Ped Problems of Oxygenation Part II,100% CORRECT

Ped Problems of Oxygenation Part II Alterations of the Lower Respiratory Tract • Pneumonia * • Bronchiolitis/RSV • Asthma • Bronchopulmonary Dysplasia (BPD) • Cystic Fibrosis • Foreign Body Obstruction/Aspiratio ...

Ped Problems of Oxygenation Part II Alterations of the Lower Respiratory Tract • Pneumonia * • Bronchiolitis/RSV • Asthma • Bronchopulmonary Dysplasia (BPD) • Cystic Fibrosis • Foreign Body Obstruction/Aspiration RESPIRATORY SYNCYTIAL VIRUS (RSV) • Viral • Affects upper and no always lower respiratory tract – complication • Causes inflammation and increased mucus o Leads to obstruction which leads to air trapping o Over-inflation of lungs • Each year, on average, in the US, RSV leads to: o 57,527 hospitalizations among children younger than 5 years old o 2.1 million outpatient visits among children younger than 5 years old o 177,000 hospitalizations and 200 deaths in children per yr and 14,000 deaths among adults older than 65 years old • Most infants are infected before 1 year of age, and virtually everyone gets an RSV infection by 2 years of age. Incidence • Peak age 2-7 months • Peak time of year: November – March • RSV is responsible for 45-75% of cases of bronchiolitis • Responsible for many cases of pneumonia First manifests as URI ? Travels to Lower respiratory tract   Pneumonia Bronchiolitis Infection causes inflammatory response and alveolar edema Bronchospasms, mucosal edema & airway plugging Mucus in the lungs sets up an environment for bacterial infection  pneumonia Antibiotics: RSV with pneumonia on chest x-ray = antibiotics  don’t know if pneumonia is due to viral or bacterial RSV no pneumonia = no antibiotics “roving areas of hyperinflation and atelectasis”  hyperinflation and patchy areas that move from one day to another BRONCHIOLITIS • Most often caused by RSV • Lower respiratory tract infection • Most common in infants • Most common cause of hospitalizations in children <1 year old • Many viruses can cause Bronchiolitis o RSV o Adenovirus o Metapneumovirus Patho- • Acute inflammation • Edema • Mucus production • Bronchospasms • Necrosis of epithelial cells that line the small airways Signs and Symptoms of RSV/Bronchiolitis RSV  Upper respiratory involvement • Nasal Congestion • Fever • Cough • Pharyngitis Bronchiolitis • Symptoms mentioned above in addition to … • Inspiratory/expiratory wheeze • Tachypnea • Sleepiness (late sign) • Apnea  need to be on pulse ox if on the med/surg floor RSV Precautions • Contact Precautions o Easily spread from person to person through contact with respiratory secretions • Immunocompromised patients o Significant morbidity and mortality if infected o Mortality post-transplant (bone marrow and solid organ) = 50% with RSV • HANDWASHING • Nosocomial infection is problematic • Parents/caregivers role  teach proper hand hygiene, mask if sick, sick children stay at home Diagnosis • Rapid Respiratory Panel (RRP) o Detects RSV • Naso/pharyngeal swab o Detects RSV • ABG • Chest X-ray o Hyperinflation o Patchy Atelectasis Non-pharmacological Treatment • Supportive measures o Airway clearance o Oxygen therapy for SpO2 >90% o NO Chest physiotherapy (CPT) o Systemic hydration • Why No Chest PT? o Nothing helps but supportive measures!!! • What are some airway clearance measures that might be used? o Suctioning o Bulb suctioning o Coughing o Chronically ill patients  coughalator o hydration Pharmacological Treatment • Inhaled epinephrine • Ribovarin o Inhaled antiviral treatment • Steroids • Bronchodilators o Severe cases to reduce wheezing Prevention of RSV • Immunoprophylaxis o Who is eligible? • Premature infants • Infants with BPD • Infants with CHD o Synagis (Palivizumab) • IM injection • Given at the start of RSV season (October-May) • Given every month during RSV season for a total of 5 injections • NOT a vaccine  decreases severity • Expensive  given to high risk groups o Premature infants o Born at 29-35 weeks gestation o 3 months or younger at the start of RSV season o Congenital Heart Disease- Under 2 Caregiver Education • Use of bulb syringe • Hand hygiene • Maintain oral hydration • Monitor temperature • Encourage rest • Notify physician o Change in behavior o Increased retractions o Breathing faster o Noisy breathing o Child appearing ill/not eating or drinking o Sleepiness A nurse at a primary care office is providing teaching