Sensory Perception: Disorder of the Eyes and Ears Exam 4

What are the S/S of epiglottitis (8)? for infants how can we promote the airway (2)? what is dysphonia? what is stridor?

- 4D's & an S: dysphagia, dyspnea/dysphonia, drooling, distress respiratory effort w/ Stridor (inspiratory stridor, high musical note) o Dysphonia: muffled hoarse voice & pain with talking o Stridor: air is going in but not going out, associated with a blockage of the airway or foreign body o Rapid onset of high fever (greater than 102.2 F and sore throat o Child refuses to lie down & assumes Tripod position (sits upright, jaw forward in sniffing position (chin out), leaning forward w/ arms on the legs, mouth open and tongue protruding) • For infants to promote airway, can be rolled towel underneath the shoulders and will be placed in neutral position where the airway is not compromised; nose is straight up to the ceiling and there's room to keep airway open o Anxiety increases as it becomes more difficult to breathe

What will be assessed in the eyes of the pediatric patient (3) and what test will be performed and why? when is the child usually diagnosed with eye disorders? What will nurses check for the presence of (4)? Who will have eye slants or presence of epicanthal folds? what will you further assess in the patient (6)? what can occur in newborns (1)? what is anisocoria?

- Assess positioning and symmetry. • Ensure the pupils are aligned, do cover uncover test - looking for any jerky movement (nystagmus) /weakness in the eye • Usually in school is when the child is identified with eye disorders - Check for presence of strabismus (lazy eye), nystagmus, and squinting. - Assess if eyelids open equally (failure to open fully is ptosis: droopy eyelid). - Note variations in eye slant (seen in Asian individuals) and the presence of epicanthal folds (ex. down syndrome) - Assess for eyelid edema, conjunctivitis, sclera color (yellow = jaundice), discharge, tearing, and pupillary equality, as well as size and shape of the pupils. • In newborns, the nasal lacrimation duct is usually clogged/blockage, and some drainage occurs • Anisocoria: unequal pupil size

What other condition may be closely related to asthma? what influences persistence and severity? what is the genetic factors in asthma development? what type of reactions can occur (2)?

- Asthma & allergies are closely related, usually pt's who are allergic to a lot of things tend to have asthma too - Influence's persistence and severity - Genetic predisposition to development of an IgE mediated response to common aeroallergens is strongest identifiable predisposing factor to development o IgE antibodies attach to mast cells and produce a series of biochemical reactions that lead to an attack - Significant for 2 reasons: Can cause an immediate reaction - Can precipitate a late reaction several hours after initial exposure • Both immediate and late reactions will cause obstruction

Asthma Medications, what is albuterol used for (2)? what is the MOA? how can u use this? what is NOT recommended? what is leukotriene modifiers do? name the med?

- B-Adrenergic Agents/Albuterol(agonists) o Used for quick relief of acute exacerbations & prevention of exercise induced bronchospasm o Bind the beta receptors on the smooth muscle, allowing it to relax o Use PRN o Most used in asthma therapy affect the beta2 receptors which help eliminate bronchospasm. o Regularly scheduled daily use of short acting beta 2 agonists is NOT recommended...indicates poor control - Leukotriene modifiers o Leukotrienes are mediators of inflammation that cause transient increases in airway hyper-responsiveness, triggering airway spasms o Singulair o By blocking these receptors, bronchospasm and inflammatory cell infiltration are eliminated

What device may be useful for asthma patients? what will be educated to the patient family (4)?

- Can put humidifiers to help purify the air Education o Help families to understand that symptom-free periods (often very long) are interspersed with episodes of exacerbation. o Teach them that the episodes of exacerbation (sometimes requiring hospitalization or emergency room visits) should NOT be viewed as an acute illness. o Inform families that the prolonged inflammatory process occurring in the absence of symptoms, primarily in children with moderate to severe asthma, can lead to airway remodeling and eventual irreversible disease. o Instruct parents to ensure the action plan is kept on file at the child's school, and relief medication is available to the child at all times.

What are the causes of ARDS (4)? what can occur in ARDS (3)? what occurs within 72hrs (2)?

- Causes: Sepsis, Viral pneumonia, Smoke inhalation, Drowning - Note that respiratory distress and hypoxemia occur acutely within 72 hours of the insult in infants and children with previously healthy lungs - pulmonary edema, lung stiffness, and atelectasis occurs

What is a characteristic of the child's airway? Where is the location of the trachea in a child and why is it important (2)? explain the metabolic rate for children and why is this important (2)?

- Child's airway is highly compliant, making it quite susceptible to dynamic collapse during airway obstruction - Location of the trachea at the third thoracic vertebra in children (its much shorter) as opposed to the sixth in adults and how this difference is important when suctioning children and assessing for risk for aspiration - Children have a significantly higher metabolic rate than adults and how this affects normal oxygen transport • If resting HR is higher, then they need more oxygen - if they don't get the oxygen, they collapse quicker

What are the classic S/S of asthma (7)? what diagnostic will be done and what are the results (2)? what is the difference between an incentive spirometer and peak blow? how do you get the patient to use the peak flow ?

- Classic: Dyspnea, Wheezing - Prolonged expiration, Dry cough initially, Tachypnea & fatigue, Begins with child feeling uncomfortable & irritable & increasingly restless - Chest XR - hyperinflation of lungs - PFT's - Reduced peak expiratory flow rate - Incentive spirometer: breathing in; peak flow: breathing out - Have to play games with the children (ex. blow the cotton ball, blow out the candle game, take the penlight and ask them to blow the light out)

What is the clinical therapy for epiglottitis (5)? can you leave the child unattended? what position can the patient NOT be placed in? what equipment needs to be available?

- Clinical therapy: insertion of endotracheal tube to maintain airway, Antibiotics, antipyretics & hydration • Usually resolves after 24-48hrs of antibiotics - Do not leave the child unattended: until the child is intubated - Do not place the child in a supine position (obstructs airway and causes more anxiety); allow them to stay in comfortable position often sitting - Provide 100% oxygen in the least invasive manner - supplemental humidified oxygen may be used to reverse hypoxemia • If complete airway occlusion occurs, tracheostomy may be necessary. • Ensure emergency equipment is available.

Eye and ear nursing diagnosis II (read over)

- Communication impairment related to physiologic condition (hearing loss) as evidenced by difficulty verbalizing or inappropriate verbalization Goal: The child will communicate effectively with the method chosen by the family (this may be sign language, oral/deaf speech, cued speech, or augmentative alternative communication device). · Encourage choice of and attendance at communication habilitation program to promote continued learning. · Provide consistency between home and hospital in regard to communication style/devices to promote continued learning. · Support the child's efforts at correct speech to promote speech development through reinforcement and praise. · Encourage family to use spoken language and read books at home to continue to promote appropriate language development. - Knowledge deficiency related to insufficient information or knowledge of resources (about sensory impairment [vision or hearing]) Goal: Parents express understanding of diagnosis and care of child: parents verbalize understanding, demonstrate use of assistive devices, or independently perform medical treatments. · Review diagnosis and plan of care with the parents to promote understanding of the disease process. · Refer family to resources available for sensory-impaired children to provide further education and support to the parents. · Demonstrate medical treatments prescribed or use of assistive devices, requiring a return demonstration, which shows the parents' ability to provide the prescribed care for the child. · Encourage exploration of different communication and learning modes available for the sensory-impaired child to allow the child and family to find the right educational and communication style fit.

What is conjunctivitis? what is the general S/S (2)? what is the treatment (2)? what are the different types and their S/S (2)(5)(3)? What is the treatment for the different types? what is periorbital cellulitis and treatment (2)?

- Conjunctivitis (pink eye): S/S: eye is red, and drainage occurs o Antibiotic eye drops, children will have to stay home (no school) o Different types: Bacterial (purulent, mucoid drainage, mild pain), Viral (watery, mucoid drainage, lymphadenopathy, photophobia, tearing), and Allergic (Watery or stringy drainage, itching) o Viral: Supportive care, perform culture to see if the cause is viral or bacterial; Antihistamine for allergic o Periorbital cellulitis: the tissues around the eye are swollen and can lead to severe eye abnormalities/blindness o Treatment: Oral or intravenous antibiotics

Common laboratory and diagnostic tests for eyes/ears, what may be cultured and why? is it painful? can the tympanic membrane be cultured and why? what is a tympanometry (3)?

