Chapter 40 Nursing Care of the Child with an Alteration in Gas Exchange/Respiratory Disorder

Question 1

Gas Exchange

Answer 1

Refers to the process by which oxygen is transported to cells and carbon dioxide is transported from cells

Question 2

What is the most common cause of illness & hospitalization in children?

Answer 2

Alterations in gas exchange (Respiratory Disorders)

Question 3

Contributing Factors to Respiratory Disorders

Answer 3

Child’s Age: Immature immune system
- Smaller airways

Socioeconomic status: Access to healthcare and good nutrition
- Poor living conditions

General Health Status: Pre-existing conditions

Season: Fall and Winter most prominent

Question 4

Variations in Pediatric Anatomy & Physiology: Nose

Answer 4

Newborns are preferential nose breathers until at least 4 weeks of age.
- Cannot automatically open his or her mouth to breathe if the nose is obstructed.
- The nares must be patent for breathing to be successful while feeding.
- Newborns breathe through their mouths ONLY while crying.

The upper respiratory mucus serves as a cleansing agent, yet newborns produce very little mucus, making them more susceptible to infection.

Newborns and young infant have very small nasal passages, so when excess mucus is present, airway obstruction is more likely.

Infants are born with maxillary and ethmoid sinuses present.

The frontal sinuses (most often associated with sinus infection) and the sphenoid sinuses develop by age 6 to 8 years.
- Therefore, younger children are less apt to acquire sinus infections compared to adults.

Question 5

Variations In Pediatric Anatomy & Physiology: Throat

Answer 5

The tongue of the infant relative to the oropharynx is larger than in adults
- Posterior displacement of the tongue can quickly lead to severe airway obstruction.

Through early school age, children tend to have enlarged tonsillar and adenoidal tissue even in the absence of illness. T
- Can contribute to an increased incidence of airway obstruction.

Question 6

Variations In Pediatric Anatomy & Physiology: Trachea

Answer 6

Airway lumen is smaller in infants and children than in adults
- When edema, mucus, or bronchospasm is present, the capacity for air passage is greatly diminished.

A small reduction in the diameter of a child’s airway (resulting from the presence of edema or mucus) will result in an exponential increase in resistance to airflow
- Increased work of breathing (effort or labor associated with respiration) then occurs

Question 7

Variations in Pediatric Anatomy & Physiology: Larynx

Answer 7

In teenagers and adults, the larynx is cylindrical and fairly uniform in width.

In infants and children younger than 10 years old, the cricoid cartilage is underdeveloped -> laryngeal narrowing
- Thus, in infants and children, the larynx is funnel shaped. In addition, the larynx and glottis are located higher in the neck, increasing the chance of aspiration of foreign material into the lower airways

Question 8

Variations In Pediatric Anatomy & Physiology: Lower Respiratory Structures

Answer 8

The bifurcation of the trachea occurs at the level of the third thoracic vertebra in children, compared to the level of the sixth thoracic vertebra in adults
- Contributes to risk for foreign material aspiration.

The bronchi and bronchioles of infants and children are narrower in diameter than the adult’s, placing them at increased risk for lower airway obstruction
- Lower airway obstruction during exhalation often results from bronchiolitis or asthma or is caused by foreign body aspiration into the lower airway.

Alveoli are developed at approximately 24 weeks’ gestation
- Term infants are born with ~ 150 million alveoli.
- At some point between the age of 3 and 8 years, the child has developed the adult number of alveoli of around 300 million

Alveoli make up most of the lung tissue and are the major sites for gas exchange.
- Oxygen moves from the alveolar air to the blood, while carbon dioxide moves from the blood into the alveolar air.
- Smaller numbers of alveoli, particularly in the premature and/or young infant, place the child at a higher risk of hypoxemia & CO2 retention

Question 9

Hypoxemia

Answer 9

Deficiency in the concentration of oxygen in arterial blood

Question 10

Variations In Pediatric Anatomy & Physiology: Chest Wall

Answer 10

Infants’ chest walls are highly compliant (pliable) and fail to support the lungs adequately.

