Chapter 18

Allergic rhinitis = hay fever

Epiglottitis = life-threatening condition characterized by inflamed epiglottis tissue. The
tissue swells and blocks your airway.
Atopic dermatitis = chronic eczematous skin disease
Atopy = genetic tendency to develop allergic diseases
Otitis Media = inflammation of the middle ear, ear infection
Reyes Syndrome = swelling in the liver and brain. Affects children recovering from a
viral infection (flu or chickenpox). Aspirin has been linked to Reyes syndrome.
Coryza = nasal discharge

Respiratory infections account for the majority of acute illnesses in children.

o Respiratory dysfunction in children tends to be more severe than in adults, and

several differences in the infants or childs respiratory system account for this
increased severity.

Nose
o Newborns are obligatory nose breathers until at least 4 weeks of age and cannot
open mouth to breath if nose is obstructed.
o New born and infants = small nasal passages which can lead to airway obstruction
when mucus is present.
o Young children (until older than 6) are less likely to get sinus infection.
Throat
o Infants tongues relative to oropharynx are larger; placement of tongues can lead to
obstruction
o Children have enlarged tonsillar and adenoid tissues, which can lead to airway
obstruction
Trachea
o Infants trachea is 4 m wide, adult is 20 mm wide.
Adventitious Breath Sounds
o Wheezing may occur with obstruction in lower trachea or bronchioles
o Rales are crackling sounds heard when alveoli become fluid filled. May occur
with pneumonia

Lower Respiratory Structures

o The bifurcation of the trachea occurs at the level of the third thoracic vertebra in
children, compared to the level of the sixth thoracic vertebra in adults
o The bronchi and bronchioles of infants and children are narrower in diameter than
the adults, placing them at increased risk for lower airway obstruction.
o Oxygen moves from the alveolar air to the blood, while carbon dioxide moves
from the blood into the alveolar air. Smaller numbers of alveoli, particularly in the
premature and/or young infant, place the child at a higher risk of hypoxemia
(deficiency in the concentration of oxygen in arterial blood) and carbon dioxide
retention.
Metabolic Rate and Oxygen Need
o Children have a significantly higher metabolic rate than adults. Their resting
respiratory rates are faster and their demand for oxygen is higher. Adult oxygen
consumption is 3 to 4 liters per minute, while infants consume 6 to 8 L per
minute.
Inspect and observation
o Color
True sign of cyanosis in infant will be central cyanosis (involving the
midline). It is a sign of hypoxia.
Note the rate and depth of respiration as well as work of breathing. Often
the first sign of respiratory illness in infants and children
is tachypnea (increased respiratory rate).
o Auscultation
Wheezing, a high-pitched sound that usually occurs on expiration, results
from obstruction in the lower trachea or bronchioles. Wheezing that clears
with coughing is most likely a result of secretions in the lower trachea.
Wheezing resulting from obstruction of the bronchioles, as in
bronchiolitis, asthma, chronic lung disease, or cystic fibrosis, does not
clear with coughing. Rales (crackling sounds) result when the alveoli
become fluid filled, such as in pneumonia.
Complications associated with the common cold

o Prolonged fever
o Increased throat pain or enlarged, painful lymph nodes
o Increased or worsening cough, cough lasting longer than 10 days, chest pain,
difficulty breathing
o Earache, headache, tooth or sinus pain
o Unusual irritability or lethargy
o Skin rash

Sinusitis
o A bacterial infection of the paranasal sinuses.
o The most common presentation of sinusitis is persistent signs and symptoms of a
cold. Rather than improving after 7 to 10 days, nasal discharge persists.
o Normal saline nose drops or spray, cool mist humidifiers, and adequate oral fluid
intake are recommended for children with sinusitis.

