NURSING 234 CROUP.docx
Management of the Child with Alterations in Respiratory Disorders
I. Croup Syndromes
o General term applied to a group of
... [Show More] symptoms characterized by hoarseness, a resonant cough described as “barking” or “brassy” (croupy), varying degrees of inspiratory stridor, and varying degrees of respiratory distress resulting from swelling or obstruction in the region of the larynx and subglottic airway.
o Most cases of croup are attributed to viruses namely parainfluenza virus (types 1, 2, and 3), influenza types A and B, human coronavirus, rhinoviruses, enterovirus, metapneumoviruses, adenovirus, RSV, and measles.
o Bacteria such as mycoplasma pneumonia can cause croup
o Number of croup cases increases in the late autumn through early winter months.
o Primarily occurs in children 6 months to 3 years of age and is rare after 6 years.
o Croup syndromes affect to varying degrees of the larynx, trachea, and bronchi.
o Laryngeal involvement often dominates the clinical picture because of the severe effects on the voice and breathing.
A. Acute epiglottitis (supraglottic)
i. What is it?
o MEDICAL EMERGENCY
o Usually caused by H.influenza
o Serious obstructive inflammatory process that occurs in children between the ages of 2 and 5 years old
ii. Clinical Manifestations (ASSESSMENT)
o Onset ABRUPT
o * Predictive signs: CAD absence of cough, drooling, and agitation
o Sitting upright with chin pointing out, mouth opened, and tongue protruding (tripod position)
o Dysphonia (thick, muffled voice and froglike croaking sound) NOT HOARSE
o Dysphagia (difficulty swallowing)
o Inspiratory stridor (noisy inspirations)
o Suprasternal and substernal retractions
o Sore throat, high fever, and restlessness
o The throat is red and inflamed, and distinctive, large, cherry red, edematous epiglottis is visible on careful throat inspection.
o ** Throat inspection should only be performed when immediate ET tube or an emergency tracheotomy can be performed if needed.
iii. Diagnostic: Lateral neck radiograph of the soft tissues is indicated for diagnosis
iv. Therapeutic Management
o Progressive obstruction leads to hypoxia, hypercapnia, and acidosis, followed by decreased muscular tone, reduced LOC, and, when obstruction becomes more or less complete, sudden death.
o Et tube is usually considered for the child with epiglottis with severe respiratory distress.
o Protect airway
o Avoid throat culture or using a tongue blade
o Prepare for intubation
o Provide humidified oxygen
o Monitor continuous pulse oximetry
o Administer corticosteroids (edema) and Iv fluids as prescribed
o Administer antibiotic therapy starting with IV, the transition to oral to complete a 7- 10-day course.
v. Prevention
o H. influenzae vaccine type B conjugate vaccine beginning at 2 months.
vi. Nursing Care Management
o Act quickly but calmly
o Allow child to remain in the position that provides the most comfort and security and reassure parent that everything is being done to make sure that their child is okay.
o Droplet precautions are indicated for first 24 hours after initiation of effective therapy to control spread of respiratory organisms.
o Prophylactic antibiotic treatment and household and other contacts may be indicated.
o **Continuous monitoring of respiratory status, including pulse oximetry is part of nursing observations, and the IV infusion is maintained.
B. Acute Laryngotracheobronchitis
i. What is it?
o Most common type of croup experienced by children
o Primarily affects children less than 5 years of age
o Cause: Parainfluenza types 1,2, followed by 2, RSV, influenzae types A and B, measles, and M. pneumoniae.
o Usually preceded by a URI which gradually descends to adjacent structures.
ii. Clinical Manifestations
o Gradual onset of low-grade fever, and the parents often report that the child went to bed and late awoke with a barky, brassy cough and at time inspiratory stridor.
o Symptoms are typically worse at night, and agitation and crying tend to exacerbate the symptoms.
o Inflammation of the mucosa lining the larynx and trachea causes a narrowing of the airway, when the airway is significantly narrowed, the child struggles to inhale air past the obstruction and into the lungs producing inspiratory stridor and suprasternal retractions
o Other classic manifestations include cough and hoarseness Ati book says:
o Low grade fever, restlessness, hoarseness, barky cough, dyspnea, inspiratory stridor, and retractions
Infants
o Nasal flaring, intercoastal retractions, tachypnea, and continuous stridor
iii. Nursing Care
o Provide humidity with cool mist Rationale: Cool temperature modalities assist by constricting edematous blood vessels
o Administer oxygen if needed
o Monitor continuous oximetry
o Administer nebulized racemic epinephrine as prescribed Rationale: beta adrenergic effects cause mucosal vasoconstriction and subsequent decreased subglottic edema
o Close observation of patients receiving nebulized racemic epinephrine is critical to detect the reappearance of symptoms, monitor response to therapy, and note any deterioration in the respiratory status.
