differences in adult and child adult child the diameter of an infant’s airway is approximately 4...
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Differences in Adult and Child Adult Child
What are the anatomic differences in the eustachian tube of adults and small children? (shorter, wider, more horizontal)
Which difference do you think could cause more problems for the child and why?
Inflammation of the middle ear sometimes accompanied by infection
Common CausesEustachian tube dysfunction
Previous URI causes mucous membranes of the eustachian tube to become edematous and blocks tube.
Enlarged adenoids Allergic rhinitis
Exposure to cigarette smoke (airborne pollutants)
Pacifier use may raise soft palate and alter dynamics in the eustachian tube
Clinical Judgment Question:
Considering the contributing factors to this condition, what age group most commonly experiences acute otitis media?
Acute Otitis Media characterized by abrupt onset, pain,
middle ear effusion, and inflammation.
Note the injected vessels and altered shape of cone of light.
Serous Otitis Media
Note effusion on otoscopy by fluid line and air bubbles
Note that the light reflex is not in the expected position due to a change in tympanic membrane shape from air bubbles.
What objective sign is this child displaying?
What does it indicate?
Clinical Manifestations
Evaluation and therapyRecent concerns of drug-resistant streptococcus
pneumoniae have caused medical professionals to re-evaluate antibiotic therapy (APA, 2004)
Many episodes of OM result from viral infectionsWaiting up to 72 hrs for spontaneous resolution is
now recommended in healthy infantsWhen antibiotics are warranted, oral amoxicillin in
high dosage is the medication of choice.
Nursing Interventions: Nursing implications for antibiotic therapy
SafetyTeaching
Comfort measuresTeaching for home care:
When to notify primary care providerFollow up visit with primary care providerPreventive measures
Myringotomy
Purpose: DrainageAir exchange by-passing Eustachian tube Prevent further scaring and hearing loss
Nursing Care Management following placement of Myringotomy:Comfort measuresAssessments immediately post operatively and ongoingPre & Post-op support for the familyDischarge teaching:
Comfort measuresWhen to notify primary care providerPreventative measures
Hygiene Recreational
Mastoiditis
MastoiditisMorbidity/mortality
Hearing lossExtension of the infectious process beyond the mastoid
system, resulting in intracranial complications Ages affected
Parallels otitis media, affecting mostly young children and peaking in those aged 6-13 months.
May occur in healthy adults as well
Nursing care for the child with mastoiditis:Assess vital signs (what additional VS do you need to
assess?)Which lab values would indicate additional concerns?Medicate aggressively with antibiotics as ordered
(usually IV if bacterial spread to mastoid) WHY?Antibiotics of choice: ticarcillin disodium (Timentin®)
and gentamicin sulfate (Garamycin®)Assess for complications (hearing loss, tinnitus)Comfort measures
Nursing interventions related to administration of antibiotics: Contraindications:
Allergies/sensitivities- what medications have a co-morbidity? (aminoglycosides- mycin or micin suffix)
Peak/ Trough- when to draw, how to interpret Assessment of adequate filtration from the body
(what organs are most effected)Why is rate of administration vitally important?
