Pediatric Disorder Children produce excessive mucus.

But their
Respiratory System bronchioles are small.
Objectives Get respiratory in the abdominal part for
The students will be able to: children. Children uses thoracic breathing.
1. Explain important concepts of the
respiratory system and appropriate Assessing Respiratory Illness in Children
diagnostic test. Common symptoms:
2. Identify data essential to the  Hypoxemia
assessment of the alterations in health  decrease level of O2 in the system
of the respiratory system in a child.  Tachypnea and tachycardia
3. Discuss the clinical manifestations and  an effort to oxygenate the cells;
pathophysiology of these alterations. respiratory will increase then circulatory
4. Formulate nursing diagnoses related to will also increase
respiratory disorders in children.  Poor feeding pattern
 the effort of eating needs ATP
Topics:
 Pale appearance
Anatomy and physiology
 poor hemoglobin in the blood; the
Physical assessment and its nursing
periphery will be the first one to pale
management
Preterm and post term babies  Anxiety and confusion
Sudden infant death syndrome  because of decrease blood supply in the
brain
Upper Respiratory  Cardiac arrhythmias
CROUP  very dangerous; erratic beating of the
Epiglottis heart; heart can no longer control; may
lead to cardiac arrest
Lower Respiratory
Bronchiolitis 100-120 beats per minute – normal heart rate
Bronchial Asthma of children
Bronchopulmonary Dysplasia
Cystic Fibrosis Physical Assessment
 Coughing
Anatomy and Physiology  a manifestation that there’s foreign
object inside the body; trying to remove
an object that is foreign
o Non-productive cough
o Productive cough – there is a
presence of mucus/sputum when
the child coughs out; greenish or
yellowish appearance
o Paroxysmal coughing
o Whooping cough
Respiratory Centers
Peripheral receptors  Rate and depth of Respirations
Central respiratory receptors  depth is high; depth is shallow or deep
Proprioceptors  Hyperventilation is deep rapid breathing
(use brown paper bag)
Respiratory Mucus differences  Retractions
Newborn  bony prominences of the clavicular area
Children and the suprasternal area
o supraclavicular and suprasternal –
problem is in the upper respiratory tract
o intercostal spaces and subcostal –
patient is having a low respiratory tract
infection
 Restlessness
 less blood supply to the brain
 Cyanosis
 not enough oxygenation level
 Clubbing of fingers
 more than 180-degree angle; curve; the
child is exposed to areas with lack of
oxygen; the nail beds develop a new
network of capillaries to compensate Older children – brachial part
 Adventitious sounds
 crackles, wheezing; checking the upper
part of the lungs – there are sounds
 Chest diameter
 1:2

Diagnostic Test
Blood Gas Analysis
 BGA Newborn – umbilical cord
 under doctor’s orders Arterial Blood Gas Analysis
 new born screening Arterial partial pressure of oxygen (PO2)
 collect sample of blood in the heel part  Indicates how well O2 can move from
to check for the O2 level and CO2 the lungs to the blood
 80-100 mmHg

If the child has a problem in the surfactant, the

child cannot breathe in properly.

Partial pressure of CO2 in arterial blood

(PCO2)
 Indicates how well CO2 can move out of
the blood to the lungs
 Indicator of how respiratory system is
functioning
 Regulated by the lungs
 Indicated whether condition is a
respiratory disturbance
 35-45 mmHg

Too high pressure – there is a problem in the

child’s carbon dioxide release (the doctor will
look at the acidity level)
 Oxygen Saturation (O2) If the problem is PaCO2 – respiratory system
 Percentage of hemoglobin carrying O2 If the problem is HCO3 – kidney (metabolic)
 95% - 100%

O2 gives color in the circulation.

Pulse Oximetry
Bicarbonate concentration in blood (HCO3)
 Is a chemical buffer that maintains the
blood’s pH within normal levels
 An indicator of how the metabolic
system is functioning
 Regulated by the kidneys
 Indicates whether there is metabolic
disturbances
 22-26 mEq/L
Normal: 95% - 100%
Too much bicarbonate means the circulation is
acidic; the damage is in the kidney, not in the Transcutaneous Oxygen Monitoring
respiratory system

Hydrogen ion concentration in blood (pH)

 Indicates the acid or base level of the
blood
 7.35-7.45

Acidic blood means toxic; but in this, below

7.35 it is acidic and above 7.45 it is alkaline.
SAMPLE QUESTION
Match the acid-base status of the following
blood samples to the disorders in the drop-
down list. (PaCO2 values are in mm Hg and
bicarbonate values in mmol/l). pH 7.57, PaCO2
22, HCO3-22.
A. Respiratory Acidosis
B. Metabolic Alkalosis
C. Metabolic Acidosis
D. Respiratory Alkalosis
ROME – Respiratory Opposite Metabolic Equal
pH is a determinant if the blood is acidic or
alkaline.
Respiratory acidosis – high CO2 and high pH
 Electrodes attach to the chest part
 Try to evaluate if there’s enough O2
beneath the skin
 Dangerous if the nurse will not change
the position after 3-4 hours
 The side effect of the electrodes can
lead to burns because this equipment
produces heat which causes
vasodilation.
 To diagnose arterial insufficiency and
venous insufficiency
Pulmonary Function Test

SAMPLE QUESTION
ph 7, PaCO2 45, HCO3-20
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Respiratory Alkalosis  checking the lung capacity
D. Metabolic Alkalosis  try to evaluate how their lungs will
function
  Prior to the test, we should withhold all
the medications like the Bronchial
dilators
 Make sure child has light meal
 no constrictive clothing
 adolescents must be not smoking prior
to the test

