N317 Nursing Care of Children
Altered Respiratory Status
Acute Upper & Lower
Infections
General Principles
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URI caused by viruses
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Rhinovirus, RSV
Most Common Bacteria
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B-Hemolytic Strep
Staph. Aureus
H. Influenza
Pneumococcus
General Principles
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Type of Organism
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“Dose” or amt. Of Exposure
Age of Child--Young children—>Sicker
Child’s Immune System
Seasonal variations
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RSVDec.Mar., Peak in February
Nasopharyngitis
“Common Cold”
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Etiology Viral-Rhinovirus
S/S
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Tx
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Dry, hacking cough
↑nasal discharge (mucous)
↓appetite & activity
Sneezing, chills, irritability
Supportive – no ASA
Rest, Fluids
Self limiting 4-10 days
Do NOT give expectorants or
cough meds to infants and young
children due to risk of S.E.
Complications: O.M.
S/S Pharyngitis “Sore Throat”
Viral
Bacterial
Cause
Virus
Onset
Gradual
Group-A ß-hemolytic
Strep (GABHS)
Sudden
Fever
Low grade
Over 100°
Throat
Red – slight to
no exudate
Cough, hoarse
Cherry –red, white
exudates
H/A, abd. Pain,
enlarged lymph nodes
Symptoms
Management of Strep Throat
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MUST get throat culture or Rapid Strep Screen to
make Dx
Usual drug of choice: Penicillin---10 days
IF ALLERGIC TO PENICILLIN:
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Erythromycin, azithromycin (Zithromax), clarithromycin
(Biaxin), cephalosporins
PCN + Rifampin is more effective than PCN alone in
carriers & those with resistant strains
24° quarantine after begin antibiotics
Symptomatic Tx
Teach imp. of taking all antibiotics & to get new
toothbrush after 24° on meds
Risk for: rheumatic fever, acute glomerulonephritis
Otitis Media
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Common causative agents—Strep pneumoniae, H.
influenzae
Patho / Etiology
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Short-wide eustachian tubes which allows for bacteria to
be swept into them when tube opens; also more
horizontal so don’t allow for drainage easily.
Increased Lymphoid tissue
Pooling of fluids (milk from bottle) in pharynx
At risk: cleft palate, Down syndrome, day care, propping
bottle, living with smoker(s)
Peak age: 6-36 mons; winter
Otitis Media
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S/S
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Tympanic membrane
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Red Bulging → Obstructed Light reflex
No visible bony landmarks
Earache
Temp---1040 F common
Swollen Glands
Cold Sx
Crying/irritable when supine
Eardrum may Rupture →
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Decrease in pain
Increase in ear drainage (on pillow)
Management of Otitis Media
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AntibioticsP.O.:Amoxicillin, Augmentin,
Trimethoprim-sulfamethoxazole (Bactrim, Septra),
E-mycin-sulfisoxazole (Pediazole), Azithrmycin
(Zithromax), Clarithromycin (Biaxin),
Cephalosporins. IM Ceftriaxone (Rocephin)
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Analgesics for pain and temperature; warmth to ears;
keep upright as much as possible
Chronic OM: prophylactic antibiotics for 6 mos or
Surgery Myringotomy to insert tympanostomy tubes
Complications
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Hearing Loss, eardrum scarring, adhesive otitis media,
chronic OM, mastoiditis
Note lack of light reflex, no bony
prominences, bright red, bulging
appearance of tympanic membrane
Acute Otitis Media
Ear Tube
Otitis Externa
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Normal ear flora becomes pathogenic in excessive
wet/dry conditions (trauma or “swimmer’s ear”)
Pain, edema so can’t visualize TM, hearing loss,
cheesy green-blue-gray discharge
Tx: antibiotic drops, 3-4x/day til pain & swelling
gone, then more days
Prevention:
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50:50 sol. of ETOH/white vinegar gtts after swim or bath; 5”
each ear
Nothing in ear smaller than “elbow”
Limit stay in water & dry ears after (with towel)
Tonsillitis
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Lymphoid tissue located in
pharyngeal cavity becomes infected
by viral or bacterial agent
Symptoms
 Palatine tonsils edematous (3-4+)
– blocks food/air
 Adenoids (pharyngeal tonsils)
block air from nose to throat
 Obstructed nasal breathing →
bad breath from mouth breathing
& nasal voice
 Persistent cough
 May block eustachian tubes→OM
Usually self limiting if viral –
must do throat culture
Resource with drawings on Tonsils & Adenoids
http://www.entnet.org/healthinfo/throat/tonsils.cfm
tonsillitis
Hypertropic
tonsils
T&A
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Surgery if documented frequent strep throats
Tonsillectomy not done until after age 3 or 4
Adenoids can be removed if < 3yrs if obstructed nasal breathing
Pre-op
 H&P, CBC, Bleeding Time, check for any loose teeth
Post-op
#1 priority---Assess for Bleeding – watch for excessive
swallowing!!
