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Course: Pediatric Nursing

Topic: Nursing Care of Child with Respiratory Disorder (Part III)

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Module Goals

Learners will be able to:

Identify common respiratory conditions in children (tonsillitis, influenza, pharyngitis).
Identify risk factors associated with respiratory illnesses in children.
List common diagnostic procedures for the respiratory conditions and nursing implications.
Describe nursing management of children experiencing the respiratory disorders.

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Tonsillitis

Tonsils are the two lymph nodes located on each side of the back of the throat.
They provide immune defense by making antibodies that fight infections and contain T-lymphocytes, macrophages and germinal centers of B-lymphocytes.
Tonsillitis is an infection or inflammation of the tonsils.
Common in childhood.
May also occur in adults..

Stelter, 2014

NHS, 2021

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Tonsillitis is generally the result of an infection, which may be viral or bacterial. Viral etiologies are the most common. The most common viral causes are usually those that cause the common cold, including rhinovirus, respiratory syncytial virus, adenovirus, and coronavirus. These typically have low virulence and rarely lead to complications. Other viral causes such as Epstein-Barr (causing mononucleosis), cytomegalovirus, hepatitis A, rubella, and HIV may also cause tonsillitis.

Bacterial infections are typically due to group A beta-hemolytic Streptococcus (GABHS), but Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenza have also been cultured. Bacterial tonsillitis may result from both aerobic and anaerobic pathogens. In unvaccinated patients, Corynebacterium diphtheriae causing diphtheria should even merit consideration as an etiology. In sexually active patients, HIV, syphilis, gonorrhea, and chlamydia are possible as additional causes. Tuberculosis has also been implicated in recurrent tonsilitis, and clinicians should assess patients' risks

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Tonsillitis: Causes

Most cases of tonsillitis are caused by a viral infection, such as the Common cold or flu virus (influenza), respiratory syncytial virus, adenovirus, and coronavirus.
Some cases may be caused by a bacterial infection, typically a strain of bacteria called A beta-hemolytic Streptococcus (GABHS).

Anderson & Paterek, 2022

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Tonsillitis is generally the result of an infection, which may be viral or bacterial. Viral etiologies are the most common. The most common viral causes are usually those that cause the common cold, including rhinovirus, respiratory syncytial virus, adenovirus, and coronavirus. These typically have low virulence and rarely lead to complications. Other viral causes such as Epstein-Barr (causing mononucleosis), cytomegalovirus, hepatitis A, rubella, and HIV may also cause tonsillitis.

Bacterial infections are typically due to group A beta-hemolytic Streptococcus (GABHS), but Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenza have also been cultured. Bacterial tonsillitis may result from both aerobic and anaerobic pathogens. In unvaccinated patients, Corynebacterium diphtheriae causing diphtheria should even merit consideration as an etiology. In sexually active patients, HIV, syphilis, gonorrhea, and chlamydia are possible as additional causes. Tuberculosis has also been implicated in recurrent tonsilitis, and clinicians should assess patients' risks

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Tonsillitis: Risk Factors

Risk factors for tonsillitis include:

Young age. Tonsillitis most often affects children ages 5 to 15.
Frequent exposure to germs: School-age children are in close contact with their peers and frequently exposed to viruses or bacteria that may cause tonsillitis.

Mayoclinic, 2020

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Tonsillitis: Symptoms

Common Symptoms:

Sore throat
Problems swallowing
High temperature (38C or above)
Cough
Headache
General malaise- Feeling sick
Earache
Fatigue

NHS, 2021

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Tonsillitis: Diagnosis

Usually diagnosed clinically: presenting symptoms and throat inspection.
Throat swab to rule out bacterial cause.
A blood test for glandular fever if symptoms are severe or do not subside.

NHS Scotland, 2021

NHS, 2021

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Tonsillitis: Treatment

Treatment will depends on the cause

Viral tonsillitis resolves without medication
Antibiotics are prescribed for bacterial tonsillitis
Surgery (tonsillectomy) only for recurrent infections

NHS Scotland, 2021

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Tonsillitis: Nursing Management

Symptomatic treatment

Encourage rest
Offer cool drinks to soothe the throat discomfort
Give paracetamol or ibuprofen as per prescription for pain and discomfort
Do not give aspirin to children under 16
Encourage gargling with warm saline for older children