for the mother of a newborn infant, born one-month ago, in September. The child's only significant past medical history is a repaired Atrial Septal Defect (ASD). The mother states that the child is up to date with shots. The nurse should recommend that the child receive which injection at the end of the office visit? A. MMR, B. TdaP, C. Varicella, D. Palivizumab Rationale: Palivizumab is a humanized monoclonal antibody that is used as prophylaxis for RSV. It is given as an intramuscular (IM) injection before the start of RSV season (usually October to May depending on location) and then every month during RSV season for a total of five injections. Treatment is recommended for high –risk groups. The Center for Disease Control and Prevention (CDC) identifies the following high-risk groups: infants born 29 to 35 weeks gestation whoa re 3 months or younger at the start of RSV season; infants and children under the age of 2 with congenital heart defects; and infants born at 35 weeks gestation with chronic lung disease or neuromuscular disorders. ASTHMA • According to the NHLBI, asthma is the most common chronic disease of childhood, affecting 6 million children o School absences and hospitalizations • Chronic obstructive inflammatory disorder • Characterized by: o Bronchospasm o Thick secretions o Mucosal edema o Airway inflammation o Airway plugging • characterized by airway hyperresponsiveness of the immune system • Recurring symptoms  airway obstruction resulting from edema of the mucous membranes  accumulation of thick secretions, • AND bronchial hyperresponsiveness resulting in spasm of the bronchial smooth muscles • results in clinical manifestations of asthma: wheezing, coughing, dyspnea, and chest tightness. This hyperresponsiveness of the airways may occur in response to any number of stimuli. Immediate Response  IgE  Release of mediators  Bronchoconstriction  Resolves within 1-2 hours Delayed Response  Chemical mediators  Immune System response  Release of inflammatory materials  Smooth muscle damage  Bronchoconstriction can last several hours  Can last weeks to months Some stimulus (allergen, infection, stress, etc) initiates a bronchial response. Mast cells, macrophages, epithelial cells, neuroendocrine cells, eosinophils, and neutrophils play an important role as bronchoactive mediators. The effects of these mediators are regulated through a number of different pathways. Result is narrowing of the airways and bronchial obstruction from smooth muscle spasm, mucosal edema (bronchi), hypersecretion of mucous, destruction of the epithelium and mucous plugging. Air is trapped in the alveoli. This results in an increase in functional residual capacity, residual volume, and total lung capacity. Abnormal ventilation/perfusion results from hyperinflation and uneven obstruction of the airways. Physiological dead space increases R/T diminished perfusion of hyperinflated alveoli. Respiratory muscles contract to force expiration. The expiratory phase is prolonged. The diaphragm must eventually become fatigued. Venous return is decreased during expiration and increased during inspiration. As a result, you see overfilling of the RV and impeded LV emptying. If this cycle is not interrupted, hypoxia, retention of CO2, respiratory acidosis and cardiac failure will occur. Eight-year-old Tommy was admitted last night with wheezing, difficulty breathing, and coughing. He was anxious and restless. He was accompanied by his mother who stated, “This always happens when he gets a cold.” Tommy has had numerous lung related illnesses requiring hospitalization during the last two years. This is his third visit this month to the emergency room with an asthma attack. His mother has remained with him all night, but as the nurse enters the room today, the mother says, “I’ll be back in a second, I have to have a cigarette.” 