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Bowden, Chapter 16: Supplemental Information
KeyTerms
apnea
atelectasis
atopy
cor pulmonale
cyanosis
dyspnea
hemoptysis
hypercarbia
hypoxemia
hypoxia
pallor
respiratory distress
respiratory failure
retractions
subcutaneous emphysema
tachypnea
ventilation-perfusion mismatch
Summary of Key Concepts
- Certain anatomic and structural features of the respiratory tract in infants and young children predispose them to develop respiratory distress more readily than older children or adults.
- Respiratory illnesses and exacerbations of chronic respiratory conditions are the most common reasons for pediatric hospital admissions and ambulatory center visits, especially during winter and early spring.
- Viral and bacterial infections of the respiratory system are common and relatively unavoidable during childhood.
- Children with chronic conditions, especially conditions that involve the respiratory or cardiac systems, are at highest risk for serious morbidity or mortality associated with common childhood respiratory infections.
- Worsening respiratory distress can be identified by frequent and thorough respiratory assessments. Early recognition and prompt intervention for respiratory distress are key to prevent respiratory failure.
- Parents of children with chronic respiratory conditions must be educated to recognize signs and symptoms of respiratory compromise and to notify their healthcare provider immediately when they occur. Good decision making skills are an essential component of daily disease management. The nurse must teach these parents how to manage emergency situations in the home
- Children with chronic respiratory conditions require regular follow-up visits with healthcare providers and use of proactive and preventive measures.
Evidence-Based Practice Guidelines
AmericanAcademy of Pediatrics. (2001). Clinical practice guideline: Management of sinusitis. Pediatrics, 108 (3), 798-808.
AmericanAcademy of Pediatrics (AAP). (2003). Apnea, Sudden Infant Death Syndrome, and home monitoring. Pediatrics, 111, 914-917.
American Association for Respiratory Care (AARC). (2007). Removal of the endotracheal tube—2007 revision & update. Respiratory Care, 52, 81-93.
American Thoracic Society. (2007). An Official ATS Workshop Report: Issues in Screening for Asthma in Children. Available at
American Thoracic Society. (2007). An Official ATS/ERS Statement: Pulmonary Function Testing in Preschool Children. Available at
American Thoracic Society. (2000). Care of the child with a chronic tracheostomy. Available at
Cincinnati Children’s HospitalMedicalCenter. (2006). Evidence-based clinical practice guideline for medical management of bronchiolitis in infants less than 1 year of age presenting with a first time episode.Cincinnati, OH: Author. Available at
Kelley, L., & Allen, P. (2007). Managing acute cough in children: Evidenced –based guidelines. Pediatric Nursing, 33, 515-524.
Organizations
Allergy & Asthma Network Mothers of Asthmatics
American Academy of Allergy, Asthma and Immunology
American Association for Respiratory Care (AARC)
American Cleft Palate-Craniofacial Association
American College of Allergy, Asthma, and Immunology
American Lung Association
American Thoracic Society
Association of Asthma Educators
Asthma and Allergy Foundation of America (AAFA)
Centers of Disease Control and Prevention (CDC)
Cystic Fibrosis Foundation
Cystic Fibrosis Worldwide
Environmental Protection Agency, Office of Children’s Health Protection
http//yosemite.epa.gov/ochp/ochpweb.nsf/homepage
Food Allergy & Anaphylaxis Network
National Asthma Education and Prevention Program, NHLBIInformationCenter
National Heart, Lung and BloodInstituteInformationCenter
National Jewish Medical and ResearchCenter
Respiratory Nursing Society
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young adults: Causes, consequences, and treatment strategies. Pediatrics, 115,
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intervention trial of asthma clubs to improve quality of life in primary school
children: The School Care and Asthma Management Project (SCAMP).
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Pediatric Tuberculosis Collaborative Group (2004). Targeted Tuberculin skin
testing and treatment of latent Tuberculosis infection in children and adolescents. Pediatrics, 114, 1175-1201.
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Schuster, M., Franke T., & Pham C.(2002). Smoking patterns of household members and visitors in homes with children in United States.Archives of Pediatric Adolescent Medicine, 156, 1094-1100.
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Addenda
Care Path 16-1 - An Interdisciplinary Plan Of Care for the Child with ApneaNursing Diagnosis: Ineffective breathing pattern related to apneic episodes.
Child/Family Outcomes: Child will have effective breathing pattern without apneic spells throughout hospitalization.
Nursing Diagnosis: Impaired home maintenance related to change in home care regimen.
Child/Family Outcomes: Parents will verbalize understanding of necessary diagnostic tests and consultations.
Parents will describe and demonstrate understanding of CPR and home apnea monitor prior to discharge.
Nursing Diagnosis: Interrupted family processes related to anxiety associated with threat of infant death.
Child/Family Outcomes: Parents will develop open communication with healthcare team and receive patient information in a timely manner.
Parents will verbalize understanding of need to develop support system to provide respite care.
Care Intervention Categories / Admission / Transition to Discharge / Discharge to Community
Consults / Social service
Specialty services such as Pulmonary and Gastroenterology / Teach parent/family members CPR (basic life support) and evaluate return demonstration
Nursing Assessment and Care Management / Check vital signs every 4 hr
Daily weights.
