RESPIRATORY TRACT DISORDERS
Upper Respiratory Infection
Upper respiratory infections are common in children and adults; they may be caused by a virus or a bacterium. Symptoms of URI may include a fever; varying degrees of dyspnea with thick, tenacious sputum and mucus; and throat edema. If no cough is present, the child may have difficulty getting rid of secretions. Children are usually cared for at home unless complications develop.
General treatment includes antibiotics, humidity, and rest. Oxygen may be necessary. The child may be put in a mist tent, or a bedside cool-air humidifier may be used. If hospitalized, the child with a contagious disease is kept in his or her room, and only adults may visit. At home, caregivers should try to keep ill children separate from well children and encourage the use of separate glasses and utensils. Frequent handwashing is a must.
Pneumonia
Pneumonia, an inflammation of the lungs, usually with consolidation and drainage, is common in children and adults. It may initially be an infectious disease (see Pneumococcal pneumonia immunization earlier in this topic); or a disease that is secondary to another disease, or it may result from aspiration. The physician differentiates pneumonia from other URIs by means of a chest x-ray examination. Pneumonia is usually treated with antibiotics, bed rest, and fluids.
When caregivers administer antibiotics for any reason, they should understand that the child must take the medication for the prescribed number of days. If the prescribed regimen is not followed, resistant strains of pathogens can develop.
Laryngotracheobronchitis
Laryngotracheobronchitis (LTB), a viral infection of the upper airways, usually follows several days of URI. It is also known as croup. Croup is a syndrome that results in a harsh, “barky” cough, inspiratory stridor (shrill sound on inhalation), hoarseness, and other signs of respiratory distress.
Croup syndromes that affect the larynx, the trachea, and bronchi are serious in children because of the smaller diameter of their airways. Acute spasmodic croup is an inflammation of the subglottic area characterized by the barking cough and varying degrees of respiratory distress occurring primarily at night. Copious, tenacious secretions and edema of the airway make breathing difficult. Cyanosis may be present. The child usually has a low fever, rapid pulse, cold and clammy skin, and flushed face. Treatment consists of cool, humidified air and keeping the child calm.
The child is placed in a mist-tent humidifying device. Oxygen may be given to assist respirations. A pulse oximeter may be used to detect hypoxia. A chest x-ray examination may be ordered. Expectorants are often given to loosen secretions and to assist the child in coughing up mucus. A semi-Fowler’s position may ease respiratory efforts. Antipyretics (acetaminophen, ibuprofen) are used to reduce temperature. Oral fluids are encouraged. If the child cannot take fluids orally, IV fluids are given. Frequently offer clear liquids, ice pops, gelatin, and other fluids.
Epiglottitis
Acute epiglottitis is an acute, rapidly progressive, life-threatening inflammation of the epiglottis usually caused by a bacterium. Severe respiratory distress, high fever, absence of cough, and drooling of saliva (with refusal to swallow owing to an extremely sore throat) are the cardinal symptoms. Intravenous antibiotics result in a rapid recovery. Endotracheal intubation for 1 to 3 days may be necessary to ensure a patent airway.
Nursing Alert If epiglottitis is suspected, do not attempt to examine the throat, obtain a throat culture, or do anything that might upset the child because this might cause respiratory obstruction.
Asthma
Asthma is a chronic inflammatory disorder of the airways affecting more than 20 million adults and children. Asthma is caused by edematous airways and excessive mucus production, which cause airway obstruction. The incidence of asthma has been steadily increasing globally as a result of multiple environmental factors. Other triggers may include strenuous physical exercise, high humidity or cold temperatures, some foods and food additives, and some medications. Emotions may play a part in asthma because the stress of the disorder complicates the person’s ability to maximize the use of his or her personal defense mechanisms. Asthma has become a common chronic illness of childhood and is a primary reason for school absences. Asthmatic children are often seen in the ED. Most asthmatic clients have their first symptoms by the age of 4 years.
Symptoms
The disorder is chronic, but acute asthma attacks generally occur when triggers or irritants affect the lungs. Attacks may occur abruptly or may gradually build over several days. The initial attack often occurs at night. Wheezing is not always present, but is a common symptom. Wheezing occurs when expired air is pushed through obstructed bronchioles. Other common symptoms include difficulty breathing, chest tightness, and coughing, particularly at nighttime or in the early morning. During an attack, the lungs become inflamed and edematous. The small bronchiole muscles constrict airways so that less air goes in and out of the lungs. Mucus forms and can clog the small airways.