1. What data does the nurse need today during the interview and the initial morning assessment? • Physical Assessment • Interview • Knowledge base of child and mother 2. What are possible asthma triggers for Tommy? • Smoking • Allergies (pollen or food) • Household products (solvents, paint vapors, dust) • Weather (cold or humidity) • Air Pollution • Exercise • Infection Risk Factors • Atopy: genetic predisposition for the development of an IgE mediated response  strongest identifiable predisposing factor • Hx Allergic rhinitis or atopic dermatitis o Eczema • Heredity (parent or sibling with asthma) • Exposure to cigarette smoke • Obesity • Ethnicity (African American @ greatest risk) • Low birth weight Causes • Genetic • Environmental • Intrinsic & Extrinsic • 20-40% have no allergic disease • Outdoor: trees, weeds, pollen, air pollution • Indoor: dust mites, mold, cockroach antigen Signs and Symptoms • Irritants: tobacco smoke, odors, sprays • Cold air • Colds/Viral infections • Stress • Pet Dander • Exercise • Food: nuts & dairy products Asthma Patient- As you view this video, think about your assessment of the patient. • Cough • SOB • Chest pain • Chest tightness • Wheezing • Prolonged expiration • Retractions • Accessory muscle use • Coarse or absent breath sounds** • Hyperresonance on percussion • Tachypnea • Tachycardia • Decreased O2 Saturation ** - ominous sign - Tachypnea is normally seen in asthma  if progresses to normal or decreased RR...WARNING SIGN of impending respiratory failure - Absence of wheezing with decreased airflow and poor respiratory effort often signals impending respiratory failure. - A child with a normal HR or bradycardia in conjunction with hypoxemia is in imminent danger of cardiac collapse. - The CNS is the system which is least tolerant of hypoxemia. Because of this, close monitoring of the LOC will provide early signs of impending respiratory failure. Patients may be restless, irritable, confused Looks & Sounds of Asthma • Retractions o watch • Expiratory wheezing (audible) o listen Diagnosis • Family history • Patient history of eczema and allergies Diagnostic Test: - Chest X-Ray - Pulse oximetry - ABG - Response to treatment- bronchodilator When you’re making a diagnosis you are taking many things into consideration  Family History: - Parental smoking - Asthma - Family or patient history of eczema or allergies Dermatologic Signs: - Allergic shiners - Nasal creases - Pebbled Conjunctiva Asthma Classification • Based on frequency of daytime & nighttime symptoms • PEF: Peak expiratory flow • FEV: Forced expiratory volume (in 1 sec = FEV1 • Classified into 4 categories: Intermittent • Symptoms less than 2 days/week • Nighttime symptoms o Age 0-4: none o Age 5-11: < 2x/month • No interference w/ normal activity • Short acting beta-agonist needed < 2 days/week • PEF or FEV: >= 80% predicted value • PEF variability: < 20% Moderate Persistent Asthma • Symptoms daily • Nighttime symptoms o Age 0-4: 3-4 times/month o Age 5-11: most nights, not nightly • Some limitations w/ normal activity • Short acting beta-agonist needed daily • PEF: 60-80% predicted value • FEV1: 75-80% Status Asthmaticus • Failure to respond to first line treatment • MEDICAL EMERGENCY!!! Mild Persistent • Symptoms > 2 times/week, but < 1 time/day • Nighttime symptoms o Age 0-4: 1-2 times/month o Age 5-11: 3-4 times/month • Minor limitations w/ normal activity • Short acting beta-agonist needed > 2 days/week, but not daily • PEF or FEV: >= 80% predicted value • PEF variability: 20-30% • PEF variability: > 30% Sever Persistent Asthma • Continual symptoms throughout the day • Frequent nighttime symptoms • Severely limited activity • Short acting beta-agonist needed several times a day • PEF: < 60% • FEV1: < 75% of predicted value • A child is said to be in status asthmatics when they have failed to respond to first line treatment. Medical emergency  can result in respiratory failure and death if unrecognized and untreated Managing Asthma • Maintain normal activity • Maintain normal pulmonary function • Prevent chronic symptoms & recurrent exacerbations • Provide optimal drug therapy • Allergen control Non-Pharmacological Management • Pulmonary Function Test o Measure of how much they are able to breath in and out via spirometry • Peak Flow Meter: o Measures peak expiratory (exhale) rate o Child blows out into device as hard as they can o Very low  impending asthma attack Pharmacological Management • Prevention & control • Reduce frequency & severity • Reverse airflow obstruction • Suppress inflammation • Long & short-term control Long-acting medications: • Inhaled corticosteroids (flovent, budesonide) • Cromolyn sodium/nedocromil • Long-acting beta 2 agonists (symbicort, advair) • Methylxanthines (theophylline) • Leukotriene modifiers (singulair) Inhaled steroids (flovent, advair) are used for prevention Parents are often concerned about long-term steroid use Rinse mouth after