Assessment of the respiratory system follows the guidelines described in Chapter 29 (for assessment of the ears, nose, mouth and throat, chest, and lungs). The assessment should include respiratory rate, depth, and rhythm; heart rate; oxygenation; hydration status; body temperature; activity level; and level of comfort. Special attention should also be given to the components and observations listed in Box 40-2. A noninvasive pulse oximeter (oxygen saturation) measurement should be performed on all children as part of the routine physical assessment. The nursing process in the care of the child with acute respiratory tract infection is outlined in the Nursing Care Plan.

Box 40-2 Components for Assessing Respiratory Function

Respirations

The pattern of respirations is observed for rate, depth, ease, and rhythm of breathing:

• Rate—Rapid (tachypnea), normal, or slow for the particular child

• Depth—Normal depth, too shallow (hypopnea), too deep (hyperpnea); usually estimated from the amplitude of thoracic and abdominal excursion

• Ease—Effortless, labored (dyspnea), difficult breathing except in upright position (orthopnea); associated with intercostal or substernal retractions (inspiratory “sinking in” of soft tissues in relation to the cartilaginous and bony thorax); flaring nares; head bobbing (head of sleeping child with suboccipital area supported on caregiver’s forearm bobs forward in synchrony with each inspiration); grunting; or wheezing

• Labored breathing—Continuous, intermittent, becoming steadily worse, sudden onset, at rest or on exertion, associated with wheezing or grunting, associated with pain

• Rhythm—Variation in rate and depth of respirations

Other Observations

In addition to respirations, particular attention is addressed to the following:

• Evidence of infection—Check for elevated temperature; enlarged cervical lymph nodes; inflamed mucous membranes; and purulent discharges from the nose, ears, or lungs (sputum).

• Cough—Observe characteristics of cough (if present); under what circumstances cough is heard (e.g., night only, on arising); nature of cough (paroxysmal with or without wheeze; “croupy” or “brassy”); frequency of cough; associated with swallowing or other activity; character of cough (moist and dry); productivity.

• Wheeze—Note if expiratory or inspiratory, high-pitched or musical, prolonged, slowly progressive or sudden, associated with labored breathing.

• Cyanosis—Note distribution (peripheral, perioral, facial, trunk, and face), degree, duration, associated with activity or feeding (infant).

• Abdominal pain—May be a complaint in preschooler and school-age children; probably represents referred pain from chest; may be a complaint in children with pneumonia.

• Chest pain—May be a complaint of older children; note location and circumstances: localized or generalized, referred to base of neck or abdomen, dull or sharp, deep or superficial, associated with rapid, shallow respirations or grunting.

• Sputum—Older children may provide sputum sample by coughing, whereas young children may need use of bulb suction to provide a sample; note volume, color, viscosity, and odor.

• Bad breath—May be associated with some lung infections.

• Stridor—A high-pitched wheezing sound; may be present on inspiration, exhalation, or both and is a sign of upper airway edema or obstruction by mass or object.