- Culture of the eye or ear discharge: performed if the patient has some sort of drainage, done to see which antibiotic is best for the type of pathogen present; usually pain free but may be painful if have to collect drainage from within the ear canal - Tympanic fluid culture: culture of fluid aspirated from the middle ear; to see what type of pathogen present and which antibiotic to use - Tympanometry: looking at the movement in the eardrum; determines extent of effusion of the middle ear • Usually, if the patient has a lot of fluid, movement will be limited

What is the most common chronic disease of childhood? this is the primary cause of ? what are school age children worried about? what is the age onset of asthma? Why is the prevalence and mortality of asthma increasing (3)?

- Most common chronic disease of childhood - Primary cause of school absences - school age child is worried about their schoolwork - Responsible for major proportion of Pedi admissions to ER and hospitals - Cost is > $1 billion/year - Onset can occur at any age - 80-90% of children have first sx before 4-5 y.o · PM & M are increasing in the US...why? Increasing air pollution, poor access to medical care, and underdiagnosis/undertx

How is asthma diagnosed (4)? what test will tell you how to treat asthma? what is the S/S criteria? how is asthma managed in the hospital (6)? what are the peak flow meters, explain (3)? Nursing diagnosis (Read over)

- Dx determined on clinical manifestations, hx, physical exam, and lab tests • Based on peak flow reading is how you treat asthma - Generally chronic cough in the absence of infection or diffuse wheezing during expiratory phase of respiration - Monitor Pulse ox.; Humidified O2 - IVF, Bronchodilators and anti-inflammatory agents (inhaled, po, IV) - High Fowlers - Peak Flow Meters (Green, yellow, red) - green: 80-100 - yellow: 50-80 - red: <50 (go to pg 14 study guide) - Nursing Diagnoses - Risk for suffocation related to airway obstruction - Ineffective airway clearance related to allergic and inflammatory processes - Interrupted family processes related to child with chronic illness

What is the diet for a cystic fibrosis patient and for infant and why is it important? when are the pancreatic enzymes taken? what are the characteristics of the stool of the cystic fibrosis patient? What medications are used for the patient (6)?

- High calorie, high protein diet. - Infants: predigested formula • Important bc these individuals may have delayed growth, or failure to thrive in infants - Administer pancreatic enzymes with all meals & snacks (they are given WITH the meals) - sprinkle onto apple sauce • These CF pt's have steatorrhea - if enzymes are given then the stools will sink and it's an indicator that the enzymes are working properly, and the child is improving - Antibiotics to treat pulmonary infections - Bronchodilators, Corticosteroids - Vitamin supplements: A, D, E, K - Diuretics (remove excess fluid from lungs) - Mucolytic

What is tonsillitis? what may be the cause (2) and what is the primary site of infection? what do you want to worry about? if the tonsils are taken out, what else is taken out? During an assessment, what number would indicate that the tonsils are touching each other? What are the S/S of tonsillitis (5)?

- Infection or inflammation (hypertrophy) of palatine tonsils • May be viral or bacterial, primary site of infection is the tonsils • Worry about strep; if they take out the tonsils, they also take out the adenoids • During assessment, if tonsils are +4 it means they are touching each other and it's a CONCERN - S/S: Frequent throat infections with breathing and swallowing difficulties, persistent redness of anterior pillars and enlargement of cervical lymph nodes (Focus on anterior cervical, posterior cervical, deep cervical lymph nodes; you will feel them if they have an infection present) • If children breathe through their mouths continuously, the mucous membranes may become dry and irritated.

What is pneumonia? what is it caused by (4)? where is the infection present (2)? what are the modes of transmission (3)? what is the end result? when assessing the patient, what is important to assess? how may consolidation appear on an x-ray?

- Inflammation of the lung parenchyma caused by a virus, bacteria, Mycoplasma, or fungus • Virus: Most common cause of pneumonia in younger children and the least common cause in older children o Infection of bronchioles and alveolar spaces caused by virus/bacteria/fungus/mycoplasma o Mode of transmission: o Inspiration (enter through upper respiratory tract), aspiration or systemic circulation (bacterial invaders) o End result is exudate from cell death pooling in dependent areas of the lungs causing areas of consolidation - When assessing the pt, it's important to assess each lobe for consolidation bc it can be in one area and not the other - on an X-RAY it may appear like whiteish areas

What is otitis media? is this common and when is the peak incidence? what are the risk factors (7)? which children are more often to experience otitis media (2)? when is this condition common? when is otitis media usually seen and what can help protect against if? which ears can it affect and what can it develop to?

- Inflammation or Infection of the middle ear • Most common childhood illness with peak incidence at 2 years of age • Very common, mostly affects boys and children in daycares, those with allergies, those exposed to tobacco smoke, and in those who use pacifiers for several hours a day, & exposure to germs. • Other risk factors: pool, drinking their bottle laying down • Children with conditions such as cleft lip and palate or down syndrome more often experience it. • Most common during the winter months - Usually seen 2 weeks after a URI (common old) - Breastfeeding protects against it - Chronic otitis media may also occur o Occurs Right/left or both ears

What is cystic fibrosis? what causes the multisystem damage (2) and which systems are mostly affected (2)? what complications may arise (4) and why (2)? if the patient has HF where does it present? what kind of genetic condition is this and how is it obtained? this condition is common in which group of children? what type of recession is it and explain? what is the life expectancy?

- Inherited disorder affecting the exocrine glands (exocrine glands dysfunction producing lots of mucous) • Chloride dysfunction in the cells causes the cells to break down - pt loses a lot of sodium and chloride - Alterations in sweat electrolytes and mucus production lead to multisystem damage (mostly affects respiratory/GI - Chronic infection and airway obstruction lead to bronchiectasis, pneumothorax, and cor pulmonale • Children who have HF, the swelling will present in the face - Growth & puberty are retarded. o Lethal genetic illness - Child inherits defective gene from both parents - Most common debilitating disease of childhood among those of European descent - Autosomal recessive: Males & females equally - Life expectancy in the 30's - now it's a little longer bc of improved medications/treatments

Eye and ear nursing diagnosis (read over)

- Injury Risk r/t insufficient vision Goal: The infant or child will remain free from injury. · Orient the child to hospital surroundings because awareness is the first step to preventing injury. · Encourage parent to be at bedside so that the child feels more comfortable. · Encourage use of assistive device to promote safety. - Fear related to sensory deficit (severe visual impairment or blindness) and/or unfamiliar setting as evidenced by apprehensiveness or verbalization of feeling of alarm Goal: Child will experience decreased fear: child will verbalize comfort with environment or react calmly to interventions. · Allow verbal child to share his feelings to promote coping in the child. · For the severely impaired or blind child, identify yourself via voice and name items in environment for the child so that the child is aware of his or her surroundings. · Engage the parents in bedside caregiving because the parents' voice and presence are reassuring to the child. · Encourage nutritious diet according to child's preferences to assist body's natural infection-fighting mechanisms. · Isolate the child as required to prevent nosocomial spread of infection. · Teach child and family preventive measures such as good hand washing, covering mouth and nose when coughing or sneezing, and adequate disposal of used tissues to prevent nosocomial or community spread of infection. - Delayed growth and development risk related to impaired vision or hearing impairment Goal: Child will achieve optimum independence for age: child participates in age-appropriate developmental activities. · Encourage attainment of developmental milestones with use of assistive devices as needed for timely developmental achievements. · Foster independence in activities of daily living (ADLs) to promote a sense of accomplishment. · Encourage participation in play with another child or within a group to promote socialization. · Assist family to set limits and apply discipline because structure and routine provide a secure environment in which the developing child can grow. · Encourage friendships with other children with a sensory impairment to promote socialization and let the child know that he or she is not the only one with these challenges.

