NCLEX: Health Promotion and Maintenance

Health Promotion and Maintenance: RESPIRATORY SYSTEM

Focus topic: Health Promotion and Maintenance

I. ACUTE OTITIS MEDIA

Focus topic: Health Promotion and Maintenance

A. Introduction: Acute bacterial ear infection (acute otitis media) is common in young children, primarily because their eustachian tube is shorter and straighter than the adult’s; this allows for ready drainage of infected mucus from URIs directly into the middle ear. In some cases, acute otitis media precedes the onset of bacterial meningitis, an
extremely serious and potentially fatal disease. Bacterial meningitis is a medical emergency, requiring early detection and prompt, aggressive therapy to prevent permanent neurological damage or death. Serous otitis (chronic) may result in hearing impairment or loss but is not likely to result in meningitis.

B. Assessment:

Focus topic: Health Promotion and Maintenance

  • Fever.
  • Pain in affected ear. An infant who is prelingual may not complain of pain but may tug at ear, cry, shake head, refuse to lie down.
  • Malaise, irritability, anorexia (possibly vomiting).
  • May have symptoms and signs of URI: rhinorrhea, coryza, cough.
  • Diminished response to sound.

C. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

Focus topic: Health Promotion and Maintenance

  • Pain related to pressure of pus/purulent material on eardrum.
  • Risk for injury/infection related to complication of meningitis.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: eradicate infection and prevent further complications (meningitis). Administer antibiotics as ordered.
2. Goal: relieve pain and promote comfort.

  • Administer decongestants as ordered.
  • Offer analgesics/antipyretics to provide symptomatic relief and to decrease fever.

3. Goal: health teaching.

  • Teach parents that the child needs to finish all medication, even though child will seem clinically better within 24 to 48 hours.
  • Review appropriate measures to control fever: antipyretics, cool sponges.

E. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • Infection is eradicated, no complications.
  • Child appears to be comfortable.
Health Promotion and Maintenance

II. PEDIATRIC RESPIRATORY INFECTIONS

Focus topic: Health Promotion and Maintenance

A. Assessment: general assessment of infant/child with respiratory distress. Note: Additional information about specific respiratory infections may be found.

  • Restlessness—earliest sign of hypoxia.
  • Difficulty sucking/eating—parents may state the infant or child has “poor appetite.”
  • Expiratory grunt, nasal flaring, retractions.
  • Changes in vital signs: fever, tachycardia, tachypnea.
  • Cough: productive/nonproductive.
  • Wheeze: expiratory/inspiratory.
  • Hoarseness or aphonic crying.
  • Dyspnea or prostration.
  • Dehydration—related to increase in insensible fluid loss and poor PO intake.
  • Color change (pallor, cyanosis)—later sign of respiratory distress.

B. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Ineffective airway clearance related to infection or obstruction.
  • Fluid volume deficit related to excessive losses through normal routes, discomfort and inability to swallow.
  • Anxiety related to hypoxia.
  • Risk for injury related to spread of infection.
  • Knowledge deficit related to disease process, infection control, home care, and follow-up.

C. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: relieve respiratory distress by reducing swelling and edema and liquefying secretions.

  • Environment: age- and disease-appropriate oxygen delivery system.
  • Administer oxygen as ordered.
  • Position: semi-Fowler’s or in infant seat to promote maximum expansion of the lungs; small blanket or diaper roll under neck to keep airway patent; change position at least q2h to prevent pooling of secretions.
  • Suction/postural drainage and percussion prn.
  • Tape diapers loosely and use only loose fitting clothing to avoid pressure on abdominal organs, which could impinge on diaphragm and impede respirations.
  • Administer medications: antibiotics, bronchodilators, steroids.
  • Monitor temperature q4h/prn; reduce fever with acetaminophen, cool sponges, hypothermia blanket.

