NCM109Lesson6RespiratoryAlterations.pptx

NCM 109 - RESPIRATORY ALTERATIONS

1. Care for Clients Respiratory Alterations Upper respiratory tract

2. Nasopharyngitis A cold; Also known as coryza Most common infection of the respiratory tract Caused by one or a number of viruses, principally the rhinoviruses, which are spread from one child to another by sneezing, coughing, or direct contact Manifestations: Virus caused inflammation of & edema of the upper respiratory tract, which damages cilia & prevents the drainage of mucus Fever, nasal discharge, irritability, sore throat, cough, & general discomfort are present There may be vomiting & diarrhea Common complications: bronchitis, pneumonitis, & ear infections

3. Nasopharyngitis Treatment & Nursing Care: There is no cure for the common cold. The following treatment is designed to relieve symptoms: Rest: Fatigue should be avoided Clear airways. Instill a few drops of saline solution into the nose & then suction with bulb syringe – best way to clear the nostrils Adequate fluid intake – to prevent dehydration Prevention of fever. Ibuprofen (Motrin) or acetaminophen (Tylenol) can be administered when a high fever accompanies a cold Skin care – a petroleum-based ointment can be applied to the nares & upper lip to prevent skin irritation from nasal discharge

4. Acute Pharyngitis Is an inflammation of the structures in the throat Common among children b/w 5 and 15 years age Caused by: virus – 80% of the cases; Group A beta-hemolytic streptococcus (strep throat) – 20% of the cases Bacterium Haemophilus innfluenzae – common in children under 3 years of age Manifestations include: fever, malaise, dysphagia, anorexia, conjunctivitis, rhinitis, cough & hoarseness A strep throat is determined by throat culture. When culture is positive, penicillin is administered. Erythromycin is administered if allergic to penicillin. Acetaminophen may be taken to relieve soreness of the throat Prompt treatment of strep throat is important to avoid serious complications such as rheumatic fever, glomerulonephritis, peritonsillar abscess, otitis media, mastoiditis, meningitis, osteomyelitis, or pneumonia

5. Tonsillitis & Adenoiditis The tonsils & adenoids, located in the pharynx (throat), are made of lymph tissue & are part of the body’s defense mechanism against infection Symptoms of tonsillitis: difficulty in swallowing & breathing Enlarged adenoids block the nasal passage, resulting in mouth breathing. Other symptoms are similar to those of nasopharyngitis . Nursing care: provide a cool mist vaporizer to keep the mucous membrane moist; salt water gargle; throat lozenges (if age-appropriate); a cool, liquid diet; & acetaminophen to promote comfort Antibiotics are not usually prescribed unless a throat culture is positive for streptococcal organisms Treatment: “T&A” – removal of tonsils & adenoids; not recommended for children under 3 years of age. Tonsillectomy (removal of palatine tonsils) is indicated only if persistent airway obstruction or difficulty in breathing occurs. The surgery is not performed during an acute infectious episode because inflamed tissue responds poorly to surgery

6. Tonsillitis & Adenoiditis The presence of loose teeth should be reported to the anesthesiologist, because there may be a danger of aspiration during the surgical procedure. Frequent swallowing while the child is sleeping is an early sign of bleeding after a tonsillectomy. Postoperative care: Side-lying & partly on the abdomen – to facilitate drainage Watch carefully for evidence of bleeding, such as an increase in pulse & respirations, restlessness, frequent swallowing (which may be from blood trickling down the back of the child’s throat), or vomiting of bright red blood. Ice collar may apply for comfort Coughing, clearing the throat, & blowing the nose are avoided to decrease the risk of precipitating bleeding at the operative site Pain relief & minimize crying (which may further irritate the throat) Complication: hemorrhage (most common) Gargling & highly seasoned food should be avoided during the first postoperative week

7. Sinusitis in Children Sinusitis in an inflammation of the sinuses that can cause them to get blocked & filled with fluid Maxillary & ethmoid sinuses are most often involved in childhood sinusitis s/s are different from those in the adult An acute sinusitis is suspected when an upper respiratory infection lasts longer than 10 days, with a daytime cough. Halitosis often present Untreated sinusitis can lead to: periorbital cellulitis, because the infection spreads from the ethmoid sinus to the subperiosteal space around the eye. Treatment: 10-to-14 day course of antibiotic therapy