Chest Radiography  To check what kind of virus stayed in

the nasopharyngeal part
 To confirm Respiratory Syncytial Virus

Respiratory Syncytial Virus Nasal Washings

 parents will wear lead apron

 pregnant women are not allowed

Sputum Specimen Analysis

AMBULATORY X-RAY – machine is brought to

the room of the patient

Magnetic Resonance Imaging

 Check for TB
Bronchography

 ask if there’s allergic reactions

 inform the parents if there’s steel in their
body (pacemakers, steal bone)
 high end than CT scan
 patient will be advised for CT scan if
there’s steel in the patient’s body
Nasopharyngeal Culture
 To see using the Contrast medium
 Make sure to inform the mother that the
child should not eat 4-6 hours prior to
the test
 Mother should be receiving a consent
 Make sure that after the test, the child
should pee
 Increase child’s fluid intake to excrete
the dye. For baby, increase
breastfeeding
  Flat on bed and remain quiet (postural
Bronchoscopy puncture headache)

Collecting Specimens for Analysis

 Blood Specimens
 Simple explanation
A, venipuncture
B. capillary puncture (heel or fingertip) –
glucose and hematocrit
 Urine specimens
Invasive procedure  Stool Specimens
The kid must be sedated
Treatment of Respiratory Illness
Purpose: 1. Expectorant Therapy
• To see if there is bleeding inside the body  they need to expel the mucus that traps
• To get an obstructed object. in the lungs because this can lead to
obstruction
The child may have turn to sides to drain the  under doctor’s order:
saliva  Liquefying agents
 nasal sprays, liquefying drugs or
The suction machine should always be at the medications, Robitussin syrup
side  Humidification
 vaporizer, nebulation
Bronchoscopy should be at the last part.
 Coughing
There should be consent from the mother.
 cough out the mucus
If there is positive gag reflex, the child can  Mucus-clearing devices
drink water.  to loosen up the thick mucus; back
tapping or back massage
Do not allow the child to drink water if he still  Chest physiotherapy
does not have positive gag reflex.

Semi-fowlers position – turning the head to

sides.

Bronchoscopy

 10-20 breaths and half cough

Aspiration Studies
 Lumbar Puncture
 Bone marrow aspiration
 Sedative
 Assess for bleeding

