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Home , Labored breathing, Respiratory compromise, Respiratory system, Work of breathing

CHAPTER 20

Alterations in Respiratory Function

Emily gets sick so much faster than my other children. I guess the bronchopul- monary dysplasia and her tracheostomy make her more susceptible to infec- tions. I really get concerned because she struggles so hard to breathe when she gets an . I have learned to suction and change her tracheostomy tube, but I’m afraid that one day her tracheostomy tube will get completely blocked. I just hope I remember all the things I’ve learned if that happens, and that the emergency medical personnel come quickly. —Father of Emily, 8 months old Ron Chapple/The Image Bank/Getty Images

LEARNING OUTCOMES

After reading this chapter, you will be able to do the following: 20.1 Describe unique characteristics of the pediatric and physiology and apply that ­information to the care of children with respiratory conditions. 20.2 Contrast the different respiratory conditions and injuries that can cause respiratory distress in infants and children. 20.3 Explain the visual and auditory observations made to assess a child’s respiratory effort or work of . 20.4 Assess the child’s respiratory status and analyze the need for supplementation. 20.5 Distinguish between conditions of the lower that cause illness in children. 20.6 Create a nursing care plan for a child with a common acute respiratory condition. 20.7 Develop a school-based nursing care plan for the child with . 20.8 Perform a nursing assessment of the child with an acute injury.

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DESIGN SERVICES OF # 153633 Cust: Pearson Education Au: Ball Pg. No. 518 C / M / Y / K S4CARLISLE Title: Principles of Pediatric Nursing: Caring for Children 6e Short / Normal Publishing Services KEY TERMS RESPIRATORY DISTRESS Adventitious sounds, 524 AND , 520 Many respiratory conditions associated with breathing difficulty can progress to , 527 respiratory distress. If the condition is not managed effectively, it can progress to Cor pulmonale, 528 respiratory failure. Foreign-body aspiration is a common cause of airway obstruc- Dysphagia, 533 tion and respiratory distress. Dysphonia, 519 Foreign-Body Aspiration Dyspnea, 519 Foreign-body aspiration is the of any object (solid or liquid, food or non- , 539 food) into the respiratory tract. It is a major health threat for infants and young , 526 toddlers because of their increasing mobility and tendency to put objects into their , 526 . Aspiration occurs most often during feeding and reaching activities, while , 519 crawling, or during playtime. However, aspiration may occur in children of any age. In 2007, 162 children less than 20 years of age died from foreign-body aspiration, , 531 and food aspiration caused 37% of these deaths. Nearly 75% of these children were Paradoxical breathing, 524 younger than age 3 years (Levin & Smith, 2010). Periodic breathing, 527 Etiology and Pathophysiology Polysomnography, 528 In infants over 6 months of age and young children, any number of small objects Retractions, 521 that enter the child’s may cause aspiration. Partial and sometimes com- , 524 plete airway obstruction can occur. The severity of the obstruction depends on the size and composition of the object or substance and its location within the , 524 respiratory tract. Tracheostomy, 526 Most aspirated foreign bodies (AFBs) usually cause bronchial, not tracheal, ob- Trigger, 540 struction. An object lodged high in the airway above the is more easily Tripod position, 524 removed by coughing or by back blows and chest thrusts. The right lung is the most common site of the AFB in the lower airway because of the sloped angle of its bron- chus. Objects may migrate from higher to lower airway locations. An object may also move back up to the , creating extreme respiratory difficulty. If the AFB is lodged in the trachea, it becomes life threatening. Clinical Manifestations In many cases the aspiration is unobserved. The child may have a sudden onset of , spasmodic coughing, , or dysphonia (muffled, hoarse, or absent voice sounds). These signs may be brief or may persist for several hours if the object drops below the trachea into one of the mainstem bronchi. Some children become asymptomatic after coughing for 15 to 30 minutes. The child may develop increased respiratory effort such as dyspnea (difficulty breathing), tachypnea, nasal flaring, and retractions. As respiratory distress progresses, the child may have a con- centrated focus on breathing, an anxious expression, and an upright position with the extended. As hypoxia (lower than normal oxygen in the tissues) increases, behavior changes such as irritability and decreased responsiveness are seen. If the AFB drops into the right and lower airway and is not removed, the child may present weeks later with a chronic , persistent or recurrent pneu- monia, or a .

Clinical Tip

Common items associated with foreign body aspiration and airway ­obstruction include the following: ■ Foods such as nuts, popcorn, or small pieces of raw vegetables or hot dog ■ Small loose toy parts, such as wheels, bells, or magnets ■ Household items such as beads, safety pins, coins, buttons, or latex balloon pieces

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The Respiratory System PEDIATRIC DIFFERENCES The child’s respiratory tract constantly grows and changes until about 12 years of age. The young child’s neck is shorter than an ANATOMY AND PHYSIOLOGY adult’s, resulting in airway structures that are closer together. The respiratory system is composed of both the upper and lower airways. The upper airway, containing the nasopharynx and Upper Airway Differences oropharynx, serves as the pathway for gases exchanged during The child’s airway is shorter and narrower than an adult’s. These ventilation, the movement of oxygen into the and carbon differences create a greater potential for obstruction (see As Chil- dioxide out of the lungs. The divides the upper and lower dren Grow: Airway Development). The infant’s airway diameter airways. The lower airways (trachea, bronchi, and ) is approximately 4 mm, about the width of a drinking straw, in serve as the pathway of gases to the alveoli in the lungs. The left contrast to the adult’s airway diameter of 20 mm. The child’s little lung is divided into two lobes, and the right lung is divided into finger is a good estimate for the child’s tracheal diameter and can three lobes. Alveolar sacs surrounded by are located be used for a quick assessment of airway size. The trachea pri- at the end of the airways and are the site of , where marily increases in length rather than diameter during the first oxygen diffuses across the alveolocapillary membrane. Sur- 5 years of life. factant secreted by alveolar cells coats the inner surface of the The tracheal division of the right and left bronchi is higher in alveolus to allow expansion during inspiration. The lung a child’s airway and at a different angle than the adult’s (see As surrounding the airways keeps them from collapsing as the oxy- Children Grow: Trachea Position). The that supports gen moves in and moves out during ventilation. the trachea is more flexible, and the airway may be compressed The lungs are positioned in the , where the if the head and neck are not appropriately positioned. The child’s and muscles protect the lungs from injury. narrower airway causes a greater increase in airway resistance The work with the diaphragm to per- (the effort or needed to move oxygen through the trachea form the . The diaphragm is a muscle that to the lungs) in any condition causing airway inflammation or separates the abdominal and thoracic cavity contents. When edema (see Pathophysiology Illustrated: Airway Diameter). the diaphragm contracts, it creates negative that in- Newborns are obligatory breathers, breathing only creases the thoracic volume and pulls air into the lungs. The through the mouth when crying. The coordination of mouth lungs and chest wall have the ability to expand during inspira- breathing is controlled by maturing neurologic pathways, and tion (compliance) and then to recoil or return to the resting infants up to 2 to 3 months of age do not automatically open the state with expiration. The work of breathing is tied to the mus- mouth to breathe when the nose is obstructed. It is important to cular effort required for ventilation, which can be increased keep the newborn’s nose patent for breathing and eating. in cases of disorders that increase the stiffness of the lungs or obstruct the airways. Lower Airway Differences The in the brain controls , send- The tracheobronchial tree is complete in the full-term newborn, ing impulses to the respiratory muscles to contract and relax. but the child’s lower airway is constantly growing. At 24 weeks’ Breathing is usually involuntary, because the gestation, no lung sacs have developed, but by 32 weeks’ gesta- automatically adjusts the ventilatory rate and volume to main- tion, lung sacs have developed and have begun to differentiate tain normal gas exchange (Brashers, 2010b). into alveoli (Smith, McKay, van Asperen, et al., 2010). Full-term monitor the pH, PaCO2, and PaO2 in the arterial and newborns have 25 million alveoli at birth, but they are not fully send signals to the respiratory center to increase ventilation in developed. Alveoli begin increasing in size and complexity after cases of arterial hypoxemia. Effective gas exchange requires a 8 years of age, and the number of alveoli increases to 300 million near even distribution of ventilation and (oxygenated by adulthood (Brashers, 2010b). blood flow to all portions of the lungs). As oxygen diffuses across The bronchi and bronchioles are lined with . the alveolocapillary membrane, it dissolves in the plasma and By 5 months of age an infant has enough smooth muscle bundles the resulting pressure (PaO2) helps bind the oxygen to the he- to react to irritants by bronchospasm and . moglobin molecules where it is then transported to the cells for Children under 6 years of age use the diaphragm to breathe . Carbon dioxide produced by cellular metabolism is because the intercostal muscles are immature. By 6 years of age dissolved in the plasma (PCO2) and/or as bicarbonate and trav- the child uses the intercostal muscles more effectively. The ribs els back to the lungs where it diffuses across the alveolocapillary are primarily cartilage and very flexible. In cases of respira- membrane (Brashers, 2010b). tory distress, the negative pressure caused by the diaphragm

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It is easy to see that a child’s airway is smaller and less developed than an adult’s airway, but why is this important? An upper respiratory tract infection, allergic reaction, positioning of the head and neck during sleep, and the small objects children play with can have serious consequences in the child.

Smaller nasopharynx, easily occluded during infection. Lymph tissue (, ) grows rapidly in early childhood; atrophies after age 12. Smaller nares, easily occluded.

Small oral cavity and large increase risk of obstruction.

Long, floppy vulnerable to swelling with resulting obstruction.

Larynx and are higher in neck, increasing risk of aspiration.

Because , cricoid, and tracheal are immature, they may easily collapse when neck is flexed. Because fewer muscles are functional in airway, it is less able to compensate for edema, spasm, and trauma.

The large amounts of soft tissue and loosely anchored mucous membranes lining the airway increase risk of edema and obstruction.

movement causes the chest wall to be drawn inward, causing D for expected laboratory values and Appendix E for retractions (see Pathophysiology Illustrated: Retraction Sites). information about diagnostic procedures. Children consume more oxygen than adults because of their Pediatric respiratory conditions may occur as a primary prob- higher metabolic rate. This rate of oxygen consumption increases lem or as a complication of nonrespiratory conditions. Respira- when the child is in respiratory distress. The child also has fewer tory problems may result from structural problems, functional muscle glycogen reserves, leading to more rapid muscle fatigue problems, or a combination of both. Structural problems involve when accessory muscles must be used for breathing (Gott & alterations in the size and shape of parts of the respiratory tract. Froh, 2010). Functional problems involve alterations in gas exchange and Use the Assessment Guide: The Child with a Respiratory Con- threats to the process of ventilation due to irritation by large dition on page 524 to perform a nursing assessment of the respi- particles and chemicals or infection. Alterations in other or- ratory system. See Table 20–1 on page 523 for a list of diagnostic gan systems, especially the immune and neurologic systems, 8 and laboratory tests used to evaluate respiratory conditions. See may also threaten respiratory function. See Chapter 19 8 for

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In children, the trachea is shorter and the Bifurcation of trachea in angle of the right bronchus at bifurcation is children is at T3 level. more acute than in the adult. When you are resuscitating or suctioning, you must allow for these differences. Do you think that the Right mainstem bronchus angle of the right bronchus is significant in in children has a steeper foreign-body aspiration? Why? slope than in adults.

Bifurcation in adults is at T6 level.

Pathophysiology Illustrated Airway Diameter

An infant’s airway diameter is approximately 4 mm, in contrast to the Newborn adult’s 20-mm airway diameter. An inflammatory process in the air- 1 mm way causes swelling that narrows the airway, and airway resistance swelling increases. Note that swelling of 1 mm reduces the infant’s airway 4 mm 2 mm diameter to 2 mm, but the adult’s airway diameter is only narrowed to Adult 18 mm. Air must move more quickly in the infant’s narrowed airway to get the needed amount of air into the lungs. The friction of the quickly moving air against the side of the airway increases airway resistance. The infant must use more effort to breathe and must breathe faster to get adequate oxygen.

1 mm 20 mm swelling 18 mm diameter of airway diameter of airway

upper respiratory conditions such as otitis media, , and conditions are a common cause of hospitalization in children . between 1 and 9 years of age and a leading cause in children be- Most respiratory problems in children produce mild symptoms, tween 10 and 17 years of age (Agency for Healthcare Research and last a short time, and can be managed at home. Other respiratory Quality, 2011). Some respiratory conditions are chronic and have problems are chronic and potentially life threatening. Respiratory a significant impact on the child’s growth and development.

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Supraclavicular Suprasternal

Intercostal

Substernal

Subcostal Subcostal

Infants and young children have immature chest muscles and ribs respiratory distress. As respiratory distress severity increases, sub- of cartilage, which makes the chest wall very flexible. The negative sternal and subcostal retractions are seen. In cases of severe distress, pressure created by the downward movement of the diaphragm is in- supraclavicular and suprasternal retractions occur as the accessory creased in cases of respiratory distress, and the chest wall is pulled muscles (sternocleidomastoid and trapezius muscles) are used. inward, causing retractions. Intercostal retractions are seen in mild

Table 20–1 Diagnostic and Laboratory Procedures/Tests for the Respiratory System*

Diagnostic Procedures Laboratory Tests

Bronchoscopy gas analysis

Chest radiograph Cultures

Polysomnography (sleep study) Neonatal screening for cystic

Pulse oximetry Protein-purified derivative (PPD), the Mantoux test

Spirometry (pulmonary function tests)

Sweat chloride test

*See Appendix D and E for information about these diagnostic procedures and tests.

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Assessment Focus Assessment Guidelines

Position of comfort ■ Is the child comfortable lying down? ■ Does the child prefer to sit up or be in the tripod position (sitting forward with arms on knees for support and extending the neck)?

Vital signs ■ Assess the rate, depth, and ease of respirations. See Table 5–9 on page 137 for expected ranges by age. ■ Assess the pulse for rate and strength. See Table 5–11 on page 140 for expected rate ranges by age.

Lung ■ Are breath sounds bilateral, diminished, or absent? ■ Are adventitious sounds (, , or rhonchi) present? Respiratory effort ■ Is stridor (an audible crow-like inspiratory and expiratory breath sound) or grunting with expiration heard? (work of breathing) ■ Is breathing labored? ■ Are retractions (visible appearance of the chest being drawn in on inspiration) present or are accessory muscles used to breathe? ■ Is nasal flaring present? ■ Is tachypnea (abnormally rapid rate of respirations) present? ■ Can the child say a full sentence or is a breath needed every few words? Is the cry strong or weak? ■ Do the chest and rise simultaneously with inspiration or is paradoxical breathing present in which the chest and abdomen do not simultaneously rise?

Color ■ What is the color of the mucous membranes, , and nailbeds (pink, pale, mottled, cyanotic)? ■ Does crying improve or worsen the color?

Cough ■ Is the cough dry (nonproductive), wet (productive, mucousy), brassy (noisy, musical), or croupy (barking, seal-like)? ■ Is the coughing effort forceful or weak?

Behavior change ■ Is irritability, restlessness, or change in level of responsiveness present?

Family history ■ Is there a family history of asthma or ?

aRefer to Chapter 5 8 for the assessment techniques mentioned in this table.

Clinical an object from an obstructed airway. (See the Clinical Skills Man- Clinical therapy focuses on taking a careful history to determine ual SKILLS .) Fluoroscopy and fiber-optic may be whether aspiration could have occurred. Witnessed coughing, used to identify, locate, and extract the AFB. The child may de- gagging, or choking associated with feeding or crawling on the velop if a foreign body is not recognized as a cause of floor may confirm the aspiration. Decreased breath sounds, respiratory distress (see page 538). stridor, and respiratory distress increase suspicion in the child without a witnessed aspiration. Because many aspirated objects NURSING MANAGEMENT for the Child are organic, only 15% of the objects are radiopaque (Srivastava, with Foreign-Body Aspiration 2010) (Figure 20–1 ●). A special radiograph, called a forced ex- piratory film, may show local hyperinflation (air trapping) and a Nursing Assessment and Diagnosis away from the affected side, abnormalities that Physiologic Assessment an AFB may cause. The child with an acute AFB will be in respiratory distress and An object lodged in the trachea is life threatening. Back requires constant . Perform the respiratory assessment blows and chest thrusts or abdominal thrusts are used to remove following the guidelines given in Assessment Guide: The Child 524

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Clinical Tip

Accuracy of readings (SpO2) can be improved by do- ing the following (Krauss & Mason, 2009; Mininni, Herzer, Marino, et al., 2009): ■ Place sensor over clean dry skin (e.g., finger, foot, or earlobe). Do not place on the same extremity used for measurements. ■ Avoid placing the sensor probe over sites covered with dark nail polish. ■ Cover sensors with a light barrier when the patient is under a bright light or in sunshine to reduce interference. ■ Confirm that the heart rate by direct measurement matches that detected by the sensor. ■ Assess when the child is not moving or shivering. ■ Recognize that anemia, , arrhythmia, or shock may lead to an inaccurate reading.

■ (Child) related to difficulty breathing, unfamiliar ● Figure 20–1 An aspirated screw is clearly visible in the child’s left surroundings, and procedures mainstem bronchus on this chest radiograph. ■ Source: Courtesy of Evelyn Anthony, MD, Department of , Brenner Children’s Hospital, Injury, Risk for related to small objects in environment Wake Forest University Health System. Planning and Implementation Be prepared to perform back blows and chest thrusts for an in- fant or abdominal thrusts for the child with complete obstruc- with a Respiratory Condition. If the object remains lodged, ob- tion (see the Clinical Skills Manual SKILLS ). When the child has serve the child for signs of increasing respiratory distress, espe- a partial obstruction, remain with the child and have resuscita- cially vital signs, altered mental status, and audible wheezing on tion equipment at the bedside. Permit the child to stay in a posi- auscultation. Note changes in breath sounds, from noisy to de- tion of comfort. Avoid performing procedures that increase the creasing to absent, on the affected side. This can indicate that the child’s anxiety because sudden movements and increased respi- object is moving and blocking a mainstem bronchus. Document ratory efforts may cause the obstruction to move and completely any subtle changes in the child’s respiratory status and report obstruct the airway. promptly. After the AFB is removed, the child is stabilized and ob- Attach the child to a cardiorespiratory monitor and pulse served for a few hours in a short-stay unit to ensure that there oximeter (a transcutaneous assessment method to detect the are no respiratory complications. amount of saturated with oxygen [SpO2]) to assess Discharge Planning and Home Care Teaching the child for subtle signs of increasing hypoxia. A pulse oximetry Prevention of future aspirations is a major focus for nursing care. reading (SpO2) of less than 95% indicates hypoxemia. Educate the family on the child’s developmental characteristics Psychosocial Assessment and how to identify potential safety in the home. En- The unexpected and acute nature of the event creates anxiety for courage the parents to learn rescue breathing, back blows, chest both parents and child. The child will be fearful because of dif- thrusts, or abdominal thrusts. ficulty breathing. Assess the family’s level of distress and coping Evaluation ability. Expected outcomes of nursing care include the following: Developmental Assessment As the child’s condition stabilizes, observe how well the child’s ■ The child breathes spontaneously after removal of the abilities match the parents’ understanding of age-appropriate be- ­foreign body. haviors. See Chapters 7 and 8 8 . ■ Parents complete a home safety check to prevent future Common nursing diagnoses for a child with an AFB include ­aspiration incidents. the following (NANDA-I © 2012): ■ Airway Clearance, Ineffective related to obstruction by a Respiratory Failure foreign body Respiratory failure occurs when the body can no longer maintain ■ Ventilation: Spontaneous, Impaired related to respiratory effective gas exchange. Poor ventilation of the alveoli initiates the muscle fatigue process that leads to respiratory failure. occurs

DESIGN SERVICES OF # 153633 Cust: Pearson Education Au: Ball Pg. No. 525 C / M / Y / K S4CARLISLE Title: Principles of Pediatric Nursing: Caring for Children 6e Short / Normal Publishing Services 526 Chapter 20 Alterations in Respiratory Function when oxygen need exceeds oxygen intake, the airway is partially oc- oxygen, , and positive end-expiratory cluded, or the transfer of oxygen and carbon dioxide in the alveoli is pressure (PEEP) to increase functional residual capacity. These disrupted. This disruption may occur when a malfunction of respi- children are admitted to the pediatric intensive care unit (PICU). ratory center stimulation occurs (the alveoli do not receive the mes- The child’s ability to maintain an open airway decreases sage to diffuse, e.g., a narcotic overdose), muscles of ventilation are as the level of responsiveness deteriorates. Endotracheal (ET) fatigued and do not work effectively (e.g., status asthmaticus), or the intubation is a short-term, emergency measure to stabilize the relationship between ventilation and blood flow to the alveoli (per- airway by placing a tube in the trachea. The ET tube must be fusion) is impaired. ­Hypoxemia (lower than normal blood oxygen protected and stabilized to prevent its displacement. End-tidal level) and hypercapnia (an excess of carbon dioxide in the blood) CO2 monitoring is used to ensure that the tube is correctly po- result from hypoventilation. When the blood levels of oxygen and sitioned in the trachea (see the Clinical Skills Manual SKILLS ). carbon dioxide reach abnormal levels, hypoxia (lower than normal A tracheostomy, the creation of a surgical opening into the tra- oxygen in the tissues) occurs and respiratory failure begins. chea through the anterior neck at the cricoid cartilage, is per- Signs of impending respiratory failure include worsening re- formed when longer term airway management is needed. spiratory distress with increased respiratory effort (dyspnea, tachy- Assisted ventilation may be needed until mechanical venti- pnea, nasal flaring, and intercostal retractions), irritability, lethargy, lation is initiated or the child breathes spontaneously. Children and . Grunting in infants is a sign of severe disease and are often sedated to improve mechanical ventilation. Continuous the potential need for mechanical ventilation (Prodhan, Sharoor- positive airway pressure is one therapy used to improve oxygen- Karni, Lin, et al., 2011). Hypoxemia that persists when supplemental ation and . results if respira- oxygen is given is a sign of respiratory failure. See Table 20–2. tory failure cannot be managed. Clinical Therapy Nursing Management Arterial blood gas values help to identify hypoxemia and hyper- Early recognition of impending respiratory failure is the most capnia. Pulse oximetry helps determine when an arterial blood important aspect of care for a child with any signs of respira- gas measurement is needed. See Appendix D for expected arte- tory compromise. Assess the child using guidelines found in the rial blood gas values and the Clinical Skills Manual SKILLS . Re- ­Assessment Guide on page 524. Monitor the child for changes in 8 fer to Chapter 18 for interpretation of acidosis and alkalosis vital signs, respiratory status, SpO2, and level of responsiveness. that must be considered simultaneously. When the child has a chronic respiratory condition, development Medical management is focused on treating the cause of of respiratory failure may be gradual and signs will be subtle. Be respiratory failure and reversing the severe hypoxemia with particularly alert to behavior changes in addition to respiratory signs. Serial blood gases may be needed to monitor the child.