8. Croup Syndromes Is a general term applied to a number of conditions whose chief symptom is a “barking” (croupy) cough & varying degrees of inspiratory stridor (a harsh, high-pitched sound) Can be benign or acute Benign croup is frightening but rarely life threatening Acute croup can develop into a respiratory emergency Benign Crouplike Conditions Congenital Laryngeal Stridor ( Laryngomalacia ) Infants are born with a weakness of the airway wall & a floppy epiglottis that causes a stridor ( crowlike noise) on inspiration & there may be an inspiratory retractions Symptoms lessen when the infant is placed prone or propped in the side-lying position & slow, small feedings Respiratory infection & crying may cause the symptoms to become frightening to the parents. The condition usually clears spontaneously as the child grows & the muscle strengthen

9. Croup Syndromes Benign Crouplike Conditions Spasmodic Laryngitis (Spasmodic Croup) usually occurs in children b/w 1 to 3 years of age & can be caused by virus, allergy, or psychological trigger Very often, gastroesophageal reflux will trigger an attack Sudden onset, usually at night & is characterized by a barking, brassy cough & respiratory distress Attacks lasts a few hours, & by morning the child appears normal & is in no distress Increasing humidity & providing fluids are helpful treatment

10. Croup Syndromes Acute Croup Laryngotracheobronchitis Viral condition manifested by edema, destruction of respiratory cilia, & exudate resulting in respiratory obstruction. A mild upper respiratory infection usually precedes the development of a characteristic barking or brassy cough. Stridor develop & classic sign of respiratory distress The infant prefers to be held in upright or sit up in bed (orthopnea) Crying & agitation worsen the symptoms Hypoxia can develop & be accompanied by tachycardia & diminished breath sounds Treatment & nursing care: Increase humidity levels around child – use an electric cold water humidifier Mist tent or croupette IVF to prevent dehydration

11. Croup Syndromes Acute Croup Laryngotracheobronchitis Treatment & nursing care: Oxygen is given to reduce hypoxia Monitor oxygen saturation – maintained above 90% oxygen sat level Opiates – contraindicated because they depress respiration Sedatives – contraindicated because it can mask the sign of respiratory distress (is a primary sign of increased respiratory obstruction) Nebulized epinephrine may be used to relieve symptoms of respiratory obstruction Corticosteroids to reduce edema caused by inflammation & prevent further destruction of ciliated epithelium

12. Epiglottitis Swelling of the tissues above the vocal cords, that is, supraglottic swelling Results in narrowing of the airway inlet, with the possibility of total obstruction Caused by H. influenza type B Most often occurs in children 3 to 6 years of age Occur in any season The course is rapid & progressive Is a life-threatening medical emergency Blood gases fluctuate & leukocytosis Manifestations: Child insists on sitting up, leans forward with the mouth open & drools saliva because of the difficulty in swallowing Child appears wide-eyed, anxious & restless Emit a froglike croaking sound on inspiration

13. Epiglottitis Manifestations: Cough is absent Enlarged, reddened edematous epiglottis much like a “beefy – red thumb” The examining tongue blade may trigger a laryngospasm & result in sudden respiratory arrest – tracheostomy set at the bedside before any examination of the throat is attempted. Treatment: Immediate tracheotomy or endotracheal intubation – treatment of choice Oxygen – prevent hypoxia, brain damage, & sudden death caused by respiratory arrest Parenteral antibiotic therapy – results in a dramatic improvement within a few days Pr evention: H. influenza type B conjugate vaccine be administered beginning at 2 months of age as part of a regular immunization program for all children

14. Care for Respiratory Alterations Lower respiratory tract

15. Bronchitis Infection of the bronchi It seldom occurs as a primary infection but is usually secondary to a cold or communicable disease Caused by a variety of organisms Poor nutrition, allergy, & chronic infection of the respiratory tract may precipitate this condition Most patients are under 4 years of age Manifestations: Gradual onset of unproductive “hacking” cough is preceded by an upper respiratory infection, or cold. The cough may become productive with purulent sputum Treatment: Cough suppressants before bedtime may be helpful in promoting restful sleep Antihistamines, cough expectorants, & antibiotics are usually not helpful

16. Bronchiolitis Is a viral infection of the small airways (bronchioles) in the lower respiratory tract Respiratory syncytial virus (RSV) is the causative organism in 50% of cases in infants Occurs in infants & children 6 months to 2 years of age, with a peak at 6 months of age Manifestations: Upper respiratory infection or cold, with a mild fever & serous (clear) nasal discharge is followed by the development of a wheezing cough & signs of respiratory distress Increase in RR interferes with successful feeding, infant becomes irritable & dehydrated An apneic episode is usually the cause of hospitalization Infants with bronchiolitis may develop a hyperactive airway or asthma later in life Treatment & Nursing Care: Treatment is symptomatic & is similar to the child with croup Semi-fowlers position with a slightly hyperextended neck facilitates respirations Oral feeding are supplemented by IVF I&O are recorded Bronchodilating aerosol therapy & high humidity tents are prescribed

