Nursing Care of the Pediatric
Individual with a Respiratory
Disorder
Differences in Adult and Child
Adult
Child
Trachea Position
In children, trachea
is shorter and the
angle of the right
bronchus at the
bifurcation is more
acute than in the
adult.
The diameter of an infant’s airway is approximately 4 mm, in contrast to an adult’s airway diameter of
20 mm. An inflammatory process in the airway causes swelling that narrows the airway, and airway
resistance increases. Note that swelling of 1 mm reduces the infant’s airway diameter to 2 mm, but
the adult’s airway diameter is only narrowed to 18 mm. Air must move more quickly in the infant’s
narrowed airway to get the same amount of air to the lungs. The friction of the quickly moving air
against the side of the airway increases airway resistance. The infant must use more effort to breathe
and breathe faster to get adequate oxygen.
Understanding Otitis Media
Question:
Of the three anatomical differences in the eustachian
tube between adults and small children (shorter, wider,
more horizontal), which do you think could cause more
problems for the child and why?
Answer:
More horizontal. Small children who are bottle fed in a
supine position have a greater probability of developing
otitis media because the eustachian tube opens when
the child sucks and the horizontal angle provides easy
access to the middle ear. In older children the greater
angle helps keep foreign substances and germs away
from the middle ear.
Common Causes

Usually preceded by a viral upper respiratory infection

Fluid and pathogens travel upward from the
nasopharyngeal area, invading the middle ear. Fluid
behind the eardrum has difficulty draining back out
toward the nasopharyngeal area because of the
horizontal positioning of the Eustachian tube.

Pathogens gain access to the Eustachian tube, where
they proliferate and invade the mucosa.
Acute Otitis Media



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Fever – hyperthermia is possible
Irritability or fussiness
Poor feeding to lack of appetite/ anorexia
Severe pain in the ear caused by pressure of fluid
Lethargy
Decreased light reflex of tympanic membrane
Red bulging tympanic membrane upon
otoscopy
Clinical Manifestations
What objective sign is
this child displaying?
What does it indicate?
Otitis media (OM)
Note the ear on the left with clear tympanic
membrane (drum); ear on the R the drum is
bulging and filled with pus
Serous Otitis Media



Intermittent pain
Drainage – yellow, green, purulent, foul-smelling
Otoscopic examination reveals:
– Dull, opaque tympanic membrane
– Visualization of fluid line and air bubbles
– Light reflex is to the side, not in expected position
(middle of the ear) due to changes caused by air
bubbles
Complications
Hearing Loss
Delayed language development
Behavior Problems
Treatment

Treatment has always been directed toward antibiotic
therapy; however, recently medical professionals are
allowing for a period of observation or “watchful
waiting” to re-evaluate

Waiting up to 72 hrs for spontaneous resolution is
now recommended in healthy infants

When antibiotics are warranted, oral amoxicillin in
high dosage is given
Nursing Care Management for OM

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Relieving pain
– Mild analgesics, narcotic analgesics
– Heat or cool compresses to affected side
– Numbing eardrops – benzocaine (Auralgan)
Facilitating drainage when possible
Preventing complications or recurrence
Educating the family in care of the child
Providing emotional support to the child and
family
Myringotomy
Pressure-equalizing tubes


A myringotomy – a pin hole opening is made in the
ear drum to allow fluid removal. Air can now enter the
middle ear through the ear drum, by-passing the
Eustachian tube.
Insertion of pressure equalizing tubes help prevents
the pin hole from closing over. With the tubes in
place, hearing should be normal and ear infections
should be greatly reduced.
Post-op Teaching

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Administer ear drops as ordered
Avoid water in the ears
– Use ear plugs in bathtub or when swimming
– Do not allow to swim in lake water- causes infection
Heat to ear
Assess motor and language development
Teach parents to give all of antibiotics completing the
entire course of antibiotics
Return for follow-up
When to Call the Doctor

Call Healthcare Provider (HCP)if:
– Decrease hearing
– Increased ear drainage
– Increased pain
– Increased bleeding
– Fever
Patient/Parent Teaching

If the ear is draining, the external canal may be
cleaned with sterile cotton swabs. These should be
loose enough to allow drainage out of the ear.
Occasionally drainage is so profuse that the auricle
and the skin surrounding the ear become excoriated
from the exudate. This is usually prevented by
frequent cleansing and application of various moisture
barriers or Vaseline.
Prevention

