alterations in gas exchange/respiratory disorders prt 1

nose

-newborns

-infants

-frontal and sphenoid sinuses

throat

-tounge

-tonsils and adenoids

trachea

-airway lumen/opening

nose newborns

-obligatory nose breathers until at least 4 weeks

-unless they are crying

-nostrels = small (any buildup could occlude)

nose infants

very small nasal passages

nose frontal/sphenoid sinuses

-not completely developed until 6-8 years old

*most infections happen here

-not likely in kids < 6 years old

maxillary and ethmoid sinus

-there and developed at birth

infant tongue

-relatively large to the oropharynx

*displacement would completely block airway

tonsils and adenoids

-inflammation can cause airway obstruction

airway lumen

smaller in children (4mm)

trachea: airways

highly compliant

-makes it susceptible to collapse with obstruction

*edema, swelling, bronchospasm

lower respiratory structures

-bifurcation of trachea

-bronchioles and bronchi

-alveoli

bifurcation of trachea

-occurs at the level of the 3rd thoracic vertebra

*don't go as far with intratracheal suction

bronchioles and bronchi

narrower

*increase the risk of obstruction

alveoli

-develop at 24 weeks and grow until 8 years old

*smaller number, especially in premature infants with increases the risk of hypoxemia and CO2 retention

chest wall

-highly compliant and less resistant

*do not support lungs adequately and put them at risk for respiratory failure and lung collapse

tidal volume

dependent on diaphragm movement

-not as deep breath = less air in and out

metabolic rate and oxygen

-higher rates and faster rates due to higher demand

*hypoxemia can occur more rapidly

-decreased O2 sat = larger decreased in peripheral tissue oxygenation (pO2)

health hx

-recurrent colds or sore throats

-atopic triad

-prematurity

-chronic lung disease

atopic triad

asthma/allergic rhinitis/atopic dermatitis

-if they have one, they have an increased risk for the others

family hx

-asthma

-chronic respiratory disorders

-infectious disease

history of present illness (HPI)

-fever

-nasal congestion (thick, thin, color)

-presence and description of cough (productive or nonproductive)

-rapid respirations

-labored breathing

*nasal flaring, retractions, accessory neck/abdominal muscles, clubbing, stridor

-ENT/sinus pain

-poor feeding

-lethargy

-exposure to secondhand smoke

exam findings

**LISTEN WELL ANTERIORLY AND POSTERIORLY

-pallor

-cyanosis

-tachypnea

-slow or irregular breathing

-oral cavity redness or exudate

-cough/stridor

-nasal flaring

-retractions

-use of accessory neck muscles

-paradoxical breathing

-clubbing

-hydration status

-wheezing and crackles

-tachycardia

retractions

-inward pulling of soft tissues with respirations

-can be mild/moderate/severe

-note the location: *suprasternal, intercostal, supraclavicular, substernal, subcostal

-note any other accessory muscle use

oxygen supplementation

-need an order for the application due to this causing vasodilation

-provide humidification

-flow rate specific to prevent CO2 buildup

*simple oxygen masks, nasal cannula, non-rebreathing mask

siple oxygen masks

35% to 50% oxygen with 6-10 L/min

nasal cannula

provides low oxygen (22% to 44%)

-max liter flow in children is 4L.om

non-rebreathing mask

provides 95% O2 concentration

-set the liter flow rate to 10-12 L/min to prevent rebreathing CO2

*ensure the bag is inflated

oxygen hood

*mainly see in the NICU

-provides 80% to 90% oxygen

-liter flow set at 10-15 L/min

-for infants only

*must be removed for feeding (unless OT or NG feeds)

-should be humidified

oxygen toxicity

-results from high concentration or a long period of time, and the degree of lung disease (causes lung damage; SOB, coughing, chest pain)

*use the lowest level of O2 needed to maintain an adequate SaO2

*decrease O2 flow rate gradually (titrate)

common cold

AKA upper respiratory infection (URI) or nasopharyngitis

-more frequent in winter (6-9 per year)

-may develop secondary bacterial infections of the ears, throat, sinuses, or lungs

sx: fever, decreased appetite, nasal congestion

common cold causes

-rhinovirus

-RSV

-parainfluenza

-adenoviruses

common cold tx

-symptom relief

-nasal congestion (humidity and normal saline wash)

-spray followed by suctioning

*OTC preparations have not been proven to reduce the length or severity of infection

