Nursing Care of the Child With a Respiratory Disorder 19 chapter Key TERMS Key atelectasis atopy clubbing coryza cyanosis expiration hypoxemia hypoxia infiltrate inspiration laryngitis oxygenation pharyngitis pulmonary Upon completion of the chapter the learner will be able to: 1. Compare how the anatomy and physiology of the respiratory system in children differs from that of adults. 2. Identify various factors associated with respiratory illness in infants and children. 3. Discuss common laboratory and other diagnostic tests useful in the diagnosis of respiratory conditions. 4. Discuss common medications and other treatments used for treatment and palliation of respiratory conditions. 5. Recognize risk factors associated with various respiratory disorders. 6. Distinguish different respiratory illnesses based on the signs and symptoms associated with them. 7. Discuss nursing interventions commonly used for respiratory illnesses. 8. Devise an individualized nursing care plan for the child with a respiratory disorder. 9. Develop patient/family teaching plans for the child with a respiratory disorder. 10. Describe the psychosocial impact of chronic respiratory disorders on children. Learning OBJECTIVES Learning pulse oximetry rales retractions rhinitis rhinorrhea stridor subglottic stenosis suctioning tachypnea tracheostomy ventilation wheeze work of breathing R estoring a full breath allows a child to participate fully in life’s adventures.
Transcript
Nursing Care of the Child With aRespiratory Disorder
Upon completion of the chapter the learner will be able to:
1. Compare how the anatomy and physiology of the respiratory system inchildren differs from that of adults.
2. Identify various factors associated with respiratory illness in infants andchildren.
3. Discuss common laboratory and other diagnostic tests useful in thediagnosis of respiratory conditions.
4. Discuss common medications and other treatments used for treatmentand palliation of respiratory conditions.
5. Recognize risk factors associated with various respiratory disorders.6. Distinguish different respiratory illnesses based on the signs and
symptoms associated with them.7. Discuss nursing interventions commonly used for respiratory illnesses.8. Devise an individualized nursing care plan for the child with a
respiratory disorder.9. Develop patient/family teaching plans for the child with a respiratory
disorder.10. Describe the psychosocial impact of chronic respiratory disorders on
children.
Learning OBJECTIVESLearningpulse oximetryralesretractionsrhinitisrhinorrheastridorsubglottic stenosissuctioningtachypneatracheostomyventilationwheezework of breathing
Restoring a full breath allows a child to participate fully in life’s adventures.
Respiratory disorders are themost common causes of illness and hospitalization inchildren. These illnesses range from mild, non-acute dis-orders (such as the common cold or sore throat), to acutedisorders (such as bronchiolitis), to chronic conditions(such as asthma), to serious life-threatening conditions(such as epiglottitis). Chronic disorders, such as allergicrhinitis, can affect quality of life, but frequent acute orrecurrent infections also can interfere significantly withquality of life for some children.
Respiratory infections account for the majority ofacute illness in children. The child’s age and living con-ditions and the season of the year can influence the eti-ology of respiratory disorders as well as the course ofillness. For example, younger children and infants aremore likely to deteriorate quickly. Lower socioeconomicstatus places children at higher risk for increased sever-ity or increased frequency of disease. Certain viruses aremore prevalent in the winter, whereas allergen-relatedrespiratory diseases are more prevalent in the spring andfall. Children with chronic illness such as diabetes, con-genital heart disease, sickle cell anemia, and cystic fibro-sis and children with developmental disorders such ascerebral palsy tend to be more severely affected with res-piratory disorders. Parents might have difficulty indetermining the severity of their child’s condition andmight either seek care very early in the course of the ill-ness (when it is still very mild) or wait and present to thehealth care setting when the child is very ill.
Nurses must be familiar with respiratory conditionsaffecting children in order to provide guidance and sup-port to families. When children become ill, families oftenencounter nurses in outpatient settings first. Nurses mustbe able to ask questions that can help determine the sever-ity of the child’s illness and determine whether they mustseek care at a health facility. Since respiratory illnessaccounts for the majority of pediatric admissions to gen-eral hospitals, nurses caring for children require expertassessment and intervention skills in this area. Detectionof worsening respiratory status early in the course of dete-rioration allows for timely treatment and the possibilityof preventing a minor problem from becoming a criticalillness. Difficulty with breathing can be very frighteningfor both the child and parents. The child and the familyneed the nurse’s support throughout the course of a res-piratory illness.
Nurses are also in the unique position of being ableto have a significant impact upon the burden of respira-tory illness in children by the appropriate identificationof, education about, and encouragement of prevention ofrespiratory illnesses. See Healthy People 2010.
Variations in PediatricAnatomy and PhysiologyRespiratory conditions often affect both the upper andlower respiratory tract, though some affect primarily oneor the other. Respiratory dysfunction in children tends tobe more severe than in adults. Several differences in theinfant’s or child’s respiratory system account for theincreased severity of these diseases in children comparedwith adults.
NoseNewborns are obligatory nose breathers until at least4 weeks of age. The young infant cannot automaticallyopen his or her mouth to breathe if the nose is obstructed.The nares must be patent for breathing to be successfulwhile feeding. Newborns breathe through their mouthsonly while crying.
The upper respiratory mucus serves as a cleansingagent, yet newborns produce very little mucus, makingthem more susceptible to infection. However, the newbornand young infant may have very small nasal passages, sowhen excess mucus is present, airway obstruction is morelikely.
Infants are born with maxillary and ethmoid sinusespresent. The frontal sinuses (most often associated withsinus infection) and the sphenoid sinuses develop by age6 to 8 years, so younger children are less apt to acquiresinus infections than are adults.
ThroatThe tongue of the infant relative to the oropharynx is largerthan in adults. Posterior displacement of the tongue canquickly lead to severe airway obstruction. Through earlyschool age, children tend to have enlarged tonsillar and
2
Alexander Roberts, 4 months old, is brought to the clinic by his mother. He presents with a cold and hasbeen coughing a great deal for 2 days. Today he has had difficulty taking the bottle and is breathing veryquickly. Mrs. Roberts says he seems tired.
Objective
Reduce hospitalizationrates for three ambulatory-care-sensitive conditions:pediatric asthma andimmunization-preventablepneumonia and influenza.
Significance
• Appropriately educatechildren with asthmaand their families aboutthe ongoing manage-ment of asthma.
• Encourage pneumo-coccal and influenzavaccinations per recom-mendations.
HEALTHY PEOPLE 2010
2
adenoidal tissue even in the absence of illness. This cancontribute to an increased incidence of airway obstruction.
TracheaThe airway lumen is smaller in infants and children thanin adults. The infant’s trachea is approximately 4 mmwide compared with the adult width of 20 mm. Whenedema, mucus, or bronchospasm is present, the capacityfor air passage is greatly diminished. A small reduction inthe diameter of the pediatric airway can significantlyincrease resistance to airflow, leading to increased workof breathing (Fig. 19.1).
In teenagers and adults the larynx is cylindrical andfairly uniform in width. In infants and children less than10 years old, the cricoid cartilage is underdeveloped,resulting in laryngeal narrowing. Thus, in infants andchildren, the larynx is funnel-shaped. When any portionof the airway is narrowed, further narrowing from mucusor edema will result in an exponential increase in resis-tance to airflow and work of breathing. In infants andchildren, the larynx and glottis are placed higher in theneck, increasing the chance of aspiration of foreign mate-rial into the lower airways. Congenital laryngomalaciaoccurs in some infants and results in the laryngeal struc-ture being weaker than normal, yielding greater collapseon inspiration. Box 19.1 gives details related to congen-ital laryngomalacia.
The child’s airway is highly compliant, making itquite susceptible to dynamic collapse in the presence ofairway obstruction. The muscles supporting the airwayare less functional than those in the adult. Children
have a large amount of soft tissue surrounding the tra-chea, and the mucous membranes lining the airway are less securely attached compared with adults. Thisincreases the risk for airway edema and obstruction.Upper airway obstruction resulting from a foreign body,croup, or epiglottitis can result in tracheal collapse dur-ing inspiration.
Lower Respiratory StructuresThe bifurcation of the trachea occurs at the level of thethird thoracic vertebra in children, compared to the levelof the sixth thoracic vertebra in adults. This anatomic dif-ference is important when suctioning children and whenendotracheal intubation is required (see Chapter 32 forfurther discussion). This difference in placement alsocontributes to risk for aspiration. The bronchi and bron-chioles of infants and children are also narrower in diam-eter than the adult’s, placing them at increased risk forlower airway obstruction (see Fig. 19.1). Lower airwayobstruction during exhalation often results from bron-chiolitis or asthma or is caused by foreign body aspirationinto the lower airway.
Alveoli develop at approximately 24 weeks’ gestation.Term infants are born with about 50 million alveoli. Afterbirth, alveolar growth slows until 3 months of age and thenprogresses until the child reaches 7 or 8 years of age, atwhich time the alveoli reach the adult number of around300 million. Alveoli make up most of the lung tissue andare the major sites for gas exchange. Oxygen moves fromthe alveolar air to the blood, while carbon dioxide movesfrom the blood into the alveolar air. Smaller numbers ofalveoli, particularly in the premature and/or young infant,place the child at a higher risk of hypoxemia and carbondioxide retention.
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 3
1 mm circum f erential edema causes 50% reduction of diameter and r adiu s , increasing pulmona r y resistance b y a f actor of 16 .
1 mm circum f erential edema causes 20% reduction of diameter and r adiu s , increasing pulmona r y resistance b y a f actor of 2.4 .
Adult
In f ant
4 mm
2 mm
2 mm
1 mm
5 mm
10 mm
4 mm
8 mm
A B
● Figure 19.1 (A) Note the smaller diameter of the child’sairway under normal circumstances. (B) With 1 cm ofedema present, note the exponential decrease in airwaylumen diameter as compared with the adult.
CONGENITAL LARYNGOMALACIA
• Inspiratory stridor is present and is intensified withcertain positions.
• Suprasternal retractions may be present, but the infantexhibits no other signs of respiratory distress.
• Congenital laryngomalacia is generally a benign condi-tion that improves as the cartilage in the larynxmatures. It usually disappears by age 1 year.
• The crowing noise heard with breathing can makeparents very anxious. Reassure parents that the condi-tion will improve with time.
• Parents become very familiar with the “normal” soundtheir infant makes and are often able to identify inten-sification or change in the stridor. Airway obstructionmay occur earlier in infants with this condition, sointensification of stridor or symptoms of respiratoryillness should be evaluated early by the primary careprovider.
BOX 19.1
Chest WallIn older children and adults the ribs and sternum supportthe lungs and help keep them well expanded. The move-ment of the diaphragm and intercostal muscles alters vol-ume and pressure within the chest cavity, resulting in airmovement into the lungs. Infants’ chest walls are highlycompliant (pliable) and fail to support the lungs ade-quately. Functional residual capacity can be greatlyreduced if respiratory effort is diminished. This lack oflung support also makes the tidal volume of infants andtoddlers almost completely dependent upon movementof the diaphragm. If diaphragm movement is impaired(as in states of hyperinflation such as asthma), the inter-costal muscles cannot lift the chest wall and respiration isfurther compromised.
Metabolic Rate and Oxygen NeedChildren have a significantly higher metabolic rate thanadults. Their resting respiratory rates are faster and theirdemand for oxygen is higher. Adult oxygen consumptionis 3 to 4 liters per minute, while infants consume 6 to 8 liters per minute. In any situation of respiratory dis-tress, infants and children will develop hypoxemia morerapidly than adults. This may be attributed not only tothe child’s increased oxygen requirement but also to theeffect that certain conditions have on the oxyhemoglobindissociation curve.
Normal oxygen transport relies upon binding of oxy-gen to hemoglobin in areas of high pO2 (pulmonary arte-rial beds) and release of oxygen from hemoglobin when thepO2 is low (peripheral tissues). Normally, a pO2 of 95 mmHg results in an oxygen saturation of 97%. A decrease inoxygen saturation results in a disproportionate (muchlarger) decrease in pO2 (Fig. 19.2). Thus, a small decrease
in oxygen saturation is reflective of a larger decrease inpO2. Conditions such as alkalosis, hypothermia, hypo-carbia, anemia, and fetal hemoglobin cause oxygen tobecome more tightly bound to hemoglobin, resulting inthe curve shifting to the left. Conditions common to pedi-atric respiratory disorders such as acidosis, hyperthermia,and hypercarbia cause hemoglobin to decrease its affinityfor oxygen, further shifting the curve to the right.
Common Medical TreatmentsA variety of interventions are used to treat respiratoryillness in children. The treatments listed in CommonMedical Treatments 19.1 and Drug Guide 19.1 usuallyrequire a physician’s order when a child is hospitalized.
4 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
Blood PaO2 (mm Hg)
% O
xyge
n S
atur
atio
n
0
10
20
30
40
50
60
70
80
90
0 10 20 30 40 50 60 70 80 90 100
100
● Figure 19.2 Normal hemoglobin dissociation curve( green), shift to the right (red ), and shift to the left (black).
Nursing Process Overview for the Child with aRespiratory Disorder
Care of the child with a respiratory disorder includesassessment, nursing diagnosis, planning, interventions,and evaluation. There are a number of general conceptsrelated to the nursing process that can be applied to respi-ratory disorders. From a general understanding of the careinvolved for a child with respiratory dysfunction, the nursecan then individualize the care based on client specifics.
ASSESSMENTAssessment of respiratory dysfunction in children includeshealth history, physical examination, and laboratory ordiagnostic testing.
Remember Alexander, the 4-month-old with the cold,cough, fatigue, feeding difficulty, and fast breathing?What additional health history and physical examinationassessment information should the nurse obtain?
Health HistoryThe health history comprises past medical history, familyhistory, history of present illness (when the symptomsstarted and how they have progressed) as well as treat-ments used at home. The past medical history might besignificant for recurrent colds or sore throats, atopy (suchas asthma or atopic dermatitis), prematurity, respiratorydysfunction at birth, poor weight gain, or history of recur-rent respiratory illnesses or chronic lung disease. Familyhistory might be significant for chronic respiratory disor-ders such as asthma or might reveal contacts for infectiousexposure. When eliciting the history of the present illness,inquire about onset and progression, fever, nasal conges-tion, noisy breathing, presence and description of cough,
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Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 5
Supplemented via mask,nasal cannula, hood, ortent or via endotrachealor nasotracheal tube
Addition of moisture toinspired air
Removal of secretions viabulb syringe or suctioncatheter
Promotes mucus clearanceby mobilizing secretionswith the assistance ofpercussion or vibrationaccompanied bypostural drainage (seeChapter 14 for moreinformation about CPTand postural drainage)
Relieves throat pain via saltwater gargle
Normal saline introducedinto the airway, followedby suctioning
Insertion of a drainage tubeinto the pleural cavity tofacilitate removal of air orfluid and allow full lungexpansion
Introduction of abronchoscope into thebronchial tree for diag-nostic purposes. Alsoallows for bronchiolarlavage.
Common cold, flu,bronchiolitis, anycondition resultingin increased mucusproduction in theupper airway
Pneumothorax,empyema
Removal of foreignbody, cleansing ofbronchial tree
Monitor response via work ofbreathing and pulseoximetry.
Infant may require extrablankets with cool mist,and frequent changes ofbedclothes under oxygenhood or tent as theybecome damp.
Should be done carefullyand only as far asrecommended for age ortracheostomy tube size, oruntil cough or gag occurs
May be performed byrespiratory therapist insome institutions, by nursesin others. In either case,nurses must be familiarwith the technique andable to educate familieson its use.
Recommended for childrenold enough to understandthe concept of gargling(to avoid choking)
Very helpful for looseningthick mucus; child mayneed to be in semi-uprightposition to avoidaspiration
Should tube becomedislodged from container,the chest tube must beclamped immediately toavoid further air entry into the chest cavity.
Watch for postprocedureairway swelling,complaints of sore throat.
Common Medical Treatments 19.1 Respiratory Disorders
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Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 7
Drug Guide 19.1
Medication Action Indication Nursing Implications
Treatment and preventionof influenza A
Treatment of severe lowerrespiratory tractinfection with RSV
Exert a potent, locallyacting anti-inflammatoryeffect to decrease thefrequency and severityof asthma attacks. Mayalso delay pulmonarydamage that occurswith chronic asthma.
Suppress inflammation and normal immuneresponse. Very effective,but long-term or chronicuse can result in pepticulceration, alteredgrowth, and numerousother side effects.
Treatment of runny orstuffy nose
Decrease inflammatoryresponse by antago-nizing the effects ofleukotrienes (whichmediate the effects ofairway edema, smoothmuscle constriction,altered cellular activity)
Influenza A
Usually reserved for treat-ment of RSV in the ventilated client. Has notbeen shown to signifi-cantly reduce length ofstay, morbidity, ormortality.
Maintenance program forasthma, chronic lungdisease. Acute treatmentof croup syndromes.
Treatment of acute exacer-bations of asthma orwheezing with chroniclung disease. Acutetreatment of severecroup.
Common cold, limited butpossible usefulness insinusitis and allergic rhinitis
Long-term control ofasthma in children age1 year and older.Montelukast: for allergicrhinitis in children 6 months and older.
Amantadine, rimantidine:Monitor for confusion,nervousness, andjitteriness.
Zanamivir, oseltamivir: Welltolerated but expensive
Administer via aerosol withthe small-particleaerosol generator(SPAG). Suction patientson assisted ventilationevery 2 hours; monitorpulmonary pressuresevery 2 to 4 hours. Maycause blurred vision andphotosensitivity.
Not for treatment of acutewheezing. Rinse mouthafter inhalation todecrease incidence offungal infections, drymouth, and hoarseness.Minimal systemic absorp-tion makes inhaledsteroids the treatment ofchoice for asthmamaintenance program.
May cause hyperglycemia.May suppress reactionto allergy tests. Consultphysician if vaccinationsare ordered duringcourse of systemiccorticosteroid therapy.Short courses of therapyare generally safe.Children on long-termdosing should havegrowth assessed.
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Drug Guide 19.1
Medication Action Indication Nursing Implications
Administered via inhalation.Prevent release of
histamine from sensitizedmast cells, resulting indecreased frequencyand intensity of allergicreactions.
Administered orally orintravenously.
To provide for continuousairway relaxation.
Sustained-release oralpreparation can beused to preventnocturnal symptoms.
Requires serum levelmonitoring.
Stimulates the respiratorycenter
Enzyme that hydrolyzesthe DNA in sputum,reducing sputumviscosity.
Monoclonal antibodyused to prevent seriouslower respiratory RSVdisease
Maintenance program forasthma and chroniclung disease, pre-exposure treatmentfor allergens
Used late in the course oftreatment for moderateor severe asthma inorder to achieve long-term control. Alsoindicated for apnea ofprematurity (see“Caffeine”).
Apnea of prematurity
Cystic fibrosis
For certain high-risk groupsof children
For prophylactic use, not torelieve bronchospasmduring an acute wheez-ing episode. Can beused 10 to 15 minutesprior to exposure toallergen, to decreasereaction to allergen.
Monitor drug levels routinely.Report signs of toxicityimmediately: tachy-cardia, nausea, vomiting,diarrhea, stomachcramps, anorexia,confusion, headache,restlessness, flushing,increased urination,seizures, arrhythmias,insomnia.
See “Methylxanthines.”
Monitor for dysphonia andpharyngitis.
Should be administeredmonthly during the RSVseason. Givenintramuscularly only.
Drug Guide 19.1 Common Drugs for Respiratory Disorders (continued)
Mast-cell stabilizers(cromolyn,nedocromil)
Methylxanthines(theophylline,aminophylline)
Caffeine
Pulmozyme (dornasealfa)
Synagis (palivizumab)
Objective
Reduce the proportion ofchildren who are regularlyexposed to tobaccosmoke at home.
Significance
• Educate the familyabout the effects thatpassive smoking has onchildren.
rapid respirations, increased work of breathing, ear, nose,sinus, or throat pain, ear pulling, headache, vomiting withcoughing, poor feeding, and lethargy. Also inquire aboutexposure to second-hand smoke. Children exposed toenvironmental smoke have an increased incidence of res-piratory illnesses such as asthma, bronchitis, and pneu-monia (Sheahan & Free, 2005). See Healthy People 2010.
Physical ExaminationPhysical examination of the respiratory system includesinspection and observation, auscultation, percussion, andpalpation.
Inspection and ObservationColor. Observe the child’s color, noting pallor or cyanosis(circumoral or central). Pallor (pale appearance) occurs asa result of peripheral vasoconstriction in an effort to con-serve oxygen for vital functions. Cyanosis (a bluishtinge to the skin) occurs as a result of hypoxia. It mightfirst present circumorally (just around the mouth) andprogress to central cyanosis. Newborns might have bluehands and feet (acrocyanosis), a normal finding. Theinfant might have pale hands and feet when cold or whenill, as peripheral circulation is not well developed in earlyinfancy. It is important, then, to note if the cyanosis iscentral (involving the midline), as this is a true sign ofhypoxia. Children with low red blood cell counts mightnot demonstrate cyanosis as early in the course of hypox-
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 9
emia as children with normal hemoglobin levels. There-fore, absence of cyanosis or the degree of cyanosis presentis not always an accurate indication of the severity of res-piratory involvement.
Note the rate and depth of respiration as well as workof breathing. Often the first sign of respiratory illness ininfants and children is tachypnea.
Nose and Oral Cavity. Inspect the nose and oral cavity.Note nasal drainage and redness or swelling in the nose.Note the color of the pharynx, presence of exudates, ton-sil size and status, and presence of lesions anywhere withinthe oral cavity.