o Administer corticosteroids oral or IM if child cannot tolerate oral (dexamethasone) or nebulized (budesonide)
o Encourage oral intake if tolerated (if child has severe respiratory distress resp. rate >60, the SHOULD NOT be given anything by mouth to prevent aspiration and increased work of breathing. Give IV fluid therapy if child is unable to take in oral fluids
C. Bacterial Tracheitis
i. What is it?
o An infection of the mucosa and soft tissues of the upper trachea and has features of croup and epiglottitis
o Believed to be a complication of LTB and S. Aureus is the most frequent organism responsible (could be cause by other organisms)
ii. Assessment/ expected findings
o Anteroposterior or lateral neck x rays show narrowing (steeple sign), and infiltrates may be seen.
o Endoscopy may be performed in OR or ICU for diagnosis and to obtain cultures of the secretions.
o Many manifestations are similar to LTB but are unresponsive to LTB therapy.
o There is a history of previous URI with croupy cough, stridor, unaffected by position, toxicity, absence of drooling, respiratory distress and high fever.
o Prominent manifestation is the production of thick, purulent tracheal secretions
o Children with this condition may develop a life-threatening upper airway obstruction, respiratory failure, acute respiratory distress syndrome, and multiple organ dysfunction.
iii. Therapeutic and Nursing care Management
o Vigorous antipyretics
o Fluids
o Antibiotics (10-day course)
o Children may require ET tube and mechanical ventilation
o Closely monitor patient who are not intubated for respiratory failure.
Management of Lower Airway Disorders
I. Respiratory syncytial Virus and Bronchiolitis (most common of lower airway)
A. What is it
o Acute viral infection with maximum effect at the bronchiolar level
o Most cases of bronchiolitis are caused by RSV
o Primarily affects the bronchi and bronchioles
o Spread through direct contact *initiate droplet precautions*
B. Signs and Symptoms of RSV
Initial (Upper)
1. Rhinorrhea
2. Pharyngitis
3. Coughing, sneezing
4. Wheezing
5. Possible ear or eye infection
With illness progression (Progressing to lower)
1. Increased coughing and wheezing
2. Fever
3. Tachypnea and retractions
4. Refusal to nurse or bottle feed
5. Copious secretions
Severe illness
1. Tachypnea >70 breaths/min
2. Listlessness
3. Apneic spells
4. Poor air exchange; poor breath sounds
5. Cyanosis
(also: emphysema, flaring nares may occur)
C. Laboratory Tests
o Test nasopharyngeal secretions using either rapid immunofluorescent antibody-direct fluorescent antibody staining or enzyme-linked immunosorbent assay techniques for RSV antigen detection.
D. Therapeutic Management (Goal: primarily supportive and aimed at decreasing airway hyperresonance and inflammation, and promoting adequate fluid intake)
o For uncomplicated cases of bronchiolitis, treat symptomatically with supplemental oxygen, adequate fluid intake, airway maintenance, and medications.
o Hospitalization is usually recommended for children with respiratory distress, those who cannot maintain adequate hydration, those with underlying lung or heart disease, or caregiver’s inability to provide adequate care during the illness.
o Supplemental oxygen to maintain O2 sat. of 90 % or greater after nasal suctioning and repositioning
o CPT is not recommended
o Nasopharyngeal or nasal suctioning as needed
o Iv fluids in acute stage of the disease.
o Short acting B agonist bronchodilator may be given as a test dose initially in case reactive airway disease is present racemic epinephrine: (3% nebulized hypertonic saline)
o Encourage breast feeding, avoid passive tobacco smoke exposure, promote preventative measures, including hand washing and the administration of palivizumab (antibody) (Synagis) to high risk infants.
E. Nursing Care Management
o Children admitted to the hospital with suspected RSV infection need separate rooms or rooms with other RSV-infected children.
o Use droplet, contact, and standard precautions, including hand washing, not touching the nasal mucosa or conjunctiva, and using gloves, and masks when entering the patient’s room.
o Reduce number of people in room
o Screen children for illnesses before allowing children to visit high risk infants.
o Make sure nurse who is taking care of patient is not caring for other patients who are considered high risk.
o Normal saline drops in nares and suction the mucus with a bulb syringe before feedings and before bedtime to help the child eat and rest better
o Offer child’s small amounts of fluids, 5 to 10 ml at a time.
