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Course: Pediatric Nursing

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

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Module Goals

Learners will be able to:

Identify common respiratory conditions in children (common cold, flu, sinusitis, pertussis, diphtheria).
Identify risk factors associated with the 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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Common Cold

Upper respiratory infection (URI)
Consists of collection of symptoms
Most common illness, leading to more doctor visits and absences from school and work
Children usually get 6-10 colds a year, adolescents 2-4 a year
This number increases for children who attend daycare
Colds do not happen as much after the age of 6

Boston Children’s Hospital , n.d.

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Common Cold (Continued)

Causes:

Rhinoviruses are the most common causative agents
Other viruses that may cause colds include:

Respiratory syncytial virus
Human parainfluenza viruses
Adenovirus
Common human coronaviruses, and human metapneumovirus.

Boston Children’s Hospital , n.d.

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Common Cold (Continued)

Diagnosis: Made based on the signs and symptoms

Risk Factors:

Season: Cold weather months
Age: younger children and people with weak immune system
Lack of sleep: Affects immune system
Stress: Activates stress hormone called cortisol
Smoking: disrupts immune system and the throat lining

Healthline, 2016

Contact info: info@nursesinternational.org

Season: Common cold is more common in cold-weather months, such as fall and winter, and rainy seasons. People usually spend a lot of time indoor in these seasons, closer with other people which increase the risk of contracting with the virus.

Age: Children under the age of 6 have lower immunity, close contact with other kids, tend to wash their hands less often, or cover mouths and noses while coughing and sneezing. Therefore they are at higher risk of having common cold. In the similar way, the individual with weak immune system like neutropenic, client in chemotherapy may have higher chances of getting virus.

Lack of Sleep: Lack of sleep may negatively affect the immune system, and inadequate sleep raises the chances of catching the common cold, as well as other diseases.

Stress: Cortisol is a stress hormone and it regulates inflammation in the body. When an individual is under stress, cortisol may be less effective at tempering the body’s inflammatory response to the cold virus. This may cause to develop symptoms.

Smoking: Smoking disrupts the immune system, irritates the throat lining. This raises the risk of catching the cold and other viruses. Symptoms of the common cold may be worse when smoking.

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Difference between Common Cold and Flu

Boston Children’s Hospital , n.d.

Cold symptoms	Flu symptoms
Low or no fever	High fever
Sometimes a headache	Always a headache
Stuffy, runny nose, sneezing	Clear nose or stuffy nose, sometimes sneezing
Sore throat, mild, hacking cough	sometimes sore throat, cough, often becoming severe
Slight aches and pains	Often severe aches and pains
Mild fatigue, normal energy level	Several weeks of fatigue, extreme exhaustion

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Common Cold: Symptoms

A blocked/stuffy or runny nose
A sore throat
Headaches
Muscle aches
Coughs
Sneezing
A raised temperature
Pressure in the ears and face
Loss of taste and smell

NHS, 2021b

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Common Cold: Pharmacological Management

Paracetamol or Ibuprofen to ease discomfort/lower temperature
Decongestant sprays, nasal drops or tablets to relieve a blocked/stuffy nose
No vaccine for common cold
Antibiotics are not effective for respiratory viruses

NHS, 2021b

CDC, 2021

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Common Cold: Reducing the Risk

Hand Washing: Encourage children to wash their hands for 20 seconds-help young children do the same
Avoid touching eyes, nose, and mouth with unwashed hands
Stay away from people who are sick
Don’t share towels or household items (like cups) with someone who has a cold
Cover mouth and nose with a towel or tissue or elbow when sneezing and coughing

NHS, 2021b

CDC, 2021

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Common Cold: Nurses’ Role

Encourage rest and sleep
Keep the child warm
Ensure hydration; drink plenty of fluids: water, soup, fruit juice or breast or bottle feeding
Salt water gargle to soothe sore throat (not suitable for younger children)
Disinfect frequently touched surfaces and objects, such as toys, doorknobs, and mobile devices
Encourage frequent hand hygiene (care providers, parents, child, visitors)

NHS, 2021b

CDC, 2021

Contact info: info@nursesinternational.org

Parent and caregiver education

Offer fluids. Liquids such as water, juice and broth might help thin secretions. Warm liquids, such as tea or chicken soup, might have a soothing effect, increase the flow of nasal mucus and loosen respiratory secretions.
Run a cool-mist humidifier. This may add moisture to the air, which might decrease the drying of the nasal passages and throat. Place the humidifier near the child's bed. Clean the humidifier after every use.
Use nasal saline. Over-the-counter saline may keep nasal passages moist and loosen mucus. In younger children, apply saline nasal drops, wait for a short period and then use a suction bulb to draw mucus out of each nostril. For older children, use a saline nasal spray or saline nasal irrigation.
Offer cold or frozen drinks or foods. Ice cream, frozen fruit pops, ice or cold beverages might feel good on a sore throat.
Encourage gargling with salt water. For children age 6 years and older, gargling with warm salt water might soothe throat pain.
Offer hard candy. For children age 5 years and older, sucking on a piece of hard candy might soothe throat pain. Hard candy is probably as effective as medicated lozenges and less likely to have harmful effects. However, hard candy is a choking hazard and shouldn't be given to younger children.

