Chapter 18:

Nursing Care of the Child With an

Alteration in Gas Exchange/Respiratory
Disorder

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Anatomy and Physiology of the Childs

Nose and Throat
Nose
Infants are obligate nose breathers; they cannot open their
mouths to breathe, produce very little mucus, which makes
them more susceptible to infections.
Newborns have very small nasal passages, making them
more prone to obstruction; sinuses are not developed,
making them less prone to sinus infection.
Throat
Infants tongues relative to oropharynx are larger;
placement of tongue can lead to airway obstruction.
Children have enlarged tonsillar and adenoid tissue, which
can lead to airway obstruction.

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Childs Airway

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Lower Respiratory Structures

Bifurcation of trachea occurs at level of the third thoracic
vertebra in children, compared to the sixth in adults.
Important when suctioning or intubating children.
The bronchi and bronchioles of infants and children are
narrower in diameter than the adults.
Increased risk for lower airway obstruction.
Smaller numbers of alveoli.
Higher risk of hypoxemia.

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Inspection and Observation of the

Respiratory System
Color: pallor, cyanosis, acrocyanosis
Rate and depth of respirations: tachypnea
Nose and oral cavity
Cough and other airway noises: atelectasis, stridor
Respiratory effort
Anxiety and restlessness
Clubbing
Hydration status

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Adventitious Breath Sounds

Wheezing
High-pitched sound on inspiration or expiration.
May occur with obstruction in lower trachea or
bronchioles.
May occur in asthma or viral infections.
Rales
Crackling sounds heard when alveoli become fluid filled.
May occur with pneumonia.

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Question
The nurse is percussing the chest of a child with a
suspected respiratory disorder. What sound might the
nurse note that would indicate pneumonia?
a. Decreased fremitus
b. Dull sound
c. Tympany
d. Hyperresonance

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Answer
b. Dull sound. A dull or flat sound would be percussed
over partially consolidated lung tissue, as occurs with
pneumonia.
Rationale: Decreased fremitus is found on palpation and
may be found with barrel chest, as may occur with cystic
fibrosis. Tympany might be percussed with
pneumothorax, and hyperresonance might be apparent
with asthma.

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Laboratory and Diagnostic Tests Ordered

for Respiratory Disorders
Pulse oximetry: oxygen saturation might be decreased
significantly.
Chest radiograph: might reveal hyperinflation and patchy
areas of atelectasis or infiltration.
Blood gases: might show carbon dioxide retention and
hypoxemia.
Nasal-pharyngeal washings: positive identification of RSV
or other viral illness via enzyme-linked immunosorbent
assay (ELISA) or immunofluorescent antibody (IFA)
testing.
Rapid strep testing via throat swab culture.

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Other Laboratory and Diagnostic Tests

Ordered for Pneumonia
Pulse oximetry: oxygen saturation might be decreased
significantly or within normal range.
Chest x-ray: varies according to child age and causative
agent.
Sputum culture: may be useful in determining causative
bacteria in older children and adolescents.
White blood cell count: might be elevated in the case of
bacterial pneumonia.

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Laboratory and Diagnostic Tests Ordered

for Cystic Fibrosis
Sweat chloride test: considered suspicious if the level of
chloride in collected sweat is above 50 mEq/L and diagnostic if
the level is above 60 mEq/L.
Pulse oximetry: oxygen saturation might be decreased,
particularly during a pulmonary exacerbation.
Chest radiograph: might reveal hyperinflation, bronchial wall
thickening, atelectasis, or infiltration.
Pulmonary function tests: might reveal a decrease in forced
vital capacity and forced expiratory volume, with increases in
residual volume.

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Common Medical Treatments for

Respiratory Disorders
Oxygen
High humidity
Suctioning
Chest physiotherapy and postural drainage
Saline gargles or lavage
Mucolytic agents
Chest tubes
Bronchoscopy

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Question
The nurse is caring for a child with cystic fibrosis. Which
of the following treatments would be used to promote
mucus clearance through percussion or vibration?
a. Suctioning
b. Chest tube
c. Bronchoscopy
d. Chest physiotherapy

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Answer
d. Chest physiotherapy. Chest physiotherapy promotes
mucus clearance through percussion or vibration.
Rationale: Suctioning removes secretions via bulb
syringe or suction catheter, chest tubes remove air or
fluid though a drain inserted into the pleural cavity, and
bronchoscopy is the introduction of a bronchoscope into
the bronchial tree for diagnostic purposes.

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Acute Infectious Disorders

Common cold, sinusitis
Influenza
Pharyngitis, tonsillitis, and laryngitis
Croup syndromes
Respiratory syncytial virus (RSV)
Pneumonia and bronchitis

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Risk Factors for Respiratory Disorders

Prematurity
Chronic illness (diabetes, sickle cell anemia, cystic fibrosis,
congenital heart disease, chronic lung disease)
Developmental disorders (cerebral palsy)
Passive exposure to cigarette smoke
Immune deficiency
Crowded living conditions or lower socioeconomic status
Daycare attendance

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Signs and Symptoms of Bronchiolitis

(RSV)
Onset of illness with a clear runny nose (sometimes
profuse).
Pharyngitis.
Low-grade fever.
Development of cough 1 to 3 days into the illness,
followed by a wheeze shortly thereafter.
Poor feeding.
Vaccination is available for at-risk populations.

