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Course: Pediatric Nursing

Topic: Nursing care of Child with Respiratory Disorders (Part VIII)

The Nurses International Community

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Module Goals

Learners will be able to:

Apply the nursing process to assess, diagnose, plan, intervene, and evaluate care for child with respiratory condition.
Discuss psychosocial impact of chronic respiratory conditions in children and their families.

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Assessment: Taking History

Onset of symptoms: slow or sudden
Previous similar episodes
Upper respiratory tract infection
Cough and duration in days
History of choking
Present since birth or acquired
Vaccination history: diphtheria, pertussis, tetanus (DPT), measles
Known HIV infection
Family history of asthma

Government of Canada, 2013

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History

Pay particular attention to:

Cough – duration in days – paroxysms with whoops or vomiting or central cyanosis.
Exposure to someone with TB (or chronic cough) in the family History of choking or sudden onset of symptoms.
Known or possible HIV infection.
Vaccination history: BCG; diphtheria, pertussis, tetanus (DPT); measles; Haemophilus influenzae type b and pneumococcus.
Individual or family history of any other respiratory disease or condition.

Government of Canada, 2013

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Assessing Respiratory Function

Rate: Tachypnea, bradypnea, normal
Rhythm: variation in rate and depth
Depth: normal, shallow, too deep
Ease: Any signs of labored breathing, dyspnea, orthopnea, nasal flarings, head bobbing
Signs of infections: fever, enlarged lymph nodes, purulent discharge from nose, color of sputum (if any)

Government of Canada, 2013

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Assessing Respiratory Function

Cough and its nature: Dry cough, productive/non-productive, night coughs.
Abnormal sounds: Wheezes, ronchi.
Chest pain: Nature of pain, onset, localized or generalized.
Cyanosis: Distribution, degree, duration, association.
Bad breath: Might be related to throat or lung infections.

Government of Canada, 2013

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Acute Respiratory Tract: Assessment

High fever
Tachypnea
Tachycardia
Nasal flaring
Dyspnea
Rhonchi or crackles
Productive/non-productive cough
Irritability, restlessness or lethargy
Ineffective breathing patterns
Ineffective airway clearance

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Nursing Goals

Provide comfort
Promote hydration
Facilitate healing
Provide nutrition
Provide family support and care

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Nursing Interventions

Ensure the airway patency: position infant in upright/fowler/semi-fowler position
Monitor vital signs
Thorough respiratory examination and oxygenation status
Provide oxygenation if necessary
Suction airway as per need
Chest percussion and chest physiotherapy

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Nursing Interventions

Administer antipyretic for fever
Bronchodilators helps to provide good ventilation
Antibiotics helps to treat infections
Adhere to aseptic techniques, use universal precautions
Monitor hydrational status
Provide all comfort measures in presence/participation of parents or caretakers

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Nursing Interventions: Education

Educate family about:

The disease, condition, prognosis and plan of care
Importance of effective ventilation
Importance of deep breathing, coughing, chest therapy, nasal suctioning
Use of nasal congestion drops/sprays
Treatment regimens
Educate family involvement

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Nursing Evaluation

A comprehensive assessment of the child.
Assessment of laboratory values.
Primary laboratory evaluation: start with non-invasive, rapid bedside testing, swab tests.
Secondary laboratory evaluation: done with severe disease/appear toxic, Complete blood count, electrolytes, renal and hepatic function tests, blood cultures.
Imaging to see prognosis or rule out problems.

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It should involve a comprehensive assessment of the child, combined with the assessment of laboratory values.

Primary laboratory evaluation: Ideally, laboratory testing should start with non-invasive, rapid bedside testing, including nasopharyngeal swab assays for influenza, respiratory syncytial virus, and human metapneumovirus when available and appropriate. This may help minimize unnecessary imaging and antibiotic treatment in children with influenza or bronchiolitis.

Secondary laboratory evaluation: Children who present with severe disease and appear toxic should have complete blood count (CBC), electrolytes, renal and hepatic function testing, and blood cultures performed. These tests are generally not required in children who present with mild disease. Inflammatory markers do not help distinguish between viral and bacterial pneumonia in the pediatric population. However, these tests may be obtained to trend disease progression and serve as prognostic indicators. Children who have been in areas endemic to TB, or have exposure history, and present with signs and symptoms suspicious for pneumonia should have sputum samples or gastric aspirates collected for culture.