Table 20–2 Clinical Manifestations of SAFETY ALERT! Respiratory Failure and Imminent As the child tires from the prolonged work effort of breathing, Respiratory Arrest the respiratory rate may begin to decrease. This is an ominous sign and may progress to respiratory arrest without intervention. Clinical Physiologic Cause Manifestations Place a child who has respiratory compromise in an up- Initial Signs of Respiratory Failure right position (elevate the head of the bed). Respiratory distress, The child is trying to compensate for oxygen Restlessness anxiety, excessive crying, and even fever can deplete metabolic deficit and airway blockage. Oxygen supply Tachypnea reserves and increase the child’s need for oxygen. Administer is inadequate; behavior and vital signs reflect Tachycardia oxygen as ordered and keep emergency equipment at the child’s compensation and beginning hypoxia. Diaphoresis bedside. Be prepared to provide assisted ventilation if the respira- SKILLS Early Decompensation Nasal flaring tory status deteriorates. (See the Clinical Skills Manual .) The child tries to use accessory muscles Retractions Because ET and tracheostomy tubes prevent vocal cord vi- to assist oxygen intake; hypoxia persists Grunting bration, intubated children cannot cry or talk. Infants and young and efforts now waste more oxygen than is Wheezing children often express initial frustration when they realize they obtained. Anxiety, irritability cannot communicate verbally. When the child is alert, provide a Mood changes bell or noisemaker as a way to gain attention. A communication Hypertension Confusion Clinical Reasoning Oxygen Delivery Devices Severe Hypoxia and Imminent Respiratory Arrest Oxygen delivery devices are selected to match the of The oxygen deficit is overwhelming and Dyspnea oxygen needed by the child. In respiratory failure, a higher concen- beyond spontaneous recovery. Cerebral Bradycardia tration of oxygen is needed to reverse the hypoxemia. Which oxygen oxygenation is dramatically affected; central Cyanosis delivery device should be used? Are there any contraindications to nervous system changes are ominous. Stupor and coma oxygen use in a child who is hypoxic?

DESIGN SERVICES OF # 153633 Cust: Pearson Education Au: Ball Pg. No. 526 C / M / Y / K S4CARLISLE Title: Principles of Pediatric Nursing: Caring for Children 6e Short / Normal Publishing Services Apnea 527 board can be used with older children. Suction airway secretions Provide emotional support. Establishing rapport and open as needed and provide tracheostomy care if present. See the Clin- communication with the parents is essential for creating a sense ical Skills Manual SKILLS . of trust. To obtain further information about the episode, use Many children are discharged from the hospital and cared open-ended questions and active listening skills. Parents are for at home for an extended period with a tracheostomy tube fearful and anxious about the infant’s prognosis. Explanations of in place. Parents must demonstrate competence in all aspects tests and treatment help to decrease their anxiety and increase of tracheostomy care (how to maintain and suction the air- their understanding of the situation. way, clean the tracheostomy site, and change the tube), as well During hospitalization the infant should be held to provide a as emergency resuscitation skills adapted to the tracheostomy. sense of security and well-being. Encouraging parents’ participa- A home healthcare nurse can provide follow-up care and support tion in the infant’s care helps to meet these needs and promotes for the child and family. (See the Clinical Skills Manual SKILLS .) family bonding. Often parents are afraid to touch the infant, be- cause they might disconnect the monitoring cable. Wrapping the cable inside the infant’s blanket helps secure the wires, increasing APNEA parents’ feelings of confidence in handling the infant. Infants commonly have periodic breathing, an irregular rhythm, Support the mother to continue breastfeeding and maintain- and may have pauses of up to 20 seconds between breaths. This ing a supply of milk by pumping, if necessary. Ensure that breathing pattern is not apnea. Apnea is the cessation of respiration the mother gets adequate fluids and nutrition. Provide privacy lasting longer than 20 seconds, or any pause in respiration associated for breast pumping and store breast milk for future feedings. with cyanosis, marked pallor, hypotonia, or bradycardia. Apnea may Discharge Planning and Home Care Teaching. Address home be the first major sign of respiratory dysfunction in the newborn. care needs in advance of the infant’s discharge. Review guidelines for safe sleep positions. Some infants may be discharged with Apparent Life-Threatening Event (ALTE) a cardiorespiratory monitor. Teach parents how to operate the Apparent life-threatening event (ALTE) is defined as a frightening monitor, what to do when the infant has an apneic episode, and how episode of apnea accompanied by a color change (e.g., cyanosis to perform cardiopulmonary resuscitation (CPR) and choking- or pallor), limp muscle tone, choking, or gagging. Most affected intervention techniques (see the Clinical Skills Manual SKILLS ). infants are about 2 months of age; ALTE does not occur after See Families Want to Know: Home Care Instructions for the Infant 12 months of age (Berg, Nadkarni, Gausche-Hill, et al., 2010). Requiring a Cardiorespiratory Monitor. Potential causes of ALTE include gastroesophageal reflux, seizures, and lower respiratory disorders. Other causes may in- clude trauma, metabolic disorder, cardiac arrhythmias, sepsis, Obstructive sleep apnea syndrome (OSAS) is a disorder of pertussis, medication dosage error, and child abuse. ALTE and breathing during sleep that involves increased respiratory re- sudden infant death syndrome (SIDS) have different clinical and sistance leading to recurrent episodes of partial and complete epidemiologic factors; however, these infants are at increased upper airway obstruction that disrupt normal ventilation and risk for SIDS (Hunt & Hauck, 2011). sleep patterns (Katz & D’Ambrosio, 2010). This results in labored A detailed history helps identify the potential condition breathing and when the child tries to move air past the associated with ALTE. Diagnostic tests may include an electro- obstruction. OSAS is believed to affect 1% to 3% of school-age cardiogram, complete blood count with differential, serum elec- children (Loghmanee & Sheldon, 2010). trolytes, cultures, serum ammonia levels, and a chest radiograph. The upper airway contains about 30 muscles that permit No cause is found for about 50% of ALTE cases (Bonkowsky & the to collapse, enabling the child to talk and swal- Tieder, 2009). Physical stimulation or emergency resuscitation low, but also maintain airway patency. When the child is awake, may be required to revive the infant. Treatment is targeted at the muscle tone is maintained and the airway remains patent even underlying condition. when potential obstructions are present. During sleep, the air- Nursing Management way muscles relax, the pharynx becomes obstructed, and airway After ALTE, infants are usually admitted to the hospital for resistance increases, leading to snoring. Reduced upper airway evaluation and cardiorespiratory monitoring. Assess the infant’s tone and obstruction cause apnea episodes that lead to hypox- responsiveness and behavior (e.g., irritability or unexplained emia, hypercapnia, and an elevated blood pressure. Hypertrophy sleepiness). Monitor vital signs, and assess the child’s growth. of the adenoids and tonsils is the most common cause of OSAS, The focus of the physical examination is to detect signs of injury, followed by craniofacial abnormalities, , and neuromus- infection, neurologic abnormalities, or features suggestive of a cular disorders (e.g., , ). genetic or metabolic syndrome. Children with OSAS snore and have labored breathing dur- Attach a cardiorespiratory monitor and pulse oximeter to ing sleep such as retractions and paradoxical breathing. After continuously assess the heart rate, respiratory rate, and oxygen- snoring or breathing pauses, the child may snort, gasp, choke, ation status while the infant is awake and asleep. Because the move, or arouse to take a breath. Sleep is restless, and the child infant who has had ALTE continues to be at risk for cardiopul- may sleep in unusual positions to hyperextend the neck and air- monary arrest, keep emergency resuscitation equipment and way. Symptoms of sleep deprivation (daytime sleepiness, poor drugs readily accessible at all times. attention, aggression, acting-out behavior, and poor school

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Families Want to Know Home Care Instructions for the Infant Requiring a Cardiorespiratory Monitor

Apnea Equipment ■ Thread cable and wires through lower end of infant’s clothes. ■ Review how the monitor operates, the lead wires, placement ■ Ensure integrity of leads, monitor cable, and power cord (replace of skin electrodes and pulse oximetry sensor, and how to set if frayed). the event recorder. Keep the battery fully charged and keep the Routine Care ­manual for troubleshooting handy. ■ Explain the reasons for the apnea monitor and frequency of Emergency Preparation use. Use it whenever the infant sleeps. Review the manual for ■ Have an emergency plan and complete an emergency informa- troubleshooting. tion form about the infant’s health problem. Notify the telephone ■ Show how to attach and detach infant chest leads and belt. company, electric company, local ambulance service, and the local Evaluate the skin for irritation or sores under the electrodes emergency department (to get priority service status). and move the electrode if skin is irritated. Use no oils or lotions ■ Post the emergency response phone numbers by all phones on the chest. and save in cell phones, along with the phone numbers for Responding to an Alarm the ­, medical equipment company, power company, ■ Observe the infant for breathing first to determine if this is a real ­neighbor, and key family members. event or a loose lead. ■ Take a cardiopulmonary resuscitation (CPR) course. ■ Stimulate the infant if respirations are absent or infant is lethargic. Safety Precautions Start by calling the infant’s name and gently touching, proceeding ■ Place monitor on firm surface; keep away from other appliances to vigorous touch if needed. (television, microwave oven) and water. ■ If no response, proceed with CPR. ■ Ensure that alarms are audible from all locations. ■ If a loose lead is suspected, determine if electrode patches are ■ Double-check that the monitor and event recorder are on before loose. Check the wires from the electrode or monitor cable. Check putting the infant down for a nap or at bedtime. the power supply. Is the monitor malfunctioning?

performance) may be noted. The child may also have daytime Following adenotonsillectomy, the hospital nurse monitors , enuresis, and a morning headache. the child for bleeding and respiratory distress, such as obstruc- Initial diagnosis occurs with a detailed history about snor- tive sleep apnea and . Continuous pulse oxim- ing. Polysomnography, a sleep study that simultaneously re- etry is used to detect oxygen desaturation. See Chapter 19 8 for cords the sleep state, gas exchange, breathing efforts, cardiac care of the child having adenoidectomy and tonsillectomy. rhythm, and muscle activity and movement, is performed. Sleep center nurses provide education and support to Adenotonsillectomy (adenoidectomy and tonsillectomy) is the families of children who need to use CPAP to treat OSAS. The most common treatment for OSAS, and the condition resolves nurse helps identify the best fitting mask or nasal prong system in the majority of children. Continuous positive airway pressure for CPAP delivery. Parents may need guidance about helping (CPAP) is used for children with surgical contraindications or children go to sleep wearing the mask until they are accus- those with persistent OSAS (craniofacial anomalies, Down syn- tomed to it. drome, or neuromuscular disorders) after adenotonsillectomy. loss strategies may be implemented for children with Sudden Infant Death Syndrome obesity. OSAS may recur in children with obesity after adeno- Sudden infant death syndrome (SIDS) is defined as the sudden tonsillectomy (Loghmanee & Sheldon, 2010). Without treat- death during sleep of an infant under 1 year of age that remains ment, complications can include failure to thrive, pulmonary unexplained after a thorough investigation, including an au- hypertension, cor pulmonale (obstruction of pulmonary blood topsy, a review of the circumstances of death, and the clinical flow that leads to right ventricular hypertrophy and heart fail- history. SIDS is the third leading cause of infant mortality in the ure), systemic hypertension, and cognitive impairment. United States (MacDorman, Hoyert, & Mathews, 2013). Most Nursing Management SIDS deaths occur in infants between 2 and 4 months of age. It is In the community setting, all children should be screened for snor- currently unpredictable and in some cases unpreventable. ing as part of their routine health care. Assess the child for signs of SIDS is called a “syndrome” because infants are believed nasal obstruction, mouth breathing, and enlarged tonsils. Deter- to have a vulnerability that increases the risk for sudden death mine if the child has symptoms of sleep deprivation or if a condi- such as a genetic cardiac dysrhythmia (e.g., long-QT syndrome) tion is present that places the child at high risk for OSAS. When or a defect in neural networks that control respirations, sleep, snoring is present, encourage the family to keep a sleep diary. and arousal (Hunt & Hauck, 2011). Abnormalities associated When a polysomnogram is ordered, talk with the parents with the neurotransmitter serotonin in the about how to prepare the child for the strange setting and wires may interfere with arousal responses during sleep in a critical that will be attached during the sleep study. Most pediatric cen- development period (Duncan, Patterson, Hoffman, et al., 2010). ters will allow the parent to stay with the child during the study. Cerebral oxygenation is depressed in healthy term infants when

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Table 20–3 Risk Factors for Sudden Infant Clinical Tip Death Syndrome (SIDS) A review of several studies evaluated the relationship between Infant Risk Factors breastfeeding and SIDS. Findings revealed that breastfeeding for ■ Preterm or low birth weight any period of time is protective, and greater protection occurs if ■ Native American and African American infants are at higher risk; breastfeeding is exclusive (Hauck, Thompson, Tenabe, et al., 2011). Caucasians, Asians, and Hispanics are at lower risk ■ Males are at higher risk ■ Maternal smoking, alcohol intake, or substance abuse ■ Socioeconomic disadvantages sleeping, was initiated in 1992 and has led to a 50% decrease in SIDS deaths (Flook & Vincze, 2012). Ask parents to make sure this posi- Environmental Risk Factors tion is used when the infant is cared for by another family member ■ Sleeping prone or side-lying position; bed sharing or childcare provider. Parents should also use a firm mattress and ■ Soft bedding, use of pillows, blankets, and stuffed avoid the use of loose bedding, toys, and pillows. A sleeper rather with bedding than a blanket should be used to keep the infant warm while sleep- ■ Overheating ing. A pacifier is also recommended for nap and bedtime (Task ■ Secondhand tobacco smoke exposure Force on Sudden Infant Death Syndrome, 2011). See Chapter 27 8 for issues related to infant flattening from sleeping on the back. Source: Data from Behm, I., Kabir, Z., Connolly, G. N., & Alpert, H. R. (2012). Increasing prevalence of smoke-free homes and decreasing rates of sudden infant death syndrome in Place hospitalized infants to sleep in supine position rather the United States: An ecological association study. Tobacco Control, 21, 6–11; Hunt, C. E., & than side-lying or prone. See Evidence-Based Practice: Infant Hauck, F. R. (2011). Sudden infant death syndrome. In R. M. Kliegman, B. F. Stanton, Sleep Positioning. J. W. St. Geme, N. F. Schor, & R. E. Behrman, Nelson textbook of (19th ed., pp. 1421–1429). Philadelphia, PA: Elsevier Saunders; Kinney, H. C., & Thach, B. T. (2009). The sudden infant death syndrome. New England Journal of , 361(8), 795–805. CROUP SYNDROMES Croup is a term applied to a broad classification of upper airway they sleep in the prone positions, making them more difficult to illnesses that result from inflammation and swelling of the epi- arouse (Wong, Witcombe, Yiallourou, et al., 2011). An additional glottis and larynx. The swelling usually extends into the trachea stressor (e.g., rebreathing exhaled air, being overheated, or a re- and bronchi. Viral croup syndromes include spasmodic spiratory infection) may contribute to SIDS. See Table 20–3 for (spasmodic croup) and laryngotracheobronchitis (LTB). Bacte- factors that place infants at risk for SIDS. rial croup syndromes include bacterial and The first symptom is a cardiopulmonary arrest. Clinical (see Pathophysiology Illustrated: Airway Changes with Croup). findings include evidence of a struggle or change in position LTB and bacterial tracheitis affect a large number of children during sleep and the presence of frothy, blood-tinged secretions across all age groups in both sexes. Epiglottitis, previously a com- from the mouth and nose. Typically parents find the infant dead mon serious respiratory illness, is rare in the United States due to in the crib in the morning or after a nap and report having heard the Haemophilus influenzae type B vaccine. The initial symptoms no cries or disturbances during the night. of all three conditions include inspiratory stridor (a high-pitched, musical sound that is created by narrowing of the airway), a “seal- Nursing Management like” barking cough, and hoarseness. LTB is the most common The sudden, unexpected nature of the infant’s death is confirmed disorder, but epiglottitis and bacterial tracheitis are more serious. in the emergency department. The nurse’s role is to be empa- thetic and provide support during one of the greatest crises a Laryngotracheobronchitis family must face. The focus is on supporting the family during Although the term croup is applied to several viral and bacterial the communication of bad news and the shock of the infant’s syndromes, it most often refers to LTB, a viral invasion of the death. See Chapter 13 8 . upper airway that extends throughout the larynx, trachea, and Reassure the parents that they are not responsible for the bronchi. infant’s death and help them contact other family members and mobilize support. Older children may need reassurance that Etiology and Pathophysiology SIDS will not happen to them. They may also believe that bad Acute viral LTB is most common in children 6 months to 6 years thoughts or wishes about their baby brother or sister caused the of age, with a peak incidence from 7 to 36 months of age (Wald, death. Support groups can help parents, siblings, and other fam- 2010). Boys are affected more often than girls. LTB is of great- ily members express these fears and work through their feelings est concern in infants and children under the age of 6 years be- about the infant’s death. The First Candle organization can help cause of potential airway obstruction. The causative organism families locate a support group in their area. is usually parainfluenza virus type I, II, or III, which appears Nurses play an important role in SIDS prevention. Educate during fall and winter months. Other viruses causing LTB in- the parents of all newborns and infants about the recommended clude , adenoviruses, respiratory syncytial virus (RSV), infant sleep position—on the back. The Back to Sleep Campaign, , metapneumovirus, and human encouraging the placement of infants in the supine position for (Wald, 2010).

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Evidence-Based Practice Infant Sleep Positioning

Clinical Question A study used focus groups and interviews with 83 African American In 2008, 15% of all infants were estimated to sleep in the prone po- mothers from diverse socioeconomic groups to learn about surfaces sition; however, the rate of prone or side-lying sleep is much higher and soft bedding used for their infants. Findings revealed that par- among African American infants (38%) (Carrier, 2009). What will help ents had different interpretations of firm bedding, and they believed encourage African American parents to place their infant to sleep in the that soft bedding (pillows, blankets, and crib bumper pads) increased supine position with safer bedding? the infant’s comfort and in some cases safety. For example, parents believed that the surface was firm if a pillow or blanket was placed The Evidence between the mattress and the sheet and the sheet was tucked tautly A qualitative study investigated the beliefs and perceptions of 73 around the pillow or blanket. Misconceptions about firm and soft bed- African American mothers from all socioeconomic levels with infants ding increase the risk for suffocation and SIDS as the infant sleeps under 6 months of age regarding SIDS. Three major themes emerged. (Ajao, Oden, Joyner, et al., 2011). Mothers did not see a plausible connection between SIDS and sleep position, because the cause of SIDS cannot be explained. Mothers also Best Practice believed SIDS occurs randomly and could be “God’s will.” The best While the Back to Sleep Campaign has successfully promoted supine protection for their baby was stated to be their own vigilance. Some sleep positions for infants, African American mothers less commonly mothers reported placing the infant in bed with them to closely monitor use this sleep position. They report awareness of the recommenda- the infant (Moon, Oden, Joyner, et al., 2010). tion but do not necessarily believe it (Oden, Joyner, Ajao, et al., 2010). The impact of nurse modeling of safe sleep practice in seven hos- Nurses need to understand the mother’s perspective so education can pitals in an urban area with a large population of African American appropriately address beliefs and concerns. Appropriate sleep position parents was evaluated. Policy changes requiring the supine sleep posi- and firm bedding should always be modeled in the hospital. tion for newborns and other infants were implemented, nurses were educated about sleep position recommendations, and crib audits were Clinical Reasoning used to assess changes in practice. The policy change and educa- Identify if policies exist for infant sleep position in the maternity and tion resulted in nurses positioning infants on their back to sleep and pediatric sections of your hospital. Conduct an audit of cribs and bassi- increasing the effort to educate parents about safe sleep positioning nets to determine what proportions of infants are sleeping in the supine (Shaefer, Herman, Frank, et al., 2010). position.

Pathophysiology Illustrated Airway Changes with Croup

Two important changes occur in the upper airway with croup: The epiglottis swells, occluding the airway, and the trachea swells against the cricoid cartilage, causing restriction.

Epiglottis swells occluding airway

Cricoid cartilage

Trachea swells against cricoid cartilage resulting in restriction

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Table 20–4 Summary of Croup Syndromes

Viral Syndromes Bacterial Syndromes Acute Spasmodic Laryngitis Laryngotracheitis/ (Spasmodic Croup) Laryngotracheobronchitis Bacterial Tracheitis Epiglottitis (Supraglottitis)

Severity Least serious Serious; progresses if Can be life threatening; requires Most life threatening (medical untreated close observation emergency)*

Age affected 3 months to 3 years 3 months to 8 years 1 month to 13 years* 2 years to 8 years

Onset Abrupt nighttime onset; Gradual onset; starts as URI, Progressive over 2 to 5 days, Progresses rapidly (hours)*; resolves over 24 to 48 hours; progresses to symptoms may present like LTB may progress to complete recurs* of respiratory distress and airway obstruction obstructed airway in 24 to 48 hours

Clinical Afebrile; mild respiratory Early: mild fever (less than High fever (higher than 39°C High fever (higher than 39°C manifestations distress; barking-seal cough 40°C [104°F]); barking-seal, [102.2°F]); URI appears as viral [102.2°F]); URI; intense sore brassy, croupy cough; rhi- croupy cough and croup initially; throat; dysphagia*; drooling*; norrhea; ; stridor stridor (tracheal); purulent increased pulse and respiratory (inspiratory); apprehension; secretions; child often prefers rate; prefers upright position restless or irritable to lie flat (tripod position with neck May progress to retractions; extended)*; cherry red epiglottis increasing stridor; cyanosis

Etiology Unknown; suspect viral with Parainfluenza, types I, II, Staphylococcus, Moraxella Haemophilus influenzae, Group allergic/emotional influences and III, RSV, influenza, catarrhalis, and nontypeable A beta-hemolytic streptococcus, adenoviruses, or Haemophilus influenzae; may staphylococcus Mycoplasma pneumoniae follow viral LTB as a bacterial superinfection

Note: *Classic parameter or key point (distinguishes condition). Source: Data from Roosevelt, G. E. (2011). Infectious upper airway obstruction. In R. M. Kliegman, B. F. Stanton, J. W. St. Geme, N. F. Schor, & R. E. Behrman, Nelson textbook of pediatrics (19th ed., pp.1445–1450). Philadelphia, PA: Elsevier Saunders; Wald, E. L. (2010). Croup: Common syndromes and therapy. Pediatric Annals, 39(1), 15–21.

