ENT AND RESPIRATORY DISORDERS IN CHILDREN : SHORT NOTE FOR NURSES

EYE, EAR, AND RESPIRATORY DISORDERS OF CHILDREN

1. STRABISMUS

• Also called squint or lazy eye or crossed eye
• Disorder in which the eyes don’t look in exactly the same direction at the same time.
• Condition in which the eyes are not aligned because of lack of coordination of extraocularmuscles
• It is normal upto 4 months, after 4 months treatment is needed

Assessment
• Amblyopia (reduced visual acuity) if not treated early
• Loss of binocular vision
• Impairement of depth perception
• Frequent headaches
• Squinting or tilting of the head to see


Interventions
Occlusion therapy : patching of good eye to strengthen the weak eye
Injection of botulinum toxin (Botox) may be injected into the eye muscle as a nonsurgical intervention. This treatment produces temporary paralysis to allow the muscles opposite the paralysed muscle to straighten the eye
• Sugical interventions are performed before the age of 2 years ,if other measures are unsuccessful



2.CONJUNCTIVITIS

• Also known as pink eye; is an inflammation of the conjunctiva
• Bacterial or viral conjunctivitis is extremely contagious
• Chlamydial conjunctivitis is rare in older children and, if diagnosed in a child who is not sexually active, the child should be assessed for possible sexual abuse
• Assessment:

Itching, burning or scratchy eyelids,redness , edema, discharge
Interventions
• Instuct for good handwashing and not sharing towels and wash cloths
• Child should be kept home from school or daycare until antibiotic eyedrops havebeen administered for 24 hours
• Instruct the child who is wearing contact lenses to discontinue wearing them and to obtain new lenses to eliminate th chance of reinfection
• Eye makeup should be discarded and replaced

3.OTITIS MEDIA

• Inflammatory disorder caused by an infection of the middle ear occuring as a result of a blocked eustachian tube, which prevents normal drinage
• It is a common complication of an acute respiratory infection
• Infants and children are more prone to otitis media because their eustachian tubes are shorter, wider and straighter
Assessment
• Fever, irritability and restlessness
• Rolling of head from side to side
• Pulling on or rubbing the ear
• Red ,opaque, bulging or retracting tympanic membrane

Interventions
• Feed infans in upright position
• Provide local heat and have the child lie with the affected ear down
• Administer the prescribed antibiotics, emphasizing that the 10 -14 day period is necessary to irradicate infective organisms
• Administration of ear medications
In a child younger than age 3, pull the lobe down and back.
In a child older than 3 years, pull the pinna up and back
Myringotomy
• Insertion of tympanoplasty tubes into the middle ear to equalize pressure and keep the ear aerated
• Client should wear earplugs while bathing ,shampooing and swimming
• Diving and submerging under water are not allowed
• Instruct the parents that if the tubes fall out, it is not an emergency, but the physician should be notified
• Child should not blow his or her nose for 7 to 10 days after surgery

4.TONSILLITIS AND ADENOIDITIS

• Tonsillitis refers to inflammation and infection of the tonsils
• Adenoiditis refers to inflammation and infection of adenoids
Assessment
• Persistent or recurrent sore throat
• Enlarged, bright red tonsils that may be covered with white exudate
• Difficulty in swallowing
• Mouth breathing and an unpleasant mouth odor
• Enlarged adenoids may cause nasal quality of speech, mouth breathing ,hearing difficulty, snoring and or obstructive sleep apnea
Postoperative interventions after tonsillectomy
• Position the child prone or side lying to facilitate drainage
• Frequent swallowing is a sign of haemorrhage, turn the child to the side and notify the physician
• Have suction equipment available, but do not suction unless there is an airway obstruction
• Do not give the child any straws, forks, or sharp objects that can be put into the mouth
• Provide clear, cool, noncitrus and noncarbonated fluids

5.EPISTAXIS(NOSEBLEEDS)

• Have the child sits up and lean forward, not lying down
• Apply continuous pressure to nose with the thumb and forefinger for atleast 10 minutes
• Insert cotton or wadded tissue into each nostril, and apply ice or a cold cloth to the bridge of the nose if bleeding persists
• Keep the child calm and quiet

