N2: Unit 7: Module 4: Interferences with Oxygen Needs

acute spasmodic laryngitis

Subglottic inflammation

-tissue below the vocal cords

etiology: viral, emotional (usually virus)

s/sx: sudden onset at net

-harsh cough, hoarseness (chief complaint)

self limiting, no LT sequelae

rx: humidity

-encourage fluids

-treat symptomatically

laryngotracheobronchitis (LTB)

inflammation of the larynx, trachea, and bronchi

-most common of the croups

the most common cause of airway obstruction in kids <5

etiology: usually viral (RSV, parainfluenza, influenza A+B)

inflammation of the mucosal lining of trachea and larynx causes airway narrowing

dx: based on history and symptoms

acute spasmodic laryngitis

Subglottic inflammation

-tissue below the vocal cords

etiology: viral, emotional (usually virus)

s/sx: sudden onset at net

-harsh cough, hoarseness (chief complaint)

self limiting, no LT sequelae

rx: humidity

-encourage fluids

-treat symptomatically

laryngotracheobronchitis (LTB)

inflammation of the larynx, trachea, and bronchi

-most common of the croups

the most common cause of airway obstruction in kids <5

etiology: usually viral (RSV, parainfluenza, influenza A+B)

inflammation of the mucosal lining of trachea and larynx causes airway narrowing

dx: based on history and symptoms

LTB s/sx

gradual onset following URI

sore throat, harsh cough

use of accessory muscles

agitation, restlessness, sweaty

increased RR, HR, increased respiratory difficulty leading to hypoxia

cyanosis

inflammation is usually followed by inspiratory stridor

supra/substernal and intercostal retractions

*if stridorous at rest, go to ER

LTB treatment

humidity and cool mist vaporizer to decrease mucosal edema

racemic epinephrine (usually neb)

IV fluids

continuous oxygen saturation monitor

humidification w/ blow by oxygen

nursing process for LTB

assess: continuous, vigilant observation and accurate respiratory assessment

recognize impending respiratory failure: FGR

-use of accessory muscles

-irritability, cyanosis

-increased HR, RR, POX<= 90%

diagnosis: ineffective airway clearance r/t mucosal swelling and airway obstruction

expected outcome/goal: child will breathe without difficulty, V/S WNL

evaluation: child has a RR and HR WDL, pink mucous membranes and nail beds, SpO2 > 955

interventions for LTB

continuous SpO2 monitoring

V/s hourly

high humidity, cool mist

emergency intubation equipment available

aerosolized racemic Epinephrine

maintain a calm, quiet environment

prevention of LTB

American Academy of Pediatrics recommends H. flu vaccine beginning at 12 months

eliminate passive smoking

asthma

A chronic allergic disorder characterized by episodes of severe breathing difficulty, coughing, and wheezing.

airway inflammation related to upper airway reactivity

airway hyperresponsiveness

airway obstruction

dx: History, s/s: chronic cough, expiratory wheeze

anti-inflammatory agents key

etiology of asthma

not well understood

factors:

-biochemical: irritants, smoke, strong odor

-immunologic: allergies

-infectious: cold, flu can trigger attack

-endocrine: paralleled with obesity (may share genetic determinants)

-psychologic

diagnosis of asthma

based on history and s/sx

-cough in the absence of infection and/or expiratory wheezes usually sufficient for diagnosis

labs and X-rays to r/o other diagnoses

pulmonary function tests to establish baseline

-objective measure of the severity of the illness and the response to treatment

spirometry is taught

s/sx of asthma

COUGH (nonproductive which becomes rattling with the production of frothy, clear sputum)

SOB, wheezes, crackles, coarse loud lung sounds

restlessness, apprehension

long term:

-barrel chest

-elevated shoulder

management of asthma

measure lung function

environmental control

pharmacologic therapy

education

lung function tests

Peak expiratory flow rate: pushing out as much air as quickly and forcefully as they can

Peak flow meter

RT consult

3 acceptable measures

-one that is unbroken that doesn't include coughing

environmental control of asthma

eliminating triggers

allergens, irritants, virus, cold air, exercises

non-environmental stimuli include laughing, crying, anxiety, stress, GERD

IDing asthma tirggers

obtaining a thorough history of previous asthma attacks (how long did it last, when did symptoms start, what made it worse/better, what were you doing) or skin tests

pharmacologic therapy of asthma

"PREVENTER"

-controller, anti-inflammatory'

-taken daily

-corticosteroids (most effective single LT control therapy for pts with asthma)

-Mast cell stabilizers (anti-infective)

-Long acting beta-2 agonist

-Methylxanthines (bronchodilator)

-Leukotriene modifiers (decrease frequency and severity of asthma attacks)

"RESCUE"

-bronchodilators

-quick relief

-inhaled short-acting beta 2 agonists to relax smooth muscle cause bronchodilation (Albuterol)

-anticholinergics (smooth muscle relaxants)

-systemic corticosteroids (PO/IV)

-magnesium sulfate (most sever, IV, high alert med)

the rule of 2-4-6 (asthma)

