Differences in Adult and Child Adult Child

What are the anatomic differences in the eustachian tube of adults and small children? (shorter, wider, more horizontal)

Which difference do you think could cause more problems for the child and why?

Inflammation of the middle ear sometimes accompanied by infection

Common CausesEustachian tube dysfunction

Previous URI causes mucous membranes of the eustachian tube to become edematous and blocks tube.

Enlarged adenoids Allergic rhinitis

Exposure to cigarette smoke (airborne pollutants)

Pacifier use may raise soft palate and alter dynamics in the eustachian tube

Clinical Judgment Question:

Considering the contributing factors to this condition, what age group most commonly experiences acute otitis media?

Acute Otitis Media characterized by abrupt onset, pain,

middle ear effusion, and inflammation.

Note the injected vessels and altered shape of cone of light.

Serous Otitis Media

Note effusion on otoscopy by fluid line and air bubbles

Note that the light reflex is not in the expected position due to a change in tympanic membrane shape from air bubbles.

What objective sign is this child displaying?

What does it indicate?

Clinical Manifestations

Evaluation and therapyRecent concerns of drug-resistant streptococcus

pneumoniae have caused medical professionals to re-evaluate antibiotic therapy (APA, 2004)

Many episodes of OM result from viral infectionsWaiting up to 72 hrs for spontaneous resolution is

now recommended in healthy infantsWhen antibiotics are warranted, oral amoxicillin in

high dosage is the medication of choice.

Nursing Interventions: Nursing implications for antibiotic therapy

SafetyTeaching

Comfort measuresTeaching for home care:

When to notify primary care providerFollow up visit with primary care providerPreventive measures

Myringotomy

Purpose: DrainageAir exchange by-passing Eustachian tube Prevent further scaring and hearing loss

Nursing Care Management following placement of Myringotomy:Comfort measuresAssessments immediately post operatively and ongoingPre & Post-op support for the familyDischarge teaching:

Comfort measuresWhen to notify primary care providerPreventative measures

Hygiene Recreational

Mastoiditis

MastoiditisMorbidity/mortality

Hearing lossExtension of the infectious process beyond the mastoid

system, resulting in intracranial complications Ages affected

Parallels otitis media, affecting mostly young children and peaking in those aged 6-13 months.

May occur in healthy adults as well

Nursing care for the child with mastoiditis:Assess vital signs (what additional VS do you need to

assess?)Which lab values would indicate additional concerns?Medicate aggressively with antibiotics as ordered

(usually IV if bacterial spread to mastoid) WHY?Antibiotics of choice: ticarcillin disodium (Timentin®)

and gentamicin sulfate (Garamycin®)Assess for complications (hearing loss, tinnitus)Comfort measures

Nursing interventions related to administration of antibiotics: Contraindications:

Allergies/sensitivities- what medications have a co-morbidity? (aminoglycosides- mycin or micin suffix)

Peak/ Trough- when to draw, how to interpret Assessment of adequate filtration from the body

(what organs are most effected)Why is rate of administration vitally important?

Upper Respiratory Tract InfectionsNasopharyngitis

Young child: fever, sneezing, vomiting or diarrheaOlder child: dryness and irritation of nose/throat, sneezing, aches, cough

PharyngitisYoung child: fever, malaise, anorexia, headachesOlder child: fever, headache, dysphagia, abdominal pain

Tonsillitis Masses of lymphoid tissue in pairsOften occurs with pharyngitisCharacterized by fever, dysphagia, or respiratory problems forcing

breathing to take place through nose

Key to understandingprevention of URI ismeticulous handwashingand avoiding exposure to infected persons

The nurse should remind the child with a positive throat culture for strep to discard their toothbrush and replace it with a new one after they have been taking antibiotics for 24 hours

Clinical Manifestations Tonsillitis

FeverPersistent or recurrent sore throatAnorexiaGeneral malaiseDifficulty in swallowing, mouth breather, foul odor breathEnlarged tonsils, bright red, covered with exudate

AdenoiditisRespirations – stridor, snoring, nasal quality speechPain in ear, recurring otitis media

Nursing Care for the Tonsillectomy and Adenoidectomy Patient

Post-operative CareProviding comfort and minimizing activities or

interventions that precipitate bleedingPlace on abdomen or side until fully awakeManage airwayMonitor bleeding, esp. new bleedingIce collar, pain medsAvoiding p.o. fluids until fully awake --then liquids and

soft cold foods. Avoid citrus juices, milkDo not use straws or put tongue blade in mouth, no

smoking

Nurse Alert for Post-Op T/A surgery Most obvious sign of early bleeding

is the child’s continuous

swallowing of trickling blood. Note the frequency of

swallowing and notify

the surgeon immediately

Indications of Respiratory Distress1. Nasal Flaring2. Circumoral cyanosis3. Expiratory grunting4. Retractions:

• Substernal, • Lower intercostal,

5. Tachypnea Repirations greater than 60

ApneaDefined as: Delay of breathing over 20 secondsAdditional Signs and Symptoms:

CyanosisMarked pallorHypotoniaBradycardia

Treatment and Nursing CareAdmit to hospital for cardio-respiratory

monitoring

Teach parents home care instructions in the use of an apnea monitor

Encourage parents to learn CPR.

