Respiratory

Respiratory system/ Khulood Shattnawi




Alteration in Respiratory Function in Children The respiratory system is made up of the organs involved in the interchanges of gases, and consists of the nose, pharynx, larynx, trachea, bronchi, and lungs. The upper respiratory tract includes the following: nose, nasal cavity, ethmoidal air cells, maxillary sinus, larynx, and trachea. While the lower respiratory tract includes the following: lungs, bronchi and alveoli.

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Functions of respiratory system: Removal of CO2 and replacement of O2 needed for metabolism. Maintenance of acid-base balance (pH level). Maintenance of body H2O level and heat balance. Production of speech. Facilitate the sense of smell.

Respiratory differences in children: • Tonsiller tissue is normally enlarged in early school-age. • Respiratory mucus ( cleaning agent) : • In newborn: is little makes them more susceptible to respiratory infections. • Increase production of mucus up to 2 years of age lead to obstructions. • After 2 years of age the right bronchus become shorter, wider, and more vertical than the left bronchus, thus inhaled foreign bodies more often lodge in the right bronchus. • Infants use their abdominal muscle for breathing, the change to thoracic begin around the age of 2-3 years and completed at age of 7 years. • Because accessory muscles are used more in children than in adult, weakness of these muscles from diseases may lead to respiratory failure. • In infants, the walls of the airways are small in size and have less cartilage than older children and adults that’s why they are more likely to collapse after expiration. • Infants are obligatory nasal breathers. Assessment of Respiratory function Information of the child’s respiratory status is obtained from observations of physical signs and behavior. Respiration, the configuration of the chest, the pattern of respiratory movement, including rate, regularity, symmetry of movement, depth, effort expended in respiration, and use of accessory muscles of respiration, should be assessed. Respiration is best determined when the child is sleeping or quietly awake. Palpation and percussion provide information regarding areas of pain and tissue density. Auscultation of the lung fields is helpful in identifying specific pathologies and in assessing the child’s responses to treatment. Auscultation is essential when determining airway patency. Noisy breathing Noisy breathing has been described as abnormal breath sounds that are audible without the use of a stethoscope. These sounds result from blockage of the airway anywhere along the pathway from the nose to the bronchioles. Blockage at these points could be the result of foreign object inhalation, inflammation, airway constriction or external compression of the airways. In general, respiratory obstruction tends to occur more often in younger patients because the larynx is smaller in younger infants. Noisy breathing in a child/infant can cause great distress for the caregiver. It is a complaint that should be investigated immediately and thoroughly. Noisy breathing can be classified into three main types: snoring, stridor and wheezing.

Respiratory system/ Khulood Shattnawi  1. Snoring Snoring is an abnormal breath sound that occurs while the child sleeps. Snoring is usually the result of a partial obstruction of the upper respiratory tract that in turn causes vibration of air as it passes through the nasopharynx and oropharynx. This obstruction may cause a child to momentarily stop breathing during his/her sleep (sleep apnea). This sleep disturbance may occur several times during the night and although the child may not be able to recall their waking, sleep apnea can lead to fatigue and irritability throughout the day. 2. Stridor Stridor is a harsh, continuous, crowing sound that is caused by variable airway obstruction that is an obstruction which blocks flow in one direction but not the other. Most commonly, stridor occurs on inspiration and is caused by an extrathoracic variable airway obstruction. Expiratory stridor can also be heard however this sound results from an intrathoracic variable airway obstruction. It should be noted that an expiratory stridor may often resemble a wheeze. A Biphasic stridor implies midtracheal involvement. If stridor occurs with hoarseness then an obstruction of the larynx is indicated. An acute onset of nocturnal stridor combined with a barky cough and hoarse voice should point you towards croup. On the other hand, a chronic stridor from early infancy indicates an underlying congenital abnormality.

3. Wheeze A wheeze is a continuous sound that is mainly heard on expiration. It indicates an intrathoracic airway obstruction, resulting from dynamic compression of the bronchi. Wheezing can be accompanied by feelings of tightness in the chest and labored breathing. It is important to distinguish wheezing (a sound heard on expiration) from stridor (a sound heard primarily on inspiration). Although anything that causes compression of the airways can potentially cause wheezing, however in most cases wheezing is caused by asthma. Specific questions should therefore be asked about environmental factors (grass, pollen, trees), factors within the home (inhalants, moldy basements, dusty areas, sprays, perfumes, parents occupation), school-related factors (dust, chalk) and pets. You should also ask about family history, and whether the child or family members smoke. **Remember, a child can start smoking at an early age, and will not feel comfortable telling you this while parents are present.** Children who are having difficult time breathing often show signs that they are not getting enough oxygen, indicating respiratory distress. It is important to learn the signs of respiratory distress to know how to respond appropriately. Signs of respiratory distress: • •

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Breathing rate: An increase in the number of breaths per minute, usually > 60 breath/minute in infants. Retractions: The chest appears to sink with each breath - one way of trying to bring more air into the lungs. In severe airway obstruction, retraction becomes extreme. Subcostal retraction, observed anteriorly at the lower costal margins, indicates a flattened diaphragm, since it not only lowers the floor of the thorax, but also pulls on the rib cage in response to a greater than normal decrease in intrathoracic pressure. In severe obstruction, retractions extend to the supraclavicular areas and the suprasternal notch. Color changes: cyanosis seen around the mouth, on the inside of the lips, or on the fingernails may occur when a person is not getting as much oxygen as needed. Cyanosis become apparent when PaO2 is lower than 40 mmHg, or with increased of unoxygenated level of hemoglobin (Hgb). The color of the skin may also appear pale or gray. Grunting: A grunting sound can be heard each time that the child exhales. This grunting is the body's way of trying to keep air in the lungs so they will stay open. Grunting is frequently

Respiratory system/ Khulood Shattnawi

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a sign of chest pain, suggesting acute pneumonia or pleural involvement. It is also observed in pulmonary edema and is a characteristic of respiratory distress syndrome. Nasal flaring: It is a sign of respiratory distress and a very significant finding in an infant. The openings of the nose spreading open while breathing may indicate that a child is having to work harder to breathe. The enlargement of the nostrils helps reduce nasal resistance and maintain airway patency. Wheezing: A tight, whistling or musical sound heard with each breath may indicate that the air passages may be smaller, making it more difficult to breathe. Other abnormal lung sounds that could be heard are rales (or crackles: short, popping; sudden inflation of alveoli), ronchi (or gurgles: continuous rattle; fluid in large airways) and pleural friction rub (grating, leathery; inflamed pleura). Associated observations: Cough, sound of coughing is caused by rapid expiration past the glottis. Cough serves as a protective mechanism, initiated by stimulation of the nerves of the respiratory tract mucosa by the presence of dust, chemicals, mucus, or inflammation. It is a useful procedure to clear excess mucus or foreign bodies, but becomes harmful and needs suppression when there is no mucus or debris to be expelled. Paroxysmal coughing is a series of expiratory coughs after a deep inspiration (as in case of pertussis), continuous coughing increases the chest pressure, which cause the venous return to heart to be decreased (decreased cardiac output), that may lead to fainting.

A cough is most often a symptom of lower respiratory disease, but can arise from a variety of central nervous, pulmonary, and nonpulmonary origins (e.g., congenital heart disease). Asthma and respiratory infections, usually viral, are the cause in most cases, but cystic fibrosis and psychological problems are significant causes in older children. Ask the patient or parent for as much information about the cough as possible, emphasizing the following points: 1. Quality of cough. It is extremely important to characterize the sound of the cough, since certain diseases produce very distinctive coughs. Although it can be very helpful to obtain and examine a sample of any sputum that is produced, infants and younger children usually swallow sputum since they have generally not yet learned to spit. Determination of whether the cough is productive or not can therefore be based on whether the cough sounds ‘dry’ (nonproductive) or ‘loose’ (productive). 2. Timing and duration of cough. A variety of timing patterns can provide clues as to the origin of the cough. Ask about the cough’s occurrence with feeding, at night, in early morning, and seasonal variations. Also determine whether the cough is of an acute or chronic nature, the latter usually having lasted more than 3 to 4 weeks. Among those coughs that are chronic, distinguishing between recurrent and persistent coughs may help to narrow the differential diagnosis by pointing to relevant triggers or the possibility of recurrent infections.

Respiratory system/ Khulood Shattnawi  3. Aggravating factors. Certain stimuli can often be pin-pointed as cough-inducing factors. Possibilities range from known infection, exercise, cigarette smoke, and weather changes (e.g. cold air), to laughing, crying, or the presence of allergens. Environmental irritants associated with molds on walls, air pollution, exhaust fumes, and wood-fire smoke should also be noted. 4. Associated clinical findings. Cough can present in association with several related signs and symptoms. Be sure to obtain information regarding fever, hemoptysis, stridor, wheezing and chest pain. 5. History. Evidence of a patient or family history of conditions such as asthma, eczema, urticaria, or allergic rhinitis suggests a potential allergic etiology.

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Clubbing: proliferation of tissue about the terminal phalanges, accompanies a variety of conditions, frequently those associated with chronic hypoxia, primarily cardiac defects and chronic pulmonary disease. The change of the angle of the nail to the fingertip is occur because of the increase of capillary growth in the fingertips, which occur as the body attempts to supply more oxygen to the distal body cells.

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Restlessness and apprehension: when children or infants have difficulty securing adequate oxygen (hypoxia), they become anxious and restless. Restlessness and tachypnea in infants are the first signs of airway obstruction. Increasing use of accessory muscles of respiration.

