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PEDS > week 5 > Flashcards

week 5 Flashcards

1
Q

Anatomical differences - kids vs adults

A
  • smaller nasal-pharynx, easily occluded with infection
  • lymph tissue grows rapidly in early childhood, slowly atrophies in adolescents
  • large tongue small mouth easily occluded
  • long floppy epiglottis
  • larynx and glottis are higher up on the neck increasing risk for aspiration
  • cartilage in neck is flexible (when neck is bent airway can collapse)
  • diaphragm is main muscle to breath in children, others less developed –/> hard to compensate for edema spasm and trauma
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2
Q

Anatomical differences - kids vs adults - nasal parynx

A
  • occludes easily when infected
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3
Q

Anatomical differences - kids vs adults - lympth tissue

A

grows faster in early childhood, atrophies in adolescents

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4
Q

Anatomical differences - kids vs adults - tongue

A

larger tongue, smaller mouth = easily occluded

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5
Q

Anatomical differences - kids vs adults - epiglottis

A

long floppy epiglottis –> aspiration

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6
Q

Anatomical differences - kids vs adults - larynx and glottis

A

higher up = increased risk for aspiration

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7
Q

Anatomical differences - kids vs adults - cartilage in neck

A

flexible –> when neck is bent airway can collapse

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8
Q

Anatomical differences - kids vs adults - diaphragm

A

main muscle for breathing (others less developed)
= less able to compensate for edema spasm trauma

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9
Q

Airway infant - normal vs edema

A
  • normal = 4mm
  • edema from sickness = 1mm
  • decreased X-sectional area = 75%
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10
Q

Respiratory assessment - what to ask (4)

A
  • family history of lung disease
  • vitals
  • audible inspiratory and expiratory breath sounds
  • retractions
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11
Q

Respiratory assessment - vitals (12)

A
  • resp rate is not just a number
  • assess rate depth and ease of respirations
  • auscultation
  • are breath sounds equally bilaterally
  • do they go all the way to bases
  • do you hear any adventitious sounds = wheezes, fine/course crackles, referred upper airway noise
  • how hard is the patient working?
  • tachypnea
  • patients colour
  • cough
  • behavioural change
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12
Q

Respiratory assessment - audible inspiratory expiratory breath sounds?

A
  • stridor - grunting on expiration
  • high pitched musical stridor on inspiration –> foreign body aspiration
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13
Q

Stridor

A

grunting on expiration

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14
Q

High pitched musical stridor on inspiration

A

foreign body aspiration

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15
Q

Respiratory assessment - retractions (5)

A
  • tracheal tug
  • intercostal
  • substernal
  • subcostal
  • scalene retractions
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16
Q

Tachypnea

A
  • can child articulate without having to catch his breath
  • paradoxical breathing/seesaw breathing
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17
Q

Patient’s colour - respiratory

A
  • mucous membranes or skin colour
  • pink pale, cyanotic, mottled
  • crying make it better or worse
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18
Q

Cough

A
  • productive/non-productive
  • seal like-croup
  • forceful/weak moving secretions or are they pooling
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19
Q

Behavioural change - respiratory

A

decrease in LOC

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20
Q

Respiratory distress vs failure - airway patency

A

RD = open and maintainable
RF = not maintainable

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21
Q

Respiratory distress vs failure - Breathing (3)

A

RD
- tachypenea
- increased effort-decreased effort
- good air movement
RF
- bradypnea
- decreased effort-apnea
- poor to absent air movement

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22
Q

Respiratory distress vs failure - circulatory (2)

A

RD = tachycardia, pallar
RF = bradycardia, cyanosis

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23
Q

Respiratory distress vs failure - LOC

A
  • RD = anxiety, agitation
  • RF = lethargy, unresponsiveness
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24
Q

Upper airway obstruction - breath sounds

A
  • stridor (typically inspiratory)
  • barking cough
  • hoarseness
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25
Q

Lower airway obstruction - breath sounds

A
  • wheezing (typically expiratory)
  • prolonged expiratory phase
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26
Q

Lung tissue disease - breath sounds

A
  • grunting
  • crackles
  • decreased breath sounds
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27
Q

Disordered control of breathing - breath sounds

A

normal

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28
Q

RSV - goals of nursing care

A
  • suction q1hr for secretions (esp before feeding)
  • maintain fluid volume
  • CPAP or BIPAP - helps with pressures, open lungs, clear secretion
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29
Q

Cystic Fibrosis - goals of nursing care

A
  • complicated genetic condition, growth curves
  • life expectancy in Canada vs US is 15 years different
  • impacts endocrine, GI, respiratory, reproductive, etc
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30
Q

Respiratory case study: 5yo male presents with chronic cough
- cough is productive increased at night
- worse with exercise and upper respiratory infections
- growth normal
- chest x rays normal except for mild hyperinflation

A

Asthma!!!

