Epiglotittis
Antipyretics for fever
A. Description
a. Is a bacterial form of croup.
b. Egiglottitis is an inflammation of the
epiglottis, which may be caused by
Haemophilus influenza type B or
Streptococcus pneumoniae.
c. Occurs most frequently between 2 to 5
years of age.
d. The onset is abrupt, and the condition
occurs most often in winter.
e. Epiglottitis is considered an emergency
situation
B. Assessment
a. High fever
b. Sore, red, and inflamed throat
c. Absence of spontaneous cough
d. Drooling
e. Difficulty in swallowing
f. Muffled voice
g. Inspiratory stridor
h. Agitation
i. Tripod positioning: while supporting the
body with the hands, the child thrusts the
chin forward and opens the mouth in an
attempt to widen the airway
C. Interventions
a. Maintain a patent airway
b. Assess respiratory status and breath
sounds, noting nasal flaring, the use of
accessory muscles, and the presence of
stridor.
c. Assess temperature by the axillary route,
not the oral route
d. To prevent spasm of the epiglottis and
airway occlusion, no attempts should be
made to visualize the posterior pharynx or
to obtain a throat culture.
e. Prepare the child for lateral neck films to
confirm the diagnosis
f. Maintain nothing-by-mouth status
g. Do not leave the child unattended
h. Do not force the child to lie down
i. Do not restrain the child
j. Administer fluids and antibiotics
intravenously as prescribed
k. Administer analgesics and antipyretics to
reduce fever and throat pain as prescribed
l. Provide cool-mist oxygen therapy to cool
the airway and decrease swelling
m. Have resuscitation equipment available,
and prepare for endotracheal intubation or
tracheotomy for severe respiratory distress
n. Ensure that the child is up-to-date with
immunization schedule.
Laryngotracheobronchitis
A. Description
a. Inflammation of the larynx, trachea, bronchi
b. Most common type of croup and may be
viral or bacterial
c. Gradual onset that may be preceded by an
upper respiratory infection
B. Assessment
a. Fever, low-grade to high
b. Irritability and restlessness
c. Hoarse voice
d. Seal bark and brassy cough
e. Inspiratory stridor and suprasternal
retraction
f. Use of accessory muscles for breathing
g. Crackles and wheezing on lung
auscultation
h. Anorexia, nausea, and vomiting
i. Signs of anoxia and carbon dioxide
retention
j. Cyanosis
C. Interventions
a. Maintain a patent airway
b. Assess respiratory status, monitoring for
nasal flaring, sterna retraction, and
insipratory stridor
c. Monitor for pallor or cyanosis
d. Elevate the head of the bed and provide
bed rest
e. Provide humidified oxygen via cool-mist for
hospitalized child
f. Instruct the parents to use a cool-air
vaporizer/ humidifier at home; other
measures include having the child
breathing in the cool night air or the air
from an open freeze
g. Provide and encourage fluid intake;
intravenous fluids may be prescribed to
maintain hydration status if the child is
unable to take fluids orally
h.
i. Avoid cough syrups and cold medicines,
which may dry and thicken secretions
j. Administer bronchodilators if prescribed to
relax smooth muscle and relieve stridor
k. Administer corticosteroids if prescribed for
the anti-inflammatory effect
l. Administer nebulized epinephrine (racemic
epinephrine) as prescribed for children with
severe distress, stridor at rest, retractions,
or difficulty of breathing
m. Administer antibiotics as prescribed, noting
that they are not indicated unless a
bacterial infection is present
n. Have resuscitation equipment available.