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Diagnostic Procedures Several procedures are available for assessing respiratory function and diagnosing respiratory disease. All of these procedures require preparation and support of the child and the family to ensure cooperation and accurate results. These procedures not only are useful in diagnosis, but also provide information that guide nursing interventions, such as positioning, use of supplemental oxygen, and assistance with coughing or deep breathing. • Pulmonary function tests: noninvasive pulmonary mechanics are often measured at the bedside of infants and children with the use of spirometry, a device that records the air exchange. These tests are useful to evaluate the severity and course of a disease and to study the effects of treatment. Pulmonary function tests used in children are: • Forced vital capacity (FVC): maximum amount of air that can be expired after maximum inspiration. • Forced expiratory volume in 1 (FEV1) or 3 (FEV3) seconds: amount of air that can be forced from lungs after maximum inspiration in 1 and 3 seconds. • Tidal volume (TV): amount of air inhaled and exhaled during any respiratory cycle. • Functional residual volume (FRV); Functional residual capacity (FRC): volume of air remaining in lungs after passive expiration. • Radiologic examination: • Radiography: x-rays produces images of internal structures of chest, including air-filled lungs, airways, vascular marking, hearts, and great vessels. • Bronchography: contrast medium is instilled directly into bronchial tree through opaque catheter inserted via orotracheal tube. Detects distal bronchial obstructions and malformations. Carried out with child under general anesthesia or sedation • Computed tomography (CT): sequence of x-rays, each representing a cross section through lung tissue at different depth. Useful in identifying presence of calcium or a cavity within a lesion, adenopathy, masses, or abnormalities.

Respiratory system/ Khulood Shattnawi

Magnetic resonance imaging (MRI): use of large magnet and radio waves to produce two or three-dimensional image. It clearly identifies soft tissues, and requires cooperation or sedation of child. • Angiography: injection of dye to produce image of pulmonary vasculature. It investigates pulmonary vascular anomalies and pulmonary hypertension. Performed with child under general anesthesia. • Other diagnostic procedures: • Tracheal aspiration: sputum obtained by direct aspiration from trachea for examination and culture. • Bronchoscopy: direct observation of tracheobronchial tree via bronchoscope. • Lung puncture: needle aspiration of lung fluid via syringe and needle through intercostal space for histologic study or culture. • Lung biopsy: removal of lung tissue via open thoracotomy or closed-needle procedures. Used for diagnosis of protracted pulmonary disease unexplained by other means. • Blood gas determination: blood gas measurements are sensitive indicators of change in respiratory status in acutely ill patients. They provide valuable information regarding lung function, lung adequacy, and tissue perfusion and are essential for monitoring conditions involving hypoxemia, CO2 retention, and PH. • Pulse oximetry: provides a continuous or intermittent noninvasive method of determining O2 saturation (SaO2). • Arterial blood gas (ABG) sampling: may be performed on blood from an artery or a capillary. The blood samples are obtained by taking a deep heel stick after dilation of the vascular bed by warming, or through an indwelling catheter (arterial line) or by arteriopuncture. Although ABG values are similar for children and adults, neonates can have slightly lower values and still be considered normal. The significance of ABG determination is related primarily to the relationships among three parameters: pH, Po2, and Pco2. Any change in a blood gas value must be compared with the other values and with previous readings, as well as with the child’s clinical appearance and behavior, medical history, and associated physiologic factors. Clinical indicators for blood gas analysis include changes in color, depth or rate of respiration, behavior, and vital signs.

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Common Therapeutic Techniques used in the Treatment of Respiratory Illness in Children Oxygen therapy: the indication of administration of O2 is hypoxemia. O2 is delivered by mask, nasal cannula, tent, hood, face tent, or ventilator. The mode of delivery is selected on the basis of the concentration needed and the child’s ability to cooperate in its use. The concentration of O2 delivered should be regulated according to the individual child’s needs. There are hazards related to its use; therefore O2 should be continued only as long as needed (oxygen is a drug and should not be administered or adjusted without a doctor's order, and is only administered as prescribed by dose, typically in liters per minute). Humidification of the gas before administration to the patient is essential. • Aerosol therapy: using the airway as the route of administration can be useful in avoiding the systemic side effects of certain drugs and in reducing the amount of drug necessary to achieve the desired effect. Medications can be aerosolized or nebulized with air or with O2-enriched gas. Hand-held nebulizers are frequently used. The medicated mist is discharged into a small plastic mask, which the child holds over the nose and mouth. To avoid particle deposition in the nose and pharynx, the child is instructed to take slow, deep breaths through an open mouth during treatment. The metered dose inhaler (MDI) is a self-contained, hand-held device that allows for intermittent delivery of a specified amount of medication. Many bronchodilators are available in this form. A major nursing responsibility during aerosol therapy is to assess the effectiveness of the treatment and the patient’s tolerance of the procedure. Assessment of breath sounds and work of breathing should be performed before and after treatment. •



Respiratory system/ Khulood Shattnawi

Postural (Bronchial) drainage: is indicated whenever normal ciliary activity and cough are not removing excessive fluid or mucus in the bronchi. Positioning the child to take maximum advantage of gravity facilitate removal of secretions. Postural drainage is most effective in children with chronic lung disease characterized by thick mucus secretions, such as cystic fibrosis. Postural drainage is carried out three to four times daily and is more effective when it follows other respiratory therapy, such as bronchodilator and/or nebulization medication. Bronchial drainage is generally performed before meals (or 1-1½ hours after meals) to minimize the chance of vomiting and repeated at bedtime. The length and duration of treatment depend on the child’s condition and tolerance level-usually 20-30 minutes. There are positions to facilitate drainage from all major lung segments, but all positions are not used at each session. Children will usually cooperate for four to six positions, but more than six tend to exceed their limits of tolerance. • Chest Physiotherapy (CPT): CPT usually refers to the use of postural drainage in combination with adjunctive techniques that are thought to enhance the clearance of mucus from the airway. • Percussion: The most common technique used in association with postural drainage is manual percussion of the chest wall. The patient is dressed in a light shirt and placed in a postural drainage position. The nurse then gently but firmly strikes the chest wall with a cupped hand. A “popping” hollow sound (not a slapping sound) should be the result. Percussion should be done over the rib cage only and should be painless. Percussion can be performed with a soft, circular mask. • Vibration: can be used to help move secretions during exhalations. Hand-held vibrators should be approved for use in an O2-enriched environment (tent, head hood). CPT is contraindicated when patients have pulmonary hemorrhage, pulmonary embolism, end-stage renal disease, or increased intracranial pressure. • Deep breathing: is often encouraged when the child is relaxed and in the desired position for drainage. The child is directed to take several deep breaths using diaphragmatic breathing. The use of deep breathing enlarges the tracheobronchial tree, enabling air to circulate around and through secretions that are not affected by usual tidal volume. Expirations after these deep breaths often carry secretions and may stimulate a cough. Other methods that can be employed to stimulate deep breathing are the use of blow method that extends the expiratory time and increases expiratory pressure. For example, play may include blowing pinwheel toys, moving small items by blowing through a straw, blowing up balloons, singing loudly, or blowing soap bubbles. • Coughing exercise: with or without stimulation, children are also encouraged to cough one or two hard coughs after a deep breath are efficient. • Tracheostomy: consist of surgical opening in the trachea between the second and fourth tracheal rings. It may be required in an emergency situation for epiglottitis, croup, or foreign body aspiration. These tracheostomies remain in place for a short time. An infant or child requiring long-term ventilatory support may also have a tracheostomy. Children who have undergone a tracheostomy must be closely monitored for complications such as hemorrhage, edema, aspiration, accidental decannulation, tube obstruction, and the entrance of free air into the pleural cavity. The focus of nursing care is maintaining a patent airway, facilitating the removal of pulmonary secretions, providing humidified air or O2, cleansing the stoma, monitoring the child’s ability to swallow, and teaching while simultaneously preventing complications. •



Respiratory system/ Khulood Shattnawi



Respiratory dysfunction: • Upper respiratory tract infections: – Otitis media (OM) – Croup (Laryngotracheobronchitis (LTB)) – Epiglottitis • Lower respiratory tract infections: – Acute Bronchitis – Bronchiolitis/ Respiratory Syncytial Virus (RSV) – Pneumonia • Long-term respiratory dysfunction: – Asthma – Cystic fibrosis (CF) • Conditions caused by physical defects: – Esophageal atresia and tracheoesophageal fistula – Diaphragmatic hernia

UPPER RESPIRATORY TRACT INFECTIONS (URTI) Otitis media (OM) OM is one of the most prevalent diseases of early childhood. Approximately 70% of children have had at least one episode and 33% have had three or more episodes by 3 years of age. The incidence is highest in children ages 6 months to 2 years; it then decreases with age. Acute OM is frequently caused by Streptococcus pneumoniae or Haemophilus influenza. The etiology of the noninfectious type is unknown, although it is frequently the result of blocked Eustachian tubes from the edema of URIs, allergic rhinitis, or hypertropic adenoids. Passive smoking has been established as a significant factor in the development of OM. A relationship has been observed between the incidence of OM and infant feeding methods. Infants fed breast milk have lower incidence of OM compared with formula-fed infants. Beside the protective effects of breast milk, reflux of milk up the eustachian tubes is less likely in breast-fed infants because of the semivertical positioning during breast-feeding compared with bottle-feeding. There is a definite link between the supine position during feeding and the reflux of fluid into the middle ear. Mechanical or functional obstruction of the Eustachian tube causes accumulation of secretions in the middle ear. Drainage is inhibited by sustained negative pressure and impaired ciliary transport within the tube. Complications: the consequences of prolonged middle ear disorders can be either functional or structural. The principal functional consequence is hearing loss, although loss in most children is conductive in nature and mild in severity. The causes of hearing loss are negative middle ear pressure, the presence of effusion in the middle ear, or structural damage to the tympanic membrane. However, the most feared consequence of hearing loss is its adverse effect on development of speech, language, and cognition. Structural complications involve primarily the tympanic membrane. Tympanic membrane retraction occurs when continued negative middle ear pressure draws the tympanic membrane inward. This retraction may result in impaired sound transmission, perforation of the thinned-out areas, or infection. Clinical manifestations: As purulent fluid accumulates in the small space of the middle ear chamber, pain results from the pressure on surrounding structures. Infants become irritable and indicate their discomfort by holding or pulling at their ears and rolling their head from side to side. A temperature as high as 40ْ C is common, and postauricular and cervical lymph glands may be enlarged. Rhinorrhea, vomiting, and diarrhea, as well as signs of concurrent respiratory or pharyngeal infection, may also be present. Loss of appetite typically occurs, and sucking or chewing tends to aggravate the pain. In children with OM

Respiratory system/ Khulood Shattnawi  with effusion exudates will accumulate and pressure will increase, with the potential for tympanic membrane rupture. As a result of rupture, there is immediate relief of pain, a gradual decrease in temperature, and the presence of purulent discharge in the external auditory canal. In acute OM, otoscope reveals an intact membrane that appears bright red and bulging, with no visible landmarks or light reflex. The usual landmarks of the bony prominence from the long and the short process of the malleus are obscured by the outwardly bulging membrane. Diagnosis is usually based on clinical manifestations, but if purulent discharge is present, it should be cultured and a specific antibiotic chosen for that organism. Treatment of acute OM involves a variety of antibiotics such as amoxicillin, sulfonamides, erythromycin-sulfisoxazole, and cephalosporins (such as cefixime (suprax), Cefzil). For fever or discomfort associated with OM, analgesic/antipyretic drugs such as acetaminophen or ibuprofen may be given. Antihistamines, decongestants, or ear drops are not recommended. Children should be seen after antibiotic therapy is complete to evaluate the effectiveness of the treatment and to identify potential complications, such as effusion or hearing impairment. Other treatments may include tympanostomy tubes where tiny tubes are inserted during a relatively simple operation (myringotomy), allow the pressure to equalize on either side of the eardrum by allowing free drainage of the fluid.

