1
Q
age related differences in A&P
A
- chest wall and respiratory muscles:
- ribs and sternum are toopliable to use intercostal muscles
- diaphragmatic breathers until 7 yo
- AP diameter inc
- airways:
- infants airways are 1/4 the size of adults, so any inflammation of airway will cause problems
- alveoli/parenchyma:
- neonates have 20 mil alveoli which inc to 300 mil by 8 yo
- WOB: paradoxical chest movements
- inc O2 consumption b/c of inc metabolic rate, inc HR, inc RR
- infants need 6-8 mL/kg/min vs adults 3-4 mL/kg/min
2
Q
if you have varying children with respiratory issues, which one do you see first?
A
- the youngest–b/c they will deteriorate the fastest
3
Q
clinical manifestations of respiratory alterations
A
- changes in LOC: restlessness
- alteration in perfusion: dec O2 sats, cyanosis/pallor (color changes)
- cough: if present, worried about chlamydial pneumonia
- dyspnea
- tachypnea
- tachycardia
- grunting (late sign of compensation)
- retractions
- stridor/wheezing
- nasal flaring
- intercostal bulging (air trapping)
- chest pain
4
Q
stridor vs. wheezing
A
- stridor: upper airway affected
- see w/ croup
- high pitched, noisy respiration
- indicates narrowing of upper airway
- can be inspiratory or expiratory
- wheezing: bronchioles affected (lower airway)
- continuous musical sound originating from vibrations in lower airways (bronchioles)
- typically heard on expiration
5
Q
respiratory distress
A
- early recognition very important
- distress is marked by inadequate elimination of CO2 or decrease in O2
- resp assessment:
- LOC
- RR
- WOB: can be inc by inflammation or excessive mucus
- color of skin/mucous membranes
6
Q
grunting
A
- late sign of sompensation
- body’s attempt to create positive end expiratory pressure (PEEP)
7
Q
retractions
A
- sinking in of soft tissues–indicates use of accessory muscles in an attempt to improve respirations
8
Q
respiratory assessment in a healthy infant
A
- response to environment: looking around, pink
- color of skin, mucous membranes
- accessory muscle use should be absent or minimal
- work of breathing
- normal breath sounds
9
Q
indications of mild respiratory distress
A
- retractions–sub or intercostal
- color changes: pink–>pale–>slight circumoral cyanosis
- nasal flaring
- response to envinronment: may not be as alert
10
Q
indications of moderate to severe respiratory distress
A
- LOC and response to environment: listless, lethargic
- retractions
- color changes: circumoral–>dusky–>cyanotic
- breath sounds: inc wheezing/stridor
- changes in O2 sats: decreased
- head bobbing
- indicates an exhausted infant
- sign of dyspnea
- use of scalene and SCM muscles–head bobs with each inspiration
11
Q
nasal cannula
A
- 2 short plastic nasal prongs: delivers 25-45% at 1-6 L/min
- usually don’t go above 5 on kids
- always humidify O2
- if in distress, always start as high as you can w/ that apparatus then titrate down
- make sure HR decreases as you add O2
- O2 delivery: 4% O2/L
- 0 L=21% RA
- 1 L=25%
- 2 L=29%
- 3 L=33%
- 4 L=37%
- 5 L=41%
- 6 L=45%
12
Q
oxygen mask
A
- poorly tolerated by infants/toddlers
- delivers 35-60% oxygen at 6-10 L/min
- RA entrained during inspiration
- reduced oxygen concentration if:
- high spontaneous inspiratory flow
- mask is loose
- oxygen flow into mask is low
13
Q
oxygen face tent/shield
A
- high flow soft plastic “bucket” over nose and mouth
- better tolerated than face mask
- delivers only 40% O2 at 10-15 L/min
14
Q
PaO2 (mmHg) vs. SaO2 (%)
A
- PaO2=SaO2 (%)
- 100=98%
- 90=97%
- 80=95%
- 70=93%
- 60=90%
- 50=84%
- 40=75%
- 30=60%
- 20=35%
- 10=14%
15
Q
chest physiotherapy
A
- postural drainage: want to try to loosen up secretions so child can cough out or suction out secretions
- percussion: cupping to loosen secretions
- vibration
- incentive spirometer
- breathing exercises
- suctioning
- if child has a lot of secretions, need to pay attn to hydration status
16
Q
Asthma
A
- wheezing occurs due to constriction of the lower airways
- higher incidence in African Americans and children who are overweight
- have to educate client about having albuterol on them at all times
- teach about maintenance vs. rescue drugs
- need to teach the client about asthma triggers:
- pollen, dust mites, mold, pet dander
- teach about using peak flow meters
- if on any corticosteroids as an anti-inflammatory: concerned about immunsuppression, may have salt cravings, and do not d/c the meds abruptly
17
Q
peak flow meters
A
- measure peak expiratory flow rate (PEFR) which is the maximum flow of air that can be forcefully exhaled in 1 second
- child’s personal best PEFR should be measured when asthma is stable
- GREEN: 80-100% of child’s best–>no symptoms, continue maintenance tx
- YELLOW: 50-79% of child’s best–>an acute exacerbation may be occurring–maintenance therapy may need to be inc
- may need to call practitioner if stay in this range
- RED: <50% of child’s best–>signals a medical alert b/c airway narrowing is occurring
- short acting bronchodilator should be administered
- notify HCP immediately if PEFR does not return to and stay in yellow/green
18
Q
which asthma drugs should not be used as rescue drugs? why?
