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consent
-laws vary by state
-parents give consent
-child over age 7 should assent (not legally binding)
-emergency treatment does not require parental consent
-adolescents (in certain states) do not need parental consent for:
—STI treatment
—mental health care
—substance abuse treatment
—pregnancy care
—contraception
tips for procedures
-do not trick kids
-traumatic care: use a separate room (so their normal room is not associated with scary procedures)
-infants cannot be NPO for a long time
-CHG used >2 mo
-1 g = 1 mL of fluid
kids’ temperatures
-fever = increase in set point
—d/t infection
—Rx: Tylenol, light climates, cool compress
—seizure risk
-hyperthermia = temp > set point
—d/t heat stroke, hyperthyroidism, seizures
—meds will not work
—Rx: cooling blankets, tepid bath
—do not over-treat; prevent shivering
pediatric meds considerations
-weight- or BSA- based dosing
-increased metabolism
-use syringe for oral meds
-give slowly
-IM: max dose = 0.5 mL (small infants) or 1 mL (older infants/kids)
-may mix meds in one bite but not in a bottle
-IV
—smallest/shortest needle & cath
—do not encircle limb w/ bandage
—allow kids to help w/ removal
O2 therapy
-hood: >7 L/min
-watch for CO2 retention
-regularly measure ETCO2 for pt with ventilator, sedation, or asthma
-intubation: 100% O2 beforehand
—may be nasotracheal, orotracheal, or tracheostomy
-ventilator
—assess Displacement, Obstruction, Pneumothorax, Equipment failure
—assess QD whether pt can extubate
-tracheostomy
—care requires 2 people
—keep spare 1 size down at bedside
—clean BID, change weekly
chest tube
-maintain gentle bubbling in suction
-drainage flat and below insertion site
-need order to milk or clamp
specimen collection
-U bag for urinalysis
—works best for male and incontinent pt
-urine culture
—clean catch for older kids (must clean area first and catch midstream)
—straight cath for younger/incontinent pt
-24 hr collection for kidney issues
respiratory assessment
-respirations (rate, rhythm, depth)
-respiratory efforts (grunting, nasal flaring, retractions)
-cough (characteristics, frequency, sputum)
-HR
-O2 sat
-skin color
-hydration (mucus membranes, I&O)
-temp
-LOC
-activity level
-comfort/pain
*treat respiratory problems to prevent respiratory failure d/t fatigue
pharyngitis
-viral or strep
-may become rheumatic fever and damage heart valves, or glomerulonephritis
-viral
—common cold
—treat S/S: rest, fluids, antipyretics, elevate HOB, suction, saline
—limit cough suppressants
-strep (GABHS)
—S/S: HA, fever, ab pain, tonsillitis, tender lymph nodes, sore throat
—dx w/ rapid test; confirm negative result w/ culture
—Rx: PCNs, compress, salin gargle, Tylenol. fluid (maybe antibiotics)
—improves w/in 24-48 hr; contagious for 24 hr after Rx
tonsillitis
-bacterial or viral
-adenoid swelling obstructs nasal airway
-S/S: sore throat, difficulty swallowing, fever, snoring
-dangerous if tonsils touch
-Rx: analgesics, antipyretics, antibiotics, T&A
T&A post op
-small amounts of old blood are ok; bleeding 5-10 days after = dangerous
—S/S: frequent swallowing, vomiting, tachycardia, pallor
-elevate head
-hydrate, soft or liquid diet (avoid red/brown colors, citrus)
-analgesics
-ice pack on neck
-no straws
-do not cough, blow nose, or clear throat
flu
-S/S: cough, fever, myalgia, sore throat, fatigue, vomiting, diarrhea, croup
-lasts 4-5 days
-Rx the S/S
-Rx w/ oseltamivir QDx5 if started w/in 48 hr of S/S onset
causes of coughs
-barky = croup
-wet = common cod (see Dr after 2 weeks)
-dry/nighttime = asthma
-whooping/gasping = pertussis
-raspy = flu, pneumonia
-rattling = bronchitis
-phlegmy/post meal = reflux
otitis media
-common under age 2
-d/t blocked tubes → negative pressure → fluid
-acute = w/ infection S/S; w/ effusion = no S/S
-d/t flu or RSV
-risk fx: URI, rhinitis, Down syndrome, cleft palate, bottle propping, daycare, no vax, winter time, secondhand smoke
-recurrent may lead to hearing loss
-prevent: vaccine, antibiotics, breastfeed for 6 mo
-Rx: antibiotics, myringotomy, tympanostomy tubes
mononucleosis
-Epstein Barr virus
-S/S: fever, sore throat, fatigue, lymphadenopathy, hepatosplenomegaly
-Rx: analgesics, gargles, steroids, rest
-avoid contact sports (risk of spleen rupture)
croup
-viral
-excessive crying worsens
-laryngeal swelling
-droplet precautions
-types
—epiglottitis: emergency!
