
● If bleeding continuous: apply epinephrine 1: 1000 to
constrict blood vessels & control bleeding as
prescribed.
● Assess the need for a nasal pack.
●
●
Investigate potential cause in the child who has
chronic nosebleeds.
Teach parents the importance of keeping the child in
an upright position & to apply firm manual pressure
for future nosebleeds.
F. LARYNGITIS
Description
● Laryngitis is inflammation of the larynx, which results
in brassy, hoarse voice sounds or inability to make
audible voice sounds.
Fluimucil can be effective in loss of voice, it may open
the airway -> loosens secretion
● It may occur as a spread of pharyngitis or from
excessive use of the voice.
At risk: singers/teacher
signs of Bacterial Laryngitis
Assessment Findings:
● Brassy, hoarse voice sounds
● Complaints of annoying tickling sensation
● History of recent pharyngitis
Nursing Implications:
● Instruct the parents to offer the child sips of fluid
(either cold or warm) to offer relief
● From annoying tickling sensation is often present.
● Tell the parents that the most effective measure is to
instruct the child not to talk for at least 24 hours until
the inflammation subsides.
● Advise the parents to try & meet the infant’s needs
before they have to cry for things; older children
simply need to be cautioned not to speak.
● Tell the parents that it is not necessary to have the
child on bed rest, & the child will probably use the
voice to ask for things if restricted to bed.
G. CROUP (LARYNGO-TRACHEOBRONCHITIS)
Description
● Croup is an inflammation of the larynx, trachea, &
major bronchi, commonly occurring between 6
months & 3 years of age.
tuspirina
● Croup is usually caused by a viral infection, such as
parainfluenza virus or Haemophilus influenzae.
● Is one of the most frightening disease in early
childhood because symptoms of respiratory distress
appear so suddenly.
● The danger of croup is the potential for glottal
obstruction from the laryngeal inflammation.
occludes epiglottis
28
●
Severe symptoms typically may last several hours &
subside in the morning, possible recurring the next
night.
may cause death to a 6-month-old baby
●
Assessment Findings:
● Upper respiratory infection at bedtime
● Barking (distinctive harsh brassy) cough during the
night
● Inspiratory stridor
● Marked respiratory retractions
● Extreme respiratory distress
● Cyanosis (maybe present)
●
●
Nursing Implications:
● Instruct the parents in the home management of
symptoms, including filling a room with steam, such
as with running a hot shower & bringing the child into
the bathroom.
heater in bathroom = hot shower, right temperature to
prevent scalding
new technology:
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Inform the parents to transport the child to the
emergency department if at –home measure (hot
shower) do not abate the child’s symptoms.
Apply cool, moist air via an air tent once the child
arrives in the emergency room.
●
●
●
relieve from stress
● if a bigger child = only until shoulders are
covered to assess breathing pattern.
(right picture) old mist air tent: plastic canopy
● back: receptacle where ice cubes are [art
● cold mist, and oxygen, while it is melting it
will go inside.
● putting a barrier at the back to make sure the
mist does not go out.
● there is oxygen at the back
(left picture) new mist tent: there is also oxygen at the
back
Advise the parents to remain constantly with the child
for observation & to reduce anxiety.
Administer dexamethasone (steroid) to reduce
airway edema.
Administer racemic epinephrine via Nebulizer for
bronchodilation.
frequent attack - advised to stock
Begin IVT to maintain the child’s hydration status.
Offer sips of liquid, if able to take, to maintain
hydration & moist secretions.
Measure I & O & urine specific gravity to evaluate
hydration.
Keep the child calm, & do not elicit gag reflex
because this can cause laryngospasm with total
occlusion of the airway.
if inserting tongue depressor don’t go deeper
eliciting may block the airway, may cause death
Monitor for restlessness, tachycardia, tachypnea,
stridor & cyanosis because they indicate increased
respiratory distress.
Maintain a continuous record of vital signs & activity
to assess for increasing respiratory rate &
restlessness.
Continuously
monitor
pulse
oximetry
&
transcutaneous PO2 to document if hypoxia is
occurring.
Obtain arterial blood gases to determine adequate
oxygenation if pulse oximetry is not available.
Prepare for & assist with tracheotomy or ET intubation
if necessary.
A tracheotomy is an opening surgically created
through the neck into the trachea (windpipe) to allow
direct access to the breathing tube.
Monitor for associated complications of a tracheotomy
such as infection, atelectasis, tracheal tube occlusion,
tracheal bleeding, Granulation or stenosis, & delayed
stoma healing.
otomy - opening
ectomy - removal
complication of tracheostomy - stenosis (narrows
again) -> ET tube is inserted. “earring analogy”
Explain the condition of croup to the parents &
discuss appropriate care after Discharge, which may
include continued use of humidity & assurance of
adequate hydration.