Bronchitis
A. Description: infection of the major bronchi that may
be referred to as tracheobronchitis
B. Assessment
a. Fever
b. Dry, hacking, and non-productive cough
that is worse at night and becomes
productive in 2 to 3 days
C. Interventions
a. Monitor for respiratory distress
b. Provide cool, humidified air
c. Monitor for signs of dehydration, such as
sunken fontanel, poor skin turgor, and
decreased and concentrated urinary output
d. Increase fluid intake
e. Antipyretics for fever
f. Antibiotic as prescribed
Bronchiolitis/ Respiratory Syncytial Virus (RSV)
A. Description
a. Bronchiolitis is an inflammation of the
bronchioles that causes a thick production
of mucus that occludes bronchiole tubes
and small bronchi
b. Respiratory syncytial virus is a common
cause of bronchiolitis
c. Respiratory syncytial virus, although not
airborne; is highly communicable and is
usually transferred by the hands (droplet
infection)
B. Assessment
 a. Upper respiratory infection symptoms such
as rhinorrhea and low-grade fever
b. Lethargy, poor feeding, and irritability in
infants
c. Tachypnea
d. Increase d difficulty in breathing
e. Nasal flaring and retraction
f. Expiratory wheeze and grunt
g. Diminished breath sound
C. Interventions
a. Maintain a patent airway
b. Position the child at a 30- to 40-degree
angle with the neck slightly extended to
maintain an open airway and decrease
pressure on the diaphragm
c. Provide cool, humidified oxygen
d. Encourage fluids; fluid administered
intravenously may be necessary until the
acute stage has passed.
e. Assess for signs of dehydration
D. The child with RSV
a. Isolate the child in a single room or place in
a room with another child with RSV.
b. Maintain good hand-washing procedures
c. Ensure that nurses caring for these
children do not care for other high-risk
children
d. Wear gowns when soiling of clothing may
occur during care
e. Administer ribavirin (Virazole), an antiviral
respiratory medication
i. Pregnant health care provider
should not care for a children
receiving ribavirin
ii. The nurse wearing contact
lenses should wear goggles
when coming in contact with
ribavirin because the mist may
dissolve soft lenses
f. Prepare for the administration of respiratory
syncytial virus immune globulin (RSV-IVIG
or RespiGam or palivizumab [Synagis])
i. The immune globulin is used
prophylactically to prevent
respiratory syncytial virus
infection in high-risk infants
ii. The immune globulin is not
administered to infants or
children with congenital heart
disease or with cyanotic
congenital heart disease.
Pneumonia
A. Description
a. Pneumonia is inflammation of the alveoli
caused by a virus, mycoplasma agents,
bacteria, or the aspiration of foreign
substances
i. Viral
ii. Primary atypical pneumonia
(mycoplasma pneumonia)
iii. Bacterial
iv. Aspiration
b. The causative agent usually is introduced
into the lungs through inhalation or from the
bloodstream.
c. Viral pneumonia occurs more frequently
than bacterial and often is associated with
a viral upper respiratory infection
d. Primary atypical pneumonia (mycoplasma)
is the most common cause of pneumonia in
children between the ages of 5 to 12 years;
it occurs primarily in the fall and winter
months and is more prevalent in crowded
living conditions
e. Bacterial pneumonia is often a serious
infection; hospitalization is indicated when
pleural effusion or emphysema
accompanies the disease and is mandatory
for children with staphylococcal pneumonia
f. Aspiration pneumonia occurs when food,
secretions, liquids, or other materials enter
the lung and cause inflammation and a
chemical pneumonitis; classic symptoms
include an increasing cough or fever with
foul-smelling sputum, deteriorating results
on chest x-rays, and other signs of airway
involvement
B. Viral Pneumonia
a. Assessment
i. Mild fever, slight cough, malaise,
low to high fever, severe cough,
and prostration
ii. Non-productive or productive
cough of small amounts of
whitish sputum
iii. Wheezes or fine crackles
b. Interventions
i. Administer oxygen with cool mist
as prescribed
ii. Increase fluid intake
iii. Administer antipyretics for fever
iv. Administer chest physiotherapy
and postural drainage as
prescribed.
v. Antimicrobial therapy is reserved
for children in whom the
presence of infection is
demonstrated by cultures.
C. Primary atypical pneumonia
a. Assessment
i. Fever, chills, anorexia,
headache, malaise, and muscle
pain
ii. Rhinitis, sore throat, and dry,
hacking cough
iii. Non-productive cough initially;
the production of seromucoid
sputum that becomes
mucopurulent or blood streaked.
