Professional Documents
Culture Documents
chapter
Nursing Care of the Child With a
Respiratory Disorder
Key TERMS Learning OBJECTIVES
atelectasis pulse oximetry Upon completion of the chapter the learner will be able to:
atopy rales
clubbing retractions 1. Compare how the anatomy and physiology of the respiratory system in
coryza rhinitis children differs from that of adults.
cyanosis rhinorrhea 2. Identify various factors associated with respiratory illness in infants and
expiration stridor children.
hypoxemia subglottic stenosis 3. Discuss common laboratory and other diagnostic tests useful in the
hypoxia suctioning diagnosis of respiratory conditions.
infiltrate tachypnea 4. Discuss common medications and other treatments used for treatment
inspiration tracheostomy and palliation of respiratory conditions.
laryngitis ventilation 5. Recognize risk factors associated with various respiratory disorders.
oxygenation wheeze
6. Distinguish different respiratory illnesses based on the signs and
pharyngitis work of breathing
pulmonary
symptoms associated with them.
7. Discuss nursing interventions commonly used for respiratory illnesses.
8. Devise an individualized nursing care plan for the child with a
respiratory disorder.
9. Develop patient/family teaching plans for the child with a respiratory
disorder.
10. Describe the psychosocial impact of chronic respiratory disorders on
children.
90
80 Health History
% Oxygen Saturation
(continued)
8 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
Mast-cell stabilizers Administered via inhalation. Maintenance program for For prophylactic use, not to
(cromolyn, Prevent release of asthma and chronic relieve bronchospasm
nedocromil) histamine from sensitized lung disease, pre- during an acute wheez-
mast cells, resulting in exposure treatment ing episode. Can be
decreased frequency for allergens used 10 to 15 minutes
and intensity of allergic prior to exposure to
reactions. allergen, to decrease
reaction to allergen.
Methylxanthines Administered orally or Used late in the course of Monitor drug levels routinely.
(theophylline, intravenously. treatment for moderate Report signs of toxicity
aminophylline) To provide for continuous or severe asthma in immediately: tachy-
airway relaxation. order to achieve long- cardia, nausea, vomiting,
Sustained-release oral term control. Also diarrhea, stomach
preparation can be indicated for apnea of cramps, anorexia,
used to prevent prematurity (see confusion, headache,
nocturnal symptoms. Caffeine). restlessness, flushing,
Requires serum level increased urination,
monitoring. seizures, arrhythmias,
insomnia.
Caffeine Stimulates the respiratory Apnea of prematurity See Methylxanthines.
center
Pulmozyme (dornase Enzyme that hydrolyzes Cystic fibrosis Monitor for dysphonia and
alfa) the DNA in sputum, pharyngitis.
reducing sputum
viscosity.
Synagis (palivizumab) Monoclonal antibody For certain high-risk groups Should be administered
used to prevent serious of children monthly during the RSV
lower respiratory RSV season. Given
disease intramuscularly only.
Nose and Oral Cavity. Inspect the nose and oral cavity. Figure 19.3 Location of retractions.
Note nasal drainage and redness or swelling in the nose.
Note the color of the pharynx, presence of exudates, ton-
sil size and status, and presence of lesions anywhere within Retractions (the inward pulling of soft tissues with
the oral cavity. respiration) can occur in the intercostal, subcostal, sub-
Cough and Other Airway Noises. Note the sound of the sternal, supraclavicular, or suprasternal regions (Fig. 19.3).
cough (is it wet, productive, dry and hacking, tight?). If Document the severity of the retractions: mild, moderate,
noises associated with breathing are present (grunting, or severe. Also note the use of accessory neck muscles.
stridor, or audible wheeze) these should also be noted. Note the presence of paradoxical breathing (lack of simul-
Grunting occurs on expiration and is produced by pre- taneous chest and abdominal rise with the inspiratory
mature glottic closure. It is an attempt to preserve or in- phase; Fig. 19.4). Bobbing of the head with each breath is
crease functional residual capacity. Grunting might occur also a sign of increased respiratory effort.
with alveolar collapse or loss of lung volume, such as in
atelectasis, pneumonia, and pulmonary edema. Stridor,
a high-pitched, readily audible inspiratory noise, is a sign Seesaw (or paradoxical) respirations are very
of upper airway obstruction. Sometimes wheezes can be ineffective for ventilation and oxygenation. The
heard with the naked ear; these are referred to as audible chest falls on inspiration and rises on expiration.
wheezes.
Respiratory Effort. Assess respiratory effort for depth
and quality. Is breathing labored? Infants and children Anxiety and Restlessness. Is the child anxious or restless?
with significant nasal congestion may have tachypnea, Restlessness, irritability, and anxiety result from diffi-
which usually resolves when the nose is cleared of mucus. culty in securing adequate oxygen. These might be very
Mouth breathing also may occur when a large amount early signs of respiratory distress, especially if accompa-
of nasal congestion is present. Increased work of breath- nied by tachypnea. Restlessness might progress to list-
lessness and lethargy if the respiratory dysfunction is not
ing, particularly if associated with restlessness and anx-
corrected (Fig. 19.5).
iety, usually indicates lower respiratory involvement.
Assess for the presence of nasal flaring, retractions, Clubbing. Inspect the fingertips for the presence of
or head bobbing. Nasal flaring can occur early in the clubbing, an enlargement of the terminal phalanx of the
course of respiratory illness and is an effort to inhale finger, resulting in a change in the angle of the nail to the
greater amounts of oxygen. fingertip (Fig. 19.6). Clubbing might occur in children
Fremitus might be decreased in the case of barrel chest, guidelines in determining ongoing treatment. Laboratory
as with cystic fibrosis. Absent fremitus might be noted or non-nursing personnel obtain some of the tests, while
with pneumothorax or atelectasis. the nurse might obtain others. In either instance the nurse
Compare central and peripheral pulses. Note the qual- should be familiar with how the tests are obtained, what
ity of the pulse as well as the rate. With significant respira- they are used for, and normal versus abnormal results.
tory distress, perfusion often becomes compromised. Poor This knowledge will also be necessary when providing
perfusion might be reflected in weaker peripheral pulses patient and family education related to the testing.
(radial, pedal) when compared to central pulses.
Laboratory and Diagnostic Testing Ambient light may interfere with pulse oximetry
Common Laboratory and Diagnostic Tests 19.1 explains readings. When the pulse oximeter probe is
the laboratory and diagnostic tests most commonly used placed on the infants foot or young childs toe,
for a child with a respiratory disorder. The tests can assist covering the probe and foot with a sock may
the physician in diagnosing the disorder and/or be used as help to ensure an accurate measurement.
Allergy skin Suggested allergen is Allergic rhinitis, asthma Close observation for anaphylaxis
testing applied to skin via is necessary. Epinephrine and
scratch, pin or prick. emergency equipment should
A wheal response be readily available. Some
indicates allergy to the children react to the skin test
substance. Carries risk almost immediately; others
of anaphylaxis. (Nursing take several minutes.
note: Antihistamines
must be discontinued
before testing, as they
inhibit the test.)
Arterial blood Invasive method (requires Usually reserved for Hold pressure for several minutes
gases blood sampling) of severe illness, the after a peripheral arterial stick
measuring arterial pH, intubated child, or to avoid bleeding. Radial
partial pressure of suspected carbon arterial sticks are common
oxygen and carbon dioxide retention and can be very painful.
dioxide, and base Note if the child is crying
excess in blood excessively during the blood
draw, as this affects the
carbon dioxide level.
Chest x-ray Radiographic image of Bronchiolitis, pneumonia, Children may be afraid of the
the expanded lungs: tuberculosis, asthma, x-ray equipment. If a parent
can show hyperinflation, cystic fibrosis, or familiar adult can accom-
atelectasis, pneumonia, bronchopulmonary pany the child, often the child
foreign body, pleural dysplasia is less afraid. If the child is
effusion, abnormal unable or unwilling to hold still
heart or lung size for the x-ray, restraint may be
necessary. Restraint should be
limited to the amount of time
needed for the x-ray.
Fluorescent Determines presence of Bronchiolitis, To obtain a nasopharyngeal
antibody respiratory syncytial virus pneumonia specimen instill 1 to 3 mL of
testing (RSV), adenovirus, sterile normal saline into one
influenza, parainfluenza nostril, aspirate the contents
or Chlamydia in using a small sterile bulb
nasopharyngeal syringe, place the contents in
secretions sterile container, and immedi-
ately send them to the lab.
(continued)
12 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
Fluoroscopy Radiographic examination Identification of masses, Requires the child to lay still.
that uses a fluorescent abscesses Equipment can be frightening.
screenreal-time Children may respond to
imaging presence of parent or
familiar adult.
Gastric washings Determines presence of Tuberculosis Nasogastric tube is inserted and
for AFB AFB (acid-fast bacilli) in saline is instilled and suctioned
stomach (children often out of the stomach for the
swallow sputum) specimen.
Peak expiratory Measures the maximum Daily use can indicate It is important to establish the
flow flow of air that can be adequacy of asthma childs personal best by
forcefully exhaled in control. taking twice-daily readings
1 second. Measured in over a 2-week period while
liters per second. well. The average of these is
termed personal best.
Charts based on height and
age are also available to
determine expected peak
expiratory flow.
Pulmonary Measures respiratory flow Asthma, cystic fibrosis, Usually performed by a respi-
function tests and lung volumes chronic lung disease ratory therapist trained to do
the full spectrum of tests.
Spirometry can be obtained
by the trained nurse in the
outpatient setting.
Pulse oximetry Noninvasive method of Can be useful in any Probe must be applied correctly
continuously (or situation in which a to finger, toe, foot, hand, or
intermittently) child is experiencing ear in order for the machine
measuring oxygen respiratory distress to appropriately pick up the
saturation pulse and oxygen saturation.
Rapid flu test Rapid test for detection of Influenza Should be done in first 24 hours
influenza A or B of illness so that medication
administration can begin.
Have the child gargle with sterile
normal saline and then spit
into a sterile container. Send
immediately to the lab.
Rapid strep test Instant test for presence Pharyngitis, tonsillitis Results in 5 to 10 minutes.
of strep A antibody in Negative tests should be
pharyngeal secretions backed up with throat
culture.
RAST (radioaller- Measures minute quantities Asthma (food allergies) Blood test that is usually sent out
gosorbent test) of immunoglobulin E in to a reference laboratory
the blood.
Carries no risk of
anaphylaxis but is not as
sensitive as skin testing.
Sinus x-rays, Radiologic tests that may Sinusitis, recurrent colds X-ray results are usually received
computed show sinus involvement more quickly than CT or MRI
tomography results.
