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Normally, adequate ventilation is maintained by frequent changes of position, ambulation , and exercise. When persons become ill, however, their respiratory functions may be inhibited, for such reasons as pain and immobility. Shallow respirations inhibit both diaphragmatic excursion and lung distensibility. The result of inadequate chest expansion is stasis and pooling of respiratory secretions, which ultimately harbor microorganisms and promote infection. This situation is often compounded by giving narcotics for pain, because narcotics further depress the rate and depth of respiration. Interventions is to maintain the normal respirations of patients include Positioning the patient to allow for maximum chest expansion. Encouraging or providing frequent changes in position. Encouraging ambulation. Implementing measures that promote comfort, such as giving pain medication.
The semi or high fowler s position allows maximum chest expansion. Encourage patient to turn from side to side frequently, so that alternate sides of the chest are permitted maximum expansion. Dyspneic patient often sit in bed and lean over their over bed tables (which are raised to a suitable height), usually with a pillow for support. This orthopneic position is an adaptation of the high-fowlers position. It has a further advantage in that, unlike in high fowler s, the abdominal organs are not pressing on the diaphragm. Also, a patient in the orthopneic position can press the lower part of the chest against the table to help exhaling. Wellness Teaching Promoting healthy Breathing Assure posture that permits full lung expansion. Exercise regularly. Breathe through the nose. Breathe in so as to expand the chest fully. Eliminate or reduce the use of household pesticides and irritating chemical substances. Avoid exposure to second hand smoke. Support a pollution-free environment.
Preschoolers: Transition to Independence Preschoolers, 3 to 5 years old, are in a transitional phase in which they retain many of the toddler s characteristics while becoming more independent and self-sufficient. Preschoolers are very magical thinkers, and this often leads to misunderstandings when adults use words and phrases that can easily be misinterpreted by the child, such as when Jamal thought a stretcher was a device that would stretch his body. Adults often do not realize that even phrases that seem simple can frighten children. If you talk about a CAT scan, they may worry about felines. Or they may hear the term IV and think it is a leafy, green plant. It is easy for clinicians to overestimate a preschooler s comprehension because they have quite good verbal skills and ask lots of questions. Preschoolers believe they can make things happen by wishing. This can be terrifying if they wished a sibling would go away the day before the family is in an auto accident and the children are separated in the ED, for example. They may also believe that an injury or illness is punishment for something they did or thought about doing. When you care for a preschooler, tell him the
treatment is not a punishment. Ask children if they feel happy or sad, scared or mad, and praise them when they try to cooperate with care. Be careful not to tell a child that being good means showing no emotion, and try to avoid using the word bad because children of this age will have a hard time understanding that a bad cough does not mean they are themselves a bad person. Never threaten dire consequences for not behaving under the stress of a hospitalization or medical treatment or a procedure. Exasperated parents sometimes say, If you don t behave, the nurse will give you a shot, which makes care very complicated if an injection is then required. Bandages are very important to preschoolers because they typically think any break in the skin can allow their insides to leak out. Bandages are seen as protective and are very comforting. Thus, any time you draw blood, focus on applying an adhesive bandage after the procedure even if it is not medically indicated. As with the toddler, allow the preschooler to become familiar with equipment by allowing them to handle it and by treating a favorite doll or stuffed animal. Children at this age will respond well to games and treatments that incorporate play. For 5-yearold Emily, who has just been admitted to the pediatric unit after having abdominal surgery, try this approach, I brought this pinwheel with me. See how pretty it is when I blow on it? Now I want you to make it spin. Provide explanations in terms of the child s senses, such as You ll feel this medicine like a feather on your face, and it will make a funny noise before a nebulizer treatment. Use simple analogies such as comparing blowing in a peak flow meter to blowing out birthday candles. Offer choices when you can, but do not accept unnecessary delays of more than 2 minutes if a preschooler stalls for time. School-Age Children: A Sense of Accomplishment School-age children, ages 6 to 11 years, are developing a sense of accomplishment as they master new skills. Experiencing success helps them develop a sense of self-esteem. At about age 7, children move from the magical thinking of preschoolers to more logical thought. They no longer see illness or injury as punishment and can begin to understand cause and effect, such as If you take two puffs every morning, your lungs will stay healthy. You can provide more complex instructions, such as We ll help you hold your arm still, but it s okay if you need to cry, when drawing an arterial blood sample. School-age children understand time since their days are scheduled at school. Be sure to tell a child how much time is left in a procedure or treatment, and offer to count the time down for the child. These children can also understand longer-term consequences of illness, and, for the first time, they understand that death is irreversible. Toward the older ages, school-age children have a better knowledge of anatomy and understand more complex explanations, such as The breathing tubes in your lungs are squeezing closed, so I need to give you medicine to open them up. At this age, children are afraid of losing control, of being separated from others their age, and of becoming more dependent on parents again. You can offer them the choice of having a caregiver present when you are with them; being able to take a treatment without a parent present may be important for the child s self-esteem. You can also support school-age children by asking them to be your helper, such as opening the plastic bag that holds a piece of equipment and handing the equipment to you. Children of this age are becoming more sensitive to privacy and may want to be covered up when you listen to their lungs, for example. They tend to hide their thoughts and feelings and act brave to protect themselves from their fears, so offer them the opportunity to talk about how they feel. They may not want to admit they do not know something, so open the door to questions by offering an explanation such as Would you like to know how this nebulizer makes a mist?
Adolescents: Not Adults Yet Adolescents are often treated like adults, but to provide the most appropriate care, clinicians should be aware of their developmental needs. Adolescents are most fearful of changes to their physical appearance and threats to their emerging independence. Their relationships with other teens are very important, and encouraging peer visitation will help support a teen s self-esteem during a hospitalization. Adolescents can be very moody and are particularly insulted when treated like a child or hospitalized on a pediatric unit with much younger children, particularly if they have to share a room with a child. If possible, offer to give treatments in a day room or other area of the teen s choosing. Be sure to provide privacy, and ask permission before you examine a teen. When you talk with a young adult, try to avoid interruptions or distractions and pay attention to nonverbal cues.
Explain treatments and procedures in detail. When possible and factual, reassure adolescents that they can fully recover, whether it is from an asthma exacerbation or a traumatic injury. Do not dismiss the teen s concerns about scarring or changes in physical appearance, even if the changes are barely noticeable to you. Discuss your assessment and emphasize the normal findings to provide reassurance. Work with adolescents to problem-solve so they can adapt treatments to their everyday lives. For example, many teens are reluctant to carry a metered-dose inhaler with them because it is big and bulky in their pocket, and visible to others at a time when the teen wants to look exactly like his or her peers. An inhaler that fits into one s pocket may be more acceptable since it is easier to conceal, or better yet, a leukotriene modifier pill may be the best option for a teen s asthma management. Unfortunately, adolescents with chronic illnesses such as asthma or diabetes may completely abandon their daily treatment during a time of rebellion and frustration about being different from their peers. This behavior can lead to potentially lifethreatening exacerbations. It is important to assess the teen without placing blame during initial treatment so you can get as much truthful information as possible to guide initial care. Once the crisis passes, you can explore the teen s motivation for stopping treatment and help develop a plan the teen can follow on discharge. Pediatric respiratory care can be fun and rewarding. By understanding the psychosocial needs of these young patients, you can provide effective age-appropriate care to achieve the most positive outcomes.