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Respiratory

Nur 106
Respiratory System
General Information
Signs and symptoms of respiratory
distress
Common diagnostic tools
Common medications and treatments
General Information
Fetus practices breathing in utero
Normal to have amniotic fluid in lungs
Absorbed as soon as takes first breath
Meconium in the amniotic fluid is problem
Surfactant reduces surface tension in
lungs so that lungs will remain open
Neonates are obligant nasal breathers
General Information
Normal respiratory rate: 3050
Lumen of respiratory system is smaller in
children
Eustachian tubes shorter and more
horizontal
Metabolic rates are higher than adults

Respiratory Assessment
Auscultation
Absent or diminished lung sounds
Adventitious lung sounds
Cracklespassage of air through moisture
WheezesNarrowed passageways
Respiratory Assessment
Observation
Barrel Shaped Chest
Respiratory Assessment
Observation
Cyanosis
Club fingers
Respiratory Assessment
Observation
Presence of retractions
Occur when airway obstructed in young children
Indication of severity of respiratory distress
Respiratory Assessment
Infants chest walls more flexible, muscles
immature, retractions common
Respiratory Assessment
Retractions
Suprasternal
Substernal
Intercostal
Common Diagnostic Tests
Chest xray
Bronchoscopyvisualizes trachea and
bronchi directly
Under anesthesia
Pulmonary function testsusually not until
5 to 6 years of age
Sputum culturebest collected in morning

Common Diagnostic Tests
Arterial blood gases
Heparinized syringe
Place on ice
Transport to lab immediately
Pressure to site for 5 minutes
Pulse oximetry
Oxygen saturation
SP
o2
8793% safe levels of saturation
Respiratory System
Laryngotracheobronchitis (croup)
Pnuemonia
Respiratory distress syndrome
Bronchopulmonary dysphasia
Cystic Fibrosis
Sudden Infant Death Syndrome (SIDS)
Respiratory System
Asthma
Respiratory Syncyntial Virus
Pharyngitis
Allergic Rhinitis
Tonsillitis/adenoiditis
Influenza
Laryngotracheobronchitis
Generalized infection of larynx, trachea and
bronchi
Croup
Frequently shows symptoms of mild URI
during day; at night, awakens with hoarse
barking cough and severe respiratory distress
Most common organisms: RSV,
parainfluenza virus and mycoplasma
pneumoniae
LTB
Etiology
Affects children under 5 (smaller
airways)
Affects boys more frequently than girls
Inflammation causes narrowing of
airways
Onset gradual
May reoccur several nights in a row
LTB
Symptoms
Low-grade fever
Barking cough
Respiratory stridor
Hypoxemia
Tripod position
Respiratory Distress
Tripod Position

LTB
Treatment
At home:
Hot steamy bathroom
Cool night air
Sit upright
Cool mist vaporizer in home made tent
Elevate head of crib
Increase fluids
LTB
Treatment
Hospitalization
Croup tent
IV fluidsoral fluids may cause aspiration
Bronchodilators
Corticosteroids
Intubation equipment available
Epiglottitis
Inflammation of epiglottis
Life threatening obstruction
Usually bacterial (hemophilus influenza)
Sudden onset in healthy child: awakens
with high fever, drooling and respiratory
distress
Do NOT examine throatmay lead to
spasm and complete obstruction
Pneumonia
Inflammation/infection of bronchioles and
alveloar spaces
Causative agents bacteria, viral,
mycoplasma
Children under 5: ViralRSV. Influenza,
adenovirus,rhinovirus
Children over 5: Bacteriastreptococcus
pneumoniae
Pneumonia
Symptoms
Fever, cough, dyspnea, tachypnea
Rhonchi, crackles, wheezes
Decreased breath sounds with consolidation
Diagnosis
Xray
Treatment
Antibiotics, IV, fever control, airway
management
Respiratory Distress Syndrome
Formally called Hyaline Membrane Disease
Disease primarily of premature
Infant of a diabetic mother

White children more frequent than black
Boys more often than girls

Primary pathology is production
deficiency in surfactant

Surfactant
Lung Compliance
Atelectasis Work of breathing
Ventilation
CO
2
Acidosis PO
2
Anaerobic metabolism
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Adapted from: London, M; Ladewig,
P; Ball, J; and Bindler, R. 2007.
Maternal & Child Nursing Care, 2nd
ed. Upper Saddle River, NJ, Prentice
Hall, p.820.

