Health Promotion, Restoration and Maintenance of the Family PDF

Health Promotion, Restoration and Maintenance of the Family: Eye Ear and Respiratory Dysfunction Professor Meghan McCrillis DNP PHNL CNE Quinsigamond Community College NUR201 Sharing and Copyright Infringement...

Health Promotion, Restoration and Maintenance of the Family: Eye Ear and Respiratory Dysfunction Professor Meghan McCrillis DNP PHNL CNE Quinsigamond Community College NUR201 Sharing and Copyright Infringement Any handouts or postings related to course content is the intellectual property of QCC faculty and cannot be shared by any means to other students or outside entities. Review of A & P and disease  Upper respiratory tract  Croup/epiglottitis  Nasopharyngitis  Pharyngitis UPPER TRACT  Tonsillitis  Otitis media  Lower respiratory tract  Asthma  Cystic fibrosis LOWER TRACT  Respiratory syncytial virus  Croup/epiglottitis 2 Trachea: Adult versus Infant Majority of acute illnesses in children are caused by respiratory illness  Children at a higher risk  Age  Low income  Chronic disorders  Seasonal influence  Winter = viruses  Spring and fall = allergen related disease process  Late recognition of severity of illness Respiratory Assessment  Inspection & Observation – Sick? Not Sick?  Color: pale, circumoral vs central cyanosis - Behavior: alert & playing? Anxious?  VS: tachypnea,  RR, tachycardia, fever, oxygen saturation (SaO2)  Nose  Obstruction  Nasal flaring  Discharge: amount, color, viscosity, odor  Respiratory Assessment  Eyes  Inspect conjunctivae: discharge, redness, eye rubbing, presence of tears  Ears  Inspect for otitis media: ear pulling, headache, lethargy, discharge, mastoid tenderness, enlarged cervical lymph nodes 6 Respiratory Assessment  Oral Cavity  Tonsils (swelling, redness or white areas), uvula, oropharynx, mucous membranes, presence of bubbles/saliva, halitosis  Cough & airway noises  Type of cough (productive, non productive, barky), grunting, stridor, audible wheezes Respiratory Assessment  Chest  Size, shape, depth, quality, work of breathing (WOB), symmetry of movement bilaterally, pain WOB  Respiratory rate  Presence of retractions  Suprasternal: above the sternum  Supraclavicular: above the clavicle  Intercostal: between ribs  Substernal: below xiphoid  Subcostal: below lower costal margin  Paradoxical (Seesaw) breathing  Nasal flaring  Head bobbing 8 Lung Sounds: Be Thorough!! Adventitious Lung Findings Potential Abnormalities Sounds Stridor High pitched whistling sound Airway obstruction – foreign during inspiration body or mechanical: abcess, tumor, tracheomalacia, edema Rales/Crackles Fine crackles: soft,  pitched Pneumonia, fibrosis, CHF Course crackles: loud,  pitched Wheezes  Pitched musical whistling Asthma, COPD, bronchiolitis, CF Rhonchi  pitched, snoring quality Secretions in large airways Expiratory Phase Prolonged Bronchiolitis, asthma, pulmonary edema, foreign body aspiration (FBA) 9  Nursing Interventions Focused assessment = respiratory status  Before and after all treatments/interventions  WOB work of breathing (Respiratory effort), lung sounds  Assess oxygenation  Assess VS and VS trends  Administer ordered meds and assess response for effectiveness  Monitor child’s behavior: pain and activity level Focused assessment = hydration and nutrition status  Monitor I & O: assess hydration and fluid balance  Monitor and assess PO intake and nutrition Teaching – family & patient:  Hand hygiene and prevention of illness  Disease process and treatment undertaken 10 Chronic Respiratory Disorders 11 Asthma  Chronic inflammatory disorder of the lower airway  Considered the “reactive” portion of the lower respiratory tract includes bronchi and bronchioles  Most common chronic childhood illness  Episodic with triggers  Limitedairflow or obstruction that reverses spontaneously or with treatment  Acute complications include status asthmaticus and respiratory failure  Etiology  Can be influenced by genetic predisposition, air pollution, allergens and viral infections. 