D. Bacterial pneumonia
a. Assessment
i. Acute onset, fever, toxic
appearance
ii. Infant: irritability, lethargy, poor
feeding, abrupt fever (may be
accompanied by seizures;
respiratory distress (air hunger,
tachypnea, and circumoral
cyanosis)
iii. Older child: headache, chills,
abdominal pain, chest painm
meningeal symptoms
(meningism)
iv. Hacking, non-productive cough
v. Diminished breath sounds or
scattered crackles
vi. As the infection resolves, coarse
crackles and wheezing are heard
and the cough become
productive with purulent sputum
b. Interventions
i. Antimicrobial therapy is initiated
as soon as the diagnosis is
suspected
 ii. Administer oxygen (via hood,
mist tent, or nasal canula) for
respiratory distress as prescribed
iii. Place the child in a mist tent as
prescribed; cool humidification
moistens the airways and assists
in temperature reduction
iv. Suction mucus from the infant to
maintain a patent airway if the
infant is unable to handle
secretions
v. Administer chest physiotherapy
and posture drainage every 4
hours as prescribed
vi. Promote bedrest to conserve
energy
vii. Encourage the child to lie on the
affected side (if pneumonia is
unilateral) to splint the chest and
reduce the discomfort caused by
pleural rubbing
viii. Provide liberal fluid intake
(administer cautiously to prevent
aspiration); intravenously
administered fluids may be
necessary
ix. Administer antipyretics for fever
as prescribed; monitor
temperature frequently because
of the risk for febrile seizures
x. Institute isolation precautions
with pneumococcal or
staphylococcal pneumonia
(according to agency policy).
xi. Administer antitussives as
prescribed before rest times and
meals if the cough is disturbing.
xii. Continuous closed chest
drainage may be instituted if
purulent fluid is present (usually
noted in staphylococcus
infections).
xiii. Fluid accumulation in the pleural
cavity may be removed by
thoracentesis: thoracentesis also
provides a means for obtaining
fluid for culture and for instilling
antibiotics directly into the pleural
activity.
Tuberculosis
A. Description
a. Tuberculosis is a contagious disease
caused by mycobacterium tuberculosis, an
acid-fast bacillus
b. Multidrug-resistant strains of M.
tuberculosis occur because of client or
family noncompliance with therapeutic
regimens
c. The route of transmission of M.
tuberculosis is through inhalation of
droplets from an individual with active
tuberculosis
d. Most children are infected by a family
member or by another individual with whom
they have frequent contact, such as a
babysitter.
B. Assessment
a. Client may be asymptomatic or develop
symptoms such as malaise, fever, cough,
weight loss, anorexia, and
lymphadenopathy
b. Specific symptoms related to the site of
infection such as the lungs, brain, or bone,
may present
C. Mantoux test
a. The test will produce a positive reaction 2
to 10 weeks after the initial infection
b. The test determines whether the child has
been infected and has developed a
sensitivity to the protein of the tubercle
bacillus; a positive reaction does not
confirm the presence of active disease
c. Once the child reacts positively, the child
will always react positively; a positive
reaction in a previously negative test
indicates that the child has been infected
since the last test.
d. Tuberculosis testing should not be done at
the same time as measles immunization;
viral interference from measles vaccine
may cause a false-negative reaction
e. Mantoux test results
i. Induration measuring 15mm or
greater is considered to be a
positive reaction in children 4
years of age or older who do not
have any risk factors
ii. Induration measuring 10mm or
greater is considered to be a
positive reaction in children
younger than 4 years of age and
in those with chronic illness or at
high risk for exposure to
Tuberculosis
iii. Induration measuring 5mm or
greater is considered to be
positive for the highest risk
groups, such as children with
immunosuppressive conditions
or human immunodeficiency
virus
D. Sputum Culture
a. A definitive diagnosis is made by
demonstrating the presence of
mycobacterium in a culture
b. Because an infant or young child often
swallows sputum rather than expectorates,
gastric washings (aspiration of lavaged
contents from the fasting stomach) may be
done to obtain a specimen; specimen is
obtained in the early morning before
breakfast
E. Interventions
a. Medications
i. Include isoniazid (INH), rifampin
(rifampicin). Pyrazinamid
ii. A 9 month course of isoniazid
may be prescribed to prevent a
latent infection from progressing
to clinically active tuberculosis
and to prevent initial infection in
children in high-risk situations; a
12-month course may be
prescribed for the child infected
with human immunodeficiency
virus
iii. Recommendation for the child
with clinically active tuberculosis
may include administration of
isoniazid, rifampin, and
pyrazinamid daily for 2 months
and then isoniazid and rifampin
twice weekly for 4 months
b. Place children with infectious disease on
airborne precautions until medications have
been initiated, sputum cultures
 demonstrate a diminished number of
organisms, and cough is improving
c. Wear a mask if the child is coughing and
does not reliably cover his or her mouth
d. Maintain airborne precautions with family
members until they are demonstrated not
to have infectious tuberculosis
e. Stress the importance of adequate rest and
adequate diet
f. Instruct the child and family in measures to
prevent transmission of tuberculosis
Asthma
A. Description
a. Asthma is a chronic inflammatory disease
of the airways
b. Asthma commonly is caused by physical
and chemical irritants such as foods,
pollens, dust mites, cockroaches, smoke,
animal dander, temperature changes,
respiratory infection, activity, and stress.