Nursing Care Plan

The Child with Acute Respiratory Tract Infection

NURSING DIAGNOSIS	EXPECTED OUTCOME	NURSING INTERVENTIONS	RATIONALES
Ineffective Breathing Pattern related to inflammatory process Child’s Defining Characteristics *(Subjective and Objective Data)* Use of accessory muscles to breathe Dyspnea Shortness of breath Nasal flaring Altered chest excursion Assumption of three-point position (tripod) Respiratory rate outside normal parameter for child’s age (increased or decreased rate)	Child’s respirations will be nonlabored.	Position child for maximum ventilatory efficiency and airway patency	To allow increased chest expansion
		Position child to facilitate drainage of secretions	To maintain patent airway and prevent airway obstruction
		Provide humidified oxygen as prescribed	To improve oxygenation
		Monitor oxygenation status, including vital signs, for changes in condition	To determine need for additional interventions
		Suction airway (nose, trachea) as necessary	To remove secretions and maintain airway patency
		Administer prescribed antibiotics (if bacterial)	To treat infection source
		Administer bronchodilator medications as prescribed	To promote bronchodilation and improve ventilation
		Administer antiinflammatory medications as prescribed	To decrease airway inflammation and inflammatory response
		Assist with coughing	To remove secretions and clear airway
Ineffective Airway Clearance related to inflammation, mechanical obstruction, increased secretions Child’s Defining Characteristics *(Subjective and Objective Data)* Dyspnea Difficulty vocalizing Orthopnea Adventitious breath sounds (crackles, wheezing, rhonchi) Cough ineffective or absent Restlessness Changes in respiratory rate and rhythm	Child’s airways will remain patent.	Position child to facilitate drainage of secretions	To prevent airway obstruction
		Perform chest percussion and postural drainage only as prescribed	To loosen and remove secretions
		Suction airway as necessary	To remove secretions
		Provide humidified oxygen as prescribed	To moisten secretions and prevent airway drying
		Assist with coughing (as developmentally or age appropriate)	To remove secretions
		Avoid throat examination if epiglottitis is suspected	To prevent airway compromise
		Assure child (as appropriate) all measures will be taken to ensure adequate airway is maintained	To allay anxiety
		Implement comfort measures such as allowing parental presence, parental holding, favorite blanket or stuffed animal at side; explain all procedures beforehand	To reduce anxiety and decrease effects of medical therapy, including hospitalization if required
Risk for Injury related to presence (only as indicated) of infective organisms Child’s or Family’s Defining Characteristics *(Subjective and Objective Data)* Tissue hypoxia Abnormal blood profile People or health care provider (HAI [health care–associated infection]) Mode of transport Developmental age	Child will remain free from complications of infection.	Maintain aseptic environment using sterile suction equipment and technique Implement and practice Standard Precautions Implement Contact and Airborne Precautions as necessary	To prevent spread of infectious organisms in child and family
		Obtain (secretion, tissue, or blood) specimen as indicated and prescribed	To identify infective organism
		Encourage child and family contacts to practice frequent hand hygiene and avoid hand-to-eye and hand-to-mouth contact	To prevent spread of infection
		Teach child (as age appropriate) and family how to decrease spread of organisms through coughing and other secretions (e.g., by covering mouth when coughing; disposing of secretions to avoid cross-contamination)	To prevent spread of infection
		Administer antibiotic or antiviral medications as prescribed	To treat infection source
		Administer fever reduction medication(s) as prescribed	To promote comfort if fever is present
		Monitor and assess for signs and symptoms of secondary complications: hypoxia, skin breakdown, poor nutrient and fluid intake, increased work of breathing, deteriorating cardiorespiratory status	To implement therapy for prevention of secondary complications
		Encourage small amounts of oral clear liquids as condition allows	To promote hydration
Interrupted Family Processes related to child’s illness, hospitalization, and medical or therapeutic regimen Child’s or Family’s Defining Characteristics *(Subjective and Objective Data)* Communication patterns Participation in decision making Availability for emotional support Expressions of conflict within family Patterns and rituals	Family will demonstrate ability to cope with child’s illness.	Encourage family to remain with child	To decrease effects of separation
		Promote family-centered care	To promote family integrity
		Explain procedures and therapeutic regimen to family	To provide accurate information regarding therapy and child’s condition
		Keep family informed of child’s status Encourage family involvement in child’s care Provide support and referral for continued support as necessary	To promote family sense of control and involvement in care

Ease Respiratory Efforts.

Many acute respiratory tract infections are mild and cause few symptoms. Although children may feel uncomfortable and have a “stuffy” nose and some mucosal swelling, respiratory distress occurs infrequently. Interventions delivered at home are usually sufficient to relieve minor discomfort and ease respiratory efforts. However, in some cases, the infant or child may require close observation by health care professionals for adequate oxygenation and fluid and electrolyte status.

Warm or cool mist is a common therapeutic measure for symptomatic relief of respiratory discomfort. The moisture soothes inflamed membranes and is beneficial when there is hoarseness or laryngeal involvement. The use of steam vaporizers in the home is often discouraged because of the hazards related to their use and limited evidence to support their efficacy.

A time-honored method of producing steam is the shower. Running a shower of hot water into the empty bathtub or open shower stall with the bathroom door closed produces a quick source of steam. Keeping a child in this environment for approximately 10 to 15 minutes humidifies inspired air and can help relieve symptoms. A small child can be held on the lap of a parent or other adult. Older children can sit in the bathroom under the supervision of an adult.

Promote Rest.

Children who have an acute febrile illness usually have limited activity. One of the cardinal signs that the child is feeling better is the increase in activity; this may, however, be temporary if a high fever returns after a few hours of increased activity. Children should be encouraged to rest or play quietly to avoid exacerbating symptoms.

Promote Comfort.

