Dr Areefa Albahri Variations in Pediatric Anatomy and

Dr. Areefa Albahri

Variations in Pediatric Anatomy and Physiology: n n Respiratory dysfunction in children tends to be more severe than in adults. Several differences in the infant’s or child’s respiratory system account for the increased severity of these diseases in children compared with adults. �Such differences, as example, are: Newborns are obligatory nose breathers until at least 4 weeks of age. The young infant cannot automatically open his or her mouth to breathe if the nose is obstructed and the airway lumen is smaller in infants and children than in adults.

Respiratory distress syndrome “Hyaline Membrane Disease” n � Is a syndrome of immature infants that is characterized by a progressive and frequently fatal respiratory disorder resulting from atelectasis and immaturity of the lungs. n � It should be noted that some situations result in the acceleration of surfactants (steroid therapy and heroin addicted mother). RDS is common in preterm babies.

Etiology: �The exact etiology of RDS is not clearly defined but resulting from decreased pulmonary surfactant. n � Contributing factors (that decrease surfactant): n a) Prematurity and immature alveolar lining cells. n b) Acidosis. c) Hypothermia. n c) Hypoxia. e) Hypervolemia f) Diabetes. n

Altered physiology: n n n 1. Immature lung: 2. Sequence of events resulting in hyaline membrane disease: a) Deficient surfactant b) Alveolar instability: c) Hypoxemia and pulmonary vascular pressure lead to ischemia in the alveoli 3. RDS is usually a self-limited disease and symptoms peak in about 3 -4 days, at which time surfactant synthesis begins to accelerate and pulmonary function and clinical appearance begins to improve.

Clinical manifestation: n n �Symptoms are usually observed soon after birth. �Primary signs and symptoms: 1. Expiratory grunting or whining (when infant is not crying). 2. Substernal and intercostal retractions.

Clinical manifestation: n n n 3. Inspiratory nasal flaring, Tachypnea, Hypothermia and cyanosis when child is in room air (in severe cases may be cyanotic even with oxygen given). 4. Decrease breath sound and dry sandpaper breath sound. �Secondary signs and symptoms: 1. Hypotension. 2. Peripheral edema. 3. Absent bowel sound. 4. Decreased urinary output.

n n n Diagnostic evaluation: 1. laboratory test: PCO 2 elevated, PO 2 low, and Blood p. H low 2. Chest x-ray �Nursing and medical management: (supportive therapy) �Maintenance of oxygenation Pa. O 2 at 60 -80 mm. Hg to prevent hypoxia.

n n n �Maintenance of respiration with ventilatory support if necessary. �Maintenance of thermoneutral state (to prevent hypothermia). �Maintenance of fluid, electrolyte and acid-base balance. �Maintenance of nutrition. �Antibiotic is indicated only when hyaline membrane disease cannot be differentiated from early onset of sepsis.

n n n Tonsillitis �Inflammation of the tonsils. Tonsils are masses of lymphoid tissue located in the pharyngeal cavity. �Causes: May be viral or bacterial usually associated with pharyngitis. 20% of acute tonsillitis and pharyngitis are caused by group A b-hemolytic streptococci (GABHS).

n n �Clinical Manifestations: �Difficulty swallowing or breathing, as the tonsils enlarged from edema ( Kissing tonsils meet in the midline). �Breathing through the mouth leads to offensive mouth odor and frequent drooling �Impaired sense of smell and taste and change of voice.

Therapeutic management: n n �Diagnosis is established from visual examination of the throat. �Throat culture positive for bacterial infection, antibiotic indicated. �If viral tonsillitis, treatment is symptomatic. Throat cultures positive for GABHS infection warrant antibiotic treatment. �The majority of children with tonsillitis respond to medical treatment others undergo surgical intervention.

Therapeutic management: n n n �Surgical Treatment; �Tonsillectomy (removal of the tonsils). Tonsillectomy is recommended for recurrent streptococcal infections and massive hypertrophy. �Tonsillectomies are reserved for children >3 years of age due to excessive blood loss and a potential for the tonsils to grow back.

Nursing considerations: n n �Provide soft to liquid diet. �Cool mist vaporizer to keep mucous membranes moist. �Warm salt - water gargles. �Analgesic and antipyretic drugs.

