ball ch25 lecture

CHILD HEALTH NURSINGCHILD HEALTH NURSINGPartnering with Children and FamiliesPartnering with Children and Families

CHAPTER

THIRD EDITION

Copyright © 2014, © 2010, © 2006 by Pearson Education, Inc.All Rights Reserved

Alterations in Respiratory Function

25

Child Health Nursing: Partnering with Familes and Children, Third EditionJane W. Ball | Ruth C. Bindler | Kay J. Cowen

LEARNING OUTCOME 1Describe unique characteristics of the pediatric respiratory

system's anatomy and physiology and apply that information to the care of children with respiratory conditions.


Pediatric vs. Adult Respiratory System Anatomy and Physiology• Anatomy of airway• Comparison of airway structures


Figure 25-1 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? The infant and child are more vulnerable to the consequences of an upper respiratory tract infection, enlarged tonsils and adenoids, an allergic reaction, positioning of the head and neck during sleep, and small objects that can be aspirated. All can cause an airway obstruction that results in respiratory distress.


Pediatric vs. Adult Respiratory System Anatomy and Physiology• Upper airway differences

– Airway diameter


Figure 25-3 The diameter of an infant's airway is approximately 4 mm, in contrast to an adult's airway diameter of 20 mm. An inflammatory process in the airway causes swelling that narrows the airway, and airwayresistance increases. Note that swelling of 1 mm reduces the infant's airway diameter to 2 mm, but the adult'sairway diameter is only narrowed to 18 mm. Air must move more quickly in the infant's narrowed airway toget the same amount of air to the lungs. The friction of the quickly moving air against the side of the airwayincreases airway resistance. The infant must use more effort to breathe and breathe faster to get adequateoxygen.



– Position of trachea


Figure 25-2 In children, the trachea is shorter and the angle of the right bronchus at bifurcation is moreacute than in the adult. Where is an aspirated foreign body likely to land? When you are resuscitating or suctioning, you must allow for the differences in the length of the trachea because it is easier to slip into the rightbronchus with an endotracheal tube or suction catheter.



– Position of right mainstem bronchus– Airway resistance


Pediatric vs. Adult Respiratory System Anatomy and Physiology• Lower airway differences

– Growth of alveoli• Diaphragm use for respirations

– Use of accessory muscles• Immaturity of respiratory system


LEARNING OUTCOME 2

Contrast respiratory conditions and injuries that can cause respiratory distress in infants

and children.


Respiratory Conditions and Injuries

• Airway obstruction• Blockage of airway passages by

different causes– Foreign-body aspiration


Figure 25-5 An aspirated screw is clearly visible in the child's left mainstem bronchus on this chest radiograph.Source: Courtesy of Evelyn Anthony, MD, Department of Radiology, Brenner Children's Hospital, Wake Forest University Health Sciences.



• Acute respiratory distress syndrome (ARDS)


FIGURE 25–7 A ventilation-perfusion mismatch can occur when an infant or child has an abnormal distribution of ventilation or perfusion. A, Children with normal lung function and circulation have a ventilation-perfusion ratio of 0.8 to 0.9 because perfusion is greater than ventilation (air exchange) in the lung bases. B, When ventilation is inadequate to well-perfused areas of the lungs, the ventilation-perfusion ratio is low or mismatched, resulting in shunting. Blood passing through the pulmonary capillaries gets less oxygen exchange than normal, and hypoxemia occurs. This is the case in asthma due to bronchoconstriction and in pneumonia because alveoli are filled with fluid. C, In the case of neonatal acute respiratory distress syndrome, ventilation does not occur because the alveoli are collapsed, so blood passes through the alveolar capillaries and no oxygenation occurs. The ventilation-perfusion ratio is very low with significant shunting that does not respond to oxygen therapy because the capillary bed never gets exposed to the supplemental oxygen (Brashers, 2010a).



• Multiple factors may cause ARDS– Sepsis– Pneumonia– Meconium aspiration– Gastric content aspiration– Smoke inhalation– Near drowning


Apnea in Infants and Children

• Cessation of respirations for longer than 20 seconds

• Obstructive apnea• Central apnea• Mixed apnea• Apnea of prematurity• Apparent life-threatening events


Apnea Monitors

• Polysomnography


Sudden Infant Death Syndrome

• The sudden death during sleep of an infant under 1 year of age that remains unexplained after a thorough investigation

• Most SIDS deaths occur in infants between 2 and 4 months of age.


Sudden Infant Death Syndrome

• Parent education related to prevention– Back to Sleep– Avoid loose bedding, toys, pillows– Discourage co-sleeping– Use of pacifier during sleep– Smoking increases risk


LEARNING OUTCOME 3

Distinguish between mild, moderate, and severe respiratory distress, and plan the appropriate nursing

care for each level of respiratory distress severity.