Respiratory Distress Syndrome
Diagnosis: x-raydiffuse bilateral density
(white-out), and atelectasis
Antenatal prevention treatment:
betamethasone
Respiratory Distress Syndrome
Nursing Care
Oxygenation/ventilation
Transcutaneous oxygen/CO
2
monitoring
Blood gas monitoring
Oxygen
Continuous positive airway pressure (CPAP)
Respirator
Respiratory Distress Syndrome
Nursing Care
Correction of acid-base imbalance
Temperature regulation
Nutrition
Protect from infection
Respiratory Distress Syndrome
Surfactant Replacement Therapy
At birth and repeated as necessary
Endotracheal administration
Bronchopulmonary dysplasia
BPD
Chronic lung disease
Precipitating factors: prematurity, high
oxygen concentrations, positive pressure
ventilation
Symptoms: Persistent respiratory distress
Wheezing, tachypnea, pulmonary edema
Failure to thrive
Bronchopulmonary Dysplasia
Nursing Care
Oxygen
Tracheostomy
Recurrent respiratory infections
Palivizumab, RSV immune globulin
Promote growth and development
Bronchopulmonary Dysplasia
Medications:
Bronchodilators
Anti-inflammatory agents
Diuretics
Antibiotic Therapy
Vitamin A
Cystic Fibrosis
Inheritedautosomal recessive
Both parents must be carriers
Each child has a 1 in 4 chance of being
affected
Affects primarily white children
Father Mother
(carrier) (carrier)
Carrier Unaffected Affected Carrier

Cystic Fibrosis
Multi-system diseaseaffects exocrine
glands
Bronchioles, small intestines, pancreas,
bile ducts
Exocrine secretionsthick and
tenacious
Abnormal sodium excretion
Sweat Chloride test
Heat Prostration
Cystic Fibrosis
LungsSecretions pool in bronchioles
leading to infection and atelectasis
Barrel shape chest
Cyanosis
Clubbing of fingers and toes
Recurrent respiratory infections
Cystic Fibrosis
Pancreasabsence of pancreatic
enzymes and malabsorption
Small intestineMeconium hardens
leading to meconium ileus
Stools are bulky and fatty (steatorrhea)
Large belly, wasted extremities
Fat soluble vitamin deficiencies
Cystic Fibrosis
Males usually sterile due to blocked vas
deferens
Females may have trouble conceiving due
to thick mucus in the reproductive tract
Cystic Fibrosis
Medical treatment
Bronchodilators
Antibiotics
Pancreatic enzymes
Vitamin supplements
Salt supplements in hot weather?
Cystic Fibrosis
Nursing Interventions
At birthmonitor for 1
st
meconium
Newborn screeningblood immunoreactive
trypsinogen
Genetic counseling
Parent Education
High calorie, high protein, low fat diet
How to administer pancreatic enzymes
Protect from infection
Breathing exercises and care



Cystic Fibrosis
Breathing Exercises
Physical activity
Chest percussion and postural drainage
Cystic Fibrosis
Medications
Aerosol Bronchodilatorsopens lungs
Aerosol DNAseloosens secretions
CorticosteroidsAnti-inflammatory
AntibioticsTreats infections
Pancreatic enzymesAids in digestion
Water soluble ADEK

Sudden Infant Death Syndrome
Risk factors--infant
Race: (decreasing order of frequency)
American Indian, black, Hispanic, white, Asian
Males more often than females
24 months of age
Winter
Exposure to passive smoke
Prone sleeping
Overheating
Sudden Infant Death Syndrome
Risk factors--maternal
Age less than 20, short interval between
pregnancies
Prenatal smoking, binge alcohol, drug use
Anemia
Poor prenatal care, poor weight gain during
pregnancy
Hx of sexually transmitted disease or UTI
Asthma
Hyper-reactive lungs
Chronic condition with acute
exacerbations
Responds to environmental irritants
Bronchial spasm, increased airway
resistance, air trapping
Asthma--Etiology
Triggers include: inhalants, airborne
pollens, stress, weather changes,
exercise, viral or bacterial agents,
allergens, strong emotions, etc.
Runs in familiesgenetics unclear
Asthma--Pathology
Exposure to irritant
Constriction of bronchial smooth
muscles
Edema of lung tissues
Increased respiratory secretions
Airway narrowing
Air trapping and hyperinflation of alveoli
Asthma--Symptoms

