PRNU 232 Peds Exam #2

Vesicoureteral reflux

o Retrograde flow of bladder urine into the ureters o Increases potential for infection o Grades 1-5

The nurse is doing a presentation for a group of nursing students about the topic of menstrual disorders. After discussing the disorder secondary amenorrhea, the students make the following statements. Which statement made by the nursing students is the most accurate regarding the cause of secondary amenorrhea? "It is caused from taking birth control pills when a girl is younger than 13 years old." "This disorder is usually seen after a girl has had a spontaneous abortion." "Emotional stress can be a cause of this disorder." "This is what happens if a 16-year-old girl has never had any periods at all."

"Emotional stress can be a cause of this disorder." Secondary amenorrhea can be the result of discontinuing contraceptives, a sign of pregnancy, the result of physical or emotional stress, or a symptom of an underlying medical condition. A complete physical examination, including gynecologic screening, is necessary to help determine the cause. Primary amenorrhea occurs when a girl has had no previous menstruation. A spontaneous abortion does not cause secondary amenorrhea.

The nurse is collecting data on a 2-year-old child admitted with a diagnosis of gastroenteritis. When interviewing the caregivers, which question is most important for the nurse to ask? "How many times a day does your child urinate?" "How long has your child been toilet trained?" "Tell me about the types of stools your child has been having." "What foods has your child eaten during the last few days?"

"Tell me about the types of stools your child has been having." For the child with gastroenteritis, the interview with the family caregiver must include specific information about the history of bowel patterns and the onset of diarrheal stools, with details on the number and type of stools per day. Recent eating patterns, determining if the child is toilet trained, and how many times a day the child urinates are important questions, but the highest priority is gathering data regarding the stools and stool pattern.

Constipation in childhood

- Often due to environmental changes or control over body functions - Encopresis—inappropriate passage of feces, often with soiling - May result from stress - Therapeutic management § Debulking of stool § Diet § Hydration § Exercise § Bowel regimen

Nursing interventions for pyloric stenosis

- Pyoloromyotomy - surgical treatment soon after diagnosis - Correct dehydration - Correct acid base balance - Post Op - start feeding 4 plus hours after surgery - Assess for infection - support family

5 year old Tommy was admitted for nephrotic syndrome. Which of the following are nursing diagnoses that could be made? Select all that apply. a.Risk for infection b.Risk for fluid volume deficit c.Imbalanced nutrition: less than body requires d.Risk for skin breakdown

A, C, and D are correct. B is incorrect because there would be risk for fluid volume excess rather than deficit

Which of the following is considered the gold standard for diagnosing CF? A.If the parents report their infant tastes salty when they kiss their head. B.A sweat chloride test performed at an accredited CF center. C.A blood test that looks at the sodium level. D.A pulmonary function test to determine lung function at 5 years of age.

A.A sweat chloride test performed at an accredited CF center.

The biological parents (who do not have CF themselves) of a child with cystic fibrosis tell the nurse that they are interested in having another baby, but they aren't sure if this baby could have CF as well. What should you tell them? A.Each child the couple conceives together has a 25% chance of having CF, independent of their other children. B.Only every other child they have could have CF. C.Cystic fibrosis is a dominant disorder, so every child they have will have CF. D.Since their last child has CF, there is a 0% chance the next one can have it.

A.Each child the couple conceives together has a 25% chance of having CF, independent of their other children.

A nurse is teaching the parents of a 8 month old with cystic fibrosis how to perform chest physiotherapy. Which of the following should the nurse tell the parents: A.Make sure you use the heel of your hand for effective mucus breakup on bare skin B.It is advised to do CPT right after mealtime C.Don't do this when your child has a cold D.Use a cupped hand or palm percussion cup

A.Use a cupped hand or palm percussion cup

What is important to include in the discharge teaching for a child that had nephrotic syndrome? Select all that apply. a.Monitor for protein in your child's urine by using an at home test. b.Take frequent weights of your child and call your provider if there is rapid weight gain c.Monitor and call your provider if there is swelling of the hands, feet, and/or face d.Monitor and call your provider if you child has foamy, dark urine.

All of the above are correct. You want to focus on preventing relapse with this condition. Teaching the parents or caregivers of the early signs of nephrotic syndrome are important for early identification and treatment for their child.

A public health nurse is teaching a group of parents about the age group that is most commonly at risk for catching strep throat, and why this is. The nurse tells the parents which of the following? A: Infants and toddlers who are breastfeeding, because the asymptomatic mother can spread it through the breast milk B: Children ages 5-15, because strep throat is often spread at crowded places like schools and daycares C: Teenagers, because strep throat is primarily spread through saliva from things like kissing and sharing drinks D: It is not common to see strep throat in children, as it is an illness that primarily affects people in their 20s and 30s

B: Children ages 5-15, because strep throat is often spread at crowded places like schools and daycares

A nurse is educating parents about the treatment of strep throat. The nurse knows further teaching is required when a parent says: A: "Cold food will help soothe my child's throat." B: "Gargling with warm salt water may relieve some discomfort." C: "After my child starts antibiotics, it will be about a week before she starts to feel better." D: "Penicillin is an antibiotic that is often prescribed for strep throat."

C: "After my child starts antibiotics, it will be about a week before she starts to feel better."

Hypertrophic pyloric stenosis

Constriction of the pyloric sphincter with obstruction of the gastric outlet

Therapeutic interventions for diarrhea

Fluids § IV fluids: isontonic (NS) to initiate promptly § If tolerating PO's Oral rehydration solution § Antibiotics: NOT routinely used § Probiotics: Appear to have a modest effect on recovery from infectious diarrhea. Effective in those children who are taking antibiotics for other reason. Nursing Care Management § Assessment (and reassessment!) § Understand and initiate appropriate treatment for mild, moderate, or severe dehydration § ORS guidelines for rehydration § Replace ongoing stool losses 1:1 with ORS § Give in small amounts frequently (teaspoon, cup, syringe or via NGT) § Continue use of breast milk § Education (prevention) § Support to family

Allergies

Hyersensitivity to an allergen - triggers immune response - Skin contact (poison plants, animal dander, latex, pollen - Injection (bee sting, medication) Ingestion (medication, nuts & shellfish) - Inhalation (pollen, dust, mold & mildew, animal dander)

