The Child with Respiratory Dysfunction

The Child with Respiratory Dysfunction

Patricia M. Conlon


Respiratory Infection

Infections of the respiratory tract are described according to the anatomic area of involvement. The upper respiratory tract, or upper airway, consists of the oronasopharynx, pharynx, larynx, and upper part of the trachea. The lower respiratory tract consists of the lower trachea, mainstem bronchi, segmental bronchi, subsegmental bronchioles, terminal bronchioles, and alveoli. In this discussion, the trachea is considered with lower tract disorders, and infections of the epiglottis and larynx are categorized as croup syndromes. However, respiratory infections seldom fall into discrete anatomic areas. Infections often spread from one structure to another because of the contiguous nature of the mucous membrane lining the entire tract. Consequently, respiratory tract infections involve several areas rather than a single structure, although the effect on one area may predominate in any given illness.

Infectious Agents

The respiratory tract is subject to a wide variety of infective organisms. Most infections are caused by viruses, particularly respiratory syncytial virus (RSV), nonpolio enteroviruses (coxsackieviruses A and B), adenoviruses, parainfluenza viruses, and human metapneumoviruses. Other agents involved in primary or secondary invasion include group A β-hemolytic streptococci (GABHS), staphylococci, Haemophilus influenzae, Chlamydia trachomatis, Mycoplasma organisms, and pneumococci.


Healthy full-term infants younger than age 3 months are presumed to have a lower infection rate than older infants because of the protective function of maternal antibodies; however, infants may be susceptible to specific respiratory tract infections, namely pertussis, during this period. The infection rate increases from 3 to 6 months of age, the time between the disappearance of maternal antibodies and the infant’s own antibody production. The viral infection rate remains high during the toddler and preschool years. By 5 years of age, viral respiratory tract infections are less frequent, but the incidence of Mycoplasma pneumoniae and GABHS infections increases. The amount of lymphoid tissue increases throughout middle childhood, and repeated exposure to organisms confers increasing immunity as children grow older.

Some viral or bacterial agents produce a mild illness in older children but severe lower respiratory tract illness or croup in infants. For example, pertussis causes a relatively harmless tracheobronchitis in childhood but is a serious disease in infancy.

Clinical Manifestations

Infants and young children, especially those between 6 months and 3 years of age, react more severely to acute respiratory tract infections than older children. Young children display a number of generalized signs and symptoms as well as local manifestations (Box 23-1).

Box 23-1   Signs and Symptoms Associated with Respiratory Tract Infections in Infants and Small Children

Nursing Care Management

image 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


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.

image Nursing Process

The Child with Acute Respiratory Tract Infection

image Animations—Bronchi and Bronchioles; Lung Sounds

image 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 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).

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 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.

image Nursing Care Plan

The Child with Acute Respiratory Tract Infection

Ineffective Breathing Pattern related to inflammatory process
Child’s Defining Characteristics
(Subjective and Objective Data)
Use of accessory muscles to breathe
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
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)
Difficulty vocalizing
Adventitious breath sounds (crackles, wheezing, rhonchi)
Cough ineffective or absent
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
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
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.

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.

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).

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.

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 image 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.


image 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.

image Case Study—Tonsillitis

image Nursing Care Plan—The Child with Tonsillectomy


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.

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.

Family Support and Home Care

Discharge instructions include (1) avoiding irritating and highly seasoned foods, (2) avoiding gargles or vigorous toothbrushing, (3) avoiding coughing or clearing of the throat or putting objects in the mouth (e.g., a straw), (4) using analgesics or an ice collar for pain, and (5) limiting activity to decrease the potential for bleeding. Chewing gum may prevent throat and ear pain in older children. Objectionable mouth odor and slight ear pain with a low-grade fever are common for 5 to 10 days postoperatively. However, persistent severe earache, fever, or cough requires medical evaluation. Most children are ready to resume normal activity within 1 to 2 weeks after the operation. The child’s voice may sound different postoperative, especially if the tonsils were large.

Hemorrhage may occur after surgery as a result of tissue sloughing from the healing process. Any sign of bleeding warrants immediate medical attention.


Influenza, or the “flu,” is caused by three orthomyxoviruses, which are antigenically distinct: types A and B, which cause epidemic disease, and type C, which is unimportant from an epidemiologic standpoint. Influenza is spread from one individual to another by direct contact (large-droplet infection) or by articles recently contaminated by nasopharyngeal secretions. There is no predilection for a specific age group, but attack rates are highest in young children who have had no previous contact with a strain. Influenza is frequently most severe in infants. During epidemics, infection among school-age children is believed to be a major source of transmission in a community. The disease is more common during the winter months and has a 1- to 3-day incubation period. Affected persons are most infectious for 24 hours before and after the onset of symptoms. The virus has a peculiar affinity for epithelial cells of the respiratory tract mucosa, where it destroys ciliated epithelium with metaplastic hyperplasia of the tracheal and bronchial epithelium with associated edema. The alveoli may also become distended with a hyaline-like material. The viruses can be isolated from nasopharyngeal secretions early after the onset of infection, and serologic tests identify the type by complement fixation or the subgroups by hemagglutination inhibition.

H1N1 (swine flu) is a subtype of influenza type A. In 2009, a pandemic of H1N1 caused significant morbidity and mortality, particularly in Mexico and the United States; it was declared at an end in August 2010. A pandemic is defined by the World Health Organization (2011) as the spread of a new disease to which the population has little or no immunity and that spreads rapidly from human to human. The signs and symptoms of H1N1 flu are the same as those mentioned below for influenza. H1N1 vaccine was combined with the seasonal influenza vaccine in the 2011 to 2012 season.

Jan 16, 2017 | Posted by in NURSING | Comments Off on The Child with Respiratory Dysfunction
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