2. Goal: observe for potential respiratory failure related to exhaustion or complete airway obstruction.

  • Place in room near nurses’ station for maximum observation.
  • Monitor vital signs: q1h during acute phase, then q4h.
  • Place emergency equipment near bedside prn: endotracheal tube, tracheostomy set.
  • Monitor closely for signs of impending respiratory failure: increased rapid, shallow respirations, progressive hoarseness/aphonia, deepening cyanosis.
  • Report adverse changes in condition STAT to physician.

3. Goal: maintain normal fluid balance.

  • May be NPO initially to prevent aspiration.
  • IVs until severe distress subsides and child is able to suck and swallow.
  • Monitor hydration status: I&O, urine specific gravity, weight.
  • When resuming PO fluids—start with sips of clear liquids, advance slowly as tolerated: Pedialyte, clear broth, gelatin, popsicles, fruit juices, ginger ale.
  • Avoid milk/milk products, which may cause increased mucus production.

4. Goal: provide calm, secure environment.

  • During acute distress: remain with child/ family (do not leave unattended).
  • Keep crying to a minimum to prevent severe hypoxia and to reduce the body’s demand for oxygen.
  • Avoid painful/intrusive procedures if possible.
  • Organize nursing care to provide planned periods of uninterrupted rest.
  • Allow parents to room-in, and encourage their participation in care of their child to keep the child relatively calm and reduce anxiety.
  • Allow child to keep favorite toy or security object.

5. Goal: provide parents with teaching, as necessary.

  • Short term: discuss equipment, treatments, procedures; offer frequent progress reports, answer parents’ questions.
  • Long term: how to handle recurrences, how to check temperature at home, medications for fever, when to call physician about respiratory problem.

D. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • No further evidence of respiratory distress.
  • Resumption of normal respiratory pattern.
  • Normal fluid balance maintained/restored.
  • Parents verbalize their concerns and express confidence in their ability to care for their child after discharge.

III. LONG-TERM RESPIRATORY DYSFUNCTION: ASTHMA

Focus topic: Health Promotion and Maintenance

A. Introduction: Asthma is generally considered a chronic, lower airway disorder characterized by heightened airway reactivity with bronchospasm and obstruction. The exact cause of asthma is unknown; however, it is believed to include an allergic reaction to one or more allergens, or “triggers,” that either precipitate or aggravate asthmatic exacerbation. The child usually exhibits other symptoms of allergy, such as infantile eczema or hay fever; in addition, 75% of children with asthma have a positive family history for asthma. The onset is usually before age 5 and the disorder remains with the child throughout life, although some children experience dramatic improvement in their asthma with the onset of puberty. Most children do not require continuous medication. Early relief of symptoms with a combination of drugs can reverse bronchospasm.

B. Assessment:

Focus topic: Health Promotion and Maintenance

  • Expiratory wheeze.
  • General signs and symptoms of respiratory distress, including: anxiety, cough, shortness of breath, crackles, cyanosis due to obstruction within the respiratory tract, use of accessory muscles of respirations.
  • Cough: hacking, paroxysmal, nonproductive; especially at night.
  • Position of comfort for breathing: sitting straight up, leaning forward, which is the position for optimal lung expansion.
  • Peak expiratory flow rate (PEFR) is in the yellow zone (50%–80% of personal best) or in the red zone (<50% of personal best).

C. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Ineffective airway clearance related to bronchospasm.
  • Anxiety related to breathlessness.
  • Knowledge deficit, actual or risk for potential, related to disease process, treatment, and prevention of future asthmatic attacks.
  • Activity intolerance related to dyspnea and bronchospasm.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

Treatment is aimed toward improvement of ventilation, correction of dehydration and acidosis, and management of concurrent infection.

1. Goal: provide patent airway and effective breathing patterns.

  • Initiate oxygen therapy (by tent, face mask, or cannula), as ordered, to relieve hypoxia, with high humidity (to liquefy secretions).
  • Administer bronchodilators, as ordered, to relieve the obstruction: epinephrine (1:1000), nebulized albuterol, Atrovent. Inhalers may be used with metered-dose inhalers (MDIs) to ensure proper delivery of the medication.
  • Administer corticosteroids as ordered (PO or IV) to reduce inflammation, relieve edema (prednisone, Decadron) and decrease bronchial hyperreactivity.
  • Administer antibiotics as ordered; infection is commonly either a trigger or complication of asthma.
  • Note: methylxanthines (theophylline, aminophylline) are third-line agents that are rarely used to treat asthma.