Functional residual capacity can be greatly reduced if respiratory effort is diminished.
- Makes the tidal volume of infants and toddlers almost completely dependent upon movement of the diaphragm

If diaphragm movement is impaired (as in states of hyperinflation, such as asthma), the intercostal muscles cannot lift the chest wall and respiration is further compromised

Question 11

Pediatric Respiratory Assessment

Answer 11

Inspect and observe
- Color: Pale or cyanotic?

Mental Status: Anxious, restless, lethargic

Nose and Oral Cavity:
- Clear or obstructed? Managing secretions?
- Muffled voice?

Respirations:
- Rate and depth: Tachypnea often first sign of respiratory illness

Effort
- Retractions?
- Grunting?
- Stridor?
- Clubbing of nails
- Hydration Status

Question 12

Variations in Pediatric Anatomy & Physiology: Metabolic Rate & O2 Need

Answer 12

Children have a significantly higher metabolic rate than adults. T
- Resting respiratory rates are faster and their demand for oxygen is higher.

Adult O2 consumption is 3 to 4 L/min, while infants consume 6 to 8 L/min.

In any situation of respiratory distress, infants and children will develop hypoxemia more rapidly than adults

Question 13

Pallor

Answer 13

Pale appearance that occurs as a result of peripheral vasoconstriction in an effort to conserve oxygen for vital functions

Question 14

Cyanosis

Answer 14

A bluish tinge to the skin & mucous membranes occurs as a result of hypoxia

Might 1st present circumorally & progress to central cyanosis
- Begins around the mouth

Infant might have pale hands and feet when cold or when ill, as peripheral circulation is not well developed in early infancy.
- Note if the cyanosis is central (involving the midline), as this is a true sign of hypoxia.

Children w/ low RBCs might not demonstrate cyanosis as early in the course of hypoxemia as children with normal hemoglobin levels.
- Absence of cyanosis or the degree of cyanosis present is not always an accurate indication of the severity of respiratory involvement.

Note the rate and depth of respiration as well as work of breathing

Question 15

What is often the 1st sign of respiratory illness in infants & children?

Answer 15

Tachypnea

Question 16

Tachypnea

Answer 16

Increased respiratory rate for age

Question 17

Nursing Assessment: Cough & Other Airway Noises

Answer 17

Note the sound of the cough (Is it wet or productive, dry and hacking, tight?

When does the cough occur? Is it only or mainly at night?).

Also note if noises associated with breathing are present (e.g., grunting, stridor, or audible wheeze).

Grunting occurs on expiration and is produced by premature glottic closure.
- It is an attempt to preserve or increase functional residual capacity.
- Might occur with alveolar collapse or loss of lung volume, such as in atelectasis (a collapsed or airless portion of the lung), pneumonia, and pulmonary edema

Question 18

Atelectasis

Answer 18

Collapsed/airless portion of the lung

Question 19

Stridor

Answer 19

A high-pitched, readily audible inspiratory noise that is often a sign of upper airway obstruction

Question 20

Audible Wheezes

Answer 20

Wheezes that can be heard by the naked ear

Question 21

Wheezing

Answer 21

A high-pitched sound that usually occurs on expiration, results from obstruction in the lower trachea or bronchioles.

Wheezing that clears w/ coughing is most likely a result of secretions in the lower trachea.

Wheezing resulting from obstruction of the bronchioles, as in bronchiolitis, asthma, chronic lung disease, or cystic fibrosis, does not clear with coughing

Question 22

Retractions

Answer 22

Inward pulling of soft tissues with respiration

Can occur in the intercostal, subcostal, substernal, supraclavicular, or suprasternal regions

Document the severity of the retractions: mild, moderate, or severe.

Also note the use of accessory neck muscles.

