#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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