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Common Cold: Nursing Considerations

Decongestants:

Should not be given to children under 6 years old
Children aged 6 to 12 should take them for no longer than 5 days

Do not give cough and cold medicines with paracetamol and ibuprofen tablets
Ensure the medications are safe for babies, children and pregnant women
There's little evidence that supplements (vitamin C, echinacea or garlic) prevent colds or speed up recovery

NHS, 2021b

CDC, 2021

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Critical Thinking Question

A nurse is taking care of an 8-yr-old who is brought to clinic for a cough, sore throat, fatigue, and nasal congestion.

The child is has not had a fever and denies body aches.

What education should the nurse provide the family and what directions should the nurse provide for how they should manage the symptoms at home?

Contact info: info@nursesinternational.org

This child's symptoms are consistent with the common cold. The nurse should inform the family of this and then provide education about supportive care measures to manage the symptoms at home. These include lots of rest, fluids, salt water gargles and cold or frozen food for the sore throat, and medications such as acetaminophen (Paracetamol) for fever and pain. The nurse should also educate the family not to use over the counter decongestants for more than 5 days and to read all the labels of cold medications to make sure they are safe for children and that they are not accidentally giving their child extra acetaminophen or ibuprofen in the cold medications. Lastly, the nurse should teach the family about antibiotic stewardship (families often want antibiotics given for colds so nurse should ensure they understand that antibiotics are not effective against viruses) and methods for reducing the spread of the cold, such as covering the mouth with the arm while sneezing, frequent good hand washing, not sharing personal items or dishes, and cleaning high touch surfaces.

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Sinusitis

Swelling of the sinuses, usually caused by an infection
Common and usually resolves on its own within 2 to 3 weeks
May be acute (present for less than 30 days) or chronic (present for greater than 90 days)

NHS, 2021a

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Sinusitis: Causes

Due to common viruses of cold and flu (rarely caused by bacteria)
Dental infection
Fungal infection
Allergies and related conditions, including allergic rhinitis, asthma and hay fever
Nasal polyps (growths inside the nose)
Smoking (passive or active)
A weakened immune system

NHS Scotland, 2020

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Sinusitis: Risk Factors

Children whose mother has asthma
Air pollution
Female gender
Allergies
Asthma
Head injuries

Chang et al, 2018

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Sinusitis: Symptoms

In younger children:

Irritability
Difficulty feeding
Mouth breathing
Nasal sounding speech

NHS Scotland, 2020

In older children:

Pain, swelling and tenderness around the cheeks, eyes or forehead
A ‘blocked’ nose
A reduced sense of smell
Green or yellow nasal mucus
Sinus headache
High fever
Toothache
Halitosis

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Sinusitis: Diagnosis

Usually diagnosed from the symptoms

Diagnosed based on the presence of:

Symptoms in case of younger children
Nasal ‘blockage’ or runny nose with facial pain
A reduction or loss of sense of smell

NHS Scotland, 2020

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Sinusitis: Pharmacological Management

Pain reducers like paracetamol, ibuprofen for fever and headaches
Corticosteroids nasal drops or sprays to reduce inflammation
Antibiotics if bacterial
Functional endoscopic sinus surgery (FESS) if no other options work

Nursing Consideration:

Decongestants should not be given to the children under 6
Never give aspirin to children under 16 years of age

NHS Scotland, 2020

NHS, 2021a

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Sinusitis: General Management

Rest
Fluids
Avoid allergic triggers and smoke
Clean/rinse nose with a salt water solution to ease congestion
Stay home
Avoid contact

NHS, 2021a

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Critical Thinking Question

How may the nurse distinguish between sinusitis versus a common cold?