Note the presence of paradoxical breathing

Question 23

Paradoxical Breathing

Answer 23

Lack of simultaneous chest and abdominal rise with the inspiratory phase).

Question 24

Restlessness & anxiety accompanied w/tachypnea is associated w/…

Answer 24

…early signs of respiratory distress

Restlessness might progress to listlessness & lethargy if respiratory dysfunction is not addressed

Question 25

Clubbing

Answer 25

An enlargement of the terminal phalanx of the finger, resulting in a change in the angle of the nail to the fingertip

Usually occurs in those w/chronic respiratory illness
- Result of increased capillary growth as the body attempts to supply more oxygen to distal body cells

Question 26

Nursing Assessment: Hydration Status

Answer 26

Palpate the infant’s fontanels to determine if sunken

Assess the oral mucosa for color and moisture

Note skin turgor, presence of tears, and adequacy of urine output

Child w/ a respiratory illness is at risk for dehydration.
- Pain related to sore throat or mouth lesions may prevent the child from drinking properly.
- Nasal congestion interferes with the infant’s ability to suck effectively at the breast or bottle

Tachypnea and increased work of breathing interfere with the ability to safely ingest fluids

Question 27

Nursing Assessment: Palpation

Answer 27

Palpate the sinuses for tenderness in the older child.

Assess for enlargement or tenderness of the lymph nodes of the head and neck

Document alterations in tactile fremitus detected on palpation
- Increased tactile fremitus might occur in the case of pneumonia or pleural effusion.
- Fremitus might be decreased in the case of barrel chest, as with cystic fibrosis.
- Absent fremitus might be noted with pneumothorax or atelectasis.

Compare central and peripheral pulses.
- Note the quality of the pulse as well as the rate. With significant respiratory distress, perfusion often becomes compromised.
- Poor perfusion might be reflected in weaker peripheral pulses (radial, pedal) when compared to central pulses

Question 28

Nursing Assessment: Percussion

Answer 28

When percussing, note sounds that are not resonant in nature

Flat or dull sounds might be percussed over partially consolidated lung tissue, as in pneumonia.

Tympany might be percussed with a pneumothorax.

Note the presence of hyperresonance (as might be apparent with asthma

Question 29

Nursing Assessment: Auscultation

Answer 29

Breath sounds should be equal bilaterally. The intensity and pitch should be equal throughout the lungs
- Document diminished breath sounds.

In the absence of concurrent lower respiratory illness, the breath sounds should be clear throughout all lung fields.

During normal respiration, the inspiratory phase is usually softer and longer than the expiratory phase.
- Prolonged expiration is a sign of bronchial or bronchiolar obstruction.
- Bronchiolitis, asthma, pulmonary edema, and an intrathoracic foreign body can cause prolonged expiratory phases.

Infants and young children have thin chest walls.
- When the upper airway is congested (as in a severe cold), the noise produced in the upper airway might be transmitted throughout the lung fields.
- When upper airway congestion is transmitted to the lung fields, the congested sounding noise heard over the trachea is the same type of noise heard over the lungs, but is much louder and more intense.

To ascertain if these sounds are truly adventitious lung sounds or if they are transmitted from the upper airway, auscultate again after the child coughs or his or her nose has been suctioned.
- Another way to discern the difference is to compare auscultatory findings over the trachea to the lung fields to determine if the abnormal sound is truly from within the lung or is actually a sound transmitted from the upper airway

Question 30

Rales

Answer 30

Crackling sounds result when the alveoli become fluid filled, such as in pneumonia

Question 31

Common Tests Used for Children with Respiratory Disorders: Allergy Skin Testing

Answer 31

Suggested allergen is applied to skin via scratch, pin, or prick.

Result: A wheal response indicates allergy to the substance.

Indications: Allergic rhinitis, asthma.

