Pulmonary Disorders

Cystic fibrosis
1. Introduction: Cystic fibrosis is a generalized dysfunction of the exocrine glands that produces multisystem involvement. Although the disorder is inherited as an autosomal recessive defect, the basic biochemical defect is unknown. However, its probable cause is an alteration in a protein or an enzyme (e.g., pancre- atic enzyme deficiency). The basic problem is one of thick, sticky, tenacious mucous secretions that obstruct the ducts of the exocrine glands, thus affecting their ability to function. Cystic fibrosis is found in all races and socioeconomic groups, although there is a significantly lower incidence in African Americans. It is a chronic disease with no known cure and guarded prognosis; median age at death in the United States is 27.6 years. Those born in the late 1990s can be expected to survive into their forties with new therapies.
2. Assessment:
  1. Newborn: meconium ileus.
  2. Frequent, recurrent pulmonary infections: bronchitis, bronchopneumonia, pneumonia, and ultimately chronic obstructive pulmonary disease (COPD) due to mechanical obstruction of respiratory tract caused by thick, tenacious mucous gland secretions.
  3. Malabsorption syndrome: failure to gain weight, distended abdomen, thin arms and legs, lack of subcutaneous fat due to disturbed absorption of nutrients that results from the inability of pancreatic enzymes to reach intestinal tract.
  4. Steatorrhea: bulky, foul-smelling, frothy, fatty stools in increased amounts and frequency (predisposed to rectal prolapse).
  5. Parents may note that child “tastes salty” when kissed, due to excessive loss of sodium and chloride in sweat.
  6. Sweat test reveals high sodium and chloride levels in child’s sweat, unique to children with cystic fibrosis.
  7. Sexual development:
    1. Male: sterile (due to aspermia).
    2. Female: difficulty conceiving and bearing children (due to increased viscosity of cervical mucus, which acts as a plug in the cervical os and mechanically blocks the entry of sperm).
3. Analysis/nursing diagnosis:
  1. Ineffective breathing patterns related to thick, viscid secretions.
  2. Altered nutrition, less than body requirements, related to diarrhea and poor intestinal absorption of nutrients.
  3. Decreased cardiac output related to COPD and decreased compliance of lungs.
  4. Activity intolerance related to respiratory compromise.
  5. Self-esteem disturbance related to body image changes.
  6. Knowledge deficit related to disease process, treatments, medications, genetics.
  7. Noncompliance (potential) related to complicated and prolonged treatment regimen.
4. Nursing care plan/implementation:
  1. Goal: assist child to expectorate sputum.
    1. Perform postural drainage as prescribed: first thing in morning, between meals, before bedtime, not after meals to prevent aspiration.
    2. Administer nebulizer treatments, expectorants, mucolytics, bronchodilators. Avoid or limit use of medications that suppress cough mechanism.
    3. Provide for exercises that promote position changes and keep sputum moving up and out.
    4. Encourage high fluid intake to keep secretions liquefied.
    5. Suction, administer oxygen pm.
  2. Goal: prevent infection.
    1. Standard precautions to prevent infection.
    2. Evaluate carefully, check continually for potential infection (especially respiratory); report to physician promptly.
    3. Limit contact with staff or visitors (especially children) with infection.
    4. Administer antibiotics as ordered, to treat respiratory infections and prevent overwhelming sepsis.
    5. May be placed on prophylactic antibiotic therapy between episodes of infection.
    6. Teach importance of prevention of infection at home: adequate nutrition, frequent medical checkups, stay away from known sources of infection.
  3. Goal: maintain adequate nutrition.
    1. Diet: well balanced, high calorie and protein to prevent malnutrition.
    2. Administer pancreatic enzyme (viokase, pancreatin) immediately before every meal and every snack to enhance the absorption of vital nutrients, especially fats.
    3. If child is unable to swallow tablets, mix pancreatic enzyme powder with cold applesauce.
    4. Administer water-miscible preparations of fiat-soluble vitamins (A, D, E, K), multivitamins, and iron.
    5. Encourage extra salt intake to compensate for excessive sodium losses in sweat (unless CHF is present).
    6. Encourage extra fluid intake (e.g., Gatorade) to prevent dehydration/electrolyte imbalance.
    7. Daily I&O and weights to monitor nutritional and hydration status.
    8. Encourage child to assume gradually increasing responsibility for choosing own foods within dietary restrictions.
  4. Goal: teach child and family about cystic fibrosis.
    1. Discuss diagnostic procedures: sweat test, stool specimens.
    2. Review multiple medications: use, effects, side/toxic effects.
    3. Stress need to care for pulmonary systems (major cause of mortality/morbidity).
    4. Teach various treatments: postural drainage, nebulizers, oxygen therapy, breathing exercise.
    5. Encourage child to assume as much responsibility for own care as possible: medications, treatments, diet.
    6. Promote development of healthy attitude toward disease/prognosis (no known cure). Heart/lung transplant may be considered as an option.
    7. Refer to appropriate community agencies for assistance with home care.
    8. Assist with genetic counseling.
    9. Discuss sexual concerns with adolescent.
  5. Goal: promote compliance with treatment regimen.
    1. Encourage child to verbalize anger or frustration at being “different"/body image alterations.
    2. Suggest alternatives to postural drainage, e.g., yoga/standing on head.
    3. Offer “rewards” for compliance: going swimming with friends or other types of peer activities.
5. Evaluation/outcome criteria:
  1. Child can clear own airway, expectorate sputum.
  2. Child is maintained in infection-free state.
  3. Adequate nutrition is maintained.
  4. Child and family verbalize understanding of the disease.
  5. Child complies with rigors of treatment.

