respiratory stressors and adaptation
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Respiratory Stressors and Adaptation
www.autocontrol.com
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Child’s Respiratory Tract
Children are prone to:
• Respiratory tract infection
• Respiratory failure
• Airway collapse
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Key Pediatric Differences in the Respiratory System
• Lack of or insufficient surfactant (premature infant)
• Smaller airways and underdeveloped cartilage• Tonsilar tissue enlarged• More flexible larynx• Obligatory nose breather (infant)• Less well developed intercostal muscles• Brief periods of apnea common (newborn)• Faster respiratory rate• Increased metabolic needs• Eustachian tubes relatively horizontal
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Respiratory Diseases and Disorders of Childhood
• Otitis Media• Pharyngitis• Epiglotitis• Broncholitis• Pneumonia• Asthma
exacerbation• Cystic Fibrosis• Tuberculosis
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Otitis Media (OM)
• One of the most common illnesses in infancy and childhood
• Peak incidence: 6 months to 6 years• Infection or blockage of the middle ear• Acute, Chronic or Serous OM
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(AOM) Acute Otitis Media
• Sudden temperature increases
• Sharp pain • Otalgia (earache); pull
on ear • Bulging, opaque red
tympanic membrane• Irritability• Sleep disturbance• Persistent crying• Fever, vomiting,
diarrhea, anorexia
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AOM
Treatment:• AOM could be viral or bacterial• Acetaminophen (pain, fever)• ABX (Amoxicillin) if bacterial• ALTERNATIVE- wait 72 hours then treat
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Serous Otitis Media or Otitis Media with Effusion
(SOM/OME)• Result of chronic
otitis media (3 in 6 mos, 4 in 1 year)
• Epithelial cells of middle ear begin producing secretions instead of absorbing them
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Surgical Interventions
Myringotomy• surgical incision of the tympanic
membrane (mucoid material removed from middle ear)
Tympanostomy tubes: placed to equalize pressure on both sides of the tympanic membrane, keeps ear aerated
• Allows middle ear mucosa to return to normal and growth of the Eustachian tube to continue
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Patient Teaching-Post Op
• Monitor for ear drainage
• Report any fever or increased pain
• Avoid blowing nose for 7-10 days
• Swimming, showers allowed only with earplugs
• Diving and swimming in deep water is prohibited
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Pharyngitis (Tonsillitis)
• Inflammation and infection of the palatine tonsils
• Viral vs. Bacterial
• Peak age 4-7 years
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Viral Pharyngitis• Gradual Sore throat• Erythema, inflammation
of pharynx and tonsils (may be slight)
• Vesicles or ulcers on tonsils
• Fever (usually low grade)• Hoarseness, cough,
rhinitis, conjunctivitis, malaise, anorexia
• Cervical lymph nodes may be enlarged, tender
• Usually lasts 3-4 days then resolves spontaneously
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Bacterial Pharyngitis • Abrupt onset (may be
gradual in children younger than 2 years)
• Sore throat (usually severe)
• Erythema, inflammation of pharynx and tonsils
• Fever usually high (103-104F) but may be moderate
• Abdominal pain, headache, vomiting
• Cervical lymph nodes may be enlarged, tender
• Requires antibiotics
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Pharyngitis
Management:Pain relief; rest; bland, soft dietPCN if bacterialTonsillectomy is controversial
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Tonsillectomy
Nursing Care (Pre-op)• Assess for current infection and
bleeding history• Check for loose teeth• Teach child and parent what to
expect post-op– May see dried blood in mouth and
teeth– Will still be able to talk– Pain management for optimal recovery
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TonsillectomyNursing care (post-op)
• Assess for bleeding number one priority!!!!– Elevated P, decreased BP, restlessness, frequent
swallowing, vomiting bright red blood, fresh blood in throat
• Clear, cool liquids, no red juices!• Advance to full liquids and soft foods on 2nd
day if no sign of hemorrhage• Pain relief 2nd priority-throat very sore• Encourage child to chew and swallow • No straws, forks or sharp, pointed toys
