Assessment of the respiratory system follows the guidelines described in Chapter 6 (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 23-2. 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 Process box.

Box 23-2 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), orthopnea (difficult breathing except in upright position), associated with intercostal or substernal retractions (inspiratory “sinking in” of soft tissues in relation to the cartilaginous and bony thorax), pulsus paradoxus (blood pressure falling with inspiration and rising with expiration), nasal flaring, head bobbing (head of sleeping child with suboccipital area supported on caregiver’s forearm bobbing forward in synchrony with each inspiration), grunting, wheezing, or stridor

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:

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

Wheeze—Observe character of wheezing: expiratory or inspiratory, high pitched or musical, prolonged, slowly progressive or sudden, association with labored breathing.

Cyanosis—Note distribution (peripheral, perioral, facial, trunk, and face), degree, duration, association with activity.

Chest pain—This may be a complaint of older children. Note location and circumstances: localized or generalized; referral to base of neck or abdomen; dull or sharp; deep or superficial; association with rapid, shallow respirations or grunting.

Nasal mucus—Whereas older children may provide sample by blowing nose or provide sputum sample by coughing, young children may need use of bulb suction, wall suction, DeLee mucus trap, or baby nasal aspirator (attaches to wall suction tubing and fits on small nose) to provide a sample. Note volume, color, viscosity, and odor.

Bad breath (halitosis)—May be associated with some upper airway infections but is more common in mouth breathers.

Nursing Process

The Child with Acute Respiratory Tract Infection

Assessment

Assessment of the respiratory system follows the guidelines described in Chapter 6 (for nose, ears, mouth and throat, chest, and lungs). In addition, special attention is given to the observations outlined in Box 23-1 and the components in Box 23-2.

Diagnoses (Problem Identification)

After a thorough assessment, several nursing diagnoses are evident. Other nursing diagnoses may be apparent in individual cases.

• Ineffective Breathing Pattern related to inflammatory process

• Impaired Gas Exchange related to hypoxemia or hypercapnia

• Ineffective Airway Clearance related to mechanical obstruction, inflammation, increased secretions

• Risk for Infection related to presence of infectious organisms, presence of optimum medium (mucus, sputum) for growth of infectious agents

• Activity Intolerance related to inflammatory process, imbalance between oxygen supply and demand

• Altered Family Processes related to child’s illness

Planning

Expected patient outcomes include:

• Child will have adequate oxygenation.

• Child will demonstrate effective clearance of secretions.

• Optimum patient comfort will be achieved.

• Child will have effective respirations.

• Child will have adequate fluid and nutrient intake.

Implementation

Numerous intervention strategies are discussed on pp. 707–710.

Evaluation

The effectiveness of nursing interventions is determined by continual reassessment and evaluation of care based on the following observational guidelines:

• Observe child’s respiratory effort and chest movements.

• Observe child’s behavior and activity.

• Observe other family members and contacts for evidence of infection.

• Take temperature, respiratory rate, pulse oximetry reading, blood pressure, and heart rate.

• Observe for signs of adequate hydration.

• Assess complications, such as dehydration, weight loss, or spread of infection to other areas of the body.

• Observe family’s behavior and interview members regarding their feelings and concerns.

Animations—Bronchi and Bronchioles; Lung Sounds

Nursing Care Plan—The Child with Acute Respiratory Infection

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 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 (albeit not evidence based!) 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 of age), ephedrine 1% (for children older than 6 years of age), or oxymetazoline 0.05% (for children older than 6 years of age) are 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 noses and mouths 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 noses 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 daycare 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 Body 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 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 22).

Nursing Alert

Parents are cautioned regarding over-the-counter combination “cold” remedies because 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) are 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). Breastfeeding infants should continue to be breastfed because human milk confers some degree of protection from infection (see Chapter 8). 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 Chapters 9 and 24), parents are advised to observe the frequency of voiding and to notify the nurse or 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 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, popsicles, and soup (see Feeding the Sick Child, Chapter 22). Urging solid foods for children who are sick may precipitate nausea and vomiting and cause an aversion to feeding that may extend into the convalescent period and beyond.

