Prepared by: Bernalyn Orpilla-Pascual RN MAN

ASSESSING RESPIRATORY ILLNESS IN CHILDREN

Components of Assessing Respiratory Function RESPIRATIONS: RATE: DEPTH: EASE: LABORED BREATHING: RHYTHM:

OTHER OBSERVATIONS:

EVIDENCE OF INFECTION: COUGH: WHEEZE: CYANOSIS: CHEST PAIN:. SPUTUM: BAD BREATH:

Signs and Symptoms Associated with Respiratory Infections FEVER: MENINGISMUS: ANOREXIA: VOMITING: DIARRHEA: ABDOMINAL PAIN: NASAL BLOCKAGE: NASAL DISCHARGE: COUGH: RESPIRATORY SOUNDS: Sounds associated with respiratory disease: Cough Hoarseness Grunting Stridor Wheezing Auscultation: Wheezing Crackles Absence of sound SORE THROAT:

NURSING DIAGNOSIS 1 Ineffective Airway Clearance r/t inflammation,obstruction,secretions, or pain 2 Ineffective Breathing Pattern r/t inflammatory process or pain 3 Tissue Perfusion altered r/t decreased oxygen delivery 4 Deficient Fluid Volume r/t fever,decreased appetite, and vomiting 5 Fatigue r/t increased work of breathing 6 Anxiety r/t respiratory distress and hospitalization 7 Parental Role Conflict r/t hospitalization of child (Others may be apparent in individual cases)

PLANNING 1. Child will exhibit normal respiratory efforts 2. Child will receive adequate rest 3. Child will remain comfortable 4. Child will not spread primary infection to others 5. Childs temperature will remain within normal limits 6. Child will maintain normal hydration and adequate nutrition 7. Child will experience no complications 8. Child and family will receive information especially for home care and support

THERAPEUTIC TECHNIQUES USED IN THE TREATMENT OF RESPIRATORY ILLNESS A. Expectorant Therapy B. Liquefying Agents C. Humidification D. Coughing E. Chest Physiotherapy F. Postural Drainage G. THERAPY TO IMPROVE OXYGENATION 1. Oxygen Administration 2. Pharmacologic Therapy 3. Incentive Spirometry 4. Breathing Techniques 5. Tracheostomy 6. Suctioning 7. Endotracheal Intubation 8. Assisted Ventilation

LABORATORY TESTS A. BLOOD GAS ANALYSIS

PULSE OXIMETRY TRANSCUTANEOUS OXYGEN MONITORING B. NASOPHARYNGEAL CULTURE

C. RSV NASAL WASHINGS D. SPUTUM ANALYSIS

DIAGNOSTIC PROCEDURES A. Chest X-ray B. Bronchography C. Pulmonary Function Studies

UPPER RESPIRATORY INFECTIONS

NASOPHARYNGITIS ASSESSMENT 1. nasal congestion 2. watery rhinitis 3. low grade fever THERAPEUTIC MANAGEMENT 1. no specific treatment 2. saline nose drops or nasal spray 3. remove nasal mucus via bulb syringe 4. cool mist vaporizer

PHARYNGITIS Viral Pharyngitis THERAPEUTIC MANAGEMENT: 1. Warm heat applied to the external neck area using warm towel or heating pad 2. Children: gargling with warm water 3. Sufficient fluid to prevent dehydration for infants

STREPTOCOCCA PHARYNGITIS . Assessment: 1. Back of the throat and palatine tonsils are usually markedly erytematous (bright red). 2. Tonsils are enlarged and there may be white exudates in the tonsillar crypts. 3. Petechiae may be present in the palate 4. High fever with extremely sore throat 5. Difficulty swallowing and overall lethargy 6. Headache with swollen abdominal lymph nodes 7. Presence of streptococcus bacteria on throat culture THERAPEUTIC MANAGEMENT: 1. Full 10 day course of oral antibiotic such as penicillin G or clindamycin 2. Measures for rest, throat pain and maintenance f hydration. 3. cold or warm compress to the neck 4. warm saline gargles 5. cool liquids or ice chips