Inform parents that the croup runs its course in 3-7
days; allow them to verbalize any concerns they may
have on returning home.
Nursing Diagnosis:
● Ineffective airway clearance related to edema &
constriction of airway.
Outcome Identification
● Child will demonstrate adequate airway clearance by
1 hour.
Outcome Evaluation
● Respiratory rate is below 22 breaths / min; No
cyanosis; PO2 is 80-100 mm hg; SaO2 is over 95%
●
●
●
H. EPIGLOTTITIS
Epiglottitis is an inflammation of the epiglottis most
commonly seen in the child age 2 to 8 years.
Although rare, epiglottitis creates an emergency
situation because the swollen epiglottis prevents the
airway from opening.
The cause of epiglottitis is either bacterial or viral;
Haemophilus influenzae type B is the most common
bacterial cause.
29
●
●
●
●
Echovirus & respiratory syncytial virus also cause
epiglottitis.
The child usually has a history of a mild upper
respiratory infection.
Inflammation spreads to the epiglottis & severe
symptoms develop.
Inspection of the edematous epiglottis with a tongue
blade can initiate the gag reflex, which can cause
complete obstruction.
REMEMBER: do not elicit gag reflex when assessing
using tongue depressor
Assessment Findings:
● Inspiratory stridor
● High fever
● Hoarseness
● Sore throat
● Difficulty swallowing with excessive drooling
● Cherry red, swollen epiglottis
● Leukocytosis
Nursing Implications:
● Evaluate all toddlers with epiglottitis symptoms
● Obtain blood cultures for evaluation of septicemia.
● Maintain a patent airway & prepare for insertion of
artificial airway if obstruction occurs.
● Prepare the parents & child if a tracheostomy or
endotracheal intubation is necessary.
● Never initiate the gag reflex with children with
symptoms of epiglottitis unless a means of providing
an artificial airway is present.
● Keep the child as calm as possible to avoid
precipitation of obstruction.
● Obtain lateral neck-X Ray films to reveal enlarged
epiglottitis.
● Explain to the parents & child what epiglottitis is &
how serious its manifestations can be.
● Accompany the child on all tests in case obstruction
occurs.
● Administer moist air to reduce the epiglottal
inflammation.
● Administer oxygen as prescribed if the child is
cyanotic.
● Prepare the parents & child for all procedures & orient
them to the hospital routine.
● Administer antibiotics intravenously as prescribed,
such as cefuroxime or chloramphenicol.
● Administer intravenous fluids for hydration, & monitor
intake and output.
● Support families throughout the hospital experience.
● Encourage the parents to stay with the child.
● Prepare the child & the parents for discharge &
educate them regarding any restrictions or
medications.
● Recommend that parents revive counseling for the
child that was not brought to the hospital soon enough
& died from complete obstruction.
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Week 5: Lower Respiratory Tract Disorders
OUTLINE
LOWER RESPIRATORY TRACT DISORDERS
A. Bronchitis
B. Bronchiolitis
C. Cystic fibrosis
D. Asthma
E. Complication of Acute Respiratory
Infection
F. Otitis Media Acute
G. Otitis Media Chronic
II.
Learning Objectives:
After lecture / discussion, the students will be able to:
1. Review the anatomy & physiology of the lower respiratory
disorders.
2. Identify the different disorders of the upper & lower
respiratory disorders
3. Define related terms.
4. Discuss the signs & symptoms of each problem.
5. Explain the Nursing Implications of each disorder.
Lower Respiratory Tract:
1. Trachea
2. Primary bronchi
a. split into 2
3. right and left lung
4. alveoli
left lobe= 2
●
●
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●
right lobe= 3
A. BRONCHITIS
Bronchitis is an inflammation of the major bronchi &
the trachea. (occurs during wet season)
This inflammation is usually secondary to an upper
respiratory tract viral infection, which spreads to the
bronchi.
It is seen in children under age 2 & more often in the
winter.
Infants with acute bronchitis can develop acute
respiratory distress.
●
●
The associated cough is pronounced at night & can
wake a child from sleep. The cough may persist for up
to 10 days.
The child’s sign & symptoms persist for about a week
& then fade.
Assessment Findings:
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●
●
●
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●
●
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Gradual development of a hoarse, hacking,
productive cough
“Noisy rattling breathing”
Wheezing
Rhonchi
Fine or coarse rales
Increased
percussion
sounds
secondary to
hyper-inflated alveoli
Signs of respiratory distress
Fever
Leukocytosis
Increased erythrocytes sedimentation rate
Chest film with diffuse alveolar hyperinflation & hilus
markings
Nursing Implications:
● Explain to the concerned parents what bronchitis is &
that normally the child does not require
hospitalization.