Special Considerations: Antihistamines must be discontinued before testing, as they inhibit the test
- Close observation for anaphylaxis is necessary. Epinephrine and emergency equipment should be readily available.
- Some children react to the skin test almost immediately; others take several minutes

Question 32

Common Tests Used for Children with Respiratory Disorders: Arterial blood gas (ABG)

Answer 32

Invasive method (requires blood sampling) of measuring arterial pH, partial pressure of oxygen and carbon dioxide, and base excess in blood

Indications: Reserved for severe illness, the intubated child, or suspected carbon dioxide retention

Special Considerations: Hold pressure for several minutes after a peripheral arterial stick to avoid bleeding.
- Radial arterial sticks are common and can be very painful.
- Note if the child is crying excessively during the blood draw, as this affects the carbon dioxide level

Question 33

Common Tests Used for Children with Respiratory Disorders: Chest Radiograph (Chest X-ray)

Answer 33

Radiographic image of the expanded lungs: can show hyperinflation, atelectasis, pneumonia, foreign body, pleural effusion, abnormal heart or lung size

Indications: Bronchiolitis, pneumonia, tuberculosis, asthma, cystic fibrosis, bronchopulmonary dysplasia

Special Considerations: Children may be afraid of the x-ray equipment. If a parent or familiar adult can accompany the child, often the child is less afraid.
- If the child is unable or unwilling to hold still for the x-ray, restraint may be necessary.
- Restraint should be limited to the amount of time needed for the x-ray.

Question 34

Common Tests Used for Children with Respiratory Disorders: Fluorescent Antibody Testing

Answer 34

Determines presence of respiratory syncytial virus (RSV), adenovirus, influenza, parainfluenza, or Chlamydia in nasopharyngeal secretion

Indications: Bronchiolitis, pneumonia

Special Considerations: To obtain a nasopharyngeal specimen, instill 1–3 mL of sterile normal saline into one nostril, aspirate the contents using a small sterile bulb syringe, place the contents in sterile container, and immediately send them to the lab

Question 35

Common Tests Used for Children with Respiratory Disorders: Gastric Washing for AFB

Answer 35

Determines presence of AFB (acid-fast bacilli) in stomach (children often swallow sputum)

Indications: TB

Special Considerations: NG tube is inserted, and saline is instilled and suctioned out of the stomach to obtain the specimen

Question 36

Common Tests Used for Children with Respiratory Disorders: Peak Expiratory Flow

Answer 36

Measures the maximum flow of air (in L/s) that can be forcefully exhaled in 1 second

Indications: Daily use can indicate adequacy of asthma control

Special Considerations: It is important to establish the child’s “personal best” by taking twice-daily readings over a 2-week period while well.
- The average of these is termed “personal best.”
- Charts based on height and age are also available to determine expected peak expiratory flow.

Question 37

Common Tests Used for Children with Respiratory Disorders: Pulmonary Function Test (PFT)

Answer 37

Measure respiratory flow and lung volumes

Indications: Asthma, cystic fibrosis, chronic lung disease

Special Considerations: Usually performed by a respiratory therapist trained to do the full spectrum of tests.
- Spirometry can be obtained by the trained nurse in the outpatient setting

Question 38

Common Tests Used for Children with Respiratory Disorders: Pulse Oximetry

Answer 38

Noninvasive method of continuously (or intermittently) measuring oxygen saturation

Indications: Can be useful in any situation in which a child is experiencing respiratory distress

Special Considerations: Probe must be applied correctly to finger, toe, foot, hand, forehead, or ear in order for the machine to appropriately pick up the pulse and oxygen saturation

Question 39

Common Tests Used for Children with Respiratory Disorders: Rapid Flu Test

Answer 39

Rapid test for detection of influenza A or B

Indications: Influenza

Special Considerations: Should be done in first 24 hours of illness so that medication administration can begin
- Have the child gargle with sterile normal saline and then spit into a sterile container
- Send immediately to the lab

