chronic respiratory illnesses

7/29/2019 Chronic respiratory illnesses

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Nursing Care of theChild with a

Respiratory Illness

Chronic illnesses


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Asthma Chronic inflammatory disorder of the lungs Subject to acute flare-ups

Cause is multiple

Genetic predisposition Environmental exposures Viral infections


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Even when asymptomatic bronchialbiopsies show

Thickening of bronchial basementmembrane Eosinophilic infiltration

Airway hyper-responsiveness

Airway obstruction


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Asthma and allergy Allergy influences the persistenceand the severity of the disease

Causes immediate reaction Or precipitates a late reaction


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Classification of Asthma Stepwise approach to managingasthma

Based on Frequency of symptoms

Frequency/severity of exacerbations

Lung function P. 881-882 in text


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Patho

Inflammation leads to airwayhyperresponsiveness which results inphysiologic

manifestations


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Respiratory Tree


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Triggers Stimulus which initiates theasthmatic episode


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More patho Antigen deposited on respiratorymucosa

Lysozymes digest outer coating Foreign protein is released

Immune sequence initiated IgE

Release of chemical mediators Increased permeability of blood

vessels


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Contraction of smooth muscle

Stimulation of mucus secretions

Mucosal edema Airway remodeling leads to

decreased lung function


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Clinical manifestations of

asthma Cough, SOB

Increased WOB Chest tightness


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Prolonged expiratory phase withwheezing, restlessness, anxiety

Tripod position Speaks in short, panting phrases

Secretions increase and cough

becomes rattling


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Clinical management of

asthma Meds p. 886 Rescue vs. controller

oxygen systemic steroids


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Drug therapy

SABA quick relief ICS

Long-term control must be used withICS Anti-inflammatory

Cromolyn, ICS, leukotriene modifiers

LABA associated with increased death inadults so Salmeterol (serevent) and

Formoterol are no longer approved inchildren (Only approved for COPD). Advair& Symbicort are still OK


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Hydration IV fluids

?NPO Plan


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Nursing Care of child

with asthma Close observation CAM/POX

monitor O2 I & O

Why is this important?


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side effects of meds Steroids

bronchodilators teaching


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Xolair

Monoclonal antibody (Omalizumab)

Reserved for refractory asthma,

must be over 12 years old. Lowers free IgE so only helpful if

allergy is the trigger.(Check Serum

IgE first). Expensive; risk of anaphylaxis

(given subcu)


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Murine monoclonal AB


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Home management Peak flow meter or symptommonitoring

Determine need for intervention Confirms effectiveness of tx

Allergen control


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GREEN

80-100% of best

Signals all is clear. Asthma is

under good control No symptoms are present and

routine treatment plan for

maintaining control can be followed


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Yellow

50-79% of best

Signals caution

Asthma is not well controlled. Anacute exacerbation may be present.Maintenance therapy may need to be

increased. Call physician if the childstays in this zone

Red


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Red

Below 50% of best

Signals medical alert.

Severe airway narrowing may beoccurring. A short-actingbronchodilator should beadministered. Notify physician iflevel does not return immediately andstay in the yellow or green zone.


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How do we know when

asthma is in control?


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Nursing Diagnoses

Ineffective airway clearance relatedto bronchoconstriction and edema

AEB cough or wheeze. Impaired gas exchange related to

airway obstruction and CO2

retention. Risk for Deficient Fluid Volumerelated to difficulty in drinking.


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Anxiety/Fear (child and parental) r/tdifficulty breathing and change in

health status. Ineffective therapeutic regimen

management (family) r/t lack of

understanding about and need fordaily mgt of a chronic disease.


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Hygiene Hypothesis

There is a school of thought that inthe USA we fail to challenge thenewborns immune system with normal

bacteria (Obsession with sterilizing,etc).

Third world countries have almost no

asthma Farm and rural environments have

minimal asthma


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Exposure to farm animals (even dogs)

to a newborn seem to lessen thechance of asthma

Soare we too clean?


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Cystic Fibrosis Chronic, genetic disorder affectingthe exocrine glands

Autosomal recessive Located on chromosome 7 Sodium transport problems

Thick, sticky mucous

Median survival 38.6 years (4/2006)


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Genetics 1 in 29 caucasians

carry the gene (in USA)


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Diagnosis of CF Positive sweat test with + family history /or

Clinical signs Not reliable in children < 3 weeks

DNA

Genetic carrier Prenatally

siblings


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Clinical manifestations of

CF Meconium ileus (7-10%), latemeconium passage.

