Pediatrics

Annette Tomlinson

RESPIRATORY
DISORDERS

Anatomy and Physiology:

Pediatric Variations
Small airways
Fewer alveoli
Increased chest compliance

Common Acute
Respiratory Alterations

Nasopharyngitis
Tonsillitis and pharyngitis
Otitis media
Croup
Bronchiolitis
Pneumonia
Sinusitis

Respiratory Assessment
Assessment

Appearance

Restless, inactive, irritable, apprehensive

Respiratory Status

Nutrition/Hydration anorexia, vomiting

Chest Examination

Respiratory rate
Breath sounds
Inspiratory/Expiratory phases

Nursing Diagnoses

Ineffective Airway Clearance

Impaired Gas Exchange
Ineffective Breathing Pattern
Anxiety, child related

Nasopharyngitis
Common Cold may be viral or bacterial
Nursing Management
Assessment

Degree and duration of symptoms

Eating and drinking
Fever or cough
Hydration, nasal discharge, respiratory distress

Interventions

Humidity, nose drops, fluids, fever control, rest

Antibiotics if cultures are positive for bacteria

Nasopharyngitis (cont.)
Planning: education of the family
Hydration
Complications
Otitis media, sepsis, meningitis

Preventing spread

Tonsillitis and
Pharyngitis
Pharyngitis and tonsillitis are infections in the
throat that cause inflammation. If the tonsils
are primarily affected, it is called tonsillitis. If
the throat is primarily affected, it is called
pharyngitis. A child might even have inflammation
and infection of both the tonsils and the throat.
This would be called pharyngotonsillitis. These
infections are spread by close contact with other
individuals. Bacterial infections are more common
during the winter. Viral infections are more
common in summer and fall.

Tonsillitis and
Pharyngitis

sore throat
white spots or pus on the tonsils or throat
fever (either low grade or high)
swollen lymph nodes
headache
decrease in appetite
not feeling well
nausea
vomiting
stomach aches
painful swallowing
visual redness or drainage in the throat

Pharyngitis
Usually viral
Symptomatic treatment
acetaminophen (for pain)
increased fluid intake
throat lozenges
Bacterial : group A beta-hemolytic strep
Fluids, bland diet, pain & fever medications, antibiotics
Surgical Intervention
Tonsillectomy
Restores impaired functioning of nose and throat

Adenoidectomy

Indication for recurrent ear infection or mouth breathing

Nursing Care for

Tonsillectomy
Pre-operatively
Clotting Time

Post-operatively

Assess for bleeding (frequent swallowing)

Prevent bleeding no hard objects or gargles
Monitor hydration
Diet cool (NO RED) liquids to soft foods
Position on side

Nursing Care for

Tonsillectomy
Post-operatively

Ice collar
Analgesics
Mouth care
Emotional support

Discharge Teaching
Sore throat for 10 days
Danger signs bleeding, infection
Soft diet no hard foods or acidic liquids

Otitis Media
Otitis media is an inflammation of
the middle ear (the cavity between
the eardrum and the inner ear).
Most common childhood disease
Complication of other infection or
allergy

Otitis Media
Factors for frequency:

Frequent URIs
Eustachian tubes short and lay on a
horizontal plane
Lying down pooling
Lymphoid tissue -- obstruction

Otitis Media
Symptoms
Pain = irritability, pulling/rubbing of ear,
rolling head
Anorexia = pain with swallowing
Fever
Lymph Nodes
URI
Vomiting/Diarrhea

Otitis Media
Interventions
Prevention

NO bottle propping
NO exposure to tobacco smoke

Early Treatment
Antibiotics compliance
Complications: hearing loss, meningitis, mastoiditis

Pain
Local heat, analgesics, ear drops
Myringotomy tubes

Laryngotracheobronchitis
(LTB)

Description
Inflammation of larynx, trachea, and bronchi
Commonly called CROUP

Laryngotracheobronchitis
(LTB)
Age Common in infants and toddlers
Agent Virus
Clinical Symptoms
Fever, irritability, restlessness, pallor or
cyanosis
Rales or rhonchi, inspiratory stridor,
retractions, crackles and wheezing on
auscultation
use of accessory muscles
Barking cough, hoarseness

Laryngotracheobronchitis (LTB)
Interventions

usually can be treated at home

Initial: Hot, steamy shower for relief at home
Administer medications as prescribed, such as
bronchodilators, corticosteroids, nebulized epinephrine
Maintain patent airway at all times
Provide humidified oxygen via cool mist tent
Monitor respiratory status frequently; report
changes immediately
Elevate HOB
Encourage fluid intake PO; if not tolerated,
administer IV as prescribed