(CT), or
magnetic
resonance
imaging (MRI)
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 13
Sputum culture Bacterial culture of Pneumonia, cystic Must be true sputum, not mucus
invasive organisms in fibrosis, tuberculosis from the mouth or nose. Child
the sputum can deep breathe, cough,
and spit, or specimen may be
obtained via suctioning of the
artificial airway.
Sweat chloride Collection of sweat on Cystic fibrosis May be difficult to obtain sweat
test filter paper after in a young infant
stimulation of skin with
pilocarpine. Measures
concentration of
chloride in the sweat.
Throat culture Bacterial culture (minimum Pharyngitis, tonsillitis Can be obtained on separate
of 24 to 48 hours re- swab at same time as rapid
quired) to determine strep test to decrease trauma
presence of streptococ- to the child (swab both appli-
cus A or other bacteria cators at once). Do not
perform immediately after the
child has had medication or
something to eat or drink.
Tuberculin skin Mantoux test (intradermal Tuberculosis, chronic Must be given intradermally; not
test injection of purified cough a valid test if injected
protein derivative) incorrectly
NURSING DIAGNOSES, GOALS, in planning nursing care for the child with a respiratory
INTERVENTIONS, AND EVALUATION disorder. The nursing care plan should be individualized
Upon completion of a thorough assessment, the nurse based on the patients symptoms and needs; refer to
might identify several nursing diagnoses, including: Chap. 15 for detailed information on pain management.
Additional information will be included later in the chap-
Ineffective airway clearance
ter as it relates to specific disorders.
Ineffective breathing pattern
Impaired gas exchange
Risk for infection Based on your top three nursing diagnoses for
Pain Alexander, describe appropriate nursing interventions.
Risk for fluid volume deficit
Altered nutrition, less than body requirements Oxygen Supplementation
Activity intolerance Oxygen may be delivered to the child by a variety of
Fear methods (Fig. 19.7). Since oxygen administration is con-
Altered family processes sidered a drug, it requires a physicians order, except when
Pain following emergency protocols outlined in a health care
facilitys policies and procedures. Many health care set-
After completing an assessment of Alexander, the tings develop specific guidelines for oxygen administra-
nurse notes the following: lots of clear secretions in the tion that are often coordinated by respiratory therapists,
airway, child appears pale, respiratory rate 68, retrac- yet the nurse still remains responsible for ensuring that
tions, nasal flaring, wheezing, and diminished breath oxygen is administered properly.
sounds. Based on these assessment findings, what would Oxygen sources include wall-mounted systems as well
your top three nursing diagnoses be for Alexander?
as cylinders. The supply of oxygen available from a wall-
mounted source is limitless, but use of a wall-mounted
Nursing goals, interventions, and evaluation for the source restricts the child to the hospital room. Cylinders
child with a respiratory disorder are based on the nursing are portable oxygen tanks; the D-cylinder holds a little less
diagnoses. Nursing Care Plan 19.1 can be used as a guide (text continues on page 000)
14 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
Nursing Diagnosis: Gas exchange, impaired, related to airway plugging, hyperinflation, atelectasis
as evidenced by cyanosis, decreased oxygen saturation, and alterations in arterial blood gases
Outcome identification and evaluation
Gas exchange will be adequate: Pulse oximetry reading on room air is within normal
parameters for age, blood gases within normal limits, absence of cyanosis.
Nursing Diagnosis: Risk for infection related to presence of infectious organisms as evidenced by
fever or presence of virus or bacteria on laboratory screening
Outcome identification and evaluation
Child will exhibit no signs of secondary infection and will not spread infection to others:
symptoms of infection decrease over time; others remain free from infection.
Nursing Diagnosis: Fluid volume deficit, risk for, related to decreased oral intake, insensible losses
via fever, tachypnea, or diaphoresis
Outcome identification and evaluation
Fluid volume will be maintained: Oral mucosa moist and pink, skin turgor elastic, urine
output at least 1 to 2 mL/kg/hr.
(continued)
16 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
Nursing Diagnosis: Nutrition, altered: less than body requirements related to difficulty feeding as
evidenced by poor oral intake, tiring with feeding
Outcome identification and evaluation
Child will maintain adequate nutritional intake: Weight gain or maintenance occurs. Child
consumes adequate diet for age.
Nursing Diagnosis: Fear related to difficulty breathing, unfamiliar personnel, procedures, and envi-
ronment (hospital) as evidenced by clinging, crying, fussing, verbalization, or lack of cooperation
Outcome identification and evaluation
Fear/anxiety will be reduced: decreased episodes of crying or fussing, happy and playful
at times.
than 400 liters of oxygen and the E-cylinder holds about checking the level of oxygen in the offices oxygen tanks
650 liters of oxygen. Cylinders turn on with a metal key each day.
that is kept with the tank. The tank empties relatively
quickly if the child requires a high flow of oxygen, so this Oxygen is highly flammable, so use safety pre-
is not the best oxygen source in an emergency. The cylin- cautions. Post signs (Oxygen in Use); inform the
family to avoid matches, lighters, and flammable
der is useful for the child on low-flow oxygen because it
or volatile materials; and use only facility-
allows mobility. approved equipment.
Respiratory therapists usually maintain the respira-
tory equipment that is found in the emergency room or The efficiency of oxygen delivery systems is affected by
hospital. However, in an outpatient setting the nurse may several variables, including the childs respiratory effort, the
be responsible for maintaining respiratory equipment and liter flow of oxygen delivered, and whether the equipment
A B C
G Figure 19.7 (A) Simple oxygen mask provides about 40% oxygen. (B) The nasal
cannula provides an additional 4% oxygen per 1 L of oxygen flow (i.e., 1 L will
deliver 25% oxygen). (C) The nonrebreather mask provides 80%100% oxygen.
18 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
Simple mask Provides 35% to 60% oxygen Must maintain oxygen flow rate of at least 6 L/minute
with a flow rate of 6 to to maintain inspired oxygen concentration and
10 L/minute. Oxygen delivery prevent rebreathing of carbon dioxide
percentage affected by Mask must fit snugly to be effective but should not be
respiratory rate, inspiratory so tight as to irritate the face.
flow, and adequacy
of mask fit.
Venturi mask Provides 24% to 50% oxygen by Set oxygen flow rate according to percentage of
using a special gauge at oxygen desired as indicated on the gauge/dial.
the base of the mask that As with simple mask, must fit snugly
allows mixing of room air
with oxygen flow
Nasal cannula Provides low oxygen con- Must be used with humidification to prevent drying
centration (22% to 44%) but and irritation of airways
needs patent nasal Can provide very small amounts of oxygen (as low as
passages 25 cc/minute)
Maximum recommended liter flow in children is
4 L/minute.
Children can eat or talk while on oxygen.
Inspired oxygen concentration affected by mouth
breathing
Requires patent nasal passages
Oxygen tent Provides high-humidity Oxygen level drops when tent is opened.
environment with up to Must change linen frequently as it becomes damp
50% oxygen concentration from the humidity
Secure edges of tent with blankets or by tucking
edges under mattress.
Young children may be fearful and resistant.
Mist may interfere with visualization of child inside
tent.
Oxygen hood Provides high concentration Liter flow must be set at 10 to 15 L/minute.
(up to 80% to 90%) for Good method for infant but need to remove
infants only. Allows easy for feeding
access to chest and lower Can and should be humidified
body.
Partial Simple facemask with an Must set liter flow rate at 10 to 12 L/min to prevent
rebreathing oxygen reservoir bag. rebreathing of carbon dioxide
mask Provides 50% to 60% oxygen The reservoir bag does not completely empty when
concentration. child inspires if flow rate is set properly.
Nonrebreathing Simple facemask with valves Must set liter flow rate at 10 to 12 L/min to prevent
mask at the exhalation ports and rebreathing of carbon dioxide
an oxygen reservoir bag The reservoir bag does not completely empty when
with a valve to prevent child inspires if flow rate is set properly.
exhaled air from entering
the reservoir. Provides 95%
oxygen concentration.
20 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
Length of illness Varies, may have year-round 10 days or less Longer than 10 to 14 days
symptoms
Nasal discharge Thin, watery, clear Thick, white, yellow, or Thick, yellow or green
green; can be thin
Nasal congestion Varies Present Present
Sneezing Varies Present Absent
Cough Varies Present Varies
Headache Varies Varies Varies
Fever Absent Varies Varies
Bad breath Absent Absent Varies
to clear the infants nose of secretions. Normal saline individuals known to have a cold. Encourage parents
nasal wash using a bulb syringe to instill the solution is and families to consume a healthy diet and get enough
also helpful for children of all ages with nasal congestion. rest (Torpy, 2003). See Healthy People 2010.
Though normal saline for nasal administration is avail-
able commercially, parents can also make it at home
(Box 19.2). Teaching Guideline 19.1 gives instructions ConsiderTHIS!
Consider
on use of the bulb syringe.
Corey Davis, a 3-year-old, is brought to the clinic by her
Counsel parents about symptoms of complications of
mother. She presents with a runny nose, congestion, and a
the common cold. These include: nonproductive cough. Her mother says, She is miserable.
Prolonged fever What other assessment information would be helpful?
Increased throat pain or enlarged, painful lymph nodes Based on the history and clinical presentation, Corey
Increased or worsening cough, cough lasting longer than is diagnosed with a common cold. What education
10 days, chest pain, difficulty breathing would be helpful for this family? Include ways to
Earache, headache, tooth or sinus pain improve Coreys comfort and ways to prevent the
Unusual irritability or lethargy common cold.
Skin rash
If complications do occur, tell parents to notify the
health care provider for further instruction or reassessment. SINUSITIS
Sinusitis (also called rhinosinusitis) generally refers to a
Preventing the Common Cold
bacterial infection of the paranasal sinuses. The disease
Teaching about ways to prevent the common cold is a
may be either acute or chronic in nature, with the treatment
vital nursing intervention. Explain that frequent hand
approach varying with chronicity. Approximately 5% of
washing helps to decrease the spread of viruses that
upper respiratory infections are complicated with acute
cause the common cold. Teach parents and family to
sinusitis. In young children the maxillary and ethmoid
avoid second-hand smoke as well as crowded places,
sinuses are the main sites of infection. After age 10 years,
especially during the winter. Avoid close contact with
the frontal sinuses may be more commonly involved.
Mucosal swelling, decreased ciliary movement, and thick-
ened nasal discharge all contribute to bacterial invasion
of the nose. Nasal polyps also place the child at risk for
BOX 19.2
bacterial sinusitis. Complications include orbital cellulitis
HOMEMADE SALT WATER NOSE DROPS and intracranial infections such as subdural empyemas.