Cough and Other Airway Noises. Note the sound of thecough (is it wet, productive, dry and hacking, tight?). Ifnoises associated with breathing are present (grunting,stridor, or audible wheeze) these should also be noted.Grunting occurs on expiration and is produced by pre-mature glottic closure. It is an attempt to preserve or in-crease functional residual capacity. Grunting might occurwith alveolar collapse or loss of lung volume, such as inatelectasis, pneumonia, and pulmonary edema. Stridor,a high-pitched, readily audible inspiratory noise, is a signof upper airway obstruction. Sometimes wheezes can beheard with the naked ear; these are referred to as audiblewheezes.
Respiratory Effort. Assess respiratory effort for depthand quality. Is breathing labored? Infants and childrenwith significant nasal congestion may have tachypnea,which usually resolves when the nose is cleared of mucus.Mouth breathing also may occur when a large amountof nasal congestion is present. Increased work of breath-ing, particularly if associated with restlessness and anx-iety, usually indicates lower respiratory involvement.Assess for the presence of nasal flaring, retractions,or head bobbing. Nasal flaring can occur early in thecourse of respiratory illness and is an effort to inhalegreater amounts of oxygen.
Suprasternal notch(Suprasternal retractions)
Xiphoid area(Suprasternal retractions)
Ribs(Intercostalretractions)
● Figure 19.3 Location of retractions.
Anxiety and Restlessness. Is the child anxious or restless?Restlessness, irritability, and anxiety result from diffi-culty in securing adequate oxygen. These might be veryearly signs of respiratory distress, especially if accompa-nied by tachypnea. Restlessness might progress to list-lessness and lethargy if the respiratory dysfunction is notcorrected (Fig. 19.5).
Clubbing. Inspect the fingertips for the presence ofclubbing, an enlargement of the terminal phalanx of thefinger, resulting in a change in the angle of the nail to thefingertip (Fig. 19.6). Clubbing might occur in children
● Figure 19.4 Seesaw respirations.
Synchronized respirations Lag on respirations Seesaw respirations
Retractions (the inward pulling of soft tissues withrespiration) can occur in the intercostal, subcostal, sub-sternal, supraclavicular, or suprasternal regions (Fig. 19.3).Document the severity of the retractions: mild, moderate,or severe. Also note the use of accessory neck muscles.Note the presence of paradoxical breathing (lack of simul-taneous chest and abdominal rise with the inspiratoryphase; Fig. 19.4). Bobbing of the head with each breath isalso a sign of increased respiratory effort.
A slow or irregular respiratory rate in an acutely ill infant or child is an ominous sign. See Chapter 32: Nursing Care of the Child During a Pediatric
Emergency.
Seesaw (or paradoxical) respirations are very ineffective for ventilation and oxygenation. Thechest falls on inspiration and rises on expiration.
10 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
● Figure 19.5 Hypoxia and respiratory distresslead to anxiety and air hunger.
A B CNormal Early clubbing Advanced clubbing● Figure 19.6 (A) Normal finger-
tip. (B) Clubbing.
with a chronic respiratory illness. It is the result ofincreased capillary growth as the body attempts to supplymore oxygen to distal body cells.
Hydration Status. Note the child’s hydration status. Thechild with a respiratory illness is at risk for dehydration.Pain related to sore throat or mouth lesions may preventthe child from drinking properly. Nasal congestion inter-feres with the infant’s ability to suck effectively at the breastor bottle. Tachypnea and increased work of breathinginterfere with the ability to safely ingest fluids.
Assess the oral mucosa for color and moisture. Noteskin turgor, presence of tears, and adequacy of urineoutput.
AuscultationAssess lung sounds via auscultation. Evaluate breathsounds over the anterior and posterior chest, as well as inthe axillary areas. Note the adequacy of aeration. Breathsounds should be equal bilaterally. The intensity andpitch should be equal throughout the lungs; documentdiminished breath sounds. In the absence of concurrentlower respiratory illness, the breath sounds should beclear throughout all lung fields. During normal respira-
tion, the inspiratory phase is usually softer and longerthan the expiratory phase.
Prolonged expiration is a sign of bronchial or bron-chiolar obstruction. Bronchiolitis, asthma, pulmonaryedema, and an intrathoracic foreign body can cause pro-longed expiratory phases.
Infants and young children have thin chest walls.When the upper airway is congested (as in a severe cold),the noise produced in the upper airway might be trans-mitted throughout the lung fields. When upper airwaycongestion is transmitted to the lung fields, the congested-sounding noise heard over the trachea is the same typeof noise heard over the lungs but is much louder andmore intense. To ascertain if these sounds are trulyadventitious lung sounds or if they are transmitted fromthe upper airway, auscultate again after the child coughsor his or her nose has been suctioned. Another way to dis-cern the difference is to compare auscultatory findingsover the trachea to the lung fields to determine if theabnormal sound is truly from within the lung or is actu-ally a sound transmitted from the upper airway.
Note adventitious sounds heard on auscultation.Wheezing, a high-pitched sound that usually occurs onexpiration, results from obstruction in the lower trachea orbronchioles. Wheezing that clears with coughing is mostlikely a result of secretions in the lower trachea. Wheez-ing resulting from obstruction of the bronchioles, as inbronchiolitis, asthma, chronic lung disease, or cystic fibro-sis, that does not clear with coughing. Rales (cracklingsounds) result when the alveoli become fluid-filled, suchas in pneumonia. Note the location of the adventitioussounds as well as the timing (on inspiration, expiration, orboth). Tachycardia might also be present. An increase inheart rate often initially accompanies hypoxemia.
PercussionWhen percussing, note sounds that are not resonant innature. Flat or dull sounds might be percussed over partiallyconsolidated lung tissue, as in pneumonia. Tympany mightbe percussed with a pneumothorax. Note the presence ofhyperresonance (as might be apparent with asthma).
PalpationPalpate the sinuses for tenderness in the older child.Assess for enlargement or tenderness of the lymph nodesof the head and neck. Document alterations in tactilefremitus detected on palpation. Increased tactile fremitusmight occur in a case of pneumonia or pleural effusion.
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 11
Fremitus might be decreased in the case of barrel chest,as with cystic fibrosis. Absent fremitus might be notedwith pneumothorax or atelectasis.
Compare central and peripheral pulses. Note the qual-ity of the pulse as well as the rate. With significant respira-tory distress, perfusion often becomes compromised. Poorperfusion might be reflected in weaker peripheral pulses(radial, pedal) when compared to central pulses.
Laboratory and Diagnostic TestingCommon Laboratory and Diagnostic Tests 19.1 explainsthe laboratory and diagnostic tests most commonly usedfor a child with a respiratory disorder. The tests can assistthe physician in diagnosing the disorder and/or be used as
guidelines in determining ongoing treatment. Laboratoryor non-nursing personnel obtain some of the tests, whilethe nurse might obtain others. In either instance the nurseshould be familiar with how the tests are obtained, whatthey are used for, and normal versus abnormal results.This knowledge will also be necessary when providingpatient and family education related to the testing.
Common Laboratory and Diagnostic Tests 19.1
Test Explanation Indication Nursing Implications
Suggested allergen isapplied to skin viascratch, pin or prick. A wheal responseindicates allergy to thesubstance. Carries riskof anaphylaxis. (Nursingnote: Antihistaminesmust be discontinuedbefore testing, as theyinhibit the test.)
Invasive method (requiresblood sampling) ofmeasuring arterial pH,partial pressure ofoxygen and carbondioxide, and baseexcess in blood
Radiographic image ofthe expanded lungs:can show hyperinflation,atelectasis, pneumonia,foreign body, pleuraleffusion, abnormalheart or lung size
Close observation for anaphylaxisis necessary. Epinephrine andemergency equipment shouldbe readily available. Somechildren react to the skin testalmost immediately; otherstake several minutes.
Hold pressure for several minutesafter a peripheral arterial stickto avoid bleeding. Radialarterial sticks are commonand can be very painful.Note if the child is cryingexcessively during the blooddraw, as this affects thecarbon dioxide level.
Children may be afraid of the x-ray equipment. If a parentor familiar adult can accom-pany the child, often the childis less afraid. If the child isunable or unwilling to hold stillfor the x-ray, restraint may benecessary. Restraint should belimited to the amount of timeneeded for the x-ray.
To obtain a nasopharyngealspecimen instill 1 to 3 mL ofsterile normal saline into onenostril, aspirate the contentsusing a small sterile bulbsyringe, place the contents insterile container, and immedi-ately send them to the lab.
Common Laboratory and Diagnostic Tests 19.1 Respiratory Disorders
Allergy skintesting
Arterial bloodgases
Chest x-ray
Fluorescentantibodytesting
(continued)
Ambient light may interfere with pulse oximetryreadings. When the pulse oximeter probe isplaced on the infant’s foot or young child’s toe,covering the probe and foot with a sock may
help to ensure an accurate measurement.
12 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
Common Laboratory and Diagnostic Tests 19.1
Test Explanation Indication Nursing Implications
Radiographic examinationthat uses a fluorescentscreen—“real-time”imaging
Instant test for presence of strep A antibody inpharyngeal secretions
Measures minute quantitiesof immunoglobulin E inthe blood.
Carries no risk ofanaphylaxis but is not assensitive as skin testing.
Radiologic tests that mayshow sinus involvement
Identification of masses,abscesses
Tuberculosis
Daily use can indicateadequacy of asthmacontrol.
Asthma, cystic fibrosis,chronic lung disease
Can be useful in anysituation in which achild is experiencingrespiratory distress
Influenza
Pharyngitis, tonsillitis
Asthma (food allergies)
Sinusitis, recurrent colds
Requires the child to lay still.Equipment can be frightening.Children may respond topresence of parent orfamiliar adult.
Nasogastric tube is inserted andsaline is instilled and suctionedout of the stomach for thespecimen.
It is important to establish thechild’s “personal best” bytaking twice-daily readingsover a 2-week period whilewell. The average of these istermed “personal best.”Charts based on height andage are also available todetermine expected peakexpiratory flow.
Usually performed by a respi-ratory therapist trained to dothe full spectrum of tests.Spirometry can be obtainedby the trained nurse in theoutpatient setting.
Probe must be applied correctlyto finger, toe, foot, hand, orear in order for the machineto appropriately pick up thepulse and oxygen saturation.
Should be done in first 24 hoursof illness so that medicationadministration can begin.
Have the child gargle with sterilenormal saline and then spitinto a sterile container. Sendimmediately to the lab.
Results in 5 to 10 minutes.Negative tests should bebacked up with throatculture.
Blood test that is usually sent outto a reference laboratory
X-ray results are usually receivedmore quickly than CT or MRIresults.
Common Laboratory and Diagnostic Tests 19.1 Respiratory Disorders (continued)
Collection of sweat onfilter paper afterstimulation of skin withpilocarpine. Measuresconcentration ofchloride in the sweat.
Bacterial culture (minimumof 24 to 48 hours re-quired) to determinepresence of streptococ-cus A or other bacteria
Mantoux test (intradermalinjection of purifiedprotein derivative)
Pneumonia, cysticfibrosis, tuberculosis
Cystic fibrosis
Pharyngitis, tonsillitis
Tuberculosis, chroniccough
Must be true sputum, not mucusfrom the mouth or nose. Childcan deep breathe, cough,and spit, or specimen may beobtained via suctioning of theartificial airway.
May be difficult to obtain sweatin a young infant
Can be obtained on separateswab at same time as rapidstrep test to decrease traumato the child (swab both appli-cators at once). Do notperform immediately after thechild has had medication orsomething to eat or drink.
Must be given intradermally; nota valid test if injectedincorrectly
Common Laboratory and Diagnostic Tests 19.1 Respiratory Disorders (continued)
Sputum culture
Sweat chloridetest
Throat culture
Tuberculin skintest
NURSING DIAGNOSES, GOALS,INTERVENTIONS, AND EVALUATIONUpon completion of a thorough assessment, the nursemight identify several nursing diagnoses, including:
• Ineffective airway clearance• Ineffective breathing pattern• Impaired gas exchange• Risk for infection• Pain• Risk for fluid volume deficit• Altered nutrition, less than body requirements• Activity intolerance• Fear• Altered family processes• Pain
in planning nursing care for the child with a respiratorydisorder. The nursing care plan should be individualizedbased on the patient’s symptoms and needs; refer toChap. 15 for detailed information on pain management.Additional information will be included later in the chap-ter as it relates to specific disorders.
Oxygen SupplementationOxygen may be delivered to the child by a variety ofmethods (Fig. 19.7). Since oxygen administration is con-sidered a drug, it requires a physician’s order, except whenfollowing emergency protocols outlined in a health carefacility’s policies and procedures. Many health care set-tings develop specific guidelines for oxygen administra-tion that are often coordinated by respiratory therapists,yet the nurse still remains responsible for ensuring thatoxygen is administered properly.
Oxygen sources include wall-mounted systems as wellas cylinders. The supply of oxygen available from a wall-mounted source is limitless, but use of a wall-mountedsource restricts the child to the hospital room. Cylindersare portable oxygen tanks; the D-cylinder holds a little less
Nursing goals, interventions, and evaluation for thechild with a respiratory disorder are based on the nursingdiagnoses. Nursing Care Plan 19.1 can be used as a guide
After completing an assessment of Alexander, thenurse notes the following: lots of clear secretions in theairway, child appears pale, respiratory rate 68, retrac-tions, nasal flaring, wheezing, and diminished breathsounds. Based on these assessment findings, what wouldyour top three nursing diagnoses be for Alexander?
Based on your top three nursing diagnoses forAlexander, describe appropriate nursing interventions.
(text continues on page 000)
14 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
Nursing Care Plan
Nursing Diagnosis: Ineffective airway clearance related to inflammation,increased secretions, mechanical obstruction, or pain as evidenced by presenceof secretions, productive cough, tachypnea, and increased work of breathing
Nursing Diagnosis: Ineffective breathing pattern related to inflammatory or infectious process as evidenced by tachypnea, increased work of breathing, nasal flaring, retractions, diminishedbreath sounds
Nursing Care Plan 19.1Overview for the Child with a Respiratory Disorder
Outcome identification and evaluationChild will maintain patent airway, free from secretions or obstruction, easy work of
breathing, respiratory rate within parameters for age.
Interventions: maintaining a patent airway• Position with airway open (sniffing position if supine): open airway allows adequate
ventilation.• Humidify oxygen or room air and ensure adequate fluid intake (intravenous or oral) to
help liquefy secretions for ease in clearance.• Suction with bulb syringe or via nasopharyngeal catheter as needed, particularly prior to
bottle-feeding to promote clearance of secretions.• If tachypneic, maintain NPO status to avoid risk of aspiration.• In older child, encourage expectoration of sputum with coughing to promote airway
clearance.• Perform chest physiotherapy if ordered to mobilize secretions.• Ensure emergency equipment is readily available to avoid delay should airway become
unmaintainable.
Outcome identification and evaluationChild will exhibit adequate ventilation: respiratory rate within parameters for age, easy
work of breathing (absence of retractions, accessory muscle use, grunting), clearbreath sounds with adequate aeration, oxygen saturation >94% or within prescribed parameters.
Interventions: promoting effective breathing patterns• Assess respiratory rate, breath sounds, and work of breathing frequently to ensure
progress with treatment and so that deterioration can be noted early.• Use pulse oximetry to monitor oxygen saturation in the least invasive manner to note
adequacy of oxygenation and ensure early detection of hypoxemia.• Position for comfort with open airway and room for lung expansion and use pillows or
padding if necessary to maintain position to ensure optimal ventilation via maximumlung expansion.
• Administer supplemental oxygen and/or humidity as ordered to improve oxygenation.• Allow for adequate sleep and rest periods to conserve energy.• Administer antibiotics as ordered: may be indicated in the case of bacterial respiratory
infection.• Encourage incentive spirometry and coughing with deep breathing (can be
accomplished through play) to maximize ventilation (play enhances the child’sparticipation).
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 15
Overview for the Child with a Respiratory Disorder (continued)
Nursing Diagnosis: Risk for infection related to presence of infectious organisms as evidenced byfever or presence of virus or bacteria on laboratory screening
Outcome identification and evaluationChild will exhibit no signs of secondary infection and will not spread infection to others:
symptoms of infection decrease over time; others remain free from infection.
Interventions: preventing infection• Maintain aseptic technique, practice good hand washing, and use disposable suction
catheters to prevent introduction of further infectious agents.• Limit number of visitors and screen them for recent illness to prevent further infection.• Administer antibiotics if prescribed to prevent or treat bacterial infection.• Encourage nutritious diet according to child’s preferences and ability to feed orally to
assist body’s natural infection-fighting mechanisms.• Isolate the child as required to prevent nosocomial spread of infection• Teach child and family preventive measures such as good hand washing, covering
mouth and nose when coughing or sneezing, adequate disposal of used tissues toprevent nosocomial or community spread of infection.
Nursing Diagnosis: Fluid volume deficit, risk for, related to decreased oral intake, insensible lossesvia fever, tachypnea, or diaphoresis
Outcome identification and evaluationFluid volume will be maintained: Oral mucosa moist and pink, skin turgor elastic, urine
output at least 1 to 2 mL/kg/hr.
Interventions: maintaining adequate fluid volume• Administer intravenous fluids if ordered to maintain adequate hydration in NPO state.• When allowed oral intake, encourage oral fluids. Popsicles, favorite fluids, and games
can be used to promote intake.• Assess for signs of adequate hydration (elastic skin turgor, moist mucosa, adequate urine
output).• Strict intake and output monitoring can help identify fluid imbalance.• Urine specific gravity, urine and serum electrolytes, blood urea nitrogen, creatinine, and
osmolality are reliable indicators of fluid status.
(continued)
Nursing Diagnosis: Gas exchange, impaired, related to airway plugging, hyperinflation, atelectasisas evidenced by cyanosis, decreased oxygen saturation, and alterations in arterial blood gases
Outcome identification and evaluationGas exchange will be adequate: Pulse oximetry reading on room air is within normal
parameters for age, blood gases within normal limits, absence of cyanosis.
Interventions: promoting adequate gas exchange• Administer oxygen as ordered to improve oxygenation.• Monitor oxygen saturation via pulse oximetry to detect alterations in oxygenation.• Encourage clearance of secretions via coughing, expectoration, chest physiotherapy,
and suctioning: mobilization of secretions may improve gas exchange.• Administer bronchodilators if ordered (albuterol, levalbuterol, and racemic epinephrine)
to treat bronchospasm and improve gas exchange.• Provide frequent contact and support to the child and family to decrease anxiety,
which increases the child’s oxygen demands.• Assess and monitor mental status (confusion, lethargy, restlessness, combativeness):
hypoxemia can lead to changes in mental status.
16 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
Overview for the Child with a Respiratory Disorder (continued)
Nursing Diagnosis: Nutrition, altered: less than body requirements related to difficulty feeding asevidenced by poor oral intake, tiring with feeding
Nursing Diagnosis: Activity intolerance related to high respiratory demand as evidenced byincreased work of breathing and requirement for frequent rest when playing
Outcome identification and evaluationChild will maintain adequate nutritional intake: Weight gain or maintenance occurs. Child
consumes adequate diet for age.
Interventions: promoting adequate nutritional intake• Weigh on same scale at same time daily: weight gain or maintenance can indicate
adequate nutritional intake.• Calorie counts over a 3-day period are helpful in determining if caloric intake is
sufficient.• Assist family and child to choose higher-calorie, protein-rich foods to optimize growth
potential.• Coax young children to eat better by playing games and offering favorite foods
resulting in improved intake.
Outcome identification and evaluationChild will resume normal activity level: Activity is tolerated without difficulty breathing. Pulse
oximetry readings and vital signs within parameters for age and activity level.
Interventions: increasing activity tolerance• Provide rest periods balanced with periods of activity. Group nursing activities and visits
to allow for sufficient rest. Activity increases myocardial oxygen demand so must bebalanced with rest.
• Provide small, frequent meals to prevent overtiring (energy is expended while eating).
• Encourage quiet activities that do not require exertion to prevent boredom.• Allow gradual increase in activity as tolerated, keeping pulse oximetry reading within
normal parameters, to minimize risk for further respiratory compromise.
Nursing Diagnosis: Fear related to difficulty breathing, unfamiliar personnel, procedures, and envi-ronment (hospital) as evidenced by clinging, crying, fussing, verbalization, or lack of cooperation
Outcome identification and evaluationFear/anxiety will be reduced: decreased episodes of crying or fussing, happy and playful
at times.
Interventions: relieving fear• Establish trusting relationship with child and family to decrease anxiety and fear.• Explain procedures to child at developmentally appropriate level to decrease fear of
unknown.• Provide favorite blanket or bear to patient, as well as comfort measures preferred by
client such as rocking or music for added security.• Involve parents in care to give child reassurance and decrease fear.
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 17
Overview for the Child with a Respiratory Disorder (continued)
Nursing Diagnosis: Family processes, altered, related to child’s illness or hospitalization as evidenced by family’s presence in hospital, missed work, demonstration of inadequate coping
Outcome identification and evaluationParents demonstrate adequate coping and decreased anxiety: Parents are involved in
child’s care, ask appropriate questions and are able to discuss child’s care andcondition calmly.
Interventions: promoting adequate family processes• Encourage parents’ verbalization of concerns related to child’s illness: allows for
identification of concerns and demonstrates to the family that the nurse also caresabout them, not just the child.
• Explain therapy, procedures, and child’s behavior to parents; developing anunderstanding of the child’s current status helps decrease anxiety.
• Encourage parental involvement in care so that parents may continue to feel neededand valued.