In otitis media, what will be observed under the otoscope (3)? what are the complications of otitis media (5)? and nursing diagnosis for otitis media (Read over)

- Otitis media with effusion is noted on otoscopy by fluid line or air bubbles. Pneumatic otoscopy or tympanometry shows a nonmobile tympanic membrane. Note that the light reflex is not in the expected position due to a change in tympanic membrane shape from air bubbles. Where would you expect to see the light reflex? - normally its lower in position - Complications: - Hearing loss - Eardrum Perforation (bc of the pressure - Tympanosclerosis (eardrum scarring) - Mastoiditis - bone behind the ear becomes infected • Bone conduction will be damaged and cause ear issues - Meningitis - the bacteria crossed the blood brain barrier and damaged lining of the spinal column/brain - Nursing Diagnosis · Risk for imbalanced Body temperature r/t infectious process. · Fatigue (child and parent) r/t sleep deprivation. · Impaired Health maintenance r/t chronic ear infections and altered sensory reception. · Acute Pain r/t inflammation and pressure on tympanic membrane · Risk for infection r/t presence of pathogens · Delayed growth & development r/t hearing loss o Assess hearing ability frequently, & motor/language development

Interventions to Minimize Psychosocial Impact of Chronic Respiratory Conditions (Read over)

- Promoting child's self-esteem through education and support - Allowing school-age child to take control of management of the disease • Meaning they are able to understand concrete concepts and can understanding things more now to help manage their condition - Promoting family coping through education and encouragement • Provide positive encouragement, encourage to be complaint with medications - Providing culturally sensitive education and interventions • These pt's have growth retardation so we have to be sensitive about this - Establish rapport with the patient since this is a chronic condition; monitor the child

What type of disorders do children commonly acquire? how do newborns breathe and what is an important intervention (1)? explain the consequence of the nose and throat anatomy in infants? what makes a difference in acquiring infection and what do children suffer more from?

- Respiratory disorders are the most common causes of illness and hospitalization in children and account for the majority of acute illnesses in children - Newborns are obligatory nose breathers until at least 4 weeks of age and cannot automatically open their mouths to breathe if the nose is obstructed - you suction the newborn before/after feedings so then they can breathe - Anatomy of the nose and throat differs in infants, making them more prone to acquire infections • Seasons make a difference (ex. fall); children suffer more respiratory arrest than cardiac arrest

What are the asthma risk factors (9)? what are the asthma triggers (10)?

- Risk factors - Age, Heredity, Gender, Children of young women < 20 y.o., Smoking / secondhand smoke, Ethnicity - African Americans at greatest risk? - Previous life-threatening attacks: pt may go periods where they have no exacerbations/attacks, but then may have periods were its really bad - Lack of access to medical care and low finances - Psychological & psychosocial problems - Asthma tiggers: Inhalants, Pollens, Dust or dust mites, molds, carpets/drapes/curtains - Stress - Weather changes - Exercise: have them take their medications prior to exercising - Viral or bacterial agents -Food additives

diagnostic tests done for a cystic fibrosis patient, what is a sweat chloride test and what are the results? what is the results of the pulse oximetry? what is the results of the chest radiography (4)? what is the results of the pulmonary function tests (3)? what can the parents say they taste? what needs to be ensured when the patient is outside?

- Sweat chloride test: tells us the level of chloride and sodium in the blood; considered suspicious if the level of chloride in collected sweat is above 50 mEq/L and diagnostic if the level is above 60 mEq/L (two tests conducted) • Sometimes the parents when hugging the child, can taste the salt • Ensure hydration of the patient when outdoors - Pulse oximetry: oxygen saturation might be decreased, particularly during a pulmonary exacerbation - Chest radiograph: might reveal hyperinflation, bronchial wall thickening, atelectasis, or infiltration - Pulmonary function tests: might reveal a decrease in forced vital capacity and forced expiratory volume, with increase in residual volume

What is the usual treatment of eye/ear disorders (8)? what education needs to be provided to children wearing glasses (3)?

- Treatment for these children: eye exam performed, eyeglasses/contacts, or any treatment plan to correct the vision (Ex. patch), warm compress, eye muscle surgery, pressure-equalizing tubes, hearing aids, cochlear implants · With young children wearing glasses - they can get bullied, so you have to educate the children how to deal with that, encourage them to continue going to school, maintaining an open line of communication

What is the correlation between ear disorders and eye disorders? what is hyperopia, myopia, astigmatism (1), strabismus (3), amblyopia (1), cataracts, glaucoma, retinoblastoma, color blindness (3), and retina of prematurity (1)?

- Visual disorders: usually when they have eye disorders, they have ear issues as well o Hyperopia: difficulty seeing near o Myopia: difficulty seeing far o Astigmatism: abnormal curvature of the eye - can cause a little blurry vision o Strabismus: symmetry of the eye is not midline and eye shifts out or in · Eye drifts in: esotropia, or out: exotropia o Amblyopia: Lazy eye, reduced vision, result of above o Cataracts: Opague lens o Glaucoma: increased intraocular pressure damages eye o Retinoblastoma: tumor of the retina o Color blindness: x-linked, usually in males, red/green. o Retina of Prematurity (ROP): injury to developing capillaries of the retina usually r/t O2 deprivation - more congenital

What is asthma? explain the pathophysiology (5)? what cells play a role (3)? what medications/therapy are given to the patient (5)?

-Chronic inflammatory disorder of the airways - It is a diffuse, obstructive pulmonary disease characterized by airway inflammation with mucosal edema, thick secretions that cause airway plugging and hyperreactivity of the tracheobronchial tree that results in bronchospasm of the smooth muscle · Many cells play a role particularly mast cells, eosinophils, and T lymphocytes · Steroids are given if pt has mucosal edema, bronchodilators if pt has bronchospasms, suction/chest physiology/mucolytics if pt has thick secretions

How is tonsillitis diagnosed (2) how will the tonsils appear (3)? what is the general treatment (2)? When would a tonsillectomy be considered (4)? How many episodes in the 3 years to be considered for tonsillectomy? What is the requirement prior to surgery (5)? what medication can be given post op? how will the back of the throat look like post surgery (3)? what does the tonsillitis diagnosis require (5)?

-Made on the basis of: Visual inspection and clinical manifestations - tonsils appear large & inflamed, exudate - Symptomatic treatment, or antibiotics if caused by a pathogen - Tonsillectomy is considered for frequent infections (>3 per year for 3 years), chronic tonsillitis, sleep apnea or speech/growth issues • Can be considered when there are at least 7 episodes of tonsillitis in the previous year, at least 5 episodes/year for 2 years, or at least 3 episodes annually for 3 years. • Children should be free of sore throat, fever, or upper respiratory infection for at least 1 week before surgery. No aspirin or ibuprofen 2 week before surgery and 1 wk postop (give acetaminophen) • Back of throat will look white/with odor for first 7-8 days after surgery and may have low-grade fever • Tonsillitis diagnoses requires a sore throat and at least one symptom (Temp above 38.3°C (101°F), cervical adenopathy, tonsillar exudate, and + group A Beta-hemolytic streptococcus infection.

Chronic respiratory disorders (read over)

Allergic rhinitis Asthma Chronic lung disease (bronchopulmonary dysplasia) Cystic fibrosis Apnea

What condition will warm compress be beneficial (1) and how is it done? what condition will corrective lenses be beneficial (2) and how is it done? what condition will patching be beneficial (2) and what needs to be educated to the pt/family (2)? what condition will eye muscle surgery be beneficial (1) and how is it done postop (2)? what condition will pressure equalizing tubes be beneficial (1) and what will be educated to the pt/family (1)? what condition will hearing aids be beneficials (1) and what needs to be ensured (1)? what condition will cochlear implants be beneficial and what needs to be educated?

Look at chart on page 2 of study guide

What is the preop for tonsillectomy (4)?

