most common cause of hospitalization in children ages 1-9 yrs
resp conditions
what needs to be maintained in respiratory disorders?
adequate hydration and nutrition
child’s upper airway is
shorter and narrower than adults
more easily occluded when secretions, edema, or foreign bodies enter upper airway
nose breathers until 3-4 months
HEENT & respiratory assessment
head
eyes
ears
nose
throat/mouth
work of breathing
cyanosis
clubbing
breath sounds
retraction locations
supraclavicular
intercostal
suprasternal
substernal
subcoastal
respiratory distress
severe difficulty in achieving adequate oxygenation despite significant efforts to breathe
signs of resp distress
restlessness
tachycardia
tachypnea
diaphoresis
cyanosis: late sign
respiratory failure
body can no longer maintain effective gas exchange
either o2 demand outweighs o2 supply (hypoxic) or co2 levels rise due to hypoventilation
most common cause of cardiopulmonary arrest in children
viral: common cold
cause: RSV, rhinovirus, parainfluenza, metapneumovirus, COVID, others
fever: low
body aches: mild
runny nose: yes
cough: mild to mod
n&v: rare
onset: gradual
itchy: rare
sore throat: yes
headache: rare
viral: flu
causes: influ A & influ B virus
fever: yes
body aches: yes
runny nose: sometimes
cough: yes
n&v: sometimes, more common in children
onset: abrupt
itchy: no
sore throat: sometimes
headache: yes
viral: allergic rhinitis
causes: pollen, dust, mold, animal dander
fever: no
body aches: rare
runny nose: yes
cough: sometimes mild to mod
n&v: no
onset: gradual or abrupt
itchy: yes
sore throat: sometimes
headache: sometimes
viral: COVID
causes: Sar-CoV-2 virus
fever: yes
body aches: yes
runny nose: sometimes
cough: yes
n&v: sometimes
onset: gradual or abrupt
itchy: no
sore throat: yes
headache: sometimes
influenza
droplet precautions
mild, mod, severe
flu signs
onset of fever, chills
dry cough
dry throat & nasal mucosa
flushed face
myalgia
fatigue
flu labs
nasal swab for rapid flu
flu meds
flu vaccine (>6months)
oseltamivir
start w/i 48 hrs of symp
PO for 5 days >1 yrs)
NO ASPIRIN
reye’s syndrome
rare but serious
unknown cause
can occur when recovering from viral inf. if taking aspirin
affects all organs, esp. brain and liver
causes inc ICP & fatty liver
reye’s signs
rapid breathing
vomiting
severe fatigue
confusion
seizures
LOC
reye’s treatment/prognosis
NO CURE
early diag to protect brain damage by dec ICP
prognosis:
depends on severity of swelling
bacterial pharyngitis: strep throat causes and signs
causes: group a strep
signs:
abrupt onset of pharyngitis, headache, fever, abdominal pain
tonsils & pharynx can be inflamed & covered with exudate (day 2 of illness)
bacterial pharyngitis: strep throat labs/nursing interventions
labs:
rapid antigen testing & throat culture
nursing interventions:
antibiotics (PO penicillin as least 10 days OR penicillin shot)
treat pain
encourage hydration
return to school 12 hrs after 1st dose IF FEVER GONE
new toothbrush after 3 days on antibiotics
wash pillowcase
follow up if not improved after 2-3 days
viral pharyngitis: mononucleosis causes/manifestations
cause: epstein-barr virus spread thru oral secretions
aka kissing disease
viral pharyngitis: mononucleosis manifestations/nursing interventions
manifestations:
fever
pharyngitis
lymphadenopathy
extreme fatigue
nursing interventions:
pain control
hydration
education: acute phase last up to 2 wks with prolonged symp. lasting several wks
no contact sports
can lead to enlarged spleen or rupture
break out with rash treat with amoxicillin
tonsillectomy nursing considerations
positioning
place in postion to facilitate drainage
EHOB when awake
assess for bleeding
most common at 1 wk after surg.
tonsils: highly vascular (protect against inf.)
