NURSING CARE OF THE CHILD WITH RESPIRATORY DYSFUNCTION

Prepared By:Ana Maria M. Pingol RN MSN

– Nursing Assessment– General Nursing Interventions– Specific Disorders

• Nasopharyngitis• Influenza• Tonsillitis

– The Tonsillectomy patient• Croup• Bronchiolitis/ RSV• Pneumonia• Asthma• Cystic fibrosis• Otitis media• SIDS

Components for Assessing Respiratory Function

• Respirations

– Rate

– Depth

– Ease

– Labored Breathing

– Rhythm

• Evidence of infection

• Cough

• Wheeze

• Cyanosis

• Chest pain

• Sputum

• Bad breath

Stridor & Retractions.mp4

Grunting baby.mp4

Head Bobbing- Respiratory Distress in infants.mp4

General Nursing Interventions

• Ease respiratory efforts

– Warm/ cool mist therapy

• Promote rest

– Bed rest or quiet play

• Promote comfort

– Nose drops, throat irrigation

– decongestants

• Prevent spread of infection– General Hygienic measures– Isolation

• Reduce temperature– TSB– antipyretics

• Promote hydration– Oral and parenteral

• Provide nutrition– Consider preference

• Provide family support and teach home care

NASOPHARYNGITIS

The common cold (also known as nasopharyngitis, acute viral rhinopharyngitis, acute coryza, or a cold) is a viral infectious disease of the upper respiratory system, caused primarily by rhinoviruses and coronaviruses

NASOPHARYNGITIS: CLINICAL MANIFESTATIONS

• Fever• Watery and profuse nasal secretions (but may

become more purulent and mucoid)• Irritability, restlessness• Sneezing• Vomiting or diarrhea• Dryness and irritation of nose and throat• Chilly sensation• Muscular aches• Cough, mild and occasional• Edema and vasodialtion of mucosa

Common Cold

• Medical Management– Antipyretics (avoid aspirin if influenza is

suspected)– Nasal decongestants– Hydration– For Cough: Antitussives, Expectorants, Mucolytics– Antihistamines– Bronchodilators

Common Cold: Nursing Management

– Assess for signs and symptoms of respiratory distress

– Promote adequate hydration– Encourage bed rest– Administer prescribed meds and monitor fo side

effects– saltwater drops in the nostrils to relieve nasal

congestion (you can buy these — also called saline nose drops — at any pharmacy)

Signs of Respiratory Complications:• Evidence of earache• Respirations faster than 50-60 breaths/ min• Fever over 38.3oC• Listlessness• Increasing irritability• Persistent cough for 2 days or more• Wheezing• Crying• Refusal to eat• Restlessness and poor sleep patterns

Common Cold: Nursing Management

• a cool-mist humidifier to increase air moisture • petroleum jelly on the skin under the nose to soothe

rawness • hard candy or cough drops to relieve sore throat (for

kids older than 3 years) • a warm bath or heating pad to soothe aches and pains • steam from a hot shower to help patient breathe more

easily

Common Cold: Preventive Measures

– Hand washing– Proper Nutrition– Isolation of sick patients– Proper disposal of secretions– Surface disinfection of contaminated surfaces

INFLUENZA

Influenza, commonly referred to as the flu, is an infectious disease caused by RNA viruses of the family. Orthomyxoviridae (the influenza viruses), with types A and B causing epidemic disease.

Clinical Manifestations:– Onset is sudden chilly sensation, hyperpyrexia (39-

39.5oC), malaise, sore throat, coryza, rhinorrhea, and myalgia

– Prostration and generalized aches and pains (most pronounced in the back and legs

– Headache with photophobia and retrobulbar pain

Clinical Manifestations:– Scratchy sore throat– Substernal burning– Nonproductive cough that eventually becomes

more persistent and productive– Lacrimation, mild conjunctivitis– Nausea and vomiting in children– Reddened tonsils and pharynx with no exudate

Complications– Directly related to primary viral infection:

• Hemorrhagic pneumonia• Encephalitis• Reye’s Syndrome• Myocarditis• SIDS• Myoglobinuria

– Superimposed bacterial infection (pneumococcal or staphylococcal)• Otitis media, Sinusitis, Pneumonia

Medical Management– Symptomatic– Antipyretics and Analgesics (acetaminophen and

aspirin)– Antiviral drugs (Amantadine)– Nasal decongestants– Steam inhalation– Antibiotics for superimposed bacterial infections

Nursing Management– Respiratory Isolation– Promote Hydration– Relieve Fever– Limit strenuous activity– Monitor for complications

Influenza: Preventive Measures– Immunization– Avoidance of crowded places– Public education regarding the importance of

basic personal hygiene– Frequent handwashing

COLD versus FLU

S & SX FLU COLD

Fever characteristic Rare

Headache Prominent Rare

General Aches Usual often severe Slight

Fatigue Extreme (2-3wks) Mild

Runny Nose Sometimes Common

Sore throat Sometimes Common

Cough Common; can become severe

Mild to moderate

TONSILLITIS

Inflammation of the tonsils caused by bacterial or viral infection; often occurs with pharyngitis

