Chapter 21 - Assessment Of Respiratory Assessment

Chapter 21 - Assessment of Respiratory Assessment

Purpose of the Respiratory System • The lungs, in conjunction with the circulatory system, deliver oxygen to and expel carbon dioxide from the cells of the body. • The upper respiratory system warms and filters air. • The lungs accomplish gas exchange. Structures of the Upper Respiratory Tract • Nose • Sinuses and nasal passages • Pharynx • Tonsils and adenoids • Larynx: epiglottis, glottis, vocal cords, and cartilages • Trachea Paranasal Sinuses 1. Frontal 3. Sphenoid 2. Ethnoid 4. Maxillary

Structures of the Lower Respiratory System • Lungs • Pleura • Mediastinum • Lobes of the lungs: – Left: upper and lower – Right: upper, middle, and lower • Bronchi / bronchioles • Alveoli

Aveoli • Where gas exchange takes place • Alveolar-capillary membrane • Surfactant

Diffusion and Perfusion in the Alveoli • Diffusion is the process by which oxygen and carbon dioxide are exchanged at the alveolar-capillary membrane. • Perfusion is the blood flow through the pulmonary circulation. Ventilation: movement of air in and out of the airways. • The thoracic cavity is an airtight chamber. • The floor of this chamber consists of the diaphragm. • Upon Inspiration: the diaphragm contracts (moves this chamber floor downward) and contraction of the external intercostal muscles increases the space in this chamber. • The expansion of space lowers the intrathoracic pressure (negative pressure) causing air to enter through the airways and inflate the lungs.

Ventilation: movement of air in and out of the airways • Expiration: diaphragm relaxes, the diaphragm moves up and intrathoracic pressure increases. • This increased pressure pushes air out of the lungs. • Expiration requires the elastic recoil of the lungs. • Inspiration normally is 1/3 of the respiratory cycle and expiration is 2/3.

Respiration • The process of gas exchange between atmospheric air and the blood at the alveoli, and between the blood cells and the cells of the body. • Exchange of gases occurs because of differences in partial pressures. • Oxygen diffuses from the air into the blood at the alveoli to be transported to the cells of the body. • Carbon dioxide diffuses from the blood into the air at the alveoli to be removed from the body.

Gas Exchange and Respiratory Function Ventilation/Perfusion (V/Q Ratio) • Ventilation is the movement of air in and out of the lungs. • Air must reach the alveoli to be available for gas exchange. • Perfusion is the filling of the pulmonary capillaries with blood. • Adequate gas exchange depends upon an adequate V/Q ratio, a match of ventilation and perfusion. • Shunting occurs when there is an imbalance of ventilation and perfusion. This results in hypoxia. What affects the Ventilation-Perfusion Ratios?

A- Normal Ratio B- Shunts C- Dead Space D- Silent Unit

Assessment of Breath Sounds • Normal breath sounds: (Table 21-5, p 575) • Vesicular – soft, relatively low sounds, sounds are longer during inspiration Heard over entire lung field except over the upper sternum & between scapulae • Bronchovesicular – intermediate sound, inspiration & expiration are equal Often heard in the anterior 1st & 2nd intercostals spaces and between the Scapulae (over the main bronchus) • Bronchial - loud and relatively high sounds, expiration sounds last longer than inspiration. Heard over the manubrium, if heard at all. - Tracheal sounds – heard over the trachea in the neck area. They are very loud, & relatively high. Inspiration & expiration are equal