Question 40

Common Tests Used for Children with Respiratory Disorders: Rapid Strep Test

Answer 40

Instant test for presence of streptococcus A antibody in pharyngeal secretions

Indications: Pharyngitis, tonsillitis

Special Considerations: Results in 5–10 minutes. Negative tests should be backed up with throat culture

Question 41

Common Tests Used for Children with Respiratory Disorders: RAST (radioallergosorbent test)

Answer 41

Measures minute quantities of immunoglobulin E in the blood
- Carries no risk of anaphylaxis but is not as sensitive as skin testing

Indications: Asthma (food allergies)

Special Considerations: Blood test that is usually sent out to a reference laboratory

Question 42

Common Tests Used for Children with Respiratory Disorders: Sputum Culture

Answer 42

Bacterial culture of invasive organisms in the sputum

Indications: Pneumonia, cystic fibrosis, TB

Special Considerations: Must be true sputum, not mucus from the mouth or nose.
- Child can deep breathe, cough, and spit, or specimen may be obtained via suctioning of the artificial airway

Question 43

Common Tests Used for Children with Respiratory Disorders: Sweat Chloride Test

Answer 43

Collection of sweat on filter paper after stimulation of skin with pilocarpine
- Measures concentration of chloride in the sweat

Indications: Cystic Fibrosis

Special Considerations: May be difficult to obtain sweat in a young infant

Question 44

Common Tests Used for Children with Respiratory Disorders: Tuberculin skin test

Answer 44

Mantoux test (intradermal injection of purified protein derivative)

Indications: TB, chronic cough

Special Considerations: Must be given intradermally; not a valid test if injected incorrectly

Question 45

Common Medical Treatments: Oxygen

Answer 45

Supplemented via mask, nasal cannula, hood, or tent or via endotracheal or nasotracheal tube

Indications: Hypoxemia, respiratory distress

Special Considerations: Monitor response via work of breathing and pulse oximetry.

Question 46

Simple Mask

Answer 46

Provides 35%–60% oxygen with a flow rate of 6–10 L/min. Oxygen delivery percentage is affected by respiratory rate, inspiratory flow, and adequacy of mask fit

Nursing Implications:
- Must maintain oxygen flow rate of at least 6 L/min to maintain inspired oxygen concentration and prevent rebreathing of carbon dioxide

• Mask must fit snugly to be effective but should not be so tight as to irritate the face

Question 47

Venturi Mask

Answer 47

Provides 24%–50% oxygen by using a special gauge at the base of the mask that allows mixing of room air with oxygen flow

Nursing Implications:
- Set oxygen flow rate according to percentage of oxygen desired as indicated on the gauge/dial.

• As with simple mask, must fit snugly

Question 48

Nasal cannula

Answer 48

Provides LOW oxygen concentration (22%–44%)

Nursing Considerations:
- Must be used with humidification to prevent drying and irritation of airways

• Can provide very small amounts of oxygen (as low as 25 mL/min)
• Maximum recommended liter flow in children is 4 L/min.
• Children can eat or talk while on oxygen.
• Inspired oxygen concentration affected by mouth breathing
• Requires patent nasal passages

Question 49

Oxygen tent

Answer 49

Provides high-humidity environment with up to 50% oxygen concentration

Nursing Implications:
- Oxygen level drops when tent is opened.

• Must change linen FREQUENTLY as it becomes damp from the humidity.
• Secure edges of tent with blankets or by tucking edges under mattress.
• Young children may be fearful and resistant.
• Mist may interfere with visualization of child inside tent.

Question 50

Oxygen hood

Answer 50

Provides high concentration (up to 80%–90%) for INFANTS ONLY
- Allows easy access to chest and lower body

Nursing Implications:
- Liter flow must be set at 10–15 L/min.

• Good method for infant but need to remove for feeding
• Can and should be humidified

Question 51

Partial rebreathing mask

Answer 51

Simple facemask with an oxygen reservoir bag. Provides 50%–60% oxygen concentration

Nursing Implications:
- Must set liter flow rate at 10–12 L/min to prevent rebreathing of carbon dioxide.

