Ch 38 Peds Respiratory

Question 1

Epiglottitis

Answer 1

bacterial form of croup
may be caused by H. influenzae type b or Strep pneumoniae
children immunized with Hib less risk
occurs most freq in children 2 - 8 yrs
onset abrupt, typically in winter
*emergency –> can rapidly progress to severe resp distress

Question 2

Epiglottitis assessment

Answer 2

fever
large, cherry red, edematous epiglottis
no spontaneous cough
drooling
swallowing pain
muffled voice
retractions
inspiratory stridor, worse in supine
tripod positioning

Question 3

Epiglottitis interventions

Answer 3

assess temp via axillary
pulse ox
lateral neck films to confirm dx
NPO
do not leave child unattended
do not place in supine position
do not agitate child
may need to delay IV line to not agitate child
administer abx (IV then oral)
admin corticosteroids to decrease inflammation and reduce throat edema
nebulized epinephrine may be rx for severe cases
heliox (helium and oxygen mix) may be rx to reduce mucosal edema
cool mix o2
prepare for endotracheal intubation or tracheotomy for severe resp distress
ensure immunizations up to date

Question 4

if epiglottitis suspected

Answer 4

NO attempt should be made to visualize the post pharynx, obtain a throat culture, or take an oral temp.
spasm of the epiglottis can occur and lead to complete airway obstruction.

Question 5

Laryngotracheobronchitis

Answer 5

inflammation of the larynx, trachea, and bronchi
most common type of croup
may be viral or bacterial
most frequently in children < 5 yrs
parainfluenzae virus types 1 & 2
respiratory syncytial virus (RSV)
Mycoplasma pneumoniae
influenza
gradual onset that may be preceded by an upper respiratory infection

Question 6

Laryngotracheobronchitis symptom progression

Answer 6

Stage 1: fever, hoarseness, SEAL bark and brassy cough, insp stridor, fear, irritability
Stage 2: continuous resp stridor, retractions, use of accessory muscles, crackles, labored respirations
Stage 3: continued restlessness, anxiety, pallor, diaphoresis, tachypnea, signs of anoxia and hypercapnia
Stage 4: intermittent cyanosis progressing to permanent cyanosis, apneic episodes progressing to cessation of breathing

Question 7

Laryngotracheobronchitis interventions

Answer 7

elevate head of bed and provide rest
humidified o2 via cool air / mist tent as rx
cool air vaporizer at home
no cough syrups or cold medicines –> may dry and thicken secretions
corticosteroids may be rx
nebulized epinephrine (for children w severe disease - stridor at rest, retractions, or difficulty breathing)
heliox

Question 8

upper resp infection - hospital

Answer 8

isolation precautions should be implemented for a hospitalized child until cause of infection is known

Question 9

Bronchitis

Answer 9

inflammation of trachea and bronchi (tracheobronchitis)
usually occurs w upper resp infection
usually mild disorder, usually viral

Question 10

bronchitis assessment

Answer 10

fever
dry, hacking, nonproductive cough that is worse at night
cough becomes productive in 2 - 3 dys

Question 11

bronchitis interventions

Answer 11

tx sxs as necessary
cool, humidified air to child
cough suppressants may be rx

Question 12

oxygen delivery systems

Answer 12

oxygen mask
nasal cannula
oxygen tent
oxygen hood, face tent

Question 13

oxygen mask

Answer 13

advantages: various sizes, higher O2 than cannula, predicatable conc. of O2 (Venturi)
disadvantages: skin irritation, fear of suffocation, moisture on face, possible aspiration of vomit, difficulty in controlling )2 conc except w Venturi

Question 14

Nasal cannula

Answer 14

adv: low - mod O2 conc (22-40%), able to eat / talk while on O2, better able to observe child
disadv: must have patent nasal passages, difficult to control O2 conc if child breathes through mouth, no mist

Question 15

Oxygen tent

Answer 15

adv: lower O2 conc (FIO2 0.3-0.5), child able to receive desired O2 even while eating
disadv: necessity for tight fit around bed to prevent leakage of O2, cool / wet tent environment, poor access to child

