Nursing Care of the Child with a Respiratory Illness

Chronic illnesses

Asthma
Chronic inflammatory disorder of the lungs
Cause is multiple
Subject to acute flare-ups Genetic predisposition Environmental exposures Viral infections

 Even when asymptomatic bronchial biopsies show

Thickening of bronchial basement membrane Eosinophilic infiltration

Airway hyper-responsiveness Airway obstruction

Asthma and allergy

Allergy influences the persistence and the severity of the disease
Causes immediate reaction Or precipitates a late reaction

Classification of Asthma
Stepwise approach to managing asthma Based on
Frequency of symptoms Frequency/severity of exacerbations Lung function

P. 881-882 in text

Patho
Inflammation leads to airway hyperresponsiveness which results in physiologic manifestations

Respiratory Tree

Triggers
Stimulus which initiates the asthmatic episode

More patho
Antigen deposited on respiratory mucosa Lysozymes digest outer coating Foreign protein is released Immune sequence initiated IgE Release of chemical mediators Increased permeability of blood vessels

Contraction of smooth muscle Stimulation of mucus secretions Mucosal edema Airway remodeling leads to decreased lung function

Clinical manifestations of asthma

Cough, SOB Increased WOB Chest tightness

 Prolonged expiratory phase with wheezing, restlessness, anxiety Tripod position Speaks in short, panting phrases Secretions increase and cough becomes rattling

Clinical management of asthma

Meds p. 886
Rescue vs. controller oxygen systemic steroids

 Drug therapy
SABA quick relief ICS Long-term control must be used with ICS
Anti-inflammatory
Cromolyn, ICS, leukotriene modifiers

LABA associated with increased death in adults so Salmeterol (serevent) and Formoterol are no longer approved in children (Only approved for COPD). Advair & Symbicort are still OK

 Hydration
IV fluids ?NPO

Plan

Nursing Care of child with asthma

Close observation CAM/POX monitor O2 I&O
Why is this important?

 side effects of meds

Steroids bronchodilators

teaching

Xolair
Monoclonal antibody (Omalizumab) Reserved for refractory asthma, must be over 12 years old. Lowers free IgE so only helpful if allergy is the trigger.(Check Serum IgE first). Expensive; risk of anaphylaxis (given subcu)

Murine monoclonal AB

Home management
Peak flow meter or symptom monitoring
Determine need for intervention Confirms effectiveness of tx

Allergen control

GREEN
80-100% of best Signals all is clear. Asthma is under good control No symptoms are present and routine treatment plan for maintaining control can be followed

Yellow
50-79% of best Signals caution Asthma is not well controlled. An acute exacerbation may be present. Maintenance therapy may need to be increased. Call physician if the child stays in this zone Red

Red
Below 50% of best Signals medical alert. Severe airway narrowing may be occurring. A short-acting bronchodilator should be administered. Notify physician if level does not return immediately and stay in the yellow or green zone.

How do we know when asthma is in control?

Nursing Diagnoses
Ineffective airway clearance related to bronchoconstriction and edema AEB cough or wheeze. Impaired gas exchange related to airway obstruction and CO2 retention. Risk for Deficient Fluid Volume related to difficulty in drinking.

 Anxiety/Fear (child and parental) r/t difficulty breathing and change in health status. Ineffective therapeutic regimen management (family) r/t lack of understanding about and need for daily mgt of a chronic disease.

Hygiene Hypothesis
There is a school of thought that in the USA we fail to challenge the newborns immune system with normal bacteria (Obsession with sterilizing, etc). Third world countries have almost no asthma Farm and rural environments have minimal asthma

 Exposure to farm animals (even dogs) to a newborn seem to lessen the chance of asthma Soare we too clean?