use – oral fungus a risk. Inhaled corticosteroids: anti-inflammatory, decrease hyper-responsiveness Mast cell inhibitor (cromolyn/nedocromil): interferes with chloride channels Long-acting beta 2 agonists: relaxes smooth muscles in airway, used in combination with inhaled corticosteroids Leukotriene modifiers: decrease inflammation cascade - Because its an immune mediated response Short-acting medications: • Anticholinergics (atropine, ipratropium) • Short-acting beta 2 agonists (albuterol, terbutaline, xopenex, ventolin) o Metered- Dose Inhaler o Short-acting beta 2 agonists: relaxes smooth muscle in the airway, increases water in mucus = promotion of clearance • Systemic corticosteroids (prednisone) Case Study 1. What effect do Ventolin and Prelone have on Tommy’s lungs and what side effects should the nurse be watching for? • Ventolin aerosol o Bronchodilator o Relaxes the airway and opens it up for easier breathing o Side Effects: tachycardia, jitteriness, tremors, headache, nausea • Prelone o Oral corticosteroid o Prevents and reverses airway inflammation o Side Effects: nausea, mood changes, increase appetite, flushed cheeks, headache 2. What evaluation criteria would indicate improvement? • Disappearance of rhonchi in lung field • Decreased coughing • Decreased severity of wheezing • Return of wheezing if breaths sounds were not audible. • Decreased chest tightness • Easier breathing (decreased RR) without use of accessory muscles 3. If improvement does not occur and he progresses to status asthmaticus, what should the nurse anticipate would be done? • ICU • O2 administration • elevate the head of the bed • Frequent respiratory assessments • Assess LOC • NPO • Prepare emergency equipment • Ventilation, Endotracheal intubation Medication Administration • Inhaled medications have faster effect • No spacer = risk for oral yeast infection- always use spacer in child • Spacers help children that do not have the coordination of inhalation technique Healthy People 2020 • Recognizes asthma as a national problem • Goals: o Reduce asthma deaths o Reduce hospitalizations o Reduce ED visits o Reduce activity limitations o Reduce the number of school days missed o Increase formal education for those with asthma o Increase the number of places (states, territories, etc.) that have a system for asthma surveillance A three-year-old child presents to the Emergency Department in status asthmaticus. One hour ago, upon initial assessment, the nurse hears inspiratory and expiratory wheezing in all lung fields. Now, no wheezes are audible. What is the priority nursing action? A. administer albuterol as scheduled and continue to monitor B. notify provider and prepare for intubation C. Admin 02 via nasal cannula D. Notify provider and suggest discontinuation of albuterol Rationale: Status Asthmaticus is a medical emergency. Inaudible breath sounds may indicate that the patient is no longer ventilating. The priority nursing action would be to notify the physician and prepare for intubation. Continuous albuterol should be continued, but this patient is in respiratory failure and requires immediate intervention. Continuous albuterol treatment should continue for at least 2 hours for patients presenting in status asthmaticus BRONCHOPULMONARY DYSPLASIA (BPD) • Often referred to as Chronic Lung Disease • Initial injury o Prenatal infection o Mechanical ventilation o Supplemental O2 o PDA o Postnatal infection o Leads to … • Pulmonary changes o Scarring of lung walls o Shrinkage of area for gas exchange • Pulmonary changes resulting from an initial injury … --Chronic lung disease--- • Risk Factors: o O2 use o Mechanical ventilation o Prematurity, Congenital heart defects, anatomical issues • Pulmonary changes: o - Interstitial edema and epithelial swelling  thickening and fibrotic proliferation of the alveolar walls BPD Incidence • Decreasing • Use of synthetic surfactant o Less time spent on ventilators • 25% of infants with severe BPD die BPD Assessment • Increased WOB • Accessory muscle use • Tachypnea • Circumoral and nail bed cyanosis • Retractions • Atelectasis • Prolonged exhalation • Weight loss/poor weight gain • Poor feeding • Right-sided heart failure BPD Spells • Clinical presentation o Bronchospasm / “clamp down” o Cyanotic/Dusky o Desaturations / increased CO2 o Tachycardia followed by bradycardia with prolonged bronchospasm o Inability to ventilate • Trying to bag, can be unsuccessful • Causes: o Agitation o Respiratory distress o Sickness o Aspiration / GERD • Severe: Sedation, paralytic (short term) Nursing Intervention • No reversal treatment exists • Reduce the risk of volutrauma • Promote and monitor respiratory function • Provide supplemental O2 • Mechanical ventilation on lowest settings • Drug therapy o Surfactant o Diuretics decrease interstitial edema o Bronchodilators o theophylline o Caffeine to increase lung compliance? o Palivizumab Comfort measures - High risk for RSV  will not do well - Avoid barotrauma with PPV by providing least support necessary to maintain oxygenation o ABG goals  allow permissive hypercarbia, pH normal, Hgb stable - Decrease noxious stimuli as much as possible - Sedation and paralytics in hospital setting if needed for acute decompensation or management of severe BPD - Diuretic therapy - helps to decrease pulmonary edema/fluid overload - Lasix, Hydrochlorothiazide, Spironolactone - Optimize nutrition – high calorie feeds to help support lung growth - PT/OT/Speech therapies to help promote growth and development NIPPV • Non-Invasive Positive Pressure Ventilation o Used in children with sleep apnea, muscle weakness, restrictive lung disease o Continuous Positive Airway Pressure (CPAP) • Continuous pressure throughout respiratory cycle o Bi-level Positive Airway Pressure (BIPAP) • Preset inspiratory and expiratory pressures Elsa is a 12-month-old, born at 29 weeks, who developed severe bronchopulmonary dysplasia after a long stay in the Neonatal ICU. She was brought in by her mother who repots a two-day fever, decreased PO intake and a productive cough. As the emergency nurse, what assessment data would you expect to obtain upon admission? (Select all that apply) A. Axillary Temp B. Basic Metabolic Panel C. Pulm Function Test D. Pulse ox reading E. Sputum and blood cultures Rationale: An axillary temperature would be indicated, as this is the most accurate temperature. The nurse would expect to draw laboratory levels including a basic metabolic panel, which would include electrolyte levels. The infant should be placed on a cardio-pulmonary monitor to obtain vital signs including a pulse oximeter to determine the patient’s oxygen saturation. Sputum and blood cultures would be obtained to identify a source of possible infection. Pulmonary function test is not indicated on admission. CYSTIC FIBROSIS • Autosomal recessive disorder of the exocrine glands • Characterized by viscous mucus and decreased pancreatic enzymes • Dysfunction causes multi-system involvement CF Etiology • Inherited autosomal recessive trait • Child inherits defective gene from both parents • Both parents carry the gene o 1:4 chance child will have CF • Deletion in chromosome 7 at the cystic fibrosis transmembrane regulator (CFTR) • Absence of CFTR as a chloride channel interferes with sodium-chloride transport CF Incidence • Most common lethal genetic illness of childhood • Approximately 30,000 children and young adults • 1 in 31 Americans carries an abnormal copy of the CF gene but isn’t sick with the disease • Median age 36.8 years (2011) • Currently close to 40 years o More than half of the CF population is 18 or older o 75% diagnosed by age 2 Multisystem Involvement • Respiratory o Excess mucous production in lungs o Chronic infections • Digestive o Thick mucous in pancreatic ducts o Blocks digestive enzymes o Unable to absorb fat, proteins, carbohydrates • Metabolic o Hypermetabolic state o Hyponatremia • Excess sodium chloride production by sweat glands • Reproductive o Sterility • Ovarian ducts and vas deferens blocked with mucous  Interference with the sodium chloride transport system effects multiple systems  Require supplemental fat soluble vitamins  Vitamins A, D, E, K o Typically fat soluble vitamins are stored in fat and used when needed o Unable to absorb fat, so there is no where for vitamins to be stored o Creon  lipase, proteinase and amylase  **Stress hyponatremia  consequences  Hypermetabolic state  require more calories  Metabolize medications quicker requiring higher dosed medications at times. Assessment • Recurrent infections o Pneumonia o Bronchitis • Salty kisses • Maldigestion o Steatorrhea  fatty stools • Growth failure • Diabetes- Degeneration of pancreas = decreased insulin production • Weight loss • Clubbing (late sign) and barrel chest  chronic