Influenza
o Bacterial infections of the respiratory system commonly occur as complications of
influenza infection, severe pneumococcal pneumonia in particular.
o Otitis media occurs in 18% to 40% of all influenza case

Pharyngitis
o Inflammation of the throat mucosa (pharynx)
o Group A streptococci account for 15% to 30% of cases
It requires antibiotics
Complications of Group A = peritonsillar or retropharyngeal abscess
Peritonsillar abscess may be noted by asymmetric swelling of the
tonsils, shifting of the uvula to one side, and palatal edema.
Retropharyngeal abscess may progress to the point of airway
obstruction
o There will be the presence of petechiae on the palate and a strawberry appearance
on the tongue.
o Treatment for comfort = saline gargles, analgesics (acetaminophen and
ibuprofen), throat lozenges or head candy, cool mist humidity, and encourage the
child to ingest popsicles, cool liquids, and ice chips to maintain hydration

o Antibiotics not necessary for pharyngitis because it will resolve in a few days but
antibiotics are necessary for streptococcal pharyngitis.
With streptococcal pharyngitis, parents should throw away toothbrush to
avoid reinfection and children can return to school after 24 hours of
antibiotic use.
Tonsillitis
o Occurs with pharyngitis.
o Treatment for bacterial tonsillitis the same as bacterial pharyngitis
o Tonsillectomy needed for:
Child with recurrent streptococcal tonsillitis
Massive tonsillar hypertrophy
o After tonsillectomy
Place child in side laying position until fully awake to promote drainage of
secretions
Once child is alert, child can sit up with head of bed elevated
Suction when necessary
Alert parents that some presence of blood is common
Hemorrhage is uncommon but may occur
Discourage child from coughing, clearing throat, blowing nose,
and using straws.
Upon discharge, instruct parents to any signs of bleeding, encourage
intake of fluids, but citrus juice and brown or red fluids should be avoided.
Infectious Mononucleosis
o Self-limiting illness caused by the Epstein-Barr virus.
o Characterized by fever, malaise, sore throat, and lymphadenopathy
o Known as kissing disease: transmitted by oropharyngeal secretions
o Complications
Splenic rupture
Guillain-Barre syndrome autoimmune disorder in which the immune
system attacks healthy nerve cells of the peripheral nervous system
Aseptic meningitis inflammation of the linings of the brain
Laryngitis
o Characterized by hoarse voice or loss of voice
o Resting voice for 24 hours will allow inflammation to subside
Croup
o Inflammation and edema of the larynx, trachea, and bronchi occur as a result of
viral infection
o Parainfluenza is responsible for the majority of cases
Parainfluenza = a disease caused by group of viruses that resemble the
influenza virus
o Children 3 months 3 years are most infected
o Mucus production, edema, and inflammation can cause obstruction of airway.
Narrowing of the subglottic area of the trachea results in audible inspiratory

stridor. Edema of the larynx causes hoarseness. Inflammation on the larynx and
trachea causes barking cough of croup.
o Symptoms mostly occur at night and lasts about 3-5 days
o Complications = worsening respiratory distress, hypoxia, or bacterial
superinfection.
o Treatment = single does corticosteroids to decrease inflammation and racemic
epinephrine aerosol demonstrate the -adrenergic effect of mucosal
vasoconstriction, helping to decrease edema.
Educate parents on signs of respiratory distress, use humidified air,
administer dexamethasone as ordered.

Epiglottitis
o Inflammation and swelling of the epiglottis caused by haemophilus influenza type
b.
o Use of the Hib vaccine has decreased the incidence
o Child has an overall toxic appearance, may refuse to speak, may refuse to lie
down, have anxiety of frightened appearance.
o Do not under any circumstance attempt to visualize the throat: reflex
laryngospasm may occur, precipitating immediate airway occlusion.
o Complications = respiratory arrest and death, pneumothorax and pulmonary
edema
o Treatment = IV antibiotics in ICU, 100% oxygen in least invasive way
Emergency tracheostomy may be necessary if airway is completely
occluded.
Ensure emergency equipment is always available
o Epiglottitis is characterized by dysphagia, drooling, anxiety, irritability, and
significant respiratory distress. Prepare for the event of sudden airway
occlusion.