Older children are usually able to manage nasal secretions with little difficulty. For very young infants, who normally breathe through their noses, an infant nasal aspirator or a bulb syringe is helpful in removing nasal secretions, especially before being put to bed to sleep and before feeding. This practice, preceded by instillation of saline nose drops as needed, may clear nasal passages and promote feeding. Saline nose drops can be prepared at home by dissolving 1 tsp of salt in 1 pint of warm water.

For older infants and children who can tolerate decongestants, vasoconstrictive nose drops may be administered 15 to 20 minutes before feeding and at bedtime. Two drops are instilled, and because this shrinks only the anterior mucous membranes, two more drops are instilled 5 to 10 minutes later. Phenylephrine 0.25% (for infants and children older than 6 months), ephedrine 1% (for children older than 6 years), or oxymetazoline 0.05% (for children older than 6 years) is sometimes prescribed. Older cooperative children often prefer nasal sprays. They are taught to compress the plastic container at the moment of inspiration while occluding the other nostril. Bottles of nose drops should be used for only one child and one illness because they are easily contaminated with bacteria and viruses. To avoid rebound congestion, nose drops or sprays should not be administered for more than 3 days. To prevent cross-contamination with nose drops, draw the nose spray solution into a clean tuberculin syringe. Inject the nose spray solution into the child’s nostrils using the blunt syringe.

Hot or cold applications sometimes provide relief for children with painful cervical adenitis. An ice bag or heating pad applied to the neck may decrease the discomfort, but safety precautions must be observed to prevent burns. The ice bag or heating device must be covered, and the heating pad should not be set at high settings.

Prevent Spread of Infection.

Careful hand washing is important when caring for children with respiratory tract infections. Older children should use a tissue or their arm to cover their nose and mouth when they cough or sneeze, dispose of the tissues properly, and wash their hands. Remembering to cover the nose or mouth is often difficult for small children. Used tissues should be immediately thrown into the wastebasket and not allowed to accumulate in a pile. Children with respiratory tract infections should not share drinking cups, eating utensils, washcloths, or towels. Well individuals generally should not touch their eyes or nose with unwashed hands. Parents should try to remove affected children from contact with other children. Parents should also keep affected children out of school or day care settings to prevent the spread of infection. This may be a problem when living arrangements are crowded and the family has several children. An effort should be made to teach well children to stay away from ill children, to wash their hands frequently, and to avoid eating and drinking from the same utensils or cups.

Reduce Temperature.

If the child has a significantly elevated body temperature, controlling the fever is important. Parents should know how to take a child’s temperature and read a thermometer accurately. Nurses should not assume that all parents can read a thermometer and should provide education when needed.

If the health care practitioner prescribes acetaminophen or ibuprofen (for infants and children 6 months and older), parents will need instruction on how to administer it. Most parents can read the label and calculate the desired dosage, but parents of infants and toddlers require detailed instruction and dosing parameters. It is important to emphasize accuracy in determining both the amount of drug to be given and the time intervals for administration.

Cool liquids are encouraged to reduce the temperature and minimize the chances of dehydration (see Controlling Elevated Temperatures, Chapter 39).

Nursing Alert

Caution parents about the use of over-the-counter combination “cold” remedies, since these often include acetaminophen. Careful calculation of both the acetaminophen given separately and the acetaminophen in combination medications is necessary to avoid an overdose.

Promote Hydration.

Dehydration is a potential complication when children have respiratory tract infections and are febrile or anorectic, especially when vomiting or diarrhea is present. Infants are especially prone to fluid and electrolyte deficits when they have a respiratory illness because a rapid respiratory rate that accompanies such illnesses precludes adequate oral fluid intake. In addition, the presence of fever increases the total body fluid turnover in infants. If the infant has nasal secretions, this further prevents adequate respiratory effort by blocking the narrow nasal passages when the infant reclines to bottle feed or breastfeed and ceases the compensatory mouth breathing effort, thus causing the child to limit intake of fluids. Adequate fluid intake is encouraged by offering small amounts of favorite fluids (clear liquids if vomiting) at frequent intervals. Oral rehydration solutions, such as Infalyte or Pedialyte, should be considered for infants, and water or a low-carbohydrate (≤5 g per 8 oz) flavored drink should be considered for older children. Fluids with caffeine (tea, coffee) should be avoided because these may act as diuretics and promote fluid loss. Sports drinks and energy drinks are not recommended for oral rehydration (American Academy of Pediatrics [AAP], 2011); some sports drinks may be diluted for older children. When encouraging oral fluids to prevent dehydration, sports drinks with “replacement electrolytes” offer no benefit over water and should be used cautiously in small children. Breastfeeding infants should continue to be breastfed because human milk confers some degree of protection from infection (see Chapter 23). Fluids should not be forced, and children should not be awakened to take fluids. Forcing fluids creates the same problem as urging unwanted food. Gentle persuasion with preferred beverages or sugar-free popsicles is usually more successful. Younger children may like to drink smaller amounts from a plastic medicine cup.