Parents need to be taught ways to prevent OM:
– sitting or holding an infant upright during bottlefeeding and breastfeeding. Propping bottles is
discouraged to avoid the supine position and to
encourage human contact during feeding.
– Avoid use of pacifiers
– Parents must also recognize the initial signs of OM
such as irritability and ear puling.
– Eliminating tobacco smoke and known allergens
from the environment is essential
Tonsillitis
Upper Respiratory Tract Infections

Nasopharyngitis
– Young child: fever, sneezing, vomiting or diarrhea
– Older child: dryness and irritation of nose/throat,
sneezing, aches, cough

Pharyngitis
– Young child: fever, malaise, anorexia, headaches
– Older child: fever, headache, dysphagia, abdominal pain

Tonsillitis
– Masses of lymphoid tissue in pairs
– Often occurs with pharyngitis
– Characterized by fever, dysphagia, or respiratory problems
forcing breathing to take place through nose
Clinical Manifestations

Pharyngitis and Tonsillitis
–
–
–
–
–
–

Fever
Persistent or recurrent sore throat
Anorexia
General malaise
Difficulty in swallowing, mouth breather, foul odor breath
Enlarged tonsils, bright red, covered with exudate
Adenoiditis
– Stertorous breathing - snoring, nasal quality speech
– Pain in ear, recurring otitis media
Treatment and Nursing Care

Saline gargles
Analgesics
Throat lozenges or hard candy
Cool mist humidifier
Hydration with cool liquids
Nurse Alert!
Key to understanding
prevention of URI is
meticulous handwashing
and avoiding exposure
to infected persons
The nurse should remind the
child with a positive throat
culture for strep to discard
their toothbrush and replace
it with a new one after they
have been taking antibiotics
for 24 hours
Nursing Care for the Tonsillectomy
and Adenoidectomy Patient
Post-operative Care

Providing comfort and minimizing activities or
interventions that precipitate bleeding
– Maintain airway - Place in prone or side-lying
position to avoid aspiration until fully awake
– Monitor bleeding, esp. new bleeding
– Nonaspirin analgesics – avoid administering red
colored medications
– Ice collar
– Avoiding p.o. fluids until fully awake --then liquids
and soft cool foods.
Nurse Alert for Post-Op T/A surgery

Most obvious sign of early bleeding
is the child’s continuous
swallowing of trickling blood.
While the child is sleeping,
note the frequency of
swallowing and notify
the surgeon immediately
Discharge Teaching



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Avoid citrus juices, milk, carbonated drinks, and
extremely hot or cold liquids
Do not use straws or put tongue blade in mouth, no
smoking (in teenagers).
Can add cream soups, gelatin, on second day an soft
foods as the child tolerates
Discourage from coughing, clearing throat, or
gargling.
See Parents Want to Know p. 1184.
Croup
Croup vs. Epiglotitis
Croup
–
–
–
–
–
–
Viral
Fever
Hoarseness
Resonant cough
Stridor (inspiratory)
Risk for significant
narrowing airway with
inflammation
– Humidity for treatment
Epiglotitis
–
–
–
–
–
–
–
Bacterial
High fever
Rapidly progressive course
Dysphagia
Drooling
Dysphonia
Distressed inspiratory
efforts
– Antibiotics needed
Child with Epiglottitis
Nursing Care

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Maintain patent airway
– Oxygen with humidification
– Keep resuscitation equipment at the bedside
– Provide mist - Cool mist humidifier or running hot
water in closed bathroom
– Take out into cool, humid night air
Meet fluid and nutritional needs
– Cool, noncarbonated, non-acid drinks
– Assess for difficulty swallowing – may need IV
therapy
Keep quiet as possible
Medications

Beta-agonist – racemic epinephrine, Albuterol

Corticosteroids

Which of these medications would the nurse give
first? Rationale?
If condition worsens

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Take to emergency room
Humidified oxygen
IV fluids
Sedatives are contraindicated – mask symptoms
Monitor vital signs and pulse oximetry
Have intubation equipment available should the childs
condition change rapidly.
Critical Thinking Exercise

Kim, a 4 year old, is admitted to the emergency
department with a sore throat, pain on swallowing,
drooling, and a fever of 102.2°. She looks ill, agitated
and prefers to sit up and lean over.

