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When is tonsillectomy indicated? x2
only difficulty eating or extreme breathing discomfort
What can happen if adenoids are enlarged? x2
eustachian tubes blocked, recurrent otitis media
What might you MD suggest if recurrent otitis media?
adenoidectomy
When in adenoidectomy indicated?
recurrent otitis media
What might bad breath suggest? Therefore what else?
mouth breathing, adenoid hypertrophy
What are most important labs to check r/t pre op tonsillectomy/adenoidectomy?
bleed & clotting time, pro-time
What's the last little thing to check for pre op for tonsillectomy/adenoidectomy (not bleeding)?
loose teeth
What position is best post op tonsillectomy/adenoidectomy?
abdomen or side
What two things to you tell kid pre op about what to expect post op tonsillectomy/adenoidectomy?
abd or side position, sore throat
What is imp to check for post op tonsillectomy/adenoidectomy?
hemorrhage
What are 2 most obvious early signs of post op hemorrhage r/t tonsillectomy/adenoidectomy?
freq swallowing, blood trickle from site
What do you do at 1st sign of hemorrhage post op tonsillectomy/adenoidectomy?
turn on side, call MD
What part change in VS indicates hemorrhage post op tonsillectomy/adenoidectomy?
^ pulse from norm or > 120 bpm
Offer what to hydrate post op tonsillectomy/adenoidectomy? How often?
chipped ice, 15-30 mL, Q15min
How and how much liquid do you offer post op tonsillectomy/adenoidectomy?
give large amounts, take in small amounts freq
How is it best to drink to cause less pain when drinking post op tonsillectomy/adenoidectomy?
take large gulps
Don't offer what 3 things r/t liquids post op tonsillectomy/adenoidectomy?
nothing red or brown, no straws, no gargling
What's a unique way to offer pain relief post op tonsillectomy/adenoidectomy?
tetracaine lollipops
How long does pt have significant pain post op tonsillectomy/adenoidectomy?
24 hours
How long, no firm foods post op tonsillectomy/adenoidectomy? h
2 wks
What do you teach re: mouth odor post op tonsillectomy/adenoidectomy?
may be present for a few days
What do you tell parents who call saying sm amt of bright red blood occured a week post op tonsillectomy/adenoidectomy? When should they call MD?
normal from scab being shed, call if more than 1 tsp
When can reg activity be resumed post op tonsillectomy/adenoidectomy?
1-2 wks
What's the following describe?: generalized dysfunction of exocrine glands characterized by thickened and tenacious secretions that occlude glandular ducts
CF
Is CF hereditary?
yup
What is the hereditary characteristics of CF?
autosomal recessive trait
What are the chances of kid getting CF if both parents are heterozygous for the trait?
25%
What are parts of the body prone to pathology r/t CF?
respiratory tract, pancreas, intestinal tract
Describe cough in CF pt if contract resp infection?
at first, dry hacking cough; then, loose and productive
How does CF disrupt digestion?
v pancreatic enzymes b/c plugged ducts lead to panc fibrosis
What are 2 common intestinal problems r/t CF?
meconium ileus, and maldigestion of foods, esp fats
What are stool like r/t CF?
steatorrhea (large, bulky, frothy), azotorrhea (foul smelling)
What is most common complication of GI tract in un-RX child w/ CF?
prolapse of rectum
What's happens w/ sweat in CF?
salty taste, salt "frosting" on skin
If kid has salt "frosting" on skin, what might it indicate?
CF
What's the highest priority NDx for CF?
ineffective airway clearance
What disease uses sweat test?
CF
What dx test is key to CF?
sweat test
When is sweat test unreliable? Why?
first 2 wks of life, NB don't sweat
What is the chemical in sweat that sweat test checks for CF dx?
chloride
What are ranges for sweat chloride r/t CF: normal?: suggestive?: positive?:
normal = < 40 mEq/L suggestive = 40-60 mEq/L positive CF = > 60 mEq/L
What is common response from parents when asked if child eats a lot r/t CF?
"He always eats, but never gains weight"
If parent says, "my kid always eats, but doesn't gain weight," what dx might it indicate?
CF
What do you suspect if when taking child hx you note: - failure to thrive - recurrent resp infections, - lrg bulky stools?
CF
What are 3 typical elements in medical hx of kid with CF?