Croup Nursing Alert

The child with
increasing signs of
respiratory distress
will need
hospitalization
The child who starts
excessive drooling is
in trouble

Acute Epiglottitis

Description
Bacterial form of croup; epiglottis is inflamed
Considered emergency situation
Age 3 to 7 years
Agent Bacterial (usually H. Flu)
Usually follows URI
Clinical Symptoms - Abrupt onset
4 classic signs- Dysphonia, dysphagia, drooling, and
distress
Sore throat, difficulty swallowing, drooling,
muffled voice, increased fever
Barking cough, hoarseness,
SEVERE respiratory distress; inspiratory stridor,
dyspnea, retractions,
Bright red, edematous epiglottis

Acute Epiglottitis
Assessment
Tripod positioning
Interventions
No attempts to: visualize posterior pharynx,
obtain throat culture, or take oral
temperature
Do not leave child unattended
Do not force child to lie down
Do not restrain child
Ensure up-to-date immunizations, including
Haemophilus influenzae type b (Hib)
conjugate vaccine

Acute Epiglottitis
Interventions
NEVER use a tongue blade to check the
throat!
Can occlude throat entirely from spasm

Have intubation equipment or tracheostomy

tray available
IV antibiotics
PICU care

Bronchitis
Description
Infection of major bronchi
Assessment
Fever; dry, hacking, nonproductive cough,
worse at night; becomes productive in 2 to 3
days
Interventions
Monitor for respiratory distress
Provide cool, humidified air as prescribed
Monitor for signs of dehydration
Increase fluid intake as prescribed
Administer acetaminophen (Tylenol) for
fever as prescribed

Bronchiolitis and Respiratory

Syncytial Virus (RSV)
Pulmonary viral infection characterized by wheezing
(classic manifestation)
Usually caused by respiratory syncytial virus (RSV)
Virus invades epithelial cells of the nasopharynx and
spreads to lower respiratory tract, causing increased
mucus production, decreased diameter of bronchi,
hyperinflation, and possible atelectasis
Typical age: 2-12 months
3rd cause of death in infants
Increased incidence of asthma as child grows older

Bronchiolitis and
Respiratory Syncytial Virus
(RSV)
Description
Highly communicable; usually transmitted by
direct contact with respiratory secretions

Assessment

Rhinorrhea
Diminished breath sounds
Low-grade fever Grunting
Lethargy
Expiratory wheezes
Poor feeding
Retractions
Tachypnea, dyspnea
Nasal flaring

Bronchiolitis and
Respiratory Syncytial
Virus (RSV)
Diagnostics
WBC normal
X-Ray reveals hyperaeration

Bronchiolitis and Respiratory Syncytial

Virus (RSV)
Interventions

Maintain patent airway

Position at 30- to 40-degree angle, neck slightly extended, Oxygen
if necessary
Small, frequent feedings
NPO if respiratory rate 60
Provide adequate rest
Bronchodilators and steroids
Provide high humidity environment
Child with RSV
Isolate in private room or with another child with RSV
Administer ribavirin (Virazole) as prescribed
No pregnant nurses should care for child receiving
ribavirin
Administer respiratory syncytial virus immune globulin (RSVIGIV, RespiGam) as prescribed

Pneumonia
Description

Inflammation of alveoli caused by virus, mycoplasmal

agent, bacteria, aspiration of foreign substance

Viral pneumonia

Often associated with viral upper respiratory infection

Primary atypical pneumonia

Most common cause of pneumonia in children between 5

to 12 years

Bacterial pneumonia

Institute isolation precautions with pneumococcal or

staphylococcal pneumonia

Pneumonia
Assessment
Fever; nonproductive to productive cough;
malaise; rhinitis; sore throat; signs of
respiratory distress; diminished breath
sounds
Interventions
Administer oxygen with cool mist as
prescribed
Increase fluid intake
Administer chest physiotherapy, respiratory
therapy as prescribed
Administer acetaminophen (Tylenol) for
fever as prescribed
Administer antibiotics for bacterial
pneumonia as prescribed

HYPERACTIVE AIRWAY
DISEASE - ASTHMA

Asthma (AZ-ma) is a chronic (long-term) lung

disease that inflames and narrows the airways.
Asthma causes recurring periods of wheezing (a
whistling sound when you breathe), chest
tightness, shortness of breath, and coughing. The
coughing often occurs at night or early in the
morning.