2. Goal: relieve anxiety

  • Provide relief from hypoxia (refer to Goal 1), which is the chief source of anxiety.
  • Remain with child, offer support.
  • Administer sedation as ordered.
  • Encourage parents to remain with child.

3. Goal: teach principles of prophylaxis.

  • Review home medications, including cromolyn sodium.
  • Review breathing exercises.
  • Discuss precipitating factors (“triggers”) and offer suggestions on how to avoid them.
  • Teach how to use peak expiratory flow meter to monitor respiratory status and determine need for treatment.
  • Introduce need for child to assume control over own care.

E. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • Adequate oxygenation provided, as evidenced by pink color of nail beds and mucous membranes and ease in respiratory effort.
  • Anxiety is relieved.
  • Child verbalizes confidence in, and demonstrates mastery of, skills needed to care for own asthma.

IV. CYSTIC FIBROSIS

Focus topic: Health Promotion and Maintenance

A. Introduction: Cystic fibrosis is a generalized dysfunction of the exocrine glands that produces multisystem involvement. The disorder is inherited as an autosomal recessive defect. The mutated gene responsible for CF is located on the long arm of chromosome 7 (CFTR). The basic problem is one of thick, sticky, tenacious mucous secretions that obstruct the ducts of the exocrine glands, thus affecting their ability to function. Cystic fibrosis is found in all races and socioeconomic groups, although there is a significantly lower incidence in Asians and African Americans. It is a chronic disease with no known cure and guarded prognosis; median age at death in the United States is 31 years. Those born in the late 1990s can be expected to survive into their 40s with new therapies.

B. Assessment:

Focus topic: Health Promotion and Maintenance

  • Newborn: meconium ileus.
  • Frequent, recurrent pulmonary infections: bronchitis, bronchopneumonia, pneumonia, and ultimately chronic obstructive pulmonary disease (COPD) due to mechanical obstruction of respiratory tract caused by thick, tenacious mucous gland secretions.
  • Malabsorption syndrome: failure to gain weight, distended abdomen, thin arms and legs, lack of subcutaneous fat due to disturbed absorption of nutrients that results from the inability of pancreatic enzymes to reach intestinal tract.
  • Steatorrhea: bulky, foul-smelling, frothy, fatty stools in increased amounts and frequency (predisposed to rectal prolapse).
  • Parents may note that child “tastes salty” when kissed, due to excessive loss of sodium and chloride in sweat.
  •  Sweat test reveals high sodium and chloride levels in child’s sweat, unique to children with cystic fibrosis.

7. Sexual development:

  • Boys/Men: sterile (due to aspermia).
  • Girls/Women: difficulty conceiving and bearing children (due to increased viscosity of cervical mucus, which acts as a plug in the cervical os and mechanically blocks the entry of sperm).

C. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Ineffective breathing patterns related to thick, viscid secretions.
  • Altered nutrition, less than body requirements, related to diarrhea and poor intestinal absorption of nutrients.
  • Decreased cardiac output related to COPD and decreased compliance of lungs.
  • Activity intolerance related to respiratory compromise.
  • Self-esteem disturbance related to body image changes.
  • Knowledge deficit related to disease process, treatments, medications, genetics.
  • Risk for noncompliance related to complicated and prolonged treatment regimen.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: assist child to expectorate sputum.

  • Perform postural drainage and percussion as prescribed: first thing in morning, between meals, before bedtime, not after meals to prevent aspiration.
  • Administer nebulizer treatments, expectorants, mucolytics, bronchodilators. Avoid or limit use of medications that suppress cough mechanism.
  • Provide for exercises that promote position changes and keep sputum moving up and out.
  • Encourage high fluid intake to keep secretions liquefied.
  • Suction, administer oxygen prn.