There are no clear guidelines for the routine use of chest x-ray in the pediatric population.Although the chest x-ray may be helpful in diagnosis/confirmation of pneumonia, it carries with it risks, including radiation exposure, healthcare-associated costs, and false-negative results, increasing the use of unwarranted antibiotics. Imaging should be restricted to children who appear toxic, those with the recurrent or prolonged course of illness despite treatment, infants age 0 to 3 months with a fever, suspected foreign body aspiration, or congenital lung malformation. Imaging may also be considered in children younger than 5 years old, who present with fever, leukocytosis, and no identifiable source of infection. Imaging may also be useful in those with acute worsening of upper respiratory infections or to rule out underlying mass in children who have "round pneumonia

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WHO, 2013

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What Would the Nurse Do?

In a community visit, a nurse finds that a 3 year old had nasal congestion.

The mother visited a local pharmacy and purchased Nasivion S drop (Normal saline with oxymetazoline) and has been giving the child nasal drops for 7 days.

How should the nurse advise the parent?

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How Illness Impacts the Family as a System

The experience of chronic illness in a family is unique.
Families may face extraordinary stressors to cope with unique circumstances.
Illnesses may family roles, relationships, and disrupts family normalcy.

La Clare, 2013

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A childhood illness in the family may cause tremendous amounts of stress for all members. It often results in changes in family roles, relationships, and disrupts family normalcy. These changes are especially difficult because when structure is so important in early childhood development. Routine and structure gives children a sense of security, helps them develop self discipline and boundaries, leads to clear and foreseeable expectations, creates a sense of mastery over their own lives, and ultimately allows them to handle change.

After diagnosis, families begin to experience the longevity and ongoing difficulty of managing the medical diagnoses (i.e. medication adherence, procedure and surgery recovery, doctor or hospital visits, etc.), in addition to managing “normal” family life, such as keeping up with daily household chores, schoolwork, jobs, and social activities. Often, the changes that occur after diagnosis produce stress and strain on individual family members, as well as the family as a unit

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Impact of Chronic Respiratory Conditions in the Families

The burden of having an illness in the family affects areas of life:

Financial
Physical
Emotional
Social
Behavioral
Individual domains

La Clare, 2013

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Stressors

Financial: Occurs when family lack insurance and medical bills are piled.

Physical: Not enough sleep, , no normal routine.

Emotional: Stress, uncertainty of future, worries about child’s health, disease and prognosis.

La Clare, 2013

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Stressors (Continued)

Social: Feeling of isolation, overburdened by extra attention and interest.

Behavioral: May be pulled in different directions, may miss work.

Personal domains: Each individual is unique in handling and coping with stress, are effected in their own way, and may result in worry, stress, disruption in routine.

La Clare, 2013

Contact info: info@nursesinternational.org

Socially, families may either feel isolated and alone from extended family members and friends or be overburdened by the extra attention that they are receiving.
Behaviorally, family members may be pulled in different directions than normally expected, such as going to the hospital or picking up the siblings from school early and missing work.
Each individual member of the family is affected in some way by childhood illness whether he or she is the patient, mother, father, grandparent, or brother or sister. Childhood chronic illness often results in worry, stress, disruptions in routine, change, financial constraints and more; these types of effects notably manifest themselves in the physical, social, financial, emotional spheres. Often, the changes that occur after diagnosis produce stress and strain on individual family members, as well as the family as a unit

Furthermore, it is important to consider the family context in which siblings are impacted by illness, as parents are gatekeepers for their children. The gatekeeper’s role include choosing to find or accept outside help such as emotional support from family members or mental health practitioners and they also chosoe the amount of information to tell siblings, such as the severity of their brother or sisters illness.

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Impact of Illness on Parents

Parents often have to ‘wear many hats’
Increase parental stress
Higher levels of role strain
Frustration and conflict around the division of labor/ expectations
May demonstrate increased levels of anxiety and overprotectiveness
Have lower expectations for their ill child than his or her siblings
May fail to provide boundaries or consistent discipline

La Clare, 2013

Contact info: info@nursesinternational.org

In any family, parents often wear many hats. They serve as doctors, police officers, role models, cooks and many more roles. In addition to their typical parenting roles, parents of chronically ill children also become “care coordinators, medical experts, systems advocates, personal ambassadors and representatives for their child”

Many illness factors and caregiving burdens increase parental stress and strains; therefore, parental distress is associated with having an impact on the family, including patients and well-siblings

In general, compared to parents without an ill child, these parents report higher levels of role strain, higher stressors associated with the parental role, as well as frustration and conflict about the division of labor and expectations

Parents also may demonstrate increased levels of anxiety and overprotectiveness; they may have lower expectations for their ill child and his or her siblings; and they may fail to provide boundaries or consistent discipline for their children

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Impact:

Children Living With Chronic Respiratory Illness

Impact usually depend on child's age and capacity

May Include:

Poor physical health.
Anxiety and stress related to frequent hospital visits, change in treatment plans.
Difficulty in treatment adherence.
Low self esteem, stress related to uncertainty of health and disease prognosis.