NHS Scotland, 2021

NHS, 2021

Better Health Channel, 2013

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Nurses’ Role: Tonsillectomy

Place the child in partially prone position with head turned to one side until the child is completely awake and keep the head slightly lower than the chest to help facilitate drainage of secretions.
Provide support and direction following anesthesia
Encourage the child to expectorate (spit) secretions
Discourage coughing
Administer analgesics, antiemetics
Monitor vital signs and bleeding
No solid foods for the first four hours after the operation

NHS Scotland, 2021

NHS, 2021

Better Health Channel, 2013

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Tonsillectomy: Client /Parent Education

Pain may last a week
Expect earache after the surgery
Encourage rest
Leave from school for two weeks
There is difficulty swallowing after having a tonsillectomy; however, gradual progression from liquid- pureed-soft- solid foods promotes healing
8 to 10 glasses of fluids a day
Encourage oral hygiene; brushing teeth and using mouthwash

NHS Scotland, 2021

NHS, 2021

Better Health Channel, 2013

Contact info: info@nursesinternational.org

Mild to moderate pain is expected after surgery.. This may last for up to a week. Analgesics like acetaminophen may help to relieve the pain.

Children who have had a tonsillectomy should be kept off school for two weeks. This is to reduce their risk of picking up an infection from another child that will make them feel more uncomfortable.

Swallowing will probably be difficult after having a tonsillectomy. However, it's important to eat solid foods, because it will help the throat to heal more quickly. Drink plenty of fluids, but avoid acidic drinks, such as orange juice, because they'll sting. Staying well hydrated after a tonsillectomy is believed to reduce the risk of postoperative bleeding.

Ensuring good oral hygiene by regularly brushing teeth and using mouthwash may help prevent infection in the mouth. Rinse mouth but do not gargle as it may ‘sting.’

The pain usually gets worse during the first week after having a tonsillectomy, before gradually improving during the second week. Earache is common with tonsillectomies, but isn't a cause for concern.

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Critical Thinking Question

A nurse is taking care of a child post tonsillectomy. What complications should the nurse be aware of?

Which complication should the nurse be most concerned about? What should the nurse do if this complication occurs?

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Influenza (FLU)

A contagious respiratory illness caused by the human influenza virus that may infect the upper and lower respiratory system
May cause mild to severe illness, and may be fatal based on individual immunity
Types of influenza (flu) viruses:

Types A and B
Both viruses routinely spread in people and are responsible for seasonal flu epidemics

CDC, 2021a

CDC 2021b

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Influenza: Risk Factors

Children younger than 18 are twice as likely to develop symptomatic flu than adults
Other risk groups include: (Immunocompromised individuals)

65 and older population
Pregnant women
People with asthma, diabetes
Children with neurological disorders
Cancer patients
Heart disease and stroke
HIV/AIDS

CDC, 2021a

CDC 2021b

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Influenza: Signs and Symptoms

Fever* or feeling feverish/chills
Cough
Sore throat
Rhinitis ‘runny” or ‘stuffy’ nose
Muscle or body aches
Headaches
Malaise
Fatigue (tiredness)
Vomiting and diarrhea may sometimes occur in children

CDC, 2021a

CDC 2021b

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Influenza: Diagnosis

Difficult to distinguish flu from other viral or bacterial respiratory illnesses based on symptoms alone.
Definitive Diagnostic Tests:

Rapid Molecular Assays
Reverse Transcription Polymerase Chain Reaction (RT-PCR)
Viral culture
Immunofluorescence assay

CDC, 2021a

CDC 2021b

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A number of tests are available to detect flu viruses in respiratory specimens. The most common are called “rapid influenza diagnostic tests (RIDTs).” RIDTs work by detecting the parts of the virus (antigens) that stimulate an immune response in nasal swabs. These tests may provide results within approximately 10-15 minutes but may not be as accurate as other flu tests. Therefore, one could still have flu, even though their rapid test result is negative. Other flu tests called “rapid molecular assays” detect genetic material of the flu virus. Rapid molecular assays produce results in 15-20 minutes and are more accurate than RIDTs.

In addition to RIDTs and rapid molecular assays, there are several more accurate flu tests available that must be performed in specialized laboratories, such as those found in hospitals or public health laboratories. These tests include reverse transcription polymerase chain reaction (RT-PCR), viral culture, and immunofluorescence assays. All of require that a health care provider swipe the inside of the nose or the back of the throat with a swab and then send the swab for testing. Results may take one to several hours.