F. Quality patient outcomes
o Adequate Fluid intake
o Oxygen saturation greater than or equal to 90%
o Respiratory rate less than 60 breaths/min
Cystic Fibrosis
i. What is CF
o It is a respiratory disorder that results from inheriting a mutated gene from each parent (autosomal recessive)
o It is characterized by mucus glands that secrete an increase in the quantity of THICK, tenacious mucus, which leads to mechanical obstruction of organs (liver, lungs, pancreas, small intestine, and reproductive system)
o It causes an increase sodium and chloride content is sweat and autonomic nervous system abnormalities.
ii. Risk Factors
o Both biological parents are carriers of recessive trait for cystic fibrosis
o Caucasian ethnicity
iii. Expected findings
o Family h/o CF
o Medical h/o respiratory infections, growth failure,
o Meconium ileus at birth manifested by distention of the abdomen and inability to pass stool ** Meconium ileus is the earliest indication of CF in newborns**
A. Respiratory (Most prominent feature is chronic cough)
o Early Manifestations
- Wheezing, rhonchi (indicative of obstruction)
- Dry, nonproductive cough
o Increased involvement
- Dyspnea
- Paroxysmal (intensified) cough
- Obstructive emphysema (lung condition that causes SOB. Air sacs in the lungs (alveoli) are damaged. Overtime, air sacs weaken and rupture creating larger air spaces instead of many smaller ones) … and atelectasis on chest x-ray
o Advanced involvement (caused by progressive pulmonary involvement with hyperaeration of functioning alveoli)
- Cyanosis
- Barrel shaped chest
- Clubbing of fingers and toes
- Multiple episodes of bronchitis or bronchopneumonia
- Pneumothorax (caused by bronchiectatic cysts and subpleural blebs in upper lobes rupturing)
- Child is subject to chronic nasal congestion, sinusitis, rhinitis, and nasal polyps. (ENT surgeries are often needed)
B. GI findings
- Earliest postnatal manifestation of CF is meconium ileus (gives rise to signs of intestinal obstruction, including abdominal distention, vomiting, failure to pass stools, and rapid development of dehydration with associated electrolyte imbalance.
- Large, frothy, bulky, greasy, foul smelling stools (steatorrhea)
- Big appetite (early) loss of appetite (later)
- Failure to gain weight or weight loss
- Delayed growth patterns (Nursing Diagnosis= failure to thrive)
- Distended abdomen
- Thin arms and legs
- Deficiency of fat-soluble vitamins (DEKA) (risk for bleeding because of deficiency in vitamin K)
- Anemia and hypoalbuminemia (b/c of decreased absorption of protein which causes generalized edema)
- Older children with CF have an increased prevalence of gastroesophageal reflux
- Potential prolapse of the rectum (r/t large bulky stools, malnutrition, and increased pressure from intensified cough)
C. Reproductive findings
- Delayed puberty in girls is common
- Vicious cervical mucus
- Decreased or absent sperm
D. Integumentary System
- Sweat, tears, and saliva have an excessively high content of sodium and chloride (R/t to chloride channel defect) which leaves the affected person at risk for abnormal salt loss, dehydration, and hypochloremic and hyponatremic alkalosis during hyper thermic conditions.
iv. Diagnostic Evaluation
▪ Can be confirmed by newborn screening, DNA identification of mutant genes
▪ Sweat chloride test (pilocarpine iontophoresis)
- Child must be well hydrated to ensure accurate results
- Involves stimulation of production of sweat with a special device, collecting sweat on a filtered paper, and the measuring the sweat electrolytes from two different sites.
- Normal sweat chloride = less than 40meq/l and sodium= less than 70 mew/l.
- ** Chloride greater than 40 mEq/l for infants less than 3 months and sodium greater than 90 mEq/l is CONFIRMATION of CF.
▪ Pulmonary function tests (provides evidence of abnormal small airway function in CF)
▪ Abdominal x ray (detect meconium ileus) Chest x-ray (atelectasis and emphysema)
▪ Stool analysis *72 hours*(detects presence of fats)
v. What would you do as a NURSE:
o Assess oxygenation
o Assess lungs sounds and resp. status
o Obtain Iv access (PICC line for home antibiotic therapy)
o Obtain sputum sample for culture and sensitivity
o Support child and family
o **Goal of CF therapy are to prevent or minimize pulmonary complication, ensure adequate nutrition for growth, encourage appropriate physical activity, and promote reasonable quality of life for both the child and family. [Show Less]