UNIT 3 RESPIRATORY Flashcards
1
Q
What are different types of respiratory devices? list 5
A
- Blow by o2
- Nasal Cannula
- simple masks
- Venturi (Mask)
- Non-Rebreather (mask)
2
Q
What should we know about blow by o2 delivery?
A
Used most often in the newborn population however, it is not used a ton due to not having the ability to know how much the patient is truly recieving and the risk of effecting the eyes
3
Q
What % of oxygen does blow by o2 provide?
A
30% but also depends on how close to the face the blow by device is
4
Q
How many liters can a nasal cannula provide?
A
1-6L
5
Q
What precentage of oxygen does a nasal cannula provide?
A
24-44%
6
Q
How many liters of oxygen can a simple mask provide?
A
5-8L
7
Q
How much oxygen does a simple mask provide?
A
40-60%
8
Q
A smiple mask must have a ____L flow because it can build up carbon dioxide
A
5L
9
Q
How many liters of oxygen can a venturi mask provide?
A
4-12L
10
Q
How much % of oxygen does a venturi mask provide?
A
24-60%
11
Q
Why do venturi makes have large holes on the side?
A
To prevent carbon dioxide build up in children
12
Q
How many liters of oxygen can a non-rebreather provide?
A
10-15L
13
Q
What % of oxygen does a non rebreather provide?
A
almost 100%
14
Q
What must we make sure happens when using a non-rebreather?
A
fill reservoir bag with pure oxygen
15
Q
Oropharynx, Pharynx, larynx, and upper trachea are part of the upper or lower airway?
A
Upper
16
Q
Lower trachea, bronchi, bronchioles and alveoli are part of the upper or lower airway?
A
Lower
17
Q
Why do full term infants less than 3 months typically have lower infection rates?
A
Due to the protective function from moms immune system and breastmilk
18
Q
Children 3-6 months are at higher risk of what respiratory disease?
A
Pertussis
19
Q
Why do we start seeing more respiratory infections/infections in children 3-6 months?
A
Moms antibodies are going away and baby is starting to produce their own so there is a gap where they are not fully covered.
20
Q
Toddlers and preschoolers start seeing more of what type of infections?
A
Viral– due to starting day cares and preschools
21
Q
Kids 5 and up start seeing what type of infection more commonly?
A
Strep increases and viral infections typically start decreasing.
22
Q
What are some anatomically differences between adults and children in terms of the respiratory tract?
A
- Airway diameter is smaller
- Distance between structures of tract shorter
23
Q
Why does size matter with the respiratory tract?
A
- Distance between structures of the tract are shorter
- Organisms move rapidly down tract
- Eustachian tube in infants and small children is short and open making them more prone to ear infections esp. in resp illness
24
Q
What is the diameter of a newborns airway vs. an adults airway?
A
Newborn: 4MM
Adult: 20MM
25
What should we keep in mind with resistance and seasonal variations with resp. Illnesses?
1. Immune system deficiencies
- Diet-- not enough nutrients/vitamins
2. Other conditions to consider
- Heart, lung and/or previous illness
3. Seasonal variations
- RSV is the biggest in the pedi world it is normally seen in nov. and april but we are starting to see it earlier and it is lasting longer
26
True or false: Preterm babies have an increased danger of respiratory obsturction?
True
27
The bronchi and trachea are so narrow that _____ can obstruct the airway?
Mucous
28
Can positioning affect the respiratory function?
Yes
29
Weak or absent gag reflexes increase the chance of ____ in premature newborns?
Aspiration
30
What are the benefits of laying a baby prone?
Being prone can help open and expand the chest cavity which helps open the airway... the ONLY time babies are placed prone in the hospital is when they are continuously monitored.
"Put them prone and leave them alone"
31
What are signs of respiratory distress in the NEWBORN?
1. **Cyanosis** (serious sign when generalized)
- Typically presents around lips 1st then spreads
2. **Tachypnea** (sustained rate >60breaths/min after first 4 hours of life)
- Normal at 1st as they try and get secretions out anything over 4 hours is cause for concern.
3. **Retractions, expiratory grunting and nasal flaring**
4. **apneic episodes**
- anything over 15 seconds and/or with color changes... periodic breathing is normal but remember this is less than 15 seconds and without can changes
5. **Diminished air entery **
6. **Presences of crackels or rhonchi on auscultation**
- crackles are normal immediately after birth but should go away
32
What is the purpose of a baby grunting?