Breathing Patterns p 572

During inspiration, the thoracic cavity must have a lower pressure than the atmosphere. Eupnea – normal respiration Bradypnea – slow breathing rate, < 10 breaths/min. normal depths and regular rhythm Tachypnea – rapid, shallow breathing, > 24 breaths/min. Hypoventilation – shallow, irregular breathing Hyperventilation – increase breathing rate & depth of breathing Called Kussmaul’s respiration when caused by a metabolic disorder (diabetic ketoacidosis) Apnea – periods of breathing cessation, time duration varies: dependent upon disorder that is causing it: (sleep apnea). Life threatening conditions if breathing is sustained Cheyne-Stokes – regular cycles of alternating rapid breathing with periods of apnea (20 sec). Biot’s respiration – periods of normal breathing (2-4 breaths) followed by varying periods of apnea lasting 10-60 seconds. Seen in patients with increase CP Breath Sounds • Abnormal (adventious) breath sounds: (Table 21-5, p 575) • Crackles (formerly called rales) • Wheezes (includes rhonchi) • Friction rubs (a form of crackles) _ Bronchopony, Egophony and Whipered pectoriloquy REVIEW

Function of Respiratory System - Oxygen transport  Supplies oxygen to and CO2 is removed from cells via the blood  Occurs by diffusion - Respiration  Breathing is regulated by the medulla oblongata in the brain  After diffusion takes place, blood returns through the veins to the pulmonary system  At the alveoli, the CO2 moves out of the blood. Oxygen moves from the alveoli into the blood. This is called respiration - Pulmonary system is considered a low pressure system (systolic 20-30, diastolic 5-15) - Pulmonary artery pressure, gravity, alveolar pressure determine the patterns of perfusuion. Gas Exchange  CO2 and O2 are exchanged at the alveoli  Oxygen diffuses across the alveolar memebrane to dissolve in blood until the oc pressure is the same in the blood as it is in the alveoli  CO2 is in venous blood is at a higher concentration than the alveolar gasses, so in the lung, CO2 diffuses from the venous blood into the alveolar gases until the pressure is the same.  O2 is carried in the blood by plasma and hemoglobin o The amt. Of O2 dissovled in the plasma varies with partial pressure of O2 in the arterires (PaO2). Norma PaO2 = 80-100 Lung Volumes & Capacities: (p.558) Lung function reflects mechanic of ventilation in view of the lung volumes & capacities. Lung Volume • Tidal volume (TV): air volume of each full breath • Inspiratory reserve volume (IRV): maximum volume of air that can be inhaled after a normal inhalation • Expiratory reserve volume (ERV): maximum volume of air exhaled after a normal exhalation. • Residual volume – is the vol. Of air remaining in the lungs after a maximum exhalation Lung Capacity • Vital capacity (VC): the max. vol. of air exhaled from a maximal inspiration, VC = TV + IRV + ERV • Inspiratory capacity – max. vol. of air inhaled after normal expiration • Functional residual capacity (FRC) – vol. of air remaining in the lungs after normal Expiration. FRV = ERV + RV • Total lung capacity (TLC) - vol. of air in lungs after mx. Inspiration Forced expiratory volume (FEV): volume exhaled forcefully over time in seconds. Time is indicated as a subscript, usually 1 second.

Measurement of Volume and Inspiratory Force • A spirometer measures volumes of air exhaled and is used to assess lung capacities. • Measure several breaths when assessing total volume. TV varies from breath to breath. • Pulmonary function tests assess respiratory function and determine the extent of dysfunction. • Peak flow rate reflects maximal expiratory flow and is frequently done by patients using a home spirometer. Inspiratory Force • Evaluates the effort of the patient in making an inspiration. • A manometer that measures inspiratory effort can be attached to a mask or endotracheal tube to occlude the airway and measure pressure. • Normal inspiratory pressure is approximately 100 cm H2O. • Force of less than 25 cm usually requires mechanical ventilation. Arterial Blood Gases • Measurement of arterial oxygenation and carbon dioxide levels. • Used to assess the adequacy of alveolar ventilation and the ability of the lungs to provide oxygen and remove carbon dioxide. • Also assesses acid-base balance Symbols for pressure gasses on p. 560-561 S/B book.