● Teach the parents appropriate interventions to relieve
the child’s symptoms.
● Have the parents maintain the child on bed rest &
provide plenty of fluids.
● Instruct the parents to keep air warm & moist & that a
bronchodilator may be prescribed to dilate the
bronchi.
● Teach the parents how to use a bronchodilator & also
about any antibiotics prescribed if the infecting
organism is a bacterium.
● Advise the parents to administer an expectorant if
the child’s mucous is viscous.
dilute the phlegm
● Recommend against cough syrups because the
child’s cough should not be suppressed but
encouraged to expectorate accumulating secretions.
expectorant not suppressant, only if child
can’t sleep
● Keep in mind that cough suppressants may be used
at night if the child has trouble sleeping.
● Teach the parents to administer antipyretics, such as
acetaminophen, to reduce fever.
● Educate the parents on worsening signs of respiratory
dysfunction, & advise them to seek medical attention
for their child if they occur or if the child does not
improve.
can be advised for confinement
B. BRONCHIOLITIS
Description
● Bronchiolitis refers to an inflammation of the fine
bronchioles secondary to an acute respiratory viral
infection in children under age 2.
● The peak incidence of bronchiolitis is 6 months.
● Bronchiolitis most commonly occurs during Winter &
spring months & occurs in boys more than girls.
● agent: The respiratory syncitial virus (RSV) is the
most common underlying cause of bronchiolitis.
31
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Respiratory syncytial virus, or RSV, is a common
respiratory virus that usually causes mild, cold-like
symptoms.
Transmission: RSV can be spread by respiratory
droplet for up to 9 days. less contact, protect other
children
The inflamed bronchioles become edematous, &
respiratory secretions accumulate, occluding the
bronchiolar lumen (narrowed)
May impair the breathing of the infant
The narrowed airways comprise expiration & cause
air to be trapped in the alveoli.
Hyperinflation occurs followed by atelectasis.
​Atelectasis, the collapse of part or all of a lung, is
caused by a blockage of the air passages (bronchus
or bronchioles) or by pressure on the lung.
The inadequate ventilation leads to hypoxemia &
hypercapnia.
The acute phase of bronchiolitis lasts 2 to 3 days,
after which the child’s condition improves rapidly.
Many children with numerous instances of
bronchiolitis in early life go on to develop asthma.
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Assessment Findings:
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Nasal drainage
Sneezing
Coughing
Poor appetite or inability to suck
Risk for confinement due to poor nutrition and
dehydration
Low-grade infection
Tachypnea
Nasal flaring
Intercostal & subcostal retractions on inspiration
Inspiratory crackles
Expiratory wheezing
Dyspnea
Tachycardia
Productive or congested cough
Cyanosis & hypoxia
Low oxygen saturation levels
Laboratory analysis of nasal washings positive for
RSV
Nursing Implications:
● Maintain the child with adequate oxygenation, &
institute humidified oxygen therapy if necessary to
counteract cyanosis & preserve hydration.
● Prevent spread of the infection with respiratory
isolation & good handwashing.
before COVID, mask is usually worn for upper
respiratory tract infections
● Administer prescribed antibiotic if causative organism
is unknown.
● Administer ribavirin by aerosol if the causative
organism is RSV.
● Caution the parents about the dangers & teratogenic
side effects of this drug.
Must know the drug study of each drug to be
administered.
● Explain to parents about their child’s condition &
about bronchiolitis.
To alleviate their anxiety
● Help the parents to understand that this child did not
have a simple cold & that they should not feel guilty.
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Help the parents to understand that although this can
be a life-threatening disorder without treatment, with
appropriate treatment, the child will be much better in
a few days.
if baby does not suck or sustain hydration -> needs
confinement for IV therapy
Institute fluid therapy to maintain hydration & liquefy
secretions.
Maintain the child in a semi-fowler’s position to
facilitate breathing.
rationale: to avoid pressure on the baby’s diaphragm
Promote airway clearance via chest physiotherapy
because bronchodilators are often ineffective in
infants because they have inadequate bronchiole
muscles to respond to the drug.
CHEST PHYSIOTHERAPY:
How to perform to a baby:
if bottle feeding, get the tsupon, put in between index
and middle finger. Tap the chest/back using the
tsupon (bottle nipple). Suction is also done after the
phlegm is dislodged.
