Chapter 18, Nursing Care of the Child With an Alteration in Gas Exchange/a Respiratory Disorder Learning Objective 1. Distinguish differences between the anatomy and physiology of the respiratory system in children versus adults.
Teach your students that respiratory disorders are the most common causes of illness and hospitalization in children and account for the majority of acute illnesses in children.
The upper and lower airways are smaller in children than adults. Tongues are proportionately larger in infants making them more susceptible to obstruction in the presence of mucus, debris, or edema. In young children, tonsils are disproportionately large increasing the risk of airway obstruction.
Emphasize the fact that newborns are obligatory nose breathers until at least 4 weeks of age and cannot automatically open their mouths to breathe if the nose is obstructed. (Refer to PowerPoint slide 2.)
Discuss how the anatomy of the nose and throat differs in infants, making them more prone to acquire infections. The child’s highly compliant airway is quite susceptible to dynamic collapse in the presence of airway obstruction. Because they have fewer alveoli, children have a higher risk for hypoxemia than adults. Note that a small reduction in the diameter of a child’s airway will result in an exponential increase in resistance to airflow, causing increased work or breathing. (Refer to PowerPoint slides 3 and 4 and Figure 18.1.)
Discuss the location of the trachea at the third thoracic vertebra in children as opposed to the sixth in adults and how this difference is important when suctioning children and assessing for risk for aspiration. Review the differences in the lower respiratory structures. (Refer to PowerPoint slide 4.)
Explain the occurrence of congenital laryngomalacia due to the funnel shape and location of the larynx, increasing the chance of aspiration of foreign material into the lower airways. (Refer to Box 18.1.)
Point out that children have a significantly higher metabolic rate than adults and how this affects normal oxygen transport.
Learning Objective 2. Identify various factors associated with respiratory illness in infants and children.
Emphasize the fact that children exposed to environmental smoke have an increased incidence of respiratory illnesses such as asthma, bronchitis, and pneumonia (WHO, 2011).
Discuss what the nurse would inspect and observe when conducting a physical assessment for respiratory disorders. (Refer to PowerPoint slide 5 and Figure 18.4.)
Tachypnea, increased work of breathing (WOB), nasal flaring, retractions, wheezing, and diminished breath sounds are classic signs of respiratory problems in children.
Define adventitious breath sounds that can be heard through auscultation. Review the breath sounds heard over the anterior and posterior chest and axillary areas including wheezing and rales as well as other types of sounds including fremitus, tympany and hyperresonance. Note that breath sounds should be equal bilaterally, and prolonged expiration is a sign of bronchial or bronchiolar obstruction.
Remind students that when percussing the chest, sounds that are not resonant in nature should be noted by location and sound. (Refer to PowerPoint slides 6, 7, and 8.)
Learning Objective 3. Discuss common laboratory and other diagnostic tests useful in the diagnosis of respiratory conditions.
Review the laboratory and diagnostic tests most commonly used for a child with a respiratory disorder. (Refer to Common Laboratory and Diagnostic Tests 18.1.)
Pulse oximetry is a useful tool for determining the extent of hypoxia. Spirometry and pulmonary function testing are often used to assess degree of disease but are not always useful in acute episodes. Findings should be correlated with the child’s clinical presentation.
Rapid streptococcus and rapid influenza tests are very useful for the quick diagnosis of strep throat or influenza so that appropriate treatment may be instituted early in the illness. (Refer to PowerPoint slide 9.)
Note the common laboratory and diagnostic tests ordered for the assessment of pneumonia. (Refer to PowerPoint slide 10.)
Outline the laboratory and diagnostic tests ordered for the diagnosis and assessment of cystic fibrosis. (Refer to PowerPoint slide 11.)
Review the use of allergy skin testing to determine triggers for asthmatic children.
Learning Objective 4. Describe nursing care related to common medications and other treatments used for management and palliation of respiratory conditions.
Discuss common medical treatments and medications used to treat respiratory illness in children. (Refer to PowerPoint slides 12, 13, and 14, Common Medical Treatments 18.1, and Drug Guide 18.1.)
Suctioning, whether with a bulb syringe or suction catheter, is very effective at maintaining airway patency, especially in the infant or younger child. Supplemental oxygen is often necessary in the child who is hospitalized (particularly with lower respiratory disease). Oxygen should be humidified to prevent drying of secretions.
