RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
Ms NISHA.P.V
M Sc Nursing 1st year
Child health nursing
Year 2011- 2013
PADMASHREE INSTITUTE OF NURSING
BANGALORE – 560 060
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. / NAME OF THE CANDIDATE AND ADDRESS / Ms. NISHA.P.VI Year M.Sc. Nursing,
Padmashree Institute of Nursing,
Kommaghata, Kengeri Hobli,
Bangalore-560 060.
2. / NAME OF THE INSTITUTION / Padmashree Institute of Nursing,
Bangalore.
3. / COURSE OF THE STUDY AND SUBJECT / 1st year M.Sc. Nursing,
Child health nursing.
4. / DATE OF ADMISSION TO THE COURSE / 16th July 2011
5. / TITLE OF THE STUDY / Assessment of effectiveness of prone Vs semi-fowler’s positioning on selected physiological parameters among under five children admitted with pneumonia in a selected hospital,Bangalore.
6. BRIEF RESUME OF THE INTENDED WORK
6.1 INTRODUCTION
Childhood is believed to be one of the most interesting , enjoyable and happiest period in one’s life. As we all are human beings we cannot escape from diseases. Many kinds of diseases affect a child, starting from the time of birth. Any of the body system or systems may get affected by the disease. Mostly under five children are prone to get respiratory tract infections. The respiratory system is made up of the organs involved in the interchanges of gases, and consists of the nose, pharynx, larynx, trachea, bronchi, and lungs. The upper respiratory tract includes the nose, nasal cavity, ethmoidal air cells, maxillarysinus, larynx, and trachea. While the lower respiratory tract includes the lungs, bronchi and alveoli.
Functions of respiratory system:
· Removal of CO2 and replacement of O2 needed for metabolism.
· Maintenance of acid-base balance (pH level).
· Maintenance of body H2O level and heat balance.
· Production of speech.
· Facilitate the sense of smell.
Assessment of Respiratory function
· Information of the child’s respiratory status is obtained from observations of physical signs and behavior. Respiration, the configuration of the chest, the pattern of respiratory movement, including rate, regularity, symmetry of movement, depth, effort expended in respiration, and use of accessory muscles of respiration, should be assessed. Respiration is best determined when the child is sleeping or quietly awake.
· Palpation and percussion- provide information regarding areas of pain and tissue density.
· Auscultation- of the lung fields is helpful in identifying specific pathologies and in assessing the child’s responses to treatment. Auscultation is essential when determining airway patency.
Noisy breathing : Noisy breathing has been described as abnormal breath sounds that are audible without the use of a stethoscope. These sounds result from blockage of the airway anywhere along the pathway from the nose to the bronchioles. Blockage at these points could be the result of foreign object inhalation, inflammation, airway constriction or external compression of the airways. In general, respiratory obstruction tends to occur more often in younger patients because the larynx is smaller in younger infants. Noisy breathing in a child/infant can cause great distress for the caregiver. It is a complaint that should be investigated immediately and thoroughly.
Noisy breathing can be classified into three main types: snoring, stridor and wheezing.
1.Snoring:
Snoring is an abnormal breath sound that occurs while the child sleeps. Snoring is usually the result of a partial obstruction of the upper respiratory tract that in turn causes vibration of air as it passes through the nasopharynx and oropharynx.
2.Stridor:
Stridor is a harsh, continuous, crowing sound that is caused by variable airway
obstruction that is an obstruction which blocks flow in one direction but not the other. Most commonly,stridor occurs on inspiration and is caused by an extrathoracic variable airway obstruction.
3.Wheeze
A wheeze is a continuous sound that is mainly heard on expiration. It indicates an intrathoracic airway obstruction, resulting from dynamic compression of the bronchi. Wheezing can be accompanied by feelings of tightness in the chest and labored breathing. Children who are having difficulty in breathing often show signs that they are not getting enough oxygen, indicating respiratory distress. It is important to learn the signs of respiratory distress to know how to respond appropriately.
Signs of respiratory distress:
· Breathing rate: An increase in the number of breaths per minute, usually > 60 breath/minute in infants.