-not recommended in children under 6

*antihistamines = dry secretions = prolong it

*drowsiness = worsened

use of bulb syringe

-gather materials

-tilt head back

-instill several drops of saline into one of the nostrils

-compress the sides completely, then place the rubber tip in the nose

-release the pressure

-remove syringe and squeeze over tissue/sink to empty secretions

-repeat on the other side if needed

-clean the syringe with warm water after each use and air dry

influenza

-viral infection occurring primarily in winter by inhalation of droplets

-may shed virus (contagious) in increased amounts for up to 2 weeks, and about 1-2 days before they actually show sx

-increased risk for more severe influenza: chronic heart or lung conditions, DM, chronic renal disease or immune deficiency

influenza s/sx

-abrupt onset of fever first

-facial flushing

-chills

-headache

-myalgia

-malaise

-cough

*infants: mildly toxic, irritable, wheezing from congestions, rash

influenza tx

*supportive

-focus: cough, fever, maintenance of hydration

-antivirals to reduce sx (must be started in the first 24-48 hours of sx)

influenza secondary infections

-pneumonea

-ear infection (up to 50%)

-reye syndrome

infectious mononucleosis

caused by epstein-barr virus

-most common in adolescents and young adults

-spread through saliva (kissing/sharing cups)

-contagious for weeks (homebound from school)

infectious mononucleosis s/sx

-fever

-sore throat

-tonsillar exudate

-lymphadenopathy

-increased WBCs with atypical lymphocytes (large under the microscope)

-hepatosplenomegaly (large spleen and liver)

-maculopapular rash

-fatigue (could last up to six weeks)

infectious mononucleosis dx

*both are blood draws

-monospot test (can be negative within the first 7 days of sx)

*finger stick/blood draw

-EBV titer (always reliable)

*blood draw

infectious mononucleosis tx

-symptomatic with analgesics

-antipyretics

-salt water gargles

*whatever sooths the throat

infectious mononucleosis complications

-risk of spleen rupture due to hepatosplenomegaly

*avoid contact sports and any strenuous activity

-jaundice (report this)

-maculopapular rash (report this)

pharyngitis

-inflammation of the pharynx (throat mucosa)

-20% to 30% caused by group A strep

pharyngitis complications

-peritonsillar abscess

*may need drainage (IV antibiotics/put to sleep)

-acute rheumatic fever

-acute glomerulonephritis

pharyngitis s/sx

-sore throat

-exudate

-petechiae

-cervical lymphadenopathy

-scarlatiniform rash (sandpaper)

pharyngitis dx

-rapid strep swab

*may send a throat culture (takes 24-48 hours to result)

pharyngitis tx

-antibiotic therapy

-saline gargles helpful

-FIRST LINE: penicillin

pharyngitis antibiotic tx

bacterial = only sore throat

-not contagious after 24 hours on medication

-anything that goes into the mouth after those 24 hours must be replaced/sanitized

viral pharyngitis

-self-limiting

-need symptom relief (analgesic and antipyretic)

-will have a sore throat and nasal congestion

strep carriers

-not more at risk for things and not going to spread it

-treated based on their sx

-will always test positive even if they don't have sx

tonsillitis

-inflammation of the tonsils often occurring with pharyngitis

-bacterial (antibiotics/penicillin) or viral (sx management)

tonsillectomy considerations

-recurrent streptococcal tonsillitis or massive tonsillar hypertrophy (3-4 grade)

tonsillar hypertrophy

*only an emergency if the child can't breathe due to the enlargement

-child may breathe through the mouth or snore

-difficulty breathing or swallowing

-enlarged adenoids may obstruct breathing

tonsillectomy post-op

-side-lying or prone until fully awake to prevent aspiration

-sit up or elevate HOB when alert

-caution with suctioning (don't want to hit the surgical site)

-monitor for bleeding (uncommon but at risk for up to 10 days)

*constant swallowing, bright red blood, frequent throat clearing, tachycardia, restlessness

-discourage coughing, blowing nose, straws

-encourage fluids (ice chips/popsicles)

-no citrus juice (irritates), brown/red fluids (looks like blood)

-ice collars (soothe throat)

-analgesic (acetaminophen/ibuprofen)

*ensure pain is managed

croup

-caused by parainfluenza in most cases

-inflammation and edema of the larynx, trachea, and bronchi = sx of airway obstruction

-usually in children 3 months - 3 years

-may need to rule out epiglottitis (emergency)

croup sx

-audible inspiratory stridor

-hoarseness

-barking cough (sounds like a seal)