Airway tissues respond to the invading virus with inflam- lateral radiographs of the upper airway may reveal the classic mation and edema. Copious secretions further increase the symmetric subglottic narrowing called a “.” child’s respiratory distress. The laryngeal inflammation causes the airway diameter to narrow in the subglottic area, site of the SAFETY ALERT! smallest upper airway diameter. Even small amounts of Throat cultures and visual inspection of the inner mouth and or edema can quickly obstruct the airway. During inspiration, throat are contraindicated in children with LTB and epiglot- the walls of the inner airway are pulled together, causing further titis. These procedures can cause (spasmodic respiratory distress. vibrations that close the larynx) as a result of the child’s anxi- ety or of probing this reactive and already compromised area. Clinical Manifestations A complete airway obstruction may result. Most children brought to the emergency department with LTB have been ill for a couple of days with upper respiratory symp- Management consists of maintaining and improving toms. These symptoms progress to a cough and hoarseness. Fever respiratory effort with medications, and in some cases sup- may be present. Children commonly have a runny nose, tachy- plemental oxygen. (See Medications Used to Treat Laryngo- pnea, inspiratory stridor, and a seal-like barking cough. Symp- tracheobronchitis.) Children who respond well to medications toms may be worse at night. Expiratory stridor, severe tachypnea, are often sent home from the emergency department after an retractions, and a low SpO indicate a more severe airway inflam- 2 observation period. Children with moderate to severe symp- mation and swelling. Mental status changes may indicate hypox- toms after nebulizer medications are admitted for further emia and potential respiratory failure. See Table 20–4 for clinical observation and treatment. Airway obstruction is a potential manifestations distinguishing these croup syndromes. complication of LTB requiring intubation and transfer to the Clinical Therapy PICU. Most children who are admitted respond to the medi- Diagnosis is often made by history and clinical signs. Pulse ox- cations and and are discharged within 48 to imetry is used to detect hypoxemia. Anteroposterior (AP) and 72 hours.

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Medications Used to Treat Pay particular attention to the child’s respiratory effort, breath sounds, preferred position, and responsiveness. Exhaus- Laryngotracheobronchitis tion can diminish the intensity of retractions and stridor. As the Medication and Action Nursing Management child uses remaining energy reserves to maintain ventilation, breath sounds may actually diminish. Noisy breathing (audible Beta-agonists and beta-adrenergics ■ Signs improve in about airway congestion, coarse breath sounds) in this situation verifies (e.g., albuterol, racemic epinephrine): 30 minutes, but relief adequate energy stores. Responsiveness decreases as hypoxemia aerosolized through face mask lasts about 2 hours, increases. Rapid-acting , providing time for the The following nursing diagnoses might be appropriate for decreases bronchial and tracheal corticosteroid to work. the child with acute LTB (NANDA-I © 2012): secretions and mucosal edema. ■ Monitor for tachycardia ■ Reduces need for intubation. (160–200 beats/min), Breathing Pattern, Ineffective related to airway narrowing, hypertension, dizziness, decreased energy, and fatigue headache, and nausea; ■ Fluid Volume: Deficient, Risk for related to inadequate may necessitate fluid intake prior to admission stopping medication. ■ Fear (Child) related to dyspnea, unfamiliar surroundings, procedures, and separation from support system Corticosteroids ■ Monitor for cardiovas- (e.g., ): IM, PO, cular symptoms Planning and Implementation nebulized budesonide (hypertension), Maintain Airway Patency Anti-inflammatory, used to observing closely for Supplemental oxygen with humidity may be needed for hypox- decrease edema; has a long half-life individual response. emia, but cool mist and humidified air have no proven benefit of 36–54 hours. Reduces need for an (Wald, 2010). Allow the child to assume a comfortable position. endotracheal tube. Be immediately available to attend to the child’s respiratory needs and keep resuscitation equipment and an intubation tray at the bedside. Administer medications. Ensure that a means of NURSING MANAGEMENT for the Child communication (sign language or simple word cues) is estab- with Laryngotracheobronchitis lished so the older child can alert nursing staff to respiratory difficulty. Nursing Assessment and Diagnosis Meet Fluid and Nutritional Needs The initial and ongoing physical assessment of the child with LTB The illness preceding the emergency department visit may have focuses on adequacy of respiratory functioning. Attach a cardio- compromised the child’s fluid status. Recognize the potential respiratory monitor and pulse oximeter. Have the child in an area fluid deficit and monitor the child’s hydration and nutritional in which continuous visual monitoring is possible to identify status. Fluids help thin secretions and provide calories for energy changes in severity of respiratory distress (see Table 20–5 for lev- and metabolism. els of croup severity). Children with LTB usually prefer cool, noncarbon- ated, nonacidic drinks such as oral rehydration fluids or Table 20–5 Assessment of Croup Severity fruit-­flavored drinks, gelatin, and popsicles. Encourage the ­parents to gain the child’s cooperation in taking oral fluids. Level of Severity Characteristics An intravenous infusion may be necessary to rehydrate the child, maintain fluid balance, or provide emergency access. Mild Occasional barking cough, no audible stridor at rest, no retractions Observe the child closely for difficulty in or drooling, which may be an early sign of epiglottitis or bacte- Moderate Frequent barking cough, audible stridor at rest, rial tracheitis. mild retractions at rest, no agitation Discharge Planning and Home Care Teaching Severe Frequent barking cough, prominent stridor, During the child’s observation period, take every opportunity to tachypnea, marked retractions, agitation, assess the parents’ knowledge of symptoms of LTB and discuss and/or distress actions to take if symptoms recur. For example, instruct parents to call the child’s healthcare provider if: Impending respiratory Frequent barking cough, stridor at rest, failure retractions, lethargy or decreased level of ■ Mild symptoms do not improve after 1 hour of exposure to consciousness, cyanosis. Cough, stridor, cool outdoor air or air conditioning. and retractions may not be present due to ■ respiratory fatigue and airway compromise The child’s breathing is rapid and labored with nasal flaring and retractions. Data from Wald, E. L. (2010). Croup: Common syndromes and therapy. Source: Pediatric ■ Annals, 39(1), 18. The child does not drink adequate fluids and the urine out- put is reduced.

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Evaluation Expected outcomes of nursing care include the following: ■ The child responds to medications with decreased respira- tory distress. ■ The child’s fear and anxiety is managed with family support and explanations about care.

Epiglottitis (Supraglottitis) Epiglottitis is an inflammation of the epiglottis, the long narrow structure that closes off the glottis during swallowing. Because edema in this area can rapidly (within minutes or hours) obstruct the airway by occluding the trachea, epiglottitis is considered a potentially life-threatening condition. (Table 20–4 compares epi- glottitis and other croup syndromes.) Epiglottitis is caused by bacterial invasion of the soft tissue of the larynx by streptococcus, staphylococcus, or by Haemophilus influenzae type B (Hib) in unimmunized children. The resulting inflammation and tissue edema surrounding the epiglottis lead to airway obstruction. Since the widespread use of the Hib vac- cination, a 10-fold decrease in the incidence of epiglottitis has occurred (D’Agustino, 2010). A previously healthy child suddenly becomes very ill with ● Figure 20–2 Children with severe respiratory distress and a narrowed a high fever (greater than 39°C [102.2°F]) and sore throat. Four airway often sit in a tripod position, leaning forward with arms on the legs. classic “D” signs include dysphonia (muffled, hoarse voice and The head and neck are extended with the jaw thrust forward to help keep with talking), dysphagia (difficulty in swallowing), drool- the airway open. This position may also be seen in a child with an acute ing, and distressed respiratory effort with inspiratory stridor. asthma flare. The child often refuses to lie down and assumes a “sniffing” or tripod position (Figure 20–2 ●). The child’s anxiety increases as it becomes more difficult to breathe. SAFETY ALERT! Diagnosis is often based on physical signs and a lateral neck Observe the child continuously for inability to swallow, ab- radiograph, which reveals a narrowed airway and an enlarged, sence of voice sounds, increasing degree of respiratory dis- rounded epiglottis, seen as a mass at the base of the tongue. Recall tress, and acute onset of drooling. A change in the child’s level that visual inspection of the mouth and throat is contraindicated. of consciousness—from anxiety to lethargy to stupor—occurs as hypoxia increases. If any of these signs occur, get medical Because of the risk for total airway obstruction, immediate assistance immediately. The quieter the child, the greater the clinical therapy usually involves insertion of an endotracheal tube cause for concern. to maintain the airway. At the same time, a blood culture and epi- glottitis culture are taken. Antibiotics effective for gram-positive Postpone anxiety-provoking procedures such as venipunc- organisms and H. influenzae (ceftriaxone, cefotaxime, or ampicil- ture until the airway is secure. Crying stimulates the airway, in- lin plus sulbactam) are given until culture sensitivities are available, creases oxygen consumption, and can precipitate laryngospasm. after which the antibiotic may be changed. Racemic epinephrine Supplemental humidified oxygen may be used initially to reverse and corticosteroids are not effective. If H. influenzae is the caus- hypoxemia. ative organism, rifampin prophylaxis should be prescribed for all Until the endotracheal tube is removed, the child is man- family members if the family includes a child under 48 months aged in the PICU to ensure continual observation (see the Clini- who is not completely immunized against H. influenzae or when cal Skills Manual SKILLS ). Support parents as they cope with the any child member is immunocompromised (American Academy sudden onset of the child’s life-threatening illness. Reassure the of Pediatrics [AAP], 2012, p. 347). child and parents that the inability to create sounds is temporary. Nursing Management Explain the need for various pieces of equipment to help reduce Nursing management consists of airway management, drug the child’s stress. Administer antibiotics to treat the infection therapy, hydration, and emotional and psychosocial support of and IV fluids to provide hydration. Because the child was febrile the child and parents. with a sore throat before admission, fluid intake may have been Until the child is intubated, do not leave the child unat- compromised. tended. Allow the child to stay in the position of comfort, often Most children show rapid improvement once oxygen, anti- sitting. Observe the child’s respiratory and airway status con- biotics, and fluid therapy are started. The endotracheal tube can tinuously. Note any change in the child’s level of consciousness. usually be removed within 1 to 2 days, and home care may involve

DESIGN SERVICES OF # 153633 Cust: Pearson Education Au: Ball Pg. No. 533 C / M / Y / K S4CARLISLE Title: Principles of Pediatric Nursing: Caring for Children 6e Short / Normal Publishing Services 534 Chapter 20 Alterations in Respiratory Function completing the course of antibiotics. Parents need instructions on Home care should emphasize the self-limiting nature of the proper administration and potential side effects of drug therapy. disorder. Advise parents who smoke that quitting or not smok- ing in the child’s presence may benefit the child. Bacterial Tracheitis Bacterial tracheitis is a secondary infection of the upper trachea and Respiratory Syncytial Virus following a viral LTB, often caused by Staphylococcus aureus, Bronchiolitis is a lower respiratory tract illness that occurs when Group A streptococcus, , or H. influenzae a viral or bacterial organism causes inflammation and obstruc- (usually in unimmunized children). The child has signs of viral tion of the bronchioles. Bronchiolitis affects 1 in 7 infants in the croup for several days before the onset of a productive cough, first year of life, and causes about 100 deaths each year in the high fever, and a toxic appearance. Dysphagia and drooling are United States (Alverson & Ralston, 2011). Children with bron- rarely present, and the child can lie flat. Table 20–4 compares chiolitis have an increased risk for wheezing and asthma later in bacterial tracheitis and other croup syndromes. childhood (Sorce, 2009). Bacterial tracheitis may be misdiagnosed initially as LTB Etiology and Pathophysiology because of similar signs. However, the child’s condition wors- ens rather than improves with LTB therapy. Diagnosis is then Respiratory syncytial virus (RSV) is the most common cause of made by blood cultures. The subglottis is edematous with bronchiolitis, but adenovirus, parainfluenza virus, and human ulceration, and thick mucopurulent exudate may obstruct metapneumovirus may also be responsible. RSV occurs in an- the airway. Most children need intubation until swelling di- nual epidemics from October to March. It is transmitted through minishes. Antibiotics are prescribed for a full 10- to 14-day direct contact with respiratory secretions or indirectly through course. contaminated surfaces. The infected child sheds the virus for 3 to 8 days, and the incubation period is 2 to 8 days. Nearly all Nursing Management children have been infected with RSV by 2 years of age, and rein- The child with bacterial tracheitis is frequently cared for in the fection throughout life is common (AAP, 2012, p. 609). Risk fac- PICU until the endotracheal tube is removed. The tube is suc- tors for severe RSV infection include immunosuppression, very tioned frequently, because thick tracheal secretions pool high in low birth weight, lung disease, severe neuromuscular disease, or the upper airway. Provide humidified air or oxygen. Antibiotics complicated congenital heart defects (Miller, 2010). are administered as ordered. The previous section on epiglottitis Viruses, acting as parasites, are able to invade the mucosal discusses other nursing care interventions that may also be ap- cells that line the small bronchi and bronchioles. The invaded propriate for the child with bacterial tracheitis. cells die when the virus bursts from inside the cell to invade adjacent cells. The membranes of the infected cells fuse with LOWER AIRWAY DISORDERS adjacent cells, creating large masses of cells or “syncytia.” The resulting cell debris clogs and obstructs the bronchioles and Lower airway disorders occur because a structural or functional irritates the airway. In response, the airway lining swells and problem interferes with the lungs’ ability to complete the respi- produces excessive mucus. Despite this protective effort by the ratory cycle. Disorders of the lower airway include , bronchioles, the actual effect is partial airway obstruction and bronchiolitis, pneumonia, and . bronchospasms. The cycle is repeated throughout both lungs as the airway Bronchitis cells are invaded by the virus. The partially obstructed airways , inflammation of the trachea and bronchi, allow air in, but the mucus and airway swelling block expulsion rarely occurs in childhood as an isolated problem. The bronchi of the air. This creates the wheezing and crackles in the airways. can be affected simultaneously with adjacent respiratory struc- Air trapped below the obstruction also interferes with normal tures during a respiratory illness. Bronchitis occurs most com- gas exchange, leading to hypoxemia. The child with RSV is monly in the winter months. therefore at risk for apnea and respiratory failure as hypoxemia The classic symptom of bronchitis is a dry, hacking cough and hypercarbia develop. that increases in severity at night. The cough may or may not be Clinical Manifestations productive. The child may swallow and vomit as a result. Some children have mild symptoms such as , cough, low- The chest and ribs may be sore because of the deep and frequent grade fever, wheezing, tachypnea, poor feeding, vomiting, and coughing. Over several days breath sounds may become coarse diarrhea. Dehydration may be present if the child has been sick with fine crackles, and some scattered high-pitched wheezing for several days. Parents report that the infant or child is acting may be heard. Treatment is palliative unless a secondary bacte- more ill—appearing sicker, less playful, and less interested in eat- rial infection occurs that needs antibiotic therapy. ing. Infants, especially, may refuse to feed or may spit up what Nursing Management they eat along with thick, clear mucus. Nursing management includes supporting respiratory function The infant or child with a more severe infection has tachy- through rest, humidification, hydration, and symptomatic treat- pnea greater than 70 breaths per minute, grunting, increased ment. Refer to the sections on asthma and pneumonia for de- wheezing, retractions, nasal flaring, irritability, lethargy, poor tailed information on treatment measures. fluid intake, and a distended abdomen from overexpanded

DESIGN SERVICES OF # 153633 Cust: Pearson Education Au: Ball Pg. No. 534 C / M / Y / K S4CARLISLE Title: Principles of Pediatric Nursing: Caring for Children 6e Short / Normal Publishing Services Lower Airway Disorders 535 lungs. As hypoxia develops the infant becomes cyanotic and Clinical Tip has decreasing mental status. As the airflow continues to de- crease, breath sounds diminish. Thus, the noisier the lungs, A study evaluating the use of EMLA cream and for pain the better—this indicates that the child is still able to move air management of palivizumab injections found that the combined use in and out of the lungs. While RSV bronchiolitis resolves in of nitrous oxide/oxygen and EMLA cream was more effective than 5 to 7 days, increased airway resistance and airway hypersen- either treatment used alone (Carbajal, Biran, Lenden, et al., 2008). sitivity may persist for weeks or even months. Bronchiolitis in infancy may increase a child’s risk of developing asthma ­(Stewart, 2008). Clinical Therapy NURSING MANAGEMENT for the Child The history and physical examination provide the data needed to with Bronchiolitis and RSV diagnose bronchiolitis. Chest radiographs show hyperinflation, Nursing Assessment and Diagnosis patchy , and other signs of inflammation. - Physiologic Assessment linked immunosorbent assay (ELISA) or immunofluorescent Assess airway and respiratory function carefully. Good ob- assay performed on a posterior nasopharyngeal specimen are servation skills are important to ensure timely interventions laboratory tests used to identify the virus causing bronchiolitis for worsening respiratory symptoms and prevention of respi- (see the Clinical Skills Manual SKILLS ). ratory failure (see the Table 20–1 and Assessment Guide on Treatment is supportive. The child is isolated to minimize pages 523 and 524). Assess the child’s hydration status, weigh the spread of the virus to other hospitalized children. Humidi- the child daily, and monitor the intake and output. Attach fied oxygen is provided to infants with severe hypoxemia, when a cardiorespiratory monitor and pulse oximeter. An oxygen the SpO readings fall to less than 90% (Selden & ­Scarfone, 2 saturation level below 90% is the best indicator of the condi- 2009). Other supportive care includes hydration with oral or tion’s severity. IV fluids and nasal suctioning before feeding. Continuous positive airway pressure (CPAP) may be used in the child with SAFETY ALERT! moderate to severe bronchiolitis. does RSV bronchiolitis often increases in severity before beginning not affect severity or length of hospital stay and is not recom- to resolve. Stay alert for signs of increasing respiratory dis- mended (Zentz, 2011). tress and a greater need for oxygen. Signs of life-threatening Common medications used to treat acute episodes of RSV illness include central cyanosis, respiratory rate greater than and bronchiolitis include nebulized epinephrine, albuterol, or 70 breaths a minute, listlessness, diminished breath sounds, nebulized saline (Tudor & Haffner, 2013). Oral dexamethasone and apnea episodes. Inform the physician immediately of any administered with nebulized albuterol shortened hospital length significant changes in respiratory status. of stay in one study (Alansari, Sakran, Davidson, et al., 2013). Antipyretics may be used. Antibiotics are used only when a bac- Psychosocial Assessment terial infection is present. Observe children and their parents for signs of fear and anxi- Prevention of RSV is a focus for children at high risk for ety. The unfamiliar hospital environment and procedures can severe bronchiolitis, including the following groups of children increase stress. Parents’ questions, as well as their nonverbal (AAP, 2012, pp. 614–616): cues, help direct nursing interventions during admission and ■ Children under age 24 months with bronchopulmo- throughout hospitalization. nary dysplasia who have needed medical therapy within The accompanying Nursing Care Plan: The Child with 6 months of the start of RSV season Bronchiolitis lists common nursing diagnoses for the child with ■ Children under age 24 months with significant congenital bronchiolitis. Others that might also be appropriate include heart disease, requiring medical therapy (NANDA-I © 2012): ■ Infants born before 32 weeks’ gestation, during their first ■ Airway Clearance, Ineffective related to increased airway 12 months of life secretions in bronchioles ■ ■ Infants born at 32 to 35 weeks’ gestation with either of Activity Intolerance related to imbalance between oxygen these two risk factors: childcare attendance or a sibling less supply and demand than 5 years of age ■ Family Processes, Interrupted related to sudden acute ­illness of the infant Intramuscular palivizumab (Synagis) is used for prophylaxis for a child in one of the high-risk categories. A dose of 15 mg/kg Planning and Implementation is given every 30 days for 5 months beginning in October or Nursing management of the hospitalized child with bron- ­November at the onset of the RSV season. Palivizumab is expen- chiolitis focuses on maintaining respiratory function, sup- sive but less costly than hospitalization for an infant with RSV. porting overall physiologic function and hydration, reducing Palivizumab does not interfere with administration of normal the child’s and family’s anxiety, and preparing the family for recommended childhood vaccines (AAP, 2012, p. 38). home care.

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Nursing Care Plan The Child with Bronchiolitis Intervention Rationale Expected Outcome 1. Nursing Diagnosis: Breathing Pattern, Ineffective related to increased work of breathing (NANDA-I © 2012) NIC Priority Intervention: NOC Suggested Outcome: Respiratory monitoring: Collection and analysis Vital signs status: , pulse, respira- of patient data to ensure airway patency and tion, and blood pressure within expected range adequate gas exchange for the child’s age Goal: The child will return to respiratory baseline and will not experience respiratory failure. ■ Assess respiratory status (see Assessment ■ Changes in breathing pattern may occur ■ Child will return to respiratory baseline Guide ) when child is calm and not crying quickly as the child’s energy reserves are within 48–72 hours. at least every 2–4 hours, or more often as depleted. Baseline and subsequent assess- indicated for an increasing or decreasing ments help detect changes in the respira- respiratory rate and episodes of apnea. tory rate and respiratory effort. ■ Attach a cardiorespiratory monitor and pulse ■ The alarm can alert the nurse to any sudden oximeter with alarms set. Record and report respiratory changes and lead to more rapid changes promptly to physician. interventions. Goal: The child’s oxygenation status will return to baseline.

■ Administer humidified oxygen via mask, ■ Humidified oxygen loosens secretions, ■ Child’s respiratory effort will ease. The SpO2 nasal cannula, hood, or tent. helps maintain oxygenation status, and level will remain at 95% or higher during eases respiratory distress. treatment.