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Acute Infectious Disease: Pertussis (Whooping cough)

Highly-contagious, acute bacterial illness of upper respiratory tract

Preventable by routine childhood immunization

Causes

Bordetella pertussis (B. pertussis) bacteria

Transmission

Aerosolized droplets of respiratory secretions
Direct contact with respiratory secretions of an infected individual

Government of Canada, 2013

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Acute Infectious Disease: Pertussis (Continued)

Risk factors

Young age and/or incomplete or low immunity
Pregnant women with pertussis near term and other household members with pertussis are an important source of pertussis for newborn infants

Government of Canada, 2013

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Pertussis (Continued)

Physical findings

Low-grade fever during catarrhal stage
Rhinorrhea/coryza
Paroxysmal cough, often within a single expiration, and audible whoop at end of coughing paroxysm
Apnea and cyanosis in infants
Signs of dehydration (may be present)

Government of Canada, 2013

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Pertussis (Continued)

Complications

Bacterial pneumonia (most common complication and cause of death in infants)
Neurological complications such as seizures (febrile and afebrile) and encephalopathy
Otitis media
Anorexia
Weight loss and dehydration
Apnea
Death

Government of Canada, 2013

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Pertussis: Complications (Continued)

Complications from intense and persistent coughing in adolescents and adults include:

Sleep disturbance
Rib fractures
Subconjunctival hemorrhages
Rectal prolapse
Urinary incontinence

Government of Canada, 2013

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Pertussis: Diagnostic and Laboratory Tests

Diagnostic test

Based on client history, risk factors, physical examination findings and test availability

Laboratory

Nasopharyngeal swab for culture and/or PCR for B. pertussis using Calgi (calcium alginate) or Dacron swabs
CBC

Government of Canada, 2013

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Pertussis: Pharmacological Management

IV therapy: Normal saline solution to treat dehydration
Antipyretic/analgesic:

Acetaminophen
Ibuprofen

Antimicrobial therapy:

Azithromycin
Trimethoprim-sulfamethoxazole

Government of Canada, 2013

Contact info: info@nursesinternational.org

IV therapy

IV fluid (such as 0.9% sodium chloride) may be required for client who is unable to tolerate oral feedings or who presents with signs of dehydration (e.g., due to vomiting).

Antipyretic/analgesic

Note: Since neonates and infants (less than 3 months of age) are less able to mount a febrile response, when they do become febrile, it is more likely to indicate a major illness. Consult physician/nurse practitioner particularly for children less than 3 months of age.

Acetaminophen

Acetaminophen 10 to 15 mg/kg PO q4-6h PRN
Maximum from all sources: acetaminophen 75 mg/kg/day or 4,000 mg/day, whichever is less

Ibuprofen

Infants <6 months

Limited data available in infants

For 6 months to 12 years of age

Ibuprofen 5 to 10 mg/kg/dose PO q6-8h PRN
Maximum 400 mg/dose*

For greater than 12 years of age

Ibuprofen 200 to 400 mg PO q4-6h PRN*

*Maximum from all sources for all ages:

Ibuprofen 40 mg/kg in 24 hours or 1200 mg in 24 hours whichever is less. Under physician/nurse practitioner supervision, daily doses ≤2,400 mg may be used

Antimicrobial therapy

Antimicrobial treatment administered in the catarrhal phase of the illness may decrease the duration and severity of symptoms
Preferred treatment for pertussis is with macrolides (i.e., azithromycin, erythromycin, clarithromycin)
A shorter course (i.e., 3 days) of azithromycin for treatment or postexposure prophylaxis of B. pertussis has not been validated and is not recommended
Azithromycin is the first choice because it is given in a short and simple regimen.
It is the drug of choice for infants less than 1 month of age

Preferred treatment

Azithromycin

Infants less than 6 months of age

Azithromycin PO daily for 5 days (calculate 10 mg/kg in 24 hours)

Infants and children 6 months of age or greater

Day 1

Azithromycin PO once daily (calculate 10 mg/kg in 24 hours; maximum 500 mg/in 24 hours for one dose on day 1)

Days 2-5

Azithromycin PO once daily on days 2 to 5 (calculate 5 mg/kg/day; maximum 250 mg in 24 hours)

Alternate treatment for client with contraindication to azithromycin

Trimethoprim-sulfamethoxazole (co-trimoxazole) (TMP-SMX) may be used as an alternative agent to macrolides in patients aged ≥2 months who are allergic to macrolides, who cannot tolerate macrolides, or who are infected with a rare macrolide-resistant strain of Bordetella pertussis.