Table 25-1 Assessment Guidelines for the Child with a Respiratory Condition*


Clinical Manifestations of Respiratory Distress

• Dyspnea• Tachypnea• Grunting• Nasal flaring• Retractions


Figure 25-4 The chest wall is flexible in infants and young children because the chest muscles are immatureand the ribs are cartilaginous. With respiratory distress, the negative pressure created by the downwardmovement of the diaphragm to draw in air is increased, and the chest wall is pulled inward causing retractions. Intercostal retractions are seen in mild respiratory distress. As the severity of respiratory distress increases, retractions can be seen in the substernal and subcostal areas. In cases of severe distress, accessory muscles (sternocleidomastoid and trapezius muscles) are used, and retractions are seen in the supraclavicularand suprasternal areas.


Assessment of Respiratory Status

• Quality of pulse• Quality of respirations• Color• Cough• Behavior changes• Signs of dehydration


Clinical Manifestations Respiratory Failure and Imminent Respiratory Arrest


Nursing Care

• ABC—airway, breathing, circulation• Determine if cause can be alleviated

– Foreign body• Supportive care

– Supplemental oxygen


Pulmonary Function for Chronic Conditions

• Force vital capacity (FVC)• Peak expiratory flow rate (PEFR)


Partnering with Families: Using a Peak Expiratory Flow Meter


Pulmonary Function for Chronic Conditions

• Forced expiratory volume in 1 second (FEVI)


LEARNING OUTCOME 4

Assess the child's respiratory status and analyze the need for oxygen

supplementation.


Diagnostic Tests to Determine Oxygen Saturation

• Pulse oximetry• Arterial blood gases


Box 25-1 Guidelines for Increasing the Accuracy of Pulse Oximetry Readings


Supplemental Oxygen

• Indicated when SPO2 level < 92%• Monitor with pulse oximetry and blood

gases• Humidified oxygen may be needed


LEARNING OUTCOME 5

Differentiate between the signs and symptoms of a child with an upper airway and lower airway respiratory condition.


Upper Airway Disorders

• Croup syndromes• Laryngotracheobronchitis• Epiglottitis• Bacterial tracheitis


Upper Airway Disorders

• Characterized by inflammation and swelling of pharynx, surrounding tissues

• Clinical manifestations vary according to severity


Table 25-4 Summary of Acute Infectious Upper Airway Obstructive Disorders


Lower Airway Disorders

• Neonatal respiratory distress syndrome• Meconium aspiration syndrome• Transient tachypnea of the newborn• Bronchitis• Bronchiolitis and respiratory syncytial

virus • Pneumonia• Tuberculosis



• Common clinical manifestations—infants– Nasal flaring– Retractions– Grunting– Irritability– Tachypnea



• Common clinical manifestations– Crackles– Labored breathing, dyspnea– Wheezing– Cyanosis (with increased severity)– Cough (bronchitis, pneumonia,

tuberculosis)



• Respiratory distress uncommon with TB


LEARNING OUTCOME 6

Create a nursing care plan for a child with a common acute respiratory condition.


Respiratory Assessment

• Determine baseline status of child• Provide pulmonary therapies as needed• Maintain oxygenation


Increased Metabolic Activity

• Increased need for calories/nutrition• Increased need for fluid


Anxiety and Fear Common

• Psychosocial support for parent• Psychosocial support for child


Discharge Planning

• Education about duration of illness• Need for follow-up• When to seek emergency care


Home-Care Planning

• Education of parents/child about home therapies


LEARNING OUTCOME 7

Plan the nursing care for a child with a chronic respiratory condition.


Chronic Lung Diseases

• Asthma• Bronchopulmonary dysplasia• Cystic fibrosis


Nursing Considerations for Chronic Respiratory Conditions

• Oxygenation• Activity intolerance• Fluid and nutrition• Growth and development• Treatment management• Social interactions• Psychosocial support


Oxygenation

• Most important consideration– Assess and reassess– Hypoxia leads to chronic changes– Permanent changes in body systems


Figure 25-18 Digital clubbing.


Oxygenation

• Activity intolerance• Stress and coping• Fluid management as necessary


Growth and Development

• Nutritional concerns– Need increased calories to meet body

requirements• Developmental

– Appropriate activities and interactions


Social Interactions

• Lack of peers for some• Decreased activity tolerance• Decreased age activities


Treatment Management

• Family collaboration required– Plan around family, if possible

• Family education– Prevention of exacerbations– When to call healthcare provider, 911– Medication administration


LEARNING OUTCOME 8

Demonstrate the nursing assessment for a child with an acute lung injury.


Assessing Acute Lung Injury

• Smoke inhalation– Vital signs– Pulse oximetry– Auscultation– Level of consciousness– Behavioral changes



• Blunt chest trauma– Observation

Dyspnea, wheezes, crackles Decreased breath sounds Hemoptysis Transient temperature elevation Level of consciousness Agitation, lethargy



• Blunt chest trauma– Careful monitoring

Inspect thorax Cyanosis is a late sign of respiratory

distress.



• Pneumothorax– Airway management– Monitoring lung inflation– Careful monitoring of vital signs and

respiratory function– Monitor chest tube, related

complications

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