Positive Expiratory Pressure (PEP)
 Basic Principle: breathe against a
resistor (at FRC)
 Positive pressure proximal to building up
in airways splints bronchiectatic airways
open, facilitating removal of distal
mucous plugs.
 Positive alveolar pressure transmitted
between alveoli (Pores of Kohn, Ducts
of Lambert) DISTAL to the mucous plug
proximally
 Each treatment cycle: 12-15 breaths
followed by forced expiratory technique,
or active cycle of breathing to clear
secretions
 Each treatment session consists of 6
cycles (20-30 minutes total)
2. Improve Oxygenation
 Inform the doctor that you inserted nasal
canula
 Oxygen administration
 Pharmacologic therapy
 Incentive spirometry
 Breathing techniques
Salbutamol – good for bronchodilations
Ventolin – a bronchodilator
High-fowlers position
To expand the lungs.
 Tracheostomy
 Endotracheal Intubation
 Assisted Ventilation
 Lung Transplantation
Intubation – depleted O2; patient is cyanotic
Mechanical Ventilator – MecVen; premature
babies’ blood vessel is fragile; they cannot
sustain high or positive pressure; monitor the
level of concentration of oxygen towards the
baby
Lung transplantation – for Cystic Fibrosis
Nursing Diagnoses
 Probable
 Impaired Has Exchange
 Ineffective airway clearance
 Ineffective breathing pattern
 Risk for infection
 Ineffective tissue perfusion:
Cardiopulmonary
 Impaired spontaneous ventilation
Possible
 Anxiety
 Delayed growth and development
 Risk for impaired skin integrity
 Imbalanced nutrition: Less than body
requirements
 Risk for deficient fluid volume
Know how to prioritize.
ABC – Airway, Breathing, Circulation
Problems in Birthweight or Gestational Age
Birth weight variations
 Fetal growth is influenced by maternal
nutrition, genetics, placental function,
environment and a. multitude of other
factors.
 The size of a newborn is away to
measure and monitor the growth and
development of the newborn at birth
 Classifies according to their weights
and weeks of gestation.
 Appropriate for gestational age (n ht,
wt, hc, and BMI)
 Small for gestational age (less than
2,500 g/5 lb or 8 oz)
 Large for gestational age (more than
400g/8 lb or 13 oz)
Other Variations
 Low birthweight
 Less than 2,500 g (5.5 lb)
 Very low birthweight
  Less than 1,500 g (3 lb/55 oz)
 Extremely low birthweight
 Less than 1,000 g (2 lb/3 oz)
Small for Gestational Age Newborns
Factors:
 Maternal Causes
 caused by the mother
 babies are developed inside the womb
depending on the circulating blood from
the placenta
 hypertensive mothers, smoker mothers,
abused with substance abuse, mother is
malnourished, TORCH (Toxoplasma
gondii, other agents, rubella,
cytomegalovirus (CMV), and herpes
simplex virus (HSV))
 Placental Factors
 Placenta abruption, Placental infarction
(decrease oxygenation level)
 Fetal Factors
 possible post-term babies (wala pa naka
gawas; 42 weeks and beyond)
 the baby cannot give enough nutrient
supply because the placenta is not
working well
 do labor initiation (induced labor)
 genetics
Nursing Assessment
 Head disproportionately large compared
to rest of body.
 Wasted appearance of extremities
 Reduced subcutaneous fat stores
 Decreased amount of breast tissue
 Scaphoid abdomen - common for
diaphragmatic hernia
 Wide skill sutures secondary to
inadequate bone growth
 Poor muscle tone over buttocks and
cheeks
 Loose and dry skin that appears
oversized
 Thin umbilical cord
Nursing Management Small for Gestational
Age
 Obtain weight, length, VS, blood
glucose
 Maintain thermoregulation
 less subcutaneous tissues (increase
demand metabolism); cause chilling
1. They do not have subcutaneous tissue.
2. They are exposed to environmental
coldness.
3. They used up glucose.
Providing rest – there should be a
scheduled manner
 Initiate early and frequent feedings
(Hypoglycemia = N 40-45 mg/dl)
 Weight daily
 Adequate rest
Large for Gestational Age Newborns
Factors:
1. Maternal diabetes
2. Multiparty
3. Postdates gestation
4. Maternal obesity
5. Genetics
Common problems: vaginal birth maybe
difficult
1. Shoulder dystocia
2. Clavicular fracture
3. Facial palsies
Small baby common problem: respiratory
system
Big baby common problem: vaginal birth is
difficult
Assessment
 Newborns has a large body and
appears plump and full-faced.
 Increase in body sized and proportional
 Newborns have poor motor skills and
have difficult in regulating behavioral
states.
 Difficult to arouse to a quiet alert state
Nursing Management Large for Gestational
Age
 Monitor blood glucose level
 Initiate feedings
 Monitored record I and O. Obtain daily
weights
 Increase fluid intake
 Phototherapy
Glucuronyl transferase is a liver enzyme. It cause birth asphyxia, but the most
changes bilirubin into a form that can be common causes include problems with
removed from the body through the bile. the uterus, placenta, and umbilical cord.
 Birth asphyxia and decreased blood flow
Complications to the baby’s brain can result in a
 Neonatal asphyxia serious condition called hypoxic-
 small for gestational age or preterm/post ischemic encephalopathy (HIE).
term newborns
Interventions:
 do suction; get oxygen; replace O2
therapy; intubate the child;
Causes:
 maternal or placental cause; depletion
of O2 in the brain; APGAR scoring is
small (2-3)
 Difficulty with thermoregulation
 Hypoglycemia
 Polycythemia Pre term Neonates
 appears only when the child is exposed  A neonate born before 38 weeks age of
to a long period of time with less O2 gestation
 Meconium aspiration  Low birth weight
 can happen to any term babies
 Hyperbilirubinemia Contributing Factors
 doctor will advise the newborn to  Low socioeconomic level
expose to the heat of the sun  Poor nutritional
 phototherapy will be used if too much  Lack of prenatal care
bilirubin (Kernicterus - too much can  Multiple pregnancy
lead to coma because it is toxic)  Cigarette smoking
 normal values of bilirubin: within 0-3  Mother’s age younger than 20
milligrams / 100 mL  Closely spaced pregnancy
 Birth trauma
 Abnormalities in the reproductive
system
Jaundice
 Infection (UTI)
1. Pathologic – appear colors in 24 hours;
 Premature rupture of BOW/separation of
there’s obstruction in the liver; structural
2. Psychologic – appears or happens in 2- the placenta
3 days; obstruction of blood cells  Early induction of labor
 Emotional and physical trauma
Bilirubin
Days Preterm Full term
0-1 day 1.0-8.0 mg / dl 2.0-6.0 mg/dl
1-2 days 6.0-10 mg / dl 6.0-12.0 mg/dl
3-5 days 10-14 mg / dl 4.0-8.0 mg / dl
Characteristics
What is Birth Asphyxia?
Fetal Oxygen Deprivation Appears small and
 A lack of oxygen to a baby’s brain or underdeveloped
birth asphyxia, is the most common subcutaneous tissues
cause of birth injuries in newborns.
There are a number of things that may
Poikilothermic
 Inability to regulate
one’s body
temperature

Physiologic weight
loss is exaggerated
(no subcutaneous
tissue)

 Weak activity
 Often assume frog-
like position Lower chest – intercostal
 Extremities have Chest ingrowing – retraction (grade 2)
less muscle
 Neuromuscular Grading of Neonotal Respiratory
immaturity Distress
 Indicates NO RD- 0

RESUL
Note:
Placenta- stars to  Indicate MODERATE RD- 4-6

TS
develop at 24 weeks  Indicate SEVERE RD- 7-10
of gestation
Surfactant- to lower COMPLICATIONS
the surface tension so
that the alveolar sac  Intraventricula - the ventricles in the
will not collapse r haemorrhage brain
Less surfactant - the - Watch the head if its
lungs will not inflate increasing
CNS center for (hydrocephalus)
respiratory is - do not lower the head
underdeveloped or do not let the baby
(irregular beathing with cry
short periods of apnea  Cold stress - prone to metabolic
(20 sec)) acidosis
Apnea- Temporary  Retinopathy - can lead to blindness
cessation of breathing; - administering too
more than 20 seconds much oxygenation
especially when using
Special Problems: mechanical ventilator
Respiratory Distress Syndrome  Necrotizing - dead organs
Nucleus Medial Media, Enterocolitis - “entero” small
(October 8, 2019). intestines
Infant Distress - the organs will not fully
Warning Signs develop
(Grunting Baby Sound) - can develop infection
https:// - causes necrotic tissue
www.youtube.com/ OTHER COMPLICATIONS:
watch?  Sepsis
v=oX3CZnrLxbQ - caused by bacterial infection
- 5000-10000 (normal wbc)
- meconium aspiration (most
 common) can lead to meconium B. Maintaining Body Temperature
aspiration pneumonia
 Hyperbilirubinemia 1. Put covers and blankets
 Anemia 2. Regulate the environment
3. Attachment of mothers (limited schedule)

