chapter 36 the child with a respiratory disorder

LEARNING OBJECTIVES

On completion of this chapter, you should be able to:

1. Discuss ways the infant and child’s respiratory system differs from theadult’s system.

2. Name the most common complication of acute nasopharyngitis.

3. Discuss nursing care of the child with allergic rhinitis.

4. Discuss nursing care of the child with tonsillitis and adenoiditis.

5. Explain the most common complication of a tonsillectomy and list thesigns requiring observation.

6. Compare the croup syndrome disorders including: (a) spasmodic laryngitis,(b) acute laryngotracheobronchitis, and (c) epiglottitis.

7. Discuss the symptoms, diagnosis, and treatment of acute bronchiolitis/respiratory syncytial virus (RSV) infection.

8. Describe asthma including (a) factors that can trigger an asthma attack, (b) the physiologic response that occurs in the respiratory tract during anasthma attack, (c) treatment, and (d) nursing care.

9. Explain the diagnosis of pneumonia including the treatment and nursingcare.

10. Identify the basic defect and organs affected by cystic fibrosis, along withdiagnostic procedures.

11. Name the most common type of complication in cystic fibrosis anddescribe the dietary and pulmonary treatments of the disorder.

12. Discuss how tuberculosis is detected and treated.

The Child With a Respiratory Disorder

KEY TERMS

achyliaadenoidscircumoralcoryzacroupdysphagiaemetichypochyliametered-dose inhaler nebulizerstridorteratogenicitytonsilswheezing

775

RESPIRATORY disorders in infants and children arecommon. They range from mild to serious, even lifethreatening. They can be acute or chronic in nature.Sometimes these problems require hospitalization, whichinterrupts development of the child–family relationshipand the child’s patterns of sleeping, eating, and stimula-tion. Although the illness might be acute, if recovery israpid and the hospitalization brief, the child probablywill experience few, if any, long-term effects. However, ifthe condition is chronic or so serious that it requireslong-term care, both child and family may suffer seriousconsequences.

GROWTH AND DEVELOPMENT OFTHE RESPIRATORY SYSTEMThe respiratory system is made up of the nose, pharynx,larynx, trachea, epiglottis, bronchi, bronchioles, and the

lungs. These structures are involved in the exchange ofoxygen and carbon dioxide and the distribution of theoxygen to the body cells. Tiny, thin-walled sacs calledalveoli are responsible for distributing air into thebloodstream. It isalso through the alve-oli that carbon diox-ide is removed fromthe bloodstream andexhaled through therespiratory system.The structures andorgans found in therespiratory systemcleanse, warm, andhumidify the air thatenters the body.

This is critical toremember. The diameter of theinfant and child’s tra-chea is about the sizeof the child’s little fin-ger. This small diame-ter makes it extremelyimportant to be awarethat something can easilylodge in this small pas-sageway and obstruct the child’s airway.

36

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776 Unit X ❚ THE CHILD WITH A HEALTH DISORDER

Respiratory problems occur more often and withgreater severity in infants and children than in adults be-cause of their immature body defenses and small, unde-veloped anatomical structures. The respiratory tractgrows and changes until the child is about 12 years ofage. During the first 5 years, the child’s airway increasesin length but not in diameter.

Infants and young children have larger tongues in pro-portion to their mouths, shorter necks, narrower airways,and the structures are closer together. This leads to the pos-sibility of respiratory obstruction, especially if there isedema, swelling, orincreased mucus inthe airways. The abil-ity to breathe throughthe mouth when thenose is blocked is notautomatic but devel-ops as the child’sneurologic develop-ment increases.

The tonsillar tissue is enlarged in the early school-agechild, but the pharynx, which contains the tonsils, is stillsmall, so the possibility of obstruction of the upper air-way is more likely. In children older than 2 years of age,the right bronchus is shorter, wider, and more verticalthan the left.

Infants use the di-aphragm and ab-dominal muscles tobreathe. Beginningat about age 2 to 3years, the child startsusing the thoracicmuscles to breath.The change from us-ing abdominal to us-ing thoracic muscles for respiration is completed by theage of 7 years. Because accessory muscles are used forbreathing, weakness of these muscles can cause respira-tory failure (Fig. 36-1).

ACUTE NASOPHARYNGITIS(COMMON COLD)The common cold is one of the most common infectiousconditions of childhood. The young infant is as suscep-tible as the older child but generally is not exposed asfrequently.

The illness is of viral origin such as rhinoviruses,Coxsackie virus, respiratory syncytial virus (RSV), in-fluenza virus, parainfluenza virus, or adenovirus. Bac-terial invasion of the tissues might cause complicationssuch as ear, mastoid, and lung infections. The child ap-pears to be more susceptible to complications than is anadult. The infant should be protected from people whohave colds because complications in the infant can beserious.

Clinical ManifestationsThe child older than age 3 months usually develops feverearly in the course of the infection, often as high as102�F to 104�F (38.9�C–40�C). Younger infants usuallyare afebrile. The child sneezes and becomes irritable andrestless. The congested nasal passages can interfere withnursing, increasing the infant’s irritability. Because theolder child can mouth breathe, nasal congestion is not asgreat a concern as in the infant. The child might havevomiting or diarrhea, which might be caused by mucousdrainage into the digestive system.

DiagnosisThis nasopharyngeal condition might appear as the firstsymptom of many childhood contagious diseases, suchas measles, and must be observed carefully. The commoncold also needs to be differentiated from allergic rhinitis.

Treatment and Nursing CareThe child with an uncomplicated cold may not need anytreatment in addition to rest, increased fluids and ade-quate nutrition, normal saline nose drops, suction with a

This is important. Because the infant is anose breather, it isessential to keep thenasal passages clearto enable the infant to breath and to eat.

Think about this. If the child inhales a for-eign body, it is morelikely to be drawninto the rightbronchus rather thanthe left.

Diaphragm

Left lung

Left bronchus

Medi-astinum

Larynx and vocal folds

Esophagus

Trachea

Frompulmonary

artery

Topulmonaryvein

Alveoli

Capillaries

Terminalbronchiole

Alveolarduct

■ Figure 36-1 Anatomy of the child’s respiratory tract.


Chapter 36 ❚ The Child With a Respiratory Disorder 777

bulb syringe, and a humidified environment. In the olderchild, acetaminophen or children’s ibuprofen can be ad-ministered as an analgesic and antipyretic. It is best if as-pirin is avoided. If the nares or upper lip become irri-tated, cold cream or petrolatum (Vaseline) can be used.The child needs to be comforted by holding, rocking,and soothing. If the symptoms persist for several days,the child must be seen by a physician to rule out com-plications, such as otitis media.

ALLERGIC RHINITIS (HAY FEVER)Allergic rhinitis in children is most often caused by sen-sitization to animal dander, house dust, pollens, andmolds. Pollen allergy seldom appears before 4 or 5 yearsof age.

Clinical ManifestationsA watery nasal discharge, postnasal drip, sneezing, andallergic conjunctivitis are the usual symptoms of allergicrhinitis. Continued sniffing, itching of the nose andpalate, and the “allergic salute,” in which the childpushes his or her nose upward and backward to relieveitching and open the air passages in the nose, are com-mon complaints. Because of congestion in the nose, thereis backpressure to the blood circulation around the eyes,and dark circles are visible under the eyes (Fig. 36-2).Headaches are common in older children.

Treatment and Nursing CareWhen possible, offending allergens are avoided or re-moved from the environment. Antihistamine–decongestant

preparations, such as Dimetapp and Actifed, can behelpful for some patients. Hyposensitization can be im-plemented, particularly if antihistamines are not helpfulor are needed chronically. Be sure to teach parents theimportance of avoiding allergens and administering antihistamines to decrease symptoms.

TONSILLITIS AND ADENOIDITISTonsillitis is a common illness in childhood resultingfrom pharyngitis. A brief description of the location andfunctions of the tonsils and adenoids serves as an intro-duction to the discussion of their infection and medicaland surgical treatments.

A ring of lymphoid tissue encircles the pharynx, form-ing a protective barrier against upper respiratory infec-tion. This ring consists of groups of lymphoid tonsils,including the faucial, the commonly known tonsils; pha-ryngeal, known as the adenoids; and lingual tonsils.Lymphoid tissue normally enlarges progressively inchildhood between the ages of 2 and 10 years andshrinks during preadolescence. If the tissue itself be-comes a site of acute or chronic infection, it may becomehypertrophied and can interfere with breathing, causepartial deafness, or become a source of infection in itself.

Clinical Manifestations and DiagnosisThe child with tonsillitis may have a fever of 101�F(38.4�C) or more; a sore throat, often with dysphagia(difficulty swallowing); hypertrophied tonsils; and ery-thema of the soft palate. Exudate may be visible on thetonsils. The symptoms vary somewhat with the causativeorganism. Throat cultures are performed to diagnosetonsillitis and the causative organism. Frequently thecause of tonsillitis is viral, although beta-hemolyticstreptococcal infection also may be the cause.

Treatment and Nursing CareMedical treatment oftonsillitis consists ofanalgesics for pain,antipyretics for fever,and an antibiotic inthe case of strepto-coccal infection.

Teach parents thata soft or liquid dietis easier for the childto swallow, and toencourage the childto maintain goodfluid intake. A cool-mist vaporizer may be used to easerespirations.

Tonsillectomies and adenoidectomies are controver-sial. One can be performed independent of the other,but they are often done together. No conclusive evidencehas been found that a tonsillectomy in itself improves achild’s health by reducing the number of respiratory

■ Figure 36-2 Back pressure to blood circulation aroundthe eyes leads to dark areas under the eyes in the child withallergic rhinitis. The child pushes the nose upward in the“allergic salute” to relieve itching and open the airway.

Here’s a pharmacologyfact.A standard 10-day courseof antibiotics is often rec-ommended for thetreatment of tonsilli-tis. Stress the impor-tance of completing thefull prescription of antibi-otic to ensure that thestreptococcal infection iseliminated.



infections, increasing the appetite, or improving gen-eral well-being. Currently, tonsillectomies generally arenot performed unless other measures are ineffective orthe tonsils are so hypertrophied that breathing and eat-ing are difficult. Tonsillectomies are not performedwhile the tonsils are infected. The adenoids are moresusceptible to chronic infection. An indication for ade-noidectomy is hypertrophy of the tissue to the extent ofimpairing hearing or interfering with breathing. Per-forming only an adenoidectomy if the tonsil tissue ap-pears to be healthy is an increasingly common practice.Tonsillectomy is postponed until after the age of 4 or 5years, except in the rare instance when it appears it isurgently needed. Often when a child has reached theacceptable age, the apparent need for the tonsillectomyhas disappeared.

Nursing Process for the Child Having a TonsillectomyAssessmentMuch of the preoperative preparation, such as completeblood count, bleeding and clotting time, and urinalysis,is done on a preadmission outpatient basis. In many fa-cilities, the child is admitted on the day of surgery or theprocedure is done in a day surgery setting. Psychologicalpreparation is often accomplished through preadmissionorientation. Acting out the forthcoming experience, par-ticularly in a group, with the use of puppets, dolls, andplay-doctor or play-nurse material helps the child de-velop security. The amount and the timing of prepara-tion before admission depend on the child’s age. Thechild may become frightened about losing a body part.Telling the child that the troublesome tonsils are going tobe “fixed” is a much better choice than saying that theyare going to be “taken out.” Include the child and thecaregiver in the admission interview. Ask about anybleeding tendencies because postoperative bleeding is aconcern. Carefully explain all procedures to the childand be sensitive to the child’s apprehension. Take andrecord vital signs to establish a baseline for postopera-tive monitoring. The temperature is an important part ofthe data collection to determine that the child has no up-per respiratory infection. Observe the child for looseteeth that could cause a problem during administrationof anesthesia, document findings.

Selected Nursing Diagnoses■ Risk for Aspiration postoperatively related to

impaired swallowing and bleeding at the operativesite

■ Acute Pain related to surgical procedure■ Deficient Fluid Volume related to inadequate oral

intake secondary to painful swallowing■ Deficient Knowledge related to caregivers under-

standing of postdischarge home care and signs andsymptoms of complications

Outcome Identification and PlanningThe major postoperative goals for the child include pre-venting aspiration; relieving pain, especially while swal-lowing; and improving fluid intake. The major goal forthe family is to increase knowledge and understanding ofpostdischarge care and possible complications. Designthe plan of care with these goals in mind.