Mix 8 oz distilled water, a half-teaspoon sea salt, and a Symptoms lasting less than 30 days generally indicate
quarter-teaspoon baking soda. Keeps for 24 hours in acute sinusitis, whereas symptoms persisting longer than
the refrigerator, but should be allowed to come to 4 to 6 weeks usually indicate chronic sinusitis. Sinusitis is
room temperature prior to use. managed with antibiotic treatment. The course of treat-
ment is a minimum of 10 days. The current American
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 21
Hold the infant on your lap or on the bed with head (If using
Place saline)
rubber tipInstill several
in infants drops
nose andof salinepressure
release solution
tilted slightly back. in
onone
the of infants nostrils.
bulb.
(If using
Place saline)
rubber tipInstill several
in infants drops
nose andof salinepressure
release solution Remove the syringe and squeeze bulb over tissue or
in
onone
the of infants nostrils.
bulb. the sink to empty it of secretions.
Compress the sides of the bulb syringe completely. Repeat on alternate nostril if necessary. Using a bulb
Use only a rubber-tipped bulb syringe. syringe prior to bottle-feeding or breastfeeding may
relieve congestion enough to allow the infant to suck
more efficiently.
Clean the bulb syringe thoroughly with warm water
after each use and allow to air dry.
22 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
39.5 C is common. Infants may be mildly toxic in either the rapid diagnostic test or throat culture (described
appearance and irritable and have a cough, coryza, and below) is positive for group A streptococci, penicillin
pharyngitis. Wheezing may occur, as influenza also can is generally prescribed. Appropriate alternative anti-
cause bronchiolitis. An erythematous rash may be pres- biotics include amoxicillin and, for those allergic to
ent, and diarrhea may also occur. Diagnosis may be penicillin, macrolides and cephalosporins (Hayes &
confirmed by a rapid assay test. Williamson, 2001).
Nursing Management
A strep carrier is a child who has a positive
Nursing management of influenza is mainly supportive. throat culture for streptococci when
Symptomatic treatment of cough and fever and main- asymptomatic. Strep carriers are not at
tenance of hydration are the focus of care. Amantadine risk for complications from streptococci as
hydrochloride (Symmetrel) and other newer antiviral are those who are acutely infected with streptococci
drugs can be effective in reducing symptoms associated and are symptomatic.
with influenza if started within the first 24 to 48 hours
of the illness.
Nursing Assessment
Preventing Influenza Infection
Onset of the illness is often quite abrupt. The history may
Yearly vaccination against influenza is recommended include a fever, sore throat and difficulty swallowing,
for high-risk groups. Children who are 6 months or older headache, and abdominal pain, which are quite common.
considered high risk are those who: Inquire about recent incidence of viral or strep throat in
the family, daycare, or school setting.
Have chronic heart or lung conditions
Inspect the pharynx and tonsils, which may demon-
Have sickle cell anemia or other hemoglobinopathy
strate varying degrees of inflammation (Fig. 19.8). Exudate
Are under medical care for diabetes, chronic renal dis-
may be present but is not diagnostic of bacterial infection.
ease, or immune deficiency
Note the presence of petechiae on the palate. Inspect the
Are on long-term aspirin therapy (risk of developing Reye
tongue for a strawberry appearance. Palpate for enlarge-
syndrome after the flu)
ment and tenderness of the anterior cervical nodes. Inspect
Among otherwise healthy children, infants and tod- the skin for the presence of a fine, red, sandpaper-like
dlers are at highest risk for developing severe disease. All rash (called scarlatiniform), particularly on the trunk
healthy children between the ages of 6 and 59 months or abdomen, a common finding with streptococcus A
should also be immunized. Refer to Chapter 9 for more infection.
information on immunizations. The nurse may obtain a throat swab for rapid diag-
nostic testing and throat culture. If both tests are being
obtained, the applicators may be swabbed simultane-
PHARYNGITIS ously to decrease perceived trauma to the child. The
Inflammation of the throat mucosa (pharynx) is referred rapid strep test is a sensitive and reliable measure rarely
to as pharyngitis. A sore throat may accompany nasal
congestion and is often viral in nature. A bacterial sore
throat most often occurs without nasal symptoms. Group
A streptococci account for 15% to 30% of cases, with
the remainder being caused by other viruses or bacteria
(Bisno, 2001).
Complications of group A streptococcal infection
include acute rheumatic fever (see Chapter 20) and acute
glomerulonephritis (see Chapter 22). An additional
complication of streptococcal pharyngitis is peritonsillar
abscess; this may be noted by asymmetric swelling of the
tonsils, shift of the uvula to one side, and palatal edema.
Retropharyngeal abscess may also follow pharyngitis and
is most common in young children (Ebell et al., 2000).
It can progress to the point of airway obstruction and
requires careful evaluation and appropriate treatment.
Viral pharyngitis is usually self-limited and does
not require therapy beyond symptomatic relief. Group A Figure 19.8 Note the red color of the pharynx, as well as
streptococcal pharyngitis requires antibiotic therapy. If redness and significant enlargement of the tonsils.
24 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
resulting in false-positive readings (Farrar-Simpson et al., the midline (kissing tonsils or 4+ in size), the airway may
2005). If the rapid strep test is negative, the second swab become obstructed (see Fig. 19.8). Also, if the adenoids
may be sent for a throat culture. are enlarged, the posterior nares become obstructed. The
child may breathe through the mouth and may snore.
Nursing Management Palpate the anterior cervical nodes for enlargement and
tenderness. Rapid test or culture may be positive for strep-
Nursing management of the child with pharyngitis focuses
tococcus A (Johansson & Mannson, 2003).
on promoting comfort and providing family education.
the lungs for adequacy of breath sounds. Various scales Extensive use of the Hib vaccine since the 1980s has
are available for scoring croup severity, though these are resulted in a significant decrease in the incidence of
of limited value in the clinical assessment and treatment epiglottitis. Epiglottitis usually occurs in children between
of croup (Leung et al., 2004). Croup is usually diagnosed the ages of 2 and 7 years and can be life threatening (Leung
based on history and clinical presentation, but a lateral et al., 2004). Respiratory arrest and death may occur if the
neck x-ray may be obtained to rule out epiglottitis. airway becomes completely occluded. Additional compli-
cations include pneumothorax and pulmonary edema.
Therapeutic management focuses on airway maintenance
The child with fever, a toxic appearance, and and support. Intravenous antibiotic therapy is necessary
increasing respiratory distress despite appropriate
(Tanner et al., 2002). The child will be managed in the
croup treatment may have bacterial tracheitis
(Orenstein, 2004). Notify the physician of these
intensive care unit. Comparison Chart 19.2 gives infor-
findings in a child with croup. mation comparing croup to epiglottitis.
Nursing Management
TEACHING GUIDELINE 19.2
If the childs care is being managed at home, advise parents
about the symptoms of respiratory distress and instruct Home Care of Croup
them to seek treatment if the childs respiratory condition Keep the child quiet and discourage crying.
worsens. Teach parents to expose their child to humidi- Allow the child to sit up (in your arms).
fied air (via a cool mist humidifier or steamy bathroom). Encourage rest and fluid intake.
Though never clinically proven, use of humidified air has If stridor occurs, take the child into a steamy bathroom
long been recommended for alleviating coughing jags and for 10 minutes.
anecdotally reported as helpful. Administer dexametha- Administer medication (corticosteroid) as directed.
sone if ordered or teach parents about home adminis- Watch the child closely. Call the physician if:
tration. Explain to parents that the effects of racemic The child breathes faster, has retractions, or has any
epinephrine last about 2 hours and the child must be other difficulty breathing
observed closely as occasionally a child will worsen again, The nostrils flare or the lips or nails have a bluish tint
requiring another aerosol. Teaching Guideline 19.2 gives The cough or stridor does not improve with exposure
information about home care of croup. to moist air
Restlessness increases or the child is confused
EPIGLOTTITIS The child begins to drool or cannot swallow
Epiglottitis (inflammation and swelling of the epiglottis) Adapted from Knutson, 2004.
is most often caused by Haemophilus influenzae type b.
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 27
BRONCHIOLITIS (RSV)
Bronchiolitis is an acute inflammatory process of the
bronchioles and small bronchi. Nearly always caused by
a viral pathogen, RSV accounts for the majority of cases
of bronchiolitis, with adenovirus, parainfluenza, and
human meta-pneumovirus also being important causative
agents. This discussion will focus on RSV bronchiolitis.
The peak incidence of bronchiolitis is in the winter
and spring, coinciding with RSV season. RSV season
in the United States and Canada generally begins in
September or October and continues through April or
May. Virtually all children will contract RSV infection
within the first few years of life. RSV bronchiolitis occurs
most often in infants and toddlers, with a peak incidence
around 6 months of age. The severity of disease is related
inversely to the age of the child, with the most severe cases Figure 19.9 Hyperinflation with atelectasis
occurring between 1 and 3 months of age (Weisman & is noted upon chest x-ray.
28 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
suction catheter to suction the mouth or pharynx of older Patients with RSV can be safely cohorted. Attention to
infants or children, rinsing the catheter after each suc- hand washing is necessary, as droplets might enter the
tioning. Nasal bulb suctioning may be sufficient to clear eyes, nose, or mouth via the hands.
the airway in some infants, while others will require
nasopharyngeal suctioning with a suction catheter. Nursing Providing Family Education
Procedure 19.1 gives further information. The routine Educate parents to recognize signs of worsening distress.
use of sterile normal saline is not indicated in all children, Tell parents to call their physician or nurse practitioner if
as its use has been demonstrated to result in decreased the breathing is rapid or becomes more difficult or if the
oxygen saturations for up to 2 minutes after suctioning child cannot eat secondary to tachypnea. Children who
is complete (Ridling et al., 2003). Adjust the pressure are less than 1 year of age or who are at higher risk (those
ranges for suctioning infants and children between 60 who were born prematurely or who have chronic heart or
and 100 mm Hg, 40 and 60 mm Hg for premature infants. lung conditions) might have a longer course of illness.