12 1. Pathophysiology Airway hyperresponsiveness- Bronchospasm  Severe, producing impaired respiratory function.  Spasmodic smooth muscle contraction in response to irritant  Causes airway edema to develop 2. Airway edema - Bronchoconstriction  Decreases diameter of bronchi and bronchioles  Increased resistance leads to air trapping difficult to inspire or expire sufficient air.  Respiratory difficulty more pronounced in expiratory phase 3. Mucus production  Tenacious secretions from mucous glands cause airways to plug – Xray findings show hyperinflation 13 Mechanisms of obstruction in asthma 14 Diagnostic Evaluation  Based on S & S  H&P  Presence of dyspnea, chronic cough in the absence of infection  wheeze during the expiratory phase of respiration  Pulmonary function tests (PFT’s)  Peak expiratory flow meter (PEFM)  Xray: shows infiltrates & hyperinflation of airways  Physical exam: Increased anteroposterior diameter (barrel chest)  Skin testing: for allergens  Pulse oximetry  Arterial blood gas: Carbon dioxide retention leading to Respiratory Acidosis, and hypoxia 15 Clinical Manifestations  Hacking nonproductive to productive cough  SOB, prolonged expiratory phase, audible wheeze, may not be able to speak in full sentences, chest tightness or pain  Inspiratory & expiratory (I & E) wheezes throughout lung fields. Note what lobes you are hearing wheezing and is there air movements in all lobes.  Increased WOB: accessory muscle use  Tachypnea, tachycardia 16  Therapeutic Management  Prevention  Bronchodilators  Andrenergics  Anticholinergics  Xanthines  Long Term Maintenance  Corticosteroids  Leukotrienes  Mast cell stabilizers  Combination meds Asthma Exacerbation Prevention  Exercise should be encouraged  May need meds for prophylactic treatment to prevent exercise-induced bronchospasm  Identify and avoid/eliminate triggers  Consistent use of maintenance treatment  Regular follow up with Licensed Independent Practitioner (LIP)  Hyposensitization to allergens  Weekly to monthly injections for a minimum of 3 years  Prognosis  Can continue into adulthood  Untreated can cause hypertension, CHF  Death is rare; adolescents more vulnerable. 18  Spacer is recommended Bronchodilators: Quick Acting Short-acting ß2- adrenergic agonist – ~~ TO THE RESCUE ~~  albuterol, epinephrine, metaproterenol, terbutaline  Use: Quick relief medication for acute asthma symptoms & exacerbations  Preparations: Metered Dose Inhaler (MDI), inhalation nebulizer (neb), oral, Sub-Q, IV  Actions: binds to beta-2 receptors to relax smooth muscle in the airway  S/E: cardiac and CNS stimulation Bronchodilators: Anticholinergics  ipratropium bromide, tiotropium  Use: Long term asthma management and/or combined with a rescue med (albuterol). Ineffective by themselves for acute bronchospasm.  Preparations: MDI, inhalation neb, PO  Action: inhibits bronchoconstriction and mucus production  S/E: cough, nervousness, nausea, GI upset, dry mouth, constipation, headache, dizziness  Bronchodilators: Xanthines theophylline (Aminophylline) Use: Long-term treatment as a second line drug for asthma, narrow therapeutic range of 5-15 mcg/ml. Preparations: PO, IV Actions:relaxes bronchial smooth muscle promoting bronchodilation S/E: Quickly toxic outside of therapeutic range. N/V, agitation, tachycardia, seizures. Long-Term Preventive/Maintenance Medications  Corticosteroids  beclomethasone (Beconase), fluticasone aerosol (Flovent), budesonide (Pulmocort Turbuhaler), prednisolone (Prelone), methylprednisolone (Solu-Medrol), triamcinolone acetonide (Azamacort), Prednisone.  