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Alteration in Respiratory Function . Jan Bazner-Chandler RN, MSN, CNS, CPNP. Allergic Rhinitis. Assessment. Itching of nose, eyes, and throat Sneezing and stuffiness Watery nasal discharge / post nasal drip Watery eyes Swelling around the eyes. Assessment. Allergic Shiner.

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Alteration in Respiratory Function

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Alteration in Respiratory Function

Jan Bazner-Chandler RN, MSN, CNS, CPNP


Allergic Rhinitis


Assessment

  • Itching of nose, eyes, and throat

  • Sneezing and stuffiness

  • Watery nasal discharge / post nasal drip

  • Watery eyes

  • Swelling around the eyes


Assessment

Allergic Shiner

Allergic Salute

eMedicine.com


Rhinitis Interdisciplinary Interventions

  • Avoid offending allergen – smoke / pets

  • Pharmacologic management:

    • Oral or nasal antihistamines - Benadryl

    • Leukotriene modifiers - Singulair

    • Mast cell stabilizers – cromylin – nasal / ophthalmic / inhaled

    • Allergen-specific immunotherapy

    • Do not use combination OTC medications especially those that contain pseudoephedrine

  • No OTC Antihistamines for children under 6 years of age.


Sinusitis

Adam.com


Assessment

  • Fever

  • Purulent rhinorrhea

  • Nasal congestion

  • Pain in facial area

  • Malodorous breath

  • Chronic night-time cough

Children more prone to sinusitis: children with asthma

and cystic fibrosis.


Interdisciplinary Interventions

  • Normal saline nose drops

  • Warm pack to face

  • Acetaminophen for pain

  • Increase po fluid intake

  • Antibiotics

    • Recent studies question their effectiveness


Tonsillitis

  • Tonsils and adenoids are important to the normal development of the body’s immune system.

  • Serve as part of the body’s defense against infection

  • Can become the site of acute or chronic infection

  • Repeated acute infections cause the tonsil tissue to swell

  • Enlarged tonsils and adenoids impinge on the pharyngeal opening of the eustachian tube


Assessment

  • Child may refuse to drink

  • Fever

  • Reddened pharynx and tonsils

  • Most common causative agent = group A beta-hemolytic stretococci

  • Chronic tonsillitis may result in snoring due to enlarged tonsils and adenoids


Tonsilitis

“Kissing tonsils” occur when the tonsils are so enlarged they touch each other.


Interdisciplinary Interventions

  • Throat culture to determine causative agent

  • Antibiotics for ten days if throat culturepositive for beta strep

  • Acetaminophen for pain

  • Cool fluids

  • Saline gargles

  • Antiseptic sprays

  • Viral throat infections will not get better faster with antibiotics.


Tonsillectomy

  • Done if child’s respiratory status is compromised

  • Post operative care:

    • Side lying position

    • Ice collar

    • Watch for swallowing

    • Cool fluids / soft diet


Croup

  • Most common acute respiratory condition seen in early childhood.

  • Highest incidence from 6 months to about 3 years

  • Respiratory symptoms are caused by inflammation of the larynx and upper airway, with resultant narrowing of the airway.

  • Severity depends on the area of the upper airway that is inflamed and narrowed.

  • Most often viral – antibiotics are not needed


Assessment

  • Symptoms:

    • Hoarseness

    • Inspiratory stridor

    • Barking cough

    • Afebrile

    • Often worsens at night


Interdisciplinary Interventions

  • Home care:

    • Cool mist

    • Fluids

  • Hospital care:

    • Racemic epinephrine inhalant

    • Mist tent – not used much anymore

    • Dexamethasone

    • IV fluids if not taking po fluids


Epiglottitis

Bowden & Greenberg

Tripod position


Acute Epiglottitis

  • Acute inflammation of supraglottic structures, the epiglottis and aryepiglottic folds.

  • True pediatric emergency

  • Delayed treatment may result in complete airway obstruction

  • Most often seen in children 2 to 7 years

  • Most common causative agent – H. influenzae type B


Assessment

  • Sudden onset

  • High fever – 102.2 or greater

  • Dysphasia and drooling

  • Agitation, irritability and restlessness

  • Epiglottis is cherry red and swollen

  • Note: Do not look into the mouth – diagnosis often made by presenting symptoms or lateral neck x-ray


Interdisciplinary Interventions

  • Keep child quiet in a controlled medical environment with emergency airway equipment readily available.

  • Do not put tongue blade in mouth to look in the throat – may cause epiglottis to spasm and shut

  • Assess respiratory status

  • Give humidified oxygen by mask and keep HOB elevated.