Pediatric respiratory infections
1. Assessment: general assessment of infant/child with respiratory distress.
  1. Restlessness - earliest sign of hypoxia.
  2. Difficulty sucking/eating - parents may state the infant or child has "poor appetite.”
  3. Expiratory grunt, flaring of nasal alae, retractions.
  4. Changes in vital signs: fever, tachycardia, tachypnea.
  5. Cough: productive/nonproductive.
  6. Wheeze; expiratory/inspiratory.
  7. Hoarseness or aphonic crying.
  8. Dyspnea or prostration.
  9. Dehydration - related to increase in sensible fluid loss and poor PO intake.
  10. Color change (pallor, cyanosis) - later sign of respiratory distress.
2. Analysis/nursing diagnosis:
  1. Ineffective airway clearance related to infection or obstruction.
  2. Fluid volume deficit related to excessive losses through normal routes, discomfort and inability to swallow.
  3. Anxiety related to hypoxia.
  4. Risk for injury related to spread of infection.
  5. Knowledge deficit related to disease process, infection control, home care, and follow-up.
3. Nursing care plan/implementation:
  1. Goal: relieve respiratory distress by reducing swelling and edema and liquefying secretions.
    1. Environment: cool, high-humidity mist (oxygen) tent.
    2. Administer oxygen as ordered.
    3. Position: semi-Fowler’s or in infant seat to promote maximum expansion of the lungs; small blanket or diaper roll under neck to keep airway patent; change position at least q2h to prevent pooling of secretions.
    4. Suction/postural drainage pm.
    5. Tape diapers loosely and use only loosefitting clothing to avoid pressure on abdominal organs, which could impinge on diaphragm and impede respirations.
    6. Administer medications: antibiotics, bronchodilators, steroids.
    7. Monitor temperature q4h/prn; reduce fever with acetaminophen, cool sponges, hypothermia blanket.
  2. Goal: observe for potential respiratory failure related to exhaustion or complete airway obstruction.
    1. Place in room near nurses’ station for maximum observation.
    2. Monitor vital signs: qlh during acute phase, then q4h.
    3. Place emergency equipment near bedside prn: endotracheal tube, tracheostomy set.
    4. Monitor closely for signs of impending respiratory failure: increased rapid, shallow respirations, progressive hoarseness/ aphonia, deepening cyanosis.
    5. Report adverse changes in condition stat to physician.
  3. Goal: maintain normal fluid balance.
    1. May be NPO initially to prevent aspiration.
    2. IVs until severe distress subsides and child is able to suck and swallow.
    3. Monitor hydration status: I8<0, urine specific gravity, weight.
    4. When resuming PO fluids - start with sips of clear liquids, advance slowly as tolerated: Pedialyte, clear broth, gelatin, popsicles, fruit juices, ginger ale, cola.
    5. Avoid milk/milk products, which may cause increased mucous production.
  4. Goal: provide calm, secure environment.
    1. During acute distress: remain with child/ family (do not leave unattended).
    2. Keep crying to a minimum to prevent severe hypoxia and to reduce the body’s demand for oxygen.
    3. Avoid painful/intrusive procedures if possible.
    4. Organize nursing care to provide planned periods of uninterrupted rest.
    5. Allow parents to room-in, and encourage their participation in care of their child to keep the child relatively calm and reduce anxiety.
    6. Allow child to keep favorite toy or security object.