evid. of bleeding
frequent swallowing
clearing of throat
restlessness
tachycardia
pallor
monitor for difficulty breathing related to oral secretions, edema, bleeding
pharm and non-pharm interventions for pain
liquid analgesics or tetracaine lollipops
admin. pain meds on regular schedule
clear diet (NO REDS, NO ACID)
wait until gag-reflex returns
advance diet as tolerated
protect surg. site
limit activity
14 days to recover
ear infection: otitis media
inner ear infection
infl. middle ear and middle ear effusion (fluid)
with acute infection: fluid in middle ear is purulent causing tympanic membrane to appear erythematous, bulging, yellow
usually accompanied by UTI
ear infection: otitis media nursing interventions
nursing interventions
monitor airway
antibiotic (azithromycin)
o2 support
feeding & hydration support
report to health department
ear infection: otitis externa
inflammation of the external ear canal
symp: ear pain, itchiness in the ear canal, discharge of liquid for ear
itchy, redness
ear drops antibiotics
inflam. steroids are added with ear drops
recurrent otitis media
3 epi in 6 months OR 4 epi in 1 yr
tympanostomy can dec freq., severity, duration
hole in ear, drain pressure and fluid out, and prevent recurrent
pertiusis
aka whooping cough
highly contagious: droplet
cause: bordetella pertussis
paroxymal cough
start 2 wks after onset
last several months
difficult breathing during coughing fit
cause post-tussive emesis
cough fit last several minutes
most at risk: <2 months
ear infection: otitis media s&s/meds/compli.
s&s: tugging ear
need antibiotics with: PO
severe pain
bilateral OM in children <2
fever >102
pain for >48 hours
follow up is not likely
All others should be a watch & wait: meaning they should be re-evaluated in 2-3 days to see if ear infection self resolves*
complication: mastoiditis, infection of mastoid bone just behind ear
first DTaP
2 months
viral URI
No antibiotics
Cold, flu, COVID
hydration loosens secretions and help get them out
no cough suppressant in children
croup
Inflammation of the epiglottis, larynx, trachea, and possibly even the bronchi
bc of inflammatory nature of croup & small diameter of child’s airway, croup can be life threatening, especially in younger children
Classified as either viral or bacterial
viral: spasmodic laryngitis or laryngotracheobronchitis
bacterial: epiglottitis and bacterial tracheitis
Laryngotracheobronchitis
barky cough with this one but not others
usually viral (parainfluenza)
Most common between ages 3 months & 8 years
Laryngotracheobronchitis signs
low grade fever
restlessness
hoarseness
barky cough
dyspnea
inspiratory stridor
retractions
infants and toddlers: nasal flaring, intercostal retractions, tachypnea, continuous stridor
can have stridor at rest & respiratory distress present in severe cases
Laryngotracheobronchitis treatment
Mild: oral steroid – usually dexamethasone
Severe: systemic corticosteroid & nebulized racemic epinephrine
oxygen if needed
systemic: methylpred, but normally just dex: epi helps decrease inflammation in airway (vasoconstrictor)
if a child has stridor and suddenly stop hearing it = bad sign that airway has potentially completely closed
Epiglottitis
a hinged piece of cartilage found at back of tongue
Job: close entry to trachea when swallowing
Epiglottitis : spread by infectious droplets
Most common cause: haemophilus influenza & strep pneumoniae
Most preventable due to Hib vaccines
Is a MEDICAL EMERGENCY
Rapid onset, usually a few hours
if this is swollen: have trouble breathing air in and swallowing
BIG THING IS DROOLING - NOT ABLE TO SWALLOW SECRETIONS, tripod position
muffled voice due to proximity of vocal cords
epiglottis findings/signs
**do not try to assess throat**
Findings: ADD AIR NURSE
A: abnormal position (tripod)
D: dysphagia
D: difficulty speaking
A: apprehension
I: increased temp – high fever
R: rapid onset
N: nasal flaring
U: using accessory muscles
R: retractions
S: stridor
E: enlarged epiglottis – visible on x-ray or on exam
epiglottis nursing interventions
never leave alone!!
protect airway
prepare for intubation
never anything in their mouth – no oral temps, no tongue depressors, no throat cultures
do not leave patient alone
keep child calm
NPO
humidified oxygen
IV corticosteroids & fluids (in OR)
antibiotics & antipyretics
tracheitis
no drooling, will hear stridor, will have sudden onset and acute decompensation
bacterial= secondary infection of upper trachea
usually caused by staph aureus, staph pneumoniae, pseudomonas
viral laryngotracheitis leads to bacterial tracheitis
most common viral causes: influenza a & b
rare, only about 2% of cases
bacteria invade tracheal mucosa & cause inflammatory response
kids usually appear ill/toxic
if untreated can lead to airway obstruction & respiratory arrest
tracheitis symp
usually have URI symptoms the week before then acute decompensation
change in voice, stridor
usually sudden decompensation with noisy breathing
high fevers
drooling= absent, able to swallow secretions unlike epiglottitis
thick purulent secretions
tracheitis treatment
need for intubation = common, should be done in OR
if less severe, oxygen, racemic epi
lower: pneumonia
Inflammation or infection of the lower airways (bronchioles and alveolar spaces)
