4.2_Peds_Oxygenation _Part 1
Problems of Oxygenation: Ventilation Part I
Objectives
At the end of this unit the student will:
• Relate
... [Show More] pathophysiology to the assessment findings in a patient with altered oxygenation
• Describe signs and symptoms of respiratory dysfunction in the pediatric patient
• Identify appropriate/effective nursing interventions to promote oxygenation and respiratory support
• Identify age and developmental considerations when caring for the pediatric patient and their family with respiratory dysfunction
• Recognize the long-term effects of chronic pulmonary dysfunction on the caregivers and child
• Implement strategies to prevent respiratory illness in the pediatric patients as well as the decline in respiratory function
o Vaccine, hygiene, prematurity
Classification of Respiratory Dysfunctions
• Congenital or Acquired
• Infectious vs. noninfectious
• Acute vs. chronic
• Upper Resp Tract vs. Lower Resp Tract
• Chronic-static or progressive
Incidence of Respiratory Illness in Children
• Respiratory infections account for the majority of acute illnesses in children
• Asthma is the most common chronic illness in children
Global Health
• Acute Respiratory illnesses -4.5 million children die every year (most in developing countries)
• 30% of all pediatric deaths are due to ARI
• Pneumonia with measles causes 70% of these deaths.
UPPER AND LOWER RESPIRATORY TRACT
• Upper
o Oronasopharynx, pharynx, larynx, and upper trachea
o Nasopharyngitis “common cold,” streptococcal pharyngitis, tonsillitis, influenza
o Croup, Epiglottis, Pertussis, Apnea of Prematurity Obstructive sleep apnea, Pneumonia
• Lower
o Bronchi, bronchioles, alveoli
o Pneumonia
• Resp tract infections account for majority of acute illnesses in kids
o management and prevention – hand washing, stay home if sick, antipyretics, decongestants, fluid intake, rest
o Lower resp tract consists of smooth muscle and have the ability to constrict so this is the reactive portion of the resp tract
Etiology of Respiratory Tract Infection
• Multifactorial
o Genetics
o Biology
o Environmental
Risk Factors – Biology and Genetics
• Age and Prematurity
o Age – healthy infants < 3 mo lower infection rate d/t protective maternal antibodies
o infection rate increased from 3-6 mo d/t disappearance of maternal antibodies, infant’s own antibody production
• Size/Anatomy
o Size – anatomic difference, smaller diameter, narrows easily from edematous mucous membranes and increased secretions. Distance between structures is shorter so organisms move rapidly down the resp tract with more extensive involvement. Short and open eustachian tube allows pathogens easy access to the middle ear
• Resistance/Immune system
o Resistance – deficient immune system + risk of infection, other factors that decrease resistance are malnutrition, anemia, fatigue, chilling of the body. Conditions that weaken defenses of resp tract and predispose a child to infection are allergies, BPD (chronic lung disease), asthma, CF, cardiac anomalies can lead to pulmonary congestion.
Risk Factors- Environmental
• Infectious agents
o Infectious agents – d/t virus RSV, adenovirus, human metapneumovirus, Para influenza. Other agents Hemophilus influenza, mycoplasma organisms and pneumococci. Viral agents may cause minimal symptoms in an older child but sever lower resp tract illness or croup in infants
• Seasonal
o Seasonal – winter and spring months, mycoplasma infections are more in early winter. Winter and spring think RSV. Children are indoors close contact leads to spread of organisms.
• Environment- day cares and environmental tobacco smoke
o Pets/animals
o Dust mites
o Cockroaches – -cockroaches produces secretions and allergens that become airborne and lock onto heaver particles like dust, when inhaled the can trigger asthma and allergies, research shows it can lead to asthma in preschool age
• Neighborhoods think Weather, allergens, industry, ETS
• School think close environment with other kids easy way to spread germs
• Lifestyle – activity and obesity
Environmental Tobacco Smoke
• 4000 different chemicals
• Carcinogenic
• Increase respiratory illness and symptoms
• Decrease PFTs
• Increased asthma exacerbations
• Maternal smoking – growth retardation, low birth weight, preterm
• BPD in adulthood
• s/s include cough, sputum, wheezing, asthma from indoor smoking
ETS
• Increase SIDs incidence
• Asthma
o Increased trips to ER, med use, impaired recovery
• Early asthma diagnosis
• Tobacco smoke causes hyperplasia of mucus glands, inflammation, and increased permeability of lungs to allergens
• Maternal smoking – increase resp symptoms, decreased fetal growth, increased low birth weight, preterm, and still born
• E-cigarettes- can lead to toxic effects from nicotine
• Thirdhand smoke – lingers in environment on clothes, cars, elevators, homes
Ways to Decrease Risk
• Parent education
• Promotion of clean air
• Non-smoking
• Prenatal care
• Well-childcare
• Nursing assessment of ETS – assess for passive smoke exposure in all children, if smoker refuses to quit need house rules to decrease smoking near child inform caregivers of health hazards tobacco smoking cessation counseling and classes.