Pediatric Respiratory Infections

Name	Definition	Age Group	Etiology	Assessment: Definitive Clinical Signs and Symptoms	Plan: Specifics of Treatment	Prognosis
Bronchiolitis/ respiratory syncytial virus (RSV)	Acute viral infection of lower respiratory tract (small, low bronchioles), with resultant trapping of air	Infants 2-12 months (peak at 2-5 months)	Respiratory syncytial virus	Hyperinflation of alveoli Scattered areas of atelectasis Acute, severe respiratory distress for first 48-72 hours, followed by rapid recovery	Supportive care during acute phase: Hospitalization Croup tent Clear liquids	Excellent (less than 1% mortality rate)
Croup (acute spasmodic laryngitis)	Paroxysmal attacks (spasms of larynx)	6 months-3 years	Viral (possible allergy or psychogenic)	Most common onset at night Inspiratory stridor "Croupy" barking cough Dyspnea Anxiety	Teach parents - turn on hot water in bathroom and close door (steam)	Excellent (but likely to recur)
Laryngotracheobronchitis (LTB)	Acute infection of lower respiratory tract: larynx, trachea, and bronchi	Children less than 5 years	Viral (possible secondary bacterial infection)	Inspiratory stridor High fever Signs and symptoms of severe respiratory distress Hoarseness, progressing to aphonia and respiratory arrest without treatment	Hospitalization: Tracheostomy set at bedside Racemic cpinephrine/steroids Antibiotics if cultures are positive	Good
Epiglottitis	Extremely acute, severe, and rapid, progressive swelling (due to infection) of epiglottis and surrounding tissue	2-5 years	Bacterial (H. influenzae type b)	Abrupt onset - rapid progression; medical emergency Dyspnea, dysphagia Sit up/chin thrust/mouth open Thick muffled voice Cherry red. swollen epiglottis	Do not visualize epiglottis unless airway support is immediately available Will need endotracheal tube or tracheostomy for 24 - 18 hours to maintain patent airway IV ampicilin for 10-14 days to treat bacterial infection IV corticosteroids (e.g., Solu-Cortef) to reduce inflammation	Very good if detected and treated early Prevent via Hib immunization