To assess their child’s level of hydration (see Chapter 41), parents are advised to observe the frequency of voiding and to notify the nurse or health care practitioner if there is insufficient voiding. Counting the number of wet diapers in a 24-hour period is a satisfactory method to assess output in infants and toddlers. In the hospital, diapers are weighed to assess output, which should be at least 1 mL/kg/hr up to 30 kg in child’s weight. Then it should be at least 30 mL per hour in patients weighing more than 30 kg. The practitioner should be notified if the urine output is low.

Provide Nutrition.

Loss of appetite is characteristic of children with acute infections. In most cases, children can be permitted to determine their own need for food. Many children show no decrease in appetite, and others respond well to foods such as gelatin, soup, and puddings (see Feeding the Sick Child, Chapter 39). Urging foods on anorexic children may precipitate nausea and vomiting and cause an aversion to feeding that may extend into the convalescent period and beyond.

Young children with respiratory tract infections are irritable and difficult to comfort; therefore the family needs support, encouragement, and practical suggestions concerning comfort measures and administration of medication. In addition to antipyretics and nose drops, the child may require antibiotic therapy. Parents of children receiving oral antibiotics must understand the importance of regular administration and continuing the drug for the prescribed length of time, regardless of whether the child appears ill. Parents should be cautioned against giving their child any medications that are not approved by the health care practitioner and to avoid giving antibiotics left over from a previous illness or prescribed for another child. Administering unprescribed antibiotics can produce serious side effects and adverse reactions (see Chapter 39 for administration of medications and teaching parents). See also the Nursing Care Plan on p. 1198.

Upper Respiratory Tract Infections

Nasopharyngitis

Acute nasopharyngitis, or the equivalent of the “common cold,” is caused by the rhinovirus, RSV, adenoviruses, enteroviruses, influenza virus, and parainfluenza virus. Symptoms are more severe in infants and children than in adults. Fever is common in young children, and older children have low-grade fevers, which appear early in the course of the illness. Other clinical manifestations are listed in Box 40-3. Symptoms may last up to 10 days.

Box 40-3 Clinical Manifestations of Nasopharyngitis and Pharyngitis

Nasopharyngitis

Pharyngitis

Younger Child

• Fever

• Irritability, restlessness

• Sneezing

• Vomiting or diarrhea

Older Child

• Dryness and irritation of nose and throat

• Sneezing, chilling sensation

• Muscular aches

• Cough, sometimes

Physical Signs

• Edema and vasodilation of mucosa

• Moderate sore throat

• Headache

Older Child

• Fever (may reach 40° C [104° F])

• Mild to moderate hyperemia

Older Child

• Mild to fiery red, edematous pharynx

• Hyperemia of tonsils and pharynx; may extend to soft palate and uvula

• Often abundant follicular exudate that spreads and coalesces to form pseudomembrane on tonsils

• Cervical glands enlarged and tender

Therapeutic Management

Children with nasopharyngitis are managed at home. There is no specific treatment, and effective vaccines are not available. Antipyretics may be indicated for mild fever and discomfort (see Chapter 39 for management of fever). Rest is recommended. The provision of a humidified environment and increasing oral fluids may be beneficial to some children with a cold.

Cough suppressants containing dextromethorphan should be used with caution (cough is a protective way of clearing secretions) but may be prescribed for a dry, hacking cough, especially at night. However, some preparations contain 22% alcohol and can cause adverse effects such as confusion, hyperexcitability, dizziness, nausea, and sedation. Parents should monitor the child carefully for potential adverse effects. Recent concerns regarding serious side effects of cough and cold preparations in young children, particularly infants, and lack of convincing evidence that such medications are effective in reducing symptoms have prompted recommendations by health care experts to carefully evaluate the benefits and risks of recommending such preparations for children younger than 6 years (Bell and Tunkel, 2010; Ryan, Brewer, and Small, 2008; Vassilev, Kabadi, and Villa, 2010). Over-the-counter cold preparation such as pseudoephedrine and some antihistamines are not appropriate for the treatment of the common cold in infants and toddlers; these may cause serious side effects in such children and have been associated with death in infants (Rimsza and Newberry, 2008; Ryan, Brewer, and Small, 2008).