Upper Respiratory Tract InfectionsNasopharyngitis
Young child: fever, sneezing, vomiting or diarrheaOlder child: dryness and irritation of nose/throat, sneezing, aches, cough
PharyngitisYoung child: fever, malaise, anorexia, headachesOlder child: fever, headache, dysphagia, abdominal pain
Tonsillitis Masses of lymphoid tissue in pairsOften occurs with pharyngitisCharacterized by fever, dysphagia, or respiratory problems forcing
breathing to take place through nose
Key to understandingprevention of URI ismeticulous handwashingand avoiding exposure to infected persons
The nurse should remind the child with a positive throat culture for strep to discard their toothbrush and replace it with a new one after they have been taking antibiotics for 24 hours
Clinical Manifestations Tonsillitis
FeverPersistent or recurrent sore throatAnorexiaGeneral malaiseDifficulty in swallowing, mouth breather, foul odor breathEnlarged tonsils, bright red, covered with exudate
AdenoiditisRespirations – stridor, snoring, nasal quality speechPain in ear, recurring otitis media
Nursing Care for the Tonsillectomy and Adenoidectomy Patient
Post-operative CareProviding comfort and minimizing activities or
interventions that precipitate bleedingPlace on abdomen or side until fully awakeManage airwayMonitor bleeding, esp. new bleedingIce collar, pain medsAvoiding p.o. fluids until fully awake --then liquids and
soft cold foods. Avoid citrus juices, milkDo not use straws or put tongue blade in mouth, no
smoking
Nurse Alert for Post-Op T/A surgery Most obvious sign of early bleeding
is the child’s continuous
swallowing of trickling blood. Note the frequency of
swallowing and notify
the surgeon immediately
Indications of Respiratory Distress1. Nasal Flaring2. Circumoral cyanosis3. Expiratory grunting4. Retractions:
• Substernal, • Lower intercostal,
5. Tachypnea Repirations greater than 60
ApneaDefined as: Delay of breathing over 20 secondsAdditional Signs and Symptoms:
CyanosisMarked pallorHypotoniaBradycardia
Treatment and Nursing CareAdmit to hospital for cardio-respiratory
monitoring
Teach parents home care instructions in the use of an apnea monitor
Encourage parents to learn CPR.
Cardiorespiratory
Monitoring
pulse oximeter desired reading
> 95%
SIDSDefined: sudden death of an infant during sleepRisk Factors
Prematurity, low birth weightMost common in infants 2-4 months oldMore prevalent in winter monthsSleeping in bed with others, sleeping prone, use of pillows
and quiltsExposure to passive smoke
SIDS – Nursing InterventionsParent teaching:
Place infant on back to sleepPlace on firm mattressDo not use loose bedding, toys, pillowsAvoid overheating with too many clothesParents should stop smoking
Provide support of parents by helping them work through feelings of guilt and loss; refer to National Foundation for SIDS
CroupCroup
Croup: viral and bacterial syndromesLaryngotracheobronchitis Bacterial tracheitisEpiglottitis
Initial symptom of all three is stridor, a seal- like barking cough and hoarseness
Croup vs. EpiglotitisCroup
Viral/BacterialFeverHoarsenessResonant coughStridor (inspiratory)Risk for significant
narrowing airway with inflammation
Humidity for treatment
EpiglottitisBacterialHigh feverRapidly progressive courseDysphagiaDroolingDysphoniaDistressed inspiratory effortsAntibiotics needed
Medications Beta-agonist /Bronchodilator– Albuterol
Corticosteroids
Which of these medications would the nurse give first? Rationale?
Nursing CareMaintain patent airway
Oxygen with humidificationKeep resuscitation equipment at the bedsideAssess VS (T102 or >, and R>60)Nothing should be placed in the mouth
Meet fluid and nutritional needsCool, noncarbonated, non-acid drinks Assess for difficulty swallowing – may need IV therapy
Child with Epiglottitis
Clinical Judgment:Kim, a 4 year old, is admitted to the emergency
department with a sore throat, pain on swallowing drooling, and a fever of 102.2°. She looks ill, agitated and prefers to sit up and lean over.
What nursing interventions should the nurse implement first in this situation?