Bronchiolitis
o An acute inflammatory process of the bronchioles and small bronchi caused by
viral pathogen
RSV accounts for majority of cases of bronchiolitis, with adenovirus,
parainfluenza, and human meta-pneumovirus are also important causative
agents.
o Peak = winter and spring coinciding with RSV seasons
o Nearly all kids will contract RSV in first few years of life
o The frequency and severity of RSV infection decreases with age.
o RSV infection causes necrosis of the respiratory epithelium of the small airways,
peribronchiolar mononuclear infiltration, and plugging of the lumens with mucus
and exudate.
The small airways become variably obstructed; this allows adequate
inspiratory volume but prevents full expiration. This leads to
hyperinflation and atelectasis.
o Management of RSV = sup oxygen, nasal and nasopharyngeal suctioning, oral or
intravenous hydration, and inhaled bronchodilator therapy (epinephrine or
albuterol) are used.
o Risk factors: Young age (younger than 2 years old), more severe disease in a child
younger than 6 months old, Prematurity, Multiple births, Birth during April to
September, History of chronic lung disease (bronchopulmonary disease),
Cyanotic or complicated congenital heart disease, Immunocompromise, Male
gender, Exposure to passive tobacco smoke, Crowded living conditions, Day care
attendance, School-age siblings, Low socioeconomic status, Lack of
breastfeeding.
o Inspection and observation = might appear air-hungry, exhibiting various degrees
of cyanosis and respiratory distress, including tachypnea, retractions, accessory
muscle use, grunting, and periods of apnea. Cough and audible wheeze might be
heard. The infant might appear listless and uninterested in feeding, surroundings,
or parents.

o Lab studies:
Pulse oximetry: oxygen saturation might be decreased significantly
Chest radiograph: might reveal hyperinflation and patchy areas of
atelectasis or infiltration
Blood gases: might show carbon dioxide retention and hypoxemia
Nasal-pharyngeal washings: positive identification of RSV can be made
via enzyme-linked immunosorbent assay (ELISA) or immunofluorescent
antibody (IFA) testing
o Palivizumab (Synagis) is a monoclonal antibody that can prevent severe RSV
disease in those who are most susceptible.
o It is given as an intramuscular injection once a month throughout the RSV season
Pneumonia
o Respiratory viruses are the most common cause of pneumonia in younger children
and the least common cause in older children.
o Viral pneumonia is usually better tolerated in children of all ages.
o Complications of pneumonia include bacteremia, pleural effusion, empyema, lung
abscess, and pneumothorax.
o Lab and diagnostic tests:
Pulse oximetry: oxygen saturation might be decreased significantly or
within normal range
Chest radiograph: varies according to child age and causative agent. In
infants and young children, bilateral air trapping and
perihilar infiltrates (collection of inflammatory cells, cellular debris, and
foreign organisms) are the most common findings. Patchy areas of
consolidation might also be present. In older children, lobar consolidation
is seen more frequently
Sputum culture: may be useful in determining causative bacteria in older
children and adolescents
White blood cell count: might be elevated in the case of bacterial
pneumonia
Tuberculosis
o Homeless and improved children are at higher risk of being exposed.
After exposure, incubation period is 2-10 weeks.
o In the case of drug-sensitive tuberculosis, the American Academy of Pediatrics
recommends a 6-month course of oral therapy.
o Children considered to be at high risk are those who:
Are infected with HIV
Are incarcerated or institutionalized
Have a positive recent history of latent tuberculosis infection
Are immigrants from or have a history of travel to endemic countriesAre
exposed at home to HIV-infected or homeless persons, illicit drug users,
persons recently incarcerated, migrant farm workers, or nursing home
residents.

Diagnosis is confirmed with a positive Mantoux test, positive gastric washings

for acid-fast bacillus, interferon-gamma release assay (IGRA), and/or a chest
radiograph consistent with tuberculosis.
Epistaxis
o Nosebleed
o Treatment = The child should sit up and lean forward. Apply continuous pressure
to the anterior portion of the nose by pinching it closed (pinch the lower third of
the nose closed).
Items smaller than 1.25 in (3.2 cm) can be aspirated easily. A simple way for parents to
estimate the safe size of a small item or toy piece is to gauge its size against a standard
toilet paper roll, which is generally about 1.5 in in diameter.
o Frequently occurs in children between 6 months and 4 years of age
o

Respiratory Distress Syndrome

o Results from lung immaturity and deficiency in surfactant
o Seem most often in preemies
o Other infants who might experience RDS include infants of diabetic mothers,
those delivered via cesarean section without preceding labor, and those
experiencing perinatal asphyxia (deprived of oxygen).
o Lack of surfactant = stiff, poorly complaint lungs with poor gas exchange
o Treatment = The administration of surfactant via an endotracheal tube shortly
after delivery helps to decrease the incidence and severity of RDS.