2. Goal: prevent infection.

  • Standard precautions to prevent infection.
  • Evaluate carefully, check continually for potential infection (especially respiratory); report to physician promptly.
  • Limit contact with staff or visitors (especially children) with infection.
  • Administer antibiotics as ordered, to treat respiratory infections and prevent overwhelming sepsis.
  • May be placed on prophylactic antibiotic therapy between episodes of infection.
  • Teach importance of prevention of infection at home: adequate nutrition, frequent medical checkups, stay away from known sources of infection.

3. Goal: maintain adequate nutrition.

  • Diet: well balanced, high calorie and protein to prevent malnutrition. Fat content in diet is controversial and must be individualized.
  • Administer pancreatic enzyme (Pancrease, Ultrase) immediately before every meal and every snack to enhance the absorption of vital nutrients, especially fats.
  • If child is unable to swallow capsules, take capsule apart and sprinkle on food at beginning of meal or mix with chilled applesauce.
  • Administer water-miscible preparations of fat-soluble vitamins (A, D, E, K), multivitamins, and iron.
  • Encourage extra salt intake to compensate for excessive sodium losses in sweat (unless congestive heart failure [CHF] is present); especially important in hot weather, after physical exertion, febrile periods.
  • Encourage extra fluid intake (e.g., Gatorade) to prevent dehydration/electrolyte imbalance, ↑ thickening of mucous secretions. g. Daily I&O and weights to monitor nutritional and hydration status.
  • Encourage child to assume gradually increasing responsibility for choosing own foods within dietary restrictions.

4. Goal: teach child and family about cystic fibrosis.

  • Discuss diagnostic procedures: sweat test, stool specimens.
  • Review multiple medications: use, effects, side/toxic effects.
  • Stress need to care for pulmonary system (major cause of mortality/morbidity).
  • Teach various treatments: postural drainage, nebulizers, oxygen therapy, breathing exercise.
  • Encourage child to assume as much responsibility for own care as possible: medications, treatments, diet.
  • Promote development of healthy attitude toward disease/prognosis (no known cure). Heart/lung transplantation may be considered as an option.
  • Refer to appropriate community agencies for assistance with home care.
  • Assist with genetic counseling.
  • Discuss sexual concerns with adolescent.

5. Goal: promote compliance with treatment regimen.

  • Encourage child to verbalize anger or frustration at being “different”/body image alterations.
  • Suggest alternatives to chest physical therapy (CPT) (e.g., yoga/standing on head).
  • Offer “rewards” for compliance: going swimming with friends or other types of peer activities.

E. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • Child can clear own airway, expectorate sputum.
  • Child is maintained in infection-free state.
  • Adequate nutrition is maintained.
  • Child and family verbalize understanding of the disease.
  • Child complies with rigors of treatment.

V. APNEA-RELATED DISORDERS

Focus topic: Health Promotion and Maintenance

A. Apnea of infancy

Focus topic: Health Promotion and Maintenance

1. Introduction: Apnea of infancy is the unexplained cessation of breathing for 20 seconds or longer in an apparently healthy, full-term infant who is more than 37 weeks of gestation. It is usually diagnosed by the second month of life and is generally thought to resolve during the first 12 to 15 months of life. The exact cause is unknown. The association between apnea of infancy and sudden infant death syndrome (SIDS) is still controversial. However, infants experiencing significant apnea without a known cause are thought to be at increased risk for SIDS and must be treated accordingly. The diagnosis of apnea of infancy (AOI) is made when no identifiable cause for the apparent life-threatening event (ALTE) is found.

2. Assessment:

  • Unexplained cessation of breathing (apnea) for 20 seconds or longer.
  • Bradycardia.
  • Color change: cyanosis or pallor.
  • Limp, hypotonic.
  • Diagnostic tests, including cardiopneumogram, pneumocardiogram, and polysomnography.