Provide Family Support and Home Care

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 of continuing the drug for the prescribed length of time regardless of whether the child appears ill. Parents are cautioned against giving their children any medications that are not approved by the health practitioner and are cautioned 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 22 for administration of medications and teaching parents). See Nursing Care Plan.

Nursing Care Plan

The Child with Acute Respiratory Tract Infection

NURSING DIAGNOSIS	PATIENT OUTCOMES	NURSING INTERVENTIONS	RATIONALE
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. The Following NOC Concept Applies to These Outcomes Respiratory Status: Airway Patency, Ventilation	Position child for maximal 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. Assist with coughing.	To decrease airway inflammation and inflammatory response To remove secretions and clear airway
		The Following NIC Concepts Apply to These Interventions
		Aspiration Precautions Positioning Respiratory Monitoring Surveillance Oxygen Therapy Airway Suctioning Vital Signs Monitoring Cough Enhancement
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. The Following NOC Concepts Apply to These Outcomes Aspiration Control Airway Patency	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
		The Following NIC Concepts Apply to These Interventions
		Cough Enhancement Positioning Chest Physiotherapy Vital Signs Monitoring Anxiety Reduction
Risk for Injury related to presence (only as indicated) of infective organisms Child’s/Family’s Defining Characteristics (Subjective and Objective Data) Tissue hypoxia Abnormal blood profile People or provider (nosocomial agents) Mode of transport Developmental age	Child will remain free from complications of infection. The Following NOC Concept Applies to These Outcomes Risk Control	Maintain aseptic environment using sterile suction equipment and technique. Implement and practice standard precautions. Implement contact and airborne precautions as indicated.	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 washing 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 indicated or 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
		The Following NIC Concepts Apply to These Interventions
		Risk Identification Environmental Management Infection Control Parent Education
Interrupted Family Processes related to child’s illness, hospitalization, and medical or therapeutic regimen Child’s/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. The Following NOC Concepts Apply to These Outcomes Family Functioning Family Normalization Parenting	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
		The Following NIC Concepts Apply to These Interventions
		Caregiver Support Family Support Coping Enhancement Emotional Support Financial Resource Assistance

NIC, Nursing Interventions Classification; NOC, Nursing Outcomes Classification.

Upper Respiratory Tract Infections

Acute Viral 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 23-3. Symptoms may last up to 10 days.

Box 23-3 Clinical Manifestations of Acute Nasopharyngitis and Pharyngitis

Nasopharyngitis

Younger Children

Fever

Irritability, restlessness

Poor feeding and decreased fluid intake

Sneezing

Nasal mucus (abundant) causing mouth breathing

Vomiting or diarrhea

Older Children

Dryness and irritation of nose and throat initially

Nasal discharge causing mouth breathing

Sneezing, chilling

Muscle aches

Cough (sometimes)

Physical Assessment Signs

Edema and vasodilation of mucosa

Fever (may reach 40° C [104° F])

Physical Assessment Signs

Younger Children

Mild to moderate hyperemia

Older Children

Mild to bright 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 22 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. Decongestants may be prescribed for children and infants older than 12 months of age to shrink swollen nasal passages (they should be used with caution in infants younger than 1 year of age).

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 experts to carefully evaluate the benefits and risks of recommending such preparations for children younger than 6 years of age (Ryan, Brewer, and Small, 2008). 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. These drugs have a weak atropine-like effect that dries secretions, but they can cause drowsiness or, paradoxically, have a stimulatory effect on children. There is no support for the usefulness of expectorants, and antibiotics are usually not indicated because most infections are viral.

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.

Nursing 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 daycare 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, noses, and mouths.

Family Support

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 of age, 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 daycare 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 professional if complications occur or the child does not improve within 2 or 3 days (Box 23-4).