Nursing considerations: n n n �Post-operative care: �Place child on abdomen or side to facilitate drainage of secretion. �Suction if needed. �Discouraged from coughing frequently. �Observe for bleeding and calms and reassure child and relieve pain. �Cool water, crushed ice or dilute fruit juice is given first after child is awake

Otitis Media (O. M) Otitis Media: is an Inflammation of the middle ear. n Classification: n A) Acute or chronic OM: bacteria or viruses cause a purulent exudate to form behind tympanic membrane in the middle ear space. n B) Serous otitis media – non purulent: sterile fluid accumulates due to blocked Eustachian tubes. n � Several factors cause children to develop Otitis media: -

. Eustachian tube, short, wide, straight, easy entry of organism. n b. Cartilage lining of E. T underdeveloped, open more easily. n c. lying down position of infant. n

Clinical manifestation: Pain: infant pull at ears n 2. Temperature n 3. Lymph node swollen n 4. Vomiting. n 5. Diarrhea 6. Anorexia. n 7. Rupture tympanic membrane, relief of pain and purulent discharge in external ear canal. n 8. On otoscopy the tympanic membrane appears red bright and bulging. n 1.

Treatment: 1. Administration of antibiotics especially ampicillin. n 2. Analgesic and antipyretic drugs to reduce pain and fever. n 3. Myringotomy: incision of the ear drum for drainage of secretion. n

Nursing consideration: 1. Pain relief analgesic. n 2. If ear drainage occurs, clean external ear canal with sterile cotton swaps soaked in H 2 O 2. n 3. Facilitate drainage place the child on the affected side. n 4. Parent education: correct administration of antibiotics n

Pneumonia n Definition: Inflammation of the lung tissue. Inflammation of the alveoli results in atelectasis. Atelectasis is defined as a collapsed or airless portion of the lung, so gas exchange becomes impaired. The inflammatory response further impairs gas exchange. �

�Etiology: 1. Viruses such as RSV (respiratory syncytiale viruse). n 2. Bacteria n 3. Mycoplasma n 4. Fungi. n 5. Aspiration of foreign substances. n 6. Ingestion of kerosene may cause pneumonia, in this condition never induce vomiting. n

Clinical manifestation: 1. History of upper respiratory tract infection n 2. Shaking chills. n 3. High fever, cough n 4. Hacking, unproductive cough n 5. Chest pain, children usually report abdominal pain. n 6. Drowsiness. n 7. dyspnea n

n n n �Diagnosis: is based on physical findings and a sputum culture. Chest x-ray demonstrates the extent and location of the involvement. � treatment: 1. Antibiotics: penicillin, ampicillin, chloramphenicol, erythromycin. 2. Bed rest to conserve energy 3. Fluid as tolerated. 4. Humidified air to reduce labored breathing and reduce hypoxemia ♣ The objective of treatment is effective ventilation and prevention of dehydration

n n n n Complications: are rare but may include worsening respiratory distress, hypoxia. �Treatment and nursing Management: Croup is usually managed on an outpatient basis cases requiring hospitalization in cases of progressive stridor. �High humidification with oxygen. �Increase fluid intake ―good hydration‖. �Minimal handling. �Monitor vital signs. Teach parents home management of croup. �Epinephrine nubilizer, Syrup of ipecac (reducing coughing).

Epiglottitis: n n n n �Causative agent: caused mainly by H. Influenza. Other agents include pneumococci, Beta hemolytic streptococci and staph aureus. �Age: 3 -10 years with seasonal variations �Clinical manifestations: �High fever, aphonia, drooling and inspiratory stridor. �Irritability with hyperextended neck. �Cherry red epiglottis. �Refusal to eat. �Intercostal retraction.

Diagnostic evaluation: n n n n n �History and physical examination. �Leukocytosis �X-Ray neck ―epiglottic edema. �Treatment and nursing management: �Antibiotic therapy ―ampicilline, chloromphenicol I. V. 7 -10 days‖. �Quite room, cool humidified oxygen and bed rest and increase fluids. �Teach parents home care ―tracheostomy‖. �Observe for signs of respiratory distress. �Medical emergency ―endotracheal intubation‖.

