NR 602 Quiz 3 Study Guide Completed and Graded A

NR 602 Quiz 3 Study Guide Respiratory Infections - Leading cause of morbidity and mortality in children - Respiratory failure can develop rapidly with ominous symptoms - Be able to recognize key respiratory sounds o ...

NR 602 Quiz 3 Study Guide Respiratory Infections - Leading cause of morbidity and mortality in children - Respiratory failure can develop rapidly with ominous symptoms - Be able to recognize key respiratory sounds o Croup cough vs. other coughs *Sound bit croup cough: see link under Croup* o Inspiratory stridor *Sound bit: (https://www.easyauscultation.com/heart-lung-soundsdetails/140/Stridor) o Wheezing * Sound bit: (https://www.easyauscultation.com/heart-lung-soundsdetails/71/Wheeze) - Critical Sign: Tachypnea! o Respiratory Rates:  Infants (birth to 12 months): 30-53 bpm (RR > 60 requires further evaluation)  Toddlers (1-2 yrs): 22-37 bpm (RR > 40 requires further evaluation)  Preschool (3-5 yrs): 20-28 bpm  School Age (6-9 yrs): 18-25 bpm  Pre-Adolescent (10-11 yrs): 18-25 bpm  Adolescent (12yrs and older): 12-20 bpm o Red Flags: Tachypnea +  grunting,  nasal flaring,  use of accessory muscles - Upper Respiratory Infections are the most common (common cold) o Most often Viral  Rhinovirus, Parainfluenza, RSV, Coronavirus, human metapneumovirus  Self-limiting lasting 7-10days o Peak: Spring and Winter o Common Sxs: (gradual onset)  Low grade fever  Nasal Congestion  Sore throat, hoarseness  *Hallmark: Rhinorrhea (clear at first, progresses to purulent)  Cough/Sneezing o Clinical Findings:  Conjunctiva: mild injection  Erythematous nasal mucosa with mucus  Erythematous posterior oropharynx  Anterior cervical lymphadenopathy - Diagnostics: o ONLY if in doubt of URI: sore throat without drainage or cough  Rapid antigen detection test (RADT): rapid strep  Throat culture if RADT negativeo Treatment: Supportive Care  Hydration  OTC antipyretics as directed (weight dose)  Normal saline nasal rinse  Topical menthol  NO Antibiotics prophylactically o Complications: secondary infection  Bacterial infection  Otitis media  Sinusitis  Asthma exacerbation - Pharyngitis, Tonsillitis, and Tonsillopharyngitis o Inflammation of mucosal lining of the throat structures o Infectious or noninfectious causes  Viral or bacterial  Viral (most common): adenovirus (pharyngitis primary sx), Epstein-Barr (EBV), herpes simplex (HSV), cytomegalovirus (CMV), enterovirus, parainfluenza, HIV o Upper nasal symptoms, cough and rhinorrhea, hoarseness, conjunctivitis, rash, diarrhea o Occur year round, except adenovirus which is predominantly summer (contaminated swimming pools)  Bacterial: GABHS (most common in 5-13 year olds), gonococcal (15-19 year olds), Corynebacterium diphtheria (RARE), Arcanobacterium haemolyticum, Neisseria gonorrheae(adolescents), Chlamydia trachomatis (adolescents), Francisella tularensis, Mycoplasma pneumonia, Group C & G Strep o GABHS: typically late winter and early spring o Acute abrupt onset: sore throat, headache, nausea, vomiting, abdominal pain, myalgia, arthralgia, malaise  Respiratory irritants (smoke) o Clinical Findings:  Erythematous tonsils and pharynx  EBV: exudates on tonsils, petechiae on soft palate, diffuse adenopathy  Adenovirus: follicular pattern on pharynx  Enterovirus: vesicles or ulcers on tonsillar pillars, coryza, vomiting, diarrhea  Herpes: anterior ulcers, adenopathy  Parainfluenza and RSV: lower respiratory sx, stridor, rales, and wheezing  Influenza: cough, fever, systemic sxs  M. pneumo & Chlamydophila pneumo: cough, pharyngitis  GABHS: exudative Erythematous pharyngitis with follicular pattern without presence of cough or nasal symptoms, swollen beefy red uvula, enlarged tonsillopharyngeal tissue, anterior cervical lymphadenopathy, bad breath, scarlatiniform rash, strawberry tongue A. haemolyticum: exudative pharyngitis, marked erythema and