ImplementationPreventing Aspiration PostoperativelyImmediately after a tonsillectomy, place the child in apartially prone position with head turned to one side un-til the child is completely awake. This position can be ac-complished by turning the child partially over and byflexing the knee where the child is not resting to helpmaintain the position. Keeping the head slightly lowerthan the chest helps facilitate drainage of secretions.Avoid placing pillows under the chest and abdomen,which may hamper respiration. Encourage the child toexpectorate all secretions, and place an ample supply oftissues and a waste container near him or her. Discour-age the child from coughing. Check vital signs every 10to 15 minutes until the child is fully awake and thencheck every 30 minutes to 1 hour. Note the child’s pre-operative baseline vital signs to interpret the vital signscorrectly. Hemorrhage is the most common complica-tion of a tonsillectomy. Bleeding is most often a concernwithin the first 24 hours after surgery and the fifth toseventh postoperative day. During the 24 hours aftersurgery, observe, document, and report any unusual rest-lessness or anxiety, frequent swallowing, or rapid pulsethat may indicate bleeding. Vomiting dark, old bloodmay be expected, but bright, red-flecked emesis or ooz-ing indicates fresh bleeding. Observe the pharynx with aflashlight each time vital signs are checked. Bleeding canoccur when the clots dissolve between the fifth and sev-enth postoperative days if new tissue is not yet present.Because the child is cared for at home by this time, givethe family caregivers information concerning signs andsymptoms for which to watch.

Providing Comfort and Relieving PainApply an ice collar postoperatively; however, remove thecollar if the child is uncomfortable with it. Administerpain medication as ordered. Liquid acetaminophen withcodeine is often prescribed. Rectal or intravenous anal-gesics may be used. Encourage the caregiver to remain atthe bedside to provide soothing reassurance. Crying irri-tates the raw throat and increases the child’s discomfort;thus, it should be avoided if possible. Teach the caregiverwhat may be expected in drainage and signs that shouldbe reported immediately to the nursing staff.

Encouraging Fluid IntakeWhen the child is fully awake from surgery, give smallamounts of clear fluids or ice chips. Synthetic juices,



carbonated beverages that are “flat,” and frozen juicepopsicles are good choices.

Avoid irritating liquids, such as orange juice and lemon-ade. Milk and ice cream products tend to cling to the sur-gical site and make swallowing more difficult; thus, theyare poor choices, de-spite the old traditionof offering ice creamafter a tonsillectomy.Continue administra-tion of intravenousfluid and record in-take and output untiladequate oral intakeis established.

Providing Family TeachingThe child typically is discharged on the day of or the dayafter surgery if no complications are present. Instruct thecaregiver to keep the child relatively quiet for a few daysafter discharge. Recommend giving soft foods and non-irritating liquids for the first few days. Teach familymembers that if at any time after the surgery they noteany signs of hemorrhage (bright red bleeding, frequentswallowing, restlessness), they should notify the careprovider. Provide written instructions and telephonenumbers before discharge. Advise the caregivers that amild earache may be expected about the third day.

Evaluation: Goals and Expected OutcomesGoal: The child’s airway will remain patent after surgery.Expected Outcomes: The child

■ shows signs of an open and clear airway. ■ expectorates saliva and drainage with no aspiration.Goal: The child will show signs of being comfortable.Expected Outcomes: The child

■ rests quietly and does not cry.■ exhibits pulse rate that is regular and normal for

their age.■ states that pain is lessened.

Goal: The child’s fluid intake will be adequate fortheir age.

Expected Outcomes: The child’s

■ skin turgor is good.■ mucous membranes are moist.■ hourly urinary output is at least 20 to 30 mL. ■ parenteral fluids are maintained until oral fluid

intake is adequate.Goal: Family caregivers will verbalize an understand-

ing of postdischarge care.Expected Outcomes: Family caregivers

■ give appropriate responses when questioned aboutcare at home.

■ verbalize signs and symptoms of complications andask appropriate questions for clarification.

CROUP SYNDROMESCroup is not a disease, but a group of disorders typicallyinvolving a barking cough, hoarseness, and inspiratorystridor (shrill, harsh respiratory sound). The disordersare named for the respiratory structures involved. Acutelaryngotracheobronchitis, for instance, affects the lar-ynx, trachea, and major bronchi.

SPASMODIC LARYNGITISSpasmodic laryngitis occurs in children between ages 1 and 3 years. The cause is undetermined; it may be ofinfectious or allergic origin, but certain children seem todevelop severe laryngospasm with little, if any, apparentcause.

Clinical Manifestations and DiagnosisThe attack may be preceded by coryza (runny nose) andhoarseness or by no apparent signs of respiratory irreg-ularity during the evening. The child awakens after a fewhours of sleep with a bark-like cough, increasing respi-ratory difficulty, and stridor. The child becomes anxious,restless, and markedly hoarse. A low-grade fever andmild upper respiratory infection may be present.

This condition is not serious but is frightening both tothe child and to the family. The episode subsides after afew hours; little evidence remains the next day when ananxious caregiver takes the child to the physician. At-tacks frequently occur 2 or 3 nights in succession.

Treatment and Nursing CareHumidified air is helpful in reducing laryngospasm. Hu-midifiers may be used in the child’s bedroom to providehigh humidity. Cool humidifiers are recommended, butvaporizers also may be used. If a vaporizer is used, cau-tion must be taken to place it out of the child’s reach toprotect the child from being burned. Cool-mist humidi-fiers provide safe humidity. Humidifiers and vaporizersmust be cleaned regularly to prevent the growth of unde-sirable organisms. Sometimes the spasm is relieved by ex-posure to cold air—when, for instance, the child is takenout into the night togo to the emergencydepartment or to seethe care provider.The physician mayprescribe an emetic(an agent that causesvomiting) in a dosageless than that neededto produce vomiting;this usually gives re-lief by helping to re-duce spasms of thelarynx.

It is important to explain which symptoms can be treatedat home (hoarseness, croupy cough, and inspiratory

Here’s a helpful hint.After a tonsillectomy, offerthe child liquids that arenot red in color toeliminate confusionwith bloody dis-charge.

Good news.Although frightening tothe child and family,spasmodic laryngitis isnot serious and canoften be lessenedquickly by taking thechild into the bathroom,shutting the door, andturning on the hot watertap. This fills the room withsteam or humidified air andrelieves the child’s symptoms.



stridor) and which symptoms might indicate a more se-rious condition in which the child needs to be seen bythe care provider (continuous stridor, use of accessorymuscles, labored breathing, lower-rib retractions, rest-lessness, pallor, and rapid respirations). The familymust be aware that recurrence of these conditions mayoccur.

ACUTE LARYNGOTRACHEOBRONCHITISLaryngeal infections are common in small children, andthey often involve tracheobronchial areas as well. Acutelaryngotracheobronchitis (bacterial tracheitis or laryn-gotracheobronchitis) may progress rapidly and become aserious problem within a matter of hours. The toddler isthe most frequently affected age group. This condition isusually of viral origin, but bacterial invasion, usuallystaphylococcal, follows the original infection. It gener-ally occurs after an upper respiratory infection withfairly mild rhinitis and pharyngitis.

Clinical Manifestations and DiagnosisThe child develops hoarseness and a barking cough witha fever that may reach 104�F to 105�F (40�C–40.6�C).As the disease progresses, marked laryngeal edema oc-curs, and the child’s breathing becomes difficult, thepulse is rapid, and cyanosis may appear. Heart failureand acute respiratory embarrassment can result.

Treatment and Nursing CareThe major goal of treatment for acute laryngotracheo-bronchitis is to maintain an airway and adequate air ex-change. Antimicrobial therapy is ordered. The child isplaced in a supersaturated atmosphere, such as acroupette or some other kind of mist tent, that also caninclude the administration of oxygen. To achieve bron-chodilation, racemic or nebulized epinephrine may beadministered, usually by a respiratory therapist. Nebu-lization is usually administered every 3 or 4 hours. Neb-ulization often produces rapid relief because it causesvasoconstriction. However, the child requires careful ob-servation for the reappearance of symptoms.

If necessary, intubation with a nasotracheal tube maybe performed for a child with severe distress unrelievedby other measures. Tracheostomies, once performed fre-quently, are rarely performed today; intubation is pre-ferred. Antibiotics are administered parenterally initiallyand continued after the temperature has normalized.

Close and careful observation of the child is impor-tant. Observation includes checking the pulse, respira-tions, and color; listening for hoarseness and stridor; andnoting any restlessness that may indicate an impendingrespiratory crisis. Pulse oximetry is used to determine thedegree of hypoxia.

EPIGLOTTITISEpiglottitis is acute inflammation of the epiglottis (thecartilaginous flap that protects the opening of the

larynx). Commonly caused by Haemophilus influenzaetype B, epiglottitis most often affects children ages 2 to7 years. The epiglottis becomes inflamed and swollenwith edema. The edema decreases the ability of theepiglottis to move freely, which results in blockage of theairway and creates an emergency.

Clinical Manifestations and DiagnosisThe child may have been well or may have had a mildupper respiratory infection before the development of asore throat, dysphagia (difficulty swallowing), and ahigh fever of 102.2�F to 104�F (39�C–40�C). The dys-phagia may cause drooling. A tongue blade should neverbe used to initiate a gag reflex because complete ob-struction may occur. The child is very anxious andprefers to breathe by sitting up and leaning forward withthe mouth open and the tongue out. This is called the“tripod” position (Fig. 36-3). Immediate emergency at-tention is necessary.

Treatment and Nursing CareThe child may need endotracheal intubation or a tra-cheostomy if the epiglottis is so swollen that intubationcannot be performed. Moist air is necessary to help re-duce the inflammation of the epiglottis. Pulse oximetry isrequired to monitor oxygen requirements. Antibioticsare administered intravenously. After 24 to 48 hours ofantibiotic therapy, the child may be extubated. Antibi-otic therapy usually is continued for 10 days. This con-dition is not common, and it is extremely frightening forthe child and the family.

■ Figure 36-3 The “tripod” position of the child withepiglottitis.



ACUTE BRONCHIOLITIS/RESPIRATORYSYNCYTIAL VIRUS INFECTIONAcute bronchiolitis (acute interstitial pneumonia) is mostcommon during the first 6 months of life and is rarelyseen after the age of 2 years. Most cases occur in infantswho have been in contact with older children or adultswith upper respiratory viral infections. It usually occursin the winter and early spring.

Acute bronchiolitis is caused by a viral infection. Thecausative agent in more than 50% of cases has beenshown to be RSV. Other viruses associated with the dis-ease are parainfluenza virus, adenoviruses, and otherviruses not always identified.

The bronchi and bronchioles become plugged withthick, viscid mucus, causing air to be trapped in thelungs. The child can breathe air in but has difficulty ex-pelling it. This hinders the exchange of gases andcyanosis appears.

Clinical ManifestationsThe onset of dyspnea is abrupt, sometimes preceded bya cough or nasal discharge. Manifestations include a dryand persistent cough, extremely shallow respirations, airhunger, and often marked cyanosis. Suprasternal andsubcostal retractions are present. The chest becomes bar-rel-shaped from the trapped air. Respirations are 60 to80 breaths per minute.

Fever is not extreme, seldom higher than 101�F to102�F (38.3�C–38.9�C). Dehydration may become a se-rious factor if competent care is not given. The infant ap-pears apprehensive, irritable, and restless.

DiagnosisDiagnosis is made from clinical findings and can be con-firmed by laboratory testing (enzyme-linked immunosor-bent assay [ELISA]) of the mucus obtained by directnasal aspiration or nasopharyngeal washing.

Treatment and Nursing CareThe child is usually hospitalized and treated with highhumidity by mist tent (see Chapter 30, Fig. 30-6), rest,and increased fluids. Oxygen may be administered in ad-dition to the mist tent. Monitoring of oxygenation maybe done by means of capillary blood gases or pulseoximetry. Antibiotics are not prescribed because thecausative organism is a virus. Intravenous fluids oftenare administered to ensure an adequate intake and topermit the infant to rest. The hospitalized child is placedon contact transmission precautions to prevent thespread of infection.

Ribavirin (Virazole) is an antiviral drug that may beused to treat certain children with RSV. It is administeredas an inhalant by hood, mask, or tent. The AmericanAcademy of Pediatrics states that the use of ribavirin mustbe limited to children at high risk for severe or complicatedRSV such as children with chronic lung disease, prematureinfants, transplant recipients, and children receiving

chemotherapy. Rib-avirin is classified asa category X drug,signifying a high riskfor teratogenicity (ca-using damage to afetus). Health carepersonnel and othersmay inhale the mistthat escapes into theroom, so care must be taken when the drug is administered.

