#2 April 11
Holistic Care of Children with Oxygenation Alterations
Greta Brinkley R.N., B.S.N.
Georgia Baptist College of Nursing
of
Mercer University
Objectives
Upon completion of this lesson the student will be able to:
Describe and identify anatomical and physiological differences between pediatric and adults in the respiratory system
Discuss the importance of respiratory assessment in pediatric patients that have respiratory dysfunction
Identify nursing considerations in managing pediatric patients and families with respiratory dysfunction
Objectives
Upon completion of this lesson the student will be able to:
Identify the holistic needs of children suffering from respiratory dysfunction
Apply the nursing process in planning for the child with respiratory dysfunction
Respiratory System
Primary responsibility of structures is to distribute air and exchange gases so that cells are supplied with oxygen for metabolism while carbon dioxide is removed as the waste product for metabolism
Structure of the Respiratory System
Nose
Pharynx
Larynx
Trachea
Bronchi
Lungs
Respiratory Units
Lungs consists of bronchi, bronchioles, and alveoli
Gas exchange
With age, changes occur that effect respiratory surface area
With age, alveoli increase in number
Infants and children have less alveolar surface area for gas exchange, airways easier for narrowing and blockage
Function
First evident at 20 weeks of gestation
In the neonate, respiratory rate is rapid to meet the high demands of metabolism
During growth, the amount of oxygen in the expired air gradually decreases and the amount of carbon dioxide increases
Anatomical Differences
At birth, chest carries a round configuration
Gradually changes to a more or less flattened anteroposterior diameter in adulthood
Anatomical Differences
Pediatrics
Bifurication of trachea third thoracic vertebrae
breathers Diaphragmatic-abdmonial
Nose breathers
Narrow, nares increasing airway resistance
Glottis is located more cephalad (toward the head) making the laryngeal reflexes more active
Epiglottis is longer, narrowed larynx (more susceptible to edema formation)
Airway cartilage is very soft and compressible, very reactive to stimuli
Air sacs are shallow with wide necks
Anatomical Differences
Adults
Bifurication of trachea at fourth and fifth thoracic vertebrae
Larger nare passages increasing moisture,filtration, warming of air to lungs
Epiglottis more anterior decreasing chance of aspiration
A large amount of smooth muscle
Decrease chances of infection and irritants to respiratory system
Gas exchange system maximized as an adult
Alveoli increase in number throughout childhood
Anatomical Differences
Adults
Lung growth affected by hormone level, glucocorticosteroids, thyroxine, prolactin
Excess insulin and phenobarbital can cause immature lungs
Pediatrics
Alveoli multiply in growth by 9x by age 12
Respiratory Assessment
Why is so important?
An assessment will help the nurse identify specific pathologies and treatments in correcting respiratory alterations
Physical assessment
Ascultation
Palpation
Percussion
Identify information regarding pain and tissue density
Respirations
regularity, rate, symmetry, depth, effort, use of accessory muscles
Nurse must know normal type and rate of respiration in relation to child size and age
Best to assess the child is sleeping or quietly awake
Associated Observations
Retractions
Nasal flaring
Head bobbing
Noisy breathing
Grunting
Color Changes
Chest pain
Clubbing
Cough
Associated Observations
Cough Assessment
Onset and duration
Type (dry,hacking, brassy)
Progress (better, worse, unchanged, persistent)
Pattern (daytime, nighttime, both)
Associated symptoms
Sore throat, dyspnea, pain
secretions
Tachypnea
Rapid respirations
Anxiety, elevated temperature, severe anemia, metabolic acidosis, respiratory alkalosis
Diagnostic Procedures
Pulmonary Function Test
Radiology
Blood Gas Determination
Pulse Oximetry
Respiratory Therapy
Oxygen therapy
Oxyhood
Nasal cannula (prongs)
Oxygen tent
Tent for Oxygen Administration
Aerosol Therapy
Nebulizers
MDI: metered dose inhaler
Spacer device
Chest Physical Therapy
To enhance clearance of mucus from the airway
Includes percussion, vibration, squeezing of the chest, cough, forceful exhalation, and breathing exercises
Percussion with Hand or Device
Artificial Ventilation
Bag-valve-mask (BVM)
Positive pressure ventilation
Negative pressure ventilation
High-frequency ventilation
ECMO: extracorporeal membrane oxygenation
Care Of The Patient
What is your nursing assessment?