 Pain Relief
 Hydration
 No milk products or anything red
Discharge Instructions
 No Spicy foods
 Avoid Gargles, vigorous brushing
 Check for bleeding – up to 10 days post op
 Foul breath odor, earache, Temp.↑
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Infectious Mononucleosis
Def: acute, self-limiting infectious disease,
common under age 25. Increase of
mononuclear elements of the blood
Etiology:
• Epstein Barr Virus(EBV) - direct transmission
with oral secretions
• Incubation: 4-6 weeks after exposure
Symptoms: Fatigue may last 1-2 mos
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malaise, sore throat, fever, HA,
lymphadenopathy, spleenomegaly, rash, exudative
pharyngitis
Infectious Mononucleosis
Diagnosis:
1. Self reported symptoms
2. Monospot (EBV antigen test); WBC - atypical lymphocytes
3. Heterophil antibody test (mono titer-1:160 is diagnostic)
Management:
1. Mild analgesia; antipyretics
2. Bed rest; fluid intake
3. Enlarged spleen - no contact activities
4. Penicillin - if Strep. B is cultured from pharynx; NO ampicillin
Prognosis:
Self-limiting
Avoid contact with live virus vaccines for several months after
recovery!!! Depressed cellular immune reactivity.
Croup Syndromes
(middle airways infections)
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Symptom complex:
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hoarseness
a resonant “barky” cough
varying degrees of inspiratory stridor
respiratory distress resulting from
swelling/obstruction in the region of the larynx.
Acute Epiglottitis
Def: inflammation and swelling of the epiglottis.
Etiology/Pathophysiology: ages 2-8.
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Haemophilus influenza most common
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Epiglottis become cherry red, swollen, causing
obstruction of airway, secretions pool in the
larynx and pharynx, complete obstruction within 2
to 6 hours.
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Froglike croak on inspiration
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Sudden onset; medical emergency
Acute Epiglottitis
Assessment:
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Sudden onset high fever & extreme sore throat
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The 4 D’s: dysphonia, dysphagia, drooling,
distress
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Anxious, restless, tripod position.
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Inspiratory stridor, tongue protrusion
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Contraindication: exam of throat unless
incubation equipment & personnel are available
**could result in spasm & complete obstruction of
airway.
Acute Epiglottitis
Assessment cont.:
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Lateral neck x-ray
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Never leave child unattended or without
intubation equipment near
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Usually intubated for 24 hours; restraints may
be necessary
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Always stay calm and help child and parent
stay comfortable and calm
TX: antibiotics 7-10 days; antipyretics, discharge
in abt 3 days from hospital
Acute Laryngotracheobronchitis
(LTB) - CROUP
Def: viral; inflammation, edema, narrowing of larynx,
trachea, and bronchi
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Common in infants, toddlers; Boys>girls; most
common of croup syndromes*****
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Causative agents: parainfluenzae virus, influenzae
A and B, RSV & mycoplasma pneumoniae
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Inflammation/narrowing airways inspiratory
stridor + suprasternal retractions
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Thick secretions produced + edema  obstruction
of airway  hypoxia + CO2 accumulation  resp
acidosis & failure
Croup: assessment and tx
Assessment & Tx
 Onset gradual, often after URI; low-grade fever, barking cough,
acute stridor, accessory muscles, retractions
 Pulse-OX, CXR: AP and Lat upper airways
 Watch for cyanosis, drooling
 Humidified O2, IV fluids
 Assist child to position of comfort; keep parents near
 Meds: Nebulized Racemic Epinephrine preferred over beta 2
adrenergic agonists, po corticosteroids like prednisone or
Orapred
 Teaching: viral, worse at night & may recur for several nights, use
cool mist humidifier in bedroom
 Seek medical help immed. if breathing is labored, child seems
exhausted or very agitated, or cool air humidity tx does not
improve symptoms
Bronchitis (lower airways)
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Inflammation of the large airways; viral;
usually associated with a URI, abrupt
Symptoms: persistent dry, hacking,
nonproductive cough; worse at night;
productive by 2nd to 3rd day; low-grade fever
Mild self-limiting; 5-10 days
Symptomatic tx: analgesics, fluids, rest &
humidity; cough suppressants only if can’t