Grunting is the babies way of trying to create a positive pressure system to try and open up their airway
33
What is apnea of prematurity?
Apnea of prematurity refers to cessation of breathing for 20 seconds or longer or for less than 20 seconds when associated with cyanosis, pallor, and bradycardia.
34
Apnea is the most common problem in the ....
preterm infant <36 weeks, presenting between day 2 and 7 of life.
35
What is the etiology of Apnea?
Multifactorial but thought primarily to be a result of neuronal immaturity
36
Central apnea is thought to be caused by...
Preterm infant's irregular breathing patterns (periodic breathing)
37
Obstructive apnea can occur in the preterm infant when there is a _____?
Cessation of airflow associated with blockage of the airway (small airway diameter, increased pharyngeal secretion, improper body alignment and positioning)
Can even be due to reflux-- painful... so they stop breathing... to prevent the hurt
38
True or false: Premature babies have smooth brains so they still can't multitask so they often have episodes of breathing simply because they forget?
True
39
Onset of apnea is often _____?
Insidious... no cause
40
When might apnea occur?
1. May occur when feeding, suctioning, or stooling (member babies cant multitask well)
2. May be no observable activity related to apnea
41
All episodes of apnea should be documented how?
All episodes of apnea and bradycardia should be documented and include time, length of episode, and treatment required even if we did not have to intervene
42
What is the intervention for Apnea?
Intervention depends on severity of episode
Caffeine citrate (methylxanthine) often used to treat apnea
42
What do we need to know about caffeine citrate (methylxanthine)?
1. Used to tx apnea
2. Babies CAN NOT go home on this medication because they have to be continuously monitored.
3.** We will wean them off before discharge. They must be off the drug for 7 CONSECTIVE days with NO apneic episodes. If they have even 1 during those 7 days the time starts over. **
4. IV or PO usually given with loading dose
43
What are ways we can stimulate a baby to breath during an apneic episode?
1. Rub back
2. tip of feet
3. Mess with the
4. Positive pressure air mask to help pop open airways.
If they continue we can put o2 on them.
44
What causes RDS (Respiratory Distress syndrome)
Surfactant deficiency-- Surfactant is the thin lubricant that allows the lung to open and close easily.
45
What age group is most at risk for RDS and why?
Usually preterm, but some near-term infants may be affected... due to immature lungs and surfactant deficiency.
46
How long does RDS typically last?
1. An uncomplicated course is charcterized by peak severity at 1-3 days
2. Onset of recovery at ~ 72 hours (usually coinciding w/diuresis)
47
What is a positive sign that a baby is on the down hill side of RDS?
They begin to diuresis--- dump urine
48
True or false: I&O is important monitor with RDS?
True
49
What are risk factors of RDS?
1. Low gestational age-- preterm babies under 36 weeks
2. Males predominance (white)
3. Maternal diabetes
4. Perinatal depression
- If mom had any drugs in system... could affect baby... avoid giving moms meds prior to deliver due to this.
50
Increased insulin and sugar can decrease _____ levels?
Surfactant levels
51
What are s/s of RDS?
| List 8
1. Tachypnea initially
2. Dyspnea
3. Intercostal or subcostal retractions
4. Inspiratory crackles
5. Audible expiratory grunt
6. Flaring of the nares
7. Cyanosis
8. Pallor
52
How are we going to manage RDS?
1. Artifical surfactant replacement
2. Repiratory support and monitoring
- "surf and turff
3. Oxygen supplementation
- Never want them to sat 100% --> can lead to blindness
4. Fluid and metabolic management
- IV fluids, TPN potentially, lavage feeding is goal... want to get them on minimal or entrophic feeds.
53
What is bronchopulmonary dysplasia?
Chronic lung disease that occurs in low birth weight preterm infants. It is defined as dependence on 02 up to 28 days of age. Secondary to oxygen and mechanical ventilation treatment of RDS.
54
Bronchopulmonary dysplasia puts infants at an increased risk for?
Reactive airway disease/ significant respiratory disease
55
What are early signs of respiratory complications in children?
1. Refusal to take oral fluids and decreased urination
2. Evidence of earache
3. RR greater than or equal to 50-60/min
4. Fever > 101f
5. listlessness
6. Confusion
7. Increased irritability
8. Persistent cough
9. wheezing
10. Restlessness and poor sleep patterns
56
What are the URI we talked about during this lecture?