Know where the secretions are located based on
x-ray/auscultation (adventitious breath sounds) so
that you know where to perform it and dislodge the
secretions na nakakapit.
When is it done:
After the administration of nebulization. It helps
loosen secretions and pinapaluwag ang narrowed
airway first.
Before or after feeding?
give prior the feeding
if after, suspend for 2 hours first to prevent aspiration.
For Bigger babies - cupped hands, cupping
technique. Not flat to prevent marks and redness.
Institute full respiratory assistance, & assist with
extracorporeal membrane
Oxygenation if necessary to maintain adequate
oxygenation.
Maintain adequate nutrition because feeding often
increases the work of breathing.
Tachypneic - NGT, TPN, IV fluid
Administer parenteral or enteral fluids if the child is
unable to take oral feedings.
Provide sufficient rest periods to help conserve the
child’s energy for breathing.
especially if after feeding at hapong hapo ang bata
(nanghihina)
Encourage the parents to verbalize their fears over
the illness of their small child.
Recommend that parents assist with the care of their
child as much as possible.
For them to know what to do incase it happen at their
own house. (eg: how to perform chest physiotherapy)
Explain all procedures & equipment to the parents &
support them throughout the hospitalization.
Nursing Diagnosis:
● Parental anxiety related to respiratory distress in
children.
Outcome Identification
● Parents will demonstrate reduced anxiety regarding a
child's illness by 24 hours.
Outcome Evaluation
● Parents state that their anxiety level is tolerable as S
& S of disease decrease.
32
C. CYSTIC FIBROSIS
Description
● Organ affected: Lungs and Pancreas
● Cystic fibrosis is a hereditary disorder causing widespread dysfunction of the exocrine glands; it is
caused by an autosomal recessive trait that occurs
predominantly in whites & affects both sexes
equally.
● Mucous secretions of the body, especially the
pancreas & lungs, are abnormally thick & have
difficulty flowing through gland ducts.
● There is a marked electrolyte change in the
secretions of the sweat glands.
affected: sodium chloride
● The pathophysiology of cystic fibrosis is the inability to
transport small molecules across cell membranes,
leading to dehydration of epithelial cells in the airway
& pancreas.
blocked across cell membrane
● Cystic fibrosis shortens life expectancy; however,
with the available option of lung transplantation, life
expectancy is increasing.
● This disorder can be found by chorionic villi
sampling or amniocentesis early in pregnancy.
​Chorionic villus sampling (CVS), or chorionic villus
biopsy, is a prenatal test that involves taking a sample
of tissue from the placenta to test for chromosomal
abnormalities and certain other genetic problems.
also can be detected in newborn screening
within/after 24 hours, should be Breast fed
● Boys with cystic fibrosis may not be able to reproduce
because they may have tenacious plugging of the vas
deferens.
● Girls may have thick cervical secretions making it
difficult for sperm to penetrate.
tenacious secretions of the woman blocks the sperm,
the sperm cannot meet the egg cell.
● The pancreas of children with cystic fibrosis
eventually atrophies from plugged ducts, which
causes an increase in back pressure; the pancreatic
enzymes are not produced.
back pressure can cause pain
● Children are unable to digest fat, protein, & some
sugars.
● Initial misdiagnosis in infants of a milk allergy occurs
often.
● Infants with cystic fibrosis are not breast-fed
because there is not sufficient protein in breast milk
for them.
The child is given milk formula: probana (formula fed)
● The lungs of children with this disorder plug with thick
mucous in the bronchioles causing obstruction,
ventilatory problems, & bacterial infection.
● The most frequent lung infections are caused by
a. Staphylococcus aureus
b. Pseudomonas aeruginosa
c. Haemophilus influenzae.
● Cystic fibrosis eventually leads to secondary
emphysema with overinflated alveoli accompanied by
chronic hypoxia & hypercapnia.
overinflation -> emphysema -> hypoxia and
hypercapnia
● Atelectasis, bronchiectasis, & pneumonia occur.
Assessment Findings:
● Chloride: sodium concentration of sweat 2 to 5 times
above normal
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Feces:
o Steatorrhea increase in fat excretion in the
stools.
o Foul-smelling stool
Protuberant abdomen
Malnutrition with emaciated extremities
Loose flabby folds of skin on the buttocks
Fat-soluble vitamin deficiencies
Meconium ileus (first obvious sign in infants)
Nausea
Colicky abdominal pain
Decreased breath sounds
Hypoxia
Hypercapnia build up of carbon dioxide in the
bloodstream
Fever
Productive cough
Tachypnea
Wheezing
Rhonchi
Barrel chest
Clubbed fingers
angle - 180 degrees, normal: 160 degrees
Failure to gain back initial weight lost as a newborn by
4 to 6 weeks.
factors of weight loss in the first 2 weeks: passing out
stool, urine, sweat. poor sucking and hormones.
regain weight after 2 weeks
Nursing Implications:
● Carefully evaluate for passage of stool & meconium in
a newborn.