Intussusception

Pathophysiology: Telescoping or invagination of one portion of intestine into another § Occasionally due to intestinal lesions § Etiology unknown—often follows viral illness Classic presentation - "currant jelly - like stools" § Caused from leaking blood and mucous into intestinal lumen Classic triad of symptoms § Sudden onset of abdominal pain, cramping, drawing up legs § Abdominal mass "sausage like" § Blood stool § Vomiting and diarrhea § Most common in 1 -2 Y/O Diagnostic evaluation § Ultrasound Attempt conservative treatment (nonsurgical) first § Air enema (radiologist guided) · With or without contrast § Hydrostatic enema (ultrasound guided) If unsuccessful, progress to surgery tx § Surgical reduction and fixation, or § Excision of nonviable segment of colon Nursing interventions § IV fluids Pre op § Post op care: pain management, VS, I&O, if orogastric tube assess drainage,

Most serious cause of gastroenteritis

Rotavirus § Diarrheal disease § Infects the intestines § Norovirus has surpassed rotavirus as the most common pathogen due to rotavirus vaccine

Anaphylaxis

Severe allergic reaction - multiple systems involved in allergic reaction (ab cramping, struggling to breathm rashes, wheezing, swollen mouth throat or tongue, risk of uncosciousness)

Most common consequences of GI dysfunction in children

o Malabsorption o Fluid and electrolyte disturbances o Malnutrition o Poor growth

Objective measurement of pulmonary function is difficult in children. True or False

True

Basic asthma medications

Two classes of Asthma management medications: Long-term-control medications •Achieve and maintain control of persistent asthma • Quick-relief medications (rescue) •Treat acute symptoms and exacerbations

Of the following which is NOT a factor increasing the risk of asthma exacerbation: a. 2 or more ED/hospital visits in the past year b. History of incubation c. Airflow obstruction on inspiration d. Taking medications as prescribed

d. Taking medications as prescribed

cryptorchidism

o 3-4% full term males o 30% preterm o Usually in the inguinal canal o Most descend spontaneously by 9 months, if not by 1 year - needs careful evaluation o Intraabdominal or high up in inguinal canal o May only find a remnant that results from torsion in utero o Undescended testicle/ surgical correction if not descended by 9-12 months

Clinical manifestations of a child with GI dysfunction

o Failure to thrive o GERD o Vomiting o Nausea o Constipation o Encopresis o Abdominal Distension o Diarrhea o Pain o GI bleed o Hematemesis o Melana o Jaundice, dysphagia fever

What is a complication of cystic fibrosis? pneumothorax urinary tract infection kidney disease Crohn disease

pneumothorax Cystic fibrosis (CF) is a genetic disorder causing thickened tenacious secretions of the sweat glands, gastrointestinal tract, pancreas, respiratory tract and exocrine tissues. The treatment is aimed at minimizing pulmonary complications, maximizing lung function, preventing infection, and facilitating growth. A pneumothorax is a complication of CF. A rupture of the subpleural blebs through the visceral pleura takes place. There is also a high reoccurrence rate and incidence increases with age. Crohn disease is a gastrointestinal disorder that is not associated with cystic fibrosis. Urinary tract infection and kidney disease are also not associated with CF. Most of the problems and complications associated with CF relate to the respiratory system, the gastrointestinal system, and infectious disorders.

hydrocele

scrotal swelling caused by a collection of fluid - painless - COmmon in ingants usually subsides on its own within first year of life

hypspadias

urethral opening on the underside of the penis

Child weighs 32 kg what is their daily maintenance fluid requirements

§ 100 x 10 for 1st 10 kg of body weight = 1000 § 50 x 10 for 2nd 10 kg of body weight = 500 § 20 x 12 for remaining body weight = 240 § 1000 + 500 + 240 = 1740 ml/24 hr § 1 cup = 240 ml; 1740 ml = 7 ¼ cups

Diagnostic evaluation IBD

§ History and Physical exam § Labs: CBC to evaluate anemia, ESR, CRP § Stools: examined for blood, leukocytes, and infectious organisms § Gold standard - GI series (colonoscopy and or endoscopy)

Ulcerative colitis

- chronic inflammation of the colon with presence of ulcers § Limited to colon and rectum § Inflammation of mucosa and submucosa - continuous inflammation with no patchiness § Ulcers penetrate the inner lining of intestine only § Typically, in lower left abdomen § Common during bowel movements

Crohn's disease

- chronic inflammation of the intestinal tract § Anywhere from mouth to anus § Inflammation involves all layers of bowel wall § Patches of inflammation can be found between healthy section of the bowel § Gastritis present in 30 percent of patients § Typically, in abdomen § Ulcers can penetrate entire thickness of intestinal lining § Uncommon

Inflammatory bowel disease

- immune-mediated inflammatory disease - ~ 800,000 children have IBD in US (Crohnscolitis Foundation) - Incidence is increasing - Crohn's more common - Median age of diagnosis is 12.5 years - Pediatric cases more aggressive than adult - Cause is not clear § Immune reaction § Genetics § Environmental

Normal urinalysis

- pH 5 to 9 - Specific gravity 1.001 to 1.035 - Protein <20 mg/dl - Urobilinogen up to 1 mg/dl - NONE OF THE FOLLOWING: § Glucose § Ketones § WBCs § RBCs § Casts § Nitrites

The nurse is caring for a 5-year-old client and notes respiratory rate of 45 breaths per minute, blood pressure 100/70 mm Hg, heart rate 115, temperature 101°F (38.3°C), and oxygen saturation 86%. Which diagnostic test is priority for the nurse to complete? Arterial blood gas (ABG) Complete blood count (CBC) Electroencephalogram (EEG) Pulmonary function test

Arterial blood gas (ABG) The most useful diagnostic test in respiratory distress is an ABG. Knowing normal blood gas values for children is very important for evaluation and proper treatment. A CBC is a blood test used to test for disorders including anemia, infection, and leukemia. An EEG is a test used to find problems related to electrical activity of the brain. A pulmonary function test is performed to evaluate the respiratory system. Based on the findings, the child is experiencing respiratory distress and has an elevated temperature. Airway and breathing are priority over an elevated temperature. The child's blood pressure is within normal range for this age.