Pulse Oximetry • A noninvasive method of measuring the oxygen saturation of the hemoglobin. • Does not replace ABGs • Normal level is 95-100%. If <85% the tissue is not receiving adequate O2 • May be unreliable some situations Diagnostic Tests • Pulmonary function tests • Arterial blood gases • Sputum culture tests – collected to determine if pathogens or malignant cells are present.. Expectoration is theusual method of collecting sputum. Imaging studies: • Chest x-ray • Computed tomography (CT) • Magnetic resonance imaging (MRI) • Fluoroscopic studies and angiography • Radioisotope procedures (lung scans) Diagnostic Tests • Bronchoscopy – endoscopic procedure for direct visualization and inspection of the larynx, trachea, bronchi, done through a scope. • Used to examine tissue, obtain biopsy, excise lesions, determine if surgery is possible, and remove foreign objects. • Sedation is given; consent form required Fiberoptic Bronchoscopy • NPO after procedure until gag reflex returns

• Thoracoscopy – examination of the pleural cavity through endoscopy. Used for evaluation of pleural effusion, staging of tumors. (similar to laproscopic procudure) Rigid Bronchoscopy

• Biopsies – excision of a small amt. of tissue for examination • Pleural biopsy – biopsy of the pleural done by a needle • Lung biopsy – done by bronchoscopy or needle biopsy • Lymph node biopsy = scalene lump nodes are in the neck and drain the lungs and mediastinum Changes indicate thoracic diseases: Hodgkin’s, TB, CA, fungal disease Position of a Patient for Thoracentesis Endoscopic Thoracoscopy

