Review – Respiratory Disorders

HESI-Comprehensive-Review-for-the-NCLEX-RN
Respiratory Disorders

Important Signs in Children

1. Normal pulse and respiratory rates (Table 5-3)
2. Signs of respiratory distress in children
   1. Cardinal signs of respiratory distress
      1. Restlessness
      2. Increased respiratory rate
      3. Increased pulse rate
      4. Diaphoresis
   2. Other signs of respiratory distress
      1. Flaring nostrils
      2. Retractions
      3. Grunting
      4. Adventitious breath sounds (or absent breath sounds)
      5. Use of accessory muscles, head bobbing
      6. Alterations in blood gases: decreased Po2, elevated Pco2
      7. Cyanosis and pallor
3. Nursing implications
4. A pediatric client often goes into respiratory failure before cardiac failure.
5. The nurse should know the signs of respiratory distress.

Asthma

Description: Inflammatory reactive airway disease that is commonly chronic

1. The airways become edematous.
2. The airways become congested with mucus.
3. The smooth muscles of the bronchi and bronchioles constrict.
4. Air trapping occurs in the alveoli.

Nursing Assessment

1. History of asthma in the family
2. History of allergies
3. Home environment containing pets or other allergens
4. Tight cough (nonproductive cough)
5. Breath sounds: coarse expiratory wheezing, rales, crackles
6. Chest diameter enlarges (late sign and symptom)
7. Increased number of school days missed during past 6 months
8. Signs of respiratory distress (see Important Signs in Children, p. 185)

Analysis (Nursing Diagnoses)

1. Impaired gas exchange related to . . .
2. Ineffective breathing pattern related to . . .

Nursing Plans and Interventions

1. Monitor carefully for increasing respiratory distress.
2. Administer rapid-acting bronchodilators and steroids for acute attacks.
3. Maintain hydration (oral fluids or IV).
4. Monitor blood gas values for signs of respiratory acidosis (see Advanced Clinical Concepts, Fluid, and Electrolyte Balance, p. 34).
5. Administer oxygen or nebulizer therapy as prescribed.
6. Monitor pulse oximetry as prescribed (usually >95% is normal).
7. Monitor beta-adrenergic agonists, as well as antiinflammatory corticosteroids, which are commonly used medications (Table 5-4; and see Table 4-4).
8. Teach home care program, including
   1. Identifying precipitating factors
   2. Reducing allergens in the  home
   3. Using metered-dose inhaler
   4. Monitoring peak expiratory flow rate at home
   5. Doing breathing exercises
   6. Monitoring drug actions, dosages, and side effects
   7. Managing acute episode and when to seek emergency care
9. Refer child and family for emotional and psychological counseling.

Cystic Fibrosis

Description: Autosomal-recessive disease that causes dysfunction of the exocrine glands

1. Tenacious mucus production obstructs vital structures.
2. Multiple problems result from the exocrine dysfunction
   1. Lung insufficiency (most critical problem)
   2. Pancreatic insufficiency
   3. Increased loss of sodium and chloride in sweat

Nursing Assessment

1. Usually found in a white infant or child
2. Meconium ileus at birth (10% to 20% of cases)
4. Recurrent respiratory infection
5. Pulmonary congestion
6. Steatorrhea (excessive fat, greasy stools)
7. Foul-smelling bulky stools
8. Delayed growth and poor weight gain
9. Skin that tastes salty when kissed (caused by excessive secretions from sweat glands)
10. Later: cyanosis, nail-bed clubbing, congestive heart failure (CHF)

Analysis (Nursing Diagnoses)

1. Ineffective airway clearance related to . . .
2. Imbalanced nutrition: less than body requirements related to . . .

Nursing Plans and Interventions

1. Monitor respiratory status.
2. Assess for signs of respiratory infection.
3. Administer IV antibiotics as prescribed; manage vascular access.
4. Administer pancreatic enzymes (Cotazym-S, Pancrease: for infants, with applesauce, rice, or cereal; for an older child, with food).
5. Administer fat-soluble vitamins (A, D, E, K) in watersoluble form.
6. Administer oxygen (Box 5-1) and nebulizer treatments (recombinant human deoxyribonuclease [DNase] or dornase alfa [Pulmozyme]) as prescribed.
7. Evaluate effectiveness of respiratory treatments.
8. Teach family percussion and postural-drainage techniques.
9. Teach dietary recommendations: high in  calories, high in protein, moderate to high in fat (more calories per volume), and moderate to low in carbohydrates (to avoid an increase in CO₂ drive).
10. Provide age-appropriate activities.
11. Refer family for genetic  counseling.

Epiglottitis

Description: Severe life-threatening infection of the epiglottis

1. Epiglottitis progresses rapidly, causing acute airway obstruction.
2. The organism usually responsible for epiglottitis is Haemophilus influenzae (H. influenzae, primarily type B).

Nursing Assessment

1. Sudden onset
2. Restlessness
3. High fever
4. Sore throat, dysphagia
5. Drooling
6. Muffled voice
7. Child assuming upright sitting position with chin out and tongue protruding (“tripod position”)

Analysis (Nursing Diagnoses)

1. Ineffective breathing pattern related to . . .
2. Anxiety related to . . .

Nursing Plans and Interventions

1. Encourage prevention with Hib vaccine (see Fig. 5-2).
2. Maintain child in upright sitting position.
3. Prepare for intubation or tracheostomy.
4. Administer IV antibiotics as  prescribed.
5. Prepare for hospitalization in intensive care unit (ICU).
6. Restrain as needed to prevent extubation.
7. Employ measures to decrease agitation and crying.