What is an uncommon but potential complication of strep throat, if left untreated? A: Liver failure B: Rheumatic fever C: Hydrocephalus D: Rhabdomyolysis

B: Rheumatic fever

The caregivers of a child report that their child had a cold and complained of a sore throat. When interviewed further they report that the child has a high fever, is very anxious, and is breathing by sitting up and leaning forward with the mouth open and the tongue out. The nurse recognizes these symptoms as those seen with which disorder? Spasmodic laryngitis Tonsillitis Laryngotracheobronchitis Epiglottitis

Epiglottitis The child with epiglottitis may have had a mild upper respiratory infection before the development of a sore throat, and then became anxious and prefers to breathe by sitting up and leaning forward with the mouth open and the tongue out. The child with tonsillitis may have a fever, sore throat, difficulty swallowing, hypertrophied tonsils, and erythema of the soft palate. Exudate may be visible on the tonsils. The child with acute laryngotracheobronchitis develops hoarseness and a barking cough with a fever, cyanosis, heart failure; acute respiratory embarrassment can also result.

A neonatal nurse teaches students how to recognize gastrointestinal disorders in infants. The nurse tells the students that failure of the newborn to pass meconium in the first 24 hours after birth may indicate what disease? Ulcerative colitis (UC) Hirschsprung disease Short bowel syndrome (SBS) Gastroenteritis

Hirschsprung disease The nurse should suspect Hirschsprung disease when the newborn does not pass meconium in the first 24 hours after birth, and has bilious vomiting or abdominal distention and feeding intolerance with bilious aspirates and vomiting. Typical signs and symptoms of gastroenteritis include diarrhea, nausea, vomiting, and abdominal pain. The characteristic GI manifestation of UC is bloody diarrhea accompanied by crampy, typically left-sided lower abdominal pain. Clinical manifestations of untreated SBS include profuse watery diarrhea, malabsorption, and failure to thrive.

The nurse is caring for a child with a diagnosis of pyloric stenosis during the preoperative phase of the child's treatment. What is the highest priority at this time? Preparing family for home care Promoting comfort Maintaining skin integrity Improving hydration

Improving hydration Preoperatively, the highest priority for the child with pyloric stenosis is to improve nutrition and hydration. Maintaining mouth and skin integrity, and relieving family anxiety are important, but these are not the priority. The child will not likely have intense pain. Preparing the family for home care would be a postoperative goal.

Metered dose inhaler deposition can decrease by up to ___% without a spacer. a. 10 b. 25 c. 70 d. 5

c. 70

The nurse is caring for a 12-year-old child with Crohn disease. What assessment finding will the nurse report to the health care provider when caring for the child? clear lung sounds fever no joint swelling report of a headache

fever Crohn disease may affect any area of the digestive tract. It causes acute and chronic inflammation. It may also cause abscesses and fistulas. Inflammation and abscesses can cause fever. An increasing temperature could be the manifestation of the inflammation worsening or the development of an abscess and subsequent infection. The progression of the disease will be reported to the health care provider. A headache may accompany the fever and is a sign of generally not feeling well. It does not indicate progression of the disease, thus does not need to be reported. Clear lung sounds and no swollen joints are good signs, but they are not associated with Crohn disease.

Inguinal hernia

happens when contents of the abdomen—usually fat or part of the small intestine—bulge through a weak area in the lower abdominal wall.

Management of asthma

•Reduce/prevent exposure to known triggers •Pharmacologic therapy - proper use •Educate patient, family, school, caregivers •Use of objective lung function measures to gauge asthma severity and the effectiveness of therapy •Control of comorbid conditions

Daily maintenance fluid requirements

- Calculate child's weight in kg - Allow 100 ml/kg for first 10 kg body weight - Allow 50 ml/kg for second 10 kg body weight - Allow 20 ml/kg for remaining body weight

pertussis

- whooping cough; highly contagious bacterial infection of the pharynx, larynx, and trachea caused by gram negative bacillus Bordetella pertussis - Cough lasts 6-10 weeks - Post-tussive vomiting in adolescents is common - Complications dependent on age: under 6 months can cause apnea - Droplet spread and contagious for two weeks after initial cough in catarrhal stage - Worldwide, there are an estimated 16 million cases of pertussis and about 195,000 deaths per year. - Cough illness on any duration who has been exposed to pertussis (school or other setting) uCough illness lasting >1 week with whoop, paroxysms, post-tussive vomiting - Prolonged cough > 2 week in the absence of a more likely diagnosis - When a patient has close contact with an infant or others at increased risk for pertussis complications, have a lower threshold Diagnosis: nasopharyngeal swab - Catarrhal: first 7-10 days Rhinitis, low grade fever, mild cough which gradually becomes more severe - Paroxysmal: usually 1-6 weeks, can last up to 10 weeks Rapid cough persistent, long aspiratory effort followed by "whoop cough", cyanosis, post tussive vomiting, exhaustion (average 15 attacks in 24 hrs) - Convalescent: 7-10 days Gradual recovery, less persistent cough that disappears in 7-21 days

In caring for an infant diagnosed with pyloric stenosis the nurse would anticipate which intervention? Prepare the infant for surgery. Medicate the infant with analgesics. Change the infant's diet to one that is lactose-free. Assist in doing a barium enema procedure on the infant.

Prepare the infant for surgery. In pyloric stenosis, the thickened muscle of the pylorus causes gastric outlet obstruction. The treatment is a surgical correction called a pyloromyotomy. The condition is not painful, so no analgesics would be needed until after surgical repair. The condition is not related to lactose in the diet, so changing to lactose-free formula would not correct the condition. A barium enema would be used to diagnose intussusception.

Asthma

a chronic inflammatory disorder of the airways...recurrent or persistent episodes...associated with variable airflow obstruction...bronchial hyper-responsiveness to a variety of stimuli..."

First line of treatment is: a. Inhaled corticosteroids b. Long-acting bronchodilators c. Leukotriene modifiers d. Systemic corticosteroids

a. Inhaled corticosteroids

tracheosophageal fistula

abnormal passageway pertaining to the trachea and esophagus § Pathophysiology · VATAR - common to see other congenital defects. § Assessment · May be identified in utero · At birth see frothy mucous in mouth and nose, abdominal distention, in attempt to feed see 3 Cs (coughing, choking cyanosis) · Required surgery

obstructive uropathy clinical manifestations

anatomic changes in the urinary system caused by obstruction § Abdominal and/or suprapubic mass § Abdominal distention § Respiratory distress § Fever § Vomiting, failure to thrive, UTI § Gross hematuria § Abnormal urinary stream § Daytime incontinence, nocturnal enuresis, polyuria § Recurrent abdominal or flank pain Complications § Inability to concentrate urine § Progressive loss of renal function § Increased incidence of UTI