rest d/t cough
Respiratory Syncytial Virus
(bronchiolitis~ lower airway, cont’d)
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Viral - produces serious lower respiratory
infections, esp. pneumonia or bronchiolitis
Young children/infants (2-24 mo)
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1-6 months highest risk; 50% will be infected
Older children: rhinorrhea, sore throat, cold
Close contact: aerosols from coughing or
sneezing; also contaminated objects. Not
airborne – contact isolation
Incubation: 4 to 8 days
Viral shedding: ~ 2 weeks
RSV – Assessment
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Begins w/simple URI; fever (102°); can progress to
severe Respiratory Distress quickly
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Thick nasal secretions, wheezing, fine rales; cough,
anorexia, retractions, nasal flaring in infants
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Severe: tachypnea, dyspnea, hypoxia, cyanosis,
can progress to apnea
Assessment: lung auscultation, oximetry
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RSV swab/washings (nasopharynx, throat)—positive result
CXR: overinflation, thickening, infiltrates
CBC w/differential: viral shift usually present
Arterial blood gases—only in severe cases
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Respiratory acidosis
RSV: Treatment
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Droplet and Contact Isolation is critical:
with gown, glove, mask, when holding infant
Cool oxygenated mist, hydration, rest, suctioning,
careful monitoring of SaO2
Respiratory Treatments via Nebulizer
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beta adrenergic agonists~Albuteral, Xopenex, racemic
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epinephrine--AAP does NOT recommend these anymore.
Relieve bronchospams; EBP does not support efficacy
Corticosteroids—may be given as anti-inflammatory
Riboviran—Nebulizer anti viral agent; precautions
Respigam—IV Immunoglobulin requires 1:1 RN
Synagis—(palivizumab) RSV “Vaccine”
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Costly, but very worthwhile to high-risk infants
IM/Monthly during high season
Indicated for preemies + hx of RDS, CHD
Pneumonia
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Inflammation of Lung Parenchyma
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Bronchioles; alveolar spaces
Causes (can be 1° or 2°)
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Viral (RSV)
Bacteria
 Pneumoncocci
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Staph aureus / Strep
 Chlamydia
Primary atypical (community acquired)
 Mycoplasma
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S. pneumoniae
Assessment and Diagnosis of Pneumonia
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Viral Etiology
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Mild fever, slight cough
& malaise OR
High fever, severe
cough, & resp. distress
(RSV)
Unproductive cough
Rhinitis
Breath sounds~ few
wheezes, fine crackles
X-ray~diffuse, patchy
infiltration
R/o bacterial or
mycoplasma (CBC, bld
cultures, microbiology
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Bacterial Etiology
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High fever & tachypnea
Bacteria in bloodstream travel to lungs
and ↑ there
Cough~unproductive→productive
w/white sputum; exhausting
Breath sounds~rhonchi or crackles
Retractions, chest pain, nasal flaring
Pallor-cyanosis
X-ray~diffuse or patchy infiltration; ↑fluid
as alveoli fill w/fluid & exudates
May involve 1 segment or entire lung
Behavior~ irritable, restless, lethargic
GI~ anorexia, V&D, abdominal pain
 WBC (neutrophils)
ASO titer if Strep
Treatment of Pnemonia
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Viral
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Supportive care:
antipyretics & hydration
Self limiting
Monitor lung sounds, VS,
respiratory status of patient;
oximetry; bld gases
Humidification; O2 prn
Chest physiotherapy
Antibiotics are not indicated
unless for prophylactic use
Teach parents s/s of
dehydration & ↑ resp
distress
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Bacterial
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Antibiotics are indicated
Outpatient~ may use po
Amoxicillin clavulanate
(Augmentin) or 2nd generation
cephalosporin
Hospitalized pt~ parenteral
antibiotic therapy with Ampicillin
sulbactam(Unasyn) and
cefuroxime
All interventions for viral etiology
are also implemented here
May need to splint chest d/t
cough
Primary Atypical Pneumonia
Etiology: mycoplasma pneumoniae, fall/winter;
crowded living conditions. Peak ages 5-12yrs.
Symptoms: sudden/insidious onset. Fever, HA,
malaise, anorexia, myalgia, rhinitis, sore throat,
cough; fine crackles over lung fields. May last up to
2 wks.
Management:
Most recover in 7-10days with symptomatic
treatment. Hospitalization not usually necessary.
Erythromycin drug of choice.