Nursing considerations: Nursing objectives for the child with OM include (1) relieving pain, (2) facilitating drainage when possible, (3) preventing complications or recurrence, (4) educating the family in care of the child, and (5) providing emotional support to the child and family. Analgesic are helpful to reduce severe earache. High fever should be reduced with antipyretic drugs. If the ear is draining, the external canal may be cleansed with sterile cotton swabs soaked in hydrogen peroxide. Parents require anticipatory guidance regarding temporary hearing loss that accompanies OM (they may need to speak louder, at closer proximity), and possible behavioral changes with hearing loss. Preventing recurrence requires adequate parent education regarding antibiotic therapy. Nurses must emphasize that although the child may appear well in a couple of days, the infection is not completely eradicated until all of the prescribed medication is taken (7-10 days). It is important to stress the potential complications of OM, especially hearing loss, which can be prevented with adequate treatment and follow-up care. Croup (Laryngotracheobronchitis (LTB)): LTB is one of the most frightening diseases of early childhood and primarily affects children less than 5 years of age (peaks between 6 months and 3 years). The cause is usually viral, organisms responsible for LTB are the parainfluenza virus (most common one), respiratory syncytial virus (RSV), influenza A and B, and Mycoplasma pneumoniae. The disease is usually preceded by a URI,

Respiratory system/ Khulood Shattnawi which gradually descends to adjacent structures. It is characterized by the gradual onset of lowgrade fever. Inflammation of the mucosa lining the larynx and trachea causes a narrowing of the airway. When the airway is significantly narrowed, the child struggles to inhale air past the obstruction and into the lungs, producing the characteristic inspiratory stridor and suprasternal retractions; other classic manifestations include barking cough and hoarseness. The child may be in slight to moderate respiratory distress, with mild wheezing and a low-grade fever. When the child is unable to inhale a sufficient volume of air, symptoms of hypoxia become evident. As the work of forcing air past the obstruction increases, negative pressure generated in the thoracic cavity also increases, leading to leakage of pulmonary vascular fluid into interstitial spaces and causing uneven ventilation and hypoxia. Obstruction severe enough to prevent adequate exhalation of carbon dioxide causes respiratory acidosis, and respiratory failure.

Therapeutic management: The major objective in medical management of infectious LTB is maintaining an airway and providing for adequate respiratory exchange. Children with mild croup (no stridor at rest) are managed at home. Parents are taught the signs of respiratory distress. High humidity with cool mist provides relief for most children. A cool-air vaporizer can be used at home. In the hospital setting, hoods for infants or mist tents for toddlers may be used to provide increased humidity and supplemental oxygen. The cool-temperature therapy modalities assist by constricting edematous blood vessels. In the home environment, suggestions to provide cool air include taking the child outside to breathe in cool night air, use of a cold-water vaporizer or humidifier, and standing in front of the open freezer. It is also essential to allow children with mild croup to continue to drink encourage they like and to encourage parents to use comforting measures with their child. If the child is unable to take oral fluids, IV fluid therapy might be indicated. Children with severe respiratory distress (respiratory rate more than 60 breaths/min for infants) should NOT be given anything by mouth to prevent aspiration and decrease the work of breathing. Nebulized epinephrine (5ml of 1:1000, cause mucosal vasoconstriction and subsequent decreases subglottic edema) is often used in children with more severe disease, stridor at rest, retractions, or difficulty breathing. The use of corticosteroids ( dexamethasone 0.6 mg/kg/dose IM injection) is beneficial because the anti-inflammatory effects decrease subglottic edema. Intubation is indicated in severe cases. Nursing considerations: The most important nursing function is continuous observation and accurate assessment of respiratory status. Intubation equipment should be readily accessible at the bedside so that it can be implemented whenever the nurse recognizes signs of impending respiratory failure. Early signs of impending airway obstruction include increased pulse and respiratory rate; substernal, suprasternal, and intercostal retractions; flaring nares; and increased restlessness. Laryngo spasm with total occlusion of the airway may occur when child’s gag reflex is elicited, or when the child is crying. It is important to comfort the child and do not elicit gag reflex (DON’T GAG CHILD WITH TONGUE BLADE). Epiglottitis Acute epiglottitis is a serious obstructive inflammatory process that occurs principally in children between 2 and 6 years of age but can occur from infancy to adulthood. The disorder requires immediate attention. The responsible organism is usually Haemophilus influenzae. The onset of epiglottitis is abrupt, less often preceded by cold symptoms and more often by a sore throat, and it can rapidly progress to severe respiratory distress. The child usually goes to bed asymptomatic to awaken later, complaining of sore throat and pain on swallowing. The child has a fever, muffled voice, stridor, appears sicker than clinical findings suggest, and usually exhibits the following behaviors: the child insists on sitting upright and leaning forward, with the chin thrust out,

Respiratory system/ Khulood Shattnawi


mouth open, and tongue protruding. Drooling of saliva is common because of the difficulty or pain in swallowing and excessive secretions. The child is irritable and extremely restless and has an anxious and frightened expression. Suprasternal and substernal retractions may be visible. The pale color of mild hypoxia may progress to frank cyanosis. The throat is red and inflamed, and a distinctive, large, cherry red, edematous epiglottis is visible on careful throat inspection. Throat inspection should be attempted only when immediate intubation can be performed if needed.

Therapeutic management: In epiglottitis, obstruction appears suddenly. Progressive obstruction leads to hypoxia (decreased O2 supply to tissue), hypercapnia (excess CO2 in blood), and acidosis followed by decreases muscular tone, reduced level of consciousness and, when obstruction becomes more or less complete, a rather sudden death. Endotracheal intubation or tracheostomy is usually considered for the child with H. influenzae epiglottits with severe respiratory distress. The epiglottal swelling usually decreases after 24 hours of antibiotic therapy, and the epiglottis is near normal by the third day. Children with suspected bacterial epiglottitis are given antibiotics intravenously, followed by oral administration to complete a 7- to 10-day course. The use of corticosteroids for reducing edema may be beneficial during the early hours of treatment. Intravenous (IV) fluids, until the child can swallow again is essential. Nursing considerations: It is important for the nurse to act quickly but calmly and provide support without increasing anxiety. The child is allowed to remain in the position that provides the most comfort and security and parents are reassured that everything possible is being done to obtain relief for their child. Nurses who suspect epiglottitis should not attempt to visualize the epiglottis directly with a tongue depressor or take a throat culture but should refer the child to a physician immediately. Continuous monitoring of respiratory status, including blood gases, is part of nursing observations, and the IV infusion is maintained.

Croup

Epiglottitis

Age

6mo-3yr

2yr-6yr

Season

Fall/winter

Anytime

Worst s/s

Night & am

24hours

History

URI, gradual onset

Sudden onset, no URI

Fever Drooling Cough Position Stridor Voice

Low-grade No Yes Sitting, lying Inspir/Expir Hoarse

Med-high Yes No Tripod sit Inspir Muffled

Respiratory system/ Khulood Shattnawi





INFECTIONS OF THE LOWER AIRWAYS Acute Bronchitis: Bronchitis is an inflammation of the large airways (trachea and bronchi), which is frequently associated with URI. Although there are several different types of bronchitis, the two most common are acute and chronic (primarily affects adults). Acute bronchitis is the inflammation of mucous membranes of the bronchial tubes. Viral agents usually cause this disease, although Mycoplasma pneumoniae is a common cause in children older than 6 years of age. It may also be caused by physical or chemical agents - dusts, allergens, strong fumes, and those from chemical cleaning compounds, or tobacco smoke. (Acute asthmatic bronchitis may happen as the result of an asthma attack, or it may be the cause of an asthma attack.). Bronchitis is a mild, self-limiting disease that requires only symptomatic treatment, including analgesics, antipyretics, and humidity. Cough suppressants may be useful to allow rest but can interfere with clearance of secretions. Most patients recover in 5 to 10 days. Bronchiolitis/ Respiratory Syncytial Virus (RSV): Bronchiolitis is an infection of the lower respiratory tract that usually affects infants (rare in children over 2 years of age). There is swelling in the smaller airways or bronchioles of the lung, which causes obstruction of air in the smaller airways. The infection occurs primarily in winter and spring. The most common cause of bronchiolitis is a virus, which is most frequently the respiratory syncytial virus (RSV) (50% of cases). However, many other viruses may be involved, including parainfluenza virus, adenovirus, and rhinovirus. Some bacteria can also cause bronchiolitis; these include mycoplasma pneumoniae and chlamydia pneumoniae. Initially, the virus causes an infection in the upper respiratory tract, and then spreads downward into the lower tract. RSV affects the epithelial cells of the respiratory tract. The virus causes inflammation and even death of the cells inside the respiratory tract. The bronchiole mucosa swell and lumina are subsequently filled with mucus and exudate. The walls of the bronchi and bronchioles are infiltrated with inflammatory cells. This leads to obstruction of airflow in and out of the child's lungs. Dilation of bronchial passages on inspiration allows sufficient space for intake of air, but narrowing of the passages on expiration prevents air from leaving the lungs. Thus air is trapped distal to the obstruction and causes progressive overinflation (emphysema). Clinical manifestations: The younger the infant, the greater the likelihood that severe lower respiratory tract disease requiring hospitalization will occur. The peak incidence for RSV is 2 to 5 months of age, but reinfection with RSV is extraordinarily common at all ages, with the highest rates being reported from daycare centers. The illness usually begins with URI after an incubation of about 5 to 8 days. Symptoms such as rhinorrhea and low-grade fever often appear first. Otitis media and conjunctivitis may also be present. In time, a cough may develop. If the disease progresses, it becomes a lower respiratory tract infection and manifests typical symptoms, which are: Initial symptoms: Rhinorrhea. Pharyngitis. Coughing/sneezing. Wheezing. Possible ear or eye infection. Intermittent fever. With progression of illness: • Increased coughing and wheezing. • Air hunger. • Tachypnea and retractions. • Cyanosis.