- failure to thrive - recurrent resp infections, - lrg bulky stools
What do you you need to provide to clear secretions and control resp infections for CF? (general category of tx)
pulmonary tx
How do you take temp in CF pt?
axillary
What are 3 pulmonary tx for CF?
aerosol Rx, mist tent, chest PT
What's chest PT?
chest physiotherapy, postural and percussion to thorax to loosen secretions
What do you do before postural drainage in CF pt?
aerosol Rx
How often and how long to you do aerosol Rx for CF?
10 min BID
What do you use in aerosol rx for CF?
NS or include meds (bronchdilators, mucolytics)
Why do mist tent for CF?
reduce viscosity of secretions
In CF, what can you do to reduce viscosity of secretions?
mist tent
How can you remove thick secretions from lungs r/t CF?
Chest PT to all lobes
What should be given before CPT related to CF?
Bronchodilator. Opens the bronchi for easier expectoration.
When are inhalations treatments given for CF?
Given before postural drainage to help loosen secretions.
When should postural drainage be performed for CF?
Before meals, to avoid possibility of vomiting or regurgitating food.
In what order should postural drainage and CPT be performed for CF?
First postural drainage, THEN CPT. (postural drainage will mobilize secretions then CPT will expectorate them out.)
How often do you do chest PT?
Q1D and more if resp infection, or on arising or in the evening.
When do you do chest PT?
one hour before meals
What are 3 creative ways to do Chest PT?
wheelbarrow, stand on head, hang by knees
What are 3 NI r/t medication types for CF? (what do you give x2, and not give x1)
give Bronchodilators, may give expectorants, no antitussives
How much can kid exercise with CF?
as tolerated
Diet r/t CF? x5
high protein, high CHO, high calorie, maybe low fat, maybe extra salt PRN
How's the appetite r/t CF?
voracious
What are two things to supplement in diet r/t CF?
pancreatic digestive enzymes, vit ADEK
What do you give along with pancreatic enzymes?
antacids
In what form and how do you give Vit ADEK r/t CF?
water soluble form, double dose
What usu. causes death r/t CF?
pulmonary complications
What pathology increases as CF life expectancy increases?
insulin dependent DM
What increases as women w/ CF get pregnant?
risk of perinatal and maternal morbidity r/t resp problems
What does the following describe?: a chronic inflammatory disorder of the airways assoc w/ reversible, episodic airway obstruction
bronchial asthma
Asthma triggers include what foods?
chocolate, nuts, dairy; food additives; food dyes
What are two highly allergenic food products?
Peanuts and food dyes
What kind of breath sounds do you hear r/t asthma?
crackles and wheezes on expiration
What spasms during asthma attack?
bronchi and bronchioles
What causes v in pO2 during asthma attack?
trapped air in alveoli blocks fresh air
What are two types of asthmatic kids?
1. continually symptomatic w/ episodes of severe airway obstruction 2. no SOB or wheezing, only chronic cough (esp at night)
What's the progression of asthma attack?
1. usu. dry, hacking cough 2. then frothy, clear mucus 3. then SOB and tight feeling in chest 4. RR ^, expiratory phase longer, expiratory wheezes
What state is kid in as airway obstruction progresses?
irritable
Why does kid w/ asthma attack sit w/ shoulders hunched forward?
to facilitate use of accessory muscles
How does a kid facilitate use of accessory muscles during asthma attack?
sits w/ shoulders hunched forward
What might you see in kid w/ chronic asthma? x2
growth delays, and barrel chest
What's a good test to check how kid w/ asthma is doing?
Peak expiratory flow rate (PEFR)
What's PEFR? (what's it stand for and how do you do it?)
peak expiratory flow rate, measures the max flow of air that can be forcefully pushed out in 1 second
How often should you measure PEFR? Why? What's that called?
every day, to know the usual for child, personal best value
What are the ranges for the zones of peak flow rate?
Green zone: 80-100% Yellow zone: 50-80% Red zone: below 50%
What are sym of green zone of peak flow rate?
usu. sym free
What might it mean if kid is in yellow zone of peak flow rate?
asthma attack may be starting
What might it mean if kid is in red zone of peak flow rate?
is experiencing asthma exacerbation
What two types of meds does asthmatic have?
preventer meds, rescue meds
What are the best meds for nighttime asthma management?
Theophylline & Severent (Salmeterol)
What's the definition of "preventer meds" for kids with asthma?
long-term control meds, control inflammation
What's the definition of "rescue meds" for kids with asthma?
quick relief meds, treat sym and exacerbations
How do you use MDI? x3
use spacer, give one puff at a time, wait 1 min between puffs
If kid too young for MDI, what can they use?
nebulizer
What routes can asthmatic take steroids?
parenteral, oral, or aerosol
What are two complications of long-term use of steroids for kids w/ asthma?