pruritic, fine scarlatiniform rash o Diagnostics:  RADT and/or throat culture if >3 years old with pharyngitis or if someone in household is + Strep  Culture if RADT negative, or suspect A. haemolyticum, N. gonorrhea or C. diphtheria  If suspect Mononucleosis: CBC o Treatment:  Supportive care: ibuprofen, acetaminophen  Hydration  GABHS with + RADT or + culture: antibiotics  PCN V potassium – 1st choice  Amoxicillin suspension  Benzathine pcn G IM  Allergy to PCN: o Cephalexin o Cefadroxil o Clindamycin (1st choice if chronic symptomatic carriage of GABHS) o Azithromycin o clarithromycin  If CMV or EBV: beta-lactam antibiotic causes diffuse morbilliform skin eruption  Discard/Clean: bathroom cups, toothbrush, orthodontic devices  Return to school when afebrile or on antibiotic for 24 hours  Tonsillectomy/adenoidectomy:  if > 7 throat infections in past year, >5 throat infections in past 2 years, >3 throat infections per year x 3 years  sleep apnea  adenoid hypertrophy  unresponsive rhinosinusitis  chronic otitis media (post tympanostomy tube placement) Sinusitis/Rhinosinusitis - URI lasting 10 to 14 days with no symptoms improvement or worsening symptoms o Acute (ARS): lasting as long as 4 weeks o Chronic (CRS): persist 12 weeks or more - Inflammation and edema of mucous membranes lining the sinuses - Bacterial: Strep pneumo., H. influenza, Moraxella catarrhalis, Staph. Aureus (less often) - Risk factors: o Preceding infection o Environmental irritants/allergies o Anatomic problems (septal deviation, nasal polyps, facial trauma)o GERD o CF, ciliary dyskinesia o Immunodeficiency - Clinical Findings: o Thick, yellow discharge o Worsening symptoms after initial improvement from URI o Sx: headache, fatigue, decreased appetite o Bad breath (halitosis) o Facial pain* o Facial/nasal congestion and fullness* o Purulent postnasal drainage and nasal discharge o Cough o Ear pain/fullness/pressure - Treatment: o Watchful waiting: do not over use antibiotics  Symptom management: ibuprofen, acetaminophen  Rest  Reassess after 72 hours o Chronic: referral to ENT o Antibiotics Criteria per AAP Guidelines:  URI with persistent nasal discharge, daytime cough, lasting >10 days without improvement  URI with worsening symptoms, new onset of fever, nasal discharge, or daytime cough after initial improvement  Fever > 102.2 F (39 C) with purulent nasal discharge for at least 3 days and sinusitis  Amoxicillin – 1st line x10-28 days or 7 days past symptom resolution  45 mg/kg divided into 2 doses/day  S. pneumo: 80-90 mg/kg/day (max: 1000 mg/dose)  Child < 2 yrs, daycare attendee, recent antibiotic use, or severe illness: Augmentin 80-90 mg/kg/day of amoxicillin part (max: 2 grams/dose)  Vomiting: ceftriaxone 50 mg/kg IV or IM  PCN allergy type I: 3rd generation cephalosporin (cefdinir, cefpodoxime, cefuroxime) Bronchitis/ Bronchiolitis/ Respiratory Syncytial Virus (RSV) - inflammatory process of the bronchus, or bronchioles (small airways) - most commonly caused by a Virus o MOST Common: Respiratory Syncytial Virus (RSV) o Others: influenza, parainfluenza, adenovirus, enterovirus, bocavirus, and rhinovirus o Rarely: can have rare bacterial cause: Mycoplasma pneumonia - Highly CONTAGIOUS - Direct Contact and Droplet Transmission o Incubation period before symptoms start- High Risk: children with o Prematurity o Chronic lung disease o Immunocompromised o Participating in Day Care - Symptoms: o Starts as URI o Worsening cough o Rhinorrhea o *HALLMARK: Wheezing - Exam Findings: o Increased work of breathing o Prolonged expiration o Intercostals retraction o Grunting o Nasal flaring o Wheezes and crackles *Sound bit: polyphonic wheeze found in RSV: (https://www.easyauscultation.com/heart-lung-sounds-details/144/Wheeze-Polyphonic), crackles (https://www.easyauscultation.com/heart-lung-sounds-details/72/Crackles-Fine- (Rales)) o Abdominal distention, palpable liver and spleen