Cox et al., 2019

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Impacts:

Children Living With Chronic Respiratory Illness

Possible disruptions:

School: May miss school, home-schooled
Friendships: Isolated from friends
Isolated from extra-curricular activities
Difficulty attending social activities
Delay normal emotional development
Overwhelmed by extra care and attention

Garey, 2022

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Negative Impact of Illness on Siblings

Vulnerability to negative feelings
Intense worry
Loneliness
Isolation
Fear
Grief
Helplessness
Abandonment
Anger
Depression
Jealousy

La Clare, 2013

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Negative Effects.

Emotional intensity and vulnerability to negative feelings is the most commonly cited effect of a sibling’s chronic illness. Various research show that siblings often experience feelings of intense worry, loneliness, isolation, fear, grief, helplessness, abandonment, anger, and depression.

On the other had it has also been found that their excessive negative feelings (anger, sadness, worry, gloo, jealousy and fear) might damage the physical and emotional health of the sick child. For instance, the sick child may get whatever they want from the parents and other healthy sibling may get mad at it and might act mean to the sick child. one child commented, “She gets whatever she wants…sometimes I get really mad at her. Sometimes I think mean thoughts. Once I didn’t want her around anymore…a few days later she had an insulin reaction and ended up in the hospital. I felt like it was my fault…it made me feel like I caused it. I really felt bad” (Hollidge, 2000, p. 58). This quote is a good example of the complexities that may occur for siblings in their thoughts and feelings from day to day, and highlights the point that “well siblings are handicapped in the race for parental attention and affection” (Hollidge, 2000, p. 59).

Similarly, other siblings might feel neglected or ignored as the parents may more attention to the health of sick child, give extra care and spend more time with the sick child.

Parents may be overwhelmed, feel guilty and worry excessively as they may have difficulty attending the needs of sick and healthy child at the same time

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Positive Impact of Chronic Illness Among the Siblings

Emotionally maturity
Family Closeness
Strengthen sibling bonds
Compassion
Increased empathy, sensitivity, family cohesion, responsibility, independence

La Clare, 2013

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Critical Thinking Question

What are some resources of support in your community that you may mobilize or refer a family to who is facing significant challenges with a loved one’s illness?

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Red Flags

Central cyanosis or gasping
Grunting with every breath
Difficulty in feeding due to respiratory distress
Severe lower chest wall indrawing (retractions)
Head nodding (i.e. a nodding movement of the head, synchronous with the respiration and indicating severe respiratory distress).
Excessive feelings of sadness, fear and worry among sick child or any family.

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs may influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued):

Religion, culture, beliefs, and ethnic customs may influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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Cultural Considerations: Examples

In Asian countries, people believe that hot/cold weather changes or using cold water as causes for catching cold
In Nepal,

Most of the people believe that children should be dressed warm despite of weather otherwise they may catch cold.
Bathing at night causes children cold/respiratory problems.

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References

Andrews, M.M., Boyle, J.S. & Collings, J. W. (2020). Transcultural Concepts in Nursing Care (8th Ed.). Wolters Kluwer, Philadelphia, PA.

Cox,N. S., Wilson, C. J., Bennett, K. A., Johnston, K., Potter, A., Chang, a.b., Lee, A. L. (2019). Health-related quality of life and psychological wellbeing are poor in children with bronchiectasis and their parents. ERJ Open Research. Vol. 5 (3). DOI: 10.1183/23120541.00063-2019

Garey, J.(2022). Child Mind Institute: Mental Health in Kids With Chronic Illness. https://childmind.org/article/mental-health-in-children-with-chronic-illness/#full_article

Government of Canada. (2013). Clinical Practice Guidelines for Nurses in Primary Care:Pediatric and Adolescent Care - Chapter 10 - Respiratory System. https://www.canada.ca/en/indigenous-services-canada/services/first-nations-inuit-health/health-care-services/nursing/clinical-practice-guidelines-nurses-primary-care/pediatric-adolescent-care/chapter-10-respiratory-system.html

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References

La Clare, Heather L.. (2013). The Impact of Childhood Chronic Illness on the Family: Psychosocial Adjustment of Siblings. Retrieved from Sophia, the St. Catherine University repository website: https://sophia.stkate.edu/msw_papers/218

Nizame, F.A., Nasreen, S., Unicomb, L. et al. Understanding community perceptions, social norms and current practice related to respiratory infection in Bangladesh during 2009: a qualitative formative study. BMC Public Health Vol. 1 (901). https://doi.org/10.1186/1471-2458-11-901

WHO-World Health Organization. (2013). Pocket Book of Hospital care for children: Guidelines for the Management of Common Childhood Illnesses (2nd Ed.). https://www.who.int/publications/i/item/978-92-4-154837-3

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