I&O
Nutritional assessment
Vital signs
Airway status
Tracheostomy
May be temporary or long term
Tracheostomy care
Suctioning procedures for tracheostomy
Routine care
Emergency care of tracheostomy: occlusion, accidental decannulation
Tracheostomy Ties Snug but Allow Finger To Be Inserted
Respiratory Emergencies
Respiratory Failure- the inabililty of the respiratory system to maintain adequate oxygenation of the blood, with or without carbon dioxide retention
Respiratory arrest-cessation of respirations
Apnea- cessation of breathing more than 20 seconds or shorter, associated with hypoxemia or bradycardia
Conditions that predisopose to Respiratory Failure
Obstructive lung disease
Restrictive lung disease
Primary inefficient gas transfer
CPR
Resuscitation procedures
Ventilations
Chest compressions
Pharmacology
Nursing Considerations
Observation and monitoring
Family support
Resuscitation procedure
The Child with Respiratory Dysfunction
Chapter 32
Clinical Manifestations
Vary with age
Generalized signs and symptoms and local manifestations different in young children
Fever
Anorexia, vomiting, diarrhea, abdominal pain
Cough, sore throat, nasal blockage or discharge
Respiratory sounds
Size
Diameter of airways
Distance between structures is shorter, allowing organisms to rapidly move down
Short eustachian tubes
General Aspects of
Respiratory Infections
Upper respiratory tract
Nose, pharynx
Lower respiratory tract
Bronchi and bronchioles
Croup syndromes
Infections of epiglottis and larynx
Infectious Agents
Viruses
RSV
Others
Group A β-hemolytic streptococci
Staphylococci
Chlamydia trachomatis, Mycoplasma, pneumococci
Haemophilus influenzae
Otitis Media (OM)
Pathophysiology and etiology
Diagnostics
Therapeutic management
Pharmacologic
Surgical
Nursing considerations
Prevention of recurrence
Anatomic Position of ET in Child and Adult
Croup Syndromes
Characterized by hoarseness, “barking” cough, inspiratory stridor and varying degrees of respiratory distress
Croup syndromes affect larynx, trachea, and bronchi
Epiglottis, laryngitis, LTB, tracheitis
Acute Laryngotracheobronchitis
(LTB)
Most common of the croup syndromes
Generally affects children younger than
5 years
Organisms responsible
RSV, parainfluenza virus, Mycoplasma pneumoniae, influenza A and B
Manifestations of LTB
Inspiratory stridor
Suprasternal retractions
Barking or “seallike” cough
Increasing respiratory distress and hypoxia
Can progress to respiratory acidosis, respiratory failure, and death
Larynx: Normal and Showing Edema of Croup
Acute Epiglottitis
Clinical manifestations
Sore throat, pain, tripod positioning, retractions
Inspiratory stridor, mild hypoxia, distress
Therapeutic management
Potential for respiratory obstruction
Nursing considerations
Prevention: Hib vaccine
Infections of the Lower Airways
Considered the “reactive” portion of the lower respiratory tract
Includes bronchi and bronchioles
Cartilaginous support not fully developed until adolescence
Constriction of airways
Bronchitis
Also called tracheobronchitis
Definitions
Causative agents
Clinical manifestations
Bronchiolitis and RSV
Definitions
RSV (respiratory syncytial virus)
Pathophysiology
Diagnostics
Therapeutic management
Prevention of RSV—prophylaxis
Nursing considerations
Pertussis
(Whooping Cough)
Caused by Bordetella pertussis
In U.S. it occurs most often in children who have not been immunized
Highest incidence in spring and summer
Highly contagious
Risk to young infants
Vaccines
Acute Respiratory Distress Syndrome (ARDS)
Also referred to as adult respiratory distress syndrome
Characterized as respiratory distress and hypoxia within 72 hours after serious injury or surgery in person with previously normal lungs
Asthma
Chronic inflammatory disorder of the airways
Inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, cough
Most common chronic disease in childhood
Results from complex interactions with inflammatory cells and tissues
Asthma
Diagnostic evaluation
Therapeutic management
Nursing considerations
Implementation
Mechanisms of Obstruction in Asthma
Drug Therapy for Asthma
Long-term control meds
Quick relief medications
Metered-dose inhaler (MDI)
Corticosteroids
Cromolyn sodium
Albuterol, metaproterenol, terbutaline
MDI with Spacer
Asthma Severity Classification in Children 5 Years and Older
