Respiratory System Disorder Among Children PDF

Respiratory System Disorder Among Children by Dr. fatma Ahmed  Objectives: At the end of this lecture the student will able to: 1- Identify the anatomy and physiology of respiratory system in children. 2- Identify the common respi...

Respiratory System Disorder Among Children by Dr. fatma Ahmed  Objectives: At the end of this lecture the student will able to: 1- Identify the anatomy and physiology of respiratory system in children. 2- Identify the common respiratory problems in children 3- Describe the nursing care of common upper respiratory system disorders among children. 4- Describe the nursing care of common lower respiratory system disorders among children. Introduction: Infants and children have smaller airway structures than those of Adults; thus obstruction of the airway can occur rapidly. In addition, the cartilage of the young pediatric airway and reactive bronchial smooth muscle places the pediatric client at risk for obstruction Due to bronchial constriction. Respiratory System - The cells of the human body require a constant stream of oxygen to stay alive. The respiratory system provides oxygen to the body’s cells while removing carbon dioxide. There are 3 major parts of the respiratory system: ―the airway, the lungs, and the muscles of respiration”. - The airway, which includes the nose, mouth, pharynx, larynx, trachea, bronchi, and bronchioles, carries air between the lungs and the body. - The lungs act as the functional units of the respiratory system by passing oxygen into the body and carbon dioxide out of the body by alveoli. - The muscles of respiratory system, including the diaphragm and intercostal muscles, work together to act as a pump, pushing air into and out of the lungs during breathing. Respiration is the act of breathing: *Inhaling (inspiration)-taking in oxygen *Exhaling (expiration)-giving off carbon dioxid. The respiratory system The upper respiratory tract includes the: *Nose *Nasal cavity *sinuses Larynx Trachea The lower respiratory tract includes the: *Airways (bronchi and bronchioles) *Lungs *Air sacs (alveoli)  The functions of the lungs: The right lung has three sections, called lobes. The left lung has two lobes. When you breathe, the air: Enters the body through the nose or the mouth Travels down the throat through the larynx and trachea Goes into the lungs through tubes called bronchi ▪ One bronchi leads to the right lung and one to the left lung ▪ In the lungs, bronchi divide into smaller bronchi ▪ And then into even smaller tubes called bronchioles ▪ Bronchioles end in tiny air sacs called alveoli Diseases of respiratory system: Pneumonia and other respiratory infections are the main causes of morbidity and mortality among children worldwide. There are many in the management of respiratory infections. The use of antibiotics, cough suppressants, antihistamines, nasal decongestants, chest physiotherapy, inhaled and systemic steroids, bronchodilators, adrenaline and oxygen are the most important.  Acute Respiratory Infections in Children: Infections of the respiratory tract are described in a number of different ways according to the general areas of involvement in the more common infections. The upper respiratory tract or upper airway consists of primarily of the nose and pharynx. The lower respiratory tract consists of bronchi and bronchioles (which constitute the reactive protein of the airway because of their smooth muscle content and ability to constrict the alveoli and lung. Factors affecting type of illness and physical response in acute respiratory infections: * Size and frequency of dose: The larger the dose and the more frequent the exposure, the greater the likelihood of a significant infection. * Age of child: Children of preschool and school age are more often exposed to infectious agents generally after 3 months of age infants have less resistance to infections. * Size of child: Airways are smaller in young children and more subjected to considerable narrowing from edema. * Ability to resist invading organisms: School age children have greater resistance to infection than infants and young children. * Presence of great conditions: Malnutrition, anemia, fatigue, chilling of the body and immune deficiencies decrease normal resistance to infection. * Presence of disorders affecting respiratory tract: Allergies, cardiac abnormalities and fibrosis weaken respiratory defense mechanism. * Seasons: The most common respiratory tract pathogens appear in epidemics during winter and spring months. Acute upper respiratory infections: (U.R.Is) (infectious processes involving any or all of the structures in the upper respiratory tract. Most are caused by viruses and are self- limited. Acute nasopharyngitis and pharyngitis (including tonsillitis) are common in pediatric age groups. Nasopharyngitis: (called common cold): Nasopharyngitis, a viral infection of the nose and throat is the most common URL fever is common: child is managed at home, no specific treatment: antipyretics , rest and decongestants. Assessment Criteria: 1. Younger child: Fever. Irritability. Diarrhea. Sneezing. Vomiting. Restlessness 2. Older child: Dryness & irritation of nose& throat. Chilly, Cough. Sneezing. Muscular aches. Complication of Nasopharyngitis; Complications of nasopharyngitis in infant are more often otitis media. Lower respiratory tract infection the older child may develop sinusitis as a complication.  