Height on admission
Complete assessment, with emphasis on respiratory system
Cardiorespiratory monitor (Apnea monitor)
Pulse oximetry
Keep head of bed elevated.
Avoid hyperflexion of neck.
Initiate documentation of apneic episodes. / Vital signs every 4 hr
Pulse oximetry spot checks.
Assess and document respiratory responses to care.
Pulse oximetry spot checks.
Keep child upright for 30-45 minutes following feeding.
Position on abdomen between feedings. / Discontinue pulse oximetry.
Place home monitoring device on child.
Assess response to reflux precautions.
Diagnostic Tests & Procedures / Possible tests include CBC, capillary blood gases, calcium, electrolytes, glucose, septic work-up
Aminophylline requires blood level monitoring.
Chest radiograph
ECG, EEG
Pneumogram (pneumocardiogram)
If history indicates, upper GI series, reflux scan, Ph probe, polysomnography / Repeat diagnostic tests as indicated by child’s condition.
PharmacologicManagement / As ordered by healthcare professional
Gastroesophageal reflux medications, if indicated / As ordered by healthcare professional
Gastroesophageal reflux medications, if indicated / Continue with medications, as ordered
Nutrition / Accurate intake and output
Reflux precautions if diagnosed with reflux. / Diet for age as tolerated.
Maintain reflux precautions if needed. / Diet for age as tolerated.
Maintain reflux precautions if needed.
Discharge planning / Teaching / Orient family to hospital and primary caregivers.
Have family verbalize understanding of monitors and diagnostic studies.
Have family verbalize understanding of infant's cardiopulmonary system.
Have family demonstrate reflux precautions, medication administration, monitor application, steps to answer monitor alarms. / Notify discharge planner of need for home nursing referral at time of discharge.
Find out whether family has telephone.
Advise family of home nursing referral.
Complete home healthcare referral.
Contact home health agency.
Begin CPR teaching.
Have family demonstrate use of home monitor.
Have family demonstrate CPR.
Review guidelines for using home monitoring with parents.
Suggest educating secondary care providers regarding monitor use and CPR. / Hold discharge conference with parents to review teaching needs, follow-up clinic visits, equipment needs, and financial resources.
Instruct parents to keep log of apneic episodes to include time, child’s activity at time of episode, and interventions to stimulate the child.
Provide parents with information on support group or name of other family with child on apnea monitoring at home.
Have parents notify neighborhood EMT of child’s status.
Home visit by home care agency is scheduled.
Follow up appointments scheduled.
CBC, complete blood count; CPR, cardiopulmonary resuscitation; EEG, electroencephalogram; ECG, electrocardiogram; EMT, emergency medical technicians; GI, gastrointestinal.
Care Path 16-2 - An Interdisciplinary Plan of Care for the Child with Bronchiolitis
Nursing Diagnosis: Ineffective breathing pattern related to bronchospasm, mucosal edema, and accumulation of mucus.
Child/Family Outcomes: Child will demonstrate improved breathing pattern, as evidenced by absence of tachypnea, retractions, nasal flaring, grunting, wheezing, cyanosis, or cough.
Nursing Diagnosis: Impaired gas exchange related to bronchiolar obstruction, atelectasis, and hyperinflation.
Child/Family Outcomes: Child will demonstrate adequate oxygenation and ventilation, as evidenced by oxygen saturation >92% and decreased work of breathing.
Nursing Diagnosis: Deficient fluid volume related to dyspnea, tachypnea, and decreased oral intake.
Child/Family Outcomes: The child will maintain adequate intake and output for age and weight.
The child will maintain adequate hydration, as evidenced by moist mucous membranes, good skin turgor, and serum electrolytes within normal range.
Nursing Diagnosis: Deficient knowledge related to home management of bronchiolitis.
Child/Family Outcomes: Family will demonstrate knowledge of and adherence to home treatment plan.
Care Intervention Categories / Admission / Transition to Discharge / Discharge to Community
Consults / Pediatric pulmonologist prior to initiation of ribavirin, if needed
Infection control specialist
Nursing Assessments and Care Management / Vital signs and pain q 2-4 hours based on acuity
Blood pressure on admission
Strict intake and output
Cardiopulmonary monitor
Continuous pulse oximetry
Keep head of bed elevated.
Activity as tolerated
Bulb suction with normal saline PRN for congestion. Suction with catheter and saline only for airway obstruction causing substantial respiratory compromise.
Contact isolation during non-epidemic period; contact precautions plus droplet precautions during RSV epidemic periods / Vital signs and pain every 4 hours
Pulse oximetry spot checks with respiratory treatments and PRN for respiratory distress
Keep head of bed elevated.
Activity as tolerated
Bulb suction with normal saline PRN for congestion. Suction with catheter and saline only for airway obstruction causing substantial respiratory compromise.
Contact isolation during non-epidemic period; contact precautions plus droplet precautions during RSV epidemic periods / Discontinue cardiopulmonary monitor.
