Guided Lecture Notes, Chapter 16, The Child with Altered Respiratory Status

Learning Objective #1. Describe the developmental and biological variances in children's

respiratory systems that predispose them to respiratory problems.

Teach your students that respiratory conditions, both acute and chronic, are the

leading causes of morbidity in children, and compromises to the respiratory

system are the most common types of problem encountered by the nurse caring

for infants, children, and youth.

Discuss the types of respiratory conditions seen during childhood. The can be

acute or chronic, life threatening, and can present as either the primary clinical

problem or a secondary complication. (Refer to PowerPoint slide #2.)

Review the anatomical structures of the respiratory tracts of infants and young

children and compare them to those of adults. Remind the students that nurses

must note these variations when identifying normal versus abnormal. (Refer to

Figures 16-1, 16-2, and 16-3; and PowerPoint slides #3, 4, and 5.)

Learning Objective #2. Describe the common alterations in health patterns within the

respiratory system in children in terms of etiology, pathophysiology, clinical

manifestations, and interdisciplinary interventions.

Discuss the role of the nurse when taking a health history. Note that the nurse

should use the parent’s own words to document all descriptions of the child’s

symptoms. Review the questions that should be included to assess a respiratory

system problem. (Refer to Focused Health History 16-1 and PowerPoint slide

#6.)

Teach your students the techniques used to perform a focused physical assessment

including observation, inspection, auscultation, palpation, and percussion. (Refer

to Focused Physical Assessment 16-1 and 16-2, and PowerPoint slides #7 and

8.)

Discuss the four major groups of diagnostic tests and procedures used in the

evaluation of the respiratory system and respiratory disorders in children

including: measurement of lung volumes and flow rates (pulmonary function tests

and peak flow measurement); direct or indirect blood and body fluid analysis

(arterial blood gases, fluid cultures, sweat chloride test); imaging techniques

(radiographs, fluoroscopy, bronchography, CT scan, scintigraphy, MRI); and

direct visualization of the respiratory tree (laryngoscopy, bronchoscopy). (Refer

to Figure 16-4, Tests and Procedures 16-1, and PowerPoint slides #9 and 10.)

Remind your students that respiratory illnesses in children, both acute and chronic

conditions, require aggressive and immediate intervention, due to the fact that

respiratory failure is one of the leading causes of cardiopulmonary arrest in

children (AHA, 2005).

Teach your students that for children with a chronic respiratory condition,

oxygen, medications, airway clearance techniques, and nutritional support can

assist them through exacerbations of the illness and provide them with the

strength to maintain a high level of wellness despite their chronic conditions. Note

that some conditions may require use of artificial airways, mechanical ventilation,

or tracheostomy. (Refer to PowerPoint slide #11.)

Discuss the proper use of oxygen for the treatment of hypoxemia. Review the

methods for delivering oxygen. (Refer to Figure 16-5, Teaching Intervention

Plan 16-1, and PowerPoint slides #12 and 13.)

Review the routes of medication administration for treating respiratory disorders

in children, including oral, inhaled, intravenous, and injectable (SQ or IM). (Refer

to PowerPoint slide #14.)

Tell your students that the main classes of medications used for respiratory

disorders include bronchodilators, corticosteroids, and leukotriene modifiers/mast

cell stabilizers. Other groups of medications often used in conjunction with these

include antibiotics, antivirals, mucolytics and expectorants, decongestants,

antihistamines, and diuretics. (Refer to Nursing Interventions 16-1; Figures 16-

6, 16-7, and 16-8; and PowerPoint slides #15 and 16.)

Review the methods available to provide artificial ventilation. Note that a bag-

mask unit, or Ambu bag, is used to manually ventilate a child who has not been

intubated. (Refer to Figure 16-9.)

Define endotracheal intubation: the insertion of an artificial airway (an

endotracheal tube) through either the nose (nasotracheal) or the mouth

(orotracheal) into the trachea. State that another less invasive device for

mechanical ventilation (used most commonly in the operating room) is the

laryngeal mask airway. (Refer to Tradition or Science 16-1, Figure 16-10, and

PowerPoint slide #17)

Learning Objective #3. Describe the nursing assessment of the child with compromised

respiratory function.

Teach your students that nurses focus postoperative nursing care for patients with

a tracheostomy on close observation to maintain a patent airway and monitoring

for possible complications such as hemorrhage, edema, subcutaneous

emphysema, pneumothorax, and accidental decannulation. (Refer to PowerPoint

slide #18.)

Discuss postoperative respiratory assessments including vital signs and

examination of the child's color, respiratory rate and effort, breath sounds, and

type and amount of secretions.

Learning Objective #4. Discuss the nursing care responsibilities associated with diagnosis

of respiratory difficulties in children.