Pharyngitis: The throat (including the tonsils) is the principal anatomic site of pharyngitis (sore  throat). Although uncommon in children under of age. The disease is prevalent throughout childhood with the peak incidence occurring between 4 and 7 years of age. The etiologic agents are withering viruses or the group AB-hemolytic streptococcus.  Assessment criteria:  1. Younger child: * Fever. Headache. Moderate sore throat. * Anorexia. General malaise.  2. Older child: * Fever may reach 40°C. Headache * Anorexia. Dysphagea. Abdominal pain. Vomiting.  Complication of pharyngitis: Complications can include otitis media, acute cervical adenitis, retropharyngeal  abscess and lower respiratory tract infection streptococcal infection sometime triggers response in the heart (rheumatic fever) or kidney (acute glomerulonephritis). Permanent damage can result from these factors especially acute rheumatic fever.  Tonsillitis:  The tonsils are masses of lymphoid tissue located in the pharyngeal cavity in pairs. Often occurs with pharyngitis.  Therapeutic Management:  Treatment of a child with pharyngitis is symptomatic because the illness is short and self-limiting. If streptococcal sore throat is present obtains a throat swab for culture, an antibiotic is prescribed penicillin G IM may be used in a dosage sufficient to control the acute local manifestation and to maintain an adequate level for at least 10 days to eliminate any organism that might remain to initiate symptoms of rheumatic fever.  Surgical treatment of chronic tonsillitis (tonsillectomy) removal of the (tonsils) has been the most frequently performed pediatric surgical procedur for 5 or more infection of the tonsils per year despite therapy. Generally, tonsils should not be removed before 3 or 4 years of age, because of the problem of excessive blood loss in small children and the possibility of regrowth or hypertrophy of lymphoid tissue.  Nursing Management: Nursing care of the child with tonsillitis and /or pharyngitis mainly involve: * Provide comfort. * A soft liquid diet is generally preferred. * A cal mist vaporize helps to keep the mucous membranes moist during periods of mouth breathing. * Warm saline gargles and analgesic, antipyretic drugs are useful to promote comfort. If antibiotics are prescribed, parents need counseling regarding their correct administration and the necessity of completing the treatment period. Nursing care of tonsillectomy: 1- providing comfort and minimizing activities to precipitate bleeding. 2- maintain airway: place in prone or side- lying position to avoid aspiration until fully awake. 3- monitor bleeding specific new bleeding. 4- Non aspirin analgesics. 5- Avoiding oral fluids until fully awake—then liquids and soft cool foods. Otitis Media: Stander Terminology for Otitis Media: *Otitis media: An inflammation of the middle ear without reference to etiology or pathogenesis. *Acute otitis media (AOM): A rapid and short onset of signs and symptoms lasting approximately 3 weeks. *otitis media with effusion (OME): An inflammation of the middle ear in which a collection of fluid is present in the middle ear space. *Chronic otitis media with effusion middle ear effusion that persists beyond 3 month Etiology; It is caused by streptococcus pneumonia, Haemophilus influenza and staphylococcus. The etiology of non-infectious type is unknown. Factors predisposing to development of otitis media in children: * The Eustachian tubes are short, wide and straight and lie in a relatively horizontal plane and it's different from adult. The cartilage lining is underdeveloped, making the tubes more distensible and therefore more likely to open inappropriately. * The normally abundant pharyngeal lymphoid tissue readily obstructs the Eustachian tube openings in the nasopharynx. * Immature humoral defense mechanisms increase the risk of infection. * The usual lying-down position of infants feeding of fluid, such as breast feeding, formula, in the pharyngeal cavity. Assessment of acute otitis media; It includes clinical manifestations and diagnostic evaluation. Otalgia (ear ache). Fever. Pus discharge may or mayn't be present. In infants and young children: Fussy. *Crying Restlessness. *Tendency to rub, hold or pull affected ear. Irritable. Rolls head side to side. Loss of appetite. Difficulty comforting child. Assessment of chronic otitis media: *Hearing loss. Tinnitus. *Difficulty communication Feeling of fullness. Therapeutic Management; Treatment of acute otitis media is administration of antibiotics dropes Ampicillin or Amoxicillin. Nursing care plan for child with acute otitis media: Nursing Diagnosis: * Pain related to pressure caused by inflammatory process. * Altered family process related to ill child. * High risk for impaired skin integrity related to drainage. * Health maintenance altered related to lack of knowledge about health care. * Anxiety related to alteration in psychology of child and family. * Sleep pattern disturbance, insomnia, related to pain. Planning: Nursing