RESPIRATORY ASSESSMENT Assessment LOC – be alert for LOC level of concsciousness: alert, confused, unresponsive. Look for changes: lethargy, agitation, inc.anxiety, somnolence, confusion, irritability  Health history focused on physical and functional problems o Usually seeking health care for dyspnea, pain, accumulation of mucus, wheezing, hemoptysis, edema of the feet, fatigue, weakness  Look for Signs & Symptoms of dyspnea, orthopnea, cough o Major s/sx – dyspnea, sputum production, chest pain, wheezing, clubbing of fingers, hemoptysis, cyanosis  Clubbing of nails, sign of lung disease found in pts. with chronic hypoxic conditions  Sputum and hemoptysis – expectoration of blood from the respiratory tract and is a symptom of both resp. and cardiac disorders. Most common causes are: o Pulmonary infections, lung CA, heart or blood vessel abnormalities, pulmonary artery or vein abnormalities, pulmonary emboli or infart. Assessment Patient’s position – are they trying to compensate LOC – be alert for LOC level of consciousness: alert, confused, unresponsive. Look for changes: lethargy, agitation, inc. anxiety, somnolence, confusion, irritability Skin – inspect under natural light. Beware! Fluorescent light – doesn’t show true skin color Cyanosis – a bluish coloring of the skin; it’s a very late indicator of hypoxia  Presence or absence is determined by amt. of deoxygenated hemoglobin in the blood  Cyanosis appears when there is 5g/dL of unoxygenated hemoglobin  A person with a hemoglobin of 15g/dL will not show cyanosis until 5g/dL of that becomes unoxygenated  Anemic pts. rarely show cyanosis.  Pts with Polycythemia may show cyanosis even if adequately oxygenated. They have a concentrated number of RBCs than the normal levels so when 5g/dL show cyanosis, they may still have enough RBCs carrying adequate (O2) oxygenation  Cyanosis is not a reliable sign of hypoxia  Assessment of cyanosis may be affected by room lighting, skin color, temperature of environment  Central cyanosis (as in pulmonary conditions) is assessed by looking at the color of the tongue and lips. This indicates a decrease of oxygen tension of the blood.  Peripheral cyanosis results from decreased blood flow to a certain area of the body, as in vasoconstriction of the nailbeds or earlobes from exposure to cold. Assessment Face – ck for signs of respiratory distress: nasal flaring - does he have O2, endotracheal tube, ck redness or exoriation neck – tracheal tube? How is the skin (infection?), Palpate for crepitus – air leaking into the subcutaneous tissue. Observe/palpate trachea for midline position – trachea deviation may indicate tension pneumothorax. Palpate for swelling, masses that might obstruct breathing. Assessment: Chest Configuration There are 4 main deformities of the chest associated with respiratory disease 1. barrel chest – occurs as a result of over inflation of the lungs.  There is an increase in the anterior-posterior diameter of the thorax.  In a pt with emphysema, the rigs are widely spaced at the intercostals spaces.  Intercostal spaces tend to bulge on expiration.  The appearance is quite characteristic of pts with advanced emphysema. 2. Funnel chest – occurs when there is depression of the lower portion of the sternum.  This may compress the heart and great vessels, resulting in murmurs.  Funnel chest may occur with rickets or Marfan’s syndrome. 3. Pegeon chest – displacement of the sternum.  There is an increase in the anterior-posterior diameter.  May occur with rickets, Marfan’s syndrome or severe kyphoscoliosis. 4. Kyphoscoliosis – Abnormal curvature of the spine characterized by an elevation of the scapula and a corresponding S-shaped spine. o Limits lung expansion within the thorax o May occur with osteoporosis, or other skeletal disorders Assessment Chest movement, are they using accessory mucles to breath? • Is there retraction of intercostals space during inspiration? A sudden violent retraction indicates airway obstruction or tension pneumothorax. • In COPD – muscles may retract during expiration as the pt forces air from the alveoli • Intercostal bulging may be seen with cardiac enlargement & aneurys, fx ribs and flail chest • Note expansion of chest – unequal thoracic expansion may indicate pleural effusion, atelectasis, pulmonary embolus, fx rib or sternum, or an endotracheal tube has been inserted too far & entered the Right mainstem broncus. Listen to Breath Sounds • Abnormal (adventious) breath sounds: (Table 21-5, p 575) • Crackles (formerly called rales) • Wheezes (includes rhonchi) • Friction rubs (a form of crackles) • Voice Sounds – vocal resonance heard through the stethoscope as pt speaks. (99 or ee) • Bronchopony – intense & clear vocal resonance than normal • Egophony – distorted voice sounds produced by consolidation (pneumonia) • Whipered pectoriloquy – a subltle sound heard only in dense consolidation p.576 Look at Breathing Patterns p 572 Eupnea – normal respiration Bradypnea – slow breathing rate, < 10 breaths/min. normal depths and regular rhythm Tachypnea – rapid, shallow breathing, > 24 breaths/min. Hypoventilation – shallow, irregular breathing Hyperventilation – increase breathing rate & depth of breathing Called Kussmaul’s respiration when caused by a metabolic disorder (diabetic ketoacidosis) Apnea – periods of breathing cessation, time duration varies: dependent upon disorder that is causing it: (sleep apnea). Life threatening conditions if breathing is sustained Cheyne-Stokes – regular cycles of alternating rapid breathing with periods of apnea (20 sec). Biot’s respiration – periods of normal breathing (2-4 breaths) followed by varying periods of apnea lasting 10-60 seconds. Seen in patients with increase CP Sputum Sputum indicates the reaction of the lung to any constant recurring irritant or to nasal discharge. Thick, viscous, frothy, mucoid, watery, or mucopurulent • Bacterial infection - indicated by a thick, yellow green, or rust colored sputum • Viral bronchitis - thin, mucoid sputum • Lung tumor - pink-tinged sputum • Pulmonary edema – profuse, frothy material often welling up in the throat • Lung abcess, Bronchiectasis – foul, smelling sputum and bad breath Bronchiectasis – chronic, irreversible dilation of the bronchi and bronchioles Sputum: Relief Measures • Decrease viscosity by increasing hydration (drink water) • Inhalation of awrosolized solutions • Stop smoking – it interferes with ciliary action, increases bronchila secrestions, causes inflammation, reduces surfactant. • Nutrition may be compromised due to smell or taste of sputum - Citrus juice before meals cleanses the palate and may make food more palatable Cough Timing; frequency- does it get worse,  Chronic, Acute, Paroxysmal  Productive – nonproductive;  Dry - moist  Barking, Hoarseness, Hacking Hemoptysis Blood tinged sputum • Review chest x-ray, chest angiography, bronchospcopy, medical history, physical. • Determine source of blood (gums, throat lungs, stomach) – From lungs – bright red, frothy – From nose or throat – usually preceded by sniffling, with blood possibly visible in the nose – From stomach – is it from vomiting or from coughing; dark “coffee grounds” color Clubbing • Sign of lung disease found in pts. with chronic hypoxic conditions, chronic lung infections, & malignancies. • Sponginess of nail beds with loss of nail-bed angle Chest Pain • Pain Associated with pulmonary or cardiac disease • May occur with pneumonia, P. emboli, lung infarction, pleurisy, cancer * Relief measures: analgesic, regional anesthetics, nonsteriodal anti- inflammatory drugs (NSAIDs) • Wheezing – airway narrowing heard mainly on expiration, but may be heard on both inspirations and expiration’ * Relief measures: oral or inhaled bronchodilators • Clubbing – sign of lung disease found in pts. c chronic hypoxic conditions, chronic lung infections, malignancies. - Sponginess of the nail beds with loss of nail-bed angle Thoracic Auscultation

