Unformatted text preview: Respiratory Alterations and Dysfunction
Respiratory infections will spread from one structure to another due to the contagious nature of the mucous
membrane lining. Infections involve several areas and most of the time, they will have mild symptoms.
However, severe symptoms may lead to hospitalization. Respiratory infections range from Respiratory Distress
to respiratory failure and then respiratory arrest.
Objective 7 - Respiratory Alterations & Dysfunction General Respiratory Illness
Symptoms Fever – often the first sign. May be absent in neonates and/or actually be below normal. May reach 39.540.5 C (103-105 F) with even mild infection. May become listless and irritable. Be aware of febrile
seizures (uncommon after 3-4 years old). When parent reports fever, it’s important to also check on
child’s behavior and LOC. Are the behaving as “normal” but lethargic or, are they delirious? Headache – is often accompanied with fever, usually subsides when temperature goes down. Pain/stiffness of neck – first thought is meningitis. During this time, children may have meningeal signs
without actually having infection of the meninges (pain and stiffness in their back and neck) Anorexia – when children don’t feel well, or are beginning to feel unwell, they tend to become anorexic
so this is often a beginning symptom that can continue into the febrile stage and into convalescence. Vomiting – children vomit easily and this can also precede several signs. This is usually short-lived but
can also persist during the illness. Vomiting may also be caused by drainage (such as sinus drainage). Diarrhea – usually mild but may become severe, a frequent cause of dehydration. With increased
respiratory rate and fever, child is losing fluids quickly. Abdominal pain – a frequent complaint of children. This can be caused by vomiting or by excessive
drainage. Nasal blockage - Children have small passages that are easily blocked with swelling. A nasal blockage
will interfere with their breathing and feeding. Especially difficult for bottle and breastfed babies. Can
also contribute to otitis media (OM) Nasal discharge – frequent symptom (snotty nose). Can be thin, watery, thick, purulent and a variety of
colors. Irritates the upper lip and nares and can cause itching. Be aware of those children and think about
the itching breaking skin integrity and what that can lead to. Cough – may be common, but usually only evident during the acute stage and is usually caused by
drainage. Cough can sometimes exist for a long time after the illness. Abnormal respiratory sounds – may be heard (cough, hoarseness, grunting, stridor, wheezing and
crackles) and the breath sounds may be diminished or absent. If you hear any change or breath sounds
are more diminished – report immediately. Sore throat – frequent complaint of older children. Non-verbal children have difficulty complaining
about sore throat and may refuse to take orally fluids. Usually cold liquids can sometimes help with this.
The sore throat may diminish as the drainage diminishes.
Nursing Diagnosis used with respiratory illness (and other illnesses) Ineffective breathing patterns – remember that infants are obligate nose breathers. Ineffective airway clearance – only older children can effectively blow their nose and cough/spit.
Difficult with young children. Activity intolerance – universal (can’t breathe, can’t be active) Fear/Anxiety – from difficulty breathing Pain Risk for infection Interrupted family processes – ex: single parent w/multiple children and difficult job, families w/out
Knowledge deficit – such as how these illnesses are started or spread Upper Airway Tract Infections (URI) Nasopharyngitis (common cold)
Laryngotracheobronchitis (LTB) Tonsillitis – lymphoid tissue located in the pharyngeal cavity. Can be caused by both viral and bacterial
agents. One of the common causative agents is Group A Beta Hemolytic Streptococci – if left untreated can
cause acute glomerular nephritis, meningitis or rheumatic fever.
o Enlarged tonsils (sometimes they can meet midline - kissing tonsils) which result in:
o Difficulty swallowing
o Mouth breather
o Mouth odor
o Nasal sounding voice
o Can cause otitis media (because adenoids ae blocked leading to fluid building causing OM and
Treatment – do a throat culture to check for positive bacterial infection Viral – treat symptoms
o Pain relief
o Gargling (warm salt water, no alcohol mouth washes)
o Cool bland liquids Bacterial - Antibiotics Tonsillectomy – more controversial treatment that once were. Need to have tonsillitis infection 3x or
more per year, hearing loss from OM or apnea. Tonsils taken out after the age of 3-4 years and adenoids
are not automatically removed with tonsillectomy as they once were. Adenoids can grow back!