Nursing Management: C. Preventing Infection

A. Improving respiratory Function  All the tubing must be monitored and

changed after 3 days/72 hours
ISOLETTE  Antibiotic – Prophylactic (wala pai
1. Place the
baby in the infection pero hatagan to prevent
ICU right infection)
away D. Maintaining Adequate Nutrition
 Use the syringe intended for preterm
Small Crib that is regulated babies.
Pulse oximetry  5-10 mL per feeding should be
2. Monitor all introduced to pre-terms
the  10-15 mL per feeding should be
machine introduced to post terms babies
attached to E. Preventing Skin Integrity
the baby
Missing: Transcutaneous  The diaper should be smooth.
Monitoring SLIDE  Make sure dili hulaton mahurot ang
diaper.
Monitor circulation and  Reposition to avoid bed sores
respiration F. Promoting Energy conservation and
3. Monitor the sensory stimulation
baby The mother is obliged everyday to visit
depending the day but with a schedule
on doctor’s
G. Reducing parental Anxiety
order
Always update the mother.
Best procedure H. Improving Parenting Skills and family
 O2 Therapy functioning
 Suctioning After discharge, the parents should
 ET if ordered undergo a BLS training (Basic Life
Support).

Semi-fowlers (15 degree) position Post Term Neonate

Mattress and bed sheet must be firm  A neonate born after 42 weeks age of
gestation

Contributing Factors
 Low socioeconomic level
Electronic Apnea
 Poor nutritional status
 Lack of prenatal care
 Multiparous mother’s
 Cigarette smoking
 Mother’s age younger than 20
 Mother’s with DM
 DM- differs from pre-term and post Medicosis
term Perfectionals,
(September 1, 2017).
CLASSIC SIGNS: Growth charts/
 Old man’s face- – lose skin because of Percemtile Curves; Are
poor skin turgor you Tall or Short?
 Long and thin with cracked skin which is https://
loose, wrinkled and stained greenish- www.youtube.com/
yellow (nakalibang na) watch?v=jyxjXZ0vlz0
 Long nails and firm skull
 Wide-eyed alertness of one month old
baby
 No vernix nor lanugo  In children FTT, malnutrition initially
results in wasting (deficiency in weight
Possible Complications: gain),
 Penuomonia  Stunting (deficiency in linear groth)
 Hypoglycaemia generally occurs after months of
 Polycythemia malnutrition,
 Head circumference is spared except
NURSING AND MEDICAL MANAGEMENT with chronic severe malnutrition.

1. Offer feedings at 1 to 2 hours of age

(1-2oz or 30 mL to 60 mL - 1 to 2 hours
of age)
2. Serial blood glucose levels monitored
3. Intravenous glucose infusion
4. Provide thermoregulated environment
5. Administer supplemental oxygen
therapy
6. Antibiotics given as ordered
7. Help facilitate a positivie parent-
newborn bond
8. Encourage them to express their
feelings

PREVENTION:
 Before 20 weeks, ultrasound
examination performed
 Evaluate the fetal development, weight,
amount of amniotic fluid and placenta
for signs of aging Know the appropriate height and weight
according to the age level.
FAILURE TO THRIVE
CRITERIA:
 Describe infants and children whose  Weight below the 5th percentile for age
weight and sometimes height fall below on the growth chart OR
the 5th percentile for their age  Wight that decreases, crossing two
 Persistent deviation from established major percentile lines on the growth
growth curve chart over time OR
 Weight that is less than 80% of the
median weight for height of the child.
 preparation, improper mealtime
Army Borynski, (July 19, environment, nutritional beliefs.
2017). Pediatric Growth
Chart.
MANIFESTATION
https://www.youtube.com/ 1. Physical Findings
watch?v=e0UjW0qWDmM  Weight below 5th percentile]sudden
or rapid deceleration in growth curve
 Delay in developmental milestones
CLASSIFICATIONS:  Decreased muscle mass
 Abdominal distention
 ORGANIC (OFTT) – growth failure that  Muscular hypotonia
is due to an acute or chronic disorder  Generalized weakness and cachexia
that interfere with nutrient intake, (malnutrition accompanied by
absorption, metabolism, excretion or muscle wasting)
that increase energy requirements.
 NONORGANIC (OFTT) – Up to 80% of
children with growth failure do not have
an apparent organix disorder; Growth
failure occurs because of environmental
neglect (e.g., lack of food), stimulus
deprivation or both

