TUBERCULOSIS

Tuberculosis is a contagious disease caused by an acid-fast bacillus, Mycobacterium tuberculosis. The transmission of tuberculosis is through inhalation of droplets from a person with active tuberculosis.

Children are more common infected than adult in family. They can be infected from family member or by another individual with whom they have frequent contact such as babysitter.

Sign and Symptoms:

• May be asymptomatic
• Malaise
• Fever
• Cough
• Weigh loss
• Anorexia
• Lymphadenopathy

Diagnose:

1. Mantoux Test
2. Sputum Culture

Medical Interventions:

1. Isoniazid (INH), rifampin (rifadin), and pyrazinamide
2. A 9 month course of INH is prescribed to prevent a latent infection from progressing to clinically active tuberculosis and to prevent initial infection in children in high risk situations
3. A 12 month course is prescribed to the HIV infected child
4. For child with active tuberculosis: INH, rifampin, and pyrazinamide daily for 2 months and then INH and rifampin twice weekly for 4 months

Nursing Interventions:

1. Wear a mask if the child is coughing and does not cover his or her mouth
2. Place children on airborne precautions until medications have been initiated, sputum cultures demonstrate a diminished number of organisms, and cough is improving
3. Maintain airborne precaution with family members
4. Adequate rest and diet
5. Advice the child and family to prevent transmission of tuberculosis

Mantoux Test:

• Positive reaction to the mantoux test will appear 2-10 weeks after the initial infections
• The test is done to determine whether the child has been infected and has developed a sensitivity to the protein of the tubercle bacillus
• A positive reaction does not confirm the presence of active disease
• Once the child reacts a positively, the child will always react positively
• A positive reaction in a previously negative test indicates that the child has been infected since the last test
• The test should not be done at the same time as measles immunization since it may cause false-negative reaction

Measuring of Mantoux Test:

• The result of the test is measured by indurations:
• 15 cm or more = positive in child 4 years or older who do not have any risk factor
• 10 cm or more = positive in children younger than 4 years and in those with chronic illness or at high risk for exposure to tuberculosis
• 5 cm or more = positive for the highest risk groups such as children with immunusuppressive conditions or human immunodeficiency virus

Sputum Culture:

• The test is positive if it demonstrates the presence of mycobacteria in a culture
• Gastric washing (aspiration of lavaged contents from the fasting stomach) is done to obtain specimen from an infant or young child since they often swallow sputum rather than expectorate it
• The specimen is obtained in the early morning before breakfast

Pneumonia

Pneumonia is an inflammation of the alveoli. It can be cause by a virus, mycoplasmal agents, bacteria, or the foreign substances aspiration. The causative agents are usually come to the lung through inhalation or from the bloodstream.

There are types of pneumonia:

1. Viral pneumonia
2. Primary atypical pneumonia (Mycoplasma pneumonia)
3. Bacterial pneumonia
4. Aspiration pneumonia

Aspiration Pneumonia

Aspiration pneumonia may occur when food, secretions, liquids, or other materials enter the lung and cause inflammation and a chemical pneumonitis.

Signs and Symptoms of Aspiration Pneumonia:

• Cough or fever with foul-smelling sputum
• Deteriorating results on chest x-rays

Bacterial Pneumonia

Bacterial pneumonia is a serious infection that sometimes need for hospitalization when pleural effusion or empyema accompanies the disease and is mandatory for children with staphylococcal pneumonia.

Signs and Symptoms of Bacterial Pneumonia:

• Acute onset, fever, toxic appearance
• In infant: irritability, poor feeding, lethargy, abrupt fever, respiratory distress
• In older child: chills, headache, abdominal pain, chest pain, and meningeal symptoms
• Diminished breath sound or scattered crackles
• Hacking, nonproductive cough
• Coarse crackles and wheezing are heard as the infections resolves

Nursing Interventions for Bacterial Pneumonia:

• Administer oxygen as prescribed
• Place the child in a mist tent as prescribed
• Administer antimicrobial, antipyretic, antitussives as prescribed
• Suction mucus if the infant is unable to handle secretions
• Chest physiotherapy and postural drainage every 4 hours as prescribed
• Encourage child to lie on the affected side to splint the chest and reduce the discomfort caused by pleural rubbing
• Provide fluid intake and take caution to prevent aspiration
• Institute isolation precautions according to the agency policy
• Continuous closed chest drainage may be instituted if purulent fluid is present
• Thoracentesis may be done to remove fluid accumulation in the pleural cavity

Primary Atypical Pneumonia

Primary atypical pneumonia is the most common cause of pneumonia in children between 5-12 years of age. Primarily it occurs in the fall and winter season and in crowded living conditions.

Signs and Symptoms of Primary Atypical

• Anorexia, headache, fever, chills, muscle pain, and malaise
• Rhinitis, sore throat, and dry-hacking cough
• Initially non productive cough, then production of seromucoid sputum that becomes mucopurulent or blood streaked

Nursing Intervention:

• Nursing interventions for patient with primary atypical pneumonia are symptomatic.

Viral Pneumonia

Viral pneumonia occurs more frequently than bacterial pneumonia. It is also associated with upper respiratory infection caused by viruses.