� Figure 19.7 (A) Simple oxygen mask provides about 40% oxygen. (B) The nasalcannula provides an additional 4% oxygen per 1 L of oxygen flow (i.e., 1 L will deliver 25% oxygen). (C) The nonrebreather mask provides 80%–100% oxygen.
A B C
than 400 liters of oxygen and the E-cylinder holds about650 liters of oxygen. Cylinders turn on with a metal keythat is kept with the tank. The tank empties relativelyquickly if the child requires a high flow of oxygen, so thisis not the best oxygen source in an emergency. The cylin-der is useful for the child on low-flow oxygen because itallows mobility.
Respiratory therapists usually maintain the respira-tory equipment that is found in the emergency room orhospital. However, in an outpatient setting the nurse maybe responsible for maintaining respiratory equipment and
checking the level of oxygen in the office’s oxygen tankseach day.
The efficiency of oxygen delivery systems is affected byseveral variables, including the child’s respiratory effort, theliter flow of oxygen delivered, and whether the equipment
Oxygen is highly flammable, so use safety pre-cautions. Post signs (“Oxygen in Use”); inform thefamily to avoid matches, lighters, and flammable or volatile materials; and use only facility-
approved equipment.
18 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
is being used appropriately. In general, oxygen facemaskscome in infant, child, and adult sizes. Select the mask thatbests fits the child. In addition, ensure that the mask issealed properly to decrease the amount of oxygen thatescapes from the mask. Ensure that the liter flow is setaccording to the manufacturer’s recommendations for usewith that particular delivery method. The oxygen flowrate or concentration is usually determined by the physi-cian’s order. Whichever method of delivery is used, pro-vide humidification during oxygen delivery to preventdrying of nasal passages and to assist with liquefying secre-tions. Table 19.1 gives details on oxygen delivery methods.
Nursing AssessmentThe child may have either a stuffy or runny nose. Nasaldischarge is usually thin and watery at first but maybecome thicker and discolored. The color of nasal dis-charge is not an accurate indicator of viral versus bacte-rial infection. The child may be hoarse and complain ofa sore throat. Cough usually produces very little spu-tum. Fever, fatigue, watery eyes, and appetite loss mayalso occur. Symptoms are generally at their worst overthe first few days and then decrease over the course ofthe illness.
Assess for risk factors such as daycare or school atten-dance. Inspect for edema and vasodilation of the mucosa.Diagnosis is based on clinical presentation rather thanlab or x-ray studies. Comparison Chart 19.1 differentiatescauses of nasal congestion.
Nursing ManagementNursing management of the child with a common coldconsists of promoting comfort, providing family education,and preventing spread of the cold.
Promoting ComfortNursing care of the common cold is aimed at support-ive measures. Nasal congestion may be relieved with the use of normal saline nose drops, followed by bulbsyringe suctioning in infants and toddlers. Older chil-dren may use a normal saline nose spray to mobilizesecretions. A cool mist humidifier also helps with nasalcongestion. Generally, other over-the-counter nose spraysare not recommended for use in children, but they aresometimes prescribed for very short-term use. Promotionof adequate oral fluid intake is important to liquefysecretions.
Educate parents about the use of cold and cough med-ications. Although they may offer some symptomatic relief,they have not been proven to shorten the length of coldsymptoms. Counsel parents to use the appropriate productdepending on the symptom relief desired, rather than acombination product. Products containing acetaminophencombined with other “cold symptom” medications maymask a fever in the child who is developing a secondarybacterial infection. As with all viral infections in children,teach parents that aspirin use should be avoided becauseof its association with Reye syndrome.
Providing Family EducationCurrently there are no medications available to treat theviruses that cause the common cold, so symptomatictreatment is all that is necessary. Antibiotics are not indi-cated unless the child also has a bacterial infection.Explain to parents the importance of reserving antibioticuse for appropriate illnesses. Provide education aboutthe use of normal saline nose drops and bulb suctioning
Acute Infectious DisordersAcute infectious disorders include the common cold,sinusitis, influenza, pharyngitis, tonsillitis, laryngitis, croupsyndromes, respiratory syncytial virus (RSV), pneumonia,and bronchitis.
● COMMON COLDThe common cold is also referred to as a viral upper res-piratory infection (URI) or nasopharyngitis. Colds canbe caused by a number of different viruses, includingrhinoviruses, parainfluenza, RSV, enteroviruses, andadenoviruses (National Institute of Allergy and InfectiousDiseases, 2004). Recently, human meta-pneumovirushas been identified as an important cause of the commoncold (Burke, 2004). Viral particles spread through the airor from person-to-person contact. Colds occur more fre-quently in winter. They affect children of all ages and havea higher incidence among daycare attendees and school-age children. It is not unusual for a child to have six tonine colds per year. Passive smoking increases the risk ofcatching colds (Johannsson et al., 2003). Spontaneousresolution occurs after about 7 to 10 days. Potential com-plications include secondary bacterial infections of theears, throat, sinuses, or lungs.
Therapeutic management of the common cold isdirected toward symptom relief. Nasal congestion may berelieved via humidity and use of normal saline nasal washor spray followed by suctioning. Antihistamines are notindicated, as they dry secretions further. Over-the-countercold preparations are available singly and in combinations.These preparations have not been proven to reduce thelength or severity of the cold but may offer symptomaticrelief in some children.
Monitor vital signs, color, respiratory effort, pulse oximetry, and level of consciousness before, during, and after oxygen therapy to evaluate its
effectiveness.
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 19
Table 19.1Table 19.1 Oxygen Delivery Methods
Delivery Method Description Nursing Implications
Simple mask
Venturi mask
Nasal cannula
Oxygen tent
Oxygen hood
Partial rebreathingmask
Nonrebreathingmask
Provides 35% to 60% oxygenwith a flow rate of 6 to 10 L/minute. Oxygen deliverypercentage affected byrespiratory rate, inspiratoryflow, and adequacy of mask fit.
Provides 24% to 50% oxygen byusing a special gauge atthe base of the mask thatallows mixing of room airwith oxygen flow
Provides low oxygen con-centration (22% to 44%) butneeds patent nasalpassages
Provides high-humidityenvironment with up to50% oxygen concentration
Provides high concentration(up to 80% to 90%) forinfants only. Allows easyaccess to chest and lowerbody.
Simple facemask with anoxygen reservoir bag.Provides 50% to 60% oxygenconcentration.
Simple facemask with valvesat the exhalation ports andan oxygen reservoir bagwith a valve to preventexhaled air from enteringthe reservoir. Provides 95%oxygen concentration.
• Must maintain oxygen flow rate of at least 6 L/minuteto maintain inspired oxygen concentration andprevent rebreathing of carbon dioxide
• Mask must fit snugly to be effective but should not beso tight as to irritate the face.
• Set oxygen flow rate according to percentage ofoxygen desired as indicated on the gauge/dial.
• As with simple mask, must fit snugly
• Must be used with humidification to prevent dryingand irritation of airways
• Can provide very small amounts of oxygen (as low as25 cc/minute)
• Maximum recommended liter flow in children is 4 L/minute.
• Children can eat or talk while on oxygen.• Inspired oxygen concentration affected by mouth
breathing• Requires patent nasal passages
• Oxygen level drops when tent is opened.• Must change linen frequently as it becomes damp
from the humidity• Secure edges of tent with blankets or by tucking
edges under mattress.• Young children may be fearful and resistant.• Mist may interfere with visualization of child inside
tent.
• Liter flow must be set at 10 to 15 L/minute.• Good method for infant but need to remove
for feeding• Can and should be humidified
• Must set liter flow rate at 10 to 12 L/min to preventrebreathing of carbon dioxide
• The reservoir bag does not completely empty whenchild inspires if flow rate is set properly.
• Must set liter flow rate at 10 to 12 L/min to preventrebreathing of carbon dioxide
• The reservoir bag does not completely empty whenchild inspires if flow rate is set properly.
20 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
● COMPARISON CHART 19.1 Causes of Nasal Congestion
Sign or Symptom Allergic Rhinitis Common Cold Sinusitis
Length of illness
Nasal discharge
Nasal congestion
Sneezing
Cough
Headache
Fever
Bad breath
Varies, may have year-roundsymptoms
Thin, watery, clear
Varies
Varies
Varies
Varies
Absent
Absent
10 days or less
Thick, white, yellow, orgreen; can be thin
Present
Present
Present
Varies
Varies
Absent
Longer than 10 to 14 days
Thick, yellow or green
Present
Absent
Varies
Varies
Varies
Varies
HOMEMADE SALT WATER NOSE DROPS
Mix 8 oz distilled water, a half-teaspoon sea salt, and aquarter-teaspoon baking soda. Keeps for 24 hours inthe refrigerator, but should be allowed to come toroom temperature prior to use.
BOX 19.2
to clear the infant’s nose of secretions. Normal salinenasal wash using a bulb syringe to instill the solution isalso helpful for children of all ages with nasal congestion.Though normal saline for nasal administration is avail-able commercially, parents can also make it at home(Box 19.2). Teaching Guideline 19.1 gives instructionson use of the bulb syringe.
Counsel parents about symptoms of complications ofthe common cold. These include:
• Prolonged fever• Increased throat pain or enlarged, painful lymph nodes• Increased or worsening cough, cough lasting longer than
10 days, chest pain, difficulty breathing• Earache, headache, tooth or sinus pain• Unusual irritability or lethargy• Skin rash
If complications do occur, tell parents to notify thehealth care provider for further instruction or reassessment.
Preventing the Common ColdTeaching about ways to prevent the common cold is avital nursing intervention. Explain that frequent handwashing helps to decrease the spread of viruses thatcause the common cold. Teach parents and family toavoid second-hand smoke as well as crowded places,especially during the winter. Avoid close contact with
individuals known to have a cold. Encourage parentsand families to consume a healthy diet and get enoughrest (Torpy, 2003). See Healthy People 2010.
● SINUSITISSinusitis (also called rhinosinusitis) generally refers to abacterial infection of the paranasal sinuses. The diseasemay be either acute or chronic in nature, with the treatmentapproach varying with chronicity. Approximately 5% ofupper respiratory infections are complicated with acutesinusitis. In young children the maxillary and ethmoidsinuses are the main sites of infection. After age 10 years,the frontal sinuses may be more commonly involved.Mucosal swelling, decreased ciliary movement, and thick-ened nasal discharge all contribute to bacterial invasionof the nose. Nasal polyps also place the child at risk forbacterial sinusitis. Complications include orbital cellulitisand intracranial infections such as subdural empyemas.
Symptoms lasting less than 30 days generally indicateacute sinusitis, whereas symptoms persisting longer than4 to 6 weeks usually indicate chronic sinusitis. Sinusitis ismanaged with antibiotic treatment. The course of treat-ment is a minimum of 10 days. The current American
Corey Davis, a 3-year-old, is brought to the clinic by hermother. She presents with a runny nose, congestion, and anonproductive cough. Her mother says, “She is miserable.”
What other assessment information would be helpful?
Based on the history and clinical presentation, Coreyis diagnosed with a common cold. What educationwould be helpful for this family? Include ways toimprove Corey’s comfort and ways to prevent thecommon cold.
ConsiderConsiderTHIS!
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 21
T E A C H I N G G U I D E L I N E 1 9 . 1
Using the Bulb Syringe to Suction Nasal Secretions
• Place rubber tip in infant’s nose and release pressureon the bulb.
• Hold the infant on your lap or on the bed with headtilted slightly back.
• (If using saline) Instill several drops of saline solutionin one of infant’s nostrils.
• Compress the sides of the bulb syringe completely.Use only a rubber-tipped bulb syringe.
• Remove the syringe and squeeze bulb over tissue orthe sink to empty it of secretions.
• Repeat on alternate nostril if necessary. Using a bulbsyringe prior to bottle-feeding or breastfeeding mayrelieve congestion enough to allow the infant to suckmore efficiently.
• Clean the bulb syringe thoroughly with warm waterafter each use and allow to air dry.
• Place rubber tip in infant’s nose and release pressureon the bulb.
• (If using saline) Instill several drops of saline solutionin one of infant’s nostrils.
22 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
Objective
Reduce the number ofcourses of antibiotics prescribed for the solediagnosis of the common cold.
Significance
• Appropriately educatefamilies that the causeof the common cold isa number of viruses andthat antibiotics areinappropriate for thetreatment of viral infections.
• Encourage families touse measures such asnormal saline nasalwashes to decreasesymptoms associatedwith the common coldmore quickly.
HEALTHY PEOPLE 2010
Academy of Pediatrics recommendations state that anti-biotics should be continued for 7 days once the child is freefrom symptoms to eradicate the infection (AAP, 2001).Naturally, chronic sinusitis requires a longer course oftreatment than acute sinusitis. Surgical therapy may beindicated for children with chronic sinusitis, particularly ifit is recurrent or if nasal polyps are present.
Nursing AssessmentThe most common presentation of sinusitis is persistentsigns and symptoms of a cold. Rather than improvingafter 7 to 10 days, nasal discharge persists. Explore thehistory for:
• Cough• Fever• In preschoolers or older children, halitosis (bad breath)• Facial pain may or may not be present, so is not a reliable
indicator of disease.• Eyelid edema (in the case of ethmoid sinus involvement)• Irritability• Poor appetite
Cold symptoms that are severe and not improvingover time may also indicate sinusitis (Leung & Kellner,2004). Assess for risk factors such as a history of recur-rent cold symptoms or a history of nasal polyps.
On physical examination, note eyelid swelling, extentof nasal drainage, and halitosis. Inspect the throat for evi-dence of postnasal drainage. Inspect the nasal mucosa forerythema. Palpate the sinuses, noting pain with mild pres-sure. The diagnosis may be made based on the historyand clinical presentation, augmented by x-ray, computedtomography scan, or magnetic resonance imaging find-ings in some cases (Leung & Kellner, 2004). (Refer toComparison Chart 19.1, which differentiates the causesof nasal congestion.)
Nursing ManagementNormal saline nose drops or spray, cool mist humidi-fiers, and adequate oral fluid intake are recommendedfor children with sinusitis. Teach families the impor-tance of continuing the full course of antibiotics toeradicate the cause of infection. Also educate the fam-ily that using decongestants, antihistamines, and intra-nasal steroids as adjuncts in the treatment of sinusitishas not been shown to be beneficial. Normal saline nosespray or nasal washes may promote drainage (Leung &Kellner, 2004).
● INFLUENZAInfluenza viral infection occurs primarily during the win-ter. “The flu” is spread through inhalation of droplets orcontact with fine-particle aerosols. Infected children shedthe virus for 1 to 2 days before symptoms begin. Averageannual infection rates in children range from 35% to 50%(Brunell et al., 2001). Influenza viruses primarily affectthe upper respiratory epithelium but can cause systemiceffects as well. Children with chronic heart or lung con-ditions, diabetes, chronic renal disease, or immune defi-ciency are at higher risk than other children for moresevere influenza infection.
Bacterial infections of the respiratory system com-monly occur as complications of influenza infection, severepneumococcal pneumonia in particular (AAP, 2002).Otitis media occurs in 30% to 50% of all influenza cases(Brunell et al., 2001). Less common complications includeReye syndrome and acute myositis. Reye syndrome is anacute encephalopathy that has been associated withaspirin use in the influenza-infected child. Acute myositisis particular to children. A sudden onset of severe painand tenderness in both calves causes the child to refuseto walk. Due to the potential for complications, a pro-longed fever or a fever that returns during convalescenceshould be investigated.
Nursing AssessmentChildren who attend daycare or school are at higher riskfor influenza infection than those who are routinelyat home. Note the presence of risk factors for severe disease, such as chronic heart or lung disease (such asasthma), diabetes, chronic renal disease, or immunedeficiency or children with cancer receiving chemother-apy. School-age children and adolescents experience theillness similarly to adults. Abrupt onset of fever, facialflushing, chills, headache, myalgia, and malaise areaccompanied by cough and coryza. About half ofinfected individuals have a dry or sore throat. Ocularsymptoms such as photophobia, tearing, burning, andeye pain are common.
Infants and young children exhibit symptoms sim-ilar to other respiratory illnesses. Fever greater than
39.5° C is common. Infants may be mildly toxic inappearance and irritable and have a cough, coryza, andpharyngitis. Wheezing may occur, as influenza also cancause bronchiolitis. An erythematous rash may be pres-ent, and diarrhea may also occur. Diagnosis may beconfirmed by a rapid assay test.
Nursing ManagementNursing management of influenza is mainly supportive.Symptomatic treatment of cough and fever and main-tenance of hydration are the focus of care. Amantadinehydrochloride (Symmetrel) and other newer antiviraldrugs can be effective in reducing symptoms associatedwith influenza if started within the first 24 to 48 hoursof the illness.
Preventing Influenza InfectionYearly vaccination against influenza is recommendedfor high-risk groups. Children who are 6 months or olderconsidered high risk are those who:
• Have chronic heart or lung conditions• Have sickle cell anemia or other hemoglobinopathy• Are under medical care for diabetes, chronic renal dis-
ease, or immune deficiency• Are on long-term aspirin therapy (risk of developing Reye
syndrome after the flu)
Among otherwise healthy children, infants and tod-dlers are at highest risk for developing severe disease. Allhealthy children between the ages of 6 and 59 monthsshould also be immunized. Refer to Chapter 9 for moreinformation on immunizations.
● PHARYNGITISInflammation of the throat mucosa (pharynx) is referredto as pharyngitis. A sore throat may accompany nasalcongestion and is often viral in nature. A bacterial sorethroat most often occurs without nasal symptoms. GroupA streptococci account for 15% to 30% of cases, withthe remainder being caused by other viruses or bacteria(Bisno, 2001).
Complications of group A streptococcal infectioninclude acute rheumatic fever (see Chapter 20) and acuteglomerulonephritis (see Chapter 22). An additionalcomplication of streptococcal pharyngitis is peritonsillarabscess; this may be noted by asymmetric swelling of thetonsils, shift of the uvula to one side, and palatal edema.Retropharyngeal abscess may also follow pharyngitis andis most common in young children (Ebell et al., 2000).It can progress to the point of airway obstruction andrequires careful evaluation and appropriate treatment.
Viral pharyngitis is usually self-limited and doesnot require therapy beyond symptomatic relief. Group Astreptococcal pharyngitis requires antibiotic therapy. If
either the rapid diagnostic test or throat culture (describedbelow) is positive for group A streptococci, penicillin is generally prescribed. Appropriate alternative anti-biotics include amoxicillin and, for those allergic topenicillin, macrolides and cephalosporins (Hayes &Williamson, 2001).
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 23
● Figure 19.8 Note the red color of the pharynx, as well asredness and significant enlargement of the tonsils.
Nursing AssessmentOnset of the illness is often quite abrupt. The history mayinclude a fever, sore throat and difficulty swallowing,headache, and abdominal pain, which are quite common.Inquire about recent incidence of viral or strep throat inthe family, daycare, or school setting.
Inspect the pharynx and tonsils, which may demon-strate varying degrees of inflammation (Fig. 19.8). Exudatemay be present but is not diagnostic of bacterial infection.Note the presence of petechiae on the palate. Inspect thetongue for a strawberry appearance. Palpate for enlarge-ment and tenderness of the anterior cervical nodes. Inspectthe skin for the presence of a fine, red, sandpaper-likerash (called scarlatiniform), particularly on the trunk or abdomen, a common finding with streptococcus Ainfection.
The nurse may obtain a throat swab for rapid diag-nostic testing and throat culture. If both tests are beingobtained, the applicators may be swabbed simultane-ously to decrease perceived trauma to the child. Therapid strep test is a sensitive and reliable measure rarely
A “strep carrier” is a child who has a positivethroat culture for streptococci when asymptomatic. Strep carriers are not at risk for complications from streptococci as
are those who are acutely infected with streptococci and are symptomatic.
resulting in false-positive readings (Farrar-Simpson et al.,2005). If the rapid strep test is negative, the second swabmay be sent for a throat culture.
Nursing ManagementNursing management of the child with pharyngitis focuseson promoting comfort and providing family education.
Promoting ComfortSaline gargles (made with 8 oz of warm water and a half-teaspoon of table salt) are soothing for children old enoughto cooperate. Analgesics such as acetaminophen andibuprofen may ease fever and pain. Sucking on throatlozenges or hard candy may also ease pain. Cool misthumidity helps to keep the mucosa moist in the event ofmouth breathing. Encourage the child to ingest Popsicles,cool liquids, and ice chips to maintain hydration.
Providing Family EducationParents may be accustomed to “sore throats” being treatedwith antibiotics, but in the case of a viral cause antibioticswill not be necessary and the pharyngitis will resolve in afew days. For the child with streptococcal pharyngitis, urgeparents to have the child complete the entire prescribedcourse of antibiotics (Parmet, 2004). After 24 hours ofantibiotic therapy, instruct the parents to discard thechild’s toothbrush to avoid reinfection. Children mayreturn to day care or school after they have been receiv-ing antibiotics for 24 hours, as they are considered non-contagious at that point.
● TONSILLITISInflammation of the tonsils often occurs with pharyngitisand thus may also be viral or bacterial in nature. Viralinfections require only symptomatic treatment. Treatmentfor bacterial tonsillitis is the same as for bacterial pharyn-gitis. Peritonsillar abscess may follow a bout of tonsillitisand requires incision and drainage of the pus-containingmass followed by a course of intravenous antibiotics(Belkengren & Sapala, 2003). Occasionally surgical inter-vention is warranted. Tonsillectomy (surgical removal ofthe palatine tonsils) may be indicated for the child withrecurrent streptococcal tonsillitis, massive tonsillar hyper-trophy, or other reasons. When hypertrophied adenoidsobstruct breathing, then adenoidectomy (surgical removalof the adenoids) may be indicated.
