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Peds Respiratory

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olanjones's version from 2017-02-22 21:48

Assessment & Evaluation Resp. Distress

Question Answer
respiratory distress can sometimes be what viral infection?myocarditis
Characteristics of face, position, behavior, energy expenditure during resp. distress?circumoral color changes more ominous; GRUNTING; flaring nasal passages; head bobbling; accessory muscles;
When is intubation imminent?Grunting and when infants/kids are not fighting provider anymore.
Tachypnea breaths per minute in a newborn?>60; Apnea is >20 seconds *listen for a full minute
Heart rate symptoms when respiratory distress is more ominous?Bradycardia (heart is not compensating anymore)
Cyanotic heart defect sxrespiratory sx such as pulmonary edema, rales, heart enlarged on xray (myocarditis)
Cyanotic heart defect interventionschange plan to bolus-loosens up secretions, wet diapers
Bolus amount cyanotic heart defects 5ml/kg up to 3x
Respiratory distress plan bolus amount20ml/kg up to 3x
What type of breathing will be heard upon auscultation if in resp. distress?inspiratory stridor
What will speech/cry sound like if in resp. distress?muffled
Cough characteristics in resp. distresslisten for fluid like coughs, kids swallow so you don't know if it is productive or not
Other equipment to check for oxygen levelspulse ox, chest xrays, ABGs, peak flow
What condition can oxygen toxicity lead to?bronchopulmonary dysplasia (use lowest O2% possible)
Finger clubbing is a sign of prolonged de sat
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Resp. Distress Interventions

Question Answer
Oxygen: how do you know if kids are likely very very sick?If they allow you to put a nasal cannula or oxygen mask on
O2 interventionsnasal cannula, mask, HIGH FLOW, CPAP, INTUBATION
Fluids amount for respiratory issues20ml/kg up to 3x bolus
Fluids amount for cardiac issues5mL/kg
Suction should be at60-100 in the green zone
Chest PTpostural drainage (< 20 min), don't percuss if you suspect pneumothorax
Nasal suction, nasotracheal suctionolive shaped suction tip (only use saline drops prn, may introduce infection): tracheal suction: don't go much farther than end of tracheal tube.
Teachingavoid irritants, smoking jacket
Increase flow to reduce whatWOB (can use mostly room air to help inflate airways)
Increase O2 in mix to mitigate whatDesat (add O2 to mixture)
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URI

Question Answer
Children have about how many colds per year?6-9; Rhinorrhea may be serous or mucopurulent
Assessresp. distress, temp., throat for white lesions, culture if appropriate
Since infants are nose breathers, what interventions should be done if there is a nasal blockagemay need to use NG or NJ tubes, hi-cal feeds can help if not tolerating PO
Difference b/t cold and allergyCold: fever, color of mucus Allergies: shiners under eyes, nasal folds, no fever, no sick contacts. Smear: ↑ eosinophils
Otitis Media Ear Infection
Otitis Media assessment findingsbulging, red tympanic membranes, pain, rubbing of the ear, fever, URI, don't tx with antibiotics, treat with analgesics
Otitis Media Interventionsanalgesics; antipyretics; myringotomy tubes
Myringotomy tubesif chronic, could cause long term problems, only helps with speech dev anecdotally. Fall out eventually (hole usu closes up)
Otitis media preventative measuresbreast feeding for first 6 mos; feed in upright position; d/c or reduce pacifier after 6months; administer pneumococcal (Prevnar) vaccine; avoid smoke exposure
Tonsillitis RF/assessmentassociated with URI, OM. hx allergic or bacterial; assess for resp effort, loose teeth, s/s URI/OM
Tonsilitis positioning & treatmentprone/side-lying. No suctioning. Ice collar, popsicles. Antibiotics, tonsillectomy.
Tonsillectomy BOLO post opswallowing - may be bleeding; hemorrhage (w/in 24 hours most likely) can occur 7-10 days following sx
Tonsillectomy interventions post opdo not suction unless ER; comfort measures
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Epiglottitis & Croup

Question Answer
Potentially life threatening, most commonly affecting children age 2-6epiglottitis (haemophilus influenzae)
Epiglottitis key assessment findings**muffled, hoarse, or absent speech
epiglottitis: usually have difficulty and painful swallowing, what would you see in the patient?increased drooling, refusal to drink & stridor.
epiglottis other assessment findingsfever, irritability & restlessness. tachycardia and tachypnea: child may extend the neck in a "sniffing" position
1) Interventions epiglottitis: 2) Why should you defer inspection?1) equipment ready for trach & intubation, antibiotics. 2) May cause spasm; ↓ # of personnel examining child to ↓ anxiety,
Croup?laryngotracheobronchitis
croup in toddlersviral-induced edema of larynx: "seal bark" cough
croup assessmentbrassy cough or hoarseness, inspiratory stridor (racemic epi) w/ varying degrees of resp. distress; ↑ dyspnea & lower accessory muscle use
croup wheezingalbuterol (cold air can also help ↓ inflammation)
croup breath soundsrales & ↓ breath sounds (worsening condition - progressed to the bronchi)
croup intervention: why should you aim to keep the child calm?conserve energy (crying triggers spasmodic coughing), clear liquids, hydration
croup educationteach s/s of resp. distress which can be tx w/ racemic epi, nebs, and/or steroids
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Bronchiolitis