Growth failure Frothy, foul-smelling stools

(steatorrhea)

Salty taste Recurrent respiratory symptoms


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Later manifestations of

CF Clubbing barrel-shaped chest

portal hypertension frequent respiratory infections

cough


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esophageal varicies

pancreatic fibrosis DM

Distal intestinal obstructionsyndrome


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http://en.wikipedia.org/wiki/File:ClubbingCF.JPG


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Management of CF

Facilitate airway clearance and gasexchange nebs

Exercise/CPT Prevent/treat infection

Antibiotics Prophylactic

Treatment Inhaled TOBI


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Provide optimum nutrition Enzymes Salt Increased calories

Emotional support lung transplant gene therapy


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Meds for CF

Nebs Bronchodilators

Pulmozyme (dornase alfa)

Hypertonic saline, TOBI

Enzymes (Ultrase, pancrease)

vitamins

Antibiotics


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Nursing Care Supportive and encouraging Meds Nutrition

High cal/high protein Supplemental feedings

Diabetes management Coordinate with RT

Education isolation


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Bronchopulmonary

dysplasia Chronic lung disease (CLD) Primarily ELBW and VLBW


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Patho of BPD Immature lung is injured anddevelops chronic inflammation Mechanical ventilation Prenatal/postnatal infection Oxygen therapy Increased pulmonary blood flow

Results in hypercarbia and hypoxemia


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Prevention of BPD Surfactant Prenatal steroids

Lowest possible pressures Lowest possible O2 concentration

Bubble CPAP


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Signs and symptoms of

BPD Sx of resp distress What are they?

Intermittent bronchospasms andmucous plugging

Barrel shaped chest

FTT O2 dependence; chronic CO2

retention


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Management of BPD Maintain oxygenation Control interstitial fluid

Adequate nutrition Avoid infection


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Nursing care for BPD Oxygenation O2 Pulse ox Normothermia Adequate rest

Strict I & O

diuretics


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Nutrition Ensure adequate calories

Oral-motor stimulation Avoid infection (RSV, flu)

Education

Support


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Nursing Diagnoses

Alteration in respiratory function

Alteration in nutrition

Anxiety Fluid volume deficit

Activity intolerance

Knowledge deficit Alteration in thermoregulation


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Alteration in respiratory

function HOB up Monitor sats, oxygen if needed

Suction Fluids

Promote rest

Meds Side effects

Teaching


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Alteration in Nutrition Calculate calorie needs Provide adequate calories

Accurate I and O Daily weight

Measure to encourage intake

E ( h k )


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MEDS (think COPD)

Albuterol or Xopenex nebs (oftenwith ipratropium/atrovent, etc)

Inhaled steroids (azmacort)

Diuretics (if so, may need KCL also) Antibiotics prn (or prophylaxis)

Vitamin A (plays a role in lung

function) Synagis


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Fourteen year old John is admittedwith LRI and CF. This is his 20thadmission.

What abnormal physical assessmentfindings would you expect to see?

What orders would you expect?

What are developmental issues atthis age?

How would you adapt your nursinginterventions to an adolescent


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A child with CF is receiving

Tobramycin 75 mg IV q 8 h. Safe dose is 2.5-3.3 mg/kg/dose

Patient weighs 50 lb

Is this a safe dose?


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A baby with CF weighs

20 lb 3 oz

Calorie needs are 120 cal/kg/day

How many ounces of 27 cal formula

would the child need per day?


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A 6 year old child is being admitted

from the MDs office with asthma.When he gets to the floor, what will

you do first?

VS weight

O2 sat

oxygen start IV

neb treatment

Hi it l i


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His vital signs are: HR 124

RR 28 T 39 C

What do you think about these?

What do you think his breath sounds

are like? How is he acting?

What other systems do you want to

assess closely?


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Which statement indicates that

parents have understood teachingabout prevention of asthma attacks?

We will replace the carpet in ourchilds bedroom with tile

Were glad the dog can still sleep inour childs room

Well be sure to use the fireplace tokeep the house warm.

Well keep the plants in our childs

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