Nursing AssessmentNote whether fever is present currently or by history.Inquire about the history of recurrent pharyngitis or ton-sillitis. Note if the child’s voice sounds muffled or hoarse.Inspect the pharynx for redness and enlargement of thetonsils. As the tonsils enlarge, the child may experiencedifficulty breathing and swallowing. When tonsils touch at
the midline (“kissing tonsils” or 4+ in size), the airway maybecome obstructed (see Fig. 19.8). Also, if the adenoidsare enlarged, the posterior nares become obstructed. Thechild may breathe through the mouth and may snore.Palpate the anterior cervical nodes for enlargement andtenderness. Rapid test or culture may be positive for strep-tococcus A (Johansson & Mannson, 2003).
Nursing ManagementTonsillitis that is medically treated requires the samenursing management as pharyngitis. Nursing care for thechild after tonsillectomy is described below.
Promoting Airway ClearanceUntil fully awake, place the child in a side-lying or proneposition to facilitate safe drainage of secretions. Oncealert, he or she may prefer to sit up or have the head ofthe bed elevated. Suctioning, if necessary, should bedone carefully to avoid trauma to the surgical site. Driedblood may be present on the teeth and the nares, withold blood present in emesis. Since the presence of bloodcan be very frightening to parents, alert them to thispossibility.
Maintaining Fluid VolumeHemorrhage is unusual postoperatively but may occur anytime from the immediate postoperative period to as late as10 days after surgery (Peterson & Losek, 2004). Inspectthe throat for bleeding. Mucus tinged with blood may beexpected, but fresh blood in the secretions indicates bleed-ing. Early bleeding may be identified by continuous swal-lowing of small amounts of blood while awake or sleeping.Other signs of hemorrhage include tachycardia, pallor,restlessness, frequent throat clearing, and emesis of brightred blood.
To avoid trauma to the surgical site, discourage thechild from coughing, clearing the throat, blowing the nose,and using straws. Upon discharge, instruct the parents toimmediately report any sign of bleeding to the physician.To maintain fluid volume postoperatively, encourage chil-dren to take any fluids they desire; Popsicles and ice chipsare particularly soothing. Citrus juice and brown or redfluids should be avoided: the acid in citrus juice may irri-tate the throat, and red or brown fluids may be confusedwith blood if vomiting occurs.
Relieving PainFor the first 24 hours after surgery, the throat is verysore. Adequate pain relief is essential to establish ade-quate oral fluid intake. An ice collar may be prescribed,as well as analgesics with or without narcotics. Counselparents to maintain pain control upon discharge fromthe facility, not only for the child’s sake but also toenable the child to continue to drink fluids (Louloudes,2006).
24 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
● INFECTIOUS MONONUCLEOSISInfectious mononucleosis is a self-limited illness caused bythe Epstein-Barr virus. It is characterized by fever, malaise,sore throat, and lymphadenopathy. Mononucleosis iscommonly called the “kissing disease” since it is trans-mitted by oropharyngeal secretions. It can occur at anyage but is most often diagnosed in adolescents and youngadults. Some infected individuals may have concomitantstreptococcal pharyngitis. Complications include splenicrupture, Guillain-Barré syndrome, and aseptic meningitis(Jensen, 2004).
Nursing AssessmentNote any history of exposure to infected individuals.Determine history of fever and onset and progression ofsore throat, malaise, and other complaints. Observe forperiorbital edema. Inspect the pharynx and tonsils forinflammation and the presence of patches of gray exudate.Petechiae may be present on the palate. Palpate for bilat-eral nontender enlargement of the posterior cervicallymph nodes. After 3 to 5 days of illness, the pharynx maybecome edematous and the tonsillar exudate more exten-sive. Lymphadenopathy may progress to include the ante-rior cervical nodes, which may become tender. Palpatethe abdomen for the presence of splenomegaly orhepatomegaly. An erythematous maculopapular rash mayappear as the illness progresses. Definitive diagnosis maybe made by Monospot or Epstein-Barr virus titers.
● LARYNGITISInflammation of the larynx is termed laryngitis. It mayoccur alone or in conjunction with other respiratorysymptoms. It is characterized by a hoarse voice or loss ofthe voice (so soft as to make it difficult to hear). Oral flu-ids might offer relief, but resting the voice for 24 hourswill allow the inflammation to subside. Laryngitis alonerequires no further intervention.
● CROUPChildren between 3 months and 3 years of age are themost frequently affected with croup, though croup mayaffect any child. Croup is also referred to as laryngotra-cheobronchitis because inflammation and edema of thelarynx, trachea, and bronchi occur as a result of viral infec-tion. Parainfluenza is responsible for the majority of casesof croup. Other causes include adenovirus, influenza virusA and B, RSV, and rarely measles virus or Mycoplasmapneumoniae (Bjornson et al., 2004). The inflammation andedema obstruct the airway, resulting in symptoms. Mucusproduction also occurs, further contributing to obstructionof the airway. Narrowing of the subglottic area of thetrachea results in audible inspiratory stridor. Edema ofthe larynx causes hoarseness. Inflammation in the lar-ynx and trachea causes the characteristic barking coughof croup. Symptoms occur most often at night, and croupis usually self-limited, lasting only about 3 to 5 days(Leung et al., 2004).
Croup often presents suddenly at night, with reso-lution of symptoms in the morning. Complications ofcroup are rare but may include worsening respiratorydistress, hypoxia, or bacterial superinfection (as in thecase of bacterial tracheitis). Croup is usually managed onan outpatient basis, with only 1% to 2% of cases requiringhospitalization (Leung et al., 2004).
Corticosteroids (usually a single dose) are used todecrease inflammation and racemic epinephrine aerosolsdemonstrate the alpha-adrenergic effect of mucosal vaso-constriction, helping to decrease edema (Bjornson et al.,2004; Schooff, 2005). Children with croup may be hos-pitalized if they have significant stridor at rest or severeretractions after a several-hour period of observation.Comparison Chart 19.2 gives information comparingcroup to epiglottitis.
Nursing AssessmentNote the age of the child; children between 3 months and3 years of age are most likely to present with viral croup(laryngotracheobronchitis). History may reveal a coughthat developed during the night (most common presen-tation) and that sounds like barking (or a seal). Inspectfor presence of mild URI symptoms. Temperature maybe normal or elevated mildly. Listen for inspiratory stri-dor and observe for suprasternal retractions. Auscultate
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 25
Nursing ManagementNursing management of mononucleosis is primarily symp-tomatic. The throat may be very sore, so analgesics andsalt-water gargles are recommended. Bed rest should beencouraged while the child is febrile. Frequent rest peri-ods may be necessary for several weeks after the onset ofillness, as fatigue may persist as long as 6 weeks. Duringthe acute phase, if tonsillar or pharyngeal edema threat-ens to obstruct the airway, then corticosteroids may begiven to decrease the inflammation. In the presence ofsplenomegaly or hepatomegaly, strenuous activity andcontact sports should be avoided. Appearance of rash orjaundice should be reported to the physician.
The Monospot is usually negative if obtained within the first 7 to 10 days of illness with infectious mononucleosis. Epstein-Barr virus titer is reliable at any point
in the illness.
Concomitant strep throat in the presence of infectious mononucleosis should be treated with an antibiotic other than ampicillin, as it may cause an allergic-type rash if used in the
presence of mononucleosis.
● COMPARISON CHART 19.2 Croup vs. Epiglottitis
Spasmodic Croup Epiglottitis
Preceding illness None or minimal None or mild coryza upper respiratory
infection
Usually affects age: 3 months to 3 years 1 to 8 years
Onset Usually sudden, often Rapid (within hours)at night
Fever Variable High
Barking cough, Yes Nohoarseness
Dysphagia No Yes
Toxic appearance No Yes
Cause Viral Haemophilus influenzae type B
Nursing ManagementIf the child’s care is being managed at home, advise parentsabout the symptoms of respiratory distress and instructthem to seek treatment if the child’s respiratory conditionworsens. Teach parents to expose their child to humidi-fied air (via a cool mist humidifier or steamy bathroom).Though never clinically proven, use of humidified air haslong been recommended for alleviating coughing jags andanecdotally reported as helpful. Administer dexametha-sone if ordered or teach parents about home adminis-tration. Explain to parents that the effects of racemicepinephrine last about 2 hours and the child must beobserved closely as occasionally a child will worsen again,requiring another aerosol. Teaching Guideline 19.2 givesinformation about home care of croup.
● EPIGLOTTITISEpiglottitis (inflammation and swelling of the epiglottis)is most often caused by Haemophilus influenzae type b.
26 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
Extensive use of the Hib vaccine since the 1980s hasresulted in a significant decrease in the incidence ofepiglottitis. Epiglottitis usually occurs in children betweenthe ages of 2 and 7 years and can be life threatening (Leunget al., 2004). Respiratory arrest and death may occur if theairway becomes completely occluded. Additional compli-cations include pneumothorax and pulmonary edema.Therapeutic management focuses on airway maintenanceand support. Intravenous antibiotic therapy is necessary(Tanner et al., 2002). The child will be managed in theintensive care unit. Comparison Chart 19.2 gives infor-mation comparing croup to epiglottitis.
the lungs for adequacy of breath sounds. Various scalesare available for scoring croup severity, though these areof limited value in the clinical assessment and treatmentof croup (Leung et al., 2004). Croup is usually diagnosedbased on history and clinical presentation, but a lateralneck x-ray may be obtained to rule out epiglottitis.
T E A C H I N G G U I D E L I N E 1 9 . 2
Home Care of Croup
• Keep the child quiet and discourage crying.• Allow the child to sit up (in your arms).• Encourage rest and fluid intake.• If stridor occurs, take the child into a steamy bathroom
for 10 minutes.• Administer medication (corticosteroid) as directed.• Watch the child closely. Call the physician if:
• The child breathes faster, has retractions, or has anyother difficulty breathing
• The nostrils flare or the lips or nails have a bluish tint• The cough or stridor does not improve with exposure
to moist air• Restlessness increases or the child is confused• The child begins to drool or cannot swallow
Adapted from Knutson, 2004.
The child with fever, a toxic appearance, andincreasing respiratory distress despite appropriatecroup treatment may have bacterial tracheitis(Orenstein, 2004). Notify the physician of these
findings in a child with croup.
Nursing AssessmentCarefully assess the child with suspected epiglottitis. Notesudden onset of symptoms and high fever. The child hasan overall toxic appearance. He or she may refuse to speakor may speak only with a very soft voice. The child mayrefuse to lie down and may assume the characteristic posi-tion, sitting forward with the neck extended. Drooling maybe present. Note anxiety or a frightened appearance. Notethe child’s color. Cough is usually absent. A lateral neckx-ray may be performed to determine the presence ofepiglottitis. This is done cautiously, so as not to induce air-way obstruction with changes in position of the child’sneck (Bjornson et al., 2004; Tanner et al., 2002).
Nursing ManagementDo not leave the child unattended. Keep the child and par-ents as calm as possible. Allow the child to assume a posi-tion of comfort. Do not place the child in a supine position,as airway occlusion may occur. Provide 100% oxygen inthe least invasive manner that is most acceptable to thechild. Do not under any circumstance attempt to visu-alize the throat: reflex laryngospasm may occur, precip-itating immediate airway occlusion. If the child withepiglottitis experiences complete airway occlusion, anemergency tracheostomy may be necessary. Ensure thatemergency equipment is available and that personnelspecifically trained in intubation of the pediatric occludedairway and percutaneous tracheostomy are notified ofthe child’s presence in the facility (Bjornson et al., 2004;Tanner et al., 2002).
Groothius, 2000). The frequency and severity of RSVinfection decrease with age. Repeated RSV infectionsoccur throughout life but are usually localized to the upperrespiratory tract after toddlerhood.
Therapeutic ManagementManagement of RSV focuses on supportive treatment.Supplemental oxygen, nasal and/or nasopharyngeal suc-tioning, oral or intravenous hydration, and inhaled bron-chodilator therapy are used. Many infants are managed athome with close observation and adequate hydration.Hospitalization is required for children with more severedisease. The infant with tachypnea, significant retractions,poor oral intake, or lethargy can deteriorate quickly, to thepoint of requiring ventilatory support, and thus warrantshospital admission.
PathophysiologyRSV is a highly contagious virus and may be contractedthrough direct contact with respiratory secretions or fromparticles on objects contaminated with the virus (Lauts,2005). RSV invades the nasopharynx, where it replicatesand then spreads down to the lower airway via aspirationof upper airway secretions. RSV infection causes necro-sis of the respiratory epithelium of small airways, peri-bronchiolar mononuclear infiltration, and plugging of thelumens with mucus and exudate. The small airwaysbecome variably obstructed; this allows adequate inspi-ratory volume but prevents full expiration. This leads to hyperinflation and atelectasis (Cooper et al., 2003)(Fig. 19.9). Serious alterations in gas exchange occur,
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 27
● BRONCHIOLITIS (RSV)Bronchiolitis is an acute inflammatory process of thebronchioles and small bronchi. Nearly always caused bya viral pathogen, RSV accounts for the majority of casesof bronchiolitis, with adenovirus, parainfluenza, andhuman meta-pneumovirus also being important causativeagents. This discussion will focus on RSV bronchiolitis.
The peak incidence of bronchiolitis is in the winterand spring, coinciding with RSV season. RSV season in the United States and Canada generally begins inSeptember or October and continues through April orMay. Virtually all children will contract RSV infectionwithin the first few years of life. RSV bronchiolitis occursmost often in infants and toddlers, with a peak incidencearound 6 months of age. The severity of disease is relatedinversely to the age of the child, with the most severe casesoccurring between 1 and 3 months of age (Weisman &
● Figure 19.9 Hyperinflation with atelectasisis noted upon chest x-ray.
Epiglottitis is characterized by dysphagia, drooling, anxiety, irritability, and significant respiratory distress. Prepare for the event of sudden airway
occlusion.
AuscultationAuscultate the lungs, noting adventitious sounds anddetermining the quality of aeration of the lung fields.Earlier in the illness, wheezes might be heard scatteredthroughout the lung fields. In more serious cases, thechest might sound quiet and without wheeze. This isattributed to significant hyperexpansion with very poorair exchange.
Laboratory and Diagnostic TestsCommon laboratory and diagnostic studies ordered forthe assessment of RSV bronchiolitis include:
• Pulse oximetry: oxygen saturation might be significantlydecreased
• Chest x-ray: might reveal hyperinflation and patchy areasof atelectasis or infiltration
• Blood gases: might show carbon dioxide retention andhypoxemia
• Nasal-pharyngeal washings: positive identification of RSVcan be made via enzyme-linked immunosorbent assay(ELISA) or immunofluorescent antibody (IFA) testing
Nursing ManagementRSV infection is usually self-limited, and nursing diag-noses, goals, and interventions for the child with bron-chiolitis are aimed at supportive care. Children with lesssevere disease might require only antipyretics, adequatehydration, and close observation. They can often besuccessfully managed at home, provided the primarycaregiver is reliable and comfortable with close observa-tion. Parents or caregivers should be educated to watchfor signs of worsening and must understand the impor-tance of seeking care quickly should the child’s condi-tion deteriorate.
Hospitalization is required for children with moresevere disease, and children admitted with RSV bronchi-olitis warrant close observation. In addition to the nurs-ing diagnoses and related interventions discussed in theNursing Care Plan for respiratory disorders, interventionscommon to bronchiolitis follow.
28 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
with arterial hypoxemia and carbon dioxide retentionresulting from mismatching of pulmonary ventilation andperfusion. Hypoventilation occurs secondary to markedlyincreased work of breathing.
Nursing AssessmentFor a full description of the assessment phase of the nurs-ing process, refer to page 00. Assessment findings perti-nent to bronchiolitis are discussed below.
Health HistoryElicit a description of the present illness and chief com-plaint. Common signs and symptoms reported during thehealth history might include:
• Onset of illness with a clear runny nose (sometimesprofuse)
• Pharyngitis• Low-grade fever• Development of cough 1 to 3 days into the illness, fol-
lowed by a wheeze shortly thereafter• Poor feeding
Explore the child’s current and past medical history forrisk factors such as:
• Young age (less than 2 years old), more severe diseasein a child less than 6 months old
• Prematurity• Multiple births• Birth during April to September• History of chronic lung disease (bronchopulmonary
disease)• Cyanotic or complicated congenital heart disease• Immunocompromise• Male gender• Exposure to passive tobacco smoke• Crowded living conditions• Daycare attendance• School-age siblings• Low socioeconomic status• Lack of breastfeeding
Physical ExaminationExamination of the child with RSV involves inspection,observation, and auscultation.
Inspection and ObservationObserve the child’s general appearance and color (cen-trally and peripherally). The infant with RSV bronchioli-tis might appear air-hungry, exhibiting various degrees ofcyanosis and respiratory distress, including tachypnea,retractions, accessory muscle use, grunting, and periodsof apnea. Cough and audible wheeze might be heard.The infant might appear listless and disinterested in feed-ing, surroundings, or parents.
Maintaining Patent AirwayInfants and young children with RSV tend to have copi-ous secretions. Position the child with the head of the bedelevated to facilitate an open airway. These children oftenrequire frequent assessment and suctioning to maintain apatent airway (Lauts, 2005). Use a Yankauer or tonsil-tip
Currently no safe and effective antiviral drug is available for definitive treatment of RSV.Aerosolized ribavirin is recommended only for the highest-risk, most severely ill patients (Lauts,
2005). Routine antibiotic use is discouraged in RSV bronchiolitistreatment because the secondary bacterial infection rate of the lower airway is very low.
suction catheter to suction the mouth or pharynx of olderinfants or children, rinsing the catheter after each suc-tioning. Nasal bulb suctioning may be sufficient to clearthe airway in some infants, while others will requirenasopharyngeal suctioning with a suction catheter. NursingProcedure 19.1 gives further information. The routineuse of sterile normal saline is not indicated in all children,as its use has been demonstrated to result in decreasedoxygen saturations for up to 2 minutes after suctioningis complete (Ridling et al., 2003). Adjust the pressureranges for suctioning infants and children between 60and 100 mm Hg, 40 and 60 mm Hg for premature infants.
Promoting Adequate Gas ExchangeInfants and children with bronchiolitis might deterioratequickly as the disease progresses. In the child ill enough torequire oxygen, the risk is even greater. Assessment shouldinclude work of breathing, respiratory rate, and oxygen sat-uration. The percentage of inspired oxygen (FiO2) shouldbe adjusted as needed to maintain oxygen saturation withinthe desired range. Positioning the infant with the head ofthe bed elevated may also improve gas exchange. Frequentassessment is necessary for the hospitalized child withbronchiolitis (Cooper et al., 2003; Steiner, 2004).
Patients with RSV can be safely cohorted. Attention tohand washing is necessary, as droplets might enter theeyes, nose, or mouth via the hands.
Providing Family EducationEducate parents to recognize signs of worsening distress.Tell parents to call their physician or nurse practitioner ifthe breathing is rapid or becomes more difficult or if thechild cannot eat secondary to tachypnea. Children whoare less than 1 year of age or who are at higher risk (thosewho were born prematurely or who have chronic heart orlung conditions) might have a longer course of illness.Instruct parents that cough can persist for several days toweeks after resolution of the disease, but infants usuallyact well otherwise.
Preventing RSV DiseaseStrict adherence to hand-washing policies in daycarecenters and when exposed to individuals with cold symp-toms is important for all groups. Though generally benignin healthy older children, RSV can be devastating inyoung infants or children with pre-existing risk factors.Palivizumab (Synagis) is a monoclonal antibody effec-tive in the prevention of severe RSV disease in those whoare most susceptible. It is given as an intramuscular injec-tion once a month throughout the RSV season. Thoughquite costly, it is covered by most insurance policies andMedicaid for those who qualify. It is generally indicated foruse in certain children less than 2 years of age. Qualifyingfactors include:
requiring medication or oxygen• Certain congenital heart diseases• Immunocompromise (AAP, 2003)
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 29
Reducing Risk for InfectionSince RSV is easily spread through contact with droplets,inpatients should be isolated according to hospital policyto decrease the risk of nosocomial spread to other patients.
1. Check to ensure the suction equipment worksproperly before starting.
2. After washing your hands, assemble the equipmentneeded:
• Appropriate-size sterile suction catheter
• Sterile gloves
• Supplemental oxygen
• Sterile water-based lubricant
• Sterile normal saline if indicated
3. Don sterile gloves, keeping dominant hand sterileand nondominant hand clean.
4. Preoxygenate the infant or child if indicated.
5. Apply lubricant to the end of the suction catheter.
6. If indicated for loosening of secretions, instill sterilesaline.
7. Maintaining sterile technique, insert the suctioncatheter into the child’s nostril or airway.
• Insert only to the point of gagging if inserting viathe nostril.
• Insert only 0.5 cm further than the length of theartificial airway.
8. Intermittently apply suction for no longer than 10 seconds, while twisting and removing the catheter.
9. Supplement with oxygen after suctioning.
Nursing ProcedureNursing Procedure 19.1Nasopharyngeal or Artificial Airway Suction Technique
In the tachypneic infant, slowing of the respiratoryrate does not necessarily indicate improvement:often, a slower respiratory rate is an indication oftiring, and carbon dioxide retention may soon be
followed by apnea.
More information related to recommendations for Synagis use can be found at http://aappolicy.aappublications.org/cgi/reprint/pediatrics;112/6/1442.pdf.
