N317 Nursing Care of Children

Altered Respiratory Status

Acute Upper & Lower Infections

General Principles

URI caused by viruses Rhinovirus, RSV

Most Common Bacteria B-Hemolytic Strep Staph. Aureus H. Influenza Pneumococcus

General Principles

Type of Organism “Dose” or amt. Of Exposure

Age of Child--Young children—>Sicker Child’s Immune System Seasonal variations

RSVDec.Mar., Peak in February

Nasopharyngitis “Common Cold”

Etiology Viral-Rhinovirus S/S

Dry, hacking cough ↑nasal discharge (mucous) ↓appetite & activity Sneezing, chills, irritability

Tx Supportive – no ASA Rest, Fluids Self limiting 4-10 days Do NOT give expectorants or

cough meds to infants and young children due to risk of S.E.

Complications: O.M.

S/S Pharyngitis “Sore Throat”

Viral Bacterial

Cause Virus Group-A ß-hemolytic Strep (GABHS)

Onset Gradual Sudden

Fever Low grade Over 100°

Throat Red – slight to no exudate

Cherry –red, white exudates

Symptoms Cough, hoarse H/A, abd. Pain, enlarged lymph nodes

Management of Strep Throat

MUST get throat culture or Rapid Strep Screen to make Dx

Usual drug of choice: Penicillin---10 days IF ALLERGIC TO PENICILLIN:

Erythromycin, azithromycin (Zithromax), clarithromycin (Biaxin), cephalosporins

PCN + Rifampin is more effective than PCN alone in carriers & those with resistant strains

24° quarantine after begin antibiotics Symptomatic Tx Teach imp. of taking all antibiotics & to get new

toothbrush after 24° on meds Risk for: rheumatic fever, acute glomerulonephritis

Otitis Media Common causative agents—Strep pneumoniae, H.

influenzae Patho / Etiology

Short-wide eustachian tubes which allows for bacteria to be swept into them when tube opens; also more horizontal so don’t allow for drainage easily.

Increased Lymphoid tissue Pooling of fluids (milk from bottle) in pharynx At risk: cleft palate, Down syndrome, day care, propping

bottle, living with smoker(s) Peak age: 6-36 mons; winter

Otitis Media S/S

Tympanic membrane Red Bulging → Obstructed Light reflex No visible bony landmarks

Earache Temp---1040 F common Swollen Glands Cold Sx Crying/irritable when supine

Eardrum may Rupture → Decrease in pain Increase in ear drainage (on pillow)

Management of Otitis Media

AntibioticsP.O.:Amoxicillin, Augmentin, Trimethoprim-sulfamethoxazole (Bactrim, Septra), E-mycin-sulfisoxazole (Pediazole), Azithrmycin (Zithromax), Clarithromycin (Biaxin), Cephalosporins. IM Ceftriaxone (Rocephin) Analgesics for pain and temperature; warmth to ears; keep upright

as much as possible Chronic OM: prophylactic antibiotics for 6 mos or Surgery Myringotomy to insert tympanostomy tubes

Complications Hearing Loss, eardrum scarring, adhesive otitis media, chronic

OM, mastoiditis

Acute Otitis Media Ear Tube

Note lack of light reflex, no bony prominences, bright red, bulging appearance of tympanic membrane

Otitis Externa

Normal ear flora becomes pathogenic in excessive wet/dry conditions (trauma or “swimmer’s ear”)

Pain, edema so can’t visualize TM, hearing loss, cheesy green-blue-gray discharge

Tx: antibiotic drops, 3-4x/day til pain & swelling gone, then more days

Prevention: 50:50 sol. of ETOH/white vinegar gtts after swim or bath; 5”

each ear Nothing in ear smaller than “elbow” Limit stay in water & dry ears after (with towel)

Tonsillitis Lymphoid tissue located in

pharyngeal cavity becomes infected by viral or bacterial agent

Symptoms Palatine tonsils edematous (3-4+)

– blocks food/air Adenoids (pharyngeal tonsils)

block air from nose to throat Obstructed nasal breathing →

bad breath from mouth breathing & nasal voice

Persistent cough May block eustachian tubes→OM

Usually self limiting if viral – must do throat culture

Resource with drawings on Tonsils & Adenoidshttp://www.entnet.org/healthinfo/throat/tonsils.cfm

tonsillitis

Hypertropic tonsils

T & A Surgery if documented frequent strep throats Tonsillectomy not done until after age 3 or 4 Adenoids can be removed if < 3yrs if obstructed nasal breathing Pre-op

H&P, CBC, Bleeding Time, check for any loose teeth Post-op

#1 priority---Assess for Bleeding – watch for excessive swallowing!!

