Respiratory Disorders (Peds)

early signs of respiratory distress

1. Restlessness

2. Tachypnea

3. Tachycardia

4. Nasal flaring

5. Retractions

6. Grunting

late signs of respiratory distress

1. cyanosis

2. bradypnea

3. bradycardia

4. apnea

Aspects of a respiratory assessment

1. respirations

2. chest contour and configuration

3. work of breathing

4. airway

5. nasal conjestion

6. breath sounds

7. cough

8. oxygenation

9. pt's color

signs of difficult work for breathing

1. use of accessory muscles

2. tripod position

3. retractions

4. tachypnea

signs of airway obstruction

1. stridor

-worse than wheezing

-better than no BS

2. drooling

3. froglike croaking

4. inability to speak

5. tripod position

6. absence of spontaneous cough

Treatment for nasal congestion

blue bulb suction

-nose before mouth (if done)

-done prior to feedings and prn

wheezing

- high-pitched musical sounds during expiration

- indicates inflamed, constricted airway

- usually lower airway

stridor

- high pitched crowing

-indicates airway obstruction

-usually upper airway

crackles (rales)

-popping sound

-indicates fluid accumulation

No cough vs absence of spontaneous cough

no cough = not at all

absence of spontaneous = cannot cough on own; will not clear airway

nursing care for cough and respiratory conditions

1. do not give cough suppressants for productive cough

- sputum will sit in lungs and lead to issues

2. swallowing after coughing can indicate productive cough in children

3. cool humidifed oxygen to decrease airway edema and thin secretions

-watch temp to prevent overchilling

4. maintain hydration

-IV if tachypnea + NPO

5. keep suction, blowbyO2 and bag valve mask by bedside

6. stay as calm as possible

-increases child anxiety and resp rate

Red flags for Respiratory status

1. stridor at rest

2. drooling, inability to cough or swallow

3. silent chest or decreased breath sounds

4. sudden agitation or quietness after distress

5. tachypnea -> bradypnea

6. accessory muscle use and tripod position

7. O2 < 92 % despite treatment

Croup Syndromes

1. epiglottitis

2. acute laryngotracheobronchitis (most common)

3. acute spasmodic bronchitis

4. acute tracheitis

5. hoarseness, barking cough, inspiratory stridor

treatment for bacterial vs viral conditions

1. bacterial= antibiotics

2. viral= symptoms management or antivirals

Epiglottitis

bacterial infection (flu type B) causes inflamed, cherry red epiglottis that can lead to airway obstruction

-abrupt onset= medical emergency

manifestations of epiglottitis

1. absence of spontaneous cough

2. drooling

3. agitation

4. fever

5. dysphagia

6. stridor

7. tachycardia/pnea

8. leaning forward with chin thrust and tongue protruding

9. froglike croaking

dx of epiglottitis

lateral soft tissue xray of neck (not priority bc airway closing)

-shows swollen epiglottis

-throat inspected by provider not nurse unless have advanced airway equipment (will be red and closing)

Care of epiglottitis

1. act quickly and calmly

2. humidified O2

3. NPO and IV fluids

4. intubation or tracheostomy if needed

5. droplet precautions until 24 hrs after antibiotics

6. antibiotics 7-10 days

7. corticosteroids for airway edema (IV)

Laryngotracheobronchitis (LTB)

a viral inflammation of the larynx/trachea causing airway narrowing; usually have upper respiratory infection prior to this development

-can be bacterial

Manifestations of LTB

1. low grade fever

2. barky cough that awakes from sleep

3. retractions

4. nasal flaring

5. tachypnea

6.stridor

7. hoarseness

If a patient with LTB has no stridor at rest...

1. can be managed at home

2. treat with cool humidified vapor and O2

3. ride in car with window down

4. take into night air or in cold basement/garage

5. stand in open freezer

-don't use croup tents anymore

If a pt with LTB has stridor or respiratory distress...

1. will be managed in the hospital

2. emergency equipment at bedside

3. humidifed oxygen (blowby for children)

4. nebulized racemic epinephrine

5. corticosteroids (dexamethasone)