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Manifestations of Croup• Begins at night; may be preceded by several
days of symptoms of upper respiratory tract infection
• Sudden onset of harsh, barky cough; sore throat; inspiratory stridor; hoarseness
• Could progress into use of accessory muscles to breathe
• Frightened appearance; agitation• Cyanosis
• Mostly viral in nature, resolves spontaneously
• Humidification and cold air resolves attacks
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Epiglottitis• Bacterial form of croup (H influenza)
with unique symptoms and treatment
• Bacterial infection invades tissues surrounding the epiglottis
• Epiglottis becomes edematous, cherry red and may completed obstruct airway
• Progresses rapidly, child is unable to swallow, drooling
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Cardinal signs and symptoms
• May have had mild URI few days prior
• Drooling• Dysphasia • Dysphonia • Distressed respiratory efforts• Tripod position: supported by arms,
chin thrust out, mouth open
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ER Management
• NEVER leave child unattended• Don’t examine or culture throat or start
IV/Blood samples• Patent airway ASAP• Monitor oxygenation status, (continuous pulse ox, humidified
O2)• Antipyretics suppository• Calm the parent! Explain what is going on…a calm
parent=calmer child!• OR- intubation• Throat & blood cultures done after intubation• Usually extubated after 48h• Antibiotics for 7-10 days• Discharge
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Nursing Interventions on unit once stable
• Continually assess for s/s of respiratory distress
• Maintain pulse ox above 95% with PaO2 between 80-100mmHg
• Maintain patent airway• Position for comfort (never force to lie
down)• Relieve anxiety• Monitor temp (antipyretics, ABX)
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BroncholitisInflammation of the
fine bronchioles and small bronchi.
• Occurs in children < 2yo; peak age 6mos
• Highest in winter and spring
• Most responsible pathogen: RSV
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Signs and Symptoms
• 1-2 days of URI, then suddenly symptoms become worse
• nasal flaring• intercostal and subcostal retractions • wheezes, crackles or rhonchi• increased respiratory rate• low pulse oximetry• tachycardia and cyanosis
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Management
Severe Symptoms• Hospitalization• Monitor: respiratory
status, pulse ox, blood gases
• Bronchdilator therapy
No antibiotics…Viral infection!
Mild-Mod symptoms• Antipyretics• Hydration• Humidification• Watch for increased
severity
Acute phase usually lasts for 2-3 days.
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Nursing Interventions
• Position: for comfort, semi-fowlers• Decrease anxiety• Administration of IV fluids • Provide humidified O2 (40% then
wean) use BB• Determine in child is candidate for
Ribavirin therapy (antiviral agent used with severe RSV cases)
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Pneunomia (PN)
• Inflammation of the alveoli usually following an URI
• Occurrence: late winter/early
spring• Pneumococcal
(bacterial) vs. Viral Pneumonia
(ABX vs. no ABX)
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Signs and Symptoms
Viral- may have mild cold symptomsBacterial- distinctly ill
– High fever, may be diaphoretic– Cough (productive or non productive)– Tachypnea– Abnormal BS (fine crackles, rhonchi)– Dull percussion– Chest pain– Increased respiratory effort– CXR changes– Lab findings (increased WBC)– Irritable, restless, occasional N/V/D, low PO
intake
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Ineffective Breathing Pattern: Interventions
• Assess breath sounds, VS, respiratory status q1-2h and PRN
• Administer humidified O2 via face mask, obtain ABG’s, pulse ox
• Administer ABX (Ampicillin, Cephalosporin), antipyretics
• Perform chest physiotherapy as ordered• Engage child in play activities (TCDB, IS)
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Activity Intolerance: Interventions
• Balance activity with rest periods, cluster nursing care• Provide small frequent
meals• Increase activity gradually
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Risk for Deficient Fluid Volume: Interventions
• Obtain baseline weight, monitor daily
• Administer IV fluids as ordered• Offer fluids frequently (jello, ices,