■ Assess and compare the child’s SpO2 level ■ Comparison of SpO2 levels provides on room air and when on supplemental information about improvement status. oxygen. ■ Note child’s response to ordered ■ Medications act systemically to improve ■ Child will tolerate therapeutic measures with medications. oxygenation and decrease inflammation. no adverse effects. ■ Position head of bed up or place child in ■ Position facilitates improved aeration and ■ Child will rest quietly in position of comfort. position of comfort on parent’s lap, if crying promotes decrease in anxiety (especially or struggling in crib or bed. in toddlers) and energy expenditure. ■ Assess tolerance to feeding and activities. ■ Provides an assessment of condition improvement. 2. Nursing Diagnosis: Fluid Volume: Deficient, Risk for related to inability to meet body requirements and increased metabolic demand (NANDA-I © 2012) NIC Priority Intervention: NOC Suggested Outcome: Fluid management: Promotion of fluid balance Hydration: Amount of water in intracellular and and prevention of complications resulting from extracellular compartments of body abnormal or undesired fluid levels Goal: The child’s immediate fluid deficit will be corrected. ■ Evaluate need for intravenous fluids. Maintain ■ Previous fluid loss may require immediate ■ Child’s hydration status will be maintained IV, if ordered. replacement. during acute phase of illness as demon- strated by appropriate urine output and moist mucous membranes. Goal: The child will be adequately hydrated, be able to tolerate oral fluids, and progress to normal diet. ■ Calculate maintenance fluid requirements ■ Assessment of fluid requirements enables ■ Child will take adequate oral fluids after and give oral fluids, IV fluids, or both. the child to maintain hydration while 24–48 hours to maintain hydration. transitioning to oral fluids. ■ Offer clear fluids and incorporate parent ■ Choice of fluid offered by parent gains the ■ Child will accept beverage of choice from in care. Offer fluid choice when tolerated. child’s cooperation. parent or nursing staff. ■ Maintain strict intake and output monitoring ■ Monitoring provides objective evidence and evaluate specific gravity at least of fluid loss and ongoing hydration status. every 8 hours. ■ Perform daily weight measurement on ■ Further evidence of improvement of ■ Child’s weight will stabilize after the same scale at the same time of day. hydration status. 24–48 hours; skin turgor will be supple. Evaluate skin turgor. ■ Assess mucous membranes and presence ■ Moist mucous membranes and tears are ■ Child will show evidence of improved of tears. signs of adequate hydration. hydration.

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Nursing Care Plan The Child with Bronchiolitis (continued ) Intervention Rationale Expected Outcome 3. Nursing Diagnosis: Anxiety (Child and Parent) related to acute illness, hospitalization, uncertain course of illness and treatment, and home care needs (NANDA-I © 2012) NIC Priority Intervention: NOC Suggested Outcome: Anxiety reduction: Minimizing apprehension, Anxiety control: Ability to eliminate or reduce dread, foreboding, or uneasiness related to an feelings of apprehension and tension from an unidentified source of anticipated danger unidentifiable source Goal: The child and parents will demonstrate behaviors that indicate less anxiety. ■ Encourage parents to express fears and ask ■ Parents have the opportunity to vent ■ Parents and child will show less anxiety questions; provide direct answers and discuss ­feelings and receive timely, relevant as symptoms improve and as child and care, procedures, and condition changes. ­information. This helps reduce parents’ parents feel more secure in hospital anxiety and increase trust in nursing staff. environment. Parent will freely ask questions ■ Incorporate parents in the child’s care. ■ Familiar people, routines, and objects and participate in the child’s care. Child ­Encourage parents to bring familiar objects ­decrease the child’s anxiety and increase will cry less and allow staff to hold or touch from home. Ask about and incorporate in parents’ sense of control over an him or her. care plan the home routines for feeding and ­unexpected, uncertain situation. sleeping. Goal: Parents will verbalize knowledge of bronchiolitis symptoms and use of home care methods before the child’s discharge from the hospital. ■ Explain symptoms, treatment, and home care ■ Anticipating the potential for recurrence ■ Parent will accurately describe respiratory of bronchiolitis. assists the family to be prepared should symptoms and initial home care actions. respiratory symptoms recur after discharge. ■ Provide written instructions for follow-up care ■ Written and verbal instructions reinforce arrangements, as needed. knowledge. Parents may not “hear” and remember details if only given verbally. ■ Make sure parents can read the instructions ■ Many families have reading difficulties or provided in family’s primary language. may read a language other than English.

Maintain Respiratory Function frightened by the child’s continued respiratory difficulty. In- Close monitoring is essential to evaluate the child’s improve- fants may respond to their parents’ anxiety and be more irri- ment or to spot early signs of deterioration. Patent nares are table. Provide parents with thorough explanations and daily important to promote oxygen intake. A bulb syringe and saline updates, and encourage their participation in the child’s care. nose drops can be used to quickly clear the nasal passages. Ele- Reassure them that holding or touching the child will not dis- vate the head of the bed to ease the work of breathing and drain lodge wires or tubing and that their presence will calm and sup- mucus from the upper airways. Supplemental oxygen with hu- port the child. midity may be provided via nasal cannula, mask, hood, or tent. If the child has been ill for a few days before admission, When the child resists or is frightened by the oxygen apparatus, the parents are likely to be tired. Acknowledging parents’ physi- engage the parent to soothe the child and promote acceptance cal and emotional needs creates a spirit of caring and enhances of the therapy. communication between staff and family. Encourage the par- Support Physiologic Function ents to take turns at the child’s bedside and to take breaks for Group nursing tasks to decrease stress and promote rest. Medica- meals and rest. tions may be administered to control temperature and promote Discharge Planning and Home Care Teaching comfort as needed. Infants may have feeding difficulty and are at Children are discharged once they maintain stable oxygenation risk for aspiration. Suction the nasal passages before giving oral on room air along with eased respiratory effort and decreased feedings. Feed smaller volumes more frequently to help conserve mucus production. In most children, symptoms decrease energy in infants who are formula- or breastfed. When the risk within 24 to 72 hours, but all symptoms like coughing may take of aspiration is high, nasogastric tube feedings may be used to weeks to resolve. See Familes Want to Know: Discharge Teaching provide nutrition. An IV infusion may be ordered to rehydrate for Bronchiolitis. the child and maintain fluid balance until oral fluid intake is Teach the parents proper administration of medications. adequate. Acetaminophen or ibuprofen may be prescribed for persistent Reduce Anxiety low-grade fevers and general discomfort. Advise parents that The need for hospitalization and assistive creates RSV infection can recur. Educate them to recognize symptoms anxiety and fear in the child and parents. The parents may be and when to call the physician.

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Families Want to Know forcefully, killing the cells and sending out cell debris. Ad- jacent areas are invaded, distributed in a scattered, patchy Discharge Teaching for Bronchiolitis pattern referred to as . General Care Instructions: ■ Aspiration of food, emesis, gastric reflux, or hydrocarbons ■ Use the bulb syringe to suction the nares of an infant under causes a chemical injury and inflammatory response, 1 year of age. which sets the stage for bacterial invasion. ■ Give fluids to help thin secretions and provide calories for CAP is often preceded by an upper respiratory tract infec- energy. tion including rhinitis and a cough. Other symptoms include ■ Encourage active toddlers to rest and take naps during fever, rhonchi, crackles, wheezes, cough, dyspnea, tachypnea, recovery. restlessness, and decreased breath sounds if consolidation Advise Parents to Call the Physician If: exists. Newborns and infants may have grunting, nasal flar- ■ Respiratory symptoms interfere with sleeping or eating. ing, retractions, irritability, lethargy, and a reduced appetite. ■ Breathing is rapid or difficult. ­Diminished breath sounds may be noted. Children with bacte- ■ Symptoms persist in a child who is less than 1 year old, has rial pneumonia may have and try to splint the chest heart or lung disease, or was premature and had lung disease when coughing. after birth. Diagnosis is based on history and physical findings. Strong ■ The child acts sicker—appears tired, less playful, and less predictors of pneumonia include SpO2 of 92% or less, crackles, ­interested in food (parents just “feel” the child is not improving). chest pain, and fever (Neuman, Monuteaux, Scully, et al., 2011). Rapid influenza and other respiratory virus testing is recom- mended to help distinguish between viral and bacterial causes of CAP. A chest radiograph and blood cultures are performed when Evaluation the child has respiratory signs requiring hospitalization (Bradley Expected outcomes of nursing care for the child with bronchiol- et al., 2011). itis are provided in the Nursing Care Plan. Clinical management for all types of pneumonia includes pain and fever control, and supportive care through airway man- Pneumonia agement, fluids, and rest. Because most CAP is viral, antibiot- ics are not routinely prescribed. Amoxicillin is prescribed for Pneumonia, an inflammation or infection of the bronchioles and bacterial . Antiviral therapy is prescribed for some alveolar spaces of the lungs, occurs most often in infants and young children. Supplemental oxygen and IV fluids are needed for hos- children. In the United States, 201.1 per 100,000 children and pitalized children with severe CAP. youth under 19 years of age are hospitalized annually for pneu- monia (Bradley, Byington, Shah, et al., 2011). Pneumonia can be Nursing Management community acquired (CAP) or hospital acquired (e.g., associated If the child with community-acquired pneumonia is hospital- with mechanical ventilation). The focus of this discussion is CAP. ized, assess the child, paying particular attention to respiratory Pneumonia may be viral, mycoplasmal, or bacterial in ori- rate, heart rate, and temperature, and observe color for pallor gin. Children under 5 years of age most often have pneumonia or cyanosis. Attach a pulse oximeter to monitor the SpO2 level. caused by RSV, , influenza, parainflu- Assess hydration status. Assess for the presence of pain with enza virus, or adenovirus. occurs in all age coughing. groups but is more common in children over 5 years old. Com- Nursing measures used for the child with bronchiolitis are mon bacterial organisms include Streptococcus pneumoniae, generally applicable (see page 535). Provide supportive thera- Chlamydophila pneumoniae, and Staphylococcus aureus. Group B pies (chest physiotherapy, antibiotics, and hydration). Teach the streptococcus, enteric gram-negative bacilli, and Chlamydia child and parent how to splint the chest by hugging a small pil- trachomatis are found in infants younger than 3 months of age. low or teddy bear to make coughing less painful. Acetamino- Children with cystic fibrosis or immunosuppression are suscep- phen or ibuprofen may be prescribed for tible to other bacterial, parasitic, or fungal . and temperature control. Promote hydration and nutrition by Bacterial and viral invaders act differently within the lungs: encouraging the intake of preferred clear liquids and small serv- ings of soft foods. ■ Bacterial invaders circulate through the bloodstream to the For home management, teach parents about administering lungs, where they damage cells and cause inflammation prescribed antibiotics, any potential side effects, and the need to and edema. Cellular debris and mucus cause airway ob- give the full course. Educate parents about signs that the child’s struction. Bacteria tend to be distributed evenly through- condition may be worsening (increased breathing difficulty or out one or more lobes of a single lung, a pattern termed refusal to take fluids). Most children recover uneventfully, but unilateral . some continue to have worsening reactive airway problems or ■ Viruses enter through the upper respiratory tract, infiltrat- abnormal results on pulmonary function tests. ing the alveoli nearest the bronchi of one or both lungs. Preventive measures are limited. The Haemophilus influen- Viruses invade the cells, replicating and bursting out zae type B (Hib) and pneumococcal conjugate (PCV13) vaccines

DESIGN SERVICES OF # 153633 Cust: Pearson Education Au: Ball Pg. No. 538 C / M / Y / K S4CARLISLE Title: Principles of Pediatric Nursing: Caring for Children 6e Short / Normal Publishing Services Lower Airway Disorders 539 protect against some causes of pneumonia. The 23-valent pneu- sounds. Adolescents may have fever, anorexia, weight loss or mococcal vaccine is recommended for children over 2 years of growth delay, productive cough, and night sweats. Hemop- age with immunosuppression or some chronic conditions (see tysis (coughing up blood from the respiratory tract) is a late Chapter 16 8 ). sign of advanced pulmonary TB. When TB spreads outside the pulmonary system, additional signs are specific to the system Tuberculosis invaded: Tuberculosis (TB) is an infection caused by Mycobacterium tu- ■ Superficial lymphadenitis: firm, nontender, matted lymph berculosis, which is transmitted through the air in infectious nodes particles called droplet nuclei. In 2007, 820 children under ■ Miliary: high fever, vomiting, lethargy, headache, 15 years of age in the United States acquired TB (Cruz & Starke, ­seizures, nuchal rigidity, cranial palsies, and 2010). Rates are higher among foreign-born persons and among ­irritability; also hepatosplenomegaly and generalized Hispanics, non-Hispanic blacks, and Asians (Centers for Disease lymphadenopathy Control and Prevention [CDC], 2011a). In U.S. children less than 5 years of age, those who are foreign-born or born in the ■ Osteoarticular: inflammation, pain, swelling, fever, and United States of foreign-born parents are at significantly higher limited range of motion of the affected or risk of TB than children with U.S.-born parents (Pang, Teeter, Clinical Therapy Katz, et al., 2014). Screening to identify a child’s risk for LTBI should occur during Etiology and Pathophysiology the first health visit, every 6 months until age 2 years, and then Children usually acquire a TB infection from infected adults who annually. Administer a tuberculin skin test (intradermal purified cough, , speak, or sing, and send out tiny droplets contain- protein derivative [PPD]) if one or more of these risk factors are ing the bacillus. When inhaled, the bacillus is small enough to present (AAP, 2012, p. 740): travel directly to the alveoli and cause infection. When the or- ■ The child was born in any country or region with endemic ganism reaches the alveolus, an immune response is initiated, infection, such as Asia, the Middle East, Africa, Latin and macrophages surround and wall off the bacillus in a small America, and countries of the former Soviet Union. hard capsule, called a tubercle. The tubercle bacilli grow slowly, ■ The child traveled outside the United States and had con- dividing every 25 to 32 hours. The bacilli grow for 2 to 12 weeks tact with the resident population for more than a week in until they number 1,000 to 10,000, at which point the cellular any country or region mentioned above. immune response to a TB skin test (TST) would occur. ■ In persons with intact cell-mediated immunity, activated The child has a family member or contact with confirmed T cells and macrophages form granulomas around the tubercles or suspected contagious TB. that limit multiplication. The proliferation of TB is arrested, but ■ A family member had a positive PPD. small numbers of viable bacilli remain in the tubercle. These A positive PPD indicates that the child has been exposed to and individuals have latent tuberculosis infection (LTBI), a positive infected with TB, and have been produced against the TST, and no clinical or radiographic signs of disease. They are bacillus. not infectious and cannot transmit the disease. An interferon-gamma release assay (IGRA; e.g., quanti­ Active TB can develop as the bacilli grow, divide within the FERON or T.Spot.TB) may help support PPD findings. For ex- tubercle, and break free. Infants and adolescents have the great- ample, a child vaccinated with bacille Calmette-Guérin (BCG) est risk of transitioning from LTBI to active TB. Factors that may have a false-positive response to multiple PPDs, but IGRA increase that risk include immunosuppressive therapy, HIV co- does not cross-react with BCG and gives a more accurate result infection, malnutrition, and chronic medical conditions (AAP, (Mazurek, Jereb, Vernon, et al., 2010). Like the PPD, the IGRA 2012, p. 738). The greatest risk for LTBI transition to active TB cannot distinguish between latent or active TB. Other diagnostic (including meningitis and disseminated TB) occurs within 2 tests include acid-fast stains of blood, gastric aspirate, and spu- to 12 months after initial infection (Ranganathan & Sonnappa, tum cultures and a chest radiograph. 2009). Children under age 10 years with active TB are rarely Active and latent TB are treated with isoniazid, rifampicin, contagious, because they have small pulmonary lesions and un- pyrazinamide, and ethambutol. Therapy for active TB usually productive coughing, during which few or no bacilli are expelled involves a 6-month regimen consisting of isoniazid, rifampin, (AAP, 2012, pp. 738–739). pyrazinamide, and ethambutol for the first 2 months and isonia- Disseminated or extrapulmonary TB occurs more com- zid and rifampicin for the remaining 4 months. LTBI in children monly in infants and young children. Bacilli are released from less than 12 years of age is treated with a single daily dose of iso- the primary site into the bloodstream, spreading to the , niazid for 9 months (or rifampicin for 6 months if TB is drug re- , , , or meninges (miliary TB). sistant to isoniazid). Direct-observed drug therapy administered Clinical Manifestations by a healthcare provider 2 to 3 times a week for the duration of Children with LTBI are asymptomatic. Children with pulmo- treatment is recommended for children with active TB and when nary TB may have a persistent cough, weight loss or failure daily therapy adherence is not assured for children with LTBI to gain weight, fever, fatigue, wheezing, and decreased breath (AAP, 2012, p. 751). Healthy youth with LTBI, ages 12 years and

DESIGN SERVICES OF # 153633 Cust: Pearson Education Au: Ball Pg. No. 539 C / M / Y / K S4CARLISLE Title: Principles of Pediatric Nursing: Caring for Children 6e Short / Normal Publishing Services 540 Chapter 20 Alterations in Respiratory Function older, may receive once-weekly, direct-observed drug therapy Developing Cultural Competence with isoniazid and rifampicin for 12 weeks (Jereb, Goldberg, Asthma Prevalence Powell, et al., 2011). The local department is notified to search for The pediatric asthma prevalence rate in the United States varies by disease contacts of the child with newly diagnosed LTBI or active racial and ethnic groups (Akinbami et al., 2011): TB. The child is considered a sentinel case, and the adult contact ■ with active TB must be identified. Non-Hispanic black: 11.1% ■ Non-Hispanic white: 8.2% Nursing Management ■ Hispanic: 6.3% (ranging from 16.6% for Puerto Ricans to 4.9% Assessment focuses on identifying children at high risk of TB ex- for Mexicans) posure and performing a PPD as appropriate. Infant and young ■ Asian: 5.3% children with a positive PPD are at greater risk to develop ac- ■ American Indian and Alaska Native: 8.8% tive TB, so assess them carefully for weight loss, fever, fatigue, coughing, and respiratory status. Consider the child’s immuno- suppression status. If TB is suspected, implement airborne isola- tion precautions until the infection status is known. disease (atopic eczema, food ). Protective factors include Nursing care of the child with LTBI focuses on administer- a large family size, later birth order, childcare attendance, dog in ing medications and providing supportive care. Teach parents the family, and living on a farm. These factors increase exposure about the disease process, medications, possible side effects, and to infections early in life, enabling the child’s to the importance of completing long-term therapy. Emphasize the develop along a nonallergic pathway (National Asthma Education importance of taking medications as prescribed on an empty and Prevention Program [NAEPP], 2007, p. 23). . Initiate direct-observed drug therapy twice a week if Inflammation causes the normal protective mechanisms poor adherence is suspected. of the lungs (mucous formation, mucosal swelling, and airway Encourage proper nutrition and rest to promote normal muscle contraction) to overreact in response to a trigger (an growth and development. The child can return to school or inflammatory or noninflammatory stimulus that initiates an childcare when effective therapy has been instituted, adherence asthma episode). Triggers include , infectious agents, al- to therapy has been documented, and clinical symptoms have lergens, fragrances, food additives, pollutants, weather changes, diminished substantially (AAP, 2012, p. 758). Children should emotions, and stress. Inflammatory mechanisms enhance air- receive all usual immunizations. Most children treated for TB way responsiveness, and triggers stimulate bronchospasms can lead essentially normal lives. See the discussion of pneumo- (smooth muscle contractions). nia on page 538 and of meningitis in Chapter 27 8 for other The trigger may activate IgE and sensitized mast cells, lead- nursing care measures. ing to the release of inflammatory mediators (e.g., histamines, , and leukotrienes). The inflammatory media- CHRONIC LUNG DISEASES tors release pro-inflammatory , causing chronic air- way inflammation, which may be associated with permanent Asthma airway damage. The resulting decreased airway elasticity and Asthma is a common chronic disorder in children characterized lung function are not prevented or fully reversed by treatment by bronchial constriction, hyperresponsive airways, and airway (Brashers, 2010a). The reactive airway responses exist before the inflammation. In 2009 in the United States, 7.1 million (9.6%) trigger initiates the physiologic sequence that results in an acute children ages 0 to 17 years had an asthma diagnosis. An acute asthma episode. asthma episode was reported by 57.2% of these children in the Airway narrowing results from bronchial constriction, air- prior 12 months, often resulting in a missed day of school. Of way swelling, and mucus production. Mucus clogs small airways, these children, 32.5% made an emergency department visit, and trapping air below the plugs (see Pathophysiology Illustrated: 8% were hospitalized. Approximately 174 deaths due to asthma Asthma). Decreased perfusion of the alveolar capillaries results occur annually in children and youth in the United States from hypoxic vasoconstriction and increased pressure due to ­(Akinbami, Moorman, & Liu, 2011; CDC, 2011b). See Develop- hyperinflation of the alveoli. Hypoxemia leads to an increased ing Cultural Competence: Asthma Prevalence. respiratory rate, but because of airway resistance, less air is in- Etiology and Pathophysiology spired per minute, worsening hypoxemia. Asthma is a chronic inflammatory disease caused by multiple fac- Clinical Manifestations tors (e.g., environmental exposures, viral illnesses, allergens, and a The sudden onset of breathing difficulty (cough, , or genetic predisposition) that occur at a crucial time in the immune shortness of breath) is an acute asthma episode or asthma attack. system’s development. More than 100 genes are associated with The infant or child who has had frequent episodes of coughing the susceptibility and of asthma (Brashers, 2010a). Risk or respiratory infections should be evaluated for asthma. Fre- factors for asthma include passive smoke exposure, indoor air quent coughing, especially at night, is a signal that the child’s contaminants (for example, pet dander, cockroach feces), outdoor airway is very sensitive to stimuli, and this could be a sign of air pollutants, recurrent respiratory viral infections, and allergic “silent” asthma.

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Pathophysiology Illustrated Asthma Clinical Tip Some asthma triggers are exercise, infection, and allergies. Asthma testing is performed when the child is able to cooperate, obstructs airflow through constriction and narrowing of the airway, usually by 5 to 6 years of age. Coach the child to give the best effort along with increased production of mucus. each time. Encourage the child to seal the tightly around the mouthpiece. The child is then instructed to breathe out as hard as

Mucous possible and then to breathe in deeply. gland Capillaries Normal and alveoli behaviors ranging from wide-eyed agitation to lethargic irritabil- ity. In children who have repeated acute episodes, a barrel chest and accessory muscle use are common findings.