Viral: both lungs, starts with cold symptoms
CAP usually caused by RSV, parainfluenza, influenza
Bacterial: usually unilateral, usually a bit sicker
Bacterial pneumonia= more common in those over age 5
PCV vaccine
lower: pneumonia risk factors
Risk factors:
children exposed to cigarette or wood stove smoke
chronic conditions such as asthma, CF, sickle cell disease, congenital heart disease or immunodeficiency
lower: pneumonia signs
signs:
fever
tachypnea
cough
poor oral intake
vomiting
abdominal pain
cough
may see retractions
nasal flaring
chest pain
lower: pneumonia diag/treatment
Diagnostic: chest x-ray
Treatment: depends on cause
anyone with tachypnea and nothing else will do CXR → tachypnea in kids with nothing else is often pneumonia
lower: bronchiolitis
Viral infection, affects bronchi & bronchioles
Bronchial mucosa swells & fills with mucus & exudate
occurs at the bronchiolar level
primarily caused by Respiratory Syncytial Virus (RSV), but also can be caused by adenoviruses and parainfluenza
The younger the infant = more severe
Day 2= more severe symptoms, respiratory distress
lower: bronchiolitis assessment
Initially: rhinorrhea, intermittent fevers, pharyngitis, coughing, sneezing, wheezing, possible ear or eye infection
With illness progression: increased coughing and sneezing, fever, tachypnea and retractions, refusal to nurse or bottle feed, copious secretions
Severe illness: tachypnea (>70 resp/min), listlessness, apneic spells, poor air exchange, poor breath sounds, cyanosis
lower: bronchiolitis labs/interventions/treatment
Lab testing: nasal swab, can test for different types of respiratory viruses
Nursing Care:
supplemental oxygen to maintain oxygen saturation >90% (over 4 = high flow)
encourage fluid intake if able to tolerate, if not IV fluids until acute phase passed
suction nasopharynx as needed
Treatment:
Supplemental oxygen (anything over 4L= high flow for peds)
Usually no steroids
Ribavirin: inhaled antiviral medication for those hospitalized
fluid hydration
fever meds: tylenol/moltrin
bronchitis
inflammation of the trachea, bronchi, and bronchioles
Usually occurs with viral respiratory tract infection
Characterized by cough due to inflammation without evidence of pneumonia
Inflammatory response in mucus membranes of bronchial passages produces hacking cough & thick phlegm
Rarefy ever bacterial; always viral
bronchitis symp
Classic symptoms:
coarse, hacking cough that worsens at night
chest pain may develop due to cough
May have vomiting at night due to swallowing of sputum
No cough meds, honey can be given in children over 1 year of age
asthma
Chronic lung disease causing narrowing and inflammation of airways
One of leading causes of hospitalizations in children
Issue = AIR TRAPPING
asthma risk factors
family hx of asthma
family hx of allergies
exposure to smoke
low birth weight
being overweight
pollution
asthma classifications
Intermittent
mild persistent
moderate persistent
severe persistent
asthma exam findings
Dyspnea
Cough
audible wheezing
mucus production
use of accessory muscles
sweating, anxiety
decreased oxygen saturation
tripod positioning
inaudible breath sounds or crackles
asthma diag
pulmonary function tests: most accurate test for diagnosing asthma & severity
peak flow meter (done every 1-2 years, blow twice and take higher of two)
Blow into device to measure amount of air coming out
asthma treatment
Inflammation: Corticosteroids
Methylprednisolone or Dexamethasone IV
Prednisone PO
fluticasone
Bronchospasm: Beta 2 Agonists
Albuterol (nebulizer or inhaler)
Increased Mucus Production: Hydration/ mobilization
Exaggerated Immune Response: Leukotriene Inhibitors
Montelukast (Singulair)
Oxygen as needed
ER/PICU:
Theophylline (high toxicity risk)
Magnesium sulfate (potent vasodilator)
albuterol
short acting
emergent only
steroids
increases risk of infections
long acting
for severe
asthma assessment/education
Assess airway patency, respiratory rate, symmetry effort and use of accessory muscles
position child to maximize ventilation
Education
Trigger Identification
Use of medications at home
Steroids
Aerosol Medications (Beta Agonists)
Correct use of spacer
Peak Flow Meters
Home Management Plan
Asthma action plan
Treatments depending on zone
status asthmaticus
Temporarily Irreversible Bronchospasm
Life-threatening episode of airway obstruction, often unresponsive to common treatment
status asthmaticus signs
wheezing
labored breathing
nasal flaring
lack of air movement
use of accessory muscles
distended neck veins
tachycardia
tachypnea
hypoxia
diaphoresis
*risk for cardiac & respiratory arrest
status asthmaticus nursing actions
Monitor oxygen saturation & cardiorespiratory monitor continuously
Nebulizer X 3 or continuous, add ipratropium to increase bronchodilation
IV access
cystic fibrosis
Genetic disorder that causes exocrine glands to work incorrectly
Basic Flaw in Chloride Exchange across cell membrane causing exocrine
Genetics: 1 in 4 chance of transmission if both parents are carriers
Autosomal recessive (must get gene from each parent)
Discovered on prenatal screen or newborn screen, or sweat chloride test (<40 is normal)
CFTR gene
Median life expectancy: 37 years old
Problems with mucus:
Lungs
Intestines
Pancreas
reproductive organs
cystic fibrosis diag.
