Guided Lecture Notes, Chapter 16, The Child with Altered Respiratory Status
Learning Objective #1. Describe the developmental and biological variances in children's
respiratory systems that predispose them to respiratory problems.

Teach your students that respiratory conditions, both acute and chronic, are the
leading causes of morbidity in children, and compromises to the respiratory
system are the most common types of problem encountered by the nurse caring
for infants, children, and youth.

Discuss the types of respiratory conditions seen during childhood. The can be
acute or chronic, life threatening, and can present as either the primary clinical
problem or a secondary complication. (Refer to PowerPoint slide #2.)

Review the anatomical structures of the respiratory tracts of infants and young
children and compare them to those of adults. Remind the students that nurses
must note these variations when identifying normal versus abnormal. (Refer to
Figures 16-1, 16-2, and 16-3; and PowerPoint slides #3, 4, and 5.)
Learning Objective #2. Describe the common alterations in health patterns within the
respiratory system in children in terms of etiology, pathophysiology, clinical
manifestations, and interdisciplinary interventions.

Discuss the role of the nurse when taking a health history. Note that the nurse
should use the parent’s own words to document all descriptions of the child’s
symptoms. Review the questions that should be included to assess a respiratory
system problem. (Refer to Focused Health History 16-1 and PowerPoint slide
#6.)

Teach your students the techniques used to perform a focused physical assessment
including observation, inspection, auscultation, palpation, and percussion. (Refer
to Focused Physical Assessment 16-1 and 16-2, and PowerPoint slides #7 and
8.)

Discuss the four major groups of diagnostic tests and procedures used in the
evaluation of the respiratory system and respiratory disorders in children
including: measurement of lung volumes and flow rates (pulmonary function tests
and peak flow measurement); direct or indirect blood and body fluid analysis
(arterial blood gases, fluid cultures, sweat chloride test); imaging techniques
(radiographs, fluoroscopy, bronchography, CT scan, scintigraphy, MRI); and
direct visualization of the respiratory tree (laryngoscopy, bronchoscopy). (Refer
to Figure 16-4, Tests and Procedures 16-1, and PowerPoint slides #9 and 10.)

Remind your students that respiratory illnesses in children, both acute and chronic
conditions, require aggressive and immediate intervention, due to the fact that
respiratory failure is one of the leading causes of cardiopulmonary arrest in
children (AHA, 2005).

Teach your students that for children with a chronic respiratory condition,
oxygen, medications, airway clearance techniques, and nutritional support can
assist them through exacerbations of the illness and provide them with the
strength to maintain a high level of wellness despite their chronic conditions. Note
that some conditions may require use of artificial airways, mechanical ventilation,
or tracheostomy. (Refer to PowerPoint slide #11.)

Discuss the proper use of oxygen for the treatment of hypoxemia. Review the
methods for delivering oxygen. (Refer to Figure 16-5, Teaching Intervention
Plan 16-1, and PowerPoint slides #12 and 13.)

Review the routes of medication administration for treating respiratory disorders
in children, including oral, inhaled, intravenous, and injectable (SQ or IM). (Refer
to PowerPoint slide #14.)

Tell your students that the main classes of medications used for respiratory
disorders include bronchodilators, corticosteroids, and leukotriene modifiers/mast
cell stabilizers. Other groups of medications often used in conjunction with these
include antibiotics, antivirals, mucolytics and expectorants, decongestants,
antihistamines, and diuretics. (Refer to Nursing Interventions 16-1; Figures 166, 16-7, and 16-8; and PowerPoint slides #15 and 16.)

Review the methods available to provide artificial ventilation. Note that a bagmask unit, or Ambu bag, is used to manually ventilate a child who has not been
intubated. (Refer to Figure 16-9.)

Define endotracheal intubation: the insertion of an artificial airway (an
endotracheal tube) through either the nose (nasotracheal) or the mouth
(orotracheal) into the trachea. State that another less invasive device for
mechanical ventilation (used most commonly in the operating room) is the
laryngeal mask airway. (Refer to Tradition or Science 16-1, Figure 16-10, and
PowerPoint slide #17)
Learning Objective #3. Describe the nursing assessment of the child with compromised
respiratory function.

Teach your students that nurses focus postoperative nursing care for patients with
a tracheostomy on close observation to maintain a patent airway and monitoring
for possible complications such as hemorrhage, edema, subcutaneous
emphysema, pneumothorax, and accidental decannulation. (Refer to PowerPoint
slide #18.)

Discuss postoperative respiratory assessments including vital signs and
examination of the child's color, respiratory rate and effort, breath sounds, and
type and amount of secretions.
Learning Objective #4. Discuss the nursing care responsibilities associated with diagnosis
of respiratory difficulties in children.

