Retractions, costal and sternal
Retractions, costal and sternal: Excerpt from Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
A cardinal sign of respiratory distress in infants and in children, retractions are visible indentations of the soft tissue covering the chest wall. They may be suprasternal (directly above the sternum and clavicles), intercostal (between the ribs), subcostal (below the lower costal margin of the rib cage), or substernal (just below the xiphoid process). Retractions may be mild or severe, producing barely visible to deep indentations.
Normally, infants and young children use abdominal muscles for breathing, unlike older children and adults, who use the diaphragm. When breathing requires extra effort, accessory muscles assist respiration, especially inspiration. Retractions typically accompany accessory muscle use.
ALERT: A severely agitated child or a child crying in pain may also have sternal retractions.
Act Now: If you detect retractions in a child, check quickly for other signs of respiratory distress, such as cyanosis, tachypnea, tachycardia, and decreased oxygen saturation. Also, prepare the child for suctioning, insertion of an artificial airway, and oxygen administration.
Observe the depth and location of retractions. Also note the rate, depth, and quality of respirations. Look for accessory muscle use, nasal flaring during inspiration, or grunting during expiration. If the child has a cough, record the color, consistency, and odor of sputum. Note whether the child appears restless or lethargic. Finally, auscultate the child’s lungs to detect abnormal breath sounds. (See Observing retractions.)
Assessment
History
After the child’s condition has been stabilized, obtain his medical history from his parents. Was he born prematurely? What was his birth weight? Was the delivery complicated? Ask about recent signs of an upper respiratory tract infection, such as runny nose, cough, and low-grade fever. How often has the child had respiratory problems during the past year? Has he been in contact with anyone who has had a cold, the flu, or other respiratory ailments? Did he ever have respiratory syncytial virus? Did he aspirate food, liquid, or a foreign body? Inquire about a personal or family history of allergies or asthma.
Physical examination
If the child isn’t in distress, complete a cardiopulmonary assessment. Take the child’s vital signs, including his temperature. Monitor the child’s level of oxygenation and breath sounds.
Pediatric pointers
When examining a child for retractions, remember that crying may accentuate the contractions.
Geriatric pointers
Although retractions may occur at any age, they’re more difficult to visualize in an older patient who’s obese or who has chronic chest wall stiffness or deformity.
Medical causes
Asthma attack
Intercostal and suprasternal retractions may accompany an asthma attack. They’re preceded by dyspnea, wheezing, a hacking cough, and pallor. Related features include cyanosis or flushing, crackles, rhonchi, diaphoresis, tachycardia, tachypnea, a frightened, anxious expression and, in patients with severe distress, nasal flaring.
Bronchiolitis
Most common in children younger than age 2 years, bronchiolitis is an acute lower respiratory tract infection that may cause intercostal and subcostal retractions, nasal flaring, tachypnea, dyspnea, cough, restlessness, and slight fever. Periodic apnea may occur in infants younger than age 6 months.
Croup (spasmodic)
Croup causes attacks of a barking cough, stridor, inspiratory crackles, expiratory wheezing, hoarseness, dyspnea, and restlessness. As distress worsens, the child may display suprasternal, substernal, and intercostal retractions accompanied by nasal flaring, tachycardia, cyanosis, and an anxious, frantic expression. Croup attacks usually subside within a few hours but tend to recur and may require intubation.
Epiglottiditis
A life-threatening bacterial infection, epiglottiditis may precipitate severe respiratory distress with suprasternal, substernal, and intercostal retractions as well as stridor, nasal flaring, cyanosis, and tachycardia. Early features include the sudden onset of a barking cough and high fever, sore throat, hoarseness, dysphagia, drooling, dyspnea, and restlessness. The child becomes panicky as edema makes breathing difficult. Total airway occlusion may occur in 2 to 5 hours.
Heart failure
Usually linked to a congenital heart defect in children, heart failure may cause intercostal and substernal retractions along with nasal flaring, progressive tachypnea and, in severe respiratory distress, grunting respirations, edema, and cyanosis. Other findings include productive cough, crackles, jugular vein distention, tachycardia, right upper quadrant pain, anorexia, and fatigue.
Laryngotracheobronchitis (acute)
A viral infection, substernal and intercostal retractions typically follow low to moderate fever, runny nose, poor appetite, barking cough, hoarseness, and inspiratory stridor. Associated signs and symptoms include shallow, rapid respirations as well as tachycardia, restlessness, irritability, and pale, cyanotic skin.
Pneumonia (bacterial)
Bacterial pneumonia begins with signs and symptoms of acute infection, such as high fever and lethargy, which are followed by subcostal and intercostal retractions, nasal flaring, dyspnea, tachypnea, grunting respirations, cyanosis, and a productive cough. Auscultation may reveal diminished breath sounds, scattered crackles, and sibilant rhonchi over the affected lung. GI effects may include vomiting, diarrhea, and abdominal distention.
Respiratory distress syndrome
Substernal and subcostal retractions are an early sign of respiratory distress syndrome — a life-threatening condition that affects premature neonates shortly after birth. Associated early signs include tachypnea, tachycardia, and expiratory grunting. As respiratory distress worsens, intercostal and suprasternal retractions typically occur, and apnea or irregular respirations replace grunting. Other effects include nasal flaring, cyanosis, lethargy, and eventual unresponsiveness as well as bradycardia and hypotension. Auscultation may detect crackles over the lung bases on deep inspiration and harsh, diminished breath sounds. Oliguria and peripheral edema may occur.
Nursing considerations
Monitor the child’s vital signs. Keep suction equipment and an appropriate-sized airway at the bedside. If the infant weighs less than 15 lb (6.8 kg), place him in an oxygen hood. If he weighs more, place him in a cool mist tent instead. Perform chest physical therapy with postural drainage to help mobilize and drain excess lung secretions. (See Positioning an infant for chest physical therapy, pages 254 and 255.) A bronchodilator or, occasionally, a steroid may also be used.
Prepare the child for chest X-rays, cultures, pulmonary function tests, and arterial blood gas analysis. Explain the procedures to his parents as well, and have them calm and comfort the child.
Patient teaching
Instruct the patient or a family member on proper administration of medication at home. Provide instructions for providing a humidified environment. Stress the importance of maintaining adequate hydration. Provide information on the use of respiratory equipment and techniques to administer respiratory therapies at home.
Pictures
Book Source Details
- Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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