1. Acute streptococcal pharyngitis (strep)
2. Tonsillitis
3. Otitis media (OM)
4. CROUP syndromes
57
What are the types of Lower respiratory tract infections we talked about during this lecture?
1. RSV/ Bronchiolitis
2. Asthma
3. CF
58
What is acute streptococal pharyngitis and what is the main cause of it?
1. Bacterial infection of the throat and tonsils
2. Causative agent- group A beta hemolytic streptococcus (GABHS)
59
What might we find during our assessment of a patient suspected of having acute streptococal pharyngitis (strep)?
1. Sore Throat
- Uvula appears edematous and red
- tonsils may be inflamed
- exudate may be present
2. Headache
3. Fever
4. abdominal pain
5. N/V can occur
6. Sandpaper rash all over the body
60
How do we diagnosis Acute Streptococal pharygitis "strep throat"?
Rapid streptococcal antigen test/throat culture
Have child sit and open mouth... inform child that the swab may make them gag... swab the back of the throat... usually takes about 15 mins to get results
61
What are our interventions for strep?
1. If rapid strep test comes back postiive--> treat with antibiotics....
2. If negative and patient is super symptomatic a throat culture may be done and patient may be placed on broad specturm antibiotic until throat culture comes back.
62
What education regarding strep should we teach patients/family?
1. Important to inform patient/parent the importance of completing full course of antibiotic
- can get rheumatic fever or acute glomurlitrits which will affect the kidneys if they do not complete antibiotics.
2. Enourage fluids
3. Return back to school 24 hours after 1st antibiotic pill
4. Discard toothbrush after they have started antibiotic
5. clean retainer
63
What is tonsilitis?
Inflammation of the tonsils
64
What is the caustive agent of tonsilitis?
May be viral or bacterial
This is what sets it apart of from strep which is bacterial?? Fix this??
65
What might we find on our assessment of a patient suspected to have tonsilitis?
1. Sore throat
2. difficulty swallowing
3. fever
4. enlarged tonsils
5. "kissing tonsils"
6. obstructed breathing
7. exudate, maybe
66
What interventions might we do for a patient w/tonsilitis?
1. Rapid "strep" test and/or throat culture
- If postive, antibiotics
2. Antipyretics
3. Ice chips, soft or liquid diet
4. Warm saline gargles
5. For frequent episodes, consider surgical options
67
What surgical options are available for tonsilitis?
1. Tonsillectomy-- removal of palatine tonsils
2. Adenoidectomy-- removal of pharyngeal tonsils
68
What are contraindications of the surgical options of tonsillectoy/adenoidectomy to tx tonsilitis?
1. celft palet-- must be completely healed from cleft repair due to speech
2. Infection-- must be completely free of infection will increase risk of bleeding and increased risk of swelling of lymphatic tissue
3. blood/clotting disorders
4. problems with anesthesia (both surgery done under general)
69
What are pre-op interventions for surgical options to treat tonsilitis?
1. Assess for
- Possible infections-- remember they cannot have active infection
- Lab values-- ensure all are normal
2. Check for loose teeth.
- During surgery there is a chance of tooth being disologed so MD may pool during procedure
70
What are some post-op interventions for surgical treatment of tonsilitis?
1. Comfort
- Prone or side lying
- Analgesics
- Ice collar (generally not tolerated)
2. Diet
- Ice chips, sips of water, and CLEAR liquids
- NO RED-colored liquids, citrus, milk-based foods initally
3. Additional instructions
- Discourage coughing, throat clearing, nose blowing--> increased risk of bleeding
4. Encourage rest
71
What is the number 1 complication of the surgical options to treat tonsilitis?
Bleeding
72
What should our discharge education include after surgical repair of tonsilitis?
1. Continue soft, bland foods and avoid sharp objects in mouth
2. Analgesics-- making sure to give it on schedule for the 1st 24-48 hours because we want to minimize breakthrough pain. Give even if we have to wake them up.
3. Limit activity for 2 weeks... they can return to school after a week but cannot participate in PE/athletics... No swimming
4. Seek immediate medical attention for signs of hemorrhage
73
What should we know about hemorrhages and surgical options for tx of tonsilitis?
#1 risk after the procedure...