17. Respiratory Syncytial Virus (RSV) Single most respiratory pathogen in infancy Is responsible for 50% of cases of bronchiolitis in infants & young children Most common cause of viral pneumonia Infants b/w 2 & 7 months of age can become seriously ill with these condition because their airways are so small & prone to obstruction by the thick mucus produced. Transmission: RSV is spread by direct contact with respiratory secretions, usually by contaminated hands to the mucus membranes (eyes, mouth, nose) Survive more than 6 hours on countertops, tissues, & soap bars Not spread via the airborne route Incubation period – 4 days Hospital cross infection is a major problem because caregivers may be carrying the organism. For this reason, an infant diagnosed with RSV infection is placed on standard contact (isolation) precautions to prevent the spread of RSV to other sick children

18. Respiratory Syncytial Virus (RSV) Diagnosis Nasopharyngeal washings for RSV antigen Treatment & Nursing Care Infection control techniques are used to prevent the spread of infection to other on the unit Contact isolation precautions are used to prevent fomite spread Frequent washing is essential Liquid soap dispensers should be available at the sink, because the organism survives for a long period on a dry bar soap Symptomatic Care Report tachypnea & tachycardia – may indicate hypoxemia Auscultate breath sounds & report wheezing, rales or ronchi . A child who has been wheezing & suddenly has a “quiet chest” on auscultation may be at risk for respiratory arrest Monitor signs of respiratory distress

19. Respiratory Syncytial Virus (RSV) Symptomatic Care Oxygen saturation levels are monitored, & oxygen is administered at levels needed to maintain a minimum of 90% to 95% saturation Suctioning of mucus may be required to maintain a patent airway Monitor IV fluids & recording of I&O – prevent dehydration Urine output should be a minimum of 1 to 2 ml/kg/ hr for infants at risk of dehydration Pedialyte or Ricelyte – clear liquid electrolyte formulas prescribed for infants at risk for dehydration Inhaled bronchodilators or steroids are not helpful with RSV infections Antiviral Medications Ribavirin ( Virazole ) Prescribed for use for severely ill infants or infants wo have lung & heart problems that place them at high risk for serious complications Effective in the treatment of RSV infection but is rarely used prophylactically because of its serious s/e

20. Respiratory Syncytial Virus (RSV) Antiviral Medications Ribavirin ( Virazole ) Administered by fine-droplet aerosol mist while the infant is in a mist tent It is administered 18-24 hours a day for a minimum of 3 days Caregivers & visitors who are of childbearing age, pregnant or breastfeeding should not care for infants receiving ribavirin because teratogenic effects have been reported Ribavirin mist can cause precipitation on the surface of plastics, therefore caregivers with contact lenses may develop conjunctivitis because of the lens changes Linen removed from the bed should be slowly rolled & carefully folded to avoid releasing droplets of ribavirin into the air

21. Status Asthmaticus Is continued severe respiratory distress that is not responsive to drugs, including epinephrine & aminophylline This is a medical emergency Child requires immediate admission to the ICU Oxygen is administered via nasal cannula because mist in a mist tent can cause coughing or wheezing v/s & flow of IV medications are carefully monitored The principles of asthma treatment are as follows: Daily monitoring Symptom diary Treatment plan with active participation of the child Identification & avoidance of triggers

22. Pneumonia Or pneumonitis is an inflammation of the lungs in which the alveoli (air sacs) become filled with exudate & surfactant may be reduced. The affected portion of the lung does not receive enough air Breathing is shallow Classification may be by causative organism (i.e., bacterial or viral) or by the part of respiratory system involved (i.e., lobar or bronchial) Group B streptococci are the most common cause of pneumonia in NBs, Chlamydia is the most common cause of pneumonia in infants 3 weeks to 3 months of age RSV, rhinovirus, adenovirus & pneumococcus are other organisms that are responsible for pneumonia in infants & children H. influenza type B infection has been decreasing with current immunization programs Lipoid pneumonia occurs when the infant inhales an oil-based substance into the airways (i.e., cod liver oil, castor oil & oil-based nose drops) Hypostatic pneumonia may occur in patients who have poor circulation in their lungs & remain in one position too long.