Preop - obtain consent and vitals, educate on what to expect during and after the surgery (for school age children they understand structures/visual; for toddlers use a doll, for infants you educate parents), assess for allergies

LTB/Croup, what can be given if fever is present? what is the focus of care? what is the goal (2)? what equipment needs to be at bedside (4)? what complications will you observe for (4) and explain?

o Give antipyretics if fever present - FOCUS ON AIRWAY MAINTENANCE; goal is to maintain airway and provide adequate respiratory exchange • Have suction, oxygen, ambu-bag, crash cart is close by o Observe for inability to swallow, absence of voice sounds, increasing respiratory distress, and acute onset of drooling (means that the airway is more narrow/obstructed and then causes pt to drool)

RSV/Bronchiolitis, what is used to suction infants under 1yr of age? what is given to patients to thin secretions and increase calories? what is encouraged of active toddlers (2)? when will you advise the parents to contact the physician (6)?

o General care instructions: o Use the bulb syringe to suction the nares of an infant under 1 year of age. o Give fluids to help thin secretions and provide calories for energy. o Encourage active toddlers to rest and take naps during recovery. o Advise parents to call the physician if: o Respiratory symptoms interfere with sleeping or eating. o Breathing is rapid or difficult. o Symptoms persist in a child who is less than 1 year old, has heart or lung disease, or was premature and had lung disease after birth. o The child acts sicker - appears tired, less playful, and less interested in food.

How is acute otitis media diagnosed (3)? What is the diagnostic used for otitis media? what does otoscopic examination include (2)? which is the best diagnostic (2)? if the child is having tympanostomy tube inserted, how long is the stay? why would treatment be delayed and for how long and why? what is the treatments available (3)?

o Acute otitis media (AOM) is diagnosed when there is a history of acute onset, presence of middle ear effusion (bulging or decreased mobility of the tympanic membrane, air fluid behind the membrane or otorrhea or discharge), and s/s of inflammation (erythema of tympanic membrane or discomfort that makes sleep and other activities difficult). o Diagnosis by visualization with otoscope o Otoscopic examination includes visualization and pneumatic otoscopy o It is best dx by a pneumatic otoscopy and tympanometry - Child having tympanostomy tubed inserted in treated in a day surgery setting. o Treatment is delayed 48-72 hr after dx in children 6 months to 2 years old with non-severe illnesses at presentation. o When it has not improved, it is treated with antibiotics (usually amoxicillin) for 10 days. o If infection continues to occur despite antibiotic treatment a myringotomy (surgical incision of the tympanic membrane) may be performed and tympanostomy tubes (pressure equalizing tubes) will be inserted to drain fluid from the middle ear.

Care of child with tympanostomy tubes, what are the nursing interventions after surgery (5)? following the postoperative period, what needs to be educated to the pt/family (4)? when do the tubes usually fall out? In regards to eye injuries, how is the snellen chart performed?

o After surgery: o Encourage the child to drink generous amounts of fluids. o Reestablish a regular diet as tolerated. o Give pain meds (acetaminophen) as ordered for discomfort and at bedtime. o Place drops in child's ears if prescribed. o Restrict the child to quiet activities. o Following Postoperative Period o Follow instructions regarding swimming and water. o Ear plugs can be used to prevent water from getting into ears. o Be alert for tubes becoming dislodged and falling out and alert care provider (they usually fall out within 1 year). o Report purulent discharge from the ear, which may indicate a new ear infection. Contact PCP. - Injury to the eye: you assess the eye, Snellen chart (w/ children they show them shapes, not letters)

Asthma Medications, what are corticosteroids (2)? what is the routes (3)? what dose should be given? which medication is used long term and what does it do? what are the side effects (2)? what is advised to do after inhalation? what does inhaled steroids decrease the need of? how long does it take for PO medications to act?

o Anti-inflammatory drugs used to treat reversible airflow obstruction o Control sx & reduce bronchial hyperactivity o Administered po/IV/aerosol • Lowest effective dose should be given • Inhaled steroids (Flovent) are used for long term prevention • Inhaled steroids also suppress, control, and reverse the inflammation. • Few side effects - include cough and oral thrush (rinse mouth after use) • Use has reduced need for po steroids o PO are metabolized slow and take up to 3 hrs to act and peak within 6-12 hrs

Nursing management for otitis media, what will the nurse assess (5)? what will you educate the family on (4)? what are the pain relief interventions that are recommended (7)? what treatment is recommended for otitis media (1), what may be obtained and when is the ear examined?

o Assessment: o Assess the tympanic membrane for color, transparency, mobility, presence of landmarks, and light reflex. o Ask the parents whether the child has had a fever, been fussy, or been pulling at the ears. o Observe for signs of impaired hearing. o Planning o Family education: Risk factors (smoking) · Emphasize preventive measures. Exposure to secondhand smoke in the home increases the incidence of otitis media in children (educate to wash their hands, change their cloths, smoke outside) · If young children are in childcare with fewer than 10 children, incidence decreases. · Placing infants/toddlers to sleep w/ a pacifier may increase incidence & should be avoided in the infant w/ prior infections o Pain relief: o Give analgesic such as acetaminophen/ibuprofen - analgesic ear drops (teach correct admin of ear drops) o Have the child sit up, raise head on pillows, or lie on unaffected ear --> Slight head Elevation decreases pressure from fluid o Apply warmth to the ear - Heat increases blood supply and reduces discomfort. o Have the child chew gum or blow on balloon to relieve pressure in ear - Attempts to open the Eustachian tube may help aerate the middle ear. Breastfeeding helps and provides some protection! o Encourage breastfeeding of infants. Breastfeeding affords natural immunity to infectious agents. o Antibiotic treatment (perform culture, but sometimes a culture may not be performed & still give antibiotic) · Examine ear 3 or 4 days after completion of antibiotic treatment.

What is atypical pneumonia? what is it caused by? who typically gets this pneumonia? what are the general S/S (5)? when will patients recover and what is the treatment (3)?

o Atypical Pneumonia (considered walking pneumonia) o Usually caused by mycoplasma pneumonae - most common cause of pneumonia in children 5-12 yrs old o General systemic sx: fever, h/a, malaise, anorexia, sore throat, dry cough o Most recover in 7-10 days with symptomatic tx and antibiotics o Zithromax, Cipro

In regards to postop tonsillectomy, what should be avoided (2)? can hemorrhage occur and when (2)? what will be inspected in the throat (3)? how can early bleeding be identified (1) and what should be reported (1)? what are other signs of hemorrhage (5)? what is done to relieve throat pain (3)? how may cauterized skin appear (3)? what is NOT offered to the patient to eat/drink/activity level (3) and what is offered (1)? after surgery, how may the throat feel? what will you educate the parents (2)?

o Avoid the use of straws or suctioning unless there is an airway obstruction o Hemorrhage is unusual postoperatively but may occur any time from the immediate postoperative period to as late as 10 days after surgery, when the scar is forming • Inspect the throat for bleeding. Mucus tinged with blood may be expected, but fresh blood in the secretions indicates bleeding. • Early bleeding may be identified by continuous swallowing of small amounts of blood while awake or sleeping (NOTIFY PCP): report any tickle, bright red blood • Other signs of hemorrhage include tachycardia, pallor, restlessness, frequent throat clearing, and emesis of bright red blood. o Essential to establish adequate oral fluid intake, Ice collar and analgesics with or without narcotics - Cauterized skin could leave white patches, scarring - Scab is coming off- bleeding 7-10 days later. - Don't give grape or red color ice pops. watch color liquids, don't give anything hot, no vigorous exercise; offer small amounts of cool liquids - For the rest 24 hours after surgery, the throat is very sore, & may have sore throat for 7-10 days - Counsel parents to maintain pain control upon discharge from the facility, not only for the child's sake, but also to enable the child to continue to drink fluids.