• Adventitious sounds (additional) - produced by abnormal conditions that affect the bronchial tree and alveoli. – The duration of the sound is important in identifying the sound as non-continuous or continuous sounds • Divided into 2 types: – Discrete: non-continuous sounds (like crackles) – result from delayed re-opening of deflated airways – pleural friction rub is an example of crackles, usually heard on inspiration and expiration – Crackles used to be called rales – May or may not clear with coughing – May hear in pneumonia, bronchitis, heart failure, bronchiectasis, pulmonary fibrosis – Continuous, musical sounds (wheezes): associated with bronchial wall oscillations (vibrations) and changes in the diameter of the airways. (include rhonchi sounds) - usually heard in asthma, chronic bronchitis Assessing light to dark skin

Description Light skin Dark skin Cyanosis - bluish Bluish tinge Ashen gray

Pallor - paleness Loss of rosy glow Ashen gray (drk skin) Yellowish brown (brown skin)

Erythema - redness Visible redness Diffused; rely on palpation of warmth or edema

Petechiae – small size Purplish pinpoints Usually invisible; check oral Description Light skin Dark skin pinpoint ecchymosis mucosa, conjunctiva, eyelids, Jaundice - yellow Yellow sclera, skin, Reliableconjunctiva on sclera,covering hard eyeballs. palate, fingernails, soles, palms and soles. palms, oral mucosa