1st 24 hours is when patient is most at risk
s/s include: tachycardia, skin tone pale (pallor), frequently clearing throat, vomiting bright red blood, restless, hypotensive
74
What should we know about post-tonsillectomy appearance of the oropharynx?
The white scabbing is normal.. it indicates healing... this typically presents itself up to 7-10 days post-op. Around day 10 it will begin to come off... this is often when kids report more pain
75
What is otitis media (OM)?
An inflammation of the middle ear
76
OM is typically precipitated by a....
Resp. infection... common w/flu and RSV
77
What is acute otitis media (AOM)?
An inflammation of the middle ear space with a rapid onset of the s/s of acute infection (fever and ear pain)
78
What is otitis media w/effusion (OME)
Fluid in the middle ear space w/out symptoms of acute infection
79
What are risk factors of OM?
1. Children under 2
2. Recent URI
3. Family hx (sibilings or parents)
4. Socieoeconomic status
5. Daycare/exposure to other children
6. Allergies
7. Crowded households
8. Secondhand smoke exposure
9. Bottle feeding (doesnt give antibodies like breast milk)
10. Bottle propping
11. Time of year
12. Enlarged tonsils/adenoids
13. Cleft lip/palate
14. down syndrome
15. gender
16. paci-- due to continous suck on the paci causes the eustachian tube to become abnormally open
80
On assessment of a an infant suspected of AOM what might we find?
1. Crying
2. Fussiness (increased when lying down)
3. tendency to rub, hold, or pull effected ear
4. rolls head from side to side
5. difficult to comfort
6. refuses to feed
7. vomiting, diarrhea
81
On assessment of older children suspected of having AOM what might we find?
1. Crying or verbailizes feeling of discomfort
2. irritability
3. lethargy
4. Loss of appetitie
82
True or false: When the tympanic membrane ruptures it can cause relief of pain but the continous build up can eventually cause progressive hearing loss?
True
83
How do we diagnosis AOM?
1. Otoscopic examiniation of the tympanic membrane
- presence of purulent discolored effusion
- bulging or full
- red
- opaque
Normally the membrane is more of a gray color
84
What are some interventions we can do for AOM?
1. Administer antibiotics (oral or by ear)
2. Administer analgesics-antipyretics (tylenol or motrin)
3. Facilitate drainage if possible
- Position child on affected ear
4. Warm compress on affected ear-- make sure its not too hot. Warmth helps relieve ear pain
85
What might our assessment of a patient suspected of OME show and how is it diagnosed?
1. May have Rhinitis, cough, diarrhea
2. Feeling off fullness and/or motion in ear
3. Popping sensation when swallowing
Diagnosed by otoscopic examination of tympanic membrane
- orange, discolored
- Immobile
86
What is a Myringotomy?
Placement of Tympanostomy tubes
to help alleviate pain, facilitate drainage and allows for ventilation
87
What are the post-op interventions for a myringotomy?
Parent education
1. Position to faciliate drainage
2. Keep ears dry.. no submerging-- certain ear plugs only
3. antibiotics
4. analgesics
5. discourage nose blowing can dislodge newly placed tubes
6. Notify provider if tubes fall out
- if you witness it 7-10 days after surgery this is a problem.... they will fall out with time but shouldnt be this early.
7. Keep immunizations up to date
8. Decrease OM/AOM risk factors
88
What are different types of croup?
1. Acute Epiglottitis
2. Acute Laryngotracheaobronchitis ("croup")
3. Acute spasmodic laryngitis (spasmodic croup)
4. Bacterial Trachetitis
89
What are the general characteristics of croup?
1. Hoarsness
2. "barking" or "brassy" cough "seal" cough
3. Varying degrees of inspiratory stridor
4. Varying degree of respiratory distress
90
What is acute epiglotitis?
| Croup Syndrome
Severe obstructive inflammatory process which is severe and life-threatening infection
91
What is the most common cause of Acute Epiglottitis?
| Croup Syndrome
Haemophilus Influenze (HIB)
92
What age group is most at risk for acute epiglottitis?
| Croup syndrome
2-5 years olds
93
On our assessment of a child suspected of having acute epiglottitis what might we see?
| Croup syndrome
Predictive signs
1. absence of spontaneous cough
2. Presence of drooling
3. Agitation
Other s/s
1. Fever and appears very sick ("toxic") usually around 102 or higher
2. Tripod positioning
3. Irritability and restlessness
4. Thick, Muffeled, froglike crog crocking voice
5. Retractions
6. Red and inflamed throat
- Large, cherry red, edematous, epiglottis visible upon CAREFUL throat inspection
94
What does the onset of acute epiglottitis look like?
| Slow or abrupt?