hypoxia o Loss of angle at base of nail bed • Barrel chest • Breath sounds tend to be clear Screening vs. Diagnostic Many false positives, not many false negatives  rather false positives ***Only Sweat test and genetic test are definitive • Prenatal: o DNA testing of amniotic fluid for deletion of delta F508 chromosome • ***Sweat Test: o Positive test shows 2-5 times normal level of sodium and chloride o Repeated to be confirmed o Not used in first year of life • Chest X-ray: o Hyperinflation, atelectasis, infiltrates, bronchial wall thickening • Pulmonary Function Test: o Gauges the progressiveness of disease o Hope to maintain PFTs o Decreased forced vital capacity o Decreased forced expiratory volume o Increased residual volume • 72 Hour Fecal Test: o Increased fat and decreased albumin Nursing Interventions • Maintain airway • Chest PT o Mobilize secretions • Postural drainage  gravity o Percussion • Cupped hands • Vibration • Handheld motorized massager • Think about patients who are fragile or in severe pain (might not tolerate) o Vest • Wrap encircles chest can go over shoulders and oscillates o Forced Exhalation/incentive spirometry • Combination to mechanically mobilize/eliminate secretions • Re-expand lung tissue • Aerosolized medications • Bronchodilators • Antibiotics • Mucolytic agents • Low humidified supplemental O2 • Individualized diet modifications o Pancreatic enzymes o Multivitamins o Caloric supplements State Rationales for Orders • High level contact precautions. • Central line for IV meds • Physical therapy - exercise bike or treadmill in patient room • Extra salt in diet • Auditory test • G-tube for overnight feeds • Miralax • PFTs on admission and after 1 week of treatment Caregiver Education • Importance of Chest PT o 3 to 4 times per day o Avoid percussing over spine or internal organs (stomach) o Feeding time/enteral feeds • Vest therapy • Exposure to infections • Physical activity- move secretions • Nebulizer treatments • Diet changes- do not limit fat, high cal/protein, • Adequate hydration • Fat-soluble vitamin supplements • Administration of enzymes BEFORE meals • NO salt restriction o Hot weather = increase Na intake • Annual flu shot Complications • S/S of infection • Require higher dose of antibiotics o Higher drug clearance rate among CF patients CF Case Study Cara is two-years-old admitted to the pediatric unit with suspected pneumonia. This is Cara’s second admission with lower respiratory tract infection in the past six months. Her history revealed a meconium ileus at birth. Clinical assessment reveals decreased breath sounds in the bases, respirations 32, productive cough with thick secretions. Cara’s weight is in the 5th percentile. Her sweat chloride is 65 mEq/L. The mother states Cara tastes salty when she kisses her skin. Cara is started on IV Ampicillin. 1. Describe the significance of the sweat chloride test in relation to the above assessment data. o Detects abnormally high Na and Cl levels in sweat o >60 mEq/L confirms diagnosis o Physical assessment considerations • Meconium ileus • Low weight • Thin extremities • Recurrent lower respiratory infections • Thick secretions • Cough • Respiratory distress • Salty taste • Steattorhea CF is confirmed. The physician orders Pancrease to be given with Cara’s high-protein and high-carb diet. Chest PT after aerosol treatments with DNase is to be implemented. Cara’s parents are overwhelmed with the diagnosis and the doctor’s referral for genetic testing. They ask if there is anything they can do to prevent this from happening again. Both parents are working full time, and Cara is currently in day care. 1. How would the nurse educate the mother about the future central line? o Describe what it is o Visual diagrams o Teaching sessions • Proper care • Warning signs • Home nursing 2. Cara is resistant to taking her medications. What strategies could the parents use? o Sticker chart o Allow child’s help o Security item o Comfort o Consistent timing The nurse is providing care for a 13-year-old patient with cystic fibrosis. The patient was admitted for a cystic fibrosis exacerbation complicated by a severe hemoptysis. The patient is reporting difficulty breathing and VS are HR 98, RR 30, BP 110/69, SpO2 93%. Which order should the nurse question? A. Preform chest physiotherapy Q4Hr and PRN B. Titrate 02 1-4L to maintain pulse ox >92% C. Draw ABG Q12hr and PRN