c. The allergic reaction in the airways can
cause an immediate reaction, with
obstruction occurring, and it can precipitate
a late bronchial obstructive reaction several
hours after the initial exposure.
d. A common symptom is coughing in the
absence of respiratory infection, especially
at night
e. Status Asthmaticus
i. Child displays respiratory
distress despite vigorous
treatment measures
ii. Status asthmaticus is a medical
emergency that can result in
respiratory failure and death if
left untreated
B. Assessment
a. Client has episodes of wheezing,
breathlessness, dyspnea, chest tightness,
and cough, particularly at night and/or in
the early morning.
b. Client has itching localized at the front of
the neck or over the upper part of the back
c. Exacerbations are episodes of
progressively worsening shortness of
breath, cough, wheezing, chest tightness,
decreases in expiratory airflow because of
bronchospasm, mucosal edema, and
mucus plugging; air is trapped behind
occluded or narrow airways, and
hypoxemia can occur
d. Asthmatic episode
i. The episode begins with
irritability, restlessness,
headache, feeling tired, or chest
tightness
ii. Respiratory symptoms include a
hacking, irritable, non-productive
cough caused by bronchial
edema
iii. Accumulated secretions
stimulate the cough, and the
cough becomes rattling and
productive of frothy, clear,
gelatinous sputum
iv. Child may be pale or flushed,
and the lips may have a deep,
dark red color that may progress
to cyanosis observed in the
nailbeds and skin, especially
around the mouth
v. Restlessness, apprehension, and
diaphoresis occur
vi. Younger children assume the
tripod sitting position; older
children sit upright with the
shoulders in a hunched-over
position, with the hands on the
bed or a chair, and arms braced
to facilitate the use of accessory
muscles of breathing (child
refuses to lie down)
vii. Child speaks in short, broken
phrases
viii. Child experiences retractions
ix. Hyperresonance on percussion
of the chest is noted
x. Breath sounds are coarse and
loud, with crackles and coarse
rhonchi and inspiratory and
expiratory wheezing; expiration is
prolonged
e. Exercise-induced bronchospasm: cough,
shortness of breath, chest pain or
tightness, wheezing, and endurance
problems during exercise
f. Severe spasm or obstruction: breath
sounds and crackles may become
inaudible, and the cough is ineffective
(represent a lack of air movement)
g. Ventilator failure and asphyxia: shortness
of breath, with air movement in the chest
restricted to the point of absent breath
sounds accompanied by a sudden rise in
the respiratory rate
C. Interventions: Acute Episode
a. Assess airway patency
b. Administer humidified oxygen by nasal
prongs or face mask
c. Administer quick-relief rescue medications
d. Continuously monitor respiratory status,
pulse oximetry, and color; be alert to
decreased wheezing or a silent chest,
which may signal the inability to move air
e. Initiate an intravenous line, and prepare to
correct dehydration, acidosis, or electrolyte
imbalances
f. Prepare the child for a chest radiograph
g. Prepare to obtain samples for determining
arterial blood gases and serum electrolytes
D. Medications
a. Quick-relief (rescue medications): to treat
symptoms and exacerbations
i. Short-acting B2-agonists
ii. Anticholinergics (for relief of
acute bronchospasms)
iii. Systemic corticosteroids (for
its anti-inflammatory action to
treat reversible airflow
obstruction)
b. Long-term control (preventer medications):
to achieve and maintain control of
inflammation
i. Corticosteroids
ii. Antiallergic medications
iii. Nonsteroidal anti-inflammatory
drugs
iv. Long-acting B2-agonists
v. Leukotrine modifiers to prevent
bronchospasm and inflammatory
cell infiltration
vi. Long-acting bronchodilators
vii. Nebulizer, metered-dose inhaler,
or peak expiratory flow meters
 c. Nebulizer, metered-dose inhaler or peak
expiratory flow meters
i. These devices delivery many of
the medications used to treat
asthma
ii. If the child has difficulty using the
metered-dose inhaler,
medication can be administered
by nebulization (medication is
mixed with saline and then
nebulized with compressed air by
a machine)
E. Chest physiotherapy
a. Chest physiotherapy includes breathing
exercises and physical training
b. Chest physiotherapy is not recommended
during an acute exacerbation