Asthma
o Chronic inflammatory airway disorder characterized by hyperresponsiveness,
airway edema, and mucus production.
o Short-acting bronchodilators may be used in the acute treatment of
bronchoconstriction and long-acting forms may be used to prevent bronchospasm.
o Exercise-induced bronchospasm may occur in any child with asthma or as the
only symptom in the child with mild intermittent asthma.
Avoid exercise-induced bronchospasm by using a longer warm-up period
prior to vigorous exercise and, if necessary, inhaling a short-acting
bronchodilator just prior to exercise
o

Cystic Fibrosis
o Autosomal recessive disorder
o There are a thickened, tenacious secretions in the sweat glands, gastrointestinal
tract, pancreas, respiratory tract, and other exocrine tissues

o The pancreas, intrahepatic bile ducts, intestinal glands, gallbladder, and submaxillary
glands become obstructed by viscous mucus and eosinophilic material.

o Pancreatic enzyme activity is lost and malabsorption of fats, proteins, and

o

carbohydrates occurs, resulting in poor growth and large, malodorous stools. Excess
mucus is produced by the tracheobronchial glands.
All children with cystic fibrosis who have pulmonary involvement require chest
physiotherapy with postural drainage several times daily to mobilize secretions from
the lungs.

o Treatment
Recombinant human DNase (Pulmozyme) is given daily using a nebulizer to

decrease sputum viscosity and help clear secretions.

Inhaled bronchodilators and anti-inflammatory agents are prescribed for
some children.
Aerosolized antibiotics are often prescribed and may be given at home as well
as in the hospital.
Pancreatic enzymes and supplemental fat-soluble vitamins are prescribed to
promote adequate digestion and absorption of nutrients and optimize
nutritional status.

o Child with cystic fibrosis often has barrel chest, clubbing on the nails, and appear
small for age.
o Lab and diagnostic test
Sweat chloride test: considered suspicious if the level of chloride in collected

sweat is above 50 mEq/L and diagnostic if the level is above 60 mEq/L

Pulse oximetry: oxygen saturation might be decreased, particularly during a
pulmonary exacerbation
Chest radiograph: may reveal hyperinflation, bronchial wall thickening,
atelectasis, or infiltration
Pulmonary function tests: might reveal a decrease in forced vital capacity and
forced expiratory volume, with increases in residual volume

o To maintain growth, Pancreatic enzyme supplements (pancrelipase [Creon,

Pancreaze, Zenpep]) must be administered with all meals and snacks to promote
adequate digestion and absorption of nutrients

Chapter 19
Notes from podcasts

Cardiac Structure and Function

o Umbilical vein, umbilical arteries-placental circulation
o Foramen ovale-opening b/w the atria
o Ductus arteriosus-b/w the pulmonary artery and the aorta
o Ductus venous-left umbilical vein and the inferior vena cava
The last 3 close when the baby is born
Circulatory Changes from Gestation to Birth
o The fetal heart is present around postconceptional day 17
o The four chamber of the heart and arteries are formed during gestational week 2
through 8.
Abnormities can be spotted here.
o During fetal development, oxygenation of the fetus occurs via oxygenation and
ventilation.
o The foramen ovale, an opening b/w the atria, allows blood flow from the right to
the left atrium.
o The ductus arteriosus allows blood flow b/w the pulmonary artery and the aorta,
shunting blood away from the pulmonary circulation.
The normal infant heart rate averages 120 to 130 beats per minute, the toddlers
preschoolers is 80 to 105, the school-age childs if 70 to 80, and the adolescents
averages 60 to 68 bpm.
Congenital Heart Disease vs. Acquired Heart Disease
o Congenital heart disease
Structural anomalies that are present at birth
CHD accounts for the largest percentage of all birth defecrs
o Acquired heart disease
Disorders that occur after birth
Develops from a wide range of causes, or can occur as a complication or
long-term effect of congestive heart disease
Hemodynamic Characteristics of Congenital Heart Defects
o Hemodynamic = relating to the flow of blood within the organs and tissues of the
body
The most common reason for admission to the hospital for children with congenital heart
disease is heart failure. Heart failure occurs most often in children with CHD and is the
most common reason for admission to the hospital for children with CHD.
Most of the kids will be on oxygen, but do not oxygenate a kids that doesnt need it.
Pediatric indicators of Cardiac Dysfunction

