NR 602 Quiz 3 Study Guide

NR 602 Quiz 3 Study Guide

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
  • Croup cough vs. other coughs *Sound bit croup cough: see link under Croup*
  • Inspiratory stridor *Sound bit: (https://www.easyauscultation.com/heart-lung-sounds-details/140/Stridor)
  • Wheezing * Sound bit: (https://www.easyauscultation.com/heart-lung-sounds-details/71/Wheeze)
• Critical Sign: Tachypnea!
  • 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
  • Red Flags: Tachypnea +
    • grunting,
    • nasal flaring,
    • use of accessory muscles
  • Upper Respiratory Infections are the most common (common cold)
    • Most often Viral
      • Rhinovirus, Parainfluenza, RSV, Coronavirus, human metapneumovirus
      • Self-limiting lasting 7-10days
    • Peak: Spring and Winter
    • Common Sxs: (gradual onset)
      • Low grade fever
      • Nasal Congestion
      • Sore throat, hoarseness
      • *Hallmark: Rhinorrhea (clear at first, progresses to purulent)
      • Cough/Sneezing
    • Clinical Findings:
      • Conjunctiva: mild injection
      • Erythematous nasal mucosa with mucus
      • Erythematous posterior oropharynx
      • Anterior cervical lymphadenopathy
    • Diagnostics:
      • ONLY if in doubt of URI: sore throat without drainage or cough
        • Rapid antigen detection test (RADT): rapid strep
        • Throat culture if RADT negative
      • Treatment: Supportive Care
        • Hydration
        • OTC antipyretics as directed (weight dose)
        • Normal saline nasal rinse
        • Topical menthol
        • NO Antibiotics prophylactically
      • Complications: secondary infection
        • Bacterial infection
        • Otitis media
        • Sinusitis
        • Asthma exacerbation
      • Pharyngitis, Tonsillitis, and Tonsillopharyngitis
        • Inflammation of mucosal lining of the throat structures
        • 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
              • Upper nasal symptoms, cough and rhinorrhea, hoarseness, conjunctivitis, rash, diarrhea
              • 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
              • GABHS: typically late winter and early spring
              • Acute abrupt onset: sore throat, headache, nausea, vomiting, abdominal pain, myalgia, arthralgia, malaise
            • Respiratory irritants (smoke)
          • 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
            • 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
          • 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 haemolyticum, N. gonorrhea or C. diphtheria
            • If suspect Mononucleosis: CBC
          • Treatment:
            • Supportive care: ibuprofen, acetaminophen
            • Hydration
            • GABHS with + RADT or + culture: antibiotics
              • PCN V potassium – 1^st choice
              • Amoxicillin suspension
              • Benzathine pcn G IM
              • Allergy to PCN:
                • Cephalexin
                • Cefadroxil
                • Clindamycin (1^st choice if chronic symptomatic carriage of GABHS)
                • Azithromycin
                • 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)

ORDER NOW FOR A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER WITH ALL INSTRUCTIONS FOLLOWED

Sinusitis/Rhinosinusitis

• URI lasting 10 to 14 days with no symptoms improvement or worsening symptoms
  • Acute (ARS): lasting as long as 4 weeks
  • 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:
  • Preceding infection
  • Environmental irritants/allergies
  • Anatomic problems (septal deviation, nasal polyps, facial trauma)
  • GERD
  • CF, ciliary dyskinesia
  • Immunodeficiency
• Clinical Findings:
  • Thick, yellow discharge
  • Worsening symptoms after initial improvement from URI
  • Sx: headache, fatigue, decreased appetite
  • Bad breath (halitosis)
  • Facial pain*
  • Facial/nasal congestion and fullness*
  • Purulent postnasal drainage and nasal discharge
  • Cough
  • Ear pain/fullness/pressure
• Treatment:
  • Watchful waiting: do not over use antibiotics
    • Symptom management: ibuprofen, acetaminophen
    • Rest
    • Reassess after 72 hours
  • Chronic: referral to ENT
  • 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 – 1^st line x10-28 days or 7 days past symptom resolution
      • 45 mg/kg divided into 2 doses/day
      • 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: 3^rd generation cephalosporin (cefdinir, cefpodoxime, cefuroxime)

NR 602 Quiz 3 Study Guide

Bronchitis/ Bronchiolitis/ Respiratory Syncytial Virus (RSV)