RESPIRATORY DISORDERS

1.EPIGLOTITIS

• Bacterial form of croup
• Inflammation of epiglottis caused by Haemophilus influenzae type b or Streptococcus pneumoniae
• Occurs most frequently between 2 – 5 years of age
• Onset is abrupt ,occurs most often in winter
• Considered an emergency situation
Assessment
• High fever
• Large, cherry red edematous epiglottis
• Drooling
• Inspiratory stridor aggravated by the supine position
• Tachycardia ,tachypnea
• Hypoxia, hypercapnea
• Respiratory acidosis
• Tripod positioning
Interventions
• Maintain a patent airway
• To prevent spasam of the epiglottis and airway occlusion, no attempts should be made to visualize the posterior pharynx, obtain a throat culture or take an oral temperature
• Do not force the child to lie down
• Provide cool mist oxygen therapy as prescribed
• Provide high humidification to cool the airway and decrease swelling
• Have resuscitation equipment available, and prepare for ET intubation or tracheostomy for severe respiratory distress
• Ensure that the child is up to date with the immunization schedule, including Hib congugate vaccine

2.LARYNGOTRACHEOBRONCHITIS

• Inflammation of the larynx, trachea, and bronchi
• Most common type of croup
Assessment
• Low grade fever
• Seal bark and brassy cough
• Inspiratory stridor
Interventions
• Monitor for pallor or cyanosis
• Provide humidified oxygen via a cool mist tent for the hospitalized child
• Use a cool air vaporizer or humidifier at home, or having the child breath in the cool night air or the air from an open freezer, or taking the child to a cool basement or garage
• Avoid cough syrups and cold medicines, which may dry and thicken secretions
• Administer nebulized epinephrine as prescribed
• Have resuscitation equipment available

3.BRONCHITIS

• Infection of the major bronchi, may be referred to as tracheobronchitis
• Fever
• Dry, hacking and nonproductive cough that is worse at night and becomes productive in 2- 3 days
• Provide cool humidified air
• Encourage increased fluid intake

4.BRONCHIOLITIS AND RESPIRATORY SYNCYTIAL VIRUS (RSV)

• Inflammation of bronchioles caused by RSV
• RSV, although not airborne, is highely communicable and is usually transferred by direct contact with respiratory secretions
Interventions
• Maintain a patent airway
• Position the child at a 30 – 40 degree angle with the neck slightely extended
The child with RSV
• Isolate the child in a single room or place in a room with another child with RSV
• Administer ribaverin (virazole),an antiviral medication ,if prescribed
Administer ribaverin via aerosol by hood, tent,mask, or through ventilator tubing
Pregnant health care providers should not care for a child receiving ribaverin
The nurse wearing contactlenses should wear goggles when coming in contact with ribaverin because the mist may dissolve soft lenses
• Prepare for the administration of RSV immune globulin or palivizumab
Used prophylatically to prevent RSV in high risk infants
Not administered to infants or children with congenital heart disease or cyanotic heart disease

5.PNEUMONIA

• Inflammation of the pulmonary parenchyma and or alveoli caused by a virus , mycoplasmal agents, bacteria or aspiration of foreign substances.
• Viral pneumonia occurs more frequently than bacterial pneumonia
• Place the child in a cool mist tent.
• Administer chest physiotherapy and postural drainage every 4 hours as prescribed.
• Encourage child to lie on the affected side ,if pneumonia is unilateral to splint the chest and reduce the discomfort caused by pleural rubbing.



6.ASTHMA

• Chronic inflammatory disorder of the airways
• Mast cell release of histamine leads to a bronchoconstrictive process
• A common symptom is coughing in the absence of respiratory infection, especially at night
• Status asthmaticus: Child displays respiratory distress despite vigorous treatment measures.It is a medical emergency that can result in respiratory failure and death if left untreated
Assessment
• Child has episodes of wheezing,breathlessness,dyspnea, chest tightness and cough, particularly at night/ or in the early morning
• Child may present with prodromal itching localized at the front of the neck or over the upper part of the neck
• Cough becomes rattling and there is production of frothy, clear, gelatinous sputum
• Severe spasm or obstruction – breath sounds and crackles become inaudible, and the cough is ineffective
• Younger children assume the tripod sitting position; older children sit upright with the shoulders in a hunched – over position, child refuses to lie down
• Child speaks in short ,broken phrases
Interventions
• Acute episode
Assess airway patency
Administer humidified oxygen by nasal prongs or face mask
Continuous monitoring
COrrect dehydration, acidosis and / or electrolyte imbalances
• Fast–acting medications
Short-acting beta2-adrenoceptor agonists (SABA), such as salbutamol (albuterol USAN) are the first line treatment for asthma symptoms. They are recommended before exercise in those with exercise induced symptoms
Anticholinergic medications, such as ipratropium bromide, provide additional benefit when used in combination with SABA in those with moderate or severe symptoms
• Long–term control
Corticosteroids are generally considered the most effective treatment available for long-term control
Long-acting beta-adrenoceptor agonists (LABA) such as salmeterol and formoterol can improve asthma control, at least in adults, when given in combination with inhaled corticosteroids
Leukotriene receptor antagonists (such as montelukast and zafirlukast) may be used in addition to inhaled corticosteroids, typically also in conjunction with a LABA
• Chest physiotherapy
• Allergen control

