Peds/OB Class 1 Flashcards
What respiratory structures are larger in infants?
Tongue and epiglottis
What age are the other structures narrower/shorter until?
8 years old
How does the chest wall differ in an infant?
It’s compliant (sucks inward), which decreases the amount of air it can take in
Infant respiratory rate
30-53
Toddler respiratory rate
22-37
Preschooler respiratory rate
20-28
School-age respiratory rate
18-25
Adolescent respiratory rate
12-20
When do accessory muscles develop
6 years old
What is the major muscle for breathing before accessory muscles develop?
The diaphragm
How does the mucosa differ in infants and young children?
It’s more vascular, more sensitive, and more affected by foreign particles (air quality, smoking)
How does the eustachian tube differ in infants and young children?
It’s shorter and more horizontal
What are the signs of initial compensation for respiratory failure in kids?
Restlessness
Tachypnea
Tachycardia
Diaphoresis
What are the signs of early decompensation for respiratory failure in kids?
Nasal flaring Retractions Grunting Anxiety/Irritability Accessory muscle use if 6y+
What are the signs of imminent respiratory arrest in children?
Dyspnea (bradypnea or apnea) Bradycardia Cyanosis (note: late sign!) Confusion Stupor Coma
How old do you need to be for peak expiratory flow measuring to be successful?
At least 4-6y old.
At what RR does a child need to be NPO?
anything greater than 60
When do you NOT want to give Ibuprofen to a child?
If they have asthma
If they’re not well hydrated
If they have stomach upset
Put these in order from bad to worst:
Substernal retractions
Supraclavicular retractions
Intercostal retractions
Intercostal
Substernal
Supraclavicular
(middle -> down -> up)
Where will you commonly hear breath sounds in kids?
At the base of the throat
At what age does Asthma usually show up?
Age 4-5
What are the three main physiological responses to immune activation in asthma?
- Thickening/constricting of smooth muscle layer in lungs
- swelling of the mucosal layer in lungs
- hypersecretion of mucus in lungs
Classic signs/symptoms of asthma
Dyspnea, wheezing, cough, chest tightness
prolonged expiratory phase
What should parents know about the peak expiratory flow meter settings as the child ages?
It needs to be adjusted based on the height of the child (regularly!)
What condition is the most common cause of hospitalization under 1 year of age?
Bronchiolitis (RSV)
What are the signs/symptoms of bronchiolitis?
Lots and lots of mucus Irritability, less sleeping, less eating Rhonchi Wet wheezes Squeaky/poppy sounds Congested cough without much coming up
How do you care for bronchiolitis?
Supportive care
Snot management
How long will bronchiolitis last? What’s the general trajectory?
Lasts about 2 weeks
Will see improvements and exacerbations
When would someone get a vaccine for RSV?
Only if high-risk: for example, very premature babies.
What is the pathophysiology of cystic fibrosis?
It’s caused by defective chloride ion transport across cell membranes, which decreases water flow and increases salt reabsorption.
Results in thick, sticky mucous that clogs up body systems
What are the initial signs of cystic fibrosis that you might see in the hospital (newborn)?
no pooping at birth: “meconium ileus”
failure to thrive
What are the signs of cystic fibrosis that you might see in children?
frothy, foul-smelling stools
chronic URTIs and LRTIs
Salty skin, distinctive smell
Dehydration
What is the definitive test for cystic fibrosis and why doesn’t it work on newborns?
Sweat chloride test
Newborns don’t sweat
What can kids with cystic fibrosis do to improve their lung condition (and prevent exacerbations)?
Hand hygiene/diet/hydration
Regular exercise (to improve aeration)
Take pancreatic enzyme replacement with meals
take DEAK vitamins in a water-miscible form
take salt supplement if sweating a lot
Use flutter valve (positive airway pressure)
Use ThAirapy vest
Use Pulmozyme (aerosolized alfa Dornase)
Where is the most common site of a Foreign Body Obstruction?
Right side of the lungs
What color will the exudate be if the RBO is in the ears or nose?
Gray
probably foul-smelling
A child shows up in triage who is drooling, sitting in a tripod position and making a frog-like low-pitched snoring sound while breathing. His parents say this started all of a sudden and they’re sure he has a fever. What is your priority nursing action?
Don’t touch him - get help. He potentially has epiglottitis and, if so, will need an airway.