Metabolism – common disorder

Nonorganic – growth fail because of
environmental neglect

CAUSES OF ORGANIC FAILURE TO

THRIVE
MECHANISM DISORDER
Decrease nutrient Cleft lip or palate,
intake cerebral palsy,
gastroesophageal
reflux, pyloric stenosis 2. Behavioral indicators
Malabsorption Celiac disease, cystic  Avoidance of eye contact or physical
fibrosis, inflammatory touch
bowel disease  Intense watchfulness
Impaired Galactosemia, fructose  Sleep disturbances
metabolism intolerance, down  Disturbed manner, such as apathy,
syndrome and turner extreme irritability, extreme
syndrome compliance
Increase excretion Diabetes mellitus,  Repetitive rocking, head banging,
proteinuria intense chewing of fingers or hands,
Increased energy Infections, heart failure, or head rolling
requirement hyperthyroidism
HISTORY
NONORGANIC FAILURE TO THRIVE PRENATAL DELIVERY,
 It’s due to poverty, psychosocial POSTNATAL
problems in the family, improper formula 1. General 1. Nenonatal
obstetrical history asphyxia
 2. Recurrent 2. Prematurity - Serum electrolytes
miscarriages 3. Birth weight - urinalysis and urine culture
3. Use of 4. Congenital - Sweat chloride test
medications, malformations or - Stool test
drugs, cigarettes. infections - hormone studies, include thyroid
5. Breast feeding function test (T4)
support - Bone scan, to determine bone age
6. Feeding - Chest Xray, ECG, IV pyelogram,
difficulties during Upper or Lower GI series
neonatal period - Tuberculin skin test Bowel and
muscle biopsies
Developmental screening Sweat chloride test –
to check for cystic fibrosis
Nutritional History
GUIDELINES:
 Details of feeding (breast feeding or 1. Improve the child’s diest and eating
formula feeding, formula preparation,
pattern
volume consumed, who feeds the
infants, position and placement of the 2. Improvement in the care givers skils
infant for feeding, timing and 3. Treat the underlying disease
introduction of solids, stool or vomiting 4. Regular and effective follow up.
patterns associated with feeding,
strength of suck. Accurate measurement ADMIT OR NOT
of caloric intake)
15 minutes in each breast • children with mild malnutrition can be
managed by the primary care physician
 Vitamin and mineral supplements . in the outpatient setting
Weaning and introduction of solid food • Children with severe malnutrition require
 Food likes and dislikes, allergies hospitalization for evaluation and proper
treatment.
GENERAL EXAMINATION
DIET AND EATING PATTERN
1. Degree of malnutrition
2. Dysmorphic features may suggest • children with FTT may require more
genetic cause. than 1.5 times the expected calorie
3. Clues for psychosocial etiology and protein intake for their age for
4. Signs of possible child abuse (skin rash, catch-up growth.
injuries, fractures) • children with FTT who are anorexic may
5. Signs of parent's neglect ( neglected not be able to consume this amount of
hygiene, diaper rash, unwashed skin, food and require energy-dense foods.
dirty fingernails) • for formula-fed infants, the concentration
6. Vital signs
of formula can be changed from 20
7. Growth chart
cal/oz to 24 or 27 cal/oz
• for toddlers adding butter, oil, peanut
LABORATORY AND DIAGNOSTIC TEST butter, or other high-calorie foods .
• DEVELOPMENTAL SCREENING • In addition, vitamin and mineral
• TESTS supplementation is needed, especially
- complete blood count (cbc) during catch-up growth.

the first priority is to achieve an ideal
weight for age
the second goal is to attain a catch-up in
length expected for the child age. .
depend on the severity of malnutrition
initiation of catch-up growth may take 2
weeks
for children with chronic, severe
malnutrition, many months are needed
to reverse all trends in growth .
Although many children with FTT
eventually reach normal size, they
continue to be at risk for developmental,
learning, and behavioral problems
MALNUTRITION-INFECTION CYCLE
• Malnutrition causes defects in host
defenses. Conversely, infection
increases the metabolic needs of the
patient and is often associated with
anorexia.
• Children with FTT may suffer from a
malnutrition-infection cycle, in which
recurrent infections exacerbate
malnutrition, which leads to greater
susceptibility to infection.
• Children with FTT must be evaluated
and treated promptly for infection and
followed closely.
NURSING CARE OF A CHILD WITH
RESPIRATORY DISORDER
• Upper airway disorder
- Croup
- Epiglottitis
• Lower airway disorder
- Bronchial asthma
- Bronchiolitis
- SIDS
- Cystic Fibrosis
ETIOLOGY AND CHARACTERISTICS
• Infectious agents
• Age
• Size
• Resistance
• Seasonal variations
• Living conditions
Pre-existing medical problems
Predisposing – cannot be chang
COMPONENTS FOR ASSESSING
RESPIRATORY FUNCTION
• Pattern of respirations
• Rate
• Depth
• Ease
• Labored breathing
• Rhythm
Upper Respiratory Tract Infection
Croup Syndromes
- Croup is a general term applied to a
symptom complex characterized by
hoarseness, a resonant cough
described as "barking" or "brassy
- A severe inflammation and
obstruction of the upper airway
- it affects the region of and subglottic
airway.
Common in our place. - the larynx is affected
TYPES
• Acute laryngotracheobronchitis- is
characterized by inflammation and
narrowing of the laryngeal and tracheal
areas. It is the most common form of
croup and usually affects children
younger than 5 years old
• Spasmodic laryngitis - typically
involves paroxysmal attacks of laryngeal
obstruction generally occurring at night
and it recurs with RTI
 - Neck X-ray: Group signs and symptoms:
Steeple Sign and Subglottic Narrowing

Note:
To confirm the person having croup
Steeple sign – narrow larynx

Therapeutic Management
- Nebulized epinephrine
- Oral steroids
- Antibiotics
Laryngoscopy - Cool humidification with a cool mist tent or
- may reveal inflammation and obstruction on room humidifier
epiglottal and laryngeal areas - Exposure of child to cool air
- Oxygen administration
- I.V. fluids
- Tracheostomy or ET and intubation tray