Question 16

oxygen hood, face tent

Answer 16

adv: provides high O2 conc (FIO2 up to 1.00), free access to child’s chest for assessment
disadv: high humidity environment, need to remove child for feeding and care

Question 17

Bronchiolitis and RSV (respiratory synctial virus)

Answer 17

bronchiolitis: inflammation of the bronchioles that cauess production of thick mucus that occludes bronchiole tubes and small bronchi.
RSV: causes an acute viral infection and is an common cause of bronchiolitis
other organisms that cause bronchiolitis:
adenoviruses
parainfluenza viruses
human metapneumovirus

Question 18

RSV

Answer 18

not airborne
highly communicable
transferred by direct contact w resp secretions
occurs primarily in winter / spring
rare in children > 2 yrs, peak incidence = 6mo
at risk children: children > 1 yr w chronic / disabling condition
dx: testing of nasal / nasophar secretions

Question 19

RSV preventions

Answer 19

encouraging breast feeding
avoiding tobacco smoke exposure
good handwashing technique
admin of palivisumab (Synagis) (monoclonal antibody, for high risk infants, via IM - monthly injection)

Question 20

palivisumab (Synagis)

Answer 20

RSV prevention
IM injection
monoclonal antibody
monthly over a 5 mo period (nov - march)
for high risk infants

Question 21

bronchiolitis / RSV interventions

Answer 21

airway maintenance, cool humifiied air, O2
hospital - isolation (private room or w RSV pt)
no nursing care for RSV AND high risk pt
contact precautions
airway maintenance, 30-40 degree bed angle, neck slightly extended
periodic suctioning (before feeding)
ribavirin (Virazole) - antiviral med (via inhalation)

Question 22

Pneumonia

Answer 22

inflammation of the pulmonary parenchyma or alveoli or both.
caused by a virus, mycoplasmal agents, bacteria, or aspiration of foreign subs
agent introduced via lungs or bloodstream

Question 23

viral pneumonia

Answer 23

seen more often than bacterial pneumonia
seen in children of all ages
often asso. w viral upper resp infection

Question 24

primary atypical pneumonia

Answer 24

mycoplasma pneumoniae or chlymydia pneumoniae
most often in the fall / winter
more common in crowded living conditions
children - 5 - 12 yrs old (most often)

Question 25

bacterial pneumonia

Answer 25

often a serious infection req hospitalization when pleural effusion or empyema accompanies the disease hospitalization also for children with staphylococcal pneumonia

Question 26

aspiration pneumonia

Answer 26

when material enters the lung and causes inflammation and a chemical pneumonitis sx: increasing cough or fever w fould smelling sputum, deteriorating results on cxrs

Question 27

pneumonia prevention

Answer 27

vaccination of infants and children w pneumococcal vaccine

Question 28

viral pneumonia assessment

Answer 28

acute onset sx: fever, cough, diaphoresis, nonproductive or productive cough of small amts of whitish sputum wheezes or fine crackles

Question 29

viral pneumonia interventions

Answer 29

tx is symptomatic | o2 w cool humidified air as prescribed

Question 30

primary atypical pneumonia assessment

Answer 30

acute sx: fever, chills, anorexia, ha, malaise, myalgia, rhinitis, sore throat, dry, hacking cough nonproductive cough --> production of seromucoid sputum --> mucopurulent / blood streaked sputum

Question 31

primary atypical pneumonia interventions

Answer 31

tx is symptomatic | recovery in 7 - 10 dys

Question 32

bacterial pneumonia assessment

Answer 32

acute sx: infant - irritability, lethargy, poor feeding, abrupt fever (poss. szs), resp distress. child - ha, chills, ab pain, cp, meningeal sxs hacking, productive cough dim breath sounds / crackles non productive --> productive (purulent sputum) w coarse crackles / wheezing