• inflammatory process of the bronchus, or bronchioles (small airways)
• most commonly caused by a Virus
  • MOST Common: Respiratory Syncytial Virus (RSV)
  • Others: influenza, parainfluenza, adenovirus, enterovirus, bocavirus, and rhinovirus
  • Rarely: can have rare bacterial cause: Mycoplasma pneumonia
• Highly CONTAGIOUS
• Direct Contact and Droplet Transmission
  • Incubation period before symptoms start
• High Risk: children with
  • Prematurity
  • Chronic lung disease
  • Immunocompromised
  • Participating in Day Care
• Symptoms:
  • Starts as URI
  • Worsening cough
  • Rhinorrhea
  • *HALLMARK: Wheezing
• Exam Findings:
  • Increased work of breathing
  • Prolonged expiration
  • Intercostals retraction
  • Grunting
  • Nasal flaring
  • 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))
  • Abdominal distention, palpable liver and spleen
  • Chest X-ray (not typically done): hyperinflation, atelectasis, flattening diaphragm
• Complications: may progress to
  • Pneumonia
  • Respiratory distress and hypoxia
  • Respiratory acidosis
• Treatment:
  • Supportive Care
    • Monitory pulse oximetry and respiratory status
    • Supplemental Oxygen
    • Hydration (oral, NG, IV)
    • Nutrition
    • Suction
  • 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 disease

Pertussis “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:
  • Most severe in infants < 6 months
    • Apnea
    • Seizures induced by hypoxemia
    • Cough without inspiratory whoop
    • Tachypnea
    • Poor feeding
    • Leukocytosis nad lymphocytosis
  • Diagnostics:
    • Gold standard: culture with Dacron or Calcium alginate swab of nasopharynx (only 12%-60% specific)
    • PCR (improved sensitivity)
  • Treatment:
    • Macrolide (not in infants < 1 month due to pyloric stenosis)
      • Azithromycin – 1^st line
      • Clarithromycin
      • Erythromycin
    • Macrolide allergy: Bactrim
    • Chemoprophylaxis in household and close contact exposure: monitor x 21 days
  • Prevention
    • “Cocooning”: vaccination of all adults and relatives close to infant and protection from environmental hazards
    • Vaccinate

Pneumonia

• Bacterial or Viral
  • Bacterial:
    • less common in childhood
    • pneumo.
      • Most common cause
      • Lobar pneumonia
    • Methicillin resistant Staph aureus(MRSA)
      • Community acquired
      • Empyema
      • Necrosis
    • Viral:
      • More common in children < 2 yrs
      • Gradual onset
    • Typical or Atypical
      • Typical: lobar, infection of alveolar space resulting in consolidation
      • Atypical: non-localized consolidation
        • Walking pneumonia
      • Risk factors: neonates
        • Prolonged rupture of membranes
        • Maternal amnionitis
        • Premature delivery
        • Fetal tachycardia
        • Maternal intrapartum fever
        • Airway anomaly
      • Symptoms (vary by age group):
        • Neonates:
          • *Fever,
          • irritability,
          • lethargy
        • Older Children:
          • *Cough
          • *Fever
          • Tachypnea, tachycardia, air-hunger
          • Downward displacement of liver and spleen
          • Obvious illness (lethargy, decreased appetite, look unwell)
        • trachomatis: repetitive staccato cough with tachypnea, cervical adenopathy, and crackles
      • Treatment:
        • If sxs not improving after 72 hours: Chest x-ray
        • Neonates: admit to hospital
        • Supportive care:
          • Antipyretics
          • Hydration
          • Rest
        • Antibiotics: by age and causative organism
          • Chlamydia: azithromycin or amoxicillin, erythromycin, ethyl succinate
          • pneumo, M. pneumo: azithromycin, macrolide+ beta-lactam
          • pneumo: 3^rd generation cephalosporin
          • aureus: vancomycin, clindamycin + beta-lactam
        • Complications:
          • Respiratory Distress, pneumothorax
          • Meningitis
          • CNS abscess
          • Endocarditis, pericarditis
          • Osteomyelitis, septic arthritis
        • Vaccination: Prevnar 13