3 year old James was brought into the hospital and diagnosed with idiopathic nephrotic syndrome. What is a symptom that would not be found upon your assessment. a.Edema b.Respiratory distress c.Clear, light yellow urine d.Fatigue

c.Clear, light yellow urine James would have foamy urine due to excess protein in the urine

esophageal atresia

congenital absence of part of the esophagus § Pathophysiology · VATAR - common to see other congenital defects. § Assessment · May be identified in utero · At birth see frothy mucous in mouth and nose, abdominal distention, in attempt to feed see 3 Cs (coughing, choking cyanosis) · Required surgery

Gastroschisis

congenital fissure of the abdominal wall not at the umbilicus § Cover gastroschisis with sterile, moist dressing § Thermal regulation § Fluid management § Care of high-risk infant · Preoperative · Postoperative o Prevention of infection and complications o Long-term support to family

The nurse is conducting a physical examination of an infant with suspected pyloric stenosis. Which finding indicates pyloric stenosis? sausage-shaped mass in the upper mid abdomen perianal fissures and skin tags abdominal pain and irritability hard, moveable "olive-like mass" in the upper right quadrant

hard, moveable "olive-like mass" in the upper right quadrant A hard, moveable "olive-like mass" in the right upper quadrant is the hypertrophied pylorus. A sausage-shaped mass in the upper mid abdomen is the hallmark of intussusception. Perianal fissures and skin tags are typical with Crohn disease. Abdominal pain and irritability is common with pyloric stenosis but are seen with many other conditions.

Prevention & treatment of allergies

•Determine allergen •Reduce or eliminate exposure to allergen •Pharmacological therapy •Asthma Action Plan •Immunotherapy (allergy shots) - can last 3 years •Breathing exercises - pursed lip breathing •Epipen RX and Education

Triggers / risk factors of asthma

•Family history •Prematurity •Viral Infection (RSV) •Tobacco smoke exposure •Wood smoke exposure •Exercise •Pollen •Dust Mites •Mold •Cold or humid air •Emotions •Menstrual cycle •Pets - dander

Inhaled corticosteroids (ICS)

•Generally well tolerated and safe •Local adverse effects •Impair growth •Oral thrush •Use chamber device •Rinse mouth after use, wipe face, brush teeth •Reflex cough/horse voice •Use chamber device •Slow the rates of inspiration

Otitis media

- Eustachian tube position - Recurrent respiratory infections - Other causes - 6 months to 2 years highest incidence uTX = ABX and pain control

Malrotation and volvolus

- Malrotation is due to abnormal rotation around the superior mesenteric artery during embryonic development - Volvulus occurs when the intestine is twisted around itself and compromises blood supply to intestines - Classic symptom of bilious emesis in the newborn period - Emergent surgical intervention required to prevent death

Differences in infant's GI tract

§ Stomach capacity § <HCL & different mix of pancreatic juices § Liver function immature until 1 year § What does this mean for a infant in regards to illness and medications? · Regulates Hormones Adolsterone and Cortisol · Regulates supply vitamins and minerals · Detoxify meds: may be less effective because less is excreted, low albumin (produced in liver) and albumin helps bind drugs in plasma) · Production of clottling proteins (albumin maintains osmosis, helps bind medications) globin, binds O2 · Storage of glycogen (glucose) for energy · Bile produced in liver, stored in gallbladder. Bile emulsifies fats and aids in vitamin absorption of VIT A, D, E, K · Infants: low bile excretion, low vitamin synthesis, meds excreted less efficiently, any illness increasing propulsion of foods thorugh GI tract.

GERD management

§ Uncomplicated GE Reflux · Happy spitter, good weight gain, normal physical exam § Education and Reassurance · Tips include gravity, not overfeeding, avoiding exposure to tobacco o Thickening feedings o Upright positioning o Frequent burping during feeds o Avoid overfeeding o Positioning to promote gastric emptying § Reflux and poor weight gain · Evaluation of caloric intake · Evaluation of swallowing · Signs of pyloric stenosis · Lab testing: stool testing, CBC, Electrolytes and review NB screening · Older child ?allergies ? Celiac § Pharmacologic Treatment · Ranitidine (H2 Blocker), · Omeprazole (Proton Pump Inhibitor) more effective, more expensive § Nissen fundoplication · PASSAGE OF GASTRIC FUNDOS BEHIND ESOPHAGUS AND ENCIRCLE IT

Hirschsprung disease diagnostic eval

§ Urgent evaluation: X-ray, barium enema, rectal suction biopsy § Anorectal manometric exam · Measures pressure in rectum (abilityof segment to relax § Confirm diagnosis with rectal biopsy § Type of surgery depends on extent/location of aganglionic bowel § Less extensive—single surgery without colostomy § Two stages · Temporary ostomy · Second stage "pull-through" procedure

Physical & clinical manifestations of IBD

§ Loose or bloody stools, belly pain, and tenesmus § Growth failure § Delayed puberty § Fever and fatigue common with flares of disease § Oral ulcerations, clubbing, rashes, eye inflammation, jaundice, arthritis § Growth failure · Malabsorption: CHO, Lactose, Fat · Maldigestion · Energy expenditure: increased energy expenditure may activate proinflammatory cytokines · Protein loss: inflammation · Hypogonadism and pubertal delay

Epinephrine doses

•We prefer use of the autoinjector in these patients for speed, reliability, and ease of use. •Infants weighing <10 kg should be given an exact weight-based dose (not estimated), whenever possible. However, if drawing up an exact dose is likely to cause a significant delay in a patient with severe symptoms or who is rapidly deteriorating, the 0.1 mg dose can be given by autoinjector or by drawing up 0.1 mL of the 1 mg/mL solution. •Children weighing from 10 kg to 25 kg give 0.15 mg by autoinjector or by drawing up 0.15 mL of the 1 mg/mL solution. •Patients weighing >25 to 50 kg give 0.3 mg by autoinjector or by drawing up 0.3 mL of the 1 mg/mL solution.. •Patients who weigh >50 kg give 0.5 mg (0.5 mL of the 1 mg/mL solution). If the patient is obese, this can be administered using a 1.5-inch needle to penetrate the subcutaneous fat. If no response in 5 - 15 minutes repeat with another unused Pen

A child with asthma has been monitoring his peak expiratory flow rate (PEFR) and has been maintaining it within 90% of his personal best. Today, the child is experiencing symptoms and his PEFR is at 40% of his personal best. The child's mother calls the office and asks the nurse what she should do. What would the nurse instruct the mother to do first? "Have him use his short-acting bronchodilator right away." "You need to take him to the emergency department right away." "Continue to watch his PEFR readings and call back if they go below 40%." "Have him use his low-dose steroid inhaler now and again in 15 minutes."

