Neuro Alterations
Pediatric Variations
* Complete but immature nervous system – until 4 years old
* Brain and spinal cord develop from neural tube
* Large head and poor developed neck muscles
* Thin cranial bones – skull expands until 2, sutures unfused
* Excess spinal mobility – immature muscles/ligaments, incomplete vertebral ossification
* Risk of cervical injury or vertebral compression fractures with falls
Pediatric Assessment
* CT – may need sedation; lesions, tumors, edema, structures
* EEG – r/o seizures, continuous brain activity, wear for different amounts of time
* LP – ICP/CSF, may need sedation; spinal infection, meningitis
* MRI – tissue and structure, requires longer sedation; lesions, tumors, edema, structures
* XRAY – skull fractures
* EVM – lower is worse, want score of 15, used for nonverbal and “A&O” assessments
ADULT
PREVERBAL & INFANTS
* Time & Place (5)
* Confused (4)
* Inappropriate words (3)
* Incomprehensible words (2)
* No response (1)
* Smiles, coos, cries
* Irritable
* Cries in pain
* Moans in pain
* No response
Intracranial Pressure (ICP)
General IPC & Posturing
* Force exerted by tissue, CSF, blood – decreased perfusion with increase in ICP
* Low EMV, neuro, LOC
* Meningitis, seizure, trauma, substance, stroke, brain tumors, electrolyte imbalance
* Treat ASAP, assess head circumference 1x/shift
* Posturing – LATE SIGNS of serious brain injury
* Decorticate = towards the body, rigid flexion from trauma ABOVE brainstem
* Decerebrate = away from the body, extension from brainstem injury
Infants VS. Child SX
* Infant = bulging fontanel, separate sutures, irritable then lethargic, increased sleeping, high pitch scream, distended veins, setting sun (sunken eyes)
* Child = HA, N/forceful vomiting, diplopia, blurry vision, seizures, indifference, drowsy, decline in activity/school, cannot follow simple commands, lethargy
Late Signs of Increased ICP
* Posturing, low HR/high BP, fixed large pupil, decreased motor/sensory, Cheyne-Stokes breathing, GCS <8, coma
* Cushing’s Triad = increased systolic with wide pulse pressure, low HR, irregular RR
Treatment of ICP
* Evacuate cranial, Mannitol, elevate HOB 30
* O2 with ventilation if needed – stabilize airway
* Antibiotics (meningitis), fluids or blood
* Norepinephrine – increase perfusion and CO, serious cases
* Ventricular catheter – accumulated CSF from tumor
Seizures
Types, Stages, Manifestations
General
* Brief paroxysmal behaviors from excessive abnormal neuron firing
* Diagnosed around 2, MOST idiopathic unless family hx
* Primary = absence of abnormality; epilepsy
* Secondary/Symptomatic = structural or metabolic dx; hydrocephalus
* Subtle signs if <1yr – eye opening, fluttering, smacking, drooling, swimming or pedal movements instead of shaking
Types of Seizures
* Focal/Partial – one hemisphere from tumor or lesion
* Generalized – entire brain, epilepsy
* Febrile – rapid temperature from acute, risk of epilepsy in future, brief or 15 mins at 6m
* Tonic – rigidity of muscles
* Clonic – jerking movements
* Tonic Clonic – tonic first; excess drool or foaming, random noises, incontinence; postictal
* Absence – NO sx, brief LOC change, NO postictal, cluster or multiple a day, looks like zoning out or daydreaming
Stages of Seizures
* Aura = sensation alerting to oncoming seizure, NOT everyone has this
* Tonic
* Clonic
* Postictal = sleepy, confused, slurred speech, arousal only to pain
Status Epilepticus (EMERGENCY)
* Seizure >30 minutes or multiple with NO return to normal LOC between
* Maintain airway, assist if needed (O2 through Ambu), turn onto side, DON’T restrain
* Administer medications (midazolam), respiratory assessment, prevent injury and falls
Management & Nursing Care
Seizure Precautions
* Padded side rails up, Ambu/suction working
* Emergency medications if >5 minutes
* Midazolam (IN, home), Lorazepam (secondary), Diazepam
* Outpatient – swim buddy, showers, driving regulations, medical bracelet, medication adherence/safety, NO fire