Ecchymosis – large Purplish to yellow- Difficult to see, check mouth diffused bluish black green or conjunctiva Brown-Tan – cortisol Bronze; Easily masked. deficiency, increased Tan to light melanin production brown Nursing 125 Pediatric Respiratory Problems Infants under 3 months have fewer respiratory infections probably because of protective maternal antibodies. The infection rate increases from 3 to 6 months. S/S Of Respiratory Infections In Infants & Small Children • Fever – may be absent in newborn; Greatest ages 6months-3yrs even /w mild infections. • Anorexia is common & often early sign; Vomiting may precede other signs by several hrs • Diarrhea usually mild 7 often accompanies viral respiratory infection • Abdominal pain is common complaint – Similar to appendicitis – Mesenteric lymphadenitis may be cause • Nasal blockage – interferes with breathing & feeding and can contribute to otitis media. • Nasal discharge, Cough, Sore throat Nursing Actions to Ease Respiratory Efforts • Ease respiratory effort, Rest, Comfort, Reduce fever • Prevent spread of infection, Promote hydration and Provide nutrition • Family support, teaching and home care. Acute Streptococcal Pharyngitis • Group a B-hemolytic (GABHS) strep throat – Not a serious infection itself but – Can lead to acute rheumatic fever or acute glomerulonephritis Assessment: • Brief illness, c/o headache, fever; Sudden onset. • Abdominal pain in small children.. Severity varies from subclinical to severe toxicity. • Inflamed tonsils and pharynx covered with exudate in 50 – 80% of cases. • Cervical lymphadenopathy. • Course of illness runs in 3 to 5 days. • Complications: Acute nephritis may occur in 10 days; and Rheumatic fever in 18 days. Acute Streptococcal Pharyngitis- Diagnostics • 80 –90% of sore throats are viral. • Throat culture should be done to rule out strep throat. • Some children harbor streptococci in their throats so a positive culture does not always mean that the infection is strep. Acute Streptococcal Pharyngitis – Treatment • Penicillin for 10 days • Cefdinir for 5 days combination of penicillin and rifampin • Obtain throat swab. • Teach parents of importance of having child take antibiotics as instructed. • Encourage bedrest; Warm or cold compressed to the neck. Acute Streptococcal Pharyngitis – Nursing Care • Warm saline gargles; Cool liquids or ice chips. • Child becomes noncontagious 24 hours after being on antibiotics. • Child should discard toothbrush after being on antibiotics for 24 hours to prevent reinfection. Croup Syndromes • Croup – broad classification of upper airway illnesses that result from swelling of the epiglottis and larynx.. The swelling usually extends to the trachea and bronchi. • It is characterized by hoarseness; barking, brassy or croupy cough and Inspiratory stridor • Infants and small children have a much smaller diameter of airway and infection here results in significantly narrowed airway. • More common in boys; in children 6 months to 3 years of age, especially 2 years of age • Occurs late autumn to early winter • Hospitalization needed for 1 to 15% of children Described according to the primary anatomic area affected 1. Epiglotitis 2. Laryngitis 3. Laryngotracheobronchitis (LTB) 4. Tracheitis

Croup Syndromes: Epiglottitis • Inflammation of the epiglottis. • Edema in this area can rapidly (within minutes or hours) obstruct the airway by occluding the trachea. • Is considered potentially life threatening • Difficulty in swallowing; drooling • As larynx becomes obstructed, stridor develops. Croup Syndromes : Acute Epiglottitis • Sits up and leans forward with jaws thrust forward in “sniffing” or “tripod posture”. • A previously healthy child suddenly becomes very ill with: – High fever >102.2 f.; Sore throat. • Dysphonia (muffled, hoarse or absent voice sounds). • The 4 classic signs of epiglotitis, in order of appearance are: Dysphonia, Dysphagia. Drooling. Distressed respiratory effort. Croup Syndromes : Epiglottitis • Often caused by bacterial infection. – Haemophilus influenzae type B (Hib); Streptococcus.; Staphylococcus. • Use of Hib vaccine has decreased number of cases of epiglottitis. • DX based on lateral neck x-ray – reveals enlarged, rounded epiglottis, seen as mass at base of tongue. • Laryngospasm can occur as result of irritation of airway muscles. For this reason visual inspection of the mouth & throat are contraindicated. • Obstruction is almost certain is physical manipulation - further irritates the tissue. • A physician can perform immediate intubation if needed • Immediate treatment consists of: – Maintaining the airway, usually via endotracheal tube (24-36 hrs) with cool mist and supplemental oxygen. – Antibiotics and Antipyretic for fever and sore throat pain. – Hydration; Emotional support.

