1 NUR124 COMMON RESPIRATORY DISORDERS PART ONE OBJECTIVES 1. 2. 3. 4.

Identify common respiratory infections and illnesses Define terms associated with common respiratory infections Give brief description of etiology and pathophysiology of some common respiratory disorders Describe the history, physical examination and associated clinical manifestations for a child with suspected respiratory disorders 5. Describe the guidelines for assessment of the respiratory system in children 6. Determine the nursing diagnosis and management for the child with respiratory disorders INTRODUCTION Respiratory tract infection is a frequent cause of acute illness in infants and children. Many of such infections are seasonal. The childs response to the infection will vary based on the age of the child, causative organism, general health of the child, existence of chronic medical conditions, and the degree of contact with other children COMMON INFECTIONS Acute upper respiratory Infection o Tonsillitis, o adenoiditis o nasopharyngitis o Otitis Media o Sinusitis o Allergic Rhinitis o influenza Upper Respiratory tract disorders/croup syndromes o Acute spasmodic Croup o AcuteLaryngotracheobronchitis o Acute Epiglottitis o Lower Respiratory Tract infections o Bronchitis o Bronchiolitis o Pneumonias Chronic Respiratory Disorder o Asthma Other infections of respiratory tract o Pertussis (whooping Cough) o Pulmonary TB

2 Accident-Related Respiratory Disorder o Foreign Body Aspiration o Aspiration Pneumonia o Near Drowning

DEFINITIONS Bronchiolitis Inflammation or infection of the bronchioles caused by the parainfluenza virus, (type 1&2), adenovirus, M Pneumoniae Most common in infants under 6 months; may occur in children up to 2 years of age Grater incidence in males than females Increased incidence in day care centers Clinical manifestations o Onset is gradual after exposure to individual with respiratory infection o Tachypnea; retractions; expiratory ronchi or wheeze; dry paroxysmal cough o Fever; cyanosis; dehydration Diagnosis evaluation: o Chest x-ray: hyperinflation of lungs Treatment: o antibiotics_ Broad spectrum antibiotics until causative organism identifies o salbutamol or ventolyn(bronchodilators) through nebulization Nursing consideration: o Avoid high density humidity- may cause bronchospasms o Monitor fluid electrolyte balance closely o Keep nasal passages free of secretions(children are obligate nose breathers) o Position child upright to facilitate effective breathing o Monitor the child closely for signs of impending respiratory failure o There is a high risk of cross contamination to non infected children o Institute contact and respiratory isolation Complication o Exhaustion resulting in a need for assisted ventilation o Secondary bacterial infection o Apneic episodes o Dehydration o Other

Acute Bronchitis An infection of the lower respiratory tract that is generally an acute sequela to an upper respiratory tract infection

3 Primarily viral but may also arise from bacterial agents Airways become inflamed and irritated with increased mucous production Clinical manifestations o Fever, tachypnea o Cough, clear to purulent sputum o Pleuritic chest pain, occasionally o Defused rhonchi and crackles heard on auscultation Diagnostic evaluation o Chest x-ray- no evidence of infiltrates Management o Antibiotic therapy for 7-10 days o Hydration if child is dehydration o Management of fever and cough

Bacterial Pneumonia Bacterial infection of the lung parenchyma by o Streptococcus pneumonia (gram positive); o Very common in children o More common in children birth to 2years o Seen occurring more in the cold season seen also in children with sickle cell disease and those without spleen Clinical manifestations o Mild upper respiratory tract infection (URTI) with sudden symptom onset o Infants will refuse to eat, vomiting, diarrhea, hypothermia or hyperthermia Tachypnea, grunting, retractions, nasal flaring o Older children Headache, anorexia, malaise, dry cough, fever, pleuritic pain, shallow, rapid respirations and abdominal pain Commonly superimposed on febrile respiratory infection in a child already ill with a viral infection URI, headache, anorexia, malaise, dry cough, fever, pleuretic pain, shallow, rapid respiration, abdominal pain Diagnostic Evaluation Chest x-ray: Patchy area around bronchi Cultures (blood, sputum) CBC, _ elevated leucocytes Treatment Antibiotics Ampicillin, Cephalosporins; Bronchodilators Nursing Considerations o Provide adequate rest with gradual increasing exercise o Monitor intake and output

4 o Administer anti pyretic o Other Complications o Complications are rare, but may include otitis media and sinusitis, bacterimia,

Streptococal Pneumonia Caused by beta-hemolytic streptococcus group A (gram positive) Common in children 3-5 years Clinical manifestations o Commonly superimposed on febrile respiratory infection in a child already ill with viral infection o Sudden increased temperature o Worsening cough o Chills, chest pain and respiratory distress Diagnostic Evaluation o Chest X-ray- patchy area around bonchi o Cultures (sputum; blood) o CBC- elevated WBC o Other Treatment o Antibiotic- penicillin G Nursing considerations o Provide adequate rest with gradual increased exercise o Monitor temperature- administer anti pyretic o Administer antibiotics