o Chest X-ray (not typically done): hyperinflation, atelectasis, flattening diaphragm - Complications: may progress to o Pneumonia o Respiratory distress and hypoxia o Respiratory acidosis - Treatment: o Supportive Care  Monitory pulse oximetry and respiratory status  Supplemental Oxygen  Hydration (oral, NG, IV)  Nutrition  Suction o Hospitalization  Age < 2 months  Respiratory distress  Progressive stridor or stridor at rest  Apnea  RR > 50-60 bpm (sleeping)  Cyanosis, hypoxia  Inability to tolerate oral feeding  Depressed sensorium  Presence of chronic cardiovascular or immunodeficiency diseasePertussis “Whooping Cough” - Gram-negative bacillus: Bordetella pertussis - Hallmark: high-pitched inspiratory whoop follows by spasms of coughing *Sound bit: (https://www.youtube.com/watch?v=zuK4honWVsE) - Aerosol droplet transmission - 7-10 day incubation, most contagious during first 2 weeks - Cough lasts 6-10 weeks (possibly longer in adolescents) - Vaccination: DTaP or Tdap - Symptoms: o Most severe in infants < 6 months  Apnea  Seizures induced by hypoxemia  Cough without inspiratory whoop  Tachypnea  Poor feeding  Leukocytosis nad lymphocytosis - Diagnostics: o Gold standard: culture with Dacron or Calcium alginate swab of nasopharynx (only 12%- 60% specific) o PCR (improved sensitivity) - Treatment: o Macrolide (not in infants < 1 month due to pyloric stenosis)  Azithromycin – 1st line  Clarithromycin  Erythromycin o Macrolide allergy: Bactrim o Chemoprophylaxis in household and close contact exposure: monitor x 21 days - Prevention o “Cocooning”: vaccination of all adults and relatives close to infant and protection from environmental hazards o Vaccinate Pneumonia - Bacterial or Viral o Bacterial:  less common in childhood  S. pneumo.  Most common cause  Lobar pneumonia  Methicillin resistant Staph aureus(MRSA)  Community acquired  Empyema  Necrosiso Viral:  More common in children < 2 yrs  Gradual onset - Typical or Atypical o Typical: lobar, infection of alveolar space resulting in consolidation o Atypical: non-localized consolidation  Walking pneumonia - Risk factors: neonates o Prolonged rupture of membranes o Maternal amnionitis o Premature delivery o Fetal tachycardia o Maternal intrapartum fever o Airway anomaly - Symptoms (vary by age group): o Neonates:  *Fever,  irritability,  lethargy o Older Children:  *Cough  *Fever  Tachypnea, tachycardia, air-hunger  Downward displacement of liver and spleen  Obvious illness (lethargy, decreased appetite, look unwell) o C. trachomatis: repetitive staccato cough with tachypnea, cervical adenopathy, and crackles - Treatment: o If sxs not improving after 72 hours: Chest x-ray o Neonates: admit to hospital o Supportive care:  Antipyretics  Hydration  Rest o Antibiotics: by age and causative organism  Chlamydia: azithromycin or amoxicillin, erythromycin, ethyl succinate  C.pneumo, M. pneumo: azithromycin, macrolide+ beta-lactam  S. pneumo: 3rd generation cephalosporin  S. aureus: vancomycin, clindamycin + beta-lactam - Complications: o Respiratory Distress, pneumothorax o Meningitis o CNS abscess o Endocarditis, pericarditiso Osteomyelitis, septic arthritis - Vaccination: Prevnar 13 Rotavirus Croup - Viral infection of the middle respiratory track (Larynx and bronchial tree - Laryngotraceitis / Laryngotracheobronchitis (LTB) o Viral: parainfluenza type 1 & 2 (HPIV) o LTB more severe, occurs 5 – 7 days in to the disease - Usually children < 6 yrs - Season: fall and winter - Incubation period: 2-4 days with viral shedding up to 1 week, lasts approx. 