Bronchitis vs. BronchiolitisBronchiolitis
Bronchitis
BronchitisRarely occurs in childhood as isolated problemMay occur with other respiratory illnessMost often viralMay result from a response to an allergenSymptoms include coarse, hacking cough (increases
at night), fatigue, sore ribs, deep and rattling respirations, audible wheezing
Bronchiolitis / Rhino Syncytial Virus (causes 50% of cases)
Primarily affects infants 2-6 months of ageInfection of bronchial mucosa leading to
obstructionBegins as upper respiratory infection (URI)
and progresses to Respiratory Distress. Diagnosed with a RSV wash
Nursing Care for Child with RSVMedication therapy
Bronchodilators SteroidsBeta-antagonistsAntiviral-Virozole (Ribavirin)Prevention – Synagis (palivizumab) administered IM.
and RespiGam (RSV immune globulin) administered IV. Droplet and contact isolationDroplet and contact isolation
Nebulized epinephrine administered for Bronchiolitis
Parents can hold nebulizer to decrease infant’s fear
Reactive Airway Disease (asthma)Chronic inflammatory disorder affecting mast cells,
eosinophils, and T lymphocytes
Inflammation causes increase in bronchial hyper-responsiveness to variety of stimuli (dander, dust, pollen, smoke)
Most common chronic disease of childhood; primary cause of school absences
Asthma
Etiology/Pathophysiology of AsthmaObstructive airflow limitation due to:
Mucosal edema - membranes that line airwaysBronchospasm (bronchoconstriction)Mucus plugging (thicker) causes:
Increased airway resistanceDecreased flow rates
Asthma (RAD) continued:Increased work of breathingProgressive decrease in tidal volume and expiratory
volumeArterial pH abnormalities due to:
Increase in number of poorly ventilated alveoliIncrease in hypoxemiaCarbon dioxide retentionRespiratory acidosis
Asthma Triggers
Interpreting Peak Expiratory Flow Rates
Green: (80-100% of personal best) signals all clear and asthma is under reasonably good control
Yellow (50-79% of personal best) signals caution; asthma not well controlled; call dr. if child stays in this zone
Red (below 50% of personal best) signals a medical alert. Severe airway narrowing is occurring; short acting bronchodilator is indicated
Medications to treat AsthmaReliever or Rescue Meds
Short acting beta-agonists - AlbuterolCorticosteroids- Prednisone, Beclomethasone for
short term therapyAnticholinergic agents: Atrovent
Preventer / Controller MedicationsMast-cell inhibitors (Cromolyn)Leukotriene modifiers – (Singulair)Inhaled steroids ( Advair, Pulmocort, Azmacort)
Child receiving nebulizer treatment
What is important patient teaching ?
Treatment and Nursing Care
Humidified Oxygen via
maskPulse Oximeter
High Fowler’s position
Emergency situations of asthmaAcute episode of reactive disease: bronchioles may
close rapidly, causing severe airway obstruction, anxiety, restlessness, and fear. Will need to be seen in ER if not relieved by med
Status asthmaticus: medical emergency with severe edema, profuse sweating, respiratory failure and death if untreated. Becomes seriously hypoxic…immediate intervention needed
Cystic Fibrosis (CF)Factor responsible for manifestations of the
disease is mechanical obstruction caused by increased viscosity of mucous gland secretions
Mucous glands produce a thick protein that accumulates and dilates them
Passages in organs such as the pancreas become obstructed
First manifestation is meconium ileus in newborn
Physical findings of the CF patient:Clubbing of the fingersIncreased respirations,
cyanosisProductive, moist coughBarrel chest
Assessment:FTT despite high caloric intake. Frequent respiratory infections. Malabsorption of fats and proteins Mild diarrhea with malodorous stools,
steatorrhea. Abnormally high levels of sodium chloride in
sweat.
Diagnosis:• Sweat test: Chloride – Normal < 40 mEq/L. Highly suggestive of CF 40-60 mEq/L Diagnostic > 60 mEq/L.
(see bags over hands and arms) • Pancreatic enzymes: Collection of stool specimen to assess Trypsin and lipase. Trypsin absent in 80% of children with CF
CF ManagementTreatment
Prevention and treatment of pulmonary infections with antibiotics
Chest Physiotherapy at least twice a day to increase sputum expectoration
Physical exercise important adjunctManagement of dietary supplements (enzymes
with meals and snacks)