Vaccinations – Review CDC guidelines
-Chicken pox/Measles- can both lead to pneumonia
Vaccinations- know diseases and how to educate parents
• Dtap –
o tetanus- 50% survival rate
o Pertussis, whooping cough- given at 2,4,6,12-15, booster at 4, 11
• HiB: bacteria, decreased incidence of pneumonia, meningitis, epiglottis – 2,4,6 and 12-15
• MMR/ Varicella- lead to pneumonia – live vaccines, given at 12m, 4-6y
• Pneumococcal – pneumonia, given at 2,4,6 12-18
• Influenza Vaccine – yearly after 6m
• Chicken Pox
A nurse is taking a health history on a new patient name Emma. Emma is 5 years old and lives at home with her family. Which finding has the greatest implication to Emma’s health?
A. Emma lives in an old high-rise apartment building in the city.
B. Emma attends after school care in a crowded day care school.
C. Emma’s brother recently had an upper respiratory infection.
D. Emma’s father works full time as a vet tech in an animal shelter.
NURSING CARE – ASSESSMENT
Objective Subjective
Inspection What does the patient report
Auscultation Family history
Palpation History of Present illness
Percussion Past medical history
Diagnostic tests Chronic illnesses
RR – how long?? Standard is one full minute either listen or watch
Auscultation – diminished breath sounds or adventitious sounds (insp/exp wheeze, crackles, rhonchi, wheezing)
Auscultate anterior and posterior breath sounds Decreased breath sounds- very concerning
Assessment
• Respiratory effort
o RR, depth, rhythm
• WOB – accessory muscle use, retractions, nasal flaring, head bobbing
• Oxygenation
o color, pulse ox
• Patient- activity level, comfort level (lethargy- very concerning)
• Body temp
• Resp effort – look at chest, pattern of movement Cough – d/t irritation – productive/non, loose,
• Color change – mottling, pallor, cyanosis
• Nasal flaring – widening of nares on inhalation
Work of Breathing (WOB)
• Tachypnea
• Retractions- look where they are
• Nasal flaring
• Grunting
• Accessory muscle use
• Head bobbing
• Tripod position
Infants are obligate nose breathers, so what happens when they have nasal congestion or edematous airways
T/F- can an infant go into sever respiratory distress due to a clogged nasal passage – true If an infant is tachypneic, should we PO feed them? – No risk for aspiration
Grunting – attempt to increase end expiratory pressure and prolong exchange of oxygen and CO2
Lungs Sounds
• Stridor –high pitched narrowing of upper airway - d/t edema, inflammation, upper airway obstruction, secretions/mucus/foreign body
• https://www.youtube.com/watch?v=gYhGIFQcCnU
• Wheeze – expiration, continuous, narrowed airways- vibrations in narrowed airways,
• https://www.youtube.com/watch?v=tWqX3kTEtbY
• Crackles – fluid in the alveoli- attempt at more efficient respirations, increase end- resp pressure and prolong oxygen/carbon dioxide exchange across the alveolocapillary membrane
• https://www.youtube.com/watch?v=VGDdqtIhUdA
Other Assessments
• Neurological
• Perfusion – Cardiovascular
• Absorption – GI & GU
• Neurovascular & Musculoskeletal
• Skin
• Pain, fever, hydration, abdominal distension can all affect respiratory
• Psychosocial – Growth & Development & Violence & Trauma
S/S of Respiratory Tract Infection
• Fever may be absent in <28 day old
• Anorexia
• Vomiting
• Diarrhea
• Abdominal pain
• Nasal blockage
• Nasal discharge
• Cough
• Respiratory sounds
• Sore throat
Nursing Diagnoses
• Potential for impaired airway clearance.