A. Cool Mist Tent – Group Tent / Croupette

Note: Do not provide toys with battery. Check Upper Respiratory Tract Infection
the back of the baby. Acute Epiglottitis
Croup Scoring System - Acute supraglottitis, is a medical emergency.
0 1 2 3 - It is a serious obstructive inflammatory
Stridor none Only At rest Severe process that occurs predominantly in children 2
with
agitation
to 5 years old but can occur from infancy to
Retractions None Mild Moderate Severe adulthood.
Air entry nml Mild Mod decr Severe Note: In just 5 hours, there is an obstruction
decr Flow:
Color nml nml nml Cyanotic - FOOD
Mental nml restless v. lethargic - Epiglottis in usual position
restless
status - Epiglottis protecting airway during swallowing
- Esophagus (leads to stomach)
Croup - Airway (leads to lungs)
Croup Severity / Management
Score Severity Management
< or = 4 mild Steroids*
5–6 Mid-mod Steroids, racemic
epi**
7–8 mod Steroids, racemic epi,
admit
> or = 9 severe Steroids, r.epi, PICU

- 0.6 mg/kg oral dexamethasone or 0.3-0.6

mg/kg IM
- observe 2-3hrs after racemic epi
Admission for hypoxia, poor po, underlying
laryngeal dz, or moderate dz with parental
anxiety or distance from ED
Note: Corticosteroid – dexamethasone

Nursing Management:
- Assess for airway obstruction by evaluating
respiratory status
- Keep emergency equipment near the bedside
- Administer oxygen and increase atmospheric
humidity
- Promote desired fluid intake
- Administer prescribed medications Causes:
- Minimize fear and anxiety - Bacterial Haemophilus influenzae
- Pneumococcal and group A beta-hemolytic
Provide child and family health teaching streptococci
- Keep the child calm
- Take the child into the bathroom, close the
door, turn on the shower’s hot water
- Take the child outside into cool air
- Use a cool-mist vaporizer near the child’s bed
after an acute episode
- Encourage clear liquid intake
 - Child is allowed to remain in the position that
provides the most comfort and security.
- Assure the parents
- Continuous monitoring of respiratory status
- Vigilant observation and accurate
assessment of respiratory status
- DON’T INSPECT THE THROAT WITHOUT
EMERGENCY PERSONNEL AND SUPPLIES
AT HAND

- streptococcuss mitis
- growth unaffected by optochin disk

Manifestations
- Abnormal position (tripod)
- Dysphagia (leads to drooling)
- Difficulty speaking (muffled/soft)
- Apprehension Croup Epiglottitis
- Increased temperature (Fever) Prevalence Very common Very rare
- Rapid Onset (decreased since
- Nasal Flaring use of Hib
- Using accessory muscles vaccine)
- Retractions (chest)
Common Parainfluenza I, H.influenza type
- Stridor (inspiration) agents II, III, RSV, b
- Enlarged epiglottis (on x-ray or visible) enterovirus

Diagnostic Findings: Age 3 months – 3 3-7 years

- Lateral neck X-ray years
- Throat examination
- Inc WBC and neutrophils Onset URI prodrome Rapid onset
- Blood Culture
Note: To check the thumb sign Physical Barking cough, Quiet stridor
exam stridor, non- toxic, respiratory
toxic distress, 3D's:
THUMB SIGN
drooling,
- Enlarged epiglottis in EPIGLOTTITIS is dysphagia,
stubby like thumb instead of its usual thin dysphonia
fingerlike projection
Therapeutic Management Fever < 39 Celsius > 39 Celsius
- Nasotracheal intubation
- Tracheostomy WBC Normal Elevated
- OXYGEN THERAPY
- Antibiotic therapy X-ray Steeple sign Thumbprint sign
Note: Tracheostomy – pinkalast (tracheal (swollen
narrowing) epiglottis)
Nursing Care Management
treatment Humidified air Intubate/ventilate
- act quickly but calmly and to provide support oxygen if Antibiotics:
without increasing anxiety
 hypoxic celuroxime
racemic
epinephrine
dexamethasone

Lower Respiratory Tract Infections

Asthma
- is a chronic inflammatory disorder of the
airways characterized by recurring symptoms,
airway obstruction, bronchial
hyperresponsiveness, and an underlying
inflammation process
Characteristics:
- Mucus membranes edema- inc Signs and Symptoms:
tenacious mucus- lower airway - Wheezing, prolonged expiration, coarse
congestion breath sounds
- Bronchi and bronchioles smooth - Retractions: intercostal and suprasternal
muscle spasm - Paroxysmal cough: hacking, initially
- Lower airway congestion and muscle nonproductive, later productive of thick clear
spasm-lower airway obstruction- mucus Dyspnea
difficulty expiration- wheezy - Diaphoresis, anxiety, red lips
breathing and air trapping in the - Hunched shoulders and barrel chest
alveoli (emphysema) for chronic type
Types of Asthma:
1. Extrinsic factor – environmental factors,
weather, dusts mite, animal and pollution
2. Intrinsic factors – infection

Hypersecretion of
Mucus

Triggers:
Inflammatory factors: respiratory infections,
work, allergens
Irritants: temperature change, exercise, strong
odors, cold air, stress and emotions
Others: medication, tobacco, food additives,
gastric reflux, pollutants
Diagnostic Test
-Methacholine challenge test (aka
bronchoprovocation test) is performed to
evaluate how “reactive” or “responsive” your
lungs are
- A decline in FEV1 of 20% or more from your
baseline is considered a positive diagnosis of
asthma
- Pulmonary Function Tests
- Spirometry
- Bronchoprovocation testing
- Peak expiratory flow rate Respiratory Syncytial Virus
- Skin prick testing Inflammation – Airway edema and
- Laboratory tests accumulation of mucus and cellular debris –
- Radiographs Narrowing or occlusion of the bronchioles – Air
Trapping – Hyperinflation of some alveoli –
Treatment Atelectasis
- Bronchodilator
- Corticosteroid
- Expectorant
- Antibiotic
- Oxygen PRN
- Sedatives for anxiety
- Cool, humified air