Pulmonary function testing
Sweat chloride test: measures amt of salt in sweat
done on arms with gauze
39 mmol/L= negative
40-49 mmol/L= needs further testing
60 mmol/L= positive
Meaning? Poor sodium exchange = thick mucus
cystic fibrosis expected findings
Respiratory:
Stasis of mucus increases risk for infection
Early manifestations: wheezing, rhonchi, dry, non-productive cough
Increased involvement: dyspnea, paroxysmal cough, obstructive emphysema and atelectasis on chest x-ray
Advanced involvement: cyanosis, barrel-shaped chest, clubbing of fingers and toes, multiple episodes of bronchitis or bronchopneumonia
Gastrointestinal:
Large, frothy, bulky, greasy, foul-smelling stools
Failure to gain weight or weight loss
Delayed growth patterns
Distended abdomen & thin arms and legs (infant)
Reflux
Prolapse of rectum (infant & child)
Integumentary:
Sweat, tears, and saliva have excessively high content of sodium & chloride
Endocrine & Reproductive:
Viscous cervical mucus, decreased or absent sperm, decreased insulin production
cystic fibrosis compl.
Respiratory
Infections, colonization, bronchial cysts, emphysema, pneumothorax, nasal polyps
Gastrointestinal
Meconium ileus, prolapse of rectum, intestinal obstruction, GERD
Endocrine
Diabetes Mellitus
Worrisome Infections
Pseudomonas Aeruginosa
Burkholderia Cepacia
Staph Aureus
Hemophilus influenza
Escherichia coli
Klebsiella Pneumoniae
cystic fibrosis interventions
Nutrition: need well balanced diet high in protein and calories
Formula supplements in addition to breast feeding or through NG tube
Add salt to food during hot weather / excess sweating
Should receive regular nutrition evaluations with nutritionist
Daily supplements of fat soluble vitamins (ADEK)
Enzymes before meals (within 30 minutes)
Encourage fluid intake
Laxatives or stool softeners for constipation
Exercise
respiratory treatments
HFCC Vest
Flutter Device
“Huffing”
Aerosol therapy
Postural drainage
Need aggressive antibiotic therapy - High dose antibiotics:, IV or inhaled
Dornase Alfa (pulmozyme/recombinant human deoxyribonuclease)
Can cause laryngitis (administer 1-2 times a day)
Oxygen: as needed but monitor for carbon dioxide retention
resp assessments
Lung sounds & respiratory status
Growth and development
Obtain IV access – may have peripherally inserted central line or IV port if getting at home antibiotics
Sputum for culture & sensitivity
resp education
Stay up to date on vaccines including annual influenza and pneumonia vaccine
Perform regular physical activity
Palliative care for those in terminal stages
May need transplant of heart, lungs, pancreas and liver for adolescents who have advanced disease
Provide support to family and patient
acute non-infectious resp disorders
foreign object asp
pneumothorax
congenital abnormalities of upper airway
diaphragmatic hernia
foreign body asp
Need to determine if cause of stridor
If foreign body, need to determine what it is
pneumothorax
accumulation of air in the pleural space; air accumulates between visceral and parietal pleura increases intrapleural pressure making it difficult to expand affected lung
Peak incidence= 16 – 24 y/o
Will have chest tube inserted
pneumothorax types
spontaneous, traumatic, tension
primary spontaneous pneumo occurs in children with no hx of lung disease
secondary occurs as complication of chronic lung disease such as Cystic fibrosis or asthma
pneumothorax assessment
Dyspnea, tachypnea
Tachycardia
Diminished breath sounds
Unequal chest expansion
Chest pain
congenital abnormalities of upper airway
Laryngomalacia: larynx = floppy
Most common cause of stridor in newborns
Not-life threatening, most outgrow by 18-20 months
Tracheomalacia: excessive collapsibility of the trachea
Depends on severity, may resolve on own or cause persistent resp distress
Tracheoesophageal fistula: abnormal connection between these two tubes
As a result, swallowed liquids or food can be aspirated into lungs
Symptoms: difficulty breathing while feeding, coughing or choking while feeding, rounded abdomen, failure to gain weight
Subglottic stenosis: narrowing of the airway below the vocal cords (subglottis) and above the trachea
Diaphragmatic Hernia
Hole or opening in the baby’s diaphragm, the muscle that separates the abdomen from the chest
Defect allows abdominal organs to move into chest cavity
Causes crowding of lungs & improper development
Breathing problems at birth
Rare