Nursing Care of the Child in a Mist (Oxygen) Tent

Nursing Actions	Rationale
Explain purpose of tent to parents and child; stress it is temporary, to make breathing easier.	Relieves anxiety.
Inspect tent for cracks, tears. Repair or replace prn.	Leaks will allow oxygen to escape.
Place unit at head of bed.	Child’s upper torso and head must be inside tent.
Cover bed with rubber/plastic sheet.	Keeps mattress dry.
Apply extra linen to bed under tent.	Absorbs extra dampness, wetness.
Secure metal frame to bedspring, and fasten tent to frame.	Prevents collapse of tent and keeps it open.
Select “cool mode” by using the control switch.	Provides cool air to reduce swelling and edema.
Close zippers and tuck in edges tightly.	Prevents loss of oxygen.
Flood” tent with oxygen for 5 minutes (flow rate = 15 L/min).	Raises oxygen concentration centration at least q2h.
Adjust flow rate per physician's order.	Usual flow rate is 8-10 L/min to maintain 35-40% oxygen concentration.
Monitor pulse oximetry or use oxygen analyzer to check concentration at least q2h.	Achieves desired therapeutic O₂ levels
Place child in tent-stay with child.	Relieves anxiety.
Place folded towel/blanket around child’s head; stockinette cap for infant’s head.	Keeps child dry and prevents heat loss.
Cover child with blanket.	Avoids chilling.
Selection of toys: Nonflammable. Items that can be wiped dry.	Oxygen is highly combustible. Avoids bacterial growth.
Change child’s clothes and bed linens frequently (q4h or pm).	High humidity in tent will cause moisture to collect on these items.

1. 1. Goal: provide parents with teaching, as necessary.
    1. Short term: discuss equipment, treatments, procedures; offer frequent progress reports, answer parents’ questions.
    2. Long term: how to handle recurrences, how to check temperature at home, medications for fever, when to call physician about respiratory problem.
2. Evaluation/outcome criteria:
  1. No further evidence of respiratory distress.
  2. Resumption of normal respiratory pattern.
  3. Normal fluid balance maintained/restored.
  4. Parents verbalize their concerns and express confidence in their ability to care for their child after discharge.

Apnea-related disorders
1. Apnea of infancy
  1. Introduction: Apnea of infancy is the unexplained cessation of breathing for 20 seconds or longer in an apparently healthy, full-term infant who is more than 37 weeks of gestation. It is usually diagnosed by the second month of life and is generally thought to resolve during the first 12-15 months of life. The exact cause is unknown. The association between apnea of infancy and sudden infant death syndrome (SIDS) is still controversial. However, infants experiencing significant apnea without a known cause are thought to be at increased risk for SIDS and must be treated accordingly.
  2. Assessment:
    1. Unexplained cessation of breathing (apnea) for 20 seconds or longer.
    2. Bradycardia.
    3. Color change: cyanosis or pallor.
    4. Limp, hypotonic.
    5. Diagnostic tests including cardiopneumogram, pneumocardiogram, and polysomnography.
  3. Analysis/nursing diagnosis:
    1. Ineffective breathing patterns related to apnea.
    2. Anxiety, fear related to apnea and threat of infant’s death.
    3. Knowledge deficit regarding home care of infant on an apnea monitor and infant cardiopulmonary resuscitation (CPR).
  4. Nursing care plan/intervention:
    1. Goal: maintain effective breathing pattern.
      1. Apnea monitor on infant at all times, including at home.
      2. Place in room near nurses’ station for maximum observation with a nurse or parent present at all times.
      3. Suction, oxygen, and resuscitation equipment readily available if needed.
      4. Observe for apnea or bradycardia; note duration and associated symptoms - color change, change in muscle tone.
      5. If apnea occurs, use gentle stimulation to start infant breathing again. If ineffective, begin CPR.
      6. If suctioning is needed, do it gently for the shortest time and least number of times possible to maintain patent airway. Note: Repeated, vigor- ous suctioning is associated with prolonged periods of apnea.

One-rescuer CPR. *If victim is breathing or resumes effective breathing, place in recovery position: (1) move head, shoulders, and torso simultaneously; (2) turn onto side; (3) leg not in contact with ground may be bent and knee moved forward to stabilize victim; (4) victim should not be moved in any way if trauma is suspected and should not be placed in recovery position if rescue breathing or CPR is required.