Question Answer
bronchiolitis lower airway infection: thick mucous
common causesRSV; adenovirus and parainfluenza as well (1-6% mortality rate in infants)
assessmentxray, RSV nasal swab, thick mucus & signs of resp. distress
interventions feedingssmall, frequent, ↑ calories; **if RR >60 HOLD NJ or HOLD feedings
what should you do before trying to feed?elevate HOB; suction or nasal aspirate
medication txnebulized albuterol or racemic epi if sx improve
other interventionshumidified oxygen, IV fluids, chest PT after edema abated
spread by droplets or contact?contact: gloves & gowns, wash hands
RSV-IVIG or RespiGamprevention for high risk infants. Monthly doses of palivizumab may lessen sx
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Asthma & Carbon monoxide

Question Answer
Asthmachronic inflammation of airways, ↑ mucus production = airway obstruction & air trapping.
asthma assessmentresp. distress symptoms
asthma findings upon auscultationprolonged expiration with expiratory wheeze*** (inspiratory wheeze when in severe distress)
asthma type of coughnight cough, hacking, nonproductive or productive (may be either)
asthma chest assessmentchest tightness or stomach hurting; barreled chest (chronic air trapping)
asthma assess forFamily hx allergies, exercise intolerance, keep 2x daily records of peak expiratory flow rates w/in 15 minutes of med administration
asthma preventative measuresskin tests, modify env't, long term controller meds; pretreat exercise induced attacks, avoid exposure to smoke
asthma medscromolyn sodium, inhaled corticosteroids, leukotrine modifiers
asthma Interventions during attacksit upright, O2, bronchodilator (B-agonist, oral corticosteroid); **GIVE BLACK COFFEE!; discuss SE of meds, IV fluids, calm env't
Carbon monoxide poisoning & causescolorless, tasteless, & non-irritating; house fires, furnaces/heaters, wood-burning stoves, motor vehicle exhaust, propane fueled equipment
CO mild toxicity sxh/a, vertigo, nausea, fatigue, flu-like sx
CO significant toxicityCNS confusion, seizures, loss of consciousness; tachycardia; HTN; myocardial ischemia
Blood carboxyhemoglobin level should be at <5 *can't use pulse ox bc it's inaccurate
CO intervention100% O2 or hyperbaric O2 therapy
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BPD & Foreign body aspiration

Question Answer
Bronchopulmonary dysplasia: a complication ofresp. distress syndrome, resulting from high O2 concentration & long-term assisted ventilation
BPD recovery time6-12 months; may be on ventilator for years
BPD interventionsO2 (cannula, trach, or ventilator); chest PT; ↑ calories; promote normal development
BPD Medsbronchodilators; dexamethasone; diuretics
Greatest risk of foreign body aspiration?dried beans bc they swell up
Other foods and objects that are high riskPopcorn, grapes, hot dogs, peanuts (other nuts and seeds), raw carrots, buttons, toy parts, coins, hair bows, barrettes, rubber bands, pen or marker caps, small button type batteries, chewing gum, chunky peanut butter, hard or stick candy
FB aspiration preventionAbdominal thrust except for infant chest thrust/back blows
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Cystic Fibrosis

Question Answer
CF genesinherited autosomal recessive (get genetic counseling; unaffected siblings may feel guilty or ignored)
CF pathophysiologyExocrine organs obstructed by mucous production, little or no release of pancreatic enzymes, increased incidence of secondary diabetes, sweat contains 2-5 times nl levels of sodium/chloride: salt depletion may occur in hot weather or heavy exercise
Assess GInewborns meconium ileus (blockage of small intestines); steatorrhea, FTT (malabsorption), distended abdomen, thin arms/legs, voracious appetite (body unable to absorb many of the nutrients), rectal prolapse
Assess respdistress, quality of chronic cough & mucus, O2 status (pulse ox clubbing), assess for resp infection, signs of chronic obstructive resp (barrel chest r/t air trapping), assess sinusitis/nasal polyps
Interventions-dietaryPancreatic enzymes, high calorie, high protein foods with added salt; predigested formula for infants (pregestimil), enteral feedings at night (caloric intake, Multivitamins esp ADED in water miscible form
Pulmonary hygieneChest percussion, postural drainage, vibration 2-4 times per day preceded by mucolytic, bronchodilator or antibiotic nebulizer inhalation treatment, flutter mucous clearing device (pickle)
Treat any infection promptly & aggressively:(bacterial colonization leads to progressive destruction of lung tissue) Pseudomonas aeruginosa (difficult to eradicate) Burkholderia cepacia (increases morbidity & mortality) Staphylococcus aureus are most common; KEEP PTS SEPARATE if colonized
Avoid which types of meds and why?cough suppressants & antihistamines; child must be able to cough & expectorate to prevent pulmonary obstruction, immunization for influenza, genetic counseling, promote normal life, may require reproduction assistance
Trach tips: what to keep at bedsidesuction, sterile saline, extra trach tube (same size & one smaller), obturator, humidification source, scissors
Trach suctioning: how big should the catheter be?1/2 size of trach diameter, go to 5cm beyond the end of the trach (measured once & posted w/in room), remove with intermittent suction - No routine use of saline
How often should trach be changed?change trach weekly to minimize granulation formation
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Acid-Base

Question Answer
Most common acid base imbalanceRespiratory acidosis
Nl pediatric serum HCO322-26 mEq/L
Nl pediatric PaCo235-45 mm/Hg
NL pediatric PaO280-100 mm/Hg
NL based excess -2.- to +2 mEq/L
The pH system is inversely related to the hydrogen ions:Increase H+ = decrease pH (acidic) Decrease H+ = increase pH (alkaline/basic)
Step one: look at the pH determine if it is high or low
Step two: Look at the CO2 and HCO# and determine which is high or low
If the source is respiratory, which is abnormalCO2
If source is metabolic, what is abnormalHCO3
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