  • Mild sedation may help the child relax


Apnea

  • Apnea is cessation of respirations lasting longer than 20 seconds.

  • Monitor in hospital for underlying problems

  • Discharge home with monitor


Foreign Body

  • Severe inspiratory stridor

  • Symptoms depend on location

  • Unilateral chest movement

  • Chest x-ray

  • Bronchoscope to remove object


Coin in Trachea


Teaching

  • No small hard candies, raisins, popcorn or nuts until age 3 or 4 years

  • Cut food into small pieces

  • No running, jumping, or talking with food in mouth

  • Inspect toys for small parts

  • Keep coins, earring, balloons out of reach


Influenza

  • Associated with community epidemic

  • Febrile, URI, achy joints

  • Management:

    • Acetaminophen for fever

    • Fluids

    • Keep away from others

    • Watch for signs of pneumonia


Bronchiolitis

  • Acute obstruction and inflammation of the bronchioles.

  • Most common causative agent: Respiratory Syncytial Virus (RSV)

  • Bronchioles become narrowed or occluded as a result of inflammatory process, edema, mucus and cellular debris clog alveoli


Assessment

  • Harsh dry cough

  • Low grade fever

  • Feeding difficulties

  • Wheezing

  • Respiratory distress with apnea

  • Thick mucus


Interdisciplinary Interventions

  • Oxygen to maintain oxygen saturation >than 95%

  • Pulse oximeter

  • Nasal suction as needed

  • Chest percussion to mobilize secretions

  • Inhalation therapy – not sure if it is beneficial

  • Mechanical ventilation as needed if increased work of breathing is seen

    • Increased heart rate, poor peripheral perfusion, apnea, bradycardia and hypercarbia


RSV Positive - Isolation

  • Respiratory Syncytial Virus is spread from respiratory secretions through close contact with infected persons or contact with contaminated surfaces or objects.

  • Patient should be on contact and respiratory isolation

  • Can be placed with other RSV + patients


Pneumonia

  • An inflammatory condition of the lungs in which alveoli fill with fluid or blood resulting in poor oxygenation and air exchange.

  • Can be primary illness or develop as a complication of another illness.

  • Incidence: 34 to 40 cases per 1000 children younger than 5 years

  • Most likely to develop when the body is unable to defend against infectious agents.


Typical X-ray


Assessment

  • High fever

  • Thick green, yellow, or blood tinged secretions

  • Grunting respirations

  • Rales, crackles, diminished breath sounds

  • Cough and cyanosis

  • Diagnostic tests: Infiltrate seen on x-ray


Interdisciplinary Interventions

  • Assess for respiratory distress

  • NPO (respiratory rate > 60 = high risk for aspiration)

  • IV fluids for hydration

  • Supplemental Oxygen to keep oxygen saturation equal to or > 92%

  • Chest percussion

  • Nasal suctioning as needed

  • Acetaminophen for fever

  • Antibiotics – ampicillin and an aminoglycoside (Gentamicin)


Pneumonia Isolation

  • Respiratory isolation

  • May be taken off isolation if RSV negative and on antibiotics for 24 hours.


Cystic Fibrosis

  • Inherited autosomal recessive disorder of the exocrine glands

  • Gene responsible for CF is located on chromosome 7

  • Life span is about 37 years

  • Complex disease requiring a holistic approach


CFTR Gene

  • Mutation of the CFTR gene disrupts the function of the chloride channels, preventing them from regulating the flow of chloride ions and water across cell membranes. As a result cells that line the passage ways of the lungs, pancreas and other organs produce mucus that is thick and sticky


Cystic Fibrosis


Cystic Fibrosis


Assessment

  • History of Meconium ileus at birth

  • Foul smelling, greasy, bulky stools / constipation

  • Voracious appetite with poor weight gain

  • Recurrent respiratory infections

  • Persistent chronic cough

  • Salty tasting skin


Diagnosis

  • Positive sweat test – Gold standard

  • Genetic marker


Medications

  • Pancreatic enzymes to help digest food

  • Inhaled antibiotics – antimicrobial for lung treatment

  • Aerosol bronchodilators to open airways

  • Mucolytic enzyme – to thin mucus

  • H2 blocker – alters gastrointestinal acidic environment

    • Tagamet

  • Prokinetic agents – enhances gastrointestinal motility

    • Reglan

  • Vitamin C to improve absorption of other meds

  • Vitamins E, A, D, K / fat soluble vitamins

  • Oral and IV antibiotics – S. aureus, H. influenzae, P aeruginosa


Long Term Complications

  • Nasal polyps

  • Sinusitis

  • Rectal polyps / rectal prolapse

  • Hyperglycemia / diabetes

  • Infertility - male


Asthma

  • Asthma is a chronic, inflammatory lung disease involving recurrent breathing problems.