CLINICAL MANIFESTATIONS

• Enlarged, reddened palatine tonsils with or without exudate

• “kissing” tonsils• Difficulty swallowing or breathing• Drooling• Lymphadenopathy• Mouth-breathing

THERAPEUTIC MANAGEMENT

• Management for viral tonsillitis is symptom relief; similar to viral pharyngitis

• Bacterial tonsillitis: antibiotic therapy• Soft/ liquid diet, nonirritating foods• Saltwater gargles, lozenges, or anesthetic

sprays• Acetaminophen for pain relief and fever• Tonsillectomy: removal of tonsils to prevent

recurrent tonsillitis

Care of the Post-Tonsillectomy Patient:• Provide pain control with analgesics and ice

collar• Observe for excessive bleeding• Offer clear, chilled fluids when awake and

alert; avoid red-colored fluids; milk products are discouraged

• Teach child and parents that a sore throat is to be expected for approximately 1 week postoperatively

• Avoid strenuous activity for about 1 week

OTITIS MEDIAA bacterial or viral infection in the

middle ear, usually secondary to an upper respiratory tract infection

CLINICAL MANIFESTATIONS

• Ear pain (otalgia)• Irritability• Diarrhea• Fever• Vomiting• pulling at affected ear• Red, bulging, nonmobile tympanic membrane• May be asymptomatic in some children

THERAPEUTIC MANAGEMENT• Avoid exposure of child to cigarette-smoke

• Antibiotics

• Acetaminophen or ibuprofen; codeine for severe pain

• Surgical management:

– Myringotomy

– Tympanostomy

CROUPAn acute viral inflammation of the upper and lower respiratory tracts, characterized by inspiratory stridor, subglottic swelling, and respiratory distress that is most pronounced on inspiration

CLINICAL MANIFESTATIONS• Croup usually begins with nonspecific respiratory

symptoms, including:• Rhinorrhea• Sore throat• Cough.• Fever is generally low grade (38-39°C) but can exceed

40°C. Within 1-2 days,• The characteristic signs of hoarseness, barking cough, and

inspiratory stridor develop, often suddenly, along with a variable degree of respiratory distress.

• Symptoms are perceived as worsening at night• Spasmodic croup typically presents at night with the

sudden onset of "croupy" cough and stridor.

Scoring systems• Croup scores have been developed to assist the clinician in

assessing the degree of respiratory compromise. One of the most commonly cited is the Westley score. The score evaluates the severity of croup by assessing the following 5 factors, with a score range of 0 to 17:

• Inspiratory stridor: None - 0 points, Upon agitation - 1 point, At rest - 2 points

• Retractions: None - 0 points, Mild - 1 point, Moderate - 2 points, Severe - 3 points

• Air entry: Normal - 0 points, Mild decrease - 1 point, Marked decrease - 2 points

• Cyanosis: None - 0 points, Upon agitation - 4 points, At rest - 5 points

• Level of consciousness: Normal, including sleep - 0 points, Depressed - 5 points

• According to the Westley score, a score of less than 3 represents mild disease; a score of 3-6 represents moderate disease; and a score greater than 6 represents severe disease.

CROUP: THERAPEUTIC MANAGEMENT• Fluids• Cool mist/ humidified air• Antibiotics• Antipyretics• Nebulized epinephrine• Corticosteroids• 100% oxygen• Suctioning• Intubation• Vigilant observation of respiratory status

BRONCHIOLITIS(RSV)

An acute viral infection of the lower respiratory tract affecting infants and young children and characterized by respiratory distress, expiratory obstruction, wheezing, and crackles.

Signs and Symptoms– Dyspnea, cough, wheezing– Fever– Apnea in infants

Complications– Acute asthmatic episode– Respiratory failure

RSV: Diagnostic Tests–CBC

• Elevated granulocytes–Chest X-ray will show

bronchopneumonia and bronchiolitis–ELISA

RSV: Medical Management:– Severe disease in infants and children requires

hospitalization and close observation to ensure adequate respiration

– ABG/ pulse oximeter monitoring– Supportive Ribavirin– Respiratory support: CPT, humidified oxygen,

assisted ventilation– IV Fluids

RSV: Nursing Management:– Monitor closely for signs of respiratory fatigue or

distress– Monitor O2 saturation levels and response to

therapy if patient is hypoxic– Monitor for adequate hydration and nutrition. – Prop infants up to an angle of 10 to 30 degrees to

ease breathing– In tachypneic patients and those in respiratory

distress, oral fluids are contraindicated due to risk of aspiration

– Institute contact isolation. Strict handwashing.