Tonsillectomy Post op nursing care – minimize activity to facilitate drainage and decrease bleeding Position – sideline helps facilitate drainage and prevent aspiration and cough Avoid coughing or blowing nose Vomiting – this is common, evaluate what they are vomiting (old vs fresh blood) Provide appropriate beverages – something cool, preferable non-citrus (acid!), nothing carbonated (may
interfere with the stitches) and NON-RED liquids (so as not to be confused for blood if vomited). No
milk or milkshakes as this can create a “coating” on throat that can lead to child trying to clear their
throat/cough. Observe – frequent swallowing may be an indication of post-operative bleeding. Monitor vital signs for
signs of hemorrhaging Provide pain relief Scab - Educate family and patient about this; usually sloughs off at about 7-10 days. Scab may be
coughed up or swallowed by child. Once scab is sloughed off, may be initial bleeding. Educate parent to
be aware of possible fresh blood or lots of swallowing. ***Critical Thinking Scenario
A 4 year-old has had four strep throat infections in the past 7 months. She has had several cases of otitis media,
which have led to decreased hearing in her left ear. She is scheduled for T&A (tonsillectomy and
Respiratory rate -32 – elevated for her age - tachypneic
Heart rate – 125 - tachycardia
B/P – 125/65 - slight hypertension
Frequent swallowing – indication of bleeding. Don’t use depressor, have her open mouth and look for
bleeding. Bleeding can affect respiratory, heart rate and b/p
Irritable – possible from pain
Temperature 38.5° - increased temperature could be caused by increased metabolic rate (tachypnea and
Oral serosanguinous mucus – sign of dehydration from fluid loss during surgery
What are the nursing actions required by the above assessment? Vital signs show that she may be in pain – 1st
look at when last received pain meds. Or use non-pharmacologic interventions if meds not yet due. OTITIS MEDIA – usually peaks in the first 2 years of life (6-20 months of age). Tends to be more common
in boys, children in daycare, have allergies, are exposed to tobacco smoke or use a pacifier several hours a day.
More common in winter and may be preceded by viral respiratory infection
Visual Symptoms Landmarks not easily identifiable No light reflection (no cone of light) on membrane Visible effusion/bubbles Inflamed tympanic membrane Child pulls on ear/jaw Fever may or may not be present Irritable/crying
Treatment of AOM (acute otitis media – means acute onset of pain and middle ear effusion) Pain relief: topical anesthetics/ear drops can be prescribed Fever control: Tylenol or ibuprofen Antibiotic use only when indicated: <6months: will receive antibiotics >6months: may delay and wait
48-72 hours before treating with antibiotics Parental education regarding antibiotic administration – increase in bacteria becoming antibiotic
resistant. Antihistamines and decongestants do NOT work on OM. Teach to give ALL antibiotics, even if
child appears to feel better Avoidance of tobacco exposure – can increase risk of ear infections, smoke can cling to clothing so
change clothing before handling young baby Overuse of pacifier - can cause ear infections Avoiding bottle propping – can cause ear infections OME (otitis media with effusion) – not treated with antibiotics, usually improves within 3 months and
can be associated with hearing loss. If continues >4 months or causes hearing loss then child received
myringotomy (tympanic tubes) to equalize pressure in the ear. SURGERY for tubes Tympanostomy tubes may be placed for history of repeated infections or complication such as hearing loss – to
help relieve pressure in the ear and facilitate drainage of fluid. Performed as outpatient surgery Small amounts of reddish drainage is normal. Educate parent to report if drainage is purulent. Educate
parent on what tubes look like/what color so can contact doctor if they fall out for possible replacement. Possible use of ear plugs to avoid water in ear: more controversial now than in the past. Avoid getting
water in patient ears because these tubes give direct access into middle ear – especially contaminated
water such as lake water (use plugs!). Regular shower water is not an issue (don’t dunk head in bathtub) CROUP
Upper airway obstruction manifested by a “barky” cough, inspiratory stridor, gradual onset of low grade fever,
and some respiratory distress. Can reoccur – usually viral.
Treatment usually at home Keeping child comfortable, calm to reduce anxiety – this is focus of care Observe for respiratory distress – teach parents to do this. Watch for increased restlessness, increased
respirations, increased heart rate (early sign), wheezing, flaring of nares, retractions, cyanosis (late sign) Encourage adequate hydration Use of cool mist vaporizer or cool shower (not cold). Warm mist humidifiers no longer recommended
because bacteria tends to grow in them if not cleaned regularly and appropriately. Acetaminophen or ibuprofen for fever and pain/discomfort.