● PNEUMONIAPneumonia is an inflammation of the lung parenchyma. Itcan be caused by a virus, bacteria, mycoplasma, or fungus.It may also result from aspiration of foreign material into thelower respiratory tract (aspiration pneumonia). Pneumoniaoccurs more often in winter and early spring. It is commonin children but is seen most frequently in infants and youngtoddlers. Viruses are the most common cause of pneumo-nia in younger children and the least common cause inolder children (Table 19.2). Viral pneumonia is usuallybetter tolerated in children of all ages. Children with bac-terial pneumonia are more apt to present with a toxicappearance, but rapid recovery generally occurs if appro-priate antibiotic treatment is instituted early.
cessfully managed at home if the work of breathing is notsevere and oxygen saturation is within normal limits.However, hospitalization is required for children withmore severe disease. The child with tachypnea, significantretractions, poor oral intake, or lethargy might requirehospital admission for the administration of supplemen-tal oxygen, intravenous hydration, and antibiotics.
30 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
Table 19.2Table 19.2 Common Causes of Pneumonia According to Age
Age Group Most Common Causative Agents
1 to 3 months
4 months to5 years
5 to 18 years
RSV, other respiratory viruses (parainfluenza, influenza,adenovirus); Streptococcus pneumoniae, Chlamydiatrachomatis
Pneumonia is usually a self-limited disease. A childwho presents with recurrent pneumonia should be eval-uated for chronic lung disease such as asthma or cysticfibrosis. Potential complications of pneumonia includebacteremia, pleural effusion, empyema, lung abscess,and pneumothorax (Nield et al., 2005). Excluding bac-teremia, these are often treated with thoracentesis and/or chest tubes as well as antibiotics if appropriate.Pneumatoceles (thin-walled cavities developing in thelung) might occur with certain bacterial pneumoniasand usually resolve spontaneously over time.
Therapeutic management of children with less severedisease includes antipyretics, adequate hydration, andclose observation. Even bacterial pneumonia can be suc-
PathophysiologyPneumonia occurs as a result of the spread of infectiousorganisms to the lower respiratory tract from either theupper respiratory tract or the bloodstream. In bacterialpneumonia, mucus stasis occurs as a result of vascularengorgement. Cellular debris (erythrocytes, neutrophils,and fibrin) accumulates in the alveolar space. Relativehyperexpansion with air trapping follows. Inflammationof the alveoli results in atelectasis. Atelectasis is definedas a collapsed or airless portion of the lung, so gas exchangebecomes impaired. The inflammatory response furtherimpairs gas exchange (Nield et al., 2005).
Viral pneumonia usually results in an inflammatoryreaction limited to the alveolar wall. Aspiration of food,fluids, or other substances into the bronchial tree canresult in aspiration pneumonia. Aspiration is the mostcommon cause of recurrent pneumonia in children andoften occurs as a result of gastroesophageal reflux disease(Turcios & Patel, 2003). Secondary bacterial infectionoften occurs following viral or aspiration pneumonia andrequires antibiotic treatment.
Nursing AssessmentFor a full description of the assessment phase of the nurs-ing process, refer to page 00. Assessment findings perti-nent to pneumonia are discussed below.
Community-acquired pneumonia (CAP) refers to pneumonia in a previously healthy person that iscontracted outside of the hospital setting. CAP isa common cause of lower respiratory infection in
North America (Ostapchuk et al., 2004).
Haemophilus influenzae type B has been nearly eliminated as a cause of pneumonia in the United States and other developed countries as a result of universal immunization
with Hib vaccine.
Health HistoryElicit a description of the present illness and chief com-plaint. Note onset and progression of symptoms. Commonsigns and symptoms reported during the health historyinclude:
• Antecedent viral URI• Fever• Cough (note type and whether productive or not)• Increased respiratory rate• History of lethargy, poor feeding, vomiting, or diarrhea
in infants• Chills, headache, dyspnea, chest pain, abdominal pain,
and nausea or vomiting in older children
Explore the child’s past and current medical historyfor risk factors known to be associated with an increase inthe severity of pneumonia, such as:
Physical ExaminationPhysical examination consists of inspection, auscultation,percussion, and palpation.
InspectionObserve the child’s general appearance and color (cen-trally and peripherally). Cyanosis might accompanycoughing spells. The child with bacterial pneumonia mayappear ill. Assess work of breathing. Children with pneu-monia might exhibit substernal, subcostal, or intercostalretractions. Tachypnea and nasal flaring may be present.Describe cough and quality of sputum if produced.
AuscultationAuscultation of the lungs might reveal wheezes or ralesin the younger child. Local or diffuse rales may be presentin the older child. Document diminished breath sounds.
Percussion and PalpationIn the older child, percussion might yield local dullnessover a consolidated area. Percussion is much less valuablein the infant or younger child. Tactile fremitus felt uponpalpation may be increased with pneumonia.
Laboratory and Diagnostic TestsCommon laboratory and diagnostic studies ordered forthe assessment of pneumonia include:
• Pulse oximetry: oxygen saturation might be significantlydecreased or within normal range
• Chest x-ray: varies according to patient age and causativeagent. In infants and young children, bilateral air trap-
ping and perihilar infiltrates are the most commonfindings. Patchy areas of consolidation might also bepresent. In older children, lobar consolidation is seenmore frequently.
• Sputum culture: possibly useful in determining causativebacteria in older children and adolescents
• White blood cell count: might be elevated in the case ofbacterial pneumonia
Nursing ManagementNursing diagnoses, goals, and interventions for the childwith pneumonia are primarily aimed at providing support-ive care and education about the illness and its treatment.Prevention of pneumococcal infection is also important.Children with more severe disease will require hospitaliza-tion. Refer to the Nursing Care Plan on page 00 for nurs-ing diagnoses and related interventions. In addition tothe interventions listed in the Nursing Care Plan, the fol-lowing should be noted.
Providing Supportive CareEnsure adequate hydration and assist in thinning of secre-tions by encouraging oral fluid intake in the child whoserespiratory status is stable. In children with increasedwork of breathing, intravenous fluids may be necessaryto maintain hydration. Allow and encourage the child toassume a position of comfort, usually with the head ofthe bed elevated to promote aeration of the lungs. Ifpain due to coughing or pneumonia itself is severe, admin-ister analgesics as prescribed. Provide supplementaloxygen to the child with respiratory distress or hypoxiaas needed.
Providing Family EducationEducate the family about the importance of adherenceto the prescribed antibiotic regimen. Antibiotics may begiven intravenously if the child is hospitalized, but upondischarge or if the child is managed on an outpatient basis,oral antibiotics will be used.
Teach the parents of a child with bacterial pneumo-nia to expect that following resolution of the acute illness,for 1 to 2 weeks, the child might continue to tire easilyand the infant might continue to need small, frequentfeedings. Cough may also persist after the acute recoveryperiod but should lessen over time.
If the child is diagnosed with viral pneumonia, par-ents might not understand that their child does notrequire an antibiotic. Pneumonia is often perceived by thepublic as a bacterial infection, so most parents will needan explanation related to treatment of viral infections. Aswith bacterial pneumonia, the child may experience aweek or two of weakness or fatigue following resolution ofthe acute illness.
The young child is at risk for the development of aspi-ration pneumonia. Parents need to understand that thechild might be at risk for injury related to his or her age and
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 31
developmental stage. To prevent recurrent or further aspi-ration, teach the parents the safety measures in TeachingGuideline 19.3.
Preventing Pneumococcal InfectionChildren at high risk for severe pneumococcal infectionshould be immunized against it. This includes all chil-dren between 0 and 23 months of age, as well as childrenbetween 24 and 59 months of age with certain conditionssuch as immune deficiency, sickle cell disease, asplenia,chronic cardiac conditions, chronic lung problems, cere-brospinal fluid leaks, chronic renal insufficiency, diabetesmellitus, and organ transplants. For additional informa-tion refer to Chapter 9. See Healthy People 2010.
● BRONCHITISBronchitis is an inflammation of the trachea and majorbronchi. It is often associated with a URI. Bronchitis isusually viral in nature, though Mycoplasma pneumoniaeis also an important causative agent in children over6 years of age. Recovery usually occurs within 5 to 10 days.Therapeutic management involves mainly supportivecare. Expectorant administration and adequate hydra-tion are important. If Mycoplasma is the cause, anti-biotics are indicated (Orenstein, 2004).
Nursing AssessmentThe illness might begin with a mild URI. Fever devel-ops, followed by a dry, hacking cough that might becomeproductive in older children. The cough might wake thechild at night. Auscultation of the lungs might revealcoarse rales. Respirations remain unlabored. The chest
x-ray might show diffuse alveolar hyperinflation andperihilar markings.
Nursing ManagementNursing management is aimed at providing supportivecare. Teach parents that expectorants will help loosensecretions and antipyretics will help reduce the fever,making the child more comfortable. Encourage ade-quate hydration. Antibiotics are prescribed only in casesbelieved to be bacterial in nature. Discourage the use ofcough suppressants: it is important for accumulatedsputum to be raised.
● TUBERCULOSISTuberculosis is a highly contagious disease caused byinhalation of droplets of Mycobacterium tuberculosis orMycobacterium bovis. Children usually contract the dis-ease from an immediate household member. Annuallyabout 1,000 U.S. children contract active tuberculosisdisease (Reznik & Ozuah, 2005). Nonwhite children andchildren with chronic illness or malnutrition are moresusceptible to infection. After exposure to an infectedindividual, the incubation period is 2 to 10 weeks. Theinhaled tubercle bacilli multiply in the alveoli and alveo-lar ducts, forming an inflammatory exudate. The bacilliare spread by the bloodstream and lymphatic system tovarious parts of the body. Though pulmonary tuberculo-sis is the most common, children may also have infectionin other parts of the body, such as the gastrointestinaltract or central nervous system (Starke & Munoz, 2004).See Healthy People 2010.
In the case of drug-sensitive tuberculosis, the Amer-ican Academy of Pediatrics recommends a 6-month courseof oral therapy. The first two months consist of isoniazid,rifampin, and pyrazinamide given daily. This is followedby twice-weekly isoniazid and rifampin; administrationmust be observed directly (usually by a public healthnurse). In the case of multidrug-resistant tuberculosis,ethambutol or streptomycin is given via intramuscularinjection (AAP, 2003).
32 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
T E A C H I N G G U I D E L I N E 1 9 . 3
Preventing Aspiration
• Keep toxic substances such as lighter fluid, solvents,and hydrocarbons out of reach of young children.Toddlers and preschoolers cannot distinguish safefrom unsafe fluids due to their developmental stage.
• Avoid oily nose drops and oil-based vitamins or homeremedies to avoid lipid aspiration into the lungs.
• Avoid oral feedings if the infant’s respiratory rate is 60or greater to minimize the risk of aspiration of thefeeding.
• Discourage parents from “force-feeding” in the eventof poor oral intake or severe illness to minimize therisk of aspiration of the feeding.
• Position infants and ill children on their right sideafter feeding to minimize the possibility of aspiratingemesis or regurgitated feeding.
Objective
Reduce invasive pneu-mococcal infections.
Significance
• Provide accurate infor-mation to familiesabout pneumococcaldisease.
Nursing AssessmentRoutine screening for tuberculosis infection is not rec-ommended for low-risk individuals, but children consid-ered to be at high risk for contracting tuberculosis shouldbe screened using the Mantoux test. Children consideredto be at high risk are those who:
• Are infected with HIV• Are incarcerated or institutionalized• Have a positive recent history of latent tuberculosis
infection• Are immigrants from or have a history of travel to
endemic countries• Are exposed at home to HIV-infected or homeless per-
sons, illicit drug users, migrant farm workers, or nurs-ing home residents
Children with chronic illnesses (except HIV infection)are not more likely to become infected with tuberculosisbut should receive special consideration and be screenedprior to initiation of immunosuppressant therapies (Reznik& Ozuah, 2005).
The presentation of tuberculosis in children is quitevaried. Children can be asymptomatic or exhibit a broadrange of symptoms. Symptoms may include fever,malaise, weight loss, anorexia, pain and tightness in thechest, and rarely hemoptysis. Cough might or might not bepresent and usually progresses slowly over several weeksto months. As tuberculosis progresses, the respiratory rate
increases and the lung on the affected side is poorlyexpanded. Dullness to percussion might be present, as wellas diminished breath sounds and crackles. Fever persistsand pallor, anemia, weakness, and weight loss are present.Diagnosis is confirmed with a positive Mantoux test, posi-tive gastric washings for acid-fast bacillus, and/or a chest x-ray consistent with tuberculosis (Reznik & Ozuah, 2005).
Nursing ManagementHospitalization of children with tuberculosis is necessaryonly for the most serious cases. Nursing management isaimed at providing supportive care and encouragingadherence to the treatment regimen. Most nursing carefor childhood tuberculosis is provided in outpatient clin-ics, schools, or a public health setting. Supportive careincludes ensuring adequate nutrition and adequate rest,providing comfort measures such as fever reduction, pre-venting exposure to other infectious diseases, and pre-venting reinfection.
Providing Care for the Child with LatentTuberculosis InfectionChildren who test positive for tuberculosis but who donot have symptoms or radiographic/laboratory evidenceof disease are considered to have latent infection. Thesechildren should be treated with isoniazid for 9 monthsto prevent progression to active disease. Follow-up andappropriate monitoring can be achieved via the child’sprimary care provider or local health department.
Preventing InfectionTuberculosis infection is prevented by avoiding contactwith the tubercle bacillus. Thus, hospitalized childrenwith tuberculosis must be isolated according to hospitalpolicy to prevent nosocomial spread of tuberculosis infec-tion. Promotion of natural resistance through nutrition,rest, and avoidance of serious infections does not preventinfection. Pasteurization of milk has helped to decreasethe transmission of Mycobacterium bovis. Administrationof bacille Calmette-Guérin (BCG) vaccine can provideincomplete protection against tuberculosis and is notwidely used in the United States.
Acute Noninfectious DisordersAcute noninfectious disorders include epistaxis, foreignbody aspiration, respiratory distress syndrome, acute res-piratory distress syndrome, and pneumothorax.
● EPISTAXISEpistaxis (a nosebleed) occurs most frequently in chil-dren younger than adolescent age. Bleeding of the nasalmucosa occurs most often from the anterior portion ofthe septum. Epistaxis may be recurrent and idiopathic
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 33
Objective
Reduce tuberculosis.Increase the proportion ofall tuberculosis patientswho complete curativetherapy within 12 months.Increase the proportion ofcontacts and other high-risk persons with latenttuberculosis infection whocomplete a course oftreatment.
Significance
• Assess the health historyof all infants, children,and adolescents for riskfactors for tuberculosisinfection.
• Provide tuberculosisscreening as recom-mended.
• Refer all tuberculosisinfections to the localpublic health department.
• Educate families aboutthe importance of com-pleting medication ther-apy as prescribed foractive and latent tuber-culosis, and the needfor appropriate follow-up and retesting fortuberculosis infection.
HEALTHY PEOPLE 2010
(meaning there is no cause). The majority of cases arebenign, but in children with bleeding disorders or otherhematologic concerns, epistaxis should be further inves-tigated and treated.
Nursing AssessmentExplore the child’s history for initiating factors such as localinflammation, mucosal drying, or local trauma (usuallynose picking). Inspect the nasal cavity for blood.
Nursing ManagementThe presence of blood often frightens children and theirparents. The nurse and parents should remain calm. Thechild should sit up and lean forward (lying down mayallow aspiration of the blood). Apply continuous pressureto the anterior portion of the nose by pinching it closed.Encourage the child to breathe through the mouth dur-ing this portion of the treatment. Ice or a cold clothapplied to the bridge of the nose may also be helpful. Thebleeding usually stops within 10 to 15 minutes. Applypetroleum jelly or water-soluble gel to the nasal mucosawith a cotton-tipped applicator to moisten the mucosaand prevent recurrence.
● FOREIGN BODY ASPIRATIONForeign body aspiration occurs when any solid or liquidsubstance is inhaled into the respiratory tract. It is com-mon in infants and young children and can present in alife-threatening manner (Qureshi & Mink, 2003). Theobject may lodge in the upper or lower airway, causingvarying degrees of respiratory difficulty. Small, smoothobjects such as peanuts are the most frequently aspirated,but any small toy, article, or piece of food smaller thanthe diameter of the young child’s airway can potentiallybe aspirated: popcorn, vegetables, hot dogs, fruit snacks,coins, latex balloon pieces, pins, and pen caps are com-monly seen (Qureshi & Mink, 2003).
Foreign body aspiration occurs most frequently inchildren ages 6 months to 5 years. Children this age aregrowing and developing rapidly. They tend to explorethings with their mouths and can easily aspirate smallitems.
The child often coughs out foreign bodies from theupper airway. If the foreign body reaches the bronchus,then it may need to be surgically removed via bron-choscopy. Postoperative antibiotics are used if an infectionis also present. Complications of foreign body aspiration
include pneumonia or abscess formation, hypoxia, respi-ratory failure, and death (Orenstein, 2004).
Nursing AssessmentThe infant or young child might present with a history ofsudden onset of cough, wheeze, or stridor. Stridor sug-gests that the foreign body is lodged in the upper airway.Sometimes the onset of respiratory symptoms is muchmore gradual. When the item has traveled down one ofthe bronchi, then wheezing, rhonchi, and decreased aer-ation can be heard on the affected side. A chest x-ray willdemonstrate the foreign body only if it is radiopaque(Fig. 19.10).
Nursing ManagementThe most important nursing intervention related to for-eign body aspiration is prevention. Anticipatory guidancefor families with 6-month-olds should include a discus-sion of aspiration avoidance. This information shouldbe reiterated at each subsequent well-child visit throughage 5. Tell parents to avoid letting their child play with toyswith small parts and to keep coins and other small objectsout of the reach of children. Teach parents not to feedpeanuts and popcorn to their child until he or she is at least3 years old. When children progress to table food, teachparents to chop all foods so that they are small enoughto pass down the trachea should the child neglect to chewthem up thoroughly. Carrots, grapes, and hot dogs shouldbe cut into small pieces. Harmful liquids should be keptout of the reach of children.
34 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
● Figure 19.10 Foreign body is noted in thebronchus upon chest x-ray.
The child with recurrent epistaxis or epistaxis thatis difficult to control should be further evaluatedfor underlying bleeding or platelet concerns.
plications of RDS include air leak syndrome, bron-chopulmonary dysplasia, patent ductus arteriosus andcongestive heart failure, intraventricular hemorrhage,retinopathy of prematurity, necrotizing enterocolitis, com-plications resulting from intravenous catheter use (infec-tion, thrombus formation), and developmental delay ordisability (Stoll & Kliegman, 2004).
Nursing AssessmentThe onset of RDS is usually within several hours ofbirth. The newborn exhibits signs of respiratory distress,including tachypnea, retractions, nasal flaring, grunting,and varying degrees of cyanosis. Auscultation revealsfine rales and diminished breath sounds. If untreated,RDS progresses to seesaw respirations, respiratory fail-ure, and shock.
Nursing ManagementRarely, mucus plugging can occur in the neonate placedon a ventilator after surfactant administration. Therefore,close observation and assessment for adequate lungexpansion are critical. In addition to expert respiratoryintervention, other crucial nursing goals include mainte-nance of normothermia, prevention of infection, mainte-nance of fluid and electrolyte balance, and promotion ofadequate nutrition (parenterally or via gavage feeding).Nursing care of the infant with RDS generally occurs inthe intensive care unit.
● ACUTE RESPIRATORY DISTRESS SYNDROME
Acute respiratory distress syndrome (ARDS) occurs fol-lowing a primary insult such as sepsis, viral pneumonia,
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 35
● RESPIRATORY DISTRESS SYNDROMERespiratory distress syndrome (RDS) is a respiratory dis-order that is specific to neonates. It results from lungimmaturity and a deficiency in surfactant, so it is seenmost often in premature infants. Other infants who mightexperience RDS include infants of diabetic mothers, thosedelivered via cesarean section without preceding labor,and those experiencing perinatal asphyxia. It is believedthat each of these conditions has an impact on surfactantproduction, thus resulting in RDS in the term infant(Stoll & Kliegman, 2004).
The administration of surfactant via endotrachealtube shortly after delivery helps to decrease the incidenceand severity of RDS. Management of RDS focuses onintensive respiratory care, usually with mechanical venti-lation. Newer techniques for ventilatory support are alsoavailable (Table 19.3).
PathophysiologyThe lack of surfactant in the affected newborn’s lungsresults in stiff, poorly compliant lungs with poor gasexchange. Right-to-left shunting and hypoxemia result.As the disease progresses, fluid and fibrin leak from thepulmonary capillaries, causing hyaline membrane to formin the bronchioles, alveolar ducts, and alveoli. Presenceof the membrane further decreases gas exchange. Com-
Table 19.3Table 19.3 Alternatives to Traditional Mechanical Ventilation
Mode Description Additional Information
High-frequencyventilators(high frequency,oscillating, or jet)
Nitric oxide
Liquid ventilation
Extracorporealmembraneoxygenation(ECMO)
Provide very high respiratory rates (up to1,200 breaths per minute) and verylow tidal volumes
Causes pulmonary vasodilation, helpingto increase blood flow to alveoli
Perfluorocarbon liquid acts as asurfactant. Provides an effectivemedium for gas exchange andincreases pulmonary function.
Blood is removed from body via catheter,warmed and oxygenated in theECMO machine, and then returned to infant.
May decrease risk of barotraumaassociated with ventilator pressures
Safe; no long-term developmental risks
Virtually no reported physiologic sequelae
Labor-intensive. Risk of bleeding is great.