Pain Relief Hydration No milk products or anything red

Discharge Instructions No Spicy foods Avoid Gargles, vigorous brushing Check for bleeding – up to 10 days post op Foul breath odor, earache, Temp.↑

Infectious Mononucleosis

Def: acute, self-limiting infectious disease, common under age 25. Increase of mononuclear elements of the blood

Etiology:• Epstein Barr Virus(EBV) - direct transmission

with oral secretions• Incubation: 4-6 weeks after exposureSymptoms: Fatigue may last 1-2 mos

malaise, sore throat, fever, HA, lymphadenopathy,spleenomegaly, rash, exudative pharyngitis

Infectious Mononucleosis

Diagnosis:1. Self reported symptoms2. Monospot (EBV antigen test); WBC - atypical lymphocytes3. Heterophil antibody test (mono titer-1:160 is diagnostic)Management:1. Mild analgesia; antipyretics2. Bed rest; fluid intake3. Enlarged spleen - no contact activities4. Penicillin - if Strep. B is cultured from pharynx; NO ampicillinPrognosis:Self-limitingAvoid contact with live virus vaccines for several months after

recovery!!! Depressed cellular immune reactivity.

Croup Syndromes (middle airways infections)

Symptom complex: hoarseness a resonant “barky” cough varying degrees of inspiratory stridor respiratory distress resulting from

swelling/obstruction in the region of the larynx.

Acute Epiglottitis

Def: inflammation and swelling of the epiglottis.

Etiology/Pathophysiology: ages 2-8. Haemophilus influenza most common Epiglottis become cherry red, swollen, causing

obstruction of airway, secretions pool in the larynx and pharynx, complete obstruction within 2 to 6 hours.

Froglike croak on inspiration Sudden onset; medical emergency

Acute EpiglottitisAssessment: Sudden onset high fever & extreme sore throat The 4 D’s: dysphonia, dysphagia, drooling,

distress Anxious, restless, tripod position. Inspiratory stridor, tongue protrusion Contraindication: exam of throat unless

incubation equipment & personnel are available **could result in spasm & complete obstruction of airway.

Acute EpiglottitisAssessment cont.: Lateral neck x-ray Never leave child unattended or without

intubation equipment near Usually intubated for 24 hours; restraints may

be necessary Always stay calm and help child and parent

stay comfortable and calm

TX: antibiotics 7-10 days; antipyretics, discharge in abt 3 days from hospital

Acute Laryngotracheobronchitis(LTB) - CROUP

Def: viral; inflammation, edema, narrowing of larynx, trachea, and bronchi

Common in infants, toddlers; Boys>girls; most common of croup syndromes*****

Causative agents: parainfluenzae virus, influenzae A and B, RSV & mycoplasma pneumoniae

Inflammation/narrowing airways inspiratory stridor + suprasternal retractions

Thick secretions produced + edema obstruction of airway hypoxia + CO2 accumulation resp acidosis & failure

Croup: assessment and tx

Assessment & Tx Onset gradual, often after URI; low-grade fever, barking cough,

acute stridor, accessory muscles, retractions Pulse-OX, CXR: AP and Lat upper airways Watch for cyanosis, drooling Humidified O2, IV fluids Assist child to position of comfort; keep parents near Meds: Nebulized Racemic Epinephrine preferred over beta 2

adrenergic agonists, po corticosteroids like prednisone or Orapred

Teaching: viral, worse at night & may recur for several nights, use cool mist humidifier in bedroom

Seek medical help immed. if breathing is labored, child seems exhausted or very agitated, or cool air humidity tx does not improve symptoms

Bronchitis (lower airways)

Inflammation of the large airways; viral; usually associated with a URI, abrupt

Symptoms: persistent dry, hacking, nonproductive cough; worse at night; productive by 2nd to 3rd day; low-grade fever

Mild self-limiting; 5-10 days Symptomatic tx: analgesics, fluids, rest &

humidity; cough suppressants only if can’t rest d/t cough

Respiratory Syncytial Virus (bronchiolitis~ lower airway, cont’d)