Use: prophylactic management of asthma and chronic asthma  Preparations: MDI, inhalation neb, PO, IV  Actions: Decreases edema, increases effectiveness of ß2- adrenergic  S/E: in children: long term use = decreased adrenal function (must be weaned, use lowest dose to control symptoms), decreased growth & bone mass, oral fungal infection. 22 Long-Term Preventive/Maintenance Medications  Leukotriene Modifiers  montelukast (Singulair)  Use: Prevention and chronic treatment of asthma, allergic rhinitis, exercise-induced bronchoconstriction.  Preparation: PO  Action: leukotriene receptor antagonist, decreases the inflammatory process  S/E: headache, nausea, diarrhea, infection. Long-Term Preventive/Maintenance Medications  Mast Cell Stabilizers  Cromolyn (NasalCrom),  Use: mild, persistent asthma, exercise-induced asthma  Preparation: MDI or inhalation neb for asthma, PO route for allergic rhinitis  Action: prevents release of histamine, decreases inflammation and bronchoconstriction.  S/E: cough, nausea, nasal and throat irritation  Goal: Reduce dosage of bronchodilators and steroids 24 Long-Term Preventive/Maintenance Medications  Combo meds (bronchodilator and inhaled steroid)  fluticasone/salmeterol (Advair) , budesonide/formoterol (Symbicort), ipratropium/albuterol (Combivent, DuoNeb)  Preparation: MDI and inhalation neb  Goal: Smaller doses of each class of drug can be given Status Asthmaticus  Respiratory distress continues despite vigorous therapeutic measures  A medical emergency that can result in respiratory failure and death if untreated  Concurrent infection in some cases 26  Goals of Asthma Management  Avoid exacerbation  Avoid allergens/triggers  Relieve asthmatic episodes promptly  Relieve bronchospasm  Monitorrespiratory function with peak expiratory flow meter  Decrease sick visits and hospitalizations, decrease school absences.  Self-management of inhalers, devices, and activity regulation  Education and follow up is critical 27  CYSTIC FIBROSIS (CF) Go to the following link to review information provided by the Cystic Fibrosis Foundation. View the 11 minute video titled, How CF Affects the Body. https://www.cff.org/What-is-CF/About-Cystic-Fibrosis/ https://www.mayoclinic.org/diseases-conditions/cystic-fibrosis/symptoms-causes/syc-203 53700 General Pathophysiology Most common inherited genetic disorder affecting Caucasians in children Autosomal recessive trait: If the defective gene is inherited from both parents: 25 percent (1 in 4) the child will have CF 50 percent (1 in 2) the child will be a carrier but will not have CF 25 percent (1 in 4) the child will not be a carrier and will not have CF Exocrine gland dysfunction that causes the production of a thick mucoprotein causing mechanical obstruction of the mucus secreting glands and dilates ducts in multiple systems Chloride secretion is decreased Sodium absorption is increased Water flow across cells is decreased Diagnostic Evaluation  Family hx  In utero dx can be made by examining DNA for CF genes.  Universal newborn screening  Barium enema to dx meconium ileus in infants  Sweat chloride test is the most reliable diagnostic procedure  > 60 mEq/L is diagnostic  Stool fat or enzyme analysis  Xray = atelectasis & obstructive emphysema as disease progresses 30 Symptoms Treatment for Cystic Fibrosis  Therapeutic Management  Therapeutic management of cystic fibrosis is aimed toward minimizing pulmonary complications, maximizing lung function, preventing infection, and facilitating growth…treatment includes  Chest physiotherapy (CPT) with postural drainage  Mobilize secretions from the lungs.  