Nursing Care of a Family

When a Child Has a

Respiratory Disorder
 OBJECTIVES

 Describe common respiratory disorders in children

 Assess a child with a respiratory disorder.
 Formulate nursing diagnoses related to respiratory disorders in
children.
 Identify expected outcomes that address the priority needs of a
child with a respiratory disorder to help him or her manage
seamless transitions across differing health care settings.
 Implement nursing care for a child with a respiratory disorder,
such as administering oxygen.
 Evaluate expected outcomes for achievement and
effectiveness of care.
 ANATOMY AND PHYSIOLOGY OF
THE RESPIRATORY SYSTEM
The respiratory system can be
separated into two divisions:
❑Upper Respiratory Tract
Nose,
Paranasal sinuses,
Pharynx,
Larynx,
Epiglottis
ANATOMY AND PHYSIOLOGY OF
THE RESPIRATORY SYSTEM
❑Lower respiratory tract
• bronchi,
• bronchioles,
• alveoli
ANATOMY AND PHYSIOLOGY OF
THE RESPIRATORY SYSTEM
 Through inspiration  Through expiration (breathing
(breathing in), the respiratory out), carbon dioxide–filled air
system delivers warmed and is discharged to the outside.
moistened air to the alveoli,
transports oxygen across the
alveolar membrane to
hemoglobin-laden red blood
cells, and allows carbon
dioxide to diffuse from red
blood cells back into the
alveoli.
ANATOMY AND PHYSIOLOGY OF
THE RESPIRATORY SYSTEM
The ethmoidal and maxillary sinuses are present
at birth, but the frontal sinuses (the sinuses most
frequently involved in sinus infection) and the
sphenoidal sinuses do not develop until 6 to 8
years of age
Newborns produce little respiratory mucus,
which makes them more susceptible to
respiratory infections than older children
Excessive production of mucus in children up to
2 years of age can actually lead to obstruction
 ASSESSING RESPIRATORY ILLNESS
IN CHILDREN
An assessment of respiratory illness in children includes
history taking, physical examination, and laboratory
testing.
The interview and health history may cover only the most
important details: when the child first became ill and
what symptoms are present
Inability to suck because an infant cannot suck and
breathe rapidly at the same time may be one of the first
signs noted in the infant
Physical Assessment

 A physical assessment of a
child with a respiratory
disorder includes observation
of symptoms such as:
✓ cough,
✓ cyanosis, or pallor,
✓ evaluation of respirations
✓ breath sounds
Normal RESPIRATORY Rates in Children

Newborn: 30-60 breaths per minute

Infant (1 to 12 months) 30-60 breaths per minute
Toddler (1-2 years) 24-40 breaths per minute
School-age child (6-12 years): 18-30 breaths per minute
Adolescent (13-17 years): 12-16 breaths per minute
 Cough
 A cough reflex is initiated by
stimulation of the nerves of the
respiratory tract mucosa by the
presence of dust, chemicals, mucus,
or inflammation.
 Useful procedure to clear excess
mucus or foreign bodies
 Paroxysmal coughing refers to a
series of expiratory coughs after a
deep inspiration
 Increase chest pressure and so may
decrease venous return to the heart
Rate and Depth of Respirations

Tachypnea (an increased respiratory rate) often is the first

indicator of airway obstruction in young children.
Assess not only the rate but also the depth and quality of
respirations to assess anoxia (lack of oxygen in body
cells).
Retractions

 parts of the chest (the

intercostal spaces) draw
inward
 occur more commonly in
newborns and infants than in
older children because the
intercostal muscles are
weaker and less developed in
younger children
Retractions

 Retraction of upper chest

muscles (supraclavicular or
suprasternal) suggests upper
airway obstruction
 Retraction of intercostal or
subcostal muscles suggests
lower airway obstruction.
Restlessness