Nebulized racemic epinephrine

1. used for LTB to rapidly unswell and open airways

2. SE= tachycardia, palpitations, restlessness, and tremors

3. nebulizer

Corticosteroids for LTB

1. often dexamethasone

2. given orally if no tachypnea or dysphagia

3. can be given IM or IV if can't tolerate

differences between epiglottis and LTB

1. epiglottitis faster onset

2. epiglottitis higher fever

3. LTB barky cough; epiglottitis usually none

4. LTB hoarse voice while epiglottitis can't speak

5. epiglottitis is droolng or unable to swallow; LTB usually able to swallow

bronchiolitis with RSV

viral infection of bronchioles causing inflammation, mucus and airway obstruction

clinical manifestations

1. rhinnorhea

2. coughing

3. sneezing

4. otitis media

5. conjunctivitis

6. severe-> wheezing, tachypnea, retractions, nasal flaring, poor feeding, dehydration, and apneic spells

diagnosis of bronchiolitis with RSV

nasopharyngeal antigen swab

transmission of bronchiolitis with RSV

contaminated resp secretions

- need a private room or with another pt with RSV

treatment of bronchiolitis with RSV

1. humidifed O2

2. blue bulb suctioning before feedings and at bedtime

3. elavate HOB for work of breathing

4. acetaminophen or ibuprofen if >6 mo

5. may be on antibiotics for conjunctivitis or otitis media (not for RSV itself)

prevention of RSV bronchiolitis

- Palivizumab (Synagis)

-monoclonal antibody

-for high risk populations

ex: premature, preexsisting conditions such as cardiac disorders

Ribavirin

antiviral for high risk children with RSV

when would a child with one of these respiratory conditions be NPO?

if they are severely tachypneic (higher risk of aspiration)

How do you know an infant has activity intolerance?

difficulty with feedings

viral nasopharyngitis

common cold

manifestations of viral nasopharyngitis

younger: fever, irritability, poor intake, mucus, sneezing

older: chills, muscle aches, + younger child symps

Preventing spread of viral nasopharyngitis

1. handwashing

2. avoid touching eyes, nose mouth

3. do not share glasses or utensils

4. clean surfaces such as doorknobs, faucets etc.

5. cover mouth when sneezing or coughing

6. dispose of contaminated tissues

treatment for nasopharyngitis

1. treat symps (viral)

2. antipyretics

3. rest

4. postural drainage

-elevate HOB

5. increase fluid

6. blue bulb suction

7. decongestants and cough suppressants *dry cough only

Bacterial Pharyngitis

1. strep throat

2. puts children at risk for scarlet fever, rheumatic fever, and acute glomerulonephritis

3. detect and treat early

bacterial pharyngitis manifestations

1. sore throat with white exudate patches

2. fever

3. lymphadenopathy

4. difficult swallowing

5. red edematous (strawberry) tongue

6. fine sandpaper rash

7. musty type smell

viral pharyngitis manifestations

1. inflamed red pharynx

2. sore throat

3. fever

4. lymphadenopathy

5. difficulty swallowing

-same as bacterial withoug white patches, rash and tongue swelling

diagnosis of pharyngitis

rapid strep test and throuat culture

- collected on all sore throats

- if negative but have white spots will still start on antibiotics

- often send rapid to lab

treatment for bacterial pharyngitis

1. amoxicillin or penicillin PO for 10 days

-can be given IM if necessary but is very painful

2. may not return to school until full 24 hrs after starting antibiotics

3. throw away toothbrushes and wash orthodontic equipment

viral pharyngitis treatment

1. cold or warm compresses to neck

2. warm gargles

3. increased fluid intake

-ice chips

4. food should be soft and bland; no hard, acidic, or drinks that cause pain bc may stop eating and drinking if associated with pain

5. tylenol or ibuprofen (>6 mo)

- also do for bacterial as needed

tonsillitis

inflammation of the tonsils that can be viral or bacterial or occur with pharyngitis

-puts at risk of aspiration and airway obstruction

-culture to determine if vitarl or bacterial

treatment of tonsillitis

1. soft to cool liquid diet

2. cool mist vaporizer

3. warm gargles

4. throat lonzeges, analgesics and antipyretics

frequent cases of tonsillitis indicate...

a tonsillectomy and adenoidectomy

contraindications of tonsillectomy and adenoidectomy

1. acute infection at time of surgery

-treat with antibiotics before surgery can be done

2. uncontrolled systemic infections (ex: sepsis)

3. blood dyscrasias

-hemophilia and thrombocytopenia

4. cleft palate

Postop care of tonsillectomy/adenoidectomy

1. main concern= aspiration/airway

2. position on side for drainage

3. do not suction routinely; only when necessary

4. avoid red or brown fluids (may think is blood)

5. give soft, non acidic or spicy foods

6. no dairy (frequently swallow, can open site)

7. no popsicle sticks, straws, spoons or tongue compressors (can poke open surgical site)

8. start with cool clear liquids and move to soft foods

9. will give tylenol or tylenol w codeine

10. ice collar to decrease pain

signs of postop tonsillectomy hemmorrhage

1. frequent swallowing

2. clearing the throat often

3. pallor

4. tachycardia

otitis media

eustachian tube blockage causes buildup of fluid and infection

-often preceded by respiratory virus such as the flu or RSV

manifestations of otits media

1. pain

2. purulent drainage

3. fever

4. loss of appetite

5. infants may pull at ear, roll head side to side or become inconsolable

6. crying

7. irritability

8. lethargy

Chronic Ear Infections can lead to...