Review the most common types of acute infectious respiratory disorders (Refer to PowerPoint slide 15.)
Teach your students that therapeutic management of respiratory distress syndrome (RDS) focuses on intensive respiratory care, usually with mechanical ventilation. Note that newer techniques for ventilatory support are also available. (Refer to PowerPoint slide 16 and Table 18.2.)
Less invasive methods, such as incentive spirometry and coughing with deep breathing (which can be accomplished through play) can be used to maximize ventilation.
Learning Objective 5. Recognize risk factors associated with various respiratory disorders.
Infants who were born prematurely; children with a chronic illness such as diabetes, congenital heart disease, sickle cell anemia, or cystic fibrosis; and children with developmental disorders such as cerebral palsy tend to be more severely affected with respiratory disorders.
In formerly premature infants, chronic lung disease can cause an increased risk for respiratory ailments later in childhood, long after infancy.
Passive cigarette smoke exposure increases the infant’s and child’s risk for respiratory disease.
Remind your students that acute infectious disorders include the common cold, sinusitis, influenza, pharyngitis, tonsillitis, laryngitis, croup syndromes, respiratory syncytial virus (RSV), pneumonia, and bronchitis.
Discuss the risk factors for respiratory infection, including chronic heart or lung disease (such as asthma), diabetes, chronic renal disease, or immune deficiency, or children with cancer receiving chemotherapy. Discuss the importance of influenza vaccination in light of these complications. (Refer to PowerPoint slide 16.)
Teach your students that pneumonia is an inflammation of the lung parenchyma caused by a virus, bacteria, Mycoplasma, or fungus. Point out that respiratory viruses are the most common cause of pneumonia in younger children and the least common cause in older children.
Review the signs and symptoms of bronchiolitis (also called respiratory syncytial virus or RSV). Discuss the passive immunization available for RSV (Synagis) in target groups. (Refer to PowerPoint slide 17.)
Outline risk factors for tuberculosis. (Refer to PowerPoint slide 18.)
Tell your students that acute respiratory distress syndrome (ARDS) occurs following a primary insult such as sepsis, viral pneumonia, smoke inhalation, or near drowning. Note that respiratory distress and hypoxemia occur acutely within 72 hours of the insult in infants and children with previously healthy lungs.
Review risk factors for acquiring a pneumothorax, including chest trauma or surgery, intubation and mechanical ventilation, or a history of chronic lung disease such as cystic fibrosis. (Refer to PowerPoint slide 19.)
Discuss the risk factors for apnea and SIDS. (Refer to Figure 18.14 andBox 18.4.)
Learning Objective 6. Distinguish different respiratory disorders based on their signs and symptoms.
Note the signs and symptoms of the following chronic respiratory disorders: allergic rhinitis, asthma, chronic lung disease (bronchopulmonary dysplasia), cystic fibrosis, and apnea. (Refer to PowerPoint slide 20 and Figure 18.10.)
Review the common signs and symptoms of sinusitis, including cough, fever, halitosis, facial pain, eyelid edema, irritability, and poor appetite.
Note that onset of pharyngitis is often quite abrupt and the history may include fever, sore throat and difficulty swallowing, headache, and abdominal pain. (Refer to Figure 18.6.)
Discuss the characteristics of asthma including signs and symptoms of airway hyperresponsiveness, airway edema, and mucus production. Define status asthmaticus and its presentation. (Refer to PowerPoint slides 21, 22, and 23, Figures 18.11 and 18.12, and Table 18.3.)
Point out that cystic fibrosis is the most common debilitating disease of childhood among those of European descent. Then, discuss the signs and symptoms of, and risk factors for, the disease. (Refer to PowerPoint slide 24 and Table 18.5.)
Learning Objective 7. Discuss nursing interventions commonly used for respiratory illnesses.
Promoting airway clearance and maintenance, effective breathing patterns, and adequate gas exchange is the priority focus of nursing intervention in pediatric respiratory disease.
Chest physiotherapy is extremely useful for mobilizing secretions in any condition resulting in an increase in mucus production and is required in children with cystic fibrosis
Positioning to ease work of breathing and maintaining a patent airway are priorities for the child with a respiratory disorder.