Wheezingcan be heard at
http://jan.ucc.nau.edu/~daa/heartlung/breaths
ounds/contents.html
Cough
Air trapping and hyperinflation leads to
prolonged expiratory phase
Lipsdark red; may progress to cyanosis
Anxiety
Sitting upright, hunched over
Asthma
Treatment
Quick relief medications
Nebulizer (metered dose inhaler)note if
contains steroids, spacer should be used
to prevent yeast infections of the mouth
Asthma
Metered Dose Inhaler--Use

Shake the inhaler well before use (3 or 4 shakes)
Remove the cap
Breathe out, away from your inhaler
Bring the inhaler to your mouth. Place it in your
mouth between your teeth and close you mouth
around it.
Start to breathe in slowly. Press the top of you
inhaler once and keep breathing in slowly until
you have taken a full breath.
Remove the inhaler from your mouth, and hold
your breath for about 10 seconds, then breathe
out.

www.asthma.ca/adults/treatment/meteredDoseInhaler.php
Asthma
Medications--Acute
Corticosteroidsoral or inhaled
Prednisone, Methylprednisolone
-Adrenergic agonists (Bronchodilators)
Albuterol, epinephrine, terbutaline
Short acting (inhaled) used to relieve an on-going
attack
Long acting (oral or inhaled) to control frequent
attacks
Asthma
Medications--Chronic
Cromolyn sodiumused prophylactically
Inhalant
Suppresses inflammation
Not bronchodilator
Prevents release of histamine
Asthma
Reducing Triggers
Smoke free environment
Allergy proofing home:
Bedroom of primary importance
Pillows and mattress enclased in covers
Eliminate stuffed toys, plants, carpets,
drapes
Do not store out of season clothing in room
Status Asthmaticus
The continued presence of severe
respiratory distress despite vigorous
therapeutic measures
Medical emergency that can lead to
respiratory failure and death
Sudden onset of agitation or the
agitated child who suddenly becomes
quiet may be seriously hypoxic
Bronchiolitis
Inflammation of the bronchioles
Edema, accumulation of mucus, air
trapping and atelectasis
Major concern for small infants
Most common caustive agent is the
respiratory syncytial virus (RSV)
Often fatal
RSV
Most important respiratory pathogen in
infancy and early childhood
Not airborne
Can remain viable for hours on
nonporous surfaces
Most frequent problem in winter and
spring
RSV
Prevention
Infants up to 24 months with chronic lung
disease
RSV Immune Globulin (RSV-ICIV):
Antibodies against RSV. Given monthly IV
beginning of season
Palivizumab (monoclonal antibody): Given
monthly IM

Pharyngitis
Sore throat
Most are caused by viruses
Most common bacteriagroup A beta-
hemolytic streptococcus (strept throat)
Symptomsfever, sore throat,
dehydration
Treatmentsymptomatically
If bacterial10 days of penicillin
Tonsillitis/adenoiditis
Tonsils: Masses of lymphoid tissue
located in pharyngeal cavitiy.
Purpose: Filter pathogens
Size: Children relatively large
Infection can be viral or bacterial
If greater than 3 infections per year, may
do tonsillectomy
Tonsillectomy
Surgical removal of palatine tonsils
Adenoidectomysurgical removal of
pharyngeal tonsils
Pre-op prep same as for all surgeries
Tonsillectomy
Recovery room
Position on abdomen or side
Suction with care


Tonsillectomy
Post op care
Bedrest for day
Clear liquids advance to full then soft
Cold
Avoid red coloring
Ice collar
Analgesics


Tonsillectomy
Post op riskhemorrhage
Up to 10 days post op
Symptoms
Bright red bloody emesis
Frequent swallowing
Pulse greater than 120
Tonsillectomy
Recommendations to prevent post-op
hemorrhage
Avoid irritating foods
Avoid gargles or vigorous toothbrushing
Discourage coughing or throat clearing
Use ice collar
Avoid medications known to promote bleeding
Limit activity
Allergic Rhinitis
Hay fever
Seen mostly in older children and adults
Treatment: antihistamine, allergy
avoidance

Influenza
Viral
Symptoms last 4 to 5 days
Complications include pneumonia,
encephalitis, otitis media
Do not treat with aspirin because of
possible link to Reye Syndrome
General Treatment for Respiratory
Conditions
Position to promote oxygenation
Humidification
Fluid intakeclear liquid, avoid milk
Oxygen???
Medications include bronchodilators,
anti-inflammatories, antibacterial and
antiviral agents
Foreign Body Aspiration
Peak age: under 3
Leading cause of death under 1
FB usually lodge in right main bronchus
Partial or complete obstruction
Sudden onset of coughing
Heimlich Maneuver
Surgical removal