For children who are at high risk for getting RSV andhaving serious complications, there are some new drugsavailable that may be given to prevent RSV. These drugsare administered only in specific cases and are given in-travenously or intramuscularly.

Warning.Women who might bepregnant should stay outof the room whereribavirin is beingadministered.

Test Yourself✔ What is the most common complication after a ton-

sillectomy? What two time periods is bleeding a con-cern after a tonsillectomy? Explain the reasons thesetime periods are a concern for bleeding.

✔ What is a fast and effective way to reduce laryn-gospasm for the child with croup?

✔ What is a complication often seen in the infant witha respiratory infection?

✔ What is the causative agent in many cases of bron-chiolitis?

ASTHMAAsthma is a spasm of the bronchial tubes caused by hy-persensitivity of the airways in the bronchial system andinflammation that leads to mucosal edema and mucoushypersecretion. Asthma is also sometimes referred to asreactive airway disease. This reversible obstructive air-way disease affects millions of people in the UnitedStates, including 5% to 10% of all children in the UnitedStates.

Asthma attacks are often triggered by a hypersensitiveresponse to allergens. In young children, asthma may bea response to certain foods. Asthma is often triggered byexercise, exposure to cold weather, irritants such aswood-burning stoves, cigarette smoke, dust, and petdander and foods such as chocolate, milk, eggs, nuts,and grains. Infections, such as bronchitis and upper res-piratory infection, can provoke asthma attacks. In chil-dren with asthmatic tendencies, emotional stress or anx-iety can trigger an attack. Some children with asthmamay have no evidence of an immunologic cause for thesymptoms.

Asthma can be either intermittent, with extended peri-ods when the child has no symptoms and does not need

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medication, or chronic, with the need for frequent orcontinuous therapy. Chronic asthma affects the child’sschool performance and general activities and may con-tribute to poor self-confidence and dependency. Asthmaaccounts for one third of the missed school days in theUnited States (Eggleston, 2006).

Spasms of the smooth muscles cause the lumina ofthe bronchi and bronchioles to narrow. Edema of themucous membranes lining these bronchial branchesand increased production of thick mucus within themcombine with the spasm to cause respiratory obstruc-tion (Fig. 36-4).

Clinical ManifestationsThe onset of an attack can be very abrupt or canprogress over several days, as evidenced by a dry hack-ing cough, wheezing (the sound of expired air beingpushed through obstructed bronchioles), and difficultybreathing. Asthma attacks often occur at night andawaken the child from sleep. The child must sit up andis totally preoccupied with efforts to breathe. Attacksmight last for only a short time, or might continue forseveral days. Thick, tenacious mucus might becoughed up or vomited after a coughing episode. Insome asthmatic patients, coughing is the major symp-tom, and wheezing occurs rarely if at all. Many chil-dren no longer have symptoms after puberty, but thisis not predictable. Other allergies may develop inadulthood.

DiagnosisThe history and physical examination are of primary im-portance in diagnosing asthma. When observing thechild’s breathing, dyspnea and labored breathing may benoted, especially on expiration. When listening to thechild’s lung sounds (auscultation), the examiner hearswheezing, which is often generalized over all lung fields.Mucus production may be profuse. Pulmonary functiontests are valuable diagnostic tools and indicate theamount of obstruction in the bronchial airways, espe-cially in the smallest airways of the lungs. A definitive

diagnosis of asthma is made when the obstruction in theairways is reversed with bronchodilators.

TreatmentChildren and their families must be taught to recognizethe symptoms that lead to an acute attack so they can betreated as early as possible. These symptoms include respi-ratory retractions and wheezing and an increased amountof coughing at night, in the early morning, or with activ-ity. Use of a peak flow meter is an objective way to meas-ure airway obstruction, and children as young as 4 or 5 years of age can be taught to use one (see Family Teach-ing Tips: How to Use a Peak Flow Meter and Fig. 36-5).A peak flow diaryshould be maintainedand also can includesymptoms, exacerba-tions, actions taken,and outcomes. Fami-lies must make everyeffort to eliminateany possible allergensfrom the home.

Normal airway Airway with inflammation Airway with inflammation,bronchospasm,and mucus production

■ Figure 36-4 Note airwayedema, mucus production, andbronchospasm occurring withasthma.

■ Figure 36-5 The child with asthma uses a peak flow me-ter and keeps track of readings on a daily basis.

Did you know?Prevention is the mostimportant aspect in thetreatment of asthma.



Family Teaching TipsHOW TO USE A PEAK FLOW METER

INTRODUCTIONYour child cannot feel early changes in the airway. Bythe time the child feels tightness in the chest or starts towheeze, he or she is already far into an asthma episode.The most reliable early sign of an asthma episode is adrop in the child’s peak expiratory flow rate, or the abil-ity to breathe out quickly, which can be measured by apeak flow meter. Almost every asthmatic child over theage of 4 years can and should learn to use a peak flowmeter (Figs. A and B.)

STEPS TO ACCURATE MEASUREMENTS

1. Remove gum or food from the mouth.2. Move the pointer on the meter to zero.3. Stand up and hold the meter horizontally with fin-

gers away from the vent holes and marker.4. With mouth wide open, slowly breathe in as much

air as possible.5. Put the mouthpiece on the tongue and place lips

around it.6. Blow out as hard and fast as you can. Give a short,

sharp blast, not a slow blow. The meter measuresthe fastest puff, not the longest.

7. Repeat steps 1–6 three times. Wait at least 10 sec-onds between puffs. Move the pointer to zero aftereach puff.

8. Record the best reading.

GUIDELINES FOR TREATMENT

Each child has a unique pattern of asthma episodes.Most episodes begin gradually, and a drop in peakflow can alert you to start medications before the actu-al symptoms appear. This early treatment can preventa flare-up from getting out of hand. One way to lookat peak flow scores is to match the scores with threecolors:

Green Yellow Red

80%–100% 50%–80% Below 50% personal best personal best personal best

No symptoms Mild to moder- Serious ate symptoms distress

Full breathing Diminished Pulmonary reserve reserve function is

significantly impaired

Mild trigger A minor trigger Any trigger may not cause produces may lead to symptoms noticeable severe

symptoms distress

Continue Augment present Contact care current treatment providermanagement regimen

A

B

Remember, treatment should be adjusted to fit the individual’s needs. Your care provider will develop a home management plan with you. When in doubt, consult your care provider.

The goals of asthma treatment include preventingsymptoms, maintaining near-normal lung function andactivity levels, preventing recurring exacerbations andhospitalizations, and providing the best medicationtreatment with the fewest adverse effects. Depending

on the frequency and severity of symptoms and exacer-bations, a stepwise approach to the treatment ofasthma is used to manage the disease. The steps areused to determine combinations of medications to beused (Table 36-1).



Medications used to treat asthma are divided into twocategories: quick-relief medications for immediate treat-ment of symptoms and exacerbations and long-term con-trol medications to achieve and maintain control of thesymptoms. The classifications of drugs used to treat asthmainclude bronchodilators (sympathomimetics and xanthinederivatives) and other antiasthmatic drugs (corticosteroids,leukotriene inhibitors, and mast cell stabilizers). Table 36-2lists some of the medications used to treat asthma. Many ofthese drugs can be given either by a nebulizer (tube at-tached to a wall unit or cylinder that delivers moist air viaa face mask) or a metered-dose inhaler ([MDI]; a hand-heldplastic device that delivers a premeasured dose). The MDImay have a spacer unit attached that makes it easier for theyoung child to use (Fig. 36-6).

BronchodilatorsBronchodilators are used for quick relief of acute exacer-bations of asthma symptoms. They are short acting andavailable in pill, liquid, or inhalant form. These drugs areadministered every 6 to 8 hours or every 4 to 6 hours byinhalation if breathing difficulty continues. In severe at-tacks, epinephrine by subcutaneous injection often affordsquick relief of symptoms. Some bronchodilators, such assalmeterol (Serevent), are used in long-term control.

Theophylline preparations have long been used in the treatment of asthma. The drug is available in short-acting and long-acting forms. The short-acting formsare given about every 6 hours. Because they enter thebloodstream quickly, they are most effective when usedonly as needed for intermittent episodes of asthma.Long-acting preparations of theophylline are givenevery 8 to 12 hours. Some of these preparations comein sustained-release forms. These are helpful in pa-tients who continually need medication because thesedrugs sustain more consistent theophylline levels in theblood than do short-acting forms. Patients hospitalizedfor status asthmaticus may receive theophylline intra-venously.

Corticosteroids Corticosteroids are anti-inflammatory drugs used tocontrol severe or chronic cases of asthma. Steroids maybe given in inhaled form to decrease the systemic effectsthat accompany oral steroid administration.

Leukotriene InhibitorsLeukotriene inhibitors are given by mouth along withother asthma medications for long-term control and pre-vention of mild, persistent asthma. Leukotrienes arebronchoconstrictive substances that are released in thebody during the inflammatory process. These drugs in-hibit leukotriene production, which helps with bron-chodilation and decreases airway edema.

Mast Cell StabilizersMast cell stabilizers help to stabilize the cell membraneby preventing mast cells from releasing the chemical me-diators that cause bronchospasm and mucous membraneinflammation. They are used to help decrease wheezingand exercise-induced asthma attacks. These are nons-teroidal anti-inflammatory drugs and have relatively fewside effects. A bronchodilator often is given to open upthe airways just before the mast cell stabilizer is used.Children dislike the taste of the medication, but receiv-ing sips of water after the administration minimizes thedistaste.

Chest PhysiotherapyBecause asthma has multiple causes, treatment and con-tinued management of the disease require more than med-ication. Chest phys-iotherapy includesbreathing exercises,physical training, andinhalation therapy.Studies have shownthat breathing exer-cises to improve res-piratory function andto control asthma

Table 36-1 ❚ STEPWISE APPROACH TOTREATING ASTHMA

Steps Symptoms

Step OneMild intermittent Symptoms occur �2 times a week

No symptoms between exacerbations

Exacerbations briefNighttime symptoms �2 times

a month

Step TwoMild persistent Symptoms occur �2 times a week

but �1 time a dayExacerbations may affect activityNighttime symptoms �2 times

a month

Step ThreeModerate persistent Daily symptoms

Daily use of inhaled short-acting beta-2 agonist

Exacerbations affect activityExacerbations �2 times a week,

may last daysNighttime symptoms �1 time

a week

Step FourSevere persistent Continual symptoms

Limited physical activityFrequent exacerbationsFrequent nighttime symptoms

Check out this tip.For the asthmatic child, ifexercises can be taughtas part of play activi-ties, children aremore likely to findthem fun and to prac-tice them more often.



Table 36-2 ❚ MEDICATIONS USED IN THE TREATMENT OF ASTHMA

Generic Name Trade Name Dose Form Uses Adverse Reactions/Side Effects

BronchodilatorsSympathomimetics (Beta-2-receptor Agonists)albuterol sulfate Proventil, Ventolin MDI Quick relief Restlessness, anxiety, fear,

PO palpitations, insomnia, tremorsNebulizer

metaproterenol Alupent, Metaprel MDI Quick relief Tremors, anxiety, insomnia, hydrochloride PO Short-term dizziness, tachycardia

Nebulizer controlterbutaline sulfate Brethine MDI MDI—Quick Tremors, anxiety, insomnia,

PO relief dizziness, tachycardiaPO—Long-term

controlsalmeterol Serevent MDI Long-term Headache, tremors, tachycardia

controlXanthine DerivativeTheophylline Slo-Phyllin, PO Long-term Nausea, vomiting, headache,

Elixophyllin Timed- control nervousness, irritability, Theo-Dur release insomnia

Antiasthma DrugsCorticosteroidsbeclomethasone Beclovent MDI Long-term Throat irritation, cough, nausea,

control dizzinesstriamcinolone Azamacort MDI Long-term Throat irritation, cough, nausea,

control dizzinessLeukotriene InhibitorsMontelukast Singulair PO Long-term Headache, nausea, abdominal

control pain, diarrheaMast Cell StabilizersCromolyn Intal Intranasal Long-term Nasal irritation, unpleasant taste,

nebulizer control headache, nausea, dry throat

MDI � metered-dose inhaler

A B

■ Figure 36-6 (A) Girl using a nebulizer with a mask. (B) Boy using a metered-dose in-haler with spacer.

attacks can be an important adjunct to using medica-tions for treatment. These exercises teach children howto help control their own symptoms and thereby buildself-confidence, which is sometimes lacking in asthmaticchildren.