PNEUMONIA

An acute infection of lung parenchyma including alveolar spaces and interstitial tissue

CLINICAL MANIFESTATIONS

• Viral Pneumonia– Mild fever, nonproductive cough, rhinitis– Wheezing, tachypnea, and increased respiratory distress

• Bacterial Pneumonia– High fever, productive cough, ill appearance– Retractions, grunting respirations, chills, chest pain– Respiratory distress is significant and accompanied by

restlessness and anxiety

• Diagnostics: Chest x-ray, pulse oximetry, blood gas analyis, CBC, blood cultures

PNEUMONIA: THERAPEUTIC MANAGEMENT

• Monitor: breath sounds, RR, use of accessory muscles, color, O2 sat, level of activity, and restlessness every 2 hours

• Encourage to assume position of comfort, usually upright

• Assist with coughing and deep breathing exercises• Administer antipyretics and analgesics• Ensure adequate hydration• Cool mist• Suctioning as needed• Cluster nursing care to allow periods of

undisturbed rest

ASTHMAA pulmonary disease characterized by reversible airway obstruction, airway inflammation, and increased airway responsiveness to a variety of stimuli.

ASTHMA: CLINICAL MANIFESTATIONS• Cough: hacking. Paroxysmal, irritative, nonproductive;

becomes rattling and productive• Shortness of breath• Prolonged expiratory phase• Audible wheeze• Malar flush, red ears• Lips deep, dark red color; may progress to cyanosis of nail

beds or circumoral cyanosis• Restlessness and apprehension; Sweating• Older children may sit upright with shoulders in a hunched-

over position• May speak in short, panting, broken phrases

ASTHMA: CLINICAL MANIFESTATIONS• Chest: hyperresonance• With repeated episodes:

– barrel chest– Elevated shoulders– Use of accessory muscles of respiration– Flattened malar bones, circles beneath the eyes,

narrow nose, prominent upper teeth

THERAPEUTIC MANAGEMENT• Eliminate allergen if possible• Recognize that emotional overlay may trigger

attacks• Hyposensitization – “allergy shots”• Position of comfort--high Fowler’s--leaning forward with chest on pillow placed on

bedside table• Education--swimming is good exercise--symptoms may decrease at puberty

Common medicationsBeta-Agonists (Ex. Albuterol)--provides bronchodilation--side effects: palpitations, tachycardia, tremorsCorticosteroids--reduces inflammation and swellingTheophylline--prevents/reduces inflammation--prevents bronchoconstriction--side effects: gastric irritation, headache, palpitations,

restlessnessCromolyn--prevents/reduces inflammation--does not work for acute attacks--not recommended under 5 years

CYSTIC FIBROSISAn inherited disease of the exocrine glands primarily affecting the GI and respiratory systems, and usually characterized by COPD, exocrine pancreatic insufficiency, and abnormally high sweat electrolytes.

CYSTIC FIBROSIS: CLINICAL MANIFESTATIONS• Intestinal obstruction

--meconium ileus (thick, putty-like meconium)• Malabsorption syndrome

--growth failure--large appetite with weight loss--steatorrhea (fatty stools) – bulky, loose, foul-smelling stools--rectal prolapse

• Chronic pneumonia/obstructive emphysema--frequent respiratory infections

• Exocrine gland dysfunction--salty taste to skin

• Diagnostic test – sweat chloride over 60 mEg/l

CYSTIC FIBROSIS: THERAPEUTIC MANAGEMENT

• Observe for any respiratory impairment:– Cough, presence and color of sputum– Dyspnea– Color of nailbeds and mucous membranes– Pulse oximetry– Auscultate breath sounds for equality, crackles,

wheezes– Observe for digital clubbing

CYSTIC FIBROSIS: THERAPEUTIC MANAGEMENTParental support--may feel guilt since disease genetically linked--chronic terminal illness--expensive and time consuming to treat, use of special

equipment--places limits on “normal” activities--use respite care as availableNutrition--need to increase calories, protein, salt--give water soluble vitaminsPancreatic enzyme replacement--give with ALL meals/snacks--dosage is determined by stools

THERAPEUTIC MANAGEMENT

Pulmonary hygiene--3-4 times daily – percussion with postural drainage

(CPT)--aerosols (nebulizer) therapy before and after CPT--breathing exercises--long term antibiotics and expectorants--oxygen should be given cautiously because of narcosis

risk--avoid exposure to respiratory infections

SIDS

The sudden and unexpected death of any infant or young child in which a thorough postmortem examination fails to show an adequate cause.

Risk Factors• Prematurity• Infections• Brain stem defects• Use of soft bedding• Sleeping in prone position• Maternal smoking during pregnancy• Sibling with SIDS• Low birth weight• Increased incidence in cold weather• Increased incidence in lower socioeconomic

groups

THERAPEUTIC MANAGEMENT

• Avoid questions that could imply parental negligence

• Provide emotional support• Assure parent(s) that there is nothing that

they could have done to prevent infant’s death

• Allow parents an opportunity to say goodbye• An autopsy may likely be necessary to confirm

cause of death