Instruct parents that cough can persist for several days to
Promoting Adequate Gas Exchange weeks after resolution of the disease, but infants usually
Infants and children with bronchiolitis might deteriorate act well otherwise.
quickly as the disease progresses. In the child ill enough to
require oxygen, the risk is even greater. Assessment should Preventing RSV Disease
include work of breathing, respiratory rate, and oxygen sat- Strict adherence to hand-washing policies in daycare
uration. The percentage of inspired oxygen (FiO2) should centers and when exposed to individuals with cold symp-
be adjusted as needed to maintain oxygen saturation within toms is important for all groups. Though generally benign
the desired range. Positioning the infant with the head of in healthy older children, RSV can be devastating in
the bed elevated may also improve gas exchange. Frequent young infants or children with pre-existing risk factors.
assessment is necessary for the hospitalized child with Palivizumab (Synagis) is a monoclonal antibody effec-
bronchiolitis (Cooper et al., 2003; Steiner, 2004). tive in the prevention of severe RSV disease in those who
are most susceptible. It is given as an intramuscular injec-
In the tachypneic infant, slowing of the respiratory tion once a month throughout the RSV season. Though
rate does not necessarily indicate improvement: quite costly, it is covered by most insurance policies and
often, a slower respiratory rate is an indication of Medicaid for those who qualify. It is generally indicated for
tiring, and carbon dioxide retention may soon be use in certain children less than 2 years of age. Qualifying
followed by apnea. factors include:
Prematurity
Reducing Risk for Infection Chronic lung disease (bronchopulmonary dysplasia)
Since RSV is easily spread through contact with droplets, requiring medication or oxygen
inpatients should be isolated according to hospital policy Certain congenital heart diseases
to decrease the risk of nosocomial spread to other patients. Immunocompromise (AAP, 2003)
1. Check to ensure the suction equipment works 5. Apply lubricant to the end of the suction catheter.
properly before starting. 6. If indicated for loosening of secretions, instill sterile
2. After washing your hands, assemble the equipment saline.
needed: 7. Maintaining sterile technique, insert the suction
Appropriate-size sterile suction catheter catheter into the childs nostril or airway.
Sterile gloves Insert only to the point of gagging if inserting via
Supplemental oxygen the nostril.
Sterile water-based lubricant Insert only 0.5 cm further than the length of the
Sterile normal saline if indicated artificial airway.
3. Don sterile gloves, keeping dominant hand sterile 8. Intermittently apply suction for no longer than
and nondominant hand clean. 10 seconds, while twisting and removing the catheter.
4. Preoxygenate the infant or child if indicated. 9. Supplement with oxygen after suctioning.
30 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
More information related to recommendations cessfully managed at home if the work of breathing is not
for Synagis use can be found at http://aappolicy. severe and oxygen saturation is within normal limits.
aappublications.org/cgi/reprint/pediatrics;112/6/1442.pdf. However, hospitalization is required for children with
more severe disease. The child with tachypnea, significant
PNEUMONIA retractions, poor oral intake, or lethargy might require
hospital admission for the administration of supplemen-
Pneumonia is an inflammation of the lung parenchyma. It tal oxygen, intravenous hydration, and antibiotics.
can be caused by a virus, bacteria, mycoplasma, or fungus.
It may also result from aspiration of foreign material into the
lower respiratory tract (aspiration pneumonia). Pneumonia Haemophilus influenzae type B has been
occurs more often in winter and early spring. It is common nearly eliminated as a cause of pneumonia
in the United States and other developed
in children but is seen most frequently in infants and young
countries as a result of universal immunization
toddlers. Viruses are the most common cause of pneumo- with Hib vaccine.
nia in younger children and the least common cause in
older children (Table 19.2). Viral pneumonia is usually
better tolerated in children of all ages. Children with bac- Pathophysiology
terial pneumonia are more apt to present with a toxic
appearance, but rapid recovery generally occurs if appro- Pneumonia occurs as a result of the spread of infectious
priate antibiotic treatment is instituted early. organisms to the lower respiratory tract from either the
upper respiratory tract or the bloodstream. In bacterial
pneumonia, mucus stasis occurs as a result of vascular
Community-acquired pneumonia (CAP) refers to
engorgement. Cellular debris (erythrocytes, neutrophils,
pneumonia in a previously healthy person that is and fibrin) accumulates in the alveolar space. Relative
contracted outside of the hospital setting. CAP is hyperexpansion with air trapping follows. Inflammation
a common cause of lower respiratory infection in of the alveoli results in atelectasis. Atelectasis is defined
North America (Ostapchuk et al., 2004). as a collapsed or airless portion of the lung, so gas exchange
becomes impaired. The inflammatory response further
impairs gas exchange (Nield et al., 2005).
Pneumonia is usually a self-limited disease. A child Viral pneumonia usually results in an inflammatory
who presents with recurrent pneumonia should be eval- reaction limited to the alveolar wall. Aspiration of food,
uated for chronic lung disease such as asthma or cystic fluids, or other substances into the bronchial tree can
fibrosis. Potential complications of pneumonia include result in aspiration pneumonia. Aspiration is the most
bacteremia, pleural effusion, empyema, lung abscess, common cause of recurrent pneumonia in children and
and pneumothorax (Nield et al., 2005). Excluding bac- often occurs as a result of gastroesophageal reflux disease
teremia, these are often treated with thoracentesis and/ (Turcios & Patel, 2003). Secondary bacterial infection
or chest tubes as well as antibiotics if appropriate. often occurs following viral or aspiration pneumonia and
Pneumatoceles (thin-walled cavities developing in the requires antibiotic treatment.
lung) might occur with certain bacterial pneumonias
Nursing Assessment
and usually resolve spontaneously over time.
Therapeutic management of children with less severe For a full description of the assessment phase of the nurs-
disease includes antipyretics, adequate hydration, and ing process, refer to page 00. Assessment findings perti-
close observation. Even bacterial pneumonia can be suc- nent to pneumonia are discussed below.
Health History ping and perihilar infiltrates are the most common
Elicit a description of the present illness and chief com- findings. Patchy areas of consolidation might also be
plaint. Note onset and progression of symptoms. Common present. In older children, lobar consolidation is seen
signs and symptoms reported during the health history more frequently.
include: Sputum culture: possibly useful in determining causative
bacteria in older children and adolescents
Antecedent viral URI
White blood cell count: might be elevated in the case of
Fever
bacterial pneumonia
Cough (note type and whether productive or not)
Increased respiratory rate
History of lethargy, poor feeding, vomiting, or diarrhea
Nursing Management
in infants Nursing diagnoses, goals, and interventions for the child
Chills, headache, dyspnea, chest pain, abdominal pain, with pneumonia are primarily aimed at providing support-
and nausea or vomiting in older children ive care and education about the illness and its treatment.
Prevention of pneumococcal infection is also important.
Explore the childs past and current medical history
Children with more severe disease will require hospitaliza-
for risk factors known to be associated with an increase in
tion. Refer to the Nursing Care Plan on page 00 for nurs-
the severity of pneumonia, such as:
ing diagnoses and related interventions. In addition to
Prematurity the interventions listed in the Nursing Care Plan, the fol-
Malnutrition lowing should be noted.
Passive smoke exposure
Low socioeconomic status Providing Supportive Care
Daycare attendance Ensure adequate hydration and assist in thinning of secre-
Underlying cardiopulmonary, immune, or nervous tions by encouraging oral fluid intake in the child whose
system disease respiratory status is stable. In children with increased
work of breathing, intravenous fluids may be necessary
Physical Examination to maintain hydration. Allow and encourage the child to
Physical examination consists of inspection, auscultation, assume a position of comfort, usually with the head of
percussion, and palpation. the bed elevated to promote aeration of the lungs. If
pain due to coughing or pneumonia itself is severe, admin-
Inspection ister analgesics as prescribed. Provide supplemental
Observe the childs general appearance and color (cen- oxygen to the child with respiratory distress or hypoxia
trally and peripherally). Cyanosis might accompany as needed.
coughing spells. The child with bacterial pneumonia may
appear ill. Assess work of breathing. Children with pneu- Providing Family Education
monia might exhibit substernal, subcostal, or intercostal Educate the family about the importance of adherence
retractions. Tachypnea and nasal flaring may be present. to the prescribed antibiotic regimen. Antibiotics may be
Describe cough and quality of sputum if produced. given intravenously if the child is hospitalized, but upon
discharge or if the child is managed on an outpatient basis,
Auscultation oral antibiotics will be used.
Auscultation of the lungs might reveal wheezes or rales Teach the parents of a child with bacterial pneumo-
in the younger child. Local or diffuse rales may be present nia to expect that following resolution of the acute illness,
in the older child. Document diminished breath sounds. for 1 to 2 weeks, the child might continue to tire easily
and the infant might continue to need small, frequent
Percussion and Palpation feedings. Cough may also persist after the acute recovery
In the older child, percussion might yield local dullness period but should lessen over time.
over a consolidated area. Percussion is much less valuable If the child is diagnosed with viral pneumonia, par-
in the infant or younger child. Tactile fremitus felt upon ents might not understand that their child does not
palpation may be increased with pneumonia. require an antibiotic. Pneumonia is often perceived by the
public as a bacterial infection, so most parents will need
Laboratory and Diagnostic Tests an explanation related to treatment of viral infections. As
Common laboratory and diagnostic studies ordered for
with bacterial pneumonia, the child may experience a
the assessment of pneumonia include:
week or two of weakness or fatigue following resolution of
Pulse oximetry: oxygen saturation might be significantly the acute illness.
decreased or within normal range The young child is at risk for the development of aspi-
Chest x-ray: varies according to patient age and causative ration pneumonia. Parents need to understand that the
agent. In infants and young children, bilateral air trap- child might be at risk for injury related to his or her age and
32 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
Nursing Assessment
TUBERCULOSIS
The illness might begin with a mild URI. Fever devel-
ops, followed by a dry, hacking cough that might become Tuberculosis is a highly contagious disease caused by
productive in older children. The cough might wake the inhalation of droplets of Mycobacterium tuberculosis or
child at night. Auscultation of the lungs might reveal Mycobacterium bovis. Children usually contract the dis-
coarse rales. Respirations remain unlabored. The chest ease from an immediate household member. Annually
about 1,000 U.S. children contract active tuberculosis
disease (Reznik & Ozuah, 2005). Nonwhite children and
children with chronic illness or malnutrition are more
TEACHING GUIDELINE 19.3 susceptible to infection. After exposure to an infected
individual, the incubation period is 2 to 10 weeks. The
Preventing Aspiration inhaled tubercle bacilli multiply in the alveoli and alveo-
Keep toxic substances such as lighter fluid, solvents, lar ducts, forming an inflammatory exudate. The bacilli
and hydrocarbons out of reach of young children. are spread by the bloodstream and lymphatic system to
Toddlers and preschoolers cannot distinguish safe various parts of the body. Though pulmonary tuberculo-
from unsafe fluids due to their developmental stage. sis is the most common, children may also have infection
Avoid oily nose drops and oil-based vitamins or home in other parts of the body, such as the gastrointestinal
remedies to avoid lipid aspiration into the lungs. tract or central nervous system (Starke & Munoz, 2004).