Question 33

bacterial pneumonia interventions

Answer 33

abx therapy as soon as dx suspected IV abx in hospital o2 for resp distress cool mist tent as rx admin chest physiotherapy and postural drainage q4h bed rest encourage to lie on affected side to splint the chest and reduce pleural rubbing discomfort monitor temp r/t risk for febrile szs isolation precautions w pneumococcal / stephylococcal pneumonia cont. closed chest drainage may be instituted if purulent fluid is present fluid accumulation in pleural cavity --> thoracentesis (also used for culture and abx)

Question 34

asthma

Answer 34

chronic inflammatory disease of the airways classified based on disease severity rxn can be immediate or delayed several hrs mast cell release of histamine --> bronchoconstrictive process / bronchospasm / obstruction

Question 35

status asthmaticus

Answer 35

acute asthma attack child displays resp distress despite vigorous tx measures *medical emergency can lead to resp failure / death

Question 36

asthma assessment

Answer 36

sx particularly in the early morning or at night

Question 37

acute asthma attacks

Answer 37

air is trapped behind occluded or narrow airways just before attack child may present w itching localized at the front of neck or over the upper back resp sxs: hacking, irritable, nonproductive cough (d/t bronchial edema) secretion accumulates --> stims cough, cough becomes rattling, sputum = frothy, clear, gelatinous sputum retractions hyperresonance crackles, coarse rhonchi, insp / exp wheezing younger children - tripod sitting position older children - upright w shoulders hunched (refuses to lie down)

Question 38

ventilatory failure and asphysia

Answer 38

acute asthma attacks SOB, air mvmt in chest restricted to the pt of absent breath sounds sudden increase in respiratory rate

Question 39

Priority Nursing Actions ACUTE ASTHMA ATTACK

Answer 39

1. assess airway patency and resp status 2. admin humidified o2 by nc or face mask 3. admine rescue meds 4. initiate an IV line 5. prepare child for chest radiograph if rx 6. prepare to obtain blood sample for arterial blood gas levels if rx

Question 40

Acute asthma meds

Answer 40

1. quick relief (rescue) meds 2. long term control meds 3. nebulizer, MDI (MDI for corticosteroids = spacer) (growth patterns monitored for cort steroids)

Question 41

chest physiotherapy

Answer 41

breathing exercises, clapping, vibration procedures with postural drainage and suctioning strengthens breathing muscles not recommended during acute

Question 42

asthma teaching

Answer 42

instruct child and family about monitoring peak expiratory flow rate decrease in expiratory flow rate may indicated inpending infection or exacerbation

Question 43

asthma precipitants

Answer 43

meds: aspirin, NSAIDS, abx, beta blockers strong emotions conditions: gerd, tracheoesophageal fistula food additives: sulfite preservatives foods: nuts, milk and other dairy produces endocrine fx: menses, pregnancy, thyroid disease

Question 44

peak expiratory flow rate

Answer 44

measures max flow of air forcefullly exhaled in 1 second | "personal best value" used for comparison at other times

Question 45

radioallergosorbent test

Answer 45

blood test used to identify a specific allergen

Question 46

Quick relief asthma meds (rescue)