• Potential for impaired gas exchange.
• Potential for Infection
• Impaired Fluid/Electrolyte Status
• Risk for caregiver stress related to chronic diseases
Nursing Interventions
• Warm or cool mist moistures soothes inflamed membranes
• Rest periods and reduce noxious environmental stimuli
• Comfort – reduce pain and discomfort
• Suction – bulb or wall suction
• Interventions
o CPT, cough, deep breath, OOB, positioning
o Consider developmental level
• Positioning – elevate the HOB, change position to open the airways- blanket roll, roll q 2 CPT – do 30 minutes before meals
• Incentive spirometer, bubbles, pin wheel, make a game – blowing a feather or
o Laughing can help to move air and secretions
• Family Support and Education
Nursing Interventions
• Hand washing
• Precautions
• IVF, PO intake, monitor I&O (Oral rehydration solutions)
• Assess parent’s ability to cope
• Communication
• Education and referrals
EPIGLOTTITIS
• Medical emergency because – airway closes d/t inflammation
• Occurrence
o 2-5 years old
• Pathophysiology
o Obstructive inflammatory process of epiglottis and surrounding structures
o Epiglottis patho – cartilaginous tissue that covers the entrance to the larynx, closes during swallowing to prevent aspiration and opens during breathing to allow air to flow into the larynx
• Causes
o HiB organism = prevention vaccine at 2,4,6 months and 12-15 months
o smoke, foreign body, hot food/liquid, cocaine exposure
• Diagnosis
o made by neck radiograph along with clinical presentations
Clinical Signs and Symptoms
• Abrupt
• Preceded by sore throat
• Pain swallowing
• Fever
• Irritable, apprehension
• Slow quiet breathing, froglike croaking sound on inspiration, retractions possible
• Red inflamed edematous epiglottis
• Tripod position, Drooling- profusely, protruding tongue – observation prediction
• Severe respiratory distress
• Leads to – hypoxia, hypercapnia (retaining C02 and acidosis, increased obstructions and sudden death
Nursing Interventions
• Continuous assessment – 1:1 nurse in isolation room
• Humidified oxygen- mostly doesn’t work with acute obstruction
• Emergency tracheostomy/intubation equipment
• Avoid inspection or suction
• Initiate antibiotic therapy and corticosteroids
o Abx IV usually swelling decreased after 24 hours of abx, corticosteroids to reduce edema, PO abx 7-10 days after
• Do not look or inspect patients mouth/throat unless intubation and emergency tracheotomy can be performed
• Keep with parent/caregiver to keep calm
• Support family and child do not increase anxiety
TX- Epiglottitis
• Antibiotics
• IV Steroids
• Oxygen
• Frequent Observations
Epiglottitis
• Droplet precautions
o Gown
o Mask
o Gloves
ACUTE LARYNGOTRACHEOBRONCHITIS
“Croup”
• Occurrence
o < 5 years old (6mo – 3 years)
o Boys > girls
o Autumn – Winter
o Seems to run in families
• Pathophysiology
o Inflammation of mucosa lining the larynx and trachea, leads to narrowed airway
o can’t inhale air past the narrowed obstruction into the lungs which causes the insp. Stridor and retractions
o If ventilation is impaired enough CO2 isn’t removed as easily and this can lead to respiratory acidosis
• Self-limiting –sound worse than they look, mostly may need to be hospitalized
Risk factors
• Preceded by URI Causes
• RSV, parainfluenza virus, measles, mycoplasma pneumoniae
Clinical Signs and Symptoms
• Low grade fever
• Barky, brassy cough- seal like
• Inspiratory stridor
• Suprasternal retractions
• Cough hoarseness
• Dyspnea
• Decreased breath sounds – upper airway, not moving air into lower resp tract
• Rhinorrhea
• Symptoms worse at night
• Tachypnea,
• When obstruction is severe – hypoxia, decrease 02 sats, prevents adequate ventilation and C02 removal – resp acidosis and resp failure
Treatment
• At home
• Cool mist or cool air
• Nebulized epinephrine
• Corticosteroids
o Dexamethasone
o -cool will decrease the edematous blood vessels, keeps child calm
o -epi – beta adrenergic cause mucosal vasoconstrictions, decreased edema rapid onset
o Steroids – decrease the inflammation and edema, Goal- maintain airway and provide adequate oxygenation
Shelby is a 3-year-old diagnosed with laryngotracheobronchitis (croup) and mild respiratory distress. Shelby is admitted to the pediatric unit to be monitored overnight. As the oncoming nurse, which of the following is not appropriate to include in Shelby’s plan of care?