Treatment
Prevention is the most important aspect of treatment. Children and their families must learn to recognize the symptoms that lead to an attack and begin treatment as soon as possible. Family caregivers should work toward eliminating any possible allergens in the home. Their children need protection against smoke inhalation. In addition, family caregivers must alert teachers, school nurses, babysitters, and others involved with the child of his or her asthma so that they can provide support as needed.
The drugs of choice are bronchodilators and steroids administered orally or through metered-dose inhalers (MDI). Bronchodilators used daily as prophylactic medications include leukotriene antagonists, such as montelukast (Singulair) or zafirlukast (Accolate). Long-term management of asthma includes bronchodilators albuterol (Ventolin), metaproterenol (Alupent), or terbutaline (Brethaire). Mast cell stabilizers, such as cromolyn sodium (Intal) or nedocromil (Tilade), may also be used as daily therapy to prevent asthma attacks. Treatment for asthma varies with the duration and intensity of the illness. In an acute attack, epinephrine is used. Corticosteroids, either orally or, preferred, by inhalation, may be used for the shortterm management of acute or chronic inflammation of the respiratory tract.
The child learns to use the nebulizer or MDI to administer medications. Use of a spacing unit makes the MDI easier to use and aids in delivering the correct dosage of the medication to the lung tissue (Fig. 72-10).
Chest physical therapy (CPT) is also a useful addition to treatment; it includes breathing exercises, physical training, postural drainage, and inhalation therapy.
Nursing Alert Status asthmaticus, which canjbe fatal, is a condition that exists when medications do not relieve an acute episode of asthma. Treatment includes administration of IV fluids, bronchodilators (e.g., aminophylline), antibiotics, and anti-inflammatory agents.
Bronchiolitis
Bronchiolitis is a viral respiratory infection resulting in inflammation of the bronchioles. It is seen most often in children younger than 2 years and tends to be a seasonal illness, occurring in winter and early spring.
FIGURE 72-10 · Child using a metered-dose inhaler (MDI) with spacer.
The illness begins with symptoms of a cold, which gradually worsen. Chest x-ray studies reveal air trapping in the lungs. The illness usually resolves within 10 days. A severe case of bronchiolitis may require hospitalization and treatment with IV fluids and oxygen administered by mist tent. Respiratory syncytial virus (RSV), discussed earlier in this topic, is believed to cause more than half the cases of bronchiolitis.
Cystic Fibrosis
Cystic fibrosis, a multisystem chronic and incurable condition, is a major dysfunction of the exocrine glands. It is the most common genetic disease in Caucasians, inherited as an autosomal recessive condition. It is rare in African Americans and Asian Americans. It affects the respiratory system, GI system (pancreas, liver), and, in adult men, reproductive organs. In cystic fibrosis, mucus-producing glands secrete abnormal quantities of thick mucus. These secretions collect in the child’s lungs, pancreas, and liver, disrupting the normal functions of these organs. Many children with cystic fibrosis eventually die of cardiopulmonary complications; however, with active treatment, children often live past adolescence.
Symptoms and Diagnosis. Symptoms may occur at any age. Some children show symptoms in infancy, including meconium ileus (causing bowel obstruction), bile-stained emesis, a distended abdomen, and no stool. The skin of these infants may have a salty taste because of the high sodium chloride content in their sweat. FTT, despite a good appetite, is common. In some children, a hard, nonproductive cough may be the first indication. Frequent respiratory infections follow. A barrel chest, finger clubbing, and signs of malnutrition may be evident.
Diagnosis is based on family history, elevated sodium chloride levels in the sweat (as determined by a sweat test), analysis of duodenal secretions for trypsin content (obtained via a nasogastric tube), and a history of frequent respiratory infections and FTT. If the sweat test is positive for high levels of sodium, only one other criterion must be met for a positive diagnosis.
Medical Treatment. During an acute infection, the client is treated with massive doses of antibiotics to prevent infection. Drugs, such as pancreatin and pancrelipase, seem to be useful in counteracting pancreatic insufficiency. These pancreatic enzymes are given with meals or snacks to aid in digesting fats and proteins. Pancreatic enzymes have an enteric coating that protects stomach acid from destroying them and delivers them safely to the duodenum. They should be administered at the beginning of the meal with cold—not hot—food because heat decreases the activity of the enzyme.
The high-calorie, high-protein, moderate-fat diet should include supplementary water-soluble forms of fat-soluble vitamins A, D, E, and K, which are necessary because of poor fat digestion. Weight should be frequently monitored. Salt should not be restricted, especially in hot weather. Fluids should be encouraged to prevent dehydration, which causes the mucus to become thicker.