Discontinue pulse oximetry.
Activity as tolerated
Discontinue isolation.
Diagnostic Tests & Procedures / CBC with differential
Blood culture if child appears very ill or temperature is >102F
Consider blood gas measurements
Nasal washing for RSV panel (if indicated)
Chest Radiograph (if indicated) / Repeat diagnostic tests as indicated by child’s condition
PharmacologicManagement / IV antibiotics if strong suspicion or evidence of bacterial infection
Acetaminophen15 mg/kg PO/PR every 4 hrs p.r.n. (if fever 1010F or mild pain);max dose = 75 mg/kg/day or 4 gm/day; whichever is less
Ibuprofen 10 mg/kg PO every 6 hrs (if fever >1010F or discomfort) if acetaminophen is not effective; max dose+ 400 mg
Neo-Synephrine 1/8%; 2-3 drops each nostril every 6 hrs PRN for nasal congestion
IV fluids at maintenance if clinically dehydrated or not taking PO feeds / Maintain IV fluids if not taking PO feeds well or change to heparin/saline lock. / Discontinue IV.
Room air
Nutrition / NPO if in respiratory distress
PO feedings if RR<60 / Diet for age
Encourage PO feeds and fluid intake. / Diet for age
Psychosocial / Parental support for anxiety
Rest for parent if sleep deprived
Respiratory / Suction prn, before feedings and before inhalation therapy.
Oxygen to keep O2 saturation >92% or for severe respiratory distress / Begin weaning oxygen to keep O2 saturation >94%. / Discontinue O2.
Room Air
Discharge planning / Teaching / Teach family to use bulb syringe and watch them practice. / Teach about home medication administration. Ensure family understands dosing and purpose of medications.
Home nebulizer, if needed
Assess smoking status in home, refer family for smoking cessation and encourage smoke-free homes and cars. / Discharge if Ribavirin therapy not needed.
Return to clinic if signs/symptoms of respiratory distress recur.
ADLs, activities of daily living; CBC, complete blood count; ECG, electrocardiogram; IM, intramuscular; IV intravenous; NPO, nothing by mouth; PO, by mouth; RR, respiratory rate; RSV, Respiratory Syncytial virus
Care Path 16-3 - An Interdisciplinary Plan of Care for the Child with Pneumonia
Nursing Diagnosis: Ineffective breathing pattern related to an inflammatory infection of the lower airway
Child/Family Outcomes: Child will demonstrate and maintain an improved breathing pattern throughout hospitalization, as evidenced by lessening or absence of tachypnea, retractions, nasal flaring, grunting, wheezing, cyanosis, and/or cough.
Nursing Diagnosis: Deficient knowledge related to disease process and home management of child upon discharge
Child/Family Outcomes: Family will verbalize understanding of illness and rationale for treatment plan.
By discharge, family will verbalize/demonstrate an understanding of how to administer medication at home, how to perform PD&P, how to use a bulb syringe and an MDI as appropriate, and when to notify physician of changes in respiratory status.
Care Intervention Categories / Admission / Transition to Discharge / Discharge to Community
Nursing Assessment and Care Management / Check vital signs every 4 hr
Strict intake and output
Consider apnea monitor for infants <6 mo with moderate to severe respiratory distress.
SpO2 check once, and then check p.r.n. for respiratory distress.
Activity as tolerated
Contact isolation / Vital signs every 4 hr
I&O every shift
Apnea monitor as indicated
SpO2 p.r.n. for respiratory distress
Activity as tolerated
Maintain contact isolation. / Discontinue apnea monitor.
Activity as tolerated
Discontinue isolation
Diagnostic Tests & Procedures / CBC with differential
Consider blood culture and cold agglutinins.
Chest radiograph
Spirometry for children (> 6 yrs) with co-morbid conditions (e.g., CF, asthma, neuromuscular, etc.) / Repeat diagnostic tests as indicated by child’s condition.
PharmacologicManagement / Ampicillin 200 mg/kg/day IV q 6 hrs (maximum 2 g/dose)
Or
Cefuroxime 75-150 mg/kg/day IV q 8 hr for bacterial pneumonia (maximum dose, 1.5 g/dose)
Neo-Synephrine 1/8%, 2-3 drops each nostril every 6 hr, p.r.n. for nasal congestion.
Acetaminophen 15 mg/kg (max dose 650 mg) PO/PR every 4 hours PRN T>101F or discomfort
Ibuprofen 10 mg/kg (max dose 400 mg) PO every 6 hours PRN T>101F or discomfort if acetaminophen is not effective.
Heparin/saline lock or consider IV fluids at maintenance if unable to take PO feeds. / Once PO intake is consistently 75% or more of maintenance, switch to heparin/saline lock IV / Discontinue Neo-Synephrine (>3 day use not recommended).
Change to oral antibiotics.
For bacterial pneumonia, discharge on PO antibiotics to complete a 10-day course.
Discontinue heparin/saline lock.
Nutrition / NPO if respiratory distress symptoms or vomiting / Diet for age; encourage fluids (clear); avoid dairy products / Diet for age as tolerated