objectives for the care of children with acute otitis media include: Relieve pain. Prevent drainage when possible. Prevent complications or recurrence. Educate family in care of child. Provide emotional support to child and family. Implementation: Application of heating pad may reduce the discomfort. Local heat should be placed be placed over the ear with the child lying on affected side. Analgesics and antipyretics are helpful in reducing the severe earache and fever. An ice bag placed over the affected ear may also be beneficial since it reduces edema and pressure (could be applied between the attack of pain). If the ear is draining, the external canal may be cleaned with sterile cotton swabs. Excoriation should be prevented by frequent cleansing and application of Zinc oxide to the area of exudate. Parents should be aware of the potential complications of acute otitis media that can be occurred with inadequate treatment such as: * Conductive hearing loss. * A perforated and starred eardrum * Intracranial infections, e.g. meningitis. Expected outcome; * Child sleeps and rests quietly and exhibits no signs of discomfort. * Child exhibits no evidence of damage skin. * Child remains free of complications. * Family demonstrates the ability to care for child's condition. * Family and child express their feelings and concerns. Infections of the lower airway: Although acute infections of the lower respiratory tract may be diagnosed in children of all ages. These tend to occur most frequently in young children who have not yet developed resistance to infectious diseases. The infection that occurs during the toddler period includes bronchitis and pneumonia.  Acute Bronchitis Definition Acute bronchitis is caused by inflammation more bronchi and occurs especially in children younger than 4 years.  usually caused by viruses. It may occur together with or following a common cold or on Respiratory infection. such as viruses can be spread from person to person by Coughing or bacterial. Predisposing factors **– Malnutrition – Allergy –– Smoke. ** Recurrent URTI.  Signs and symptoms  Shotness of breath.  Nausea and vomiting.  Low grad fever.  Feeling of tightness in the chest.  Wheezing.  Lab investigation **X ray ** Complete blood count.  Analgesics  Antipyretics  Humidity  Cough suppressants  Antibiotic are not used to treat viral illness or reduce the incidence of Complications.  Nursig management f patient with depends on the severit us by monitoring the severity of symp  Bed rest  Provide well balanced diet.   Encourage adequate fluid intake, provide small frequent amount to Prevent nausea & vomiting.   Ensure warm atmosphere, encourage the child to inhale steam to Nebulizer inhalation.   "Change position (postural drainage) to facilitate the drainage of Mucous.   Administer oxygen according to doctor order (flow rate).   Reassure the child & His parents or Emotional support especially during oxygen Administration & postural drainage.  Care of fever  Care of cough  Care dyspnea  Bronchial asthma  is a chronic inflammatory disorder of the airways in which many cells play a role.  Etiology: family history –Allergy –– Smoke– pollutants, change in weather (cold, heat), strong odors and perfumes. ** Recurrent URTI ◼ Chronic exposure to airway irritants(Dust- animals) ◼ Exercise, emotional stress. ◼ Specific type of Food ◼ Some medication: aspirin, nonsteroidal anti-inflammatory drugus.  Pathophysiology:  There is general agreement that heightened airway reactivity is characteristic of children with asthma. The mechanisms responsible for the obstructive symptoms of asthma are: * Inflammation and edema of the mucous membranes. * Accumulation of tenacious secretions from mucous glands. * Spasm of the smooth muscle of the bronchi and bronchioles, which decreases the capacity of bronchioles.  Clinical manifestation  An asthmatic episodes  Dyspnea, Cough (with or without mucus production), wheezing and chest tightness.  Attacks frequently occur at night or early morning.  Prolonged expiration and requires effort and Shortness of breath  Children with asthma may experience symptom- free periods alternating with acute phase that last from minutes to hours or days.  The lips that may progress to cyanosis observed in the fingernails and skin especially around the mouth.  Therapeutic management:  Allergen control. Drug therapy, e.g. B-adrenergic especially epinephrine aminophylline and  corticosteroids preparation.  Chest physiotherapy (C.P.T.)  