Viral Pneumonia Viral infection of the lungs Caused by influenza viruses Common in children birth to 2 years with higher incidence in females rather than males Clinical manifestation o Gradual unset following and upper respiratory infection o Infants have significant respiratory distress o May have apneic spells Diagnostic evaluation o Chest x-ray: one or more lobes infiltrate o Culture Treatment- broad spectrum antibiotic therapy initiated until confirmation of suspected organism established

5 Antiviral treatment Nursing consideration o Monitor the infant closely to watch for signs of fatigue, indications that the infant requires supplemental oxygen or intubation for ventilator support o Other

Epiglottitis and croup Croup-Viral infection of the larynx and trachea Called- acute Laryngotracheo-bronchitis Epiglottitis is infection of the epiglottis Caused by H- influenza, Rhinovirus, Adenovirus and others Croup seen more in children between the age of 3 months and 3years Seen more in the cold season Epiglottitis seen more in the age group 3-10 years; peaks 1-5 years Incidence of epiglottitis have decreased due to the influenza vaccine which is administered Clinical presentations o For croup Unset is usually gradual and progresses slowly; occurs 1 in several days after an upper respiratory infection Croupy, barking cough Inspiration stridor Hoarseness; low grade fever, apprehension, anxiety o Nursing goals and responsibilities for Acute Lrayngotracheo-bronchitis Assess respiratory status and detect any impending airway obstruction Monitor heart rate and respirations Auscultate lungs Observe colour of skin Observe for retractions, flaring of nares Observe for increased respiration Ease respiratory efforts Provide high humidity environment Promote rest; reduce anxiety and apprehension Provide severe respiratory distress to prevent aspiration Encourage parents presence Minimize crying if possible Prevent dehydration Administer (iv) fluids at prescribed rate Monitor intake and output Measure urine specific gravity Be prepared to assist with intubation or tracheostomy

6 Have equipment at bed side Reduce parental anxiety Provide information and support; Encourage involvement in childs care Encourage expression of feelings other

For epiglottitis Onset and progression are rapid (6-24 hours) May follow short duration Severe inspiration stridor with marched retractions Sore throat, refusal to eat, dysphagia, high fever, tachycardia, drooling, hoarsness Child sits in Tripod position(erect) Flexed forward at waist with hands on knees for suppot Apprehension, anxiety, restlessness; absence of cough Epiglottitis-This is a medical emergency Initial treatment is based on avoiding agitation of the child and preparation to take the child to OR for intubation by highly skilled personnel Antibiotic therapy Intubation and mechanical ventilation are required Nursing considerations o Prior to OR observe closely o Keep emergency tracheostomyat bed side o Allow child to assume position of comfort o Allow parents to hold and remain with child o Administer antibiotics as prescribed o Avoid agitation in the intubated child because this may cause increased airway edema

Otitis Media Bacterial infection caused most commonly by streptococcus pneumoniae or Haemophilus influenza It is an inflammation/infection of the mid ear caused by the entrance of pathogenic organisms with rapid onset of signs and symptoms. It is a major problem in children but may occur at any age

7 Pathogenic organisms gain entry into the normally sterile middle ear, usually through a dysfunctional Eustachian tube Clinical manifestations o Pain is usually the first symptom o Fever may rise to 40o- 40.6o C (104- 1050 F o Purulent drainage (otorrhea) is present if tympanic membrane is perforated o Irritability may be noted in the young person o Headache, hearing loss, anorexia, nausea and vomiting may be present o History may reveal prior upper respiratory infection, allergies, immunologic defect or head injury (fractured skull) o Diagnostic evaluation Cultures of discharge through ruptured tympanic Pneumatic otoscopy shows a tympanic membrane that is full, bulging and opaque with impaired mobility for retracted mobility o Management Antibiotic treatment: amoxicillin and others Administration of nasal decongestions and or anti histamines to promote Eustachian tube drainage Surgery o Complications Chronic ottitis media and mastoiditis Conductive hearing loss Meningitis , brain abscess o Nursing interventions Nursing diagnosis Pain related to inflammatory process and increased middle ear pressure Risk for infection.. Nursing interventions Relieve pain o Administer analgesics o Administer antibiotics o Be alert for signs of head ache,slow pulse,vomiting, and vertigo which may be significant for ascended infection to brain Facilitate drainage if necessary Prevent complications or reoccurrence Educate family in care of the child Provide emotional support

GENERAL GUIDELINES FOR ASSESSMENT OF RESPIRATORY SYSTEM Respirations: o rate, depth, ease, rhythm, labored breath Evidence of infection: o Fever, enlarged cervical lymph nodes; o inflamed mucous membranes o purulent discharges from nose, ears or lungs cough: o nature, frequency, characteristics wheeze: o expiratory or inspiratory, characteristics cyanosis: o distribution, duration, associated with activity Chest pain: o Location, circumstances, character, deep or superficial Sputum: o Volume, color, viscosity, odor Bad breath: presence or absence