A. Encourage the use of cool mist to promote comfort.
B. Encourage and promote increased oral fluid intake.
C. Administration of IV antibiotics per physician order. – viral
D. Administration of IV Decadron per physician order.
Nursing Interventions
• Frequent respiratory assessments
• Comfort child- why?
• Provide fluids and hydrate
• Rest
• Have emergency equipment nearby
o s/s of impending airway obstruction: increased pulse, increase RR, substernal/suprasternal/intercostal retractions, nasal flaring, increased restlessness
• cardiac, resp, pulse ox, and visual observation
• Keeping the child calm is important because increased crying/distress can lead to increased resp distress and hypoxia
• Blow by mist can help for comfort – oxygen near face
A child is brought to the ED with suspected epiglottitis. The nurse would avoid doing which of the following for the child with epiglottitis, which distinguishes the care needed by this child from the care needed by a child in the adjacent treatment area who has laryngeotracheobronchitis? (croup)
1) Allowing the child to remain in the position of choice
2) Placing intubation equipment at the bedside
3) Encouraging parents to comfort the child
4) Examining the throat
PERTUSSIS
• Occurrence
o < 4 years old
• Cause
o Bordetella pertussis
• Incidence
o Spring and Summer
o Resurgence lead to booster 10-18 yr. old
• Highly contagious but Preventable!
Pathophysiology
o Bacteria proliferate in respiratory tract
• Presentation
o URI cough symptoms can last 6-10 weeks Risk factors
• Not immunized – which immunization? Dtap at 2,4,6 months, 15-18 mon, 4-6 yr, (tdap11-12)
Transmission - Droplet or direct contact Incubation period- 6-20 days
Diagnosis- confirmed by culture using nasopharyngeal secretions
Pertussis Signs and Symptoms
Early Symptoms Later
URI Cough, followed by inspiration “whoop” sound
Sneezing Violent coughing spells
Lacrimation Vomiting
Rhinorrhea Aspiration
Low grade fever Apneic spells
1-2 weeks 4-6 weeks
Watery eyes, runny nose
During coughing spell – eyes bulge, cheeks flush, cyanotic, tongue protrudes, may have thick mucus plug expelled,
Complications
• Encephalopathy
• Seizures
• Pneumonia- death in infants < 6 months
• Rib fractures – adolescents
• Hemorrhage
• Weight loss
• Hernia
• Hemorrhage- scleral, conjunctival, epistaxis, pulmonary in infants
Management
• Maintain precautions
• Fluid intake
• Monitor Respiratory status
o Observe for airway obstruction
• Provide oxygen
• Comfort – positioning, humidified oxygen, suction,
• Position on side to prevent aspiration
Treatment
• Treat at home with PO antibiotics
o Erythromycin (Erythrocin) antibiotic macrolide
o Azithromycin (Zitrhomax, Zpak) antibiotic
o Clarithromycin (Biaxin) antibiotic macrolide
• What education does the nurse need to provide regarding antibiotic therapy?
o Take full course, etc.
Recommendations
• Families in contact with infant < 6mo should be vaccinated
• Pregnant women should be vaccinated will pass on some of the antibodies to their newborn
• Adolescents need boosters
• Health care workers
PNEUMONIA
• Pathophysiology
o Inflammation of pulmonary parenchyma
o Parenchyma- alveoli, alveolar ducts, bronchioles – the functional part of the lung tissue
• Incidence
o Common in childhood, more in infancy/early childhood
o Can be a primary dx or complication
• Causes
o Occurs when causative agent is inhaled or introduced into the bloodstream
o Histomycosis, coccidioidomycosis, other fungi
o Group B streptocci, Respiratory Syncytial Virus (RSV), parainfluenza virus, influenza virus, Mycoplasma pneumoniae, adenovirus
Classification
• Morphology
o Lobar-all or large part of lobe is involved.