	Objectives	ACTIONS
	Objectives	Adult (>8 years)	Child (1-8 years)	Infant (< 1 year)
AIRWAY	Assessment: determine unresponsiveness.	Tap or gently shake shoulder.
	Assessment: determine unresponsiveness.	Say, "Are you okay?"		Speak loudly.
	Get help.	Activate EMS.	Shout for help. If second rescuer available, have person activate EMS.
	Position the victim.	Turn on back as a unit, supporting head and neck if necessary (4-10 seconds).
	Open the airway.	Head tilt/chin lift.
BREATHING	Assessment: determine breathlessness.	Maintain open airway. Place ear over mouth, observing chest. Look, listen, feel for breathing (3-5 seconds).
	Give 2 rescue breaths.	Maintain open airway.
		Seal mouth to mouth.		Mouth to nose/mouth.
		Give 2 slow breaths. Observe chest rise. Allow lung deflation between breaths.
		1 1/2-2 seconds each	1 -1 1/2 seconds each
	Option for obstructed airway.	Reposition victim's head. Try again to give rescue breaths.
			Activate EMS.
		Give 5 subdiaphragmatic abdoominal thrusts (the Heimlich maneuver)		Give 5 back blows.
				Give 5 chest thrusts.
		Tongue-jaw lift and finger.	Tongue-jaw lift, but finger sweep only if you finger sweep. see a foreign object.
		If unsuccessful, repeat a, c, and d until successful.
CIRCULATION	Assessment: determine pulselessness	Feel for carotid pulse with one hand; maintain head tilt with the other (5-10 seconds).		Feel for brachial pulse: keep head-tilt.
CPR	Pulse absent: begin chest compressions landmark check	Run middle finger along bottom edge of rib cage to notch at center (top of sternum).		Imagine a line drawn between the nipples.
	Hand position.	Place index finger next to finger on notch.		Place 2-3 fingers on sternum. 1 finger's width below line. Depress 1/2-1 in.
	Hand position.	Two hands next to index finger. Depress 1 1/2 — 2 in.	Heel of one hand next to index finger. Depress 1 - 1 1/2 in.
	Compression rate.	80-100/minute	100/minute	At least 100/min
	Compressions to breaths.	2 breaths to every 15 compressions	1 breath to every 5 compressions
	Number of cycles.	4	20 (approximately 1 minute)
	Reassessment.	Feel for carotid pulse.		Feel for brachial pulse.
	Reassessment.	If no pulse, resume CPR, starting with compressions.	If alone, activate EMS. If no pulse, resume CPR, starting with compressions.
	Pulse present; not breathing: begin rescue breathing.	1 breath every 5 seconds (12/minute)	1 breath every 3 seconds (20/minute)

1. 1. 1. 1. Medications: respiratory stimulant drugs (such as caffeine) may be given until 2 to 3 months have passed without an episode of apnea.
      2. Positions: side-lying or supine, never prone, to prevent SIDS.
      3. Feedings: smaller and more frequent; avoid overfeeding, which can lead to reflux and apnea.
    2. Goal: teach parents how to care for their infant at home.
      1. Thoroughly explain discharge plans to parents; encourage questions and discussion.

Two-rescuer CPR. Note: Two-rescuer CPR for children ages 1 to 8 years can be performed similarly to that for adults with appropriate changes in chest compressions and ventilations.