"Have him use his short-acting bronchodilator right away." The child's symptoms and drop in PEFR suggest a medical alert or "red" situation, indicating the need for the short-acting bronchodilator and then a trip to the office or emergency department. The child should use his short-acting bronchodilator first and then go to the physician's or nurse practitioner's office or emergency room. Waiting for a greater drop in his PEFR readings would be inappropriate because the child is experiencing an acute condition that warrants immediate attention. The child is experiencing an acute situation and requires immediate attention. A low-dose steroid inhaler would not be appropriate because it would not help his bronchospasm.

Acute glomerulonephritis

- May be primary event or evidence of systemic disorder, immune modulated disease, can be mild to severe - Common features § Kidney appears normal to moderately enlarged, inflammation of the capillary loops in - Symptoms § Generalized edema due to decreased glomerular filtration · Begins with periorbital edema · Progresses to lower extremities and then to ascites § HTN due to increased ECF § Has had infection, viral or bacterial prior to symptoms, this may be mild, acute post streptoccocal glomerlunephritis § Oliguria: small amounts of urine § Loss of appetite § Hematuria · Bleeding in upper urinary tract → smoky urine, tea or cola color of urine § Proteinuria · Increased amount of protein = increase in severity of renal disease

Asthma and obesity

- Patients with obesity: •Do not respond as well to the flu shot •May suffer from obese sleep apnea •More at risk for depression •If eating a high fat diet (western diet) have a decreased response to bronchodilators Diet high in soluble fiber increases lung function Diet high in fruits and vegetables decreases asthma exacerbations Dash diet improves asthma control Goal to lose 10% body weight to improve asthma control Can be difficult due to Shortness of Breath and if on oral cortisone

Respiratory Syncytial Virus (RSV)

- A virus that causes an infection of the lungs and breathing passages; can lead to other serious illnesses that affect the lungs or heart, such as bronchiolitis and pneumonia. RSV is highly contagious and spread through droplets. - Affinity for the small airways: producing main symptom WHEEZE - More prevalent in the winter months - Spread by droplets - Highly contagious Inoculation in eyes and nose by direct contact with drops or indirect contact with - Transmitted by cough up to three feet - Remains active on clothes for 20 minutes or more - Remains active for 8 hours on nonporous objects - Patho: affects the epithelial cells of the respiratory tract, cells swell, and lumina filled with mucus and exudate - S/S: URI symptoms, Rhinorrhea and low grade fever, Otitis media and conjunctivitis, Wheeze, retractions, tachypnea - Diagnosis: Swab done only when possible admission otherwise on clinical symptoms - Care: supportive, hydration, airway support for small infants, close observation

Edema

- Abnormal accumulation of fluid within the interstitial tissue and subsequent tissue expansion § Congenital heart disease, increased venous pressure § Failure of lymphatic drainage § Peripheral edema, ascites, pulmonary, cerebral, or overall fluid gain § Local edema from an injury § Management: treatment of underlying disease process

Renal structure and funtion

- Primary responsibility of kidney is to maintain the composition and volume of the body fluids in equilibrium - Urine: product of glomerular filtration - Reabsorption: transport of substances from the tubular lumen to the blood - Secretion: transport from blood to tubule - Excretion: elimination of substance from body (urine) - Secondary function of the kidney is production of erythropoietin stimulating factor stimulates erythropoietin (RBC) in bone marrow - Also secretes renin in response to reduced blood volume (regulates blood pressure) - Activates vitamin D which helps synthesis of Ca - Maintains acid-base balance in body

Medication actions

- SABAs: short acting B agonist •Albuterol and levalbuterol - relax smooth muscle •Therapy of choice for relief of acute symptoms - Anticholinergics: •Inhibit cholinergic receptors and reduce muscle constriction in the airway •Atrovent (ipratropium) via nebulizer - Systemic corticosteroids: •Although not short acting, oral systemic corticosteroids are used for moderate and severe exacerbations as adjunct to SABAs to speed recovery and prevent recurrence of exacerbations

Testing spirometry

- Spirometry (%predicted FEV1) forced expiratory volume in 1 second (+) reliable modality (- ) interpretation can be difficult

Which of the following is not a common sign of strep throat? A: Cough B: Fever C: Swollen lymph nodes D: Pain when swallowing

A: Cough

Assessment of GI function

o History o Clinical examination and observation o I&O o Weight and height o Abdominal assessment o Lab tests: > 2 weeks, fever, blood § Stool exam § O & P especially if immigration recent, backcountry camping, exposure to farm animals § If ill appearing: may see order for blood work: CBC with diff, Electrolytes with BUN and CR o Dietary history: What is the patient eating? Typical day? o How often are they stooling? What does the stool look like? o Observe growth chart over time, BMI o Potential for dehydration o Duration o Living environment, access to water o Recent antibiotic use

An 18-month-old infant is brought to the emergency department with flu-like symptoms. The infant is diagnosed with pneumonia secondary to aspiration of stomach contents. The nurse explains to the parents that pneumonia is a condition that often occurs secondary to: gastroesophageal reflux disease. cystic fibrosis. Hirschsprung disease. inflammatory bowel disease.

gastroesophageal reflux disease. Gastroesophageal reflux (GER) is the passage of gastric contents into the esophagus. These refluxed contents may be aspirated into the lungs. The child with gastroesophageal reflux disease may present with the physical findings of pneumonia or GER-induced asthma. GER may cause apnea or an apparent life-threatening event in the younger infant. Pneumonia can occur in children with cystic fibrosis, but the child would need to have the cystic fibrosis diagnosis first. Hirschsprung and inflammatory bowel diseases are diseases of the gastrointestinal tract that do not present with respiratory symptoms.

The nurse is caring for an 11-year-old child with pneumonia who is exhibiting an increased work of breathing. Which intervention is the priority? positioning the child in Fowler position administering intravenous fluids as prescribed providing supplemental oxygen as prescribed administering analgesics as prescribed

positioning the child in Fowler position Positioning the child in Fowler position helps to open the airway and provide more room for lung expansion, resulting in more effective breathing patterns while supplemental oxygen and intravenous fluids are administered. Administering intravenous fluids and administering oxygen are appropriate actions after the child is placed in a comfortable position. Analgesics may be prescribed and administered if the child is experiencing pain from coughing.