Avoid oral feedings if the infants respiratory rate is 60 See Healthy People 2010.
or greater to minimize the risk of aspiration of the In the case of drug-sensitive tuberculosis, the Amer-
feeding. ican Academy of Pediatrics recommends a 6-month course
Discourage parents from force-feeding in the event of oral therapy. The first two months consist of isoniazid,
of poor oral intake or severe illness to minimize the rifampin, and pyrazinamide given daily. This is followed
risk of aspiration of the feeding. by twice-weekly isoniazid and rifampin; administration
Position infants and ill children on their right side must be observed directly (usually by a public health
after feeding to minimize the possibility of aspirating nurse). In the case of multidrug-resistant tuberculosis,
emesis or regurgitated feeding. ethambutol or streptomycin is given via intramuscular
injection (AAP, 2003).
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 33
HEALTHY PEOPLE 2010 increases and the lung on the affected side is poorly
expanded. Dullness to percussion might be present, as well
Objective Significance as diminished breath sounds and crackles. Fever persists
Reduce tuberculosis. Assess the health history and pallor, anemia, weakness, and weight loss are present.
Increase the proportion of of all infants, children, Diagnosis is confirmed with a positive Mantoux test, posi-
all tuberculosis patients and adolescents for risk tive gastric washings for acid-fast bacillus, and/or a chest
who complete curative factors for tuberculosis x-ray consistent with tuberculosis (Reznik & Ozuah, 2005).
therapy within 12 months. infection.
Increase the proportion of Provide tuberculosis Nursing Management
contacts and other high- screening as recom-
risk persons with latent mended. Hospitalization of children with tuberculosis is necessary
tuberculosis infection who only for the most serious cases. Nursing management is
complete a course of Refer all tuberculosis
aimed at providing supportive care and encouraging
treatment. infections to the local
public health
adherence to the treatment regimen. Most nursing care
department. for childhood tuberculosis is provided in outpatient clin-
ics, schools, or a public health setting. Supportive care
Educate families about
includes ensuring adequate nutrition and adequate rest,
the importance of com-
pleting medication ther-
providing comfort measures such as fever reduction, pre-
apy as prescribed for venting exposure to other infectious diseases, and pre-
active and latent tuber- venting reinfection.
culosis, and the need
for appropriate follow- Providing Care for the Child with Latent
up and retesting for Tuberculosis Infection
tuberculosis infection. Children who test positive for tuberculosis but who do
not have symptoms or radiographic/laboratory evidence
of disease are considered to have latent infection. These
children should be treated with isoniazid for 9 months
Nursing Assessment to prevent progression to active disease. Follow-up and
appropriate monitoring can be achieved via the childs
Routine screening for tuberculosis infection is not rec- primary care provider or local health department.
ommended for low-risk individuals, but children consid-
ered to be at high risk for contracting tuberculosis should Preventing Infection
be screened using the Mantoux test. Children considered Tuberculosis infection is prevented by avoiding contact
to be at high risk are those who: with the tubercle bacillus. Thus, hospitalized children
Are infected with HIV with tuberculosis must be isolated according to hospital
Are incarcerated or institutionalized policy to prevent nosocomial spread of tuberculosis infec-
Have a positive recent history of latent tuberculosis tion. Promotion of natural resistance through nutrition,
infection rest, and avoidance of serious infections does not prevent
Are immigrants from or have a history of travel to infection. Pasteurization of milk has helped to decrease
endemic countries the transmission of Mycobacterium bovis. Administration
Are exposed at home to HIV-infected or homeless per- of bacille Calmette-Gurin (BCG) vaccine can provide
sons, illicit drug users, migrant farm workers, or nurs- incomplete protection against tuberculosis and is not
ing home residents widely used in the United States.
(meaning there is no cause). The majority of cases are include pneumonia or abscess formation, hypoxia, respi-
benign, but in children with bleeding disorders or other ratory failure, and death (Orenstein, 2004).
hematologic concerns, epistaxis should be further inves-
tigated and treated. Nursing Assessment
The infant or young child might present with a history of
The child with recurrent epistaxis or epistaxis that
sudden onset of cough, wheeze, or stridor. Stridor sug-
is difficult to control should be further evaluated gests that the foreign body is lodged in the upper airway.
for underlying bleeding or platelet concerns. Sometimes the onset of respiratory symptoms is much
more gradual. When the item has traveled down one of
the bronchi, then wheezing, rhonchi, and decreased aer-
Nursing Assessment ation can be heard on the affected side. A chest x-ray will
demonstrate the foreign body only if it is radiopaque
Explore the childs history for initiating factors such as local (Fig. 19.10).
inflammation, mucosal drying, or local trauma (usually
nose picking). Inspect the nasal cavity for blood. Nursing Management
The most important nursing intervention related to for-
Nursing Management eign body aspiration is prevention. Anticipatory guidance
The presence of blood often frightens children and their for families with 6-month-olds should include a discus-
parents. The nurse and parents should remain calm. The sion of aspiration avoidance. This information should
child should sit up and lean forward (lying down may be reiterated at each subsequent well-child visit through
allow aspiration of the blood). Apply continuous pressure age 5. Tell parents to avoid letting their child play with toys
to the anterior portion of the nose by pinching it closed. with small parts and to keep coins and other small objects
Encourage the child to breathe through the mouth dur- out of the reach of children. Teach parents not to feed
ing this portion of the treatment. Ice or a cold cloth peanuts and popcorn to their child until he or she is at least
applied to the bridge of the nose may also be helpful. The 3 years old. When children progress to table food, teach
bleeding usually stops within 10 to 15 minutes. Apply parents to chop all foods so that they are small enough
petroleum jelly or water-soluble gel to the nasal mucosa to pass down the trachea should the child neglect to chew
with a cotton-tipped applicator to moisten the mucosa them up thoroughly. Carrots, grapes, and hot dogs should
and prevent recurrence. be cut into small pieces. Harmful liquids should be kept
out of the reach of children.
Items smaller than 1.25 inches (3.2 cm) can plications of RDS include air leak syndrome, bron-
be aspirated easily. A simple way for parents chopulmonary dysplasia, patent ductus arteriosus and
to estimate the safe size of a small item or toy congestive heart failure, intraventricular hemorrhage,
piece is to gauge its size against a standard retinopathy of prematurity, necrotizing enterocolitis, com-
toilet paper roll, which is generally about 1.5 inches in plications resulting from intravenous catheter use (infec-
diameter.
tion, thrombus formation), and developmental delay or
disability (Stoll & Kliegman, 2004).
High-frequency Provide very high respiratory rates (up to May decrease risk of barotrauma
ventilators 1,200 breaths per minute) and very associated with ventilator pressures
(high frequency, low tidal volumes
oscillating, or jet)
Nitric oxide Causes pulmonary vasodilation, helping Safe; no long-term developmental risks
to increase blood flow to alveoli
Liquid ventilation Perfluorocarbon liquid acts as a Virtually no reported physiologic sequelae
surfactant. Provides an effective
medium for gas exchange and
increases pulmonary function.
Extracorporeal Blood is removed from body via catheter, Labor-intensive. Risk of bleeding is great.
membrane warmed and oxygenated in the
oxygenation ECMO machine, and then returned
(ECMO) to infant.
36 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
smoke inhalation, or near-drowning. Acute onset of res- soothing the childs fears. As the disease worsens and pro-
piratory distress and hypoxemia occur within 72 hours gresses, especially when ventilatory support is required,
of the insult in infants and children with previously psychological support of the family as well as education
healthy lungs. The alveolarcapillary membrane becomes about the intensive care unit procedures will be especially
more permeable and pulmonary edema develops. Hyaline important.
membrane formation over the alveolar surfaces and
decreased surfactant production cause lung stiffness. PNEUMOTHORAX
Mucosal swelling and cellular debris lead to atelectasis. Gas
diffusion is impaired significantly. ARDS can progress to A collection of air in the pleural space is called a pneu-
respiratory failure and death, though some individuals mothorax. It can occur spontaneously in an otherwise
recover completely or have residual lung disease. healthy child, or as a result of chronic lung disease, car-
Medical treatment is aimed at improving oxygena- diopulmonary resuscitation, surgery, or trauma. Trapped
tion and ventilation. Mechanical ventilation is used air consumes space within the pleural cavity, and the
affected lung suffers at least partial collapse. Needle aspi-
with special attention to lung volumes and positive end-
ration and/or placement of a chest tube is used to evacuate
expiratory pressure (PEEP). Newer treatment modalities
the air from the chest. Some small pneumothoraces resolve
show promise for improving outcomes of ARDS.
independently, without intervention (Cunnington, 2002).
Nursing Assessment Nursing Assessment
Tachycardia and tachypnea occur over the first few hours Primary pneumothorax (spontaneous) occurs most often
of the illness. Significantly increased work of breathing in adolescence. The infant or child with a pneumothorax
with nasal flaring and retractions develops. Auscultate might have a sudden or gradual onset of symptoms.
for breath sounds, which might range from normal to Chest pain might be present as well as signs of respiratory
high-pitched crackles throughout the lung fields. Hypox- distress such as tachypnea, retractions, nasal flaring, or
emia develops. Bilateral infiltrates can be seen on a grunting. Assess potential risk factors for acquiring a
chest x-ray. pneumothorax, including chest trauma or surgery, intu-
bation and mechanical ventilation, or a history of chronic
Nursing Management lung disease such as cystic fibrosis. Inspect the child for
Nursing care of the child with ARDS is mainly supportive a pale or cyanotic appearance. Auscultate for increased
and occurs in the intensive care unit. Closely monitor res- heart rate (tachycardia) and absent or diminished breath
piratory and cardiovascular status. Comfort measures such sounds on the affected side. The x-ray reveals air within
as hygiene and positioning as well as pain and anxiety the thoracic cavity (Fig. 19.11).
management, maintenance of nutrition, and prevention of
Nursing Management
infection are also key nursing interventions. The acute
phase of worsening respiratory distress can be frightening The child with a pneumothorax requires frequent respira-
for a child of any age, and the nurse can be instrumental in tory assessments. Pulse oximetry might be used as an
Tear in
tracheobronchial
tree
Air in
pleural space
Chest tube
A B
Figure 19.11 Pneumothorax.