• The reservoir bag does not completely empty when child inspires if flow rate is set properly

Question 52

Nonrebreathing mask

Answer 52

Simple facemask w/ valves at the exhalation ports and an oxygen reservoir bag w/ a valve to prevent exhaled air from entering the reservoir
- Provides 95% oxygen concentration

Nursing Implications:
- Must set liter flow rate at 10–12 L/min to prevent rebreathing of carbon dioxide.
- The reservoir bag does not completely empty when child inspires if flow rate is set properly

Question 53

Common Medical Treatments: High Humidity

Answer 53

Addition of moisture to inspired air

Indications: Common cold, croup, tonsillectomy

Special Considerations: Infant may require extra blankets with cool mist, and frequent changes of bedclothes under oxygen hood or tent as they become damp.

Question 54

Common Medical Treatments: Suctioning

Answer 54

Removal of secretions via bulb syringe or suction catheter

Indications: Excessive airway secretions (common cold, flu, bronchiolitis, pertussis)

Special Considerations: Should be done carefully and only as far as recommended for age or tracheostomy tube size, or until cough or gag occurs

Question 55

Common Medical Treatments: Chest physiotherapy (CPT) & postural drainage

Answer 55

Promotes mucus clearance by mobilizing secretions with the assistance of percussion or vibration accompanied by postural drainage

Indications: Bronchiolitis, pneumonia, cystic fibrosis, or other conditions resulting in increased mucus production
- NOT EFFECTIVE in inflammatory conditions without increased mucus

Special Considerations: May be performed by respiratory therapist in some institutions, by nurses in others.
- In either case, nurses must be familiar with the technique and able to educate families on its use

Question 56

Common Medical Treatments: Saline Gargles

Answer 56

Relieves throat pain via salt water gargle

Indications: Pharyngitis, tonsillitis

Special Considerations: Recommended for children old enough to understand the concept of gargling (to avoid choking)

Question 57

Common Medical Treatments: Saline Lavage

Answer 57

NS introduced into the airway, followed by suctioning

Indications: Common cold, flu, bronchiolitis, any condition resulting in increased mucus production in the upper airway

Special Considerations: Very helpful for loosening thick mucus
- Child may need to be in semi-upright position to avoid aspiration

Question 58

Common Medical Treatments: Chest Tube

Answer 58

Insertion of a drainage tube into the pleural cavity to facilitate removal of air or fluid and allow full lung expansion

Indications: Pneumothorax, empyema

Special Considerations: Should tube become dislodged from container, the chest tube must be clamped immediately, or the open end placed into a container of sterile water to avoid further air entry into the chest cavity

Question 59

Common Medical Treatments: Bronchoscopy

Answer 59

Introduction of a bronchoscope into the bronchial tree for diagnostic purposes. Also allows for bronchiolar lavage

Indications: Removal of foreign body, cleansing of bronchial tree

Special Considerations: Watch for post-procedure airway swelling, complaints of sore throat.

Question 60

Upper Respiratory Infections: Acute Nasopharyngitis

Answer 60

AKA “Common Cold”

Causes: Rhinoviruses, parainfluenza, RSV, enteroviruses, adenoviruses, and human metapneumovirus

Clinical Manifestations: (More severe in infants & children than adults)
- Nasal discharge: Thick, white, yellow, or green (can be thin)
- Nasal congestion: Causes mouth breathing
- Sneezing
- Cough
- Headache (varies)
- Fever is common in young and older children
- Irritability/restlessness

Duration: 10 days or less

Potential Complications: Secondary bacterial infections of the ears, throat, sinuses, or lung

Question 61

Therapeutic Management of Acute Nasopharyngitis

Answer 61

Therapeutic management is directed towards symptom relief

Question 62

Acute Otitis Media

Question 63

Therapeutic Management of Otitis Media