Antihistamines are largely ineffective in treatment of nasopharyngitis (Kinyon Munch, 2010). These drugs have a weak atropine-like effect that dries secretions, but they can cause drowsiness or, paradoxically, have a stimulatory effect on children. Second-generation antihistamines such as loratadine or cetirizine are nonsedating but also have not been shown to be effective in relieving the symptoms of the common cold in small children and are not recommended by the American College of Chest Physicians (Pratter, 2006). There is no support for the usefulness of expectorants, and antibiotics are usually not indicated because most infections are viral.

Supportive treatment with antipyretics, nasal saline irrigation, and adequate fluid hydration is still the safest and most often recommended therapy for infants and small children with the common cold (Kinyon Munch, 2010).

Prevention

Nasopharyngitis is so widespread in the general population that it is impossible to prevent. Children are more susceptible because they have not yet developed resistance to many viruses. Young infants and those with decreased resistance and pulmonary illness are subject to serious complications, so attempts should be made to protect them from exposure.

Care Management

A cold is often the parents’ first introduction to an illness in their infant. Most discomfort of nasopharyngitis is related to the nasal obstruction, especially in small infants. Elevating the head of the bed or crib mattress assists with drainage of secretions. Suctioning and vaporization may also provide relief. Saline nose drops and gentle suction with a bulb syringe before feeding and sleep time may be useful.

Maintaining adequate fluid intake is essential. Although a child’s appetite for solid foods is usually diminished for several days, it is important to offer appropriate fluids to prevent dehydration.

Because nasopharyngitis is spread from secretions, the best means for prevention is avoiding contact with affected persons. This goal is difficult to accomplish in family settings, classrooms, and day care centers. Family members with a cold should try to “keep it to themselves” by carefully disposing of tissues; not sharing towels, glasses, or eating utensils; covering the mouth and nose with tissues when coughing or sneezing; and washing the hands thoroughly after nose blowing or sneezing. The most frequent carriers of infection are the human hands, which deposit viruses on doorknobs, faucets, and other everyday objects. Children should be taught to wash their hands thoroughly and avoid touching their eyes, nose, and mouth.

Support and reassurance are important elements of care for families of young children with recurrent upper respiratory infections (URIs). Because URIs are frequent in children younger than 3 years, families may feel they are on an endless roller coaster of illness. They need reassurance that frequent colds are a normal part of childhood and that by 5 years of age, their children will have developed immunity to many viruses. When children spend time in day care centers, their infection rate is higher than if they are cared for in the home because of increased exposure. Parents should know the signs of respiratory complications and should notify a health care professional if complications occur or the child does not improve within 2 to 3 days (Box 40-4).

Acute Streptococcal Pharyngitis

Children who experience GABHS infection of the upper airway (strep throat) are at risk for rheumatic fever (RF), an inflammatory disease of the heart, joints, and central nervous system (CNS) (see Chapter 42), and acute glomerulonephritis (AGN), an acute kidney infection (see Chapter 44). Permanent damage can result from these sequelae, especially RF. GABHS may also cause skin manifestations, including impetigo and pyoderma.

Clinical Manifestations

Group A β-hemolytic streptococci infection is generally a relatively brief illness that varies in severity from subclinical (no symptoms) to severe toxicity. The onset is often abrupt and characterized by pharyngitis, headache, fever, and abdominal pain. The tonsils and pharynx may be inflamed and covered with exudate (Fig. 40-1), which usually appears by the second day of illness. However, streptococcal infections should be suspected in children older than 2 years who have pharyngitis without exudate or nasal symptoms. The tongue may appear edematous and red (strawberry tongue), and the child may have a fine sandpaper rash on the trunk, axillae, elbows, and groin seen in scarlet fever (caused by a strain of group A streptococcus). The uvula is edematous and red. Anterior cervical lymphadenopathy (in ≈30% to 50% of cases) usually occurs early, and the nodes are often tender. Pain can be relatively mild to severe enough to make swallowing difficult. Clinical manifestations usually subside in 3 to 5 days unless complicated by sinusitis or parapharyngeal, peritonsillar, or retropharyngeal abscess. Nonsuppurative complications may appear after the onset of GABHS—AGN in about 10 days and RF in an average of 18 days.