F. Allergen Control
a. Prevention and reduction of exposure to
airborne and environmental allergens
b. Skin testing to identify allergens;
immunotherapy (hyposensitization) is not
recommended for allergens that can be
eliminated effectively
G. Home care measures
a. Instruct the client in measures to eliminate
allergens
b. Avoid extremes of environmental
temperature; in cold temperatures, instruct
the child to breathe through the nose, not
the mouth and to cover the nose and
mouth with a scarf
c. Avoid exposure to individuals with a viral
respiratory infection
d. Instruct the child in how to recognize early
symptoms of an asthma attack
e. Instruct the child in the administration of
medications as prescribed
f. Instruct the child in the use of a nebulizer,
metered-dose inhaler, or peak expiratory
flow meter
g. Instruct the child about the importance of
home monitoring of peak expiratory flow
rate; decrease in rate may indicate
impending infection or exacerbation
h. Instruct the child in the cleaning of devices
used for inhaled medications (oral
candidiasis can occur with the use of
aerosolized steroids)
i. Encourage adequate rest, sleep, and well
balanced diet
j. Instruct the child in the importance of
adequate fluid intake to liquefy secretions
k. Assist in developing an exercise program
l. Instruct the child in the procedure for
respiratory treatments and exercises as
prescribed
m. Encourage the child to cough effectively
n. Encourage the parents to keep
immunizations up to date; annual influenza
vaccinations are recommended
o. Inform other health care providers and
school personnel of the asthma condition
p. Allow the child to take control of self-care
measures based on age appropriateness
Cystic Fibrosis
A. Description
a. Cystic fibrosis is a chronic multisystem
disorder (autosomal recessive trait
disorder) characterized by exocrine gland
dysfunction
b. The mucus produced by the exocrine
glands is abnormally thick, causing
obstruction of the small passageways of
the affected organs
c. The most common symptoms are
pancreatic enzyme deficiency caused by
duct blockage, progressive chronic lung
disease associated with infection, and
sweat gland dysfunction resulting in
increased sodium and chloride sweat
concentrations
d. An increase in sodium and chloride in
sweat and saliva forms the basis for the
most reliable diagnostic test, the sweat
chloride test
B. Respiratory system
a. Symptoms are produced by the stagnation
of mucus in the airway, leading to bacterial
colonization and destruction of lung tissue.
b. Emphysema and atelectasis occur as the
airways become increasingly obstructed
c. Chronic hypoxemia causes contraction and
hypertrophy of the muscle fibers in
pulmonary arteries and arterioles, leading
to pulmonary hypertension and eventual
cor pulmonale
d. Pneumothorax from ruptured bullae and
hemoptysis from erosion of the bronchial
wall through an artery occur as the disease
progresses.
e. Other respiratory symptoms include the
following:
i. Wheezing and dry non-
productive cough
ii. Dyspnea
iii. Cyanosis
iv. Clubbing of the fingers and toes
v. Repeated episodes of bronchitis
and pneumonia
C. Gastrointestinal system
i. Meconium ileus in the neonate
ii. Intestinal obstruction (distal
intestinal obstructive syndrome)
caused by thick intestinal
secretions; signs include pain,
abdominal distention, nausea,
and vomiting
iii. Steatorrhea (frothy, foul-smelling
stool)
iv. Deficiency of the fat-soluble
vitamins A, D, E, and K which
causes easy bruising and
anemia
v. Malnutrition and failure to thrive,
demonstration of
hypoalbuminemia from
diminished absorption of protein,
resuling in generalized edema
vi. Rectal prolapsed that can result
from the large, bulky stools, and
lack of the supportive fat pads
around the rectum
D. Integumentary System
a. Abnormally high concentrations of sodium
and chloride in sweat
b. Parents reporting that the infant tastes
‘salty’ when kissed
c. Dehydration and electrolyte imbalance,
especially during hyperthermic conditions
E. Reproductive system
a. Cystic fibrosis can delay puberty in girls
 b. Fertility can be inhibited by highly viscous
cervical secretions, which act as a plug and
block sperm entry.
c. Males are usually sterile, caused by the
blockage of the vas deferens by abnormal
secretions or by failure of normal
development of duct structures.