Nursing care of patients with asthma depends on the severity of the symptoms  -- Assess the patient respiratory status by monitoring the severity of symptoms, breath sounds, and vital signs  Nursing care plan of a child with bronchial asthma: Nursing Diagnosis: Ineffective breathing pattern related to allergic response in bronchial tree. Goal: Patient with exhibit evidence of improved ventilatory capacity .Intervention; *Instruct and /or supervise breathing exercise, controlled breathing. *Teach correct use of prescribed medication. *Assist child and family in selecting activities appropriate to child's capacity and preferences. *Encourage regular exercise. *Encourage good posture. *Encourage physical exercise. *Discourage physical inactivity. Expected outcome: *Child breathes easily and without dyspnea. Child engages in activities according to abilities and interest. Nursing diagnosis: Altered family process related to having a child with a chronic illness. Goal: Patient will exhibit positive adaptation the disorder. Intervention; *Foster positive family relationships. *Be alert to signs of parental rejection or overprotection. *Intervene appropriately of these is evidence of maladaptation. *Use every opportunity to increase parent's and child's understanding of the disease and its therapies. *Be alert to signs that child is depressed. *Refer family to appropriate support groups and community agencies. Expected outcome; *Family copes with symptoms and effects of the disease and provides a normal environment for the child. Nursing diagnosis: High risk for suffocation related to interaction between individual and allergen. Goal: (1) Patient will experience no asthmatic attack. Intervention: Teach child and family correct use of bronchodilater, corticosteroids. Assist parent Meal planning to eliminate allergic food. Teach child and parent Modification of environment home especially no smoking in home. Avoid extremes of environmental temperature. Assist parents in obtaining and/ or installing device to control environment. (Humidifier air conditioner- electronic air filter). Teach child and family to recognize early signs and symptoms so that an impending attack can be controlled before it becomes distressful. Teach child correct use of inhalers. Expected outcome: Family makes every effort to remove possible allergens or precipitating events. Family and /or child are to detect signs of an impending attack and implement appropriate actions. * Recommendation: the following recommendations are suggested:- For mothers: * Mothers should be instructed about best position of the infant during feeding. * Mothers should be educated about preventive measures of upper respiratory tract infection. * Mothers should be educated about healthy behavior and life style modification to reduce risk for acquiring acute otitis media. * Mothers should receive adequate information about acute otitis media, management and complication. * Mothers should be educated about preventive measures of lower respiratory tract infection. * Mothers should be educated about healthy behavior and life style modification to reduce risk for acquiring bronchial asthma.  Pneumonia:  It is inflammation of the lung is common in childhood but occurs more frequently in infancy and early childhood.  Alveoli fill with air when healthy person breathes. But an pneumonia , the alveoli are filled with pus and fluid lead to limits oxygen intake and breathing painful.  Cause by including bacteria, viruses and fungi. but most common are caused by viruse.  * Degree of Pneumonia:- 1) Pneumonia: Children with bacterial pneumonia appear ill and exhibit both general and localized physical findings: Fever. Malaise. Cough. Chills. Rapid and shallow respiration (fast breathing) 1) Severe Pneumonia: Child in severe pneumonia has the previous signs plus chest indrawing (chest wall goes, in when the child breaths in, it occurs when the child breaths in, it occurs when the effort required to breath in is much greater than normal C- Very severe pneumonia: In very severe pneumonia, the child has all previous manifestations plus the following danger signs: * Grunting. * Not able to drink. *Abnormal sleep or difficulties * Steroids in a calm child. *Severe malnutrition. Hospitalization is indicated when pleural effusion or emphysema accompanies the disease. Nursing Assessment: 1. Fever may then increase to 39-40°C and chills. 2. cough with (grunting or wheezing sound), unproductive to productive with whitish sputum, tachypnea. 3. With continuing obstruction, hyperventilation become more severe leading to hypoxemia (increasing depth of respiration). 4. With rapid or difficult breathing, dyspnea. The use of the accessory muscles of respiration and suprasternal and intercostal retractions. 5. Some progress to hypoxia with cyanosis. 6. Restlessness and anxiety. 7. Chest pain 8. Gastrointestinal: Loss of appetite, nausea, vomiting and diarrhea and abdominal pain 9. Decreased activity. Therapeutic management; 1.Children with moderately severe symptoms may be hospitalized for observation and therapy with cool mist and racemic epinephrine as for L.T.B. 2. Patient may respond to corticosteroid therapy. 3. Antibiotics. 4. Chest physiotherapy.  Rest: physical rest and psychological rest through reassurance of the child and his parents.  Encourage fluids to decrease fever, and prevent dehydration which may result from diarrhea and vomiting  Change position frequently as the child usually like to sleep on the affected side.  I.V fluids if vomiting persisted in severe cases  Oxygen therapy if needed.  