etc.)• Administer antipyretics• Monitor I&O, urine for specific
gravity increases
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Asthma
A reversible obstructive airway disease characterized by
• Hypersensitivity of many cells (Mast, Eosinophils, T Lymphocytes)
• Increased airway responsiveness to a variety of stimuli
• Bronchospasm resulting from constriction of bronchial smooth muscle
• Inflammation and edema of the mucous membranes that line the small airways and the subsequent accumulation of thick secretions in the airways
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Acute Asthma Exacerbation Symptoms
• Chest tightness• Wheezing• Shortness of breath• Nonproductive cough
(with or without wheezing); later becomes productive
• Tachypnea, orthopnea
• Tripod position or straight
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Triggers
• Cold air exposure• Smoke/fumes• Viral infection• Stress• Exercise• Odors (perfume)• Animal dander• Dust, cockroaches, rodents• Certain drugs (aspirin, NSAID’s)• GI reflux• Food allergens, outdoor allergens
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Management of Acute Exacerbation
• Monitor respiratory rate and effort, color
• Provide oxygen therapy:warmed and humidifiedat 30-40% not 100%keep O2 sat > 95%; need CO2 stimulation for inhalation
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Acute Asthma Exacerbation
• Administer short acting beta2 agonist bronchodilators– Ventolin, Proventil, Albuterol
• Administer corticosteroids– Predinsone, Prednisolone, Solumedrol
• Monitor effectiveness of meds
• Easily fatigable
• Frequent position changes
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Acute Asthma Exacerbation
• Observe for Status Asthmaticus
• Occurs when child fails to respond to treatment (severe emergency)
• Often caused by pulmonary infection
• Call MD!
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Asthma Severity
• Classified as– Mild intermittent
•Symptoms < 2 x week– Mild Persistent
•Symptoms > 2 x week, but less than once a day
– Moderate•Day symptoms 2 x week, 1 or more night
symptoms per week– Severe
•Continual day symptoms, frequent night symptoms
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Maintenance Medications
• Mild asthma: –PRN anti-inflammatory
corticosteroids (Flovent inhaler QD)
• Moderate: –anti-inflammatory corticosteroids QD – long-acting bronchodilator
(Theophylline, Serevent)HS
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Maintenance Medications
• Severe: – oral corticosteroid qd– inhaled corticosteroid qd – long-acting bronchodilator HS – short-acting beta-2-agonist bronchodilator
(Albuterol) if attack beginsAlso:– Mast Cell inhibitors (Intal),– Leukotriene Blocker (Singulair) (prevents severe bronchospasm, not effective if
symptoms present)
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Discharge Planning• teaching self-
management– Identify triggers– Avoidance of
allergens– May need skin
testing and hyposensitization
– Assess availability of home meds (proper inhaler use and storage, nebulizer)
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Teach use of Peak Flow Meter
• Measures maximum peak expiratory flow rate
• Need to first use when healthy to mark baseline
• Can use to predict acute exacerbation in kids 5-6 years and older
• Take a deep breath, blow out hard and fast
• If peak flow is 30-50% of child’s predicted baseline=ER
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Cystic Fibrosis (CF)
• Mutated gene on chromosome 7 CFTR
• Inherited autosomal recessive trait
• Both parents carry gene)
(1/4 chance of conceiving affected child)
X XCarrier mom
XCarrier Dad
XXCarrierfemale
XXAffectedFemale
Y XYNormal male
XYCarrier female
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CF
• Chronic multisystem disorder affecting the exocrine glands
• Affects: bronchioles, small intestines, pancreatic & bile ducts
• Incurable• Median life expectancy is 33 yrs• Usually diagnosed before 1st birthday• Symptoms worsen as disease
progresses
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CF: Respiratory System
• Wheezing, dry, non-productive cough, repeated URI’s
• Copious, thick sputum• Crackles, wheezes, decreased breath sounds• Increasing signs of respiratory distress =>
emphysema & atelectesis• Clubbing, barrel chest
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CF: Digestive System
• Steatorrhea: frothy, foul-smelling stools 2-3 times bulkier than normal