When to consider long term control for asthma in infants and preschoolers

More than 2 asthma episodes/week requiring treatment

4 or more episodes of wheeze lasting long than a day and affecting sleep in the past year

6 severe exacerbations less than 6 weeks apart requiring the use of a beta agonist

reactive airway disease (RAD)

respiratory condition characterized by wheezing, shortness of breath, and coughing after exposure to an irritant

considered this until it is established as asthma

treatment steps for asthma (for kids <2)

1. bronchodilator and O2 prn

2. step 1 + corticosteroid x5d

3. step 2 + controller (2-3 months)

4. step 2+ controller (long term)

5. look for cause of Rx failure

-misdiagnosed

-noncompliance/poor technique

-refer to pulmonologist

patient education for asthma

help patient decide on plan and take action

discuss barriers and benefits

put plans in writing

-every pt goes one with a color coded Asthma Action Plan

-reviewed at every visit

assess patient needs at every visit

teach and review

what a caregiver should know about asthma

what may trigger an exacerbation

s/sx that warn of an exacerbation

techniques that can prevent an exacerbation

which meds the child is on and how to administer

side effects of those meds

when to call the PCP or go to the ED

assessment of asthma

history

family history

exacerbations

alleviation

parent knowledge base

management

in acute phase:

-V/S, LS, SpO2

-retractions

-LOC

-WOB

-hydration

nursing process for asthma

diagnosis: risk for suffocation r/t bronchospasm

goal: no acute asthma episode

interventions: assessment

-O2 at 2L/min, position of comfort

-NPO, IV access

-use play techniques for breathing exercises

cystic fibrosis

Chronic multisystem disorder that is genetic and ultimately lethal

exocrine glands, mucous produced is abnormally thick, causing obstruction of bronchioles, small intestine, pancreas, and bile duct

autosomal recessive trait that is genetically transmitted

average survival age in Americans is about 40 years old

more common in white people

diagnostics for cystic fibrosis

diagnosis made based on family history of CF, absence of certain pancreatic enzymes, and a sweat test

sweat test: pilocarpine iontophoresis: stimulates sweating, NaCl level positive value is >60mEq

fecal fat determination

LFT

PFT

amniocentesis: early interventions, gives better outcomes

s/sx of CF

vary widely and are system specific

-bronchial obstruction

-intestinal obstruction

-malabsorption syndrome

-portal hypertension

respiratory s/sx of CF

progresses overtime to worsening outcomes over the lifespan

-wheezing

-cough

-pneumonia

-bronchitis

-copious purulent sputum

-accessory muscle use

-dyspnea

-tachypnea

-cyanosis

-emphysema

-atelectasis

-cor pulmonale

-digital clubbing

-barrel chest

GI symptoms of CF

progresses overtime to worsening outcomes over the lifespan

-meconium ileus

-steatorrhea (frothy fatty stools because of malabsorption)

-malnutrition

-vitamin deficiencies

-protuberant abdomen

-thin extremities

-wasted buttocks

-rectal prolapse

-biliary cirrhosis

-portal hypertension

-esophageal varices

-higher incidence of diabetes

integument s/sx of CF

abnormally high NaCl in sweat

risk electrolyte imbalance

dry mouth

reproductive s/sx of CF

delayed development

difficulty conceiving

increased rate of fetal loss

sterility in men (congenital bilateral absence of the vas deferens [CBAVD] is common)

women have normal hormones but frequent reproductive issues

treatment of CF

Chest physiotherapy

-with bronchodilators and mucolytics

regular aerobic exercise may be as effective as CPT

antibiotics: pseudomonas aeruginosa

O2/steroids with caution because of CO2 retention risk and risk of pseudomonas with steroids

immunizations

-flu vaccine

ivacaftor, TOBI

calorie requirements are 1.5x normal due to increased WOB and malabsorption

-high calorie, high protein

-pancreatic enzyme replacement

-vitamin supplement

GT feeds/TPN as needed if unable to maintain weight

pancreases/pancreatin with meal

Ivacaftor

this can cure kids if they have a specific genetic mutation

TOBI

inhaled tobramycin 28 days on, 28 days off

helpful with bacteria found in half of CF and is the leading cause of lung damage

Pancrease/Pancreatin

encapsulated pancreatic enzyme powder that should be administered with every meal or snack and the dosage is adjusted based on stool formation

-constipated, decreased dose; diarrhea, increased dose)

psychological support for CF

chronic illness

-1-800-fight-cf

normal activities

birth control

genetic counseling

nursing process for CF

assessment of L/s, exp. phase, nail beds, digits, SpO2, cough (sputum color and quality), exercise tolerance, height and weight, s/s of malabsorption, ability to sleep laying down

diagnosis: ineffective airway clearance r/t increased pulmonary secretions

goal: child with be able to move secretions from airway

interventions:

-assess respiratory status q2h

-CPT q4h around the clock

-administer expectorants and bronchodilators in between

-humidified low flow O2

-increased HOB

evaluation:

-child exhibits improved breath sounds, ability to participate in usual activities, pOx >94% on RA

-parent demonstrates CPT, inhalation therapy, ability to administer meds