Hirschsprung disease manifestations

§ Aganglionic segment of colon § In more than 80% of cases affects the internal sphincter, rectum, and a few centimeters of the sigmoid colon (short-segment disease) § Accumulation of stool with distention § Failure of internal anal sphincter to relax § Enterocolitis may occur

Renal development and function in infancy

- Glomerular filtration and absorption low in infancy until age 1-2 - Newborn is unable to concentrate urine effectively - Newborn unable to reabsorb sodium and water - Newborn produces very dilute urine

Gastroesophageal reflux (GERD)

- Defined as transfer of gastric contents into the esophagus - Occurs in everyone - Frequency and persistency may make it abnormal - May occur with or without tissue damage - 50% of infants <2 months old are reported to have "physiologic" GER § Usually resolves spontaneously by age 1 year - Warning signs of underlying pathology § Bilious vomit § GI bleed: hematemesis, hematochezia § Projectile vomiting § Constipation § Recurrent pneumonia § Concurrent neuro disease § Fever, pneumonia, lethargy, poor weight gain

Influenza

- Highly contagious disease spread person to person by direct contact, droplet contamination and fomites contaminated with nasopharyngeal secretions. - Symptoms - high fever, headache, chills, coryza, vertigo, sore throat, muscle pain, cough, malaise - Complications - secondary bacterial infections ie. Pneumonia, otitis media

Clinical presentation of asthma in children

- Extremely variable - Symptoms: cough (particularly worse at night, wakes from sleep, with exertion), wheeze, shortness of breath, fatigue, increased work of breathing/recurrent difficulty breathing, recurrent chest tightness, exercise intolerance, colds/URIs that last greater than 2 weeks - Signs: none, or tachypnea, wheeze, decreased aeration, retractions, prolongation of the expiratory phase, increased AP diameter

Newborn period constipation

- First meconium should be passed within 24 to 36 hours of life; if not, assess for § Hirschsprung disease, hypothyroidism - Often related to diet - Constipation in exclusively breast-fed infant almost unknown § Infrequent stool may occur because of minimal residue from digested breast milk - Formula-fed infants may develop constipation - What interventions would you use in an infant? § Interventions include glycerine suppository, rectal stimulation, bicycling legs, pear juice is persisting

Diarrhea

- Abnormal intestinal water and electrolyte transport. - Passage of loose or watery stools. - WHO defines it as 3 or more loose or watery stools per day. - Higher mortality and morbidity among infants and children <5 years - Higher incidence in low-income homes and communities worldwide - Remember infants have a decreased absorption of water and nutrients already, now increased propulsion Types § Acute: · Often Infectious: viral, bacterial · Related to another illness: otitis media · Related to ABX use: augmentin worse § Chronic: lasting > 14 days § Chronic nonspecific (irritable colon) § Life threatening Causes · Sepsis: salmonella · Intussusception · Hemolytic Uremic Syndrome (can be complication of E coli infections · Cdiff · Appendicitis

Croup

- Acute respiratory disease - Hoarseness - barking cough - inspiratory stridor - varying degrees of respiratory distress - Etiology: mainly parainfluenza virus, influenza, RSV - Most common in ages 6 months to 3 years old

Hirschsprung diseas

- Also called congenital aganglionic megacolon - Motor disorder of the gut, failure of neural crest cells (precursors of ganglionic cells) to completely form resulting in segment of colon that fails to relax leading to obstruction - Incidence: 1 in 5000 live births; more common in males and in Down syndrome - Mutations in several genes have been identified - This may be associated with other anomalies as well: GU, Vision, Hearing, heart and anorectal - ABSENCE OF GANGLION CELLS. LACK OF ENTERIC NERVOUS SYSTEM STIMULATION>> DECREASED INTERNAL SPHINCTER ABILITY TO RELAX, INCREASED RECTAL TONE, DECREASED PERISTALSIS,

Celiac disease

- Also called gluten-induced enteropathy and celiac sprue (permanent intestinal intolerance to dietary gluten) - Four characteristics § Steatorrhea and chronic diarrhea § General malnutrition, failure to thrive § Abdominal distention § Secondary vitamin deficiencies, fatigue - Pathophysiology: villi atrophy after gluten ingestion - Diagnostic evaluation § labwork; Tissue transglutenase, ANA, followed if positive for GI endoscopy and biopsy of small intestine - Therapeutic management § Dietary management eliminating gluten - Nursing considerations § Assist with assessment and diagnosis § Education and support § Adherence to regimen throughout lifetime

How to obtain urine?

- Clean catch is preferred - U-bag for collection from child - Specimen obtained by catheterization or suprapubic needle aspiration has more accurate results § May be necessary when clean-catch cannot be obtained

Long-term control medications (to be aware of)

- Cromolyn sodium and nedocromil: •Stabilize mast cells and interfere with chloride channel function. They are used as alternative, but not preferred, medication for the treatment of mild persistent asthma. - Immunomodulators: •Omalizumab (anti-IgE) is a monoclonal antibody that prevents binding of IgE to the high-affinity receptors on basophils and mast cells. •Omalizumab is used as adjunctive therapy for patients ≥12 years of age who have allergies and severe persistent asthma. •Clinicians who administer omalizumab should be prepared and equipped to identify and treat anaphylaxis that may occur. - Methylxanthines: •Sustained-release theophylline is a mild to moderate bronchodilator used as alternative, not preferred, adjunctive therapy with ICS. •Theophylline may have mild anti-inflammatory effects. •Monitoring of serum theophylline concentration is essential.