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Risk Factors for Tuberculosis

HIV infection.
Incarceration or institutionalization.
Positive recent history of latent TB infection.
Immigration or travel to endemic countries.
Exposure at home to HIV-infected or homeless persons,
illicit drug users, persons recently incarcerated, migrant
farm workers, or nursing home residents.

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Signs and Symptoms and Risk Factors for

a Pneumothorax
Signs and symptoms
Chest pain might be present as well as signs of
respiratory distress such as tachypnea, retractions,
nasal flaring, or grunting.
Risk factors
Chest trauma or surgery, intubation and mechanical
ventilation, or a history of chronic lung disease such
as cystic fibrosis.

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Chronic Respiratory Disorders

Allergic rhinitis
Asthma
Chronic lung disease (bronchopulmonary dysplasia)
Cystic fibrosis
Apnea

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Asthma Severity Classification

Tiered system of therapy with fast acting short-acting 2

agonist (SABA) later adding by longer-acting 2 agonist
(LABA) if symptoms persist.
Classified by severity:
mild (no or minor interference in normal activity,
FEV >80% of predicted).
moderate (some limitation of activity, FEV 60% to
80% of predicted).
severe (extremely limited, FEV <60% of
predicted).
Frequency of symptoms.
- intermittent or persistent.

Adapted from National Asthma Education and Prevention Program. (2007). Expert panel report 3: Guidelines for
the diagnosis and management of asthma (NIH Publication No. 07-4051). Bethesda, MD: National Institutes of
Health, National Heart, Lung and Blood Institute.

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Question
Is the following statement true or false?
The nurse caring for a child with asthma documents lung
function as forced expiratory volume (FEV) 60% to 80%
of predicted. This child is classified as having intermittent
asthma.

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Answer
False. A child with lung function documented as forced
expiratory volume (FEV) 60% to 80% predicted is
classified as having moderate persistent asthma.
Rationale: Intermittent and mild persistent asthma is
FEV 80% or more and severe persistent asthma is FEV
less than 60% of predicted.

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Cystic Fibrosis

Complex genetic disease affecting both the respiratory

and gastrointestinal (GI) systems.
Characterized by excess thick, tenacious mucus lining
airways causing decreased resistance to infection and
air trapping.
Eventually can destroy pulmonary parenchyma.
GI symptoms include decreased pancreatic enzymes
and hypersecretion of gastric acids.
Diagnostic testing includes chloride sweat testing.

Adapted from Federico, M. J. (2011). Respiratory tract & mediastinum. In W. W. Hay, M. J. Levin, J. M. Sondheimer, &
R. R. Deterding (Eds.), Current pediatric diagnosis and treatment (20th ed.). New York: McGraw-Hill; and Hazle,
L. A. (2010). Cystic fibrosis. In P. J. Allen, J. A. Vessey, & N. A. Schapiro (Eds.), Primary care of the child with a
chronic condition (5th ed.). St. Louis: Mosby.

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Methods of Oxygen Delivery

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Alternatives to Traditional Mechanical

Ventilation
Mode

Description

High-frequency oscillators

Provide respiratory rates up to 1200

bpm with low tidal volume.

Nitric oxide inhalation

(iNO)

Inhaled nitric oxide gas, causes

vasodilation to increase blood flow to
alveoli.

Perfluorocarbon liquid

Acts like a surfactant; provides

improved gas exchange.

Extracorporeal membrane
oxygenation (ECMO)

Blood is removed from the body,

warmed, oxygenated and returned to
the patient via pump.

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Nursing Management of Epiglottis

Do not attempt to visualize the throat.
Do not leave the child unattended.
Do not place the child in a supine position.
Provide 100% oxygen in the least invasive manner.
If complete airway occlusion occurs, tracheostomy may
be necessary.
Ensure emergency equipment is available.

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Nursing Care Posttonsillectomy

Promoting airway clearance
Place child in side-lying or prone position.
Maintaining fluid volume
Discourage coughing.
Encourage fluids; avoid citrus, brown, or red fluids.
Relieving pain
Ice collar and analgesics with or without narcotics.

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Acute Noninfectious Respiratory Disorders

Epistaxis
Foreign body aspiration
Respiratory distress syndrome
Acute respiratory distress syndrome
Pneumothorax

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Interventions to Minimize Psychosocial

Impact of Chronic Respiratory Conditions
Promoting childs self-esteem through education and
support.
Allowing school-age child to take control of management
of the disease.
Promoting family coping through education and
encouragement.
Providing culturally sensitive education and interventions.

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