Management of Asthma
A – Adrenergic (Beta 2 Agonists) (Albuterol)
S – Steroids
T – Theophylline
H – Hydration (IV) Assessment findings
M – Mask O2 Early signs and symptoms
A – Anticholinergics - Irritability
- Rhinorrhea
Nursing Management - Pharyngitis
- Proper position: high fowlers or sit up in a - Coughing
chair - Sneezing
- Administer prescribed medications - Thick mucus
- Monitor respiration and other signs of distress - Wheezing and crackles
- Administer oxygen - Diffuse rhonchi and rales
- Monitor IV fluids - Intermittent fever
- Provide proper non-allergenic diet with Note: Respiratory distress syndrome
increased fluids
- Promote relaxation and sleep Diagnostic Evaluation
- Provide health teachings, AVOIDING - Bronchial mucus (Nasal Washing)
IRRITANTS - Chest X-ray

Lower Respiratory Tract Infections Therapeutic Management

Bronchiolitis - Humidified oxygen
- Bronchiolitis is a common lung infection in - I.V. fluids
young children and infants. It causes - Isolation
inflammation and congestion in the small - Prevent exposure to
airways (bronchioles) of the lung. - Secondhand smoke
- Bronchiolitis is almost always caused by a
virus. Typically, the peak time for bronchiolitis Medications
is during the winter months. - Epinephrine
- Palivizumab (Synagis)
CAUSATIVE AGENTS Note:
Respiratory Syncytial Virus and Isolation – protecting other health care
Bronchiolitis providers from the patient
- RSV infection is the most frequent cause of Palivizumab – can kill the presence of RSV
hospitalization in children younger than 1 year (anti-viral infection
old
Nursing Care Management
- Monitor vital signs and pulse oximetry infants bacteria es,
- Assess respiratory and cardiovascular status but may , fungi, parainfluen
- Use gloves, gowns, and aseptic hand be any of allergic za viruses,
washing as secretion precautions a variety disorder human
- Administer chest physiotherapy after edema of URI s, metapneu
has abated pathogen airborn movirus,
- Administer humidified oxygen therapy s e and
- Administer and maintain IV therapy irritants) Mycoplas
- Administer fluids by mouth after acute crisis can ma
trigger pneumonia
Comparison of Conditions Affecting the sympto
Bronchi ms
Asthma Bronch Bronchioli Predomi Wheezin Persiste Labored
itis tis nant g, cough, nt dry, respiration
Descripti Exaggera Usually Most characte labored hacking s, poor
on ted of occurs common ristics respiratio cough feeding,
bronchi in infectious ns (worse cough,
to a associa disease of at night) tachypnea,
trigger tion lower becomi retractions
such as with airways. ng and flaring
URI, URI Maximum producti nares,
animal Seldom obstructive ve in 2 emphysem
dander, an impact at to 3 a,
cold air, isolated bronchiolar days increased
exercise. entity level nasal
Bronchos mucus,
pasm, wheezing,
exudation may have
, and fever
edema of
bronchi Treatme Inhaled Cough Suppleme
Inflamma nt corticoste suppres ntal
tory roids, sants if oxygen if
response bronchod needed saturations
Age Infancy to First 4 Usually ilators, <90%;
group adolesce years of children 2 leukotrien bronchodil
affected nce life to 12 e ators
months modifiers, (optional)
old; rare allergen Suctioning
after 2 and nasophary
years old. “triggers” nx
Peak control, Ensure
incidence, long-term adequate
approximat anti- fluid intake
ely 6 inflammat Maintain
months old ory adequate
Etiologic Most Usually Viruses, medicatio oxygenatio
agents often viral predomina ns n
viruses Other ntly RSV;
such as agents also SUDDEN INFANT DEATH SYNDROME
RSV in (e.g., adenovirus - A sudden and unexpected death of an
apparently health infant (SIDS)
Causes Nursing Interventions
- Unknown cause - Provide, support them and reinforce the fact
- Physical factors: that the death wasn’t their fault
Brain defects - Stay calm and let the parents express their
Low birth weight feelings
Respiratory infection - Prepare the family for how the infant will look
- Sleep environmental factors: and feel
Sleeping on the stomach or side - Let the parents touch, hold, and rock the infant,
Sleeping on a soft surface if desired; allow them to say good-bye
Sharing a bed - Prepare the parents for the need for an autopsy
Overheating - Suggest psychological support for the surviving
children
Risk Factors - Encourage the mother to participate in a
- Sex prenatal or postnatal smoking-cessation
- Age program, as appropriate, and provide emotional
- Race support
- Family history - Provide a handprint, footprint, and lock of hair
- Secondhand smoke - Give post-mortem care
- Prematurity
Prevention
Manifestations: - Back to sleep
- Late manifestations - Keep the crib as bare as possible
- Apneic, bluish discoloration - Don’t overheat your baby
- Lifeless Frothy blood tinged fluid in the nose - Have your babe sleep in your room
and mouth - Breastfeed your baby, if possible
- Typically found in the disheveled bed with - Don’t use baby monitors and other commercial
blankets over the head devices that claim to reduce the risk of SIDS
- Maybe clutching bedding - Offer a pacifier
- Immunize your baby
Diagnostic Findings
- Autopsy findings:
- Pulmonary edema
- Intrathoracic petechiae LOWER RESPIRATORY TRACT INFECTIONS
- Other minor changes suggesting chronic
hypoxia Cystic Fibrosis
- A generalized dysfunction of the exocrine
Medical Management glands characterized by abnormally thick
- Resuscitation pulmonary secretions
- Suctioning - Affects multiple organ
- Intubations
- Mechanical ventilation
- Apnea monitor