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 37
adjunct, but clinical evaluation of respiratory status is most cockroach antigens, and molds. Seasonal allergic rhinitis
useful. In some cases, administration of 100% oxygen has- is caused by elevations in outdoor levels of allergens. It is
tens the reabsorption of air, but it is generally used only for typically caused by certain pollens, trees, weeds, fungi,
a few hours. If a chest tube connected to a water seal or and molds. Complications from allergic rhinitis include
suction is present, provide care of the drainage apparatus exacerbation of asthma symptoms, recurrent sinusitis and
as appropriate (Fig. 19.12). A pair of hemostats should be otitis media, and dental malocclusion.
kept at the bedside to clamp the tube should it become
dislodged from the drainage container. The dressing Pathophysiology
around the chest tube is occlusive and is not routinely
Allergic rhinitis is an intermittent or persistent inflamma-
changed. If the tube becomes dislodged from the childs
tory state that is mediated by immunoglobulin E (IgE).
chest, apply Vaseline gauze and an occlusive dressing,
In response to contact with an airborne allergen protein,
immediately perform appropriate respiratory assessment,
the nasal mucosa mounts an immune response. The anti-
and notify the physician.
gen (from the allergen) binds to a specific IgE on the
surface of mast cells, releasing the chemical mediators
Chronic Diseases of histamine and leukotrienes. The release of mediators
Chronic respiratory disorders include allergic rhinitis, results in acute tissue edema and mucous production
asthma, chronic lung disease (bronchopulmonary dys- (Banasiak & Meadows-Oliver, 2005). Late-phase medi-
plasia), cystic fibrosis, and apnea. ators are released and more inflammation results. IgE
binds to receptors on the surfaces of mast cells and
basophils, creating the sensitization memory that causes
ALLERGIC RHINITIS the reaction with subsequent allergen exposures. Allergen
Allergic rhinitis is a common chronic condition in child- exposure then results in mast cell degranulation and release
hood, affecting up to 40% of children (Hagemann, 2005). of histamine and other chemotactic factors. Histamine and
Allergic rhinitis is associated with atopic dermatitis and other factors cause nasal vasodilation, watery rhinorrhea,
asthma, with as many as 80% of asthmatic children also and nasal congestion. Irritation of local nerve endings by
suffering from allergic rhinitis (Corren, 2000). Perennial histamine produces pruritus and sneezing (Hagemann,
allergic rhinitis occurs year-round and is associated with 2005). Treatment of allergic rhinitis is aimed at decreas-
indoor environments. Allergens commonly implicated in ing response to these allergic mediators as well as treat-
perennial allergic rhinitis include dust mites, pet dander, ing inflammation.
Visceral pleura
Parietal Lung
pleura
Drainage
collection
chambers 250
mm
Water seal
2 cm
B
Figure 19.12 The chest tube is connected to suction or water seal via a drainage container.
38 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
Nursing Assessment
For a full description of the assessment phase of the nurs-
ing process, refer to page 00. Assessment findings perti-
nent to allergic rhinitis are discussed below.
Health History
Elicit a description of the present illness and chief com-
plaint. Common signs and symptoms reported during
the health history might include:
Mild, intermittent to chronic nasal stuffiness
Thin, runny nasal discharge
Sneezing
Itching of nose, eyes, palate
Mouth breathing and snoring
Determine the seasonality of symptoms. Are they
perennial (year-round) or do they occur during certain
seasons? What types of medications or other treatments
have been used, and what was the childs response?
Explore the history for the presence of risk factors
such as:
Figure 19.13 Allergic shiners beneath
Family history of atopic disease (asthma, allergic rhinitis, the eyes and allergic salute across
or atopic dermatitis) the nose.
Known allergy to dust mites, pet dander, cockroach anti-
gens, pollens, or molds
Early childhood exposure to indoor allergens
tic studies ordered for the assessment of allergic rhinitis
Early introduction to foods or formula in infancy
may include:
Exposure to tobacco smoke
Environmental air pollution Nasal smear (positive for eosinophilia)
Recurrent viral infections Positive allergy skin test
Nonwhite race and higher socioeconomic status have Positive RAST
also been noted as risk factors (Hagemann, 2005). To distinguish between the causes of nasal conges-
tion, refer to Comparison Chart 19.1 on page 00.
Physical Examination
Physical examination of the child with allergic rhinitis
includes inspection, observation, and auscultation.
Nursing Management
In addition to the nursing diagnoses and related inter-
Inspection and Observation ventions discussed in the Nursing Care Plan for disorders
Observe the childs facies for red-rimmed eyes or tearing, of the nose, mouth, and throat, interventions common to
mild eyelid edema, allergic shiners (bluish or grayish cast allergic rhinitis follow.
beneath the eyes), and allergic salute (a transverse nasal
crease between the lower and middle thirds of the nose that Maintaining Patent Airway
results from repeated nose rubbing) (Fig. 19.13). Inspect The continual nasal obstruction that occurs with aller-
the nasal cavity. The turbinates may be swollen and gray/
gic rhinitis can be very problematic for some children.
blue in color. Clear mucoid nasal drainage may be
Performing nasal washes with normal saline may keep the
observed. Inspect the skin for rash. Listen for nasal phona-
nasal mucus from becoming thickened. Thickened, immo-
tion with speech.
bile secretions often lead to a secondary bacterial infection.
Auscultation The nasal wash also decongests the nose, allowing for
Auscultate the lungs for adequate aeration and clarity of improved nasal airflow. Anti-inflammatory (corticosteroid)
breath sounds. In the child who also has asthma, exacer- nasal sprays can help to decrease the inflammatory
bation with wheezing often occurs with allergic rhinitis. response to allergens. A mast cell stabilizing nasal spray
such as cromolyn sodium may decrease the intensity and
Laboratory and Diagnostic Tests frequency of allergic responses. Oral antihistamines are
The initial diagnosis is often made based on the history now available in once-daily dosing, providing conve-
and clinical findings. Common laboratory and diagnos- nience for the family. Some children may benefit from a
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 39
combined antihistamine/nasal decongestant if nasal are available from a number of vendors, such as www.
congestion is significant. Leukotriene modifiers such as onlineallergyrelief.com.
montelukast may also be beneficial for some children
(Banasiak & Meadows-Oliver, 2005).
ASTHMA
Providing Family Education Asthma is a chronic inflammatory airway disorder charac-
One of the most important tools in the treatment of terized by airway hyperresponsiveness, airway edema, and
allergic rhinitis is learning to avoid known allergens. mucus production. Airway obstruction resulting from
Teaching Guideline 19.4 gives information on educat- asthma might be partially or completely reversed. Severity
ing families about avoidance of allergens. Children may ranges from long periods of control with infrequent acute
be referred to a specialist for allergen desensitization exacerbations in some children to the presence of persis-
(allergy shots). Products helpful with control of allergies tent daily symptoms in others (Kieckhefer & Ratcliffe,
2004). It is the most common chronic illness of childhood
and affects about 9 million American children (Kumar
et al., 2005). A small percentage of children with asthma
account for a large percentage of health care use and
TEACHING GUIDELINE 19.4 expense (Wakefield et al., 2005). Asthma accounts for
Controlling Exposure to Allergens about 12 million lost school days per year and a significant
number of lost workdays on the part of parents (Lara et al.,
Tobacco 2002). The incidence and severity of asthma are increas-
Avoid all exposure to tobacco smoke (this includes ing; this might be attributed to increased urbanization,
self-smoking). increased air pollution, and more accurate diagnosis.
If parents cannot quit, they must not smoke inside the Severity ranges from symptoms associated only with
home or car. vigorous activity (exercise-induced bronchospasm) to
daily symptoms that interfere with quality of life. Though
Dust Mites uncommon, childhood death related to asthma is also on
Use pillow and mattress covers. the rise worldwide. Air pollution, allergens, family his-
Wash sheets, pillowcases, and comforters once a week tory, and viral infections might all play a role in asthma.
in 130 degree F water. Many children with asthma also have gastroesophageal
Use blinds rather than curtains in bedroom. disease, though the relationship between the two diseases
Remove stuffed animals from bedroom. is not clearly understood.
Reduce indoor humidity to <50%. Complications of asthma include chronic airway
Remove carpet from bedroom. remodeling, status asthmaticus, and respiratory failure.
Clean solid surface floors with wet mop each week. Children with asthma are also more susceptible to serious
Pet Dander
bacterial and viral respiratory infections.
Current goals of medical therapy are avoidance of
Remove pets from home permanently. asthma triggers and reduction or control of inflammatory
If unable to remove them, keep them out of bedroom episodes. Current recommendations by the National
and off carpet and upholstered furniture. Asthma Education and Prevention Program suggest a
Cockroaches stepwise approach to management as well as avoidance of
allergens. The stepwise approach involves increasing treat-
Keep kitchen very clean.
ment as the childs condition worsens, then backing off
Avoiding leaving out food or drinks.
treatment as he or she improves (Table 19.4). Leukotriene
Use pesticides if necessary, but ensure that the asth-
modifiers have been found to be effective in the short-term
matic child is not inside the home when it is sprayed.
management of chronic asthma (Berkhof et al., 2003).
Indoor Molds Long-term prevention usually involves inhaled steroids.
Repair water leaks. Bronchodilators may be used in the acute treatment of
Use dehumidifier to keep basement dry. bronchoconstriction or in the long-acting form to pre-
Reduce indoor humidity to <50%. vent bronchospasm. Exercise-induced bronchospasm may
occur in any child with asthma or as the only symptom in
Outdoor Molds, Pollen, and Air Pollution the child with mild intermittent asthma. Most children
Avoid going outdoors when mold and pollen counts may avoid exercise-induced bronchospasm by using a
are high. longer warm-up period prior to vigorous exercise and, if
Avoid outdoor activity when pollution levels are high. necessary, inhaling a short-acting bronchodilator just prior
to exercise. See Healthy People 2010.
Table 19.4 Asthma Severity Classification and Treatment Approach
Classification Lung
& Referral Symptoms Function Long-Term Control Quick Relief
HEALTHY PEOPLE 2010 function changes, and airway smooth muscle responsive-
ness increases (Kiecheter & Ratcliffe, 2004). As a result,
Objective Significance acute bronchoconstriction, airway edema, and mucus
Reduce asthma deaths, Provide appropriate plugging occur (Fig. 19.14).
hospitalizations for education and triage to In most children, this process is considered reversible
asthma, and hospital families of children with and until recently it was not considered to have long-
emergency department asthma, particularly standing effects on lung function. Current research and
visits for asthma. when the child is experi- scientific thought, however, recognize the concept of air-
encing symptoms way remodeling. Airway remodeling occurs as a result of
or a decreased peak chronic inflammation of the airway. Following the acute
flow rate. response to a trigger, continued allergen response results
in a chronic phase. During this phase, the epithelial cells
are denuded and the influx of inflammatory cells into the
airway continues. This results in structural changes of the
Currently many manufacturers use chlorofluoro- airway that are irreversible, and further loss of pulmonary
carbon (CFC) as the propellant in metered-
function might occur (Kiecheter & Ratcliffe, 2004).
dose inhalers. In 2005, the U.S. Food and Drug
Administration announced that these types of
inhaler would be phased out of the market by the end of Nursing Assessment
2008. Environmentally friendly formulations of hydrofluo-
For a full description of the assessment phase of the nurs-
roalkane (HFA) will be used in all metered-dose inhalers by
that time (Bederka, 2006).
ing process, refer to page 00. Assessment findings pertinent
to asthma are discussed below.