Bronchiolitis

Description: Viral infection of the bronchioles that is characterized by thick secretions

1. Bronchiolitis is usually caused by respiratory syncytial virus (RSV) and is found to be readily transmitted by close contact with hospital personnel, families, and other children.
2. Bronchiolitis occurs primarily in young infants.

Nursing Assessment

1. History of upper respiratory symptoms
2. Irritable, distressed infant
3. Paroxysmal coughing
4. Poor eating
5. Nasal congestion
6. Nasal flaring
7. Prolonged expiratory phase of respiration
8. Wheezing, rales can be auscultated
9. Deteriorating condition that is often indicated by shallow, rapid respirations

Analysis (Nursing Diagnoses)

1. Impaired gas exchange related to . . .
2. Ineffective airway clearance related to . . .

Nursing Plans and Interventions

1. Isolate child (isolation of choice for RSV is contact isolation).
2. Assign nurses to clients with RSV who have no responsibility for any other children (to prevent transmission of the virus).
3. Monitor respiratory status; observe for hypoxia.
4. Clear airway of secretions using a bulb syringe for suctioning.
5. Provide care in mist tent; administer oxygen as prescribed.
6. Maintain hydration (oral and IV fluids).
7. Evaluate response to respiratory therapy treatments.
8. Administer palivizumab (Synagis) to provide passive immunity against RSV in high-risk children (younger than 2 years of age with a history of prematurity, lung disease, or congenital heart disease).

HESI Hint • In planning and providing nursing care, a patent airway is always the priority of care, regardless of age!

Otitis Media

Description: Inflammatory disorder of the middle ear

1. Otitis media may be suppurative or serous.
2. Anatomic structure of the ear predisposes young child to ear infections.
3. There is a risk for conductive hearing loss if untreated or incompletely treated.

Nursing Assessment

1. Fever, pain; infant may pull at ear
2. Enlarged lymph nodes
3. Discharge from ear (if drum is ruptured)
4. Upper respiratory symptoms
5. Vomiting, diarrhea

Analysis (Nursing Diagnoses)

1. Risk for infection related to . . .
2. Acute pain related to . . .

Nursing Plans and Interventions

1. Administer antibiotics if prescribed.
2. Reduce body temperature (can be very high, with risk for seizures).
   1. Tepid baths
   2. Acetaminophen (Tylenol) if prescribed
3. Position child on affected side.
4. Provide comfort measure: warm compress on affected ear.
5. Teach home care.
   1. Teach to finish all prescribed antibiotics.
   2. Encourage follow-up visit.
   3. Monitor for hearing loss.
   4. Teach preventive care (smoking and bottle feeding when child is in supine position are predisposing factors).

Tonsillitis

Description: Inflammation of the tonsils

1. Tonsillitis may be viral or bacterial.
2. Tonsillitis may be related to infection by a Streptococcus species.
3. If related to strep, treatment is very important because of the risk for developing acute glomerulonephritis or rheumatic heart disease.

Nursing Assessment

1. Sore throat and may have difficulty swallowing
2. Fever
3. Enlarged tonsils (may have purulent discharge on tonsils)
4. Breathing may be obstructed (tonsils touching, called “kissing tonsils”)
5. Throat culture to determine viral or bacterial cause

Analysis (Nursing Diagnoses)

1. Impaired swallowing related to . . .
2. Risk for injury related to . . .

Nursing Plans and Interventions

1. Collect throat culture if prescribed.
2. Instruct parents in home care.
   1. Encourage warm saline gargles.
   2. Provide ice chips.
   3. Administer antibiotics if prescribed.
   4. Manage fever with acetaminophen.
3. Provide surgical care if indicated.
   1. Provide preoperative teaching and assessment.
   2. Monitor for signs of postoperative bleeding.
      1. Frequent swallowing
      2. Vomiting fresh blood
      3. Clearing throat
   3. Encourage soft foods and oral fluids (avoid red fluids, which mimic signs of bleeding); do not use straws.
   4. Provide comfort measures: ice collar helps with pain and with vasoconstriction.
   5. Teach that the highest risk for hemorrhage is during the first 24 hours and 5 to 10 days after surgery.

Review of Respiratory Disorders Describe the purpose of bronchodilators. What are the physical assessment findings for a child with asthma? What nutritional support should be provided for a child with cystic fibrosis? Why is genetic counseling important for the family of a child with cystic fibrosis? List seven signs of respiratory distress in a pediatric client. Describe the care of a child in a mist tent. What position does a child with epiglottitis assume? Why are IV fluids important for a child with an increased respiratory rate? Children with chronic otitis media are at risk for developing what problem? What is the most common postoperative complication following a tonsillectomy? Describe the signs and symptoms of this complication.

Answers to Review To reverse bronchospasm Expiratory wheezing, rales, tight cough, and signs of altered blood gases Pancreatic enzyme replacement, fat-soluble vitamins, and a moderate- to low-carbohydrate, high-protein, moderate- to high- fat diet Because the disease is autosomal recessive in its genetic pattern Restlessness, tachycardia, tachypnea, diaphoresis, flaring nostrils, retractions, and grunting Monitor child’s temperature, keep tent edges tucked in, keep clothing dry, assess respiratory status, look at child inside tent. Upright sitting, with chin out and tongue protruding (“tripod position”) The child is at risk for dehydration and acid-base imbalance. Hearing loss Hemorrhage; frequent swallowing, vomiting fresh blood, and clearing throat