I.   Assessment of respiratory function  

II.  兒童常見呼吸系統疾病

Nursing care of children with respiratory dysfunction

Assessment of respiratory function

Health history Physical assessment p418 Table 13-1

Quality of respirationsQuality of pulseColorCoughBehavior changeSigns of dehydration

Diagnostic assessment胸部 X 光檢查痰液檢查血液氣體分析支氣管鏡檢查肺功能檢查 (Pulmonary function test)

兒童常見呼吸系統疾病 Urgent respiratory threats

Sudden infant death syndrome P423

Upper respiratory tract infection

Otitis Media P703

Tonsilitis P718

Common cold

Epidemic Influenza

Acute pharyngitis

Reactive airway disordersCroup P427

AsthmaLower respiratory tract infection

BronchitisBronchiolitis P447

Pneumonia P451

Long-term respiratory dysfunctionCystic fibrosis

Otitis medial P703

Inflammation of the middle ear.

At least one episode by 6 years of age , with peak incidence at 2 years

Boys

Winter months.

Etiology and pathophysiology (1)

Eustachian tube equalizes air pressure between the middle ear and the outside environment and allows for drainage of secretions from middle ear mucosa. P691 圖19-1 Anatomical differences in the Eustachian tube between adult and small children （ short, wider, more horizontal ） . P691 圖 19-1

Cause ： unknown, but it appears to be related to Eustachian tube dysfunction P703 倒數第 3 行

Often an upper respiratory infection precedes the development of otitis medial. P703 倒數第 2 行

Etiology and pathophysiology (2)

Infection →the mucous membranes of the Eustachian tube to become edematous→Eustachian tube blocked →air in the middle ear is reabsorbed into the bloodstream→fluid is pulled from the mucosal lining into the former air space→infected. P703 最後 1 行 .

Causative organisms ： streptococcus pneumoniae, Haemophilus influenzae . P704 第 1 段第 4 行

Allergic rhinitis, cleft palate, Down syndrome. P704 第 2段 Higher risk ： crowded conditions, exposed to cigarette smoke, attend child care with multiple children.Breastfeeding provides protection.

Clinical manifestations

Pulling at the ear 第 2行 Diarrhea, vomiting, and fever

Irritability and “acting out” may be signs of a related hearing impairmentAsymptomatic （ some ） p705 第 1 行

Otoscopic examination. 第 1 段第 1 行

Otitis medial : red, bulging, nonmobile tympanic membrane 圖 19-7

Otitis medial with effusion : fluid line or air bubbles 圖 19-8

Pneumatic otoscopy ( 氣式耳鏡 ) 第 3 行

Special gradient acoustic reflectometry （ SGAR ） ( 聽覺反射傾斜度 )

Tympanogram ( 鼓室壓力圖 ) 第 2 段

Diagnostic tests

Medical management

Acute and recurrent otitis media 第 3 段

Antibiotic therapy － wide spectrum antibiotics• Amoxicllin → Amoxicllin with clavulanate or cefuroxime

axetil→ ceftriaxome

Chronic otitis media with effusion 第 5 段→ result in sensorineural or conductive hearing loss and cochlear damage

Audiology

If infection recurs → Myringotomy and tympanostomy tube 最後 1 段第 2 行

Neither decongestants nor antihistamines 最後 1 段第 1 行

Nursing assessment p706

Assess tympanic membrane－ color, transparency, mobility, presence of landmarks, and light reflex.

Ask the parents if the child has had a fever, been fussy, or been pulling at the ears.

Observe for signs of impaired hearing.

Nursing management P707 care plan

Pain

Infection

Risk for caregiver role strain

Knowledge deficit about infection

Altered growth and development

Etiology and pathophysiology An infection or inflammation （ hypertrophy ） of the palatine tonsils. P718

Most children with pharyngitis may have infected tonsils.May be caused by virus or bacterium. P719

Tonsillitis

Clinical manifestations

Frequent throat infections with breathing and swallowing difficulties.