Treatment for maintaining optimum pulmonary function includes chest physical therapy, inhalation therapy,antibacterial drugs for the prophylaxis or treatment of infection, as indicated, and immunization against childhood communicable diseases. All immunizations should be maintained and given at appropriate intervals. Encourage physical activity because it improves mucus secretion as well as a positive self-image. Encourage the child to participate in any aerobic activity he or she enjoys. Limit activity, along with physical therapy, only according to the child’s endurance.
Inhalation therapy is prescribed as a preventive or therapeutic measure. A bronchodilator drug (albuterol) is usually administered by a hand-held nebulizer. Agents that break down DNA molecules in sputum result in a breakup of the thick mucus in the airways. The addition of a mucolytic agent, such as acetylcysteine (Mucomyst), may be prescribed during periods of acute infection. A humidifier can provide a beneficial moist atmosphere. During the summer, a room air conditioner can help provide the child with comfort and controlled humidity.
Chest physical therapy is performed regularly. CPT is a combination of postural drainage and chest percussion (clapping and vibrating of the affected areas). Chest percussion that is performed correctly helps to loosen and move secretions out of the lungs. A nurse, physical therapist, or respiratory therapist can teach family caregivers to perform this routine as an essential part of home care.
The family needs much teaching and support. Caregivers should avoid overprotecting the child. They will need to learn CPT, postural drainage, administration of IV antibiotics, and enzyme regulation, according to the child’s needs. In summer, the active child may need extra salt. Caring for the child places enormous stress on the family’s financial resources. The Cystic Fibrosis Foundation, a national organization, provides education and services for these children and their families. In addition, assistance may be available through local sources. The caregivers must also learn to take time to care for themselves.
GASTROINTESTINAL DISORDERS
Review the information on general surgery and pediatric surgery.
Pyloric Stenosis
In pyloric stenosis, also called congenital hypertrophic pyloric stenosis, the child’s pyloric sphincter thickens, narrowing the canal through which food passes from the stomach to the intestine. This condition is more common in boys than in girls. An infant usually does not show signs of pyloric stenosis until he or she is about 2 months old. The stenosis may be so extensive that the obstruction is complete; the pylorus then closes, and food cannot pass into the intestine. As a result, the child regurgitates food into the esophagus, causing severe projectile vomiting. Vomiting is the most common symptom of pyloric stenosis. Other symptoms include loss of weight, hunger, irritability, and dehydration. Often, constipation and oliguria are associated with it. Diagnosis is made on the basis of an upper GI x-ray examination.
Medical and Surgical Treatment. The treatment of choice for pyloric stenosis is surgery (pyloromyotomy). However, if the child is a poor surgical risk and if the stenosis is not life-threatening, medical means of treatment may be used, including sedation, antispasmodic drugs, and thickened feedings.
Nursing Considerations. Before surgery, IV fluids should be given to correct fluid and electrolyte imbalance caused by vomiting. Electrolyte laboratory studies identify the type of solution to administer. An accurate record of I&O and the amount and type of vomitus is essential.
After surgery, precautions should be taken to prevent aspiration. Position the child on the right side, with his or her head slightly elevated. Schedule care so that you give the child a bath before feeding. Glucose water feedings are started 2 to 3 hours after surgery; bubble the child frequently. Increase the amount of feedings when the infant is able to retain more. Progress the diet from glucose water, to halfstrength formula, to full-strength formula. Recovery is usually complete, and the child experiences no further problems.
Meckel’s Diverticulum
Meckel’s diverticulum is a congenital disorder in which a small portion of the child’s ileum ends in a blind pouch just before its junction with the colon. Symptoms include the passage of bloody or tarry stools. The child experiences no pain unless the diverticulum is inflamed; the condition may exist without ever causing symptoms. When symptoms do occur, surgical removal of the pouch is necessary. Complications are rare. Preoperative and postoperative care is routine.
Hernia
A hernia is the protrusion of part of an organ through an abnormal opening. In children, a congenital defect is most often the cause of hernia. Hernias take various forms:
• Diaphragmatic hernia, which occurs rarely, is a condition in which a portion of the intestine protrudes through the diaphragm. It is usually diagnosed at birth and repaired through immediate surgery.