HYPERACTIVE AIRWAY
DISEASE - ASTHMA
Onset: 3-8 years
May have infant history of allergy
Allergic hypersensitivity to foreign
substances
Inheritable tendency
Chronic disorder

Asthma
Types of Asthma

Spasmodic intermittent attacks

Continuous daily wheezing
Exercise-induced
Status Asthmaticus
no response to medications
respiratory function compromised
hospitalized

Asthma
Pathophysiology
Edema and inflammation of the mucus
membranes
Tenacious secretions
Smooth muscle spasms of the bronchi

Asthma
Triggers (initiator of an attack)

Environmental substances
Temperature changes
Psychological stress
Physical stress
Respiratory tract infections

Asthma
Assessment

Asthmatic episode begins with irritability,

restlessness, malaise, chest tightness;
progresses to hacking, irritable, nonproductive
cough, with development of retractions,
hyperresonance, crackles, rhonchi, wheezing,
dyspnea, prolonged expiration, chronic use of
accessory muscles causes a barrel chest
Ventilatory failure, asphyxia may occur
Young children may assume tripod position;
older children sit upright with shoulders in
hunched-over position

Asthma
Diagnostics
Chest x-ray reveals hyperinflation of
airways
Pulmonary function tests reveal reduced
peak expiratory flow rate

Asthma
Interventions: Acute episode
Medications
Quick relief (rescue): Short-acting 2 agonists,
systemic corticosteroids
Long term (preventer): Corticosteroids, antiallergy
agents, NSAIDs, long-acting 2 agonists, leukotriene
modifiers, long-acting bronchodilators, nebulizers

Chest physiotherapy
Breathing exercises; physical training

Asthma - Interventions
Assess for cyanosis/respiratory distress
Administer oxygen, monitor SaO2

Maintain IV access
Ensure fluid intake & med administration

High-Fowlers position
Cluster nursing care to conserve childs
energy

Asthma - Interventions
Medications
Bronchodilators (acute and daily use)
Parental, inhaled and oral routes

Corticosteroids
Reduces inflammatory response during or to prevent an
attack
Oral, inhaled, parenteral routes

NSAIDs
Used as prophylaxis/treatment
Oral, nasal, inhaled routes

Asthma - Interventions
Allergen control

Prevention of exposure to airborne and environmental

allergens
Skin testing to identify allergens

Home care measures

Eliminate allergens
Avoid extreme temperature changes
Instruct child, parents to recognize early signs of
asthma attack
Instruct child, parents in correct administration of
medications

Cystic Fibrosis

Autosomal recessive disorder; causes chronic

multisystem disorder of exocrine gland dysfunction
Inherited disorder affecting the exocrine glands
Inherited as an autosomal recessive trait
Usually diagnosed in infancy and early childhood
Life expectancy increased to 30 years
Disease is terminal
Most common symptoms include pancreatic enzyme
deficiency, progressive chronic lung disease, sweat gland
dysfunction

Cystic Fibrosis (cont.)

Alterations in sweat electrolytes and mucus production lead
to multisystem damage
Lung problems most serious threat to life
Stagnation of mucus in airways, destroying lung tissue
Chronic infection and airway obstruction lead to
bronchiectasis, pneumothorax, and or cor pulmonale
Pancreatic ducts become clogged and prevent pancreatic
enzymes from reaching the duodenum
Impairs digestion and absorption
-Integumentary system: Abnormally high
concentrations of sodium and chloride in sweat
Small intestines, in the absence of pancreatic enzymes
are unable to absorb fats and protein. Intestinal and
pancreatic obstruction secondary to excessive mucus
production
Growth and puberty are retarded

Cystic Fibrosis
Diagnostics
Sweat test
Analyzes sodium and chloride content in sweat
Chloride concentration 60 meq/L is positive

72 hour fecal fat

Chest x-ray
DNA analysis of amniotic fluid

Cystic Fibrosis
Diagnostic tests
Quantitative sweat chloride test: NaCl level higher than
60 mEq/L definitive for CF
Interventions
Measures to prevent, treat pulmonary infections,
improve aeration, remove secretions, administer
medications as prescribed, including antibiotics
Administer pancreatic enzymes PO as prescribed; highcalorie, high-protein diet; administer of vitamins A, D, E,
K as prescribed; ensure adequate salt intake
Home care
Instruct child, parents about treatment regimen
Inform child, parents about support through CF
Foundation