7.CYSTIC FIBROSIS (CF)

• This is a chronic multisystem disorder characterized by exocrine gland dysfunction
• It is an autosomal recessive trait disorder
• Cystic fibrosis affects the cells that produce mucus, sweat, and digestive juices. It causes these fluids to become thick and sticky. They then plug up tubes, ducts, and passageways.
• The most common symptoms are pancreatic enzyme deficiency caused by duct blockage, progressive chronic lung disease associated with infection, and swet gland dysfunction resuiting in increased sodium and chloride swet concentrations
• An increase in sodium and chloride in swet and saliva forms the basis for the most reliable diagnostic test, the swet chloride test
• CF is a fatal genetic disorder and respiratory failure is the most common cause of death
Resiratory system
a. Cyanosis
b. Difficulty in breathing
c. Choked nasal passage
d. Wheezing and dry non productive cough
e. Increased tendency to develop sinusitis and nasal polyps (swelling on the walls of nasal cavity or sinuses)
f. Barrel chest
g. Clubbing of fingers and toes
Gastrointestinal system
h. Meconium ileus in the neonate
i. Poor digestion
j. Constipation
k. Frothy ,foul smelling stools(steatorrhea)
l. Blocked intestine
m. Undernourishment due to lack of absorption of nutrients
n. Weakness
o. Difficulty to gain weight
 Integumentary system
p. Infants taste salty when kissed
q. Dehydration and electrolyte imbalances
 Reproductive system
r. Delay puberty in girls
s. Infertility
t. Males are usually sterile
Diagnostic tests
Immunoreactive Trypsinogen (IRT) Test
screening test that checks for abnormal levels of the protein .The immunoreactive trypsinogen (IRT) test is a standard newborn led IRT in the blood. A high level of IRT may be a sign of cystic fibrosis. However, further testing is required to confirm the diagnosis.
• Sweat Chloride Test
swet is collected, and the swet electrolytes are measured, a minimum of 50 mg of swet is needed
Normally, swet chloride concentration is lower than 40 mEq/L
>60 mSwet production is stimulated (pilocarpine iontophoresis), the Eq/L is a positive test result
40 – 60 mEq/L are highely suggestive of CF and require a repeat test
• Sputum Test
During a sputum test, the doctor takes a sample of mucus. The sample can confirm the presence of a lung infection. It can also show the types of germs that are present and determine which antibiotics work best to treat them.
Chest X-Ray
A chest X-ray is useful in revealing swelling in the lungs due to blockages in the respiratory passageways.
• CT Scan
A CT scan creates detailed images of the body by using a combination of X-rays taken from many different directions. These images allows your doctor to view internal structures, such as the liver and pancreas, making it easier to assess the extent of organ damage caused by cystic fibrosis.
• Pulmonary Function Tests (PFTs)
Pulmonary function tests (PFTs) determine whether your lungs are working properly. The tests can help measure how much air can be inhaled or exhaled and how well the lungs transport oxygen to the rest of the body. Any abnormalities in these functions may indicate cystic fibrosis.
Interventions
• Bronchodilators, aerosols and liquid medicines are given to relax the muscles and open up the airways.
• Mucolytics are given to thin the mucus.
• Antibiotics may be given orally, intravenous or in the form of inhalers to fight respiratory infections. Tobramycin is widely used to treat infections caused by Pseudomonas bacteria. Azithromycin is another antibiotic which is effective in treating infections.
• Corticosteroids are prescribed to reduce the swelling in case of nasal polyps.
• Chest physiotherapy on awakening and in the evening
• Administer oxygen as prescribed
• Replace pancreatic enzymes
• Child should be vaccinated yearly for influenza

8.FOREIGN BODY AASPIRATION

• Swallowing and aspiration of a foreign body in to the air passages
• Abdominal thrust in children over 1 year of age (Heimlich maneuver) to remove the foreign body
• Back blows and chest thrust in children younger than 1 year of ag to remove the foreign body

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