o Broncho-starts in terminal bronchioles, clogged with mucopurulent exudate, form consolidated patches in nearby lobes
o Interstitial – inflammation within the alveolar walls and tissues of the bronchi and lobes
• Etiology
o Viral, bacterial, mycoplasma, aspiration
o Agents- virus, RSV, group B streptococci, CMV, influenza, adenovirus, M. Pneumoniae
General s/s of Pneumonia
• Fever
• Cough nonproductive or productive
• Tachypnea
• Rhonchi- low pitched rattling, resembles snoring. d/t obstruction or secretions in larger airways
• fine crackles - popping noise on inspiration or expiration, crackling, from small airways and alveoli popping open from being filled with fluid or pus
• Dullness with percussion
• Chest pain
• Retractions
• Nasal flaring
• Pallor to cyanosis
General signs of Pneumonia
• Chest X-ray
o Diffuse or patchy infiltration with parabronchial distribution
• Patient
o Irritable, restless, lethargic
o Anorexia, vomiting, diarrhea, abdominal pain
Viral
• More frequently occurring
• Clinical signs and symptoms:
o Mild fever
o Cough
o Wheezes/fine crackles
o Diffuse/patchy infiltration
• Viruses that cause pneumonia
o RSV in infants and parainfluenza, influenza and adenovirus in older children
• Treatment
o Supportive treatment:
▪ CPT, antipyretics, hydration, oxygen, comfort measures
Bacterial
• Follows a viral infection
• Abrupt onset
• Infants at most risk-high morbidity in newborns
• Serious infections
• Aspiration or spread in bloodstream
• Pneumonia in the newborn has a high morbidity and mortality rate, so all neonates with respiratory symptoms should be suspected of bacterial pneumonia
• Cause
o Streptococcus Pneumoniae
o Group A streptococci, Staphylococcus Aureus, Mycoplasma Pneumoniae
Clinical signs and symptoms Bacterial-
• Fever
• Malaise
• Rapid/shallow respirations
• Cough
• Chest pain
• Headache
• Chills
• Abdominal pain
• Hacking non-productive cough, diminished breath sounds, crackles
Diagnosis
• radiography shows lobar consolidation may show pleural effusion
• Gram stain, sputum culture, blood culture, nasopharyngeal specimen
• Increased WBC
Treatment
• Treat with antimicrobials
• Outpatient:
o PO amoxicillin (Amoxil) antibiotic, penicillin
o PO erythromycin (Arythrocin ) antibiotic, macrolide
• Inpatient:
o IV cefuroxime (Ceftin) antibiotic, cephalosporin
o IV cefotaxime (Claforan) antibiotic, cephalosporin
o IV ceftriaxone (Rocephin) antibiotic cephalosporin
• Erythromycin is the drug of choice for adolescents since it protects against M. pneumoniae
• Why IV vs PO inpatient – fast and rapid onset
Treatment and Management
● If pleural effusion or empyema are present
● Chest tube
● Thoracentesis
● Video Assisted Thoracoscopic Surgery (VATs)
● Effusion – fluid collection around the lung
● Empyema – pus collection in a body cavity usually pleural
● Thoracentesis –will help remove air/fluid from the pleural space need inserted into pleural space to remove fluid
● Vats- video assisted thorascopic surgery – uses a video thorascope to go in and diagnose problems occurring in the chest
Nursing Interventions
• Respiratory status
• CPT, oxygen, suction, OOB
• Hydration
• Administer antipyretics and antibiotics
• Pain management
o Acetaminophen (Tylenol) analgesic, antipyretic
o Ketorolac (Toradol) NSAID (worry about Kidney/GI)
• Chest tube management
o maintain suction, monitor respiratory assessment, no air leaks, need occlusive dressing and sterile water in case dislodgement
Prevention
• Pneumococcal vaccine
o 2,4,6,12-15mo
• Hemophilus influenza B
• Prevention of URI
o Hand hygiene, infection control practices in day care
• Prevention of hospital acquired infections (RSV)
APNEA OF PREMATURITY (can also occur in non-premature infants)
• Functional problem
o Neurologic immaturity
o Immunologic immaturity
o Poor neurologic and respiratory control mechanisms
o Don’t response well to hypoxemia
o Respiratory reflexes are immature
o Weakened muscles of thorax, diaphragm, upper airway
• Structural problem
o Immature muscle development
o Immature coordination
Apnea of Prematurity
• Immature neurologic and chemical respiratory control mechanisms
• Weak muscles of thorax, diaphragm, upper airway
• Cessation of spontaneous breathing 20 seconds or more
• Shorter pauses with bradycardia or oxygen desaturations
Types of Apnea
• Central
o CNS doesn’t transmit signals to respiratory muscles, absence of diaphragmatic and respiratory muscle function
• Obstructive
o air flow stops du/t upper airway obstruction, still see chest/abdominal movement
• Mixed
o combination of central and obstructive most common form in preterm infants
• Expected in the premature infant, but all causes should be ruled out before determining it benign, ie) obstruction, dehydration, hypoglycemia, sepsis, seizures, IVH
Management
• Caffeine (Stimulant)
o Considerations r/t effects?