Answer 46

``` short acting B2 agonists (bronchodilation) anticholinergics (relief of acute bronchosp) systemic corticosteroids (anti-inflam to tx reversible airflow obstruction) ```

Question 47

Long Term Asthma control (preventative)

Answer 47

corticosteroids (anti-inflam) antiallergic meds NSAIDS (anti-inflam) long acting B2 agonists (long act bronchod) leukotriene modifiers (prevent bronchosp and inflammatory cell infiltration) monoclonal antibody (blocks binding of IgE to mast cells to inhibit inflammation)

Question 48

cystic fibrosis

Answer 48

chronic multisystem disorder (autosomal recessive) characterized by exocrine gland dysfxn mucus from exocrine glands = thick, tenacious, and copious --> particularly affects resp, GI, and reproductive systems *progressive and incurable disorder - resp failure is a common cause of death organ transplantation may be an option

Question 49

cystic fibrosis common sxs

Answer 49

asso. w pancreatic enzyme deficiency and pancreatic fibrosis (caused by duct blockage, progressive chronic lung disease r/t infection, and sweat gland dysfxn --> increases sodium and chloride sweat conc)

Question 50

sweat chloride test

Answer 50

CF increases Na and Cl in sweat and saliva 1. production of sweat is stim., sweat is collected, sweat electrolytes are measures (> 75 mg sweat needed) normal = < 40 mEq/L sweat chloride conc. positive test = > 60 mEq/L >40mEq/L = dx in infants <3mo chloride conc. 40 - 60 mEq/L are highly suggestive of CF, req repeat test

Question 51

CF resp system

Answer 51

stagnant mucus in airway --> bac colonies / destruction of lung tissue emphysema + atelectasis chronic hypoxemia --> conc. and hypertrophy of muscle fibers in pulm arteries and arterioles --> pulm HTN --> cor pulmonale pneumothorax: d/t ruptured bullae and hemoptysis d/t erosion of bronchial wall sxs: wheezing / cough, dyspnea, cyanosis, clubbing of figners/toes, barrel chest, bronchitis/ pna

Question 52

CF GI system

Answer 52

``` meconium ileus in newborn = early manif. intestinal obstruction d/t thick intestinal secretions can occur (s: pain, ab distention, N&V) stools = frothy and foul smelling ADEK deficient --> easy bruising / anemia malnutrition / FTT concern hypoalbuminemia can occur (d/t dim. absorb of protein) --> general edema rectal prolapse (d/t large, bulky stools) pancreatic fibrosis (ups risk of DM) ```

Question 53

CF integumentary system

Answer 53

high conc. of Na and Cl in sweat infant tastes "salty" dehydration + electrolyte imbalanes (esp when hyperthermic)

Question 54

CF reproductive system

Answer 54

can delay puberty in girls fertility inhibited by highly viscous cervical secretions (act as plug --> block sperm) males: usually sterile (d/t blocked vas deferens by abnormal secretions or abnormal dev of duct structures)

Question 55

CF dx tests

Answer 55

1. quantitative sweat chloride test positive 2. newborn screening: immunoreactive trypsinogen analysis and direct DNA analysis for mutant genes 3. cxr = atelectasis and obstructive emph. 4. pulmonary fxn tests = abnormal small airway fxn 5. stool, fat, enzyme analysis: 72 hr stool sample to check fat or enzyme (trypsin) content --> food intake recorded

Question 56

CF interventions: resp system

Answer 56

prevent/tx pulmonary infection, monitor resp status, chest physiotherapy on awakening / evening (should not be before/soon after meal), flutter mucus clearance device, hand held percussors to loosen secretions, positive expiratory pressure mask (forces secretion to the upper airway for cough out), forced expiratory tech (huffing), bronchodilator med by aerosol, physical exercise program, aerosol / IV abx, o2 during acute episodes, monitor for hemoptysis (should be < 250 mL / dy)

Question 57

Flutter Mucus Clearance device

Answer 57

small, hand held plastic pipe w stainless steel ball on inside facilitates removal of mucus store away from small children bc steel ball poses choking hazard

Question 58

CF oxygen admin

Answer 58

monitor closely for o2 narcosis s: N&V, malaise, fatigue, numbness and tingling of exremities, substernal distress * children w cystic fibrosis may have chronic co2 retention

Question 59

CF interventions: GI

Answer 59

high cal, high protein, well balanced diet, multivit + vit ADEK, moitor weight and FTT, monitor stool patterns and for signs of intestinal obstruction, replace pancreatic enzymes (admin w/in 30 min of eating and admin w all snacks, should not be given if NPO), pancreatic enzyme amt = 2-3 stools / dy, pancreatic enzyme capsules can be sprinkled on small amt of food, monitor for constipation, intestinal obstruction, and rectal prolapse, monitor for signs of gerd (sit upright after eating)

Question 60

CF interventions

Answer 60

monitor BG levels and for signs of DM, adequate salt intake, and fluids w electrolytes in hot weather, monitor bone growth, monitor for signs of retinopathy or nephropathy