Medications
Emergency
Midazolam – IN, 1st line
Lorazepam – IV push 2-3mins, secondary
Diazepam – IV or rectal
Phenytoin/Fosphenytoin or Phenobarbital – IV 2nd round
Maintenance
Try to stay on only one, follow-ups with neuro, need routine dental for gum AEs (gingivitis)
Phenytoin – monitor levels (neurotoxic), IV dose in NS
Fosphenytoin – less AEs
Valproic – monitor levels, PO
Levetiracetam – psych impulsivity, monitor gross motor, IV/PO
Phenobarbital – monitor levels, withdrawal sx if abrupt, sedation or hyperactive if toxic, drug interactions
Nursing Care
* Maintain appointment for levels
* DON’T suddenly stop taking the medication
* Birth control less effective
* Decreased seizure threshold with alcohol, weed, and street drugs
* Try keto or high fat diet
* Check driving regulations for recent seizures
* IF medication and diet NOT working…
* Vagal nerve stimulation – implant that sends impulses to increase perfusion and decrease number of seizures
Hydrocephalus
General
* Imbalance in production and absorption of CSF
* Common in spina bifida, acquired from trauma/abuse
* Production > absorption = accumulates, increasing ICP, dilation of ventricles
* DX: CT/MRI
In Infants
* Head grows abnormally, fontanels bulging, dilated scalp veins, separated sutures
* IF SEVERE – frontal bossing or protrusion, setting sun, sluggish fixed pupils
Ventriculo-Peritoneal Shunt
* Shunt in the ventricle to direct and reabsorb excess CSF
* Internal and end in the abdomen or RA of the heart
* Can be for life if congenital
* Needs revisions with growth – breakdown or length
* Risk of malfunction, infection, or occlusion
* May need to remove and place externally until infection treated
* Monitor ICP, head circumference, elevate HOB, keep calm (less crying)
Meningitis
General
* SX: poor feeding, crying, V/D, poor muscle tone, temperature changes, apnea in clusters, seizures
* Infant = fever (bacterial), bulging fontanels, lethargy, irritability
* Child = signs, severe HA, photophobia, drowsy, altered LOC
* Kernig – lift leg but cannot extend at knee, pain prevents flexion in supine
* Brudzinski – flex head causes involuntary knee/hip flexion
Management
* Private room if viral, droplet precautions – quiet rest periods to decrease ICP, cluster care
* VS/neuro/I&O – pupils, EMV, fontanels, head circumference, eating or drinking
* Antibiotics – broad until C/S
* Seizure precautions and medications – risk from high ICP and meningitis
* Alter for progressive sepsis – purpura, petechiae, low BP, mental status changes
* Vaccine – 12yrs to prevent severe, can lessen if given at diagnosis
Bacterial Meningitis
* Inflammation of meninges -> cerebral edema -> elevated ICP
* NEED antibiotics, more serious for newborns because immature immunity
* DX: lumbar puncture; high WBC/protein, low glucose, +gram stain
Acute Head Injury
General
* Complication of head trauma – seen with shaken baby
* SX: changes in LOC, transient confusion, somnolence, listless, irritable, pallor, 1+ episodes of projectile vomiting
* Progress = altered mental/difficult arousal, mounting agitation (behavior), focal neurological (movement), high BP, apnea
* Severe = increased ICP, bulging fontanel, retinal hemorrhage (SBS), hemiparesis, quadriplegia, elevated temp, unsteady gait
Medications
* Mannitol/Hypertonic 3% - pull off fluid and decrease pressure
* Steroids (dexa or methyl) – decrease ICP/pressure
* Anticonvulsants (pheno/y) – decrease seizure risk
* Sedative – caution with children, hard to tell if med or progression
* Ventricular drain if needed
Infant Botulism
General
* Soil, honey <1yr, improperly canned foods
* Progressive so catch early
* SX: HA, V/C, neurological impairment, weak descending paralysis and tone in respiratory muscles, hypotonia
* Seen in 12-36 hours after contamination
* TX: IV antitoxin, supportive or respiratory/nutritional
* MOST recover, but can lead to death if untreated