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31
Q

Asthma - what

A
  • chronic inflammatory disease of airway
  • increased 40% in last decade
  • typically develops in childhood, 50% before age 3, majority before 8 y/o
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32
Q

asthma - challenge with ICU

A

CAN’T intubate!! lungs are too hyper-inflated

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33
Q

Asthma - pathogenesis (6)

A
  • airway inflammation contributing to airflow limitation
    • bronchioconstriciton
    • edema
    • chronic mucus plugging
    • airway wall remodeling
  • leads to bronchial obstruction
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34
Q

Normal airway vs asthmatic airway

A
  • bronchoconstriction due to edema !
  • sludgy mucus plugfs
  • muscles are constricted
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35
Q

challenge with Treating asthma

A
  • ventalin = bronchodilator
  • but can only open airways so far… like balloon with elastics on it and trying to blow it up
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36
Q

Asthma - physical exam findings (4)

A
  • wheezing
  • crackles in lung
  • forced expiratory phase
  • muscle retractions (often can be normal)
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37
Q

Diagnostic studies for asthma

A
  • chest X-ray (will diffuse hyper inflation)
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38
Q

Wheezing + asthma (6)

A
  • localized or diffuse airway narrowing or obstruction from larynx to small bronchi
  • high pitched whistling sound made while breathing
  • associated with difficulty breathing
  • presents on expiration or inspiration
  • absence of wheezing in asthmatic = improvement of bronchoconstriction, or severe widespread airflow obstruction
  • “silent chest” = sign of respiratory muscle fatigue and failure leading to status asthmaticus
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39
Q

PRAM scoring (pediatric respiratory assessment measure) - assesses what (5)

A
  • suprasternal retractions
  • scalene muscle contractions
  • air entry
  • wheezing
  • oxygen saturation
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40
Q

PRAM scoring - suprasternal retractions

A

absent = 0
present = 2

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41
Q

PRAM scoring - scalene muscle contractions

A

absent = 0
present = 2

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42
Q

PRAM scoring - air entry

A

normal = 0
decreased at base = 1
widespread decrease = 2

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43
Q

PRAM scoring - wheezing

A

absent = 0
expiratory only = 1
expiratory and inspiratory = 2
audible without stethoscope/silent chest = 3

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44
Q

PRAM scoring - O2 sat on room air

A

> 95% = 0
92-94% = 1
<92% = 2

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45
Q

PRAM scoring - what is a concerning score

A

6 or higher

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46
Q

Asthma treatment - at home (4)

A

1) bronchodilators (short acting ventolin/salbutamol)
2) leukotriene modifiers (singulair/montelukast)
3) inhaled corticosteroids (fluticasone/Flovent)
4) combination therapy (inhaled steroid and long-acting bronchodilator)

47
Q

Asthma treatment - in hospital (4)

A

1) Atrovent/Ipratropium bromide (anticholinergic bronchodilator)
2) dexamethasone (systemic steroids)
3) salbutamol nebulizers via IV
4) magnesium sulfate via IV

48
Q

when asthmatics should come in to hospital

A

puffers ever 4 hours

49
Q

Salbutamol side effect

A

makes Heart race (tachycardia)

50
Q

Asthma and exercise (5)

A
  • exercise can trigger asthma
  • symptoms are worse with cold dry air
  • exercise helps lung function better and prevent obesity
  • as long as asthma is well controlled and short acting bronchodilator is used before, children with asthma should be able to do sports
  • pulmonary function testing best first, then exercise testing
51
Q

Respiratory case: 4 month old infant brought to ER because of lethargy. Physical exam finds
- 24 week preemie with chronic lung disease, patent ductus arteriosus (PDA), apnea of prematurity
- occasional apneic episodes with feeds, desats to 80s and bradycardia
- now 4 months of age (41 weeks gestational age)
- baseline O2 sats are normal