Question 61

SIDS

Answer 61

unexpected death of an apparently healthy infant < 1 yr - autopsy fails to show adequate cause of death most frequent in winter months usually during sleep periods typically 2-3 month olds higher in boys higher in Native Americans, african americans, hispanics, lower socioeconomic lower in breastfed infants and those sleeping w pacifier

Question 62

SIDS high risk conditions

Answer 62

prone position use of soft bedding, sleep in a noninfant bed overheating cosleeping mother who smoked / abused substances during pregnancy exposure to tobacco smoke after birth

Question 63

SIDS assessment

Answer 63

apneic, blue, lifeless frothy, blood tinged fluid in nose / mouth typically in disheveled bed w blankets over head, huddled in corner clutching bedding diaper may be wet / full of stool

Question 64

SIDS prevention / interventions

Answer 64

supine position for sleep | monitor for positional plagiocephaly (flat head) caused by supine sleeping position

Question 65

Foreign body aspiration

Answer 65

most inhaled foreign bodies lodge in the main stem or lobar bronchus most common: round food - hot dogs, candy, peanuts, popcorn, grapes

Question 66

FBA assessment

Answer 66

choking, gaggin, coughing, retractions

Question 67

laryngotracheal obstruction

Answer 67

leads to dyspnea, stridor, cough, hoarseness

Question 68

bronchial obstruction

Answer 68

paroxysmal cough, wheezing, asymmetrical breath sounds, dyspnea

Question 69

FBA interventions

Answer 69

nonemergency care: | removal by endoscopy - post: child receives high humidity air, observe for s/sx of edema

Question 70

Tuberculosis

Answer 70

contagious disease caused by Myocobacterium tuberculosis (acid fast bacillus) multidrug resistant strains of M. tuberculosis occur bc of child/fam noncompliance w therapeutic regime route of trans: inhalation of droplets from indv w active TB increased incidence in urban low income area, nonwhite racial/ethnic group, 1st gen immigrants from endemic countries *most children infected from a fam member or by an indv w whom they have freq contact

Question 71

TB assessment

Answer 71

may be asymptomatic sx: malaise, fever, cough, weight loss, anorexia, lymphadenopathy specific sx r/t site of infection (lungs, brain, bone) increased time --> asym expansion of lungs, dec breath sounds, crackles/dullness to percussion

Question 72

Mantoux test

Answer 72

produces a postive rxn 2 - 10 wks after initial infection determines if a child has been infected and dev. a sensitivity to the protein of the tubercle bacillus --> positive rxn does not confirm presence of active disease (exposure v. presence) after a positive rxn --> always positive tb test should not be at same time as measles immunization (viral interference may cause false negative result) induration > 15 mm is positive rxn in children > 4yrs w/o high risk fxs induration > 10 mm is positive rxn in children < 4 yrs and high risk children induration > 5 mm is positive for highest risk groups (ex. HIV)

Question 73

TB sputum culture

Answer 73

definitive dx is made by showing the presence of mycobacteria in a culture cxr supplemental to sputum culture / not definitive alone gastic washing may be done to obtain specimen

Question 74

gastric washing

Answer 74

bc infant / young child often swallows sputum instead of expectorating it gastric washing may be used to obtain sputum sample this is an aspiration of lavaged contents from the fasting stomach done in the early morning before breakfast

Question 75

TB interventions

Answer 75

9 month course of isoniazid (INH) may be rx to prevent a latent infection from progressing to clinically active TB, or to prevent infection in high risk children 12 mo course may be prescribed for HIV child clinically active TB --> combo admin of isoniazid, rifampin (Rifadin), and pyrazinamide daily for 2 mo, then isoniazid and rifampin only 2x weekly for 4 mo body fluids / urine may turn orange-red w tx

Question 76

TB hospital

Answer 76

respiratory isolation until meds initiate, sputum cultures show diminishing of organisms, and cough is improved use personal air purifying gN95 or N100 respirator when caring for child

Question 77

hemoptysis

Answer 77

coughing up blood