Preventive measures: Isolate the child. Nursing Management: Nursing care of the child with pneumonia is primarily supportive and symptomatic to meet the needs of each child. * Isolation. * Rest and conservation of energy are encouraged by relief of physical and psychological stress. * If the cough is disturbing, anti-tussive should be used before rest time and meals. * Increase of fluid intake to prevent dehydration, fluids are frequently administered intravenously during the acute phase. Oral fluids if allowed are given continuously to avoid aspiration. * Children may be placed in a mist tent will oxygen. * Cool mist moistens the airways and provides a cool atmosphere that aids in temperature reduction. * Children often require frequent clothing. * Fever is usually controlled by administration of antipyretic drugs as prescribed and temperature is monitored regularly. * Children with ineffectual cough or those with difficulty handling secretion especially infants will require suctioning to maintain patient airway. * Postural drainage and chest physiotherapy are generally prescribed every 4 hours or more often depending on the child's condition. * Reducing anxiety and apprehension, which result from hospitalization and treatment, will reduce psychological distress in the child. When the child is more relax, the respiratory efforts are lessened. * The family also needs support. * Lying on the affected side (if pneumonia was unilateral) splints the chest on that side and reduces the pleural rubbing that often causes discomfort. * They are usually more comfortable in a semi-erect position but should be allowed to determine the position of comfort. * Nursing Diagnosis: Ineffective airway clearance related to mechanical distinction, increase secretion. Goal: (1) Patient will maintain patent airway. Intervention: * Aspirate (suction) secretion from airway as needed. * Position to aspiration of secretions (semi prone position- side lying position). * Assist child in expectorating sputum. * Provide nebulizer with appropriate solution and equipment as prescribed. * Give nothing by mouth to prevent aspiration of fluid (severe tachypnea). Expected Outcome: * Airway remains clear. * Child breathes easily, respiration within normal limits. Other respiratory tract infection Tuberculosis: Tuberculosis is bacillus mycobacterium tuberculosis. Although its incidence has decreased in more advanced countries, it is still prevalent in underdeveloped countries. Pathophysiology; The bacillus usually enters the body through the respiratory tract. Today it is spread by droplet infection or by direct contact with infected humans. Primary infection; It occurs when the tuberculosis bacillus enters the body usually in the tissue of the lungs. The disease process may extend to other parts of the lung and to the gastrointestinal tract. Secondary infections: It usually occurs during adolescence or early in adult life from the original focus or re- infection. Secondary infection differs from the primary type because of the allergic response of the body. Secondary infection may include extensive inflammatory reaction with tissue destruction and cavitation healing in secondary infection is largely by means of scar tissue or fibrosis. Nursing Assessment; Many times affected children and adolescents are asymptomatic or have aboard range of symptoms: *Fever at night and sweating. Malaise. *Anorexia. Weight loss. *Aching pain. Lightness in chest *Cough may or may not be present (progress slowly over weeks- months). *Hemoptesis (rare). With progression; Respiratory rate increases. Poor expansion of lung on the affected side. Diminished breath sounds. Fever persists. Generalized symptoms are manifested: Develops pallor, anemia, weakness and weight loss. Diagnostic evaluation: Skin tests are the most important tests for tuberculosis. The two antigens are used for testing: Old tuberculin "O.T."the test should be read in 48 to 72 hrs. Other diagnosis tests include chest X-ray and bacterial culture in older children. Sputum is examined if infant and young children don't cough but swallow their sputum gastric aspiration is performed (before breakfast a lavage tube is passed. The test should be repeated three times before the result is considered negative. Therapeutic Management: 1. the nurse is responsible for making sure that the entire family is screened. 2. If a child has a positive test but no sign of tuberculosis, the family should be aware of the need for the child to take I.N.H. daily. This child does not have to protect from others and is not contagious to friends or other family members. 3. Most of the children with active disease can be cared for at home. These children are encouraged to lead as normal life as possible. 4. With appropriate antituberculosis therapy(rifampicin) there is complete bed rest and use a special diet unless the current diet is nutritionally inadequate. 5. Children may attend school and don't need any activity limitation. 6. The usual childhood immunization may be given if the medication therapy has been started. Prevention: Three methods are somewhat effective in preventing tuberculosis: 1. Isolation of adults with infectious tuberculosis. 2. Immunization with bacilli calmette-gueria vaccine "B.C.G.". 3. Prophylactic treatment with I.N.H. of infant and children who must live a household with an infectious adult. N.B: the vaccine is thought to be effective for 7-12 years although follow up studies are inadequate. A major drawback is that the vaccinated converts to a positive tuberculin test, which eliminates the use of the tuberculin test as a screening tool. Good by