NCLEX-RN: Pediatric Nursing

Pediatric Nursing: RESPIRATORY SYSTEM

Focus topic: Pediatric Nursing

The respiratory system accomplishes pulmonary ventilation through the process of inspiration and expiration. The act of breathing involves a complex chemical and osmotic process in which oxygen is taken into the lungs and carbon dioxide, the end product, is given off.

Pediatric Nursing: Lower Respiratory Obstructive Conditions

Focus topic: Pediatric Nursing

Pediatric Nursing: Bronchitis

Focus topic: Pediatric Nursing

Definition: Inflammation of the large airways, usually associated with a URI.

Assessment

A. Assess for “hacking” and moderately productive cough.
B. Examine for crackles and wheezes.

C. Assess for acute respiratory distress with acute bronchitis.

D. Evaluate fever and hydration.

Implementation

A. Perform chest physiotherapy as ordered (not after meals).
B. Administer humidified air or oxygen as necessary.
C. Increase and monitor fluid intake.
D. Instruct child how to cough and breathe deeply.
E. Administer cough suppressants and expectorant as ordered.

Pediatric Nursing: Bronchiolitis/Respiratory Syncytial Virus

Focus topic: Pediatric Nursing

Definition: An acute infection characterized by thick production of mucus causing spasm and occlusion of the bronchioles and small bronchi. It occurs most frequently in winter and spring in infants and children under age 2, and is usually preceded by a viral upper respiratory infection. Respiratory syncytial virus (RSV) is responsible for over half of all bronchiolitis. Adenoviruses and parainfluenza virus may also cause bronchiolitis.

Assessment

A. Assess for rapid respiratory rate, nasal flaring, and intercostal retractions with prolonged expiratory wheezes, and coarse lung sounds throughout. A noisy chest indicates that the infant has sufficient air exchange.
B. Evaluate cough, which is usually moist with thick nasal secretions.
C. Assess for tachycardia, hydration status, nutritional intake, and fever
D. Assess oxygenation via continuous pulse oximetry.
E. Infants may present with apnea episodes.

Implementation

A. Place upright with the head of bed elevated at least 30 degrees.
B. Administer cool, humidified oxygen by delivery mode best tolerated (mask for nasal cannula).
C. Maintain adequate hydration and encourage intake of fluids.
D. IV fluids are necessary if marked respiratory distress and unable to tolerate PO feedings (in infant with respiratory rate > 60/min).
E. Conserve energy, allow to rest. Encourage parents to stay at bedside to calm infant.
F. Place infant in contact isolation alone or with other children with same diagnosis. RSV infection is diagnosed by a nasopharyngeal swab.
G. Suction thick nasal secretions and thin with saline solution as needed.
H. Administer or coordinate chest physiotherapy, as ordered, to loosen secretions.

I. Administer medications.

  •  Antibiotics, if secondary pneumonia occurs in conjunction with RSV bronchiolitis.
  • Proventil (albuterol) nebulized treatments and/or corticosteroids may be ordered for suspected underlying reactive airway disease.
  •  Antipyretics for elevated temperature. Remove heavy thick blankets. Cooling measures (sponge baths, etc., do not reduce fever as effectively as antipyretics in children).

J. To prevent RSV infection, administer Synagis (palivizumab), a passive immune vaccine.

  •  Give to children < 2 years old with chronic lung disease and congenital cardiac defect sand to premature infants born < 32 weeks’ gestation.
  •  Give 15 mg per kg of body weight monthly by intramuscular injection during months with highest RSV incidence (usually October– December onset through March–May).

Pediatric Nursing: Pneumonia

Focus topic: Pediatric Nursing

Definition: Inflammation of the pulmonary parenchyma caused by bacteria, viruses, mycoplasma organisms, aspiration, or inhalation. May be lobar, lobular, or interstitial in location.

