Chapter 40:

Nursing Care of the Child

With an Alteration in Gas
Exchange/Respiratory
Disorder

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Alteration in Gas Exchange/Respiratory
Disorder
 Respiratory disorders are the most common causes of
illness and hospitalization in children and account for the
majority of acute illnesses in children
 Newborns are obligatory nose breathers until at least 4
weeks of age and cannot automatically open their mouths
to breathe if the nose is obstructed
 Anatomy of the nose and throat differs in infants, making
them more prone to acquire infections

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Anatomy and Physiology of the Child’s
Nose and Throat
 Nose
o Infants are obligate nose breathers; newborns produce
very little mucus, making them more susceptible to
infections.
o Newborns have very small nasal passages, making them
more prone to obstruction; sinuses are not developed,
making them less prone to sinus infection.
 Throat
o Infants’ tongues relative to oropharynx are larger;
placement of tongue can lead to airway obstruction.
o Children have enlarged tonsillar and adenoid tissue, which
can lead to airway obstruction.

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Respiratory Structures Differences #1

 Airway lumen is smaller in infants and children than in

adults and when edema, mucus, or bronchospasm is
present, the capacity for air passage is greatly diminished
 Small reduction in the diameter of a child’s airway will
result in an exponential increase in resistance to airflow,
causing increased work or breathing
 Congenital laryngomalacia due to the funnel shape and
location of the larynx, increases the chance of aspiration
of foreign material into the lower airways

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Respiratory Structures Differences #2

 Child’s airway is highly compliant, making it quite

susceptible to dynamic collapse during airway obstruction
 Location of the trachea at the third thoracic vertebra in
children as opposed to the sixth in adults and how this
difference is important when suctioning children and
assessing for risk for aspiration
 Children have a significantly higher metabolic rate than
adults and how this affects normal oxygen transport

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Factors Respiratory Illness

 Exposed to environmental smoke have an increased

incidence of respiratory illnesses such as asthma,
bronchitis, and pneumonia
 Breath sounds heard over the anterior and posterior
chest and axillary areas including wheezing and rales.
Note that breath sounds should be equal bilaterally, and
prolonged expiration is a sign of bronchial or bronchiolar
obstruction
 Percussion of the chest, sounds that are not resonant in
nature should be noted

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Inspection and Observation of the
Respiratory System
 Color: pallor, cyanosis, acrocyanosis
 Rate and depth of respirations: tachypnea
 Nose and oral cavity
 Cough and other airway noises: atelectasis, stridor
 Respiratory effort
 Anxiety and restlessness
 Clubbing
 Hydration status

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Adventitious Breath Sounds

 Wheezing
o High-pitched sound on expiration
o May occur with obstruction in lower trachea or
bronchioles
 Rales
o Crackling sounds heard when alveoli become fluid
filled
o May occur with pneumonia

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Question #1

The nurse is percussing the chest of a child with a

suspected respiratory disorder. What sound might the
nurse note that would indicate pneumonia?
a. decreased fremitus
b. dull sound
c. tympany
d. hyperresonance

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Answer to Question #1

b. dull sound
A dull or flat sound would be percussed over partially
consolidated lung tissue, as occurs with pneumonia.
Decreased fremitus is found on palpation and may be
found with barrel chest, as may occur with cystic fibrosis.
Tympany might be percussed with pneumothorax, and
hyperresonance might be apparent with asthma.

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Laboratory and Diagnostic Tests Ordered
for Bronchiolitis (RSV)
 Pulse oximetry: oxygen saturation might be decreased
significantly
 Chest radiograph: might reveal hyperinflation and patchy
areas of atelectasis or infiltration
 Blood gases: might show carbon dioxide retention and
hypoxemia
 Nasal-pharyngeal washings: positive identification of RSV
can be made via enzyme-linked immunosorbent assay
(ELISA) or immunofluorescent antibody (IFA) testing

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Laboratory and Diagnostic Tests Ordered
for Pneumonia
 Pulse oximetry: oxygen saturation might be decreased
significantly or within normal range
 Chest x-ray: varies according to child age and causative
agent
 Sputum culture: may be useful in determining causative
bacteria in older children and adolescents
 White blood cell count: might be elevated in the case of
bacterial pneumonia

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Laboratory and Diagnostic Tests Ordered
for Cystic Fibrosis
 Sweat chloride test: considered suspicious if the level of
chloride in collected sweat is above 50 mEq/L and diagnostic if
the level is above 60 mEq/L
 Pulse oximetry: oxygen saturation might be decreased,
particularly during a pulmonary exacerbation
 Chest radiograph: might reveal hyperinflation, bronchial wall
thickening, atelectasis, or infiltration
 Pulmonary function tests: might reveal a decrease in forced
vital capacity and forced expiratory volume, with increase in
residual volume

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Common Medical Treatments for
Respiratory Disorders
 Oxygen
 High humidity
 Suctioning
 Chest physiotherapy and postural drainage
 Saline gargles
 Saline lavage
 Chest tubes
 Bronchoscopy

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Question #2

The nurse is caring for a child with cystic fibrosis. Which

treatment would be used to promote mucus clearance
through percussion or vibration?
a. suctioning
b. chest tube
c. bronchoscopy
d. chest physiotherapy

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Answer to Question #2

d. chest physiotherapy
Chest physiotherapy promotes mucus clearance through
percussion or vibration.
Suctioning removes secretions via bulb syringe or suction
catheter, chest tubes remove air or fluid through a drain
inserted into the pleural cavity, and bronchoscopy is the
introduction of a bronchoscope into the bronchial tree for
diagnostic purposes.

