AFAMS Master Lesson Plan (MLP)
Nursing Program
Nursing Care for Chronic Pediatric Respiratory Disorders
Instructor
Serial/Semester
Location
Start/Finish Time
Date
LESSON OBJECTIVE
Performance: To gain an understanding
Conditions:
The student will be presented a powerpoint presentation by the instructor and will have
all necessary references made available to him/her.
Standard:
1.
Given a scenario of a pediatric patient with a chronic respiratory disorder by
correctly responding to written, oral and experiential assessment measures.
TEACHING POINTS
1. Describe the pathophysiology, manifestations,
diagnosis, treatment and nursing care for
allergic rhinitis.
6.
2.
Examine the interdisciplinary management of
the pediatric patient with asthma.
7.
3.
Describe patient teaching and self-care related
to asthma.
Describe the pathophysiology, manifestations,
complications and treatment of cystic fibrosis.
Determine appropriate nursing care and
patient/parent teaching for a child with cystic
fibrosis.
8
4.
5.
Identify the pathophysiology, prevention,
symptoms, treatment and nursing care for a
child with bronchopulmonary dysplasia
(BPD).
Describe the pathophysiology, prevention,
nursing care and parent education related to
sudden infant death syndrome (SIDS).
9.
10.
INSTRUCTIONAL STRATEGY
Interactive Lecture
Method:
Instructor
Media:
Classroom
Environment:
OTHER LESSON SPECIFICATIONS
Knowledge Lesson
Type of Lesson:
1/50
Ratio:
Resources:
.
LESSON PLAN APPROVAL
End of Lesson Test: None
Minutes
Instructional Time: 168
Reference(s):
ISBN 0-323-01727-4
Foundations of Nursing, 4th Edition
01 Jan 2003
ISBN 0-7216-9334-2
Introduction to Maternity & Pediatric Nursing, 4th
Edition
01 Jan 2003
AFAMS Master Lesson Plan (MLP)
Nursing Program
Nursing Care for Chronic Pediatric Respiratory Disorders
Signature of Standards Officer
1
Date
AFAMS Master Lesson Plan (MLP)
Nursing Program
Nursing Care for Chronic Pediatric Respiratory Disorders
INTRODUCTION
Allocated Time:
Review:
5 Minutes
You have had previous anatomy and physiology lectures in your combat medic
training, this lecture will build upon prior instruction.
Objective:
To discuss/describe topics related to the nursing process.
Importance:
Nurses work in various health care settings so it is important to gain an
understanding of this subject as it will apply to your clinical practice.
Fit:
A child with a chronic respiratory condition presents many challenges to health
care providers as well as parents. These children are frequently hospitalized
and may require extensive home care. They and their families will need your
support for physical as well as emotional care.
Approach:
You will be presented the subject in lecture format and will be tested using a
written exam at a later date.
Control Statement:
If you have any questions during the lesson please feel free to ask.
BODY
1. Teaching Point: Describe the pathophysiology, manifestations, diagnosis, treatment and nursing care
for allergic rhinitis.
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
a. Pathophysiology- also called hay fever.
(1) Inflammation of the nasal mucosa as a result of an allergic reaction. Usually seasonal.
(2) Not life-threatening and does not require hospitalization. 10% of all children affected.
3) The mast cells in the nasal mucosa respond to an antigen by releasing histamine. Histamine
response: edema and increased mucous secretion.
b. Manifestations- nasal congestion; clear, watery, nasal discharge; sneezing; itching of the eyes. See fig.
25-4, p. 602, Leifer.
c. Diagnosis.
(1) Presence of eosinophils in laboratory testing of mucous membranes of nose.
(2) Positive skin test for specific allergens.
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Nursing Care for Chronic Pediatric Respiratory Disorders
(3) History of seasonal occurrence, family history, and typical manifestations without fever or purulent
drainage.
d. Treatment.
(1) Symptoms treated with antihistamines and decongestants. No topical medications to prevent
"rebound effect".
(2) May treat prophylactically if antihistamines don't work. Cromolyn inhalants or glucocorticoid nasal
sprays. Daily dosing and compliance required.
(3) Immunotherapy for specific allergens may be prescribed.
e. Nursing Care.