 Be careful not to interpret the

excessive movements of
infants with respiratory
distress as a sign that they are
improving.
 a signal of respiratory
obstruction
 first signs of airway
obstruction
Cyanosis

 Cyanosis (a blue tinge to the

skin) indicates hypoxia.
 children increase respiratory
effort in an attempt to supply
more oxygen to tissues.
 unoxygenated hemoglobin
increases to over 3 g per 100
ml because oxygenated red
blood cells in the circulation
are what give blood its red
color
Clubbing of Fingers

 a change in the angle between

the fingernail and nail bed
because of increased capillary
growth in the fingertips
 occurs as the body attempts
to supply more oxygen routes
(more capillaries) to distal
body cells
 Adventitious Sounds

 extra or abnormal breathing

sounds,which can be heard on lung
assessment
 The vibrations produced as air is
forced past an obstruction, such as
mucus in the nose or pharynx,
cause a snoring sound (
rhonchi ).
 If the obstruction is at the base of
the tongue or in the larynx, a
harsher, strident sound on
inspiration ( stridor)
Adventitious Sounds

 If an obstruction is in the
lower trachea or bronchioles,
an expiratory whistle sound(
wheezing)
 If alveoli become fluid filled,
fine crackling sounds (rales)
are heard
 Diminished or absent breath
sounds
 Laboratory Tests

 Blood Gas Analysis

 an invasive method for determining
the effectiveness of ventilation and
acid–base status
 provides important information
about oxygenation of the blood
because values may indicate not
only whether the arterial partial
pressure of oxygen (P o 2 ) is
adequate, but also whether the
oxygen saturation of hemoglobin is
adequate
 Children who are hypoventilating
(breathing very shallowly), Pco2
will be increased
 Children who are hyperventilating
(breathing deeply), Pco2 will be
decreased
 concentration of carbonic acid
 amount of bicarbonate in the
bloodstream
 With alkalosis, the respiratory rate
decreases as the child tries to
conserve CO
 Nasopharyngeal Culture

 reveal a great deal of information

about the microorganisms causing a
disease
 Firm, calm support during the
procedure while you touch a
moistened swab to the mucus
membrane of the nose or throat is
essential
 A throat culture will miss
pathogenic organisms if the culture
tip is not touched to the infected
aspect of the pharynx.
Respiratory Syncytial Virus Nasal
Washings
 Nasal washings are obtained
to diagnose an infection by
the respiratory syncytial virus
(RSV).
 child is placed in the supine
position, and 1 to 2 ml of
sterile normal saline is
dropped with a sterile
needleless syringe into one
nostril.
 The secretions removed are placed in a sterile container to be sent to the
laboratory for analysis
Sputum Analysis

is rarely feasible in

children younger than
school age.
ask them to breathe in
and out several times,
cough deeply, and spit
mucus they have raised
into a sterile specimen
container.
 Diagnostic Procedures

 Chest Radiography
 Chest X-ray films show areas of
infiltration or consolidation in the
lungs
 more difficult to obtain in infants
than in older children because
infants cannot take a breath and
hold it when instructed
 Computed tomography (CT) scans
may be ordered for children with
chronic lung disease because this
technique can best mark disease
progress
Bronchography

 a radiopaque solution may be

introduced into the
respiratory tract by an
ultrasonic nebulizer or by a
catheter inserted into the
trachea before the X-ray
 require conscious sedation
 Observe them carefully after
such a procedure for possible
respiratory obstruction from
accumulating mucus
 HEALTH PROMOTION AND
RISK MANAGEMENT
Teach children as young as toddlers to help avoid
spreading colds by washing their hands, properly
disposing of tissues, and blocking a cough by their shirt or
blouse sleeve
Be certain that children with chronic respiratory illnesses
receive the pneumococcal vaccine as well.
Reducing respiratory irritation by reducing secondary
smoke can help prevent upper respiratory infections and
can reduce the incidence of asthma
 THERAPEUTIC TECHNIQUES USED IN THE
TREATMENT OF RESPIRATORY ILLNESS IN
CHILDREN
 Expectorant Therapy
Nebulizers
✓ are mechanical devices that
provide a stream of
moistened air directly into the
respiratory tract
✓ important means for the
delivery of respiratory tract
medications
 Chest Physiotherapy
✓ loosen mucus for
expectoration
✓ Moving mucus toward the
main stem bronchus when
performed together.
✓ Postural drainage, percussion,
and vibration
Chest Physiotherapy