o Caffeine- reduces apnea/bradycardic spells
o CNS stimulant
o Acts as a mild diuretic – consider I&Os and weights daily
o Toxicity- tachycardia > 180-190beats/min at rest, vomiting, irritability, diuresis, dysrhythmia, gastritis
• Nasal CPAP
Nursing Interventions
• Frequent respiratory assessments and monitoring
• CRM- alarms when apnea occurs
o What to do when the alarm sounds?
o Assess patient, color, respirations, HR, oxygen
• Tactile stimulation
o rub chest/back, reposition
o Raise the chin to reposition the airway
• Oxygen
• Suctioning
• Record number of apneic episodes= episode of apnea, number of spells, appearance during and after, self-resolve or tactile stimulation, supplemental oxygen were needed
ALTE= ACUTE (APPARENT) LIFE THREATENING EVENT
• Apnea, color change, change in muscle tone, choking, gagging, coughing
• Increased risk of SIDs
• Determine underlying cause, observation – most times a cause is never found
• May or may not occur with apnea
• Was called near miss SIDs
• Pallor, cyanosis, hypotonic,
• Significant intervention or CPR
• Common risk factor – maternal smoking
• Usually appear asymptomatic when taken to ED
o Observe in ED, take detailed history and details of the event, observe in car seat, feeding, central of acrocyanosis?
ALTE
• Management
o At home apnea monitor
• Provide education
o Education parents on what to look for, how to observe the infant, the monitor, and CPR
o Proper sleep care
The nurse is caring for a premature baby girl born at 32 weeks who is experiencing apnea of prematurity. The student nurse asks what to do if the patient is having an apneic event. Which of the following are appropriate interventions for the nurse to tell the student? (Select all that apply).
1. Tickle the hands. (not enough) 2. Rub the chest.
3. Rub the back. (should be supine not stomach)
4. Gently shake the baby. (never shake)
5. Perform a jaw thrust. (tilt chin)
6. Change the baby’s position.
Obstructive Sleep Apnea
• 10- 12% of children ages 2-8 years old
• Prolonged partial upper airway obstruction or complete obstruction and disrupts sleep respirations and patterns
• Can be caused by large tonsils, obesity, kids with low muscle tone/muscle disease
OSA Signs and Symptoms
• Snoring
• Labored breathing
• cyanosis
• sleep enuresis
• daytime sleepiness
• behavioral problems
• disrupted sleep
OSA Complications
• Growth failure
• Cor pulmonale - abnormal enlargement of the right side of the heart as a result of disease of the lungs or the pulmonary blood vessels d/t pulmonary htn R side of
heart fails d/t constantly pushing against pulmonary artery pressure, leads to venous congestion liver and spleen, ascites, dependent edema
• HTN
• Behavioral problems
• ADHD
• Death
OSA
• Diagnosis
o Overnight sleep study
• Treatment
o T&A first line treatment
o CPAP and BiPAP
Non-Invasive Positive pressure Ventilations
● CPAP
● BiPAP
Continuous Positive Airway Pressure (CPAP)
• Constant flow of positive pressure
• Provides Oxygenation not ventilation
• Prevents collapse of alveoli
• Improved gas exchange
Bi-level Positive Airway Pressure (BiPAP)
• Constant positive pressure delivered to lungs at two different pressure settings: inspiration and expiration
• Provides ventilation – the movement of air between environment and alveoli
Reasons for Use
• Noninvasive
• Maintain adequate ventilation
• Improve atelectasis
• Prolongs life expectancy
Uses of CPAP and BiPAP
• OSA
• Apnea of prematurity
• Airway anomalies (ex- Tracheomalacia)
• Diaphragm paralysis
• Neuromuscular disorders- use before trach needed
• CF
• Asthma
Nursing Interventions
• Respiratory status
• Vital signs
• Comfort: fit and is patient tolerating well?