Normal Clinical Therapy bronchiole Diagnosis is made by history, physical examination, and pulmo- nary function testing (spirometry) that shows evidence of epi- Mucus Inflammatory Normal production sodic airflow obstruction (that is at least partially reversible) and reaction such as alveoli increases. increased airway hyperresponsiveness. Spirometry readings are most com- Mucous membranes permeability and monly measured as forced expiratory volume in 1 second (FEV1) become inflamed histamine release. and edematous. and expressed as a percentage of predicted FEV1 for the child’s height, age, gender, and race. A chest radiograph may help deter- mine if a foreign body could account for symptoms. Skin testing may be used to identify allergens (asthma triggers). Asthma may go into remission or increase in severity over time. Asthma severity is categorized by the child’s amount of impairment and risk (or the number of acute episodes needing oral systemic corticosteroid therapy). See Tables 20–6 and 20–7 for the classification of asthma severity in children of different age groups. Recommended therapy is tied to this asthma sever- Thickened Mucous glands basement hypersecrete ity classification. While asthma treatment is effective in Airway membrane. and proliferate. narrows, controlling symptoms, reducing airflow limitations, and pre-

restricting venting exacerbations, the underlying severity of asthma is not airflow. prevented (NAEPP, 2007, p. 28). Smooth muscles Restricted airflow constrict. prevents proper Clinical therapy includes medications, hydration, educa- filling of alveoli and tion, and support of parents and child. Pharmacologic treat- gas exchange. Hyperinflated ment is matched to the severity of asthma for daily control alveoli and for management of acute episodes. See Medications Used Collapsed alveoli to Treat Asthma. The goal is to maintain asthma control long term, using the least amount of medication and reducing the risk for adverse effects. A stepwise approach to medication therapy is recom- mended that matches the child’s asthma severity, adding and changing specific medications if the severity progresses During an acute episode, respirations are rapid and labored, and the child often appears tired because of the ongoing effort to breathe. Nasal flaring and intercostal retractions may be visible. Clinical Tip The child exhibits a productive cough and expiratory wheezing, a prolonged expiratory phase, decreased air movement, acces- Signs of well-controlled asthma in children under 12 years old sory muscle use, and respiratory fatigue. The child may com- ­include symptoms 2 or fewer days a week; no more than one night- plain of chest tightness. Anxiety increases as the acute episode time awakening a month; no interference with normal activity, worsens, and the increasing anxiety intensifies the child’s physi- school, or exercise; use of a short-acting beta2-agonist for symptom cal responses. control 2 or fewer days a week; greater than 80% of predicted peak In a severe acute episode, wheezing may not be heard be- flow (in children 5 years and older); and no more than 1 asthma cause of low airflow. Head bobbing may be seen in young episode a year requiring oral corticosteroids (NAEEP, 2007, pp. 309, children using the accessory muscles to breathe. Hypoxia and 310, 345). the cumulative effect of administered medications may cause

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Table 20–6 Classification of Asthma Severity for Children Birth to 4 Years of Age

Components of Severity Classification of Asthma Severity (0 to 4 Years of Age) Intermittent Persistent Mild Moderate Severe

Impairment Symptoms 2 or fewer days a Greater than 2 days a Daily Throughout the day week week, but not daily Nighttime awakenings 0 1 to 2 times a month 3 to 4 times a month Greater than 1 time a week SABA use for symptom control 2 or fewer days a Greater than 2 times Daily Several times a day (not prevention of exercise- week a week, but not daily induced bronchospasm) Interference with normal activity None Minor limitation Some limitation Extremely limited

Risk Exacerbations requiring oral 0 to 1 time a year ← 2 or more times a year → systemic corticosteroids ← consider severity and interval since last exacerbation → Frequency and severity may fluctuate over time for patients in any severity category.

Recommended step for initiating therapy (see Step 1 Step 2 Step 3 and consider short course of oral systemic Figure 20–3) corticosteroids In 2 to 6 weeks, depending on severity, evaluate level of asthma control that is achieved. If no clear benefit is observed in 4 to 6 weeks, consider adjusting therapy or alternative diagnoses

Note: SABA = short-acting beta2 agonist. Source: Adapted from National Asthma Education and Prevention Program. (2007). Expert panel report 3: Guidelines for the diagnosis and management of asthma (p. 307), Bethesda, MD: National Heart Lung and Blood Institute, National Institutes of Health. Retrieved from http://www.nhlbi.nih.gov/guidelines/asthma.

or diminishes while maintaining control (NAEPP, 2007, with a short-acting beta2-agonist immediately before exercise p. 284). The child’s response to therapy after 2 to 6 weeks guides often prevents exercise-induced asthma and provides relief for the need to further step up the medications to better control up to 3 hours (Robinson & Van Asperen, 2009). symptoms. See Figures 20–3 ●, 20–4 ●, and 20–5 ● for the na- Severe Asthma Episodes. Children with potentially life- tionally recommended stepwise approach by age group (see threatening asthma episodes need aggressive intervention in pages 546–548). Reducing or stepping down medications may the intensive care unit, such as those treated for an acute asthma be considered if the child’s asthma has been well controlled for episode in the past 24 hours. Laboratory findings indicating a at least 3 months (Williams, 2009). need for ICU admission include hypoxemia (may be masked Recommendations for children with persistent asthma in- by supplemental oxygen), a PaCO of 42 mmHg or greater, clude the use of daily inhaled corticosteroids and additional 2 , and sometimes metabolic acidosis (Gott & long-term control medications as severity increases. Children Froh, 2010). Intravenous sulfate may be added to with intermittent asthma may only need short-acting beta -­ 2 other medications used for the acute episode. (70% , agonists. If asthma control is difficult to achieve, refer the child 30% oxygen) may be used to drive the nebulizer (Robinson & to an asthma specialist. Van Asperen, 2009). Some children need mechanical ventilation Acute Asthma Episodes. Most children with acute exacerbations or CPAP. A few children progress to respiratory failure and die. respond to aggressive management in the emergency department with continuous albuterol by nebulizer, oral systemic corticosteroids, NURSING MANAGEMENT for the Child and inhaled ipratropium. Children who do not respond or who are with Asthma already being managed at home on corticosteroids have a greater chance of hospital admission. Nursing Assessment and Diagnosis Exercise-Induced Asthma. More than 75% of children and youth The nurse usually encounters the child and family in the emer- report shortness of breath, wheezing, coughing, difficulty taking gency department, health center, or nursing unit. In these set- a deep breath, noisy breathing, or chest tightness to occur during tings, acute care has become necessary, because the child’s level and after exercise (Ostrom, Eid, Craig, et al., 2011). Pretreatment of respiratory compromise cannot be managed at home.

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Table 20–7 Classification of Asthma Severity in Children 5 Years to Adulthood

Components of Severity Classification of Asthma Severity (5 to 11 Years of Age and 12 Years to Adulthood) Intermittent Persistent Mild Moderate Severe

Impairment Symptoms 2 or fewer days a week Greater than 2 days a Daily Throughout the day week, but not daily Nighttime awakenings 2 times or less per 3 to 4 times a month Greater than 1 time a Often 7 times a week month week, but not nightly SABA for symptom control (not 2 or fewer days a week Greater than 2 times Daily Several times a day prevention of exercise-induced a week, but not daily bronchospasm) Interference with normal None Minor limitation Some limitation Extremely limited activity

Lung function (5 to 11 years) ■ Normal FEV1 be- ■ FEV1 greater than ■ FEV1 equals 60% ■ FEV1 less than 60% tween exacerbations 80% predicted to 80% predicted predicted

■ FEV1 greater than ■ FEV1/FVC greater ■ FEV1/FVC equals ■ FEV1 /FVC less than 80% predicted than 80% 70% to 80% 75%

■ FEV1/FVC greater than 85%

Normal Lung function ■ Normal FEV1 ■ FEV1 greater than ■ FEV1 equals 60% ■ FEV1 less than 60% FEV1/FVC: (12 years to adulthood) between 80% predicted to 80% predicted predicted (8 to 19 exacerbations ■ FEV1/FVC normal ■ FEV1/FVC reduced ■ FEV1 /FVC reduced years) 85% ■ FEV1 greater than 5% more than 5% 80% predicted

■ FEV1/FVC normal

Risk Exacerbations requiring oral 0 to 1 time a year ← 2 or more times a year → systemic corticosteroids

← consider severity and interval since last exacerbation → Frequency and severity may fluctuate over time for patients in any severity category.

Recommended step for initiating therapy Step 1 Step 2 Step 3, medium dose Step 3, medium dose (5 to 11 years) (see Figure 20–4 ●) ICS option ICS option, or step 4

Recommended step for initiating therapy Step 1 Step 2 Step 3 Step 4 or 5 (12 years to adulthood) (see Figure 20–5 ●)

Consider short course of oral system corticosteroids

Evaluate level of asthma control achieved in 2–6 weeks and adjust therapy accordingly

Note: FEV1 = forced expiratory volume in 1 second; FVC = forced ; SABA = short-acting beta2-agonist; ICS = inhaled corticosteroids. Source: Adapted from National Asthma Education and Prevention Program. (2007). Expert panel report 3: Guidelines for the diagnosis and management of asthma (pp. 308 and 344), Bethesda, MD: National Heart Lung and Blood Institute, National Institutes of Health. Retrieved from http://www.nhlbi.nih.gov/guidelines/asthma.

Physiologic Assessment the severity of respiratory distress. Move on to other aspects of Identify the child’s current respiratory status first by assess- assessment only after finding no life-threatening respiratory ing the ABCs—airway, breathing, and circulation—to make distress. sure the child’s condition is not life threatening. If the child is Attach a pulse oximeter; a SpO2 reading of less than 92% moving air or talking, assess the quality of breathing. Observe indicates hypoxemia. Assess skin turgor, intake and output, and the child’s color, and assess the respiratory and heart rates. urine specific gravity. The child may be unable to use the spirom- Auscultate the lungs for the quality of breath sounds and for eter due to respiratory distress. Because asthma can be a symptom the presence or absence of wheezing. Note whether a cough of another illness, perform a head-to-toe assessment to identify or stridor is present. Inspect the chest for retractions to assess other associated problems. See the Assessment Guide on page 524.

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Medications Used to Treat Asthma

Quick Relief Medications, Route, and Action Nursing Management

Short-acting beta2-agonists (SABA) ■ Use before inhaled , wait 1–2 minutes between puffs, Albuterol, levalbuterol, pirbuterol wait 15 minutes to give inhaled steroid. Child should hold breath Metered-dose or nebulizer 10 seconds after inspiring. Then rinse mouth and avoid swallowing Relaxes smooth muscle in airway leading to rapid bronchodilation medication. Use a spacer. (within 5 to 10 minutes) and mucus clearing ■ Differences in potency exist, but all products are comparable on a Drug of choice for acute therapy and prevention of exercise-induced per puff basis. bronchospasm ■ Dose-related side effects include tachycardia, nervousness, nausea and vomiting, . ■ Regular use more than 2 days a week for symptom control indicates a loss of control and need for additional therapy.

Corticosteroids ■ Short-term therapy should continue until child achieves 80% peak Methylprednisolone, prednisone, prednisolone expiratory flow personal best, or until symptoms resolve. Oral ■ Give with food to reduce gastric irritation. Diminishes airway inflammation, secretions, and obstruction, ■ Give oral dose in early morning to mimic normal peak

enhances bronchodilating effect of beta2-agonists. corticosteroid blood level. Used for acute episodes not fully responsive to beta2-agonists; ■ Assess for potential adverse effects of long-term therapy, such as reduces hospitalization rates decreased growth, unstable blood sugar, immunosuppression.

Anticholinergic ■ Rinse mouth afterward to get rid of bitter taste. Ipratropium ■ Side effects include increased wheezing, cough, nervousness, dry Metered-dose inhaler or nebulizer mouth, tachycardia, dizziness, headache, palpitations. Inhibits and decreases mucus production ■ Prevent medication contact with eyes. Not for primary emergency treatment because of 30- to 90-minute time of onset. Daily Control Medications, Route, and Action Nursing Management

Long-acting beta2-agonists (LABA) ■ Do not use for acute asthma episode. Salmeterol, formoterol ■ Take pre-exercise dose 30 to 60 minutes before activity. Do not Dry powder inhaler use additional dose before exercise if already using twice daily Relaxes smooth muscle in airway. doses, which should be 12 hours apart. Used for nocturnal symptoms and prevention of exercise-induced ■ Caution against overdosage because side effects such as bronchospasm. tachycardia, tremor, irritability, insomnia will last 8 to 12 hours. For children, used in combination with corticosteroids (U.S. Food ■ Report failure to respond to usual dose because this may indicate and Drug Administration, 2010). need for stepped-up therapy.

Inhaled corticosteroids (ICS) ■ Administer with spacer or holding chamber. Beclomethasone, budesonide, flunisolide, fluticasone, mometasone, ■ Separate parts and clean inhaler daily. triamcinolone ■ Rinse mouth and gargle following treatment to remove drug from Metered-dose inhaler or nebulizer oropharynx to reduce chance of cough, thrush, and dysphonia. Anti-inflammatory, controls seasonal, allergic, and exercise-induced ■ Prevent eye exposure through proper metered-dose inhaler, asthma; effectively reduces mucosal edema in airways. nebulizer, or DPI administration. ■ Monitor for headache, gastrointestinal upset, dizziness, infection. ■ Use exactly as prescribed.

Methylxanthines ■ Do not crush or chew . Give at same time each day. Theophylline ■ Maintain therapeutic serum level of 10–20 mcg/L; requires serum Oral level checks and dose adjustment. Relaxes muscle bundles that constrict airways; dilates airway; ■ Limit caffeine intake. provides continuous airway relaxation. ■ Side effects include tachycardia, dysrhythmias, restlessness, Used for long-term control and prevention of nocturnal symptoms. tremors, seizures, insomnia, hypotension, severe headaches, vomiting, and diarrhea.

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Medications Used To Treat Asthma (continued)

Daily Control Medications, Route, and Action Nursing Management Mast cell inhibitors ■ Do not use at time of symptom development or acute episode. Cromolyn sodium, nedocromil ■ Must be used up to 4 times a day to be effective. Metered-dose inhaler or nebulizer ■ Therapeutic response seen in 2 weeks, maximum benefit may not Anti-inflammatory, inhibits early and late phase asthma response be seen for 4 to 6 weeks. to allergens and exercise-induced bronchospasm. ■ Adverse reactions include wheezing, bronchospasm, throat May be used for unavoidable allergen exposure. irritation, nasal congestion, and . Immediately report these symptoms to physician.

Leukotriene receptor antagonist (LTRA) ■ Available in granules for infants and chewable tablets for young Montelukast, zafirlukast children. Oral ■ Administer montelukast in the evening; may be given with food or Reduces inflammation cascade responsible for airway inflammation; without. improves lung function and diminishes symptoms and need for ■ Make sure child chews montelukast chewable tablet rather than quick-relief medications. swallowing whole. Granules may be mixed in applesauce or ice cream; do not mix in liquid. ■ Administer zafirlukast 1 hour before or 2 hours after meal. ■ Report fever, acute asthma episodes, flu-like symptoms, severe headaches, or lethargy. ■ Take as prescribed; do not withdraw abruptly.

Immunotherapy ■ Approved for children 12 years and older with moderate or severe Omalizumab persistent asthma. Subcutaneous ■ Injections required every 2 to 4 weeks based on serum IgE levels. A therapeutic that blocks IgE from causing reactions leading ■ Be alert for anaphylaxis; it should be administered in a health to asthma symptoms. center prepared to treat anaphylaxis.

Other ■ May be of value for child with persistent asthma having allergies Hyposensitization ( shots) that can be addressed by immune therapy. Subcutaneous Series of injections with gradual dose increase that can increase the child’s tolerance of unavoidable allergens (e.g., mold, pollen)

Source: Data from Robinson, P. D., & Van Asperen, P. (2009). Asthma in childhood. Pediatric Clinics of North America, 56, 191–226; Stewart, L. J. (2008). Pediatric asthma. Primary Care: Clinics in Office Practice, 35, 25–40; Wilson, B. A., Shannon, M. T., & Shields, K. M. (2011). Nurse’s drug guide 2011. Upper Saddle River, NJ: Pearson.

Assess Asthma Management acute episode? Are they anxious, concerned, or frustrated? Do Key questions to consider asking parents and older children or they potentially have concerns about finances, missing work, adolescents include the following (Lynch, 2011): or other family members at home? Assess whether the child thinks this episode could have been avoided if medications had ■ Which is the child currently taking? How often? been used. ■ How and when is the medication administered? Examples of nursing diagnoses for the child experiencing an ■ Have you missed taking any of your medications? How acute asthma episode include the following (NANDA-I © 2012): many times a week? ■ Airway Clearance, Ineffective related to airway compro- ■ What issues have you had related to giving the medicine mise, copious mucous secretions, and coughing (cost, time, lack of perceived need)? Do you have any con- ■ Gas Exchange, Impaired related to airway obstruction cerns about the prescribed asthma medication? ■ Fluid Volume: Deficient, Risk for related to inability to ■ What other treatments for asthma have you tried or are drink adequate fluids when in respiratory distress you using (e.g., complementary therapies)? ■ Anxiety/Fear (Child and Parents) related to difficulty ■ Show me how you use your inhaler. breathing Psychosocial Assessment ■ Therapeutic Regimen Management: Family, Ineffective Assess the child’s anxiety or fear related to the asthma episode related to lack of understanding about the need for daily or hospitalization. How are parents responding to the current management of a chronic disease

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Persistent Asthma: Daily Medication Intermittent Consult with asthma specialist if step 3 care or higher is required. Asthma Consider consultation at step 2.

Step 6 Step 5 Step up if Preferred: needed Preferred: Step 4 High-dose ICS + either (first, check High-dose ICS + LABA or Preferred: either adherence, Montelukast Step 3 LABA or inhaler Medium-dose Montelukast Preferred: Oral systemic technique, and Step 2 ICS + either LABA or corticosteroids environmental Medium-dose Preferred: Montelukast control) Step 1 ICS Low-dose ICS Assess Preferred: control Alternative: SABA PRN Step down if Cromolyn or possible Montelukast (and asthma is well controlled Patient Education and Environmental Control at Each Step at least 3 months) Quick-Relief Medication for All Patients • SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms. • With viral respiratory infection: SABA q 4-6 hours up to 24 hours (longer with physician consult). Consider short course of oral systemic corticosteroids if exacerbation is severe or patient has history of previous severe exacerbations. • Caution: Frequent use of SABA may indicate the need to step up treatment. See text for recommendations on initiating daily long-term-control therapy.

Key: Alphabetical order is used when more than one treatment option is listed within either preferred or alternative therapy. ICS, inhaled corticosteroid; LABA, inhaled long-acting beta2-agonist; SABA, inhaled short- acting beta2-agonist ● Figure 20–3 Stepwise approach to managing asthma in children 0 to 4 years of age. Source: From National Asthma Education and Prevention Program. (2007). Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (p. 305). Bethesda, MD: National Institutes of Health, National Heart Lung and Blood Institute. Retrieved January 10, 2009, from http://www.nhlbi.nih.gov/guidelines/asthma/.

Planning and Implementation Most medications are given by inhalation (Figure 20–7 ●). Pharmacologic and supportive therapies are used to reverse the (See the Clinical Skills Manual SKILLS .) The aerosol droplets airway obstruction and promote respiratory function. Nursing provide the added benefit of moisture. Continuous nebulizer interventions focus on maintaining airway patency, meeting treatments may be used for some children with severe acute fluid needs, promoting rest and stress reduction for the child episodes. See Growth and Development for considerations in and parents, supporting the family’s participation in care, and administering medications with inhalation devices. Monitor the providing the family with information to enable them to manage child for medication side effects. The frequency of vital sign as- the child’s disease. sessment is determined by the severity of symptoms. Maintain Airway Patency Meet Fluid Needs If the child is exhibiting breathing difficulty, give supplemental hu- Fluid therapy is often necessary to restore and maintain ad- midified oxygen by nasal cannula or face mask. Humidity prevents equate fluid balance. Adequate hydration is essential to thin and drying and thickening of mucous secretions. Place the child in a break up trapped mucous plugs in the narrowed airways. An in- sitting (semi-Fowler’s) or upright position to promote and ease travenous infusion may be needed if the child cannot meet fluid respiratory effort. Evaluate the effectiveness of positioning and needs by mouth, and for administering certain medications and oxygen administration by pulse oximeter and by observing for im- glucose. Monitor the child’s intake, output, and specific gravity proved respiratory status (see the Clinical Skills Manual SKILLS ). to avoid overhydration that could lead to pulmonary edema in The respiratory distress and need for supplemental oxygen severe asthma episodes. can be stressful for parents and child alike (Figure 20–6 ●). En- As respiratory difficulty diminishes, offer oral fluids slowly. couraging the parents’ presence can be reassuring for the child. The child’s fluid preferences should be determined and choices Keep the parents informed of procedures and results and get given when possible. Involve parents to help gain the child’s co- their input when developing the treatment plan. operation in taking oral fluids.

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Persistent Asthma: Daily Medication Intermittent Consult with asthma specialist if step 4 care or higher is required. Asthma Consider consultation at step 3.

Step 6 Step up if Step 5 Preferred: needed Preferred: Step 4 High-dose ICS + (first, check LABA + oral High-dose ICS + adherence, systemic Preferred: LABA Step 3 corticosteroid inhaler technique, Medium-dose Alternative: Preferred: Alternative: environmental Step 2 ICS + LABA High-dose ICS + control, and EITHER: High-dose ICS + Preferred: Alternative: either LTRA or either LTRA or comorbid Step 1 Low-dose ICS + Theophylline Medium-dose Theophylline + conditions) Low-dose ICS either LABA, Preferred: ICS + either oral systemic LTRA, or LTRA or corticosteroid Assess Alternative: Theophylline SABA PRN Theophylline control OR Cromolyn, LTRA, Medium-dose Step down if Nedocromil, or ICS Theophylline possible

Patient Education and Environmental Control at Each Step (and asthma is well controlled Quick-Relief Medication for All Patients at least 3 months) • SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of oral systemic corticosteroids may be needed. • Caution: Increasing use of SABA or use greater than 2 days a week for a symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step up treatment.