Abrupt
95
What is the name of this position?
Tripod position
96
How is Acute Epiglottits diagnosed?
| Croup syndrome
1. Throat inspection
2. Laryngoscpy- with airway protected
- Will try and intubate but if unable they will trach the patient
3. Lateral neck X-ray
- To try and visulize the "thumb sign" epiglottitis
4. Throat and blood cultures after airways is secured
97
Why are oral temps and tongue depressors avoided with acute epiglottits?
The Hib B virus sits in the throat and if irritated it will cause the epiglotis to swell even more risking closure of the airway. We do not do oral temps or tongue depressors to avoid chance of irriataing the epiglotis
98
How do we manage acute Epiglottitis?
| Croup syndrome
1. Protect airway-- keep child NPO
2. Position of comfort-- Avoid supine
3. Pulse ox
4. Antibiotics
5. Corticosteriods (helps w/swelling)
6. Droplet isolation
99
Why do we avoid letting the child lay supine with acute epiglottits?
| croup syndrome
When the child lays back the epiglottis will continue to put pressure on the back of the throat causing an airway obsturction
100
How long is a child with acute epiglottits on droplet isolation?
For atleast 24 hours after the start of antibiotics per the CDC
101
What are some emergent signs of acute epiglotttis?
| Croup syndrome
1. Tripod positioning
2. Absense of cough
3. Drooling
At this point avoid putting anything into mouth
102
What is Acute Laryngotracheobronchitis
"Croup"
| Croup syndrome
Inflammation of the larynx, trachea, and bronchi
This is the most common croup syndrome and is often preceeded by a URI
103
What age group is "croup" most common in?
| croup syndrome
Children under 5
104
What is the causative agent of "Croup"?
Most commonly viral
105
On our assessment of a child suspected of having "croup" what might we see?
1. Low grade fever-- 101 or lower
2. Barky, brassy ("seal-like") cough
3. Hoarseness--> trachea and larynx inflamed
106
On our assessment of a child suspected of having "croup" what might we see symptom wise as the airway narrows?
| Croup syndrome
1. Inspiratory stridor
2. Retractions
3. Increasing respiratory distress and hypoxia which can lead to respiratory acidosis and respiratory failure.
107
What lung sounds are you likely to hear in an URI?
Stridor
108
What lung sounds might you hear in a lower airway obstruction?
Wheezing
109
What parent education can we give for "mild croup"
| croup syndrome?
1. Countinously observe respiratory status
- Monitoring for worsening symptoms
2. Cool-air vaporizer
- Or cool-air environment
3. Oral hydration and nourishment
4. Comfort measures
- Keep them calm dont let them work up any emotions
110
What is our managment of "croup" if the child is hospitalized?
| Croup syndrome
1. Cool mist humidity and o2 as needed
2. pulse ox
3. hydration
- IV fluids as needed
4. Nebulized epinephrine
5. Corticosteriods
- Will help with the inflammation of the larynx and trachea
111
What do we need to know about Nebulized epinephrine?
Many places have a policy regarding the admin of this drug... covenant is as follows
1. One treatment in clinic child can go home
2. Two treatments child will be sent to the ED
3. Three or more treatments they will be admitted
112
Why arent kids given antibiotics given for "croup"
It is viral
113
What is respiratory syncytial virus "RSV" and bronchiolits?
| Lower Resp. Tract
It is a highly communicable acute viral infection with maximum effect at the bronchiolar level
114
What age group does RSV effect most?
Kids under 2 but can occur and reoccur in other ages
115
How long can RSV live on surfaces?
RSV can live on surfaces up to 7 hours and hands up to 30 mins.
116
What is the intubation period for RSV?
2-8 days
117
What is the peak season for RSV?
Nov-april but it has started to be seen as early as august and going through april
118
What is the most common cause of hospitalization in children under 1?
RSV
119
During our inital assessment of a child with RSV what might we see?
1. Hx of a URI
2. Rhinorrhea (very SNOTTY)
3. Pharyngitis
4. Coughing, Sneezing
5. Wheezing
6. Possible ear or eye drainage
7. Intermittent fever
8. Refusal to nurse or bottle feed
9. Copious nasal secreations
120
During our assessment of a child with RSV what symptoms may present with progression of the infection?