F. Diagnostic tests
a. Quantitative sweat chloride test
i. The production of sweat is
stimulated (pilocarpine
iontophoresis), the sweat is
collected, and the sweat
electrolytes are measured ( a
minimum of 50mg of sweat is
needed)
ii. Normally, sweat chloride
concentration is less than 40
mEq/L
iii. A chloride concentration greater
than 60 mEq/L is a positive test
result
iv. Chloride concentrations of 40 to
60 mEq/L are high suggestive of
cystic fibrosis and require a
repeat test.
b. Chest x-ray film reveals atelectasis and
obstructive emphysema
c. Pulmonary function test provide evidence
of abnormal small airway function
d. Stool/ fat and /or enzyme analysis: a 72-
hour stool sample is collected to check the
fat and/or enzyme trypsin content (food
intake is recorded during the collection
G. Interventions
a. Respiratory System
i. Goals of treatment include
preventing and treating
pulmonary infection by improving
aeration, removing secretions,
and administering antimicrobial
medications
ii. Chest physiotherapy (percussion
and postural drainage) on
awakening and in the evening
(more frequently during
pulmonary infection).
iii. Chest physiotherapy should not
be performed before or
immediately after a meal
iv. Bronchodilator medication by
aerosol opens the bronchi for
easier expectoration
(administered before the chest
physiotherapy when the child has
a reactive airway disease or is
wheezing)
v. Instruct the parents not to give
cough suppressants, for they will
inhibit expectoration of
secretions and promote infection
vi. Teach the child forced expiratory
technique (huffling) to mobilize
secretions
vii. Develop a physical exercise
program with the aim of
establishing a good habitual
breathing pattern
viii. Administer antibiotics as
prescribed, which may be
prescribed prophylactically or
when pulmonary symptoms
develop
ix. Aerosolized antibiotics may be
prescribed and are administered
after chest physiotherapy is
performed, or antibiotics may be
prescribed and administered
intravenously at home through a
central venous access device
x. Administer oxygen as prescribed
during acute episodes; monitor
closely for oxygen narcosis
xi. Monitor for hemoptysis; greater
than 300ml in 24 hours for the
older child (less for a younger
child) needs to be treated
immediately
xii. Hmoptysis may be controlled by
bed rest, cough suppressants,
antibiotics, and vitamin K, if
hemoptysis persists, the site of
bleeding may be cauterized or
embolized.
xiii.Lung transplantation is a final
therapeutic option for the child
with end-stage disorder.
b. Gastrointestinal system
i. The goal of treatment for
pancreatic insufficiency is to
replace pancreatic enzymes;
administer with meals and
snacks (or within 30 minutes of
eating meals and snacks) to
ensure that digestive enzymes
are mixed with food in the
duodenum
ii. The amount of pancreatic
enzymes administered is
adjusted to achieve normal
growth and a decrease in the
number of stools to two or three
per day
iii. Enteric-coated pancreatic
enzymes should not be crushed
or chewed
iv. Pancreatic enzymes should not
be give if the child is to receive
nothing by mouth
v. Encourage a well-balanced, high
protein, high calorie diet;
multivitamins and vitamins A, D,
E, and K are also administered
vi. Assess weight and monitor for
failure to thrive
vii. Monitor for constipation and
intestinal obstruction
viii. Ensure adequate salt intake
during extremely hot weather or
if the child has a fever, include
fluids such as Gatorade which
provide an adequate supply of
electrolytes.
H. Home Care
a. Instruct the parent about the prescribed
treatment measures and their importance
b. Instruct the parents to be sure
immunizations are up to date
c. Inform the parents that the child should be
vaccinated yearly for influenza.
Penumococcus vaccine may also be
prescribed
d. Inform the parents about the Cystic
Fibrosis foundation