Drug study
- Epinephrine
- Atropine
- Sodium bicarbonate

Nursing Diagnosis
- High risk for altered family processes r/t
grieving
- Anxiety r/t difficulty of acceptance Causes:
 - Genetic inheritance transmitted as an
autosomal recessive trait
- CF has a problem with CHROMOSOME NUMBER
7
- Cystic Fibrosis Conductane Transmembrane
Regulator (CFTR) as a “CHANNEL” of cell
membranes that produces mucus, sweat,
digestive enzymes
Class Mutation
Classic or typical CF
Class I CFTR is not synthesized
Class II CFTR is synthesized but in an
abnormal form, which fails to
become released from the
cellular endoplasmic reticulum

Inheritance Of Cystic Fibrosis Class III CTFR is synthesized and is

transported in the cell, but there
is disruption in its activation and
regulation at the cell membrane

Nonclassic or atypical CF
Class IV CFTR is synthesize and is
expressed at the cell membrane,
but chloride conducted is
reduced

Class V CFTR synthesis or processing is

partly defective

Class VI CFTR is synthesized, but there is

impaired conductance of ions
other than chloride

Organs Affected by Cystic Fibrosis

Sinuses
- Sinusitis (infection)
Lungs
- Thick, sticky mucus buildup, bacterial infection,
and widened airways
Skin
HOW IS CYSTIC FIBROSIS CONDUCTANE
- Sweat glands produce salty sweat
TRANSMEMBRANE REGULATOR MADE?
Liver
- Blocked biliary ducts
Pancreas
- Blocked pancreatic ducts
Intestines
- Cannot fully absorb nutrients
Reproductive organs
- (male and female) complications
- infertility

SWEAT GLANDS

Normal Sweat gland

Classification of Cystic Fibrosis - More salt is reabsorbed
 - Dermis (beneath the surface of the skin) - Trouble digesting food
- Usual salt concentration at surface of the skin

Cystic fibrosis sweat gland Assessment Findings

- Less salt is reabsorbed
- High salt concentration at surface of the skin
GENE MUTATIONS IN CYSTIC FIBROSIS
Respiratory
- Wheezing, dyspnea, cough and cyanosis
- Atelectasis and generalized obstructive
emphysema: barrel chest and finger clubbing
- Chronic sinusitis, bronchitis,
bronchopneumonia, and ear, nose and throat
problems

Gastrointestinal Signs
- Meconium ileus at birth
- Rectal prolapse
- Loose, bulky, frothy, fatty stools; voracious
appetite; weight loss; marked tissue wasting;
failure to thrive; distended abdomen; thin
extremities; and evidence of vitamin ADEK
deficiencies
- partial or complete intestinal obstruction

Reproductive Signs
- females will have delayed puberty and
decreased fertility
Pathway from Gene Mutation to Syndrome - males are infertile, sterility

CYSTIC FIBROSIS Cardiovascular Signs

- corpulmonale, right-sided heart enlargement,
INFECTION, INFLAMMATION and CHF
- s/s of hyponatremia
BLOCKED DUCTS
IMPAIRED MUCOSAL DEFENSE Integumentary Signs
- increased concentrations of sodium and
ALTERED SECRETIONS chloride in sweat; parents report a “salty” taste
when they kiss their babies
ION TRANSPORT - failure to thrive may result in hypoalbuminemia
-edema
CFTR PROTEIN

CFTR DNA DIAGNOSTIC TEST

- prenatal testing
- amniocentesis
Health Problems with Cystic Fibrosis - chorionic villus sampling
- Sinus problems - Newborn screening test
- Nose polyps (growths) - Immunoreactive Trypsinogen test
- Salty sweat - Sweat test
- Trouble breathing - Abdominal radiograph
- Frequent lung infections - Genetic test
- Enlarged heart - Chest x-ray
- Abnormal pancreas function - Pulmonary function test
- Gallstones - Sputum cultures
- Fatty BM’s - Stool evaluations
 Greater than 60 Indicative of cystic
mmol/L fibrosis
Sweat tests

Medical Management
- Oral pancreatic enzymes with meals and snacks
- Fat-solute vitamin A, D, E, and K supplements
- Chest physiotherapy
- Postural drainage
- Breathing exercise
- Aerosol therapy (bronchodilators, mucolytics)
- Dornase Alfa (Pulmozyme)
- Antihistamine are contraindicated
- Lung transplantation if needed

Nursing Management
- 1. The electrode drive the medicine into the
skin
- 2. Sweat is collected on filter paper or gauze
- 3. Sweat is tested for chloride concentration
- 4. High Cl- concentration is most likely due to
CFTR mutation
- Teach the child and parents not to restrict salt
- Administer pancreatic enzymes with meals and
snacks, necessity for a high-calorie, high-protein
diet
- Provide high-calorie, high-protein foods; the
infant may need predigested formula such as
pregestimil
- Give multivitamins twice a day, especially fat-
soluble vitamins
- Perform pulmonary hygiene
- Encourage physical activity or creative
breathing exercises
- Promote as normal a life as possible
- Weigh daily

Sample Test and Result: Sweat Chloride Test

- Negative: less than 30 mmol/L
- Borderline: between 30 and 59 mmol/L
- Positive: 60 mmol/L or greater

Chloride Concentration Result

for Infants (birth to 6
months)
0-29 mmol/L Cystic fibrosis is
unlikely
30-59 mmol/L Intermediate
Greater than 60 Indicative of cystic
mmol/L fibrosis

Chloride Concentration Result

for Infants (older than
6 months) children and
adults
0-39 mmol/L Cystic fibrosis is
unlikely
40-59 mmol/L Intermediate