Trimethoprim-sulfamethoxazole

Infants aged < 1 months

Contraindicated because of risk for kernicterus

Infants from 1 to 5 months

Trimethoprim-sulfamethoxazole PO, TMP 8 mg/kg and SMX 40 mg /kg in two divided doses for 14 days

Infants and children greater than six months of age

Trimethoprim-sulfamethoxazole PO, TMP 8 mg/kg and SMX 40 mg /kg in two divided doses for 14 days (maximum TMP 320 mg, SMX 1600 mg per day)

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Pertussis: Non-Pharmacological Management

Client education

Activity as tolerated
Fluid intake to maintain hydration
Keep home free from irritants that may trigger coughing
Limit visitors
Isolate a client with confirmed or suspected pertussis and who does not receive antibiotics for 21 days after cough onset
Knowledge of appropriate use of medications, potential side effects and interactions

Government of Canada, 2013

Contact info: info@nursesinternational.org

Non-pharmacological interventions

Client education

Provide the following education/counselling to the parent(s)/caregiver(s) and/or client:

Activity as tolerated
Encourage adequate fluid intake to maintain hydration
Keep the home free from irritants that may trigger coughing, such as smoke, dust, and chemical fumes
Limit new visitors to the home until 5 days after antibiotic therapy has started.
Isolate a client with confirmed or suspected pertussis from young children and infants until the client has received at least 5 days of antibiotics
Isolate a client with suspected pertussis who does not receive antibiotics for 21 days after cough onset,
Counsel parent(s)/caregiver(s) and/or client on appropriate use of medications; including dose, frequency, importance of adherence, potential side effects and interactions.

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Pertussis: Nursing Management

Monitor the client closely for risk of anaphylaxis
Monitor vital signs
Follow up every few days to every week (or SOS)
Advise the care providers to return to hospital if complication arises
Arrange medical evacuation if necessary
Report case to the local authority
Educate care providers/parents regarding the disease and treatment

Government of Canada, 2013

Contact info: info@nursesinternational.org

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Case Study

A nurse in the emergency department is assigned to care for a 1-month-old brought in for coughing. Upon assessment, the nurse notes a paroxysmal cough with a whoop and cyanosis around the mouth. Lung sounds are clear on the left and diminished on the right with crackles. The infant is lethargic with a capillary refill of 5 seconds. The family states the infant has stopped breastfeeding feeding because of the coughing.

What diagnosis should the nurse expect?

Should the nurse put on any personal protective equipment?

What should the nurse do next?

Contact info: info@nursesinternational.org

What diagnosis should the nurse expect? The infant's symptoms are consistent with pertussis. The diminished lung sounds and crackles should lead the nurse to expect a diagnosis of pertussis leading to pneumonia.
Should the nurse put on any personal protective equipment? Yes. Pertussis is highly contagious and spreads through aerosolized droplets and close contact with respiratory secretions. As such, the nurse should put on a surgical mask and wear gloves/perform good hand washing if they suction the infant. The nurse should follow these precautions even if they are vaccinated because the effectiveness of the pertussis vaccine wears off over time, which means the nurse could become infected with pertussis (often asymptomatic or mild symptoms) and unknowingly spread it to other vulnerable individuals.
What should the nurse do next? If the nurse has the equipment to check oxygen saturation, the nurse should check to see if the infant is hypoxic and needs supplemental oxygen. If the nurse cannot check oxygen saturation, they may use assessment clues such as pallor and cyanosis to make a decision about supplemental oxygen. Oxygen may only be required during coughing fits when the infant becomes cyanotic. After addressing the infant's breathing, the nurse should start an IV as this infant will need an antibiotic to treat the pertussis as well as IV fluids for dehydration (lethargic, inability to feed, capillary refill of 5 seconds).

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Diphtheria

Preventable with vaccine
Acute, toxin-mediated infectious disease
Affects pharynx and the tonsils

Causes

Corynebacterium diphtheriae (C. diphtheriae) bacteria

Transmission

Respiratory droplets from infected cases or carriers
Contact with articles contaminated by secretions of infected individuals

Government of Canada, 2013

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Diphtheria (Continued)

Risk factors

Children and adults with no up-to-date immunizations
Exposure to people with diphtheria
Social risk factors
Poor skin care and hygiene
Unimmunized clients living in crowded, unsanitary, or impoverished conditions

Government of Canada, 2013

Contact info: info@nursesinternational.org

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Diphtheria: Signs and Symptoms

Fever (usually low grade)
Appears toxic/acutely ill
Mucopurulent nasal discharge which may become blood-tinged
Adherent nasal and/pharyngeal membrane
Respiratory obstruction
The child with severe disease may develop "bull neck" appearance
Cough, hoarseness
Stridor
Respiratory distress