• In umbilical hernia, a portion of the intestine protrudes through a weak umbilical ring, producing a bulge beneath the child’s navel. Because this condition usually disappears by the time the child is 3 to 4 years old, surgery is usually unnecessary. Strangulation of the protruded part is rare, with surgery necessary only if the protruding part is large or if other congenital defects are present.
• In indirect inguinal hernia, which is most frequent in boys, the intestine protrudes through the round ligament into the inguinal area and may descend into the scrotal sac. Surgery is required if strangulation develops. In girls, an inguinal hernia may involve the ovary or the uterus, and immediate surgery is needed to prevent damage to these structures.
• A direct inguinal hernia protrudes through the weakest part of the abdominal wall. Because the peritoneum overlying the protruding abdominal contents is transparent, all or part of the abdominal contents may be seen. Should the hernia rupture, severe hemorrhage, peritonitis, a generalized septicemia, or strangulation of the hernia could occur. Surgery is usually performed early in life.
Treatment. The treatment of choice for most hernias is surgery. The specific procedure varies with the condition. Preoperative and postoperative care is routine. Often hernia repair is completed in the same-day surgery suite and may be done by laparoscopy.
Diarrhea
Diarrhea is a sudden increase in frequency of loose and watery stools. It is most often caused by pathogens in the GI tract. Stress, prolonged temperature elevation, and spoiled food are other causes. Certain antibiotics can alter the bacteria normally present in the intestine, resulting in an increased number of stools.
Diarrhea can be very dangerous for young children. Smaller and younger children are at increased risk for fluid and electrolyte imbalance and dehydration. Severe diarrhea can be rapidly fatal in an infant.
Medical Treatment. Mild forms of diarrhea are treated at home. Family caregivers should administer an oral rehydration solution (ORS), such as Pedialyte, to children with diarrhea. ORSs are available in different flavors. Clear liquids with sugar and/or caffeine should be avoided. An age-appropriate diet should be offered within 24 hours. Family caregivers should avoid giving salty broth to children with diarrhea because the salt content may further disturb their electrolyte balance.
In severe diarrhea, stools are frequent and forceful, and are green or yellow liquid. The child is lethargic and irritable. Skin turgor is poor, mucous membranes are dry, the eyes and anterior fontanels are sunken, urination is decreased, and the pulse is weak and rapid, indicating dehydration. Usually IV fluids, based on electrolyte studies, are necessary to replace water loss and to restore fluid and electrolyte balance. A chest x-ray examination determines any complicating respiratory condition, and a stool culture identifies the causative organism.
Nursing Considerations. Transmission-Based Precautions should be followed when caring for the child with diarrhea. IV therapy is necessary to replace body fluids; restraints may be necessary during IV infusion. Be sure to comfort the child, and to release restraints periodically so that the child can change position at will.
Maintain accurate I&O records and carefully describe the amount and character of all stools. Continue food and fluids, except in cases of severe vomiting. Teach caregivers to use ORSs and observe the child for any signs of dehydration. Clear fluids and juices are inadequate because they are high in carbohydrates but low in electrolytes. Encourage the early reintroduction of regular nutrients.
Good skin care is essential because the child’s buttocks can become sore and irritated. Thorough, gentle cleansing from the front of the perineal area to the back is necessary each time the child defecates. Expose the child’s buttocks to air as much as possible. Sitz baths in clear, tepid water and protective ointments help ease discomfort.
Encopresis
Encopresis is incontinence of feces without physical cause. It occurs in previously toilet-trained children. Usually, symptoms begin with stool withholding late in infancy.
Treatment should be geared toward improving family relationships and understanding personality patterns. Nursing support and a nonjudgmental, nonpunishing approach from family caregivers is fundamental to the therapeutic plan. The child with prolonged encopresis and the caregivers may need counseling. Oil-retention enemas and mineral oil are usually prescribed. Increased dietary fiber and fluids is recommended.
Lactose Intolerance
If a child has frequent attacks of diarrhea, lactose intolerance, an inherited disorder characterized by an inability to metabolize lactose in milk and milk products, may be the problem. It is more common in Asian Americans and African Americans than in other ethnic groups.
The lactose-intolerant child cannot drink milk or eat dairy products. Not only does the lactose-intolerant person’s body improperly absorb and metabolize dairy products, but the presence of such substances also interferes with the absorption of other foods. If the problem is not recognized and treated in a child, he or she could die from malnutrition.