Recombinant human DNase (Pulmozyme) via nebulizer  Decrease sputum viscosity and help clear secretions.  Inhaled bronchodilators and anti-inflammatory agents  Pancreatic enzymes and supplemental fat-soluble vitamins  promote adequate digestion and absorption of nutrients and optimize nutritional status.  Increased-calorie, high-protein diets  Lung transplantation has been successful in some children with cystic fibrosis. D R. M E G H A N M C C R I L L I S N U R 2 0 1 P E D I AT R I C S 32  Acute Infectious Respiratory Disorders  Bronchiolitis Respiratory Syncytial Virus (RSV)  Highly contagious acute inflammatory process of the bronchioles & small bronchi  Occurs primarily from September through May  Affects infants & toddlers with a peak age of 6 months.  Transmission  Exposure to contaminated secretions  RSV lives on fomites for several hours and on hands for 30 minutes 34  Signs & Diagnostics Symptoms  ELISA or DFA from  ↓ grade fever direct aspiration of nasal secretions or  Poor feeding nasopharyngeal  Viscous clear rhinorrhea washings  OM & conjunctivitis may be present  Wheezing, grunting, accessory muscle use, cough  Air hunger  Tachypnea >60 breaths/min & retractions  Cyanosis  Xray will reveal  Listlessness hyperinflation of the  Apnea lungs & atelectasis.  ↑ PaCO2, respiratory acidosis & hypoxemia 35 Therapeutic Management  Admit: pulm/cardiac disease, premies  Maintain patent airway  Pulmonary toilet: Suction nares & oral cavity, CPT, HOB ↑  Airway maintenance, intubate with severe cases Oxygen & Humidity: nasal cannula (NC), high flow NC  Continuous monitoring of pulse ox, cardiac monitor  A ↓ RR is an indication of tiring, ↑CO2 retention resulting in apnea  Fluid hydration maintenance - PO or IV  Meds  Antipyretics  Bronchodilator (albuterol) trial, in most cases it is not effective 36  RSV Bronchiolitis  Nursing considerations  Focused respiratory assessment, reassess frequently  Private room or cohort patients  Contact & Droplet precautions  Good hand washing!  Suction nares with bulb syringe & CPT before feeds and sleep – Why?  I & O – assess hydration and fluid balance  Daily weight with infants  Prevention of RSV  Handwashing!!!  Palivizumab (Synagis) monthly IM  For high risk groups only 37 Pharyngitis  Etiology  Viral (self-limited) or bacterial  A streptococci infection (strep throat) for 15-25% of cases  Complications of group A streptococci  Sinusitis, paraphrayngeal, peritonsillar or retropharyngeal abscess  Head ache, fever, abdominal pain, sore throat, difficulty swallowing  Inspect tonsils & pharynx for redness, exudate and white strawberry tongue coating  Anterior cervical lymphadenopathy with tender nodes  At risk for rheumatic fever & acute glomerulonephritis 38  Pharyngitis  Diagnostic evaluation  Rapid strep test  Throat culture for sensitivities  Management for group A strep  Penicillin (PCN) X 10 days  Erythromycin with PCN allergy  Incision & drainage (I & D) may be indicated for abscesses 39 Tonsillitis  Pathophysiology Swelling and infection of lymphoid tissue in pharyngeal cavity: filter & protects respiratory & alimentary tracts from organisms. Has a role in antibody formation  Palatine tonsils are removed during tonsillectomy  Pharyngeal (adenoids) tonsils removed during adenoidectomy  Tubal & adenoid tonsils are located near the eustachian tubes 40 Tonsillitis  Nursing  Etiology Considerations  Assess, assess &  Often occurs with viral or reassess bacterial  Soft liquid diet pharyngitis  Cool-mist vaporizer  Clinical Manifestations  Salt water gargles  Edema  Throat lozenges  Difficulty swallowing &  Analgesic/antipyretic breathing drugs  Kissing tonsils (touch at midline) can lead to a medical emergency d/t airway obstruction 41 Therapeutic Management  Treat viral symptomatically & bacterial with antibiotics  