Health History
Pathophysiology Elicit a description of the present illness and chief com-
plaint. Common signs and symptoms reported during the
In asthma, the inflammatory process contributes to in-
health history might include:
creased airway activity. Thus, control or prevention of
inflammation is the core of asthma management. Asthma Cough, particularly at night: hacking type of cough that
results from a complex variety of responses in relation to a is initially nonproductive, becoming productive of frothy
trigger. When the process begins, mast cells, T lympho- sputum
cytes, macrophages, and epithelial cells are involved in the Difficulty breathing: shortness of breath, chest tightness
release of inflammatory mediators. Eosinophils and neu- or pain, dyspnea with exercise
trophils migrate to the airway, causing injury. Chemical Wheezing
mediators such as leukotrienes, bradykinin, histamine, and
Explore the childs current and past medical history
platelet-activating factor also contribute to the inflamma-
for risk factors such as:
tory response. The presence of leukotrienes contributes
to prolonged airway constriction (Banasiak & Meadows- History of allergic rhinitis or atopic dermatitis
Oliver, 2005). Autonomic neural control of airway tone is Family history of atopy (asthma, allergic rhinitis, atopic
affected, airway mucus secretion is increased, mucociliary dermatitis)
Recurrent episodes diagnosed as wheezing, bronchiolitis, way and effective breathing pattern as well as promoting
or bronchitis adequate oxygenation and ventilation (gas exchange).
Known allergies Refer to the Nursing Care Plan on page 00. Additional AQ7
Seasonal response to environmental pollen considerations are reviewed below.
Tobacco smoke exposure (passive or self-smoking)
Poverty Educating the Child and Family
Asthma is a chronic illness and needs to be understood as
Physical Examination such. Figure 19.15 displays the Kids with Asthma Bill
Physical examination of the child with asthma includes of Rights developed by the American Lung Association.
inspection, auscultation, and percussion. Teach families of children with asthma, and the children
themselves, how to care for the disease. Symptom-free
Inspection periods (often very long) are interspersed with episodes of
Observe the patients general appearance and color. exacerbation. Parents and children often do not under-
During mild exacerbations, the childs color might remain stand the importance of maintenance medications for
pink, but as the child worsens, cyanosis might result. Work long-term control. They may view the episodes of exacer-
of breathing is variable. Some children present with mild bation (sometimes requiring hospitalization or emergency
retractions, while others demonstrate significant accessory room visits) as an acute illness and are simply relieved when
muscle use and eventually head-bobbing if not effectively they are over. Frequently during the periods between
treated. The child may appear anxious and fearful or be acute episodes, children are viewed as disease-free and
lethargic and irritable. An audible wheeze might be pres- long-term maintenance schedules are abandoned. The
ent. Children with persistent severe asthma may have a prolonged inflammatory process occurring in the absence
barrel chest and routinely demonstrate mildly increased of symptoms, primarily in children with moderate to
work of breathing. severe asthma, can lead to airway remodeling and even-
tual irreversible disease.
Auscultation and Percussion To provide appropriate education to the child and
A thorough assessment of lung fields is necessary. family, determine the severity of the asthma as outlined
Wheezing is the hallmark of airway obstruction and might in the NAEPP Expert Panel Report: Guidelines for the
vary throughout the lung fields. Coarseness might also be Diagnosis and Management of Asthma (Kumar et al.,
present. Assess the adequacy of aeration. Breath sounds 2005). Stress the concept of maintenance medications for
might be diminished in the bases or throughout. A quiet the prevention of future serious disease in addition to con-
chest in an asthmatic child can be an ominous sign. With trolling or preventing current symptoms.
severe airway obstruction, air movement can be so poor Educate families and children on the appropriate use
that wheezes might not be heard upon auscultation. of nebulizers, metered-dose inhalers, spacers, dry-powder
Percussion may yield hyperresonance. inhalers, and Diskus, as well as the purposes, functions,
and side effects of the medications they deliver. Require
Laboratory and Diagnostic Tests return demonstration of equipment use to ensure that
Laboratory and diagnostic studies commonly ordered for children and families can use the equipment properly
the assessment of asthma include: (Teaching Guideline 19.5).
Pulse oximetry: oxygen saturation may be significantly
The NAEPP recommends use of a spacer or holding
decreased or normal during a mild exacerbation
chamber with metered-dose inhalers to increase
Chest x-ray: usually reveals hyperinflation the bioavailability of medication in the lungs.
Blood gases: might show carbon dioxide retention and
hypoxemia
Each child should have a management plan in place
Pulmonary function tests (PFTs): can be very useful in
to determine when to step up or step down treatment.
determining the degree of disease but are not useful dur-
The recommendations for treatment based on severity of
ing an acute attack. Children as young as 5 or 6 years
asthma are listed in Table 19.4. Figure 19.16 provides an
might be able to comply with spirometry.
example of a written format that may be helpful to fami-
Peak expiratory flow rate (PEFR): is decreased during
lies in the management of asthma. This written action
an exacerbation
plan should also be kept on file at the childs school, and
Allergy testing: skin test or RAST can determine aller-
relief medication should be available to the child at all
gic triggers for the asthmatic child
times. Children who experience exercise-induced bron-
chospasm may still participate in physical education or
Nursing Management athletics but may need to be allowed to use their medi-
Initial nursing management of the child with an acute cine before the activity.
exacerbation of asthma is aimed at restoring a clear air- (text continues on page 000)
42
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 43
Nebulizer
Plug in the Add the medication
nebulizer and to the medicine cup.
connect the air
compressor
tubing.
Metered-Dose Inhaler
Shake the Attach the inhaler
inhaler and to the spacer or
take off the cap. holding chamber.
Breathe out
completely.
Diskus
Hold the Push the lever
Diskus in a until it clicks
horizontal (the dose is
position in one now loaded).
hand and push Breathe out fully.
the thumbgrip
with the thumb
of your other
hand away
from you until
mouthpiece
is exposed.
(continued)
46 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
Turbuhaler
Hold the Then twist it to the
Turbuhaler left until you hear
upright. Load it click.
the dose by
Breathe out fully.
twisting the
brown grip fully
to the right.
47
48 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
*The National Asthma Education and Prevention Program recommended the traffic light
approach for educating individuals on PEFRs and management plans.
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 49
Defect in the
CFTR Gene
Affects Pathophysiology Clinical Manifestations
Auscultation Palpation
Auscultation may reveal a variety of adventitious breath Palpation might yield a finding of asymmetric chest
sounds. Fine or coarse crackles and scattered or localized excursion if atelectasis is present. Tactile fremitus may
wheezing might be present. With progressive obstructive be decreased over areas of atelectasis. Note if tenderness
pulmonary involvement, breath sounds might be dimin- is present over the liver (might be an early sign of cor
ished. Tachycardia might be present. Note the presence pulmonale).
of a gallop (might occur with cor pulmonale). Note the
adequacy of bowel sounds. Laboratory and Diagnostic Tests
Common laboratory and diagnostic studies ordered for
Percussion the diagnosis and assessment of cystic fibrosis include:
Percussion over the lung fields usually yields hyperreso- Sweat chloride test: considered suspicious if the level of
nance due to air trapping. Diaphragmatic excursion might chloride in collected sweat is above 50 mEq/L and diag-
be decreased. Percussion of the abdomen might reveal nostic if the level is above 60 mEq/L (Fig. 19.18)
dullness over an enlarged liver or mass related to intestinal Pulse oximetry: oxygen saturation might be decreased,
obstruction. particularly during a pulmonary exacerbation
52 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
(continued)
54 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
POSITION #2
UPPER LOBES, Posterior segments
POSITION #3
UPPER LOBES, Anterior segments
POSITION #4 POSITION #5
LINGULA MIDDLE LOBE
POSITION #6 POSITION #7
LOWER LOBES, Anterior basal segments LOWER LOBES, Posterior basal segments
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 55
3. Place the ball of the hand on the lung segment, keep- 4. Encourage the child to deep breathe and cough.
ing the arm and shoulder straight. Vibrate by tensing
and relaxing your arms during the childs exhalation. 5. Change drainage positions and repeat percussion
Vibrate each lung segment for at least five exhalations. and vibration.
In infants, breastfeeding should be continued with Starting at the time of diagnosis, families often
enzyme administration. Some infants will require fortifi- demonstrate significant stress as the severity of the diag-
cation of breast milk or supplementation with high-calorie nosis and the significance of disease chronicity become
formulas. Commercially available infant formulas can real for them. The family should be involved in the childs
continue to be used for the formula-fed infant and can care from the time of diagnosis, whether in the outpatient
be mixed to provide a larger amount of calories if neces- setting or in the hospital. Ongoing education about the
sary. Supplementation with vitamins A, D, E, and K is illness and its treatments is necessary. Once the initial
necessary. Administer gavage feedings or total parenteral shock of diagnosis has passed and the family has adjusted
nutrition as prescribed to provide for adequate growth. to initial care, the family usually learns how to manage the
requirements of care. Powerlessness gives way to adapta-
Promoting Family Coping tion. As family members become more comfortable with
Cystic fibrosis is a serious chronic illness that requires inter- their understanding of the illness and the required treat-
vention on a daily basis. It can be hard to maintain a sched- ments, they will eventually become the experts on the
ule that requires pulmonary hygiene several times daily as childs care. It is important for the nurse to recognize and
well as close attention to appropriate diet and enzyme sup- respect the familys changing needs over time.
plementation. Adjusting to the demands that the illness Providing daily intense care can be tiring, and non-
places on the child and family is difficult. Continual on- compliance on the part of the family or child might occur
going adjustments within the family must occur. Children as a result of this fatigue. Overvigilance may also occur as
are frequently hospitalized, and this may place an addi- a result of the need for control over the difficult situation
tional strain on the family and its finances. Children with as well as a desire to protect the child. Families welcome
cystic fibrosis may express fear or feelings of isolation, and support and encouragement. Most families will eventu-
siblings may be worried or jealous (Carpenter & Narsavage, ally progress past the stages of fear, guilt, and powerless-
2004). The family should be encouraged to lead a normal ness. They move beyond those feelings to a way of living
life through involvement in activities and school attendance that is different than what they anticipated but is some-
during periods of wellness. thing that they can manage.