● Monitor the infant’s weight & note if the child regains
initial loss of weight by 4 to 6 weeks.
● Note any child seen at a health visit with complaints
from the mother that the child has a feeding problem
because the child always appears hungry. (these
children absorb only about 50% of their intake &
then eat so ravenously that they swallow air, which is
then manifested as colic.
swallowed too much air -> colic
● Assess type & frequency of stool & whether there is a
foul odor with it.
● Note any child seen frequently in the health care
setting between 4 & 6 months because of frequent
respiratory infections, a chronic cough, & failure to
gain weight.
● Support the parents & child through initial tests for
o duodenal analysis of pancreatic enzymes
o sweat testing to determine sodium chloride
values
o chest film (xray) to check lungs
o pulmonary function tests. To check lung
capacity, PFR
● Explain all procedures & answer any questions that
the parents may have.
● After confirmation of cystic fibrosis occurs, spend time
with the parents to help them understand this
multifaceted disease.
● Promote airway clearance, & control respiratory
infections & teach the parents the importance of
maintaining adequate hydration in this population.
● Provide supplemental high humidity oxygen if
prescribed.
To moisten the mucous membrane
● Encourage a child on bed rest to make a frequent
position every 2 to 4 hours so that all lobes of the
lungs drain by being in a superior position.
33
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mobilizes secretion and prevents stagnation
Observe the hospitalized child frequently to assess for
rapid deterioration in pulmonary status.
oxygen saturation
Provide respiratory hygiene & mouth care to aid with
the disagreeable taste & odor of secretions.
Maintain adequate rest & comfort to avoid exhaustion
& ensure that the child is adequately rested before
eating.
Educate the parents on the use of bronchodilators if
prescribed to combat airway narrowing & to help the
child expel mucus.
Teach the parents how to perform chest
physiotherapy & breathing exercises & support
them as they begin to realize the lifelong commitment
to maintenance of a clear airway.
Prepare the parents for the expectation of acute
pulmonary infections, which will need to be treated
with intravenous & inhaled antibiotic therapy.
Instruct the parents on how to promote digestive
function in their child. foul odor stool
Nutrition-related:
● Place the infant on Probana, a high- protein
formula. milk formula prescribed by the doctor
Instructions should be based if
the child is a
breast-fed, milk formula-fed, or solid food-fed baby.
● Place the child on a high-calorie, high-protein,
moderate –fat diet.
● Supplement the diet with water-miscible forms of
vitamins A, D, & E.
● Inform the parents of the need to add extra salt to
food, especially in hot months, because of the excess
salt lost in perspiration.
● Instruct parents that medium-chain triglycerides are
used with the diet because they are more readily
digested than other oils.
● Educate the parents & child that before each meal &
snack they need to take a synthetic pancreatic
enzyme to replace the enzyme they cannot produce.
● Instruct the parents on the different methods of
administering these large capsules.
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Educate the parents on how to assess for delivery
absorption by monitoring their child’s stool & weight.
Monitor skin integrity in this population as related to
acid stools & frequent periods of prolonged bedrest
from pulmonary complications.
Provide skin care
Assess for rectal prolapse after stools.
Observe family dynamics & assess for ineffective or
compromised coping.
Provide assistance & support to the parents regarding
home of these children.
Promote a normal childhood & have the child attend
regular school if possible.
Allow the child to participate in physical fitness
activities as tolerated.
Ensure that the child has routine health assessments
& maintains adequate immunizations
Encourage parents to verbalize their frustrations & put
them in contact with support agencies such as the
Cystic Fibrosis Foundation.
Nursing Diagnosis:
● Imbalanced nutrition, less than body requirement,
related to inability to digest fat.
Outcome Identification
● Child will absorb an adequate nutritional amount daily.
Outcome Evaluation
● Child’s height & weight follow percentile growth
curves; quantity of stool decreases; S & S of vitamin
deficiency are absent.
Hyperinflation of the lungs & bronchiectasis in cystic
fibrosis
D. ASTHMA
Description
● Asthma is a chronic disorder characterized by
hypersensitivity of the trachea & bronchi.
● It is a leading cause of chronic illness in children,
affecting children first between ages 2 & 8 & affecting
more boys than girls.
● Incidence: occur initially before age 5 years of age
although in the early years it may be diagnosed as
frequent occurrences of bronchiolitis rather than
asthma.