Indications for a tonsillectomy & adenoidectomy (T & A)  Malignancy  Recurrent peritonsillar abscess, adenoiditis, sinusitis & otitis media with effusion  Airway obstruction  Sleep apnea 42  Post-op T & A Care  IV fluids until tolerating PO intake  Cool/cold liquids, no straws  Ice collar, analgesics  Facilitate drainage of secretions, position side lying or prone  Careful suctioning  Discourage: coughing, clearing throat, blowing nose or using straws  Common to see blood tinged mucus or dark old blood in emesis or nose  Observe for Post-op hemorrhage up to 10 days  Assess back of throat   pulse, pallor, frequent swallowing, frequent throat clearing, restlessness, vomiting bright red blood,  BP (late sign of shock) 43 Croup, Laryngotracheobronchitis Inflammation and edema of the larynx &trachea, and bronchi Parainfluenza is the main pathogen Common age is 3 months – 3 years, self-limited (3-5 days) Clinical manifestations Usually sudden onset atnight, audible inspiratory stridor, hoarseness, barking cough, steeple sign on xray is diagnostic for epiglotitis. Management Usually manage at home Humidified air Dexamethasone: Corticosteroid Racemic epinephrine Complications are rare Worsening respiratory distress, hypoxia, bacterial tracheitis http://www.youtube.com/watch?v=Qbn1Zw5CTbA 44 Acute Epiglottitis  2-7 years of age and can be life threatening  Inflammation and edema of the epiglottis often caused by Heamophilus influenzae  Onset is abrupt, can cause severe respiratory distress (obstruction), sudden death can occur. A presumptive dx constitutes a medical emergency  Hallmark S & S: absence of spontaneous cough, drooling, agitation, irritability, dysphagia, significant respiratory distress, tripod positioning. 45 46 Acute Epiglottitis  Therapeutic management  Diagnostic: chest xray lateral neck film  Contraindicated to examine throat with a tongue blade  Patent IV / fluids  Provide 100% oxygen  Be prepared for respiratory emergency: intubation or tracheostomy  Antibiotic for 7-10 days, Corticosteroids  Nursing considerations  ↓ anxiety, position for optimal comfort  Assess respiratory status, pulse ox, blood gases, maintenance IVF  Prevention: Incidence has declined with Hib vaccine. 47 Disorders of the Eye and ear Acute Otitis Media (AOM)  Viral(most common cause) or bacterial infection of fluid in the middle ear.  Highest incidence in the winter  Fever and pain  Ear canal drainage with perforation  Risk factors  Eustachian tube dysfunction  URI is a frequent precursor to AOM 49 Bulging ear drum Swollen eustachian tube preventing drainage 50 Therapeutic Management  Viral usually resolves spontaneously  Antibiotics should be used judiciously because of drug- resistances  Generally there is a period of observation prior to making a decision to administer antibiotics  See table 17.3 clinical practice guidelines for recommendations  Anti-Infective (PO route): amoxicillin (Amoxil, Trimox), ciprofloxacin (Cipro)  Anti-Infective /Glucocorticoid (otic route): neomycin- polymyxin B-hydrocortisone (Cortisporin Otic, Coly-Mycin S Otic, ciprofloxin-hydrocortisone (Cipro HC Otic), ofloxacin (Floxin Otic)  Treat fever and pain Otitis Media With Effusion (OME)  Fluid in the middle ear without S & S of infection  Risk factors  Recent hx of AOM, passive smoking, bottle fed, frequent URI, allergy, young age, male, adenoid hypertrophy, Eustachian tube dysfunction  S&S  May be asymptomatic, popping sensation, fullness behind the eardrum, usually resolves spontaneously, exam every 4 weeks until resolved  DX confirmed with tympanometry  Complications  AOM  Hearing loss and deafness https://youtu.be/b80LyZRZOFY OME and Hearing Loss  Hearing evaluation needed with follow up  All children with persistent OME lasting 3 months