A

diagnosis - apnea of infancy

52
Q

Apnea of infancy - what (4)

A
  • unexplained episodes of cessation of breathing for 20 seconds or longer, OR a shorter respiratory pause associated with bradycardia, cyanosis, pallor, and/or marked hypotonia
  • called apnea of prematurity when present in infant less than 37 weeks gestational age
  • usually ceases by 37 weeks post-menstrual age but may persist for several weeks beyond term
  • extreme episodes usually cease at 3 weeks post-conceptional age
53
Q

Apparent Life-Threatening Event (ALTE) (5)

A
  • Episode in an infant that is frightening to observer and is characterized by a combo of
    • apnea
    • colour change
    • unresponsive
    • change in muscle tone, choking, gagging
54
Q

Prematurity (3)

A
  • preterm infants -= greater risk of extreme apnea episodes
  • risk decreases with time, ceasing at approx. 43 weeks post-menstrual age
  • in infants with recurrent significant apnea monitoring may be considered
55
Q

Obstructive sleep apnea (what)

A
  • disorder of breathing during sleep characterized by a) prolonged partial upper airway obstruction, and/or b) intermittent complete obstruction that disrupts ventilation during sleep
  • combo of structural and neuromuscular factors
  • dynamic process
  • site of airway collapse in children most often at level of adenoid
56
Q

Prevalence of obstructive sleep apnea (3)

A
  • children all ages
  • most common in preschool-aged children (when tonsils and adenoids are largest in r/t underlying airway size
  • estimated prevalence rates of approx. 2%
57
Q

Obstructive sleep apnea - high risk populations (5)

A
  • obesity
  • downs syndrome
  • Prader Willi syndrome
  • neuromuscular disease
  • craniofacial anomalies
58
Q

Respiratory case -
- 6 y/o female presents to ER after one week nasal congestion adn mild cough, two days ago developed high fevers, chills, increased cough
- ill appearing, tachypneic, febrile
- crackles on exam over right posterior lung fields
- no prior pneumonia or wheezing
- FHx of asthma
- no recent travel out of country
- WBC 35,000
- white-out on X-Ray of right lung

A

Right upper Pneumonia

59
Q

Pneumonia - what (3)

A
  • inflammation of lung parenchyma
  • portion of lung involved in gas transfer
  • alveoli, alveolar ducts, respiratory bronchioles
60
Q

Pneumonia - comon cause

A
  • respiratory virus in first years of life
61
Q

pneumonia - risk factors (2)

A

daycare
cigarette smoking

62
Q

Pneumonia - clinical signs (10)

A
  • shaking chills
  • high fever
  • cough
  • chest pain
  • mild URI
  • decreased appetite
  • abrupt onset high fever
  • rusty-coloured sputum
  • respiratory distress
  • cyanosis
63
Q

Pneumonia - physical exam (6)

A
  • retractions
  • dullness to percussion
  • tubular breath sounds
  • rales
  • diminished tactile and vocal fremitus
  • decreased breath sounds
64
Q

Pneumonia - lab findings (5)

A
  • leukocytosis with left shift
  • WBC <5000/mm3 (poor prognosis)
  • ABG: hypoxemia
  • bacteremia on blood culture
  • positive sputum culture
65
Q

Mild pneumonia clinical features (temp, respirations, mental status, colour, feeding, HR, cap refil)

A
  • temp <38.5
  • mild or absent resp distress
  • increased RR (but moderately)
  • mild or absent retractions
  • no grunting
  • no nasal falring
  • no apnea
  • mild SOB
  • normal colour
  • normal mental status
  • normozemia (O2 sat >92 RA)
  • normal feeding (infants) no vomiting
  • normal HR
  • cap refil <2 seconds
66
Q

severe pneumonia clinical features (temp, respirations, mental status, colour, feeding, HR, cap refil)

A
  • temp >38.5
  • moderate to severe respiratory distress (infant >70, children >50)
  • moderate/severe suprasternal, intercostal, subcostal retractions
  • severe difficulty breathing
  • grunting
  • nasal flaring
  • apnea
  • significant SOB
  • cyanosis
  • altered mental status
  • hypoxemia <90 percent at RA
  • not feeding (infants) S/S of dehydration (older children)
    -tachycardia
  • cap refil >2 seconds
67
Q

Complications of pneumonia (6)