Cystic Fibrosis
Chronic, genetic disorder affecting the exocrine glands Autosomal recessive Located on chromosome 7 Sodium transport problems Median survival 38.6 years (4/2006)
Thick, sticky mucous

Genetics 1 in 29 caucasians
carry the gene (in USA)

Diagnosis of CF
Positive sweat test with
+ family history /or Clinical signs Not reliable in children < 3 weeks

DNA
Genetic carrier Prenatally siblings

Clinical manifestations of CF
Meconium ileus (7-10%), late meconium passage. Growth failure Frothy, foul-smelling stools (steatorrhea) Salty taste Recurrent respiratory symptoms

Later manifestations of CF
Clubbing barrel-shaped chest portal hypertension frequent respiratory infections cough

 esophageal varicies pancreatic fibrosis DM Distal intestinal obstruction syndrome

Management of CF
Facilitate airway clearance and gas exchange Prevent/treat infection
Antibiotics
Prophylactic Treatment Inhaled TOBI

nebs Exercise/CPT

 Provide optimum nutrition

Enzymes Salt Increased calories

Emotional support lung transplant gene therapy

Meds for CF
Nebs
Bronchodilators Pulmozyme (dornase alfa) Hypertonic saline, TOBI

Enzymes (Ultrase, pancrease) vitamins Antibiotics

Nursing Care
Supportive and encouraging
Meds Nutrition
High cal/high protein Supplemental feedings

Diabetes management Coordinate with RT Education isolation

Bronchopulmonary dysplasia
Chronic lung disease (CLD) Primarily ELBW and VLBW

Patho of BPD
Immature lung is injured and develops chronic inflammation
Mechanical ventilation Prenatal/postnatal infection Oxygen therapy Increased pulmonary blood flow

Results in hypercarbia and hypoxemia

Prevention of BPD
Surfactant Prenatal steroids Lowest possible pressures Lowest possible O2 concentration Bubble CPAP

Signs and symptoms of BPD

Sx of resp distress
What are they?

Intermittent bronchospasms and mucous plugging Barrel shaped chest FTT O2 dependence; chronic CO2 retention

Management of BPD
Maintain oxygenation Control interstitial fluid Adequate nutrition Avoid infection

Nursing care for BPD

Oxygenation
O2 Pulse ox Normothermia Adequate rest

Strict I & O diuretics

 Nutrition
Ensure adequate calories Oral-motor stimulation

Avoid infection (RSV, flu) Education Support

Nursing Diagnoses
Alteration in respiratory function Alteration in nutrition Anxiety Fluid volume deficit Activity intolerance Knowledge deficit Alteration in thermoregulation

Alteration in respiratory function

HOB up Monitor sats, oxygen if needed Suction Fluids Promote rest Meds
Side effects Teaching

Alteration in Nutrition
Calculate calorie needs Provide adequate calories Accurate I and O Daily weight Measure to encourage intake

MEDS (think COPD)

Albuterol or Xopenex nebs (often with ipratropium/atrovent, etc) Inhaled steroids (azmacort) Diuretics (if so, may need KCL also) Antibiotics prn (or prophylaxis) Vitamin A (plays a role in lung function) Synagis

 Fourteen year old John is admitted with LRI and CF. This is his 20th admission. What abnormal physical assessment findings would you expect to see? What orders would you expect? What are developmental issues at this age? How would you adapt your nursing interventions to an adolescent

 A child with CF is receiving Tobramycin 75 mg IV q 8 h. Safe dose is 2.5-3.3 mg/kg/dose Patient weighs 50 lb Is this a safe dose?

A baby with CF weighs 20 lb 3 oz Calorie needs are 120 cal/kg/day How many ounces of 27 cal formula would the child need per day?

 A 6 year old child is being admitted from the MDs office with asthma. When he gets to the floor, what will you do first? VS weight O2 sat oxygen start IV neb treatment

 His vital signs are:

HR 124 RR 28 T 39 C

What do you think about these? What do you think his breath sounds are like? How is he acting? What other systems do you want to assess closely?

 Which statement indicates that parents have understood teaching about prevention of asthma attacks?

We will replace the carpet in our childs bedroom with tile Were glad the dog can still sleep in our childs room Well be sure to use the fireplace to keep the house warm. Well keep the plants in our childs room dusted