1. Increased coughing and wheezing
2. Retractions
3. Crackles
4. Dyspnea
5. Trachypnea
6. cyanosis
7. diminished breath sounds
This is where we wil see hospitalization.
121
During our assessment of a child with severe RSV what are some s/s we might see?
1. Tachypnea >70 breaths/min
2. Listlessness
3. Apneic spells
4. Poor air exchange
5. Poor breath sounds...
6. may need intubattion
122
What is the patho of RSV?
1. Replication of the virus in the nasopharnyx
2. Spreads to the small bronchilar level and epitheileal lining of the airway and lungs and then into the lower resp. tract
3. Infection starts 1-3 days after getting there
123
How is RSV diagnosed
1. Nasopharyngeal secreation ~ RSV antigen detection
2. Results usually available within the hour
124
What interventions can we implement for a child with RSV?
1. Contact isolation-- esp. until we know what is going on with the patient
2. Monitor airway
3. Humidified o2 w/pulse oxiemetry
4. Hydration-,IV if oral is not tolerated
5. Nasal suctioning as needed
6. Antibiotics, possibly-- sometimes we will see a cobacterial infection--- antibiotics not normally given for RSV alone
7. Bronchodilators,possibly--- will see how they respond with a single tx and determine from there if they will continue
8. Racemic Epi, possibly-- to help open up airways for kids who will need mechanical ventilation
9. Ribavirn-- antiviral med-- not a go to med
125
What is important to keep in mind with patient assigment and RSV?
As the nurse for a patient with a RSV kiddo it is important to avoid having patients on chemo tx.
126
Why is Ribavirin not a go to med for RSV?
Cost and it is an aerosol so it has a chance of also affecting those who administer it
127
More fluids... do what to the secreations?
Thin
128
How can we prevent RSV?
1. Enourage breastfeeding
2. Avoid tobacco and smoke exposure-- lung irritant
3. Good handwashing
4. Palivizumab (synagis)
- Monthly IM injection for high risk infants given novemeber- march
129
What drug can be given to high risk infants to help decrease the risk of hospitalization of RSV?
Palivizumab (synagis)-- dosent prevent illness
130
What is asthma?
Chronic inflammatory reactive airway disease
131
How is asthma categorized?
4 categories based on symptom indicators of disease severity
132
80-90% of children have their first symptoms of asthma before the age of....____ or _____?
4 or 5
133
What is intermittent Asthma?
less than 2 episodes a week
134
What is mild persistent asthma?
More than twice a week but not daily
135
What is Moderate Persistance asthma?
Daily symptoms occur w/ exasturbations twice a week
136
Wht is severe persistance asthma?
Symptoms occur along w/ frequent exasturbations that limit the childs quality of lfe
137
What are risk factors of asthma?
1. Hx of asthma in the family
2. Hx of allergies-- can cause inflammation then mucous
3. Gender-- boys until adolescents
4. Smoking or exposure to secondhand smoke
5. Maternal smoking during pregnancy
6. Ethnicity-- African Americans are at greatest risk
7. Low Birth weight-- preterm--> ties to underdeveloped lungs
8. Being overweight
138
What can trigger asthma?
1. Allergens (outdoor/indoor/irritants)
2. Excerise-- mouth breathing and air temp
3. Cold air or changes in weather or temp
4. Environmental change
5. Cold and infections-- creates airway issues
6. Animals (cockroach)
7. Medications-- asprin, NSAIDS, bblockers
8. Strong emotions
9. Foods and food additives-- nuts, milk allergies... preservatives
139
What are the "classic" or most common signs of asthma?
1. Shortness of breath
2. Wheezing
3. Non-productive coughing
- Worsens during nighttime
4. Chest tightness/pain
5. Increased restlessness/anxiousness
140
How is asthma diagnosed?
Diagnosis is based on
1. Clinical manifestations
- Non productive cough, SOB, wheeze, rash on chest and neck, lips may become more dark purple or red, nail beds may appear more cynotic, may tripoid, pant when speaking.
2. history
- who what when where and how...
3. physical
- lung sounds... wheezing present and possibly crackles
- Look for accessory muscle use
4. cbc
- **WBC can be elevated during an acute asthma attack.. if bands are elevated this could indicate resp. infection**
5. CXR
6. PFT
7. Peak expiratory flow rate (PEFR)
8. Skin Prick testing (SPT)
9
141
What are the different types of asthma medications?