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Respiratory Distress Syndrome (RDS)

 Intensive respiratory care

 Mechanical ventilation
 New techniques for ventilator support

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Acute Infectious Disorders

 Common cold, sinusitis

 Influenza
 Pharyngitis, tonsillitis, and laryngitis
 Croup syndromes
 Respiratory syncytial virus (RSV)
 Pneumonia and bronchitis

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Severe Influenza Infection

 Chronic heart or lung disease (such as asthma)

 Diabetes
 Chronic renal disease
 Immune deficiency
 Children with cancer receiving chemotherapy

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Pneumonia #1

 Inflammation of the lung parenchyma caused by a virus,

bacteria, Mycoplasma, or fungus
 Most common cause of pneumonia in younger children
and the least common cause in older children

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Risk Factors for Tuberculosis

 HIV infection
 Incarceration or institutionalization
 Positive recent history of latent TB infection
 Immigration or travel to endemic countries
 Exposure at home to HIV-infected or homeless persons,
illicit drug users, persons recently incarcerated, migrant
farm workers, or nursing home residents

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Acute Respiratory Distress Syndrome
(ARDS)
 Sepsis
 Viral pneumonia
 Smoke inhalation
 Drowning
 Note that respiratory distress and hypoxemia occur
acutely within 72 hours of the insult in infants and
children with previously healthy lungs

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Pneumothorax

 Chest trauma or surgery

 Intubation and mechanical ventilation
 History of chronic lung disease such as cystic fibrosis

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Sinusitis

 Cough
 Fever
 Halitosis
 Facial pain
 Eyelid edema
 Irritability
 Poor appetite

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Pharyngitis

 Quite abrupt
 History
o Fever
o Sore throat
o Difficulty swallowing
o Headache
o Abdominal pain

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Signs and Symptoms of Bronchiolitis
(RSV)
 Onset of illness with a clear runny nose (sometimes
profuse)
 Pharyngitis
 Low-grade fever
 Development of cough 1 to 3 days into the illness,
followed by a wheeze shortly thereafter
 Poor feeding

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Signs and Symptoms and Risk Factors for
a Pneumothorax
 Signs and symptoms
o Chest pain might be present as well as signs of
respiratory distress such as tachypnea, retractions,
nasal flaring, or grunting
 Risk factors
o Chest trauma or surgery, intubation and mechanical
ventilation, or a history of chronic lung disease such
as cystic fibrosis

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Chronic Respiratory Disorders

 Allergic rhinitis
 Asthma
 Chronic lung disease (bronchopulmonary dysplasia)
 Cystic fibrosis
 Apnea

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Question #3

Is the following statement True or False?

The nurse caring for a child with asthma documents lung
function as forced expiratory volume (FEV) 60% to 80%
of predicted. This child is classified as having intermittent
asthma.

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Answer to Question #3

False.
A child with lung function documented as forced
expiratory volume (FEV) 60% to 80% predicted is
classified as having moderate persistent asthma.
Intermittent and mild persistent asthma is FEV 80% or
more and severe persistent asthma is FEV less than 60%
of predicted.

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Cystic Fibrosis

 Most common debilitating disease of childhood among

those of European descent
 Signs and symptoms
 Risk factors

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Methods of Oxygen Delivery

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Nursing Management Common Cold

 Symptom relief
 Promote comfort
 Provide family education
 Prevent spread of cold

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Nursing Management Mononucleosis

 Symptomatic
 Analgesics
 Salt water gargles
 Bed rest
 Rest periods
 Avoid contact sports

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Croup

 Significant stridor at rest

 Severe retractions after a several hour period of
observation

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Nursing Management of Epiglottis

 Do not attempt to visualize the throat.

 Do not leave the child unattended.
 Do not place the child in a supine position.
 Provide 100% oxygen in the least invasive manner.
 If complete airway occlusion occurs, tracheostomy may
be necessary.
 Ensure emergency equipment is available.

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Airway

 Maintain patent airway at all times

 Foreign body aspiration is prevention

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Asthma

 Stepwise approach
 Increasing medications as child’s condition worsens
 Backing off medications as child’s condition improves

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Nursing Care Posttonsillectomy

 Promoting airway clearance

o Place child in side-lying or prone position
 Maintaining fluid volume
o Discourage coughing
o Encourage fluids; avoid citrus, brown, or red fluids
 Relieving pain
o Ice collar and analgesics with or without narcotics

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Pneumonia #2

 Diagnosis
 Goals
 Interventions

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Acute Noninfectious Respiratory Disorders

 Epistaxis
 Foreign body aspiration
 Respiratory distress syndrome
 Acute respiratory distress syndrome
 Pneumothorax
 Allergic rhinitis

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Medications

 Anti-inflammatory inhaled medications: maintenance

chronic lung disease
 Short-acting bronchodilators: wheezing episodes
 Supplemental long-term oxygen therapy may be required
in some infants

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Care Plan Brainstorming

 Tracheostomy
 Croup
 Aspiration pneumonia

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Teaching for Asthma

 Nebulizers
 Metered-dose inhalers
 Spacers
 Dry-powder inhalers
 Diskus

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Interventions to Minimize Psychosocial
Impact of Chronic Respiratory Conditions
 Promoting child’s self-esteem through education and
support
 Allowing school-age child to take control of management
of the disease
 Promoting family coping through education and
encouragement
 Providing culturally sensitive education and interventions

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