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Severe illness: • Tachypnea > 70 breaths/min. • Listlessness. • Apneic spells. • Poor air exchange; poor breath sounds. With infants there may be several days of URI symptoms or no symptoms except slight lethargy, poor feeding, or irritability. Therapeutic management: Bronchiolitis is treated symptomatically with high humidity, adequate fluid intake, rest, and medications. Most children with bronchiolitis can be managed at home. The child who is tachypneic, has marked retractions, seems listless, or has a history of poor fluid intake should be admitted. Mist therapy is generally combined with oxygen by hood or tent in concentrations sufficient to alleviate dyspnea and hypoxia, after which mist alone is continued for mild dyspnea. Fluids by mouth may be contraindicated because of tachypnea, weakness, and fatigue; therefore, IV fluids are preferred until the acute stage of the disease has passed. Medical therapy for bronchiolitis is controversial. Bronchodilators, corticosteroids, cough suppressants, and antibiotics have not proved to be effective in uncomplicated disease and are not recommended for routine use. Corticosteroids, theophylline, and furosemide have all been used for intubated and ventilated infants and children. Ribavirin, an antiviral agent may be used to treat RSV. Pneumonia Pneumonia is an inflammation of the pulmonary parenchyma caused by bacteria, viruses, or chemical irritants. It is a serious infection or inflammation in which the air sacs fill with exudate. Clinically, pneumonia may occur either as a primary disease or as a complication of another illness. Pneumonia can occur year round, but is usually seen in the winter and spring. Boys are affected by pneumonia more often than girls. There is an increased chance of developing pneumonia in a crowded area. Ten to 15 percent of children with a respiratory infection have pneumonia.

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Types of pneumonia: Lobar pneumonia - affects one or more lobes of the lungs.

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Bronchial pneumonia (or bronchopneumonia) – begins in the terminal bronchioles, which become clogged with mucopurulent exudate to form consolidated patches throughout both lungs; also called lobular pneumonia.

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Interstitial pneumonia – the inflammatory process is more or less confined within the alveolar walls and the peribronchial and interlobular tissues. Viral Pneumonia Viral pneumonia is caused by various viruses, including respiratory syncytial virus (most commonly seen in children under age 5), parainfluenza virus, influenza virus, adenovirus. Early symptoms of viral pneumonia are the same as those of bacterial pneumonia. However, with viral pneumonia, the respiratory involvement happens slowly. Wheezing may occur and the cough may worsen. Viral pneumonias may make a child susceptible to bacterial pneumonia. Treatment of viral pneumonia will be symptomatic, including: oxygenation (with cool mist), comfort, CPT and postural drainage, fluids and family support. Bacterial pneumonia Bacterial pneumonia is caused by various bacteria. Streptococcus pneumoniae (pneumococcus) is the most common bacterium that causes bacterial pneumonia. Many other bacteria may cause

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bacterial pneumonia including group B streptococcus, staphylococcus aureus, group A streptococcus and Haemophilus influenza type b (Hib). Bacterial pneumonia may have a quick onset and the following symptoms may occur: • Productive cough • Tachypnea. • Fever. • Breathe sounds: ronchi or fine crackles. • Chest pain (increased with deep breathing). • Retractions. • Nasal flaring. • Pallor to cyanosis (depends on severity) • Chest x-ray film: diffuse or patchy infiltration, with peribronchial distribution. • Behavior: irritable, restless and lethargic. • Gastrointestinal: anorexia, vomiting, diarrhea, and abdominal pain. Therapeutic management: Antimicrobial therapy has significantly reduced the morbidity and mortality from bacterial pneumonia. Therapy with penicillin G, intramuscularly or intravenously, or for penicillin-allergic children, erythromycin, clindamycin, chloramphenicol, or a cephalosporin, is effective in the treatment of pneumococcal pneumonia. Antibiotic therapy, bed rest, liberal oral intake or fluid, and administration of antipyretic for fever constitute the principal therapeutic measures. In addition, IV fluid administration is frequently necessary, and oxygen may be required if the child is in respiratory distress. Nursing considerations: Nursing care of the child with pneumonia is primarily supportive and symptomatic but necessitates thorough respiratory assessment and administration of oxygen and antibiotics. The child’s respiratory rate and status, as well as general disposition and level of activity are frequently assessed. Isolation procedures are instituted according to hospital policy; rest and conservation of energy are encouraged by the relief of physical and psychologic stress. If the cough is disturbing, the use of antitussive, especially before rest times and meals, is often helpful. To prevent dehydration, fluids are frequently administered intravenously. Children may be placed in a mist tent, with cool humidification moistening the airways and providing an atmosphere that assists in temperature reduction. Fever is controlled by the cool environment and administration of antipyretic drugs as prescribed. Asthma: Asthma is defined as a chronic inflammatory disorder of the airway. In susceptible children, inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night and/or in the early morning. These episodes are usually associated with variable airflow limitation or obstruction that is reversible either spontaneously or with treatment. The inflammation that occurs in asthma also causes an associated increase in bronchial hyperresponsiveness to a variety of stimuli. Triggers tending to precipitate and/or aggravate asthmatic exacerbation: • Allergens: • Outdoor: trees, grasses, molds, pollens, airpollution. • Indoor: dust, mold, cockroach antigen. • Irritants: tobacco smoke, wood smoke, odor sprays. • Exposure to occupational chemicals. • Exercise. • Cold air.

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Changes in weather or temperature. Environmental change: moving to new home, starting new school, etc. Colds and infections. Animals: cats, dogs, rodents, horses. Medications: aspirin, NSAIDs, antibiotics. Strong emotions: fear, anger, laughing, crying. Conditions: gastroesophageal reflux, tracheoesophageal fistula. • Food additives: sulfite preservatives. • Foods: nuts, milk/dairy products. • Endocrine factors: menses, pregnancy, and thyroid disease. • • • • • • •

The mechanisms responsible for the obstructive symptoms in asthma include: • Inflammation and edema of the mucus membrane. • Accumulation of tenacious secretions from mucus glands. • Spasm of the smooth muscle of the bronchi and bronchioles, which decreases the diameter of bronchioles.

Exacerbations are episodes of progressively worsening shortness of breath, cough, wheezing, chest tightness, or some combination of these changes. They also are characterized by decreases in expiratory airflow. Airways narrow because of bronchospasm, mucosal edema, and mucous plugging, with air being trapped behind occluded or narrowed airways. Functional residual capacity rises because the child is breathing close to total lung capacity; hyperinflation enables the child to keep the airways open and permits gas exchange to occur. Hypoxemia (decrease O2 in blood) can occur during episodes because of the mismatching of ventilation and perfusion. This is seen as increasing oxygen tension levels. Clinical manifestations: The classic manifestations of asthma are dyspnea, wheezing, and coughing. However, the timing of these symptoms varies among children. Bronchoconstriction in response to an allergen can have an immediate, histamine-type pattern or a late response with airway hypersensitivity lasting for days, weeks, or months. A second wave of symptoms can occur 6 to 8 hours after the initial antigen exposure. An asthmatic episode usually begins with children feeling uncomfortable or irritable and increasingly restless. They may also complain of a headache, feeling tired, or their chest feeling tight. Respiratory symptoms include a hacking, paroxysmal, irritative, and nonproductive cough caused by bronchial edema. Accumulated secretions, acting as a foreign body, stimulate the cough. As the secretions become more profuse, the cough becomes rattling and productive of frothy, clear, gelatinous sputum. Bronchial spasm and mucosal edema reduce the size of the bronchial lumen, and the bronchi may be occluded by mucus plugs. Auscultation may reveal: • Prolonged expiratory phase, usually with wheezing • Inspiratory wheezing suggests secretions in large airways • A silent chest may indicate such severe obstruction that flow rates are too low to generate breath sounds