Signs and Symptoms of Viral Pneumonia:

• Slight cough, malaise, and mild fever, to severe cough, prostration, and high fever
• Non productive or productive cough with small amounts of whitish sputum
• Wheezing or fine crackles

Nursing Interventions for Patient with Viral Pneumonia:

1. Oxygenation with cool mist as prescribed
2. Encourage to increase fluid intake
3. Administer antipyretics and antimicrobials as prescribed
4. Chest physiotherapy and postural drainage as prescribed

Bronchiolitis / Respiratory Syncytial Virus (RSV)

Bronchiolitis is defined as an inflammation of the bronchioles. It causes production of tick mucus that occludes bronchiole tubes and small bronchi. The common cause of bronchiolitis is respiratory syncytial virus that is higly communicable and usually transferred by the hands.

Signs and Symptoms:

• Upper respiratory infection symptoms: rhinorrhea and low-grad fever
• Tachypnea
• Lethargy, poor feeding and irritability
• Increased difficulty in breathing
• Expiratory wheeze and grunt
• Nasal flaring and retractions
• Diminished breath sounds

Nursing Interventions:

1. Maintain patent airway
2. Place child at a 30-50 degree angle with the neck is slightly extended to maintain an open airway as well as decrease pressure on diaphragm
3. Provide cool and humidified oxygen
4. Assess for any signs of dehydration
5. Encourage fluid intakes

Special Consideration in Giving Care Child with RSV:

• Isolate the child in a single room or in a room with another child with RSV
• Good hand washing procedures
• The nurses who care for these children do not care for other high-risk children
• Wear gowns when soiling of clothing may occur during care
• Administer ribavirin (Virazole) as prescribed
• Prepare for the administration of respiratory syncitial virus immune globulin ((RSV-IGIV or RespiGam or palivizumav)

Key Concept in Administration of Ribavirin (Virazole)

• Administer Ribavirin via aerosol by hood, tent, mask, or through ventilator tubing
• Pregnant health care providers should not care for a child receiving ribavirin
• The nurse who wear contact lenses should wear goggles when coming in contact with ribavirin since the mist may dissolve soft lenses

Respiratory Syncytial Virus Immune Globulin

• The immune globulin is used prophylactically to prevent respiratory syncytial virus infection in high-risk child
• The immune globulin is not administered to infants or children with congenital heart disease or with cyanotic congenital heart disease

Bronchitis

Bronchitis is an infection of the major bronchi that may be referred to as tracheobronchitis.

Signs and Symptoms:

• Fever
• Dry, hacking, and nonproductive cough that is worse at night and becomes productive in 2-3 days

Nursing Interventions:

1. Monitor for respiratory distress
2. Provide cool and humidified air
3. Monitor for any signs of dehydration
4. Increased fluid intake
5. Administer acetaminophen (Tylenol) for fever as prescribed

Laryngotracheobronchitis

Laryngotracheobronchitis is gradual inflammation of the larynx, trachea and bronchi. It is a most common type of croup and may be caused by virus or bacteria.

Sign and Symptoms:

• Irritability and restlessness
• Fever at low to high grade
• Hoarse voice
• Inspiratory striddor and suprasternal retraction
• Seal bark and brassy cough
• Crackles and wheezing
• Use of accessory muscles for breathing
• Anorexia, nausea, and vomiting
• Signs of anoxia and carbon dioxide retention
• Cyanosis

Nursing Interventions:

1. Keep a paten airway
2. Assess respiratory status (nasal flaring, inspiratory stridor, sternal retraction)
3. Monitor for pallor or cyanosis
4. Elevate the head of the bed and provide bed rest
5. Provide humidified oxygen
6. Encourage fluid intake
7. Administer medication as prescribed (antibiotics, analgetics, bronchodilators, corticosteroids)
8. Epinephrine nebulizer may be given for children with severe disease, stridor at rest, retractions, or difficulty breathing
9. Have resuscitation equipment available

Epiglottitis

Epiglottitis is an inflammation on the epiglottitis. It mah be caused by Haemophilus influenzae type B or Streptococcus pneumoniae.

Epiglottitis most frequently occurs in winter in child between age 2 and 5 years. If it is happened, it is consideres as an emergency situation.

Signs and Symptoms:

• High fever
• Sore, red, and inflamed throat
• Drooling
• Absence of spontaneous cough
• Muffled voice
• Difficulty swallowing
• Inspiratory stridor
• Agitation
• Tripod positioning

Nursing Interventions:

1. Maintain a patent airway
2. Assess respiratory status and breath sounds (nasal flaring, stridor, using accessory muscles)
3. Avoid assess body temperature by oral route
4. To prevent spasm of the epiglottis and airway occlusion, no attempts should be made to visualize the posterior pharynx or to obtain a throat culture
5. Prepare for lateral neck films to confirm the diagnosis
6. Keep NPO
7. Do not restrain the child
8. Do not leave the child unattended
9. Do not force the child to lie down
10. Administer fluids and antibiotic intravenously as prescribed
11. Administer analgesics and antipyretics as prescribed
12. Provide high humidification to cool the airway and decrease swelling
13. Provide cool-mist oxygen therapy as prescribed
14. Have resuscitation equipment available
15. Prepare for endotracheal intubation or tracheotomy if there is severe respiratory distress
16. Ensure that the child has up-to-date immunization schedule