Persistent redness of the anterior pillars

Enlargement of the cervical lymph nodes

Mucous membranes may become dry and irritated

Visual inspection

Clinical manifestations

Throat culture

Diagnostic tests

Medical management

Symptomatic treatmentPenicilline for 10 days （ or erythromycin ）

Tonsillectomy3 per year for 3 yearsChronic tonsillitisObstructive sleep apneaMalformations causing nasal speech or a facial growth abnormality

If the pharyngeal tonsils are enlargedMouth breathing, cough, impaired taste and smell, a muffled quality to the voice, and chronic otitis media.

Nursing assessment

Assess the throat

Observe for tonsils

Pain or difficulty swallowing

History

Nursing management P720

Supportive care （ symptomatic relief ）Completion of the full course of treatment. （ 10-day ）Acetaminophen reduces throat pain and generalized fever. P718

Cool, nonacidic fluids and soft foods, ice chips or frozen juice pops given frequently in small amounts facilitate swallowing and prevent dehydration.Humidification, chewing gum, and gargling with warm salt water soothe an irritated throat. Encourage the child to rest.

Nursing management

Before surgery P720 第 2 段Free of sore throat, fever, or URI for at least 1 week before surgery.Not be given aspirin or ibuprofen for 2 weeks before surgery.Check if any herbal medications are taken

After surgery局部用冷觀察嘔吐次數，可能早期出血的徵象避免不必要的擤鼻涕、咳嗽或清喉嚨術後採側臥或俯臥避免酸性飲料或辛辣食物，且避免使用吸管術後 1 ～ 2 週可恢復正常活動合併症— bleeding, infection, pain P720

Croup syndrom

Swelling of the epiglottis and larynx. p427 第 1 段第 2 行 Viral syndromes and bacterial syndromes p429 Table13-5

Viral syndromes • Acute Spasmodic Laryngitis

• Laryngotracheitis

• Laryngotracheobronchitis (LTB)

Bacterial syndromes• Epiglottitis

• Bacterial Tracheitis

Big three － LTB, epiglottis, and bacterial tracheitis p428 第 2

段 Stridor, seal-like barking cough, and hoarseness

Etiology and pathophysiologyViral invasion

Throughout the larynx, trachea, and bronchi

Age ： 3 months to 4 years of age

Boys than girls

Cause ： Parainfluenze virus （ 75% ）、 RS virus 、 Influenze virus

Airway tissues produce copious, tenacious secretions and swelling. P429 第 1 段圖 13-5

Laryngotracheobronchitis （ LTB ） p428

Clinical manifestations

Tachypnea, inspiratory stridor, seal-like barking cough, and hoarseness

Fever may or may be not present.

Diagnostic tests Clinical signs

Pulse oximetry

Anteroposterior and lateral x-rays － steeple sign

HumidificationMedications P430 上表

Beta-agonists and beta-adrenergics• Aerosolized through face mask

• Improvement in 30’ & lasts about 2 hours

• Tachycardia & hypertension

• Dizziness, headache, and nausea stop medication

Corticosteroids• IM, PO, Nebulized budesonide

• CV symptoms

• Stridor resolves faster

Oxygen

Medical management

Nursing management P431

Maintain airway patency

Meet fluid and nutritional needs

Epiglottitis （ Supraglottitis ） P431

Etiology and pathophysiology 第 1 段

An inflammation of the epiglottis.Edema can rapidly obstruct the airway by occluding the trachea. Potentially life-threateningCause ： bacterial invasion of the soft tissue of the larynx 第 2段

StreptococcusStaphylococcusHaemophilus influenzae type B

Inflammation and edema → airway obstruction

Clinical manifestations 第 3段

Suddenly becomes very illHigh fever （＞ 39oC ）Sore throat4D （ Dysphonia 、 Dysphagia 、 Drooling 、 Distressed respiratory effort ）StridorSits up and leans forward

Diagnostic tests P432 第 4 段

Lateral neck x-ray

Blood culture

圖 13-6

PS ： Laryngospasm and airway obstruction → visual inspection of the mouth and throat is contraindicated

Medical management

On endotracheal tubeAntibioticsAntipyreticsHydrationHumidifies oxygen

Nursing management

Airway management 第 2 段

Sit upright or assume a position of comfort to maintain the airway

Humidifies oxygen

Provide a quiet environment

Treat the infection and provide fluid to provide hydration 第 3 段

Provide emotional support 第 4 段

Bacterial Tracheitis P433

Etiology and pathophysiology 第 1 段Senondary infection of the upper trachea after viral laryngotracheitis.