Symptoms of lactose intolerance include diarrhea, abdominal pain, vomiting, listlessness, and FTT. These symptoms may appear 1 to 2 weeks after birth. The baby is switched to a lactose-free formula. Yogurt, which has inactive lactase that is activated by the temperature and pH of the duodenum, is an excellent source of calcium. Teach family caregivers to observe for hidden sources of lactose that the child must avoid.
Intussusception
Intussusception is the telescoping of one bowel part into another. It is usually caused by hyperactive peristalsis in one bowel part and hypoactivity in another. Cardinal symptoms include abdominal pain and passage of a currant-jelly stool (clear mucus with blood). One danger of this condition is that the bowel’s blood supply may be blocked, causing gangrene and possible bowel rupture.
Intussusception is most common in infants; yet affected babies usually appear to be thriving. A definite diagnosis is based on the findings of a barium enema. The x-ray examination itself may reduce the intussusception; if not, surgery is necessary to prevent complications. Preoperative and postoperative care is routine, and the healthy child seldom has complications.
Nursing Alert Passage of a normal stool indicates reduction of the intussusception and should be reported to the physician immediately
Colic
Colic is paroxysmal abdominal pain, most commonly occurring in the first 3 months of an infant’s life. The baby almost always outgrows the condition by the time he or she is 3 to 4 months old. Although colic is not serious, it can be extremely frustrating for family caregivers. Affected babies have frequent crying episodes. These children double up as though they are in great pain. Symptoms seem to worsen in the evenings.
Treatment consists of feeding the baby slowly, and reducing the amount of air that the infant swallows. The formula given is usually one with a soy base. A pacifier may help by promoting nonnutritive sucking. Soothing the infant through touching, rocking, and gently speaking is also recommended. Family caregivers need a break from the baby’s constant crying; encourage them to develop a support system of relatives, friends, and babysitters.
Megacolon
In megacolon, also known as Hirschsprung’s disease or aganglionic megacolon, the child’s colon lacks parasympathetic nerve supply. Because of a lack of peristalsis, the abdomen becomes abnormally enlarged with stool and flatus. If a large colon segment is affected, palliative treatment may be the only alternative. Surgical treatment may be effective if the damaged or malfunctioning portion can be removed.
Symptoms and Diagnosis. Feces accumulation in the child’s bowel causes symptoms that include diarrhea, constipation, nausea, and vomiting. The abdomen becomes distended, and bowel movements are abnormal, resulting in malnutrition. Usually, the effects of megacolon appear shortly after birth when the newborn fails to pass meconium within 24 to 48 hours.
Signs of obstruction, such as bile-stained or fecal vomiting, abdominal distention, irritability, feeding problems, FTT, or dehydration, may occur. The older child exhibits intractable constipation that usually requires laxatives and saline enemas. Surgery is usually required.
Diagnosis is made on the basis of medical history, x-ray studies, barium enema, and palpation of the distended abdomen. A proctoscopy usually reveals an empty rectum and lower colon, and biopsy of the rectal wall usually indicates an absence of nerve fibers.
Medical and Surgical Treatment. If possible, corrective surgery is delayed until the child is about 1 year old and better able to withstand the procedure. During the waiting period, preventing constipation is important. Small saline enemas, stool softeners, and digital removal of fecal impactions are used. Sometimes colonic irrigations are done. These are similar to enemas, except that they require a larger tube to be passed into the descending colon.
Drugs that act on the parasympathetic and sympathetic nervous systems may be given to improve peristalsis. Surgery often involves a temporary colostomy (opening of the large intestine onto the abdominal wall).
Key Concept Watch for abdominal distention, temperature spikes, and irritability after surgery for megacolon. These are signs of possible anastomotic leaks (leakage where the two ends of the bowel are sewn together).
Nursing Considerations. Preoperative preparation may include saline enemas for colon evacuation. Keep accurate records of the quantity of solution administered. The return solution should be clear of fecal particles. Administer ordered antibiotics as a bowel preparation.
Keep the surgical wound clean and dry after surgery. Do not take rectal temperatures. The child’s first liquid bowel movement will be approximately 3 to 4 days after surgery. Observe for the presence of blood in the child’s urine because bladder trauma can result from extensive surgical manipulation.
Clear oral feedings usually begin after active bowel sounds are audible. The diet progresses according to the child’s tolerance. Instruct family caregivers to watch closely for foods that increase the child’s number of stools and to avoid including them in the child’s diet at home. Assure caregivers that the child will eventually achieve sphincter control and be able to eat a normal diet. Complete continence may take several years for the child to attain. Encourage caregivers to participate in the child’s care as much as possible, to gain confidence in caring for the child at home.