3. Analysis/nursing diagnosis:

  • Ineffective breathing patterns related to apnea.
  • Anxiety, fear related to apnea and threat of infant’s death.
  • Knowledge deficit regarding home care of infant on an apnea monitor and infant cardiopulmonary resuscitation (CPR).

4. Nursing care plan/intervention:

a. Goal: maintain effective breathing pattern.

  • Apnea monitor on infant at all times, including at home.
  • Place in room near nurses’ station for maximum observation with a nurse or parent present at all times.
  • Suction, oxygen, and resuscitation equipment readily available if needed.
  • Observe for apnea or bradycardia; note duration and associated symptoms—color change, change in muscle tone.
  • If apnea occurs, use gentle stimulation to start infant breathing again. If ineffective, begin CPR.
  • If suctioning is needed, do it gently for the shortest time and least number of times possible to maintain patent airway.
    Note: Repeated, vigorous suctioning is associated with prolonged periods of apnea.
  • Medications: respiratory stimulant drugs (such as theophylline or caffeine) may be given until 2 to 3 months have passed without an episode of apnea.
  • Positions: side-lying or supine; never prone, to prevent SIDS.
  • Feedings: smaller and more frequent; avoid overfeeding, which can lead to reflux and apnea.

b. Goal: teach parents how to care for their infant at home.

  • Thoroughly explain discharge plans to parents; encourage questions and discussion.
  • Begin teaching use of apnea monitor and infant CPR techniques several days before discharge; allow parents to handle the monitor and become thoroughly familiar
    with its use.
  • Provide parents with emergency response numbers and community health nurse referral.
  • Stress need for at least 1 year of ongoing care with constant use of monitor, or 2 to 3 months without an episode requiring intervention.
  • Discuss need for support and refer to local self-help/support group.
  • Encourage parents to take time for themselves if a reliable caregiver is available who is trained in use of monitor and infant CPR.

5. Evaluation/outcome criteria:

  • Effective breathing pattern is established.
  • Parents verbalize their concerns and express confidence in their ability to care for their infant at home.

B. Sudden infant death syndrome (SIDS)

Focus topic: Health Promotion and Maintenance

1. Introduction: SIDS is the sudden, unexpected death of an apparently healthy infant under 1 year of age, which remains unexplained after a complete postmortem examination. Various theories have been suggested, none proved; research is ongoing. It has been suggested that prone sleeping position, cigarette smoke, and excessive swaddling may be associated with SIDS. It is the third leading cause of death between 1 month and 1 year, affecting almost 2500 infants annually.

2. Assessment:

  • Sudden, unexplained death in otherwise “normal” infant; occurs exclusively during sleep.
  • Note overall appearance of infant (differentiate from child abuse).
  • Obtain history from parents—note affect or how parents are dealing with grief.

3. Analysis/nursing diagnosis:

  • Dysfunctional grieving related to loss of infant.
  • Knowledge deficit related to SIDS.

4. Nursing care plan/implementation:

a. Immediate goal: support parents who are grieving.

  • Stress that nothing could have been done to prevent the death.
  • Allow parents to express grief emotions; provide privacy.
  • Offer parents opportunity to see, hold infant.
  • Explain purpose of autopsy (physician to obtain consent).
  • Contact spiritual advisor: priest, rabbi, minister.
  • Assist parents to plan what to tell siblings.

b. Ongoing goal: provide factual information regarding SIDS.

  • Offer information that is known about SIDS in simple, direct terms.
  • Answer questions honestly.
  • Give parents printed literature on SIDS.
  • Refer to local/national SIDS foundation group.

c. Long-term goal: assist family to resolve grief.

(1)Track progress of other siblings.
(2)Refer to local perinatal bereavement group.
(3) Consider subsequent pregnancy to be at risk for:

  • Attachment/bonding.
  • SIDS recurrence.

5. Evaluation/outcome criteria:

  • Parents are able to express their grief and receive adequate support.
  • Parents raise questions about SIDS and can understand answers.
  • Family’s grief is resolved; in time, normal family dynamics resume.

FURTHER READING/STUDY:

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