NCM FINALS PT1

• Respiratory disorders


  Among the most common causes of illness and hospitalization in children
• Respiratory dysfunction in children


  • Tends to be more serious than in adults because the lumens of a child's respiratory tract are smaller and therefore more likely to become obstructed
  • Respiratory disorders range from minor illnesses such as a simple upper respiratory tract infection to life-threatening lower respiratory tract diseases, such as pneumonia
  • The level of acuity can change quickly

  
• Both a child and parents need a great deal of nursing support when disease interferes with the function of breathing, because even very young children can panic when breathing becomes labored
• Early diagnosis and treatment are essential in preventing a minor problem from turning into a more serious one
• Divisions of the respiratory system


  • Upper respiratory tract (nose, paranasal sinuses, pharynx, larynx, epiglottis)
  • Lower respiratory tract (bronchi, bronchioles, alveoli)

  
• Inspiration (breathing in)


  1. Delivers warmed and moistened air to the alveoli

  2. Transports oxygen across the alveolar membrane to hemoglobin-laden red blood cells

  3. Allows carbon dioxide to diffuse from red blood cells back into the alveoli

  
• Expiration (breathing out)


  Carbon dioxide–filled air is discharged to the outside
• Partial pressure of gas (millimeter of mercury [mmHg])


  • As measured in peripheral and systemic circulation
  • Differences in partial pressure cause O2 to move from alveoli to pulmonary capillaries and O2 to move from tissue capillaries into tissues while CO2 moves out
• Respiratory tract differences in children


  • Ethmoidal and maxillary sinuses present at birth, frontal and sphenoidal sinuses develop at 6-8 years
  • Rapid growth of lymphoid tissue causes normally enlarged tonsillar tissue in early school-age children
  • Infant airway is funnel-shaped with narrowest portion at cricoid cartilage rather than vocal cords
  • Infants have large occiputs that can obstruct the airway
  • Infants have large tongues that can obstruct the airway
  • Infants are obligate nose breathers until 6 months, nasal obstruction can cause respiratory distress
  • Wheezing may not be prominent in infants even with severely compromised airway
• Assessing respiratory illness in children


  1. History taking

  2. Physical examination

  3. Possible laboratory testing
• If the child is in acute distress, the interview and health history may cover only the most important details: when the child first became ill and what symptoms are present
• Physical assessment


  • Cough
  • Rate and depth of respirations
  • Retractions
  • Restlessness
  • Cyanosis
  • Clubbing of fingers
  • Adventitious sounds
  • Chest diameter

  
• Cough


  Cough reflex initiated by stimulation of respiratory tract mucosa, sound caused by rapid expiratory air movement, useful to clear excess mucus or foreign bodies, paroxysmal coughing refers to a series of expiratory coughs after a deep inspiration

  
• Tachypnea


  An increased respiratory rate, often the first indicator of respiratory distress in young children

  
• Retractions


  Inward drawing of intercostal spaces when children must inspire more forcefully than normal to inflate their lungs due to airway obstruction or stiff, noncompliant lungs

  
• Restlessness


  Anxious or restless stirring may signal respiratory obstruction becoming acute or be one of the first signs of airway obstruction

  
• Cyanosis


  Blue tinge to the skin indicating hypoxia, may not be apparent if low unoxygenated red blood cell count
• Clubbing of fingers


  Change in angle between fingernail and nail bed due to increased capillary growth in fingertips, occurs in chronic respiratory illnesses as body attempts to supply more oxygen
• Adventitious sounds


  • Rhonchi (snoring sound from obstruction)
  • Stridor (harsh, strident sound on inspiration from obstruction at base of tongue or larynx)
  • Wheezing (expiratory whistle sound from obstruction in lower trachea or bronchioles)
  • Rales (fine crackling sounds from fluid-filled alveoli)
  • Diminished or absent breath sounds from fluid-filled alveoli
• Chest diameter


  Elongated anteroposterior diameter ("pigeon breast") and tympanic/hyperresonant sound on percussion in chronic obstructive lung disease from air trapping

  
• Laboratory tests


  • Pulse oximetry
  • Nasopharyngeal culture
  • Sputum analysis
• Pulse oximetry


  Noninvasive technique for estimating arterial oxygen saturation
• Nasopharyngeal culture


  Can provide information about microorganisms causing disease, but children often resist the procedure
• Sputum analysis


  Rarely feasible in children younger than school age, older children can cough and expectorate sputum
• Diagnostic procedures


  • Chest radiograph
  • Pulmonary function studies

  
• Chest radiograph


  Shows areas of infiltration or consolidation, more limited in infants who cannot hold their breath
• Pulmonary function tests


  Measure forces of inertia, elasticity, and flow resistance, spirometry is the most common test in children
• Home treatments


  • Humidification
  • Inhalation devices
  • Coughing
  • Mucus-clearing devices
  • Chest physiotherapy
• Therapy to improve oxygenation


  • Oxygen administration
  • Pharmacologic therapy
  • Incentive spirometry
  • Breathing techniques
  • Endotracheal intubation
  • Tracheostomy
  • Assisted ventilation

  
• Common pediatric respiratory disorders


  • Choanal atresia
  • Acute nasopharyngitis (common cold)
  • Pharyngitis
  • Epistaxis
  • Laryngitis
  • Epiglottitis
  • Tonsillitis

  
• Choanal atresia


  Congenital obstruction of posterior nares, may be unilateral or bilateral, causes respiratory distress at birth

  
• Acute nasopharyngitis (common cold)


  Caused by viruses, characterized by dehydration, watery rhinitis, nasal congestion, low-grade fever
• Pharyngitis


  Inflammation of the pharynx, may be caused by virus or Streptococcus, characterized by fever, sore throat, enlarged lymph nodes, erythematous pharynx

  
• Epistaxis


  Bleeding from the nose caused by trauma, mucosal inflammation from allergy or upper respiratory infection

  
• Laryngitis


  Inflammation of the larynx, may spread from pharyngitis or from excessive vocal cord use, characterized by brassy voice or inability to make audible sounds
• Epiglottitis


  Inflammation of the epiglottis caused by bacteria or viruses, occurs most frequently in children 3-8 years old, characterized by high fever, dysphagia, stridor, drooling
• Epiglottitis assessment


  • Fever
  • Sore, red and inflamed throat
  • Drooling, dysphagia
  • Inspiratory stridor
  • Muffled voice
  • Nasal flaring

  
• Epiglottitis implementation


  • Maintain patent airway
  • Assess respiratory status and breath sounds
  • Assess use of accessory muscles and presence of stridor
  • Assess temperature
  • Do not attempt to visualize posterior pharynx or obtain throat culture
  • Obtain lateral neck film
  • Do not force child to lie down or restrain
  • Administer antibiotics and IV fluids
  • Use cool mist oxygen and high humidification
  • Have resuscitation equipment available
  • Immunization

  
• Tonsillitis


  Infection and inflammation of the palatine tonsils, adenitis refers to infection and inflammation of the adenoids
• Epiglottitis


  Inflammation of the epiglottis caused by bacteria (H. influenzae, streptococci, pneumococci and staphylococci) and echovirus (RSV)