What nursing interventions should the nurse
implement in this situation?
Bronchitis vs. Bronchiolitis
Bronchitis
Bronchiolitis
Bronchiolitis / RSV

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RSV is rhino syncytial virus
Affects 2-6 month olds primarily
Infection of bronchial mucosa leading to obstruction
Starts out with Upper Respiratory Infection and
progresses to Respiratory Distress.
Diagnosed with a RSV wash
Clinical Manifestations
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Tachypnea
Tachycardia
Wheezing, crackles, or rhonchi
Intercostal and subcostal retractions
Cyanosis
Difficulty feeding
Nursing Care for Child with RSV
Treatment and Nursing Care

Medication therapy
– Bronchodilators –
– Steroids
– Beta-antagonists
– Antiviral
• Virozole (Ribavirin)
– Prevention drug – Synagis (pavilzumab) given
IM. and RespiGam (RSV immune globulin)
given IV.
Nebulized epinephrine administered for
Bronchiolitis
Parents can hold nebulizer to decrease infant’s fear
Indications of Respiratory Distress
1.
2.
3.
4.
5.
Nasal Flaring
Circumoral cyanosis
Expiratory grunting
Retractions
– Substernal, lower intercostal,
Tachypnea
– Repirations greater than 60 bpm
Nursing Care

Maintain open airway
– Position with airway open
– Humidify oxygen
– Give IV fluids to help liquefy secretions for ease in
clearance
– Perform chest physiotherapy
– Ensure emergency equipment is readily available
Apnea


Defined as: Delay of breathing over 20 seconds
Additional Signs and Symptoms:
– Cyanosis
– Marked pallor
– Hypotonia
– Bradycardia
Diagnosis
 Pneumocardiography
– Tests for apnea
– Records the heart rate and chest wall
movements
Treatment and Nursing Care

Admit to hospital for cardiorespiratory monitoring and
maintain pulse oximetry above 95%

Teach parents home care instructions in the use of an
apnea monitor

Encourage parents to learn CPR.
Cardiorespiratory
Monitoring
pulse oximetry
Want reading > 95%
SIDS

Sudden death of a previously healthy infant during
sleep. Usually <1 year of age.

Risk Factors
–
–
–
–
Prematurity, low birth weight
Most common in infants 2-4 months old
More prevalent in winter months
Sleeping in bed with others, sleeping prone, use of
pillows and quilts
– Exposure to passive smoke
SIDS – Nursing Interventions


Parent teaching:
– place infant on back to sleep
– Place on firm mattress
– Do not use loose bedding, toys, pillows
– Avoid overheating with too many clothes
– Parents should stop smoking
Provide support of parents by helping them work
through feelings of guilt and loss; refer to National
Foundation for SIDS
Reactive Airway Disease (asthma)



Chronic inflammatory disorder affecting mast cells,
eosinophils, and T lymphocytes
Inflammation causes increase in bronchial
hyperresponsiveness to variety of stimuli (dander,
dust, pollen, etc.)
Most common chronic disease of childhood; primary
cause of school absences
Asthma
Etiology/Pathophysiology of Asthma

Obstructive airflow limitation due to:
– Mucosal edema - membranes that line airways
– Bronchospasm (bronchoconstriction)
– Mucus plugging (thicker) causes:
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Increased airway resistance
Decreased flow rates
Increased work of breathing
Progressive decrease in tidal volume
Arterial pH abnormalities include:
– Respiratory alkalosis (early) or acidosis (late)
– Metabolic acidosis - from hypoxemia, work of
breathing
Asthma Triggers
Medications to treat Asthma

Reliever or Rescue Meds
– Short acting beta-agonists
• albuterol
• terbutaline
– Anticholinergic agents: Atrovent
– Corticosteroids- prednisone (Prelone), for
short term therapy
Medication Therapy

Preventer / Controller Medications
– Mast-cell inhibitors (Cromolyn)
– Inhaled steroids ( Advair, Pulmocort, Azmacort)
(always rinse mouth following administration)
– Leukotriene modifiers - (Singulair)
Children can receive nebulizer
treatment / Metered Dose Inhaler
What is important patient teaching ?
Metered-Dose Inhaler with spacer
A spacer is a chamber that can be attached to a metered-dose
inhaler (MDI). The spacer chamber allows the medication to be held
in the chamber before it is inhaled so the child can inhale the
medicine in one or many breaths, depending on ability.
A spacer:
 Helps prevent getting a yeast infection in the mouth (candidiasis)
 Increases the amount of medicine delivered directly to airways
 Reduces the amount of medicine swallowed, which minimizes side
effects.
Interpreting Peak Expiratory Flow
Rates