5 days - HALLMARK: Barking Cough *Sound bit: 1, 2, 3 (https://mommyhood101.com/croup-audioclips - Diagnosis: made by symptoms/clinical presentation - Symptoms: o Low grade fever o URI symptoms- gradual onset (rhinorrhea, congestion) o Barking Cough o Hoarseness o Dyspnea o Respiratory Distress (Intercostal retraction, tachypnea, cyanosis, accessory muscles, nasal flaring) - Clinical Findings: o Tachypnea o Prolonged inspiration o Inspiratory stridor (as airway obstruction worsens) *Sound bit: 4, 5 (https://mommyhood101.com/croup-audio-clips) o Wheezing (if lower airway involved) o Chest X-Ray (not typically done): subglottic narrowing – Steeple Sign - Treatment: o Supportive Care: Symptom Management  Cold air  Hydration o Glucocorticoids: reduce airway swelling  Dexamethasone 0.6 mg/kg to1 mg/kg IM PO o Aerosolized racemic epinephrine: reduce swelling of larynx and subglottis o Bronchodilator o Hospitalization:  RR > 70 bpm Stridor at rest  Temperature > 102.2 F (39C) - Complications: o Pneumonia o Respiratory distress Epiglottitis - Inflammation of epiglottis, aryepiglottic folds, and ventricular bands at the base of the epiglottis - Cause: H. influenza type B (HiB) - Prevention: HiB vaccine - Typically age 1-5 yrs (most under 2 yrs) - Symptoms: o Abrupt onset fever o Severe sore throat o Dyspnea o Inspiratory distress without stridor o *drooling o Toxic look - Clinical Findings: Emergent- Death within hours o * If epiglottitis is suspected: do NOT examine throat, do NOT place in supine position, Immediately transfer to ER o Expiratory stridor o Drooling o Aphonia (muffled, „hot potatoe‟ voice) o Rapid progression of respiratory obstruction o High fever o Flaring ala nasi and retraction of supraclavicular, intercostals, and subcostal spaces o Hyperextension of the neck - Diagnostic: o Blood culture o Lateral neck radiograph: absence of „thumb‟ sign rules out condition o Confirmed in OR - Treatment: o Establish airway (possible intubation or tracheostomy) o Start antimicrobials IV broad spectrum  Rifampin prophylaxis to all household members (20 mg/kg, max: 600 mg, x 4 days) o O2/ respiratory support Foreign Body Occlusion/ Aspiration Nasal Occlusion - Symptoms: o Recurrent, unilateral purulent nasal dischargeo Foul odor o Epistaxis o Nasal obstruction/ mouth breathing - Detection of FB in nasal passageway - Removal: o Alligator forceps o Suction with narrow tips o Cotton tipped applicators w/ or w/o topical vasoconstrictor o Hook or curette o 5-Fr catheter balloon inflation behind FB o Refer to ENT Laryngeal FB Aspiration - Symptoms: o Rapid onset hoarseness o Croupy cough o Aphonia Tracheal FB Aspiration - Symptoms: o Brassy cough o Hoarseness o dyspnea Bronchial FB Aspiration - Symptoms: o Unilateral wheeze, usually aspirated into *Right lung o Recurrent pneumonia o HX of Choking episode - Clinical Findings: o Cyanosis o Hemoptysis, blood streaked sputum o Decreased vocal fremitus o Limited chest expansion o Diminished breath sounds o Unilateral wheezes  Tracheal: homophonic wheeze: wheeze with audible „slap‟ and palpable „thud‟ on expiration - Diagnostic: o Inspiratory and forced expiratory chest radiographs o Chest fluoroscopy - Treatment: Referral to Pulmonary Specialist - Complications:o If vegetable matter: severe condition  Fever, sepsis-like sxs, dyspnea, cough o Lobar pneumonia o Status asthmaticus o Emphysema, atelectasis - Prevention: Education on high risk foods/objects: o Carrots, nuts, popcorn, hot dog chunks o Small toys, coins, buttons, etc Restrictive Airway Diseases - Less common in pediatrics - Decreased lung compliance with relatively normal flow rates - HALLMARK: tachypnea and decreased tidal volume/capacity - Causes: o Neuromuscular weakness o Lobar pneumonia o Pleural effusion or mass o Severe pectus excavatum o Abdominal distention Asthma *Know Levels of severity* Cystic Fibrosis (CF) - Genetic disorder, autosomal recessive, mutation of CFTR protein on chromosome 7 - Multisystem, progressive disease: COPD, GI disturbances, *exocrine dysfunction - Life expectancy: 41 yrs - Symptoms: o Respiratory: chronic airway inflammation and lung infections, viscous mucus, *mucociliary transport dysfunction, chronic cough, and *excess sputum production, respiratory