TONSILLITIS Assessment: 1. children drool 2. painful swallowing as if swallowing bits of metal or glass 3. high fever , lethargy 4. bright red tonsilar tissue and enlarged 5. two areas of palatine tonsilar tissue meet in the midline 6. signs of adenoidal tissue infection: a. nasal quality of speech b. mouth breathing c. difficulty hearing d. halitosis with sleep apnea

THEAPEUTIC MANAGEMENT 1. antipyretic for fever, analgesic for pain 2. full 10 day course of antibiotic 3. Tonsillectomy and Adenoidectomy Nursing Care Post Surgery 1. soft liquid diet 2. cool mist vaporizer 3. measures of comfort: 4. until fully awake place on their abdomen or side 5. avoid coughing or clearing throat, blowing nose 6. ice colar may provide relief 7. offer cool water, crushed ice, flavored ice pops, or diluted fruit juice 8. fluids with red or brown color are avoided; citrus juice may cause discomfort 9. soft foods particularly gelatin, cooked fruits, soup, mashed potatoes 10. avoid milk, ice cream and pudding. 11. Assess for signs of hemorrhage: A. increased pulse rate B. Pallor and frequent clearing of throat or swallowing. C. Restlessness

INFLUENZA Assessment: 1. dry throat and nasal mucosa, dry cough and hoarseness 2. flushed face, myalgia, prostration with sudden onset of fever and chills 3. subglottal croup is common especially in infants THERAPEUTIC MANAGEMENT 1. symptomatic treatment: antipyretics, analgesic and fluids 2. avoid using aspirin as treatment

OTITIS MEDIA THERAPEUTIC MANAGEMENT: 1. Antibiotic: oral amoxicillin 2. Myringotomy and tympanostomy 3. polyvalent pneumococcal polysaccharide vaccine 4. Bacterial polysaccharide immune globulin (BPIG) 5. relieve pain: acetaminophen, ice compress placed on affected ear 6. facilitate drainage 7. prevent complication 8. educate family:

CHOANAL ATRESIA THERAPEUTIC MANAGEMENT: 1. local piercing of the obstructing membrane 2. surgical removal of the bony growth 3. IV fluids to maintain their glucose and fluid level

EPISTAXIS

THERAPEUTIC MANAGEMENT: 1. place on upright position with head tilted slightly forward 2. apply pressure to the sies of the nose with fingers 3. epinephrine (1:1000) may be appied to the bleeding site 4. nasal pack may be applied

SINUSITIS Signs and symptoms 1. fever 2. purulent nasal discharge 3. headache 4. tenderness over the affected sinus Therapeutc Management: 1. antipyretics, analgesic for pain and antibiotic 2. Oxymetazolie Hydrochloride (nose drops/nasal spray) for 3 days 3. warm compress to the sinus area

CONGENITAL LARYNGOMALACIA/TRACHEOMALACIA Assessment: 1. retraction on infants sternum and intercostal spaces on inspiration 2. stridor on inspiration Therapeutic Management: 1. feed slowly; provide rest periods as needed 2. assess for signs of upper respiratory infection 3. condition improves as cartilage in the larynx becomes stronger at about 1 year of age

CROUP SYNDROMES

ACUTE EPIGLOTITIS Assessment: 1. sore throat and pain on swallowing 2. fever; insists on sitting upright and leaning forward, with chin thrust out, mouth open, and tongue protruding (Tripod Position) 3. drooling of saliva 4. predictive of epiglotitis: absence of spontaneous cough, drooling and agitation 5. voice is thick and muffled, with froglike croaking sound on inspiration, but child is not hoarse 6. throat is red and inflamed, and a distinctive large, cherry red, edematous epiglottis

Therapeutic Management: 1. Do not attempt to view throat without properly experienced personnel is present with emergency equipment like intubation set and tracheostomy. 2. lateral neck films 3. Antbiotic therapy: 7 to 10 day course (second generation cephalosporins:cefuroxime) 4. cortecosteroids 5. intravenous fluid therapy

ACUTE LARYNGITIS viruses are the usual offending agents and principal complaint is hoarseness, which may be accompanied by an upper respiratory infection( coryza, sore throat, nasal congestion) and systemic manifestations. Therapeutic Management: 1. fluids 2. humidified air

ACUTE LARYNGOTRACHEOBRONCHITIS Characterized by gradual onset of low grade fever. Assessment: 1. the child struggles to inhale air past the obstruction and into the lungs producing: inspiratory stridor and supratsternal retractions 2. classic barking or seal-like cough and acute stridor after several days of coryza.