Endocrine & Metabolic Dysfunction
Pediatric Variations
* Immature but similar to adults – sex differentiation as fetus, growth/development, puberty
* Release of hormones controls cellular activity that regulates growth and metabolism
Disorders of the PITUITARY
Diabetes Insipidus – Dry Inside
* LOW ADH – cannot HOLD water, concentrate urine, or sustain hydration
* Inadequate production = central; autoimmune, tumor, trauma
* Ineffective action = nephrogenic; medication AEs or medication toxicity
* SX: polydipsia, polyuria, enuresis in kids (dehydration)
* HIGH serum Na/osmolarity, dilute urine
* TX: DDAVP to decrease UOP and thirst
* Nursing – daily weight, I&O, cold fluids, assess dehydration
SIADH – Soaked Inside
* HIGH ADH from feedback failure – HOLDS water, water toxicity, cellular edema
* Brain tumors/trauma, CNS, pulmonary disorders, positive pressure ventilation
* SX: FVO, HTN, JVD, crackles, weight gain WITHOUT edema, concentrated urine
* LOW serum Na, HIGH urine Na, LOW BUN (cellular expansion)
* TX: diuretics, vasopressin
* Nursing – restrict fluids, monitor fluid balance, I&O, daily weights
Precocious or Early Puberty
* Sexual development before 9 (males) and 8 (females) – more in females
* HPA axis has premature activation
* Results in premature skeletal maturation and short stature
* TX: leuprolide IM or nafarelin acetate IN 2x/day to slow progress
Disorders of the THYROID
Congenital Hypothyroidism
* MOST from organ abnormality or genetics, acquired is RARE, 3 months best prognosis
* C = few signs; thick tongue, hypotonia, umbilical hernia, hoarse cry
* A = like adult; cold, dry, constipated, thin hair, small height, delay bone/dental age
* Decreased hormones = delayed growth and developmental/intellectual delay
* Complications – retarded skull, delayed teeth eruption, ataxia, strabismus
* DX: newborn screening, LOW T3/T4, HIGH TSH
* TX: lifelong levothyroxine (10-15mcg/kg/day), T4/TSH checks
* Nursing – routine newborn screening before discharge, length/weight each visit (delays)
Disorders of the PANCREAS
Diabetes Mellitus
* Disorder of hyperglycemia from insulin secretion or production deficiencies leading to metabolism problems
* MOST children have type 1 – only difference from adults is treatment
Types of DM
* Type 1 = autoimmune, abrupt, NO insulin production
* DX – fasting >126, random >200, A1C >6.5
* SX – hyperglycemia, polyuria, polyphagia, polydipsia, weight loss, fatigue, enuresis
* Undiagnosed and leads to DKA
* TX – insulin; basal 1x/day, bolus with each meal or snack
Carbohydrate Counting
x grams/x units
Glucose
glucose - >x, divided by ratio
Total Insulin
Carbs + Glucose (round at end)
Insulin Pump Therapy
* Glycemic control especially in kids – continuous basal, like normal pancreas
* Can get disconnected, change site 2-3 days, risk of infection and pump failure (DKA)
Blood Glucose Monitoring
* 4x/day and A1C every 3 months
* Before meals, bedtime, any hypoglycemia sx, before activity, illness (more)
Sick Days
* Monitor glucose q.1-4 hours – more frequently, increased DKA risk
* Test urine ketones if BG >200 or q.2-4 hours
* Increase usual insulin dose but DON’T skip doses
* Maintain hydration
* Notify if cannot tolerate fluids, ketones, BG out of target, sx of dehydration
Developmental Considerations
* Toddler = funny feelings
* Preschool = reports lows and shaking
* School Age = supervise for mistakes with insulin, can inject and monitor carbs/sx self
* Adolescents – compliance; activity, substances
Hyperglycemia
* Causes – high carbs, too little insulin, incorrect administration, illness, injury, stress, decreased activity, eating too close together
* Gradual onset
* SX: lethargy, confusion, Kussmaul, thirst, hunger, dehydration, weak, fruity breath, fatigue
Diabetic Ketoacidosis (DKA)
* Relative or absolute insulin deficiency – new dx, noncompliance, stress, trauma, infection