23. Pneumonia Severe acute respiratory syndrome (SARS) is a severe type of pneumonia caused by the corona virus (SARS- CoV ). Symptoms similar to pneumonia, but often the severity of the respiratory distress requires assisted ventilation & treatment. Airborne isolation precautions are recommended Manifestations: may develop suddenly or preceded by URTI Cough is dry at first, but it gradually becomes productive Fever rises as high as 39.5 to 40 degrees Celsius & may fluctuate widely in 24-hour period Tachypnea Chest pain Sternal retractions Nasal flaring Diagnosis Chest X-ray Blood specimen – increased WBC count

24. Pneumonia Treatment Antipyretics to reduce fever Oxygen – for dyspnea or cyanosis Increase fluid intake Pediazole (a combination of erythromycin ethysuccinate & sulfisoxazole acetyl) may be prescribed for infants younger than 6 months of age, but amoxicillin is the drug of choice for children up to 5 years of age Rest, fluids, & cough suppressant before bedtime are the basics of home care. Parents education concerning the need to complete all medication prescribed is essential Tobacco use in the environment should be avoided H. influenza type B immunizations is stressed Proper use & disposal of tissues, covering mouth during a cough, & proper handwashing techniques are preventive measures to teach the family

25. Bronchopulmonary Dysplasia (BPD) Is a fibrosis or thickening of the alveolar walls & the bronchiolar epithelium caused by oxygen concentrations above 40% or by the mechanical pressure ventilation given to NBs for a prolonged time Swelling of the tissues causes edema, & the respiratory cilia are paralyzed by the high oxygen concentrations & lose their ability to clear mucus from the airways. Respiratory obstruction, mucus plugs, & atelectasis follow. Prevention: Respiratory distress in the NB is the major reason why oxygen & ventilators are used for prolonged periods Main cause of respiratory distress in the NB is PREMATURITY . The prevention of preterm births is the best way to prevent BPD Goal of treatment for respiratory distress in the NB: Administer only the amount of oxygen required to prevent hypoxia at the minimum ventilator pressures needed to prevent tissue trauma Use of antenatal steroids to hasten lung development during preterm labor Administration of surfactant within 15 minutes after delivery in a very premature infant

26. Bronchopulmonary Dysplasia (BPD) Symptoms: Symptoms of chronic respiratory distress include the following: Wheezing Cyanosis on exertion Use of accessory respiratory muscles Clubbing of the fingers Failure to thrive Irritability caused by hypoxia Treatment: Goal of therapy – reduce inflammation of the airway & to wean the infant from the mechanical ventilator Noninvasive ventilation techniques: synchronous intermittent mandatory ventilation (SIMV) via nasal cannula prongs, continuous positive airway pressure (CPAP), high-flow blended nasal cannulas, & high0flow humidified oxygen – safer & may minimize the development of BPD

27. Bronchopulmonary Dysplasia (BPD) Treatment: Fluid restriction, bronchodilators & diuretics may be prescribed Nasogastric tube feedings may be required to conserve energy while maintaining adequate nutrition Ongoing home care is required & respiratory problems persist through adulthood. Maintaining optimum growth & development is a challenge Education & support of the family for a technology-dependent child at home are essential, & a multidisciplinary health care team approach is essential When oxygen is used un the home, the family should be taught safety precautions to prevent fire & injury.

28. Cystic Fibrosis (CF) An inherited recessive trait, with both parent carrying the a gene for the disease There is a defect in chromosome number 7 that is thought to have developed many years ago as a protective response of the human body against cholera. As the chromosomes mutated to develop the body’s resistance to cholera, the change in gene resulted in another defect that cause CF. CDC (Centers for Disease Control & Prevention) highly recommends screening of all NBs for CF by use of a measure of immunoreactive trypsinogen level, which id elevated in CF. The screening will enable early detection & treatment Basic defect: exocrine gland dysfunction that includes: Increased viscosity (thickness) of mucous gland secretions A loss of electrolytes in sweat because of an abnormal chloride movement

29. Cystic Fibrosis (CF) CF is considered a multisystem disease because the thick, viscid secretions affect the following: The respiratory system: Small & large airways are obstructed by the thick secretions, resulting in difficulty breathing. The thick secretions in the lungs & response of tissues to infections cause hypoxia that can result in heart failure. Emphysema, wheezes, & respiratory distress are common. The digestive system : The thickened secretions prevent the digestive enzymes from flowing to GIT, resulting in poor absorption of food & general growth failure. Bulky, foul-smelling stools that are frothy because of undigested fat content. Thick, impacted feces can cause rectal prolapse. Pancreatic, liver, & biliary obstruction occur. Skin: Loss of electrolytes (sodium & chloride) in the sweat causes a “salty” skin surface. Loss of electrolytes via the skin predisposes the child to electrolyte imbalances during hot weather. Reproductive system: Thi9ck secretions can decrease sperm motility. Thick cervical mucus can inhibit sperm from reaching the fallopian tubes.