Step I: mild, intermittent asthma
Step II: mild, persistent asthma
Step III: moderate, persistent asthma
Step IV: severe, persistent asthma
Clinical features of each classification
Status Asthmaticus
Respiratory distress continues despite vigorous therapeutic measures
Emergency treatment—epinephrine
0.01 ml/kg subQ (max dose 0.3 ml)
Concurrent infection in some cases
Therapeutic intervention
Drug Therapy for Asthma
Long-term bronchodilators (Serevent)
Theophylline—monitor serum levels
Leukotriene modifiers
Others
Goals of Asthma Management
Avoid exacerbation
Avoid allergens
Relieve asthmatic episodes promptly
Relieve bronchospasm
Monitor function with peak flowmeter
Self-management of inhalers, devices, and activity regulation
Cystic Fibrosis (CF)
Exocrine gland dysfunction that produces multisystem involvement
Most common lethal genetic illness among white children
Approximately 3% of U.S. white population are symptom-free carriers
CF Incidence in U.S. Live Births
1 in 3300 whites (95% of cases)
1 in 16,000 African-Americans
1 in 32,000 Asians
Cystic Fibrosis
Etiology
Autosomal recessive trait
Inherits defective gene from both parents with an overall incidence of 1:4
Increased Viscosity of Mucous Gland Secretion
Results in mechanical obstruction
Thick inspissated mucoprotein accumulates, dilates, precipitates, coagulates to form concretions in glands and ducts
Respiratory tract and pancreas are predominantly affected
Increased Sweat Electrolytes
Basis of the most reliable diagnostic procedure—sweat chloride test
Sodium and chloride will be two to five times greater than the controls
Respiratory Manifestations
Present in almost all CF patients, but onset/extent is variable
Stagnation of mucus and bacterial colonization result in destruction of lung tissue
Tenacious secretions are difficult to expectorate—obstruct bronchi/bronchioles
Respiratory Manifestations
Decreased O2/CO2 exchange
Results in hypoxia, hypercapnea, acidosis
Compression of the pulmonary blood vessels and progressive lung dysfunction lead to pulmonary hypertension, cor pulmonale, respiratory failure, and death
Infectious Pathogens
Pseudomonas aeruginosa
Burkholderia cepacia
Staphylococcus aureus
Haemophilus influenzae
Escherichia coli
Klebsiella pneumoniae
Respiratory Progression
Gradual progression follows chronic infection
Bronchial epithelium is destroyed
Infection spreads to peribronchial tissues, weakening bronchial walls
Peribronchial fibrosis
Decreased O2/CO2 exchange
GI Tract
Thick secretions block ducts → cystic dilation → degeneration → diffuse fibrosis
Prevents pancreatic enzymes from reaching duodenum
Impaired digestion/absorption of fat → steatorrhea
Impaired digestion/absorption of protein → azotorrhea
GI tract
Endocrine function of pancreas initially stays unchanged
Eventually pancreatic fibrosis occurs; may result in diabetes mellitus
Focal biliary obstruction results in multilobular biliary cirrhosis
Impaired salivation
Clinical Manifestations
Pancreatic enzyme deficiency
Progressive COPD associated with infection
Sweat gland dysfunction
Failure to thrive
Increased weight loss despite increased appetite
Gradual respiratory deterioration
Diagnostic Evaluation
Quantitative sweat chloride test
Chest x-ray
PFT
Stool fat and/or enzyme analysis
Barium enema
Respiratory Management
CPT
Bronchodilator medication
Forced expiration
Aggressive treatment of pulmonary infections
Home IV antibiotic therapy
Aerosolized antibiotics
GI Management
Replacement of pancreatic enzymes
High-protein, high-calorie diet as much as 150% RDA
Intestinal obstruction
Reduction of rectal prolapse
Salt supplementation
Prognosis of CF
Estimated life expectancy for child born with CF in 2003 is 40 to 50 years
Maximize health potential
Nutrition
Prevention/early aggressive treatment of infection
Pulmonary hygiene
Sudden Infant Death Syndrome
Sudden death of an infant under 1 year of age that remains unexplained after a complete postmortem examination
The third leading cause of death in children between the ages of 1 month and 1 year
Etiology
Unknown
Brainstem abnormality in neuroregulation of cardiorespiratory control
Sleep apnea
cosleeping
Nursing Care Management
Emotional support
Genetic Testing
CPR
Questions
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