What is the cause of bacterial pneumonia in infants less than 3yrs old (4)? what is the cause in 3 month-5yr old (3)? what is the cause in older than 5 yr old (1)? what is the S/S of bacterial pneumonia (8)? what is the medical management (4)? what should be suspected in infants with respiratory symptoms (1)? what is the key preliminary diagnosis (1)?

o Bacterial o Infants <3mo= streptococcus pneumoniae (pneumococcus), group A strep, staphylococcus, or enteric bacilli o 3 mo-5 y.o.= S Pneumoniae, HiB, and staphylococcus aureus (vaccines prevent and decrease incidence) o > 5 y.o.=Mycoplasma o Bacterial o S & Sx: Acute onset, fever, chills, H/A, chest pain, irritability, lethargy, respiratory distress o Management: o Antimicrobial therapy, Antipyretics, Steroids/bronchodilators · Bacterial infections should be suspected in all neonates with resp sx.. o The key to a preliminary diagnosis is finding infiltrates on an x-ray

What is bronchiolitis? what type of illness is this and what is it caused by (2)? what age group is it mostly severe, and what does it place the child at risk for (2)? what are most cases caused by? what season does it tend to happen? how is RSV transmitted (2)? what is the incubation period and shedding the virus period? what are the risk factors (5)?

o Bronchiolitis is an acute viral infection with inflammation and obstruction of smaller airways (bronchioles) • Lower respiratory tract illness, occurs due to viral or bacterial organism o Most severe in infants under 6 months of age - Affects 1 in 7 infants in the first year of life. • Children have an increased risk for wheezing and asthma later in childhood. o Most cases are caused by Respiratory Syncytial Virus (RSV) - occurs in annual epidemics from October-March. • Transmitted through direct contact w/ respiratory secretions (cough or sneeze droplets) or indirectly through contaminated surfaces. • Mainly as a result of inoculation from hand to eye, nose, or other mucous membrane (droplet precautions needed) • RSV can survive for hrs on counters, gloves, paper tissues, and cloth and for half an hr on skin...handwash!!!! • The infected child sheds the virus for 3 to 8 days, and the incubation period is 2 to 8 days. o Risk Factors - immunosuppression, low birth weight, lung disease, severe neuromuscular disease, or complicated congenital heart defects

What is foreign body aspiration (FBA) caused by? and where can those objects/particles end up? what should be educated to the parents? What does FBA follow a hx of (2)? what age group can this affect (2)? In regards to poisoning what should the parents have on hand? what type of intentions are behind poisoning (3)?

o Caused by food items, coins, toys, earrings, latex balloons, small disc batteries - could end up in the lung or cause some sort of obstruction in the airway (educate parents to cut the food up in small pieces) o Follows hx of gagging or sudden episode of coughing-severity depends on size and composition of object or substance o Occurs most in children 6 mo-4y.o., but can be at any age • In regard to poisoning, parents should have poison control number; the younger the child the higher the incidence of being exposed to poisoning, the older the child it would be considered unintentional, and then if they are even older (adolescents) it would be intentional

Asthma therapeutic management, what does chest physiotherapy include (2)? what position will the patient be placed? what needs to be ensure prior? what does chest physiotherapy produce (5)? what is the stepwise approach?

o Chest Physiotherapy o Includes breathing exercises and physical training o Position child to promote drainage if necessary • Make sure the child did NOT recently eat *** o Help produce physical & mental relaxation o Improve posture o Strengthen respiratory musculature o Develop more efficient patterns of breathing - Stepwise approach: referring back to the peak flow diagram • Increasing medications as child's condition worsens • Backing off medications as child's condition improves

Otitis media, what can chronic ear infections lead to and what needs to be assessed at regular intervals (2)? what possible treatment for otitis media may be necessary and explain each? what are the two bacterias that can cause otitis media (2)? what medications can be given (6)?

o Chronic ear infections could lead to hearing loss • Provide hearing & language examination at regular intervals o Possible need for myringotomy and tube placement - if they have multiple ear infections • Myringotomy - procedure that creates a hole in the ear drum to allow fluid that is trapped in the middle ear to drain out • Tube placement - the tubes (plastic) are supposed to fall out after a while, and even when they fall out the children may still have ear infections and then they have to reinsert them - Strep Pneumoniae 85% (Penicillin), H. Influenzae, M. Catarrhalis - Medications: Lactimase: Bactrim, Septra, Augmentin, One shot - Ceftriaxone (Rocephin)

LTB/Croup, what observations will be done (7)? what can diminish the intensity of retractions and stridor? what is a cause of concern? can the parents be with the child? how is airway patency maintained for the LTB/Croup patient (4)? what is required for the nutrition and hydration of the patient (4)? why are fluids good (2)? what do you want to educate the family on?

o Continuous observation and respiratory assessments o Attach a cardiorespiratory monitor and pulse oximeter. Pay attention to the child's respiratory effort, breath sounds, preferred positioning, and responsiveness. Exhaustion can diminish the intensity of retractions and stridor (avoid agitation). The quieter the child the greater the cause for concern. - If the child is having respiratory distress, leave the child with the parents as much as you can to reduce any anxiety - Maintain Airway Patency: supplemental oxygen with humidity may be needed to hypoxemia, but cool mist and humidified air have no power benefit. o Allow the child to assume a comfortable position. Keep resuscitation equipment and an intubation tray at the bedside. - Meet Fluid and Nutritional Needs: monitor the child's hydration and nutritional status. o Fluid helps thin secretions and provide calories for energy and metabolism. - Children usually prefer cool, noncarbonated, nonacidic drinks such as oral rehydration fluids or fruit-flavored drinks, gelatin, and popsicles. o Family education and updates on POC

What is diagnosis based on for epiglottitis (2)? what CANNOT be done (2) and why? what do you need to have at bedside? what will you observe in the patient (3)? what can a change of LOC mean? what is a concern? what should be avoided (2)? what occurs if the child is crying (3), and what can be done to soothe the patient? what is the risk?

o Diagnosis is based on physical signs and a lateral neck radiograph: which reveals a narrowed airway and an enlarged, rounded epiglottis, seen as a mass at the base of the tongue (Cherry red, swollen epiglottis - don't inspect or put anything in throat bc of risk of --> laryngospasm). o Do not attempt to use tongue depressor to visualize because you can cause more stress. o Try to do everything in a controlled environment, so that you have all equipment to intubate. • Observe respiratory and airway status. Note changes in LOC. • A change in LOC from anxiety to lethargy to stupor occurs as hypoxia increases. The quieter the child, the greater the cause for concern! • Postpone anxiety-provoking procedures such as venipuncture until the airway is secure. • Crying stimulates the airway, increases oxygen consumption, and can precipitate laryngospasms • If child is crying - put them on the parents lap, don't let the child cry because it will further close the airway (risk of airway obstruction)

What are the S/S of exacerbation of asthma attack? why does it occur? when does the cough occur? what may the patient also feel (3)? what are the characteristics of the bronchial secretions (3)?; what are the categories of asthma and what does it describe?

o Exacerbations are episodes of progressively worsening SOB, cough, wheezing, and chest tightness o Increase in bronchial hyperresponsiveness to a variety of stimuli o Cough especially at night and early morning o May also c/o h/a, feeling tired, chest tightness o Bronchial edema and secretions begin to form, so the secretions become frothy, clear, like gelatin - Describes the frequency of asthma - Mild intermittent: not having frequently ex. 1x a week - Mild persistent - Moderate persistent - Severe persistent: having it multiple times a day

Explain what occurs in the GI tract of a cystic fibrosis patient (4)? explain what occurs in the respiratory system of a cystic fibrosis patient (3)? what will you educate the patient on (1)?

o GI Tract: o Clogged pancreatic ducts - by the excessive mucous • Pancreatic ducts become clogged with thick secretions & prevent pancreatic enzymes from reaching the duodenum, impairing digestion & absorption (obstruction can cause DM, possible insulin tx) o Impaired digestion & absorption o Small intestine, in the absence of pancreatic enzymes are unable to absorb fats and protein. o Respiratory tract: o Increased viscosity of bronchial mucus o Eventual bacterial colonization - this when the respiratory infections come in o Sticky secretions pool in bronchioles leading to atelectasis (ensure to teach about incentive spirometry)

What is the goal of asthma management? what is allergen control? how are house dust mites eliminated? how are cockroaches eliminated? what is the goal of drug therapy (3)? what are the two general classes of medications used?