failure o GI: meconium ileus, pancreatic insufficiency, rectal prolapsed, GI obstruction, failure to thrive, edema, hypoproteinemia, steatorrhea, poor muscle mass, GERD, *vitamin deficiencies (A, K, E, D) o Hepatic: biliary cirrhosis, jaundice, ascites, hematemesis, esophageal varices, cholelithiasis o Endocrine: recurrent acute pancreatitis, CF related diabetes (CFRD) o Musculoskeletal: osteoporosis o Reproductive: delayed sexual development, nonfunctional vas deferens (male sterility), undescended testes, hydrocele, demale decreased fertility, cervicitis o Sweat: *“taste salty”, hypochloremic alkalosis, dehydration - Diagnostic: o Newborn screening performedo Gold Standard: pilocarpine iontophoresis sweat test  Only ordered if child has more than one clinical feature of CF  Sweat chloride concentration > 60 mmol/L (age > 6 months), > 30 mmol/L (in infants) o PFTs o Glycosylated hemoglobin (elevated) - Treatment: complicated, require multidisciplinary team o Pulmonary: promote airway clearance  Inhaled dornase alfa :reduce mucus viscosity  Hypertonic saline: thins mucus  Postural drainage (cycle: active breathing, autogenic drainage, percussion, positive expiratory pressure, exercise, high frequency chest wall oscillation) BID  High dose Ibuprofen: reduce airway inflammation  Azithromycin 3x/week (ibuprofen decreases neutrophil mitigation)  Lung transplant o GI:  Pancreatic enzyme supplementation  Vitamin replacement and serum monitoring (A, D, E, K)  Osmotic laxatives, Gastrografin enemas o Endocrine  Glucose tolerance test  Diabetes management Salmonella Clostridium difficile Cryptosporidium Pyloric Stenosis Pinworms Gastric Esophageal Reflux (GERD) - Common in young infants: anatomical reasons o Spitting up after mealsForeign Body Ingestion - Common in children exploring their environment with mouths and hands - Common locations: o Thoracic inlet, pyloris, ileocecal junction - Common Culprits: Coins o Most pass without problem; 10-20% need surgery - Symptoms: o Dysphagia o odynophagia, o drooling, o regurgitation, o abdominal pain, o difficulty breathing Urinary Tract Infection - More common in females > uncircumcised male > circumcised males o Girls who have > 2 UTIs, urology consult is recommended o Boys who have >1 UTIs, urology consult is recommended - Lower UTI: uncomplicated, bladder and urethra - Upper UTI: complicated, urethra, bladder, ureters, kidneys o May require hospitalization  Fluid stabilization  Treatment  Monitoring for sepsis - Risk Factors: o Perineal irritation (soaps, bubble baths, fragrances, wipes) o Not wiping front to back o uncircumcised - Symptoms: o Infants:  Fever/hypothermia  Jaundice  Poor feeding  Irritability  Vomiting  Strong smelling urine  Failure to thrive  Sepsis o Children:  Abdominal/ flank pain  Urinary frequency  Dysuria Urgency  Enuresis  Vomiting  Fever - Diagnostics: o Urinalysis o Urine culture and sensitivity o Gram stain o Hydration status and electrolyte values - Most common cause: E. coli (85%) o Others: Klebsiella, Proteus, Enterococcus, Staphylococcus, and Streptococcus - Treatment: dependent on culture, child‟s age, and clinical guidelines Primary Enuresis Glomerulonephritis - Result of renal insult caused by immunoglobulin damage to the kidney - Red Flag: hematuria - Types: o Post-infection: most common  Post-streptococcal infection: occurs 10 to 14 days post-primary infection  Sx: edema, renal insufficiency  Dark, tea-colored urine o Membranoproliferative o IgA nephropathy o Henoch – Schonlein purpura (HSP):  Most common cause of small vessel vasculitis in children 2-7 yrs old  Sx: itching, urticaria, maculopapular rash with purpura on legs, buttocks, and elbows  Joint pain  50% chance of renal involvement o Systemic lupus o Alport syndrome Osgood-Schlatter Juvenile Rheumatoid Arthirits OsteomyelitisTranscient Synovitis of the Hip Legg-Calve’ – Perthes Disease Idiopathic Scoliosis