• Malnutrition and failure to thrive despite normal caloric intake
• Protuberant abdomen• Fat soluble vitamin deficiencies: K, A,
D, E (caused by inability to absorb fats)• Meconium illeus in the newborn might
be 1st sign
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CF: Exocrine Glands
• Abnormally high concentrations of sodium and chloride in the sweat
• Sweat Test: determines amount of sodium chloride in sweat > 60 is diagnostic
• Risk for electrolyte imbalance during hot weather
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CF: Reproductive System
• Average of 2 year delay in the development of secondary sex characteristics
• Females have thick cervical mucus (trouble getting pregnant)
• Some male patients sterile due to lack of sperm
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Management
• Prevention and treatment of pulmonary infections
• Maintaining optimal nutritional status– High calorie, high protein– Enzyme supplements
• Managed at home most of time– Flutter device– CPT BID– Postural drainage– Exercise
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Interventions for Hospitalized CF Child
• Facilitating airway clearance
• Prevent pooling of secretions
• Limit procedures
• CPT every 4 hours (1 hour before or 2 hours after meals, prior to bedtime)
• Forced expiration (“huffing”)
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Interventions
• Administer bronchodilators and mucolytics
• Humidified oxygen, low flow • IV ABX• Well balanced diet high in calories,
protein, carbohydrates• Pancreatic enzymes within 30 minutes
of eating all meals and snacks • Extra salt and fluid in hot weather
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Long Term Support
• Cystic Fibrosis Foundation
• American Lung Association
• Coordination of care from home to school
• Increase self-esteem
• Foster independence
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Tuberculosis
• Bacterial infection that multiplies in the lung tissue, alveoli and lymph nodes
• Initially asymptomatic• Incubation period 2-12 weeks, will
test + PPD• Immune system can ward off full
development and become dormant• Children rarely develop active TB, but
are excellent transmitters to others
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Risk Factors for Development of
Tuberculosis• Contact with infected adults • Chronic illness, immunosuppression, HIV
infection, malnutrition• Young age (infancy, adolescence)• Nonwhite racial, ethnic groups,
immigrants from areas with high incidence
• Urban, low-income living conditions• Incarcerated adolescents• Contact with adults from high-risk groups
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Active TB Symptoms• +PPD• Malaise• Fever• Night Sweats• Slight cough• Weight loss• Anorexia• Lymphadenopathy• Confirmed by CXR,
sputum sample, or gastric washing
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Management
Asymptomatic children
• INH x 9 months• 12 months if
HIV+• Household
contacts treat for 12 weeks
Symptomatic children• INH, rifampin and
pyrazinamide x 2 months
• Followed by INH and rifampin x 4 months
Side effects: GI, orange tears, urine= noncompliance
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Dehydration and Fluid Loss
• Large portion of a child’s fluids is located in extracellular fluid (increased BSA)– Infants: 75-80% of the weight– 2 year old: 60% of weight
• First two years of life kidneys are not functionally mature
• Inefficient at excreting waste products
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Dehydration and Fluid Loss
• Fluid and electrolyte imbalances develop and progress very quickly
• Sick children often have low PO intake and diarrhea and vomiting =
• Infants and young children are highly susceptible to rapid and profound fluid and electrolyte imbalances
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Types of Fluid Loss
• Sensible Fluid Loss• Insensible Fluid Loss
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Sensible Fluid Loss
• Can be measured and observed• Urine output• Drains and tubes• Emesis • Diarrhea
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Insensible Fluid Loss
• Loss of fluid through lungs (2/3) and skin (1/3)
• Influenced by heat and humidity, body temp, respiratory rate (children have higher RR than adults)
• Basal metabolic rate increases 10% for each degree Celsius above normal body temperature
• Example 39 Celsius = 102.2F – BMR increases by 20% !