Stages: Stage I: fear, hoarseness, croupy cough, inspiratory stridor Stage II: continuous respiratory stridor, lower rib retraction, retraction of soft tissue of the neck, use of accessory muscles of respiration, labored respiration Stage III: signs of anoxia and carbon dioxide retention, restlessness, anxiety, pallor, sweating, rapid respirations Stage IV: intermittent cyanosis, permanent cyanosis, cessation of breathing

Therapeutic Management: 1. mild croup: home care (fluids and comfort measures with cool-air vaporizer) 2. high humidity with cool mist 3. cool-air vaporizer 4. hoods for infants/tents for toddlers 5. racemic epinephrine administration (severe) 6. Cortecosteroid 7. IV therapy 8. Watch for early signs of impending airway obstruction: increased pulse and respiratory rate; substernal, suprasternal, and intercostals retractions; flaring nares; increased restlessness

ACUTE SPASMODIC LARYNGITIS Assessment: 1. child goes to be well /mild resp symptoms and awakes suddenly with: 1. Barking, metallic cough 2. hoarseness 3. noisy respirations 4. restlessness, anxious, frightened and prostrated 5. dyspnea is noted with excitement with no fever

Therapeutic Management and Nursing Considerations 1. cool mist 2. warm mist provided by steam from hot running water in a closed bathroom 3. spasm is relieved by sudden exposure to cool air(as when the child is taken out at night) 4. sleeping in a humidified air 5. severe: racemic epinephrine; cool mist and corticosteroid therapy

BACTERIAL TRACHEITIS Assessment: 1. similar to LTB but unresponsive to LTB therapy 2. history of previous URI with croupy cough, stridor unaffected by position, toxicity and high fever 3. production of thick, purulent tracheal secretions Therapeutic Management and Nursing Considerations 1. humidified oxygen 2. antipyretics 3. antibiotics 4. severe: endotracheal suctioning

INFECTIONS OF THE LOWER AIRWAYS

BRONCHITIS Assessment: 1. dry hacking cough, nonproductive that wosens at night 2. cough becomes productive in 2 to 3 days Therapeutic Management: 1. antipyretics, analgesics and humidity 2. cough suppressants

RESPIRATORY SYNCYTIAL VIRUS AND BRONCHIOLITIS

Assesment: 1. rhinorrhea and low grade fever 2. otitis media and conjunctivitis 3. cough develops: 4. chest radiographs: hyperaeration and areas of consolidation which is difficult to differentiate from bacterial pneumonia 5. apnea 6. Severe: rise in arterial carbon dioxide tension (hypercapnia)-respiratory acidosis and hypoxemia

Signs and Symptoms 1. INITIAL: rhinorrhea, pharyngitis, coughing/sneezing, wheezing, possible ear or eye drainage, intermittent fever 2. WITH PROGRESSION OF ILLNESS: increased coughing and wheezing, air hunger, tachypnea and retractions, cyanosis 3. SEVERE ILLNESS : tachypnea greater than 70 breaths per minute, listlessness, apneic spells, poor air exchange; poor breath sounds

Dianostic Evaluation: Enzyme-linked immunosorbent Assay (ELISA)/rapid immunoflourescent antibody (IFA) Therapeutic Management and Nursing Consideration 1. high humidity, adequate fluid intake, oxygen mist and rest 2. Ribavirin 3. Prevention RSV immune globulin (RSV-IGIV) Monoclonal Antibody, Palivizumab 4. Prophylaxis recommendations: a. Infants born 32 and 35 weeks gestation if they are younger than 6 months of age b. infants who have two or more additional risk factors: b.1 school-age siblings b.2 crowding in the home b.3 day care attendance b.4 exposure to tbacco smoke in the home c. children who are 24 months of age or younger 5. infection control measures:

PNEUMONIAS Types of Pneumonia: 1. Lobar Pneumonia 2. Bronchopneumonia 3. Interstititial

BACTERIAL PNEUMONIA A.1 PNEUMOCOCCAL Assessment: 1. high fever,nasal retractions, chest pain, chills and dyspnea 2. some: abdominal pain, febrile seizures 3. tachypnea and tachycardia 4. breath sounds become bronchial 5. crackles or rales as a result of the fluid, dullness on percussion on lobe indicates consolidation
A.2 STREPTOCOCCAL A.3 STAPHYOCOCCAL A.4 HAEMOPHILUS A.5 CHLAMYDIAL

VIRAL PNEUMONIA MYCOPASMAL PNEUMONIA LIPID PNEUMONIA HYDROCARBON PNEUMONIA -

ATELECTASIS Primary Atelectasis: Assessment: respirations are irregular with nasal flaring and apnea; Respiratory grunt and cyanosis (sound of respiratory grunt is caused by the newborns glottis closing on expiration) Secondary Atelectasis: Causes: mucus plugs, aspiration of foreign objects, trauma or pressure on lung tissue Assessment: asymmetry of the chest; breath sounds on affected chest is diminished; tachypnea and cyanosis; CXR: a white out a collapsed alveoli

Therapeutic Management: 1. Foriegn object: bronchoscopy 2. Mucus plugs: expectorated 3. place on semi fowlers position 4. increase humidity in the childs environment 5. suctioning and CPT

OTHER INFECTIONS OF THE RESPIRATORY TRACT

PERTUSSIS (WHOOPING COUGH) Assessment: STAGE I : (Catarrhal Stage) STAGE II : ( Paroxysmal Stage) STAGE III : ( Convalescent Stage) Therapeutic management: 1. erythromycin estolate, azithromycin, clarithromycin 2. supportive: antipyretics, bed rest, quiet environment,gentle suctioning, increase fluid intake, oxygen 3. prevention: pertussis vaccine

TUBERCULOSIS Diagnosis: TST (Mantoux Test, PPD): dose: 5 tuberculin units, 27 gauge needle and a 1 ml syringe. ID. Read by 48-72 hours. Postive reaction: individual has been infected 1. Latent TB infection (LTBI): 2. TB disease:. Gastric washing-aspiration of the lavaged contents into a fasting stomach

Clinical Manifestations 1. fever, malaise, anorexia, weight loss, Cough may or may not be present ( progresses slowly over weeks to months), aching pain and tightness in the chest 2. with progression: RR increases, poor expansion of lung on the affected side, diminished breath sounds and crackles; dullness to percussion, fever persists 3. generalized symptoms are manifested, pallor, anemia weakness and weight loss

Therapeutic management: 1. nutrition and general supportive measures 2. prevention of unnecessary exposure 3. chemotherapy: combinations of isoniazid (INH), rifampin, and pyrazinamide (PZA) a. 6 months regimen: INH, rifampin and PZA given daily for the first 2 months; followed by INH and Rifampin given 2 to 3 times per week for the remaining 4 months. b. when drug resistance is suspected: ethambutol or aminoglycoside is added to the therapeutic regimen 4. Prevention: avoid contact and maintain an optimal state of nutrition Bacille Calmette-Guerrin (BCG)

PULMONARY DYSFUNCTION CAUSED BY NONINFECTIOUS IRRITANTS

FOREIGN BODY ASPIRATION Assessment: 1. choking, gagging, wheezing, or coughing 2. laryngotracheal obstruction: dyspnea, cough, stridor, and hoarseness because of decreased air entry. 3. cyanosis if obstruction becomes worse 4. Bronchial obstruction: cough(frequently paroxysmal), wheezing, asymmetric breath sounds, decreased airway entry, and dyspnea. 5. Larynx: unable to speak or breathe

Therapeutic management and Nursing Considerations 1. Bronchoscopy: larynx and trachea 2. Flouroscopic Exam: bronchi 3. Back blows or the Hemleich Maneuver 4. The child in distress: 1.cannot speak, 2. Becomes cyanotic,3. Collapses. These signs indicate that the child is truly choking and requires immediate action. The child can die within 4 minutes.