 best scheduled before meals or

at least an hour after a meal so
the subsequent coughing does
not cause vomiting
 Therapy to Improve Oxygenation

 Oxygen Administration
 elevates the arterial oxygen
saturation level by supplying more
oxygen to red blood cells through
the respiratory tract.
 Nasal catheters provide a
concentration of approximately
50% with an oxygen flow of 4 l/min
 A snug-fitting oxygen mask is a
method for supplying nearly 100%
oxygen and is the method
frequently used in emergencies
 Pharmacologic Therapy
 Nasal sprays such as normal
saline can be administered to
moisten and loosen nasal
secretions.
 Antihistamines
 Corticosteroids
 Decongestants
 Expectorants
 Antibiotics
Metered-Dose Inhalers

 A metered-dose inhaler (MDI)

is a hand-held device that
provides a route for
medication administration
directly to the respiratory
tract
 five general rules: shake the
canister, exhale deeply,
activate the inhaler and place
it in their mouth as they begin
to inhale, take a long slow
inhalation, and then hold their
 Endotracheal Intubation
✓ the preferred means of
bypassing upper airway
obstruction and allowing free
entry of air to the trachea.
✓ Endotracheal tubes are held in
place by being taped to the
face. Make sure tubes are
carefully secured, otherwise
children can easily dislodge
them
 Tracheostomy
 is an opening into the trachea to
create an artificial airway to relieve
respiratory obstruction
 route for suctioning mucus when
accumulating mucus causes lower
airway obstruction
 Be certain parents understand why
the tube is in place and how
important it is that it remain patent
DISORDERS OF THE UPPER
RESPIRATORY TRACT
Choanal Atresia

 is congenital obstruction of
the posterior nares by an
obstructing membrane or
bony growth, which prevents
a newborn from drawing air
through the nose and down
into the nasopharynx
 assessed by holding the
newborn’s mouth closed, then
gently compressing fi rst one
nostril, then the other.
treatment

 local piercing of the

obstructing membrane or
surgical removal of the bony
growth.
 an oral airway inserted to
ensure they continue to
breathe through their mouths
Acute Nasopharyngitis (Common Cold)

Upper respiratory infections are caused by one of several

viruses,
✓ most predominantly by rhinovirus,
✓ coxsackievirus,
✓ RSV, adenovirus,
✓ parainfluenza and influenza viruses
Assessment

 nasal congestion, a watery

rhinitis, and a low-grade fever.
 edematous and inflamed,
constricting airway space and
causing difficulty breathing
 often develop a fever elevated
out of proportion to the
symptoms, possibly as high as
102° to 104°F (38.8° to 40°C)
Therapeutic Management

 no specific treatment
 can be controlled by an
antipyretic such as
acetaminophen (Tylenol) or
children’s ibuprofen (Motrin)
 saline nose drops or nasal
spray may be prescribed to
liquefy nasal secretions
Pharyngitis

is infection and inflammation of the throat

peak incidence occurs between 5 to 15 years of age
It may occur as a result of a chronic allergy in which there
is constant postnasal discharge that results in a secondary
irritation.
Viral Pharyngitis

 causative agent of pharyngitis

is usually an adenovirus
 ASSESSMENT:
 generally mild: a sore throat,
fever, rhinorrhea, cough, and
general malaise
 Erythema will be present in
the back of the pharynx and
the palatine arch.
 Increased white blood cell
count.
Therapeutic management

oral analgesic such as

acetaminophen or
ibuprofen for comfort.
Warm heat applied to the
external neck area
gargling with a solution
such as warm water to
help reduce the pain
 Streptococcal Pharyngitis