Acute Laryngotracheobronchitis (LTB) • LTB is the most common type of croup. • Usual cause is viral. Infection affects the larynx, trachea, & bronchi. • Most common in children under 5 years. • Usually preceded by URI which descends. • Gradual onset of fever; with Swelling of the airway occurs ASSESSMENT • History of being ill for several days with upper respiratory symptoms which progress to a cough and hoarseness. • Fever may or may not be present, Copious, tenacious secretions are produced. • Tachypnea; Inspiratory stridor; Seal-like barking cough. • Forced air passing through the obstruction increases negative pressure in the thoracic cavity. This causes pulmonary vascular fluid to leak into interstitial spaces. • Can progress to respiratory failure. THERAPEUTIC MANAGMENT – Maintain airway; Children with no stridor are managed at home. – Parents must be taught to recognize signs of respiratory distress. – Cool mist – constricts edematous blood vessels; Oxygen Hoods for infants; Mist tents for toddlers. – Maintain fluid intake. – Nebulized epinephrine is used to TX severe cases of croup (stridor at rest, retraction). – Corticosteroids – anti-inflammatory effect reduces subglottic edema. – Nursing care involves continuous observation & assessment of respiratory system. – Intubation equipment should be sent with child during transport to areas such as x-ray. Acute Spasmodic Laryngitis • Also called midnight croup. Usually ocurs among ages 1 – 3 yrs. • Paroxysmal attacks for laryngeal obstruction that chiefly occurs at night, • Signs of inflammation are absent or mild; Suspected cause is viral, allergy or emotional; usually no fevers; Child goes to bed apparently well or with mild respiratory symptoms. • Awakens suddenly with barking, metallic cough, hoarseness, noisy inspiration and restlessness. Attack subsides in few hours. • Interventions: Managed at home; Cool mist; Racemic epinephrine

Bacterial Tracheitis • Infection of the mucosa of the upper trachea • Occurs mostly among children ages 1 month to 6 years; Often a complication of LTB • Interventions: Humidified oxygen, Suctioning; Antipyretics; Antibiotics; Many children require endotracheal intubation

Respiratory Syncytial Virus (RSV) • Bronchiolitis – acute viral infection of the bronchiolar level. Occurs primarily in winter and spring. • Rare in children over 2 years of age. Caused by RSV 80% of time. • RSV causes fusion of infected cell membrane with those of adjacent epithelial cells forming a giant cell with multiple nuclei. • Bronchiole mucosa swell; Filled with mucus and exudate. Air trapping.occurs • Transmitted through direct contact with respiratory secretions. • RSV can survive for hours on counter tops, gloves, & paper. • Assessment: 2 – 5 mo. is peak age for infection • Can be reinfected. 5 – 8 day incubation • Rhinorrhea, Low grade fever • Otitis media and conjunctivitis may be present • Cough, Wheezing, Retractions, Crackles, Dyspnea, Tachypnea, Diminished breath sounds DIAGNOSIS • Use nasal or nasopharyngeal secretions for rapid immunofluorescent antibody (IFA) or • Enzyme-linked immunosorbent assay (ELISA) • High humidity, Increase fluid intake, Rest, IV fluids, O2 sats, Oxygen by hood or tent • More seriously ill child treated in hospital setting • Ribavirin, (antiviral agent ). Give aerosolized 12 – 20 hrs/day for 1 - 7 days – Controversy over use – Shut aerosol generator off a few minutes before opening tent – Pregnant health care worker should not care for a child receiving ribavirin.