or longer  When hearing loss, speech, language or learning difficulties are suspected  School nurses provide screening  Communication with a hearing impaired child  Turn off all background noise  Face the child at a distance of 3 feet or closer  Speak clearly and slightly louder  Evaluate if the child heard you Procedures  Myringotomy  Surgical incision of the eardrum to alleviates pain, provides drainage of OME  Insertion of pressure-equalizing tubes into the tympanic membrane to facilitate drainage of fluid in the middle ear & provided adequate hearing.  Minimally invasive procedure done as outpatient by an ENT specialist  Post op education & prevention  Administration of ear drops  Earplugs when in water  Contact MD if ear drainage noted  Tubes do not prevent infection only allows fluid to drain  Adenoidectomy  Recurrent AOM with obstruction, adenoiditis, or chronic sinusitis. 54  Patient Education  AOM  Antipyretic/analgesic/NSAID/ numbing eardrops  Acetaminophen, ibuprofen, benzocaine  Heat or cool compresses to ear  Take all prescribed meds  Breastfeed for 1st 6 to 12 months  No exposure to 2nd hand smoke  Immunize children  Teach prevention for OME  Hold infant upright during feeds  **Do not prop bottles  Eliminate smoking 55 Otitis Externa aka swimmer’s ear  Infection and swelling in the external ear canal  Causes  Pseudomonas, staphylcoccus, fungus  Moist ear canal promotes infection  S&S  Itching, pain (especially on the tragus), ear drainage, feeling of fullness, difficulty hearing  Treatment  Analgesics, eardrops for infection, ear wick  Prevention  Keep ear canals dry, wear ear plugs Conjunctivitis  Inflammation of the conjunctiva  Causes  Virus (adenovirus, influenza), bacteria (Staph, strep, H- flu), allergy (environmental, chemical).  Newborns: chlamydia, neisseria gonorrhoeae  Those at risk  Infants < 2 weeks of age, school attendance, viral URI, pharyngitis or otitis media, exposure to allergens.  S&S  Eye redness, edema, tearing, discharge, pain, itchiness Conjunctivitis: Treatment  Bacterial infectious is very contagious (eye culture): antibiotic drops or ointments, warm compress for comfort.  Antibacterial drugs: ciprofloxacin opthalmic (Ciloxan), ofloxan (Ocuflox)  Viral: symptom relief, compresses  Allergic: antihistamine drops, cool or warm compress  Prevent spread- extremely contagious  Bacterial: wash hands, back to school after 24 to 48 hours after start of antibiotic treatment Noninfectious Disorders Strabismus  Misalignment of the eyes  Exotropia: eyes turned outward  Esotropia: eyes turned inward  Vision may be impaired  May cause diplopia S &S  Noticeable misalignment, c/o blurred vision, adjusting head to focus on an object.  Treatment  Patching the eye, corrective lenses, eye muscle surgery Foreign Body Aspiration (FBA)  High risk among children especially age 6 months to 4 yrs S &S  Choking, gagging, wheezing, coughing  Dyspnea, stridor, hoarseness, asymmetric breath sounds  If cannot speak, cyanotic, collapses = child can die within 4 minutes  Diagnostic evaluation  Endoscopy for dx and to remove the FB, Xray , bronchoscopy & fluoroscopy  Therapeutic management  BLS: be aware of new resuscitation interventions  Prevention  No access to small objects, and high risk food items 61 Aspiration Pneumonia  Causes inflammation & chemical pneumonitis  High risk for child with feeding difficulties  Primary goal: prevention of aspiration  Proper feeding techniques  Upright position during feeds  Tachypnea > 60/minute. NGT/GT feeds may be indicated / check placement  Positioning: HOB ↑ during and after feeds  Avoid aspiration risks  Oily nose drops  Solvents  Talcum powder 62 Dr. Seuss Inspiration of the Day D R. M E G H A N M C C R I L L I S N U R 2 0 1 P E D I AT R I C S 63