Characteristics

A. Viruses cause cellular destruction and accumulation of debris in the bronchioles and alveoli. Bacteria cause fluid accumulation and cellular debris in bronchioles and alveoli, causing consolidation. Impaired gas exchange occurs from atelectasis and from the inflammatory process with both viruses and bacteria.
B. Pneumonia in children is commonly caused by viruses, especially since the use of HIB and PCV- 13 vaccines.

Pediatric Nursing

C. Children with chronic conditions and very young infants are likely admitted to the hospital for treatment with IV fluids, IV antibiotics, and supportive care that includes oxygen, suctioning, and chest physiotherapy.

Assessment

A. Tachypnea, for infant often > 60/min; know respiratory rates for age.
B. Fever (higher with bacterial causes).
C. Retractions, crackles, wheezing more common with RSV-related pneumonia.
D. Absent or decreased breath sounds.
E. Cough, nonproductive or productive.
F. Pallor, malaise, fatigue.
G. Normal or decreased oxygen saturation.
H. Assess for fluid loss, decreased intake by mouth, and poor appetite.
I. May be accompanied by headache, abdominal pain, nausea, and/or vomiting.

Implementation

A. Place child in transmission-based isolation, depending on the suspected organism (droplet most likely).
B. Administer IV antibiotics specific to suspected organism, often a second- or third-generation cephalosporin and a macrolide like Zithromax (azithromycin).
C. Splint the chest when the child coughs. Administer analgesics for pain.
D. See RSV on previous page for nursing care.

Pediatric Nursing: Asthma

Focus topic: Pediatric Nursing

Definition: A reversible obstructive airway disease characterized by increased airway responsiveness to a variety of stimuli mediated by immunoglobulin E (IgE) receptors on the sensitized airway mast cells resulting in bronchospasm, inflammation of mucous membranes that line the small airways, and accumulation of thick secretions.

Characteristics

A. An asthma episode can be triggered by cold air, smoke, allergens (e.g., pollen, dander, cockroach, dust, mold), viral infection, stress, exercise, odors, environmental pollutants, and occasionally, food allergy.
B. Improvement of symptoms in response to nebulized bronchodilators as measured by pulmonary function testing (PFT) is necessary for diagnosis in children over 5 years of age.
C. Asthma symptoms vary from mild wheezing and dry cough intermittently to acute respiratory distress. Management varies depending on the classification of the disease.

Assessment
A. Classification.

  •  Mild intermittent (no daily medication needed); Proventil, a bronchodilator, is used when symptoms occur (wheeze, cough, or shortness of breath).
  •  Mild persistent (symptoms requiring a bronchodilator > 2/week but < 1/day). Preferred treatment: daily use of a low-dose inhaled corticosteroid (ICS) in a metered-dose inhaler (MDI) or dry powder inhaler (DPI) for “controlling” symptoms. ICS include Flovent (fluticasone), Pulmicort (budesonide), Beclovent (beclomethasone), and others. A bronchodilator is used for “rescue.” Another option for a “controller” drug is a leukotriene inhibitor such as Singulair (montelukast), but ICS are preferred.
  • Moderate persistent: daily meds low dose inhaled corticosteroids and long acting inhaled beta2 agonists, often in a combination inhaler such as Flovent and Advair (salmeterol). A leukotriene inhibitor may be added in for moderate to severe persistent asthma. A bronchodilator is used for “rescue.”
  •  Severe persistent—continual/frequent meds needed. Prefer high-dose inhaled corticosteroids AND long-acting inhaled beta2 agonists AND systemic corticosteroids, if needed for exacerbations. A bronchodilator is used for “rescue.” Systemic corticosteroids may be given PO, IM, or IV and include Medrol (methylprednisolone) and Deltasone (prednisone). Children with severe asthma over 12 years may receive anti-immunoglobulin E antibody (anti-IgE) called Xolair (omalizumab), given IM at regular intervals.