Government of Canada, 2013

Contact info: info@nursesinternational.org

Physical findings

Fever (usually low grade)
Client appears quite toxic/acutely ill
Mucopurulent nasal discharge which may become blood-tinged
Adherent nasal and/pharyngeal membrane. Membrane may be white, bluish-white, greyish-green or black if bleeding has occurred
The pseudomembrane is firmly adherent to the tissue
Minimal amount of mucosal erythema surrounding the membrane
Extensive pseudomembrane formation may result in respiratory obstruction
The child with severe disease may develop marked edema of the submandibular areas and the anterior neck, along with lymphadenopathy, giving a characteristic "bull neck" appearance
Cough, hoarseness
Stridor
Respiratory distress
Cutaneous diphtheria is characterized by a scaling rash or non-healing ulcers with clearly demarcated edges and membrane
Cutaneous lesions may resemble impetigo
Late effects of absorbed toxin, appearing after 2 to 6 weeks, include myocarditis and neuropathy

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Diphtheria (Continued)

Diagnostic Tests

Usually made by presumptive diagnosis due to emergent treatment.

Laboratory Tests

Throat and/or nasopharyngeal swabs of the lesion for culture and sensitivity.

Government of Canada, 2013

Contact info: info@nursesinternational.org

Diagnostic test selection is based on client history, risk factors, physical examination findings and test availability.

Presumptive diagnosis

Presumptive diagnosis for diphtheria is made clinically because prompt treatment is essential
Presumptive diagnosis may include observation of a greyish-white, grey or black membrane, especially if extending to the uvula and soft palate, in association with tonsillitis, pharyngitis or cervical lymphadenopathy, or a serosanguinous nasal discharge

Laboratory

consideration

Throat and/or nasopharyngeal swabs of the lesions for culture and sensitivity (C+S) to confirm diagnosis
Culture of cutaneous lesions

Sample collection

For pharyngeal samples, ensure that any discoloured areas, ulcerations and tonsillar crypts are swabbed
For cutaneous samples:

Material should be taken from the affected area of the skin, either by aspirate or swab
Membranous material may also be cultured
Remove any crusted material and swab the base of the lesion(s)

Diphtheria is primarily a respiratory infection; however specimens should be collected from suspect skin lesion(s) during the acute phase of illness

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Diphtheria: Pharmacological Management

IV therapy: 0.9% normal saline
Antibiotic therapy upon consultation with the physician
Diphtheria antitoxin upon consultation with a physician

Government of Canada, 2013

Contact info: info@nursesinternational.org

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Diphtheria: Non-pharmacological Management

Non-pharmacological interventions

Monitor vital signs
Provide oxygen and maintain airway
NPO as clinically indicated

Government of Canada, 2013

Contact info: info@nursesinternational.org

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Diphtheria: Nursing Interventions

Monitor vital signs as clinically indicated
Monitor respiratory status
Monitor neurological status
Monitor intake and output
If administering an agent with risk of anaphylaxis, monitor the child closely for 30 minutes
Arrange for medical evacuation if clinically indicated
Diphtheria is a reportable disease, notify the authorities

Government of Canada, 2013

Contact info: info@nursesinternational.org

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Critical Thinking Question

What should be the nurse's foremost concern when caring for a child with diphtheria?

What should be the nurse's top assessment priority?

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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 color
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
Anaphylactic reaction with medications

(Best-Brandt, 2019)

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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 effect 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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References

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

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

Boston Children’s Hospital. (n.d.). Cold: Overview. https://www.childrenshospital.org/conditions/cold

CDC- Center for Disease Control and Prevention. (2021, November 29). Common Colds: Protect Yourself and Others. https://www.cdc.gov/features/rhinoviruses/index.html

Chang, E. H., Stern, D. A., Willis, A. L., Guerra, S., Wright, A. L., & Martinez, F. D. (2018). Early life risk factors for chronic sinusitis: A longitudinal birth cohort study. The Journal of allergy and clinical immunology, 141(4), 1291–1297.e2. https://doi.org/10.1016/j.jaci.2017.11.052

Contact info: info@nursesinternational.org

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References:

Government of Canada. (2013). Clinical Practice Guidelines for Nurses in Primary Care:Pediatric and Adolescent Care - Chapter 18 - Communicable Diseases. 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-18-communicable-diseases.html#a3

Healthline. (2016, September 19). Common Cold Risk Factors. https://www.healthline.com/health/common-cold-risk-factors

NHS. (2021a, February 02). Sinusitis (sinus infection). https://www.nhs.uk/conditions/sinusitis-sinus-infection/

NHS. (2021b, February 04). Common cold. https://www.nhs.uk/conditions/common-cold/

NHS Scotland. (2020, December 22). Illness and Conditions: Sinusitis. https://www.nhsinform.scot/illnesses-and-conditions/ears-nose-and-throat/sinusitis

Contact info: info@nursesinternational.org

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