● A chronic inflammatory disorder of the airways in
which many mast cells, eosinophils and T
lymphocytes may play a role.
● An allergic manifestation characterized by spasms
of the smooth muscles of the bronchi due to edema &
overabundance of mucus.
spasm - tightening of muscles, constriction
● Tends to occur in children with atrophy or those with
a tendency to react with hypersensitivity to allergen.
● Mast cells release histamine & leukotrienes that result
in diffuse obstructive & restrictive airway disease
because of inflammation, bronchoconstriction, &
increased mucus production.
● Asthma results in diffuse pulmonary obstructive
disease.
● Associated
pathophysiologic
responses
or
mechanisms of the disease include bronchospasm,
mucosal edema, & increased accumulated thick
bronchial secretions.
● These responses reduce the size of the lumen of the
airway leading to distress.
● Factors that may trigger severe bronchoconstriction
include inhaled irritants, such as cold air, fumes,
smoke, inhalation of known allergen, viral upper
respiratory infections, & exercise.
swimming is the best exercise
● Bronchoconstriction is the result of stimulation of
the parasympathetic nervous system, which initiates
smooth muscle constriction.
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Inflammation occurs because of mast cell activation
to release leukotrienes, histamine, & prostaglandins.
These
cause broncho-constriction & mucus
production.
Drugs used for asthma aim to control or dilate the
bronchiole.
antihistamine, corticosteroids, nebulizer
Goals for managing asthma include
o maintaining airway patency
o hydration lots of fluid to dilute/liquefy
secretion to expectorate
o ventilation open windows, use electric fan
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Assessment Findings:
● Chest tightness
● Dyspnea - difficult to force air into the narrowed
lumen of the inflamed bronchioles filled with mucus.
● Decreased breath sounds
● Wheezing on inspiration due to obstruction of airflow
in the bronchioles & smaller bronchi. Expiration is
prolonged because not all the inspired air can be
expired. When severe, it is heard during inspiration.
● Paroxysmal cough
● Thick, copious, mucoid sputum / secretions
● Tachypnea
● Tachycardia
● Cyanosis
● Frightened - due to acute feeling of suffocation
● Sputum analysis with white casts
● Respiratory acidosis - hypercarbia - due to impaired
respiration & increased formation of carbonic acidPaCO2 due to bronchospasm.
● Hyper-resonant lungs on percussion - (louder,
hollower noise) due to pockets of trapped air behind
clogged bronchi. As constriction becomes acute, the
wheezing sound may decrease because so little air is
leaving the alveoli.
● Expiratory time increased
● Decreased PaO2 - hypoxia- inability to fully aerate the
lungs. due to tenacious secretions
● Difficulty speaking
● Respiratory failure - when hypoxemia & cyanosis
becomes severe & when blood gases show increased
PCO2 level & sound of wheezing stops.
due to too much secretions, should be suctioned
● During the attack position in sitting or standing
position
to open the airway and prevent diaphragm pressure
● Stunted growth - if given long periods of steroids
especially if started young in children, epiphyseal
bones are just starting to grow.
● Shield-like or barrel shaped chest from constant over
inflation of air in the alveoli
● Clubbing of fingers from the growth of excess
capillaries initiated when polycythemia is sensed
because of poor tissue O2 in distal parts.
● Anxiety & restlessness
● Elevated
eosinophil count - suppress the
inflammatory response by neutralizing histamine.
● Reduced pulmonary function test
● Excessive perspiration, dilated neck veins
Nursing implication:
● Obtain a thorough family history of atopic disease.
● Teach parents about pathology of the disease, normal
management, emergency management, medications
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tests:
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& their uses & side effects, administration, & how to
avoid exposure to allergies.
know the allergen to prevent exposure
Explain all procedures to the child & encourage
parents to stay with the child to allay his fears
Suggests skin testing & hypo-sensitization to
identified allergens. Radioallergosorbent test
(RAST)
hypo-sensitization -> eating food you are allergic to in
small amounts to desensitize.
Use bronchodilators & corticosteroids to maintain a
patent airway.
Educate parent & child on the dangers of overusing
inhalant medication.
to prevent overdose, follow interval prescribed by
doctor in using nebulizer (eg: every 4 or 6 hours)
Teach parents & child use of a spacer tube between
the inhaler & the mouthpiece for children under 12
years to ensure proper dose administration from
metered inhalants.
Monitor for dehydration & teach signs to parents.
Administer fluids as necessary to hydrate because an
asthmatic child can become dehydrated quickly from
insensible losses, decreased oral intake, & diuretic
effects of some bronchodilators.