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Electrolytes
• NA- major electrolyte in ECF– Needed to establish osmolarity
• K- major electrolyte in ICF– Needed for excitability of neurons and
muscles
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Three Types of Dehydration
• Isotonic• Hypotonic• Hypertonic
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Isotonic Dehydration
• Sodium and water deficits are the same (salt and water are lost in equal amounts in ICF and ECF)
• NA+ 130-150meq/L (normal)• Most common type in children
from low PO intake• Can result in hypovolemic shock
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Hypotonic Dehydration
• Sodium deficit is greater than the water deficit
• Water moves from ECF to ICF• NA+ < 130meq/L• Results from GI losses
• May result in shock
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Hypertonic Dehydration
• Water loss exceeds sodium loss• Body compensates with fluid
shifts from ICF to ECF• NA+ > 150meq/L• May be caused by severe
vomiting, too much IV NA• Can result in seizures
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Know the S+S of Dehydration
• Mild– Normal VS, moist mucous membranes,
alert, normal urine output, normal turgor, fontanelle, normal cap refill, thirsty
• Moderate– Rapid pulse and RR, normal BP, dry
mucous membranes, irritable, dark urine and decreased output, poor turgor, sunken fontanelle, delayed cap refill, moderately thirsty
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Know the S+S of Dehydration
• Severe• Changes in respirations depth and pattern,
rapid weak pulse, low BP, mucous membranes parched, can be comatose, absent urine output, very poor turgor, sunken fontanelle, cool skin
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Monitor for Dehydration
URINE OUTPUT SHOULD BE AT LEAST 1-2 ml/kg/hr
ALL children are on I+O pay attention to the balance
Monitor labs for:– Increased BUN– Increased serum bicarb– Hyponatermia– Hyperkalemia– Increased urine specific gravity
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PREVENT dehydration
• Monitor temperature, prevent overheating
• Give frequent fluids, may need oral rehydration (pedialyte) 50 ml/kg/ in 4 hours when febrile and GI losses
• Use small medicine cups, syringe without needed to administer fluids…even 1 tsp every few minutes
• Monitor IV fluid administration, ensure patent IV site
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A teenager with chronic asthma asks the nurse, “How come I make so much noise when I breathe?” The nurse’s best response is:
a. It is the sound of air passing through fluid in your alveoli
b. It is the sound of air passing through fluid in your bronchus
c. It is the sound of air being pushed through narrowed bronchi on expiration
d. It is the sound of air being pushed through narrowed bronchi on inspiration
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Which school related activity might the school nurse prohibit for a child with asthma?
a. Swim teamb. The Bandc. Pet “show and tell”d. An art class
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A toddler with cystic fibrosis is placed in a high-humidity cool-mist tent operated with compressed air. The nurse knows the primary reason for this therapy is to:
a. Provide oxygenb. Lower the child’s temperaturec. Moisten the airway and mobilize
secretionsd. Provide additional fluids
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. A preschooler with a diagnosis of epiglottitis is admitted to the hospital. Which MD order should the nurse question for this child?
a. Place a pediatric size tracheostomy tray in the room
b. Monitor pulse oxygen saturation every 15 minutes
c. IV D5W at 42 ml/hrd. Obtain CBC and Throat Culture
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When assessing a child who is suspected of having asthma, the nurse should specifically ask the parents about which symptom that they may have noted?
a. Coughing a night in absence of respiratory infection
b. Coughing throughout the dayc. Expiratory wheezingd. Shortness of breath
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. When caring for a child who has recently undergone a tonsillectomy, the nurse should be aware that the child is discouraged from:
a. Talkingb. Blowing the nosec. Eating flavored ice popsd. Taking pain medication
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When caring for a child who has had a tonsillectomy the nurse’s priority observation should be for:
a. Coffee ground emesisb. Frequent swallowingc. Complaints of a sore throatd. A slight increase in temperature
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When assessing a child who is preverbal for otitis media, the nurse should anticipate that the child will:
a. Have difficulty swallowingb. Rub the affected side of head on the
mattressc. Have a runny nosed. Have vomiting and diarrhea
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The nurse’s health care teaching to assist parents in preventing otitis media should include instructions to:
a. Finish the entire prescription of antibiotics
b. Administer acetaminophen to reduce painc. Apply warm compresses to affected eard. Refrain from putting the child to bed with
a bottle