 Group A B-hemolytic streptococcus

is the organism most frequently
involved in bacterial pharyngitis in
children
Assessment

 back of the throat and palatine

tonsils are usually markedly
erythematous (bright red); the
tonsils are enlarged and there
may be a white exudate in the
tonsillar crypts.
 with a high fever, an extremely
sore throat, difficulty swallowing,
and overall lethargy
Therapeutic Management

 10-day course of an oral

antibiotic such as penicillin G
or clindamycin.
 Help parents understand the
importance of completing the
full prescribed days of therapy
in order to ensure all the
streptococci are eradicated
 importance of rest, relief of
throat pain, and maintaining
hydration
Tonsillitis

Tonsillar tissue is
lymphoid tissue that
filters pathogenic
organisms from the head
and neck area
Assessment

 swallowing as so painful it
feels as if they are swallowing
bits of metal or glass
 high fever and are lethargic
 bright red and may be so
enlarged that the two areas of
palatine tonsillar tissue meet
in the midline
 most commonly occurs in
school-age children.
Therapeutic Management

 an antipyretic for fever

 an analgesic for pain
 a full 7- to 10-day course of an
antibiotic such as penicillin or
amoxicillin.
 SURGICAL
✓ Tonsillectomy is removal of
the palatine tonsils.
✓ Indicated in chronic tonsillitis
 Epistaxis

 Nosebleeds may also occur after

strenuous exercise, with hemolytic
disorders such as sickle-cell anemia,
or may be associated with nasal
polyps, sinusitis, or allergic rhinitis.
 Keep children with nosebleeds in an
upright position with their head
tilted slightly forward
 Apply pressure to the cartilage on
the sides of the nose with your
fingers for about 10 minutes
 Laryngitis

 is inflammation of the larynx, which

results in brassy, hoarse voice
sounds or the inability to make
audible voice sounds
✓ Sips of fluid (either warm or cold,
whichever feels best) offer relief
from the annoying tickling
sensation
✓ rest the voice for at least 24 hours
until inflammation subsides
✓ paper and pencil or chalkboard for
communication.
Congenital
Laryngomalacia/Tracheomalacia
means that an infant’s
laryngeal structure is
weaker than normal and
collapses more than usual
on inspiration
Assessment

 laryngeal stridor (a high-

pitched crowing sound on
inspiration) present from birth
and possibly intensified when
the infant is in a supine
position or when sucking.
 infant’s sternum and
intercostal spaces may retract
on inspiration
Therapeutic Management

 need no routine therapy other

than to have parents feed
them slowly and provide rest
periods as needed.
 importance of bringing the
child for early care if signs of
an upper respiratory tract
infection should develop
Epiglottitis

 is inflammation of the
epiglottis, which is the flap of
cartilage that covers the
opening to the larynx to keep
out food and fluid during
swallowing
 most frequently in children
from 2 to about 8 years of age
 Assessment
 begin as those of a mild upper
respiratory tract infection
 inflammation spreads to the
epiglottis, the child suddenly
develops severe inspiratory stridor,
a high fever, hoarseness, and a very
sore throat
 laboratory studies will show
leukocytosis (20,000 to 30,000 mm 3
), with the proportion of
neutrophils increased
 X-ray film or ultrasound will reveal
the enlarged epiglottis.
Therapeutic Management

An antibiotic, such as a third-generation cephalosporin

like cefotaxime, may be prescribed until a throat culture
indicates the need for a specific antibiotic drug.
Oxygen as necessary
Intravenous fluid therapy to maintain hydration
tracheotomy or intubation set ready at the bedside
DISORDERS OF THE LOWER
RESPIRATORY TRACT
Bronchitis