Help parents understand the importance of hydration
to help thin bronchiolar secretions.
Support parents & child to help them understand how
to prevent attacks & manage them.
Pulmonary function studies - provide an objective &
reproducible method of evaluating the presence &
degree of lung disease as well as the response to
therapy.
Peak expiratory flow rate (PEFR) - measures the
maximum flow of air that can be forcefully exhaled in
1 second. Measured in liters / minute using a peak
expiratory flow meter (PEFM)
Skin testing is useful in identifying specific allergens.
inhaled: Provocative testing direct exposure of the
mucous membrane to a suspected antigen in
increasing concentrations, helps to identify inhaled
allergens.
food: Radioallergosorbent test (RAST) helps
identify antigens against various foods & is often
useful in determining appropriate therapy.
multiple puncturing of the skin to determine food
allergies
Therapeutic Management:
1. Overall goal is to prevent disability & minimize
physical & psychological morbidity- to help the child
live a normal & happy life.
2. Allergen control-prevention & reduction of the child’s
exposure to airborne allergens & irritants; or eliminate
offending allergens; desensitize
especially if it is still a young child
3. Maintenance of a physical exercise regimen:
a. Teach breathing exercises (deep inhaling
and exhaling)
b. Blowing pingpong balls helps lengthen
expiratory period of respiration
c. Reduction of anxiety prevent stress
d. At first sign of wheezing, encourage or force
fluids to keep mucus thin. liquefy secretions
35
e.
Give Cromolyn Sodium before a wheezing
attack - for severely asthmatic children to
prevent the release of histamines; inhaled
through the mouth.
●
Management of Acute Attacks- Drug therapy- goal to prevent
& control asthma symptoms, reduce the frequency & severity
of asthma exacerbations & reverse airflow obstruction.
●
Classifications:
1. Long term control medications (preventionmedicines) to achieve & maintain control of
inflammation.
2. Quick-relief medications (rescue medications /
emergency ) to treat symptoms & exacerbations
3.
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Metered`-dose- inhaler (MDI)- nebulizer:
●
6.
7.
8.
Cromolyn sodium - is an NSAID for
asthma. It stabilizes mast cell membranes,
inhibits activation & release of mediator from
eosinophil & epithelial cells, & inhibits the
acute airway narrowing after exposure to
exercise, cold dry air, & sulfur dioxide.
B-Adrenergic
agonists
(albuterol,
metaproterenol & terbutaline) for treatment
of acute exacerbations & for prevention of
exercise- induced bronchospasm.
Salmeterol
(serevent)
long-acting
bronchodilator, used 2x a day, anti
-inflammatory therapy, used for long term
prevention of symptoms at night
Methylxanthines –theophylline- relieve
symptoms & prevent asthma attacks- central
respiratory stimulant & increases respiratory
muscle contractility.
Leukotriene- mediators of inflammation that
cause
increases
in
airway
hyper-responsiveness
Exercise
Chest physiotherapy
Hypo-sensitization- seasonal allergies
Prognosis is good if they adhere to their treatment
regimen.
Nursing diagnosis:
● Fear related to sudden onset of asthma attack.
Outcome identification
● Parents & child will demonstrate ability to manage
sudden attacks within 1 month. long term
Outcome Evaluation:
● parents & child express confidence in their ability to
prevent attacks & handle any that occur.
4.
Nebulization – medication is mixed w/ saline & then
nebulized w/ compressed air , breathe normally w/ the
mouth open to provide a direct route to the trachea
now: no more mixing with saline, at is what is in the
nebule
Spirometer to measure forcefully she can inhale
open the medicine cap
put 2 cc of medication in the medication cap
mist will get in -> bubbles
it is consumed when ubos na ang nilagay na 2 cc
5.
Corticosteroids – are inflammatory drugs used to
treat reversible airflow obstruction & control
symptoms & reduce bronchial hyperactivity. side
effects: stunned growth, increased in weight
Pulse oximeter - to measure O2 saturation
36
remove manicure and pedicure to determine if nail
beds are pinkish or cyanotic
●
E. OTITIS MEDIA ACUTE
Description
● Acute otitis media is an inflammation of the middle
ear. luga in tagalog
● It is the most prevalent disorder of childhood after
respiratory tract infections.
● It occurs most often in the child 6 to 36 months of age
& again at 4 to 6 years.
● It occurs more frequently in males.
● There is a higher incidence in formula-fed infants
because of the more slanted position that
formula-fed infants are held while feeding, allowing
milk to enter the eustachian tube.
propping bottles - ​bottle propping is when you lean a
baby's bottle on a pillow or other support to feed your
baby hands-free rather than holding both them and
the bottle.
danger: spilling of milk, the milk will enter the ear
(inside)
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If acute otitis media is not treated & cured, permanent
damage can occur to middle ear structures, leading to
hearing impairment.