A
- salmeterol and foradil
- long acting beta 2 agonists
19
Q
Nasopharyngitis
A
- concerned about alteration in respiratory distress, ineffective airway clearance, impaired oxygenation
- S/S: fussy, peeing less, skin color, high RR, congestion and thick nasal drainage, high HR, may have some signs of dehydration
- nursing interventions:
- bulb suction
- can use saline nose drops if needed after trying to suction
- clean at least 1x/day
- weigh infant: to look at hydration
- cool mist vaporizer
- educate parents about what to look for w/ resp distress
- inc WOB, use of accessory Ms, dec activity, change in color
- bulb suction
20
Q
pertussis
A
- whopping cough
- S/S: dry cough that progresses to high pitched/whooping sound while inhalaing during cough, runny nose, inc temperatures, periods of apnea, color change
- would obtain cultures, ABGs
- more concerning the lower the pH is–>resp acidosis
- administer tylenol, abx, fluids
- fluids b/c dehydration may occur otherwise
- nursing interventions:
- educate about being vaccinated
21
Q
bronchopulmonary dysplasia (BPD)
A
- caused by damage to the tissues of the lungs r/t high pressure of ventilator
- due to a child’s prematurity/resp distress, may need to be placed on a ventilator which will cause trauma to the lung tissue, causing interstitial edema, epithelial swelling, then thickening of the tissue, proliferation of alveolar walls
- may need to receive inc calories and has to conserve calories while feeding, so may need G tube
- may need inc cal/oz, b/c can’t take extra volume, but if you inc the caloric content, then you inc solute load–>have to monitor kidney function
22
Q
tonsillitis
A
- can be tx w/ abx, but may need to do a tonsillectomy/adenoidectomy
- often caused by strep
- w/ a tonsillectomy, need to monitor for bleeding which will show up as bright red blood and excessive swallowing
- dark blood–old blood that child swallowed in surgery, not concerned
- concern for bleeding immediately post op, up to 10 days later
- has to have fluids after surgery and need to monitor urinary output
- often should avoid milk products b/c will make you cough which could cause bleeding
- give clear fluids–don’t need to check gag reflex first, b/c will vomit
- can give opioids for pain relief
- have to be diligent about pain control, or she will not drink and will become dehydrated
23
Q
equipment needed when caring for a child with a trach
A
- extra trach–same size and size smaller
- resuscitation bag and oxygen
- suction set up and at least 6 catheters
- scissors
- goggles
- sterile water/saline–only good for at least 24 hours
- Q tips
- 4x4 gauze
24
Q
suctioning a child w/ a trach
A
- don’t go down until cough b/c hitting the bifurcation of the airway and causing inflammation and scar tissue
- should measure length of trach and go just beyond the end of it (~0.5 cm)
- don’t put saline down the trach
- as suction, don’t apply pressure when you go down
- apply no more than 80-100 mmHg of pressure
- suction continuously as you come out
- 5 sec at most for little ones
- 10 sec at most for older kids
25
list risk factors for RSV
* prematurity
* BPD
* preexisting heart and respiratory conditions
* neuromuscular impairment
* immunodeficiency
* Down's syndrome
* attendance at daycare centers
* exposure to environmental pollutants (particular cigarette smoke)
* having school aged siblings
* living in crowded conditions
26
respiratory assessment with RSV
* fuzziness
* dyspnea
* wheezing
* tachypnea (b/c of inc WOB)
* nasal drainage
* cough (b/c of nasal drainage)
* retractions (w/ inc WOB)
* grunting (r/t extreme resp distress due to body trying to create PEEP)
27
what causes the airway obstruction in bronchiolitis?
* edema
* accumulation of mucus
* dyspnea
28
why should you administer O2 to RSV patients?
* to maintain O2 over 93%
* to dec WOB
29
when do you withhold food from an infant?