D. Flush PICC line with heparin Q8hr to maintain patency Rationale: Chest physiotherapy (CPT) is contraindicated for patient’s with chest wall trauma, lung contusion or abscess, pneumothorax or hemoptysis. Alternative clearance mechanisms should be used until the pneumothorax resolves such as Dornase alfa (a genetically engineered pulmonary enzyme administered via nebulizer to thin mucus and improve lung function). Gentle vibration might be appropriate. All other orders are appropriate. The nurse caring for a 10 year-old patient with cystic fibrosis is providing parent teaching upon discharge. The nurse knows that parents demonstrate knowledge of their child's nutritional needs when they state: A. My child should continue taking pancreatic enzymes after eating breakfast, lunch, dinner and snacks B. My child really enjoys chicken, I cook chicken frequently for dinner and boil eggs for breakfast C. My child loves milkshakes. I allow one a day because I do not want her to consume too much fat. D. My child’s diet should be limited to ensure she eats no more than 2000 cals per day. Rationale: Patient’s with cystic fibrosis should consume a high-protein, high-caloric, unrestricted fat diet. Patient’s with CF require extra calories for a few reasons. Fighting infections and coughing burn extra calories. Maintaining a healthy weight is required to keep your lungs and body strong. Foods high in protein help build muscle, repair tissue, and keep bones healthy and strong. Pancreatic enzymes should be taken every day with meals and snacks. Foods high in dairy may contribute to secretion viscosity. FOREIGN BODY ASPIRATION • Solid or liquid inhaled into respiratory tract Aspiration • Mainstem, lobar bronchus, or distal portion of lung or trachea • Most common 6 months to 5 years old • Objects placed into the nose or mouth can be aspirated into the airway causing obstruction. • May lodge in a mainstem, lobar bronchus or distal portion of the lung or trachea Signs & Symptoms • Coughing • Wheezing • Stridor • Choking/gagging • Possible cyanosis • Asymptomatic • Unconsciousness and death o Asphyxiation if object is not removed Infant or child may be asymptomatic for hours or weeks - Eventually irritation, edema, and obstruction will develop, producing symptoms Laryngeal/Tracheal: potential total airway obstruction- usually present with stridor, dyspnea, hoarseness, aphonia (no voice) Bronchial: paroxysmal cough (frequent/violent), wheezing, asymmetrical breath sounds Esophageal: symptoms of airway aspiration with excessive salivation, dysphagia, and / or emesis. Diagnosis • Clinical signs • Chest X-ray • Bronchoscopy o Identify and remove object Button Battery Ingestion • CATCH quickly • Eroded esophagus  trachea  started to erode through aorta • ECMO pt.  open heart surgery to repair aorta  can’t ventilate themselves so ECMO will do it for you • Batteries lodged in esophagus must be removed within 2 hours  BUT may be asymptomatic initially • Battery pole causes significant injury (polarized side of the battery) • Hyperinflation below the area of obstruction because it is blocking off • Listen to the child, wheezing on one side if past the mainstem Management • Management is subject to location and severity of the foreign body aspiration • Supplemental O2, support respiratory status • Decrease anxiety / agitation – calm environment • Bronchoscopy to retrieve item • Pain management • Monitor for signs of post- removal swelling or respiratory distress Caregiver Education • Teach about the dangers of aspiration. • Age appropriate foods • Cut table food into small pieces. • Choking interventions o Infants: Back blows and abdominal thrusts with head lower than chest o Children: Heimlich maneuver BLS Infant Choking Algorithm The nurse is providing parent teaching for the parents of a 10-month-old being discharged from the ER after choking on a button. Which information will be most helpful in teaching parents about the primary prevention of foreign body aspiration? A. Signs & symptoms of foreign body aspiration B. Therapeutic management of foreign body aspiration C. Most common objects that toddlers aspirate D. Risks associated with foreign body aspiration Rationale: Primary prevention is aimed at preventing the onset of disease and reducing the incidence of disease. It involves interventions that are appropriate before there is any evidence of disease or injury.