GUIDELINES FOR THE CARE OF THE CHILD WITH RESPIRATORY DISORDERS Nursing assessment Determine the severity of the respiratory distress that the child is experiencing Make an initial assessment o observe the respiratory rate and pattern Count respiratory rate for 1 full minute Observe the child for retractions and note severity and locations Listen to the chest with stethoscope to determine if crackles are present and to evaluate the breath sounds o Observe the childs color and note any presence of cyanosis o Observe for nasal flaring or grunting o Evaluate the childs degree of restlessness, apprehension and motor tone o Note any wheezing, stridor or hoarseness

Nursing diagnosis Effective Airway clearance related to inflammatory or infection process Ineffective breathing pattern related to inflammatory process Fluid volume deficit or risk for fluid volume deficit related to o Fever

9 o Decreased appetite o Vomiting Fatigue related to increased work of breathing Activity intolerance Anxiety related to respiratory distress and hospitalization Parental role conflict related to hospitalization Pain related to infectious process Other

Nursing interventions Promoting effective airway clearance Improving breathing o Place child in comfortable position to promote easier ventilation Semi fowlers- use of pillows, infant seat, elevate head of bed Allow child to assume position which is comfortable o Provide messures to improve ventilation of affected lung Change position frequently Provide postural drainage Relieve nasal obstruction that contributes to breathing difficulties Instill nasal saline drops or prescribed nose drops Apply nasal suctioning Quiet prolong crying which can irritate the airway by soothing the child; however crying may be an effective way to inflate the lungs Realize coughing is a normal tracheobronchial clensing procedure but temporarily relieve coughing by allowing the child to sip water o Administer appropriate medications; antibiotics, broncho dilators, etc,] o Observe the childs response to therapy Promote adequate hydration o Administer (iv) fluids at prescribed rate o To prevent aspiration, withhold all oral food and fluids if the child is in severe respiratory distress o Offer child sips of clear fluid when respiratory status improves Note vomiting, or abdominal distention after oral fluid is given Monitor fluid intake to prevent fluid overload especially when child begins to feed- would have to modify fluid intake Do not force child to take fluids orally because this may cause increased distress and possibly vomiting- anorexia will subside as condition improve Assist the control of fever to reduce respiratory rate and fluid loss o Give antipyretics as prescribed o Increase evaporation from the skin with tepid sponges o Record childs intake and output

10

Promote adequate rest o Disturb the child as little as possible by organizing nursing care and protect child from unnecessary interruptions o Be aware of childs age and be familiar with level of development as it applies to hospitalization o Encourage parents to stay with child as much as possible o Provide opportunities for quiet play Reducing anxiety o Explain procedure and hospital routine to the child as appropriate for age o Provide for quiet stress- free environment o Other Strengthening parent role o Help parents understand the purpose treatment e.g nebulizer and how it works o Discuss fears and concerns about childs therapy o Include the parents in planning for the childs care o Recognize that the parents will need rest periods o Encourage them to take breaks etc.

Family education/health maintenance o o o o Teach the importance of good hygiene. Include information on hand washing and appropriate ways to handle respiratory secretions at home Teach methods to isolate sick from well children in home. Teach the family when it is appropriate to keep the child home from school.. Teach methods to keep child well Teach methods of hydration Provide small amounts Offer clear liquids Other Teach ways to assess for signs of dehydration Decreased no of wet diapers Decreased activity Dry lip or dry mucus membrane No tears when child cries Teach about medication and followup other

o o

11

TERMS TO KNOW Rhonchi: Expiratory noise producing by air passing through swollen edematous airways. The second may have a high or low pitch and is often described as musical or snorelike Stridor: Inspiratory noise often described as a seal back indicating air way obstruction Wheezing: Inspiratory or expiratory noise produced by air passing through edematous mucous membranes over thick secretions and through constricted bronchioles, all of which create a partial obstruction in the bronchi or bronchioles. The sound is high pitched whistle like (sibilant sound) or low snore (sonorous sound) Expiratory grunting: A Moaning sound produced by the approximation of the cocal cords with expiration. It is typically seen in newborns with lower airway obstruction or uneven expansion of the lungs Intercostal or sterna retractions: Secondary to decreased lung compliance. The infant chest is much softer and more pliable than the adults so that when expansion of the lungs meets with increased resistance, the softest parts of the chest will pull inward with inspiration, producing retractions Nasal Flaring: An inspiratory widening of the nares, a primitive reflex with hardly any physiologic significance. It is however, a good sign of general respiratory distress Rales: Inspiratory noice produced by air passing through secretions as in bronchiolitis. This sound is often described as a low pitched bubbling crackling or popping sound

Bibliography: Mott, R.S., James, R.S., & Sperhac, H. A. (1990). Nursing Care of Children & Families (2nd edition).Cummings Publishing company. Canada Nettina,M. S. (1996). The Lippincott Manual of Nursing Practice. (6th ed). Lippincott. New York

12