CROUP SYNDROMES: Spasmodic LTB
(laryngotracheobronchitis) 1-3 yrs
Subglottic 3mo-3 yrs
Subglottic, vocal cords, bronchi Viral, emotional
Treated at home Viral, bacterial
Hospitalization Epiglottitis (bacterial form of
croup)– don’t use tongue
depressors or look!
Supraglottic (caused by H.influenza
virus. HIB vaccine helps)
Dysphasia (diff swallowing)
Dyspnea (diff breathing)
Dysphonia (diff speaking)
Dyspnea - istressed inspiratory effort
Artificial airway ready to use!
Hospitalization/ICU Bronchiolitis - Obstruction at bronchiolar level in small airwaves (most common disease of lower airways)
2-12 mo. rare after 2 yrs. (peaks between 2-6 months)
Usually a viral infection (80% caused by RSV)
o RSV Season - begins in fall, peaks winter, ends spring (Sept/Oct – Mar/May)
o RSV is common cold to healthy adult, but can be deadly for infants
Symptoms: the virus invades the mucosal cells lining the bronchioles, causing cell death and the virus causes
the cells to burst. Membranes spill over with the virus into neighboring systems. Cell debris will block the
airway and irritate the airways resulting in an excessive amount of mucous and swelling. This leads to
obstruction and bronchiole spasms. Dyspnea non-productive cough retractions nasal flaring wheezing tachypnea listlessness irritability labored breathing
Treatment: usually supportive with high humidity and adequate fluid intake
Severe infection may require hospitalization to give: Humidified oxygen IV Fluids Medications (prophylactic for RSV)
o Ribovarin- antiviral aerosol, very $$$, only for severe cases and has severe teratogenic effects (care
needed for pregnant caregivers to avoid exposure)
o RespiGam (RSV-IVIG) – an immunoglobulin product that required blood administration
precautions. Patients had to come in regularly to have IV started and Respi-Gam administered. Not
good family compliance.
o Synagis (palivizumab) – monthly injection given every 28 days to high risk infants. Infants required
to meet certain criteria before insurance/Medicaid would pay for treatment. Approx $2000/month vs
stay in PICU. Criteria varies but usually required for infant to be premature (before 32 weeks) with
sibling in school/daycare, family that smokes or child went to daycare. Easiest way for family
compliance. ***Critical Thinking Scenario
3 month old admitted with RSV+ bronchiolitis. Has oxygen .5L per NC to keep sats above 94%. HR 150, RR
66, T 38° were last vital signs.
What interventions would the nurse question?
Raising the oxygen level
Checking patient’s output
Feeding infant 5 oz of enfamil
Monitoring patient’s input
Requesting prn respiratory treatment Pneumonia
o Chest pains
o Nasal flaring
o Irritable, restless, lethargic
o Anorexia, vomiting, diarrhea, abdominal pain
Treatment: Nursing care is supportive and symptomatic involving oxygen, antibiotics administration, fluids,
fever and pain control. Treatment of symptoms will help patients feel better to get them additional nutrition.
o Bacterial – treated with antibiotics or
o Viral – treat the symptoms
o Fluid replacement
o Respiratory treatment (updrafts and CPT)
o Keep comfortable
o Cluster care to allow for rest periods.
o Nurse – very important to monitor breath sounds ***Critical Thinking Scenario
A 7-year-old (44 lbs) is admitted with bacterial pneumonia. He is irritable with shallow respirations at 50 with
substernal, supraclavicular, and intercostal retractions. He is getting oxygen 3L/min per mask and the sats are
91%. His RT treatments are ordered every 3 hours. His IV is infusing at 30 cc/hr.
What is your nursing assessment of his current status and what interventions should be done? Asthma (RAD – reactive airway disease)
Chronic inflammatory disorder of the airways – with acute exacerbations that is brought on by triggers.
Pathophysiology: Inflammation & edema of membranes - small airways in infants and children are easily blocked when
there is inflammation and edema in those membranes Accumulation of secretions – doesn’t take much to cause additional blockage in children Spasms of smooth muscles causing decrease in airway diameter – causing difficulty breathing an
anxiety in these patients.