Step	Objective	Actions
Step 1: AIRWAY	One rescuer (ventilator): Assessment: determine unresponsiveness.	Tap or gently shake shoulder.
		Shout, "Are you okay?"
	Gill for help.	Activate EMS.
	Position the victim.	Turn on back if necessary (4-10 seconds).
	Open the airway.	Use a proper technique to open airway.
Step 2: BREATHING	Assessment: determine breathlessness.	Look, listen, and feel (3-5 seconds).
Step 2: BREATHING	Ventilate twice.	Observe chest rise: 1-1.5 second/inspiration.
Step 3: CIRCULATION	Assessment: determine pulselessness.	Feel for carotid pulse (5-10 seconds).
	State assessment results.	Say, "No pulse."
	Other rescuer (compressor): Get into position for compressions.	Hand, shoulders in correct position.
	Locate landmark notch.	Landmark check.
Step 4: COMPRESSION/ VENTILATION CYCLES	Compressor: begin chest compressions.	Correct ratio compressions/venlilations: 5:1
		Compression rate: 80-100/minute (5 compressions/3-4 seconds).
		Say any helpful mnemonic.
		Slop compressing for each ventilation.
	Ventilator: ventilate after every 5th compression and check compression effectiveness, (Minimum of 10 cycles.)	Ventilate 1 time (1.5-2 seconds/inspiration).
		Check pulse occasionally to assess compressions.
Step 5: CALL FOR SWITCH	Compressor: coll for switch when fatigued.	Give clear signal Io change.
		Compressor completes 5th compression.
		Ventilator completes ventilation after 5th compression.
Step 6: SWITCH	Simultaneously switch:
	Ventilator: move to chest.	Move to chest.
		Become compressor.
		Get into position for compressions.
		Locate landmark notch.
	Compressor: move Io head.	Move to head.
		Become ventilator.
		Check carotid pulse (5 seconds).
		Say, "No pulse."
		Ventilate once (1.5-2 seconds/inspiration).
Step 7: CONTINUE CPR	Resume compression/ventilation	Resume Step 4.

1. 1. 1. 1. Begin teaching use of apnea monitor and infant CPR techniques several days before discharge; allow parents to handle the monitor and become thoroughly familiar with its use.
      2. Provide parents with emergency response numbers and PHN referral.
      3. Stress need for at least 1 year of ongoing care with constant use of monitor.
      4. Discuss need for support and refer to local self - help/support group.
      5. Encourage parents to take time for themselves if a reliable caregiver is available who is trained in use of monitor and infant CPR.

CPR and airway. Procedures for cardiopulmonary resuscitation (A through H) and clearing airway obstruction (I through K).

1. Evaluation/outcome criteria:
  1. Effective breathing pattern is established.
  2. Parents verbalize their concerns and express confidence in their ability to care for their infant at home.
Sudden infant death syndrome
1. Introduction: SIDS is the sudden, unexpected death of an apparently healthy infant under 1 year of age, which remains unexplained after a complete postmortem examination. Various theories have been suggested, none proved; research is ongoing. It is the leading cause of death between 1 mo and 1 yr, affecting fewer than 3500 infants annually.
2. Assessment:
  1. Sudden, unexplained death in otherwise "normal" infant; occurs exclusively during sleep.
  2. Note overall appearance of infant (differentiate from child abuse).
  3. Obtain history from parents - note affect or how parents are dealing with grief.
3. Analysis/nursing diagnosis:
  1. Dysfunctional grieving related to loss of infant.
  2. Knowledge deficit related to SIDS.