Items smaller than 1.25 inches (3.2 cm) can be aspirated easily. A simple way for parents to estimate the safe size of a small item or toypiece is to gauge its size against a standard
toilet paper roll, which is generally about 1.5 inches in diameter.
smoke inhalation, or near-drowning. Acute onset of res-piratory distress and hypoxemia occur within 72 hoursof the insult in infants and children with previouslyhealthy lungs. The alveolar–capillary membrane becomesmore permeable and pulmonary edema develops. Hyalinemembrane formation over the alveolar surfaces anddecreased surfactant production cause lung stiffness.Mucosal swelling and cellular debris lead to atelectasis. Gasdiffusion is impaired significantly. ARDS can progress torespiratory failure and death, though some individualsrecover completely or have residual lung disease.
Medical treatment is aimed at improving oxygena-tion and ventilation. Mechanical ventilation is usedwith special attention to lung volumes and positive end-expiratory pressure (PEEP). Newer treatment modalitiesshow promise for improving outcomes of ARDS.
Nursing AssessmentTachycardia and tachypnea occur over the first few hoursof the illness. Significantly increased work of breathingwith nasal flaring and retractions develops. Auscultatefor breath sounds, which might range from normal tohigh-pitched crackles throughout the lung fields. Hypox-emia develops. Bilateral infiltrates can be seen on achest x-ray.
Nursing ManagementNursing care of the child with ARDS is mainly supportiveand occurs in the intensive care unit. Closely monitor res-piratory and cardiovascular status. Comfort measures suchas hygiene and positioning as well as pain and anxietymanagement, maintenance of nutrition, and prevention ofinfection are also key nursing interventions. The acutephase of worsening respiratory distress can be frighteningfor a child of any age, and the nurse can be instrumental in
soothing the child’s fears. As the disease worsens and pro-gresses, especially when ventilatory support is required,psychological support of the family as well as educationabout the intensive care unit procedures will be especiallyimportant.
● PNEUMOTHORAXA collection of air in the pleural space is called a pneu-mothorax. It can occur spontaneously in an otherwisehealthy child, or as a result of chronic lung disease, car-diopulmonary resuscitation, surgery, or trauma. Trappedair consumes space within the pleural cavity, and theaffected lung suffers at least partial collapse. Needle aspi-ration and/or placement of a chest tube is used to evacuatethe air from the chest. Some small pneumothoraces resolveindependently, without intervention (Cunnington, 2002).
Nursing AssessmentPrimary pneumothorax (spontaneous) occurs most oftenin adolescence. The infant or child with a pneumothoraxmight have a sudden or gradual onset of symptoms.Chest pain might be present as well as signs of respiratorydistress such as tachypnea, retractions, nasal flaring, orgrunting. Assess potential risk factors for acquiring apneumothorax, including chest trauma or surgery, intu-bation and mechanical ventilation, or a history of chroniclung disease such as cystic fibrosis. Inspect the child fora pale or cyanotic appearance. Auscultate for increasedheart rate (tachycardia) and absent or diminished breathsounds on the affected side. The x-ray reveals air withinthe thoracic cavity (Fig. 19.11).
Nursing ManagementThe child with a pneumothorax requires frequent respira-tory assessments. Pulse oximetry might be used as an
36 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
● Figure 19.11 Pneumothorax.
T ear in t r acheobronchial tree
Air in pleural space
A BChest tube
adjunct, but clinical evaluation of respiratory status is mostuseful. In some cases, administration of 100% oxygen has-tens the reabsorption of air, but it is generally used only fora few hours. If a chest tube connected to a water seal orsuction is present, provide care of the drainage apparatusas appropriate (Fig. 19.12). A pair of hemostats should bekept at the bedside to clamp the tube should it becomedislodged from the drainage container. The dressingaround the chest tube is occlusive and is not routinelychanged. If the tube becomes dislodged from the child’schest, apply Vaseline gauze and an occlusive dressing,immediately perform appropriate respiratory assessment,and notify the physician.
Chronic DiseasesChronic respiratory disorders include allergic rhinitis,asthma, chronic lung disease (bronchopulmonary dys-plasia), cystic fibrosis, and apnea.
● ALLERGIC RHINITISAllergic rhinitis is a common chronic condition in child-hood, affecting up to 40% of children (Hagemann, 2005).Allergic rhinitis is associated with atopic dermatitis andasthma, with as many as 80% of asthmatic children alsosuffering from allergic rhinitis (Corren, 2000). Perennialallergic rhinitis occurs year-round and is associated withindoor environments. Allergens commonly implicated inperennial allergic rhinitis include dust mites, pet dander,
cockroach antigens, and molds. Seasonal allergic rhinitisis caused by elevations in outdoor levels of allergens. It istypically caused by certain pollens, trees, weeds, fungi,and molds. Complications from allergic rhinitis includeexacerbation of asthma symptoms, recurrent sinusitis andotitis media, and dental malocclusion.
PathophysiologyAllergic rhinitis is an intermittent or persistent inflamma-tory state that is mediated by immunoglobulin E (IgE).In response to contact with an airborne allergen protein,the nasal mucosa mounts an immune response. The anti-gen (from the allergen) binds to a specific IgE on thesurface of mast cells, releasing the chemical mediatorsof histamine and leukotrienes. The release of mediatorsresults in acute tissue edema and mucous production(Banasiak & Meadows-Oliver, 2005). Late-phase medi-ators are released and more inflammation results. IgEbinds to receptors on the surfaces of mast cells andbasophils, creating the sensitization memory that causesthe reaction with subsequent allergen exposures. Allergenexposure then results in mast cell degranulation and releaseof histamine and other chemotactic factors. Histamine andother factors cause nasal vasodilation, watery rhinorrhea,and nasal congestion. Irritation of local nerve endings byhistamine produces pruritus and sneezing (Hagemann,2005). Treatment of allergic rhinitis is aimed at decreas-ing response to these allergic mediators as well as treat-ing inflammation.
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 37
A
B
Water seal
Lung
Visceral pleura
Parietalpleura
Drainage collectionchambers
From patient To suctionsource or air
To ventroom air
2 cm
250mm
● Figure 19.12 The chest tube is connected to suction or water seal via a drainage container.
38 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
Nursing AssessmentFor a full description of the assessment phase of the nurs-ing process, refer to page 00. Assessment findings perti-nent to allergic rhinitis are discussed below.
Health HistoryElicit a description of the present illness and chief com-plaint. Common signs and symptoms reported duringthe health history might include:
• Mild, intermittent to chronic nasal stuffiness• Thin, runny nasal discharge• Sneezing• Itching of nose, eyes, palate• Mouth breathing and snoring
Determine the seasonality of symptoms. Are theyperennial (year-round) or do they occur during certainseasons? What types of medications or other treatmentshave been used, and what was the child’s response?
Explore the history for the presence of risk factorssuch as:
• Family history of atopic disease (asthma, allergic rhinitis,or atopic dermatitis)
• Known allergy to dust mites, pet dander, cockroach anti-gens, pollens, or molds
• Early childhood exposure to indoor allergens• Early introduction to foods or formula in infancy• Exposure to tobacco smoke• Environmental air pollution• Recurrent viral infections
Nonwhite race and higher socioeconomic status havealso been noted as risk factors (Hagemann, 2005).
Physical ExaminationPhysical examination of the child with allergic rhinitisincludes inspection, observation, and auscultation.
Inspection and ObservationObserve the child’s facies for red-rimmed eyes or tearing,mild eyelid edema, “allergic shiners” (bluish or grayish castbeneath the eyes), and “allergic salute” (a transverse nasalcrease between the lower and middle thirds of the nose thatresults from repeated nose rubbing) (Fig. 19.13). Inspectthe nasal cavity. The turbinates may be swollen and gray/blue in color. Clear mucoid nasal drainage may beobserved. Inspect the skin for rash. Listen for nasal phona-tion with speech.
AuscultationAuscultate the lungs for adequate aeration and clarity ofbreath sounds. In the child who also has asthma, exacer-bation with wheezing often occurs with allergic rhinitis.
Laboratory and Diagnostic TestsThe initial diagnosis is often made based on the historyand clinical findings. Common laboratory and diagnos-
tic studies ordered for the assessment of allergic rhinitismay include:
• Nasal smear (positive for eosinophilia)• Positive allergy skin test• Positive RAST
To distinguish between the causes of nasal conges-tion, refer to Comparison Chart 19.1 on page 00.
Nursing ManagementIn addition to the nursing diagnoses and related inter-ventions discussed in the Nursing Care Plan for disordersof the nose, mouth, and throat, interventions common toallergic rhinitis follow.
Maintaining Patent AirwayThe continual nasal obstruction that occurs with aller-gic rhinitis can be very problematic for some children.Performing nasal washes with normal saline may keep thenasal mucus from becoming thickened. Thickened, immo-bile secretions often lead to a secondary bacterial infection.The nasal wash also decongests the nose, allowing forimproved nasal airflow. Anti-inflammatory (corticosteroid)nasal sprays can help to decrease the inflammatoryresponse to allergens. A mast cell stabilizing nasal spraysuch as cromolyn sodium may decrease the intensity andfrequency of allergic responses. Oral antihistamines arenow available in once-daily dosing, providing conve-nience for the family. Some children may benefit from a
● Figure 19.13 Allergic shiners beneaththe eyes and allergic salute across the nose.
combined antihistamine/nasal decongestant if nasalcongestion is significant. Leukotriene modifiers such asmontelukast may also be beneficial for some children(Banasiak & Meadows-Oliver, 2005).
Providing Family EducationOne of the most important tools in the treatment ofallergic rhinitis is learning to avoid known allergens.Teaching Guideline 19.4 gives information on educat-ing families about avoidance of allergens. Children maybe referred to a specialist for allergen desensitization(allergy shots). Products helpful with control of allergies
are available from a number of vendors, such as www.onlineallergyrelief.com.
● ASTHMAAsthma is a chronic inflammatory airway disorder charac-terized by airway hyperresponsiveness, airway edema, andmucus production. Airway obstruction resulting fromasthma might be partially or completely reversed. Severityranges from long periods of control with infrequent acuteexacerbations in some children to the presence of persis-tent daily symptoms in others (Kieckhefer & Ratcliffe,2004). It is the most common chronic illness of childhoodand affects about 9 million American children (Kumaret al., 2005). A small percentage of children with asthmaaccount for a large percentage of health care use andexpense (Wakefield et al., 2005). Asthma accounts forabout 12 million lost school days per year and a significantnumber of lost workdays on the part of parents (Lara et al.,2002). The incidence and severity of asthma are increas-ing; this might be attributed to increased urbanization,increased air pollution, and more accurate diagnosis.
Severity ranges from symptoms associated only withvigorous activity (exercise-induced bronchospasm) todaily symptoms that interfere with quality of life. Thoughuncommon, childhood death related to asthma is also onthe rise worldwide. Air pollution, allergens, family his-tory, and viral infections might all play a role in asthma.Many children with asthma also have gastroesophagealdisease, though the relationship between the two diseasesis not clearly understood.
Complications of asthma include chronic airwayremodeling, status asthmaticus, and respiratory failure.Children with asthma are also more susceptible to seriousbacterial and viral respiratory infections.
Current goals of medical therapy are avoidance ofasthma triggers and reduction or control of inflammatoryepisodes. Current recommendations by the NationalAsthma Education and Prevention Program suggest astepwise approach to management as well as avoidance ofallergens. The stepwise approach involves increasing treat-ment as the child’s condition worsens, then backing offtreatment as he or she improves (Table 19.4). Leukotrienemodifiers have been found to be effective in the short-termmanagement of chronic asthma (Berkhof et al., 2003).Long-term prevention usually involves inhaled steroids.Bronchodilators may be used in the acute treatment ofbronchoconstriction or in the long-acting form to pre-vent bronchospasm. Exercise-induced bronchospasm mayoccur in any child with asthma or as the only symptom inthe child with mild intermittent asthma. Most childrenmay avoid exercise-induced bronchospasm by using alonger warm-up period prior to vigorous exercise and, ifnecessary, inhaling a short-acting bronchodilator just priorto exercise. See Healthy People 2010.
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 39
T E A C H I N G G U I D E L I N E 1 9 . 4
Controlling Exposure to Allergens
Tobacco
• Avoid all exposure to tobacco smoke (this includesself-smoking).
• If parents cannot quit, they must not smoke inside thehome or car.
Dust Mites
• Use pillow and mattress covers.• Wash sheets, pillowcases, and comforters once a week
in 130 degree F water.• Use blinds rather than curtains in bedroom.• Remove stuffed animals from bedroom.• Reduce indoor humidity to <50%.• Remove carpet from bedroom.• Clean solid surface floors with wet mop each week.
Pet Dander
• Remove pets from home permanently.• If unable to remove them, keep them out of bedroom
and off carpet and upholstered furniture.
Cockroaches
• Keep kitchen very clean.• Avoiding leaving out food or drinks.• Use pesticides if necessary, but ensure that the asth-
matic child is not inside the home when it is sprayed.
Indoor Molds
• Repair water leaks.• Use dehumidifier to keep basement dry.• Reduce indoor humidity to <50%.
Outdoor Molds, Pollen, and Air Pollution
• Avoid going outdoors when mold and pollen countsare high.
• Avoid outdoor activity when pollution levels are high.
Table 19.4Table 19.4 Asthma Severity Classification and Treatment Approach
Classification Lung & Referral Symptoms Function Long-Term Control Quick Relief
• One or twotimes a week
• No symptomsand normalPEFR betweenexacerbations
• Intensity of exacerbationsvaries, thoughusually brief inlength.
• Nighttime symp-toms one or twotimes a month
• Symptoms morethan twice aweek but lessthan once a day
• Exacerbationsmay affectactivity level.
• Nighttimesymptoms <2times a month
• Daily symptoms• Daily use of
inhaled short-acting beta2-agonist
• Exacerbationsaffect activity.
• Exacerbations 2or more times aweek; may lastdays
• Nighttimesymptoms >1time a week
• Continualsymptoms
• Limited physicalactivity
• Frequentexacerbations
• Frequentnighttimesymptoms
PEFR 80% or moreof predicted,variability <20%
PEFR 80% or moreof predicted,with 20% to 30%variability
PEFR 60% to 80% ofpredicted, withvariability >30%
PEFR 60% or less ofpredicted, withvariability >30%
PEFR, peak expiratory flow rate.Adapted from National Asthma Education and Prevention Program. (1997, July). Expert panel
report 2: Guidelines for the diagnosis and management of asthma (NIH Publication No.97-4051) and (2002). Update on selected topics. (Publication No. 02-5075). Bethesda, MD:National Institutes of Health, National Heart, Lung and Blood Institute. These recommen-dations are intended to be used as a guide in individualized asthma care.
Step 1: Mild intermittent
Step 2: Mild persistent (referral to asthmaspecialistshould beconsidered)
Step 3:Moderate persistent (referral to asthmaspecialistrecommended)
PathophysiologyIn asthma, the inflammatory process contributes to in-creased airway activity. Thus, control or prevention ofinflammation is the core of asthma management. Asthmaresults from a complex variety of responses in relation to atrigger. When the process begins, mast cells, T lympho-cytes, macrophages, and epithelial cells are involved in therelease of inflammatory mediators. Eosinophils and neu-trophils migrate to the airway, causing injury. Chemicalmediators such as leukotrienes, bradykinin, histamine, andplatelet-activating factor also contribute to the inflamma-tory response. The presence of leukotrienes contributesto prolonged airway constriction (Banasiak & Meadows-Oliver, 2005). Autonomic neural control of airway tone isaffected, airway mucus secretion is increased, mucociliary
function changes, and airway smooth muscle responsive-ness increases (Kiecheter & Ratcliffe, 2004). As a result,acute bronchoconstriction, airway edema, and mucusplugging occur (Fig. 19.14).
In most children, this process is considered reversibleand until recently it was not considered to have long-standing effects on lung function. Current research andscientific thought, however, recognize the concept of air-way remodeling. Airway remodeling occurs as a result ofchronic inflammation of the airway. Following the acuteresponse to a trigger, continued allergen response resultsin a chronic phase. During this phase, the epithelial cellsare denuded and the influx of inflammatory cells into theairway continues. This results in structural changes of theairway that are irreversible, and further loss of pulmonaryfunction might occur (Kiecheter & Ratcliffe, 2004).
Nursing AssessmentFor a full description of the assessment phase of the nurs-ing process, refer to page 00. Assessment findings pertinentto asthma are discussed below.
Health HistoryElicit a description of the present illness and chief com-plaint. Common signs and symptoms reported during thehealth history might include:
• Cough, particularly at night: hacking type of cough thatis initially nonproductive, becoming productive of frothysputum
• Difficulty breathing: shortness of breath, chest tightnessor pain, dyspnea with exercise
• Wheezing
Explore the child’s current and past medical historyfor risk factors such as:
• History of allergic rhinitis or atopic dermatitis• Family history of atopy (asthma, allergic rhinitis, atopic
dermatitis)
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 41
Normal airway Airway with inflammation Airway with inflammation,bronchospasm,and mucus production
Reduce asthma deaths,hospitalizations forasthma, and hospitalemergency departmentvisits for asthma.
Significance
• Provide appropriateeducation and triage tofamilies of children withasthma, particularlywhen the child is experi-encing symptoms or a decreased peakflow rate.
HEALTHY PEOPLE 2010
Currently many manufacturers use chlorofluoro-carbon (CFC) as the propellant in metered-dose inhalers. In 2005, the U.S. Food and DrugAdministration announced that these types of
inhaler would be phased out of the market by the end of 2008. Environmentally friendly formulations of hydrofluo-roalkane (HFA) will be used in all metered-dose inhalers by that time (Bederka, 2006).
• Recurrent episodes diagnosed as wheezing, bronchiolitis,or bronchitis
• Known allergies• Seasonal response to environmental pollen• Tobacco smoke exposure (passive or self-smoking)• Poverty
Physical ExaminationPhysical examination of the child with asthma includesinspection, auscultation, and percussion.
InspectionObserve the patient’s general appearance and color.During mild exacerbations, the child’s color might remainpink, but as the child worsens, cyanosis might result. Workof breathing is variable. Some children present with mildretractions, while others demonstrate significant accessorymuscle use and eventually head-bobbing if not effectivelytreated. The child may appear anxious and fearful or belethargic and irritable. An audible wheeze might be pres-ent. Children with persistent severe asthma may have abarrel chest and routinely demonstrate mildly increasedwork of breathing.
Auscultation and PercussionA thorough assessment of lung fields is necessary.Wheezing is the hallmark of airway obstruction and mightvary throughout the lung fields. Coarseness might also bepresent. Assess the adequacy of aeration. Breath soundsmight be diminished in the bases or throughout. A quietchest in an asthmatic child can be an ominous sign. Withsevere airway obstruction, air movement can be so poorthat wheezes might not be heard upon auscultation.Percussion may yield hyperresonance.
Laboratory and Diagnostic TestsLaboratory and diagnostic studies commonly ordered forthe assessment of asthma include:
• Pulse oximetry: oxygen saturation may be significantlydecreased or normal during a mild exacerbation
• Chest x-ray: usually reveals hyperinflation• Blood gases: might show carbon dioxide retention and
hypoxemia• Pulmonary function tests (PFTs): can be very useful in
determining the degree of disease but are not useful dur-ing an acute attack. Children as young as 5 or 6 yearsmight be able to comply with spirometry.
• Peak expiratory flow rate (PEFR): is decreased duringan exacerbation
• Allergy testing: skin test or RAST can determine aller-gic triggers for the asthmatic child
Nursing ManagementInitial nursing management of the child with an acuteexacerbation of asthma is aimed at restoring a clear air-
way and effective breathing pattern as well as promotingadequate oxygenation and ventilation (gas exchange).Refer to the Nursing Care Plan on page 00. Additionalconsiderations are reviewed below.
Educating the Child and FamilyAsthma is a chronic illness and needs to be understood assuch. Figure 19.15 displays the “Kids with Asthma Billof Rights” developed by the American Lung Association.Teach families of children with asthma, and the childrenthemselves, how to care for the disease. Symptom-freeperiods (often very long) are interspersed with episodes ofexacerbation. Parents and children often do not under-stand the importance of maintenance medications forlong-term control. They may view the episodes of exacer-bation (sometimes requiring hospitalization or emergencyroom visits) as an acute illness and are simply relieved whenthey are over. Frequently during the periods betweenacute episodes, children are viewed as disease-free andlong-term maintenance schedules are abandoned. Theprolonged inflammatory process occurring in the absenceof symptoms, primarily in children with moderate tosevere asthma, can lead to airway remodeling and even-tual irreversible disease.
To provide appropriate education to the child andfamily, determine the severity of the asthma as outlinedin the NAEPP Expert Panel Report: Guidelines for theDiagnosis and Management of Asthma (Kumar et al.,2005). Stress the concept of maintenance medications forthe prevention of future serious disease in addition to con-trolling or preventing current symptoms.
Educate families and children on the appropriate useof nebulizers, metered-dose inhalers, spacers, dry-powderinhalers, and Diskus, as well as the purposes, functions,and side effects of the medications they deliver. Requirereturn demonstration of equipment use to ensure thatchildren and families can use the equipment properly(Teaching Guideline 19.5).
42 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
4242
Each child should have a management plan in placeto determine when to step up or step down treatment.The recommendations for treatment based on severity ofasthma are listed in Table 19.4. Figure 19.16 provides anexample of a written format that may be helpful to fami-lies in the management of asthma. This written actionplan should also be kept on file at the child’s school, andrelief medication should be available to the child at alltimes. Children who experience exercise-induced bron-chospasm may still participate in physical education orathletics but may need to be allowed to use their medi-cine before the activity.
