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Teach various treatments: postural drainage, nebulizers, oxygen therapy, breathing exercise.
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Encourage child to assume as much responsibility for own care as possible: medications, treatments, diet.
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Promote development of healthy attitude toward disease/prognosis (no known cure). Heart/lung transplant may be considered as an option.
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Refer to appropriate community agencies for assistance with home care.
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Assist with genetic counseling.
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Discuss sexual concerns with adolescent.
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Goal:
promote compliance with treatment regimen.
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Encourage child to verbalize anger or frustration at being “different"/body image alterations.
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Suggest alternatives to postural drainage, e.g., yoga/standing on head.
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Offer “rewards” for compliance: going swimming with friends or other types of peer activities.
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Evaluation/outcome criteria:
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Child can clear own airway, expectorate sputum.
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Child is maintained in infection-free state.
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Adequate nutrition is maintained.
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Child and family verbalize understanding of the disease.
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Child complies with rigors of treatment.
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Pediatric respiratory infections
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Assessment: general assessment of infant/child with respiratory distress.
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Restlessness -
earliest
sign of hypoxia.
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Difficulty sucking/eating - parents may state the infant or child has "poor appetite.”
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Expiratory grunt, flaring of nasal alae, retractions.
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Changes in vital signs: fever, tachycardia, tachypnea.
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Cough: productive/nonproductive.
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Wheeze; expiratory/inspiratory.
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Hoarseness or aphonic crying.
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Dyspnea or prostration.
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Dehydration - related to increase in sensible fluid loss and poor PO intake.
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Color change (pallor, cyanosis) -
later
sign of respiratory distress.
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Analysis/nursing diagnosis:
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Ineffective airway clearance
related to infection or obstruction.
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Fluid volume deficit
related to excessive losses through normal routes, discomfort and inability to swallow.
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Anxiety
related to hypoxia.
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Risk for injury
related to spread of infection.
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Knowledge deficit
related to disease process, infection control, home care, and follow-up.
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Nursing care plan/implementation:
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Goal:
relieve respiratory distress by reducing swelling and edema and liquefying secretions.
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Environment: cool, high-humidity mist (oxygen) tent.
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Administer oxygen as ordered.
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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.
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Suction/postural drainage pm.
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Tape diapers loosely and use only loosefitting clothing to
avoid
pressure on abdominal organs, which could impinge on diaphragm and impede respirations.
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Administer medications: antibiotics, bronchodilators, steroids.
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Monitor temperature q4h/prn; reduce fever with acetaminophen, cool sponges, hypothermia blanket.
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Goal:
observe for potential respiratory failure related to exhaustion or complete airway obstruction.
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Place in room near nurses’ station for maximum observation.
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Monitor vital signs: qlh during acute phase, then q4h.
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Place emergency equipment near bedside prn: endotracheal tube, tracheostomy set.
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Monitor closely for signs of impending respiratory failure: increased rapid, shallow respirations, progressive hoarseness/ aphonia, deepening cyanosis.
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Report adverse changes in condition stat to physician.
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Goal:
maintain normal fluid balance.
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May be NPO initially to prevent aspiration.
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IVs until severe distress subsides and child is able to suck and swallow.
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Monitor hydration status: I8<0, urine specific gravity, weight.
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When resuming PO fluids - start with sips of clear liquids, advance slowly as tolerated: Pedialyte, clear broth, gelatin, popsicles, fruit juices, ginger ale, cola.
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Avoid milk/milk products, which may cause increased mucous production.
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Goal:
provide calm, secure environment.
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During acute distress: remain with child/ family (do not leave unattended).
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Keep crying to a minimum to prevent severe hypoxia and to reduce the body’s demand for oxygen.
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Avoid
painful/intrusive procedures if possible.
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Organize nursing care to provide planned periods of uninterrupted rest.
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Allow parents to room-in, and encourage their participation in care of their child to keep the child relatively calm and reduce anxiety.
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Allow child to keep favorite toy or security object.