o Poor feeding
o Tachypnea/tachycardia
o Failure to thrive/poor weight gain/activity intolerance
o Developmental delays
o Prenatal history
o Family history of cardiac disease
Focus of Nursing Care for Child with a Cardia Disorder
o Improve oxygenation
o Promoting adequate nutrition
o Assisting the child and family with coping
o Providing postoperative nursing care
o Preventing infection
o Providing child and family education

Give digoxin at regular intervals, every 12 hours, such as at 8 and 8 pm, 1 hour before or 2
hours after feeding. If a digoxin dose is missed and more than 4 hours have elapsed, withhold
the dose and give the dose at the regular time; if less than 4 hours have elapsed, give the
missed dose. If the child vomits digoxin, do not give a second dose. Monitor potassium levels,
as a decrease enhances the effects of digitalis, causing toxicity.

Many children have functional or innocent murmurs, but all murmurs must be evaluated
on the basis of the following characteristics:
o Location
o Relation to the heart cycle and duration
o Intensity: grade I, soft and hard to hear; grade II, soft and easily heard; grade III,
loud without thrill; grade IV, loud with a precordial thrill; grade V, loud, with a
precordial thrill, audible with a stethoscope partially off chest; grade VI, very
loud, audible with a stethoscope or with the naked ear
o Quality: harsh, musical, or rough; high, medium, or low pitch
o Variation with position (sitting, lying, standing)
Determine the pulse pressure by subtracting the diastolic pressure from the systolic
pressure. The pulse pressure is less than 50 mm Hg, or less than half the systolic
pressure. A widened pulse pressure, which usually is accompanied by a bounding pulse,
is associated with PDA, aortic insufficiency, fever, anemia, or complete heart block. A
narrowed pulse pressure is associated with aortic stenosis.
o There should be no major differences between the upper and lower extremities
Congenital heart defects are categorized based on hemodynamic characteristics (blood flow
patterns in the heart):
o Disorders with decreased pulmonary blood flow: tetralogy of Fallot and tricuspid
atresia
o Disorders with increased pulmonary blood flow: PDA, atrial septal defect (ASD), and
ventricular septal defect (VSD)
o Obstructive disorders: coarctation of the aorta, aortic stenosis, and pulmonary
stenosis

o Mixed disorders: transposition of the great vessels (TGV), total anomalous

pulmonary venous return (TAPVR), truncus arteriosus, and hypoplastic left heart
syndrome (HLHS)

Exam Review
What will you see with UTI?
- Symptoms with a baby?
- How do we fix it?
- What to teach parents?
Development preschool, school age
- Gross and fine motor skills
- Social and cognitive development
- Safety
- Piaget and Erikson
Diagnostic tests need to know
- CBC viral vs infection
- UAs
- X-rays
- CT scans
- Swabs
GU system
- UTIs
- Necrotic syndrome
- Acute renal failure
- Post strep glomerulonephritis
o What will it look like?
o Teaching?
Torsed testicle and overawes
- Immediate surgery
Respiratory
- Trying to clear an airway
- Asthma

o Presents as: wheezes, rapid breathing, decreased o2 states

o Bronchodilators help
o On steroids to decrease inflammation
o Teach parents to: good med usage, no smoking, rinse out mouth after inhaler use
Cystic fibrosis
o Know meds
o Involves two different systems GI and respiratory

Musculoskeletal
- Most common fractures, sprains, strains
- Assess neurovascular status with fractures distal to injury
- Treatment = skin and skeletal traction
- Know difference between tractions
- Assess pin care with a child with skeletal traction, can cause osteomyelitis
o Important to do meticulous skin care
- Kids bone heal faster b/c they are more vascular and kids bones are harder to break
- Cerebral palsy
Skin
-

Rashes that dont blanch are bad meningitis

Petechia
Know how to describe a rash
Vesicular, linear rash (poison ivy, scabies)
Ringworm, tinea
Eczema
Moisturizing is important foe kids with skin issues