o Goal: o To prevent disability & to minimize physical & psychologic morbidity & to assist the child in living as normal & happy a life as possible o Allergen Control: Prevent & reduce exposure to airborne allergens & irritants o House dust mites...eliminate them by keeping humidity inside house under 50%. o Cockroaches...in some houses they are more common than the dust mites...like inner city environments. o To get rid of them you need to do repeated & vigorous extermination and take measures to eliminate droppings as well o Drug Therapy o Prevent & control symptoms o Reduce frequency & severity of exacerbations o Reverse airflow obstruction o Two general classes: o Long-term control medications (ex. what a pt under green would take, they don't have symptoms but their managing them) o Quick-relief medications (Ex. what a pt under yellow/red would take) o Long term control meds are used to achieve and maintain control, while quick relief meds treat the acute sx and exacerbations

What is the maturity of hearing in pediatrics? what test is conducted and when? what may affect hearing and give an example? What are the factors that make ears prone to infection (2)? Describe the eustachian tubes in pediatric patients (3)?

o Hearing is intact at birth - hearing test is performed on the newborn o Recurrent ear disorders may affect hearing - otitis media (middle ear) is the most common type of infection o Placement of Eustachian tubes and enlarged adenoids makes ears prone to infection. • In children, the eustachian tubes are shorter and wider than adults; the angle is more straight (rather than down), bc of its straight position the fluid accumulates and isn't able to drain - then pathogens grow bc the fluid is able to accumulate

How is otitis media diagnosed (3)? what is otitis media with effusion and what is a consequence of being long term? what are the signs and symptoms of otitis media (11)?

o It is diagnosed when the child has acute onset of ear pain, marked redness of the tympanic membrane, and middle ear effusion. o Otitis media with effusion (OME) is evidence of fluid in the middle ear without inflammation. • If OME becomes chronic (continuing more than 3 months) it can lead to hearing loss *** o Infants and young children have characteristics behaviors that indicate otitis media may be present. • S/S include: pulling at the ear (sign of ear pain, ear ache), diarrhea, vomiting, and fever. • Irritability and "acting out" may be signs of a related hearing impairment. • Night awakenings with crying due to increased pressure when prone or supine. • Poor appetite, and tympanic membrane is red; older child may say they have pain

RSV/Bronchiolitis, how can nurses maintain respiratory function in the patient (5)? what may infants have difficulty doing and what interventions can be done (2)? if risk for aspiration is high, what can be done (2)? when can the patient be discharged (3)? what will be educated to the parents (1)?

o Maintaining Respiratory Function: o Patent nares are important to promote oxygen intake. o A bulb syringe and saline nose drops can be used to quickly clear the nasal passages. o Elevate the HOB to ease the work of breathing and drain mucus from the upper airways. o Supplemental oxygen with humidity via nasal cannula, mask, hood, or tent. o Support Physiologic Function: o Infants may have feeding difficulty and are at risk for aspiration. o Suction the nasal passages before giving oral feedings. o Feed smaller volumes more frequently to help conserve energy in infants who are formula-or breastfed. o When risk of aspiration is high, NG tube feedings may be used. An IV infusion to rehydrate the child and maintain fluid balance until oral fluid intake is adequate. o Discharge Planning and Home Care Teaching: o Children are discharged once they maintain stable oxygenation on room air along with eased respiratory effort and decreased mucus production. o Teach the parents proper administration of meds. Acetaminophen or ibuprofen for persistent low-grade fevers and general discomfort.

What are the medications for a cystic fibrosis patient (4)? what can be done to remove secretions from the lungs (3)? what is important to prevent and what is an intervention (1)? can oxygen be given?

o Medications o Inhaled recombinant human deoxyribo-nuclease (DNase) o Antibiotics - to help eliminate the pathogens that may be growing o Pancreatic enzymes and vitamins A, D, E, K - to help with digestion o Maximizing lung functioning o Promote the removal of secretions from the lungs - chest physiotherapy, mucolytics, fluids o Prevent and treat lung infections - encourage for the patient to move often o Manage pulmonary complications. o Supplemental oxygen as needed, Dietary supplements

What do most foreign body aspirations (FBA) cause (1)? which lung is most likely to be affected and why? what are the S/S of FBA (7)? what is the management (3)? why would an x-ray be done? what is difficult to see? what other procedure may be indicated (1)?

o Most F.B.'s cause bronchial, not tracheal (cough reflex) obstruction o Right lung most common due to anatomy - bc its shorter • Can be upper or lower o S & Sx: stridor, drooling, asymmetric wheezing or breath sound, spasmodic cough, gagging, inability to say P words o Sudden resp. distress in absence of illness? SUSPECT FBA o Immediate basic life support (ex. crash cart, CPR) -AIRWAY o Inadequate air exchange: back blows and chest thrusts <1 y.o. Heimlich maneuver o May be revealed with X-ray - depending on the object, it may not illuminate in the x-ray o Non-radiopaque items can be difficult to see o Bronchoscopy may be indicated - to see the bronchioles; can be used as screening or diagnostic

Asthma, How are nebulizer's used (4)? how are metered-dose inhalers used (6)? what are spacers? how are diskus's used (5)?

o Nebulizers: o Attach the mask or the mouthpiece and hose to the medicine cup. o Place the mask on the child o Instruct the child to close the lips around the mouthpiece and breathe through the mouth. o After use, wash the mouthpiece and medicine cup with water and allow to air dry o Metered-dose inhalers: o Shake the inhaler and take off the cap. o Attach the inhaler to the spacer or holding chamber. o Breathe out completely. o Put the spacer mouthpiece in the mouth (or place the mask over the child's nose and mouth, ensuring a good seal). o Compress the inhaler and inhale slowly and deeply. Hold the breath for a count of 10. o Wait 1 full minute before second inhalation, if prescribed. o Spacers - help to get the medication in o Dry-powder inhalers o Diskus: o Hold the Diskus in a horizontal position in one hand and push the thumb grip with the thumb of your other hand away from you until mouthpiece is exposed. o Push the lever until it clicks (the dose is now loaded). o Breathe out fully. o Place your mouth securely around the mouthpiece then inhale. o Remove the Diskus, hold the breath for 10 seconds, and then breathe out.

what is the treatment for RSV/Bronchiolitis (7)? which medications may be controversial (2)?

o Noninvasive O2 monitoring - Humidified oxygen is provided to infants w/ severe hypoxemia, when the SpO2 readings fall to less than 90% o Supportive care (treat the symptoms bc its viral) - child is isolated to minimize spread of virus o Hydration (Oral or IV fluids to thin secretions) and nasal suctioning before feedings to prevent vomiting o Bronchodilators, Corticosteroids (to decrease inflammation) o Antipyretics may be used, nebulized hypertonic saline (3%) can improve clinical severity score and reduce hospital stay length o Antibiotics - used only when a bacterial infection is present o Intramuscular palivizumab (Synagis): used for prophylaxis for child at high risk, given to preterm infants to prevent RSV infection - Much controversy on using steroids/antibiotics. No evidence to suggest that they work, but MD's still use prophylactically

Anatomy & physiology of child's nose and throat, explain the nose characteristics of infants (4)? explain the throat characteristics in infants and children? Explain the airway lumen in children vs adults and what occurs when mucous is present?

o Nose o Infants are obligate nose breathers; newborns produce very little mucus, making them more susceptible to infections - remember: if they have mucus, it will help fight off the infection they may have o Newborns have very small nasal passages, making them more prone to obstruction; sinuses are not developed, making them less prone to sinus infection. o Throat o Infants' tongues relative to oropharynx are larger; placement of tongue can lead to airway obstruction. o Children have enlarged tonsillar and adenoid tissue, which can lead to airway obstruction. o Airway lumen is smaller in infants and children than in adults and when edema, mucus, or bronchospasm is present, the capacity for air passage is greatly diminished o If swelling is present in a child is going to constrict the airway more than in an adult bc of the size - Small reduction in the diameter of a child's airway will result in an exponential increase in resistance to airflow, causing increased work or breathing

How should breath sounds be? What is adventitious breath sounds? what do normal breath sounds sound like (2)? what does the percussion sound like (3)? what does hyper-resonance indicate (2)? what may prolonged expiration indicate (2)? When is wheezing heard (2) and what does it sound like (1) and what may it also occur with (2)? what are rales (1) and what condition may have it (1)? Explain the structures in the upper airway (5) and lower airway (4)?