Box 23-4

Early Evidence of Respiratory Complications

Parents are instructed to notify the health professional if any of the following are noted:

• Refusal to take oral fluids and decreased urination

• Evidence of earache (see p. 718)

• Respirations faster than 50 to 60 breaths/min in a toddler or older child

• Fever over 38.3° C (101° F)

• Listlessness

• Confusion

• Increasing irritability with or without fever

• Persistent cough or exacerbating cough

• Wheezing

• Restlessness and poor sleep patterns

Modified from National Association of Pediatric Nurse Practitioners (NAPNAP): Baby’s first cold, New York, 1989, Winthrop Consumer Products. Copies available from NAPNAP, 20 Brace Road, Suite 200, Cherry Hill, NJ 08034-2634; 856-857-9700; http://www.napnap.org.

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 25), and acute glomerulonephritis (AGN), an acute kidney infection (see Chapter 27). 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. 23-1), which usually appear by the second day of illness. However, streptococcal infections should be suspected in children older than 2 years of age 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%–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.

FIG 23-1 Tonsillitis and pharyngitis. (Courtesy Dr. Edward L. Applebaum, Head, Department of Otolaryngology, University of Illinois Medical Center, Chicago.)

Children who are GABHS carriers may have a positive throat culture but often experience a coincidental viral illness. Although antibiotic administration is not indicated for most GABHS carriers, some conditions require antibiotic therapy; these are published in the AAP’s Red Book (AAP, Committee on Infectious Diseases and Pickering, 2009).

Diagnostic Evaluation

Although 80% to 90% of all cases of acute pharyngitis are viral, a throat culture or rapid streptococcal identification test should be performed to rule out GABHS. Most streptococcal infections are short-term illnesses, and antibody responses (e.g., antistreptolysin-O titer) appear later than symptoms and are useful only for retrospective diagnosis.

Rapid identification of GABHS with diagnostic test kits (rapid antigen detection test) is possible in the office or clinic setting. Because of the high specificity of these rapid tests, a positive test result generally does not require throat culture confirmation. However, the sensitivities of these kits vary considerably, and a confirmatory throat culture is recommended in patients who have a negative test result (AAP, Committee on Infectious Diseases and Pickering, 2009).

Therapeutic Management

If streptococcal sore throat infection is present, oral penicillin is prescribed in a dose sufficient to control the acute local manifestations and to maintain an adequate level for at least 10 days to eliminate any organisms that might remain to initiate RF symptoms. Penicillin does not prevent the development of AGN in susceptible children; however, it may prevent the spread of a nephrogenic strain of GABHS to others in the family. Penicillin usually produces a prompt response within 24 hours. Patients who have a history of RF or who remain symptomatic after a full course of antibiotics may require a follow-up throat swab.

Intramuscular (IM) benzathine penicillin G is an appropriate therapy, but it is painful and is not the first choice for children. Oral erythromycin is indicated for children who are allergic to penicillin. Other antibiotics used to treat GABHS are azithromycin, clarithromycin, oral cephalosporins, amoxicillin, and amoxicillin with clavulanic acid (AAP, Committee on Infectious Diseases and Pickering, 2009).

Nursing Care Management

The nurse often obtains a throat swab for culture or rapid antigen testing and instructs the parents about administering oral antibiotics and analgesics as prescribed. Cold or warm compresses to the neck may provide relief. In children who can cooperate, warm saline gargles may offer relief of throat discomfort. Acetaminophen and ibuprofen may be effective in decreasing the throat pain; liquid preparations or chewable forms may be preferable because of the pain associated with swallowing. Pain may interfere with oral intake, and children should not be forced to eat, but fluid intake is essential. Cool liquids or ice chips may be more acceptable than solids.

Special emphasis is placed on correct administration of oral medication and completion of the course of antibiotic therapy (see Administration of Medication, and Compliance, Chapter 22). If an injection is required, it must be administered deep into a large muscle mass (e.g., vastus lateralis or ventrogluteal muscle). To prevent pain, application of a topical anesthetic cream such as EMLA (an eutectic mixture of lidocaine and prilocaine) over the injection site hours before the injection or LMX4 (4% lidocaine) over the site 30 minutes before the injection is helpful (see Administration of Medication: Intramuscular Administration, Chapter 22). The injection site may be tender for 1 to 2 days.