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Therapeutic management: Nonpharmacologic therapy: the goal of nonpharmacologic therapy is prevention and reduction of the child’s exposure to allergens and irritants. Basic to any therapeutic plan is an evaluation of the child’s general health and an assessment of the specific allergic factors and the nonspecific factors that precipitate symptoms. Specific allergens are identified by skin testing, and steps are taken to eliminate or avoid the offending allergens. Pharmacologic: pharmacologic therapy is used to prevent and control asthma symptoms, reduce the frequency and severity of asthma exacerbations, and reverse airflow obstruction. Medications used to treat asthma are categorized into two general classes: long-term control medications (preventor medications) to achieve and maintain control of inflammation and quick-relief medications (rescue medications) to treat acute symptoms and exacerbations. Quick-relief ang long-term medications are often used in combination. Corticosteroids, cromolyn sodium and nedocromil, methylxanthines, and long-acting β2-agonists are used as long-term control medications. Short-acting β2-agonists, anticholinergics, and systemic corticosteroids are used as quick-relief medications. Many medications used to treat asthma are given by inhalation with a nebulizer or metered-dose inhaler (MDI). Corticosteroids are used to treat reversible airflow obstruction and to control symptoms and reduce bronchial hyperreactivity in chronic asthma. Corticosteroids may be administered parenterally, orally, or by aerosol. Cromolyn sodium is a nonsteroidal antiinflammatory drug. This drug blocks both the early and late reaction to allergens. Nedocromil sodium has both antiallergic and antiinflammatory properties. This drug inhibits the bronchoconstrictor response to inhaled antigens and inhibits the activity of and release of histamine and prostaglandins from inflammatory cells associated with asthma. The drug is used for maintainance therapy in asthma and is not effective for reversal of acute exacerbations. β-adrenergic agonists (albuterol, metaproterenol, terbutaline) are used for quick relief of acute exacerbations and for the prevention of exercise-induced bronchospasm. β-adrenergic agonists can be given via inhalation or as oral or parenteral preparations. The methylxanthines, principally theophylline, have been used for decades to relieve symptomes and prevent asthma attacks. Theophylline, however, is now considered a third-line agent and perhaps even unnecessary for treating asthma exacerbations. it is a weaker bronchodilator than the β-adrenergics, and because inflammation contributes to asthma, other drugs are of increased benefit. Theophylline may be administered intravenously, intramuscularly, orally, or rectally. In addition to its bronchodilator effect, theophylline is a central respiratory stimulant and increases respiratory muscle contractility. Anticholinergic therapy, the oldest form of bronchodilator therapy for asthma, reduces intrinsic vagal tone to the airways and blocks reflex bronchoconstriction caused by inhaled irritants. Anticholinergics are used for relief of acute bronchospasm. The primary drugs used are atropine or its derivative, ipratropiun, which does not cross the blood-brain barrier and therefore elicits no central nervous system effects. ■ Avoid – Sedatives ■ Depress respiratory drive – Antihistamines ■ Decrease LOC, dry secretions – Aspirin ■ High incidence of allergy Chest physiotherapy (CPT) includes breathing exercises and physical training. These therapies help produce physical and mental relaxation, improve posture, strengthen respiratory musculature, and develop more efficient patterns of breathing.

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Nursing considerations: • Airway • Breathing – Sitting position – Humidified O2 by NRB mask • Dry O2 dries mucus, worsens plugs – Encourage coughing – Be prepared for possible intubation, assisted ventilation • Circulation – IV – Assess for dehydration Also refer to nursing care plan/ the child with asthma. Status Asthmaticus: Status Asthmaticus is a severe, prolonged asthma exacerbation that has not been broken with repeated doses of bronchodilators. It is a true emergency that requires early recognition and immediate transport. Patients are in imminent danger of respiratory failure The symptoms of status asthmaticus are extreme difficulty with breathing, which causes restlessness and anxiety. Although coughing and wheezing are common symptoms of asthma, a child with status asthmaticus may not cough or wheeze because there is not enough airflow. Advanced symptoms include little or no breath sounds, inability to speak, cyanosis, and heavy sweating. Status asthmaticus can lead to unconsciousness and cardiopulmonary arrest, which can be fatal. Status asthmaticus is an emergency situation that can lead to death. Patient management is based upon administering large doses of corticosteroid drugs and bronchodilators and ensuring that the patient is receiving adequate oxygenation until the attack is completed Cystic Fibrosis (CF): CF, a condition characterized by exocrine (or mucus-producing) gland dysfunction that produces multisystem involvement, is the most common lethal genetic illness among white children, adolescents, and young adults. CF is inherited as autosomal recessive trait; the affected child inherits the defective gene from both parents, with an overall incidence of 1:4. The mutated gene responsible for CF is located on the long arm of chromosome 7. CF is characterized by several apparently unrelated clinical features: increased viscosity of mucus gland secretions, a striking elevation of sweat electrolytes, an increase in several organic and enzymatic constituents of saliva, and abnormalities in autonomic nervous system function. Patients with CF demonstrate decreased pancreatic secretion of bicarbonate and chloride, and the primary transport abnormality in CF involves an electrogenic chloride channel or its regulation. An increase in sodium and chloride in both saliva and sweat is characteristic of children with CF and forms the basis for one of the most reliable diagnostic procedures, the sweat chloride test. The sweat electrolyte abnormality is present from birth throughout life and is unrelated to the severity of the disease or the extent to which other organs are involved. The sodium and chloride content of sweat in children with CF is two to five times greater than that of the controls in 98% to 99% of affected children. The primary factor, and the one responsible for the multiple clinical manifestations of the disease, is mechanical obstruction caused by the increased viscosity of mucous gland secretions.

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Instead of forming a thin, freely flowing secretion, the mucous glands produce a thick mucoprotein that accumulates and dilates them. Small passages in organs such as the pancreas and bronchioles become obstructed as secretions precipitate or coagulate to from concretions in glands and ducts. Diagnosis of CF: • The first indicator is often meconium ileus in newborn babies. • Parents note that their baby " tastes salty" when kissed. • The sweat chloride test is used to diagnose the disease; > 60mEq/L is diagnostic. • Stool fat or enzyme analysis may be done. • CXR : patchy atelactesis and obstructive emphysema. Respiratory Tract: Because of the increased viscosity of bronchial mucus, there is greater resistance to ciliary action, a slower flow rate of mucus, and incomplete expectoration, which also contributes to the mucous obstruction. This retained mucus serves as an excellent medium for bacterial growth. Reduced oxygen-carbon dioxide exchange causes variable degreed of hypoxia, hypercapnia, and acidosis. In severe, progressive lung involvement, compression of pulmonary blood vessels and progressive lung dysfunction frequently lead to pulmonary hypertension, cor pulmonale (cor pulmonale is the term for CHF resulting from obstructive lung diseases), respiratory failure, and death. Pulmonary complications are present in almost all children with CF, but the onset and extent of involvement are variable. Symptoms are produced by stagnation of mucus in the airways, with eventual bacterial colonization leading to destruction of lung tissue. The abnormally vicous and tenacious secretions are difficult to expectorate and gradually obstruct the bronchi and bronchioles, causing scattered area of atelectasis and emphysema. Gastrointestinal Tract. In the pancreas of many patients, the thick secretions block the ducts, leading to cystic dilations of the acini (small lobes of the gland), which then undergo degeneration and progressive diffuse fibrosis. This event prevents essential pancreatic enzymes from reaching the duodenum, which causes marked impairment in the digestion and absorption of nutrients, particularly fats, proteins, and, to a lesser degree, carbohydrates. Disturbed absorption in reflected in excessive stool fat (steatorrhea) and protein (azotorrhea). The endocrine function of the pancreas often remains unchanged, since the islets of Langerhans are normal but may decrease in number as pancreatic fibrosis progresses. Howevere, the incidence of diabetes mellitus is greater in these children than in the general population. Clinical manifestations: Respiratory manifestations: initial manifestations are often wheezing respirations and a dry, nonproductive cough. Diffuse bronchial and bronchiolar obstruction leads to irregular aeration with progressive pulmonary disturbance and secondary infection. Dyspnea increases, the cough often becomes paroxysmall, and the mucoid impactions within the small air passages cause a generalized obstructive emphysema and patchy areas of atelactasis. Progressive pulmonary involvement with hyperaeration of functioning alveoli produces the overinflated, barrel shaped chest. When ventilation and subsequent diffusion and gas exchange are significantly impaired, cyanosis and clubbing of the fingers and toes may occur. Gastrointestinal manifestations: the earliest postnatal manifestation of CF is meconium ileus, which occurs in 7% to 10% of newborns with the disease. Thick intestinal secretions continue to be a problematic throughout life. Gumlike masses in the cecum can obstruct the bowel, causing pain, nausea, and vomiting. As the disease progresses, obstruction of pancreatic ducts prevents digestive enzymes (trypsin, lipase, chymotrypsin, & amylase) from being released into the duodenum, which prevents conversion of ingested food into compounds that can be absorbed by the intestinal mucosa. Consequently, the nondigested food is excreted (chiefly unabsorbed fats and proteins), increasing the bulk of feces to two or three times the normal amount. Because so little is absorbed from the intestine, affected children have difficulty maintaining weight despite a healthy appetite and diet. Unable to compensate for the fecal losses, children lose weight and exhibit marked wasting of tissues

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and failure to grow. The abdomen is distended, the extremities are thin, and the pale skin droops from wasted buttocks. The impaired ability to absorb fats results in a deficiency of the fat-soluble vitamins A, D, E, and K, which causes easy bruising. Anemia is a common complication. Reproductive system: delayed puberty in females with CF is common even when their nutritional and clinical status is good. Fertility can be inhibited by highly viscous cervical secretions, which act as a plug, blocking sperm entry. With few exceptions, males are sterile, which may be caused by blockage of the vas deferens with abnormal secretions or by failure of normal development of the wolffian duct structures resulting in decreased or absent sperm production. Integumentary system: parents frequently observe that their infants taste “salty” when they kiss them. The chloride channel defect in sweat glands prevents reabsorption of sodium and chloride, which leaves the affected person at risk for abnormal slat loss, dehydration, and hypochloremic and hyponatremic alkalosis during hyperthermic conditions. Therapeutic management: Pulmonary problems: prevention of infection by a daily routine of chest physiotherapy (CPT) to maintain pulmonary hygiene. Bronchodilator medication delivered in an aerosol helps open bronchi for easier expectoration and is administered before CPT. Pulmonary infections are treated as soon as they are recognized. Oxygen administration is usually recommended for children with acute episodes. GI problems: replacement of pancreatic enzymes (enteric-coated products) are administered with meals and snacks to ensure that digestive enzymes are mixed with food in the duodenum. Usually one to five capsules are administered with a meal, and a smaller amount is taken with snacks. The amount of enzyme is adjusted to achieve normal growth and a decrease in the number of stools to two or three per day. Children with CF require a well-balanced, high-protein, high-calorie diet. Since the uptake of fat-soluble vitamins is decreased, water-miscible forms of these vitamins (A, D, E, K) are given. When high-fat foods are eaten, the child is encouraged to add extra enzymes. Pancreatic enzymes should be taken within 30 minutes of eating, and the beads should not be chewed or crushed. Salt depletion through sweating can be a problem during hot weathers or physical exertion. Salt supplementation is often needed during hot weather or febrile periods and should include use of fluids.