Nursing considerations for constipation

- History of bowel patterns, medications, diet - Educate parents and child: can be self perpetuating - Dietary modifications (age appropriate) § High-fiber diet § Milk/dairy relationship § Fluids - Clean out: usually Polyethyl glycol (Miralax) will work (usually 3-5 days) - Maintenance 6-12 months: laxatives and high fiber foods - Weaning: slow wean off laxatives an continue high fiber foods - POLYETHYLENE GLYCOL 3350 powder is a laxative used to treat constipation. It increases the amount of water in the stool. Bowel movements become easier and more frequent

Pneumonia

- Inflammation of pulmonary parenchyma - Causative agents are age specific - Neonates and infants: group B strep, chlamydia, RSV, parainfluenza, adenovirus - Older infants and preschoolers: strep pneumonia, haemophilus influenza (HIB), RSV, parainfluenza, influenza - Children > 5 years old: strep pneumonia, mycoplasma - Bacterial: serious infection, child appears ill, fever, rapid and shallow breathing, cough and chest pain - S&S: crackles, productive cough - Viral: preceded by viral URI, less severe, usually low grade fever, malaise (more common) - S&S: scattered wheeze and crackles, non productive cough

Long term control asthma meds

- Inhaled Corticosteroids: •First-line treatment for mild to moderate persistent asthma •The most potent and effective anti-inflammatory medication currently available •Block late-phase reaction to allergen, reduce airway hyper-responsiveness, and inhibit inflammatory cell migration and activation

Approach to asthma management by severity

- Intermittent •prn b agonist (rescue inhaler) - Mild persistent •Inhaled prophylactic anti-inflammatory therapy (Cortisol: Flovent) •prn b agonist - Moderate persistent •long-acting bronchodilator (LABA: Serevent) or leukotriene modifier (Singular) (First) •inhaled corticosteroid daily (Second) •prn b agonist - Severe persistent •inhaled corticosteroid (high dose) •long-acting bronchodilator +/- LT modifier •systemic corticosteroid + prn b agonist

Constipation

- Is a symptom rather than a disease - An alteration in the frequency, consistency, or ease of passage of stool - May be secondary to other disorders - Idiopathic (functional) constipation—no known cause - Chronic constipation—may be due to environmental or psychosocial factors - Affects up to 30% of children - Peak incidence preschool years - Children with functional constipation will benefit from prompt and thorough treatment interventions.

how to give epipen

- Lay person flat - If breathing is difficult allow to sit but do not stand or walk - Blue to the sky, orange to the thigh - form fist around epipen and pull off blue safety release - Place orange end against outer mid-thigh (with or without clothing) - Push down hard until a click is hear or felt and hold in place for 3 seconds - Call an ambulance

Fluid and electrolyte assessment

- Length of illness - Precipitating events - Age and developmental level - History of feedings - Fever (increases insensible fluid loss) - Infection - Site of fluid loss - Skin § Color, turgor, temperature § Loss of skin elasticity due to dehydration - Mucous membranes - Eyes § Tears? - Fontanels (sunken?) - Vital signs § Tachycardia § Tachypnea/ > Respiratory rate- metabolic acidosis may occur with fluid volume deficit and child may compensate with hyperventilation § BP: What changes would you expect as dehydration moves from mild to moderate to severe? · Hypotensive in moderate dehydration - Weight § Intake and output - Behavioral assessment § see irritability and as it worsens lethargy or decreased response to stimuli

Dehydration

- Occurs when total output of fluid exceeds the total input regardless of underlying cause. - Isotonic: electrolyte and water deficits occur in balanced proportions. 80% of all dehydration is isotonic - Hypertonic: water loss in excess of electrolyte loss: children given high concentration of formula through an NG tube, can lead to neurologic disturbances - Hypotonic: electrolyte deficit exceeds the water deficit - Diagnosis § Degree of dehydration based on PE § Type of dehydration base of specific case § Physical signs § Initial plasma sodium concentration § Associated electrolyte imbalance - Management § Oral rehydration § Parenteral fluid therapy · Initial goal to expand ECF · Then replace deficits · Return slowly to normal and begin oral feedings

Diarrhea in a serious ill child

- Peritonitis or abdominal mass -> appendicitis, intussusception, toxic megacolon - Not peritonitis or abdominal mass -> YES bloody diarrhea -> severe dehydration, sepsis, hemolytic uremic syndrome, intussusception, toxic megacolon, c. difficile enterocolitis - Not peritonitis or abdominal mass -> NO bloody diarrhea -> sever dehydration, sepsis, appendicitis, intussusception, toxic megacolon organophosphate poisoning

Renal system assessment

- Physical assessment § Palpation, percussion - Health history § Previous UTIs, calculi, stasis, retention, pregnancy, STDs, bladder cancer § Medications: antibiotics, anticholinergics (benadryl, atrovent), antispasmodics § Urologic instrumentation § Urinary hygiene § Patterns of elimination

Asthma history

- Respiratory diary •Establish severity: • course of cough (episodic in nature?), diurnal variability, frequency, activity level, response to treatment (what makes it better or worse?) •Associated symptoms: •fever, rhinitis, rash, exposure to illness, travel or visitors/family, chronic infections (usual treatment plan and its efficacy) •relation to meals, difficulty swallowing, questions regarding foreign body aspiration •Immunization status (flu shot) •Environmental exposures: parental/caregiver smoking, possible allergies, home is heated with? (wood stove), basement rooms (playroom or bedrooms) and ventilation. - Physical Exam: physical exam should include ear, nose, throat, nasal polyps, lungs/chest evaluation, cardiac, abdominal assessment, skin assessment (atopic/rashes), social/psychological, neurological

Internal control mechanisms influencing fluid balance

- Thirst: stimulated when > osmolality of ECF - Antidiuretic hormone: stimulated > osmolality and < volume of intravascular fluid (promotes water retention, released from posterior pituitary) - Aldosterone: enhances sodium reabsorption in renal tubules (promoting water reabsorption, adrenal cortex) - Renin-angiotensin system: when diminished blood flow to kidneys released and causes increased aldosterone - Angiotensin: vasoconstrictor that stimulates release of aldosterone as well

Distribution of body fluids

- Total body water (TBW) - about 80% at birth - Involves ICF (fluid within the cells) primary electrolyte K+ - Involves ECF (fluid outside the cells) primary electrolyte Na · Intravascular (within blood cells) · Interstitial (surrounds the cells) · Transcellular (CSF, synovial fluid, pleural fluid) · Sodium is the chief solute in ECF and the primary determinant of ECF volume

Key differences in infant respiratory tract

- Trachea ` Diameter triples between birth and 3 years ` Rich vascular and secretory beds `Shorter so air warmed and humidified less `1mm mucous decreases diameter by 75% ` Short length lends itself to ^ infections - Lungs ` Nine times more alveoli at age 9 than at birth ` ^ dead space `Move more air per minute than adults to meet metabolic demands -Thorax ` Infants have round thoraces ` Only 65% cartridge is ossified in infant's so rib cage is much more pliable ` Diaphragmatic breathers as infants, accessory muscles not as well developed - Nose breathers - Narrow passages

Lung auscultation

- Upper tract: noisy breathing, snoring, stridor, rhonchi - Lower tract: crackles or rales, rhonchi, rattles, wheeze - Look for nasal flaring, grunting, retractions