Nursing Process for the Child With AsthmaAssessmentObtain information from the caregiver about the asthmahistory, the medications the child takes, and the medications



taken within the last 24 hours. Ask whether the child hasvomited because vomiting would prevent absorption oforal medications. Ask about any history of respiratoryinfections; possible allergens in the household such aspets; type of furniture and toys; if there is a damp base-ment (which could contain mold spores); and a historyof breathing problems after exercise.

In the physical exam, include vital signs, observationfor diaphoresis and cyanosis, position, type of breathing,alertness, chest movement, intercostal retractions, andbreath sounds. Note any wheezing.

If the child is old enough and alert enough to cooper-ate, involve him or her in gathering the history, and en-courage the child to add information. Ask questions thatcan be answered “yes” or “no” to minimize tiring thedistressed child.

Selected Nursing Diagnoses■ Ineffective Airway Clearance related to bron-

chospasm and increased pulmonary secretions■ Risk for Deficient Fluid Volume related to water loss

from tachypnea and diaphoresis and reduced oralintake

■ Fatigue related to dyspnea■ Anxiety related to sudden attacks of breathlessness■ Deficient Knowledge of the caregiver related to dis-

ease process, treatment, home care, and control ofdisease

Outcome Identification and PlanningThe initial major goals for the child include maintaininga clear airway and an adequate fluid intake and relievingfatigue and anxiety. The family’s goals include learninghow to manage the child’s life with asthma. Base thenursing plan of care on these goals.

ImplementationMonitoring Respiratory FunctionContinuously monitor the child while he or she is inacute distress from an asthma attack using pulse oxime-try and an electronic monitor. If this equipment is un-available, take the child’s respirations every 15 minutesduring an acute attack and every 1 or 2 hours after thecrisis is over. Listening to lung sounds should be done tofurther monitor the respiratory function. Observe fornasal flaring and chest retractions; observe the skin forcolor and diaphoresis.

Elevate the child’s head. An older child may be morecomfortable resting forward on a pillow placed on anover-bed table. Monitor the child for response to med-ications and their side effects such as restlessness, gas-trointestinal upset, and seizures. Use humidified oxy-gen and suction as needed during periods of acutedistress.

Monitoring and Improving Fluid IntakeDuring an acute attack, the child may lose a great quan-tity of fluid through the respiratory tract and may havea poor oral intake because of coughing and vomiting.Theophylline administration also has a diuretic effect,which compounds the problem. Monitor intake and out-put. Encourage oral fluids that the child likes. Intra-venous (IV) fluids are administered as ordered. IV fluidintake is monitored, and all precautions for parenteraladministration are followed. Note the skin turgor andobserve the mucous membranes at least every 8 hours.Weigh the child daily to help determine fluid losses.

Promoting Energy ConservationThe child might become extremely tired from the exer-tion of trying to breathe. Activities and patient careshould be spaced to provide maximum periods of unin-terrupted rest. Provide quiet activities when the childneeds diversion. Keep visitors to a minimum, and main-tain a quiet environment.

Reducing Child and Parent AnxietyThe sudden onset of an asthma attack can be frighteningto the child and the family caregivers. Respond quicklywhen the child has an attack. Reassure the child and thefamily during an episode of dyspnea.

A Personal Glimpse

The first time I put Bobbie in the hospital it was very scary.I knew the nurses, but I was still afraid for him. I felt likesomeone was punishing me. I couldn’t leave him for aminute. I was afraid he wouldn’t be alive when I came back.I was also afraid he would be frightened. He was so small,he needed me to protect him, but I couldn’t help him. Wewere in the hospital every couple of weeks. He would getbetter then have another attack. It got to the point where Iwould call the doctor and say that Bobbie was having an-other attack and they would just send us to admitting. Af-ter a few times, I got used to caring for him in the hospital.The nurses taught me how to keep his tent humidified andI could just take care of it myself. Finally I was able to goback to work during the day and care for him on my breaksand time off. It was very difficult each and every time, butwe adjusted to hospital life. Although I was afraid for him, Iknew he was a fighter and I had to be too. I feel this expe-rience made him a stronger person. He is now 8 years oldand has had no severe attacks since he was about 2 yearsold. He has had a few mild attacks, but it doesn’t affect himor myself.

Tracee

Learning Opportunity: Give specific examples of whatthe nurse could do to support this mother and to help de-crease the fear she had when her child was hospitalized.



Teach the childand the caregiver thesymptoms of an im-pending attack andthe immediate re-sponse needed to decrease the threatof an attack. Thisknowledge will helpthem to cope withimpending attacksand plan how to handle the attacks. When they are pre-pared with information, the child and family may beless fearful. Give the child examples of sports figures,entertainers, actors and actresses, and political leaderswho have or have had asthma, for example, Olympictrack and field athlete Jackie Joyner Kersee and Presi-dent John F. Kennedy. Others include Jerome Bettis,professional football player; Amy Van Dyken, Americanswimming champion; Nancy Hogshead, Olympic goldmedalist in swimming; Dennis Rodman, NBA basket-ball player; and Diane Keaton, actress.

Providing Family TeachingChild and family caregiver teaching is of primary im-portance in the care of asthmatic children. Family care-givers might overprotect the child because of the fearthat an attack will occur when the child is with ababysitter, at school, or anywhere away from the care-giver. Asthma attacks can be prevented or decreased byprompt and adequate intervention. Teach the caregiverand child, within the scope of the child’s ability to un-derstand, about the disease process, recognition ofsymptoms of an impending attack, environmental con-trol, infection avoidance, exercise, drug therapy, andchest physiotherapy.

Teach the caregiver and the child how to use metered-dose inhaler medications and have them demonstratecorrect usage (see Family Teaching Tips: How to Use aMetered-Dose Inhaler). Give instructions on home useof a peak flow meter. Urge them to maintain a diary torecord the peak flow as well as asthma symptoms, onsetof attacks, action taken, and results. Include instruc-tions about administering premedication before thechild is exposed to situations in which an attack mayoccur.

Inform caregivers of allergens that may be in thechild’s environment and encourage them to eliminate orcontrol the allergens as needed. Stress the importance ofquick response when the child has a respiratory infec-tion. Give instructions for exercise and chest physio-therapy.

Stress to the caregivers the importance of informingthe child’s classroom teacher, physical education teacher,school nurse, babysitter, and others who are responsiblefor the child about the child’s condition. With a physi-cian’s order, including directions for use, the child should

be permitted to bring medications to school and keepthem so they can be used when needed.

Provide information on support groups available inthe area. The American Lung Association has many ma-terials available to families and can provide informationabout support groups, camps, and workshops (Web site:www. lungusa.org). The Asthma and Allergy Founda-tion of America (Web site: www.aafa.org) and the Na-tional Heart, Lung, and Blood Institute (Web site:www.nhlbi.nih.gov) are also resources.

Evaluation: Goals and Expected OutcomesGoal: The child’s airway will remain open.Expected Outcomes: The child’s

■ breath sounds are clear with no wheezing, retrac-tions, or nasal flaring.

■ skin color is good.

Goal: The child’s fluid intake will be adequate.Expected Outcomes: The child’s

■ hourly urine output is 30 to 40 mL.■ mucous membranes are moist.■ skin turgor is good.■ weight remains stable.

Goal: The child will have increased energy levels.Expected Outcomes: The child

■ participates in age-appropriate activities. ■ rests between activities.

Nursing judgment is in order.The asthmatic child’s fearof attacks can beincreased by the care-giver’s behavior. ■ When ready to use, shake the inhaler well with the

cap still on. The child should stand, if possible.■ Remove the cap.■ Hold the inhaler with the mouthpiece down,

facing the child.■ Be sure the child’s mouth is empty.■ Hold the mouthpiece about 1 to 1.5 in from the

lips.*■ Breathe out normally. Open mouth wide and

begin to breathe in.■ Press top of medication canister firmly while

inhaling deeply. Hold breath as long as possible(at least 10 seconds—teach child to count slowlyto 10).

■ Breathe out slowly through nose or pursed lips.■ Relax 2 to 5 minutes repeat as directed by physi-

cian.

*The mouthpiece can also be put between the lips, with the lipsforming an airtight seal, or a spacer can be attached to theinhaler and the mouthpiece held between the lips.

Family Teaching TipsHOW TO USE A METERED-DOSE INHALER



Goal: The child’s and caregivers’ anxiety and fear re-lated to impending attacks will be minimized.

Expected Outcomes: The child and the caregiver

■ list symptoms of an impending attack.■ describe appropriate responses.■ display confidence in their ability to handle an

attack.

Goal: The child and the caregiver will gainknowledge of how to live with asthma.

Expected Outcomes: The child and the caregiver

■ verbalize an understanding of the disease process,treatment, and control.

■ interact with health care personnel and ask andanswer relevant questions.

■ obtain information and makes contact with supportgroups.

conjugate vaccine (HIB) is currently recommended, be-ginning at 2 months of age.

Clinical ManifestationsThe onset of the pneumonic process is usually abrupt,following a mild upper respiratory illness. Temperatureincreases rapidly to 103�F to 105�F (39.4�C–40.6�C).Respiratory distress is marked with obvious air hunger,flaring of the nostrils, circumoral (around the mouth)cyanosis, and chest retractions. Tachycardia and tachyp-nea are present, with a pulse rate frequently as high as140 to 180 beats per minute and respirations as high as80 breaths per minute.

Generalized convulsions may occur during the periodof high fever. Cough may not be noticeable at the onsetbut may appear later. Abdominal distention caused byswallowed air or paralytic ileus commonly occurs.

DiagnosisDiagnosis is based on clinical symptoms, chest radi-ograph, and culture of the organism from secretions.The white blood cell count may be elevated. The anti-streptolysin titer (ASO titer) is usually elevated in chil-dren with staphylococcal pneumonia.

TreatmentThe use of anti-infectives early in the disease gives aprompt and favorable response. Penicillin or ampicillinhas proved to be the most effective treatment and is gen-erally used unless the child has a penicillin allergy.Cephalosporin anti-infectives are also used. Oxygenstarted early in the disease process is important. In someinstances, a croupette or mist tent is used. Some considerthe use of mist tents without constant observation un-safe. Children have become cyanotic in mist tents, withsubsequent arrest, because of the difficulty of seeing thechild; therefore, a mask or hood is thought to be the bet-ter choice. Intravenous fluids are often necessary to sup-ply the needed amount of fluids. Prognosis for recoveryis excellent.

NURSING PROCESS FOR THE CHILD WITH PNEUMONIAAssessmentConduct a thorough interview with the caregiver. In ad-dition to standard information, include specific datasuch as when the symptoms were first noticed, the courseof the fever thus far, a description of respiratory difficul-ties, and the character of any cough. Collect data re-garding how well the child has been taking nourishmentand fluids. Ask about nausea, vomiting, urinary andbowel output, and history of exposure to other familymembers with respiratory infections.

Conduct a physical exam, including measurement oftemperature, apical pulse, respirations (rate, respiratory

Test Yourself✔ What is the most important aspect in the treatment

of asthma?

✔ What are the two categories of medications used inthe treatment of asthma?

✔ What are the routes of administration for many ofthe medications used to treat asthma?

✔ Why is chest physiotherapy used in the treatment ofasthma?

BACTERIAL PNEUMONIAPneumococcal pneumonia is the most common form ofbacterial pneumonia in infants and children. Its inci-dence has decreased during the last several years. Thisdisease occurs mainly during the late winter and earlyspring, principally in children younger than 4 years ofage.

In the infant, pneumococcal pneumonia is generally ofthe bronchial type. In older children, pneumococcalpneumonia is generally of the lobar type. It is usuallysecondary to an upper respiratory viral infection. Themost common finding in infants is a patchy infiltrationof one or several lobes of the lung. Pleural effusion is of-ten present. In the older child, the pneumonia may lo-calize in a single lobe. Immunization with the pneumo-coccal vaccine (PCV) is currently recommended,beginning at 2 months of age.

H. influenzae pneumonia also occurs in infants andyoung children. Its clinical manifestations are similar tothose of pneumococcal pneumonia, but its onset is moreinsidious, its clinical course is longer and less acute, andit is usually seen in the lobe of the lung. Complicationsin the infant are common—usually bacteremia, peri-carditis, and empyema (pus in the lungs). The treatmentis the same. Immunization with H. influenzae type B



effort, retractions [costal, intercostal, sternal, suprasternal,substernal], and flaring of nares) (see Chapter 28). Alsonote breath and lung sounds (crackles, wheezing), cough(dry, productive, hacking), irritability, restlessness, con-fusion, skin color (pallor, cyanosis), circumoral (aroundthe mouth) cyanosis, cyanotic nail beds, skin turgor, an-terior fontanelle (depressed or bulging), nasal passagecongestion (color, consistency), mucous membranes(mouth dry, lips dry or cracked), and eyes (bright, glassy,sunken, moist, crusted). If the child is old enough tocommunicate verbally, ask questions to determine howthe child feels.