 (inflammation of the major

bronchi and trachea) is one of
the more common illnesses
affecting preschool and
school-age children
 influenza viruses, adenovirus,
and Mycoplasma pneumonia
Assessment

 a mild upper respiratory tract

infection for 1 or 2 days, after
which they develop a fever and a
dry, hacking cough, which is
hoarse and mildly productive and
serious enough to wake a child
from sleep.
 rhonchi and coarse crackles (the
sound of rales) can be heard.
Therapeutic Management

aimed at relieving
respiratory symptoms,
reducing fever, and
maintaining adequate
hydration
An antibiotic will be
prescribed
A cough expectorant
necessary
Bronchiolitis

 is inflammation of the fine

bronchioles and small bronchi.
 most common lower
respiratory illness in children
younger than 2 years of age,
peaking in incidence at 6
months of age
 Viruses, such as adenovirus,
parainfluenza virus, and RSV
Assessment
 1 or 2 days of an upper respiratory
tract infection, then suddenly begin
to demonstrate an increased
respiratory rate, nasal flaring, and
intercostal and subcostal retractions
on inspiration.
 mild fever, leukocytosis, and an
increased erythrocyte
sedimentation rate
 Wheezing
 shows low oxygen saturation
 A throat culture will identify the
offending organism.
Therapeutic Management

 antipyretics, adequate
hydration, and maintaining a
watchful eye for progression
to more serious illness is all
that is necessary
 anti-RSV immunoglobulin
 nebulize budesonide (a
glucocorticoid steroid
 Intravenous fluids may be
given for the first 1 or 2 days
Asthma

 tends to occur in children with atopy or those who tend to be

hypersensitive to allergens
 mast cells release histamine and leukotrienes that result in diffuse
obstructive and restrictive changes in the airway because of a triad
of inflammation, bronchoconstriction, and increased mucus
production.
Assessment

 An episode begins with a dry

cough.
 difficult for them to force air
through the narrowed lumen
of the bronchioles that are not
only inflamed and swollen but
also filled with mucus
 Wheezing is heard primarily
on expiration
 Therapy for children with asthma involves planning for the
three goals of all allergic disorders:

(1) avoidance of the allergen by environmental control;

(2) skin testing and hyposensitization to identified allergens;
(3) relief of symptoms by pharmacologic agents
Therapeutic Management

Cough suppressants are contraindicated with asthma

Prescribed an inhaled anti-inflammatory corticosteroid
such as fluticasone (Flovent) either daily or every other
day
Oral corticosteroid
A long-acting Beta-2 agonist bronchodilator, such as
terbutaline, albuterol, or budesonide
May be given by a nebulizer or metered dose inhaler
Pneumonia

 The disease is commonly divided into two types:

✓ hospital acquired (pneumococcal or streptococcal pneumonia)
✓ community acquired (chlamydia, viral pneumonias).
 Bacterial origin (pneumococcal, streptococcal, staphylococcal, or
chlamydial) or viral in origin (RSV)
 occurs at a rate of 2 to 4 children out of 100.
Pneumococcal Pneumonia

 In infants, the infection tends

to remain bronchopneumonia
with poor consolidation
(infiltration of exudate into
the alveoli)
 In older children, pneumonia
may localize in a single lobe,
and full consolidation may
occur.
 Assessment

 high fever, nasal flaring, retractions,

chest pain, chills, and dyspnea
 febrile seizure
 breath sounds will be diminished
and bronchial (the sound is
transmitted from the trachea)
 Crackles (rales) may be present as a
result of the fluid
 Leukocytosis
 X-ray will reveal the extent
Therapeutic Management

 Ampicillin and third-generatio

cephalosporins are both
effective against
pneumococci.
 plan nursing care carefully
 reposition a child frequently
 Intravenous therapy
 Assess oxygen saturation
levels frequently via pulse
oximetry.