Key: Alphabetical order is used when more than one treatment option is listed within either preferred or alternative therapy. EIB, exercise-induced bronchospasm; ICS, inhaled corticosteroid; LABA, inhaled long-acting beta2-agonist; LTRA, leukotriene receptor antagonist; SABA, inhaled short-acting beta2-agonist ● Figure 20–4 Stepwise approach to managing asthma in children 5 to 11 years of age. Source: From National Asthma Education and Prevention Program. (2007). Expert panel report 3: Guidelines for the diagnosis and management of asthma (p. 306). Bethesda, MD: National Institutes of Health, National Heart Lung and Blood Institute. Retrieved from http://www.nhlbi.nih.gov/guidelines/asthma.

Clinical Tip extend the child’s hospital stay. Communicate with the family of the hospitalized child frequently about the child’s condition. Iced beverages precipitate bronchospasms in some children with Discharge Planning and Home Care Teaching asthma. Offer room-temperature or slightly cooled fluids instead. Parents need a thorough understanding of asthma—how to pre- vent asthma episodes and how to follow the asthma action plan to manage the child’s acute episodes earlier to prevent unneces- Promote Rest and Stress Reduction sary hospitalization. When possible, educate parents when they The child having an acute asthma episode is usually very tired are rested but refer the child to a healthcare provider for more when admitted to the nursing unit because of labored breathing comprehensive education. Make sure the child receives an ap- and hypoxemia. Put the child in a quiet room that is accessible pointment with an allergist or asthma specialist if moderate to for frequent monitoring to promote relaxation and rest. Group severe persistent asthma exists. Support of parents and the child tasks to avoid repeatedly disturbing the child. should focus on helping them to understand and cope with the Support Family Participation diagnosis and the need for daily management to promote near- Recognize that parents may be exhausted after spending hours normal respiratory function while the child continues to grow with their child in respiratory distress. Give parents the option of and develop normally. See Developing Cultural Competence: assisting with the child’s treatments, rather than expecting them Asthma Disparity Factors. to help, in addition to comforting the child. Provide frequent up- Discharge planning for the child with asthma focuses on in- dates about the child’s condition and encourage the parents to creasing the family’s knowledge about the disease, medication take breaks as needed. therapy, and the need for follow-up care. The required lifestyle Length of hospitalization depends on the child’s response to changes may be difficult for the child and parents. The need to therapy. Any underlying or accompanying health problem, such modify the home to remove allergens, to remove a loved pet, or as preexisting lung disease or pneumonia, can complicate and to have family members stop smoking in the home may create

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Step 6 Step up if Step 5 Preferred: needed

Preferred: High-dose Step 4 ICS + LABA + (first, check High-dose oral adherence, Preferred: ICS + LABA corticosteroid Step 3 environmental Medium-dose AND AND control, and Preferred: ICS + LABA comorbid Step 2 Consider Consider Low-dose Alternative: Omalizumab Omalizumab conditions) Preferred: ICS + LABA for patients who Step 1 for patients who OR Medium-dose have allergies have allergies Assess Low-dose ICS Medium-dose ICS + either Preferred: ICS LTRA, control Alternative: Theophylline, or SABA PRN Alternative: Zileuton Step down if Cromolyn, LTRA, Nedocromil, or Low-dose ICS + possible Theophylline either LTRA, Theophylline, or (and asthma is Zileuton well controlled at least Each step: Patient education, environmental control, and management of comorbidities. 3 months) Step 2–4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma.

Quick-Relief Medication for All Patients • SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of oral systemic corticosteroids may be needed. • Use of SABA greater than 2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step up treatment.

Key: Alphabetical order is used when more than one treatment option is listed within either preferred or alternative therapy. EIB, exercise-induced bronchospasm; ICS, inhaled corticosteroid; LABA, inhaled long-acting beta2-agonist; LTRA, leukotriene receptor antagonist; SABA, inhaled short-acting beta2-agonist ● Figure 20–5 Stepwise approach to managing asthma in children 12 years of age and older. Source: From National Asthma Education and Prevention Program. (2007). Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (p. 343). Bethesda, MD: National Institutes of Health, National Heart Lung and Blood Institute. Retrieved January 10, 2009, from http://www.nhlbi.nih.gov/guidelines/asthma/.

● Figure 20–6 An acute asthma episode requires management in the emergency department. The child is placed in a semi-Fowler position to ● Figure 20–7 Medications given by inhalation therapy reach the facilitate respiratory effort. Support both the child and parent during these bloodstream rapidly while minimizing the systemic effects. A nebulizer acute episodes. This mother looks exhausted after a sleepless night of works well for young children because it does not require coordination of caring for her son. breathing with medication inhalation. 548

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Growth and Development Asthma Inhaler Use

Metered-dose (MDIs), nebulizers, and dry powder inhalers only needs to breathe normally. The nebulizer mouthpiece should (DPIs) are devices used for inhalation therapy. These devices cause be sealed by the lips, and mouth breathing is important for drug special challenges for infants and young children because many de- delivery. If the child cannot coordinate mouth breathing, use a vices require cooperation and coordination. The appropriate technique face mask. Nebulizers take 8 to 10 minutes per treatment, and must be taught and reinforced frequently. it may be difficult for infants and young children to cooperate for ■ Children over 5 years usually have the ability to use an MDI, co- that duration. ordinating medication release and inspiration; however, they may ■ DPIs are activated when the patient takes a breath, so puffs do not prefer to use a holding chamber or spacer with a valve. Spacers need to be coordinated with inhalation. No spacer or propellant enhance the amount of drug delivered to the lungs while reducing is used. Children starting at age 5 years may be able to take the the amount of drug deposited in the mouth and throat, which can rapid, deep, and sustained breath needed to effectively use the cause local and systemic effects (Zagaria, 2010). device. Children less than 6 years of age who are wheezing may ■ Spacers have a mouthpiece or mask attachment. Select a spacer not be able to inspire at a rate fast enough to obtain the optimal with a mask for infants and young children that fits the face and amount of medication. has a flexible seal to prevent an air leak. Crying leads to prolonged ■ Steps for using DPI include the following: Remove the lid, load the and short inspiration, reducing lung deposition. Use dose (puncturing the blister or capsule), fully breathe out away from play and distraction to improve cooperation for medication deliv- the device, put the mouthpiece between the lips and teeth, and ery. Wash the plastic spacer with household detergent and air dry breathe in deeply and forcefully. Hold the breath for 10 seconds it to reduce the static charge that can attract medication particles. and remove the mouthpiece from the mouth (Asthma Initiative of ■ When a spacer is used, release a puff of medication and imme- Michigan for Healthy Lungs, 2011). To teach the child to use a DPI, diately put the mask on the face or the mouthpiece in the mouth. have the child place a paper tissue over the open mouth and inhale Have the child take 4 to 6 breaths. Move the spacer away from deeply for a count of 5 seconds. The tissue should stay against the the face or mouth and have the child hold his or her breath for mouth without being held for that time to be able to use a DPI cor- 10 seconds (Asthma Initiative of Michigan for Healthy Lungs, rectly (Amirav, 2010). 2011). Wash the child’s face after using a spacer with a mask. ■ Some MDIs or DPIs have a whistle. It may warn that the inhaled Source: Data from Zagaria, M. A. E. (2010). Inhalant agents for asthma, broncho- spasm, and COPD: Focus on delivery devices and inhalation technique. American breath is too fast or too shallow, but in other devices it indicates the Journal for Nurse Practitioners, 14(3), 21–25; Everard, M. L. (2006). Aerosol delivery breath was adequate. Be sure to inform the child and family about to children. Pediatric Annals, 35(9), 630–636; Virchow, J. C. (2005). What plays a what the whistle on the child’s inhaler indicates. Teach the child to role in the choice of inhaler device for asthma therapy? Current Medical Research use an MDI without a spacer by breathing slowly through a straw. and Opinion, 21(Suppl. 4), S19–S25; Sleath, B., Ayala, G. X., Gillette, C., Williams, D., ■ A nebulizer changes liquid medication into aerosol particles. No Davis, S., Tudor, G., . . . Washington, D. (2011). Provider demonstration and assess- ment of child device technique during pediatric asthma visits. Pediatrics, 127(4), coordination of breathing is required, making them easier for 642–648; Asthma Initiative of Michigan for Healthy Lungs. (2011). How to use a young children to use. Nebulizers are not more efficient than MDIs metered-dose inhaler the right way. Retrieved from http://www.getasthmahelp.org/ with a spacer, but the outcome may be better because the child inhalers-how-to.aspx.

stress and resistance. The nurse can facilitate discussion and clarification of ways to prevent asthma episodes. Teach the fam- Developing Cultural Competence ily how to measure and interpret readings Asthma Disparity Factors (see Families Want to Know: Using a Peak Expiratory Flow Meter). Discuss quick-relief medications to manage asthma episodes, as African American and Hispanic children have a higher prevalence rate well as control medications for daily management. Reassure the for asthma. A major factor may be lower access to high-quality am- family that most children with asthma can lead a normal life bulatory care than Caucasian children. Other factors associated with with some modifications. the high prevalence rate may include (Hill, Graham, & Divgi, 2011): Community-Based Nursing Care ■ Environmental exposures (e.g., in urban areas, Nurses provide care to children with asthma in pediatricians’ of- ­public housing with more exposure to molds and cockroaches) fices, specialty asthma clinics, schools, and summer camps. The ■ Medication beliefs associated with concerns over safety of child’s asthma control and management should be assessed at ­inhaled corticosteroids and development of tolerance with each visit. The Test for Respiratory and Asthma Control in Kids daily use (TRACK) is a validated tool that can be used to help the health- ■ Emotional stress within the home care provider obtain basic information about the child’s asthma control (Chipps, Zeiger, Murphy, et al., 2011). Identify potential factors contributing to child’s asthma to provide Review the family’s daily plan for monitoring the child’s re- ­effective education and support to the child and family. spiratory status. Encourage the school-age child or the parents of

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Families Want to Know Using a Peak Expiratory Flow Meter

A peak expiratory flow meter is a useful tool for asthma self-­ identifying early symptoms of an acute asthma episode onset management. It measures the child’s ability to push air forcefully out (increased cough, wheezing, or shortness of breath). The peak of the lungs. Changes in the peak expiratory flow rate (PEFR) signal flow meter measures the change in how hard the child can blow worsening lung function and the beginning of an asthma episode. To out air. Using the zones established by the healthcare provider, the use a peak expiratory flow meter: child and family can determine what action to take. ■ Set the device at zero or the base level. ■ Green zone: The PEFR reading is between 80% and 100% of the ■ Stand up and take as deep a breath as possible. child’s personal best. Air is moving well in the child’s lungs. In this ■ Put the mouthpiece of the meter in the mouth and firmly close the case the child has good asthma control and can continue daily lips around it. Do not cough or let your tongue block the mouth- activities. No modification of the treatment plan is needed. piece. Blow out as hard and fast as possible over 1 to 2 seconds. ■ Yellow zone: The PEFR reading is between 50% and 80% of the To help toddlers learn how to use a peak flow meter, have them child’s personal best. In this case the child is developing breath- practice by blowing into a noisemaker or party favor. ing problems. The parents should follow directions in the child’s ■ Write down the reading. asthma action plan, which usually involves quick-relief medica- ■ Repeat the process 2 times and record the highest of the 3 num- tions. The child should feel better and the PEFR should improve bers on the chart. over the next hour. If symptoms and the PEFR do not improve, ■ Measure and record the best PEFR reading twice a day for 2 weeks contact the child’s healthcare provider for additional treatment so the physician can determine the child’s personal best reading. guidance. (Make sure the child is optimally treated with medications during ■ Red zone: The PEFR is less than 50% of the child’s personal best. the day to obtain the best reading.) In this case the child has a severe asthma episode and needs ■ The physician will use the child’s personal best average readings urgent treatment with quick-relief medication. Call the child’s to set the green, yellow, and red color zones to guide treatment in healthcare provider for additional care guidelines or take the child the child’s asthma action plan. The child’s personal best changes to the emergency department. as the child grows taller, so the child’s personal best should be Source: Data from American Academy of Allergy, Asthma, and (AAAAI). measured every year. (2009). Peak flow meter. Retrieved from http://www.aaaai.org/conditions-and- ■ The physician provides guidelines for the child and family to use treatments/library/at-a-glance/peak-flow-meter.aspx; Johns Hopkins Medicine. (2012). Peak flow measurement. Retrieved from http://www.hopkinsmedicine.org/ when monitoring the peak expiratory flow rate. If the child or par- healthlibrary/test_procedures/pulmonary/peak_flow_measurement_92,P07755; ent suspects the child might have the onset of breathing difficulty, WebMD. (2012). Asthma and the peak flow meter. Retrieved from http://www the peak flow meter can be used. Some children have problems .webmd.com/asthma/guide/peak-flow-meter.

Clinical Tip when the child uses inhaled corticosteroids and episodic oral corticosteroids, which can slow growth (Williams, 2009). A 2012 study revealed that using a peak expiratory flow meter Assess the child’s activity and exercise level and any symp- provided parents with an objective measure of the child’s asthma toms experienced such as chest tightening, wheezing, or short- symptoms and empowered them to initiate treatment earlier than ness of breath. Exercise-induced bronchospasm typically occurs without the meter. Communication with the child’s healthcare pro- 5 to 10 minutes after stopping the activity and resolves 20 to vider was more effective when a peak expiratory flow meter was 30 minutes later. First, make sure the child gets some exercise used (Burkhart, Rayens, & Oakley, 2012). and then assess how frequently the child has exercise-induced symptoms. Compare that information to the classification of asthma severity in Tables 20–6 or 20–7. A step-up in medica- tion management may be needed. Make sure the child uses the younger children to keep a symptom diary that includes PEFR for daily control and quick-relief medication asthma action plan. 2 weeks prior to a health visit as well as all daytime and nighttime See Complementary Care: Exercise and Asthma. symptoms. Evaluate the child’s use of the peak expiratory flow me- ter and MDI or DPI and correct the child’s technique as needed. Assess the parent’s ability to identify the timing and type of Complementary Care Exercise and Asthma stepped-up care needed to manage worsening symptoms identi- Exercise is a frequent trigger of asthma symptoms in many patients, fied on the child’s asthma action plan. The goal is to bring asthma but routine exercise such as and swimming has benefits such episodes under control with stepped-up care before emergency as improved fitness and decreased severity of asthma symptoms care is needed. (Rance & O’Laughlen, 2011). A study with 45 children evaluated the Health Maintenance Provide routine health promotion and safety of a 9-week program of vigorous swimming and moderate- maintenance care, including immunizations. Live virus vaccines intensity golf. Benefits found were reduced childhood asthma symp- may need to be postponed if the child has used oral corticoste- toms and physician office visits (Weisgerber, 2008). roids recently. Carefully monitor the child’s growth, especially

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Families Want to Know Home Care for the Child with Asthma

Identify Current Knowledge About the Condition and Its Impact control. Keep a record of peak flow readings for 2 weeks prior on the Child: to each health visit. ■ What happens in the lungs during an asthma episode? Review Parents’ Understanding of Medication Therapy: ■ What are the child’s early warning signs of an asthma episode? ■ Provide information about medications: name, type of drug, dose, ■ What are the child’s symptoms (wake up at night, cough a lot)? method of administration, expected effect, possible side effects. How does the child respond to them? Make sure families understand that daily control medications help ■ Is the child involved in any exercise activity? If no, why not? prevent acute asthma episodes; the child will not feel them work Do asthma symptoms occur when the child is exercising? like the quick-relief medications. Discuss any concerns the family ■ Does asthma interfere with social activities or activities with has about the use of “steroid” medication and describe how they friends? differ from the anabolic abused by athletes. ■ What are the child’s personal asthma triggers? (Suggest keeping ■ Assess the child’s MDI or DPI technique and correct as needed. a log of symptoms that occur during the day and night, including ■ When a nebulizer is used to treat an infant or young child, when and where, to help identify triggers, e.g., home, school, suggest diversions to promote cooperation during the 8- to outdoors, with exercise.) 10-minute treatment. Set Up a Schedule for Parents to Learn Asthma Management: Address Associated Issues: ■ Make sure the parents and child know that asthma is a chronic ■ What are the financial considerations of medication cost and life- condition that needs daily management and environmental control style changes? to reduce or prevent acute asthma episodes. ■ Have arrangements been made for the child to use medications at ■ Review the asthma action plan for daily management, quick relief, childcare or school? and when to call the physician or to seek emergency care. ■ Does the child have a medical identification bracelet or tag? ■ Assess the child’s technique with a peak expiratory flow meter, ■ Would a self-help group or camp experience be helpful for the and correct technique as needed. Discuss when to use the child? meter and how to interpret and use the results for asthma

Child and Family Education Once the stress of an acute episode asthma episode (coughing, breathlessness, or peak expiratory has passed, take advantage of opportunities to provide more flow meter reading) and to take quick-relief medication before extensive education at each health visit. See Families Want to signs become more serious. Determine if the family uses any Know: Home Care for the Child with Asthma to guide asthma complementary care therapies for asthma management. education. Preventing Asthma Episodes Environmental control is an im- Engage the child in learning about how the lungs work and portant part of asthma management. When possible, remove pets what happens when an acute asthma episode occurs. Teach the and from the home (especially from the child’s bedroom). child how to begin steps toward self-management as appropri- Dust live in the carpets, mattresses, upholstered furniture, ate. Encourage the child to ask questions. Provide an activity or bedcovers, soft toys, and clothes. Controlling dust mites in the coloring book for the child and printed educational materials for child’s bed and bedroom is a high priority. Encase the child’s the parents. Refer parents to a local support group to gain addi- mattress and pillow in plastic covers. Bathe pets frequently to tional knowledge and confidence in asthma management. Many reduce pet dander. Initiate cockroach eradication. Smoke from hospitals have family resource centers that can assist the parents cigarettes, wood stoves, and should be eliminated. See to find helpful information on the Internet. 8 Chapter 22 for Families Want to Know: Removing Common Teach the child and family about the importance of the Allergens from the Home. daily control medication program and collaborate with the phy- sician to develop a written asthma action plan for the child and School Management Provide a physician order so the child’s family. The plan should include the daily control medications, asthma symptoms can be treated at school. The parents should quick-relief medications to take once symptoms of an asthma work with school administrators to have an individualized episode are identified, and when to call the health professional. health plan (that includes an asthma action plan) developed so Identify routines that may improve adherence to daily medica- medications can be administered, including pretreatment for tion use, such as keeping medications where they will be seen exercise. Provide a supply of medications to the school or child- at mealtime. care organization. Make sure teachers of young children can Encourage school-age children to assume more responsibil- help recognize signs of an acute asthma episode and reduce a ity for care, including avoidance of known triggers, early symp- child’s anxiety about going to the nurse for quick-relief medica- tom recognition, relaxation breathing, and the proper use of tions. Many schools are attempting to improve the environment inhaled medication. Help the child learn the early signs of an and reduce asthma triggers.

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Clinical Tip Pathophysiology Illustrated Barrel Chest All 50 states have legislation that entitles a child with asthma to A barrel chest may result from chronic respiratory conditions such carry and self-administer asthma medications at school (Allergy and as asthma or bronchopulmonary dysplasia, in which air trapping Asthma Network, 2010). Families of children old enough to recognize or hyperinflation of the alveoli occurs. The chest’s anteroposterior worsening asthma symptoms and to self-administer rescue medica- ­diameter increases to give a rounded chest shape. tions should make sure the school knows about the state law.

Evaluation Expected outcomes of nursing care include the following: ■ The child recognizes early asthma symptoms and promptly uses quick-relief medications, fluids, and relaxation breath- ing before severe respiratory distress occurs. ■ The child learns to identify and avoid asthma triggers. ■ The child and family implement the prescribed daily treat- ment plan and asthma action plan to reduce the number of asthma episodes the child has. ■ The child with a serious asthma episode responds to ­oxygen, fluids, and medication therapy, avoiding hospital admission.

Bronchopulmonary Dysplasia (Chronic Lung Disease) Bronchopulmonary dysplasia (BPD) is defined as the need for supplemental oxygen for at least 28 days after premature birth. It is one of the most serious chronic respiratory disorders in infancy. BPD more commonly develops in infants born at less than 28 weeks’ gestation with a birth weight less than 1000 g (Fakhoury, Sellers, Smith, et al., 2010). BPD is estimated to oc- Clinical Therapy cur in one third of newborns with a birth weight less than 1500 g Diagnosis is made by the neonate’s dependence on supplemental (Stroustrup & Trasande, 2010). oxygen for at least 28 days after birth, and severity is increased Etiology and Pathophysiology if CPAP or mechanical ventilation is also needed. A chest radio- graph is often obtained. BPD results from positive-pressure ventilation and oxygen treat- Medical management involves symptomatic treatment ment for respiratory failure and respiratory distress syndrome. that supports respiratory function and good nutrition, which Abnormal pulmonary development or arrested lung develop- helps to accelerate lung maturity. Supplemental oxygen with ment may be a factor; the infant has fewer and larger alveoli humidity is used. A tracheostomy may be needed for long- with less functional surface area and abnormal development of term airway management to prevent narrowing of the trachea. capillaries in the alveolar region (Gott & Froh, 2010). Inflamma- Infants with severe BPD are carefully weaned off of assisted tion following intrauterine infection or sepsis or a patent ductus ventilation. Increased calories are needed to support growth, arteriosus may also contribute to BPD development. Antenatal but fluids are restricted to prevent pulmonary edema. Some corticosteroids, replacement therapy, and gentle ven- children need gastrostomy or nasogastric tube feeding to get tilation techniques have reduced the incidence of BPD in more adequate calories. mature preterm infants (Pfister & Goldsmith, 2010). Chest physiotherapy and medications (diuretics, broncho- Clinical Manifestations dilators, anti-inflammatories, and methylxanthines) are used The infant with BPD has persistent signs of respiratory dis- (see Medications Used to Treat Bronchopulmonary Dysplasia). tress: tachypnea, nasal flaring, grunting, retractions, wheezing, Antibiotics are used to aggressively treat infections. Palivizumab crackles, and irritability. Normal activities like feeding create is given monthly to prevent RSV (see page 535). With improve- increased oxygen demands and fatigue that may lead to failure ment and adequate weight gain, the child is weaned off oxygen, to thrive. The infant has intermittent bronchospasms, mucous diuretics, and . Some infants develop recurrent plugging, and chronic air trapping, which may lead to a barrel- infections and complications, and some die due to respiratory shaped chest (see Pathophysiology Illustrated: Barrel Chest). Cya- failure. BPD is a significant risk factor for motor and cognitive nosis may be seen in severe cases. impairments (Kelly, 2010).