(text continues on page 000)
AQ7
The NAEPP recommends use of a spacer or holdingchamber with metered-dose inhalers to increasethe bioavailability of medication in the lungs.
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 43
● Figure 19.15 The Asthma Bill of Rights.
44 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
T E A C H I N G G U I D E L I N E 1 9 . 5
Using Asthma Medication Delivery Devices
Nebulizer
• Plug in thenebulizer andconnect the aircompressortubing.
• Attach themask or themouthpieceand hose to themedicine cup.
• Instruct thechild to closethe lips aroundthe mouthpieceand breathethrough themouth.
• Add the medicationto the medicine cup.
• Place the maskon the child OR
• After use, washthe mouthpieceand medicinecup with waterand allow toair dry.
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 45
T E A C H I N G G U I D E L I N E 1 9 . 5 (Continued)
Using Asthma Medication Delivery Devices
Metered-Dose Inhaler
• Shake the inhaler and take off the cap.
• Put the spacermouthpiece inthe mouth (orplace the maskover the child’snose and mouth,ensuring a goodseal).
Diskus
• Hold theDiskus in ahorizontalposition in onehand and pushthe thumbgripwith the thumbof your otherhand awayfrom you untilmouthpieceis exposed.
• Place yourmouth securelyaround themouthpieceand breathe infully andquickly throughyour mouth.
• Attach the inhalerto the spacer orholding chamber.
• Breathe out completely.
• Compress theinhaler and inhaleslowly and deeply.Hold the breathfor a count of 10.
• Push the leveruntil it clicks(the dose isnow loaded).
In addition to the presence or absence of symptoms,the NAEPP recommends the use of the peak expiratoryflow rate (PEFR) to determine daily control. PEFR mea-surements obtained via a home peak flow meter can bevery helpful as long as the meter is used appropriately(Teaching Guideline 19.6 gives instructions on peak flowmeter use). The child’s “personal best” is determined col-laboratively with the health care practitioner during asymptom-free period. PEFR is measured daily at homeusing the peak flow meter. The asthma management planthen gives specific instructions based on the PEFR mea-surement (Table 19.5).
Avoidance of allergens is another key component ofasthma management. Avoiding known triggers helps toprevent exacerbations as well as long-term inflammatorychanges. This can be a difficult task for most families, par-ticularly if the affected child suffers from several allergies.Teaching Guideline 19-4 outlines strategies for allergenavoidance.
Young children with asthma receiving inhaled medicationsvia a nebulizer should use a snugly fitting mask to ensureaccurate deposition of medication to the lungs. “Blow-by”via nebulizer should be discouraged, as medication deliveryis variable and unreliable.
ConsiderConsiderTHIS! Research has found a lag in parent/child education inrelation to asthma management (Horner, 2004). Asthmaeducation is not limited to the hospital or clinic setting.Nurses can become involved in community asthma educa-tion: community-centered education in schools, churches,and daycare centers or through peer educators has beenshown to be effective. Education should include patho-physiology, asthma triggers, and prevention and treat-ment strategies. With such a large number of childrenaffected with this chronic disease, community educationhas the potential to make a broad impact. See HealthyPeople 2010.
School nurses must also become experts in asthmamanagement as well as being committed to ongoing edu-cation of the child and family (Sander, 2002). Resourcesfor schools include:
• Open Airways for Schools is an educational programpresented by the American Lung Association or its localchapter, focusing on increasing asthma awareness andcompliance with asthma action plans and decreasingasthma emergencies. Contact the local lung associationor call 1-800-LUNG-USA.
• Asthma and Allergies at School is a kit available fromAANMA at www.breatherville.org/schoolhouse or 1-800-878-4403.
• Healthy School Environments Assessment Tool is avail-able at http://www.epa.gov/schools/.
● Figure 19.16 Asthma Action Plan.
47
48 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
T E A C H I N G G U I D E L I N E 1 9 . 6
Using a Peak Flow Meter
• Slide the arrow down to “zero.”• Stand up straight.• Take a deep breath and close the lips tightly around
the mouthpiece.• Blow out hard and fast.• Note the number the arrow moves to.• Repeat three times and record the highest reading.• Keep a record of daily readings, being sure to measure
peak flow at the same time each day.
Data from the American Lung Association.
*The National Asthma Education and Prevention Program recommended the “traffic light”approach for educating individuals on PEFRs and management plans.
Table 19.5Table 19.5 Assessment of Peak Expiratory Flow Rate (PEFR)
Zone* PEFR Symptoms Action
Green: Good control
Yellow: Caution
Red: Medical alert
>80% personalbest
50% to 80%personalbest
<50% personalbest
None
Possibly present
Usually present
Take usualmedications.
Take short-actinginhaled beta2-agonist right away.Talk to your healthcare provider.
Take short-actinginhaled beta2-agonist rightaway. Go to officeor emergencydepartment.
Objective
Reduce activity limita-tions among persons withasthma. (Developmental)Reduce the number ofschool or workdaysmissed by persons withasthma. Increase theproportion of personswith asthma who receiveformal patient educa-tion, including informa-tion about communityand self-help resources,as an essential part ofthe management of theircondition.
Significance
• Encourage appropriatephysical activity in children with asthma.
• Provide extensive education to childrenand families aboutpeak flow meter useand its meaning, main-tenance and rescuemedications, symptomsof asthma exacerba-tion, and a written planfor how to “step up”and “step down”asthma management.
• Refer children and theirfamilies to local asthmaor Internet resourcesand support groups.
• Refer families to formalclasses on asthmaeducation.
HEALTHY PEOPLE 2010
Moodiness, acting out, and withdrawal correlate withincreases in school absence, which can contribute topoor school performance. To live in fear of an exacer-bation or to be unable to participate in activities affectsthe child’s self-esteem.
Through education and support, the child can gain asense of control. Children need to learn to master theirdisease. Accurate evaluation of asthma symptoms and
Promoting the Child’s Self-EsteemFear of an exacerbation and feeling “different” from otherchildren can harm a child’s self-esteem. In qualitativeresearch studies, children have made such statements as“my body shuts down” and “I feel like I’m going todie” (Yoos et al., 2005). The fatigue and fear associatedwith chronic asthma may reduce the child’s confidenceand sense of control over his or her body and life. Inaddition to coping with a chronic illness, the asthmaticchild often also has to cope with school-related issues.
Exposure to second-hand smoke increases theneed for medications in children with asthma aswell as the frequency of asthma exacerbations.Both indoor air quality and environmental pollu-
tion contribute to asthma in children.
Nursing AssessmentTachypnea and increased work of breathing are character-istic of chronic lung disease. After discharge from theNICU, these symptoms can continue. Exertion such asactivity or oral feeding can cause dyspnea to worsen.Failure to thrive might also be evident. Auscultation mightreveal breath sounds that are diminished in the bases.These infants have reactive airway episodes, so wheezingmight be present during times of exacerbation. If fluidoverload develops, rales may be heard.
Nursing ManagementIf the infant is oxygen dependent, provide education tothe parents about oxygen tanks, nasal cannula use, pulseoximetry use, and nebulizer treatments. Often thesechildren require increased-calorie formulas to growadequately. Fluid restrictions and/or diuretics are neces-sary in some infants. Follow-up echocardiograms might beused to determine resolution of pulmonary artery hyper-tension prior to weaning from oxygen. Encourage devel-opmentally appropriate activities. It might be difficult forthe oxygen-dependent infant or toddler to reach grossmotor milestones or explore the environment because thelength of his oxygen tubing limits him or her.
Parental support is also a key nursing intervention.After a long and trying period of ups and downs withtheir newborn in the intensive care unit, parents findthemselves exhausted caring for their medically fragileinfant at home.
● CYSTIC FIBROSISCystic fibrosis is an autosomal recessive disorder thatoccurs about once in every 3,300 live white births andabout once in every 16,000 live black births (Boat, 2004).A deletion occurring on the long arm of chromosome 7at the cystic fibrosis transmembrane regulator (CFTR) isthe responsible gene mutation. DNA testing can be usedprenatally and in newborns to identify the presence ofthe mutation. The American College of Obstetrics andGynecology currently recommends screening for cysticfibrosis to any person seeking preconception or prenatalcare. At present, 11 states include testing for cystic fibro-sis as part of newborn screening (Gross, 2004).
Cystic fibrosis is the most common debilitating diseaseof childhood among those of European descent. Medicaladvances in recent years have greatly increased the lengthand quality of life for affected children: about 50% now livepast the age of 30 years (Boat, 2004), and many live a high-quality life into their 40s (Carpenter & Narsavage, 2004).Complications include hemoptysis, pneumothorax, bacte-rial colonization, cor pulmonale, volvulus, intussusception,intestinal obstruction, rectal prolapse, gastroesophagealreflux disease, diabetes, portal hypertension, liver failure,gallstones, and decreased fertility.
improvement of self-esteem may help the child to expe-rience less panic with an acute episode. Improved self-esteem might also help the child cope with the disease ingeneral and with being different from his or her peers.The school-age child has the cognitive ability to begin tak-ing responsibility for asthma management, with contin-ued involvement on the part of the parents. Transferringcontrol of asthma care to the child is an important devel-opmental process that will contribute to the child’s feel-ing of control over the illness (Buford, 2004).
Promoting Family CopingParent denial is an issue in many families. The family,through education and encouragement, can become theexperts on the child’s illness as well as advocates for thechild’s well-being. The resilient child is better able tocope with difficulties presented to him or her, includingasthma. Cohesiveness and warmth in the family envi-ronment can improve a child’s resiliency as well as con-tribute to family hardiness. Parents need to be allowedto ask questions and voice their concerns. A nurse whounderstands the family’s issues and concerns is betterable to plan for support and education. Provide cultur-ally sensitive education and interventions that focus onincreasing the family’s commitment to and control ofasthma management. As the child and parents becomeconfident in their ability to recognize asthma symptomsand cope with asthma and its periodic episodes, thefamily’s ability to cope will improve (Svavarsdottir &Rayens, 2005).
● CHRONIC LUNG DISEASEChronic lung disease (formerly termed bronchopulmonarydysplasia [BPD]) is often diagnosed in infants whohave experienced RDS and continue to require oxygenat 28 days of age. It is a chronic respiratory conditionseen most commonly in premature infants. It results froma variety of factors, including pulmonary immaturity,acute lung injury, barotrauma, inflammatory mediators,and volutrauma. Epithelial stretching, macrophage andpolymorphonuclear cell invasion, and airway edema affectthe growth and development of lung structures. Cilia lossand airway lining denudation reduce the normal cleansingabilities of the lung. The number of normal alveoli isreduced by one third to one half. Lower birthweights,white race, and male gender pose increased risk for devel-opment of chronic lung disease. Complications includepulmonary artery hypertension, cor pulmonale, congestiveheart failure, and severe bacterial or viral pneumonia.(Harvey, 2004; Stoll & Kliegman, 2004).
Anti-inflammatory inhaled medications are used formaintenance, and short-acting bronchodilators are usedas needed for wheezing episodes. Supplemental long-termoxygen therapy may be required in some infants.
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 49
50 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
Therapeutic ManagementTherapeutic management of cystic fibrosis is aimed towardminimizing pulmonary complications, maximizing lungfunction, preventing infection, and facilitating growth. Allchildren with cystic fibrosis who have pulmonary involve-ment require chest physiotherapy with postural drainageseveral times daily to mobilize secretions from the lungs.Physical exercise is encouraged. Recombinant humanDNase (Pulmozyme) is given daily using a nebulizer todecrease sputum viscosity and help clear secretions.Inhaled bronchodilators and anti-inflammatory agents areprescribed for some children. Aerosolized antibiotics areoften prescribed and may be given at home as well as in thehospital. Choice of antibiotic is determined by sputum cul-ture and sensitivity results. Pancreatic enzymes and sup-plemental fat-soluble vitamins are prescribed to promoteadequate digestion and absorption of nutrients and opti-mize nutritional status. Increased-calorie, high-proteindiets are recommended, and sometimes supplementalhigh-calorie formula, either orally or via feeding tube, isneeded. Some children require total parenteral nutritionto maintain or gain weight (McMullen, 2004). Lungtransplantation has been successful in some children withcystic fibrosis.
PathophysiologyIn cystic fibrosis, the CFTR mutation causes alterations inepithelial ion transport on mucosal surfaces, resulting ingeneralized dysfunction of the exocrine glands. The epi-thelial cells fail to conduct chloride, and water transportabnormalities occur. This results in thickened, tenacioussecretions in the sweat glands, gastrointestinal tract, pan-creas, respiratory tract, and other exocrine tissues. The in-creased viscosity of these secretions makes them difficultto clear. The sweat glands produce a larger amount ofchloride, leading to a salty taste of the skin and alterationsin electrolyte balance and dehydration. The pancreas,intrahepatic bile ducts, intestinal glands, gallbladder, andsubmaxillary glands become obstructed by viscous mucusand eosinophilic material. Pancreatic enzyme activity islost and malabsorption of fats, proteins, and carbohydratesoccurs, resulting in poor growth and large, malodorousstools. Excess mucus is produced by the tracheobronchialglands. Abnormally thick mucus plugs the small airways,and then bronchiolitis and further plugging of the airwaysoccur. Secondary bacterial infection with Staphylococcusaureus, Pseudomonas aeruginosa, and Burkholderia cepaciaoften occurs. This contributes to obstruction and inflam-mation, leading to chronic infection, tissue damage, andrespiratory failure. Nasal polyps and recurrent sinusitisare common. Boys have tenacious seminal fluid and expe-rience blocking of the vas deferens, often making theminfertile. In girls, thick cervical secretions might limit pen-etration of sperm (Boat, 2004; Simpson & Ivey, 2005).Table 19.6 gives further details of the pathophysiology and
resulting respiratory and gastrointestinal clinical manifes-tations of cystic fibrosis.
Nursing AssessmentFor a full description of the assessment phase of the nurs-ing process, refer to page 00. Assessment findings perti-nent to cystic fibrosis are discussed below.
Health HistoryElicit a description of the present illness and chief com-plaint. Common signs and symptoms reported during thehealth history in the undiagnosed child might include:
• A salty taste to the child’s skin (resulting from excesschloride loss via perspiration)
• Meconium ileus or late, difficult passage of meconiumstool in the newborn period
• Abdominal pain or difficulty passing stool (infants ortoddlers might present with intestinal obstruction orintussusception at the time of diagnosis)
• Bulky, greasy stools• Poor weight gain and growth despite good appetite• Chronic or recurrent cough and/or upper or lower res-
piratory infections
Children known to have cystic fibrosis are oftenadmitted to the hospital for pulmonary exacerbationsor other complications of the disease. The health historyshould include questions related to:
• Respiratory status: has cough, sputum production, orwork of breathing increased?
• Appetite and weight gain• Activity tolerance• Increased need for pulmonary or pancreatic medications• Presence of fever• Presence of bone pain• Any other changes in physical state or medication regimen
Physical ExaminationThe physical examination includes inspection, ausculta-tion, percussion, and palpation.
InspectionObserve the child’s general appearance and color. Checkthe nasal passages for polyps. Note respiratory rate, workof breathing, use of accessory muscles, position of comfort,frequency and severity of cough, and quality and quantityof sputum produced. The child with cystic fibrosis oftenhas a barrel chest (anterior–posterior diameter approxi-mates transverse diameter) (Fig. 19.17). Clubbing of thenail beds might also be present. Note whether rectal pro-lapse is present. Does the child appear small or thin for hisor her age? The child might have a protuberant abdomenand thin extremities, with decreased amounts of subcuta-neous fat present. Observe for the presence of edema (signof cardiac or liver failure). Note distended neck veins or thepresence of a heave (signs of cor pulmonale).
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 51
AuscultationAuscultation may reveal a variety of adventitious breathsounds. Fine or coarse crackles and scattered or localizedwheezing might be present. With progressive obstructivepulmonary involvement, breath sounds might be dimin-ished. Tachycardia might be present. Note the presenceof a gallop (might occur with cor pulmonale). Note theadequacy of bowel sounds.
PercussionPercussion over the lung fields usually yields hyperreso-nance due to air trapping. Diaphragmatic excursion mightbe decreased. Percussion of the abdomen might revealdullness over an enlarged liver or mass related to intestinalobstruction.
PalpationPalpation might yield a finding of asymmetric chestexcursion if atelectasis is present. Tactile fremitus maybe decreased over areas of atelectasis. Note if tendernessis present over the liver (might be an early sign of corpulmonale).
Laboratory and Diagnostic TestsCommon laboratory and diagnostic studies ordered forthe diagnosis and assessment of cystic fibrosis include:
• Sweat chloride test: considered suspicious if the level ofchloride in collected sweat is above 50 mEq/L and diag-nostic if the level is above 60 mEq/L (Fig. 19.18)
• Pulse oximetry: oxygen saturation might be decreased,particularly during a pulmonary exacerbation
Table 19.6Table 19.6 Pathophysiology of Cystic Fibrosis and Resultant Respiratoryand Gastrointestinal Clinical Manifestations
Defect in the CFTR Gene Affects Pathophysiology Clinical Manifestations
Respiratory tract
Gastrointestinal tract
• Infection leads to neutrophilic inflammation.• Cleavage of complement receptors and
immunoglobin G leads to opsonophago-cytosis failure.
• Chemoattractant interleukin-8 and elastindegradase contribute to inflammatoryresponse.
• Thick, tenacious sputum that is chronicallycolonized with bacteria results.
• Air trapping related to airway obstruction• Pulmonary parenchyma is eventually
destroyed.
• Decreased chloride and water secretioninto the intestine (causing dehydration ofthe intestinal material) and into the bileducts (causing increased bile viscosity)
• Reduced pancreatic bicarbonatesecretion
• Hypersecretion of gastric acid• Insufficiency of pancreatic enzymes
necessary for digestion and absorption• Pancreas secretes thick mucus.
• Airway obstruction• Difficulty clearing secretions• Respiratory distress and impaired gas
• Meconium ileus• Retention of fecal matter in distal intestine,
resulting in vomiting, abdominal distentionand cramping, anorexia, right lowerquadrant pain
• Sludging of intestinal contents may lead tofecal impaction, rectal prolapse, bowelobstruction, intussusception.
• Obstructive cirrhosis with esophagealvarices, and splenomegaly
• Gallstones• Gastroesophageal reflux disease
(compounded by postural drainage withchest physiotherapy)
• Inadequate protein absorption• Altered absorption of iron and vitamins A,
D, E, and K• Failure to thrive• Hyperglycemia and development of
diabetes later in life
related interventions discussed in the Nursing Care PlanOverview for respiratory disorders, interventions commonto cystic fibrosis follow.
Maintaining Patent AirwayChest physiotherapy is often used as an adjunct therapy inrespiratory illnesses, but for children with cystic fibrosis itis a critical intervention. Chest physiotherapy involves per-cussion, vibration, and postural drainage, and either it oranother bronchial hygiene therapy must be performed sev-eral times a day to assist with mobilization of secretions.Nursing Procedure 19.2 gives instructions on the chestphysiotherapy technique.
For older children and adolescents, the flutter-valvedevice, positive expiratory pressure therapy, or a high-frequency chest compression vest may also be used. Theflutter valve device provides high-frequency oscillation tothe airway as the child exhales into a mouthpiece thatcontains a steel ball. Positive expiratory pressure therapyinvolves exhaling through a flow resistor, which createspositive expiratory pressure. The cycles of exhalation arerepeated until coughing yields expectoration of secretions.The vest airway clearance system provides high-frequencychest wall oscillation to increase airflow velocity to createrepetitive cough-like shear forces and to decrease the vis-cosity of secretions (Goodfellow & Jones, 2002). Breathingexercises are also helpful in promoting mucus clearance.Encourage physical exercise, as it helps to promote mucussecretion as well as providing cardiopulmonary condition-ing. Ensure that Pulmozyme is administered, as well asinhaled bronchodilators and anti-inflammatory agents ifprescribed.
Preventing InfectionVigorous pulmonary hygiene for mobilization of secretionsis critical to prevent infection. Aerosolized antibiotics canbe given at home as well as in the hospital. Children withfrequent or severe respiratory exacerbations might requirelengthy courses of intravenous antibiotics.
Maintaining GrowthPancreatic enzymes must be administered with all mealsand snacks to promote adequate digestion and absorptionof nutrients. The number of capsules required depends onthe extent of pancreatic insufficiency and the amount offood being ingested. The dosage can be adjusted until anadequate growth pattern is established and the number ofstools is consistent at one or two per day. Children willneed additional enzyme capsules when high-fat foods arebeing eaten. In the infant or young child, the enzyme cap-sule can be opened and sprinkled on cereal or applesauce.A well-balanced, high-calorie, high-protein diet is neces-sary to ensure adequate growth. Some children requireup to 1.5 times the recommended daily allowance ofcalories for children their age. A number of commerciallyavailable nutritional formulas and shakes are available fordiet supplementation.
52 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
• Chest x-ray: may reveal hyperinflation, bronchial wallthickening, atelectasis, or infiltration
• Pulmonary function tests: might reveal a decrease inforced vital capacity and forced expiratory volume, withincreases in residual volume (Boat, 2004; McMullen,2004)
Nursing ManagementManagement of cystic fibrosis focuses on minimizing pul-monary complications, promoting growth and develop-ment, and facilitating coping and adjustment of the childand family. In addition to the nursing diagnoses and
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 53
1. Provide percussion via a cupped hand or an infantpercussion device. Appropriate percussion yields ahollow sound (not a slapping sound).