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Esophageal atresia and tracheoesophageal fistula Atresia: absence of a normal opening Fistula: abnormal passage from a body organ to the body surface or between two internal body organs. Congenital esophageal atresia (EA) represents a failure of the esophagus to develop as a continuous passage. Instead, it ends as a blind pouch. Tracheoesophageal fistula (TEF) represents an abnormal opening between the trachea and esophagus. EA and TEF can occur separately or together. EA and TEF are diagnosed in the ICU at birth and treated immediately. The presence of EA is suspected in an infant with excessive salivation (drooling) and in a newborn with drooling that is frequently accompanied by choking, coughing and sneezing. When fed, these infants swallow normally but begin to cough and struggle as the fluid returns through the nose and mouth. The infant may become cyanotic (the 3 C's: coughing, choking & cyanosis) and may stop breathing as the overflow of fluid from the blind pouch is aspirated the trachea. The cyanosis is a result of laryngospasm. Aspiration and pneumonia will be common complication, and over time respiratory distress will develop. If any of the above signs/symptoms are noticed, a catheter is gently passed into the esophagus to check for resistance. If resistance is noted, other studies will be done to confirm the diagnosis. A catheter can be inserted and will show up as white on a regular x-ray film to demonstrate the blind

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pouch ending. Sometimes a small amount of barium is placed through the mouth to diagnose the problems. Treatment of EA and TEF is surgery to repair the defect. If EA or TEF is suspected, all oral feedings are stopped and intravenous fluids are started. The infant will be positioned to help drain secretions and decrease the likelihood of aspiration. Babies with EA may sometimes have other problems.

Types of esophageal atresia/ tracheoesophageal fistula. The most common type is the left-most diagram. In each diagram 1=esophagus (upper and lower portions) and 2=trachea Nursing considerations: refer to nursing care plan/the infant with esophageal atrasia and tracheoesophageal fistula. Congenital Diaphragmatic hernia: Congenital Diaphragmatic Hernia (CDH) occurs in about one in every 2,500 live births. Absence of the diaphragm may occur on the left, right or both sides, but the left side is most common. This defect allows abdominal organs to move into the chest cavity. With the heart, lungs, and abdominal organs all taking up space in the chest cavity, the lungs do not have space to develop properly. This underdevelopment of the lungs is called pulmonary hypoplasia. Diaphragmatic hernia is a multifactorial condition, which means that many factors, both genetic and environmental, are involved. Further (careful) fetal evaluation is indicated to rule out other birth defects as well as chromosomal anomalies, since they may adversely affect the outcome. Important prognostic predictors (for survival) include the degree of fetal liver herniation into the chest, the presence or absence of other anomalies. Prenatal evaluation consists of an ultrasound, fetal MRI, fetal chromosome studies, as well as a fetal echocardiogram. Whether a family chooses to terminate the pregnancy or carry to term for postnatal management, accurate counseling regarding the expected outcome is crucial. For CDH fetuses with chromosomal anomalies, survival would be rare. Postnatal management strategies include planned delivery, immediate stabilization, and immediate access to specialized ventilation techniques. Once the infant is stabilized, the diaphragmatic hernia is repaired with an operation. The stomach, intestine, and other abdominal organs are moved from the chest cavity back to the abdominal cavity and the hole in the diaphragm is repaired. Many babies will need to remain in the neonatal intensive care unit for a while after surgery. Although the abdominal organs are now in the right place, the lungs still remain underdeveloped. The baby will usually need to have breathing support for a period of time after surgery. The symptoms of diaphragmatic hernia are often observable soon after birth. The following are the most common symptoms: • Difficulty in breathing. • Tachycardia. • Cyanosis. • Abnormal chest development, with one side being larger than the other. • Concave abdomen. Management: repairing the herniated diaphragm

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Foreign Body Aspiration • Risk among older infants & children age 1 – 3 years. • Severity is determined by: – Location – Type of object aspirated – Extent of obstruction What do they aspirate? • Anything that can fit in the mouth • Most common – Food matter • Peanut = most common • Common, but less than food matter – Inorganic matter • Balloons = most lethal • Toy parts • Crayons • Coins Manifestations • Symptoms depends on the site of obstruction • Initially, choking, gagging, or coughing • laryngotracheal obstruction: dyspnea, cough, stridor, hoarseness because of decreased air entry. Cyanosis may occur if obstruction becomes worse • Bronchial obstruction: paroxysmal cough, wheezing, asymmetric breath sounds, decreased air entry, dyspnea. • With progressive obstruction: child’s face become discolored, child becomes unconscious and dies of asphyxiation • If the obstruction is partial, hours, days, or even weeks may pass without symptoms after the initial period. • secondary symptoms are related to the anatomic location of FB and usually caused by a persistent respiratory infection Therapeutic management • abdominal thrust older than 1 year, back blows and chest thrusts younger than 1, Heimlich •

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What IF…child conscious but cannot speak or cough? – Look for object in mouth/oropharynx • If visible – Remove it • NO blind finger sweeps – <12mo old • 5 Back blows then • 5 Chest thrusts – >12mo old • Heimlich maneuver Until object removed or child unconscious

Back blows to relieve foreign body obstruction in the infant.

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Infant is held lying face up along the length of an adult thigh while a hand administers chest thrusts in the proper direction to relieve a complete foreign body airway obstruction

Back slaps and Heimlich maneuver for older child

If child is Unconscious • <12mo old – ABC – Tongue-jaw lift – look for object – Attempt to ventilate – Continue 5 back blows and 5 chest thrusts – CPR as needed •

>12mo old – Lie child on floor – ABC – Tongue-jaw lift – look for object – Attempt to ventilate – 5 Abdominal thrusts – CPR if needed

Nursing consideration • Recognition signs of FB aspiration and distress. – Not every child who gags or coughs while eating is truly choking • The child in distress (truly choking): – Cannot speak – Becomes cyanostic – Collapses • Follow-up care after removal of FB include monitoring for signs of airway edema and respiratory distress • Place child in a high-humidity atmosphere. • Antibiotic: for secondary infection




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NURSING CARE PLAN The Child with Acute Respiratory Infection

Nursing Diagnosis: Ineffective breathing pattern related to inflammatory process Patient Goal 1: Will exhibit normal respiratory function • NURSING INTERVENTIONS/RATIONALES Position for maximum ventilation (i.e., open airway and permit maximum lung expansion) Allow position of comfort (e.g., tripod position of child with epiglottitis or maintain head elevation of at least 30 degrees) Check child's position frequently to ensure child does not slide down to avoid compressing the diaphragm Avoid constricting clothing or bedding Use pillows and padding to maintain open airway (e.g., in infant or child with hypotonia) Provide increased humidity and supplemental oxygen by placing child in small tent or hood (infant) or administer via nasal cannula or mask (preferred methods for children older than infancy because of safety issues) Promote rest and sleep by scheduling appropriate activity and rest periods Encourage relaxation techniques Teach child and family measures to ease respiratory efforts (i.e., appropriate positioning) For most respiratory illnesses use cool-mist humidifier in child's room For spasmodic croup create warm mist by running hot water in a closed bathroom (warm mist, often used for children with spasmodic croup, may be helpful because of its relaxing effect, but mostly because child is being held upright in the shower) • EXPECTED OUTCOMES Respirations remain within normal limits (see inside back cover for normal variations) Respirations are unlabored Child rests and sleeps quietly Patient Goal 2: Will receive optimum oxygen supply • NURSING INTERVENTIONS/RATIONALES Position for maximum ventilatory efficiency (see Goal 1, above) Use pulse oximetry to monitor oxygen saturations Place in cool, humidified environment, using appropriate oxygen delivery system Provide oxygen as prescribed and/or needed • EXPECTED OUTCOMES Child breathes easily Respirations remain within normal limits (see inside back cover for normal variations) Oxygen saturation is >95% Nursing Diagnosis: Fear/anxiety related to difficulty breathing, unfamiliar procedures, and possibly environment (hospital) Patient Goal 1: Will experience reduction of fear/anxiety • NURSING INTERVENTIONS/RATIONALES

Respiratory system/ Khulood Shattnawi  Explain unfamiliar procedures and equipment to child in developmentally appropriate terms Establish rapport with child and parents Remain with child and parent during procedures Use calm, reassuring manner Provide frequent attendance during acute phase of illness Provide comfort measures child prefers (e.g., rocking, stroking, music) Provide attachment objects (e.g., familiar toy, blanket) Encourage family-centered care with increased parental attendance and, when possible, involvement Do nothing to make child more anxious or fearful Instill confidence in both parents and child Try to avoid any intrusive or painful procedures Be aware of child's rest/sleep cycle or pattern in planning nursing activities Assess and implement appropriate pain management therapy (i.e., sedatives and/or analgesics) (see Pain Assessment; Pain Management, Chapter 26) Provide diversional activities appropriate to child's cognitive ability and condition Administer medications that promote improved ventilation (e.g., bronchodilators, expectorants) as prescribed

• EXPECTED OUTCOMES Child exhibits no signs of respiratory distress or physical discomfort Parents remain with child and provide comfort Child engages in quiet activities appropriate for age, interest, condition, and cognitive level Nursing Diagnosis: Ineffective airway clearance related to mechanical obstruction, inflammation, increased secretions, pain Patient Goal 1: Will maintain patent airway • NURSING INTERVENTIONS/RATIONALES Position child in proper body alignment to allow better lung expansion and improved gas exchange, as well as to prevent aspiration of secretions (prone, semiprone, side lying; for infants not at risk for aspiration, use supine or side-lying position for sleeping) Suction secretions from airway as needed Limit each suction attempt to 5 seconds with sufficient time between attempts to allow reoxygenation Position supine with head in "sniffing" position with neck slightly extended and nose pointed to ceiling Avoid neck hyperextension Assist child in expectorating sputum Administer expectorants if prescribed Perform chest physiotherapy Give nothing by mouth to prevent aspiration of fluids (e.g., child with severe tachypnea) Administer appropriate pain management Have emergency equipment available to avoid delay in treatment if needed Avoid throat examination and culture with suspected epiglottitis, because it could cause airway obstruction Assist child in splinting any incisional/injured area to maximize effects of coughing and chest physiotherapy • EXPECTED OUTCOMES Airways remain clear Child breathes easily; respirations are within normal limits (see inside back cover)

