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Pediatrics 2


    1. Respiratory infections (illustration)
      1. Etiology: bacterial, viral; often influenced by age, season, preexisting disorder, living conditions
      2. Findings: increased respiratory and heart rate, fever, nausea/vomiting, nasal discharge and blockage, mucus production, coughing, adventitious lung sounds
      3. Nursing care goals:
        1. child will not exhibit findings of respiratory distress, will be able to clear secretions, and remain comfortable with a patent airway
        2. child will not spread infection to others
        3. child will ingest adequate fluids, and maintain hydration
      4. Management:
        1. medications: antibiotics, antipyretics
        2. possible: anti-inflammatory, anti-mucolytics, bronchodilators, oxygen as needed
        3. chest physiotherapy
        4. nutrition and fluids
    2. Respiratory failure: inability to maintain adequate oxygenation
      1. Predisposing factors
        1. obstructive anomalies, aspiration
        2. infections, tumors, anaphylaxis
        3. restrictive conditions: respiratory distress, cystic fibrosis, pneumonia, pneumothorax
        4. paralytic conditions
      2. Findings
        1. restlessness, mood changes
        2. changes in LOC
        3. increasing rates of respiration and pulse
        4. dyspnea
      3. Management
        1. frequent observation and physical exams, with pulse oximeter
        2. correct hypoxemia, maintain ventilation and deliver oxygen
        3. monitor for side effects and expected outcomes of therapy
    3. Airway obstruction and basic life support
      1. Cardiac arrest is usually due to prolonged hypoxemia secondary to inadequate ventilation, oxygen or circulation
      2. When following guidelines for pediatric life support, consider not just the child's age, but his or her size. Individual anatomy and development will vary.
      3. Airway clearance techniques
        1. determine conscious versus unconscious child
        2. for infants and toddlers: back blows and chest thrusts
        3. for preschool and school-age: modified Heimlich maneuver ("astride")

Infant Respiratory Disorders

    1. Respiratory distress syndrome ( RDS): "hyaline membrane disease"
      1. Etiology
        1. premature infants: usually due to surfactantdeficiency
        2. newborns: birth asphyxia, multiple gestations, diabetic mother
        3. older children: trauma, drowning
      2. Pathophysiology
        1. decrease in amount and/or quality of pulmonary surfactant
        2. in older children, surfactant may be washed out by drowning or fluid aspiration
      3. Findings  
        1. tachypnea, increased respiratory effort
        2. paradoxic "seesaw" respirations
        3. nasal flaring
        4. substernal retractions
        5. expiratory grunt, possible apnea
        6. cyanosis
        7. hypoxia
      4. Diagnostics
        1. physical exam, pulse oximeter
        2. serum: ABG's, glucose, calcium
        3. chest radiograph confirmation
      5. Management
        1. oxygen therapy (possible mechanical ventilation) and chest physiotherapy
        2. possible medications: surfactant, prophylactic antibiotics, diuretics, inotropes, methyl-xanthines
      6. Concerns
        1. increased alveolar surface tension
        2. impaired gas exchange (illustration 1  illustration 2)
        3. increased pulmonary resistance
        4. hypoperfusion
    2. Bronchopulmonary dysplasia: (BPD), chronic obstructive lung disorder
      1. Etiology - at risk:
        1. infants requiring oxygen and/or lengthy mechanical ventilation
        2. infants surviving RDS
        3. lung immaturity
      2. Pathophysiology
        1. mechanical ventilation presses lung tissue
        2. bronchial epithelium is damaged
        3. products of inflammation introduced, alveolar walls become thick, fibrotic
        4. continued mechanical ventilation affects the growth of new cells and paralyzes cilia
        5. lungs develop cystic areas (sacs) and atelectasis (collapsed alveoli); mucus moves less
      3. Findings
        1. tachycardia and tachypnea
        2. increased work of breathing
        3. pallor
        4. cyanosis with activity
        5. restlessness
      4. Management
        1. oxygen (possible mechanical ventilation)
        2. medications: diuretics, bronchodilators, anti-inflammatory agents in gradually decreasing amounts
        3. diet: increased calorie formulas and hydration
    3. Apnea: cessation of breathing for over 20 seconds
      1. Etiologies
        1. prematurity
        2. foreign-body aspiration, drowning, or trauma
        3. incorrect positioning
        4. gastroesophageal reflux
        5. infections
        6. seizure
        7. hypoglycemia
      2. Pathophysiology: dependent on type of apnea:
        1. central - absence of respiratory effort and air movement
        2. obstructive - respiratory effort but no air movement
        3. mixed - first central, then obstructive
      3. Findings
        1. depend on type (above)
        2. color changes, hypotonia
      4. Diagnostics: laboratory tests, chest x-rays, EEG, ECG, pneumocardiography, upper GI series
      5. Management
        1. home apnea monitoring and basic life support (BLS) training to family
        2. medications: based on type and underlying condition

Upper Respiratory Conditions

    1. Upper respiratory tract infections (URI) (illustration)
      1. Etiology: often acute viral nasopharyngitis, or the "common cold"
      2. Pathophysiology
        1. organism invades mucous membranes
        2. edema, vasodilation and increased mucus production
        3. usually self-limiting
      3. Findings: nasal congestion, sneezing, colored nasal discharge, low grade fever, cough, irritability
      4. Management:
        1. pharmacologic: antipyretics, decongestants (oral or nasal), analgesics
        2. cool mist humidifier
        3. adequate fluids
        4. rest
    2. Sinusitis (illustration)
      1. Etiology: viral, bacterial, URI, obstructive deformities, cystic fibrosis
      2. Findings
        1. cold that does not improve
        2. chronic nasal congestion, purulent nasal discharge
        3. headache
        4. tenderness over sinus areas
        5. halitosis
      3. Diagnostics: sinus x-rays, CT
      4. Management: antibiotics, antipyretics, analgesics, decongestants, antihistamines
    3. Acute pharyngitis
      1. Etiology: streptococcus (bacterial); or viral (often accompanies tonsillitis)
      2. Findings
        1. bacterial
          1. "sicker" with sudden onset
          2. very sore throat
          3. high fever
          4. headache
        2. viral
          1. gradual onset
          2. fever
          3. cough, rhinitis
      3. Diagnostics
        1. throat culture
        2. rapid strep
      4. Management: medications
        1. penicillin for strep
        2. possible antipyretics and analgesics
    4. Tonsillitis
      1. Etiology: bacterial, viral in association with pharyngitis
      2. Pathophysiology: infection and inflammation enlarge tonsils; as airway narrows, it hinders swallowing and breathing
      3. Findings
        1. "kissing tonsils"
        2. sore throat
        3. halitosis
        4. mouth breathing; snores at night
        5. fever
      4. Diagnostics: history, physical exam, throat culture
      5. Management
        1. supportive: antibiotics, fluids, rest, antipyretics, analgesics
        2. surgery - tonsillectomy
      6. Concern: teach parents that, post tonsillectomy for several days, child needs quiet activity, monitoring for bleeding, antipyretics and analgesics (no aspirin).
      7. Adenoidectomy may be done with tonsillectomy, if adenoiditis is present