o Note that breath sounds should be equal bilaterally o Adventitious breath sounds: sounds that are heard in addition to the expected breath sounds (any abnormalities) o Normal breath sounds: bronchial and vesicular; Percussion: resonant sounds is normal (low-pitch, dull) - Hyper-resonance sound indicates lung pathology ex. pneumothorax/pleural effusion o Prolonged expiration: May indicate bronchial or bronchiolar obstruction o Wheezing (seen in asthma, allergies) o High-pitched sound on expiration (can also hear in inspiration) o May occur with obstruction in lower trachea or bronchioles o Rales: Crackling sounds heard when alveoli become fluid filled o May occur with pneumonia - Upper airway: nose, nasal passage, sinus, pharynx, and larynx - Lower airway: larynx below vocal folds, trachea, bronchi, and bronchioles

Explain the 3 anatomical differences between adults and small children ears? why are small children prone to getting otitis media? what about in the older child? what does the Eustachian tube equal and what does it allow? what are the conditions that affect the ear (3)? what is recommended for outer ear (3)?

o Of the three anatomical differences in the eustachian tube between adults and small children (shorter, wider, more horizontal), which do you think could cause more problems for the child and why? o Small children who are bottle fed in a supine position have a greater probability of developing otitis media because the eustachian tube opens when the child sucks and the horizontal angle provides easy access to the middle ear. In older children the greater angle helps keep foreign substances and germs away from the middle ear. - Conditions that affect the ear - Inner ear: sensory neuro hearing loss; brain issues - Middle ear: ex. otitis media - Outer ear: ex. swimmer's ear · Educate that they keep the ear dry, can put alcohol and dry it out, ear plugs in the water (controversial, bc if you didn't properly dry the ear prior to inserting plugs, can cause bacteria) - Eustachian tube equalizes air pressure between the middle ear and outside environment and allows for drainage of secretions from middle ear mucosa.

What type of examination will be done on the ear and what presence needs to be noted (4)? in regards to position how should the ear be and what if its not? How should the tympanic membrane present (2)? what does it mean if the cone of light is upwards? what will be observed in the tympanic membrane (6)? why may scars appear? what are two things that may be seen in the ear and what is the nursing intervention (2)?

o Otoscopic examination (can view internal and external ear) o Note the presence of cerumen, discharge, inflammation, or a foreign body in the ear canal. o Outside Ear: you assess the position (should be aligned with outer area of the eye), if ear is lower than eye then some genetic disorder may be occurring in the child o Visualize the tympanic membrane (normal color is pearly grey, important landmark: you see a cone of light meaning that you see a reflection in the ear) o If the cone of light is up high, means that the membrane is inflamed (bulging) o Observe its color, landmarks, and light reflex, as well as presence of perforation, scars, bulging, or retraction. • Scars may appear from previous ruptured eardrums • Other things seen in the ear: live/dead insects, objects o Feels like it tickles the ear - as a nurse, you shine a light or mineral oil (NEVER WATER, bc it'll cause the insect to swell)

RSV/Bronchiolitis, what assessment will be done on the patient (4)? what type of monitoring will be done (2)? what are signs of life-threatening illness (5)? nursing diagnosis (Read over)

o Physiologic Assessment o Assess airway and respiratory function, hydration status, weigh daily, monitor intake and output. o Attach a cardiorespiratory monitor and pulse oximeter: An oxygen saturation level below 90% is the best indicator of the condition's severity. o Signs of life-threatening illness include central cyanosis, respiratory rate greater than 70 breaths/min, listlessness, diminished breath sounds (means airway is obstructed), and apnea episodes. o Nursing Diagnoses: Ineffective Airway clearance r/t increased airway secretions in bronchioles. o Activity intolerance r/t imbalance between oxygen supply and demand. o Interrupted Family processes r/t sudden acute illness of the infant.

What does asthma result from and explain the patho behind? what does asthma patho lead to (3)? explain the sequence of events that occurs (4)?

o Results from complex interactions among inflammatory cells, mediators, and the cells and tissues present in the airways o An initial release of inflammatory mediators from bronchial mast cells, macrophages, and epithelial cells o Migration and activation of other inflammatory cells o Alterations in epithelial integrity and autonomic neural control of airway tone o An increase in airway smooth muscle responsiveness · Which lead to wheezing/dyspnea/obstruction · You also have inflammation/edema of mucous membranes --> which leads to tenacious secretions --> spasm of smooth muscle --> which decrease the caliber of the bronchioles

Nursing care post tonsillectomy, what are the risks that may be present (2)? what is supposed to occur with the bleeding? how do we position the patient (2)? can suctioning be performed? where can dried blood be and where can old blood be? what do you want to educate the parents on (1)? what do you want to discourage the patient from doing (4) and why? what will you report (1) and observe for (3)? what diet is encouraged in the patient (6)? what foods should be avoided (3) and why? what food should older adults avoid (1)?

o Risk for bleeding (first 24 hrs then again 7-10 days), infection (white, malodorous) • Bleeding is supposed to subside, we don't want continuous bleeding o Until fully awake, place the child in a side-lying or prone position to facilitate safe drainage of secretions. • Once alert, the child may prefer to sit up or have the head of the bed elevated. • Suctioning, if necessary, should be done carefully to avoid trauma to the surgical site. • Dried blood may be present on the teeth and the nares, with old blood present in emesis. • Since the presence of blood can be very frightening to parents, alert them of this o Discourage the child from coughing and nose blowing, clearing the throat, and using straws • Avoid trauma to the surgical site, report any bleeding to PCP, Observe for respiratory distress, hemorrhage, and dehydration post-op o Encourage fluids (ex. popsicles/ice chips); avoid citrus, brown, or red fluids • Brown or red fluid is hard to distinguish if its blood or not; the acid in citrus juice may irritate throat and cause burning sensation • Soft foods such as gelatin, applesauce/ apple juice, frozen juice pops, and mashed potatoes can be added as tolerated - food older ppl w/ dentures is able to chew and break down (no Doritos)

What are the S/S of RSV/bronchiolitis (7)? what are the S/S of severe distress (3)?

o S & SX: o Begins w/ a URI after incubation of about 5-8 days; onset of illness w/ clear runny nose (sometimes profuse) o Wheezing, retractions, crackles, worsening cough, dyspnea, tachypnea, and diminished breath sounds o N/V, dehydration - if child has been sick for several days o Pharyngitis (sore throat)/Rhinitis o Low-grade fever o Development of cough 1 to 3 days into the illness, followed by a wheeze shortly thereafter o Poor feeding - infants may have poor appetite and get to the point where they need to be admitted o Severe distress: nasal flaring, retraction and respiratory distress

What are the S/S of severe infection of RSV/bronchiolitis (6)? when does RSV resolve, but what can persist (2)? what may RSV increase the risk of developing? what kind of breathers are babys? what are some interventions to help the babies breathe (6)? what kids are often affected? what is important to remember? what is important to assess in pediatrics (2)?

o Tachypnea, greater than 70 breaths/min, grunting, increased wheezing, retractions, nasal flaring, irritability, lethargy, poor fluid intake, and a distended abdomen from over-expanded lungs. - As hypoxia develops the infant becomes cyanotic and has decreasing mental status. - As the airflow continues to decrease, breath sounds diminish. o While RSV bronchiolitis resolves in 5 to 7 days, increased airway resistance and airway hypersensitivity may persist for weeks or even months. - Bronchiolitis in infancy may increase risk of developing asthma. o Children don't have the resources that adults do - Babies are nose breathers. o When their nose is stuffed, they can't breathe! - We have to help them by suctioning; sitting up-right; providing IV fluids, oxygen, and anti-inflammatories, aerosol Tx; elevate HOB; small frequent feedings (when stomach fills up it's difficult to breathe) with rest periods; suction before eating o Often affects kids with older siblings who are in daycare. o Always remember the nosier the lungs the better the air exchange! Busy lungs mean no congestion. - Important in pediatric to see their respiratory workload and behavior pattern

RSV/Bronchiolitis, what is the diagnostic evaluation (3)? what may the CXR show (3)?

o Through NP washes - putting normal saline in the nostril, and then suctioning o CXR-nonspecific findings of inflammation - Chest radiographs show hyperinflation, patchy atelectasis, and other signs of inflammation; sometimes you may not see anything - Enzyme-linked immune-absorbent assay (ELISA) or immune-fluorescent assay performed on a posterior nasopharyngeal specimen are lab tests used to identify the virus causing bronchiolitis.