Foreign body airway obstruction management.(

The trully choking child cannot speak, become cyanotic, and collapses
	Objectives	Actions
	Objectives	Adult (over 8 years)	Child (1 to 8 years)	Infant (under 1 year)
CONSCIOUS VICTIM	Assessment: Determine airway obstruction	Ask, "Are you choking?" Determine if victim can cough or speak.		Observe breathing difficulty, ineffective cough, no strong cry.
	Act to relieve obstruction	Perform up to 5 diaphragmatic abdominal thrusts (Heimlich maneuver).		Give 5 back blows.
	Act to relieve obstruction			Give 5 chest thrusts.
	Be persistent.	Repeat Stop 2 until obstruction is relieved or victim becomes unconscious.
VICTIM WHO BECOMES UNCONSCIOUS	Position the victim: call for help.	Turn on back as a unit, supporting head and neck, face up, arms by sides. Call out, "Help!" Activate EMS. If second rescuer available, have person activate EMS.
	Check for foreign body.	Perform tongue-jaw lift and finger sweep.	Perform longue-jaw lift. Remove foreign object only if you actually see it.
	Give rescue breaths,	Open ifreairway with head-lilt/chin-lift Try to give rescue breaths. If airway is obstructed, reposition head and try to ventilate again.
	Act to relieve obstruction	Perform up to 5 subdiaphragmatic abdominal thrusts(Heimlich Maneuver).		Give 5 back blows.
	Act to relieve obstruction			Give 5 chest thrusts.
	Be persistent.	Repeat steps 4-6 until obstruction is relieved.
UNCONSCIOUS VICTIM	Assessment: Determine unresponsiveness.	Top or gently shake shoulder. Shout, "Are you okay?"	Top or gently shake shoulder.
	Assessment: Determine unresponsiveness.	If unresponsive, activate EMS.
	Call out for help: position the victim.	Turn on back as a unit, supporting head and neck, face up, arms by sides.
	Call out for help: position the victim.		Call out for help.
	Open the airway.	Head-tilt/chin-lift.		Head-tilt/chin-lift, but do not till too for.
	Assessment: Determine breathlessness.	Maintain on open oirway. Ear over mouth; observe chest, look, listen, feel for breathing (3-5 seconds).
	Give rescue breaths.	Make mouth-to-mouth seal.		Make mouth-to-nose-and-mouth seal.
	Give rescue breaths.	Try to give rescue breaths.
	If chest is not rising, try	Reposition head. Try rescue breaths again.
	Activate the EMS system		If airway obstruction not relieved after about 1 minute, activate EMS as rapidly as possible.
	Act to relieve obslruc-	Perform up to 5 subdiaphragmatic abdominal thrusts (Heimlich maneuver).		Give 5 back blows.
	Act to relieve obslruc-			Give 5 chest thrusts.
	Check for foreign body.	Perform tongue-jaw lift and finger sweep.	Perform tongue-jaw lift. Remove foreign object only if you actually see it.
	Rescue breaths.	Open the airways with head-tilt/chin-lift. Try opain Io give rescue breaths.
	Be persistent.	Repeat steps 8-10 until obstruction is relieved.

Guidelines for Home Care of Infant on Apnea Monitor

Show the parents how to connect the monitor leads.
Remind parents to remove the leads unless they are connected to the infant.
Stress that the infant must be on the monitor whenever respirations are not being directly observed and that a trained person must be present in the home at all times in case the alarm sounds.
Teach parents not to adjust the monitor to eliminate false alarms.
Explain that the infant will need direct observation whenever loud noises could obscure the monitor alarm, e.g., dishwasher, vacuum.
Teach parents what to look for when the alarm sounds, i.e., loose monitor leads vs. apnea.
Teach parents how to assess the infant for an episode of apnea, i.e., lack of respirations, duration, color, muscle tone.
Teach the parents to first use gentle physical stimulation if the infant experiences an apnea spell, e.g., touching the face or stroking the soles of the feet.
Demonstrate infant CPR to be used if tactile stimulation is not effective in reestablishing respirations.
Encourage parents to keep emergency numbers posted near the telephone.
Explain that monitor will not interfere with normal growth and development. Encourage the parents to promote normal growth and development as much as possible.

SIDS: What To Tell Families

Concern	Facts
Cause	Unknown (possibly related to delayed maturation of cardiorespiratory system)
Incidence	Fewer than 3500 cases annually; leading cause of death between ages 1 month and 1 year
When	Occurs during sleep (nap, night)
Age	Peak at 2-4 months; 95% of cases occur by age 6 months
Sex	More common in boys
Race	More common in African Americans and Native Americans
Season	More common in winter, peaks in January
Siblings	May have greater incidence
Perinatal	More common in preterm infants, in multiple births, and in infants with low Apgar scores
Socioeconomic	More common in lower socioeconomic classes
Feeding habits	More common in bottle-fed infants; less common in breast-fed infants.
Means of prevention	Supine (on back) sleeping position prevention (mnemonic: “back to sleep”)