77 Bronchiolitis
Overview/pathophysiology
Acute bronchiolitis is most often a viral infection and is usually caused by the respiratory syncytial virus (RSV). RSV is highly contagious and is transmitted by droplets and direct contact with secretions or contaminated surfaces. Almost 100% of young children are infected by the age of 2 yr. RSV is the leading cause of lower respiratory tract disease (e.g., bronchiolitis and pneumonia) in infants, causing approximately 75,000-125,000 hospitalizations annually (CDC, MMWR, Dec 2008). Most infants and young children can be cared for at home, but approximately 0.5%-2% of those infected are hospitalized (CDC, RSV, 2009).
Assessment
Initially upper respiratory infection (URI) symptoms for 2-3 days: fever, rhinorrhea, and cough.
Diagnostic tests
Diagnosis should be made on the basis of history and, physical examination American Academy of Pediatrics (AAP) in Clinical Practice Guidelines for Bronchiolitis (2006) recommends not routinely prescribing laboratory and radiologic studies.
Pulse oximetry:
Noninvasive method of monitoring oxygen saturation. It facilitates atraumatic care of the infant.
Rsv washing on nasal or nasopharyngeal secretions:
To identify cause of respiratory distress; detects RSV antigen.
Nursing diagnosis:
Ineffective airway clearance
related to increased mucosal edema and secretions occurring with respiratory infection
Desired Outcomes: Within 24 hr of treatment/intervention, child exhibits decreased RR and decreased WOB. By discharge, child is able to manage respiratory secretions as evidenced by more normal RR and minimal WOB.
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess respiratory status q2h: level of consciousness (LOC), RR, breath sounds, signs of increased WOB (nasal flaring, retractions, use of accessory muscles), cough, and skin and mucous membrane color. | Early identification of changes that might indicate increasing respiratory distress (decreased LOC, increased RR, adventitious or decreasing breath sounds, increased WOB, and pallor or bluish tint) ensures prompt intervention, which results in decreased severity of respiratory symptoms. |
| Assess heart rate (HR), RR, O2 saturation, and breath sounds before and after nebulizer treatment. | These assessments monitor effectiveness of treatment and for its side effects (see next rationale). |
| Hold nebulizer treatment if HR is greater than 230 bpm for a child 1 yr of age or younger or greater than 180 bpm for a child older than 1 yr. Notify health care provider accordingly. | Tachycardia is one of the main side effects of both medications. Side effects should not outweigh the benefit of improving airway clearance. |
| Administer racemic epinephrine or albuterol with handheld nebulizer (HHN), if prescribed (not recommended to be used routinely per AAP, 2006). | These agents decrease mucosal edema, which will open the airway and decrease WOB. Racemic epinephrine is a specific type of epinephrine that is administered via nebulizer, generally for croup or bronchiolitis. Use remains controversial. |
| Instill saline nose drops, wait 1-2 min, and suction nares before feedings and prn. | Instilling saline drops before suctioning is helpful if the secretions are not loose or the child sounds congested. Suctioning before feedings to clear nares will improve intake inasmuch as infants are obligate nose breathers. Suctioning too often causes nasal edema if using a bulb syringe. |
Nursing diagnosis:
Impaired gas exchange
related to edema of the bronchiole mucosa and presence of increased mucus
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess for signs and symptoms of hypoxia (restlessness, change in LOC, dyspnea). Remember that cyanosis is a late sign of hypoxia in children. | Ongoing observation results in early detection of problems and early intervention, thereby decreasing severity of the hypoxia if it occurs. |
| Assess respiratory status q2h: LOC, RR, breath sounds, signs of increased WOB (nasal flaring, retractions, use of accessory muscles), cough, and skin and mucous membrane color. | This ensures early identification of changes that might indicate increasing respiratory distress. See details in previous nursing diagnosis. |
| Assess vital signs q2-4h and prn. | Hypoxia causes an increase in HR, RR, and blood pressure (BP). A drop in BP and decreasing RR may be signs of impending respiratory arrest. |
| Maintain continuous oximetry while child is hospitalized and document at least q2h. | Oximetry provides continuous monitoring of O2 saturation and alerts nurse to changes. |
| Provide humidified O2 via nasal cannula to maintain O2 saturation greater than 90%. | Delivering oxygen increases oxygen to the tissues. Oxygen is drying to the nasal mucosa, and humidity liquefies mucus. |
| Report to health care provider if O2 saturation is 90% or less. | O2 saturation 90% or less may indicate deteriorating condition. |
| Position child for maximum ventilation (e.g., head elevated but without compression on diaphragm). | Children are diaphragmatic breathers until 7 yr of age. Preventing compression of the diaphragm enables optimal breathing effort. |
| Use cardiorespiratory monitor for infant or young child at high risk for or with history of apnea. | This monitor ensures quick detection of deterioration in status or apneic episode. |
| Consolidate care to provide maximum rest. | Oxygen needs decrease with decreased energy expenditure. |
| Provide a neutral thermal environment. | An environment in which the child does not need to use any energy to cool or warm self reduces O2 demand. |
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