Emphasize the fact that health promotion and disease prevention activities are
essential for infants, children, and adolescents with acute and chronic respiratory
conditions. Note the focus of these activities: promoting a child’s growth and
development and adequate home management. (Refer to PowerPoint slide #19.)

Note the many nursing diagnoses that may be used to address altered respiratory
function and status. (Refer to Nursing Plan of Care 16-1.)

Teach your students that congenital abnormalities or malformations of the
respiratory systems are rare. Discuss the congenital conditions that may occur in
children, and remind students that the primary goal of treatment is to maintain a
patent airway. (Refer to Figure 16-12 and PowerPoint slides #20 and 21.)
Learning Objective #5. Select the treatments that are most effective for specific
respiratory conditions.

Tell your students that upper respiratory tract infections are extremely common in
infants and young children. Note that most upper respiratory conditions are
treated in the home or in ambulatory care settings. Review the conditions
associated with altered upper respiratory functioning. (Refer to PowerPoint slides
#22 and 23.)

Discuss the characteristic features that distinguish allergic rhinitis from the
common cold. (Refer to Table 16-1.)

Discuss the diagnosis and treatment of epiglottitis. Describe the “tripod position”
and note that agitation, characterized by irritability and restlessness, is almost
always present. (Refer to Clinical Judgment 16-1 and PowerPoint slides #24
and 25.)

Warn students that respiratory distress is a key symptom in bacterial tracheitis and
requires immediate medical attention; vigorous management, including early
recognition of bacterial tracheitis and prompt attention to the airway, is necessary
to prevent the airway from being obstructed by the thick secretions.

Note the three types of apnea that may occur including central apnea, obstructive
apnea, and mixed apnea. (Refer to PowerPoint slide #26.)

Review the types of lower respiratory infections and obstructions seen in children:
influenza, bronchiolitis, bronchitis, and pneumonia. (Refer to PowerPoint slide
#27.)

Tell your students that chronic conditions of the respiratory system can have a
serious effect on children and adolescents and may substantially alter their quality
of life and physical and social development. Note the types of chronic conditions
that affect children. (Refer to PowerPoint slide #28.)
Learning Objective #6. Select nursing care interventions to support the child with an
acute or chronic respiratory illness.

Note that the mainstay of treatment for allergic rhinitis is avoiding the offending
allergens. Review environmental control measures that can help relieve
symptoms. (Refer to Community Care 16-1.)

State that antimicrobial therapy and symptomatic relief measures are the main
interventions for sinusitis. (Refer to Figures 16-13 and 16-14, and Table 16-2.)

Tell your students that when tonsillitis is present, it is necessary to screen for
GABHS by culturing the tonsillar surface that may contain the exudates in order
to determine the antibiotic course that will be used (usually penicillin). Note that
tonsillectomy and adenoidectomy (T&A) are controversial surgical interventions
for chronic tonsillitis. (Refer to Teaching Intervention and Prevention 16-3.)

Discuss the recommendations for use of inactivated influenza vaccine to prevent
influenza in children. Note that interventions for children with influenza include
supportive care to alleviate or minimize symptoms and use of antiviral agents
such as zanamivir and oseltamivir. (Refer to Community Care 16-2.)

Discuss the etiology, prevalence, and treatment modalities for bronchiolitis. State
that the care of a child with bronchiolitis involves respiratory, pharmacologic, and
nutritional support.

Emphasize the fact that chronic bronchitis in children may be a symptom of an
underlying pulmonary disorder and may be an important factor in predisposing
the child to chronic respiratory symptoms and lung dysfunction even into the
adult years. (Refer to Table 16-4.)

Teach your students that pneumonia is distinguished from the more common
upper respiratory tract infections by the presence of lower respiratory tract signs
and symptoms such as tachypnea, rales, and associated areas of infiltration on
chest radiographs. Discuss the causes of, and treatments for, pneumonia.

Discuss the four components of care for asthma presented in the National Institute
of Health guidelines. Note that asthma is the third leading cause of hospitalization
among children under the age of 15 years. (Refer to Clinical Judgment 16-2;
Focused Health History 16-2; Figures 16-16 and 16-17; and PowerPoint slides
#29 and 30.)

Review the risk factors for asthma-related death and recommended treatment
modalities for asthma. (Refer to Tables 16-5, 16-6, 16-7, 16-8, 16-9, 16-10; and
PowerPoint slide #31.)

Tell your students that once considered a fatal childhood disease, cystic fibrosis
(CF) is a chronic, multisystem condition that requires a holistic approach to care
by a trained, interdisciplinary team, including physicians, advanced practice
nurses, nurses, dietitians, social workers, psychologists, and respiratory care
therapists. (Refer to PowerPoint slide #32.)

Stress the fact that each developmental stage merits review with the family and
the patient, when age appropriate, to facilitate strategies that will allow
specialized care for CF to be provided daily (Refer to Developmental
Considerations 16-1).