A
  • empyema (purulent drainage in pleural space)
  • pleural effusion
  • pericarditis
  • meningitis
  • osteomyelitis
  • metastatic abscesses
68
Q

Treatment of pneumonia - all children (7)

A
  • decision to hospitalize based on severity of illness and home environment
  • can often treat as outpatient
  • patients with empyema or pleural effusion should be hospitalized
  • oxygen
  • thoracentesis
  • chest tube drainage
  • decortication
69
Q

Treatment of pneumonia - neonates (3)

A
  • parenteral antibiotics (ampicilin, gentamicin)
  • treat as rule out sepsis
  • once stabilized, they can be discharged
70
Q

Respiratory case - 2 month old infant brought to ER with persistant cough and difficulty breathing
- audible stridor, harsh honking cough, suprasternal subcostal cest wall retractions
- Upper Resp Infection symptoms. low grade fever, nontoxic appearing

A

whooping cough?

71
Q

Stridor - what (3)

A
  • harsh, high-pitched predominantly inspiratory sound produced by partial obstruction of airway, resulting in turbulent airflow
  • associated with degrees of difficulty in breating
  • usually associated with suprasternal retractions, when severe with intercostal, subcostal, substernal
72
Q

Causes of stridor in infants and children - nasopharynx

A
  • choanal atresia
  • thyroglossal cyst
  • hypertrophic tonsils
  • retropharyngeal or peritonsillar abscess
73
Q

choanal atresia

A

narrowing of back of nasal cavity c

74
Q

retropharyngeal or peritonsillar abscess

A

tonsil stones

75
Q

Causes of stridor in infants and children - larynx

A
  • laryngomalcia
  • viral croup
  • vocal cord paralysis
  • laryngeal stenosis
  • laryngospasm
  • vocal cord dysfunction
76
Q

Laryngomalcia

A

laryngeal web, cyst, or laryngocele = noisy breathing
falls in, blocks the airway

77
Q

Viral croup

A
  • spasmodic croup
  • epiglottitis
78
Q

Causes of stridor in infants and children - trachea

A
  • subglottic stenosis
  • hemangioma
  • forein body
  • tracheomalacia
  • bacterial tracheitis
  • external compression
79
Q

Acute laryngotracheobronchitis - etiology

A
  • parainfluenza virus 1, 2, 3
  • respiratory syncytial virus
  • rhinovirus
  • influenza virus a
  • adenovirus
80
Q

Acute laryngotracheobronchitis - epidemiology

A
  • fall and early winter
  • more common in boys
  • mostly at night
  • duration from hours to days
81
Q

Recurrent (spasmodic croup) (7)

A
  • 6% of children
  • not associated with obvious infection
  • abrupt onset, usually during sleep
  • barking cough, hoarsness, stridor
  • usually resolves within hours
  • may be a hypersensitivity reaction
  • associated with airway hyper-reactivity
82
Q

Epiglottitis - what (5)

A
  • threatening infection
  • incidence is 10-40 cases per 1 million
  • widespread vaccination against haemophilus influenzae type B and has decreased incidence dramatically
  • age 2-4 years
  • various organisms can cause it streptococcus pneumoniae, haemophilus parainfluenzae, varicella, etc.
83
Q

Epiglottitis symptoms (6)

A
  • sore throat
  • muffling or changes in voice
  • difficulty speaking
  • high fever
  • dysphagia
  • drooling
  • respiratory distress
84
Q

treating croup

A

treat with nebulized epi and puffers of epi to help vasoconstrict everything there to open up airway
- q1hr
dexamethozone (kicks in in 4 hours)

85
Q

What is cystic fibrosis (what, prevelance, symptoms, complications)

A
  • genetic disorder impacting CFTR gene
  • most common debilitating disease of childhoodd-
  • results in thickened secretion of sweat glands, GI tract, pancreas, respiratory tract, exocrine tissues
  • complications = obstruction, chronic infection, tissue damage, resp failure
86
Q

Cystic fibrosis - pathophysiology - respiratory (3)

A
  • thickened mucous
  • secretions plug tubes in lungs
  • difficulty clearing secretions
87
Q

Cystic fibrosis - pathophysiology - pancreas and digestive (3)

A
  • bile ducts, intestinal glands, gal bladder obstructed by mucous
  • pancreatic enzyme activity lost
  • malabsorption
88
Q