* Glucose too low = breakdown of fats = ketones and metabolic acidosis/osmotic diuresis
* DX: >200, positive ketones, pH <7.3, HCO3 <15, urine glucose, high BUN/Cr, electrolytes
* SX: abdominal pain, N/V, polydipsia, polyuria, fruity acetone breath, dehydration, Kussmaul respiration, mental status changes
Treatment
* Fluid restriction -> NS bolus (10-20mL/kg) -> dextrose (if drop or <250 rapidly)
* Slowly replace electrolytes
* Insulin therapy for 12-24 hours then titrated and transition to SQ when stable
* Oral feedings when stable
* Monitor (q.1hr) – BG, neuro, VS, perfusion, RR
Prevention
* Monitor for abdominal pain, N/V, anorexia, 1-2 days with polyuria/polydipsia, illness without being able to eat
* Still need insulin when not able to eat
* Educate about the symptoms
* Check BG and ketones frequently, extra insulin or fluids
Hypoglycemia
* Low blood sugar between 70-80; MUST be symptomatic
* Kids at increased risk from growth, activity, insulin mistakes, eating patterns
* SX: irritable, nervous, shaky, difficulty concentrating, HA, dizzy, blurry vision, pallor, sweating, shallow respirations, high HR, palpitations
* Rule of 15 = test, 15 grams of carbs, retest and repeat until 70
* If unstable or unconscious glucagon kit, sugar gel, glucose paste
Inborn Errors of Metabolism
* Inherited RARE, biochemical – urea, protein, metabolism
Phenylketonuria (PKU)
* Mutation disorder of amino acids that affects the body’s use of protein
* Results in CNS damage from toxic levels of phenylamine
* DX: newborn screening
* SX: restricted ht/wt, musty urine, hypopigmentation, vomiting, irritable, seizures, hypertonia, cognitive `delays
* Irreversible brain injury if left undiagnosed
* NO CNS concerns if diet managed
* Dietary – formula low in phenylalanine, low protein diet that meets needs, NO aspartame
* Nursing – restricted throughout life, avoid in formula or in mom’s diet if breastfeeding
Galactosemia
* Disorder of carb metabolism – cannot convert glucose, galactose accumulates
* Leads to organ dysfunction, sepsis, brain and kidney damage
* DX: newborn screening
* S/S – poor sucking, no weight gain, V/D, hypoglycemia, hepatomegaly, ascites, jaundice, lethargy, seizures, coma
* TX: lactose or galactose free formula or diet, watch for added milk (antibiotics, etc.)
Cardiac Dysfunction
Pediatric Considerations
Fetal Circulation
* Ductus Venosus/Arteriosus, Foramen Ovale
* Fetal shunts close shortly after birth
* Permanently in 10-21 days
Pediatric Variations
* Can have congenital or acquired cardiovascular concerns
* SVR increases and right atrial pressure falls
* RV > LV – less use in utero from placenta, slowly grows
* Higher HR to maintain CO, metabolic rates, O2 demands
* Higher risk of HF – immature until 5, sensitive to volume and pressure overload
Cardiovascular Disease in Children
Manifestations
* Heart murmur is 1st sign
* Can be symptomatic after cord cutting or asymptomatic with a murmur
* If undiagnosed – exercise intolerance, CP, arrhythmias, syncope, sudden death
Diagnostics
* Chest X-Ray – anatomy, heart shape/size
* ECG – electrical activity, arrhythmias
* Echocardiogram – structure, flow, pressure
* MRI – anatomy, severity of defect
* Cardiac Cath – invasive to diagnose or treat; O2, CO, pressure, correct arrhythmias
* Bedrest for 4-6hrs with legs straight, minimal exercise for first 24hrs
* Monitor distal pulse (weak initially, loss of feeling/pulse), coolness or blanching (clot), HR/BP, bleeding, hematoma, F&E (IVF dextrose if low glucose, flush dye)
* Exercise Testing – stress test to monitor during exercise
* Labs – ABGs, SpO2, H&H
Assessment & Management
* Respiratory (more tired/WOB when eating), pulses (compare sides), BP between extremities, color of skin, murmurs, edema/distension (FVO and HF), cap refill, exercise tolerance, growth (higher O2 and metabolic demand, decreased with WOB)
* GOALS
* Improve resistance – vasodilators, ACEI, beta blockers, antihypertensives