1. loss of hearing (get treatment immediately if < 2)

2. difficulty communicating

3. feeling of fullness in ears

4. tinnitus

5. vertigo

diagnosis of otitis media

examination with otoscope of tympanic membrane

Management of pain for otitis media

1. acteaminophen, ibuprofen or benzocaine drops

2. external heat or cold application

3. facilitate drainage

treatment of otitis media

1. amoxicillin

2. myringotomy -> surgiccal incision to relieve pain

3. tympanovstomy tubes and adenoidectomy for chronic cases

when will tubes from a tympanostomy fall out?

after 8-18 months

-requires no intervention

prevention and anticipatory guidance of otitis media

1. immunizations

2. breastfeed exclusively until 6 months

3. no qtips to clean ears

4. sit in an upright position during feedings and do not prop bottles with pillows during feedings

5. avoid smoke or allergen exposure

6. may need ear plugs for swimming

mononucleosis

condition caused by the epstein-barr virus transmitted by saliva in direct contact

manifestations of mononucleosis

1. fever

2. malaise

3. sore throat

4. persistent fatigue for 2-4 wks

5. enlargement of lymph nodes, liver and spleen that may persist for several weeks

diagnosis of mononucleosis

positive Monospot test

Treatment of mononucleosis

1. rest

2. soft and bland foods

3. gargles and analgesis

4. antibiotics only if has a bacterial infection as well

5. may give corticosteroids for significant tonsillar inflammation

6. avoid contact sports until cleared to prevent spleen rupture

7. will be treated in hospital if reports of stridor, abd pain, or unable to eat or drink (dehydration)

asthma

chronic inflammatory disorder of the airways causing recurring airway obstruction, hyperresponsivenesss, and constriction

common triggers of asthma

1. allergens

-outside= trees, grass pollen

-inside= mold, mites, cig smoke

2. infection

3. exercise

4. cold air

5. smoke exposure

6. stress

7. meds

8. food additives

manifestations of asthma

1. dyspnea, wheezing, cough

2. if silent chest= emergency

diagnosis of asthma

1. PFTs

2. allergy testing

3. peak flow rate

- green = 80 -100%; no change

- yellow = 50-79%; watch

- red = <50%; go to hospital

4. XRAY= will have hyperexpansion of lungs

Exercise with asthma

1. can maintain normal sport activities

2. may need bronchodilators prior to prevent exacerbation

Allergen control

1. wash bedding

2. dust

3. keep children indoors with windows closed when mowing

4. limit exposure to cigarette smoke

5. child not present during cleaning

6. security items bust be washed in hot water

Rescue Medications for asthma attacks

1. start with a bronchodilator (albuterol)

-se: tachycardia, palpitations and restlessness

2. anticholinergics (ipratropium)

-se: dry mouth, blurred vision, cardiac and cns depression

3. steroids to decrease inflammation

controller medications for asthma

1. inhaled corticosteroids

2. long acting bronchodilators

3. leukotriene modifiers -> montelukast

breathing exercises for asthma

done preventatively to strengthen resp muscles; do not do during exacerbations

status asthmaticus

Severe asthma attack unresponsive to treatment.

- will need to be in ICU

- oxygen

-IM or IV corticosteroids

- continuous albuterol

-IV fluids

-anticholinergics

Cystic Fibrosis

inherited, autosomal recessive disorder that increases mucus secretions to thicker and more viscous

earliest sign of cystic fibrosis

meconium ileus -> small intestine blocked with think, putty meconium

manifestations of cystic fibrosis

1. steatorrhea -> bulky, frothy, fatty stools

2. azotorrhea -> foul smelling stools

3. constipation

4. gerd

5. rectum may prolapse

6. thick resp secretions

7. cough and wheezing

8. clubbing

9. recurrent infections

10. often infertile

complications of cystic fibrosis

1. pneumothorax

2. increased incidence of diabetes -> monitor glucose, diet and exercise

3. restricted growth bc cant absorb nutrients

Diagnosis of Cystic Fibrosis

1. sweat/sodium chloride test

2. chest xray

3. stool analysis for fat and enzyme

Treatment of Cystic Fibrosis pulmonary interventions

1. airway clearance therapy (ACT) -> chest PT, vests, or huff coughing

- 2-3 times daily

-not near mealtimes (decreased appetite or throwing up)

-bronchodilators before or during

2. lung transplants if severe

3. keep cystic fibrosis children away from each other

4. flutter device to get rid of mucus

treatment of Cystic fibrosis GI interventions

1. will need lifelong pancreatic enzyme supplements before meals and snacks to decrease steatorrhea

-may be taken apart and sprinkled or taken whole

-do not chew or inhale powder

-powder for infants

2. high protein and high calorie diet with vitamins