Cushing's syndrome, and growth suppression
What med does asthmatic take before exercise or cold exposure?
cromolyn sodium, Serevent(Salmeterol).
What drug category is Cromolyn sodium? Why is it used for asthma?
NSAID, inhibits airway narrowing (during exercise or in cold)
What are two ex of B-adrenergic agonist meds for asthma?
albuterol, terbutaline
What are the category and uses of albuterol and terbutaline? (1 cat, 2 uses)
bronchodilators, used in acute attacks and to prevent exercise-induced asthma
What is the expected theophylline blood range?
5 to 15 mcg/ml.
What is best position for acute asthma?
High Fowler's
What meds do you give during acute asthma?
nebulized albuterol and corticosteroids, usu.
Why use spacer w/ asthma meds?
prevents oral yeast infection
What do you give as acute asthma begins to improve?
oral fluids
What temp for oral fluids for recovering acute asthma?
warm or room temp (cold can trigger bronchospasm)
What do you give for unresponsive status asthmaticus?
subcut epinephrine
How can you teach kid w/ asthma to breathe to v chance of attack? x2
thru nose, not mouth; cover nose and mouth w/ scarf or cupped hands
What can you teach to practice breathing for kid w/ asthma?
practice pursed lip and diaphragmatic exercises
What are some examples of pursed lip and diaphragmatic exercises?
blow bubbles, blow cotton balls or ping pon balls on a table, blow pin wheel, prevent tissue from falling by blowing it against a wall
What are 3 better sports to try for asthmatic?
swimming, baseball, gymnastics
What do the following describe?: an antigen-antibody reaction that follows an infection caused by group A beta-hemolytic step (not ARF)
Acute glomerulonephritis
What's another name for Group A beta-hemolytic streptococci?
Streptococcal pharyngitis, or Strep throat
What's another name for Strep Throat?
Group A beta-hemolytic strep
What can Group A strep cause?
ARF
What characterizes croup syndrome? (what's the resulting condition, where's it occur, what's its most common characteristics)
Acute infections of larynx or trachea causing hoarse cough and dyspnea
What usually causes croup?
virus
What causes epiglottitis? Is this form of croup preventable?
HIB (hamophilus influenzae bacteria). YES! Take the Hib vaccine!
What type of croup is not caused by a virus?
epiglottitis
What is likely to occur if a child contracts a particular kind of croup?
same kind of croup is likely to recur
How fast is onset of sym for epiglottitis?
rapid onset
What are the sym of the epiglottitis form of croup?
Emergency if acute !
Pulse ^
Inspiratory stidor (can't breathe in!)
Gagged (muffled voice), dysphagia, drooling!
Lacks cough and hoarseness ** IMPORTANT
Obstructed airway (why you cannot cough).
Tripod position
Tossing and turning (restless)
Indigo skin (cyanosis)
Temp ^ In a panic (frightened)
Severe sore throat
Why is acute epiglottitis an emergent condition?
rapid total airway obstruction may occur w/in minutes
What's are two signs a kid might have a sore throat?
drools saliva, tripod position (leaned forward, mouth wide, tongue out)
What is tripod position? Why do infants do it?
while sitting up, leans forward with mouth open and tongue out; sore throat
What's the characteristic and the name of the breath sound you hear from a kid with epiglottitis?
rapidly increasing inspiratory stridor
What's the sound of stridor in pt w/ epiglottitis?
frog-like croaking sound
What's immediate Rx for kid with epiglottitis? 2x
child upright, maybe 02
What is kept with epiglottitis pt AT ALL TIMES?
intubation equip.
What is main way to dx epiglottitis?
x-ray neck
What must be readily available as MD does direct visualization of epiglottis?
resuscitation equip.
Besides x-ray, what's another way to dx epiglottitis? Who can do it?
Direct visualization of epiglottis, done only my MD
What two meds do you give for epiglottitis?
antibiotics and steroids
How do you give antibiotics for epiglottitis? For how long?
IV, then PO total of 7-10 days
Why are steroids given to epiglottitis pt?
v edema
When does swelling go down after beginning antibiotics for pt. w/ epiglottitis?
24 hours
What's LTB? What's the lay term for it?
acute laryngotracheobronchititis, viral croup
What kind of onset to symptoms of LTB have?
gradual
When does LTB often occur?
with or after URI
What type of croup syndrome has no cough associated w/ it?
epiglottitis
With any form of croup, what do you need to keep near the child at all times?
intubation equip.