Bronchial Asthma n n n �Asthma is a recurrent and reversible condition of chronic inflammatory airway disorder characterized by airway hyper responsiveness, airway edema, and mucus production. �It’s the most common chronic illness of childhood and affects 9 million American children �Causes: allergic reaction to plants, pollens, foreign body in the air way.

Bronchial Asthma n n Spasmodic: sporadic in nature, with varying intervals of freedom from difficulty and with precipitating factors often readily defined. 2. Continuous: no outward signs or symptoms of Asthma, but there is some shortness of breath on occasion, transitory wheezing on strenuous exercise and wheezy rales heard during deep inspiration. 3. Intractable: persistent wheezing 4. Status Asthmaticus: severe attack in which the patient deteriorates in spite of adequate treatment with sympathomymetic drugs. � 1.

Clinical manifestation: n n Usually begin with a hashing paroxysmal, irritative, and non- productive cough and then when condition progress cough become productive. �Shallow irregular and short breathing with prolonged expiratory phase. �Expiratory wheezes (The sound of air being pushed through constricted bronchioles). �Neck veins distended and cyanosis caused by CO 2 retention. �

Treatment: Current goals of medical therapy are avoidance of asthma triggers n � Corticosteroides; anti-inflammatory to reduce mucosal edema. n � Bronchodilator, β-adrenergic agonist(ventoline, albuterol) and expectorants n � Hydration with oral and I. V fluids. n

Cystic Fibrosis n n �Cystic fibrosis (CF) is an inherited autosomal recessive trait disorder that affects the exocrine glands of the body. The condition is characterized by an alteration in sweat, electrolytes, and mucus production that leads to multisystem involvement. �The exocrine glands of the body produce extremely thick, tenacious mucus. The sweat glands produce a larger amount of chloride, leading to a salty taste of the skin and alterations in electrolyte balance and dehydration.

n n n Lab tests: �Sweat test the child sweats at normal rate but it is very high in sodium chloride. �A quantitative sweat chloride test > 60 m. Eq/L. �Chest radiography, pulmonary involvement. �Stool fat and enzyme analysis, absence of pancreatic enzymes.

n n n n Pancreatic in sufficiency: thick mucus obstruct pancreatic duct and make atrophy for the pancreatic cells, blocking the secretion of pancreatic enzymes (lipase for digestion, trypsine for protein, amylase for carbohydrates). Food is then not broken down and absorbed. Symptoms of pancreatic insufficiency. 1. Bulky, floating, greasy, foul - smelling stools. (steatorrhea) 2. Inability to utilize vitamins, fat soluble vitamins A, D, E, and K. 3. Malabsorption symptoms (4. seems very hungry. 5. Absence of pancreatic enzymes in stool. 6. Meconium ileus in newborn (obstruction in intestine so during 24 hr no passage of meconium)

Pulmonary infections: n n n thick mucus obstruct alveoli, decreasing O 2 - CO 2 exchange and trapping air, over inflating the lungs result in the following symptoms: 1. Cough, tenacious mucus. 2. Worsening respiratory distress (increased pulse, retractions, flaring nares, dyspnea, and cyanosis). 3. Symptoms due to retained air in alveoli (respiratory acidosis, barrel chest). 77 | P a g e 4. Clubbing of fingers due to chronic inadequate O 2, inadequate peripheral tissue perfusion. 5. Repeated lung infection, related to pooling of secretions.

6. Complications: Pneumothorax (air collected in the pleural cavity from ruptured alveoli), atelectasis (collapse of lung alveoli with obstruction, no air enter and residual air absorbed), and pneumonia. n ♣ Management of cystic fibrosis focuses on minimizing pulmonary complications, promoting growth and development, and facilitating coping and adjustment of the n

n n n n n Nursing Interventions: 1. Lung (most emphasized) a. Postural drainage and chest physiotherapy. b. Antibiotics for infections. c. Expectorants, nebulizers, bronchodilators. d. Humidified O 2. e. Mist or croup tents. f. Force fluids to liquify secretions. g. I & O chart. h. Monitor symptoms of respiratory distress and lung infections.

n n n 2. Intestines: a. Give pancreatic enzymes with (or before each meal) to promote adequate digestion and absorption of nutrients and optimize nutritional status. . b. Daily weight. c. Monitor stools, should appear more normal. d. Water- soluble forms of fat soluble vitamins. Low fat, high protein, high CHO diet.

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