Cardiorespiratory

Monitoring

pulse oximeter desired reading

> 95%

SIDSDefined: sudden death of an infant during sleepRisk Factors

Prematurity, low birth weightMost common in infants 2-4 months oldMore prevalent in winter monthsSleeping in bed with others, sleeping prone, use of pillows

and quiltsExposure to passive smoke

SIDS – Nursing InterventionsParent teaching:

Place infant on back to sleepPlace on firm mattressDo not use loose bedding, toys, pillowsAvoid overheating with too many clothesParents should stop smoking

Provide support of parents by helping them work through feelings of guilt and loss; refer to National Foundation for SIDS

CroupCroup

Croup: viral and bacterial syndromesLaryngotracheobronchitis Bacterial tracheitisEpiglottitis

Initial symptom of all three is stridor, a seal- like barking cough and hoarseness

Croup vs. EpiglotitisCroup

Viral/BacterialFeverHoarsenessResonant coughStridor (inspiratory)Risk for significant

narrowing airway with inflammation

Humidity for treatment

EpiglottitisBacterialHigh feverRapidly progressive courseDysphagiaDroolingDysphoniaDistressed inspiratory effortsAntibiotics needed

Medications Beta-agonist /Bronchodilator– Albuterol

Corticosteroids

Which of these medications would the nurse give first? Rationale?

Nursing CareMaintain patent airway

Oxygen with humidificationKeep resuscitation equipment at the bedsideAssess VS (T102 or >, and R>60)Nothing should be placed in the mouth

Meet fluid and nutritional needsCool, noncarbonated, non-acid drinks Assess for difficulty swallowing – may need IV therapy

Child with Epiglottitis

Clinical Judgment:Kim, a 4 year old, is admitted to the emergency

department with a sore throat, pain on swallowing drooling, and a fever of 102.2°. She looks ill, agitated and prefers to sit up and lean over.

What nursing interventions should the nurse implement first in this situation?

Bronchitis vs. BronchiolitisBronchiolitis

Bronchitis

BronchitisRarely occurs in childhood as isolated problemMay occur with other respiratory illnessMost often viralMay result from a response to an allergenSymptoms include coarse, hacking cough (increases

at night), fatigue, sore ribs, deep and rattling respirations, audible wheezing

Bronchiolitis / Rhino Syncytial Virus (causes 50% of cases)

Primarily affects infants 2-6 months of ageInfection of bronchial mucosa leading to

obstructionBegins as upper respiratory infection (URI)

and progresses to Respiratory Distress. Diagnosed with a RSV wash

Nursing Care for Child with RSVMedication therapy

Bronchodilators SteroidsBeta-antagonistsAntiviral-Virozole (Ribavirin)Prevention – Synagis (palivizumab) administered IM.

and RespiGam (RSV immune globulin) administered IV. Droplet and contact isolationDroplet and contact isolation

Nebulized epinephrine administered for Bronchiolitis

Parents can hold nebulizer to decrease infant’s fear

Reactive Airway Disease (asthma)Chronic inflammatory disorder affecting mast cells,

eosinophils, and T lymphocytes

Inflammation causes increase in bronchial hyper-responsiveness to variety of stimuli (dander, dust, pollen, smoke)

Most common chronic disease of childhood; primary cause of school absences

Asthma

Etiology/Pathophysiology of AsthmaObstructive airflow limitation due to:

Mucosal edema - membranes that line airwaysBronchospasm (bronchoconstriction)Mucus plugging (thicker) causes:

Increased airway resistanceDecreased flow rates

Asthma (RAD) continued:Increased work of breathingProgressive decrease in tidal volume and expiratory

volumeArterial pH abnormalities due to:

Increase in number of poorly ventilated alveoliIncrease in hypoxemiaCarbon dioxide retentionRespiratory acidosis

Asthma Triggers

Interpreting Peak Expiratory Flow Rates

Green: (80-100% of personal best) signals all clear and asthma is under reasonably good control

Yellow (50-79% of personal best) signals caution; asthma not well controlled; call dr. if child stays in this zone

Red (below 50% of personal best) signals a medical alert. Severe airway narrowing is occurring; short acting bronchodilator is indicated

Medications to treat AsthmaReliever or Rescue Meds

Short acting beta-agonists - AlbuterolCorticosteroids- Prednisone, Beclomethasone for

short term therapyAnticholinergic agents: Atrovent

Preventer / Controller MedicationsMast-cell inhibitors (Cromolyn)Leukotriene modifiers – (Singulair)Inhaled steroids ( Advair, Pulmocort, Azmacort)

Child receiving nebulizer treatment

What is important patient teaching ?

Treatment and Nursing Care

Humidified Oxygen via

maskPulse Oximeter

High Fowler’s position

Emergency situations of asthmaAcute episode of reactive disease: bronchioles may

close rapidly, causing severe airway obstruction, anxiety, restlessness, and fear. Will need to be seen in ER if not relieved by med

Status asthmaticus: medical emergency with severe edema, profuse sweating, respiratory failure and death if untreated. Becomes seriously hypoxic…immediate intervention needed

Cystic Fibrosis (CF)Factor responsible for manifestations of the

disease is mechanical obstruction caused by increased viscosity of mucous gland secretions

Mucous glands produce a thick protein that accumulates and dilates them

Passages in organs such as the pancreas become obstructed

First manifestation is meconium ileus in newborn

Physical findings of the CF patient:Clubbing of the fingersIncreased respirations,

cyanosisProductive, moist coughBarrel chest

Assessment:FTT despite high caloric intake. Frequent respiratory infections. Malabsorption of fats and proteins Mild diarrhea with malodorous stools,

steatorrhea. Abnormally high levels of sodium chloride in

sweat.

Diagnosis:• Sweat test: Chloride – Normal < 40 mEq/L. Highly suggestive of CF 40-60 mEq/L Diagnostic > 60 mEq/L.

(see bags over hands and arms) • Pancreatic enzymes: Collection of stool specimen to assess Trypsin and lipase. Trypsin absent in 80% of children with CF

CF ManagementTreatment

Prevention and treatment of pulmonary infections with antibiotics

Chest Physiotherapy at least twice a day to increase sputum expectoration

Physical exercise important adjunctManagement of dietary supplements (enzymes

with meals and snacks)