Selected Nursing Diagnoses■ Ineffective Airway Clearance related to obstruction

associated with edema, mucous secretions, nasal andchest congestion

■ Impaired Gas Exchange related to inflammatoryprocess

■ Risk for Deficient Fluid Volume related to respiratoryfluid loss, fever, and difficulty swallowing

■ Hyperthermia related to infection process■ Risk for Further Infection related to location and

anatomical structure of the eustachian tubes■ Activity Intolerance related to inadequate gas

exchange■ Anxiety related to dyspnea, invasive procedures, and

separation from caregiver■ Compromised Family Coping related to child’s respi-

ratory symptoms and child’s illness■ Deficient Knowledge of the caregiver related to

child’s condition and home care

Outcome Identification and PlanningThe major goals for the child with pneumonia are main-taining respiratory function, preventing fluid deficit,maintaining body temperature, preventing otitis media,conserving energy, and relieving anxiety. Goals for thefamily include relieving anxiety and improving caregiverknowledge.

The need for immediate intubation is always a possi-bility; thus, vigilance is essential. The child’s energy mustbe conserved to reduce oxygen requirements. The childmay need to be placed on infection control precautions,according to the policy of the health care facility, to pre-vent nosocomial spread of infection. Many children witha respiratory condition need to be placed in a croupetteor mist tent, making additional nursing interventionsnecessary. If IV fluids are ordered, interventions that pro-mote tissue and skin integrity are needed. To ensure thatthe child does not interfere with the IV infusion site, itmay be necessary to prepare restraints. Intravenous ad-ministration and the use of restraints are discussed inChapter 30 (see Nursing Care Plan 36-1: The Child WithPneumonia).

ImplementationMaintaining Airway ClearanceA humidified atmosphere is provided with an ice-cooledmist tent or cool vaporizer. The moisturized air helpsthin the mucus in the respiratory tract to ease respira-tions. Suction or clear secretions as needed to keep theairway open. Position the child to provide maximumventilation, and change positions at least every 2 hours.Use pillows and padding to maintain the child’s position.Observe frequently for slumping, which causes crowdingof the diaphragm. Avoid use of constricting clothes andbedding. Stuffed toys are not recommended in mist tentsbecause they become saturated and provide an environ-ment in which organisms flourish.

Monitoring Respiratory FunctionBe continuously alert for warning signs of airway ob-struction. Monitor the child at least every hour; uncoverthe child’s chest and observe the child’s breathing efforts.Observe for tachypnea (rapid respirations), and note theamount of chest movement, shallow breathing, and re-tractions. Listen with a stethoscope for breath sounds,particularly noting the amount of stridor, which indi-cates difficult breathing. Oxygen saturation levels aremonitored using oximetry. Increasing hoarseness shouldbe reported. In addition, observe for pallor, listlessness,circumoral cyanosis, cyanotic nail beds, and restlessness;these are indications of impaired oxygenation andshould be reported at once. Cool, high humidity pro-vides relief. Oxygen may be administered by hood, misttent, or nasal cannula if the practitioner orders.

Promoting Adequate Fluid IntakeIt is important to clear the nasal passages immediatelybefore feeding. For the infant, use a bulb syringe. Ad-minister normal saline nose drops to thin secretionsabout 10 to 15 minutes before feedings and at bedtime.Feed the child slowly, allowing frequent stops with suc-tioning during feeding, as needed. Avoid overtiring theinfant or child during feeding.

Adequate hydration helps reduce thick mucus. Main-taining adequate fluid intake may be a problem for chil-dren of any age because the child may be too ill to wantto eat. Offer warm, clear fluids to encourage oral intake.Between meals, offer juices and water appropriate forthe infant or child’s age. For infants, use a relativelysmall-holed nipple so he or she does not choke, but doesnot work too hard. Maintain accurate intake and outputmeasurements. Observe carefully for aspiration, espe-cially in severe respiratory distress. The child may needto be kept NPO to prevent this threat. Parenteral fluidsmay be administered to replace those lost through respi-ratory loss, fever, and anorexia. Follow all safety meas-ures for administration of parenteral fluids. Observe pa-tency, placement, site integrity, and flow rate, at leasthourly. Fluid needs are determined by the amount

[AU3]



Nursing Care Plan 36-1

THE CHILD WITH PNEUMONIA

CASE SCENARIO:CW, a 6-month-old child with pneumonia, has been brought to the hospital from the doctor’s office by hismother. He has a copious amount of thick nasal discharge and has rapid, shallow respirations with substernaland intercostal retractions. His temperature is 101.5�F (39.1�C). His young mother appears very anxious.

NURSING DIAGNOSISIneffective Airway Clearance related to infectious process

GOAL: The child’s respiratory function will improve and airway will be patent.

EXPECTED OUTCOMES:• The child no longer uses respiratory accessory muscles to aid in breathing.• The child’s breath sounds are clear and respirations are regular.• Mucous secretions become thin and scant; nasal passages are clear.

Nursing Interventions

Provide moist atmosphere by placing him in ice-cooled mist tent.

Keep nasal passages clear, using bulb syringe.Monitor respiratory function by observing for

retractions, respiratory rate, and listening to breathsounds at least every 4 hours. Monitor morefrequently if tachypnea or deep retractions are noted.

Monitor child’s bedding and clothing every 4 hours.

Rationale

Moisture helps liquefy and thin secretions for easierrespirations.

Open passages increase air flow.Changes in the child’s breathing may be early indica-

tors of respiratory distress.

Clothing and bedding can become very wet from mist.Dry clothing and bedding help to prevent chilling.

NURSING DIAGNOSISImbalanced Nutrition: Less Than Body Requirements related to inability to suck, drink, or swallow because ofcongested nasal passages or fatigue from difficulty breathing

GOAL: The child will have adequate food and fluid intake to maintain normal growth and development.

EXPECTED OUTCOMES:• The child has an adequate caloric intake as evidenced by appropriate weight gain of 1 oz or more a day.• The child is able to suck, drink, and swallow easily without tiring.• Skin turgor returns to normal.


Clear nasal passages immediately before feeding.Teach family caregiver to use bulb syringe.

Administer normal saline nose drops before feedingsand at bedtime.

Weigh infant daily in morning before first feeding.

Rationale

Infants are obligatory nasal breathers. Clearing easeschild’s breathing to permit adequate feeding. Familycaregiver can use this technique at home, as needed.

Normal saline nose drops help thin mucoussecretions.

Child will maintain appropriate weight gain.

NURSING DIAGNOSISRisk for Further Infection (otitis media) related to current respiratory infection and the size and location ofchild’s eustachian tube

GOAL: The child will remain free from further infection and complications of otitis media.

EXPECTED OUTCOMES:• The child shows no signs of ear pain, such as irritability, shaking head, pulling on ears.



needed to maintain body weight with sufficient amountsadded to replace the additional losses. Monitor dailyweights and accurately record intake and output. Moni-tor serum electrolyte levels to ensure they are within nor-mal limits. At least once per shift, observe and recordskin turgor and the condition of mucous membranes.Observe the child for dehydration; skin turgor, anteriorfontanelle (in infants), and urine output are good indica-tors of dehydration. For the infant, maintain diapercounts and weigh diapers to determine the amount ofurine output (1 mL urine weighs 1 g).

Maintaining Body TemperatureMonitor the child’s temperature frequently, at least every2 hours if it is higher than 101.3�F (38.6�C). If the childhas a fever, remove excess clothing and covering. An-tipyretic medications may be ordered.

Promoting Energy ConservationDuring an acute stage, allow the child to rest as much aspossible. Plan work so that rest and sleep are interruptedno more than necessary.

Preventing Additional InfectionsTurn the child from side to side every hour so that mu-cus is less likely to drain into the eustachian tubes,thereby reducing the risk for development of otitis me-dia. An infant seat may help facilitate breathing andprevent the complication of otitis media in theyounger child. Observe the child for irritability, shak-ing of the head, pulling at the ears, or complaints ofear pain. Do not give the infant a bottle while he orshe is lying in bed. The best position for feeding is up-right to avoid excessive drainage into the eustachiantubes.

Reducing the Child’s AnxietyWhen frightened or upset and crying, the child with arespiratory condition may hyperventilate, which causesadditional respiratory distress. For this reason, maintaina calm, soothing manner while caring for the child.When possible, the child should be cared for by a con-stant caregiver with whom a trusting relationship hasbeen achieved. Offering support to the child during in-vasive procedures, such as when an IV is being started,

Nursing Care Plan 36-1 (continued)

THE CHILD WITH PNEUMONIA


Change child’s position, turning from side to sideevery hour.

Feed child in upright position.

Observe for irritability, shaking of head, or pulling at ears.

Rationale

Turning child prevents mucus from pooling in the eusctachian tubes.

Upright position improves drainage and helps opennasal passages.

Early recognition of signs of otitis media promotesearly diagnosis and treatment.

NURSING DIAGNOSISCompromised Family Coping related to child’s illness

GOAL: The caregiver’s anxiety will be reduced.

EXPECTED OUTCOMES:• The family caregivers verbalize understanding of the child’s condition and treatments.• The family caregivers reflect confidence in the staff evidenced by cooperation and appropriate questions.


Actively listen to caregivers’ concern.

Provide reassurance and explain what you are doingand why you are doing it when working with thechild.

Involve caregivers in caring for child. Teachtechniques of care that can be used at home.

Rationale

Family members gain confidence when they feel theirconcerns are being heard.

Understanding the disease and treatment methodshelps family to feel that the child’s illness is undercontrol.

Family caregivers feel valued and benefit fromnursing care tips that they can use at home.



will help decrease the child’s anxiety. The family can pro-vide the child with a favorite blanket or toy. The familycaregiver is encouraged to stay with the child if possibleto provide reassurance and avoid separation anxiety inthe child. Plan care to minimize interrupting the child’smuch-needed rest. Give the child age-appropriate expla-nations of treatment and procedures.

As the child’s condition improves, provide age-appro-priate diversional activities to help relieve anxiety andboredom. Make extra efforts to relieve the child’s feel-ings of loneliness, especially when infection control pre-cautions are being used.

Promoting Family CopingWatching a child with severe respiratory symptoms isfrightening for the parent or family caregiver. Familycaregivers need teaching and reassurance. The parent orcaregiver may feel helpless, and these feelings of anxietyand helplessness may be exhibited in a variety of ways.To alleviate these feelings, encourage the caregiver to dis-cuss them. Using easily understood terminology, explainequipment, procedures, treatments, the illness, and theprognosis to the caregiver. Include the caregiver in thechild’s care as much as possible and encourage him orher to soothe and comfort the child. Actively listen tocaregivers and use communication skills to respond totheir worries.

Providing Family TeachingProvide the caregiver with thorough explanations of thecondition’s signs and symptoms. Teach the use of coolhumidifiers or vaporizers, including cleaning methodsand safety measures to avoid burns when using a steamvaporizer. Explain the effects, administration, dosage,and side effects of medications. To be certain the infor-mation was understood, have the parent relate specificfacts to you. Write the information down in a simpleway so that it can be clearly understood, and determinethat the parent can read and understand the written ma-terial. When appropriate, observe the caregiver demon-strating care of equipment and any treatments to bedone at home. See Family Teaching Tips: Respiratory Infections.

Evaluation: Goals and Expected OutcomesGoal: The child’s airway will remain clear and patent.Expected Outcomes: The child’s

■ airway is clear with no evidence of retractions, stri-dor, hoarseness, or cyanosis.

■ mucous secretions are thin and scant.

Goal: The child’s respiratory function will be withinnormal limits for age.

Expected Outcomes:

■ The child’s respiratory rate is 20 to 35 breaths perminute, normal range for child’s age, regular, withbreath sounds clear.

■ The infant no longer uses respiratory accessory mus-cles to aid in breathing.

■ The child’s oxygen saturation levels are within estab-lished limits.

Goal: The child’s fluid intake will be adequate for ageand weight.

Expected Outcomes: The child

■ exhibits good skin turgor and moist, pink mucousmembranes.

■ has urine output of 1 to 3 mL/kg/hr.

Goal: The child will maintain a temperature withinnormal limits.