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Medications Used to Treat Bronchopulmonary Dysplasia

Medication and Action Nursing Management Bronchodilators ■ Monitor vital signs and for signs of toxicity.

(beta2-adrenergics, anticholinergics, theophylline, albuterol ■ Administer medications at the same time each day. ­nebulizer) ■ Encourage fluid intake. Decreases airway resistance; increases expiratory flow in small airways; stimulates mucous clearance.

Anti-inflammatories ■ Ensure parents use proper technique for inhaler and spacer. (cromolyn sodium) ■ Clean inhaler daily, rinsing and drying parts. Decreases inhibition of inflammatory mediators from mast cells.

Diuretics ■ Follow guidelines for allowable fluid intake. (furosemide, chlorothiazide, spironolactone) ■ Monitor serum potassium and sodium levels. Removes excess fluid from lungs; decreases pulmonary resistance ■ Teach families about sodium- and potassium-rich foods to eat or and increases pulmonary compliance; may cause electrolyte avoid, depending on diuretic prescribed. imbalances.

Potassium chloride ■ Monitor serum potassium level. Prevents electrolyte imbalances associated with diuretics. ■ Teach families about potassium-rich foods to avoid or use in moderation.

Methylxanthines ■ Monitor vital signs and respiratory status. (caffeine, theophylline) ■ Monitor for adverse effects such as irritability, tremor, tachycardia, Increases respiratory drive, decreases apnea, and relaxes muscle nausea, and vomiting. bundles that constrict airways.

NURSING MANAGEMENT for the Child ■ Nutrition, Imbalanced: Less Than Body Requirements with Bronchopulmonary Dysplasia related to high metabolic needs and fatigue associated with feeding Nursing management focuses on assessing and managing the in- ■ fant’s acute episodes, ensuring adequate nutrition, and promot- Caregiver Role Strain related to 24-hour responsibility for ing growth and development. infant with BPD ■ Development: Delayed, Risk for related to chronic Nursing Assessment and Diagnosis ­condition and limited opportunities to practice motor At each healthcare visit, assess the infant’s respiratory status and skills growth. The infant may have poor weight gain, because the work Planning and Implementation of breathing requires extra calories. Assess how well the family Organize care for the hospitalized child to reduce unnecessary is managing care for the child in the home and any stressors that physical stimulation. Position the infant to facilitate breathing. might exist. Evaluate development regularly because the infant Administer medications as prescribed. Careful fluid man- may have motor, language, and cognitive delays. Coordinate a agement is essential to reduce the risk for pulmonary edema. periodic assessment of hearing and vision. Infants with BPD may Provide nutrition to meet energy needs. Support the mother who become acutely ill at any time, so observe for signs of infection. desires to breastfeed. A high-calorie formula (24 to 30 calories/ During hospitalization for acute infections, a cardiorespi- oz) may be given to promote weight gain. Some children need ratory monitor and pulse oximeter are used. Assess airway and nasogastric or enteral feedings to get adequate nutrition when respiratory function, vital signs, color, and behavior changes to cyanosis is noted with feeding. identify signs of worsening respiratory symptoms, even when Once home, many infants need ventilation therapy, oxygen, oxygen is provided. Observe for airway obstruction when the in- tracheostomy care, multiple medications, fluid restrictions, and fant has a tracheostomy and suction as needed. See the Clinical high-calorie feedings (Figure 20–8 ●). Make referrals for needed Skills Manual SKILLS for tracheostomy care. oxygen, respiratory supplies, medications, an early interven- Nursing diagnoses that may be appropriate include tion program, and follow-up care well in advance of the infant’s (NANDA-I © 2012): discharge. Some families need home health nursing assistance, ■ Gas Exchange, Impaired related to ventilation-perfusion especially during the initial transition period. Teach parents to imbalance provide the complex care needed by the infant and to identify

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● Figure 20–9 Cystic fibrosis is an inherited autosomal recessive disorder of the exocrine glands, so it is not uncommon to see siblings with it such as this brother and sister.

Clinical Reasoning Infant with BPD

Emily is an 8-month-old infant with BPD cared for at home by her parents. She has a tracheostomy and receives humidification. Em- ily has periodic infections and episodes of respiratory distress that require hospitalization. When she develops a fever, more secretions ● Figure 20–8 Home care for BPD. Many children with BPD are than usual collect in the trachea. Suctioning is needed to ease Emily’s cared for at home, with the support of a home care program to monitor breathing. What signs indicate that Emily needs to be suctioned? How the family’s ability to provide airway management, oxygen, and do you select the correct size of suction catheter? How do you suc- support. This premature infant girl, who is now 4 months old but weighs only tion Emily without causing hypoxia? When is it necessary to change about 5 pounds, still requires supplemental oxygen. ­Emily’s tracheostomy tube? the signs of respiratory compromise indicating a need for rapid and adults have CF in the United States, and approximately 45% intervention. are older than age 18 years. The median life span for individuals All infants with BPD need more frequent health promo- with CF is mid-30s (Cystic Fibrosis Foundation [CFF], 2011a) tion visits and all immunizations. Electrolytes may be monitored (Figure 20–9 ●). monthly. Suggest ways to provide for the infant’s normal develop- Etiology and Pathophysiology ment through rest, nutrition, stimulation, and family support (see Health Promotion: The Child with Bronchopulmonary ­Dysplasia). A gene isolated on the long arm of chromosome 7 directs the function of the transmembrane conductance regulator (CFTR), Evaluation a protein that controls the movement of chloride and sodium Expected outcomes of nursing care may include: in and out of the cells that line respiratory, digestive, and re- ■ The infant receives adequate calories to sustain growth. productive organs. More than 1,700 mutations of the CFTR gene on chromosome 7 can cause CF (Lomas & Fowler, 2010). ■ The family identifies acute illness episodes rapidly and An estimated 1 in 31 persons in the United States is a carrier seeks appropriate care. of a defective CFTR gene, and carriers are healthy (Gott & ■ The infant’s acute respiratory decompensation episodes are Froh, 2010). effectively managed. With a defective CFTR protein, chloride-ion transport across the exocrine and epithelial cells is impaired and increased sodium absorption reduces water movement across cell mem- Cystic Fibrosis branes. Secretions become thickened in the sweat ducts, airway, Cystic fibrosis (CF) is a common inherited autosomal recessive pancreatic duct, intestine, biliary tree, and vas deferens. The disorder of the exocrine glands, leading to physiologic altera- lungs become clogged with thickened mucus that can harbor tions in the respiratory, gastrointestinal, and reproductive sys- bacteria. The lubricating layer between the airway tems. The incidence of CF varies by race—1:3200 in Caucasians, and mucus inhibits normal ciliary action and cough clearance. 1:7000 in Hispanics, 1:15,000 in African Americans, and 1:31,000 Air becomes trapped in the small airways, leading to hy- in Asian Americans (Gott & Froh, 2010; Hazle, 2010). Gender is perinflation, atelectasis, and secondary respiratory infections. not a factor in disease incidence. Approximately 30,000 children Even with antibiotics and a good response, over time the

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Health Promotion The Child with Bronchopulmonary Dysplasia

Health Supervision Nutrition ■ Assess blood pressure to detect abnormal findings associated ■ Review fluid and caloric intake. Ensure that increased calories with . are provided to support growth while limiting fluids to prevent ■ Coordinate vision screening by an ophthalmologist every 2 to pulmonary edema. Assess feeding difficulties related to oral 3 months during the first year of life. Myopia and strabismus are ­motor function associated with long-term enteral feeding. Refer common in premature infants. to a nutritionist as necessary. ■ Coordinate pulmonary function tests annually or as needed for Physical Activity clinical condition. ■ Organize care to provide rest periods during the day. ■ Perform hearing and other screening tests as recommended ■ Give parents ideas for promoting the infant’s motor development, for age. such as reaching for and moving toward toys and objects of Growth and Developmental Surveillance interest. ■ Assess growth and plot measurements on a growth chart corrected Family Interactions for gestational age. Even if length and weight are lower than nor- ■ Identify ways to coordinate nighttime care to reduce child and mal, monitor for continued growth following the growth curves. family sleep disturbances. ■ Perform a developmental assessment and record the findings ■ Provide discipline appropriate for developmental age. after correcting for gestational age. Disease Prevention Strategies ■ Reduce exposure to infections. Encourage selection of a child- care provider who cares for a small number of children, if one is used. If possible, avoid the use of childcare centers during RSV season. ■ Immunize the child with the routine schedule based on ­chronologic age. ■ Administer the 23-valent pneumococcal vaccine at 2 years of age. ■ Provide monthly injections of palivizumab throughout the RSV season. Condition-Specific Guidance ■ Develop an emergency care plan for times when the infant’s ­condition rapidly worsens.

airways develop chronic bacterial and fungal colonization and The imbalances created by excessive electrolyte loss through (a persistent abnormal dilation of the bronchi), perspiration, saliva, and mucous secretion alter metabolic func- and respiratory failure occurs. and tion. These children are at risk for hyponatremic dehydration may occur in older children. The rate of disease progression is secondary to electrolyte imbalance. variable. Clinical Manifestations Obstructions in the pancreatic ducts impede the natural One of the first signs of CF noticed by the parents is a salty taste enzyme flow that enables the body to digest fats, fat-soluble vi- to the skin. A meconium ileus may be found in the newborn. tamins, and proteins. Nutritional deficits may cause failure to Other primary symptoms are associated with thick, sticky mu- thrive. As the child ages, the may stop producing suf- cus. See Table 20–8. ficient insulin, leading to glucose intolerance and the develop- ment of cystic fibrosis–related diabetes mellitus. Clinical Therapy Failure to secrete enough chloride and fluid into intestines CF is usually diagnosed in infancy or early childhood with causes meconium ileus (a small bowel obstruction in newborns), one of four major presentations: newborn meconium ileus, affecting 15% of newborns with CF (O’Sullivan & Freedman, malabsorption or failure to thrive, chronic recurrent respira- 2009). Older children may have intermittent and recurrent epi- tory infections, or fecal impaction and intussusception (see sodes of partial small bowel obstruction that can progress to Chapter 25 8 ). total obstruction, abdominal distention, and vomiting. Chronic Newborn screening is performed (in all 50 states and the inflammation may occur in the intestines, leading to the devel- District of Columbia) on dried blood samples to detect immu- opment of Crohn’s disease. About 5% of children with CF de- noreactive trypsinogen (IRT) , which are high velop liver disease (O’Sullivan & Freedman, 2009). in newborns with CF (CFF, 2011b). If the reading is high, a

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Table 20–8 Clinical Manifestations of Cystic Fibrosis

Pathophysiology Clinical Manifestations Upper Respiratory

Clogged sinuses Nasal polyps Chronic sinusitis, frontal headaches, purulent nasal discharge, postnasal discharge Lower Respiratory

Reduced ciliary clearance; obstructed airways; air trapping Chronic moist, productive cough; wheezing; coarse crackles and ­hyperinflation; bacterial colonization Frequent infections Chronic fibrotic lung changes Shortness of breath, decreased exercise tolerance Barrel chest Clubbing of fingers and toes (Figure 20–10 ●) Pancreas

Damaged pancreatic ducts obstruct needed for digestion Poorly digested food Produced enzymes damage the pancreas, leading to inadequate insulin Vitamin A, D, E, and K deficiencies secretion Poor weight gain or failure to thrive; delayed onset of puberty CF-related diabetes mellitus Gastrointestinal

Thickened intestinal secretions and decreased gut mobility Meconium ileus at birth Obstructed bile ducts Abdominal distention Greasy, bulky stools (steatorrhea) that are frothy, foul smelling, and floating Constipation or intestinal obstruction Rectal prolapse Liver cirrhosis Reproductive

Males—absence of vas deferens, low sperm count Males—infertility Females—thick vaginal discharge and decreased cervical secretions Females—may have difficulty conceiving Sweat Glands

Excess chloride and sodium electrolyte loss in the sweat Salty sweat Salt depletion, hyponatremia

Source: Data from Kelly, M. M. (2010). Prematurity. In P. J. Allen, J. A. Vessey, & N. A. Shapiro, Primary care of the child with a chronic condition (5th ed., pp. 756–771). St. Louis, MO: Elsevier Mosby; O’Sullivan, B. P., & Freedman, S. D. (2009, May 30). Cystic fibrosis. The Lancet, 373, 1891–1904; Wiehe, M., & Arndt, K. (2010). Cystic fibrosis: A systems review. AANA Journal, 78(3), 246–251.

second IRT concentration test is performed in 2 to 3 weeks. Some states perform a DNA analysis to detect a CF chromo- some mutation on the same blood sample if the second IRT concentration is high (Rock & Sharp, 2010). The IRT and DNA analyses are considered screening tests for CF. Genetic testing is also available for adults with a positive family history, partners of individuals with CF, and couples seeking prenatal testing to identify carriers of CF gene mutations. A sweat chloride test by pilocarpine iontophoresis is con- sidered the gold standard for diagnosis of CF. A sweat chlo- ride concentration of 50 to 60 mEq/L is suspicious. A chloride concentration greater than 60 mEq/L is diagnostic with other ● Figure 20–10 Digital clubbing, enlargement of the distal phalanges, signs (meconium ileus, high IRT level, or positive family occurs in children with cystic fibrosis due to chronic fibrotic changes within history). The test is often repeated to confirm the diagnosis the lungs. (­Figure 20–11 ●).

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A spirometer is used to monitor pulmonary function in children 6 years and older. Forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) readings are taken. Sputum cultures are obtained to identify infectious organisms and antibiotic sensitivities. Clinical therapy focuses on maintaining respiratory func- tion, managing infection, promoting optimal nutrition and ex- ercise, and preventing gastrointestinal blockage (Table 20–9). Newly diagnosed children without symptomatic lung disease are aggressively treated to slow the development of chronic respi- ratory infections and reduction in pulmonary function, and to improve nutrition and support growth. Treatment is focused on controlling infection and inflam- mation, and on reducing mucus accumulation. Various devices and airway clearance techniques are used regularly to reduce the accumulation of mucus in the lungs, such as chest physiotherapy, forced expiratory technique (huffing), and high-frequency chest wall oscillation. Research has revealed no significant differences between airway clearance techniques to increase mucus trans- port out of the lungs used for short-term and long-term manage- ● Figure 20–11 This 6-month-old girl is being evaluated for cystic ment (Pryor, Tannenbaum, Scott, et al., 2010). fibrosis using the sweat chloride test. Frequent prolonged courses of antibiotics for infections may be prescribed to improve pulmonary function, exercise

Table 20–9 Clinical Therapy for Cystic Fibrosis

Clinical Therapy Rationale Respiratory Therapy

Exercise and physical fitness Promotes maintenance of lung function.

Airway clearance techniques—chest physiotherapy twice a day for all Helps secretions move to bronchi from smaller airways in association with lung segments ( or vibration with the child positioned to coughing and breathing airway clearance techniques. promote sputum drainage), oscillating chest vests, or other expiratory techniques (see page 560)

Immunizations Prevents viral and some bacterial infections.

Chest tube drainage of air leaks Resolves pneumothorax.

Thoracoscopy to sew over ruptured alveoli Repairs area of recurrent pneumothorax and prevents future episode in same location.

Lung transplantation Reverses respiratory failure. Therapy

Acid suppression therapy Gastroesophageal reflux worsens lung function; enteric coating of enzyme supplements is affected by high acid content in duodenum.

Hyperosmolar enemas, isotonic fluid lavage of the intestines (oral or Enema relieves meconium ileus in most infants; fluid lavage reduces distal by nasogastric tube) intestinal obstruction. Nutrition

Well-balanced diet with 110% to 150% of recommended daily Promotes essential nutrient balance for health, growth, weight mainte- allowance (RDA) for calories with 35% to 40% fat intake for energy nance, and increased lung capacity and survival. (Michel, Maqbool, Hanna, et al., 2009)

Pancreatic enzyme supplements Promotes digestion of fats and proteins.

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Medications Used to Treat Cystic Fibrosis

Medications and Actions Nursing Management

Beta2-adrenergic receptor agonist bronchodilators ■ Use before airway clearance procedure. Have the child hold the Aerosol breath 10 seconds after inhalation. Opens large and small airways. ■ Avoid swallowing the medicine, and rinse the mouth afterward.

Dornase alpha ■ Keep refrigerated until placed in the nebulizer. (DNAse or Pulmozyme) ■ Monitor for improvement in dyspnea and mucus clearance. Aerosol Loosens, liquefies, and thins pulmonary secretions.

Hypertonic saline (7%) ■ Use following a bronchodilator. Aerosol Hydrates the airway mucus and stimulates coughing (Montgomery & Howenstine, 2009).

Ibuprofen ■ Educate the child and parents to monitor for signs of Oral ­gastrointestinal bleeding. Slows the rate of pulmonary function decline (Cohen-Cymberknoh, ■ Ensure that the child does not take aspirin or other NSAIDs unless Shoseyov, & Kerem, 2011). approved by physician.

Antibiotics ■ Higher doses than normal and prolonged courses may be Aerosol, oral, or IV prescribed. Used to treat and suppress infections. ■ Teach the child and family to develop a schedule to give the correct dose at appropriate intervals.

Pancreatic enzyme supplements ■ Given prior to food ingestion. (Cotazym-S, Pancrease, Viokase) ■ Ensure that enzymes are taken with meals and snacks. Oral Assists in digestion of nutrients decreasing fat and bulk.

Vitamins A, D, E, and K ■ Ensure that vitamins are prescribed in non–fat-soluble form to Oral ­promote absorption. Supplements vitamins not produced. ■ Give twice a day.

Recombinant human growth hormone ■ Rotate injection sites in the abdomen and thighs. Subcutaneous ■ Monitor height growth regularly. May improve height and weight, and pulmonary function in ■ Monitor blood glucose level in children with family history of ­prepubertal children; its value in treating CF is still not clear (Phung, diabetes. Coleman, Baker, et al., 2010). tolerance, and quality of life. results and sensitiv- difficult to manage, because the child needs a large caloric intake ities help guide the selection of the specific antibiotics. Children that must be balanced by insulin dosage. with Pseudomonas aeruginosa or Burkholderia cepacia infections Approximately 120 to 150 lung transplants are performed have a poorer outcome. Medications are used to reduce sputum in individuals with CF each year in the United States, and about viscosity and to dilate the airways. Anti-inflammatory treatment 60% of cases survive for the first 5 years (Hazle, 2010; Wiehe & is sometimes prescribed. Vitamins and pancreatic enzymes Arndt, 2010). Immunosuppressive medications cause significant are also provided to improve the child’s nutritional status. See problems in individuals infected with Pseudomonas or Burk- ­Medications Used to Treat Cystic Fibrosis. holderia cepacia, making them ineligible for transplant at many Collaborative care by , nurses, respiratory thera- centers. End-stage lung disease is the cause of death in 80% of pists, and nutritionists has resulted in improved medical man- patients with CF (O’Sullivan & Freedman, 2009). agement and nutrition that prolongs the lives of children and adults with CF. However, new complications such as CF-related NURSING MANAGEMENT for the Child diabetes (often with insulin insufficiency and insulin resistance) with Cystic Fibrosis that develops in 20% of adolescents must be carefully managed along with the progression of the disease (see Chapter 30 8 ) Care of the child with previously diagnosed CF is the focus of the (Moran, Becker, Casella, et al., 2010). CF-related diabetes is following discussion.

