Bowden, Chapter 16: Supplemental Resources
Key Terms
apnea
atelectasis
atopy
cor pulmonale
cyanosis
dyspnea
hemoptysis
hypercarbia
hypoxemia
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 health care 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 health care providers and use of proactive and preventive measures.
Evidence-Based Practice Guidelines
American Academy of Pediatrics. (2001). Clinical practice guideline: Management of sinusitis. Pediatrics, 108(3), 798–808.
American Academy of Pediatrics. (2003). Apnea, sudden infant death syndrome, and home monitoring. Pediatrics, 111, 914–917.
American Association for Respiratory Care. (2007). Removal of the endotracheal tube—2007 revision & update. Respiratory Care, 52, 81–93.
Cincinnati Children’s Hospital Medical Center. (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. Retrieved from http://www.guideline.gov
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
www.aanma.org
American Academy of Allergy, Asthma & Immunology
www.aaaai.org
American Association for Respiratory Care
www.aarc.org
American Cleft Palate-Craniofacial Association
www.acpa-cpf.org
American College of Allergy, Asthma & Immunology
www. acaai.org
American Lung Association
http://www.lung.org/
American Thoracic Society
www.thoracic.org
Association of Asthma Educators
www.asthmaeducators.org
Asthma and Allergy Foundation of America
www.aafa.org
Centers of Disease Control and Prevention
www.cdc.gov
Cleft Palate Foundation
www.cleftline.org
Cystic Fibrosis Foundation
www.cff.org
Cystic Fibrosis Worldwide
www.cfww.org
Food Allergy & Anaphylaxis Network
(FAAN; now Food Allergy Research & Education, formed by a merger between FAAN and the Food Allergy Initiative)
www.foodallergy.org
National Asthma Education and Prevention Program
NHLBI Information Center
www.nhlbi.nih.gov/about/naepp/
National Heart, Lung, and Blood Institute Health Information Center
www.nhlbi.nih.gov/health/infoctr
National Jewish Health
http://www.nationaljewish.org/
Respiratory Nursing Society
www.respiratorynursingsociety.org
U.S. Environmental Protection Agency
Office of Children’s Health Protection
http://yosemite.epa.gov/OCHP/OCHPWEB.nsf/content/whatwe.htm
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Addenda
Nursing Diagnosis: Ineffective breathing pattern related to apneic episodes
Child/Family Outcome: 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 health care 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 hours.
Daily weights
Height upon 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. / Check vital signs every 4 hours.
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 and procedures / Possible tests include CBC, capillary blood gases, calcium, electrolytes, glucose, septic workup
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.
Pharmacologic management / As ordered by health care professional
Gastroesophageal reflux medications, if indicated / As ordered by health care professional
Gastroesophageal reflux medications, if indicated / Continue with medications, as ordered.
Nutrition / Accurate intake and output
Reflux precautions if suspected or documented 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, and 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 health care 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 educational 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; ECG, electrocardiogram; EEG, electroencephalogram; 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 Outcome: 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 Outcome: Child will demonstrate adequate oxygenation and ventilation, as evidenced by oxygen (O2) saturation >92%, improved aeration, 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 Outcome: Family will demonstrate knowledge of and adherence to home treatment plan.
Care Intervention Categories / Admission / Transition to Discharge / Discharge to Community