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Green: (80-100% of personal best) signals all clear
and asthma is under reasonably good control
Yellow (50-79% of personal best) signals caution;
asthma not well controlled; call dr. if child stays in
this zone
Red (below 50% of personal best) signals a medical
alert. Severe airway narrowing is occurring; short
acting bronchodilator is indicated
How to Use Peak Flow Meter
A peak flow meter is simple to use for
tracking asthma.
Here's what to teach:
 Stand up or sit up straight.
 Make sure the indicator is at the bottom of the meter (zero).
 Take a deep breath in, filling the lungs completely.
 Place the mouthpiece in the mouth and blast the air out as
hard and as fast as possible in a single blow.
 Remove the meter from the mouth and record the number
that appears on the meter.
Repeat three times
Treatment and Nursing Care
High fowlers
position
Humidified
Oxygen via
mask
Pulse
Oxymetry
Emergency situations of asthma


Acute episode of reactive disease: bronchioles
may close rapidly, causing severe airway
obstruction, anxiety, restlessness, and fear.
Will need to be seen in ER if not relieved by
med
Status asthmaticus: medical emergency with
severe edema, profuse sweating, respiratory
failure and death if untreated. Becomes
seriously hypoxic…immediate intervention
needed
Cystic Fibrosis
Cystic Fibrosis (CF)

Factor responsible for manifestations of the disease is
mechanical obstruction caused by increased viscosity
of mucous gland secretions

Mucous glands produce a thick protein that
accumulates and dilates them

Passages in organs such as the pancreas become
obstructed

First manifestation is meconium ileus in newborn
Pathophysiology


Respiratory System
– Chronic changes, due to accumulation and
retention of mucus in the airways, air trapping
– Cycle of infection > increased mucus >
inflammation > further obstruction
Pancreas
– Mucus inhibits the flow of trypsin, lipase, and
amylase to the duodenum. Thus malabsorption of
fats.
Pathophysiology


Intestine
– Mucus accumulation may lead to bowel obstruction
– Meconium ileus happens in 10-15%
– Sludging of intestinal contents leads to rectal
prolapse, fecal impaction, bowel obstruction and
intussusception
– Altered absorption of fat soluble vitamins
Reproductive System
– 99% of males sterile due to mucus obstruction;
females have decrease fertility due to thick cervical
secretions.
Cystic Fibrosis
Clinical Manifestations

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Salty taste to child's skin
Meconium ileus
Abdominal pain or difficulty passing stool
Clubbing of the fingers
Barrel chest
Increased respirations, cyanosis
Productive cough
Mild diarrhea with malodorous stools, steatorrhea.
Continued Assessment

FTH despite high caloric intake.

Frequent respiratory infections.

Malabsorption of fats and proteins
Diagnosis
• Sweat test:
Chloride – Normal < 40 mEq/L.
Highly suggestive of CF 40-60 mEq/L
Diagnostic > 60 mEq/L.
(see bags over hands and arms)
• Pancreatic enzymes:
Collection of stool specimen to
assess Trypsin and lipase. Trypsin
absent in 80% of children with CF.
r/t Failure to absorb nutrients
Cystic Fibrosis Confirmation
 Diagnosis
is confirmed with:
– absence of pancreatic enzymes
– increase in electrolyte concentration
in sweat
– pulmonary symptoms
Treatment and Nursing Care

Relieve airway obstruction
 Chest Physiotherapy at least twice a day to
increase sputum expectoration
 Physical exercise important adjunct
 Administration of mucolytic agents

Prevention and treatment of pulmonary
infections
 Administer antibiotics
Treatment and Nursing Care

Provide optimal nutrition for growth
– Provide well balanced diet which is high in calories,
protein, CHO. Increase salt in hot weatjer.
– Administer fat soluble vitamins in water soluble form
– Administration of pancreatic enzymes prior to all
meals and snacks
• Comes in enteric coated capsule – may swallow
capsule or open and sprinkle beads over food
• Note color, consistency, frequency of stools
because enzyme dosing is correlated with child’s
bowel elimination patterns.
Chest Physiotherapy
cupping and clapping
The End