* Remove excess fluid and Na – furosemide
* Decrease demands and SVR
* Improve oxygenation – CAREFUL supplementation of cyanotic defects
Digoxin Administration
* Used to improve strength, contractility, rate, rhythm, flexibility
* 2x/day, 1 hour before or 2 hours after eating, DON’T mix with food or fluids
* DON’T repeat dose if vomiting or double dose
* <4hrs give dose, >4hrs hold dose, miss 2 call provider
* Hold if HR <100 – educate about counting pulses
* IF toxicity occurs – N/V, bradycardia, anorexia, yellow vision
NANDA Considerations for ALL Cardiovascular Disorders
Ineffective Tissue Perfusion
* Administer Digoxin (monitor HR), diuretics, antihypertensives
* Monitor telemetry, I&O (fluid restrictions), daily weights, electrolytes
* Observe for circulation changes – pulses, edema, HR, skin, cap refill
* Rest periods – easily tired, heart cannot keep up, cluster care
Activity Intolerance
* Promote rest and utilize cluster care
* Prevent crying, encourage short play, prevent fevers – decrease O2 demands
* Supplemental O2 – CAREFUL administration with cyanotic disorders
Altered Nutrition
* Anticipate hunger to prevent crying
* Small frequent feedings - <30-45mins, relaxed environment, semi-erect position
* Burp before, during, after or every ounce
* Increased calories in formula – burn more calories from O2 demands
* Soft preemie nipple with large opening – decreased WOB to suck
Ineffective Breathing Patterns
* Assess respiratory – WOB, O2 stats, RR, retractions, belly breathing, nasal flaring
* Position to encourage maximum expansion
* NO tight clothes or tight swaddling
* Supplemental O2 during crying or invasive UNLESS cyanotic duct dependent
Acyanotic Lesions
Summary
* Left to right = increased pulmonary flow
* Higher lung resistance pressure creates right hypertrophy overtime
* NO cyanosis but murmurs with ALL
* SX: tachypnea, diaphoresis, eating exhaustion, pulmonary edema, rales, rhonchi
Types of Acyanotic
Patent Ductus Arteriosus (PDA)
* Left is open and patent
* Shunts from aorta to pulmonary arteries like in utero
* Can be NO sx or pulmonary
* TX: surgical ligation, Indomethacin (decrease prostaglandins to close)
Atrial Septal Defect (ASD)
* Opening between atria – blood to lungs
* Can close on own or patch surgically
* Can live with until sx, NOT immediate surgery
* Can involve tricuspid if large enough
Ventricular Septal Defect (VSD)
* Opening between the ventricles
* MOST common heart defect in children
* Can close on own or patch surgically
Obstructive Defects
Coarctation of Aorta (COA)
* Block in aorta – impaired flow to the body
* Increased WOB/pressure in left or abnormality in aortic valve leaflets
* Different BP in upper and lower extremities – low in lower with PDA close
* TX: prostaglandins, EMERGENCY heart cath or stent to stretch, anastomosis
Aortic Stenosis (AS)
* Narrowing of aortic valve – 2 leaflets instead of 3
* Increased WOB/CP from work on left – hypertrophy, injury
* Can have sudden death if only mild or asymptomatic
* TX: balloon, Ross, valve replacement
* Balloon – can renarrow, need valve replacement
* Ross – take own pulmonary valve to replace aortic
* Replacement – mechanical, will eventually need, lifelong anticoagulants
Cyanotic Lesions
Summary
* Right to left = decreased pulmonary flow
* Deoxygenated blood through aorta to the body – CAREFUL with supplemental O2
* SX: clubbing, HF, cyanosis, TET/hypercyanotic spells (common when crying), polycythemia
* Risk of decreased end-organ perfusion and hypoxemia
Types of Cyanotic
Transposition of the Great Arteries
* Pulmonary artery (leaves left) and aorta (leave right) connected to wrong chambers
* Oxygenated blood goes to the lungs, NO O2 reaching body
* MUST have VSD/PDA open to gets O2, ductal-dependent
* SX: cyanosis (increased as ducts close)
* TX: arterial switch of vessels, prostaglandins or balloon if delayed surgical at birth
Tricuspid Atresia