Nursing Management and

Treatment
Maximizing lung functioning
Promote removal of secretion from lungs
Prevent and treat lung infections
Manage pulmonary complication

Medications
Inhaled recombinant human deoxyribonucleae
Antibiotics
Pancreatic enzymes and vitamins A,D,E,K

Nursing Management and

Treatment

Pulmonary hygiene
Supplemental oxygen as needed
High calorie, high protein diet
Dietary supplements

CF Nursing Diagnosis

Ineffective airway clearance

Impaired gas exchange
Risk for infection
Alteration in nutrition
Risk for ineffective family coping
Fear/anxiety
Activity intolerance

Sudden Infant Death

Syndrome

Description
Unexpected death of apparently healthy infant younger
than 1 year in which autopsy fails to demonstrate adequa
cause of death
Assessment
Child found apneic, cyanotic, lifeless
Frothy, blood-tinged fluid may be present in nose, mouth
Typically found in disheveled bed with blankets over head
huddled in corner
Diaper may be full of urine and/or stool

Sudden Infant Death

Syndrome
Prevention
*Place infants supine for sleep*
No pillows, quilts, soft moldable mattresses
or bedding should be placed under infant
Instruct parents to remove stuffed animals
during sleep
Discourage bed sharing (sleeping with adult)

Foreign Body Aspiration

Inhalation of an object into the
respiratory tract, intentional or otherwise
Peak age is in children under 3 years
Leading cause of death in children under 1
year

Usually lodge in the right main stem

bronchus

Foreign Body Aspiration

Most common offending foods round in shape,
including hot dogs, candy, peanuts, grapes
Assessment
Choking, gagging, coughing, retractions
Interventions
Emergency care
Heimlich maneuver
Nonemergency management
Prepare for endoscopy as prescribed

Foreign Body Aspiration

Assessment
Sudden coughing and gagging
Partial obstruction may cause
respiratory infection for days or weeks
If complete obstruction, child will have
stridor, cyanosis, difficulty swallowing
and speaking

Foreign Body Aspiration

Keep small objects out of reach; avoid
small pieces of food, such as hot dogs;
keep helium balloons out of reach
Parent, day care provider, babysitter
education
Heimlich maneuver, cardiopulmonary
resuscitation for signs of aspiration

FB - Interventions
Respiratory assessment to determine
severity of problem and degree of
obstruction
Total airway obstruction
Back blows and chest thrusts for infants
Heimlich in children over 1 year
NPO

FB Nursing
Interventions

Ineffective airway clearance

Ineffective breathing pattern
Fear/anxiety
Knowledge deficit related to child
safety

Tuberculosis (TB)
Description

Contagious respiratory disease;

caused by Mycobacterium tuberculosis

Assessment

May be asymptomatic
If symptoms develop, include malaise, fever,
cough, weight loss, anorexia, lymphadenopathy

Mantoux test

Induration of 15 mm or greater in child 4 years or older

considered positive for TB
Induration 10 mm or greater is positive in child younger
than 4 years
Induration of 5 mm or greater is positive in children from
high-risk group, such as with immunocompromised condition

Tuberculosis (TB)

Sputum culture
Definitive diagnosis made with
presence of mycobacterium in sputum
Interventions
Administer 9-month course of isoniazid
(INH) or rifampin (Rifadin) and pyrazinamide as
prescribed to prevent TB after exposure
If active TB, place on airborne, respiratory
precautions
If active TB, administer medications daily for 2
months, then twice weekly for 4 months as prescribed
Instruct family in prevention of TB transmission

1.
2.
3.
4.

The nurse employed in an emergency department is

instructed to monitor a child diagnosed with
epiglottitis. The nurse notes that the child is
leaning forward, with the chin thrust out. The
nurse interprets this finding as indicating:
The presence of dehydration
The presence of pain
Extreme fatigue
An airway obstruction

Elsevier items and derived items 2008

by Saunders, an imprint of Elsevier Inc.

37-67

Answer: 4

Rationale:
Clinical manifestations suggestive of
airway obstruction include tripod
positioning (leaning forward supported by
arms, chin thrust out, mouth open), nasal
flaring, tachycardia, high fever, and sore
throat. Options 1, 2, and 3 are incorrect.

Elsevier items and derived items 2008

by Saunders, an imprint of Elsevier Inc.

37-68