S/S: drooling, tripod
Rx: calm child, O2, steroids
must be dx w/ x-ray
—laryngotracheobronchitis: Barry cough, Rx w/ racemic EPI and steroids
—spasmodic: at night, self-limiting, Rx w/ mist
—bacterial tracheitis: thick secretions that obstruct airway
tuberculosis
-airborne precautions
-risk fx: HIV
-dx: physical exam, hx, skin test, cultures, x-ray
-Rx: meds, nutrition
-under age 2 = serious
-vaccine available
asthma
-chronic airway inflammation → bronchospasm
-may grow out of it
-onset by age 5
atopy = genetic predisposition for IgE response to allergens
-bronchospasm, irritants, inflammation, mucus→decreased lumen size/airway remodeling→obstruction→air trapping→hyperinflation, increased effort, decreased cough effectiveness
-silent breath sounds are BAD (airway constriction)
-may lead to status asthmaticus: severe emergency requiring SABA, IV steroids/fluids, magnesium sulfate, possibly intubation
asthma S/S
-cough
-SOB
-prolonged expiration
-wheezing
-crackles
-coarse breath sounds
-restlessness
--apprehension
-tripod
-sweating
-hyperresonance
-retractions
-hypoxia
asthma Rx
-dx: S/S, hx, physical exam, CXR, PFTs, PEFR (amount of air forcefully expelled in 1 min: >80% is good, <50% is emergency)
-Rx:
—rescue meds: albuterol, steroids
—long term meds: inhaled steroids, LABAs, montelukast
—decrease exposure to allergens
—exercise
—breathing exercises
asthma meds
-short acting / rescue
—beta agonists (e.g. albuterol) to treat spasm
—steroids to decreased inflammation
—magnesium sulfate to relax smooth muscle
-long acting / prevention
—inhaled steroids to decrease inflammation
—beta agonists
—theophylline (later resort)
—leukotriene modifiers (e.g. montelukast) to decrease spasm & inflammation
—cromolyn sodium to decrease inflammation
—omalizumab to manage atopy
cystic fibrosis
-viscous mucus secretions systematically
-CFTR protein → abnormal movement of chloride ions → mucus is more viscous
-genetic (autosomal recessive)
-may lead to DM
-life expectancy = 37 years
CF S/S
-respiratory: emphysema, pneumonia, infections, pulmonary HTN, respiratory failure
-GI: meconium ileus, bowel obstruction, rectal prolapse
-liver: acidic bile, portal HTN, gallstones
-pancreas: malabsorption, DM
-reproductive: cervical plug, preterm labor, SGA, male sterility
-development: FTT, delayed bone growth
CF dx
-newborn screening
-sweat chloride test
-DNA test
-CXR, PFTs
-stool analysis
Rx for cystic fibrosis
-pulmonary: CPT, nebulizers, antibiotics, airway clearance therapy, O2, NSAIDs, lung transplant
-GI: pancreatic enzymes, high kcal/protein diet, supplements, maybe TPN
—risk of obstruction, GERD
—Rx decreased motility with laxatives
—limit to 1-2 stools per day
-endocrine: GH injections
-CFTRE modulators, dry powder mannitol
sleep apnea
-airway obstruction during sleep
-S/S: snoring, pause in breathing, daytime sleepiness, choking, neuro/behavioral problems
-may lead to death
-dx: sleep study
-Rx: T&A, CPAP or BiPAP, weight loss
trach care
-humidified
-suction PRN
-clean BID, change weekly
-may have speaking valves
-keep extra trach at bedside (1 size down)
-TWO people needed for care!
-if it dislodges, cover with gauze and bag pt
RSV/bronchiolitis
-risk fx: young baby, chronic lung disease, daycare, no breastfeeding
-airway swelling, mucus
-dx: CXR, panel
-S/S: rhinorrhea, choky cough, fever, adventitious breath sounds, dyspnea, retractions, apnea
-Rx: fluids, suction, O2, Palivizumab
-contact and/or droplet precautions
pneumonia
-viral, bacterial, mycoplasma, or aspiration
-S/S: never, cough, chest/ab pain, distress, crackles
-Rx: O2, percussion, fluids, Tylenol, antibiotics, suction, bronchodilator, lie on side w/ bad lung
pulmonary edema
-fluid in alveoli
-increased pulmonary pressure or permeability
-Rx: high pressure O2, ventilator, elevate HOB, monitor F&E
-S/S: respiratory distress, orthopnea, heart murmur, JVD, pink sputum, BP change
ARDS
-life-threatening
-d/t injury (sepsis, drug OD, submersion)
-inflammation → pulmonary edema, pulmonary HTN, low lung FC
-leads to hyperventilation, cyanosis, tachypnea
-Rx: ECMO, diuretics, vasodilators, arterial lines, supplemental nutrition
smoke inhalation injury
-heat injury in upper airways
-chemical injury deep in lungs
-systemic injury from CO (low O2 though pulse ox reads normal sats)
-assess w/ scope
-Rx: O2, bronchodilators, steroids, fluids, chest percussion
respiratory emergencies
-insufficiency = increased work to breathe, normal gas exchange, abnormal ABG
-failure = inability to exchange gases
-arrest = respirations cease (may lead to cardiac arrest)
-apnea = respirations cease for >20 sec or <20 sec + hypoxemia + bradycardia