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Nursing Assessment and Diagnosis Planning and Implementation Physiologic Assessment Nursing management involves supporting the child and family Physical assessment of the child focuses on respiratory func- initially, when the diagnosis is made, during subsequent hospi- tion. Inquire about the frequency and characteristics of the talizations, and during visits to specialty and primary healthcare child’s cough and sputum. Compare this information with the providers. The nurse’s role begins with implementing spe- child’s baseline. Changes in the cough may be more important cific medical therapies and providing nursing care to meet the than its presence or absence related to the development of a new child’s physiologic and psychosocial needs. Airway clearance infection. Auscultate the chest for breath sounds, crackles, and techniques, medications, and nutrition must be coordinated to wheezes. Note any cyanosis or clubbing of the extremities. Ob- promote optimal body function. Psychosocial support and rein- tain SpO2 and spirometry readings if changes in respiratory sta- forcement of the child’s daily care needs are important in prepa- tus are suspected. ration for home care. Determine if the child is maintaining an appropriate growth Children with CF require periodic hospitalization when a pattern by plotting the weight, height, and body mass index on severe infection occurs or for a pulmonary and nutritional as- a growth curve. Children with significantly lower percentiles for sessment. The child is often placed in a private room with stan- height and weight should be considered malnourished. Inquire dard precautions to reduce the spread of infectious organisms. about the child’s appetite and dietary intake. Ask how nutritional Children with CF are not co-roomed to reduce the risk for trans- supplements, pancreatic enzymes, and vitamins are used. Ob- mission of Pseudomonas aeruginosa and Burkholderia cepacia serve the adolescent for the appearance of secondary sex charac- between them. teristics, which are often delayed due to nutritional status. Respect the parents’ experiences as the child’s primary care Assess the child’s stooling pattern. Identify whether the provider and include them in the child’s routine care as much as child has problems with abdominal pain or bloating and whether possible. However, parents may view the hospital stay as a break these problems can be related to eating, stooling, or other ac- from the rigorous daily pulmonary routine at home and need tivities. Palpate the abdomen for liver size, fecal masses, and evi- support in taking advantage of the respite. While the family is dence of pain. often proficient at providing physical care to the child, the nurse Psychosocial Assessment should take the opportunity to review basic and new informa- The emotional stress of this chronic disease may not be read- tion about airway clearance techniques, medications, and nutri- ily apparent, particularly if the child’s symptoms are mild and tion. This is especially important as the child matures and begins not imminently life threatening. Ongoing observation of the to assume some self-care responsibilities. child’s and parents’ behavior helps direct nursing interven- Provide Respiratory Therapy tions. Parents may feel guilt as carriers of the disease. Siblings Chest physiotherapy or an alternate airway clearance technique may also show signs of difficulty in dealing with the illness, is usually performed 1 to 3 times per day to facilitate the removal particularly if not affected by the disease. Siblings with CF may of secretions from the lungs. (See the Clinical Skills Manual be affected if the child is showing signs of significant deteriora- SKILLS .) Perform this before meals because coughing may tion, being forced to acknowledge their own future course with stimulate vomiting. Aerosol treatments with a bronchodilator, the disease. as well as DNAse and hypertonic saline to help thin respira- Ask parents how the child’s illness has affected day-to-day tory secretions, may precede the airway clearance procedure. functioning, potential conflicts with family activities, and how Respiratory therapists and nurses often collaborate in teach- they have adapted to the child’s plan of care. Investigate the need ing parents and other family members the skills for these for respite care. Ask what the parents have told the child and necessary treatments. Some children use an oscillating vest siblings about the disease. What questions have the child and for 30 minutes twice a day rather than chest physiotherapy siblings asked about CF, and how have parents answered them? (Figure 20–12 ●). Has the child ever asked about his or her life expectancy? If not, Administer Medications and Meet Nutritional Needs what would parents say if asked? Antibiotics for acute exacerbation are provided by oral, inhala- Common nursing diagnoses for the child with cystic fibrosis tion, and intravenous routes. Because children with CF have an include the following (NANDA-I © 2012): increased clearance of most antibiotics, they need higher doses ■ Airway Clearance, Ineffective related to thick mucus in and long treatment courses, often for at least 14 days until the lungs child achieves the best possible lung function. Serum antibiotic drug levels may be ordered to ensure therapeutic dosing; how- ■ Nutrition, Imbalanced: Less Than Body Requirements ever, monitor renal function tests to detect problems related to related to need for increased calories to meet growth and higher antibiotic dosages. In some cases, a portacath or periph- metabolic needs erally inserted central catheter (PICC) line is placed so that IV ■ Infection, Risk for related to the presence of mucous secre- antibiotics can be given at home. tions conducive to bacterial growth Digestive problems can be eased with pancreatic enzymes ■ Role Conflict, Parental related to interruptions in fam- and dietary modification. Pancreatic enzyme supplements come ily life due to the home care regimen and child’s frequent in powder sprinkles and capsule form and are taken orally with exacerbations all meals and large snacks. The amount needed is individualized

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diagnosis of CF creates anxiety and fear in both the parents and the child. They need assistance with emotional and psychosocial issues relating to discipline, body image (stooling odor, barrel chest), frequent rehospitalization, the potentially fatal nature of the illness, the child’s feeling of being different from friends, and overall financial, social, and family concerns. Because CF is in- herited, families may have more than one child with CF. Refer families to genetic counseling and support groups. Discharge Planning and Home Care Teaching The financial burden of medications, supplies, and medical follow-up may not be recognized immediately by a family over- whelmed by the diagnosis. Initially, parents need assistance in obtaining necessary equipment. If the parents require financial assistance, refer them to social services and the Cystic Fibrosis Foundation. Home care of the child with CF is expensive and can impact the family’s finances. A Community-Based Nursing Care Nurses may encounter the child with CF in specialty clin- ics, health centers, and schools. Use the Assessment Guide on page 524 to assess the child. Observe the child’s physical appear- ance, noting overall body proportions and any changes charac- teristic of CF. Respiratory function tests are usually performed every 6 months during CF visits. Assess hearing acuity on a regu- lar basis, especially if the antibiotic tobramycin is used. A psychosocial assessment is especially important when the child is going through major developmental stages. School-age children and adolescents are often embarrassed at being viewed as different from peers. Ask how the child or adolescent feels about the need for a special diet, medications, and the daily rou- tine of respiratory management. B Review the child’s use of bronchodilators and airway clear- ance techniques. If additional short-term therapies are pre- ● Figure 20–12 Chest physiotherapy with can be achieved by clapping with a cupped hand on the chest wall over the scribed to help improve pulmonary status, educate the child and segment to be drained to create vibrations that are transmitted to the family about the techniques to use and help them identify the bronchi to dislodge secretions. A, If the obstruction is in the left posterior best time to fit the additional treatment into the daily schedule. segment, the child should be lying on the right side. Several other positions Having to do the chest physiotherapy regimen 3 or 4 times a day can be used depending on the location of the obstruction. B, A high- has a significant impact on family time. Alternate airway clear- frequency chest wall oscillation vest is another option for airway clearance ance therapy techniques, such as a vest, may be more easily ac- that the child can independently manage. cepted by the family, especially because the parent does not have to physically perform the percussion and vibration. Daily aero- based on the child’s nutritional needs and digestive response to bic exercise is recommended to promote airway clearance and these supplements. Help families identify any foods that contrib- overall health (Cohen-Cymberknoh et al., 2011). ute to a child’s gastrointestinal problems. The goal is to achieve Managing the child’s nutrition is important and takes near-normal, well-formed stools and adequate weight gain. time and energy. Refer the parents to a nutritionist to custom- Fat-soluble vitamins (A, D, E, and K) are not completely ab- ize a meal plan for the child’s caloric needs. Despite the child’s sorbed from food; therefore, they must be taken in water-soluble voracious appetite, parents may have difficulty getting the child form. Multivitamins taken twice daily usually are sufficient to with CF to eat enough calories for optimal nutrition. Parents prevent deficiency. need suggestions for preparing calorie-dense meals and snacks. Respiratory complications and a higher metabolic rate make A gastrostomy tube for nighttime feeding may be needed when additional calories essential. Some children and youth need sup- the child’s weight is 85% to 90% of ideal for height. Children with plemental nasogastric or gastrostomy feedings to gain and main- adequate nutrition have a longer life expectancy. tain weight. The diet should be well balanced, with an emphasis Children with CF lose more than normal amounts of salt on high caloric value. Fats and salt are both necessary in the diet. in their sweat, especially during hot weather, strenuous exercise, Provide Psychosocial Support and fever. During periods of exercise and increased sweating, Help the parents and child learn what they must do to maintain encourage the child to drink more fluids and increase salt in- health after discharge. Emotional support is essential, because the take. Allow the child to add extra salt to food and permit some

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Clinical Tip neck is flexed or hyperextended, the soft laryngeal cartilage may also compress and obstruct the airway. Use of cream or Half and Half added to soups, casseroles, and pud- dings; cream cheese spread on breads, muffins, and crackers; sour Smoke-Inhalation Injury cream added to casseroles; and powdered milk added to regular Exposure of the child’s face and airway to smoke or extreme heat milk, meatloaf, and custards are all ways to increase the calories leads to dramatic responses in the child’s respiratory tract. Smoke in food eaten. and heat increase the child’s risk for airway obstruction, carbon monoxide poisoning, acute respiratory distress syndrome, and late complications such as pneumonia and pulmonary (Antoon & Donovan, 2011). The child’s higher respiratory rate salty snacks (pretzels with salt, pickles, carbonated soda). Teach also increases exposure to noxious chemicals. parents to recognize early symptoms of salt depletion, including The severity of the smoke-inhalation injury is influenced by fatigue, weakness, abdominal pain, and vomiting, and to contact the type of material burned and is more severe if the child was the child’s healthcare provider if these symptoms occur. found in a closed space. Smoke, a product of the burning process Gradual assumption of responsibility for daily disease man- that is composed of gases and particles, is generated in varying agement is necessary and may be challenging if the child rebels volumes and density. The type and concentration of toxic gases, or is defiant regarding therapy. Individualize the child’s daily which are usually invisible, affect the severity of pulmonary care regimen to facilitate time for interaction with peers and damage. The duration of exposure to the smoke and toxic gases participation in school activities. Link adolescents to vocational contributes significantly to the child’s prognosis. service planning to help plan for their future. Initiate palliative Exposure to extreme heat, common in house fires, leads to care planning as the disease progresses to respiratory failure. surface injury and upper airway damage. The upper airway nor- Adolescents with CF need special assistance in coping mally removes heat from inhaled gases, sparing the lower airway with their disorder, especially because the median survival is from thermal damage. Airway edema develops rapidly over a few now more than 35 years. Help them identify normal adolescent hours and potentially leads to acute respiratory distress syndrome. changes versus those related to CF. Discuss ways to cope with Carbon monoxide (CO) is a clear, colorless, odorless gas the difference they know exists between themselves and peers. that develops as a fire consumes oxygen. The CO molecule They need to develop normal relationships and establish inti- binds more firmly to hemoglobin than does oxygen. As a result, macy with a partner. Information about potential infertility must it replaces oxygen in the circulation and rapidly produces tis- be provided along with the guidelines for safe sexual practices to sue hypoxia in the child. The brain receives inadequate oxygen, reduce the risk for sexually transmitted infections. Females with resulting in confusion and progressing to loss of consciousness. CF may be able to conceive and should be offered contraception. This is one reason fire victims have difficulty escaping. The Evaluation process can be rapidly reversed by the timely administration of Expected outcomes of nursing care include the following: 100% oxygen or hyperbaric oxygen treatment, if provided before hypoxia becomes too severe (Baum, 2008). ■ The child and family develop proficiency in providing Damage to the lower airway often results from chemical or the daily pulmonary care and reducing the incidence of toxic gas inhalation. Soot carried deeply into the lungs combines ­respiratory infections. with water to deposit acid-producing chemicals on the lung tis- ■ The child and family develop a schedule and routine for sue. These acids burn the tissue and destroy the cilia and sur- daily pulmonary care that fits into family and school factant. Tissue destruction, pulmonary edema, and disrupted activities. gas exchange are the initial insult to the lungs. Days later, the ■ The child consumes adequate calories and pancreatic damaged tissue sloughs off, obstructing the airways. The lungs enzymes to support growth and to stay within desirable become a breeding ground for microorganisms, leading to pneu- weight ranges. monia. Healing scars in the damaged alveoli that can re- ■ The child and family cope effectively with the child’s duce future lung function. disease. Clinical manifestations of inhalation injury include burns of the face and neck, singed nasal hairs, soot around the mouth or nose, and hoarseness with stridor or voice change, even when INJURIES OF THE the child initially has no respiratory distress. Edema develops RESPIRATORY SYSTEM rapidly over a few hours and may lead to airway obstruction with signs such as tachypnea, stridor, coughing, and wheezing. Airway compromise after an injury to the respiratory system can Respiratory distress develops and can lead to respiratory failure. cause death if not managed quickly and effectively. Children are If carbon monoxide poisoning is present, the child will be con- vulnerable to changes in respiratory function after injury, be- fused or unconscious and have cardiac arrhythmias. cause their airway is small and can become easily obstructed. Diagnosis is based on history of smoke exposure in a closed Airway obstruction can be caused by the tongue, small amounts area and physical signs of soot around the nose and mouth. Arte- of blood, mucus, foreign debris, and swelling in the respiratory rial blood gases and a carboxyhemoglobin level may be obtained. tract or adjacent neck tissue, leading to hypoxia. If the child’s The child with minimal when seen in the

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Observe for hemop- suctioning may be provided in an effort to keep the airway clear. tysis, dyspnea, decreased breath sounds, wheezes, crackles, and a All other injuries sustained in the fire are treated. transient temperature elevation. Agitation and lethargy can sig- Nursing Management nal increasing hypoxia. Inspect the for symmetric chest Assess the child for the development of respiratory distress. wall movement and auscultate for breath sounds in both lungs. Check vital signs frequently and monitor the SpO2. Auscultate The child may initially appear well but requires careful monitor- the lungs for crackles, wheezes, and decreased breath sounds. ing to detect signs of deterioration. Children with significant in- Assess for level of consciousness and behavior changes that juries are cared for in the ICU. Some children require ventilator could indicate increasing hypoxia. support as the pulmonary tissues heal. Provide oxygen as ordered. Position the child to promote respiratory function. If the child’s condition deteriorates, assist Pneumothorax with procedures to secure the child’s airway and prepare the A pneumothorax occurs when air enters the pleural space be- child for transfer to the ICU. Assess the family’s response to the cause of tears in the tracheobronchial tree, the , or life-threatening crisis and offer support with information about the chest wall. If blood collects in the pleural space, it is called a 8 the child’s condition (see Chapter 13 ). ­hemothorax, and if blood and air collect, it is called a pneumohe- mothorax. A pneumothorax is one of the more common thoracic Blunt Chest Trauma injuries in pediatric trauma patients. Blunt chest trauma in infants and toddlers is most often due to The three types of pneumothorax are open, closed, and motor vehicle crashes and abuse. Bicycles, scooters, skateboards, tension. An open pneumothorax results from any penetrating and skates are more commonly associated with blunt chest trauma injury that exposes the pleural space to , in school-age children. Injuries from high-energy motor vehicle thereby collapsing the lung. A sucking sound may be heard as crashes more commonly occur in adolescents. Chest injuries may the air moves through the opening on the chest wall. The child not be obvious and can be extremely difficult to evaluate. may show signs of restlessness, cyanosis, and subcutaneous em- Most children who die after sustaining severe blunt chest physema (air leakage in the tissue). trauma were hypoxic because of poor airway and ventilatory A closed pneumothorax is sometimes caused by blunt chest control. A child’s elastic, pliable chest wall and thin with no evidence of fracture (see Pathophysiology Il- muscles provide minimal protection to underlying organs. This lustrated: Pneumothorax). The chest may be compressed against elasticity of the ribs often prevents rib fractures in children less a closed glottis (such as with breath holding), causing a sudden than 12 years of age, but the energy from blunt trauma is trans- increase in pressure within the thoracic cavity. The pressure in- ferred directly to the internal organs. A pulmonary contusion or crease is transferred to the alveoli, causing them to burst. A single pneumothorax may result. burst alveolus may be able to seal itself off, but the lung collapses when many alveoli are damaged. Breath sounds are decreased or Pulmonary Contusion absent on the injured side, and the child is in respiratory distress. A pulmonary contusion is defined as bruising damage to the A thoracostomy is performed and a inserted (see the tissues of the lung that often occurs without rib fracture. The Clinical Skills Manual SKILLS ). A closed drainage system is at- lung tissue bruising causes capillaries to bleed into the alveoli. tached to remove the air and reinflate the lung by reestablishing Pulmonary edema develops in the lower airways as blood and negative pressure. fluid from damaged tissues accumulate over a couple of days. A tension pneumothorax is a life-threatening emergency Acute respiratory distress syndrome and long-term respiratory that results when the air leaks into the chest during inspiration dysfunction may result. but cannot escape during expiration. Internal pressure contin- Initially the child may appear asymptomatic. Respiratory ues to build, compressing the chest contents and collapsing the distress, along with fever, wheezing, hemoptysis, and crackles, lung. Venous return to the heart is impaired as the mediasti- often develops over several hours. Careful observation is re- num shifts and the trachea, heart, vena cava, and esophagus are quired during the first 12 hours after the injury to detect de- compressed toward the unaffected lung, leading to decreased creased perfusion related to ventilatory impairment. cardiac output. Signs of tension pneumothorax include increas- Chest radiographs or computed tomography may be diag- ing respiratory distress, decreased breath sounds, and para- nostic for a pulmonary contusion several hours after the injury. doxical breathing. Immediate care for a tension pneumothorax Therapy includes fluid restriction, supplemental oxygen, pain is a needle to allow air to escape and relieve the control, incentive spirometry, and avoiding prolonged immo- tension. A chest tube is then inserted and attached to a closed bilization. Children with severe injury to the lungs will require drainage system.

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Pathophysiology Illustrated Pneumothorax

Parietal pleura (outer lining) Air in pleural space Visceral pleura (inner lining)

Partially collapsed lung

A B

A, A pneumothorax is air in the pleural space that causes a lung to collapse. Whether the air results from an open injury or from bursting of alveoli due to a blunt injury, it is important to focus on airway management and maintain lung inflation. B, Tension pneumothorax. Note the collapsed lung on the patient’s left side and the deviation of the child’s heart and trachea (see arrow) to the right side of the chest. Source: Courtesy of Dorothy Bulas, MD, Professor of Radiology and Pediatrics, Children’s National Medical Center, Washington, DC.

Nursing Management covered with an occlusive dressing and the child’s respiratory Nursing management focuses on airway management and status is monitored for signs of respiratory distress. Complica- maintaining lung inflation. The child arrives on the nursing tions include hemothorax (if the thoracostomy and chest tube unit with a chest tube and drainage system in place. Continued are improperly placed), lung tissue injury, and scarring from close observation for respiratory distress is essential. Carefully poor tube placement (especially if the tube is placed too near monitor vital signs. When the chest tube is removed, the site is the breast in girls).

Critical Concept Review Learning Outcome 20.1: Describe unique characteristics of the pediatric respiratory system anatomy and physiology and apply that information to the care of children with respiratory conditions. 1. A child’s airway is shorter and narrower than an adult’s: 4. Newborn has inadequate smooth muscle bundles to help trap airway ■ Increased potential for obstruction. invaders: 2. Trachea is higher and bronchial branching occurs at a different angle: ■ Increased possibility of upper respiratory infection. ■ Increased risk for right mainstem aspiration and obstruction. 5. Until age 6 the child uses the diaphragm for breathing: 3. Newborns are obligatory nose breathers: ■ So observe the abdomen to count respirations. ■ They do not open mouth if nose is obstructed.

Learning Outcome 20.2: Contrast the different respiratory conditions and injuries that can cause respiratory distress in infants and children. 1. Respiratory conditions and injuries that can cause respiratory distress ■ Acute lower airway conditions—bronchiolitis, pneumonia. include: ■ Chronic lung disorders—bronchopulmonary dysplasia, asthma, ■ Acute upper airway obstructions—foreign-body aspiration, croup cystic fibrosis. syndrome, epiglottitis, bacterial tracheitis. ■ Acute lung injury—smoke inhalation, blunt chest trauma, pulmonary ■ Obstructive sleep apnea—disorder of breathing during sleep related to contusion, pneumothorax. enlarged tonsils and adenoids and neuromuscular disorders.

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Learning Outcome 20.3: Explain the visual and auditory observations made to assess a child’s respiratory effort or work of breathing. 1. The child is observed for the following signs: ■ Inspiratory or expiratory sounds (e.g., stridor, wheezing, grunting). ■ Nasal flaring. ■ Weak cry, inability to speak an entire sentence without a breath. ■ Retractions or use of accessory muscles. ■ Asynchronous chest and abdominal rise with inspiration. ■ Tachypnea.

Learning Outcome 20.4: Assess the child’s respiratory status and analyze the need for oxygen supplementation. 1. Assess the following to identify respiratory distress: ■ Cough. ■ Vital signs and color. ■ Mental status and behavior change. ■ Respiratory effort (retractions, accessory muscle use). ■ Position of comfort. ■ Breath sounds and stridor, wheezes, crackles. 2. Any child in respiratory distress needs oxygen.

Learning Outcome 20.5: Distinguish between conditions of the lower respiratory tract that cause illness in children. 1. Bronchitis: dry hacking cough, increases in severity at night, painful 3. Pneumonia: initial rhinitis and cough, followed by fever, crackles, wheezes, chest and ribs. dyspnea, tachypnea, restlessness, diminished breath sounds. 2. Bronchiolitis: mild respiratory symptoms that progress to tachypnea, 4. Active pulmonary tuberculosis: persistent cough, decreased appetite, wheezing, retractions, nasal flaring, irritability, poor fluid intake, hypoxia, weight loss or failure to gain weight, low-grade fever, night sweats, chills, cyanosis, and decreased mental status. enlarged lymph nodes.

Learning Outcome 20.6: Create a nursing care plan for a child with a common acute respiratory condition. 1. Maintain airway patency. 5. Provide oxygen if ordered.

2. Frequently assess vital signs, SpO2, respiratory effort, color, breath 6. Promote rest and stress reduction for the child and parents. sounds, and observe for behavior changes. 7. Support the family’s participation in care. 3. Allow child to assume position of comfort. 8. Give the family members information that lets them learn to manage the 4. Meet fluid needs. child’s disease.

Learning Outcome 20.7: Develop a school-based nursing care plan for the child with asthma. 1. Develop an individual health plan. Include quick-relief medications, 3. Monitor child after giving quick-relief medications for response. Call exercise, and avoidance of known asthma triggers. parents if little or no response. 2. Maintain a log of PEFRs and quick-relief medication administration. Give 4. Assess for signs of exercise-induced bronchospasm and report. the family a copy for the child’s healthcare provider. 5. Coordinate an education and support group for children with asthma.

Learning Outcome 20.8: Perform a nursing assessment of the child with an acute lung injury. 1. Collect historical information and mechanism of injury that has damaged 4. Inspect the face for signs of burns or soot in case of smoke inhalation, the lungs. or the chest for signs of bruising that could indicate a blunt injury that 2. Monitor the child’s responsiveness and behavior to detect hypoxia and damaged underlying tissues. the potential for airway obstruction. 5. Auscultate the lungs for crackles, wheezes, decreased breath sounds.

3. Monitor vital signs and SpO2 frequently to identify changes indicating 6. Note changes in voice quality or coughing. deterioration in condition. 7. Monitor the child’s perfusion.

Clinical Reasoning in Action Adam and his mother have come to the flow meter, the guidelines, and what type of action to take as needed. Based health center to follow up on his hospi- on his height of 48 inches, his peak flow meter green zone is 160–128, his talization to get an asthma action plan yellow zone is 128–80, and his red zone is 80 or below. Adam is to use his daily and to discuss how to reduce his asthma control medications twice a day. If he has symptoms, he is to take his albuterol episodes. Adam, who is 7 years old, MDI with spacer, two puffs every 4 to 6 hours as needed. has a history of episodic wheezing and 1. What are some of the side effects associated with Adam’s albuterol MDI? nebulizer treatments, but he had never 2. What is the benefit to using a spacer on Adam’s albuterol and inhaled been hospitalized for asthma until last corticosteroid MDI? week. During his 2-day hospitalization, 3. Address the concerns of Adam’s mother about the daily use of inhaled his parents were given initial education about how to manage his moderate corticosteroids. persistent asthma. 4. What are the signs of respiratory distress to observe for with Adam? His mother has brought along Adam’s medications (inhaled corticosteroid 5. Construct a concept map for Adam that addresses nursing management and salmeterol MDI for daily control, and an albuterol MDI for quick relief), in the school setting and developmentally appropriate education for Adam his peak flow meter, spacer, and his asthma action plan. She tells you that about asthma, recognizing early signs of an acute episode, and initial he is also completing a dose of oral corticosteroids. You discuss the peak steps of self-management.

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