On completion of this chapter the reader will be able to: • Identify the factors leading to respiratory tract infection in infants and young children. • Contrast the effects of various respiratory infections observed in infants and children. • Describe the postoperative nursing care of a child with a tonsillectomy. • Outline a nursing care plan for a child with croup. • Describe priorities of nursing care for a child with acute otitis media. • Identify priorities of nursing care for an infant with respiratory syncytial virus bronchiolitis. • Describe the various therapeutic measures to relieve the symptoms of asthma. • Outline a plan for teaching home care management of a child with asthma. • Describe the physiologic effects of cystic fibrosis on the gastrointestinal and pulmonary systems. • Outline a care plan for a child with cystic fibrosis. • List the major signs of respiratory distress in infants and children. • Describe emergent procedures for the relief of foreign body obstruction in an infant or child. evolve.elsevier.com/wong/essentials Animations—Asthma; Bag Ventilation; Bronchi and Bronchioles; Intubation; Intubation in Infant; Intubation, Incorrect Placement; Lung Sounds; Pediatric CPR; Pneumonia; Respiratory Failure, Infant Case Studies—Acute Epiglottitis; Asthma; Bronchiolitis; Cystic Fibrosis; Mononucleosis; Tonsillitis Nursing Care Plans—The Child with Acute Respiratory Infection; The Child with Asthma; The Child with Bronchiolitis and Respiratory Syncytial Virus (RSV) Infection; The Child with Cystic Fibrosis; The Child with Respiratory Failure; The Child with Tonsillectomy 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. 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. 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). 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. 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 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). 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. 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.
The Child with Respiratory Dysfunction
Respiratory Infection
Nursing Care Management
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.
Animations—Bronchi and Bronchioles; Lung Sounds
Nursing Care Plan—The Child with Acute Respiratory Infection
Promote Hydration
Provide Nutrition
Upper Respiratory Tract Infections
Acute Viral Nasopharyngitis
Therapeutic Management
Acute Streptococcal Pharyngitis
Nursing Care Management
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.
Tonsillitis
Nursing Care Plan—The Child with Tonsillectomy
Therapeutic Management
Nursing Care Management
The Child with Respiratory Dysfunction
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