Cystic fibrosis - pathophysiology - integumentary (4)

A
  • sweat glands produce too much chloride
  • salty taste of skin
  • electrolyte imbalance
  • dehydration
89
Q

Cystic fibrosis - pathophysiology - other complications

A

fertility issues

90
Q

complications of CF (8)

A
  • hemoptysis
  • pneumothorax
  • bacterial colonization
  • intestinal obstruction
  • GERD
  • diabetes
  • portal hypertension
  • decreased fertility
91
Q

Diagnosis of cystic fibrosis

A
  • newborn screening panel
92
Q

Presentation of patient with cystic fibrosis (9)

A
  • respiratory infections
  • poor weight gain
  • pancreatic insufficiency
  • “sweat test”
  • persistent cough with thick sputum
  • foul smelling greasy stools
  • malnutrition
  • dehydration/electrolyte imbalance
  • nasal polyps
93
Q

Non-phamacological orders for patient with CF

A
  • contact isolation
  • vitals q12hr
  • physiotherapy to mobilize secretions
  • CF diet (high fat high protein)
  • Pancreatic elastase stool test
  • Pulmonary function test
94
Q

Drug therapy for cystic fibrosis (9)

A
  • ANTIBIOTICS - oral, inhaled/nebulized, IV
  • bronchodilators (salbutamol, levalbuterol)
  • mucous thinners (hypertonic saline, dornase alfa)
  • CFTR modulators (ivacaftor, lumacaftor, tezacafter, etc)
  • anti inflammatorys (steroids, NSAIDs)
  • oral pancreatic enzymes (pancrelipase)
  • acid reducing meds (omeprazole)
  • stool softener (polyethylene glycol)
  • oxygen therapy
95
Q

Goals for cystic fibrosis management (2)

A
  • nutrition management
  • airway clearance techniques
96
Q

Cystic fibrosis potential surgeries/procedures (5)

A
  • bowel surgery
  • nasal and sinus surgery
  • lung transplant
  • liver transplant
  • non-invasive ventilation
97
Q

Life expectancy - CF

A
  • median survival 50 years old
98
Q

What is dornase alfa used for

A

enzyme that decreases viscosity of mucus present in the lungs

99
Q

what is salbutamol used for

A

bronchodilation

100
Q

what is tobramycin

A

antibiotic used to treat bacterial infections in respiratory tract

101
Q

what is pancrelipase

A

enzyme med that aids food digestion

102
Q

why do CF patients take vitamin d supplements?

A
  • CF –> decreased metabolism of vit D = defficiency
  • promote bone health, improve lung function
103
Q

Omeprazole role

A

proton pump inhibitor to decrease production of gastric acid
- allow for pancreatic enzymes to function better

104
Q

ursodiol use

A
  • gallstone dissolusion agent
105
Q

piperacillin tazobactam use

A

antibiotic (penicillin and beta-lactamase inhibitor) to treat bacterial infections

106
Q

SMOFlipid

A
  • a lipid emulsion providing fatty acids to meet metabolic demands
107
Q

Bronchiolitis and Respiratory Syncytial virus - what

A
  • lower respiratory tract infection caused by virus/bacteria = inflammation/obstruction of bronchioles
108
Q

Pathophysiology of RSV (3)

A
  • mucus hyper-secretion
  • cell wall thickening
  • smooth muscle contraction
109
Q

Diagnosis of RSV

A
  • children under 2, esp infants under 3 months
  • chest X ray –> hyperinflation, patchy atelectasis, inflammation
  • Labs = enzyme linked immunosorbent assay (ELISA) or immunoflurescent assay
110
Q

Management of RSV (3)

A
  • educate parents and caregivers to reduce exposure and transmission of disease
  • hand hygiene
  • limit exposure to crowds other children cigarette smoke
111
Q

Treatment of RSV (4)

A
  • humidified O2 (severe)
  • hydration (IV/oral)
  • nasal suctioning
  • fowler’s position
112
Q

Meds to treat RSV (4)

A
  • nebulized hypertonic saline
  • acetaminophen
  • vitamin D
  • nebulized salbutamol/ventolin
113
Q

Goals of care - RV (7)

A
  • care for equipment
  • med admin
  • head to toe (vitals, resp)
  • o2 support
  • client education
  • fluid and nutrition support
  • emotional suport

PEDS (9 decks)

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