Children are considered infectious to others at the onset of symptoms and up to 24 hours after initiation of antibiotic therapy, but they should not return to school or daycare until they have been taking antibiotics for a full 24-hour period. Nurses should remind the children to discard their toothbrushes and replace them with new ones after they have been taking antibiotics for 24 hours. Orthodontic appliances should be washed thoroughly because they may harbor the organisms. Parents are cautioned to prevent other household members, especially if immunocompromised, from having close contact with the sick child and avoid sharing drinking or eating items.

If the child continues to have a high fever that does not respond to antipyretics, has an extremely sore throat, refuses liquids, and appears toxic 24 to 48 hours after starting antibiotics, further evaluation by the practitioner is recommended.

Drug Alert!

Never administer penicillin G procaine or penicillin G benzathine suspensions intravenously (they may cause embolism or toxic reaction with ensuing death in minutes). Instead, administer these medications deep into the muscle tissue to decrease localized reactions and pain.

Tonsillitis

The tonsils are masses of lymphoid tissue located in the pharyngeal cavity. They filter and protect the respiratory and alimentary tracts from invasion by pathogenic organisms and play a role in antibody formation. Although their size varies, children generally have much larger tonsils than adolescents or adults. This difference is thought to be a protective mechanism because young children are especially susceptible to URIs.

Case Study—Tonsillitis

Nursing Care Plan—The Child with Tonsillectomy

Pathophysiology

Several pairs of tonsils are part of a mass of lymphoid tissue encircling the nasal and oral pharynx, known as the Waldeyer tonsillar ring (Fig. 23-2). The palatine, or faucial, tonsils are located on either side of the oropharynx behind and below the pillars of the fauces (opening from the mouth). A surface of the palatine tonsils is usually visible during oral examination. The palatine tonsils are those removed during tonsillectomy. The pharyngeal tonsils, also known as the adenoids, are located above the palatine tonsils on the posterior wall of the nasopharynx. Their proximity to the nares and eustachian tubes causes difficulties in instances of inflammation. The lingual tonsils are located at the base of the tongue. The tubal tonsils, found near the posterior nasopharyngeal opening of the eustachian tubes, are not part of the Waldeyer tonsillar ring.

FIG 23-2 Location of various tonsillar masses.

Etiology

Tonsillitis often occurs with pharyngitis. Because of the abundant lymphoid tissue and the frequency of URIs, tonsillitis is a common cause of illness in young children. The causative agent may be viral or bacterial.

Clinical Manifestations

The manifestations of tonsillitis are caused by inflammation. As the palatine tonsils enlarge from edema, they may meet in the midline (kissing tonsils), obstructing the passage of air or food. The child has difficulty swallowing and breathing. When enlargement of the adenoids occurs, the space behind the posterior nares becomes blocked, making it difficult or impossible for air to pass from the nose to the throat. As a result, the child breathes through the mouth.

Therapeutic Management

Because tonsillitis is self-limiting, treatment of viral pharyngitis is symptomatic. Throat cultures positive for GABHS infection warrant antibiotic treatment. It is important to differentiate between viral and streptococcal infection in febrile exudative tonsillitis. Because most infections are of viral origin, early rapid tests can eliminate unnecessary antibiotic administration.

Tonsillectomy is the surgical removal of the palatine tonsils. Absolute indications for a tonsillectomy are recurrent peritonsillar abscess, airway obstruction, tonsillitis resulting in febrile convulsions, and tonsils requiring tissue pathology (American Academy of Otolaryngology—Head and Neck Surgery, 2011). Relative indications include three or more tonsil infections per year, persistent foul taste or breath caused by chronic tonsillitis, unilateral tonsil hypertrophy presumed to be malignant, and chronic tonsillitis in a streptococcus carrier who fails to respond to antibiotics (American Academy of Otolaryngology—Head and Neck Surgery, 2011).