B. Obtain history of conditions that led to asthmatic attack: exposure to certain foods, infections, vigorous activity, or emotional factors.
C. Assess for spasms of bronchiole tubes manifested by increased wheezing, increased mucus, and shortness of breath.
D. Assess cough, which can be dry or productive, and when it occurs.
E. Assess for symptoms of acute respiratory distress: retractions, tachypnea, prolonged expiratory wheezing, absent air exchange, decreasing oxygen saturation, client “winded” when speaking, tripod position, poor color, and altered mental status.

Implementation
A. National Heart Lung and Blood Institute guidelines for asthma are aimed at four components:

  •  Assessment and monitoring the severity of symptoms in order to classify the type of asthma and treat accordingly.
    a. Peak flow monitoring and/or symptom diary on a daily basis; a peak flow meter may also be used before and after use of a bronchodilator to determine degree of improvement.
    b. Development of an asthma action plan for home and school.
    c. Routine follow-up visits with the healthcare provider.

Pediatric Nursing: Classifying Severity of Asthma Exacerbations

Focus topic: Pediatric Nursing

Pediatric Nursing

  •  Education of parents and child to manage symptoms
  •  Treatment of comorbid conditions (sinusitis, allergic rhinitis, gastroesophageal reflux). May include allergy skin testing or radioallergosorbent (RAST) testing. Treat underlying infections.
  • Determine compliance with client’s use of daily “controller” medications and frequency of use of “rescue” bronchodilator. Ensure that child knows how to use spacer devices and inhaler devices.

B. Treatment of acute exacerbations of asthma: continuous Proventil nebulized treatments; PO, inhaled, or intravenous corticosteroids; oxygen as needed.
C. Identify and remove suspected allergens and avoid triggers if possible (“allergy-proof ” the home).
D. Supervise medication administration.

Pediatric Nursing: Cystic Fibrosis

Focus topic: Pediatric Nursing

Definition: Cystic fibrosis (CF) is an autosomal recessive genetic disorder of the exocrine glands characterized by thick and viscous mucus and decreased pancreatic enzyme production. CF affects approximately 30,000 children and adults in the United States; approximately 10 million are carriers.

Characteristics
A. Cystic fibrosis may be identified with a screening blood test during pregnancy or by routine neonatal blood testing enabling children to be diagnosed soon after birth.

B. Cystic fibrosis is a multisystem disorder affecting

  • The respiratory system with excess mucus, which leads to secondary bacterial infections.
  • The digestive system: Thick mucus blocks pancreatic enzymes used to digest and absorb nutrients. Eventually the hepatic bile ducts and gallbladder are also blocked by mucus.
  •  Metabolic system: Excess sodium chloride production by sweat glands causes hyponatremia.
  •  Reproductive system: Ovarian ducts and vas deferens are blocked with mucus, causing sterility.

Assessment
A. Failure to pass meconium—often presenting sign in neonates.
B. Weight loss, protruding abdomen with thin extremities; may have increased appetite to make up for loss of nutrients with undigested food.
C. Recurrent respiratory infections (sinusitis, bronchitis, pneumonia).
D. Crackles, wheezes, or diminished breath sounds; prolonged expiration.
E. Barrel chest.
F. Clubbing, as a sign of chronic low oxygen saturation.
G. With chronic disease and resulting liver damage and/or cor pulmonale, distended neck veins, and edema.

H. Bulky malodorous stools caused by malabsorption of fats and proteins (steatorrhea).
I. Parents report that the child has a salty tasting skin.
J. Evaluate diagnostic tests, including the sweat test for elevated chloride content and trypsin test. (< 60 mEq/L chloride in sweat is considered diagnostic of CF. Trypsin is absent in cystic fibrosis.)

Implementation
A. Provide adequate nutritional intake of calories, protein, and fat. Clients with CF require 130% more kcal and protein than usual daily requirements for age.

  •  Replace pancreatic enzymes such as Viokase and Cotazym, which are given just prior to each meal and with snacks.
  •  Water-soluble vitamins and fat-soluble vitamins (A, D, E, K in water-miscible form) as well as mineral supplements should be given daily.