LTB/Croup Treatment, what are we going to treat? What is the treatment at home (1) and at the hospital (2)? what will the parents be educated on in regards to that treatment (2) and why may parents get scared (2)? what medications will be given to the patient (2) and why is it helpful? what other medication may be given (1) and why/ when can this medication be used? what is the treatment if the airway is obstructed (1) and why (2)? what size tube?

o Treatment (tx symptoms bc its viral) o Steam bath (at home), Cool mist/O2 (at hospital) - cool mist constricts edematous blood flow o Many times, coughing gets really bad in the middle of the night. - Parent gets very frantic because child looks like they are having difficulty breathing. o Teach parents to take their child to the freezer, open it up and put their head in the cool mist. o Another treatment is to take the child into the bathroom, close the door turn on the hottest water and fill the bathroom with hot steam and let them breathe it in. o IV fluids, Parenteral/Oral dexamethasone (Decadron): will reduce airway edema usually after 6 hrs with a continued improvement 12-24 hours after start o Nebulized racemic epinephrine: produces topical mucosal vasoconstriction which decrease edema. • May be used q30 minutes and monitor for at least 4 hrs b/c sx may reappear • Med has short life, and pt can have the attack again (determine if pt will be admitted) o Intubation (if airway obstructed) - indicated if sx do not improve & resp distress worsens, use .5mm smaller tube

What is the etiology of otitis media? what does it often proceed after and what is the outcome (1)? Explain the pathophysiology of otitis media (4)? what conditions can obstruct the eustachian tube and lead to otitis media (2)?

o Unknown but thought to be related to Eustachian tube dysfunction (shape and length) o Often proceeded by an upper respiratory infection that causes the mucous membranes of the Eustachian tube to become edematous (related to eustachian tube dysfunction) o Air in the middle ear becomes blocked and reabsorbed into the bloodstream. o Fluid is pulled from the mucosal lining into the former air space, providing a medium for the rapid growth of pathogens --> The tympanic membrane and fluid behind it become infected. o Conditions such as enlarged adenoids or edema from allergic rhinitis can also obstruct the Eustachian tube and lead to otitis media.

What is LTB/croup? what is this caused by and what occurs to the airway? What are the syndromes that may be caused by viral (2) and bacterial (2)? what are the MAIN S/S (4) and others (10)? what is the common age group and season?

o Upper airway illnesses that result from inflammation and swelling of epiglottis and larynx, which extends to trachea and bronchi. • DD: viral infection/tightening on the upper airway. • Viral croup syndromes include spasmodic laryngitis (spasmodic croup) and laryngotracheobronchitis (LTB); Bacteria croup syndrome include bacterial tracheitis and epiglottis. o Initial symptoms include inspiratory respiratory stridor (a high-pitched musical sound that is created by narrowing of the airway), a "seal-like" barking cough worse at night, and hoarseness. • Leads child to struggle to inhale air past the obstruction, possible respiratory distress o Most common in children 3 mo-4yrs & occurs in late autumn through early winter months, usually occurs at night o Viral: Parainfluenza type I, II or III o Hx: URI which leads to rhinorrhea, low grade fever, runny nose, tachypnea, nasal retractions, inspiratory stridor. Wheezing occasionally reported • Expiratory stridor, and a low SpO2 indicate a more severe airway inflammation and swelling. Mental status changes indicate hypoxemia and potential respiratory failure.

Which type of pneumonia occurs most frequently? Who does viral pneumonia occur most frequently in? what is viral pneumonia associated with (4)? what are the S/S of viral pneumonia (5)? how do you want to assess the temperature in children/infants? What is the management for viral pneumonia (5)? what other type of therapy might be recommended and why?

o Viral, Occur more frequently than bacterial o Seen in children of all age groups o Associated with viral URIs, RSV, parainfluenza, & adenovirus o S & Sx: Mild-severe fever, slight cough, malaise, wheezes, fine crackles - Assessing temperature in a child do axillary and in infants do rectal since its more accurate - Management: o Promote oxygenation and comfort o In infants, can put the oxygen tent bc they won't tolerate the nasal cannula o Antipyretics (ex. Tylenol), Steroids (to decrease inflammation), bronchodilators (to open up the airways) o Fluid intake - to help loosen up the secretions o Some recommend antimicrobial therapy to prevent secondary bacterial infection

What occurs to the visual acuity in pediatrics? are the eyes injury prone and why/why not? What two characteristics of the eyes are incomplete (2)?

o Visual acuity develops from birth through early childhood - at birth, vision is very poor but as they get older, it gets better o Eyeball occupies larger space in the face, making it injury prone. o Color discrimination is incomplete - they see black and whites first, then colors like bright red, etc. o Retinal vascularization is incomplete

What is epiglottitis? why is this considered life-threatening? what age group can this occur (2)? what is epiglottis caused by (3)? what immunization can decrease the cases? give a general overview of what happens to the airway and what is the nurses responsibility?

• Inflammation of the epiglottis & surround area, the long narrow structure that closes off the glottis during swallowing. - Because edema is this area can rapidly obstruct the airway by occluding the trachea it is considered a severe, rapidly progressive life-threatening condition --> leads to narrowing of airway & turbulent air flow (decreases oxygen) • Occurs at any age, but usually b/w 2-6 years old. • Caused by bacterial invasion of the soft tissue of the larynx by streptococcus, staphylococcus, or by haemophilus influenza type B (Hib) in unimmunized children (beta strep is common causing agent) • AAP recommends vaccination for HiB so there is a huge decrease of cases. • Epiglottis gets inflamed, you need to intubate the patient because they can't breathe. • Airway will completely close you need to protect it. • Nurses' first action is to prepare for intubation - never stick anything down child's throat (gagging), don't examine, don't put a tongue depressor, don't try to get a throat culture, don't disturb the child, and airway maintenance.

When does the symptoms of LTB appear? what is the general usual treatment (4)? what if it's viral? what causes the airway diameter to decrease (2)? what is the clinical presentation of LTB (4) what is contraindicated (2)?

• Symptoms occur at night • Treatment: Cool night air, fluids, Humidification, Steroids • Usually, viral - therefore just treating symptomatically - Copious, tenacious secretions & laryngeal inflammation cause the airway diameter to decrease. o Anteroposterior/Lateral radiograph films of upper airway may show symmetric, subglottic narrowing (steeple sign) o Pulse oximetry to detect hypoxia - stats will be low typically o Significant stridor at rest - BAD SIGN, have to monitor these patients closely o Severe retractions (sucking in air) after a several hour period of observation; any nasal flaring in kids? - Throat c/s and inspection contraindicated due to potential for laryngospasm **

Explain the pathophysiology of bronchiolitis/RSV (5)? where is the cycle repeated? What occurs to the airway and what lung sounds can be heard? what is the risks that can occur (3) and why?

• Viruses, acting as parasites, invade the mucosal cells that line the small bronchi and bronchioles. o The membranes of the infected cells fuse with adjacent cells, creating large masses of cells or "Syncytia". o The resulting cells debris clogs and obstructs the bronchioles and irritates the airway. o Airways lining swells and produces excessive mucus (thick secretions) o Effect is partial airway obstruction and bronchospasms. o Partially obstructed airway allows air in but mucus and airway swelling block expulsion of air o Cycle is repeated throughout both lungs as the airway cells are invaded by the virus. o Mucus and airway swelling block expulsion of the air creating wheezing and crackles in the airways (once the lower airway is involved) o Air trapped also interferes with gas exchange, leading to hypoxemia and risk for respiratory failure o Child is at risk for apnea and respiratory failure as hypoxemia and hypercarbia (CO2 retention) develop.