Most caused by group A streptococcus or Haemophilus influenzae

Clinical manifestationsStarts with croupy cough and stridor

High fever greater than 390C ， persists for several days.

Prefer lying flat to sitting up

Diagnostic tests

Blood culture

Medical management•Antibiotics are given for a full 10-day course•Artificial airway and ventilatory support.

Nursing management

Airway assessment and support

Airway maintenance

Suctioning as needed

Humidified oxygen

Antibiotics

Preparation for resuscitation

Bronchiolitis P447

An infecting agent （ virus or bacterium ） causes inflammation and obstruction of the small airway, the bronchioles.

Infection occurs most frequently in toddlers and preschooers.

Etiology and pathophysiology

RSV is the most common cause.Direct or close contact with respiratory secretions of infected individuals. Viruses invade the mucosal cell→cell debris clogs and obstruct the bronchioles and irritates the airway. Partial airway obstruction and bronchospasms. →Wheezing & Crackles→respiration failure （ O2 ↓, CO2 ↑ ）→ Apnea and pulmonary edemaThe noisier the lungs, the better. 第 3 段

Clinical manifestations

URI symptoms－ Nasal stuffiness, cough, and fever for a few days（＜ 39oC） → LRI symptoms－ wheezing; a deeper, more frequent

cough; more labored breathing

Respirations are rapid, shallow, and accompanied by nasal flaring and retraction.

Acting more ill－ appearing sicker, less playful, and less interested in eating

Diagnostic tests

History

PE

X-ray

Nasal swab or nasopharyngeal wash 第 2 段第 2 行

Nursing assessment

Physiologic assessment Psychosocial assessment 參考 P439 Table13-10

Developmental assessment

Nursing implementation P449, 450-451 care plan

Maintain respiratory function Support physiologic functionReduce anxiety Discharge planning

Use of the bulb syringe to suction the naresFluid intakeRest P452 Families want to know

Pneumonia p451

Etiology and pathophysiology

An inflammation or infection of the bronchioles and alveolar spaces.

Most often in infants and young children

Viral, mycoplasmal, or bacterial in origin 第 2 段

Clinical manifestations

Fever, rhonchi, crackles, wheezes, cough, dyspnea, tachypnea, restlessness, and decreased breath sound Bacteria ： one or more lobes of a single lung; unilateral lobar pneumoniaViruses ： infiltrating the alveoli nearest the bronchi of one or both lungs.

Diagnostic tests P452 第 4 段 PE

X-ray

Sputum culture（ blood culturelung puncture）

Symptomatic therapy

Supportive care（ airway management, fluids, and rest）Organism-sensitive antibiotics

Oxygen and anti-inflammatory medications

Pulmonary care

Antibiotics

Hydration

Pain management

持續性密閉式胸腔引流 Discharge planning

Administration of drugs and any side effects

F/U chest X-ray

Medical management Nursing management

Nursing care plan for the children with respiratory dysfunction

Ineffective breathing pattern related to increased work of breathing and decreased energy （ fatigue ） .Altered tissue perfusion （ cardiopulmonary ） related to partially obstructed airway.Risk for fluid volume deficit related to inability to meet body requirements and increased metabolic demand Fear/Anxiety （ child and parent ） related to acute illness, hospitalization, and uncertain course of illness and treatment .Knowledge deficit （ child and parent ） related to diagnosis, treatment, prognosis, and home care needs .High risk infectionPain活動無耐力營養狀況少於身體需求睡眠型態混亂