· Retractions: The chest appears to sink with each breath - one way of trying to bring more air into the lungs.
· Color changes:cyanosis seen around the mouth, on the inside of the lips, or on fingernails may occur when a person is not getting as much oxygen as needed.
· Grunting: A grunting sound can be heard each time that the child exhales. This grunting is the body's way of trying to keep air in the lungs so they will stay open. Grunting is frequently a sign of chest pain, suggesting acute pneumonia or pleural involvement. It is also observed in pulmonary edema and is a characteristic of respiratory distress syndrome.
· Nasal flaring: It is a sign of respiratory distress and a very significant finding in infant. The openings of the nose spreading open while breathing may indicate that a child is having to work harder to breathe. The enlargement of the nostrils helps reduce nasal resistance and maintain airway patency.
· Wheezing: A tight, whistling or musical sound heard with each breath may indicate that the air passages may be smaller, making it more difficult to breathe. Other abnormal lung sounds that could be heard are rales (or crackles: short, popping; sudden inflation of alveoli), ronchi (or gurgles:continuous rattle; fluid in large airways) and pleural friction rub (grating, leathery; inflamed pleura).1
Among the lower respiratory tract infections, the most common and dangerous one affecting children is pneumonia. Pneumonia is a form of acute respiratory infection that affects the lungs. A germ such as bacteria, virus, fungus or parasite can cause it. When a child gets pneumonia, tiny air sacs in the lungs can fill with fluid. This fluid blocks the air sacs and oxygen cannot get to the body from the lungs. 2
Pneumonia is caused by a number of infectious agents, including viruses, bacteria and fungi.
The most common are:
· Streptococcus pneumoniae – the most common cause of bacterial pneumonia in children;
· Haemophilus influenzae type b (Hib) – the second most common cause of bacterial pneumonia;
· Respiratory syncytial virus is the most common viral cause of pneumonia; in infants infected with HIV. Pneumocystis jiroveci is one of the commonest causes of pneumonia, responsible for at least one quarter of all pneumonia deaths in HIV-infected infants.
The symptoms of viral and bacterial pneumonia are similar. However, the symptoms of viral pneumonia may be more numerous than the symptoms of bacterial pneumonia.
The symptoms of pneumonia include:
· rapid or difficult breathing
· cough
· fever
· chills
· loss of appetite
· wheezing (more common in viral infections).
When pneumonia becomes severe, children may experience lower chest wall indrawing, where their chests move in or retract during inhalation (in a healthy person, the chest expands during inhalation). Infants may be unable to feed or drink and may also experience unconsciousness, hypothermia and convulsions.
Pneumonia can be treated with antibiotics. These are usually prescribed at a health centre or hospital, but the vast majority of cases of childhood pneumonia can be administered effectively within the home. Hospitalization is recommended in infants aged two months and younger, and also in very severe cases. As pneumonia is associated with increased secretions and breathing difficulty, proper positioning is very important . However, there are still controversies going on regarding which position is best for relieving distress associated with pneumonia. A caregiver will usually lay the child in 4 to 6 different positions. This may be done 3 to 4 times a day. The fluid will then drain to the upper part of the child's lungs. From their , it can be drained out using chest physiotherapy.3
6.2 NEED FOR THE STUDY
Pneumonia, whether viral or bacterial, accounts for significant mortality and morbidity.4 Pneumonia and other lower respiratory tract infections are the leading causes of death worldwide. Because pneumonia is common and is associated with significant morbidity and mortality, properly diagnosing pneumonia, correctly recognizing any complications or underlying conditions, and appropriately treating patients are important. Although in developed countries the diagnosis is usually made on the basis of radiographic findings, the World Health Organization (WHO) has defined pneumonia solely on the basis of clinical findings. Pneumonia may originate in the lung or may be a focal complication of a contiguous or systemic inflammatory process.