What causes epiglottitis? Can you prevent it? How is it treated?
H. Influenza
There’s a vaccine to prevent it - not common to see it now
Treated fairly quickly with antibiotics
A parent’s child needs a tracheostomy d/t epiglottitis- they’re afraid about the long-term effects. What do you tell them?
A tracheostomy won’t do long-term damage to the airway - they’ll recover fully.
What’s the common name for laryngeotracheobronchitis?
Croup
What can parents do to treat croup at home?
Bring child into cool, moist air (like the garage in winter), or into the shower if cool air isn’t an option.
Prop her upright
It will last for a few days and be worse at night
Mom is calling an advice line, says her daughter has a seal bark cough and is breathing really fast. What do you tell her?
to bring her in (assuming RR over 60) and don’t give her anything to eat or drink
A parent says their child has had a cold for a few days, but suddenly got a fever, is vomiting and seems wheezy and pretty tired. What do you suspect?
Pneumonia
A parent of a child with pneumonia wants to give them cough suppressant because it’s keeping them up at night. What do you tell them?
Cough suppressant isn’t recommended because we want them to get that mucous out of their lungs.
The parent of a toddler has been told her child has nasopharyngitis. She asks if she should take antibiotics. What do you tell her?
Nasopharyngitis is a fancy name for the common cold. It’s caused by a virus and antibiotics are likely to do more harm (by killing off microbiome) than good - they won’t get rid of the virus. It will go away on it’s own in 4-10 days.
The mom of an 18-month old with a cold asks if she can give her child benadryl or sudafed - what do you tell her?
No antihistamines for kids under 6
No decongestants for kids under 2
At what age can a parent give their child tylenol?
6 months
You look inside a child’s mouth and see swollen tonsils and a uvula that’s off to one side. What’s probably causing the offset uvula?
An abscess near the tonsils
If strep throat isn’t treated, it can lead to…
…rheumatic fever or streptococcal glomerulonephritis
A child is going home after a tonsillectomy. You know there’s a bleeding risk after surgery. What should you tell her to watch for?
Watch child while sleeping to see if she’s swallowing
…or vomit that looks like coffee grounds
A child is going home after a tonsillectomy. How often can her parents give her tylenol?
Every 4 hours.
A dad brings a child in to the clinic: says she hasn’t been eating much, her breath smells off, and her voice sounds a little funny and muffled. She’s developed a cough in the last day or two. Her nose hasn’t been runny and her cough sounds dry. What do you suspect?
Tonsilitis
Most common burn injury under four years old?
Scald injuries
What types of burns will heal: where the injured tissue can regenerate?
Partial thickness: 1st and 2nd degree.
Signs of 1st degree burn
Erythema and pain
Blanches with pressure
Dry
(epidermis only: also called superficial)
Signs of 2nd degree burn
Erythema and pain
Blanches with pressure
Blisters
(epidermis and into dermis: also called partial thickness)
Signs of 3rd degree burn
Red/tan/black/brown/white
through epidermis and into subcutaneous tissue
(also called full thickness)
What are some of the less obvious complications of burns?
Fluid loss (d/t capillary permeability)
Poor circulation (d/t myocardial depression)
Heat, fluid and electrolyte loss (through dermis)
Changes in glucose, acid-base and lipid metabolism (d/t stress response hormones)
Immunosuppression
With what presenting symptoms should you assess fluid status (dehydration) in children?
Assess fluid status in ALL children. Lose fluid really easily with lots of different conditions.
How much fluid with they lose with every degree over 37C
7ml/kg/24h
A mom wants to give her child with diarrhea Immodium AD - what do you tell her?
We don’t recommend giving meds for diarrhea - just make sure she’s comfortable (tylenol) and has plenty of fluids.
A dad brings his child to the office and says she’s been acting “off.” She’s had a low-grade fever for a few days. She’s looks pale to you, but she’s playing with blocks. She seems fussy. There are no other symptoms. What do you consider? If you’re correct, what do you recommend?
Consider dehydration - ORS to replenish.
A dad brings his 9m to the office and says she’s been acting “off.” She looks very pale… even ashen. She’s cranky and when she cries there are no tears. Dad says her diaper smells a little stronger than usual. Cap refill is 3s, HR is 158, BP is 73/50. Fontanels look slightly sunken. What do you consider? What do you recommend?
Isotonic Dehydration: attempt ORS, if no luck, IV.