(1) Teach parents differences between allergy symptoms and cold symptoms so they can initiate proper
treatment at home.
(2) Referrals for medical and support for allergy testing and immunotherapy.
(3) Teach environmental controls to limit exposure to allergens.
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
What are the typical signs of allergic rhinitis?
Nasal congestion, clear, watery nasal discharge, sneezing and itchy eyes.
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
2. Teaching Point: Examine the interdisciplinary management of the pediatric patient with asthma.
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
a. Description.
(1) Principal cause of chronic illness in children; leading cause of school absenteeism, emergency room
visits and hospitalization.
(2) First symptoms in 80% of cases will occur before age 5.
(3) Prior to puberty, twice as many boys suffer from asthma; incidence is equal afterward.
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Nursing Care for Chronic Pediatric Respiratory Disorders
(4) A recurrent and reversible obstruction of the airways in which bronchospasm, mucosal edema, and
secretion and plugging of mucous contribute to significant narrowing of the airways and subsequent
impaired gas exchange. (nursing diagnosis)
(5) Precipitating agents cause a release of chemical mediators such as histamines, serotonin, eosinophil
and chemotactic factors. This leads to bronchoconstriction and an increase in bronchial secretions.
b. Precipitating agents.
(1) Environmental.
(a) Humidity.
(b) Air pressure changes.
(c) Temperature changes.
(d) Work.
(e) Emotion.
(f) Stress.
(2) Pollutants.
(a) Smoke.
(b) Air pollution.
(c) Perfume.
(3) Allergic Substances.
(a) Food.
(b) Animal dander.
(c) Plants, trees.
(d) Flowers.
(4) Drugs- aspirin, Motrin.
c. Manifestations.
(1) Symptoms vary greatly; may begin slowly or abruptly; can be mild, moderate or severe; often
occurs at night.
(2) Acutely, child coughs, wheezes, has dyspnea and may complain of chin, neck or chest itching.
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Nursing Care for Chronic Pediatric Respiratory Disorders
(3) May exhibit signs of air hunger:
(a) Nostril flaring.
(b) Cyanosis.
(c) Use of accessory muscles.
(d) Orthopnea.
(4) Other signs and symptoms:
(a) Restlessness.
(b) Abdominal pain/vomitting.
(c) Perspiration.
(d) Increased pulse and respirations.
(e) Rales.
(f) Inflammation of the nose and sinuses.
(5) Repeated attacks over a long period of time may lead to emphysema.
(6) Complications include pneumonia, atelectasis, mucus plugs in the bronchi and status asthmaticus.
(7) Status asthmaticus is a true medical emergency in which attack does not respond to usual treatment.
If untreated, respiratory arrest and death may result.
d. Treatment.
(1) Offending irritant identified and eliminated.
(2) Pulmonary function tests to determine obstructive process of the bronchioles.
(3) Adequate rest, good health habits, exercise and generous amounts of fluid may prevent attacks.
(4) If patient provided flow meter to monitor their own lung function, encourage the patient to take
peak flow meter reading at the same time every day (readings < 100ml/sec indicate a problem).
(5) Common medications used in the management of asthma (aim is bronchodilation):
(a) Epinephrine.
(b) Beta-adrenergics such as albuterol, isoetharine, metaproternol, and terbutaline.
(c) Xanthine derivative such as theophyline. Aminophylline loading dose then IV infusion to
maintain serum levels at 10-12 mcg/dl.
5
AFAMS Master Lesson Plan (MLP)
Nursing Program
Nursing Care for Chronic Pediatric Respiratory Disorders
(6) In more severe attacks, child is hospitalized. Oxygen given as ordered to reduce hypoxia.
(7) Care must be taken in pediatric medication administration because the combining of multiple drugs
may affect the rate of clearance.
(8) Steroids may also be used to decrease inflammation.
(9) Generally controlled with minor limitations; often disappears by age of puberty.
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
What are the signs of air hunger?
Nostril flaring, cyanosis, use of accessory muscles and orthopnea.
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
3. Teaching Point: Describe patient teaching and self-care related to asthma.
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
a. Home care- ensure that the child and parents understand the importance of eliminating all agents that
trigger the onset of an attack.