NR 602 Quiz 3 Study Guide

Rotavirus

Croup

• Viral infection of the middle respiratory track (Larynx and bronchial tree
• Laryngotraceitis / Laryngotracheobronchitis (LTB)
  • Viral: parainfluenza type 1 & 2 (HPIV)
  • 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-audio-clips
• Diagnosis: made by symptoms/clinical presentation
• Symptoms:
  • Low grade fever
  • URI symptoms- gradual onset (rhinorrhea, congestion)
  • Barking Cough
  • Hoarseness
  • Dyspnea
  • Respiratory Distress (Intercostal retraction, tachypnea, cyanosis, accessory muscles, nasal flaring)
• Clinical Findings:
  • Tachypnea
  • Prolonged inspiration
  • Inspiratory stridor (as airway obstruction worsens) *Sound bit: 4, 5 (https://mommyhood101.com/croup-audio-clips)
  • Wheezing (if lower airway involved)
  • Chest X-Ray (not typically done): subglottic narrowing – Steeple Sign
• Treatment:
  • Supportive Care: Symptom Management
    • Cold air
    • Hydration
  • Glucocorticoids: reduce airway swelling
    • Dexamethasone 0.6 mg/kg to1 mg/kg IM PO
  • Aerosolized racemic epinephrine: reduce swelling of larynx and subglottis
  • Bronchodilator
  • Hospitalization:
    • RR > 70 bpm
    • Stridor at rest
    • Temperature > 102.2 F (39C)
  • Complications:
    • Pneumonia
    • Respiratory distress

NR 602 Quiz 3 Study Guide

Epiglottitis

• Inflammation of epiglottis, aryepiglottic folds, and ventricular bands at the base of the epiglottis
• Cause: influenza  type B (HiB)
• Prevention: HiB vaccine
• Typically age 1-5 yrs (most under 2 yrs)
• Symptoms:
  • Abrupt onset fever
  • Severe sore throat
  • Dyspnea
  • Inspiratory distress without stridor
  • *drooling
  • Toxic look
• Clinical Findings: Emergent- Death within hours
  • * If epiglottitis is suspected: do NOT examine throat, do NOT place in supine position, Immediately transfer to ER
  • Expiratory stridor
  • Drooling
  • Aphonia (muffled, ‘hot potatoe’ voice)
  • Rapid progression of respiratory obstruction
  • High fever
  • Flaring ala nasi and retraction of supraclavicular, intercostals, and subcostal spaces
  • Hyperextension of the neck
• Diagnostic:
  • Blood culture
  • Lateral neck radiograph: absence of ‘thumb’ sign rules out condition
  • Confirmed in OR
• Treatment:
  • Establish airway (possible intubation or tracheostomy)
  • Start antimicrobials IV broad spectrum
    • Rifampin prophylaxis to all household members (20 mg/kg, max: 600 mg, x 4 days)
  • O2/ respiratory support

Foreign Body Occlusion/ Aspiration

Nasal Occlusion

• Symptoms:
  • Recurrent, unilateral purulent nasal discharge
  • Foul odor
  • Epistaxis
  • Nasal obstruction/ mouth breathing
• Detection of FB in nasal passageway
• Removal:
  • Alligator forceps
  • Suction with narrow tips
  • Cotton tipped applicators w/ or w/o topical vasoconstrictor
  • Hook or curette
  • 5-Fr catheter balloon inflation behind FB
  • Refer to ENT

Laryngeal FB Aspiration

• Symptoms:
  • Rapid onset hoarseness
  • Croupy cough
  • Aphonia

Tracheal FB Aspiration

• Symptoms:
  • Brassy cough
  • Hoarseness
  • dyspnea

Bronchial FB Aspiration

• Symptoms:
  • Unilateral wheeze, usually aspirated into *Right lung
  • Recurrent pneumonia
  • HX of Choking episode
• Clinical Findings:
  • Cyanosis
  • Hemoptysis, blood streaked sputum
  • Decreased vocal fremitus
  • Limited chest expansion
  • Diminished breath sounds
  • Unilateral wheezes
    • Tracheal: homophonic wheeze: wheeze with audible ‘slap’ and palpable ‘thud’ on expiration
  • Diagnostic:
    • Inspiratory and forced expiratory chest radiographs
    • Chest fluoroscopy
  • Treatment: Referral to Pulmonary Specialist
  • Complications:
    • If vegetable matter: severe condition
      • Fever, sepsis-like sxs, dyspnea, cough
    • Lobar pneumonia
    • Status asthmaticus
    • Emphysema, atelectasis
  • Prevention: Education on high risk foods/objects:
    • Carrots, nuts, popcorn, hot dog chunks
    • 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:
  • Neuromuscular weakness
  • Lobar pneumonia
  • Pleural effusion or mass
  • Severe pectus excavatum
  • Abdominal distention