-sx worse at night

-usually lasts 3-5 days

*monitor for respiratory distress (retractions, tachypnea, accessory muscle use, grunting, nasal flaring)

croup dx

-x-ray to identify that "steeple sign"

steeple sign

-narrowing of the subglottal

*looks like a rip of the trachea

croup tx

-corticosteroids for inflammation

-racemic epinephrine aerosols (nebulizer tx, only lasts about 2 hours (may need another dose)

*monitor for rebound inflammation

-humidified air (for bad cough)

-hospitalization for severe stridor (tells how severe the inflammation is)

croup nursing care

-teach about home care

*close monitoring

-discourage crying (makes sx worse)

-sit upright

-steamy bathroom

croup call physician

-any form of respiratory distress sx

-can't eat or drink (focused on breathing)

-increased stridor

-retractions

-accessory/neck muscle use

epiglottitis

-most often caused by Haemophilus influenzae type B

-inflammation and swelling of the epiglottis

-children 1-8 years and can be life-threatening

epiglottitis sx

-sudden onset of high fever

-dysphagia

-drooling

-anxiety

-irritability

-respiratory distress

-toxic appearance

-no cough

-may refuse to lay down or speak

epiglottitis dx

-lateral neck x-ray done cautiously

-let them be however is comfortable for them

-changes in position could cause airway closure

epiglottitis tx

-airway maintenance and support (intubate)

-IV antibiotics (ceftriaxone)

-ICU

epiglottitis nursing

**keep them calm and cappy

-do not leave unattended

-do not place in supine position

-100% O2 until decided how we are going to secure the airway

-ensure equipment is available

DO NOT EVER ATTEMPT TO VISUALIZE THE THROAT = Laryngospasm may occur and cause closure

bronchiolitis

-acute inflammation of the bronchioles and small bronchi

-almost always caused by a virus, usually RSV

*highly contagious, respiratory secretion or objects contaminated with virus

-infants and toddlers affected with a peak at 6 months

bronchiolitis s/sx

-low-grade fever

-dehydration

-clear coryza; inflammation of the mucous membrane (mouth and nose)

-cough then wheezing

-varying degrees of respiratory distress

-poor feeding

-may have diminished breath sounds

bronchiolitis dx

-pulse oximetry

-chest x-ray

-blood gases

-nasal pharyngeal washing (positive RSV)

bronchiolitis tx

-supportive

-hydration

-close observation

-suction before eating or lying down

-no safe or effective antivirals

-routine antibiotic use discourages

bronchiolitis nursing

-elevate HOB

-Yankauer to suction mouth and pharynx before feeding and nap (older infants and toddlers)

-nasal bulb to suction (young infants)

-close monitoring and assessment of respiratory effort

-teach family to recognize signs of worsening distress

prevention of RSV

-handwashing

-syangis injection monthly for those at high risk (to protect babies)

*prematurity, congenital heart/chronic lung disease

pneumonia

inflammation of the lung parenchyma

-common causes are different for each age group

*virus, bacteria, mycoplasma or fungus, aspiration of foreign material

pneumonia young children causes

viruses

pneumonia all ages cuases

Streptococcus pneumonia

pneumonia school-age/adolescent causes

mycoplasma penymonia

pneumonia complications

-bactermia

-pleural effusion

-empyema

-lung abscess

-pneumothorax

penumonia s/sx

-recurrent URI

-fever

-cough

-increased RR (tachypenic)

-toxic appearance

-retractions

-adventitious breath sounds

pneumonia infant s/sx

-poor feeding

-lethargy

-vomiting

-diarrhea

pneumonia older children s/sx

-chills

-headache

-dyspnea

-chest pain

-N/V/D

penumonia dx

-chest x-ray with infiltrates and consolidation

-diminished sounds around those areas

-sputum culture (to find causative agent)

-elevated WBC

pneumonia nursing

-encourage fluid intake

*may need IV fluids

-O2 prn

-oral or IV antibiotics (depending on bacteria present)

-viral cause needs no antibiotic

*educate the family on why they are not getting antibiotics

epistaxis

-bleeding of the nasal mucosa (usually from the anterior portion of the septum)

-should be investigated with hematologic concerns if it is recurrent and difficult to control

epistaxis causes

-inflammation

-mucosal drying

-local trauma (nose picking)

epistaxis nursing management

-sit up and lean them forward

-apply continuous pressure to the anterior portion of the nose by pinching it closed and having them breathe through their mouths

*ice or cold cloth may be helpful

*should stop within 10-15 minutes

*water-soluble gel to the mucosa to moisten

-do not pack the nose or blow the nose