Refer parents to a local support group for families
of children with cystic fibrosis. The Cystic Fibrosis Foun-
Massage therapy performed by the parent, dation has chapters throughout the United States and
nurse, or licensed massage therapist may help to can be accessed at www.cff.org. Additional resources can
decrease anxiety in the child with cystic fibrosis. It be found at www.cysticfibrosis.com, www.cfri.org, and
may have the added benefit of improving respi- www.cfww.org.
ratory status, but it does not replace chest physiotherapy (Huth Parents of children with a terminal illness might face
et al., 2005). the death of their child at an earlier age than expected.
56 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
Nursing Management breathing, and increases patient comfort. In some cases the
tracheostomy facilitates mechanical ventilation weaning. It
When an infant is noted to be apneic, gently stimulate may be permanent or temporary depending on the condi-
him or her to take a breath again. If gentle stimulation is tion that leads to the tracheostomy. The tracheostomy tube
unsuccessful, then rescue breathing or bag-valve-mask varies in size and type depending on the childs airway
ventilation must be started. size and health and the length of time the child will require
To avoid apnea in the newborn, maintain a neutral the tracheostomy. Silastic tracheostomy tubes are soft and
thermal environment. Avoid excessive vagal stimulation flexible; they are available with a single lumen or may have
and taking rectal temperatures (the vagal response can an outer and inner lumen. Both types have an obturator
cause bradycardia, resulting in apnea). Administer caffeine (the guide used during tube changes). Typically, the tubes
or theophylline if prescribed and teach families about the with inner cannulas are used with older children and in
use of these medications. children with increased mucus production. Cuffed tra-
Infants with recurrent apnea or ALTE may be dis- cheostomy tubes are generally used in older children also.
charged on a home apnea monitor (Fig. 19.19). Provide The cuff is used to prevent air from leaking around the
education on use of the monitor, guidance for when to tube. The funnel-shaped airway in younger children acts a
notify the physician or monitor service about alarms, and physiological cuff and prevents air leak. Figure 19.20 shows
training in infant CPR. The monitor is usually discontin- various types of tracheostomy tubes.
ued after 3 months without a significant event of apnea Complications immediately postoperatively include
or bradycardia. In some ways the monitor gives parents hemorrhage, air entry, pulmonary edema, anatomic dam-
peace of mind, but in others it can make them more ner- age, and respiratory arrest. At any point in time the tra-
vous about the well-being of their child. Also, the alarm cheostomy tube may become occluded and ventilation
on home monitors is extremely loud and parents often go compromised. Complications of chronic tracheostomy
for months with inadequate sleep. Providing appropriate include infection, cellulitis, and formation of granulation
education to the parents about the nature of the childs tissue around the insertion site (Russell, 2005).
disorder as well as action to take in the event of apnea
may give the family a sense of mastery over the situation, Nursing Assessment
thus decreasing their level of anxiety. Refer families to When obtaining the history for a child with a tracheostomy,
local area support groups such as those offered by Parent note the reason for the tracheostomy, as well as the size and
to Parent and Parents Helping Parents. type of tracheostomy tube. Inspect the site. The stoma
should appear pink and without bleeding or drainage. The
Tracheostomy tube itself should be clean and free from secretions. The
tracheostomy ties should fit securely, allowing one finger to
A tracheostomy is an artificial opening in the airway; slide beneath the ties (Fig. 19.21). Inspect the skin under
usually a plastic tracheostomy tube is in place to form a the ties for rash or redness. Observe work of breathing.
patent airway. Tracheostomies are performed to relieve air- When caring for the infant or child with a tra-
way obstruction, such as with subglottic stenosis (nar- cheostomy, whether in the intensive care unit, the patient
rowing of the airway sometimes resulting from long-term floor, or the home, a thorough respiratory assessment
intubation). They are also used for pulmonary toilet and in is necessary. Note presence of secretions and their color,
the child who requires chronic mechanical ventilation. The thickness, and amount. Auscultate for breath sounds,
tracheostomy facilitates secretion removal, reduces work of which should be clear and equal throughout all lung
fields. Pulse oximetry may also be measured. When infec-
tion is suspected or secretions are discolored or have
a foul odor, a sputum culture may be obtained.
1. Gather the necessary equipment: 4. Cleanse around the tracheostomy site with pre-
Cleaning solution scribed solution (half-strength hydrogen peroxide
or acetic acid, normal saline or soap and water if at
Gloves
home) and cotton-tipped applicators working from
Precut gauze pad just around the tracheostomy tube outward.
Cotton-tipped applicators 5. Rinse with sterile water and cotton-tipped applicator
Clean tracheostomy ties in similar fashion.
Scissors 6. Place the precut sterile gauze under the tracheostomy
Extra tracheostomy tube in case of accidental tube.
dislodgement 7. With the assistant holding the tube in place, cut the
2. Position the infant/child supine with a blanket or ties and remove from the tube.
towel roll to extend the neck. 8. Attach the clean ties to the tube and tie or secure in
3. Open all packaging and cut tracheostomy ties to place with Velcro.
appropriate length if necessary.
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62 Unit 4 NURSING CARE OF THE CHILD WITH A HEALTH DISORDER
Chapter
ChapterWORKSHEET
MULTIPLE CHOICE QUESTIONS 5. Which is the most appropriate treatment for epistaxis?
1. A 5-month-old infant with RSV bronchiolitis is in a. With the child lying down and breathing through
respiratory distress. The baby has copious secretions, the mouth, apply pressure to the bridge of the nose.
increased work of breathing, cyanosis, and a respira- b. With the child lying down and breathing through
tory rate of 78. What is the most appropriate initial the mouth, pinch the lower third of the nose closed.
nursing intervention? c. With the child sitting up and leaning forward,
a. Attempt to calm the infant by placing him in his apply pressure to the bridge of the nose.
mothers lap and offering him a bottle. d. With the child sitting up and leaning forward,
b. Alert the physician to the situation and ask for an pinch the lower third of the nose closed.
order for a stat chest x-ray.
c. Suction secretions, provide 100% oxygen via CRITICAL THINKING EXERCISES
mask, and anticipate respiratory failure. 1. A 10-month-old girl is admitted to the pediatric unit
d. Bring the emergency equipment to the room and with a history of recurrent pneumonia and failure to
begin bag-valve-mask ventilation. thrive. Her sweat chloride test confirms the diagnosis
of cystic fibrosis. She is a frail-appearing infant with
2. A toddler has moderate respiratory distress, is mildly thin extremities and a slightly protuberant abdomen.
cyanotic, and has increased work of breathing, with a She is tachypneic, has retractions, and coughs fre-
respiratory rate of 40. What is the priority nursing quently. Based on the limited information given here
intervention? and your knowledge of cystic fibrosis, choose three of
a. Airway maintenance and 100% oxygen by mask the categories below as priorities to focus on when
b. 100% oxygen and pulse oximetry monitoring planning her care:
c. Airway maintenance and continued reassessment a. Prevention of bronchospasm
d. 100% oxygen and provision of comfort b. Promotion of adequate nutrition
c. Education of the child and family
3. The nurse is caring for a child with cystic fibrosis
who receives pancreatic enzymes. The nurse realizes d. Prevention of pulmonary infection
that the childs mother understands the instructions e. Balancing fluid and electrolytes
related to giving the enzymes when the mother
f. Management of excess weight gain
makes which of the following statements?
g. Prevention of spread of infection
a. I will stop the enzymes if my child is receiving
antibiotics. h. Promoting adequate sleep and rest
b. I will decrease the dose by half if my child is 2. A child with asthma is admitted to the pediatric unit
having frequent, bulky stools. for the fourth time this year. The mother expresses
c. Between meals is the best time for me to give the frustration that the child is getting sick so often.
enzymes. Besides information about onset of symptoms and
events leading up to this present episode, what other
d. The enzymes should be given at the beginning of types of information would you ask for while obtain-
each meal and snack. ing the history?
4. Which of these factors contributes to infants and 3. The mother of the child in the previous question tells
childrens increased risk for upper airway obstruction you that she smokes (but never around the child), the
as compared with adults? family has a cat that comes inside sometimes, and
a. Underdeveloped cricoid cartilage and narrow she always gives her child the medication prescribed.
nasal passages She gives salmeterol and budesonide as soon as the
b. Small tonsils and narrow nasal passages child starts to cough. When he is not having an
episode, she gives him albuterol before his baseball
c. Cylinder-shaped larynx and underdeveloped sinuses games. Diphenhydramine helps his runny nose in the
d. Underdeveloped cricoid cartilage and smaller springtime. Based on this new information, what
tongue advice/instructions would you give the mother?
Chapter 19 NURSING CARE OF THE CHILD WITH A RESPIRATORY DISORDER 63
4. A 7-year-old presents with a history of recurrent nasal 2. The nurse is caring for a child with asthma. The
discharge. He sneezes every time he visits his cousins, child has been prescribed Advair (fluticasone and sal-
who have pets. He lives in an older home that is meterol), albuterol, and prednisone. Develop a sam-
carpeted. Tobacco smokers live in the home. His ple teaching plan for the child and family. Include
mother reports that he snores and is a mouth breather. appropriate use of the devices used to deliver the
She says he has symptoms nearly year-round, but they medications, as well as important information about
are worse in the fall and the spring. She reports that the medications (uses and side effects).
diphenhydramine is somewhat helpful with his symp-
3. While caring for children in the pediatric setting,
toms, but she doesnt like to give it to him on school
compare the signs and symptoms and presentation of
days because it makes him drowsy. Based on the
a child with the common cold to those of a child with
history above, develop a teaching plan for this child.
either sinusitis or allergic rhinitis.
5. The nurse is caring for a 4-year-old girl who returned
4. While caring for children in the pediatric setting,
from the recovery room after a tonsillectomy 3 hours
review the census of clients and identify those at risk
ago. She has cried off and on in the past 2 hours and
for severe influenza and thus those who would benefit
is now sleeping. What areas in particular should the
from annual influenza vaccination.
nurse assess and focus on for this patient?
5. Compare the differences in oxygen administration
STUDY ACTIVITIES between a young infant and an older child.
1. While caring for children in the pediatric setting,
compare the signs and symptoms of a child with
asthma to those of an infant with bronchiolitis. What
are the most notable differences? How does the his-
tory of the two children differ?