  • Third leading cause of hospitalization among children younger than 15 years.

  • Most common, chronic health problem in children


Pathophysiology

  • Reversible changes in airway that lead to bronchoconstriction, airway hyper-responsiveness and airway edema.

  • At the cellular level mast cells release histamine causing smooth muscle contraction and bronchoconstriction.

  • Increased mucous secretion by goblet cells causes epithelial damage

  • Increased mucus secretion results in airway edema, mucus hypersecretion and plugging, airway narrowing, leading to airway obstruction


Assessment

  • Wheezing

  • Cough

  • Tightness of chest

  • Prolonged expiratory phase


Assessment

  • Hypoxemia – universal in child with moderate to severe symptoms

  • Hypercarbia – carbon dioxide retention from air trapping in the alveoli and ventilation – perfusion mismatch

  • Monitor blood gases – PaCO2 level more than 50 mm Hg indicated ventilatory failure

  • Diagnostics: chest x-ray = hyper-expansion of lungs


Asthma Attack


Interdisciplinary Interventions

  • High fowlers position / bed rest

  • Pulse oximetry

  • Nebulized albuterol – beta 2 agonist

  • Chest percussion to mobilize secretions

  • Methylprednisone / Solu-medrol IV

  • IV fluids

  • Oxygen to keep oxygen sats > 95%


Home Management

  • Peak flow spirometer

  • Identify triggers

  • Maximize lung function

  • Optimal physical growth

  • Optimal psycho-social state

  • Maximum participation


Peak Flow Meter

Peak flow meters are used to measure

PEFR and are designed for monitoring purposes rather than diagnosis of asthma.


Home Medications

  • Rescue drugs: short acting albuterol beta 2 agonist – used as a quick-relief agent for acute bronchospasm and for prevention of exercise induced bronchospasm.

  • Anti-inflammatory or preventative: low-dose inhaled corticosteroid: inhaled or oral prednisone

  • Allergy: leukotrines such as Singulair


Bronchodilators

  • Bronchodilators rapidly relax the airway smooth muscle cells, thus reversing the bronchospasm until anti-inflammatory effect of steroids is attained.

    • Aerosols

      • Via mouth piece 3 years and older

      • Via facial mask for less than 3 years


Spacer mdi

About.com: pediatrics


Nebulizer

About.com: pediatrics


Corticosteroids

  • Steroids reduce the inflammatory component of bronchial obstruction, decrease mucus production and mediator release, as well as the late phase (cellular) inflammatory process.

  • Methyl prednisone IV in severe cases

  • May need histamine H2 receptor antagonists (cimetadine or ranitidine) if experiencing GI upset

  • PO prednisone – always give with food to decrease GI upset


Inhaled Corticosteroids

  • Inhaled corticosteroids: Pulmicort, AeroBid, Flovent

    • Infant: mask should fit firmly to prevent cataracts

    • Older child: rinse and spit after treatment to prevent thrush


Family Teaching

  • Teach how to use medication

  • When to use and how often

  • No OTC drugs

  • Increase fluid intake

  • Signs and symptoms of respiratory distress


Neonate Disorders

Bronchopulmonary

Dysplasia

Pediatric Nursing January/February 1999


History

It occurs in newborns who are born prematurely and or have a variety of pulmonary disorders and who require ventilatory support with high pressure and oxygen in the first 2 weeks of life.


Pathophysiology

  • Fibrosis of airways and marked hyperplasia of the bronchial epithelium

  • Increased fluid in the lungs, as a result of disruption of the alveolar-capillary membrane

  • Over distention due to damage to alveolar supporting structures resulting in air trapping

  • Fibrosis, airway edema, and broncho-constriction


BPD Assessment

  • Persistent respiratory distress

  • Dependent on supplemental oxygen

  • Failure to thrive

  • Gastro-esophageal reflux

  • Pulmonary hypertension


Long-term Outcomes

  • Oxygen dependent

  • Visual problems

  • Feeding difficulties

  • Developmental delay

  • Learning difficulties


Long Term Management

  • Supplemental oxygen

  • CPT

  • Bronchodilators

  • Diuretics (pulmonary hypertension)

  • Anti-inflammatory medication

  • Nutritional support: po formula + NG supplement

  • Gastrostomy tube (GER)

  • Bicarbonate in formula due to chronic state of acidosis


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