* if RR is over 60, b/c high risk of aspiration
30
nursing interventions w/ RSV patients
* saline nose drops w/ bulb suctioning--try suctioning first
* raising HOB
* humidified O2
* fever control
* adequate fluid intake
* suctioning of upper airway
31
abx and RSV
* not effective b/c RSV is a virus
* may be used for a child who develops a complication from RSV, like pneumonia
* may be used prophylactically for children who require intubation and mechanical intubation for respiratory failure
32
short acting beta agonists and RSV
* not recommended for routine care of first time wheezing assoc with RSV
* but we will use it if they have pre-existing condition
* ie. albuterol
* administered by respiratory therapist
33
antivirals and RSV
* Ribavirin: only specific tx of RSV approved by FDA
* has been assoc with small inc in O2 sats
* but has not consistently decreased the need for ventilation, dec LOS in ICU, or dec length of hospitalization
* administered by aerosol--so possible ADRs for healthcare workers
* does have teratogenic effects
34
corticosteroids and RSV
* has not demonstrated any effect on dz length or severity
* not recommended for first time wheezing assoc with RSV
* should not be given to infant w/ diagnosis of bronchiolitis
35
prevention of RSV
* Palivizumab/Synagis
* IM injection only
* reduces RSV hospitalization
* prophylaxis for RSV, but can also be given to children who've already had RSV and want to try to dec S/S and help prevent again
* get injections once a month \*3 or \*5, during RSV season Oct-March
* eligible: premies if \<30 weeks; other infants born b/w 32 weeks and 34 weeks 6 days and attend child care center/live w/ a sibling under 5 yo
36
CF
* autosomal recessive (so both parents have to be carriers)
* can do a transplant to tx bt doesn't cure
* problem is w/ inc viscosity of secretions
* bronchial obstruction
* pancreatic duct obstruction--\>malabsorption syndrome
* biliary cirrhosis and portal HTN
* steatorrhea
* FTT, inc AP diameter, inc Hgb/HCT (b/c body not being oxygenated properly so inc RBC production (polycythemia)--\>makes blood thicker), inc risk of infection
* w/ polycythemia, inc risk of stroke b/c of thick blood so need to keep pt adequately hydrated
* pt needs to be fully vaccinated
* must have pancreatic enzyme replacement prior to meals/snacks
* must have chest physiotherapy to get mucus out and prevent infection
37
how to dx CF
* buccal biopsy
* sweat chloride test: make child sweat and then test how much NaCl in sweat and can indicate CF
* child "tastes" salty
38
diet of CF pts
* need a high intake of fat--b/c have difficulty absorbing fat and have steatorrhea
* pancreatic duct is often blocked, so need pancreatic enzyme replacement before meals and snacks
* for babies, open capsule and sprinkle on bite of applesauce b/c crushing them changes composition!
39
Croup Syndromes
* to varying degrees it affects the larynx, trachea, and bronchi
* usually described according to the primary anatomic site affected
* all are under the umbrella of laryngotracheal bronchitis
40
Croup
* AKA acute laryngotracheobronchitis (LTB)
* most common form of croup
* usually viral
* RSV, parainfluenza, influenza A/B
* usually preceded by a URI
* usually affects smaller/younger kids
* s/s:
* hoarseness
* low grade feever
* resonant cough ("brassy" or "barky")
* inspiratory stridor, mild wheezing
* respiratory distress
* suprasternal retractions
* from inflammation or obstruction in region of larynx
* tx:
* maintain airway: cool mist, nebulized epinephrine, IV corticosteroids
41
acute epiglottitis
* AKA supraglottitis
* usually bacterial
* high fever common
* usually affects slightly older kids
* these kids are usually sicker than they are with croup
* S/S
* onset is abrupt--very sick, very fast
* responsible organism is Haemophilus influenza--dec incidence since Hib vaccine
* preceded by sore throat--pain on swallowing
* dysphagia--drooling is common
* toxic looking
* tripod position
* don't really do anything with these kids, esp if it will upset them/make them cry b/c this leads to inc airway inflammation and may close the airway
* do NOT do a throat inspection (only should be done by someone immediately prepared to intubate)
* do NOT obtain throat culture
* tx:
* IV abx
* corticosteroids
42
pneumonia
* inflammation of pulmonary parenchyma
* common in childhood, more common in infants/early childhood
* clinical manifestations:
* depends on child's age and the etiological agent, as well as degree of bronchial/bronchiolar obstruction
43
viral pneumonia
* occurs more frequently than bacterial pneumonia--usually assoc with URI
* pathological changes include interstitial pneumonitis along with inflammation of the mucosa and the walls of the bronchi/bronchioles
* organisms:
* RSV in infants
* parainfluenzae, influenzae, adenovirus in older children
* clinical manifestations:
* abrupt/insidious
* mild to high fever
* slight to severe cough
* nonproductive cough to productive of small amounts of white mucus
* tachypnea
* diminished breath sounds over area of consolidation
* grunting respirations b/c body trying to create PEEP
* mgmt:
* prognosis is good, does make child susceptible to bacterial infection
* tx is symptomatic: promote oxygenation
44
therapeutic mgmt of bacterial pneumonia
* antimicrobial therapy
* promote oxygenation
* promote hydration
* thoracentesis--pleural effusion
Pediatrics Test II
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