Expected Outcome:

■ The child’s temperature is 98.6�F to 100�F(37�C–37.8�C).

Goal: The child’s energy will be conserved.Expected Outcome:

■ The child has extended periods of uninterrupted restand tolerates increased activity.

Goal: The child will be free from complications ofotitis media.


■ shows no signs of ear pain such as irritability, shak-ing of the head, pulling on the ears.

■ does not complain of ear pain.

Goal: The child will experience a reduction in anxiety.Expected Outcomes: The child

■ rests quietly with no evidence of hyperventilation.■ cooperates with care, cuddles a favorite toy for reas-

surance, smiles, and plays contentedly.

Goal: The family caregiver’s anxiety will be reduced.Expected Outcomes: The family caregivers

■ Clear nasal passages with a bulb syringe for theinfant.

■ Feed the child slowly, allow the infant to breast-feed without tiring.

■ Frequently burp the infant to expel swallowed air.■ Offer child extra fluids.■ Leave the child in mist tent except for feeding and

bathing (unless otherwise indicated).■ Soothe and comfort child in mist or croup tent.■ Follow respiratory infection control precautions

and good hand-washing techniques.■ Discourage persons with infections from visiting

child.■ Use a humidifier at home after discharge.■ Clean humidifier properly and frequently.

Family Teaching TipsRESPIRATORY INFECTIONS



■ cooperate with and participate in the child’s care.■ appear more relaxed, verbalize his or her feelings,

and soothe the child.

Goal: The family caregivers will verbalize anunderstanding of the child’s condition and how toprovide home care for the child.

Expected Outcomes: The family caregivers

■ accurately describe facts about the child’s condition.■ ask appropriate questions.■ relate signs and symptoms to observe in the child.■ name the effects, side effects, dosage, and administra-

tion of medications.

CYSTIC FIBROSISWhen first described, cystic fibrosis (CF) was called “fi-brocystic disease of the pancreas.” Additional researchhas revealed that this disorder represents a major dys-function of all exocrine glands. The major organs affectedare the lungs, pancreas, and liver. Because about half of allchildren with CF have pulmonary complications, thisdisorder is discussed here with other respiratory condi-tions.

CF is hereditary and transmitted as an autosomal re-cessive trait. Both parents must be carriers of the genefor CF to appear. With each pregnancy, the chance is onein four that the child will have the disease. In the UnitedStates, the incidence is about 1 in 3,300 in white childrenand 1 in 16,300 in African American children.

The normal gene produces a protein, cystic fibrosistransmembrane conductance regulator, which serves as achannel through which chloride enters and leaves cells.The mutated gene blocks chloride movement, whichbrings on the apparent signs of CF. The blocking of chlo-ride transport results in a change in sodium transport;this in turn results in abnormal secretions of the exocrine(mucous-producing) glands that produce thick, tenaciousmucus rather than the thin, free-flowing secretion nor-mally produced. This abnormal mucus leads to obstruc-tion of the secretory ducts of the pancreas, liver, and re-productive organs. Thick mucus obstructs the respiratorypassages, causing trapped air and over inflation of thelungs. In addition, the sweat and salivary glands excreteexcessive electrolytes, specifically sodium and chloride.

Clinical ManifestationsMeconium ileus is the presenting symptom of CF in 5%to 10% of the newborns who later develop additional

manifestations. Depletion or absence of pancreatic en-zymes before birth results in impaired digestive activity,and the meconium becomes viscid (thick) and mucilagi-nous (sticky). The inspissated (thickened) meconium fillsthe small intestine, causing complete obstruction. Clini-cal manifestations are bile-stained emesis, a distendedabdomen, and an absence of stool. Intestinal perforationwith symptoms of shock may occur. These newbornstaste salty when kissed because of the high sodium chlo-ride concentration in their sweat.

Initial symptoms of CF may occur at varying ages dur-ing infancy, childhood, or adolescence. A hard, nonpro-ductive chronic cough may be the first sign. Later, frequentbronchial infectionsoccur. Developmentof a barrel chest andclubbing of fingers(Fig. 36-7) indicatechronic lack of oxy-gen. The abdomenbecomes distended,and body muscles be-come flabby.

Pancreatic InvolvementThick, tenacious mucus obstructs the pancreatic ducts,causing hypochylia (diminished flow of pancreatic en-zymes) or achylia (absence of pancreatic enzymes). Thisachylia or hypochylia leads to intestinal malabsorptionand severe malnutrition. The deficient pancreatic en-zymes are lipase, trypsin, and amylase. Malabsorption offats causes frequent steatorrhea. Anemia or rectal pro-lapse is common if the pancreatic condition remains un-treated. The incidence of diabetes is greater in these chil-dren than in the general population, possibly because ofchanges in the pancreas. The incidence of diabetes in pa-tients with CF is expected to increase because of their in-creasing life expectancy.

Pulmonary InvolvementThe degree of lung involvement determines the progno-sis for survival. The severity of pulmonary involvementdiffers in individual children, with a few showing onlyminor involvement. Now more than half of childrenwith CF are expected to live beyond the age of 18 years,with increasing numbers living into adulthood.

Respiratory complications pose the greatest threat tochildren with CF. Abnormal amounts of thick, viscidmucus clog the bronchioles and provide an ideal medium

A B CNormal Early clubbing Advanced clubbing

■ Figure 36-7 Clubbing of fingersindicates chronic lack of oxygen.(A) Normal angle; (B) early clubbing—flattened angle; (C) advanced clubbing—the nail isrounded over the end of the finger.

Nutrition NewsDespite an excellentappetite in the child withCF, malnutrition isapparent andbecomes increasinglysevere.



for bacterial growth. Staphylococcus aureus coagulasecan be cultured from the nasopharynx and sputum ofmost patients. Pseudomonas aeruginosa and H. influen-zae also are found frequently. However, the basic infec-tion appears most often to be caused by S. aureus.

Numerous complications arise from severe respiratoryinfections. Atelectasis and small lung abscesses are com-mon early complications. Bronchiectasis and emphy-sema may develop with pulmonary fibrosis and pneu-monitis; this eventually leads to severe ventilatoryinsufficiency. In advanced disease, pneumothorax, rightventricular hypertrophy, and cor pulmonale are commoncomplications. Cor pulmonale is a common cause ofdeath.

Other Organ InvolvementThe tears, saliva, and sweat of children with CF containabnormally high concentrations of electrolytes, andmost such children have enlarged submaxillary salivaryglands. In hot weather, the loss of sodium chloride andfluid through sweating produces frequent heat prostra-tion. Additional fluid and salt should be given in the dietas a preventive measure. In addition, males with CF whoreach adulthood will most likely be sterile because of theblockage or absence of the vas deferens or other ducts.Females often have thick cervical secretions that prohibitthe passage of sperm.

DiagnosisDiagnosis is based on family history, elevated sodiumchloride levels in the sweat, analysis of duodenal secre-tions (via a nasogastric tube) for trypsin content, a his-tory of failure to thrive, chronic or recurrent respiratoryinfections, and radiologic findings of hyperinflation andbronchial wall thickening. In the event of a positivesodium chloride sweat test, at least one other criterionmust be met to make a conclusive diagnosis.

The principal diagnostic test to confirm CF is a sweatchloride test using the pilocarpine iontophoresis method.This method induces sweating by using a small electriccurrent that carries topically applied pilocarpine into alocalized area of the skin. Elevations of 60 mEq/L ormore are diagnostic, with values of 50 to 60 mEq/Lhighly suspect. Although the test itself is fairly simple,conducting the test on an infant is difficult, and false-positive results do occur.

TreatmentIn the newborn, meconium ileus is treated with hyperos-molar enemas administered gently. If this does not re-solve the blockage of thick, gummy meconium, surgeryis necessary. During surgery, a mucolytic, such as Mu-comyst, may be used to liquefy the meconium. If thisprocedure is successful, resection may not be necessary.

In the older child, treatment is aimed at correctingpancreatic deficiency, improving pulmonary function,and preventing respiratory infections. If bowel obstruc-

tion does occur (meconium ileus equivalent), the pre-ferred management includes hyperosmolar enemas andan increase in fluids, dietary fiber, oral mucolytics, lactu-lose, and mineral oil.

The overall treat-ment goals are to im-prove the child’squality of life and toprovide for long-term survival. Ahealth care team isneeded, including aprimary care provi-der, a nurse, a respira-tory therapist, a dietitian, and a social worker, to work to-gether with the child and family. Treatment centers with astaff of specialists are becoming more common, particu-larly in larger medical centers.

Dietary TreatmentCommercially prepared pancreatic enzymes given duringmeals or with snacks aid digestion and absorption of fatand protein. Because pancreatic enzymes are inactivatedin the acidic environment of the stomach, microencapsu-lated capsules are used to deliver the enzymes to the duo-denum, where they are activated. These enzymes come incapsules that can be swallowed or opened and sprinkledon the child’s food. A powdered preparation is used forinfants.

The child’s diet should be high in carbohydrates andprotein, with no restriction of fats. The child may need1.5 to 2 times the normal caloric intake to promotegrowth. These children have large appetites unless theyare acutely ill. However, even with their large appetitesthey can receive little nourishment without a pancreaticsupplement. With proper diet and enzyme supplements,these children show evidence of improved nutrition, andtheir stools become relatively normal. Enteric-coatedpancreatic enzymes essentially eliminate the need for di-etary restriction of fat.

Because of the increased loss of sodium chloride, thesechildren are allowed to use as much salt as they wish,even though onlookers may think it is too much. Duringhot weather, additional salt may be provided with pret-zels, salted bread sticks, and saltine crackers.

Supplements of fat-soluble vitamins A, D, and E arenecessary because of the poor digestion of fats. VitaminK may be supplemented if the child has coagulationproblems or is scheduled for surgery. Water-misciblepreparations can be given to provide the needed supple-ment.

Pulmonary TreatmentThe treatment goal is to prevent and treat respiratory in-fections. Respiratory drainage is provided by thinningthe secretions and by mechanical means, such as postural drainage and clapping to loosen and drain

Good news!!With improved treatment,it is not unusual for achild with CF to growinto adulthood.



secretions from the lungs. Antibacterial drugs for thetreatment of infection are necessary as indicated. Somephysicians prescribe a prophylactic antibiotic regimenwhen the child receives the diagnosis of CF. Antibioticsmay be administered orally or parenterally, even in thehome. With home parenteral administration of antibi-otic therapy, a central venous access device is used. Im-munization against childhood communicable diseases isextremely important for these chronically ill children.All immunization measures may be used and should bemaintained at appropriate intervals.

Physical activity is essential because it improves mu-cous secretion and helps the child feel good. The childcan be encouraged to participate in any aerobic activityhe or she enjoys. Activity along with physical therapyshould be limited only by the child’s endurance.

Inhalation therapy can be preventive or therapeutic. Abronchodilator drug, such as theophylline or a beta-adrenergic agonist (metaproterenol, terbutaline, or al-buterol), may be administered either orally or throughnebulization. Recombinant human DNA (DNase, Pul-mozyme) breaks down DNA molecules in sputum,breaking up the thick mucus in the airways. A mucolytic,such as Mucomyst, may be prescribed during acute in-fection. Hand-held nebulizers are easy to use and con-venient for the ambulatory child.

Humidifiers provide a humidified atmosphere. In sum-mer, a room air conditioner can help provide comfortand controlled humidity.

Chest physical therapy, a combination of posturaldrainage and chest percussion, is performed routinely atleast every morning and evening, even if little drainageis apparent (Fig. 36-8). Performed correctly, chest per-cussion (clapping and vibrating of the affected areas)helps to loosen and move secretions out of the lungs.The physical therapist usually performs this procedurein the hospital and teaches it to the family. Chest phys-ical therapy, although time consuming, is part of theongoing, long-term treatment and should be continuedat home.

Home CareThe home care for a child with CF places a tremendousburden on the family. This is not a one-time hospitaltreatment and there is no prospect of cure to brighten thehorizon. Each day, much time is spent performing treat-ments. Family caregivers must learn to perform chestphysical therapy, how to operate respiratory equipment,and administer IV antibiotics, when necessary. Thechild’s diet must be planned with additional enzymesregulated according to need. Great care is needed to pre-vent exposure to infections.

Family caregivers must guard against overprotectionand against undue limitation of their child’s physical ac-tivity. Somehow, caregivers must preserve a good familyrelationship, also giving time and attention to othermembers of the family.