Viral culture is a laboratory test in which samples are placed with a cell type that the virus being tested for is able to infect. If the cells show changes, known as cytopathic effects, then the culture is positive.

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Influenza: Treatment and Prevention

Influenza antiviral drugs:

Oseltamivir phosphate
Zanamivir
Peramivir
Baloxavir marboxil

Flu vaccine: Should be taken every year
Common preventive measures (avoid others with the Flu, cover mouth when coughing and sneezing, frequent handwashing)

CDC, 2021a

CDC 2021b

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Influenza: Nurses’ Role

Assess vitals
Auscultate lungs for wheezing and rales
Assess oxygenation and respiration
Assess breathing (viscous secretions and poor cough may make breathing difficult)
Monitor temperature
Encourage fluids
Provide oxygen if saturation is less than 94%
Monitor skin color for cyanosis
Monitor intake and output

Boktor, 2021

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Influenza: Nurses’ Role (Continued)

Perform postural drainage to drain thick secretions
Encourage deep breathing and coughing
Oral suction as needed
Encourage hydration
Encourage semi-Fowler position
Encourage coughing and deep breathing
Administer bronchodilators for wheezing as needed
Emphasize the avoidance of crowded areas

Boktor, 2021

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Influenza: Nurse’s Role (Continued)

Education

Teach procedure and hourly use of incentive spirometry
Importance of handwashing
Importance of annual flu vaccine
Limited contact until symptoms subside
Encourage smoking cessation
Sneeze or cough in a tissue to avoid the spread of aerosol droplets
Encourage rest and nutritious diet
Encourage avoidance of crowded areas

Boktor, 2021

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Critical Thinking Question

What education should nurses give to parents to help prevent the spread of influenza in the community?

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Pharyngititis

Inflammation of the mucous membranes and underlying structures of the throat.
Acute pharyngitis is one of the most common illnesses for which children visit primary care physicians.
Most cases occur during the colder months of the year (in temperate climates).
Group A beta-hemolytic streptococcal pharyngitis is common in children age 5 to 15.

Delayed treatment of a Group A strep infection may result in Rheumatic fever.

Gerber, 2005

CDC, 2018

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Pharyngitis: Risk Factors

Rare in children younger than 3 years of age
Close contact with another individual with group A strep pharyngitis
Crowding, such as found in schools, military barracks, and daycare centers, increases the risk of disease spread
Adults at increased risk for group A strep pharyngitis include:

Parents of school-aged children
Adults who are often in contact with children (Teachers, day care providers

CDC, 2022

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Pharyngitis: Signs and Symptoms

Acute onset
Sore throat
Fever
Scarlet fever rash
Headache
Nausea, vomiting, and abdominal pain
Inflammation of pharynx and tonsils

(CDC, 2022)

Patchy discrete exudates
Tender, enlarged anterior cervical nodes
Presentation in winter or early spring
Conjunctivitis
Coryza
Cough
Diarrhea

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Pharyngitis: Diagnosis

Throat culture (essential to differentiate from a viral infection)
Rapid antigen detection tests
Repeat diagnostic testing as needed

Gerber, 2005

CDC, 2022

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Pharyngitis: Treatment

The use of a recommended antibiotic regimen to treat group A strep pharyngitis:

Shortens the duration of symptoms
Reduces the likelihood of transmission to family members, classmates, and other close contacts
Prevents the development of complications, including acute rheumatic fever

CDC, 2022

Wolford , 2022

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Special Considerations

Clinicians should confirm group A strep pharyngitis in children older than 3 years of age to appropriately guide treatment decisions. Giving antibiotics to children with confirmed group A strep pharyngitis may reduce their risk of developing sequela (acute rheumatic fever). Testing for group A strep pharyngitis is not routinely indicated for:

Children younger than 3 years of age
Adults

Acute rheumatic fever is very rare in those age groups.

Clinicians may use a positive Rapid Antigen Detection Test( RADT) as confirmation of group A strep pharyngitis in children. However, clinicians should follow up a negative RADT in a child with symptoms of pharyngitis with a throat culture. Clinicians should have a mechanism to contact the family and initiate antibiotics if the back-up throat culture is positive.