Bolded is most important.. do not need to know specific drugs
1. **Corticosteriods (anti-inflammatory)**
- Fluticasone (flovent)-INH
- Budesondie (pulmicort)-INH
2. **Mast Cell Stabilizer (anti-histamine)**
- Cromolyn sodium (intal)- INH
- Nedocromil (tilade)-INH (not used in children younger than 5)
3. **Long-active b2 agonists "LABA" (bronchodialtor))**
- Salmeterol (servent)-INH
- Formoterol (foradil)-INH
4. **Leukotriene modifers (blocks inflammatory and bronchospasm)**
- Montelukast (singulair)- po not used in children younger than 12mo.
- Zafirlukast (accolate)-po not used in children younger than 7
5. **Monoclonal antibodies (blocks binding of immunoglobulin E to mast cells to inhibit inflammation)**
- Omalizumab (xolair)-- subq not used in children under 12
6. **Methylaxanthine (bronchodilator)**
- Theophylline-- PO
- Aminophylline -- IV
- Used primarly in the ED when the child is not responding to maximal therapy
7. **Short-Acting B agonists "SABA" (Bronchodialator)**
- Albuterol (Ventolin)-PO, INH
- Levalbuterol (xopenex)- INH
- Terbutaline- PO, INH, SQ, IV
8. **Anticholinergics (bronchodilator)**
-Ipratropium Bromide (atrovent)
9. **Corticosteriods (Anti-inflammatory)**
- Methylprednisolone (solu-medrol, prednisone)-- IV, PO
## Footnote
Need to know the short acting b2 agonists
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What are MOA's of long and short term asthma medications
2. **Quick relief (rescue) medications**
- To treat symptoms and exacerbations for emergent use
1. **Long-term control (prevenative) medications**
- To achieve and maintain control of inflammation-- taken daily
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What should we know about short acting b2 agonists "saba" (bronchodilators)
This is our
1. Albuterol (ventolin)--PO,INH
2. Levalbuterol (xopenex)-INH
3. Terbutaline- PO, INH, SQ, IV
Given for exacerbations it is a quick relief medication... and given in conjunction to long term meds.
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What is exercise-induced bronchospasm (EIB)?
It is an acute, reversible airway obstruction that develops during or after vigorous exercise. Usually rare in activities that require short burts of energy.
145
How might exercise-induced bronchospasm (EIB) present?
Cough, SOB, chest pain or tightness, wheezing, endurance problems
Usually seen in our distance runners, soccer and basketball players. Our more vigiorous long term sports
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What type of asthma medication might a child with exercise-induced bronchospasm (EIB) be prescribed?
Prophylactic quick relief (rescue) medication
Taken before exercise.
Typically albuterol or a short acting beta 2
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Inpatient care of a asthmatic child would include...
1. Position of comfort
2. Supplemental o2--keep o2 sats above 90
3. Short-Acting b2 agonists (quick-relief medications)
- Anticholinergic, may be added
4. Corticosteriods
5. Hydration
6. Reassurance, support, education
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What is status Asthmaticus?
Repiratory distress despite vigorous theraputic managment
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Treatment for Status Asthmaticus includes?
1. Supplemental o2- Keep Sats above 90%
2. Inhaled nebulized short acting b2 agonists
- 3 treatments 20-30 mins apart
- Contionous IV if needed
3. Anticholinergic
4. corticosteriods
5. IV fluids
6. magnesium sulfate, possibly
- Potentate muscle relaxent that will decrease the inflammation of the lungs
7. Heliox, possibly
- Combo of helium/oxygen which helps decrease airway resistance
8. Ketamine
- Anasthetic that helps relax the body.
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What is heliox?
| Asthma
Used to treat status asthmaticus. Combination of helium/oxygen that decreases airway resistance
151
What is Ketamine?
| Asthma
Anasthetic used to treat status asthmaticus. Helps relax the body
152
If a child is in status asthmaticus and they suddenly become quiet what is happening?
They are becoming hypoxic and will likely need to be intubated soon.
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What are different ways to deliever asthma medications?