B. Prevent gastrointestinal blockage by giving sufficient fluids, fiber, and stool softeners.

C. Major objective is to keep lungs clear of mucus.

  • Pulmozyme (dornasealfa) improves lung function.
    a. Breaks down extracellular DNA in thick sputum.
    b. Administration via inhalation through nebulizer device helps liquefy secretions.
  •  Postural drainage and vibration with an oscillator vest, following breathing treatments.
  • Breathing exercises: forced exhalation and incentive spirometer. (Children tend to breathe shallowly.)
  •  Low-dose humidified oxygen as needed.

D. Administer antibiotics as ordered to treat infection.

  •  Inhaled antibiotics like Tobrex (tobramycin) useful in children with chronic Pseudomonas aeruginosa infection.
  •  IV antibiotics may include Pipracil (piperacillin), Timentin (ticarcillin), Keflex (cephalexin), Fortaz (ceftazidime), or Cipro (ciprofloxacin).

E. Provide parental education and support.

  • Information about the disease and its long term effects.
  •  Genetic counseling.
  • New drugs: Most target gene therapy attempting to replace gene causing CF, adding normal genes to airways to correct defective cells.
  •  Resource centers such as Cystic Fibrosis Foundation (www.cff.org) and local organizations.
  • Care of the child at home.
    a. Normal family routine.
    b. Children are irritable, frightened, and insecure.
    c. Children need attention, discipline, and reassurance.
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Pediatric Nursing: Bronchopulmonary Dysplasia

Focus topic: Pediatric Nursing

Definition: Chronic lung disease seen in infants who were born prematurely (often less than 30 weeks’ gestation) managed with mechanical ventilation, requiring high inspiratory pressures and oxygen concentrations. Alveolar damage ensues, with hyperinflation, atelectasis, pulmonary edema, inflammation and hypertension, and chronic oxygen dependence.

Assessment
A. Infant is barrel chested and oxygen dependent.
B. Infants exhibit failure to thrive and are difficult feeders.

  •  Obtain history and feeding habits.
  • Assess ability to feed in conjunction with respiratory exam.

C. Assess respiratory effort.

  •  Tachypnea, retractions, and wheezing.
  •  Circumoral and nail bed cyanosis (if chronic hypoxia).
  •  Chest x-ray shows lung disease, scattered areas of hyperinflation, and patchy infiltrates.
  •  ABGs show chronic respiratory acidosis.

D. Prevent respiratory infections and RSV: Administer Synagis vaccine during the winter months. Strict hand hygiene.

E. Infants often require frequent hospitalizations for infections, acute respiratory distress or failure, and congestive heart failure.

  • Assess family functioning and parental bonding.
  •  Evaluate degree of developmental delay present, related to gestational age.

Implementation

A. Goal is to maintain adequate oxygenation and ventilation.
B. Usual therapy includes oxygen, bronchodilators, diuretics, surfactant, Respbid (theophylline), and caffeine.
C. Monitor pulse oximetry carefully to adjust oxygen requirements. Need for supplemental oxygen will vary according to activity.

  • . Assist family in preparing for discharge with home oxygen therapy.
  •  Teach family members methods of monitoring oxygen needs and administration.

D. Monitor electrolytes carefully if on diuretic therapy.
E. Administer and teach families to administer inhaled bronchodilators (e.g., Proventil) and occasionally inhaled corticosteroids (ICS) like Beclovent.
F. Nutritional support is a key component of management.

  •  High-calorie diet should be administered in low volumes.
  •  Infants frequently are “difficult feeders” and families may require extensive teaching.
  •  Observe for gastroesophageal reflux and treat accordingly.

G. Families require extensive support.

  •  If hospitalized, involve parents in daily care and teach to do as much of care as possible.
  • Prepare for home care: skilled nursing care may be required, or respite care may need to be arranged.
  • Educate families on signs of deterioration and need for medical evaluation/intervention.
  •  Support infant’s development and provide appropriate stimulation.
  •  BPD is a chronic condition, requiring multidisciplinary planning and teamwork, but infants can recover and develop to optimal capabilities with adequate support.
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