Assessment Findings
● History of recent respiratory infection
● Red, bulging tympanic membrane
● Fever
● Sharp, constant pain in one or both ears
● Pulling on the ear
● Irritability
● Purulent drainage in external ear canal
● Loss of appetite
● Nasal congestion
● Positive culture & sensitivity for organism
Nursing implications:
● Administer antipyretics as prescribed to reduce
fever.
● Administer analgesics as prescribed to relieve pain.
● Help the child limit chewing to reduce pain by offering
liquids or soft foods.
limit giving chewing gum, baka mas sumakit sa
eardrum
● Apply local heat or cool compress over the affected
ear to minimize pain; encourage the child to prevent
pressure on the affected ear by lying on the
opposite side.
lying on opposite ear to reduce pressure and pain
● If the tympanic membrane has ruptured, place the
child on the side of the affected ear in a dependent
position to facilitate drainage.
● Keep the external ear clean & dry to prevent skin
breakdown.
moist area causes bacterial growth
●
Assess for hearing impairment & refer for
audiometric testing if indicated.
to know how much decibels is heard
Administer
antibiotics,
such
as
ampicillin,
erythromycin,
gentamycin,
amoxicillin,
or
sulfonamides as prescribed.
read the label
● otic - ear drops
● ophthalmic - eyes
interval of 10 minutes giving another drug
manual of nursing procedures:
● maintain the position for 2-3 minutes.
● position: side-lying position with the ear
facing up. If ambulatory, sit with head well
tilted to the side.
Administer decongestant nose drops as
Prescribed to relieve nasal congestion & open up the
eustachian tube allowing air to enter the middle ear;
caution the parents to administer the nose drops for
no more than 3 days because a rebound effect may
occur, causing edema & increasing the mucus
membrane size.
Instruct the parents in the medication regimen,
importance or completing entire
Prescription of antibiotics, signs of hearing loss, &
need for follow-up.
Instruct the parents in preventing measures, such as
holding the child upright during feeding, gentle nose
blowing games, & chewing sugarless gum.
do not blow too hard
Educate the parents to recognize the signs &
symptoms for early diagnosis & treatment.
Anticipate the possibility of surgical intervention if
chronic otitis media occurs.
F. OTITIS MEDIA CHRONIC
Description
● Otitis media is inflammation or infection of the middle
ear.
● Chronic otitis media is usually caused by
gram-negative bacteria, such as Proteus, Klebsiella,
& Pseudomonas.
● Chronic otitis media causes serous otitis media.
● The source of air to the middle ear is cut off, & the
epithelial cells become secretory cells.
● The middle ear fills with secretions, which are a good
medium for infection.
● The fluid becomes thick & tenacious.
● There may be a drop of 20 to 40 decibels in hearing
secondary to the fluid.
● Children aged 3 to 10 years of age are most
commonly seen with this disorder.
Assessment Findings:
● History of chronic ear infections following recent
upper respiratory infection.
● Red, bulging tympanic membrane
● Sharp, constant pain in one or both ears
● Purulent drainage in external ear canal
● Fever
● Gradual loss of hearing
Nursing implications:
● Maintain careful records & evaluate a child’s history
for recent ear infections & treatment.
ask recent history of cough and cold, Upper
respiratory tract problems or complications
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Educate the parents to recognize the symptoms of
acute otitis media & to seek medical attention early for
this serious disorder.
Refer the child to an ear specialist for further
evaluation.
Administer antibiotics as prescribed & educate the
parents on administering a full dose for pain & fever.
Administer analgesics/ antipyretics as prescribed for
pain & fever.
Encourage the child to lie on the opposite side of
the infected ear to decrease pressure.
Assess hearing & evaluate for any hearing
Impairment.
Instruct the parents on the potential need for a
myringotomy to allow purulent drainage & to prevent
rupture from bulging eardrum.
Myringotomy is a procedure to create a hole in the
eardrum to allow fluid that is trapped in the middle ear
to drain out.
Prepare the parents & child for the surgical
procedure, usually done in day surgery & requiring
general anesthesia.
Educate the parents on postoperative care, continued
antibiotics or ear drops (or both), & the need to keep
water out of the ear during swimming & bathing.
depends on doctor’s order if one or both
no swimming and bathing because there is dressing
and to let it heal
Ensure the child & parents have a follow-up
appointment.
Purulent effusion behind the bulging tympanic membraneotitis media
38