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Pharyngitis: Treatment (Continued)

When left untreated, the symptoms of group A strep pharyngitis are usually self-limiting but may result in Rheumatic fever
Penicillin or amoxicillin is the antibiotic of choice to treat group A strep pharyngitis
Group A strep pharyngitis in children older than 3 years should be confirmed for treatment decisions

CDC, 2022

Wolford, 2022

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Pharyngitis: Education for Home Management

Drink soothing liquids; warm liquids like lemon tea with honey, or cold liquids, such as ice water, ice pops
Gargle several times a day with warm salt water (1/2 tsp or 3 grams of salt in 240 milliliters of water)
Suck on hard candies or throat lozenges (Young children should not be given due to choking hazards)
Cool-mist vaporizer or humidifier
Over-the-counter pain medicines like acetaminophen

MedlinePlus, 2021

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Pharyngitis: Nurses’ Role

Nursing interventions for a child with acute nasopharyngitis:

Semi-Fowler's position-using pillows to facilitate lung expansion.
Increase fluid intake: Decreases the viscosity of secretions.
Increase room humidity: Increases the humidity by using cool mist vaporizers to relieve ‘stuffiness’ of the nose.
Administer medications: Administer antibiotics as prescribed after a positive culture result.

Nurses lab, 2021

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What Would the Nurse Do?

A nurse is taking care of a 6-yr-old with an acute onset of fever, severe sore throat, rash, and vomiting. Upon examination, the nurse notes enlarged cervical lymph nodes and patches of white exudate at the back of the child's throat.

The physician tells the family to administer acetaminophen at home for pain and fever and tells the nurse to go ahead and discharge the child.

What should the nurse do?

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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 (con.):

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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Red Flags

Increased rate and/or depth of respirations
Retractions
Abnormal lung sounds; rales, ronchi, wheezes
Diminished lung sound in either lobes
Apnea
Pale skin colour
Excessive coughing, labored breathing
Asymmetric rise and fall of chest
Decreasing oxygen saturation/increased O2 requirement
Change in LOC or decreased level of consciousness CIRCU

Best-Brandt, 2019

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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.

Anderson J, Paterek E. (2022, April 30). Tonsillitis. StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544342/

Best-Brandt, T. (2019, August). Mary Bridge Children’s Hospital. Pediatric Assessment & Red Flags. https://www.marybridge.org/file_viewer.php?id=344&title=Peds+Assessment+and+Red+Flags

Better Health Channel. (2013, June 30). Ear Nose and Throat: Tonsillitis. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/tonsillitis

Boktor SW, Hafner JW, Doerr C. ( 2021, Jul 18). Influenza (Nursing). StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK568788/

CDC- Centers for Disease Control and Prevention. (2022, June 27). Pharyngitis (Strep Throat). https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html

Contact info: info@nursesinternational.org

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References

CDC- Centers for Disease Control and Prevention. (2021a, August 26). Key Facts About Influenza (Flu). https://www.cdc.gov/flu/about/keyfacts.htm#:~:text=Flu%20is%20a%20contagious%20respiratory,a%20flu%20vaccine%20each%20year.

CDC- Centre for Disease Control and Prevention. (2021b, November 18). Influenza: About Flu. https://www.cdc.gov/flu/about/index.html

Gerber M. A. (2005). Diagnosis and treatment of pharyngitis in children. Pediatric clinics of North America, 52(3), 729–vi. https://doi.org/10.1016/j.pcl.2005.02.004

Mayo Clinic. (2020, November o7). Tonsilitis: Overview. https://www.mayoclinic.org/diseases-conditions/tonsillitis/symptoms-causes/syc-20378479#:~:text=Tonsillitis%20most%20commonly%20affects%20children,or%20patches%20on%20the%20tonsils

MedlinePlus. Gov. (2021, September 19). Pharyngitis- Sore throat. https://medlineplus.gov/ency/article/000655.htm

Contact info: info@nursesinternational.org

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References

NHS. (2021, Feb 10). Tonsillitis. https://www.nhs.uk/conditions/tonsillitis/

NHS Scotland. (2021, October 28). Illness and Conditions : Tonsillitis. https://www.nhsinform.scot/illnesses-and-conditions/ears-nose-and-throat/tonsillitis

Nurses Lab. (2021, February 11). Acute Nasopharyngitis. https://nurseslabs.com/acute-nasopharyngitis/

Stelter K. (2014). Tonsillitis and sore throat in children. GMS current topics in otorhinolaryngology, head and neck surgery, 13, Doc07. https://doi.org/10.3205/cto000110

Wolford, R. W., Goyal, A., Belgam, S. S.Y. et al. (2022, May 8). Pharyngitis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519550/

Contact info: info@nursesinternational.org

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