Emphasize the fact that health promotion and disease prevention activities are

essential for infants, children, and adolescents with acute and chronic respiratory

conditions. Note the focus of these activities: promoting a child’s growth and

development and adequate home management. (Refer to PowerPoint slide #19.)

Note the many nursing diagnoses that may be used to address altered respiratory

function and status. (Refer to Nursing Plan of Care 16-1.)

Teach your students that congenital abnormalities or malformations of the

respiratory systems are rare. Discuss the congenital conditions that may occur in

children, and remind students that the primary goal of treatment is to maintain a

patent airway. (Refer to Figure 16-12 and PowerPoint slides #20 and 21.)

Learning Objective #5. Select the treatments that are most effective for specific

respiratory conditions.

Tell your students that upper respiratory tract infections are extremely common in

infants and young children. Note that most upper respiratory conditions are

treated in the home or in ambulatory care settings. Review the conditions

associated with altered upper respiratory functioning. (Refer to PowerPoint slides

#22 and 23.)

Discuss the characteristic features that distinguish allergic rhinitis from the

common cold. (Refer to Table 16-1.)

Discuss the diagnosis and treatment of epiglottitis. Describe the “tripod position”

and note that agitation, characterized by irritability and restlessness, is almost

always present. (Refer to Clinical Judgment 16-1 and PowerPoint slides #24

and 25.)

Warn students that respiratory distress is a key symptom in bacterial tracheitis and

requires immediate medical attention; vigorous management, including early

recognition of bacterial tracheitis and prompt attention to the airway, is necessary

to prevent the airway from being obstructed by the thick secretions.

Note the three types of apnea that may occur including central apnea, obstructive

apnea, and mixed apnea. (Refer to PowerPoint slide #26.)

Review the types of lower respiratory infections and obstructions seen in children:

influenza, bronchiolitis, bronchitis, and pneumonia. (Refer to PowerPoint slide

#27.)

Tell your students that chronic conditions of the respiratory system can have a

serious effect on children and adolescents and may substantially alter their quality

of life and physical and social development. Note the types of chronic conditions

that affect children. (Refer to PowerPoint slide #28.)

Learning Objective #6. Select nursing care interventions to support the child with an

acute or chronic respiratory illness.

Note that the mainstay of treatment for allergic rhinitis is avoiding the offending

allergens. Review environmental control measures that can help relieve

symptoms. (Refer to Community Care 16-1.)

State that antimicrobial therapy and symptomatic relief measures are the main

interventions for sinusitis. (Refer to Figures 16-13 and 16-14, and Table 16-2.)

Tell your students that when tonsillitis is present, it is necessary to screen for

GABHS by culturing the tonsillar surface that may contain the exudates in order

to determine the antibiotic course that will be used (usually penicillin). Note that

tonsillectomy and adenoidectomy (T&A) are controversial surgical interventions

for chronic tonsillitis. (Refer to Teaching Intervention and Prevention 16-3.)

Discuss the recommendations for use of inactivated influenza vaccine to prevent

influenza in children. Note that interventions for children with influenza include

supportive care to alleviate or minimize symptoms and use of antiviral agents

such as zanamivir and oseltamivir. (Refer to Community Care 16-2.)

Discuss the etiology, prevalence, and treatment modalities for bronchiolitis. State

that the care of a child with bronchiolitis involves respiratory, pharmacologic, and

nutritional support.

Emphasize the fact that chronic bronchitis in children may be a symptom of an

underlying pulmonary disorder and may be an important factor in predisposing

the child to chronic respiratory symptoms and lung dysfunction even into the

adult years. (Refer to Table 16-4.)

Teach your students that pneumonia is distinguished from the more common

upper respiratory tract infections by the presence of lower respiratory tract signs

and symptoms such as tachypnea, rales, and associated areas of infiltration on

chest radiographs. Discuss the causes of, and treatments for, pneumonia.

Discuss the four components of care for asthma presented in the National Institute

of Health guidelines. Note that asthma is the third leading cause of hospitalization

among children under the age of 15 years. (Refer to Clinical Judgment 16-2;

Focused Health History 16-2; Figures 16-16 and 16-17; and PowerPoint slides

#29 and 30.)

Review the risk factors for asthma-related death and recommended treatment

modalities for asthma. (Refer to Tables 16-5, 16-6, 16-7, 16-8, 16-9, 16-10; and

PowerPoint slide #31.)

Tell your students that once considered a fatal childhood disease, cystic fibrosis

(CF) is a chronic, multisystem condition that requires a holistic approach to care

by a trained, interdisciplinary team, including physicians, advanced practice

nurses, nurses, dietitians, social workers, psychologists, and respiratory care

therapists. (Refer to PowerPoint slide #32.)

Stress the fact that each developmental stage merits review with the family and

the patient, when age appropriate, to facilitate strategies that will allow

specialized care for CF to be provided daily (Refer to Developmental

Considerations 16-1).