ASPIRATION PNEUMONIA Nursing Considerations: 1. same as pneumonia 2. Prevention: proper feeding techniques; use of talcum powder should be avoided; infants and debilitated children should be positioned on their right side after feedings to minimize aspiration.

SMOKE INHALATION -

Three types of Injury: 1. Heat Injury 2. Chemical Injury 3. Systemic Injury Therapeutic management: 1. humidified oxygen as quickly as possible 2. baseline arterial blood gases and COHb levels 3. If CO poisoning s confirmed: 100% oxygen is continued until COHb level falls below 10% 4. Intubation /tracheostomy available at bedside for transient edema Indications: severe burns in the nose mouth and face; Vocal cord edema; Progressive respiratory distress 5. cortecosteroid

PASSIVE SMOKING - children exposed to passive smoking increases the number f respiratory illness and reduced performance to pulmonary function test. Exposure has been linked to the prevalence of asthma in the family.

LONG TERM RESPIRATORY DYSFUNCTION

ASTHMA The mechanism responsible for the obstructive symptomsinclude: 1. inflammation and edema of the mucuous membrane 2. accumulation of tenacio secretions from the mucous glands 3. spasm of the smooth muscle of the bronchi and bronchioles, which decreases the caliber of the bronchioles

ASTHMA SEVERITY CLASSIFICATION 1. STEP 4: Severe Persistent Asthma 1. continual symptoms, frequent nighttime symptoms 2. PEF or Forced expiratory volume in second is less than 60% of the predicted value; 2. STEP 3 : Moderate Persistent Asthma 1. daily symptoms, nighttime symptoms more than 1 night/week 2. PEF or FEV is more than 60% to below 80% of predicted value; 3. STEP 2: Mild Persistent Asthma 1. Symptoms more than 2 times /week, but less than 1 time a day,nighttime symptoms more than 2 times a month 2. PEF or FEV is greater than or equal 80% of predicted value, 4. STEP 1 : Mild Intermittent Asthma 1. symptoms less than 2 times / week, nighttime symptoms less than 2 times a month 2. PEF or FEV is greater than or equal to 80% of predicted value,

Diagnostic Evaluation:
1. Pulmonary Function Test (PFT) : spirometry 2. Peak expiratory flow rate: 3. skin testing 4. provocative testing

Therapeutic management 1. Allergen Control: housedust mites and cockroaches 2. Drug Therapy: a. long term control medications (preventor medicines) b. Quick relief medications (rescue medications) c. Metered dose inhaler with spacer d. Cortecosteroids: oral / inhaled (low dose inhaled corticosteroid) e. Cromolyn Sodium f. B-adrenergic agonistg. Leukotirene modifiers: Leukotriene modifiers(Montelukast) Omalizumab (Xolair) 3. Exercise: EIB (exercise induce bronchspasm) Swimming and exhaling under water 4. Chest Physiotherapy 5. Status Asthmaticus: Therapy: Bronchospasm( inhaled aerosolized shrt acting b2 agonsts along with cortecosteroids: oral/parenteral) If unresponsive to above therapy, subcutaneous epinephrine or subcutaneous terbutaline is administered

CYSTIC FIBROSIS -

Assessment: 1. meconim ileus: earliest 2. panceatic fibrosis 3. steatorrhea nd azotorrhea 4. prolapsed rectum 5. pulmonary complications: most serious, bronchial and bronchiolar obstruction by the abnormally thick tenacious mucus causing patchy atelectasis with hyperinflainflation; child is unable to expectorate mucus

Diagnosis: 1. history of the dsease in te family 2. absence of pancreatic enzymes 3. increase in electrolyte conc of sweat 4. chronic pulmonary involvement 5. sweat chloride test (pilocarpine) Normal sweat chloride= 40 mEq/L Greater than 60 mEq/L= CF Therapeutic Management 1. management of pulmonary problems: 2. management of gastrointestinal problem