A mom brings her 3yr old to the office and says something is really wrong. He had a stomach bug the last few days, but now he’s super tired, doesn’t seem to care about anything and his skin looks mottled. His BP is 75/40, his skin shows tenting when you check for turgor, and his cap refill is 4s. What do you consider? What do you recommend?
Severe isotonic dehydration. Need IV. Normal Saline.
What are two common causes of isotonic dehydration?
Vomiting/Diarrhea
High Fever
(Blood loss: not as common)
What kind of dehydration does diluting formula create?
Hypotonic dehydration
If a child has severe and prolonged diarrhea, what kind of dehydration would you suspect?
Hypotonic dehydration
What is a big concern with hypotonic dehydration?
Low sodium levels and resulting muscle weakness
What kind of dehydration does making extra concentrated formula result in?
Hypertonic dehydration
How much NS should you give to a dehydrated child who needs an IV?
10-20ccs/kilo (original weight)
repeat if they don’t perk up
Can push
How much ORS should you give to a child with mild-moderate dehydration?
mild: 50ml/kg over 4h
moderate: 60-100 ml/kg over 4h
give 5ml Q15m for 1 hr. Then you can increase the volume or frequency (slowly).
Mom wants to know why you’re not giving her dehydrated child juice or jello?
Because they’re high in sugar and low in electrolytes.
A 4y/o child vomits 30 minutes into getting small, 5ml feedings. What do you do?
Wait an hour and start again.
What does the ductus venosus connect?
The umbilical vein and the inferior vena cava
What does the ductus arteriosus connect?
The pulmonary artery and the aorta
What vessel does the blood flow through to return to the placenta?
Umbilical arteries (2)
Which shoulder is delivered first (OB)
anterior shoulder
When would you use DeLee suction?
If the baby has not started crying and there’s green/black in the urine
When would you use bulb suction?
You’d try to avoid it. If you need suction, DeLee suction is probably better.
When does the foramen ovale close and why?
within 1-2 hours of birth. It closes because of the pressure decrease in the lungs (first breath), which decreases pressure in the pulmonary artery, which decreases the pressure in the right atrium.
When does the ductus arteriosus close and why?
It closes within 72 hours of birth.
Senses a) the O2 increase in the blood and b) the decrease in prostaglandin from the removal of the placenta: the smooth muscle constricts and closes it off as a result.
When does the ductus venosus close?
at around 2 months… at which point you’ll have full perfusion of the liver.
What are your two primary focuses after the baby is born?
1) Respiratory assessment (clean face/clear airway if difficulty breathing)
2) temperature maintenance (dry them off, warm blanket or skin-to-skin; radiant warmer if away from mom)
APGAR categories
Activity Pulse Grimace Appearance Respiration
APGAR: What kind of response will get you a “2” for Grimace?
If the baby cries and actively resists interference
APGAR: What kind of response will get you a “1” for Grimace?
If the baby grimaces or makes a face when you’re interfering with them
APGAR: What will get you a “2” for Pulse?
Over 100bpm
APGAR: What will get you a “1” for Pulse?
Under 100bpm
APGAR: What will get you a 1 for Appearance?
Pink body, blue extremities (acrocyanosis)
APGAR: What will get you a 2 for appearance?
Pink body, pink extremities
APGAR: What will get you a 1 for Activity?
Flexed arms and legs
APGAR: What will get you a 2 for Activity
Actively moving.
APGAR: what range counts as “good”?
7-9
APGAR: What range would you want to watch closely in nursery?
5-7
APGAR: What range would you want to transfer to the NICU?
Under 5
Normal HR for a newborn?
110-160
How close do you want a baby to mom’s face so they can make out her facial features?
8-10in
As the baby gets older in gestational age, is there more or less vernix?
Less
Will Port wine stains go away on their own? What about stork bites? Strawberry marks? Mongolian spots?
Port wine stains: permanent
Stork bites: will fade
Strawberry marks: will fade
Mongolian spots: will disappear in about 2 yrs.
What scale do you use for the gestational age assessment?
The Ballard Scale
What’s the difference between a cephalohematoma and a caput?
Cephalohematoma: blood. Stays btw suture lines. Takes from 2wks to three months to reabsorb. Increases risk of physiologic jaundice.
Caput: Edema d/t sustained pressure and decreased venous return. Crosses suture lines. Resolves in 12h to a few days.