Viral - produces serious lower respiratory infections, esp. pneumonia or bronchiolitis

Young children/infants (2-24 mo) 1-6 months highest risk; 50% will be infected

Older children: rhinorrhea, sore throat, cold Close contact: aerosols from coughing or

sneezing; also contaminated objects. Not airborne – contact isolation

Incubation: 4 to 8 days Viral shedding: ~ 2 weeks

RSV – Assessment Begins w/simple URI; fever (102°); can progress to

severe Respiratory Distress quickly Thick nasal secretions, wheezing, fine rales; cough,

anorexia, retractions, nasal flaring in infants

Severe: tachypnea, dyspnea, hypoxia, cyanosis, can progress to apnea

Assessment: lung auscultation, oximetry RSV swab/washings (nasopharynx, throat)—positive result CXR: overinflation, thickening, infiltrates CBC w/differential: viral shift usually present Arterial blood gases—only in severe cases

Respiratory acidosis

RSV: Treatment Droplet and Contact Isolation is critical:

with gown, glove, mask, when holding infant Cool oxygenated mist, hydration, rest, suctioning,

careful monitoring of SaO2 Respiratory Treatments via Nebulizer

beta adrenergic agonists~Albuteral, Xopenex, racemic epinephrine--AAP does NOT recommend these anymore.

Relieve bronchospams; EBP does not support efficacy Corticosteroids—may be given as anti-inflammatory Riboviran—Nebulizer anti viral agent; precautions

Respigam—IV Immunoglobulin requires 1:1 RN Synagis—(palivizumab) RSV “Vaccine”

Costly, but very worthwhile to high-risk infants IM/Monthly during high season Indicated for preemies + hx of RDS, CHD

Pneumonia

Inflammation of Lung Parenchyma Bronchioles; alveolar spaces

Causes (can be 1° or 2°) Viral (RSV) Bacteria

Pneumoncocci S. pneumoniae

Staph aureus / Strep Chlamydia

Primary atypical (community acquired) Mycoplasma

Assessment and Diagnosis of Pneumonia

Viral Etiology Mild fever, slight cough

& malaise OR High fever, severe

cough, & resp. distress (RSV)

Unproductive cough Rhinitis Breath sounds~ few

wheezes, fine crackles X-ray~diffuse, patchy

infiltration R/o bacterial or

mycoplasma (CBC, bld cultures, microbiology

Bacterial Etiology High fever & tachypnea Bacteria in bloodstream travel to lungs

and ↑ there Cough~unproductive→productive

w/white sputum; exhausting Breath sounds~rhonchi or crackles Retractions, chest pain, nasal flaring Pallor-cyanosis X-ray~diffuse or patchy infiltration; ↑fluid

as alveoli fill w/fluid & exudates May involve 1 segment or entire lung Behavior~ irritable, restless, lethargic GI~ anorexia, V&D, abdominal pain WBC (neutrophils) ASO titer if Strep

Treatment of Pnemonia

Viral Supportive care:

antipyretics & hydration Self limiting Monitor lung sounds, VS,

respiratory status of patient; oximetry; bld gases

Humidification; O2 prn Chest physiotherapy Antibiotics are not indicated

unless for prophylactic use Teach parents s/s of

dehydration & ↑ resp distress

Bacterial Antibiotics are indicated Outpatient~ may use po

Amoxicillin clavulanateAmoxicillin clavulanate (Augmentin) or 2nd generation cephalosporincephalosporin

Hospitalized pt~ parenteral antibiotic therapy with Ampicillin Ampicillin sulbactamsulbactam(Unasyn) and cefuroximecefuroxime

All interventions for viral etiology All interventions for viral etiology are also implemented hereare also implemented here

May need to splint chest d/t May need to splint chest d/t coughcough

Primary Atypical Pneumonia

Etiology: mycoplasma pneumoniae, fall/winter; crowded living conditions. Peak ages 5-12yrs.

Symptoms: sudden/insidious onset. Fever, HA, malaise, anorexia, myalgia, rhinitis, sore throat, cough; fine crackles over lung fields. May last up to 2 wks.

Management:

Most recover in 7-10days with symptomatic treatment. Hospitalization not usually necessary. Erythromycin drug of choice.