Children with any degree of respiratory distress require frequent assessment and early intervention to prevent progression to respiratory failure.
Discuss the variety of methods that oxygen may be delivered to a child. (Refer to PowerPoint slides 25 and 26, Tables 18.1 and 18.2, and Figure 18.5.)
Point out that therapeutic management of the common cold is directed toward symptom relief and includes promoting comfort, providing family education, and preventing spread of the cold. Include suctioning in young children and normal saline nasal wash to clear excess secretions. (Refer to Comparison Chart 18.1, Box 18.2, and Teaching Guidelines 18.1.)
Teach your students that nursing management of mononucleosis is primarily symptomatic and includes analgesics, salt water gargles, bed rest, rest periods, and avoiding contact sports.
Define croup and stridor. Contrast the symptoms of croups with those of epiglottitis. Note that children with croup may be hospitalized if they have significant stridor at rest or severe retractions after a several-hour period of observation. (Refer to Comparison Chart 18.2.)
Warn your students not to attempt, under any circumstance, to visualize the throat of a child with epiglottis. A reflex laryngospasm may occur, precipitating immediate airway occlusion. (Refer to PowerPoint slide 27.)
Review the procedure for maintaining a patent airway. (Refer to Nursing Procedure 18.1.)
Emphasize the fact that the most important nursing intervention related to foreign body aspiration is prevention. (Refer to Figure 18.7.)
Note that the stepwise approach to asthma treatment involves increasing medications as the child’s condition worsens, then backing off treatment as he or she improves. (Refer to Box 18.3.)
Avoidance of allergens is critical in the treatment plan for the child with allergic rhinitis and also the focus of asthma management.
Learning Objective 8. Devise an individualized nursing care plan for the child with a respiratory disorder.
Review the postoperative care of a child following tonsillectomy. Continual swallowing while awake or asleep is an indication of bleeding in the postoperative tonsillectomy child. (Refer to PowerPoint slide 28.)
Discuss the nursing management of pneumonia including diagnoses, goals, and interventions. (Refer to Nursing Care Plan 18.1.)
Ask your students to prepare a nursing care plan for a child who has one of the following acute noninfectious disorders: epistaxis, foreign body aspiration, respiratory distress syndrome, acute respiratory distress syndrome, or pneumothorax. (Refer to PowerPoint slide 29.)
Discuss the education provided to families of children with allergic rhinitis. (Refer to Teaching Guidelines 18.4.)
Teach your students that anti-inflammatory inhaled medications are used for maintenance of chronic lung disease, and short-acting bronchodilators are used as needed for wheezing episodes. Further, note that supplemental long-term oxygen therapy may be required in some infants.
With the class participating, develop a nursing care plan for a child with a tracheostomy. (Refer to Nursing Procedure 18.3.)
Learning Objective 9. Develop child/family teaching plans for the child with a respiratory disorder.
Discuss teaching guidelines for a child with croup. Brainstorm with the class to develop a teaching plan for a child with croup. (Refer to Teaching Guidelines 18.2.)
Review safety measures to teach parents of children with aspiration pneumonia to prevent recurrent or further aspiration. (Refer to Teaching Guidelines 18.3.)
Tell your students that children with asthma and their families need a teaching to master an asthma action plan focused on the appropriate use of nebulizers, metered-dose inhalers, spacers, dry-powder inhalers, and Diskus, as well as the purposes, functions, and side effects of the medications they deliver based on the child’s state of health. Point out that the teaching requires a return demonstration of equipment. (Refer to Table 18.4, and Teaching Guidelines 18.5.)
Learning Objective 10. Describe the psychosocial impact of chronic respiratory disorders on children.
Remind your students that fear of an exacerbation and feeling “different” from other children can harm a child’s self-esteem. Brainstorm with the class to devise of list of interventions to promote self-esteem in children with chronic respiratory disorders.
Point out that transferring control of asthma care to the child as soon as it is developmentally appropriate is an important developmental process that will increase the child’s feeling of control over the illness.
Emphasize the fact that a nurse who understands the family’s issues and concerns and provides culturally sensitive education and interventions is better able to plan for support and education regarding chronic respiratory disorders. (Refer to PowerPoint slide 30.)