(1) No pets, live Christmas trees, plants, aquariums, stuffed toys, pillows with irritants. Use only
cotton blankets.
(2) Avoid play in damp basements.
(3) Bare necessities/furniture in room; damp dust daily; keep doors and windows shut; air conditioning
is best.
b. Hospital care- same as above plus:
(1) Place pillow over bed table; have child place elbows over it to facilitate chest expansion.
(2) Assess lungs frequently for wheezing, rhonchi or rales.
(3) Document patient assessment.
(4) Serve all fluids at room temperature; encourage oral fluids to liquefy secretions; avoid milk
products.
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Nursing Care for Chronic Pediatric Respiratory Disorders
(5) Organize activity to allow for adequate rest.
(6) Monitor ABGs, vital signs.
c. Self-care.
(1) As child grows older, teach him to observe personal triggers that forewarn an attack.
(2) Encourage child to wear medical alert bracelet and carry an emergency epinephrine injection.
(3) Emphasize importance of exercise to strengthen vulnerable lungs (swimming is good).
(4) Teach child how to use peak flow meters and multiple dose inhalers.
d. Selected nursing diagnoses.
(1) Ineffective breathing pattern r/t increased mucous production and narrowed respiratory passages as
evidenced by coughing and wheezing, restlessness.
(2) Impaired gas exchange r/t inadequate respiratory function.
(3) Knowledge deficit r/t limited understanding of home care of child with asthma.
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
What is a good exercise for children to strength muscles of breathing?
Swimming.
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
4. Teaching Point: Describe the pathophysiology, manifestations, complications and treatment of cystic
fibrosis.
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
a. Description.
(1) The most common fatal genetic disease in the U.S.. It occurs in 1 in 3000 Caucasian infants and 1
in 17,000 African-American infants.
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Nursing Care for Chronic Pediatric Respiratory Disorders
(2) It is a multi-system disease caused by a genetic defect. The defect is an endocrine gland
dysfunction that leads to increased viscosity of mucous gland secretions and loss of electrolytes in sweat
because of abnormal chloride movement.
(3) Respiratory system involvement: Difficulty breathing related to obstruction of airways with thick
secretions. Increased susceptibility to infections related to accumulation of thick secretions. This can
lead to hypoxia which in turn can cause heart failure. Complications include emphysema, wheezing and
respiratory distress.
(4) Digestive system involvement: Poor absorption of food and overall growth resulting from thick
secretions preventing the flow of digestive enzymes into the gastrointestinal tract. Undigested fat in
stools makes them bulky, foul-smelling and frothy. Complications include rectal prolapse, pancreatic,
liver and biliary obstruction.
(5) Skin involvement: "Salty" skin. Potential for electrolyte imbalances, especially in hot weather, due
to electrolyte loss through the skin.
(6) Reproductive system involvement: Decreased motility of sperm related to thick secretions. Thick
cervical mucous may block the flow of sperm to the fallopian tubes.
b. Manifestations- see. fig. 25-9, p. 608, Leifer.
(1)
Salty tears, saliva and sweat.
(2) Clubbing of fingers and toes.
(3) Heat intolerance.
(4) Distended abdomen, rectal prolapse, meconium ileus (newborn) and large, foul-smelling stools.
(5) Sinusitis, cough, cyanosis, dyspnea, wheezing and barrel chest.
(6) Obstructed pancreas, poor digestion and atrophy of the thighs and buttocks.
(7) Lung involvement.
(a) Air passages become clogged with mucous resulting in widespread obstruction of the
bronchioles; breathing difficulties ensue, especially during expiration.
(b) As more air is trapped in the lungs (obstructive emphysema), small areas of collapse (atelectasis)
occur and the child's chest will become barrel-shaped.
(c) The right ventricle enlarges.
(8) GI involvement.
(a) The pancreatic duct is blocked by thickened secretions, inhibiting flow of pancreatic juices into
the duodenum.
(b) As a result of the blockage, the body is unable to utilize fats and proteins.
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Nursing Care for Chronic Pediatric Respiratory Disorders
(c) Poor growth is the end result.
c. Diagnosis- The analysis of the sweat for salt level (sweat test) is the best test for CF.
d. Treatment .
(1) Respiratory relief.