Abnormalities of airway patency as well as alveolar ventilation and perfusion occur frequently due to various mechanisms. These derangements often significantly alter gas exchange and dependent cellular metabolism in the many tissues and organs that determine survival and contribute to quality of life. Recognition, prevention, and treatment of these problems are major factors in the care of children with pneumonia.Findings obtained by visual inspection and on timing of the respiratory rate.5
Pneumonia is the single largest cause of death in children worldwide. Every year, it kills an estimated 1.6 million children under the age of five years, accounting for 18% of all deaths of children under five years old worldwide. Pneumonia affects children and families everywhere, but is most prevalent in South Asia and sub-Saharan Africa. 6
In 2009, WHO and UNICEF launched the Global action plan for the prevention and control of pneumonia (GAPP). The aim is to accelerate pneumonia control with a combination of interventions to protect, prevent, and treat pneumonia in children with actions to:
· protect children from pneumonia include promoting exclusive breastfeeding and hand washing, and reducing indoor air pollution ;
· prevent pneumonia with vaccinations ;
· treat pneumonia are focused on making sure that every sick child has access to the right kind of care -- either from a community-based health worker , or in a health facility if the disease is severe -- and can get the antibiotics and oxygen they need to get well. 7
Pneumonia is a form of acute respiratory infection that affects the lungs. The lungs are made up of small sacs called alveoli, which fill with air when a healthy person breathes. When an individual has pneumonia, the alveoli are filled with pus and fluid, which makes breathing painful and limits oxygen intake. In case of children with pneumonia, a comfortable position itself can act as a relieving factor. Child must be positioned in such a way that breathing will be eased and secretions from within the lower respiratory tract can be drained out. This study aims at finding out the most effective position that can be used to relieve the distress that occurs in the under five children with pneumonia.8
In most of the disease affecting the respiratory tract, fluids or secretions will be accumulated in the different segments of lungs. In order to drain out theses secretions, give different positions to the child. Different studies have proved different positions to be effective for lower respiratory infections. A quasi experimental study was conducted in California among 50 children suffering from bronchiolitis to study the effectiveness of semifowler’s position in relieving symptoms of breathlessness. The study proved that nearly all the children experienced relief from symptoms of breathlessness.9
Another study was conducted in Mexico to compare the effectiveness of prone Vs supine position in relieving chest congestion among pneumonia children. The study concluded that there was a massive reduction in the chest congestion for the children who were given prone position compared to those given supine position.10
The aim of this study is to find out whether prone position or semi-fowler’s position is most effective for improving the respiratory status of under five children with pneumonia.
6.3 STATEMENT OF THE PROBLEM
A study to assess the effectiveness of prone Vs semi fowlers positioning on selected physiological parameters among under five children admitted with pneumonia in a selected hospital, Bangalore.
6.4 OBJECTIVES
1. To assess the selected physiological parameters of respiration among under five children with pneumonia before giving prone position and semi fowlers position.
2. To assess the selected physiological parameters of respiration among under five children with pneumonia after giving prone position and semi fowlers position.
3. To compare the selected physiological parameters of respiration among under five children with pneumonia before and after prone positioning.
4. To compare the selected physiological parameters of respiration among under five children with pneumonia before and after semi fowlers positioning.
5. To compare the selected physiological parameters of respiration among under five children with pneumonia between the two groups after giving prone position and semi-fowler’s position.
6. To associate the selected physiological parameters of respiration among under five children with pneumonia with their selected demographic variables.
6.5 OPERATIONAL DEFINITIONS
Effectiveness :
In this study effectiveness refers to the significant change in the selected parameters of respiration among under five children with pneumonia after providing prone and semi fowlers position.
Prone positioning :
It refers to lying on abdomen with supporting pillow with face turned aside and hands extended.
Semi fowlers positioning :
It refers to semi upright sitting position( 450- 600).
Physiological parameters :
In this study, the physiological parameters of respiration such as oxygen saturation, respiratory rate and breath sounds are selected. Oxygen saturation will be measured using pulse oximeter, respiratory rate measured by observation and breath sounds by auscultation.
Pneumonia :
It refers to lung disease characterized by consolidation and exudation, manifested by fever, cough, shortness of breath, abnormal breath sounds, chest pain, tachypnea and cyanosis.
6.6 ASSUMPTIONS
1. Most of the under five children may be admitted with pneumonia in hospitals.
2. Prone position may have an effect on the physiological parameters of respiration among under five children with pneumonia.