Respiratory Syncytial Virus (RSV) • Respiratory syncytial virus immune globulin (RSV-IGIV or RespiGam) have been used prophylactically to prevent infection in high risk infants. • Private room or grouped with other RSV children • Hand washing; Do not touch nasal mucosa or conjunctiva; Minimal hospital personal and visitors • Nurses caring for infants with RSV should not care for other infants. List at Least 5 Complications of Otitis Media. • 1. Tympanic membrane rupture • 2. Tympanosclerosis • 3. Meningitis • 4. Labyrinthitis • 5. Chronic suppurative otitis media • 6. Mastoiditis Foreign Body Aspiration • Common in children ages 1 - 3 yrs. • Severity is determined by location, type of object aspirated, and extent of obstruction. • Dry vegetable matter such as seed, nut or piece of carrot or popcorn that do not dissolve, may swell when wet and cause major problem. • Fatty foods like potato chips pose problem of lipoid pneumonia. • Offending food in order of frequency : Hot dogs, Round candy, Peanut or other nut, Grape , Cookie or biscuit, Meat, Carrot, Apple, Peanut butter. Asessment: • Choking, gagging or coughing., Symptoms depend on the site. • Cyanosis asymmetrical breath sounds; Wheezing; Dyspnea. • May asphyxiation and die or may show few symptoms for hours, days or weeks. • X-rays reveal opaque objects; Bronchoscopy is required for definitive diagnosis of objects in trachea and larynx. Therapeutic management: • Abdominal thrust for children over 1 yr.; Back blows and chest thrust or infants less than 1 yr. • Can be removed by bronchscopy. • High humidity environment. • Appropriate antibiotics for resulting infections. Cystic Fibrosis Cystic Fibrosis • Characterized by exocrine or mucus-producing gland dysfunction - producing multisystem involvement. • Most common lethal genetic illness among white children, adolescents and young adults. • 3.3 % of white persons in U.S. are symptom free carriers. Clinical manifestations: • Primary symptom is production of thick, sticky mucus. Chronic moist, productive cough • Early signs in newborn is meconium ileus, a small bowel obstruction that occurs the first few days of life. • In infants & toddlers: fecal impaction & intussusception may be first signs. • Steatorrhea (fatty stool). • Rectal prolapse from large, bulky, difficult-to-pass stools. Clinical manifestations: • Frequent respiratory infections, Poor weight gain, Delayed bone age, Short stature; Delayed onset of puberty, Clubbing of fingers. Cystic Fibrosis: Etiology • Gene on chromosome 7 causes defective chloride-ion transport across epithelial cells. • Leads to viscous secretions. • All body organs with mucous ducts become obstructed and damaged. GI Symptoms: • Pancreatic ducts are blocked & result in pancreatic damage. • Enzymes needed to digest fats and proteins are not secreted and essential nutrients are excreted in the stool.

• Cough occurs because lungs are filled with mucus that the cilia cannot clear. • Air becomes trapped in small airways leading to atelectasis. Reproductive system: • Nearly all males /w CF are sterile because the vas deferens is blocked or absent. • Females have difficulty conceiving because of increased mucus in reproductive system interfering with passage of sperm. Metabolic function • Altered due to excessive electrolyte loss thru perspiration, saliva, & mucus secretions. Skin has salty taste. Cystic Fibrosis: Dignostic tests • Newborn –meconium ileus, malabsorbtion or failure to thrive or chronic respiratory infections. • Absence of pancreatic enzymes • Definitive test is a positive sweat test (increase in electrolytes) • Positive family history and Chronic pulmonary involvement Cystic Fibrosis: Medical management Maintain respiratory function, Manage infection; Promote optimal nutrition & exercise Prevent GI blockage; The disease is terminal but many survive to adulthood. Aerosol bronchodilators.; Aerosol Dormase alfa – liquefies secretions. Anti-inflammatory agents: steroids, high dose ibuprofen. Chest physiotherapy for all lung segments; and Infection management. Nutritional needs. • Pancreatic enzyme supplement (Cotazym-S, Pancrease, Viokase) taken with meals 7 snacks. • Well balanced diet with 120-150% of RDA calories and 200% of RDA protein, moderate fat, nutritional counseling needed. • Multivitamin, vit. E in water soluble form, vit. A,D, & K when deficient, iron supplement. • Oxygen Administered via Plastic Hood; Tent for Oxygen Administration • Percussion with Hand or Device • Silastic Pediatric Tracheostomy Tube and Obturator: Temporary vs. long term • Routine care and Trach care, Trach suctioning • Emergency care: occlusion, accidental decannulation