Omphalocele

- bowel covered with peritoneal sac, seen at birth or on ultrasound - Associated with other anomalies - Varies in size - 2 in 10,000 births

umbilical hernia

- protrusion of the intestine through a weakness in the abdominal wall around the umbilicus (navel) - Common in newborn period - Typically resolves in first years of life

Symptoms of asthma

•Symptoms •Nighttime awakenings •Frequency of SABA (short acting beta agonist) use for quick relief of symptoms •School days missed •Ability to engage in normal daily activities or in desired activities •Quality-of-life assessments • •Lung function: measured by spirometry • •Peak flow has not been found to be a reliable variable for classifying severity. It may serve as a useful tool for monitoring trends in asthma control over time

Etiology of chronic cough

•Important Differential Diagnosis - to be ruled out as asthma can be difficult to diagnose •Cough variant asthma •Rhinitis (allergic, non-allergic, post-nasal drip) •Gastroesophageal reflux •Respiratory illness and post infectious cough •Foreign body aspiration •Dysfunctional swallowing •Congenital anomalies •Benign tumors •Malignancies •Immunodeficiency disorders •Primary Ciliary Dyskinesia •Cystic fibrosis

Infants prone to sensible loss due to

§ Fast respiratory rate § Higher metabolic rate, >production of metabolic waste to excrete § Treatments such as radiant warmers § Greater body surface area to fluid volume - Kidney function immature until age 1-2 years § Inefficient excretion, unable to concentrate urine § Fluid and electrolyte disruption can happen rapidly

IBD tx

§ Goal: control the inflammation § CD is more disabling, has more serious complications, often less amenable to medical and surgical treatments § UC: confined to colon, a colectomy may be curative § Medical treatment: · 5-ASA's,steroids, · immunomodulators · antibiotics · biologics Prevention § Dietary advice, energy intake often has to be higher § Minimize use of steroids § Enteral nutrition Nursing Care § Nutritional Support § Hi protein, hi caloric, vitamins, folic acid § NG tube feeding (nights) § TPN (bowel rest) Prepare and Care after Surgery Chronic Disease support § Transition to adult care Care Coordination § Wound and ostomy team Anticipatory guidance § Cancer screening Infliximab § Biologic therapy § Block the Tumor Necrosis Factor alpha (TNF alpha) § IV administration § 0 - 2 - 6 - 8 weeks § Benefits: · Prolongs remission · Slows the development of complications · Delays or avoid the need for colectomy · Reverses growth delay (steroid use - impairs growth

Effects of UC and Crogn's disease

§ Inflammation and ulceration of colon mucosa · Exudation of pus, bleeding from ulcers, loss of protein - Pus, mucus, blood in stool - Loose or watery stools - Anemia - Hypoalbuminemia · Increased bowel motility - Frequent bowel movements - Urgency with incontinence - Tenesmus - Nocturnal urge to defecate · Colonic distention aggravated by ingestion of food - Abdominal distention - Crampy abdominal pain, nausea, vomiting - Anorexia, dehydration, electrolyte imbalance - Growth restriction, delayed sexual development

Acute poststreptococcal glomerulonephritis

§ Is a noninfectious renal disease (autoimmune)? § Onset 5 to 12 days after other type of infection § Often group A β-hemolytic streptococci § Most common in children 6 to 7 years old § Uncommon in children younger than 2 years old § Can occur at any age § Prognosis · 95%—rapid improvement to complete recovery · 5% to 15%—chronic glomerulonephritis · 1%—irreversible damage § Nursing management of APSG · Manage edema o Daily weights o Accurate I&O o Daily abdominal girth · Nutrition - Low sodium, low to moderate protein · Susceptibility to infections

Nephrogenic diabetes insipidus (NDI)

§ Major disorder associated with a defect in ability to concentrate urine § Distal tubules and collecting ducts are insensitive to action of ADH (vasopressin) § X-linked recessive inheritance § Clinical manifestations (DI) · Newborn—vomiting, fever, failure to thrive, hypernatremia (due to polyuria) · Polydipsia, irritability · Copious amounts of dilute urine · Growth retardation § Therapeutic management · Fluid management (management of extreme thirst in child) · Pharmacologic interventions: desmopressin (ADH analog), chlorothiazide (diuretic that helps increase reabsorption of sodium and water in proximal tubule) · Low sodium, low solute diet

types of glomerulonephritis

§ Most are postinfectious · Pneumococcal, streptococcal, or viral § May be distinct entity or § May be a manifestation of a systemic disorder · Systemic Lupus · Sickle cell disease · Others

Pyloric stenosis manifestations

§ Non-bilious projectile vomiting § Visible peristalsis § Failure to thrive in infant who is "always hungry" § Dehydration § Metabolic acidosis § 2-3.5 per 1,000 births § Males > Females § May palpate or see lump § Etiology · Environmental: smoking exposure, bottle feeding, · Genetic: studies show increased incident in twins · Macrolide antibiotics: Azithromycin, erythromycin

Obstructive uropathy diagnosis/ prognosis

§ Renal ultrasonography § Voiding cystourethrography § Diuretic renography § Intravenous pyelogram § Renal function studies, electrolytes Prognosis § Depends on type of obstruction, degree of irreversible renal damage, degree of renal dysplasia present, age at which diagnosis made, severity of complications

Hirschsprung disease nursing interventions

§ What are nursing interventions needed during: § Diagnosis § Pre-operation § Post op § Primary care § Support - diagnosis § Anticipatory guidance regarding surgery § Education regarding stoma care § Pain assessment and management § Education on signs and symptoms of infection

Extra-intestinal complications that occur during active phase of IBD

· Conjunctivitis · Iritis · Episcleritis · Mouth ulcers · Fatty liver · Liver abscess · Mesenteric or portal vein thrombosis · Venous thrombosis · Arthralgia of large joints · Erythema nodosum · Pyoderma gangrenosum

Using inhaler

•Take of cap, shake inhaler •Insert inhaler into spacer or chamber •Breathe out all air •Insert spacer or chamber in mouth •Once lungs are empty, press down on inhaler once •Breath in slowly through spacer or chamber. Count to 5 while inhaling •Hold your breath for 10 seconds, if possible •Breathe out after holding your breath; wait one minute before taking the next puff •If under 6 y/o; use a mask and keep on the face for 6 breaths •(Use Bronchodilator first - then corticosteroid)