Physical activity isan important ad-junct to the child’swell-being and isnecessary to get ridof secretions. Capac-ity for exercise issoon learned, andthe child can betrusted to become self-limiting as necessary, especially if given an opportunity tolearn the nature of the disease. The child may find posturaldrainage fun when a caregiver raises the child’s feet in theair and walks the child around “wheelbarrow” fashion.

Providing as much normalcy as possible is always de-sirable. Hot-weather activity should be watched a littlemore closely, with additional attention to increased saltand fluid intake during exercise.

Caring for a child with CF places great stress on a fam-ily’s financial resources. The expense of daily medica-tions, frequent clinic or office visits, and sometimeslengthy hospitalizations can be devastating to an ordi-nary family budget, even with medical insurance cover-age. The Cystic Fibrosis Foundation (www. cff.org), withchapters throughout the United States, is helpful in pro-viding education and services. Some assistance may beavailable through local agencies or community groups.

Nursing Process for the Child With Cystic FibrosisAssessmentThe collection of data on the child with CF varies, de-pending on the child’s age and the circumstances of theadmission. Conduct a complete parent interview that in-cludes the standard information, as well as data con-cerning respiratory infections, the child’s appetite andeating habits, stools, noticeable salty perspiration, his-tory of bowel obstruction as an infant, and family his-tory for CF, if known. Also determine the caregiver’sknowledge of the condition.

When collecting data about vital signs, include obser-vation of respirations, such as cough, breath sounds, andbarrel chest; respiratory effort, such as retractions andnasal flaring; clubbing of the fingers; and signs of pan-creatic involvement, such as failure to thrive and steat-orrhea. Examine the skin around the rectum for irrita-tion and breakdown from frequent foul stools. Involvethe child in the interview process by asking age-appro-priate questions, and determine the child’s perception ofthe disease and this current illness.

Selected Nursing Diagnoses■ Ineffective Airway Clearance related to thick, tena-

cious mucus production■ Ineffective Breathing Pattern related to tracheo-

bronchial obstruction

A little fun can be good.The older child with CFcan learn to hang from amonkey bar by theknees, having fun andat the same timeincreasing posturaldrainage.



POSITION #1UPPER LOBES, Apical segments

POSITION #1, for infantsUPPER LOBES, Apical segments

POSITION #2UPPER LOBES, Posterior segments

POSITION #3UPPER LOBES, Anterior segments

POSITION #4LINGULA

■ Figure 36-8 Positions for postural drainage.

POSITION #5MIDDLE LOBE

POSITION #6LOWER LOBES, Anterior basal segments



■ Risk for Infection related to bacterial growth medi-um provided by pulmonary mucus and impairedbody defenses

■ Imbalanced Nutrition: Less Than Body Requirementsrelated to impaired absorption of nutrients

■ Anxiety related to hospitalization■ Compromised Family Coping related to child’s

chronic illness and its demands on caregivers■ Deficient Knowledge of the caregiver related to ill-

ness, treatment, and home care

Outcome Identification and PlanningAs already stated, much depends on the reason for thespecific admission and other factors discussed in NursingDiagnoses. The child’s age and ability for self-expressionaffect any goal setting the child can do. The major goalsfor the child include relieving immediate respiratory dis-tress, maintaining adequate oxygenation, remaining freefrom infection, improving nutritional status, and reliev-ing anxiety. The caregivers’ primary goal may include re-lieving problems related to this admission. However,other goals may include concerns about stress on thefamily related to the illness, as well as a need for addi-tional information about the disease, treatment, and pre-vention of complications.

ImplementationImproving Airway ClearanceMucus obstructs the airways and diminishes gas ex-change. Monitor the child for signs of respiratory dis-tress, while observing for dyspnea, tachypnea, laboredrespirations with or without activity, retractions, nasalflaring, and color of nail beds. Perform aerosol treat-ments. Teach the child to cough effectively. Examine anddocument the mucus produced, noting the color, consis-tency, and odor. Send cultures to the laboratory, as ap-propriate. Increase fluid intake to help thin mucous se-cretions. Encourage the child to drink extra fluids andask the child (or the caregiver if the child is too young)what favorite drinks might be appealing. Intravenousfluids may be necessary. Provide humidified air, either inthe form of a cool mist humidifier or mist tent, as pre-scribed.

Improving BreathingMaintain the child in a semi-Fowler’s position, with theupper half of the body elevated about 30 degrees, orhigh Fowler’s position, with the upper half of the bodyelevated about 90 degrees, to promote maximal lung ex-pansion. Pulse oximetry may be used. Maintain oxygensaturation higher than 90%. Administer oxygen as

POSITION #7LOWER LOBES, Posterior basal segments

POSITION #8 & 9LOWER LOBES, Lateral basal segments

POSITION #10LOWER LOBES, Superior segments

■ Figure 36-8 Continued



ordered if the oxygen saturation falls below this levelfor an extended period. Administer mouth care every 2to 4 hours, especially when oxygen is administered. Per-form chest physical therapy every 2 to 4 hours, as or-dered. If respiratory therapy technicians or physicaltherapists do these treatments, observe the child afterthe treatment to determine effectiveness and if more fre-quent treatments may be needed. Supervise the childwho can self-administer nebulizer treatments to ensurecorrect use.

Conserve the child’s energy. Plan nursing and thera-peutic activities so that maximal rest time is provided forthe child. Note dyspnea and respiratory distress in rela-tion to any activities. Plan quiet diversional activities asthe child’s physical condition warrants. Help the childand family to understand that activity is excellent for thechild not in an acute situation. Teach them that exercisehelps loosen the thick mucus and also improves thechild’s self-image.

Preventing InfectionThe child with CF has low resistance, especially to res-piratory infections. For this reason, take care to protectthe child from any exposure to infectious organisms.Good hand-washing techniques should be practiced byall; teach the child and family the importance of this firstline of defense. Practice and teach other good hygienehabits. Carefully follow medical asepsis when caring forthe child and the equipment. Monitor vital signs every 4 hours for any indication of an infectious process. Re-strict people with an infection, such as staff, familymembers, other patients, and visitors, from contact withthe child. Advise the family to keep the child’s immu-nizations up to date. Administer antibiotics as pre-scribed, and teach the child or caregiver home adminis-tration, as needed. Also, teach the family the signs andsymptoms of an impending infection so they can beginprophylactic measures at once.

Maintaining Adequate NutritionAdequate nutrition helps the child resist infections.Greatly increase the child’s caloric intake to compensatefor impaired absorption of nutrients and to provide ad-equate growth and development. In addition to in-creased caloric intake at meals, provide the child withhigh-calorie, high-protein snacks, such as peanut butterand cheese. Low-fat products can be selected, if desired.Administer pancreatic enzymes with all meals andsnacks. In addition, multiple vitamins and iron may beprescribed. Reinforce the need for these supplements toboth the child and the family. The child also may requireadditional salt in the diet. Encourage the child to eatsalty snacks. If the child has bouts of diarrhea or consti-pation, the dosage of enzymes may need to be adjusted.Report any change in bowel movements. Weigh andmeasure the child. Plot growth on a chart so thatprogress can easily be visualized.

Reducing the Child’s AnxietyProvide age-appropriate activities to help alleviate anxi-ety and the boredom that can result from hospitalization.Choose activities such as reading or arts and crafts ac-cording to age. Schoolwork may help ease some anxiety.Some older children may enjoy a video game, if available,but watch the child for overexcitement. Encourage thefamily caregiver to stay with the child to help diminishsome of the child’s anxiety. Allow the child to have fa-miliar toys or mementos from home. Stay with the childduring acute episodes of coughing and dyspnea to reduceanxiety. Give the child age-appropriate informationabout CF. Quiz the child in a relaxed, friendly manner tohelp determine what the child knows and what teachingmay be needed. Learning about CF can be turned into agame for some children, making it much more enjoyable.

Providing Family SupportThe family with a child who has CF is faced with a long-term illness and may have already seen deterioration inthe child’s health. Give the family and the child oppor-tunities to voice fears and anxieties. Respond with ac-tive-listening techniques to help authenticate their feel-ings. Provide emotional support throughout the entirehospital stay. Demonstrate an interest and willingness totalk to the family; do not make family members feel asthough they are intruding on time needed to do otherthings. As the nurse, you are the person who can bestprovide overall support.

Providing Family TeachingEvaluate the family’s knowledge about CF to determinetheir teaching needs. The family may need to have all theinformation repeated or may need clarification in just afew areas. Provide information for resources such as theCystic Fibrosis Foundation, the American Lung Associa-tion (www.lungusa.org), and other local organizations.The family may have questions about genetic counselingand may need referrals for counseling.

Evaluation: Goals and Expected OutcomesGoal: The child’s airway will be clear.Expected Outcomes: The child

■ effectively clears mucus from the airway and the airway remains patent.

■ cooperates with chest physical therapy.

Goal: The child will exhibit adequate respiratory function.Expected Outcomes: The child

■ rests quietly with no dyspnea; the respiratory rate iseven and appropriate for age.

■ maintains oxygen saturation above 90%.

Goal: The child will remain free of signs and symptomsof infection.

Expected Outcomes:

■ The child’s vital signs are within normal limits for age.■ The child and family follow infection-control practices.



Goal: The child’s nutritional intake will be adequate tocompensate for decreased absorption of nutrients andto provide for adequate growth and development.


■ demonstrates weight gain appropriate for age.

■ exhibits normal growth as indicated by growth chart.

Goal: The child’s anxiety will subside.Expected Outcome:

■ The child engages in age-appropriate activities andappears relaxed.

Goal: The family caregivers will verbalize feelings re-lated to the child’s chronic illness.

Expected Outcome:

■ The family caregivers verbalize fears, anxieties, andother feelings related to the child’s illness.

Goal: The family caregivers will verbalize anunderstanding of the child’s illness and treatment.

Expected Outcomes: The family caregivers

■ explain CF and describe treatments and possiblecomplications.

■ become involved in available support groups.

Tuberculosis is caused by Mycobacterium tuberculosis,a bacillus spread by droplets of infected mucus that be-come airborne when the infected person sneezes,coughs, or laughs. The bacilli, when airborne, are in-haled into the respiratory tract of the unsuspectingperson and become implanted in lung tissue. Thisprocess is the beginning of the formation of a primarylesion.

Clinical ManifestationsPrimary tuberculosis is the original infection that goesthrough various stages and ends with calcification. Pri-mary lesions in children are generally unrecognized. Themost common site of a primary lesion is the alveoli ofthe respiratory tract. Most cases arrest with the calcifi-cation of the primary infection. However, in childrenwith poor nutrition or health, the primary infection mayinvade other tissues of the body, including the bones,joints, kidneys, lymph nodes, and meninges. This iscalled miliary tuberculosis. In the small number of chil-dren with miliary tuberculosis, general symptoms ofchronic infection, such as fatigue, loss of weight, andlow-grade fever, may occur accompanied by nightsweats.

Secondary tuberculosis is a reactivation of a healedprimary lesion. It often occurs in adults and contributesto the exposure of children to the organism. Althoughsecondary lesions are more common in adults, they mayoccur in adolescents. Symptoms resemble those in anadult, including cough with expectoration, fever, weightloss, malaise, and night sweats.

DiagnosisThe tuberculin skin test is the primary means by whichtuberculosis is detected. A skin test can be performedusing a multipuncture device that deposits purifiedprotein derivative intradermally (tine test) or by intra-dermal injection of 0.1 mL of purified protein deriva-tive. Both tests are administered on the inner aspect ofthe forearm. The site is marked and read at 48 and 72hours. Redness, swelling, induration, and itching ofthe site indicate a positive reaction. Persons with apositive reaction are further examined by radiographicevaluation. Sputum tests of young children are rarelyhelpful because children do not produce a good speci-men. Screening by means of skin testing is recom-mended for all children at 12 months, before enteringschool, and in adolescence. Screening is recommendedannually for children in high-risk situations or com-munities including children in whose family there is anactive case; Native Americans; and children who re-cently immigrated from Central or South America, theCaribbean, Africa, Asia, or the Middle East. Otherhigh-risk children are those infected with human im-munodeficiency virus, those who are homeless or livein overcrowded conditions, and those immunosup-pressed for any reason.

Cultural Snapshot

In some cultures, it is common for many people tolive together in one home or in a close livingarrangement. Respiratory illness is easily spread fromperson to person when people live in close contactwith each other.

Test Yourself✔ What two immunizations have decreased the inci-

dence of bacterial pneumonia in children?

✔ What major organs are affected by CF?

✔ What is the dietary treatment for CF?

✔ For what type of infection is the child with CF mostsusceptible?