(a) Antibiotics to combat acute infections; preventive therapy controversial.
(b) Expectorants to thin secretions (if contain iodides) and bronchodilators to aid in elimination of
secretions.
(c) Intermittent aerosol therapy to promote elimination of secretions from the lower respiratory tract.
(d) Human recombinant dornase alfa (Pulmozyme) improves pulmonary function.
(2) Diet.
(a) High calorie, high protein.
(b) Give oral pancreatic preparation with meals and snacks to aid digestion and absorption.
(c) Unlimited access to salt.
(d) Supplement with vitamins A, D, E and K, and iron and zinc as prescribed.
(e) Record I & O and daily weight in hospital.
(f) Infants may breast feed with added enzymes or bottle feed with a high calorie-per-ounce formula.
(3) Long term care.
(a) Goals.
1) Minimize pulmonary complications.
2) Promote growth and development.
3) Assist family with adjustments to long term illness.
(b) Emotional support for the child and family.
9
AFAMS Master Lesson Plan (MLP)
Nursing Program
Nursing Care for Chronic Pediatric Respiratory Disorders
Knowledge Lesson:
Question:
Answer:
Skill Lesson:
Check on Learning
In a knowledge lesson, pose questions to the class.
What are the two basic problems related to endocrine gland dysfunction as
seen in Cystic Fibrosis?
Increased viscosity of endocrine gland secretions and loss of electrolytes in
sweat.
In a skill lesson, provide practice and watch students perform a skill.
5. Teaching Point: Determine appropriate nursing care and patient/parent teaching for a child with cystic
fibrosis.
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
a. Postural drainage and chest physical therapy helpful in moving secretions up and out. Teach parents to
do these at home. See fig. 25-11, p. 612-613, Leifer.
(1) Nursing Care- see nursing care plan 25-1, p. 610-611, Leifer.
b. General exercise (headstands and wheelbarrow play) within the child's activity limits are encouraged
because exercise stimulates coughing.
c. Teach purse lip breathing and other breathing exercises to older children.
d. Teach parents and children the extreme importance of limiting exposure to respiratory infections and
completing immunizations.
e. General hygiene.
(1) Meticulous skin care, especially to diaper area.
(2) Frequent position changes.
(3) Loose-fitting clothes.
(4) Good oral care.
10
AFAMS Master Lesson Plan (MLP)
Nursing Program
Nursing Care for Chronic Pediatric Respiratory Disorders
Knowledge Lesson:
Question:
Answer:
Skill Lesson:
Check on Learning
In a knowledge lesson, pose questions to the class.
What exercises can the parents be taught to do at home to help move secretions
up and out?
Postural drainage and chest physical therapy.
In a skill lesson, provide practice and watch students perform a skill.
6. Teaching Point: Identify the pathophysiology, prevention, symptoms, treatment and nursing care for a
child with bronchopulmonary dysplasia (BPD).
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
a. Pathophysiology.
(1) Thickening of the alveolar walls and bronchiolar epithelium.
(2) Result of oxygen concentrations above 40% or mechanical pressure ventilation in the newborn
period for a prolonged period of time.
(3) Swelling of the tissues cases edema. Respiratory cilia paralyzed and lose ability to clear mucous.
(4) Respiratory obstruction, mucus plugs and atelectasis.
b. Prevention.
(1) Prevent preterm births is the best.
(2) Treat RDS in the newborn with only enough oxygen to prevent hypoxia and use minimal ventilator
pressures.
c. Symptoms- chronic RDS.
(1) Wheezing.
(2) Retractions.
(3) Cyanosis with exertion.
(4) Accessory respiratory muscles used.
(5) Clubbing of fingers.
(6) Failure to thrive.
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Nursing Care for Chronic Pediatric Respiratory Disorders
(7) Irritability related to hypoxia.
d. Treatment- goal is reduction of airway inflammation and weaning from mechanical ventilation.
(1) Fluid restriction, bronchodilators and diuretics as prescribed.
(2) May need tracheostomy.
(3) Home care required.
(4) Maintain optimum growth and development- may be difficult.
(5) Family support and education, especially safety precautions with oxygen use in the home.
(6) Multidisciplinary approach needed.
e. Complications.