Adenoidectomy (the surgical removal of the adenoids) is recommended for children who have hypertrophied adenoids that obstruct nasal breathing; additional indications for adenoidectomy include recurrent adenoiditis and sinusitis, chronic otitis media (OM) with effusion (especially if associated with hearing loss), airway obstruction and subsequent sleep-disordered breathing, persistent mouth-breathing, nasal speech, and recurrent nasopharyngitis (Benninger and Walner, 2007a). For some children, the effectiveness of tonsillectomy or adenoidectomy is modest and may not justify the risk of surgery. In practice, many physicians rely on individualized decision making and do not subscribe to an absolute set of eligibility criteria for these surgical procedures. Contraindications to either tonsillectomy or adenoidectomy are (1) cleft palate because the tonsils help minimize escape of air during speech, (2) acute infections at the time of surgery because locally inflamed tissues increase the risk of bleeding, (3) uncontrolled systemic diseases or blood dyscrasias, and (4) poor anesthetic risk.

Nursing Care Management

Nursing care involves providing comfort and minimizing activities or interventions that precipitate bleeding. Patients with sleep-disordered breathing require close monitoring of airway and breathing postoperatively. A soft to liquid diet is preferred. A cool-mist vaporizer keeps the mucous membranes moist during periods of mouth breathing. Warm salt-water gargles, throat lozenges, and analgesic–antipyretic drugs such as acetaminophen are used to promote comfort. Often opioids are needed to reduce pain for the child to drink. Combination nonopioid and opioid elixirs such as acetaminophen with codeine or with hydrocodone (Lortab) relieve pain and should be given routinely every 4 hours.

If surgery is required, the child requires the same psychologic preparation and physical care as for any other surgical procedure (see Chapters 21 and 22). Most tonsillectomy and adenoidectomy (T&A) surgeries now take place in outpatient settings; however, the priorities of preoperative and postoperative care remain the same. The following discussion focuses on postoperative nursing care for T&A, although both procedures may not be performed.

Until they are fully awake, the child is placed on his or her abdomen or side to facilitate drainage of secretions. Routine suctioning is avoided, but when performed, it is done carefully to avoid trauma to the oropharynx. When alert, the child may prefer sitting up. The child is discouraged from coughing frequently, clearing the throat, blowing the nose, and any other activity that may aggravate the operative site.

Some secretions are common, particularly dried blood from surgery. All secretions and vomitus are inspected for evidence of fresh bleeding (some blood-tinged mucus is expected). Dark brown (old) blood is usually present in the emesis, in the nose, and between the teeth. If parents do not expect this, they often become frightened at a time when they need to be calm and reassuring.

The throat is sore after surgery. An ice collar may provide relief, but many children find it bothersome and refuse to use it. Most children experience moderate pain after a T&A and need pain medication regularly for at least the first few days. Analgesics may be given rectally or intravenously to avoid the oral route. Because the pain is continuous, analgesics should be administered at regular intervals even at night (see Pain Management, Chapter 7). An antiemetic such as ondansetron (Zofran) may be administered postoperatively if nausea or vomiting is present.

Food and fluids are restricted until the child is fully alert and there are no signs of hemorrhage. Cool water, crushed ice, flavored ice pops, or diluted fruit juice may be given, but fluids with a red or brown color are avoided to distinguish fresh or old blood in emesis from the ingested liquid. Citrus juice may cause discomfort and is usually poorly tolerated. Soft foods, particularly gelatin, cooked fruits, sherbet, soup, and mashed potatoes, are started on the first or second postoperative day or as the child tolerates feeding. The pain from surgery often inhibits fluid intake, reinforcing the need for adequate pain control. Milk, ice cream, and pudding are usually not offered because milk products coat the mouth and throat and may cause the child to clear the throat, which can initiate bleeding.

Postoperative hemorrhage is uncommon but can occur in up to 5% of patients up to 14 days after surgery. The nurse observes the throat directly for evidence of bleeding; using a good source of light; and, if necessary, carefully inserting a tongue depressor. Other signs of hemorrhage are tachycardia, pallor, frequent clearing of the throat or swallowing by a younger child, and vomiting of bright red blood. Restlessness, an indication of hemorrhage, may be difficult to differentiate from general discomfort after surgery. Decreasing blood pressure is a late sign of shock.

Surgery may be required to ligate a bleeding vessel. Airway obstruction may also occur as a result of edema or accumulated secretions and is indicated by signs of respiratory distress, such as stridor, drooling, restlessness, agitation, increasing respiratory rate, and progressive cyanosis. Suction equipment and oxygen should be available after tonsillectomy.

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