How long does it take the anterior fontanelle to disappear? what about the posterior fontanelle?
Anterior: 1.5-2 years
Posterior: 2-3m
What should you be worried about if you see jittery eye movements in a newborn
Seizures
What is pseudostrabismus?
Normal eye-crossing of the newborn.
What is espadius?
When the urinary orifice isn’t at the center of the glans (penis)
A smooth scrotum (without many rugae) indicates a newborn closer to or farther from gestational age?
Farther from. More rugae appear as fetus matures.
What’s the primary worry with circumcision? In what time frame? What about the secondary worry?
within 2 h: bleeding risk.
secondary: infection: 24-72h
What is brachial palsy? How does it differ from Erb’s palsy?
Both are caused by swelling/damage around the brachial plexus from aggressive traction to the anterior shoulder at delivery.
Brachial palsy: arm muscles weak/floppy
Erb’s palsy: arm AND chest muscles weak/floppy
How do you test for hip dysplasia?
Barlow’s maneuver (bring knees up and together with gentle downward pressure). If hip dislocates, report to provider.
How do you test for unstable or dislocated hips?
Ortolani’s maneuver: hips & knees at 90 degree angle, abduct (pull apart) and feel for clunks
What is the missing enzyme in PKU?
phenalynine hydroxylase
How soon can you do the metabolic screening?
After 24h (48h is better)
What is a normal PKU test result?
1mg/dl
What is an abnormal PKU test result?
6-80 mg/dl (usually over 30mg/dl)
Baby presents with an eczema-like rash, vomiting, irritability, more active muscle tone and reflexes and a mousy odor to the urine. What are these symptoms of?
elevated PKU
What serious effects can happen as a result of elevated PKU?
seizures and mental retardation
What causes pathologic jaundice? When will it show up?
It will show up early: in 1st 24h.
Caused by infection, incompatible blood type… something pathological.
What causes physiologic jaundice? When will it show up?
It won’t show up until about day 3.
It can show up with poor feedings, prematurity, cephalohematoma
What is a nomogram?
Bilirubin chart that combines age and risk factors to determine safe bilirubin range for each baby
How are congenital heart defects screened for?
SpO2 is compared between hand and foot
When does brown fat begin to accumulate?
production increases at 25-26weeks gestation. Will continue to accumulate until 3-5weeks postpartum.
Where does brown fat accumulate?
Necktie formation in front (heart, neck, down front center); between shoulder blades and around kidneys
When should you initiate baby’s first feeding?
Within first 2h
What is progressive atelectasis and how does it occur?
Inability to develop sufficient respiratory capacity after birth. Happens because of inadequate surfactant (prematurity)
What can happen with the ductus arteriosus in premature infants?
Smooth muscle isn’t well enough developed to constrict after birth. Leads to pulmonary congestion.
How is transferred immunity occur in babies (2)? How does this affect premature newborns?
IgG crosses through the placenta to the newborn in the 3rd trimester.
IgA crosses through breastmilk. Smaller babies (before 32-34 weeks) don’t have coordination to suck.
What is IUGR?
Intrauterine growth restriction
Something that prevents the baby from growing well: placental health, elevated BP, etc.
NIPS scale categories and point systems
Face (0-1) Cry (0-2) Breathing (0-1) Arm movements (0-1) Leg movements (0-1) State of arousal (0-1) (Lower is better)
At how many seconds do periods of apnea become abnormal in a newborn?
3s+
What is Respiratory Distress Syndrome?
Newborn complication d/t not enough surfactant production. Can make the reinflation of the alveoli progressively harder and lead to hypoxia, acidosis and respiratory failure.
What does TORCH stand for?
Acronym for a series of diseases that can be cause infection and sepsis in a newborn if mom is infected.
Toxoplasmosis (from raw meat/fish)
Other infections (Hep B, syphilis, shingles)
Rubella
Cytomegalovirus (in herpes family)
Herpes simplex
(Pregnant mom should avoid people who are ill with these sicknesses and wash hands well)
What is the threshold for hypoglycemia in a newborn?
40-45
What are the signs of a baby going through drug withdrawal?
high-pitched cry irritability tremors unquiet sleep hiccups, sneezing, stuffy nose loose stools poor feeder excoriation on buttocks, knees, elbows
What scale would you use for drug withdrawal screening in newborns?
ESC: eating, sleeping, consoling