Asthma *Know Levels of severity*

NR 602 Quiz 3 Study Guide

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:
  • Respiratory: chronic airway inflammation and lung infections, viscous mucus, *mucociliary transport dysfunction, chronic cough, and *excess sputum production, respiratory failure
  • 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)
  • Hepatic: biliary cirrhosis, jaundice, ascites, hematemesis, esophageal varices, cholelithiasis
  • Endocrine: recurrent acute pancreatitis, CF related diabetes (CFRD)
  • Musculoskeletal: osteoporosis
  • Reproductive: delayed sexual development, nonfunctional vas deferens (male sterility), undescended testes, hydrocele, demale decreased fertility, cervicitis
  • Sweat: *“taste salty”, hypochloremic alkalosis, dehydration
• Diagnostic:
  • Newborn screening performed
  • 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)
  • PFTs
  • Glycosylated hemoglobin (elevated)
• Treatment: complicated, require multidisciplinary team
  • 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
  • GI:
    • Pancreatic enzyme supplementation
    • Vitamin replacement and serum monitoring (A, D, E, K)
    • Osmotic laxatives, Gastrografin enemas
  • Endocrine
    • Glucose tolerance test
    • Diabetes management

Salmonella

 

Clostridium difficile

 

Cryptosporidium

 

Pyloric Stenosis

 

Pinworms

 

Gastric Esophageal Reflux (GERD)

• Common in young infants: anatomical reasons
  • Spitting up after meals

Foreign Body Ingestion

• Common in children exploring their environment with mouths and hands
• Common locations:
  • Thoracic inlet, pyloris, ileocecal junction
• Common Culprits: Coins
  • Most pass without problem; 10-20% need surgery
• Symptoms:
  • Dysphagia
  • odynophagia,
  • drooling,
  • regurgitation,
  • abdominal pain,
  • difficulty breathing

NR 602 Quiz 3 Study Guide

ORDER NOW FOR AN ORIGINAL, PLAGIARISM-FREE, AND RESOURCEFUL PAPER

Urinary Tract Infection

• More common in females > uncircumcised male > circumcised males
  • Girls who have > 2 UTIs, urology consult is recommended
  • Boys who have >1 UTIs, urology consult is recommended
• Lower UTI: uncomplicated, bladder and urethra
• Upper UTI: complicated, urethra, bladder, ureters, kidneys
  • May require hospitalization
    • Fluid stabilization
    • Treatment
    • Monitoring for sepsis
  • Risk Factors:
    • Perineal irritation (soaps, bubble baths, fragrances, wipes)
    • Not wiping front to back
    • uncircumcised
  • Symptoms:
    • Infants:
      • Fever/hypothermia
      • Jaundice
      • Poor feeding
      • Irritability
      • Vomiting
      • Strong smelling urine
      • Failure to thrive
      • Sepsis
    • Children:
      • Abdominal/ flank pain
      • Urinary frequency
      • Dysuria
      • Urgency
      • Enuresis
      • Vomiting
      • Fever
    • Diagnostics:
      • Urinalysis
      • Urine culture and sensitivity
      • Gram stain
      • Hydration status and electrolyte values
    • Most common cause: coli (85%)
      • Others: Klebsiella, Proteus, Enterococcus, Staphylococcus, and Streptococcus
    • Treatment: dependent on culture, child’s age, and clinical guidelines

NR 602 Quiz 3 Study Guide

Primary Enuresis

 

Glomerulonephritis

• Result of renal insult caused by immunoglobulin damage to the kidney
• Red Flag: hematuria
• Types:
  • Post-infection: most common
    • Post-streptococcal infection: occurs 10 to 14 days post-primary infection
    • Sx: edema, renal insufficiency
    • Dark, tea-colored urine
  • Membranoproliferative
  • IgA nephropathy
  • 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
  • Systemic lupus
  • Alport syndrome

Osgood-Schlatter

 

Juvenile Rheumatoid Arthirits

 

Osteomyelitis

 

Transcient Synovitis of the Hip

 

Legg-Calve’ – Perthes Disease

 

Idiopathic Scoliosis