PULMONARY TUBERCULOSISTuberculosis is present in all parts of the world and is themost important chronic infectious disease in terms of ill-ness, death, and cost (Starke, 2006). The incidence of tu-berculosis in the United States had declined steadily un-til about 1985. In the years since, there has been anincrease in the number of cases reported in the UnitedStates. Several factors contribute to this increase; onefactor is the number of people who have human im-munodeficiency virus and have become infected with tuberculosis.



TreatmentDrug therapy for tuberculosis includes administration ofisoniazid (INH), often in combination with rifampin. Al-though INH has been known to cause peripheral neuri-tis in children with poor nutrition, few problems occurin children whose diets are well balanced. Rifampin istolerated well by children but causes body fluids such asurine, sweat, tears, and feces to turn orange-red. A pos-sible disadvantage for adolescents is that it may perma-nently stain contact lenses. Rifamate is a combination ofrifampin and INH. Other drugs that may be used areethambutol, streptomycin, and pyrazinamide.

Drug therapy is continued for 9 to 18 months. Afterdrug therapy has begun, the child or adolescent may re-turn to school and normal activities unless clinical symp-toms are evident. An annual chest radiograph is neces-sary from that time on.

PreventionPrevention requires improvements in social conditionssuch as overcrowding, poverty, and poor health care.Also needed are health education; medical, laboratory,and radiographic facilities for examination; and controlof contacts and persons suspected of infection.

A vaccine called bacilli Calmette-Guérin (BCG) is usedin countries with a high incidence of tuberculosis. It isgiven to tuberculin-negative persons and is said to be ef-fective for 12 years or longer. Mass vaccination is notconsidered necessary in parts of the world where the in-cidence of tuberculosis is low. After administration ofBCG vaccine, the skin test will be positive, so screeningis no longer an effective tool. The use of BCG vaccine re-mains controversial because of the effect it has onscreening for the disease, as well as the questionable ef-fectiveness of the vaccine.

Key Points

➤ An infant or child’s respiratory system, because ofits small size and underdeveloped anatomicstructures, is more prone to respiratory problems.Smaller structures lead to a greater chance ofobstruction and respiratory distress. As the childgrows, the use of the thoracic muscles takes theplace of the use of the diaphragm and abdominalmuscles for breathing.

➤ The most common complication of acutenasopharyngitis (common cold) is otitis media.

➤ Avoiding or removing allergens is the best way toprevent allergic rhinitis. Antihistamines andhyposensitization may be helpful for some patients.

➤ The child with tonsillitis may have a fever, sorethroat, difficulty swallowing, hypertrophied tonsils,and erythema of the soft palate. Exudate may bevisible on the tonsils. Treatment of tonsillitisconsists of analgesics, antipyretics, and antibiotics.Surgical removal of the tonsils and adenoids maybe indicated.

➤ The most common complication of a tonsillectomyis hemorrhage or bleeding. The child must beobserved, especially in the first 24 hours, after sur-gery and in the fifth to seventh postoperative daysfor unusual restlessness, anxiety, frequent swallow-ing, or rapid pulse. Vomiting bright, red-fleckedemesis or bright red oozing or bleeding mayindicate hemorrhage. If noted, these should bereported immediately.

➤ Spasmodic laryngitis may be of infectious or aller-gic origin. An attack is often preceded by a runnynose and hoarseness. The child awakens after a fewhours of sleep with a bark-like cough; respiratorydifficulty; stridor; and may be anxious, restless, and

hoarse. Humidified air is used to decrease the laryn-gospasm. A low dose of an emetic may be used toreduce spasms of the larynx. Acute laryngotracheo-bronchitis is often caused by the staphylococcalbacterium. The child may become hoarse and havea barking cough and elevated temperature. Breath-ing difficulty, a rapid pulse, and cyanosis mayoccur. Antibiotics are given and the child is placedin a croupette or mist tent with oxygen. Epiglottitisis an acute inflammation of the epiglottis and is notcommonly seen.

➤ Bronchiolitis/RSV is caused by a viral infection.Dyspnea occurs as well as a dry and persistentcough, extremely shallow respirations, air hunger,and cyanosis. Suprasternal and subcostal retractionsare present with respirations as high as 60 to 80breaths per minute. Diagnosis is made from clinicalfindings confirmed by laboratory testing (enzyme-linked immunosorbent assay [ELISA]). The child ishospitalized, placed on contact transmissionprecautions, and treated with high humidity by misttent, rest, and increased fluids. Ribavirin (Virazole),an antiviral drug, may be used.

➤ An asthma attack can be triggered by a hypersensi-tive response to allergens; foods such as chocolate,milk, eggs, nuts, and grains; exercise; or exposureto cold or irritants such as wood-burning stoves,cigarette smoke, dust, and pet dander. Infections,stress, or anxiety can also trigger an asthma attack.

➤ During an asthma attack, the combination ofsmooth muscle spasms, which cause the lumina ofthe bronchi and bronchioles to narrow; edema; andincreased mucus production causes respiratory obstruction.



INTERNET RESOURCESCystic Fibrosis Foundationwww.cff.org

National Heart, Lung, and Blood Institutewww.nhlbi.nih.gov

Asthma and Allergywww.aafa.org

American Lung Associationwww.lungusa.org

American Academy of Allergy Asthma andImmunology www.aaaai.org

RSVwww.marchofdimes.com/pnhec/298_9546.asp

free-flowing secretions. These secretions obstructthe secretory ducts of the pancreas, liver, and repro-ductive organs.

➤ The sweat chloride test, which shows elevatedsodium chloride levels in the sweat, is the principaldiagnostic test used to confirm CF. Family history,analysis of duodenal secretions for trypsin content,history of failure to thrive, chronic or recurrent res-piratory infections, and radiologic findings also helpdiagnose the disorder.

➤ The most common and serious complications of CFarise from respiratory infections, which may lead tosevere respiratory concerns.

➤ Pancreatic enzymes given with meals and snacks areused in the dietary treatment of children with CF.The child’s diet is high in protein and carbohydrates,and salt in large amounts is allowed. The use ofchest physiotherapy, antibiotics, and inhalationtherapy help in the prevention and treatment of respiratory infections.

➤ Tuberculosis can be detected by doing a tuberculinskin test using purified protein derivative. When aperson has a positive reaction to the skin test, addi-tional evaluation using radiography is done to con-firm the disease. INH and Rifampin are used totreat tuberculosis and are given for 9 to 18months.

➤ The goals of asthma treatment include preventingsymptoms, maintaining near-normal lung functionand activity levels, preventing recurringexacerbations and hospitalizations, and providingthe best medication treatment with the fewestadverse effects. Nursing care is focused on maintain-ing a clear airway, maintaining an adequate fluid intake, and relieving fatigue and anxiety.

➤ Bacterial pneumonia is usually caused by pneumo-coccal or H. influenzae bacterium. The onset is usu-ally abrupt, following a mild upper respiratory ill-ness. Symptoms may include a high temperature,respiratory distress with air hunger, flaring of thenostrils, circumoral cyanosis, and chest retractions.Tachycardia and tachypnea are present, with apulse rate as high as 140 to 180 beats per minuteand respirations as high as 80 breaths per minute.Anti-infectives, such as penicillin or ampicillin, haveproved to be the most effective in the treatment ofpneumonia. If the child has a penicillin allergy,cephalosporin anti-infectives are also used. Nursingcare is focused on maintaining respiratory function,preventing fluid deficit, maintaining body tempera-ture, preventing otitis media, conserving energy,and relieving anxiety.

➤ CF causes the exocrine (mucous-producing) glandsto produce thick, tenacious mucus, rather than thin,


Workbook■ NCLEX-STYLE REVIEW QUESTIONS

1. The nurse is doing teaching with the caregivers of achild who has had a tonsillectomy the previous dayand is being discharged. The nurse would reinforcethat which of the following should be reported immediately to the child’s physician?

a. The child complains of a sore throat on the thirdpostoperative day.

b. The child refuses to leave the ice collar on formore than 10 minutes.

c. The child vomits dark, old blood within 4 hoursafter being discharged.

d. The child has frequent swallowing around thesixth day after surgery.

2. A toddler with a diagnosis of a respiratorydisorder has a fever and decreased urinary output.When planning care for this child, which of thefollowing goals would be most appropriate for thistoddler?

a. The child’s anxiety will be reduced.b. The child’s fluid intake will be increased.c. The child’s caregivers will talk about their

concerns.d. The child’s caloric intake will be adequate for

age.

3. The nurse is teaching a group of caregivers ofchildren who have asthma. The caregivers make thefollowing statements. Which of these statements in-dicates a need for additional teaching?

a. “We need to identify the things that trigger ourchild’s attacks.”

b. “I always have him use his bronchodilator beforehe uses his steroid inhaler.”

c. “We will be sure our child does not exercise toprevent attacks.”

d. “She drinks lots of water, which I know helps tothin her secretions.”

4. A child with cystic fibrosis will have which of thefollowing interventions included in the child’s planof care?

a. Maintain a flat lying position when in bed.b. Provide low protein snacks between meals.c. Perform postural drainage in the morning and

evening.d. Teach infection control procedures when

hospitalized.

5. After discussing the disease with the caregiver of achild with cystic fibrosis, the caregiver makes thefollowing statements. Which of these statementsindicates a need for additional teaching?

a. “It is good to know that my other children won’thave the disease.”

b. “I will be sure to give my child the medicationevery time she eats.”

c. “It is important to let my child play with theother kids when she is at school.”

d. “When she exercises, I will feed her a saltysnack.”

6. The nurse is completing the intake and outputrecord for a toddler who has a respiratory infection.The dry weight of the child’s diaper is 38 g. Thechild has had the following intake and outputduring the shift:

Intake: 3 oz of apple juice1⁄2 serving of pancakes5 oz of milk4 saltine crackers1⁄4 cup of chicken soup2 oz of gelatin130 cc of IV fluidOutput: Diaper with urine weighing 87 fDiaper with stool only weighing 124 fDiaper with urine weighing 138 fDiaper with urine weighing 146 fDiaper with urine weighing 95 f

a. How many milliliters should the nurse documentas the child’s total intake?

b. How many milliliters should the nurse documentas the child’s urinary output?

■ STUDY ACTIVITIES

1. Draw a diagram to explain the heredity pattern ofcystic fibrosis.

2. Research your community to find sources of help for families with children who have cystic fibrosis.What support groups and organizations are avail-able that you might recommend to families of children with cystic fibrosis? Discuss with your peers what you found and make a list of resourcesto share.

3. Go to the following Web site: www.lungusa.org. Findthe section on Asthma and on the drop down menu,click on “Asthma & Children.” Click on “EarlyWarning Signals: Asthma Always Gives a Sign.”

a. List six areas covered on this site that you couldshare with a family of a child with asthma.

b. What five suggestions are given in the area cover-ing “What to Listen For?”

c. Read the section on “How to Listen.”d. Describe how you listen to the breath sounds in a

child with asthma.e. What are five emergency signs that require imme-

diate treatment?



■ CRITICAL THINKING: WHAT WOULD YOU DO?

1. Sandy calls the 24-hour pediatric health line at10:30 p.m. about her 2.5-year-old child Jared. Jaredhad gone to bed at his usual bedtime of 8:00 p.m.after an uneventful evening. He had awakened witha bark-like cough, respiratory difficulty, and a high-pitched harsh sound on inspiration.

a. What questions would you ask this mother tofurther clarify Jared’s situation?

b. What would you suggest Sandy should do to de-crease Jared’s symptoms?

c. What would you tell Sandy to watch for thatmight indicate Jared needs emergency attention?

2. Rachel, a 6-year-old girl, is brought to the clinicwith a dry hacking cough, wheezing, and difficultybreathing. Rachel is coughing up thick mucus. Herparents are with her and are extremely anxiousabout Rachel’s condition. The pediatrician examines

Rachel, and a diagnosis of an acute asthma attack ismade.

a. What other findings might have been noted dur-ing a physical exam of Rachel?

b. What will most likely be done to treat Rachel’scurrent condition?

c. What medications might have been given?d. What would you teach Rachel’s parents about

prevention of additional attacks?

3. Dosage calculation: A toddler with a diagnosis ofcystic fibrosis is being treated with the bronchodila-tor Theophylline. The child weighs 32 lb. The usualdosage of this medication is 4 mg/kg/dose every 6 hours. Answer the following:

a. How many kilograms does the child’s weigh?b. How many milligrams per dose will be given?c. How many doses will the child receive in a day?d. How much Theophylline will be given in a

24-hour period?



chapter 36 the child with a respiratory disorder

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