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Patient Goal 2: Will expectorate secretions adequately • NURSING INTERVENTIONS/RATIONALES Ensure adequate fluid intake to liquefy secretions Provide humidified atmosphere to prevent crusting of nasal secretions and drying of mucous membranes Explain importance of expectoration to child and family Assist child in coughing effectively; provide tissues Remove accumulated mucus; suction if needed Administer pain medications as indicated before attempt to clear airway Provide nebulization with appropriate solution and equipment as prescribed Assist with splinting so child will experience minimal discomfort Perform percussion, vibration, and postural drainage to facilitate drainage of secretions • EXPECTED OUTCOME Older child expectorates secretions without undue stress and fatigue; younger child will be able to have a productive cough

Nursing Diagnosis: Risk for infection related to presence of infective organisms Patient Goal 1: Will exhibit no signs of secondary infection • NURSING INTERVENTIONS/RATIONALES Maintain aseptic environment, using sterile suction catheters and good handwashing Isolate child as indicated to prevent nosocomial spread of infection Administer antibiotics as prescribed to prevent or treat infection Provide nutritious diet according to child's preferences and ability to consume nourishment to support body's natural defenses Encourage good chest physiotherapy Teach child and/or family manifestations of illness • EXPECTED OUTCOME Child exhibits evidence of diminishing symptoms of infection Patient Goal 2: Will not spread infection to others • NURSING INTERVENTIONS/RATIONALES Use standard precautions (see Infection Control, Chapter 27) Instruct others (parents, members of staff) in appropriate precautions Teach affected children protective methods to prevent spread of infection (e.g., handwashing, disposal of soiled tissues) Limit the number of visitors/family members/siblings and screen for any recent illness in visitors Try to keep infants and small children from placing hands and objects in contaminated areas Assess home situation and implement protective measures as feasible in individual circumstances Administer antimicrobial medications if prescribed • EXPECTED OUTCOME Others remain free from infection

Nursing Diagnosis: Activity intolerance related to inflammatory process, imbalance between oxygen

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supply and demand Patient Goal 1: Will maintain adequate energy levels • NURSING INTERVENTIONS/RATIONALES Assess child's level of physical tolerance Assist child in those activities of daily living that may be beyond tolerance Provide diversional activities appropriate to child's age, condition, capabilities, and interest Provide diversional play activities that promote rest and quiet but prevent boredom and withdrawal Provide rest and sleep periods appropriate to age and condition Instruct child to rest when feeling tired Balance rest and activity when ambulatory • EXPECTED OUTCOMES Child plays and rests quietly and engages in activities appropriate to age and capabilities (specify) Child exhibits no evidence of increased respiratory distress Child tolerates increasingly more activity Patient Goal 2: Will receive optimum rest • NURSING INTERVENTIONS/RATIONALES Provide quiet environment Organize activities for maximum sleep time Do not perform nonessential treatments or procedures to maximize rest Schedule visiting to allow for sufficient rest Encourage parents to remain with child Schedule treatments or other activities around the needs of the child so that fatigue will be minimized. Administer sedatives and analgesics as indicated if ordered for restlessness and pain Encourage frequent rest periods and regular sleep times Follow child's usual routine for bedtime and nap time Implement measures to ensure sleep, such as quiet, darkened room • EXPECTED OUTCOMES Child remains calm, quiet, and relaxed Child rests a sufficient amount (specify) Nursing Diagnosis: Pain related to inflammatory process, surgical incision

Patient Goal 1: Will experience no pain or reduction of pain/discomfort to level acceptable to child • NURSING INTERVENTIONs/RATIONALES Use local measures (gargles, troches, warmth or cold) to reduce throat pain Apply heat or cold as appropriate to affected area Administer analgesic as prescribed (see Pain Management, Chapter 26) Assess response to pain control measures (see Pain Assessment, Chapter 26) Encourage diversional activities appropriate to age, condition, capabilities

• EXPECTED OUTCOME



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Child has no pain or acceptable level of pain

Nursing Diagnosis: Altered family processes related to illness and/or hospitalization of a child Patient (family) Goal 1: Will experience reduction of anxiety and increased ability to cope • NURSING INTERVENTIONS/RATIONALES Recognize parental concern and need for information and support Explore family's feelings and "problems" surrounding hospitalization and child's illness Explain therapy and child's behavior Provide support as needed Encourage family-centered care and encourage family to become involved in their child's care • EXPECTED OUTCOME Parents ask appropriate questions, discuss child's condition and care calmly, and become involved positively in child's care See also Nursing Care Plan: The Family of the Child Who Is Ill or Hospitalized, Chapter 26 Nursing Care Plan: The Child in the Hospital, Chapter 26

Data from Wong DL: Whaley & Wong's Nursing Care of Infants and Children, ed. 6, St. Louis, 1999, Mosby, Inc.



Respiratory system/ Khulood Shattnawi

NURSING CARE PLAN The Child with Asthma Nursing Diagnosis: Risk for suffocation related to interaction between individual and allergen(s) Patient Goal 1: Will experience no asthmatic episode • NURSING INTERVENTIONS/RATIONALES Teach child and family how to avoid conditions or circumstances that precipitate asthmatic episode Assist parents in eliminating allergens or other stimuli that trigger exacerbation (see Box 32-17 for complete listing), such as: Meal planning to eliminate allergenic foods Removal of pets Modification of environment: "allergy-proof" home, especially no smoking in home Avoid extremes of environmental temperature When child is exposed to cold air, recommend breathing through nose (not mouth) and wearing a mask or scarf, or cupping hand over nose and mouth to create a reservoir of warm air to breathe Assist parents in obtaining and/or installing device to control environment (dehumidifier, air conditioner, electronic air filter) Teach child and family to recognize early signs and symptoms so that an impending episode can be controlled before it becomes distressful Teach child and family correct use of bronchodilators and antiinflammatory drugs (e.g., corticosteroids, cromolyn sodium), adverse effects, and dangers of overuse or underuse of drugs Teach child to understand how equipment works Teach child correct use of inhalers, nebulizers, and peak expiratory flow meters (PEFMs) Teach child and family prophylactic treatment when appropriate (e.g., prevent exercise-induced bronchospasm by using medication before exercise) Explain to child and family possible benefits of hyposensitization therapy when allergen(s) can be defined and cannot be avoided (e.g., pollen, mold) or controlled satisfactorally by drugs Administer hyposensitization therapy if prescribed • EXPECTED OUTCOMES Family makes every effort to remove or avoid possible allergens or precipitating events Child/family are able to detect signs of an impending episode early and implement appropriate actions Child/family are able to administer medications and use inhalers and other equipment Patient Goal 2: Will experience optimum health • NURSING INTERVENTIONS/RATIONALES Encourage sound health practices to support body's natural defenses: Balanced, nutritious diet Adequate rest Good hygiene Appropriate exercise Follow-up care Prevent respiratory infection, since it can trigger an attack or aggravate the asthmatic state Avoid exposure to infection Take meticulous care of equipment to avoid bacterial and/or fungal growth Use good handwashing • EXPECTED OUTCOMES Child and parents practice sound health practices



Respiratory system/ Khulood Shattnawi



Child exhibits no evidence of infection

Nursing Diagnosis: Activity intolerance related to imbalance between oxygen supply and demand Patient Goal 1: Will receive optimum rest • NURSING INTERVENTIONS/RATIONALES Encourage activities appropriate to child's condition and capabilities (specify) Provide ample opportunities for sleep, rest, and quiet activities to conserve oxygen supply • EXPECTED OUTCOMES Child engages in appropriate activities (specify) Child appears rested Nursing Diagnosis: Altered family processes related to having a child with a chronic illness Patient/Family Goal 1: Will exhibit positive adaptation to the condition • NURSING INTERVENTIONS/RATIONALES Foster positive family relationships Reinforce positive coping mechanisms of child and family Use every opportunity to increase parents' and child's understanding of the disease and its therapies, since adequate knowledge is related to family's timely use of preventive and emergency intervention Reinforce the need for responding to early signs of impending asthma episode using prescribed medications as needed to decrease potential for a severe exacerbation Intervene appropriately if there is evidence of maladaptation Be alert to signs of parental rejection or overprotection Be alert to signs that child is depressed and make appropriate referral for psychologic support, since depressed children, especially adolescents, may not comply with therapies as a means of passive suicide Teach child and family how to give respiratory treatments to eliminate any confusion regarding medication or inhalers/nebulizers Encourage family to contact school personnel (e.g., nurse, teachers, coaches, principal) to develop a consistent plan of care for school setting Refer family to appropriate support groups and community agencies • EXPECTED OUTCOMES Family copes with symptoms and effects of the disease and provides a normal environment for the child See Nursing Care Plan: The Child with Chronic Illness or Disability, Chapter 22 Nursing Diagnosis: Risk for suffocation related to bronchospasm, mucus secretions, edema Patient Goal 1: Will experience cessation of bronchospasm • NURSING INTERVENTIONS/RATIONALES Establish IV infusion for administration of medication and hydration Administer aerosolized bronchodilators and either oral or IV corticosteroids with or without epinephrine as prescribed to relieve bronchospasm Carefully monitor IV aminophylline infusion or oral theophylline for maximum efficacy and minimum side effects Closely monitor vital signs before, during, and after administration for maximum efficacy and

Respiratory system/ Khulood Shattnawi



minimum side effects Interview parents to determine medications given before admission to avoid possible overdose Have emergency equipment and medications readily available to prevent delay in treatment • EXPECTED OUTCOMES Child breathes more easily Child does not suffocate Patient Goal 2: Will exhibit normal respiratory function • NURSING INTERVENTIONS/RATIONALES Administer humidified oxygen by tent, face mask, or cannula to maintain satisfactory oxygenation Closely monitor oxygen saturations and blood gases via pulse oximetry to detect early or impending hypoxia Closely monitor percentage of oxygen delivered, since high levels may depress respirations Position for optimum lung expansion High-Fowler position Provide overbed table with pillow on which to lean if more comfortable for child Implement measures to reduce fear/anxiety to decrease respiratory efforts and oxygen consumption Encourage relaxation techniques to decrease anxiety and promote lung expansion Administer sedatives and tranquilizing agents, if prescribed, with extreme caution and when agitation is not caused by anoxia, since these drugs can depress respirations and mask signs of anoxia Organize activities to allow for rest, sleep, and minimum expenditure of energy