POSITION #8 & 9LOWER LOBES, Lateral basal segments
3. Place the ball of the hand on the lung segment, keep-ing the arm and shoulder straight. Vibrate by tensingand relaxing your arms during the child’s exhalation.Vibrate each lung segment for at least five exhalations.
4. Encourage the child to deep breathe and cough.
5. Change drainage positions and repeat percussionand vibration.
In infants, breastfeeding should be continued withenzyme administration. Some infants will require fortifi-cation of breast milk or supplementation with high-calorieformulas. Commercially available infant formulas cancontinue to be used for the formula-fed infant and canbe mixed to provide a larger amount of calories if neces-sary. Supplementation with vitamins A, D, E, and K isnecessary. Administer gavage feedings or total parenteralnutrition as prescribed to provide for adequate growth.
Promoting Family CopingCystic fibrosis is a serious chronic illness that requires inter-vention on a daily basis. It can be hard to maintain a sched-ule that requires pulmonary hygiene several times daily aswell as close attention to appropriate diet and enzyme sup-plementation. Adjusting to the demands that the illnessplaces on the child and family is difficult. Continual on-going adjustments within the family must occur. Childrenare frequently hospitalized, and this may place an addi-tional strain on the family and its finances. Children withcystic fibrosis may express fear or feelings of isolation, andsiblings may be worried or jealous (Carpenter & Narsavage,2004). The family should be encouraged to lead a normallife through involvement in activities and school attendanceduring periods of wellness.
Starting at the time of diagnosis, families oftendemonstrate significant stress as the severity of the diag-nosis and the significance of disease chronicity becomereal for them. The family should be involved in the child’scare from the time of diagnosis, whether in the outpatientsetting or in the hospital. Ongoing education about theillness and its treatments is necessary. Once the initialshock of diagnosis has passed and the family has adjustedto initial care, the family usually learns how to manage therequirements of care. Powerlessness gives way to adapta-tion. As family members become more comfortable withtheir understanding of the illness and the required treat-ments, they will eventually become the experts on thechild’s care. It is important for the nurse to recognize andrespect the family’s changing needs over time.
Providing daily intense care can be tiring, and non-compliance on the part of the family or child might occuras a result of this fatigue. Overvigilance may also occur asa result of the need for control over the difficult situationas well as a desire to protect the child. Families welcomesupport and encouragement. Most families will eventu-ally progress past the stages of fear, guilt, and powerless-ness. They move beyond those feelings to a way of livingthat is different than what they anticipated but is some-thing that they can manage.
Refer parents to a local support group for familiesof children with cystic fibrosis. The Cystic Fibrosis Foun-dation has chapters throughout the United States andcan be accessed at www.cff.org. Additional resources canbe found at www.cysticfibrosis.com, www.cfri.org, andwww.cfww.org.
Parents of children with a terminal illness might facethe death of their child at an earlier age than expected.
Massage therapy performed by the parent,nurse, or licensed massage therapist may help todecrease anxiety in the child with cystic fibrosis. Itmay have the added benefit of improving respi-
ratory status, but it does not replace chest physiotherapy (Huthet al., 2005).
56 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
SUDDEN INFANT DEATH SYNDROME (SIDS)
DefinitionSudden death of a previously healthy infant <1 year of age
Prevention• Place all infants in the supine position to sleep (even
side-lying is not as safe and is not recommended bythe AAP).
• Provide a firm sleep surface and avoid soft bedding,excess covers, pillows, and stuffed animals in the crib.
• Avoid maternal prenatal smoking and exposure of theinfant to second-hand smoke.
• Ensure the infant sleeps separately from the parents.• Avoid overbundling or overdressing the infant.• Encourage pacifier use at nap and bed time if the
infant is receptive to it (AAP, 2005).
Support and Information• www.sidsalliance.org: SIDS alliance• www.sidscenter.org: National SIDS/Infant Death
Resource Center• www.asip1.org: Association for SIDS and Infant
Mortality Program• sids-network.org/: Sudden Infant Death Syndrome
Network, Inc.
BOX 19.3Assisting with anticipatory grieving and making decisionsrelated to end-of-life care are other important nursinginterventions.
Preparing the Child and Family for AdulthoodWith Cystic FibrosisWith current technological and medication advances,many more children with cystic fibrosis are surviving toadulthood and into their 30s and 40s. Lung transplanta-tion is now being used in some patients with success, thusprolonging life expectancy (barring transplant complica-tions). Children should have the goal of independent liv-ing as an adult, as other children do. Making the transitionfrom a pediatric medical home to an adult medical homeshould be viewed as a rite of passage (Madge & Byron,2005). Pediatric clinics are focused on family-centeredcare that heavily involves the child’s parents, but adultswith cystic fibrosis need a different focus, one that viewsthem as independent adults.
Adults with cystic fibrosis can make the transition frompediatric to adult care with thoughtful preparation andcoordination. They desire and deserve a smooth transitionin care that will result in appropriate ongoing medical man-agement of cystic fibrosis provided in an environment thatis geared toward adults rather than children.
Adults with cystic fibrosis are able to find rewardingwork and pursue relationships. Most men with cystic fibro-sis are capable of sexual intercourse, though unable toreproduce. Females might have difficulty conceiving, andwhen they do they should be cautioned about the addi-tional respiratory strain that pregnancy causes. All childrenof parents with cystic fibrosis will be carriers of the gene.
● APNEAApnea is defined as absence of breathing for longer than20 seconds; it might be accompanied by bradycardia.Sometimes apnea presents in the form of an acute life-threatening event (ALTE), an event in which the infant orchild exhibits some combination of apnea, color change,muscle tone alteration, coughing, or gagging. Apnea mayalso occur acutely at any age as a result of respiratory dis-tress. This discussion will focus on apnea that is chronic orrecurrent in nature or that occurs as part of an ALTE.
Apnea in infants may be central (unrelated to anyother cause) or occur with other illnesses such as sepsisand respiratory infection. Apnea in newborns might beassociated with hypothermia, hypoglycemia, infection,or hyperbilirubinemia. Apnea of prematurity occurs sec-ondary to an immature respiratory system. Apnea shouldnot be considered as a predecessor to sudden infant deathsyndrome (SIDS). Current research has not proven thistheory, and SIDS generally occurs in otherwise healthyyoung infants (AAP, Task Force on Sudden Infant DeathSyndrome, 2005; Ramanathan et al., 2001). Box 19.3gives more information about SIDS and its prevention.
Therapeutic management of apnea varies dependingupon the cause. When apnea occurs as a result of anotherdisorder or infection, treatment is directed toward thatcause. In the event of apnea, stimulation may trigger theinfant to take a breath. If breathing does not resume, res-cue breathing or bag-valve-mask ventilation is necessary.Infants and children who have experienced an ALTEor who have chronic apnea may require ongoing cardiac/apnea monitoring. Caffeine or theophylline is sometimesadministered, primarily in premature infants, to stimulaterespirations.
Nursing AssessmentQuestion the parents about the infant’s position and activ-ities preceding the apneic episode. Did the infant experi-ence a color change? Did the infant self-stimulate (breatheagain on his or her own), or did he or she require stimu-lation from the caretaker? Assess risk factors for apnea,which may include prematurity, anemia, and history ofmetabolic disorders. Apnea may occur in association withcardiac or neurologic disturbances, respiratory infection,sepsis, child abuse, or poisoning.
In the hospitalized infant, note absence of respiration,position, color, and other associated findings, such asemesis on the bedclothes. If an infant who is apneic failsto be stimulated and does not breathe again, pulselessnesswill result.
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 57
Nursing ManagementWhen an infant is noted to be apneic, gently stimulatehim or her to take a breath again. If gentle stimulation isunsuccessful, then rescue breathing or bag-valve-maskventilation must be started.
To avoid apnea in the newborn, maintain a neutralthermal environment. Avoid excessive vagal stimulationand taking rectal temperatures (the vagal response cancause bradycardia, resulting in apnea). Administer caffeineor theophylline if prescribed and teach families about theuse of these medications.
Infants with recurrent apnea or ALTE may be dis-charged on a home apnea monitor (Fig. 19.19). Provideeducation on use of the monitor, guidance for when tonotify the physician or monitor service about alarms, andtraining in infant CPR. The monitor is usually discontin-ued after 3 months without a significant event of apneaor bradycardia. In some ways the monitor gives parentspeace of mind, but in others it can make them more ner-vous about the well-being of their child. Also, the alarmon home monitors is extremely loud and parents often gofor months with inadequate sleep. Providing appropriateeducation to the parents about the nature of the child’sdisorder as well as action to take in the event of apneamay give the family a sense of mastery over the situation,thus decreasing their level of anxiety. Refer families tolocal area support groups such as those offered by Parentto Parent and Parents Helping Parents.
TracheostomyA tracheostomy is an artificial opening in the airway;usually a plastic tracheostomy tube is in place to form apatent airway. Tracheostomies are performed to relieve air-way obstruction, such as with subglottic stenosis (nar-rowing of the airway sometimes resulting from long-termintubation). They are also used for pulmonary toilet and inthe child who requires chronic mechanical ventilation. Thetracheostomy facilitates secretion removal, reduces work of
breathing, and increases patient comfort. In some cases thetracheostomy facilitates mechanical ventilation weaning. Itmay be permanent or temporary depending on the condi-tion that leads to the tracheostomy. The tracheostomy tubevaries in size and type depending on the child’s airwaysize and health and the length of time the child will requirethe tracheostomy. Silastic tracheostomy tubes are soft andflexible; they are available with a single lumen or may havean outer and inner lumen. Both types have an obturator(the guide used during tube changes). Typically, the tubeswith inner cannulas are used with older children and inchildren with increased mucus production. Cuffed tra-cheostomy tubes are generally used in older children also.The cuff is used to prevent air from leaking around thetube. The funnel-shaped airway in younger children acts aphysiological cuff and prevents air leak. Figure 19.20 showsvarious types of tracheostomy tubes.
Complications immediately postoperatively includehemorrhage, air entry, pulmonary edema, anatomic dam-age, and respiratory arrest. At any point in time the tra-cheostomy tube may become occluded and ventilationcompromised. Complications of chronic tracheostomyinclude infection, cellulitis, and formation of granulationtissue around the insertion site (Russell, 2005).
Nursing AssessmentWhen obtaining the history for a child with a tracheostomy,note the reason for the tracheostomy, as well as the size andtype of tracheostomy tube. Inspect the site. The stomashould appear pink and without bleeding or drainage. Thetube itself should be clean and free from secretions. Thetracheostomy ties should fit securely, allowing one finger toslide beneath the ties (Fig. 19.21). Inspect the skin underthe ties for rash or redness. Observe work of breathing.
When caring for the infant or child with a tra-cheostomy, whether in the intensive care unit, the patientfloor, or the home, a thorough respiratory assessmentis necessary. Note presence of secretions and their color,thickness, and amount. Auscultate for breath sounds,which should be clear and equal throughout all lungfields. Pulse oximetry may also be measured. When infec-tion is suspected or secretions are discolored or have a foul odor, a sputum culture may be obtained.
● Figure 19.19 The home apnea monitor uses a soft beltwith Velcro attachment to hold two leads in the appropriateposition on the chest.
● Figure 19.20 Note smaller size and absence of inner cannula on particular brands of pediatric tracheostomy tubes.
Many pediatric tracheostomy tubes do not have aninner cannula that requires periodic removal and clean-ing, so periodic removal and replacement of the chronictracheostomy tube is required. Clean the removed tra-cheostomy tube with half-strength hydrogen peroxideand pipe cleaners. Rinse with distilled water and allow itto dry. The tracheostomy tube can be reused many timesif adequately cleaned between uses.
Perform tracheostomy care every 8 hours or perinstitution protocol. Change the tracheostomy tube onlyas needed or per institution protocol. Nursing Proce-dure 19.3 gives information about tracheostomy care.
If the older child or teen has a tracheostomy tubewith an inner cannula, provide care of the inner can-nula similar to that of an adult. Involve parents in care ofthe tracheostomy and begin education about caring for thetracheostomy tube at home as soon as the child is stable.Refer the family to local support groups or to www.tracheostomy.com, which offers many resources for afamily whose child has a tracheostomy. The child with atracheostomy often qualifies for a Medicaid waiver thatwill provide a certain amount of home nursing care.
58 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
● Figure 19.21 Properly fitting trachties. One finger width fits betweenthe ties and the child’s neck.
● Figure 19.22 The trach collar allows for humidification ofinspired air or supplemental oxygen.
EMERGENCY EQUIPMENT (AVAILABLE AT BEDSIDE)
• Two spare tracheostomy tubes (one the same sizeand one a size smaller)
• Suction equipment• Stitch cutter (new tracheostomy)• Spare tracheostomy ties• Lubricating jelly• Bag-valve-mask device• Call bell within child’s/parent’s reach
BOX 19.4
Nursing ManagementIn the immediate postoperative period the infant or childmay require restraints to avoid accidental dislodgment ofthe tracheostomy tube. Infants and children who have hada tracheostomy for a period of time become accustomed toit and usually do not attempt to remove the tube. Since airinspired via the tracheostomy tube bypasses the upper air-way, it lacks humidification, and this lack of humidity canlead to a mucus plug in the tracheostomy and hypoxia.Provide humidity to either room air or oxygen via a tra-cheostomy collar or ventilator, depending upon the child’sneed (Fig. 19.22). Box 19.4 lists the equipment thatshould be available at the bedside of any child who has atracheostomy.
Tracheostomies require frequent suctioning to main-tain patency. The appropriate length for insertion of the suction catheter depends on the size of the tra-cheostomy and the child’s needs. Place a sign at thehead of the child’s bed indicating the suction cathetersize and length (in centimeters) that it should beinserted for suctioning. Keep an extra tracheostomytube of the same size and one size smaller at the bedsidein the event of an emergency.
Keep small toys (risk of aspiration), plastic bibs or bedding (risk of airway occlusion), and talcum powder (risk of inhalation injury) out of reach of the child
with a tracheostomy.
1. Gather the necessary equipment:
• Cleaning solution
• Gloves
• Precut gauze pad
• Cotton-tipped applicators
• Clean tracheostomy ties
• Scissors
• Extra tracheostomy tube in case of accidental dislodgement
2. Position the infant/child supine with a blanket ortowel roll to extend the neck.
3. Open all packaging and cut tracheostomy ties toappropriate length if necessary.
4. Cleanse around the tracheostomy site with pre-scribed solution (half-strength hydrogen peroxideor acetic acid, normal saline or soap and water if athome) and cotton-tipped applicators working fromjust around the tracheostomy tube outward.
5. Rinse with sterile water and cotton-tipped applicatorin similar fashion.
6. Place the precut sterile gauze under the tracheostomytube.
7. With the assistant holding the tube in place, cut theties and remove from the tube.
8. Attach the clean ties to the tube and tie or secure inplace with Velcro.
Nursing ProcedureNursing Procedure 19.3Tracheostomy Care
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Websites
asthmatrack.org/: Ed’s Asthma Track—for parents of children withasthma
www.aaaai.org: American Academy of Allergy, Asthma, andImmunology
www.aafa.org: Asthma and Allergy Foundation of Americawww.aanma.org/: Allergy & Asthma Network Mothers of
Asthmatics—offers extensive resources for families with childrenwho have asthma
www.acaai.org/: American College of Allergy, Asthma, andImmunology
www.asthma-carenet.org/: The Childhood Asthma Research andEducation (CARE) network founded by the National Heart, Lungand Blood Institute
www.asthmaandchildren.com/: information about asthma andchildren (supported by AstraZeneca)
www.asthmabusters.org/: online club for kids with asthmawww.asthmacamps.org/asthmacamps/: consortium on children’s
asthma campswww.cff.org: Cystic Fibrosis Foundationwww.cfri.org: Cystic Fibrosis Research, Inc.www.cfww.org: Cystic Fibrosis Worldwidewww.childasthma.com/: Childhood Asthma Foundationwww.cysticfibrosis.com: support forum for the cystic fibrosis
communitywww.guideline.com: National Guideline Clearinghousewww.jcaai.org: Joint Council of Allergy, Asthma, and Immunologywww.lungusa.org/site/pp.asp?c�dvLUK9O0E&b�22691:
American Lung Association, section on children and asthmawww.niaid.nih.gov: National Institute of Allergy and Infectious
Diseasewww.noattacks.org: site provides education about asthma, section
for children, also available in Spanishwww.tracheostomy.com: Aaron’s Tracheostomy Site
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 61
ChapterWORKSHEETChapter
● M U L T I P L E C H O I C E Q U E S T I O N S1. A 5-month-old infant with RSV bronchiolitis is in
respiratory distress. The baby has copious secretions,increased work of breathing, cyanosis, and a respira-tory rate of 78. What is the most appropriate initialnursing intervention?
a. Attempt to calm the infant by placing him in hismother’s lap and offering him a bottle.
b. Alert the physician to the situation and ask for anorder for a stat chest x-ray.
c. Suction secretions, provide 100% oxygen viamask, and anticipate respiratory failure.
d. Bring the emergency equipment to the room andbegin bag-valve-mask ventilation.
2. A toddler has moderate respiratory distress, is mildlycyanotic, and has increased work of breathing, with arespiratory rate of 40. What is the priority nursingintervention?
a. Airway maintenance and 100% oxygen by mask
b. 100% oxygen and pulse oximetry monitoring
c. Airway maintenance and continued reassessment
d. 100% oxygen and provision of comfort
3. The nurse is caring for a child with cystic fibrosiswho receives pancreatic enzymes. The nurse realizesthat the child’s mother understands the instructionsrelated to giving the enzymes when the mothermakes which of the following statements?
a. “I will stop the enzymes if my child is receivingantibiotics.”
b. “I will decrease the dose by half if my child ishaving frequent, bulky stools.”
c. “Between meals is the best time for me to give theenzymes.”
d. “The enzymes should be given at the beginning ofeach meal and snack.”
4. Which of these factors contributes to infants’ andchildren’s increased risk for upper airway obstructionas compared with adults?
a. Underdeveloped cricoid cartilage and narrownasal passages
b. Small tonsils and narrow nasal passages
c. Cylinder-shaped larynx and underdeveloped sinuses
d. Underdeveloped cricoid cartilage and smallertongue
5. Which is the most appropriate treatment for epistaxis?
a. With the child lying down and breathing throughthe mouth, apply pressure to the bridge of the nose.
b. With the child lying down and breathing throughthe mouth, pinch the lower third of the nose closed.
c. With the child sitting up and leaning forward,apply pressure to the bridge of the nose.
d. With the child sitting up and leaning forward,pinch the lower third of the nose closed.
● C R I T I C A L T H I N K I N G E X E R C I S E S1. A 10-month-old girl is admitted to the pediatric unit
with a history of recurrent pneumonia and failure tothrive. Her sweat chloride test confirms the diagnosisof cystic fibrosis. She is a frail-appearing infant withthin extremities and a slightly protuberant abdomen.She is tachypneic, has retractions, and coughs fre-quently. Based on the limited information given hereand your knowledge of cystic fibrosis, choose three ofthe categories below as priorities to focus on whenplanning her care:
a. Prevention of bronchospasm
b. Promotion of adequate nutrition
c. Education of the child and family
d. Prevention of pulmonary infection
e. Balancing fluid and electrolytes
f. Management of excess weight gain
g. Prevention of spread of infection
h. Promoting adequate sleep and rest
2. A child with asthma is admitted to the pediatric unitfor the fourth time this year. The mother expressesfrustration that the child is getting sick so often.Besides information about onset of symptoms andevents leading up to this present episode, what othertypes of information would you ask for while obtain-ing the history?
3. The mother of the child in the previous question tellsyou that she smokes (but never around the child), thefamily has a cat that comes inside sometimes, andshe always gives her child the medication prescribed.She gives salmeterol and budesonide as soon as thechild starts to cough. When he is not having anepisode, she gives him albuterol before his baseballgames. Diphenhydramine helps his runny nose in thespringtime. Based on this new information, whatadvice/instructions would you give the mother?
62 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 63
2. The nurse is caring for a child with asthma. Thechild has been prescribed Advair (fluticasone and sal-meterol), albuterol, and prednisone. Develop a sam-ple teaching plan for the child and family. Includeappropriate use of the devices used to deliver themedications, as well as important information aboutthe medications (uses and side effects).
3. While caring for children in the pediatric setting,compare the signs and symptoms and presentation ofa child with the common cold to those of a child witheither sinusitis or allergic rhinitis.
4. While caring for children in the pediatric setting,review the census of clients and identify those at riskfor severe influenza and thus those who would benefitfrom annual influenza vaccination.
5. Compare the differences in oxygen administrationbetween a young infant and an older child.
4. A 7-year-old presents with a history of recurrent nasaldischarge. He sneezes every time he visits his cousins,who have pets. He lives in an older home that iscarpeted. Tobacco smokers live in the home. Hismother reports that he snores and is a mouth breather.She says he has symptoms nearly year-round, but theyare worse in the fall and the spring. She reports thatdiphenhydramine is somewhat helpful with his symp-toms, but she doesn’t like to give it to him on schooldays because it makes him drowsy. Based on thehistory above, develop a teaching plan for this child.
5. The nurse is caring for a 4-year-old girl who returnedfrom the recovery room after a tonsillectomy 3 hoursago. She has cried off and on in the past 2 hours andis now sleeping. What areas in particular should thenurse assess and focus on for this patient?
● S T U D Y A C T I V I T I E S1. While caring for children in the pediatric setting,
compare the signs and symptoms of a child withasthma to those of an infant with bronchiolitis. Whatare the most notable differences? How does the his-tory of the two children differ?