* Tricuspid valve doesn’t work or exist – small RV from not working, hypoplastic
* ASD/VSD to get O2 – ductal-dependent
* Can lead to CHF, arrhythmias, stroke, clots – eventually need heart transplant
* Requires 3 surgeries in phases
* 1st = VT shunt to connect pulmonary artery and aorta, like PDA right flow, outgrows
* 2nd (Glenn) = superior vena cava to pulmonary artery to get pulmonary flow
* 3rd (Fontan) = connect superior and inferior vena cava to pulmonary artery
Tetralogy of Fallot
* 4 separate heart defects together
* Pulmonic stenosis – narrowing, hard to get blood to lungs, open or remove block
* RV hypertrophy – overworked from stenosis, remove tissue to decrease work
* Ventricular septal defect – large VSD, patched surgically to close
* Overriding aorta – enlarged about VSD, too much poor O2 blood, NO surgery
* Need VT shunt and then complete repair in few months with sx
* Tet spells – blue skin during crying or feeding
* Squat or knee to chest to increase pressure and send blood to pulmonary artery
* THEN O2 supplementation, surgery with increased frequency in episodes
Acquired Heart Conditions
Kawasaki’s Disease
* Acute systemic vasculitis that affects coronary arteries – possible virus component
* Common in younger children, boys <2 yrs
* MOST recovery, few progress to HF - can get arthritis and thrombocytopenia
Criteria (Crash & Burn)
* Conjunctivitis, Rash (chest/genitals), Adenopathy, Strawberry tongue, Hands/feet swollen and peeling + 5 days of fever
Treatment
* High ASA and antiplatelets – fever and clots
* Immunoglobulin – prevents LT damage; consent, 2 nurses, hydrated, check renal before
* Nursing –cardiac, I&O, daily weight, fluids, monitor for MI (coronary involvement)
Dysrhythmias
* DX: 24hr Holter, ECG, Transesophageal (picture of heart)
* Brady – atropine or epi if symptomatic, check if HR normal for them first
* Tachy – can be normal in fever or shock
* SVT – MOST common; 200-300 bpm with narrow QRS
* Vagal/Valsalva first, adenosine (IV push fast), cardioversion, pacing (if reoccurring), ablation of source, digitalis, education (digoxin, maneuvers)
Respiratory Dysfunction
Eyes, Ears, Nose & Throat
Anatomical Differences
Eyes
* Decreased visual acuity (8 inches) until 6-7 years
* Cannot distinguish eye color initially – can change
* Eyes smaller and more easily injured
Ears
* Tube smaller, narrower, horizonal
* Sucking, yawning, swallowing allows free air, more prone to ear infections
* Membrane close to surface
* Hearing begins at 20 weeks’ gestation, tested at newborn screening
Nose, Mouth & Throat
* Nose breathers – prone to mucus accumulation
* Large tonsils
* Teeth in first six months
Nose & Throat Disorders
Nasopharyngitis
* Viral common cold, contact/droplet precautions
* SX: fever, clear drainage, sore red throat, sneezing, V/D (draining secretions)
* Risk of hospitalization in young from inability to clear secretions – NEED to clear for airway
* TX: supportive; hydrate, antipyretics, rest, cool mist, saline/suction, smaller frequent meals
Acute Streptococcal Pharyngitis
* SX: fever, enlarged tonsils, sore throat, SOME have tonsil exudate
* IF strawberry tongue or sandpaper rash – progressed to Scarlet Fever (NOT always)
* TX: antibiotics; contagious until 24hrs post
* Nursing – oral intake (cold, non-acidic), pain management, full AB
* If difficulty breathing, excess drooling, sx of respiratory distress see provider, can lead to abscess of epiglottitis
Tonsillitis & Adenoiditis
* Inflammation or infection of tonsils and adenoids from virus or bacteria
* SX: red tonsils, enlarged nodes, sore throat, fever, exudate, nasal stuffiness/discharge
* IF swollen enough, can obstruct airway
* TX: antibiotics, tonsillectomy/adenoidectomy if 7+/year or sleep concerns
* Nursing – fluids, pain control, monitor for post-op hemorrhage
* Scabs falling off -> excess swallowing or throwing up blood -> ligate vessels
Otitis Media
* Inflammation and/or infection –allergies, smoke, daycare, URI