• EXPECTED OUTCOMES Child's respirations are unlabored and within normal limits (see inside back cover) Child rests and sleeps comfortably Child does not experience decreased oxygen saturations Patient Goal 3: Will successfully expel bronchial secretions • NURSING INTERVENTIONS/RATIONALES Provide adequate hydration, oral or IV, to liquefy secretions for easier removal Maintain NPO, if necessary, to prevent aspiration of fluids and food Provide humidified atmosphere to prevent drying of mucous membranes Encourage child to cough effectively Provide tissues Explain need to remove secretions Suction, using correct technique, only when necessary Do not use chest physiotherapy (CPT) during an acute episode, since it will only agitate an alreadyanxious, dyspneic child and aggravate the episode Position, if necessary, to prevent aspiration of secretions Semiprone Side-lying • EXPECTED OUTCOMES Secretions are adequately and easily expelled Child coughs effectively Child does not aspirate secretions, food, or fluids Nursing Diagnosis: Risk for fluid volume deficit related to difficulty taking fluids, insensible fluid losses from hyperventilation, and diaphoresis

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Patient Goal 1: Will exhibit adequate hydration • NURSING INTERVENTIONS/RATIONALES Maintain IV infusion at appropriate rate, since fluid therapy will enhance liquifaction of secretions (IV usually run two-thirds to three-quarters maintenance [unless dehydration present] in order to minimize the risk of pulmonary edema because of high inspiratory pressures) Encourage oral fluids Offer fluids when acute respiratory distress subsides to decrease risk of aspiration Avoid cold liquids, since they can trigger reflex bronchospasm Give fluids (and food) in small, frequent feedings to avoid abdominal distention that might interfere with diaphragmatic excursion Use play techniques appropriate to child's age to encourage fluid intake Measure intake and output Correct dehydration slowly, since overhydration can increase the accumulation of interstitial pulmonary fluid, leading to increased airway obstruction • EXPECTED OUTCOME Child exhibits adequate hydration Nursing Diagnosis: Risk for injury (respiratory acidosis, electrolyte imbalance) related to hypoventilation, dehydration Patient Goal 1: Will not experience acidosis • NURSING INTERVENTIONS/RATIONALES Closely monitor blood pH, since pH less than 7.25 impairs systemic, pulmonary, and coronary blood flow, and normal pH enhances effect of bronchodilators Administer sodium bicarbonate as ordered to prevent or correct acidosis Maintain IV infusion for administration of emergency medications and to prevent dehydration Prevent vomiting and subsequent dehydration; initially, child will experience alkalosis, but if vomiting becomes severe or uncontrolled, can lead to acidosis Implement measures to improve ventilation; hypoventilation may cause an accumulation of carbon dioxide, which will decrease pH • EXPECTED OUTCOME Child exhibits no evidence of respiratory acidosis Patient Goal 2: Will exhibit normal serum electrolytes • NURSING INTERVENTIONS/RATIONALES Closely monitor serum electrolytes, since dehydration, as well as medications, can alter normal serum electrolytes Maintain IV infusion at appropriate rate Prevent dehydration and vomiting, since they cause electrolyte imbalances • EXPECTED OUTCOME Child exhibits normal serum electrolytes Nursing Diagnosis: Altered family processes related to emergency hospitalization of child Patient/Family Goal 1: Will experience reduction of anxiety

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• NURSING INTERVENTIONS/RATIONALES Keep parents informed of child's condition Encourage expression of feelings, especially severity of condition and prognosis Allow parents to be with child as much as possible by encouraging family-centered care concepts Point out any evidence of improvement to encourage positive coping behaviors If/when possible, schedule treatments and care to child's routines Reduce sensory stimuli by maintaining quiet, relaxed environment • EXPECTED OUTCOMES Family verbalizes concerns and spends time with child Family exhibits no signs of distress See also: Nursing Care Plan: The Family of the Child Who Is Ill or Hospitalized, Chapter 26 Nursing Care Plan: The Child in the Hospital, Chapter 26

Nursing Diagnosis: Ineffective airway clearance related to allergenic response and inflammation in the bronchial tree Patient Goal 1: Will exhibit evidence of improved ventilatory capacity • NURSING INTERVENTIONS/RATIONALES Instruct and/or supervise breathing exercises and controlled breathing to promote proper diaphragmatic breathing, side expansion, and improved chest wall mobility Use play techniques for breathing exercises with young children (e.g., blow a pinwheel or blow cotton balls on table to extend expiratory time and increase expiratory pressure) Teach correct use of prescribed medications Teach correct use of PEFM, nebulizer, and metered-dose inhaler (MDI) if indicated Teach family to perform percussion and postural drainage and to encourage coughing if indicated Encourage physical exercise Recommend activities requiring short bursts of energy (e.g., baseball, sprints, skiing), since they may be better tolerated than those requiring endurance exercise (e.g., soccer, distance running) Recommend swimming because child breathes air saturated with moisture, and exhaling underwater prolongs expiration and increases end-expiratory pressure Restrict physical activity only when child's condition makes it necessary Encourage good posture for maximum lung expansion Assist child and family in selecting activities appropriate to child's capabilities and preferences • EXPECTED OUTCOMES Child breathes easily and without dyspnea Child exhibits improved ventilatory capacity (specify) Child engages in activities according to abilities and interest (specify)

Data from Wong DL: Whaley & Wong's Nursing Care of Infants and Children, ed. 6, St. Louis, 1999, Mosby, Inc.

Respiratory system/ Khulood Shattnawi



NURSING CARE PLAN The Infant with Esophageal Atresia and Tracheoesophageal Fistula

Nursing Diagnosis: Ineffective airway clearance related to abnormal opening between esophagus and trachea or obstruction to swallowing Patient Goal 1: Will maintain patent airway

• Nursing Interventions/Rationales Suction as necessary to remove accumulated secretions from oropharynx Position supine with head elevated on an inclined plane (at least 30 degrees) to decrease pressure against thoracic cavity and to minimize reflux of gastric secretions up distal esophagus and into trachea and bronchi Administer oxygen per unit guidelines (pulse oximetry, blood gases) to help relieve respiratory distress Do not use positive pressure (e.g., resuscitation bag/mask), since it may introduce air into stomach and intestines, creating additional pressure in thoracic cavity Administer nothing by mouth to prevent aspiration Maintain intermittent or continuous suction of esophageal segment, if ordered preoperatively, to keep blind pouch empty of secretions Leave gastrostomy tube, if present, open to gravity drainage so that air can escape, minimizing risk of regurgitation of gastric contents into trachea • Expected Outcomes Airway remains patent Infant does not aspirate secretions Respirations remain within normal limits Nursing Diagnosis: Impaired (difficulty) swallowing related to mechanical obstruction Patient Goal 1: Will receive adequate nourishment • Nursing Interventions/Rationales Administer gastrostomy feedings as prescribed to provide nourishment until oral feedings are possible Progress to oral feedings as prescribed according to infant's condition and surgical correction Observe closely to make certain infant is able to swallow without choking Monitor intake, output, and weight to assess adequacy of nutritional intake Give infant pacifier to provide for nonnutritive sucking Teach family appropriate feeding techniques to prepare for discharge • Expected Outcome Infant receives sufficient nourishment and exhibits a satisfactory weight gain Patient Goal 2: Patient will learn to take oral feedings (following complete repair) • Nursing Interventions/Rationales Introduce foods one at a time to evaluate tolerance of food item Provide age-appropriate foods with various textures and flavors to stimulate interest in eating Begin with pureed foods and progress to more solid food as child shows readiness

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Cut food in small, noncylindrical pieces to prevent choking Avoid foods such as whole hot dogs or large pieces of meat to decrease risk of choking Teach child to chew foods well to decrease risk of choking Refer to speech or occupational therapist, if appropriate, to facilitate learning • Expected Outcome Child takes an adequate amount of nourishment and displays no evidence of feeding resistance, malnutrition, or dysphagia Nursing Diagnosis: Risk for injury related to surgical procedure Patient Goal 1: Will not experience trauma to surgical site

• Nursing Interventions/Rationale Suction only with catheter premeasured to a distance that does not reach to surgical site to prevent trauma to mucosa • Expected Outcome Child does not exhibit evidence of injury to surgical site Nursing Diagnosis: Anxiety related to difficulty swallowing, discomfort from surgery Patient Goal 1: Will experience a sense of security without discomfort • Nursing Interventions/Rationales Provide tactile stimulation (e.g., cuddling, rocking) to facilitate optimum development and promote comfort Administer mouth care to keep mouth clean and mucous membranes moist Offer pacifier frequently to provide nonnutritive sucking Administer analgesics as prescribed Encourage parents to participate in child's care to provide comfort and security • Expected Outcomes Infant rests calmly, is alert when awake, and engages in nonnutritive sucking Mouth remains clean and moist Child experiences no or minimal pain Nursing Diagnosis: Altered family processes related to child with a physical defect Patient (family) Goal 1: Will be prepared for home care of child • Nursing Interventions/Rationales Teach family skills and observations needed for home care Positioning to prevent aspiration Signs of respiratory distress to prevent delay in treatment Signs of complications-refusal to eat, dysphagia, increased coughing-so practitioner can be notified Acquiring needed equipment and services Care of gastrostomy and esophagostomy when infant has staged surgery, including techniques such as suctioning, feeding, care of operative site and/or ostomies, dressing changes, to ensure appropriate care after discharge • Expected Outcome

Respiratory system/ Khulood Shattnawi

Family demonstrates ability to provide care to infant, an understanding of signs of complications, and appropriate actions See also: Nursing Care Plan: The Family of the Child Who Is Ill or Hospitalized, Chapter 26 Nursing Care Plan: The High-Risk Infant, Chapter 10

Data from Wong DL: Whaley & Wong's Nursing Care of Infants and Children, ed. 6, St. Louis, 1999, Mosby, Inc.