(1) May become oxygen dependent and develop reactive airway bronchoconstriction.
(2) Right-sided heart failure.
(3) Respiratory stridor and retraction with minor respiratory infections- hospitalization.
(4) Respiratory problems through adulthood.
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
Is BPD something that a child will outgrow with age?
No, it is a chronic illness that lasts through adulthood.
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
7. Teaching Point: Describe the pathophysiology, prevention, nursing care and parent education related
to sudden infant death syndrome (SIDS).
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
a. Description- sudden, unexpected death of an apparently healthy infant between two weeks and one
year old. No cause identified with a routine autopsy.
b. Incidence
12
AFAMS Master Lesson Plan (MLP)
Nursing Program
Nursing Care for Chronic Pediatric Respiratory Disorders
(1) Has decreased by 38% between 1992-1996 related to the "back to sleep" program.
(2) The peak incidence is between 2-4 months.
(3) About 2500 occurrences in the U.S. in 1998.
c. Manifestations- there are no symptoms. The infant dies during sleep and does not cry out in distress.
d. Causes
(1) Exact cause unknown. May be from a brainstem abnormality of cardiorespiratory control.
(2) Face down sleeping may cause rebreathing or airway occlusion.
e. Contributing Factors
(1) Overheating
(2) Irregular respiratory patterns
(3) A decreased arousal response
f. Risk Factors
(1) Maternal smoking or cocaine use
(2) Preterm birth
(3) Poor postneonatal care
g. Prevention- not 100% but may help.
(1) Home apnea monitoring of high-risk infants. Not very effective due to alarm malfunctions and
noncompliance.
(2) Parents should receive CPR training, especially if a monitor will be used.
(3) Discourage the use of soft pillows and fluffy blankets.
h. Grieving Parents
(1) Should be told that the baby died of SIDS which can't be treated or prevented and they are not
responsible.
(2) Allow the parents to say good bye to the baby:
(a) Encourage them to hold and rock the baby.
(b) Encourage to shed tears and assist in burial preparation.
13
AFAMS Master Lesson Plan (MLP)
Nursing Program
Nursing Care for Chronic Pediatric Respiratory Disorders
(3) May experience more guilt from family members wanting explanations or blaming them.
(4) Refer to local SIDS support group and other support as needed.
Knowledge Lesson:
Question:
Answer:
Skill Lesson:
Check on Learning
In a knowledge lesson, pose questions to the class.
Name at least two items that should not be placed in a crib with a sleeping
baby.
Soft pillows and fluffy blankets.
In a skill lesson, provide practice and watch students perform a skill.
END OF LESSON TEST
Allocated Time:
Instructions:
Test Questions or
Performance
Expected:
Test Key:
0 Minutes
You will be tested on this subject at a later date.
You will be expected to review and study the material taught in this session in
order to pass the associated written test. If you have difficulty with the material
please see me so we can review together.
None.
CONCLUSION
Allocated Time:
Summary:
5 Minutes
Review and re-emphasize the difficult Teaching Points below.
1.
2.
3.
4.
5.
6.
7.
Describe the pathophysiology, manifestations, diagnosis, treatment
and nursing care for allergic rhinitis.
Examine the interdisciplinary management of the pediatric patient
with asthma.
Describe patient teaching and self-care related to asthma.
Describe the pathophysiology, manifestations, complications and
treatment of cystic fibrosis.
Determine appropriate nursing care and patient/parent teaching for a
child with cystic fibrosis.
Identify the pathophysiology, prevention, symptoms, treatment and
nursing care for a child with bronchopulmonary dysplasia (BPD).
Describe the pathophysiology, prevention, nursing care and parent
education related to sudden infant death syndrome (SIDS).
8
9.
10.
Closing Statement:
14
Nurses work in various health care settings so it is important to gain an
understanding of this subject as it will apply to your clinical practice.
AFAMS Master Lesson Plan (MLP)
Nursing Program
Nursing Care for Chronic Pediatric Respiratory Disorders
Re-motivating
Statement:
15
A child with a chronic respiratory condition presents many challenges to health
care providers as well as parents. These children are frequently hospitalized
and may require extensive home care. They and their families will need your
support for physical as well as emotional care.