* Can be with effusions if sx of infection and fluid in middle ear
* SX: otalgia pulling at ears, fever, crying/fussy, loss of appetite, hearing loss, vertigo
* TX: high dose antibiotics then ear drops, supportive if NO infection
* Tubes if 3+/6 months or 4+/year to allow continuous drainage
Respiratory System Variations
Anatomical Differences
* Grows and changes until 12 years old
* Shorter neck and narrower nostrils – higher risk of obstruction and congestion
* Less effective alveoli to ventilate
Upper Airway
* Shorter and narrower – size of pinkie finger
* Cartilage in trachea more flexible and easily compressed
* Increased airway resistances – narrow, increased effort with inflammation
Lower Airways
* <36 weeks’ – immature lungs, bronchi/bronchioles highly sensitive to inflammation
* Children <6 use diaphragm instead of intercostal muscles to breath
* Rib cartilage immature and flexible
* Higher metabolic rate – need more oxygen, little reserve, fatigue quickly
Airway & Breathing
* NEED to determine airway patency – clear secretions/objects, provide airway
* Adequate rise and fall – auscultate, retractions (sternal, subcostal/ribs, intercostal)
Interventions
* Patency – suction, sitting up HOB up, pillow or neck roller, tripod
* Oxygen supplementation if needed
* NC = colds, 10-15L/min
* Non-Rebreather = bag reservoir, high O2 quickly, emergency
* Venturi Mask = specific amount of O2
* High Flow NC = different machine, positive high pressure to open airway
* Medication – bronchodilators (asthma), hypertonic saline (secretions)
Worsening Conditions
* Distress – high RR, use of accessory, nasal flaring, grunting, tense face, irregular breathing patterns, bobbing of the head
* Worsening condition – increased O2 need >50% FiO2/>2L, periods of apnea, decreased breath sounds (any is BEST), decreased RR (high initially then fatigue), parental perception
Respiratory Distress & Upper Airway Disorders
Foreign Body Aspiration
* Inhalation of object into the respiratory tract – severity based on size, composition, age
* Leading cause of unintentional death <5 years old
* SX: choking, coughing, SOB, muffled or absent voice sounds, dyspnea, hypoxia, cyanosis
* TX: back blows (higher) or chest thrusts (lower, severe) 5x or until unresponsive
* Bronchoscopy in mouth or nose to remove if lower
Sudden Infant Death Syndrome (SIDs)
* Leading cause of infant mortality <1 year (2-4 months)
* Prevention is key – sleep on back, NO bed sharing, limited objects in bed, 1 layer of clothes, decreased secondhand tobacco smoke exposure
* If roll on stomach during sleep, OKAY if rolling milestone met
* Often found morning later because NO symptoms of distress, blood-tinged frothy sputum
Acute Respiratory Tract Infections
* Swelling of the epiglottis and larynx – can extend to trachea and bronchi
* Contact and droplet precautions
* SX: 103-105 fever, poor feeding, vomiting from coughing, swollen abdominal lymph nodes, nasal blockage, cough, advantageous respiratory sounds, sore throat
* TX: supportive; hydration, antipyretics, saline/suction, cool mist, AB if bacterial (rare)
Acute Epiglottis
* Inflammation and obstruction of tissue in back of larynx
* Rapid progression, can be life-threatening if airway lost – MEDICAL EMERGENCY
* Prevention with HIB vaccine
* SX: drooling, sudden sore throat, absence of spontaneous cough, dystonia (thick muffled voice), dysphagia, stridor, high HR/RR, cherry red edematous epiglottis
* TX: intubation, constant VS in ICU, O2, cultures, suction, fluids, IV AB and steroids
* NOTHING in the back of the throat – tongue depressor, throat cultures or exam can cause sudden loss of airway
Laryngotracheobronchitis (Croup)
* Viral inflammation of the larynx, epiglottis, bronchi, and trachea
* Any virus can trigger
* SX: barky brassy seal-like cough, hoarseness, stridor, mild fever, runny nose, irritable
* Only inpatient if stridor present