• Settings
• Skin integrity - – look for all points of contact, remove protective products like, hydrocolloids, silicones, and assess underlying skin. Eye, nose dryness/redness
• Abdomen- distention, pain, bloating, gas
Room air is 21%. Each 1 liter of oxygen flow is equal to an additional 4% of oxygen. The child is receiving 3 liters of oxygen. 21% (room air) + 3(4%) = 33% of oxygen.
Case Study
History of Presenting Illness->
Patient L.B. 4-year-old female weight 17.2 kg no PMH and no allergies. All immunizations up to date. Two-day hx of fever (103 F/ 39.4 C), abdominal pain, emesis, mild cough, decreased urine output. Tylenol and Motrin given by mom. Went to PCP diagnosed with viral illness. Two days later, with worsening symptoms mom brought L.B. to CHOP’s ED. ED
• Vitals
o Temp 37.6 (99.6 F), HR 150, RR 44, BP 113/59, Sp02 98%
• Mom told the RN take a history of L.B.’s s/s of emesis, mild cough, abdominal pain, decreased PO intake and urine output
• Assessment: decreased in bases + slight crackles
• What tests do you as the nurse think may be ordered?
o CBC, BMP, RRP - negative
o WBCs
▪ Elevated
o Chest xray
▪ RUL lobar consolidation
o Abdominal xray
▪ Negative
As the nurse, you anticipate which diagnosis?
What about L.B’s tachycardia and decreased urine output????
Pneumonia
• NSS bolus 20mL/kg (17.2 kg)
o How many mLs are you going to administer?
• Order Recommendations: IV Ampicillin 75mg/kg/dose switch to PO Amoxicillin when symptoms improve
o What is her dose?
o What other recommendations would be appropriate for L.B.’s plan of care?
• Pulse ox
• Respiratory assessment
• Monitor HR/RR
• Initiate IVF (17.2 kg) - what should IVF rate be??
• Ultrasound if respiratory status decreases
• Encourage PO intake
• Monitor urine output
L.B. was admitted to the General Peds floor
• Overnight, her Sp02 dropped to 89%
• Temperature was 38.7 (101.6 F)
o What is are your priority nursing interventions?
• L.B. was on 2 L of oxygen via Nasal Cannula overnight and maintained Sp02 > 98- 100%
• Acetaminophen was given for fever
• Over the next day and a half L.B.’s symptoms improved, she was on RA with normal Sp02, was discharged to home with PO amoxicillin.
• Part of her D/C instructions was to follow up with her PCP
Follow up at PCP
• Mom states there is no improvements
• PCP ordered a chest x-ray which showed fluid in the Right lung.
• L.B. was sent to the ED at CHOP
• Mom told the RN that L.B. continued to have decreased PO intake and urine output
ED at CHOP
• Temp 38.9 (102 F) HR 152 RR 62 BP 112/56 Sp02 97%
• Chest x-ray – bilateral pleural effusion R > L
• RRP – negative
• Mycoplasma Polymerase Chain Reaction (PCR)
• CBC/BMP
• 20mL/kg NSS bolus administered as well as tylenol
• IVF initiated
• L.B. was admitted to the floor and overnight began to desat to 86- 87%
o What are your nursing interventions?
• At midnight her temperature was 39.4 (102.9 F)
• Ultrasound obtained – moderately increased R pleural effusion small L pleural effusion
• IV vancomycin and ceftriaxone started
Surgery team consulted
• As the nurse what diagnosis do you anticipate may be the cause of L.B.’s symptoms ?
Surgery Recommendations
• Video Assisted Thoracoscopic Surgery procedure and Chest tube placement
• NPO at midnight
• What is a VATs procedure?? What is the purpose of the CT?
Post Surgery
• L.B. did well in surgery and now has bilateral chest tubes to -20cm wall suction
o What is your priority nursing assessments and care?
• Discontinued IV vancomycin, started IV ceftriaxone
• Plan of Care
o Daily chest x-rays – why?
o Change chest tube to water seal – why?
o Surgical MD to remove 1 chest tube per day
• Chest tubes were removed on days 4 and 5
• Chest x-rays improved
L.B. was sent home on PO clindamycin for a 7 day course
• What will you include in your discharge teaching? [Show Less]