Common triggers Exercise Allergens such as pollens, molds, dust, tobacco smoke Changes in weather Infections Food or food additives Medications Beta Blockers may be a trigger (not a treatment) for asthma because it is a vaso-stabilizer
and this can interfere with the body’s normal autonomic system to widen airways. Emotions
Attacks may be sudden or gradual respiratory distress
Early detection of subtle signs is a focus for controlling attacks and can be accomplished using the Peak Flow
meter Correct use of Peak Flow Meter Slide marker or arrow at bottom of scale Stand up straight No gum or food in mouth Lips tight around mouthpiece Tongue away from mouthpiece Blow as hard and fast as you can Note number by marker – red/yellow/green marks good for younger child Repeat three times (30 second between) not usually a problem for children over 5 years Record highest reading Measure same time and same way each day (i.e. morning, evening, before or 15 minutes after meds) Keep daily chart
Asthma Medications ** know medications** Quick-relief (rescue) – treatment of symptoms -albuterol, levalbuterol, terbutaline.
o Short-acting B2-agonists
o Oral corticosteroid
o Anticholinergics Routine/long-term (preventative) - Long Term (routine) meds (preventive) – inhaled/oral
corticosteroids. Long acting β₂-agonists (bronchodilator)- salmeterol. Leukotriene modifiers (block
inflammatory and bronchospasm effects)-montelukast.
Cromolyn sodium, nedocromil sodium
Corticosteroid (inhaled or oral)
Methylxanthines – commonly known as aminophylline (IV version), theophylline (PO – not
commonly used anymore) and caffeine (don’t need to measure patient heart rate prior to
administration). Caffeine can keep children awake – don’t give at bedtime.
Review all specific medications
o MDI with spacer may be required for some medications – spacer available for children under 5 years
Correct use of MDI – metered dose inhaler Shake well Breath out fully Lips tightly around mouthpiece Press down Breath slowly Hold breath 10sec Remove inhaler Repeat 2 minutes Rinse with water – to prevent thrush Nebulizer may be required for administration of some medications
Correct use of nebulizer. Nebulizer medication is a liquid that is converted into an aerosol. NOT more effective
than an MDI, simply another form of administration. Be sure that the medication is placed in the proper
chamber of the nebulizer machine. Clean hands Add medication Slow deep breaths Tight lips 10-15 minutes Clean equipment Air dry Disinfect equipment daily
The key to chronic asthma management is long-term control of airway inflammation. Many things will interfere
with asthma treatment. Beta blocker (vaso-stabilizer) given with bronchodilator will not respond as well
because Beta Blocker keeps bronchodilator from working
Education is the key in reducing under appreciation of disease, failure to follow treatment guidelines, nonadherence, and difficulty using inhalation devices. This includes educating family and additional caregivers.
Make sure patients can use different inhalation devices they have, training and return demonstration is vital.
Patient pictured is in “tripod position”. She has a little arch in her back and she is stretching her back, trying to
decrease pressure on her diaphragm to take bigger breaths. Not being able to breathe is very scary for these
patients and one of the best things they can do is relax – but sometimes that is very difficult.
***Classification*** - know these Mild intermittent asthma - symptoms less than twice weekly, patient otherwise asymptomatic,
pulmonary function studies normal except during periods of disease & exacerbations are brief & easily
treated Mild persistent asthma - symptoms more than twice a week but less than daily, severe enough to
interfere with daily activities & may interrupt sleep up to twice a month, pulmonary function studies
normal or show mild airflow obstruction which is reversible with the inhalation of a bronchodilator. Moderate persistent asthma - symptoms occur daily, severity warrants regular use of medications for
control. Patient constantly aware of their disease, require medications on a daily basis, sleep interrupted
at least weekly, & have to accommodate their life style to the disease. Pulmonary function is moderately
abnormal, with the FEV1 being 60-80% of the predicted value. Severe persistent asthma - continuous symptoms despite the correct use of medications, severity limits
physical activities, frequent exacerbations & sleep interruption. Treatment requires combinations of
medications on a constant basis. Pulmonary function tests are severely affected with the FEV1 being
<60% of predicted. What are your impressions about the case study situation?
What pertinent information is missing?
What factors place Suzy at risk for experiencing an “asthma attack”?
Why is Suzy prescribed montelukast (Singuliar) and Azmacort?
While assessing Suzy, the school nurse asks her when she last used her Albuterol inhaler. Why is this important
information for the school nurse? When is it appropriate for Suzy to use her Albuterol inhaler? Cystic Fibrosis – severe, chronic multisystem disorder Affects exocrine glands
o Reproductive systems
Transmitted by autosomal recessive gene
o If both par...
View Full Document
- Spring '18
- Respiratory distress, labored breathing, ***Critical Thinking Scenario