* TX: racemic epinephrine 1-2x then monitor, steroids for LT
* Nursing – O2 if hypoxic, monitor respiratory and airway, cool mist, PO fluids or NPO/IVFs depending on distress
* NEED to maintain the airway
Influenza
* A/B most common, C is more mild
* Contact and droplet precautions
* SX: sore throat, dry cough, rhinitis, fever, chills, HA
* TX: supportive if uncomplicated, IV AB if pneumonia, oseltamivir within 48hrs for 5 days
Lower Airway Disorders
Bronchiolitis
* Infection of bronchioles from RSV – NOT the same as bronchitis (URI)
* Common in winter and <12 months, contact and droplet precautions
* 2nd/3rd days worse, recover in 5-7 days
* SX: runny nose, cough, wheeze, fever, high RR (>70), retractions, cyanosis, dehydration, listless, apnea, respiratory failure, diminished breath sounds
Treatment & Nursing Care
* Symptomatic treatment
* Humidified oxygen (high flow NC), fluids, airway maintenance, saline drops or hypertonic saline, AB if bacterial
* NO inhalers or bronchodilators unless asthma dx or hx
* Synagis vaccine if increased RSV risk - $$$, NOT everyone
* Nursing – suction, saline/suction education, monitor WOB/O2/NC patency
Pneumonia
* Inflammation or infection of the bronchioles and alveolar spaces
* Community common, hospital acquired from vents
* SX: URI 1st, high RR, crackles, wheezes, increased WOB, CP, poor appetite, fever
* TX: IV AB and supportive, chest tube if pus/complicated
Chronic Lung Disorders
Asthma
* Reversible constriction, inflammation, hyperresponsive airway resulting in bronchospasms
* DX: PFT
* Triggers – exercise, temperature, air pollutants, allergens, tobacco, emotions, GERD, aspirin/NSAIDS, viral infections, stress, chemicals, fragrance, pet dander, genetics
* NEED to determine and remove triggers
* SX: dry hacking cough at night, chest tightness, wheezing, SOB, dyspnea, restless, fatigue, anxiety, tripod position, retractions, nasal flaring
Medication Treatment
* Albuterol – bronchodilator, use spacer, hold breath for 10 seconds after use
* Beclomethasone – inflammation, 1x/day; inhaler first, wash components, rinse mouth after
* Montelukast – relax muscle, decrease edema/mucous, PO in evening (sedation)
Acute Episodes
* Access ABCs, monitor response
* Bronchodilator, O2, steroids (burst/maintenance), IV mag/terbutaline (inflammation)
Long-Term Management
* Inform school and provide medication access
* Peak flow meter – home management of respiratory function; push air out, used for 2 weeks to determine normal and progression (lower number)
* Asthma action plan
* Education – medication use/how to, nebulizers, cleaning, identifying/removing triggers
Cystic Fibrosis
* Multisystem recessive– defective protein causing mucus obstruction in pancreas, GI, lungs
* Low life expectancy from complications and lung transplant needs
* DX: sweat test; medication to induce sweating and test for chloride (GOLD)
* NO cure only prevention of progress
* GOALS = facilitate airway/exchange, prevent infection, provide nutrition, promote exercise for lung function, meet emotional needs
Manifestations
* Respiratory = wheeze, cough, pneumonia, infection, thick sticky mucus; frequent hospital
* Endocrine = salty taste when kissed; pancreatic fat enzymes blocked DM in future
* Digestive = decreased motility; constipation, steatorrhea, flatus, unable to pass meconium
* Reproductive = blocked sperm duct, thick cervical mucus
Treatment
* Respiratory– chest physiotherapy, forced expiration, physical activity, bronchodilators
* Nutrition – pancrelipase, fat vitamins, high calorie/fat diet, monitor BG
* Vaccines to prevent infection, AB if it occurs
* Lumacaftor/Imacaftor – corrects protein malfunction in specific mutations, NOT everyone
* Opens chloride channels and decrease thickness of mucus
Complications
* Infection – highly colonized, NO sharing rooms with other CF patients
* CF diabetes
* End stage lung disease, respiratory failure, lung transplant – depends on access to tx