1. Metered dose inhaler (MDI)
- Spacer allows them to take the medication in more slowly as the medicene will sit in the chamber
2. Nebulizer
3. MDI/MDI with Spacer
4. Nebulizer
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What should we know about the asthma management tool:
Peak Expiratory FLow Meter (PEFM)
1. Used in children 5 and older
2. Uses the child's personal best
- Zones for asthma managment
- Green zone-mild (80-100%)
- yellow zone- moderate (50-80%)
- Red zone- severe (<50%)
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What is the asthma action plan?
Plan based on the peak flow meter results using the childs best to formulate a action plan for when asthma is mild, moderate, in severe. Helps parents know when and what medication to use when.
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What is some prevention education we can teach asthamtic patients?
1. Recognition and avoidance of triggers
2. Recognize s/s of exacerbation
3. Compliance with asthma action plans
- Medications and use of delivery devices
4. Good handwashing
5. Up-to-date immunizations
6. Exercise
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What is cystic fibrosis (CF)?
Autosomal recessive disease that causes exocrine gland (mucus producing glands) dysfunction
Caused by a mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gener
Results in exocrine gland secreting mucus that is thick and sticky
158
True or false: CF is more common in black males?
False-- More common in caucasians
159
True or false: CF is progressivve and incurable?
True
160
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What is the patho of CF?
In CF, the exocrine glands produce thick and sticky mucus which leads to obstruction of the affected organs altering their function
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What organs does CF primarly affect?
1. Skin
- Salty skin due to an increase in sodium chloride
2. Resprirtory
- Can lead to progressive lung disorders
3. GI
- pancreatic enzyme and fibrosis which can cause blockage in the pancreases making it where they cant break down fats
4. Reproductive
- Late menses or sterile in men
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How is CF diagnosed?
1. Family history
2. Genetic testing
3. Newborn Screening
4. Sweat chloride test (golden standared test)
5. Other diagnostic tests include:
- Chest x ray
- Pulmonary function tests
- Stool analysis-- would have lots of fat in stool?
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What is a normal sweat chloride concentration?
<40 mEq/L
165
What is a postive sweat chloride concentration?
above>60 mEq/L
166
How is the sweat chloride test done?
1. A mild electrical current pushes medicine into skin to cause sweating
2. Sweat is collected, and salt content is measured
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What respiratory symptoms may we see on our assessment of a CF patient
Symptoms produced by stagnation of mucus in airway
1. Persistent coughing
-May be productive
2. Recurrent resp. tract infections
- Pneumonia and bronchitis
3. Wheezing
4. SOB
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What are our respiratory interventions for CF patients?
Prevent or minimize pulmonary complications
1. airway clearance therapies w/chest physiotherapy
2. Inhaled medications
- Bronchodilator
- Dornase alfa (pulmozyme)
3. Ecercise-- stimulates mucous secreations and helps clear mucous out
4. Antibiotics as needed
169
What should we know about Dornase Alfa (pulmozyme)
1. Given daily during nebulizer tx.
2. Helps decrease the viscosity of the mucus
3. Done with chest physiotherapy as well
170
What are some GI symptoms we may see on our assessment of a patient with CF?
1. Meconium IIeus at birth
- Earliest postnatal manifestations... small intestine is blocked w/thick poop
2. Pancreatic fibrosis: Impaired digestion and absorption of nutrients
- Fat-soluble vitamins (ADEK)
- Steatorrhea (excessie fat, greasy stools)
- Foul-smelling bulky stools
- Failure to gain weight and delayed growth patterns
3. Diabetes Mellitus
- Due to the blockage in the pancreases it leads to a insulin insufficiency
4. Rectal prolapse as a result of large bulky stools
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What are some gastrointestinal interventions for CF patients?
1. Replace pancreatic enzymes
- With meals and snacks to ensure digestive enzymes are mixed with food
- The more fat the more enzymes you will need so dosage will vary.
2. High-calorie, high-protien, high-fat diet
- Because they are only getting partial amounts of the nutrition they need
3. Vitamin A,D,E,K and multivitamins
- Because they are only getting parts of the nutrition they need from their diet
4. Laxatives or stool softners
- Prevent rectal prolapse from large bulky stool
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How do we fix rectal prolapse?
Guide rectum back with a glove and lubercated finger
173
What education should we provide for CF?
1. CF is a multidisciplinary approach
- MD, Nurse, Resp therapist, Nutritionalist, social services
2.Infection prevention
- Discoraging close contact with other CF children
- Up-to-date immunizations
- Notify provider for s/s of infection
3. Encourage compliance with care plan
4. Encourage physical activity