What are three types of croup?
1. epiglottitis 2. LTB 3. spasmodic (midnight) croup
What are sym of LTB?
Vociferous cough (barking/brassy cough)
Increasing inspiratory stridor, gradual Retractions
Achromatic (pallor)
Labored respirations
Croaky (hoarse)
Restlessness
Off-color (cyanosis)
Unrestful (restless)
Pyrosis is mild (low grade fever)
What type of croup has rapid or sudden onset?
epiglottitis and midnight croup
What type of croup has gradual onset?
LTB
What croup is Rx with humidity?
viral croup (LTB and spasmodic croup)
What is the NI for viral croup besides keeping intubation equip. close?
high humidity cool mist
What is Rx for viral croup if stridor at rest?
racemic epinephrine
1. Why is epi given for viral croup? 2. What does this reduce the need for? 3. In how long does it work? 4. When do sym often recur?
1. v edema 2. reduces need for trache or intubation 3. 10-15 min 4. recur in 2 hrs
What type of croup may utilize epinephrine?
viral croup (LTB and spasmodic croup)
With spasmodic croup, of what are there paroxysmal attacks?
laryngeal obstruction
What are the symptoms of spasmodic croup related to LTB?
same as LTB, except no fever
What's another name for spasmodic croup?
midnight croup
When and how long do sym of spasmodic croup occur?
often last several hours at night
What sym might a kid with spasmodic croup wake up with in the morning?
cough and hoarseness
When and how long do sym of spasmodic croup usu. recur?
next 1-2 nights
What type of peds disorder might be relieved if taken out into the cool night air to go to ER?
spasmodic croup
What type of humidity is best for viral croup, cool or steamy?
cool
What is the cause of half of the cases of bronchiolitis?
RSV (respiratory syncytial virus)
How contagious is bronchiolitis?
very
How can RSV be prevented?
Hand washing, avoiding others with URI's, avoid smoking.
What does RSV cause?
bronchiolitis
Who is at high risk for RSV? 3x h
preemies OR kids with lung issues OR kids with heart issues
What's the Rx for bronchiolitis caused by RSV?
Ribavirin
What does Ribavirin Rx?
RSV
Pregnant nurses should not Rx kids taking what med?
Ribavirin
How is Ribavirin given? (also, w/ what 3 methods)
mist (via mask, tent or hood)
In what age range does bronchiolitis usually occur? When is the peak incidence?
usually 2-12 months, peaks at 6 mos.
What's often the first sign of hypoxia?
restlessness
What are symtoms of bronchiolitis? x12
Bone-dry (dehydrated)
Restlessness
O-shaped chest (barrel-shaped)
Frequent, dry cough ... thick nasal secretions
Hypoxia and dyspnea
Irritability
Obstructed breathing
Lung sounds (fine rales, expiratory wheezes)
Intercostal retractions
Tachypnea
Impending resp failure
Schnoz flaring
What's a resp rate you may expect with bronchiolitis?
60-80
What are two signs of impending respiratory failure with bronchiolitis?
severe inspiratory retractions, and sudden diminished or absent inspiratory breath sounds
What is it important to check for r/t inability to suck well?
dehydration
What are 7 signs of dehydration in infant?
weight loss, v urine output, ^ urine specific gravity, poor skin turgor, dry mucus membrane, depressed anterior fontanel, no tears with crying
What isolation precautions do you use for pt w/ bronchiolitis? What materials does that include? x3
airborne (respiratory); gown, gloves, mask
What do you implement for all infants with breathing problems?
airborne isolation precautions
What do you implement do help liquefy secretions and facilitate removal for pt with bronchiolitis?
high humidity, cool environment
What 3 things should you do regarding the high humidity environment of bronchiolitis pt?
wipe down canopy, have extra linens on mattress, change clothes & linens frequently
How often do you wipe down canopy for pt with bronchiolitis?
Q2 hours
How do you calculate micro drip?
cc/hr = gtts/min
What's the best way to measure fluid loss or gain for infant with bronchiolitis?
daily weight
Why is no unnecessary handling implemented for pt w/ bronchiolitis?
to promote rest
What are five interventions for pt w/ bronchiolitis?
isolation, humidity, hydration, rest, HOB
What elevation do you put the head of the crib for pt w/ bronchiolitis? What's an alternative to raising HOB?
30-40 degree; or use infant seat